Immediate Vs. Early Loading of Immediately Placed Implants

Immediate Vs. Early Loading of Immediately Placed Bone Level Tapered Dental Implants

The study aims to compare implant stabilities between immediate and early loaded, immediately placed bone-level tapered dental implants in the upper jaw in the partial and total edentulous patients assessing marginal bone loss, oral health-related quality of life, and patient satisfaction within one, two and five years of follow-ups.

Study Overview

• Status: Completed
• Conditions: Implant; Implant Complication
• Intervention / Treatment: Device: Immediate implant loading; Device: Early implant loading

Detailed Description

The objectives of the study

The primary objective of this study will be to compare primary and secondary stability between immediate and early loaded, immediately placed bone-level tapered dental implants in the upper jaw in partial and total edentulous patients. The second objective will be marginal bone level changes and soft tissue changes such as keratinised tissue width and gingival thickness which will be assessed at one, two and five years postoperatively. The gained results will assess and compared within partial and total edentulous patients.

Additionally, the study also will be analyse functional and aesthetic outcomes as well as the possibility of the complication and its prevalences including (biological, mechanical, and procedure-related complications) comparing the their incidence between partial and total edentulous patients.

Materials and methods

The study is design as a prospective, randomised, controlled clinical trial which will be conducted at School of Dental Medicine in accordance with the Declaration of Helsinki (World Medical Association, 2013) and the CONSORT Statement.

Before the treatment procedure, after clinical examination patients will be divided into two groups:

1. Group A- patient requires on both sides one implant to be placed
2. Group B- patient requires full-arch reconstruction

Thereafter, in the both groups, patients will be randomly divided into two subgroups in which immediate loading (test group) or early loading (six week postoperatively) will be performed.

Surgical procedure

One hour before the surgery, antibiotic prophylaxis will be administered, and the patients should rins their mouths with 0.12% chlorhexidine solution for 1 minute preoperatively. The procedures will be performed under local anesthesia using 4% articaine, 1:100.000 epinephrine. A midcrestal incision will be made, and full-thickness will be elevated. Failing tooth or teeth will be extracted using periotomes, elevators, and forceps to preserve socket walls integrity. Extracted alveolus will be immediately prepared following by the epicrestal or subcrestal implant placement. If the gap between the implant surfaces and socket walls is wider than 2 mm, bovine-derived xenograft (Geistlich Bio-Oss®, Wolhusen, Switzerland) and collagen membrane (Geistlich Bio-Gide®, Wolhusen, Switzerland) will be placed. Healing screws (Institute Straumann AG, Basel, Switzerland; NC healing abutment ∅4.8 mm conical 5 mm and RC healing abutment ∅5 mm conical 6 mm) will be placed, and primary wound closure was achieved with 5-0 single resorbable sutures (AssuCryl Lactin, Pully-Lausanne, Switzerland). The presence of apical fenestration, cortical dehiscence, an apico-marginal defect, or the need for contour augmentation will also recorded in the patient study charts. Patients will be prescribed antibiotic therapy for the next five days (Amoxicillin with clavulonic acid, 1 g, twice a day, or, in case of allergy, Clindamycin, 0.6 g, three times a day).

2.3 Prosthetic protocol

Implants in subgroup marked as the test group will be immediately loaded with temporary restorations using S-R abutments (Institute Straumann AG, Basel, Switzerland) whereas the patients from the subgroup marked as control group wouldn't receive any kind of prosthetic restauration, and will left with healing abutments (HA).

For the provisional restoration, an open tray impression technique will be used. Plaster models with scan bodies will be digitized by the laboratory scanner (3Shape E1, 3Shape, Kopenhagen, Denmark), and the virtual design of provisional restoration will be performed with 3D designing software (Exocad-Matera 2.3, Exocad, Darmstadt, Germany). Provisional restorations will be then created using polymethyl methacrylate (PMMA) (Telio®CAD, Ivoclar Vivadent, Schaan, Lichtenstein) and were drilled from PMMA blocks using the 5-axis milling machine (Zenotec Select, Wieland, Pforzheim, Germany). Screw-retained abutments for the prosthetic bridge will be chosen according to implant angulation and surrounding soft tissue height.

At the end of the six-week healing period, definitive prosthetic restorations will be manufactured and delivered to the patients in both groups.

Data Collection and measurements

Implant stability, assessed as the primary study outcome, was measured using the Resonance Frequency Analysis (RFA) method with Osstell Mentor® (Osstell, Gothenburg, Sweden) (Fig. 7b) and Penguin® (PenguinRFA, Gothenburg, Sweden).

Marginal bone loss will be assessed as the difference between the postoperative and followed up years by means of CBCT measurements.

The distance between the implant shoulder and the crestal bone will be estimated as the shortest distance, using the same HA for each patient.

The results will be statistically analysed.

• Study Type: Interventional
• Enrollment (Actual): 24
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Serbia
  • Belgrad, Serbia, 11000
    • School of Dental Medicine, Univeristy of Blegrade

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

1. Adults ≥ 18 years of age;
2. systemically healthy;
3. periodontally healthy or with stable treated periodontitis and good oral hygiene (FMPS and FMBS ≤ 15%, measured at six sites per tooth)
4. Have maxillary dentition with one or multiple failing teeth
5. Have sufficient bone volume to immediately place implants
6. Non-smoker or light smoker

Exclusion Criteria:

1. An active or chronic disease that affects bone metabolism or wound healing (ASA III type);
2. Diminished mental capacities that could mitigate the ability to comply with the protocol;
3. History of maxillary augmentation; oral carcinoma or inflammatory changes;
4. History of head and neck radiotherapy.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Test: Immediate implant loading; Implants will be immediately following surgical procedure loaded with temporary restorations.	Device: Immediate implant loading; Implants will be received immediately prosthetic restoration following surgical procedure. For the provisional restoration, an open tray impression technique will be used. Plaster models with scan bodies will be digitized by the laboratory scanner (3Shape E1, 3Shape, Kopenhagen, Denmark), and the virtual design of provisional restoration will be performed with 3D designing software (Exocad-Matera 2.3, Exocad, Darmstadt, Germany). Provisional restorations will be then created using polymethyl methacrylate (PMMA) (Telio®CAD, Ivoclar Vivadent, Schaan, Lichtenstein) and were drilled from PMMA blocks using the 5-axis milling machine (Zenotec Select, Wieland, Pforzheim, Germany). Screw-retained abutments for the prosthetic bridge will be chosen according to implant angulation and surrounding soft tissue height. At the end of the six-week healing period, definitive prosthetic restorations will be manufactured and delivered to the patients.; Other Names: test group
Experimental: Control: Early implant loading; Implants will not be received prosthetic restoration, and will left with healing abutments (HA) for 6 weeks.	Device: Early implant loading; Implants won't receive immediately prosthetic restoration following surgical procedure and will be left only healing caps. At the end of the six-week healing period, definitive prosthetic restorations will be manufactured and delivered to the patients.; Other Names: control group

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Implant stability	Implant stability is measured using the Resonance Frequency Analysis (RFA) method with Osstell Mentor® (Osstell, Gothenburg, Sweden) and Penguin® (PenguinRFA, Gothenburg, Sweden). The result is expressed as ISQ values.	Change implant stability at 12 months
Implant stability	Implant stability is measured using the Resonance Frequency Analysis (RFA) method with Osstell Mentor® (Osstell, Gothenburg, Sweden) and Penguin® (PenguinRFA, Gothenburg, Sweden). The result is expressed as ISQ values.	Change implant stability at 2 years
Implant stability	Implant stability is measured using the Resonance Frequency Analysis (RFA) method with Osstell Mentor® (Osstell, Gothenburg, Sweden) and Penguin® (PenguinRFA, Gothenburg, Sweden). The result is expressed as ISQ values.	Change implant stability at 5 years

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change of Marginal bone loss (MBL)	MBL will be measured in millimetres as distance between the implant shoulder and the crestal bone postoperative and one, second, and five year postoperatively by using CBCT.	Change baseline marginal bone at 12 months
Change of Marginal bone loss (MBL)	MBL will be measured in millimetres as distance between the implant shoulder and the crestal bone postoperative and one, second, and five year postoperatively by using CBCT.	Change baseline marginal bone at 2 years
Change of Marginal bone loss (MBL)	MBL will be measured in millimetres as distance between the implant shoulder and the crestal bone postoperative and one, second, and five year postoperatively by using CBCT.	Change baseline marginal bone at 5 years
Change of keratinised tissue width (KTW)	KTW will be measured in millimetres at the middle of the inserted implant as the distance between the free MM to a mucogingival junction (MGJ)	Change baseline marginal bone at 12 months
Change of keratinised tissue width (KTW)	KTW will be measured in millimetres at the middle of the inserted implant as the distance between the free MM to a mucogingival junction (MGJ)	Change baseline marginal bone at 2 years
Change of keratinised tissue width (KTW)	KTW will be measured in millimetres at the middle of the inserted implant as the distance between the free MM to a mucogingival junction (MGJ)	Change baseline marginal bone at 5 years

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Patient satisfaction	Patient will be recorded by using visual analog score (VAS). Patients will indicate their satisfaction relating to function, aesthetics, and discomfort/pain.	12 moths postoperatively
Patient satisfaction	Patient will be recorded by using visual analog score (VAS). Patients will indicate their satisfaction relating to function, aesthetics, and discomfort/pain.	2 years postoperatively
Patient satisfaction	Patient will be recorded by using visual analog score (VAS). Patients will indicate their satisfaction relating to function, aesthetics, and discomfort/pain.	5 years postoperatively
Pink aesthetic score (PES)	A clinical photograph performed at 12 months examination, will be used for assessment. Seven variables of the implant supported crown will be evaluated vs. a contralateral natural tooth: mesial papilla, distal papilla, soft tissue level, soft tissue contour, alveolar process deficiency, soft tissue color and texture. A 0-1-2 scoring system will be used, 0 being the lowest and 2 being the highest value.	12 months after implant loading
Pink aesthetic score (PES)	A clinical photograph performed at 2 years examination, will be used for assessment. Seven variables of the implant supported crown will be evaluated vs. a contralateral natural tooth: mesial papilla, distal papilla, soft tissue level, soft tissue contour, alveolar process deficiency, soft tissue color and texture. A 0-1-2 scoring system will be used, 0 being the lowest and 2 being the highest value.	2 years after implant loading
Pink aesthetic score (PES)	A clinical photograph performed at 5 years examination, will be used for assessment. Seven variables of the implant supported crown will be evaluated vs. a contralateral natural tooth: mesial papilla, distal papilla, soft tissue level, soft tissue contour, alveolar process deficiency, soft tissue color and texture. A 0-1-2 scoring system will be used, 0 being the lowest and 2 being the highest value.	5 years after implant loading

Collaborators and Investigators

• Sponsor: University of Belgrade
• Investigators: Study Director: Aleksa Markovic, Professor, School of dental medicine, University of Belgrade

Publications and helpful links

General Publications

• Chambrone L, Shibli JA, Mercurio CE, Cardoso B, Preshaw PM. Efficacy of standard (SLA) and modified sandblasted and acid-etched (SLActive) dental implants in promoting immediate and/or early occlusal loading protocols: a systematic review of prospective studies. Clin Oral Implants Res. 2015 Apr;26(4):359-370. doi: 10.1111/clr.12347. Epub 2014 Feb 21.
• Chung S, McCullagh A, Irinakis T. Immediate loading in the maxillary arch: evidence-based guidelines to improve success rates: a review. J Oral Implantol. 2011 Oct;37(5):610-21. doi: 10.1563/AAID-D-JOI-10-00058.1.
• Del Fabbro M, Testori T, Kekovic V, Goker F, Tumedei M, Wang HL. A Systematic Review of Survival Rates of Osseointegrated Implants in Fully and Partially Edentulous Patients Following Immediate Loading. J Clin Med. 2019 Dec 4;8(12):2142. doi: 10.3390/jcm8122142.
• Garcia-Sanchez R, Dopico J, Kalemaj Z, Buti J, Pardo Zamora G, Mardas N. Comparison of clinical outcomes of immediate versus delayed placement of dental implants: A systematic review and meta-analysis. Clin Oral Implants Res. 2022 Mar;33(3):231-277. doi: 10.1111/clr.13892. Epub 2022 Jan 28.
• Ibrahim A, Chrcanovic BR. Dental Implants Inserted in Fresh Extraction Sockets versus Healed Sites: A Systematic Review and Meta-Analysis. Materials (Basel). 2021 Dec 20;14(24):7903. doi: 10.3390/ma14247903.
• Markovic A, Misic T, Janjic B, Scepanovic M, Trifkovic B, Ilic B, Todorovic AM, Markovic J, Dard MM. Immediate Vs Early Loading of Bone Level Tapered Dental Implants With Hydrophilic Surface in Rehabilitation of Fully Edentulous Maxilla: Clinical and Patient Centered Outcomes. J Oral Implantol. 2022 Oct 1;48(5):358-369. doi: 10.1563/aaid-joi-D-21-00045.

Study record dates

Study Major Dates

• Study Start (Actual): January 31, 2019
• Primary Completion (Actual): May 15, 2021
• Study Completion (Actual): May 1, 2023

Study Registration Dates

• First Submitted: May 11, 2023
• First Submitted That Met QC Criteria: May 11, 2023
• First Posted (Actual): May 22, 2023

Study Record Updates

• Last Update Posted (Actual): May 22, 2023
• Last Update Submitted That Met QC Criteria: May 11, 2023
• Last Verified: May 1, 2023

More Information

Terms related to this study

• Keywords: Marginal Bone Loss; Immediate implant placement; immediate loading; Implant stability; Early loading
• Other Study ID Numbers: 36/16

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: The one and two years outcome will be statistically analysed and published in the journal which will be shared and available to public.
• IPD Sharing Time Frame: 2022-2035
• IPD Sharing Access Criteria: The investigators will be shared analyzed outcomes and surgical procedure protocols
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF

Study Data/Documents

1. Study Protocol
   Information comments: Study protocol will be set and described at following link

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No