The success of your treatment?
I can think of some of the reasons that would be thrown at me:
The patient insists on an immediate prosthesis
The patient cannot return after a few months for the loading
Most dentists do it – so should I
I will be considered old- fashioned if my neighboring dentist does it and I do not offer it
My patient refuses to wear a removable prosthesis etc.
Each dentist should be forewarned that not all patients and not all situations are the same for us to generalize this this protocol. For instance would it be possible to implement the immediate load protocol in the following situations?
1. Severe metabolic disease 2. Inadequate bone volume for correct implant placement
3. Very poor bone density (D4)
4. Severe parafunction (eg, bruxing, clenching, tongue thrust)
5. Noncompliant patient types (eg. Diet limitations, gum chewing)
6. Heavy smokers
7. Patients with uncontrolled periodontal disease
The list can go on and on but the serious implantologist needs to first understand the differenttypes of edentulous situations that one encounters and how each needs to be treated with the immediate load protocol.
There are 4 different patient groups for the immediate occlusal loading protocol
1. Patients who are completely edentulous desiring a fixed restoration
Immediate loading in the edentulous mandibular arch has been studied for many years and specific protocols as loading 5 or more implants to support the immediate restoration has been tried and tested. In the case under review, 4 implants have been immediately loaded in the mandibular region and given the location, size and bone quality, this protocol should work successfully. One has to be more careful when app0lying the same protocol to the maxillary arch due to bone quality, implant angulation , occlusal loads etc. As such, a more cautious approach is warranted.
2. Patients who are completely edentulous with an implant overdenture
In general, patients with completely edentulous mandibles, restored with an overdenture are at the least risk of occlusal overload for immediate loading protocols. This approach has been presented adequately in the literature, along with more recent reports, suggesting 4 or more implants splinted together to support the restoration. To this date, maxillary overdentures have not been adequately addressed in the literature and the immediate load protocol for maxillary overdentures would have a high risk-benefit ratio.
3. Patients who are partially edentulous replacing several teeth with a fixed prosthesis
This procedure has been evaluated only since 1998 and has the fewest clinical studies. The patient who is partially edentulous and missing several adjacent teeth should limit the use of immediate restoration to the esthetic zones, where 1 implant may be inserted for each tooth. The transitional overload. These are guidelines as per the Misch protocol for immediate loading but I still am of the opinion that the dentist has no control on the forces the patient will apply on the immediately loaded implants, even if they are out of occlusion. The forces could be from the lip or tongue musculature or even constant touching with finger pressure.
4. Patients who are replacing a single tooth
The immediately restored single tooth implant has an increased risk of failure of about 5% in the first Year and has also been evaluated for the least amount of time in the literature. In my experience, this protocol works well when the soft and hard tissue conditions are ideal, long implants with bicortical engagement are used and when they are kept out of occlusion. Above all, patient compliance regarding diet is of paramount importance. In conclusion, the traditional 2-stage approach to implant restorations has been evaluated for almost 3 decades while the immediate occlusal load approach is relatively new and has far less research and documented studies. Therefore, the staged approach to implant restoration should always be the first approach. This is especially noteworthy for the less-experienced practitioner. Minimal micromotion at the implant-bone interfacial zone during bone healing appears to be a key factor in the success of immediate of immediate loading.