Immediate Loading

Abstract

I should begin by differentiating this concept from Immediate Placement (non-exact osteotomy with bone regenerative techniques) in conjunction with Immediate Loading. Immediate load as discussed in this essay refers to an interim or temporary restoration on a “just placed” implant fixture. While attending a formal oral implantology fellowship at the University of Pittsburgh in 1986, we were taught to understand and appreciate the efforts and accomplishments of those pioneers dedicated to the desire to help those patients whom conventional dental education and techniques could not satisfy. We hear how history has a way of repeating itself (that’s why it should be studied) and that few ideas are actually new. This is one of those ideas. Turning a two-stage protocol, as we understand it, into a one-stage technique is just turning the clock back from 1982 to 1972 and presenting this idea in 2002! This history, along with the evolution of implant materials and better bone physiology understanding, bring the need for, and practicality of, immediate loading to the forefront. The desire and demand for implant restorations have grown tremendously. Single-tooth restorative dentistry, often achieved via dental implants, is more predictable and successful than complex and advanced restorative dentistry requiring multiple abutments, pontics, and precision attachments. With the concept of interceptive prosthodontics, immediate load protocol is our most current challenge. This challenge must be approached with a scientific basis and understanding to be resolved. Applied research as it relates to a predictable outcome for our patients must be a science that applies to all clinicians, not a skill that can be mastered by only a few. We must separate our desire to help our patients from the actual bone physiology of healing. The big question is whether we are able to handle any prosthetic issues during healing (ie, occlusion, esthetics, function, etc.) without compromising the bone’s ability to stabilize the implant fixture as it osseointegrates. For predictable clinical dentistry we must calculate risks and minimize errors. In private practice communities, who will be responsible for the added failures? If we accept a 5 to 10% failure rate with immediate implant loading, when we are accustomed to a 1% failure rate with conventional two-stage implant protocol, then who explains and absorbs the costs of money and time? Private dental practice is not a research situation that is grant-based or state subsidized, but is patient-based relying on the judgment and expertise of the dental implant team. Who will place, reline, and adjust the interim prosthesis at the time of surgery before closure? By immediately loading the implant, are we evolving away from the team concept to a one-stop shop concept? Are we potentially disillusioning patients by presenting a possible “immediate gratification” that may prove to diminish the long-term quality of the treatment outcome? Immediate load concepts are further limited in implant overdenture prosthetics as the support bar is either prefabricated or designed by connecting the implants over the existing ridge. With a two-stage approach, the implant bar is created to develop a “new ridge” that can support the intended tooth position. With this approach, the implant bar can be fabricated in the proper buccolingual, anterioposterior, and vertical location to properly support the prosthesis. Prosthetic techniques used with immediate loading may give patients “teeth in a day,” but isn’t the profession more directed toward benefits for a lifetime? Patients are paying higher fees for less time and receiving less than desired results. The philosophy of a two-stage dental implant protocol has provided a predictable, scientifically based method for patient care and brought implant dentistry out of the “dark ages.” It has provided the opportunity to change the philosophy of restorative dentistry. It has given patients and practitioners new hope with excellent results. Studies have shown that primary bone stabilization of the implant fixture may occur 2 months after initial placement. I present that as a first step toward reaching immediate loading. We should first look at indexing of the implant at the time of first stage surgery, then place a provisional restoration at uncovery 2 months later. I believe we must be comfortable with this approach initially, doing it routinely and achieving excellent results. This technique allows everyone in the implant team to develop their skills, improve their communication, decrease risks, and evaluate their results. Currently, I feel that possible indications for using immediate dental implant loading (with associated risks) are as follows: Teeth receiving minimal load (eg, maxillary lateral incisors, teeth with no opposing occlusion, etc.). The ability to temporarily splint the provisional implant restoration to adjacent teeth or integrated implants. Dense Type II bone. I look forward to and believe that Immediate Loading will continue to evolve and mature and that scientific research will clarify its predictability in our implant treatment plans. ** John P. Davliakos, DMD