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SUMMER 2012 ISSUE
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The Do's and Don'ts of
Immediate Loading or Provisionalization of
Dental Implants

video continuing education

Darrin M. Wiederhold, DMD, MS

Overview

As the cosmetic expectations of implant patients increase, clinicians are strongly motivated to meet the demand for immediate loading or provisionalization of freshly placed implants. Bearing in mind the fundamental importance of unimpeded osseointegration, Glidewell Laboratories staff dentist Dr. Darrin Wiederhold outlines the Do's and Don'ts of immediate loading, providing guidelines for maximizing short- and long-term restorative success. After reviewing the article and accompanying video, take the CE test to earn two free credits.

About Dr. Wiederhold

wiederholdDr. 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 inclusivemagazine@glidewelldental.com.

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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

  • Attard NJ, Zarb GA. Immediate and early implant loading protocols: a literature review of clinical studies. J Prosthet Dent. 2005 Sep;94(3):242-58.
  • Balshi TJ, et al. A prospective analysis of immediate provisionalization of single implants. J Prosthodont. 2011 Jan;20(1):10-5.
  • Block M, et al. Single tooth immediate provisional restoration of dental implants: technique and early results. J Oral Maxillofac Surg. 2004 Sep;62(9):1131-8.
  • Block MS, et al. Prospective evaluation of immediate and delayed provisional single tooth restorations. J Oral Maxillofac Surg. 2009 Nov;67(11 Suppl):89-107.
  • Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants. 2004;19 Suppl:43-61.
  • Davidoff SR. Late stage soft tissue modification for anatomically correct implant-supported restorations. J Prosthet Dent. 1996 Sep;76(3), pp:334-8.
  • Degidi M, et al. Five-year outcome of 111 immediate nonfunctional single restorations. J Oral Implantol. 2006;32(6):277-85.
  • Kinsel RP, Lamb RE. Tissue-directed placement of dental implants in the esthetic zone for long-term biologic synergy: a clinical report. Int J Oral Maxillofac Implants. 2005 Nov-Dec; 20(6):913-22.
  • Kourtis S, et al. Provisional restorations for optimizing esthetics in anterior maxillary implants: a case report. J Esthetic Restor Dent. 2007;19(1):6-16.
  • Wismeijer D, et al. ITI Treatment Guide, Vol. 4: Loading Protocols in Implant Dentistry: Edentulous Patients. 2010. Berlin: Quintessence Publishing Co, Ltd.

Course Objectives (2 CE Credits)

With manufacturers touting the success rates of immediately loaded dental implants, clinicians may find themselves under increasing pressure to meet patient expectations for a same-day restorative solution – whether temporary or final – upon implant placement. Doing so, however, may endanger osseointegration in certain clinical situations. As with any surgical procedure, there are selection criteria that, if heeded, can help maximize the chances of success. Conversely, there are guidelines that clinicians ignore at their own peril. Dr. Darrin Wiederhold outlines the Do's and Don'ts of immediate loading with an analysis of the following concepts:
  • Distinguishing between "immediate loading" and "immediate non-functional provisionalization"
  • Measuring initial stability
  • Assessing bone quantity and quality
  • Identifying evidence of parafunctional habits or metabolic disorders
  • Splinting in multi-unit cases
  • Determining intra-arch space

CE Summary

As the cosmetic expectations of implant patients increase, clinicians are strongly motivated to meet the demand for immediate loading or provisionalization of freshly placed implants. For long-term success, however, it is critical that esthetic concerns do not outweigh factors used to promote successful osseointegration. Only after assessing the relevant clinical parameters and implementing the appropriate precautions should a clinician immediately provisionalize or load a newly placed implant.

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Newport Beach, Calif.
800-854-7256
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