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Implant Loading Protocols for the Partially

Edentulous Posterior Mandible
Luca Cordaro, MD, DDS, PhD1/Ferruccio Torsello, DDS, PhD2/Mario Roccuzzo, DDS3

Purpose: To evaluate the predictability of early and immediate loading protocols of implants in the pos-
terior mandible and to investigate whether there is a difference in success rates, survival rates, and
peri-implant parameters, including marginal bone level changes, between loading protocols. Materials
and Methods: A comprehensive systematic review of the literature was conducted. The selection of
publications reporting on human clinical studies was based on predetermined inclusion criteria and
was agreed upon by two reviewers. Results: A total of 19 papers were selected: 8 on early loading, 9
addressing immediate loading, and 2 comparing immediate and early loading. Of the 19 studies, 5
were randomized clinical trials and 14 were prospective studies. Conclusions: Existing literature sup-
ports the early loading of microroughened dental implants in the partially edentulous posterior
mandible at 6 to 8 weeks in the absence of modifying factors. Therefore, loading within this time frame
can be considered routine for the majority of clinical situations in the posterior mandible, either with
single crowns or fixed dental prostheses. Immediate loading of microroughened dental implants in the
partially edentulous posterior mandible proved to be a viable treatment alternative. Caution is neces-
sary when interpreting published outcomes for immediate loading, as the inclusion exclusion criteria
are inconsistent and many subjective confounding factors are evident. Additional studies with longer
follow-ups, specifically randomized clinical trials, are needed to consolidate the data for immediate
loading. Priority should be given to trials testing immediate loading. INT J ORAL MAXILLOFAC IMPLANTS
2009;24(SUPPL):158–168

Key words: dental implants, fixed dental prostheses, loading protocol, partial edentulism, posterior
mandible, single crown, systematic review

here are several factors that may influence the the second molars and progressively decreases in the
T process of successful osseointegration of oral
implants. Bone quality, implant surface characteris-
anterior region of the jaws.1 This situation is main-
tained when teeth are replaced with implants.2 It has
tics, and the amount of micromovement during heal- also been shown that bone density varies between
ing are involved in this complex phenomenon. different regions of the jaws. Various attempts have
Functional and anatomical factors vary between the been made to classify the various bone types with
different sectors of the jaws. It has been demon- regard to bone density. The first widely used classifi-
strated that the chewing load on teeth is maximal on cation, by Lekholm and Zarb,3 was questioned by Trisi
and Rao4 because of its subjective nature and the
absence of a direct correlation to the anatomy and
histology of the site.
1Head, Department of Periodontics and Prosthodontics, Eastman More recently, different approaches, less depen-
Dental Hospital, Rome, Italy.
2Department of Periodontics and Implant Dentistry, Eastman dent on the subjective examination of the clinician,
Dental Hospital, Rome, Italy. have been used to determine bone density. Com-
3Lecturer, Department of Oral and Maxillofacial Surgery, Univer- puted tomography may be used, and measurements
sity of Torino, Torino, Italy. can be performed using the Hounsfield Scale. A
recent study demonstrated that the anterior
None of the authors reported a conflict of interest.
mandible is the site with the highest bone density
Correspondence to: Dr Luca Cordaro, Via Guido d’ Arezzo, 2, I- (927 ± 237 HU), followed by the posterior mandible
00198 Rome, Italy. Fax: +39 06 855 3162. Email: (721 ± 291), the anterior maxilla (708 ± 277), and the
[email protected] posterior maxilla (505 ± 274 HU).5 These data con-
This review paper is part of the Proceedings of the Fourth ITI Consen-
firmed a previous study that found mandibular pos-
sus Conference, sponsored by the International Team for Implantology terior bone density to be greater than posterior
(ITI) and held August 26–28, 2008, in Stuttgart, Germany. maxilla density.6

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Group 3

Dental implant
Titles Abstracts Full text
+
Survival 810 267 220

Success 487 93 54 Full-text

after eliminating
Posterior maxilla 335 139 99 duplicates

Posterior
291 75 32 400
mandible

Early loading 204 65 37 10* Early loading

11* Immediate
loading
Immediate 34
366 79 52
loading

Marginal bone
319 164 130
resorption
35 19
Complication 865 234 78

Healing time 485 137 42 16

Excluded after
Manual further discussion
1
searching 26 in the group

Fig 1 Search strategy and procedures. Two papers (*) deal with immediate and early loading in the posterior
mandible.

Other means are used to measure implant stability, evaluate the performance of early or immediate load-
such as insertion torque values or resonance frequency ing per se. The evaluation has to be performed for dif-
analysis (RFA), and are partly correlated to bone den- ferent clinical indications to provide the practitioner
sity.7 Usually, better outcomes are found in the poste- with the appropriate evidence that is related to those
rior mandible than in the posterior maxilla. However, it indications.
should be noted that primary implant stability is The aim of this systematic review was to evaluate
largely dependent not only on bone density but also the predictability of early and immediate loading
on implant design and surface, as well as on the tech- protocols for implants in the posterior mandible and
nique and accuracy of the osteotomy preparation. to investigate whether there is a difference in success
Usually, the posterior mandible presents with suffi- rates, survival rates, and peri-implant parameters,
cient bone density but faces a very demanding load- including marginal bone level changes, between the
ing situation. This contrasts with the posterior maxilla, respective protocols. The loading definitions estab-
in which the loading conditions are similar to the lished by the 2003 ITI Consensus Conference were
posterior mandible, but the bone is usually of lower used for the purpose of this review.13
density.
Shortening the interval between implant insertion
and prosthetic loading may lead to improved patient MATERIALS AND METHODS
comfort. Several systematic reviews on immediate
and early loading protocols have been published.8–12 Search Strategy and Procedures
All of these aimed to compare conventional and A comprehensive review of the literature was con-
early/immediate loading by compiling the outcomes ducted to select pertinent full-length articles pub-
of selected clinical studies. Each systematic review, lished in English. The most recent electronic search
however, was based on the selection and inclusion of was undertaken on May 1, 2008.
a number of articles with a great variety in baseline Searching was performed using the electronic data-
parameters, such as local oral condition, implant sys- bases MEDLINE (PubMed) and Specialist Register of the
tem used, prosthesis type, jaw location, or other fac- Cochrane OHG. Key words used in the search included:
tors that could affect loading mechanics and dental implants, early loading, healing time, immediate
potentially result in misleading interpretation of out- loading, posterior mandible, marginal bone resorption,
comes. This suggests that it is clinically not useful to complications, success rate, and survival rate (Fig 1).

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Cordaro et al

To expand this, a hand search of the following • Method of randomization. This was classified as
journals was undertaken, covering the years 1991 to adequate when a random number table, a coin
present: Clinical Oral Implants Research, International toss, or shuffled cards were used; as inadequate
Journal of Periodontics & Restorative Dentistry, Journal when other methods of randomization such as
of Periodontology, Journal of Clinical Periodontology, alternate assignment, hospital number, or
and International Journal of Oral & Maxillofacial odd/even birth date were applied; and as unclear
Implants. when the method of randomization was not
Bibliographies from selected articles, the proceed- reported or explained.
ings of the second (1997) and third (2003) ITI Consen- • Allocation concealment. This was classified as ade-
sus Conference, the position papers of the American quate when examiners were kept unaware of the
Academy of Periodontology, and the Proceedings of randomization sequence; as inadequate when
the Third European Workshop on Periodontology other methods of allocation concealment were
(1999) were also screened. Every attempt was made used, such as alternate assignment, hospital num-
to obtain recent studies that had been accepted but ber, or odd/even birth date; and as unclear when
not yet published, through personal contacts of the the method of allocation concealment was not
authors. reported or explained.
All levels of the hierarchy of evidence except for • Completeness of follow-up was considered
expert opinions were included. For case reports, only present if the number of patients was reported
studies with 10 or more cases specifically in the pos- both at baseline and at completion of the follow-
terior mandible were accepted. For prospective data, up, and if the analysis took into account the
only studies reporting outcomes after 12 or more dropouts.
months were included.
The search was limited to human subject studies Significant data from the selected articles were
published in English that evaluated various healing recorded for the following two categories:
times between surgery and loading. Outcome mea-
sures were survival rate, success rate, and marginal 1. Early loading of implants placed in the posterior
bone loss. mandible (Table 1)
2. Immediate loading of implants placed in the pos-
Data Collection and Analysis terior mandible (Table 2)
Titles and abstracts obtained through the described
search were screened by two independent reviewers
(Marco Aglietta, Ferruccio Torsello). The screening was RESULTS
performed on a printout of the titles and abstracts,
and included studies meeting the following criteria: A total of 19 papers14–32 were included in the present
review: 8 on early loading, 9 addressing immediate
• Human trials loading, and 2 comparing immediate and early load-
• Loading time ing. Of the 19 studies, 5 were randomized controlled
• Longitudinal studies clinical trials (RCTs) and 14 were prospective studies.
• Clinical outcomes A number of valuable articles had to be excluded
because they did not meet the inclusion criteria. Some
Studies including implants in extraction sockets, papers could not be considered because in some of
guided bone regeneration (GBR), or full-arch recon- the treated subjects the early or immediate loading
structions were excluded. Moreover, articles that protocols were associated with implant placement in
reported combined data from the posterior and ante- fresh extraction sockets, and results could not be sep-
rior mandible, and/or from the maxilla and mandible, arated from implants placed in native bone,33–37 or in
without the possibility to extract the results for the other instances because simultaneous bone augmen-
area of interest were not included. tation was performed.38 In other studies it was not
Full-text copies of studies with possible relevance possible to determine the exact number of implants
were evaluated by two reviewers (Mario Roccuzzo placed in the posterior mandible and their specific
and Luca Cordaro). Any disagreement was discussed survival rate in this anatomical region.39–41 A further
and resolved. Authors were contacted to provide study had to be excluded because different loading
missing information when possible. Two email protocols were used for different sites, and it was not
attempts were made to contact each author. possible to separate out the number of early loaded
The methodological quality of the studies was implants in the posterior mandible.42
assessed to appraise:

160 Volume 24, Supplement, 2009

 Table 1 Selected Articles on Early Loading in the Partially Edentulous Posterior Mandible
158_3c_Cordaro.qxd

No. of No. of No of
Study Implant patients Smallest implants implants Time of Occlusal Type of Survival Other
Study type surface included Sites implant placed loaded loading Follow-up contacts prostheses Splinted rate Failures results

Cochran et al Pros SLA 80 Posterior ø 4.1 ⫻ 8 mm 198 198 6 wk; 12 wk 2y Yes FDP Yes 99% 1 y 1 Success rate:
9/8/09

(2002)14 mandible if bone (n =166) 99%

quality = 4 99% 2 y
(n = 94)‡
Nordin et al (2004)15 Pros SLA 15 Posterior NR 41 41 9d 12 mo NR FDP Yes 100% 0 NR
3:21 PM

mandible (range 4–22 d)

Salvi et al (2004)16 RCT SLA 27 No third molars ø 4.1 ⫻ 8 mm 31 29 2 wk 12 mo Yes SC No 100% 0 BL 0.57 mm
Salvi et al (2004) 16 RCT SLA 27 No third molars ø 4.1 ⫻ 8 mm 36 35 6 wk 12 mo Yes SC No 100% 0 BL 0.72 mm
Vanden Bogaerde Pros TiUnite > 10† Posterior 8.5 mm 42 42 4–16 d 18 mo Light FDP Yes 100% 0 NR
et al (2003)17* mandible (mean 9 d)
Page 161

Vanden Bogaerde Pros Machined > 10† Posterior 8.5 mm 56 55 < 20 d 18 mo Light FDP Yes 98% 1 NR
et al (2004)18 mandible (average 11 d)
Bornstein et al Pros SLA 45 No third molars ø 4.1 ⫻ 4.8 mm 89 88 6 wk 5y NR SC-FDP FDP 99% 1 Success rate:
(2005)19 only 99% bone resorp-
tion: 0.15 mm
Sullivan et al Pros Osseotite > 10† Posterior NR 262 257 2 mo 5y NR SC-FDP FPD 98.8% of 5 early NR
(2005)20 mandible only loaded failures;
implants; 3 after
96.9% of loading
inserted
implants
Achilli et al (2007)21 Pros TiUnite 15 No third molars ø 3.5 ⫻ 10 mm 32 32 6 wk 12 mo Light FPD Yes 100% 0 NR
Roccuzzo et al RCT SLA 14 No third molars ø 4.1 ⫻ 8 mm 33 32 6 wk 5y Yes SC-FDP No 100%§ 0 NR
(2008)22
Ganeles et al RCT SLActive > 10† No second and ø 4.1 ⫻ 8 mm 134 134 28–34 d 12 mo No SC-FDP NR 96%II 4 early NR
(2008)23 third molars failures;
1 after
loading
Pros = prospective; RCT = randomized controlled clinical trial; FDP = fixed dental prosthesis; SC = single crown; NR = not reported; BL = bone loss.
* Additional specific data provided by the authors on request.
† Data deduced from analysis of the text.
‡ One lost implant. Two spinners at the time of abutment connection: loading was postponed and implants successfully healed.
§ One spinner; successfully loaded with definitive crown after 6 additional weeks of healing.
|| Data extrapolated from Zollner et al (2008)44 on the same patient population.
Group 3

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 Table 2 Selected Articles on Immediate Loading in the Partially Edentulous Posterior Mandible
No. of Bone quality/ No. of Restoration
158_3c_Cordaro.qxd

Study Implant patients primary Smallest implants time Occlusal Type of Survival Other
Study type surface included Sites stability implant placed limit Follow-up contacts prostheses Splinted rate results
Cordaro et al

Buchs et al Pros Altiva NTR > 10† No third NR NR 82 < 24 h 10–29 Light SC-FDP NR 92.7% —
( 2001)24 molars mo
9/8/09

Calandriello Pros Machined > 10† Premolars Torque > 45 Ncm ø 5 ⫻ 10 or 21 < 24 h 12–24 Light SC-FDP NR 100% —
et al (2003)25 and molars ø 3.75 ⫻ 13 mm mo
Calandriello Pros TiUnite > 10† First or Torque > 35 Ncm ø 5 ⫻ 10 mm 24␣ < 24 h 12 mo Light SC No 100%§ 1.1 mm without GBR
et al (2003)26 second molars and 1.8 mm with GBR
3:21 PM

Rocci et al RCT TiUnite 22 Premolars Primary stability 7 mm 66‡ < 24 h 12 mo NR FDP Yes 95.5 % Bone resorption:

162 Volume 24, Supplement, 2009

(2003)27 and molars checked by hand 0.9 (0.7) mm
Success rate 95.5%
Rocci et al RCT Machined 22 Premolars Primary stability 7 mm 55‡ < 24 h 12 mo NR FDP Yes 85.5 % Bone resorption:
(2003)27 and molars checked by hand 1 (0.9 ) mm
Page 162

Success rate 85.5%

Cornelini et al Pros SLA 30 First molars ISQ > 62 ø 4.1 ⫻ 12 or 30 < 24 h 12 mo Yes SC No 97% Bone resorption: 0.22 mm
(2004)28 ø 4.8 ⫻ 10 mm Success rate 96.7%
Abboud et al Pros Sandblasted 11 Premolars NR 9.5 mm 11 < 24 h 12 mo Light SC No 100% 0.03
(2005)29 Ankylos and first
molars
Cornelini et al Pros SLA 20 Premolars ISQ > 62 ø 4.1 ⫻ 12 or 40 < 24 h 12 mo Yes FDP Yes 98% Bone resorption: 0.1 mm
(2006)30 and molars 4.8 ⫻ 10 mm mesial and 0.5 mm distal
Success rate 97.5%
Romanos and Pros Sandblasted 12 Premolars No tapping in soft ø 3.5 ⫻ 11 or 36 < 24 h 24 mo Light FDP Yes 100% 22.2% minimal horizontal
Nentwig Ankylos and molars bone ø 4.5 ⫻ 9.5 mm BL (< 2 mm); 19.4% min-
(2006)31 imal vertical BL (< 2 mm)
Achilli et al Pros TiUnite 25 No third No type 4 bone ø 3.5 ⫻ 10 mm 56 < 24 h 12 mo Light FDP Yes 100% NR
(2007)21* molars torque > 30 Ncm
Schincaglia et al RCT TiUnite 10 No third ISQ > 60 and 8.5 mm 20 < 24 h 12 mo Light FDP Yes 100% 1.06 mm
(2007)32 molars torque > 30 Ncm
Schincaglia et al RCT Machined 10 No third ISQ > 60 and 10 mm 22 < 24 h 12 mo Light FDP Yes 91% 0.92 mm
(2007)32 molars torque > 30 Ncm
Ganeles et al RCT SLActive > 10† No second Sufficient primary ø 4.1 ⫻ 8 mm 127 < 24 h 12 mo No SC-FDP NR 98%II NR
(2009)23* or third stability checked
molars by hand
Pros = prospective; RCT = randomized controlled clinical trial; FDP = fixed dental prosthesis; SC = single crown; NR = not reported; ISQ= Implant Stability Quotient
(measured with resonance frequency analysis); BL = bone loss.
* Additional specific data provided by the authors upon request.
† Data deduced from analysis of the text.
‡ Flapless surgery.
§ Only implants with at least 12 months of follow-up were considered.
|| Data extrapolated from Zollner et al (2008)44 on the same patient population.
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Group 3

Early Loading loading, which was performed earlier than 20 days

Ten papers fulfilled the inclusion criteria and were after insertion (average 11 days). The overall survival
evaluated with regard to outcome of implants rate for this group (including the early failure) was 99%.
restored with an early loading protocol. Of these, Five-year results after early loading in the posterior
three were RCTs and seven were prospective clinical mandible were reported in two different studies involv-
trials. The three RCTs contained an adequate method ing two different types of implants.19,20 In a prospec-
of randomization and complete follow-up, but the tive study performed by Bornstein and coworkers in
allocation concealment was unclear.16,22,23 Some of 51 patients,19 104 SLA implants were inserted, 89 of
these studies did not solely include implants placed which were in the posterior mandible. Implants were
in the posterior mandible. But it was possible to loaded after 6 weeks with either single crowns or
extrapolate the requested data from each of these FDPs. One early failure occurred, and a 99% survival
publications. If there was any remaining uncertainty, rate resulted after 5 years. The mean marginal bone
the respective authors were contacted by email and resorption was 0.15 mm. In a second prospective mul-
asked to provide the missing data. ticenter study, Sullivan et al evaluated 262 implants
In one of those publications, a multicenter prospec- with a microtextured acid-etched surface that were
tive clinical trial by Cochran and coworkers, implants inserted in the posterior mandible with a transmu-
with a sandblasted and acid-etched (SLA) surface cosal technique and loaded 2 months after inser-
were inserted in different zones of the jaws and tion.20 Five early failures were reported, and three
divided in groups. 14 A total of 198 implants were further failures occurred after loading, resulting in a
inserted in the posterior mandible and loaded with 97% implant survival rate. In both studies implants
fixed dental prostheses (FDP) after 6 weeks when were restored either with single crowns or FDPs.
bone type 1, 2, or 3 was found at the time of surgery. In a prospective study comparing early and imme-
In the case of type 4 bone, loading was postponed to diate loading, Achilli et al evaluated 32 oxidized tita-
12 weeks postinsertion. Implants had completed the nium tapered implants that were inser ted in
12-month (n = 166) or 24-month (n = 61) follow-up. mandibular molar and premolar sites and loaded
Only one implant was lost, resulting in a success rate after 6 weeks with FDPs. A 100% success rate was
of 99% at both intervals. reported after 1 year.21
In another study, early loading of SLA implants was Implants with a titanium plasma-sprayed surface
studied by Nordin and coworkers in a prospective that were loaded at 12 weeks were compared to SLA
three-arm trial. 15 Posterior partially edentulous implants loaded at 6 weeks by Roccuzzo and cowork-
mandibles and maxillae were included in one group. ers in an RCT with a 5-year follow-up. 22 This split-
A total of 41 implants were placed in mandibular pos- mouth study compared similar edentulous areas, and
terior sites and restored with fixed dental prostheses implants were loaded with either single crowns or
(FDPs), with a mean loading interval of 9 days (range FDPs. After 5 years of observation, a 100% survival
4 to 22 days). In this paper a 100% survival rate was rate was seen with both protocols.
seen after 1 year. In a recently published RCT, Ganeles and coau-
In one RCT that fulfilled the inclusion criteria for thors compared early and immediate loading of
this review, Salvi and collaborators compared SLA implants placed in posterior sites of both jaws. A total
implants inserted in the posterior mandible and of 134 implants with a chemically modified SLA sur-
restored with single crowns in occlusal contact after 2 face were placed in the posterior mandible and
or 6 weeks. A total of 67 implants were inserted in the loaded after an interval of 28 to 34 days with either
two groups, with a 100% survival rate after 1 year of single crowns or FDPs. Four early failures and one fail-
loading. No statistically significant difference could ure after loading were reported, leading to a 96%
be found between the two groups.16 implant survival rate.23
In two separate papers, Vanden Bogaerde and
coworkers reported the 18-month outcome of early Immediate Loading
loaded, splinted implants either with a machined or According to the inclusion criteria, 11 papers on
oxidized titanium surface in the maxilla and posterior immediate loading could be included in this review: 8
mandible.17,18 In the group with an oxidized titanium were prospective clinical studies and 3 were RCTs. Of
surface, 42 implants were inserted, then loaded an the 3 RCTs, 2 compared machined versus oxidized
average of 9 days after surgery. The authors reported a titanium surfaces27,32 and one compared early versus
100% implant survival rate after 18 months. For immediate loading.23 From the latter study,23 only
implants with a machined surface, 31 consecutive data concerning immediate loading in the posterior
patients with 56 implants in the posterior mandible mandible were included in the present section, while
were included in the study. One implant failed before data concerning early loading were addressed in the

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Cordaro et al

previous part regarding early loading in the posterior ures) in the oxidized-surface implant test group. The
mandible. Data on posterior maxilla were discussed in results of this study suggested that immediate load-
the review paper on implant loading in the partially ing with rough-surfaced implants seemed to be safer
edentulous posterior maxilla. than the same procedure with machined implants. A
In one RCT, both the methods of randomization and more detailed analysis showed that the main differ-
allocation concealment were not clearly described, but ences were found when implants were placed in soft
complete follow-up of patients and implants was bone (type 4). In such cases, the success rate for
included.28 Two of the RCTs described an adequate machined implants was 56% versus 92% for rough-
method of randomization and complete follow-up, but surfaced implants. Thus it may be speculated that the
the allocation concealment was unclear.24,33 use of a modified surface becomes more important
In a case series study, Buchs and coworkers in jaw locations with “soft” bone.
reported a 92.7% success rate 1 year after immediate Cornellini et al published two studies on immedi-
loading of titanium oxide–blasted implants in the pos- ate loading in posterior sites.28,30 In both papers an
terior mandible either with single crowns or FDPs.24 implant stability quotient (ISQ) value of 62 or more
Calandriello and coworkers performed two studies was required as an inclusion criterion for immediate
on immediate loading.25,26 One of these focused on loading. In the first study the authors analyzed the
immediate loading with single crowns and FDPs. Fifty performance of 30 SLA implants placed in first molar
machined, immediately restored implants with areas and immediately restored in occlusion with the
occlusal contacts in centric relation were studied in opposing dentition. At the 12-month reevaluation,
the maxilla and mandible. For the purposes of this only 1 implant was lost, giving a survival rate of 97%.
review, only the 21 implants placed in partially eden- A mean bone loss of 0.2 mm was recorded.28
tulous posterior mandibles were considered. After a In the second paper, the authors evaluated 40 SLA
12- to 24-month follow-up, the implant survival rate implants that were immediately functionally loaded
was 100%. It was not possible to determine the mean with 20 three-unit FDPs in mandibular premolar and
bone resorption for the mandibular implants, but the molar areas. Only one implant was lost, resulting in a
authors stated that a mean bone loss of 1.2 mm was survival rate of 97.5%. A mean crestal bone resorption
found for all implants in the study and that no statis- of 0.1 mm mesially and 0.5 mm distally was mea-
tically significant differences were found between sured.30 Thus, the authors concluded that immediate
maxillary and mandibular implants.25 loading of SLA implants supporting single crowns or
In a second study on immediate loading of wide- fixed partial dentures showed encouraging results,
platform implants with an oxidized titanium surface, provided that good primary stability could be
50 implants were placed and immediately loaded in achieved during surgery.30
first and second molar areas. All restorations were sin- Abboud and coworkers investigated 20 immedi-
gle crowns with occlusal contacts in centric relation, ately loaded sandblasted implants for single-tooth
but with no contacts during mandibular excursions. In replacement in premolar or first molar areas.29 Of
7 cases a simultaneous GBR procedure was per- these, 11 were mandibular implants that showed a
formed. The 6-month results demonstrated a 100% 100% survival rate at the 12-month follow-up and a
survival rate and a crestal bone resorption of 0.9 mm mean crestal bone loss of 0.03 mm.
for implants without GBR (43 implants), and 1.1 mm of In another study, Romanos and Nentwig evaluated
crestal bone loss for the 7 implants with GBR. Only 24 the same implant design and sandblasted surface
implants could be examined at the 24-month follow- immediately loaded with FDPs in mandibular molar
up.They demonstrated a 100% survival rate, 1.3 mm of and premolar areas. 31 In 12 patients a total of 36
bone resorption in sites without GBR, and 1.8 mm of implants were placed to support 12 three-unit restora-
bone resorption for the implants that received GBR.26 tions. This study was designed as a split-mouth RCT, so
Another RCT was designed by Rocci and cowork- that 36 implants were placed on the contralateral side
ers to compare immediate loading of oxidized tita- of the mandible with similar local conditions. These
nium versus machined implants in the posterior implants were restored after 12 weeks (conventional
mandible.27 In the test group, 22 patients received 66 loading). A survival rate of 100% was found in both
implants with an oxidized surface supporting 24 groups. Concerning bone resorption after 24 months,
restorations, while 22 control group patients received 19% of test implants showed minimal vertical bone
55 machined-surface implants supporting 22 restora- loss (< 2 mm), compared to 25% of controls. Moreover,
tions. Neither cantilever nor pontic units were in one control implant, bone loss > 2 mm was present.
allowed. After 12 months, there was a significant dif- Since no statistical comparison of bone loss distribu-
ference in survival rates: 85.5% (8 failures) in the tion was performed, it cannot be stated that the better
machined-surface implant group versus 95.5% (3 fail- outcome found in the immediately loaded group is sta-

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Group 3

tistically significant. However, the authors concluded loading with this protocol. However, the results seem
that the 2-year prognosis of immediately restored encouraging, since no failures after loading were reg-
implants in partially edentulous mandibular areas was istered and only one early failure of a machined-sur-
similar to the prognosis with conventional loading.31 face implant was found.
Achilli and coworkers conducted a study on early The results of loading between 3 and 6 weeks after
and immediate loading of oxidized titanium surgery were studied in a greater number of implants
implants in the maxilla and mandible. A total of 56 (n = 522). Six early failures and one failure after load-
implants placed in the mandible with an immediate- ing were reported. Implants in the posterior mandible
loading protocol could be included in the present loaded at the 2-month interval were studied in one
review. The immediately loaded implants supporting prospective study including a large number of
FDPs in contact with the opposing dentition showed implants (n = 262), and the 3- and 5-year results were
a survival rate of 100% after 12 months.21 reported in two different publications. Five early fail-
A recent split-mouth RCT compared immediate ures and three failures after loading were reported,
loading of oxidized titanium versus machined demonstrating a survival rate of 98.8% for loaded
implants in posterior mandibular sites. 32 Ten implants and 96.9% for inserted implants.
patients were included in the study and bilaterally Five-year results were also reported for a 6-week
treated, with 20 implants in the test group and 22 in healing interval in one multicenter study and one
the control group. All implants had to exhibit good prospective study. A total of 122 implants loaded
primary stability (insertion torque > 20 Ncm and ISQ with either single crowns or FDPs demonstrated a
> 60) at the time of surgery and were loaded within survival rate of 99% to 100%.19,20
24 hours with light occlusal contacts in centric More recently, a multicenter RCT including
occlusion. The results showed no implant loss implants with a chemically modified sur face 23
among the oxidized titanium implants (100% sur- demonstrated that loading between 4 and 5 weeks
vival rate) and two implant losses for the machined after implant placement leads to an acceptable sur-
group (91% survival rate). The mean bone loss vival rate regardless of the available type of bone.
recorded was 1.06 mm in the test group and 0.92 In the earlier studies, great emphasis was placed
mm in the control group. The authors’ conclusion on the necessity of having excellent primary stability
was that when implant primar y stability was in order to apply early loading. 14 In these studies
achieved, immediate loading seems to be a safe pro- great care was taken to include only implants placed
cedure, especially with rough surfaces. in type 1, 2, or 3 bone, or sites that demonstrated high
A recent RCT compared early and immediate load- values of insertion torque. More recently, authors
ing of SLA implants with chemically modified–surface have applied the early loading protocol to all
implants.24 There were 134 implants randomized to implants regardless of type of bone, and similar
the early loading group in the posterior mandible results were achieved (see Table 1).
and 127 implants immediately loaded in the same A recent review discussed conventional, early, and
region. All implants supported single crowns or fixed immediate loading in partially edentulous patients.43
partial dentures. After a 12-month follow-up, a 98% It was clearly stated that the evolution of implant sur-
survival rate was recorded for immediately loaded faces (from machined to microrough to chemically
implants. Fifteen implants were placed in type 4 bone active) has allowed the healing periods to be
(8 in the early loading group and 7 in the immediate reduced. The author differentiated between single-
loading group), but none of these failed. This study, tooth-gap and multiple-tooth-gap situations in ante-
providing a large sample compared with previous rior and posterior areas of both jaws. It was suggested
papers, confirms the positive outcome of immedi- that single-tooth situations are more demanding
ately loaded implants in the posterior mandible. when compared with cross-arch stabilization of
implants because the unsplinted implant may be less
protected against deleterious micromovements gen-
DISCUSSION erated by functional forces. Thus, the necessity to
achieve good primary stability has been stressed. In
Early Loading the same paper it was argued that single implants
In this review, “early loading” included various load- can share the loading forces with the rest of the adja-
ing intervals and surgical protocols. More aggressive cent teeth, while this is less likely to happen in multi-
protocols consisted of loading at a time earlier than ple-tooth gaps in the posterior areas. In such cases
3 weeks after implant placement with either FDPs or the masticatory forces may be concentrated on the
single crowns.15–18 It should be noted that only 170 implant-supported restorations, thus creating an
implants could be followed for at least 1 year after even more demanding situation.

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Two of the papers selected for the present review The reviewed studies reported information on
involved single-tooth gaps, five involved multiple- single-tooth replacement and on FDPs placed in the
tooth gaps, and three did not differentiate between partially edentulous posterior mandible. Six papers
the two situations. No differences could be identified considered only implant-supported FDPs, three stud-
on the basis of this parameter. The studies included in ied only single crown indications (with only 65
this review, with approximately 1,000 implants fol- implants included), and two included both single
lowed for periods varying from 1 to 5 years, demon- crowns and FDPs (see Table 2). The results did not
strated a minimal survival rate of 96% for inserted show significant differences between prosthetic
implants (including early failures) and 99% for loaded designs. Almost all papers described the type of
implants. Therefore, on the basis of the evidence occlusion provided to the immediately delivered
available to date, early loading of implants with restoration. Some authors preferred to leave the
rough surfaces in posterior mandibular sites may be implants without functional load, while others chose
considered a routine procedure, regardless of the to design restorations with light contacts in maxi-
type of restoration used (single crown or FDP). mum intercuspation (see Table 2). Almost all authors
It must also be noted that whereas earlier studies emphasized the necessity of avoiding any occlusal
mostly compared early loading and conventional contact during excursive movements.
loading, more recently early-loading protocols have Finally, some consideration should be given to the
been compared with immediate loading, which is follow-up periods in the selected studies. Since
considered the most demanding procedure from a immediate loading in posterior areas has only rarely
biomechanical point of view. This suggests that, at been documented in the past, its use has been lim-
least in the hands of experienced clinicians, early ited to rehabilitation of edentulous patients with sev-
loading may be considered the “benchmark” to which eral implants splinted together via a full-arch
more aggressive loading protocols are to be com- prosthesis, or to restorations of small edentulous
pared. Another consideration is that in the context of gaps in the esthetic area with limited functional
early or immediate loading, the submerged surgical needs. Studies on immediate loading for partial
placement of implants is rarely indicated. edentulism in the posterior arches have been con-
ducted only in recent years. Thus, only papers with
Immediate Loading short follow-up periods are available. Among the 10
The articles selected for the present review provided studies that were selected for this review, 8 articles
data on a total of 580 implants that were placed and reported on 12-month follow-ups, and only 2 had
immediately loaded in partially edentulous areas of observational periods of up to 24 months. It is evi-
the posterior mandible. Almost all authors consider dent that further studies with longer follow-up are
immediate loading to be a more demanding proce- required.
dure than early or conventional loading. It presents Moreover, there is some concern regarding the
additional risks, and added precautions are usually immediate loading of implants in the posterior jaws.
taken to obtain survival rates comparable to those of In particular, the pretreatment analysis should evalu-
the more conservative loading protocols. Some stud- ate whether the patient will indeed benefit from this
ies documented that the implant surface is critical to faster procedure. While it is clear that immediate
maximize the survival rate, especially in soft bone.28,31 loading in the esthetic area can substantially add to
The necessity of obtaining satisfactory primary patients’ comfort and satisfaction, it is not clear in
stability has also been stressed by several authors. posterior zones with limited esthetic involvement if
Many studies used the attainment of satisfactory pri- this is of equal benefit to the patient.43
mary stability as an inclusion criteria, either verified A recent systematic review concluded that a high
by hand or by measuring the ISQ, or by recording the degree of primary stability at implant insertion is a
insertion torque.20,23,25–29,31 Since almost all studies key prerequisite for a successful immediate or early
considered only implants with good primary stability, loading procedure.12 A recent RCT23 suggested that
the resulting equivalence of survival rates of immedi- the use of modern implant surfaces may permit the
ately and conventionally loaded implants cannot be achievement of high survival rates even when bone
extended to all the cases. Thus, even if the results are of poor quality is present. This assumption has to be
quite promising, it is recommended to limit the confirmed by other studies.
immediate-loading procedure to selected cases that In the present review only the results related to
demonstrate satisfactory implant stability at the the partially edentulous posterior mandible have
moment of placement. When this is not the case, the been analyzed. Thus, the information presented in
immediate-loading procedure should be aborted and this review paper may be used when planning a reha-
implants should be left unloaded during healing. bilitation in similar clinical situations.

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Group 3

The use of different methods to assess bone den- 6. Norton MR, Gamble C. Bone classification: An objective scale
sity has not yet been related to the treatment out- of bone density using the computerized tomography scan.
Clin Oral Implants Res 2001;12:79–84.
come, even in situations that the clinician would
7. Meredith N, Book K, Friberg B, Jemt T, Sennerby L. Resonance
consider highly demanding from a clinical point of frequency measurements of implant stability in vivo. A cross-
view. sectional and longitudinal study of resonance frequency mea-
Since many of the reviewed studies applied surements on implants in the edentulous and partially
restrictive inclusion criteria, the results reported with dentate maxilla. Clin Oral Implants Res 1997;8:226–233.
8. Attard NJ, Zarb GA. Immediate and early implant loading pro-
this technique involve multiple confounding factors,
tocols: A literature review of clinical studies. J Prosthet Dent
including bone quality and quantity, primary stability, 2005;94:242–258.
and implant dimension. There is no consistency in the 9. Ioannidou E, Doufexi A. Does loading time affect implant sur-
literature regarding the threshold values related to vival? A meta-analysis of 1,266 implants. J Periodontol
these confounding factors. 2005;76:1252–1258.
10. Del Fabbro M, Testori T, Francetti L, Taschieri S, Weinstein R. Sys-
tematic review of survival rates for immediately loaded dental
implants. Int J Periodontics Restorative Dent 2006;26:249–263.
CONCLUSIONS 11. Jokstad A, Carr AB.What is the effect on outcomes of time-to-
loading of a fixed or removable prosthesis placed on implant(s)?
The existing literature supports loading of micro- Int J Oral Maxillofac Implants 2007;22(suppl):19–48.
12. Esposito M, Grusovin MG, Willings M, Coulthard P, Worthington
roughened dental implants in the partial edentulous
HV. The effectiveness of immediate, early, and conventional
posterior mandible at 6 to 8 weeks in the absence of loading of dental implants: A Cochrane systematic review of
modifying factors such as fresh extraction sockets, randomized controlled clinical trials. Int J Oral Maxillofac
GBR, and short implants. Therefore, loading within Implants 2007;22:893–904.
this time frame should be considered routine for the 13. Cochran DL, Morton D, Weber HP. Consensus statements and
recommended clinical procedures regarding loading proto-
majority of clinical situations in the posterior
cols for endosseous dental implants. Int J Oral Maxillofac
mandible, either with single crowns or FDPs. Immedi- Implants 2004;19(suppl):109–113.
ate loading of microroughened dental implants in 14. Cochran DL, Buser D, ten Bruggenkate CM, et al. The use of
the partially edentulous posterior mandible is a reduced healing times on ITI implants with a sandblasted and
viable treatment alternative. acid-etched (SLA) surface: Early results from clinical trials on
ITI SLA implants. Clin Oral Implants Res 2002;13:144–153.
Caution is recommended in interpreting published
15. Nordin T, Nilsson R, Frykholm A, Hallman M. A 3-arm study of
outcomes for the immediate-loading group, as the early loading of rough-surfaced implants in the completely
inclusion and exclusion criteria are inconsistent and edentulous maxilla and in the edentulous posterior maxilla
many subjective confounding factors are evident. and mandible: Results after 1 year of loading. Int J Oral Max-
Additional studies and longer follow-ups are needed illofac Implants 2004;19:880–886.
16. Salvi GE, Gallini G, Lang NP. Early loading (2 or 6 weeks) of
to consolidate the data for immediate loading.
sandblasted and acid-etched (SLA) ITI implants in the poste-
Well-designed RCTs are needed, and priority rior mandible. A 1-year randomized controlled clinical trial.
should be given to trials testing immediate loading. Clin Oral Implants Res 2004;15:142–149.
17. Vanden Bogaerde L, Pedretti G, Dellacasa P, Mozzati M, Rangert
B. Early function of splinted implants in maxillas and posterior
mandibles using Brånemark system machined-surface
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168 Volume 24, Supplement, 2009