The International Journal of Periodontics & Restorative Dentistry COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.NO PART OF THIS ARTICLE MAY BE REPRO- DUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 451 DUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. WRITTEN PERMISSION FROM WITHOUT TRANSMITTED IN ANY FORM DUCED OR THI OF PART PERSONAL USE ONLY.NO INC.TO PUBLISHING CO, COPYRIGHT © 2002 BY QUINTESSENCE THIS DOCUMENT IS RESTRICTED PRINTING OF Immediate Loading of Osseotite Implants: A Case Report and Histologic Analysis After 4 Months of Occlusal Loading Tiziano Testori, MD, DDS*/Serge Szmukler-Moncler, DDS**/ The original Brånemark protocol rec- Luca Francetti, MD, DDS***/Massimo Del Fabbro, BSc, PhD****/ ommended long stress-free healing Antonio Scarano, DDS*****/Adriano Piattelli, MD, DDS******/ periods to achieve the osseointe- Roberto L. Weinstein, MD, DDS******* gration of dental implants.1–4 However, a growing number of A growing number of clinical reports show that early and immediate loading of 5–11 endosseous implants may lead to predictable osseointegration; however, these experimental and clinical stud- studies provide mostly short- to mid-term results based only on clinical mobility and ies12–19 are now showing that early radiographic observation. Other methods are needed to detect the possible pres- and immediate loading may lead to ence of a thin fibrous interposition of tissue that could increase in the course of time predictable osseointegration. A and lead to clinical mobility. A histologic evaluation was performed on two immedi- review of the experimental9 and clin- ately loaded Osseotite implants retrieved after 4 months of function from one ical19 literature discussing early load- patient. He had received a total of 12 implants in the mandible, of which six were immediately loaded and six were left to heal in a submerged way. Clinical and his- ing (< 3 months of healing) protocols tologic osseointegration was consistently achieved for both of the retrieved imme- in implant dentistry came to the con- diately loaded implants. Osteogenesis and bone remodeling on the Osseotite sur- clusion that early loading per se is face were not impeded by immediate loading as shown by histomorphometric not responsible for the lack of evaluation, which revealed high levels of bone-to-implant contact ranging from osseointegration; the latter is rather 78% to 85%. This immediate loading protocol involving bilateral splinting of six due to the presence of excessive Osseotite implants in the mandible proved to be successful after 4 months of load- ing. Further long-term clinical and histologic studies are needed before introducing micromotion during the healing this immediate loading protocol as a routine procedure in implant therapy. (Int J phase. The authors showed that Periodontics Restorative Dent 2001;21:451–459.) implant design, surface state, load- ing mode, and prosthetic rehabilita- *******Visiting Professor, Department of Periodontology, University of Milano, Italy. tion type dictate the bone response *******Visiting Professor, Department of Periodontology, University of Milano, Italy; and Institute of Stomatology, Plastic Surgery and Maxillo-facial Surgery, to implants loaded before the tradi- Salpetrière Hospital, University of Paris VI, France. tional 3 months of healing.9 *******Researcher, Department of Periodontology, University of Milano, Italy. S ARTICLE MAY BE REPRO- MAY S ARTICLE *******Department of Periodontology, University of Milano, Italy. For fixed rehabilitations, imme- *******Research Fellow, Dental School, University of Chieti, Italy. diate loading with various implant *******Professor, Dental School, University of Chieti, Italy; and Eastman Dental systems has been studied, and high Institute for Oral Health Care Sciences, London. *******Professor and Chair, Department of Periodontology, University of Milano, Italy. success rates have been report- ed.12–14,16–18 Yet, in all these studies, *******Reprint requests: Dr Tiziano Testori, Dipartimento di Medicina, Chirurgia e Odontoiatria, Cattedra di Parodontologia, Via Beldiletto 1/3, 20142 Milano, the number of enrolled patients did Italy. e-mail: [email protected] not exceed 10 individuals per study. Volume 21, Number 5, 2001 452 DUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. WRITTEN PERMISSION FROM WITHOUT TRANSMITTED IN ANY FORM DUCED OR THI OF PART PERSONAL USE ONLY.NO INC.TO PUBLISHING CO, COPYRIGHT © 2002 BY QUINTESSENCE THIS DOCUMENT IS RESTRICTED PRINTING OF Although clinical results seem to be Method and materials immediately loaded implants. These promising in regard to immediate would be retrieved after 4 months of loading with a fixed cross-arch pros- Case report function, at uncovering the sub- thesis, further long-term follow-ups merged implants. The patient vol- and larger numbers of patients are A healthy 61-year-old nonsmoking unteered for the protocol and required. Moreover, the above- man was examined for a failing fixed signed an informed consent form. It mentioned clinical studies provide partial denture (FPD) retained on five was therefore decided to place 12 mostly short- to mid-term results teeth and two implants. His teeth Osseotite implants, six implants to based only on clinical mobility and were in a state of advanced peri- support the immediately loaded radiographic observation. These odontal disease, one implant dis- provisional FPD and six submerged methods are not suitable to detect played noticeable bone loss be- implants to retain the final com- the possible presence of a thin cause of untreated periimplantitis, plete-arch rehabilitation of the fibrous interposition of tissue that and the second one was lingually mandible. The two implants des- can increase over the course of time angled. It was decided to extract all tined to be retrieved were chosen to and lead to clinical mobility.9,19 of the remaining teeth and remove allow for adequate prosthetic sup- While several animal experi- the preexisting dental implants. As port by the remaining implants. ments dealing with early and imme- the patient wore an overdenture in Oral hygiene instructions were diate loading protocols have been the maxilla, he could not cope psy- given, and before surgery the published,5–11 extrapolation from chologically with another denture or patient was scheduled for proce- the animal model to the clinical with any other kind of partially dures to control his inflammatory application is not fully reliable removable appliance and therefore disease. Subgingival scaling and because of the distinct loading requested an immediate fixed root planing were performed. schemes and exerted stresses. restoration. An immediate loading Augmentin (SmithKline Beecham) Retrievals of immediately loaded protocol according to Schnitman et and Flagyl (Pharmacia & Upjohn) implants displaying clinical stability al,12 involving simultaneous place- were administered 7 days before have been scarce20–24 and have ment of submerged and immedi- implant placement and were con- involved a limited number of im- ately loaded implants in the eden- tinued for 6 days. Teeth were gen- plants. As surface state7 and loading tulous mandible, was discussed with tly removed and the sockets de- mode9 play a determinant role in the patient. In this protocol, the granulated. The implants were healing under loading, demonstra- immediately loaded implants are explanted with a premolar forceps, tion of osseointegration by means of intended to sustain a provisional trephining was avoided to preserve histologic evidence is warranted for FPD, while the submerged implants bone quantity, and the implant bed each implant type differing in design are left to heal in the traditional way. was thoroughly cleaned to remove and/or surface. The rationale is that, should every any remaining soft tissue. Self-tap- The aim of the present article is immediately loaded implant fail dur- ping Osseotite implants were to report on two Osseotite implants ing the provisional period, a suffi- placed according to the manufac- (3i), retrieved from one patient, that cient number of submerged turer’s instructions (Fig 1a). All had been immediately loaded after implants would still support the final implants displayed a high degree S ARTICLE MAY BE REPRO- MAY S ARTICLE placement and were in function for fixed rehabilitation. of primary stability, requiring a ≥ 32 4 months in the mandible. It was proposed to the patient Ncm torque as tested with a torque- that he receive two additional control instrument. At a freshly immediately loaded implants to explanted implant site, congruence retain his provisional FPD, with the at the implant neck was not aim of obtaining biopsies of the obtained, and the resulting circular The International Journal of Periodontics & Restorative Dentistry 453 DUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. WRITTEN PERMISSION FROM WITHOUT TRANSMITTED IN ANY FORM DUCED OR THI OF PART PERSONAL USE ONLY.NO INC.TO PUBLISHING CO, COPYRIGHT © 2002 BY QUINTESSENCE THIS DOCUMENT IS RESTRICTED PRINTING OF Fig 1a (left) Surgical template in situ dur- ing surgery. Fig 1b (right) Provisional restoration 4 hours after surgery. Standard abutments have been screwed on the six implants and immediately loaded. Fig 1c (left) Final restoration, anterior view. Fig 1d (right) Final restoration, occlusal view. crestal bone