Prgressive Load in Modern Oral Implantology, Concepts, Principles and Case Report.

Dr. Ivn Navarro, Fellowship in Oral Implantology, University of Miami, JMH Dr. Adrian Brenes, Resident of Maxillofacial Surgery, Javeriana University, Colombia. Dr. Mauricio Clare, General Dentist, Prosthodontics Internship, UCR

Summary The following article presents a new concept derived from the immediate load, which is called Progressive load, illustrated with a clinical case and answering the questions of WHEN, WHERE, HOW AND WHY?, often questions that present themselves while facing clinical cases in the professional development of the Oral Implantlogy of our time. At the end of this article, the clinician will be able to determine the different Implant treatment alternatives, in cases where it is convenient to charge early dental implants. Introduction In previous articles we have defined immediate load from its pure concept, as it is presented to us by Dr. Carl Misch, describing Immediate loadging as the occlusal charge within the first 2 weeks after the implant placement. Many concepts derived from this one have developed as are, Early occlusal loading: between 2 weeks and 3 months after the implant placement. Nonfunctional immediate restoration: implantsupported restoration within the first 2 weeks after the implant placement with no direct occlusal charge. Delayed occlusal loading: Restoration with occlusal charge 3 months after the implant placement. Nonfunctional early restoration: implantsupported restoration between 2 weeks and 3 months after implant placement with no direct occlusal charge. All concepts that apply to our implant treatment which otherwise organize the different clinical applications before us. Different authors have presented us the concept of Progressive load, defined as the immediate charge that dental implants, with provisional restorations, are subjected to within the first two weeks in being placed, without direct occlusal contact, using different dental materials (acrylics), and progressively increasing the occlusal contact in the provisional restoration. In order to make a predictable professional practice, we have given ourselves the task of answering the following questions, that apply to our dental implant treatment, When, Where, How and Why? And so, being able to orient the proper functioning of our treatment. BODY We begin our theoretical framework with the objective of applying the different concepts to answer the first question, WHEN you can dental implants be immediately load? It is described that the main thing to think or consider immediately loading dental implants is its initial stability, this, from the scientific point of view, is presented as having more than 35 Newton per square centimeter. N/cm2 of initial stability, where most trading houses agree on this number. The second question in our reasoning is HOW this procedure should be performed? Here we will focus on running all the concepts to develop provisional restorations free of occlusal charges and of interproximal contacts, another concept that we must consider is to place the dental implants in parallel to the longitudinal axis of the roots,

in order to obtain compressive forces and thereof have greater ease at the time of restoration. We must be emphatic that the use of the surgical guide is essential for optimal results. We focus on the third part of the reasoning of our article that leads to the question WHERE should we place the implants that can be immediately or early load? Is very logical to go back to the different classifications of bone density in Oral Implantology, but this time we will use the one from Dr. Carl Misch, which in a very simple states, such as D1, the most cortical bone found in the mandibular symphysis, thus it will be the place of the oral cavity where we will find a greater initial stability of dental implants immediately upon placement, likewise, sequentially we will find the D2 and D3, spongy cortical bone density, located in the posterior mandible and front maxilla, described in literature as suitable sites for immediate loading procedures in dental implants. Finally, the bone density that has the lowest initial stability to load dental implants immediately is the D4, porous or spongy bone lacking cortical bone in most cases.

Fig. 1 Preoperative x-ray, congenital absence.

The last question that remains to be developed is WHY? This question directs us to scientifically explain why dental implants are integrated when they are immediately load, for it we will take two fundamental concepts, the first is known as the phenomenon of accelerated bone repair, which has its basis on traumatology, where it is defined as an internal bone bleeding, immediately after the cause of trauma to the bone, known in the specialty of periodontics as bone decortification, which releases various growth factors and repair substances, developing a favorable environment for an adequate osseointegration. The second concept which is essential for success where dental implants are early or immediately loaded, is the occlusal load that these implants will be subject to. For the above, we will take the physical concept of Stress = Force / Area, S=F/A, taking Stress as the different loads, overloads or occlusal contacts that the implants will undergo during the osseointegration process. The factors of Force will be defined as all the processes that increase the Stress, therefore

it will be all that is detrimental to the proper bone healing and thus the success of the treatment, they are: habits, bruxism, angulation of the implants, cantilever, pontics, individually restored implants, implants occluding against natural teeth, bone grafts and membranes. Furthermore the factors of Area are those that reduce Stress, thus favoring the proper development of the osseointegration process, they are: Number of implants, the implant's longitude, diameter of the implants, occlusion against dental prosthesis, premolarization of the dental crowns, splinting of the implants. Two factors that can be framed as much as a force factor or an area factor are the patient's age and bone density, therefore the D1 density will offer a lower Stress, however, the implants placed in the D4 density will be under greater Stress, likewise the young patients have a greater ability to bypass them therefore they have a greater healing that leads to a more favorable osseointegration of dental implants.

Fig. 2 Surgical Guide implants in 3.3, 3.2, 4.3, 4.2

Fig. 3 Incision and alveolar plasty

Clinical Case Considering all of the above we have selected a very predictable case, a male patient of 20 years with congenital absence of the front jaw incisors. After clinical and radiographic analysis, a surgical guide and a prosthetic treatment plan is made, which decided to rehabilitate the patient with a metal porcelain permanent bridge composed of six units, so four dental implants will be placed in positions of 3.3, 3.2, 4.2 and 4.3, leaving two pontics in position of 3.1 and 4.1, at the moment of surgery we will to take an impression of the implants, to make the pillars and an acrylic permanent bridge that will be placed 2 weeks after surgery, periodic inspections of the case will be made to rehabilitate the patient completely 6 months after the implant placement. It is important to note that the patient is left with an occlusal free of eccentric contacts especially the protrusion contacts which would be very harmful in this particular case. In this particular case we used the Intralock system, placing implants of 4.0mm in diameter and 13mm long, in position of 3.3 and 4.3, likewise we placed implants of 3.3mm in diameter and 13mm long in position of 3.2 and 4.2, the implants are of internal connection system from Morse Taper and inverted Spline.

Fig.4 Initial osteotomy in implant position

Fig.5 Parallel pins according to the surgical guide

Fig. 6 Final placement of the implants

Fig.7 Immediate control x-ray

Fig. 8 Immediate impression in surgery

Fig. 9 Straight pillars to make the immediate temporary bridge

Fig. 10 Placed pillars 2 weeks post surgery

Fig. 11 Immediate acrylic bridge, 2 weeks post surgery

Fig. 12 Rx. Control 5 months post surgery with the final straight pillars, ready for the final rehabilitation

Fig. 13 y 14 Final stone model for work and final metallic structure

Fig. 15 Processed metal porcelain bridge

Fig. 16 Passive metallic test, 6 months post surgery

Fig. 17 Final metal porcelain bridge, occlusal view

Fig. 18 Control, one year after the rehabilitation

Fig. 19 X-ray control, one year post rehabilitation

Discussion It is very clear in our time, the Oral Implantology has made great strides, all dental implant companies have budgets for research and continuing education for its users, just as it has developed new trends, different types of surfaces, designs and types connections in endosseous dental implants. We cannot overlook in our time the different options that will favor our patients by developing an implant practice that offers immediate or progressive charging, it is definitely our duty to establish the parameters for an adequate and predictable osseointegration of dental implants which are subject to earlier charges. If you want to use the answers to the questions, "When, How, Where and Why? As a guide to predictably attain success in our dental implant treatments, we can say that initially, we should be clear that the initial stability of implants is critical (torque higher than 30 N/cm2), that they are free of direct occlusal contacts which produce

overloads or unwanted contacts during the process of osseointegration, also that the implants are placed parallel to each other and on the longitudinal axis of the tooth to be replaced, so that the occlusal force is compressive, likewise we would like that in most cases, that we will immediately restore, our implants are placed in optimum bone density (D1, D2, D3), using the longest and widest implant possible, and better yet, in cases of multiple implants, splinter each other. Finally the patient's age is a very important factor to consider and we must take into account the revascularization and the phenomenon of accelerated bone repair which is different in all of our patients, let us not forget the various force factors that will make our treatment a failure and all the area factors that will help us to succeed in a predictable way. Bibliography 1. Misch Carl E. Dental Implant Prosthetics. Primera edicin, Mosby, 2005 2. Friberg B, Sennerby L, Linden B, Grondahl K, Lekholm U. Stability measurements of one-stage Branemark implants during healing in mandibles. A clinical resonance frequency analysis study. Int J Oral Maxillofac Surg 1999;28:266-72. 3. Glauser R, Sennerby L, Meredith N, Ree A, Lundgren A, Gottlow J, Hammerle CH. Resonance frequency analysis of implants subjected to immediate or early functional occlusal loading. Successful vs. failing implants. Clin Oral Implants Res 2004;15:428-34. 4. Misch CE, Dietsh-Misch F, Hoar J, Beck G, Hazen R, Misch CM. A bone qualitybased implant system: first year of prosthetic loading. J Oral Implantol 1999;25:185-97. 5. Misch CE, Hahn J, Judy KW, Lemons JE, Linkow LI, Lozada JL, Mills E, Misch CM, Salama H, Sharawy M, Testori T, Wang HL. Workshop guidelines on immediate loading in implant dentistry. J Oral Implantol 2004;30:283-8. 6. Aparicio C, Rangert B, Sennerby L. Immediate/early loading of dental implants: a report from the Sociedad Espanola de Implantes World Congress consensus meeting in Barcelona, Spain, 2002. Clin Implant Dent Relat Res 2003;5:57- 60. 7. Morton D, Jaffin R, Weber HP. Immediate restoration and loading of dental implants: clinical considerations and protocols. Int J Oral Maxillofac Implants 2004;19(Suppl):103-8. 8. Romanos GE. Present status of immediate loading of oral implants. J Oral Implantol 2004;30:189-97. 9. Cooper LF, Rahman A, Moriarty J, Chaffee N, Sacco D. Immediate mandibular rehabilitation with endosseous implants: simultaneous extraction, implant placement, and loading. Int J Oral Maxillofac Implants 2002;17:517-25.

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