Discussion: Time table when restoring maxillary implants

A few weeks ago I was reading replies to a question (I forget which one, I apologize) and in a number of the comments, there were some guys speaking of routinely allowing 6 months of healing before restoring a maxillary implant.

Obviously, when grafting or poor bone quality is a concern, an extended integration time is understandable. However, concerning the case that was being discussed and in examples being given, it did not appear that there were any extenuating circumstances that would call for a period of 6 months to pass before the restorative phase to begin.

Honestly, I was a bit alarmed concerning my practice of restoring what appears to be a solidly integrated maxillary implant at 12 weeks, sometimes sooner. This may be because I am both the placing and restoring dentist.

I would like to open the discussion as to what people are doing with respect to healing periods regarding maxillary implants when “all things are equal”. That is, bone quality and quantity are good, there has been little or no grafting done, primary stability has been achieved and maintained throughout the healing process and there are really no other contributing findings to suggest a longer than “usual” integration period is called for. What are your thoughts in this situation? Thank you.

13 Comments on Discussion: Time table when restoring maxillary implants

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CRS

4/19/2014

What's the hurry?

Kevin

4/19/2014

No hurry outside the normal considerations when doing any other work. Care to give your thoughts on integration times, though?

CRS

4/19/2014

Full integration maxilla 4-6 months, mandible 3-4 months dependent on bone quality, primary stability etc. it is just biology, healing takes time. Other modalities, teeth in a day, all on four have restoration protocols such as cross arch stabilization, full liquid diet, or protected occlusion..

Kevin

4/22/2014

Wow. Those time tables are surprising given the advancements in implant coating treatments and wide acceptance of flapless placement. Do you charge based on per month of integration?! Just kidding! Just to confirm, though, those time tables are for a straight forward single placement, no complications, no grafting, no flap? Thanks. -Kevin

John Manuel, DDS

4/22/2014

For Bicon, I restore all normal cases in 90 days. Large sinus lifts, etc. May need 4-6 months depending upon the bulk of mature bone support. Bicon is placed passively so you don't have the initial die back and reconversion taking 2-3 weeks on tightly placed designs. Of course, one considers the bone physiology of each patient also. John

Don Rothenberg

4/22/2014

I agree with CRS..."what's the hurry"... I wait 5-6 months in the maxilla...4 months in the mandible... Longer if any osseous work was done. I just don't understand the rush unless there is an esthetic problem...ie: maxillary anterior. Do I ever change this... Of course...but not by much!

Kevin

4/22/2014

Thanks for the input. However, again, I'm not coming from a position of "how can we do this as quick as possible?" Or "what's the least amout of time that we can give an implant to integrate?" That was never the backdrop of this conversation. What is is the fact, at least that I've observed, that it seems a period of 6-9 months of waiting for integration and subsequent restoration is perhaps somewhat overkill at this point considering the advances in materials and methods of the past decade or so. And, honestly, I don't think it's a matter of "why not give it more time to make sure for the benefit of the patient or yourself, for that matter?" That would be like saying we should premedicate patients regardless of the most recent guidelines for premeds "just to be safe". What I am trying to get to the bottom of here is why it seems, at least to me, that the backdrop of scores of posts on this blog has been an understood integration time of 2-3 months vs this 4-9 months that was recently talked about. It just personally threw me for a loop. That said, the longer integration times are 2 for 2. We need more input from more posters to come to a broader based conclusion, I believe.

Peter Fairbairn

4/23/2014

Hi Kevin , first thing get hold of an Osstell meter to be able to assess the ISQ of your cases . There are always different approaches which are generally adopted as we learn more and can change . AS you said this is not " to give the patient Implants earlier " , I am old school in this respect but work in line with patient bone healing thus load at 10 weeks in maxillary cases .Integration per se has taken place at 4 weeks post placement .It is much faster say than long bone healing as it is in cancelous , more vascular bone . I am Also doing a study on this for publication later in the Year hopefully , Using Osstell readings at placement and at 10 weeks all caes in very poor bone situations in the Maxilla . The best reading for this is Sasaki H Koyama S et al Jomi Vol 23 No 5 pges 832 . Regards Peter

CRS

4/27/2014

Peter, I am stuck at the six weeks minimum for alveolar bone healing based on my background with facial fractures. I don't use ISQ but I understand that it tells you the mechanical stability vs osteointegration. Am I missing something? I like 3-4 months maxilla and 3-4 months mandible as a basic rule of thumb since I don't have the luxury of controlling the restorative phase. An avulsed tooth requires six weeks but it is different since there is a PDL. We will release IMF in subcondylar fractures to prevent TMJ issues but in these instances it is healing by secondary intention with callous formation. Implants I consider need to be rigidly fixed for six weeks minimum for primary healing, with a longer time allowed for bone remodeling. The six week period is when implant stability is changing from mechanical stability to osteointegration. Am I missing something here? An implant is not a tooth or vital bone but a rigid fixture which I think should heal no different than a titanium bone screw.

peter Fairbairn

4/28/2014

Hi CRS , Agreed I am also very cautious ( Load at 10 weeks and placed at same practice for 23 years ) but these seem to be the parameters that the body works . A number of factors are different Implant surfaces are different to screws and they up-regulate host bone metabolism. The Sasaki paper is a good read here as well as earlier loading for improved host healing response . I have countless cases where there was NO primary stability at placement hence impossible to even take an Osstell reading at placement as you could not remove the peg without removing the Implant and at 8-10 weeks we get readings of 75-82 ISQ which are even higher than readings attained in normal healthy host bone at that timescale ...... All I am saying is that we are learning and the host wants to heal .... We are doing further study in this area as well and have learnt a bit from Synchotron CT studies on the bone adjacent to Implant surfaces and timescales for healing Regards Peter

Jaime

4/30/2014

I have personally placed a single15 Replace ( RP ) - using as my last bur the NP ( not to the full length ) with immediate loading ( provisional ) Engaged the sinus cortical . 4 years - no problem . Bone type 2. Do we have any problems when immediate loading a upper canine , central incisor , lateral incisor or premolar ? Sure you have the cortical plate ! I have not . Sure , I use at least 80N/cm torque and always engage the sinus cortical .IÂ´ve done at least 20 cases because I was obliged to . Underprepare , overtorque if patient insists on a immediate tooth , The type of gingiva is also important . IÂ´ve got about 10 cases with one implant and 2 crowns ( cantilever ) because the adjacent bone was not acceptable . I would not do this with bone graft or type 3 or 4 bone unless IÂ´m splinting with 3 implants.Please note I have never done this in the mandible because the opportunity has not arisen . Please note that I would not do this using bone graft or threads exposed or less than 80n/cm.

greg steiner

5/9/2014

This is an interesting discussion as I have recently decided to not have any set guidelines about when to restore. At the time of surgery I will assess the health of the patient, the vitality and density of the bone, the placement of the implant, the location of the implant and the implant in relationship to the rest of the dentition in regard to load and make an individual determination as to when to restore. Last week I placed and implant in a regenerated ridge and next week I will remove the sutures, place a healing abutment and refer the patient for final restoration. Loading will vary between 1 and 3 months of implant placement. Wish me luck. Greg Steiner Steiner Laboratores

dr.m

5/24/2014

Given all ideal conditions 16 weeks for the upper, and 12 weeks for the lower