Loading Protocols

Immediate placement and loading is here to stay. This is also the place one can get in the most trouble. Case selection is the primary determining factor with any treatment. If there's good bone quality and occlusion could be worked out then an immediate load might be indicated. The only time I load the case immediately is if I must, ie:anterior fractured root plenty of bone (if it was caught early enough),immediate place and load is a tremendous service to the patient.Many times I would combine the few remaining teeth in an arch and immediately load a few of the implants to acheive a stable restoration while the rest of the case is healing .This gives us the ability to stay away from a removable appliance. Overall if neither of the above situations demand it I prefer to let eveything heal four to six months and then load. I'm having excellent results with both of the above mentioned protocols,but again not every case is going to permit this. Most important is to explain to the patient the long way and the way you can shorten the treatment time. They may not want to risk the "shortcut" . Make everything crystal clear,doing the work is the easy part. I believe that primary stability is what we want and regardless of what magic coating the implant company is tauting this week, it won't integrate without stability. I'm not belittling the fantastic coatings that are out there I just don't build my case around the coatings.

I agree with everything Dr. Mosery mentioned. And to add to it the esthetics and preservation of tissue with the appropriately contoured temporary restoration is second to none. Case selection and Initial stability are very important.

Good comments. What is meant by "aggressive" ? For example, is immediate loading more aggressive than early loading? I think not -- there is typically less stability in 2-5 weeks than there was at placement. By aggressive, do you mean immediate loading on cases that are not as stable ? What is your clinical protocol for determining when an implant has adequate stability for immediate loading?

Great Comments! I am interested in immediate loading for my patients. However I am a little unsure of the predictability, as The comments above indicate that weeks 2-5 are the least stable. Straumann ITI just released a new chemically active surface with increases healing time to 3-4 weeks. If this product does what it says it does, wouldn't this be a more predictable treatment for my patients? Any thoughts?

I believe that even with the new Straumann surface, the "protocol" for imediate loading is based on oclusion and primary stability. I am waiting to see the future results of this new implant.

Yes, I agree with Dr. Augusto, case selection and primary stability are the top predictors of success. The research thats out there is that if you have use a scew retained, roughened surface implant, you better your chances of success, but this ranks third to the previous 2, whatever coating/modification is on the implant surface. As far as the stability at weeks 2-5, the bone quality or bone area and bone to implant contact are still better for immediate load cases versus submerged cases at the same time frame due to mechanical strain imposed on the implant. The way the bone reacts to an immediately loaded implant is different versus that in a submerged case. The mechanical strain results in "reactive woven bone" (more organized, in general better quality) versus woven bone repair in submerged cases.

I think we need to focus on a big point of the new surface from Straumann - SLActive. The biggest benefit with the new surface is achieving secondary stability sooner. By getting to secondary stability sooner, I get more security and predictability as I'm immediately loading (or just loading early) the implant - huge for the protocol that I want to do. Give me good primary stability - great - but give me the security to know that I get to secondary stability sooner and am, by definition, getting faster osseointegration - PHENOMENAL! On another note, I think some other companies (nameless) are missing the point. Healing time (as much as 12 weeks at best in some cases!) is not the same as having the indication to immediately load. Compare apples to apples and tell us the truth.

What do Straumans studies note in percentage of Bone-to-implant at a given timeframe with the new surface? Just curious.

JCP: Daniel Buser's study shows greater BIC at 2, 4 and 8 weeks vs SLA: JDR 83 (7): 529 – 533, 2004.

i agree with most comments here. if we get good initial stability and we can splint multiple implants together at time of surgery by "immediately stabilizing and temporization" but keep "loading" to a minimum(out of occlusion) and post op to not chew at all on that side or soft diet if full arch case. we are getting just as good success rates and actually better esthetics and patient satisfaction. scott

osseintegration means renewing of bone,and according to dr branemark team it should be take place after 3 month in mandible,revascularization completed in 2-3 week,then osteoblastic and osteoclastic activity and bone remodelling begin,these step are scientifically and experimentally approved that if we prematurely load the implants a fibros tissue instead of bone will be formed.and afer one year we can see perifixtural radiolucency in radiography. the surface treatment of implant make a better biocompatibility but never could influence the healing process or compensate the destructive property of the immediate loading.