Loading protocols in implant

Loading Protocols In Implant
Piyali Bhattacharya
Dept of Prosthodontics and Crown & Bridge
HIDSAR

Introduction
• Since Branemark introduced the osseointegration
system in 1977 , new protocols have been
proposed regarding the prosthetic-load timing,
up to the immediate implant loading.
• Classic protocols propose that implants should
receive no loading during the osseointegration
period, usually 3 to 4 months in the mandible and
6 to 8 months in the maxilla *
* L. Tettamanti, Immediate Loading Implants: Review Of The Critical Aspects, ORAL &
Implantology - Anno X - N. 2/2017 129

• Esposito et al. have defined 3 protocols for
implant load timing: *
a) Immediate loading implants (ILI): within 1 week
from implant placement;
b) Early loading implants (ELI) : between 1 week
and 2 months; and
c) Conventional loading implants (CLI) : after 2
months from implant placement.
*Esposito M, Grusovin MG, Maghaireh H, Worthington HV. Interventions for replacing missing
teeth: different times for loading dental implants. Cochrane Database Syst Rev. 2013;3:
CD003878.

• Different implant placement options have been clinically
applied as defined by the last three ITI Consensus
Conferences in 2003, 2008, and 2013*
(a) Immediate implant placement on the day of extraction
(Type 1),
(b) Early implant placement after 4–8 weeks of soft tissue
healing (Type 2),
(c) Early implant placement after 12–16 weeks of partial
bone healing (Type 3), and
(d) Late implant placement after complete bone healing of
at least 6 months (Type 4).
*Gallucci et al., Implant placement and loading protocols in partially edentulous patients: A
systematic review, Clin Oral Impl Res. 2018;29(Suppl. 16):106–134.

Two sub-classifications point out the different
loading modality:
1) Occlusal loading or Non- Occlusal loading,
2) Direct loading or Progressive loading.
*Esposito M, Grusovin MG, Maghaireh H, Worthington HV. Interventions for replacing missing
teeth: different times for loading dental implants. Cochrane Database Syst Rev. 2013;3:
CD003878.

Process of osseointegration
Abrahamsson I, Berglundh T, Linder E, Lang NP, Lindhe J. Early bone formation adjacent to
rough and turned endosseous implant surfaces. An experimental study in the dog. Clin. Oral
Impl. Res. 15, 2004; 381–392

Abrahamsson I, Berglundh T, Linder E, Lang NP, Lindhe J. Early bone formation adjacent to
rough and turned endosseous implant surfaces. An experimental study in the dog. Clin. Oral
Impl. Res. 15, 2004; 381–392

Considerations for Immediate/Early Implant Loading
• Adequate initial implant stability is considered
important for a successful outcome.
• Controlled occlusal loads for full-arch cases and
non-occlusal loads for short-span bridges and
single-teeth replacements are considered
important for a successful outcome.
• Site evaluation for bone density/volume and
controlled infection and inflammation are
considered important for a successful outcome.
Consensus on Immediate and Early Loading of Dental Implants, Clinical Implant Dentistry and
Related Research, Volume 5, Number 1,2003

Rationale Of Immediate Loading
• Immediate loading implant has been defined as
an ―implant that carries a prosthetic
superstructure which makes occlusal contact
within the first 1 or 2 days after placement.
• It can also be described as a situation where the
superstructure is attached to the implants no
later than 72hr after surgery.
Chaudhary H, Williams C, Beniwal J, Barot P. Immediate Loading Implants – A paradigm shift:
A review. Int J Oral Health Med Res 2017;4(1):76-79.

• It not only includes not submerged one stage surgery
but actually loads the implant without compromising
osseointegration.
• When the occlusion is re-established within 2 weeks
it is called an early loading implant but when loading
is only allowed after several weeks, it should be
called delayed loading irrespective of the fact that it
is a one stage - or a two-stage procedure.
• Under these conditions, successful immediate
loading of screw-type dental implants has been
reported as early as 1979.

PRINCIPLE OF IMMEDIATE LOADING
• It has been described by Frost mechanostat theory which suggests that
bone adapts itself by different biologic processes: trivial, physiological,
overload and pathological.
• Remodelling is described as a simultaneous process of formation and
resorption that replaces previously existing bone, tends to remove or
conserve bone and is activated by reduced mechanical usage in the
trivial loading zone or micro damage in the pathological loading zone.
• Main objective of immediately loaded implant prosthesis is to reduce
the risk of occlusal overload and thereby, resulting in increase in the
remodeling rate of bone.
• Woven and lamellar are the two types of bone forming at the interface.
Woven bone is produced in response to extraordinary loading condition,
forming at a rate of more than 60 microns each day and is found to be
less mineralized whereas lamellar bone forms at a rate of 1-5 microns
each day. Thereby, a higher turnover rates lead to higher risks for the
bone-implant interface.

Indication*
• Completely edentulous jaw.
• Partially edentulous jaw.
• Patients with missing dentition requiring long
span fixed partial denture .
• Patient who are not willing to use a removable
type prosthesis.
• Patients who cannot wait for 3 months for the
prosthesis.
• Patients who cannot tolerate a removable
prosthesis due to social or psychological reasons.
* Chaudhary H, Williams C, Beniwal J, Barot P. Immediate Loading Implants – A paradigm shift:

Other indications
1. Poor oral muscular coordination.
2. Unrealistic patient expectations for complete
dentures.
3. Patient psychologically against removable
prosthesis.
4.Single tooth loss; avoid preparation of sound
teeth

Contraindications
• Chronic smoker.
• If bone volume is not adequate.
• If dentisty of bone is not good (D4).
• Parafunctional chewing habits (bruxing,
clenching, tongue thrust)
• Severe metabolic disease
• Noncompliant patient types (eg, diet limitations,
gum chewing)

GUIDELINES FOR IMMEDIATE LOADING
IMPLANTS by Tarnow et al
1. Immediate loading should be attempted in
dentulous arches only, to create cross-arch stability
2. The implants should be at least 10mm long.
3. A diagnostic wax-up should be used for the
template and the provisional restoration fabrication.
4. A rigid metal casting should be used on the lingual
aspect of the provisional restoration.

5. A screw retained provisional restoration should
be used where possible.
6. If cemented, the provisional restoration should
not be removed during the 4-6 month healing
period.
7. All implants should be evaluated with Periotest
at StageI, and the implants that show the least
mobility should be selected for the immediate
loading.
8. The widest possible anterior-posterior
distribution of the implants should be used.

Primary stability
• It has been proved that if the micro-movements
range results to be over 150 μm, this could
jeopardize the osseointegration process. This
excessive micro-motion results to be directly
implicated in the formation of the implant fibrous
encapsulation
• The literature suggests that there is a critical
threshold of micro-motion above which fibrous
encapsulation prevails over osseointegration. This
critical level, however, was not zero micro-motion as
generally interpreted. Instead, the tolerated micro-
motion threshold was found to lie somewhere
between 50 and 150 microns

Implant primary stability
evaluation
• Torque values ranging from 30 to 40 Ncm and
higher have been usually chosen as thresholds for
immediate loading
• some studies assess that also ILI placed in a weak
bone with a final torque ≥ 20 Ncm have an equally
successful prognosis as the CLI
• methods to measure the primary stability are the
Resonance Frequency Analysis (RFA) and the
Periotest (PT).

• Torque:*
Torque measures the rotational friction between
the implant surface and the bone combined with
the force required to cut the bone if that is the
case, and the pressure force from the surrounding
bone.
* Ostell , The guide to monitoring implant stability

• The RFA (Osstell®) is a reliable device that
measures the resonance frequency of a
transductor attached to the implant body
• The result of the measurement is the implant
stability quotient (ISQ), which reveals the
hardness of the implant-bone connection .
• ISQ values greater than 65 have been regarded as
most favorable for implant stability, whereas ISQ
values below 45 indicate a poor primary stability.

Periotest
• It is composed of a metallic tapping rod in a handpiece,
which is electromagnetically driven and electronically
controlled. Signals produced by tapping are converted
to unique values called ‘‘periotest values’’.
• According to Dilek et al. IL can only occur if their
periotest values in between the range of 8 to +9.
• Results by Abboud et al.38 also reported that periotest
values of ‘‘4’’ are indicative of a successful IL protocol.
Javed F, Romanos GE, The role of primary stability for successful immediate loading of dental implants.
A literature review, journal of dentistry 38 ( 2 0 1 0 ) 612– 620

Bone quality and quantity
• Lekholm and Zarb’s bone type classification –
I. Type I bone is a homogeneous, compact bone;
II. Type II bone is a thick layer of compact bone
surrounding a core of dense trabecular bone;
III. Type III bone is a thin layer of cortical bone
surrounding a core of dense trabecular bone of
good strength; and
IV. Type IV bone represents a thin layer of cortical
bone surrounding a core of low density bone
* G Ajay Kumar ,Criteria for immediate placement of oral implants – a mini review , Biology
and Medicine, 4 (4): 188–192, 2012

• The ideal extraction site for an immediate
implant demonstrates little or no periodontal
bone loss, adequate remaining supporting
alveolar bone, adequate sub-apical bone, and
dense crestal bone (Types II and III bone are
desirable and increase the likelihood of success).
Such sites are most often found in the
parasymphyseal mandible.
* G Ajay Kumar ,Criteria for immediate placement of oral implants – a mini review , Biology
and Medicine, 4 (4): 188–192, 2012

• Initial implant stability is essential for successful
osseointegration. Achieving this is dependent on
the apico-palatal bone volume present beyond
the tooth root to allow for sufficient engagement
of the implant.
• The amount of bone beyond the apex required to
gain the critical element of stability is 3-5 mm

Immediate loading suggested guidelines for
overdentures
1. Completely edentulous mandible.
2. Abundant to moderate bone height and width.
3. Prosthetic space 12 mm.
4. Opposing a maxillary denture.
5. At least 4 implants inserted between the mental
foramenae.
6. Screw-type implants 10 mm long and 4 mm wide
at the crest module.
* Carl E. Misch et al, Immediate Loading In Implant Dentistry, Journal of Oral Implantology,
Vol. XXX/No. Five/2004

7. When possible, the implants should engage the
opposing cortical plate.
8. Splint implants together with a bar or a fixed
bridge.
9. Minimum cantilever on bar (<1 X A-P distance)
10. Sleep without the prosthesis.
11. Severe bruxism contraindicated.

Suggested guidelines for immediate loading
complete edentulous fixed prostheses
Surface-area factors
1. Implant number : Eight or more splinted implants for the
completely edentulous maxillary
arch and 5 or more splinted implants for the mandible. More
implants if
the bone is poorer in quality (D3) or force factors are greater (eg,
crown
height, mild to moderate parafunction).
2. Implant size : At least 10 mm long and 4 mm wide. Larger-
diameter implants in the posterior molar regions of the mouth. If
larger diameter is not possible, greater implant number is
suggested (eg, 2 implants for each molar).
3. Implant design : Threaded implants.
4. Implant surface condition : Rough surface area implants.

Force factors
1. Patient conditions : Mild to moderate parafunction, and
muscular dynamics require more implants.
2. Implant position : In the completely edentulous maxilla,
anterior implants should be at least in the bilateral canine
position and posterior implants in the first to second molar
position for the largest anterior-posterior dimension. In the
implant in the anterior section and 1 in each posterior
region is necessary. The largest anterior-posterior
dimension possible should be used.
3. Occlusal contacts : Only anterior occlusal contacts in the
transitional restoration (first bicuspid to first bicuspid).

3. Occlusal contacts : Only anterior occlusal
contacts in the transitional restoration (first
bicuspid to first bicuspid).
4. Cantilevers : No posterior cantilevers should
exist on transitional restorations in either arch.
5. Occlusal load direction : Narrow occlusal tables
and no posterior offset loads on the transitional
prosthesis.
Long axis loads to the implant bodies whenever
possible.

Single tooth
• Immediately restored single tooth implant has an
increased risk of failure of about 5% in the first
year and
• Has also been evaluated for the least amount of
time in the literature.
• Both soft and hard tissue should be ideal, and the
implant size should obliterate the socket yet not
be positioned too close to the adjacent teeth or
too facial in position

Immediate loading in healed sites
IL in healed sites has been shown to osseointegrate
successfully provided the preoperative planning, patient
selection and surgical guidelines are appropriately
followed.
A high degree of primary stability and insertion torque are
also a major prerequisite.

Immediate loading at the time of extraction
(fresh extraction sites)
• A recent study investigated the outcome of IL in extraction
sites affected by periapical infection, such as fistulas and
suppuration. In this study, the test group included 15 patients
with periapical lesions or radiolucencies (such as fistulas or
suppuration); whereas the control group included 15 patients
without periapical lesions but with root caries or root
fractures.
• The 2-year follow-up results showed that IL in extraction sites
affected by periapical infection, osseointegrated successfully
revealing a positive outcome.

Guidelines
1. In the esthetic zone
2. Ideal soft-tissue conditions
3. Ideal bone condition
4. Ideal implant position
5. No occlusion on transitional restoration
6. D1, D2, and D3 bone type in region
7. Screw, shape implant body
8. 12 mm long (engage cortical bone at apex where
possible)
9. Soft diet
10. Cement the transitional prosthesis with definitive
cement or screw retain

Contraindication
1. Parafunction habits that load the transitional
restoration (eg, gum chewing)
2. Hard foods

Immediate Loading Suggested Guidelines For Patients Who
Are Partially Edentulous (Missing 2 Or More Adjacent Teeth)
Patient conditions
1. Esthetics zones
Implant number : One implant or tooth when possible
Implant size
1. At least 10 mm long and 4 mm wide (when possible)
2. Larger diameters for molars Implant design
Screw-type implant
Implant surface condition : Rough

Occlusal contacts-
1. No occlusal load for at least
2 to 3 months
Cantilever-
1. No cantilever load
Diet-
1. Soft
Parafunction-
1. No gum or pencil chewing
2. No tongue thrust

Conditions For Immediate Implant Placement
And Immediate Provisionalization
1. Absence of active infection :
• When active purulent infection is present, placing an
implant in such a site is contraindicated due the increased
risk of failure
• In the presence of active infection, a delayed approach
comprising of an atraumatic extraction together with
thorough debridement of the infected socket and
possible adjunctive antibiotics may be indicated to allow
for resolution of infection in order to reduce the risk of
complications.
*Bhekare A, Elghannam M, Somji SH, Florio S, Suzuki T. Case Selection Criteria for Predictable
Immediate Implant Placement and Immediate Provisionalization. J Oral Biol. 2018; 5(1): 6

2. Harmonious gingival contour :
• Healthy gingival tissue that is in harmony with the
neighboring dentition is a prerequisite for IIPIP.
• When ideal gingival contour is lacking, hard
and/or soft tissue augmentation should be
performed prior to, or simultaneous with implant
placement in order to re-establish ideal soft
tissue esthetics.

3. Stable buccal plate
• Type 1 extraction sockets, with intact buccal bone, have
traditionally been favored for IIPIP.
• Maintaining this buccal plate is clinically significant to
avoid midfacial recession and an atraumatic extraction is
therefore fundamental
• Immediate implant placement into sockets with
dehiscence defects, however with a stable buccal plate,
have been shown to give satisfactory results when a
provisional restoration or custom contoured abutment is
used concomitantly with a bone graft with or without a
membrane

• When immediate placement of the implant is
contraindicated, the clinician can perform a ridge
preservation procedure or wait 4-8 weeks for complete
soft tissue coverage of the socket

• Early implant placement with simultaneous horizontal
bone regeneration can then be performed to re-establish
the buccal bone and cover the exposed implant threads .

Progressive loading
• In 1983 Misch introduced the concept of Progressive
loading. and indicated that bone could mature when
tension during the prosthetic phase increases gradually
without overloading the implant.
• Bone is slightly overloaded and reacts by increasing its
formation, growing This protocol uses transitional
prostheses made of acrylic resin that minimally disturb
the integration of the implant-bone interface during the
healing phase and improving its quality.
Vergara Buenaventura A. et al., Progressive loading: a literature review,
J Osseointegr 2019;11(3):513-518.

• Esposito et al. defined PL as the load of the implants
obtained by the gradual increase of the occlusal table
height through increments from infraocclusion to
complete occlusion.
• In the study of Appleton et al. infraocclusion was
defined while the subject was applying his maximum
biting force and a piece of 0.015 mm thick shim stock
passed freely through the occlusal contact.
Vergara Buenaventura A. et al., Progressive loading: a literature review, J Osseointegr
2019;11(3):513-518.

Benefits of the progressive loading
• Crestal bone loss on conventional loading has been
reported between 0.9 to 1.6 mm after the first year of
implant placement and an annual average loss of 0.05 to
0.13mm. Crestal bone loss around progressively loaded
implants showed less bone loss than in conventionally
placed implants.
• Observational studies have reported less marginal bone
loss when used PL as a protocol reporting survival rates
of 98.2% and some authors recommend its use when
the cortical bone is very thin or even lacking . Different
studies even have described that PL considerably
improves the stability of the implants.
Vergara Buenaventura A. et al., Progressive loading: a literature review,
J Osseointegr 2019;11(3):513-518.

Delayed loading
• Branemark advocated an unloaded healing time
of 3–6 months. A healing period without early
loading is currently still considered a prerequisite
for implant integration.
• This shares some added advantages when
compared to the early loading, including
extraction site preservation and allows time for
soft tissue healing.
Aspalli, et al.: Keys to higher success in lesser dense bone, Journal of Dental Implants,
Jan - Jun 2015, Vol 5 ,Issue 1

Rationale Of Delayed Loading
• The placement of implants is associated with a local
inflammatory reaction in the narrow gap between the
implant surface and the local host bone. This reaction is
rather a sequence of events and any error in this
sequence may be responsible for compromised bone.
• Premature loading may lead to fibrous tissue
encapsulation instead of direct bone apposition. The
necrotic bone at the implant bed border is not capable
of load bearing and must be first replaced by woven
bone followed by lamellar bone, which is the ideal bone
for implant.

• Hence, delayed loading is important at the beginning of
prosthetic procedures, especially in the less dense bone
types.
• On allowing healing for a period of 3–8 months
depending on bone densities, a clinical study determined
the overall implant survival rate to be 98% that is, 100%
for D1 bone, 98.9% for D2 bone, 99% for D3 and 100%
for D4.
• Implant survival may be improved when implant design
and surgical approach were modified according to
specific bone density.

• According to Wolff’s law bone remodels in relationship
to the forces upon it. The load given during delayed
loading is introduced to the surrounding bone in a
scientific and mathematically perfect fashion. This will
then produce the most favorable bone and clinical
situation for long-term implant success.

Periimplant Evaluation
• Mobility at follow-up is A sign of the final stage of
peri-implant pathology and indicates A complete
failure of osseointegration . mobility as A clinical
parameter is specific but lacks sensitivity.
• Using radiographic analysis, albrektsson et al. Showed
that accepted amount of total bone resorption is 2.3
mm after 5 years in the following way that is, ≤1.5 mm
after the 1st year of prosthetic loading and < 0.2 mm
for each following year.
• According to Wennstrom and Palmer the acceptable
bone loss is 2 mm after 5 years of prosthetic loading.

• this can be explained as-
(1) potential role of micro gap at the implant abutment
interface for the bacterial colonization of the
peri-implant sulcus.
(2) Adequately dimensioned biological width to be
associated
with marginal bone resorption at sites with thin mucosa.
(3) Butt joint connections associated to implant
abutment configurations with matching diameters have
been linked with an inflammatory cell infiltrate and bone
loss.

References
1. L. Tettamanti, Immediate Loading Implants: Review Of The Critical
Aspects, ORAL & Implantology - Anno X - N. 2/2017 129.
2. Esposito M, Grusovin MG, Maghaireh H, Worthington HV. Interventions
for replacing missing teeth: different times for loading dental implants.
Cochrane Database Syst Rev. 2013;3: CD003878.
3. Gallucci et al., Implant placement and loading protocols in partially
edentulous patients: A systematic review, Clin Oral Impl Res.
2018;29(Suppl. 16):106–134.
4. Abrahamsson I, Berglundh T, Linder E, Lang NP, Lindhe J. Early bone
formation adjacent to rough and turned endosseous implant surfaces.
An experimental study in the dog. Clin. Oral Impl. Res. 15, 2004; 381–
392
5. Consensus on Immediate and Early Loading of Dental Implants, Clinical
Implant Dentistry and Related Research, Volume 5, Number 1,2003
6. Chaudhary H, Williams C, Beniwal J, Barot P. Immediate Loading
Implants – A paradigm shift: A review. Int J Oral Health Med Res
2017;4(1):76-79.

7. Ostell , The guide to monitoring implant stability
8. G Ajay Kumar ,Criteria for immediate placement of oral implants – a
mini review , Biology and Medicine, 4 (4): 188–192, 2012
9. Javed F, Romanos GE, The role of primary stability for successful
immediate loading of dental implants. A literature review,
journal of dentistry 38 ( 2 0 1 0 ) 612– 620
10. Carl E. Misch et al, Immediate Loading In Implant Dentistry, Journal of
Oral Implantology, Vol. XXX/No. Five/2004
11. Bhekare A, Elghannam M, Somji SH, Florio S, Suzuki T. Case Selection
Criteria for Predictable Immediate Implant Placement and Immediate
Provisionalization. J Oral Biol. 2018; 5(1): 6
12. Vergara Buenaventura A. et al., Progressive loading: a literature review,
J Osseointegr 2019;11(3):513-518.
13. Aspalli, et al.: Keys to higher success in lesser dense bone, Journal of
Dental Implants, Jan - Jun 2015, Vol 5 ,Issue 1.

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