While attending the annual meeting of Academy of Osseointegration a few years ago, I heard a well-respected dentist discuss immediate loading. He passionately defended the traditional protocol of a two-stage surgery and blasted dentists who push the envelope and load implants at the time of surgery.
He got a standing ovation.
Although I agree that immediate loading can be harmful to a patient if done incorrectly, there are significant advantages when it is done correctly. You owe it to yourselves and to your patients to consider immediately loading a case when appropriate.
(1) Better soft tissue contours
A solid lab can make you a pretty crown. What makes the real esthetic difference is how the soft tissue looks around that pretty crown. So when we extract teeth and place implants, what keeps the gingiva in place?
Bone, connective tissue fibers, and the physical support offered by crown contours are responsible for gingival esthetics. When a tooth is extracted, we lose some bone and rip out some of the connective tissue fibers and there’s very little we can do about it, depending upon the scenario.
Soft tissue support from bone (yellow), supracrestal fibers (red), and tooth contours (blue).
But what is always under our control is the ability to preserve the physical support offered by the anatomic crown. Introducing a pontic via a provisional bridge allows us to continue to prop up the papilla. This won’t necessarily keep every fraction of a millimeter of papilla (again, depending upon the scenario), but it’s the best we can do.
By far, the best way to develop the emergence profile of your final implant restoration is to preserve the original soft tissue contours with a provisional that connects to the implant platform; an immediately loaded provisional.
(2) Most patient-friendly provisional option
For a full discussion on the other implant provisional options, check out this post. An immediately loaded implant is a patient-fixed, doctor-removable option just like a provisional fixed partial denture (temporary bridge). Patients love that.
But the main disadvantage of the provisional FPD is that the adjacent teeth must be committed to crowns. If the adjacent teeth are virgin or only have small restorations, I usually won’t consider cutting them down just for the implant provisional.
Immediately loading the implant offers all of the advantages of the provisional FPD with the bonus of not having to sacrifice adjacent teeth. That is truly patient-friendly.
(3) Fewer adjustment visits
A flipper, Essix, Maryland bridge, and provisional FPD can all take up extra chair time.
Some, like the flipper in particular, need careful adjusting to remove sore spots from the gingiva.
Perhaps most frustrating of all, however, is that all of these options are subject to fracture. Patching and replacing broken provisionals is costly in terms of materials and your time.
A provisional crown that has been immediately loaded does not require adjacent teeth or soft tissue for retention and therefore is less fragile. It is also never placed in occlusion, which offers further protection.
(4) No stage 2 surgery
Patients love not having to go through a second surgery for implant exposure.
More importantly (and this goes back to reason number 1), the soft tissue is more fully matured and anatomically correct around the emergence profile of a provisional crown that has been immediately loaded as opposed to the less mature, circular gingiva around a circular healing abutment. For more discussion about this point, check out this post on my technique.
I think immediate loading presents significant advantages to the restorative and surgical dentists.
However, there are very strict guidelines that must be followed in order for a patient to be considered for this procedure. I’ll discuss those rules in another post.