Clinical Outcomes Following Immediate Loading of

Single-Tooth Implants in the Esthetic Zone:

A Systematic Review and Meta-Analysis
Qian Cheng, MD1/Ying-Ying Su, PhD2/Xin Wang, PhD3/Su Chen, PhD4

Purpose: To identify whether or not immediate loading yields different clinical outcomes from conventional
loading of single-tooth implants in the esthetic zone. Materials and Methods: Various databases (MEDLINE/
PubMed, Cochrane [CENTRAL], and Embase) were searched electronically to find articles published in the
English language from January 2000 to April 2018. Only randomized controlled clinical trials (RCTs) that
compared conventional and immediate implant loading with a minimum follow-up period of 1 year or more
were considered. Available data were pooled for meta-analysis using the Review Manager software. Results:
Seven RCTs were included. There was no significant difference between immediate and conventional loading
protocols on implant survival at the 1-year follow-up (risk ratio [RR] = 0.99; 95% confidence interval [CI]:
0.95 to 1.02). The differences regarding marginal bone loss between the two protocols were statistically
insignificant (mean difference [MD] = 0.03 mm; 95% CI: –0.09 to 0.15 mm at the 1-year follow-up, and MD =
–0.01 mm; 95% CI: –0.16 to 0.15 mm at the 2-year follow-up). Soft tissue changes following different loading
protocols revealed no significant differences in the mesial papillae (MD = 0.30 mm; 95% CI: –0.25 to 0.85
mm), the distal papillae (MD = –0.00 mm; 95% CI: –0.42 to 0.42 mm), and the midfacial mucosa (MD = –0.33
mm; 95% CI: –1.17 to 0.50 mm) at the 1-year follow-up. The esthetic outcomes and patient satisfaction were
reported in two and three RCTs, respectively. Conclusion: A short-term follow-up of single-tooth implants
in the esthetic zone showed that the loading protocols (conventional or immediate loading) are not likely to
influence the clinical outcomes, including implant survival and peri-implant stability of soft and hard tissues.
Int J Oral Maxillofac Implants 2020;35:167–177. doi: 10.11607/jomi.7548

Keywords: esthetic zone, immediate loading, peri-implant, single implant, stability

T raditionally, a submerged healing period (12 to 25

weeks) was always a requisite to establish the os-
seointegration of endosseous implants.1 Due to the
designs in terms of forms, dimensions, materials, and
surface coatings are available.2–4 These developments
resulted in enhanced primary implant stability and
recent developments in oral implantology, dental improved prognosis. Consequently, the restoration
implants with better osseointegration and different protocol for dental implants has been modified from
conventional loading to an earlier and even immedi-
ate loading, particularly in patients with edentulous
1Graduate Student, School of Stomatology, Capital Medical mandibles with good bone quality.5 The key benefits
University, Beijing, China. of immediate loading include a reduction of surgical
2Medical Doctor, Department of Dentistry, Beijing Tian Tan
interventions and total treatment time; hence, the
Hospital, Capital Medical University, Beijing, China.
3Medical Doctor, VIP Clinic, Beijing Stomatological Hospital, time span between tooth extraction and insertion of
Capital Medical University, Beijing, China. implant-supported restorations may be remarkably
4Professor and Director, VIP Clinic, Beijing Stomatological decreased.6 Therefore, the immediate loading proto-
Hospital, Capital Medical University, Beijing, China. col has been extensively adopted and showed prom-
ise in selected cases,7 especially in the anterior maxilla,
Correspondence to: Dr Su Chen, VIP Clinic, Beijing
Stomatological Hospital, Capital Medical University, Tian Tan owing to its esthetic advantages.8–10
Xi Li No.4, Beijing 100050, China. Fax: +86 10 5709 9279. The immediate loading protocol can be commonly
Email: [email protected] applied in both postextraction sockets and healed al-
veolar ridges.11,12 Moreover, the comparison of survival
Submitted December 17, 2018; accepted September 9, 2019
rate and marginal bone stability between healed and
©2020 by Quintessence Publishing Co Inc. fresh extraction sites of immediately loaded implants

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Cheng et al

Table 1   Electronic Search Strategy

1. ((((“Dental Implants, Single-Tooth”[Mesh]) OR “Dental Implantation, Endosseous”[Mesh]) OR “Dental Prosthesis, Implant-
Supported”[Mesh]) OR “Dental Restoration, Temporary”[Mesh]) OR “Dental Restoration, Permanent”[Mesh]
2. (((((((endosseous implant[Title/Abstract]) AND (dental[Title/Abstract] OR oral[Title/Abstract]))) OR dental implant[Title/
Abstract]) OR implant supported prosthesis[Title/Abstract]) OR implant supported restorations[Title/Abstract]) OR
implant supported crowns[Title/Abstract]) OR single crown[Title/Abstract]
3. (#1) OR (#2)
4.  “Esthetics, Dental”[Mesh]
5.  ((esthetic[Title/Abstract]) OR anterior[Title/Abstract]) OR premaxillary[Title/Abstract]
6. (#4) OR (#5)
7.  (“Dental Prosthesis Design”[Mesh]) OR “Time Factors”[Mesh]
8. ((((((immediate restoration[Title/Abstract]) OR conventional restoration[Title/Abstract]) OR delayed restoration[Title/
Abstract]) OR immediate loading[Title/Abstract]) OR conventional loading[Title/Abstract]) OR delayed loading[Title/
Abstract]) OR immediate provisionalization[Title/Abstract]
9. (#7) OR (#8)
10.  (“Randomized Controlled Trial” [Publication Type]) OR “Controlled Clinical Trial” [Publication Type]
11. (((randomized[Title/Abstract]) OR randomly[Title/Abstract]) OR trial[Title/Abstract]) OR groups[Title/Abstract]
12. (#10) OR (#11)
13.  (“Animals”[Mesh]) NOT “Humans”[Mesh]
14. (#12) NOT (#13)
15. (#3) AND (#6) AND (#9) AND (#14)

showed comparable results. These findings suggest clinical outcomes from conventional loading of single-
that the immediate loading protocol may provide pre- tooth implants in the esthetic zone.
dictable and beneficial outcomes in different implant
sites.13–16
The concepts of nonocclusal17,18 and progressive MATERIALS AND METHODS
loading19,20 of the prostheses have been suggested
to decrease the failure risks of immediately loaded The present study constructed a focused question:
single implants. However, in a recent RCT, single im- “Does immediate loading yield different clinical out-
plants restored with definitive crowns in direct func- comes from conventional loading of single-tooth
tional occlusion (within 48 hours) provided promising implants in the esthetic zone?”; this followed the
results of short-term follow-up.21 Another prospective guidelines described by Preferred Reporting Items for
RCT22 compared the immediate nonloaded (nonoc- Systematic Reviews and Meta-Analyses (PRISMA).34
clusal) and immediately loaded single-tooth maxillary
implants and reported no significant differences be- Selection Criteria
tween groups in terms of radiographic bone loss and The following criteria were implemented: (1) RCTs; (2)
soft tissue esthetics. number of patients/implants: ≥ 10/group; (3) follow-
For dental implants in the esthetic zone, one of up duration: ≥ 12 months; (4) implants definitively
the crucial parameters to assess clinical success is the restored with fixed prostheses; (5) immediate loading
stability of peri-implant soft and hard tissues. Most in the test group should be within 24 hours following
recently, additional parameters such as the patient’s implant placement; (6) studies reporting the use of
perception have been regarded as nonnegligible pa- identical implant system for both groups; (7) studies re-
rameters and are being increasingly considered by cli- porting specified implant survival data; and (8) provid-
nicians for comprehensive evaluation.23–26 ing quantitative data for assessing changes of marginal
A number of systematic reviews published recently bone and soft tissues (mean ± standard deviation [SD]).
have focused on the impact of different loading pro-
tocols on dental implants of various clinical condi- Search Strategy
tions concerning different experiment designs.27–32 It Two investigators (Q.C., Y.-Y.S.) conducted an electronic
is well-known that the highest level of evidence de- search using databases (MEDLINE/PubMed, Cochrane
rives from data of RCTs,33 and unfortunately, relevant [CENTRAL] and Embase) for articles published in the
systematic reviews involving the esthetic zone are still English language from January 2000 to April 2018 (Ta-
limited. Therefore, the aim of this study was to iden- ble 1). A manual search of the references of relevant
tify whether or not immediate loading yields different literature was conducted as well.

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 Cheng et al

Study Selection and Data Extraction Electronic search of titles from

Two investigators (Q.C., Y.-Y.S.) screened the searched PubMed, Embase, and Cochrane
articles’ titles and abstracts independently. Following CENTRAL database
the initial screening, full texts of all studies satisfying (n = 505)
the inclusion criteria were retrieved for further indepen- Excluded (n = 26)
dent assessment by the same two reviewers. Disagree- Evaluation of relevant abstracts
ment (if any) between the reviewers was solved through (n = 479)
further discussion. The following information was ex-
Excluded (n = 460)
tracted from included studies: (1) publication year; (2)
author(s); (3) number of patients included/dropouts; (4) Evaluation of relevant full-text
articles (n = 19)
patient demographic data; (5) number of implants; (6) Screening of the
follow-up period; (7) implant sites (healed or fresh ex- reference list (n = 3)
traction sites); (8) type of incision (flap or flapless); (9) Excluded (n = 15)
insertion torque; (10) bone grafting; (11) occlusal con- Included articles
tact of immediate loading group; (12) time of definitive (n = 7)
crown insertion; (13) antibiotic prophylaxis; (14) implant
Fig 1   Flowchart summarizing the selection process.
system; (15) implant survival rate; and (16) level changes
in the marginal bone and soft tissues.
Characteristics of the Included Studies
Quality Assessment A total of 386 single-tooth implants (189 implants im-
Two investigators (Q.C., X.W.) evaluated the quality of mediately loaded, and 197 conventionally loaded)
the RCTs following the bias risk assessment recom- were placed (Table 2). All RCTs were parallel designed,
mendations provided by the Cochrane Handbook for and only one multicenter study38 adopted both parallel
Systematic Reviews of Interventions.35 Disagreement and split-mouth designs. One trial40 included patients
(if any) between the reviewers was settled by further only with a missing single maxillary lateral incisor,
discussion. and patients enrolled in the other studies required
single-tooth rehabilitation from premolar to premolar.
Statistical Analysis Sample-size calculation was performed in four stud-
Meta-analysis was carried out if a minimum of two ies39–42; and the homogeneity of the study population
studies reported similar findings with adequate uni- was stated in two reports.36,40 Three RCTs assessed im-
formity. For dichotomous outcomes (implant survival), plants placed in fresh extraction sites, two37,39 without
the assessment of relative effect was expressed in risk bone wall dehiscence or fenestration, and one42 with
ratio (RR) and 95% confidence interval (CI); for continu- the vertical buccal bone defect (< 5 mm). The quality
ous outcomes (marginal bone loss and soft tissue level assessment showed that the majority of included RCTs
changes), the estimate of relative effect was expressed had a low to moderate risk of bias (Table 3).
in mean difference (MD) and 95% CI. The statistical unit
was the implant, and the chi-squared test for hetero- Main Outcomes of the Study
geneity was performed. If noteworthy heterogeneity Implant Survival.
was found, the significance of intervention outcomes All articles reported implant survival. The overall sur-
was assessed by a random-effect model. In cases of vival rate at the 1-year follow-up remained 97.9%
no evident heterogeneity, a fixed-effect model was (184/188) for immediately loaded implants, and 99.0%
applied for the analysis. The meta-analysis was con- (190/192) for conventionally loaded implants (Table
ducted using the Review Manager statistical software 4). According to the meta-analysis, no significant dif-
(v5.3.5, The Nordic Cochrane Centre). ferences were observed between groups with RR of
0.99 (95% CI: 0.95 to 1.02), and no evident heterogene-
ity was found (Fig 2). Two studies reported no implant
RESULTS failure throughout the follow-up duration.37,40
Marginal Bone Loss. All RCTs reported the overall
The electronic search found a total of 505 articles marginal bone loss and/or changes restricted to me-
(Fig 1). After initial screening of the titles/abstracts, sial/distal sites (Table 5). Data of four and two studies
only 19 articles were considered for further evaluation. with the comparative baseline were pooled for meta-
In addition, three articles extracted from the reference analysis at the 1-year and 2-year follow-ups, respec-
lists of relevant literature were retrieved for full-text tively.37–41 The weighted mean differences were 0.03
screening. Out of 22 publications, seven articles36–42 mm (95% CI: –0.09 to 0.15 mm) for the 1-year compari-
were finally included in the present review. son and –0.01 mm (95% CI: –0.16 to 0.15 mm) for the

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Cheng et al

Table 2   Characteristics of Included Studies

No. of No. of patient No. of No. of implant Implant sites
patients dropouts implants dropouts Follow- (healed or fresh
Mean age (range) up extraction
Study Year IL CL IL CL (y) IL CL IL CL (mo) sites)
Hall et al36 2007 14 14 1 2 43.25 (23–71) 14 14 1 2 12 HS

Crespi 2008 20 20 0 0 47.21 (24–68) 20 20 0 0 24 FES

et al37

Donati 2008 NR NR NR NR Male: 46.7 ± 18.3 50 57 0 2 12 HS

et al38 Female: 44.2 ± 12.9

Degidi 2009 30 30 0 0 31.5 ± 11.8 (18–55) 30 30 0 0 36 HS

et al40

De Rouck 2009 24 25 0 0 IL: 55 ± 13 24 25 0 0 12 FES

et al39 CL: 52 ± 12

den Hartog 2011 31 31 0 0 IL: 38.4 ± 14.0 31 31 0 0 18 HS

et al41 (18–66)
CL: 40.1 ± 14.4
(18–67)
Slagter 2015 20 20 0 1 IL: 39.4 ± 16.9 20 20 0 1 12 FES
et al42 (19–70)
CL: 42.3 ± 14.2
(23–66)

IL = immediate loading; CL = conventional loading; NR = not reported.

Table 3   Bias and Quality Assessment of Included RCTs

Random Blinding of Incomplete Free of
sequence Allocation outcome outcome selective Free of other
RCT generation concealment assessment data addressed reporting bias
Hall et al36 Y U U Y Y U
Crespi et al37 U U U Y Y U
Donati et al38 Y U U Y Y U
De Rouck et al39 Y N Y Y Y U
Degidi et al40 Y Y U Y Y U
den Hartog et al41 Y Y Y Y Y U
Slagter et al42 Y U U Y Y U
Y = yes (bias risk is low); U = unclear (bias risk is unclear); N = no (bias risk is high).

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 Cheng et al

Occlusal Time of
Flap Insertion contact of provisional crown Time of
reflection torque Bone grafting immediate (after implant definitive Antibiotic
(yes/no) (Ncm) (yes/no) loading group placement) crown prophylaxis Implant system
Y NR Y (autogenous Out of IL: within 4 hours 8 weeks after 0.2% chlorhexidine Tapered, external
bone) occlusion CL: 26 weeks provisional mouthwash hexagon,
crown for 2 weeks roughened
postoperatively surface (Southern
Implants)
N ≥ 25 N Centric IL: immediately 6 months 1 g amoxicillin 1 h Outlink
occlusion (specific time not after implant before surgery and (Sweden &
reported) placement twice daily for a week; Martina)
CL: 3 months chlorhexidine (0.2%)
mouthwash twice
daily for 15 days
following surgery
Y ≥ 20 N Centric IL: within 24 hours 6 months 1 g of augmentin 1 OsseoSpeed
occlusion CL: 3 months after implant h before surgery (Astra Tech
placement Dental)
Y > 25 N Out of IL: on the day of 6 months 500 mg amoxicillin XiVE Plus
occlusion surgery after implant 1 h before surgery (Dentsply-
CL: no provisional placement and twice daily for Friadent)
crown 5 days
Y ≥ 35 Y (anorganic Out of IL: within a few 6 months NR NobelReplace
bovine bone) occlusion hours after Tapered TiUnite
CL: 3 months provisional (Nobel Biocare
crown AB)
Y ≥ 45 Y (autogenous Out of IL: within 24 hours 6 months NR NobelReplace
bone chips occlusion CL: 3 months after implant Tapered Groovy
and anorganic placement (Nobel Biocare
bovine bone) AB)
N NR Y (autogenous Out of IL: approximately 3 months Amoxicillin (500 NobelActive
bone 1:1 mixed occlusion 6 hours after mg, t.i.d.) and (Nobel Biocare
with anorganic CL: 3 months provisional chlorhexidine (0.2%) AB)
bovine bone) crown mouthwash (b.i.d.)
for a week pre-
operatively

Table 4   Implant Survival Reported by Included Studies

Implant survival rate (%)
No. of implants No. of implant
available for analysis failures 1y 2y 3y
Study IL CL IL CL IL CL IL CL IL CL
Hall et al36 13 12 1 0 92 100
Crespi et al37 20 20 0 0 100 100 100 100
Donati et al38 50 55 1 0 98 100
Degidi et al40 30 30 0 0 100 100 100 100 100 100
De Rouck et al39 24 25 1 2 96 92
den Hartog et al41 31 31 1 0 97 100
Slagter et al42 20 19 0 0 100 100
IL = immediate loading; CL = conventional loading.

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Cheng et al

IL CL
Weight Risk ratio
Study or subgroup Events Total Events Total (%) M-H, Fixed, 95% CI
Hall et al, 2007 12 13 12 12 6.8 0.93 [0.75, 1.15]
Crespi et al, 2008 20 20 20 20 10.7 1.00 [0.91, 1.10]
Donati et al, 2008 49 50 55 55 27.7 0.98 [0.93, 1.03]
Degidi et al, 2009 30 30 30 30 16.0 1.00 [0.94, 1.07]
De Rouck et al, 2009 23 24 23 25 11.8 1.04 [0.90, 1.20]
den Hartog et al, 2011 30 31 31 31 16.5 0.97 [0.89, 1.06]
Slagter et al, 2015 20 20 19 19 10.5 1.00 [0.91, 1.10]

Total (95% CI) 188 192 100.0 0.99 [0.95, 1.02]

Total events 184 190
0.7 0.85 1 1.2 1.5
Heterogeneity: Chi2 = 1.42, df = 6 (P = .96); I2 = 0% Favors IL Favors CL
Test for overall effect: Z = 0.61 (P = .54)

Fig 2   Forest plot for implant survival comparing immediate loading (IL) and conventional loading (CL) at 1-year follow-up.

Table 5   Marginal Bone Loss Reported by Included Studies

1 y (mean ± SD) (mm) 2 y (mean ± SD) (mm) 3 y (mean ± SD) (mm) Follow-
up
Study IL CL IL CL IL CL baseline
Hall et 0.63 ± 1.00 0.78 ± 1.01 Definitive
al36 crown
placement
Crespi Mean: 1.02 ± 0.53 Mean: 1.16 ± 0.51 Implant
et al37 Mesial: 0.93 ± 0.51 Mesial: 1.16 ± 0.32 placement
Distal: 1.10 ± 0.27 Distal: 1.17 ± 0.41
Donati Mean: 0.32 ± 0.87 Mean: 0.38 ± 0.89 Implant
et al38 Mesial: 0.32 ± 0.87 Mesial: 0.33 ± 0.89 placement
Distal: 0.31 ± 0.50 Distal: 0.43 ± 0.88
Degidi 0.69 ± 0.38 0.58 ± 0.28 0.73 ± 0.40 0.70 ± 0.29 0.85 ± 0.71 0.75 ± 0.63 Implant
et al40 placement
De Rouck Mean: 0.86 ± 0.54 Mean: 0.97 ± 0.35 Provisional
et al39 Mesial: 0.92 ± 0.49 Mesial: 0.96 ± 0.25 crown
Distal: 0.79 ± 0.54 Distal: 0.97 ± 0.35 placement
den Mean: 0.91 ± 0.61 Mean: 0.90 ± 0.57 Implant
Hartog et Mesial: 0.87 ± 0.55 Mesial: 0.91 ± 0.66 placement
al41 Distal: 0.95 ± 0.84 Distal: 0.90 ± 0.77
Slagter Mesial: 0.75 ± 0.69 Mesial: 0.68 ± 0.65 Definitive
et al42 Distal: 0.70 ± 0.64 Distal: 0.68 ± 0.64 crown
placement
IL = immediate loading; CL = conventional loading.

2-year comparison. In addition, there were no signifi- mesial and distal sites (Fig 4). Similarly, in terms of
cant differences between the two protocols for both of midfacial recession, there was no significant difference
the comparisons (Fig 3). between immediate and conventional loading proto-
Soft Tissue Level Changes. The results with diver- cols (Fig 5). Only two studies36,38 provided information
siform baselines of soft tissue level changes are pre- about changes of the width of keratinized mucosa.
sented in Table 6. One study41 reported the gain of Esthetic Outcomes. Only two studies41,42 assessed es-
midfacial mucosa for the immediate loading group thetic outcomes, with one41 focusing on healed sites, and
and papilla height for both groups. Two studies39,42 the other42 concerning fresh extraction sites. Both stud-
evaluated papilla recession and midfacial recession ies41,42 used the Implant Crown Aesthetic Index (ICAI)43
from preoperative status to the 1-year follow-up. Due and the Pink Esthetic Score-White Esthetic Score (PES-
to the heterogeneity of these studies, the present WES),44 and reported no statistical differences between
study used a random-effects model. The meta-analysis immediate and conventional loading groups (Table 7).
regarding papilla recession revealed no significant dif- Patient Satisfaction. Three studies39,41,42 estimated
ferences between the two loading protocols in both the patients’ satisfaction. One trial39 utilized the 10-cm

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 Cheng et al

IL CL
Weight Mean difference
Study or subgroup Mean SD Total Mean SD Total (%) IV, Fixed, 95% CI
1.1.1 1 year
Donati et al, 2008 0.32 0.87 49 0.38 0.89 55 12.5 –0.06 [–0.40, 0.28]
Degidi et al, 2009 0.69 0.38 30 0.58 0.28 30 50.4 0.11 [–0.06, 0.28]
De Rouck et al, 2009 0.86 0.54 23 0.97 0.35 23 20.8 –0.11 [–0.37, 0.15]
den Hartog et al, 2011 0.91 0.61 30 0.9 0.57 31 16.3 0.01 [–0.29, 0.31]
Subtotal (95% CI) 132 139 100.0 0.03 [–0.09, 0.15]
Heterogeneity: Chi2 = 2.24, df = 3 (P = .52); I2 = 0%
Test for overall effect: Z = 0.44 (P = .66)

1.1.2 2 years
Crespi et al, 2008 1.02 0.53 20 1.16 0.51 20 23.1 –0.14 [–0.46, 0.18]
Degidi et al ,2009 0.73 0.4 30 0.7 0.29 30 76.9 0.03 [–0.15, 0.21]
Subtotal (95% CI) 50 50 100.0 –0.01 [–0.16, 0.15]
Heterogeneity: Chi2 = 0.82, df = 1 (P = .36); I2 = 0%
Test for overall effect: Z = 0.12 (P = .91)
–1.0 –0.5 0 0.5 1.0
Test for subgroup differences: Chi2 = 0.13, df = 1 (P = .72); I2 = 0% Favors IL Favors CL

Fig 3   Forest plot for marginal bone loss comparing immediate loading (IL) and conventional loading (CL) at 1- and 2-year follow-up.

IL CL
Weight Mean difference
Study or subgroup Mean SD Total Mean SD Total (%) IV, Random, 95% CI
1.1.1 mesial
De Rouck et al, 2009 0.44 0.77 23 0.43 0.42 23 47.9 0.01 [–0.35, 0.37]
Slagter et al, 2015 0.89 0.46 20 0.32 0.43 19 52.1 0.57 [0.29, 0.85]
Subtotal (95% CI) 43 42 100.0 0.30 [–0.25, 0.85]
Heterogeneity: Tau2 = 0.13; Chi2 = 5.83, df = 1 (P = .02); I2 = 83%
Test for overall effect: Z = 1.08 (P = .28)

1.1.2 distal
De Rouck et al, 2009 0.31 0.81 23 0.53 0.55 23 49.5 –0.22 [–0.62, 0.18]
Slagter et al, 2015 1 0.58 20 0.79 0.66 19 50.5 0.21 [–0.18, 0.60]
Subtotal (95% CI) 43 42 100.0 –0.00 [–0.42, 0.42]
Heterogeneity: Tau2 = 0.05; Chi2 = 2.27, df = 1 (P = .13); I2 = 56%
Test for overall effect: Z = 0.01 (P = .99) –2 –1 0 1 2
Test for subgroup differences: Chi2 = 0.74, df = 1 (P = .39); I2 = 0% Favors IL Favors CL
Fig 4   Forest plot for papilla recession in mesial and distal sites comparing immediate loading (IL) and conventional loading (CL) at
1-year follow-ups.

IL CL
Weight Mean difference
Study or subgroup Mean SD Total Mean SD Total (%) IV, Random, 95% CI
De Rouck et al, 2009 0.41 0.75 23 1.16 0.66 23 51.0 –0.75 [–1.16, –0.34]
Slagter et al, 2015 0.95 0.62 20 0.85 0.86 19 49.0 0.10 [–0.37, 0.57]
Total (95% CI) 43 42 100.0 –0.33 [–1.17, 0.50]
Heterogeneity: Tau2 = 0.31; Chi2 = 7.12, df = 1 (P = .008), I2 = 86% –2 –1 0 1 2
Test for overall effect: Z = 0.79 (P = .43)
Favors IL Favors CL
Fig 5   Forest plot for midfacial recession comparing immediate loading (IL) and conventional loading (CL) at 1-year follow-up.

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Table 6   Soft Tissue Level Changes Reported by Included Studies

Papilla recession Midfacial recession Width of keratinized
(mean ± SD) (mean ± SD) mucosa (mean ± SD)
(mm) (mm) (mm)
Follow-up
Study IL CL IL CL IL CL baseline
Hall et al36 0.67 ± 0.49 0.33 ± 0.78 1.08 ± 1.31 0.83 ± 1.59 4 weeks after
definitive crown
placement
Donati Mesial: 0.43 ± 1.20 Mesial: 0.55 ± 1.14 Provisional crown
et al38 Distal: 0.21 ± 1.27 Distal: 0.50 ± 0.95 0.21 ± 1.41 0.26 ± 1.00 placement
De Rouck Mesial: 0.44 ± 0.77 Mesial: 0.43 ± 0.42 0.41 ± 0.75 1.16 ± 0.66 Preoperative
et al39 Distal: 0.31 ± 0.81 Distal: 0.53 ± 0.55 status
den Hartog Mean: –0.34 ± 0.49 Mean: –0.27 ± 0.42 Definitive crown
et al41 Mesial: –0.41 ± 0.49 Mesial: –0.19 ± 0.29 –0.06 ± 0.42 0.09 ± 0.34 placement
Distal: –0.27 ± 0.49 Distal: –0.35 ± 0.52
Slagter Mesial: 0.89 ± 0.46 Mesial: 0.32 ± 0.43 0.95 ± 0.62 0.85 ± 0.86 Preoperative
et al42 Distal: 1.00 ± 0.58 Distal: 0.79 ± 0.66 status
IL = immediate loading; CL = conventional loading.
Negative values mean gain of the mucosa level.

Table 7   Evaluation of Esthetic Characteristics

PES (mean ± SD) WES (mean ± SD) ICAI (mean ± SD)
P P P
Study IL CL value IL CL value IL CL value
den Hartog 7.1 ± 1.5 6.5 ± 1.63 > .05 7.8 ± 1.5 7.6 ± 1.6 > .05 NR (gingival NR (gingival > .05
et al41 esthetic esthetic
satisfactory satisfactory
rate: 80%) rate: 62%)
Slagter et al42 7.50 ± 1.59 7.40 ± 1.46 .79 8.10 ± 0.90 7.90 ± 1.08 .79 4.2 ± 2.38 5.2 ± 4.10 .37
IL = immediate loading; CL = conventional loading; NR = not reported.

visual analog scale (VAS) to assess the patients’ es- protocols are equally beneficial for clinical success
thetic satisfaction, and found insignificant differences during short-term follow-up. Undoubtedly, long-term
between the immediate loading group (mean: 93%) follow-up data can provide more compelling evidence,
and conventional loading group (mean: 91%). In an- and a longer follow-up period is required to validate
other RCT,41 a self-administered questionnaire with a the present findings.
five-point rating scale and a 100-mm VAS were used. Considering the benefits of shortened treatment
The study reported a high level of patient satisfaction time and meeting patients’ expectations, the immedi-
in both groups without any obvious differences. The ate loading protocol has been extensively performed
third trial42 used a 100-mm VAS and the Oral Health Im- in various clinical conditions. Although the immediate
pact Profile (OHIP)-14 questionnaire.45 The VAS scores loading of single-tooth implants and full-arch restora-
were 8.2 ± 0.9 and 9.1 ± 0.8 for the immediate and tions showed comparable survival rates, single-tooth
conventional loading group, respectively (P < .002), implants were thought to have a higher risk of failure.32
whereas insignificant differences were detected be- For implant sites, loading protocols (immediate or con-
tween groups regarding the OHIP-14. ventional) were supposed to be irrelevant for clinical
success concerning the implant survival or stability of
marginal bone in fresh extraction or healed sites.46
DISCUSSION Previously, it was deemed that implant placement
into fresh extraction sites would intervene in bone
The present review exclusively analyzed RCTs compar- remodeling and therefore likely maintain the original
ing immediate and conventional loading of single- dimension of the alveolar ridge.47 Later, a review48
tooth implants in the esthetic zone for a minimum recommended that clinicians should be conservative
follow-up period of 1 year. When assessing the im- while planning immediate implant insertion and pro-
plants’ survival rate and changes in the levels of sur- visionalization to restore a single tooth in the maxillary
rounding soft and hard tissues, the meta-analyses anterior segment, since postoperative bone remod-
suggest that immediate and conventional loading eling and marginal gingival change would proceed

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 Cheng et al

regardless of implant placement timing. In contrast, however, the pressure coming from surrounding soft
another review49 reported that immediate loading or tissues (tongue and perioral musculature) cannot
restoration of single-tooth implants in the anterior re- be neglected.55 The absence of excessive interfacial
gion did not interfere with the stability of peri-implant micromotion was thought to be vital for osseointe-
soft and hard tissues compared with the conventional gration.56 Szmukler-Moncler et al indicated that the
approach, and these findings are in agreement with tolerable micromotion threshold ranged between 50
the present study. and 150 microns.57 Moreover, Brunski et al believed
It is commonly believed that implant stability is a that the micromovement of more than 100 μm was
prerequisite for successful osseointegration and a sufficient to jeopardize the osseointegration with the
promising clinical outcome of immediately loaded im- formation of fibrous encapsulation.58
plants.7 In addition, considering implant survival rate Immediate loading of dental implants plays a vital
and the stability of marginal bone, the conventionally role in maintaining the structural integrity of peri-
and immediately loaded single implants were similarly implant soft tissues with the provisional prosthetic
successful when inserted with an adequate torque restoration during the healing process.59 The included
(≥ 20 to 45 Ncm) and implant stability quotient (≥ 60 to RCTs36,38,39,41,42 reported gingival recession and soft
65).6 In the present review, the insertion torque men- tissue changes within the range of clinically accept-
tioned in the included studies was between the afore- able level. Surprisingly, one RCT41 reported the gain of
mentioned range, although two studies36,42 did not the mucosa. The promising outcome was supposedly
report the specific values. In a previous study,50 nonoc- attributed to the bone augmentation procedure be-
clusal provisional crowns were delivered immediately fore implant placement and comparatively less bone
after implant insertion in the range of 25 to 35 Ncm or loss near the adjacent teeth. The interproximal bone
higher than 80 Ncm. The assessment of marginal bone level of adjacent teeth is directly related to the sta-
loss and associated complications showed no signifi- tus of the implant’s interproximal papillae.60–62 There-
cant differences between immediate and conventional fore, the bone level of adjacent teeth should also be
loading groups. However, in order to attain a high sur- considered as a critical factor to predict the esthetic
vival rate of immediately loaded single implants, the outcomes.41 The RCTs included in this review failed
authors believed that the medium insertion torque (25 to offer unified reference time points; hence, limited
to 35 Ncm) was not enough.50 data were pooled for conducting the meta-analysis of
Traditionally, implant surgery involves the exposure soft tissue changes.
of the alveolar ridge using a full-thickness mucoperios- Although a number of outcome measures have
teal flap to prepare the site for implant positioning.1,51 been used in dental implant research, there is a lack
The flapless approach was considered advantageous of standardized assessment methods for dentate sub-
in the esthetic zone, since it avoids compromise of the jects.63–65 Vilhjálmsson et al found that the modified
vascular supply of peri-implant tissues.52 In the present Implant Crown Aesthetic Index (mod-ICAI) delivered
review, two RCTs37,42 adopted the flapless approach, an effective combination of objective and subjec-
while the other studies used the traditional approach. tive evaluation to assess the esthetic components of
A recent systematic review53 suggested that the flap implant-retained crowns.66 On the other hand, Tet-
design should be chosen for patients’ comfort, need tamanti et al concluded that the PES-WES and Peri-
for access and bone augmentation, and experience Implant-Crown Index were preferable to assess the
level of the surgeon. Encouragingly, with the help of single implant crowns compared with the ICAI, due
a computer-guided implant technique, implants prob- to reproducibility considerations.67 In a recent sys-
ably can be placed more accurately with reduced risk tematic review,68 the PES and the Papilla Index were
of associated complications.54 related to the patients’ responses about peri-implant
There is a continuous debate concerning whether soft tissues, whereas the ICAI and mod-ICAI showed
dental implants’ immediate loading should be occlusal an association to soft tissue and crown satisfaction.
or nonocclusal. A recent meta-analysis suggested that In the authors’ opinion, there was a need to develop
neither the occlusal nor nonocclusal implant loading is a comprehensive and practical index to estimate es-
associated with clinical outcomes regarding marginal thetic components of single-tooth implant restora-
bone loss and survival rate.55 In the present review, tions in the anterior maxilla.68
only two RCTs37,38 reported using provisional crowns The results of the present review should be inter-
of immediately loaded implants in centric occlusion. preted carefully, as both the amount of currently avail-
For all other RCTs, provisional crowns were adjusted able RCTs and the quantitative data extracted from the
(nonocclusal) to avoid any centric or lateral excursion original articles are relatively limited. Rigorous experi-
occlusal interferences. The aim of obliterating all the mental design and blind method can help to reduce
occlusal contacts was to ensure undisturbed healing; risk of bias and ensure the credibility of the study.

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Cheng et al

CONCLUSIONS 14. Berberi AN, Sabbagh JM, Aboushelib MN, Noujeim ZF, Salameh ZA.
A 5-year comparison of marginal bone level following immediate
loading of single-tooth implants placed in healed alveolar ridges
A short-term follow-up of single-tooth implants in the and extraction sockets in the maxilla. Front Physiol 2014;5:29.
esthetic zone showed that the loading protocols (con- 15. Cooper LF, Reside GJ, Raes F, et al. Immediate provisionalization
of dental implants placed in healed alveolar ridges and extrac-
ventional or immediate loading) are not likely to influ- tion sockets: A 5-year prospective evaluation. Int J Oral Maxillofac
ence clinical outcomes, regarding implant survival rate Implants 2014;29:709–717.
and the stability of peri-implant soft and hard tissues. 16. Han CH, Mangano F, Mortellaro C, Park KB. Immediate loading of
tapered implants placed in postextraction sockets and healed
More RCTs comprising larger sample sizes and with a sites. J Craniofac Surg 2016;27:1220–1227.
longer follow-up period are required to validate these 17. Andersen E, Haanaes HR, Knutsen BM. Immediate loading of
findings. single-tooth ITI implants in the anterior maxilla: A prospective
5-year pilot study. Clin Oral Implants Res 2002;13:281–287.
18. Ariano V, Mancini M, Cardi A, Condò R, Cerroni L, Pasquantonio G.
Immediate nonfunctional loading of two single-maxillary postex-
ACKNOWLEDGMENTS tractive implants: 6-year postloading results of two case reports.
Case Rep Dent 2016;2016:6816907.
19. Appleton RS, Nummikoski PV, Pigno MA, Cronin RJ, Chung KH. A
This study was financially supported by the National Natural Sci- radiographic assessment of progressive loading on bone around
ence Foundation of China (grant no. 81570999). The authors single osseointegrated implants in the posterior maxilla. Clin Oral
reported no conflicts of interest related to this study. Implants Res 2005;16:161–167.
20. Ghoveizi R, Alikhasi M, Siadat MR, Siadat H, Sorouri M. A radio-
graphic comparison of progressive and conventional loading on
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