Richard S.

Appleton A radiographic assessment of

Pirkka V. Nummikoski
Mark A. Pigno
progressive loading on bone around
Robert J. Cronin single osseointegrated implants in
Kwok-Hung Chung
the posterior maxilla

Authors’ affiliations: Key words: dental implant, progressive loading, radiographic assessment
Richard S. Appleton, Private Practice, Baton Rouge,
LA, USA
Pirkka V. Nummikoski, Department of Dental Abstract
Diagnostic Science, University of Texas Health Objectives: The aim of this clinical study was to determine the effectiveness of progressive
Science Center at San Antonio, San Antonio, TX,
USA loading procedures on preserving crestal bone height and improving peri-implant bone
Mark A. Pigno, Robert J. Cronin, Kwok-Hung density around maxillary implants restored with single premolar crowns by an accurate
Chung, Department of Prosthodontics, University
longitudinal radiographic assessment technique.
of Texas Health Science Center at San Antonio, San
Antonio, TX, USA Materials and methods: Twenty-three HA-coated, endosseous dental implants were placed
Kwok-Hung Chung, Institute of Oral Biology, in 20 subjects and permitted to heal for 5 months before surgical uncovering. The implants
National Yang-Ming University, Taipei, Taiwan &
Dental Department, Kaohsiung Veterans General were randomly assigned to either an experimental or control group. Following a
Hospital, Kaohsiung, Taiwan conventional healing period, the control group implants were restored with a metal ceramic
Correspondence to:
crown and the experimental group implants underwent a progressive loading protocol. The
Prof. Kwok-Hung Chung experimental group was progressively loaded by increasing the height of the occlusal table in
Institute of Oral Biology increments from a state of infraocclusion to full occlusion by adding acrylic resin to a heat-
National Yang-Ming University
No. 155 Li-Nong St, Section 2 processed acrylic crown. The progressively loaded crowns were placed in infraocclusion for
Taipei 11221 the first 2 months, light occlusion for the second 2 months, and full occlusion for the third
Taiwan
Tel.: 886-2-2826-7028
2 months. At this point, a metal ceramic crown replaced the acrylic crown. Standardized
Fax: 886-2-2826-4053 radiographs of each implant were made at the time of restoration, then after 2, 4, 6, 9, and 12
e-mail: chungkh@ym.edu.tw or months of function. Digital image analysis and digital subtraction radiography were used to
chungk@uthscsa.edu
measure changes in crestal bone height and peri-implant bone density.
Results: The mean values of crestal bone height loss at 12 months were 0.2
0.27 mm for
the progressively loaded implants and 0.59
0.27 for the conventionally loaded implants,
and when tested with repeated-measure ANOVA across the time periods, the differences
were statistically significant (P  0.05). The progressively loaded group showed a trend for
higher bone density gain in the crestal area than the conventionally loaded group, but the
conventionally loaded group showed a trend for higher bone density gain at the apex of
the implants.
Conclusion: The peri-implant bone around progressively loaded implants demonstrates less
crestal bone loss than the bone around implants placed conventionally into full function.
The peri-implant density measurements of the progressively loaded implants show
continuous increase in peri-implant bone density by time.
Date:
Accepted 25 February 2004

To cite this article:

Appleton RS, Nummikoski PV, Pigno MA, Cronin RJ,
Chung K-H. A radiographic assessment of progressive
loading on bone around single osseointegrated implants
in the posterior maxilla.
Clin. Oral Impl. Res. 16, 2005; 161–167
doi: 10.1111/j.1600-0501.2004.01089.x
Copyright r Blackwell Munksgaard 2004
After the osseointegration healing period is
completed and the abutment connection is
made to an implant, the implant is placed
into function. It is at this time that the
implant is most at risk of failure (Adell
et al. 1981; Ericsson et al. 2000). Roberts
et al. (1989) have attributed this to prema-
ture loading of the immature bone beyond
its stress-bearing capacity. Other factors
that could lead to implant failure are poor
oral hygiene, non-passive superstructures,
partially retained restorations, poor bone

161
Appleton et al . Radiographic assessment of progressive loading
quality and quantity, inadequate osseoin-
tegrated surface area, and other biomechan-
ical factors that adversely effect the stress
exerted on the bone–implant interface
(Misch 1999a). The bone at the alveolar
crest is a high stress-bearing area and when
overloaded it is subject to cervical cratering
or ‘saucering’. This phenomenon is a com-
mon prelude to the failure of an implant
(Roberts et al. 1989). The poorer load-
bearing characteristics of lesser qualities
of bone means that the probability of over-
load through dental implants increases as
bone quality decreases, and indeed, this
fact is evidenced by decreasing success
rates of implants with decreasing bone
quality (Adell et al. 1981).
The concept of progressive loading arose
in 1980 based on empirical information
supporting the idea that gradual loading or
stimulation will allow bone to mature and
grow denser and improve in quality (Misch
1999b). Greater density equates to greater
strength and thus the ability to tolerate
greater forces and permit successful im-
plant prosthetic treatment (Skalak 1983;
Roberts et al. 1987; Rice et al. 1988).
Roberts et al. (1989) and Misch (1999b)
described progressive loading protocols that
generally controlled the load on a dental
implant by controlling the size of the
occlusal table, the direction and location
of the occlusal contacts, the absence of
cantilevers, and the firmness of the diet.
While there has been much attention
given to the concept of progressive loading
of dental implants, there has been little
direct scientific evidence supporting its
effectiveness. One pilot study utilizing
the Periotest (Siemens AG, Bensheim,
Germany) concluded that implant rigidity
in bone is enhanced by progressive loading
(Rotter et al. 1996). There is no scientific
data assessing the effectiveness of progres-
sive loading in reducing alveolar crestal
bone loss and increasing bone density
around endosseous dental implants. More
recently, Barone et al. (2003) used a volu-
metric radiographic assessment to analyze
and to compare the bone density around
immediately loaded and unloaded im-
plants. They concluded that the measure-
ments of the densitometric profile for bone
density was an acceptable method and
could reduce the need for histological
analysis from human biopsy in implant
study.
162 | Clin. Oral Impl. Res. 16, 2005 / 161–167
The objective of this in vivo prospective
randomized controlled trial is to determine
the effectiveness of progressive loading pro-
cedures on maxillary dental implants re-
stored with single crowns. To achieve this
objective, two specific outcomes were eval-
uated in this study:
(1) To compare alveolar crestal bone
height changes, using digital image
analysis of standardized radiographs,
in progressively loaded and non-
progressively loaded single dental im-
plants placed in the maxillary bicuspid
area of human subjects.
(2) To compare peri-implant bone density
changes, using digital subtraction radio-
graphy of standardized radiographs, in
progressively loaded and non-progres-
sively loaded single dental implants
placed in the maxillary bicuspid area
of human subjects.
Materials and methods
Twenty subjects selected for this pros-
pective and controlled clinical study were
randomly assigned into either a control or
an experimental group. The selection cri-
teria for this study was limited to subjects
with single or bilateral missing maxillary
premolars and opposing occlusion by nat-
ural teeth or a tooth-borne fixed partial
denture. A health history questionnaire,
oral examination, radiographic examina-
tion, and a patient interview determined
the suitability of subjects for the study. The
study protocol was explained in detail to all
patients and they were asked to sign the
consent forms. All the subjects in this
study had implants placed in the maxillary
bicuspid region to control for location as
a factor in the results. Three subjects
had maxillary implants placed bilaterally.
These subjects had one implant assigned to
the experimental group and one to the
control group. The control group received
metal ceramic permanent restorations with
metal occlusal surfaces immediately after
uncovering of the dental implant and soft
tissue healing. The experimental group
underwent progressive loading of the dental
implant. All implants in the study had
standardized radiographs taken at a base-
line point and at predetermined intervals to
assess bone changes around the implants.
Bone changes around the implants in each
group were assessed for 1 year and com-
pared for differences.
A hydroxyapatite-coated dental implant
system (Omnilocs or Threadlocs, Calci-
tek Inc., Carlsbad, CA, USA) was used for
the study. Implant placement was per-
formed in the Oral and Maxillofacial Sur-
gery Clinic at the University of Texas,
Health Science Center at San Antonio
(UTHSCSA) according to the protocol re-
commended by the manufacturer. The
implants were placed with the help of a
surgical template; after insertion, all im-
plants showed a good primary stability. All
implants in this study underwent a 5-
month osseointegration healing period be-
fore the second stage surgery to uncover the
implants. After uncovering, a minimum
2-week soft-tissue healing period was al-
lowed before prosthetic procedures were
begun. All provisional restorations were
screw retained and fabricated indirectly
with heat-curing resin (Justis resin, Amer-
ican Tooth Industries, Oxnard, CA, USA).
Progressive loading of the implants was
done in four prosthodontic stages as
follows:
(1) During the first 2-month period, the
implant was restored with the resin
provisional crown placed into infraoc-
clusion (Fig. 1a, b). Infraocclusion was
defined as a piece of 0.015 mm thick
shim stock passing freely through the
occlusal contact region with no resis-
tance while the patient was applying
maximum biting force in this study.
The patient was placed on a soft diet
during this period.
(2) After 2 months, the occlusion of the
restoration was adjusted into light
contact. This was determined by a
piece of 0.015 mm plastic shim stock
being pulled through the occlusal con-
tact with resistance while the patient
was applying maximum biting force
(Fig. 1c). The occlusion on the dental
implant restoration provided only axi-
ally directed forces over the implant
body, and the patient was permitted a
firmer diet.
(3) After 4 months, the provisional re-
storation was adjusted into full occlu-
sion. While the patient was applying
maximum biting force, it was not
possible to pull a piece of 0.015 mm
plastic shim stock through the occlu-
 Appleton et al . Radiographic assessment of progressive loading

The radiographs were converted to 640 

480 pixel digital images with a calibrated
CCD video camera (Dage-MTI CCD-72,
Dage-MTI Inc., Michigan City, IN, USA)
and interfaced with a framegrabber (VFG
100, Imaging Technology Inc., Woburn,
MA, USA). The images were displayed
and manipulated on a high-resolution
VGA monitor (NEC Multisync 4FG,
NEC Corp., Tokyo, Japan). The range of
optical densities in the radiographic image
was converted into 256 different pixel
values, zero representing the black areas
and value 255 representing the lightest area
on the film. The transillumination light
was adjusted to bring the area of interest
such as the crestal bone next to implants,
to pixel gray values of 120–200 for opti-
mum visualization. The calculated pixel
size in the digitized images in this investi-
gation was 63  63 mm. After the baseline
radiograph was digitized and saved into the
computer memory, the follow-up radio-
Fig. 1. Progressive loading sequence. The experimental group implant undergoing progressive loading begins
with its provisional crown in infraocclusion for a 2-month period as seen in a buccal view (a), and occlusal view graphs were aligned with the baseline using
(b). Note the absence of occlusal contact marks. The second 2-month period begins with its provisional crown a real-time subtraction program. In this
in light occlusion as seen in occlusal view (c) with light occlusal contact marks. The implant undergoes its procedure the superimposing images were
third 2-month period of progressive loading with its provisional crown in full occlusion as seen in view (d) with moved back and forth and rotated with a
evidence of heavier occlusal contact marks. The experimental implant receives its final restoration in full
micrometer driven stage until the best
occlusion after 6 months of progressive loading as seen in this buccal view (e) and occlusal view (f) with heavy
occlusal contact marks. subtraction was visualized on the monitor.
The follow-up radiograph was then digi-
sal contact (Fig. 1d). The occlusal ment of the final restoration (control group) tized in this spatial orientation.
contacts were axially directed and or provisional restoration (experimental The linear measurements were done by a
the patient was on a regular diet. group) and following 2, 4, 6, 9, and 12 trackball driven cursor on a 12 times mag-
(4) After 6 months, the dental implant months of function. The experimental nified digitized image of the implant site
received a metal ceramic restoration group also required adjustments to the on the monitor, using the dimensional
with a metal occlusal surface placed provisional restorations at the 2- and 4- analysis software RadWorks (Dove et al.
into full occlusal contact (Fig. 1e, f). month recall visits and had a final restora- 1990). On each image the implant–crown
tion delivered at the 6-month recall visit. interface and the first contact of the alveo-
During the assessment periods, all peri- The radiographic images were acquired lar crestal bone and the implant was iden-
apical radiographs were taken and analyzed by seating the subject in the cephalometric tified and marked with a cursor on the
in the longitudinal radiographic assessment unit, his/her head aligned to the best pro- mesial and distal side of the implant
(LRA) facility at UTHSCSA. The alveolar jection (perpendicular) to the implant site. (Fig. 2a). The analysis program calculated
bone reaction to progressive implant load- The horizontal and vertical alignment of and reported the distance between the two
ing and to standard loading (control group) the subject’s head was registered for stan- points with 63 mm accuracy. The same
was assessed by radiographic means. The dardized follow-up radiography. One #2 procedure was performed with all the fol-
primary treatment focus was the change in size or #1 size D-speed (Eastman Kodak low-up radiographs.
the alveolar crestal bone height as meas- Co., Rochester, NY, USA) double-pack The bone density change of the peri-
ured from digitized radiographs, and a sec- periapical radiograph in vertical or horizon- implant region was measured using a CA-
ondary treatment focus was the density tal orientation was exposed using a medical DIA procedure along the mesial and distal
changes in the peri-implant bone as meas- X-ray unit with 65 kVp, 150 mA, 0.75 s sides with 1 mm2 regions-of-interest (ROI)
ured with computer-assisted densito- exposure at 60 in distance. The collimator (Fig. 2b). The crestal bone density change
metric image analysis (CADIA) (Brägger of the tubehead was adjusted to the size of was measured at two sites: (1) on the
et al. 1988). In order to monitor these the #2 radiograph to reduce the effect of cortical bone layer immediately apical to
changes, the experimental and control secondary radiation to a minimum. The the bone–implant contact, and (2) 1 mm
groups received radiographs at the same radiographs were developed in 4.5 min with apical to the first site. The mid-implant
time intervals. Therefore, each of the 23 a well-controlled automatic processor (Dent- region was measured mesially and distally
implants was radiographed at the place- X 9000, Dent-X Co., Elmsford, NY, USA). at one site positioned in the middle of the

163 | Clin. Oral Impl. Res. 16, 2005 / 161–167

Appleton et al . Radiographic assessment of progressive loading

ing on the crestal bone loss and bone

Fig. 2. Computer-assisted dimensional and density analysis. (a) To measure the crestal vertical bone loss, the
operator marks the implant shoulder (a), apex (b), and the level of the bony crest contacting at both the mesial
and distal side of the implant, (c) and (d), respectively. (b) To measure the change in bone density, the operator
positions nine 1 mm2 regions of interest around the implant at five levels; crestal (#1 and 2), subcrestal
immediately below the crestal (#3 and 4), mid-implant (#5 and 6), mesial and distal apical area (#7 and 8) and at
the apex (#9).
Table 1. Results of crestal vertical bone loss
Follow-up period Experimental group
Mean (mm)
2 Months 0.12
4 Months 0.25
6 Months 0.26
9 Months 0.27
12 Months 0.2
Mean of 10 implants.
Scheffe’s interval calculated at the 95% level for comparison is 0.32 mm.
implant length. The apical area was meas-
ured at the mesial, distal, and apical sides
of the implant apex. These ROIs were
positioned 0.12 mm (2 pixel width) away
from the implant surface to avoid contact
with the metallic implant. Once the meas-
urements of ROIs were positioned, the
CADIA analysis was launched.
The radiographic images were subtracted
and the image noise was measured on the
subtraction image. Image noise was de-
fined as the standard deviation of gray
values in the subtraction image. Before
the CADIA procedure was performed, a
threshold value for the CADIA algorithm
was set to be twice the noise in the sub-
traction image. Setting the threshold to
twice the image noise excludes 95% of
the subtraction image noise. Only density
changes that were more than the threshold
to the negative or positive direction were
taken into account when calculating the
net-CADIA value.
density change adjacent to endosseous
implants. However, the data from three
implants were removed from the database.
The reason for this was that two of
these implants displayed radiographic
evidence of extensive vertical pocket
formation at one side of the implant with-
in 4 months after placement of restoration.
One implant belonged to the experimental
group and the second belonged to the con-
trol group. The third implant was removed
from the study because the patient failed
to show up for recall radiographs. Final-
ly, the linear bone loss data and the
density change data (CADIA values)
from the 20 implants were collected for
assessment.
Means of the crestal vertical bone loss
values and the standard deviations at the
different time points for experimental and
control groups are listed in Table 1. Mean
crestal bone loss values ranged from
0.12
0.14 to 0.63
0.25 mm. Scheffe’s
Control group interval for comparison among means at
the 95% confidence level was 0.32 mm.
SD (mm) Mean (mm) SD (mm)
The crestal bone loss values of progressive
0.14 0.35 0.24
loading were significantly less than the
0.13 0.54 0.34
0.04 0.61 0.23 values of control group with immediate
0.18 0.63 0.25 loading (P  0.05). The follow-up time
0.27 0.59 0.32 period was also a statistically significant
factor (P  0.05), and this is consistent
with the continuous crestal bone height
loss that occurs from the 6-month up to
The vertical bone loss at each time point the 12-month tested period.
was calculated by subtracting the bone A repeated-measure ANOVA test was
height in the baseline radiographs from performed to analyze the effect of the load-
those of follow-up radiographs. The mesial ing method on the peri-implant bone den-
and distal bone loss was averaged and sity change at each measurement level
entered in the database. Similarly, the (crestal, subcrestal, mid-implant, lateral
mesial and distal CADIA values at the apical area, and at the implant apex). The
five levels next to the implant were aver- five time points were the repeated data
aged for each level. The measurement data factors. At the crestal measurement level,
were grouped according to the follow-up there was higher bone density gain with
time period. The data of the crestal experimental group implants, but not a
bone height changes and bone density statistically significant difference (P ¼
changes for the experimental and control 0.09). The same effect was evident at the
groups were analyzed with an ANOVA. subcrestal area with the progressively
Scheffe’s test was used for all post hoc loaded implants gaining more density
pairwise comparison at the 95% confi- (P ¼ 0.25), but without statistical signifi-
dence level. cance. In the mid-implant region and in
the lateral apical region, there were only
very small changes in bone density, but
Results at the apex region, the conventionally
loaded implants showed a strong trend
The data from 20 subjects were used in (P ¼ 0.07) for gaining more peri-implant
the analysis of the effect of progressive load- bone density.

164 | Clin. Oral Impl. Res. 16, 2005 / 161–167


Discussion
In this investigation, randomization of sub-
jects into experimental and control groups
was used to attempt to control for natural
human variation. In order to control for
varying bone qualities and quantities in
different regions of the jaws (Branemark
et al. 1985; Schnitman 1988; Jaffin & Ber-
man 1991), only implants placed in the
maxillary premolar region were included
in the subject population. This anatomic
region was selected because the posterior
maxilla has the poorest bone quality and
would be most likely to exhibit detectable
changes in density. It was also the logical
choice because it is an area that could most
benefit from progressive loading procedures
with vertical occlusal force. Variation in
occlusal force generated was controlled by
only including implants that oppose nat-
ural dentition or a fixed partial denture
retained only by natural abutments. Dif-
ferent forms of artificial tooth replacement
such as complete dentures, removable par-
tial dentures, implant-retained restorations
can result in subjects with varying capaci-
ties to generate occlusal force (Haraldson
et al. 1979; Lindquist & Carlsson 1985).
Only single tooth implant restorations
were chosen to provide better control of
the intensity of the occlusal contacts, and
allow for a mechanism to slowly bring an
implant into full function.
Statistical analysis showed a significant
difference in crestal bone height loss be-
tween implants that are progressively
loaded and those that are conventionally
loaded. Progressively loaded implants ex-
hibited more than 50% less crestal bone
loss than conventionally loaded implants,
and this held true for the duration of the
12-month time span of this investigation.
Analysis of the results of the changes in
peri-implant bone density did not reveal
any statistically significant differences be-
tween implants that were progressively
loaded and implants that were convention-
ally loaded. However, while not statisti-
cally significant (P ¼ 0.09), a strong trend
was seen in that the progressively loaded
implants appeared to achieve a greater den-
sity of bone at the crestal level of measure-
ment. Also, a strong trend (P ¼ 0.07)
existed for the conventionally loaded im-
plants to achieve a greater bone density at
the apex of the implant.
Appleton et al . Radiographic assessment of progressive loading
The decreased peri-implant crestal bone
loss and the improved peri-implant crestal
bone density for progressively loaded im-
plants could be attributed to preventing
overload of the still immature bone at the
crest around the implants (Roberts 1988).
The high stress produced in this region acts
on remodeling immature bone that is still
undergoing lamellar compaction and crys-
tal growth maturation and has many
months to go before reaching maximum
strength (Skalak 1983; Roberts et al. 1989).
Progressive loading attempts to control the
level of stress transmitted into this damage-
susceptible crestal bone so that the load
applied more closely matches and progres-
ses with the load-bearing capacity of the
maturing bone (Roberts et al. 1989; Misch
1999b). The crestal bone was not lost
around the progressively loaded implants
and became increased in density. This may
be due to the response to a level of stress
that stimulates bone growth and matura-
tion (Roberts et al. 1984, 1987, 1989).
While, in related studies, all implants
tended to show a pattern of increased bone
density at their apices (Barone et al. 2003),
the reason the conventionally loaded im-
plants showed a pattern of greater apical
density is unclear. It is possible that the
periapical bone of these implants is exposed
to greater stress over a longer period of time
than the progressively loaded implants. By
avoiding early heavy stresses, the crestal
bone around a progressively loaded implant
develops greater load-bearing capacity and
this could reduce the amount of load trans-
mitted to the bone around the apex of the
implant. This lesser amount of stimulation
would produce bone of a lesser density in
this region.
The two ailing implants that were ex-
cluded, one in the experimental group and
one in the control group, were exhibiting
rapid crestal bone loss. A rate of loss that
exceeded the suggested value for a healthy
implant of 1 mm the first year and 0.2 mm
annually thereafter (Adell et al. 1986; Cox
& Zarb 1987). While this very loosely
translates into a failure rate of approxi-
mately 9%, within the 10% average failure
for maxillary implants (Adell et al. 1981;
Albrektsson et al. 1986), the cause of this
rapid excessive bone loss is uncertain. It is
possible that some disease or condition,
such as periodontal disease or parafunc-
tional habits that went undiagnosed is
actively destroying the bony support of
these two implants.
The implants remaining in the database
all exhibited a rate of bone loss well within
this value, approximately 0.2–0.6 mm total
crestal bone loss after 12 months of function.
One of the limitations of this study is
that only single tooth restorations were
investigated and the results achieved with
progressive loading may not be applicable
to the implant-supported fixed partial den-
ture, or any of the implant restorations for
the completely edentulous condition. Also,
the manner in which the implant crown
was incrementally brought into full occlu-
sion was not quantitatively measurable and
a more subjective measure of occlusal con-
tact was used.
The concept of progressive loading of
endosseous dental implants warrants
further research. There are numerous ques-
tions to consider such as how would
progressive loading compare in hydroxyl-
apatite-coated vs. titanium implants, or
cylindrical vs. screw-shaped implants. The
level of benefit of progressive loading
in different anatomic locations, or even
grafted or augmented implantation sites
needs further investigation.
Conclusion
This investigation was designed to exam-
ine the effect of progressive loading of
endosseous dental implants supporting sin-
gle freestanding maxillary premolars. This
narrow population in a broad range of
implant-supported restoration possibilities
was chosen to control for the many vari-
ables encountered in in vivo human trials.
Standardized radiographic technique was
used to permit accurate linear measure-
ment of peri-implant crestal bone (com-
puter-assisted dimensional analysis) as
well as to permit computer-assisted densi-
tometric image analysis. That is, using
digital subtraction technology to measure
peri-implant bone density. These are accu-
rate and precise techniques for quantifying
peri-implant bony reactions to different
therapeutic modalities. The following
conclusion can be drawn from this investi-
gation: Progressively loaded single endo-
sseous implants in the posterior maxilla
demonstrated significantly less peri-im-
plant crestal bone loss (0.2 mm) than
165 | Clin. Oral Impl. Res. 16, 2005 / 161–167
Appleton et al . Radiographic assessment of progressive loading
conventionally loaded implants (0.6 mm)
after a 12-month follow-up period.
Résumé
Le but de cette étude clinique a été de déterminer
l’efficacité des processus de charge progressive, de
préserver la hauteur osseuse crestale et d’améliorer
la densité osseuse paroı̈mplantaire autour d’im-
plants maxillaires restaurés avec des couronnes pré-
molaires uniques par une technique de mesure
radiographique longitudinale précise. Vingt-trois im-
plants dentaires endo-osseux recouverts de HA ont
été insérés chez vingt patients et ont eu une guérison
de cinq mois avant la deuxième étape chirurgicale.
Les implants ont été répartis au hasard en groupes
expérimental et contrôle. A la suite d’une période de
guérison conventionnelle, le groupe contrôle était
restauré avec une couronne céramo-métallique et
l’expérimental comportait un protocole de charge
progressive. Le groupe expérimental était donc pro-
gressivement chargé en augmentant la hauteur de la
table occlusale en étapes partant de l’infraocclusion à
l’occlusion totale par des couronnes en acrylique par
chauffage sur lesquelles on ajoutait de la résine
acrylique. Les couronnes progressivement chargées
étaient placées en infraocclusion durant les deux
premiers mois, légère occlusion pour les deux mois
suivants et occlusion complète pour les deux mois
restants. A ce moment, une couronne céramo-mé-
tallique remplaçait cette couronne acrylique. Des
radiographies standardisées de chaque implant ont
été prises au moment de la restauration et après
deux, quatre, six, neuf et douze mois de mise en
fonction. L’analyse par images digitales et radio-
graphies de soustraction ont été utilisées pour me-
surer les variations dans la hauteur osseuse crestale
et la densité osseuse paroı̈mplantaire. Les valeurs
moyennes de la perte osseuse crestale après douze
mois étaient de 0,20
0,27 mm pour les implants
chargés progressivement et de 0,59
0,27 mm
pour les implants chargés conventionnellement, et
lorsqu’ils étaient testés par les mesures ANOVA
répétées suivant le temps les différences étaient
statistiquement significatives (P  0,05). Le
groupe à charge progressive montrait une tendance
à un gain de densité osseuse plus important dans la
zone crestale que le groupe à charge conventionnelle
mais ce dernier groupe s’orientait vers un gain de
densité osseuse plus important au niveau de l’apex
des implants. L’os paroı̈mplantaire autour des im-
plants mis en charge progressive affiche moins de
perte osseuse crestale que l’os autour des implants
placés de manière conventionnelle en fonction im-
médiate. Les mesures de densité paroı̈mplantaires
des implants mis en charge progressive accusaient
une augmentation continue de la densité osseuse
paroı̈mplantaire avec le temps.
Zusammenfassung
Eine radiologische Auswertung der progressiven
Belastung von Knochen um osseointegrierte
Einzelimplantate im posterioren Oberkiefer
Ziel: Das Ziel dieser klinischen Studie war, den
Nutzen von progressiven Belastungsprotokollen
166 | Clin. Oral Impl. Res. 16, 2005 / 161–167
zum Erhalt der Knochenhöhe im Kammbereich
und zur Verbesserung der peri-implantären Kno-
chendichte um Implantate im Oberkiefer mittels
einer genauen longitudinalen radiologischen Aus-
wertungstechnik zu bestimmen. Die Implantate
waren mit Einzelkronen versorgt worden.
Material und Methoden: Dreiundzwanzig HA-
beschichtete enossale dentale Implantate wurden
bei 20 Probanden eingesetzt. Die Einheilzeit betrug
5 Monate, danach wurden die Implantate chirur-
gisch freigelegt. Die Implantate wurden zufällig
entweder der experimentellen oder der Kontroll-
gruppe zugeteilt. Nach einer konventionellen Ein-
heilphase wurden die Implantate der Kontrollgruppe
mit metallkeramischen Kronen versorgt und die
Implantate der Testgruppe wurden einem progressi-
ven Belastungsprotokoll unterzogen. Die progres-
sive Belastung der Testgruppe erfolgte, indem bei
zunächst infraokkludierten heiss polimerisierten
Kunststoffkronen die okklusale Höhe durch Auftra-
gen von Kunststoff in Portionen ständig erhöht
wurde, bis die Kronen voll in Okklusion standen.
Die progressiv belasteten Kronen wurden für die
ersten 2 Monate in Infraokklusion belassen, darauf
folgte eine Phase über 2 Monate in leichter Okklu-
sion und für die dritten 2 Monate wurden die
Kronen voll in Okklusion gestellt. Zu diesem Zeit-
punkt wurden die Kunststoffkronen durch metallk-
eramische Kronen ersetzt. Zum Zeitpunkt der
Rekonstruktion und nach 2, 4, 6 und 12 Monaten
wurden von jedem Implantat standardisierte Rönt-
genaufnahmen gemacht. Um die Veränderungen in
der Knochenhöhe und in der peri-implantären Kno-
chendichte zu messen, wurden die digitale Bildana-
lyse und die digitale Subtraktionsradiographie ver-
wendet.
Resultate: Die Mittelwerte des Verlustes an
Knochenhöhe nach 12 Monaten betrugen 0.2

0.27 mm für die progressiv belasteten Implantate
und 0.59
0.27 mm für die konventionell belas-
teten Implantate. Wenn mit wiederholten Mes-
sungen ANOVA über die Zeitperioden getestet
wurde, waren die Unterschiede statistisch signifi-
kant (P  0.05). Die progressiv belastete Gruppe
zeigte im Vergleich zur konventionell belasteten
eine Tendenz zu vermehrtem Gewinn an
Knochendichte im Kammbereich, aber die konven-
tionell belastete Gruppe zeigte eine Tendenz zu
mehr Gewinn an Knochendichte am Apex der
Implantate.
Schlussfolgerung: Der peri-implantäre Knochen
bei progressiv belasteten Implantaten zeigt einen
geringeren Knochenverlust im Kammbereich als
der Knochen um Implantate, welche konventionell
in volle Funktion gesetzt werden. Die Messungen
der peri-implantären Dichte um progressiv belastete
Implantate zeigen eine stetige Zunahme in der
peri-implantären Knochendichte über die Zeit.
Resumen
Objetivos: La intención de este estudio clı́nico fue
determinar la efectividad de los procedimientos de
carga progresiva en la preservación de la altura de la
cresta ósea y mejorar la densidad ósea periimplan-
taria alrededor de los implantes maxilares restaura-
dos con corona premolares unitarias por medio de
una técnica de valoración radiográfica longitudinal
precisa.
Material y métodos: Se colocaron veintitrés im-
plantes endoóseos, cubiertos de HA, en veinte
sujetos permitiéndoseles cicatrizar durante 5 meses
antes del descubrimiento quirúrgico. Los implantes
fueron asignados aleatoriamente a un grupo experi-
mental o de control. Tras un periodo de cicatrización
convencional, los implantes del grupo de control se
restauraron con coronas ceramometálicas y los im-
plantes del grupo experimental fueron sometidos a
un protocolo de carga progresiva. El grupo experi-
mental fue cargado progresivamente incrementán-
dose la tabla oclusal en incrementos desde un estado
de infraoclusión hasta una oclusión completa por
medio de la adición de resina acrı́lica a una corona
acrı́lica termoprocesada. Las coronas de carga pro-
gresiva se colocaron en infraoclusión durante los
primeros 2 meses, en una ligera oclusión durante
los segundos 2 meses y en oclusión completa dur-
ante los terceros 2 meses. En este punto una corona
ceramometálica sustituyó a la corona acrı́lica. Se
tomaron radiografı́as estándar de cada implante en el
momento de la restauración, y tras 2 meses, 4
meses, 6 meses, 9 meses y 12 meses en función.
Se usaron análisis digitales de imagen y radiografı́as
de sustracción digital para medir los cambios en la
altura del hueso crestal y en la densidad del hueso
periimplantario.
Resultados: Los valores medios de la pérdida de la
altura de hueso crestal a los 12 meses fueron de
0.2
0.27 mm para los implantes cargados progre-
sivamente y de 0.59
0.27 para los implantes de
carga convencional, y cuando se probaron con med-
iciones repetidas de ANOVA a lo largo de los
periodos de tiempo las diferencias fueron estadı́sti-
camente significativas (P  0.05). El grupo de carga
progresiva mostró una tendencia hacia una ganancia
mayor de densidad ósea en el área crestal que los del
grupo de carga convencional, pero el grupo de carga
convencional mostró una tendencia hacia una mayor
densidad ósea en el ápice de los implantes.
Conclusión: El hueso periimplantario alrededor de
los implantes con carga progresiva demostró una
menor pérdida de hueso crestal que el hueso alrede-
dor de los implantes colocados convencionalmente
en función total. Las mediciones de la densidad
periimplantaria de los implantes cargados progresi-
vamente muestran incrementos continuos en la
densidad periimplantaria a lo largo del tiempo.

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