Immediate Loading: When Is This Approach Indicated?

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Adriana, a dental implant patient, asks:
I am a female patient in excellent health and I need an implant to replace #8. Is immediate loading a possibility in a case like mine or would a more conservative approach be preferable? Typically, how long do you have patients in a situation like mine wait before loading? If immediate loading is not possible, what temporary solutions have worked best for your patients?

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12 Responses to “ Immediate Loading: When Is This Approach Indicated? ”

  • Stephen Kim June 9th, 2008

    Dear Adriana.
    I can not answer if you are a candidate for an immediate loading due to lack of info. However, whether you are a candidate or not, i always do it traditional way because #8 is the most difficult area to restore and make it look like a natural tooth. So this is what i usually do. I extract the tooth from the socket via non-traumatic way, place the implant into the socket, bone graft if necessary, and suture. Now to temporize, I cut the root off the extracted tooth, make an ovate pontic with an extracted tooth, then bond it to adjacent teeth with composite. I also give a flipper in a case and ask the patient to carry it in purse just in case there is an emergency in public. (usually there are no emergencies). Then we wait 6 months.
    In order for you to come out with a brilliant smile, it is extremely important to be very careful with 1)implant placement in terms of location (I prefer bit more lingual part of ext socket) and depth (how far it should go beyond cej of #9) and 2) soft tissue management during implant recovery phase. Then tooth making part is very easy. With all that being said, I have done immediate loading on #8 and #9, but the method I have just described is the most predictable for me. All dentist, surgeons have their own personal preference, but this is how i do it.

  • SFOMS June 10th, 2008

    Usually for an immediate placement, you are compromising the implant to begin with due to lack of native bone on the facial aspect of the implant. Most of the immediate implant placement stability is gained from the apical and palatal bone, like Dr. Kim has stated. I have done immediate placement and loading with a temporary abutment and a temporary crown, it all depends on the individual clinical factors of available bone, length of planned implant, initial stability of the implant. One advantage you have for immediate loading is that the gingival esthetics are generally superior due to the preservation of the orientation the gingival fibers.

  • Robert Lemke DDS MD June 10th, 2008

    Dear Adriana,
    As mentioned above, there is some missing information.
    1. Are you already missing #8 or is failing and if it is failing, is it cracked or abscessed?
    2. When you smile, do you see only teeth in the upper jaw or some of the “gum” gingival tissue?
    If you still have tooth #8, an implant can be placed and an immediate temporary made in most cases. I emphasize “can” and “most.”
    If you have an infection or if the tooth has been missing, there is some bone loss. The more bone loss, the better it is it replace the bone and come back and then place the implant.
    It is important for the surgeon to always be aware of the amount of bone relative to the implant’s front (facial) part. This will help ensure a nice outcome not only in the short term, but long term as well.
    Good luck with you care!

  • david,omfs June 11th, 2008

    the previous comments ai agree with, this is the most challenging site and to add risk ok if w2orking with very experienced surgeon and prosthodontist. yes immediate extract, placement and a temporary out of funtion is an option but higher risk for porblems if the corrct case is not chosen hopefully you will be old of the pros and cons and dont jump into this treament as the best it might be but is more challenging

  • Adriana June 11th, 2008

    Thank you all so much for your comments and for sharing your expertise with me.

    To answer your questions, #8 is still there. A crown was placed on it 25 years ago when I broke my tooth due to trauma. The remainder of the original tooth recently broke at the gumline. (The crown is cemented there now temporarily). I have no infection or other issues.

    When I smile, I show only teeth, but my upper lip is right at my gumline.

  • Ron Neff June 12th, 2008

    Adriana,

    Tooth number eight is probably as important a tooth to a patient as can be imagined. Going for a period without it is mortifying for most, even if it is only over a luncheon.

    The pros of putting a temporay on immediately are:

    Preserves soft tissue papilla (triangles between teeth)
    Can be used to “mould” healing
    Looks good
    Feels Solid
    Can be a copy or modification of the existing crown———- making transistion “invisible”
    Patient confidence
    Patient convenience
    Reduction in chair time for patient (and doc)
    Great bony plates for solidity (see below)
    Tremendous bone depth for longer length, (stronger) implants
    plus more

    The cons:
    Loss of triagular height of gum (papillae) as bone peaks melt during healing
    Highest operator technique requirement
    Bone grafting needed inside socket toward the face because implant is postioned more toward the palate (more doctor time, effort, skill)
    Painstaking doctor esthetic requirement for proper temporary to guide healing appropriately
    Abcesses, or holes in bone (dehiscenses) from long postponed teeth replacement causing a manditory two stage (six month) method
    plus more

    I have had good success with immediate temporization with the Sargon (expandable) Implant System in this region.

    (I use four other implant systems as well and they all have there place, Zimmer, PerioSeal, Imtec, and NobleBio). But not for the top front teeth.

    The anatomy of the front upper finds a hard ‘plate’ of bone in front and behind the tooth root. The expansion design of the implant allow for stablization against these plates. This would be like a molly bolt in a world of screws.

    You have probably hung pictures with screws and then molly bolts and have a familiarity with the difference in supporting a load.

    Sometimes dentists talk about “immediate load” almost as a slang when referring to ‘immediate temporization’ (an actual temporary crown placed on the implant the day of extraction of the root and implant placement.

    When a temporay is placed it can be inadvertantly loaded, not when biting which is usually easy for the doctor to insure, but when chewing, even if only by food causing pressure against the temporary in chewing movements. The angular load can then compromise the implant “taking” (ossteo-integrating) because of the wiggling forth and back.

    Only the (Patented) Sargon can be further expanded to restabilize if this occurs. So no wonder doctors using screw shaped implants are wanting to postpone the crown for six months. With the expandable implant the final crown is cemented in 8-10 weeks.

    Frankly how vigorous a patient chews is unpredictable. Hence the nay sayers about immediate temporization. With an unforgiving screw design any looseness and it’s over…

    A tooth fragment bonded to the adjacent teeth won’t cause the implant to wiggle, but it will prevent flossing; (and picks and rubber tips, etc. will shrink the soft tissue as will no cleaning at all.

    Neither will a flipper allow the implant to wiggle in most cases, but it may compress the soft tissue, and compromise the blood flow and result in shrinking of the soft tissue.

    I hope this offers some insight into the thought processes of dentists. We recommend what we are comfortable with, and what works in our own hands. Nevertheless, we can fall into thinking our way is the only way.

    Good luck in your search, and your outcome.

    Ronald A. Neff DDS

  • Robert56 June 17th, 2008

    Read all you can on PH Ledermann
    He is the father of immediate load.
    German is most of the articles

  • Dr.B.Praveen June 24th, 2008

    I have a 30 year olfd female patient who has a history of SLE (systemic lupus erytematosis). She has been on steroids for 10 years and has got about 8 deciduos teeth in her mouth. These have to be extracted and implant surgery needs to be done for her.The rheumatolgist has given an opinion that as she has a connective tissue disorder implants should not be done. Has anyone got experience of such a case and what was the reatment plan.

  • Ambrish Maniar June 27th, 2008

    What type of Sle does she suffer from? The condition is basically is not very favourable for osseointegration.
    Ambrish

  • R. Hughes August 17th, 2008

    We are beating root forms to death. Let’s consider blades, ramus blades, subs, disk and ramus frames! They have a long, tried and true record, yet more skill is required by the operator. Let’s face it, root forms are very easy to place, thus used alot but alot af accessory exotic procedures have been dreamed up to make them work!

  • R. Hughes, D.D.S. August 18th, 2008

    I believe Drs. Ralph Roberts and Leonard Linkow are the fathers of immediate loading!!!!!!!!!

  • viniti August 23rd, 2008

    its a good task to solve d Quaries Pl. elaborate about Case selection in Immediate loading Implants…Im a Dentist

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