Received: 19 September 2021 | Revised: 9 December 2021
DOI: 10.1111/edt.12730
COMPREHENSIVE REVIEW
Implant treatment after traumatic tooth loss: A systematic
review
Frej Nørgaard Petersen1
1
Department of Oral and Maxillofacial
Surgery, Copenhagen University Hospital,
Rigshospitalet, Copenhagen, Denmark
2
Research Area: Oral Surgery, Section
for Oral Biology and Immunopathology,
Department of Odontology, Faculty of
Health and Medical Sciences, University
of Copenhagen, Copenhagen, Denmark
Correspondence
Frej Nørgaard Petersen, Department
of Oral and Maxillofacial Surgery,
Copenhagen University Hospital,
Rigshospitalet, Copenhagen, Denmark.
Email: frejnoergaardpetersen@gmail.com
© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Dental Traumatology. 2022;38:105–116. 
| Accepted: 10 December 2021
| Simon Storgård Jensen1,2 | Morten Dahl1
Abstract
Background/Aims: Treatment after traumatic tooth loss is challenging and is currently
guided by expert opinion and the individual patient situation. The aim of this study
was to provide an overview on the outcome of dental implant treatment in the ante-
rior maxilla after traumatic tooth loss, based on a systematic review of the existing
evidence.
Materials and Methods: A systematic search of the literature was performed on
PubMed, Cochran Library and Web of Science following the PRISMA guidelines based
on a structured research question (PICO). All clinical studies of five patients or more
with follow-­up of at least 1 year after implant loading were included. Patients were
at least 18 years of age. Cohen’s Kappa-­coefficient was calculated. The Newcastle–­
Ottawa Scale was applied to assess the quality of the included studies. Descriptive
statistical methods were applied.
Results: Nine hundred and ninety-­nine articles were identified through the systematic
search. Finally, six articles were eligible for inclusion. The studies comprised prospec-
tive and retrospective cohort studies and case series. From these, 96 patients with
120 implants were included. The age ranged from 18 to 59 years. The survival rates of
implants and superstructures were 97% and 95%, respectively, after a mean follow-
­up of 3.5 years. Mean marginal bone resorption was 0.56 mm (range 0.21–­1.30 mm).
Complication rates were 7% and 11% on implant and superstructure level, respec-
tively. Patient-­reported outcome measures and objective evaluations showed a high
level of satisfaction with the aesthetic outcome. Bone augmentation was performed
in 60 implant sites. Three patients underwent pre-­surgical orthodontic treatment.
The maxillary central incisor was the most frequently replaced tooth (70%).
Conclusions: This systematic review revealed a low level of evidence on the outcome
of dental implant treatment after traumatic tooth loss. Systematic reporting of treat-
ment outcomes of tooth replacements after dental trauma is highly encouraged to
further guide dentists for the benefit of these challenging patients.
KEYWORDS
dental implants, maxilla, maxillofacial injuries, tooth loss, traumatic dental injuries
wileyonlinelibrary.com/journal/edt | 105
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106
1 | I NTRO D U C TI O N
Traumatic dental injuries (TDIs) are frequently observed in the pri-
mary (23%) and permanent dentitions (15%).1 The maxillary central
incisors are the most frequent teeth (70%) exposed to TDI. 2–­4 TDI is
most common among children (8–­12 years), and boys are more prone
3,4
to TDI (1.5:1). The difference may be explained by environmen-
tal factors, such as sports.5 Furthermore, increased overjet/class II
malocclusion, short facial profile, low socioeconomic status and not
having orthodontic treatment are considered etiological factors for
TDI.6,7
8
The majority of TDIs have a good prognosis. However, intrusions
and avulsions have been reported to be at higher risk for ankylosis-­
related (replacement) and infection-­related (inflammatory) resorp-
9–­12
tion, 0.5–­2% and 0.5–­3%, respectively. When a traumatized
tooth has been deemed hopeless, several replacement alternatives
exist –­these include orthodontic space closure, autotransplantation,
resin-­bonded bridge, and a tooth-­ or implant-­supported fixed den-
tal prosthesis (FDP). Irrespective of the treatment option indicated,
most often an interdisciplinary approach between a prosthodontist,
orthodontist and surgeon is needed.
In 1971, Brånemark was the first to report on the osseointe-
grated dental implant and a new alternative for prosthetic tooth re-
placement was introduced.13 Today, implant therapy is considered
a reliable treatment to replace missing teeth, and with a long-­term
prognosis equal to tooth-­supported FDPs.14,15 The advantages of
dental implants include low morbidity, high biocompatibility and
good treatment prognosis. In addition, sound adjacent teeth can be
left untouched, thereby avoiding compromising their pulps while
reconstructing a missing tooth. Disadvantages include potential
technical, biological and aesthetic complications. These are more fre-
quent in implant-­supported single crowns than for tooth-­supported
FDPs.,14 although these are often easier to manage. From a cost-­
benefit point of view, the question would be why dental implants are
not the standard-­of-­care procedure for all patients with tooth loss.
The answer is that other factors to consider are the patient’s econ-
omy, general health and the different surgical procedures required.
Treatment with dental implants is considered to be contraindicated
until cessation of growth due to the risk of infraposition compared
to the adjacent teeth, as implants behave like ankylosed teeth.16–­18
Often, the traumatized teeth may be preserved as long-­term provi-
sionals, assuming that they are monitored closely and signs of patho-
logic conditions are addressed appropriately. Irreversible pathologic
conditions such as ankylosis, or infection-­related resorption, or apical
periodontitis not responding to endodontic treatment may warrant
decoronation or extraction. In growing young patients, the space must
be kept for later rehabilitation. This is best achieved with bonded re-
tainers, night splints and an intermediate removable prosthesis.18 In
cases where space must be increased or reduced, pre-­surgical ortho-
19
dontics should be initiated. Orthodontic treatment should be timed
according to later implant treatment, and in some cases may be used
to limit or treat alveolar bone resorption following TDI.20,21
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PETERSEN et al.
When teeth are extracted in the anterior maxilla, the labial bone
wall undergoes the highest degree of bone resorption, which is often
accompanied by soft tissue recession. This has mainly been ascribed
to the fact that the labial bone plate almost entirely consists of bun-
dle bone, which is nourished by the blood supply of the periodontal
ligament. 22 TDI will by itself often inflict additional trauma to the
alveolar hard and soft tissues causing horizontal and vertical bone
atrophy.19,23 Bone augmentation is often necessary to compensate
for the marked resorption following early tooth loss. A study re-
ported that 50% of all implants, as well as almost 75% of implants
placed in the anterior maxilla, required bone augmentation. 24 Soft
tissue augmentation may sometimes be indicated due to atrophy of
the peri-­implant mucosa. In addition, scar tissue often develops after
traumatic injuries and surgical procedures. 23 So far, no studies have
reported on the frequency of soft tissue augmentation following
TDI. However, a recent consensus paper recommends considering
soft tissue augmentation whenever placing implants in areas of aes-
thetic priority. 25
Considering the complexity of treating patients with traumatic
tooth loss, the aim of this study was to provide an overview of the
outcome of dental implant treatment in the anterior maxilla after
traumatic tooth loss, based on a systematic review of the existing
evidence.
2 | M ATE R I A L S A N D M E TH O DS
This systematic review followed the PRISMA guidelines (Preferred
Reporting Items for Systematic Reviews and Meta-­Analyses). 26
The following structured research question was developed
according to population, intervention, comparison and outcome
(PICO):
Population: Patients (at least 18 years old) with tooth loss in the
anterior maxilla due to TDI.
Interventions: Implant therapy in the anterior maxilla with subse-
quent prosthetic rehabilitation and with at least 1 year of loading.
Comparison: None.
Outcome: Primary: Implant survival. Secondary: Survival of su-
perstructures, peri-­implant marginal bone resorption, rate of
complications (intra-­ and postoperatively, biological, and tech-
nical). The recorded parameters were: tooth type replaced,
need for pre-­surgical orthodontics, need for hard and soft tissue
augmentation, vertical height change of adjacent teeth/contin-
uous tooth eruption and patient-­reported outcome measures
(PROMs).
A comprehensive search of the literature was completed in June
2021 with a combination of MeSH terms keywords and free text
words (Table 1) in the following databases: MEDLINE (PubMed),
The Cochrane Library and Web of Science. Only papers published
in English were included. No restriction on year of publication was
applied.
 TA B L E 1 Search strategy with description of search words used in MEDLINE (PubMed), Web of Science and The Cochrane library

Databases Search strategy Description

MEDLINE ("Injuries, Teeth" OR "Injury, Teeth" OR "Teeth Injury" OR "Injuries, Tooth" OR "Injury, Tooth" OR "Tooth Injury" OR "Teeth Injuries" OR A combination of MeSH and text words
PETERSEN et al.

(PubMed) "Tooth Injuries"[Mesh] OR "Avulsion Tooth" OR "Avulsions, Tooth" OR "Tooth Avulsions" OR "Avulsed Tooth" OR "Tooth, Avulsed" OR were searched through PubMed
"Dislocation, Tooth" OR "Dislocations, Tooth" OR "Tooth Dislocation" OR "Tooth Dislocations" OR "Tooth Luxation" OR "Luxation, records and MeSH entries.
Tooth" OR The operators “OR” and “AND” were
"Luxations, Tooth" OR "Tooth Luxations" OR "Fracture, Tooth" OR "Fractures, Tooth" OR "Tooth Fracture” OR "dental trauma" OR used to combine terms in an inclusive
"traumatic injury, tooth" OR "tooth exarticulation” OR "Maxillary Fractures"[Mesh]) (OR) or exclusive (AND) manner.
AND
("Upper lateral incisor" OR "maxillary lateral incisor" OR "upper incisor" OR “incisor, upper anterior region" OR "maxillary anterior
region" OR
"upper anterior tooth" OR "maxillary anterior tooth" OR "upper anterior teeth" OR "maxillary anterior teeth" OR "Incisor"[Mesh] OR
“incisor”)
AND
("Orthodontic Space Closure"[Mesh] OR "orthodontic space closure" OR "Orthodontics"[Mesh] OR "orthodontic*" OR
"Tooth Movement Techniques"[Mesh] OR “orthodontics” OR “orthodontic treatment” OR “orthodontic therapy” OR “tooth movement”
OR
“teeth movement” OR “orthodontic movement” OR “orthodontic dental space closure” OR “canine substitution” OR “mesial movement
of canine”
OR “mesial movement of cuspid” OR "Dental Implants"[Mesh] OR “dental implant*” OR "Dental Prosthesis, Implant-­Supported"[Mesh]
OR
“implant placement” OR “single tooth implant*” OR “single-­tooth implant*” OR “single tooth dental implant*” OR
“dental prosthesis, implant-­supported” OR “prosthesis implant-­supported dental” OR
“dental prostheses implant supported” OR “single-­tooth implant restoration”)
Web of Science #1: TS=("Injuries, Teeth" OR "Injury, Teeth" OR "Teeth Injury" OR "Injuries, Tooth" OR "Injury, Tooth" OR "Tooth Injury" OR "Teeth The tag “OR” was used to perform search
Injuries" inclusively on related keywords
OR "Tooth Injuries" OR "Avulsion Tooth" OR "Avulsions, Tooth" OR "Tooth Avulsions" OR "Avulsed Tooth" OR "Tooth, Avulsed" OR within one topic “TS=”. Then the
"Dislocation, Tooth" three topics were combined using the
OR "Dislocations, Tooth" OR "Tooth Dislocation" OR "Tooth Dislocations" OR "Tooth Luxation" OR "Luxation, Tooth" OR "Luxations, tag “AND”.
Tooth" OR All document types were searched, but
"Tooth Luxations" OR "Fracture, Tooth" OR "Fractures, Tooth" OR "Tooth Fracture" OR "dental trauma" OR "traumatic injury, tooth" only in English
OR" tooth exarticulation" OR "Maxillary Fractures")
#2: TS=("Upper lateral incisor" OR "maxillary lateral incisor" OR "upper incisor" OR “incisor, upper anterior region" OR "maxillary
anterior region"
OR "upper anterior tooth" OR "maxillary anterior tooth" OR "upper anterior teeth" OR "maxillary anterior teeth" OR “incisor”)
#3: TS=("orthodontic space closure" OR "orthodontic*" OR "Tooth Movement Techniques" OR "orthodontics" OR "orthodontic
treatment"
OR "orthodontic therapy" OR "tooth movement" OR "teeth movement" OR "orthodontic movement" OR "orthodontic dental space
closure"
OR "canine substitution" OR "mesial movement of canine" OR "mesial movement of cuspid" OR "Dental Implants" OR "dental implant*"
OR "Dental Prosthesis, Implant-­Supported" OR "implant placement" OR "single tooth implant*" OR "single-­tooth implant*" OR "single
tooth dental implant*"
OR "dental prosthesis, implant-­supported" OR "prosthesis implant-­supported dental" OR "dental prostheses implant supported" OR
"single-­tooth implant restoration")
|

#1 AND #2 AND #3 AND LANGUAGE: (English); All document types

107

(Continues)

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 TA B L E 1 (Continued)
| 108

Databases Search strategy Description

The Cochrane #1: MeSH descriptor: [Incisor] explode all trees The term “explode all trees” were used
Library to include
#2: "upper lateral incisor" all entries within the MeSH entry
hierarchy.
#3: "maxillary lateral incisor" “OR” and “AND” operators were used
#4: "upper incisor" to combine terms inclusively and
exclusively.
#5: "maxillary incisor"
#6: "upper anterior tooth"
#7: {OR #1-­#6}
#8: MeSH descriptor: [Dental Implants] explode all trees
#9: "dental implant"
#10: "single tooth implant"
#11: "single-­tooth implant"
#12: "dental prostheses implant supported"
#13: MeSH descriptor: [Orthodontic Space Closure] explode all trees
#14: MeSH descriptor: [Orthodontics] explode all trees
#15: MeSH descriptor: [Tooth Movement Techniques] explode all trees
#16: "orthodontic space closure"
#17: orthodontic
#18: "orthodontic therapy"
#19: "tooth movement"
#20: {OR #8-­#19}
#21: MeSH descriptor: [Tooth Injuries] explode all trees
#22: MeSH descriptor: [Tooth Avulsion] explode all trees
#23: "tooth injury"
#24: "dental trauma"
#25: "tooth fracture"
#26: "tooth avulsion"
#27: "tooth luxation"
#28: MeSH descriptor: [Maxillary Fractures] explode all trees
#29: {OR #21-­#28}
#30: #7 and #20 and #29
PETERSEN et al.

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PETERSEN et al.
Any clinical study (randomised clinical trials, prospective cohort
studies, retrospective studies, case series and cross-­sectional stud-
ies) reporting on more than five patients who had received dental
implants and prosthetic rehabilitation after traumatic tooth loss in
the anterior region of the maxilla with follow-­up for at least 1 year
after implant loading were included in the present study. The target
age of patients was 18 years and above. Any other study that did not
meet the inclusion criteria was excluded (e.g. in vitro studies, animal
studies and single case reports).
Two of the authors (FNP, MD) screened all retrieved data inde-
pendently using table sheets prepared during the developing phase
of the protocol. Any disagreement was solved through discussion
consulting a senior experienced reviewer (SSJ).
Initially, all duplicates were removed. Titles and abstracts which
did not meet the inclusion criteria were excluded. Cohen’s Kappa-­
coefficient (K score) was calculated after abstract and full-­text anal-
ysis to weight the level of agreement between the two reviewers.
Data extraction from included studies was performed and discussed
among all authors to reach consensus.
Each included full-­text study was analysed for relevant out-
comes (PICO). Missing data from the included studies were sought
by contacting the corresponding authors by e-mail or through the
web portal www.resea​rchga​te.net. The following parameters were
recorded: study design, number of patients, number of implants,
inclusion criteria, surgical procedure, implant and prosthetic char-
acteristics, implant survival rate, superstructure survival rate, peri-­
implant marginal bone resorption, rate of complications, tooth type
replaced, pre-­surgical orthodontic treatment, bone and soft tissue
augmentation, vertical height change of adjacent teeth/continuous
tooth eruption and any PROMs.
The Newcastle–­O ttawa Scale, for assessing the quality of non-­
randomized studies in meta-­analyses, was used to assess the qual-
ity of the individual cohort studies. 27 More specifically, the tool
consisted of eight domains. Each domain was scored with a ‘star’
if it was found satisfactory in the study. Two of the authors (FNP,
MD) independently assessed the quality of each included study,
and any disagreement was solved with a third reviewer (SSJ). The
quality of the studies was categorized as low (0–­3 stars), medium
(4–­6 stars) or high (7–­9 stars), relating to the methodology and
reporting quality.
Due to the heterogeneity of the included studies, only descrip-
tive statistics were applied.
3 | R E S U LT S
A PRISMA Flow Diagram illustrates the search and selection pro-
cess in detail (Figure 1). Nine hundred and ninety-­nine articles were
identified through the initial search of which 66 duplicates were
removed. Eight hundred and five articles were excluded after title
screening. Screening of abstracts on the remaining 128 articles re-
sulted in exclusion of 43 articles due to the inclusion and exclusion
criteria. Articles not including an abstract were assessed for full-­text
|
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109
analysis. Five articles could not be acquired leaving 80 articles for
full-­text analysis. Seventy-­four articles were excluded for specific
reasons (Table S1). Eventually, six cohort studies met the inclu-
sion criteria. Details of the included studies are given in overview
(Table 2). The quality assessment of the included studies is pre-
sented in Table 3. Outcomes and recorded parameters of the stud-
ies are presented in Table 4. To measure the inter-­rater reliability, a
K score was measured at abstract level (0.76) and at full-­text level
(0.82). These showed a high level of agreement between the two
reviewers.
Three of the included studies were prospective cohort stud-
ies, 28–­30 two were retrospective cohort studies,31,32 and the last
study was a case series.33 Two studies compared data from two
groups of patients.30,31 Four studies only reported data from one
cohort or group, 28,29,32,33 of which two studies reported different
data from the same group. 28,29 All the included studies reported
data from treatments performed in hospital settings. The cohort re-
ported across two studies was treated by multiple surgeons. 28,29 The
number of surgeons involved in the remaining studies is unclear.30–­33
One study reported a 10-­year follow-­up after loading of the
implants,30 while the rest reported follow-­up between 1 and
9 years. 28,29,31–­33
A total of 124 patients (age range 18–­59 years) were treated with
149 implants due to dentoalveolar trauma in the anterior maxilla.
Most of the patients in the included studies were trauma patients,
though three studies also included patients treated because of tooth
agenesis. The agenesis patients were excluded from further analy-
sis. 28–­30 Twenty-­seven implants (27 patients) were excluded because
of insufficient follow-­up or because they were no longer eligible for
inclusion at follow-­up. 29 Two implants (only one patient) replacing
first maxillary premolars were excluded.30,31 Eventually, a total of 96
patients with 120 implants could be included.
All articles provided inclusion criteria, but only two provided de-
tails of exclusion criteria,30,31 and only one study reported on smok-
ing which was not an exclusion criteria.31 All studies reported on the
periodontal status of the teeth.
Table 3 presents the quality assessment of the individual studies.
Overall, the studies were rated as medium to high quality. Two stud-
ies were rated as high quality.30,31
Three studies reported on implant brands and dimensions. 30–­32
The reported implant characteristics were most detailed in one of
the studies, where a wide range of brands was used. 31 In this study,
the brand, site, length and diameter were all reported for each in-
dividual patient. In four studies, the patients underwent bone aug-
mentation with autogenous bone either before or simultaneously
with implant placement. 29,31–­33 When augmentation with block
grafts was performed, the bone was most often taken from intra-
oral donor sites (symphysis, retromolar area or ascending ramus
of the mandible), but a few blocks were also harvested from the
iliac crest for larger reconstructions. 31–­33 Particular autogenous
bone chips were mostly harvested locally, from the nasal spine,
during implant placement. 31 One study had the patients divided
in two groups according to early or delayed implant placement
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110
F I G U R E 1 PRISMA Flow Diagram illustrating the search and selection process in detail. Kappa score (K score) was used to measure the
inter-­rater reliability at abstract and full-­text level
protocols. 30 In four studies, implants were loaded according to a
delayed protocol (3–­6 months of osseointegration). 30–­33 The two
28,29
remaining studies did not report the loading protocol. Two
studies used provisional crowns during the healing period. 32,33 The
final prosthetic restorations were single ceramic crowns (porcelain
fused to metal or all-­ceramic) in all studies. One study included
31
screw-­retained as well as cemented superstructures. Two stud-
ies included cemented superstructures only. 30,32 The remaining
studies did not report on this.
The implant survival rate is defined as the continued presence
of the osseointegrated implant after 1 year of functional loading. All
studies reported survival rates ranging from 92 to 100%. 28–­33 The
lowest survival rate (91.6%) was reported by Landes31 and the high-
est (100%) by Gotfredsen.30 One hundred and nineteen implants
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PETERSEN et al.
were followed up for at least 1 year, of which 115 implants (97%)
were still in situ after a mean follow-­up period of 3.5 years (range
1–­10 years). Landes had an average of 3.9 years follow-­up while
Gotfredsen had a follow-­up of 10 years.30,31 Three implants (2.5%)
were lost before functional loading and one implant (0.8%) was lost
after loading.
Only two studies reported the survival rate of the superstruc-
tures.30,32 In these studies, 54 out of 57 crowns (95%) were still pres-
ent after a mean follow-­up of 6 years (range 2–­10 years).
Five studies reported on the peri-­implant marginal bone lev-
29–­33
el. After a mean follow-­up of 4.2 years, the mean marginal bone
resorption was 0.56 mm (range 0.21–­1.30 mm). Andersson and co-­
workers reported a 1 mm bone loss on 1 implant and none on the
rest at the 2-­year follow-­up.32
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PETERSEN et al. 111

IS, implant survival; ISSC, implant-­supported single crowns; MBR, marginal bone resorption; mo, month; MU, membranes used; PO, pre-­surgical orthodontics; PROMs, patient-­reported outcome measures;
Four studies reported on post-­operative complications (98 im-

Abbreviations: +/−, with and without; †, same cohort of patients; BA, bone augmentation; CE, continuous eruption; DIP, delayed implant placement; EIP, early implant placement; G1, group 1; G2, group 2;
IS, MBR, RoC, TTR, PROMs
Outcomes & parameters
plants).30–­33 At the implant level, the rate of complications was 7%

IS, PS, MBR, RoC, TTR,

(7 implants). Complications included abutment screw loosening, ex-

IS, MBR, RoC, TTR

IS, MBR, RoC, TTR

IS, MBR, CE, TTR
posed implant, peri-­implantitis and fistula. At the crown level, the

TTR, PROMs
rate of complications was 11% (11 crowns), and the complications

PROMs
were a lost or loose crown, porcelain fracture and infraposition.
Generally, few complications were reported.
The most frequently replaced tooth across all studies was the
central incisor (70%), followed by the lateral incisor (21%) and canine
Group A: EIP, Group B:

(9%). 29–­33 Andersson and co-­workers reported as high as 75% of the

Treatment provided

Surgical procedure

teeth replaced were maxillary central incisors,32 whereas Landes re-

ported that 54% of the teeth to be replaced were maxillary central

DIP, BA, PO
DIP, +/− BA

DIP, +/− BA
DIP MU

incisors.31
DIP, BA

DIP BA

PROMs were reported in three studies. 28,30,32 Andersson and

co-­workers measured patients’ and professionals’ satisfaction con-
cerning the implant-­supported single crown’s colour, shape, height,
and size on a four-­point scale. The highest degree of satisfaction
ISSC replacing teeth lost due to trauma (G1) or
cleft, lip, palate defects (G2) in the anterior

ISCC replacing teeth lost due to trauma in the

ISSC replacing teeth lost due to trauma in the

was reported in 93%–­98% of the patients and 91%–­95% of the pro-

ISSC replacing teeth lost due to trauma or

ISSC replacing teeth lost due to trauma or

ISSC replacing teeth lost due to trauma or

fessionals.32 Gotfredsen reported patient satisfaction with implant

function and aesthetics which were assessed by using a visual an-
agenesis in the anterior maxilla

agenesis in the anterior maxilla

agenesis in the anterior maxilla

alogue scale from 0 to 10, where 10 related to the highest degree

of satisfaction. After 3 years, the mean visual analogue scale scores
in both the early and the delayed implant groups were 9.4 and 9.3
for implant function and aesthetics, respectively. After 10 years, the
anterior maxilla

anterior maxilla

visual analogue scale scores reduced to 8.4 and 7.6, respectively.30

Vilhjálmsson and co-­workers reported patients’ satisfaction with
maxilla
Inclusion

the crown form, crown colour and the form and colour of the peri-­
implant mucosa. They used a six-­point scale from very dissatisfied
to very satisfied and 88%, 84% and 72% of the patients were satis-
fied or very satisfied with the crown form, colour and the mucosa,
patients, 25 implants

respectively. 28
20 patients, 20 implants
50 patients, 56 implants

50 patients, 56 implants

34 patients, 42 implants
Two groups: A & B

5 patients, 5 implants

PS, prosthetic survival; RoC, rate of complications; TTR, tooth type replaced; y, year.

Most of the studies reported on bone augmentation. 29–­33 Bone

Population baseline

implants G2: 20
G1: 20 patients, 37

augmentations were performed in 60 of 149 implant sites (40%). The

augmentations were carried out as a separate procedure (block grafts)
or at the time of implant placement (particulate grafts). Raghoebar
and co-­workers treated all patients with autogenous block grafts
from the mandibular ramus 3 months before implant placement.
All augmented areas allowed placement of the implants, and no ad-
Case-­series 12–­15 mo follow-­up

ditional grafting was necessary.33 Andersson and co-­workers aug-

Retrospective 47 mo (average)

Retrospective 2 y follow-­up
TA B L E 2 Characteristics of the included studies

Retrospective 1 y follow-­up
Prospective 10 y follow-­up

mented seven implant sites (17%) because of bone deficiency. Ridge

Prospective 3 y follow-­up

splitting or block grafts from the mandibular chin or ramus were per-
formed.32 In one case, a titanium-­reinforced expanded polytetraflu-
oroethylene membrane was used for augmentation without the use
follow-­up
Study details

of a bone grafting material. Landes augmented 16 implant sites with

block grafts from the iliac crest, mandibular ramus or chin 4 months
Design

(mean) before implant placement. The remaining 20 implant sites

were augmented at the time of implant placement with locally har-
Vilhjálmsson et al. 28,†
29,†

vested autogenous bone chips.31 Gotfredsen performed guided

Raghoebar et al.33

Andersson et al.32
Vilhjálmsson et al.

bone regeneration using non-­resorbable membranes, without

Gotfredsen30

bone grafting materials, at the time of implant placement followed

Authors (y)

Landes31

by submerged healing for 6 months in selected cases. The number

of cases in need of guided bone regeneration was not specified.30
Vilhjálmsson and co-­workers augmented 12 implant sites but did not
 |

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112 PETERSEN et al.

report on the timing or type of bone augmentation. 29 None of the

Score
included studies reported on soft tissue augmentation procedures.

6*
8*
6*
5*
8*
6*
One study reported that three patients underwent pre-­surgical
orthodontics to create sufficient mesio-­distal space before implant

Adequacy of
placement. In two additional cases, with limited mesio-­distal space,

follow-­up
a narrow-­diameter implant was inserted.32
Vilhjálmsson and co-­workers reported on continuous eruption

B*

B*
A*

A*
A*
A*
of teeth adjacent to the implants. They found a significant mean
vertical change of 0.67 mm (range 0.13–­1.75 mm) during the 3-­year
Follow-­up

follow-­up (p < .001). 29

The form consists of eight domains. Each domain is answered with a letter from A to D of which answers are scored with a ‘star’ (*) if it is found satisfactory in the study.
A*
A*
A*
A*
A*
A*
4 | DISCUSSION
Assessment

The aim of this study was to review the existing evidence on survival
Outcome

and prognosis of implant placement in the anterior maxilla after trau-

A*
A*
A*
A*
A*
A*

matic tooth loss. Six studies met the inclusion criteria and were rated
TA B L E 3 Quality assessment form using the Newcastle-­Ottawa Scale (NOS) for assessing the quality of non-­randomized studies

as medium to high quality.

An overall implant survival rate of 97% after a mean follow-­up
Comparability

period of 3.5 years was calculated across the included studies. 28–­33
A* & B* = **

A* & B* = **
No control

No control
No control

No control

This is in accordance with systematic reviews and cohort studies on

medium to long-­term survival of implant treatment in general.14,15,34
A retrospective study, on single dental implant treatment secondary
to TDI in the anterior maxilla, reported a similar implant survival rate
of around 96%.35 The study was excluded from the present review
Demonstration

due to insufficient data on the follow-­up, but it presented data on 53

patients, which was a relatively large cohort. Vergara and Caffesse
followed 16 patients for about 1 year after implant treatment in the
A*
A*
A*
A*
A*
A*

anterior maxilla and found an implant survival rate of 87%.36 They

reported that most teeth were extracted because of crown or root
Ascertainment

fractures, but it was unclear whether these fractures were due to

TDI, and the follow-­up period was short. Although mean follow-­up
was 3.5 years across the included studies, only one study had a long-­
term follow-­up.30
A*
A*
A*
A*
A*
A*

Survival of superstructures was 95% based on an average of two

studies.30,32 This is comparable to the general long-­term prosthetic
Selection

survival rate, reported by Jung and co-­workers.14

Marginal bone resorption was reported to be low. 29–­33 This may
A*

A*
C

C
C

be taken as an indicator of stable peri-­implant bone conditions, at

least within the first 4–­5 years, and is comparable to bone levels
reported around implants in general in the recent literature.37
Representativeness

Complication rates were calculated to be 7% at implant level and

11% at superstructure level. However, complications were not con-
Selection

sistently reported in the included studies.30–­33 Landes reported a

few early implant losses as complications, but these were regarded as
B*
B*
B*

B*
B*
D

failures.31 Schwartz-­Arad and Levin indicated a significantly higher

post-­operative complication rate of around 45%.35 The most fre-
quent complications were fistulas and implant exposure, which were
Vilhjálmsson et al. 29

28

33

32
Vilhjálmsson et al.

comparable to the findings of the present study. Schwartz-­Arad and

Raghoebar et al.

Andersson et al.
Cohort studies

Gotfredsen30

Levin suggested that the high rate may be explained by one-­third

Landes31

of the patients presenting with inflammatory lesions at the time of

Study

implant placement. This was found to increase the risk of compli-

cations.35 The large spread in complication rates may illustrate the
 PETERSEN et al.

TA B L E 4 Outcomes and recorded parameters of the included studies

Included Implant Peri-­implant Complications Bone

patients/ survival, Superstructure marginal bone loss, implants/ augmen-­ Tooth type Pre-­surgical Implant
Authors (y) implants % survival, % mm (mean) superstructures tation, % replaced PROMs orthodontics infraposition

Vilhjálmsson 21/21‡ 100% NR 0.5 mm NR 57% I1: 14 —­ NR 0.67 mm (mean)

et al. 29,† I2 : 5 0.13–­1.75 mm
C: 2 (range)
Gotfredsen30 16/16§ 100% 86.6% 0.78 mm 4/6 None I1: 14 VAS NR NR
I2 : 0 8.4 (function)
C: 2 7.0 (aesthetics)
Vilhjálmsson 21/21‡ —­ —­ —­ —­ —­ —­ 6-­point scale§§ —­ —­
et al. 28,† 88% (form)
84% (colour)
72% (mucosa)
Raghoebar 5/5 100% NR 0.22 mm None 100% I1: 5 NR NR NR
et al.33 I2 : 0
C: 0
Landes31 20/36¶ 91.6% NR 1.3 mm None 100% I1: 20 NR NR NR
I2: 11
C: 5
Andersson 34/42 97.6% 97.6% 0.02 mm 3/5 16% I1: 34 4-­point scale¶¶ 3 patients NR
et al.32 I2 : 6 93%–­98%
C: 2
Total 96/120 96.6% 94.7% 0.56 mm 7 (7,1%)††/11 (11,1%)†† 40%‡‡ I1: 87 —­ 3 patients 0.67 mm
(70.1%)
I2: 26
(20.9%)
C: 11
(8.87%)

Abbreviations: §, three implants in agenesis patients excluded, one implant in premolar site excluded; §§, six-­point satisfaction scale on crown form, colour and the mucosa: percentage of patients very
satisfied or satisfied; ¶, one implant in premolar site excluded; ¶¶, four-­point scale on different crown aesthetics parameters: percentage range of patients scoring highest degree of satisfaction; †, same
cohort of patients; ††, calculated based on a total of 99 implants; ‡, only one implant per patient were analysed in the study, two implants in agenesis patients excluded; ‡‡, calculated based on number
of implants at base-­line; C, maxillary canine; I1, maxillary central incisor; I2, maxillary lateral incisor; NR, not reported; PROMs, patient-­reported outcome measures; VAS, visual analogue scale, 0 –­10 (10
highest); y, year.
| 113

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 |
114
complexity in restoring the anterior maxilla after TDI and the many
factors that need to be considered in treatment planning.
Patient satisfaction with the implant treatments was reported
to be high. 28,30,32 However, no validated questionnaires were used.
Only one study reported on the professional evaluation of the aes-
thetic result.32 However, no validated index was used. This under-
lines the missing validated clinical evidence of aesthetic outcome,
especially concerning the peri-­implant soft tissue. A retrospective
clinical study used a validated index for objective evaluation of pink
38
and white aesthetics of anterior maxillary implants. They reported
a mean score above what is considered clinically acceptable, espe-
cially the pink aesthetics scored high among the professionals. They
also found that patients in general were more satisfied than the pro-
fessionals with the aesthetic outcome. This was in agreement with
the findings of the present review.
Bone augmentation and bone splitting were used in the included
studies. The latter is seldom indicated in the anterior maxilla due to
39
a minimum requirement of 3 mm ridge width for the entire height.
Most of the studies that reported on the type of bone augmentation
used a bone block graft. It could be speculated that patients suffer-
ing TDI are subject to more pronounced bone resorption following
tooth loss. This would explain the need for separate and substantial
reconstruction of the alveolar process before implant placement is
possible. Interestingly, a relatively low percentage (40%) of the im-
plant sites in the included studies were bone augmented compared
24
to other reports in the literature (75%). Onlay block augmentations
using autogenous bone blocks are well-­documented in the litera-
ture, and the horizontal augmentation technique using an autolo-
gous bone block alone, or in combination with particulate bone is
40,41
considered predictable. Today, there is increasing focus on the
frequent need for soft tissue augmentation around implants in the
aesthetic zone. 25 Therefore, it is striking that none of the included
studies discussed the indication for soft tissue augmentation before
or simultaneously with implant placement after traumatic tooth loss.
Only one study reported on the need for pre-­surgical ortho-
dontics.32 The need to create or reduce space before prosthetic
treatment is dictated by biological, technical and aesthetic consid-
erations. Implants require a minimum of 1.5 mm of space from the
adjacent teeth in order not to compromise the vascular supply to
the marginal bone of the adjacent teeth.42,43 Cervical and coronal
space requirements are determined by the contralateral tooth’s clin-
ical crown dimensions to achieve symmetry. There are no studies
reporting on the frequency of pre-­surgical orthodontics prior to im-
plant placement following TDI. However, since tooth loss often leads
to migration or tilting of adjacent teeth, timely planning and initia-
tion of orthodontic treatment are essential to establish the required
space for later rehabilitation.19,44
One of the main challenges of dental implant treatment in the
anterior maxilla is the continued eruption of the adjacent teeth, even
after cessation of skeletal growth, leading to infraposition of the im-
plant.16,17 It has been suggested that best practice is to document the
end of growth by height measurements, superimposition of cepha-
lostatic radiographs and additionally securing contact between the
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PETERSEN et al.
anterior teeth before implant placement, although there is still a risk
of continued eruption.42,45,46 Vilhjálmsson and co-­workers found a
significant mean vertical height change in patients treated after end
of growth. 29 A recent clinical study, with long-­term follow-­up, and a
review confirmed this finding.47,48 A gap exists in the literature on
the prognosis of long-­term aesthetic outcomes of implant treatment
following TDI as the implants are expected to be in function for a
lifetime.
This review found that the most frequently replaced tooth in the
anterior maxilla is the central incisor (70%). This corresponds well
with the distribution of TDI in the permanent dentition. 2,8,9 Most
patients only injure one tooth.4 Replacing a central incisor is often
a complex task. Orthodontic closure will in such a case often result
in an aesthetically displeasing asymmetry. Full-­crown preparation
for a tooth-­supported FDP is very invasive if the neighbouring teeth
are intact, especially in young patients. The best option appears to
be implant treatment, but as this review has shown, there is limited
clinical evidence currently exists to support this treatment modality
compared to the former mentioned options.
Biological, functional and aesthetic outcomes of orthodontic
space closure and prosthetic replacement (resin-­b onded bridge,
implant-­supported single crown and tooth-­supported FDP) have
been compared in patients with agenesis of the lateral maxillary
incisors.49 That study concluded that when both options were
applicable, orthodontic space closure should be the treatment of
choice. Orthodontic space closure was favourable because of the
longevity and aesthetics of the treatment result, the possibility of
completing the treatment early and the lower prevalence of later
biological and technical prosthodontic complications. However,
not all patients are candidates for orthodontic closure and the
choice of treatment will always be a decision based on the individ-
ual case. The type of occlusion, facial profile, canine colour and di-
mensions are factors that should be considered during treatment
planning.
When deciding the treatment modality, the cost-­effectiveness
should also be considered. Except for orthodontic space closure,
all treatment alternatives have been analysed for treating maxillary
lateral incisor agenesis.50 Autotransplantation was the most cost-­
effective treatment in relation to survival and cost. While implants
and implant-­supported crowns have a high survival rate, the cost
was high, and thus, the cost-­effectiveness was significantly lower.50
Later expenses to replace implant-­supported crowns should also be
anticipated, especially in young patients who have an expected long
lifespan. There are no studies reporting on the outcomes and cost-­
effectiveness in relation to treatment alternatives following TDI in
the anterior maxilla, although it seems obvious to draw similar con-
clusions regarding these patients.
The literature search presented in the present review was
wide and inclusive and reviewed by two of the authors with high
inter-­r ater reliability. At the same time, the inclusion criteria were
demanding. This indicates that practically all current data on the
topic have been reviewed, but only a handful of studies could be
included.

PETERSEN et al.
Considering that good long-­term evidence on implant therapy in
14,15
general is available today, this review identified a lack of studies
with larger patient cohorts and longer follow-­up on the investigated
topic. Most relevant studies identified through the search were case
reports of less than five patients and with limited follow-­up. It was
not possible to identify systematic reviews exclusively on this topic.
Additionally, most of the outcome parameters investigated were not
reported consistently in the included studies. A few were barely or
not reported at all (such as pre-­surgical orthodontic treatment and
soft tissue augmentation). It should be considered that many im-
plants placed in the anterior maxilla after traumatic tooth loss could
be ‘hidden’ in studies on general implant treatment, as sometimes
the reason for tooth loss is not known or recorded.
5 | CO N C LU S I O N
This systematic review found studies of medium to high quality.
Despite this, the level of evidence on outcomes after implant treat-
ment in the anterior maxilla after traumatic tooth loss was regarded
as low, since a small number of patients and implants were included.
However, a high survival rate of implants and implant-­supported su-
perstructures was shown after mid-­term follow-­up. The choice of
treatment must still be based on the individual patient situation and
expert opinions. Therefore, future research should focus on system-
atic reporting of biological, technical and aesthetic outcomes to as-
sist the dentist in planning these complex cases, to further elucidate
prognostic factors for success and to improve the alignment of pa-
tient expectations.
AC K N OW L E D G E M E N T S
No funding was received during to complete this review.
C O N FL I C T O F I N T E R E S T
All authors declare no conflict of interest.
AU T H O R S ’ C O N T R I B U T I O N S
Petersen, F.N.: Conceptualization and design, data collection, data
analysis and interpretation, drafting manuscript and agreement
for accountability. Jensen, S.S.: Conceptualization and design,
critical revision of the manuscript, approval of the manuscript
and agreement for accountability. Dahl, M.: Conceptualization
and design, data analysis and interpretation, critical revision of
the manuscript, approval of the manuscript and agreement for
accountability.
DATA AVA I L A B I L I T Y S TAT E M E N T
The data that supports the findings of this study are available in the
supplementary material of this article.
ORCID
Frej Nørgaard Petersen https://orcid.org/0000-0001-8446-4213
Simon Storgård Jensen https://orcid.org/0000-0002-3519-4103
|
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115
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Additional supporting information may be found in the online
version of the article at the publisher’s website.
How to cite this article: Nørgaard Petersen F, Jensen SS,
Dahl M. Implant treatment after traumatic tooth loss:
A systematic review. Dental Traumatology. 2022;38:105–­
116. doi:10.1111/edt.12730