Much like Hamlet's ageless lament, "To be, or not
to be," implant surgeons around the world are
plagued daily by the conundrum: "To immediately
load, or not to load?" Is it far better to suffer a patient's wrath
over a missing maxillary anterior tooth than endanger the
neophyte implant as it osseointegrates? That is the question,
and this, hopefully, is the answer.
An important distinction that must first be made concerns
the terms "immediate loading" versus "immediate nonfunctional
provisionalization" (or "temporization"). From an
academic point of view, "immediate loading" would be any
component that is attached to the implant within zero to
20 days of implant insertion and is placed under occlusal
stress or load. This term is further applied to any situation
where the implant undergoes micromotion and is designed
to be functional rather than just cosmetic. "Immediate nonfunctional
provisionalization" is a generic term denoting the
temporizing – generally for esthetics – of the implant, but
where the provisional component is purposely taken out
of occlusion in an effort to minimize any micromovement
of the implant that might hinder or compromise its
osseointegration. It is important to differentiate the two
terms and recognize that patients are demanding more
and more that we immediately provisionalize their implant,
but are not generally concerned with whether there is true
occlusal loading of the implant.
As with any surgical procedure, there are certain selection
criteria that, if heeded, can help to maximize the chance
of success. Conversely, there are those guidelines that
clinicians ignore at their own peril. The following are the
classic Do's and Don'ts of immediate provisionalization or
immediate loading.
DO'S
- Initial stability of 35 Ncm (Fig. 1)
- ISQ score of 50–80, with a higher
score correlating to a greater
degree of initial stability (Fig. 2)
- 1 mm–1.5 mm of facial bone
surrounding the implant (Fig. 3)
- Healthy, non-infected,
non-compromised bone (Fig. 4)
- No history of bruxism or other
parafunctional habits (Fig. 5)
DON'TS
- Initial stability of less than 35 Ncm
- ISQ scores below 50
- Deficiency of bone, particularly on
the facial aspect, or where bone
grafting is indicated or performed
(Fig. 6)
- Bone that has been compromised,
either through abscess,
periodontal disease, or other
local pathology
(Fig. 7)
- History of heavy bruxism,
clenching, or other destructive
parafunctional habits (Fig. 8)
When deciding whether to immediately provisionalize
or load, it is important to consider the
number of implants being placed and the ability to
splint those implants together. For single implant cases, the caveats noted previously are critical. For multiunit
cases, the ability to splint the implants together via the
provisional prosthesis – be it a complete denture, short- or
long-span bridge, or a hybrid – affords greater flexibility
in the decision to immediately load or provisionalize. There
is greater initial stability, minimization of occlusal stresses
and, therefore, reduced micromovement as a whole when
implants are splinted. As such, the ability of the implant to
integrate successfully into the surrounding osseous matrix
is greatly improved.
Bear in mind that these simple Do's and Don'ts can help
maximize the odds of success when placing implants.
Patient demand for immediate provisionalization is greater
than ever, and as providers of a service, we are strongly
motivated to meet that demand. But as dental professionals,
we are the final arbiters of what is in the patient's best
interest. If there is inadequate initial stability, compromised
bone quality or quantity, or if any of the other clinical
parameters are less than ideal, it is imperative that we as
clinicians make the unpopular decision not to immediately
provisionalize or load. It can be difficult to inform a patient
with high esthetic expectations that they will have to
endure a less-than-ideal cosmetic situation for the four to
six months of osseointegration. But, in the long run, what's
best for the implant is best for the patient.
Once the decision is made to temporize an implant case,
the method must be chosen. There are a variety of materials
and techniques available, but only the Inclusive® Tooth
Replacement System comes packaged with patient-specific
temporary components at the time of surgery, with the
goal of increasing restorative predictability and reducing
chairtime when compared to the use of stock components
or handmade custom components. Additionally, the
Inclusive Tooth Replacement System gives the clinician
the flexibility to temporize the case at any point in the
process, be it the day of placement, or at a future date –
whenever it is determined that the implant has achieved
sufficient stability. In those instances where placement of
a custom temporary abutment and BioTemps® provisional
crown are not immediately indicated, the option exists to
place the custom healing abutment instead. By doing so,
the benefit of immediately beginning to develop the soft tissue architecture around the implant is achieved
without the worry of any occlusal stress on the
newly placed fixture.
By treatment planning with the end in mind from
the outset, many of the challenges clinicians often
encounter, both surgically and restoratively, can
be minimized. Having custom-fitted components
designed to guide implant placement, develop
soft tissue architecture, satisfy the patient's
esthetic demands, and improve impression
quality all help to simplify the implant process.
Furthermore, because the process is more
efficient and streamlined, fewer appointments
are required, and there is greater predictability
during those appointments. Greater predictability
means fewer scheduling challenges for the front
office staff, translating to greater profitability for
the practice.
GENERAL REFERENCES
Dr. Darrin Wiederhold received his DMD in 1997 from Temple University School of Dentistry and a master's degree in oral biology in 2006 from the Medical University of Ohio at Toledo. Before joining Glidewell in August 2011, he worked in several private practices and as a staff dentist for the U.S. Navy. As a staff dentist in Glidewell's Implant division, he performs implant and conventional restorative procedures at the lab's on-site training facility, and helps support the lab's digital treatment planning and guided surgery services. An integral part of the lab's Implant Research & Development group, he is also involved in training and education on implant surgery and prosthetics. Contact him at 
