The Evidence for Immediate Loading of Implants

The Evidence for Immediate Loading of ImplantsDavid L. Cochran, DDS, PhDFrom the Departments of Periodontics, The University of Texas Health Science CenterSan Antonio, San Antonio, TX

INTRODUCTION

Many clinicians today recommend implant therapy for pa-tients requiring tooth replacement. This therapy can providea highly successful restoration of both function and esthetics.As such, more and more dentists are providing restorationsand patients are demanding these restorations. Along withsuch an increase in procedures comes a desire to simplify theexperience in regard to many aspects including the time in-volved from starting the restoration to finishing the proce-dure. The shortest amount of time involved would be toplace the restoration on the implant immediately after thesurgical placement of the implant, a procedure called imme-diate restoration and/or loading. While immediate loadinghas been discussed in the literature and papers report on thistechnique, this procedure has not gained widespread accep-tance. To understand the possibilities of immediate loading,one must take a careful look at the implant procedure from ahistorical perspective, from a biological perspective, and froma prospective of the available literature on the topic. This isthe focus of this report.One confounding area when discussing immediate loading

or any loading protocols is how various terms are defined.Different investigators define certain terms different waysand this can change the interpretation of the results of studies.An example is how Bimmediate loading[ is defined or even theterm Bloaded.[ Some investigators suggest that placing animplant into bone and submerging it below the soft tissuesresults in loading of the implant. The rationale is that flextureof the jawbone upon opening and closing and during chewingexerts forces on the implant and thus Bloading[ the implant.Others would suggest that an implant is loaded when it be-comes visible in the oral cavity. This would occur when a non-submerged implant is used or when a submerged implantsclosure screw becomes exposed through the soft tissue. Therationale here is that tongue movements, cheek pressure, andfood could impact the top of the implant therefore placing aBload[ onto the implant. Other individuals would suggest thatthe implant is not Bloaded[ until a temporary restoration orimplant component of some shape is placed onto the implant

and is in the oral cavity but is not in occlusion with the op-posing dentition. Again the rationale in these cases would betongue and cheek movements and food that would contact thetemporary restoration and the opposing dentition. Last, otherinvestigators and authors define Bloading[ as when the im-plant restoration is in direct contact with the opposing denti-tion. This is usually confirmed in centric occlusionwith coloredocclusal marking paper or shim stock. This is a more objectivemeasure of loading and the term that will be used in this reportfor the loading of an implant restoration.

HISTORICAL PERSPECTIVE

To understand the loading of implants, it is necessary to ap-preciate how loading protocols were established. Loadingprotocols were arrived at originally by Branemark and asso-ciates1 while working out clinical protocols for placing im-plants. These investigators described 3 distinct phases ofdevelopment in the technique, which resulted in improvedsuccess rates after each stage of trial and error. The initial stageof development lasted from the mid 1960s until 1968. A de-velopment phase followed from 1968 until 1971 and then aroutine stage for the technique followed from 1971 until 1975.During the early and development stages, one aspect that wasinvestigated was loading protocols. Various healing times wereevaluated and it was determined that shorter healing times re-sulted in failure of the implants. These findings suggested thata healing time of 3 months was required in the mandible and6 months of healing was required for the maxilla. These heal-ing times were used by clinicians and in many studies and, assuch, 3 months in the mandible and 6 months in the maxillabecame recognized as conventional healing times.The clinical experience that suggested a 3- and 6-month

healing time in the mandible and maxilla respectively did notsuggest a biological rationale for such a recommendation.Szmukler-Moncler et al2 speculate on 4 possible biologicalevents that could account for the required healing times clini-cally established by Branemark et al.1 The first possibilitywas that early loading would result in fibrous encapsulationof the implant and no osseointegration. A second possibilitywas that the overheated bone tissue, which undergoes necro-sis from the osteotomy preparation, needs to be replaced andduring this time the tissue is not capable of supporting theimplant. A third possibility suggested was that the necroticbone created during osteotomy preparation is rapidly re-modeled and turned over and that during the remodeling,the strength of the bone to implant contact is compromised.Last, it was speculated that the 3- to 6-month healing period

Presented at the 2nd Evidence-Based Dentistry ConferenceNovember 6, 2005Chicago, Illinois

J Evid Base Dent Pract 2006;6:155

was required in order to remodel bone adjacent to the bone-implant interface. This adjacent bone remodeling could com-promise the ability to support the implant. Thus, severalscenarios were envisioned that could explain why an extendedhealing period was required prior to loading of the implant.The findings regarding healing times established by

Branemark et al1 were reinforced by work performed byRoberts.3 These latter findings suggested that the same heal-ing periods were required prior to loading the implant. With-out such a healing time prior to loading, the bone to implantinterface was thought to be damaged by loading. Such reportsled to the establishment of the conventional healing periods.These healing times were also reinforced by work during the1970s in the orthopedic field.4

process was critical. In the final third phase, the RefinementPeriod, shortened healing protocols have been investigatedand immediate loading protocols have been examined underdefined conditions. This Refinement Period has been oc-curring in the last 5 to 6 years since 2000. These evolutionaryperiods have translated to patient care such that in the De-velopment Period, techniques were developed to replaceteeth in edentulous patients. During the Exploratory Period,these techniques were extended to provide tooth replacementin partially edentulous patients, and in the Refinement Periodall these techniques are being optimized (Fig. 2).Features of the evolutionary periods in implantology in-

clude the following. In the Development Period, the tech-niques were begun in edentulous patients, the techniqueswere developed so that they became predictable, biocompat-ible materials were used, many implants were placed in eachpatient, the implants had long undisturbed healing times of3 to 9 months, implants were placed in high-quality (pre-dominantly cortical dense) bone, cross-arch stabilization wasused, the opposing dentition was a denture, and, most signi-ficantly, there was minimal heating of the bone tissue duringimplant surgery. The outcome of the Development Periodwas help for the denture patient.During the Exploration Period, the implant technique be-

gan to be applied to partially edentulous patients. The sameprinciples that had been learned in edentulous patients wereassumed to be valid for partially edentulous patients; how-ever, various aspects of the techniques were examined fortheir necessity since different clinical indications were beingused. Some questions that were raised and that have beenexplored include the following: could the material the im-plants were made from change (eg, alloys of titanium ratherthan pure titanium), could you oppose teeth or fixed partialdentures rather than dentures with the implant restoration,was cross-arch stabilization required, could the implants beplaced in lower quality bone, was bicortical stabilization nec-essary, could fewer implants be used including just a singleimplant, did you need to cover (submerge) the implant underthe soft tissues in order to achieve osseointegration (although

Andre Schroeder had been using nonsubmerged implantssince the 1970s12), could you load the implant prior to the3- to 9-month healing time, and could you place the implantinto extraction sites? The answers to these questions helped todefine the implant technique in partially edentulous patientsand thus benefited those patients missing 1 or more teeth.By the time of the Refinement Period, dental implant place-

ment became a routine successful tooth replacement therapyfor both edentulous and partially edentulous patients. Re-search during this time focused on optimizing surface char-acteristics of the implant including both morphology andchemistry and exploring ways to further shorten the healingtimes of the implant prior to restoration and loading, with theultimate goal of loading the implant immediately, meaning atthe time of implant placement. Also during the RefinementPeriod, tissue-engineering techniques were introduced to en-hance the rate of healing and the quantity and quality of bonetissue around the implant (eg, the bone-to-implant contact).The outcome of these improvements during the RefinementPeriod led to the use of implant therapy to replace missingteeth in more indications and thus more patients.

BIOLOGICAL CONSIDERATIONS

Loading protocols for endosseous dental implants can bestbe interpreted on the biologic basis of how the tissues re-spond to implant placement. In fact, few appear to realize thatosseointegration occurs instantaneously on implant place-ment. Osseointegration was first defined as bone-to-implantcontact at the light microscopic level and then later defined asa direct structural and functional connection between or-dered living bone and the surface of a load-carrying im-plant.1 Cochran et al,13 in a study of the bone response toimplants with 2 different surface characteristics, stated thatwhen an implant is placed clinically into an osteotomy pre-paration, that the bone directly contacts the implant surface.This results in immediate osseointegration of the implant asdefined by direct bone-to-implant contact if analyzed at thelight microscopic level. In fact, when an osteotomy site isprepared, bone tissue is cut to a dimension of the implantdrill. This leaves edges of the bone surrounding the hole leftby the drill. More dense bone is found in the cortical areaswhile less dense bone, in the form of interrupted trabeculae,are found in areas of cancellous bone. When an implant isthen placed into the preparation, especially if the implant hasa slightly larger diameter than the implant drill, the implant isBpress-fit[ along the cut bone edges and the implant contactsthe bone, ie, is osseointegrated (bone-to-implant contact at thelight microscopic level). These areas of bone contact with theimplant surface are referred to as Bprimary bone contact.[13

Histologic analysis of such bone reveals intimate contact ofthe bone with the implant surface (osseointegration) includ-ing lamellar plastic deformation, elongated Haversion sys-tems, and micro-fractures in the bone (Fig. 3). Because bonetissue is dynamic and remodels over time, these areas of bonecontact are remodeled and are replaced by new bone. This

Figure 2. Decades listed for the 3 development periodsalso listing the predominant patients treated.

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Volume 6, Number 2 157Cochran

new bone contact is termed Bsecondary bone formation.[At the same time, new bone is also formed on the implantsurface (especially if the surface is osteoconductive) in areasbetween the areas of primary bone contact. This new boneis also termed Bsecondary bone formation.[ Thus, at earlytime points there is a lot of primary bone contact alongthe implant surface (dependent on the existing quantityand quality of bone at the implant site) and very little sec-ondary bone formation. At later time points, however, theratio reverses such that primary bone contact decreases andsecondary bone contact increases. This can be viewed dia-grammatically as is shown in Fig. 4.Histological analyses of large numbers of implants in pa-

tients is not possible, so clinical alternatives have been usedto determine if an implant is osseointegrated. One such sur-

rogate for osseointegration is to determine if the implant isstable in the jaw. Several methods are available to evaluatestability and one more recent way is to use resonance fre-quency analyses. Barewal et al14 have followed the stability ofimplants over early healing times with resonance frequencymeasurements. Their findings indicated that implants placedin areas of high bone quality are relatively stable over theearly healing periods. However, as the quality of bone de-creases, the stability of the implant decreases over the first3 to 4 weeks with the least stability found for those implantsin the lowest bone quality (Fig. 5). These findings suggestthat implants placed in high-quality bone are surrounded byenough primary bone contact that stability of the implantis maintained by the primary contact while the remodelingand formation of new bone can occur to such a degree as tofurther maintain the stability as measured by resonance fre-quency analyses (Fig. 6 and Fig. 7). However, when the im-plant is placed into a site with poor bone quality, very littleprimary contact exists around the implant (Fig. 8 and Fig. 9).As remodeling occurs, the implant becomes less stable be-cause (1) the remodeling process in this case takes place in arelatively high percentage of the bone surrounding the im-plant (little bone-to-implant contact initially because of poorbone quality; therefore, as remodeling occurs, this representsa large proportion of that small amount of bone), and (2)there has not been sufficient time for new bone to form (sec-ondary bone formation). Thus, stability of the implant asmeasured by resonance frequency analyses reveals a sig-nificant decrease in stability between the time of primarybone contact remodeling and the formation of new boneor secondary bone contact. Therefore, the clinical stabilityof implants in bone, as measured by resonance frequencyanalyses, reflects the biological processes that are ongoing atthe bone-to-implant interface. These events further empha-size that Bosseointegration[ is not a static event but ratherrepresents a Bdynamic equilibrium[ at the site of bone-to-implant contact. Thus, given this understanding, a new

Figure 3. Primary contact of implant with cortical bone.Original magnification: X25. Compression of the corti-cal bone can be observed. Reprinted with permissionfrom Cochran DL, Schenk RK, Lussi A, HigginbottomFL, Buser D. Bone response to unloaded and loaded tita-nium implants with a sandblasted and acid-etched sur-face: a histometric study in the canine mandible. J BiomedMater Res. 1998 Apr;40(1):1-11.13

Figure 4. Schematic of bone contact against an implantsurface and what happens to the bone over time.


158 Cochran June 2006

definition of osseointegration could be Bstability of animplant in bone that represents a dynamic equilibrium be-tween existing native bone (primary bone contact) and re-modeling and new bone formation (secondary bone contact),and its maintenance, at the bone-implant interface[ (Fig. 10).

LITERATURE EXAMPLES

Understanding the biological consequences of implant inte-gration allows an appreciation of what is possible in regardto the loading of implants. These events are then reflectedby the literature on loading protocols. For instance, under-standing that implants placed in excellent bone quality will

be stable over the early healing periods and remain stable(osseointegrated as defined above), suggests that multipleimplants placed in the anterior mandible and are rigidly fixedorally can be successfully loaded. Thus, publications byBabbush et al,15 Schnitman et al,16 Tarnow et al,17 andChiapasco et al18 are not surprising. Loading protocols inother indications are certainly possible but the implant sitesmust be carefully chosen as to reflect sites that can have highbone quality, the implant restoration can be stabilized byadjacent tooth structure etc, where implant stability can bemaintained in the transition from primary bone contact tosecondary bone contact. This is reflected in papers publishedand in reviews of literature on this topic as noted below.

Figure 5. Stability of implants in different qualities of bone as detected by resonance frequency analyses over time. ISQis the implant stability quotient. Reprinted with permission from Barewal RM, Oates TW, Meredith N, Cochran DL.Resonance frequency measurement of implant stability in vivo on implants with a sandblasted and acid-etched surface. IntJ Oral Maxillofac Implants. 2003 Sep-Oct; 18(5):641-51.14



An example of a recent study evaluating implant loadingprotocols examined various healing periods prior to loadingincluding no healing period, 10 days, 21 days, and 3 monthsof loading.19 Teeth were extracted bilaterally in the caninemandible and after 5 months, implants were placed at dif-ferent time points such that each animal received 3 implantsat each of the 4 healing times. All gold, screw-retained crownswere placed on all the implants the same day and radio-graphs taken at monthly intervals until the study animalswere killed at 3 months post-loading. Block sections were ob-tained from each implant site and histological analyses wereperformed in addition to the monthly radiographic analyses(Fig. 11 and Fig. 12). No implants were lost in spite of thevarying loading times and occlusal wear on the gold crowns.

The conclusions demonstrated that no significant differenceswere found between the implants loaded after different heal-ing times as evaluated clinically, radiographically, and his-tologically. Thus, both immediate and early loading of theimplants did not have adverse effects on the survival or suc-cess of the implants.A meta-analysis was performed on more than 1000 im-

plants in patients and compared loading times as evaluatedby implant survival.20 This article analyzed 13 prospectiveclinical trials, 6 of which were randomized. Overall, nosignificant differences were detected between loading proto-cols. Furthermore, although a higher actual number of fail-ures occurred in the early loading protocols (2 to 6 weeks ofhealing prior to loading) relative to the conventional loading

Figure 6. The change in primary bone contact when animplant placed in a site with a large proportion of densebone such as cortical bone.

Figure 7. The stability of an implant placed in high qual-ity bone is large (represented by a small gray area).

Figure 8. The change in primary bone contact when animplant is placed in a site with a large proportion of lessdense bone such as cancellous bone.

Figure 9. The lack of stability of an implant placed inlow quality bone (represented by large gray area).



protocol, there was no significant difference in the implantfailure rate between loading protocols. It should be notedthat conventional loading was defined as 3 to 6 months andimmediate loading from 1 to 2 days; however, early loadingincluded studies with a range of healing times (less than14 days, within the first 35 days, and within the first 6weeks). The authors noted a number of limitations of theirstudy including only 6 randomized studies out of a total13 studies, only 1266 implants evaluated, all the trials beingunderpowered, and the clinical heterogeneity of the studies.

An implant consensus conference was held in Gstaad,Switzerland, in 2003 by the International Team for OralImplantology. One group at the consensus meeting eval-uated immediate and early loading restoration and loadingprotocols for dental implants.21 Three papers were submittedthat evaluated loading protocols in the literature related toedentulous patients,22 partially edentulous patients,23 andclinical techniques.24 After careful analyses and evaluation ofthe literature reviews, an international group of 17 cliniciansmade recommendations on loading protocols based on theliterature and the collective experience of the group. Thisgroup determined that the volume of literature on loadingprotocols was moderate and the evidence was limited at bestfor the procedures considered. The predominant literaturewas case reports. Loading was defined as contact with theopposing dentition as opposed to restoration without contact.Conventional healing was defined as 3 months postYimplantplacement until restoration, whereas immediate restorationwas defined as restoration within 48 hours of implant place-ment but not in occlusion with the opposing dentition. Thisdefinition was based on the capacity to perform the restor-ative clinical procedures within a limited time frame fromsurgery (such as the surgical placement occurring in oneoffice one day and the restorative procedures performed in

Figure 10. New definition of osseointegration reflectingthe dynamic biological processes that occur around an im-plant placed in bone.

Figure 11. Histologic cross-sections of implants from a) Group A: 3 months, b) Group B: 21 days, c) Group C: 10 days,d) Group D: 2 days after 3 months of loading. Reprinted with permission from Quinlan P, Nummikoski P, SchenkR, Cagna D, Mellonig J, Higginbottom F, Lang K, Buser D, Cochran D. Immediate and early loading of SLA ITIsingle-tooth implants: an in vivo study. Int J Oral Maxillofac Implants. 2005 May-June;20(3):360-70.19



another office the next day). Early restoration was defined asthe placement of the restoration at least 48 hours subsequentto implant placement but not later than 3 months. Immediateloading was therefore defined as restoration within 48 hoursof implant placement and occlusal contact with the opposingdentition. Early loading was therefore restoration at least48 hours subsequent to implant placement but not later than3 months and the restoration in contact with the opposingdentition. The consensus group noted that the results ofthe studies were obtained from conditions that were con-sidered favorable in that the inclusion and exclusion criteriaused in many of the studies limited their evaluation to a se-lected population.The consensus conference concluded that in the edentu-

lous mandible, immediate loading (up to 48 hours) in patientswith both overdentures and fixed prostheses was well doc-umented in the literature (Fig. 13). Early loading was sepa-rated into 2 periods based on studies in the literature. Oneearly loading period was between 48 hours and 6 weeksand the second period from 6 weeks to 3 months. In theedentulous mandible in the period of early loading from48 hours to 6 weeks, the procedure for overdentures andfixed prostheses was not well documented. In the period from6 weeks to 3 months, no overdenture literature was availablebut the literature on fixed prostheses was well documented.In regard to the edentulous maxilla, no literature was avail-

able on overdentures that involved immediate or early load-ing (Fig. 14). In regard to fixed prosthesis in the edentulousmaxilla, literature was available on both immediate and earlyloading; however, the group determined that this procedurewas not well documented in the literature. In regard to thepartially dentate maxilla andmandible, overdentures were not

applicable (Fig. 15). Fixed prostheses used in immediate res-toration or loading indications in the partially dentate patientwere not well documented. In regard to early restoration orloading in the partially dentate patient, the procedure waswell documented only after 6 to 8 weeks and then when animplant was used with a roughened titanium surface.

CONCLUSION

A summary of loading protocols, based on historical de-velopment, biological considerations, and the literature in-dicate that shortened loading protocols are dependent on (1)the quantity and quality of bone at the implant site and, asa consequence, the amount of primary bone contact, and(2) the rapidity of the bone formation and remodeling of the

Figure 12. Tissue-to-implant contact between tissueand primary and secondary bone, bone marrow, and con-nective tissue for Groups A (3 months), B (21 days), C(10 days), and D (2 days). Bars indicate SE. Reprintedwith permission from Quinlan P, Nummikoski P, SchenkR. Immediate and early loading of SLA ITI single-toothimplants: an in vivo study. Int J Oral Maxillofac Im-plants. 2005 May-June;20(3):360-70.19

Figure 13. Loading documentation in the literature foredentulous mandible. Reprinted with permission fromCochran DL, Morton D, Weber HP. Consensus state-ments and recommended clinical procedures regardingloading protocols for endosseous dental implants. Int JOral Maxillofac Implants. 2004;19 Suppl:109-13.21

Figure 14. Loading documentation in the literature foredentulous maxilla. Reprinted with permission fromCochran DL, Morton D, Weber HP. Consensus state-ments and recommended clinical procedures regardingloading protocols for endosseous dental implants. Int JOral Maxillofac Implants. 2004;19 Suppl:109-13.21



bone surrounding the implant with resultant secondary bonecontact. These conditions result in 2 clinical scenarios forsupporting reduced healing times. If the implant site has highquality and quantity of existing bone, immediate loading pro-tocols are possible. If the implant site has low quality andquantity of native bone and bone remodeling and boneformation are required, immediate loading is more contra-indicated and early loading protocols are possible. However,many factors can be important such as the characteristics ofthe implant surface, the location of high-quality bone in theimplant site, the ability to protect the implant restoration withadjacent tooth structure, the use of proteins (growth factorsor stimulants) or materials and matrices used around theimplant, and so forth. These factors are related to either (1)stimulating new bone-to-implant contact or (2) minimizingmicromotion of the implant. In all situations, it is impor-tant to remember that the goal is improved patient care.Procedures that put the implant restoration at high risk inthe patient are unacceptable. Understanding the historicaldevelopment of implant healing times, the biological eventsthat result in osseointegration as defined above, and knowingthe literature on shortened healing times on implants, allowsthe clinician to appreciate options for various loading pro-tocols and to improve the patient care they deliver.

REFERENCES

1. Branemark PI, Hansson BO, Adell R, Breine U, Lindstrom J, Hallen O,et al. Osseointegrated implants in the treatment of the edentulous jaw.Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl1977;16:1-132.

2. Szmukler-Moncler S, Piattelli A, Favero GA, Dubruille JH. Considerations

preliminary to the application of early and immediate loading protocols indental implantology. Clin Oral Implants Res 2000;11(1):12-25.

3. Roberts WE. Bone tissue interface. J Dent Educ 1988;52(12):804-9.4. Schatzker J, Horne JG, Sumner-Smith G. The effect of movement on the

holding power of screws in bone. Clin Orthop 1975;111:257-62.5. Cameron H, Macnab I, Pilliar R. Porous surfaced Vitallium staples. S

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bonding of porous metal to bone. J Biomed Mater Res 1973;7(4):301-11.7. Ducheyne P, De Meester P, Aernoudt E. Influence of a functional

dynamic loading on bone ingrowth into surface pores of orthopedicimplants. J Biomed Mater Res 1977;11(6):811-38.

8. Unthoff HK, Germain JP. The reversal of tissue differentiation aroundscrews. Clin Orthop 1975;123:248-52.

9. Cochran DL, Buser D, ten Bruggenkate CM, Weingart D, Taylor TD,Bernard J-P, et al. The use of reduced healing times on ITI(R) implantswith a sandblasted and acid-etched (SLA) surface. Clin Oral Impl Res2002;13(2):144-53.

10. Chiapasco M, Abati S, Romeo E, Vogel G. Implant-retained mandibularoverdentures with Branemark System MKII implants: a prospectivecomparative study between delayed and immediate loading. Int J OralMaxillofac Implants 2001;16(4):537-46.

11. Ledermann P. [Complete denture support in edentulous problem man-dibles with help from 4 titanium plasma-coated PDL screw implants].SSO Schweiz Monatsschr Zahnheilkd 1979;89(11):1137-8. (German)

12. Schroeder A, van der Zypen E, Stich H, Sutter F. The reactions of bone,connective tissue, and epithelium to endosteal implants with titanium-sprayed surfaces. J Maxillofac Surg 1981;9(1):15-25.

13. Cochran DL, Schenk RK, Lussi A, Higginbottom FL, Buser D. Boneresponse to unloaded and loaded titanium implants with a sandblastedand acid-etched surface: a histometric study in the canine mandible.J Biomed Mater Res 1998;40(1):1-11.

14. Barewal RM, Oates TW, Meredith N, Cochran DL. Resonancefrequency measurement of implant stability in vivo on implants with asandblasted and acid-etched (SLA) surface. Int J Oral and MaxillofacImplants 2003;18(5):641-51.

15. Babbush CA, Kent JN, Misiek DJ. Titanium plasma-sprayed (TPS)screw implants for the reconstruction of the edentulous mandible. J OralMaxillofac Surg 1986;44(4):274-82.

16. Schnitman PA, Wohrle PS, Rubenstein JE. Immediate fixed interimprostheses supported by two-stage threaded implants: methodology andresults. J Oral Implantology 1990;16(2):96-105.

17. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded im-plants at stage 1 surgery in edentulous arches: ten consecutive case reportswith 1- to 5-year data. Int J Oral Maxillofac Implants 1997;12(3):319-24.

18. Chiapasco M, Gatti C, Rossi E, Haefliger W, Markwalder TH.Implant-retained mandibular overdentures with immediate loading. Aretrospective multicenter study on 226 consecutive cases. Clin OralImplants Res 1997;8(1):48-57.

19. Quinlan P, Nummikoski P, Schenk R, Cagna D, Mellonig J,Higginbottom F, et al. Immediate and early loading of ITI SLA singletooth implants: an in vivo study. Int J Oral Maxillofac Implants 2005;20:360-70.

20. Ioannidou E, Doufexi A. Does loading time affect implant survival? Ameta-analysis of 1,266 implants. J Periodontol 2005;76(8):1252-8.

21. Cochran DL, Morton D, Weber H-P. Consensus statements and recom-mended clinical procedures regarding loading protocols for endosseousdental implants. Int J Oral Maxillofac Implants 2004;19(Suppl):109-13.

22. Chiapasco M. Early and immediate restoration and loading of implantsin completely edentulous patients. Int J Oral Maxillofac Implants 2004;19(Suppl):76-91.

23. Ganeles J, Wismeijer D. Early and immediately restored and loadeddental implants for single-tooth and partial-arch applications. Int J OralMaxillofac Implants Suppl., 2004;19:92-102.

24. Morton D, Jaffin R, Weber H-P. Immediate restoration and loading ofdental implants: clinical considerations and protocols. Int J Oral Maxil-lofac Implants 2004;19(Suppl):103-8.

Figure 15. Loading documentation in the literature forpartially dentate maxilla and mandible. Reprinted withpermission from Cochran DL, Morton D, Weber HP.Consensus statements and recommended clinical proce-dures regarding loading protocols for endosseous dentalimplants. Int J Oral Maxillofac Implants. 2004;19 Suppl:109-13.21



The Evidence for Immediate Loading of ImplantsINTRODUCTIONHISTORICAL PERSPECTIVEBIOLOGICAL CONSIDERATIONSLITERATURE EXAMPLESCONCLUSIONReferences

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The Evidence for Immediate Loading of Implants