Implants – Post Surgical Management I

Advanced Surgery and Implant Literature Review

 

Rapid Search Terms

Late, Early and Immediate loading,  Functional and Non-functional loading

References:

Concepts and Principles

  • Trise and del Fabbro. Biology and Biomechanics in Immediate Loading (CH 2) pp 18-45. Immediate Loading: A New Era in Oral Implantology. Testori, Galli, del Fabbro. 2011. Quintessence.
  • Del Fabbro and Taschieri. A Systematic Review of the Literature (CH 4) pp 66-91. Immediate Loading: A New Era in Oral Implantology. Testori, Galli, del Fabbro. 2011. Quintessence.
  1. Becker CM, Wilson TG Jr, Jensen OT. Minimum criteria for immediate provisionalization of single-tooth dental implants in extraction sites: a 1-year retrospective study of 100 consecutive cases. J Oral Maxillofac Surg. 2011 Feb;69(2):491-7
  2. Ghoul WE, Chidiac JJ. Prosthetic requirements for immediate implant loading: a review. J Prosthodont. 2012 Feb;21(2):141-54.
  3. Suarez F, Chan HL, Monje A, Galindo-Moreno P, Wang HL. Effect of the timing of restoration on implant marginal bone loss: a systematic review. J Periodontol. 2013 Feb;84(2):159-69.
  4. Chrcanovic BR, Albrektsson T, Wennerberg A. Immediate nonfunctional versus immediate functional loading and dental implant failure rates: a systematic review and meta-analysis.J Dent. 2014 Sep;42(9):1052-9.
  5. Sanz-Sánchez I, Sanz-Martín I, Figuero E, Sanz M. Clinical efficacy of immediate implant loading protocols compared to conventional loading depending on the type of the restoration: a systematic review.Clin Oral Implants Res. 2015 Aug;26(8):964-82. doi: 10.1111/clr.12428. Epub 2014 Jun 11.
  6. Esposito M, Grusovin MG, Maghaireh H, Worthington HV. Interventions for replacing missing teeth: different times for loading dental implants. Cochrane Database Syst Rev. 2013 Mar 28;3:CD003878.
  7. Atieh MA, Alsabeeha NH, Payne AG, et al. The prognostic accuracy of resonance frequency analysis in predicting failure risk of immediately restored implants. Clin Oral Implants Res. 2014 Jan;25(1):29-35. doi: 10.1111/clr.12057. Epub 2012 Oct 31.
  8. Barewal RM, Stanford C, Weesner TC A randomized controlled clinical trial comparing the effects of three loading protocols on dental implant stability. Int J Oral Maxillofac Implants. 2012 Jul-Aug;27(4):945-56.
  9. Pozzi A, Mura PImmediate Loading of Conical Connection Implants: Up-to-2-Year Retrospective Clinical and Radiologic Study.Int J Oral Maxillofac Implants.2016 Jan-Feb;31(1):142-52. doi: 10.11607/jomi.4061.
  10. Del Fabbro M, Ceresoli V, Taschieri S, Ceci C, Testori T. Immediate Loading of Postextraction Implants in the Esthetic Area: Systematic Review of the Literature. Clin Implant Dent Relat Res. 2013 Apr 22. doi: 10.1111/cid.12074.
  11. Mijiritsky E, Mardinger O, Mazor Z, Chaushu G. Immediate provisionalization of single-tooth implants in fresh-extraction sites at the maxillary esthetic zone: up to 6 years of follow-up. Implant Dent. 2009 Aug;18(4):326-33.
  12. Anitua E, Piñas L, Alkhraisat MH. Long-Term Outcomes of Immediate Implant Placement Into Infected Sockets in Association With Immediate Loading: A Retrospective Cohort Study.J Periodontol. 2016 May 13:1-15. [Epub ahead of print]
  13. Vogl S, Stopper M, Hof M, et a. Immediate Occlusal versus Non-Occlusal Loading of Implants: A Randomized Clinical Pilot Study. Clin Implant Dent Relat Res. 2013 Sep 30. [Epub ahead of print]
  14. Benic GI, Mir-Mari J, Hammerle CHF, Loading Protocols for Single-Implant Crowns: A Systematic Review and Meta-analysis. Int J Oral Maxillofac Implants. 2014 Jan-Feb; 29(supplement):222-238.
  15. Kolerman R, et al. Radiological and Biological Assessment of Immediately Restored Anterior Maxillary Implants Combined with GBR and Free Connective Tissue Graft.Clin Implant Dent Relat Res.2016 Mar 20. doi: 10.1111/cid.12417. [Epub ahead of print]
  16. Papaspyridakos et al. Implant Loading Protocols for Edentulous Patients with Fixed Prostheses: A Systematic Review and Meta-analysis. Int J Oral Maxillofac Implants. 2014 Jan-Feb; 29(supplement):256-270.
  17. Schrott A, Riggi-Heiniger M, Maruo K, Gallucci GO. Implant loading protocols for partially edentulous patients with extended edentulous sites–a systematic review and meta-analysis. Int J Oral Maxillofac Implants. 2014;29 Suppl:239-55.
  18. Heinemann F, et al. Immediate occluding definitive partial fixed prosthesis versus non-occluding provisional restorations – 4-month post-loading results from a pragmatic multicenter randomised controlled trial.Eur J Oral Implantol. 2016 Spring;9(1):47-56.

Abstracts:

Topic: immediate provisionalization

Authors:Becker CM, Wilson TG Jr, Jensen OT

Title: Minimum criteria for immediate provisionalization of single-tooth dental implants in extraction sites: a 1-year retrospective study of 100 consecutive cases.

Source: J Oral Maxillofac Surg. 2011 Feb;69(2):491-
Type:Retrospective study

Keywords:

Purpose:Minimum criteria were used in the placement of 100 consecutive provisional restorations on single-tooth dental implants placed into extraction sites within 3 days of surgery.

Materials and Methods:

  • Provisional restorations were placed on 4.1- and 4.8-mm diameter standard ITI (Straumann, Waltham, MA) implants in the anterior mandible and maxilla in 100 treatment sites over a 3-year period.
  • Provisionals were placed despite low insertion torque values of 15 N-cm or 50 implant stability quotient using radiofrequency analysis. Minimum 3 mm of apical circumferential bone for implant fixation of implant 5.8 mm or longer, and Implant placement at least 1 mm inside facial plate.
  • Implants had final impressions for definitive restorations done 8 to 12 weeks after implant placement.
  • All patients were recalled 1 year after restoration and evaluated. Routine maintenance appointments continued over a 4- to 6-year follow-up period.

Results:

Eighty implants were placed in the anterior maxilla and 20 in the anterior mandible. The implants were standard platform 4.1- or 4.8-mm-diam- eter sandblasted acid-etched surface implants. All implants were placed in single tooth sites bordered by adjacent teeth

One implant was not osseointegrated. The remaining implants were judged successful at the 1-year recall appointment.

Conclusion:immediate provisional restoration can be done using even minimal quantitative criteria with implants placed at relatively low torque and ISQ val- ues simultaneous to dental extractions. However, cri- teria used for this study suggest that successful pro- visionalization must include primary stability and at least 3 mm of circumferential bone at the apex in an occlusally protected scheme.

Topic: Immediate loading


AuthorsGhoul WE, Chidiac JJ

Title:Prosthetic requirements for immediate implant loading: a review.

Source: J Prosthodont. 2012 Feb;21(2):141-54.

Type:Systematic review

Keywords: prosthetic considerations, Immediate loading

Purpose: The aim of this article is to review the current literature with regard to prosthetic considerations and their influence on the outcome of immediately loaded implants.

Method: A broad search of the published literature was performed using MEDLINE and PubMed to identify pertinent articles.

Results:One hundred fifty six references were selected. They were mainly descriptive, prospective, follow-up studies. They were reviewed and were categorized with respect to 6 factors that influence immediate loading:

1- Cross-arch stability and micromovements: Cross-arch stabilization by splinting (full arch) or by good interproximal contacts (single implant) provides the necessary stability to minimize micromotion and stimulate bone growth (osseointegration).

2. Interim prostheses: is fabricated with resin or metalframe- work is important for long-term success. It is an effective method to reduce deleterious mechanical stresses on immediately loaded implants.

3. Definitive restorations inserted immediately: It is advised to usea CAD/CAM system to predict the vital structures and the position of implants, with the possibility of slightly modifying the implant position and placement. The main advantage is to reduce the postoperative sequelae. It is a reliable procedure when a temporary prosthesis is used and later replaced by a definitive prosthesis after complete osseointegration.

4- Screw- or cement- retained prostheses: crew-retained restorations seem to have a superior out- come compared with the cement-retained restorations as it is easier to follow up during the healing period.

5-Occlusion: There is a general disagreement on when and how to provide occlusal contacts, but all authors agree to keep centric contacts only.

6-Number and distribution of implants in overdentures and fixed prostheses: The number of implants needed when restoring implant cases with fixed prostheses is greater than the number needed for overdentures. In general, at least four implants are needed in the anterior mandible to support a fixed prosthesis, and a greater number of implants are necessary in a maxilla with a good bone quality and high primary stability. The consensus is that micromovements should be controlled by splinting all the implants using a U-shaped bar. To achieve this goal, the distribution of the fixtures is important.

Conclusion:Immediate loading seems to be a relatively safe procedure. From the prosthodontic point of view, there are specific guidelines to follow.

Topic:Implant marginal bone loss
Authors: Suarez F, Chan HL, Monje A, Galindo-Moreno P, Wang HL.

Title:Effect of the timing of restoration on implant marginal bone loss: a systematic review.

Source:Periodontol. 2013 Feb;84(2):159-69.

Type:Review

Keywords:alveolar bone loss; dental implantation; dental implants; dental prosthesis design; dental prosethesis; implant-supported

Purpose:To compare the marginal bone loss (MBL) between implants that were restored with the following protocols: 1) immediate restoration/loading (IR/L); 2) early loading (EL); and 3) conventional (CL).

Methods:Electronic literature search (PubMed, Ovid, Cochrane Central) and a hand search in implant related journals were conducted. Inclusion criteria: clinical human studies in English that had reported a comparison of MBL bewtween implants with IR/L, EL, or CL with at least 12 month follow up. Also a minimum number of 10 implants for each group. Immediate placement and delayed placement were included and analyzed separately.

Results:11 studies (eight RCTs, two controlled clinical trials, and one retrospective study) qualified for the study and were split into four groups:

  1. IR/L + DP vs CL + DP (6 articles): A meta-analysis showed that the IR/L group had 0.09 mm less mean MBL but this was not significant.
  2. IR + DP versus EL + DP (2 articles): NSSD
  3. EL + DP versus CL + DP (1 article): NSSD
  4. IL + IP versus CL + IP (2 articles): NSSD

The RCTs showed a moderate to high risk of publication bias.

Conclusion:This study does not show that the timing of restorations affects MBL. The selection of restoration protocols should be based on factors other than MBL.

Topic:Immediate loading
Authors:Chrcanovic BR, Albrektsson T, Wennerberg A

Title: Immediate nonfunctional versus immediate functional loading and dental implant failure rates: a systematic review and meta-analysis

Source:J Dent. 2014 Sep;42(9):1052-9.

Type:Systematic Review

Keywords:Dental implants; Immediate loading; Nonfunctional loading; Functional loading; Implant failure rate; Marginal bone loss; Meta-analysis

Purpose:To compare the survival rate of dental implants submitted to Immediate Functional Loading (IFL) and Immediate Nonfunctional Loading (INFL) protocols, in order to test the hypothesis that the immediate full occlusal load would compromise or jeopardize the osseointegration process.

Method:An electronic search without time or language restrictions was undertaken in March 2014. Eligibility criteria included clinical human studies, either randomized or not. The exclusion criteria were case reports, technical reports, animal studies, in vitro studies, and reviews papers. The estimates of relative effect were expressed in risk ratio (RR) and mean difference (MD) in millimeters.

Results:1059 studies were identified and 11 studies were included, of which 7 were of high risk of bias, whereas four studies were of low risk of bias. The results showed that the procedure used (nonfunctional vs. functional) did not significantly affect the implant failure rates (P=0.70), with a RR of 0.87 (95% CI 0.44-1.75). The wide CI demonstrates uncertainty about the effect size. The analysis of postoperative infection was not possible due to lack of data. No apparent significant effects of non-occlusal loading on the marginal bone loss (MD 0.01mm, 95% CI -0.04-0.06; P=0.74) were observed.

Conclusion:The results of this study suggest that the differences in occlusal loading between INFL and IFL might not affect the survival of these dental implants and that there is no apparent significant effect on the marginal bone loss.

Topic:Immediate loading
Title: Clinical efficacy of immediate implant loading protocols compared to conventional loading depending on the type of the restoration: a systematic review.

Author: Sanz-Sánchez I,Sanz-Martín I,Figuero E,Sanz M.

Source: Clin Oral Implants Res.2015 Aug;26(8):964-82.

Type:Case series/discussion article

Keywords:immediate loading, delayed loading, implants

Purpose:The aim of this systematic review was to assess whether immediate loading protocols achieve comparable clinical outcomes when compared to conventional loading protocols depending on the type of prosthetic restoration.

Methods and Materials:A protocol was developed aimed to answer the following focused question: “What are the effects of immediate implant loading protocols compared to conventional implant loading, in terms of implant failure, marginal bone levels, and biological and mechanical complications based on the type of restoration?” The next sub-analysis were performed as follows: the extent, type, and material of the restoration and the type of occlusal contact in function. This systematic review only included randomized controlled trials (RCTs) with a follow-up of at least 6 months after implant loading.

Results:Thirty-seven final papers were included. The results from the meta-analyses have shown that the immediately loading implants demonstrated a statistically significant higher risk of implant failure [P = 0.036, a statistically significant lower bone loss [P = 0.000] and a smaller increase in ISQ values [P < 0.001, although both groups attained high survival rates (98.2% in the test and 99.6% in the control). Single teeth implants were greater risk of failure, when compared to immediately loaded full arch restorations, so as the occlusal pattern when compared to non-occlusal.

Conclusions:Immediate loading may impose a greater risk for implant failure when compared to conventional loading, although the survival rates were high for both groups.

Topic:Functional and Non Functional Loading
Authors: Esposito M, Grusovin MG, Maghaireh H, Worthington HV.

Title: Interventions for replacing missing teeth: different times for loading dental implants. Source: Cochrane Database Syst Rev. 2013 Mar 28;3:CD003878.

Type:Retrospective study

Keywords: randomized controlled trial, root form osseointegrated dental implants, immediate occlusal loading, non occlusal loading.

Background:To minimize the risk of implant failures after their placement, dental implants are kept load-free for 3 to 8 months to establish osseointegration (conventional loading). It would be beneficial if the healing period could be shortened without jeopardizing implant success. Nowadays implants are loaded early and even immediately and it would be useful to know whether there is a difference in success rates between immediately and early loaded implants compared with conventionally loaded implants.

Purpose:To evaluate the effects of (1) immediate (within 1 week), early (between 1 week and 2 months), and conventional (after 2 months) loading of osseointegrated implants; (2) immediate occlusal versus non-occlusal loading and early occlusal versus non-occlusal loading; (3) direct loading versus progressive loading immediately, early and conventionally.

Methods: The following electronic databases were searched: Cochrane Oral Health Group’s Trials Register (to 8 June 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2012, Issue 4), MEDLINE via OVID (1946 to 8 June 2012) and EMBASE via OVID (1980 to 8 June 2012). Authors of identified trials were contacted to find unpublished randomized controlled trials (RCTs). There were no restrictions regarding language or date of publication.

All RCTs of root-form osseointegrated dental implants, having a follow-up of 4 months to 1 year, comparing the same implant type immediately, early or conventionally loaded, occlusally or non-occlusally loaded, or progressively loaded or not. Outcome measures were: prosthesis and implant failures and radiographic marginal bone level changes.

Data were independently extracted, in duplicate, by at least two review authors. Trial authors were contacted for missing information. Risk of bias was assessed for each trial by at least two review authors, and data were extracted independently, and in duplicate. Results were combined using fixed-effect models with mean differences (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI). A summary of findings table of the main findings was constructed.

Results:Forty-five RCTs were identified and, from these, 26 trials including a total of 1217 participants and 2120 implants were included. In nine of the included studies there were no prosthetic failures within the first year, with no implant failures in 7 studies and the mean rate of implant failure in all 26 trials was a low 2.5%. From 15 RCTs comparing immediate with conventional loading there was no evidence of a difference in either prosthesis failure (RR 1.87; 95% CI 0.70 to 5.01; 8 trials) or implant failure (RR 1.65; 95% CI 0.68 to 3.98; 10 trials) in the first year, but there is some evidence of a small reduction in bone loss favoring immediate loading (MD -0.10 mm; 95% CI -0.20 to -0.01; P = 0.03; 9 trials), with some heterogeneity (Tau² = 0.01; Chi² = 14.37, df = 8 (P = 0.07); I² = 44%). However, this very small difference may not be clinically important. From three RCTs which compared early loading with conventional loading, there is insufficient evidence to determine whether or not there is a clinically important difference in prosthesis failure, implant failure or bone loss. Six RCTs compared immediate and early loading and found insufficient evidence to determine whether or not there is a clinically important difference in prosthesis failure, implant failure or bone loss. From the two trials which, compared occlusal loading with non-occlusal loading there is insufficient evidence to determine whether there is a clinically important difference in the outcomes of prosthesis failure, implant failure or bone loss.

Conclusion:Overall there was no convincing evidence of a clinically important difference in prosthesis failure, implant failure, or bone loss associated with different loading times of implants. More well-designed RCTs are needed and should be reported according to the CONSORT guidelines.

Topic:implant stability of immediate loaded implants
Authors:Atieh MA, Alsabeeha NH, Payne AG, et al.

Title:The prognostic accuracy of resonance frequency analysis in predicting failure risk of immediately restored implants.

Source:Clin Oral Implants Res. 2014 Jan;25(1):29-35. doi: 10.1111/clr.12057

Type:clinical

Keywords:dental implants, prognosis, ROC curve, sensitivity and specificity.

Purpose: to evaluate the prognostic accuracy of ISQ measurements recorded at implant placement and 8-week post-op, and to determine the optimal threshold value for predicting failure risk of immediately restored/loaded implants.

Methods: on twenty-eight patients, twenty-eight 8 or 9 mm diameter implants were placed in either a fresh molar extraction socket (immediate) or a healed site (delayed) in posterior mandible. The implant stability quotients (ISQs) was measured at implant placement surgery, 8 weeks and 1 year post-op. Acrylic provisional crown was placed out of occlusion within 48 hours. At 8 weeks, the provisional crown was replaced with permanent screw-retained zirconia-ceramic crown. ISQ Receiver operating characteristic (ROC) analysis was used to identify the optimal cut-off level. Sensitivity and specificity were also determined at the selected cut-off value.

Results:Overall implant survival rate after 1 year was 78.6%. Out of the six failed implants: four implants lost their osseointegration within the first 3 months, and the remaining two implants were lost by the end of the 1-year observation period. All the failed implants exhibited signs of mobility without inflammatory signs apart from the one lost after 1 year, which showed tenderness, mobility and signs of peri-implant mucositis. The 1-year implant survival rates for the immediate implants was 71.4% and for delayed placement was 85.7%.The optimum cut-off value for detecting implant stability was 60.5 ISQmeasured at 8 weeks, with sensitivity of 95.2% and specificity of 71.4%. The implant stability measurements after 8 weeks showed a better accuracy in predicting implants that were at risk of failure than those taken at the time of implant placement.

Conclusion:The results show that the RFA measurements (ISQs) taken at the time of surgery were not a significant predictor of the failure riskof immediately restored/loaded single implants in the posterior mandible. In contrast, the RFA measurements at 8 weeks were more effective in detecting the implant failure risk.

Topic:Loading protocols
Author:Barewal RM, Stanford C, Weesner TC

Title:A randomized controlled clinical trial comparing the effects of three loading protocols on dental implant stability.

Source:Int J Oral Maxillofac Implants. 2012 Jul-Aug;27(4):945-56.

Type:Randomized controlled clinical trial

Keywords:dental implants; immediate loading; implant stability; randomized controlled clinical trial; resonance frequency analysis; single-tooth replacement

Background: ISQ measures the axial stability of the implant. Insertion Torque Value (ITV) measures the rotational stability of the implant. ITV is a numeric value given to the peak insertion torque reached by the surgical motor during placement. ITV is a more objective, quantifiable assessment of bone density.

Purpose:The purpose of this RCT was to compare the stability of dental implants placed under three different loading regimens during the first 16 weeks of healing following dental implant placement.

Methods: 40 patients (15m, 25f) between the ages of 20 and 82 years old requiring a single implant in the maxilla or mandible were assessed. The insertion torque value (ITV) was the primary determinant of load assignment. Group A=Immediate loading group: ITV >20 Ncm; Group B=Early loading (6wks)=10<ITV<20 Ncm; Group C=Conventional/delayed loading (12 weeks). Resonance Frequency Analysis (RFA) was assessed every 2 weeks for the first 16 weeks, and then at 1,2, and 3 years. Crestal bone height was assessed radiographically at baseline, at 16 weeks, 1, 2, and 3 years (standardized system with bite blocks).

Results:Of the 40 implants placed, one implant was lost in type 4 bone (ITV, 8.1 Ncm) in the delayed group. The cumulative survival rate over the 3-year period for the implants was 97.5%. All implants, when classified by bone and loading type, increased in stability over time, with a minor reduction of 1.3 ISQ units seen at 4 weeks in the immediate loading group. The mean marginal bone loss over 3 years was 0.22mm. The mean ITVs at implant placement for bone types 1 and 2 (grouped together), 3 and 4 were 32, 17 and 10 respectively, and were SS.

Discussion: ITV was a good objective measure of bone type. Using an ITV of 20 Ncm as the determinant for immediate loadingand an ITV of 10 Ncm or greater as a determinant for early loadingprovided long-term success for implants, with no negative changes in tissue response. All bone type groups and loading groups showed no reduction in stability during the first 4 months of healing.

Topic:Immediate implant loading
Authors: Pozzi A, Mura P

Title:Immediate Loading of Conical Connection Implants: Up-to-2-Year Retrospective Clinical and Radiologic Study

Source: Int J Oral Maxillofac Implants. 2016 Jan-Feb;31(1):142-52. doi: 10.11607/jomi.4061

Type:Retrospective study

Keywords:conical connection, dental implant, immediate loading, platform switching, postextraction

Purpose:To report the clinical and radiologic outcomes of patients treated with a rough oxidized tapered-body implant, with an internal conical connection and built-in platform shifting placed according to immediate loading protocol.

Methods:64 patients were treated with a total of 148 novel tapered body implants with internal conical connections, built in platform shifting, and moderately rough oxidized surfaces were used in this study. Some implants were immediate, post extraction (67 out of 148). Prophylactic antibiotics were administered prior to surgery, as well as chlorhexidine rinse. Implants were placed using a flapless or miniflap approach. Implants were places with an insertion torque of at least 45 Ncm. Provisional or definitive abutments were fixed after implant placement and tightened to 30 Ncm. Light occlusion was used. Periapical radiographs were obtained at the time of surgery and then annually with a positioning jig.

Results:One postextractive, immediately loaded, maxillary implant failed during healing, resulting in a success rate of 99.3%. BOP was detected around 12 implants at follow up. Mean marginal bone loss was 0.71 mm at the 2 year follow up.

Conclusion:The Nobel-Replace Conical Connection implant system, immediately loaded and followed up to 2 years, demonstrated good treatment outcomes with regard to implant and prosthetic survival rate, marginal bone levels, and soft tissue conditions in both postextraction and healed sites.

Topic:Immediate Loading of Post extraction Implants
Authors:Del Fabbro et al.
Title:Immediate Loading of Postextraction Implants in the Esthetic Area: Systematic Review of the Literature

Source: Clin Implant Dent Relat Res. 2013 Apr 22. doi: 10.1111/cid.12074.

Type:Systematic Review

Keywords:dental implants, immediate implants, immediate loading, postextraction socket, systematic review

Purpose:To estimate the survival rate of implants placed in fresh extraction sockets and immediately restored, after at least 1 year of function. Secondary purpose was to compare the clinical outcomes of such protocol with those of standard protocols such as delayed placement in healed ridges and delayed loading, and to assess the influence of various confounding factors on the survival rate of implants immediately placed and restored.

Method:an electronic search was conducted on MEDLINE, EMBASE, and CENTRAL databases to find studies published from 1990 to October 2012. Search terms used were “dental implants,” “extraction socket*,” “immediate implant*,” “immediate loading,” “immediate restoration*,” “immediate placement*,” “immediate installation*,” and “fresh extraction socket*” alone or combined with the Boolean operator “AND”. Also, a hand search of issues from 1995 to October 2012 in the following journals: Clinical Implant Dentistry and Related Research, Clinical Oral Implants Research, Implant Dentistry, European Journal of Oral Implantology, International Journal of Oral and Maxillofacial Implants, International Journal of Periodontics and Restorative Dentistry, Journal of Clinical Periodontology, Journal of Periodontology, and Journal of Prosthetic Dentistry. Inclusion Criteria are:
1. RCT, CCT, case-control studies, and prospective case series.
2. At least 10 patients (older than 18 years) treated immediately placed and loaded (within 48 hours of surgery).
3. At least 1 year of follow up after implant placement.
4. Immediate implants placed in the aesthetic zone (anterior maxilla) and studies presenting success and survival data of immediate implants.

Results: Seven randomized trials, three controlled trials, and 35 case series were included, accounting for 1170 patients and 1974 postextraction implants immediately restored. Twenty‐eight studies had a low risk of bias. The overall 1‐year IS was 97.6%. All failures occurred within 1 year of function. Meta‐analysis showed a significant better outcome for implants placed in healed ridge (IS = 99.4%) as compared with postextraction implants (IS = 95.6%). No other parameter had a significant effect on clinical outcomes. Most variables, among which the esthetic aspect, could not be assessed as they were not systematically reported.
Discussion:

  1. Type of incision did not affect implant survival.
  2. No significant difference in clinical outcome in relation to the graft type, and neither between grafted cases and cases without grafts.
  3. Presence of infection did not affect implant survival.
  4. Cases restored in centric occlusion displayed significant better results than cases restored without occlusion.
  5. Meta-analysis showed that survival rate of immediately loaded implants in fresh post-extraction sockets is excellent; however, it is inferior implants placed in healed ridges.
  6. The confounding factors could not be evaluated because they were not systematically reported in the included studies.
  7. Conclusion:Based on a sample of nearly 2000 implants, the mean survival rate of immediately placed and restored implants in extraction sites in the aesthetic region is 97.6%; however, the meta-analysis showed that the outcome of immediate implants resulted inferior to that of implants placed in healed ridges. Also, due to the wide range of survival rates observed in this systematic review (78.6%-100%), generalization from the results of the included trials to clinical practice should be made with extreme caution.

Topic:Immediate Provisionalization


Authors:Mijiritsky E, Mardinger O, Mazor Z, Chaushu G.

Title:Immediate Provisionalization of single-tooth implants in fresh extraction sites at the maxillary esthetic zone: Up to 6 years of follow-up

Source:Implant Dentistry 2009.18(4): 326-333.

Type:Clinical Report

Keywords:immediate provisionalization, immediate implantation, anterior maxilla, nonfunctional immediate loading, single implant.

Purpose:Evaluate the long term survival of single-tooth implants immediately placed in fresh extraction sites at the anterior maxilla with immediate infraocclusion-provisional restorations and nonfunctional immediately loading.

Materials and methods:

A total of 16 patients (7 females and 9 males), ages from 23 to 62 years. Patients included required extraction of a single tooth in the maxillary esthetic zone. All patients were given amoxicillin 1 hour before surgery. Gentle elevation of the tooth root, flaps avoided. Atraumatic extraction and titanium implants were placed with diameters of 3.3 to 5.5 and length from 13 to 16 mm. The platform was set 1.5 to 2 mm below the level of the interseptal bone, and respected the space of 1.5 to 2mm space between adjacent tooth and implant. Implants were positioned palatally and autogenous bone graft obtained from the drill was used to fill space discrepancies of spaces greater than 2mm.

If insertion torque values were 32 N cm greater, they were included in the study. After placement, they were connected to a prefabricated plastic provisional abutment. Fixed provisional restorations cemented to the abutments. Occlusal contacts were avoided. Patients were asked to eat soft food for one month, examined once a week for 3 weeks and then once a month for 6 months. Examiner measured the radiographs to evaluate marginal bone loss.

Results:One implant failed one month after placement due to unscrewing of a temporary abutment that resulted in implant overload. Overall implant survival rate resulted in 95.8%. The mean marginal bone loss increased by 0.9 1mm, starting from implant placement.

Discussion: The soft tissue reaction was described as very favorable due to the provisional crown in the healing phase and preservation of papilla. This provisional should not be removed to prevent jeopardizing osseointegration.The marginal bone loss was of the same magnitude as with conventional approach. Occlusal loads should be eliminated and use of a occlusal splint for 6 to 8 weeks day and night to prevent loading. This technique seems to be beneficial in many ways; there is no need for second stage surgery, and need for transitional removable dentures was avoided.

Conclusion:Nonfunctional immediate loading of single-tooth implants in fresh extraction sites at the anterior maxilla can result in successful implant integration and stable periimplant conditions.

Topic:Immediate loading
Author:Anitua E, et al.

Title: Long-Term Outcomes of Immediate Implant Placement Into Infected Sockets in Association With Immediate Loading: A Retrospective Cohort Study

Source:J Periodontol.2016 May 13:1-15.

Type:Retrospective Cohort study

Keywords:Dental implants; immediate dental implant loading; infection; tooth extraction; tooth loss.

Background:There is a paucity of studies examining long-term outcomes of immediate loading of dental implants immediately placed into infected sites.

Purpose:This study aims to evaluate long-term outcomes of immediate loading of postextraction implants placed in infected sites.

Methods:Patients were selected if they had postextraction implants in the anterior maxilla that were inserted in the period from December 2006 to June 2015 and immediately loaded. Information collected about patients included: 1) demographic data; 2) implant details; 3) soft tissue stability; 4) prosthodontics data. Marginal bone loss (BL) and implant and prosthesis survival rates were calculated. Recommended insertion torque ranges between 30 and 45 Ncm for a single-unit prosthesis and a minimum of 20 Ncm for multiple prosthses.

Results:Thirty patients (mean age: 56 years) had 43 implants immediately inserted into infected sites and immediately loaded. Implants were inserted at torque >35 Ncm. Mean follow-up time was 6 years (range: 1 to 8 years), and 65% of implants had a follow-up time >5 years. No implant failure occurred, and implant success rate was 93%. Proximal BL was 1.42mm (range: 0.21 to 5.61mm0. Three prosthetic complications (all fracture of veneer material) occurred.

Conclusion:Immediate loading of implants inserted into fresh and infected extraction sockets is not a risk factor for implant survival. However, stability of peri-implant soft and hard tissues indicates the need to take measures that minimize loss. Use of PRGF and placement of dental implants were evaluated for treatment of extraction sockets in the anterior maxilla.

Topic: Immediate Occlusal versus Non-Occlusal Loading
Authors:Vogl S, Stopper M, Hof M, et al

Title: Immediate Occlusal versus Non-Occlusal Loading of Implants: A Randomized Clinical Pilot Study.

Source: Clin Implant Dent Relat Res. 2013Sep 30. [Epub ahead of print]
Type: A Randomized Clinical Pilot Study.

Keywords: computer-assisted, immediate loading, marginal bone loss, surgical guides, survival rate

Purpose:This study was performed to compare clinical outcomes of immediate occlusal versus non-occlusal loading of posterior implants.

Materials and Methods:

  • N=19 patients with 52 screw-type implants replacing mandibular molars or premolars
    • 9 patients with 21 implants were randomized to a study group that received immediate restorations with occlusal loading
    • 10 patients with 31 implants were randomized to a control group that received provisional restorations without occlusal loading.
  • Occlusal loading was defined as full loading in maximum intercuspidation.
  • Single-tooth or splinted multiunit restorations were incorporated by screw retention or cementation. Marginal bone defects (MBD) were evlautated by obtaining digital perpendicular longcone radiographs at baseline, 1, 2, 3, 6, and 12 months. Implant survival, and implant success were evaluated 12 months after insertion.

Results:Both groups revealed similar MBD levels consistent with previous reports. No implants were lost (overall survival: 100%) or found to fail (overall success: 100%). No significant intergroup

differences were noted for any of the evaluated parameters.

Conclusions:

No clinically relevant differences in radiographic 12-month results were observed between functionally loaded and nonloaded immediate restorations in partially edentulous posterior mandibles. Both types of restorations yielded 100% success and survival rates over observation periods of 12 months and can therefore be considered a viable treatment concept in selected patients.

Larger long-term prospective studies are needed to confirm the final evidence and predictability of immediate functional loading as a standard treatment concept for partially edentulous jaws.

Topic:Immediate Loading
AuthorsBenic GI, Mir-Mari J, Hammerle CHF,

Title:Loading Protocols for Single-Implant Crowns: A Systematic Review and Meta-analysis.

Source: Int J Oral Maxillofac Implants. 2014 Jan-Feb; 29(supplement):222-238.

Type: Systematic Review and Meta-analysis

Keywords: Loading

Purpose: To test whether or not immediate loading of single-implant crowns renders different results from early and conventional loading with respect to implant survival, marginal bone loss, stability of peri-implant soft tissue, esthetics, and patient satisfaction.

Method: An electronic search of Medline and Embase databases including studies published prior to August 1, 2012, was performed and complemented by a manual search. Randomized controlled trials (RCTs) comparing different loading protocols of single- implant crowns with a follow-up after restoration of at least 1 year were included. A meta-analysis yielded odds ratios (OR) and standardized mean differences (SMD) together with the corresponding 95% confidence intervals (95% CI).

Results:

The search provided 10 RCTs comparing immediate and conventional loading and 1 RCT comparing immediate and early loading.

Implant survival at 1 year of loading: the meta-analysis of 10 studies found NSSDbetween immediate and conventional.

Marginal bone loss during the first year of function: between immediate and conventional loading protocols in 7 was NSSD

Implant survival and marginal bone loss at 2, 3, and 5 years of loading: NSSDbetween immediate and conventional loading

Change of papilla level between immediate and conventional loading: Three RCTs identified NSSD.

Recession of the buccal mucosa after implant placement: One study found significantly inferior soft tissue loss for immediate loading as compared to conventional loading. Two RCTs investigated the recession of the buccal mucosa after insertion of the definitive crown and found NSSD between immediate and conventional loading.

Esthetics and the patient satisfaction: were assessed in one and two RCTs, respectively. There were NSSDbetween immediate and conventional loading.

Conclusion:Immediately and conventionally loaded single-implant crowns are equally successful regarding implant survival and marginal bone loss. This conclusion is primarily derived from studies evaluating implants inserted with a torque ≥ 20 to 45 Ncm or an implant stability quotient (ISQ) ≥ 60 to 65 and with no need for simultaneous bone augmentation. Immediately and conventionally loaded implants do not appear to differently affect the papilla height during the first year of loading. Due to the heterogeneity of the time point of baseline measurements and contradictory findings in the studies, it is difficult to draw clear conclusions regarding the recession of the buccal mucosa. With respect to the assessment of esthetic outcomes and patient satisfaction, the data available remain inconclusive.

Topic:Immediately restored anterior maxilla implants
Authors: Kolerman R, et al.

Title:Radiological and Biological Assessment of Immediately Restored Anterior Maxillary Implants Combined with GBR and Free Connective Tissue Graft.

Source:Clin Implant Dent Relat Res.2016 Mar 20. doi: 10.1111/cid.12417

Type:Retrospective study

Keywords:biologic complications, connective tissue, immediate loading, radiographic data, single-tooth implants

Purpose:To assess immediately restored implants combined with guided bone regeneration (GBR) and connective tissue graft.

Methods:34 patients with maxillary immediately restored anterior single implants were included in this study with follow up ranging from 1-4 years. Patient’s alveolar process had to have at least 5 mm of bone apical to the alveolus of the failing tooth to ensure initial implant stability. 32Ncm insertion torque. FDBA was applied to the gap between the implant and buccal bone and a resorbable collagen membrane was placed over this. A CTG was harvested from the palate and placed over the membrane. An abutment was placed and a non-functional acrylic temporary was seated. 6 months later a permanent restoration was fabricated. Patients were assessed for soft tissue dimensions, radiographic bone loss, and biological and prosthetic complications.

Results:Mean follow up was 29 months. Mean mesial and distal bone loss was similar (1.10 mm vs 1.19 mm). Periimplant PD was significantly greater for the implant vs the contralateral tooth (3.49 mm vs 2.35 mm). BOP was present in 29.4% at implant sites vs the contralateral tooth 10.4% (P<0.001.

Conclusion: Using GBR and CTG for anterior maxillary single-tooth replacement (immediate implant placement and non-functional loading) achieves favorable peri-implant soft tissue condition.

Topic:Functional and Non-functional loading
Authors:Papaspyridakos P, Chen CJ, Chuang SK, Weber HP.

Title: Implant Loading Protocols for Edentulous Patients with Fixed Prostheses: A Systematic Review and Meta-analysis.

Source:Int J Oral Maxillofac Implants. 2014;29 Suppl:239-55.

Type:Systematic Review

Keywords:dental implants, edentulous patients, fixed prosthesis, immediate loading, loading protocols

Purpose:To report on the effect of immediate implant loading with fixed prostheses compared to early and conventional loading on implant and prosthesis survival, failure, and complications.

Method:An electronic and manual search was conducted to identify randomized controlled clinical trials (RCTs) as well as prospective and retrospective studies involving rough surface implants and implant fixed complete dental prostheses for edentulous patients.

• Immediate loading: A prosthesis is connected to the dental implants within 1 week following implant placement.

• Early loading: A prosthesis is connected to the dental implants between 1 week and 2 months following implant placement.

• Conventional loading: Dental implants are allowed to heal for a period greater than 2 months after implant placement without connection of prosthesis.

Results:The 62 studies that fulfilled the inclusion criteria featured 4 RCTs, 2 prospective case-control studies, 34 prospective cohort studies, and 22 retrospective cohort studies. These studies yielded data from 2,695 patients (2,757 edentulous arches) with 13,653 implants. Studies were grouped according to the loading protocol applied; 45 studies reported on immediate loading, 8 on early loading, and 11 on conventional loading. For the immediate loading protocol with flap surgery, the implant and prosthesis survival rates ranged from 90.1% to 100% and 93.75% to 100%, respectively (range of follow-up, 1 to 10 years). When immediate loading was combined with guided flapless implant placement, the implant survival rates ranged from 90% to 99.4%. For the early loading protocol, the implant and prosthesis survival rates ranged from 94.74% to 100% and 93.75% to 100%, respectively (range of follow-up, 1 to 10 years). For the conventional loading protocol, the implant and prosthesis survival rates ranged from 94.95% to 100% and 87.5% to 100%, respectively (range of follow-up, 2 to 15 years). No difference was identified between maxilla and mandible.

Conclusion:When selecting cases carefully and using dental implants with a rough surface, immediate loading with fixed prostheses in edentulous patients results in similar implant and prosthesis survival and failure rates as early and conventional loading. For immediate loading, most of the studies recommended a minimal insertion torque of 30 Ncm. The estimated 1-year implant survival was above 99% with all three loading protocols. Caution is necessary when interpreting these results, as there are many confounding factors that affect treatment outcomes with each of the loading protocols.

Topic:Immediate loading
Title: Implant loading protocols for partially edentulous patients with extended edentulous sites–a systematic review and meta-analysis

Author:Schrott A, Riggi-Heiniger M, Maruo K, Gallucci GO.

Source:Int J Oral Maxillofac Implants. 2014;29 Suppl:239-

Type:Case series/discussion article

Keywords:immediate loading, delayed loading, implants

Purpose:The aim of this study was to systematically review the evidence for immediate implant loading in partially edentulous patients with extended edentulous sites and evaluate potential treatment modifiers.

Methods:An electronic search was performed in Medline, Embase, and Central to identify studies investigating the outcome of implants subjected to immediate loading (IL) (less than 1 week), early loading (EL) (1 week to 2 months), or conventional loading (CL) (more than 2 months) with implant-supported fixed dental prostheses (IFDPs) in partially edentulous patients with extended edentulous sites, ie, at least two adjacent teeth are missing. Only human studies with at least 10 cases and a minimum follow-up time of 12 months, reporting on solid-screw-type implants with rough surfaces and a diameter of at least 3 mm, were included. Weighted means of implant survival rates and risk ratios for implant survival at 1 year using meta-analytic tools were calculated to perform the following comparisons: IL vs EL, IL vs CL, and IL in the maxilla vs mandible. Non-comparative studies reporting on IL and EL protocols were summarized through descriptive methods.

Results:The search provided 3,872 titles, 837 abstracts, and 444 full-text articles. A total of 24 publications that comprised six comparative studies (five randomized controlled trials, one nonrandomized controlled trial) and 18 noncomparative studies were included for analysis. The comparison of weighted mean survival rates revealed no statistically significant difference between IL (97.9%) and EL (97.8%, P = .9405), and between IL (100%) and CL (99.3%, P = .3280). Meta-analysis showed no statistically significant difference in implant survival at 1 year between IL and EL (P = .502). A meta-analysis comparing IL and CL could not be performed due to the low number of failures. No statistically significant difference was found for IL implants placed in the maxilla vs the mandible (RR 1.55; 95% CI 0.49, 4.84; P > .05). Due to the small number of IL implants placed in the anterior, a comparison between implant survival in anterior vs posterior zones was not performed. Treatment modifiers were bone quality, primary stability, insertion torque, ISQ values, implant length, the need for substantial bone augmentation, the timing of implant placement, and the presence of parafunctional and smoking habits.

Conclusions:IL presents similar implant survival rates as EL or CL for partially edentulous patients with extended edentulous sites in the posterior zone, as long as strict inclusion/exclusion criteria are followed. There is a lack of evidence for IL of multiple implants in the anterior zone of partially edentulous patients. Preliminary evidence suggests that IL may be equally successful in either the maxilla or mandible. Further research is needed before IL in partially edentulous patients with extended edentulous sites can be recommended in everyday practice.

Topic:Functional and Non Functional Loading
Authors: Heinemann F, et al.

Title: Immediate occluding definitive partial fixed prosthesis versus non-occluding provisional restorations-4-month post-loading results from a pragmatic multicenter randomized controlled trial Source: Eur J Oral Implantol. 2016 Spring;9(1):47-56.

Type:Clinical study

Keywords:immediate loading, non occlusal loading, partial edentulism

Problem:To compare the clinical outcome of dental implants restored with definitive occluding partial fixed prostheses within 1 week, after implant placement with immediate non-occluding provisional restorations, which were to be replaced by definitive prostheses after 4 months.

Methods:Fifty partially edentulous patients treated with one to three dental implants, at least 8.5 mm long and 4.0 mm wide inserted with a torque of at least 35 Ncm, were randomized in two groups of 25 patients each, to be immediately loaded with partial fixed prostheses. Patients of one group received one definitive screw-retained metal-ceramic prosthesis in occlusion within 1 week after placement. Patients of the other group received one non-occluding provisional acrylic reinforced prosthesis within 24 h after implant placement. Provisional prostheses were replaced after 4 months by definitive ones. The follow-up for all patients was 4-months post-loading. Outcome measures were prosthesis and implant failures, any complications, peri-implant marginal bone level changes, aesthetic evaluation by a clinician, patient satisfaction, chair time and number of visits at the dental office from implant placement to delivery of definitive restorations.

Results:No patient dropped out. Two immediately occlusally loaded implants with their related definitive prostheses (8%) failed early (difference in proportions = 0.08; 95% CI: -0.03 to 0.19; P = 0.490). Four complications occurred in the occlusal group versus one in the non-occlusal group; (difference in proportions = 0.12; 95% CI: -0.04 to 0.28; P = 0.349). Four months after loading, patients subjected to non-occlusal loading lost an average of 0.72 mm of peri-implant bone versus 0.99 mm of patients restored with occluding definitive partial fixed prostheses. There were no statistically significant differences for marginal bone level changes between the two groups (mean difference = -0.27 mm; 95% CI: -0.84 to 0.30; P = 0.349). The differences for aesthetic scores showed no statistical significance (8.26 versus 7.58; P = 0.445); the same was seen for aesthetics evaluated by patients (Mann-Whitney U test: P = 0.618). Patients in the non-occlusal group were significantly more satisfied with the function of their implant-supported prostheses (Mann-Whitney U test: P = 0.039). Significantly less chair time (mean difference = -28.4 min; 95% CI: -48.82 to -7.99; P = 0.007) and the number of visits (mean difference = -1.88; 95% CI: -2.43 to -1.33; P < 0.001) were required for the immediate definitive prosthesis group.

Conclusion:This study did not provide a conclusive answer but may suggest that provisional prostheses non-occlusally immediately loaded may increase patient functional satisfaction, chair time and the number of visits, with respect to definitive prostheses immediately loaded in functional occlusion.