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dc. Maurizio Serafini

Clinical Cases

Oral Implantology

One to One Immediate Load Implant

Immediate load is a technique which allows to place titanium implants and temporary crowns on top, immediately after or within 24-48 hours from surgery.

Definition

A one-to-one immediate load implant is a perfectly balanced implant between the edentulous width and the number of implants inserted, so that the load on a wide area of spongy and cortical bone is dispersed.
Immediate load is a technique which allows to place titanium implants and temporary crowns on top, immediately after or within 24-48 hours from surgery. Of course first it is necessary to take an analysis of the quantity and quality of the bone available in the region where the rehabilitation with immediate loading is performed.
The immediate load originates as a need to promptly minimise the patient's functional and aesthetic deficit. It is a rapidly expanding technique, also thanks to scientific studies carried out by researchers and prestigious producing companies on the mechanical and physical-chemical properties of the implants and on the histological interactions of the bone-implant interface.

Occlusion problems

Implant occlusion must be carefully evaluated - especially the neuromuscular one, that is, the occlusion determined exclusively by the muscle and the proprioceptive system – in order to avoid implant fractures due to overload and implant loss.
It occurs when the overimplant prosthesis transfers its occlusal load on every implant pillar connected. .

The choice of manufacturing single crowns has a double function: primarily for oral hygiene purposes, and secondly in order to achieve an appearance similar to natural teeth.
This obviously affects the mucogingival aspect.

Historical background

The first pioneers to use immediate load implants in Italy were S. Tramonte, D. Garbaccio, Pierazzini, U. Pasqualini , G. Muratori, S. Lobello, A. Morra Greco, N. Marini and M.S. Formiggini, while in the US they were L.Linkow, A. J. Viscido, L. C. Ward, Lew, Weiss, and many more in Europe.

Of course the implants of 50 years ago did not have the same characteristics as the modern ones. Apart from the different materials used (titanium or steel), they were only turned smoothly and in order to load them they had to be welded using an electro welded tube.

New implant concepts

The implants used for case reports adopting the immediate load technique are self tapping with deep spirals gradually thicker in an apical-coronal direction, allowing to efficiently discharge forces and providing excellent initial stability.
Since they break down forces into different vectors, they are better absorbed by the surrounding spongy tissues and are reassembled till they are completely annulled into the cortical tissues. At the same time, the cylindrical implant reacts dispersing the forces onto the last spiral.
In order make the concept clearer, here are some images showing the biomechanical behaviour of the implants, as documented in an experimental study using the photo-elastography technique.

The cone-shaped or root - form implants should be mainly used in immediate implant placement into extraction sites, although they can be also used in surgical alveolar.

These implants can be inserted in all types of bones from D1 to D4 because as they penetrate they determine vertical and horizontal osteocondensation allowing for an excellent primary stability.

Another engineering innovation is the so-called “tapered” implant, which despite maintaining the same shape and spirals, presents a shoulder screw increasing the volume in between the implants called biological surface. This determines a better vascularisation of the papilla stroma (true papilla) .

The implant surface is treated with sandblasting and double acid mordanting inducing a porosity ranging from 0.5 to 20 - 40 micron, determining a high BIC (bone implants contact).

After these procedures the wettability of the implant is high and thus allows the blood to coagulate on the surface, creating the conditions for the fibrin matrix to adhere and inducing contact osteogenesis.

The latest research by BIOMET 3i has discovered an implant which, as well as preparing the surface as described above, uses applied nanotechnology through Discrete Crystalline Deposition of calcium phosphate (DCD).

In order to use the immediate load technique, the implant has to have an excellent primary stability because initially it is mainly a mechanical phenomenon. Later progressive bone remodeling leads to osseointegration, that is, cells colonise the wrinkled surface of the implant becoming one thing.

Can immediate load implants always be used?

No, because they respond to precise bone rules in qualitative and quantitative terms. If they cannot be used, deferred implants will be utilised instead.

For a detailed explanation see “Split-crest”, the other case report published.

Case reports:

1st Case report

75-year-old female patient with a mobile prosthesis, suffering from resin allergies and wanting to have an implant inserted.
After blood examinations, within regular levels, and a computerised bone mineral measurement of the spine and femur – since she had been taking Strontium ranelate for two years, maintaining her in perfect bone balance – she underwent implant surgery.
Images 1-2-3-4 show the dental scan and orthopantomography necessary to perform surgery.

Image 5 shows the upper arch from a clinical point of view.

Image 6 shows venous blood samples that after centrifugation separate forming Platelet-Rich Plasma (PRP). Image 6/b shows growth factors for bone regeneration.

Image 7: surgical guide testing, left upper part.

Image 8: implant placement with mounted abutments - to be made parallel - left upper part.

Image 9: surgical guide, right upper part.

Image 10: implant placement with mounted abutments - to be made parallel - right upper part.

Image 11: Before...

Image 12: And after

Images 14 and 15 show the definitive titanium-ceramic single crowns

After two years the patient returned for a check-up because of a moving incisor (image 16)

X-ray (image 17), we opted for the placement of two implants.

Image 18: surgical site after tooth avulsion and huge crater bearing on the left upper incisor

Image 19: implant placement and left implant dehiscence

Image 20: dappen dish with bone extracted from the surgical site of the right incisor

Image 21: bone grafting

Image 22: sutures and temporary elements

X-ray after 6 months. Image 23: negative

The definitive prosthesis is made of titanium-ceramic single teeth (image 2).


2nd Case report

50-year-old female patient with an implant placed in 2001 in the upper left part and a fixed prosthesis in the right part. Given the good results, she decided to replace the old prosthesis with implants in the toothless parts.

After the prosthesis was taken out, one could notice an advanced decay on the eight tooth, with destruction of the supporting crown.

A pivot stump was inserted on 1.1 together with 4 implants, of which one was an immediate implant placement into the extraction site 1.8 with crestal sinus lift.

Orthopantomography after surgery,

abutments placed in the same sites

and temporary prosthesis

The patient returned after four months and an x-ray examination was performed (notice the bone formation on the inserted implant 1.7), image 12.

Definitive galvano-ceramic prosthesis of single teeth (images 13 - 14).

3rd Case report

54-year-old male patient who has been carrying a mobile prosthesis for years, not by choice, but because of frequent international travels making it impossible to have deferred implants. He recently decided to have an immediate load implant. Therefore, at first 6 implants were inserted to fill the gaps of the mobile prosthesis and as soon as he comes back the sinus will be lifted via crestal approach and other five implants will be placed to establish a normal occlusion, like in the 3D model (images 1-2-3-4-5).

Clinical examination:

After diagnostic waxing, a temporary reinforced structure was created serving also as a template before surgery with points of reference traced.

Images 10 and 11 show blood samples that after centrifugation separate into two layers: an upper layer with PRP and a lower one consisting of a heavier corpuscular part.

Image 12 shows an x-ray after surgery, while images 13 and 14 show inserted abutments to be made parallel.

Images 15 and 16 show the temporary prosthesis on site.

Image 18: zirconia-ceramic definitive teeth, frontal view
Image 19: occlusal view
Image 20: right lateral view
Image 21: left lateral view