What are the advantages and disadvantages of immediate loading?

How would
you ensure the success of immediately loaded implants?

Objectives:

1. To identify and discuss advantages of immediate loading over early and delayed
loading

2. To Identify and discuss disadvantages of immediate loading over early and

delayed loading

3. To identify and discuss success/failure rate of immediate loading

4. To identify the ways to ensure success of immediately loaded implants

Introduction:

The science of placing implants after the tooth extraction is decades old now; it was
introduced in 1969 by branemark (2). This technique has been a turning point in the
modern dental history. The more exciting and new addition to these restorative
techniques were marked by introduction of early and immediate loading of implants.
The healing of the implants loaded is based on the process of osseointegration;
which establishes a bonding between implanted body and the alveolar bones. As
initially given by branemark, dental implants placement involved two steps/stages;
this is called as conventional or delayed loading technique. The basic purpose of two
stages of surgical process included avoiding of complications and failures which may
be associated with immediate loading as the bone resorption occurs in the first 3 to 6
months, post extraction. The first stage is marked by placing and positioning of ridge
preservation material which may be tissue or bone grafts without loading underneath
the crestal bone in the jaw and maintaining the same for atleast 3 to 6 months. This
is done for healing purposes and to reduce the naturally occurring alveolar bone
resorption process (1). The second stage included uncovering of the ridge and
placement of prosthetic abutment. Hence, the process was unavoidably lengthy in all
the cases irrespective of system and design of implants; mandible implants required
3 months while maxilla required 6 months. While, the purpose of long term treatment
was clear but it came with handful of drawbacks. The drawbacks included
discomfort, anxiety, aesthetic issues, social and psychological resentment in the
patients. In order to tackle these issues, the concept of immediate loading post tooth
extraction came into picture. This process involves loading of the implants within the
72 hours of the tooth extraction. Undoubtedly, the technique saves time,
inconvenience, social and psychological embarrassment suffered by the patient. The
third technique involves loading within the two weeks post tooth extraction and is
called early loading (2). The basic purpose this review is to analyze the advantages
and disadvantages of immediate loading of implant in comparison to delayed implant
loading. In addition to this, success/failure rate of immediately loaded implants will be
analysed and discussed along with the factors which will ensure success of
immediate loaded implants.

Eligibility criteria:

The present study was conducted to analyse the advantages, disadvantages and
success rate of immediate loading. To obtain better search outcomes the use of
Boolean operators, truncation, and wildcards were made. To effectively navigate the
search outcomes PICO criteria was utilised in this study. The below table suggests
the framework in the PICO criteria:

Participants Interventions Comparison Outcome

30 to 80 years of Immediately Early and  Advantages and
age (No loaded implants delayed loaded disadvantages of Immediately
restriction was implants loaded implants
applied on  Success and Failure rate
gender) of Immediately
loaded implants
 Strategies to ensure
success of Immediately
loaded implants
 Complications occurred
after implantation
Advantages and Disadvantages of Immediately Loaded Implants

In 2011, a study was conducted by Felice and colleagues which included two sets of
patients being treated at three centres; one set (n=54) included patients who were
subjected to immediate loading process while the second set (n=52) included
patients were treated in the conventional/delayed implant loading way. The outcome
measures that were evaluated included failure of the implants placed,
biomechanical/biological complications (fracture and loosening of provisional crown
and abutment screws), aesthetic aspects of implants and most importantly patient
satisfaction. The results depicted failure of implants in two patients of immediate
group contrary to no failure reported in delayed implant group though this failure rate
was not statistically significant at P = 0.50. In addition to this, eight complications (n=
4; suffered provisional crown fracture, n=2; provisional crown loosening, n=1;
discomfort, n=1; postoperative pain) were reported by patients of immediate group in
contrast to one complication observed in delayed group; this was statistically
significant at P = 0.032. The aesthetic aspects and patient satisfaction was similar in
both the groups. It can be said that immediate loading is associated with greater
failure and complication risk at the same time the technique offers advantage of
shorter treatment span and early rehabilitation. Though the study is not free of
limitations which include deviation from initial protocol, shorter timeline and small
sample size which may have contributed to bias but on the other hand study meets
the general applicability requirements as was conducted in general population in real
clinical settings (1).

Ensuring Success of Immediately Loaded Implants

In another study conducted by Cannizzaro and colleagues in 2012, the optimum

torque (medium; 25 to 35 Ncm or high; >80 Ncm) required for immediate loading of
implants was evaluated. The study was single centric and included 50 patients (with
2 single non-adjacent implant sites) who were presented with provisional abutments
initially which were replaced by permanent crowns after 6 weeks. A follow up tenure
of 6 months was included. The results were in favour of employing high torque >80
Ncm for immediate loading as out of 50, 7 patients came up with implant failure. All
of failure cases belonged to medium range of torque (25 to 35 Ncm). Three patients
from high torque implants came up with complications compared to one complication
observed in medium range group (not statistically significant). Also, the instances of
pain were more in medium range, both after 1 and 6 weeks though not statistically
significant. It can be said from results of this study that high torque value is
associated with high success rate of immediate implant loading. Nevertheless, the
limitations of this study being unicentric, shorter follow up time post surgery and
small sample size cannot be sidelined. Also, the applicability risk is high because of
this study being conducted at single centre (3).

Similarly, the success rate of immediate loading was assessed in 2 versus 4

implants loaded in patients who were completely edentulous. The study was followed
upto 1 year post surgery. A total of 60 patients (n=30) in both the groups. The
outcomes were weighed in terms of failed implant and prosthesis, marginal bone
changes and complications. The results interpreted equal number of complication
(n=8) in both groups which could be due to misfit of implants or biomechanical
tension. The study concluded in suggesting 2 implants in completely edentulous
patients rather than 4. The risk of bias in this study are plenty; they did not report
outcomes clearly with solid reason to support their conclusion, small sample size,
use of different implant systems and procedures at both the centres, longer follow
up with patients is required. Similarly, applicability bias can also not be ruled out as
the study was carried out be extremely experienced professionals with flapless
surgery though the study included more real patient and clinic conditions (4).
References:

1. Felice P e. Immediate non-occlusal loading of immediate post-extractive versus

delayed placement of single implants in preserved sockets of the anterior maxill... -
PubMed - NCBI [Internet]. Ncbi.nlm.nih.gov. 2019 [cited 6 October 2019]. Available
from: https://www.ncbi.nlm.nih.gov/pubmed/26669546

2. Esposito M, Grusovin M, Maghaireh H, Worthington H. Interventions for replacing

missing teeth: different times for loading dental implants. Cochrane Database of
Systematic Reviews. 2013.

3. Cannizzaro G, Felice P, Leone M, Ferri V, Viola P, Esposito M. Immediate loading

of single implants placed flapless with medium or high insertion torque: a six-month

follow-up of a split-mouth randomised controlled trial. Eur J Oral Implantol

2012;5(4):333-342.

4. Cannizzaro G, Felice P, Soardi E, Ferri V, Leone M, Viola P, Lazzarini M, Audino

S,Esposito M. Immediate loading of 2 (all-on-2) versus 4 (all-on-4) implants placed
with a flapless technique supporting mandibular cross-arch fixed prostheses: 1-year
results from a pilot randomised controlled trial. Eur J Oral Implantol 2013;6(2):121-
131.