Immediate loading: anecdotal evidence?
I’d like to start a discussion on peoples’ experience with immediate loading. For once, I am not looking so much for scientific studies and statistics so much as anecdotal evidence and one’s personal experiencing having placed implants and immediately loading them. As someone who both places and restores, I’d be most interested in the experiences of guys that also do both, as this should limit responses to “real” feedback rather than ideal, textbook “should dos”, etc. Personally, I have found that my immediate loading cases fail at a higher rate, especially if it’s an immediate placement as well. What prompted this discussion is a failure I had yesterday of an implant I immediately placed, 2 weeks ago, and had achieved 40nm of primary stability. I am relatively new at placing screw type implants, having placed Bicon for years and thought I was “safe” to immediately load if I achieved this magic number. Thank you for any comments.
28 Comments on Immediate loading: anecdotal evidence?
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peter Fairbairn
9/26/2013
That is the way things are , you will find maybe 1 or 2% higher failure rate as issues become more critical .
Immediate Place and load may really depend on site preparation to a far higher level as infection may be an issue etc .
So you need to be more thorough and careful and understand bio-mechanics fully .
But Wolffe describe over a hundred years ago , function can be our friend as well.
Peter
Hulda Wright
10/1/2013
a Ct scan can be a big tool in planning immediate load in implant placement ,for a 99% intergration with no occlusion interferance
kurt wirth, dds
10/1/2013
My experience is a much higher failure rate and most of that can be attributed to patient over use of the prosthesis............. They seem to not follow instructions. Because this is out of my control... I do not any longer load immediately.
In order to keep them off a bone graft site, I have made partial tooth supported frames spaced off the ridge.........
I had another dr twice pull his own sutures and pull the membrane (pericardial) because it itched..........
a slightly increased failure rate would be ok.. a risk you take but my immediate load rate was quite high.too high. Further, the questions listed above are pretty obvious and unnecessary.kw
Dennis Flanagan DDS MSc
9/27/2013
We need top keep in mind that an immediately placed implant is cantilevered from the supporting apical bone only. There is no cervical cortical support so any load that induces a micromovement will cause a failure. The anterior loads are about 1/3 those in the posterior so immediate placement and loading (nonfunctional) can be done in the #7-10 positions and the pt must then follow a knife and fork diet. Men will not follow these instructions so these cases can only be done in women. A seating torque needs top be at least 32 Ncm at a minimum, the higher the better.
Richard Hughes, DDS, FAAI
10/1/2013
Dennis, again you have made excellent points.
Hossam Barghash
9/30/2013
first the term immediate loading is a wrong term what we get is immediate aesthetic and that what the patient need ,with this concept in mind we respect the biology of bone healing and we we know our limits even with immediate implantation immediate prosthesis.
richard simons
10/2/2013
if one is aiming for an aesthetic interim measure, there is something to be said for an adhesive bridge- which should have no impact on success rates. Interesting comments about patient compliance- a proportion of them need implants precisely for this reason!!
Robert J. Miller
9/30/2013
Several questions for you:
1. Is this immediate load full function or immediate provisionalization out of function?
2. Are these healed sites or extraction/immediate placement?
3. Anterior or posterior placement?
4. What type of implant architecture are you using?
5. Are these splinted implants or single tooth?
6. Long term edentulous area or recent extraction?
If you do not understand the biologic and biomechanical consequences of loading an implant at time of placement in each of these categories, I would suggest that you not attempt this type of case until you are farther along in your training.
RJM
Kevin Mischley
9/30/2013
Really, Doctor. Your condescending tone is not warranted nor appreciated. Before you recommend further training, I would propose you wait for the answers to the questions you pose. I see this type of response from certain doctors too often in this forum. I do not know if it is due to some insecurity regarding GPs placing implants or if it is due to an all too common God complex or to some other reason, but I highly doubt that advise through a guise of concern for the profession actually helps anyone with a decent question. Worst of all, you added absolutely nothing to the conversation.
CRS
10/1/2013
Actually Dr Miller is asking qualifying questions to aid in the discussion. I don't think one can determine a "tone" from these questions On a clinical note, I don't recommend immediate load on non-integrated implants, I don't trust my patients. One exception could be cross arch stabilized implants but I don't perform these I'm' not God! Lighten up Francis!
Dr Sanjay Jamdade
10/21/2013
Dr Kevin I think there is a misunderstanding here. Dr Miller has always made meaningful contributions at osseonews. The questions he asked are valid pre qualifiers. I don't think he is looking down upon anyone here. Rather he has been very helpful. An appropriate response can be issued only when a complete background is provided. I am just trying to clear up the air. The discussion is great.
gerald rudick
10/1/2013
Recently I made a statement for this forum ......... "when Robert J. Miller speaks, everybody listens".
The purpose of this forum is to share information; and Robert in his comments, was not condescending at all...he really was being helpful, and sparing less experienced practitioners future headaches.
I fully agree with the person who started this discussion.... in my opinion, the success rates of immediate loaded implants are definitely much lower than following the Branemark protocol..... a lot of immediate implant studies are funded by implant manufacturers, who want to keep producing implants at a very fast pace.
You can pour concrete on a sidewalk, an hour later it is dry to the touch, two hours later, you can walk on it....but in actuality it takes 28 days for the concrete to be fully cured.
No matter how careful you tell the patient to be; eat soft foods, stay out of occlusion,etc.......inevitably, the patient misses his bite, and torques the implant.....and bonjour....it is gone!!!!!
So listen to Robert, he is what we call a Maven in Implant Dentistry.
Gerry Rudick
CRS
10/1/2013
I think he is also a "Mensch!"
Bj
10/1/2013
I think you've asked a very good question. I choose to place an immediate implants into single root sites almost exclusively. Occasionally some two rooted bicuspids are sometimes used if the site size permits good primary stability. Furthermore the type of site that I choose to do immediate implants in, usually has very little bone loss and the tooth is being removed for a restorative problem rather than a periodontal or an endodontic lesion. In these I have had very few failures. I have had sites which have taken longer to stabilize and integrate possibly due to the thick cortical bone within the socket. I have found that if I can match the implant size to only slightly larger than the existing socket site I have little problems with integration. In cases where there is still unprepared bone within the socket, these areas may take longer in order to be able resist the torquing forces of the abutment screw while tightening.
As mentioned By others above I like to avoid immediate loading. Obtaining a cosmetic result is usually the reason for directly placing a temporary over a fresh implant. These temporaries I find are best off being left out of function.
Jihad Joseph AKL
10/1/2013
We are often put under pressure from our patients to attempt an immediate loading and we therefore end up selecting patients where this fascinating concept can be applicable instead of selecting cases. I truly believe that it works as long as I know how to secure myself regardless the patient desire.
Obviously I do not agree on the term anecdotal evidence, it s rather a clinical evidence well supported by good knowledge of biomechanics, osteology and most importantly our limitations.
CRTooth
10/1/2013
Colleagues,
The days of immediate extraction and placement of fixtures is fast coming to an end as this very clinically "real" question asks. The reasons to follow this protocol are now becoming few and far between compared to the reasons not to. Agreed that the manufacturers have a vested interest in this treatment protocol and of course, the promise of riches to all concerned tends to move science in that direction. The saving grace is that the clinical reality(especially over longer observational periods) is one nobody can escape unless you view peri-implantitis associated suppuration as "liquid bone".
Rafael Ourique
10/1/2013
I have more than 10 years on implantodontics practice and I have been "graduated" in immediate load. In those times I used just Branemark type implants for about 4 years and my failure rate was acceptable doing just immediate load. But.... when I shifted from those old fashioned implants to the new cone morse types, my failure rate more than quadrupled!!! Nowadays I still use cone morse implants, but rarely use imediate load. My failure rate become acceptable again. Hope I've helped the discussion.
charles schlesinger
10/1/2013
The first thing that will help with your success is using an implant that was designed for immediate loading. I use the OCO Biomedcial implant which holds a patent for immediate load capability. I have been placing implants for quite a long time and have used many systems. All are possibly capable of immediate load, but the window of acceptable conditions is much smaller with most of these implants. Yes- you must attain sufficent primary stability. Usually 35+ N/cm will allow you to at least immediately temporize, but be cautious of loading.
With the current system I use, OCO, I immediately load approximaytely 80-85% of my cases. My insertion torque values are usually between 50 and 70 N/cm with ISQ readings of above 60. This affords me the confidence to place a full contour temporary and go into full funtion immediately. In most extraction/ immediate placement scenarios, I am placing a full contour temporary since I am still able to achieve sufficient primary stability.
Charles Schlesinger, DDS, FICOI
Kevin Mischley
10/1/2013
I would like to offer an apology to Dr. Miller, whose comments I may have interpreted incorrectly. While I have read comments on these forums that have undoubtedly meant to tell doctors to 'get more training' and have surely given direction, rather than advise, in a condescending tone, I believe I am guilty of having read Dr. Miller's comments through a defensive prism. I have to admit that when I read someone suggesting I or someone else not perform a precedure for whatever reason, my first reaction is "who the heck are THEY to pass that judgement?!" After all, the professional decision had been made by a licensed peer to perform whatever procedure they had shared on this forum and for someone to suggest they not do so can, frankly, be insulting. Again, I have seen this occur to many other doctors who have put themselves out there, often showing one of their worst cases. That is not, in my opinion, the time to suggest someone give up on something they obviously want to do and feel comfortable doing. Unless someone flatly asks, "should I not place implants because I made this mistake?", I do not feel any advice given should include that suggestion. We are all peers. We have all made and will continue to make mistakes. The important thing, obviously, is to learn from them. Again, I apologize to you, Dr. Miller, if your intention was not to suggest I not continue performing surgery. -Kevin Mischley
Donald Rothenberg,D.M.D.
10/1/2013
All the comments above are interesting.
I have been placing Bicon implants since 1986, so we have quite a number of implants in over 20 years...many only 8mm long. Our success rate for 20 years is 97%.
We do not load implants until 3/4 months (mand/maxilla). This is the only concession to time we have made...we used to wait 4/6 months.
Until we have an implant with this success rate we will not change...and we tell this to all our patients.
Very rarely a patient will not accept this... and we may not do the case but we still have a 97% success rate.
Why rush?
Sam Jain DMD
10/2/2013
If px comes with a tooth in the mouth, no matter how much abscessed, almost always gets a immediate implant and if it is from premolar to premolar, always gets a unloaded temporary.... Always successful.
It is the work horse of my implant center.
When you talk about failure of immediate implant, hard for me to understand....why?
Guys, always use CT scan for diagnosis and planning, do your surgery slowly and patiently, and over engineer the treatment.
Dr G John Berne
10/2/2013
It really concerns me when I see the comment "if a patient comes with a tooth in the mouth, no matter how much abscessed, almost always gets a immediate implant...always successful"
We had recently numerous posts on the use of antibiotics in implant dentistry and I believe the consensus was to eliminate active infection in the mouth prior to any surgery and avoid using antibiotics routinely. To do elective surgery in an area of active infection is I believe poor practice and to rely on antibiotics to prop up poor surgery technique is even worse and should be strongly resisted.
CRS
10/2/2013
I agree with your comment, it just sounds like bravado to me. I have a different perspective and have treated serious infections and complications from dentists with that attitude. We are not exactly peers there are some wonderful very experienced colleagues posting, one has to weed thru the comments based on clinical parameters and the ones that have an agenda. When there is bragging or defensiveness, or trying to defend one's position then I tend to ignore the comment and take it for what it is, just baloney.
Sambhav Jain
10/2/2013
The patient always asks me
Doc how can u place the implant in infected site and I say, that I am going to disinfect the site first and then place the implant.
I tell them exactly what you guys are saying that the implant will fail if placed in the infected site. That is pretty much common sense.
This kind of talk comes a GP who images, who decides/plans the treatment, who does the surgery, and who makes the prosthesis. I don't want to partner with people who don't share the same passion for the job as me.
Hard for me to understand why immediate implant will fail if done with proper thought and and you would not put the needed energy in thinking if you dont have the passion for the job.
I just met Dr Malo in NJ at Malo clinic and man oh man what an awesome guy, passion exudes from every word that comes out of his mouth.
What a thinker of dental concepts.
Sam Jain, DMD, MICOI
Center for Implant Dentistry
Fremont CA
Sam Jain
10/3/2013
Hello CRS
Which dental school do u teach at. You seem very knowledgeful.
Your posts have been very enlightening.
Sam Jain
CRS
10/4/2013
Dear Sam, I was a associate clinical professor at the university of Illinois. I will share something with you , I struggle with the referring doctors on implant planning and restoration, it is sometimes very difficult to share my passion for implant dentistry. I wish they could see how my talents can benefit the patient, proper grafting, placement and planning especially on more complex cases which require provisionalization. Simple education on the surgical principles and techniques. I get how implantologists have been burned by specialists and are left with unrestorable unplanned implants I belong to AAID. But from my viewpoint I have fixed a lot of poorly placed implants and grafts and watched patients get poor care. On a positive note I had a patient come back to me telling me she did Internet research and found that I used the best materials, techniques and implants on her even though her dds told her I did too much and he might as well place the implants himself. She is looking for a new dds. My issue with you is that your posts seem over the top perhaps just enthusiasm since every case is different and I see the more complex cases which can't be immediately placed or loaded. I just hope you can see the difference and know when to seek specialist help for the patient's benefit as I seek help and imput from my restoring doctors.It is about mutual respect, knowing what you can do well and knowing one's limitations. Sometimes I cloak another's sin's for the patient's benefit and to keep the case out of court. Thank you for the complement .
Sam Jain
10/4/2013
Dear poster of this thread:
There is no need to get discouraged by the talk of those who only do surgery and not the prosthetics. To be a good implantologist you gotta do the both. Only then can u really enjoy your work and excel at it. Being able to do only part of the job will be a utter handicap.
I have developed my own protocols for immediate implant work. The success rate is 99% or more and the cosmetics is best you can ever achieve. And I have been able to do this is because I am not worried/dependent on referring dentists. I do things my way, all
the way. I teach my techniques to my local aspiring GP colleagues and above all how to think about a problem.
I can show u cases( before and after CT ) of all sorts, all immediates. It is a wonderful art and very satisfying tx.
You can contact me at 510 574 0496 if u like.
Sam Jain, DMD
Center For Implant Dentistry
CRS
10/4/2013
you know it's funny at the AAID implant conference on complications it seems to me that a general dentist seems to receive the information much better from another general dentist ve a specialist even though it is the same information. I guess I need to look at my delivery and speak the common language . I am however an optimist!
