DENTAL IMPLANT PLACEMENT AND LOADING PROTOCOLS

BY

Prof. Dr. Osama Baraka

Implant placement protocols:

Implant placement protocols have been differentiated by the duration

of the healing period following tooth extractions prior to implant placement.
Different implant placement options have been clinically applied. These
options include the following:

a- Immediate implant placement on the day of extraction (Type 1).

The overall treatment time with immediate and early implant placement is
reduced. However, dimensional changes following tooth extraction occur,
which may lead to compromised long‐term aesthetic outcomes. There is
often a bone defect at the facial aspect where the alveolar buccal bone wall
is either thin or missing. This is more marked in the anterior maxilla than
posterior sites and varies according to the initial thickness of the buccal
plate at the time of tooth extraction. This approach is often associated with
a local contour augmentation at the time of implant placement using guided
bone regeneration (GBR) to compensate for these ridge alterations.

b- Early implant placement after 4–8 weeks of soft tissue healing

(Type 2).

c- Early implant placement after 12–16 weeks of partial bone healing

(Type 3).

d- Late implant placement after complete bone healing of at least 6

months (Type 4).

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 Implant loading protocols

Implant loading protocols have been differentiated by the duration of

the healing period following implant placement prior to the initial delivery of
a provisional or definitive implant restoration. Implant loading protocols are
(a) Immediate loading of dental implants is defined as being earlier than 1
week after implant placement, (b) Early loading of dental implants between
1 week and 2 months after implant placement, (c) Conventional loading of
dental implants >2 months after implant placement and (d) progressive
loading.

Determining Loading Protocol

In order to determine which loading protocol is most appropriate for a

specific patient, several factors must be considered. These factors are:

1- 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. However, 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.
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 Immediate placement and provisionalization in esthetically critical area

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.

2- 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.

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

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in cases of worn dentition where the etiology cannot be distinguished and/or
occlusion cannot be managed adequately.

3- 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. 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.

Implant site require augmentation.

4- Biology

Successful osseointegration depends on several factors:

1. Suitability of the implant material
2. Careful site preparation
3. Adequate stabilization of the implant
Of these three factors, adequate stabilization of the implant is the
most critical to selecting a loading protocol. Loading protocols should be

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viewed as dependent on, among the other factors described here, two
distinct processes: primary and secondary implant stabilization.

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.

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
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.

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 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.

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.

Conventional (Delayed) Loading

Implant dentistry is based on the osseointegration´s concept, which

consists of the direct and close union between dental implant and bone
surface without the interposition of any tissue. Conventional loading is
defined as the prosthetic restoration and functional loading of an
osseointegrated implant after a healing period of three to six months. The
delayed loading may be:

a. One-stage delayed occlusal loading: The implant is positioned

slightly above the soft tissue during the initial implant placement. The implant
is restored into occlusal load after more than 3 months.

b. Two-stage delayed occlusal loading: The soft tissue covers the

implant after initial placement. A second-stage surgery after 3 months
exposes the implant to the oral environment.

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 Prerequisites for the 2-stage surgical protocol:

1- Countersinking the implant below the crestal bone.

2- Obtaining and maintaining a soft-tissue covering over the implant for

3 to 6 months.

3- Maintaining a minimally loaded implant environment for 3 to 6

months.

The primary reasons cited for the submerged, countersunk, surgical

approach to implant placement were:

1- To reduce and minimize the risk of bacterial infection.

2- To prevent apical migration of the oral epithelium along the body of

the implant.

3- To minimize the risk of early implant loading during bone

remodeling. After this procedure, a second-stage surgery was necessary to
uncover these implants and place a prosthetic abutment. Predictable, long-
term, clinical rigid fixation has been reported after this protocol in patients
who were either completely or partially edentulous.

Indications of delayed loading:

As a general rule, the delayed healing approach is the most predictable

for osseointegration in implant dentistry. It depends less on patient
cooperation relative to diet, maintenance, and parafunctional habits.
Therefore, if the patient is able to wear a removable restoration and does not

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have a concern relative to the delayed-treatment approach, it is prudent to
use the long-established protocols of delayed loading.

Immediate loading

It was believed that osseointegration could only be achieved if no loads

were applied to the implant for periods of not less than 3-4 months in the
mandible and 5 to 6 months in the maxilla. Excessive functional load or
traumatic occlusion might cause overstress leading to marginal bone loss
around dental implants. Currently information indicates that dental implants
can be loaded immediately after placement when there are adequate height
and bone density. But in bone types III or IV, higher failure rate was reported.

Immediate occlusal loading: Occlusal load to an implant prosthesis

within 2 weeks of implant insertion. The implant is placed with adequate
primary stability; its corresponding provisional or definitive restoration has
full centric occlusion in maximum intercuspation.

Nonfunctional immediate restoration: An implant prosthesis in a

patient who is partially edentulous delivered within 2 weeks of implant
insertion with no direct occlusal load. The implant is placed with adequate
primary stability but is not in functional occlusion. These implant restorations
are essentially used for aesthetic purposes, frequently in single-tooth or
short-span applications. Immediate non-occlusal loading is often performed
when a provisional removable prosthesis is undesirable during the healing
period. These are evaluated by sliding tapes of known thickness, up to 1 mm
clearances for the anterior sector, and 1.5 mm for the posterior sector.

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 Advantages of immediate loading:

1- Eliminates the need for and maintenance of a removable provisional

prosthesis.

2- Provides emotional benefit for a patient scheduled to be rendered

edentulous.

3- Improves bone healing.

4- Facilitates soft tissue shaping.

5- Eliminates premature implant exposure often associated with

wearing of a removable denture during healing period.

Disadvantages of immediate loading:

1- Bone turnover during the healing period may compromise implant

stability and reduce the ability of an implant to resist significant lateral forces
prior to adequate osseointegration.

2- It requires more chair time at the time of implant placement for both
the patient and the restorative practitioner.

3- Requires effective communication and coordination among the

surgical and restorative teams. The surgical and restorative procedures can
be completed in a single appointment for straightforward cases. For other
cases, the prosthesis may be more appropriately delivered one to two days
following implant placement.

Indications of Immediate loading:

1- Completely edentulous jaw, partially edentulous jaw and patients

with missing dentition requiring long span fixed partial denture.

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 2- Patient who are not willing to use a removable type prosthesis.

3- Immediate loading protocol should be limited to the patients who

have the most to gain and least to lose. E.g. Patients who cannot tolerate a
removable prosthesis due to social or psychological reasons.

4- Patients who cannot wait for 3 months for the prosthesis.

5- Adequate bone quality (Types I, II, or III)

6- Sufficient bone height (i.e. approximately 12mm) for a minimum

length 10mm implant

7- Sufficient bone width (i.e. approximately 6mm)

8- Ability to achieve an adequate anterior-posterior (AP) spread

between the implants. A poor AP spread decreases the mechanical
advantage gained by splinting and the ability to cantilever the restoration.

Illustration of the proper anterior-posterior (AP) spread used to calculate cantilever of

the prosthesis (Cantilever length=1.5x).

Contraindications of Immediate loading:

1. Severe metabolic disease

2. Inadequate bone volume for correct implant placement

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 3. Very poor bone density (D4)

4. Severe parafunction (eg, bruxing, clenching, tongue thrust).

5. Noncompliant patient types (eg, diet limitations, gum chewing).

6- Chronic smoker.

Guidelines for immediate loading by Tarnow et al:

1. Immediate loading should be attempted in dentulous arches only, to

create cross-arch stability

2. The implants should be at least 10mm long.

3. A diagnostic wax-up should be used for the template and the

provisional restoration fabrication.

4. A rigid metal casting should be used on the lingual aspect of the

provisional restoration.

5. A screw retained provisional restoration should be used where

possible.

6. If cemented, the provisional restoration should not be removed

during the 4-6-month healing period.

7. All implants should be evaluated with Periotest at StageI, and the

implants that show the least mobility should be selected for the immediate
loading.

8. The widest possible anterior-posterior distribution of the implants

should be used.

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 Immediate loading with overdentures:

Patients with completely edentulous mandibles restored with an

overdenture are at the least risk of occlusal overload for immediate loading
protocols.

The guidelines for a mandibular implant overdenture:

1. Completely edentulous mandible.

2. Abundant to moderate bone height and width.

3. Prosthetic space ≥12 mm.

4. Opposing a maxillary denture.

5. At least 4 implants inserted between the mental foramenae.

6. Screw-type implants ≥10 mm long and ≥ 4 mm wide at the crest

module.

7. When possible, the implants should engage the opposing cortical

plate.

8. Splint implants together with a bar or a fixed bridge.

9. Minimum cantilever on bar (≤1 × anterio-posterior distance).

10. Sleep without the prosthesis.

11. Severe bruxism contraindicated.

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 Left, Panoramic radiograph of edentulous mandible well suited for immediate load
overdenture. Right, Flapless procedure for placement of six one-piece, single-stage
implants.

Left, Immediate impression taken with impression coping for laboratory model and
analogs. Middle, Bar fabricated for placement within 24 hours. Right, Bar placement
passively seated and rigidly connecting all implants.

Left, Full maxillary denture and mandibular over-denture. Middle, Conversion of bar to
fixed mandibular prosthesis. Right, Panoramic radiograph 2 years after implant
placement and insertion of fixed bridge.

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 Immediate loading with fixed restoration- completely edentulous:

The benefit-risk relationship for a patient with completely edentulous

mandibles who desires a fixed prosthesis is high.

Immediate loading guidelines for immediate loading complete

edentulous fixed prostheses: The cemented transitional restoration should
be screw retained or use a definitive cement (e.g. polycarboxylate or glass
ionomer cement) rather than a more temporary, weaker cement.

Surface-area factors

1. Implant number

Eight or more splinted implants for the completely edentulous maxillary

arch and 5 or more splinted implants for the mandible. More implants if the
bone is poorer in quality (D3) or force factors are greater (e.g. crown height,
mild to moderate parafunction).

2. Implant size

a- At least 10 mm long and 4 mm wide.

b- Larger-diameter implants in the posterior molar regions of the

mouth. If larger diameter is not possible, greater implant number is
suggested (e.g. 2 implants for each molar).

3. Implant design: Threaded implants.

4. Implant surface condition: Rough surface area implants.

Force factors

1. Patient conditions: Mild to moderate parafunction, and muscular

dynamics require more implants.
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 2. Implant position: In the completely edentulous maxilla, anterior
implants should be at least in the bilateral canine position and posterior
implants in the first to second molar position for the largest anterior-posterior
dimension. In the mandible, at least 1 implant in the anterior section and 1 in
each posterior region is necessary. The largest anterior-posterior dimension
possible should be used.

3. Occlusal contacts: Only anterior occlusal contacts in the

transitional restoration (first bicuspid to first bicuspid).

4. Cantilevers: No posterior cantilevers should exist on transitional

restorations in either arch.

5. Occlusal load direction

a- Narrow occlusal tables and no posterior offset loads on the

transitional prosthesis.

b- Long axis loads to the implant bodies whenever possible.

6. Diet: Soft.

Partially edentulous- multiple adjacent teeth:

The patient who is partially edentulous, missing 2 or more adjacent

teeth, and requesting immediate restoration is a moderate benefit risk ratio.
The patient who is partially edentulous and missing several adjacent teeth
should limit the use of immediate restoration to the esthetic zones, where 1
implant may be inserted for each tooth. The transitional restoration should
avoid occlusal contact to decrease the risk of parafunctional overload.

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 Immediate loading guidelines for patients who are partially
edentulous (missing 2 or more adjacent teeth):

Patient conditions: Esthetics zones

Implant number: One implant or tooth when possible

Implant size

1. At least 10 mm long and 4 mm wide (when possible).

2. Larger diameters for molars.

Implant design: Screw-type implant.

Implant surface condition: Rough.

Occlusal contacts: No occlusal load for at least 2 to 3 months.

Cantilever: No cantilever load.

Diet: Soft

Parafunction: No gum or pencil chewing or tongue thrust.

Left, Prefabricated final zirconia abutments for two implants and a three-unit bridge.
Middle, Acrylic temporary bridge used after implant placement. Right, Prefabricated
surgical guide replication model-based planning.

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 Left, Implants placed with final zirconia abutments torqued onto implants. Middle,
Temporary bridge placed and soft tissue positioned and sutured to establish emergence
profile of teeth and provide soft tissue support. Right, Final bridge cemented at 2
months.

Immediate loading with single tooth

The immediately restored single tooth implant has an increased risk of

failure of about 5% in the first year.

Immediate loading guidelines for single-tooth replacement

1. In the esthetic zone

2. Ideal soft-tissue conditions and ideal bone condition

3. Ideal implant position

4. No occlusion on transitional restoration

5. D1, D2, and D3 bone type in region

6. Screw, shape implant body

7. 12 mm long (engage cortical bone at apex where possible)

8. Soft diet

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 9. Cement the transitional prosthesis with definitive cement or screw
retain.

Left, Edentulous site (tooth #5) 8 weeks following extraction and socket preservation.
Middle, Placement of implant with figure mount transfer pin (note the mark on transfer
pin to precisely place implant at level of bone). Right, immediate impression taken for
future final abutment and restoration.

Left, Custom chair-side fabrication of composite provisional on temporary plastic

abutment. Middle, Contours established for emergence profile and soft tissue support.
Right, Temporary provisional in place (screw retained) immediately after implant
placement.

Early occlusal loading

An implant is placed with adequate primary stability and is placed

under full occlusal load and prosthetic function within two months. A
fundamental goal of early loading is improving bone formation in order to

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support occlusal loading at two months. Early loading, in contrast to
immediate occlusal loading, is based on the interaction of the implant surface
with the host bone for achieving biologic implant stability.

Nonfunctional early restoration

An implant restoration delivered to a patient who is partially edentulous

between 2 weeks and 3 months after implant insertion with no direct occlusal
load.

Guidelines for early loading:

1- The final restoration should be performed after six to eight weeks,

with a final torque of 35 N. There is greater risk of osseointegration failure
than in conventional loading, and no significant differences with immediate
loading.

2- Improvements in surface treatments are essential.

3- It also requires greater clinical experience.

4- Stability measurement must be performed, it assesses the stability

of the implant and helps determine the appropriate loading time or predict
early signs of failure.

5- An important factor is the existence of sufficient volume and bone

tissue of suitable quality.

6- Implant diameter does not appear to be significantly important, but

length is, as better values are obtained with an increase in the BIC area.

7- Avoiding parafunctional habits, especially before six to eight weeks

have elapsed.

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 8- As for immediate loading, Occlusal contacts are selected only in
cases of full arches without occlusal contacts for individual restorations, with
spaces without occlusion.

9- For all cases, soft diet is indicated after 4 to 8 weeks, as well as

avoiding chewing on the compromised side.

Progressive bone loading protocol (PL)

Misch proposed the concept of progressive or gradual bone loading

during prosthetic reconstruction to decrease crestal bone loss and early
implant failure of endosteal implants. It allows the bone to adapt to increasing
amounts of biomechanical stress. Hence, rather than immediately loading
the bone–implant interface, methods to slowly increase the stress over time
are a benefit. Bone is slightly overloaded and reacts by increasing its
formation, growing denser and improving its quality.

The progressive loading protocol uses a cement-retained prosthesis

when implants are splinted together. Because a screw retained splinted
restoration is not completely passive and a torque force applied to a screw
is greater than a bite force, a traditional screw-retained restoration cannot
use progressive loading to gradually load the bone.

Indications of progressive loading:

Full-arch prostheses with little or no cantilever and adequate implant

number, position, and size rarely require progressive loading. However, the
fewer the number of implant or the softer the bone types, the more
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progressive loading is suggested. As a general rule, the higher the risk
factors, the more progressive loading is recommended.

Elements of Progressive Loading:

Fig. (): Elements of progressive loading protocol.

1- Time interval:

The time period between surgical placement and full occlusal loading
is variable, depending on the bone density. In softer bone, a longer period of
time of initial healing and gradual loading is suggested. As a general rule, D1
bone uses a 3 or more-month period before loading, D2 bone a 4 or more-
month period, D3 bone a 5 or more-month initial healing period, and D4 bone
uses a 6 or more-month period.

Four prosthodontic steps are suggested for the reconstruction of a

partially or completely edentulous patient, with endosteal implants
supporting a cemented prosthesis. The four prosthetic steps are (1)
abutment insertion, preparation, final impression and temporary (of the
esthetic zone); (2) a metal try-in and new bite registration; (3) initial delivery
of the prosthesis; and (4) final evaluation of the restoration and hygiene

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appointment. Each of the four major prosthodontic appointments also are
separated by a period of time related to the bone density observed at the
initial time of surgery. In addition, the dentist attempts to gradually increase
the load to the implant at each prosthetic step. (Table ).

Table (): Treatment Times for Progressive Bone Loading for

Cement-Retained Prostheses:

Bone Density Initial Healing Interval Reconstruction Total Time

(months) Between (weeks) (months)
Appointments
(weeks)

D1 3 1 3 4

D2 4 2 6 5-5

D3 5 3 9 7

D4 6 4 12 9

2- Diet:

The dentist controls the diet of the patient to prevent overloading during
the early phases of the restorative process. During the initial healing phase,
the dentist instructs the patient to avoid chewing in the area, especially when
the implants are placed in a one-stage approach, with an exposed healing
abutment. After being uncovered, the implant connected to an abutment for
cement retention is at greater risk of loading during mastication. The patient
is limited to a soft diet such as pasta and fish, from the final impression stage
until the initial delivery of the final prosthesis. After the initial delivery of the
final prosthesis, the patient may include meat in the diet. A normal diet is

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permitted only after evaluation of the final prosthesis function, occlusion, and
proper cementation.

3- Occlusal Material:

The occlusal material may be varied to gradually load the bone–

implant interface. During the initial steps, the implant has no occlusal contact
and thus in essence has no material over it. At subsequent appointments,
the dentist uses acrylic as the occlusal material, with the benefit of a lower
impact force than metal or porcelain. Either metal or porcelain can be used
as the final occlusal material.

If parafunction or cantilever length causes concern relative to the

amount of force on the early implant–bone interface, the dentist may extend
the softer diet and acrylic restoration phase several months. In this way, the
bone has a longer time to mineralize and organize to accommodate the
higher forces.

4- Occlusion:

No occlusal contacts are permitted during initial healing (step 1). The
first transitional prosthesis is left out of occlusion in partially edentulous
patients (step 2). The occlusal contacts then are similar to those of the final
restoration for areas supported by implants. However, no occlusal contacts
are made on cantilevers or offset loads (step 3). The occlusal contacts of the
final restoration follow the implant protective occlusion concepts.

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 5- Prosthesis Design:

During initial healing, the dentist attempts to avoid any load on the
implants, including soft tissue loads. Hence, in a completely edentulous
patient, relief and a soft tissue conditioner (also relieved) may be used. The
first transitional acrylic restoration in partially edentulous patients has no
occlusal contact and no cantilevers. Its purpose is to splint the implants
together and reduce stress by the mechanical advantage and to have
implants sustain masticatory forces solely from chewing.

The second acrylic transitional restoration has occlusal contacts

placed over the implants with occlusal tables similar to the final restoration
but with no cantilevers in non-esthetic regions. The final restoration has
narrow occlusal tables and cantilevers designed with occlusal contacts
following implant-protective occlusion guidelines.

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 Summary of implant loading protocols
Loading Indications Contraindications Advantages Disadvantages
Concepts
IMMEDIATE - Adequate - Poor systemic - Eliminates the - Cannot be
LOADING bone quality health need for and applied to every
- Sufficient - Severe maintenance of a implant patient
bone height parafunctional removable - Requires more
and width habits provisional chair side time
- Ability to prosthesis
achieve an - Bone of poor
adequate quality - Improves bone
antero posterior healing
spread - compromised - Reduced
between the Bone height and treatment time
implants. width and Cost
- Inability to effective
achieve an
adequate AP
spread
EARLY - Sufficient - Smokers with - Reduced - Crestal bone
LOADING bone quality uncontrolled DM treatment time loss
- History of failed - Cost effective - primary stability
implants compromised
- Large deviation
in saggital/vertical
bite relation
DELAYED - Can be done - No absolute - Reduced risk of - Time consuming
LOADING for all contraindication bacterial infection
prosthesis - Prevents apical
migration of oral
epithelium along
implant body
PROGRESSI - Few implants - No absolute - Decreased - Time consuming
VE LOADING planned contraindication crestal bone loss
- Softer bone but most critical in - No early implant
types D4 type bone failure

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