Early loading versus immediate loading: case examples

Drs. Alberto Maltagliati, Andrea Ottonello, Giulio Raffaghello, and Andrea Mascolo explore esthetics and function of early and immediate loading implants

Introduction
“Immediate loading” is a favorite way to maintain appropriate anatomic and topographic proportions between dental arches, to maintain the contact with periodontal tissues, and for the “occlusal/ contact memory”.1-2 An edentulous area that remains this way for a long period of time may modify and even preclude the possibility of recreating an occlusion that is esthetic, functional, always predictable, and similar to the original.3 The concept of “primary stability,” torque wrench, osseointegration, and adequate/suitable denture, are the fundamental factors for immediate and long-distance clinical results.4-5 With immediate loading, the management of peri-implant soft tissues can lead to a long-term predictability with 30-year old case-studies;6-7 moreover, the waiting time for osseointegration allows for modulation/mediation of some human mistakes not managed in the early loading phases in the 72-hour prosthetic technique.8 The use of autologous fibrin glue in the same surgery increases the neoangiogenesis and the healing factors’ activity, also obtaining a better predictability regarding soft-tissue management.9-10

Case 1: (left to right): Figure 1A: Initial OPG; Figure 1B: Intra surgery: extractions and inserting fixtures; Figure 1C: Immediately after surgery: taking impression; Figure 1D: Detail; Figure 1E: Immediately after restoration; Figure 1F: OPG check after surgery.
Case 1: (left to right): Figure 1A: Initial OPG; Figure 1B: Intra surgery: extractions and inserting fixtures; Figure 1C: Immediately after surgery: taking impression; Figure 1D: Detail; Figure 1E: Immediately after restoration; Figure 1F: OPG check after surgery.

Aim of the study
The aim of this study was to demonstrate the concept of middle and long-term esthetic and functional predictability differentiating:

– full arch implant restoration, cemented technique, with loading after 60-90 days (early loading)

– full arch implant restoration, screwed technique, with loading after 72 hours (immediate loading) since fixture insertion.

Materials and methods
A retrospective analysis was conducted of patients undergoing implant therapy with a load time period shorter than the standard; the inclusion criteria was a follow-up period of over 2 years. Included in the study were 233 implants, of which 110 were in the jaw and 123 were in the maxilla: 18 patients, eight male and 10 female, received early loading treatment; two patients were under 50 years old, seven were under 60 years old, and the last nine were under 70 years old. Some patients presented systemic conditions: three were affected by heart disease, and one patient was affected by diabetes. In this patients’ group, we had 10 totally edentulous patients and eight only one arch edentulous patients.

Thirteen patients, seven male and six female, received immediate load treatment; eight patients were under 60 years old and five were under 70 years old. Two patients presented with heart disease. In this patients’ group, we had eight totally edentulous patients and five only one arch edentulous patients.

For the patients selected, two kinds of implants were used: Intra-Lock®International (Boca Raton, FL) and Tekka In-Kone® (Brignais, FR/EU), with a length from 4 to 13 mm. One hundred and seven implants were fitted with the finished prosthesis with a cemented technique after 60-90 days (early loading); 126 implants were fitted with the finished prosthesis with screwed technique after 72 hours (immediate loading).

The chosen technique was opercular and flapless, with the insertion of the implants at least 1 mm under the crestal bone level, to avoid the conic reabsorption peri-implant process. The impression was taken with the pick-up technique with polyvinyl siloxane (Identium® Kettenbach GmbH & Co. KG., Eschenburg, Germany). In the following 36 hours, we tried on the structure. Pick-up impression technique cemented. The prosthesis in metal-ceramic was cemented after 72 hours from implant placement.

Autologous fibrin glue was used with PRF methodic to increase peri-implant connective tissue formation and manage inflammation and healing, and accelerate vascularization by the growth factors (i.e. VEGF, PDGF) contained in the buffy coat.

All clinical cases have been monitored radiographically with the same machine 12 and 24 months after the loading date. The same doctor monitored all the clinical cases performing a periodontal probe after 6, 12, 18, and 24 months.

Case examples

Case 1 (Figures 1A-1F)
A 60-year-old female patient presented with a totally edentulous maxilla and previous maxillary sinus augmentation before implant restoration, with three 3Iimplants with external hexagon supporting a mandibular overdenture. It was decided that the best course of action was immediate loading with cemented technique adding five Intra-Lock CT 4 mm implants and using the previous implants.

The technique chosen was the opercular one, flapless, with the insertion of the implants at least 1 mm under the crestal bone level, to avoid the conic reabsorption peri-implant process. The impression was taken with the pick-up technique with polyvinyl siloxane. In the following 36 hours, the structure was tried on and cementation of the prosthesis in metal-ceramic took place 72 hours after surgery.

Case 2 (Figures 2A-2F)
A 45-year-old female patient was affected by chronical periodontitis. The treatment involved immediate loading at the maxilla with eight Intra-Lock CT implants 4 mm; we maintained first and second superior left molars for inter arch occlusal contacts. The prosthetic technique included a posterior region flat-one bridge with composite filling with screwed technique, with the intercanine area in metal-ceramic.

Multiple extractions were performed with maintenance of vestibular and interproximal cortical, and insertion of six Tekka In-Kone implants, which we chose for the excellent esthetic profile given by the switch-platform that reduces prosthetic spaces, increasing the periimplant connective tissue. Implant insertion 2 mm under the cortical bone allows for peri-implant bone regeneration. Pickup impression technique cemented. The prosthetic restoration was in metal-ceramic cemented after 72 hours from implant placement.

Case 2. (Left to right): Figure 2A: Fixture insertion: operculum; Figure 2B: Immediately after surgery: taking impression; Figure 2C: Impression: parallelism between fixtures; Figure 2D:Abutment inserted immediately after surgery; Figure 2E: Restoration cementation; Figure 2F: OPG.
Case 2. (Left to right): Figure 2A: Fixture insertion: operculum; Figure 2B: Immediately after surgery: taking impression; Figure 2C: Impression: parallelism between fixtures; Figure 2D:Abutment inserted immediately after surgery; Figure 2E: Restoration cementation; Figure 2F: OPG.

Results

After 18 months, we report a 2 mm conical peri-implant reabsorption on six implants loaded after 72 hours in parafunctional patients, having natural teeth opposing prosthetic full-arch rehabilitations. No reabsorption was noticed in patients with upper and lower full-arch restorations.11-12Two implants in the maxilla (first left molar and first right molar in the same patient), both loaded after 72 hours (immediate loading), failed.

Results confirmed an augmentation in short-term esthetics in the immediate loading technique within 24 months, with a physiological maintenance of the inter-implant papilla and a good trophism of the periodontal tissues.

Every technique used needed a good mid-and long-term predictability and repeatability, and with both methods we can assure esthetics and function.13

Table 1
Table 1
Top: Table 2; Bottom: Table 3
Top: Table 2; Bottom: Table 3

Conclusions

Finally, in our opinion, supported from the recorded data, the immediate loading technique (full-arch with screwed technique) represents the current “gold standard” in implant prosthetic restoration, because it reduces intraoperatory time and increases wound healing, in hard and soft tissues, with excellent patient compliance.

Alberto Maltagliati, DDS, earned his dental degree from the University of Genoa, in Italy. He has taught at the University of Genoa and the University of Chieti.

Andrea Ottonello, DDS, PhD, received his degree from the University of Genoa, and also earned a PhD at the same university. He has been a visiting PhD student and obtained a Fellowship in Periodontology at the Department of Periodontics and Oral Medicine at the University of Michigan, and is now a professor in Periodontology at the University of Genoa.

Giulio Raffaghello, DDS, graduated from the University of Pavia, Italy, and attended a course in endodontics. He is in private practice, with Dr. Mascolo, DDS, in research activities.

Andrea Mascolo, DDS, has a Master in Oral Surgery from the University of Pisa, Italy. He qualified for Implantology at the Brånemark Clinic, Gothenburg, Sweden and attended the Summer School Clinical Implantology Periodontology at the University of Heidelberg, Germany. He is founder and an active member of the Computer Aided Implantology (CAI) Academy and has been a Professor at the University of Genoa since 2001. He is a speaker and author in Italy and abroad, and is an international peer reviewer. He maintains a private practice in Novi Ligure, Italy, devoted to minimally invasive surgical procedures on compromised patients. He is UK GDC registered, and is an expert in periodontics and implantology in private clinics.

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