Sebastian Engelhardt* Annual failure rates and marginal

Petros Papacosta*
Florian Rathe
bone-level changes of immediate

lide Ozen
Ju compared to conventional loading of
John A. Jansen
Ru diger Junker dental implants. A systematic review
of the literature and meta-analysis

Authors affiliations:
Sebastian Engelhardt, Section Parodontologie, C1
Centre M
edico-Dentaire, Geneva, Switzerland
Petros Papacosta, Department of Implantology and
Periodontology, Radboud University Nijmegen
Medical Centre, Nijmegen, The Netherlands
Florian Rathe, Department of Prosthodontics and
Biomaterials, Danube Private University, Krems,
Austria
Private Practice, Forchheim, Germany
J
ulide Ozen, Department of Prosthetic Dentistry,
Private Dental Clinic, Aachen, Germany
John A. Jansen, Department of Biomaterials,
Radboud University Nijmegen Medical Centre,
Nijmegen, The Netherlands
Rudiger Junker, Department of Prosthodontics and
Biomaterials, Danube Private University, Krems,
Austria
Corresponding author:
Prof. Dr. R
udiger Junker
Department of Prosthodontics and Biomaterials
Danube Private University
Steiner Landstrae 124
A-3500 Krems, Austria
Tel.: +43 676 842 419 348
Fax: +43 2732 70478 7060
e-mail: Ruediger.Junker@Dp-Uni.ac.at
Key words: Boneimplant interactions, periodontology, prosthodontics, surgical techniques
Abstract
Background: Immediate loading of dental implants appears to be a successful option. Questions
still remain whether annual failure rates (AFRs) as well as annual marginal bone-level changes are
comparable with conventionally loaded implants.
Hypothesis: Immediately loaded implants (24 h after implantation) do not show different annual
survival rates or peri-implant bone-level changes as compared to conventionally loaded implants
(3 months after implantation).
Material and methods: An electronic search in the National Library of Medicine and in Cochrane
Central Register of Controlled Trials was performed for articles published up to November 2013.
Only publications in English were considered. Additionally, the bibliographies of the full-text
papers were searched. Primary outcome variable was percentage AFR; secondary outcome variable
was annual radiographic bone-level change.
Results: Electronic search yielded 154 full-text articles; ten randomized controlled clinical trials
were eventually meta-analyzed. Annual failure rates were 2.3% and 3.4% for conventionally and
immediately loaded implants, respectively. No difference in implant failure rates was found (RR:
0.82). Regarding marginal bone-level changes, the weighted mean difference (WMD) between
immediate and conventional loading amounted to 0.02 mm at 1 year (P > 0.05), to 0.08 mm at
2 years (P > 0.05), 0.10 mm at 3 years (P > 0.05) and 0.3 mm at 5 years (P < 0.05). The total
WMD for the combined follow-up was 0.01 mm (P > 0.05).
Conclusion: No clinically relevant differences regarding annual failure rates or radiographic bone-
level changes between conventionally and immediately loaded implants can be found for up to
5 years of follow-up.

*Both authors contributed equally.
Date:
Accepted 9 February 2014
To cite this article:
Engelhardt S, Papacosta P, Rathe F, Ozen J, Jansen JA, Junker
R. Annual failure rates and marginal bone-level changes of
immediate compared to conventional loading of dental
implants. A systematic review of the literature and meta-
analysis.
Clin. Oral Impl. Res. 26, 2015, 671687
doi: 10.1111/clr.12363
At present, replacing missing teeth by means
of dental implants has become a predictable
treatment option (Berglundh et al. 2002; Pje-
tursson et al. 2004). In the past, titanium
dental implants with a machined surface
were loaded after a submerged healing period
of 34 months in the mandible and 6
8 months in the maxilla (Branemark et al.
1977). For the reason that recently developed
and marketed dental implants enhance pri-
mary implant stability, earlier and even
immediate loading became an option (Esposi-
to et al. 2013). Moreover, early and even
more important in daily clinical implant den-
tistry immediate loading has been proven
successful (Esposito et al. 2013). However,
immediate loading is neither uniform nor
generally accepted. For example, in 2002
during the ITI Consensus Conference, imme-
diate loading was defined as loading on the
same day of implant placement (Aparicio
et al. 2003). Later on, in the course of the ITI
consensus conference in 2003, immediate
loading was extended to within 48 h after
implant placement (Cochran et al. 2004).
Thereafter, during the Consensus Conference
of the European Association for Osseointegra-
tion (EAO) in 2006, immediate loading was
defined as loading within 72 h after implant
installation (Nkenke & Fenner 2006). More
recently, for the purpose of a meta-analytical
approach to the literature, immediate loading
was prolonged to 1 week after implant place-
ment (Esposito et al. 2013).
Up to now, several meta-analyses regarding
the outcome of immediate loading of dental

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 671
Engelhardt et al
Immediate vs. conventional implant loading
implants have been published (Ioannidou &
Doufexi 2005; Atieh et al. 2009; Esposito
et al. 2013; Suarez et al. 2013). However,
methodological concerns do exist and ques-
tion their suitability for decision making in
routine, daily clinical practice (Ioannidou &
Doufexi 2005; Atieh et al. 2009; Esposito
et al. 2013 and Suarez et al. 2013). For exam-
ple, Esposito and coworkers defined immedi-
ate loading as loading within 1 week after
implant placement and included outcome
data of different time points in their meta-
analysis (Esposito et al. 2013). Accordingly,
the value of their findings is, for example,
challenged by loading the same day.
Because guided implant installation surgery
along with loading of prefabricated removable
as well as fixed dentures at the same time
point is becoming more and more attractive,
the aim of the current study was to meta-
analyze only randomized controlled clinical
trials (RCT) reporting at least 1-year outcome
data (i.e., survival rates and marginal bone-
level changes) on loading within 24 h after
implant placement as compared to conven-
tional loading (CL).
It was hypothesized that implant survival
rates as well as mean peri-implant bone-level
changes for loading at the day of implant
placement do not differ significantly from CL.
Material and methods
Outcome variables
The primary outcome variable was percent-
age annual failure rate (AFR).
The secondary outcome variable for imme-
diate loaded implants was radiographic bone-
level change between the day of implant
placement/loading and predefined follow-up
end points. Analogous the secondary out-
come variable for implants loaded after con-
ventional healing intervals was chosen.
Inclusion criteria
The following detailed inclusion criteria were
operated:
1. Only randomized controlled clinical trials
(RCTs);
2. For the test group, immediate loading
had to be defined as 24 h after implant
placement and both functional and non-
functional loading procedures were appli-
cable;
3. For the control group, CL had to be
defined as 3 months after implant place-
ment;
4. Number of subjects: 20;
5. Follow-up time: 1 year;
672 | Clin. Oral Impl. Res. 26, 2015 / 671687
6. Implant survival data had to be presented
clearly;
7. Marginal bone-level changes in terms of
mean  standard deviation (SD) had
either to be given or possible to be calcu-
lated according to the given data;
8. Standardized radiographs had to be used;
9. Both immediately and conventionally
loaded implants had to be restored with
fixed dental prosthesis;
10. Within each included trial, equal screw
form implants had to be compared under
two different loading protocols (i.e.,
immediate loading vs. CL).
Studies that did not meet all the above-
mentioned inclusion criteria were excluded.
Search strategy
An extensive electronic search in the databas-
es of the National Library of Medicine (http://
www.ncbi.nlm.nih.gov) and in Cochrane Cen-
tral Register of Controlled Trials (CENTRAL)
was carried out for articles published up to
November 2013. Only publications in English
were considered. The search strategy applied
in PubMed was as follows: (dental
implants[MeSH Terms] OR (dental[All
Fields] AND implants[All Fields]) OR den-
tal implants[All Fields]) OR ((mouth[MeSH
Terms] OR mouth[All Fields] OR oral[All
Fields]) AND implants[All Fields]) AND
(immediate[All Fields] AND loading[All
Fields]) OR (immediate[All Fields] AND resto-
ration[All Fields]) OR (immediate[All Fields]
AND functional[All Fields] AND loading[All
Fields]) OR (conventional[All Fields] AND
loading[All Fields]) OR (delayed[All Fields]
AND loading[All Fields]) OR (early[All Fields]
AND loading[All Fields]).
The search strategy applied in Cochrane
Central using the Search Manager was as fol-
lows:
#1 MeSH descriptor: [Dental Implants]
explode all trees
#2 MeSH descriptor: [Dental Implanta-
tion] explode all trees
#3 MeSH descriptor: [Immediate Dental
Implant Loading] explode all trees
#4 Conventional loading
#5 Delayed loading
#6 Early loading
#7 #1 or #2 and #3 or #4 or #5 or #6
Additionally, the reference lists of all
selected full-text articles were screened. No
hand search was performed.
Study selection and data extraction
Two independent reviewers (Sebastian Engel-
hardt [SE] and Petros Papacosta [PP]) initially
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
screened the publication titles and abstracts as
identified by the electronic search for possible
inclusion. Full texts of all papers which were
considered eligible for inclusion by one or both
of the reviewers were obtained for further
assessment against the stated inclusion crite-
ria (Fig. 1). Any disagreements between the
reviewers regarding inclusion of a certain pub-
lication or data extraction were resolved by
discussion. A data extraction form was used
by the reviewers to independently extract the
data from the selected full-text articles.
Risk of bias of the included articles
A risk of bias assessment was performed.
According to the Cochrane Risk of Bias Tool
(Higgins et al. 2009), the following aspects
were analyzed:
1. Sample size calculation performed
2. Adequate randomization procedure
3. Allocation concealment
4. Blinding of surgeon
5. Blinding of assessor
6. Incomplete outcome data adequately
addressed
Heterogeneity
For the purpose of the current meta-analysis,
heterogeneity was analyzed according to the
Cochrane Handbook for Systematic Reviews
(Deeks et al. 2008a). Heterogeneity was
detected using the chi-squared test, and its
possible impact on the meta-analysis was
quantified via I2. A large chi-squared statistic
with P < 0.1 was thought to prove substan-
tial heterogeneity. The influence of heteroge-
neity on the results was considered
substantial with an I2 exceeding 80%.
Statistical analysis
All analyses were performed using RevMan
(Review Manager [Computer program]. Ver-
sion 5.1. Copenhagen: The Nordic Cochrane
Centre, The Cochrane Collaboration, 2011).
Results
Study selection
The electronic search in the databases of the
National Library of Medicine and in Cochra-
ne Central Register of Controlled Trials
(CENTRAL) resulted in the identification of
12,380 and 2322 titles, respectively (Fig. 1).
As mentioned, these titles were initially
screened by two independent reviewers (SE
and PP) for possible inclusion, resulting in
further consideration of 582 publications in
PubMed and 169 publications in Cochrane
Central. Screening the abstracts led to 153
articles from PubMed considered for full-text
 Engelhardt et al
Immediate vs. conventional implant loading
Cochrane Central Register of
PubMed Controlled Trials (Central)
Titles Titles
12380 2322
Discarded titles Discarded titles
= 0.72 = 0.79
11798 2153
Abstracts Abstracts
582 169
Discarded abstracts Discarded abstracts
= 0.75 = 0.84
429 123
Discarded duplicates
45
Articles via screening
of the reference lists
7
Full-text articles
161
Pubmed: 153
Cochrane: 1
Screening: 7
Excluded articles
151
= 0.83 Pubmed: 144
Cochrane: 0
Screening: 7
Included articles
10
Fig. 1. Selection process.
evaluation and 46 articles from Cochrane 2009; Prosper et al. 2010), high in three pub-
Central, 45 of which were duplicates. Bibliog- lications (Hall et al. 2006; Donati et al. 2008;
raphy screening bared seven additional scien- De Rouck et al. 2009) and unclear for four
tific papers, and therefore, the total number papers (Danza et al. 2010; Shibly et al. 2010;
of full-text articles assessed was 161. Of Den Hartog et al. 2011; Margossian et al.
these, 151 full-text articles were not suitable 2012). The risk of bias appraisal is summa-
for inclusion and are detailed in the refer- rized in Table 3.
ences (Appendices 1, 2 and 3). 115 studies
were excluded as non-RCTs (Appendix 1), 27 Percentage annual failure rate
as RCTs not comparing immediate and CL as Up to the 1-year follow-up, 17 of 520 imme-
defined in inclusion criteria 2 and 3 (Appen- diately loaded implants were lost, resulting
dix 2). The reason(s) of exclusion for the in an AFR of 3.3%. Likewise, 6 of 365 con-
remaining nine RCTs are stated in Table 1 ventionally loaded implants were lost at the
(Appendix 3). 1-year follow-up (1.6%). Additionally, six
Eventually, 10 RCTs were eligible for implants were lost to follow-up (drop outs),
inclusion into the systematic review and are five conventionally and one immediately
summarized in Table 2. As mentioned loaded. Assuming that 50% of those implants
before, any disagreement between the review- were really lost, the calculated AFR was
ers regarding data extraction as well as data 2.3% for CL and 3.4% for IL.
interpretation was resolved by discussion. For immediately loaded implants and
Observers agreement (Cohens kappa coeffi- conventionally loaded implants, the AFRs at
cient) was calculated for each step of the the 2nd, 3rd and 5-year interval were 0%
selection process (Fig. 1). (Table 4).
Additionally, a meta-analysis for relative
Risk of bias in included studies risk was performed for seven studies (Hall
The estimated overall risk of bias was low in et al. 2006; Donati et al. 2008; De Rouck
three articles (Crespi et al. 2008; Degidi et al. et al. 2009; Prosper et al. 2010; Shibly et al.
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
2010; den Hartog et al. 2011; Margossian
et al. 2012) after excluding the studies with-
out implant failures in any of the groups
(Crespi et al. 2008; Degidi et al. 2009; Danza
et al. 2010). The analysis revealed a risk
ratio of 0.82 (95% CI: 0.351.94, P > 0.05) for
CL, with no statistically significant differ-
ence between the two loading protocols
(Fig. 2).
Bone-level changes
Regarding the outcome variable marginal
bone-level change, the overall weighted mean
differences (WMD) between immediately
loaded and conventionally loaded implants
for all 10 included studies did not reveal any
statistically significant differences.
The WMD between immediately loaded
and conventionally loaded implants was
0.02 mm after the first year (95% CI: 0.07
to 0.11 mm; P > 0.05), 0.08 mm after the sec-
ond year (95% CI: 0.01 to 0.17 mm;
P > 0.05) and 0.10 mm after the third year
(95% CI: 0.44 to 0.24 mm; P > 0.05). A sta-
tistically significant difference of 0.30 mm
was found in favor of CL at 5th year time
interval (95% CI: 0.49 to 0.11 mm;
P < 0.05). All in all, the WMD for the 1st,
2nd, 3rd and 5th year of follow-up was
0.01 mm (95% CI: 0.05 to 0.08 mm;
P > 0.05) and not statistically significant
(Fig. 3).
Additionally, subsection analyses have
been performed depending on two variables,
the loading protocol applied for immediate
loading group (functional or non-functional
loading) and the implantation site (healed
bone or fresh extraction site). The study of
Margossian et al. 2012 was used for both
immediate functional and non-functional
loading subsection analyses.
The first subgroup analysis with regard to
immediate functional loaded implants
(Crespi et al. 2008; Donati et al. 2008; Danza
et al. 2010; Prosper et al. 2010; Shibly et al.
2010; Margossian et al. 2012) revealed no
statistically significant difference at 1 and
2 years of follow-up. The WMD at 1 year
between immediately functional vs. CL
amounted to 0.04 mm (95% CI: 0.08 to
0.16 mm; P > 0.05) and 0.11 mm for 2-year
interval (95% CI: 0.00 to 0.21 mm; P > 0.05).
The WMD was found to be statistically sig-
nificant for 5 years of follow-up and resulted
to 0.30 (95% CI: 0.49 to 0.11 mm;
P < 0.05) in favor of CL. The overall WMD
for the 1st, 2nd and 5th year of follow-up was
0.03 mm (95% CI: 0.06 to 0.12 mm;
P > 0.05) and not statistically significant
(Fig. 4).
673 | Clin. Oral Impl. Res. 26, 2015 / 671687
Engelhardt et al
Immediate vs. conventional implant loading
Table 1. Excluded randomized controlled trials (RCTs) with reasons
Interventions and
Publication comparisons
Degidi et al. Comparative analysis of
(2009) immediate functional
loading and immediate
non-functional loading
to traditional
(conventional) healing
periods
Romanos & Immediate vs. delayed
Nentwig functional loading in the
(2006) posterior mandible;
split-mouth design
Schincaglia Comparison of single
et al. (2008) implant-supported
mandibular molar
restorations using
either an immediate
functional or a delayed
loading protocol
Oh et al. Immediate functional
(2006) loading (same day)
with conventional
loading (4 months)
in the maxilla
(anterior and
premolar regions)
Gu ncu
et al. Immediate functional
(2008) and conventional
loading in mandibular
molar sites; split-mouth
design
Elsyad et al. Immediate and
(2012) conventional loading
of two unsplinted
implants supporting
mandibular overdentures
Meloni et al. Immediate non-
(2012) functional and
conventional loading
of single mandibular
molars; split-mouth
design
Hall et al. Immediate non-
(2007) functional and
(follow-up of conventional loading
the of single implants in
included the anterior maxilla
article
Hall et al.
2006)
Jokstad & Immediate and
Alkumru conventional loading
(2013) of four implants in
edentulous mandibles
supporting 1012 unit
FDP
MBL, marginal bone level; SD, standard deviation; FDP, fixed dental prosthesis.
The subgroup analysis comparing immedi-
ate non-functional to CL (Hall et al. 2006;
De Rouck et al. 2009; Degidi et al. 2009;
den Hartog et al. 2011; Margossian et al.
2012) resulted in no statistically significant
674 | Clin. Oral Impl. Res. 26, 2015 / 671687
Test group
264 implants were
inserted in 82 patients
with immediate functional
loading (if completely
edentulous) or immediate
non-functional loading (if
partially edentulous) within
a few hours after surgery
Immediate functional
loading of 36 implants in
12 patients directly after
implant placement
Immediate functional
loading of 15 implants
within 24 h
Immediate functional
loading of 12 implants in
12 patients directly after
implant placement
Immediate functional
loading of 12 single crowns
on 12 patients on the same
day of the surgery
Immediate loading of 30
implants in 15 patients in
the same day
Immediate non-functional
loading of 20 implants in
20 patients within 24 h of
implant placement
Immediate non-functional
loading of 14 implants in
14 patients within 4 h of
implant placement
Immediate loading of four
implants in the
interforaminal region with
1012 unit FDP on the same
day of implant placement
difference between the analyzed loading pro-
tocols at any time interval. The WMD for
the 1st, 2nd and 3rd year of follow-up was
0.00 mm (95% CI: 0.06 to 0.07 mm;
P > 0.05), 0.05 mm (95% CI:
Reason(s) for
Control group Radiographic analysis exclusion
286 implants inserted in Intraoral; non- Non-standardized
73 patients with a standardized radiographs; Mean MBL
one-stage or two-stage changes without
surgical procedure and SD; both implant-
conventionally loaded supported removable
and fixed prostheses
were used
Conventional loading of Orthopantomography; Number of
36 implants in 12 patients (12); non-
patients 3 months after non-standardized standardized + extra
implant placement oral radiographs; MBL
changes not in terms of
mean  SD; survival
data not clearly
presented
Conventional loading of Intraoral; non- No standardized x-rays
15 implants after standardized
34 months
Conventional loading of Not performed No radiographic
12 implants in 12 analysis
patients 4 months after
implant placement
Conventional loading of Intraoral; non- Number of patients (12);
12 single crowns in 12 standardized non-standardized
patients 3 months after radiographs
implant placement
Conventional loading of Extra oral, computer Removable prostheses
30 implants in 15 tomography (CT);
patients 3 months after standardized
implant placement
Conventional loading of Intraoral; non- Non-standardized
20 implants in 20 standardized radiographs
patients 45 months
after implant placement
Conventional loading of Intraoral; standardized Implant survival data are
14 implants in 14 not reported (refers to
patients 26 weeks after Hall et al. 2006)
implant placement
Conventional loading of Intraoral; non- Implant survival data not
four implants in the standardized clearly presented;
interforaminal region at implant placement; non-standardized
with 1012 unit FDP standardized at radiographs at implant
34 months after 34 months placement for the
implant placement after implant placement immediate loading
(baseline) up to 5 years group
of follow-up
0.12 mm; P > 0.05) and 0.10 mm (95% CI:
0.44 to 0.24 mm; P > 0.05), respectively.
The overall WMD amounted to 0.02 mm
(95% CI: 0.03 to 0.07 mm; P > 0.05)
0.02 to (Fig. 5).
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Engelhardt et al
Immediate vs. conventional implant loading

Table 2. Characteristics of studies included in meta-analysis

Loading
protocol Implantation
Number of implants Implant loss* in site (healed
immediate or fresh
No. of Follow-up loading extraction
Study patients (months) Total CL IL CL IL group sites)
Crespi et al. (2008) 40 24 40 20 20 0 0 IFL FES
Danza et al. (2010) 25 12 40 20 20 0 0 IFL HS
De Rouck et al. 49 12 49 25 24 2 1 INFL FES
(2009)
Degidi et al. (2009) 60 36 60 30 30 0 0 INFL HS
den Hartog et al. 62 18 62 31 31 0 1 INFL HS
(2011)
Donati et al. (2008) 149 12 159 57 102 0 (2) 4 IFL HS
Hall et al. (2006) 28 12 28 14 14 0 (2) 1 INFL HS
Margossian et al. 117 24 307 98 209 0 7 INFL HS
(2012) and IFL
Prosper et al. (2010) 71 60 120 60 60 2 2 IFL FES
Shibly et al. (2010) 60 24 60 30 30 2 (1) 1 (1) IFL FES

CL, conventional loading; IL, immediate loading; IFL, immediate functional loading; INFL, immediate non-functional loading; FES, fresh extraction sites; HS,
healed sites.
*
In parenthesis is the number of implants lost to follow-up.

Implantation sites are in each study the same for both CL and IL groups.

All failures occurred in the IFL group.

Two IL groups: INFL = 104 implants, IFL = 105 implants.

Table 3. Risk of bias analysis

Allocation
concealment: Incomplete Sample size
Random sequence adequate/ Blinding Blinding outcome calculation
generation: inadequate/ of surgeon: of examiner: data adequately performed: Estimated overall
yes/no/unclear unclear yes/no/unclear yes/no/unclear reported: yes/no yes/no risk of bias
Hall et al. (2006) + High
Crespi et al. (2008) + + + + + Low
Donati et al. (2008) + + + High
Degidi et al. (2009) + + + + + + Low
De Rouck et al. (2009) + + + High
Danza et al. (2010) + + + + + Unclear
Prosper et al. (2010) + + + + + Low
Shibly et al. (2010) + + + + + Unclear
den Hartog et al. (2011) + + + + Unclear
Margossian et al. (2012) + + + Unclear

+, yes/adequate; , no/inadequate; , unclear.

The third subgroup analysis compared
immediate to CL when implantation was per-
formed in fresh extraction sites (Crespi et al.
2008; De Rouck et al. 2009; Prosper et al.
2010; Shibly et al. 2010). Statistically signifi-
cant differences were found at the 2nd and 5-
year interval revealing a WMD of 0.18 mm
(95% CI: 0.06 to 0.30 mm; P < 0.05) in favor of
immediate loading and 0.30 mm (95% CI:
0.49 to 0.11 mm; P < 0.05) in favor of CL,
respectively. The WMD for 1-year follow-up
was 0.09 mm (95% CI: 0.15 to 0.33 mm;
P > 0.05), while the total amount was
0.05 mm (95% CI: 0.12 to 0.21 mm; P > 0.05)
and not statistically significant (Fig. 6).
The last subsection analysis of studies
where implantation had been carried out in
healed sites for both groups (Hall et al. 2006;
Donati et al. 2008; Degidi et al. 2009; Danza
et al. 2010; den Hartog et al. 2011; Margos-
sian et al. 2012) showed an overall WMD of
0.01 mm (95% CI: 0.03 to 0.05 mm;
P > 0.05), which was not statistically signifi-
cant. The same applied for the examined
time intervals: 0.01 mm at 1 year (95% CI:
0.06 to 0.05 mm; P > 0.05), 0.04 mm at
2 years (95% CI: 0.02 to 0.10 mm; P > 0.05)
and 0.10 mm at 3 years (95% CI: 0.44 to
0.24 mm; P > 0.05) (Fig. 7).
Heterogeneity
Statistical heterogeneity was found across all
ten included studies [s2 = 0.01; v2 = 54.21,
df = 14 (P < 0.00001); I2 = 74%]. Conse-
quently, the random-effect model was chosen
for meta-analysis. Heterogeneity was induced
by various parameters that differ within the
analyzed studies.
As shown in Table 2, immediate functional
and non-functional loading protocols were
applied and both healed and non-healed sites
were used in the included investigations.
Bone augmentation procedures were used
extensively in one case (Shibly et al. 2010),
not at all in five studies (Crespi et al. 2008;
Donati et al. 2008; Degidi et al. 2009; Danza
et al. 2010; Prosper et al. 2010), to fill the
jumping gap in case of immediate implant
placement or to cover implant dehiscences/
fenestrations in three studies (Hall et al.
2006; De Rouck et al. 2009; den Hartog
et al. 2011) and not clearly mentioned if
used or not in one study (Margossian et al.
2012). The approach by Shibly et al. (2010)
resulted in radiographic marginal bone-level
gain at both the conventionally and immedi-
ately loaded implants at one and 2 years of

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 675 | Clin. Oral Impl. Res. 26, 2015 / 671687
Engelhardt et al
Immediate vs. conventional implant loading

Table 4. Annual failure rates (AFR,%) Additionally, den Hartog et al. (2011) per-
No. of implants Implants lost AFR (%) formed clinical and radiographic evaluation
at either 6 or 18 months post-op. Therefore,
Years CL IL CL IL CL IL
the 1-year results correspond to 18 months of
1 365 520 8.5* 17.5 2.3 3.4 follow-up for both immediate and CL.
2 175 280 0 0 0 0
3 30 30 0 0 0 0
Immediate loading was compared to CL
5 58 58 0 0 0 0 varying from 3 months (Crespi et al. 2008;
Donati et al. 2008; De Rouck et al. 2009;
CL, conventional loading.
*
In total, six implants were clinically lost and five implants were lost to follow-up. The review team Prosper et al. 2010; den Hartog et al. 2011),
assumed that 50% of the implants lost to follow-up were really failures, and subsequently, 8.5 4 months (Shibly et al. 2010), 5 months
implants were considered to be lost. (Margossian et al. 2012), to around 6 months

In total, 17 implants were clinically lost and one implant was lost to follow-up. Following the
assumption of 50% loss, 17.5 implants were considered to be lost.
(Hall et al. 2006; Degidi et al. 2009) after
implantation. Danza et al. (2010) loaded after
3 months in the mandible and 6 months for
follow-up. In contrast, all remaining articles (2010). It was interpreted by the authors of the maxilla. Furthermore, CL was performed
found marginal bone-level loss. this review as time of loading. In principle, as either one-stage procedure (Degidi et al.
All but two studies clearly defined base- implant placement and loading time points 2009; Prosper et al. 2010; Margossian et al.
line as the time of implant placement. De coincide with respect to immediate loading 2012) or two-stage procedure (Hall et al.
Rouck et al. (2009) determined baseline as within 24 h, and consequently, any heteroge- 2006; Crespi et al. 2008; Donati et al. 2008;
time of loading, while the definition is not neity emanating from baseline time De Rouck et al. 2009; Danza et al. 2010;
very accurate in the study of Danza et al. point discrepancies is only related to CL. Shibly et al. 2010; den Hartog et al. 2011).

(a)
Conventional loading (CL) Immediate loading (IL) Risk ratio Risk ratio
Study or subgroup Events Total Events Total Weight IV, Random, 95% CI IV, Random, 95% CI
De Rouck et al. (2009) 2 25 1 24 13.4% 1.92 [0.19, 19.82]
den Hartog et al. (2011) 0 31 1 31 7.3% 0.33 [0.01, 7.88]
Donati et al. (2008) 1 57 4 102 15.6% 0.45 [0.05, 3.91]
Hall et al. (2006) 1 14 1 14 10.2% 1.00 [0.07, 14.45]
Margossian et al. (2012) 0 98 7 209 9.0% 0.14 [0.01, 2.45]
Prosper et al. (2010) 2 60 2 60 19.7% 1.00 [0.15, 6.87]
Shibly et al. (2010) 3 30 2 30 24.8% 1.50 [0.27, 8.34]

Total (95% CI) 315 470 100.0% 0.82 [0.35, 1.94]

Total events 9 18
Heterogeneity: 2 = 0.00; 2 = 3.12, df = 6 (P = 0.79); I 2 = 0%
Test for overall effect: Z = 0.44 (P = 0.66) 0.005 0.1 1 10 200
Favours CL Favours IL

(b)
SE (log[RR])
0

0.5

1.5

RR
2
0.005 0.1 1 10 200

Fig. 2. (a) Forest plot for implant failures regarding conventional loading (CL) vs. immediate loading*. (b) Funnel plot for implant failures regarding CL vs. immediate loading.
*Shibly et al. (2010) had one drop out in each group, and therefore, implant loss should be 2.5 for the CL group and 1.5 for the IL group. Decimal numbers could not be used for
the analysis, and hence, the worst scenario was chosen.

676 | Clin. Oral Impl. Res. 26, 2015 / 671687 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Engelhardt et al
Immediate vs. conventional implant loading

(a)
Conventional loading (CL) Immediate loading (IL) Mean difference Mean difference
Study or subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.1.1 1 year data
Danza et al. (2010) 0.38 0.21 20 0.44 0.22 20 8.5% 0.06 [0.19, 0.07]
De Rouck et al. (2009) 0.97 0.35 23 0.86 0.54 23 4.4% 0.11 [0.15, 0.37]
Degidi et al. (2009) 0.58 0.28 30 0.69 0.38 30 7.1% 0.11 [0.28, 0.06]
den Hartog et al. (2011) 0.9 0.57 31 0.91 0.61 30 3.8% 0.01 [0.31, 0.29]
Donati et al. (2008) 0.38 0.89 55 0.29 1 98 3.6% 0.09 [0.22, 0.40]
Hall et al. (2006) 0.78 1.9 12 0.64 1.36 12 0.3% 0.14 [1.18, 1.46]
Margossian et al. (2012) 0.98 0.27 98 0.96 0.3 202 11.2% 0.02 [0.05, 0.09]
Prosper et al. (2010) 0.17 0.11 58 0.24 0.12 58 11.9% 0.07 [0.11, 0.03]
Shibly et al. (2010) 0.75 0.17 24 0.99 0.22 25 9.5% 0.24 [0.13, 0.35]
Subtotal (95% CI) 351 498 60.3% 0.02 [0.07, 0.11]
Heterogeneity: 2 = 0.01; 2 = 31.27, df = 8 (P = 0.0001); I2 = 74%
Test for overall effect: Z = 0.43 (P = 0.67)

1.1.2 2 year data

Crespi et al. (2008) 1.16 0.51 20 1.02 0.53 20 3.3% 0.14 [0.18, 0.46]
Degidi et al. (2009) 0.7 0.3 30 0.73 0.39 30 6.9% 0.03 [0.21, 0.15]
Margossian et al. (2012) 1.33 0.25 98 1.28 0.29 202 11.3% 0.05 [0.01, 0.11]
Shibly et al. (2010) 1 0.2 24 1.19 0.26 25 8.7% 0.19 [0.06, 0.32]
Subtotal (95% CI) 172 277 30.2% 0.08 [0.01, 0.17]
Heterogeneity: 2 = 0.00; 2 = 5.09, df = 3 (P = 0.17); I2 = 41%
Test for overall effect: Z = 1.73 (P = 0.08)

1.1.3 3 year data

Degidi et al. (2009) 0.75 0.63 30 0.85 0.71 30 3.1% 0.10 [0.44, 0.24]
Subtotal (95% CI) 30 30 3.1% 0.10 [0.44, 0.24]
Heterogeneity: Not applicable
Test for overall effect: Z = 0.58 (P = 0.56)

1.1.4 5 year data

Prosper et al. (2010) 1.01 0.59 58 1.31 0.44 58 6.4% 0.30 [0.49, 0.11]
Subtotal (95% CI) 58 58 6.4% 0.30 [0.49, 0.11]
Heterogeneity: Not applicable
Test for overall effect: Z = 3.10 (P = 0.002)

Total (95% CI) 611 863 100.0% 0.01 [0.05, 0.08]

Heterogeneity: 2 = 0.01; 2 = 54.21, df = 14 (P < 0.00001); I2 = 74%
Test for overall effect: Z = 0.40 (P = 0.69) 1 0.5 0 0.5 1
Test for sub group differences: 2 = 13.02 , df = 3 (P = 0.005), I2 = 77.0% Favours CL Favours IL

(b)
SE (MD)
0

0.2

0.4

0.6

0.8

MD
1
1 0.5 0 0.5 1
Subgroups
1 year data 2 year data 3 year data 5 year data

Fig. 3. (a) Forest plot for marginal bone-level changes (all nine studies included). (b) Funnel plot for marginal bone-level changes (all nine studies included).

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 677 | Clin. Oral Impl. Res. 26, 2015 / 671687
Engelhardt et al
Immediate vs. conventional implant loading

(a) Conventional loading (CL) Immediate loading (IL) Mean difference Mean difference
Study or subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.6.1 1 year data
Danza et al. (2010) 0.38 0.21 20 0.44 0.22 20 11.7% 0.06 [0.19, 0.07]
Donati et al. (2008) 0.38 0.89 55 0.29 1 98 5.7% 0.09 [0.22, 0.40]
Margossian et al. (2012) 0.98 0.27 98 0.95 0.31 97 13.9% 0.03 [0.05, 0.11]
Prosper et al. (2010) 0.17 0.11 58 0.24 0.12 58 15.1% 0.07 [0.11, 0.03]
Shibly et al. (2010) 0.75 0.17 24 0.99 0.22 25 12.8% 0.24 [0.13, 0.35]
Subtotal (95% CI) 255 298 59.2% 0.04 [0.08, 0.16]
Heterogeneity: 2 = 0.01; 2 = 29.28, df = 4 (P < 0.00001); I2 = 86%
Test for overall effect: Z = 0.61 (P = 0.54)

1.6.2 2 year data

Crespi et al. (2008) 1.16 0.51 20 1.02 0.53 20 5.3% 0.14 [0.18, 0.46]
Margossian et al. (2012) 1.33 0.25 98 1.28 0.28 97 14.2% 0.05 [0.02, 0.12]
Shibly et al. (2010) 1 0.2 24 1.19 0.26 25 11.9% 0.19 [0.06, 0.32]
Subtotal (95% CI) 142 142 31.4% 0.11 [0.00, 0.21]
Heterogeneity: 2 = 0.00; 2 = 3.48, df = 2 (P = 0.18); I2 = 42%
Test for overall effect: Z = 2.02 (P = 0.04)

1.6.3 5 year data

Prosper et al. (2010) 1.01 0.59 58 1.31 0.44 58 9.4% 0.30 [0.49, 0.11]
Subtotal (95% CI) 58 58 9.4% 0.30 [0.49, 0.11]
Heterogeneity: Not applicable
Test for overall effect: Z = 3.10 (P = 0.002)

Total (95% CI) 455 498 100.0% 0.03 [0.06, 0.12]

Heterogeneity: = 0.01; = 50.97, df = 8 (P < 0.00001); I = 84%
2 2 2
0.5 0.25 0 0.25 0.5
Test for overall effect: Z = 0.67 (P = 0.50)
Favours CL Favours IL
Test for subgroup differences: 2 = 13.75, df = 2 (P = 0.001), I2 = 85.5%

(b)
SE (MD)
0

0.05

0.1

0.15

MD
0.2
0.5 0.25 0 0.25 0.5
Subgroups
1 year data 2 year data 5 year data

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

The anatomical region of implant place- quality. In five articles (Hall et al. 2006; Crespi placed in the maxilla, in two studies (Prosper
ment also varied between the analyzed arti- et al. 2008; De Rouck et al. 2009; Degidi et al. et al. 2010; Margossian et al. 2012) in the
cles, which is in turn correlated with bone 2009; den Hartog et al. 2011), implants were mandible and in three studies (Donati et al.

678 | Clin. Oral Impl. Res. 26, 2015 / 671687 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Engelhardt et al
Immediate vs. conventional implant loading

(a)
Conventional loading (CL) Immediate loading (IL) Mean difference Mean difference
Study or subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.5.1 1 year data
De Rouck et al. (2009) 0.97 0.35 23 0.86 0.54 23 3.2% 0.11 [0.15, 0.37]
Degidi et al. (2009) 0.58 0.28 30 0.69 0.38 30 7.9% 0.11 [0.28, 0.06]
den Hartog et al. (2011) 0.9 0.57 31 0.91 0.61 30 2.6% 0.01 [0.31, 0.29]
Hall et al. (2006) 0.78 1.9 12 0.64 1.36 12 0.1% 0.14 [1.18, 1.46]
Margossian et al. (2012) 0.98 0.27 98 0.96 0.29 105 37.9% 0.02 [0.06, 0.10]
Subtotal (95% CI) 194 200 51.7% 0.00 [0.06, 0.07]
Heterogeneity: 2 = 0.00; 2 = 2.59, df = 4 (P = 0.63); I2 = 0%
Test for overall effect: Z = 0.14 (P = 0.89)

1.5.2 2 year data

Degidi et al. (2009) 0.7 0.3 30 0.73 0.39 30 7.2% 0.03 [0.21, 0.15]
Margossian et al. (2012) 1.33 0.25 98 1.27 0.3 105 39.1% 0.06 [0.02, 0.14]
Subtotal (95% CI) 128 135 46.4% 0.05 [0.02, 0.12]
Heterogeneity: 2 = 0.00; 2 = 0.85, df = 1 (P = 0.36); I2 = 0%
Test for overall effect: Z = 1.29 (P = 0.20)

1.5.3 3 year data

Degidi et al. (2009) 0.75 0.63 30 0.85 0.71 30 1.9% 0.10 [0.44, 0.24]
Subtotal (95% CI) 30 30 1.9% 0.10 [0.44, 0.24]
Heterogeneity: Not applicable
Test for overall effect: Z = 0.58 (P = 0.56)

Total (95% CI) 352 365 100.0% 0.02 [0.03, 0.07]

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

0.5 0.25 0 0.25 0.5

Test for overall effect: Z = 0.90 (P = 0.37)
Favours CL Favours IL
Test for subgroup differences: 2 = 1.22, df = 2 (P = 0.54), I2 = 0%

(b)
SE (MD)
0

0.2

0.4

0.6

0.8

MD
1
0.5 0.25 0 0.25 0.5
Subgroups
1 year data 2 year data 3 year data

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

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 679 | Clin. Oral Impl. Res. 26, 2015 / 671687
Engelhardt et al
Immediate vs. conventional implant loading

(a)
Conventional loading (CL) Immediate loading (IL) Mean difference Mean difference
Study or subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.4.1 1 year data
De Rouck et al. (2009) 0.97 0.35 23 0.86 0.54 23 13.7% 0.11 [0.15, 0.37]
Prosper et al. (2010) 0.17 0.11 58 0.24 0.12 58 20.6% 0.07 [0.11, 0.03]
Shibly et al. (2010) 0.75 0.17 24 0.99 0.22 25 19.1% 0.24 [0.13, 0.35]
Subtotal (95% CI) 105 106 53.4% 0.09 [0.15, 0.33]
Heterogeneity: 2 = 0.04; 2 = 27.79, df = 2 (P < 0.00001); I2 = 93%
Test for overall effect: Z = 0.71 (P = 0.48)

1.4.2 2 year data

Crespi et al. (2008) 1.16 0.51 20 1.02 0.53 20 11.6% 0.14 [0.18, 0.46]
Shibly et al. (2010) 1 0.2 24 1.19 0.26 25 18.5% 0.19 [0.06, 0.32]
Subtotal (95% CI) 44 45 30.2% 0.18 [0.06, 0.30]
Heterogeneity: 2 = 0.00; 2 = 0.08, df = 1 (P = 0.78); I2 = 0%
Test for overall effect: Z = 2.98 (P = 0.003)

1.4.3 5 year data

Prosper et al. (2010) 1.01 0.59 58 1.31 0.44 58 16.4% 0.30 [0.49, 0.11]
Subtotal (95% CI) 58 58 16.4% 0.30 [0.49, 0.11]
Heterogeneity: Not applicable
Test for overall effect: Z = 3.10 (P = 0.002)

Total (95% CI) 207 209 100.0% 0.05 [0.12, 0.21]

Heterogeneity: = 0.03; = 47.36, df = 5 (P < 0.00001); I = 89%
2 2 2

0.5 0.25 0 0.25 0.5

Test for overall effect: Z = 0.58 (P = 0.56)
Favours CL Favours IL
Test for subgroup differences: 2 = 17.91, df = 2 (P = 0.0001), I2 = 88.8%

(b)
SE (MD)
0

0.05

0.1

0.15

MD
0.2
0.5 0.25 0 0.25 0.5
Subgroups
1 year data 2 year data 5 year data

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

680 | Clin. Oral Impl. Res. 26, 2015 / 671687 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Engelhardt et al
Immediate vs. conventional implant loading

(a)
Conventional loading (CL) Immediate loading (IL) Mean difference Mean difference
Study or subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.3.1 1 year data
Danza et al. (2010) 0.38 0.21 20 0.44 0.22 20 9.1% 0.06 [0.19, 0.07]
Degidi et al. (2009) 0.58 0.28 30 0.69 0.38 30 5.6% 0.11 [0.28, 0.06]
den Hartog et al. (2011) 0.9 0.57 31 0.91 0.61 30 1.8% 0.01 [0.31, 0.29]
Donati et al. (2008) 0.38 0.89 55 0.29 1 98 1.7% 0.09 [0.22, 0.40]
Hall et al. (2006) 0.78 1.9 12 0.64 1.36 12 0.1% 0.14 [1.18, 1.46]
Margossian et al. (2012) 0.98 0.27 98 0.96 0.3 202 35.3% 0.02 [0.05, 0.09]
Subtotal (95% CI) 246 392 53.6% 0.01 [0.06, 0.05]
Heterogeneity: 2 = 0.00; 2 = 3.08, df = 5 (P = 0.69); I2 = 0%
Test for overall effect: Z = 0.21 (P = 0.84)

1.3.2 2 year data

Degidi et al. (2009) 0.7 0.3 30 0.73 0.39 30 5.2% 0.03 [0.21, 0.15]
Margossian et al. (2012) 1.33 0.25 98 1.28 0.29 202 39.8% 0.05 [0.01, 0.11]
Subtotal (95% CI) 128 232 45.0% 0.04 [0.02, 0.10]
Heterogeneity: 2 = 0.00; 2 = 0.70, df = 1 (P = 0.40); I2 = 0%
Test for overall effect: Z = 1.33 (P = 0.18)

1.3.3 3 year data

Degidi et al. (2009) 0.75 0.63 30 0.85 0.71 30 1.4% 0.10 [0.44, 0.24]
Subtotal (95% CI) 30 30 1.4% 0.10 [0.44, 0.24]
Heterogeneity: Not applicable
Test for overall effect: Z = 0.58 (P = 0.56)

Total (95% CI) 404 654 100.0% 0.01 [0.03, 0.05]

Heterogeneity: 2 = 0.00; 2 = 5.48, df = 8 (P = 0.71); I2 = 0%
0.5 0.25 0 0.25 0.5
Test for overall effect: Z = 0.67 (P = 0.50)
Favours CL Favours IL
Test for subgroup differences: 2 = 1.70, df = 2 (P = 0.43), I2 = 0%

(b)
SE (MD)
0

0.2

0.4

0.6

0.8

MD
1
0.5 0.25 0 0.25 0.5
Subgroups
1 year data 2 year data 3 year data

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

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 681 | Clin. Oral Impl. Res. 26, 2015 / 671687
Engelhardt et al
Immediate vs. conventional implant loading
2008; Danza et al. 2010; Shibly et al. 2010) in
both maxilla and mandible. Additional varia-
tion exists in relation to posterior and anterior
maxilla and mandible regions.
Lastly, considerable variation between the
studies became obvious concerning implant
systems, implant diameter, implant length
and implant configuration. All studies used
rough-surfaced implants, and the minimal
insertion torque ranged from 20 Ncm (Donati
et al. 2008) to 45 Ncm (den Hartog et al.
2011) with the remaining studies adopting a
value in between. In two studies (Hall et al.
2006; Prosper et al. 2010), the insertion
torque value is not mentioned or recorded.
Furthermore, the implant stability quotient
(ISQ) values are only mentioned in three
studies (Crespi et al. 2008; Degidi et al. 2009;
Margossian et al. 2012) as more than 60.
Discussion
The objective of the present study was to
meta-analyze exclusively RCTs reporting at
least 1-year outcome data on loading within
24 h after implant placement as compared to
CL. The H0-hypotheses of no significant dif-
ferences regarding implant survival rates and
mean peri-implant bone-level changes for the
two loading protocols were not rejected.
The reported implant failure rates are in
line with other reviews (Ioannidou & Doufexi
2005; Atieh et al. 2009; Alsabeeha et al.
2010; den Hartog et al. 2011; Esposito et al.
2013).
For the purpose of this review, the two
immediate loading groups (functional and
non-functional loading) in the study of Mar-
gossian et al. (2012) were statistically com-
bined in terms of AFRs and marginal bone-
level changes.
However, in the present review, the prob-
lem of missing data has to be addressed.
Shibly et al. (2010) had a dropout of two
References
Alsabeeha, N., Atieh, M. & Payne, A.G. (2010)
Loading protocols for mandibular implant over-
dentures: a systematic review with meta-analysis.
Clinical Implant Dentistry & Related Research
12(Suppl. 1): e28e38.
Aparicio, C., Rangert, B. & Sennerby, L. (2003)
Immediate/early loading of dental implants: a
report from the Sociedad Espanola de Implantes
World Congress consensus meeting in Barcelona,
Spain, 2002. Clinical Implant Dentistry &
Related Research 5: 5760.
Atieh, M.A., Atieh, A.H., Payne, A.G. & Duncan,
W.J. (2009) Immediate loading with single
implant crowns: a systematic review and
682 | Clin. Oral Impl. Res. 26, 2015 / 671687
patients, and there was no information which
group they had been allocated to. To com-
pensate for this lack, the review team
decided to equally distribute the dropout
implants within the groups (one implant in
the immediate loading group, one implant in
the conventionally loading group) and
assumed that one of the two implants was a
failure (see Table 2). Looking at survival rates
in the literature, this assumption is rather
generous in favor of implant failures. An
alternative option would be a sensitivity
analysis (Deeks et al. 2008b), meaning that
for each implant in each group a best case
and a worst case scenario are calculated to
evaluate possible influence on statistical out-
come. This would (assuming that all
dropped-out implants survived) decrease the
AFR for CL from 2.3% to 1.6% or increase
the AFR (assuming the opposite) for immedi-
ate loading from 2.3% to 3.0%. Both of these
(very hypothetical) results are still in the
range of failure rates given in the current
literature.
Despite methodological dissimilarities, the
currently found differences between immedi-
ate loading and CL with regard to marginal
bone-level changes over time are in clinical
terms in line with other meta-analytical
approaches to the literature (Atieh et al.
2009; Esposito et al. 2013; Suarez et al.
2013). Esposito et al. (2013) found a clinically
irrelevant difference of 0.1 mm, Atieh et al.
(2010) of 0.31 mm and Suarez et al. (2013) of
0.09 mm favoring immediate loading. Note-
worthy in the current review with reference
to MBL changes are the missing data in one
study (Shibly et al. 2010) where 11 of 60
implants were not radiographically analyzed,
and their group allocation was not stated.
Therefore, the missing data were distributed
within the groups (five implants in IL group,
six in CL group). The statistical significance
did not change after reversing the numbers.
meta-analysis. The International Journal of Pros-
thodontics 22: 378387.
Atieh, M.A., Payne, A.G., Duncan, W.J., de Silva, R.K.
& Cullinan, M.P. (2010) Immediate placement or
immediate restoration/loading of single implants
for molar tooth replacement: a systematic review
and meta-analysis. The International Journal of
Oral & Maxillofacial Implants 25: 401415.
Berglundh, T., Persson, L. & Klinge, B. (2002) A sys-
tematic review of the incidence of biological and
technical complications in implant dentistry
reported in prospective longitudinal studies of at
least 5 years. Journal of Clinical Periodontology
29(Suppl. 3): 197212; discussion 232-3.
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Moreover, the overall differences in marginal
bone-level changes between immediate func-
tional vs. non-functional loading and CL as
well as immediate compared to CL in healed
or fresh extraction sites appeared to be not
statistically significant.
However, the results of the current review
should be interpreted with caution and
understood as an analysis of a relatively
small number of currently available RCTs
comparing immediate loading within 24 h
with CL.
Evidence is still limited to draw definitive
conclusions, but the present and formerly
published results of meta-analytical
approaches to the literature seem to confirm
that the loading protocol i.e., immediate
loading or CL is irrelevant for clinical out-
come data as implant survival or marginal
bone-level stability.
Conclusion
Within the limits of this meta-analytic
approach to the literature, we conclude that
(1) the number of studies regarding RCTs
reporting at least 1-year outcome data on
loading within 24 h after implant placement
as compared to CL is limited and that (2) no
clinically relevant difference regarding AFRs
as well as radiographic bone-level changes
between conventionally and immediately
loaded implants can be found, for up to 5
years of follow-up.
Acknowledgements: The authors
would like to thank Dr. Ewald M.
Bronkhorst, Department of Preventive and
Curative Dentistry and Biostatistics,
Radboud University Nijmegen Medical
Centre, for his invaluable statistical support.
Branemark, P.I., Hansson, B.O., Adell, R., Breine,
U., Lindstrom, J., Hallen, O. & Ohman, A. (1977)
Osseointegrated implants in the treatment of the
edentulous jaw. Experience from a 10-year period.
Scandinavian Journal of Plastic and Reconstruc-
tive Surgery and Hand Surgery Supplementum
16: 1132.
Cochran, D.L., Morton, D. & Weber, H.P. (2004)
Consensus statements and recommended clinical
procedures regarding loading protocols for endos-
seous dental implants. The International Journal of
Oral & Maxillofacial Implants 19(Suppl.): 109113.
Crespi, R., Cappare, P., Gherlone, E. & Romanos,
G.E. (2008) Immediate versus delayed loading of

dental implants placed in fresh extraction sockets
in the maxillary esthetic zone: a clinical compar-
ative study. The International Journal of Oral &
Maxillofacial Implants 23: 753758.
Danza, M., Tortora, P., Quaranta, A., Perrotti, V.,
Vozza, I. & Piattelli, A. (2010) Randomised study
for the 1-year crestal bone maintenance around
modified diameter implants with different load-
ing protocols: a radiographic evaluation. Clinical
Oral Investigations 14: 417426.
De Rouck, T., Collys, K., Wyn, I. & Cosyn, J. (2009)
Instant provisionalization of immediate single-
tooth implants is essential to optimize esthetic
treatment outcome. Clinical Oral Implants
Research 20: 566570.
Deeks, J.J., Higgins, J.P.T. & Altman, D.G. (2008a)
Chapter 9: analysing data and undertaking meta-
analyses. In: Higgins, J.P.T. & Green, S. eds.
Cochrane Handbook for Systematic Reviews of
Interventions, 282289. Chichester, UK: John Wi-
ley & Sons.
Deeks, J.J., Higgins, J.P.T. & Altman, D.G. (2008b)
Chapter 16: special topics in statistics. In:
Higgins, J.P.T. & Green, S., eds. Cochrane Hand-
book for Systematic Reviews of Interventions,
482484. Chichester, UK: John Wiley & Sons.
Degidi, M., Nardi, D. & Piattelli, A. (2009) Immedi-
ate versus one-stage restoration of small-diameter
implants for a single missing maxillary lateral
incisor: a 3-year randomized clinical trial. Journal
of Periodontology 80: 13931398.
Den Hartog, L., Raghoebar, G.M, Stellingsma, K. ,
Vissink, A. & Meijer, H.J. (2011) Immediate
non-occlusal loading of single implants in the
Appendix 1
General exclusions
Aalam, A., Nowzari, H. & Krivitsky, A. (2005)
Functional restoration of implants on the day of
surgical placement in the fully edentulous mandi-
ble: a case series. Clinical Implant Dentistry &
Related Research 7: 1016.
Abboud, M., Koeck, B., Stark, H., Wahl, G. & Pail-
lon, R. (2005) Immediate loading of single-tooth
implants in the posterior region. The Interna-
tional Journal of Oral & Maxillofacial Implants
20: 6168.
Agliardi, E., Cleric
o, M., Ciancio, P. & Massironi,
D. (2010) Immediate loading of full-arch fixed
prostheses supported by axial and tilted
implants for the treatment of edentulous atro-
phic mandibles. Quintessence International 41:
285293.
Anitua, E., Orive, G., Aguirre, J. & And
a, I. (2008)
Clinical outcome of immediately loaded dental
implants bioactivated with plasma rich in growth
factors: a 5-year retrospective study. Journal of
Periodontology 79: 11681176.
Artzi, Z., Kohen, J., Carmeli, G., Karmon, B., Lor,
A. & Ormianer, Z. (2010) The efficacy of full-arch
immediately restored implant-supported recon-
structions in extraction and healed sites: a 36-
month retrospective evaluation. The Interna-
tional Journal of Oral & Maxillofacial Implants
25: 329335.
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Engelhardt et al
Immediate vs. conventional implant loading
aesthetic zone: a randomized clinical trial. Jour-
nal of Clinical Periodontology 38: 186194.
Donati, M., La Scala, V., Billi, M., Di Dino, B.,
Torrisi, P. & Berglundh, T. (2008) Immediate
functional loading of implants in single tooth
replacement: a prospective clinical multicenter
study. Clinical Oral Implants Research 19:
740748.
Esposito, M., Grusovin, M.G., Maghaireh, H. &
Worthington, H.V. (2013) Interventions for replac-
ing missing teeth: different times for loading
dental implants. Cochrane Database of System-
atic Reviews 3: CD003878.
Hall, J., Payne, A., Purton, D. & Torr, B. (2006) A
randomized controlled clinical trial of conven-
tional and immediately loaded tapered implants
with screw-retained crowns. The International
Journal of Prosthodontics 19: 1719.
den Hartog, L., Raghoebar, G.M., Stellingsma, K.,
Vissink, A. & Meijer, H.J. (2011) Immediate non-
occlusal loading of single implants in the aes-
thetic zone: a randomized clinical trial. Journal of
Clinical Periodontology 38: 186194.
Higgins, J.P.T., Altman, D.G. & Sterne, J.A.C. (2009)
Chapter 8: assessing risk of bias in included stud-
ies. In: Higgins, J.P.T. & Green, S. eds. Cochrane
Handbook for Systematic Reviews of Interventions
Version 5.1.0 Chapter 8.3. The Cochrane Colla-
boration, 2011. Available from www.cochrane-
handbook.org.
Ioannidou, E. & Doufexi, A. (2005) Does loading
time affect implant survival? A meta-analysis of
1,266 implants. Journal of Periodontology 76:
12521258.
Arvidson, K., Esselin, O., Felle-Persson, E., Jonsson,
G., Smedberg, J. & Soderstrom, U. (2008) Early
loading of mandibular full-arch bridges screw
retained after 1 week to four to five Monotype
implants: 3-year results from a prospective multi-
centre study. Clinical Oral Implants Research
19: 693703.
Balshi, S., Wolfinger, G. & Balshi, T. (2005) A pro-
spective study of immediate functional loading,
following the Teeth in a DayTM protocol: a case
series of 55 consecutive edentulous maxillas.
Clinical Implant Dentistry & Related Research
7: 2431.
Barone, A., Rispoli, L., Vozza, I., Quaranta, A. &
Covani, U. (2006) Immediate restoration of single
implants placed immediately after tooth
extraction. Journal of Periodontology 77:
19141920.
Bergkvist, G., Nilner, K., Sahlholm, S., Karlsson, U.
& Lindh, C. (2009) Immediate loading of implants
in the edentulous maxilla: use of an interim fixed
prosthesis followed by a permanent fixed prosthe-
sis: a 32-month prospective radiological and clini-
cal study. Clinical Implant Dentistry & Related
Research 11: 110.
Bergkvist, G., Sahlholm, S., Karlsson, U., Nilner, K.
& Lindh, C. (2005) Immediately loaded implants
supporting fixed prostheses in the edentulous
Margossian, P., Mariani, P., Stephan, G., Margerit,
J. & Jorgensen, C. (2012) Immediate loading of
mandibular dental implants in partially edentu-
lous patients: a prospective randomized compara-
tive study. International Journal of Periodontics
and Restorative Dentistry 32: e51e58.
Nkenke, E. & Fenner, M. (2006) Indications for
immediate loading of implants and implant suc-
cess. Clinical Oral Implants Research 17(Suppl.
2): 1934.
Pjetursson, B.E., Tan, K., Lang, N.P., Bragger, U.,
Egger, M. & Zwahlen, M. (2004) A systematic
review of the survival and complication rates of
fixed partial dentures (FPDs) after an observation
period of at least 5 years. Clinical Oral Implants
Research 15: 667676.
Prosper, L., Crespi, R., Valenti, E., Cappare, P. &
Gherlone, E. (2010) Five-year follow-up of
wide-diameter implants placed in fresh molar
extraction sockets in the mandible: immediate
versus delayed loading. The International
Journal of Oral & Maxillofacial Implants 25:
607612.
Shibly, O., Patel, N., Albandar, J.M. & Kutkut, A.
(2010) Bone regeneration around implants in peri-
odontally compromised patients: a randomized
clinical trial of the effect of immediate implant
with immediate loading. Journal of Periodontol-
ogy 81: 17431751.
Suarez, F., Chan, H.L., Monje, A., Galindo-Moreno,
P. & Wang, H.L. (2013) Effect of the timing of
restoration on implant marginal bone loss: a
systematic review. Journal of Periodontology 84:
159169.
maxilla: a preliminary clinical and radiologic
report. The International Journal of Oral & Max-
illofacial Implants 20: 399405.
Boronat-Lopez, A., Carrillo, C., Pe~narrocha, M. &
Pe~narrocha-Diago, M. (2009) Immediately
restored dental implants for partial-arch applica-
tions: a study of 12 cases. Journal of Oral and
Maxillofacial Surgery 67: 195199.
Br
anemark, P., Engstrand, P., Ohrnell, L., Gr
ondahl,
K., Nilsson, P., Hagberg, K., Darle, C. & Lek-
holm, U. (1999) Branemark Novum: a new treat-
ment concept for rehabilitation of the edentulous
mandible. Preliminary results from a prospective
clinical follow-up study. Clinical Implant Den-
tistry & Related Research 1: 216.
Buchs, A., Levine, L. & Moy, P. (2001) Preliminary
report of immediately loaded Altiva Natural
Tooth Replacement dental implants. Clinical
Implant Dentistry & Related Research 3: 97106.
Calandriello, R. & Tomatis, M. (2005) Simplified
treatment of the atrophic posterior maxilla via
immediate/early function and tilted implants: a
prospective 1-year clinical study. Clinical
Implant Dentistry & Related Research 7: S1S12.
Calandriello, R., Tomatis, M. & Rangert, B. (2003)
Immediate functional loading of Br anemark Sys-
tem implants with enhanced initial stability: a
prospective 1to 2-year clinical and radiographic
683 | Clin. Oral Impl. Res. 26, 2015 / 671687
Engelhardt et al
Immediate vs. conventional implant loading
study. Clinical Implant Dentistry & Related
Research 5: 1020.
Calandriello, R., Tomatis, M., Vallone, R., Rangert,
B. & Gottlow, J. (2003) Immediate occlusal load-
ing of single lower molars using Br anemark Sys-
tem Wide-Platform TiUniteTM implants: an
interim report of a prospective open-ended clini-
cal multicenter study. Clinical Implant Dentistry
& Related Research 5: 7480.
Cannizzaro, G. & Leone, M. (2003) Restoration of
partially edentulous patients using dental
implants with a microtextured surface: a prospec-
tive comparison of delayed and immediate full
occlusal loading. The International Journal of
Oral & Maxillofacial Implants 18: 512522.
Cannizzaro, G., Leone, M. & Esposito, M. (2007)
Immediate functional loading of implants placed
with flapless surgery in the edentulous maxilla:
1-year follow-up of a single cohort study. The
International Journal of Oral & Maxillofacial
Implants 22: 8795.
Capelli, M., Zuffetti, F., Del Fabbro, M. & Testori,
T. (2007) Immediate rehabilitation of the com-
pletely edentulous jaw with fixed prostheses sup-
ported by either upright or tilted implants: a
multicenter clinical study. The International
Journal of Oral & Maxillofacial Implants 22:
639644.
Chaushu, G., Chaushu, S., Tzohar, A. & Dayan, D.
(2001) Immediate loading of single-tooth
implants: immediate versus non-immediate
implantation. A clinical report. The International
Journal of Oral & Maxillofacial Implants 16:
267272.
Chiapasco, M. & Gatti, C. (2003) Implant-retained
mandibular overdentures with immediate load-
ing: a 3- to 8-year prospective study on 328
implants. Clinical Implant Dentistry & Related
Research 5: 2938.
Chiapasco, M., Gatti, C., Rossi, E., Haefliger, W. &
Markwalder, T. (1997) Implant-retained mandibu-
lar overdentures with immediate loading. Clini-
cal Oral Implants Research 8: 4857.
Chow, J., Hui, E., Liu, J., Li, D., Wat, P., Li, W.,
Kwong Yau, Y. & Law, H. (2001) The Hong Kong
Bridge Protocol. Immediate loading of mandibular
Branemark fixtures using a fixed provisional pros-
thesis: preliminary results. Clinical Implant Den-
tistry & Related Research 3: 166174.
Collaert, B. & De Bruyn, H. (2008) Immediate func-
tional loading of TiOblast dental implants in full-
arch edentulous maxillae: a 3-year prospective
study. Clinical Oral Implants Research 19: 1254
1260.
Cooper, L., Rahman, A., Moriarty, J., Chaffee, N. &
Sacco, D. (2002) Immediate mandibular rehabili-
tation with endosseous implants: simultaneous
extraction, implant placement, and loading. The
International Journal of Oral & Maxillofacial
Implants 17: 517525.
Cornelini, R., Cangini, F., Covani, U., Barone, A. &
Buser, D. (2004) Immediate restoration of single-
tooth implants in mandibular molar sites: a 12-
month preliminary report. The International
Journal of Oral & Maxillofacial Implants 19:
855860.
Cornelini, R., Cangini, F., Covani, U., Barone, A. &
Buser, D. (2006) Immediate loading of implants
684 | Clin. Oral Impl. Res. 26, 2015 / 671687
with 3-unit fixed partial dentures: a 12-month
clinical study. The International Journal of Oral
& Maxillofacial Implants 21: 914918.
Cornelini, R., Cangini, F., Covani, U. & Wilson, T.
Jr (2005) Immediate restoration of implants placed
into fresh extraction sockets for single-tooth
replacement: a prospective clinical study. The
International Journal of Periodontics & Restor-
ative Dentistry 25: 439447.
Crespi, R., Cappare, P., Gherlone, E. & Romanos,
G. (2007) Immediate occlusal loading of implants
placed in fresh sockets after tooth extraction. The
International Journal of Oral & Maxillofacial
Implants 22: 955962.
De Smet, E., Duyck, J., Vander Sloten, J., Jacobs, R.
& Naert, I. (2007) Timing of loadingimmediate,
early, or delayedin the outcome of implants in
the edentulous mandible: a prospective clinical
trial. The International Journal of Oral & Maxil-
lofacial Implants 22: 580594.
Degidi, M., Perrotti, V. & Piattelli, A. (2006) Imme-
diately loaded titanium implants with a porous
anodized surface with at least 36 months of fol-
low-up. Clinical Implant Dentistry & Related
Research 8: 169177.
Degidi, M. & Piattelli, A. (2003) Immediate func-
tional and non-functional loading of dental
implants: a 2- to 60-month follow-up study of
646 titanium implants. Journal of Periodontology
74: 225241.
Degidi, M. & Piattelli, A. (2005) A 7-year follow-up
of 93 immediately loaded titanium dental
implants. Journal of Oral Implantology 31: 2531.
Degidi, M., Piattelli, A. & Carinci, F. (2006) Parallel
screw cylinder implants: comparative analysis
between immediate loading and two-stage healing
of 1005 dental implants with 2-year follow up.
Clinical Implant Dentistry & Related Research
8: 151160.
Degidi, M., Piattelli, A. & Carinci, F. (2007) Imme-
diate loaded dental implants: comparison
between fixtures inserted in postextractive and
healed bone sites. Journal of Craniofacial Surgery
18: 965971.
Degidi, M., Piattelli, A., Felice, P. & Carinci, F.
(2005) Immediate functional loading of edentulous
maxilla: a 5-year retrospective study of 388 tita-
nium implants. Journal of Periodontology 76:
10161024.
Degidi, M., Piattelli, A., Gehrke, P. & Carinci, F.
(2006) Clinical outcome of 802 immediately
loaded 2-stage submerged implants with a new
grit-blasted and acid-etched surface: 12-month
follow-up. The International Journal of Oral &
Maxillofacial Implants 21: 763768.
Degidi, M., Piattelli, A., Gehrke, P., Felice, P. &
Carinci, F. (2006) Five-year outcome of 111
immediate nonfunctional single restorations.
Journal of Oral Implantology 32: 277285.
Degidi, M., Piattelli, A., Iezzi, G. & Carinci, F.
(2007) Do longer implants improve clinical out-
come in immediate loading? The International
Journal of Oral and Maxillofacial Surgery 36:
11721176.
Degidi, M., Piattelli, A., Iezzi, G. & Carinci, F.
(2007) Immediately loaded short implants: analy-
sis of a case series of 133 implants. Quintessence
International 38: 193201.
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Degidi, M., Piattelli, A., Iezzi, G. & Carinci, F.
(2007) Retrospective study of 200 immediately
loaded implants retaining 50 mandibular overden-
tures. Quintessence International 38: 281288.
Drago, C. & Lazzara, R. (2004) Immediate provi-
sional restoration of Osseotite implants: a clinical
report of 18-month results. The International
Journal of Oral & Maxillofacial Implants 19:
534541.
Drago, C. & Lazzara, R. (2006) Immediate occlusal
loading of Osseotite implants in mandibular
edentulous patients: a prospective observational
report with 18-month data. Journal of Prostho-
dontics 15: 187194.
Erakat, M., Chuang, S., Yoo, R., Weed, M. & Dod-
son, T. (2008) Immediate loading of splinted lock-
ing-taper implants: 1-year survival estimates and
risk factors for failure. The International Journal
of Oral & Maxillofacial Implants 23: 105110.
Ferrara, A., Galli, C., Mauro, G. & Macaluso, G.
(2006) Immediate provisional restoration of
postextraction implants for maxillary single-tooth
replacement. The International Journal of Peri-
odontics & Restorative Dentistry 26: 371377.
Finne, K., Rompen, E. & Toljanic, J. (2007) Clinical
evaluation of a prospective multicenter study on
1-piece implants. Part 1: marginal bone level eval-
uation after 1 year of follow-up. The Interna-
tional Journal of Oral & Maxillofacial Implants
22: 226234.
Fischer, K., Backstrom, M. & Sennerby, L. (2009)
Immediate and early loading of oxidized tapered
implants in the partially edentulous maxilla: a
1-year prospective clinical, radiographic, and reso-
nance frequency analysis study. Clinical Implant
Dentistry & Related Research 11: 6980.
Ganeles, J., Rosenberg, M., Holt, R. & Reichman, L.
(2001) Immediate loading of implants with fixed
restorations in the completely edentulous mandi-
ble: report of 27 patients from a private practice.
The International Journal of Oral & Maxillofa-
cial Implants 16: 418426.
Gatti, C. & Chiapasco, M. (2002) Immediate load-
ing of Br
anemark implants: a 24-month follow-up
of a comparative prospective pilot study between
mandibular overdentures supported by Conical
transmucosal and standard MK II implants. Clini-
cal Implant Dentistry & Related Research 4:
190199.
Glauser, R., Ree, A., Lundgren, A., Gottlow, J.,
Hammerle, C. & Scharer, P. (2001) Immediate
occlusal loading of Br anemark implants applied
in various jawbone regions: a prospective, 1-year
clinical study. Clinical Implant Dentistry &
Related Research 3: 204213.
Glauser, R., Ruhstaller, P., Windisch, S., Zembic,
A., Lundgren, A., Gottlow, J. & Hammerle, C.
(2005) Immediate occlusal loading of Br anemark
System TiUniteTM implants placed predominantly
in soft bone: 4-year results of a prospective clini-
cal study. Clinical Implant Dentistry & Related
Research 7: S52S59.
Glauser, R., Zembic, A., Ruhstaller, P. & Windisch,
S. (2007) Five-year results of implants with an
oxidized surface placed predominantly in soft
quality bone and subjected to immediate occlusal
loading. Journal of Prosthetic Dentistry 97: S59
S68.

Groisman, M., Frossard, W., Ferreira, H., de Mene-
zes, F. & Touati, B. (2003) Single-tooth implants
in the maxillary incisor region with immediate
provisionalization: 2-year prospective study. Prac-
tical Procedures and Aesthetic Dentistry 15:
115122.
Grunder, U. (2001) Immediate functional loading
of immediate implants in edentulous arches:
two-year results. The International Journal of
Periodontics & Restorative Dentistry 21: 545
551.
Hahn, J. (2007) Clinical and radiographic evaluation
of one-piece implants used for immediate func-
tion. Journal of Oral Implantology 33: 152155.
Henry, P., Steenberghe, D., Blomback, U., Polizzi,
G., Rosenberg, R., Urgell, J. & Wendelhag, I.
(2003) Prospective multicenter study on immedi-
ate rehabilitation of edentulous lower jaws
according to the Br anemark Novum protocol.
Clinical Implant Dentistry & Related Research
5: 137142.
Hinze, M., Thalmair, T., Bolz, W. & Wachtel, H.
(2010) Immediate loading of fixed provisional
prostheses using four implants for the rehabilita-
tion of the edentulous arch: a prospective clinical
study. The International Journal of Oral & Max-
illofacial Implants 25: 10111018.
Horiuchi, K., Uchida, H., Yamamoto, K. & Sugim-
ura, M. (2000) Immediate loading of Branemark
system implants following placement in edentu-
lous patients: a clinical report. The International
Journal of Oral & Maxillofacial Implants 15:
824830.
Hui, E., Chow, J., Li, D., Liu, J., Wat, P. & Law, H.
(2001) Immediate provisional for single-tooth
implant replacement with br anemark system:
preliminary report. Clinical Implant Dentistry &
Related Research 3: 7986.
Iba~nez, J. & Jalbout, Z. (2002) Immediate loading of
Osseotite implants: two-year results. Implant
Dentistry 11: 128136.
Ibanez, J., Tahhan, M., Zamar, J., Menendez, A.,
Juaneda, A., Zamar, N. & Monqaut, J. (2005)
Immediate occlusal loading of double acid-etched
surface titanium implants in 41 consecutive full-
arch cases in the mandible and maxilla: 6-to
74-month results. Journal of Periodontology 76:
19721981.
Jaffin, R., Kumar, A. & Berman, C. (2004) Immedi-
ate loading of dental implants in the completely
edentulous maxilla: a clinical report. The Interna-
tional Journal of Oral & Maxillofacial Implants
19: 721730.
Kacer, C.M., Dyer, J. & Kraut, R. (2010) Immediate
loading of dental implants in the anterior and
posterior mandible: a retrospective study of 120
cases. Journal of Oral and Maxillofacial Surgery
68: 28612867.
Kan, J., Rungcharassaeng, K., Liddelow, G., Henry,
P. & Goodacre, C. (2007) Periimplant tissue
response following immediate provisional resto-
ration of scalloped implants in the esthetic
zone: a one-year pilot prospective multicenter
study. Journal of Prosthetic Dentistry 97: S109
S118.
Kan, J., Rungcharassaeng, K. & Lozada, J. (2003)
Immediate placement and provisionalization of
maxillary anterior single implants: 1-year
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Engelhardt et al
Immediate vs. conventional implant loading
prospective study. The International Journal of
Oral & Maxillofacial Implants 18: 3139.
Kan, J., Rungcharassaeng, K., Sclar, A. & Lozada, J.
(2007) Effects of the facial osseous defect mor-
phology on gingival dynamics after immediate
tooth replacement and guided bone regeneration:
1-year results. Journal of Oral and Maxillofacial
Surgery 65: 1319.
Kinsel, R., Lamb, R. & Moneim, A. (2000) Develop-
ment of gingival esthetics in the edentulous
patient with immediately loaded, single-stage,
implant-supported fixed prostheses: a clinical
report. The International Journal of Oral & Max-
illofacial Implants 15: 711721.
Kinsel, R. & Liss, M. (2007) Retrospective analysis
of 56 edentulous dental arches restored with 344
single-stage implants using an immediate loading
fixed provisional protocol: statistical predictors of
implant failure. The International Journal of Oral
& Maxillofacial Implants 22: 823830.
Lee, C. (2006) Immediate load protocol for anterior
maxilla with cortical bone from mandibular
ramus. Implant Dentistry 15: 153159.
Li, W., Chow, J., Hui, E., Lee, P. & Chow, R. (2009)
Retrospective study on immediate functional
loading of edentulous maxillas and mandibles
with 690 implants, up to 71 months of follow-up.
Journal of Oral and Maxillofacial Surgery 67:
26532662.
Locante, W. (2004) Single-tooth replacements in the
esthetic zone with an immediate function
implant: a preliminary report. Journal of Oral
Implantology 30: 369375.
Longoni, S., Sartori, M., Apruzzese, D., Davide, R.
& Baldoni, M. (2007) Immediate loading: a simple
protocol to create a passively fitting provisional
fixed implant-supported complete denture in
1 day. The International Journal of Periodontics
& Restorative Dentistry 27: 369377.
Lorenzoni, M., Pertl, C., Zhang, K., Wimmer, G. &
Wegscheider, W. (2003) Immediate loading of sin-
gle-tooth implants in the anterior maxilla. Preli-
minary results after one year. Clinical Oral
Implants Research 14: 180187.
Machtei, E., Frankenthal, S., Blumenfeld, I., Gutm-
acher, Z. & Horwitz, J. (2007) Dental implants for
immediate fixed restoration of partially edentu-
lous patients: a 1-year prospective pilot clinical
trial in periodontally susceptible patients. Journal
of Periodontology 78: 11881194.
Mal
o, P., De Ara
ujo Nobre, M., Petersson, U. &
Wigren, S. (2006) A pilot study of complete eden-
tulous rehabilitation with immediate function
using a new implant design: case series. Clinical
Implant Dentistry & Related Research 8: 223
232.
Mal
o, P., Friberg, B., Polizzi, G., Gualini, F., Vigha-
gen, T. & Rangert, B. (2003) Immediate and early
function of Br anemark System implants placed
in the esthetic zone: a 1-year prospective clinical
multicenter study. Clinical Implant Dentistry &
Related Research 5: 3746.
Mal
o, P., Rangert, B. & Nobre, M. (2005) All-on-4
immediate-function concept with Br anemark Sys-
tem implants for completely edentulous maxil-
lae: a 1-year retrospective clinical study. Clinical
Implant Dentistry & Related Research 7: s88
s94.
Marchetti, C., Felice, P., Lizio, G. & Rossi, F.
(2009) Le Fort I osteotomy with interpositional
graft and immediate loading of delayed modified
SLActive surface dental implants for rehabilita-
tion of extremely atrophied maxilla: a case report.
Journal of Oral and Maxillofacial Surgery 67:
14861494.
Mart
nez-Gonz
alez, J., Barona-Dorado, C., Cano-
S
anchez, J., Fern
andez-C
aliz, F. & S
anches-
Turrin, A. (2006) Evaluation of 80 implants sub-
jected to immediate loading in edentulous mandi-
bles after two years of follow-up. Medicina Oral,
Patologa Oral y Ciruga Bucal 11: E165E170.
Marzola, R., Scotti, R., Fazi, G. & Schincaglia, G.
(2007) Immediate loading of two implants support-
ing a ball attachment-retained mandibular over-
denture: a prospective clinical study. Clinical
Implant Dentistry & Related Research 9: 136143.
Nikellis, I., Levi, A. & Nicolopoulos, C. (2004)
Immediate loading of 190 endosseous dental
implants: a prospective observational study of 40
patient treatments with up to 2-year data. The
International Journal of Oral & Maxillofacial
Implants 19: 116123.
Norton, M. (2004) A short-term clinical evaluation
of immediately restored maxillary TiOblast sin-
gle-tooth implants. The International Journal of
Oral & Maxillofacial Implants 19: 274281.
Oliva, J., Oliva, X. & Oliva, J. (2007) One-year fol-
low-up of first consecutive 100 zirconia dental
implants in humans: a comparison of 2 different
rough surfaces. The International Journal of Oral
& Maxillofacial Implants 22: 430435.
Ormianer, Z., Garg, A. & Palti, A. (2006) Immediate
loading of implant overdentures using modified
loading protocol. Implant Dentistry 15: 3540.
Ostman, P., Hellman, M., Albrektsson, T. & Senn-
erby, L. (2007) Direct loading of Nobel Direct
and Nobel Perfect one-piece implants: a 1-year
prospective clinical and radiographic study. Clini-
cal Oral Implants Research 18: 409418.
Ostman, P., Hellman, M. & Sennerby, L. (2005)
Direct implant loading in the edentulous maxilla
using a bone density-adapted surgical protocol
and primary implant stability criteria for
inclusion. Clinical Implant Dentistry & Related
Research 7: S60S69.
Ostman, P., Hellman, M. & Sennerby, L. (2008)
Immediate occlusal loading of implants in the
partially edentate mandible: a prospective 1-year
radiographic and 4-year clinical study. The Inter-
national Journal of Oral & Maxillofacial
Implants 23: 315322.
Ostman, P., Wennerberg, A. & Albrektsson, T.
TM
(2010) Immediate occlusal loading of NanoTite
PREVAIL
implants: a prospective 1-year clinical
and radiographic study. Clinical Implant Den-
tistry & Related Research 12: 3947.
Parel, S. & Schow, S. (2005) Early clinical experi-
ence with a new one-piece implant system in sin-
gle tooth sites. Journal of Oral and Maxillofacial
Surgery 63: 210.
Payer, M., Heschl, A., Wimmer, G., Wegscheider,
W., Kirmeier, R. & Lorenzoni, M. (2010) Immedi-
ate provisional restoration of screw-type implants
in the posterior mandible: results after 5 years of
clinical function. Clinical Oral Implants
Research 21: 815821.
685 | Clin. Oral Impl. Res. 26, 2015 / 671687
Engelhardt et al
Immediate vs. conventional implant loading
Proussaefs, P. & Lozada, J. (2004) Immediate loading
of hydroxyapatite-coated implants in the
maxillary premolar area: three-year results of a
pilot study. Journal of Prosthetic Dentistry 91:
228233.
Ribeiro, F., Pontes, A., Marcantonio, E., Piattelli,
A., Neto, R. & Marcantonio, E. Jr (2008) Success
rate of immediate nonfunctional loaded single-
tooth implants: immediate versus delayed
implantation. Implant Dentistry 17: 109117.
Rompen, E., Raepsaet, N., Domken, O., Touati, B.
& Van Dooren, E. (2007) Soft tissue stability at
the facial aspect of gingivally converging abut-
ments in the esthetic zone: a pilot clinical
study. Journal of Prosthetic Dentistry 97: S119
S125.
Rungcharassaeng, K., Lozada, J., Kan, J., Kim, J.,
Campagni, W. & Munoz, C. (2002) Peri-implant
tissue response of immediately loaded, threaded,
HA-coated implants: 1-year results. Journal of
Prosthetic Dentistry 87: 173181.
Schnitman, P., W ohrle, P., Rubenstein, J., DaSilva,
J. & Wang, N. (1997) Ten-year results for Brane-
mark implants immediately loaded with fixed
prostheses at implant placement. The Interna-
tional Journal of Oral & Maxillofacial Implants
12: 495503.
Siebers, D., Gehrke, P. & Schliephake, H. (2010)
Delayed function of dental implants: a 1-to 7-year
follow-up study of 222 implants. The Interna-
tional Journal of Oral & Maxillofacial Implants
25: 11951202.
Spiekermann, H., Jansen, V. & Richter, E. (1995) A
10-year follow-up study of IMZ and TPS implants
in the edentulous mandible using bar-retained
overdentures. The International Journal of Oral
& Maxillofacial Implants 10: 231243.
Stricker, A., Gutwald, R., Schmelzeisen, R. & Gell-
rich, N. (2004) Immediate loading of 2 interfora-
minal dental implants supporting an overdenture:
clinical and radiographic results after 24 months.
The International Journal of Oral & Maxillofa-
cial Implants 19: 868872.
Susarla, S., Chuang, S. & Dodson, T. (2008) Delayed
versus immediate loading of implants: survival
analysis and risk factors for dental implant
failure. Journal of Oral and Maxillofacial Surgery
66: 251255.
Appendix 2
Excluded RCTs
Assad, A., Hassan, S., Shawky, Y. & Badawy, M.
(2007) Clinical and radiographic evaluation of
implant-retained mandibular overdentures with
immediate loading. Implant Dentistry 16: 212223.
Cannizzaro, G., Torchio, C., Leone, M. & Esposito,
M. (2008) Immediate versus early loading of flap-
less-placed implants supporting maxillary full-
arch prostheses: a randomized controlled clinical
trial. European Journal of Oral Implantology 1:
127139.
Chiapasco, M., Abati, S., Romeo, E. & Vogel, G.
(2001) Implant-retained mandibular overdentures
with Branemark System MKII implants: a
prospective comparative study between delayed
686 | Clin. Oral Impl. Res. 26, 2015 / 671687
Tarnow, P., Emtiaz, S. & Classi, A. (1997) Immedi-
ate loading of threaded implants at stage 1 sur-
gery in edentulous arches: ten consecutive case
reports with 1- to 5-year data. The International
Journal of Oral & Maxillofacial Implants 12:
319324.
Tealdo, T., Bevilacqua, M., Pera, F., Menini, M.,
Ravera, G., Drago, C. & Pera, P. (2008) Immediate
function with fixed implant-supported maxillary
dentures: a 12-month pilot study. Journal of Pros-
thetic Dentistry 99: 351360.
Testori, T., Del Fabbro, M., Galli, F., Francetti, L.,
Taschieri, S. & Weinstein, R. (2004) Immediate
occlusal loading the same day or the day after
implant placement: comparison of 2 different
time frames in totally edentulous lower jaws.
Journal of Oral Implantology 30: 307313.
Testori, T., Del Fabbro, M., Szmukler-Moncler, S.,
Francetti, L. & Weinstein, R. (2003) Immediate
occlusal loading of Osseotite implants in the
completely edentulous mandible. The Interna-
tional Journal of Oral & Maxillofacial Implants
18: 544551.
Testori, T., Meltzer, A., Fabbro, M., Zuffetti, F.,
Troiano, M., Francetti, L. & Weinstein, R. (2004)
Immediate occlusal loading of Osseotite implants
in the lower edentulous jaw. A multicenter pro-
spective study. Clinical Oral Implants Research
15: 278284.
Tsirlis, A. (2005) Clinical evaluation of immediate
loaded upper anterior single implants. Implant
Dentistry 14: 94103.
Van de Velde, T., Collaert, B. & De Bruyn, H.
(2007) Immediate loading in the completely eden-
tulous mandible: technical procedure and clinical
results up to 3 years of functional loading. Clini-
cal Oral Implants Research 18: 295303.
Van de Velde, T., Collaert, B., Sennerby, L. & De
Bruyn, H. (2010) Effect of implant design on pres-
ervation of marginal bone in the mandible. Clini-
cal Implant Dentistry & Related Research 12:
134141.
Van Steenberghe, D., Glauser, R., Blomback, U., An-
dersson, M., Schutyser, F., Pettersson, A. & Wen-
delhag, I. (2005) A computed tomographic scan
derived customized surgical template and fixed
prosthesis for flapless surgery and immediate load-
ing of implants in fully edentulous maxillae: a
and immediate loading. The International Journal
of Oral & Maxillofacial Implants 16: 537546.
Degidi, M., Nardi, D. & Piattelli, A. (2010) A compar-
ison between immediate loading and immediate
restoration in cases of partial posterior mandibular
edentulism: a 3-year randomized clinical trial.
Clinical Oral Implants Research 21: 682687.
Fischer, K. & Stenberg, T. (2004) Early loading of
ITI implants supporting a maxillary full-arch
prosthesis: 1-year data of a prospective, random-
ized study. The International Journal of Oral &
Maxillofacial Implants 19: 374381.
Fr
oberg, K., Lindh, C. & Ericsson, I. (2006) Immedi-
ate loading of Br anemark System Implants: a
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
prospective multicenter study. Clinical Implant
Dentistry & Related Research 7: s111s120.
Van Steenberghe, D., Molly, L., Jacobs, R., Van-
dekerckhove, B., Quirynen, M. & Naert, I. (2004)
The immediate rehabilitation by means of a
ready-made final fixed prosthesis in the edentu-
lous mandible: a 1-year follow-up study on 50
consecutive patients. Clinical Oral Implants
Research 15: 360365.
Van Steenberghe, D., Naert, I., Andersson, M., Braj-
novic, I., Van Cleynenbreugel, J. & Suetens, P.
(2002) A custom template and definitive prosthesis
allowing immediate implant loading in the
maxilla: a clinical report. The International
Journal of Oral & Maxillofacial Implants 17: 663
670.
Vanden Bogaerde, L., Pedretti, G., Dellacasa, P.,
Mozzati, M., Rangert, B. & Wendelhag, I. (2004)
Early function of splinted implants in maxillas
and posterior mandibles, using Br anemark
System TiUniteTM implants: an 18-month pro-
spective clinical multicenter study. Clinical
Implant Dentistry & Related Research 6: 121
129.
Villa, R. & Rangert, B. (2005) Early loading of inter-
foraminal implants immediately installed after
extraction of teeth presenting endodontic and
periodontal lesions. Clinical Implant Dentistry &
Related Research 7: s28s35.
Wolfinger, G., Balshi, T.J. & Rangert, B. (2003)
Immediate functional loading of Br anemark sys-
tem implants in edentulous mandibles: clinical
report of the results of developmental and simpli-
fied protocols. The International Journal of Oral
& Maxillofacial Implants 18: 250257.
Zafiropoulos, G., Deli, G., Bartee, B. & Hoffmann,
O. (2010) Single-tooth implant placement and
loading in fresh and regenerated extraction sock-
ets. Five-year results: a case series using two dif-
ferent implant designs. Journal of Periodontology
81: 604615.
Zhou, W., Han, C., Li, Y., Li, D., Song, Y. & Zhao,
Y. (2009) Is the osseointegration of immediately
and delayed loaded implants the same? Compari-
son of the implant stability during a 3-month
healing period in a prospective study. Clinical
Oral Implants Research 20: 13601366.
comparison between TiUniteTM and turned
implants placed in the anterior mandible. Clini-
cal Implant Dentistry & Related Research 8:
187197.
Ganeles, J., Z
ollner, A., Jackowski, J., Ten Brug-
genkate, C., Beagle, J. & Guerra, F. (2008) Imme-
diate and early loading of Straumann implants
with a chemically modified surface (SLActive) in
the posterior mandible and maxilla: 1-year results
from a prospective multicenter study. Clinical
Oral Implants Research 19: 11191128.
Grandi, T., Garuti, G., Guazzi, P., Tarabini, L. &
Forabosco, A. (2012) Survival and success rates of
immediately and early loaded implants: 12-month

results from a multicentric randomized clinical
study. Journal of Oral Implantology 38: 23949.
Grandi, T., Guazzi, P., Samarani, R. & Grandi, G.
(2013) A 3-year report from a multicentre rando-
mised controlled trial: immediately versus early
loaded implants in partially edentulous patients.
European Journal of Oral Implantology 6: 217
224.
Jokstad, A., Ellner, S. & Gussgard, A. (2011) Com-
parison of two early loading protocols in full arch
reconstructions in the edentulous maxilla using
the Cresco prosthetic system: a three-arm parallel
group randomized-controlled trial. Clinical Oral
Implants Research 22: 455463.
Liddelow, G. & Henry, P. (2010) The immediately
loaded single implant-retained mandibular
overdenture: a 36-month prospective study. The
International Journal of Prosthodontics 23:
1321.
Lindeboom, J., Frenken, J., Dubois, L., Frank, M.,
Abbink, I. & Kroon, F. (2006) Immediate loading
versus immediate provisionalization of maxillary
single-tooth replacements: a prospective random-
ized study with BioComp implants. Journal of
Oral and Maxillofacial Surgery 64: 936942.
Ma, S., Tawse-Smith, A., Thomson, W.M. & Payne,
A. (2010) Marginal bone loss with mandibular
two-implant overdentures using different loading
protocols and attachment systems: 10-year out-
comes. The International Journal of Prosthodon-
tics 23: 321332.
Merli, M., Bernardelli, F. & Esposito, M. (2008)
Immediate versus early nonocclusal loading of
dental implants placed with a flapless procedure
in partially edentulous patients: preliminary
results from a randomized controlled clinical
trial. The International Journal of Periodontics &
Restorative Dentistry 28: 453459.
Appendix 3
RCTs excluded for specific reasons
Degidi, M., Iezzi, G., Perrotti, V. & Piattelli, A.
(2009b) Comparative analysis of immediate func-
tional loading and immediate nonfunctional load-
ing to traditional healing periods: a 5-year follow-
up of 550 dental implants. Clinical Implant Den-
tistry & Related Research 11: 257266.
Elsyad, M.A., Al-Mahdy, Y.F. & Fouad, M.M. (2012)
Marginal bone loss adjacent to conventional and
immediate loaded two implants supporting a ball-
retained mandibular overdenture: a 3-year ran-
domized clinical trial. Clinical Oral Implants
Research 23: 496503.
Guncu, M.B., Aslan, Y., T
umer, C., G uncu, G.N. &
Uysal, S. (2008) In-patient comparison of immedi-
ate and conventional loaded implants in mandib-
ular molar sites within 12 months. Clinical Oral
Implants Research 19: 335341.
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Engelhardt et al
Immediate vs. conventional implant loading
Merli, M., Moscatelli, M., Mariotti, G., Piemontese,
M. & Nieri, M. (2012) Immediate versus early
non-occlusal loading of dental implants placed
flapless in partially edentulous patients: a 3-year
randomized clinical trial. Journal of Clinical Peri-
odontology 39: 196202.
Palattella, P., Torsello, F. & Cordaro, L. (2008)
Two-year prospective clinical comparison of
immediate replacement vs. immediate restoration
of single tooth in the esthetic zone. Clinical Oral
Implants Research 19: 11481153.
Payne, A., Tawse-Smith, A., Duncan, W. & Kumar-
a, R. (2002) Conventional and early loading of un-
splinted ITI implants supporting mandibular
overdentures. Two-year results of a prospective
randomized clinical trial. Clinical Oral Implants
Research 13: 603609.
Rocci, A., Martignoni, M. & Gottlow, J. (2003)
Immediate loading of Br anemark System
TiUniteTM and machined-surface implants in the
posterior mandible: a randomized open-ended
clinical trial. Clinical Implant Dentistry &
Related Research 5: 5763.
Romeo, E., Chiapasco, M., Lazza, A., Casentini, P.,
Ghisolfi, M., Iorio, M. & Vogel, G. (2002)
Implant-retained mandibular overdentures with
ITI implants. Clinical Oral Implants Research
13: 495501.
Salvi, G., Gallini, G. & Lang, N. (2004) Early load-
ing (2 or 6 weeks) of sandblasted and acid-etched
(SLA) ITI implants in the posterior mandible. A
1-year randomized controlled clinical trial. Clini-
cal Oral Implants Research 15: 142149.
Schincaglia, G., Marzola, R., Scapoli, C. & Scotti,
R. (2007) Immediate loading of dental implants
supporting fixed partial dentures in the posterior
mandible: a randomized controlled split-mouth
studymachined versus titanium oxide implant
Hall, J., Payne, A., Purton, D., Torr, B., Duncan, W.
& De Silva, R. (2007) Immediately restored, sin-
gle-tapered implants in the anterior maxilla: pros-
thodontic and aesthetic outcomes after 1 year.
Clinical Implant Dentistry & Related Research
9: 3445.
Jokstad, A. & Alkumru, H. (2013) Immediate func-
tion on the day of surgery compared with a delayed
implant loading process in the mandible: a ran-
domized clinical trial over 5 years. Clinical Oral
Implants Research 111. doi: 10.1111/clr12279.
Meloni, S.M., De Riu, G., Pisano, M., De Riu, N.
& Tulio, A. (2012) Immediate versus delayed
loading of single mandibular molars. One-year
results from a randomized controlled trial.
European Journal of Oral Implantology 5:
345353.
surface. The International Journal of Oral &
Maxillofacial Implants 22: 3546.
Tawse-Smith, A., Payne, A., Kumara, R. & Thom-
son, W. (2002) Early loading of unsplinted implants
supporting mandibular overdentures using a one-
stage operative procedure with two different
implant systems: a 2-year report. Clinical Implant
Dentistry & Related Research 4: 3342.
Testori, T., Bianchi, F., Del Fabbro, M., Szmukler-
Moncler, S., Francetti, L. & Weinstein, R. (2003)
Immediate non-occlusal loading vs. early loading
in partially edentulous patients. Practical Proce-
dures and Aesthetic Dentistry 15: 787794.
Testori, T., Galli, F., Capelli, M., Zuffetti, F. &
Esposito, M. (2007) Immediate nonocclusal versus
early loading of dental implants in partially eden-
tulous patients: 1-year results from a multicenter,
randomized controlled clinical trial. The Interna-
tional Journal of Oral & Maxillofacial Implants
22: 815822.
Turkyilmaz, I. & Tumer, C. (2007) Early versus late
loading of unsplinted TiUnite surface implants
supporting mandibular overdentures: a 2-year
report from a prospective study. Journal of Oral
Rehabilitation 34: 773780.
Zembi
c, A., Glauser, R., Khraisat, A. & Hammerle,
C. (2010) Immediate vs. early loading of dental
implants: 3-year results of a randomized con-
trolled clinical trial. Clinical Oral Implants
Research 21: 481489.
Z
ollner, A., Ganeles, J., Korostoff, J., Guerra, F.,
Krafft, T. & Bragger, U. (2008) Immediate and
early non-occlusal loading of Straumann implants
with a chemically modified surface (SLActive) in
the posterior mandible and maxilla: interim
results from a prospective multicenter random-
ized-controlled study. Clinical Oral Implants
Research 19: 442450.
Oh, T., Shotwell, J., Billy, E. & Wang, H. (2006)
Effect of flapless implant surgery on soft tissue
profile: a randomized controlled clinical trial.
Journal of Periodontology 77: 874882.
Romanos, G. & Nentwig, G. (2006) Immediate ver-
sus delayed functional loading of implants in the
posterior mandible: a 2-year prospective clinical
study of 12 consecutive cases. The International
Journal of Periodontics & Restorative Dentistry
26: 459469.
Schincaglia, G., Marzola, R., Giovanni, G., Chiara,
C. & Scotti, R. (2008) Replacement of mandibular
molars with single-unit restorations supported by
wide-body implants: immediate versus delayed
loading. A randomized controlled study. The
International Journal of Oral & Maxillofacial
Implants 23: 474480.
687 | Clin. Oral Impl. Res. 26, 2015 / 671687
Copyright of Clinical Oral Implants Research is the property of Wiley-Blackwell and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.