UNIVERSIDADE ESTADUAL PAULISTA

“JÚLIO DE MESQUITA FILHO”

Instituto de Ciência e Tecnologia

Campus de São José dos Campos

CASE REPORT DOI: https://doi.org/10.4322/bds.2023.e3569

Braz Dent Sci 2023 Apr/June;26 (2): e3569

Peri-implant bone level assessment of early loaded dental implants

submitted to diﬀerent prosthetic protocols: a case report

Avaliação do nível ósseo peri-implantar de implantes dentários com carregamento antecipado submetidos a protocolos

protéticos diferentes: relato de caso

Rodrigo Hideki YOSHIYASU

, Carolina Accorsi CARTELLI

, Camila Pereira VIANNA

, Waleska CALDAS

,

Sergio Rocha BERNARDES

, Larissa Carvalho TROJAN

, Rubens Moreno de FREITAS



1 - Prática privada, Curitiba, PR, Brazil.

2 - Neodent, Segurança Clínica, Curitiba, PR, Brazil.

3 - Faculdade Ilapeo, Curitiba, PR, Brazil.

4 - Neodent, Clinical Affairs, Irvine, CA, USA.

How to cite: Yoshiyasu RH, Cartelli CA, Vianna CP, Caldas W, Trojan LC, Bernardes SR, et al. Peri-implant bone level assessment of

early loaded dental implants submitted to different prosthetic protocols: a case report. Braz. Dent. Sci. 2023;26(2):e3569. https://doi.

org/10.4322/bds.2023.e3569

ABSTRACT

Aim: The present split-mouth case report aims to describe the clinical and radiographic long-term outcomes of

the implant rehabilitation of two mandibular premolars in which the digital workow was used to apply different

prosthetic protocols. Case description: A female 42-year-old patient with the absence of both mandibular second

premolars was submitted to guided surgery for the placement of platform-switching Grand Morse connection

implants. Digital workow was used for implant and prosthetic planning, applying early loading protocol 21 days

after surgery. The implant on the right side received the nal abutment at the time of surgery (without loading),

whereas the implant on the left side had a healing abutment placed, which was replaced by a temporary abutment

and then by a nal abutment. Two months after surgery, both implants had nal ceramic restorations delivered.

The patient was followed clinically and radiographically for 30 months, presenting excellent hard and soft tissue

outcomes, with bone level changes lower than 2mm for both implants. Conclusion: The use of digital workow

and early loading, made the present implant-supported rehabilitation predictable, safe and time-efcient, resulting

in total patient satisfaction. Peri-implant bone level was observed to be stable after early loading protocol for

both platform-switching connection implants inserted, despite the prosthetic protocol applied.

KEYWORDS

Dental implants; Prosthesis; Computer-aided design; Platform-switching; Bone loss; Patient satisfaction.

RESUMO

Objetivo: O presente relato de caso de boca dividida tem como objetivo descrever os resultados clínicos e

radiográcos a longo prazo da reabilitação com implante de dois pré-molares inferiores em que o uxo de

trabalho digital foi usado para aplicar os conceitos de “

one abutment-one time

” em uma das reabilitações e

troca de componente no outro. Descrição do caso: Paciente do sexo feminino, 42 anos, com ausência de ambos

os segundos pré-molares inferiores, foi submetida à cirurgia guiada para colocação de implantes de conexão

Grand Morse plataforma-switching. Foi utilizado uxo de trabalho digital para planejamento de implante e

prótese, aplicando protocolo de carga antecipada 21 dias após a cirurgia. O implante do lado direito recebeu o

componente protético denitivo no momento da cirurgia (sem carga), enquanto o implante do lado esquerdo

recebeu um cicatrizador, que foi substituído por um pilar provisório e depois por um componente denitivo.

Dois meses após a cirurgia, ambos os implantes tiveram restaurações cerâmicas nais entregues. A paciente foi

acompanhada clínica e radiogracamente por 30 meses, apresentando excelentes resultados de tecidos duros e

Braz Dent Sci 2023 Apr/June;26 (2): e3569

Yoshiyasu RH et al.

Peri-implant bone level assessment of early loaded dental implants submitted to different prosthetic protocols: a case report

Yoshiyasu RH et al.

Peri-implant bone level assessment of early loaded dental

implants submitted to diﬀerent prosthetic protocols:

a case report

INTRODUCTION

The use of the CAD-CAM technology in the

field of implant dentistry provides consistent

accuracy and reproducible outcomes by means

of digital designs and computer-aided production

of surgical guides and restorations [1,2].

Reduced intraoperative discomfort as well

as postoperative morbidity are some benefits

that have been associated with guided implant

surgery. This technique uses Cone Bean Computed

Tomography (CBCT), intraoral scanning and

virtual treatment planning to achieve optimal

implant positioning, regarding anatomical and

prosthetic parameters [3]. Moreover, this system

can be very helpful to reduce the time between

implant placement and loading, since it provides

better surgical predictability [4].

Another factor that reduces treatment time

is the immediate or early loading of implants,

that have been applied especially in cases of

good bone quality, providing enhanced esthetics

and function, with high implant survival rates.

The insertion of a prosthesis within 72 hours of

implant placement denes the immediate loading

protocol [5] whereas when implants are put into

function between 1 and 8 weeks after surgery,

it defines early loading [6].The reduction of

the healing period is not expected to result in

increased marginal bone loss or implant failure,

as reported in several studies [7,8].

Regarding marginal bone loss preservation,

the use of implants with platform-switching

conguration has already been reported as an ally

to achieve better long-term results [9]. Moreover,

the one abutment one time concept has been

introduced to avoid repeated dis/reconnection

of abutments - which can jeopardize peri-implant

tissue stability - thus maintaining all the platform-

switching advantages [10]. However, it is still not

clear if different prosthetic protocols really have

clinical signicance.

Therefore, the present split-mouth case report

aims to describe the clinical and radiographic

long-term outcomes of the implant rehabilitation

of two mandibular premolars in which the digital

workow was used to apply the concept of early

loading of dental implants while applying the

concept of one abutment at one time in one of the

rehabilitation and abutment removal in the other.

CASE DESCRIPTION

Surgical and prosthetic procedures

A female, 42-year-old patient, referred

to Ilapeo College (Curitiba, Brazil) with the

absence of both mandibular second premolars,

ASA 1, wishing for implant-supported prosthesis

rehabilitation (Figure 1). The patient gave written

consent, and the study was approved by the local

ethics committee (CAAE: 11965719.6.0000.5218)

under the protocol 3.367.313. Pre-operatory

intraoral scans and CBCT were obtained. The “.stl”

and DICOM files were then sent for virtual

planning on coDiagnosticX Software (Dental

Wings GmbH, Chemnitz, Germany) (Figure 2)

and, after surgeon´s approval, the surgical guide

was printed (Rapid Shape GmbH, Heimsheim,

Germany). Before surgery, the guide was tried-in

to verify its adequate seating (Figure 3).

Surgical procedure was performed by a

single operator and carried out under local

anesthesia (mepivacaine 2% with epinephrine

1:100.000) in order to avoid inferior alveolar

nerve lesion and to keep patient´s partial

sensibility. Stabilizing pins were screwed through

the sleeves into the implant connection with the

specic Guided Surgery Surgical kit for Helix

GM implants (Neodent, Curitiba, Brazil) to

increase guide stability. Each site was prepared

following the drill sequence recommended by

the manufacturer and 3.75x10mm platform-

switching Grand Morse connection implants (GM

moles, com alterações do nível ósseo inferiores a 2mm para ambos os implantes. Conclusão: O uxo de trabalho

digital e carregamento precoce, tornou a presente reabilitação implantossuportada previsível, segura e eciente

em termos de tempo, resultando em total satisfação do paciente. O nível ósseo peri-implantar foi observado

como estável após o protocolo de carregamento inicial para ambos os implantes de conexão plataforma-switching

inseridos, independente do protocolo protético aplicado.

PALAVRAS-CHAVE

Implantes dentários; Próteses; Desenho assistido por computador; Plataforma-switching; Perda óssea; Satisfação

do paciente.

Braz Dent Sci 2023 Apr/June;26 (2): e3569

Yoshiyasu RH et al.

Peri-implant bone level assessment of early loaded dental implants submitted to different prosthetic protocols: a case report

Yoshiyasu RH et al.

Peri-implant bone level assessment of early loaded dental

implants submitted to diﬀerent prosthetic protocols:

a case report

Helix Acqua, Neodent, Curitiba, Brazil) were

inserted in both, with a nal toque of 35 N.cm.

In order to evaluate peri-implant bone level

alterations regarding the one abutment one time

concept, the following protocol was applied: on

the implant of the left side, a GM Customizable

Healing Abutment (Neodent, Curitiba, Brazil)

was inserted and, on the one on the right side, a

3.5x6x1.5mm Titanium Base (Neodent, Curitiba,

Brazil) was placed and protected with a cement-

retained Zirconia Coping that had been planned

and milled previously to the surgery, without

loading (Figure 4). Antibiotics (Amoxicilin

Figure 1 - Patient´s initial aspects. A) Periapical x-ray, B) lateral and C) occlusal view showing the absence of teeth 35. D) Periapical x-ray, E)

lateral and F) occlusal view showing the absence of teeth 45.

Figure 2 - Implant and prosthetic digital planning on CoDiagnosticX Software. A) Occlusal view of digital planning. B) and C) lateral views of

digital planning.

Figure 3 - Surgical guide try-in to check adequate seating on

adjacent teeth.

Braz Dent Sci 2023 Apr/June;26 (2): e3569

Yoshiyasu RH et al.

Peri-implant bone level assessment of early loaded dental implants submitted to different prosthetic protocols: a case report

Yoshiyasu RH et al.

Peri-implant bone level assessment of early loaded dental

implants submitted to diﬀerent prosthetic protocols:

a case report

875mg) and pain relief medication (Ibuprophen

600mg) were prescribed.

Nineteen days thereafter, the GM Customizable

Healing Abutment of implant #35 was removed

and conventional impressions were obtained of

both regions, at implant (#35) and abutment

level (#45). After that, the healing abutment was

placed back on implant #35. At the 21

day after

surgery, early loading was applied on both implants

by means of insertion of Polymethyl methacrylate

(PMMA) acrylic resin prostheses – with centric and

eccentric occlusal contacts. For that, a 5.5x4.5mm

Pro Peek Abutment was inserted on implant

#35 and the Titanium Base maintained in place

on implant #45 (Figure 5).

Two months after surgery, a new intraoral

scanning was performed for the confection of

a printed model and final prostheses planning

(Figure 6). A 3.5.x6x1.5mm titanium base was

selected in order to replace the Pro Peek Abutment

on region #35 and a Zirconia coping was drilled.

Final prostheses were then delivered, and periapical

x-rays were taken (Figure 7). Prosthetic procedures

were performed by another clinician. A summary of

procedures sequence is shown on Figure 8.

Figure 4 - A) to D) Immediate clinical and radiographic conditions after implants and abutments insertion on region 35. E) to H) Immediate

clinical and radiographic conditions after implants and abutments insertion on region 45.

Figure 5 - A) View of prostheses occlusal points. B) and C) Lateral view of acrylic resin provisional rehabilitation on regions 35 and 45.

Braz Dent Sci 2023 Apr/June;26 (2): e3569

Yoshiyasu RH et al.

Peri-implant bone level assessment of early loaded dental implants submitted to different prosthetic protocols: a case report

Yoshiyasu RH et al.

Peri-implant bone level assessment of early loaded dental

implants submitted to diﬀerent prosthetic protocols:

a case report

Figure 6 - A) Printed model with analogue of implant 35. B) Customized zirconia coping on Tibase of region 35. C) Drilled copings of #35 and

#45. D) Final zirconia-ceramic crowns.

Figure 7 - A) and C) Frontal and occlusal view of ﬁnal protheses. B) and D) Periapical x-rays of rehabilitation of #35 and #45.

Braz Dent Sci 2023 Apr/June;26 (2): e3569

Yoshiyasu RH et al.

Peri-implant bone level assessment of early loaded dental implants submitted to different prosthetic protocols: a case report

Yoshiyasu RH et al.

Peri-implant bone level assessment of early loaded dental

implants submitted to diﬀerent prosthetic protocols:

a case report

Follow-up and outcomes

The patient was followed-up with visits at

6 ,12 (Figure 9) and 30 months (Figure 10) after

loading. Keratinized tissue width measurement with

a graded periodontal probe was performed [11],

and photographs were obtained by a third

clinician. Digital periapical x-rays were obtained

(Heliodent Plus, Dentsply Sirona, USA), using the

parallelism radiography technique to standardize

the images.

No complications were observed during

the follow-up period and both implants

presented clinical and radiographic success

by means of implant stability, absence of

signs of peri-implantitis, complete implant

osseointegration [12]. Regarding peri-implant

bone level, it was measured at mesial and

distal peri-implant bone levels closest to the

implant platform [13], using Sidexis XG version

2.6 software (Sirona, Bensheim, Germany). Mild

changes could be observed after loading, with

region 35 (abutment removal) presenting mean

bone loss of 1.8 mm and region 45 (one abutment-

one time) only 0.3 mm after 30 months. Soft tissue

evaluation revealed good outcomes [14] with

keratinized gingiva width of 1mm after denitive

prostheses placement and increasing to 2mm at

the 30-month follow-up visit. In addition, very

good soft-tissue esthetic outcomes were achieved

in the long-term, by means of maintenance of

harmonic interdental papillae shape and natural

form of gingiva margin [15].

Figure 8 - Summary of surgical and prosthetic procedures.

Braz Dent Sci 2023 Apr/June;26 (2): e3569

Yoshiyasu RH et al.

Peri-implant bone level assessment of early loaded dental implants submitted to different prosthetic protocols: a case report

Yoshiyasu RH et al.

Peri-implant bone level assessment of early loaded dental

implants submitted to diﬀerent prosthetic protocols:

a case report

Figure 9 - A) and B) Periapical x-rays of regions 35 and 45 at the

one-year follow-up.

Figure 10 - Clinical and radiographic aspects at 30-month follow-up

visit. A), B) and C) Occlusal and lateral view of regions 35 and 45. D)

and E) Periapical x-rays of #35 and #45.

Patient satisfaction

The Portuguese translation of OHIP–14 (Oral

Health Impact Prole) questionnaire [16] was

applied during screening visit, and the patient

reported she very often had trouble eating, relaxing,

felt self-conscious and that life was less satisfying

in general, because of her teeth problems. All that

resulted in an OHIP-14 score of 15.7, revealing

how unsatisfied she was with her initial oral

conditions. However, at the 12-month follow-up,

OHIP-14 score decreased to 0, showing patient´s

great satisfaction with treatment outcomes, which

remained at the 30-month follow-up.

DISCUSSION

New technologies and different approaches are

continuously applied in the dentistry eld to obtain

accurate, predictable, and time-efcient diagnosis,

planning and treatment [17]. In the present case

report, digital workow, guided surgery, platform-

switching, and one abutment-one time concepts

were combined along with early loading to provide

an efcient treatment to the patient and evaluate

differences regarding bone loss.

The guided surgery based on CBCT images

allows the ideal placement of implants according

to the planned restoration, surrounding anatomy

and principles of implant positioning and

spacing. This is known to enhance safety and

predictability when compared to freehand

technique, preventing undesiring adverse events

and reducing patient´s morbidity [4]. In the

present case, no adverse events such as excessive

bleeding, edema or pain was reported in the intra

or post-operative period.

Another factor that should be considered

when using surgical guides is the possibility of

overheating during implant site preparation, that

can culminate in bone loss. This phenomenon

can happen due to reduced access for adequate

irrigation [18]. In the post-operative periapical

images of the presented case, no signs of

overheating as early bone loss [19] can be

observed, since adequate drilling protocol and

irrigation were followed.

Regarding loading protocol, PMMA acrylic

provisional prostheses were inserted 21 days after

surgery, characterizing early loading, since both

implants achieved primary stability (35 N.cm) [20].

It has been reported that immediate or early

loading can only be successful when protheses are

Braz Dent Sci 2023 Apr/June;26 (2): e3569

Yoshiyasu RH et al.

Peri-implant bone level assessment of early loaded dental implants submitted to different prosthetic protocols: a case report

Yoshiyasu RH et al.

Peri-implant bone level assessment of early loaded dental

implants submitted to diﬀerent prosthetic protocols:

a case report

delivered without centric and eccentric occlusal

contacts [21]. In the present case, however,

provisional prostheses were inserted with occlusal

forces and osseointegration and, thus, implant

survival was not jeopardized. Furthermore,

PMMA presents durability, strength, high impact

toughness and resistance to the environment [22].

For the nal prostheses, zirconia was the chosen

material, since used it has been reported to be

successful for posterior restorations [23].

The soft tissue health was also evaluated

and presented good outcomes, which might be

related to the zirconia-based restoration that does

not affect soft tissues, corroborating with other

authors [24].

Another concern when applying immediate

or early loading, is extensive bone loss [25]. Thus,

platform-switched implants have been introduced

as a great alternative as they may present reduced

marginal bone loss even in one-stage procedures,

when compared to platform-matched implants [26].

Moreover, the non-removal of the abutment placed

at the time of implant insertion, known as one

abutment one time concept, has been reported to

help in maintaining peri-implant bone level [9,10].

This could be observed in the present case, since the

region in which the nal abutment was inserted at

the time of implant placement surgery presented

less bone loss than implant in which abutment

removal was performed during temporary and nal

prostheses confection process.

Nevertheless, neither implants presented

extensive bone loss and both were considered

successful, with bone level changes lower than

2mm, at the 30-month follow-up. Therefore,

although applying the one abutment one time

protocol seems benecial regarding bone level, it

may not be clinically relevant to the clinician nor

to the patient, as discussed by other authors [9].

Likewise, the need to replace the abutments may

not be critical to the stability of peri-implant bone

level, when implants with platform-switching

taper connection are used, corroborating with

previous results [8].

Regarding patient´s satisfaction with

treatment, the OHIP-14 questionnaire score

showed that the patient´s quality of life was initially

affected by her teeth problems, as reported in the

literature [27]. That, however, was completely

resolved with the implant-supported rehabilitation,

improving her quality of life in the long-term.

The difference regarding the prosthetic protocols

seemed to not affect patient´s perception.

Since this is a report of a single case, there

is a lack of ability to generalize the outcomes,

further controlled studies with larger samples

and blinded procedures are needed to provide

better evidence.

CONCLUSION

The use of digital workow and early loading,

made the present implant-supported rehabilitation

predictable, safe and time-efcient, resulting in

complete patient satisfaction. Peri-implant bone

level was observed to be stable both with and

without abutment removal. Therefore, platform-

switching connection implants seem to be able to

prevent extensive bone loss, despite of the prosthetic

protocol, of early loaded implants. The present

rehabilitation showed success, with excellent hard

and soft tissue outcomes in the long-term.

Author’s Contributions

RHY, CAC, SRB: Investigation. CPV: Writing

– Original Draft Preparation. WC: Writing –

Review & Editing LCT: Project administration and

Funding Acquisition. RMF: Conceptualization

and supervision.

Conict of Interests

The authors C.A.C., C.P.V., W.C., S.R.B., and

L.T.C. work for the company that provided the

devices. The authors R. H.Y. and R.M.F. declare

that they have no conict of interest.

Funding

The devices used in this case report was

provided by Neodent.

Regulatory Statement

This study was conducted in accordance with

all the provisions of the local human subjects

oversight committee guidelines and policies of

Local Human Research and Ethics Committee.

The approval code for this study is 3.367.313.

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Peri-implant bone level assessment of early loaded dental implants submitted to different prosthetic protocols: a case report

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Peri-implant bone level assessment of early loaded dental

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a case report

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Date submitted: 2022 July 08

Accept submission 2022 Oct 31

Waleska Caldas

(Corresponding address)

Neodent, Segurança Clínica, Curitiba, PR, Brazil.

E-mail: waleska.caldas@alumni.usp.br