Periodontology 2000, Vol. 47, 2008, 90–112  2008 The Author.

Printed in Singapore. All rights reserved Journal compilation  2008 Blackwell Munksgaard
PERIODONTOLOGY 2000

Immediate ⁄ early loading of

dental implants. Clinical
documentation and presentation
of a treatment concept
P Ä R -O L O V Ö S T M A N

During the past 40 years, prosthetic rehabilitation of proper scientific studies rather than on the partly
the edentulous patient with implant-supported unsupported claims of implant manufacturers. One
bridges has developed into a viable and predictable example of insufficient information is the Nobel
treatment option. High clinical success rates with the Direct implant (Nobel Biocare, Göteborg, Sweden); at
original implant protocols (5) have given clinicians the time of its introduction, with little or no docu-
and researchers confidence to further develop and mentation, it was claimed to reduce marginal bone
refine the osseointegrated technique and, conse- loss and to improve the aesthetic outcome as a result
quently, implants are used in increasingly more of Ôsoft tissue integrationÕ. Recent studies showed
challenging situations and on broader indications higher failure rates and more bone loss with the
(117). For example, the dental profession has pro- Nobel Direct implant system than with conventional
gressed from rehabilitation of the totally edentulous implants (7, 87, 110). Having said this, it should be
mandible with implants in the interforamina region to remembered that manufacturers have also been
single implants in grafted areas in the posterior part of instrumental in developing implant surfaces and
the maxilla. A similar trend is seen for the timing of designs that have increased the predictability of im-
implant loading. A submerged healing period of 3– plant therapy in challenging situations, such as the
6 months was originally considered a prerequisite for use of immediate-loaded implants. This paper re-
achieving osseointegration of titanium implants (4). views the literature on and presents a protocol for
However, during the past 10–15 years this traditional immediate ⁄ early loading of implants.
protocol has been questioned and numerous clinical
studies have reported on the outcome of early and
immediate loading of implants in various clinical sit- Terminology
uations (29, 61). There has also been a change of focus
in implant therapy from being originally a strictly The terminology in implant dentistry is often
functional rehabilitation to being a treatment confusing despite attempts to agree upon proper
modality with a major emphasis on aesthetics (27). definitions (11, 19). The following definitions are
Another consequence of the widespread use of the used in the present article.
osseointegration technique is the rapid launching of
new implant designs and treatment concepts. Al-
Definition of timing of implant loading
though some of the new implant systems are sup-
ported by clinical research data, the majority is not. • Immediate ⁄ direct loading: the provisional ⁄
In some sense, it is therefore the task of clinicians definitive prosthetic construction is attached to the
and researchers to critically scrutinize new implant implant within 24 hours of the implant being
and treatment concepts. Dentists should rely on placed.

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 Immediate ⁄ early loading of dental implants

• Early loading ⁄ Early functional loading: the pro-

Biological response
visional ⁄ definitive prosthetic construction is
attached to the implant within days ⁄ weeks of the The original Brånemark implant protocol (Nobel
implant being placed. Biocare) required a stress-free submerged healing
• Delayed loading: the provisional ⁄ definitive pros- time of 3–6 months to obtain osseointegration (2–4,
thetic construction is attached at a second proce- 6, 24–26). The prolonged undisturbed healing time
dure after a conventional healing period of was thought to be necessary to avoid fibrous tissue
3–6 months. encapsulation around the implants instead of
• One stage: the implant heals without protection of osseointegration (8, 9). However, later clinical and
the oral mucosa and is accessible through the experimental evidence revealed that implants osseo-
mucosa during healing time. integrate even when left exposed to the oral cavity
• Two stage: the implant heals under the soft tissue during healing (12, 18, 33, 109, 123).
and is, after a healing period, accessed through a Experimental histological studies of clinically re-
second-stage surgery. trieved implants have shown similar, and sometimes
improved, bone–implant contact with immediate-
loaded implants compared with conventional
Definition of prosthetic load of implant
implants (38, 60, 92–94, 99, 104, 119, 120). Piattelli
• Occlusal loading: the crown ⁄ bridge is in et al. (92) compared the histology of non-submerged,
contact with the opposing dentition in centric unloaded and early-loaded titanium screw implants in
occlusion. monkeys. They found a tight contact of new bone to
• Non-occlusal loading: the crown ⁄ bridge is not in implant surfaces in all the samples examined. How-
contact in centric occlusion with the opposing ever, around the implant neck of early-loaded
dentition in the natural jaw position. implants, they observed lamellar cortical bone that
was thicker than that in unloaded implants. A pilot
study in monkeys examined bony reactions to early-
loaded titanium plasma-sprayed implants (93).
Why immediate loading? Twenty implants were immediately loaded and four
implants served as controls. The mean bone–implant
Immediate oral handicap relief
contact of immediate-loaded implants was 67.2% in
Edentulous patients seeking dental treatment to re- the maxilla (10 implants) and 80.71% for implants in
store function and aesthetic appearance have tradi- the mandible (10 implants). Also, the bone of the
tionally received removable full or partial dentures. loaded implants had a more compact appearance than
However, use of removable dentures may lead to a that of controls. Testori et al. (119) reported bone–
sense of patient insecurity, reduced chewing capac- implant contact of 64.2% for a single immediate-loa-
ity and taste, and low self-esteem. In a controlled ded Osseotite implant (Biomet 3i, Palm Beach, FL,
study, Blomberg et al. (20) investigated 26 denture USA) compared to a bone–implant contact of 38.9%
patients before and at 3 months and 2 years after for a single submerged implant. Rocci et al. (99)
the insertion of an implant-supported bridge. The retrieved nine oxidized titanium implants after
majority of patients stated that there had been a 5–9 months in use. Two implants were loaded at the
significant improvement in their lives, that they had day of insertion and seven implants were loaded after
gained in self-confidence, and that, in contrast to 2 months of submerged healing. Eight of the implants
their conventional denture, they had accepted the were able to be used for histology. The mean
fixed bridge as part of their body. However, the bone–implant contact value was 92.9% for the two
insertion of implants according to traditional proto- immediate-loaded implants and 81.4% for the six
cols includes a prolonged period of healing time, early-loaded implants. Despite the limited number of
especially if the treatment involves tooth extraction implants studied, immediate-loaded implants seem
and healing before implant surgery. Extended peri- to yield a higher bone–implant contact value than
ods with no teeth or with removable dentures have non-immediate-loaded implants. Frost (60) postu-
the disadvantages discussed above. The use of lated that not only excessive loading but also too
immediate ⁄ early-loaded implants has obvious modest loading of implants might result in a negative
advantages because patients can be rehabilitated tissue response.
with functional crowns for immediate function and The present author studied immediate-loaded
aesthetics. implants in total edentulous maxillae (84). One

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hundred and twenty-six immediate-loaded implants rate of 97.5%. The corresponding cumulative implant
were compared to 120 submerged implants with a survival rate in the control group was 99.7%. The
healing period of 6 months. Resonance frequency mean marginal bone resorption during the first year
analysis showed a tendency toward a more rapid of function was 0.4 mm in both groups.
increase in implant stability and less marginal bone
Immediate loading
resorption for the immediate-loaded implants
compared with the submerged implants. Fischer & Table 1 presents a summary of articles on immedi-
Stenberg (52) also found statistically less marginal ate-loaded implants with a fixed prosthesis in the
bone resorption with immediate-loaded, sand- fully edentulous mandible.
blasted, large-grit, acid-etched implants (Straumann, Ledermann (74) showed as early as 1979 that
Basel, Switzerland) than with a delayed loading group immediate-loaded titanium plasma-sprayed screw
of implants. Although more histological studies are implants (Straumann) could support overdentures in
needed comparing immediate-loaded with delayed- the mandible. The first report on immediate-loaded
loaded implants, the available data indicate not only Brånemark implants with fixed prostheses was pre-
a similar but also a more beneficial bony response for sented in 1990 by Schnitman et al. (108). Five or six
immediate-loaded implants, at least for implants Brånemark implants were placed between, and two
with a moderately rough surface topography. additional fixtures were placed distally to, the mental
foramina. Three of the installed implants in strategic
positions were connected to a provisional prosthesis,
Clinical outcome studies converted from the patientÕs denture. The remaining
fixtures were allowed to heal in a conventional
Totally edentulous mandible manner. The authors concluded that the implant
treatment was successful in seven patients, who were
Early loading
reconstructed with a mandibular fixed-detachable
Scientific reports in the past decade have described bridge without ever wearing a removable prosthesis.
acceptable outcomes with early loading implants (17, Also, the overall, long-term implant therapy was not
34, 45, 48, 50, 73). Engquist et al. (46) studied 108 adversely affected by using the immediate-loading
patients with edentulous mandibles. Each patient technique. In a follow-up study by Schnitman et al.
was treated with a full fixed prosthesis attached to (107), 28 Brånemark implants in 10 patients were
four Brånemark System implants (Nobel Biocare). immediately loaded with a screw-retained fixed pro-
Patients were distributed into four groups: group A visional prosthesis. Four (15.3%) of the immediate-
(one-stage surgery), group B (two-stage surgery), loaded implants failed, while all implants with a
group C (one-piece implants), and group D (early conventional healing time survived. Statistical analy-
loading). Twenty-six patients in group D received a sis showed a significantly higher failure rate for the
total of 104 implants. The healing time before loading immediate-loaded implant group. The authors con-
the permanent fixed prosthesis ranged from 10 days cluded that although immediate-loaded implants in
to 3 weeks. Seven of the 104 (6.7%) implants in group the mandible in the short-term can support a fixed
D failed within 3 years of loading. In the control provisional prosthesis, the long-term prognosis is
group (group B), three of 120 (2.5%) implants failed. guarded for implants placed into immediate function
The difference in failure rates between the two distally to the incisor region.
groups was not statistically significant. Patients in Ten consecutive patients were treated by Tarnow
group D exhibited significantly less marginal bone et al. (114) with immediate-loaded implants. A min-
loss than those in the control group, whereas no imum of 10 implants was placed in each patientÕs
difference in marginal bone change was detected arch, and a minimum of five submerged implants
among patients in the other study groups. was allowed to heal without loading. The remaining
Friberg et al. (56) studied 152 individuals with 750 implants were loaded at the day of stage 1 surgery. All
Brånemark System implants of various designs 10 patients received a fixed provisional prosthesis at
placed in edentulous mandibles by means of one- the time of stage 1 surgery, and all were restored with
stage surgery. The fixed prosthesis was inserted a definitive prosthesis. Two implants that had been
approximately 13 days after implant placement. A immediately loaded and one of the submerged
total of 18 implants in 12 patients in the study group implants failed. The authors concluded that imme-
were found to be mobile at the first annual check-up, diate loading of multiple implants, which are rigidly
equivalent to a 1-year implant cumulative survival splinted, can be a viable treatment modality in a

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 Immediate ⁄ early loading of dental implants

Table 1. Immediate-loaded implants with fixed prosthesis in the totally edentulous mandible
No. of No. of Implant
No. of loaded Years of lost survival
Authors Type of study patients implants follow-up implants rate in %
Schnitman et al. (107) Prospective 10 28 10 4 85.7
Tarnow et al. (114) Prospective 6 36 1–5 2 97.4
Brånemark et al. (22) Prospective 50 150 6 months to 3 98
3 years
Balshi & Wolfinger (16) Prospective 10 40 1 8 80
De Bruyn et al. (37) Prospective 20 60 1 6 90
Chow et al. (30) Prospective 14 56 1 0 100
Testori et al. (116) Prospective 15 103 4 1 98.9
Testori et al. (118) Prospective ⁄ multicenter 62 325 1–5 2 99.4
Wolfingeret al. (125) Prospective 24 144 3–5 5 97
Engstrand et al. (47) Prospective 95 295 1–5 18 93.3
Henry et al. (68) Prospective 51 153 1 14 91
Aalam et al. (1) Prospective 16 90 3 3 96.6
Total 373 1480 – – 94

completely edentulous jaw. Other investigators, who prosthesis with good long-term results. Chow et al.
used the same study design of a mixture of sub- (30) studied 14 patients, each of whom had four
merged and non-submerged implants in the same implants placed in the interforamina area in the fully
patient, reported similar results (16, 125). edentulous mandible. The implants were loaded
Studies have found three to be the minimum within 24 hours with a screw-retained temporary
number of implants that is required to support a fixed prosthesis. At a 1-year follow-up the survival rate was
partial denture in the totally edentulous mandible 100%. Testori et al. (116) treated 15 patients who
(22, 37, 47, 67, 68, 76, 96, 121). De Bruyn et al. (37) received a total of 103 Osseotite implants. The first
studied 19 patients, who received five implants in the two patients received both immediately loaded and
mandible, of which three were functionally loaded submerged implants, while the remaining patients
using the one-stage technique. The loaded implants were treated with immediate-loaded implants. Tem-
were inserted in a tripodal position, one implant porary prosthesis was delivered 4–36 hours after
placed in the symphysis and two anterior to the implant insertion. Of the 92 immediate-loaded
mental foramen in the bicuspid area. Two additional implants, one failed as the result of infection after
implants were inserted for safety reasons but were 3 weeks. A cumulative success rate of 98.9% was
not loaded. Immediately following surgery, the achieved at 48 months, while the prosthetic cumu-
implants were loaded with a relined denture. The lative success rate in the same period was 100%. The
patients received a 10- to 12-unit prosthetic recon- level of marginal bone loss for the immediate-loaded
struction 4–5 weeks after implant surgery. Six of the implants was similar to that described for implants
60 functionally loaded implants (10%) and three of inserted by a delayed loading protocol.
20 prostheses (15%) failed within the first year. The In a prospective four-center study, Testori et al.
authors concluded that the outcome of treatment (118) examined 325 Osseotite implants in 62 patients.
with one-stage surgery using three implants to sup- The temporary prosthesis was inserted 4 hours fol-
port a fixed mandibular arch reconstruction was less lowing implant surgery. Two implants failed to inte-
favorable than the expected outcome of a standard grate within 2 months. A cumulative implant success
four- to six-implant construction. rate of 99.4% was achieved over a period of
At present, four to six implants in a fully edentu- 12–60 months (mean 28.6 months). Crestal bone loss
lous mandible seem to be sufficient to retain a fixed around the immediate-loaded implants was similar

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to that reported for standard delayed loading of sandblasted, large-grit, acid-etched surfaces. In total,
implants. It was concluded that the rehabilitation of 142 implants were placed and 139 implants were
the edentulous mandible by an immediate-loaded loaded with full-arch prostheses. The cumulative
protocol supported by five to six Osseotite implants implant success rate after 3 years of loading was
represents a viable treatment alternative to delayed 100%. The 3-year radiographic evaluation showed
loading protocols. less marginal bone resorption in the early-loaded
Aalam et al. (1) studied 16 patients with completely group compared to controls. No significant differ-
edentulous mandibles, who received a total of 90 ences between the study groups were noted for any
immediate-loaded Brånemark System Mk III other outcome measures. The authors concluded that
implants (Nobel Biocare) with cross-arch screw-re- the early loading protocol was a viable alternative to
tained hybrid prostheses. Seventy-seven (85.5%) of the standard protocol in the rehabilitation of the fully
the dental implants were placed in high-density edentulous maxilla with an implant-supported fixed
bone. At the 3-year follow-up, three implants failed to prosthesis.
meet the criteria of success, bringing the cumulative Olsson et al. (90) studied 10 patients with a total of
success rate to 96.6%. The prosthetic success rate 61 oxidized titanium implants over a period of 1 year.
was 100%. The average bone loss was 1.2 ± 0.1 mm. The patients had received a fixed full-arch provisional
bridge in the maxilla at 1–9 days after implant
Conclusion for immediate-loaded implants in the
placement. Nine patients had six implants and one
fully edentulous mandible
patient had eight implants supporting the bridge. The
Survival ⁄ success rates of immediate-loaded im- provisional bridge was replaced with a permanent
plants should be compared with those of the classic bridge after 2–7 months of loading. Four implants
two-stage implant approach. In the fully edentulous failed (6.6%), and they were all lost as the result of
mandible, an immediate-implant survival rate of 99% infection in one patient after 10 weeks of loading.
after 15 years was reported by Lindquist et al. (77). The remaining 57 implants were clinically stable with
The use of three immediate-loaded implants to carry a mean marginal bone loss of 1.3 mm after 1 year of
a fixed prosthesis has resulted in survival rates loading.
ranging from 90 to 98%. Obviously, re-treatment and
Immediate loading
extra expense are required if an implant is lost, but a
lower number of implants initially reduces the up- Table 2 presents a summary of articles on immedi-
front costs of therapy. Four or more immediate- ate-loaded implants with a fixed prosthesis in the
loaded implants are sufficient to support a fixed totally edentulous maxilla.
prosthesis in the totally edentulous mandible, with a The survival rate of 168 immediately loaded sand-
success rate of 95–100%. However, patient selection blasted, large-grit, acid-etched implants in the
must be considered if predictable, high success rates edentulous maxilla of 28 patients after 8 months of
are to be achieved. The slightly lower survival rate of loading was evaluated by Bergkvist et al. (19). Each
immediate-loaded implants compared with the two- patient received a fixed provisional prosthesis within
stage implant approach may be acceptable when 24 hours of implant surgery. After a mean healing
considering the benefits of immediate handicap time of 15 weeks, the patient received a definitive,
reduction, one-time surgery, and fewer total visits to screw-retained, implant-supported fixed prosthesis.
the dental office. Three implants failed during the healing period
(1.8%). The mean marginal bone resorption was
1.6 mm during an 8-month follow-up. The authors
Totally edentulous maxilla
discussed the importance of splinting implants
There are relatively few long-term data on immedi- immediately after placement.
ate-loaded implants in the fully edentulous maxilla, Ibanez et al. (71) treated 26 patients who had
and most papers are case reports (41, 65, 69, 83, 114). fully edentulous maxillae with implants that were
loaded within 48 hours with either resin provisional
Early loading
prostheses, metal-reinforced provisional prostheses,
Fischer & Stenberg (53) studied early implant loading or definitive prostheses (metal–acrylic or metal–
of 24 patients with completely edentulous maxillae, ceramic). Double acid-etched surface implants
randomized into a test group of 16 patients and a (Osseotite) were used, and patients were followed for
control group of eight patients. All patients received 12–74 months. The success rate was 100% after 12–
five or six solid, screw-type titanium implants with 74 months. The average radiographic bone level

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 Immediate ⁄ early loading of dental implants

Table 2. Immediate-loaded implants with fixed prosthesis in the totally edentulous maxilla
No. of No. of Implant
No. of loaded Years of lost survival
Authors Type of study patients implants follow-up implants rate in %
Tarnow et al. (114) Prospective ⁄ cross-sectional 4 14 1–4 0 100
Horiuchi et al. (69) Prospective ⁄ cross-sectional 5 44 1–2 2 96.5
Grunder (65) Retrospective ⁄ cross-sectional 5 48 1–5 6 87.5
Bergkvist et al. (19) Prospective 28 168 8 months 3 98.2
Degidi et al. (39) Retrospective 43 388 5 8 98
Balshi et al. (15) Prospective 55 522 1 5 99
Östman et al. (84) Prospective 20 123 1 1 99.2
Fisher et al. (53) Prospective 24 139 3 0 100
Total 184 1446 – – 97.3

change was 0.56 mm at 12 months and 0.94 mm at more than six, to support the prosthesis. Three
72 months. The authors concluded that a high suc- studies on early loading and one study on immediate
cess rate could be achieved when double acid-etched loading with six to eight implants report implant
surface implants were immediately loaded with fixed survival rates from 93.4 to 100% after 1–3 years,
full-arch restorations in the maxilla. which is comparable with the 5-year survival rates
Forty-three patients with a total of 388 implants reported for two-stage implant protocols. One study
(mean nine implants per patient) were studied by presenting 5-year data found no change in survival
Degidi et al. (39). Their implants were loaded with rate after initial failures that had occurred during the
cross-arch acrylic provisional restorations at the time first 6 months (39). The data indicate that if good
of implant surgery and at the 5-year follow-up, the primary implant stability is achieved in sites with
survival rate was 98%. All failures occurred within medium to dense bone quality, a successful outcome
6 months of loading. The authors concluded that of immediate-loaded implants in the fully edentulous
immediate functional loading was a reliable surgical– maxilla can be expected. However, more long-term
prosthetic procedure in edentulous maxillae. Their data are needed before immediate loading of
findings also suggested that implants with a wider implants can be recommended as a standard proce-
diameter were associated with a higher risk of failure. dure in the maxilla.
Balshi et al. (15) included 55 patients in an inves-
tigation of immediate functional loading of 552
Partially edentulous maxilla ⁄ mandible
Brånemark System implants placed in immediate
extraction sockets or in healed sites of edentulous Early ⁄ immediate loading is theoretically more chal-
maxillae. A mean number of 10 implants were placed lenging in the partially edentulous maxilla ⁄ mandible
per patient. All implants were immediately loaded compared to the totally edentulous jaw. Implants in
with screw-retained, all-acrylic, fixed prostheses at partially edentulous patients are fewer and are often
the time of implant surgery. Each patient received a placed in a straight line and therefore exposed to
definitive metal-reinforced prosthesis 4–6 months lateral forces, whilst implants in edentulous patients
after surgery. The immediate-loaded implants had a can be placed in an arch shape to efficiently coun-
cumulative survival rate of 99.0%, and the prosthesis teract bending forces. Moreover, the posterior region
survival rate was 100%. of the oral cavity usually has less dense bone and
experiences stronger bite forces compared to the
Conclusion of immediate-loaded implants in the
anterior part of the mouth (21). However, histological
fully edentulous maxilla
studies have shown favorable results with immediate
Few studies have been published on immediate-loa- implant loading in the posterior mandible. For in-
ded implants in the edentulous maxilla. Most papers stance, Rocci et al. (99) retrieved nine oxidized
report treatments using a high number of implants, Brånemark implants; two implants were loaded on

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Östman

the day of implant surgery and seven implants were maxilla and mandible was reported by Luongo et al.
loaded after 2 months of healing. A gross histological (79). Eighty-two sandblasted, large-grit, acid-etched
examination showed an undisturbed healing pattern implants in 40 patients were loaded between 0 and
of mucosal and bony tissues with no apparent 11 days after implant placement. For inclusion in the
difference in tissue response between immediate- study, two implants had to support either two splin-
loaded and early-loaded implants. Lamellar bone ted crowns or a three-unit bridge. The torque value
surrounded the implants with evidence of bone was between 15 and 45 N cm. Four sites had a bone
remodeling, which was most pronounced close to the quality of 4. One implant failed during the first year,
implant surface. Morphometric measurements giving an overall survival rate of 98.8%. The mean
showed bone–implant contact values as high as 84– bone loss at 1 year was 0.52 ± 0.98 mm. The authors
92%. concluded that early and immediate loading of two
implants in the posterior maxilla or mandible may be
Early loading
suitable in selected patients. On the basis of 1 year of
Testori et al. (115) reported on 475 Osseotite implants observation, the results appeared similar to those
in a longitudinal, prospective, multicenter study of achieved with a delayed loading implant protocol.
early implant loading. All implants were placed in the Vanden Bogaerde et al. (122) included 31 consec-
posterior region of 175 patients and restored within utive patients in a multicenter study. A total of 111
2 months. Six of the 475 implants were classified as implants were inserted in 37 edentulous areas. Of
early failures and three implants were classified as these, 69 implants were inserted in 22 partial eden-
late failures, giving a cumulative survival rate of tulous ridges in the maxilla, and 42 implants were
97.7% after 3 years. Cochran et al. (31) presented a inserted in 15 partial edentulous posterior ridges in
longitudinal, prospective, multicenter study on 383 the mandible. Bruxism and uncontrolled periodontal
sandblasted, large-grit, acid-etched implants placed disease were exclusion criteria. Temporary prosthe-
in the posterior jaws of 307 patients. Healing time ses were generally placed within 9 days of, but not
was 42 to 63 days for implants in class 1–3 quality 16 days after, the time of implant placement. Of the
bone and 105 days for class 4 bone. At the time of 111 implants installed, one failed, giving an overall
abutment placement, three implants were mobile survival rate of 99.1% after 18 months. The failed
and removed. In addition, three implants were not implant was located in the posterior maxilla. The
rotationally stable and six were associated with pain. prosthesis survival rate was 100%. The marginal bone
These nine implants were allowed to heal and even- resorption from readable (about 85%) radiographs
tually became stable. The survival rate after 1 year was 0.8 mm. The authors concluded that a clinical
was 99.1%. Roccuzzo & Wilson (103) reported on 36 protocol, aimed at achieving high primary implant
implants placed in the posterior maxilla of 29 non- stability, which uses oxidized titanium implants for
smoking patients. Abutments were placed after early functional loading in the maxilla or in the
43 days and the implants were loaded with a tem- posterior mandible, can result in a high implant
porary bridge in infraocclusion. After an additional survival rate and a favorable marginal bone level.
6 weeks the definitive prosthesis was inserted. One A prospective controlled clinical trial by Salvi et al.
implant failed, giving a survival rate of 97.2% after (105) evaluated the effect of early loading of sand-
1 year of loading. In a split-mouth prospective study, blasted, large-grit, acid-etched implants. Twenty-
Roccuzzo et al. (102) compared 68 sandblasted, seven consecutively admitted patients with bilateral
large-grit, acid-etched implants loaded 6 weeks after edentulous posterior mandibular areas were
implant surgery and 68 titanium plasma-sprayed included. Sixty-seven implants were installed bilat-
screw implants loaded 12 weeks after implant sur- erally in the molar and premolar regions according to
gery. Four of the 68 sandblasted, large-grit, acid- a one-stage surgical protocol. One week (test) and 5
etched implants were rotationally unstable at 6-week weeks (control) after implant placement, abutments
abutment placement and were allowed to heal for an were connected using a torque of 35 N cm. No pro-
additional 6 weeks. After 1 year, a 100% survival rate visional restoration was used. Two test implants and
was noticed for both groups of implants, and no one control implant rotated at the time of abutment
significant differences in clinical and radiographic connection and were left unloaded for a further
measurements could be observed between the two 12 weeks. Two weeks (test) and 6 weeks (control)
groups. after implant placement the porcelain-fused-to-me-
A multicenter 1-year follow-up study of an imme- tal, single-tooth crowns were cemented. After 1 year,
diate ⁄ early loading implant protocol in the posterior the implant survival rate was 100%. At the 1-year

96
 Immediate ⁄ early loading of dental implants

examination, no statistically significant differences surface implants after 1 year of prosthetic loading in
were found between the test and control sites with the posterior mandible. The corresponding cumula-
respect to pocket probing depth, mean clinical tive success rate for turned-surface implants was
attachment level, mean percentage of sites bleeding 85.5%. The marginal bone resorption after 1 year of
on probing, mean width of keratinized mucosa, mean loading showed no difference between the two types
PerioTest values or mean crestal bone loss mea- of implants. The authors concluded that a rough
surement. The authors concluded that early implant surface, such as that of TiUnite implants, provided a
loading (2 weeks) did not appear to jeopardize the 10% decrease in failure rate compared to turned
osseointegration healing process in the posterior implants.
mandible. Drago & Lazzara (42) reported on 93 Osseotite
implants that were restored with fixed provisional
Immediate loading
crowns without occlusion immediately after implant
Table 3 presents a summary of articles on immedi- placement. Thirty-eight partially edentulous patients
ate-loaded implants with a fixed prosthesis in the were included in the study. All implants were
partially edentulous maxilla ⁄ mandible. immediately restored with pre-fabricated abutments
Rocci et al. (101) studied immediate-loaded and cement-retained provisional crowns without
implants with partial fixed dentures in the posterior centric or eccentric occlusal contacts. Definitive res-
mandible. Forty-four patients were randomized for torations were inserted approximately 8–12 weeks
test and control therapy. In the test group, 22 patients after implant placement. All patients included in the
received 66 Brånemark System TiUnite surface study were followed for at least 18 months after im-
implants (Nobel Biocare) supporting 24 fixed partial plant placement. Seventy-seven of the 93 implants
bridges, all of which were connected on the day of satisfied the inclusion criteria, and 75 implants
implant insertion. In the control group, 22 patients became osseointegrated. The overall implant survival
received 55 Brånemark System turned-surface rate was 97.4%. Bone loss on radiographs at
implants supporting 22 fixed partial bridges, which 18 months after implant placement (the mean of
were also connected on the day of implant insertion. both interproximal surfaces) was 0.76 mm.
All restorative constructions were two- to four-unit Twenty chronic periodontitis patients, who were
bridges. Three TiUnite and eight turned-surface treated with implants in the partially edentulous
implants failed during the first 7 weeks of loading. mandible, were studied by Machtei et al. (80). Five of
The cumulative success rate was 95.5% for TiUnite the 49 (10%) implants failed. The authors concluded

Table 3. Early ⁄ immediate-loaded implants with fixed prosthesis in the partially edentulous maxilla ⁄ mandible
No. of No. of Implant
Type of Immediate ⁄ No. of loaded Years of lost survival
Authors study early loading patients implants follow-up implants rate in %
Testori et al. (115) Prospective Early (2 months) 175 405 3 9 97.7
Cochran et al. (32) Prospective Early (3 weeks) 307 383 1 3 99.1
Roccuzzo et al. (103) Prospective Early (6 weeks) 29 36 1 1 97.2
Roccuzzo et al. (102) Prospective Early (6 weeks) 32 68 1 0 100
Luongo et al. (79) Prospective Early 40 82 1 1 98.8
Vanden Bogaerde et al. (122) Prospective Early 31 111 1 1 99.1

Rocci et al. (101) Prospective Immediate 22 55 1 3 95.5

Östman et al. (86) Prospective Immediate 77 257 1–4 4 98.4
Schincaglia et al. (106) Prospective Immediate 20 44 1 2 95
Cornelini et al. (35) Prospective Immediate 20 40 1 1 97.5
Machtei et al. (80) Prospective Immediate 20 49 1 5 90
Total 159 445 – – 96.6%

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Östman

that immediate loading protocols provide a predict- bone and mucosal augmentation procedures may be
able therapy in periodontally susceptible patients, needed. A retrospective study by Vermylen et al.
but careful consideration should be given to implants (124) determined patient opinion and professional
placed in the molar region. evaluation of 43 implant supported single-tooth res-
Schincaglia et al. (106) studied 10 patients with torations. Single implant crowns were evaluated
bilateral partially edentulous posterior mandibles. A according to design, fit, occlusion ⁄ articulation, and
split-mouth study design compared implants with aesthetics. Patients were very positive with regard to
either a turned surface or a titanium oxide surface. aesthetics, phonetics, eating comfort, and overall
Forty-two implants, 20 test and 22 control, were satisfaction. Nevertheless, six of the 40 patients
placed and loaded within 24 hours. No implant was would not undergo the same treatment again,
lost in the test group and two failed in the control although all patients would recommend the treat-
group. The overall implant success rate was 95%. No ment to others.
statistically significant difference was seen between
Early loading
the test and control groups although there was a
tendency to less bone resorption in the test group. Andersen et al. (10) evaluated immediate ⁄ early
The authors concluded that immediate loading of loading of single-tooth implants in the maxilla.
implants in the posterior mandible may be an Temporary acrylic resin restorations, which were
acceptable treatment option if implants are inserted fabricated from impressions obtained immediately
with a torque exceeding 20 N cm and show an after implant placement, were connected 1 week la-
Implant Stability Quotient value above 60 N cm. ter. The temporary restorations were adjusted to
Twenty patients were treated by Cornelini et al. avoid any direct occlusive contacts. At 6 months, the
(35) with a total of 40 immediate-loaded implants provisional crowns were replaced by definitive cera-
supporting 20 three-unit bridges in the posterior mic crowns. If the strict definition of immediate
mandible. At 1-year follow-up, one implant had loading (within 24 hours) is used, this article de-
failed, giving a survival rate of 97.5%. scribes a group of early-loaded implants. Eight
implants in eight different patients were followed for
Conclusion of immediate-loaded implants in the
5 years. No implant was lost, and the mean marginal
partially edentulous maxilla ⁄ mandible
bone level for the eight implants increased by
The longest published follow-up period of early 0.53 mm between placement and the final examina-
loading implants is 3 years and of immediate-loaded tion. Only minor complications were noted, and
implants is 1 year. The published implant survival overall patient satisfaction was high.
rate ranges from 85 to 98.8%, which is less than the 5-
Immediate loading
year survival rates of 94–96% obtained for two-stage
implant procedures. More long-term studies are Table 4 presents a summary of articles on immedi-
needed before immediate loading of implants can be ate-loaded single implants in the maxilla ⁄ mandible.
recommended as a standard procedure in the pos- Ericsson et al. (49) performed a prospective study
terior maxilla ⁄ mandible. on single tooth replacements with artificial crowns
retained to implants installed according to an
immediate loading protocol and compared that to
Early ⁄ immediate loading implants for
the original two-stage implant procedure. The
single-tooth replacement in the
immediate loading group comprised 14 patients (14
maxilla ⁄ mandible
implants) and the two-stage control group com-
Single tooth loss is probably the most common prised eight patients (eight implants), all with single
indication for implant placement (112). The loss of a tooth losses anterior to the molars. The patients had
single tooth is a traumatic experience for many to be non-smokers and have sufficient bone to re-
patients and early ⁄ immediate implant loading is ceive a 13-mm implant with the regular platform
therefore an attractive treatment option. On the other diameter of 3.75 mm. Moreover, the jaw relationship
hand, single teeth replaced by implants in the aes- had to allow for bilateral occlusal stability and the
thetic zone are one of the most challenging situations patients had to be judged as not displaying bruxism.
facing a clinician, even when using a two-stage im- In the immediate-loaded group, a temporary crown
plant protocol. Careful assessment must be made of was connected to the implant within 24 hours fol-
mucosal and bone volumes in relation to implant lowing implant installation, and the permanent
placement. In case of significant bone resorption, crown was installed at 6 months. Of the 14 implants

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 Immediate ⁄ early loading of dental implants

Table 4. Early ⁄ immediate-loaded implants with single restorations in the maxilla ⁄ mandible
No. of No. of Implant
No. of loaded Years of lost survival
Authors Type of study patients implants follow-up implants rate in %
Andersen et al. (10) Retrospective ⁄ Early loading 8 8 5 0 100
Ericsson et al. (49) Prospective 14 14 1 2 86
Hui et al. (70) Prospective 24 24 1–15 months 0 100
Calandriello et al. (28) Prospective 44 50 6–12 months 0 100
Rocci et al. (100) Retrospective 27 27 3 5 81
Lorenzoni et al. (78) Retrospective 12 12 1 0 100
Digidi et al. (40) Retrospective 111 111 5 5 95.5
Total 240 246 – – 95.2

in the immediate-loaded group, two (14%) were lost unit restorations. Nine implants in eight patients
after 5 months in function. The remaining 12 failed during the first 8 weeks of loading. Five of the
implants were stable. No implant losses were re- eight patients lost single-tooth implants, of which
corded in the traditional two-stage protocol group two had been inserted in fresh extraction sites. Three
and all implants were stable at follow-up. The patients lost four implants incorporated in fixed
radiographic analysis at the 12-month follow-up prosthesis restorations. After 3 years of prosthetic
showed a mean loss of bone support of about load, the survival rate for implants with fixed pros-
0.1 mm for both implant groups. theses was 94% and that with single implant resto-
Twenty-four patients who had received single- rations was 81% (P = 0.04). The marginal bone
tooth implants according to an immediate-loaded resorption was on average 1.0 mm during the first
implant placement protocol were evaluated by Hui year of loading, 0.4 mm during the second year, and
et al. (70). Thirteen of the 24 patients received the 0.1 mm during the third year.
implants immediately after tooth extraction. All The clinical outcome of immediate-loaded FRIA-
implants were placed in the aesthetic zone. The LIT-2 Synchro implants (FRIADENT GmbH, Mann-
surgical protocol aimed to enhance primary im- heim, Germany) was evaluated by Lorenzoni et al.
plant stability with a minimum insertion torque of (78) 12 months after placement in the maxillary
at least 40 N cm. Within a follow-up period of anterior region. The implants were inserted with an
1 month to 15 months, all implants in the 24 increasing torque of up to 45 N cm. All implants were
patients were stable. A crestal bone loss greater immediately restored with unsplinted acrylic resin
than one implant thread was not detected. All provisional crowns and the patients were provided
patients considered the aesthetic result to be with an occlusal stent. No implant failed within
satisfactory. 12 months of insertion, providing a survival rate of
Calandriello et al. (28) reported on a prospective 100%. The authors noted on radiographs taken after
multicenter study including 44 patients with a total of 6 and 12 months that coronal bone resorption was
50 Brånemark System TiUnite Wide-Platform less than that of implants placed by a standard two-
implants (Nobel Biocare). All implants received pro- stage procedure.
visional crowns in centric occlusion at the time of Degidi et al. (40) evaluated 111 single implants that
surgery. No implant was lost at the 6-month and the non-functionally had been immediately loaded. All
1-year follow-ups. Marginal bone level was found to implants were placed with a minimum insertion
be in accordance with normal biological width torque of 25 N cm. During 5 years of follow-up, the
requirements. Resonance frequency analysis showed implant survival rate was 95.5%. A statistically sig-
high and consistent implant stability. nificant difference in implant survival rate was found
Rocci et al. (100) evaluated 97 Brånemark System for healed and fresh-extraction implant sites (100%
Mk IV implants that were placed flapless and and 92.5%, respectively) and for type 1 and 4 quality
immediately loaded; 27 of the implants were single- bone (100% and 95.5%, respectively).

99
Östman

implants were placed by a two-stage method and

Conclusion of immediate-loaded single implants in
1,303 implants were immediately loaded. Excluded
the partially edentulous maxilla ⁄ mandible
from this summary are two cases of Teeth-in-an-
The longest follow-up period recorded is 5 years for Hour implants (Nobel Biocare) and 48 cases of Nobel
early-loaded and 1 year for immediate-loaded Direct implants; the problems with the latter implant
implants. The overall implant survival rate in avail- system have already been discussed in this article. No
able papers ranges from 81 to 100%. Additional long- statistically significant difference in clinical outcome
term studies are needed before immediate-loaded was found between the two-stage and the immedi-
single implants can be recommended as a standard ate-loaded implants. A failure rate of 1.0% was seen
procedure in the maxilla ⁄ mandible. in the two-stage group compared to 1.2% in the
immediate-loaded group.

A practical concept for treatment

Treatment planning
with immediate-loaded implants
Today, most patients seeking implant treatment are
The present author has, since 1998, developed and not totally edentulous. If following a traditional pro-
evaluated a therapeutic concept for immediate tocol, a 4- to 6-month healing time after tooth extrac-
loading of implants. A total of 1,420 immediate-loa- tion would be standard. In addition, a two-stage pro-
ded implants, with a minimum of 3 years follow-up, cedure often requires a healing time of 4–6 months. In
in 519 patients has been inserted on a variety of other words, a complete implant treatment often takes
indications following a protocol aimed at reducing 8–12 months (Fig. 1A). During that time, the patient is
negative biomechanical factors. Emphasis is placed wearing a removable denture or, worse, no dentures.
upon obtaining firm primary implant stability, as As therapists, we have to cause as little dental handicap
measured by insertion torque and resonance fre- as possible to our patients. Therefore, the first task in
quency analysis, to allow splinting within 12 hours in planning an implant therapy is to evaluate whether
a fixed bridge construction with controlled occlusion. some teeth can remain during the primary healing
Part of the concept is also the use of surface-modified phase of bone and mucosa. Fig. 1(B–E) illustrate dif-
implants, which in challenging clinical situations are ferent options for oral rehabilitations without using a
believed to perform better than turned implants. The complete denture during primary healing. Key teeth,
period of evaluation ranged from 3 to 7 years. such as canines, can often be maintained and used in a
Table 5 shows a summary of two-stage vs. imme- temporary bridge construction during the healing
diate-loaded implant placement. A total of 670 phase. By leaving some strategic teeth, the dentist has

Table 5. Outcome summary of two-stage vs. immediate-loaded implants

Two-stage implants Immediate-loaded implants Total patients ⁄ implants

Total
No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) Total Total no. of
of of of failed of of of failed no. of no. of failed
patients implants implants patients implants implants patients implants implants
279 (38%) 670 (34%) 7 (1.0%) 453 (62%) 1303 (66%) 16 (1.2%) 732 1973 23
Site of implant
placement
Total mandible 0 0 0 88 388 4 (1%) 88 388 4
Total maxilla 44 261 4 (1.5%) 56 336 1 (0.3%) 100 597 5
Partial mandible 22 45 0 149 350 4 (1.1%) 171 395 4
Partial maxilla 95 246 2 (0.8%) 41 110 3 (2.7%) 136 356 5
Single mandible 39 39 0 55 55 3* (5.4%) 94 94 3
Single maxilla 79 79 1 (1.3%) 64 64 1 (1.5%) 143 143 2

*All first or second molars, without posterior tooth protection.

100
 Immediate ⁄ early loading of dental implants

4-6 months

4-6 months

Fig. 1. Different approaches to maintenance of teeth merged healing. (B–E) Different options for oral rehabili-
during implant treatment. (A) A traditional implant pro- tation without using a complete denture during the pri-
tocol that requires a 4- to 6-month healing time after mary healing phase.
tooth extraction and an additional 4–6 months for sub-

not only helped the patients but also provided different ing. At the time of implant surgery, the posterior
treatment options. If the patient case is not suitable for maxillary region has healed sufficiently to place
immediate loading, a two-step procedure can be per- implants in a tilted position to allow for adequate
formed without leaving the patient orally handicapped space between individual fixtures. The remaining
with a removable prosthesis (Fig. 1B). If immediate implants are placed in fresh extraction sites or in
loading is feasible, the remaining teeth can be ex- healed bone adjacent to the extraction socket. In the
tracted during surgery and replaced by implants latter situation, it can be difficult to achieve optimal
(Fig. 1C). Fig. 1(D) shows a patient in which both ca- fixture position. Fig. 1(E) illustrates a treatment option
nines and first incisors were left during primary heal- with all implants placed in extraction sites. However,

101
Östman

such treatment may give rise to a less predictable gives rise to implant failures. It should be emphasized
healing of bone and mucosa. that these pioneering works correlating bone quality
with implant failure were conducted with turned
implants and conventional protocols, involving
Patient selection
pre-tapping even in bone of class 4 quality. From a
Inclusion criteria biological point of view, trabecular bone represents a
superior tissue compared to cortical bone. Trabecular
Candidates for immediate loading implant therapy
bone exhibits a high surface area, which is contigu-
must often receive occlusal and articulation adjust-
ous with the bone marrow compartment (36), and
ment before or during the temporary phase to avoid
bone healing is far more rapid compared to the
unnecessary trauma to the fixtures. As the final
healing pattern present in cortical bone.
decision of immediate loading is made at the time of
Stability of an implant can be defined as its
implant surgery, the type of fixed restoration should
capacity to withstand loading forces in axial, lateral,
not be promised to patients before the placement of
and rotational directions. Sennerby & Roos (111)
the fixtures.
stated that primary implant stability is determined by
Exclusion criteria bone quality and quantity, implant design, and sur-
gical technique. Depending on bone quality and
Patients who are skeptical about the concept of
quantity, dentists need to adapt the drilling protocol
immediate-loaded implants are not candidates for this
and choice of fixture to the clinical situation to
type of treatment. One firm contraindication for
achieve sufficient primary implant stability.
immediate loading is a history of implant failure. Also,
irradiated cancer patients and smokers with uncon- Drill protocol, type of fixture, fixture diameter,
trolled diabetes are poor candidates for immediate- numbers, and degree of countersink
loaded implants. Less strict contraindications are
The ability of the dentist to judge the implant site is of
factors such as bruxism, large deviations in sagittal ⁄
critical importance in succeeding with an immediate-
vertical bite relations, and deep bite that may influence
loading protocol. Bone quality and quantity, as well as
the loading of implants in an unfavorable way.
the thickness of cortex, must be determined before
proceeding to final drill and implant placement. Sev-
Clinical assessments during surgery eral scientific reports have described modified drill
protocols according to varying bone quality (13, 14, 54,
Bone quality ⁄ quantity 59, 85). Östman et al. (85) analyzed a total of 905
Bone quantity and quality at the implant site are the Brånemark-type implants, which, depending on dif-
most important parameters in immediate-loading fering bone quality, were placed by using varying final
protocols. Critical bone features are difficult to eval- drill diameters and implant designs. Implant stability
uate solely by radiography. The Lekholm & Zarb (75) was assessed by resonance frequency analysis at the
index originally served to standardize preoperative time of placement surgery. The influence of different
planning of an implant case to make the outcome of patient, implant, and surgical factors on implant sta-
various studies comparable. However, this author bility was estimated. It was concluded that high pri-
suggests that the precise bone quality can only be mary stability could be achieved in all regions of the
determined pre-operatively. Bony features differ jaw when using an adapted surgical protocol. Although
within the edentulous jaw of the same patient, which the use of thin drills and ⁄ or tapered implants cannot
often necessitates a site-specific analysis. fully compensate for the effect of soft bone, slightly
Class 4 quality bone is often referred to as ÔpoorÕ tapered or tapered implant design and implant surface
bone for implants because it is soft, which from a modification can dramatically improve implant sur-
biomechanical view can challenge efforts to obtain a vival rate in soft bone. Glauser et al. (64) showed that
firm initial stability for an implant. Jaffin & Berman significantly higher torque values were achieved if pre-
(72) showed a high implant failure rate (35%) in class tapping was avoided before placing MKIV (Nobel
4 bone. In a study of early outcome of 4,641 Bråne- Biocare) implants in class 3 bone. Friberg et al. (58)
mark fixtures, Friberg et al. (57) concluded that most showed that the slightly tapered MKIV implant more
implant losses occurred in fully edentulous maxillae, frequently required a higher insertion torque and
in which the jawbone exhibited soft quality and showed a significantly higher primary stability com-
severe resorption. More than 40% of class 4 bone pared to standard implants. The difference in implant

102
 Immediate ⁄ early loading of dental implants

Fig. 2. Type of final drill and im-

plant with various bone densities to
obtain high initial implant stability.

stability leveled off over time, and the two different Brånemark MKIII, Osseotite), the slightly conical
implants exhibited similar secondary stability at implant design (MKIV), and the tapered implant de-
abutment placement and at the 1-year follow-up visit. sign with a diameter of 4.3 mm [e.g., Replace Select
The authorÕs own results (84) showed a high survival Tapered, Nanotite NT (Biomet 3i)]. The final torque
rate (99.2%) of immediate-loaded implants in the fully should be between 30 and 50 N cm. It is recom-
edentulous maxilla when using adapted surgical pro- mended to start with a thinner final drill. Two options
tocol and slightly tapered (MKIV) or tapered Replace exist if the bone quality is misjudged and the implant
Select Tapered implants, even in bone of quality class 3 stops at 50 N cm before being finally seated; either
and 4. unscrew the implant and choose a wider final drill, or
Besides a modified drill protocol and implant de- manually, with a torque wrench, tighten the implant
sign, enhanced primary stability can be accom- into position, thereafter loosening the fixture by
plished by choosing a wider implant diameter. A reverse torque and then using a machine at 50 N cm
wider implant will engage the buccal and palatal seating the implant to its final depth. Those methods
compacta bone more easily, and will enlarge the aim to eliminate the risk of over-tightening the
bone–metal surface contact. Our research group implant. Fig. 2 describes the recommended type of
(125) found significant higher initial implant stability, final drill and implant with bone of various density.
measured with resonance frequency analysis, with
Distribution of implants
wider implants compared to narrow ⁄ regular implant
designs. Friberg et al. (55) suggested a drilling pro- The biomechanical rules in implant treatment have
tocol that used a 3.0-mm end-burr, and a short-peg long been known and should be adhered to ensure a
countersink to widen the implant site entrance en- successful outcome. A carefully planned ⁄ treated
ough to fit a 5.0-mm implant. implant patient has by the far best long-term prog-
Cortical compacta bone differs both in thickness nosis. To allow implants to osseointegrate without
and density and is almost non-existent in class 4 unnecessary stress is of utmost importance in placing
bone. Pierrisnard et al. (95) showed that bony stress immediate-loaded implants. Implants should pref-
is concentrated in the cervical area of an implant. It is erably be positioned in a tripod or horseshoe pattern.
also assumed that the 1-mm cervical cortical bone
Evaluation of installed implants
layer serves as the major anchoring point for an im-
plant. In the case of a thin cortex, countersinking is A final torque of 30 N cm and an implant stability
not recommended at all. Thus, the final burr diam- quotient above 60 is needed to securely insert
eter and countersinking should not be standardized immediate-loaded implants. Deviation from this rule
to fit all clinical situations. can be made if several implants are inserted in the
maxilla or the mandible in a cross-arch pattern. The
Recommendation for drill protocol with various
most posterior implant should always show a torque
bone quality
of 30 N cm and an implant stability quotient of 60 or
The following guidelines are based on the 3.75-mm higher. If not achievable, the implant placement may
diameter, straight cylindrical implant design (e.g. proceed as a two-step procedure.

103
Östman

than the timing of implant loading. Brunski (23)

Post-operative care
proposed the threshold level of micromotion for a
During the initial 10-day post-operative period, it is turned implant to be 100 lm. Søballe et al. (113)
recommended that the patient consume soft food, suggested the acceptable micromotion for roughened
rinse twice daily with chlorhexidine, and, perhaps, implants to be 50–150 lm.
take penicillin-V to minimize the risk of infection.

Prosthetic procedures
Prosthetic considerations Chair-side-made temporary bridge – according to
Splinting by a temporary construction the QuickBridgeTM concept

Different approaches to temporary denture construc- The QuickBridgeTM concept from Biomet 3i aims to
tion are available to implant patients. Dental techni- convert a screw-retained temporary prosthesis to a
cians, for example, may convert an existing denture cement-retained temporary prosthesis during the
into an acrylic bridge. Compared to making a chair- healing period. The QuickBridge components fit onto
side temporary construction, laboratory procedures conical abutments and consist of two parts. A conical
are well controlled and provide a better finish and titanium alloy part is mounted, with an integrated
aesthetics, and possibly reduce the risk for contami- screw, onto the conical abutment, and a PEEK
nation of newly operated areas. On the other hand, a (polyetheretherketone) plastic cap, which covers the
laboratory-produced temporary construction tends to abutment (Fig. 3A), will become part of the provi-
be more expensive and have a longer production time. sional prosthesis. The retention of the PEEK cap
Temporary constructions made chair-side have the to the titanium cone is firm, which will allow the
advantage of immediate handicap reduction, imme- provisional prosthesis to be retained only by a snap.
diate splinting, cost effectiveness, and installation Fig. 3(A–R) shows a typical treatment of a par-
during the anesthesia phase of implant placement. tial ⁄ total implant treatment. The treatment starts
Several papers on implant-supported dental pros- with selective extraction and a fixed temporary den-
theses argue that splinting reduces the occlusal load ture during the healing period (Fig. 3B–D). Extraction
transfer more effectively than freestanding implant of the remaining teeth can occur during implant
units. According to Glantz et al. (62, 63), favorable surgery, if sufficient stability of the fixtures is ob-
loading conditions are achieved via a rigid implant tained. Before surgery, an alginate impression of both
supported bridge. Conceivably, splinting of implants jaws is made. In patients with full dentures, impres-
to each other via a temporary bridge decreases mi- sions are made of the denture. An occlusal record is
cromotions at the bone–implant interface, which in preformed. At the dental laboratory, stone casts are
turn helps to reinforce osseointegration. Therefore, a made and placed in an articulator. In case of missing
provisional bridge should be connected to implants teeth, a tooth wax-up is made. A translucent vacuum
as soon as possible after fixture placement. template is fabricated using a 2.5-mm thick thermo-
Splinting provides an option for reducing lateral formed material (ethyl-vinyl-acetate, Ergoflex 95,
forces on implants, if three or more implants are Erkodent, Pfalzgrafenweiler, Germany). On the
placed in a tripod or a cross-arch configuration (97, template, an impression is obtained of the opposite
98). Such positioning allows lateral forces to be jaw to orient the template in the mouth.
converted to more favorable axial implant forces. The bony crest is exposed through a mid-crestal
Two splinted implants will not offer the same load surgical incision. After reflecting the surgical flap,
reduction because they will be placed Ôin-lineÕ with the optimal implant position is decided upon based
no offsetting counteracting lateral forces. The benefit on aesthetic and biomechanical considerations.
of cross-arch stabilization is well-documented clini- Insertion torque and resonance frequency analysis
cally (81, 82) and by load measurements in vivo (44). measurements are used to check the stability of the
fixtures and to evaluate the feasibility of employing
Reduction of micromotion immediate-loaded implants. Next, the conical abut-
ments are mounted (Fig. 3E), and the QuickBridgeTM
The degree of micromotion of implants can be of
titanium cone and PEEK cap are placed onto the
major importance for implant integration. It has even
conical abutments (Fig. 3F,G) before closing the
been postulated that the absence of micromotion of
surgical flap (Fig. 3H).
an implant is more important for osseointegration

104
 Immediate ⁄ early loading of dental implants

The translucent template is mounted to verify that total of 377 implants (66 turned and 311 oxidized
the temporary parts fit the template. ProtempTM 3 implants, Nobel Biocare) were inserted using a
Garant, (3M, ESPE, St Paul, MN, U.S.A.) is then surgical protocol for enhanced primary stability,
injected into the template. The template is seated meaning a reduced final drilling in soft bone to
with guidance from adjacent teeth and ⁄ or the maximize bone to implant contact. Patients received
opposite jaw, and allowed to set for 4 minutes three (one patient, three implants), four (41 patients,
(Fig. 3I) while the patient is biting together. The 164 implants) or five (42 patients, 210 implants)
temporary prosthesis is removed from the titanium implants. All patients were also provided with a
interface and trimmed outside the mouth and temporary, 10- to 12-unit fixed prosthesis within
remounted (Fig. 3J). During the initial healing time, 12 hours of implant surgery. No cantilever exceeded
which is approximately 10 days, the temporary 5 mm. Permanent prosthetic delivery took place from
prosthesis is fixed with a 1% chlorhexidine gel. 10 days to 3 months following implant surgery. Using
Cantilevers cannot exceed 5 mm. the criteria of Lekholm & Zarb (75), bone of class 1
After an additional 3–6 months of healing, the quality was seen in four (5%) patients, of class 2 in 32
temporary prosthesis is snapped off and impression (38%) patients, of class 3 in 38 (45%) patients and of
copings are mounted on the titanium copings class 4 quality in 10 (12%) patients. Five of the 377
(Fig. 3K,L). A closed tray impression is then made. A implants failed, giving a cumulative implant survival
translucent template bite registration is produced by rate of 98.5% after 12 months of loading. Two of the
filling the mould with bite registration material. This implant failures were probably the result of overload
procedure provides an exact index that can be and three implants were lost because of infection.
mounted on the QuickBridge titanium copings, and
Totally edentulous maxilla (84)
can give the dental technician additional information
about tooth shape (Fig. 3M,N). The template can be Twenty patients scheduled for prosthetic rehabilita-
reused by the dental laboratory to make the frame- tion with implant-supported bridges in the edentu-
work master for copy-milled frameworks, e.g. Cam lous maxilla were studied. A total of 123 oxidized
StructSURETM (Biomet 3i) (Fig. 3O–Q). The final implants (TiUnite, Nobel Biocare) were placed using
screw-retained porcelain ⁄ titanium construction is a surgical protocol for enhanced primary stability. A
then delivered (Fig. 3R). screw-retained temporary bridge was delivered
within 12 hours and a final bridge within 3 months
Check-up and maintenance
of implant placement. Twenty patients with 120
Check-ups are initially carried out 2 weeks post- implants treated according to a two-stage protocol
treatment and then once every month. Oral hygiene, were included for comparison. One (0.8%) of the
mucosal healing, the stability of the provisional immediate-loaded implants failed, whereas no two-
bridge, and fixture status are evaluated. After stage inserted implant failed. The marginal bone
obtaining adequate mucosal healing at 1–6 months, resorption was 0.78 mm in the immediate-loaded
depending on the oral site and the healing capability implant group and 0.91 mm in the two-stage implant
of the patient, the permanent prosthetic rehabilita- group. At 6 months after implant insertion, the
tion is constructed, preferably using a biocompatible immediate-loaded implants tended to show a higher
material such as titanium or zirconia. Occlusion and implant stability quotient than implants inserted by
articulation contacts are carefully adjusted to mini- the two-stage procedure. However, no statistically
mize lateral forces. Oral hygiene measures are rein- significant difference was found between the two
forced at the time of delivery of the final prosthesis. implant groups at any time or parameter.
Thereafter, check-ups are individualized but, at a
Partially edentulous mandible (86)
minimum, are performed at 6 and 12 months post-
implant insertion, and then once a year. Seventy-seven consecutive patients in need of im-
plant treatment in the partially edentulous mandible
Clinical documentation of the presented were included in the study. A total of 111 bridges
technique supported by 257 Brånemark System implants (77
turned and 180 TiUniteTM implants) were studied.
Totally edentulous mandible
The implants were placed with enhanced initial
Eighty-four consecutive patients scheduled for pros- stability. A temporary bridge was delivered within
thetic rehabilitation with implant-supported bridges 24 hours and a final bridge was placed within
in the totally edentulous mandible were evaluated. A 3 months of implant surgery. Stability of the fixtures

105
Östman

was measured using resonance frequency analysis at (0.6%) failed after 4–13 months in three patients with
the time of placement and after 6 months. Four bruxism. The average marginal bone resorption was
(1.6%) of the 257 implants did not integrate, giving 0.7 ± 0.7 mm during the first year in function. Reso-
an overall survival rate of 98.4% after 4 years. Three nance frequency analysis showed a mean implant
turned implants (3.9%) and one oxidized implant stability quotient value of 72.2 ± 7.5 at the time of

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placement and 72.5 ± 5.7 after 6 months of loading. prostheses ranged from two unit bridges supported
Apparently, direct loading of implants with firm pri- by two implants to a full arch construction supported
mary stability in partially edentulous areas of the by six implants. The functional period of the tem-
mandible constitutes a viable therapeutic procedure porary prostheses ranged from 3 to 6 months. No
with a predictable outcome. implants were lost during the observation time. One
(3%) temporary prosthesis fractured and two (6%)
Provisional implants (88)
prostheses became loose during the follow-up
Provisional or temporary implants can be used to period.
provide patients with a temporary fixed denture
Nobel Direct and Nobel Perfect One-Piece
during the healing period of submerged fixtures.
Implants (87)
Twenty female and 25 male patients were consecu-
tively included in a prospective study of provisional The Nobel DirectTM and Nobel PerfectTM one-piece
implants. The 45 patients were treated for either implant systems represent a novel immediate loading
partial (16 patients) or total (29 patients) edentulism concept, including flapless surgery and placement of
of the maxilla. The permanent implants were placed a one-piece titanium implant (43, 66, 91). The tech-
first, and as many provisional implants as possible nique offers a simple solution to the problem of
were then installed between the permanent implants. missing teeth because surgery is minimally invasive
After implant placement and suturing, impressions and conventional prosthetic methods are used. The
were taken to manufacture provisional bridges to be implant systems are also intended for use in imme-
cemented onto the provisional implants. Five (2.2%) diate replacement of extracted teeth. This one-piece
of the 230 permanent Brånemark System implants implant system is allegedly designed to minimize
did not integrate. None of the failures could be re- marginal bone resorption because there is no sub-
lated to the presence of the provisional implants mucosal microgap, which is believed to cause the
between the permanent implants. Seven provisional initial bone loss usually associated with two-piece
implants failed during the study period. In addition, implants (43). Moreover, the entire implant has a
17 (9%) of the 192 provisional implants showed moderately rough surface (TiUnite), which is
mobility at the second-stage surgery despite having suggested to facilitate attachment of the mucosa to
supported the provisional bridges without clinical the implant surface, thereby promoting a better
symptoms. Forty-four of 45 patients showed stable Ôsoft tissue integrationÕ and long-term aesthetic
provisional implant bridges at the time of second- outcome.
stage surgery. It is concluded that provisional Forty-eight patients were provided with 115 one-
implants can be successfully used to provide patients piece implants for loading with a provisional crown
with a fixed provisional bridge during the healing or a bridge within 24 hours and were followed for at
period of permanent implants. least 12 months with clinical and radiographic
examinations. Ninety-seven patients previously trea-
Provisional implant prosthesis according to a
ted under identical conditions by the same team with
chair-side concept (89)
380 two-piece implants for immediate loading in the
Thirty-seven partially or totally edentulous older mandible and maxilla served as controls. Six (5.2%)
patients (mean age 66.7 years) were treated with one-piece implants failed during the follow-up peri-
chair-side QuickBridge temporary restorations. The od because of extensive bone loss. Five (1.3%)

Fig. 3. Reconstruction of a partially edentulous maxilla plate. The template is seated and allowed to set for
with QuickBridge and Cam Structure. (A–R) An implant 4 minutes (H). The temporary prosthesis is removed from
treatment of a partially edentulous patient. (A) shows the the titanium interface and trimmed outside the mouth
QuickBridgeTM components, a titanium cone and a poly- and remounted (I,J). After additional healing for 3–
etheretherketone (PEEK) snap on cap. (B–D) shows 6 months the temporary prosthesis is snapped off and
selective extraction and fixed temporary construction impression copings are mounted on the titanium copings
during appropriate healing time. Conical abutments (K,L). A closed tray impression is made. Using the trans-
(Biomet 3i) are mounted (E). On the conical abutments, lucent template, bite registration is made by filling up the
the QuickBridge titanium coping and PEEK cap are mould with bite registration material (M,N). The template
mounted (F,G) before the surgical flap is closed (H). The can be reused at the dental laboratory to make the
translucent template is mounted to verify that the tem- framework master for copy milled frameworks, e.g. Cam
porary parts fit into the template. ProtempTM 3 Garant, StructSURETM (Biomet 3i) (O–Q). The final copy milled
(3M, ESPE, St Paul, MN, U.S.A) is injected into the tem- porcelain ⁄ titanium is delivered (R).

107
Östman

implants failed in the two-piece implant group. After chological factors for the patients that warrant more
1 year, the mean marginal bone loss was 2.1 ± attention?
1.3 mm for one-piece implants and 0.8 ± 1.0 mm for Implants with high initial primary stability seem to
two-piece implants. Twenty per cent of one-piece function well under the influence of immediate
implants and 0.6% of two-piece implants showed loading. Available bone quality needs to be evaluated
bone loss exceeding 3 mm. When compensating for to ensure the proper implant diameter. By using
vertical placement depth, one-piece implants still surgical methods capable of enhancing primary
showed a lower marginal bone level and thus more implant stability, the placement of immediate-loaded
exposed threads than two-piece implants. Depending implants in less dense bone can result in a successful
on the criteria used, the success rate for one-piece outcome. A successful integration of immediate-loa-
implants was 46.1–72.2% compared to 85.0–91.6% ded implants may require a final torque exceeding
for two-piece implants. It was concluded that the 30 N cm and an implant stability quotient value
Nobel Direct and Nobel Perfect one-piece implants above 60. No difference in bone remodeling seems to
showed lower success rates and more bone resorp- exist between immediate-loaded and two-stage
tion than two-piece implants after 1 year in position. implants. Splinting of implants with temporary pros-
Factors such as implant design, insertion depth, theses reduces the lateral forces on the fixtures and
rough implant surface towards the mucosa, in situ can be important in maximizing osseointegration.
preparation, and immediate loading may have influ- Requirements for long-term success with immedi-
enced the clinical outcome. ate-loaded implants include:
This critical opinion about the Nobel Direct ⁄ Nobel • excellent primary implant stability,
Perfect one-piece implants is supported by recent • moderately rough implant surface,
papers by Albrektsson et al. (5) and Sennerby et al. • prolonged implant stabilization by splinting,
(110). Finne et al. (51) reported a 1-year cumulative • controlled occlusion, and
survival rate of 98.7% for the one-piece implant • biocompatible prosthetic material.
system. However, Finne et al. (51) studied bone level,
not bone loss, and 16.5% of implants were not eval-
uated radiographically. Also, 17 of a total of 152
implants experienced a bone loss exceeding 3 mm.
References
Thus, the actual success rate would be less than 70% 1. Aalam AA, Nowzari H, Krivitsky A. Functional restoration
if the entire study material were included. of implants on the day of surgical placement in the fully
edentulous mandible: a case series. Clin Implant Dent
Relat Res 2005: 7: 10–16.
Conclusions 2. Adell R, Lekholm U, Brånemark PI. Surgical procedures.
In: Brånemark PI, Zarb GA, Albrektsson T, editors. Tissue
integrated prostheses: osseointegration in clinical dentistry.
Obviously, more short- and long-term data are nee- Chicago: Quintessence Publishing Company, 1985: 211–
ded to fully evaluate the benefits and risks of imme- 232.
diate ⁄ early-loaded implants. Only the outcome of 3. Adell R, Lekholm U, Rockler B, Brånemark PI. A 15-year
immediate-loaded implants in the totally edentulous study of osseointegrated implants in the treatment of the
edentulous jaw. Int J Oral Surg 1981: 10: 387–416.
mandible can be regarded as well documented. With
4. Albrektsson T, Brånemark PI, Hansson HA, Lindstrom J.
good primary implant stability, immediate-loaded Osseointegrated titanium implants. Requirements for
implants in the totally edentulous maxilla show good ensuring a long-lasting, direct bone-to-implant anchorage
short- and medium-term outcomes, although more in man. Acta Orthop Scand 1981: 52: 155–170.
data are needed before the safety of the treatment 5. Albrektsson T, Gottlow J, Meirelles L, Östman PO, Rocci A,
Sennerby A. Survival of NobelDirect implants: an analysis
can be fully established. Excellent short-term data
of 550 consecutively placed implants at 18 different
have been presented for immediate ⁄ early loaded clinical centers. Clin Implant Dent Relat Res 2007: 9: 65–
implants in partially edentulous jaws. However, it 70.
must be remembered that most of the papers re- 6. Albrektsson T, Sennerby L. State of the art in oral implants.
viewed here are produced by practitioners who are J Clin Periodontol 1991: 18: 474–481.
7. Albrektsson T. Direct bone anchorage of dental implants.
highly trained in dental implant placement. Few
J Prosthet Dent 1983: 50: 255–261.
long-term multicenter studies are available. More 8. Albrektsson T, Brånemark PI, Hansson HA, Lindström J.
studies on patient benefits are also needed. Besides Osseointegrated titanium implants: requirements for
shorter treatment time for the doctor ⁄ patients with ensuring a long-lasting, direct bone to implant anchorage
immediate ⁄ early-loaded implants, are there psy- in man. Acta Orthopaed Scand 1981: 52: 155–170.

108
 Immediate ⁄ early loading of dental implants

9. Albrektsson T, Hansson T, Lekholm T. Osseointegrated 25. Brånemark PI, Hansson BO, Adell R, Breine U, Lindström
dental implants. Dent Clin North Am 1986: 30: 151–174. J, Hallén O, Öhman H. Osseointegrated implants in the
10. Andersen E, Haanaes HR, Knutsen BM. Immediate loading treatment of the edentulous jaw. Experience from a 10-
of single-tooth ITI implants in the anterior maxilla: a year period. Scand J Plastic Reconstructive Surg 1977: 16:
prospective 5-year pilot study. Clin Oral Implants Res 1–132.
2002: 13: 281–287. 26. Brånemark PI, Zarb GA, Albrektsson T, editors. Tissue
11. Aparicio C, Rangert B, Sennerby L. Immediate ⁄ early integrated prostheses: osseointegration in clinical dentistry.
loading of dental implants: a report from the Sociedad Chicago: Quintessence Publishing Company, 1985: 1–343.
spanola de Implantes World Congress Consensus Meeting 27. Buser D, Martin W, Belser UC. Optimizing esthetics for
in Barcelona,Spain, 2002. Clin Implant Dent Relat Res implant restorations in the anterior maxilla: anatomic and
2003: 5: 57–60. surgical considerations. Int J Oral Maxillofac Implants
12. Babbush CA, Kent JN, Misiek DJ. Titanium plasma- 2004: 19(Suppl.): 43–61.
sprayed (TPS) screw implants for the reconstruction of the 28. Calandriello R, Tomatis M, Vallone R, Rangert B, Gottlow J.
edentulous mandible. J Oral Maxillofac Surg 1986: 44: Immediate occlusal loading of single lower molars using
274–282. Brånemark System Wide-Platform TiUnite implants: an
13. Bahat O. Brånemark system implants in the posterior interim report of a prospective open-ended clinical mul-
maxilla: clinical study of 660 implants followed for 5 to ticenter study. Clin Implant Dent Relat Res 2003: 5(Suppl.
12 years. Int J Oral Maxillofac Implants 2000: 15: 646–653. 1): 74–80.
14. Bahat O. Treatment planning and placement of implants 29. Chiapasco M. Early and immediate restoration and load-
in the posterior maxillae: report of 732 consecutive No- ing of implants in completely edentulous patients. Int J
belpharma implants. Int J Oral Maxillofac Implants 1993: Oral Maxillofac Implants 2004: 19(Suppl.): 76–91.
8: 151–161. 30. Chow J, Hui E, Liu J. Immediate loading of Brånemark
15. Balshi SF, Wolfinger GJ, Balshi TJ. A prospective study of system fixtures in the mandible with a fixed provisional
immediate functional loading, following the Teeth in a prosthesis. Appl Osseointegration Res 2001: 1: 30–35.
Day protocol: a case series of 55 consecutive 31. Cochran DL, Buser D, ten Bruggenkate CM, Weingart D,
edentulous maxillas. Clin Implant Dent Relat Res 2005: Taylor TM, Bernard JP, Peters F, Simpson JP. The use of
7: 24–31. reduced healing times on ITI implants with a sandblasted
16. Balshi TJ, Wolfinger GJ. Immediate loading of Brånemark and acid-etched (SLA) surface: early results from clinical
implants in edentulous mandibles: a preliminary report. trials on ITI SLA implants. Clin Oral Implants Res 2002: 13:
Implant Dent 1997: 6: 83–88. 144–153.
17. Becker W, Becker BE, Huffstetlert S. Early functional 32. Cochran DL, Morton D, Weber HP. Consensus statements
loading at 5 days for Brånemark implants placed into and recommended clinical procedures regarding loading
edentulous mandibles: a prospective, open-ended, longi- protocols for endosseous dental implants. Int J Oral
tudinal study. J Periodontol 2003: 74: 695–702. Maxillofac Implants 2004: 19(Suppl.): 109–113.
18. Becker W, Becker BE, Israelson H, Lucchini JP, Handels- 33. Collaert B, De Bruyn H. Comparison of Brånemark fixture
man M, Ammons W, Rosenberg E, Rose L, Tucker LM, integration and short-term survival using one-stage or
Lekholm U. One-step surgical placement of Brånemark two-stage surgery in completely and partially edentulous
implants: a prospective multicenter clinical study. Int J mandibles. Clin Oral Implants Res 1998: 9: 131–135.
Oral Maxillofac Implants 1997: 12: 454–462. 34. Collaert B, De Bruyn H. Early loading of four or five
19. Bergkvist G, Sahlholm S, Karlsson U, Nilner K, Lindh C. Astra Tech fixtures with a fixed cross-arch restoration in the
Immediately loaded implants supporting fixed prostheses mandible. Clin Implant Dent Relat Res 2002: 4: 133–135.
in the edentulous maxilla: a preliminary clinical and 35. Cornelini R, Cangini F, Covani U, Barone A, Buser D.
radiologic report. Int J Oral Maxillofac Implants 2005: 20: Immediate loading of implants with 3-unite fixed partial
399–405. dentures: a 12-month clinical study. Int J Oral Maxillofac
20. Blomberg S, Lindquist LW. Psychological reactions to Implants 2006: 21: 914–918.
edentulousness and treatment with jawbone-anchored 36. Davies JE. Understanding peri-implant endosseous heal-
bridges. Acta Psychiatr Scand 1983: 68: 251–262. ing. J Dent Educ 2003: 67: 932–949.
21. Book K, Karlsson S, Jemt T. Functional adaptation to full- 37. De Bruyn H, Kisch J, Collaert B, Linden U, Nilner K,
arch fixed prosthesis supported by osseointegrated Dvarsater L. Fixed mandibular restorations on three early-
implants in the edentulous mandible. Clin Oral Implants loaded regular platform Brånemark implants. Clin
Res 1992: 3: 17–21. Implant Dent Relat Res 2001: 3: 176–184.
22. Brånemark PI, Engstrand P, Ohrnell LO, Grondahl K, 38. Degidi M, Petrone G, Iezzi G, Piattelli A. Histologic eval-
Nilsson P, Hagberg K, Darle C, Lekholm U. Brånemark uation of human immediately loaded titanium implant
Novum: a new treatment concept for rehabilitation of the with a porous anodized surface. Clin Implant Dent Relat
edentulous mandible. Preliminary results from a pro- Res 2002: 4: 110–114.
spective clinical follow-up study. Clin Implant Dent Relat 39. Degidi M, Piattelli A, Felice P, Carinci F. Immediate
Res 1999: 1: 2–16. functional loading of edentulous maxilla: a 5-year retro-
23. Brunski J. In vivo bone response to biomechanical loading spective study of 388 titanium implants. J Periodontol
at the bone ⁄ dental implant interface. Adv Dent Res 1999: 2005: 76: 1016–1024.
13: 99–119. 40. Degidi M, Piattelli A, Gehrik P, Felice P, Carinci F. Five-
24. Brånemark PI. Osseointegration and its experimental year outcome of 111 immediate non-functional single
background. J Prosthet Dent 1983: 50: 399–410. restorations. J Oral Implantol 2006: 32: 277–285.

109
Östman

41. Degidi M, Piattelli A. Immediate functional and non- 56. Friberg B, Henningsson C, Jemt T. Rehabilitation of
functional loading of dental implants: a 2- to 60-month edentulous mandibles by means of turned Brånemark
follow-up study of 646 titanium implants. J Periodontol System implants after one-stage surgery: a 1-year retro-
2003: 74: 225–241. spective study of 152 patients. Clin Implant Dent Relat Res
42. Drago CJ, Lazzara RJ. Immediate provisional restoration of 2005: 7: 1–9.
Osseotite implants: a clinical report of 18-month results. 57. Friberg B, Jemt T, Lekholm U. Early failures in 4,641 con-
Int J Oral Maxillofac Implants 2004: 19: 534–541. secutively placed Brånemark dental implants: a study from
43. Dragoo MR. Prototyp eines einteiligen Implantats. Dental- stage 1 surgery to the connection of completed prostheses.
praxis 2005: XXII: 319–325. Int J Oral Maxillofac Implants 1991: 6: 142–146.
44. Duyck J, Van Oosterwyck H, Vander Sloten J, De Cooman 58. Friberg B, Jisander S, Widmark G, Lundgren A, Ivanoff CJ,
M, Puers R, Naert I. Magnitude and distribution of Sennerby L, Thoren C. One-year prospective three-center
occlusal forces on oral implants supporting fixed pros- study comparing the outcome of a Ôsoft bone implantÕ
theses: an in vivo study. Clin Oral Implants Res 2000: 11: (prototype Mk IV) and the standard Brånemark implant.
465–475. Clin Implant Dent Relat Res 2003: 5: 71–77.
45. Engquist B, Astrand P, Anzén B, Dahlgren S, Engquist E, 59. Friberg B, Sennerby L, Meredith N, Lekholm U. A com-
Feldmann H, Karlsson U, Nord PG, Sahlholm S, Svärd- parison between cutting torque and resonance frequency
ström P. Simplified methods of implant treatment in the measurements of maxillary implants. A 20-month clinical
edentulous lower jaw. A controlled prospective study. Part study. Int J Oral Maxillofac Surg 1999: 28: 297–303.
II: Early loading. Clin Implant Dent Relat Res 2004: 6: 90– 60. Frost HM. A 2003 update of bone physiology and WolffÕs
100. law for clinicians. Angle Orthod 2004: 74: 3–15.
46. Engquist B, Åstrand P, Anzén B, Dahlgren S, Engquist E, 61. Ganeles J, Wismeijer D. Early and immediately restored
Feldmann H, Karlsson U, Nord P, Sahlholm S, Svärdström P. and loaded dental implants for single-tooth and partial-
Simplified methods of implant treatment in the edentulous arch applications. Int J Oral Maxillofac Implants 2004:
lower jaw: a 3-year follow-up report of a controlled pro- 19(Suppl): 92–102.
spective study of one-stage versus two-stage surgery and 62. Glantz P-O, Strandman E, Randow K. On functional strain
early loading. Clin Implant Dent Relat Res 2005: 7: 95–104. in fixed mandibular reconstructions. II. An in vivo study.
47. Engstrand P, Grondahl K, Ohrnell LO, Nilsson P, Nann- Acta Odontol Scand 1984: 42: 269–276.
mark U, Brånemark PI. Prospective follow-up study of 95 63. Glantz P-O, Strandman E, Svensson SA, Randow K. On
patients with edentulous mandibles treated according to functional strain in fixed mandibular reconstructions. I.
the Brånemark Novum concept. Clin Implant Dent Relat An in vitro study. Acta Odontol Scand 1984: 42: 241–249.
Res 2003: 5: 3–10. 64. Glauser R, Ree A, Lundgren A, Gottlow J, Hammerle CH,
48. Ericsson I, Nilner K. Early functional loading using Scharer P. Immediate occlusal loading of Brånemark
Brånemark dental implants. Int J Periodontics Restorative implants applied in various jawbone regions: a prospec-
Dent 2002: 22: 9–19. tive, 1-year clinical study. Clin Implant Dent Relat Res
49. Ericsson I, Nilson H, Lindh T, Nilner K, Randow K. 2001: 3: 204–213.
Immediate functional loading of Brånemark single tooth 65. Grunder U. Immediate functional loading of immediate
implants. An 18 monthsÕ clinical pilot follow-up study. implants in edentulous arches: two-year results. Int J
Clin Oral Implants Res 2000: 11: 26–33. Periodontics Restorative Dent 2001: 21: 545–551.
50. Ericsson I, Randow K, Nilner K, Peterson A. Early func- 66. Hahn J. One-piece root-form implants: a return to sim-
tional loading of Brånemark dental implants: 5-year clin- plicity. J Oral Implantol 2005: 31: 77–84.
ical follow-up study. Clin Implant Dent Relat Res 2000: 2: 67. Hatano N. The Maxis New. A novel one-day technique for
70–77. fixed individualized implant-supported prosthesis in the
51. Finne K, Rompen EJ, Toljanic J. Clinical evaluation of edentulous mandible using Brånemark System implants.
a prospective multicenter study on 1-piece implants. Appl Osseointegration Res 2001: 2: 40–43.
Part 1: Marginal bone level evaluation after 1 year of 68. Henry PJ, van Steenberghe D, Blomback U, Polizzi G,
follow up. Int J Oral Maxillofac Implants 2007: 22: 226– Rosenberg R, Urgell JP, Wendelhag I. Prospective multi-
234. center study on immediate rehabilitation of edentulous
52. Fischer K, Stenberg T. Early loading of ITI implants sup- lower jaws according to the Brånemark Novum protocol.
porting a maxillary full-arch prosthesis: 1-year data of a Clin Implant Dent Relat Res 2003: 5: 137–142.
prospective, randomized study. Int J Oral Maxillofac Im- 69. Horiuchi K, Uchida H, Yamamoto K, Sugimura M.
plants 2004: 19: 374–381. Immediate loading of Brånemark system implants fol-
53. Fischer K, Stenberg T. Three-year data from a randomized, lowing placement in edentulous patients: a clinical report.
controlled study of early loading of single-stage dental Int J Oral Maxillofac Implants 2000: 15: 824–830.
implants supporting maxillary full-arch prostheses. Int J 70. Hui E, Chow J, Li D, Liu J, Wat P, Law H. Immediate
Oral Maxillofac Implants 2006: 21: 245–252. provision for single-tooth implant replacement with
54. Friberg B, Ekestubbe A, Mellstrom D, Sennerby L. Bråne- Brånemark system: preliminary report. Clin Implant Dent
mark implants and osteoporosis: a clinical exploratory Relat Res 2001: 3: 79–86.
study. Clin Implant Dent Relat Res 2001: 3: 50–56. 71. Ibanez JC, Tahhan MJ, Zamar JA, Menendez AB, Juaneda
55. Friberg B, Ekestubbe A, Sennerby L. Clinical outcome of AM, Zamar NJ, Monqaut JL. Immediate occlusal loading of
Brånemark System implants of various diameters: a ret- double acid-etched surface titanium implants in 41 con-
rospective study. Int J Oral Maxillofac Implants 2002: 17: secutive full-arch cases in the mandible and maxilla: 6- to
671–677. 74-month results. J Periodontol 2005: 76: 1972–1981.

110
 Immediate ⁄ early loading of dental implants

72. Jaffin RA, Berman CL. The excessive loss of Brånemark adapted surgical protocol and primary implant stability
fixtures in type IV bone: a 5-year analysis. J Periodontol criteria for inclusion. Clin Implant Dent Relat Res 2005:
1991: 62: 2–4. 7(Suppl. 1): S60–69.
73. Kronström M, Widbom T, Löfquist LE, Henningson C, 88. Östman PO, Hellman M, Wendelhag I, Sennerby L. Reso-
Widbom C, Lundberg T. Early functional loading of coni- nance frequency analysis measurements of implants at
cal Brånemark implants in the edentulous mandible: a placement surgery. Int J Prosthodont 2006: 19: 77–83.
12 month follow-up clinical report. J Prosthet Dent 2003: 89. Östman PO, Hellman PO, Sennerby L. Direct loading of
89: 335–340. Brånemark System implants in the partially edentate
74. Ledermann PD. Stegprothetische Versorgung des mandible: a prospective 1-year radiographic and up to
zahnlosen Unterkiefers mit Hilfe plasmabeschichteten 4-year clinical study. J Oral Maxillofac Implants 2008, in
Titanschraubimplantaten. Dtsch Zahnärtz Z 1979: 34: 907– press.
911. 90. Olsson M, Urde G, Andersen JB, Sennerby L. Early loading
75. Lekholm U, Zarb GA. Patient selection and preparation. of maxillary fixed cross-arch dental prostheses supported
In: Brånemark PI, Zarb GA, Albrektsson T, editors. Tissue- by six or eight oxidized titanium implants: results after
integrated prostheses: osseointegration in clinical dentistry. 1 year of loading, case series. Clin Implant Dent Relat Res
Chicago: Quintessence, 1985: 199–209. 2003: 5(Suppl. 1): 81–87.
76. Lekholm U. Patient selection for Brånemark Novum 91. Parel SM, Schow SR. Early clinical experience with a new
treatment. Appl Osseointegration Res 2001: 2: 36–40. one-piece implant system in single tooth sites. J Oral
77. Lindquist LW, Carlsson GE, Jemt T. A prospective 15-year Maxillofac Surg 2005: 63(9 Suppl. 2): 2–10.
follow-up study of mandibular fixed prostheses supported 92. Piattelli A, Corigliano M, Scarano A, Costigliola G, Pao-
by osseointegrated implants. Clinical results and marginal lantonio M. Immediate loading of titanium plasma-
bone loss. Clin Oral Implants Res 1996: 7: 329–336. sprayed implants: an histologic analysis in monkeys.
78. Lorenzoni M, Pertl C, Zhang K, Wimmer G, Wegscheider J Periodontol 1998: 69: 321–327.
WA. Immediate loading of single-tooth implants in the 93. Piattelli A, Corigliano M, Scarano A, Quaranta M. Bone
anterior maxilla. Preliminary results after one year. Clin reactions to early occlusal loading of two-stage titanium
Oral Implants Res 2003: 14: 180–187. plasma-sprayed implants: a pilot study in monkeys. Int J
79. Luongo G, Di Raimondo R, Filippini P, Gualini F, Paoleschi Periodontics Restorative Dent 1997: 17: 162–169.
C. Early loading of sandblasted, acid-etched implants in 94. Piattelli A, Ruggeri A, Franchi M, Romasco N, Trisi P. An
the posterior maxilla and mandible: a 1-year follow-up histologic and histomorphometric study of bone reactions
report from a multicenter 3-year prospective study. Int J to unloaded and loaded non-submerged single implants
Oral Maxillofac Implants 2005: 20: 84–91. in monkeys: a pilot study. J Oral Implantol 1993: 19: 314–
80. Machtei EE, Frankenthal S, Blumenfeld I, Gutmacher Z, 320.
Horwitz J. Dental implants for immediate fixed restora- 95. Pierrisnard L, Renouard F, Renault P, Barquins M. Influ-
tions of partially edentulous patients: a 1-year prospective ence of implant length and bicortical anchorage on
pilot clinical trial in periodontally susceptible patients. implant stress distribution. Clin Implant Dent Relat Res
J Periodontol 2007: 78: 1188–1194. 2003: 5: 254–262.
81. Maló P, Rangert B, Nobre M. ÔAll-on-4Õ immediate-function 96. Raghoebar GM, Friberg B, Grunert I, Hobkirk JA, Tepper G,
concept with Brånemark System implants for completely Wendelhag I. 3-year prospective multicenter study on one-
edentulous maxilla: a 1-year retrospective clinical study. stage implant surgery and early loading in the edentulous
Clin Implant Dent Relat Res 2005: 7(Suppl. 1): 88–94. mandible. Clin Implant Dent Relat Res 2003: 5: 39–46.
82. Maló P, Rangert B, Nobre M. ÔAll-on-FourÕ immediate- 97. Rangert B, Jemt T, Jörneus L. Forces and moments on
function concept with Brånemark System implants for Brånemark Implants. Int J Oral Maxillofac Implants 1989:
completely edentulous mandibles: a retrospective clinical 4: 241–247.
study. Clin Implant Dent Relat Res 2003: 5(Suppl. 1): 2–9. 98. Rangert B, Sullivan R, Jemt T. Load factor control for
83. Misch CE, Degidi M. Five-year prospective study of implants in the posterior partially edentulous segment. Int
immediate ⁄ early loading of fixed prostheses in com- J Oral Maxillofac Implants 1997: 12: 360–370.
pletely edentulous jaws with a bone quality-based implant 99. Rocci A, Martignoni M, Burgos PM, Gottlow J, Sennerby L.
system. Clin Implant Dent Relat Res 2003: 5: 17–28. Histology of retrieved immediately and early loaded oxi-
84. Östman P-O, Hellman M, Albrektsson T, Sennerby L. Di- dized implants: light microscopic observations after 5 to
rect loading of Nobel Directs and Nobel Perfects one-piece 9 months of loading in the posterior mandible. Clin
implants: a 1-year prospective clinical and radiographic Implant Dent Relat Res 2003: 5(Suppl. 1): 88–98.
study. Clin Oral Impl Res 2007: 18: 409–418. 100. Rocci A, Martignoni M, Gottlow J. Immediate loading in
85. Östman PO, Hellman M, Nilson H, Ericsson I. Provisional the maxilla using flapless surgery, implants placed in
implants: a clinical prospective study in 45 patients, from predetermined positions, and prefabricated provisional
implant placement to delivery of the final bridge. Clin restorations: a retrospective 3-year clinical study. Clin
Implant Dent Relat Res 2004: 6: 142–149. Implant Dent Relat Res 2003: 5(Suppl. 1): 29–36.
86. Östman PO, Hellman M, Sennerby L, Wennerberg A. 101. Rocci A, Martignoni M, Gottlow J. Immediate loading of
Provisional implant prosthesis according to a chair-side Brånemark System TiUnite and turned-surface implants
concept – technical note and results of 37 temporary fixed in the posterior mandible: a randomized open-ended
prosthesis. Clin Implant Dent Relat Res 2008, in press. clinical trial. Clin Implant Dent Relat Res 2003: 5(Suppl. 1):
87. Östman PO, Hellman M, Sennerby L. Direct implant 57–63.
loading in the edentulous maxilla using a bone density-

111
Östman

102. Roccuzzo M, Bunino M, Prioglio F, Bianchi SD. Early ten consecutive case reports with 1- to 5-year data. Int J
loading of sandblasted and acid-etched (SLA) implants: a Oral Maxillofac Implants 1997: 12: 319–324.
prospective split-mouth comparative study. Clin Oral 115. Testori T, Del Fabbro M, Feldman S, Vincenzi G, Sullivan
Implants Res 2001: 12: 572–578. D, Rossi R Jr, Anitua E, Bianchi F, Francetti L, Weinstein
103. Roccuzzo M, Wilson T. A prospective study evaluating a RL. A multicenter prospective evaluation of 2-months
protocol for 6 weeksÕ loading of SLA implants in the pos- loaded Osseotite implants placed in the posterior jaws:
terior maxilla: one year results. Clin Oral Implants Res 3-year follow-up results. Clin Oral Implants Res 2002: 13:
2002: 13: 502–507. 154–161.
104. Romanos GE, Toh CG, Siar CH, Swaminathan D. Histo- 116. Testori T, Del Fabbro M, Szmukler-Moncler S, Francetti L,
logic and histomorphometric evaluation of peri-implant Weinstein RL. Immediate occlusal loading of Osseotite
bone subjected to immediate loading: an experimental implants in the completely edentulous mandible. Int J
study with Macaca fascicularis. Int J Oral Maxillofac Im- Oral Maxillofac Implants 2003: 18: 544–551.
plants 2002: 17: 44–51. 117. Testori T, Meltzer A, Del Fabbro M, Zuffetti F, Troiano M,
105. Salvi GE, Gallini G, Lang NP. Early loading (2 or 6 weeks) Francetti L, Weinstein RL. Immediate occlusal loading of
of sandblasted and acid-etched (SLA) ITI implants in the Osseotite implants in the lower edentulous jaw. A multi-
posterior mandible. A 1-year randomized controlled clin- center prospective study. Clin Oral Implants Res 2004: 15:
ical trial. Clin Oral Implants Res 2004: 15: 142–149. 278–284.
106. Schincaglia GP, Marzola R, Scapoli C, Scotti R. 118. Testori T, Szmukler-Moncler S, Francetti L, Del Fabbro M,
Immedate loading of dental implants supporting fixed Scarano A, Piattelli A, Weinstein RL. Immediate loading of
partial dentures in the posterior mandible: a randomized Osseotite implants: a case report and histologic analysis
controlled split-mouth study—turned versus titanium after 4 months of occlusal loading. Int J Periodontics
oxide implant surface. Int J Oral Maxillofac Implants Restorative Dent 2001: 21: 451–459.
2007: 22: 35–46. 119. Testori T, Szmukler-Moncler S, Francetti L, Del Fabbro M,
107. Schnitman PA, Wohrle PS, Rubenstein JE, DaSilva JD, Trisi P, Weinstein RL. Healing of Osseotite implants under
Wang NH. Ten-year results for Brånemark implants submerged and immediate loading conditions in a single
immediately loaded with fixed prostheses at implant patient: a case report and interface analysis after 2 months.
placement. Int J Oral Maxillofac Implants 1997: 12: 495– Int J Periodontics Restorative Dent 2002: 22: 345–353.
503. 120. Testori T, Wiseman L, Woolfe S, Porter SS. A prospective
108. Schnitman PA, Wohrle PS, Rubenstein JE. Immediate fixed multicenter clinical study of the Osseotite implant: four-
interim prostheses supported by two-stage threaded year interim report. Int J Oral Maxillofac Implants 2001:
implants: methodology and results. J Oral Implantol 1990: 16: 193–200.
16: 96–105. 121. van Steenberghe D, Molly L, Jacobs R, Vandekerckhove B,
109. Schroeder A, van der Zypen E, Stich H, Sutter F. The Quirynen M, Naert I. The immediate rehabilitation by
reactions of bone, connective tissue, and epithelium to means of a ready-made final fixed prosthesis in the
endosteal implants with titanium-sprayed surfaces. edentulous mandible: a 1-year follow-up study on 50
J Maxillofac Surg 1981: 9: 15–25. consecutive patients. Clin Oral Implants Res 2004: 15: 360–
110. Sennerby L, Becker W, Jonsson L, Johansson L-Å, 365.
Albrektsson T. Short-term clinical results of Nobel Direct 122. Vanden Bogaerde L, Pedretti G, Dellacasa P, Mozzati M,
implants. A retrospective multicentre analysis. Clin Oral Rangert B, Wendelhag I. Early function of splinted
Implants Res 2008, in press. implants in maxillas and posterior mandibles, using
111. Sennerby L, Roos J. Surgical determinants of clinical suc- Brånemark System Tiunite implants: an 18-month pro-
cess of osseointegrated oral implants: a review of the lit- spective clinical multicenter study. Clin Implant Dent
erature. Int J Prosthodont 1998: 11: 408–420. Relat Res 2004: 6: 121–129.
112. Sulzer TH, Bornstein MM, Buser D. Indications for oral 123. Weber HP, Buser D, Fiorellini JP, Williams RC. Radio-
implantology in a referral clinic. A three-year retrospective graphic evaluation of crestal bone levels adjacent to
analysis of 737 patients with 1176 implants. Schweiz nonsubmerged titanium implants. Clin Oral Implants Res
Monatsschr Zahnmed 2004: 114: 444–450. 1992: 3: 181–188.
113. Søballe K, Hansen ES, Brockstedt-Rasmussen H, Bünger C. 124. Vermylen K, Collaert B, Linden U, Bjorn AL, De Bruyn H.
The effects of osteoporosis, bone deficiency, bone grafting Patient satisfaction and quality of single-tooth restora-
and micromotion on fixation of porous-coated hydroxy- tions. Clin Oral Implants Res 2003: 14: 119–124.
apatite-coated implants. In: Gesink RGT, Manley MT 125. Wolfinger GJ, Balshi TJ, Rangert B. Immediate functional
editors. Hydroxylapatite coatings in orthopaedic surgery. loading of Brånemark system implants in edentulous
New York: Raven Press, 1993: 107–136. mandibles: clinical report of the results of developmental
114. Tarnow DP, Emtiaz S, Classi A. Immediate loading of and simplified protocols. Int J Oral Maxillofac Implants
threaded implants at stage 1 surgery in edentulous arches: 2003: 18: 250–257.

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