tiziano testori Fabio Galli massimo del Fabbro

immediate loadinG: A New Era in Oral Implantology

London, BerL in , Ch iCago, Tokyo, BarCeLona, isTanBuL , M iLan, MosCow,new deLhi , Paris , Be i j ing , Prague, são PauLo, seouL and warsaw

IV —ImmedIate LoadIng: a new era in oral Implantology

Editors

Tiziano TesTori Dr Testori is head of the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. He is also a visiting professor at New York University College of Dentistry in New York, New York. He is the former president of the Italian Society of Oral Surgery and Implantology (SICOI), a founding member of the Advanced Implantology Study Group (AISG), author to over 200 scientific articles, and coeditor of Maxillary Sinus Surgery and Alternative Therapies (Quintessence, 2009). He maintains a private practice in Como, Italy.

Fabio Galli Dr Galli is head of Prosthodontics in the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. He is a founding member of the Advanced Implantology Study Group (AISG) and a contributing author to Maxillary Sinus Surgery and Alternative Therapies (Quintessence, 2009). Dr Galli is a lecturer and author in the fields of implant and prosthetic dentistry and maintains a private practice in Monza, Italy.

MassiMo Del Fabbro Dr Del Fabbro is head of Oral Physiology at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. He has authored several articles in the fields of periodontology, implant dentistry, endodontics, physiology, and biochemistry. He also coedited Maxillary Sinus Surgery and Alternative Therapies (Quintessence, 2009). Dr Del Fabbro is a researcher in dentistry and oral surgery and medicine on the Faculty of Medicine at the University of Milan.

V

TheGaleazziImplantGroup

6

3 9

2 1

10

7 14

13 4

11 5

8 12

1 Tiziano TesTori

2 Fabio Galli

3 MaTTeo Capelli

4 FranCesCo zuFFeTTi

5 anDrea parenTi

6 luCa FuMaGalli

7 ilaria FranChini

8 Maria CrisTina rossi

9 Carlo ValTorTa

10 roberTo CasTellaneTa

11 luiGi DaVerio

12 MaTTeo DeFlorian

13 MarCo FossaTi

14 pierpaolo raCCo

VI — ImmedIate LoadIng: a new era in oral Implantology

MaTTeo Capelli Dr Capelli is a lecturer and tutor in the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. He is a founding member of the Advanced Implantology Study Group (AISG), author of many scientific papers in the field of dental implants, and a contributing author to the book Maxillary Sinus Surgery and Alternative Therapies (Quintessence, 2009). Dr Capelli maintains a private practice in Milan, Italy.

FranCesCo zuFFeTTi Dr Zuffetti is a lecturer and tutor in the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. He is a founding member of both the Advanced Implantology Study Group (AISG) and the European Board of Oral Surgery (EFOSS), author of over 80 scientific papers, and contributing author to the book Maxillary Sinus Surgery and Alternative Therapies (Quintessence, 2009). Dr Zuffetti maintains private practices in Milan and Crema, Italy.

anDrea parenTi Dr Parenti is a lecturer and tutor in the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. He is a founding member of the Advanced Implantology Study Group (AISG), author of many scientific papers in the field of dental implants, and a contributing author to the book Maxillary Sinus Surgery and Alternative Therapies (Quintessence, 2009). Dr Parenti maintains a private practice in Piacenza, Italy.

VII

luCa FuMaGalli Dr Fumagalli is a lecturer and tutor in the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. He is a founding member of the Advanced Implantology Study Group (AISG), author of many scientific papers in the field of dental implants, and a contributing author to the book Maxillary Sinus Surgery and Alternative Therapies (Quintessence, 2009). Dr Fumagalli maintains a private practice in Milan, Italy.

ilaria FranChini Dr Franchini is a tutor in the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. She is an author and lecturer in the fields of dental implants and implant surgery, and she is a contributing author to the book Maxillary Sinus Surgery and Alternative Therapies (Quintessence, 2009). Dr Franchini maintains a private practice in Milan, Italy.

Maria CrisTina rossi Dr Rossi is a tutor in the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. She is the author or coauthor of many scientific papers in the field of dental implants and a contributing author to the book Maxillary Sinus Surgery and Alternative Therapies (Quintessence, 2009). Dr Rossi maintains a private practice in Milan, Italy.

Carlo ValTorTa Dr Valtorta is a tutor in the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan, where he is currently an intern.

FranCesCa bianChi Dr Bianchi is a lecturer and tutor in the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. She is the author or coauthor of several scientific papers in the fields of dental implants and periodontics. Dr Bianchi maintains a private practice in Como, Italy.

roberTo CasTellaneTa Dr Castellaneta is a tutor in the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan, where he is currently an intern. He is the author or coauthor of several scientific papers in the field of dental implants. Dr Castellaneta maintains a private practice in Milan, Italy.

luiGi DaVerio Dr Daverio is a tutor in the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan, where he is currently an intern. He is the author or coauthor of several scientific papers in the field of dental implants. Dr Daverio maintains a private practice in Milan, Italy.

VIII — ImmedIate LoadIng: a new era in oral Implantology

MaTTeo DeFlorian Dr Deflorian is a tutor in the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan, where he is currently an intern. He is the author or coauthor of several scientific papers in the field of dental implants. Dr Deflorian maintains private practices in Milan and Piacenza, Italy.

MarCo FossaTi Dr Fossati is a tutor in the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan, where he is currently an intern. He is the author or coauthor of several scientific papers in the field of dental implants. Dr Fossati maintains a private practice in Milan, Italy.

FeDeriCo ManDelli Dr Mandelli is a tutor in the Department of Advanced Oral Surgery at the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. He is a postgraduate student in implantology and oral rehabilitation at New York University College of Dentistry in New York, New York. Dr Mandelli maintains a private practice in Milan, Italy.

pierpaolo raCCo Dr Racco is a tutor in the Implantology and Oral Rehabilitation Department of the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan, where he is currently an intern. He is the author or coauthor of many scientific papers in the field of dental implants. Dr Racco maintains a private practice in Cantù, Italy.

IX

X —ImmedIate LoadIng: a new era in oral Implantology

Coauthors

enriCo aGliarDi Dr Agliardi is a mentor in implantology and implant prosthetics for the Brånemark implant system and an instructor for the NobelGuide implant method for Nobel Biocare. He is a lecturer and author in the field of implant dentistry and has many years of experience in oral, orthognathic, preprosthetic, and preimplant surgery.

MiChel araÚJo Mr Araújo is a research assistant at the University of Toronto in the group of Dr J. E. Davies.

MaTTeo basso Dr Basso coordinates clinical activities at the dental clinic at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan, where he is a visiting professor in dental ergonomics. He is a lecturer and author in the fields of periodontics and implant dentistry.

alberTo beCCaTTelli Dr Beccattelli maintains a private practice in Villa Bartolomea, Italy, focusing on oral and implant surgery.

leo bisCaro Dr Biscaro is president elect of the Italian Academy of Prosthetic Dentistry (AIOP). He specializes in prosthetics as well as implant and periodontal surgery. Dr Biscaro maintains a private group practice in Adria, Italy.

GiorGio CasTellazzi Dr Castellazzi works as a specialist in radiology in the Department of Diagnostic and Interventional Radiology at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan.

roberTo CoCCheTTo Dr Cocchetto is a lecturer for the postgraduate program in Oral Implantology at the G. d’Annunzio University in Chieti, Italy. He lectures in the fields of implant and prosthetic dentistry and has authored and coauthored many scientific papers on those subjects. Dr Cocchetto maintains a private practice in Verona, Italy.

MiThriDaDe DaVarpanah Dr Davarpanah is head of the Oral Rehabilitation Center at the American Hospital of Paris. He has authored more than 100 scientific papers and 7 textbooks on the subjects of clinical implantology and surgery, including his Clinical Manual of Implant Dentistry (Quintessence, 2003), which has been translated into 8 languages. Dr Davarpanah maintains a private practice limited to periodontology and surgical implantology.

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XII —ImmedIate LoadIng: a new era in oral Implantology

John DaVies Dr Davies is a professor of biomaterials at the University of Toronto, where he serves on the Faculty of Dentistry and the Institute of Biomaterials and Biomedical Engineering. He is the coeditor of The Bone-Biomaterial Interface (Univeristy of Toronto, 1991) and editor of Bone Engineering (Em Squared, 2000). Dr Davies is also the founding president of the biotech company Tissue Regeneration Therapeutics.

luCa FranCeTTi Dr Francetti is an associate professor and head of the Periodontology Department at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. He is president of the Italian Society of Periodontology (SIDP) and is both a lecturer and author in the fields of prosthodontics and dental hygiene.

JeFFrey Ganeles Dr Ganeles is a periodontist at the Florida Institute for Periodontics and Dental Implants in Boca Raton, Florida. He is also a clinical assistant professor at Nova Southeastern University in Fort Lauderdale, Florida. He is a lecturer and author in the fields of periodontics, implant dentistry, technology applications in dentistry, patient education, and treatment planning. Dr Ganeles maintains a private practice in Florida.

sTeFano GraCis Dr Gracis serves on the editorial boards of the International Journal of Prosthodontics, the European Journal of Esthetics, and the European Journal of Oral Implantology. He is the former president of the Italian Academy of Prosthetic Dentistry (AIOP) and is a lecturer and author in the fields of restorative dentistry and prosthodontics. Dr Gracis maintains a private practice in Milan, Italy.

paul Khoury Dr Khoury has collaborated with Drs Szmukler-Moncler and Davarpanah designing new orthodontic devices with three-dimensional modeling software. He is the coauthor of several implantology textbooks.

iGnazio loi Dr Loi is an author and lecturer in the field of prosthetic dentistry. He maintains a private practice limited to prosthodontics in Cagliari, Italy.

Vanessa MenDes Dr Mendes is a postdoctoral fellow at the University of Toronto under Dr Davies’s group, working to clarify the mechanisms of early endosseous healing around implants with complex surface topographies.

alessanDro MoTroni Dr Motroni is a biomedical engineer who works with the application of three-dimensional reconstruction techniques in the medical field and develops radiologic image segmentation filters both for diagnostic use and for planning and simulating surgical operations.

XIII

XIV —ImmedIate LoadIng: a new era in oral Implantology

Fabrizio MonTaGna Dr Montagna is a visiting professor in the Department of Oral and Dental Diseases and Orthodontics at the University of Cagliari in Cagliari, Italy. He is the coauthor of several scientific papers in the fields of oral diseases and forensic dentistry. Dr Montagna maintains a private practice in Sommacampagna, Italy.

FranCo perona Dr Perona is a specialist in radiology and head of the operative radiologic unit at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. He is a lecturer and author in the field of radiodiagnostics and has taught on this subject in Genoa and Milan.

paola Maria poGGio Dr Poggio is a specialist in orthodontics and fixed prostheses. She maintains a private practice in Adria, Italy.

JoerG MiChael riTzMann Dr Ritzmann is a researcher on photopolymerization at the Academic Center for Dentistry Amsterdam and is currently a consultant to implant manufacturers for the development of innovative prosthetic components. He is also a lecturer in the field of implant prosthodontics. Dr Ritzmann maintains a private practice in Milan, Italy.

DaViDe roMeo Dr Romeo is currently engaged in a research doctorate on innovative techniques in oral implantology at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. He is the coauthor of several scientific papers in the fields of periodontology and implant prosthetics.

MarCo lorenzo sCarpelli Dr Scarpelli is a forensic dentist and coordinates the master’s degree in forensic dentistry at the University of Florence, where he is a visiting professor in the Department of Dentistry, teaching courses on ethics and private conduct. He maintains a private practice in Milan, Italy.

Fabio sCuTellà Dr Scutellà is a lecturer in the field of prosthetic dentistry. He maintains private practices limited to prosthodontics in Rome and Como, Italy.

Chiarella sForza Dr Sforza is a full professor of human anatomy at the Medical, Dental, and Nursing School and the director of the Department of Human Morphology and Biomedical Sciences at the University of Milan. She is a visiting professor at the University of São Paulo School of Dentistry in Ribeirão Preto, Brazil and has authored or coauthored over 200 scientific publications.

XV

XVI —ImmedIate LoadIng: a new era in oral Implantology

serGe szMuKler-MonCler Dr Szmukler-Moncler is an associate professor in the Department of Stomatology and Maxillofacial Surgery at the University of Paris 6 (UPMC) and a visiting professor in the Department of Odontology at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. He is also a lecturer at the University of Strasbourg and La Sapienza University of Rome. Dr Szmukler-Moncler maintains a consulting firm specializing in biomaterials and implantology in Basel, Switzerland.

GianluCa TarTaGlia Dr Tartaglia is a visiting professor in the Department of Human Anatomy and a consultant professor of gnathology in the School of Dentistry at the University of L’Aquila in L’Aquila, Italy. He is also a visiting professor at both the University of São Paulo School of Dentistry in Ribeirão Preto, Brazil and the School of Dentistry at the University of Milan. Dr Tartaglia has authored over 80 scientific papers related to functional anatomy and maintains a private practice in Milan, Italy.

XVII

silVio TasChieri Dr Taschieri is a visiting professor and head of the Department of Endodontics and Endodontic Surgery at the IRCCS Galeazzi Orthopaedic Institute, Deparment of Health Technologies, University of Milan. He is the author of several scientific articles in the field of endodontics. Dr Taschieri maintains a private practice in Milan, Italy.

paolo Trisi Dr Trisi is the scientific director of the Biomaterial Clinical Research Association Center (BIOCRA) in Pescara, Italy, where he maintains a private practice. He is also a lecturer at the Universities of Chieti and Genoa and director of the Biomaterials and Biomechanics Laboratory at the IRCCS Galeazzi Orthopaedic Institute, Department of Health Technologies, University of Milan. He is a founding member of the International Congress of Oral Implantologists (ICOI) and author of more than 70 scientific papers in the fields of tissue response to implant materials and bone regeneration.

XVIII — ImmedIate LoadIng: a new era in oral Implantology

TableofContents

page chapter

XX Foreword by RIchaRd LazzaRa and dennIs taRnow

XXII Foreword by RobeRto LodoVIco weInsteIn

XXIII Preface tIzIano testoRI, FabIo gaLLI, massImo deL FabbRo

1 01 BiologicBackground

massImo deL FabbRo, PaoLo tRIsI

17 02 BiologyandBiomechanicsinImmediateLoading PaoLo tRIsI, massImo deL FabbRo

47 03 TheRoleofImplantSurfaceTopographyonBiologicStabilization John daVIes, mIcheL aRaúJo, massImo deL FabbRo, Vanessa mendes, tIzIano testoRI

65 04 ASystematicReviewoftheLiterature massImo deL FabbRo, sILVIo taschIeRI

93 05 PresurgicalDiagnosticPhase FabIo scuteLLà, FabIo gaLLI, tIzIano testoRI

163 06 AdvancedDiagnosticImagingTechniques FRanco PeRona, aLessandRo motRonI, gIoRgIo casteLLazzI, tIzIano testoRI

189 07 TheTherapeuticApproachoftheGaleazziOrthopaedicInstituteImplantDepartment massImo deL FabbRo, tIzIano testoRI, FabIo gaLLI, matteo caPeLLI, FRancesco zuFFettI, andRea PaRentI,

Luca FumagaLLI, ILaRIa FRanchInI, maRIa cRIstIna RossI, caRLo VaLtoRta, RobeRto casteLLaneta, LuIgI

daVeRIo, matteo deFLoRIan, maRco FossatI, PIeRPaoLo Racco

Part1: ClinicalProcedures

Part2: ScientificResearchActivity 295 08 TherapeuticAlternativesfortheImmediateRehabilitationofAtrophicJaws UsingTiltedImplants Luca FRancettI, daVIde Romeo, enRIco agLIaRdI, massImo deL FabbRo

335 09 ComplexRehabilitationsinCompletelyEdentulousPatients Leo bIscaRo, aLbeRto beccatteLLI, PaoLa maRIa PoggIo

table of contents XIX

361 10 Surgical-ProstheticInteractionsintheImmediateLoadingofImplantsintheEstheticZone RobeRto coccheto, IgnazIo LoI

377 11 IntraoperativeImpressionandControlofPassiveFitinImmediateLoading ILaRIa FRanchInI, FabIo gaLLI, maRIa cRIstIna RossI, massImo deL FabbRo

393 12 ChairsideVersusLaboratoryPreparationoftheProvisionalProsthesis inImmediatelyLoadedCases:ARationale seRge szmukLeR-moncLeR, mIthRIdade daVaRPanah, PauL khouRy

419 13 IndicationsandContraindicationsofMini-Implants FabRIzIo montagna, JöRg mIchaeL RItzmann, LIVIa montagna

433 14 OcclusioninImplant-SupportedProsthesesUnderImmediateLoading andDelayedLoading steFano gRacIs, FabIo gaLLI, Luca FumagaLLI

455 15 OralRehabilitationwithImmediateLoading:NoninvasiveMorphofunctional Assessment gIanLuca taRtagLIa, chIaReLLa sFoRza

469 16 ImplantSupportTherapy matteo basso, FRancesca bIanchI

481 17 Patient-CenteredOutcomes:ThePatient’sViewpoint massImo deL FabbRo, tIzIano testoRI

491 18 ManagementoftheImplantPatient:StateoftheArt JeFFRey ganeLes, FRancesca bIanchI, FedeRIco mandeLLI

509 19 MedicolegalImplicationsandClinicalGuidelinesinImmediateLoading maRco LoRenzo scaRPeLLI, Luca FumagaLLI, massImo deL FabbRo

517 20 TheRoleofComputer-AssistedSurgery tIzIano testoRI, Luca FumagaLLI, massImo deL FabbRo

539 21 GuidelinesfortheCollectionandOrganizationofScientificData massImo deL FabbRo, tIzIano testoRI

550 Index

Foreword

Among the innovative procedures that have marked significant steps forward in terms of quality of implant protocols, immediate loading stands out for its importance in routine clinical applications. The evolu-tion of the immediate loading protocol is the most significant example of the extent to which, over recent years, implant therapy has been influenced, guided, and transformed by new concepts in biology and biomechanics originating from other branches of science. Immediate loading undoubtedly offers completely or partially edentulous patients advantages of a psychologic and social order; in addition, it is highly efficient in operative terms, reducing treatment times and minimizing the invasiveness of surgery.

During the past 10 years, numerous studies on immediate loading designed and carried out by prestigious international centers have been published. Through a formidable collection of data and scientific evidence, these have established the ideal indications, clinical parame-ters, and therapeutic results of treatment. The clinicians and research-ers involved have documented the applicability and benefits of the treatment approach through a series of articles published in the most significant specialized journals. There can be no doubt that following the rules promoted by the international scientific community provides clear and consolidated benefits for the patients treated, where possible, by immediate loading procedures.

This new book, Immediate Loading: A New Era in Oral Implantology, brings together and illustrates, in 21 detailed chapters, all of the aspects linked to immediate loading in oral implantology: scientific and clinical components, protocols, and medicolegal implications.

The first remarkable characteristics of this book are the completeness of the information and the exhaustive treatment of the subject. The biologic and biomechanical foundations for immediate loading are dealt with, as are its links with the latest generation implant surfaces, medi-cal history, diagnostics, surgery, prosthetics, and medicolegal issues.

The second significant feature is that it places the patient at the center of the treatment plan. The patient is the protagonist during treatment planning and in the therapeutic strategy, which is adapted to individual requirements to ensure the highest possible esthetic and functional result, preserving criteria for predictability, reduction of operative times, and patient comfort.

XX — ImmedIate LoadIng: a new era in oral Implantology

XXI Foreword

The third notable facet of this book resides in the rigor and clarity with which the principles of causality are explained. The underlying ratio-nale and scientific findings are presented in the light of the intercon-nections between the different arguments. The reader can trace these connections and find explanations relating to his or her questions. The didactic instruments presented make treatment modalities, mecha-nisms, and implant healing time frames clearly understandable. The authors focus on how these factors influence treatment outcome, how implant surface topography and the new growth factors can condition primary stability, and the contribution provided by new biotechnologic products in peri-implant bone reconstruction.

All of this is bolstered by the authors’ impressive clinical experience, as they base their clinical decisions on research and a consolidated interdisciplinary team approach, succeeding in seamlessly bringing together the wide range of individual skills. This is a tried and tested team of clinicians and researchers who are recognized worldwide for having successfully applied their professionalism, passion, and dedica-tion to the discipline of implant dentistry, while at the same time pre-serving their critical capabilities.

The chief goal of this book is to provide all the elements useful and necessary for the reader to successfully integrate in his or her own clinical practice a protocol that is the fruit of experience and team consensus, resulting from the continual and detailed exchanges of views among all the authors. We would like to thank all of the authors and congratulate them for this work that, we are certain, will meet with great success and will contribute to improving our patients’ health, the goal for which all clinicians strive.

richard lazzara

assosiaTe CliniCal proFessorperioDonTal anD iMplanT reGeneraTiVe CenTeruniVersiTy oF MarylanDbalTiMore, MarylanD

Dennis Tarnow

proFessor anD DireCTor oF iMplanT eDuCaTionColleGe oF DenTal MeDiCineColuMbia uniVersiTynew yorK, new yorK

Foreword

The so-called Young’s equation runs as follows:

I + E = M

What does this mean?

I stands for intelligence, E is effort, and M, the result of the equation, indicates merit.

This beautiful book, which I have the pleasure and the honor to pres-ent, is perfectly defined by the above equation. The project was put together with great intelligence, cultural refinement, and sophisticated teaching methods, so as to offer the reader a didactic product of great value.

The authors have explored the theme of implantology with extraordinary commitment and effort, as is shown by a series of clinical cases that is unique for quality and size and by a series of papers published in the most prestigious scientific journals that bear witness to the quality of the original research, which underlies the innovative therapeutic pro-posals.

The merit resulting from this process is very high. The authors have produced a synthesis, at the highest levels of clinical intelligence and scientific effort, that has led them to write a modern book through which the reader will be able to acquire a solid knowledge of the field.

Running right through this book is a scientific rigor derived from the authors’ ability to apply the principles of scientific method to clinical research and its applications. After reading this book, the reader will find that he or she has acquired all of the knowledge available today on the subject.

To me, as I present this book, goes the joy and the great good fortune to share day-to-day work with the authors, who have made excellence their reason for living.

roberto lodovico weinstein

irCCs Galeazzi orThopeDiC insTiTuTeDean oF The DenTal CliniCDeparTMenT oF healTh TeChnoloGiesuniVersiTy oF MilanMilan, iTaly

XXII — ImmedIate LoadIng: a new era in oral Implantology

XXIII

Preface

It is not a simple matter to write a complete and updated book on a subject that is in continual evolution, as is the immediate loading of dental implants. Immediate loading is one of the most important inno-vations in the modern era of oral implantology. Since its introduction, immediate loading has entered broadly into clinical practice, and con-tinual clinical and experimental research activity has enabled many of the mechanisms underlying its success to be understood. This success not only depends on the clinician’s pure skill, but comes about through a close collaboration among professional figures, each with specific but complementary skills, which enables a high degree of predictability to be achieved. The need to collaborate and to integrate different skills in order to achieve as complete a result as possible has been at the basis of our writing this book. The topics in the various chapters have been dealt with by specialists in the fields at hand so as to provide the reader with specialized information that is as precise, reliable, and updated as possible.

The book is aimed at experts who have been interested in implant den-tistry for many years and who wish to implement this fascinating clini-cal application with the high predictability that comes from following the correct, scientifically based guidelines. But it is also for those who have newly come to this field, including students, who will be able to apply immediate loading in implant dentistry with a solid theoretical knowledge concerning the biologic response, the predictability of the various indications, and the correct surgical and prosthetic applica-tions. The editorial project thus combines the goals of a textbook for students with those typical of a work aimed at updating the experi-enced clinician.

It was not simple to coordinate this book, but thanks to the willingness to collaborate and the professionalism of all those involved we have been able to complete it. We hope our readers will benefit from the result.

Tiziano Testori

Fabio Galli

Massimo Del Fabbro

16 — ImmedIate LoadIng: a new era in oral Implantology

17

02Biology and Biomechanics in Immediate Loading

P. TrIsIM. DeL FaBBro

144 — IMMEDIATE LOADING: A New Era in Oral Implantology

145 Chapter 5 — Presurgical Diagnostic Phase

Fig 5-23 > Maxillary and mandibular removable overdentures with bolts on milled and screwed bars. (Prosthetic phase by Dr r. nonelli.)

Fig 5-23a > Mandibular denture.

Figs 5-23b and 5-23c > Mandibular milled and screw-retained bar.

Fig 5-23d > Mandibular denture in situ, occlusal view.

Fig 5-23e > Maxillary denture.

Figs 5-23f and Fig 5-23g > Maxillary milled and screw-retained bar.

Fig 5-23h > Maxillary prosthesis in situ, occlusal view.

Figs 5-23i to Fig 5-23k > Maxillary and mandibular prostheses in maximum intercuspation.

Fig 5-23l to 5-23n > Definitive esthetic evaluation of face and smile.

23j 23k

23l 23M 23n

23i23a

23b

23c

23e

23F

23G

23D 23H

Part One: CliniCal PrOCedures

Immediate loading in completely eden-tulous patients and in patients whose residual dentition cannot be salvaged not only limits the invasiveness of the surgery but also miti-gates the psychologic and social disadvantages associated with the edentulous period. Patients are subjected to only one surgical operation, which decreases their physical discomfort, and are not obliged to wear a removable prosthe-sis that, although conditioned with specific materials during the healing period, causes discomfort and tenderness. Patients who have undergone this type of approach have reported greater comfort and less discomfort postsurgery compared with the classic approach. This is because the fixed prosthesis protects the area involved in surgery and enables better healing of the soft tissues which are not traumatized by a removable prosthesis.

Immediate loading offers several other advantages: It reduces the number of clinical sessions required to finalize the prosthesis; results in overall more efficacious and efficient treatment; and costs less than delayed load-ing.1

This chapter describes different clinical approaches to immediate loading, subdivided by the type of edentulousness with which the patient presents.

pATIenTs wITh A COMpleTely eDenTulOus MAnDIble

InDexInG TeChnIque

using a surgical template to determine

maxillomandibular relationship,

vertical height, and implant posit ion

The correct diagnostic procedure includes extraoral and intraoral clinical evaluation, tar-

geted radiologic investigations, casts mounted in the articulator, and diagnostic waxing so that the surgical phase can be guided by the pros-thetic plan with predictable esthetic and func-tional results. If the patient is already eden-tulous and wears an esthetically satisfactory, full-arch denture with correct occlusal planes, then a duplicate of the denture is made, and the stability of the retromolar zone is checked. If the denture has incorrect parameters, it is advisable to restore the correct vertical dimen-sion and the occlusal stability before the surgi-cal phase.

The duplicate prosthesis thus prepared will be used as a surgical template and will enable information concerning the position of implants, the vertical dimension, and the cor-rect maxillomandibular relationship to be com-municated to the technician. It is important to try out the template at a session prior to the surgical phase to evaluate its stability, the cor-rect maxillomandibular relationship, and the correct occlusion2 (FIGs 7-1A AnD 7-1b).

During the surgical phase, only those tissues in the area where implants are to be positioned are elevated, whereas the tissues of the retromolar area are not (FIGs 7-1C AnD 7-1D). The sequence of the implant site preparation is influenced by the quality of bone, which is revealed by the radiologic examination and, above all, by the surgeon’s clinical findings dur-ing the operative phase; in general, underprep-aration of the implant site will be needed when the quality of bone is poorer. In any case, the final implant insertion torque must be at least 40 Ncm. This value can always be achieved in the mandible, where the interforaminal bone can be classified as dense or normal.3

With regard to the number of implants, the literature reports clinical cases with five to six implants with insertion axes perpendicular to the bone ridge or four implants of which two are tilted distally. The clinical decision between these two therapeutic options is dictated by the shape of the mandible, by the linear develop-

07190 — IMMEDIATE LOADING: A New Era in Oral Implantology

191 Chapter 7 — The Therapeutic Approach of the Galeazzi Orthopaedic Institute Implant Department

DIAGnOsTIC phAseFig 7-1 > Male patient, 63 years old, wearing two complete dentures. The maxillary denture was well tolerated by the patient, whereas the mandibular denture was not. It was agreed with the patient to undertake implant-prosthetic rehabilitation of the mandibular arch.

Figs 7-1a and 7-1b > Frontal view of the surgical template on the study cast (a) and in the oral cavity (b); there is proper mucosal support in the posterior area, which will not be involved in flap elevation. note that the correct intercuspation in occlusion is recorded using self-curing resin. In the symphysis area, the surgical template will be useful in positioning the implants.

surGICAl phAseFigs 7-1c and 7-1d > (c) Full-thickness flap with elevation limited to the interforaminal area. View of the exposed bone. (d) The left distal implant is inserted with the surgical template in place. subsequently, the corresponding right implant is positioned, and finally the remaining interimplant space is subdivided with the remaining implants.

1A 1b

1C 1D

be agreed upon that cantilevers of less than 15 mm are associated with better prosthetic survival than are longer ones.41

From the radiographic standpoint, clini-cal studies reported in the literature do not indicate statistically significant differences in marginal bone resorption between axial and tilted implants, either in the mandible or in the maxilla1–3,7,9,42–50 (TAbLe 8-1).

Some experimental biomechanical studies have been published that analyze the perfor-mance of loaded implants inserted nonaxi-ally to the occlusal plane.51–57 Experimental tests51,54 and studies employing finite element analysis52,55 have shown that on applying an axial force or one at a specific angle to a tilted implant, stress and bone compression increase, and bending moments are generated. But if the tilted implant is firmly attached to the other axial implants by means of a prosthetic structure, the distribution of these forces and stresses and the rigidity of the framework can reduce this bending moment.19,42

A two-dimensional finite element analy-sis found that the inclination of an implant does not affect the extent of marginal bone stress compared with configurations with axial implants alone.57 Subsequent investigations compared configurations made up of axial implants alone and models that also included tilted implants, both in the mandible and in the maxilla. With all the limitations involved in such methods, it appears clear that the highest values of compression stresses are recorded in marginal bone on the same side that the load is applied; on the opposite side, tensile traction stresses occur.53,55,56 Furthermore, the stress increases as the length of the distal cantilever increases, whereas there appears to be no cor-relation with the length of the implants.57,58

The authors’ group used a three-dimen-sional finite element model to compare the Toronto-Brånemark rehabilitation and the all-on-four rehabilitation. Preliminary results have not revealed any significant differences between the two with regard to compressive

298 — IMMEDIATE LOADING: A New Era in Oral Implantology

Author Number of tilted implants Follow-up Cumulative survival rate (%)

Krekmanov et al 20004236 mandibular

40 maxillary5 years

100

95.7

Aparicio et al 200143 42 maxillary 7 years 95.2

Fortin et al 200245 90 maxillary 5 years 92.2

Malò et al 20031 88 mandibular 3 years 98.9

Malò et al 20052 64 maxillary 1 year 95.3

Calandriello and Tomatis 200546 27 maxillary 3 years 96.3

Malò et al 2006318 mandibular

88 maxillary1 year 98.9

Capelli et al 2007748 mandibular

82 maxillary

Up to 52 months

Up to 40 months

100

97.59

Testori et al 200848 82 maxillary Up to 36 months 97.1

Francetti et al 20089 124 mandibular Up to 48 months 100

Agliardi et al 200949 84 maxillary Up to 36 months 100

Table 8-1 > Survival of tilted implants as reported in the most recent studies

299 Chapter 8 — Therapeutic Alternatives for the Immediate Rehabilitation of Atrophic Jaws Using Tilted Implants

Author Number of tilted implants Follow-up Cumulative survival rate (%)

Krekmanov et al 20004236 mandibular

40 maxillary5 years

100

95.7

Aparicio et al 200143 42 maxillary 7 years 95.2

Fortin et al 200245 90 maxillary 5 years 92.2

Malò et al 20031 88 mandibular 3 years 98.9

Malò et al 20052 64 maxillary 1 year 95.3

Calandriello and Tomatis 200546 27 maxillary 3 years 96.3

Malò et al 2006318 mandibular

88 maxillary1 year 98.9

Capelli et al 2007748 mandibular

82 maxillary

Up to 52 months

Up to 40 months

100

97.59

Testori et al 200848 82 maxillary Up to 36 months 97.1

Francetti et al 20089 124 mandibular Up to 48 months 100

Agliardi et al 200949 84 maxillary Up to 36 months 100

Figs 8-1a to 8-1c > Tilting the implant enables fixtures of greater length to be inserted in close contact with the emergence of the inferior alveolar nerve.

Fig 8-2 > by engaging the mesial wall of the maxillary sinus, higher levels of primary stability can be achieved.

Figs 8-3a and 8-3b > Difference in A-p spread between an all-on-four rehabilitation (a) and a Toronto-brånemark rehabilitation (b).

1A 1b 1c

2

3A 3b

428 — IMMEDIATE LOADING: A New Era in Oral Implantology

429 Chapter 13 — Indications and Contraindications of Mini-Implants

Fig 13-6 > three-dimensional illustration of the surgical and prosthetic procedures.

Fig 13-6a > drilling the implant sites with a flapless approach.

Fig 13-6b > positioning the mini-implants.

Figs 13-6c and 13-6d > the implants are tightened.

Figs 13-6e to 13-6g > prosthetic phases and delivery of the prosthesis.

6g6C 6d

6e 6F

6a 6b