Received: 23 October 2017 | Revised: 16 March 2018 | Accepted: 17 March 2018

DOI: 10.1111/clr.13278

REVIEW ARTICLE

Immediate loading vs. early/conventional loading of

immediately placed implants in partially edentulous patients
from the patients’ perspective: A systematic review

Guy Huynh‐Ba1 | Thomas W. Oates2 | Mary Ann H. Williams3

1
Department of Periodontics, School of
Dentistry, University of Texas Health Abstract
Science Center at San Antonio, San Antonio, Objectives: This systematic review aimed at answering the following PICO question:
Texas
2
In patients receiving immediate (Type 1) implant placement, how does immediate
Department of Advanced Oral Sciences &
Therapeutics, School of Dentistry, University compare to early or conventional loading in terms of Patient‐Reported Outcome
of Maryland, Baltimore, Maryland
Measures (PROMs)?
3
Health Sciences & Human Services
Material and Methods: Following search strategy development, the OVID, PubMed,
Library, University of Maryland, Baltimore,
Maryland EMBASE, and Cochrane Database of Systematic Reviews databases were search for
the relevant literature. All levels of evidence including randomized controlled trials,
Correspondence
Guy Huynh‐Ba, Department of Periodontics, prospective and retrospective cohort studies, and case series of at least five patients
University of Texas Health Science
were considered for possible inclusion. An additional manual search was performed
Center at San Antonio, 7703 Floyd Curl
Drive, Mailcode 7894, San Antonio, TX by screening the reference lists of relevant studies and systematic reviews published
78229‐3900.
up to May 2017. The intervention considered was the placement of immediate
Email: [email protected]
implant.
Study selection and data extraction were performed independently by two
reviewers.
Results: The search yielded a list of 1,102 references, of which nine were included in
this systematic review. The limited number of studies included and the heterogeneity
of the data identified prevented the performance of a meta‐analysis. Three studies,
one of which was a randomized controlled trial, allowed the extraction of compara‐
tive data specific to the aim of the present systematic review. The remaining studies
allowed only data extraction for one single treatment modality and were viewed as
single cohort studies. Overall, irrespective of the PROMs chosen, patients’ satisfac‐
tion was overall high with little difference between the two loading protocols.
Moreover, studies indicated a positive impact on oral health‐related quality of life
following immediate implant placement and loading.
Conclusions: Within the limitations of the present systematic review, immediate im‐
plant placement and loading in single tooth edentulous space seems to be a well‐ac‐
cepted treatment modality from the patients’ perspective and is worthy of
consideration in clinical practice. However, the paucity of comparative data limits any
definitive conclusions as to which loading protocol; immediate or early/conventional,
should be given preference based on PROMs.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2018 The Authors. Clinical Oral Implants Research Published by John Wiley & Sons Ltd.

Clin Oral Impl Res. 2018;29(Suppl. 16):255–269. 

wileyonlinelibrary.com/journal/clr | 255
256 | HUYNH‐BA et al.

KEYWORDS
clinical trial, immediate dental implant loading, patient‐reported outcome measures, visual
analog scale

1 | I NTRO D U C TI O N tooth gap fresh extraction socket and immediately temporized with
a single implant‐supported provisional restoration. In 1998; Wöhrle
Dental implants have become a well‐accepted and predictable treat‐ reported on 14 consecutive patients treated successfully with im‐
ment modality. From the pioneer work of Brånemark and Schroeder mediate implants and immediate temporization. The success with
describing osseointegration in the 70s to the more recent digital de‐ this treatment protocol has been further documents in multiple
velopments in implant dentistry, our understanding in implant sci‐ case series and small cohort studies have (Ferrara, Galli, Mauro, &
ence has evolved. Similarly, outcome assessment of dental implants Macaluso, 2006; Groisman, Frossard, Ferreira, de Menezes Filho,
has considerably evolved. & Touati, 2003; Kan, Rungcharassaeng, & Lozada, 2003; Palattella,
Initially, the main outcome that was documented included im‐ Torsello, & Cordaro, 2008; Shibly, Patel, Albandar, & Kutkut, 2010).
plant survival. The dichotomous nature of this outcome does not Patient selection, risk analysis, and clinical expertise seem to be key
allow for specific discrimination between the two extremes of this for successful outcome (Ganeles & Wismeijer, 2004; Jivraj, Reshad,
assessment parameter; that is, the implant is either in the alveolar & Chee, 2005). The majority of these reports have focused on the
bone or it is not. Later, a set of proposed criteria for success based on outcome of this protocol in the aesthetic zone; that is, in the anterior
the knowledge acquired on the Brånemark implant system has been maxilla. From an aesthetic standpoint, successful outcome can be
described by Albrektsson, Zarb, Worthington, and Eriksson (1986) achieved with immediate implant placement although mucosal mid‐
and has been widely used. Comprehensive evaluation of implant facial recession is not uncommon (Chen & Buser, 2014).
therapy outcome included further parameters taking in account While there seem to be no difference in implant survival rate
not only the dental implant but also the health of the peri‐implant and marginal bone level between immediate and conventional load‐
hard and soft tissue interface, the integrity of prosthetic reconstruc‐ ing, from an aesthetic perspective controversial outcomes preclude
tion and the overall aesthetic integration of the prostheses (Belser, any definitive conclusion (Benic, Mir‐Mari, & Hammerle, 2014). The
Buser, & Higginbottom, 2004; Belser et al., 2009; Cosyn, Thoma, proceedings of Fifth ITI Consensus Conference concluded that, irre‐
Hammerle, & De Bruyn, 2017; Furhauser et al., 2005; Lang et al., spective of the timing of implant placement or loading protocol, suc‐
2004; Papaspyridakos, Chen, Singh, Weber, & Gallucci, 2012; Salvi cessful outcomes can be achieved and reinforced the notions that
& Lang, 2004). highly trained clinicians were a prerequisite for success. Based on
Patients’ perceptions of implant therapy outcome have gained the classic clinical outcomes reported, there are still no clear guide‐
considerable attention in the last two decades (De Bruyn, Raes, lines as to which treatment protocol should be favored in daily prac‐
Matthys, & Cosyn, 2015). The generic term used to describe the pa‐ tice (Gallucci et al., 2014; Morton, Chen, Martin, Levine, & Buser,
tients’ view is PROMs or Patient‐Reported Outcome Measures and 2014). The practitioner is then faced with multiple treatment options
is defined as follows: “report of the status of a patient’s health con‐ that could lead to similar results. In such a situation, the patients’
dition that comes directly from the patient, without interpretation of perspective may be decisive in determining the preferred treatment
the patient’s response by a clinician or anyone else” (US Department modality.
of Health and Human Services, 2006). The importance of PROMs Therefore, the aim of this systematic review was to answer the
is underlined by the fact that they may improve delivery of care as following PICO question: In patients receiving immediate (Type 1)
illustrated by improved patient–clinician communication, clinical implant placement, how does immediate compare to early or con‐
outcomes and patient satisfaction (Nelson et al., 2015). Therefore, ventional loading in terms of patient‐reported outcomes?
PROMs represent an important tool to develop treatment guidelines
in which the patients are actively engaged.
2 | M ATE R I A L A N D M E TH O DS
Over the last four decades, progress made in biological un‐
derstanding of implant wound healing, refinement of surgical pro‐
2.1 | Protocol registration
cedures combined with technological advances related to implant
design and surface developments have challenged the initial treat‐ The systematic review was registered in the PROSPERO interna‐
ment guidelines that were established by the pioneers in implant tional database on October 2016 (Registration number #49604).
dentistry. While early guidelines recommended an undisturbed
healing for 3–6 months prior to prosthesis loading (Brånemark
2.2 | Search methodology
et al., 1977), protocols have been developed to shorten the over‐
all treatment duration for the patient. The most extreme develop‐ A health sciences librarian (M.A.W), in collaboration with the
ment is represented by the placement of a dental implant in single systematic review team, developed and conducted searches
HUYNH‐BA et al. | 257

in MEDLINE (OVID, 1946‐present), PubMed (1809—present), Reference lists of relevant studies and systematic reviews pub‐
EMBASE and the Cochrane Database of Systematic Reviews lished up to May 2017 were “hand‐searched” for potential relevant
(Issue 5 of 12, May 2017). Search strategies were developed for literature.
MEDLINE but revised appropriately for each database to take ac‐
count of differences in controlled vocabulary and syntax rules. The
2.3 | Study selection
main concepts identified were as follows: dental implants, imme‐
diate implant loading, and treatment outcomes. Terms searched The type of studies considered for this review included randomized
related to the concept of treatment outcomes included, but were controlled trials, prospective and retrospective cohort studies, and
not limited to: quality of life, visual analog scale, and patient out‐ case series of at least five patients. The different components of
come assessment. Terms searched related to the concept of dental the PICO questions served as the basis for study inclusion. The pa‐
implantation included but were not limited to edentulous jaw or tient population comprised partially edentulous patients receiving
mouth, endosseous dental implants, and implant‐supported den‐ immediate dental implants (Type 1). The tested intervention under
tal prosthesis. Terms searched related to the concept of immediate scrutiny was immediate loading, that is, within 1 week of implant
dental implant loading included but were not limited to immedi‐ placement, while the comparison group entailed early (1 week to
ate implants or functions or temporizations, and teeth‐in‐a‐day. 2 months) or conventional loading (>2 months) as previously de‐
Results were limited to humans. No other search restrictions were fined by the ITI (Gallucci et al., 2014) and others (Esposito, Grusovin,
made. The PubMed (1809—present) Search Strategy is described Willings, Coulthard, & Worthington, 2007). Studies reporting on
thereafter: PROMS as defined by the FDA were considered for inclusion (US
Department of Health and Human Services, 2006). Moreover, the
“partially edentulous”[tiab] OR “partial edentulism”[tiab] OR “par‐ patient‐centered outcomes had to be supported by presented data
tially dentate”[tiab] OR “dental implant*”[tiab] OR “complete in the article.
edentulous”[tiab] OR “complete edentulism”[tiab] OR “total eden‐ Studies reporting on “All‐on‐4” protocol, as initially described
tulous” [tiab] OR “total edentulism”[tiab] OR “totally edentulous”[‐ by Malo and coworkers (Malo, Rangert, & Nobre, 2003, 2005), and
tiab] OR “endosseous implant*”[tiab] OR “implant borne”[tiab] full‐arch restoration were excluded for the following reasons. First,
OR “edentulous jaw”[tiab] OR “edentulous mouth”[tiab] OR “Jaw, it could not be ascertained that all the implants placed according to
Edentulous”[Mesh] OR “Mouth, Edentulous”[Mesh] OR “Dental im‐ this protocol were immediate implants (Type 1). These treatment
plantation, endosseous” [Mesh:NoExp] OR “Dental Implants”[Mesh] protocols are usually used in failing dentitions of partially edentu‐
OR “Dental implantation”[Mesh:NoExp] OR “Dental prosthesis, im‐ lous patients. While the remaining failing dentition is extracted im‐
plant supported”[Mesh:NoExp] mediately prior to implant placement, some implants may have been
AND placed in long‐standing edentulous healed sites (Type 4). Second,
“immediate implant*”[tiab] OR “all on 4”[tiab] OR “all on four”[‐ the technique used for immediate implant placement in the all‐on‐4
tiab] OR “teeth in an hour”[tiab] OR “teeth in a day”[tiab] OR protocol calls for the placement of tilted implants with a crossarch
“immediate loading”[tiab] OR “immediate function”[tiab] OR stabilization prosthetic reconstruction which differs drastically from
“immediate temporization”[tiab] OR “Immediate dental implant the immediate load of implants placed in fresh extraction socket
loading”[Mesh:NoExp] of partially edentulous sites. Third, the crossarch stabilization rep‐
AND resents a different biomechanical entity compared to single or short
“quality of life”[tiab] OR “qol”[tiab] OR “OHRQoL”[tiab] OR span fixed dental prostheses. Finally, indications for full‐arch res‐
“OHIP‐14”[tiab] OR “HRQL”[tiab] OR “visual analog scale”[tiab] OR toration treatment usually include patients who have experienced
“visual analogue scale”[tiab] OR “VAS”[tiab] OR “patient centered”[‐ a failing dentition over time, which is no longer satisfactory and a
tiab] OR “PCOR”[tiab] OR “patient preference*”[tiab] OR “patient more drastic and permanent therapy is sought for. The impact of
satisfaction”[tiab] OR “patient reported”[tiab] OR “patient out‐ such treatment cannot be combined with that of implants placed in
come*”[tiab] OR “treatment outcome*”[tiab] OR “restoration fail‐ fresh extraction socket typically involving a limited number of teeth
ure*”[tiab] OR “follow up studies”[tiab] OR “follow up study”[tiab] replaced which was the focus of this review.
OR “comparative effectiveness research’”[tiab] Studies including zygomatic implants were excluded and publi‐
OR cations in other languages than English, German, or French were not
“Quality of life”[Mesh] OR “Visual analog scale”[Mesh] OR “Patient considered.
outcome assessment”[Mesh:NoExp] OR “Patient centered research Two investigators (G.H‐B. and T.W.O.) independently screened
outcomes”[Mesh] OR “Patient Satisfaction”[Mesh] OR “Treatment the literature search results for possible inclusion in the systematic
Outcome”[Mesh] OR “Dental restoration failure”[Mesh] OR review. The screening was performed at the title and abstract level.
“Follow‐up studies”[Mesh] OR “Patient reported outcome Any disagreement was resolved by discussion. The same two inves‐
measures”[Mesh] tigators independently read the full‐text articles and consensus was
AND reached by discussion in case of disagreement. Kappa statistics was
Humans used to determine interrater agreement (Cohen, 1960).
258 | HUYNH‐BA et al.

Data extraction table for included study was created and popu‐
lated independently by the two investigators. Any disagreement was
resolved by discussion.

3 | R E S U LT S

Final searches were run on 5/9/17 and resulted in 1,102 results

following de‐duplication. The screening of the abstracts led to the
inclusion of 28 articles (ƙ = 0.60 or “good agreement”). After evalu‐
ation of the full texts, 19 studies were excluded and a total of nine
studies were included in the present systematic review (ƙ = 0.93 or
“very good agreement”). The hand search did not add any additional
references (Figure 1). The reasons for exclusion of the full‐text arti‐
FIGURE 1 Search flow diagram
cles can be found in Table 1.

TA B L E 1 Studies excluded based on full‐text evaluation and reason for exclusion. *Reference list of systematic reviews were screened
for other possible study inclusion

Study Journal Reason for exclusion

Abboud, Wahl, Guirado, and Orentlicher (2012) The International Journal of Oral Maxillofacial Implants No immediate implant
placement
Andersen, Haanaes, and Knutsen (2002) Clinical Oral Implants Research No immediate implant
placement
Atieh, Atieh, Payne, and Duncan (2009)* The International Journal of Prosthodontics Systematic review
Atieh, Payne, Duncan, de Silva, and Cullinan The International Journal of Oral Maxillofacial Implants Systematic review
(2010)*
Barone et al. (2016) The International Journal of Oral Maxillofacial Implants No immediate loading
Benic et al. (2014)* The International Journal of Oral Maxillofacial Implants Systematic review
Bianchi and Sanfilippo (2004) Clinical Oral Implants Research No immediate loading
Boedeker, Dyer, and Kraut (2011) Journal of Oral Maxillofacial Surgery No immediate implant
placement
Cosyn et al. (2011) Journal of Clinical Periodontology No patient‐reported outcome
measure
De Rouck et al. (2008a,2008b) The International Journal of Oral Maxillofacial Implants Review
Di Alberti et al. (2012) The International Journal of Oral Maxillofacial Implants No data presented to support
patient satisfaction claims
Dolz, Silvestre and Montero (2014) The International Journal of Oral Maxillofacial Implants No immediate implant
placement
Hui et al. (2001) Clinical Implant Dentistry and Related Research No data presented to support
patient satisfaction claims
Grandi, Guazzi, Samarani, and Grandi (2013) European Journal of Oral Implantology No patient‐reported outcome
measure
Lang et al. (2007) Clinical Oral Implants Research No immediate loading
Malchiodi et al. (2010) Journal of Oral Implantology No patient‐reported outcome
measure
McAllister et al. (2012) The International Journal of Oral Maxillofacial Implants Same patient study population
as Kolinski et al. (2014; which
was included)
Rosa, Rosa, Francischone, and Sotto‐Maior The International Journal Prosthetic and Reconstructive No patient‐reported outcome
(2014) Dentistry measure
Spies, Balmer, Patzelt, Vach, and Kohal (2015) Journal of Dental Research Less than 5 cases of Immediate
implant placement
HUYNH‐BA et al. | 259

3.1 | Study characteristics 3.2 | Patient‐centered outcomes in studies with

an available comparison group consisting of Type 1
The data extracted from the included studies are detailed
implant placement with conventional loading
in Table 2. Of the nine included articles, three studies were
randomized controlled trials (De Rouck, Collys, Wyn, & Cosyn, In the study by De Rouck et al. (2009), the test group received
2009; Felice, Pistilli, Barausse, Trullenque‐Eriksson, & Esposito, immediate implants and was restored with immediate screw‐retained
2015; Felice et al., 2011). However, only the study by De Rouck provisional crowns, whereas the implants in the control group were
et al. (2009) included test and control groups similar to those allowed to heal for 3 months before provisionalization. In both
defined in our PICO question. In the two publications by Felice groups, final restorations were placed after 3 months of temporary
et al. (2011, 2015), the test group received immediate implants loading. At the end of the study period, that is, 12 months after
(Type 1) following extraction while the control group was treated implant provisionalization, patients’ satisfaction of the aesthetics
with a ridge preservation and a staged approach for implant based on a visual analog scale (from zero to ten) was recorded by
placement (Type 4). Provided that the implant insertion torque asking the following question: “How would you rate your satisfaction
was >35 Ncm, provisional implant restorations were placed in with respect to the aesthetic outcome of your treatment?”. Patients’
both treatment groups. Conversely, if the insertion torque was satisfaction averaged 93% (range 82%–100%) in the test group and
≤35 Ncm, the implants were left to heal for 4 months before 91% (range 80%–96%) in the control group. Midfacial soft tissue
loading. For these two studies, only one treatment arm, that is, level was stable in both groups over the study period. However, the
immediate implant placement (Type 1) with two subgroups based conventionally loaded restoration group showed on average 2.5–3
on nonrandomized loading protocol was considered for data times more recession as compared to the test group with a mean
extraction pertaining PROMS. difference of 0.75 mm favoring immediate restoration.
The remainder of the included studies (six studies) did not pro‐ Two randomized controlled trials by Felice et al. (2011, 2015)
vide an adequate comparison group comprising of Type1 implant with similar methodology aimed at comparing the outcomes of im‐
placement and conventional loading. Four of those were single‐arm mediate postextractive implants (Type 1) and implants placed in
studies with Type 1 implant placement and immediate tempori‐ healed ridge preserved sites (Type 4). Only one arm of each study,
zation (De Rouck, Collys, & Cosyn, 2008a, 2008b; Ferrara et al., that is, Type 1 implant placement, was within the scope of our
2006; Kolinski et al., 2014; Takeshita et al., 2015). Two studies by review. In this arm, implants that were placed with an insertion
Raes, Cooper, Tarrida, Vandromme, and De Bruyn (2012), Raes, torque >35 Ncm were immediately restored with a cemented provi‐
Cosyn, and De Bruyn (2013) were multiarms studies and only data sional crown following an abutment level impression. If the torque
from one arm consisting Type 1 implant placement and immediate was inferior to 35 Ncm implants were placed and left to heal for
temporization was extracted for the purpose of the present sys‐ 4 months. Final cemented metal‐ceramic crowns were fabricated
tematic review. on customized abutments 4 months after implant placement. In
The PROMs reported included the use of visual analogue scale to both studies, patients’ satisfaction was recorded using a 5‐point
determine patient satisfaction with regards to aesthetics (De Rouck scale with regards to aesthetics and function. The questions asked
et al., 2008a, 2008b, 2009; Kolinski et al., 2014), function, speech, were as follows: “Are you satisfied with your function of your im‐
sense of implant feeling like one’s own and self‐esteem (Kolinski plant‐supported tooth?” and “Are you satisfied with the aesthetic
et al., 2014). Other PROMs included the use of a 5‐point categor‐ outcome of the gums surrounding this implant?”. For these ques‐
ical scale to evaluate function and aesthetic (Felice et al., 2011, tions, the possible answers were as follows: (a) Yes absolutely, (b)
2015), a 10‐point categorical scale to evaluate patient satisfaction Yes partly, (c) Not sure, (d) Not really, and (e) Absolutely not. A
(Ferrara et al., 2006), the use of close‐ended questions (Felice et al., third, close‐ended question inquired if the patient would undergo
2011,2015) and the use of Oral Health Impact Profile (OHIP) ques‐ the same therapy again. Felice et al. (2011, 2015) did not separate
tionnaires consisting of 14 questions (Raes et al., 2012, 2013) or 54 patients’ responses within the immediate placement group be‐
questions specific for a Japanese population (Takeshita et al., 2015). tween the implants with immediate restorations with those receiv‐
Three studies evaluated PROMs prior to and after treatment ing conventionally loaded restorations. Felice et al. (2011) reported
(Kolinski et al., 2014; Raes et al., 2012, 2013) while the remainder two failures in the immediate implant placement group but did not
of the included studies only evaluated PROMs after treatment (De mention if they occurred in the immediately restored subgroup or
Rouck et al., 2008a,2008b, 2009; Felice et al., 2011, 2015; Ferrara the conventional loading subgroup. Nonetheless, data pertaining
et al., 2006; Takeshita et al., 2015). When evaluated after treatment, to patients’ satisfaction were extrapolated based on the informa‐
the timeline to report the PROMs varied between 4 months after tion provided in the respective studies. With regard to function,
implant placement (Felice et al., 2011) to 4 years after final crown 88.2%–100% of the patients in the immediately restored subgroup
delivery (Ferrara et al., 2006). answered that they were absolutely satisfied. The corresponding
Given the heterogeneity in study design, in PROMs reported value for the conventional loading subgroup was 93.9%–100%. In
and time frame of reporting PROMS a qualitative review was the immediately and conventionally loaded subgroups, 0%–5.9%
undertaken. and 0%–3.0% of patients, respectively, were “partially satisfied” or
260 | HUYNH‐BA et al.

“unsure.” For aesthetics, 100% of patients who received immediate et al. (2012) reported that over a 1‐year period, the overall OHIP‐14
implants answered that they were absolutely satisfied irrespective average score increased from baseline to 6 months and remained
of the loading protocol. Similarly, 100% of patients stated that they stable thereafter. More specifically, two dimensions, psychologi‐
would undergo the same therapy again. cal discomfort and disability, decreased significantly from baseline
to 1 month which indicated that patients were less self‐conscious,
felt less tense, found it less difficult to relax, and were more relaxed
3.3 | Patient‐centered outcomes of studies
with regard to their oral condition. The physical pain dimension de‐
reporting on Immediate implant placement (Type
creased from the 1‐month to the 6‐month follow‐up illustrating that
1) and immediate loading
the patient experienced less pain and could eat comfortably.
De Rouck et al. (2008a,2008b) followed thirty patients who received Similarly, Raes et al. (2013) showed that the overall OHIP‐14 score
immediate implant placement and an immediate single crown screw‐ increased from baseline (66.25 ± 3.86) to 12 months (69.67 ± 0.62)
retained temporary restoration over a 1‐year period. At the end of in patients receiving immediate implant and immediate provisional‐
the study period (12 months after implant placement), patients were ization in the aesthetic anterior maxilla (teeth 15–25).
asked “How would you rate your satisfaction with respect to the In a retrospective study, Takeshita et al. (2015) used a modified
aesthetic outcome of your treatment?” using a visual analogue scale OHIP questionnaire specifically adapted to Japanese populations
(VAS) of 10 cm. The average satisfaction pertaining aesthetics aver‐ with 54 questions (Yamazaki, Inukai, Baba, & John, 2007) to report
age 93% with a range from 82% to 100%. on patient satisfaction. The authors converted the overall OHIP‐J
Ferrara et al. (2006) in a case series of 33 patients with a fol‐ scores recorded into percentage of satisfaction. One year and a half
low‐up time up to 50 months (average 28 months) after immediate after immediate implant placement and provisionalization, the re‐
implant placement and restoration recorded patients’ satisfaction ported satisfaction rate amounted to 96.7% ± 2.16 (92.6%–100%).
using a 10‐point categorical scale with the zero value corresponding
to “completely unsatisfactory result” and 10 to “complete satisfac‐
tion.” Patients were followed up every 3 months and satisfaction 4 | D I S CU S S I O N
was recorded at each follow‐up. No details pertaining the question
asked were given in the study. The results reported an average pa‐ The present systematic review sought to answer the following ques‐
tient satisfaction pertaining to aesthetics at the 4‐year recall time‐ tion: In patients receiving immediate (Type 1) implant placement,
line of 9.3 ± 0.65, which included seven patients. how does immediate compare to early or conventional loading in
A 3‐year multicenter case series by Kolinski et al. (2014), evalu‐ terms of patient‐reported outcomes? The relevance of this question
ated the following PROMs based on VAS: (a) Function, (b) Aesthetics, is based on the fact that there is no clinical consensus as to which
(c) Speech, (d) Sense of implant feeling like one’s own tooth, and (e) treatment protocol should be favored (Gallucci et al., 2014; Morton
Self‐esteem. et al., 2014).
The two extremities of the scale were 0 = poor and 100 = excel‐ In the medical field, patient‐centered outcome research is fairly
lent. Kolinski et al. reported these PROMS prior to treatment, at time new and is focusing on valuating questions and outcomes that are
of implant placement, prosthesis delivery and then annually up to important to the end‐user of the research, that is, the patient. The
the 3‐year follow‐up visit. The mean pretreatment baseline value for patients’ views through this research are voiced and reduces the im‐
function, aesthetics, speech, sense of implant feeling like one’s own balance represented in more traditional research in which the views of
tooth and self‐esteem were 62.2, 58.9, 80.0, 66.3 and 68.7, respec‐ the empowered, the physicians and researchers, are mostly expressed.
tively. All the parameters increased gradually up to prosthesis deliv‐ This is performed with the premise that improving the relevance of
ery and remained stable throughout the study. The corresponding clinical research by incorporating PROMs and thereby helping dissem‐
values at the 3‐year follow‐up were 93.7 ± 6.4, 89.2 ± 9.4, 93.5 ± 6.7, inate new evidence will ultimately improve patient care (Frank, Basch,
87.0 ± 18.5 and 92.2 ± 7.2, which were statistically significantly dif‐ & Selby, 2014). The growing importance of this type of research is illus‐
ferent from baseline (p < 0.001). trated by a federal initiative to create the Patient‐Centered Outcomes
Raes et al. (2012, 2013) conducted two multiarm clinical trials Research Institute which goals are to improve the quantity and quality
comparing the outcomes of Type 1 implant placement and immediate of research, facilitate its dissemination and implementation with a pa‐
provisionalization to Type 4 implant placement and immediate pro‐ tient‐centered approach as the overarching concept (Selby & Lipstein,
visionalization. The data for the single arm of interest, that is, Type 1 2014, https://www.pcori.org/about-us accessed on 9/15/17).
implant placement, were extracted. The assessment of PROMs was In the field of implant dentistry, despite the fact that multiple con‐
based on the shortened version of the original Oral Health Impact sensus conferences and workshops have recommended the inclu‐
Profile (OHIP) questionnaire (Slade & Spencer, 1994). The question‐ sion on patient‐centered outcomes to evaluate therapy (Albrektsson
naire used included 14 questions (OHIP‐14) with two questions as‐ & Isidor, 1994; Klinge et al., 2015; Lang, Karring, & Meredith, 2002;
sessing each of the seven dimensions including functional limitation, Lang & Zitzmann, 2012), patient‐centered outcomes have only
physical pain, psychological discomfort, physical disability, psycho‐ rarely been reported in the literature (Pjetursson, Karoussis, Burgin,
logical disability, social disability, and handicap (Slade, 1997). Raes Bragger, & Lang, 2005).
HUYNH‐BA et al. | 261

TA B L E 2 Data extraction table of included studies. [In PDF format, this table is best viewed in two-page mode]

Patient age
Authors Patients (Mean (±SD), Implants Implant
(year) Journal Study type Duration (n) Gender range) Treatment group(s) (n) site(s)

De Rouck COIR Multicenter 1 year Group 1: Group 1: 13 Group 1: Group 1: Group 15–25
et al. Randomized 24 females 11 55 ± 13 Type 1 Implant 1: 24
(2009) Controlled Group males Group Group 2: placement Immediate Group
Trial 2: 25 2: 13 females 52 ± 12 provisionalization 2: 25
12 males Group 2:
Type 1 Implant
placement and delayed
loading

Felice et al. Eur J Single Center 4 months Group 1: 32 females 22 Mean 48 Group 1: Type 1 Implant Group 15–25
(2011) Oral Randomized 54 males (28–70) placement + Immediate 1: 54
Impl Controlled Group provisionalization (if Group
Trial 2: 52 insertion torque 2: 52
>35 Ncm) and Delayed
loading (at 4 months if
insertion torque was
≤35 Ncm) Group2:
Ridge preserva‐
tion + Type 4 Implant
placement + Immediate
provisionalization (if
insertion torque
>35 Ncm)

Felice et al. Eur J Randomized 1 year Group 1: Group 1: 13 Group 1: 51.3 Group 1: Type 1 Implant Group 15–25
(2015) Oral Controlled 25 females 12 (32–71) Group placement + Immediate 1: 25
Impl Trial Group males Group 2: 53.1 (39–72) provisionalization (if Group
2: 25 2: 12 females insertion torque 2: 25
13 males >35 Ncm) and Delayed
loading (at 4 months if
insertion torque was
≤35 Ncm) Group2:
Ridge preserva‐
tion + Type 4 Implant
placement + Immediate
provisionalization (if
insertion torque
>35 Ncm)

(Continues)
262 | HUYNH‐BA et al.

TA B L E 2 (additional columns)

Implant Occlusion
Implant insertion Provisional of Final
manufaturer torque restorations provisional restoration Follow‐up Patient‐centered outcomes Comments

Nobel At least Screw‐re‐ Cleared of At 6 months 3, 6, At the end of study period

35 Ncm tained centric and after implant 12 months (12 months after implant provision‐
provsional eccentric placement alization), patients were asked
single crown contacts with “How would you rate your
cemented satisfaction with respect to the
restoration aesthetic outcome of your
treatment?” using an Visual
analogue scale of 10 cm. 0 =  not at
all satisfied 10 = completely
satisfied Group 1: Average 93%
(range 82%–100%) Group 2:
Average 91% (range 80%–96%)
MegaGen >35 Ncm (In Cemented Non‐­ 4 months Final crown Patient satisfaction was recorded at Patient‐centered
Group 1: 19 provisional occluding after implant delivery, i.e. the time of final crown delivery with outcomes
of 54 were single crown placement 4 months regards to: 1) Function: “Are you extracted only
immediately on with after satisfied with your function of your for one arm
provisional‐ temporary provisionally loading implant‐supported tooth?” 2) (Type 1 Implant
ized and 35 abutment cemented Aesthetic:”Are you satisfied with the placement). Two
of 54 crown on aesthetic outcome of the gums implants failed
received customized surrounding this implant?” Possible in Group 1.
delayed abutment answers were: a)yes absolutely, b) Details not
loading) Yes partly, c)not sure, d) not really given if the two
and e)absolutely not 3) Another implants were
question (closed‐ended question): immediate or
“Would you undergo the same delayed loaded
therapy again?” For function: Group implants.
1 with immediate temporization: *Patient
88.2%–100% were “absolutely satisfaction
satisfied”, 0%–5.9% were “partially range extrapo‐
satisfied”and 0%–5.9% were lated from data
“unsure” Group 1 with delayed available in
loading: 93.9%–100% were study.
“absolutely satisfied”, 0%–3.0%
were “partially satisfied” and
0%–3.0% were “unsure” 100% of
patients were “absolutely satisfied”
with aesthetic and 100% would
undergo the same therapy again
Dentsply >35 Ncm (In Cemented Absence of 4 months 6 months Patient satisfaction was recorded at Patient‐centered
Group 1: 16 provisional contact in after implant and 1 year time of final crown delivery and outcomes
of 25 were single crown static and placement 12 months after with regards to: 1) extracted only
immediately on dynamic Function: “Are you satisfied with for one arm
provisional‐ temporary occlusion your function of your implant‐sup‐ (Type 1 Implant
ized and 9 abutment ported tooth?” 2) Aesthetic:”Are you placement)
of 25 satisfied with the aesthetic outcome
received of the gums surrounding this
delayed implant?” Possible answers were: a)
loading) yes absolutely, b) Yes partly, c)not
sure, d) not really and e) absolutely
not 3) Another question (closed‐
ended question): “Would you
undergo the same therapy again?”
100% of patients were “absolutely
satisfied” with function and
aesthetic and 100% would undergo
the same therapy again

(Continues)
HUYNH‐BA et al. | 263

TA B L E 2 (Continued) [In PDF format, this table is best viewed in two-page mode]

Patient age
Authors Patients (Mean (±SD), Implants Implant
(year) Journal Study type Duration (n) Gender range) Treatment group(s) (n) site(s)

De Rouck JCP Case series 1 year 30 16 females 14 Mean 54 Group 1: Type 1 Implant 30 15–25
et al. males (24–76) placement Immediate
(2008a, provisionalization
2008b)

Ferrara et al. IJPRD Case series Up to 33 17 females 16 24–58 Group 1: Type 1 Implant 33 14–24
(2006) 50 months. males placement Immediate
Average: provisionalization
28 months

Kolinski J Perio Multicenter 3 years 55 31 females 24 52.6 ± 13.3 Group 1: Type 1 Implant 60 3 Molars
et al. (2014) case series males (19–82) placement Immediate 26
provisionalization Premolars
31
Maxillary
anterior

Raes et al. COIR Prospective 1 year 96 55 females 41 42 ± 14.8 Group1: Type 1 Implant Group 1: 15–25
(2012) Multicenter Group males (18–72) placement Immediate­ 48
Case‐control 1: 46 provisionalization Group
study Group Group 2: Type 4 Implant 2: 54
2: 54 placement Immediate
provisionalization

(Continues)
264 | HUYNH‐BA et al.

TA B L E 2 (additional columns - continued)

Implant Occlusion
Implant insertion Provisional of Final
manufaturer torque restorations provisional restoration Follow‐up Patient‐centered outcomes Comments

Nobel At least Screw‐re‐ Cleared of At 6 months 1, 3, 6, At the end of study period

35 Ncm tained centric and after implant 12 months (12 months after implant place‐
provsional eccentric placement ment), patients were asked “How
single crown contacts with would you rate your satisfaction
cemented with respect to the aesthetic
restoration outcome of your treatment?” using
an Visual analogue scale of 10 cm.
0 =  not at all satisfied 10 = com‐
pletely satisfied Average 93%
(range 82%–100%)
Friadent Not reported Cemented No contact At 6 months Once a Patient satisfaction was recorded
provisional in after implant month for at each follow‐up (3‐month recall
single crown maximum placement the first visit) using a 10‐point scale
on intercus‐ with 6 months (0 = completely unsatisfactory
temporary pation and cemented and every result; 10 = complete satisfaction)
abutment eccentric restoration 3 months Average at 4‐year recall: 9.3 ± 0.65
movement thereafter (ecompassing 7 patients)
up to
4 years
Nobel At least 58 implants Temporary Within 3, 6 months Aesthetic and function of
35 Ncm with single restoration 6 months of 1, 2, 3 years restoration evaluated by patients
crowns 2 in light or implant at baseline (i.e. prior to treatment),
implants for no contact placement implant placement, definitive
an FDP (lost with prosthesis insertion, and at 1‐, 2‐,
to follow‐up opposing 3‐year follow‐up. VAS was used:
at 3 years dentition 0 = poor, 100 = excellent Pre‐oper‐
examination) ative/Baseline: Function: 62.2
Aesthetics: 58.9 Speech: 80.0
Sense of implant feeling like one’s
own tooth: 66.3 Self‐esteem: 68.7
3‐y follow‐up: Function: 93.7 ± 6.4
Aesthetics: 89.2 ± 9.4 Speech:
93.5 ± 6.7 Sense of implant feeling
like one’s own tooth: 87.0 ± 18.5
Self‐esteem: 92.2 ± 7.2 All scores
increased significantly from
baseline to 3‐y follow‐up visit
(p < 0.001)
Astra Not reported Cemented Not At 10 weeks Baseline, 1, OHIP‐14 questionnaire ((14 ‐Patient centered
provisional reported 6, questions, Scores 1–5 for a outcomes
single crown 12 months maximum of 70) for Group 1 extracted only
on recorded at all time points: Overall, for one arm
temporary imited oral health‐related quality of (Type 1 Implant
abutment life problems were reported placement)
(because they were never
toothless) by these patients.
Patients described a significant
decrease in3 domains: Physical
pain, Psychological discomfort and
Psychological disablitity. Patient‐
reported less pain and tension,
were less occupied with their
teeth, were able to eat comfortably
and relax over time and were less
embarrassed. These improvement
were mainly seen the first six
months.

(Continues)
HUYNH‐BA et al. | 265

TA B L E 2 (Continued) [In PDF format, this table is best viewed in two-page mode]

Patient age
Authors Patients (Mean (±SD), Implants Implant
(year) Journal Study type Duration (n) Gender range) Treatment group(s) (n) site(s)

Raes et al. CIDRR Prospective 1 year 48 Group 21 females 27 Group 1: Group1: Type 1 Implant Group 1: 15–25
(2013) 3‐arm 1: 16 males Group 45 ± 14 placement Immediate­ 16
clinical trial Group 1: 16, 6 (22–68) provisionalization Group
2: 9 females, 10 Group 2: Group 2: GBR at time of 2: 9
Group males Group 35 ± 15 extraction, Type 4 Group
3: 23 2: 9, 4 (20–69) Implant placement 3: 23
females, 5 Group 3: Immediate provisional‐
males Group 40 ± 19 ization Group 3: Type 4
3: 23, 11 (19–75) Implant placement
females, 12 Immediate
males provisionalization
Takeshita IJPRD Retrospective 1.5 year 18 12 females 6 48 ± 11 Group 1: Type 1 Implant 21 12–22
et al. case series males (32–77) placement
(2015) Immediate­
provisionalization

Given the general sense that PROMs tend to be underreported Nonetheless, the authors decided to keep the study by Kolinski et al.
for clinical situations other than two implants supporting a mandibu‐ (2014) and to report their findings based on the following rationale:
lar overdenture (De Bruyn et al., 2015) and in an effort to capture all
relevant data present in the literature, the present systematic review 1. At baseline, the PROMs from the one patient who received
did not chose a specific PROM as an inclusion factor to address the immediate implants for an FDP out of a total of 55 patients
PICO question. This led to the inclusion of a total of nine studies was unlikely to significantly change the reported values for
using different PROMs. Only one randomized controlled trial ad‐ the overall cohort.
dressed specifically the PICO question (De Rouck et al., 2009) and 2. At the 3‐year follow‐up examination, 37 patients with 37 implants
two further randomized controlled trials included data for both im‐ were evaluated, indicating that the patient with the two implants
mediate and conventional loading following type 1 implant place‐ supported FDP had been lost to follow‐up. Therefore, the PROMs
ment within the same treatment arm (Felice et al., 2011, 2015). The reported at the 3‐year timeline only included data from implant‐
loading protocol was not randomized and was based on the implant supported single tooth restorations.
placement insertion torque. Therefore, the studies by Felice et al. 3. As a qualitative review was undertaken, the authors felt that in‐
(2011, 2015) had to be viewed as nonrandomized for the purpose of cluding the study by Kolinski et al., 2014 which had the longest
this review. The remaining studies only included the test interven‐ follow‐up of all included studies would add useful information to
tion of interest as the sole treatment investigated (De Rouck et al., the review which would outweigh the fact that the baseline data
2008a,2008b; Ferrara et al., 2006; Kolinski et al., 2014; Takeshita included a single patient who received two implants for an FDP
et al., 2015) or as part of a multiarm trial in which the other treat‐ when the remaining data included in this review only included sin‐
ment arms were outside the scope of the present work (Raes et al., gle tooth restorations.
2012, 2012). Therefore, the majority of the included studies (six of
nine) were single cohort uncontrolled studies. For data derived from controlled trials, combining results
All studies included in the present review reported exclusively on of randomized and nonrandomized controlled trials has been
single tooth implant‐supported restoration except for Kolinski et al. questioned as it has been shown that results of nonrandom‐
(2014). In this study, the authors reported the outcomes of 60 im‐ ized controlled trials tended to show greater treatment effects
plants up to 3 years. Of the 60 implants placed, 58 were placed for sin‐ than randomized controlled trials (Ioannidis et al., 2001). While
gle tooth restorations while two were placed to support a fixed dental newer Network Meta‐analysis may overcome this shortcoming
prosthesis (FDP). Ideally, for the purpose of the present review, data (Cameron et al., 2015), two different sets of PROMs were used
related to the two implants supporting the FDP should be excluded. in the three comparative studies preventing pooling of the data
Unfortunately, the report by Kolinski et al., 2014 did not discriminate and meaningful comparison between studies. Another shortcom‐
the outcomes based on the restorative indication, hampering the ing of these comparative trials was the fact that only one time
author’s ability to extract the data for single tooth restorations only. point after treatment was considered for recording the PROMs
266 | HUYNH‐BA et al.

TA B L E 2 (additional columns - continued)

Implant Occlusion
Implant insertion Provisional of Final
manufaturer torque restorations provisional restoration Follow‐up Patient‐centered outcomes Comments

Astra Not reported Cemented Absence of 11–12 weeks Baseline, 1, Based on OHIP‐14 questionnaire Patient‐centered
provisional centric and after implant 3, 6, (14 questions, Scores 1–5 for a outcomes
single crown eccentric placement 12 months maximum of 70) for group 1: There extracted only
on contacts was a signifcant improvement in for one arm
temporary overall OHIP‐14 score from (Type 1 Implant
abutment baseline (66.25 ± 3.86) to placement)
12 months (69.67 ± 0.62)

Dentsply At least Cemented Temporary 14 weeks 1.5 year Based on OHIP‐J (Japanese version
35 Ncm provisional restoration after implant of Oral Health Impact
single crown placed placement Profile = 49 + 5 = 54 questions,
on slightly of Scores 1–4, for a maximum of 216).
temporary occlusal Scores was converted in %
abutment contact satisfaction. Satisfaction based on
OHIP‐J: 96.7% ± 2.16
(92.6%–100%)

which limited the prospective evaluation of the treatment ben‐ Given the sense of relative paucity of PROMs reported in the
efits. These shortcomings were already mentioned in previous literature, the authors wanted to be as inclusive as possible and the
reviews (De Bruyn et al., 2015; McGrath, Lam, & Lang, 2012). scope encompassed all types of partial edentulism treated with either
Nonetheless, these studies indicated little to no difference in single or multiple tooth implant‐supported restorations. However,
patient satisfaction following the two different loading proto‐ the included studies reported almost exclusively on single tooth res‐
cols following immediate implant. This was irrespective of the torations. Therefore, the findings in the present review may not be
PROMs reported which included a VAS for aesthetic satisfaction, extended to implant‐supported fixed dental prostheses (FDPs) re‐
a 5‐point scale assessing function, aesthetics, and open‐ended placing multiple teeth. This maybe further supported by the fact that
questions placement. in clinical settings, the technical approach for immediate loading in
From the uncontrolled studies, overall patient satisfaction was extended tooth gaps may be more challenging as compared to single
high following immediate implant placement and loading. Three tooth restorations. Adjustment of the occlusion to limit the amount
studies (Kolinski et al., 2014; Raes et al., 2012, 2013) reported of forces in immediate loading situations, including full to the ab‐
PROMs with a baseline evaluation prior to treatment up to 1 year sence of contacts in centric and absence of excursive contacts have
(Raes et al., 2012, 2013) or 3 years (Kolinski et al., 2014) after treat‐ been reported (Schrott, Riggi‐Heiniger, Maruo, & Gallucci, 2014).
ment. The impact of treatment could be objectified by the significant This may be more readily achievable for single tooth restorations as
increase in the VAS scores pertaining to function, aesthetic, speech, compared to longer span implant‐supported FDPs. Finally, the clin‐
sense of the implant feeling like one’s own, and self‐esteem (Kolinski ical guidelines derived from the previous ITI consensus conference
et al., 2014) and by the improvement of oral health‐related quality (Gallucci et al., 2014) recommended that immediate loading of single
of life as measured by the OHIP‐14 (Raes et al., 2012, 2013). While tooth restoration can be successfully implemented for all area except
this information is valuable to demonstrate the positive impact of for maxillary molar regions which lacked solid scientific backup. For
Type1 implant placement and immediate provisionalization, no clin‐ immediate loading of implant‐supported FDPs the recommendations
ical recommendation can be made pertaining the timing of loading emphasized careful case selection and advanced clinical expertise,
as only one protocol was implemented. The psychometric proper‐ especially for anterior sites for which insufficient documentation
ties of OHIP‐14 have been well documented and the questionnaire had been identified. These clinical recommendations emphasize the
has been validated to evaluate the outcome of clinical interventions fact that outcomes of immediate loading in single tooth sites and
(Allen, 2003; Slade, 1997). OHIP questionnaires presented the ad‐ multiple tooth sites have to be reported separately.
vantage to be standardized in comparison with other patient satis‐ A further limitation of the available literature resides in the mul‐
faction questionnaires, for example, using VAS or categorical scales, titude of factors likely to influence the assessment of subjective out‐
which lacked standardization across studies and, thereby, hampered comes and the limited ability of the existing studies to control for
the ability to make any meaningful comparison between studies. confounders.
HUYNH‐BA et al. | 267

In conclusion, and within the limitations of the available liter‐ and proposed criteria of success. International Journal of Oral and
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R E S E A RC H single implants for molar tooth replacement: A systematic review
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There is little discussion that incorporating the patient in the deci‐ Implants, 25, 401–415.
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(2016). Esthetic outcome of implants placed in fresh extraction
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• Evaluation of PROMs should be evidence‐based tools that have Belser, U. C., Grutter, L., Vailati, F., Bornstein, M. M., Weber, H. P., & Buser,
D. (2009). Outcome evaluation of early placed maxillary anterior
been previously validated, for example, OHIP.
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• Evaluation of PROMs should include at the very least two time tional, retrospective study in 45 patients with a 2‐ to 4‐year follow‐
points: a baseline, that is, prior to treatment, and a posttherapeu‐ up using pink and white esthetic scores. Journal of Periodontology,
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