A literature review on progressive loading

A. VERGARA - BUENAVENTURA1, M. VILLANUEVA2, J. P. MONTOYA2, G. MENDOZA - AZPUR2

1
Department of Periodontology, School of Dentistry, Universidad Cientifica del Sur, Lima, Peru
2
School of Dentistry, Universidad Cientifica del Sur, Lima, Peru
3
Department of Periodontology and Implantology, School of Dentistry, Universidad Cientifica del Sur, Lima, Peru

TO CITE THIS ARTICLE

Vergara - Buenaventura A, Villanueva M, Montoya JP, Mendoza - Azpur G. A literature review on
progressive loading. J Osseointegr 2019;11(3):513-518.

DOI 10.23805 /JO.2019.11.03.07

INTRODUCTION
ABSTRACT
Implant dentistry has become a predictable and
Aim The planning of implant-supported dentures can widely accepted option for patients with total or
become complex when the patient has low or poor quality partial edentulism (1,2). This treatment is based on the
of bone. Some studies suggest that excessive functional load osseointegration´s concept, which consists of the direct
or traumatic occlusion over dental implants placed in bone and close union between dental implant and bone
of poor quality and density may cause marginal bone loss surface without the interposition of any tissue (3,4).
and increase implant failure rate. In 1980, Misch proposed An important factor to evaluate the success in implant
the progressive loading of a dental implant. A protocol that therapy is the conservation of peri-implant bone
may produce a lower crestal bone loss compared to the (5) especially the bone crest, a critical area that can
conventional loading protocol, as well it may increase bone present physiological bone loss during the adaptation
density in poor quality areas. The aim of this review of the to occlusal forces (6) or due to overloading (7). The
literature was to update and summarize the progressive density of available bone is a determining factor when
loading protocol and to describe its benefits and its possible planning the surgical approach, healing time and time
effect on dental implant success. loading (8,9). Up to date, different loading protocols
Methods The following combinations of controlled terms have been established and investigated (10,11) because
(MeSH) and keywords were used: (“progressive loading”[All several authors have affirmed that when the implant
Fields] OR “progressive bone loading”[All Fields] OR is loaded and enters into function the risk of failure
“progressive bone load”[All Fields] OR “progressive load”[All increases (12,13).
Fields]) AND (“dental implants”[MeSH Terms] OR “dental Literature reports a higher failure rate in poor bone
implant”) quality and density (14,15) especially in bone types
Conclusion Within the limitations of this study, all authors III and IV(16,17) and when an implant is prematurely
concluded that PL produces less crestal bone loss and trends loaded into immature bone (7). For these cases, the
to high bone density around dental implants. Authors also progressive loading (PL) protocol is recommended (8).
support the idea that PL may stimulate bone growth and This concept supports the empirical idea that gradual
maturation and offer benefits in bone quality and density and loading causes bone maturation, improves density and
suggest the use of gradual loading especially in bones with bone quality, decreases crestal bone loss and early
low density. implant failure (18). Several studies have reported
success rates of more than 90% for immediate and
conventional loading protocols (19,20), but there are
gaps in the literature if the progressive loading protocol
produces changes in bone quality and density. There
are only few studies that have evaluated it in the long
term.
The aim of this review of the literature was to update
KEYWORD Bone density, Dental implants, Implant loading, and summarize the PL protocol and to describe its
Progressive loading osseodensification. benefits and its possible effect on dental implant
success.

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METHODS

Identification
A literature search on the PubMed, MEDLINE Paper identified Addtional records
trough the database found in the
and Cochrane Database was made to update the searching =90 other sources =0
concept of progressive bone load on dental implants.
The search included articles up to December 2018 and
Records Records excluded after
written in English. All levels of evidence (randomized

Screening
screened n=90 language filters n=3
controlled trials, prospective and retrospective studies,
case series and animal studies) were considered for Abstracts Records excluded from the
read =87 title and abstract n=61
possible inclusion.
The following combinations of controlled terms (MeSH)

Eligibility
and keywords were used: (“progressive loading”[All Full text assessed Full text
Fields] OR “progressive bone loading”[All Fields] OR for eligibility n=26 excluded =5
“progressive bone load”[All Fields] OR “progressive
load”[All Fields]) AND (“dental implants”[MeSH Terms]
OR “dental implant”) Articled

Included
The search identified 99 results and after applying included n=21
language filters and read title and abstracts only 21
relevant articles were included in this review Process
selection of articles to be included in this review is
shown in figure 1. FIG. 3 Process selection

RESULTS protocol in their studies (Table 1).

Payne et al. (27) conducted a study to clinically evaluate
Concept of progressive loading implant success in early and PL of 20 unsplinted conical
It was believed that osseointegration could only be Branemark implants of 10 edentulous patients with
achieved if no loads were applied to the implant for overdentures in the lower jaws. For immediate PL
periods of not less than 3-4 months in the mandible and following surgery, tissue conditioners in the patient’s
5 to 6 months in the maxilla (3,21). Authors concluded dentures were used. Radiographic marginal bone levels
that excessive functional load or traumatic occlusion were measured and individual stability was evaluated
might cause overstress leading to marginal bone loss using Periotest. On the conical implants, marginal bone
around dental implants.(12,13). Currently information was between limits of success, 0.22 mm (SD = 0.48 mm)
indicates that dental implants can be loaded immediately mesially and 0.30 mm (SD = 0.39 mm) distally. Periotest
after placement when there are adequate height and values did not show statistically significant levels.
bone density (22). But in bone types III or IV, a higher Anitua et al. (28) described a novel drilling technique
failure rate has been reported (16,17). for the treatment of severely atrophied mandible with
1993 In 1983 Misch (23) introduced the concept of PL in 1980 extra short implants supported by prostheses with
reference and indicated that bone could mature when tension PL. They used 2- stage drilling perforations for the
during the prosthetic phase increases gradually without visual control of the depth avoiding the injury of the
overloading the implant. Bone is slightly overloaded and mandibular nerve and acrylic provisionals supported
reacts by increasing its formation, growing denser and by screws. The study found an implant survival rate
improving its quality. of 98.2% and a mean marginal bone loss proximal to
This protocol uses transitional prostheses made of implants of 1mm without any prosthetic complications.
acrylic resin that minimally disturb the integration of the Arora et al. (29) recommended its use to prevent
implant-bone interface during the healing phase (24). microfractures during bone remodeling. In this study,
Esposito et al. (25) defined PL as the load of the implants they compare crestal bone loss and pocket depth
obtained by the gradual increase of the occlusal table around 80 platform-switched implants placed in the
height through increments from infraocclusion to maxillary anterior region (MAR) and in the mandibular
complete occlusion. posterior region (MPR). They found a significantly
In the study of Appleton et al. (26) infraocclusion was higher amount of bone loss in the MAR group. Pocket
defined while the subject was applying his maximum depths were significantly greater in palatal regions of
biting force and a piece of 0.015 mm thick shim stock the mandible (p = 0.01) and in distal regions in the
passed freely through the occlusal contact. maxilla (p = 0.002).

Observational studies Comparative studies

The literature shows that some authors use PL as a Animal studies: only one animal study by Podaropoulos

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 Progressive loading: a literature review

AUTHORS Payne et al. (2001)27 Falisi (2013)32 Anitua et al Arora et al (2015)29

(YEAR) (2013)28
STUDY TYPE Observational longitudinal Longitudinal Retrospective Observational longitudinal
study retrospective study study study
TREATMENT Cohort of 10 patients with Cohort of 11patients Loading period Group – ANT: single missing
GROUP(S) conical implants placed in ≤ 12 months tooth in maxillary anterior
the anterior mandible With Loading period region Group – post: single
mandatory primary stability >12 months missing tooth in mandibular
with bicortical anchorage and Posterior region)
ball abutment connection
PATIENTS 10 55-80 years old 11 72 58±9 years 80 25- 45 years
(N) / AGE
NO. OF 20 30 114 extra short – 80 Group – ANT: 40
IMPLANTS implants implants Group – POST: 40
implants
TYPE OF Conventional mandibular Provisional prosthesis Implant supported The first and second
RESTO- dentures temporarily relined prostheses in the Transitional prosthesis
RATION with tissue conditioner and posterior mandible in acrylic, and finally
worn with moderation for with progressive a porcelain-fused to
the first 2 weeks to allow loading metal crown as definitive
progressive loading. Early prosthesis for both groups
loading of the implants
followed 2 weeks.
ASSESSMENT Panoramic and lateral Implant Stability Cone beam CT Digital x- ray Pocket depths
TECHNIQUE cephalometric radiographs quotient(ISQ) by scans were recorded using plastic
Periotest resonance frequency Probes
X ray Cone beam CT
scans
IMPLANT Conical Branemark Implants 11.5 x 4mm Tekka Not specified 4×11.5 mm (GS-II, osstem,
SYSTEM implants (sand-blasted Seoul, south Korea)
And double acid etch)
FOLLOW UP 2, 6, 12, And 52 weeks. Of at least 12
0,6,12 months Isqt1= 6-month
months after
0 months ISQT2= 6
implant insertion.
months ISQT3= 12
6, 12 months -
months
anually
MEASURED Marginal bone 0.22 mm (SD Implants lost 2 Implant Implant survival Bone loss Group – ant: 40
OUTCOMES/ = 0.48 mm) mesially on the stability ISQ T0 vs ISQ rate 98.2% implants1.2 ± 0.3 Mm Group
RESULTS conical implants 0.30 mm (SD T1, z = 3.408 ISQ T0 vs Marginal bone – POST: 40 implants0.7
= 0.39 mm) distally on the ISQ T2, z = 7.016 ISQ loss proximal to ± 0.02 mm Pocket depth
conical implants T1 vs ISQ T2, z = 3.608 implants 1mm increase Group – ant: palatal
Critical z = 2.394 (mean) (p = 0.01) Group – POST:
distal (p = 0.002).

TABLE 1 Observational studies that included progressive loading as a loading protocol

et al. (30) was found. They evaluated bone reaction in table 3.

around dental implants to static PL. The study used In 2005, Appleton et al. (26) conducted a study to
controlled orthodontic forces on osseointegrated compare the effectiveness of PL versus direct load to
implants placed in 3 beagle dogs. preserve crestal bone loss and improving peri-implant
The percentage of bone-to implant contact in the bone density around dental implants supporting
PL group increased significantly (P = 0.018). No single tooth restorations after a healing period of 5
differences were found in crestal bone resorption months. They demonstrated that progressively loaded
between groups (P = 0.813) or in bone density 1mm (P group reported less crestal bone loss (0.2 ±0.27 mm)
= 0.734) or 2 mm (P = 0.961) distant to the threads. compared to conventional loading (0.59±0.27 mm).
Table 2 summarize animal studie.s These differences were statistically significant (P ≤
Comparative clinical studies: although this theory 0.05).
was based on empirical information, the efficiency of Ghoveizi et al. (18) performed a similar study but with
PL is supported by a few clinical prospective studies. a shorter healing period (2 months) and reported
The summary of prospective clinical studies is shown an increase in bone density when a PL protocol

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AUTHORS (YEAR) Podaropoulos et al (2015)30

STUDY TYPE Experimental study in animals
ANIMAL MODEL / n Beagle dogs/ 3
NO. OF IMPLANTS/ IMPLANT SYSTEM 24 OsseotitE surface and machined neck implants (Biomet 3i, Palm Beach Gardens, FL, USA).)
TREATMENT GROUP(S) Experimental group: 12 progressive Loading (PL) control group: 12 Unloaded (UL)
TYPE OF RESTORATION Abutments were adapted and connected by pairs with Ni-Ti orthodontic springs PL:A gradual static
force of 100, 200 and 300 g was applied for a 3-week period each. UL: left to heal undisturbed
ASSESSMENT TECHNIQUE Clinical, histologic and histo-morphometric
TORQUE INSERTION Not specified
FOLLOW UP 9-week loading period
MEASURED OUTCOMES/ RESULTS Bone-to-implant contactPL group exhibited significantly higher percentage (P = 0.018). Bone
density 1mm distant to the threads P = 0.734 Bone density 2mm distant to the threads P =
0.961 Crestal bone resorption (P = 0.813).

TABLE 2 Animal studies.

was used. They also found less crestal bone loss DISCUSSION
around progressively loaded implants (0.11mm)
when compared to the conventionally loaded group Benefits of the progressive loading
(0.36mm) after 12 months (P<0.05). On the other Crestal bone loss on conventional loading has been
hand, Turner et al. (31) used the Periotest to study reported between 0.9 to 1.6 mm after the first year of
implant mobility in the progressively loaded and implant placement and an annual average loss of 0.05 to
conventionally loaded group and recommended the 0.13mm. Crestal bone loss around progressively loaded
use of PL when there is poor bone quality. implants showed less bone loss than in conventionally
Falisi et al. (32) evaluated the stability of implants placed implants (18,26,33). Observational studies have
applied with fit lock method in upper maxillae with reported less marginal bone loss when used PL as a
bone availability less than 4 mm in 3 follow-up periods protocol (27,28) reporting survival rates of 98.2% and
(0, 6 and 12 months) finding that implant stability some authors recommend its use when the cortical
increased progressively over time after placement. A bone is very thin or even lacking (21,35).
significant difference was found between the three Different studies even have described that PL
follow-up periods. ISQ T2 was higher than ISQ T1 considerably improves the stability of the implant
and ISQ T1 was higher than ISQ T0 (p=0.000). They (31,32,34).
concluded that implants placed with this technique An important factor in deciding to use PL is the type of
in areas with poor bone availability showed a similar bone (bone quality) of the patient. Goodacre et al. (36)
stability as reported with other techniques. evaluated 7 studies to compare 3192 dental implants
Khorshid et al. (33) evaluated changes in the peri- placed into different types of bone. The results showed
implant supporting structures when comparing two implant loss in 16% of implants placed into type IV
different immediate loading protocols (functional bone and only 4% in types I to III. Based on this review,
and progressive). They found a more favorable bone Sheridan (37) suggested a solution based on the use of
reaction with a statistically significant difference PL of the implant in patients with poor bone quality
(P ≤ 0.009) in the buccolingual and mesiodistal (type IV).
surfaces of immediate implants. Juboori et al. (34)
measured implant stability during the healing period
and throughout the follow-up. The study showed CONCLUSIONS
significant differences between delayed loading and
immediate progressive loading implants (IPL). IPL Within the limitations of this study, all authors concluded
enhances soft and hard tissue maturation and implant that PL produces less crestal bone loss and trends to
stability. high bone density around dental implants.
Authors also support the idea that PL may stimulate
Systematic reviews bone growth and maturation and offer benefits in bone
In 2013 Esposito et al. (25) conducted a systematic quality and density and suggest the use of gradual
review to estimate success rates between different loading especially in bones with low density.
loading time protocols but when evaluated the
effects of direct loading versus PL immediate, early Acknowledgments
and conventional did not identify any trials to make The authors would like to thank our colleagues for
a conclusion. comments that greatly improved the manuscript.

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 Progressive loading: a literature review

AUTHORS Appleton Khorshid et al Ghoveizi et al Turner (2014)31 Juboori et al

(YEAR) et al (2005)26 (2011)33 (2013) 18 (2018)34
STUDY TYPE Prospective Prospective and Prospective Prospective and controlled Pilot study
and controlled controlled clinical randomized clinical study randomized
clinical trial trial controlled trial controlled
clinical trial
PATIENTS (n) 20 5 40.3 years 10 34-62 years 15 6
/ AGE average old
NO. OF 23 Experimental 30 Immediate 20 Experimental 25 Progressive loading 12 Delayed
IMPLANTS / group Functional group group (PL)=14 Conventional loading (DL)=
TREATMENT Progressive loading group Progressive Loading group (CL)= 11 6 Immediate
GROUP(S) loading (IFG)=15 loading (EG)= 10 progressive
Control group: Immediate Control group: loading group
Conventional Progressive Conventional (IPL)= 6
Loading loading group Loading (CG)=
(IPG)= 15 10
TYPE OF EG: screw IFG: acrylic resin EG: cemented PL: composite resin DL: Temporary
RESTORATION retained in full occlusal temporary heat provisional Restorations CL: crowns after
Provisional contact cured acrylic Porcelain fused to metal 4 months IPL:
restorations CG: IPG: acrylic resin resin crowns CG: (PFM) crowns. temporary
metal ceramic in metal ceramic plastic
Crown Crown abutment, and
light-cured
composite
crowns
ASSESSMENT X- ray Computer X- ray Computer Periotest X-ray
TECHNIQUE infraocclusion X- ray
TORQUE Not specified 30 N/cm At least 30 N/cm Not specified DL: more than
INSERTION 30 N/cm IPL:
less than 30
N/cm
IMPLANT HA - coated Screw Indirect Micro Thread- ANKYLOS implants SLA (Superline,
SYSTEM dental implant one-piece OsseoSpeed; (Dentsply Implants, Hanau, Dentium).
System implants Astra Tech, Germany)
(omnilocs or (ImplantDirect LLC Mölndal, Sweden
threadlocs, Spectra-System
calcitekInc., Dental Implants,
Carlsbad, CA, Calabasas Hills,
USA) CA)
FOLLOW UP 2, 4, 6, 9, and 12 4, 9, and 24 2, 4, 6, 8, and 12 0 and 45 days after 1, 2, 3 and 6
Months months Months cementation months.
MEASURED Crestal bone Crestal bone Crestal bone Periotest values in CL group Mean ISQ
OUTCOMES/ height loss Eg: height loss IFG: height loss EG: At day 0 and 45 Good value at
RESULTS 0.2 ±0.27mm A decrease in 0.11 (0.19) mm bone quality: -2.5/ -2.74 surgery, 1, 2,3
Cg: 0.59 ±0.27 the percentage CG: 0.36 (0.36) p = 0.0723 > 0.025 Poor and 6 months
Statistically change of the mm Statistically bone quality: -2.08/-1.38 DL: 57,-, - 69,
significant (P≤ crestal bone significant (P≤ p= 0.0211 < 0.025 decrease 76 IPL: 63,
0.05).Bone height in 0.05).Bone in rigidity was found to 73,75, 76, 79
density EG: buccolingual densityEG: trend be significantly lower in significant
higher bone and mesiodistal for higher bone poor bone quality Periotest differences
density gain surfaces (P≤ density but not values in PL group At day 0 between DL
in the crestal 0.011) Bone statistically and 45 Good bone quality: and IPL groups
area CG: trend density IFG: trend significant (P > -4.8/-5.6 p= 0.0143 < 0.025
for higher bone for decrease 0.05). Poor bone quality: -3.5
density gain at bone density in /-5.01p= 0.000264 < 0.025
the apex of The buccolingual Significantly increased
implants. and mesiodistal implant rigidity in both
surfaces. (P groups with progressive
≤0.009) loading. (P=0.001)
.
TABLE 3 Comparative clinical studies

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progressive and conventional loading on crestal bone loss and density

Conflict of interests in single dental implants: a randomized controlled trial study. J Dent
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