One-Year Prospective Evaluation of the Early Loading of Unsplinted Conical Brånemark Fixtures with Mandibular Overdentures Immediately following Surgery

In oral implantology, a 3-6 month stress-free healing period is presently accepted as a prerequisite to achieve bone apposition without interposition of a fibrous scar tissue. This protocol was introduced by Brånemark and co-workers in 1977. The aim of the present paper is to review the reasons that led Brånemark and collaborators to require long delayed loading periods. It is shown that the requirement for long delayed loading periods was drawn from the initiation and development periods of their original clinical trial. Demanding conditions were met involving simultaneously: 1) patients with poor bone quality and quantity, 2) non-optimized implant design, 3) short implants, 4) non-optimized surgical placement, 5) non-optimized surgical protocol and 6) biomechanically non-optimized prosthesis. Extrapolation of the requirement for long healing periods from these particular conditions to more standard situations involving refined surgical protocols and careful patient selection might be questioned. Albeit premature loading has been interpreted as inducing fibrous tissue interposition, immediate loading per se is not responsible for fibrous encapsulation. It is the excess of micromotion during the healing phase that interferes with bone repair. A threshold of tolerated micromotion exists, that is somewhere between 50 microns and 150 microns. It is suggested that loading protocols might be shortened through 2 different approaches. The first way would be to decrease stepwise the delayed loading period for free-standing implants below the presently accepted 3-6 months of healing. The second way would be to identify immediate loading protocols that are capable of keeping the amount of micromotion beneath the threshold of deleterious micromotion. Immediate loading protocols for implants-retained overdentures and fixed bridges are reviewed. It is shown that successful premature loading protocols require a careful and strict patient selection aimed to achieve the best primary stability. These various protocols need to be further documented in order to assess their predictability.

Since dental implants must withstand relatively large forces and moments in function, a better understanding of in vivo bone response to loading would aid implant design. The following topics are essential in this problem. (1) Theoretical models and experimental data are available for understanding implant loading as an aid to case planning. (2) At least for several months after surgery, bone healing in gaps between implant and bone as well as in pre-existing damaged bone will determine interface structure and properties. The ongoing healing creates a complicated environment. (3) Recent studies reveal that an interfacial cement line exists between the implant surface and bone for titanium and hydroxyapatite (HA). Since cement lines in normal bone have been identified as weak interfaces, a cement line at a bone-biomaterial interface may also be a weak point. Indeed, data on interfacial shear and tensile "bond" strengths are consistent with this idea. (4) Excessive interfacial micromotion early after implantation interferes with local bone healing and predisposes to a fibrous tissue interface instead of osseointegration. (5) Large strains can damage bone. For implants that have healed in situ for several months before being loaded, data support the hypothesis that interfacial overload occurs if the strains are excessive in interfacial bone. While bone "adaptation" to loading is a long-standing concept in bone physiology, researchers may sometimes be too willing to accept this paradigm as an exclusive explanation of in vivo tissue responses during experiments, while overlooking confounding variables, alternative (non-mechanical) explanations, and the possibility that different types of bone (e.g., woven bone, Haversian bone, plexiform bone) may have different sensitivities to loading under healing vs. quiescent conditions.

The aim of this study was to evaluate the soft tissue conditions at osseo-integrated oral implants in relation to the width of masticatory mucosa. Thirty-nine patients who had received a full-arch fixed bridge reconstruction > or = 10 years ago or a partial reconstruction > or = 5 years ago on a total of 171 implants ad modum Brånemark were included in the study. The examinations involved assessments of plaque, gingivitis, bleeding on probing, probing depth, width of masticatory mucosa and marginal tissue mobility. Simple correlation analysis as well as multiple regression analysis were performed to evaluate relationships between recorded parameters. The results showed that 24% of the sites were lacking masticatory mucosa, and an additional 13% of the implants had a width of less than 2 mm. Mobility of the facial marginal soft tissue, i.e., lack of an attached portion of masticatory mucosa, was observed at 61% of all implants. No major differences in the clinical parameters examined were found between sites with and without an "adequate" width of masticatory mucosa. Multiple regression analyses revealed that neither the width of masticatory mucosa nor the mobility of the border tissue had a significant influence on (i) the standard of plaque control or (ii) the health condition of the peri-implant mucosa, as determined by bleeding on probing. Hence, the study failed to support the concept that the lack of an attached portion of masticatory mucosa may jeopardize the maintenance of soft tissue health around dental implants.