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Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 52-57

Maxillary immediate implant loading: A comprehensive review

Department of Prosthodontics, SDM College of Dental Sciences, Dharwad, India

Date of Web Publication10-May-2013

Correspondence Address:
Sagar J Abichandani
Ashiyana, 105-B, 1st Floor, Sindhi Society, Chembur, Mumbai - 400 071
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-6781.111697

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The tremendous success of osseointegration and predictability of implant treatment modality in the mandible prompted its investigations in the maxillary segment too for verifying whether similar success rates can be achieved. This review of literature gives us an idea about the various treatment modalities and investigations carried out by various researchers as an attempt to find out the predictability and longevity of immediate implant loading in the maxilla. The basic nomenclature, advantages and disadvantages of immediate loading, immediate loading and its relationship to osseointegration, its influence on primary stability, and micro-motion are considered and discussed. Over-emphasis has been placed on prosthodontically driven implant modality keeping the end-result and final outcome in mind. Few guidelines have been proposed that would help in the successful implementation of implant restorations.

Keywords: Immediate implants, implant loading, immediate provisionalization, immediate restorations

How to cite this article:
Abichandani SJ, Nadiger R. Maxillary immediate implant loading: A comprehensive review. J Dent Implant 2013;3:52-7

How to cite this URL:
Abichandani SJ, Nadiger R. Maxillary immediate implant loading: A comprehensive review. J Dent Implant [serial online] 2013 [cited 2021 Sep 25];3:52-7. Available from:

   Introduction Top

Implants have revolutionized the art and science of modern dentistry giving a new lease of life to the restorative aspects in day-to-day practice. It has transformed into a reliable and predictable treatment modality for fully and partially edentulous arches. [1],[2],[3],[4],[5],[6] According to Branemark, there should be a period of at least 4-6 months before any restoration can be planned. [7] Conventional loading [8] is a predictable and an accepted treatment modality that has been used as a benchmark to compare other implant loading protocols. [9] However, efforts have been made by various clinicians to find whether there is any possibility to shorten the treatment time of implant supported restorations or by the placement into the extraction sockets immediately post-extraction. [2],[3],[10],[11],[12],[13]

   Nomenclature Top

Cochran et al. [8] carried out an exhaustive review of the literature on implants and published their recommendations giving the following terms: (1) Immediate restoration (immediate provisionalization) - Restoration is delivered within 48 h of implant placement but not in occlusion. (2) Immediate loading - Implant supported restoration is placed within 48 h of implant placement and is in occlusion. (3) Early loading - Implant is restored with a fully functional restoration (in occlusion) at the second procedure between 48 h and 3 months from the time of implant placement. (4) Conventional loading - The restoration is attached to the implant in the second procedure 3-6 months after the implant surgery. (5) Delayed loading - An implant supported restoration is placed over the implant after a time period more than 6 months.

   Advantages of Immediate Loading Top

  • Reduction in alveolar ridge resorption and overall treatment time. [2],[14]
  • Offers an acceptable restoration esthetically. [4],[10],[15],[16],[17]
  • Increased patie acceptance. [2],[4],[15],[16],[18]
  • Quicker return of function. [4],[14],[15],[17]
  • Removable prosthesis is avoided that may interfere with healing or simultaneous bone grafting and/or may require additional maintenance during the healing period. [2],[4],[17]
  • Potentially superior soft tissue profile when accompanying immediate dental implant placement. [12],[14],[18],[19]
  • Reduced surgical trauma and ease of surgery. [14],[20],[21]
Qualitative and quantitative factors that guide treatment planning of immediately loaded implants

  • Bone quality and quantity should be appropriate
  • The rate of bone formation in a given region of the jaw should be considered
  • If required, extractions should be atraumatic
  • Initial implant stability (torque at the time of placement) at the time of crucial surgery
  • Implant positioning should be prosthodontically driven
  • All forms of parafunctional habits should be avoided
  • Cautions should be taken in patients with specific and recent (within 2 years) systemic conditions (radiotherapy), excessive chronic smokers or alcohol users, and those with uncontrolled systemic conditions (e.g. poorly controlled diabetes)
  • Implants should not be placed into extraction sockets if they are currently infected
  • Balanced occlusion against natural teeth or prosthesis should be ensured
  • A minimum of 32 N-cm of torque should be used at the time of implant placement (although protocols suggest torque as low as 25 N-cm)
  • The implant system should be conducive to high primary stability/initial torque
  • Splinting of implants (and cross-arch stabilization) should be performed when possible
  • Prosthodontic rehabilitation should be balanced and passively fitting; if possible, a non-functional occlusal scheme should be implemented
  • Rough-surfaced rather than smooth-surfaced implants should be used

   Immediate Loading: Site Specificity Top

Immediate loading has shown excellent longevity and is a reliable treatment option for edentulous mandible. Chiapasco [3] described the overall survivability of immediate loaded overdentures as 98% and of fixed partial dentures as 95%. These studies included implants placed both interforaminally and more posteriorly in the mandible. This stupendous success in maxillary setting sought the application of similar treatment in the maxilla. Tarnow et al. [6] demonstrated that immediate loading in the maxilla was possible when they reported 100% survival of immediately loaded implants restored with a full-arch fixed prosthesis. However, because of the poorer bone density, there is a more limited degree of success in the maxilla vs the mandible. [2],[21] Lekholm and Zarb [22] described maxillary bone as more trabecular and softer in nature (also known as type 3 or type 4), whereas mandibular bone is more cancellous and denser (type 1 or type 2) which results in lower primary stability, greater micro-motion, and a greater likelihood of fibrous healing and failure of implants to osseointegrate in the maxilla when implants are immediately loaded. [21],[23],[24],[25],[26]

   Primary Stability Top

Primary stability has been classified as a crucial factor that determines implant success in immediately loaded implants. [27] First proposed in 1974 by Cameron et al. [28] and later confirmed by Szmukler-Moncler, [29] the goal of primary stability is the limitation of excessive micro-movement. Micro-movement can be influenced by the implant-bone relationship and by prosthodontic design. This is of utmost importance in the maxilla, where the quality is typically less favorable. Excess of micro-movement results in fibrous healing instead of osseointegration. [4],[23],[24],[25],[30],[31] Insertion torque, cited as an indicator of primary stability [2] and as a non-linear, indirect indicator of micro-movement of an implant in bone. [24]

   Bone Quality Top

Primary stability is also affected by the quality and quantity of bone. Because of factors such as lesser bone density, a thin cortical plate, and proximity to the maxillary sinus, maxillary immediate implant placement can be quite challenging. [2],[21] Bone preservation by atraumatic extraction can be a determinant of successful osseointegration of immediately loaded maxillary implants. [32] Radiographic investigations (such as cone beam computer tomography [CT] scans) can help us evaluate the quality and quantity of bone at the surgical site which aids in treatment planning. [31] Others have suggested using Hounsfield units as a means of assessing the bone density of sites where implants will be placed. [33],[34]

Micro-movement levels between 50 μm and 150 μm are known to cause no detriment to osseointegration [2],[4],[14],[24] even though early reports indicated that osseointegration could succeed with micro-movements up to 500 μm. [35] Consistent with these limits, recent recommendations indicate that torque values at the time of placement should be greater than 32 N-cm. [31],[36] but what is seen is that these ranges of torque values are non-detrimental to soft maxillary bone even though they permit primary stability. At the histological level, collagen fiber formation occurs in a transverse manner with secondary osteon formation rather than parallel orientation with large marrow spaces. This histoanatomic difference is more favorable to resist the mechanical stresses of function following healing. [37] Others have stated that a minimum of 3-5 mm of vertical bone-to-implant contact should be attained to provide adequate primary stability to facilitate favorable osseointegration which is extremely critical for immediate implantation in a fresh extraction socket.

Quantity of bone volume that is available to receive implant is also affected by the timing of implant placement. Within the first 3-12 months of tooth extraction, up to 50% loss of bone width [13],[38],[39],[40] and 1.3-4.0 mm loss of bone weight may occur. Factors like whether site is of a single tooth or of multiple teeth notably affect the rate of bone resorption. [13],[39],[40],[41] When bone levels are examined, it is seen that immediate placement of implants has been used to preserve crestal bone [10],[12],[21],[30] and has been shown to produce similar or better results than delayed implant placement. Two major observations associated with immediate implant placement in fresh extraction sockets followed by immediate loading (preferably non-functional) are: [21],[42],[43],[44],[45],[46] (1) the esthetic outcome seems to be equal, if not superior, to the conventional approach and (2) similar survival rates with conventional loading can be achieved at single implant sites when rough-surfaced implants, achieving high torque values, are placed by experienced clinicians.

   Immediate Implantation Top

Drilling temperatures greater than 47°C for longer than 1 minute have been shown to cause bone necrosis. Therefore, it is desirable to have immediate implant placement as the recipient site is already partially prepared. [38] Canullo et al. [15] reported that extension of bone remodeling was less extensive in cases of immediate placement (1.7 mm) than with delayed placement (3.0 mm). Despite this limit in the healing zone, it has been shown that bone can fill osseous defects around implants if they are three-walled in nature [13] and <1.5-2.0 mm wide. [12],[13],[30] Autogenous bone grafts have been shown to be more osteogenic when used in conjunction with immediately placed implants. [38] However, disadvantages may include risk of failure due to residual periosteal infection, [47] unpredictable site morphology, [12] and a potentially limited amount of soft tissue. [12]

Guidelines recommended if immediate implant placement and/or loading is to be considered

  1. Excellent primary stability/initial torque of placement
  2. Rigid splinting preferred over lone-standing adjacent implants
  3. Adequate keratinized tissue
  4. Use of a surgical guide
  5. Use of a cone beam computed tomography scan technology
  6. Prosthodontically driven implant placement
  7. Absence of residual infection at the placement site by removal of all contaminated tissue

   Prosthodontically Dictated Implant Dentistry Top

This principle promotes a reduction in implant micro-movement through appropriately positioned and loaded restorations. Axial implant loading is a desirable treatment goal because lateral forces greater than 30 N cm have been shown to produce micro-motions greater than 100 μm. Non-axial loading can also contribute to loosening of abutment screws which is a major cause of prosthodontic failure. Nordin et al. described that a high precision and passively fitting prosthesis reduced stresses and strains that could be detrimental to a healing implant. Some researchers have implemented splinting and cross-arch stabilization on implants that are not loaded along their long axis. In an effort to avoid maxillary sinus, Tealdo et al. placed distal implants in an angulated manner. This technique has shown bone loss around the distal implants that is similar to that seen with more conventionally placed implants. Others have demonstrated 100% survivability using a similar concept called V-II-V, whereby six implants are placed into the maxilla at 30-45° angulations to the occlusal plane in the posterior maxilla to avoid the maxillary sinus. Lengths and diameters of immediately loaded maxillary implants as given in [Table 1].
Table 1: Lengths and diameters of immediately loaded maxillary implants

Click here to view

   Conclusion Top

Current reports [Table 2] suggest that survival of implants has increased following careful surgical protocols and its optimum implementation along with optimum restorative protocols with respect to designing and maintenance, periodic check-up, and recall in addition to maintenance of a good oral hygiene. It is possible to simulate the long-term success rates of mandible even in the maxilla following the necessary guidelines.
Table 2: Survival rates of immediately loaded rough-surfaced implants in the maxill

Click here to view

   References Top

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2.Wang HL, Boyapati L. "PASS" principles for predictable bone regeneration. Implant Dent 2006;15:8-17.  Back to cited text no. 2
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  [Table 1], [Table 2]

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[Pubmed] | [DOI]


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