Short Wait for Osseointegration?

Dr. G: Where did the 4-6 month wait come from?What scientific proof is there validating that waiting period?

branemark did that way and it worked, until recently few were willing to tinker with his success. but if an implant is coated and tightened to 30ncm. i think few would object to loading at 8 weeks in the mandible and 16 weeks in the maxilla.

Am I wrong in saying that intergration of the implant surface to the bone can take up to 3 months?I am led to believe that any micro-movement of the implant with-in the initial period, post placement,could see the intergration of the implant failing.Did Branemark in his initial research (and subsequent research by others) not find that if there was any stress placed on the implant,before intergration, that the implant failed?

Just as I thought. The implant world is brainwashed because "Branemark said." Read G Romanos' Imm Load of Endosseous Implants, 2003,Quint Pub,on the current research (and answers)in his PhD thesis.It's all about eliminating micromovement before woven bone turns into organized, lamellar bone (usually in 90 days). That is where the 3 months comes from; bone physiology. Back to Dr. G's original question. I've used 6 diffent implant systems and they all worked, immed or delayed load. I'm skectical of manufacturers claiming that their coating and design is superior to all.

I have heard from one doctor in particular that he has been loading the implant in a day but places the temporary crown on and takes the temporary out of occlusion all together for 4 months. He said he has had great success in doing this, however he tells his patients not to eat anything too hard that could affect the temporary crown. Then after 3-4 months he places the final crown. I wouldn't say this is the best practice, however if he has had success with it and he takes every precaution and puts full trust in the patient to follow his instructions then I say, "Good Job".

The point that I am trying to make is that in my experience, all the systems that I've used have worked very well. Back to Dr. G's question about new surfaces and designs contributing to earlier loading; personally, I feel good clinical judgement and surgical/prosthetic technique are the important factors in implant success. As RB has implied,good Dr/pt communication may contribute to the success of immed "load". I agree that keeping the implants out of occlusion contributes to the implant success, thus no or minimal (less than 35 microns)micromovement. Regardless of implants being immediately "loaded" or loaded after osseiintegration,the implant supported crown(s)must engage after the natural teeth engage due to the dicotomy of vertical movement between natural and implant supported teeth.

I believe that the Branemark studies were based on implants that were machined surface, non-threaded implants. The current iteration of rough surfaced threaded implants are significantly different and interact with bone differently. They integrate more quickly, as attested to by the myriad of more recent studies.

In my opinion, it is multi factorial and need individual assessment based on risk analysis,it depends upon primary stability, single or multiple implants connected, bone type,implant location,implant length, opposing occlusion and patient compliance

In response to RB, I have made a lot of temporary crowns on anterior and posterior implants, which are to be placed immediatly after surgery, which I always strive to keep out of the bite. Trying to emulate, by hand, any protrusive or excursive movements the patient may make, looking at any "wear" facets the working models may exhibit.I have made full temporary restorations on 6 to 8 implants, which splints all the implants together, but the day after placement of the implants, I have not asked whether the patients are on a soft diet for any period of time after sugery.I have not yet made the final restoration on any of these multiple implants before 10-12 weeks. The restoring doc's are not keen to "load" them before that time.Single implants have been crowned before that time period.

Some of the new technologies that have come out are not based on any valid research or any research at all sometimes. At 2-6 weeks bone turnover produces a very soft bone that may be susceptible to micromovement if loaded. Obviously, each situation needs to be evaluated separately and splinting multiple implants reduces micromovemet. Regardless, the 3-6 months is a valid waiting period based off studies looking at bone healing around implants. By the time Lamellar bone has replaced woven bone, 3 months minimum have passed. Mandible has denser bone and therefore is more capable of loading earlier...not always true but a trend. occasional success can occur using ANY protocol but predictability is means following a protocol that is biologically sound and tailored to the patient. my 2 cents

Dan Mayeda is 100% correct. my 3 cents

In vitro studies showed that high insertion torques, above 100 N/cm, increase the primary stability of different implant systems by reducing the amount of micromotion underneath the threshold of 30-50 µm. In an animal study, it was observed that non-loaded implants placed in dense cortical bone using high insertion torques (>100 N/cm) showed an increased remodeling rate compared to implants placed with low insertion torque (10 N/cm), and up to 6 weeks, no implant failed or became fibro-integrated. Moreover, the high-torque group showed at all the time frames a much higher resistance to removal torque and a higher BIC compared to the low-insertion torque group. This study allows assuming that an increased insertion torque may be helpful in reducing the micromotion in the initial healing period, before the osseointegration is achieved in cortical bone. On the other side, the compression in cancellous bone impairs the achievement of the osseointegration compared to the non-compressed implants and does not influence significantly the micromotion. For this reason, it may be assumed that in soft bone, the primary stability must be achieved trough splinting. In conclusion, in vivo and in vitro studies suggest that caution is needed when immediately loading implants in soft bone, particularly for a single non-splinted tooth. Conversely, in compact bone, an increased insertion torque allows to reduce the micromotion underneath the risk threshold. For different bone qualities, different loading time frames were described: shorter for the mandible (better bone quality) and longer for the maxilla (softer bone quality). Classical implant loading time frame also brings with it the problem of temporization. However, due to evolution of implant design regarding the development of improved surfaces and connections with the purpose of achieving a better primary stability and osseointegration, immediate loading became more and more popular, representing nowadays an important issue, what is demonstrated in the fact that many research plans and protocols are moving in this direction.

Living bone is still an enigma with respect to the reaction to external forces to some respect. For instance: Traumatised bone that is oactivated due to implantplacement within 2 weeks show more osteoclastic proliferation, whereas "irritation" due to implantplacement after 2 weeks stimulates osteoblastic proliferation. Recent studies as presented at the ICRPS in Charleston 2007 have revealed that if implants are placed with a certain torque, eg >25 Ncm, with oesseointegration this torquevalues change with an unpredictable rate aswell in a negative and a positive direction. So more research should be done to evaluate at what exact conditions placement of implants with >25Ncm torque will be able to withstand the forces of immediate loading in such a way that osseointegration will be the result.

I recently placed a 3.75x13mm tapered screw in the maxillary ist premolar area after expanding the ridge.while torquing the implant in,the buccal plate gave leaving me with 1/2 the buccal threads expose & the implant stable at 20 ncm.I swaged back the #ed buccal plate,grafted with Bio-oss & a barrier & achieved primary closure about 3mm palatal to the implant location,and advised 6 months unloaded period.immediate post op has been uneventful.What are the chances for the implant to take?was there anything else I could have done?

Progressive loading is the practise of immediately loading of the implants but having no occlusal contact initially. After 30 to 60 days, the bite of the temporary crowns or permanent crowns is raised to full occlussion. One study on monkeys at the University of Malaya in Malaysia has shown that even though there is no occlusion initially,the bone around the implant showed a greater degree of ossification as compared to those implants that were buried. This discovery gave rise to the concept of "bone training" where implants were immediately loaded but not brought to occlussion until 30 to 60 days later when the permanent prosthesis would then be placed....after "training" the bone up for loading. Professor Nentwig may have been the first to propound this.

Dear Narayan You have done right thing. Just do not place any prosthesis touching mucosa.You will be surprised to see cover screw burried in the new bone. I assume your barrier membrane is fixated properly.

Dear Satish I am interested in hearing of your technique for fixation of barrier membranes. I am still a new boy with implants and currently use the cover screw as the primary means of location and fixation of the membrane (I punch a hole in the membrane with a critically tracked rubberdam hole punch, and then place the cover crew through that hole) - works pretty well at placement yet to see the results though. Many thanks John

Hi Dr. Jafari Please let me have the details of the in vitro studie that concludes a benefit of higher torque-out when placing implants. Thank you.

Not to hijack this fascinating thread.. but I would like to know your opinion re timelines for implant plaement in areas where a sinus lift was done? Material used was Bio Oss with some autogenous bone at the area of the bony window, and a Bio Guide membrane.Thank you!

we need more research to measured the length of waiting period of the bone healing. there are lots of x factor for the result. like bruxism, gender male and female ? the strength of mastication for my tips is... its up to the case for example woman 30 years old low mastication, you can see by the profile. the place you put implant can be as consideration too. for the incisive central, if the over jet is big so better put the immediate implant. its up to the case... if molar, high risk, you put grafting for defect better you buried for 4-6 months really its up to the case....

I think that immediate loading is a very promise approach and very benefecial and it is related highly to implant design and implant surface treatment, however please I need the most up to date articles about splinting of immediatly loaded implants