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ARTICLE
Comparing clinical outcomes of immediate implant placement
with early implant placement in healthy adult patients
requiring single-tooth replacement in the aesthetic zone: a
systematic review and meta-analysis of randomised controlled
trials
✉
Aisha Maria Asghar1 , Durre Sadaf2 and Muhammad Zubair Ahmad3

© The Author(s), under exclusive licence to British Dental Association 2023

KEY POINTS
● This can help with making a clinical decision on the timing of implant placement in the aesthetic zone.
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● This can help with the discussion with the patient on the pros and cons of each option in detail.
● Provides a better understanding of the pros and cons of each clinical scenario so as to be more prepared and to predict the
outcome better.

BACKGROUND: The aim of this systematic review and meta-analysis was to assess the clinical efficacy of the immediate implant
placement (IIP) protocol in the aesthetic zone with early dental implant placement (EIP) protocol.
METHODS: Electronic databases MEDLINE (via OVID), EMBASE (via OVID), ISI Web of Science core collection, Cochrane, SCOPUS, and
Google Scholar were searched for the studies comparing the two clinical protocols. Randomised controlled trials were included.
Cochrane Risk of Bias tool (ROB-2) was used to assess the quality of included students.
RESULTS: A total of six studies were selected. Implant failure was observed at 3.84%, 9.3%, and 4.45% in three studies while in the
other studies, no implant failure was reported. Meta-analysis of four studies showed no statistically significant difference in the
vertical bone levels between IIP and EIP (148 patients), mean difference (MD)0.10 [95% CI: –0.29 to 0.091.32] P > 0.05. Meta-analysis
of two studies showed the probing depth between IIP versus EIP was not significantly different (100 patients), mean
difference(MD)-0.00 [95% CI; –0.23 to 0.23]; P > 0.05. The pink aesthetic score (PES) was improved in EIP as compared to IIP with a
statistically significant difference (P < 0.05).
CONCLUSION: The available evidence supports the clinical efficacy of the IIP protocol. Present findings indicate aesthetics and
clinical results of immediate implant placement protocol are comparable to early and delayed placement protocols. Therefore,
future research with long-term follow-up is warranted.
Evidence-Based Dentistry (2023) 24; https://doi.org/10.1038/s41432-023-00902-7

INTRODUCTION
The replacement of a single tooth in the anterior region is
challenging for clinicians due to its aesthetic and functional
requirements. A single-tooth implant in the aesthetic region is
considered a treatment of choice due to the successful and
predictable osseointegration. However, despite the high survival
rate of implants, aesthetic concerns in anterior regions are the
main focus for patients and clinicians1.
The success of the implants depends on the condition of the
periodontal support system. The hard and soft tissues around
dental implants undergo a very complicated healing and
remodelling process which results in dimensional changes in
bone both vertically as well as horizontally. Implants can be placed
at any time post-extraction starting from immediately after
removal of the tooth structure to a few years after the patient
has lost the tooth provided there is space present to restore it.
The international team for implantology (ITI) defined the
timings of placement post-extraction into three types:
Immediate Implant Placement involves the placement of the
dental implant in the socket on the same day as the extraction.
This concept was explained by Schulte and Heimke in 19762 and
was reintroduced in the same year by Lazzara3.
Early Implant Placement is when dental implants are placed
after soft tissue healing (4–8 weeks) or with partial bone healing
(12 to 16 weeks) after tooth extraction.
Late Implant Placement is when implants are placed after
complete bone healing (six months or more after tooth
extraction).

1
Mix practice, Good Wood Court Dental Practice, 52-54 Cromwell Road, London BN3 3DX, UK. 2Microbial Disease Department, University College London, Eastman Dental
Institute, London WC1E6DE, UK. 3Restorative Dentistry Department, College of Dentistry in Ar Rass, Qassim University, Ar Rass 58883, Saudi Arabia.
✉email: aisha.asghar@hotmail.com

Received: 25 November 2022 Accepted: 23 March 2023

Published online: 5 June 2023
2
In more recent years immediate and early placements have
been gaining popularity. Immediate placement is even more well-
liked. Advantages of this approach include shorter treatment time,
less surgical trauma, reduced number of appointments, shorter
healing time because of a single surgical procedure, and Improved
aesthetics.
Notably, studies indicate a higher risk of failure after immediate
implant placement when compared with early or delayed
placement4. The aesthetic outcome is more predictable with early
or delayed placement as compared to the immediate as soft tissue
healing and shrinkage cause dimensional changes which cannot
be precisely calculated prior to the procedure. Most of the studies
have reported a high success rate of dental implants and implant-
supported restorations5,6. The procedure still carries a risk of
failure which involves peri-implant bone loss.
Peri-implantitis is a pathological condition occurring in tissues
around dental implants, caused by inflammation in the peri-
implant mucosa and progressive loss of supporting bone7.
Untreated peri-implant mucositis can progress to peri-implanti-
tis, but the histological pattern is still unclear. It is characterised by
inflammation in the peri-implant connective tissue around the
implant leading to bone loss.
There is a lack of clarity on the evaluation of the success of
implants1. The basic criteria for implant success in clinical dentistry
are immobility, absence of peri-implant radiolucency, adequate
width of the attached gingiva, and the absence of infection.
Moreover, co-existing medical conditions and smoking also play an
important role in evaluating the success of an implant8. Dental
researchers along with clinicians are working fast and diligently on
implant-modifying surfaces to offer the best replacement for a
missing tooth or teeth. There is a vast amount of ongoing research
dedicated to improve bonding, decreasing the time for osseointe-
gration, and promoting bone apposition9. Several surface modifiers
such as hydroxyapatite, composites, carbon, glass, ceramic and
titanium oxide have been tried. Mechanical treatments (sandblast-
ing), chemical treatments (acid etching, fluoridation, medication),
electrochemical treatments (anodic oxidation), vacuum treatments,
thermal treatments, and laser treatment are also part of research10.
Following tooth extraction, alveolar bone undergoes dimen-
sional changes both buccolingually as well as longitudinally
consequently and as a result, there is a three-dimensional
reduction of the bone volume.
Some of the risk factors which can lead to implant failure
include chronic periodontitis, poor oral hygiene, smoking and
alcohol, diabetes, history of Implant failure11. Certain risk factors
associated with the surgical technique of implant placement such
as overheating of the surrounding bone with the handpiece bur,
traumatic surgical procedure, perioperative bacterial contamina-
tion, premature loading, fitness discrepancies, surface purity and
sterility, occlusion trauma, dense hypovascular or traumatized
bone can also lead to the failure of the prostheses12–14.
Histologically, peri-implantitis lesions often show circumferen-
tial patterns of bone loss and have bigger inflammatory lesions
when compared to periodontitis. Clinically, they present as
inflammation at the site and increased probing depth as
compared to baseline measurements and bleeding.
Ting et al.15, concluded in their systematic review that more
research is required to fully understand the aetiology and risk
factors of peri-implantitis. It was concluded the incidence of peri-
implantitis increases after five years of function and the risk is
higher in patients with periodontitis or a history of it although the
pathogens in peri-implantitis are different from periodontitis and
not only limited to periodontopathic pathogens and may include
opportunistic pathogens. Both clinical and radiographic assess-
ments are equally vital to diagnose and assess the disease. Several
guidelines and measurement techniques have been proposed to
evaluate the presence or absence of peri-implant bone levels and
conditions. Clinical evaluation of the soft tissue around the
implant and general oral hygiene assessment is vital on a regular
basis. Regular radiographic evaluation is also essential with regular
comparisons with baseline radiographs. Dental implants must be
visually examined and probed at least once a year. Bleeding on
probing (BOP) must be identified and recorded. It is vital that it
must be differentiated from bleeding due to soft tissue trauma. It
is generally perceived that following implant installation and initial
loading, some crestal bone height is lost which is approximately
between 0.5 and 2 mm as a part of the healing process16. If there
is any additional radiographic evidence of bone loss, this strongly
suggests peri-implant disease17.
This systematic review was conducted to evaluate the safest
approach to restoring an edentulous space in the aesthetic zone
using a dental implant. The comparison was made between
immediate and early placement to assess which technique carried
a low risk of peri-implantitis irrespective of the loading times or
any bone grafting procedures.
MATERIALS AND METHODS
The review followed the Preferred Reporting Items for Systematic
Reviews and Meta-Analysis (PRISMA) guidelines 2020. The
protocol was registered in PROSPERO (ID# CRD42022297778).
Search strategy
Five electronic databases were searched: MEDLINE (via OVID),
EMBASE (via OVID), ISI Web of Science core collection, Cochrane,
and SCOPUS from inception to February 2022 (See Search
StrategyAppendix I). In addition, grey literature was searched
using Open Grey and Google Scholar to explore unpublished
studies; finally, there was a search of the reference list of included
studies. The search included a combination of text words,
keywords, MeSH terms, and synonyms developed from the
Participants-Intervention-Comparator-Outcomes-Study (PICOS)
design format and searched from MEDLINE (via Ovid), books,
and related journal articles. The studies exclusively published in
English were selected.
Supplemental Material (Appendix 1) describes the details of the
search strategy of electronic databases. The reference list of all of
the selected studies was also explored.
Selected studies from electronic databases and other sources
were imported to a reference management system, EndNote
(version 20, Clarivate Analytics). Duplicate studies were
removed by the EndNote (version 20, Clarivate Analytics)
program. Only randomised controlled trials (RCT) conducted
on humans were selected (see the supplemental material for
selection criteria).
Eligibility criteria
A structured review question in PICOS format was formulated as
follows:
Has immediate implant placement (Intervention) shown a
similar success rate in terms of bone loss, probing depth, and
aesthetic scores (Outcome) as early implant plant placement
(Comparator) in healthy adult patients requiring single-tooth
replacement in the anterior region (Population)?
The principal investigator (AMA) designed the search strategy
and carried out the searches. A consultation was sought from a
librarian and information specialist with expertise in systematic
reviews.
A broad search strategy was developed to cover all single-tooth
implant systems so important studies would not be missed.
Moreover, the terminology was focused on combining areas of
PICOS:
● P (Population/Problem): Healthy adult humans (>18 years)
(participants) needing single tooth replacement in
aesthetic zones.
● I (Intervention): Single-tooth implant systems with full immedi-
ate placement.
● C (Comparison): Single-tooth implant systems with early
placement (comparisons).
● O (Outcome): Bone loss, probing depth, pink aesthetic score,
and white aesthetic score.
● S (Study design): Clinical studies and interventional study
design (Randomised Controlled Trial).
Evidence-Based Dentistry (2023) 24

Inclusion criteria
● Only RCTs published in the English language on healthy adults
(>18+) years were included
● Studies on single tooth implant placement in aesthetic zones
● Studies comparing immediate versus early implant placement
protocol.
Exclusion criteria
● Animal studies
● Reviews
● Studies not published in the English language
● Letters and comments
● In vitro studies
● Cross-sectional design
● Case reports.
All studies from electronic databases and other sources were
imported into the reference management system, EndNote (version
20, Clarivate Analytics). The study selection process was executed
and then reviewed independently by two reviewers (AMA and DS).
Any disagreement concerning eligibility was planned to be resolved
by contacting the supervisor (MZA). It was not needed. If multiple
reports of a study exist, it was combined in such a way that the
study of interest was the original report.
Data collection and risk of bias
The following information was collected from each study; author/
year, sample size/dropout, types of teeth, intervention,
Fig. 1 The PRISMA flowchart 2020 presented the process of study selection.
Evidence-Based Dentistry (2023) 24
3
comparison, types of implants, augmentation, time of definitive
restoration placement, duration of follow-up, outcome interven-
tion, outcome comparison, and conclusion.
Cochrane criteria RoB 2.0 was used to assess the risk of bias in
each study. Data extraction and risk of bias assessment were done
by two reviewers (AMA and DS) independently. Any disagreement
was decided to be resolved through discussion; a third reviewer
(MZA) arbitrated if there was no consensus. The cohen-kappa test
was used to check inter-examiner reliability (k = 1.0). There was no
disagreement.
Data synthesis
Mean difference and 95% confidence interval to measure effect
size was included. The random-effect model for the Cochrane
Collaboration’s software (RevMan 5.3, Copenhagen: The Nordic
Cochrane Centre) for meta-analysis was used. Heterogeneity was
assessed using the I- square (I2) statistics; an I2 value greater than
70% was judged as substantial heterogeneity.
RESULTS
Studies selection process
PRISMA flow chart 2020 was used for the selection of studies
(Fig. 1). A total of 1200 citations from electronic databases and 400
from other sources were identified. A total of 500 citations were
identified after duplication removal and were eligible for screen-
ing by the abstract and title. Eighteen studies were found suitable
for full-text evaluation. A total of 12 studies were excluded for
the following reasons: two studies were excluded because they
were not completed, five studies were excluded because of
4
the different comparators, and five studies were excluded due to
different comparators. Six studies were selected for qualitative and
quantitative analysis.
Characteristics of studies
The characteristics of the studies are presented in Table 1.
Study design. All six studies were randomized controlled trials
conducted on adult patients who needed single tooth
replacement1,18–22. Most studies (No of studies = 4) were
conducted in University dental clinic setup1,19,20,22. One study
was conducted in a private specialist practice18, and one study
lacked the information of clinical set-up21. Treatment duration was
mentioned by four studies18–21. which was between 2004 to 2016,
and 2 studies didn’t mention the duration of treatment1,22. Sample
size per group was variable from 9 to 35 among studies. A total of
five studies out of six used Straumann implants1,18,20–22, and one
study used Biomet USA19. Five studies used soft and hard tissue
augmentation1,18–20,22, and one study didn’t use any augmenta-
tion21. Autogenous bone for augmentation was used by one
study, collagen membrane was used in three studies1,18,20. Most
studies had placed definitive restoration within four months of
implant placement.
Follow-ups were variable among studies. Follow-up was
conducted from two years to four years by three studies19,21,22,
and two studies conducted follow-up for one year18,20.
Comparing different outcomes in immediate versus early
implant placement
A study by Palattella et al. measured implant stability quotient
(ISQ) and ISQ final restoration in which ISQ was significantly better
in early implant placement than immediate implant placement.
However, Final Restoration (ISQ) was not significantly different
between the two groups21.
Implant failure was observed at 3.84%, 9.3%, and 4.45% in three
studies1,22 while in other studies no implant failure was seen.
Meta-analysis
The forest plot showed significant improvement in the PES score
with early implant placement than immediate implant placement:
4 studies, No of patients=184; Mean Difference (MD): 0.84 [95%
CI:0.36–1.32]; P = 0.0006; I2 = 19% (Fig. 2).
The vertical bone level between immediate implant placement
and early implant placement was not significantly different: 4
studies, No of patients=148; MD:-0.10 [95%CI:= –0.29 to 0.09];
P = 0.32; I2 = 66% (Fig. 3).
The probing depth between immediate versus early implant
placement was not significantly different: No of studies= 2; No of
patient=100; MD:0.00 [95% CI; -0.23-0.23]; P = 0.99; I2 = 55%.
Risk of bias
A Robvis visualization tool was used for generating summary plots
and traffic light plot.
Four out of six studies were ranked as low risk of bias1,18,20,21,
and two studies were at high risk of bias19,22. Three studies have
some concerns about the process of randomisation18,19,22. Three
studies have a bias due to missing data19,20,22 (Fig. 4a). Also,
more than 65% of the studies were ranked as low risk of bias
(Fig. 4b). The overall risk of bias was categorised as a moderate
risk of bias.
Publication bias
Publication bias was not conducted as the studies included were
less than ten and the publication bias test subsequently becomes
not meaningful.
DISCUSSION
Palattella et al. (2008) conducted the RCT comparing the
immediate and early implant placement protocol21. Although
the study had a small sample size of 16 patients and recall time
was up to two years. Clinical parameters used in this study were
the papilla index—both mesial and distal (single implant
placement cases were used). Furthermore, the position of the
mucosal margin was measured and the distance from the most
apical point of the gingival margin to the implant shoulder was
measured in millimetres and periapical radiographs. Sixteen
patients were selected for this study between 2004 and 2005 to
replace a single tooth in the upper arch. The study has very strict
inclusion and exclusion criteria. The patients were divided
randomly into two groups and tapered effect Straumann dental
implants (10 mm to 12 mm in length) were used:
Test Group: Immediate placement following the extraction and
restoring (non-occlusal loading).
Control Group: Implant placement eight weeks post-extraction
and immediate restoration.
This study utilised the ISQ which was measured at the time of
placement and also measured at the time of delivering the final
restoration. One included study used ISQ in its results. There was
a negligible difference in the papilla index, mucosal margin, and
mean bone resorption after two years between the groups.
There was a significant difference noted in the ISQ between the
two groups at the time of placement but was no longer
significant at the two-year review period. These results indicate a
slightly compromised stability in the immediate placement
protocol at the time of the procedure yet they are unlikely to
affect the procedure’s success. This study has a low risk of bias
and gives very good evidence of early placement procedures are
slightly safer in the early stages. This study also emphasised the
importance of primary stability and if loading is required it
should be non-occlusal due to the risk of movement and no
implant movement is the most critical factor in
osseointegration23.
Hof et al. (2015) had the biggest sample size (n = 153) and the
longest recall period (over four years)19. Their study looked at
radiological as well as clinical and aesthetic aspects with all
treatment protocols. There was the assessment of plaque, probing
depth, bleeding on probing, recession, the height of buccal
keratinized mucosa, gingival biotype, interproximal bone levels,
horizontal implant toot distance, and crown length. Radiographs
were also used for assessment. The aesthetic assessment was
performed by two observers using PES and WES, papilla index, and
patient-based evaluation based on subjective aesthetic score. There
is a lack of clarity and missing details of randomisation in the study
which is considered as a limitation. It is a retrospective study but it
can be relevant for clinicians as it offers insights into several clinical
scenarios and has used several assessments, which can be useful
from the clinical viewpoint. The study showed excellent aesthetic
outcome but the strict selection criteria meant that complicated
cases or moderate to high-risk cases were excluded which is
favourable to achieving a great outcome. Immediate loading carries
a significant risk of failure and long waiting time for prostheses and
is not ideal for patients and is usually considered as a drawback by
patients. From the patient’s perspective, immediate implant
placement and loading is preferred but it must be done with
caution. Looking at several scenarios and assessments together
makes this study very relevant to clinical dentistry.
Arora and Ivanovski (2018) also used the PES and WES for aesthetic
assessment18. The biggest drawback of this study was the lack of
randomisation, but the procedures were carried out by the same
surgeon and the same implant system (Straumann) was used in both
groups which gives a meaningful comparison of the two protocols. A
small sample size of 30 patients was divided into two groups and
implants were placed in the anterior maxilla. There was noticeable
shrinkage observed in immediate implant placement cases affecting
the aesthetic outcome. Therefore, it was concluded that short-term
results for both protocols are relatively similar but careful patient
selection is vital if the immediate placement is planned for a good
aesthetic outcome. The mid-facial recession discussed in this study
shows similarity with similar findings with another randomised
control trial21 included in this systematic review.
The other retrospective study was Soydan et al., (2013) which
had a high risk of bias due to lack of clarity on details of the study
procedures and randomisation22. They used bone levels value
from radiographs and mobility or pain to assess the success or
failure of the procedure.
Evidence-Based Dentistry (2023) 24
 Table 1. Characteristics of studies comparing immediate vs early implant placement.
Author/Year Settings Study Design Treatment Sample size Types of Intervention (n) Comparison Types of Augmentation Permanent Duration Conclusion
Duration teeth (n) implants restoration of follow-
placement up
Palattella et al./2008 NR Randomized 2004-2005 18 Anterior- G 1 Immediate G2 Early Tapered None NR 24 months No
Controlled single Implant Placement Implant Effect difference
Trial tooth (n = 9) Placement Straumann, between
(Maxilla) (n = 9) Switzerland the two
groups
Soydan et al./2013 Baskent Randomized NR 50 Maxillary G 1 Immediate G2 Early Straumann, Autogenous 2 months 24-84 for No
University Controlled and Implant Placement Implant Switzerland bone and (mandible)- G1, 20-90 difference
Turkey Trial mandible (n = 26) Placement xenogenic bone 4 months months between
(anterior (n = 24) (maxilla) for G2 the two

Evidence-Based Dentistry (2023) 24

and groups
posterior)
Hof et al./2015 Bernhard Randomized 2008-2011 153 Anterior- G 1 Immediate G2 Early All types: Autologous NR 4.5 ± 2.4 No
Gottlieb Controlled single Implant Placement Implant Branmark, bone chips years difference
University, Trial tooth (n = 26) Placement Nobel combined with between
Austria (Maxilla) (n = 35) Replace, deproteinized the two
Sweden bovine (Bio-Oss) groups
Rieder et al. a/2016 University of Randomized NR 48 Anterior- G 1: Immediate G3: Early Imp. (Straumann, Collagen after 10–12 8 months No
Erlangen- Controlled single implant. placement Placement + Germany) membrane(Bio- weeks difference
Nuremberg, Trial tooth +immediate Immediate Gide) between
Germany (Maxilla) temporary (n = 12) temp. rest, the two
(n = 12) groups
Rieder et al. b/2016 University of Randomized NR 48 Anterior- G2: Immediate Imp. G4= Early Straumann, Collagen 10–12 weeks 8 months No
Erlangen- Controlled single Placement+ Early implant Switzerland membrane(Bio- difference
Nuremberg, Trial tooth restoration (n = 12) placement Gide) between
Germany (Maxilla) +Early the two
restoration. groups
(n = 12).
Huynh-BH et al./2018 University of Randomized December 46 Anterior- G 1 Immediate G2 Early Straumann, Mineralized after 4 12 months No
Texas, Taxes Controlled 2010- single Implant Placement Implant Bone Level freeze dried weeks difference
Trial February tooth (n = 20) Placement Implant bone allograft + between
2013 (Maxilla (n = 15) SLActive Collagen the two
and Membrane groups
Mandible) (BioGide)
Arora et al./2018 Specialist Randomized 2014 to 30 Anterior- G 1 Immediate G2 Early Straumann, deproteinized 3–4 months 12 months No
Practice Controlled 2016 single Implant Implant Switzerland bovine bone difference
Australia Trial tooth Placement(n = 15) Placement (Bio-Oss) between
(Maxilla) (n = 15) +Collagen the two
Membrane (Bio- groups
Gide)
5
6
Fig. 2 Forest plot representing pink aesthetic score (PES) comparing immediate implant placement versus early implant placement.
Fig. 3 Forest plot showing a vertical bone loss in immediate versus early implant placement.
There were two parameters of my interest in one of the studies
included in this systematic review1. It included 48 patients divided
into four groups, with a single failing incisor in the maxilla.
Group 1a: Immediate implant placement and immediate
temporary prosthetic replacement. The permanent restoration
was planned after the completion of bone and soft tissue healing
(10–12 weeks afterward).
Group 1b: Immediate implant placement with an early
temporary restoration that is four to six weeks of undisturbed
healing24 and final restoration 6-8 weeks afterwards.
Group 2a: This included the initial undisturbed healing period
(6 weeks)following the extraction and early placement protocol in
the dental implant25 followed by an immediate temporary crown.
The final restoration was planned 10 to 12 weeks after the initial
implant placement.
Group 2b: This group also had initial undisturbed healing after
extraction (6 weeks) followed by early implant placement and
early temporary restoration four to six weeks later. The final
restoration was placed after a further delay of six to eight weeks.
The overall treatment time was matched as 10 to 12 weeks after
implant placement surgery in all four groups. The study has a low
risk of bias but in contrast, the sample size is very small, the other
limitation is the short recall period. This study compared the time
of implant placement as well as the time of restoration placement.
Successful implant placement in the aesthetic zone does not
only restore the gap but also requires the harmonious integration
of the restoration into the patient’s overall appearance. Most of
the studies incorporate the use of the PES and WES to assess and
evaluate the aesthetic outcome of the restoration. The PES was
first introduced by Furhauser26 to evaluate the soft tissue around a
single implant-supported restoration. Belser24 later introduced the
PES and WES to evaluate the aesthetic outcome of the soft tissue
around the crown and visible part of the restoration itself
respectively. PES comprises of:
● Mesial papilla
● Distal papilla
● The curvature of facial mucosa
● Level of facial mucosa
● Root convexity/soft tissue colour and texture at the facial
aspect.
WES comprises of:
● Tooth form
● Outline/volume
● Colour (hue/value)
● Surface texture
● Translucency/characterisation.
Together these ten parameters are compared with the contra-
lateral tooth and graded from 0 to 2. The PES and WES cover
almost every cosmetic aspect of the soft tissue as well as the
restoration and hence applied in almost every study as a reliance
index. These indices are now widely used for aesthetic assessment
of restoration but there is a need for further standardisation and
refinement. The subjective and objective success of implants in an
aesthetic zone is an area of growing interest for clinicians as well
as patients. The limitation of these scores is caused by the small
sample size and will require further refinement with prospective
clinical trials.
The earliest signs of peri-implantitis are inflamed soft tissue,
bleeding on probing (BOP), and increasing pocket depth (PD)
(Fig. 5)27. Studies have indicated that poor OH and smoking have a
significant influence on bone loss whereas factors such as
occlusion, tooth cleansing, and lengths of cantilevers have
relatively less influence on bone loss16. Adequate bone levels
are vital for the long-term success of the procedure. Moreover,
good treatment planning takes into account several factors such
as adequate vertical soft tissue thickness, micro gap, implant
surface, screw retention, ideal emergence profiles of restoration,
and the surface of zirconia in the subgingival region - prior to the
treatment.
Dental implants are vital in oral rehabilitation now, but atrophic
ridges are still a challenge for clinicians. Bone augmentation is
often indicated in cases to achieve stability and an acceptable
aesthetic outcome. A noticeable finding of this systematic review
was the wide range of surgical protocols adopted by clinicians
when placing dental implants such as autogenous bone grafts,
Bio-Oss membrane, deproteinised bovine bone, and collagen
membrane. There was a lack of details of the surgical procedures
involved such as donor sites, and any post-op complications of
such procedures were missing in the studies. These procedures
have gained popularity, especially in the last two decades. The
advantage is the correction of alveolar ridge height and width
improving surgical, aesthetic, and prosthetic success28. Autolo-
gous bone grafts offer several advantages such as lack of
immunological response and hence are considered as the “Gold
Standard” and studies have indicated a success rate of over 95%29.
Intraoral donor sites offer several benefits like easy access, less
discomfort and morbidity, and close proximity to donor and
recipient sites. Like any treatment, it presents a risk of failure and
unpredictable resorption, additional surgical wound, morbidity,
and restricted bone availability and donor sites. Extraoral sites are
rarely required for dental implants and are used in complicated
procedures such as mandibular reconstruction30. Guided bone
regeneration is gaining popularity among clinicians offering
dental implants and several studies are showing promising results
Evidence-Based Dentistry (2023) 24

Fig. 4 a Risk of bias plot. b Risk of bias graph.
Fig. 5 Forest plot showing probing depth (PD) in immediate versus early implant placement.
in both aesthetic and non-aesthetic zones31. The concept
advocates the regeneration of osseous defects is attained through
the application of occlusive membranes. Consequently, non-
osteogenic cells are excluded in the region thereby increasing the
population of the cells with the osteogenic ability to inhabit the
osseous wound32. Allogenic bone grafts are also gaining
popularity and an organic bovine bone is also gaining attention
from clinicians due to promising results33,34. Most of the studies
used the Straumann system in the RCT.
The overall failure rate is negligible which is common for these
studies. There is no doubt that immediate implant placement is a
viable option and is usually favoured as it is considered quicker
and less surgical procedures and appointments saving cost and
time both for the clinicians as well as the patients. This procedure
requires very careful case selection such as low lip line, thick
biotype on gingival mucosa, operators’ skill and experience, the
integrity of buccal bone, and any need for bone graft. As such, it is
difficult to predict the healing and final position of soft tissue but
most studies as above have revealed promising results.
There is an inconsequential difference between the outcome of
immediate and early implant placement protocols. It is still
clinically pertinent to understand the risks related to each protocol
and to pay attention to case selection and surgical and prosthetic
protocol also must be followed very carefully.
There is 19% heterogeneity (I2 = 19%) when the PES is utilised
to do a comparison between immediate and early implant
placement indicating the validity of results favoringthe early
Evidence-Based Dentistry (2023) 24
7
implant placement protocol.The rest of the heterogeneityis
I2 = 66% and I2 = 55%when the comparison was based on vertical
bone loss and bleeding on probing among both protocols
respectively.Hence the results must be interpreted with caution
due to moderate heterogeneity values.
The results of this systematic review and meta-analyses echo
similar results as those or previous systematic analysies; moreover,
there is no significant effectof the timing of implant placement on
the success and failureof the treatment. Another systematic review
comparing the placement of implant timings indicated similar
resultswith the failure rate of <5% in the two protocols and also
indicated the failure was more linked with immediately loaded
implants35.Sample size, number of patients per groups and the
follow-up period was not adequate in studies in this review. The
total sample size was 18 to 153, with 9 to 35 patients per group
and a follow-up period that varied from eight months to five years.
Only one implant failed in two studies1,22. Most of the studies used
bone and soft tissue augmentation. Missing outcome data was
observed in three studies19,20,22. Missing outcome data may
potentially likely to increase the effect size. It was observed that
there was an inadequate randomisation process in three
studies18,19,22. Over all two studies out of six were ranked as
having a high risk of bias (Table 2).
Since the studies included a single placement in the aesthetic
region, this makes the aesthetic outcome very important and
relevant. Chen and Buser36 conducted a systematic review on the
aesthetic outcome of the implants placed in the anterior region.
8

(comparison)
They reported that immediate protocol carried a high risk and

9.27 ± 1.62;
6.62 ± 3.24

8.10 ± 3.25

5.53 ± 0.43
Score PES
Aesthetic

10.4 ± 2.2
Pink showed buccal recession of >1 mm and soft tissue position was
move favourable in the early placement. It is prudent to consider

NR

NR
this finding when treating aesthetic zone as small changes that
can be detrimental to the final outcome.

9.40 ± 1.76;
8.47 ± 2.08

7.93 ± 3.21

6.60 ± 0.44
Score PES
Aesthetic

10.7 ± 2.4
The exclusion of grey literature and studies not in the English
Pink

language is one of the study’s limitations. Furthermore, only RCTs

NR

NR
(I)

were included. Both these limitations may slightly affect the

findings of the meta-analysis. It is also important to note that very
Comparison
Restoration
ISQ final

few RCTs are conducted with direct comparisons between

73 ± 2

different protocols. It must also be highlighted the studies

NR

NR

NR

NR

NR

NR
conducted have a very short recall period and there should be
studies to be conducted with long recall periods to assess the
Restoration

long-term success of the procedure.

ISQ final

72 ± 3

NR

NR

NR

NR

NR

NR
(I)

Clinical implications
It is essential to keep oneself updated with the ongoing clinical
Quotient
Stability
Implant

research concerning dental implants and to follow the protocols

(ISQ) C
74 ± 3

correctly as the latest studies are reporting promising results.

NR

NR

NR

NR

NR

NR

Some recent studies have shown comparable results over five

years and ten years recall periods with different placement
Quotient
Stability
Implant

(ISQ) (I)

protocols37. It is safe to say that several parameters play a role in

65 ± 5

NR

NR

NR

NR

NR

NR

the successful outcome of treatment which includes both soft and

hard tissue in both the aesthetic and non-aesthetic zone. In the
(Mean ± SD)

anterior region, the case selection becomes extremely critical and

2.53 ± 0.22
Depth (C)

3.42 mm
Probing

factors such as the thickness of gingivae, presence of keratinized

mucosa, need for any hard or soft tissue grafting, loading
NR

NR

NR

NR

NR

protocols, lip line, etc. are very critical, and thorough assessment
(Mean ± SD)

is required in treatment planning. Therefore, future studies must

2.45 ± 0.15
3.57 mm
Depth(I)
Probing

also be conducted on patient-focused outcomes and different

protocols of placements and loading.
NR

NR

NR

NR

NR

The studies selected for this systematic review had very little
consideration of patient-centred factors. This is often missed in
(Comparison)
Radiographic
Bone Level

clinical research but is now gaining popularity in research.

0.46 ± 0.54

0.06 ± 0.27

0.09 ± 0.27
0.88 mm

NR

NR

NR

CONCLUSION
(Intervention)
Radiographic

The data show that there is a lack of uniform classification and

(mean ± SD)
Bone Level

0.54 ± 0.51

0.07 ± 0.27

0.05 ± 0.33

diagnostic methodology for peri-implantitis38.

0.55 mm

The outcome of this systematic review is that there is no

NR

NR

NR

significant difference in the success of immediate and early

placement of implant protocol and the timing of placement has
(comparison)

no role in bone loss. The protocol of immediate placement

however carries a risk of aesthetic failure due to the unknown final
Implant
Failure

None

None

None

None

None

None

None

position of soft tissue. There is careful patient selection and

complicated soft tissue handling, and procedures may be
(Intervention)

required.
Table 2. Outcomes comparing immediate versus early implant placement.

Unfortunately, this systematic review showed that only a small

Implant

1/3.84%
Failure

portion of published data on restorative treatments could be used

None

None

None

None

None

for inference. There is a need for studies with a long recall period
1

to assess the long-term success of any protocol.

(Comparison)
Drop out

None

None

None

None

None

None

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AUTHOR CONTRIBUTIONS
AMA: conceptualization, data extraction, methodology, software, writing, editing, and
reviewing. DS: methodology, data extraction, software, and analysis. MZA: software,
writing, reviewing, and editing.
FUNDING
This research work was self-funded.
COMPETING INTERESTS
The authors declare no competing interests.
ADDITIONAL INFORMATION
Supplementary information The online version contains supplementary material
available at https://doi.org/10.1038/s41432-023-00902-7.
Correspondence and requests for materials should be addressed to Aisha Maria
Asghar.
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