1.

Chapter

ELECTION OF SCREW-RETAINED EMENTED PROVISIONAL

Mithridade Davarpanah Serge Szrnukler-Moncler Boris Jakubowicz-Kohen Paul M. Khoury Mihaelc ara!an

'R STHESES

In most immediate-loading protocols, edentulous areas are restored with two prostheses, a provisional and a final. For both phases, the prosthodontist must decide whether the prosthesis should br' screw retained or cemented :n some cases, the retention mode for the prosthesis is obvious, as it is for the hybrid fixed-detachable prosthesis (ad modum ranemar!" used to restore the edentulous mandible #n the other hand, for other restorations, such as single crowns in the anterior piaxilla, either techni$ue might be %cceptable. &he provisional and final prostheses do not have to be affixed to implants in the same way. Rather, the retention mode depends on specific individual re$uirements Figure '-( presents the range of possibilities For the traditional delayed-loading protocols, the type of fixation is determ)"*d by the amount of space available for the prosthesis, occlusion, esthetic re$uirements, and the posthodontist's personal preference &hese rules apply to immediate loading as well, in additioi+ '0 ,,p(-cih. re$uirement- that will be discussed later

. ,
1I I I
i

3 .

Screw-Retained Provisional Prostheses

&he provisi/01.2I prosthesis is either screwed directly into the implant or screwed into a provisional abutment that 3- screwed into the implant.

89

2.

Advantages
&he clinician can easily remove the prosthesis without any mechanical demand on the implant. &he clinician can assess implant stability without disturbing the progress of osseointegration. 4crew retention avoids the ris! that excess cement will remain between the implant and the gingivaor even worse in the extraction soc!et-and compromise implant osseointegration. 4crew retention is particularly indicated when implants are placed in extraction soc!ets In cases where many implants have been placed, the clinician can easily detect the absence of passive seating

Disadvantages
&he shape of the occlusal surface is altered by the screw access path. &he screw access path wea!ens the mechanical resistance of the occlusal material, enhancing the ris! of coronal fracture. For incisors, the implant axis must be palatally inclined with respect to the incisal edge. &his limits the number of instances where screw retention can be selected. &he process of screwing in a complete prosthesis that is supported by a number of implants increases the chair time needed for placement and removal of the prosthesis. &he small screws may loosen or fracture

Indications
4crew retention is the solution of choice for provisional prostheses in the following cases. Restoration of a completely edentulous mandible Restoration of a completely edentulous maxilla by the means of the conversion prosthesis (removable denture converted to a fixed prosthesis" Restoration of a partially edentulous anterior mandible 4crew retention can be considered for a provisional prosthesis replacing a single tooth or a few teeth in the anterior maxilla, provided that the angulation of the implants, is palatal with regard to the incisal edges. If the implant is angled too far labially, esthetics might be compromised and cementation is a more practical solution 4crew retention of a provisional prosthesis is not indicated for a restoration of partial edentulism in posterior areas, because high forces are exerted on the fixation screws.

T Cemented Provisional Prostheses

&he prosthesis is attached to abutments with temporary cement, while the abutments are screw retained in the implants.

Advantages
&he anatomy of the occlusal surface is preserved. &he buccolingual angulation is more readily regulated. 5hen a number of implants are involved, the clinician can more easily place and remove the prosthesis /ementation allows placement of final abutments instead of provisional abutments, which is especially desirable in patients with a thin periodontal biotype or when esthetics is a '/oncern. Final abutments are not unscrewed when the final prosthesis is being prepared. If n1cessary, they are reshaped in the mouth, and an impression is made and sent to the laboratory.

90

3.

4ct+swprof.6thcsis provisional pr-;);.thee.is

re-...ained provisional

Cemented

t
I

'-i~ --~--- ___'"--o-S-I---..

__ ---I,.,L. -- ,.1 .8

f~

-9-7
'

71

ie

!-final prosthl'Jsis

crew-r.cta3 ,,d ( /emented final: prosthesis

'------- 7;---;.;" '-(I

I Screw-retained ! tCerl"en###$d nnal

'. final prosthesis

II- pros+t-hesis

%i& '-" a Range of possibilities for fixation of both pmvisional and final pmstheses,&he choice of fixation mode f#l' the provisional pms&hesis does not pl'event the use of a different retention mode for the final <# c he'"ls if i( I4 more appropliate. rour p("'1si'"lc c#rrl=-i(dtions ale ther'er-xe available. a s/I'ew-retained or a '1/llcntcd provisional prosthesIs succeeded by a screw-I'etained or' r.. cemented final prosthesis,

Disadvantages
1 i-xcess cerrent r<(ay irritRto surrou->iing sc:t ?issue . in,,- caus(,- inflammation or even interfere '@ith thA" process of osseointewation &his ris! is rnm1t pronounced in extraction sites, /ementation of a provisional prosthesis is not indicated 'lvhen placement of the implants is deeply subcrestal . 88 /ementation does not permit the clinician to verify Imol,mt stability, because removal of (,-'mented prostheses might m$uire a leve: of forl...* Jut @ould compromise the progress of osseointeg ration, , /clm*ntation has to be performed with some speer" to c"nform to the setting time of the m*.terial. &he prosthesis may debond

ndications

/ementation is the solution of choice for a provisional pr"sthesis in the following cases. lBlestoration of a completely edentulous maxilla, especially where the final abutments are placed immediately, as is common for patients with a thin periodontal biotype 1 Restoration of partial edentulism in posterior regions /ementation can be considered for a restoration of only one or a few missing maxillary anterior teeth, because esthetics and emergence profile are more easily managed with this method /erl=ntation of a pr(wisional prosthesis is not inciicalt'd for 1i:C following cases. , &reatment of an edentulous mandible when a Ilybrill prosthesis is indicated D% ',e-"lal.,omont of lril11sing maiidirEd,c'l- c,ntD.il+ior l*e'(( vrcn ..r.1 d'Failahie mesiodistal space is I.n'lte)

Com(ination of Retention )ethods for the Provisional and %inal Prostheses

rheoretically, it is possible to select any combination of fixGtion 1.ype tor the provisional and the final prostheses (see Fig '-(a", as long the choices conform to the logic at the treatment plan.
(

92
4.
4crew-retained final prosthesis

%i*ation methods for provisional and final prostheses

II

/emented provisional prosthesis

/emented final prosthesis /emented final prosthesis

Screw-retained provisional and final prostheses

&his combination (Fig '-(b" is appropriate when. En edentulous mandible is rehabilitated with a hybrid prosthesis.

.t'. %i& '-" ( Screw-retained provisiona

and !ina prost"eses.

 &he space available is insufficient to accommodate a H-mm abutment. 3imited space is available for the prosthetic teeth.

#.

%i*ation methods for provisional and final prostheses

/emented provisional prosthesis '

4crew-retained final prosthesis

r /emented final

Screw-retained final prosthesis

prosthesis

i;. %i& '-" c Screw-retained provisiona prost"esis and cemented !ina prost"esis.

Screw-retained provisional prosthesis and cemented final prosthesis

&his combination (Fig '-( c" is appropriate when In the edentulous mandible, the provisional prosthesis will be a hybrid prosthesis supported by some of the placed implants and the final prosthesis will be a cemented prosthesis supported by all the implants. &he practitioner wants to avoid diffusion of excess cement in newly sutured soft tissues &he practitioner wants to avoid diffusion of excess cement in an extraction site, especially when there is a gap between the implant and the alveolus. , &he clinical situation ma!es removal of excess cement difficult (ie, for deeply subcrestal implants". &he clinician anticipates substantial gingival recession to occur, compromising esthetics E screw-retained provisional prosthesis avoids the placement of abutments with their metalcrown )unction near the gingival sulcus. &he clinician wants to be able to verify implant stability during the osseointegration period.

In all of the aforementioned cases, the screw-retained method is preferable for the provisional prosthesis. y the time the final prosthesis is placed. however, osseointegration will be completed and soft tissues will be healed &he ris! of diffusion of excess cement will be greatly diminished, so that cement fixation, with its anticipated esthetic benefits, can be selected.

%.

%i*ation methods for provisional and final prostheses

4crew-retained provisional prosthesis

4crew-ret..ained /emented final final prosthesis prosthesis Cemented final prosthesis

II

1 %i& '-" d Cemented

!ina prost"esis.

provisiona prost"esis and screw-retained

Cemented provisional final prosthesis

prosthesis and screw-retained

&his combination (Fig '-( d" is appropriate when. En esthetic failure in the edentulous maxilla re$uires management. E screw-retained final prosthesis allows the use of false gingiva made of acrylic resin or ceramic material.

$.
Screw-retained

%i*ation methods for provisional and final prostheses

4crew-retained provisional prosthesis

e!ented final final prosthesis prosthesis Screw-retained final prosthesis

%i& '-" e Cemented provisiona and !ina prost"eses.

Cemented provisional and final prostheses

&his combination (Fig '-(e" is appropriate when. Asthetic considerations are important for the provisional denture, because cementation allows better management of the emergence profile .
-:;.; ;;..

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 &he patient has a thin periodontal biotype. For these patients, final abutments are placed immediately to avoid disruption of the soft tissue attachment when the final prosthesis is prepared. &he implant is angled too far buccally and re$uires correction &he screw access hole of a screwretained prosthesis would be located on the buccal side of the crown and would be unesthetic. In all of the aforementioned situations, cementation is the method of choice for retention of the provisional prosthesis. Kowever, this mode of retention re$uires more chair time and attention, as the clinician must remove all excess cement. In such cases, the final prosthesis is cemented for the same reasons as the provisional prosthesis.

,. +. 10.

94

-',..,-

Chapter
-i .

FAILURE OF IMMEDIATELY LOADED IMPLANTS

Serge Sz!ukler-Monc"er Mithridade Davarpanah Paul M. Khoury #driana #gachi

Immediate-loading and delayed-loading protocols ali!e are predisposed to ob)ective or sub)ective implant failures. En objective failure is when an immediately loaded implant, after having demonstrated satisfactory primary stability, does not achieve osseointegration and becomes mobile over the course of time. E subjective failure is when an immediately loaded implant fails esthetically. It is more difficult to decide whether the blame can be placed on the immediate-loading protocol, because several studies have shown that no specific bone loss can be attributed to immediate loading. 1-3 It may be possible that soft tissues react in a specific manner to immediate loading, but this remains to be established. 4o far, the opposite has been documented based on results of short-term data 4

9 5

... Ca/ses and Timin& of %ail/re

&here are two causes of implant mobility. 11. Infection 12. iomechanical problems &he less fre$uent of the two is infection, but when infection occurs it becomes $uic!ly evident, usually within the first % to H wee!s after immediate loading. It can be caused by. Infection of the bone during the surgery Infection of soft tissues that diffuses to the bone Residual postextraction infection of the alveolus Ligration of excess cement to the bone

1I

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1mplants fail more fre$ue ntly becau se of mecha nical loadin g- this type of mobilit y manife sts later, betwe en H and (M wee!s after loadin g. &he cause s are excess ive mecha nical stress exerte d on the implan ts and deleter ious micro move ments at the boneimplan t interfa ce, in excess of its toleran ce level. &olerat ed micro move ments vary from %= I0m for a machi ned surfac

e# to (== I0m for a % t r1d surface ) the tolerance increases to at least 2#0 I0m when the surface is bioactiveN 'lhese micromovements interfere with the osseointegration process' that aims to establish secondary biologic stabiliOation Furthermore, they cause resorption of the peri-implant bone, whic:0..had provided primary mechanical stability to the implant. hen the conditions of primary stability at the bone-implant interface are favorable, u.odifferentiated pluripotential mesencnymal cel&4arrive at the implant site and, following the =.P(P.J.2(a.s(.).c d'(fferentiation pathway, differentiate into osteocytes. #steoblasts lay down calcified tissue that parti.JlQates in the biologic stability of the implant, and osseointegration is obtained. 15hen deleterious micromovements occur at the implant-bone interface, however, the mesenchymal cells arriving at the site are detoured from the osteoblastic differentiation pathway toward the fibroblastic pathway and, instead, become fibroblastsN &he fibroblasts organiOe a fibrous encapsulation around the implant in which fibers are parallel to the implant axis. + Es this fibrous tiss1efRl. . thic!er, the implant becomes more mobile, leading to fi1in1ion Instead of osseolntegratlon. Lobile implants must be unloaded or removed as soon as possible, because implant mobility leads to horiOontal resorption of the surrounding cortical bone. Failures of osseointegration are detected most fre$uently H to (M wee!s after loading. &his is the time necessary for osteoclasts to resorb the original bone that participated in the purely mechanical primary stability. Failure to osseointegrate can be attributed to. Insufficient primary stability associated with implant placement in bone of poor density Insufficient primary stability associated with implant placement in an extraction soc!et Inade$uate splinting of implants supporting a complete or partial prosthesis &he effect of constant pea!s of stress on the implant because of imperfectly ad)usted occlusion &he effect of intermittent pea!s of stress on the implant during mastication of certain foods

----.---

&he presence of intermittent pea!s of stress is enough to trigger bone resorption , Kowever, when these stresses are eliminated in the first % or H wee!s after immediate loading, it is still possible for the fibroblastic cellular differentiation pathway to revert to the original osteoblastic pathway (=-(M /alcification can resume at the bone-implant interface, and osseointegration can still be obtained. Efter H to S wee!s of mobility at the bone-implant interface, the progression toward fibrous encapsulation is more difficult to stop.(M

" Clinical Si&ns of 0sseointe&ration %ail/re

&he clinical signs of osseointegration failure are /linical mobility 4ensitivity during mastication 4ensitivity to percussion Qossibly, the presence of inflammation 5hen implant mobility is suspected or the patient complains of symptoms, a periapical radiograph should provide useful information. &he presence of peri-implant radiolucency indicates that osseointegration has failed. Kowever, clinical signs of mobility can exist even in the absence of this radiographic finding. E T-shaped area of resorption located at the bone crest around the limplant reflects a bone response to biomechanical overloading (Fig *-(" i &he radiograph in Fig *-( shows two implants that became mobile % months after placement. &he failure followed fracture of the maxillary complete denture in the canine region. E more or less continuous peri-implant radiolucency is visible around the implant in the position of the right canine.

14. 1#.

%ail/re within the first 1 wee2s of loadin&

5hen implant mobility has been identified with certainty, it is sometimes possible to restore its clinical stability, but only when the mobility has been discovered during the first S wee!s after immediate loading. If the implant cannot be replaced with an implant of larger diameter' or if the mobile implant is not indispensable to the function of the prosthesis, eg, the last implant supporting a maxillary complete denture, it can be removed from function and further protected from loading stress. &he unloaded implant should be followed for a %-month period, during which time its mobility and related symptoms are evaluated every H wee!s. Et the time of the first month's examination, the clinical signs of mobility and the related symptoms should have abated. #b)ective assessors of mobility, such as Qeriotest (LediOintechni! Culden" or #sstell (#sstell", are very useful. If implant mobility has not decreased by the second month's assessment, the clinician should radiograph the implant and then remove it. Kowever, if the Qeriotest or #sstell suggests that mobility is decreasing, the clinician should wait until the end of the third month. Et that time, a finding of progressively improving stability will give assurance that the implant can be restored to function. /linicians who do not have access to ob)ective evaluation devices can measure implant stability manually and ma!e a clinical )udgment about the extent to which clinical stability has improved while the implant has been out of function. efore attaching the implant to the final prosthesis, however, the clinician should test the level of osseointegration by applying a countertor$ue of M= @cm or by ob serving how the implant withstands occlusal stress for % months in support of a provisional prosthesis In a clinical trial in which (( implants were identified as mobile, ' mobile implants (S%X" were able to recover clinical stability after they were left to heal unloaded for several months (unpublished data, M=='". &hese implants were successfully returned to function
+. @atiella 0R, Ermitage 0A, Leenaghan LE, Creene C5 &issue response to dental implants protruding through mucous membrane. #r,al 4ci Rev (J'H-V.*V-(=V. ,. Uuyc! 0, Ronold K0, Tan #osterwyc! K, @aert I, Tander 4ioten 0, Allingsen 0A'. &he influence of static and dynamic loading on marginal bone reactions around osseo-integrated implants En animal experimental stud-y., /lin #ral Implants Res M==(- (M.M='-M(*. 10. 9hthoff K>, Cermain 0Q. &he reversal of tissue differenliation around screws. /lin #rthop Relat Res (J''(M%MH*-MVM. 11. 4=balle >, Kansen A4, roc!stedt-Rasmussen K, unger /. &he effects of osteoporosis, bone deficiency, bone grafting and micromotion on fixation of porouscoated hydroxyapatitecoated implants. In. Ceesin! RC&, Lanley L& (eds" Kydroxylapatite /oatings in #rthopaedi/ 4urgery. @ew <or!. Raven Qress, (JJ%. (='-(%S. (M Uietrich 9, 4chramm-4cherrer . >ompli!ationen nach &Q44chraubenimplantationen. W WahnartOl Implantol (JJ=-S(V(J. 13. Uavarpanah L, /araman L, 0a!ubowicO->ohen, >ebir2uelin L, 4Omu!ler-Loncler 4. Qrosthetic success with a maxillary immediate-loading protocol in the multipleris! patient. Int 0 Qeriodontics Restorative Uent M=='-M'. (S((SJ.

References
1. &estori &, Uel Fabbro L, 4Omu!ler-Loncler 4, Francetti 3, 5einstein R3. Immediate occlusal loading of #sseotite implants in the completely edentulous mandible. Int 0 #ral Laxillofac Implants M==%- (*.VHH-VV(. 2. erg!vist C, 4ahlholm 4, >arlsson 9, @ilner >, 3indh /. Immediately loaded implants supporting fixed prostheses in the edentulous maxilla E preliminary clinical and radiologic report. Int 0 #ral Laxillofac Implants M==V-M=. %JJ-H=V.

% /orso L, 4irota /, Fiorellini 0, Rasool F, 4Omu!ler-Loncler 4, 5eber KQ. /linical and radiographic evaluation of early loaded free-standing dental implants with various coatings in beagle dogs. 0 Qrosthet Uent (JJJ-*M HM*-H%V. 4. Clauser R, Wembic E, Kammerle /K. E systematic review of marginal soft tissue at implants sub)ected to immediate loading or immediate restoration. /lin #ral Implants Res M==S-('(suppl M"*M-JM. #. runs!i 0 . Evoid pitfalls of overloading and micromotion of intraosseous implants Uent Implantol 9pdate (JJ%-H ''-*(

%. #vergaard 4, romose 9, 3ind L, unger /, 4=balle >. &he influence of crystallinity of the hydroxyapatite coating on the fixation of implants. Lechanical and histomorphometric results. 0 one 0oint 4urg r (JJJ-*( .'MV-'%(. $. uchler Q, Qioletti UQ, Ra!otomanana 3R. iphasic constitutive laws for biological interface evolution. iomech Lodel Lechanobiol M==%- (M%J-MHJ

1%.

Chapter

K$% CONCEPTS OF TREATMENT

PLANNING
Serge Sz!ukJer-Moncler Mithridade &avarpanah Paul M. Khoury #driana #gachi

Qart ( of the boo! provides the basic and theoretic information specific to immediate-loading protocols. Qart 2 explains and iilustrM(.tes the practical application of these protocols. For each group of indications, the strategies and the appropriate treatment options are discussed. &he different phases-preoperative, surgical, and prosthetic--are presented in detail, as are the se$uence of procedures.

/ 3e4 nformation for 5ach Treatment 0ption at a 6lance

In the subse$uent chapters, the most important practical issues of each treatment option are listed in a format that can be grasped at a glance. &he aim is to help the reader to rapidly discern the best solu tion to any clinical situation and its related practical aspects. &he !ey points are arranged in two groups. (. E panel of eight pictograms with information covering the most important aspects of the treatrno-(t options. &echnical difficulty of preparing the provisional prosthesis Uegree of coordination among of the members of the treatment team Emount of time re$uired for treatment @umber of implants needed Importance of esthetic considerations Axtra costs specific to the immediate-loading protocol compared with the conventional treatment Ue4lme of ris! involved in the immediate-loading treatment Emount of documentation in the literature

2. E chart depicting the se$uence and timing of the steps in each treatment option, so that all mem bers of the treatment team can identify the phases in which they participate in treatment and their roles. &he se$uence of the phases is divided into the following segments. Qreoperative phase 4urgical phase Qrovisional prosthetic phase Final prosthetic phase y !eeping this se$uence of events in mind, clinicians can determine the best way to harmoniously incorporate the special tas!s re$uired for each phase into the overall plan.

Content of the pictogram panel

Aach !ey point is classified into three levels.

'echnical di((iculty

&his category deals primarily with the prosthetic phase. &he level of difficulty depends on whether the prosthesis is prepared at chairside or in the laboratory and whether or not precise occlusal ad)ustments are needed. &he procedure is most difficult when the prosthesis must be prepared at chairside and re$uires occlusal ad)ustment or when a final prosthesis made in the laboratory needs fine occlusal ad)ustments after placement.
&echnical difficulty

I.

&

Technical diffic/lt4 is low

&he prosthesis is made in the laboratory and is designed to be !ept out of occlusion. &he prosthetic phase presents no particular technical challenge.
&echnical .difficulty

Technical diffic/lt4 is avera&e

&he prosthetic phase presents the prosthodontist with some technical problems and re$uires close attention. &he clinician prepares the prosthesis at chairside or executes precise occlusal ad)ustments on a laboratory-made prosthesis.
&echnical difficulty

Technical diffic/lt4 is hi&h

&he prosthetic phase ta!es place exclusively at chairside, and presents difficulties in preparation of the provisional prosthesis and ad)ustment of the occlusion, or involves fine occlusal ad)ustment of a final prosthesis made in the laboratory.

'ea! coordination
&o can'y out an immediate-loading procedure as effectively and as expeditiously as possible, all mem; :-*('1 =( tfle treating leam nl94l !now precisely \N~e l they will bo called on to paliicipate in the ente ; r;,ris(", &he patient should be aware that short and pmcisely delin ilted schedules will have to be resQe r; (/'d. &he prosthodontist will have to wor! aft*r1h(= f'9r1*=n elt the same' appointment or on a stri/t ,'-hed'-le after completion of the surgical proce/lue. /0oldina.ioi, botween these practitioners does n /t -onsttute a ma)or difficulty- if the laboratory is not Involved In preparing the provisional prosthesis, t1 nlNed for coordination can be considered limited e 5hen the laboratory is involved, the aTailability of 9-e laboratory is the principal concern, because it participation is the !ey element in the precise unfolding of the treatment within the preconceived tlm s frame. &he practitioners should t"* certain that they have chosen a laboratory technician who is ex.p 1 rienced in this treatment modality, because reliability and adherence to a well-defined schedule are /1; tical. &he level of team coordination will vary according to the extent and the difficulty of the restoration t 1:.+ )."rKpMrpd in the laboratt"ry. 0
-ream

C...,ordinatiun
&eam coordination

Teai'"" coordination is limited

.(e rel*tiveiy relaxed level of coordinatiol. b(%twe*(( team .lllnb'0rs sEfic 4 because time constraints ar T7sa!. &he labomtory is not included in th* schedule because ihc" prosthesis is made at chairside.
&eam coordination

C#$
!
Team coordination is moderate
Elthough a celiain amount of coordination with the laboratory is needed, the team does not have t .7, ,.orm to demanding, tight time constraints. rhe laboratory is involved immediately after implant Qla.1 ,-er('ant but the prosthetic wor! is relatively simple to pnrf=lnl. In Alddition, in the absence of any crit'; . -'I-.s,letic considerations, the pro')i1oionr-' QiI<' r'+'..%is 7. all ue '1omt'"leted vvitllin 'M hours rather than I .ill.ro hect!. MH-hour pCliod. a.

Team coordination is ti&ht

1.-t,ict coordination is indispensable because time constraints are critical. &he laboratory is inT#lved immediately after Implant placement in a complex prosthetic design that re$uires considerable time t be completed, or the prosthetic wor! rnust '0+ urgently prep.lred in the laboratory without dela. 0 "*/,%94e of the patient's psychologic n%/iI0irerc(onts. in the lutter (else, the prosthesis must be, at besi completed on the day of implant placement or, at least, de.ayed no more than MH or H* hours, not h,)urs.

$2

"reatment time

'reat!ent ti!e
&his information is important for planning the prosthetic phase and for estimation of the treatment costs. In addition, an understanding of time re$uirements eases office time management. &hese guidelines estimate the average time it would ta!e a practitioner with average experience to complete a given tas!.
"reatment time

Treatment time is limited

"reatment time

&he prosthesis is made in the laboratory and is to be !ept out of occlusion. &he provisional prosthetic phase re$uires a relatively small time commitment from the prosthodontist, especially because fine occlusion ad)ustment is not re$uired.

Treatment time is avera&e

&he provisional prosthesis re$uires more of the practitioner's time. t is fabricated at chairside and placed out of occlusion or fabricated in the laboratory but re$uires o/clusN( ad)ustment.

Treatment time is e*tended

&he provisional prosthetic phase re$uires a considerable amount of the practitioner's time. t must be highlighted in the schedule as re$uiring a long and tiring appointment. Aither the provisional prosthesis is prepared at chairside and the prosthodontist has to ad)ust the occlusion carefully, or the prosthesis is fabricated in the laboratory but much time must be spent carefully ad)usting the occlusion (eg, for an immediately delivered final prosthesis in the edentulous mandible".
@umber of implants

)u!ber of i!plants
&he number of implants re$uired to provide a satisfactory support varies from case to case. &here is no $uestion for replacement of a single crown, but the number of implants necessary can widely vary when an edentulous mandible or maxilla is rehabilitated. &he number of implants depends on the ris! involved in the treatment. 4ometimes, to minimiOe the ris! of failure, the authors will recommend including more implants in the treatment plan than is normally recommended in the literature. &herefor-e, the num-

Axtra costs

$*tra costs speci(ic to the i!!ediate-loading protocol

Immediate loading may incur extra costs for patients compared with fees for traditional provisional iOation, because immediate loading may necessitate the use of specific, expensive materials. In some cases, material costs are similar. &he initial demands on the practitioner's time are greater with immediate loading, but they diminish considerably during the course of treatment.

5*tra costs are low

#nly a modest increase in fee, if any, is re$uired. Edditional prosthetic materials are not re$uired, the laboratory ma!es the prosthesis, and the clinician's chair time is not extended. Reuse of materials from the provisional prosthesis for the final prosthesis can also help to reduce costs.
Ris! assessment

5*tra costs are moderate

E moderate increase in fee is re$uired because some specific additional prosthetic materials are re$uired or the prosthodontist must spend additional time at chairside.
Ris! assessment

Ris! assessment

5*tra costs are s/(stantial

/onsiderable amounts of supplementary prosthetic materials are re$uired, and the prosthodontist has to spend much more time at chairside. &his forces a ma)or increase in the total fee.

+isk assess!ent
efore treatment, the clinician has to outline for the patient the potential ris!s of the immediate-loading procedure. &he clinician and patient must analyOe the ris!-benefit ratio and discuss alternative measures that can be ta!en should the immediate-loading protocol fail. &he ris! analysis should be based not only on applicable success rates published in the literature but also on the parameters of the individual case and the practitioner's own experience in the field.

7oc/mentation 7oc/mentation 7oc/mentation

+dditional ris2 is low

&he ris! specific to immediate loading is minimal and the ris! factors are readily under control. 4uccess rates published in the literature for the treated indication are high and are comparable with those for tra-

ditional-loading protocols.

+dditional ris2 is moderate

&he ris!s associated with immediate loading are not negligible, but the clinician should be able to manage them without undue difficulty.

+dditional ris2 is hi&h

Ris! factors specific to immediate loading do exist. &he clinician should scrupulously adhere to all the principles of immediate loading and ma!e certain that all the conditions re$uired for a successful out come are in place.

Docu!entation in the literature

@ot all indications for immediate loading are e$ually well documented in the literature. Kowever. neither extensive nor scarce documentation gives assurance of the reliability or the ris! of the procedure.

7oc/mentation in the literat/re is scarce

Few studies on this indication have been published.

7oc/mentation in the literat/re is moderate

E reasonable number of studies on this indication have been published.

7oc/mentation in the literat/re is e*tensive

&his indication for immediate loading has been abundantly documented in the literature .

.... Principal 7eterminants of Treatment

Uepending on the type of rehabilitation involved, patients, with the guidance of their clinician, are motivated to see! immediate-loading treatment for a variety of reasons, including. "sycholo#ic need. &he patient's emotional distress at an unsightly appearance drives him or her to see! restoration of the missing teeth as rapidly as possible.

1$.

$neasiness in the dental chair. &he patient wants rapid restoration of the missing teeth, but has %ifficulty in &ee'in# a''ointments.

difficulty in submitting to a drawn-out dental procedure. ecause of busy schedules or other reasons, the patient is unavailable for multiple appointments and therefore prefers rapid treatment. (inancial incentive. E final prosthesis is immediately delivered, so the patient will not have to pay for a provisional denture. Es discussed in chapter %, anyone of these re$uirements may be the principal determinant of treatment that persuades the clinicians and the patient, wor!ing together, to select a given immediate-loa ding protocol and treatment time frame.