How to Perform a Predictable and Successful Implant Loading?

Dentists nowadays, love to perform immediate implant loading; This is perhaps their patients do not want to wait

Dentists nowadays, love to perform immediate implant loading; This is perhaps their patients do not want to wait for six months before they can start chewing with their implants. Whatever the reason may be, if you look at the statistics, you will find that almost every dentist around you will prefer to go for immediate implant loading, whenever possible.

But What Actually Immediate Loading is?

While searching for these statistics, I found something very interesting; There are a huge controversy and difference of opinion among dentists regarding immediate loading. While there is a consensus that immediate implant loading refers to functionalizing an implant within 48-72 hours of its insertion, there are differing opinions between occlusal and non-occlusal loading.

Before we discuss more achieving success with immediate implant loading, let us look at its primary objective, apart from patient demand. The idea behind immediate implant loading is to minimize the risk of fibrous integration. Ideally, we want to promote the formation of lamellar bone around the implant, which is a highly mineralized and strongest type of bone. In contrast, the woven bone is an immature, unorganized and poorly mineralized type of bone[1] which is really a nightmare for dentists when it comes to implant stabilization.

Ensuring Success with Immediate Implant Loading

Coming back to the point. Here are some points which you need to consider before you opt for immediately loading an implant with a prosthesis.

  1. The Timing of Loading; Is it Important?

Research has shown that during the first and fourth week of implant insertion, bone resorption can be seen around some areas. According to Turkyilmaz et al[2], the interface around the bone and the implant is at the highest risk of distortion as a result of overloading during the 3-5th week of insertion. Overloading of implant results in micromotion, which is detrimental for implant stability and osseointegration. This happens because the bone surrounding the implant is least mineralized at this stage.

Here’s what you can conclude for this; It’s not the timing of loading which is important. Rather, it’s the possibility of micromotion which can be more damaging for implant stability. In my opinion, the presence of micromotion greater than 50mm during the healing phase can cause impair initial implant stability, and ultimately cause implant failure.

  1. Assessment of Bone Quality

I agree that it is generally very difficult to histologically differentiate between Type I and Type III bone type. But at the same time, it’s really important to assess the quality of the underlying bone before you embark on the implant insertion journey. We know that depending on the region where the implant has to be placed, the quality and volume of bone varies. However, we see that immediate implant placement is most successful when it is performed in the anterior mandibular region.

While assessing bone quality, we either use CT imaging and intra-oral scanning. You can also use various software available in the market, which allows you to combine the possibility of merging CT with digital imaging technology. Naturally, it will make things easier for you.

  1. Optimizing Implant Stability

As a dentist, I cannot stress enough the importance of implant stability in ensuring long-term clinical success. I would never recommend immediately loading an implant if there are lesser chances of achieving implant stability. Here are some factors which help you in evaluating implant stability:

  • The Good Old Percussion Test – this test can never go wrong, as you can assess micromotion and possibility of peri-implantitis.
  • Radiographic bone analysis – as discussed earlier, you can use x-ray or CT images to assess the changes taking place around the bone-implant interface.
  • The torque applied during implant insertion – generally, a minimum of 32 N.cm torque must be used during insertion to ensure optimal implant stability. However, there is some disagreement here. Some protocols also allow optimal torque as low as 35 N.cm. So here, you can use your own judgment of clinical experience.
  • Resonance frequency analysis or Ostell® – the Resonance Frequency Analysis (RFA), which was introduced about 20 years ago, evaluates the stiffness of bone-implant interface with the help of self-curing resin.

Similarly, the Ostell® implant stability quotient (ISQ) scale can also be used for measuring implant stability. Generally, experts do not recommend opting immediate implant loading where ISQ is lower than 70. According to the ISQ scale, when you have ISQ less than 60, you must wait till optimal healing has taken place and the ISQ quotient is above 70. Similarly, if the ISQ is between 60-65, then immediate loading may be performed with splinting. Alternatively, you may opt for the conventional 2-stage implant loading.  You can find more information on the ISQ scaler here.

  1. Prosthodontic Factors

When planning immediate implant loading, you should consider the following prosthodontic factors:

  • Prosthodontic rehabilitation should be passively fitting.
  • You may also consider non-functional occlusion to ensure optimal stability of the implant.
  • Splinting and cross-arch stabilization should be considered, wherever and whenever possible.
  • It may also be a good idea to use implants with a rough surface; this promotes osseointegration.
  1. Clinical Examination

Finally, it all comes down to the quality of your clinical examination. You must consider your patient’s demands, aspirations, and motivation. It goes without saying that you must not opt for immediate loading if your patient does not have excellent oral hygiene status. In addition, you must consider the following:

  • If extraction is required before implant insertion, make every effort for the extraction process to be as atraumatic as possible.
  • If the extraction socket is currently infected, DO NOT opt for immediate insertion or loading.
  • Make sure that there is an underlying infection
  • Make sure that there your patient does not have parafunctional habits like bruxism etc. as they can promote micromotion and may affect implant stability.
  • Don’t opt for immediate loading if a patient has any history of any systemic disease.

Factors which can influence the success of immediate implant loading are endless. However, here we have highlighted the most important aspects which must be taken care of. Finally, I must say that not all cases are suitable for immediate loading. You should consider early or delayed implant loading in cases where the prognosis of immediate loading is not good. In the end, it all comes down to your clinical judgment and decision.

 

[1] Lee, Jennifer Wing Yee, and Manohar Lal Bance. “Physiology of Osseointegration.” Otolaryngologic Clinics of North America52.2 (2019): 231-242.

[2] Turkyilmaz, Ilser, and Ashley Brooke Hoders. “Immediate Loading in Implant Dentistry.” Current Concepts in Dental Implantology. IntechOpen, 2015.