LOADING PROTOCOLS
Presented by:
Polykarpos Memy Mahrous
OUTLINE
• Introduction
• Classification Of Loading Protocols
• Factors Affecting Loading
• Advancements In Loading Protocols
• Case Examples
Introduction
1. Definition of loading
2. Loading VS placement
3. Biology and biomechanics after
implant placement
Introduction
Dental implant loading:
“the process of placing axial or tangential force
on a dental implant, usually associated with the
intentional exposure of the dental implant, either
at the time of initial surgical placement of the
dental implant or subsequent to surgical
exposure.”
Ferro, K.J., Morgano, S.M., Driscoll, C.F., Freilich, M.A., Guckes, A.D., Knoernschild, K.L., McGarry, T.J. and Twain, M., 2017. The glossary
of prosthodontic terms.
Introduction
1. Definition of loading
2. Loading VS placement
3. Biology and biomechanics after
implant placement
Introduction
Implant Loading Implant Placement
Introduction
Implant Loading: Implant Placement:
Introduction
1. Definition of loading
2. Loading VS placement
3. Biology and biomechanics after
implant placement
Introduction
Biomechanics after implant placement
• The bone healing process after implant
placement is comparable to the primary
healing of stable fractures.
• The phase immediately subsequent to
implant placement is initiated by the
surgical trauma of implant site
preparation,
• it occurs independently of whether an
implant has been inserted or not.
Nevins, M. and Wang, H.-L. (2020) Implant therapy: Clinical approaches and evidence of success, Second edition.
Batavia: Quintessence Publishing Co.
Introduction
Biomechanics after implant placement
• With optimal site preparation, the bone walls
of the implant site provide the necessary
primary stability.
• Immediately after implant insertion,
resorption of the peri-implant bone occurs,
a natural process that is needed to create
the space for the new bone that will
eventually replace the original bone.
Nevins, M. and Wang, H.-L. (2020) Implant therapy: Clinical approaches and evidence of success, Second edition.
Batavia: Quintessence Publishing Co.
Introduction
Biomechanics after implant placement
• Therefore, the bone remodeling process implies a
decrease of the implant’s initial stability,
• Certain period of healing time is necessary before a
new secondary stability, due to newly formed bone,
is achieved.
• Implant manufacturers attempted to reduce the
duration and magnitude of this stability dip by
improving the mechanical and surface
characteristics of the implant and by altering the
drilling protocol.
Nevins, M. and Wang, H.-L. (2020) Implant therapy: Clinical approaches and evidence of success, Second edition.
Batavia: Quintessence Publishing Co.
Introduction
Biomechanics after implant placement
Primary stability Stability dip secondary stability
Resnik, R.R. and Misch, C.E. (2021) Misch's contemporary implant dentistry. St. Louis: Elsevier.
Introduction
Biomechanics after implant placement
• Histologic and biomechanical analyses suggest that, if implants are
subjected to immediate loading, the peri-implant bone undergoes
rapid and intense resorption between the second and fourth week of
functional loading.
• Consequently, the primary stability is reduced and may reach a
critical threshold
• It might be risky to perform prosthetic maneuvers on implants during
this period since they might compromise implant stability and cause
early failure.
Nevins, M. and Wang, H.-L. (2020) Implant therapy: Clinical approaches and evidence of success, Second edition.
Batavia: Quintessence Publishing Co.
Introduction
Biomechanics after implant placement
• For this reason, the conclusive phase of the prosthetic rehabilitation
should preferably be postponed to at least 2 to 3 months after
implant Placement
• At this stage, the newly formed bone should provide adequate
secondary stability to the implant in order to withstand the
procedures of screwing and unscrewing the abutment.
Nevins, M. and Wang, H.-L. (2020) Implant therapy: Clinical approaches and evidence of success, Second edition.
Batavia: Quintessence Publishing Co.
OUTLINE
• Introduction
• Classification Of Loading Protocols
• Factors Affecting Loading
• Advancements In Loading Protocols
• Case Examples
Classification Of Loading Protocols
According to Timing According to Forces
1. Immediate Loading 1. Functional Loading
2. Early Loading 2. Non-functional Loading
3. Conventional Loading
4. Delayed Loading
Tettamanti L, Andrisani C, Bassi MA, Vinci R, Silvestre-Rangil J, Tagliabue A. Immediate loading implants: review of the critical aspects. Oral Implantol
(Rome). 2017 Sep 27;10(2):129-139. doi: 10.11138/orl/2017.10.2.129. PMID: 29876038; PMCID: PMC5965071.
Classification Of Loading Protocols
1. According to Timing:
• Immediate loading:
“A prosthesis is connected at the time of implant placement. This is
usually a provisional restoration that is replaced with a definitive
restoration after implant and soft tissue healing.”
• Early loading:
“The prosthesis connection occurs from 2 to 3 weeks after implant
placement. This is considered to be a less predictable loading
protocol because the restoration is sometimes placed during the
stability dip, which is the period of lowest implant stability.”
Resnik, R.R. and Misch, C.E. (2021) Misch's contemporary implant dentistry. St. Louis: Elsevier.
Classification Of Loading Protocols
1. According to Timing:
• Conventional loading:
“Restoration occurs after the initial bone and soft tissue healing
process, usually in 3 to 6 months, depending on bone density”
• Delayed loading:
“The prosthesis is connected 6 to 12 months after implant
placement. This method is often chosen in poor quality bone and
in situations in which primary stability cannot be achieved during
surgical placement.”
Resnik, R.R. and Misch, C.E. (2021) Misch's contemporary implant dentistry. St. Louis: Elsevier.
Classification Of Loading Protocols
1. According to Timing:
Resnik, R.R. and Misch, C.E. (2021) Misch's contemporary implant dentistry. St. Louis: Elsevier.
Classification Of Loading Protocols
According to Timing According to Forces
1. Immediate Loading 1. Functional Loading
2. Early Loading 2. Non-functional Loading
3. Conventional Loading
4. Delayed Loading
Tettamanti L, Andrisani C, Bassi MA, Vinci R, Silvestre-Rangil J, Tagliabue A. Immediate loading implants: review of the critical aspects. Oral Implantol
(Rome). 2017 Sep 27;10(2):129-139. doi: 10.11138/orl/2017.10.2.129. PMID: 29876038; PMCID: PMC5965071.
Classification Of Loading Protocols
2. According to Forces:
• Functional loading:
“The prosthesis is in contact with the
opposing dentition in centric occlusion.”
• Non-Functional loading:
“The prosthesis is not in contact in centric
occlusion with the opposing dentition in the
natural jaw position.”
Resnik, R.R. and Misch, C.E. (2021) Misch's contemporary implant dentistry. St. Louis: Elsevier.
Classification Of Loading Protocols
According to Timing According to Forces
1. Immediate Loading 1. Functional Loading
2. Early Loading 2. Non-functional Loading
3. Conventional Loading
4. Delayed Loading
Tettamanti L, Andrisani C, Bassi MA, Vinci R, Silvestre-Rangil J, Tagliabue A. Immediate loading implants: review of the critical aspects. Oral Implantol
(Rome). 2017 Sep 27;10(2):129-139. doi: 10.11138/orl/2017.10.2.129. PMID: 29876038; PMCID: PMC5965071.
Classification Of Loading Protocols
A. According to Timing:
• Classic protocols propose that implants should receive no loading during
the osseointegration period, usually 3 to 4 months in the mandible and 6 to
8 months in the maxilla .
• Updated protocols have shortened the healing period, so that implants
could be loaded early and even immediately, before osseointegration is
completely obtained.
Resnik, R.R. and Misch, C.E. (2021) Misch's contemporary implant dentistry. St. Louis: Elsevier.
Classification Of Loading Protocols
Tettamanti L, Andrisani C, Bassi MA, Vinci R, Silvestre-Rangil J, Tagliabue A. Immediate loading implants: review of the critical aspects. Oral
Implantol (Rome). 2017 Sep 27;10(2):129-139. doi: 10.11138/orl/2017.10.2.129. PMID: 29876038; PMCID: PMC5965071.
Classification Of Loading Protocols
Esposito M, Grusovin MG, Willings M, Coulthard P, Worthington HV. The effectiveness of immediate, early, and conventional loading of dental implants: a
Cochrane systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Implants. 2007 Nov-Dec;22(6):893-904. PMID: 18271370.
Classification Of Loading Protocols
According to Timing According to Forces
1. Immediate Loading 1. Functional Loading
2. Early Loading 2. Non-functional Loading
3. Conventional Loading
4. Delayed Loading
Tettamanti L, Andrisani C, Bassi MA, Vinci R, Silvestre-Rangil J, Tagliabue A. Immediate loading implants: review of the critical aspects. Oral Implantol
(Rome). 2017 Sep 27;10(2):129-139. doi: 10.11138/orl/2017.10.2.129. PMID: 29876038; PMCID: PMC5965071.
Immediate Loading
Advantages:
1. Less Discomfort for Patients
2. Faster Treatment
3. More Ideal Soft Tissue healing
4. Patient Satisfaction and Acceptance
Resnik, R.R. and Misch, C.E. (2021) Misch's contemporary implant dentistry. St. Louis: Elsevier.
Immediate Loading
Disadvantages:
1. Increased Skill Level Required
2. Initial Surgical/Prosthetic Appointment
Longer
3. Possible Increased Implant failure
Resnik, R.R. and Misch, C.E. (2021) Misch's contemporary implant dentistry. St. Louis: Elsevier.
Immediate Loading
Prerequisites for Immediate-Loading
Protocol:
1. Adequate Bone Density:
• Bone density should be favorable for an immediate
loaded prosthesis
• However, in some cases of poor bone quality,
achieving an insertion torque greater than 35 N-cm is
unachievable
• In ssituations the immediate-loading protocol is not
recommended, and a healing period of 4 to 6 months is
suggested before loading the dental implants
Resnik, R.R. and Misch, C.E. (2021) Misch's contemporary implant dentistry. St. Louis: Elsevier.
Immediate Loading
Prerequisites for Immediate-Loading
Protocol:
2. Sufficient Bone Dimensions
• it is essential that sufficient height and width of
bone are available for the placement of implants.
• Lazzara et al. stated that 12 mm of available
bone height is recommended and 6 mm of
available bone width is required for adequate
support
Resnik, R.R. and Misch, C.E. (2021) Misch's contemporary implant dentistry. St. Louis: Elsevier.
Immediate Loading
Prerequisites for Immediate-Loading
Protocol:
2. Sufficient Bone Dimensions.
• In clinical cases of compromised bone quantity,
immediate-loaded implants may be at higher
risk for bone loss or failure, therefore more
implants or implants with a greater surface
area are recommended.
Resnik, R.R. and Misch, C.E. (2021) Misch's contemporary implant dentistry. St. Louis: Elsevier.
Immediate Loading
Prerequisites for Immediate-Loading
Protocol:
3. Ideal Insertion Torque
• the immediate-loading concept is based on obtaining
an insertion torque of greater than 35 N-cm to
provide sufficient implant stability
• In most clinical situations with favorable bone quality
(D1, D2, D3), insertion torque of greater than 35 N-cm
is usually attainable.
• In clinical situations of less dense bone (D3, D4), this
is often difficult.
Resnik, R.R. and Misch, C.E. (2021) Misch's contemporary implant dentistry. St. Louis: Elsevier.
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