Immediate implant loading protocols.pptx

Introduction of immediate implant loading
Advantage and disadvantage
Indication and contraindication
Rational for immediate loading
Factor affecting immediate loading
Diagnosis and treatment planning for immediate loading
Clinical procedure for immediate loading implant

1. IMMEDIATE LOADING PROTOCOL IN DENTAL IMPLANTS Presented By :-Dr. KAVAN Y. DOSHI

2. INDEX Introduction Advantage and disadvantage Indication and contraindication Rational for immediate loading Factor affecting immediate loading Diagnosis and treatment planning for immediate loading Clinical procedure for immediate loading implant Conclusion References

3. Direct implant to bone contact formation is the consistent treatment goal in implant dentistry For that, Branemark et al gave two stage surgical protocol to accomplish Osseointegration The suggestions were : Countersink the implant below the crestal bone Obtain the soft tissue coverage for 3 to 6 months Maintain the non loaded environment for 3 to 6 months Introduction Tettamanti L, Andrisani C, Bassi MA, Vinci R, Silvestre-Rangil J, Tagliabue A. Immediate loading implants: review of the critical aspects. Oral Implantol (Rome). 2017 Sep 27;10(2):129-139. 

4. The reasons behind were : To reduce bacterial infection To prevent apical migration of the oral epithelium along with implant body To reduce the risk of early implant loading during bone remodeling In this procedure, the 2 nd stage surgery is necessary and a high degree of long term clinical rigid fixation has been reported Tettamanti L, Andrisani C, Bassi MA, Vinci R, Silvestre-Rangil J, Tagliabue A. Immediate loading implants: review of the critical aspects. Oral Implantol (Rome). 2017 Sep 27;10(2):129-139. 

5. In the last decades, a deeper understanding of bone biology and advance in implant technology allowed a significant evolution of surgical and prosthetic protocols. Immediate loading protocols have been introduced to reduce the total treatment time and to accommodate new patient needs. Babbush C. Dental Implants. Implant Dentistry. 1993;2(1):59

6. Immediate loading protocol

7. Esposito et al. (49) have defined 3 protocols for implant load timing: immediate loading implants (ILI), within 1 week from implant placement; early loading implants (ELI), between 1 week and 2 months; and conventional loading implants (CLI), after 2-3 months from implant placement. Tettamanti L, Andrisani C, Bassi MA, Vinci R, Silvestre-Rangil J, Tagliabue A. Immediate loading implants: review of the critical aspects. Oral Implantol (Rome). 2017 Sep 27;10(2):129-139. 

8. During last several years, several authors have reported that the implants may osseointegrated even though they are not submerged & reside above the bone through the soft tissue. This surgical approach is called a one stage or non submerged implant procedure Immediate loading of a dental implant not only include a non submerged one stage surgery but also actually loads the implants with the provisional prosthesis at the same appointment of surgery or shortly thereafter Babbush C. Dental Implants. Implant Dentistry. 1993;2(1):59

9. Adequate bone quality (Types D1,D2 or D3) Sufficient bone height ( ie , approximately 12mm ) for a minimum length 10mm implant Sufficient bone width ( ie , approximately 6mm ) Ability to achieve an adequate anterior-posterior (AP) spread between the implants. INDICATIONS Schneider RL, Higginbottom FL, Webber H, Sones AD: For your patients receiving endosseous implants for immediate loading, how are the implant-supported crowns or the prosthesis initially put into occlusal function, and what instructions are given for their use. Int J Oral Maxillofac Imp 2002; 17:881-4. Bhola, M., Neely, A. L., & Kolhatkar, S Immediate Implant Placement: Clinical Decisions, Advantages, and Disadvantages. Journal of Prosthodontics, 2008 17(7), 576–581.

10. CONTRAINDICATIONS Poor systemic health Inadequate bone volume for correct implant placement Bone height less than 12 mm Bone width less than 6 mm Very poor bone density (D4) Severe parafunction such as bruxism, clenching, tongue thrust. Schneider RL, Higginbottom FL, Webber H, Sones AD: For your patients receiving endosseous implants for immediate loading, how are the implant-supported crowns or the prosthesis initially put into occlusal function, and what instructions are given for their use. Int J Oral Maxillofac Imp 2002; 17:881-4. Bhola, M., Neely, A. L., & Kolhatkar, S Immediate Implant Placement: Clinical Decisions, Advantages, and Disadvantages. Journal of Prosthodontics, 2008 17(7), 576–581.

11. Reduction in Time of Therapy. One stage surgical approach Patient does not need to wear removable prosthesis during osseointegration Preservation of The Bone and Gingival Tissues. [facilitates soft tissue shaping ] Psychological factors, function & stability also enhanced ADVANTAGES Schneider RL, Higginbottom FL, Webber H, Sones AD: For your patients receiving endosseous implants for immediate loading, how are the implant-supported crowns or the prosthesis initially put into occlusal function, and what instructions are given for their use. Int J Oral Maxillofac Imp 2002; 17:881-4. Bhola, M., Neely, A. L., & Kolhatkar, S Immediate Implant Placement: Clinical Decisions, Advantages, and Disadvantages. Journal of Prosthodontics, 2008 17(7), 576–581.

12. DISADVANTAGES More patient co-operation is needed. Inadequate Soft Tissue Coverage. Parafunctional from tongue or foreign bodies [pen biting ] may cause trauma and crestal bone loss Peri-implant bone reaction is highest after surgical trauma due to immediate loading. Difficulty Obtaining Primary Stability. Too soft bone , small implant diameters or implant design with less surface area ,may cause too great crestal bone stress contours and cause bone loss or implant failure Schneider RL, Higginbottom FL, Webber H, Sones AD: For your patients receiving endosseous implants for immediate loading, how are the implant-supported crowns or the prosthesis initially put into occlusal function, and what instructions are given for their use. Int J Oral Maxillofac Imp 2002; 17:881-4. Bhola, M., Neely, A. L., & Kolhatkar, S Immediate Implant Placement: Clinical Decisions, Advantages, and Disadvantages. Journal of Prosthodontics, 2008 17(7), 576–581.

13. RATIONALE FOR IMMEDIATE LOADING

14. One goal for immediately loaded implant prosthesis is to decrease the risk of occlusal overload and its resultant increase in the remodeling rate of bone. Surgical Trauma Bone Loading Trauma primary stability Chiapasco M, Abati S, Romeo E: Implant-retained mandibular overdentures with Branemark System MK II implants. A prospective comparative study between delayed and immediate loading. Int J Oral Maxillofac Imp 2001;16: 537-546. Emanuelli M, Knutsen BM: Immediate placement of implants: A Study on 86 immediately placed and loaded implants. J Prosthet Dent 2005; 94:242-58.

15. LAMELLAR BONE Highly mineralized, organized Strongest bone High modulus of elasticity (nearer to titanium) Also called load bearing bone WOVEN BONE Less mineralized, unorganized Weaker bone Low modulus of elasticity Also called as Repair bone Chiapasco M, Abati S, Romeo E: Implant-retained mandibular overdentures with Branemark System MK II implants. A prospective comparative study between delayed and immediate loading. Int J Oral Maxillofac Imp 2001;16: 537-546. Emanuelli M, Knutsen BM: Immediate placement of implants: A Study on 86 immediately placed and loaded implants. J Prosthet Dent 2005; 94:242-58.

16. SURGICAL TRAUMA Once the osteotomy site prepared & implant is inserted, the regional bone repair process gets started around implant As a result of surgical placement organized, mineralized lamellar bone in the preparation site becomes unorganized, less mineralized woven bone of repair next to implant The implant bone interface is the weakest & at the risk of overload at 3 to 6 weeks after implant placement Actually, the bone interface is stronger on the day of implant placement compared with the time 3 months later. Chiapasco M, Abati S, Romeo E: Implant-retained mandibular overdentures with Branemark System MK II implants. A prospective comparative study between delayed and immediate loading. Int J Oral Maxillofac Imp 2001;16: 537-546. Emanuelli M, Knutsen BM: Immediate placement of implants: A Study on 86 immediately placed and loaded implants. J Prosthet Dent 2005; 94:242-58.

17. Buchs et al found that immediately loaded implants fail mostly at 3 to 5 week time period One method to decrease the immediate overload is to reduce the surgical trauma as much as possible, so the amount of bone remodeling & woven bone will also reduced Cause of the trauma includes: Thermal injury Chiapasco M, Abati S, Romeo E: Implant-retained mandibular overdentures with Branemark System MK II implants. A prospective comparative study between delayed and immediate loading. Int J Oral Maxillofac Imp 2001;16: 537-546. Emanuelli M, Knutsen BM: Immediate placement of implants: A Study on 86 immediately placed and loaded implants. J Prosthet Dent 2005; 94:242-58.

18. THERMAL INJURY Roberts et al reported a devital zone of bone for 1mm around the implant due to surgical trauma Excessive heat production during drilling will cause necrosis of the bone and fibrous encapsulation around implant Chiapasco M, Abati S, Romeo E: Implant-retained mandibular overdentures with Branemark System MK II implants. A prospective comparative study between delayed and immediate loading. Int J Oral Maxillofac Imp 2001;16: 537-546. Emanuelli M, Knutsen BM: Immediate placement of implants: A Study on 86 immediately placed and loaded implants. J Prosthet Dent 2005; 94:242-58.

19. Temperature should be 38-41 °c and not more than that during osteotomy preparation ( C.E.Misch , N.Wellner 2002 ) Slow intermittent pressure with internal irrigation should be done Sharp drills should be used This will reduce the risk of fibrous tissue formation Chiapasco M, Abati S, Romeo E: Implant-retained mandibular overdentures with Branemark System MK II implants. A prospective comparative study between delayed and immediate loading. Int J Oral Maxillofac Imp 2001;16: 537-546. Emanuelli M, Knutsen BM: Immediate placement of implants: A Study on 86 immediately placed and loaded implants. J Prosthet Dent 2005; 94:242-58.

20. MICRO-FRACTURE OF BONE Implant should be non mobile on insertion but excess strain from additional torque may increase microdamage Increased microdamage will increase remodeling of the bone and immediate loading will not be possible Excessive torque should be avoided 2.BONE LOADING TRAUMA Chiapasco M, Abati S, Romeo E: Implant-retained mandibular overdentures with Branemark System MK II implants. A prospective comparative study between delayed and immediate loading. Int J Oral Maxillofac Imp 2001;16: 537-546. Emanuelli M, Knutsen BM: Immediate placement of implants: A Study on 86 immediately placed and loaded implants. J Prosthet Dent 2005; 94:242-58.

21. FACTORS AFFECTING IMMEDIATE LOADING

22. Misch CE, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KM: Rationale for the application of immediate load in implant dentistry: Part I. Implant Dent 2004;13:207-217 Misch CE, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KM: Rationale for the application of immediate load in implant dentistry: Part II. Implant Dent 2004; 13:310-321

23. 1 Increased surface area Implant number Functional surface area can be increased by increasing the number of implants More implants increase retention More implants increase force distribution area More implants decrease number of pontics Decrease in number of pontics will decrease the chance of prosthesis fracture Misch CE, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KM: Rationale for the application of immediate load in implant dentistry: Part I. Implant Dent 2004;13:207-217 Misch CE, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KM: Rationale for the application of immediate load in implant dentistry: Part II. Implant Dent 2004; 13:310-321

24. 2 IMPLANT SIZE Implant size can be increased either by length or by width Each 3 mm increase in length will increase 20% surface area Long implants also permit to engage in the opposite cortical plate, which further increase primary stability (necessary for immediate loading) Misch CE, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KM: Rationale for the application of immediate load in implant dentistry: Part I. Implant Dent 2004;13:207-217 Misch CE, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KM: Rationale for the application of immediate load in implant dentistry: Part II. Implant Dent 2004; 13:310-321

25. The natural dentition root surface area is 2 times greater in molar region For immediate loading, the implant size should be increased especially in posterior maxilla However the crestal bone loss can not be prevented by length of the implant Wider implants provides greater surface area and reduce crestal bone loss Misch CE, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KM: Rationale for the application of immediate load in implant dentistry: Part I. Implant Dent 2004;13:207-217 Misch CE, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KM: Rationale for the application of immediate load in implant dentistry: Part II. Implant Dent 2004; 13:310-321

26. Implant body design should be more specific for immediate loading because bone has not time to grow into the recesses of the design For ex: Press fit implant with cylinder design doesn’t have bone integration on the day of placement Cylinder design have low initial primary stability so it is not useful for immediate loading 3. IMPLANT BODY DESIGN Schneider RL, Higginbottom FL, Webber H, Sones AD: For your patients receiving endosseous implants for immediate loading, how are the implant-supported crowns or the prosthesis initially put into occlusal function, and what instructions are given for their use. Int J Oral Maxillofac Imp 2002; 17:881-4.

27. For threaded implants, bone is present in the depth of threads from the day of implant insertion. Therefore more functional surface area to resist the forces during immediate loading The greater the number of threads, the greater the functional surface area The greater the depth of the threads, the greater the surface area Schneider RL, Higginbottom FL, Webber H, Sones AD: For your patients receiving endosseous implants for immediate loading, how are the implant-supported crowns or the prosthesis initially put into occlusal function, and what instructions are given for their use. Int J Oral Maxillofac Imp 2002; 17:881-4.

28. d. Implant surface condition Implant surface condition may affect the rate of bone contact and lamellar bone formation Hydroxyapatite coating has been shown to reduce the bone remodeling rate during occlusal loading Less bone remodeling is beneficial in immediate loading. Schneider RL, Higginbottom FL, Webber H, Sones AD: For your patients receiving endosseous implants for immediate loading, how are the implant-supported crowns or the prosthesis initially put into occlusal function, and what instructions are given for their use. Int J Oral Maxillofac Imp 2002; 17:881-4.

29. B) PATIENT FACTORS Habits Bruxism and clenching are parafunctional forces that represent significant forces, because the magnitudes of the forces are high , the duration of the forces are extensive , and the direction of the forces are more horizontal than axial to the implants . Balshi et al reported that 75% of immediate loading failures occurs in patient of bruxism Parafunctional loads also increase the risk of abutment screw loosening, unretained prosthesis, or fracture of the transitional restoration used for immediate loading Schneider RL, Higginbottom FL, Webber H, Sones AD: For your patients receiving endosseous implants for immediate loading, how are the implant-supported crowns or the prosthesis initially put into occlusal function, and what instructions are given for their use. Int J Oral Maxillofac Imp 2002; 17:881-4.

30. 2. Diet and oral hygiene The hygiene procedures usually consist of a regimen of Chlorhexidine rinses twice daily beginning immediately. The surgical site may be brushed with a very soft tooth brush or “tooth Ette”- type sponge applicator usually seven days after the implant placement. Following the initial soft tissue healing (2 weeks), the patient may assume a more normal diet; they are cautioned not to function directly on the immediately placed provisional for another 4 weeks. Schneider RL, Higginbottom FL, Webber H, Sones AD: For your patients receiving endosseous implants for immediate loading, how are the implant-supported crowns or the prosthesis initially put into occlusal function, and what instructions are given for their use. Int J Oral Maxillofac Imp 2002; 17:881-4.

31. DIAGNOSIS AND   TREATMENT PLANNING IN   IMMEDIATE LOADING

32. Diagnosis protocol in implants prosthesis First phase Second phase Third phase Clinical history Assembly in the articulator Radiological exploration: CBCT Photographs Contact to laboratory: diagnosis wax-up and diagnostic radiological splint Prosthodontist-surgeon joint evaluation: location, inclination, size, and number of implants Initial radiological analysis   Budget, informed consent, and sequence of appointments Study models     Table 1 Diagnosis planning schema Misch C. Contemporary Implant Dentistry. Implant Dentistry. 1999;8(1):90. Chong W. Immediate Loading. Implant Dentistry. 2002;11(4):315-316

33. The physical examination prior to implant treatment :- The extraoral evaluation includes the exam of the perioral soft tissues , the lips, the nasolabial groove, the mouth corners, the facial symmetry , and the smile line . The intraoral evaluation includes the inspection of oral mucosa and periodontal tissues, the palpation of target sites, the evaluation of the residual teeth, the vestibular fornix, and the shape of the edentulous alveolar ridge. Misch C. Contemporary Implant Dentistry. Implant Dentistry. 1999;8(1):90. Chong W. Immediate Loading. Implant Dentistry. 2002;11(4):315-316

34. Immediate loading provides functional and esthetic advantages, improving the quality of life of the patient during the osseointegration period. The three key parameters that should be evaluated for prosthetic planning of the totally edentulous patient are prosthetic space, lip support, and smile line. The radiographic evaluation should include a prosthetic reference or guide that allows relating the alveolar process axis with the ideal prosthetic axis. Misch C. Contemporary Implant Dentistry. Implant Dentistry. 1999;8(1):90. Chong W. Immediate Loading. Implant Dentistry. 2002;11(4):315-316

35. Fourth Planning Phase: Decision-Making Primary stability depends on bone quality and quantity, surgical technique, and implant selection. Implant features such as dimensions and micro- and macro-design might influence immediate loading success. Appropriate selection of implant type, number, and position must be part of the surgical diagnosis and treatment planning workflow Misch C. Contemporary Implant Dentistry. Implant Dentistry. 1999;8(1):90. Chong W. Immediate Loading. Implant Dentistry. 2002;11(4):315-316

36. MAXILLA According to Bedrossian et al. [2008] , the maxilla can be divided into three zones: zone 1, the premaxilla; zone 2, the premolar area; and zone 3, the molar area CBCT can be used to determine the amount of bone in these zones as well as in the zygomatic arch, in both horizontal and vertical dimensions. Moreover, any pathology in these areas, as well as in the maxillary sinuses, needs to be verified preoperatively. Misch C. Contemporary Implant Dentistry. Implant Dentistry. 1999;8(1):90. Chong W. Immediate Loading. Implant Dentistry. 2002;11(4):315-316

37. Chong W. Immediate Loading. Implant Dentistry. 2002;11(4):315-316

38. Bone presence in zones 1, 2, and 3: traditional four to six axial implants Bone presence in zones 1 and 2: four implants – two anterior axial implants and two posterior tilted implants guided by the anterior maxillary sinus wall. All-on-four protocol Misch C. Contemporary Implant Dentistry. Implant Dentistry. 1999;8(1):90. Chong W. Immediate Loading. Implant Dentistry. 2002;11(4):315-316

39. Chong W. Immediate Loading. Implant Dentistry. 2002;11(4):315-316

40. Class A : Enough bone in the molar region above the inferior alveolar nerve canal ; sufficient bone above the mental foramen ; enough interforaminal length . Surgical recommendation: four to six axial implants, two in position of the first molars and two to four in the interforaminal region Chong W. Immediate Loading. Implant Dentistry. 2002;11(4):315-316

41. Class B : No bone presence in the posterior areas ; sufficient bone above the mental foramen; enough interforaminal length . Surgical recommendation: four implants, two anterior axial implants and two posterior tilted implants. The entrance point of the two posterior implants is above the mental foramen with a 30° angulation to save the nerve loop and reduced the cantilever length. All-on-four protocol (Fig. 14). Chong W. Immediate Loading. Implant Dentistry. 2002;11(4):315-316

42. Class C : No bone presence in the posterior areas. No bone presence above the mental nerve . Slightly reduced interforaminal length. Surgical recommendation: four implants, two anterior axial implants and two posterior tilted implants. The entrance point of the two posterior is forward the mental foramen with a 30° angulation. All-on-four protocol . Chong W. Immediate Loading. Implant Dentistry. 2002;11(4):315-316

43. Class D : No bone presence in the posterior areas or above the mental foramen. Reduced interforaminal length . This mandible corresponds to Cawood and Howell classes V– VI.  Surgical recommendation : three implants, one anterior axial implant in the midline or close to it and two posterior tilted implants. As an alternative, four interforaminal axial implants can be placed . Chong W. Immediate Loading. Implant Dentistry. 2002;11(4):315-316

44. 1 Implant position once the countersink has used 2 Since the countersink was not used the implant is not completely buried ,making abutment placement and preventing the entrapment of bone particles at the junction

45. Immediate implant loading ? Wang H, Ormianer Z, Palti A, Perel M, Trisi P, Sammartino G. Consensus Conference on Immediate Loading: The Single Tooth and Partial Edentulous Areas. Implant Dentistry. 2006;15(4):324-333

46. Question: What is the current definition of immediate implant loading? Answer: Immediate loading is defined as an implant supported restoration placed into occlusal load within at least 48 hours after implant placement. Question: What implant length is better suited for immediate load? Answer: 10 mm Question: What implant design is better suited for immediate load? Answer: The thread design, such as a tapered screw . Question: What implant surface texture is better suited for immediate load? Answer: Rough titanium implant surface . Wang H, Ormianer Z, Palti A, Perel M, Trisi P, Sammartino G. Consensus Conference on Immediate Loading: The Single Tooth and Partial Edentulous Areas. Implant Dentistry. 2006;15(4):324-333.

47. Question: Is there any difference upon implant survival rates between tooth type/location for immediate implant loading on a single tooth? Answer: A . Premolars (either maxillary or mandibular) had the highest success rates. B. Incisors and molars may not be the best candidates for immediate implant occlusal loading, but they are suggested for immediate non occlusal (restoration) loading. Question: What implant diameter is better suited for immediate load? Answer: At this time, it appears that a minimum of 3.5-mm implant diameter is required. Wang H, Ormianer Z, Palti A, Perel M, Trisi P, Sammartino G. Consensus Conference on Immediate Loading: The Single Tooth and Partial Edentulous Areas. Implant Dentistry. 2006;15(4):324-333.

48. Question: What are the conditions that are not recommended for implant immediate load on a single tooth restoration? Answers: Heavy occlusion ( eg bruxism, parafunctional habits); lack of primary implant stability ( poor quality bone ; eg D4); shorter implant length ; smooth surface; press-fit implants; poor crown/implant ratio (1:1); and poor oral hygiene . Question. What is the condition of the patient’s oral hygiene? immediate implant loading is not advisable for patients with poor oral hygiene. It can affect periodontal health, quality of bone, and directly affect the osseointegration potential of an implant. 3 Wang H, Ormianer Z, Palti A, Perel M, Trisi P, Sammartino G. Consensus Conference on Immediate Loading: The Single Tooth and Partial Edentulous Areas. Implant Dentistry. 2006;15(4):324-333.

49. Question : When should you use each protocol? It can be difficult to establish which loading protocol is better, and the choice for implant loading varies with each patient. Research has shown that immediate implant loading may be successful in the following clinical situations: Edentulous maxilla—when fixed prostheses are used Edentulous mandible—treatment is successful with both removable and fixed appliances Single-tooth replacement in esthetically critical zones Short-span fixed partial dentures Wang H, Ormianer Z, Palti A, Perel M, Trisi P, Sammartino G. Consensus Conference on Immediate Loading: The Single Tooth and Partial Edentulous Areas. Implant Dentistry. 2006;15(4):324-333.

50. Implant number increase increase the surface area increase retention increase force distribution area Decrease in number of pontics will decrease the chance of prosthesis fracture Implant size can be increased either by length or by width Wider implants provides greater surface area and reduce crestal bone loss Long implants also permit to engage in the opposite cortical plate, which further increase primary stability Implant body design greater the number of depth and threads, the greater the functional surface area Implant surface condition Hydroxyapatite –coated implants in poor density types Rough versus smooth or machine surface condition implants in good bone density situations [D2,D3] CONCLUSION

51. REFERENCES Wang H, Ormianer Z, Palti A, Perel M, Trisi P, Sammartino G. Consensus Conference on Immediate Loading: The Single Tooth and Partial Edentulous Areas. Implant Dentistry. 2006;15(4):324-333. Tettamanti L, Andrisani C, Bassi MA, Vinci R, Silvestre-Rangil J, Tagliabue A. Immediate loading implants: review of the critical aspects. Oral Implantol (Rome). 2017 Sep 27;10(2):129-139 Babbush C. Dental Implants. Implant Dentistry. 1993;2(1):59 Bhola, M., Neely, A. L., & Kolhatkar, S Immediate Implant Placement: Clinical Decisions, Advantages, and Disadvantages. Journal of Prosthodontics, 2008 17(7), 576–581.

52. Chiapasco M, Abati S, Romeo E: Implant-retained mandibular overdentures with Branemark System MK II implants. A prospective comparative study between delayed and immediate loading. Int J Oral Maxillofac Imp 2001;16: 537-546. Emanuelli M, Knutsen BM: Immediate placement of implants: A Study on 86 immediately placed and loaded implants. J Prosthet Dent 2005; 94:242-58. Misch CE, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KM: Rationale for the application of immediate load in implant dentistry: Part I. Implant Dent 2004;13:207-217 Misch CE, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KM: Rationale for the application of immediate load in implant dentistry: Part II. Implant Dent 2004; 13:310-321

53. Schneider RL, Higginbottom FL, Webber H, Sones AD: For your patients receiving endosseous implants for immediate loading, how are the implant-supported crowns or the prosthesis initially put into occlusal function, and what instructions are given for their use. Int J Oral Maxillofac Imp 2002; 17:881-4. Misch C. Contemporary Implant Dentistry. Implant Dentistry. 1999;8(1):90. Chong W. Immediate Loading. Implant Dentistry. 2002;11(4):315-316 Schneider RL, Higginbottom FL, Webber H, Sones AD: For your patients receiving endosseous implants for immediate loading, how are the implant-supported crowns or the prosthesis initially put into occlusal function, and what instructions are given for their use. Int J Oral Maxillofac Imp 2002; 17:881-4.

54. THANK YOU