Immediate Loading: The Gold Standard?

David, a dentist, asks:

It seems like immediate loading is becoming the gold standard in dental implant placement and restoration.

My understanding is that for single free-standing dental implants all you have
to do is place a temporary crown that is out of occlusion. I see more
and more of these cases being done. With all the new surface coatings
on dental implants available now, this makes sense because
osseointegration is much quicker. What are your experiences? Am I correct that all you have to do is place a temporary crown that is out of occlusion? Thanks.

9 thoughts on “Immediate Loading: The Gold Standard?

  1. I personally have been involved in implant dentistry, since I met Dr. Leonard Linkow in 1968. Initially, the blade implants of that era were loaded immediately,and generally functioned well for a number of years because they were in a “fibro-osseouseous state”….which translated, the blade of the implant was encapsulated by strong fibrous tissue, and was always in a state of elastic suspension with some degree of inflammation and mobility, but did carry a load. It was not healthy as we consider the standards today.

    Immediate load, in my opinion, should be done very cautiously, and the patient forwarned that it could lead to failure….Branemark described a protocol 40 years ago which should be adhered to….make sure there is absolutely no micromovement for osseointegration to take place……beware, and do not believe all you hear about the success of immediate loading.

  2. Immediate load is not the “gold standard”. It is becoming popular since it is a great marketing tool for both manufacturers and dentists. “Teeth in an hour” is a great sales pitch. For the right case, immediate load can be a great and successful service. The concept of implant failure is forces and micromovement are allowed to occur during healing is true for immediate load as well as traditional two-stage implants. Not only does the success depend upon keeping the temporary restoration out of occlusion, it must also not experience any lateral loading. If the patient decides to chew with it, forces can be placed on the implant even though it is out of occlusion. With proper case selection, the success rates for immediate load are still quite high. They are not as high as two-stage implant placement and as such, cannot be considered as a “gold standard”. From a personal standpoint, I have done immediate load and had successes and failures. I tend to be extremely selective with immediate load cases. In the anterior (where they are most popular), my first choice is to do the two-stage and give the patient a Maryland bridge as a temporary. Then I can sleep at night without wondering what the patient is eating for dinner.

  3. The implant field requires more careful selection of the terms they bring into the dental vocabulary. Why in the world should the term “immediate load implant” be used for anything except what it says, which is an implant that can sustain a functional load immediately after it is placed.

    “…becoming popular since it is a great marketing tool” is a terribly unprofessional reason to use the term when it doesn’t mean what it says. It is as bad or worse than ‘whitening toothpastes’ that lack an active ingredient that can whiten.

    To require several sentences to clarify that the phrase doesn’t mean what it says (it is out of occlusion and shouldn’t have lateral loading forces) tells us that the phrase is inappropriate… a better phrase needs to be created.

    The fact that it is “one-stage” is understood. This might be able to cleaned up a little, but how about “immediate mock temp” or “immediate hypo temp” or “immediate no-load temp”.

  4. I have been involved with this technique (immediate non-loaded implants after extractions of anterior or premolar teeth) for the last 6 years and having done more than 200 cases, i believe the following:.

    The techniques works extremely well in different situations including infected sites. However, you have to be ready to move to conventional technique if you do not get enough anchorage.

    The technique can be done with practically any implant system. However, some dental implants are very easier than others when you are doing immediate implants.

    From the esthetic point of view, you get the best possible results without having to perform many surgeries to correct deficiencies created by tooth loss.
    Now, to get minimal gingival tissue changes you must have atraumatic extractions, support wall sockets with bone graft and gingival margin with a non-irritant material. Any space will create gingival changes.

    From the occlusal point of view, any pressure most likely lead to implant failure unless the implants in well anchored.

    Buccal performation and lack of sufficient anchorage are common problems unless you use the proper implant and select the case properly.

    After having all these issuees clear, it is a very easy procedure.

    Dr. Vergara

  5. I have been very exceptic about immediate loading in the past.
    I started doing immediate loading in the mandible with the classical 5 interforaminal implants with a wonderful result. Then I started doing immediate postextraction implants with a temporary crown out of occlusion and I am still doing this. I don´t find any advantage in doing full occlusion in my temporarys, but I found that doing Immediate postextraction implants with a temporary allows me to preserve bone and soft tissue at the level that I want.

  6. I am a General Practitioner who has been selectively treating Implant Cases, surgically and prosthetically since 1995.
    My training includes about 500 hours of Dental Continuting Education Courses, in addition to constantly reading the literature…and it seems there is never enough time to do this properly!
    I have only started placing Dental Implants with Immediate Load in the past two years, and out of 55 Implants placed, All Replace Select TiUnite, I have had only one failure, to date.
    Why are we doing this “Immediate Load”?….yes, it probably keeps the patient happier, but in my opinion, a Temporary Crown, properly fabricated, allows me to better sculpt the tissue, at least in the anterior region, compared to a Maryland Temp…just my experience….and I have restored several Mandibular cases, with six Implants placed, and then the temporary prosthetis fixed in place the next day…..At the ICOI Meeting in SanDiego in FEB 2006, Linkow spoke about Immediate Loading and said he had been doing it for years, long before the sudden surge in popularity, and feels it is warranted, given that certain criteria are met etc.

    All the best to everyone in this exciting field of our profession.

  7. How about “progressive loading”? Immediate loading in the full sense of the word means to load it to the full immediately and probably this should only be done when the bone is dense enough and the primary stability is good. Progressive loading means you start the prosthesis (usually resin type) out of occlusion though even then, there will still be some “load” in the sense of stimulation from the tongue and food that will inevitably impinge on it even though it is out of occlusion. A study in the University of Malaya, Malaysia in monkeys has shown that over a few months the immediate margin of bone around the implant increases in density i.e. ossification. They call this process bone training and forms the rationale behind allowing progressive loading before full loading after a period of several months.

  8. Instant implant function is a safe and predictable procedure if you use an adequate type of implants and if the bone allows loading. Usually, if you need grafting or have an infected site it could not be the case, because you would hardly get a primary stability needed for temporization.

  9. Look at the literature and you will find that if you have proper stability of a single anterior (35 Ncm or better), with a proper occlusal scheme, that this procedure is well supported. The key is to reduce micromotion. You will also find this to be true for the edentulous mandible immediately loaded within 48 hrs. Other than these procedures the literature on other immediately functional/non-functional loading is not good and you should proceed with caution. IJOMI put out some very good articles, summarizing the literaure, on their supplemental edition in 2004. Look these up, make up your own mind, and forget about what the implant companies tell you.

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