LOADING PROTOCOLS

Mahmoud Ahmed Hassanin

5220008
 INTRODUCTION

• When a patient presents with an edentulous or soon-to-be edentulous area,

the question is often

"How soon can we fix this?“

 INTRODUCTION

• Implant Supported Prosthesis could be an answer to that question; As Treatment with dental

implants has proven to be a predictable modality for replacing missing or failing teeth with

various types of fixed or removable dental prostheses.

 INTRODUCTION

• So, if we are considering osseointegrated implants as the optimal treatment choice, we need

to have a good understanding of factors that may influence just how soon we can load

that implant.
• Multiple factors have been found to influence and/or alter the quality and predictability of
various loading protocols for completely and partially edentulous arches.

• These factors include the

• health of the patient; oral conditions such as periodontal status, occlusion, and
function/parafunction;
• characteristics of the proposed implant site; implant size and shape; implant material and
surface properties.
• Timing and methodology of implant placement, including primary implant stability, loading
procedures, and long-term maintenance.
 PROSTHETIC LOADING
• While it was traditionally thought that healing periods of 3 to 6 months combined with
submersion of implants under the oral mucosa was critical for predictable osseointegration
of dental implants.

• Advances in clinical techniques and innovations in implant surface technology have reduced
healing times before loading. Today, options for prosthetic loading can be considered by
category.
 DEFINITIONS
• Loading protocols were considered during a consensus meeting held at a congress
in Barcelona, Spain, in 2002.
• following definitions for implant loading were agreed upon by Aparicio and coworkers:
• Immediate loading
• prosthesis is attached to the implants on the same day the implants are placed.
• Early loading
• prosthesis is attached in a second procedure, earlier than the conventional healing period of 3 to 6 months.
• Conventional loading
• prosthesis is attached to the implants in a second procedure 3 to 6 months after the implants are placed
• Delayed loading
• prosthesis is attached in a second procedure later than the conventional healing period of 3 to 6 months.
 DEFINITIONS
• The Third ITI Consensus Conference, held in 2003 modified Definitons
(Cochran et al, 2004)
• Immediate loading
• restoration is placed in occlusion with the opposing dentition within 48 hours of implant placement
• Early loading
• A restoration in contact with the opposing dentition and placed at least 48 hours after implant
placement but not later than 3 months afterward
• Conventional loading
• prosthesis is attached in a second procedure after a healing period of 3 to 6 months.
• Delayed loading
• A restoration inserted within 48 hours of implant placement but not in occlusion with the opposing
dentition.
 DEFINITIONS
• European Association for Osseointegration (EAO),in 2006
• Immediate loading: A situation in which the superstructure is attached to the implants in occlusion with
the opposing dentition within 72 hours.
• Conventional loading: A situation in which the prosthesis is attached to the implants after an unloaded
healing period of at least 3 months in the mandible and 6 months in the maxilla.
• Nonfunctional immediate loading and immediate restoration are used when a prosthesis is fixed to the
implants within 72 hours without achieving full occlusal contact with the opposing dentition.
 DEFINITIONS
• The newly proposed classification assessing both the timing of implant placement and loading
combinations allows for comprehensive treatment selection.
(German Gallucci, Adam Hamilton, Wenjie Zhou, Daniel Buser and Stephen Chen.)
A. Type 1A (immediate placement plus immediate restoration/ loading)
a clinically documented protocol. The survival rate was 98% (median 100, range 87%–100%).
B. Type 1B (immediate placement plus early loading)
a clinically documented protocol. The survival rate was 98% (median 100, range 93%–100%).
C. Type 1C (immediate placement plus conventional loading)
a scientifically and clinically valid protocol. The survival rate was 96% (median 99, range 91%–
100%).
 DEFINITIONS
• The newly proposed classification assessing both the timing of implant placement and loading
combinations allows for comprehensive treatment selection.
(German Gallucci, Adam Hamilton, Wenjie Zhou, Daniel Buser and Stephen Chen.)
A. Type 2-3A (early placement plus immediate restoration/loading)
presents clinically insufficient documentation.
B. Type 2-3B (early placement plus early loading)
presents clinically insufficient documentation.
C. Type 2-3C (early placement plus conventional loading)
a scientifically and clinically valid protocol. The survival rate was 96% (median 96, range 91%–
100%).
 DEFINITIONS
• The newly proposed classification assessing both the timing of implant placement and loading
combinations allows for comprehensive treatment selection.
(German Gallucci, Adam Hamilton, Wenjie Zhou, Daniel Buser and Stephen Chen.)
A. Type 4A (late placement plus immediate restoration/loading)
a clinically documented protocol. The survival rate was 98% (median 99, range 83%–100%).
B. Type 4B (late placement plus early loading)
a scientifically and clinically valid protocol. The survival rate was 98% (median 99, range 97%–
100%).
C. Type 4C (late placement plus conventional loading)
a scientifically and clinically valid protocol. The survival rate was 98% (median 100, range 95%–
100%).
 DETERMINING LOADING PROTOCOL

• In order to determine which loading protocol is most appropriate for a specific patient
situation, several factors must be considered. These factors may be grouped into the same
categories as facially generated treatment planning.
• Esthetics
• Function
• Structure
• Biology
ESTHETICS
 ESTHETICS

• Esthetic considerations are often implicated when patients and dentists consider shortened

implant loading protocols.

• Quite understandably, many patients would prefer to have an implant-supported provisional

rather than an alternative provisional design.

 ESTHETICS
• rushing to load an implant in an esthetically critical area is counterproductive if the implant
fails to osseointegrate. Often, esthetic recovery following an implant failure is more difficult
than the original clinical situation.
 ESTHETICS
• Conventional and early loading protocols are more predictable than immediate loading in

esthetically critical areas when implants are placed using a delayed approach.

• When implants are placed immediately following an extraction, there may be some additional

value to immediate restoration, especially in cases with thin biotype.

• Yet, the same benefits of preserving the soft tissue profile can be achieved using a customized

healing abutment.
FUNCTION
 FUNCTION
• Occlusal function and parafunctional forces have been implicated in mechanical and possibly biologic

complications with implant-supported restorations.

• As a result, careful assessment of a patient's wear pattern is recommended.

• Findings from the occlusal exam can influence the number of implants chosen, their location and the

manner in which an implant restoration is designed.

• Similarly, occlusal function can influence implant loading protocols.

 FUNCTION

• The application of force to a healing implant may lead to excessive implant movement which could disturb

osseointegration.

• Occlusal schemes for shortened healing protocols are still being determined.

• Immediate loading and even immediate restoration should be considered higher risk protocols in cases of

worn dentition where the etiology cannot be distinguished and/or occlusion cannot be managed adequately.
STRUCTURE
 Structure
• Determining the anticipated restorative outcome is crucial in order to determine the most

optimal implant position.

• Once the optimal implant position has been determined, the potential implant site may

be evaluated from a surgical perspective.

 Structure
• Will the site need to be augmented horizontally? Vertically? Would soft tissue

augmentation help mask bony resorption which followed a prior tooth extraction?

• Many authors suggest avoiding immediate and early loading in clinical situations that

required significant grafting, even in cases where the grafting was completed prior to the

implant being placed.

BIOLOGY
 Biology
• Successful osseointegration depends on several factors:

1. Suitability of the implant material

2. Careful site preparation

3. Adequate stabilization of the implant.

• Among these three factors, adequate stabilization of the implant is the most critical to selecting a loading protocol.
 Biology
• Loading protocols should be viewed as dependent on, among the other factors described here,

two distinct processes: primary and secondary implant stabilization.

• Understanding these concepts helps in understanding why different loading protocols could be

used, or should be avoided, depending on the clinical situation.

 Biology
• As an implant is placed into a prepared osteotomy, parts of the implant body and threads come into direct contact with

bone. This primary bone contact provides primary stability. Since the stabilization provided is mechanical in nature, this

is often referred to as mechanical stability.

• As healing progresses, the original bone around the implant surface remodels and areas of new bone emerge at the implant

surface. The remodeled bone contact and new bone contact result in secondary or biologic stability. Biologic stability

predominates at later healing times and the influence of the primary stability decreases over time.
 Biology
• Bone healing resulting in biologic stability can be disturbed if the mechanical stability is

inadequate. Movement of the implant above a physiologic threshold is thought to disturb the

adjacent tissues and vascular structures, eventually resulting in failed osseointegration.

• As a result, when considering shortened loading protocols clinicians should focus on the:

1. Amount of primary bone contact/primary stability 

2. Quantity and quality of bone at the implant site

3. Pace of bone formation around the implant

 Biology
• In the case of inadequate primary stability, surgeons may elect to increase the diameter of the
implant being placed and/or avoid immediate loading.

• When existing bone of high quality and quantity is found and when other factors are favorable,
immediate loading of the implant may be possible.

• Bone quality and bone quantity are related to different areas in the mouth.

• An implant site in the anterior mandible is often a better candidate for a shortened loading protocol
when compared to a site in the posterior maxilla.

• In cases where implants are placed in type IV bone or heavily grafted bone, conventional loading
protocol may be beneficial.
 Biology
• The pace of bone formation may be favorably influenced by advances in, among other things,

implant surface technology.

• As a result, early loading is becoming routinely possible. Depending on the specific surface

technology, early loading may be accomplished in as little as three weeks.

CLINICAL RECOMMENDATIONS
 CLINICAL RECOMMENDATIONS

• Treatment planning for implant therapy should commence once the indication for tooth
extraction has been confirmed. Both the implant placement and loading protocol should be
planned prior to tooth extraction. The selection of the implant placement and
restoration/loading protocol should be based on achieving predictable outcomes:
A. Long-term hard and soft tissue stability

B. Optimal aesthetics.

C. Reduced risk for complications

D. Meet patient-specific and site-related criteria.

 CLINICAL RECOMMENDATIONS

• As part of the planning and consent process, alternative treatment modalities should be
in place, in the event that specific intra-operative procedural criteria are not met.

• Implant placement and restoration/loading protocols present with different levels of

clinical difficulty and overall treatment risk.

• When selecting treatment modalities, clinician skill and experience should match the
challenges associated with the selected protocol.
 CLINICAL RECOMMENDATIONS

• The implant placement and loading protocol can have a negative impact on survival and

success of specific selection criteria are not met, and/or execution of the clinical

procedure is of insufficient quality.

• Careful consideration of patient-centered benefits of the different implant placement and

loading protocols and the associated risks should be taken into consideration.
 CLINICAL RECOMMENDATIONS
IMMEDIATE PLACEMENT AND IMMEDIATE
RESTORATION/LOADING
• Complex surgical and prosthodontic procedure and should only be performed by clinicians with a high level of clinical
skill and experience.
• should only be considered when there are patient-centered advantages (e.g., aesthetic requirements, reduced
morbidity), and when the following clinical conditions are met:

A. Intact socket walls.

B. Facial bone wall at least 1 mm in thickness.

C. Thick soft tissue.

D. No acute infection at the site.

E. The availability of bone apical and lingual to the socket to provide primary stability.

F. Insertion torque 25–40 Ncm and/or ISQ value >70.

G. An occlusal scheme which allows for protection of the provisional restoration during function.

H. Patient compliance.
 CLINICAL RECOMMENDATIONS
WITH EARLY IMPLANT PLACEMENT
• Early implant placement may be considered in most clinical situations, such as sites with
thin facial walls and defects, often requiring simultaneous bone augmentation
procedures.

• Conventional loading (type 2-3C) is well documented and is recommended with early
implant placement.

• Immediate (type 2-3A) and early (type 2-3B) loading protocols combined with early
implant placement are not sufficiently well documented to be recommended as routine
procedures.
 CLINICAL RECOMMENDATIONS
WITH LATE IMPLANT PLACEMENT
• In the case of late implant placement,

Early loading (type 4B) and conventional loading (type 4C) are well-documented

protocols and may be considered routine.

• Late implant placement with immediate loading (type 4A) may be considered

when patient-centered advantages are present, and the criteria for immediate

restoration/loading are met.

CLINICAL CASE
 CLINICAL CASE
• This case illustrates some of the risks and dangers involved with a shortened loading
protocol. Here the patient presented with a non-restorable maxillary left central incisor and
would like to have an implant placed.
• Esthetics:
The implant site is in the esthetic zone
• Function:
The patient lacks posterior support
deep vertical overlap (overbite) present
• Structure:
Additional teeth require restoration
due to dental caries
• Biology: Thin biotype
 CLINICAL CASE
• The non-restorable tooth was extracted and an implant placed into the socket. The implant
was immediately restored with a screw-retained provisional.
 CLINICAL CASE

• At a three week post operative visit, the patient complained of mobility with the implant
restoration. The implant/provisional crown complex was removed by hand.
 CONCLUSION
• When using modern dental implants, conventional and early loading protocols are both

well-documented and predictable. Interdisciplinary teams may choose a longer healing

period in sites that are compromised or in patients in which healing is expected to be

altered.

• Immediate loading in partially edentulous patients is possible in select cases, but the

evidence for successful outcomes is less extensive.

 CONCLUSION
• Many patients are eager to have their treatment completed as rapidly as possible.

• Individual dentists and interdisciplinary teams are reminded that immediate loading has

increased risk of implant failure and should be used in esthetically critical areas only

after careful consideration of the benefits, risks and alternatives.

 REFERENCES
1.Albrektsson T, Wennerberg, A. (2013). The Science of Osseointegration. In Zarb, Hobkirk,
Eckert, Jacob. Prosthodontic Treatment for Edentulous Patients. St. Louis: Elsevier.
2.Beumer J, Faulkner R, Shah K, Moy P.(2015). Fundamentals of Implant Dentistry.
Quinessence.
3.Rowan M , Lee D, Pi-Anfruns J, Shiffler, P, Aghaloo, T, Moy P. (ahead of print). Mechanical
versus Biological Stability of Immediate and Delayed Implant Placement Using Resonance
Frequency Analysis. Journal of Oral and Maxillofacial Surgery.
4.A validation tool was used to determine the level of scientific and clinical documentation
for each combination of implant placement and loading protocols (Gallucci et al., 2009).
Thank you