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J Clinic Periodontology - 2020 - Seyssens - Immediate Implant Placement With or Without Connective Tissue Graft A

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1600051x, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13397 by Hacettepe Universitesi, Wiley Online Library on [15/12/2022].

See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Received: 7 August 2020 | Revised: 29 September 2020 | Accepted: 25 October 2020

DOI: 10.1111/jcpe.13397

S Y S T E M AT I C R E V I E W

Immediate implant placement with or without connective

tissue graft: A systematic review and meta-analysis

Lorenz Seyssens1 | Liesa De Lat1 | Jan Cosyn1,2

1
Faculty of Medicine and Health Sciences,
Oral Health Sciences, Department of Abstract
Periodontology and Oral Implantology,
Objectives: To assess the effect of connective tissue graft (CTG) in terms of vertical
Ghent University, Ghent, Belgium
2
Faculty of Medicine and Pharmacy, Oral
mid-facial soft tissue change when applied at the buccal aspect following single im-
Health Research Group (ORHE), Vrije mediate implant placement (IIP).
Universiteit Brussel (VUB), Brussels,
Belgium
Materials and methods: Two independent reviewers conducted an electronic litera-
ture search in PubMed, Web of Science, EMBASE and Cochrane databases as well as
Correspondence
Lorenz Seyssens, Faculty of Medicine and
a manual search to identify eligible clinical studies up to January 2020. Randomized
Health Sciences, Oral Health Sciences, controlled trials (RCTs) and non-randomized controlled studies (NRSs) comparing IIP
Department of Periodontology and Oral
Implantology, Ghent University, Corneel
with CTG and without CTG over a mean follow-up of at least 12 months were included
Heymanslaan 10, B-9000 Ghent, Belgium. for a qualitative analysis. Meta-analyses were performed on data provided by RCTs.
Email: [email protected]
Results: Out of 1814 records, 5 RCTs and 3 NRSs reported on 409 (IIP + CTG: 246,
IIP: 163) immediately installed implants with a mean follow-up ranging from 12 to
108 months. Only 1 RCT showed low risk of bias. Meta-analysis revealed a significant
difference in terms of vertical mid-facial soft tissue change between IIP + CTG and
IIP pointing to 0.41 mm (95% CI [0.21; 0.61], p < .001) in favour of soft tissue grafting.
This outcome was clinically relevant since the risk for ≥1 mm asymmetry in mid-facial
vertical soft tissue level was 12 times (RR 12.10, 95% CI [2.57; 56.91], p = .002) lower
following IIP + CTG. Soft tissue grafting also resulted in a trend towards less bleeding
on probing (MD 17%, 95% CI [−35%; 1%], p = .06). Meta-analyses did not reveal sig-
nificant differences in terms of pink aesthetic score, marginal bone level change and
probing depth. Results were inconclusive for horizontal mid-facial soft tissue change
and papilla height change. Based on GRADE guidelines, a moderate recommendation
for the use of a CTG following IIP can be made.
Conclusion: CTG contributes to mid-facial soft tissue stability following IIP. Therefore,
CTG should be considered when elevated risk for mid-facial recession is expected in
the aesthetic zone (thin gingival biotype, <0.5 mm buccal bone thickness).

KEYWORDS
connective tissue graft, dental implant, immediate, single tooth, soft tissue augmentation

284 |
wileyonlinelibrary.com/journal/jcpe J Clin Periodontol. 2021;48:284–301.
|

1600051x, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13397 by Hacettepe Universitesi, Wiley Online Library on [15/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
SEYSSENS et al. 285

1 | I NTRO D U C TI O N
Clinical Relevance
Immediate implant placement (IIP) and provisionalization have
Scientific rationale for the study: Mid-facial recession has
gained considerable scientific interest over the last 20 years.
become a concern following immediate implant placement
While minimizing the duration of edentulism and number of surgi-
(IIP). This systematic review aimed to evaluate the effect of
cal interventions may be advantageous for surgeons and patients
connective tissue graft (CTG) in terms of vertical mid-facial
(Hartlev et al., 2014; Khzam et al., 2015), IIP is not able to mitigate
soft tissue change when applied following single IIP.
the buccal hard and soft tissue remodelling following tooth ex-
Principal findings: Vertical mid-facial soft tissue change was
traction (Araujo et al., 2005; Botticelli et al., 2004; Covani et al.,
0.41 mm lower following soft tissue grafting. Also, soft
2007; Vignoletti et al., 2009). This may result in unsatisfactory
tissue disharmony and peri-implant bleeding were lower
results as aesthetic single-tooth replacement encompasses both a
when a CTG had been applied.
natural appearance of the restoration as well as peri-implant mu-
Practical implications: CTG should be considered when el-
cosa. The most common complication following IIP appears mid-
evated risk for mid-facial recession is expected in the aes-
facial recession (Chen & Buser, 2014; Cosyn Hooghe et al., 2012a;
thetic zone (thin gingival biotype, <0.5 mm buccal bone
Lin et al., 2014). More so, 26% of immediately installed implants
thickness).
displayed advanced recession of the mid-facial mucosa (≥1 mm)
according to a systematic review by Chen and Buser (2014). Also,
satisfactory results observed during the first year of function may
still be followed by progressive recession over time (Cosyn et al., 2.1 | Objectives
2016; Kan et al., 2011). In a recent 10-year prospective study,
even 33% of the cases demonstrated advanced mid-facial reces- The primary objective was to compare IIP with and without a buccal
sion (Seyssens et al., 2020a). Apart from facial bone wall dimen- CTG in terms of vertical mid-facial soft tissue change. The focused
sions, the gingival biotype seems to play a role in the extent of research question was: “In patients undergoing IIP, will insertion of a
soft tissue collapse and the risk for mid-facial recession around buccal CTG as compared to no CTG result in different vertical mid-
immediately installed implants (Bittner et al., 2019; Evans & Chen, facial soft tissue change?”.
2008; Kan et al., 2011; Kinaia et al., 2017). Since a thin gingival The PICO elements relating to this focused research question
architecture is frequently observed in the anterior maxilla (De were as follows:
Rouck et al., 2009b; Kan et al., 2010; Zweers et al., 2014), the use
of soft tissue grafts to convert a thin-scalloped gingival biotype to Patient: adult patients undergoing IIP (within 24 h
a thick biotype when installing implants in the aesthetic zone has post-extraction)
been advocated (Thoma et al., 2014). Three systematic reviews
have been published on IIP with additional soft tissue augmenta- Intervention: submucosal placement of a CTG at the
tion by means of a connective tissue graft (CTG) (Lee et al., 2016; buccal aspect
Lin et al., 2014; Rojo et al., 2016). However, due to the scarcity
of controlled clinical studies at the time, no direct comparison Comparison: no CTG
could be made between immediately installed implants with or
without soft tissue grafting. Consequently, decisive statements Outcome: vertical mid-facial soft tissue change
on the benefit of a CTG in addition to IIP are lacking. Hence, the
primary study objective of the present systematic review was Secondary objectives related to the same comparison, yet fo-
to assess the effect of a CTG in terms of vertical mid-facial soft cusing on the following variables: frequency of ≥1 mm asymmetry
tissue change when applied following single immediate implant in vertical mid-facial soft tissue level, horizontal mid-facial soft
placement. tissue change, mesial and distal papilla height change, pink aes-
thetic score, marginal bone level change, probing depth, bleeding
on probing.
2 | M ATE R I A L A N D M E TH O DS

This systematic review was performed applying the Preferred 2.2 | Eligibility criteria
Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA)
as described by Moher et al., (2010). Inclusion criteria comprised:
The protocol was registered in PROSPERO (International
Prospective Register of Systematic Reviews) at the UK’s National • Human clinical studies published in English
Institute for Health Research (NIHR), University of York, Centre for • At least 18-year-old patients
Reviews and Dissemination (CRD42020153680). • Systemically healthy patients
|

• Single implant site in any position extraction, tooth [MeSH Terms] OR immediate
placement OR immediately placed OR
• Studies reporting on titanium implants
immediate installation OR immediately
• Randomized controlled trials (RCTs) and non-randomized con- installed OR immediate insertion OR
trolled studies (NRSs) allowing for a direct comparison of IIP immediately inserted OR immediate
(within 24 h post-extraction) with CTG and without CTG implants OR fresh extraction socket

• Data on at least one outcome variable of interest Intervention connective tissue [MeSH Terms] OR gingiva/
transplantation [MeSH Terms] OR
• At least 10 cases in each treatment arm at final study evaluation
connective tissue graft OR soft tissue graft
• At least 12 months of follow-up on average following implant
OR soft tissue augmentation OR soft tissue
placement transplantation OR free gingival graft OR
gingival autograft OR ridge augmentation
Studies were excluded on the basis of study design (prospective OR soft tissue correction

as well as retrospective case series, cross-sectional studies, letters The final search string included a combination of these search
to editors, reviews). items as follows: Patient AND Intervention.
Additional exclusion criteria were defined as studies: The two reviewers (LS, LDL) independently evaluated all studies
on their eligibility based on inclusion and exclusion criteria as listed
• Reporting on zirconia implants below. First, this was performed at title level, then at abstract level.
• Involving sinus floor elevation procedures Articles that still qualified at the abstract level were printed and full
• Reporting bone ring techniques texts were read. If doubt arose at title or abstract level, studies were
• Reporting on alveolar socket shield technique further scrutinized in the next level to avoid overlooking of appro-
• Involving vertical ridge augmentation priate studies. Any disagreement that arose at full-text level was re-
• Reporting on distraction osteogenesis solved by discussion with a third reviewer (JC). Cohen's kappa was
• Reporting on alveolar ridge splitting calculated to assess inter-rater reliability in the selection of appro-
• Reporting on subperiosteal implants priate studies at title and abstract level.
• Reporting on bicortical implants Bibliographies of the studies that had been included by the
• Reporting on patients taking medications/therapy affecting bone electronic search were screened and checked for cross-refer-
metabolism (i.e. bisphosphonates, radiation therapy) ences. An attempt was made to identify grey literature by search-
• Reporting on patients with pathologies affecting bone metabo- ing through the database of the U.S. National Library of Medicine
lism (i.e. osteoporosis, osteopenia, rheumatoid arthritis) (www.clinic altrials.gov) and by contacting researchers who pub-
• Reporting on implants placed in sites affected by tumours lished on connective tissue grafting around immediate implants.
• Containing lack of information on whether augmentation proce- Finally, the following journals were hand-searched up to January
dures were performed or not 2020: Journal of Clinical Periodontology, Journal of Periodontology,
• Involving the application of any additional therapy that could have Clinical Implant Dentistry and Related Research, Clinical Oral Implants
affected healing outcomes (e.g. use of healing enhancers, such as Research, Clinical Oral Investigations, International Journal of Oral &
PRP, PRF, growth factors) Maxillofacial Implants, International Journal of Oral & Maxillofacial
• Containing insufficient information on the surgical protocol and Surgery.
timing after tooth extraction

2.4 | Data extraction

2.3 | Information sources and search strategy
The same reviewers (LS, LDL) independently extracted all data
Two independent reviewers (LS, LDL) conducted an electronic lit- of interest from the finally selected articles and constructed ta-
erature search as well as a manual search to identify eligible clinical bles on study characteristics and outcomes. Disagreement was
studies. resolved by discussion with a third reviewer (JC). Authors of in-
The electronic search was performed in PubMed, Web of cluded studies were contacted by email to provide missing or in-
Science, EMBASE and Cochrane databases until January 2020 using complete data.
a combination of the following controlled MeSH terms and key-
words not indexed in MeSH:
Patient dental implant [MeSH Terms] OR dental 2.5 | Risk-of-bias assessment
implantation [MeSH Terms] OR dental
implant OR dental implantation OR oral
Quality assessment was independently performed by 2 review-
implant OR tooth implant OR tooth
ers (LS, JC) using specific risk assessment tools depending on the
implantation
study design. RCTs were assessed using the Revised Cochrane
AND
Risk-of-bias Tool for Randomized Trials (RoB 2) as developed by
|

PRISMA 2009 Flow Diagram

Records idenfied through Addional records idenfied

database searching through other sources

Identification
(n = 2504) (n = 1)

Records aer duplicates removed

(n = 1814)

Records excluded aer tle screening

(n = 1407)
Screening

Abstracts screened
(n = 407)

Records excluded aer abstract screening

(n = 316)

Full-text arcles assessed

for eligibility
Eligibility

(n = 91)

Full-text arcles excluded, with reasons

(n = 83)

Arcles included in
qualitave synthesis
(n = 8)
Included

Arcles included in
quantave synthesis
(meta-analysis)
(n = 5)

F I G U R E 1 PRISMA flow chart on the search strategy [Colour figure can be viewed at wileyonlinelibrary.com]

Sterne et al. (2019). This quality assessment is structured into the 2.6 | Statistical analysis
following domains: (a) bias arising from the randomization process,
(b) bias due to deviations from intended interventions, (c) bias due Data analysis was performed in Review Manager 5.3® (Cochrane
to missing outcome data, (d) bias in measurement of the outcome Collaboration, Oxford, UK). A meta-analysis was performed for
and (e) bias in selection of the reported result. All five domains outcome variables that were reported in at least 2 Randomized
were judged as low, unclear or high risk of bias. The Newcastle– Controlled Trials. The I2 index was used to express the percentage
Ottawa Scale (NOS) (Wells et al., 2009) was applied to evaluate of the total variation across studies due to heterogeneity (Higgins
the (a) selection and (b) comparability of the study groups as well as et al., 2003). The GRADE guidelines were adopted to categorize het-
the (c) outcome assessment of included NRSs using a star system. erogeneity with <40% corresponding to low, 30%-60% to moderate,
NRSs were judged as poor, fair or good quality by converting NOS 50%-90% to substantial and 75%-100% to considerable heterogene-
ratings to Agency for Healthcare Research and Quality standards ity (Guyatt et al., 2011).
(AHRQ) (Viswanathan et al., 2008). Weighted kappa with linear Effect sizes for continuous outcome variables were expressed
weights (Cicchetti & Allison, 1971) was calculated to assess inter- as mean difference and 95% confidence intervals using the inverse
rater reliability in quality assessment. Disagreement that arose fol- variance statistical method in an a priori fixed-effects model. For
lowing quality assessment was resolved by discussion with a third dichotomous variables, the same process was followed, however,
reviewer (JC). using the Mantel–Haenszel statistical method with effect sizes
TA B L E 1 Reasons for exclusion
| 288

Reason for Inappropriate study design Not reporting on Not reporting on soft No comparison between Insufficient number Insufficient Subgroup of an
exclusion (no RCT/NRS) immediate implants tissue grafting IIP + CTG and IIP of cases follow-up period already included paper

Arora and Ivanovski (2017) Cooper et al. (2015) Amato et al. (2018) Boardman et al. (2016) Chen et al. (2007) Fujita et al. (2019) Noelken et al. (2018)
Arora et al. (2017) Mijiritsky et al. (2013) Atalay et al. (2013) Esposito et al. (2017) Frizzera et al. (2019) Grunder (2011)
Assaf et al. (2017) Poli et al. (2019) Baer et al. (2013) Felice et al. (2016)
Bae et al. (2011) Barias et al. (2013) Kato et al. (2018)
Barroso-Panella et al. (2018) Block et al. (2009) Lang et al. (2007)
Benic et al. (2012) Canullo et al. (2009) Nemcovsky et al. (2002)
Blanco et al. (2019) Canullo et al. (2017)
Caiazzo et al. (2013) Capelli et al. (2013)
Cardaropoli et al. (2015) Cardaropoli et al. (2014)
Castellon and Yukna (2004) Cooper et al. (2010)
Cheng et al. (2019) Cordaro et al. (2009)
Cosyn et al. (2013) Covani et al. (2004)
Cosyn et al. (2016) Esposito et al. (2015)
Covani et al. (2007) Felice et al. (2015)
Degidi et al. (2014) Felice et al. (2011)
Dominguez et al. (2015) Grandi et al. (2015)
Groenendijk et al. (2017) Hof et al. (2015)
Guarnieri et al. (2014) Hu et al. (2017)
Hasan et al. (2015) Hu et al. (2018)
Hattingh et al. (2019) Huynh-Ba et al. (2010)
Hayacibara et al. (2013) Huynh-Ba et al. (2019)
Jiansheng et al. (2012) Lopez et al. (2016)
Jyothi et al. (2013) Mastrangelo et al. (2018)
Kolerman et al. (2016) Mazzocco et al. (2017)
Levin (2011) O'Brien et al. (2004)
Noelken et al. (2014) Paknejad et al. (2017)
Noelken et al. (2016) Paolantonio et al. (2001)
Redemagni et al. (2009) Raes et al. (2013)
Redemagni et al. (2013) Raes et al. (2018)
Roccuzzo et al. (2019) Rieder et al. (2016)
Roe et al. (2012) Rompen et al. (2007)
Rosenquist and Ahmed (2000) Sanz et al. (2017)
Stimmelmayr et al. (2010) Spinato et al. (2012)
Waki and Kan (2016) Tarnow et al. (2014)
SEYSSENS et al.

Abbreviations: CTG, Connective Tissue Graft; IIP, Immediate Implant Placement; NRS, Non-Randomized Controlled Study; RCT, Randomized Controlled Trial.

expressed as risk ratio and 95% confidence intervals. A random-ef- one early implant loss in each group of the study by van Nimwegen
fects model using the DerSimonian–Laird method (DerSimonian et al. (2018) and Zuiderveld et al. (2018), all implants survived during
& Laird, 1986) was applied in case of substantial heterogeneity the follow-up period. At study termination, 289 patients with 310
(Nasser, 2020). Forest plots were created to illustrate effect sizes implants remained available for evaluation (IIP + CTG: 162 implants
in the overall analysis. The level of significance was set at .05. in 152 patients; IIP: 148 implants in 137 patients).
Five of the studies reported on the gingival phenotype at the
surgical site (Migliorati et al., 2015; van Nimwegen et al., 2018;
3 | R E S U LT S Noelken et al., 2018; Rungcharassaeng et al., 2012; Yoshino et al.,
2014; Zuiderveld et al., 2018). Yoshino et al. (2014), Migliorati et al.
3.1 | Search (2015), Van Nimwegen et al. (2018) and Zuiderveld et al. (2018) pro-
vided the number of thin phenotype sites per group, accounting for
The search strategy is illustrated in Figure 1. The electronic search 53.1% and 46.9% of their included patients for IIP +CTG and IIP, re-
rendered 2504 titles in total (1176 in PubMed, 1020 in Web of spectively. Rungcharassaeng et al. (2012) and Noelken et al. (2018)
Science, 269 in EMBASE and 39 in Cochrane). Grey literature search both included sites with a thin gingival biotype, but provided no
yielded 1 unpublished manuscript (Fujita et al., 2019) potentially eli- numbers per group.
gible for inclusion. After removing duplicates across databases, 1814 Studies were heterogeneous in the inclusion of cases with
unique titles were screened. Good inter-rater agreement was found baseline gingival recession. Noelken et al. (2018), van Nimwegen
in the selection of appropriate studies at both title and abstract et al. (2018) and Zuiderveld et al. (2018) included such sites,
level, given a Cohen's kappa value of 0.658 (95% CI [0.615; 0.701], whereas Rungcharassaeng et al. (2012) and Migliorati et al. (2015)
p < .001) and 0.727 (95% CI [0.641; 0.813], p < .001), respectively only included cases with harmonious mucosal levels. The same ap-
(Altman, 1999). Ninety-one papers remained for full-text analysis plied to the inclusion of cases with incomplete facial bone walls.
and led to the exclusion of 83 articles. The reasons for exclusion can Rungcharassaeng et al. (2012) excluded all cases with some de-
be found in Table 1. Thus, 8 articles fully met the selection criteria gree of missing facial bone. In contrast, the majority of sockets
for qualitative analysis (Bianchi & Sanfilippo, 2004; Cornelini et al., (90.8%) in the study by Noelken et al. (2018) presented partial or
2008; Migliorati et al., 2015; van Nimwegen et al., 2018; Noelken complete loss of facial bone prior to implant placement. Cornelini
et al., 2018; Rungcharassaeng et al., 2012; Yoshino et al., 2014; et al. (2008), Migliorati et al. (2015), van Nimwegen et al. (2018)
Zuiderveld et al., 2018). Of those, 5 articles were included for quan- and Zuiderveld et al. (2018) allowed limited buccal bone loss for
titative analysis (Bianchi & Sanfilippo, 2004; Migliorati et al., 2015; inclusion. The majority of articles related to single implants lo-
van Nimwegen et al., 2018; Yoshino et al., 2014; Zuiderveld et al., cated in the anterior segment of the dentition, either in the max-
2018). These articles corresponded to 4 clinical studies since 2 ar- illa (Migliorati et al., 2015; van Nimwegen et al., 2018; Noelken
ticles pertained to the same study material (van Nimwegen et al., et al., 2018; Rungcharassaeng et al., 2012; Yoshino et al., 2014;
2018; Zuiderveld et al., 2018). Meta-analyses could be performed Zuiderveld et al., 2018) or in both jaws (Cornelini et al., 2008).
on all outcome variables except for horizontal mid-facial soft tissue Bianchi and Sanfilippo (2004) also installed implants in the poste-
change and papilla height change. rior region of both the mandible and maxilla.
In all but one study (Rungcharassaeng et al., 2012), the entire
surgical (flap/flapless surgery, socket grafting and CTG donor site)
3.2 | Description of selected studies and prosthetic (immediate restoration) protocol could be verified.

The characteristics of included studies are reported in Table 2. Five

articles were RCTs (Bianchi & Sanfilippo, 2004; Migliorati et al., 3.3 | Risk-of-bias assessment
2015; van Nimwegen et al., 2018; Yoshino et al., 2014; Zuiderveld
et al., 2018) and 3 were NRSs (Cornelini et al., 2008; Noelken et al., Quality assessment of the included RCTs using the RoB 2 frame-
2018; Rungcharassaeng et al., 2012). The qualitative analysis com- work is given in Table 3. Good inter-rater agreement was found,
prised data of 409 single immediate implants installed in 388 pa- given a weighted kappa coefficient of .783 (95% CI [0.414; 1.151],
tients with a mean age ranging from 43 to 53 years (IIP + CTG: 246 p = .021) (Altman, 1999). The study of van Nimwegen et al. (2018)
implants in 236 patients; IIP: 163 implants in 152 patients). Mean and Zuiderveld et al. (2018) demonstrated the highest quality since
follow-up ranged from 12 to 108 months. Major selective loss to all 5 domains were judged as low risk of bias. Some concern about
follow-up was found in the study of Bianchi and Sanfilippo (2004). the randomization process was raised in the study of Migliorati et al.
The investigators provided annual data on 116 initially treated pa- (2015). Two domains were judged as high risk of bias in the studies of
tients (IIP + CTG: 96, IIP: 20). Yet, their final observation was lim- Bianchi and Sanfilippo (2004) and (Yoshino et al., 2014). The evalua-
ited to 19 patients (IIP + CTG: 13, IIP: 6). As a result of the limited tion of NRSs using the NOS is displayed in Table 4. A weighted kappa
measurements performed at both the 6- and 9-year intervals, only coefficient of 0.583 (95% CI [0.075; 1.091], p = .050) was found,
the data collected at the 3-year evaluation were included. Except for
|

TA B L E 2 Characteristics of included studies

Mean Cases with thin Cases with baseline Bone to Cases with
Study No. of patients/ age gingival biotype gingival recession implant gap incomplete buccal
Author design no. of implants (years) included included grafted bone wall included

Bianchi and RCT IIP+CTG: 96/96 45.4 NR NR IIP+CTG: no IIP+CTG: NR

Sanfilippo IIP: 20/20 IIP: no IIP: NR
(2004)
Cornelini et al. NRS IIP+CTG: 17/17 43 NR NR IIP+CTG: no IIP+CTG: yes
(2008) IIP: 17/17 IIP: no IIP: yes
Rungcharassaeng NRS IIP+CTG: 31/31 44.6 IIP+CTG: yes IIP+CTG: no IIP+CTG: yes IIP+CTG: no
et al. (2012) IIP: 24/24 IIP: yes IIP: no IIP: yes IIP: no
Yoshino et al. (2014) RCT IIP+CTG: 10/10 52.6 IIP+CTG: no NR IIP+CTG: yes NR
IIP: 10/10 IIP: yes IIP: yes
Migliorati et al. RCT IIP+CTG: 24/24 47.5 IIP+CTG: yes IIP+CTG: no IIP+CTG: yes IIP+CTG: yes
(2015) IIP: 24/24 IIP: yes IIP: no IIP: yes IIP: yes
Noelken et al. NRS IIP+CTG: 28/38 53 IIP+CTG: yes IIP+CTG: yes IIP+CTG: yes IIP+CTG: yes
(2018) IIP: 27/38 IIP: yes IIP: yes IIP: yes IIP: yes
Van Nimwegen RCT IIP+CTG: 30/30 46.7 IIP+CTG: yes IIP+CTG: yes IIP+CTG: yes IIP+CTG: yes
et al. (2018), IIP: 30/30 IIP: yes IIP: yes IIP: yes IIP: yes
Zuiderveld et al.
(2018)

Abbreviations: ant, anterior; CTG, connective tissue graft; IIP, immediate implant placement; mand, mandible; max, maxilla; NR, not reported;
NRS, non-randomized controlled study; post, posterior; RCT, randomized controlled trial.

indicating moderate inter-rater agreement (Altman, 1999). The over- et al., 2018). Following discussion among the authors of this system-
all quality of the included NRSs was judged as poor. atic review, it was decided to include the data from the article of
Zuiderveld et al. (2018) in the meta-analysis since these related to
the entire study sample. Yoshino et al. (2014) and Migliorati et al.
3.4 | Primary outcome variable: vertical mid-facial (2015) both assessed mid-facial soft tissue change using stone cast
soft tissue change models, whereas Zuiderveld et al. (2018) utilized standardized intra-
oral photographs. Mean vertical mid-facial soft tissue change ranged
Five studies reported on the vertical soft tissue level at the buc- from −0.70 mm to −0.50 mm around implants when no CTG was in-
cal aspect of immediately installed implants (Cornelini et al., 2008; serted in the buccal mucosa (Table 5). When a CTG was added, mean
Migliorati et al., 2015; van Nimwegen et al., 2018; Noelken et al., mid-facial soft tissue change ranged from −0.32 mm to +0.10 mm.
2018; Yoshino et al., 2014; Zuiderveld et al., 2018). Cornelini et al. All authors reported a more apical position of the soft tissue level
(2008) and Noelken et al. (2018) assessed mid-facial recession by when no CTG was used when compared to augmented sites. The
comparing the level of the mid-facial mucosa at final evaluation to meta-analysis revealed a significant difference in terms of vertical
the level at the neighbouring and contra-lateral tooth, respectively. mid-facial soft tissue change between IIP and IIP + CTG pointing to
In comparison with the adjacent tooth, Cornelini et al. (2008) found 0.41 mm (95% CI [0.21; 0.61], p < .001) in favour of soft tissue aug-
a mean recession of 0.85 mm around implants without additional mentation (Figure 2). Heterogeneity across studies was low, given
CTG. A more coronal position (+0.2 mm) was observed follow- an I2 of 0% (p = .62).
ing IIP + CTG. Noelken et al. (2018) found a similar position of the
mid-facial soft tissue level following both treatment modalities (IIP
+ CTG: −0.50 mm, IIP: −0.45 mm). Since the factual change from 3.5 | Secondary outcome variables
the baseline soft tissue level was not evaluated by Cornelini et al.
(2008) and Noelken et al. (2018) and because it concerned non-ran- Table 5 depicts all relevant outcomes as described in the included
domized studies, both articles were excluded for quantitative evalu- studies.
ation. Consequently, 3 RCTs with a total sample of 128 (IIP + CTG:
64, IIP: 64) immediately installed implants followed between 12
and 24 months were included in the meta-analysis (Migliorati et al., 3.5.1 | Frequency of ≥1 mm asymmetry in mid-facial
2015; Yoshino et al., 2014; Zuiderveld et al., 2018). Because van vertical soft tissue level
Nimwegen et al. excluded 8 patients for final analysis, data on verti-
cal mid-facial soft tissue change slightly differed across both articles Three studies reported on the frequency of ≥1 mm asymmetry in
from the Groningen group (van Nimwegen et al., 2018; Zuiderveld vertical soft tissue level at the buccal aspect of immediately installed
|

Flapless No. of patients/no.

Immediate implant Follow-up of implants at study
Implant position restoration placement CTG donor site (months) termination No. drop-outs

IIP+CTG: ant+post/ IIP+CTG: No IIP+CTG: No Palate, tuber, IIP+CTG: 12 IIP+CTG: 13/13 IIP+CTG: 83
max+mand IIP: No IIP: No edentulous – 108 IIP: 6/6 IIP: 14
IIP: ant+post/max+mand ridge IIP: 108
IIP+CTG: ant/max+mand IIP+CTG: Yes IIP+CTG: No Palate IIP+CTG: 12 IIP+CTG: 17/17 IIP+CTG: 0
IIP: ant/max+mand IIP: Yes IIP: No IIP: 12 IIP: 17/17 IIP: 0
IIP+CTG: ant/max IIP+CTG: Yes IIP+CTG: NR Palate IIP+CTG: 6 – 24 IIP+CTG: 31/31 IIP+CTG: 0
IIP: ant/max IIP: Yes IIP: NR IIP: 6 – 17 IIP: 24/24 IIP: 0
IIP+CTG: ant/max IIP+CTG: Yes IIP+CTG: Yes Palate IIP+CTG: 12 IIP+CTG: 10/10 IIP+CTG: 0
IIP: ant/max IIP: Yes IIP: Yes IIP: 12 IIP: 10/10 IIP: 0
IIP+CTG: ant/max IIP+CTG: Yes IIP+CTG: Yes Palate IIP+CTG: 24 IIP+CTG: 24/24 IIP+CTG: 0
IIP: ant/max IIP: Yes IIP: Yes IIP:24 IIP: 23/23 IIP: 1
IIP+CTG: ant/max IIP+CTG: Yes IIP+CTG: Yes Palate IIP+CTG: 36 IIP+CTG: 28/38 IIP+CTG: 0
IIP: ant/max IIP: Yes IIP: Yes IIP: 36 IIP: 27/38 IIP: 0
IIP+CTG: ant/max IIP+CTG: Yes IIP+CTG: Yes Tuber IIP+CTG: 12 IIP+CTG: 29/29 IIP+CTG: 0
IIP: ant/max IIP: Yes IIP: Yes IIP:12 IIP: 29/29 IIP: 0

implants in comparison to either the adjacent (Bianchi & Sanfilippo, 3.5.2 | Horizontal mid-facial soft tissue change
2004) or contra-lateral tooth (Migliorati et al., 2015; Noelken et al.,
2018). The meta-analysis was based on 2 RCTs pertaining to 164 Three studies reported on the horizontal soft tissue change at the
(IIP + CTG: 120, IIP: 44) immediately installed implants followed buccal aspect of immediately installed implants (Migliorati et al.,
between 12 and 36 months (Bianchi & Sanfilippo, 2004; Migliorati 2015; van Nimwegen et al., 2018; Rungcharassaeng et al., 2012).
et al., 2015). Both studies reported a higher risk for ≥1 mm asymme- Rungcharassaeng et al. (2012) and Migliorati et al. (2015) assessed
try in vertical soft tissue level following IIP without soft tissue aug- changes in buccal soft tissue thickness by means of an endodontic
mentation. The meta-analysis revealed that 25.6% of the IIP cases reamer and wax calliper, respectively. Van Nimwegen et al. (2018)
and 1.0% of the IIP + CTG cases demonstrated ≥1 mm asymmetry performed a three-dimensional analysis using digital STL files to cal-
in vertical soft tissue level. A CTG had a significant protective ef- culate changes in buccal soft tissue profile. Migliorati et al. (2015)
fect, as the risk for such asymmetry following IIP + CTG decreased demonstrated 0.5 mm increase in buccal soft tissue thickness as a
up to a 12-fold (RR 12.10, 95% CI [2.57; 56.91], p = .002) (Figure 3). result of CTG, whereas minute loss (0.2 mm) was observed in the
Heterogeneity across studies was low, given an I2 of 0% (p = .38). IIP group. Rungcharassaeng et al. (2012) reported 0.43 and 0.32 mm
increase in buccal soft tissue thickness following IIP + CTG and IIP,
respectively. In the study of van Nimwegen et al., (2018) CTG failed
TA B L E 3 Quality assessment of included randomized controlled
trials according to the Revised Cochrane Risk-of-bias Tool to increase buccal soft tissue profile. In fact, shrinkage was observed
in both groups (IIP + CTG: 0.68 mm; IIP: 0.49 mm). A meta-analysis
Risk-of-bias domains
could not be performed since Migliorati et al. (2015) did not provide
D1 D2 D3 D4 D5 Overall SDs on the outcome of interest.

Bianchi and Sanfilippo (2004) − + − + x −

Yoshino et al. (2014) − + + − + −
3.5.3 | Mesial and distal papilla height change
Migliorati et al. (2015) x + + + + x
van Nimwegen et al. (2018) + + + + + +
Two studies reported on papilla height change at the mesial and dis-
Zuiderveld et al. (2018) + + + + + +
tal aspect of immediately installed implants (Migliorati et al., 2015;
Judgement: red = high risk of bias; yellow = some concerns; green = low Zuiderveld et al., 2018). In comparison with the interproximal soft
risk of bias.
tissue level around the failing tooth, Zuiderveld et al. (2018) demon-
Domains: D1 = bias arising from the randomization process; D2 = bias
strated slightly shorter mesial papillae following IIP + CTG (−0.3 mm)
due to derivations from intended intervention; D3 = bias due to missing
outcome data; D4 = bias in measurement of the outcome; D5 = bias in and IIP (−0.4 mm). Shrinkage of the distal papillae was found follow-
selection of the reported result. ing both treatment modalities (IIP + CTG: −0.4 mm, IIP: −0.6 mm).
|

stars in Comparability domain AND 2 or 3 stars in Outcome domain. Fair quality: 2 stars in Selection domain AND 1 or 2 stars in Comparability domain AND 2 or 3 stars in Outcome domain. Poor quality: 0
In the study by Migliorati et al. (2015), baseline measurements of

Quality
Overall

Thresholds for converting NOS star ratings to an overall quality rating according to AHRQ standards (Viswanathan et al., 2008) were as follows: Good quality: 3 or 4 stars in Selection domain AND 1 or 2
Poor

Poor

Poor
the papilla height were performed immediately after implant sur-
(out of 9) gery. They reported a gain in both mesial (IIP + CTG: +0.8 mm,
IIP: +0.8 mm) and distal (IIP + CTG: +0.6 mm, IIP: +0.7 mm) papilla
Total

height. Because of the difference in methodology and the fact that

6
Migliorati et al. (2015) did not provide SDs on the outcome of inter-
(Maximum:
est, a meta-analysis could not be performed.
of cohorts
follow-up
Adequacy of

★)

3.5.4 | Pink aesthetic score

★

★
(Maximum: ★)

Two studies reported on the peri-implant aesthetic outcome by means

Follow-up long
enough for
outcomes

of the PES following immediate implant placement (Migliorati et al.,

to occur

2015; van Nimwegen et al., 2018; Zuiderveld et al., 2018). Both used a
modified index generating a score on a total of 10 (Belser et al., 2009).
★

The meta-analysis based on these RCTs pertained to 108 (IIP + CTG:

(Maximum:
Assessment of

54, IIP: 54) immediately installed implants followed between 12 and

outcome

24 months (Migliorati et al., 2015; Zuiderveld et al., 2018), yet failed to

Outcome

demonstrate a significant difference between IIP and IIP +CTG (MD

★)

0.49, 95% CI [−1.23; 2.20], p = .58) (Figure 3). Considerable heteroge-

★

neity across studies was observed, given an I2 of 91% (p < .001).

(Maximum: ★★)
basis of design
Comparability of
Comparability

cohorts on

or analysis

3.5.5 | Marginal bone level change

TA B L E 4 Quality assessment of included non-randomized studies according to Newcastle–Ottawa Scale

★★

Five studies reported on MBL change around immediately installed

implants (Cornelini et al., 2008; Migliorati et al., 2015; Noelken et al.,
or 1 star in Selection domain OR 0 stars in Comparability domain OR 0 or 1 stars in Outcome domain.
(Maximum: ★)

2018; Yoshino et al., 2014; Zuiderveld et al., 2018). The meta-analysis

interest not

study start
present at

was based on 3 RCTs pertaining to 128 (IIP +CTG: 64, IIP: 64) im-
Outcome of

mediately installed implants followed between 12 and 24 months

(Migliorati et al., 2015; Yoshino et al., 2014; Zuiderveld et al., 2018), yet
★

failed to demonstrate a significant difference in MBL change between

IIP and IIP + CTG (MD 0.05 mm, 95% CI [−0.08; 0.18], p = .42) (Figure 3).
of exposure
Ascertainment

(Maximum:

Heterogeneity across studies was low, given an I2 of 0% (p = .69).

★)

3.5.6 | Probing depth

(Maximum: ★)
non-exposed
Selection of the

Three studies reported on probing depth around immediately in-

cohort

stalled implants (Cornelini et al., 2008; Migliorati et al., 2015;

Zuiderveld et al., 2018). The meta-analysis was based on 2 RCTs
★

pertaining to 108 (IIP + CTG: 54, IIP: 54) immediately installed im-
plants followed between 12 and 24 months (Migliorati et al., 2015;
Representativeness
of the exposed

(Maximum: ★)

Zuiderveld et al., 2018), yet failed to demonstrate a significant dif-

ference in probing depth between IIP and IIP + CTG (MD 0.08 mm,
cohort
Selection

95% CI [−0.24; 0.41], p = .61) (Figure 3). Moderate heterogeneity

across studies was observed, given an I2 of 31% (p = .23).
★

★
Rungcharassaeng
et al. (2012)
Cornelini et al.

Noelken et al.

3.5.7 | Bleeding on probing

(2008)

(2018)
Author

Two studies reported on bleeding on probing around immediately

installed implants (Migliorati et al., 2015; Zuiderveld et al., 2018).
|

F I G U R E 2 Forest plot on vertical mid-facial soft tissue change [Colour figure can be viewed at wileyonlinelibrary.com]

F I G U R E 3 Forest plots on the secondary outcome variables, top to bottom: Frequency of ≥1 mm asymmetry in mid-facial vertical
soft tissue level; Pink aesthetic score; marginal bone level change; probing depth; bleeding on probing [Colour figure can be viewed at
wileyonlinelibrary.com]
|

TA B L E 5 Outcomes of included studies

Vertical mid-facial soft tissue Horizontal mid-facial soft tissue

change Frequency of ≥1 mm asymmetry in change
Author Mean (SD) vertical mid-facial soft tissue level Mean (SD)

Bianchi and Sanfilippo (2004) NR IIP+CTG: 0%a NR

IIP: 20%a
Cornelini et al. (2008) NR NR NR

Rungcharassaeng et al. (2012) NR NR IIP + CTG: 0.43 (0.59)

IIP: 0.32 (0.36)
Yoshino et al. (2014) IIP+CTG: −0.25 (0.35) NR NR
IIP: −0.7 (0.48)

Migliorati et al. (2015) IIP+CTG: −0.32 (0.34) IIP+CTG: 4% IIP+CTG: 0.5 (NR)
IIP: −0.65 (0.56) IIP: 31.8% IIP: −0.2 (NR)

Noelken et al. (2018) NR IIP+CTG: 10.5% NR

IIP: 5.3%
Van Nimwegen et al. (2018), IIP+CTG: 0.1 (0.8) NR IIP+CTG: −0.68 (0.59)
Zuiderveld et al. (2018) IIP: −0.50 (1.1) IIP: −0.49 (0.54)

Note: Positive value = coronal advancement/buccal advancement.

Negative value = apical advancement/lingual advancement.
Abbreviations: CTG, connective tissue graft; IIP, immediate implant placement; NR, not reported.
a
Data collected after 3 years of follow-up.

The meta-analysis based on these RCTs pertained to 108 (IIP + CTG: 95% CI [−35%; 1%], p = .06). This is in accordance with a recent
54, IIP: 54) immediately installed implants followed between 12 systematic of Thoma et al. (2018) showing more favourable peri-
and 24 months. Lower bleeding scores were found following IIP + implant health following soft tissue grafting. Besides CTG, it has
CTG, yet only by a trend (MD −17%, 95% CI [−35%; 1%], p = 0.06) also been shown that flapless implant placement (Raes et al., 2011)
2
(Figure 3). Heterogeneity across studies was low, given an I of 0% and immediate restoration (De Rouck et al., 2009a) may enhance
(p = .54). mid-facial mucosal stability. The vast majority of included studies
performed these protective interventions.
Based on the quality of evidence in this systematic review as
4 | DISCUSSION rated by the GRADE guidelines, a moderate recommendation for
the use of a CTG following IIP can be made (Guyatt et al., 2011).
Mid-facial recession has become a concern following IIP (Chen Risk assessment for mid-facial recession is required when consider-
& Buser, 2014; Cosyn Hooghe et al., 2012a; Khzam et al., 2015; ing soft tissue augmentation as an adjunct to IIP in clinical practice.
Kinaia et al., 2017; Lee et al., 2016; Lin et al., 2014; Rojo et al., This should be primarily based on the gingival biotype, the integ-
2016; Slagter et al., 2014). This systematic review aimed to eval- rity and thickness of the buccal bone wall and the aesthetic prior-
uate the effect of a CTG in terms of vertical mid-facial soft tissue ity of the implant site. Indeed, patients with a thin gingival biotype
change when applied following single IIP. Meta-analysis could be are more prone to develop recession (Bittner et al., 2019; Kan et al.,
performed on the basis of 3 RCTs reporting on 128 (IIP + CTG: 64, 2011). Migliorati et al. (2015) found that these patients especially
IIP: 64) implants after an observation period ranging from 12 to benefit from CTG following IIP, as they demonstrated similar mid-fa-
24 months (Migliorati et al., 2015; Yoshino et al., 2014; Zuiderveld cial soft tissue levels than patients with a thick gingival biotype
et al., 2018). These articles consistently reported more apical ad- who did not receive soft tissue grafting. In contrast, mid-facial re-
vancement of the mid-facial mucosa when no CTG was added. A cession was more than double in patients with a thin gingival bio-
mean difference of 0.41 mm in favour of soft tissue grafting was type who did not receive CTG. This has also been confirmed in a
found (95% CI [0.21; 0.61], p < .001). This outcome is clinically rel- recent study (Tatum et al., 2020). All this suggests that by adding
evant since the risk for ≥1 mm asymmetry in mid-facial vertical soft a CTG to thin gingival biotype sites, one may achieve similar out-
tissue level was 12 times (RR 12.10, 95% CI [2.57; 56.91], p = .002) comes as IIP at thick gingival biotype sites. In a recent study, it has
lower following IIP + CTG when compared to IIP. Also, from a clini- also been shown that very thin buccal bone walls (<0.5 mm) suffer
cal point of view soft tissue augmentation led to more favourable more resorption and mid-facial recession (Yang et al., 2019). Finally,
results given a trend towards lower bleeding on probing (MD 17%, mid-facial recession is more critical in the incisor/cuspid area due to
|

Mesial papilla height Distal papilla height Marginal bone level

change change Pink aesthetic score change Probing depth Bleeding on
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) probing %

NR NR NR NR NR NR

NR NR NR IIP+CTG: −0.7 (NR) IIP+CTG: 2.86 (NR) NR

IIP: −0.7 (NR) IIP: 2.33 (NR)
NR NR NR NR NR NR

NR NR NR IIP+CTG: −0.01 (0.27) NR NR

IIP: −0.14
(0.53)
IIP+CTG: 0.8 (NR) IIP+CTG: 0.6 (NR) IIP+CTG: 8/10 (1.26) IIP+CTG: −0.06 (0.45) IIP+CTG: 3.4 (0.5) IIP+CTG: 20%
IIP: 0.8 (NR) IIP: 0.7 (NR) IIP: 6.65/10 (0.99) IIP: −0.166 IIP: 3.2 (0.5) IIP: 40%
(0.3)
NR NR NR IIP+CTG: −0.29 (0.69) NR NR
IIP: −0.13 (0.49)
IIP+CTG: −0.3 (0.7) IIP+CTG: −0.4 (0.7) IIP+CTG: 6.4/10 (1.5) IIP+CTG: 0.01 (0.33) IIP+CTG: 2.28 (0.79) IIP+CTG: 59%
IIP: −0.4 (1.0) IIP: −0.6 (0.6) IIP: 6.8/10 (1.5) IIP: 0.01 IIP: 2.44 (1.19) IIP: 66%
(0.36)

aesthetic reasons. Therefore, CTG should be especially considered yet more research is needed to elucidate the true need for soft tissue
in this part of the dentition. Apart from these indications for soft grafting following IIP based on clear criteria.
tissue grafting, CTG may also be contra-indicated. This particularly Although it was previously assumed that implants may primarily
applies to situations with gingival overgrowth, where mid-facial re- benefit from a buccal CTG in terms of horizontal mid-facial soft tissue
cession needs to be provoked instead of avoided to end up with an change (Boardman et al., 2016), the results on this outcome remained
aesthetic outcome. Another concern with respect to CTG relates to inconclusive. van Nimwegen et al. (2018) observed mucosal volume
increased patient morbidity due to the need for a second surgical loss despite the addition of a CTG, whereas Rungcharassaeng et al.
site (Thoma et al., 2014). Therefore, there is strong scientific inter- (2012) and Migliorati et al. (2015) demonstrated increase in buccal
est for the development and clinical evaluation of non-autogenous soft tissue thickness. A possible explanation for these conflicting re-
collagen matrices (Eeckhout et al., 2020; Thoma et al., 2016, 2020; sults may be the difference in methodology. Rungcharassaeng et al.
Zeltner et al., 2017). In the present systematic review, post-opera- (2012) and Migliorati et al. (2015) assessed changes in buccal soft
tive complications hardly occurred (Migliorati et al., 2015; Yoshino tissue thickness by means of an endodontic reamer or wax calliper,
et al., 2014; Zuiderveld et al., 2018) and patient satisfaction was whereas van Nimwegen et al. (2018) assessed changes in buccal soft
high (van Nimwegen et al., 2018; Zuiderveld et al., 2018). Apart from tissue profile using digital STL files. The latter also includes under-
the donor site, also the recipient site may be negatively affected by lying facial bone wall resorption. Given the loss in buccal soft tissue
CTG. Inferior soft tissue texture was observed when CTG had been profile, it seems that CTG was not able to compensate for the under-
harvested from the tuberosity area (van Nimwegen et al., (2018), lying facial bone wall resorption.
Zuiderveld et al., 2018). This donor site seems more prone to result While it has been advocated that a CTG may positively influence
in a hyperplastic tissue response as compared to grafts harvested the mesial and distal papilla height change following IIP (Thoma et al.,
from the palate (Dellavia et al., 2014). According to a recent RCT by 2014), included data on vertical changes were not consistent due to
Rojo et al. (2020), a CTG harvested from both the lateral palate and the difference in measurement methodology.
tuberosity region may offer similar volume stability after a follow pe- Contradictory results were observed in terms of pink aesthetic
riod of 12 months. Based on all this, it is clear that soft tissue grafting score (Migliorati et al., 2015; Zuiderveld et al., 2018). While the aes-
may be not be considered standard of care following IIP. Cosyn et al. thetic outcome was superior following IIP + CTG in the study by
(2013) described a need for soft tissue grafting in one third of the Migliorati et al. (2015), Zuiderveld et al. (2018) reported lower PES
patients. These patients remained stable in terms of mid-facial soft scores for augmented sites. The inclusion of cases with baseline re-
tissue level over 10-year follow-up (Seyssens et al., 2020a,2020b), cession in their study may have contributed to this finding. In spite of
|

coronal soft tissue advancement following IIP + CTG, some dishar- C O N FL I C T O F I N T E R E S T

mony in comparison with the adjacent teeth may still be observed. The authors have stated explicitly that there are no conflicts of in-
This asymmetry may be detrimental from an aesthetic standpoint terest in connection with this article. Prof. Dr. Jan Cosyn has a col-
(Buser et al., 2004; Papaspyridakos et al., 2012). Therefore, cases laboration agreement with Nobel Biocare (Kloten, Switzerland) and
with mid-facial recession at the failing tooth are probably better Straumann (Basel, Switzerland).
treated with a staged approach (Seyssens et al., 2019).
Meta-analysis did not reveal a significant difference in terms of DATA AVA I L A B I L I T Y S TAT E M E N T
marginal bone level change between both treatment modalities (MD The authors confirm that the data supporting the findings of this
0.05 mm, 95% CI [−0.08; 0.18], p = .42). This contradicts a previ- study are available within this systematic review and its supple-
ous systematic review by Thoma et al. (2018) in which it was stated mentary tables and figures. Upon reasonable request, the Review
that interproximal bone levels may be more stable following IIP Manager 5.3® data file is available from the corresponding author
+ CTG. As proposed by Sanz et al. (2017), buccal socket grafting (LS).
was performed in all studies included in the present meta-analy-
sis (Migliorati et al., 2015; Yoshino et al., 2014; Zuiderveld et al., ORCID
2018). Therefore, data on MBL should be interpreted with caution Lorenz Seyssens https://orcid.org/0000-0002-1547-057X
as the baseline assessment is mainly related to the vertical level of Jan Cosyn https://orcid.org/0000-0001-5042-2875
the bone graft material.
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J Clinic Periodontology - 2020 - Seyssens - Immediate Implant Placement With or Without Connective Tissue Graft A

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J Clinic Periodontology - 2020 - Seyssens - Immediate Implant Placement With or Without Connective Tissue Graft A

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1600051x, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13397 by Hacettepe Universitesi, Wiley Online Library on [15/12/2022].

Immediate implant placement with or without connective

Lorenz Seyssens1 | Liesa De Lat1 | Jan Cosyn1,2

2.4 | Data extraction

PRISMA 2009 Flow Diagram

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The characteristics of included studies are reported in Table 2. Five

TA B L E 2 Characteristics of included studies

Bianchi and RCT IIP+CTG: 96/96 45.4 NR NR IIP+CTG: no IIP+CTG: NR

Flapless No. of patients/no.

Bianchi and Sanfilippo (2004) − + − + x −

height. Because of the difference in methodology and the fact that

3.5.4 | Pink aesthetic score

Two studies reported on the peri-implant aesthetic outcome by means

of the PES following immediate implant placement (Migliorati et al.,

The meta-analysis based on these RCTs pertained to 108 (IIP + CTG:

54, IIP: 54) immediately installed implants followed between 12 and

24 months (Migliorati et al., 2015; Zuiderveld et al., 2018), yet failed to

demonstrate a significant difference between IIP and IIP +CTG (MD

0.49, 95% CI [−1.23; 2.20], p = .58) (Figure 3). Considerable heteroge-

neity across studies was observed, given an I2 of 91% (p < .001).

3.5.5 | Marginal bone level change

Five studies reported on MBL change around immediately installed

2018; Yoshino et al., 2014; Zuiderveld et al., 2018). The meta-analysis

mediately installed implants followed between 12 and 24 months

failed to demonstrate a significant difference in MBL change between

Heterogeneity across studies was low, given an I2 of 0% (p = .69).

3.5.6 | Probing depth

Three studies reported on probing depth around immediately in-

stalled implants (Cornelini et al., 2008; Migliorati et al., 2015;

Zuiderveld et al., 2018), yet failed to demonstrate a significant dif-

95% CI [−0.24; 0.41], p = .61) (Figure 3). Moderate heterogeneity

3.5.7 | Bleeding on probing

Two studies reported on bleeding on probing around immediately

TA B L E 5 Outcomes of included studies

Vertical mid-facial soft tissue Horizontal mid-facial soft tissue

Bianchi and Sanfilippo (2004) NR IIP+CTG: 0%a NR

Rungcharassaeng et al. (2012) NR NR IIP + CTG: 0.43 (0.59)

Noelken et al. (2018) NR IIP+CTG: 10.5% NR

Note: Positive value = coronal advancement/buccal advancement.

Mesial papilla height Distal papilla height Marginal bone level

NR NR NR IIP+CTG: −0.7 (NR) IIP+CTG: 2.86 (NR) NR

NR NR NR IIP+CTG: −0.01 (0.27) NR NR

coronal soft tissue advancement following IIP + CTG, some dishar- C O N FL I C T O F I N T E R E S T

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