1. 11. Early and Immediate Loading
John Beumer III DDS, MS
Distinguished Professor Emeritus
Division of Advanced Prosthodontics, Biomaterials and Hospital
Dentistry, UCLA
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2. Three basic types of surfaces in use during
the last 30 years.
v Originalmachined surfaces
v Micro-rough surfaces
v Nano-enhanced surfaces
v Do the new surfaces permit earlier loading?
v Do the new surfaces allow for more predictable
immediate loading?

3. Recent Advances in Implant
Surface Science:
Let us compare the science behind each of these
surfaces from the perspective of early loading.
v Original machined surfaces developed by Branemark
v Micro-rough surfaces
v Nano-enhanced surfaces

4. Prerequisites for Achieving Osseointegration
v Uncontaminated
implant surfaces
v Creation of congruent,
non-traumatized
implant sites
v Primary implant
stability
v No relative movement
of the implant during
the healing phase

5. Prerequisites for Achieving Osseointegration
Primary implant stability and no micro-movement
during the initial phase of healing
Submerged Implants
Micro-movement disturbs the tissue and vascular
structures necessary for initial bone healing.
v Davies (1994) found that excessive micromotion of the implant during
healing prevents the fibrin clot from adhering to the implant surface.
v Eventually, the mesenchymal stem cells migrating to the site are
reprogrammed into fibroblasts leading to a connective tissue interface
as opposed to a bone implant interface.

6. Prerequisites for Achieving Osseointegration
Absence of micromotion during the healing period
v Immediately following placement the bone
contact area is approximately 10-15% even in
favorable bone sites such as the anterior
mandible.
v If the implant is subjected to occlusal load at
this point and mobilized, the mesencymal stem
cells differentiate into fibroblasts and a fibrous
connective tissue encapsulation results.
With original machine surfaces it took 4 months to repair the
trauma secondary to preparation of the implant site and
develop sufficient bone anchorage to withstand occlusal loads

7. Early and Immediate Loading
of Osseointegrated Implants
v With the original machined surfaces, two stage surgical
procedures were employed, primarily to reduce the risk of
micro-movement during healing
v In the mandible the implants were allowed to rest beneath the
mucosa for 3 months before uncovering, in the maxilla for 6
months
v When machine surface implants were placed into function
immediately following surgical placement, the failure rates
were about 20%
v Have the micro-rough and now the new nano-enhnanced
surfaces allowed clinicians to place these implants into
function earlier or immediately with better predictability?
To answer this question we need to understand the reasons why these new
surfaces represent an improvement over the original machined surfaces.

8. Titanium Implants – 2nd Generation
Why are they an improvement?
Definition: Micro-rough surfaces –Peaks and valleys are one
mm apart. This surface roughness can be created by:
" Electrolytically
" Acid etching the surface
" Combination acid etching and sand blasting
" Titanium dioxide grit blasting
1 micron

9. Micro-rough Surfaces
Micro-rough surface textures – Why are they a
significant improvement
" Improved adsorption of plasma proteins
" Better retention of the fibrin clot
" Cell adhesion enhanced
" Cell differentiation accelerated
" Cell activity – Gene expression upregulated and
accelerated
" Shape
of the cell affects its gene expression.
" The microenviroment affects cell behavior.

10. Micro-rough Surfaces
Micro-rough surface textures – Why are they a
significant improvement
" Improved adsorption of plasma proteins
" Better retention of the fibrin clot
" Cell adhesion enhanced
" Cell differentiation accelerated
" Cell activity – Gene expression upregulated and
accelerated
Result:
" More
bone contact area on the implant surface

11. Micro-rough surfaces
Why are they a significant improvement
v Kohavi (2010) – Initial adsorption of plasma proteins is
enhanced by the microrough surfaces
v Davies (1998) showed that micro-rough
surfaces captured and retained the fibrin clot
initially deposited on the implant surface more
effectively than machined surfaces and thereby
better facilitated the initial events (clot
formation, angiogenesis, osteoprogenitor cell
migration etc.) associated with osseointegration.
v Ogawa and Nishimura (2000, 2003 and 2004)
showed that micro-rough surfaces changes gene
expression of the differentiating osteoblasts

12. 50 µm
Histomorphometry
Acid etched vs Machine surface Near zone
Far zone
Machined
Acid etched
(%)
80
*
60
40
*
The events associated
20
with osseointegration are
0
W2
W4
also accelerated as
indicated in the chart.
Bone-implant
contact ratio
(Ogawa and Nishimura, 2000, 2003),

13. 50 µm
Histomorphometry
Acid etched vs Machine surface Near zone
Far zone
Machined
Acid etched
(%)
80
*
60
40
*
20
Why is the process
accelerated?
0
W2
W4
Bone-implant
contact ratio
(Ogawa and Nishimura, 2000, 2003),

14. Gene Expression
Machine Surface vs Acid Etched Surface
T-cell implant Machined Acid-etched
" Ogawa and Nishimura implanted T-cell shaped
implants into the femurs of rats and retrieved the
specimens at various time intervals.
" They hypothesized that gene expression is
controlled at local levels by the surface texture of
the implant.

15. Pattern A
Implant-free osteotomy
Machined implant
D3
W1
W2
W4
D3
W1
W2
W4
DAE implant
Col I
OPN
Pattern B
Osteopontin upregulated
Osteocalcin upregulated
(Calcium binding molecules)
D3
W1
W2
W4
D3
W1
W2
W4
ONC
OCN
Pattern C
D3
W1
W2
W4
D3
W1
W2
W4
D3
W1
W2
W4
D3
W1
W2
W4
BSP II
Col III
IGN b-1
IGN b-3
They found that osteopontin and osteocalcin, genes associated with the
calcification process were upregulated and their expression accelerated by the
micro-rough surface.

16. Pattern A
Implant-free osteotomy
Machined implant
D3
W1
W2
W4
D3
W1
W2
W4
DAE implant
Col I
OPN
Pattern B
Osteopontin upregulated
Osteocalcin upregulated
(Calcium binding molecules)
D3
W1
W2
W4
D3
W1
W2
W4
ONC
OCN
Pattern C
D3
W1
W2
W4
D3
W1
W2
W4
D3
W1
W2
W4
D3
W1
W2
W4
BSP II
Col III
IGN b-1
IGN b-3
They also noted that the bone applied to the micro-rough implant surfaces appeared
to be different than the bone deposited on the machined implant surfaces.

17. Why was the bone different?
Nishimura and Ogawa suggested
several reasons including:
Bone repair and generation may not be the
primary prerequisite for osseointegration"
Might it be an implant dependent mechanism?"
Hypothesis: !
A set of genes that are NOT involved in bone
repair initiate and/or regulate the process of
osseointegration Ogawa and Nishimura,
2000, 2002, and 2003!

18. Purpose of the study
Identify the genes that are expressed around implants
but not in non-implant wound healing of bone."
Non-implant defect
Turned implant
Etched implant
Screening of candidate
osseointegration-specific genes
Differential display
polymerase chain
reaction (DD-PCR)

19. Testing the candidate DD-PCR products"
From 1853 DD-PCR products,
19 implant-specific (- + +)
2 acid-etched-specific (- - +)
42 different clones
3 Osseointegration-specific genes
(TO1, TO2 and TO3)
These genes were expressed only in the bone formed
around a titanium implant and were not expressed in
normal healing bone absent the implant

20. TO genes showed
Osseointegration-specific expression
Upregulation in early stages of
implantation
Accelerated expression for the double
acid etched surface

21. TO3 happens to be P4H
Enhanced gene expression of prolyl
4-hydroxylase (P4H)
" This gene is associated with collagen synthesis

22. Collagen and P4H
P4H

23. Why was the accelerated
expression of P4H on micro-
rough surfaces significant?
" Collagen density and orientation, as well as the
degree of mineralization are contributing
factors relative to the microhardness and elastic
modulus of bone

24. Bone Implant Interface
Double Acid Etched Surfaces
" Collagen synthesis is initiated earlier by the osteoblasts
adhering to the micro-rough implant surface
" A different combination of collagenous and noncollagenous
proteins make up the bone deposited on the dual acid etched
surface as compared to a machined surface.
" As a result resorption and remodeling of bone deposited on
acid etched surfaces appears to be different than bone
deposited on

25. Distinct osteogenesis on DAE
Day 14
7
Day 21
0
28
3
Osteoblast
Non-collagenous matrix
Mineral deposition
Collagen matrix

26. Nano Scratch Test
3 times harder bone on dual acid etched
2000nm indentation depth
P=0.0252
Nanohardness
P=0.0339
(GPa)
0.2
0.1
0
Bone on
Bone on
Bone on
Polystyrene
Machined Ti
DAE

27. Nano indentation test
2 times harder bone on dual acid etched
200mN maximum load
P=.0005
P=0.0153
P=0.0130
Nanohardness
0.8
(GPa)
0.6
0.4
0.2
0
Bone on
Bone on
Bone on
Polystyrene
Machined Ti
DAE

28. Nanoindentation: in vivo bone
Ogawa et al, 2005
Bone deposited on machined surfaces is equivalent in
hardness to trabecular bone, while the bone around the
DAE surfaces is as hard and stiff as the cortical bone. "

29. Impact of Strengthened Peri-implant
Bone
Trabecular
bone
Cortical
bone
Cortical bone:
l Very dense
l Less subject to
resorption or
remodeling

30. Micro-rough surfaces
Surface roughness and the bone contact area
Animal studies have shown that the bone contact area
achieved is 50% greater with micro -rough surfaces as
compared to machined surfaces (Buser et al, 1991, Weinlander,
1993, Hamada, 1995, Nishimura and Ogawa, 2000, 2003).
There appears to be little difference in bone contact area
achieved after implant placement between the most
common microrough surfaces currently on the market.. Courtesy Dr. M Weinlander

31. Bone contact area
Microrough surfaces (Weinlander et al, 2004)
70 64.15 65.03
61.69
60
51.53
48.1
50 44.7
37.7
40 34.8
1. 2X
30 2. 10X
20
10
0
NBC- TiU 3I ITI Xive- CP
Courtesy Dr. M Weinlander

32. Enhancement of titanium surfaces
Fluoride treated surfaces (Astra)
v Improves the wetability of the surface
v Cbfa expression is high for the grit blasted
fluoride prepared surface (Isa et al, 2006)
" Cbfa is a transcription protein that promotes
cell differentiation of osteoprogenitor cells)
" Accelerates the events leading to deposition
of bone on the implant surface

33. Enhancement of current titanium
surfaces
SLA active (implant packaged in saline)
(Strauman)
" Maintains the wetability of the surface
" Wetable surfaces significantly enhance initial
adsorption of plasma proteins
" This, in turn facilitates migration, adhesion and
differentiation of mesenchymal stem cells

34. Titanium Implant Surfaces"
1st generation! 2nd generation! 3rd generation
Machined surface" Nano-enhanced
"
Ti blasted surface!
Sand-blasted surface
"
surfaces
NO DIFFERENCE!
• HA crystal
TPS
" Sand-blasted, ! deposition
HA coated surface
"
acid-etched • Titanium particle
surface!
Genetically
Dual acid-etched ! engineered
surface!
Electrolytically Recombinant
enhanced! proteins-BMP

35. Nano-enhancement of implant surfaces
Potential Benefits
v Increased surface area and with it better
interlocking of the bone to the implant
surface
v Enhanced wetability and adsorption of
plasma proteins
v More favorable surface chemistry with HA-
CaP coatings and TiO2 pico-nanometer
coatings

36. Effect of Nano-Structure:
Long-term stability of osseointegration
v Recent theoretical
models suggests
there is increased
mechanical
interlocking of bone
with nano-structured
surfaces.
Loberg
et
al,
Open
Biomater
J,
2010
Hansson
et
al,
Open
Biomater
J,
2010

37. Effect of Nano-Structure: Cell response
Overwhelming numbers of studies report significant
effect of nano-structure on cellular behaviors
Human
corneal
epithelial
cells
with
Fibroblast
growth
was
inhibited
70nm
groove
(A)
or
flat
surface
(B)
on
nano-­‐structured
surface

38. proportional to the protein binding affinity [33,44]. fluorescent signalapproach, commercial micp
with a fluorescence
PSIM results show that surface nanoscale morphology 2A). For investigating the role of nanoscal
(Fig. drasti- FPQ consists in imaging t
Effect of Nano-Structure:
cally influences the amount of adsorbed proteins. Theprotein adsorptionperpendicular a PSIM exper
saturation we performed
to the surfac
uptake significantly increases as nanoscale roughnessdifferent concentrations of bovine serum albumi
increases. immediately after photoble
gen and streptavidin (10 replicates per concent
Surprisingly, when changing surface roughness by 15 nm,nanostructured surfaces described above
titania the zone allows accurate m
Controlled protein adsorption
saturation uptake increases up to 600%, depending on mentary Discussion S1 for proteins charact
Figure 1. Nanostructured surface synthesis. (A–C)also images of
the protein background fluorescence,
used (Fig. 3A, 3B, 3C). Results AFM demonstrate that thewe studied 1,200The background
surface morphology for sample 1 (SMP1, A), sample 3 (SMP3, B) and
experiment solution. protein-surface int
adsorption mechanism follows different modalities than those
sample 5 (SMP5, C). Colour scale range is 0–120 nm (black to white). (D)
ing protein adsorption isotherms on aberra
affected by optical nanostr
expected, since the effect produced by increasing roughness 2C,not 2E). The Langmuirisisotherm m
Schematic view of the supersonic cluster beam deposition (SCBD) (Fig. is 2D, adsorbed layer isolated
justified
doi:10.1371/journal.pone.0011862.g001
v Protein adsorption
apparatus equippedby mere geometry, i.e.cluster creation of new widely used protein adsorption model [44], adequ
with a pulsed microplasma the source (PMCS). adsorption from the raw signal. Addi
our experimental data for all the tested proteins (
sites. If this were the case, the amount of adsorbed proteins should
increased significantly
increase linearly at most, as a function of the sample specific area,
proteins in the solution i
quantify the layer signal (Fi
because www.plosone.org on ~30nm structured
PLoS ONE | of the consequent increase of adsorption sites. Moreover,
since samples have identical surface chemistry, binding affinity
2 July 2010 | Volume 5 |
is worth stressing that FP
principle, may be applied
TiOx surface.
would be expected to remain constant when nanoscale morphol- rough surface. Fig. 4A and
ogy changes. However, measured SU is not directly proportional adsorbed on samples 1 a
to the number of adsorption sites on the surface; in fact, the surfaces in the previous
normalized saturation uptake (NSU), defined as the SU divided by detected the same non-line
v Surface nano-structure
the sample specific area, follows an evident growing trend for all we observed with PSIM, w
the considered proteins (Fig. 3A, 3B, 3C). This shows that the of adsorbed proteins on s
determines the protein
increase in protein adsorption is more than linear as a function of (Fig. 4A, 4B). Quantitati
adsorption
the increase of disposable adsorption space on the surface. calibration and the mea
PLoS ONE | www.plosone.org 3 J
ScopelliG
et
al,
The
effect
of
surface
nanometre-­‐scale
morphology
on
protein
adsorpGon,
PlosOne,
2010

39. Effect of Nano-Structure:
Controlled protein adsorption
v Protein adsorption to
nano-structured surfaces
requires less energy than
to a flat surface
v Nano-structure orients
the direction of adsorbed
protein
Sabirianov
et
al,
Enhanced
iniGal
protein
adsorpGon
on
engineered
nanostructured
cubic
zirconia

40. Nano-coating of HA-CaP Crystals
applied to the miro-rough surfaces

41. Nano-coating of HA-CaP Crystals
applied to the miro-rough surfaces

42. Shear Strength (MPa) - DAE Ti-nanoHA
Chemical Bonding?
Machined Ti
DAE Ti
DAE Ti-nanoHA
Shear Strength
Shear strength at 2 wk
12
11
10
S=F/A [N/mm2]
Shear Strength [MPa]
9
8
7
6
5
4
3
2
1
-
2

43. A B
Synergistic effect of DAE topography
0 7mm 11mm 15mm
and HA nano-layer:
Over 100% increase in the bone-implant anchorage
C D 25 30 Nishimura and
20 Butz et al, 2004
25
o ad (N)
15
10
5
20
L
0 Machined
15 0 0.1 0.2 0.3 Acid etch
Displacement (mm)
Acid etch HA
E 10
140 (%)
n test value
120
5
N or maliz ed
100
0
When nano-HA coating was added to conventional smooth and DAE implants,
pus h- i
80
bone anchorage was increased over 100%. In fact DAE Ti-nanoHA implant
60
showed theof implant12(degree)
Inclination accelerated bone-implant integration at the level that has never
0 4 8 16
been reported.

44. Bone-implant integration
Machined DAE+HA-nano-topography
bone
Weak Link – Cement Line
" Smooth implant was almost naked because surrounding bone did not stay
on implant.
" DAE plus nano-HA was covered by the surrounding bone indicating that
bonding was so strong the push-in force fractured the bone.

45. Bone-implant integration
Machined DAE+HA-nano-topography
bone
The bond between the bone and implant surface was greater
than between the new bone and old bone.
No cement line?

46. Titanium Implants - Surface Modifications
Nano-surface modification with titanium particles
Further enhancement of the surface topography
Increased surface area
l Almost
100 % of the surface of the implant is
covered with bone

47. Pico-super-thin surface
modification of Ti
v Ogawa and associates have shown that a pico-
meter thin TiO2 coating improves the
bioreactivity of microrough implant surfaces by
modulating its surface chemistry while
preserving the existing surface morphology
Sugita et al, 2011

48. No surface thin as 300 pm change before and after
As topography
The coating is as thin as 300 pm
Control Ti! Liquid TiO2 - 15 min!
The micro-rough topgraphy is unchanged by the coating
Sugita et al, 2011

49. Effects of pico-nanometer TiO2 Coating
Impact on osteoblasts
v Improves cell attachment
v Enhances spreading behavior
v Increased proliferation
v Accelerates differentiation

50. Increased osteoblast proliferation (Day 2)
P<0.05
BrdU incorporation
/ cell
0.3
0.2
0.1
0
Untreated Liquid TiO2 coated
N=3
Sugita et al, 2011

51. Rate of Osteoblastic Differentiation
Enhanced bone cell function (Day 5)
P<0.05
ALP activity
0.15
0.1
0.05
0
Untreated Liquid TiO2 coated N=3
Sugita et al, 2011

52. Bone-related gene expression (Days 7 and 14)
Sugita et
al, 2011

53. Mineral deposition (Day 14)
Sugita et al, 2011

54. Control! Liquid TiO2 coated!
Mineralized nodule
area at day 14
(arizarin red)
Control! Liquid TiO2 coated!
Sugita et al, 2011

55. Clinical Impact of advances in
implant surface science?
" The biologic events leading to
osseointegration have been accelerated
" Cell differentiation, adhesion and gene
expression is enhanced
" Better bone anchorage
" The bone deposited on the micro-rough surfaces
is denser and stiffer
Does this make a difference regarding early loading or
the predictability of immediate loading?

56. Clinical Issues
" Earlier loading.
" Yes!!
" Immediate loading.
" Probably not!!

57. Do these data justify the concept of
Earlier Loading?
Yes!! Several animal and human studies
indicate that under the right conditions,
earlier loading of osseointegrated implants
is possible.
l Micro-rough Surfaces
l 6-8 weeks
l Nano-enhanced surfaces
l 2-4 weeks?

58. Immediate Loading? Probably not!!!
3Ｄ Simulation software and CAD CAM technologies
enables the fabrication of the prosthesis before implant
placement
" With the new 3D simulation software now
available it is now possible to fabricate
various types of prostheses (primarily
provisional) prior to surgical implant
placement. Courtesy T. Sugai

59. 3D Simulation Software
The implant lengths, type, angulation and position can be determined
and a surgical drill guide can be designed and fabricated with CAD-
CAM technologies. Courtesy Dr. T. Sugai

60. 3D Simulation Software
CAD/CAM
The data is
developed and
inputted and the
surgical drill
guide is milled.
Courtesy T. Sugai

61. Immediate Loading
The implants are placed, torqued to the prescribed amount and
the premade provisional prosthesis is secured.
Courtesy T. Sugai
Resonance frequency analysis

62. Immediate loading?
" Do these data make immediate loading
more predictable. No they do not!!!
" Immediate loadingis still a dependent upon
the quality of initial anchorage
Success is dependent upon the absence of micro
motion of the implant during the healing period.

63. Micromotion
Two types of micromotion: it may be
tolerated , or it may be deleterious
Micromotion of less than 100 micros appears to
permit bone ingrowth,
Macromotion appears to preclude it
50µm 100µm 500µm
Tolerated Deleterious
From Maniatopoulos et al, J Biomed.Mater Res 1986
Szmuckler and Monclear, Clin Oral Implant Res, 2000

64. Immediate Loading
v For
the implant to become
osseointegrated it must remain
immobilized during the healing period.
v Thereforethe key to successful immediate
loading continues to be the effectiveness
of primary implant stability

65. Initial Primary Stability
(First day)
Function of: Courtesy Dr. C. Stanford
v Localbone quantity and quality
v Implant geometry
" Tapered better than cylindrical because
you have a better chance of maximizing
bone contact with the internal and
external diameters of the implant
v Surgical procedure (skill)
" Insertion torque – in excess of 45
Newtons
Two main factors:
1. Amount of initial bone contact
2. Lateral compression of the osteotomy site creating local
compression stresses (hoop stresses)

66. Will these stresses lead to pressure
necrosis of the investing bone?
Courtesy Dr. C. Stanford
v Branemark maintained that necrosis
of bone occurred if implants were
initially anchored at torques about
45 Newtons an impaired the process
of osseointegration Is this true?
v There is no evidence to substantiate
this claim.
v Indeed, higher insertion torques may
actually lead to better bone
anchorage (Trisi et al, 2011).
Be careful with regard to implant selection. Some
implants may fracture or the hex may be stripped
at higher levels of torque during insertion.

67. Immediate Loading – When Is it Feasible?
Clinical issues to be considered:
The degree of initial bone anchorage
v Skill
of the surgeon. Immediate loading is not for
beginners
" Consider bicortical stabilization when possible
" You must attempt to engage the inner and outer diameter
of the implant with bone when appropriate
" Insertion torque – in excess of 45 Newtons
" ISQ’s – 70 and above
v Volumeand density of the bone associated with
implant site
" Sites with dense trabecular bone are preferred
" Longer implants are generally preferred

68. Immediate Loading – When Is it Feasible?
Clinical issues to be considered:
Tapered vs Cylindrical
Implant geometry
v Tapered better than
cylindrical because
you have a better
chance of maximizing
bone contact with the
internal and external
diameters of the
implant upon initial
insertion.

69. Immediate Loading – When Is it Feasible?
Clinical issues to be considered:
Implant geometry
v Avoid implants with
voids associated with
the apical portion
particularly in
extraction sites
v In extraction sites most
of the anchorage is in
the apical third of the
implant

70. Immediate Loading - Clinical issues
Occlusal loads, occlusion and provisionals
" Control the occlusion. Most damage is done
by “para-function “
" Bilateral balance for patients with at least one
edentulous arch
" Clinical remounts are essential
" Anterior guidance for posterior quadrant cases
" Anterior single teeth out of occlusion

71. Immediate Loading
Clinical issues to be considered:
Compliance
v Post op instructions must be clear
" Patient must avoid tough foods during the first month
after implant surgery
" Taking the prosthesis out of occlusion may not be
sufficient. Remember, teeth do not come into contact
during mastication of the bolus.
" Implants are most vulnerable to mobilization and loss
during the 1-3 week transitional period between
implant placement and when a reasonable bone
implant contact area is achieved
v Contra-indicated in those with chronic bruxism

72. Immediate Loading – When Is it Feasible?
Clinical issues to be considered:
" Cost
" Clinician and patient must be willing
to accept a 5-20% lower success rate

73. The Keys to Immediate Loading:
v Initial immobilization of the implant
v Maximize implant length
v Maintaining anchorage during the dip in anchorage
during the transitional period between implant
placement and when there is a reasonable level of
bone deposition.
v During
this one to three week period, the implants are
most vulnerable to micro-movement and failure
v Occlusion
v Clinical remounts necessary to refine the occlusion
v Patients
with significant para-functional habits are
poor candidates for immediate loading

74. Fixed in Edentulous Mandible
v This patient is a good candidate for
immediate loading.
v Favorable bone sites
v Minimal defects secondary to
extraction. Note the super eruption of
the teeth and alveolus associated
with the incisors. Therefore
alveolectomy is performed to create
sufficient interocclusal space for the
proposed prosthesis anteriorly.

75. Fixed in Edentulous Mandible
Good initial anchorage
v Insertion torque of in
excess of 45 Newtons
v ISQ values of 70 and
above
v Maximize implant lengths

76. Fixed in Edentulous patients
v Additional
implants are usually employed in
an immediate loading case
v Note
that in this patient 6 have been placed as
opposed to the usual 4 or 5 implants

77. Fixed in Edentulous Mandible
v Limit cantilevers
v Rigid frameworks enhances cross arch
stabilization
v Clinical remount record to refine the occlusion
(bilateral balance,group function, etc depending
upon the status of the opposing arch)

78. Fixed in Edentulous Maxilla
v Good initial anchorage
v Insertion torque of in excess of
45 Newtons
v ISQ values of 70 and above
v Rigid frameworks
v Limit cantilever length. Note that
there are no cantilevers in this
prosthesis

79. Fixed in Edentulous Maxilla
v Rigid frameworks to enhance
cross arch stabilization
v Place additional implants
when possible
v Maximize implant length
v Clinical remount record to
refine the occlusion

80. Edentulous Mandible
Immediate loading of Implant assisted
overdentures in the mandible
“O” ring attachment
v Immediateloading with overlay dentures using “O” rings for
retention may not be as predictable as first thought. In a recent
study (Kronstrom et al, 2010) the loss rates approached 20% at
12 months.
v Therefore, we would not recommend this option.

81. Immediate Loading
Single tooth defects
v Predictable in experienced
hands in the incisor region
v Not recommended in the cuspid
region because of the difficulty in
controlling lateral forces in this
area

82. Immediate Loading
Posterior quadrants
Linear configuration – Posterior quadrants
Not recommended

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