Loading of dental implants / general dental courses

GOOD MORNINGGOOD MORNING
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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LOADING OF IMPLANTSLOADING OF IMPLANTS
IMMEDIATE IMPLANT PLACEMENTIMMEDIATE IMPLANT PLACEMENT
IMMEDIATE LOADINGIMMEDIATE LOADING
DELAYED LOADINGDELAYED LOADING
PROGRESSIVE BONE LOADINGPROGRESSIVE BONE LOADING

DEFINITIONSDEFINITIONS
Immediate Loading : Placing full
occlusal/incisal loading upon a dental implant.
Axial Loading : The force directed down the
long axis of a body. Usually used to describe
the force of occlusal contact upon a natural
tooth, dental implant or other object, “axial
loading” is best described as “the force down
the long axis of the tooth” or whatever body is
being described. (As per GPT- 8)

Implant ProsthodonticsImplant Prosthodontics :: The phase ofThe phase of
prosthodontics concerning the replacement ofprosthodontics concerning the replacement of
missing teeth and/or associated structures bymissing teeth and/or associated structures by
restorations that are attached to dentalrestorations that are attached to dental
implants.implants. (As per GPT- 8)
Implant SystemImplant System:: Dental implant componentsDental implant components
that are designed to mate together. An implantthat are designed to mate together. An implant
system can represent a specific concept,system can represent a specific concept,
inventor, or patent. It consists of the necessaryinventor, or patent. It consists of the necessary
parts and instruments to complete the implantparts and instruments to complete the implant
body placement and abutment componentsbody placement and abutment components
body and abutment.body and abutment.

ImplantologyImplantology:: A term historically conceivedA term historically conceived
as the study or science of placing and restoringas the study or science of placing and restoring
dental implants.dental implants. (As per GPT- 8)
Implant SurgeryImplant Surgery :: The phase of implantThe phase of implant
dentistry concerning the selection, planning,dentistry concerning the selection, planning,
and placement of the implant.and placement of the implant. (As per GPT- 8)
Progressive LoadingProgressive Loading :: The gradualThe gradual
increase in the application of force on a dentalincrease in the application of force on a dental
implant whether intentionally done with aimplant whether intentionally done with a
prosthesis or unintentionally via forces placedprosthesis or unintentionally via forces placed
by adjacent anatomic structures or paraby adjacent anatomic structures or para
functional loading.functional loading. (As per GPT- 8)

IMMEDIATEIMMEDIATE
IMPLANTIMPLANT
PLACEMENTPLACEMENT

CONTENTSCONTENTS
1. INTRODUCTION
2. HISTORY
3. DIFFERENT APPROACHES TO IMPLANT
INSERTION
4. ADVANTAGES, INDICATONS AND
CONTRAINDICATIONS OF IMMEDIATE IMPLANT
PLACEMENT
5. GUIDELINES FOR EXTRACTION IN
IMMEDIATE IMPLANT PLACEMENT
6. IMPLANT PLACEMENT

INTRODUCTIONINTRODUCTION
An alternative to the complete removableAn alternative to the complete removable
denture is the use of endosseous implants asdenture is the use of endosseous implants as
support for a fixed prosthesis. Branemark andsupport for a fixed prosthesis. Branemark and
colleagues proposed the concept ofcolleagues proposed the concept of
osseointegration over 37 years ago, but totalosseointegration over 37 years ago, but total
acceptance of implant based therapy has beenacceptance of implant based therapy has been
hampered by the cost of treatment and limitedhampered by the cost of treatment and limited
access to professional care. But one of theaccess to professional care. But one of the
biggest drawbacks to implant therapy has beenbiggest drawbacks to implant therapy has been
the length of time required by traditionalthe length of time required by traditional
placement protocols.placement protocols.www.indiandentalacademy.comwww.indiandentalacademy.com

A 3 to 14 month treatment sequence isA 3 to 14 month treatment sequence is
commonplace, oftencommonplace, often
including multiple surgeries. Patientsincluding multiple surgeries. Patients
undertaking such therapy have to resignundertaking such therapy have to resign
themselves to enduring significantthemselves to enduring significant
inconvenience and discomfort before they caninconvenience and discomfort before they can
begin to enjoy an amelioration of theirbegin to enjoy an amelioration of their
appearance, speech, masticatory function andappearance, speech, masticatory function and
self-confidence.self-confidence.
Immediate placement of dental implantsImmediate placement of dental implants
protocol is gaining great popularity throughoutprotocol is gaining great popularity throughoutwww.indiandentalacademy.comwww.indiandentalacademy.com

HISTORYHISTORY
The modern era of dental implant therapy beganThe modern era of dental implant therapy began
with the May 1982 Toronto Conference onwith the May 1982 Toronto Conference on
Osseointegration in Clinical Dentistry. TheOsseointegration in Clinical Dentistry. The
conference show cased Professorconference show cased Professor Per IngvarPer Ingvar
BranemarkBranemark and the concept ofand the concept of
osseointegration. It was organized by Georgeosseointegration. It was organized by George
Zarb and supported financially by the OntarioZarb and supported financially by the Ontario
Ministry of Health and the University of Toronto.Ministry of Health and the University of Toronto.

At this conference, educational leaders fromAt this conference, educational leaders from
North American dental schools in theNorth American dental schools in the
specialties of oral and maxillofacial surgery andspecialties of oral and maxillofacial surgery and
prosthodontics were exposed to the scientificprosthodontics were exposed to the scientific
background of osseointegration and to thebackground of osseointegration and to the
clinical success that had been achieved inclinical success that had been achieved in
Sweden and in early clinical trials in Toronto.Sweden and in early clinical trials in Toronto.
The conference was a watershed event inThe conference was a watershed event in
prosthodontics.prosthodontics.

The early investigations of Branemark thatThe early investigations of Branemark that
eventually led to the dental application ofeventually led to the dental application of
osseointegration focused on wound healingosseointegration focused on wound healing
and rheology in bone and soft tissue. The useand rheology in bone and soft tissue. The use
of titanium implants (referred to as "fixtures" byof titanium implants (referred to as "fixtures" by
Branemark) to support dental prostheses wasBranemark) to support dental prostheses was
first described in a study on dogs. The firstfirst described in a study on dogs. The first
human patient received implants inhuman patient received implants in
Branemark's Gothenburg clinic in 1965. For theBranemark's Gothenburg clinic in 1965. For the
next decade, the application ofnext decade, the application of
osseointegration as a foundation for dentalosseointegration as a foundation for dental
prostheses was carefully documented andprostheses was carefully documented and
reported.reported.

The 1970’s saw the accumulation of sufficientThe 1970’s saw the accumulation of sufficient
data relative to the predictability ofdata relative to the predictability of
osseointegration to move it from experimentalosseointegration to move it from experimental
to routine clinical use in European centers. Theto routine clinical use in European centers. The
University of Toronto was the first NorthUniversity of Toronto was the first North
American center to use osseointegrated dentalAmerican center to use osseointegrated dental
implants in clinical trials. The replication ofimplants in clinical trials. The replication of
Swedish success in Toronto led to the 1982Swedish success in Toronto led to the 1982
Toronto conference and, shortly thereafter, toToronto conference and, shortly thereafter, to
the widespread use of osseointegrated dentalthe widespread use of osseointegrated dental
implants.implants.

DIFFERENT APPROACHES TODIFFERENT APPROACHES TO
IMPLANTIMPLANT
PLACEMENTPLACEMENT
DELAYED IMPLANT PLACEMENTDELAYED IMPLANT PLACEMENT
STAGED IMPLANT PLACEMENTSTAGED IMPLANT PLACEMENT
ONE STAGE IMPLANT PLACEMENTONE STAGE IMPLANT PLACEMENTwww.indiandentalacademy.comwww.indiandentalacademy.com

IMMEDIATE IMPLANTIMMEDIATE IMPLANT
PLACEMENTPLACEMENT

Gore tex
membrane
fixed to
implant
Connective
tissue graft
placed over the
membrane and
immobilised
with sutures

DELAYED IMPLANT PLACEMENTDELAYED IMPLANT PLACEMENT

After several
weeks gingival
margin will
cover the
socket gap

(SOCKET SEAL SURGERY)(SOCKET SEAL SURGERY)

ONE STAGE IMPLANTONE STAGE IMPLANT
PLACEMENTPLACEMENT

ADVANTAGES OF IMMEDIATEADVANTAGES OF IMMEDIATE
IMPLANT PLACEMENTIMPLANT PLACEMENT
Prevents atrophy alveolar ridges, gingival and
mucosal tissues after the removal of teeth.
Can be placed in the same position as the
extracted teeth.
Minimizes the need for severely angled
abutments

Can position the implant more favorably than
the original tooth by redirecting the burs when
preparing the implant receptor site.
With the extraction socket as a guide, the
surgeon can also more easily determine the
appropriate parallelism and alignment relative
to the opposing and adjacent residual dentition
and to adjacent implants when there are
multiple extractions and implants.

Improved final function and aesthetics typicallyImproved final function and aesthetics typically
result.result.
Significantly shorten the overall treatment timeSignificantly shorten the overall treatment time
and the interval during which the patient mustand the interval during which the patient must
live in a transitional state with or without teeth.live in a transitional state with or without teeth.
Consequently. more patients accept treatmentConsequently. more patients accept treatment
and also increase the overall cost effectivenessand also increase the overall cost effectiveness
of cases.of cases.

INDICATIONS OF IMMEDIATEINDICATIONS OF IMMEDIATE
Failed endodontically treated teeth
Teeth with advanced periodontal disease
Root fractures
Advanced caries beneath the gingival margin

CONTRAINDICATIONS OFCONTRAINDICATIONS OF
IMMEDIATEIMMEDIATE
Teeth with suppuration
Teeth with large periapical infection

There areThere are five determining factorsfive determining factors identified to beidentified to be
prerequisites for positive treatment outcomes inprerequisites for positive treatment outcomes in
the immediate placement of implants:the immediate placement of implants:
1. Preservation of the bony margins of the1. Preservation of the bony margins of the
alveolus during extraction.alveolus during extraction.
2. Precise preparation of an implant bed in the2. Precise preparation of an implant bed in the
apical portion or along the walls of the socket.apical portion or along the walls of the socket.
3. Tight circumferential adaptation of a barrier3. Tight circumferential adaptation of a barrier
membrane as a collar around the neck of themembrane as a collar around the neck of the
implant extending over the borders of theimplant extending over the borders of the
alveolus by 3 – 4 mm.alveolus by 3 – 4 mm.www.indiandentalacademy.comwww.indiandentalacademy.com

4. Careful management of the soft tissue flap and4. Careful management of the soft tissue flap and
close flap adaptation to the neck of the implant.close flap adaptation to the neck of the implant.
5. Meticulous plaque control for the entire healing5. Meticulous plaque control for the entire healing
period of approximately 6 months.period of approximately 6 months.

GUIDELINES FOR EXTRACTIONGUIDELINES FOR EXTRACTION
WHEN PLANNING FOR IMMEDIATEWHEN PLANNING FOR IMMEDIATE
The following guidelines for extractions areThe following guidelines for extractions are
provided when planning for immediateprovided when planning for immediate
placement of implants:placement of implants:
Preoperative evaluationPreoperative evaluation
Antibiotic therapy initiationAntibiotic therapy initiation
Preservation of the bony receptor sitePreservation of the bony receptor sitewww.indiandentalacademy.comwww.indiandentalacademy.com

Procedural delaysProcedural delays
Avoidance of excessive pressureAvoidance of excessive pressure
Osteotomy preparationOsteotomy preparation
Improvements for placementImprovements for placement
Bone graftsBone grafts
Soft tissues closureSoft tissues closure

Successful osseointegrationSuccessful osseointegration
IMPLANT PLACEMENTIMPLANT PLACEMENT : An implant can
be placed immediately if any one of the
conditions exist at the extraction site
1. Bone is type I or II
2. Site can accommodate an implant with a
length of atleast 13 mm.
3. Once placed, the implant can be completely
protected from function and occlusal forces.

TAPERED IMPLANTSTAPERED IMPLANTS
Tapered anatomically shaped implants are theTapered anatomically shaped implants are the
implants of choice for this indication.implants of choice for this indication.
More closely mimic the shape of natural toothMore closely mimic the shape of natural tooth
roots – wider at the cervix than at the apex.roots – wider at the cervix than at the apex.
Implant Diameter – 3.5mm, 4.3mm, 5.0mm,Implant Diameter – 3.5mm, 4.3mm, 5.0mm,
and 6.0mm.and 6.0mm.

Implant Length - 10mm, 13mm, and 16 mm.Implant Length - 10mm, 13mm, and 16 mm.
Implant Surface – acid etched titanium,Implant Surface – acid etched titanium,
hydroxyapatite(HA) coated,hydroxyapatite(HA) coated,
TPS – coatedTPS – coated

ADVANTAGES OF THE TAPEREDADVANTAGES OF THE TAPERED
IMPLANTSIMPLANTS
Larger cervical diameter provides better buccalLarger cervical diameter provides better buccal
support and helps preserve the rootsupport and helps preserve the root
prominence.prominence.
Larger cervical diameter also improves theLarger cervical diameter also improves the
implant to bone interface.implant to bone interface.
Tapered design may obviate the need to useTapered design may obviate the need to use
grafting materials or membranes.grafting materials or membranes.

Allows implant to be placed in the sameAllows implant to be placed in the same
position as the extracted teeth and avoidsposition as the extracted teeth and avoids
buccal or labial wall perforation.buccal or labial wall perforation.
Since the position of implant is similar to theSince the position of implant is similar to the
extracted tooth, restoration is placed in moreextracted tooth, restoration is placed in more
favourable position in relation to the opposingfavourable position in relation to the opposing
arch thus reducing the excessive off axisarch thus reducing the excessive off axis
loadingloading
Can be used in cases of tooth with convergentCan be used in cases of tooth with convergent
rootsroots

By using a straight or maximum 15 degreeBy using a straight or maximum 15 degree
angled abutment for fixed prosthesis, theangled abutment for fixed prosthesis, the
occlusal table will have more acceptableocclusal table will have more acceptable
buccolingual dimension.buccolingual dimension.

TAPERED OSTEOTOMESTAPERED OSTEOTOMESwww.indiandentalacademy.comwww.indiandentalacademy.com

TAPERED OSTEOTOMESTAPERED OSTEOTOMES
AdvantagesAdvantages ::
In areas of soft( type III or type IV) bone canIn areas of soft( type III or type IV) bone can
create a denser bony interface for the implant.create a denser bony interface for the implant.
Generate no heatGenerate no heat
Allow for better visibility than drills in posteriorAllow for better visibility than drills in posterior
maxillamaxilla
Offer the user greater tactile sensationOffer the user greater tactile sensation

Indications :Indications :
When bone at the extraction site is type III orWhen bone at the extraction site is type III or
type IV and the use of burs for the preparationtype IV and the use of burs for the preparation
of the impalnt receptor site is deterimental.of the impalnt receptor site is deterimental.
When the apical cortical socket of a molar orWhen the apical cortical socket of a molar or
premolar abuts the floor of maxillary sinus .premolar abuts the floor of maxillary sinus .

BONE COMPACTIONBONE COMPACTION
2 mm pilot drill is used to achieve a purchase2 mm pilot drill is used to achieve a purchase
point and to ensure proper alignment at thepoint and to ensure proper alignment at the
osseous receptor site.osseous receptor site.
An appropriate osteotome is selected which isAn appropriate osteotome is selected which is
then placed into the sulcus , pushed andthen placed into the sulcus , pushed and
rotated to the desired depth.rotated to the desired depth.
Depending on the bone density a mallet mayDepending on the bone density a mallet may
be used, more porous the bone more easily thebe used, more porous the bone more easily the
osteotome is inserted.osteotome is inserted.

Increasingly larger osteotomes are then used toIncreasingly larger osteotomes are then used to
enlarge the socket until it will accommodate theenlarge the socket until it will accommodate the
implant selected for the site.implant selected for the site.
In posterior maxilla wider the bone less dense itIn posterior maxilla wider the bone less dense it
usually is.usually is.
In some osteotomy site areas of increasedIn some osteotomy site areas of increased
bone density may be encountered as the sinusbone density may be encountered as the sinus
floor approaches( e.g. cortical crestal areas,floor approaches( e.g. cortical crestal areas,
apical portion of the osteotomy). In these casesapical portion of the osteotomy). In these cases
conventional hand piece drilling may be usedconventional hand piece drilling may be used
with the osteotome compaction technique.with the osteotome compaction technique.www.indiandentalacademy.comwww.indiandentalacademy.com

DRILL METHODDRILL METHOD
Basic Considerations of OsteotomyBasic Considerations of Osteotomy
DrillingDrilling
Following tooth removal, inspect the crest ofFollowing tooth removal, inspect the crest of
the remaining bone, especially labially. Itsthe remaining bone, especially labially. Its
heightheight should be within 5 mmshould be within 5 mm of that of theof that of the
adjacent bone on either side. If it is greater thanadjacent bone on either side. If it is greater than
5 mm, the chance of a harmonious esthetic5 mm, the chance of a harmonious esthetic
result is diminished.result is diminished.

Inspect the socket and preoperativeInspect the socket and preoperative
radiograph to fix in mind the amount andradiograph to fix in mind the amount and
variation of available bone mesial and distal tovariation of available bone mesial and distal to
socket.socket.
Clinically evaluate the labial extent of theClinically evaluate the labial extent of the
opening, which is most often closer to idealopening, which is most often closer to ideal
than that found in healed ridges that havethan that found in healed ridges that have
undergone some resorption.undergone some resorption.

Twist Drill Pathway :Twist Drill Pathway :
The pathway is determined by the socket.The pathway is determined by the socket.
However, with a D3 twist drill of coordinatedHowever, with a D3 twist drill of coordinated
depth, measure whether the socket depthdepth, measure whether the socket depth
reaches the 13 mm required for the selectedreaches the 13 mm required for the selected
implant configuration. If necessary, use the D3implant configuration. If necessary, use the D3
twist drill to deepen the socket to the depth oftwist drill to deepen the socket to the depth of
the implant.the implant.
The socket is usually short of that depth if theThe socket is usually short of that depth if the
implant was selected according to the selectionimplant was selected according to the selection
principlesprinciples www.indiandentalacademy.comwww.indiandentalacademy.com

Completion Of The Implant OsteotomyCompletion Of The Implant Osteotomy ::
An appropriate stepped drill, is now used. ThisAn appropriate stepped drill, is now used. This
drill obliterates the socket and carries thedrill obliterates the socket and carries the
osteotomy to its final depth. Cleansing andosteotomy to its final depth. Cleansing and
suctioning are performed before the next step.suctioning are performed before the next step.
Evaluate And Test Prepared OsteotomyEvaluate And Test Prepared Osteotomy ::
The depth stop on the stepped drill, coupledThe depth stop on the stepped drill, coupled
with careful drilling, helps ensure accuracy.with careful drilling, helps ensure accuracy.
Some practitioners test the osteotomy using aSome practitioners test the osteotomy using a
coordinated bone compactor. If necessary, thecoordinated bone compactor. If necessary, the
compactor can be tapped with a mallet to bringcompactor can be tapped with a mallet to bring
the osteotomy to its correct depth.the osteotomy to its correct depth.www.indiandentalacademy.comwww.indiandentalacademy.com

Final Seating Of The ImplantFinal Seating Of The Implant ::
The implant is removed from its sterileThe implant is removed from its sterile
packaging by snapping the implant driver intopackaging by snapping the implant driver into
the adapter screw on top of the implant.the adapter screw on top of the implant.
The implant is withdrawn from the inner vial toThe implant is withdrawn from the inner vial to
be placed into its prepared osteotomy.be placed into its prepared osteotomy.

When the implant is placed into the osteotomy,When the implant is placed into the osteotomy,
the driver is unsnapped and an implant seatingthe driver is unsnapped and an implant seating
instrument is carefully positioned to nest snuglyinstrument is carefully positioned to nest snugly
into the adapter screw supplied with theinto the adapter screw supplied with the
implant, such that the long axis of its handle isimplant, such that the long axis of its handle is
parallel with that of the implant.parallel with that of the implant.
With several sharp taps, the implant isWith several sharp taps, the implant is
malleted to its final position. The adapter screwmalleted to its final position. The adapter screw
is removed with a O.9-mm hex-driver.is removed with a O.9-mm hex-driver.

If the coronal ridge of the implant is not entirelyIf the coronal ridge of the implant is not entirely
below the ridge crest, tap again with the mallet.below the ridge crest, tap again with the mallet.
Do not remove the implant once it has beenDo not remove the implant once it has been
malletted into position.malletted into position.

When using the single stage procedure, theWhen using the single stage procedure, the
implant should be positioned so that theimplant should be positioned so that the
platform is either even with or 1mm above theplatform is either even with or 1mm above the
crestal bone. Depending on the thickness of thecrestal bone. Depending on the thickness of the
soft tissue, either profile(3mm) healingsoft tissue, either profile(3mm) healing
abutment or a cover screw is placed into theabutment or a cover screw is placed into the
implants.implants.
After hard and soft tissue healing, the top ofAfter hard and soft tissue healing, the top of
the implant will protrude above the muco-the implant will protrude above the muco-
gingival tissues, therefore circumventing thegingival tissues, therefore circumventing the
need for a second stage procedure to exposeneed for a second stage procedure to expose
the implantthe implant

IMMEDIATEIMMEDIATE
LOADING OFLOADING OF
IMPLANTSIMPLANTS

CONTENTSCONTENTS
1. INTRODUCTION
2. DEFINITIONS
3. EVOLUTION
4. IMPLANT STABILITY
5. ADVANTAGES, DISADVANTAGES,
INDICATONS AND CONTRAINDICATIONS OF
IMMEDIATE LOADING OF IMPLANTS
6. NOVUM CONCEPT
7. RESCUE PROCEDURE FOR NOVUM
8. EARLY AND IMMEDIATE IMPLANT LOADING
PROTOCOL
9. DISCUSSION

Immediate loading or function in implantImmediate loading or function in implant
dentistry is a fairly new technique that allowsdentistry is a fairly new technique that allows
certain types of patients to have their teethcertain types of patients to have their teeth
removed and implants placed, along with theremoved and implants placed, along with the
prosthesis, in the same day. Providingprosthesis, in the same day. Providing
immediate implant loading requires a great dealimmediate implant loading requires a great deal
of previous experience, as well as advancedof previous experience, as well as advanced
knowledge of implant dentistry and significantknowledge of implant dentistry and significant
surgical and prosthodontic skills.surgical and prosthodontic skills.www.indiandentalacademy.comwww.indiandentalacademy.com

Because immediate implant loading requires theBecause immediate implant loading requires the
cooperation of many different practitioners,cooperation of many different practitioners,
hence the importance of teamwork in thehence the importance of teamwork in the
achievement of satisfactory results in successachievement of satisfactory results in success
rates, function and esthetics, all of which arerates, function and esthetics, all of which are
required for success in any treatmentrequired for success in any treatment
employing implants cannot be undermined.employing implants cannot be undermined.

DEFINITIONSDEFINITIONS
Immediate Occlusal LoadingImmediate Occlusal Loading : An implant: An implant
is placed with adequate primary stability itsis placed with adequate primary stability its
corresponding restoration has full centriccorresponding restoration has full centric
occlusion in maximum intercuspation and mustocclusion in maximum intercuspation and must
be placed within 48 hours post surgery.be placed within 48 hours post surgery.

Early loadingEarly loading : Early Loading Protocol is wherein: Early Loading Protocol is wherein
a provisional prosthesis was inserted at aa provisional prosthesis was inserted at a
subsequent visit prior to osseointegration (betweensubsequent visit prior to osseointegration (between
2 days to 3 months after surgery). Though the2 days to 3 months after surgery). Though the
implants, were not loaded the same day, thisimplants, were not loaded the same day, this
protocol directly challenged the healing process byprotocol directly challenged the healing process by
introducing loading during wound healing. Aintroducing loading during wound healing. A
fundamental goal of early loading is improvingfundamental goal of early loading is improving
bone formation in order to support occlusal loadingbone formation in order to support occlusal loading
at two months.at two months.

Conventional Loading ProtocolConventional Loading Protocol : is the: is the
original healing periods as envisaged byoriginal healing periods as envisaged by
different implant systems, typically after 12 todifferent implant systems, typically after 12 to
24 weeks.24 weeks.
Delayed Loading ProtocolDelayed Loading Protocol : is one in which: is one in which
the healing period was extended due to thethe healing period was extended due to the
compromised host site conditions and, typically,compromised host site conditions and, typically,
prosthesis connection is later than theprosthesis connection is later than the
conventional healing period.conventional healing period.

Occlusal loadingOcclusal loading : means that the: means that the
immediately or early loaded prosthesis is inimmediately or early loaded prosthesis is in
contact with the opposing dentition.contact with the opposing dentition.
Non-occlusal loadingNon-occlusal loading : means that the: means that the
immediately or early loaded prosthesis is not inimmediately or early loaded prosthesis is not in
contact with the opposing dentition. It shouldcontact with the opposing dentition. It should
be recognized that in non-occlusal loading,be recognized that in non-occlusal loading,
forces on implants could be generated throughforces on implants could be generated through
the oral musculature and food bolus.the oral musculature and food bolus.

Immediate Non Occlusal LoadingImmediate Non Occlusal Loading : An: An
implant is placed with adequate primaryimplant is placed with adequate primary
stability but is not in functional occlusion. Thesestability but is not in functional occlusion. These
implant restorations are essentially used forimplant restorations are essentially used for
esthetic purposes, frequently in single tooth oresthetic purposes, frequently in single tooth or
short span applications. Immediate nonshort span applications. Immediate non
occlusal loading is often performed to provideocclusal loading is often performed to provide
the patient with aesthetic or psychologicalthe patient with aesthetic or psychological
benefit during implant therapy, particularlybenefit during implant therapy, particularly
when a provisional removable prosthesis iswhen a provisional removable prosthesis is
undesirable during the healing period.undesirable during the healing period.

EVOLUTIONEVOLUTION
1990 Schnitman1990 Schnitman et al initially describedet al initially described
immediate loading off mandibular implants withimmediate loading off mandibular implants with
a detachable hybrid prosthesis, however aa detachable hybrid prosthesis, however a
statistically significant number of thestatistically significant number of the
immediately loaded implants failed.immediately loaded implants failed.

1994 Henry et al placed 61994 Henry et al placed 6 mandibular implantsmandibular implants
in a series of 5 patients 4/6 implantsin a series of 5 patients 4/6 implants
immediately loaded with provisional removableimmediately loaded with provisional removable
overdentureoverdenture then , at 7 weeks a permanentthen , at 7 weeks a permanent
prosthesis was placed. 100% implant success.prosthesis was placed. 100% implant success.
1997 Tarnow et al,1997 Tarnow et al, landmarklandmark study withstudy with
immediate loading of implants in both mandibleimmediate loading of implants in both mandible
and maxilla.and maxilla.

1999 – Branemark published initial report1999 – Branemark published initial report
on the Novum systemon the Novum system
50 patients, 150 implants50 patients, 150 implants
3 implants placed in the anterior mandible3 implants placed in the anterior mandible andand
immediately loading with hybrid dentureimmediately loading with hybrid denture
Failure of 3/150 implantsFailure of 3/150 implants
Failure of 1 prosthesisFailure of 1 prosthesis
Initial introduction of a mainstream immediateInitial introduction of a mainstream immediate
load implant systemload implant system

20002000 RandowRandow et al compared one stage andet al compared one stage and
two stage technique for hybrid dentures intwo stage technique for hybrid dentures in
patients with edentulous mandibles.patients with edentulous mandibles.
20012001 ChiapascoChiapasco et al prospectively comparedet al prospectively compared
delayeddelayed v/sv/s immediate load mandibularimmediate load mandibular hybridhybrid
dentures using Branemarke MKII implants.dentures using Branemarke MKII implants.
20032003 EngstrandEngstrand et al 5 yr follow up of 95et al 5 yr follow up of 95
patients treated with Novumpatients treated with Novum system.system. 93.7%93.7%
implant success rate andimplant success rate and 99% prosthesis99% prosthesis
survival.survival.

2003 Henry et al2003 Henry et al
1 yr survival rates of1 yr survival rates of NovumNovum system in 51 ptssystem in 51 pts
91% implant survival91% implant survival
94% prosthesis94% prosthesis surivivalsurivival

IMPLANT STABILITYIMPLANT STABILITY
A fundamental requisite for IOL is adequateA fundamental requisite for IOL is adequate
primary implant stability. While stability wasprimary implant stability. While stability was
traditionally achieved through a period oftraditionally achieved through a period of
undisturbed healing( i.e. osseointegration )undisturbed healing( i.e. osseointegration )
primary stability is now achieved via aprimary stability is now achieved via a
mechanical phenomenon of screw stability andmechanical phenomenon of screw stability and
splintingsplinting
Each implant system tolerates micromotionEach implant system tolerates micromotion
differently.differently.

For implants with roughened surfaces, toleranceFor implants with roughened surfaces, tolerance
is in the range of 50 to 150 micrometers,is in the range of 50 to 150 micrometers,
machined surfaces can withstandmachined surfaces can withstand
approximately 100 micrometers ofapproximately 100 micrometers of
micromovement.micromovement.
Regardless of the type of implant selected, allRegardless of the type of implant selected, all
restorative procedures should be completedrestorative procedures should be completed
with in two days of implant placement,with in two days of implant placement,
according to the specific needs of the patientaccording to the specific needs of the patient
and after which time of bone healing andand after which time of bone healing and
implant stability may be disrupted by suchimplant stability may be disrupted by suchwww.indiandentalacademy.comwww.indiandentalacademy.com

INDICATIONSINDICATIONS
Adequate bone quality ( type I, II and III)Adequate bone quality ( type I, II and III)
Sufficient bone height ( i.e. approximatelySufficient bone height ( i.e. approximately
12mm ) for a minimum length of 10 mm implant12mm ) for a minimum length of 10 mm implant
Sufficient bone width ( i.e. approximately 6 mm)Sufficient bone width ( i.e. approximately 6 mm)
Ability to achieve an adequate antero posteriorAbility to achieve an adequate antero posterior
spread between the implants. A poor APspread between the implants. A poor AP
spread decreases the mechanical advantagespread decreases the mechanical advantage
gained by splinting and the ability to cantilevergained by splinting and the ability to cantilever
the restorationthe restoration

CONTRAINDICATIONSCONTRAINDICATIONS
Poor systemic healthPoor systemic health
Severe parafunctional habitsSevere parafunctional habits
Bone of poor quality ( e.g. type IV)Bone of poor quality ( e.g. type IV)
Bone height less than 10 mmBone height less than 10 mm
Bone width less than 6 mmBone width less than 6 mm
Inability to achieve an adequate AP spreadInability to achieve an adequate AP spread

ADVANTAGESADVANTAGES
Eliminates the need for and maintenance ofEliminates the need for and maintenance of aa
removable provisional prosthesisremovable provisional prosthesis
Provides emotional benefit for a patientProvides emotional benefit for a patient
scheduled to rendered edentulousscheduled to rendered edentulous
Improves bone healingImproves bone healing
Facilitates soft tissue shapingFacilitates soft tissue shaping
Eliminates premature implant exposure oftenEliminates premature implant exposure often
associated with wearing of a removableassociated with wearing of a removable
prosthesis during healing periodprosthesis during healing periodwww.indiandentalacademy.comwww.indiandentalacademy.com

DISADVANTAGESDISADVANTAGES
Cannot be applied to every implant patientCannot be applied to every implant patient
Requires more chair side time at the time ofRequires more chair side time at the time of
implant placement of both the patient and theimplant placement of both the patient and the
restorative practitionerrestorative practitioner

Immediate implant loading requires effectiveImmediate implant loading requires effective
communication and coordination betweencommunication and coordination between
surgical and restorative teams, as there is asurgical and restorative teams, as there is a
degree of flexibility involved in the delivery ofdegree of flexibility involved in the delivery of
the prosthesis. For example the surgical andthe prosthesis. For example the surgical and
restorative procedures may be completed in arestorative procedures may be completed in a
single appointment for straight forward casessingle appointment for straight forward cases
for others prosthesis may be most appropriatelyfor others prosthesis may be most appropriately
delivered one or two days after the placementdelivered one or two days after the placement
of implant .of implant . www.indiandentalacademy.comwww.indiandentalacademy.com

Hence careful patient screening andHence careful patient screening and
selection is required when an IOLselection is required when an IOL
procedure isprocedure is treatment consideration.treatment consideration.

THETHE
NOVUMNOVUM
CONCEPTCONCEPT
Per Ingvar BranemarkPer Ingvar Branemark

According to the Classic procedure screw-
shaped fixtures( generally between 4 to 6)
made of pure titanium (standard 3.75mm) are
placed in the anterior part of the mandible. This
concept, first applied clinically in 1965, was
based on available knowledge relating to the
healing of bone, for example after fractures or
osteotomies, and subsequently involved a
healing period of 3 to 6 months before
functional load was gradually applied.

The distinctive feature of Novum is that itThe distinctive feature of Novum is that it
requires only 6 to 8 hours for the entirerequires only 6 to 8 hours for the entire
reconstruction and thus gives the patient areconstruction and thus gives the patient a
third dentition in just 1 day.third dentition in just 1 day.

HISTORYHISTORY
The Novum ConceptThe Novum Concept was conceived in 1980was conceived in 1980
After 15 years of system design initial clinicalAfter 15 years of system design initial clinical
application was done in 1996application was done in 1996
Initial report (1999)Initial report (1999)
50 patients, 150 implants 50 patients, 15050 patients, 150 implants 50 patients, 150
implantsimplants
3 implants placed in the anterior mandible3 implants placed in the anterior mandible
and immediately loading withand immediately loading with hybrid denturehybrid denture
Failure of 3/150 implantsFailure of 3/150 implants

Failure of 1 prosthesisFailure of 1 prosthesis
System includes 4 drill templates and 8 drill guidesSystem includes 4 drill templates and 8 drill guides
to allow precise positioning of 3 implants in theto allow precise positioning of 3 implants in the
anterior mandibleanterior mandible
Prefabricated lower Ti bar placed on 3 implantsPrefabricated lower Ti bar placed on 3 implants
Prefabricated upper bar forms base of hybridPrefabricated upper bar forms base of hybrid
denturedenture
Upper bar and denture screwed to lower bar andUpper bar and denture screwed to lower bar and
implants allowing delivery of Teeth in a Dayimplants allowing delivery of Teeth in a Daywww.indiandentalacademy.comwww.indiandentalacademy.com

BRANEMARK NOVUMBRANEMARK NOVUM
ADVANTAGESADVANTAGES
Surgery and delivery of prosthesis in one daySurgery and delivery of prosthesis in one day
Reduced cost of surgical phaseReduced cost of surgical phase
Reduced cost of restorative phaseReduced cost of restorative phase

BRANEMARK NOVUMBRANEMARK NOVUM
DISADVANTAGESDISADVANTAGES
Limited to Class I and III occlusionLimited to Class I and III occlusion
Very demanding surgical procedure compared toVery demanding surgical procedure compared to
traditional techniquetraditional technique
Limited patient selection due to anatomic limitationsLimited patient selection due to anatomic limitations
Surgical template does not fit all mandiblesSurgical template does not fit all mandibles
Loss of 1 implant can be catastrophicLoss of 1 implant can be catastrophic
Initial cost of surgical kit $2500Initial cost of surgical kit $2500www.indiandentalacademy.comwww.indiandentalacademy.com

HYPOTHESIS IN FAVOUR OFHYPOTHESIS IN FAVOUR OF
NOVUMNOVUM
It may be that during the critical period of 0 toIt may be that during the critical period of 0 to
16 weeks, the quality of osseointegration may16 weeks, the quality of osseointegration may
be better at comparable times in the one-stepbe better at comparable times in the one-step
procedure as compared to the two-stepprocedure as compared to the two-step
procedure.procedure.

The effects of any misalignment of a prosthesisThe effects of any misalignment of a prosthesis
and the fixtures may be less hazardous andand the fixtures may be less hazardous and
minimized in the long run by a one-stepminimized in the long run by a one-step
procedure. It is clear from the experimentalprocedure. It is clear from the experimental
data of Branemark (1997, 1998) that thedata of Branemark (1997, 1998) that the
elastic modulus and pull-out strength of anelastic modulus and pull-out strength of an
osseointegrated fixture are smallest just after itosseointegrated fixture are smallest just after it
has been placed.has been placed.

The stresses caused by misalignment of aThe stresses caused by misalignment of a
prosthesis may be dissipated during the earlyprosthesis may be dissipated during the early
weeks of osseointegration in the one-stepweeks of osseointegration in the one-step
procedure. The initial stresses must be borneprocedure. The initial stresses must be borne
by the old lamellar bone present. As this boneby the old lamellar bone present. As this bone
is resorbed, these stresses may be relieved.is resorbed, these stresses may be relieved.
The new woven bone growing in will probablyThe new woven bone growing in will probably
not reinstate the misalignment stresses. Thisnot reinstate the misalignment stresses. This
suggests the intriguing hypothesis that residualsuggests the intriguing hypothesis that residual
stresses caused by misalignment may bestresses caused by misalignment may be
relieved by the sequence of remodelingrelieved by the sequence of remodeling
processes leading to osseointegration. In aprocesses leading to osseointegration. In a
two-step procedure, residual stresses may betwo-step procedure, residual stresses may be
locked in indefinitely.locked in indefinitely.www.indiandentalacademy.comwww.indiandentalacademy.com

HOWEVER THESE HYPOTHESIS MERITHOWEVER THESE HYPOTHESIS MERIT
EXPERIMENTAL VERIFICATIONEXPERIMENTAL VERIFICATION

Also it may be remarked that the two stepAlso it may be remarked that the two step
procedure by limiting the load applied duringprocedure by limiting the load applied during
the first phase, provides a margin of safetythe first phase, provides a margin of safety
against clinical factors, such as accidentalagainst clinical factors, such as accidental
damage to bone by overheating at initialdamage to bone by overheating at initial
placement, survival of osseointegration in caseplacement, survival of osseointegration in case
of minor infection, poor bone quality orof minor infection, poor bone quality or
accidental trauma.accidental trauma.

Routine clinical procedure involves the use ofRoutine clinical procedure involves the use of
prefabricated templates for preplanned,prefabricated templates for preplanned,
precision placement of three fixtures in theprecision placement of three fixtures in the
anterior mandible. The precisely positionedanterior mandible. The precisely positioned
anchoring elements are to be immediatelyanchoring elements are to be immediately
connected with a predesigned lower bar . Thisconnected with a predesigned lower bar . This
bar was intended to prevent individual torquebar was intended to prevent individual torque
and multidirectional load on the individualand multidirectional load on the individual
fixture and thus eliminate relative motion duringfixture and thus eliminate relative motion during
the initial healing phase.the initial healing phase.

The purpose of the upper bar was toThe purpose of the upper bar was to
standardize and facilitate the prostheticstandardize and facilitate the prosthetic
procedure as well as allow easyprocedure as well as allow easy
modifications of topography and materialsmodifications of topography and materials
relating to the prosthetic dentition.relating to the prosthetic dentition.

Predetermined fit of substructuresPredetermined fit of substructures
and suprastructuresand suprastructures

Sample orthopantograph showing theSample orthopantograph showing the
topographical position of anchoring fixtures intopographical position of anchoring fixtures in
relation to the anatomy of the mandiblerelation to the anatomy of the mandiblewww.indiandentalacademy.comwww.indiandentalacademy.com

Novum theory assumed that it would beNovum theory assumed that it would be
possible to position the anchoring fixtures sopossible to position the anchoring fixtures so
precisely that the prosthetic base could also beprecisely that the prosthetic base could also be
predesigned. This would not only reduce thepredesigned. This would not only reduce the
clinical treatment time, but also connect andclinical treatment time, but also connect and
thus adequately secure the prostheticthus adequately secure the prosthetic
components in passive fit, which wouldcomponents in passive fit, which would
minimize undue stress and mobility.minimize undue stress and mobility.

The various directions ofThe various directions of
functional load that mayfunctional load that may
occur at an individualoccur at an individual
fixture if it is notfixture if it is not
connected to adjacentconnected to adjacent
fixtures.fixtures.

Concept of control of functional load by precisionConcept of control of functional load by precision
connection of three fixtures according to theconnection of three fixtures according to the
Novum principle.Novum principle. www.indiandentalacademy.comwww.indiandentalacademy.com

Continued clinical application revealed decisiveContinued clinical application revealed decisive
parameters related to preoperative radiographicparameters related to preoperative radiographic
and clinical evaluations as well as gentleand clinical evaluations as well as gentle
surgery and controlled prosthetics. Optimizedsurgery and controlled prosthetics. Optimized
healing at the abutment interface and control ofhealing at the abutment interface and control of
initial tissue injury and edema could beinitial tissue injury and edema could be
obtained with surgical templates, meticulousobtained with surgical templates, meticulous
control of mechanical and thermal injury (ie,control of mechanical and thermal injury (ie,
never to exceed 42°C), and careful handling ofnever to exceed 42°C), and careful handling of
the soft tissue-with particular focus onthe soft tissue-with particular focus on
controlling the barrier to the oral cavity.controlling the barrier to the oral cavity.

More recently, it has been suggested that theMore recently, it has been suggested that the
cyclic deformation of bone tissue undercyclic deformation of bone tissue under
functional loading is likely to promote the flowfunctional loading is likely to promote the flow
of fluid within the various spaces in the matrixof fluid within the various spaces in the matrix
(e.g., canaliculi connecting lacunae) as well as(e.g., canaliculi connecting lacunae) as well as
possibly connecting to the open circulation inpossibly connecting to the open circulation in
the marrow. This phenomenon may have athe marrow. This phenomenon may have a
controlling influence on the rationale of thecontrolling influence on the rationale of the
remodeling phase, which enables the boneremodeling phase, which enables the bone
adjacent to the fixture to adapt to the functionaladjacent to the fixture to adapt to the functional
load of mastication.load of mastication.www.indiandentalacademy.comwww.indiandentalacademy.com

6 – 8 hours6 – 8 hours
Sequence of events according to the precisionSequence of events according to the precision
clinical protocol.clinical protocol.www.indiandentalacademy.comwww.indiandentalacademy.com

Single stage surgery with immediate loadingSingle stage surgery with immediate loading
concepts are well established in the mandible,concepts are well established in the mandible,
they should be considered experimental inthey should be considered experimental in
maxilla until long term evidence-based datamaxilla until long term evidence-based data
and guidelines are established. Nevertheless,and guidelines are established. Nevertheless,
limited reports are accumulating and indicatelimited reports are accumulating and indicate
that in certain circumstances, successful resultsthat in certain circumstances, successful results
can be achieved.can be achieved.

RESCUE PROCEDURE FOR THERESCUE PROCEDURE FOR THE
BRANEMARK NOVUM PROTOCOLBRANEMARK NOVUM PROTOCOL
In the event of a lost or failed implant with the
Novum protocol, rescue components are
available that allow the recovery of stabilized
function without modification to the existing
restoration. The rescue set contains drills and
templates for immediately replacing the failed
implant in either the central or distal sites,
enabling subsequent immediate use of the
original bar structures at the same appointment.
The precision in implant placement required for
this intervention is the same as in the original
procedure. www.indiandentalacademy.comwww.indiandentalacademy.com

The surgical approach for rescue in this caseThe surgical approach for rescue in this case
involved removal of the upper and lower barsinvolved removal of the upper and lower bars
and exposure of the failed implant and theand exposure of the failed implant and the
surrounding bone adjacent to the centralsurrounding bone adjacent to the central
implant.implant.

The rescue set includes templates for replacingThe rescue set includes templates for replacing
either the distal or central implants and drillseither the distal or central implants and drills
and drill guides for resizing the osteotomy.and drill guides for resizing the osteotomy.

IMMEDIATE AND EARLY LOADINGIMMEDIATE AND EARLY LOADING
PROTOCOLS WITH THE FIXEDPROTOCOLS WITH THE FIXED
PROSTHESISPROSTHESIS
Edentulous mandible
The initial impetus for this novel approach was
the anterior zone of the mandible.
High success rates (>90%) in short to medium
term studies.
It was concluded that in the rehabilitation of an
edentulous patient at least 4 implants be placed
in an edentulous mandible to support a fixedwww.indiandentalacademy.comwww.indiandentalacademy.com

Edentulous maxillaEdentulous maxilla
The success outcomes for the maxilla, althoughThe success outcomes for the maxilla, although
high, are limited since the data werehigh, are limited since the data were
confounded by grouping of completely andconfounded by grouping of completely and
partially edentulous patients, including implantspartially edentulous patients, including implants
placed in both the jawbones and extractionplaced in both the jawbones and extraction
sites.sites.
Around 5 to 8 number of implants wereAround 5 to 8 number of implants were
required to rehabilitate an edentulous maxillarequired to rehabilitate an edentulous maxilla
but with airborne particle abraded, large grit,but with airborne particle abraded, large grit,
acid etched( SLA; sand blasted, large grit, acidacid etched( SLA; sand blasted, large grit, acid
etched ) surfaces.etched ) surfaces.

Although the comparative short term caseAlthough the comparative short term case
series studies did suggest that rough-surfaceseries studies did suggest that rough-surface
implants performed better than machinedimplants performed better than machined
implants, the outcomes were confounded byimplants, the outcomes were confounded by
the use of the variety and number of implants,the use of the variety and number of implants,
the limited number of patients, and lack ofthe limited number of patients, and lack of
improperly defined success outcomes.improperly defined success outcomes.

The Partially Edentulous PatientsThe Partially Edentulous Patients
The implant surface deserves specialThe implant surface deserves special
consideration within context of the partiallyconsideration within context of the partially
edentulous patients.edentulous patients.
The use of an oxidized implant improved theThe use of an oxidized implant improved the
success rate up to 97%, even though 76% ofsuccess rate up to 97%, even though 76% of
the implants were placed in soft bone. Implantsthe implants were placed in soft bone. Implants
(machined and modified surfaces) placed in the(machined and modified surfaces) placed in the
posterior maxilla integrated when the surgicalposterior maxilla integrated when the surgical
technique was modified by under preparationtechnique was modified by under preparation
and partial tapping of the osteotomy sites ,and partial tapping of the osteotomy sites ,
implying that if primary stability is obtained,implying that if primary stability is obtained,
osseointegration is possible irrespective of theosseointegration is possible irrespective of the
surface.surface.

Implants placed in fresh extraction sitesImplants placed in fresh extraction sites
The rationale proposed for implant placementThe rationale proposed for implant placement
in fresh extraction sites was to preserve softin fresh extraction sites was to preserve soft
tissue esthetics and to further reduce thetissue esthetics and to further reduce the
treatment time and associated costs bytreatment time and associated costs by
avoiding an intermediate stage of removableavoiding an intermediate stage of removable
denture wear. The conclusions that can bedenture wear. The conclusions that can be
reached from these studies are limited becausereached from these studies are limited because
of the study design, short follow-up times in theof the study design, short follow-up times in the
majority of reports, and lack of site specificmajority of reports, and lack of site specific
outcomes.outcomes.

Furthermore, not all extraction sockets wereFurthermore, not all extraction sockets were
used as implant sites since, in some situations,used as implant sites since, in some situations,
the extraction site was obliterated due tothe extraction site was obliterated due to
surgical reduction of the residual ridge, not allsurgical reduction of the residual ridge, not all
studies stated clearly how the extraction sitesstudies stated clearly how the extraction sites
were managed, making comparison difficult.were managed, making comparison difficult.
Within these limitations, the studies suggestedWithin these limitations, the studies suggested
that success was not compromised bythat success was not compromised by
placement in extraction sockets as long asplacement in extraction sockets as long as
primary stability was achieved. Nevertheless,primary stability was achieved. Nevertheless,
success was reduced when implants weresuccess was reduced when implants were
placed in morphologically compromisedplaced in morphologically compromised
jawbone sites.jawbone sites.

To conclude, these short to medium termTo conclude, these short to medium term
studies suggested that implant placementstudies suggested that implant placement
should be restricted to extraction sitesshould be restricted to extraction sites
without a history of periodontal diseaseswithout a history of periodontal diseases
and limited to the anterior mandible,and limited to the anterior mandible,
Further long term clinical research isFurther long term clinical research is
required to support these observations torequired to support these observations to
determine the efficacy of a similar protocoldetermine the efficacy of a similar protocol
in other jawbone sites.in other jawbone sites.

Single Implant StudiesSingle Implant Studies
The studies of single implant-supportedThe studies of single implant-supported
prostheses reported good treatment outcomes.prostheses reported good treatment outcomes.
Low success rates were reported with implantLow success rates were reported with implant
placement in fresh extraction sites, which mayplacement in fresh extraction sites, which may
have been compromised by the presence ofhave been compromised by the presence of
infection. The reasons for tooth extractioninfection. The reasons for tooth extraction
included trauma, retained root and rootincluded trauma, retained root and root
resorption, and non restorable crowns.resorption, and non restorable crowns.
Contraindications are active periodontal andContraindications are active periodontal and
per apical infection, suggesting that placementper apical infection, suggesting that placement
of implants in fresh extraction sites should beof implants in fresh extraction sites should be
avoided in clinical situations with ongoingavoided in clinical situations with ongoing
inflammatory processes.inflammatory processes.

There were failures as well as success withThere were failures as well as success with
occclusal and non-occlusal loadingoccclusal and non-occlusal loading
suggesting that studies are required tosuggesting that studies are required to
conclusively determine the role ofconclusively determine the role of
occlusion in these clinical situations. Sameocclusion in these clinical situations. Same
is true in relation to bone quality.is true in relation to bone quality.

IMMEDIATE LOADING OF IMPLANTS WITHIMMEDIATE LOADING OF IMPLANTS WITH
OVERDENTURE PROSTHESISOVERDENTURE PROSTHESIS
Implant retained overdentures proved to be aImplant retained overdentures proved to be a
predictable and effective method in thepredictable and effective method in the
management of edentulous patients. In earlymanagement of edentulous patients. In early
progressive loading, the dentures are not wornprogressive loading, the dentures are not worn
for 1 to 2 weeks, or else worn, but completelyfor 1 to 2 weeks, or else worn, but completely
relieved from the healing abutment. Typically,relieved from the healing abutment. Typically,
the prosthesis is then relined for 3 to 4 monthsthe prosthesis is then relined for 3 to 4 months
when the definitive prosthesis and attachmentswhen the definitive prosthesis and attachments
(ball or bar assembly) are connected.(ball or bar assembly) are connected.

In early functional loading, the dentures are notIn early functional loading, the dentures are not
worn for 2 weeks or are relined after surgery.worn for 2 weeks or are relined after surgery.
The retentive components (ball attachments)The retentive components (ball attachments)
are then connected within 3 weeks.are then connected within 3 weeks.
In immediate early functional loading, theIn immediate early functional loading, the
retentive attachments are connected within 5retentive attachments are connected within 5
days. In this, the retentive components are adays. In this, the retentive components are a
bar/clip assembly.bar/clip assembly.

Studies have suggested that implants shouldStudies have suggested that implants should
be splinted together with ,1 bar within a shortbe splinted together with ,1 bar within a short
period of time to prevent axial rotation andperiod of time to prevent axial rotation and
implant micro motion. However, other studiesimplant micro motion. However, other studies
have used fewer implants (minimum of 2) thathave used fewer implants (minimum of 2) that
were left exposed and unsplinted after an initialwere left exposed and unsplinted after an initial
healing phase of 2 to 3 weeks. Therefore, ithealing phase of 2 to 3 weeks. Therefore, it
would be argued that splinting of implants is notwould be argued that splinting of implants is not
a definite requirement for osseointegration witha definite requirement for osseointegration with
these protocols in the anterior mandible.these protocols in the anterior mandible.
However, it should be noted that healing wasHowever, it should be noted that healing was
unobstructed for the first couple of weeks andunobstructed for the first couple of weeks and
led to a high success rate with such protocols.led to a high success rate with such protocols.

In most of these studies, the loading wasIn most of these studies, the loading was
progressive, with the next stage involvingprogressive, with the next stage involving
relining for a few weeks. Final attachment and,relining for a few weeks. Final attachment and,
presumably, full functional loading typicallypresumably, full functional loading typically
progressed within 3 to 4 months, while othersprogressed within 3 to 4 months, while others
constructed the frameworks within 2 to 3 week.constructed the frameworks within 2 to 3 week.
The peri-implant soft tissues appeared to beThe peri-implant soft tissues appeared to be
comparable to conventional protocols and didcomparable to conventional protocols and did
not compromise implant outcomes. However,not compromise implant outcomes. However,
others observed a change in the mucosa,others observed a change in the mucosa,
mainly describing it as soft-tissue shrinkage.mainly describing it as soft-tissue shrinkage.
This suggests that a period of soft tissueThis suggests that a period of soft tissue
healing, along with a change, is to be expectedhealing, along with a change, is to be expected
following surgery.following surgery.

It is, therefore, safe to assume that time shouldIt is, therefore, safe to assume that time should
be allowed for optimal soft tissue health. If not,be allowed for optimal soft tissue health. If not,
it could be hypothesized that the denturesit could be hypothesized that the dentures
would require relining to maintain the bestwould require relining to maintain the best
possible adaptation of the prosthesis to thepossible adaptation of the prosthesis to the
tissue. Peri-implant bone behavior wastissue. Peri-implant bone behavior was
observed with intraoral radiographs orobserved with intraoral radiographs or
panoramic radiographs corrected forpanoramic radiographs corrected for
magnification. The observed bone loss wasmagnification. The observed bone loss was
with in 0.2 mm / year and immediate loadingwith in 0.2 mm / year and immediate loading
was not a high risk factor for early or latewas not a high risk factor for early or late
marginal bone loss when compared tomarginal bone loss when compared to
conventional loading protocols.conventional loading protocols.

CONCLUSIONS ON IMMEDIATELYCONCLUSIONS ON IMMEDIATELY
ANDAND
EARLY LOADING PROTOCOLSEARLY LOADING PROTOCOLS
Patients should be healthy or a controlled
medical condition
Cigarette smokingCigarette smoking
Primary stability of the implant is an underlyingPrimary stability of the implant is an underlying
for predictable results. Primary stability isfor predictable results. Primary stability is
virtually guaranteed with screw shaped implantvirtually guaranteed with screw shaped implant
in the anterior mandible and in other jaw sites.in the anterior mandible and in other jaw sites.www.indiandentalacademy.comwww.indiandentalacademy.com

However a modified surgical protocol mayHowever a modified surgical protocol may
improve the success likeimprove the success like
1.avoiding /reducing bone tapping of the1.avoiding /reducing bone tapping of the
osteotomy site or tapping. osteotomies sites inosteotomy site or tapping. osteotomies sites in
dense bone only;dense bone only;
2.avoiding countersinking or limiting it to2.avoiding countersinking or limiting it to
cancellous bone conditionscancellous bone conditions
3.engaging both cortices where available to3.engaging both cortices where available to
provide bicortical stabilizationprovide bicortical stabilization
4.performing under preparation of the osteotomy4.performing under preparation of the osteotomy
site using narrower twist drills or the osteotomesite using narrower twist drills or the osteotome
5. using wider implant when primary stability was5. using wider implant when primary stability was
not obtained with the initial implantnot obtained with the initial implant

It is tempting to propose that in the anteriorIt is tempting to propose that in the anterior
mandible, the traditional protocol may suffice,mandible, the traditional protocol may suffice,
whereas a modified surgery may be advisablewhereas a modified surgery may be advisable
for other sites. Also the minimum implant lengthfor other sites. Also the minimum implant length
of 10 mm is necessary for immediate and earlyof 10 mm is necessary for immediate and early
loading protocol but further studies are requiredloading protocol but further studies are required
on this aspect. Atleast 4 implants should beon this aspect. Atleast 4 implants should be
placed in the edentulous anterior mandible toplaced in the edentulous anterior mandible to
support a fixed prosthesis. Caution is requiredsupport a fixed prosthesis. Caution is required
with a fewer number of implants due towith a fewer number of implants due to
potential complete prosthodontic failure if onepotential complete prosthodontic failure if one
implants fails to osseointegrate..implants fails to osseointegrate..

Studies suggest that to achieve predictableStudies suggest that to achieve predictable
result in extraction sites, implant placementresult in extraction sites, implant placement
should be restricted to sites without a history ofshould be restricted to sites without a history of
periodontal involvement. Finally, the marginalperiodontal involvement. Finally, the marginal
bone loss measured, irrespective of prosthesisbone loss measured, irrespective of prosthesis
design was of the same magnitude asdesign was of the same magnitude as
presented for the conventional loadingpresented for the conventional loading
approachapproach

DISCUSSIONDISCUSSION
The requisites for predictable osseointegrationThe requisites for predictable osseointegration
of immediately loaded implants have yet to beof immediately loaded implants have yet to be
determined. One parallel consideration isdetermined. One parallel consideration is
whether provisional loading of a tissue bornewhether provisional loading of a tissue borne
prosthesis over an implant during theprosthesis over an implant during the
osseointegration (healing) period will affect theosseointegration (healing) period will affect the
integration of that implant. To date there is nointegration of that implant. To date there is no
scientific evidence (and no clearly documentedscientific evidence (and no clearly documented
subjective clinical evidence ) that early failure ofsubjective clinical evidence ) that early failure of
dental implant can be attributed to early -dental implant can be attributed to early -www.indiandentalacademy.comwww.indiandentalacademy.com

-loading or overload resulting from a tissue--loading or overload resulting from a tissue-
supported interim prosthesis being worn over asupported interim prosthesis being worn over a
recently placed dental implant. Loading ofrecently placed dental implant. Loading of
implant through the use of an interimimplant through the use of an interim
restoration has not been documented as arestoration has not been documented as a
cause of early implant failure. It is also safe tocause of early implant failure. It is also safe to
state that, at this time , there is no scientificstate that, at this time , there is no scientific
evidence that the factor associated with implantevidence that the factor associated with implant
restoration (provisional or restorative) have arestoration (provisional or restorative) have a
predictable impact on the survival of thepredictable impact on the survival of the
supporting implant.supporting implant.

This apparent lack of effect may be deceiving, inThis apparent lack of effect may be deceiving, in
that very real determinants of implant successthat very real determinants of implant success
or failure are likely to be related directly to theor failure are likely to be related directly to the
prosthodontic aspects of the treatment.prosthodontic aspects of the treatment.
Unfortunately, those as yet unidentifiedUnfortunately, those as yet unidentified
determinants are hidden from the view ofdeterminants are hidden from the view of
clinicians.clinicians.

Immediate post insertion impressions andImmediate post insertion impressions and
modelmodel
1. Placement of transfer coping and cap1. Placement of transfer coping and cap
2. Direct bone impressioning2. Direct bone impressioning
3. Place the sealing screw3. Place the sealing screw
4. Inter occlusal arch registration4. Inter occlusal arch registration

5. Post insertion soft tissue procedure5. Post insertion soft tissue procedure
6. Final closure – suturing6. Final closure – suturing
7. Provisional prosthesis option7. Provisional prosthesis option
Flipper optionFlipper option
Bonded tooth optionBonded tooth option

BONDED TOOTH OPTIONBONDED TOOTH OPTION

Post Insertion Home Care InstructionsPost Insertion Home Care Instructions
1.Trauma1.Trauma
2. Prophylactic antibiotic medication2. Prophylactic antibiotic medication
3. Comfort medication3. Comfort medication
4. Cleanliness4. Cleanliness
5. Diet/Function5. Diet/Function

PROGRESSIVPROGRESSIV
EE BONEBONE

CONTENTSCONTENTS
1. INTRODUCTION1. INTRODUCTION
2. PRORESSIVE BONE LOADING PROTOCOL2. PRORESSIVE BONE LOADING PROTOCOL
3. PHASES OF PROGRESSIVE BONE3. PHASES OF PROGRESSIVE BONE
LOADINGLOADING
4. PROGRESSIVE BONE LOADING4. PROGRESSIVE BONE LOADING
APPOINTMENT SEQUENCE FORAPPOINTMENT SEQUENCE FOR
CEMENT RETAINED PROSTHESISCEMENT RETAINED PROSTHESIS

The surgical and prosthetic protocols for aThe surgical and prosthetic protocols for a
predictable direct bone-to-implant interface withpredictable direct bone-to-implant interface with
root form implants were developed androot form implants were developed and
reported by Branemark. However, to reducereported by Branemark. However, to reduce
early implant failure, attention must be broughtearly implant failure, attention must be brought
to the strength of the bone-to-implant interfaceto the strength of the bone-to-implant interface
during early implant loading.during early implant loading. Once an initialOnce an initial
direct bone-to-implant interface has beendirect bone-to-implant interface has been
obtained and confirmed at the posthealingobtained and confirmed at the posthealing
Stage II surgery, the implant is most at risk forStage II surgery, the implant is most at risk for
failure or crestal bone loss within the first year.failure or crestal bone loss within the first year.www.indiandentalacademy.comwww.indiandentalacademy.com

This occurs primarily as a result of excessiveThis occurs primarily as a result of excessive
stress and/or poor bone strength at thestress and/or poor bone strength at the
interface. If the treatment plan is satisfactory forinterface. If the treatment plan is satisfactory for
adequate support, the three most commonadequate support, the three most common
causes of early prosthetic-related implantcauses of early prosthetic-related implant
failure are non passive superstructures,failure are non passive superstructures,
partially unretained restorations, and loading ofpartially unretained restorations, and loading of
the implant support system beyond the strengththe implant support system beyond the strength
of the bone-to-implant interface. The concept ofof the bone-to-implant interface. The concept of
progressive or gradual bone loading was firstprogressive or gradual bone loading was first
proposed during prosthetic reconstruction toproposed during prosthetic reconstruction to
decrease crestal bone loss and early implantdecrease crestal bone loss and early implant
failure of endosteal implants in 1980 on thefailure of endosteal implants in 1980 on the
basis of empirical information.basis of empirical information.

Over the years this was evaluated andOver the years this was evaluated and
modified to incorporate time intervals, diet,modified to incorporate time intervals, diet,
occlusion, prosthesis design and occlusalocclusion, prosthesis design and occlusal
materials.materials.

PRORESSIVE BONE LOADINGPRORESSIVE BONE LOADING
PROTOCOLPROTOCOL

TIMETIME
The two surgical appointments used for initialThe two surgical appointments used for initial
implant placement and Stage II uncovery areimplant placement and Stage II uncovery are
separated by 4 to 8 months depending on theseparated by 4 to 8 months depending on the
bone density at the initial surgerybone density at the initial surgery
The macroscopic coarse trabecular bone healsThe macroscopic coarse trabecular bone heals
approximatelyapproximately 50%50% faster tnan dense corticalfaster tnan dense cortical
bone. However,D1 bone has the greatestbone. However,D1 bone has the greatest
strength and greater bone contact so evenstrength and greater bone contact so even
though it heals in a slower fashion, the bone tothough it heals in a slower fashion, the bone to
implant contact at the interface is high andimplant contact at the interface is high and ofof
lamellar type.lamellar type.

Therefore the healing time between the initialTherefore the healing time between the initial
and second stage surgeries is kept similar forand second stage surgeries is kept similar for
D1 and D2 boneD1 and D2 bone
A longer time is suggested for the initial healingA longer time is suggested for the initial healing
phasephase of D3 anof D3 and D4 bone (6 and 8 months,d D4 bone (6 and 8 months,
respectively) becauserespectively) because ofof the lesser bonethe lesser bone
contact and decreased amount of cortical bonecontact and decreased amount of cortical bone
An implant surgery may initially trigger anAn implant surgery may initially trigger an
increase in the amount of bone in the region.increase in the amount of bone in the region.
However, to improve the bone density andHowever, to improve the bone density and
strength long term, the implant must be loaded.strength long term, the implant must be loaded.

When multiple implants are used, the weakest
bone area determines the gradual load protocol.

DIETDIET
The diet of the patient is controlled to preventThe diet of the patient is controlled to prevent
overloading during the early phases of theoverloading during the early phases of the
restorative-phaserestorative-phase
The patient is limited to a soft diet such asThe patient is limited to a soft diet such as
pasta and fish, from the initial transitionalpasta and fish, from the initial transitional
prosthesis delivery until the initial delivery of theprosthesis delivery until the initial delivery of the
final prosthesis. The masticatory force for thisfinal prosthesis. The masticatory force for this
type of food is approximately 10 pounds/in oftype of food is approximately 10 pounds/in of
force.force. www.indiandentalacademy.comwww.indiandentalacademy.com

This not only minimizes the masticatory forceThis not only minimizes the masticatory force
on the implants but also decreases the risk ofon the implants but also decreases the risk of
temporary restoration fracture or partiallytemporary restoration fracture or partially
uncemented restoration.uncemented restoration.
After the initial delivery of the final prosthesis,After the initial delivery of the final prosthesis,
the patient may include meat in the diet, whichthe patient may include meat in the diet, which
requires approximately 21 pounds/in sq. biterequires approximately 21 pounds/in sq. bite
force. The final restoration can bear the greaterforce. The final restoration can bear the greater
force without risk of fracture or uncementation.force without risk of fracture or uncementation.
After the final evaluation appointment, theAfter the final evaluation appointment, the
patient may include raw vegetables into thepatient may include raw vegetables into the
diet.diet. www.indiandentalacademy.comwww.indiandentalacademy.com

It takes 27 pounds/ in sq. force to chew a rawIt takes 27 pounds/ in sq. force to chew a raw
carrot. A normal diet is permitted after the finalcarrot. A normal diet is permitted after the final
prosthesis function, occlusion and properprosthesis function, occlusion and proper
cementation are evaluated.cementation are evaluated.
OCCLUSAL MATERIALOCCLUSAL MATERIAL
The occlusal material may be varied toThe occlusal material may be varied to
gradually load the bone-to-implant interface.gradually load the bone-to-implant interface.
During initial steps there is no occlusal materialDuring initial steps there is no occlusal material
over the implant. During subsequentover the implant. During subsequent
appointments, acrylic is used as the occlusalappointments, acrylic is used as the occlusal
material, with the benefit of a lower impactmaterial, with the benefit of a lower impact
force than metal or porcelain.force than metal or porcelain.

Either metal or porcelain can be used for theEither metal or porcelain can be used for the
occlusal aspect of the final prosthesis. Ifocclusal aspect of the final prosthesis. If
parafunction or cantilever length causeparafunction or cantilever length cause
concern, the softer diet and acrylic restorationconcern, the softer diet and acrylic restoration
phase may be extended several months.phase may be extended several months.
OCCLUSIONOCCLUSION
The occlusal contacts are gradually intensifiedThe occlusal contacts are gradually intensified
during prosthesis fabrication. There are noduring prosthesis fabrication. There are no
occlusal contacts during initial healing. The firstocclusal contacts during initial healing. The first
transitional prosthesis is left out of occlusion intransitional prosthesis is left out of occlusion in
partially edentulous patients.partially edentulous patients.

The occlusal contacts are then similar to thoseThe occlusal contacts are then similar to those
of the final restoration for areas supported byof the final restoration for areas supported by
implants. However, there are no occlusalimplants. However, there are no occlusal
contacts on any cantilevers.contacts on any cantilevers.
The occlusal contacts of the final restorationThe occlusal contacts of the final restoration
follow the IPO concepts.follow the IPO concepts.
The occlusal contacts are very important toThe occlusal contacts are very important to
address because parafunction is common andaddress because parafunction is common and
generates greater stresses in magnitude andgenerates greater stresses in magnitude and
duration than eating food.duration than eating food.

PROSTHESIS DESIGNPROSTHESIS DESIGN
During initial healing, an attempt is made toDuring initial healing, an attempt is made to
avoid any load on the implants, including softavoid any load on the implants, including soft
tissue loads. The first transitional acrylictissue loads. The first transitional acrylic
restoration in partially edentulous patients hasrestoration in partially edentulous patients has
no occlusal contact and no cantilevers. It’sno occlusal contact and no cantilevers. It’s
purpose is to splint the implants together, topurpose is to splint the implants together, to
reduce stress by the biomechanical advantage,reduce stress by the biomechanical advantage,
and to have implants sustain masticatory forcesand to have implants sustain masticatory forces
solely from chewing. The second acrylicsolely from chewing. The second acrylic
transitional restoration has occlusal contactstransitional restoration has occlusal contacts
above implants with occlusal tables similar toabove implants with occlusal tables similar to
the final restoration but no cantlevers in non-the final restoration but no cantlevers in non-
esthetic regions.esthetic regions.

The final restoration has final occlusalThe final restoration has final occlusal
table and cantilevers and has occlusaltable and cantilevers and has occlusal
contacts following IPO guidelines.contacts following IPO guidelines.

GOOD MORNINGGOOD MORNING

The progressive bone-loading appointmentThe progressive bone-loading appointment
sequence for cement-retained prostheses issequence for cement-retained prostheses is
as follows :as follows :
1. Initial abutment selection and preliminary1. Initial abutment selection and preliminary
impressionimpression
2. Final impression and transitional prosthesis I2. Final impression and transitional prosthesis I
3. Metal superstructure try-in and transitional3. Metal superstructure try-in and transitional
prosthesis IIprosthesis II
4. Initial insertion of final prosthesis4. Initial insertion of final prosthesis
5. Final delivery and evaluation5. Final delivery and evaluation

FIRST APPOINTMENTFIRST APPOINTMENT
Initial Abutment Selection and PreliminaryInitial Abutment Selection and Preliminary
ImpressionsImpressions
goal of this first prosthetic appointment is to
assess the implant and soft tissues
this appointment may occur during either the
suture removal appointment after StageII
surgery or during the uncovery procedure
The Stage II permucosal extensions are
removed by the restoring dentist, and straight
abutments for cement retention or indirect
impression transfers are inserted.

The abutment for cement retention is placed
with finger pressure and no torque wrench
because of' the immature interface and also
because the abutment will be removed at the
end of this appointment.
If abutments diverge more than 30 degrees, the
preliminary impression will be very difficult to
remove from the mouth
The occlusal plane is also corrected to the
proper curves of Wilson and Spee at this
appointment hefore the impressions as
indicated. www.indiandentalacademy.comwww.indiandentalacademy.com

The abutments for cement are removed,
implant body analogs are attached, and the
abutments are inserted into the corresponding
position within the impression.
The low-profile permucosal healing caps are
reinserted into the implant bodies.
An occlusal bite registration is made in centric
relation occlusion.
The patient is dismissed, with instructions not
to chew in the region and to gently brush the
permucosal extensions with chlorhexidine.

LABORATORY PHASE ILABORATORY PHASE I
pour the impression and attached analogs with
dental stone
mounted to the opposing arch with the bite
registration
The implant abutments are prepared for height,
parallelism, and position within the prosthesis
contours.

Two transitional acrylic prostheses may then be
fabricated. Ideally, for partially edentulous
patients, the first transitional restoration is
completely out of occlusion.

SECOND APPOINTMENTSECOND APPOINTMENT
Final Impression and Transitional Prosthesis IFinal Impression and Transitional Prosthesis I
The patient returns after 1 to 4 weeks,
depending on the bone density. The
permucosal extensions are removed from the
implant bodies. A one-piece straight abutment
is used for multiple abutment restorations when
possible. An anaerobic setting sealer is used
on the abutment screw, and the abutment is
hand-threaded into position with approximately
10 N-cm force. www.indiandentalacademy.comwww.indiandentalacademy.com

The complete seating of the abutment is
verified with a radiograph
For a single tooth or angled implant, a two
piece abutment is inserted using a counter
torque system and torque wrench to preload
the abutment screw at a 20 to 35 N-cm force,
depending on screw material and design.
One-piece abutments do not need preload, as
long as the preparation has one or two flat
sides on the abutments to prevent unthreading
or rotation within the prosthesis.

Final abutment preparation is performed at this
appointment.
The transitional prosthesis may also be relined
to create an emergence profile below the
tissue, if necessary. Another alternative is to
remove the abutment, place it into an implant
analog, and prepare it out of the mouth.
The margins of the restoration may be
extended to the abutment margin and develop
the emergence profile of the final crown. An
impression may then be made of the abutment,
and a separate die may be poured in dental
stone. www.indiandentalacademy.comwww.indiandentalacademy.com

The abutment post is reinserted into the implant
body and tightened to 10 N-cm6 (with
anaerobic cement).
A final impression is obtained.
The centric occlusal registration is recorded
with a closed mouth centric position when
centric relation is harmonious with centric
occlusion. The closed mouth centric recording
reduces the need for an exact face-bow and
hinge-axis location. An earbow/face-bow record
is made, along with protrusive and check bites
when required. www.indiandentalacademy.comwww.indiandentalacademy.com

The first transitional prosthesis is luted with a
non eugenol zinc oxide cement, and there is a
total absence of occlusal contacts . Petroleum
jelly may be added to the cement when the
restoration is very retentive, to facilitate the
transitional prosthesis retrieval at the next
appointment.
LABORATORY PHASE IILABORATORY PHASE II
Porcelain fracture is more common on implants
than teeth, and unsupported porcelain is more
common on small diameter implant abutments.

A full-contour wax-up and cut down of 2 mm in
regions of porcelain is made for the prosthesis
framework.
A precious metal superstructure is fabricated.
An occlusal acrylic index is also fabricated

THIRD APPOINTMENT Metal Try-inTHIRD APPOINTMENT Metal Try-in
The patient returns in 1 to 4 weeks (or more)
depending on the bone density.
The first transitional restoration is removed
The metal superstructure is tried-in.
The centric relation can be checked. If the
patient bites into the laboratory occlusal acrylic
index, the previous record was accurately
registered. If incorrect, the occlusion is
evaluated and corrected as indicated, and a
closed mouth centric occlusal registration is
recorded using a rigid addition silicone on top
of the casting. www.indiandentalacademy.comwww.indiandentalacademy.com

The second transitional prosthesis is delivered
This may be a new transitional prosthesis or
the first transitional with a modified occlusal
table through the addition of acrylic on the
occlusal contact areas.
Occlusion is evaluated using a heavy bite force
occlusal adjustment.
Occlusal contacts are limited to those directly
on Implant bodies. The diet remains soft with
pasta, fish, or softer food types.

LABORATORY PHASE IIILABORATORY PHASE III
The prosthesis is completed with an occlusalThe prosthesis is completed with an occlusal
scheme that follows IPO guidelines and withscheme that follows IPO guidelines and with
occlusal contact, corresponding to the long axisocclusal contact, corresponding to the long axis
of each implant body. The laboratory evaluatesof each implant body. The laboratory evaluates
the first model of the preliminary impression.the first model of the preliminary impression.
Angled implant bodies are noted, so theAngled implant bodies are noted, so the
occlusal contacts may be modified to be in theocclusal contacts may be modified to be in the
long axis of the implant body, or reduced inlong axis of the implant body, or reduced in
intensity.intensity.

FOURTH APPOINTMENTFOURTH APPOINTMENT
Initial Prosthesis DeliveryInitial Prosthesis Delivery
The next appointment follows 1 to 4 weeks later
depending on the bone density
The final restoration is inserted and carefully
evaluated relative to occlusal contacts. After a
light bite force is used to equilibrate the
occlusal contacts, a heavy bite force occlusal
adjustment is made, with no lateral contacts in
excursions www.indiandentalacademy.comwww.indiandentalacademy.com

A radiograph is obtained and used as a
baseline for future radiographic evaluation for
crestal bone loss and implant health. If crestal
bone loss is observed when compared with the
Stage II uncovery appointment, parafunction is
suspected, and night guards are fabricated to
control stresses.
The bone is now more mineralized and exhibits
improved load-bearing capability than at the
first transitional prosthesis delivery.

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