Questioning Traditional Implant Loading Protocol
Why do we wait to load an implant? Does it really get better with time? The traditional approach, established by Dr. Branemark and Dr. Albrektsson, recommends waiting three to six months before loading an implant, based on the belief that the necrotic bone around the implant needs time to become vital again. However, this guideline has been followed without much question or further research.
We should ask ourselves why we can’t provide patients with a new tooth sooner. Most implant companies recommend placing the healing abutment and leaving the implant undisturbed for 2 to 4 weeks to ensure stable healing. This indicates potential issues with implant stability during this period. It’s time to challenge these long-held beliefs, explore the possibilities of immediate or early loading, and address the reasons behind necrotic bone development to enhance patient satisfaction and treatment outcomes.
Implant Stability Dip: Critical Week 1 to Week 8
The classic stability dip graph was developed from data starting with the research of Dr. Albrektsson and Dr. Branemark. Implant companies followed these guidelines by either loading implants immediately and splinting them or waiting for secondary bone growth over several months. Notably, they never loaded implants between week 1 and week 8.
Why does the stability dip happen between week 1 and week 8? Is that possible to eliminate the stability dip or any osseointegration failure?
Shifts in the Classic Stability Dip Graph
Straumann attempted to move the secondary stability line by adding the SLA surface treatment. This change marks the only major shift since Dr. Branemark and Dr. Albrektsson’s work in the 1970s.
Standard Loading Period for Dental Implants
Immediate Loading: Prosthesis loaded within 1 week after implant placement.
Early Loading: Prosthesis loaded between 1 week and 8 week after implant placement.
Conventional Loading: Prosthesis loaded between month 2 and month 6 after implant placement.
Insights from Meta-Analysis by ITI
In 2008, ITI, an independent partner of Straumann, conducted a consensus study involving 796 implants from various companies. The implants were placed in fully healed post-extraction sites. Implant length was limited to 8-11mm, and immediately placed provisional prosthesis were either in full occlusion or light occlusion with no excursive contacts.
Alexander, S. et al. (2014). Implant Loading Protocols for Partially Edentulous Patients with Extended Edentulous Sites— A Systematic Review and Meta-Analysis. JOMI
Key findings:
Nine studies required an insertion torque of at least 30N/cm.
One study found 20N/cm torque sufficient if implants were splinted.
Minimum ISQ values for immediate loading ranged between 50 and 62.
Immediate loading of 285 implants and early loading of another 272 implants both showed a 98% success rate in comparative studies(IL vs EL).
Non-comparative Studies Results:
Early Loading Group: One failure in 205 implants after osseointegration, a 99.5% success rate.
Immediate Loading Group: 15 failures in 685 implants placed within 48 hours, a 97.8% success rate.
Even among studies categorized under early loading, the majority of implants were loaded after 6 weeks. This cautious approach aims to mitigate the risks associated with the stability dip, a phenomenon where the implant’s stability temporarily decreases during the early phases of healing. And only one study loaded 161 implants between 28 and 34 days post-op using the SLA active surface. This only one study pushed the boundaries with the new SLA active surface at the sensitive part of the stability dip.
Alexander, S. et al. (2014). Implant Loading Protocols for Partially Edentulous Patients with Extended Edentulous Sites— A Systematic Review and Meta-Analysis. JOMI
Straumann did not load implants between week 1 and week 6 with their new SLA active surface coating, despite having data suggesting it could be a viable option. The reasons for this include tradition and a reluctance to deviate from established loading protocols.
Dr. Youngku Heo's No Stability Dip Theory
In 2013, Dr. Youngku Heo proposed the ‘No Stability Dip’ theory. The stability dip, a common issue where implant stability decreases shortly after placement, might be eliminated by minimizing old bone resorption while new bone forms simultaneously. This approach can potentially maintain or even increase overall implant stability.
To address this, Dr. Heo and his GAO colleagues have been developing a drilling and placement protocol since 2007, specifically using CMI IS-II & IS-III implants. Their research emphasizes that while implant design is crucial, the techniques used for drilling and placement are equally important. By refining these methods, they aim to minimize the stability dip and enhance the overall success of dental implants.
Neobiotech's AnyTime Loading Concept
Neobiotech has introduced an innovative concept called “AnyTime Loading,” which redefines traditional implant loading timelines. This flexible protocol aims to accommodate the unique healing and stability needs of each patient, enhancing the overall success and satisfaction with dental implants.
Neobiotech proposes the following AnyTime Loading guidelines:
Immediate Loading: Prosthesis loaded anytime within the first week after implant placement.
Early Loading: Prosthesis loaded between week 1 and week 12 after implant placement.
Conventional Loading: Prosthesis loaded between month 3 and month 6 after implant placement.
With Neobiotech’s advanced CMI implants and protocol, it is possible to perform anytime loading without encountering the traditional stability dip period. This new IL/EL standard eliminates the restricted loading phases, allowing for a seamless and more efficient implant process. This approach not only sets a new benchmark in implant dentistry but also ensures that patients receive their implants and crowns promptly, securely, and with minimal disruption.
Retrospective Clinical Study on AnyTime Loading: Validating Neobiotech’s Theory
In 2013, a retrospective clinical study was conducted on AnyTime Loading, focusing on partially edentulous posterior jaws. The study involved 290 CMI implants from Neobiotech, placed in 105 patients across two clinics. The patients were divided into four groups based on when they received their provisional prostheses: 1-2 weeks, 2-4 weeks, 4-6 weeks, and 6-8 weeks post-implantation. Periapical radiographs were taken using a parallel imaging technique to evaluate marginal bone levels at the time of surgery, and after 3, 6, 12, and 24 months of loading.
Key Findings
Success Rate: Early loading with CMI implants showed a remarkable success rate of 97% over two years.
Bone Loss: Marginal bone loss was consistent across different loading times (2 weeks, 4 weeks, 6 weeks, and 8 weeks), with an average bone loss of only 0.3mm after two years. There was no significant difference in bone loss between the maxilla and mandible.
Long-term Results: Even after 8 years, marginal bone loss around CMI implants was minimal, indicating long-term stability and success.
Conclusion
The study concludes that implants can be successfully loaded between 1 and 8 weeks if specific criteria are met. Using Neobiotech CMI implants and following the prescribed protocol ensures high success rates and minimal bone loss, regardless of the loading time.
Summary & Next Step
In this blog post, we questioned traditional implant loading times and explored the potential of immediate and early loading. The ITI meta-analysis revealed high success rates for both immediate and early loading protocols. However, there were very few studies where early loading was performed between 1 and 6 weeks because of stability dip.
We introduced Dr. Heo’s ‘No Stability Dip’ theory, which aims to minimize implant stability loss during healing, and discussed Neobiotech’s unique concept that allows AnyTime Loading through specific implant designs and protocols.
By challenging long-held beliefs and embracing innovative methods, we can continue to advance the field of dental implantology, providing faster and more predictable results for our patients.
In the next post, we will delve deeper into optimal bone-implant contact(BIC) and stability, ensuring successful implant outcomes and fulfilling the conditions necessary for AnyTime Loading. We will also discuss in detail the protocols and CMI fixation that ensure high success rates and minimal bone loss, regardless of loading time.