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Implants can be loaded immediately after placement

Thomas J. Balshi, DDS, FACP

Glenn J. Wolfinger, DMD, FACP

Immediate Implant Loading: A New Protocol for Esthetic Restorations By Thomas J. Balshi, DDS, FACP and Glenn J. Wolfinger, DMD, FACP Appeared in Clinical Techniques in Dentistry in Contemporary Esthetics and Restorative Practice, June 2002, Page 40

ONE OF THE biggest drawbacks to implant therapy has been the length of time required by traditional placement protocols. A 3- to 14- month treatment sequence is commonplace, often including multiple surgeries. Patients undertaking such therapy have to resign themselves to enduring significant inconvenience and discomfort before they can begin to enjoy an amelioration of their appearance, speech, masticatory function, and self-confidence. In an effort to improve the implant experience, dental researchers have increasingly focused on ways to shorten the course of treatment. A substantial body of evidence demonstrates that implants can be loaded immediately after placement.1-5 Candidates for this approach must have enough quantity and quality of bone to ensure initial stability. They also must agree to scrupulously follow all postsurgical instructions. In the author's experience, when these conditions are met, the results are excellent.

IMMEDIATE GRATIFICATION Since 1993, the authors have used a protocol for fabricating a functional prosthesis on the day of implant surgery. It works as follows: The prosthodontist first makes a custom provisional restoration. On the day of surgery, osteotomies are performed with a series of standardized drills and copious irrigation. If the bone quality and quantity appear adequate to ensure initial stability, one or more implants can be placed, and abutments are connected to the implants. After flap closure, modified stainless steel impression copings are connected to the abutments using guide pins. Transfer ink is then applied to the top of the guide pins and a rubber dam is positioned over them to record the position of the implants. A punch is used to create a hole in the rubber dam at each site. The dam is then gently eased over each guide pin and impression coping, taking care to avoid creating wrinkles or folds in the rubber. Article continues below:

Patients treated with immediately loaded implants are also urged to follow a soft diet for 8 to 12 weeks.

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Figure 1 -- Preoperative frontal view showing missing mandibular incisors.

Figure 3 -- Modified mandibular immediate complete denture with wire reinforcement to maintain denture integrity during adaptation procedure.

Figure 2 -- Postsurgical view of the mandible with six implants and abutments in place.

Continued from Above: Acrylic resin is applied to the prosthetic cylinders with a syringe. Additional acrylic is placed on the internal surface of a prosthesis that was previously hollowed and adjusted. The denture-bearing areas of this prosthesis are kept free of contact with the acrylic to maintain the proper vertical dimension of occlusion. The denture is placed in the patient's mouth in the proper inter-occlusal position in centric relation, and the patient is instructed not to move for approximately 4 minutes. As the acrylic polymerizes, the rubber dam insulates the tissue from the released heat. The rubber dam also ensures that no undercuts between the abutments are engaged when the resin polymerizes. The denture is then removed and undergoes structural enhancement, refinement, and polishing in the laboratory. After panoramic and cephalometric radiographs have confirmed the position of the implants, the completed prosthesis (Teeth in a DayTM, Pi Dental Center) is attached to the abutments with gold screws, and the occlusal relations are evaluated again. The patient is sent home with postoperative medication and instructions about the importance of applying cold packs throughout the night. Patients treated with immediately loaded implants are also urged to follow a soft diet and otherwise avoid placing excessive pressure on the prosthesis for 8 to 12 weeks after the surgery. After that period, a secondary impression is recorded, using the prosthesis as an impression stent. The patient then returns for delivery of the final metal-reinforced, custom designed, tissue-integrated prosthesis.

Figure 4 -- Modified stainless steel impression copings with guide pins installed immediately after abutment placement at Stage 1 surgery. These will function as interim prosthetic components.

Figure 5 -- Fabrication of the conversion prosthesis in the laboratory, using long guide pins to maintain screw access channels.

Figure 6 -- An occlusal view of the mandibular conversion prosthesis in place immediately after abutment placement.

Figure 7 -- Frontal view of the improved esthetic result after placement of the implants and attachment of the conversion prosthesis.

References: Schnitman PA, Wohrle PS, Rubenstein JE, et al: Ten-year results of Brånemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Implants 12(4):495-503, 1997. Balshi TJ, Wolfinger GJ: A new protocol for immediate functional loading of dental implants Dent Today 20(9):60-65, 2001. Szmukler-Moncler S, Piatelli A, Favera GA, et al: Considerations preliminary to the application of early and immediate loading protocols in dental implantology. Clin Oral Implants Res 11(1):12-25, 2000. Wohrle PS: Single-tooth replacement in the aesthetic zone with immediate provisionalization: fourteen consecutive case reports. Pract Periodontics Aesthet Dent 10(9):1107-1114, 1998. Tarnow DP, Emtiaz E, Classi A: Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with 1- to 5-year data. Int J Oral Maxillofac Implants 12(3):319-324, 1997. Published in Contemporary Esthetics and Restorative Practice, 241 Forsgate Drive, Jamesburg, NJ 08831

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