This document describes a technique for immediate loading of implants in the completely edentulous mandible using a custom-fabricated interim implant-supported prosthesis. Four implants were placed between the mental foramina and immediately loaded with an interim acrylic resin prosthesis. Transparent surgical guides and templates were used to identify implant positions, which allowed for minimal denture modification and improved structural integrity and esthetics of the interim prosthesis. At 3 months, a definitive implant-supported prosthesis was fabricated. This technique aims to reduce treatment time and postoperative discomfort through immediate loading of implants in the mandible.

1. A technique for immediate occlusal
implant loading of a completely
edentulous mandible: A clinical report
Gianluca Paniz, DDS, MS,a Andrea Chierico, DDS,b Paolo
Tomasi, CDT,c and Stefano Cuel, CDTd
Department of Prosthodontics and Operative Dentistry, Tufts
University, Boston, Mass; Department of Prosthodontics, Dental
School, University of Padova, Padova, Italy; A.F.E. Lab, Trento, Italy
The protocols described are designed for immediate implant loading of the completely edentulous mandible and to
provide the patient with a prosthesis that incorporates structural durability and esthetics in a time efficient manner.
Incorporating appropriate diagnostic and surgical procedures, this clinical report describes the use of custom-fabri-
cated transparent devices that help the clinician identify implant position, thereby reducing the procedural time and
improving the structural durability and esthetics of the immediate prosthesis. (J Prosthet Dent 2012;107:221-226)
Immediate implant loading has which reduces postoperative pain and implants, autopolymerizing acrylic
been documented as a predictable before postoperative swelling, which resin is used intraorally to connect
option for restoring missing teeth. jeopardizes ease of positioning of the the abutments and prosthesis.24-27 A
This concept was developed to pro- implant-supported restoration.19,20 The similar technique is prosthesis con-
vide restoration of the dentition im- rehabilitation of the edentulous mandi- version, which adapts the patient’s
mediately after implant placement, ble with an immediate occlusally loaded existing denture to the temporary
and thereby reduce treatment time, implant-supported prosthesis is equally abutments.3,28 This protocol includes
patient discomfort, and postopera- successful when loading is applied the the use of specific transmucosal com-
tive care.1-5 In addition, immediate same day or the day after implant place- ponents that help the clinician during
loading has a positive psychological ment.21 High success rates have been the indirect procedure by moving the
effect on both partially and complete- documented with a combination of 4 prosthesis interface more coronally.29
ly edentulous patients.6-12 implants placed between the mental fo- This clinical report describes a proto-
Immediate implant loading of the ramen and consecutive immediate load- col that involves the use of transpar-
completely edentulous mandible is ing with a fixed acrylic resin prosthesis.22 ent devices to better identify implant
well documented in the literature. Its Because of technical problems, the position during the transfer proce-
success is partly due to good bone Novum procedure (Nobel Biocare, dure for immediate occlusal loading
quantity and quality in the anterior Göthenburg, Sweden), which uses in the edentulous mandible.
mandible, which has been consid- precision-fit surgical and prosthetic
ered the most successful region for templates to load the implant with a CLINICAL REPORT
this procedure.3,13-17 Histologic and prefabricated prosthesis on the same
histomorphometric evaluation con- day, does not guarantee clinical out- A 65-year-old healthy white man
firmed that immediate occlusal load- comes comparable to those of con- complaining of functional and esthet-
ing could present a high level of bone- ventionally loaded restorations.23,24 ic problems with his complete den-
to-implant contact in humans.18 The A commonly used technique for pro- tures was referred for treatment. The
use of a fixed screw-retained immedi- viding immediate loading involves the patient had been wearing maxillary
ate prosthesis is the most described use of temporary abutments and a and mandibular complete dentures
solution for treating these situations. prefabricated prosthesis, which is ret- for about 30 years and was no lon-
It is necessary to place the prosthe- rofitted around the abutments. After ger satisfied with the esthetics of the
sis as soon as possible after surgery, the abutments are positioned on the maxillary complete denture or with
a
Adjunct Assistant Professor, Graduate and Postgraduate Prosthodontics, Department of Prosthodontics and Operative Dentistry,
Tufts University, and Visiting Professor, Department of Prosthodontics, University of Padova.
b
Private practice, Bure di San Pietro in Cariano, Italy.
c
Dental Technician, A.F.E. Lab.
d
Dental Technician, A.F.E. Lab.
Paniz et al

2. 222 Volume 107 Issue 4
1 Pretreatment frontal view with prostheses. 2 Pretreatment frontal view.
3 Mandibular interim complete denture, occlusal view. 4 Transparent surgical guide, occlusal view.
the stability of the mandibular pros- the condition of the soft tissue before for a maxillary complete denture was
thesis (Fig. 1). The initial examination definitive impression procedures, and made (Permlastic; Kerr Corp, Romu-
for possible implant placement in- no interim prosthesis was fabricated. lus, Mich). The definitive cast for the
cluded extraoral and intraoral evalu- In the mandibular arch, 4 dental im- maxillary complete denture was fabri-
ations with and without the existing plants were planned with an interim cated with Type IV dental stone (New
prosthesis, analysis of the dentures, immediate acrylic resin-based pros- Fuji-Rock, GC Corp, Tokyo, Japan).
and radiographic examination of the thesis designed to be screw-retained The inter-occlusal registration was
residual bone (Fig. 2). To address the and left in place for 3 months before obtained by using record bases with
patient’s chief complaint, the treat- definitive prosthesis fabrication. wax rims and wax (Aluwax Dental
ment plan included the fabrication of During the initial examination, Products Co, Allendale, Mich) as the
a maxillary complete denture and an preliminary impressions of the eden- registration material. Before proceed-
implant-supported complete denture tulous arches were made with irrevers- ing with the completion of the defini-
for the mandible. Implant-supported ible hydrocolloid materials (Jeltrate tive maxillary complete denture and
or implant-assisted restorations were Plus, Dentsply Caulk, Milford, Del). interim mandibular complete den-
considered but were not chosen for Preliminary casts were fabricated ture, a trial insertion was performed
treatment because the patient was with Type III dental stone (Dental Hy- to visualize the final functional and
concerned only with the esthetics of drocal, Kerr Corp, Romulus, Mich), esthetic outcome. A definitive com-
the existing complete denture. An- and the maxillary cast was used for plete denture was then fabricated
terior vestibuloplasty was discussed the fabrication of a custom tray (SR for the maxillary arch and an interim
with the patient for the maxillary arch Ivolen; Ivoclar Vivadent, Schaan, complete denture, prepared to be
but was not planned (Fig. 2). Tissue Liechtenstein). After border mold- modified at the implant placement,
conditioning material (Hydro-cast; ing with modeling plastic impression was fabricated for the mandible (Fig.
Kay-See Dental Manufacturing Co, compound (Impression Compound; 3). The mandibular denture was du-
Kansas City, Mo) was used to improve Kerr Corp), a definitive impression plicated in transparent autopolymer-
The Journal of Prosthetic Dentistry Paniz et al

3. April 2012 223
izing material (Ortho Resin; Dentsply nosis and using the surgical guide, 4 the temporary cylinders, which were
DeTrey GmbH, Konstanz, Germany) dental implants (Osseotite tapered recorded with a diamond rotary in-
to fabricate a surgical guide, which FNT; Biomet 3i, Palm Beach Garden, strument (FG Diamond Bur; Komet
was opened on the lingual side of the Fla) were placed between the mental Italia srl, Milan, Italy) and a marker
incisal edge of the mandibular teeth foramen. The 2 distal implants were (Fig. 6). The vacuum-formed plastic
(Fig. 4). This surgical guide was made placed at an incline to reduce the dis- template was then transferred to the
to be used first during placement tal cantilever of the prosthesis and to interim complete denture, guiding an
of the implants and also during the avoid the anterior loop of the man- appropriate denture reduction for the
immediate loading procedures. Ad- dibular inferior alveolar nerve. For all cylinder transfer procedure. The use
ditionally, a vacuum-formed plastic of the implants, an insertion torque of the transparent devices and the
template (Essix Tray-Rite; Dentsply higher than 50 Ncm and an Implant identification of the implant position
DeTrey) was fabricated for the man- Stability Quotient higher than 70 through the relining material resulted
dibular complete denture (Fig. 5). (Osstell Integration Diagnostics, Go- in a minimal denture reduction on the
Therefore, on the day of surgery, a thenburg, Sweden) were obtained. prosthesis without compromising es-
definitive maxillary complete denture After the insertion of 4 straight coni- thetics and structural integrity (Figs.
and an interim mandibular complete cal abutments (Biomet 3i), the tis- 7, 8). The proper position of the man-
denture (Fig. 3) to be modified after sues were sutured (5/0 Vicryls, Ethi- dibular complete denture was verified
implant placement were prepared. In con; Johnson & Johnson, Cincinnati, by using the remaining soft tissues in
addition, a surgical guide fabricated Ohio). The proper heights of the mul- the molar region and from the occlu-
from the interim denture (Fig. 4) and tiunit abutments were selected to be sal relationship with the definitive max-
a plastic vacuum-formed template slightly above the sutured soft tissue. illary complete denture. Dental dam
were prepared for the immediate oc- All of the abutments were torqued to was placed around the temporary cyl-
clusal loading procedure (Fig. 5). 32 Ncm (Contra Angle Torque Driver; inders, and cotton pellets were secured
The patient was anesthetized (4% Biomet 3i) according to the manufac- inside the screw access holes before the
articaine with 1:100,000 epineph- turer’s recommendations. transfer of the temporary cylinder with
rine, Alfacaina SP; Dentsply Italy Srl, Before the insertion of the tempo- autopolymerizing acrylic resin (Tokuso
Rome, Italy), and a midline crestal rary cylinders for the multiunit abut- Rebase Fast; Tokuyama Dental, Yama-
incision was made to maximize ke- ments, the interim complete denture guchi, Japan). Once the acrylic resin
ratinized mucosa on each side of was relined with a silicone material was polymerized, the abutments were
the incision. A full-thickness muco- (Fit Checker; GC Corporation, To- unscrewed and the prosthesis finalized.
periosteal flap was elevated to bet- kyo, Japan) to identify the position The distal extension and the flanges
ter visualize the mental foramen and of the implants. The temporary cylin- were removed for ease of cleaning,
residual ridge anatomy. A reduction ders (Biomet/3i) were torqued to 10 and the surfaces were polished (Figs.
of the knife-edge residual bone was Ncm (Contra Angle Torque Driver; 9,10). The interim implant-supported
performed before the implant place- Biomet/3i), and the surgical guide complete denture was then inserted,
ment, predominantly in the mandibu- was adapted around the cylinders. and the screws were torqued to 12
lar right quadrant. By following the The vacuum-formed shell, was placed Ncm. The occlusion was verified and
indications of the radiographic diag- on the surgical guide, to help locate adjusted to even contact in centric
5 Vacuum-formed acrylic resin template, occlusal view. 6 Position of temporary cylinders identified through
transparent surgical guide and vacuum-formed acrylic
resin template.
Paniz et al

4. 224 Volume 107 Issue 4
7 Vacuum formed acrylic resin template, with posi- 8 Interim complete denture prepared for transfer pro-
tions of cylinders marked, placed over interim complete cedure. Note that acrylic resin reduction was performed
denture. with guidance from transparent vacuum formed template.
9 Interim implant-supported complete denture, occlusal 10 Interim implant-supported complete denture, inta-
view. glio view
11 Definitive maxillary complete denture and interim 12 Definitive maxillary complete denture and defini-
implant-supported mandibular complete denture imme- tive implant-supported complete denture 4 months after
diately after implant placement. implant placement.
and light group function. The screw (Fermit; Ivoclar Vivadent, Schaan, and minimally adjusted. The patient’s
access holes were closed with gutta Liechtenstein) (Fig. 11). One week af- progress was followed at 3 weeks and
percha (Gutta Percha Points; Roydent ter the implant placement and pros- at 2 months after the procedure.
Dental Products, Johnson City, Tenn), theses insertion, the sutures were re- Three months after the implant
cotton, and a provisional material moved and the occlusion was verified placement, when osseointegration
The Journal of Prosthetic Dentistry Paniz et al

5. April 2012 225
was considered optimal and tissues such as fracture. Furthermore, reduc- 2. Chee W, Jivraj S. Efficiency of immedi-
ate loaded mandibular full arch implant
were remodeled, the definitive im- ing the amount of acrylic resin used restorations. Clin Implant Dent Relat Res
plant-supported complete denture provides improved marginal precision 2003;5:52-6.
was fabricated with Computer Aided and adequate cross-arch stabilization 3. Misch CM. Immediate loading of definitive
implants in the edentulous mandible using
Design/Computer Aided Manufactur- of the implants.1,2,14,22 Moreover, pros- a fixed provisional prosthesis: The denture
ing (CAM StructSURE Precision Milled thetic and technical aspects should conversion technique. J Oral Maxillofac
Bars and Frameworks; Biomet/3i). The be completed in the shortest possible Surg 2004;62:106-15.
4. Romanos G, Froum S,Hery C, Cho SC,
titanium-acrylic resin prosthesis was time to improve patient comfort after Tarnow D. Survival rate of immediately vs
torqued to the implant heads at 32 the surgical procedure.7 The use of the delayed loaded implants: analysis of the
Ncm (Contra Angle Torque Driver; 2 transparent devices also favors easier current literature. J Oral Implantology
2010;36:315-24.
Biomet/3i). The distal cantilever ex- identification of the position of the cyl- 5. Tarnow DP, Emtiaz S, Classi A. Immediate
tensions were extended to the first inders, and for this reason, the denture loading of threaded implants at stage 1
molar, respecting the anterior-poste- preparation for the transfer procedure surgery in edentulous arches: ten consecu-
tive case reports with 1- to 5-year data. Int J
rior spread, and a lingualized occlu- becomes less time consuming. Oral Maxillofac Implants1997;12:319-24.
sal scheme was followed (Fig. 12).30 Limitations need to be considered 6. Schropp L, Isidor F, Kostopoulos L, Wenzel
A. Patient experience of, and satisfaction
The patient has been observed for especially when reduced bone resorp-
with, delayed-immediate vs. delayed single-
3 years and no complications have tion has limited interarch space. In tooth implant placement. Clin Oral Impl
been reported. these situations, the use of this tech- Res 2004;15:498-503.
7. Dierens M, Collaert B, Deschepper E,
nique can be difficult and technique Browaeys H, Klinge B, De Bruyn H.
DISCUSSION sensitive. Moreover, a consideration Patient-centered outcome of immediately
of the reduced thickness and height of loaded implants in the rehabilitation of
fully edentulous jaws. Clin Oral Impl Res
This clinical report illustrates a the prosthesis reinforcement should 2009;20:1070-7.
practical technique for improving be part of the acrylic resin prosthesis 8. Romanos, GE, Nentwig, GH. Immediate
the predictability and efficiency of an design. This technique should be used functional loading in the maxilla using
implants with platform switching: five-year
immediate complete-arch occlusal only for the fabric ation of an interim results. Int J Oral Maxillofac Implants
loading procedure in the edentulous prosthesis that needs to be substi- 2009;24:1106-12.
mandible. In these situations, imme- tuted with a definitive one as soon as 9. Pieri F, Aldini NN, Fini M, Corinaldesi G.
Immediate occlusal loading of immediately
diate loading is commonly used since implant integration and hard and soft placed implants supporting fixed restora-
it provides a high success rate and tissue stability are achieved. tions in completely edentulous arches: a
1-year prospective pilot study. J Periodontol
improves patient comfort.1,20 Differ-
2009;80:411-21.
ent prosthetic protocols have been SUMMARY 10.Romanos GE, Nentwig GH. Immediate
described, and the transfer procedure loading using cross-arch fixed restorations
in heavy smokers: nine consecutive case
is one of the most used for providing In the treatment of edentulous reports for edentulous arches. Int J Oral
immediate occlusal loading after im- mandibular arches with an implant- Maxillofac Implants 2008;23:513-9.
plant placement.23 supported complete denture, imme- 11.Portmann M, Glauser R. Report of a case
receiving full-arch rehabilitation in both
The predictability of the transfer diate occlusal loading was performed jaws using immediate implant loading
technique, especially when the im- with a modified transfer procedure. protocols: a 1-year resonance frequency
plants are intentionally or acciden- Before surgery, an immediate denture analysis follow-up. Clin Implant Dent Relat
Res 2006;8:25-31.
tally tilted, might be reduced given and 2 transparent guides were fabri- 12.Calandriello R, Tomatis M, Vallone R,
the difficulties in identifying the posi- cated. The transparent devices were Rangert B, Gottlow J. Immediate occlu-
tion and angulation of the implants. used during the surgery for proper sal loading of single lower molars using
Brånemark System Wide-Platform TiUnite
The use of the 2 transparent devices implant positioning and then used to implants: an interim report of a prospective
described allows a limited and selec- limit the amount of acrylic resin re- open-ended clinical multicenter study. Clin
tive immediate prosthesis reduction duction of the prefabricated denture. Implant Dent Relat Res 2003;1:74-80.
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6. 226 Volume 107 Issue 4
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implants with a full-arch fixed prosthesis: IM. Immediate loading of the edentulous Dr Gianluca Paniz
a preliminary study. J Oral Maxillofac Surg mandible: delivery of the final restoration or a via Cesarotti 31
2009;67:1286-93. provisional restoration--which method to use? 35100 Padova
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H. Immediate loading in the completely 26.Gallucci GO, Bernard JP, Bertosa M, Belser Fax: +39-049-8776791
edentulous mandible: technical proce- UC. Immediate loading with fixed screw- E-mail: panizg@hotmail.com
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functional loading. Clin Oral Impl Res lous jaws: the pickup technique. Int J Oral Copyright © 2012 by the Editorial Council for
2007;18:295-303. Maxillofac Implants 2004;19:524-33. The Journal of Prosthetic Dentistry.
Noteworthy Abstracts of the Current Literature
Effect of implant diameter on reliability and failure modes of molar crowns
Freitas-Júnior AC, Bonfante EA, Martins LM, Silva NR, Marotta L, Coelho PG.
Int J Prosthodont 2011;24:557-61.
The reliability and failure modes of molar crowns supported by three different implant-supported designs were tested
according to the following groups: group 1, one standard-diameter implant (3.75 mm); group 2, one narrow-diame-
ter implant (3 mm); and group 3, two narrow-diameter implants (3 mm). Loads were applied as mouth-motion cycles
using a step-stress accelerated life-testing method. β values for groups 1 and 3 (1.57 and 2.48, respectively) indicated
that fatigue accelerated the failure of both groups, but not for group 2 (0.39). Abutment screw failure was the chief
failure mode. Strength and reliability were significantly higher for groups 1 and 3 compared to group 2.
Reprinted with permission from Quintessence Publishing.
The Journal of Prosthetic Dentistry Paniz et al