Implant Loading Protocols For The Partially Edentulous Esthetic Zone
Implant Loading Protocols For The Partially Edentulous Esthetic Zone
Implant Loading Protocols For The Partially Edentulous Esthetic Zone
Purpose: The scientific evidence related to different or novel implant loading (primary objective) and
directly associated implant placement (secondary objective) protocols developed for the anterior maxil-
lae of partially edentulous patients was reviewed. Materials and Methods: A comprehensive search of
electronic databases and a hand search of six relevant journals was performed. The principal outcome
variables were implant survival, implant success, and esthetic appearance. Concerning esthetic treat-
ment outcomes, articles were specifically screened for the presence of objective evaluation parameters
and patient satisfaction assessment. Results: The analysis of the literature on immediately restored or
conventionally loaded implants in the esthetic zone revealed an initial survival rate of 97.3% after 1
year (10 prospective cohort studies and one case series). For periods of 1 to 5 years, the survival rate
was 96.7%. These survival rates are consistent with previous reports on more traditional loading
modalities. However, for immediately placed implants with immediate restoration and occlusal loading,
the survival rate dropped by approximately 10% (four studies). Success criteria such as stable crestal
bone levels, soft tissue recession, and probing depth could not be evaluated on the basis of the avail-
able literature. Conclusion: There is a paucity of prospective cohort studies addressing patient-cen-
tered outcomes. No parameters specific to immediate loading protocols were available for evaluation.
In order to validate or reject such implant protocols for use in the esthetically sensitive anterior maxilla,
long-term clinical trials should routinely include objective esthetic criteria that comprehensively
embrace the pertinent elements of “pink and white esthetics” in the form of readily used indices. INT J
ORAL MAXILLOFAC IMPLANTS 2009;24(SUPPL):169–179
Key words: anterior mandible, anterior maxilla, dental implants, esthetics, fixed dental prostheses,
loading protocol, partial edentulism, single crown, systematic review
n implant placement and implant loading proto- established in the 1980s, suggesting a healing period
I cols, there has been an increasing trend in recent
years toward reducing both the time between tooth
of approximately 3 months after tooth removal and
an osseointegration period of 3 to 6 months after
extraction and implant insertion, and the delay implant placement, although leading to highly pre-
between implant placement and implant restoration. dictable outcomes, are currently more and more chal-
In fact, the traditional, more conservative guidelines lenged. Furthermore, according to numerous authors,
patients appear to be increasingly interested in
reduced treatment time between tooth removal and
delivery of the final implant-supported prosthesis,
provided the level of predictability established dur-
1Assistant Professor, Department of Fixed Prosthodontics and ing the previous two decades is maintained.
Occlusion, School of Dental Medicine, University of Geneva,
In the extreme, this involves insertion of an
Geneva, Switzerland.
2Professor and Chair, Department of Fixed Prosthodontics and implant immediately after tooth extraction, poten-
Occlusion, School of Dental Medicine, University of Geneva, tially using simplified procedures such as flapless
Geneva, Switzerland. surgery, and subsequent restoration of the implant in
the same session. Ultimately, this combination may
The authors reported no conflict of interest.
not only lead to a reduction in the overall treatment
Correspondence to: Dr Linda Grütter, School of Dental Medicine, time, but may also substantially decrease the associ-
University of Geneva, Rue Barthelemy-Menn 19, CH-1205 Geneva, ated costs. Furthermore, it has been claimed that the
Switzerland. Fax: +41 22 379 4052. Email: [email protected] described approach is clearly associated with
This review paper is part of the Proceedings of the Fourth ITI Con-
reduced surgical procedures and may more effi-
sensus Conference, sponsored by the International Team for Implan- ciently preserve the existing bone and soft tissues at
tology (ITI) and held August 26–28, 2008, in Stuttgart, Germany. the site of implantation.1–7
Grütter/Belser
With occlusion
Immediate
restorations
Without occlusion
Early
With occlusion (3)
placement
Early restorations
Without occlusion (1)
To date, several articles have provided evidence • How does immediate/early implant loading/
that the results associated with shortened treatment restoration compare to traditional delayed/late
times after tooth extraction,8 termed immediate or loading in terms of implant survival, implant suc-
early implant placement, and/or after implant place- cess, and long-term esthetic treatment outcome?
ment,9 termed immediate or early implant restoration, • Does the combination of immediate/early implant
may under well-defined conditions be similar to placement and immediate/early implant restora-
those reported for conventional protocols.8–11 In a tion affect (positively or negatively) implant sur-
consensus report based on eight case series studies vival, implant success, and long-term esthetic
encompassing a total of 197 implants, Ganeles and treatment outcome?
Wismeijer stated that immediate implant restorations
in extraction sockets appear to have longitudinal As a consequence, two distinct working hypothe-
bone loss and soft tissue stability similar to those ses were tested:
observed for traditionally loaded implants.12
Currently, the number of scientific mid- and long- • There is no correlation between implant loading/
term reports on combining immediate implant restoration protocols (immediate/early/late) and
restoration with immediate implant placement is still long-term implant success and esthetic outcome
limited. This is particularly true for information related of anterior maxillary fixed implant restorations.
to fixed implant restorations in the partially edentu- • There is no correlation between the combination
lous anterior maxilla that specifically comprises treat- of various implant placement/implant restoration
ment outcome data based on objective esthetic protocols (immediate/early/late) and long-term
criteria. implant success and esthetic outcome of anterior
The aim of this review was to screen the recent lit- maxillary fixed implant restorations.
erature for scientific evidence related to different or
novel implant loading (primary objective) and A diagram depicting the 15 theoretically possible
directly associated implant placement (secondary treatment modalities based on the combination of
objective) protocols developed for the anterior maxil- the 3 main variables timing of placement, timing of
lae of partially edentulous patients. In this context, restoration, and presence or absence of direct occlusal
the following questions were addressed: contacts is presented in Fig 1.
Group 3
Grütter/Belser
Table 1 Studies Reporting Immediate, Early, and Delayed Loading Protocols of Anterior Implants
Immediate Early Delayed
restoration restoration restoration
Time of (patients/ (patients/ (patients/
Implant Total
placement implants) implants) implants)
Study system/ no. of Delay
Study design surface implants Immed E L Occl No occl Occl No occl period Occl No occl
Prosp = prospective; Retrosp = restrospective; RCT = randomized controlled trial; ant = anterior; max = maxilla; CI = central incisor; LI = lateral incisor; CA = canine;
Group 3
PM = premolar; mand = mandible; immed = immediate; NA = not applicable; occl = occlusal; no occl = not occlusal; E = early; L = late.
Grütter/Belser
Table 1 continued Studies Reporting Immediate, Early, and Delayed Loading Protocols of Anterior Implants
Immediate Early Delayed
restoration restoration restoration
Time of (patients/ (patients/ (patients/
Implant Total
placement implants) implants) implants)
Study system/ no. of Delay
Study design surface implants Immed E L Occl No occl Occl No occl period Occl No occl
Prosp = prospective; Retrosp = restrospective; RCT = randomized controlled trial; ant = anterior; max = maxilla; CI = central incisor; LI = lateral incisor; CA = canine;
Group 3
Grütter/Belser
Table 2 Studies Reporting Immediate, Early, and Delayed Loading Protocols of Anterior Implants Fulfilling All Inclusion Criteria
Immediate Early Delayed
restoration restoration restoration
Time of (patients/ (patients/ (patients/
Implant Total
placement implants) implants) implants)
Study system/ no. of Delay
Study design surface implants Immed E L Occl No occl Occl No occl period Occl No occl
The studies highlighted with a darker background identify those comprising two distinctly different cohorts (test/control).
Prosp = prospective; Retrosp = restrospective; RCT = randomized controlled trial; ant = anterior; max = maxilla; mand = mandible; CI = central incisor; LI = lateral incisor; CA = canine;
Group 3
PM = premolar; NA = not applicable; occl = occlusal; No occl = No occlusal; Immed = immediate; E = early; L = late.
esthetic point of view in particular.10,11,15 In this con- short- and mid-term implant survival and success
text, the pertinence of evaluation tools such as the rates similar to those of more traditional treatment
PES/WES index for the objective outcome assessment approaches. However, when it comes to their routine
of the esthetic dimension of anterior single-tooth implementation in the anterior maxilla, these proto-
implants has been confirmed. cols may lead to less favorable results from an
Implant dentistry has constantly evolved toward esthetic point of view, as for example recessions of
simplification of clinical procedures and shortened the facial peri-implant mucosa. In fact, the recently
treatment times, with such developments as flapless published evidence suggests that immediately
surgery and immediate implant placement.39–41 Stud- placed but not yet restored implants in the esthetic
ies that have applied these protocols mostly report zone yield a significant number of sites with soft tis-
Grütter/Belser
Group 3
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