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Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 69-75

Delayed loading and peri-implant evaluation of dental implants: Keys to higher success in lesser dense bone

Department of Periodontics and Oral Implantology, A.M.E's Dental College and Hospital, Raichur, Karnataka, India

Date of Web Publication2-Apr-2015

Correspondence Address:
Shivanand Aspalli
Department of Periodontics and Oral Implantology, A.M.E's Dental College and Hospital, Raichur - 584 103, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-6781.154454

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The success of osseointegrated dental implants has revolutionized dentistry. A healing period without early loading is currently still considered a prerequisite for implant integration. The aim of this case report was to assess the soft and hard tissue changes around the dental implant after delayed loading in a D 3 type of bone and thereby evaluating its success rate. Necessary documentation and investigation have been done. An implant was placed in a D 3 bone using standard surgical protocol. After an ensured healing of soft and hard tissues, the prosthesis was placed after 4 months. Peri-implant evaluation was done at intervals. At the end of 1 st year, the implants satisfied the criteria for the success rate. Thus with regards to implant survival in less dense bone, higher success rates can be achieved with aseptic and atraumatic procedure with delayed loading and appropriate postoperative care along with a consistent supportive periodontal therapy.

Keywords: Bone quality, delayed loading, dental implants, peri-implantitis

How to cite this article:
Aspalli S, Prebha M, Guttiganur N, Gaddale R. Delayed loading and peri-implant evaluation of dental implants: Keys to higher success in lesser dense bone. J Dent Implant 2015;5:69-75

How to cite this URL:
Aspalli S, Prebha M, Guttiganur N, Gaddale R. Delayed loading and peri-implant evaluation of dental implants: Keys to higher success in lesser dense bone. J Dent Implant [serial online] 2015 [cited 2020 Feb 22];5:69-75. Available from:

   Introduction Top

Brånemark's serendipitous work on osseointegration is a boon and is a proven milestone to dentistry. This event has forever changed the way dentists view their options when confronted with a patient requiring replacement of missing tooth or teeth. The use of endosseous dental implants is a highly predictable treatment modality supported by the wealth of evidence reporting their safety and high survival rates over the long-term. [1]

Delayed loading of implants

To achieve predictable osseointegration for dental implants, Branemark advocated an unloaded healing time of 3-6 months. A healing period without early loading is currently still considered a prerequisite for implant integration. Till date, this happens to be the most acceptable and most commonly followed treatment protocol. [2],[3],[4] This shares some added advantages when compared to the early loading, including extraction site preservation and allows time for soft tissue healing. The aim is to bring the implant prosthesis gradually into occlusion, after fixed intervals depending on the bone quality. This in turn, permits the bone to remodel and organize in accordance to Wolff's law, which states that trabecular bone places and displaces itself in relationship to the forces around it. [5] On allowing healing for a period of 3-8 months depending on bone densities, a clinical study determined the overall implant survival rate to be 98% that is, 100% for D 1 bone, 98.9% for D 2 bone, 99% for D 3 and 100% for D 4. Implant survival may be improved when implant design and surgical approach were modified according to specific bone density. [6]

Clinical peri-implant evaluation

Periodontal indices like the clinical inspection for signs of inflammation, that is plaque assessment by Mombelli's modified plaque index, [7],[8] bleeding on probing, probing depth, exudate, mobility and a radiographic evaluation of the peri-implant bony housing still remains the standard mode for evaluating the long-term status of endosseous dental implants. Periodontal indices have all been suggested as useful diagnostic tool for detecting the biological complications. [9],[10]

The debate about the diagnostic and prognostic value of crevicular implant probing depth is still going on. A healthy peri-implant sulcus has been reported to range from 1.3 to 3.8 mm, which is greater than those depths reported for natural teeth. [8] This is because epithelial attachment adheres weakly, some investigators would consider probing being invasive, allowing penetration of the probe close to the bony crest. [11]

Mobility at follow-up is a sign of the final stage of peri-implant pathology and indicates a complete failure of osseointegration. Mobility as a clinical parameter is specific but lacks sensitivity. [12] Misch described clinical implant mobility scale in which the implant is held firmly between two instruments and a labio lingual force of approximately 500 g is applied [Table 1].
Table 1: Misch's clinical implant mobility scale

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Some amount of bone loss is reported every year. Using radiographic analysis, Albrektsson et al. [13] showed that accepted amount of total bone resorption is 2.3 mm after 5 years in the following way that is, ≤1.5 mm after the 1 st year of prosthetic loading and < 0.2 mm for each following year. According to Wennstrom and Palmer [14] the acceptable bone loss is 2 mm after 5 years of prosthetic loading. Explanation to this can be (1) potential role of micro gap at the implant abutment interface for the bacterial colonization of the peri-implant sulcus. (2) Adequately dimensioned biological width to be associated with marginal bone resorption at sites with thin mucosa. (3) Butt joint connections associated to implant abutment configurations with matching diameters have been linked with an inflammatory cell infiltrate and bone loss. [15],[16]

   Case report Top

A 19-year-old female patient reported to the department of periodontics with the desire to replace missing tooth [Figure 1]. She gave a history of extraction of this tooth before 1-year due to caries. On intraoral examination, 36 was found to be missing. The adjacent and opposing teeth were in proper occlusion without drifting or supraeruption. Patient had good general and dental health and so patient was motivated for implant treatment. Patient had a very good ridge width and interarch space to accommodate for the prosthodontic components and had no temporomandibular joint disturbances or parafunctional habits. Preoperative investigations were done [Figure 2],[Figure 3] and [Figure 4].
Figure 1: Partially edentulous i.r.t 36 (clinical view)

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Figure 2: Panoramic radiograph

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Figure 3: Intra-oral periapical i.r.t missing 36

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Figure 4: (a) Computed tomography slice i.r.t 36. (b) Computed tomography slice i.r.t 36 (buccal view)

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Two staged surgical procedures were carried out. A crestal incision was made along the crest of the ridge, bisecting the existing zone of keratinized mucosa. A full thickness flap was raised buccally and lingually to the level of the mucogingival junction, exposing the alveolar ridge at the implant surgical site of 36 [Figure 5]. A series of drills starting from the round bur to 3 mm twist drill were used to prepare the osteotomy site precisely and incremently [Figure 6]. Implant was placed by hand with a wrench [Figure 7]. The cover screw was secured. The flaps were approximated, and sutures were given.

After the healing period of 4 months, presence of thin, soft tissues with an adequate amount of keratinized attached gingiva along with good oral hygiene ensured that there was a healthier peri-implant soft tissue. An intra-oral periapical radiograph showed that there was no bone loss, which ensured a healthy hard tissue [Figure 8]. Crestal incision was given to expose the implant. The gingival former was placed after the cover screws was removed [Figure 9]. Patient was recalled after 2 weeks for abutment placement and impressions were taken [Figure 10]. The screw retained final prosthesis was fabricated.

The soft tissue and hard tissue were evaluated by clinical and radiographic parameters at the time of prosthesis placement, 1-month, 3 months, 6 months, 9 months and 12 months [Table 2] and [Figure 11],[Figure 12],[Figure 13],[Figure 14],[Figure 15],[Figure 16],[Figure 17],[Figure 18],[Figure 19],[Figure 20],[Figure 21],[Figure 22].
Figure 5: Exposure of the alveolar ridge at the surgical site

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Figure 6: Osteotomy site preparation with drills

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Figure 7: Implant placed

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Figure 8: Intra-oral periapical after a healing period of 4 months

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Figure 9: Gingival former placed

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Figure 10: Impressions taken after abutment placement

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Figure 11: Screw retained prosthesis placed

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Figure 12: Intra-oral periapical after prosthesis placement

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Figure 13: Follow-up after 1-month

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Figure 14: Intra-oral periapical after 1-month

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Figure 15: Follow-up after 3 months

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Figure 16: Intra-oral periapical after 3 months

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Figure 17: Follow-up after 6 months

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Figure 18: Intra-oral periapical after 6 months

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Figure 19: Follow-up after 9th month

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Figure 20: Intra-oral periapical after 9 months

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Figure 21: Follow-up after 12 months

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Figure 22: Intra-oral periapical after 12 months

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Table 2: Evaluation of hard and soft tissues by clinical and radiographic parameters

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   Discussion Top

The placement of implants is associated with a local inflammatory reaction in the narrow gap between the implant surface and the local host bone. This reaction is rather a sequence of events and any error in this sequence may be responsible for compromised bone. Premature loading may lead to fibrous tissue encapsulation instead of direct bone apposition. The necrotic bone at the implant bed border is not capable of load bearing and must be first replaced by woven bone followed by lamellar bone, which is the ideal bone for implant. [4],[17] Hence, delayed loading is important at the beginning of prosthetic procedures, especially in the less dense bone types.

The importance of supportive periodontal therapy (SPT) should be emphasized where clinical and radiographic parameters should be re-assessed at every follow-up visit to detect peri-implant problems as early as possible and to find adequate therapy to intercept the problems. [10] In addition, the SPT program permits monitoring and maintenance of periodontal stability, as this appears to be a key factor for the success of implant therapy. There has been a significant decrease in the incidence of peri-implantitis and implant loss due to the protective effect of preventive maintenance. [18],[19]

With delayed loading and consistent SPT, the present case report was successful according to Albrektsson's criteria. [13]

   Conclusion Top

Bone remodels in relationship to the forces upon it. The load given during delayed loading is introduced to the surrounding bone in a scientific and mathematically perfect fashion. This will then produce the most favorable bone and clinical situation for long-term implant success. Understanding the basis of clinical indices for evaluation allows these criteria to establish a health-disease implant quality scale related to implant therapy.

   References Top

Taylor RC, McGlumphy EA, Tatakis DN, Beck FM. Radiographic and clinical evaluation of single-tooth Biolok implants: A 5-year study. Int J Oral Maxillofac Implants 2004;19:849-54.  Back to cited text no. 1
Misch CE. Available bone and dental treatment plans. In: Misch CE, editor. Contemporary Implant Dentistry. St. Louis: Mosby; 1999. p. 178-99.  Back to cited text no. 2
Corso M, Sirota C, Fiorellini J, Rasool F, Szmukler-Moncler S, Weber HP. Clinical and radiographic evaluation of early loaded free-standing dental implants with various coatings in beagle dogs. J Prosthet Dent 1999;82:428-35.  Back to cited text no. 3
Brånemark PI, Hansson BO, Adell R, Breine U, Lindström J, Hallén O, et al. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl 1977;16:1-132.  Back to cited text no. 4
Cavallaro JS Jr. Implant survival and radiographic analysis of proximal bone levels surrounding a contemporary dental implant. Implant Dent 2011;20:146-56.  Back to cited text no. 5
Misch CE, Hoar J, Beck G, Hazen R, Misch CM. A bone quality-based implant system: A preliminary report of stage I and stage II. Implant Dent 1998;7:35-42.  Back to cited text no. 6
Mombelli A, van Oosten MA, Schurch E Jr, Land NP. The microbiota associated with successful or failing osseointegrated titanium implants. Oral Microbiol Immunol 1987;2:145-51.  Back to cited text no. 7
Mombelli A, Mericske-Stern R. Microbiological features of stable osseointegrated implants used as abutments for overdentures. Clin Oral Implants Res 1990;1:1-7.  Back to cited text no. 8
Mombelli A. Prevention and therapy of peri-implant infections. Proceedings of the 3 rd European workshop on Periodontology. Implant Dent 1999;1:281-98.  Back to cited text no. 9
Mombelli A, Lang NP. The diagnosis and treatment of peri-implantitis. Periodontal 2000 1998;17:63-76.  Back to cited text no. 10
Block ME. Color Atlas of Implant Surgery. 2 nd ed. Missouri: Mosby; 2007.  Back to cited text no. 11
Mombelli A, Lang NP. Clinical parameters for the evaluation of dental implants. Periodontol 2000 1994;4:81-6.  Back to cited text no. 12
Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: A review and proposed criteria of success. Int J Oral Maxillofac Implants 1986;1:11-25.  Back to cited text no. 13
Wennstrom J, Palmer R, editors. Consensus report session 3: Clinical trials. In: Karring T, Lindhe J, editors. Proceedings of the 3 rd European Workshop on Periodontology, Implant Dentistry. Berlin, Germany: Quintessence; 1999. p. 255-9.  Back to cited text no. 14
Canullo L, Cicchese P, Sisti A, Francischone CE Jr, Francischone CE, Vasconcelos LW. Multicenter, clinical retrospective analysis (4-6 year follow up) of P-I Branemark Philosophy dental implants. Implant News 2009;6:517-24.  Back to cited text no. 15
Adell R, Lekholm U, Rockler B, Brånemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387-416.  Back to cited text no. 16
Duyck J, Rønold HJ, Van Oosterwyck H, Naert I, Vander Sloten J, Ellingsen JE. The influence of static and dynamic loading on marginal bone reactions around osseointegrated implants: An animal experimental study. Clin Oral Implants Res 2001;12:207-18.  Back to cited text no. 17
Schou S, Holmstrup P, Worthington HV, Esposito M. Outcome of implant therapy in patients with previous tooth loss due to periodontitis. Clin Oral Implants Res 2006;17 Suppl 2:104-23.  Back to cited text no. 18
Costa FO, Takenaka-Martinez S, Cota LO, Ferreira SD, Silva GL, Costa JE. Peri-implant disease in subjects with and without preventive maintenance: A 5-year follow-up. J Clin Periodontol 2012;39:173-81.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22]

  [Table 1], [Table 2]


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