|Year : 2015 | Volume
| Issue : 1 | Page : 69-75
Delayed loading and peri-implant evaluation of dental implants: Keys to higher success in lesser dense bone
Shivanand Aspalli, M Prebha, Nagappa Guttiganur, Reetika Gaddale
Department of Periodontics and Oral Implantology, A.M.E's Dental College and Hospital, Raichur, Karnataka, India
|Date of Web Publication||2-Apr-2015|
Department of Periodontics and Oral Implantology, A.M.E's Dental College and Hospital, Raichur - 584 103, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
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 2019 Sep 22];5:69-75. Available from: http://www.jdionline.org/text.asp?2015/5/1/69/154454
| Introduction|| |
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. 
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. ,, 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.  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. 
Clinical peri-implant evaluation
Periodontal indices like the clinical inspection for signs of inflammation, that is plaque assessment by Mombelli's modified plaque index, , 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. ,
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.  This is because epithelial attachment adheres weakly, some investigators would consider probing being invasive, allowing penetration of the probe close to the bony crest. 
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.  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].
Some amount of bone loss is reported every year. Using radiographic analysis, Albrektsson et al.  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  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. ,
| Case report|| |
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 4: (a) Computed tomography slice i.r.t 36. (b) Computed tomography slice i.r.t 36 (buccal view)|
Click here to view
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].
|Table 2: Evaluation of hard and soft tissues by clinical and radiographic parameters|
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| Discussion|| |
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. , 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.  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. ,
With delayed loading and consistent SPT, the present case report was successful according to Albrektsson's criteria. 
| Conclusion|| |
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.
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[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]