DIEM™ Immediate Occlusal Loading™ Guidelines ... - Dental-Depot

DIEM
Immediate Occlusal Loading
Guidelines
Mandibular Fully Edentulous
IOL Abutment
IOL Temporary
Cylinder
Provisional Restoration
IOL Restorative Components
OSSEOTITE NT Certain Implant
OSSEOTITE NT Implant

Table Of Contents
Introduction Page 2
Treatment Planning Considerations Page 3
IOL Product Chart Page 4
IOL Guidelines For Fully Edentulous Mandible
Standard Diameter 4.1mm implant platform Page 6
Icon Key:
OSSEOTITE NT Certain Internal
Connection Implant System:
OSSEOTITE ® External Hex
Connection Implant System:
OSSEOTITE NT Certain Internal
and OSSEOTITE External Hex
Connection Implant System:
1

Introduction
These guidelines were designed to serve as a reference
for the dental practitioner to utilize 3i implants and surgical
instruments in immediate occlusal loading of the fully
edentulous mandible.
Initially, occlusal loading of dental implants was governed
by a strict protocol. 1,2 Immediate occlusal loading of dental
implants in some cases in the 1960’s resulted in fibrous
encapsulation of the implants, implant mobility and loss of
implants. 3 There are significant differences between immediate
occlusal loading of dental implants and the immediate
restoration of dental implants without occlusal function.
Immediate occlusal loading requires multiple implants rigidly
splinted by a fixed prosthesis. Immediate restoration of dental
implants can be accomplished with single implants, but the
restorations are contoured to have no occlusal contact in
centric occlusion, lateral working or balancing movements.
Authors have reported favorable results on immediate loading
of dental implants. In 1997, Tarnow et al reported 98%
cumulative survival rates (CSR) 1 to 6 years post-implant
treatment. 4 In 2000, Cooper et al reported 98% CSR 18 months
post-implant treatment. 5 Testori et al (2003) reported one
failure, due to infection, in a study involving 92 OSSEOTITE ®
Implants that were immediately loaded with fixed prostheses
in edentulous mandibles. Testori et al reported a CSR for
OSSEOTITE Implants of 98.9%, which was achieved for up to
48 months of follow-up. 6 The prosthetic cumulative success
rate for the same period was 100%. 6
DIEM, the latin word for day, has been chosen by 3i as the
name for our initiative to incorporate immediate loading
procedures into your practice. Evidence based research will
drive the development of clinician driven guidelines for each
type of immediate loading procedure. This initiative by 3i is
divided into 4 phases:
1. Immediate occlusal loading of the fully edentulous mandible.
2. Immediate occlusal loading of the fully edentulous maxilla.
Immediate non-occlusal loading of the partially edentulous
mandible/maxilla.
3. Immediate occlusal loading of the partially edentulous
mandible/maxilla.
4. Immediate non-occlusal loading of the single tooth implant.
The following DIEM Guidelines for the fully edentulous
mandible have been developed for clinicians by consensus
from a peer leading group of implant surgeons and restorative
dentists. It is intended to provide clinicians interested in
treating patients with Immediate Occlusal Loading (IOL),
using 3i OSSEOTITE Implants and IOL Components, with
guidelines relative to patient selection, diagnostic work-ups,
surgical parameters and restorative techniques. The guidelines
illustrate the use of OSSEOTITE NT Implants and a new line
of IOL Abutments and IOL Cylinders that were designed for this
treatment concept. The guidelines have been specifically
developed to emphasize simplicity and flexibility in multiple
clinical situations. Patients may be edentulous or dentulous
on the day of surgery. If they are edentulous, implants can be
placed crestally or sub-crestally. If the patient presents with a
hopeless mandibular dentition, the teeth will be extracted and
an alveolectomy performed in order to obtain optimal surgical
sites for implant placement. In addition, it is the responsibility
of the implant clinician to determine the benefits and
limitations of a particular treatment protocol for each patient.
DIEM Guidelines are intended to serve as a roadmap to
immediate loading. Once the doctor has become comfortable
performing immediate load procedures they may take a variety
of personally selected detours to enhance their technique.
There are two main objectives to Phase 1 of the DIEM Guidelines:
1. To create a full-arch, fixed, implant-supported provisional
restoration for the immediate occlusal loading of an
edentulous mandible.
2. To create a full-arch, fixed, implant-supported provisional
restoration for the immediate occlusal loading of a partially
edentulous mandible, which is to be rendered fully
edentulous as part of the IOL procedure.
Before
After
A determination needs to be made prior to performing an
immediate loading procedure; (1) are the surgical and prosthetic
procedures to be rendered in the same office or (2) is the
patient moving from the surgical office to the prosthetic office.
If the patient is to move between offices, coordination of
appointments is critical.
2

DIEM
Immediate Occlusal Loading
Guidelines
Mandibular Fully Edentulous
PRE-TREATMENT DIAGNOSTICS:
(Surgeon, Restorative Dentist And Laboratory Technician)
• Medical work up
• Clinical and radiographic evaluation
(1) Periapical X-rays
(2) Panoramic X-rays
(3) CT Scans
• Pre-prosthetic evaluation, articulated casts with record
of vertical dimension
• Verified wax try-in(s) set to 1st molar occlusion if
implants will only be placed between the mental foramina
(if a provisional denture is made)
• Measure gingival thickness. This will facilitate IOL
abutment selection
TREATMENT INDICATIONS:
• Adequate bone quality equal to or greater than Type III
• Bone height equal to or greater than 12mm
to allow for a minimum 10mm implant
• Bone width equal to or greater than 6mm
to allow for a minimum 4mm diameter implant
• Adequate curvature of the arch and space between
mental foramina to permit proper anterior/posterior
spread measurement will allow functional cantilevers
to first molar occlusion
TREATMENT CONTRAINDICATIONS:
• Health complications
• Para-functional habits
• Poor bone quality - Type IV (not able to achieve
primary stability)
• Limited curvature of the arch and space between mental
foramina (will not allow good anterior/posterior spread
measurement to achieve functional cantilevers to 1st
molar occlusion)
• Bone height less than 12mm
• Bone width less than 6mm
A/P SPREAD DEFINED:
• The A/P, or anterior/posterior, spread measurement is a
formula used to calculate the maximum indicated cantilever
length off the posterior-most implant on a fixed restoration.
It is calculated by measuring the distance between two
parallel lines, one drawn across the distal of the posteriormost
implants and one drawn through the center of the
anterior-most implant, and multiplying the result by 1.5. 7
Distal of Posterior-Most Implants
A/P x 1.5 = Cantilever
Center of the Anterior-Most Implant
3

IOL Product Chart
IOL ABUTMENTS:
For 4.1mm Platform 3i Implants
CERTAIN IOL ABUTMENTS
Description:
• Two-piece non-hexed (external hex)
• One-piece non-hexed (Certain)
• Titanium alloy
Diameter:
• 4.1mm platform
• 4.5mm abutment collar diameter
Collar Heights:
• 2.0mm
• 3.0mm
• 4.0mm
• 5.5mm
• 7.0mm
Instrumentation:
• PAD00 or PAD24 abutment driver
• RASA3 abutment driver tip
Abutment Screw Recommended Torque:
• 20Ncm
IOL TITANIUM TEMPORARY CYLINDER:
Description:
• Titanium alloy
• Knurled surface to aid in mechanical locking of acrylic
to cylinder
• Notch at bottom of cylinder retains the rubber dam
and inhibits dam movement
• Trimmed with a carbide cross-cut bur
• Secured with a hex Gold-Tite Retaining Screw (GSH30)
(An abutment waxing screw [WSK10] may be used
during luting.)
Height:
• 10mm
Instrumentation:
• PHD02N or PHD03N large hex driver
• RASH3N or RASH8N large hex driver tip
Retaining Screw Recommended Torque:
• 10Ncm
IIOL20T
2mm
IOL20T
2mm
IIOL30T
3mm
IOL30T
3mm
IOL ABUTMENTS
4.5mm
4.1mm
IIOL40T
4mm
IOL40T
4mm
IIOL55T
5.5mm
EXTERNAL HEX IOL ABUTMENTS
(Two-piece)
H
IOL55T
5.5mm
IIOL70T
7mm
IOL70T
7mm
IOL TEMPORARY CYLINDER
AND HEX RETAINING SCREW
IOLTC
GSH30
(GSH30 and IOLTC are packaged separately.)
4

IOL DISTAL EXTENSION:
Description:
• Titanium alloy
• Placed on the two posterior-most temporary cylinders
• Provides up to 8mm of distal support for provisional
denture cantilevers
• Length may be adjusted when necessary with carbide
cross-cut bur
• Retained in place with acrylic resin
3.2mm
IOL DISTAL EXTENSION
7.9mm
IOL HEALING CAP:
Description:
• One-piece
• Titanium alloy
• Height 4.3mm
IOL IMPRESSION COPINGS:*
Pick-Up Impression Coping
Description:
• Two-piece (coping and guide pin)
• Stainless steel
Transfer Impression Coping
Description:
• One-piece
• Stainless steel
IOL ANALOG:*
Description:
• Replicates IOL Abutment
• Stainless steel
GOLD CYLINDERS:*
Description:
• Used for definitive framework
• Gold/palladium alloy
• Secured with a hex Gold-Tite Retaining Screw (GSH30)
IOL HEALING CAP
4.3mm
2.8mm
4.5mm
IOLHC
IOL PICK-UP
IMPRESSION
COPING
IOLDE
IOL TRANSFER
IMPRESSION
COPING
IOL GOLD CYLINDER
WITH SLEEVE
3.9mm
4.5mm
IOLGC
IOL ANALOG
*Indicates prosthetic components to be used for definitive restoration.
IOLPIC
IOLTIC
IOLLAS
5

DIEM
Immediate Occlusal Loading
Guidelines
Mandibular Fully Edentulous
OSSEOTITE NT Certain
1. PRE-OPERATIVE
A. Surgeon
Order 4mm diameter OSSEOTITE NT or OSSEOTITE NT Certain
Implants in lengths determined during treatment planning.
OSSEOTITE NT
10mm 11.5mm 13mm
Distal Extension
Gold-Tite retaining screw
IOL Temporary Cylinder
IOL Abutment
or
Certain External Hex
B. Surgeon Or Restorative Dentist
• Order IOL Abutment Components.
• Other required materials:
Light to medium rubber dam and punch
Impression adhesive
Impression bite putty (Blue Mousse)
Heavy body impression putty
Equipment to polish acrylic
Syringe for acrylic resin
Dappen dishes
Small paint brushes
Cross-cut carbide bur for titanium
Acrylic resin (hard autopolymerizing or light cure)
Acrylic bur
Articulating paper
• Instruments needed:
Abutment Driver (PAD00 or PAD02)
Abutment Driver Tip (RASA3)
Large Hex Driver (PHD02N or PHD03N)
Large Hex Driver Tip (RASH3N or RASH8N)
Torque Device
Surgical Kit
C. Restorative Dentist And Laboratory
• Fabricate a surgical guide stent by duplicating the patient’s
existing denture in clear acrylic resin.
OR
• Using an immediate or provisional denture, fabricate
surgical guide stent in clear acrylic resin from the wax try-in.
OR
• The immediate or provisional denture may be used as
the surgical guide stent.
6

D. Prepare Surgical Guide Stent
• Drill guide holes in the clear guide stent or provisional
denture from 1st premolar to 1st premolar where 5-6
implants will be positioned between the mental foramina
to achieve a good Anterior/Posterior (A/P) spread and
provide cross arch stabilization.
• Open the lingual side of the surgical guide stent using an
acrylic bur.
• Placement beyond the mental foramina is okay if there is
adequate bone.
E. Prepare Immediate Or Provisional Denture
• Process the immediate or provisional denture in acrylic
resin from the wax try-in. Make the denture a little thicker
buccolingually than usual for the prosthesis. This will
provide additional strength to the prosthesis.
• Relieve the denture approximately 8mm beyond the
posterior-most implant locations and to the proper depth
if distal extensions are used.
2. SURGERY AND IMPLANT PLACEMENT
A. Try-in Of Denture And Surgical Stent
• If the patient is partially edentulous, cut all remaining teeth
off at gingival crest.
•Verify that the opposing occlusion is stable. If necessary,
add denture adhesive.
• Place adhesive bilaterally in free-end saddle areas of
denture and surgical guide stent.
• Add thin layers of bite registration material to free-end
saddle areas of denture and have patient bite to place. This
will ensure a stable and reproducible seat for the denture.
• Place adhesive bilaterally on occlusal surfaces of
posterior teeth on the denture.
• Place bite registration material on posterior occlusal
surfaces on the denture. Return denture to position and
have patient occlude in maximum intercuspation. This will
produce a stable and reproducible occlusal position.
• Repeat the above process for the surgical stent.
Clinical Tip: Some surgeons prefer to have the bite
registration for the stent recorded in protrusive to improve
access for implant site preparation and implant placement.
• Remove denture(s).
7

DIEM
Immediate Occlusal Loading
Guidelines
Mandibular Fully Edentulous
B. Ridge Preparation
• Make a mid-crestal incision extending along the ridge and
continue beyond the mental foramina, where a releasing
incision is made buccal to lingual. If the patient is partially
edentulous, extend the incision sulcularly around the
remaining roots.
• Visually locate the mental foramina and alveolar nerve
bundles and separate flap 5-10mm beyond this landmark.
• On the alveolar ridge, with a round bur, mark the location
of the inferior alveolar nerve as it exists the mental
foramina for landmarks.
• If the patient is partially edentulous, extract the residual
tooth roots at this time.
• Reduce uneven bone contours to create a level plane.
C. Surgical Placement Of OSSEOTITE NT
Or OSSEOTITE NT Certain Implants
• Position the guide stent in the mouth by seating it on the
retromolar pads and placing the buccal and lingual flanges
in the vestibules as positioning guides.
• Place anterior-most implant first followed by the two
posterior-most implants. Next, split the difference
between the anterior and posterior implants and place
the final implants.
• Place implants using the OSSEOTITE NT Drilling Sequence
for crestal or sub-crestal placement to achieve adequate
primary stability for immediate loading.
NOTE:
When placing External Hex Implants do not remove the
implant mounts at this time.
D. Immediate Load Determination
• Place the IIPDTS or IIPDTL placement driver (for Certain)
or a MDR10 hand-piece connector (for external hex) in a
torque device.
• Apply forward torque of 20Ncm to each implant to
check stability.
• If the implant does not move and is stable in the bone, the
implant may be immediately loaded.
• If the implant moves and does not feel stable in the bone, the
implant should not be immediately loaded. A single or twostage
surgical technique may be used on a non-loaded implant.
• Immediate Occlusal Loading ideally includes all implants in
the arch. However, if at least 4 implants are determined to
be stable, the provisional prosthesis may be attached to
and supported by them while the others are not loaded.
8

E. For External Connection Implants
• Remove all mounts from the external hex implants.
F. Select And Place IOL Abutments
• Select an IOL Abutment height for each implant so that the
interface will be 1-2mm above the level of the gingiva. The
abutment platforms should be as level as possible.
• Place an IOL Abutment on each implant using the
Abutment Driver.
• Torque the abutment screws to 20Ncm using the Abutment
Driver Tip and a torque device.
G. Suture Gingiva
• Suture the gingival tissue closed around the IOL Abutments
using resorbable suture.
• If the patient is to be sent to the restorative dentist, place
the IOL Healing Caps on the abutments using the large
hex driver.
9

DIEM
Immediate Occlusal Loading
Guidelines
Mandibular Fully Edentulous
3. RESTORATIVE
A. Surgeon Or Restorative Dentist
Provisional Restoration
• Cut a piece of rubber dam to follow the anterior arch curve.
• Cut holes at the implant locations using a rubber dam
punch so it fits over the abutments.
• Adapt the rubber dam to the ridge where acrylic will be
added into the denture. This will separate the surgical and
prosthetic fields.
• Fill the anterior portion of the denture with heavy bodied
impression putty.
• Articulate the lower denture with the opposing using the
bite registration and have the patient close onto the IOL
Abutments. Allow the putty to set.
• Remove the denture(s) and drill holes in the provisional
denture at the abutment locations. Drill each hole to the
approximate diameter of the temporary cylinders.
B. Place IOL Temporary Cylinders
• Place the IOL Temporary Cylinders on the abutments
and attach using hand tightened hex Gold-Tite
retaining screws.
• Reposition the rubber dam into the grooves of the IOL
Temporary Cylinders (see insert).
C. Place IOL Distal Extensions
• If you are using the distal extensions, slide the distal
extension support bars over the two posterior-most
temporary cylinders and position them so they will support
the distally extended posterior teeth (see insert).
• Apply a small amount of acrylic resin around the distal
extensions to hold them in proper position.
10

D. Adjust The Denture
• Try in the provisional denture over the temporary cylinders
and distal extensions.
• Relieve the acrylic resin at the cylinder and distal extension
locations as needed so the denture passively seats on the
edentulous ridge and retromolar pads.
E. Verify Occlusion
• Evaluate the occlusion to verify that there is no interference
with the cylinders and the denture is fully seated. If one or
more cylinders interferes, reduce its height only enough to
clear the opposing occlusion at this time. Do not prepare
the cylinder flush with the denture at this time unless the
occlusion requires it.
• Place access hole filler (cotton, wax, etc.) inside the
cylinders to prevent acrylic resin from entering the
access openings.
F. Lute Denture To Temporary Cylinders
• Mix hard autopolymerizing acrylic resin and place in
a syringe.
• Place the acrylic resin inside the denture relief area and
into the retention groove around the temporary cylinder
on the anterior-most implant.
• Have the patient close into the established vertical using
the bite registration to verify the denture is in the correct
position. Maintain centric occlusion while the acrylic resin
is setting.
• Allow the acrylic resin to set per the manufacturer’s
instructions.
• Remove the access hole filler from the luted cylinder and
remove the hex screw.
• Continue with luting all other cylinders into the denture.
11

DIEM
Immediate Occlusal Loading
Guidelines
Mandibular Fully Edentulous
G. Remove Denture From Mouth
And Reduce Cylinders
• Remove all access hole filler from the temporary cylinders.
• Unscrew the retaining screws and remove the denture
from the abutments.
• Remove the rubber dam from the mouth.
• Using a carbide cross-cut bur adjust the heights of the
cylinders to conform with the lingual surface of the denture.
H. Modify Denture Into Fixed Provisional
Restoration
• Place polishing protectors onto the cylinder interfaces.
• Add acrylic resin to any areas with voids.
• Verify the stability of the cylinders.
• Using an acrylic bur remove all flanges, the acrylic resin
on ridge contact areas and all excess acrylic from the
bottom of the denture between the cylinders and posterior
of the first molars.
• Remove the polishing protectors.
I. Adjust Occlusion
• Place the provisional restoration on the IOL Abutments
and attach using retaining screws until finger tight.
• Adjust the occlusion using articulating paper into group
function to ensure even distribution of support, minimizing
lateral forces.
• Mark any areas where acrylic may be contacting the tissue.
• Remove the provisional restoration.
12

J. Polish The Fixed Provisional Restoration
• Place polishing protectors onto the cylinder interfaces.
• Relieve any marked areas.
• They are in place! Polish the entire provisional denture
so surfaces are smooth.
• Remove the polishing protectors.
K. Seat The Fixed Provisional Restoration
• Place the provisional denture back onto the IOL Abutments
and attach using the Hex Gold-Tite Retaining Screws.
•Torque the screws to 10Ncm using the large hex driver tip
and a torque device.
L. Complete Fixed Provisional Restoration
• Place a protective material over the screw heads, seal
the access holes with acrylic resin and polish.
• The provisional denture should not be removed or
loosened during the following six weeks.
• Instruct the patient on hygiene care of the
provisional restoration.
• Place the patient on a soft diet for two weeks.
• Patient should be seen after two weeks for follow-up.
13

M. Final Impression For Definitive Restoration
• The final impression of the definitive restoration may be
made 4-6 weeks after the surgical appointment.
• Refer to the 3i Restorative Manual for instructions on
fabrication of the definitive restoration.
This manual will instruct practitioners in the use of 3i’s implant systems. The success of any dental implant system depends upon proper use of the components and
instrumentation. This manual is not intended for use as a substitute for professional training and experience.
1. Branemark, P.I., Hansson, B.O., Adell, R., Breine, U., Lindstrom, J., “Osseointegrated implants in the treatment of the edentulous jaw: experience from a 10-year period.” Scand J Plast Reconstr Surg 1977; 2 (Suppl 16): 1-132
2. Albrektsson, T., Zarb, G.A., Worthington, P., Eriksson, A.R., “The long-term efficacy of currently used dental implants: a review and proposed criteria for success.” Inter J Oral Maxillofac Implants: 1986; 1: 11-25
3. Linkow, L., Charchee, R.,“Theories and Techniques of Oral Implantology.” St. Louis: Mosby: 1970; 1: 74-76
4. Tarnow, D., Emtiaz, S., Classi, A., “Immediate loading of threaded implant at stage I surgery in edentulous arches: ten consecutive case reports with 1 to 5 year data.” Inter J Oral Maxillofac Implants: 1997; 12: 319-324
5. Cooper, L.F., Rahman, A., Moriarty, J., Chafee, N., Sacco, D., “Immediate mandibular rehabilitation with endosseous implants: simultaneous extraction, implant placement and loading.” Inter J Oral Maxillofac Implants: 2002; 17: 517-525
6. Testori, T., Del Fabbro, M., Szmukler-Moncler, S., Francetti, L., Weinstein, R., “Immediate occlusal loading of osseotite implants in the completely edentulous mandible.” Inter J Oral Maxillofac Implants: 2003; 18: 544-551
7. English, C. E.,” The critical A-P Spread” The Implant Society: 1990; Mar-Apr; 1 (1): 2-3
Implant Innovations, Inc.
Global Headquarters
4555 Riverside Drive
Palm Beach Gardens, FL 33410
1.800.342.5454
Outside U.S.: + 561.776.6700
Fax: + 561.776.1272
www.3i-online.com
3i, design and OSSEOTITE are registered trademarks and OSSEOTITE NT, Diem, IOL,
Immediate Occlusal Loading, Gold-Tite and Certain are trademarks of Implant
Innovations, Inc. © 2003 Implant Innovations, Inc. All rights reserved.
ART860
Rev. A 11/03
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