dental implant prosthetic restoration

1. GOOD MORNING

2. LOADING OF IMPLANTS
IMMEDIATE IMPLANT PLACEMENT IMMEDIATE
LOADING
IMMEDIATE IMPLANT PLACEMENT DELAYED
LOADING
PROGRESSIVE BONE LOADING

3. IMMEDIATE
IMPLANT
PLACEMENT

4. DEFINITIONS
Immediate Loading : Placing full
occlusal/incisal loading upon a dental implant.
Axial Loading : The force directed down the
long axis of a body. Usually used to describe
the force of occlusal contact upon a natural
tooth, dental implant or other object, “axial
loading” is best described as “the force down
the long axis of the tooth” or whatever body is
being described. (As per GPT- 8)

5. Implant Prosthodontics: The phase of
prosthodontics concerning the replacement of
missing teeth and/or associated structures by
restorations that are attached to dental
implants. (As per GPT- 8)
Implant System: Dental implant components
that are designed to mate together. An implant
system can represent a specific concept,
inventor, or patent. It consists of the necessary
parts and instruments to complete the implant
body placement and abutment components
body and abutment.

6. Implantology: A term historically conceived
as the study or science of placing and restoring
dental implants. (As per GPT- 8)
Implant Surgery : The phase of implant
dentistry concerning the selection, planning,
and placement of the implant. (As per GPT- 8)
Progressive Loading : The gradual increase
in the application of force on a dental implant
whether intentionally done with a prosthesis or
unintentionally via forces placed by adjacent
anatomic structures or para functional loading.
(As per GPT- 8)

7. CONTENTS
1. INTRODUCTION
2. HISTORY
3. DIFFERENT APPROACHES TO IMPLANT INSERTION
4. ADVANTAGES, INDICATONS AND
CONTRAINDICATIONS OF IMMEDIATE IMPLANT
PLACEMENT
5. GUIDELINES FOR EXTRACTION IN
IMMEDIATE IMPLANT PLACEMENT
6. IMPLANT PLACEMENT

8. INTRODUCTION
An alternative to the complete removable
denture is the use of endosseous implants as
support for a fixed prosthesis. Branemark and
colleagues proposed the concept of
osseointegration over 37 years ago, but total
acceptance of implant based therapy has been
hampered by the cost of treatment and limited
access to professional care. But one of the
biggest drawbacks to implant therapy has been
the length of time required by traditional
placement protocols.

9. A 3 to 14 month treatment sequence is
commonplace, often including multiple
surgeries. Patients undertaking such therapy
have to resign themselves to enduring
significant inconvenience and discomfort before
they can begin to enjoy an amelioration of their
appearance, speech, masticatory function and
self-confidence.
Immediate placement of dental implants
protocol is gaining great popularity throughout
the world among both professionals and
patients, interested in reducing, or even
eliminating the waiting period for implant
supported fixed teeth.

10. HISTORY
The modern era of dental implant therapy
began with the May 1982 Toronto Conference
on Osseointegration in Clinical Dentistry. The
conference show cased Professor Per Ingvar
Branemark and the concept of
osseointegration. It was organized by George
Zarb and supported financially by the Ontario
Ministry of Health and the University of
Toronto.

11. At this conference, educational leaders from
North American dental schools in the specialties
of oral and maxillofacial surgery and
prosthodontics were exposed to the scientific
background of osseointegration and to the
clinical success that had been achieved in
Sweden and in early clinical trials in Toronto.
The conference was a watershed event in
prosthodontics.

12. The early investigations of Branemark that
eventually led to the dental application of
osseointegration focused on wound healing and
rheology in bone and soft tissue. The use of
titanium implants (referred to as "fixtures" by
Branemark) to support dental prostheses was
first described in a study on dogs. The first
human patient received implants in
Branemark's Gothenburg clinic in 1965. For the
next decade, the application of
osseointegration as a foundation for dental
prostheses was carefully documented and
reported.

13. The 1970’s saw the accumulation of sufficient
data relative to the predictability of
osseointegration to move it from experimental
to routine clinical use in European centers. The
University of Toronto was the first North
American center to use osseointegrated dental
implants in clinical trials. The replication of
Swedish success in Toronto led to the 1982
Toronto conference and, shortly thereafter, to
the widespread use of osseointegrated dental
implants.

14. DIFFERENT APPROACHES TO IMPLANT
PLACEMENT
IMMEDIATE IMPLANT PLACEMENT
DELAYED IMPLANT PLACEMENT
STAGED IMPLANT PLACEMENT
ONE STAGE IMPLANT PLACEMENT

15. IMMEDIATE IMPLANT PLACEMENT

16. IMMEDIATE IMPLANT PLACEMENT

17. Gore tex
membrane
fixed to
implant
Connective
tissue graft
placed over the
membrane and
immobilised
with sutures

18. DELAYED IMPLANT PLACEMENT

19. After several
weeks gingival
margin will
cover the socket
gap

20. DELAYED IMPLANT PLACEMENT

21. STAGED IMPLANT PLACEMENT

22. STAGED IMPLANT PLACEMENT
(SOCKET SEAL SURGERY)

23. ONE STAGE IMPLANT PLACEMENT

25. ADVANTAGES OF IMMEDIATE
IMPLANT PLACEMENT
Prevents atrophy alveolar ridges, gingival and
mucosal tissues after the removal of teeth.
Can be placed in the same position as the
extracted teeth.
Minimizes the need for severely angled
abutments

27. Can position the implant more favorably than
the original tooth by redirecting the burs when
preparing the implant receptor site.
With the extraction socket as a guide, the
surgeon can also more easily determine the
appropriate parallelism and alignment relative
to the opposing and adjacent residual dentition
and to adjacent implants when there are
multiple extractions and implants.

28. Improved final function and aesthetics typically
result.
Significantly shorten the overall treatment time
and the interval during which the patient must
live in a transitional state with or without teeth.
Consequently. more patients accept treatment
and also increase the overall cost effectiveness
of cases.

29. INDICATIONS OF IMMEDIATE
IMPLANT PLACEMENT
Failed endodontically treated teeth
Teeth with advanced periodontal disease
Root fractures
Advanced caries beneath the gingival margin

30. CONTRAINDICATIONS OF IMMEDIATE
IMPLANT PLACEMENT
Teeth with suppuration
Teeth with large periapical infection

31. There are five determining factors identified to be
prerequisites for positive treatment outcomes in
the immediate placement of implants:
1. Preservation of the bony margins of the
alveolus during extraction.
2. Precise preparation of an implant bed in the
apical portion or along the walls of the socket.
3. Tight circumferential adaptation of a barrier
membrane as a collar around the neck of the
implant extending over the borders of the
alveolus by 3 – 4 mm.

32. 4. Careful management of the soft tissue flap and
close flap adaptation to the neck of the
implant.
5. Meticulous plaque control for the entire healing
period of approximately 6 months.

33. GUIDELINES FOR EXTRACTION
WHEN PLANNING FOR IMMEDIATE
IMPLANT PLACEMENT
The following guidelines for extractions are
provided when planning for immediate
placement of implants:
Preoperative evaluation
Antibiotic therapy initiation
Preservation of the bony receptor site

34. Procedural delays
Avoidance of excessive pressure
Osteotomy preparation
Improvements for placement
Bone grafts
Soft tissues closure

36. Successful osseointegration
IMPLANT PLACEMENT : An implant can
be placed immediately if any one of the
conditions exist at the extraction site
1. Bone is type I or II
2. Site can accommodate an implant with a
length of atleast 13 mm.
3. Once placed, the implant can be completely
protected from function and occlusal forces.

37. TAPERED IMPLANTS
Tapered anatomically shaped implants are the
implants of choice for this indication.
More closely mimic the shape of natural tooth
roots – wider at the cervix than at the apex.
Implant Diameter – 3.5mm, 4.3mm, 5.0mm,
and 6.0mm.

38. Implant Length - 10mm, 13mm, and 16 mm.
Implant Surface – acid etched titanium,
hydroxyapatite(HA) coated,
TPS – coated

39. ADVANTAGES OF THE TAPERED
IMPLANTS
Larger cervical diameter provides better buccal
support and helps preserve the root
prominence.
Larger cervical diameter also improves the
implant to bone interface.
Tapered design may obviate the need to use
grafting materials or membranes.

40. Allows implant to be placed in the same
position as the extracted teeth and avoids
buccal or labial wall perforation.
Since the position of implant is similar to the
extracted tooth, restoration is placed in more
favourable position in relation to the opposing
arch thus reducing the excessive off axis
loading
Can be used in cases of tooth with convergent
roots

41. By using a straight or maximum 15 degree
angled abutment for fixed prosthesis, the
occlusal table will have more acceptable
buccolingual dimension.

42. TAPERED OSTEOTOMES

43. TAPERED OSTEOTOMES
Advantages :
In areas of soft( type III or type IV) bone can
create a denser bony interface for the implant.
Generate no heat
Allow for better visibility than drills in posterior
maxilla
Offer the user greater tactile sensation

44. Indications :
When bone at the extraction site is type III or
type IV and the use of burs for the preparation
of the impalnt receptor site is deterimental.
When the apical cortical socket of a molar or
premolar abuts the floor of maxillary sinus .

45. BONE COMPACTION
2 mm pilot drill is used to achieve a purchase
point and to ensure proper alignment at the
osseous receptor site.
An appropriate osteotome is selected which is
then placed into the sulcus , pushed and
rotated to the desired depth.
Depending on the bone density a mallet may
be used, more porous the bone more easily the
osteotome is inserted.

46. Increasingly larger osteotomes are then used to
enlarge the socket until it will accommodate the
implant selected for the site.
In posterior maxilla wider the bone less dense
it usually is.
In some osteotomy site areas of increased
bone density may be encountered as the sinus
floor approaches( e.g. cortical crestal areas,
apical portion of the osteotomy). In these cases
conventional hand piece drilling may be used
with the osteotome compaction technique.

50. DRILL METHOD
Basic Considerations of Osteotomy Drilling
Following tooth removal, inspect the crest of
the remaining bone, especially labially. Its
height should be within 5 mm of that of the
adjacent bone on either side. If it is greater
than 5 mm, the chance of a harmonious
esthetic result is diminished.

51. Inspect the socket and preoperative
radiograph to fix in mind the amount and
variation of available bone mesial and distal to
socket.
Clinically evaluate the labial extent of the
opening, which is most often closer to ideal
than that found in healed ridges that have
undergone some resorption.

52. Twist Drill Pathway :
The pathway is determined by the socket.
However, with a D3 twist drill of coordinated
depth, measure whether the socket depth
reaches the 13 mm required for the selected
implant configuration. If necessary, use the D3
twist drill to deepen the socket to the depth of
the implant.
The socket is usually short of that depth if the
implant was selected according to the selection
principles

53. Completion Of The Implant Osteotomy :
An appropriate stepped drill, is now used. This
drill obliterates the socket and carries the
osteotomy to its final depth. Cleansing and
suctioning are performed before the next step.
Evaluate And Test Prepared Osteotomy :
The depth stop on the stepped drill, coupled
with careful drilling, helps ensure accuracy.
Some practitioners test the osteotomy using a
coordinated bone compactor. If necessary, the
compactor can be tapped with a mallet to bring
the osteotomy to its correct depth.

54. Final Seating Of The Implant :
The implant is removed from its sterile
packaging by snapping the implant driver into
the adapter screw on top of the implant.
The implant is withdrawn from the inner vial to
be placed into its prepared osteotomy.

56. When the implant is placed into the osteotomy,
the driver is unsnapped and an implant seating
instrument is carefully positioned to nest snugly
into the adapter screw supplied with the
implant, such that the long axis of its handle is
parallel with that of the implant.
With several sharp taps, the implant is
malleted to its final position. The adapter screw
is removed with a O.9-mm hex-driver.

57. If the coronal ridge of the implant is not
entirely below the ridge crest, tap again with
the mallet. Do not remove the implant once it
has been malletted into position.

58. When using the single stage procedure, the
implant should be positioned so that the
platform is either even with or 1mm above the
crestal bone. Depending on the thickness of the
soft tissue, either profile(3mm) healing
abutment or a cover screw is placed into the
implants.
After hard and soft tissue healing, the top of
the implant will protrude above the muco-
gingival tissues, therefore circumventing the
need for a second stage procedure to expose
the implant

60. GOOD MORNING

61. IMMEDIATE
LOADING OF
IMPLANTS

62. CONTENTS
1. INTRODUCTION
2. DEFINITIONS
3. EVOLUTION
4. IMPLANT STABILITY
5. ADVANTAGES, DISADVANTAGES, INDICATONS
AND CONTRAINDICATIONS OF IMMEDIATE
LOADING OF IMPLANTS
6. NOVUM CONCEPT
7. RESCUE PROCEDURE FOR NOVUM
8. EARLY AND IMMEDIATE IMPLANT LOADING
PROTOCOL
9. DISCUSSION

63. INTRODUCTION
Immediate loading or function in implant
dentistry is a fairly new technique that allows
certain types of patients to have their teeth
removed and implants placed, along with the
prosthesis, in the same day. Providing
immediate implant loading requires a great deal
of previous experience, as well as advanced
knowledge of implant dentistry and significant
surgical and prosthodontic skills.

64. Because immediate implant loading requires the
cooperation of many different practitioners,
hence the importance of teamwork in the
achievement of satisfactory results in success
rates, function and esthetics, all of which are
required for success in any treatment
employing implants cannot be undermined.

65. DEFINITIONS
Immediate Occlusal Loading : An implant is
placed with adequate primary stability its
corresponding restoration has full centric
occlusion in maximum intercuspation and must
be placed within 48 hours post surgery.

66. Early loading : Early Loading Protocol is wherein
a provisional prosthesis was inserted at a
subsequent visit prior to osseointegration
(between 2 days to 3 months after surgery).
Though the implants, were not loaded the same
day, this protocol directly challenged the healing
process by introducing loading during wound
healing. A fundamental goal of early loading is
improving bone formation in order to support
occlusal loading at two months.

67. Conventional Loading Protocol : is the
original healing periods as envisaged by
different implant systems, typically after 12 to
24 weeks.
Delayed Loading Protocol : is one in which
the healing period was extended due to the
compromised host site conditions and, typically,
prosthesis connection is later than the
conventional healing period.

68. Occlusal loading : means that the
immediately or early loaded prosthesis is in
contact with the opposing dentition.
Non-occlusal loading : means that the
immediately or early loaded prosthesis is not in
contact with the opposing dentition. It should
be recognized that in non-occlusal loading,
forces on implants could be generated through
the oral musculature and food bolus.

69. Immediate Non Occlusal Loading : An
implant is placed with adequate primary
stability but is not in functional occlusion.
These implant restorations are essentially used
for esthetic purposes, frequently in single tooth
or short span applications. Immediate non
occlusal loading is often performed to provide
the patient with aesthetic or psychological
benefit during implant therapy, particularly
when a provisional removable prosthesis is
undesirable during the healing period.

70. EVOLUTION
1990 Schnitman et al initially described
immediate loading off mandibular implants
with a detachable hybrid prosthesis, however a
statistically significant number of the
immediately loaded implants failed.

71. 1994 Henry et al placed 6 mandibular implants
in a series of 5 patients 4/6 implants
immediately loaded with provisional removable
overdenture then , at 7 weeks a permanent
prosthesis was placed. 100% implant success.
1997 Tarnow et al, landmark study with
immediate loading of implants in both mandible
and maxilla.

72. 1999 – Branemark published initial report
on the Novum system
50 patients, 150 implants
3 implants placed in the anterior mandible and
immediately loading with hybrid denture
Failure of 3/150 implants
Failure of 1 prosthesis
Initial introduction of a mainstream immediate
load implant system

73. 2000 Randow et al compared one stage and
two stage technique for hybrid dentures in
patients with edentulous mandibles.
2001 Chiapasco et al prospectively compared
delayed v/s immediate load mandibular hybrid
dentures using Branemarke MKII implants.
2003 Engstrand et al 5 yr follow up of 95
patients treated with Novum system. 93.7%
implant success rate and 99% prosthesis
survival.

74. 2003 Henry et al
1 yr survival rates of Novum system in 51 pts
91% implant survival
94% prosthesis surivival

75. IMPLANT STABILITY
A fundamental requisite for IOL is adequate
primary implant stability. While stability was
traditionally achieved through a period of
undisturbed healing( i.e. osseointegration )
primary stability is now achieved via a
mechanical phenomenon of screw stability and
splinting
Each implant system tolerates micromotion
differently.

76. For implants with roughened surfaces, tolerance
is in the range of 50 to 150 micrometers,
machined surfaces can withstand approximately
100 micrometers of micromovement.
Regardless of the type of implant selected, all
restorative procedures should be completed
with in two days of implant placement,
according to the specific needs of the patient
and after which time of bone healing and
implant stability may be disrupted by such
intervention.

77. INDICATIONS
Adequate bone quality ( type I, II and III)
Sufficient bone height ( i.e. approximately
12mm ) for a minimum length of 10 mm
implant
Sufficient bone width ( i.e. approximately 6
mm)
Ability to achieve an adequate antero posterior
spread between the implants. A poor AP spread
decreases the mechanical advantage gained by
splinting and the ability to cantilever the
restoration

78. CONTRAINDICATIONS
Poor systemic health
Severe parafunctional habits
Bone of poor quality ( e.g. type IV)
Bone height less than 10 mm
Bone width less than 6 mm
Inability to achieve an adequate AP spread

79. ADVANTAGES
Eliminates the need for and maintenance of a
removable provisional prosthesis
Provides emotional benefit for a patient
scheduled to rendered edentulous
Improves bone healing
Facilitates soft tissue shaping
Eliminates premature implant exposure often
associated with wearing of a removable
prosthesis during healing period

80. DISADVANTAGES
Cannot be applied to every implant patient
Requires more chair side time at the time of
implant placement of both the patient and the
restorative practitioner

81. Immediate implant loading requires effective
communication and coordination between
surgical and restorative teams, as there is a
degree of flexibility involved in the delivery of
the prosthesis. For example the surgical and
restorative procedures may be completed in a
single appointment for straight forward cases
for others prosthesis may be most
appropriately delivered one or two days after
the placement of implant .

82. Hence careful patient screening and
selection is required when an IOL
procedure is treatment consideration.

83. THE
NOVUM
CONCEPT
Per Ingvar Branemark

84. INTRODUCTION
According to the Classic procedure screw-
shaped fixtures( generally between 4 to 6)
made of pure titanium (standard 3.75mm) are
placed in the anterior part of the mandible. This
concept, first applied clinically in 1965, was
based on available knowledge relating to the
healing of bone, for example after fractures or
osteotomies, and subsequently involved a
healing period of 3 to 6 months before
functional load was gradually applied.

85. The distinctive feature of Novum is that it
requires only 6 to 8 hours for the entire
reconstruction and thus gives the patient
a third dentition in just 1 day.

86. HISTORY
The Novum Concept was conceived in 1980
After 15 years of system design initial clinical
application was done in 1996
Initial report (1999)
50 patients, 150 implants 50 patients, 150
implants
3 implants placed in the anterior mandible
and immediately loading with hybrid denture
Failure of 3/150 implants

87. Failure of 1 prosthesis
System includes 4 drill templates and 8 drill guides
to allow precise positioning of 3 implants in the
anterior mandible
Prefabricated lower Ti bar placed on 3 implants
Prefabricated upper bar forms base of hybrid
denture
Upper bar and denture screwed to lower bar and
implants allowing delivery of Teeth in a Day

89. BRANEMARK NOVUM ADVANTAGES
Surgery and delivery of prosthesis in one day
Reduced cost of surgical phase
Reduced cost of restorative phase

90. BRANEMARK NOVUM DISADVANTAGES
Limited to Class I and III occlusion
Very demanding surgical procedure compared to
traditional technique
Limited patient selection due to anatomic limitations
Surgical template does not fit all mandibles
Loss of 1 implant can be catastrophic
Initial cost of surgical kit $2500

91. HYPOTHESIS IN FAVOUR OF NOVUM
It may be that during the critical period of 0 to
16 weeks, the quality of osseointegration may
be better at comparable times in the one-step
procedure as compared to the two-step
procedure.

92. The effects of any misalignment of a prosthesis
and the fixtures may be less hazardous and
minimized in the long run by a one-step
procedure. It is clear from the experimental
data of Branemark (1997, 1998) that the
elastic modulus and pull-out strength of an
osseointegrated fixture are smallest just after it
has been placed.

93. The stresses caused by misalignment of a
prosthesis may be dissipated during the early
weeks of osseointegration in the one-step
procedure. The initial stresses must be borne
by the old lamellar bone present. As this bone
is resorbed, these stresses may be relieved.
The new woven bone growing in will probably
not reinstate the misalignment stresses. This
suggests the intriguing hypothesis that residual
stresses caused by misalignment may be
relieved by the sequence of remodeling
processes leading to osseointegration. In a
two-step procedure, residual stresses may be
locked in indefinitely.

94. HOWEVER THESE HYPOTHESIS MERIT
EXPERIMENTAL VERIFICATION

95. Also it may be remarked that the two step
procedure by limiting the load applied during
the first phase, provides a margin of safety
against clinical factors, such as accidental
damage to bone by overheating at initial
placement, survival of osseointegration in case
of minor infection, poor bone quality or
accidental trauma.

96. Routine clinical procedure involves the use of
prefabricated templates for preplanned,
precision placement of three fixtures in the
anterior mandible. The precisely positioned
anchoring elements are to be immediately
connected with a predesigned lower bar . This
bar was intended to prevent individual torque
and multidirectional load on the individual
fixture and thus eliminate relative motion
during the initial healing phase.

98. The purpose of the upper bar was to
standardize and facilitate the prosthetic
procedure as well as allow easy
modifications of topography and materials
relating to the prosthetic dentition.

100. Predetermined fit of substructures
and suprastructures

101. Sample orthopantograph showing the
topographical position of anchoring fixtures in
relation to the anatomy of the mandible

102. Novum theory assumed that it would be
possible to position the anchoring fixtures so
precisely that the prosthetic base could also be
predesigned. This would not only reduce the
clinical treatment time, but also connect and
thus adequately secure the prosthetic
components in passive fit, which would
minimize undue stress and mobility.

103. The various directions of
functional load that may
occur at an individual
fixture if it is not
connected to adjacent
fixtures.

104. Concept of control of functional load by precision
connection of three fixtures according to the
Novum principle.

105. Continued clinical application revealed decisive
parameters related to preoperative radiographic
and clinical evaluations as well as gentle
surgery and controlled prosthetics. Optimized
healing at the abutment interface and control
of initial tissue injury and edema could be
obtained with surgical templates, meticulous
control of mechanical and thermal injury (ie,
never to exceed 42°C), and careful handling of
the soft tissue-with particular focus on
controlling the barrier to the oral cavity.

106. More recently, it has been suggested that the
cyclic deformation of bone tissue under
functional loading is likely to promote the flow
of fluid within the various spaces in the matrix
(e.g., canaliculi connecting lacunae) as well as
possibly connecting to the open circulation in
the marrow. This phenomenon may have a
controlling influence on the rationale of the
remodeling phase, which enables the bone
adjacent to the fixture to adapt to the
functional load of mastication.

107. 6 – 8 hours
Sequence of events according to the precision
clinical protocol.

108. Single stage surgery with immediate loading
concepts are well established in the mandible,
they should be considered experimental in
maxilla until long term evidence-based data
and guidelines are established. Nevertheless,
limited reports are accumulating and indicate
that in certain circumstances, successful results
can be achieved.

109. RESCUE PROCEDURE FOR THE
BRANEMARK NOVUM PROTOCOL
In the event of a lost or failed implant with the
Novum protocol, rescue components are
available that allow the recovery of stabilized
function without modification to the existing
restoration. The rescue set contains drills and
templates for immediately replacing the failed
implant in either the central or distal sites,
enabling subsequent immediate use of the
original bar structures at the same appointment.
The precision in implant placement required for
this intervention is the same as in the original
procedure.

110. The surgical approach for rescue in this case
involved removal of the upper and lower bars
and exposure of the failed implant and the
surrounding bone adjacent to the central
implant.

111. The rescue set includes templates for replacing
either the distal or central implants and drills
and drill guides for resizing the osteotomy.

114. IMMEDIATE AND EARLY LOADING
PROTOCOLS WITH THE FIXED PROSTHESIS
Edentulous mandible
The initial impetus for this novel approach was
the anterior zone of the mandible. The success
rates of immediately loaded implants in this site
were high (>90%) in short to medium term
studies. It was concluded that the rehabilitation
of an edentulous patient with 3 implants was
inadvisable and the recommendation that at
least 4 implants be placed in an edentulous
mandible to support a fixed prosthesis was
made.

115. Edentulous maxilla
The success outcomes for the maxilla, although
high, are limited since the data were
confounded by grouping of completely and
partially edentulous patients, including implants
placed in both the jawbones and extraction
sites. Most studies discussing treatment of
edentulous maxillae suggested that around 5 to
8 number of implants were required to
rehabilitate an edentulous maxilla but with
airborne particle abraded, large grit, acid
etched( SLA; sand blasted, large grit, acid
etched ) surfaces.

116. Although the comparative short-term case
series studies did suggest that rough-surface
implants performed better than machined
implants, the outcomes were confounded by
the use of the variety and number of implants,
the limited number of patients, and lack of
improperly defined success outcomes.

117. The Partially Edentulous Patients
The implant surface deserves special
consideration within context of the partially
edentulous patients. The use of an oxidized
implant improved the success rate up to 97%,
even though 76% of the implants were placed
in soft bone. Implants (machined and modified
surfaces) placed in the posterior maxilla
integrated when the surgical technique was
modified by under preparation and partial
tapping of the osteotomy sites , implying that if
primary stability is obtained, osseointegration is
possible irrespective of the surface.

118. Implants placed in fresh extraction sites
The rationale proposed for implant placement
in fresh extraction sites was to preserve soft
tissue esthetics and to further reduce the
treatment time and associated costs by
avoiding an intermediate stage of removable
denture wear. The conclusions that can be
reached from these studies are limited because
of the study design, short follow-up times in
the majority of reports, and lack of site specific
outcomes.

119. Furthermore, not all extraction sockets were
used as implant sites since, in some situations,
the extraction site was obliterated due to
surgical reduction of the residual ridge, not all
studies stated clearly how the extraction sites
were managed, making comparison difficult.
Within these limitations, the studies suggested
that success was not compromised by
placement in extraction sockets as long as
primary stability was achieved. Nevertheless,
success was reduced when implants were
placed in morphologically compromised
jawbone sites.

120. To conclude, these short to medium term
studies suggested that implant placement
should be restricted to extraction sites
without a history of periodontal diseases
and limited to the anterior mandible,
Further long term clinical research is
required to support these observations to
determine the efficacy of a similar protocol
in other jawbone sites.

121. Single Implant Studies
The studies of single implant-supported
prostheses reported good treatment outcomes.
Low success rates were reported with implant
placement in fresh extraction sites, which may
have been compromised by the presence of
infection. The reasons for tooth extraction
included trauma, retained root and root
resorption, and non restorable crowns.
Contraindications are active periodontal and per
apical infection, suggesting that placement of
implants in fresh extraction sites should be
avoided in clinical situations with ongoing
inflammatory processes.

122. There were failures as well as success with
occclusal and non-occlusal loading
suggesting that studies are required to
conclusively determine the role of
occlusion in these clinical situations. Same
is true in relation to bone quality.

123. IMMEDIATE LOADING OF IMPLANTS WITH
OVERDENTURE PROSTHESIS
Implant-retained overdentures proved to be a
predictable and effective method in the
management of edentulous patients. In early
progressive loading, the dentures are not worn
for 1 to 2 weeks, or else worn, but completely
relieved from the healing abutment. Typically,
the prosthesis is then relined for 3 to 4 months
when the definitive prosthesis and attachments
(ball or bar assembly) are connected.

124. In early functional loading, the dentures are
not worn for 2 weeks or are relined after
surgery. The retentive components (ball
attachments) are then connected within 3
weeks.
In immediate early functional loading, the
retentive attachments are connected within 5
days. In this, the retentive components are a
bar/clip assembly.

125. Studies have suggested that implants should be
splinted together with ,1 bar within a short
period of time to prevent axial rotation and
implant micro motion. However, other studies
have used fewer implants (minimum of 2) that
were left exposed and unsplinted after an initial
healing phase of 2 to 3 weeks. Therefore, it
would be argued that splinting of implants is
not a definite requirement for osseointegration
with these protocols in the anterior mandible.
However, it should be noted that healing was
unobstructed for the first couple of weeks and
led to a high success rate with such protocols.

126. In most of these studies, the loading was
progressive, with the next stage involving
relining for a few weeks. Final attachment and,
presumably, full functional loading typically
progressed within 3 to 4 months, while others
constructed the frameworks within 2 to 3 week.
The peri-implant soft tissues appeared to be
comparable to conventional protocols and did
not compromise implant outcomes. However,
others observed a change in the mucosa,
mainly describing it as soft-tissue shrinkage.
This suggests that a period of soft tissue
healing, along with a change, is to be expected
following surgery.

127. It is, therefore, safe to assume that time should
be allowed for optimal soft tissue health. If not,
it could be hypothesized that the dentures
would require relining to maintain the best
possible adaptation of the prosthesis to the
tissue. Peri-implant bone behavior was
observed with intraoral radiographs or
panoramic radiographs corrected for
magnification. The observed bone loss was with
in 0.2 mm / year and immediate loading was
not a high risk factor for early or late marginal
bone loss when compared to conventional
loading protocols.

128. CONCLUSIONS ON IMMEDIATELY AND
EARLY LOADING PROTOCOLS
Patients should be healthy or a controlled
medical condition
Cigarette smoking
Primary stability of the implant is an underlying
for predictable results. Primary stability is
virtually guaranteed with screw shaped implant
in the anterior mandible and in other jaw sites.

129. However a modified surgical protocol may
improve the success like
1.avoiding /reducing bone tapping of the
osteotomy site or tapping. osteotomies sites in
dense bone only;
2.avoiding countersinking or limiting it to
cancellous bone conditions
3.engaging both cortices where available to
provide bicortical stabilization
4.performing under preparation of the osteotomy
site using narrower twist drills or the osteotome
5. using wider implant when primary stability was
not obtained with the initial implant

130. It is tempting to propose that in the anterior
mandible, the traditional protocol may suffice,
whereas a modified surgery may be advisable
for other sites. Also the minimum implant
length of 10 mm is necessary for immediate
and early loading protocol but further studies
are required on this aspect. Atleast 4 implants
should be placed in the edentulous anterior
mandible to support a fixed prosthesis. Caution
is required with a fewer number of implants
due to potential complete prosthodontic failure
if one implants fails to osseointegrate..

131. Studies suggest that to achieve predictable
result in extraction sites, implant placement
should be restricted to sites without a history of
periodontal involvement. Finally, the marginal
bone loss measured, irrespective of prosthesis
design was of the same magnitude as
presented for the conventional loading
approach

132. DISCUSSION
The requisites for predictable osseointegration
of immediately loaded implants have yet to be
determined. One parallel consideration is
whether provisional loading of a tissue borne
prosthesis over an implant during the
osseointegration (healing) period will affect the
integration of that implant. To date there is no
scientific evidence (and no clearly documented
subjective clinical evidence ) that early failure
of dental implant can be attributed to early -

133. -loading or overload resulting from a tissue-
supported interim prosthesis being worn over a
recently placed dental implant. Loading of
implant through the use of an interim
restoration has not been documented as a
cause of early implant failure. It is also safe to
state that, at this time , there is no scientific
evidence that the factor associated with
implant restoration (provisional or restorative)
have a predictable impact on the survival of the
supporting implant.

134. This apparent lack of effect may be deceiving,
in that very real determinants of implant
success or failure are likely to be related
directly to the prosthodontic aspects of the
treatment. Unfortunately, those as yet
unidentified determinants are hidden from the
view of clinicians.

135. PROGRESSIVE
BONE LOADING

136. MAINTENANCE
OF IMPLANT
PATIENTS

137. REVIEW OF LITERATURE