Workshop guidelines on immediate loading in implant dentistry

The delivery of care for patients missing 1 or all of their teeth very often requires implants to restore function, esthetics, bone and softtissue contours, speech, and intraoral health. The delayed occlusal loading protocol, either the 1- or 2-stage approach, has been evaluated for more than 30 years by a number of clinical settings and situations. However, in some patient conditions, the delayed-healing process can cause physchologic, social, speech, or function problems. A full range of treatment options relative to the initial hard- and soft-tissue healing is available. Immediate restoration of a patient after implant surgery is one of these alternatives. A benefit-risk ratio may be assessed for each patient condition to ascertain whether immediate occlusal loading is a worthwhile alternative. The greater the benefit or the lower the risk, the more likely immediate loading is considered. A complete edentulous mandible restored with an overdenture supported by 4 or more implants is a very low-risk condition. If the patient cannot tolerate a mandibular denture and does not wear the device, an immediate loading protocol would be highly beneficial. The highest risk for immediate loading would be a posterior single- tooth implant. Implant number cannot be increased, and implant length cannot engage cortical bone. When the singletooth replacement is out of the esthetic zone, very low benefit is obtained with the immediate restoration approach. In patients who are partially edentulous, immediate restoration does not necessarily mean immediate occlusal loading. A nonfunctional transitional device is less likely to cause occlusal overload during the initial bonehealing response. Whether or not the restoration is in function is not the most critical factor. Minimal micromotion at the implantto- bone interfacial zone during bone healing, however accomplished, appears to be a key factor. The traditional 2-stage approach to implant restorations have been evaluated for almost 3 decades. The immediate occulsal load approach, in comparison, is relatively new and has far less research and documented studies. Therefore, the staged approach to implant restoration should always be the first approach. This is especially noteworthy for the less-experienced practitioner. Immediate restoration does not necessarily mean immediate loading at the higher magnitude forces and cycles. Conservative approaches to reduce stress to the prostheses should lead to enhanced outcomes. Additional clinical studies to evaluate the associated risks, especially in the maxillary arch, are expected over the next several years. Until the profession has longer-term evidence and more multicenter studies, immediate occlusal loading will be a secondary treatment option, restricted on a case-by-case basis.