Titelblatt
Copyright-Seite
Preface
Acknowledgment
Editors and Authors
Contributors
1 Introduction
2 Proceedings of the Third ITI Consensus Conference: Loading Protocols in Implant Dentistry
2.1 Consensus Statements and Recommended Clinical Procedures Regarding Loading Protocols for Endosseous Dental Implants
2.1.1 Definition of Terms
2.1.2 Review of Loading Protocols
2.1.3 Consensus Statements
2.1.4 Clinical Recommendations
2.1.5 Conclusions
2.2 Review of Implant Loading Protocols
2.2.1 Original Loading Protocols
2.2.2 Evolution of Loading Protocols
2.2.3 Edentulous Mandible
Conventional Loading
Immediate Loading
Early Loading
2.2.4 Edentulous Maxilla
Conventional Loading
Immediate Loading
Early Loading
2.2.5 Single-Tooth Gaps
Conventional Loading
Immediate Loading/Restoration
Early Loading/Restoration
Esthetic Factors
2.2.6 Multi-Tooth Gaps
Conventional Loading
Immediate Restoration/Loading
Early Loading
2.2.7 Conclusion
3 General Principles for the Pre-Treatment Assessment of and Planning for Partially Dentate Patients Receiving Dental Implants
3.1 Summary of Treatment Risk Profile
3.2 Treatment Regulators and Risk Factors
3.3 Factors Influencing Decision-Making in Treatment Approaches
3.3.1 Scientific Documentation
3.3.2 Benefit for the Patient
3.3.3 Risk for Complications
3.3.4 Difficulty Level of the Prosthodontic Treatment
3.3.5 Cost-Effectiveness
4 Clinical Case Presentations Based on Different Loading Protocols
Posterior Multi-Tooth Gaps and Free-End Situations in the Maxilla or Mandible
4.1 Replacement of Multiple Teeth in a Partially Dentate Posterior Mandible with a Fixed Dental Prosthesis Using an Early Loading Protocol
Acknowledgments
4.2 Replacement of Multiple Teeth in a Partially Dentate Posterior Mandible with a Fixed Dental Prosthesis Using an Early Loading Protocol
Acknowledgments
4.3 Replacement of Multiple Teeth in a Partially Dentate Posterior Maxilla and Mandible with Fixed Dental Prostheses Using a Conventional Loading Protocol
Acknowledgments
4.4 Replacement of Multiple Teeth in a Partially Dentate Posterior Maxilla with a Fixed Dental Prosthesis and a Crown Using Conventional Loading Protocols
Acknowledgments
4.5 Replacement of Multiple Teeth in a Partially Dentate Posterior Maxilla with Crowns Using a Conventional Loading Protocol
Acknowledgments
4.6 Replacement of Two Teeth in a Partially Dentate Posterior Maxilla with a Fixed Dental Prosthesis Using a Conventional Loading Protocol
Acknowledgments
Single-Tooth Gaps in the Posterior Maxilla or Mandible
4.7 Replacement of a Maxillary Left Second Premolar Using an Immediate Restoration Protocol
Acknowledgments
4.8 Replacement of a Maxillary Right First Molar Using an Early Loading Protocol
Acknowledgments
4.9 Replacement of a Maxillary Right Second Premolar Using an Early Loading Protocol
Acknowledgments
4.10 Replacement of a Maxillary Left First Molar Using an Early Loading Protocol
Acknowledgments
Single-Tooth Gaps in the Anterior Maxilla
4.11 Replacement of a Maxillary Right Central Incisor Using an Immediate Restoration Protocol
Acknowledgments
4.12 Replacement of a Maxillary Right Central Incisor Using an Early Loading Protocol
Acknowledgments
4.13 Replacement of a Maxillary Right Central Incisor Using an Early Loading Protocol
Acknowledgments
Multi-Tooth Gaps in the Anterior Maxilla
4.14 Replacement of the Four Maxillary Incisors with a Fixed Dental Prosthesis Using an Immediate Loading Protocol
Acknowledgments
4.15 Replacement of the Four Maxillary Incisors with a Fixed Dental Prosthesis Using an Early Loading Protocol
Acknowledgments
4.16 Replacement of the Four Maxillary Incisors with a Fixed Dental Prosthesis Using a Conventional Loading Protocol
Three-year follow-up
Acknowledgments
5 Conclusions Regarding Loading Decisions for the Partially Dentate Maxilla or Mandible
5.1 Introduction
5.2 Degree of Treatment Difficulty
5.3 Conclusions: Loading Protocols for Partially Dentate Patients
Literature/References
German National Library CIP Data
The German National Library has listed this publication in the German National Bibliography. Detailed bibliographical data are available on the Internet at http://dnb.ddb.de.
© 2008 Quintessence Publishing Co, Ltd
Ifenpfad 2-4,12107 Berlin,
www.quintessenz.de
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.
Medical Editing: Dr. Kati Benthaus, CH-Basel
Illustrations: Ute Drewes, CH-Basel, www.drewes.ch
Copyediting: Triacom Dental, D-Barendorf, www.triacom-dental.de
Graphic Concept: Wirz Corporate AG, CH-Zurich
Production: Bernd Burkart, D-Berlin
Printing: Bosch-Druck GmbH, D-Landshut, www.bosch-druck.de
Printed in Germany
ISBN: 1850973458
The materials offered in the ITI Treatment Guide are for educational purposes only and intended as a step-by-step guide to treatment of a particular case and patient situation. These recommendations are based on conclusions of the ITI Consensus Conferences and, as such, in line with the ITI treatment philosophy. These recommendations, nevertheless, represent the opinions of the authors. Neither the ITI nor the authors, editors and publishers make any representation or warranty for the completeness or accuracy of the published materials and as a consequence do not accept any liability for damages (including, without limitation, direct, indirect, special, consequential or incidental damages or loss of profits) caused by the use of the information contained in the ITI Treatment Guide. The information contained in the ITI Treatment Guide cannot replace an individual assessment by a clinician, and its use for the treatment of patients is therefore in the sole responsibility of the clinician.
The inclusion of or reference to a particular product, method, technique or material relating to such products, methods, or techniques in the ITI Treatment Guide does not represent a recommendation or an endorsement of the values, features, or claims made by its respective manufacturers.
All rights reserved. In particular, the materials published in the ITI Treatment Guide are protected by copyright. Any reproduction, either in whole or in part, without the publisher’s prior written consent is prohibited. The information contained in the published materials can itself be protected by other intellectual property rights. Such information may not be used without the prior written consent of the respective intellectual property right owner.
Some of the manufacturer and product names referred to in this publication may be registered trademarks or proprietary names, even though specific reference to this fact is not made. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.
The components of the implant system shown are part of the Straumann® Dental Implant System.
The tooth identification system used in this ITI Treatment Guide is that of the FDI World Dental Federation.
The ITI Mission is …
“… to promote and disseminate knowledge on all aspects of implant dentistry and related tissue regeneration through research, development and education to the benefit of the patient.”
Implant dentistry is probably the most interesting and dynamic discipline in modern dental science. It has evolved from a trial-and-error field to an evidence-based predictable treatment modality. This has given dentistry a whole new palette of options for patient treatment. The loading protocols advocated in the early years of implant dentistry (3 to 6 months) are now behind us. Due to advances in surgical and prosthetic protocols as well as the innovation of implant surfaces, the conventional healing period before loading has been brought down to 6 weeks or even less. According to the Proceedings of the Third ITI Consensus Conference, published in a special 2004 supplement of JOMI, immediate implant loading is defined as restoring the implant with a provisional or final restoration in occlusal contact within 24 hours. Immediate implant loading, properly carried out, has shortened the transitional period between implant placement and implant restoration immensely. This has many benefits for our patients when we look at total treatment time, the number of clinic visits, comfort during the healing period, and esthetic and phonetic aspects of the implant treatment. At the same conference, early loading was defined as the prosthetic loading or utilization of an implant at any time between immediate and conventional loading, and conventional loading was defined as the restoration and loading of an implant after a healing period of 3 to 6 months. These definitions are likely to be reviewed in the future, as today’s evidence-based and improved techniques allow for shorter healing periods to be considered predictable and safe.
Immediate loading always includes an element of risk. As in the ITI Treatment Guide Volume 1, where each patient’s esthetic risk profile was presented, in Volume 2 we have chosen to present a treatment risk profile for immediate loading, which will be a great help for clinicians planning cases that involve choices between various implant loading protocols. This risk profile instrument can be used as an indicator to predict the risk involved in not reaching an acceptable result when treating patients following an immediate loading concept. Optimal results in immediate implant loading can only be achieved when following a comprehensive clinical protocol based on science, preoperative diagnosis, treatment planning, and precise management of the patient treatment, and, last but not least, experience. Based on this, we have included the SAC (Straightforward, Advanced, and Complex) classification for all the patients presented in this volume. The SAC classification, which is based on a series of items that are checked for every patient, gives the dentist insight into the complexity of each individual patient. The SAC classification for implant dentistry, as described in this volume, will soon be published in book form, reflecting the results of a consensus conference organized by the ITI in March 2007.
Supported by the literature, the results of the ITI Consensus Conference, which were published in a special 2004 supplement of the JOMI, and a large variety of clinical cases, this second volume of the ITI Treatment Guide presents comprehensive details on how to treat patients with crowns and fixed dental prostheses on implants following immediate, early, and conventional loading protocols.
Daniel Wismeijer
Daniel Buser
Urs C. Belser
The authors wish to express their special thanks to Dr. Kati Benthaus for her excellent support and outstanding commitment to maintaining the high quality of this second in the series of ITI Treatment Guides.
Editors:
Urs C. Belser, DMD, Professor
University of Geneva
Department of Prosthodontics
School of Dental Medicine
Rue Barthélemy-Menn 19,1211 Genève 4, Switzerland
E-mail: urs.belser@medecine.unige.ch
Daniel Buser, DMD, Professor
University of Berne
Department of Oral Surgery and Stomatology
School of Dental Medicine
Freiburgstrasse 7,3010 Bern, Switzerland
E-mail: daniel.buser@zmk.unibe.ch
Daniel Wismeijer, DMD, Professor
Academic Center for Dentistry Amsterdam (ACTA)
Free University
Department of Oral Function
Section of Implantology and Prosthetic Dentistry
Louwesweg 1,1066 EA Amsterdam, Netherlands
E-mail: dwismeij@acta.nl
Authors:
Jeffrey Ganeles, DMD
Florida Institute for Periodontics & Dental Implants
3020 North Military Trail, Suite 200
Boca Raton, FL 33431, USA
Adjunct Associate Professor
Nova Southeastern University College of Dental Medicine
Ft. Lauderdale, FL 33328, USA
E-mail: jganeles@perio-implant.com;
Dean Morton, BDS, MS
University of Florida, Gainesville
Center for Implant Dentistry
Department of Oral and Maxillofacial Surgery
1600 W Archer Road, D7-6, Gainesville, FL 32610, USA
E-mail: dmorton@dental.ufl.edu
Stephen Chen, MDSc, Dr
School of Dental Science
The University of Melbourne
720 Swanston Street
Melbourne, VIC 3010, Australia
E-mail: schen@balwynperio.com.au
Anthony Dickinson, BDSC, MSD
1564 Malvern Road
Glen Iris, VIC 3146, Australia
E-mail: ajd1@iprimus.com.au
Christopher Evans, BDSc Hons (Qld), MDSc (Melb)
75 Asling St., Brighton
Melbourne, VIC 3186, Australia
E-mail: cdjevans@mac.com
German O. Gallucci, DMD, Dr med dent
Assistant Professor
Harvard School of Dental Medicine
Department of Restorative Dentistry and Biomaterial Sciences
188 Longwood Avenue, Boston, MA 02115, USA
E-mail: german_gallucci@hsdm.harvard.edu
Christopher Hart, BDSc, Grad Dip Clin Dent, MDSc
4 Linckens Cres
Balwyn, VIC 3103, Australia
E-mail: cnhart@mac.com
Frank Higginbottom, DDS
3600 Gaston Avenue, Suite 1107
Dallas, TX 75246, USA
E-mail: bottom@dallasesthetics.com
Murray Kaufman, DDS
9911 W. Pico Blvd., Suite 780
Los Angeles, CA 90035, USA
E-mail: murray300@aol.com
William C. Martin, DMD, MS
University of Florida, Gainesville
Center for Implant Dentistry
Department for Oral and Maxillofacial Surgery
1600 W Archer Road, D7-6
Gainesville, FL 32610, USA
E-mail: wmartin@dental.ufl.edu
Yasushi Nakajima, DDS
3-10-1 Higashihagoromo Takaishi
Osaka, 592-0003, Japan
E-mail: njdc3805@crest.ocn.ne.jp
Mario Roccuzzo, DMD, Dr med dent
Corso Tassoni 14, Torino, 10143, Italy
E-mail: mroccuzzo@iol.it
Adam Rosenberg, BDS, MS
401 Wattletree Rd
Malvern East, VIC 3145, Australia
E-mail: perio@bigpond.net.au
James Ruskin, DMD, MD, Professor
University of Florida, Gainesville
College of Dentistry
P.O.Box 100416, Gainesville, FL 32601, USA
E-mail: jruskin@dental.ufl.edu
Bruno Schmid, DMD
Bayweg 3,3123 Belp, Switzerland
E-mail: brunoschmid@vtxmail.ch
Gary Solnit, DDS, MS
9675 Brighton Way, Suite 330
Beverly Hills, CA 90210, USA
E-mail: gssolnit@earthlink.net
Francesca Vailati, MD, DMD, MSc
Senior Lecturer
University of Geneva
Department of Prosthodontics
School of Dental Medicine
Rue Barthélemy-Menn 19
1211 Genève 4, Switzerland
E-mail: francesca.vailati@medecine.unige.ch
Thomas G. Wilson Jr, DDS, PA
Periodontics and Dental Implants
5465 Blair Road, Suite 200
Dallas, TX 75231, USA
E-mail: tom@tgwperio.com
Through research, development and education, the ITI has a mission to promote and disseminate knowledge on all aspects of implant dentistry and related tissue regeneration. Positioned at the forefront of a dynamic and exciting era in implant dentistry, the ITI has assumed, through its Education Committee and projects, a leading role in the delivery of information to the professional community and their patients.
Endeavors of particular relevance to this mission include:
The ITI Consensus Conferences, which are held periodically to allow for the systematic and critical evaluation of existing knowledge as it relates to recent and perhaps controversial trends in implant dentistry.
The ITI Treatment Guides, which provide readers with objective and simplified recommendations for patient treatment that are documented by science, supported by experienced clinicians, and beneficial to patients.
The ITI Treatment Guide Volume 2 is devoted to the restoration of partially dentate patients. Central to this volume of the ITI Treatment Guide are loading protocols available to the clinician and the patient, and how they relate to various treatment indications, including both single and multiple missing teeth in the posterior and anterior regions of the mouth.
Through the presentation of the findings from the ITI Consensus Conference held in 2003, historic reference and a range of patient treatments, it is anticipated that this volume of the ITI Treatment Guide will provide concise and meaningful recommendations that can improve the prospects of optimal treatment for patients. The authors believe that this volume will provide a valuable reference and resource that will help clinicians and patients achieve their treatment goals.
With over 4500 Fellows and Members in more than 40 countries, the International Team for Implantology (ITI) is a non-profit academic organization of professionals in implant dentistry and tissue regeneration. The ITI organizes Consensus Conferences at 5-year intervals to discuss relevant topics in implant dentistry.
The first and second ITI Consensus Conferences in 1993 and 1998 (Proceedings of the ITI Consensus Conference, published in 2000) primarily discussed basic surgical and prosthetic issues in implant dentistry. The third ITI Consensus Conference was convened in 2003. For this conference, the ITI Education Committee decided to focus the discussion on four special topics that had received much attention in recent years, “Loading Protocols for Endosseous Dental Implants” being one of them (Proceedings of the Third ITI Consensus Conference, JOMI Special Supplement, 2004).
One group, under the leadership of Professor David Cochran, was asked to focus on, review the relevant literature on, and find consensus relating to loading protocols for endosseous dental implants.
Group participants:
Matteo Chiapasco
Roberto Cornelini
Kerstin Fischer
Jeffrey Ganeles
Siegfried Heckmann
Robert A. Jaffin
Regina Mericske-Stern
Dean Morton
Ates Parlar
Edwin Rosenberg
Paul Rousseau
Yoshikazu Soejima
Pedro Tortamano
Wilfried Wagner
Hans-Peter Weber
Daniel Wismeijer
The group was asked to develop evidence-based reviews on topics related to various loading protocols for dental implants. The following literature reviews were prepared and presented to the group for discussion:
Matteo Chiapasco: “Early and Immediate Restoration and Loading of Implants in Completely Edentulous Patients”
Jeffrey Ganeles, Daniel Wismeijer: “Early and Immediately Restored and Loaded Dental Implants for Single-Tooth and Partial-Arch Applications”
Dean Morton, Robert Jaffin, Hans-Peter Weber: “Immediate Restoration and Loading of Dental Implants: Clinical Considerations and Protocols”
The prime objective of the literature reviews was to determine whether a procedure could be recommended as routine based on the available evidence. The second objective was to identify whether patients perceived a benefit associated with these procedures.
At the ITI Consensus Conference, the authors presented their manuscripts to the group for discussion. There was discussion concerning how the authors approached writing the draft, how the literature was searched and reviewed, what the major findings were, and finally, what conclusions could be drawn.
During the discussion, several statements were made regarding immediate or early restoration and/or loading of implants in edentulous and partially dentate patients. These are listed below, along with issues that were identified throughout the discussions.
In recent years, confusion has been evident with terminology as it relates to loading protocols in implant dentistry. The group discussed this terminology in detail, in relation to both existing literature and ITI consensus. Most of these terms were defined in a conference on immediate and early loading that was held in Spain in May 2002 (Aparicio and coworkers, 2003). However, the group modified these definitions for use in their report. The modified definitions are presented here:
Conventional loading
The prosthesis is attached in a second procedure after a healing period of 3 to 6 months.
Early loading
A restoration in contact with the opposing dentition and placed at least 48 hours after implant placement but not later than 3 months afterward.
Immediate restoration
A restoration inserted within 48 hours of implant placement but not in occlusion with the opposing dentition.
Immediate loading
A restoration placed in occlusion with the opposing dentition within 48 hours of implant placement.
Delayed loading
The prosthesis is attached in a second procedure that takes place some time later than the conventional healing period of 3 to 6 months.
The choice of loading protocols should be viewed as dependent, among other factors on two distinct processes: primary and secondary bone contact. By understanding these concepts, it is possible to appreciate how various loading protocols are viable and why they are dependent on these processes.
Primary bone contact
As soon as an implant is placed into the jawbone, certain areas of the implant surface are in direct contact with bone.
Secondary bone contact
As healing occurs, the bone around the implant surface is remodeled, and areas of new bone contact with the implant surface appear. This remodeled bone and new bone contact, termed secondary bone contact, predominates at later healing times when the amount of primary contact is decreased.
Shortened loading protocols
Immediate and early loading protocols should focus on (1) the amount of primary bone contact, (2) the quantity and quality of bone at the implant site, and (3) the rapidity of bone formation around the implant.
Immediate loading
When existing bone of high quality and quantity is found and when other factors are favorable, immediate loading of the implant may be possible.
Early loading
If the existing bone is not of high quality and quantity, then bone formation must occur within a relatively short time so that early loading of the implants can take place.
Direct occlusal contact
In the case of direct occlusal contact, the restoration makes contact with the opposing dentition.
Indirect occlusion
With indirect occlusion, the implant is restored without directly contacting the opposing dentition, i.e. it is out of occlusion.
Progressive loading
With progressive loading, the implant is restored in “light” contact initially and is gradually brought into full contact with the opposing dentition.
With the understanding that the literature base is small and the strength of evidence graded as inadequate to fair, the group reached the following conclusions with regard to loading protocols for endosseous dental implants in 2003:
Statements A:
Edentulous Mandible
Statement A.1
In edentulous mandibles, the immediate loading of 4 implants with an overdenture in the interforaminal area with rigid bar fixation and cross-arch stabilization is a predictable and well-documented procedure.
Statement A.2
The early loading of implants (splinted or unsplinted) in the edentulous mandible with an overdenture is not well-documented.
Statement A.3
Immediate loading of implants supporting fixed restorations in the edentulous mandible is a predictable and well-documented procedure, provided that a relatively large number of implants are placed.
Statement A.4
The Consensus Group found only six publications supporting the early loading of implants in the edentulous mandible with a fixed restoration.
Statements B:
Edentulous Maxilla
Statement B.1
No articles were found supporting immediate or early loading of implants with an overdenture in the edentulous maxilla. Therefore, this procedure would have to be considered experimental at this time.
Statement B.2
In the edentulous maxilla, immediate or early loading of implants utilizing a fixed prosthesis is not well-documented.
Statements C:
Partially Dentate Mandible or Maxilla
Statement C.1
In the partially dentate maxilla and mandible, the immediate restoration or loading of implants supporting fixed prostheses is not well-documented. It should be noted that in many of these cases the restoration is not in contact with the opposing dentition. This observation highlights the care that must be expended to plan and successfully complete such a restoration.
Statement C.2
The early restoration or loading of titanium implants with a roughened surface supporting fixed prostheses after 6 to 8 weeks of healing is well-documented and predictable in the partially dentate maxilla and mandible. Results seem to indicate that the outcome is similar to results obtained with conventional procedures. However, further studies are necessary before these procedures can be proposed as routine due to the limited number of implants placed in comparison to the number of conventionally loaded implants, and the short follow-up period.
Statement C.3
Interproximal crestal bone levels and soft tissue changes adjacent to immediately restored or loaded implants were found to be similar to those reported for conventional loading protocols.
Statements D:
Other Issues Discussed
Statement D.1
A conventional loading period of 3 to 6 months is likely to be modified for implants with roughened surfaces. The 3- to 6-month period was originally defined for implants with machined surfaces, and it is well-documented that the machined surface is not as successful as the roughened surface in certain indications.
Statement D.2
A question that needs to be addressed is whether the patient benefits from an immediate or early loading protocol. There is an associated risk with immediate and/or early loading, and this risk must be evaluated in terms of patient benefit. Postoperative care must be evaluated in such calculations.
Statement D.3
A related question is whether conventional loading is justified in certain cases. For example, does delaying the restoration of an implant place the patient at a disadvantage?
Statement D.4
The types of occlusal schemes need to be specified in various loading protocols. Occlusal schemes for immediately and early loaded implants that result in successful outcomes need to be determined.
The following types of treatment were recommended by the Consensus Group in 2003 (published in a supplement of JOMI in 2004), provided that all other aspects of diagnosis and treatment planning have been performed and are considered acceptable by the clinician. Immediate restoration and loading procedures are considered advanced or complex. As such, it is assumed that the clinician has the requisite level of skills and experience. The recommendations are based on the literature available in 2003 and the collective experience of the Consensus Working Group.
Immediate Restoration or Loading:
Edentulous mandible
Four implants are suitable for use in 2 protocols: an overdenture retained and/or supported by a bar that rigidly connects the implants, or a fixed restoration on a framework (acrylic resin and/or metal) that rigidly connects the implants. More than 4 implants are suited for rigid provisional restoration connecting all of the implants, or for a fixed restoration on a framework (acrylic resin and/or metal) that rigidly connects the implants.
Edentulous maxilla
No routine procedure is recommended.
Partially dentate maxilla and mandible
No routine procedure is recommended.
Early Restoration or Loading:
Edentulous Mandible
Two implants
Two implants may be placed to retain an overdenture, supported by a bar connecting the implants or by freestanding implants, when the implants are characterized by a rough titanium surface and allowed to heal for at least 6 weeks.
Four implants
In a four-implant scenario, either of two options is recommended: an overdenture retained and supported by a bar connecting the implants or by unconnected implants, or a fixed restoration on a framework that rigidly connects the implants. The implants should be characterized by a rough titanium surface and allowed to heal for at least 6 weeks.
More than four implants