Indications for immediate loading ofimplants and implant success

Emeka NkenkeMatthias Fenner

Authors’ affiliations:Emeka Nkenke, Matthias Fenner, Department ofOral and Maxillofacial Surgery, University ofErlangen-Nuremberg, Erlangen, Germany

Correspondence to:PD Dr Dr Emeka NkenkeDepartment of Oral and Maxillofacial SurgeryUniversity of Erlangen-NurembergGlueckstr 1191054 ErlangenGermanyTel.: þ49 9131 8533653Fax: þ49 9131 8534219e-mail: emeka.nkenke@mkg.imed.uni-erlangen.de

Key words: dental implant, edentulism, immediate loading, level of evidence, oral implant,

osseointegration, partial edentulism, single-tooth implant

Abstract: It was the aim of this review to compare the survival and success rates of

immediately loaded dental implants with those of conventionally loaded dental implants,

based on prospective controlled studies and prospective studies without controls. Studies

on immediate loading were identified in the current literature by electronic and hand

searches. Only clinical data on root-form or cylindrical threaded oral implants were

included. For immediate loading of oral implants in the edentulous and partially dentate,

mandible and maxilla controlled studies could be found. All of these studies were based on

limited patient numbers. Therefore, definitive conclusions could not be drawn concerning

survival and success rates of immediately loaded implants compared with conventionally

loaded implants. The compilation of the current literature shows that prospective

controlled studies as well as prospective studies without controls using several different

approaches to immediate loading have demonstrated high implant survival and success

rates. However, more high-level evidence-based studies are needed to demonstrate the

relative merits of immediate loading compared with conventional loading in all potential

applications.

Immediate loading of oral implants has

been defined as a situation where the

superstructure is attached to the implants

no later than 72 h after surgery (Aparicio

et al. 2003; Cochran et al. 2004). The

definition of immediate loading also in-

cludes occlusion with the teeth of the

opposite jaw. Under these conditions, suc-

cessful immediate loading of screw-type

dental implants has been reported as early

as 1979 (Ledermann 1979).

Several experimental studies have shown

that immediate loading of threaded im-

plants does not necessarily lead to fibrous

tissue healing. Instead, a bone-to-implant

contact develops over time, which is com-

parable with that of implants that are

loaded conventionally (Romanos et al.

2001; Nkenke et al. 2003; Siar et al.

2003; Nkenke et al. 2005a, 2005b).

Implants retrieved from humans with

adjacent bone have confirmed these experi-

mental results both in the mandible and

maxilla. Bone-to-implant contact of up to

93% of the intra-bony part of the implant

has been found (Piattelli et al. 1997;

Ledermann et al. 1999; Rocci et al.

2003a), and osseointegration of immedi-

ately loaded implants observed even in

heavy smokers (Romanos & Johansson

2005).

Several different indications for immedi-

ate loading have been discussed. They

range from implant placement in the eden-

tulous mandible and maxilla to single-

tooth applications in extraction sockets.r 2006 The Authors

Journal compilation r Blackwell Munksgaard 2006

To cite this article:Nkenke E, Fenner M. Indications for immediate loadingof implants and implant success.Clin. Oral Imp. Res. 17 (Suppl. 2), 2006; 19–34

19

It was the aim of this review to compare

implant survival and success rates for im-

mediately loaded and conventionally

loaded oral implants, based on the highest

levels of evidence in the literature for the

different indications for these two clinical

approaches.

Material and methods

For the present review, ‘immediate loading’

was defined as a situation where the super-

structure is attached to the implants in

occlusion with the opposing dentition

within 72 h (Aparicio et al. 2003). ‘Con-

ventional loading’ describes a situation

where the prosthesis is attached to the

implants after an unloaded healing period

of at least 3 months in the mandible and 6

months in the maxilla, respectively. The

terms ‘non-functional immediate loading’

and ‘immediate restoration’ are used when

a prosthesis is fixed to the implants within

72 h without achieving full occlusal con-

tact with the opposing dentition.

At the beginning of the search of the

relevant literature for the review, it was

decided to include in the study only clin-

ical data on root-form or cylindrical

threaded oral implants. An additional se-

lection criterion was the observation per-

iod, which had to be at least 12 months

after implant placement. Different levels

available in the hierarchy of evidence were

collected: systematic reviews, randomized-

controlled trials, controlled trials and pro-

spective studies (Bluhm 2005; Table 1).

The studies had to comprise at least five

patients. Retrospective studies and case

reports were excluded. When studies com-

bined data for mandible and maxilla, the

results were given separately for the two

jaws in the review.

Studies were excluded,

(i) if placed and failed implants could not

be attributed to a specific jaw situation

(edentulous mandible, edentulous

maxilla, partially dentate mandible,

partially dentate maxilla),

(ii) if the time interval between implant

placement and loading was not clearly

defined for the test group or for the

control group,

(iii) if immediately loaded and conven-

tionally loaded implants supported

the same prosthesis within the first

year of loading,

(iv) if transitional implants were used,

(v) if data included in reviews were not

based on the original literature but on

personal communication with the

authors of the original literature and

(vi) if implants were placed to facilitate

orthodontic treatment.

In the initial phase of the review, a

computerized literature search was per-

formed. Medline and Embase databases

were used for the years 1966–2005 inclu-

sive. Keywords were ‘dental implant’,

‘oral implant’ and ‘immediate loading’.

Moreover, the Cochrane Controlled Trials

Register and The Cochrane Health Group

Specialized Register were checked for pub-

lications on the immediate loading of den-

tal implants.

Additional publications were identified

from the reference lists of the retrieved

articles. In addition, a hand search was

carried out in the British Journal of Oral

and Maxillofacial Surgery, Clinical Im-

plant Dentistry and Related Research,

Clinical Oral Implants Research, Dental

Clinics of North America, Implant Den-

tistry, International Journal of Oral

and Maxillofacial Surgery, International

Journal of Periodontics & Restorative

Dentistry, International Journal of

Prosthodontics, Journal of Clinical Perio-

dontology, Journal of Cranio-Maxillofacial

Surgery, Journal of Oral Implantology,

Journal of Oral and Maxillofacial Surgery,

Journal of Periodontology, Journal of Pros-

thetic Dentistry, Journal of the American

Dental Association, Oral Surgery Oral

Medicine Oral Pathology, Periodontology

2000, Scandinavian Journal of Plastic and

Reconstructive Surgery and The Interna-

tional Journal of Oral & Maxillofacial

Implants.

Two examiners reviewed titles, abstracts

and full-text articles and assessed whether

the references met the inclusion criteria or

had to be excluded. From the selected

papers, data were extracted concerning in-

clusion and exclusion criteria for immedi-

ate loading, measures for the reduction of

micromotion, outcome criteria for im-

mediate loading and survival rates of im-

mediately loaded implants in edentulous

and partially dentate arches.

Results

The electronic literature search provided a

total of 288 articles, of which 38 original

papers fulfilled the inclusion criteria. The

review of the literature identified five stu-

dies containing data directly relevant to

testing the hypothesis that there were sig-

nificant differences in the survival and

success rates of immediately and conven-

tionally loaded oral implants. These stu-

dies were either randomized-controlled

trials or prospective cohort studies (Erics-

son et al. 2000; Chiapasco et al. 2001;

Romeo et al. 2002; Cannizzaro & Leone

2003; Ostman et al. 2005). Two studies

combined immediate loading in the mand-

ible and the maxilla. Therefore, the results

for the two jaws were extracted from the

papers and given separately (Ericsson et al.

2000; Cannizzaro & Leone 2003).

Six additional controlled trials were iden-

tified that provided data concerning the

relevance of the timing of immediate load-

ing, implant surfaces and designs, immedi-

ate functional loading and immediate non-

functional loading (Chaushu et al. 2001;

Gatti & Chiapasco 2002; Degidi & Piat-

telli 2003; Rocci et al. 2003a; Testori et al.

2003, 2004a).

Table 1. Levels of evidence according tothe Oxford Center of Evidence-BasedMedicine

Level Study on therapy

Ia Systematic review withhomogeneity of randomized-controlled studies

Ib Individual randomized-controlledstudies with narrow confidenceinterval

Ic All or noneIIa Systematic review with

homogeneity of cohort studiesIIb Individual cohort study including

low-quality randomized-controlledstudies

IIc ‘Outcomes’ research; ecologicalstudies

IIIa Systematic review withhomogeneity of case–controlstudies

IIIb Individual case–control studyIV Case-series and poor quality cohort

and case–control studiesV Expert opinion without explicit

critical appraisal, or based onphysiology, bench research or ‘firstprinciples’

Nkenke & Fenner . Immediate loading of implants and implant success

20 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 19–34

Exclusion and inclusion criteria forimmediate loading

None of the papers with the highest level of

evidence for the different indications of

immediate loading was designed for the

analysis of the relevance of different possi-

ble exclusion and inclusion criteria men-

tioned in these studies. Therefore, they did

not contribute to a higher level of evidence

compared with all other studies available,

when addressing this question.

A great variety of exclusion criteria for

immediate loading of dental implants are

given in the different papers. These exclu-

sion criteria include insufficient bone vo-

lume, severe maxillomandibular skeletal

discrepancy, gagging reflexes, drug and

alcohol abuse, heavy smoking, local radio-

therapy to the head and neck region for

malignancies, antiblastic chemotherapy,

severe chronic renal or liver disease,

uncontrolled diabetes, stroke, recent in-

farction, immunocompromised status in-

cluding HIV infection, pregnancy at the

time of evaluation, haemophilia, bleeding

disorders or cumarin therapy, metabolic

disorders, poor oral hygiene, mucosal

disease such as lichen planus, acute infec-

tion of the implant site, extraction rem-

nants, signs of chronic bone disease,

bruxism and general contraindications

for surgical procedures (Chiapasco et al.

2001; Chow et al. 2001; Hui et al. 2001;

Proussaefs et al. 2002; Jaffin et al. 2004;

Proussaefs & Lozada 2004; Ibanez et al.

2005).

Other authors have shown that immedi-

ate loading of dental implants has been

successfully performed in bruxers, heavy

smokers, controlled diabetics and patients

with other systemic diseases (Cannizzaro

& Leone 2003; Jaffin et al. 2004; Bergkvist

et al. 2005; Ibanez et al. 2005). Immedi-

ately loaded implants have been reported as

surviving even in HIV-positive patients

(Cannizzaro & Leone 2003).

The relevance of reduced bone quality to

implant failure after immediate loading has

been discussed in one study, in which 71%

of the patients had bone quantity/quality

C3 or C4 (Bergkvist et al. 2005). Three out

of 168 implants that were immediately

loaded failed during the first 8 months, of

which two were in the same patient. The

failure rate was comparable with other

studies, where implants were placed in

better bone quality.

Measures for the reduction of micromotion

The question of reduction of micromove-

ment has not been addressed in controlled

studies dealing with immediate loading of

oral implants. Therefore, they did not con-

tribute to a higher level of evidence com-

pared with all other studies available,

where this question was addressed.

In order to increase the implants’ resis-

tance to movement, they were placed pre-

ferentially in regions with high bone

density. CT scans were used to identify

these regions (Jaffin et al. 2004), with 400

Hounsfield units being the threshold for

implant placement.

A minimal number of two implants was

advocated for the edentulous mandible and

five for the maxilla (Stricker et al. 2004;

Bergkvist et al. 2005). Insertion torque

values over 32 Ncm were chosen as a pre-

requisite for immediate loading by some

authors (Wohrle 1998; Hui et al. 2001;

Lorenzoni et al. 2003). After installation,

the implants were splinted by bars or fixed

superstructures (Chiapasco et al. 2001;

Romeo et al. 2002; Jaffin et al. 2004; van

Steenberghe et al. 2004). It has been re-

ported that even 3.3 mm diameter implants

have been successfully loaded immediately

under these conditions (Romeo et al. 2002;

Chiapasco & Gatti 2003).

van Steenberghe et al. (2005) have stated

that fixed superstructures should not be

removed during the healing period in order

to avoid any extrusional forces on the

implants.

Passive fit of provisional prostheses has

been mentioned as an important factor in

the osseointegration of immediately loaded

implants. A prosthesis that is ill-fitting

may become loose, resulting in increased

stress on the implants, which can lead to

excessive micromotion and loss of an im-

plant (Jaffin et al. 2004). In this context, it

has been hypothesized that screw-retained

passively fitting restorations may be super-

ior to cement-retained ones with respect to

this problem, because they are less likely to

loosen. If a cemented restoration is desired,

the abutments should be long enough to

provide adequate retention (Jaffin et al.

2004).

When immediate non-functional loading

was compared with immediate loading in a

controlled study, immediate non-func-

tional loading increased the implant survi-

val rate (Degidi & Piattelli 2003). Some

authors have avoided occlusal contacts for

single-tooth implants (Hui et al. 2001;

Proussaefs et al. 2002), while others have

protected their immediately restored sin-

gle-tooth implants with occlusal splints

(Lorenzoni et al. 2003).

Rough surfaced implants showed a better

survival rate (95.5%) compared with ma-

chined implants (85.5%) when immedi-

ately loaded in a randomized-controlled

trial (Rocci et al. 2003b). However, the

difference was not statistically significant.

It has been stated that the opposing jaw

has to have a sufficient number of teeth to

provide a stable occlusion (Bergkvist et al.

2005). An unbalanced occlusal scheme

seemed to contribute to the loosening of

the prosthesis, which can result in implant

loss (Jaffin et al. 2004).

Outcome criteria for immediate loading

In order to compare the outcome of im-

mediate loading with conventional loading,

different parameters have been defined. In

controlled trials that compared immediate

loading with conventional loading, out-

come measures have included marginal

bone loss, bleeding index, plaque index,

peri-implant probing depth, implant mobi-

lity and success criteria comparable with

those of Albrektsson et al. (1986) but

adapted to a reduced follow-up period

(Table 2). Marginal bone loss ranged from

0.14� 0.36 to 0.78� 0.90 mm for im-

mediately loaded implants (Ericsson et al.

2000; Ostman et al. 2005). The data for

conventionally loaded implants were com-

parable and did not reveal statistically sig-

nificant differences.

Bleeding index, plaque index and peri-

implant probing depth did not show any

significant differences when immediately

loaded and conventionally loaded implants

were compared (Chiapasco et al. 2001;

Romeo et al. 2002; Ostman et al. 2005).

The same is true for implant stability

measured either by Periotest values or

resonance frequency analysis (Chiapasco

et al. 2001; Romeo et al. 2002; Ostman

et al. 2005).

When success criteria were adopted

that were comparable with those of Al-

brektsson et al. (1986) but with a reduced

follow-up period, no relevant differences

could be found between immediately

loaded and conventionally loaded implants

(Ericsson et al. 2000; Chiapasco et al.

Nkenke & Fenner . Immediate loading of implants and implant success

21 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 19–34

2001; Romeo et al. 2002; Cannizzaro &

Leone 2003).

Survival rate of immediately loaded oralimplants in the edentulous mandible

In the current literature, one meta-analysis

of immediately loaded dental implants

could be found that met the inclusion

criteria of the present review (Ioannidou

& Doufexi 2005). Two randomized-con-

trolled trials on immediate loading in the

mandible were included in the meta-ana-

lysis (Chiapasco et al. 2001; Romeo et al.

2002; Table 3). Both studies dealt with

edentulous situations with adequate bone

shape and quality. Four implants were

placed inter-foraminally. They were rigidly

connected with a bar and loaded with an

implant-supported overdenture. In both

trials, 10 patients were included in the

control group (conventional loading after

3–8 months) as well as the test group

(immediate loading after 2–3 days). No

withdrawals occurred in the studies. In

one study, one implant was lost in each

group (Chiapasco et al. 2001), while in the

other one implant was lost in the control

group (Romeo et al. 2002).

In a prospective cohort study, it was

shown that the use of two-piece and one-

piece transmucosal immediately loaded

implants led to comparable results, when

bar-retained implant-supported overden-

tures were used (Gatti & Chiapasco

2002). Another prospective cohort study

revealed that immediate loading of the

implants on the day of placement or 1

day later did not influence implant survival

rates (Testori et al. 2004a; Table 15).

Additional prospective studies on im-

mediate loading of bar-retained implant-

supported overdentures have also shown

high survival rates as well as success rates

(Gatti et al. 2000; Chiapasco & Gatti 2003;

Table 4). The minimal success rate was

88.2% in one study (Chiapasco & Gatti

2003). Out of 328 implants placed, seven

had to be removed and 18 did not fulfil all

the success criteria described by Albrekts-

son & Zarb (1998), although they were

osseointegrated.

Several additional trials on immediate

loading of dental implants in the edentu-

lous mandible supporting fixed prostheses

can be found in the current literature (Table

4). The implant survival rates range fromTab

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Nkenke & Fenner . Immediate loading of implants and implant success

22 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 19–34

80% to 100% over follow-up periods of

1–10 years.

Immediate loading of oral implants in theedentulous maxilla

No randomized-controlled trials are avail-

able that compare immediate loading with

conventional loading in the edentulous

maxilla. One prospective cohort study re-

ported a survival rate of 99.6% for imme-

diately loaded implants compared with

100% for conventionally loaded implants

(Ostman et al. 2005; Table 5). Additional

knowledge on immediate loading of im-

plants in the edentulous maxilla is limited

to only a few prospective studies (Rocci

et al. 2003b; Jaffin et al. 2004; van Steen-

berghe et al. 2004, 2005; Bergkvist

et al. 2005; Table 6), with implant survival

rates ranging from 83.3% to 100%.

Successful immediate loading was

achieved with five to seven implants

placed in the maxilla of each of 25 patients

(Bergkvist et al. 2005) over a 1–2-year

follow-up period, when a survival rate of

98% was observed. For immediate loading

of implants in the maxilla, Jaffin et al.

(2004) used minimal implant lengths of

8 mm, placing six to eight implants in

each of 34 edentulous maxillae. After 12

months, the survival rate was 92.2%,

although implants with a diameter of

3.3 mm were included.

Some authors placed immediately loaded

implants in the maxilla using flapless

surgery (van Steenberghe et al. 2004). In a

multi-centre study in which 24 patients

were followed for 1 year, implants were

installed transmucosally (van Steenberghe

et al. 2005). The method was facilitated by

computer-assisted techniques, which were

based on a CT scan allowing virtual plan-

ning of the implant positions and CAD/

CAM fabrication of a surgical stent. The

superstructures were prefabricated before

the implants were placed, and survival

and success rates of 100% were achieved

(Table 6).

Immediate loading of oral implants inmulti-unit applications in the partiallydentate mandible

Cannizzaro & Leone (2003; Table 7) con-

ducted a controlled study that compared

immediate and conventional loading of

implants in partially dentate mandibles.

Five patients received 25 immediately

loaded implants, while 23 implants were

loaded conventionally in eight patients.

The survival rates were 100% and

95.7%, respectively, after 2 years.

In a randomized-controlled study, im-

mediate loading was compared with early

loading of implants in the partially dentate

mandible (Testori et al. 2003). The survival

rate was 95.7% for immediately loaded

implants and 100% for early loaded

implants after 2 years.

Other prospective studies of the survival

rates of immediately loaded implants

yielded values of 88.5–100% (Nikellis

et al. 2004; Degidi & Piattelli 2005;

Glauser et al. 2005; Table 8).

In a prospective cohort study, immediate

functional and non-functional loading

were compared in the partially dentate

mandible in multi-unit applications

(Degidi & Piattelli 2003; Table 15). Im-

mediate functional loading reduced the

survival rate to 92.3% compared with

100%, when immediate non-functional

loading was used.

Immediate loading of oral implants inmulti-unit situations in the partiallydentate maxilla

Cannizzaro & Leone (2003; Table 9) com-

pared immediate and conventional loading

in a controlled study in partially dentate

maxillae, in which four patients received

15 immediately loaded implants, while in

the control group 16 implants in five pa-

tients were loaded conventionally. The

survival rate after a mean follow-up of

two years was 100% in both groups.

In a randomized-controlled study, im-

mediate loading was compared with early

loading of implants in the partially dentate

maxilla (Testori et al. 2003). The survival

rate was 96.6% for immediately loaded

implants and 96.3% for early loaded im-

plants after 2 years.

Additional prospective studies on im-

mediate loading in the maxilla revealed

implant survival rates of 88.5–100% after

follow-up periods of up to 7 years (Nikellis

et al. 2004; Calandriello & Tomatis 2005;

Degidi & Piattelli 2005; Glauser et al.

2005; Table 10).

Immediate loading of single-toothimplants in the mandible

For immediate loading of single-tooth im-

plants, two controlled studies were avail-Tab

le3.

Ran

do

miz

ed

-co

ntr

oll

ed

stu

die

sco

mp

ari

ng

imm

ed

iate

an

dco

nven

tio

nal

load

ing

inth

eed

en

tulo

us

man

dib

le

Au

tho

rsIm

pla

nt

surf

ace

Nu

mb

er

of

pati

en

ts/

imp

lan

ts

Tim

ein

terv

al

befo

reim

pla

nt

load

ing

Foll

ow

-up

peri

od

(years

)

Imp

lan

tlo

sses

Imp

lan

tsu

rviv

al

rate

(%)

Pati

en

tag

era

ng

e(y

ears

)

Pro

sth

esi

s

Ro

meo

et

al.

(2002),

test

SLA

(ITI

imp

lan

t,St

rau

man

n,

Wald

en

bu

rg,

Swit

zerl

an

d)

10/4

02

days

20

test

100

test

42–7

3fo

rte

stan

dco

ntr

ol

gro

up

Ove

rden

ture

Ro

meo

et

al.

(2002),

con

tro

l10/4

03–4

mo

nth

s1

con

tro

l97.5

con

tro

l

Ch

iap

asc

oet

al.

(2001),

test

Mach

ined

(Bra

nem

ark

Syst

em

MkII

,N

ob

el

Bio

care

,G

oth

en

bu

rg,

Swed

en

)

10/4

02–3

days

21

test

97.5

test

44–7

3fo

rte

stan

dco

ntr

ol

gro

up

Ove

rden

ture

Ch

iap

asc

oet

al.

(2001),

con

tro

l10/4

04–8

mo

nth

s1

con

tro

l97.5

con

tro

l

Nkenke & Fenner . Immediate loading of implants and implant success

23 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 19–34

Tab

le4.

Pro

spect

ive

stu

die

so

nim

med

iate

load

ing

inth

eed

en

tulo

us

man

dib

le

Au

tho

rsIm

pla

nt

surf

ace

Nu

mb

er

of

pati

en

ts/i

mp

lan

tsTim

ein

terv

al

befo

reim

pla

nt

load

ing

Foll

ow

-up

peri

od

(years

)

Imp

lan

tlo

sses

Imp

lan

tsu

rviv

al

rate

(%)

Pati

en

tag

era

ng

e(y

ears

)

Pro

sth

esi

s

Deg

idi

&Pia

tell

i(2

005)

Gri

t-b

last

ed

,aci

d-e

tch

ed

(Fri

ali

t-2,

IMZ,

Fria

den

t,M

an

nh

eim

,G

erm

an

y)

6/4

324

h7

0100

?O

verd

en

ture

fixe

dp

rost

hesi

s

Gla

use

ret

al.

(2005)

Oxi

diz

ed

(Bra

nem

ark

Syst

em

MkIV

,TiU

nit

e,

No

bel

Bio

care

,G

oth

en

bu

rg,

Swed

en

)

1/5

Load

ing

at

the

day

of

imp

lan

tp

lace

men

t4

0100

?Fi

xed

pro

sth

esi

s

Iban

ez

et

al.

(2005)

Do

ub

leaci

d-e

tch

ed

(Oss

eo

tite

imp

lan

ts,

3i

Imp

lan

tIn

no

vati

on

s,Palm

Beach

Gard

en

s,FL

,U

SA)

?/126

48

h1–6

0100

?Fi

xed

pro

sth

esi

s

Nik

ell

iset

al.

(2004)

San

d-b

last

ed

,aci

d-e

tch

ed

(scr

ew

-ty

pe

imp

lan

t,So

uth

ern

Imp

lan

ts,

Iren

e,

Sou

thA

fric

a)

10/5

172

h1–2

0100

28–7

1Fi

xed

pro

sth

esi

s

Stri

cker

et

al.

(2004)

San

d-b

last

ed

,la

rge-g

rit,

aci

d-

etc

hed

(ITI

imp

lan

tsy

stem

,In

stit

ute

Stra

um

an

n,

Wald

en

bu

rg,

Swit

zerl

an

d)

10/2

024

h2

0100

48–7

4O

verd

en

ture

Test

ori

et

al.

(2004b

)A

cid

-etc

hed

(scr

ew

-sh

ap

ed

imp

lan

t,3i,

West

Palm

Beach

)62/3

25

4h

1–5

299.4

33–8

3Fi

xed

pro

sth

esi

s

Ch

iap

asc

o&

Gatt

i(2

003)

San

d-b

last

ed

,an

od

ized

(Ha-T

i,M

ath

ysD

en

tal,

Bett

lach

,Sw

itze

rlan

d)

Mach

ined

(Bra

nem

ark

Co

nic

al,

No

bel

Bio

care

)A

cid

-etc

hed

(Fri

alo

c,Fr

iate

c)

82/3

28

24

h3–8

796.1

42–8

7O

verd

en

ture

Hen

ryet

al.

(2003)

Mach

ined

(No

bel

Bio

care

,)

51/1

53

48

h1

14

91

43–7

9Fi

xed

pro

sth

esi

sva

nSt

een

berg

he

et

al.

(2004)

Oxi

diz

ed

(Bra

nem

ark

MkII

I,Ti

Un

ite,

No

bel

Bio

care

)1/5

Load

ing

imm

ed

iate

lyaft

er

imp

lan

tp

lace

men

t

10

100

?Fi

xed

pro

sth

esi

s

Ru

ng

chara

ssaen

get

al.

(2002)

HA

-co

ate

d(S

teri

-Oss

,N

ob

el

Bio

care

USA

Inc,

Yo

rba

Lin

da,

CA

,U

SA)

5/2

024

h1

0100

49–7

7O

verd

en

ture

Iban

ez

&Ja

lbo

ut

(2002)

Hyb

rid

:m

ach

ined

an

dd

ou

ble

-aci

detc

hed

(Oss

eo

tite

imp

lan

ts,

3i

Imp

lan

tIn

no

vati

on

s)

5/3

024–4

8h

2–2

.50

100

?Fi

xed

pro

sth

esi

s

Ch

ow

et

al.

(2001)

Mach

ined

(Bra

nem

ark

imp

lan

ts,

No

bel

Bio

care

,)

27/1

23

24

h2.5

298.3

40–8

0Fi

xed

pro

sth

esi

s

Gatt

iet

al.

(2000)

Tita

niu

mp

lasm

a-s

pra

yed

(ITI

imp

lan

tsy

stem

,In

stit

ute

Stra

um

an

n)

21/4

824

h2.1

–53

96

45–8

7O

verd

en

ture

Hen

ry&

Ro

sen

berg

(1994)

Mach

ined

(scr

ew

-sh

ap

ed

,st

an

dard

Bra

nem

ark

imp

lan

ts,

No

belp

harm

a,

USA

,C

hic

ag

o,

IL,

USA

)

5/2

024

h2

0im

med

iate

lylo

ad

ed

100

imm

ed

iate

lylo

ad

ed

44–6

2Fi

xed

pro

sth

esi

s

?,d

ata

no

tsp

eci

fied

.

Nkenke & Fenner . Immediate loading of implants and implant success

24 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 19–34

Tab

le5.

Co

ntr

olled

stu

die

sco

mp

ari

ng

imm

ed

iate

an

dco

nven

tio

nal

load

ing

inth

eed

en

tulo

us

maxilla

Au

tho

rsD

esi

gn

of

the

stu

dy

Imp

lan

tsu

rface

Nu

mb

er

of

pati

en

ts/

imp

lan

ts

Tim

ein

terv

al

befo

reim

pla

nt

load

ing

Foll

ow

-up

peri

od

(years

)

Imp

lan

tlo

sses

Imp

lan

tsu

rviv

al

rate

(%)

Pati

en

tag

era

ng

e(y

ears

)

Pro

sth

esi

s

Ost

man

et

al.

(2005),

test

Pro

spect

ive

coh

ort

stu

dy

Oxi

diz

ed

(Bra

nem

ark

MkIV

TiU

nit

e,

Bra

nem

ark

MkII

ITiU

nit

e,

Rep

lace

Sele

ctTa

pere

d,

No

bel

Bio

care

,G

oth

en

bu

rg,

Swed

en

)

20/1

23

test

12

h1–3

1te

st99.6

test

58–8

7te

stFi

xed

pro

sth

esi

sO

stm

an

et

al.

(2005),

con

tro

l20/1

20

con

tro

l6

mo

nth

s0

con

tro

l100

con

tro

l50–8

0co

ntr

ol

Tab

le6.

Pro

spect

ive

stu

die

so

nim

med

iate

load

ing

inth

eed

en

tulo

us

maxilla

Au

tho

rsIm

pla

nt

surf

ace

Nu

mb

er

of

pati

en

ts/

imp

lan

ts

Tim

ein

terv

al

befo

reim

pla

nt

load

ing

Foll

ow

-up

peri

od

(years

)

Imp

lan

tlo

sses

Imp

lan

tsu

rviv

al

rate

(%)

Pati

en

tag

era

ng

e(y

ears

)

Pro

sth

esi

s

Berg

kvi

stet

al.

(2005)

San

d-b

last

ed

,la

rge-g

rit,

aci

d-e

tch

ed

(ITI

imp

lan

tsy

stem

,St

rau

man

nIn

stit

ute

,W

ald

en

bu

rg,

Swit

zerl

an

d)

28/1

68

24

h0.6

6–2

.66

398

45–8

8Fi

xed

pro

sth

esi

s

Deg

idi

&Pia

tell

i(2

005)

Gri

tb

last

ed

,aci

d-e

tch

ed

(Fri

ali

t-2,

IMZ,

Fria

den

t,M

an

nh

eim

,G

erm

an

y)1/1

224

h7

283.3

?Fi

xed

pro

sth

esi

s

Iban

ez

et

al.

(2005)

Do

ub

le-a

cid

etc

hed

(Oss

eo

tite

imp

lan

ts,

3i

Imp

lan

tIn

no

vati

on

s,Palm

Beach

Gard

en

s,FL

,U

SA)

?/217

48

h1–6

0100

?Fi

xed

pro

sth

esi

s

van

Steen

berg

he

et

al.

(2005)

Oxi

diz

ed

(Bra

nem

ark

MkII

I,TiU

nit

e,

No

bel

Bio

care

,G

oth

en

bu

rg,

Swed

en

)27/1

84

1h

0.5

–10

100

34–8

9Fi

xed

pro

sth

esi

s

Jaffi

net

al.

(2004)

San

d-b

last

ed

,la

rge-g

rit,

aci

d-e

tch

ed

(ITI

imp

lan

tsy

stem

,St

rau

man

nIn

stit

ute

)34/2

36

48–7

2h

0–6

016

92.2

43–8

2Fi

xed

pro

sth

esi

s

Nik

ell

iset

al.

(2004)

San

d-b

last

ed

,aci

d-e

tch

ed

(So

uth

ern

Imp

lan

ts,

Iren

e,

Sou

thA

fric

a)

14/8

572

h1–2

0100

28–8

2Fi

xed

pro

sth

esi

s

van

Steen

berg

he

et

al.

(2004)

Oxi

diz

ed

(Bra

nem

ark

MkII

I,TiU

nit

e,

No

bel

Bio

care

)8/?

Load

ing

imm

ed

iate

lyaft

er

imp

lan

tp

lace

men

t

10

100

54–6

4Fi

xed

pro

sth

esi

s

Iban

ez

&Ja

lbo

ut

(2002)

Hyb

rid

:m

ach

ined

an

dd

ou

ble

-aci

d-

etc

hed

(Oss

eo

tite

imp

lan

ts,

3i

Imp

lan

tIn

no

vati

on

s,Palm

Beach

Gard

en

s,FL

)

6/5

724–4

8h

2–2

.50

100

?Fi

xed

pro

sth

esi

s

?,d

ata

no

tsp

eci

fied

.

Nkenke & Fenner . Immediate loading of implants and implant success

25 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 19–34

Tab

le7.

Co

ntr

oll

ed

stu

die

sco

mp

ari

ng

imm

ed

iate

an

dco

nven

tio

nal

load

ing

inm

ult

i-u

nit

situ

ati

on

sin

part

ially

den

tate

pati

en

tsin

the

man

dib

le

Au

tho

rsLe

vel

of

evi

den

ceIm

pla

nt

surf

ace

Nu

mb

er

of

pati

en

ts/

imp

lan

ts

Tim

ein

terv

al

befo

reim

med

iate

load

ing

Foll

ow

-up

peri

od

(years

)

Imp

lan

tlo

sses

Imp

lan

tsu

rviv

al

rate

(%)

Pati

en

tag

era

ng

e(y

ears

)

Pro

sth

esi

s

Can

niz

zaro

&Le

on

e(2

003),

test

Pro

spect

ive

coh

ort

stu

dy

Mic

rote

xtu

red

(Sp

lin

eTw

ist

MTX

,C

en

terp

uls

eD

en

tal,

Carl

sbad

,C

A,

USA

)

5/2

5te

st3

h2

0te

st100

test

23–6

2te

stFi

xed

part

ial

den

ture

Can

niz

zaro

&Le

on

e(2

003),

con

tro

l8/2

3co

ntr

ol

3m

on

ths

1co

ntr

ol

95.7

con

tro

l20–7

2co

ntr

ol

Tab

le8.

Pro

spect

ive

stu

die

so

nim

med

iate

load

ing

inp

art

ial

ed

en

tulism

wit

hm

ult

i-u

nit

situ

ati

on

sin

the

man

dib

le

Au

tho

rsIm

pla

nt

surf

ace

Nu

mb

er

of

pati

en

ts/

imp

lan

ts

Tim

ein

terv

al

befo

reim

pla

nt

load

ing

Foll

ow

-up

peri

od

(years

)

Imp

lan

tlo

sses

Imp

lan

tsu

rviv

al

rate

(%)

Pati

en

tag

era

ng

e(y

ears

)

Pro

sth

esi

s

Deg

idi

&Pia

tell

i(2

005)

Gri

tb

last

ed

,aci

d-e

tch

ed

(Fri

ali

t-2,

IMZ,

Fria

den

t,M

an

nh

eim

,G

erm

an

y)

5/2

324

h7

291.3

?Fi

xed

pro

sth

esi

s

Gla

use

ret

al.

(2005)

Oxi

diz

ed

(Bra

nem

ark

Syst

em

MkIV

TiU

nit

e,

No

bel

Bio

care

,G

oth

en

bu

rg,

Swed

en

)

20/5

1Lo

ad

ing

at

the

day

of

imp

lan

tp

lace

men

t

40

100

?Fi

xed

part

ial

den

ture

Nik

ell

iset

al.

(2004)

San

d-b

last

ed

,aci

d-e

tch

ed

(So

uth

ern

Imp

lan

ts,

Iren

e,

Sou

thA

fric

a)

14/3

772

h1–2

0100

39–6

2Fi

xed

part

ial

den

ture

?,d

ata

no

tsp

eci

fied

.

Tab

le9.

Co

ntr

oll

ed

stu

die

sco

mp

ari

ng

imm

ed

iate

an

dco

nven

tio

nal

load

ing

inm

ult

i-u

nit

situ

ati

on

sin

part

ially

den

tate

pati

en

tsin

the

maxil

la

Au

tho

rsD

esi

gn

of

the

stu

dy

Imp

lan

tsu

rface

Nu

mb

er

of

pati

en

ts/

imp

lan

ts

Tim

ein

terv

al

befo

reim

med

iate

load

ing

Foll

ow

-up

peri

od

(years

)

Imp

lan

tlo

sses

Imp

lan

tsu

rviv

al

rate

(%)

Pati

en

tag

era

ng

e(y

ears

)

Pro

sth

esi

s

Can

niz

zaro

&Le

on

e(2

003),

test

Pro

spect

ive

coh

ort

stu

dy

Mic

rote

xtu

red

(Sp

lin

eTw

ist

MTX

,C

en

terp

uls

eD

en

tal,

Carl

sbad

,C

A)

4/1

5te

st3

h2

0te

st100

test

25–4

7te

stFi

xed

part

ial

den

ture

Can

niz

zaro

&Le

on

e(2

003),

con

tro

l5/1

6co

ntr

ol

6m

on

ths

0co

ntr

ol

100

con

tro

l33–7

2co

ntr

ol

Nkenke & Fenner . Immediate loading of implants and implant success

26 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 19–34

Tab

le10.

Pro

spect

ive

stu

die

so

nim

med

iate

load

ing

inp

art

ial

ed

en

tuli

smw

ith

mu

lti-

un

itsi

tuati

on

sin

the

maxil

la

Au

tho

rsIm

pla

nt

surf

ace

Nu

mb

er

of

pati

en

ts/

imp

lan

ts

Tim

ein

terv

al

befo

reim

pla

nt

load

ing

Foll

ow

-up

peri

od

(years

)

Imp

lan

tlo

sses

Imp

lan

tsu

rviv

al

rate

(%)

Pati

en

tag

era

ng

e(y

ears

)

Pro

sth

esi

s

Cala

nd

riell

o&

Tom

ati

s(2

005)

Mach

ined

,o

xid

ized

(TiU

nit

e)

or

aci

d-e

tch

ed

(Rep

lace

,N

ob

el

Bio

care

,G

oth

en

bu

rg,

Swed

en

)

11/2

624

h1

0100

?Fi

xed

part

ial

den

ture

Deg

idi

&Pia

tell

i(2

005)

Gri

t-b

last

ed

,aci

d-e

tch

ed

(Fri

ali

t-2,

IMZ,

Fria

den

t,M

an

nh

eim

,G

erm

an

y)

4/2

024

h7

290

?Fi

xed

pro

sth

esi

s

Gla

use

ret

al.

(2005)

Oxi

diz

ed

(scr

ew

-sh

ap

ed

,B

ran

em

ark

Syst

em

MkIV

TiU

nit

e,

No

bel

Bio

care

)

10/2

6Lo

ad

ing

at

the

day

of

imp

lan

tp

lace

men

t

43

88.5

?Fi

xed

part

ial

den

ture

Nik

ell

iset

al.

(2004)

San

d-b

last

ed

,aci

d-e

tch

ed

(So

uth

ern

Imp

lan

ts,

Iren

e,

Sou

thA

fric

a)

6/1

572

h1–2

0100

19–6

2Fi

xed

part

ial

den

ture

?,d

ata

no

tsp

eci

fied

.

Tab

le11.

Co

ntr

olled

stu

die

sco

mp

ari

ng

imm

ed

iate

an

dd

ela

yed

load

ing

of

sin

gle

-to

oth

imp

lan

tsin

the

man

dib

le

Au

tho

rsLe

vel

of

evi

den

ceIm

pla

nt

surf

ace

Nu

mb

er

of

pati

en

ts/

imp

lan

ts

Tim

ein

terv

al

befo

reim

pla

nt

load

ing

Foll

ow

-up

peri

od

(years

)

Imp

lan

tlo

sses

Imp

lan

tsu

rviv

al

rate

(%)

Pati

en

tag

era

ng

e(y

ears

)

Can

niz

zaro

&Le

on

e(2

003),

test

Pro

spect

ive

coh

ort

stu

dy

Mic

rote

xtu

red

(Sp

lin

eTw

ist

MTX

,C

en

terp

uls

eD

en

tal,

Carl

sbad

,C

A,

USA

)

2/2

3h

20

100

20–3

3C

an

niz

zaro

&Le

on

e(2

003),

con

tro

l2/2

3m

on

ths

0100

18–7

2

Eri

csso

net

al.

(2000),

test

Pro

spect

ive

coh

ort

stu

dy

Mach

ined

(Bra

nem

ark

Syst

em

,N

ob

el

Bio

care

,G

oth

en

bu

rg,

Swed

en

)

3/3

24

h1

0100

?Eri

csso

net

al.

(2000),

con

tro

l1/1

3m

on

ths

0100

?

?,d

ata

no

tsp

eci

fied

.

Nkenke & Fenner . Immediate loading of implants and implant success

27 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 19–34

able that met the inclusion criteria of this

review (Ericsson et al. 2000; Cannizzaro &

Leone 2003; Table 11). In both studies,

only small case numbers were included.

The survival rate was 100% for the test

group as well as the control group. Pro-

spective studies showed survival rates of

96.7–100% (Lorenzoni et al. 2003; Corne-

lini et al. 2004; Nikellis et al. 2004; Glau-

ser et al. 2005; Table 12).

In a prospective cohort study, the out-

comes of immediate loading of single-tooth

implants placed in fresh extraction sockets

in the mandible were compared with those

when immediately loaded single-tooth im-

plants were placed in healed sites (Chaushu

et al. 2001; Table 15). Only small numbers

of patients were included in each group,

and the survival rate for each was 100%.

Immediate loading of single-toothimplants in the maxilla

For single-tooth implants in the maxilla,

two controlled studies were available that

compared immediate loading with conven-

tional loading (Ericsson et al. 2000; Can-

nizzaro & Leone 2003; Table 13). In the

larger study, the survival rate of the im-

plants in the study group was 81.2% (Erics-

son et al. 2000), while the control groups in

both studies had survival rates of 100%

after follow-up periods of up to 2 years. A

number of additional prospective studies on

immediate loading of single-tooth implants

can be found in the literature (Table 14).

These indicated survival rates of 96.7–

100% after follow-up periods of up to 5

years. Even for the replacement of single

premolars in the maxilla, success rates of

100% have been described (Proussaefs

et al. 2002; Proussaefs & Lozada 2004).

In a prospective cohort study, immediate

loading of single-tooth implants in fresh

extraction sockets in the maxilla was com-

pared with immediate loading of single-

tooth implants in healed sites (Chaushu

et al. 2001; Table 15). Only small numbers

of patients were included in each group,

and the survival rate was 75% for the test

group and 100% for the control group.

Minimal insertion torque values of

40–50 N cm have been advocated as a pre-

requisite for immediate loading of single-

tooth implants (Hui et al. 2001); others

have avoided incisal contacts (Andersen

et al. 2002), and some authors have even

used occlusal splints in an attempt toTab

le12.

Pro

spect

ive

stu

die

so

nim

med

iate

load

ing

of

sin

gle

-to

oth

imp

lan

tsin

the

man

dib

le

Au

tho

rsIm

pla

nt

surf

ace

Nu

mb

er

of

pati

en

ts/

imp

lan

ts

Tim

ein

terv

al

befo

reim

pla

nt

load

ing

Foll

ow

-up

peri

od

(years

)

Imp

lan

tlo

sses

Imp

lan

tsu

rviv

al

rate

(%)

Pati

en

tag

era

ng

e(y

ears

)

Gla

use

ret

al.

(2005)

Oxi

diz

ed

(Bra

nem

ark

Syst

em

MkIV

TiU

nit

e,

No

bel

Bio

care

AB

,G

oth

en

bu

rg,

Swed

en

)?/

8Lo

ad

ing

at

the

day

of

imp

lan

tp

lace

men

t4

0100

?

Co

rneli

ni

et

al.

(2004)

San

d-b

last

ed

,la

rge-g

rit,

aci

d-e

tch

ed

(ITI

imp

lan

tsy

stem

,St

rau

man

nIn

stit

ute

,W

ald

en

bu

rg,

Swit

zerl

an

d)

30/3

024

h1

196.7

27–5

9

Nik

ell

iset

al.

(2004)

San

d-b

last

ed

,aci

d-e

tch

ed

(So

uth

ern

Imp

lan

ts,

Iren

e,

Sou

thA

fric

a)

2/2

72

h1–2

0100

39–5

3

Lore

nzo

ni

et

al.

(2003)

Gri

t-b

last

ed

,aci

d-e

tch

ed

(Fri

ali

t-2

Syn

cro

step

ped

scre

w-s

hap

ed

imp

lan

ts,

Fria

den

t,M

an

nh

eim

,G

erm

an

y)

12/1

2Lo

ad

ing

at

the

day

of

imp

lan

tp

lace

men

t1

0100

?

Tab

le13.

Co

ntr

olled

stu

die

sco

mp

ari

ng

imm

ed

iate

an

dd

ela

yed

load

ing

of

sin

gle

-to

oth

imp

lan

tsin

the

maxilla

Au

tho

rsD

esi

gn

of

the

stu

dy

Imp

lan

tsu

rface

Nu

mb

er

of

pati

en

ts/

imp

lan

ts

Tim

ein

terv

al

befo

reim

pla

nt

load

ing

Foll

ow

-up

peri

od

(years

)

Imp

lan

tlo

sses

Imp

lan

tsu

rviv

al

rate

(%)

Pati

en

tag

era

ng

e(y

ears

)

Can

niz

zaro

&Le

on

e(2

003),

test

Pro

spect

ive

coh

ort

stu

dy

Mic

rote

xtu

red

(Sp

lin

eTw

ist

MTX

,C

en

terp

uls

eD

en

tal,

Carl

sbad

,C

A,

USA

)

3/3

3h

20

100

25–3

6C

an

niz

zaro

&Le

on

e(2

003),

con

tro

l1/1

60

100

35

Eri

csso

net

al.

(2000),

test

Pro

spect

ive

coh

ort

stu

dy

Mach

ined

(Bra

nem

ark

Syst

em

,N

ob

el

Bio

care

AB

,G

oth

en

bu

rg,

Swed

en

)

11/1

124

h1

281.2

?Eri

csso

net

al.

(2000),

con

tro

l7/7

6m

on

ths

0100

?

?,d

ata

no

tsp

eci

fied

.

Nkenke & Fenner . Immediate loading of implants and implant success

28 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 19–34

eliminate loading of the restoration by non-

occlusal forces exerted by the tongue or

food (Lorenzoni et al. 2003). Liquid and

soft diets have also been recommended

after the placement of immediately loaded

single-tooth implants (Kan et al. 2003).

At the moment, there is no reported con-

trolled study that compares immediate

functional and non-functional loading of

single-tooth implants.

One study has shown that patients were

highly satisfied with the aesthetics of their

immediately loaded single-tooth implants

(Kan et al. 2003); however, again controlled

studies on this aspect are missing.

Discussion

Extended integration periods and multiple

surgeries present a challenge to patient

acceptance of implant therapy in the treat-

ment of partially dentate and edentulous

jaws. Immediate loading of oral implants

could potentially overcome these pro-

blems. It is widely accepted that immedi-

ate loading is a desirable procedure, if the

outcome in terms of implant survival and

success is comparable with that of conven-

tional loading. Therefore, it has been the

aim of the present review to compile dif-

ferent indications for immediate loading, to

assess the level of evidence and to discuss

implant survival rates and the success rates

of the different protocols.

The experience in immediate occlusal

loading of oral implants has led to different

consensus papers (Aparicio et al. 2003;

Cochran et al. 2004; Misch et al. 2004a).

Moreover, some review papers have been

published on immediate loading (Szmuk-

ler-Moncler et al. 2000; Gapski et al. 2003;

Castellon et al. 2004; Chiapasco 2004;

Esposito et al. 2004; Ganeles and Wismei-

jer 2004; Lazzara et al. 2004; Misch et al.

2004b; Morton et al. 2004; Penarrocha

et al. 2004; Attard & Zarb 2005; Cooper

et al. 2005; Ioannidou & Doufexi 2005;

Uribe et al. 2005). The large number of

consensus statements and reviews suggests

that immediate loading is a field that

is still developing, and currently leaves

room for different interpretations and phi-

losophies.

In several studies on immediate loading,

a large number of inclusion and exclusion

criteria have been defined (Chiapasco et al.Tab

le14.

Pro

spect

ive

stu

die

so

nim

med

iate

load

ing

of

sin

gle

-to

oth

imp

lan

tsin

the

maxilla

Au

tho

rsIm

pla

nt

surf

ace

Nu

mb

er

of

pati

en

ts/

imp

lan

ts

Tim

ein

terv

al

befo

reim

pla

nt

load

ing

Foll

ow

-up

peri

od

(years

)Im

pla

nt

loss

es

Imp

lan

tsu

rviv

al

rate

(%)

Pati

en

tag

era

ng

e(y

ears

)

Gla

use

ret

al.

(2005)

Oxi

diz

ed

(Bra

nem

ark

Syst

em

MkIV

TiU

nit

e,

No

bel

Bio

care

,G

oth

en

bu

rg,

Swed

en

)12/1

2Lo

ad

ing

at

the

day

of

imp

lan

tp

lace

men

t4

0100

?

Co

rneli

ni

et

al.

(2004)

San

d-b

last

ed

,aci

d-e

tch

ed

(ITI

imp

lan

tsy

stem

,St

rau

man

nIn

stit

ute

,W

ald

en

bu

rg,

Swit

zerl

an

d)

30/3

024

h1

196.7

27–5

9

Nik

ell

iset

al.

(2004)

San

d-b

last

ed

,aci

d-e

tch

ed

(So

uth

ern

Imp

lan

ts,

Iren

e,

Sou

thA

fric

a)

2/2

72

h1–2

0100

19–3

3

Pro

uss

aefs

&Lo

zad

a(2

004)

HA

-co

ate

d(R

ep

lace

,N

ob

el

Bio

care

,Y

orb

aLi

nd

a,

CA

)10/1

0A

tth

ed

ay

of

imp

lan

tp

lace

men

t3

0100

37–7

7

Kan

et

al.

(2003)

HA

-co

ate

d(R

ep

lace

,N

ob

el

Bio

care

,Y

orb

aLi

nd

a,

CA

)35/3

5Pro

visi

on

ali

zati

on

on

the

day

of

imp

lan

tp

lace

men

t1

0100

18–6

5

Lore

nzo

ni

et

al.

(2003)

Gri

t-b

last

ed

,aci

d-e

tch

ed

(Fri

ali

t-2

Syn

cro

step

ped

scre

w-s

hap

ed

imp

lan

ts,

Fria

den

t,M

an

nh

eim

,G

erm

an

y)

12/1

2Lo

ad

ing

dir

ect

lyaft

er

imp

lan

tp

lace

men

t1

0100

?

An

ders

en

et

al.

(2002)

Pla

sma-s

pra

yed

(ITI

soli

dTPS

imp

lan

ts,

Stra

um

an

nIn

stit

ute

,W

ald

en

bu

rg,

Swit

zerl

an

d)

8/8

Load

ing

imm

ed

iate

lyaft

er

imp

lan

tp

lace

men

t5

0100

17–2

8

Pro

uss

aefs

et

al.

(2002)

HA

-co

ate

d(R

ep

lace

,N

ob

el

Bio

care

,Y

orb

aLi

nd

a,

CA

)10/1

0Lo

ad

ing

imm

ed

iate

lyaft

er

imp

lan

tp

lace

men

t1

0100

?

Hu

iet

al.

(2001)

Mach

ined

(self

-tap

pin

gM

kII

I,co

nic

al

MkIV

,N

ob

el

Bio

care

,G

oth

en

bu

rg,

Swed

en

)24/2

4Lo

ad

ing

imm

ed

iate

lyaft

er

imp

lan

tp

lace

men

t0–1

.25

0100

19–5

9

Wo

hrl

e(1

998)

Aci

d-e

tch

ed

,ti

tan

ium

pla

sma-s

pra

yed

or

HA

-co

ate

d(R

ep

lace

,St

eri

-Oss

,Y

orb

aLi

nd

a,

CA

)14/1

4Pro

visi

on

ali

zati

on

at

the

day

of

imp

lan

tp

lace

men

t

0.7

5–3

0100

?

?,d

ata

no

tsp

eci

fied

.

Nkenke & Fenner . Immediate loading of implants and implant success

29 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 19–34

Tab

le15.

Ad

dit

ion

al

con

tro

lled

stu

die

sco

mp

ari

ng

dif

fere

nt

asp

ect

so

fim

med

iate

load

ing

Au

tho

rsD

esi

gn

of

the

stu

dy

Reg

ion

of

imp

lan

tp

lace

men

t

Imp

lan

tsu

rface

Nu

mb

er

of

pati

en

ts/

imp

lan

ts

Tim

ein

terv

al

befo

reim

pla

nt

load

ing

Foll

ow

-up

peri

od

(years

)

Imp

lan

tlo

sses

Imp

lan

tsu

rviv

al

rate

(%)

Pati

en

tag

era

ng

e(y

ears

)

Pro

sth

esi

s

Test

ori

et

al.

(2004a),

test

Pro

spect

ive

coh

ort

stu

dy

Ed

en

tulo

us

man

dib

leD

ualaci

d-e

tch

ed

(Oss

eo

tite

,3i,

West

Palm

Beach

,FL

,U

SA)

11/6

4Lo

ad

ing

at

the

day

of

imp

lan

tp

lace

men

t

0.6

6–5

.42

96.9

?Fi

xed

pro

sth

esi

s

Test

ori

et

al.

(2004a),

con

tro

l8/5

224

h1.3

3–4

.51

98.1

?Te

sto

riet

al.

(2003),

test

Ran

do

miz

ed

-co

ntr

oll

ed

stu

dy

Part

iall

yd

en

tate

man

dib

leD

ual

aci

d-e

tch

ed

(Oss

eo

tite

,Im

pla

nt

Inn

ova

tio

ns

Inc,

Palm

Beach

Gard

en

s,FL

,U

SA)

Du

ala

cid

-etc

hed

(Oss

eo

tite

NT,

Imp

lan

tIn

no

vati

on

sIn

c)

?/23

24

h24

h1

95.7

?Fi

xed

pro

sth

esi

sTe

sto

riet

al.

(2003),

con

tro

l?/

22

8w

eeks

8w

eeks

0100

?Fi

xed

pro

sth

esi

sTe

sto

riet

al.

(2003),

test

Ran

do

miz

ed

-co

ntr

oll

ed

stu

dy

Part

iall

yd

en

tate

maxi

lla

?/29

24

h24

h1

96.6

?Fi

xed

pro

sth

esi

sTe

sto

riet

al.

(2003),

con

tro

l?/

27

8w

eeks

8w

eeks

196.3

?Fi

xed

pro

sth

esi

sD

eg

idi

&Pia

ttell

i(2

003),

test

Pro

spect

ive

coh

ort

stu

dy

Part

iall

yd

en

tate

man

dib

leIF

LA

cid

-etc

hed

(Fri

ali

t2,Fr

iad

en

t,M

an

nh

eim

,G

erm

an

y)A

cid

-etc

hed

(IM

Z,

Fria

den

t,M

an

nh

eim

,G

erm

an

y)A

cid

-etc

hed

(Fri

alo

c,Fr

iad

en

t,M

an

nh

eim

,G

erm

an

y)M

ach

ined

(Bra

nem

ark

imp

lan

t,N

ob

el

Bio

care

,G

oth

en

bu

rg,

Swed

en

)Ti

tan

ium

pla

sma-s

pra

yed

(Rest

ore

,Li

feco

reB

iom

ed

ical,

Ch

ask

a,

MN

,U

SA)

Reso

rbab

leb

last

text

uri

ng

(Maest

ro,

Bio

ho

rizo

ns,

Bir

min

gh

am

,A

L,U

SA)

6/2

6Lo

ad

ing

at

the

day

of

imp

lan

tp

lace

men

t

0.1

7–5

292.3

?Fi

xed

part

ial

den

ture

Deg

idi

&Pia

ttell

i(2

003),

con

tro

lPart

iall

yd

en

tate

man

dib

leIN

FL33/9

80

100

Deg

idi

&Pia

ttell

i(2

003),

test

Part

iall

yd

en

tate

maxi

lla

IFL

6/2

22

90.9

Deg

idi

&Pia

ttell

i(2

003),

con

tro

lPart

iall

yd

en

tate

maxi

lla

INFL

25/6

80

100

Ro

cci

et

al.

(2003b

),te

stR

an

do

miz

ed

-co

ntr

oll

ed

stu

dy

Part

iall

yd

en

tate

man

dib

leO

xid

ized

(scr

ew

-sh

ap

ed

,M

kII

,M

kII

I,M

kIV

,TiU

nit

e)

22/6

6Lo

ad

ing

at

the

day

of

surg

ery

13

95.5

20–6

9Fi

xed

part

ial

den

ture

Ro

cci

et

al.

(2003b

),co

ntr

ol

Mach

ined

(Bra

nem

ark

,N

ob

el

Bio

care

,G

oth

en

bu

rg,

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en

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Nkenke & Fenner . Immediate loading of implants and implant success

30 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 19–34

2001; Chow et al. 2001; Hui et al. 2001;

Proussaefs et al. 2002; Jaffin et al. 2004;

Proussaefs and Lozada 2004; Ibanez et al.

2005). These criteria are similar to those

chosen for conventional loading of dental

implants (Lekholm 2003). However, in the

studies selected for the present review,

immediate loading was performed success-

fully when implants were placed in bruxers

and non-bruxers, smokers and non-smo-

kers and in patients having diabetes or

other systemic diseases (Cannizzaro &

Leone 2003; Degidi & Piattelli 2003; Jaffin

et al. 2004; Bergkvist et al. 2005; Ibanez

et al. 2005). From the data available in the

current literature, no conclusions can be

drawn concerning relevant exclusion and

inclusion criteria for immediate loading of

oral implants, and controlled studies are

needed to address this problem.

In most of the studies on immediate

loading, good bone quality has been men-

tioned as an important prognostic factor for

the success of the procedure (Chiapasco

et al. 2001; Romeo et al. 2002). Although

this conclusion seems reasonable, the level

of evidence that supports the assumption

is low. There are no controlled studies

that have been especially designed to com-

pare immediate loading of oral implants

in bone of different qualities. The same is

true for the implant lengths and diameters

that should be used for immediate loading.

In a controlled study, rough implant

surfaces improved the survival rate of

immediately loaded implants (Rocci et al.

2003a); however, the influence of the

rough as opposed to machined surfaces

was not significant.

Review papers on immediate loading

have addressed additional biomechanical

aspects of this procedure (Szmukler-Mon-

cler et al. 2000; Gapski et al. 2003; Chia-

pasco et al. 2004). Based on different

experimental studies, they have stated

that a micromotion threshold should not

be exceeded; otherwise, osseointegration

would be hindered. The critical threshold

seems to be 50–150 mm (Maniatopoulos

et al. 1986; Pilliar et al. 1986; Szmukler-

Moncler et al. 1998). Therefore, it has been

claimed that a high initial stability is ne-

cessary for immediate loading of dental

implants (Chaushu et al. 2001; Calan-

driello et al. 2003a). For this purpose, these

authors used modified drilling protocols

combined with bone compaction with

osteotomes to achieve increased primary

stability.

Some authors have chosen insertion tor-

que as a measure of implant stability, and

arbitrarily selected torque values of 32, 35,

40 N cm and higher have been chosen as

thresholds for immediate loading (Wohrle

1998; Hui et al. 2001; Lorenzoni et al.

2003). However, successful immediate

loading of an implant with an insertion

torque of 15 Ncm has been shown under

some conditions (Calandriello et al.

2003a). Until now, there has been no

reported controlled study that has com-

pared the relationship of different implant

stability levels with the implant survival

rate. Consequently, there is currently no

proven threshold value that indicates that

immediate loading will be successful.

Besides high initial stability, it has been

stressed that immediately loaded implants

in multi-unit situations should be rigidly

splinted by their superstructures (Nikellis

et al. 2004; van Steenberghe et al. 2004). In

order to optimize splinting, metal rein-

forced superstructures have been used;

however, it could be shown that high

success rates may be achieved with super-

structures that were not metal reinforced

(Nikellis et al. 2004). Again, there are no

evidence-based data that support the hy-

pothesis that superstructures supported by

immediately loaded implants should be

metal reinforced.

As rigid splinting is not possible for

single-tooth implants, immediate restora-

tions without or with reduced occlusal

contacts have been advocated for single-

tooth implants by some authors (Wohrle

1998; Ericsson et al. 2000; Chaushu et al.

2001; Kan et al. 2003). Again, there is no

evidence-based protocol for loading of sin-

gle-tooth implants.

The experience in immediate occlusal

loading of dental implants has led to three

consensus papers (Aparicio et al. 2003;

Cochran et al. 2004; Misch et al. 2004a,

2004b). All of them accept immediate

loading in the edentulous mandible,

which is the most common indication

for immediate loading. Randomized-con-

trolled trials have shown that survival and

success rates of immediately loaded im-

plants in the edentulous mandible are

comparable to those with conventionally

loaded implants (Chiapasco et al. 2001;

Romeo et al. 2002).

Immediate occlusal loading of prostheses

supported on multiple implants in partially

dentate subjects has a high level of evi-

dence, and a randomized-controlled study

is available (Cannizzaro & Leone 2003). In

this configuration, an implant survival rate

has been found comparable to that of con-

ventionally loaded implants.

In controlled studies, the survival rate of

immediately restored single-tooth im-

plants was comparable or slightly lower

than that of conventionally loaded single-

tooth implants (Ericsson et al. 2000; Can-

nizzaro & Leone 2003). The former had a

restoration placed immediately, and occlu-

sal contacts were removed or avoided (Ta-

ble 6). Some authors even tried to protect

these implants from forces exerted by the

tongue or soft food by using occlusal splints

(Lorenzoni et al. 2003). To date, there are

no controlled studies that would permit

evidence-based decisions as to whether

single-tooth implants can be loaded imme-

diately or should only be restored without

occlusal contacts.

It seems that planning for immediate

loading of dental implants is facilitated by

advanced imaging techniques. These tech-

niques allow for selection of implant sites

that have the highest Hounsfield values,

which correlate with denser bone (Jaffin et

al. 2004). Moreover, flapless implant pla-

cement becomes easier as conventional

bone mapping is no longer necessary. The

implant positions can be virtually planned

and precisely transferred to the clinical

situation using CAD/CAM-derived surgi-

cal templates (van Steenberghe et al. 2005).

Additionally, the implants can be rigidly

splinted directly after placement using a

prefabricated, passively fitting superstruc-

ture. High implant survival and success

rates have been described for this technique

in multicentre studies (van Steenberghe et

al. 2005); however, randomized-controlled

studies are necessary to test whether this

treatment option is superior to standard

techniques.

Conclusions

The compilation of the current literature

shows that several different approaches to

immediate loading can lead to survival

rates in controlled studies comparable

with those of conventionally loaded im-

Nkenke & Fenner . Immediate loading of implants and implant success

31 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 19–34

plants. This is true for edentulous as well

as partially dentate situations; however,

these studies are only based on small case

numbers.

At the moment, it is not possible to

draw conclusions concerning exclusion

and inclusion criteria for immediate

loading, threshold values for implant

stability that allow immediate loading,

bone quality needed for immediate

loading and the relevance of immediate

functional loading and immediate non-

functional loading under certain

conditions.

More controlled studies with larger pa-

tient numbers are needed to make immedi-

ate loading of oral implants completely

evidence based.

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