Annual failure rates and marginal bone-level changes of immediate compared to conventional loading of dental implants. A systematic review of the literature and meta-analysis.

Sebastian Engelhardt* Petros Papacosta* Florian Rathe € € lide Ozen Ju John A. Jansen € diger Junker Ru

Authors’ affiliations: Sebastian Engelhardt, Section Parodontologie, C1 Centre M edico-Dentaire, Geneva, Switzerland Petros Papacosta, Department of Implantology and Periodontology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands Florian Rathe, Department of Prosthodontics and Biomaterials, Danube Private University, Krems, Austria Private Practice, Forchheim, Germany € J€ ulide Ozen, Department of Prosthetic Dentistry, Private Dental Clinic, Aachen, Germany John A. Jansen, Department of Biomaterials, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands R€ udiger Junker, Department of Prosthodontics and Biomaterials, Danube Private University, Krems, Austria Corresponding author: Prof. Dr. R€ udiger Junker Department of Prosthodontics and Biomaterials Danube Private University Steiner Landstraße 124 A-3500 Krems, Austria Tel.: +43 676 842 419 348 Fax: +43 2732 70478 7060 e-mail: [email protected]

Annual failure rates and marginal bone-level changes of immediate compared to conventional loading of dental implants. A systematic review of the literature and meta-analysis

Key words: Bone–implant interactions, periodontology, prosthodontics, surgical techniques Abstract Background: Immediate loading of dental implants appears to be a successful option. Questions still remain whether annual failure rates (AFRs) as well as annual marginal bone-level changes are comparable with conventionally loaded implants. Hypothesis: Immediately loaded implants (≤24 h after implantation) do not show different annual survival rates or peri-implant bone-level changes as compared to conventionally loaded implants (≥3 months after implantation). Material and methods: An electronic search in the National Library of Medicine and in Cochrane Central Register of Controlled Trials was performed for articles published up to November 2013. Only publications in English were considered. Additionally, the bibliographies of the full-text papers were searched. Primary outcome variable was percentage AFR; secondary outcome variable was annual radiographic bone-level change. Results: Electronic search yielded 154 full-text articles; ten randomized controlled clinical trials were eventually meta-analyzed. Annual failure rates were 2.3% and 3.4% for conventionally and immediately loaded implants, respectively. No difference in implant failure rates was found (RR: 0.82). Regarding marginal bone-level changes, the weighted mean difference (WMD) between immediate and conventional loading amounted to 0.02 mm at 1 year (P > 0.05), to 0.08 mm at 2 years (P > 0.05),

0.10 mm at 3 years (P > 0.05) and

0.3 mm at 5 years (P < 0.05). The total

WMD for the combined follow-up was 0.01 mm (P > 0.05). Conclusion: No clinically relevant differences regarding annual failure rates or radiographic bonelevel changes between conventionally and immediately loaded implants can be found for up to 5 years of follow-up.

*Both authors contributed equally. Date: Accepted 9 February 2014 To cite this article: € Engelhardt S, Papacosta P, Rathe F, Ozen J, Jansen JA, Junker R. Annual failure rates and marginal bone-level changes of immediate compared to conventional loading of dental implants. A systematic review of the literature and metaanalysis. Clin. Oral Impl. Res. 26, 2015, 671–687 doi: 10.1111/clr.12363

At present, replacing missing teeth by means of dental implants has become a predictable treatment option (Berglundh et al. 2002; Pjetursson et al. 2004). In the past, titanium dental implants with a machined surface were loaded after a submerged healing period of 3–4 months in the mandible and 6– 8 months in the maxilla (Branemark et al. 1977). For the reason that recently developed and marketed dental implants enhance primary implant stability, earlier and even immediate loading became an option (Esposito et al. 2013). Moreover, early – and even more important in daily clinical implant dentistry – immediate loading has been proven successful (Esposito et al. 2013). However, immediate loading is neither uniform nor generally accepted. For example, in 2002

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

during the ITI Consensus Conference, immediate loading was defined as loading on the same day of implant placement (Aparicio et al. 2003). Later on, in the course of the ITI consensus conference in 2003, immediate loading was extended to within 48 h after implant placement (Cochran et al. 2004). Thereafter, during the Consensus Conference of the European Association for Osseointegration (EAO) in 2006, immediate loading was defined as loading within 72 h after implant installation (Nkenke & Fenner 2006). More recently, for the purpose of a meta-analytical approach to the literature, immediate loading was prolonged to 1 week after implant placement (Esposito et al. 2013). Up to now, several meta-analyses regarding the outcome of immediate loading of dental

671

Engelhardt et al Immediate vs. conventional implant loading

implants have been published (Ioannidou & Doufexi 2005; Atieh et al. 2009; Esposito et al. 2013; Suarez et al. 2013). However, methodological concerns do exist and question their suitability for decision making in routine, daily clinical practice (Ioannidou & Doufexi 2005; Atieh et al. 2009; Esposito et al. 2013 and Suarez et al. 2013). For example, Esposito and coworkers defined immediate loading as loading within 1 week after implant placement and included outcome data of different time points in their metaanalysis (Esposito et al. 2013). Accordingly, the value of their findings is, for example, challenged by loading the same day. Because guided implant installation surgery along with loading of prefabricated removable as well as fixed dentures at the same time point is becoming more and more attractive, the aim of the current study was to metaanalyze only randomized controlled clinical trials (RCT) reporting at least 1-year outcome data (i.e., survival rates and marginal bonelevel changes) on loading within 24 h after implant placement as compared to conventional loading (CL). It was hypothesized that implant survival rates as well as mean peri-implant bone-level changes for loading at the day of implant placement do not differ significantly from CL.

Material and methods Outcome variables

The primary outcome variable was percentage annual failure rate (AFR). The secondary outcome variable for immediate loaded implants was radiographic bonelevel change between the day of implant placement/loading and predefined follow-up end points. Analogous the secondary outcome variable for implants loaded after conventional healing intervals was chosen. Inclusion criteria

The following detailed inclusion criteria were operated: 1. Only randomized controlled clinical trials (RCTs); 2. For the test group, immediate loading had to be defined as ≤24 h after implant placement and both functional and nonfunctional loading procedures were applicable; 3. For the control group, CL had to be defined as ≥3 months after implant placement; 4. Number of subjects: ≥20; 5. Follow-up time: ≥1 year;

672 |

Clin. Oral Impl. Res. 26, 2015 / 671–687

6. Implant survival data had to be presented clearly; 7. Marginal bone-level changes in terms of mean standard deviation (SD) had either to be given or possible to be calculated according to the given data; 8. Standardized radiographs had to be used; 9. Both immediately and conventionally loaded implants had to be restored with fixed dental prosthesis; 10. Within each included trial, equal screw form implants had to be compared under two different loading protocols (i.e., immediate loading vs. CL). Studies that did not meet all the abovementioned inclusion criteria were excluded. Search strategy

An extensive electronic search in the databases of the National Library of Medicine (http:// www.ncbi.nlm.nih.gov) and in Cochrane Central Register of Controlled Trials (CENTRAL) was carried out for articles published up to November 2013. Only publications in English were considered. The search strategy applied in PubMed was as follows: (“dental implants”[MeSH Terms] OR (“dental”[All Fields] AND “implants”[All Fields]) OR “dental implants”[All Fields]) OR ((“mouth”[MeSH Terms] OR “mouth”[All Fields] OR “oral”[All Fields]) AND implants[All Fields]) AND (immediate[All Fields] AND loading[All Fields]) OR (immediate[All Fields] AND restoration[All Fields]) OR (immediate[All Fields] AND functional[All Fields] AND loading[All Fields]) OR (conventional[All Fields] AND loading[All Fields]) OR (delayed[All Fields] AND loading[All Fields]) OR (early[All Fields] AND loading[All Fields]). The search strategy applied in Cochrane Central using the Search Manager was as follows: #1 MeSH descriptor: [Dental Implants] explode all trees #2 MeSH descriptor: [Dental Implantation] explode all trees #3 MeSH descriptor: [Immediate Dental Implant Loading] explode all trees #4 Conventional loading #5 Delayed loading #6 Early loading #7 #1 or #2 and #3 or #4 or #5 or #6 Additionally, the reference lists of all selected full-text articles were screened. No hand search was performed. Study selection and data extraction

Two independent reviewers (Sebastian Engelhardt [SE] and Petros Papacosta [PP]) initially

screened the publication titles and abstracts as identified by the electronic search for possible inclusion. Full texts of all papers which were considered eligible for inclusion by one or both of the reviewers were obtained for further assessment against the stated inclusion criteria (Fig. 1). Any disagreements between the reviewers regarding inclusion of a certain publication or data extraction were resolved by discussion. A data extraction form was used by the reviewers to independently extract the data from the selected full-text articles. Risk of bias of the included articles

A risk of bias assessment was performed. According to the Cochrane Risk of Bias Tool (Higgins et al. 2009), the following aspects were analyzed: 1. 2. 3. 4. 5. 6.

Sample size calculation performed Adequate randomization procedure Allocation concealment Blinding of surgeon Blinding of assessor Incomplete outcome data adequately addressed

Heterogeneity

For the purpose of the current meta-analysis, heterogeneity was analyzed according to the Cochrane Handbook for Systematic Reviews (Deeks et al. 2008a). Heterogeneity was detected using the chi-squared test, and its possible impact on the meta-analysis was quantified via I2. A large chi-squared statistic with P < 0.1 was thought to prove substantial heterogeneity. The influence of heterogeneity on the results was considered substantial with an I2 exceeding 80%. Statistical analysis

All analyses were performed using RevMan (Review Manager [Computer program]. Version 5.1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011).

Results Study selection

The electronic search in the databases of the National Library of Medicine and in Cochrane Central Register of Controlled Trials (CENTRAL) resulted in the identification of 12,380 and 2322 titles, respectively (Fig. 1). As mentioned, these titles were initially screened by two independent reviewers (SE and PP) for possible inclusion, resulting in further consideration of 582 publications in PubMed and 169 publications in Cochrane Central. Screening the abstracts led to 153 articles from PubMed considered for full-text



PubMed

Cochrane Central Register of Controlled Trials (Central)

Titles 12380

Titles 2322

Discarded titles 11798

κ = 0.72

κ = 0.79 Abstracts 169

Abstracts 582 Discarded abstracts 429

Discarded titles 2153

κ = 0.75

κ = 0.84

Bone-level changes

Discarded abstracts 123

Discarded duplicates 45 Articles via screening of the reference lists 7 Full-text articles 161 Pubmed: 153 Cochrane: 1 Screening: 7 Excluded articles 151 Pubmed: 144 Cochrane: 0 Screening: 7

κ = 0.83

Included articles 10 Fig. 1. Selection process.

evaluation and 46 articles from Cochrane Central, 45 of which were duplicates. Bibliography screening bared seven additional scientific papers, and therefore, the total number of full-text articles assessed was 161. Of these, 151 full-text articles were not suitable for inclusion and are detailed in the references (Appendices 1, 2 and 3). 115 studies were excluded as non-RCTs (Appendix 1), 27 as RCTs not comparing immediate and CL as defined in inclusion criteria 2 and 3 (Appendix 2). The reason(s) of exclusion for the remaining nine RCTs are stated in Table 1 (Appendix 3). Eventually, 10 RCTs were eligible for inclusion into the systematic review and are summarized in Table 2. As mentioned before, any disagreement between the reviewers regarding data extraction as well as data interpretation was resolved by discussion. Observers’ agreement (Cohen’s kappa coefficient) was calculated for each step of the selection process (Fig. 1). Risk of bias in included studies

The estimated overall risk of bias was low in three articles (Crespi et al. 2008; Degidi et al.

2009; Prosper et al. 2010), high in three publications (Hall et al. 2006; Donati et al. 2008; De Rouck et al. 2009) and unclear for four papers (Danza et al. 2010; Shibly et al. 2010; Den Hartog et al. 2011; Margossian et al. 2012). The risk of bias appraisal is summarized in Table 3. Percentage annual failure rate

Up to the 1-year follow-up, 17 of 520 immediately loaded implants were lost, resulting in an AFR of 3.3%. Likewise, 6 of 365 conventionally loaded implants were lost at the 1-year follow-up (1.6%). Additionally, six implants were lost to follow-up (drop outs), five conventionally and one immediately loaded. Assuming that 50% of those implants were really lost, the calculated AFR was 2.3% for CL and 3.4% for IL. For immediately loaded implants and conventionally loaded implants, the AFRs at the 2nd, 3rd and 5-year interval were 0% (Table 4). Additionally, a meta-analysis for relative risk was performed for seven studies (Hall et al. 2006; Donati et al. 2008; De Rouck et al. 2009; Prosper et al. 2010; Shibly et al.


2010; den Hartog et al. 2011; Margossian et al. 2012) after excluding the studies without implant failures in any of the groups (Crespi et al. 2008; Degidi et al. 2009; Danza et al. 2010). The analysis revealed a risk ratio of 0.82 (95% CI: 0.35–1.94, P > 0.05) for CL, with no statistically significant difference between the two loading protocols (Fig. 2).

Regarding the outcome variable marginal bone-level change, the overall weighted mean differences (WMD) between immediately loaded and conventionally loaded implants for all 10 included studies did not reveal any statistically significant differences. The WMD between immediately loaded and conventionally loaded implants was 0.02 mm after the first year (95% CI: 0.07 to 0.11 mm; P > 0.05), 0.08 mm after the second year (95% CI: 0.01 to 0.17 mm; P > 0.05) and 0.10 mm after the third year (95% CI: 0.44 to 0.24 mm; P > 0.05). A statistically significant difference of 0.30 mm was found in favor of CL at 5th year time interval (95% CI: 0.49 to 0.11 mm; P < 0.05). All in all, the WMD for the 1st, 2nd, 3rd and 5th year of follow-up was 0.01 mm (95% CI: 0.05 to 0.08 mm; P > 0.05) and not statistically significant (Fig. 3). Additionally, subsection analyses have been performed depending on two variables, the loading protocol applied for immediate loading group (functional or non-functional loading) and the implantation site (healed bone or fresh extraction site). The study of Margossian et al. 2012 was used for both immediate functional and non-functional loading subsection analyses. The first subgroup analysis with regard to immediate functional loaded implants (Crespi et al. 2008; Donati et al. 2008; Danza et al. 2010; Prosper et al. 2010; Shibly et al. 2010; Margossian et al. 2012) revealed no statistically significant difference at 1 and 2 years of follow-up. The WMD at 1 year between immediately functional vs. CL amounted to 0.04 mm (95% CI: 0.08 to 0.16 mm; P > 0.05) and 0.11 mm for 2-year interval (95% CI: 0.00 to 0.21 mm; P > 0.05). The WMD was found to be statistically significant for 5 years of follow-up and resulted to 0.30 (95% CI: 0.49 to 0.11 mm; P < 0.05) in favor of CL. The overall WMD for the 1st, 2nd and 5th year of follow-up was 0.03 mm (95% CI: 0.06 to 0.12 mm; P > 0.05) and not statistically significant (Fig. 4).

673 |



Table 1. Excluded randomized controlled trials (RCTs) with reasons Publication

Interventions and comparisons

Degidi et al. (2009)

Comparative analysis of immediate functional loading and immediate non-functional loading to traditional (conventional) healing periods

Romanos & Nentwig (2006)

Immediate vs. delayed functional loading in the posterior mandible; split-mouth design

Schincaglia et al. (2008)

Comparison of single implant-supported mandibular molar restorations using either an immediate functional or a delayed loading protocol Immediate functional loading (same day) with conventional loading (4 months) in the maxilla (anterior and premolar regions) Immediate functional and conventional loading in mandibular molar sites; split-mouth design Immediate and conventional loading of two unsplinted implants supporting mandibular overdentures Immediate nonfunctional and conventional loading of single mandibular molars; split-mouth design Immediate nonfunctional and conventional loading of single implants in the anterior maxilla

Oh et al. (2006)

€ ncu € et al. Gu (2008)

Elsyad et al. (2012)

Meloni et al. (2012)

Hall et al. (2007) (follow-up of the included article Hall et al. 2006) Jokstad & Alkumru (2013)

Immediate and conventional loading of four implants in edentulous mandibles supporting 10–12 unit FDP

Reason(s) for exclusion

Test group

Control group

Radiographic analysis

264 implants were inserted in 82 patients with immediate functional loading (if completely edentulous) or immediate non-functional loading (if partially edentulous) within a few hours after surgery Immediate functional loading of 36 implants in 12 patients directly after implant placement

286 implants inserted in 73 patients with a one-stage or two-stage surgical procedure and conventionally loaded

Intraoral; nonstandardized

Non-standardized radiographs; Mean MBL changes without SD; both implantsupported removable and fixed prostheses were used

Conventional loading of 36 implants in 12 patients 3 months after implant placement

Orthopantomography;

Immediate functional loading of 15 implants within 24 h

Conventional loading of 15 implants after 3–4 months


Number of patients (12); nonstandardized + extra oral radiographs; MBL changes not in terms of mean SD; survival data not clearly presented No standardized x-rays

Immediate functional loading of 12 implants in 12 patients directly after implant placement


Not performed

No radiographic analysis

Immediate functional loading of 12 single crowns on 12 patients on the same day of the surgery

Conventional loading of 12 single crowns in 12 patients 3 months after implant placement


Number of patients (12); non-standardized radiographs

Immediate loading of 30 implants in 15 patients in the same day


Extra oral, computer tomography (CT); standardized

Removable prostheses

Immediate non-functional loading of 20 implants in 20 patients within 24 h of implant placement

Conventional loading of 20 implants in 20 patients 4–5 months after implant placement


Non-standardized radiographs

Immediate non-functional loading of 14 implants in 14 patients within 4 h of implant placement

Conventional loading of 14 implants in 14 patients 26 weeks after implant placement

Intraoral; standardized

Implant survival data are not reported (refers to Hall et al. 2006)

Immediate loading of four implants in the interforaminal region with 10–12 unit FDP on the same day of implant placement

Conventional loading of four implants in the interforaminal region with 10–12 unit FDP 3–4 months after implant placement

Intraoral; nonstandardized at implant placement; standardized at 3–4 months after implant placement (baseline) up to 5 years of follow-up

Implant survival data not clearly presented; non-standardized radiographs at implant placement for the immediate loading group

non-standardized

MBL, marginal bone level; SD, standard deviation; FDP, fixed dental prosthesis.

The subgroup analysis comparing immediate non-functional to CL (Hall et al. 2006; De Rouck et al. 2009; Degidi et al. 2009; den Hartog et al. 2011; Margossian et al. 2012) resulted in no statistically significant

674 |


difference between the analyzed loading protocols at any time interval. The WMD for the 1st, 2nd and 3rd year of follow-up was 0.00 mm (95% CI: 0.06 to 0.07 mm; P > 0.05), 0.05 mm (95% CI: 0.02 to

0.12 mm; P > 0.05) and 0.10 mm (95% CI: 0.44 to 0.24 mm; P > 0.05), respectively. The overall WMD amounted to 0.02 mm (95% CI: 0.03 to 0.07 mm; P > 0.05) (Fig. 5).



Table 2. Characteristics of studies included in meta-analysis

Implant loss*

Number of implants No. of patients

Study Crespi et al. (2008) Danza et al. (2010) De Rouck et al. (2009) Degidi et al. (2009) den Hartog et al. (2011) Donati et al. (2008) Hall et al. (2006) Margossian et al. (2012) Prosper et al. (2010) Shibly et al. (2010)

Follow-up (months)

IL

CL

IL

Loading protocol in immediate loading group

Implantation site (healed or fresh extraction sites)†

Total

CL

40 25 49

24 12 12

40 40 49

20 20 25

20 20 24

0 0 2

0 0 1

IFL IFL INFL

FES HS FES

60 62

36 18

60 62

30 31

30 31

0 0

0 1

INFL INFL

HS HS

149 28 117

12 12 24

159 28 307

57 14 98

102 14 209

0 (2) 0 (2) 0

4 1 7‡

HS HS HS

71 60

60 24

120 60

60 30

60 30

2 2 (1)

2 1 (1)

IFL INFL INFL and IFL§ IFL IFL

FES FES

CL, conventional loading; IL, immediate loading; IFL, immediate functional loading; INFL, immediate non-functional loading; FES, fresh extraction sites; HS, healed sites. * In parenthesis is the number of implants lost to follow-up. † Implantation sites are in each study the same for both CL and IL groups. ‡ All failures occurred in the IFL group. § Two IL groups: INFL = 104 implants, IFL = 105 implants.

Table 3. Risk of bias analysis

Hall et al. (2006) Crespi et al. (2008) Donati et al. (2008) Degidi et al. (2009) De Rouck et al. (2009) Danza et al. (2010) Prosper et al. (2010) Shibly et al. (2010) den Hartog et al. (2011) Margossian et al. (2012) +, yes/adequate;

Random sequence generation: yes/no/unclear

Allocation concealment: adequate/ inadequate/ unclear

○ + + + + + + + + +

○ + ○ + ○ + + + + +

Blinding of surgeon: yes/no/unclear + ○ + ○ + + ○

Blinding of examiner: yes/no/unclear + + + + + + + + ○ ○

Incomplete outcome data adequately reported: yes/no + + +

Sample size calculation performed: yes/no

+ + +

+ +

+ +

+ +

Estimated overall risk of bias High Low High Low High Unclear Low Unclear Unclear Unclear

, no/inadequate; ○, unclear.

The third subgroup analysis compared immediate to CL when implantation was performed in fresh extraction sites (Crespi et al. 2008; De Rouck et al. 2009; Prosper et al. 2010; Shibly et al. 2010). Statistically significant differences were found at the 2nd and 5year interval revealing a WMD of 0.18 mm (95% CI: 0.06 to 0.30 mm; P < 0.05) in favor of immediate loading and 0.30 mm (95% CI: 0.49 to 0.11 mm; P < 0.05) in favor of CL, respectively. The WMD for 1-year follow-up was 0.09 mm (95% CI: 0.15 to 0.33 mm; P > 0.05), while the total amount was 0.05 mm (95% CI: 0.12 to 0.21 mm; P > 0.05) and not statistically significant (Fig. 6). The last subsection analysis of studies where implantation had been carried out in healed sites for both groups (Hall et al. 2006; Donati et al. 2008; Degidi et al. 2009; Danza

et al. 2010; den Hartog et al. 2011; Margossian et al. 2012) showed an overall WMD of 0.01 mm (95% CI: 0.03 to 0.05 mm; P > 0.05), which was not statistically significant. The same applied for the examined time intervals: 0.01 mm at 1 year (95% CI: 0.06 to 0.05 mm; P > 0.05), 0.04 mm at 2 years (95% CI: 0.02 to 0.10 mm; P > 0.05) and 0.10 mm at 3 years (95% CI: 0.44 to 0.24 mm; P > 0.05) (Fig. 7). Heterogeneity

Statistical heterogeneity was found across all ten included studies [s2 = 0.01; v2 = 54.21, df = 14 (P < 0.00001); I2 = 74%]. Consequently, the random-effect model was chosen for meta-analysis. Heterogeneity was induced by various parameters that differ within the analyzed studies.


As shown in Table 2, immediate functional and non-functional loading protocols were applied and both healed and non-healed sites were used in the included investigations. Bone augmentation procedures were used extensively in one case (Shibly et al. 2010), not at all in five studies (Crespi et al. 2008; Donati et al. 2008; Degidi et al. 2009; Danza et al. 2010; Prosper et al. 2010), to fill the jumping gap in case of immediate implant placement or to cover implant dehiscences/ fenestrations in three studies (Hall et al. 2006; De Rouck et al. 2009; den Hartog et al. 2011) and not clearly mentioned if used or not in one study (Margossian et al. 2012). The approach by Shibly et al. (2010) resulted in radiographic marginal bone-level gain at both the conventionally and immediately loaded implants at one and 2 years of

675 |



(a)

Conventional loading (CL)

Immediate loading (IL)

Mean difference

Mean difference

Total Weight

IV, Random, 95% CI

20

11.7%

–0.06 [–0.19, 0.07]

98

5.7%

0.09 [–0.22, 0.40]

0.31

97

13.9%

0.03 [–0.05, 0.11]

0.24

0.12

58

15.1%

–0.07 [–0.11, –0.03]

–0.99

0.22

25 298

12.8% 59.2%

0.24 [0.13, 0.35] 0.04 [–0.08, 0.16]

Mean

SD

Total

Mean

SD

Danza et al. (2010)

0.38

0.21

20

0.44

0.22

Donati et al. (2008)

0.38

0.89

55

0.29

1

Margossian et al. (2012)

0.98

0.27

98

0.95

Prosper et al. (2010)

0.17

0.11

58

–0.75

0.17

24 255

Study or subgroup

IV, Random, 95% CI

1.6.1 1 year data

Shibly et al. (2010) Subtotal (95% CI)

Heterogeneity: τ2 = 0.01; χ2 = 29.28, df = 4 (P < 0.00001); I2 = 86% Test for overall effect: Z = 0.61 (P = 0.54) 1.6.2 2 year data Crespi et al. (2008)

1.16

0.51

20

1.02

0.53

20

5.3%

0.14 [–0.18, 0.46]


1.33

0.25

98

1.28

0.28

97

14.2%

0.05 [–0.02, 0.12]

–1

0.2

24 142

–1.19

0.26

25 142

11.9% 31.4%

0.19 [0.06, 0.32] 0.11 [0.00, 0.21]

1.31

0.44

58 58

9.4% 9.4%

–0.30 [–0.49, –0.11] –0.30 [–0.49, –0.11]

498 100.0%

0.03 [–0.06, 0.12]


Heterogeneity: τ2 = 0.00; χ2 = 3.48, df = 2 (P = 0.18); I2 = 42% Test for overall effect: Z = 2.02 (P = 0.04) 1.6.3 5 year data 58 58

0.59

1.01

Prosper et al. (2010) Subtotal (95% CI) Heterogeneity: Not applicable

Test for overall effect: Z = 3.10 (P = 0.002) 455

Total (95% CI)

Heterogeneity: τ = 0.01; χ = 50.97, df = 8 (P < 0.00001); I = 84% 2

2

2

–0.5 –0.25 0 0.25 0.5 Favours CL Favours IL

Test for overall effect: Z = 0.67 (P = 0.50) Test for subgroup differences: χ2 = 13.75, df = 2 (P = 0.001), I2 = 85.5%

(b) 0

SE (MD)

0.05

0.1

0.15

MD

0.2 –0.5 Subgroups 1 year data

–0.25 2 year data

0

0.25

0.5

5 year data

Fig. 4. (a) Forest plot for marginal bone-level changes (immediate functional vs. conventional loading [CL]). (b) Funnel plot for marginal bone-level changes (immediate functional vs. CL).

The anatomical region of implant placement also varied between the analyzed articles, which is in turn correlated with bone

678 |


quality. In five articles (Hall et al. 2006; Crespi et al. 2008; De Rouck et al. 2009; Degidi et al. 2009; den Hartog et al. 2011), implants were

placed in the maxilla, in two studies (Prosper et al. 2010; Margossian et al. 2012) in the mandible and in three studies (Donati et al.



(a)



Mean difference

Mean

SD

Total

Mean

SD

De Rouck et al. (2009)

0.97

0.35

23

0.86

0.54

23

13.7%

0.11 [–0.15, 0.37]


0.17

0.11

58

0.24

0.12

58

20.6%

–0.07 [–0.11, –0.03]

–0.75

0.17

24 105

–0.99

0.22

25 106

19.1% 53.4%

0.24 [0.13, 0.35] 0.09 [–0.15, 0.33]

Study or subgroup

Total Weight

Mean difference

IV, Random, 95% CI

IV, Random, 95% CI

1.4.1 1 year data



1.16

0.51

20

1.02

0.53

20

11.6%

0.14 [–0.18, 0.46]


–1

0.2

24 44

–1.19

0.26

25 45

18.5% 30.2%

0.19 [0.06, 0.32] 0.18 [0.06, 0.30]

1.31

0.44

58 58

16.4% 16.4%

–0.30 [–0.49, –0.11] –0.30 [–0.49, –0.11]

209 100.0%

0.05 [–0.12, 0.21]

Heterogeneity: τ2 = 0.00; χ2 = 0.08, df = 1 (P = 0.78); I2 = 0% Test for overall effect: Z = 2.98 (P = 0.003) 1.4.3 5 year data 1.01

Prosper et al. (2010) Subtotal (95% CI)

0.59

58 58

Heterogeneity: Not applicable Test for overall effect: Z = 3.10 (P = 0.002) Total (95% CI)

207


2

2

–0.5 –0.25

Test for overall effect: Z = 0.58 (P = 0.56)

Favours CL

Test for subgroup differences: χ2 = 17.91, df = 2 (P = 0.0001), I2 = 88.8%

0

0.25

0.5

Favours IL

(b) 0

SE (MD)

0.05

0.1

0.15

MD


–0.25 2 year data

0

0.25

0.5

5 year data

Fig. 6. (a) Forest plot for marginal bone-level changes (immediate loading vs. conventional loading [CL] in fresh extraction sites). (b) Funnel plot for marginal bone-level changes (Immediate loading vs. CL in fresh extraction sites).

680 |




(a)



Mean difference

Mean difference

Total Weight

IV, Random, 95% CI

20

11.7%

–0.06 [–0.19, 0.07]

98

5.7%

0.09 [–0.22, 0.40]

0.31

97

13.9%

0.03 [–0.05, 0.11]

0.24

0.12

58

15.1%

–0.07 [–0.11, –0.03]

–0.99

0.22

25 298

12.8% 59.2%

0.24 [0.13, 0.35] 0.04 [–0.08, 0.16]

Mean

SD

Total

Mean

SD

Danza et al. (2010)

0.38

0.21

20

0.44

0.22


0.38

0.89

55

0.29

1


0.98

0.27

98

0.95


0.17

0.11

58

–0.75

0.17

24 255

Study or subgroup

IV, Random, 95% CI

1.6.1 1 year data



1.16

0.51

20

1.02

0.53

20

5.3%

0.14 [–0.18, 0.46]


1.33

0.25

98

1.28

0.28

97

14.2%

0.05 [–0.02, 0.12]

–1

0.2

24 142

–1.19

0.26

25 142

11.9% 31.4%

0.19 [0.06, 0.32] 0.11 [0.00, 0.21]

1.31

0.44

58 58

9.4% 9.4%

–0.30 [–0.49, –0.11] –0.30 [–0.49, –0.11]

498 100.0%

0.03 [–0.06, 0.12]


Heterogeneity: τ2 = 0.00; χ2 = 3.48, df = 2 (P = 0.18); I2 = 42% Test for overall effect: Z = 2.02 (P = 0.04) 1.6.3 5 year data 58 58

0.59

1.01

Prosper et al. (2010) Subtotal (95% CI) Heterogeneity: Not applicable

Test for overall effect: Z = 3.10 (P = 0.002) 455

Total (95% CI)


2

2


Test for overall effect: Z = 0.67 (P = 0.50) Test for subgroup differences: χ2 = 13.75, df = 2 (P = 0.001), I2 = 85.5%

(b) 0

SE (MD)

0.05

0.1

0.15

MD


–0.25 2 year data

0

0.25

0.5

5 year data

Fig. 4. (a) Forest plot for marginal bone-level changes (immediate functional vs. conventional loading [CL]). (b) Funnel plot for marginal bone-level changes (immediate functional vs. CL).

The anatomical region of implant placement also varied between the analyzed articles, which is in turn correlated with bone

678 |


quality. In five articles (Hall et al. 2006; Crespi et al. 2008; De Rouck et al. 2009; Degidi et al. 2009; den Hartog et al. 2011), implants were

placed in the maxilla, in two studies (Prosper et al. 2010; Margossian et al. 2012) in the mandible and in three studies (Donati et al.



(a)



Mean difference

Mean difference

Mean

SD

Total

Mean

SD


0.97

0.35

23

0.86

0.54

23

3.2%

0.11 [–0.15, 0.37]


0.58

0.28

30

0.69

0.38

30

7.9%

–0.11 [–0.28, 0.06]

Study or subgroup

Total Weight

IV, Random, 95% CI

IV, Random, 95% CI

1.5.1 1 year data

0.9

0.57

31

0.91

0.61

30

2.6%

–0.01 [–0.31, 0.29]

Hall et al. (2006)

0.78

1.9

12

0.64

1.36

12

0.1%

0.14 [–1.18, 1.46]

Margossian et al. (2012) Subtotal (95% CI)

0.98

0.27

98 194

0.96

0.29

105 200

37.9% 51.7%

0.02 [–0.06, 0.10] 0.00 [–0.06, 0.07]

den Hartog et al. (2011)

Heterogeneity: τ2 = 0.00; χ2 = 2.59, df = 4 (P = 0.63); I2 = 0% Test for overall effect: Z = 0.14 (P = 0.89) 1.5.2 2 year data Degidi et al. (2009) Margossian et al. (2012) Subtotal (95% CI)

0.7

0.3

30

0.73

0.39

30

7.2%

–0.03 [–0.21, 0.15]

1.33

0.25

98 128

1.27

0.3

105 135

39.1% 46.4%

0.06 [–0.02, 0.14] 0.05 [–0.02, 0.12]

0.85

0.71

30 30

1.9% 1.9%

–0.10 [–0.44, 0.24] –0.10 [–0.44, 0.24]

365 100.0%

0.02 [–0.03, 0.07]


Degidi et al. (2009) Subtotal (95% CI)

0.63

30 30

Heterogeneity: Not applicable Test for overall effect: Z = 0.58 (P = 0.56) 352

Total (95% CI)

Heterogeneity: τ = 0.00; χ = 4.65, df = 7 (P = 0.70); I = 0% 2

2

2

–0.5 –0.25


Favours CL

Test for subgroup differences: χ2 = 1.22, df = 2 (P = 0.54), I2 = 0%

0

0.25

0.5

Favours IL

(b) 0

SE (MD)

0.2

0.4

0.6

0.8

MD

1 –0.5 Subgroups 1 year data

–0.25 2 year data

0

0.25

0.5

3 year data

Fig. 5. (a) Forest plot for marginal bone-level changes (immediate non-functional vs. conventional loading [CL]). (b) Funnel plot for marginal bone-level changes (immediate non-functional vs. CL).


679 |



(a)



Mean difference

Mean

SD

Total

Mean

SD


0.97

0.35

23

0.86

0.54

23

13.7%

0.11 [–0.15, 0.37]


0.17

0.11

58

0.24

0.12

58

20.6%

–0.07 [–0.11, –0.03]

–0.75

0.17

24 105

–0.99

0.22

25 106

19.1% 53.4%

0.24 [0.13, 0.35] 0.09 [–0.15, 0.33]

Study or subgroup

Total Weight

Mean difference

IV, Random, 95% CI

IV, Random, 95% CI

1.4.1 1 year data



1.16

0.51

20

1.02

0.53

20

11.6%

0.14 [–0.18, 0.46]


–1

0.2

24 44

–1.19

0.26

25 45

18.5% 30.2%

0.19 [0.06, 0.32] 0.18 [0.06, 0.30]

1.31

0.44

58 58

16.4% 16.4%

–0.30 [–0.49, –0.11] –0.30 [–0.49, –0.11]

209 100.0%

0.05 [–0.12, 0.21]


Prosper et al. (2010) Subtotal (95% CI)

0.59

58 58

Heterogeneity: Not applicable Test for overall effect: Z = 3.10 (P = 0.002) Total (95% CI)

207


2

2

–0.5 –0.25


Favours CL

Test for subgroup differences: χ2 = 17.91, df = 2 (P = 0.0001), I2 = 88.8%

0

0.25

0.5

Favours IL

(b) 0

SE (MD)

0.05

0.1

0.15

MD


–0.25 2 year data

0

0.25

0.5

5 year data

Fig. 6. (a) Forest plot for marginal bone-level changes (immediate loading vs. conventional loading [CL] in fresh extraction sites). (b) Funnel plot for marginal bone-level changes (Immediate loading vs. CL in fresh extraction sites).

680 |




(a)



Mean difference

Mean difference

Total Weight

IV, Random, 95% CI

IV, Random, 95% CI

20

9.1%

–0.06 [–0.19, 0.07]

30

5.6%

–0.11 [–0.28, 0.06]

0.61

30

1.8%

–0.01 [–0.31, 0.29]

0.29

1

98

1.7%

0.09 [–0.22, 0.40]

12

0.64

1.36

12

0.1%

0.14 [–1.18, 1.46]

98 246

0.96

0.3

202 392

35.3% 53.6%

0.02 [–0.05, 0.09] –0.01 [–0.06, 0.05]

Mean

SD

Total

Mean

SD

Danza et al. (2010)

0.38

0.21

20

0.44

0.22


0.58

0.28

30

0.69

0.38

0.9

0.57

31

0.91


0.38

0.89

55

Hall et al. (2006)

0.78

1.9

Margossian et al. (2012) Subtotal (95% CI)

0.98

0.27

Study or subgroup 1.3.1 1 year data

den Hartog et al. (2011)

Heterogeneity: τ2 = 0.00; χ2 = 3.08, df = 5 (P = 0.69); I2 = 0% Test for overall effect: Z = 0.21 (P = 0.84) 1.3.2 2 year data Degidi et al. (2009) Margossian et al. (2012) Subtotal (95% CI)

0.7

0.3

30

0.73

0.39

30

5.2%

–0.03 [–0.21, 0.15]

1.33

0.25

98 128

1.28

0.29

202 232

39.8% 45.0%

0.05 [–0.01, 0.11] 0.04 [–0.02, 0.10]

0.85

0.71

30 30

1.4% 1.4%

–0.10 [–0.44, 0.24] –0.10 [–0.44, 0.24]

654 100.0%

0.01 [–0.03, 0.05]

Heterogeneity: τ2 = 0.00; χ2 = 0.70, df = 1 (P = 0.40); I2 = 0% Test for overall effect: Z = 1.33 (P = 0.18) 1.3.3 3 year data Degidi et al. (2009) Subtotal (95% CI)

0.63

0.75

30 30

Heterogeneity: Not applicable Test for overall effect: Z = 0.58 (P = 0.56) 404

Total (95% CI)

Heterogeneity: τ2 = 0.00; χ2 = 5.48, df = 8 (P = 0.71); I2 = 0%


Test for overall effect: Z = 0.67 (P = 0.50) Test for subgroup differences: χ2 = 1.70, df = 2 (P = 0.43), I2 = 0%

(b) 0

SE (MD)

0.2

0.4

0.6

0.8

MD

1 –0.5

–0.25

0

0.25

0.5

Subgroups 1 year data

2 year data

3 year data

Fig. 7. (a) Forest plot for marginal bone-level changes (Immediate loading vs. Conventional loading [CL] in healed sites). (b) Funnel plot for marginal bone-level changes (Immediate loading vs. CL in healed sites).


681 |



2008; Danza et al. 2010; Shibly et al. 2010) in both maxilla and mandible. Additional variation exists in relation to posterior and anterior maxilla and mandible regions. Lastly, considerable variation between the studies became obvious concerning implant systems, implant diameter, implant length and implant configuration. All studies used rough-surfaced implants, and the minimal insertion torque ranged from 20 Ncm (Donati et al. 2008) to 45 Ncm (den Hartog et al. 2011) with the remaining studies adopting a value in between. In two studies (Hall et al. 2006; Prosper et al. 2010), the insertion torque value is not mentioned or recorded. Furthermore, the implant stability quotient (ISQ) values are only mentioned in three studies (Crespi et al. 2008; Degidi et al. 2009; Margossian et al. 2012) as more than 60.

Discussion The objective of the present study was to meta-analyze exclusively RCTs reporting at least 1-year outcome data on loading within 24 h after implant placement as compared to CL. The H0-hypotheses of no significant differences regarding implant survival rates and mean peri-implant bone-level changes for the two loading protocols were not rejected. The reported implant failure rates are in line with other reviews (Ioannidou & Doufexi 2005; Atieh et al. 2009; Alsabeeha et al. 2010; den Hartog et al. 2011; Esposito et al. 2013). For the purpose of this review, the two immediate loading groups (functional and non-functional loading) in the study of Margossian et al. (2012) were statistically combined in terms of AFRs and marginal bonelevel changes. However, in the present review, the problem of missing data has to be addressed. Shibly et al. (2010) had a dropout of two

patients, and there was no information which group they had been allocated to. To compensate for this lack, the review team decided to equally distribute the dropout implants within the groups (one implant in the immediate loading group, one implant in the conventionally loading group) and assumed that one of the two implants was a failure (see Table 2). Looking at survival rates in the literature, this assumption is rather generous in favor of implant failures. An alternative option would be a “sensitivity analysis” (Deeks et al. 2008b), meaning that for each implant in each group a “best case” and a “worst case” scenario are calculated to evaluate possible influence on statistical outcome. This would (assuming that all dropped-out implants survived) decrease the AFR for CL from 2.3% to 1.6% or increase the AFR (assuming the opposite) for immediate loading from 2.3% to 3.0%. Both of these (very hypothetical) results are still in the range of failure rates given in the current literature. Despite methodological dissimilarities, the currently found differences between immediate loading and CL with regard to marginal bone-level changes over time are – in clinical terms – in line with other meta-analytical approaches to the literature (Atieh et al. 2009; Esposito et al. 2013; Suarez et al. 2013). Esposito et al. (2013) found a clinically irrelevant difference of 0.1 mm, Atieh et al. (2010) of 0.31 mm and Suarez et al. (2013) of 0.09 mm favoring immediate loading. Noteworthy in the current review with reference to MBL changes are the missing data in one study (Shibly et al. 2010) where 11 of 60 implants were not radiographically analyzed, and their group allocation was not stated. Therefore, the missing data were distributed within the groups (five implants in IL group, six in CL group). The statistical significance did not change after reversing the numbers.

Moreover, the overall differences in marginal bone-level changes between immediate functional vs. non-functional loading and CL as well as immediate compared to CL in healed or fresh extraction sites appeared to be not statistically significant. However, the results of the current review should be interpreted with caution and understood as an analysis of a relatively small number of currently available RCTs comparing immediate loading within 24 h with CL. Evidence is still limited to draw definitive conclusions, but the present and formerly published results of meta-analytical approaches to the literature seem to confirm that the loading protocol – i.e., immediate loading or CL – is irrelevant for clinical outcome data as implant survival or marginal bone-level stability.

Conclusion Within the limits of this meta-analytic approach to the literature, we conclude that (1) the number of studies regarding RCTs reporting at least 1-year outcome data on loading within 24 h after implant placement as compared to CL is limited and that (2) no clinically relevant difference regarding AFRs as well as radiographic bone-level changes between conventionally and immediately loaded implants can be found, for up to 5 years of follow-up.

Acknowledgements: The authors would like to thank Dr. Ewald M. Bronkhorst, Department of Preventive and Curative Dentistry and Biostatistics, Radboud University Nijmegen Medical Centre, for his invaluable statistical support.

References Alsabeeha, N., Atieh, M. & Payne, A.G. (2010) Loading protocols for mandibular implant overdentures: a systematic review with meta-analysis. Clinical Implant Dentistry & Related Research 12(Suppl. 1): e28–e38. Aparicio, C., Rangert, B. & Sennerby, L. (2003) Immediate/early loading of dental implants: a report from the Sociedad Espanola de Implantes World Congress consensus meeting in Barcelona, Spain, 2002. Clinical Implant Dentistry & Related Research 5: 57–60. Atieh, M.A., Atieh, A.H., Payne, A.G. & Duncan, W.J. (2009) Immediate loading with single implant crowns: a systematic review and

682 |


meta-analysis. The International Journal of Prosthodontics 22: 378–387. Atieh, M.A., Payne, A.G., Duncan, W.J., de Silva, R.K. & Cullinan, M.P. (2010) Immediate placement or immediate restoration/loading of single implants for molar tooth replacement: a systematic review and meta-analysis. The International Journal of Oral & Maxillofacial Implants 25: 401–415. Berglundh, T., Persson, L. & Klinge, B. (2002) A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. Journal of Clinical Periodontology 29(Suppl. 3): 197–212; discussion 232-3.

Branemark, P.I., Hansson, B.O., Adell, R., Breine, U., Lindstrom, J., Hallen, O. & Ohman, A. (1977) Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery Supplementum 16: 1–132. Cochran, D.L., Morton, D. & Weber, H.P. (2004) Consensus statements and recommended clinical procedures regarding loading protocols for endosseous dental implants. The International Journal of Oral & Maxillofacial Implants 19(Suppl.): 109–113. Crespi, R., Cappare, P., Gherlone, E. & Romanos, G.E. (2008) Immediate versus delayed loading of



dental implants placed in fresh extraction sockets in the maxillary esthetic zone: a clinical comparative study. The International Journal of Oral & Maxillofacial Implants 23: 753–758. Danza, M., Tortora, P., Quaranta, A., Perrotti, V., Vozza, I. & Piattelli, A. (2010) Randomised study for the 1-year crestal bone maintenance around modified diameter implants with different loading protocols: a radiographic evaluation. Clinical Oral Investigations 14: 417–426. De Rouck, T., Collys, K., Wyn, I. & Cosyn, J. (2009) Instant provisionalization of immediate singletooth implants is essential to optimize esthetic treatment outcome. Clinical Oral Implants Research 20: 566–570. Deeks, J.J., Higgins, J.P.T. & Altman, D.G. (2008a) Chapter 9: analysing data and undertaking metaanalyses. In: Higgins, J.P.T. & Green, S. eds. Cochrane Handbook for Systematic Reviews of Interventions, 282–289. Chichester, UK: John Wiley & Sons. Deeks, J.J., Higgins, J.P.T. & Altman, D.G. (2008b) Chapter 16: special topics in statistics. In: Higgins, J.P.T. & Green, S., eds. Cochrane Handbook for Systematic Reviews of Interventions, 482–484. Chichester, UK: John Wiley & Sons. Degidi, M., Nardi, D. & Piattelli, A. (2009) Immediate versus one-stage restoration of small-diameter implants for a single missing maxillary lateral incisor: a 3-year randomized clinical trial. Journal of Periodontology 80: 1393–1398. Den Hartog, L., Raghoebar, G.M, Stellingsma, K. , Vissink, A. & Meijer, H.J. (2011) Immediate non-occlusal loading of single implants in the

aesthetic zone: a randomized clinical trial. Journal of Clinical Periodontology 38: 186–194. Donati, M., La Scala, V., Billi, M., Di Dino, B., Torrisi, P. & Berglundh, T. (2008) Immediate functional loading of implants in single tooth replacement: a prospective clinical multicenter study. Clinical Oral Implants Research 19: 740–748. Esposito, M., Grusovin, M.G., Maghaireh, H. & Worthington, H.V. (2013) Interventions for replacing missing teeth: different times for loading dental implants. Cochrane Database of Systematic Reviews 3: CD003878. Hall, J., Payne, A., Purton, D. & Torr, B. (2006) A randomized controlled clinical trial of conventional and immediately loaded tapered implants with screw-retained crowns. The International Journal of Prosthodontics 19: 17–19. den Hartog, L., Raghoebar, G.M., Stellingsma, K., Vissink, A. & Meijer, H.J. (2011) Immediate nonocclusal loading of single implants in the aesthetic zone: a randomized clinical trial. Journal of Clinical Periodontology 38: 186–194. Higgins, J.P.T., Altman, D.G. & Sterne, J.A.C. (2009) Chapter 8: assessing risk of bias in included studies. In: Higgins, J.P.T. & Green, S. eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 Chapter 8.3. The Cochrane Collaboration, 2011. Available from www.cochranehandbook.org. Ioannidou, E. & Doufexi, A. (2005) Does loading time affect implant survival? A meta-analysis of 1,266 implants. Journal of Periodontology 76: 1252–1258.

Margossian, P., Mariani, P., Stephan, G., Margerit, J. & Jorgensen, C. (2012) Immediate loading of mandibular dental implants in partially edentulous patients: a prospective randomized comparative study. International Journal of Periodontics and Restorative Dentistry 32: e51–e58. Nkenke, E. & Fenner, M. (2006) Indications for immediate loading of implants and implant success. Clinical Oral Implants Research 17(Suppl. 2): 19–34. Pjetursson, B.E., Tan, K., Lang, N.P., Bragger, U., Egger, M. & Zwahlen, M. (2004) A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years. Clinical Oral Implants Research 15: 667–676. Prosper, L., Crespi, R., Valenti, E., Cappare, P. & Gherlone, E. (2010) Five-year follow-up of wide-diameter implants placed in fresh molar extraction sockets in the mandible: immediate versus delayed loading. The International Journal of Oral & Maxillofacial Implants 25: 607–612. Shibly, O., Patel, N., Albandar, J.M. & Kutkut, A. (2010) Bone regeneration around implants in periodontally compromised patients: a randomized clinical trial of the effect of immediate implant with immediate loading. Journal of Periodontology 81: 1743–1751. Suarez, F., Chan, H.L., Monje, A., Galindo-Moreno, P. & Wang, H.L. (2013) Effect of the timing of restoration on implant marginal bone loss: a systematic review. Journal of Periodontology 84: 159–169.

Arvidson, K., Esselin, O., Felle-Persson, E., Jonsson, G., Smedberg, J. & Soderstrom, U. (2008) Early loading of mandibular full-arch bridges screw retained after 1 week to four to five Monotypeâ implants: 3-year results from a prospective multicentre study. Clinical Oral Implants Research 19: 693–703. Balshi, S., Wolfinger, G. & Balshi, T. (2005) A prospective study of immediate functional loading, following the Teeth in a DayTM protocol: a case series of 55 consecutive edentulous maxillas. Clinical Implant Dentistry & Related Research 7: 24–31. Barone, A., Rispoli, L., Vozza, I., Quaranta, A. & Covani, U. (2006) Immediate restoration of single implants placed immediately after tooth extraction. Journal of Periodontology 77: 1914–1920. Bergkvist, G., Nilner, K., Sahlholm, S., Karlsson, U. & Lindh, C. (2009) Immediate loading of implants in the edentulous maxilla: use of an interim fixed prosthesis followed by a permanent fixed prosthesis: a 32-month prospective radiological and clinical study. Clinical Implant Dentistry & Related Research 11: 1–10. Bergkvist, G., Sahlholm, S., Karlsson, U., Nilner, K. & Lindh, C. (2005) Immediately loaded implants supporting fixed prostheses in the edentulous

maxilla: a preliminary clinical and radiologic report. The International Journal of Oral & Maxillofacial Implants 20: 399–405. Boronat-Lopez, A., Carrillo, C., Pe~ narrocha, M. & Pe~ narrocha-Diago, M. (2009) Immediately restored dental implants for partial-arch applications: a study of 12 cases. Journal of Oral and Maxillofacial Surgery 67: 195–199. € Br anemark, P., Engstrand, P., Ohrnell, L., Gr€ ondahl, K., Nilsson, P., Hagberg, K., Darle, C. & Lekholm, U. (1999) Br anemark Novumâ: a new treatment concept for rehabilitation of the edentulous mandible. Preliminary results from a prospective clinical follow-up study. Clinical Implant Dentistry & Related Research 1: 2–16. Buchs, A., Levine, L. & Moy, P. (2001) Preliminary report of immediately loaded Altiva Natural Tooth Replacement dental implants. Clinical Implant Dentistry & Related Research 3: 97–106. Calandriello, R. & Tomatis, M. (2005) Simplified treatment of the atrophic posterior maxilla via immediate/early function and tilted implants: a prospective 1-year clinical study. Clinical Implant Dentistry & Related Research 7: S1–S12. Calandriello, R., Tomatis, M. & Rangert, B. (2003) Immediate functional loading of Br anemark Systemâ implants with enhanced initial stability: a prospective 1–to 2-year clinical and radiographic

Appendix 1 General exclusions Aalam, A., Nowzari, H. & Krivitsky, A. (2005) Functional restoration of implants on the day of surgical placement in the fully edentulous mandible: a case series. Clinical Implant Dentistry & Related Research 7: 10–16. Abboud, M., Koeck, B., Stark, H., Wahl, G. & Paillon, R. (2005) Immediate loading of single-tooth implants in the posterior region. The International Journal of Oral & Maxillofacial Implants 20: 61–68. Agliardi, E., Cleric o, M., Ciancio, P. & Massironi, D. (2010) Immediate loading of full-arch fixed prostheses supported by axial and tilted implants for the treatment of edentulous atrophic mandibles. Quintessence International 41: 285–293. Anitua, E., Orive, G., Aguirre, J. & Andıa, I. (2008) Clinical outcome of immediately loaded dental implants bioactivated with plasma rich in growth factors: a 5-year retrospective study. Journal of Periodontology 79: 1168–1176. Artzi, Z., Kohen, J., Carmeli, G., Karmon, B., Lor, A. & Ormianer, Z. (2010) The efficacy of full-arch immediately restored implant-supported reconstructions in extraction and healed sites: a 36month retrospective evaluation. The International Journal of Oral & Maxillofacial Implants 25: 329–335.


683 |



study. Clinical Implant Dentistry & Related Research 5: 10–20. Calandriello, R., Tomatis, M., Vallone, R., Rangert, B. & Gottlow, J. (2003) Immediate occlusal loading of single lower molars using Br anemark Systemâ Wide-Platform TiUniteTM implants: an interim report of a prospective open-ended clinical multicenter study. Clinical Implant Dentistry & Related Research 5: 74–80. Cannizzaro, G. & Leone, M. (2003) Restoration of partially edentulous patients using dental implants with a microtextured surface: a prospective comparison of delayed and immediate full occlusal loading. The International Journal of Oral & Maxillofacial Implants 18: 512–522. Cannizzaro, G., Leone, M. & Esposito, M. (2007) Immediate functional loading of implants placed with flapless surgery in the edentulous maxilla: 1-year follow-up of a single cohort study. The International Journal of Oral & Maxillofacial Implants 22: 87–95. Capelli, M., Zuffetti, F., Del Fabbro, M. & Testori, T. (2007) Immediate rehabilitation of the completely edentulous jaw with fixed prostheses supported by either upright or tilted implants: a multicenter clinical study. The International Journal of Oral & Maxillofacial Implants 22: 639–644. Chaushu, G., Chaushu, S., Tzohar, A. & Dayan, D. (2001) Immediate loading of single-tooth implants: immediate versus non-immediate implantation. A clinical report. The International Journal of Oral & Maxillofacial Implants 16: 267–272. Chiapasco, M. & Gatti, C. (2003) Implant-retained mandibular overdentures with immediate loading: a 3- to 8-year prospective study on 328 implants. Clinical Implant Dentistry & Related Research 5: 29–38. Chiapasco, M., Gatti, C., Rossi, E., Haefliger, W. & Markwalder, T. (1997) Implant-retained mandibular overdentures with immediate loading. Clinical Oral Implants Research 8: 48–57. Chow, J., Hui, E., Liu, J., Li, D., Wat, P., Li, W., Kwong Yau, Y. & Law, H. (2001) The Hong Kong Bridge Protocol. Immediate loading of mandibular Br anemark fixtures using a fixed provisional prosthesis: preliminary results. Clinical Implant Dentistry & Related Research 3: 166–174. Collaert, B. & De Bruyn, H. (2008) Immediate functional loading of TiOblast dental implants in fullarch edentulous maxillae: a 3-year prospective study. Clinical Oral Implants Research 19: 1254– 1260. Cooper, L., Rahman, A., Moriarty, J., Chaffee, N. & Sacco, D. (2002) Immediate mandibular rehabilitation with endosseous implants: simultaneous extraction, implant placement, and loading. The International Journal of Oral & Maxillofacial Implants 17: 517–525. Cornelini, R., Cangini, F., Covani, U., Barone, A. & Buser, D. (2004) Immediate restoration of singletooth implants in mandibular molar sites: a 12month preliminary report. The International Journal of Oral & Maxillofacial Implants 19: 855–860. Cornelini, R., Cangini, F., Covani, U., Barone, A. & Buser, D. (2006) Immediate loading of implants

684 |


with 3-unit fixed partial dentures: a 12-month clinical study. The International Journal of Oral & Maxillofacial Implants 21: 914–918. Cornelini, R., Cangini, F., Covani, U. & Wilson, T. Jr (2005) Immediate restoration of implants placed into fresh extraction sockets for single-tooth replacement: a prospective clinical study. The International Journal of Periodontics & Restorative Dentistry 25: 439–447. Crespi, R., Cappare, P., Gherlone, E. & Romanos, G. (2007) Immediate occlusal loading of implants placed in fresh sockets after tooth extraction. The International Journal of Oral & Maxillofacial Implants 22: 955–962. De Smet, E., Duyck, J., Vander Sloten, J., Jacobs, R. & Naert, I. (2007) Timing of loading–immediate, early, or delayed–in the outcome of implants in the edentulous mandible: a prospective clinical trial. The International Journal of Oral & Maxillofacial Implants 22: 580–594. Degidi, M., Perrotti, V. & Piattelli, A. (2006) Immediately loaded titanium implants with a porous anodized surface with at least 36 months of follow-up. Clinical Implant Dentistry & Related Research 8: 169–177. Degidi, M. & Piattelli, A. (2003) Immediate functional and non-functional loading of dental implants: a 2- to 60-month follow-up study of 646 titanium implants. Journal of Periodontology 74: 225–241. Degidi, M. & Piattelli, A. (2005) A 7-year follow-up of 93 immediately loaded titanium dental implants. Journal of Oral Implantology 31: 25–31. Degidi, M., Piattelli, A. & Carinci, F. (2006) Parallel screw cylinder implants: comparative analysis between immediate loading and two-stage healing of 1005 dental implants with 2-year follow up. Clinical Implant Dentistry & Related Research 8: 151–160. Degidi, M., Piattelli, A. & Carinci, F. (2007) Immediate loaded dental implants: comparison between fixtures inserted in postextractive and healed bone sites. Journal of Craniofacial Surgery 18: 965–971. Degidi, M., Piattelli, A., Felice, P. & Carinci, F. (2005) Immediate functional loading of edentulous maxilla: a 5-year retrospective study of 388 titanium implants. Journal of Periodontology 76: 1016–1024. Degidi, M., Piattelli, A., Gehrke, P. & Carinci, F. (2006) Clinical outcome of 802 immediately loaded 2-stage submerged implants with a new grit-blasted and acid-etched surface: 12-month follow-up. The International Journal of Oral & Maxillofacial Implants 21: 763–768. Degidi, M., Piattelli, A., Gehrke, P., Felice, P. & Carinci, F. (2006) Five-year outcome of 111 immediate nonfunctional single restorations. Journal of Oral Implantology 32: 277–285. Degidi, M., Piattelli, A., Iezzi, G. & Carinci, F. (2007) Do longer implants improve clinical outcome in immediate loading? The International Journal of Oral and Maxillofacial Surgery 36: 1172–1176. Degidi, M., Piattelli, A., Iezzi, G. & Carinci, F. (2007) Immediately loaded short implants: analysis of a case series of 133 implants. Quintessence International 38: 193–201.

Degidi, M., Piattelli, A., Iezzi, G. & Carinci, F. (2007) Retrospective study of 200 immediately loaded implants retaining 50 mandibular overdentures. Quintessence International 38: 281–288. Drago, C. & Lazzara, R. (2004) Immediate provisional restoration of Osseotite implants: a clinical report of 18-month results. The International Journal of Oral & Maxillofacial Implants 19: 534–541. Drago, C. & Lazzara, R. (2006) Immediate occlusal loading of Osseotiteâ implants in mandibular edentulous patients: a prospective observational report with 18-month data. Journal of Prosthodontics 15: 187–194. Erakat, M., Chuang, S., Yoo, R., Weed, M. & Dodson, T. (2008) Immediate loading of splinted locking-taper implants: 1-year survival estimates and risk factors for failure. The International Journal of Oral & Maxillofacial Implants 23: 105–110. Ferrara, A., Galli, C., Mauro, G. & Macaluso, G. (2006) Immediate provisional restoration of postextraction implants for maxillary single-tooth replacement. The International Journal of Periodontics & Restorative Dentistry 26: 371–377. Finne, K., Rompen, E. & Toljanic, J. (2007) Clinical evaluation of a prospective multicenter study on 1-piece implants. Part 1: marginal bone level evaluation after 1 year of follow-up. The International Journal of Oral & Maxillofacial Implants 22: 226–234. Fischer, K., B€ackstr€ om, M. & Sennerby, L. (2009) Immediate and early loading of oxidized tapered implants in the partially edentulous maxilla: a 1-year prospective clinical, radiographic, and resonance frequency analysis study. Clinical Implant Dentistry & Related Research 11: 69–80. Ganeles, J., Rosenberg, M., Holt, R. & Reichman, L. (2001) Immediate loading of implants with fixed restorations in the completely edentulous mandible: report of 27 patients from a private practice. The International Journal of Oral & Maxillofacial Implants 16: 418–426. Gatti, C. & Chiapasco, M. (2002) Immediate loading of Br anemark implants: a 24-month follow-up of a comparative prospective pilot study between mandibular overdentures supported by Conicalâ transmucosal and standard MK II implants. Clinical Implant Dentistry & Related Research 4: 190–199. Glauser, R., Ree, A., Lundgren, A., Gottlow, J., Hammerle, C. & Scharer, P. (2001) Immediate occlusal loading of Br anemark implants applied in various jawbone regions: a prospective, 1-year clinical study. Clinical Implant Dentistry & Related Research 3: 204–213. Glauser, R., Ruhstaller, P., Windisch, S., Zembic, A., Lundgren, A., Gottlow, J. & H€ammerle, C. (2005) Immediate occlusal loading of Br anemark System TiUniteTM implants placed predominantly in soft bone: 4-year results of a prospective clinical study. Clinical Implant Dentistry & Related Research 7: S52–S59. Glauser, R., Zembic, A., Ruhstaller, P. & Windisch, S. (2007) Five-year results of implants with an oxidized surface placed predominantly in soft quality bone and subjected to immediate occlusal loading. Journal of Prosthetic Dentistry 97: S59– S68.



Groisman, M., Frossard, W., Ferreira, H., de Menezes, F. & Touati, B. (2003) Single-tooth implants in the maxillary incisor region with immediate provisionalization: 2-year prospective study. Practical Procedures and Aesthetic Dentistry 15: 115–122. Grunder, U. (2001) Immediate functional loading of immediate implants in edentulous arches: two-year results. The International Journal of Periodontics & Restorative Dentistry 21: 545– 551. Hahn, J. (2007) Clinical and radiographic evaluation of one-piece implants used for immediate function. Journal of Oral Implantology 33: 152–155. Henry, P., Steenberghe, D., Blomback, U., Polizzi, G., Rosenberg, R., Urgell, J. & Wendelhag, I. (2003) Prospective multicenter study on immediate rehabilitation of edentulous lower jaws according to the Br anemark Novum protocol. Clinical Implant Dentistry & Related Research 5: 137–142. Hinze, M., Thalmair, T., Bolz, W. & Wachtel, H. (2010) Immediate loading of fixed provisional prostheses using four implants for the rehabilitation of the edentulous arch: a prospective clinical study. The International Journal of Oral & Maxillofacial Implants 25: 1011–1018. Horiuchi, K., Uchida, H., Yamamoto, K. & Sugimura, M. (2000) Immediate loading of Branemark system implants following placement in edentulous patients: a clinical report. The International Journal of Oral & Maxillofacial Implants 15: 824–830. Hui, E., Chow, J., Li, D., Liu, J., Wat, P. & Law, H. (2001) Immediate provisional for single-tooth implant replacement with br anemark system: preliminary report. Clinical Implant Dentistry & Related Research 3: 79–86. Iba~ nez, J. & Jalbout, Z. (2002) Immediate loading of Osseotite implants: two-year results. Implant Dentistry 11: 128–136. Ibanez, J., Tahhan, M., Zamar, J., Menendez, A., Juaneda, A., Zamar, N. & Monqaut, J. (2005) Immediate occlusal loading of double acid-etched surface titanium implants in 41 consecutive fullarch cases in the mandible and maxilla: 6-to 74-month results. Journal of Periodontology 76: 1972–1981. Jaffin, R., Kumar, A. & Berman, C. (2004) Immediate loading of dental implants in the completely edentulous maxilla: a clinical report. The International Journal of Oral & Maxillofacial Implants 19: 721–730. Kacer, C.M., Dyer, J. & Kraut, R. (2010) Immediate loading of dental implants in the anterior and posterior mandible: a retrospective study of 120 cases. Journal of Oral and Maxillofacial Surgery 68: 2861–2867. Kan, J., Rungcharassaeng, K., Liddelow, G., Henry, P. & Goodacre, C. (2007) Periimplant tissue response following immediate provisional restoration of scalloped implants in the esthetic zone: a one-year pilot prospective multicenter study. Journal of Prosthetic Dentistry 97: S109– S118. Kan, J., Rungcharassaeng, K. & Lozada, J. (2003) Immediate placement and provisionalization of maxillary anterior single implants: 1-year

prospective study. The International Journal of Oral & Maxillofacial Implants 18: 31–39. Kan, J., Rungcharassaeng, K., Sclar, A. & Lozada, J. (2007) Effects of the facial osseous defect morphology on gingival dynamics after immediate tooth replacement and guided bone regeneration: 1-year results. Journal of Oral and Maxillofacial Surgery 65: 13–19. Kinsel, R., Lamb, R. & Moneim, A. (2000) Development of gingival esthetics in the edentulous patient with immediately loaded, single-stage, implant-supported fixed prostheses: a clinical report. The International Journal of Oral & Maxillofacial Implants 15: 711–721. Kinsel, R. & Liss, M. (2007) Retrospective analysis of 56 edentulous dental arches restored with 344 single-stage implants using an immediate loading fixed provisional protocol: statistical predictors of implant failure. The International Journal of Oral & Maxillofacial Implants 22: 823–830. Lee, C. (2006) Immediate load protocol for anterior maxilla with cortical bone from mandibular ramus. Implant Dentistry 15: 153–159. Li, W., Chow, J., Hui, E., Lee, P. & Chow, R. (2009) Retrospective study on immediate functional loading of edentulous maxillas and mandibles with 690 implants, up to 71 months of follow-up. Journal of Oral and Maxillofacial Surgery 67: 2653–2662. Locante, W. (2004) Single-tooth replacements in the esthetic zone with an immediate function implant: a preliminary report. Journal of Oral Implantology 30: 369–375. Longoni, S., Sartori, M., Apruzzese, D., Davide, R. & Baldoni, M. (2007) Immediate loading: a simple protocol to create a passively fitting provisional fixed implant-supported complete denture in 1 day. The International Journal of Periodontics & Restorative Dentistry 27: 369–377. Lorenzoni, M., Pertl, C., Zhang, K., Wimmer, G. & Wegscheider, W. (2003) Immediate loading of single-tooth implants in the anterior maxilla. Preliminary results after one year. Clinical Oral Implants Research 14: 180–187. Machtei, E., Frankenthal, S., Blumenfeld, I., Gutmacher, Z. & Horwitz, J. (2007) Dental implants for immediate fixed restoration of partially edentulous patients: a 1-year prospective pilot clinical trial in periodontally susceptible patients. Journal of Periodontology 78: 1188–1194. Mal o, P., De Ara ujo Nobre, M., Petersson, U. & Wigren, S. (2006) A pilot study of complete edentulous rehabilitation with immediate function using a new implant design: case series. Clinical Implant Dentistry & Related Research 8: 223– 232. Mal o, P., Friberg, B., Polizzi, G., Gualini, F., Vighagen, T. & Rangert, B. (2003) Immediate and early function of Br anemark Systemâ implants placed in the esthetic zone: a 1-year prospective clinical multicenter study. Clinical Implant Dentistry & Related Research 5: 37–46. Mal o, P., Rangert, B. & Nobre, M. (2005) All-on-4 immediate-function concept with Br anemark Systemâ implants for completely edentulous maxillae: a 1-year retrospective clinical study. Clinical Implant Dentistry & Related Research 7: s88– s94.


Marchetti, C., Felice, P., Lizio, G. & Rossi, F. (2009) Le Fort I osteotomy with interpositional graft and immediate loading of delayed modified SLActive surface dental implants for rehabilitation of extremely atrophied maxilla: a case report. Journal of Oral and Maxillofacial Surgery 67: 1486–1494. Martınez-Gonzalez, J., Barona-Dorado, C., CanoSanchez, J., Fernandez-Caliz, F. & SanchesTurriόn, A. (2006) Evaluation of 80 implants subjected to immediate loading in edentulous mandibles after two years of follow-up. Medicina Oral, Patologıa Oral y Cirugıa Bucal 11: E165–E170. Marzola, R., Scotti, R., Fazi, G. & Schincaglia, G. (2007) Immediate loading of two implants supporting a ball attachment-retained mandibular overdenture: a prospective clinical study. Clinical Implant Dentistry & Related Research 9: 136–143. Nikellis, I., Levi, A. & Nicolopoulos, C. (2004) Immediate loading of 190 endosseous dental implants: a prospective observational study of 40 patient treatments with up to 2-year data. The International Journal of Oral & Maxillofacial Implants 19: 116–123. Norton, M. (2004) A short-term clinical evaluation of immediately restored maxillary TiOblast single-tooth implants. The International Journal of Oral & Maxillofacial Implants 19: 274–281. Oliva, J., Oliva, X. & Oliva, J. (2007) One-year follow-up of first consecutive 100 zirconia dental implants in humans: a comparison of 2 different rough surfaces. The International Journal of Oral & Maxillofacial Implants 22: 430–435. Ormianer, Z., Garg, A. & Palti, A. (2006) Immediate loading of implant overdentures using modified loading protocol. Implant Dentistry 15: 35–40. € Ostman, P., Hellman, M., Albrektsson, T. & Sennerby, L. (2007) Direct loading of Nobel Directâ and Nobel Perfectâ one-piece implants: a 1-year prospective clinical and radiographic study. Clinical Oral Implants Research 18: 409–418. € Ostman, P., Hellman, M. & Sennerby, L. (2005) Direct implant loading in the edentulous maxilla using a bone density-adapted surgical protocol and primary implant stability criteria for inclusion. Clinical Implant Dentistry & Related Research 7: S60–S69. € Ostman, P., Hellman, M. & Sennerby, L. (2008) Immediate occlusal loading of implants in the partially edentate mandible: a prospective 1-year radiographic and 4-year clinical study. The International Journal of Oral & Maxillofacial Implants 23: 315–322. € Ostman, P., Wennerberg, A. & Albrektsson, T. (2010) Immediate occlusal loading of NanoTite PREVAILâ implants: a prospective 1-year clinical and radiographic study. Clinical Implant Dentistry & Related Research 12: 39–47. Parel, S. & Schow, S. (2005) Early clinical experience with a new one-piece implant system in single tooth sites. Journal of Oral and Maxillofacial Surgery 63: 2–10. Payer, M., Heschl, A., Wimmer, G., Wegscheider, W., Kirmeier, R. & Lorenzoni, M. (2010) Immediate provisional restoration of screw-type implants in the posterior mandible: results after 5 years of clinical function. Clinical Oral Implants Research 21: 815–821. TM

685 |



Proussaefs, P. & Lozada, J. (2004) Immediate loading of hydroxyapatite-coated implants in the maxillary premolar area: three-year results of a pilot study. Journal of Prosthetic Dentistry 91: 228–233. Ribeiro, F., Pontes, A., Marcantonio, E., Piattelli, A., Neto, R. & Marcantonio, E. Jr (2008) Success rate of immediate nonfunctional loaded singletooth implants: immediate versus delayed implantation. Implant Dentistry 17: 109–117. Rompen, E., Raepsaet, N., Domken, O., Touati, B. & Van Dooren, E. (2007) Soft tissue stability at the facial aspect of gingivally converging abutments in the esthetic zone: a pilot clinical study. Journal of Prosthetic Dentistry 97: S119– S125. Rungcharassaeng, K., Lozada, J., Kan, J., Kim, J., Campagni, W. & Munoz, C. (2002) Peri-implant tissue response of immediately loaded, threaded, HA-coated implants: 1-year results. Journal of Prosthetic Dentistry 87: 173–181. Schnitman, P., W€ ohrle, P., Rubenstein, J., DaSilva, J. & Wang, N. (1997) Ten-year results for Branemark implants immediately loaded with fixed prostheses at implant placement. The International Journal of Oral & Maxillofacial Implants 12: 495–503. Siebers, D., Gehrke, P. & Schliephake, H. (2010) Delayed function of dental implants: a 1-to 7-year follow-up study of 222 implants. The International Journal of Oral & Maxillofacial Implants 25: 1195–1202. Spiekermann, H., Jansen, V. & Richter, E. (1995) A 10-year follow-up study of IMZ and TPS implants in the edentulous mandible using bar-retained overdentures. The International Journal of Oral & Maxillofacial Implants 10: 231–243. Stricker, A., Gutwald, R., Schmelzeisen, R. & Gellrich, N. (2004) Immediate loading of 2 interforaminal dental implants supporting an overdenture: clinical and radiographic results after 24 months. The International Journal of Oral & Maxillofacial Implants 19: 868–872. Susarla, S., Chuang, S. & Dodson, T. (2008) Delayed versus immediate loading of implants: survival analysis and risk factors for dental implant failure. Journal of Oral and Maxillofacial Surgery 66: 251–255.

Tarnow, P., Emtiaz, S. & Classi, A. (1997) Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with 1- to 5-year data. The International Journal of Oral & Maxillofacial Implants 12: 319–324. Tealdo, T., Bevilacqua, M., Pera, F., Menini, M., Ravera, G., Drago, C. & Pera, P. (2008) Immediate function with fixed implant-supported maxillary dentures: a 12-month pilot study. Journal of Prosthetic Dentistry 99: 351–360. Testori, T., Del Fabbro, M., Galli, F., Francetti, L., Taschieri, S. & Weinstein, R. (2004) Immediate occlusal loading the same day or the day after implant placement: comparison of 2 different time frames in totally edentulous lower jaws. Journal of Oral Implantology 30: 307–313. Testori, T., Del Fabbro, M., Szmukler-Moncler, S., Francetti, L. & Weinstein, R. (2003) Immediate occlusal loading of Osseotite implants in the completely edentulous mandible. The International Journal of Oral & Maxillofacial Implants 18: 544–551. Testori, T., Meltzer, A., Fabbro, M., Zuffetti, F., Troiano, M., Francetti, L. & Weinstein, R. (2004) Immediate occlusal loading of Osseotite implants in the lower edentulous jaw. A multicenter prospective study. Clinical Oral Implants Research 15: 278–284. Tsirlis, A. (2005) Clinical evaluation of immediate loaded upper anterior single implants. Implant Dentistry 14: 94–103. Van de Velde, T., Collaert, B. & De Bruyn, H. (2007) Immediate loading in the completely edentulous mandible: technical procedure and clinical results up to 3 years of functional loading. Clinical Oral Implants Research 18: 295–303. Van de Velde, T., Collaert, B., Sennerby, L. & De Bruyn, H. (2010) Effect of implant design on preservation of marginal bone in the mandible. Clinical Implant Dentistry & Related Research 12: 134–141. Van Steenberghe, D., Glauser, R., Blomb€ack, U., Andersson, M., Schutyser, F., Pettersson, A. & Wendelhag, I. (2005) A computed tomographic scan– derived customized surgical template and fixed prosthesis for flapless surgery and immediate loading of implants in fully edentulous maxillae: a

prospective multicenter study. Clinical Implant Dentistry & Related Research 7: s111–s120. Van Steenberghe, D., Molly, L., Jacobs, R., Vandekerckhove, B., Quirynen, M. & Naert, I. (2004) The immediate rehabilitation by means of a ready-made final fixed prosthesis in the edentulous mandible: a 1-year follow-up study on 50 consecutive patients. Clinical Oral Implants Research 15: 360–365. Van Steenberghe, D., Naert, I., Andersson, M., Brajnovic, I., Van Cleynenbreugel, J. & Suetens, P. (2002) A custom template and definitive prosthesis allowing immediate implant loading in the maxilla: a clinical report. The International Journal of Oral & Maxillofacial Implants 17: 663– 670. Vanden Bogaerde, L., Pedretti, G., Dellacasa, P., Mozzati, M., Rangert, B. & Wendelhag, I. (2004) Early function of splinted implants in maxillas and posterior mandibles, using Br anemark Systemâ TiUniteTM implants: an 18-month prospective clinical multicenter study. Clinical Implant Dentistry & Related Research 6: 121– 129. Villa, R. & Rangert, B. (2005) Early loading of interforaminal implants immediately installed after extraction of teeth presenting endodontic and periodontal lesions. Clinical Implant Dentistry & Related Research 7: s28–s35. Wolfinger, G., Balshi, T.J. & Rangert, B. (2003) Immediate functional loading of Br anemark system implants in edentulous mandibles: clinical report of the results of developmental and simplified protocols. The International Journal of Oral & Maxillofacial Implants 18: 250–257. Zafiropoulos, G., Deli, G., Bartee, B. & Hoffmann, O. (2010) Single-tooth implant placement and loading in fresh and regenerated extraction sockets. Five-year results: a case series using two different implant designs. Journal of Periodontology 81: 604–615. Zhou, W., Han, C., Li, Y., Li, D., Song, Y. & Zhao, Y. (2009) Is the osseointegration of immediately and delayed loaded implants the same? Comparison of the implant stability during a 3-month healing period in a prospective study. Clinical Oral Implants Research 20: 1360–1366.

and immediate loading. The International Journal of Oral & Maxillofacial Implants 16: 537–546. Degidi, M., Nardi, D. & Piattelli, A. (2010) A comparison between immediate loading and immediate restoration in cases of partial posterior mandibular edentulism: a 3-year randomized clinical trial. Clinical Oral Implants Research 21: 682–687. Fischer, K. & Stenberg, T. (2004) Early loading of ITI implants supporting a maxillary full-arch prosthesis: 1-year data of a prospective, randomized study. The International Journal of Oral & Maxillofacial Implants 19: 374–381. Fr€ oberg, K., Lindh, C. & Ericsson, I. (2006) Immediate loading of Br anemark System Implantsâ: a

comparison between TiUniteTM and turned implants placed in the anterior mandible. Clinical Implant Dentistry & Related Research 8: 187–197. Ganeles, J., Z€ ollner, A., Jackowski, J., Ten Bruggenkate, C., Beagle, J. & Guerra, F. (2008) Immediate and early loading of Straumann implants with a chemically modified surface (SLActive) in the posterior mandible and maxilla: 1-year results from a prospective multicenter study. Clinical Oral Implants Research 19: 1119–1128. Grandi, T., Garuti, G., Guazzi, P., Tarabini, L. & Forabosco, A. (2012) Survival and success rates of immediately and early loaded implants: 12-month

Appendix 2 Excluded RCTs Assad, A., Hassan, S., Shawky, Y. & Badawy, M. (2007) Clinical and radiographic evaluation of implant-retained mandibular overdentures with immediate loading. Implant Dentistry 16: 212–223. Cannizzaro, G., Torchio, C., Leone, M. & Esposito, M. (2008) Immediate versus early loading of flapless-placed implants supporting maxillary fullarch prostheses: a randomized controlled clinical trial. European Journal of Oral Implantology 1: 127–139. Chiapasco, M., Abati, S., Romeo, E. & Vogel, G. (2001) Implant-retained mandibular overdentures with Branemark System MKII implants: a prospective comparative study between delayed

686 |




results from a multicentric randomized clinical study. Journal of Oral Implantology 38: 239–49. Grandi, T., Guazzi, P., Samarani, R. & Grandi, G. (2013) A 3-year report from a multicentre randomised controlled trial: immediately versus early loaded implants in partially edentulous patients. European Journal of Oral Implantology 6: 217– 224. Jokstad, A., Ellner, S. & Gussgard, A. (2011) Comparison of two early loading protocols in full arch reconstructions in the edentulous maxilla using the Cresco prosthetic system: a three-arm parallel group randomized-controlled trial. Clinical Oral Implants Research 22: 455–463. Liddelow, G. & Henry, P. (2010) The immediately loaded single implant-retained mandibular overdenture: a 36-month prospective study. The International Journal of Prosthodontics 23: 13–21. Lindeboom, J., Frenken, J., Dubois, L., Frank, M., Abbink, I. & Kroon, F. (2006) Immediate loading versus immediate provisionalization of maxillary single-tooth replacements: a prospective randomized study with BioComp implants. Journal of Oral and Maxillofacial Surgery 64: 936–942. Ma, S., Tawse-Smith, A., Thomson, W.M. & Payne, A. (2010) Marginal bone loss with mandibular two-implant overdentures using different loading protocols and attachment systems: 10-year outcomes. The International Journal of Prosthodontics 23: 321–332. Merli, M., Bernardelli, F. & Esposito, M. (2008) Immediate versus early nonocclusal loading of dental implants placed with a flapless procedure in partially edentulous patients: preliminary results from a randomized controlled clinical trial. The International Journal of Periodontics & Restorative Dentistry 28: 453–459.

Merli, M., Moscatelli, M., Mariotti, G., Piemontese, M. & Nieri, M. (2012) Immediate versus early non-occlusal loading of dental implants placed flapless in partially edentulous patients: a 3-year randomized clinical trial. Journal of Clinical Periodontology 39: 196–202. Palattella, P., Torsello, F. & Cordaro, L. (2008) Two-year prospective clinical comparison of immediate replacement vs. immediate restoration of single tooth in the esthetic zone. Clinical Oral Implants Research 19: 1148–1153. Payne, A., Tawse-Smith, A., Duncan, W. & Kumara, R. (2002) Conventional and early loading of unsplinted ITI implants supporting mandibular overdentures. Two-year results of a prospective randomized clinical trial. Clinical Oral Implants Research 13: 603–609. Rocci, A., Martignoni, M. & Gottlow, J. (2003) Immediate loading of Br anemark Systemâ TiUniteTM and machined-surface implants in the posterior mandible: a randomized open-ended clinical trial. Clinical Implant Dentistry & Related Research 5: 57–63. Romeo, E., Chiapasco, M., Lazza, A., Casentini, P., Ghisolfi, M., Iorio, M. & Vogel, G. (2002) Implant-retained mandibular overdentures with ITI implants. Clinical Oral Implants Research 13: 495–501. Salvi, G., Gallini, G. & Lang, N. (2004) Early loading (2 or 6 weeks) of sandblasted and acid-etched (SLA) ITIâ implants in the posterior mandible. A 1-year randomized controlled clinical trial. Clinical Oral Implants Research 15: 142–149. Schincaglia, G., Marzola, R., Scapoli, C. & Scotti, R. (2007) Immediate loading of dental implants supporting fixed partial dentures in the posterior mandible: a randomized controlled split-mouth study–machined versus titanium oxide implant

surface. The International Journal of Oral & Maxillofacial Implants 22: 35–46. Tawse-Smith, A., Payne, A., Kumara, R. & Thomson, W. (2002) Early loading of unsplinted implants supporting mandibular overdentures using a onestage operative procedure with two different implant systems: a 2-year report. Clinical Implant Dentistry & Related Research 4: 33–42. Testori, T., Bianchi, F., Del Fabbro, M., SzmuklerMoncler, S., Francetti, L. & Weinstein, R. (2003) Immediate non-occlusal loading vs. early loading in partially edentulous patients. Practical Procedures and Aesthetic Dentistry 15: 787–794. Testori, T., Galli, F., Capelli, M., Zuffetti, F. & Esposito, M. (2007) Immediate nonocclusal versus early loading of dental implants in partially edentulous patients: 1-year results from a multicenter, randomized controlled clinical trial. The International Journal of Oral & Maxillofacial Implants 22: 815–822. Turkyilmaz, I. & Tumer, C. (2007) Early versus late loading of unsplinted TiUnite surface implants supporting mandibular overdentures: a 2-year report from a prospective study. Journal of Oral Rehabilitation 34: 773–780. Zembic, A., Glauser, R., Khraisat, A. & H€ammerle, C. (2010) Immediate vs. early loading of dental implants: 3-year results of a randomized controlled clinical trial. Clinical Oral Implants Research 21: 481–489. Z€ ollner, A., Ganeles, J., Korostoff, J., Guerra, F., Krafft, T. & Br€agger, U. (2008) Immediate and early non-occlusal loading of Straumann implants with a chemically modified surface (SLActive) in the posterior mandible and maxilla: interim results from a prospective multicenter randomized-controlled study. Clinical Oral Implants Research 19: 442–450.

Hall, J., Payne, A., Purton, D., Torr, B., Duncan, W. & De Silva, R. (2007) Immediately restored, single-tapered implants in the anterior maxilla: prosthodontic and aesthetic outcomes after 1 year. Clinical Implant Dentistry & Related Research 9: 34–45. Jokstad, A. & Alkumru, H. (2013) Immediate function on the day of surgery compared with a delayed implant loading process in the mandible: a randomized clinical trial over 5 years. Clinical Oral Implants Research 1–11. doi: 10.1111/clr12279. Meloni, S.M., De Riu, G., Pisano, M., De Riu, N. & Tulio, A. (2012) Immediate versus delayed loading of single mandibular molars. One-year results from a randomized controlled trial. European Journal of Oral Implantology 5: 345–353.

Oh, T., Shotwell, J., Billy, E. & Wang, H. (2006) Effect of flapless implant surgery on soft tissue profile: a randomized controlled clinical trial. Journal of Periodontology 77: 874–882. Romanos, G. & Nentwig, G. (2006) Immediate versus delayed functional loading of implants in the posterior mandible: a 2-year prospective clinical study of 12 consecutive cases. The International Journal of Periodontics & Restorative Dentistry 26: 459–469. Schincaglia, G., Marzola, R., Giovanni, G., Chiara, C. & Scotti, R. (2008) Replacement of mandibular molars with single-unit restorations supported by wide-body implants: immediate versus delayed loading. A randomized controlled study. The International Journal of Oral & Maxillofacial Implants 23: 474–480.

Appendix 3 RCTs excluded for specific reasons Degidi, M., Iezzi, G., Perrotti, V. & Piattelli, A. (2009b) Comparative analysis of immediate functional loading and immediate nonfunctional loading to traditional healing periods: a 5-year followup of 550 dental implants. Clinical Implant Dentistry & Related Research 11: 257–266. Elsyad, M.A., Al-Mahdy, Y.F. & Fouad, M.M. (2012) Marginal bone loss adjacent to conventional and immediate loaded two implants supporting a ballretained mandibular overdenture: a 3-year randomized clinical trial. Clinical Oral Implants Research 23: 496–503. G€ unc€ u, M.B., Aslan, Y., T€ umer, C., G€ unc€ u, G.N. & Uysal, S. (2008) In-patient comparison of immediate and conventional loaded implants in mandibular molar sites within 12 months. Clinical Oral Implants Research 19: 335–341.


687 |


Immediate nonfunctional versus immediate functional loading and dental implant failure rates: a systematic review and meta-analysis.

Immediate versus early loading of flapless placed dental implants: a systematic review.

Bone-implant contact around crestal and subcrestal dental implants submitted to immediate and conventional loading.

Replacement of severely traumatized teeth with immediate implants and immediate loading: literature review and case reports.

Clinical efficacy of immediate implant loading protocols compared to conventional loading depending on the type of the restoration: a systematic review.

Dental extraction, immediate placement of dental implants, and immediate function.

Clinical efficacy of early loading versus conventional loading of dental implants.

Comparative study of immediate functional loading and immediate non-functional loading of monocortical implants.

Immediate versus delayed loading of dental implants in edentulous patients' maxillae: a 6-year prospective study.

Behaviour of the buccal crestal bone levels after immediate placement of implants subjected to immediate loading.

Bisphosphonate treatment and dental implants: A systematic review.

Annual bone loss and success rates of dental implants based on radiographic measurements.

Immediate loading in partially and completely edentulous jaws: a review of the literature with clinical guidelines.

New-design dental implants: a 1-year prospective clinical study of 344 consecutively placed implants comparing immediate loading versus delayed loading and flapless versus full-thickness flap.

Impact of osteoporosis in dental implants: A systematic review.

Prospective, 1-year observational study of double-threaded tapered body dental implants with immediate loading.

Short dental implants versus standard dental implants placed in the posterior jaws: A systematic review and meta-analysis.

Immediate and Early Loading of Hydrothermally Treated, Hydroxyapatite-Coated Dental Implants: 2-Year Results from a Prospective Clinical Study.

Clinical evaluation of immediate loading of titanium orthodontic implants.

Marginal masticatory mucosa dimensional changes in immediate post-extractive implants: a 2 year prospective cohort study.

Biomechanics and load resistance of small-diameter and mini dental implants: a review of literature.

Extracorporeal life support for acute respiratory failure. A systematic review and metaanalysis.

Fractures in indigenous compared to non-indigenous populations: A systematic review of rates and aetiology.

Systematic review on success of narrow-diameter dental implants.