SYSTEMATIC REVIEW
In luence o low inse ion o que alues on su i al a e
o immedia ely loaded den al implan s: A sys ema ic e iew
and me a-analysis
I ia Da iba
1
| Anna Seidel
2
| Fede ico Mo eno
3
|Jo
˜
ao Bo elho
4,5
|
Vanessa Machado
4,5
| José Jo˜
ao Mendes
4,5
| Yago Lei a
1,3,6
| Juan Blanco
1
1
Pe iodon ology Uni , Facul y o Odon ology
and Medicine, Uni e si y o San iago de
Compos ela and Medical-Su gical Den is y
Resea ch G oup, Heal h Resea ch Ins i u e o
San iago de Compos ela, San iago de
Compos ela, Spain
2
Depa men o P os hodon ics, Uni e si y
Hospi al E langen o F ied ich-Alexande
Uni e si y E langen-Nü nbe g (FAU), E langen,
Ge many
3
Pe iodon ology Uni , UCL Eas man Den al
Ins i u e and NIHR UCLH Biomedical Resea ch
Cen e, Uni e si y College London,
London, UK
4
Pe iodon ology Depa men , Clinical
Resea ch Uni (CRU), Cen o de In es igaç˜ao
In e disciplina Egas Moniz (CiiEM), Ins i u o
Uni e si á io Egas Moniz (IUEM), Capa ica,
Po ugal
5
E idence-Based Hub, CRU, CiiEM, Egas
Moniz –Coope a i a de Ensino Supe io ,
Capa ica, Po ugal
6
Clinical Neu osciences Resea ch Labo a o y,
Heal h Resea ch Ins i u e o San iago de
Compos ela, Uni e si y Clinical Hospi al,
San iago de Compos ela, Spain
Co espondence
I ia Da iba, Pe iodon ology Uni , Facul y o
Odon ology, Uni e si y o San iago de
Compos ela, Rúa En e íos SN, 15782
San iago de Compos ela, Spain.
Email: i iada [email protected]
Abs ac
Aim: The aim was o sys ema ically e alua e he e ec o low inse ion o que alues
on he su i al a e o immedia ely loaded den al implan s.
Ma e ials and Me hods: The p o ocol was egis e ed wi h PROSPERO (ID
CRD42020189499). An elec onic sea ch was pe o med in PubMed, Embase, Web
o Science, and Coch ane Cen al Regis e o Con olled T ials un il June 2022 in
English and Spanish. S udies analysing he ailu e o su i al a e o immedia ely
loaded den al implan s acco ding o di e en inse ion o que alues we e included.
Resul s: Fi e-hund ed se en y- h ee a icles we e assessed o eligibili y, o which
se en a icles, ou andomized clinical ials (RCTs), one con olled clinical ial, and
wo p ospec i e case se ies s udies we e included in he quali a i e analysis. The
RCTs we e classi ied as ha ing low isk o bias and he non-RCTs as ha ing mode a e
and se ious isk o bias. The mean su i al a e o implan s wi h low inse ion oque
(≤35 Ncm) was 96% (p> .001, 95% con idence in e al [CI]: 0.91–0.98) and ha o
implan s wi h medium o high inse ion o que (>35 Ncm) was 92% (p> .001, 95%
CI: 0.86–0.96) (incidence a e a io [IRR] =1.05, 95% CI: 0.79–1.39, p=.175,
I
2
=0.0%). Splin ed implan s wi h inse ion o que >20 Ncm and single implan s wi h
inse ion o que >35 Ncm had a highe su i al a e han implan s wi h lowe inse -
ion o que alues (IRR =1.05, 95% CI: 0.78–1.43, p=.956, I
2
=0.0%, and
RR =0.92, 95% CI: 0.48–1.75, p=.799, I
2
=0.0%, espec i ely). Di e en inse ion
o que alues achie ed equi alen ou comes. The mean ollow-up was 24 mon hs.
Conclusions: Low inse ion o que alues ha e no signi ican e ec on su i al a es
o immedia e loading implan s a a mean ollow-up o 24 mon hs.
KEYWORDS
den al implan s, immedia e loading, inse ion o que
Recei ed: 6 June 2022 Re ised: 26 Sep embe 2022 Accep ed: 4 Oc obe 2022
DOI: 10.1111/jcpe.13733
This is an open access a icle unde he e ms o he C ea i e Commons A ibu ion-NonComme cial-NoDe i s License, which pe mi s use and dis ibu ion in any
medium, p o ided he o iginal wo k is p ope ly ci ed, he use is non-comme cial and no modi ica ions o adap a ions a e made.
© 2022 The Au ho s. Jou nal o Clinical Pe iodon ology published by John Wiley & Sons L d.
158 J Clin Pe iodon ol. 2023;50:158–169.
wileyonlinelib a y.com/jou nal/jcpe
Clinical Rele ance
Scien i ic a ionale o s udy: Implan inse ion o que is he mos common endpoin assessed
o adequa e p ima y s abili y. This sys ema ic e iew aimed o assess he e ec o low
inse ion o que (≤35 Ncm) on he su i al a e o immedia ely loaded den al implan s.
P incipal indings: The pooled su i al a e o implan s wi h inse ion o que ≤35 Ncm was
5% highe han implan s wi h >35 Ncm (Incidence a e a io =1.05, 95% con idence in e -
al: 0.79–1.39, p=.175), wi hou any signi ican di e ence. Bo h g oups a ained high
su i al a es.
P ac ical implica ions: Implan s wi h inse ion o que ≤20 Ncm can be immedia ely loaded
wi h splin ed p os heses and hose wi h >20 Ncm wi h single-uni p os hesis.
1|INTRODUCTION
The long- e m success o an implan -suppo ed es o a ion is depen-
den on success ul osseoin eg a ion. I has been desc ibed ha p i-
ma y s abili y and absence o mic o-mo emen s a e wo o he main
ac o s necessa y o achie e a high p edic able success o osseoin e-
g a ed o al implan s (Alb ek sson e al., 1981). Lede mann, in 1977,
was he i s o desc ibe he use o implan s wi h immedia e loading
o s abilize mandibula o e den u es, in o de o minimize discom o
and p oblems ela ed wi h he use o p o isional ull den u es
(Lede mann, 1977). This echnique was u he demons a ed in se -
e al subsequen a icles (Szmukle -Moncle e al., 2000). Mos ea ly
publica ions using his concep showed excellen esul s, mainly
epo ing high implan su i al a es (Sanz-Sánchez e al., 2015). A
ecen sys ema ic e iew has es ima ed a 96.8% su i al in 1880
immedia e loading den al implan s wi h a mean ollow-up o
21.9 mon hs (Chen e al., 2019).
Reduced o e all ea men imes wi hin immedia e loading p o o-
cols, oge he wi h he po en ial o a oid a emo able p o isional
p os hesis, p esen a ac i e solu ions o clinicians and pa ien s
(Gallucci e al., 2018). Immedia e loading can be an al e na i e o con-
en ional loading in speci ic cases when pa ien -cen ed ad an ages
a e p esen (Mo on e al., 2018), and is cu en ly accep ed as being
ea lie han 1 week a e implan placemen (Webe e al., 2009;
Gallucci e al., 2014).
Implan inse ion o que is he mos common endpoin assessed
o an adequa e p ima y s abili y, which is equi ed by mos o he
s udies when a emp ing o conduc immedia e loading (Gallucci
e al., 2018). This indica o is judged in a-ope a i ely by he su geon;
howe e , he speci ic alue may a y among s udies (Gallucci
e al., 2018). Addi ionally, he minimum inse ion o que needed o
achie e success ul osseoin eg a ion o immedia ely loaded single
implan s is s ill inconclusi e (Benic e al., 2014). Fo any ype o p os-
heses, he minimum o que equi ed is no accu a ely es ablished
(Sanz-Sánchez e al., 2015), hough an accep ed in e al anges om
25 o 45 Ncm (Mo on e al., 2018). In cases o immedia e loading
wi h ull-a ch ixed p os heses, a minimum inse ion o que o 30 Ncm
has been ecommended (Papaspy idakos e al., 2014); howe e ,
implan s wi h lowe inse ion o ques splin ed wi h implan s wi h
o que ≥30 Ncm did no show low su i al a es (Ecke e al., 2019).
The le el o e idence ega ding an inse ion o que o 30 Ncm o
implan su i al in cases o immedia e loading is cu en ly conside ed
no s ong (Douglas De Oli ei a e al., 2016). A co ela ion be ween
high inse ion o que alues (>45 Ncm) and p ima y s abili y has been
epo ed, because he mic omo ion o implan s is educed (T isi
e al., 2009); howe e , implan s immedia ely placed and loaded using
a low inse ion o que p o ocol o ≤25 Ncm yield a a ou able clinical
ou come (No on, 2011). Fu he mo e, he impac o o que on he
su i al a e o implan s wi h immedia e loading was deemed no pos-
sible o analyse due o da a inconsis encies o he included andom-
ized con olled ials (RCTs) (Chen e al., 2019). Also, a consensus on
he de ini ion o high, egula , and low o que is lacking (Lemos
e al., 2021).
The aim o his sys ema ic e iew was o assess he e ec o low
inse ion o que (≤35 Ncm) on he su i al a e o immedia ely loaded
den al implan s. Secondly, he ype o es o a ion, changes in ma ginal
pe i-implan bone le els, changes in pe i-implan so issues, as well
as mechanical, biological, and echnical complica ions we e e alua ed
in e ms o he inse ion o que alue.
2|MATERIALS AND METHODS
2.1 |Repo ing o ma
The p o ocol o his e iew was p epa ed and egis e ed on he
PROSPERO (In e na ional P ospec i e Regis e o Sys ema ic
Re iews) da abase (CRD42020189499). No modi ica ions we e made
in he ma e ials and me hods sec ion in compa ison wi h he p o ocol
egis e ed in PROSPERO. This e iew was epo ed based on he P e-
e ed Repo ing I ems o Sys ema ic Re iews and Me a-Analyses
(PRISMA) s a emen (Page e al., 2021).
2.2 |Eligibili y c i e ia
The ocus ques ion was: “In immedia ely loaded den al implan s, wha
a e he e ec s o lowe inse ion o ques compa ed o medium o
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highe inse ion o ques in e ms o implan su i al a e?”This ques-
ion conside ed he ollowing PECO (S one, 2002) de ini ions:
•P (Popula ion): pa ien s ecei ing immedia ely loaded den al
implan s.
•E (Exposu e): low inse ion o ques (≤35 Ncm).
•C (Compa ison): medium o high inse ion o ques (>35 Ncm).
•O (Ou come): implan su i al a e.
The ollowing seconda y ou comes a iables we e conside ed:
ma ginal bone le els changes (in mm); pe i-implan so issues
changes (changes in he posi ion o he mucosal ma gin); mechanical
( ailu e o a p e ab ica ed componen caused by mechanical o ces),
echnical (e.g., sc ew loosening, p os heses ac u e, con ou ing
adjus men s), and biological complica ions (consis ing o pe i-
implan i is and pe i-implan mucosi is).
2.3 |Sea ch s a egy
An elec onic sea ch was unde aken on The Na ional Lib a y o Medi-
cine (MEDLINE ia PubMed), Embase, Web o Science, and Coch ane
Cen al Regis e o Con olled T ials, including s udies published un il
June 2022. The sea ch was limi ed o publica ions on ials in ol ing
humans published in English and Spanish. G ey li e a u e was no con-
side ed. The ollowing sea ch e ms we e used:
•CENTRAL and MEDLINE
Popula ion: ((((“Den al Implan s”[Mesh]) OR “Den al Implan a-
ion”[Mesh]) OR den al implan *[Ti le/Abs ac ]) OR o al
implan *[Ti le/Abs ac ]) AND ((“Immedia e Den al Implan Loa-
ding”[Mesh]) OR ((immedia e*[Ti le/Abs ac ]) AND ((((((load*
[Ti le/Abs ac ]) OR c own*[Ti le/Abs ac ]) OR b idge*[Ti le/
Abs ac ]) OR p os hes*[Ti le/Abs ac ]) OR es o a ion*[Ti le/
Abs ac ]) OR ehabili a *[Ti le/Abs ac ]))).
In e en ion: (((p ima y s abili y[Ti le/Abs ac ]) OR implan s a-
bili y[Ti le/Abs ac ]) OR inse ion o que*[Ti le/Abs ac ]))).
•EMBASE
Popula ion: ((‘ oo h implan ’/exp) OR (‘ oo h implan a ion’/exp)
OR (den al AND implan *: ab, kw, i) OR (o al AND implan *: ab,
kw, i)) AND ((immedia e*: ab, kw, i) AND ((((((load*: ab, kw, i)
OR c own*: ab, kw, i) OR b idge*: ab, kw, i) OR p os hes*: ab,
kw, i) OR es o a ion*: ab, kw, i) OR ehabili a *: ab, kw, i)).
In e en ion: (((p ima y s abili y: ab, kw, i) OR implan s abili y:
ab, kw, i) OR inse ion o que*: ab, kw, i).
2.4 |Selec ion p ocess
The e alua ion o i les and abs ac s, as well as ull- ex analysis, was
conduc ed acco ding o he ollowing eligibili y c i e ia:
A icles we e selec ed based on he ollowing inclusion c i e ia:
•Randomized clinical ials, con olled clinical ials (CCTs), and p o-
spec i e s udies wi h a minimum sample o 10 pa ien s;
•Pa ien s aged 18 yea s o olde and in good gene al heal h;
•Immedia ely loaded den al implan s epo ing he inse ion o que
alues ( he immedia e loading p o ocol is de ined as implan load-
ing ea lie han 1 week a e placemen [Gallucci e al., 2014]);
•Ti anium alloy den al implan s;
•Minimum ollow-up pe iod o 12 mon hs a e implan placemen .
The exclusion c i e ia we e as ollows:
•Animal o in i o s udies;
•Zygoma ic implan s;
•Insu icien in o ma ion o de e mine implan su i al a e.
2.5 |Da a selec ion and da a ex ac ion
The selec ion o s udies was ca ied ou in wo s ages by wo inde-
penden e iewe s (ID and FM). In he i s s age, e iewe s
sc eened i les and abs ac s acco ding o p e-se eligibili y c i e ia.
In he second s age, he selec ed s udies we e assessed o eligibil-
i y based on a ull- ex analysis. The easons o exclusion we e
eco ded. Da a ex ac ion was conduc ed independen ly by wo
e iewe s using cus omized da a ex ac ion ables (ID and AS). Any
disag eemen was esol ed by discussion wi h a hi d e iewe (YL).
In case o mul iple publica ions on he same s udy popula ion, only
he s udy wi h he longes ollow-up was included. The in e -
e iewe eliabili y o he da a ex ac ed was de e mined ia Cohen
Kappa sco es.
The ollowing da a we e ex ac ed om he ull- ex publica ions:
au ho (s), yea o publica ion, coun y, s udy design, blind, ounding
sou ce, numbe o cen es, se ing, numbe , age and sex o pa ien s
included, numbe o pa ien d op-ou s, numbe o implan s placed, num-
be o implan d op-ou s, numbe o ailed implan s, sample size calcula-
ion, andomiza ion, isk ac o s, ollow-up pe iod, ime o implan
placemen ollowing oo h ex ac ion, loading p o ocol, jaw, in ao al
egion, implan sys em, implan leng h and diame e , simul aneous bone
augmen a ion p ocedu e, and ype o es o a ion. Also, mean alues o
implan inse ion o que, su i al a e (p ima y ou come), ma ginal bone
le els changes, changes in he posi ion o he mucosal ma gin, as well as
mechanical, echnical, and biological complica ions (seconda y ou comes)
we e eco ded.
Desc ip i e analyses we e pe o med o de e mine he quan i y
o da a, in ela ion o he cha ac e is ics, in e en ions, and esul s o
he included s udies.
2.6 |Risk o bias assessmen
The quali y assessmen o he selec ed a icles was pe o med by wo
e iewe s independen ly and in duplica e (ID and AS). Disag eemen s
160 DARRIBA ET AL.
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o e he isk o bias in pa icula s udies we e esol ed by discussion
be ween he wo e iewe s and in consul a ion wi h a hi d e iewe
(YL) i equi ed.
Risk o bias assessmen o andomized clinical ials was done
using he RoB 2.0 ool (S e ne e al., 2019), which is s uc u ed
in o i e bias domains: bias a ising om he andomiza ion p o-
cess, bias due o de ia ions om in ended in e en ions, bias due
o missing ou come da a, bias in measu emen o he ou come,
and bias in selec ion o he epo ed esul . S udies we e classi ied
as ha ing low isk o bias, some conce ns, o high isk o bias. The
isk o bias o he included CCT and he case se ies s udies was
assessed using he ROBINS-1 ool (S e ne e al., 2016). C i e ia
o quali y assessmen comp ise se en main domains: bias due o
con ounding, bias in selec ion o pa icipan s in o he s udy, bias
in classi ica ion o in e en ions, bias due o depa u es om
in ended in e en ions, bias due o missing da a, bias in measu e-
men o ou comes, and bias in selec ion o epo ed esul s. The
ca ego ies o isk o bias judgemen s in which a icles can be clas-
si ied a e low isk, mode a e isk, se ious isk, and c i ical isk o
bias (S e ne e al., 2016).
2.7 |S a is ical analysis
The so wa e Mendeley (Else ie BV, Ams e dam, The Ne he lands)
was used o manage he eco ds and e iew he ou comes o he sys-
ema ic sea ch, and a s anda d sp eadshee so wa e (Excel o Mac,
e sion 16.50. Mic oso , Redmond, WA) was used o ca y ou da a
ex ac ion. We used S a a 11 (S a aCo p LLC, College S a ion, TX) o
pe o m s a is ical analysis. To compu e pooled su i al a es we used
he me a package o R (R Co e Team, 2020). Rega ding binomial da a
and single p opo ions, he me ainc command was used o pe o m
andom-e ec s models o su i al a e o implan s wi h >35 o
>20 Ncm and implan s wi h ≤35 o ≤20 Ncm, using he Coch an–
Man el–Haenszel me hod. To compa e medium o highe inse ion
o que implan s wi h lowe inse ion o que implan s, he me abin
command was used wi h he in e se calcula ion me hod and andom-
e ec s model.
He e ogenei y was s a is ically analysed using he Q- es a a5%sig-
ni icance le el and I
2
index. The I
2
index assesses he he e ogenei y in
me a-analysis and he ex en o ha he e ogenei y. Fo es plo s we e p o-
duced o illus a e he di e ences be ween g oups. Publica ion bias was
Reco ds iden i ied om:
Da abases (n = 3465)
Regis e s (n = 0)
Reco ds emo ed be o e
sc eening:
Duplica e eco ds emo ed (n
= 2445)
Reco ds ma ked as ineligible
by au oma ion ools (n = 0)
Reco ds emo ed o o he
easons (n = 0)
Reco ds sc eened
(n = 2445)
Reco ds excluded
(n = 1872)
Repo s sough o e ie al
(n = 0)
Repo s no e ie ed
(n = 0)
Repo s assessed o eligibili y
(n = 573) Repo s excluded:
Type o a icle (n = 73)
Inse ion o que alues no
speci ied (n = 187)
Su i al a e no de e mined
(n = 19)
Di e en inse ion o que
alues no compa ed (n =
287)
S udies included in e iew
(n = 7)
Repo s o included s udies
(n = 7)
Iden i ica ion o s udies ia da abases and egis e s
Iden i ica ion
Sc eening
Included
FIGURE 1 PRISMA 2020 low
diag am
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no measu ed because su i al a es a e always a posi i e numbe , and
he likelihood o asymme ic unnel plo s will be due o publica ion bias.
3|RESULTS
3.1 |S udy selec ion
The sea ch esul ed in 3465 a icles: 702 ob ained ia PubMed, 2097
ia Embase, 315 ia Web o Science, and 351 ia Coch ane Cen al
Regis e o Con olled T ials. A e emo al o duplica es, 2445
eco ds we e sc eened o i le and abs ac , and 1872 s udies we e
excluded owing o no mee ing he inclusion c i e ia, lea ing 573 a i-
cles o ull- ex assessmen . A e ull- ex examina ion, 566 a icles
we e excluded, 73 because hey we e e ospec i e, included less
han 10 pa ien s, o he ollow-up was less han 12 mon hs;
187 because inse ion o que alues we e no speci ied; 19 because
he su i al a e was no de e mined; and 287 because hey did no
compa e di e en inse ion o que alues. The e o e, se en a icles
we e included in he sys ema ic e iew and in he quan i a i e analy-
sis (Figu e 1) (PRISMA FLOW DIAGRAM; Page e al., 2021). Ou o
hese se en s udies, ou we e andomized clinical ials, one was a
CCT, and wo we e p ospec i e s udies. The global ag eemen
be ween he wo e iewe s was 94.78% and he Kappa sco e was
0.61 (95% con idence in e al [CI]: 0.35–0.87) o he selec ed s udies
( ull- ex a icles), indica ing subs an ial ag eemen (Landis &
Koch, 1977) be ween he e iewe s.
3.2 |Me hodological quali y assessmen
Acco ding o RoB 2.0 ool (S e ne e al., 2019), all a icles (Cesa e i
e al., 2016; Schincaglia e al., 2016; Dahe e al., 2019; Vogl
e al., 2019) we e classi ied as o low isk o bias (Figu e 2). The CCT
(O oni e al., 2005) and he p ospec i e case se ies s udy o Degidi
e al. (2012) we e judged o be o mode a e isk o bias and he s udy
o Kou ouzis e al. (2011) o se ious isk o bias (Figu e 3) acco ding o
ROBINS-I ool (S e ne e al., 2016).
3.3 |Cha ac e is ics o he included a icles
The cha ac e is ics, inse ion o que alues, su i al a e, and conclu-
sions o he included ials a e p esen ed in Table 1.
Mos selec ed a icles we e unded by he indus y (O oni
e al., 2005;Kou ouzise al.,2011;Schincagliae al.,2016; Dahe
e al., 2019) o by a esea ch associa ion (Cesa e i e al., 2016), and all
bu one (Degidi e al., 2012) we e uni e si y-based s udies. The s udies
we e ca ied ou in B azil (O oni e al., 2005), Uni ed S a es (Kou ouzis
e al., 2011;Schincagliae al.,2016), I aly (Degidi e al., 2012;Cesa e i
e
e
al.,
al.,
e al.,
FIGURE 3 ROBINS-1 ool o assessmen he
isk o bias in non- andomized s udies
e al.,
e al.,
e
e
al.,
al.,
FIGURE 2 Risk o bias summa y o selec ed
andomized clinical ials
162 DARRIBA ET AL.
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TABLE 1 Cha ac e is ics o he included a icles
A icles
included
T ial design o immedia e loading implan s Immedia e loading p o ocol Ou comes
Conclusions
S udy
design Funding
Pa icipan s' No. o implan s
Risk ac o s D op-ou s
Follow-up
pe iod Implan ype
In a-o al
egion Occlusion
Type o
es o a ion
Time-
poin o
ailu e
Su i al
a e (sel -
calcula ed)
Reason o ailu e
and numbe Numbe
Mean age
( ange)
(yea s) To al
By g oups
≤35
Ncm
>35
Ncm
O oni
e al.
(2005)
CCT; spli -
mou h;
non-
blinded
Indus y (F iaden ) 23 35.4 (18–60) 23 20
(10 ≤
20
Ncm)
3 None None 24
mon hs
Machined colla ,
ape ed
implan s wi h
shaped h eads
(F iali -2,
F iaden );
leng h: 10–15
mm; diame e :
3.8 and 4.5
mm
An e io
maxilla
and
mandible
In aocclusion Single c owns 3–9
mon hs
≤35 Ncm
=50%;
>35
Ncm =
100%
Failu es =10
implan s.
Inse ion o que
20 Ncm (9) and
>20 Ncm and
≤35 Ncm (1)
Lowe
inse ion o que
alues a ec ed
su i al a e
Cesa e i
e al.
(2016)
RCT;
pa allel;
blinded
Resea ch
Associa ion (ITI
Resea ch
G an , ARDEC
[A iminum
Odon ologica
SRL, Rimini,
I aly] and by
he Clinical
Resea ch
Founda ion o
he P omo ion
o O al Heal h
[B ienz,
Swi ze land])
15 64.5 (51–76) 36 36 (25
≤20
Ncm)
—Smoke s ≥
10
ciga e es/
day =2
pa ien s
None 36
mon hs
Polished neck o
2.8 mm
implan s
(Tissue Le el
SLA S anda d,
S aumann);
leng h: 8–12
mm; diame e :
4.1 mm
Pos e io
maxilla
Cen ic occlusion
and cen ic
ela ion
con ac s and
physiological
la e al
mo emen s
Sc ew- e ained
b idges (on
≥2 implan s)
3 weeks 94.4% No
osseoin eg a ion
=2 implan s (1
pa ien ).
Inse ion o que
>20 Ncm and
≤35 Ncm
Inse ion o que
alues did no
a ec
osseoin eg a ion
Dahe e al.
(2019)
RCT; spli -
mou h;
blinded
Indus y (Nobel
Bioca e AG,
g an numbe
2010-954)
24 49.2 (34–67) 84 32 (17
≤20
Ncm)
48 Smoke s ≥
10
ciga e es/
day =13
pa ien s
2
pa ien s
36
mon hs
Va iable- h ead
ape ed
implan s
(NobelAc i e,
Nobel Bioca e);
leng h: 10–15
mm; diame e :
3.5, 4.3, and 5
mm
Pos e io
maxilla
Ve y ligh occlusal
con ac s in MI,
no la e al
wo king and
non-wo king
con ac s
Sc ew- e ained
3- o 4-uni
b idges (no
pon ics o
can ile e s)
6
mon hs
≤35 Ncm
=
100%;
>35
Ncm =
91.6%
No
osseoin eg a ion
=4 implan s (1
pa ien ).
Inse ion o que
>35 Ncm
Tes implan s
splin ed wi h
o he implan s
p esen ing
highe inse ion
o que can
achie e and
main ain
osseoin eg a ion
and ha e simila
success a es
and c es al bone
emodelling o
con ol implan s
Degidi
e al.
(2012)
P ospec i e
case
se ies;
pa allel;
non-
blinded
N/A 13 (42–81) 82 67 (51
≤20
Ncm)
15 Smoke s <
20
ciga e es/
day
None 12
mon hs
Sel - apping
h ead (XiVE
implan s,
Den sply
F iaden );
leng h: 11–18
Pos e io
and
an e io
maxilla
and
mandible
Ligh cen ic
occlusion
Sc ew- e ained
ull-a ch
p os heses
6 mon hs ≤35 Ncm
=98%;
>35
Ncm =
100%
No
osseoin eg a ion
=1 implan .
Inse ion o que
20 Ncm
The success a e
and he c es al
bone
emodelling
we e e y
simila be ween
(Con inues)
DARRIBA ET AL.163
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TABLE 1 (Con inued)
A icles
included
T ial design o immedia e loading implan s Immedia e loading p o ocol Ou comes
Conclusions
S udy
design Funding
Pa icipan s' No. o implan s
Risk ac o s D op-ou s
Follow-up
pe iod Implan ype
In a-o al
egion Occlusion
Type o
es o a ion
Time-
poin o
ailu e
Su i al
a e (sel -
calcula ed)
Reason o ailu e
and numbe Numbe
Mean age
( ange)
(yea s) To al
By g oups
≤35
Ncm
>35
Ncm
mm; diame e :
3.4, 3.8, 4.5,
and 5.5 mm
es and con ol
g oups wi hou
s a is ically
signi ican
di e ences
Kou ouzis
e al.
(2011)
P ospec i e
case
se ies;
non-
blinded
Indus y (As a
Tech)
18 53.4 (21–77) 20 16 4 N/A None 12
mon hs
S aigh implan
wi h
Mic oTh ead
neck
(OsseoSpeed,
As a Tech);
leng h: 9–15
mm; diame e :
3.5 and 4.05
mm
An e io
(un il
second
p emola )
maxilla
and
mandible
Ligh cen ic
occlusion wi h
no
in e e ences
in la e al
excu sions
Sc ew- e ained
single
c owns
3 mon hs ≤35 Ncm
=
100%;
>35
Ncm =
75%
No
osseoin eg a ion
=1 implan .
Inse ion o que
>35 Ncm
I migh no be a
simple
ela ionship
be ween
placemen
o que alue
and implan
ailu e o
immedia ely
loaded implan s
o single oo h
eplacemen s
Schincaglia
e al.
(2016)
RCT;
pa allel;
blinded
Indus y (As a
Tech/Den sply)
17 66.6 (53–79) 34 12 (5 ≤
20
Ncm)
22 Smoke s <
10
ciga e es/
day =2
None 12
mon hs
S aigh implan
wi h
Mic oTh ead
neck (TX
OsseoSpeed,
As a Tech/
Den sply);
leng h: 8–15
mm; diame e :
4.0 mm
An e io
mandible
(canine/
la e al
si e)
Full occlusal
loading (no
limi a ion o
chewing)
Loca o
o e den u es
4 weeks ≤35 Ncm
=
100%;
>35
Ncm =
90.9%
No
osseoin eg a ion
=2 implan s (1
pa ien ).
Inse ion o que
>30 Ncm
No di e ence was
obse ed o
inse ion o que
be ween
g oups, no
co ela ion
be ween inse i
and adiog aphic
bone le el
change
Vogl e al.
(2019)
RCT;
pa allel;
non-
blinded
N/A 19 54 (33–70) 53 5 48 Smoke s <
10
ciga e es/
day
1
pa ien
36
mon hs
Sel -
apping h ead
(XiVE implan s,
Den sply
F iaden );
leng h: 9.5–15
mm; diame e :
3.5, 3.8, 4.5,
and 5.5 mm
Pos e io
and
an e io
mandible
Full occlusal
loading ( es ),
in aocclusion
in MI (con ol)
Sc ew- e ained
o cemen ed
single o
splin ed
c owns
24
mon hs
≤35 Ncm
=
100%;
>35
Ncm =
97.9%
Implan loss =1
implan .
Inse ion o que
>35 Ncm
Implan s wi h
inse ion
o ques <35
Ncm had no
no able e ec s
on clinical
ou comes.
Splin ing o he
p o isional
es o a ion may
well ha e
p e en ed
mic omo ion o
hese implan s
Abb e ia ions: CCT, con olled clinical ial; MI, maximum in e cuspa ion; RCT, andomized con olled ial.
164 DARRIBA ET AL.
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e al., 2016), Lebanon (Dahe e al., 2019), and Aus ia (Vogl
e al., 2019). Sample size calcula ion was p esen in only wo RCTs
(Schincaglia e al., 2016; Dahe e al., 2019) using di e ences in ma -
ginal bone le el changes. In all s udies, he ope a o was a single su -
geon, who inse ed he implan s in healed si es, wi hou simul aneous
bone augmen a ion p ocedu e. The de ini ion o implan loss o ailu e
a ied be ween a icles, including implan mobili y, p og essi e pe i-
implan bone loss equi ing implan emo al, and pain, among o he s.
This sys ema ic e iew pooled da a om 326 implan s, om
129 pa icipan s (58 males and 71 emales), 108 wi h an inse ion o -
que ≤20 Ncm (10 single implan s and 98 splin ed implan s), 80 wi h an
inse ion o que be ween >20 and ≤35 Ncm (31 single implan s and
49 splin ed implan s), and 138 wi h an inse ion o que >35 Ncm (55 sin-
gle implan s and 83 splin ed implan s). Inse ion o que alues ≤35 Ncm
we e conside ed as low inse ion o que and hose >35 Ncm as medium
o high inse ion o que. Acco ding o he da a o he selec ed a icles, a
cu -o poin o 20 Ncm was de e mined. Subg oup analysis compa ed
splin ed implan s wi h inse ion o que >20 Ncm e sus implan s wi h
inse ion o que ≤20 Ncm, and single implan s wi h inse ion o que
be ween 20 and 35 Ncm e sus single implan s wi h inse ion o que
>35 Ncm. The maximum ollow-up pe iod was 36 mon hs (Cesa e i
e al., 2016; Dahe e al., 2019; Vogl e al., 2019) and he minimum was
12 mon hs (Kou ouzis e al., 2011; Degidi e al., 2012; Schincaglia
e al., 2016). One pa ien in he s udy o Vogl e al. (Vogl e al., 2019)
was no a ailable o he las ollow-up, and wo pa ien s d opped ou
be o e he deli e y o he de ini i e p os heses in he s udy o Dahe
e al. (2019). These pa ien s we e no included in he analysis.
3.4 |Su i al a e
The pooled su i al a e o implan s wi h inse ion o que ≤35 Ncm
was 5% highe han ha o implan s wi h inse ion o que >35 Ncm
(Incidence a e a io [IRR] =1.05, 95% CI: 0.79–1.39, p=.175), how-
e e wi hou a signi ican di e ence and wi h absolu e homogenei y
(I
2
=0.0%) (Figu e 4). The su i al a e was simila in he con ol and
es g oups, achie ing equi alen ou comes in bo h g oups. The mean
su i al a es we e 96% (SR =0.96, 95% CI: 0.91–0.98, p> .001) o
implan s wi h inse ion o que ≤35 Ncm and 92% (SR =0.92, 95% CI:
0.86–0.96, p> .001) o implan s wi h inse ion o que >35 Ncm. The
le el o he e ogenei y was conside ed insigni ican in he es and con-
ol g oup (I
2
=0.0%).
The subg oup analysis, compa ing splin ed implan s wi h inse ion
o que >20 Ncm e sus implan s wi h inse ion o que ≤20 Ncm,
esul ed in no s a is ically signi ican supe io i y be ween g oups. The
su i al a e o implan s wi h an inse ion o que >20 Ncm was 5%
highe han ha o implan s wi h an inse ion o que less han
20 Ncm (IRRI =1.05, 95% CI: 0.78–1.43, p=.956, I
2
=0.0%)
(Figu e 5). Single implan s wi h an inse ion o que be ween 20 and
35 Ncm had 8% less isk o ailu e han single implan s wi h an inse -
ion o que >35 Ncm (IRR =0.92, 95% CI: 0.48–1.75, p=.799,
I
2
=0.0%) (Figu e 6). No s a is ical supe io i y was ound wi h di e -
en inse ion o ques in immedia ely loaded single implan s.
The he e ogenei y in he me a-analysis was I
2
=0, which means
ha all a iabili y in e ec size es ima es was due o sampling e o
wi hin s udies.
3.5 |Ma ginal bone le els changes
Only Degidi e al. (2012) epo ed changes on he pe i-implan c es al
bone le els measu ed wi h pe iapical x- ays acco ding o he inse ion
o que alues. The mean bone loss was 0.6 mm (±1.0 mm) in implan s
wi h inse ion o que ≤20 Ncm and 0.5 mm (±0.8 mm) o implan s
wi h inse ion o que ≥25 and ≤50 Ncm a e 1 yea . This di e ence
was no s a is ically signi ican .
3.6 |Mechanical, echnical, and biological
complica ions
None o he a icles epo ed mechanical complica ions o pe i-
implan i is o pe i-implan mucosi is. Some echnical complica ions
occu ed in empo a y es o a ions, such as imp ecise i (n=3 [Vogl
FIGURE 4 Risk a io o es plo compa ing implan s wi h ≤35 Ncm wi h >35 Ncm. CI, con idence in e al
DARRIBA ET AL.165
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e al., 2019]), chipping o he ac ylic (Degidi e al., 2012;n=4 [Dahe
e al., 2019]), o ac u e (n=2 [Vogl e al., 2019]). Se en echnical
complica ions occu ed wi h he den u es in he s udy o Schincaglia
e al. (2016) and wo ce amic ac u es in he de ini i e p os heses
(Dahe e al., 2019; Vogl e al., 2019). Howe e , none o he a icles
epo ed hese complica ions as a unc ion o he inse ion o que
alues.
4|DISCUSSION
This sys ema ic e iew suppo s ha immedia ely loaded den al
implan s wi h lowe inse ion o ques ha e simila implan su i al
a es as hose wi h medium o highe inse ion o ques. The quan i a-
i e analysis p o ided by bo h andomized and non- andomized in e -
en ion ials e ealed subs an ial su i al a es (96% o inse ion
o que ≤35 Ncm and 92% o inse ion o que >35 Ncm).
Me a-analysis o da a om he s udies did no e eal di e ences
be ween he e ec s o lowe inse ion o ques compa ed o medium o
highe inse ion o ques in e ms o implan su i al a e. Bo h immedi-
a e loading wi h low and medium o high inse ion oque a ained high
su i al a es; howe e , splin ed implan s wi h inse ion o que
>20 Ncm and single implan s wi h inse ion o que >35 Ncm had less
isk o ailu e, bu s a is ically he di e ences we e no signi ican .
Inse ion o que e e s o he o ce used o inse an implan in o
bone and is conside ed an objec i e su oga e measu e o p ima y
s abili y (Coope , 2012). P ima y s abili y is necessa y o immedia ely
loaded den al implan s. Howe e , he e a e many con ounding ac o s
ha a ec immedia e loading. Adequa e bone quali y and quan i y,
implan s wi h a ough su ace and adequa e dimension, and a good
clinical echnique o main ain con ac be ween implan and bone a e
necessa y o achie e p ima y s abili y (Mo on & Ja in, 2004). Un o -
una ely, his sys ema ic e iew could no analyse seconda y ou -
comes, such as ma ginal bone le els changes, pe i-implan so issues
change, o mechanical, echnical, and biological complica ions, since
mos o he s udies did no epo hese da a. Fu he mo e, he
included s udies showed a sho ollow-up pe iod because only ou
s udies epo ed ollow-up pe iods o e 24 mon hs (O oni
e al., 2005; Cesa e i e al., 2016; Dahe e al., 2019; Vogl
e al., 2019). The e o e, he esul s mus be in e p e ed wi h ca e. P e-
ious e iews iden i ied ew complica ions (Douglas De Oli ei a
e al., 2016; Ecke e al., 2019), un ela ed o he loading p o ocol
(Papaspy idakos e al., 2014; Chen e al., 2019). Once osseoin eg a-
ion has been achie ed, he e a e many o he ac o s besides he load-
ing p o ocol ha may be ela ed o biological and echnical
complica ions (Romanos, 2004; Papaspy idakos e al., 2014). The
smalle numbe o ele an s udies analysed in his sys ema ic e iew
highligh s he need o mo e well-designed compa a i e s udies o
FIGURE 6 Fo es plo compa ing single implan s wi h 20–35 Ncm e sus implan s wi h >35 Ncm. CI, con idence in e al
FIGURE 5 Fo es plo compa ing splin ed implan s wi h ≤20 Ncm e sus implan s wi h >20 Ncm. CI, con idence in e al
166 DARRIBA ET AL.
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