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Achieving immediate function with provisional prostheses after implant placement: A clinical report
Achieving immediate function with provisional prostheses after implant placement: A clinical report Kung-Rock Kwon, DDS, MSD, PhD,a Amit Sachdeo, BDS, MS,b and Hans-Peter Weber, DMDc College of Dentistry, Kyung Hee University, Seoul, Korea; Harvard School of Dental Medicine, Boston, Mass When using a conventional implant treatment protocol in edentulous patients, reduced function and comfort for up to 6 months after implant surgery is inevitable until bone healing is complete and a prosthesis is securely attached to the implants. The following report highlights 2 treatment modalities that enable immediate function by inserting provisional prostheses immediately after implant placement. (J Prosthet Dent 2005;93:514-7.)
C
onventional implant treatment protocols involved the placement of implants followed by a healing period of 3 to 6 months in a submerged or nonsubmerged placement.1 This protocol resulted in relatively long treatment periods from surgery to prosthodontic completion. According to the original recommendations of Branemark and Schroeder,2 these periods were necessary to allow for complete osteogenesis and woven bone remodeling into load-bearing lamellar bone prior to any occlusal loading. Shortly thereafter, some clinicians proposed early or immediate loading, with implant placement and prosthetic loading for edentulous patients at the same clinical visit or separated by 2 to 4 weeks.3-6 This approach was primarily applied in the mandible, where excellent primary implant stability can be achieved in the interforaminal region.7 Bone formation has been shown to be enhanced by adequate mechanical stimulation.8-10 Initially, the attachment of the implant to the bone is purely mechanical (primary stability).10 Thus, primary stability depends on the implant (dimension, design) and the implant bed (bone density). Over the course of bone healing, both mechanical and biological factors are important in implant anchorage (secondary stability).10 Several authors have reported the successful use of transitional implants for restoring both partially and completely edentulous patients.11,12 These authors concluded that this approach was more economical and feasible for immediate patient restoration that allowed for osseointegration of unloaded, submerged implants to occur free from prosthetic loads. An implant-retained overdenture, using 4 implants, represents another attempt to restore edentulous patients immediately.13-16 A rigid cross-arch bar that rigidly connects the implants a
Associate Professor, Department of Prosthodontics, College of Dentistry, Kyung Hee University; Visiting Assistant Professor, Department of Restorative Dentistry, Harvard School of Dental Medicine. b Advanced Graduate Fellow in Prosthodontics, Department of Restorative Dentistry, Harvard School of Dental Medicine. c Professor and Chairman, Department of Restorative Dentistry, Harvard School of Dental Medicine.
514 THE JOURNAL OF PROSTHETIC DENTISTRY
is recommended with this procedure.8,9,17 The purpose of this clinical report is to demonstrate 2 prosthetic treatment options for obtaining immediate function after implant surgery.
CLINICAL REPORT Patient 1: Provisional overdenture using transitional implants A 70-year-old edentulous woman, of Korean descent and with a resorbed alveolar ridge (Fig. 1), presented for treatment at the Department of Graduate Prosthodontics, Kyung Hee University, Seoul, Korea, following the long-time use of ill-fitting complete dentures. The patient complained of difficulty in mastication and tenderness of the supporting residual ridge due to the constant instability of the mandibular denture. Two, 4.1 3 12-mm implants (ITI standard form; Straumann AG, Waldenburg, Switzerland) were placed in the canine regions of the mandible. Four transitional implants (Chercheve; Astra Tech AB, Molndal, Sweden) were additionally placed in the area adjacent to the 2 implants (Fig. 2). The patient’s existing denture was used as the provisional overdenture and, after chair-side rebasing of the intaglio surface (Tokuyama Rebase; Tokuyama Dental, Tokyo, Japan), it was immediately placed. This immediate prosthesis was supported by the 4 transitional implants that were prepared as telescopic crowns (Fig. 3). Six months later and, after complete osseointegration of the 2 standard form implants, the definitive overdenture was constructed in the traditional manner,18 using a bar and clip attachment (Dolder; Cendres & Metaux SA, Biel-Bienne, Switzerland). The transitional implants were removed, and the definitive prosthesis was inserted immediately so the patient’s masticatory function could be maintained throughout the treatment process (Fig. 4).
Patient 2: Bar-supported overdenture using 4 implants A 77-year-old edentulous Korean woman presented with an atrophic mandible, complaining of an unstable VOLUME 93 NUMBER 6
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Fig. 1. Panoramic radiograph of resorbed residual ridge of Patient 1.
Fig. 2. Panoramic radiograph after placement of 2 implants and 4 additional transitional implants in edentulous mandible.
Fig. 3. Interim prosthesis for immediate function supported by transitional implants, allowing 2 other implants to osseointegrate.
Fig. 4. Removal of 4 transitional implants and attachment of bar prior to placement of definitive prostheses.
mandibular denture causing difficulty in mastication. Four airborne-particle–abraded and acid-etched implants (FRIALOC; Dentsply Friadent, Mannheim, Germany), 4 mm in diameter and 13 mm in length, were placed between the mental foramens of the mandible (Fig. 5). The implants were placed as far apart from each other as anatomically possible to optimize load distribution. A torque of 30 Ncm was applied when inserting the implants. An impression was made immediately after flap closure using vinyl polysiloxane impression material (Pentamix; 3M ESPE, St. Paul, Minn) in a metal perforated tray (COE impression Tray; GC America, Alsip, Ill). A rigid bar (CM-Bar; Cendres & Me´taux SA) was fabricated (Fig. 6) and inserted 3 days after surgery to assist in preventing potential micromovement caused by immediately loading the implants with the overdenture (Fig. 7). All steps for overdenture JUNE 2005
Fig. 5. Four implants placed between mental foramens of edentulous mandible in Patient 2.
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Fig. 6. Panoramic radiograph of 4 implants with U-shaped bar.
fabrication were completed before placing the implants, allowing the prosthesis to be inserted immediately after placement of the bar.
DISCUSSION Immediate loading of implants will be consistent with osteogenesis/osseointegration if excellent primary stability and splinting of multiple implants can be achieved to minimize the risk of excessive load creating an unfavorable amount of micro-movement of the implants.3 Consequently, the use of a minimum of 4 implants is recommended.3,13 Screw-type implants of at least 10 mm in length should be used.8 If this is not possible for various reasons, immediate loading of the definitive implants may not be a predictable choice. Transitional implants, as described for Patient 1, offer a valid alternative to provide a patient with immediate masticatory function without compromising osseointegration of the permanent implants. These transitional provisional implants render enough support for an interim removable prosthesis. The type of supporting bar system appears to be of lesser importance.19,20 The treatment modality using an implant-supported overdenture is a more predictable and simple option when restoring an edentulous mandible.7,17 This approach offers a benefit, especially to older patients, who frequently have difficulty with the stability and function of complete dentures. Four-year clinical and radiographic follow-up on the 2 patients revealed successful patient and implant/denture adaptation. The fact that both patients were able to leave with functional dentures, immediately after implant surgery, was a key deciding factor in accepting implant-supported overdentures as a treatment modality as opposed to conventional residual ridge-supported dentures.
SUMMARY Two different techniques for ‘‘immediate function’’ after implant placement, using an implant-supported 516
KWON, SACHDEO, AND WEBER
Fig. 7. Definitive overdenture supported by implants using U-shaped bar and clip attachment, allowing for immediate function.
mandibular overdenture, were presented. Both options help reduce the time between implant placement and restoration of the patient’s masticatory function, making implant treatment more acceptable to the patient. REFERENCES 1. Adell R, Eriksson B, Lekholm U, Branemark PI, Jemt T. Long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaw. Int J Oral Maxillofac Implants 1990;5:347-59. 2. Branemark PI, Hansson BO, Adell R, Breine U, Lindstrom J, Hallen O, et al. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scan J Plat Reconstr Surg Suppl 1977; 16:1-132. 3. Schnitman PA, Wohrle PS, Rubenstein JE, DaSilva JD, Wang NH. Ten-year results for Branemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Implants 1997;12:495-503. 4. Balshi TJ, Wolfinger GJ. Immediate loading of Branemark implants in edentulous mandibles. a preliminary report. Implant Dent 1997;6:83-8. 5. Randow K, Ericsson I, Nilner K, Petersson A, Glantz PO. Immediate functional loading of Branemark dental implants. An 18-month clinical follow-up study. Clin Oral Implants Res 1999;10:8-15. 6. Babbush CA, Kent JN, Misiek DJ. Titanium plasma-sprayed (TPS) screw implants for the reconstruction of the edentulous mandible. J Oral Maxillofac Surg 1986;44:274-82. 7. 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. 8. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with 1-to-5 year data. Int J Oral Maxillofac Implants 1997;12:319-24. 9. Lefkove MD, Beals RP. Immediate loading of cylinder implants with overdentures in the mandibular symphysis: the titanium plasma-sprayed screw technique. J Oral Implantol 1990;16:265-71. 10. Sennerby L, Roos J. Surgical determinants of clinical success of osseointegrated oral implants: a review of the literature. Int J Prosthodont 1998;11:408-20. 11. el Attar MS, el Shazly D, Osman S, el Domiati S, Salloum MG. Study of the effect of using mini-transitional implants as temporary abutments in implant overdenture cases. Implant Dent 1999;8:152-8. 12. Bohsali K, Simon H, Kan JY, Redd M. Modular transitional implants to support the interim maxillary overdenture. Compend Contin Educ Dent 1999;20:975-83. 13. Ledermann PD, Schenk RK, Buser D. Long-lasting osseointegration of immediately loaded, bar-connected TPS screws after 12 years of function:
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14.
15.
16.
17.
18.
19.
a histologic case report of a 95-year-old patient. Int J Periodontics Restorative Dent 1998;18:552-63. Romeo E, Chiapasco M, Lazza A, Casentini P, Ghisolfi M, Iorio M, Vogel G. Implant-retained mandibular overdentures with ITI implants. Clin Oral Implants Res 2002;13:495-501. Gatti C, Chiapasco M. Immediate loading of Branemark implants: a 24-month follow-up of a comparative prospective pilot study between mandibular overdentures supported by Conical transmucosal and standard MK II implants. Clin Implant Dent Relat Res 2002;4:190-9. Chiapasco M, Gatti C, Rossi E, Haefliger W, Markwalder TH. Implant-retained mandibular overdentures with immediate loading. A retrospective multicenter study on 226 consecutive cases. Clin Oral Implants Res 1997;8:48-57. Gatti C, Haefliger W, Chiapasco M. Implant-retained mandibular overdentures with immediate loading: a prospective study of ITI implants. Int J Oral Maxillofac Implants 2000;15:383-8. Zarb GA, Bolender CL, Eckert SE, Jacob RF, Fenton AH, Mericske-Stern R. Prosthodontic treatment for edentulous patients–complete dentures and implant-supported prostheses. 12th ed. St. Louis: Mosby; 2004;389-414. Oetterli M, Kiener P, Mericske-Stern R. A longitudinal study on mandibular implants supporting an overdenture: the influence of retention mechanism and anatomic-prosthetic variables on periimplant parameters. Int J Prosthodont 2001;14:536-42.
JUNE 2005
THE JOURNAL OF PROSTHETIC DENTISTRY
20. Naert IE, Hooghe M, Quirynen M, van Steenberghe D. The reliability of implant-retained hinging overdentures for the fully edentulous mandible. An up to 9-year longitudinal study. Clin Oral Investig 1997;1:119-24. Reprint requests to: DR AMIT SACHDEO HARVARD UNIVERSITY SCHOOL OF DENTAL MEDICINE DEPARTMENT OF GRADUATE PROSTHODONTICS 188 LONGWOOD AVENUE BOSTON, MA 02115 Fax: 617-432-0901 E-MAIL: [email protected] 0022-3913/$30.00 Copyright Ó 2005 by The Editorial Council of The Journal of Prosthetic Dentistry.
doi:10.1016/j.prosdent.2005.04.002
517
C
onventional implant treatment protocols involved the placement of implants followed by a healing period of 3 to 6 months in a submerged or nonsubmerged placement.1 This protocol resulted in relatively long treatment periods from surgery to prosthodontic completion. According to the original recommendations of Branemark and Schroeder,2 these periods were necessary to allow for complete osteogenesis and woven bone remodeling into load-bearing lamellar bone prior to any occlusal loading. Shortly thereafter, some clinicians proposed early or immediate loading, with implant placement and prosthetic loading for edentulous patients at the same clinical visit or separated by 2 to 4 weeks.3-6 This approach was primarily applied in the mandible, where excellent primary implant stability can be achieved in the interforaminal region.7 Bone formation has been shown to be enhanced by adequate mechanical stimulation.8-10 Initially, the attachment of the implant to the bone is purely mechanical (primary stability).10 Thus, primary stability depends on the implant (dimension, design) and the implant bed (bone density). Over the course of bone healing, both mechanical and biological factors are important in implant anchorage (secondary stability).10 Several authors have reported the successful use of transitional implants for restoring both partially and completely edentulous patients.11,12 These authors concluded that this approach was more economical and feasible for immediate patient restoration that allowed for osseointegration of unloaded, submerged implants to occur free from prosthetic loads. An implant-retained overdenture, using 4 implants, represents another attempt to restore edentulous patients immediately.13-16 A rigid cross-arch bar that rigidly connects the implants a
Associate Professor, Department of Prosthodontics, College of Dentistry, Kyung Hee University; Visiting Assistant Professor, Department of Restorative Dentistry, Harvard School of Dental Medicine. b Advanced Graduate Fellow in Prosthodontics, Department of Restorative Dentistry, Harvard School of Dental Medicine. c Professor and Chairman, Department of Restorative Dentistry, Harvard School of Dental Medicine.
514 THE JOURNAL OF PROSTHETIC DENTISTRY
is recommended with this procedure.8,9,17 The purpose of this clinical report is to demonstrate 2 prosthetic treatment options for obtaining immediate function after implant surgery.
CLINICAL REPORT Patient 1: Provisional overdenture using transitional implants A 70-year-old edentulous woman, of Korean descent and with a resorbed alveolar ridge (Fig. 1), presented for treatment at the Department of Graduate Prosthodontics, Kyung Hee University, Seoul, Korea, following the long-time use of ill-fitting complete dentures. The patient complained of difficulty in mastication and tenderness of the supporting residual ridge due to the constant instability of the mandibular denture. Two, 4.1 3 12-mm implants (ITI standard form; Straumann AG, Waldenburg, Switzerland) were placed in the canine regions of the mandible. Four transitional implants (Chercheve; Astra Tech AB, Molndal, Sweden) were additionally placed in the area adjacent to the 2 implants (Fig. 2). The patient’s existing denture was used as the provisional overdenture and, after chair-side rebasing of the intaglio surface (Tokuyama Rebase; Tokuyama Dental, Tokyo, Japan), it was immediately placed. This immediate prosthesis was supported by the 4 transitional implants that were prepared as telescopic crowns (Fig. 3). Six months later and, after complete osseointegration of the 2 standard form implants, the definitive overdenture was constructed in the traditional manner,18 using a bar and clip attachment (Dolder; Cendres & Metaux SA, Biel-Bienne, Switzerland). The transitional implants were removed, and the definitive prosthesis was inserted immediately so the patient’s masticatory function could be maintained throughout the treatment process (Fig. 4).
Patient 2: Bar-supported overdenture using 4 implants A 77-year-old edentulous Korean woman presented with an atrophic mandible, complaining of an unstable VOLUME 93 NUMBER 6
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THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. Panoramic radiograph of resorbed residual ridge of Patient 1.
Fig. 2. Panoramic radiograph after placement of 2 implants and 4 additional transitional implants in edentulous mandible.
Fig. 3. Interim prosthesis for immediate function supported by transitional implants, allowing 2 other implants to osseointegrate.
Fig. 4. Removal of 4 transitional implants and attachment of bar prior to placement of definitive prostheses.
mandibular denture causing difficulty in mastication. Four airborne-particle–abraded and acid-etched implants (FRIALOC; Dentsply Friadent, Mannheim, Germany), 4 mm in diameter and 13 mm in length, were placed between the mental foramens of the mandible (Fig. 5). The implants were placed as far apart from each other as anatomically possible to optimize load distribution. A torque of 30 Ncm was applied when inserting the implants. An impression was made immediately after flap closure using vinyl polysiloxane impression material (Pentamix; 3M ESPE, St. Paul, Minn) in a metal perforated tray (COE impression Tray; GC America, Alsip, Ill). A rigid bar (CM-Bar; Cendres & Me´taux SA) was fabricated (Fig. 6) and inserted 3 days after surgery to assist in preventing potential micromovement caused by immediately loading the implants with the overdenture (Fig. 7). All steps for overdenture JUNE 2005
Fig. 5. Four implants placed between mental foramens of edentulous mandible in Patient 2.
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THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 6. Panoramic radiograph of 4 implants with U-shaped bar.
fabrication were completed before placing the implants, allowing the prosthesis to be inserted immediately after placement of the bar.
DISCUSSION Immediate loading of implants will be consistent with osteogenesis/osseointegration if excellent primary stability and splinting of multiple implants can be achieved to minimize the risk of excessive load creating an unfavorable amount of micro-movement of the implants.3 Consequently, the use of a minimum of 4 implants is recommended.3,13 Screw-type implants of at least 10 mm in length should be used.8 If this is not possible for various reasons, immediate loading of the definitive implants may not be a predictable choice. Transitional implants, as described for Patient 1, offer a valid alternative to provide a patient with immediate masticatory function without compromising osseointegration of the permanent implants. These transitional provisional implants render enough support for an interim removable prosthesis. The type of supporting bar system appears to be of lesser importance.19,20 The treatment modality using an implant-supported overdenture is a more predictable and simple option when restoring an edentulous mandible.7,17 This approach offers a benefit, especially to older patients, who frequently have difficulty with the stability and function of complete dentures. Four-year clinical and radiographic follow-up on the 2 patients revealed successful patient and implant/denture adaptation. The fact that both patients were able to leave with functional dentures, immediately after implant surgery, was a key deciding factor in accepting implant-supported overdentures as a treatment modality as opposed to conventional residual ridge-supported dentures.
SUMMARY Two different techniques for ‘‘immediate function’’ after implant placement, using an implant-supported 516
KWON, SACHDEO, AND WEBER
Fig. 7. Definitive overdenture supported by implants using U-shaped bar and clip attachment, allowing for immediate function.
mandibular overdenture, were presented. Both options help reduce the time between implant placement and restoration of the patient’s masticatory function, making implant treatment more acceptable to the patient. REFERENCES 1. Adell R, Eriksson B, Lekholm U, Branemark PI, Jemt T. Long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaw. Int J Oral Maxillofac Implants 1990;5:347-59. 2. Branemark PI, Hansson BO, Adell R, Breine U, Lindstrom J, Hallen O, et al. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scan J Plat Reconstr Surg Suppl 1977; 16:1-132. 3. Schnitman PA, Wohrle PS, Rubenstein JE, DaSilva JD, Wang NH. Ten-year results for Branemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Implants 1997;12:495-503. 4. Balshi TJ, Wolfinger GJ. Immediate loading of Branemark implants in edentulous mandibles. a preliminary report. Implant Dent 1997;6:83-8. 5. Randow K, Ericsson I, Nilner K, Petersson A, Glantz PO. Immediate functional loading of Branemark dental implants. An 18-month clinical follow-up study. Clin Oral Implants Res 1999;10:8-15. 6. Babbush CA, Kent JN, Misiek DJ. Titanium plasma-sprayed (TPS) screw implants for the reconstruction of the edentulous mandible. J Oral Maxillofac Surg 1986;44:274-82. 7. 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. 8. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with 1-to-5 year data. Int J Oral Maxillofac Implants 1997;12:319-24. 9. Lefkove MD, Beals RP. Immediate loading of cylinder implants with overdentures in the mandibular symphysis: the titanium plasma-sprayed screw technique. J Oral Implantol 1990;16:265-71. 10. Sennerby L, Roos J. Surgical determinants of clinical success of osseointegrated oral implants: a review of the literature. Int J Prosthodont 1998;11:408-20. 11. el Attar MS, el Shazly D, Osman S, el Domiati S, Salloum MG. Study of the effect of using mini-transitional implants as temporary abutments in implant overdenture cases. Implant Dent 1999;8:152-8. 12. Bohsali K, Simon H, Kan JY, Redd M. Modular transitional implants to support the interim maxillary overdenture. Compend Contin Educ Dent 1999;20:975-83. 13. Ledermann PD, Schenk RK, Buser D. Long-lasting osseointegration of immediately loaded, bar-connected TPS screws after 12 years of function:
VOLUME 93 NUMBER 6
KWON, SACHDEO, AND WEBER
14.
15.
16.
17.
18.
19.
a histologic case report of a 95-year-old patient. Int J Periodontics Restorative Dent 1998;18:552-63. Romeo E, Chiapasco M, Lazza A, Casentini P, Ghisolfi M, Iorio M, Vogel G. Implant-retained mandibular overdentures with ITI implants. Clin Oral Implants Res 2002;13:495-501. Gatti C, Chiapasco M. Immediate loading of Branemark implants: a 24-month follow-up of a comparative prospective pilot study between mandibular overdentures supported by Conical transmucosal and standard MK II implants. Clin Implant Dent Relat Res 2002;4:190-9. Chiapasco M, Gatti C, Rossi E, Haefliger W, Markwalder TH. Implant-retained mandibular overdentures with immediate loading. A retrospective multicenter study on 226 consecutive cases. Clin Oral Implants Res 1997;8:48-57. Gatti C, Haefliger W, Chiapasco M. Implant-retained mandibular overdentures with immediate loading: a prospective study of ITI implants. Int J Oral Maxillofac Implants 2000;15:383-8. Zarb GA, Bolender CL, Eckert SE, Jacob RF, Fenton AH, Mericske-Stern R. Prosthodontic treatment for edentulous patients–complete dentures and implant-supported prostheses. 12th ed. St. Louis: Mosby; 2004;389-414. Oetterli M, Kiener P, Mericske-Stern R. A longitudinal study on mandibular implants supporting an overdenture: the influence of retention mechanism and anatomic-prosthetic variables on periimplant parameters. Int J Prosthodont 2001;14:536-42.
JUNE 2005
THE JOURNAL OF PROSTHETIC DENTISTRY
20. Naert IE, Hooghe M, Quirynen M, van Steenberghe D. The reliability of implant-retained hinging overdentures for the fully edentulous mandible. An up to 9-year longitudinal study. Clin Oral Investig 1997;1:119-24. Reprint requests to: DR AMIT SACHDEO HARVARD UNIVERSITY SCHOOL OF DENTAL MEDICINE DEPARTMENT OF GRADUATE PROSTHODONTICS 188 LONGWOOD AVENUE BOSTON, MA 02115 Fax: 617-432-0901 E-MAIL: [email protected] 0022-3913/$30.00 Copyright Ó 2005 by The Editorial Council of The Journal of Prosthetic Dentistry.
doi:10.1016/j.prosdent.2005.04.002
517