Progressive Bone Loading

of Implant
Carl Misch

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Progressive Loading Protocol:

where the restoration is restored
with light contact initially and then
gradually brought into full contact
with the opposing dentition.

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Concept
Lamellar bone is a load bearing bone and the
ideal choice for an implant interface.
However, this bone does not initially form in
trabecular bone around an unloaded implant.
The presence of this bone type is improved with
a gradual loading of the implant interface.
Progressive loading of the implant permits the
bone to remodel and organize in accordance to
Wolff's law, which states that trabecular bone
places and displaces itself in relationship to the
forces around it.
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 Each step of the progressive loading

process is allowed sufficient time for
the bone to respond to the increased
stimulation.
Ideally, woven bone transforms into
load bearing lamellar bone, along
with an increase in the percentage of
bone at the implant interface.
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 Misch - During prosthetic reconstruction to permit

development time for load-bearing bone at the
bone-to-implant interface and provide bone with
adaptability to loading via a gradual increase in
loading.
Then he modified this concept by incorporating
time intervals (from 3 to 6 months), diet (avoid
chewing with a soft diet, then harder food),
occlusion (gradually intensify the occlusal contacts
during prosthesis fabrication), prosthesis design,
and occlusal materials (from resin to metal to
porcelain)
for poor bone quality conditions.
Misch CE. Progressive loading of bone with implant
prostheses. J Dent Symp, 1: 50-53, 1993.
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 Appleton et al. found that

progressively loaded implants
preserved the crestal bone height
and improved the peri-implant bone
density around implants.
Their findings suggest that an
extended healing time and
progressive bone loading may be
needed in patients with poor bone
quality.
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 At the post healing Stage II surgery,

the implant is most at risk for failure
or crestal bone loss within the first
year.
Failure results primarily from
excessive stress or poor bone strength
at the interface during early implant
loading.
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The three most common causes of

early prosthetic related implant
failure non passive superstructures
partially unretained restorations
loading of the implant support
system beyond the strength of the
bone-to-implant interface
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 Misch et al. reported on 364

consecutive implants in 104 patients
with 98.9% survival at Stage II
uncovery followed with a progressive
loading format and found no early
loading failures during the first year
of function.
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 Full-arch prostheses with little or no

cantilever and adequate implant number,
position, and size rarely require
progressive loading unless the bone
density is poor.
However, the fewer the number of
implants or the softer the bone types, the
more progressive loading is suggested.
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 The concept of progressive loading is

to allow the bone to adapt to
increasing amounts of biomechanical
stress.
Hence, rather than immediately
loading the boneimplant interface,
methods to slowly increase the stress
over time are a benefit.
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 The progressive loading protocol uses a

cement-retained prosthesis when implants
are splinted together.
Because a screw retained splinted
restoration is not completely passive and
a torque force applied to a screw is
greater than a bite force, a traditional
screw-retained restoration cannot use
progressive loading to gradually load the
bone.
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 In addition, most of the forces placed

onto the implants for a screw-retained
bar or prosthesis are generated at the
delivery from nonpassive
superstructures.
As a result, screw-retained prostheses
do not use a progressive loading
protocol.
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Bone density
Wolff's law
"Every change in the form and function of
bones or of their function alone is followed
by certain definite changes in their
internal architecture, and equally definite
alteration in their external conformation,
in accordance with mathematical laws.
This phenomenon occurs throughout the
skeletal system.
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 Functional loading can compete and

maintain bone mass.
Increase in cortical bone thickness and
overall mineral content under stressful
stimuli.
Clinical evaluation confirms an increase
in the amount of trabecular bone and
cortical plate thickness in patients with
natural teeth exhibiting parafunction.
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 Cantilevers, patient force factors, and

implant position also may influence
the risk factors in implant dentistry.
As a general rule, the higher the
risk factors, the more
progressive loading is
recommended.
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Elements Of Progressive
Loading

Time interval
Diet
Occlusal material
Occlusal contacts
Prosthesis
Design

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Time Interval
Two surgical appointments are
separated by
4-8 months

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Time interval
The macroscopic coarse trabecular bone heals
about 50% faster than dense cortical bone.
The healing time between the initial and
second-stage surgeries is kept similar for Dl and
D2 bone and is 3 to 4 months.
A longer time is suggested for the initial healing
phase of D3 and D4 bone (5 and 6 months,
respectively) because of the lesser bone contact
and decreased amount of cortical bone to allow
for the maturation of the interface and the
development of some lamellar bone.
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Diet
The diet of the patient is controlled to
prevent overloading during early
phases of restorative phase
During initial healing phase, avoid
eating from that area.
The patient is limited to a soft diet
from the initial transitional prosthesis
delivery until the initial delivery of the
final prosthesis
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Diet
After the initial delivery of the final prosthesis,
the patient may include meat in the diet.
The final restoration can bear the greater force
without risk of fracture or uncementation.
After the final evaluation appointment, the
patient may include raw vegetables.
A normal diet is permitted only after evaluation
of the final prosthesis function, occlusion, and
proper cementation.

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Occlusal material
Acrylic is used as the occlusal material,
with the benefit of a lower impact force
than metal or porcelain.
Either metal or porcelain can be used as
the final occlusal material.
If parafunction or cantilever length cause
concern relative to the amount of force on
the early implant-bone interface, the
dentist may extend the softer diet and
acrylic restoration phase several months.
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Occlusion
Occlusal contacts are gradually intensified during
prosthesis fabrication.
No occlusal contacts are permitted during initial
healing (step 1).
The first transitional prosthesis is left out of occlusion
in partially edentulous patients (step 2).
The occlusal contacts then are similar to those of the
final restoration for areas supported by implants.
However, no occlusal contacts are made on
cantilevers (step 3).
The occlusal contacts of the final restoration follow
the implant protective occlusion concepts.
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Prosthesis Design
First transitional acrylic restorations has
no occlusal contact and no cantilevers
second acrylic transitional restoration,
occlusal contacts are placed on the implants
with occlusal tables similar to the final
restoration but with no cantilevers in non
esthetic regions.
final restoration, narrow occlusal tables and
cantilevers are designed with occlusal contacts
following implant-protective occlusion
guidelines.
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Progressive loading phases

During the surgical Stage II uncovery
procedure,
- clinical mobility,
- bone loss (horizontal and vertical),
- proper placement in reference to prosthetic
design and
- angulation to load,
- zones of attached gingiva, and
- gingival thickness.
.
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The progressive bone-loading

appointment sequence for cementretained prostheses is as follows :
1. Initial abutment selection and
preliminary impression.
2. Final impression and transitional
prosthesis I.
3. Metal superstructure try-in and
transitional prosthesis II.
4. Initial insertion of final prosthesis.
5. Final delivery and evaluation.
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Initial abutment selection and

preliminary impression
The goal of this first prosthetic
appointment is to assess the implant and
soft tissues and make sure that all the
prosthetic components and details of the
prosthetic appointment are addressed.
This appointment may occur during the
suture removal appointment after stage
II surgery or during the uncovery
procedure.
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Final Impression and Transitional Prosthesis I

Remove the PMEs

from the implant
bodies and selects
the appropriate or
two-piece abutment
for cement
retention.
Thread the abutment
by hand into position
with about a 10Ncm force
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An abutment for cement retention

is inserted and torqued into the
implant bodies.

 verify complete seating of the

abutment with a radiograph.

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 Obtain a final impression, record the

centric occlusal registration with a closedmouth centric position when centric
relation is harmonious with centric
occlusion, or make a face-bow record
along with protrusive and check bites
when required.
Lute the first transitional prosthesis with a
noneugenol zinc oxide cement, and
occlusal contacts are totally absent.
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The first transitional restoration is cemented with

temporary cement. It is completely out of occlusion.
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Instructions To Patient
Avoid this region of the mouth while eating.
Diet should consist of soft food such as pasta or
fish.
Not chew sticky foods or gum
Avoid aggressive chewing or oral habits that may
cause the temporary prosthesis to loosen or
break.
Inform the patient that complications created by
the improper use of the temporary prosthesis
will add additional surgeries, prosthetic
appointments, and costs to the treatment.
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Laboratory Phase I
pour the final impressions
with die stone
mount the models
make a full-contour waxup and cutdown of 2 mm
in regions of porcelain
for
the
prosthesis
framework.
fabricate a precious metal
superstructure and use
an occlusal acrylic index
to indicate the occlusal
registration recorded for
the
implant-supported
prostheses.
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The laboratory technician

fabricates a precious metal
framework that splints the
abutments together.

Second Prosthetic Appointment

Metal Try-in
The patient returns in 1 to
4
weeks
(or
more)
depending on the bone
density.
The dentist removes the
first
transitional
restoration and evaluates
its retention to help select
the proper luting agent for
the final restoration. The
metal superstructure is
tried in.
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verify
the
centric
relation.
If the patient bites into
the
laboratory
occlusal acrylic index,
the previous occlusal
record was accurately
registered.
If the patient occludes
in a different position,
evaluate and correct
the occlusion on the
casting as indicated
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A
closed-mouth
centric recording is
made over
the
metal
framework.

The dentist delivers the

second transitional prosthesis
This
may
be
a
new
transitional
prosthesis
or
more often
the
first
transitional
prosthesis with a modified
occlusal table through the
addition of acrylic on the
occlusal contact areas.
Monomer is first applied to
the occlusal aspect of the
temporary prosthesis, and
petroleum jelly is applied over
the opposing teeth.
add acrylic on the occluding
surfaces of the temporary
restoration, and the patient
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occludes into the material and

 The dentist eliminates the nonworking

and working occlusal contacts and can
bring the pontic areas and angled
abutments into light centric occlusion.
Occlusal contacts are limited to those
directly over implant bodies.
The diet remains soft with pasta, fish,
or softer food types.
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Laboratory Phase II
The laboratory technician
completes the prosthesis
with an occlusal scheme
that follows implantprotective occlusal
guidelines.
The dentist notes angled
implant bodies so that the
occlusal contacts may be
modified to be in the long
axis of the implant body
or reduced in intensity.
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Third Prosthetic Appointment:

Initial Prosthesis Delivery

The next appointment follows 1 to 4 weeks

later, depending on the bone density.
Removes the transitional prosthesis and
evaluates its retention to help select the
cement used in the final prosthesis.
If retention is satisfactory, use a similar cement
at the initial delivery of the final restoration.
However, eugenol-based cements may be used
as desired because a metal rather than acrylic
restoration is cemented.
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 Insert the final

restoration and
evaluate it carefully
relative to occlusal
contacts.
After using a light bite
force to equilibrate the
occlusal contacts, make
a heavy bite force
occlusal adjustment
with no lateral contacts
in excursions
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Obtain a radiograph to use

as a baseline for future
radiographic evaluation
for crestal bone loss and
implant health
If crestal bone loss is
observed compared with
the stage II uncovery
appointment, should
suspect parafunction and
fabricate night guards to
control stresses.
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 The bone has benefited from the additional

time and is now more mineralized and
exhibits improved load-bearing capability
compared with the first transitional
prosthesis delivery.
In addition, the stronger final restoration
(compared with transitional) can sustain
greater masticatory loads.
Therefore, the diet of the patient now may
include harder foods.
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Fourth Prosthetic Appointment:

Final Evaluation and Hygiene
The patient returns in about 4 weeks.
This appointment is maintenance appointment.
First evaluate retention of the prosthesis. If retention is
adequate, does not remove the restoration and uses
the soft access cement for the definitive restoration.
If , can remove the prosthesis with finger pressure,
cement the restoration with a stronger cement.
Evaluate the soft tissues and home care and perform a
final occlusal equilibration.
The diet include raw vegetables and harder foods.
Another maintenance appointment - 3 to 4 months.

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Completely Edentulous Patient Protocol

Some modifications to the previously

discussed protocol are included with
fabrication of full-arch restorations.
A full-arch restoration often uses an
indirect (laboratory) approach to select
or prepare (or fabricate) the abutments.
Because no natural teeth are present,
the implants are loaded when the initial
transitional prosthesis is delivered.
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First Prosthetic Appointment

Initial Abutment Selection and Preliminary Impression

Before or during surgical phases, fabricate

a treatment prosthesis that restores the
patient to the proper occlusal vertical
dimension (OVD) and determines the
correct tooth position for the final
prosthesis.
Fabricate a clear template over the
removable prosthesis and trims it to the
surrounding soft tissue border.
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 Position the denture

and clear template
(0.008 inch) in the
mouth and a bite
registration to the
opposing arch.
Remove the denture
from the template,
which then acts as a
customized impression
tray indexed to the
opposing occlusion.
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t w o - pi ec e t ra nsf er copi ng e ngages t he

he
xa gon o f t he i mpl ant b ody
. A cl o sed- t ray i mpress i on i s m ade w i t h
t he cust omi z ed i m pressi on t ray o ver t hese i mpl a nt bo dy t ransf ers.

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 A and B
The customized impression tray with
the occlusal bite registration in
centric relation occlusion
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 Reinsert the stage II PMEs into the implant bodies

and relieves the soft liner over the PMEs.
The patient is instructed to limit mastication to
very soft foods and to remove the denture at night
to prevent nocturnal parafunction.
Parafunction during this time is a major concern of
overload for a completely edentulous patient
because the implants are independent and do not
have the biomechanical advantage of splinting.
The patient returns in 1 to 2 weeks for the next
prosthetic appointment.
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Laboratory Phase I
Laboratory steps after the first prosthetic
appointment include
pouring the preliminary impression with
the implant abutment and implant body
analogs in dental stone.
The laboratory technician mounts the casts
on an articulator using the prosthetic
template or custom tray and occlusal
registration before it is separated from the
cast (Figure 32-41).
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The impression transfer copings are attached to

the implant bodies, poured, and mounted to the
opposing arch with the customized impression tray.
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 The technician may adjust the

abutments in length, angulation, and
proper clearance for crown contours
using the clear overlay template of
the wax-up or denture as a guide.
A wax-up using denture teeth
elaborates the proposed form of the
final prosthesis.
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The final abutments are selected and

prepared for parallelism and tooth position
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 The technician fabricates a modified

baseplate and wax rim over the
abutments.
With a technique similar to that of
complete denture fabrication, the
wax rim is used to record the incisal
edge position, OVD, midline, high lip
line,

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Second Prosthetic Appointment

Final Impression and Transitional Prosthesis I

The dentist removes the PMEs and

inserts the final abutments for
cement.
evaluate the abutments for ideal
placement and height (at least 1 to 2
mm less than the occlusal plane,
depending on the occlusal material),
and recontour them as required
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The laboratory-prepared abutments are

positioned over the antirotation component of
the implant body and are secured with an
abutment screw at 30 N-cm of torque.
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 The dentist inserts the first

transitional prosthesis .
A most important step for
the provisional prosthesis
is the evaluation of incisal
edge position for esthetics
and phonetics.
The dentist should
establish this position
before fabricating the
superstructure to ensure
ideal support of porcelain
or acrylic in the final
restoration.
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 This is the first time the patient has

worn a fixed prosthesis since the
denture.
The diet of the patient at this time is
still very soft.

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Third Appointment: Metal Try-in and

Transitional Prosthesis II

The dentist evaluates the transitional

prosthesis retention and then
removes the prosthesis.
If the prosthesis is not loose, use the
same cement at the conclusion of
this appointment. Try the metal
framework .

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The accuracy of the prior centric

occlusion
recording is verified and repeated
as necessary.

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The secondary transitional device is delivered at

the conclusion of the third appointment.

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Fourth Appointment: Initial Delivery

The fourth restorative appointment

(24 weeks later) marks the initial
delivery of the final restoration.

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 The dentist uses a soft access cement

in the restoration and reinforces,
demonstrates, and stresses oral
hygiene regimens.
The diet of the patient still does not
include hard foods, but patients can
enjoy most foods.
No raw vegetables or hard, crunchy
foods are yet in the diet at this time.
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Fifth Prosthetic Appointment: Final

Evaluation and Hygiene

At the fifth prosthetic appointment (about 4

weeks later), evaluate the final restorative result
and improve difficult access areas for hygiene.
Scrutinize the patients soft tissue health and
hygiene regimen.
Periimplant probing is indicated to establish soft
tissue baseline measurements at this
appointment.
Refine occlusion. No posterior contacts are
present during excursions when opposing
natural dentition or a fixed prosthesis
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The final restoration is delivered to the patient.

This restoration is a fixed prosthesis type 2, with porcelain fused to metal.

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 The diet of the patient is normal at

this time.
Ask the patient to return every 3 to 4
months during the first year so that
the dentist may evaluate bone
changes and occlusal patterns.
Maintenance hygiene appointments,
often are scheduled every 4 to 6
months.
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Outline form
Progressive bone loading
Concept
Wolfs law- Bone Density
Bone- Implant Interface
Protocols
Phases- RPD
Complete Denture

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