Immediate Loading Imperiled?

I really don't 'get it' with the concept of immediate loading. I am a general practitioner, place and restore my own implants, where appropriate, been doing this for 12 years. I have yet to find a case where the patient is pushing for this type of approach, or where there is not some reasonably neat temporisation that can be done while healing occurs. To date, I have not found it worth the risk. In the case of extraction, I have in the last couple of years settled on post immediate implantation, after 6 weeks, and in a non smoker with no other factors to delay, I seek to place load and restore at 6 weeks. If I am missing the point with regard to the advantages of immediate loading, I am most open to be enlightened. Regards MC

Hallelujia: There are very few times when immediate loading is necessary or warranted. The issue is not nobel biocare per se, in my opinion, I am a gp and have been placing and restoring Replace successfully for years, it is the idea of over-loading or pre-loading these implants. If you can't obliterate the socket, don't place the implant immediately. The only reason more aren't failing is because they are splinted together. A little healing goes a long way. Sometimes we have to be careful of our "fast food" mentality. Good luck, Dr. P

I have been using the NobelGuide technique for both immediate placement and provisionalization, as well as full arch immediate function cases for almost two years now. I would like to have the link to that article sent to me so that I can review it myself and I would be happy to post commentary accordingly. Thanks, DAS

There are two points that must be reached in order to produce new bone (in a fracture or in implant healing): vascularization(oxigen supply), stability; and if possible, bone stimulation. this stimulation comes from loading. Independently of the implant you use, immediate loading can offer a beneffit of the immediate stimulation of the bone and increase the metabolic reactions that produce new bone. of course, the two points still have more strenght than the later. And, finally, I agree that this urge to deliver everything right away must be carefully measured, in order not to compromise the quality and principles of adequate treatment.

If good patient care is the goal, temporary implants (2 mm. wide) placed next to 4mm wide implants allow patients to have temporary coverage while the permanent implants are healing without micromovement. This works for implant supported bridgework or implant retained dentures. Both long term and short term patient needs are met within the boundaries of normal human bone healing and calcification. Immediate load welcomes micromovement and fibrous tissue formation. Why begin with a compromise when temporary implants allow for immediate gratification without compromise of the finished product?

To DAS: The story can easily be found on Google News. Just search for "one-hour tooth" Having spoken to a number of physicists involved in this kind of product development, they all agree that the technology has great potential, but it's still 3-5 years away from being reliable enough. So we've heard that NobelDirect and NobelPerfect were irresponsibly marketed. And now the NobelGuide chickens could be coming home to roost. How much longer is NB going to use us as guinea pigs?

We are about to start a study on short term results on NBC immediate loading. I wonder if the results would be similar... I agree that NBC is marketed irresponsibly, but the strength of the company enables them to do so... We will see what happens in some 5 to 10 years...

Immediate loading has several benefits to patients who fit into that category, ( 34% of Patients in our practice) The benefits are simple teeth in one day. Now if you practice in NY you need to deliver so stakes are high and so are their demands this is what continually drives the need for this treatment. Periodontaly and prsthetically it BEST preserves the bone/periodontal/abutment connection/papilary response ...areas.. hands down the best aesthetic affect. DOes it have risk.. yes.. has to do with knowledge of the research and practical experience.. Whwn we choose this tx.. trust me it's been planned and definitley not "fast food" concept ... more like " excellent precision surg/prosth tx" Our private practice failure rate is 4% .. usually clenchers, smokers, and people who have been warned about the failure... bottom line a temp flipper is a terrible proviaionalrest. and tkae away any chance of an aesthetic anteior implant... unless you have 4mm of keratizized tissue... the 2nd modality we use it on is full arch splinted implant to avoid a complete denture...another disabiling tx that I do not like...Hope this helps.. Dr dean

"How much longer is NB going to use us as guinea pigs? " I find this hysterical and sad at the same time. This is dead-on accurate regarding "in-the-field" research that would make me irate if I were placing NBs. I can't believe they get away with this to be honest. How about the recent "All on 4" or whatever they call it? Four upper implants that have off-axis loading immediately placed on them even though in most arches the law of beams will be violated by the span of restorative material? I question the ethics of a company that endorses this protocol to newly trained docs. I don't doubt the gentleman who does them well has great success but is that an indication to announce an industry wide protocol with the assumptions that case selection criteria will remain constant? I like the one line that says "no parafunction".... Well no crap! Geez.... And how are they guaging parafunction, specifically clenching? I have a colleage that got lured into this (he did make assumptions he shouldn't have) and now the patient suffers due to a slipshod approach to treating our patients all to keep the bucks coming in. Sad when the #1 marketer is the #1 seller of implants despite a history of horrendous failures and recalls. Why do NB docs keep coming back for an inferior product that is the most expensive with little research backing? Immediate placement with immediate loading is here guys and whether you like it or not, patients want the teeth and they want them now. I will intentionally over-engineer the foundation if I have a patient that has such demands and yet there are some cases that still have to be done with a more conservative healing approach due to certain variables. With biologically active surfaces that speed osteoblastic healing and implant designs that stimulate adjacent bone for proper maintenance, more and more cases are able to qualify. With certain criteria met you can get identical success in the anterior maxilla and preserve the tissue contours while minimizing the patient's chair time. This is the only instance we encourage immediate place / load except full arches where sequential treatment isn't an option. If I was paying $40K for teeth, I sure wouldn't go to the guy who insisted on the dentures when others were offering immediate protocols. Case selection is such a biggie here though. Jackson

Dr Dean. I am interested in chatting with you re today's email .I have been placing single implants for 10 yrs and am interested in doing larger cases especially fixed vs bar supported dentures. I have found placing implants is the easy part,doing the prosthetics is frustrating and time consuming. Sincerely ,Joseph W Competiello DDS

Great post Jackson. I absolutelly agree with you.

Dr. Competiello, the grass is always greener on the other side. Unless you plan to be a mandibular anterior only surgeon, you better learn how to block graft from multiple sites. I am a surgeon and find plenty of challenges in my full mouth implant cases. Your single implant surgeries do not compare to multiple sites that are deficient in 9 out of 10 cases. My suggestion to you is to stick to what you know. You will safe yourself many sleepless nights. There are days when I feel the same as you. Such as, restoring the case looks easy. A great lab tech does most of the work! ( I knw that is the perception, not reality) Does that put it in perspective for you?

Your site is a refreshing change from the majority of sites I have visited. When I first started visiting web sites I was excited by the potential of the internet as a resource and was very disappointed initially. You have restored my enthusiasm and I thank you for your efforts to share your insights and help the world become a better place.

Dear Dr. J Competiello, my office number is 212 319 6363 regarding long span immediate loaded cases,,, when planned correctly.. thay are time saving and a home run with the patients... because they get immediate function day one... clear planning with surg/prosth perspective would love to chat...

Well said Jackson. Time will prove what works and what doesn't....I would bet the backlash against NB has only just begun.

I have a small dental laboratory. I am holding a CE course on dental implants. Nobel wants to present "Teeth in an hour" information to a group of my doctors. After reading a few of these posts, should I be concerned about allowing NB to present this to them?

The teeth in an hour seems to work with my local dentists that have used the technique. Patients that need the proceedure just do not want to wait the length of time needed for traditional methods.

Premolars (either maxillary or mandibular) have the highest success rates. Incisors and molars may not be the best candidates for immediate implant occlusal loading, but they are suggested for immediate non-occlusal (restoration) loading. Implant primary stability as detected by insertion torque (final abutment torque force of 35 or 32 N/cm, or dependent upon implant design required torque force is mandatory. Other methods, such as RFA, reverse torque… etc.), may be used to detect the primary implant stability. In an area where bone augmentation is needed, although primary implant stability can be achieved, caution should be taken when attempting to load such an implant immediately.

I've read a few posts now from colleagues stating that "patients want their teeth right away." I find it worrying that we're doing such a poor job of managing patient expecations and capitulating to distorted patient needs that are driven by some overzealous implant companies. It's just like the pharma companies 'instructing' patients to demand a particular drug from their MD. If I don't feel comfortable offering a treatment that is overly aggressive - for the sake of saving a couple of weeks - I'll be up front with my patient. "Here's how I would do it and here's my success rate. If you want teeth in an hour, you can get it, but I can't guarantee the same success." I've rarely had a patient go elsewhere for treatment with this approach. Paraphrasing Jackson's post: if your patient is shelling out $40k, I'd bet they will wait a few extra weeks and go with a more proven technique.

Hi All, I am a general dentist with four "Teeth-in-an-Hour" cases completed. Frankly, we have had no trouble with either the implants or the prosthetics. I also feel the Nobel solution offers us a chance to place the implants more accurately, and closer together. We recently placed eight maxillary implants anterior to the molars 3 and 14, with a palatal bar for extra temporary stability. So far, we seem to get along with the "protocol" quite nicely... Am I missing something? John

It is hard to imagine that there is still a discussion about whether immediate loading works or not. There are so many published, refereed papers with so many cases that the concept is validated, period. It doesn't matter what the readers of this blog think. Certainly there are indications that are more predictable than others. There are also patients in whom this service makes a difference and others who don't really care. For instance, taking a patient who has worn dentures for years and suddenly giving them fixed teeth makes great headlines, but really isn't much different than doing the job conventionally, which would take a couple of months longer. However, taking a patient with a failing dentition to a new, fixed restoration is a real advantage as you could have this person completely avoid ever becoming edentulous! Again, case selection is critical! I have documented over 1600 immediately loaded implants in my practice with over 95% success (learning curve included) on all kinds of cases ranging from single teeth to full mouth cases. It works, plain and simple. It is also teachable as I have had many successful dentists use our techniques with similar success. And rest assured, demanding patients will find those practitioners who will provide the services that avoid removable provisional restorations.

Immediate loading concept works. NBC was smart to figure out a total concept solution along with a great marketing plan which has been beautifully executed. There are some FUNDAMENTAL problems with NBC plan: lack of scientific evidence for some of their radical procedures, lack of adequate training to the new comers, lack of information to patients. Problem with NBC is they are pushing the envelope too much. In their utter greed for higher sales, they are promoting concepts to patients who demand this from their dentist. If the patient is not an ideal candidate for such a procedure, the dentist will still do the case as otherwise he would lose it to his colleague. This is one reason what is driving NBC failures. The other reason is NBC is pushing flapless procedures with NobelDirect to total novices. 2 years ago I had warned NBC reps to be careful when Dr. Mick Dragoo invited novices at Quintessence Congresses in India to do NobelDirect flapless withOUT undergoing any training. I found this utterly irresponsible coming from the person who developed this concept. Greed will kill NBC sooner than later. I wonder why no one in USA is complaining to FDA and other authorities about NBC "buying" universities by paying US$ 5million to each of them. I know that authorities have clamped on pharma, cardiac stents/valves and orthopaedic implant companies from going this way. This is probably why companies such as Biomet, Zimmer and so on are not coming forward to "buying" universities, because they are wiser. I predict NBC will have a big fall. Patient law suits and federal agencies will go for them big time.

Jackson is 100% correct. Nobel is for nobel and the h--l with the rest of us. the nobel speakers are just as bad and care less about the patient, I have seen their work, not all of them, but for the most part it some bad stuff. It is sad to see all of this, and it will hurt implant dentistry. But,they will all get the big money and we are left correcting the problem!!!!!!!!!!

The percentege of the Dr. in sweden refelects what is happenining when we load immediately. It is our responsability to show the patients that the technique has less support than the conventional implant placement.....eventhough we charge more!...for a technique we still do not know.... Oh yes Nobel is making huge money and we all allow this, because the lack of character and personality led to many relevant doctors to be clowns of Nobel. I work for myself and my family, not for companies!!!!!

My respect to the Dr. with 1600 implants /immediate loading history(story)...have you ever read Pinocchio?

I do not understand why everybody complains so hard about a company which proposes a tx protocol to get higher sales. All companies work the same way. We are the doctors and that means we make decisions regarding pt treatment. Nobody can force us to do something if we disagree and nobody can tell them not to market their product after they pass the initial testing. Regarding NC buying universities that's a joke, because Straumann does it more aggressively. They are in direct partnership with many more universities than NC. At the end I believe we choose what we feel comfortable doing and what works well in our hands, based on the available research. But sometimes unfortunately long term studies are published long after a product enters the market.

Hello Mr Ruumi Daruwalla, you summarized the scene so aptly! No wonder you are held in high esteem in INDIA as an honest and straight forward businessman. Who so ever I come accross tells me that. It's a shame that we haven't met personally.You are BRAVE. An Implant is an Implant is an Implant! Period! As most implantologists will admit in private, all implant system work well, if you have sound basics to go along with them. All doctors are not equally gifted nor equally careful in handling them. Not all follow sterilizations protocols perfectly. Neither do all do equally good pre operative evaluations. So many patients are not even asked the basic questions regarding medical history. Implant failures are often related to poor application of the mind to the case especially during the preoperative planning stage. The company manufacturing the implant has little to do with the same. Hence it does not matter whether it is NBC or 3i, Strauman,Zimmerman or Ostem who produces them. NBC's "failures" may not be due to their implants per se' but due to their suspect marketing tactics for retaining center stage and achieving colossal sales targets, all driven by greed. It seems in his last days Dr Ingmark Branemark washed his hands off NBC when the inventor couldn't tolerate the sales greed of the other directors of NBC. He has said the same on video which I had the good fortune to view. The pro NBC lobby just doesn't get it right. It isn't the quality of NBC implant systems which everyone is really grumbling about, it's the "greed" and shameless "purchase" of all authority figures in the dental field in any country it sells it's products. When the authorities get "sold" who would raise a voice or stop NBC from doing any wrong? Dental Schools, Universities, Eminent doctors, Licensing authorities like the Dental Councils, National office bearers of Dental Associations, Editors of Journals and magazines, you name it and NBC has them eating out of NBCs palms. The implant world is becoming "Unipolar" just like USA in global politics and Microsoft in computer operating systems. NBC is the next biggest threat to the dental markets globally. So it isn't about "Whether One hour implants work or not". It's about the greed and ruthlessness of NBC. NBC has a clout in the Dental field most would'nt even begin to imagine. Try doing something that does not favour NBC at any level whether it is associations, magazines, journals, research, trade fairs or even e-chat forums and sample first hand the arm twisting that you wont forget. So don't take Helen Canepa at face value! This company has rotten global strategy driven by greed and lust for power. And any one driven just by greed is dangerous becomes automatically untouchable and worthy of scorn and disregard.