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Case Report

Increased Bone Quantity Around an Ailing Implant in Esthetic

Zone using Progressive Bone Loading: A Case Report
Safoura Ghodsi, Amirreza Hendi1
Dental Research Center, Dentistry Research Institute, Department of Prosthodontics, 1Department of Prosthodontics, School of Dentistry, Tehran University of
Medical Sciences, Tehran, Iran

Abstract
Introduction: Progressive loading protocol is a high-demanding procedure suggested to increase the quality of bone when the implant is
inserted in D3 or D4-typed bone. The purpose of this study was to present a case report regarding simultaneously progressive and immediately
loading implants in the anterior position of the maxilla. Case report: One patient whose implants in the anterior maxilla (in site of teeth #7,
#9, #11) had questionable to poor prognosis who was treated immediate and delayed progressive loading protocol and was followed up for 2
years. Discussion: Although the number of studies in this field is limited, it can be concluded that the progressive loading protocol can
predictably enhance the treatment success in immediate-loaded implants with poor prognosis and when inserted in low quality bone such as the
present case.

Keywords: Dental implant, immediate loading, implant-supported, progressive loading

INTRODUCTION To increase the primary stability of the implant, which has

The success of dental implants depends on integration between
the implant and the surrounding hard and soft tissues.[1]
Mechanical stresses that have both positive and negative
consequences for bony tissue predominantly concentrate at
the crestal region of an osseointegrated implant.[2] The bone
at the alveolar crest is a high stress-bearing area, and
when overloaded, subjected to cervical cratering or
“saucerization.”[3] Initial breakdown of the implant–tissue
interface generally begins at this area (early bone loss), and
this phenomenon is a common prologue for the failure of an
implant.[4] Delayed implant loading (after 3 months in the
mandible and 6 months in the maxilla) was mainly based on
the belief that transfer of any micromotion to the implant
surface during the healing period would result in fibrous
encapsulation rather than osseointegration.[5] However, the
growing concern on patient esthetic demands questioned the
acceptability of delayed loading protocol for all patients and
attracted attention to immediate and early loading protocol,
especially in the esthetic zone.[2,5] Immediate loading is defined
as placing the implant in functional occlusion at the time of the
surgery or within 48 hours after placement.[6]
greater importance in the immediate loading protocol,
various clinical techniques have been suggested such
as the under-preparation of the implant site, use of
a nonoccluding temporary prosthesis during the first
2 months of healing, or progressive loading of the
implant.[7]
In 1980 Carl E. Misch introduced the concept of progressive
or gradual bone loading to use the advantages of controlled
loading to increase bone density and stability.[4] He declared
that load control plays a critical role in the success of
progressive loading protocol. This load-control concept
was based on the absence of cantilevers and controlling
the size of the occlusal table, direction and location of the
occlusal contacts, and diet to help the bone to adapt to the
increasing amounts of biomechanical stresses.[3] This
technique allows the bone to mature during the loading
period without overloading the implant, which may lead to
Address for Correspondence: Dr Amirreza Hendi, Department of
Prosthodontics, Tehran University of Medical Sciences, School of Dentistry,
Kargar Shomali, Hakim HWY, 14399591, Tehran Iran.
E-mail: Amirreza1990@ymail.com

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DOI: How to cite this article: Ghodsi S, Hendi A. Increased bone quantity
10.4103/denthyp.denthyp_25_17 around an ailing implant in esthetic zone using progressive bone loading:
A case report. Dent Hypotheses 2017;8:74-9.

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Ghodsi and Hendi: Progressive loading in esthetic zone
bone loss and implant failure.[8] The bone adapts to a certain
strain in the steady state. When the strain is gradually
increased, the bone becomes mildly overloaded and
compensates by increasing bone formation and density.[2]
Table 1 summarizes the available articles. The number of
articles on progressive loading protocol is limited, mainly
case reports, using this procedure in the posterior maxilla
(especially in premolar area), within dependent
restorations.[3,4,8] The limitation in the application of the
process goes back to the high-demanding nature of the
progressive loading protocol. However, literature suggests
that progressive bone loading could be a predictable
procedure for immediately-loaded implants in high-risk
situations such as augmented bone[8] or softer bone
types.[9] Furthermore, clinical studies have reported a
reduction in crestal bone loss[3,5] and an increase in bone
density[4,10] around progressively-loaded implants compared
with implants loaded in the conventional delayed manner. In
routine clinical practice, a clinician may encounter
questionable or high-risk situations where the safe margin
of treatment is seriously limited. In such a situation in implant
dentistry, if a pretreatment protocol could maintain or even
enhance the peri-implant bone (that is the main determinant of
treatment success), an unpredictable result could change to
success. Progressive loading protocol is reported to have such
a potential. This procedure concentrates the stress on crestal
portion of the surrounding bone,[11] however, in contrast to
conventional loading, the amount of this stress is precisely
controlled; and the gradually increasing load could be the
success key even in the esthetic zone.
This case report aims at demonstrating the bone quantity
increase using progressive bone loading around an ailing
implant in the anterior sextant of the maxilla.
Case Report
A 25-year-old woman was referred to the Department of
Prosthodontics of the Faculty of Dentistry, Tehran University
of medical science, Tehran, Iran. The patient was a
nonsmoker, nonbruxer, and had no history of systemic
diseases. Three implants (Implantium, Dentium, Seoul,
South Korea) had been inserted 4 months ago in the
anterior maxilla (one implant with 3.8 × 12 mm dimension
for tooth #7 and two implants with 3.4 × 12 mm dimension for
tooth #9 and #11), but one implant (in the #11 position) failed
Figure 1: (a) Intraoral view after second surgical phase. Note the immediate implantation in tooth #11 position. (b) Radiographic view demonstrated
bone loss around all 3 implants. Note the level of bone indicated by a red line
Dental Hypotheses ¦ Volume 8 ¦ Issue 3 ¦ July-September 2017
in osseointegration and was explanted in the second surgical
session. Applying a single-stage approach and immediate
implantation, a nonsubmerged implant (3.8 × 12 mm) had
been reinserted at the same position [Figure1]. The
insertion torque of the latter implant was 35 N-cm.
The surgeon in the referral form had clearly mentioned the
questionable prognosis of the implants due to bone resorption
around the inserted implants and the bone density, which was
claimed to be D4, according to clinical and radiographic
examinations. The patient had high esthetic demands, and
while discussing the treatment options, she strongly refused
delayed loading protocol and even temporary removable
prosthesis option. Therefore, due to the importance of bone
preservation in the esthetic zone, it was decided to progressively
increase the load on ailing implants to improve the response of
the bone. Consequently, the immediately placed implant (#11)
was exposed to immediate progressive bone loading and the
other implants sustained delayed progressive bone loading.
An open-tray impression of implants was taken on the same day
of the surgery using a vinyl-polysiloxane materia (A-silicones,
Kettenbach, Eschenburg, Germany). The final models were
mounted on a nonarcon semiadjustable articulator (Hanau
96H2, Whip Mix Corp, USA), and anterior wax-up was
performed to determine the prosthesis contour. The wax-up
was indexed in silicone to use for abutment preparation and
provisional restoration fabrication in the subsequent steps. The
final abutments (Combi abutment, Dentium, Seoul, South
Korea) were selected, secured on implant analogues in the
cast, and prepared for height, parallelism, and position within
the prosthesis wax-upped contours. A transitional acrylic
prosthesis was fabricated using temporary heat-cured acrylic
resin (Meliodent, Bayer Dental Co, Wasserburg, Germany) on
cast. The occlusion was adjusted following Misch[12] protocol
in a manner that the restoration was infraocclusion in the centric
and all eccentric positions. Within 24 hours, the abutments were
transferred to the patient’s mouth and torqued to 20 N-cm.
Temporary crowns were cemented with zinc oxide eugenol
cement (Temp-Bond, Kerr, West Collins, USA). During the
first month, the acrylic provisional crowns were completely out
of occlusion [Figure 2]. The free passing of 40-mm articulating
paper (Arti-Fol, Bousch, Köln, Germany) through the occlusal
contact in the maximum biting force was confirmed in all
mandibular positions. The patient was asked to use a soft
diet such as pasta, soup, and fish during this period.
75
76
Table 1: Studies on progressive loading protocol
Reference Study type Patient Smallest Implant Follow-up Type of splinted Loading Type of Results
no. temporary protocol restoration
material
[9]
Mangano FG, et al. Case Report 1 4.1 × 12 1 3 months Acrylic resin No Progressive Cemented The placement of an early-progressive-loaded,
loading Morse taper implant in the grafted site is
acceptable
from clinical and esthetic point of views.
Al-Juboori MJ[8] Case Report 1 4.5 × 10 2 3 months Compositeresin No Immediate Screw type Progressive implant loading is a predictable
loading/ procedure for immediately loaded implants
progressive placed in the soft bone types.
loading
Appleton RS, et al.[3] Randomized 20 Not 20 6 months Acrylic resin No Progressive Screw type The peri-implant bone around progressively
Controlled mentioned loading/ loaded implants demonstrates less crestal bone
Trial Study delayed loss than the bone around implants placed
loading conventionally into full function.
[4]
Ghoveizi R, et al. Randomized 10 4.5 × 11 20 8 months Acrylic resin No Progressive Not Bone density around progressively loaded
Controlled loading/ mentioned implants increased in crestal, middle and
Trial Study delayed apical portions of surrounding bone.
loading
[5]
Elsaih E.A, et al. Prospective 24 3.6 × 13 48 3 months Acrylic resin No Early Complete Early progressive loading procedure permits
Clinical Progressive preservation of more alveolar bone around dental
study loading/ implants in mandibular overdenture
delayed / Survival rate: 100%
loading
Turner PS, et al.[10] Prospectiv 15 3.5 × 8 25 45 days Composite No Early Not Progressive bone loading improves rigidity
Progressive of the bone in good bone quality.
loading/
delayed
loading
[11]
Mahaseth P, et al. Finite 18 4.2 × 10 18 10 weeks Acrylic resin No Immediate Not For progressively loaded implants the highest
Ghodsi and Hendi: Progressive loading in esthetic zone

Element loading/ mentioned stresses are concentrated in the cortical bone for
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Study progressive both D2 and D3 types of bone densities.

loading

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Ghodsi and Hendi: Progressive loading in esthetic zone

The occlusion and soft diet consumption were reevaluated and
reemphasized during follow-up visits every 10 days. After 4
weeks, the occlusion of the restoration was adjusted and
brought into light centric contacts by adding acrylic resin on
the occlusal centric contact areas [Figure 3]. This was
confirmed using a 40-mm articulating paper. The occlusal
contacts of the restorations were eliminated during excursive
movements and the diet remained soft. Two sessions with 4
weeks’ interval were arranged for the patient in which occlusal
contacts, home care, and diet were reevaluated, and fiber
containing foods were added to the diet. After 2 months,
mutually protected occlusion was considered for excursive
movements by adding acrylic resin to the restoration
[Figure 4], and patient’s diet was returned to normal and raw
vegetables and hard foods were added. One month later, the
radiographic examination showed increasing bone height
around implants, and the situation was ready for fabrication
of final restoration. The transitional prosthesis was removed,
abutments were torqued to 35 N-cm, and final impression
of the abutments was taken applying vinyl siloxane
impression material in the conventional impression
technique. Metal ceramic restoration was fabricated in full
centric occlusal contact, and mutually protected occlusion
was considered for excursive movements. The occlusion
was adjusted using 12-mm articulating paper (Arti-Fol,
Bousch Co, Köln, Germany). The restoration was evaluated
clinically and radiographically, and cemented with
temporary cement (Temp-Bond, Kerr, West Collins, USA).
The prosthetic restoration provided good aesthetic results and
the patient’s smile esthetics was highly improved [Figure 5].
The first follow-up visit was scheduled for 4 weeks later.
The patient was followed up every 3 to 4 months for 2
years. She was satisfied by the esthetic and functional
results and the radiograph showed good bone-implant
integration and increased bone height around all 3 implants
[Figure 6].

Figure 2: Temporary restoration placed completely out of centric or Figure 3: Temporary restoration placed in 40 m occlusal contacts in
eccentric occlusal contact. centric relation, eccentric contacts were eliminated

Figure 4: Temporary crowns placed in full occlusal contacts in centric

and eccentric relations Figure 5: Final restoration

Figure 6: (a) Radiographic view after 2 years. The level of bone is indicated by a blue line. (b) Superimposition of baseline and follow-up radiographic
views. Compare the level of crestal bone in the primary (red) radiograph with the last (blue) radiograph after 2 years

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Ghodsi and Hendi: Progressive loading in esthetic zone
DISCUSSION
Immediate and early loading procedures provide benefits
including reduced surgical steps by eliminating the second
procedure, shortened treatment time, and providing a
functional and psychological advantage of early prosthetic
rehabilitation. However, the stability of the implant during
accelerated loading procedures is not as predictable as
delayed loading after implant osseointegration. Progressive
loading protocol was introduced to increase the predictability
of immediately-loaded implant treatment.
Progressive loading controls the level of stress transmitted
to the susceptible crestal bone. The applied load matches
and progresses more closely with the load-bearing capacity
of the maturing bone. A study by Appleton[3] compared two
groups of patients with different loading protocols. The
peri-implant bone around progressively-loaded implants
demonstrated less crestal bone loss compared to
delayed-loaded implants. Progressive loading procedure
has been recommended for implants placed in softer
bone types. A study by Misch[12] revealed that the
poorer the bone density (D3 and D4), the more dramatic
is the decrease in Periotest values using progressive loading
protocol. Periotest values relate to mobility and density of
bone around the implant.
This case report presented a unique situation. One
immediately progressively-loaded implant and two ailing
implants with questionable prognosis and crestal bone loss
up to their 5th thread that underwent delayed progressive-
loading presented a high-risk situation in the anterior esthetic
zone of the maxillary arch. A distinction has been made
between irreversible failing implants and ailing implants.[13]
Ailing implant has been described in the literature as an
implant that has not failed but needs some form of treatment
modality to prevent failure and explantation.[14] On the other
hand, anterior maxilla has compromised bone density and
sustained an increased angulation of occlusal loads.[6,12]
These situations put the implants at a high risk of failure.
In the presented case, the surgeon reported D4 density in the
peri-implant bone, and the patient demanded immediate
restorative rehabilitation. However, the risk of failure with
immediate loading is extremely high in the anterior maxillary
area; progressive bone loading could enhance the prognosis
of ailing implants and provide a more predictable option for
high-risk situations.[3-5,8,9] Splinting the progressively-loaded
implants could increase the success rate and improve the
results when other situations compromised the treatment
results.[2,8]
The 2-year follow-up of the presented case confirmed that
immediate progressive loading could immediately fulfill the
esthetic and phonetic requirement, as well as increase the
success potential in ailing implants. According to the
primary compromised condition of the present case and
considering the limited cases in available literature, it seems
rational to consider the progressive loading protocol as a
potentially rescue treatment modality. However, further
78
clinical studies are recommended for documentation of the
results obtained in case-based reports.
CONCLUSION
Considering the limitation in the present article, following
conclusions could be obtained:
(1) The number of available articles in the field
of progressive bone loading is limited, which
could be because of the time-consuming procedure
and the necessity of patient cooperation.
(2) The available articles clearly report that progressive
bone loading protocol could increase the success rate in
compromised situations, increasing surrounding bone
density and volume.
(3) This case report showed that progressive bone loading
with gradual increase in occlusal contact intensity
could improve bone-implant contact in compromised
situations.
Financial support and sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
REFERENCES
1. Oh TJ, Yoon J, Misch CE, Wang HL. The causes of early
implant bone loss: Myth or science. J Periodontol 2002;73:
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2. Isidor F. Influence of forces on peri-implant bone. Clin Oral Implants
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3. Appleton RS, Nummikoski PV, Pigno MA, Cronin RJ, Chung KH,
Cronin XX, Kwok-Hung Chung. A radiographic assessment of
progressive loading on bone around single osseointegrated implants
in the posterior maxilla. Clin Oral Implants Res 2005;16:161-7.
4. Ghoveizi R, Alikhasi M, Siadat MR, Siadat H, Sorouri M. A
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10. Turner PS, Nentwig GH. Evaluation of the value of bone training
(progressive bone loading) by using the Periotest: A clinical study.
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Ghodsi and Hendi: Progressive loading in esthetic zone

11. Mahaseth P, Shetty S, Satish Babu CL, Pitti V, Anand D, Lakhanpal S,
et al. Peri-implant stress Analysis of immediate loading and
progressive loading implants in different bone densities (D2
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12. Misch CE. Progressive bone loading. In: Misch CE, editor. Dental
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13. Poli PP, Cicci ÃM, Beretta M, Maiorana C. Peri-implant mucositis and
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14. Tabanella G, Nowzari H, Slots J. Clinical and microbiological
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