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Introduction
Definitions
Bone physiology
Loading protocols
Progressive loading
Conclusion
References
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INTRODUCTION
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High success rates of implants and the advantages that
go with them have earned them the name of the "third
dentition".
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Various factors like bone strength, volume, density,
biocompatability of implant materials, design of implant,
and forces or LOADS acting on the implant play an
important role in establishing a good bone to implant
interface.
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If the treatment plan provides adequate support, the three most
common causes of early prosthetic implant failure are :
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WHAT IS LOAD ?
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Horizontal loads like perioral forces of tongue and
circumoral musculature.
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Progressive Loading (1998): the gradual increase in the
loading.
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The concept of progressive or gradual loading during prosthetic
reconstruction is to decrease crestal bone loss and early implant
failure.
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EVOLUTION OF CONCEPTS OF
IMPLANT LOADING
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About 25 years ago, Branemark et al (1977) published the
first long-term follow-up (15 years) on oral implant,
providing the scientific foundation of modern dental
implantology.
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BRANEMARK’S ORIGINAL PROTOCOL :
Stage II Surgery or
Prosthesis Placement
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PROTOCOLS OF IMPLANT LOADING
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1.BRANEMARK’S LOADING PROTOCOL
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The surgical and prosthetic protocols for the development
of a predictable direct bone-to-implant interface with root-
form implants were developed and reported by Branemark
et al.
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Consequent to their 10-year clinical experience, they
asserted that osseointegration required a long healing
period of atleast 3months in the mandible and atleast 5-6
months in maxilla.
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– The necrotic bone at the implant bed border is not
capable of load-bearing and must be first replaced by
new bone
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ADVANTAGES OF BRANEMARK’S PROTOCOL:
DISADVANTAGES:
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BONE PHYSIOLOGY IN LOADING
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Wolff’s law states that “Every change in the form and
function of bone or their function alone is followed by
certain definite changes in their internal architecture and
equally definite alteration in their external conformation
in accordance with mathematical laws.”
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A decrease of 40% in CORTICAL BONE and 12% in
trabecular bone is reported by disuse.
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Bone quality is one of the key determinants to ensure
Primary Implant Stability, which is the key to a successful
osseointegration.
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Ideal bone for implant prosthetic support is lamellar bone
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periotest
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By reducing the risk of fibrous tissue formation, by
minimizing woven bone formation and promoting lamellar
bone maturation we can achieve success through implant
loading.
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2. PROGRESSIVE LOADING
PROTOCOL
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Concept of progressive loading/
gradual bone loading
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submerged implant-loading after 3-6 months of initial
healing.
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5 prosthodontic steps are suggested for the
reconstruction of the partial or completely edentulous
patient, with endosteal implants supporting a cemented
prosthesis.
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The loading forces applied to the newly integrated
implants are gradually increased through the use of
provisional restorations and dietary modifications.
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At each appointment, the provisional restoration is
modified or replaced in an attempt to progressively
increase the occlusal contact and to develop the desired
occlusal scheme.
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ELEMENTS OF IMPLANT LOADING
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ELEMENTS OF IMPLANT LOADING
Time interval
Diet
Occlusal material
Occlusal contacts
Prosthesis design
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1. TIME INTERVAL
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2.DIET
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This diet not only minimizes the masticatory force on the
implants but also decreases the risk of temporary
restoration fracture or partially decemented restoration.
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3.OCCLUSAL MATERIAL
Initial healing period- no occlusal material over implant
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4.OCCLUSAL CONTACTS
No occlusal contacts are permitted during initial healing .
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5.PROSTHESIS DESIGN
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In the second acrylic transitional restoration, occlusal
contacts are placed on the implants with occlusal tables
similar to the final restoration but with no cantilevers in
nonesthetic regions.
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PROGRESSIVE LOADING
PHASES
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The progressive bone loading appointment sequence (for
cement retained prosthesis) is as follows.
1st appointment :-
– Laboratory phase 1
2nd appointment :-
– Laboratory phase 2
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3rd appointment
– Metal try in
– Laboratory phase 3
4th appointment
5th appointment
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APPOINTMENT - 1
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2. 2nd stage surgery done to expose implants
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3. Radiographic assessment done
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4. Abutments or transfer copings fixed after
permucosal extensions are removed
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5. Making preliminary impression
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7.Mounting the casts with bite registration record
after preliminary impressions
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8. Preperation of 1st and 2nd transitional
prosthesis with acrylic
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APPOINTMENT 2
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For a straight implant, a one piece abutment is inserted
by hand into position with about a 10-N/cm force.
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The dentist also may reline the transitional prosthesis to
foster soft tissue healing and create an improved
emergence profile.
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10. Make the final impression after fixing the prepared
abutments into implants intraorally to obtain definitive
casts having separate dies.
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10.Fixation of transitional prosthesis-1 (with out
occlusal contacts)
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11.Fabricatin of wax patterns and metal
substructure
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APPOINTMENT -3
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13. fixation of transitional prosthesis -2
( with occlusal contacts)
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APPOINTMENT - 4
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15. Radiographic Examination Of Final
Prosthesis And Bone For Crestal Bone Loss.
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APPOINTMENT-5
The dentist evaluates retention first. If retention is
adequate, the dentist does not remove the restoration and
uses the soft access cement for the definitive restoration.
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Some modifications – are included with fabrication of full
arch restorations.
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Phases:
1st appointment - abutment selection & preliminary
impression
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APPOINTMENT – 1- initial abutment selection and
preliminary impression
- Fabrication of treatment prosthesis– to restore OVD,
correct tooth position.
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Place denture and clear template in mouth and record a bite
registration.
Place abutments into the implant bodies- & place template with
template.
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Using this template as custom tray for closed tray impression –
make preliminary impression using putty material.
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Lab phase I
- Pour impression with dental stone
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- Adjust the abutment in length, angulation & proper clearance for
crown contours.
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Care should be taken:
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2nd appointment – final impression and transitional
prosthesis I
Remove the permucosal extension and inserts the final
Place the clear template into mouth and evaluate abutment for
their position.
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Make an impression and occlusal registration when the
transitional prosthesis has the correct incisal edge, vertical
dimension and necessary prosthetic guidelines.
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Carefully evaluates the occlusal contacts .
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Lab phase II
Make wax-up of the final restoration & then cut backs
2mm for porcelain thickness in the appropriate regions.
Then fabricate the metal framework.
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3rd appointment- metal try-in & transitional
prosthesis II
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fixation of transitional prosthesis- 2
no nonworking and
working occlusal contacts
pontic areas and angled
abutments- light contact.
Heavier contacts are
developed on the implants
in ideal position.
No cantilevers unless
need for esthetics
occlusal scheme similar
to the final
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4th appointment- initial delivery
- 2to 4 weeks later
- Marks initial delivery of final restoration
- Adjust final occlusion as indicated
- Use soft access cement in the restoration.
- Stress on oral hygiene maintainence
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APPOINTMENT -5- final delivery
4 weeks later.
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The dentist may use harder cement (e.g., zinc phosphate)
on the most distal and anterior abutments when
cantilevers are present because tensile forces are more
likely on these positions.
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Conclusion
Maintenance of rigid fixation during the first year of prosthesis
construction and function with minimum bone loss is related to
the bone remodelling process.
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Gradual increase in loads permits :
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