Received: 17 July 2018 | Revised: 15 October 2018
DOI: 10.1111/jcpe.13054
SUPPLEMENT ARTICLE
The effectiveness of immediate implant placement for single
tooth replacement compared to delayed implant placement:
A systematic review and meta-­analysis
Jan Cosyn1,2 | Liesa De Lat1 | Lorenz Seyssens1 | Ron Doornewaard1 |
Ellen Deschepper3 | Stijn Vervaeke1
1
Faculty of Medicine and Health
Sciences, Dental School, Department
of Periodontology and Oral
Implantology, Ghent University, Ghent,
Belgium
2
Oral Health Research Group
(ORHE), Faculty of Medicine and
Pharmacy, Vrije Universiteit Brussel (VUB),
Brussels, Belgium
3
Faculty of Medicine and Health
Sciences, Department of Biomedical
statistics, Ghent University, Ghent, Belgium
Correspondence
Jan Cosyn, Faculty of Medicine and Health
Sciences, Dental School, Department of
Periodontology and Oral Implantology,
Ghent University, Ghent, Belgium.
Email: jan.cosyn@ugent.be
224 | © 2019 John Wiley & Sons A/S.
Published by John Wiley & Sons Ltd
| Accepted: 19 October 2018
Abstract
Aim: To compare immediate implant placement (IIP) to delayed single implant placement
(DIP, ≥3 months post-­extraction) in terms of implant survival (primary outcome), surgical,
clinical, aesthetic, radiographic and patient-­reported outcomes (secondary outcomes).
Materials and Methods: Two reviewers independently performed an electronic
search in PubMed, Web of Science, EMBASE and Cochrane and a hand search to
identify eligible studies up to May 2018. Only randomized controlled trials (RCTs) and
non-­randomized controlled studies (NRSs) comparing IIP to DIP with at least 1 year
of follow-­up were selected for a qualitative analysis and meta-­analysis.
Results: The search identified 3 RCTs and 5 NRSs out of 2,589 titles providing data
on 473 single implants (IIP: 233, DIP: 240) that had been in function between 12 and
96 months. One RCT showed unclear risk of bias, whereas all other studies
demonstrated high risk. Meta-­analysis showed significantly lower implant survival
for IIP (94.9%) as compared to DIP (98.9%) (RR 0.96, 95% CI [0.93; 0.99], p = 0.02). All
were early implant failures. A subgroup meta-­analysis demonstrated a trend towards
lower implant survival for IIP when postoperative antibiotics had not been
administered (RR: 0.93, 95% CI [0.86; 1.00], p = 0.07). This was not observed among
studies including the administration of postoperative antibiotics (RR: 0.98, 95% CI
[0.94; 1.02], p = 0.35). Meta-­analyses showed similar probing depth (WMD 0.43 mm,
95% CI [−0.47; 1.33], p = 0.35) and aesthetic outcomes as assessed by the pink
aesthetic score (standardized WMD −0.03, 95% CI [−0.46; 0.39], p = 0.88) for IIP and
DIP. Data on marginal bone loss were conflicting and highly biased. Soft tissue
recession was underreported and available data were highly biased. Patient-­reported
outcomes were underreported, yet both IIP and DIP seemed well tolerated.
Conclusion: Immediate implant placement demonstrated higher risk for early implant loss
than DIP. There is a need for RCTs comparing IIP to DIP with CBCT analyses at different
time points and data on midfacial recession with the preoperative status as baseline. In
these studies, the need for hard and soft tissue grafting should also be evaluated.
KEYWORDS
delayed, Dental implant, immediate, single, survival
wileyonlinelibrary.com/journal/jcpe J Clin Periodontol. 2019;46(Suppl. 21):224–241.

COSYN et al.
1 | I NTRO D U C TI O N
Immediate implant placement (IIP) has been a popular treatment
concept for patients as well as for clinicians since it reduces the
number of surgical interventions and the total treatment time. In
addition, it was assumed for many years that the immediate inser-
tion of an implant into a fresh extraction socket could counteract
the three-­dimensional alterations of the alveolar process as a re-
sult of tooth extraction. However, preclinical and clinical studies
failed to show this (Araujo, Sukekava, Wennstrom, & Lindhe, 2005;
Botticelli, Berglundh, & Lindhe, 2004), making it a potentially risky
procedure from an aesthetic point of view. After all, considerable
post-­extraction bone remodelling may be expected, mainly at the
buccal aspect often resulting in a deficient alveolar ridge. Given
this, the immediate installation of an implant into a fresh extraction
socket may lead to a lack of buccal convexity and even midfacial
recession. These soft tissue alterations have been demonstrated
in multiple prospective and retrospective clinical studies (Chen,
Darby, & Reynolds, 2007; Chen, Darby, Reynolds, & Clement, 2009;
Cordaro, Torsello, & Roccuzzo, 2009; Cosyn et al., 2016; De Rouck,
Collys, Wyn, & Cosyn, 2009a; Kan, Rungcharassaeng, Lozada, &
Zimmerman, 2011).
IIP is also a challenging procedure from a surgical point of view.
The osteotomy usually engages the bone apical to the alveolus in
order to be able to install a long implant with sufficient primary sta-
bility (De Rouck, Collys, & Cosyn, 2008). At the same time, special
attention should be paid to an optimal three-­dimensional implant
position. The latter differs significantly from the original tooth posi-
tion, especially in the premaxilla. In the hands of untrained or poorly
skilled surgeons, osteotomies often follow the long axis of the orig-
inal tooth resulting in implants too buccally positioned and angu-
lated. Such a buccal shoulder position has been identified as one of
the main causes of midfacial recession at single implants (Chen et al.,
2007, 2009; Cosyn, Hooghe, & De Bruyn, 2012b).
The above applies to all clinical scenarios, even to straightfor-
ward cases with intact bone walls essentially following extractions
for unrestorable caries or endodontic reasons. Most studies on IIP
in the literature report on such ideal, strictly selected cases (Cosyn,
Vandenbulcke, Browaeys, Van Maele, & De Bruyn, 2012a; De Rouck
et al., 2008). The results of these studies demonstrate limited exter-
nal applicability to the population since a lot of teeth are removed
because of root fractures or periodontal disease in daily practice.
Both result in substantial bone loss, further hampering primary im-
plant stability and the chance of achieving osseointegration. When
opting for IIP under these circumstances, the combination with bone
augmentation procedures is highly indicated. Some clinical studies
have addressed this with variable success (Kan, Rungcharassaeng,
Sclar, & Lozada, 2007; Tonetti et al., 2017).
Delayed implant placement (DIP) in healed bone is a straightfor-
ward surgical procedure. In addition, long-­term clinical and aesthetic
outcomes have been reported (Dierens, Vandeweghe, Kisch, Nilner,
& De Bruyn, 2012; Dierens et al., 2013). As a result, DIP is often used
as a reference treatment modality in scientific research.
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225
Clinical Relevance
Scientific rationale for the study: Immediate implant
placement (IIP) and delayed implant placement (DIP) are
popular treatment concepts. However, there are no
systematic reviews comparing these concepts in terms of
implant survival, surgical, clinical, aesthetic, radiographic
and patient-­reported outcomes.Principal findings: A
significantly lower implant survival rate was found for IIP,
which could be partially explained by the lack of
postoperative administration of antibiotics in some studies.
Based on only 3 studies, clinical (probing depth) and
aesthetic outcomes (pink aesthetic score) were similar.
Results were inconclusive for all other outcomes.Practical
implications: Clinicians should outweigh the benefits of IIP
against a higher risk for early implant loss.
Two recent systematic reviews have been published on the compari-
son of IIP in fresh extraction sockets with DIP in healed bone (Chrcanovic,
Albrektsson, & Wennerberg, 2015; Mello et al., 2017). Both report on
single as well as multiple implants and found significantly lower implant
survival following IIP. However, as stated by the authors, these findings
should be interpreted with caution given a high risk of bias in terms of
randomization, allocation and blinding (Mello et al., 2017). In addition,
only implant survival, marginal bone loss and probing depth changes
were evaluated. Besides these outcome variables, clinical decision-­
making should also be based on surgical, aesthetic and patient-­reported
outcomes. The objective of the present systematic review and meta-­
analysis was to compare single IIP to DIP in terms of implant survival,
surgical, clinical, aesthetic, radiographic and patient-­reported outcomes.
2 | M ATE R I A L S A N D M E TH O DS
This systematic review was performed applying the Preferred
Reporting Items for Systematic Reviews and Meta-­Analyses
(PRISMA) as described by Moher et al. (2010).
2.1 | Objectives
The primary objective was to compare single IIP to DIP in terms of
implant survival. The focused research question was as follows: ‘In
patients in need of a single implant, will IIP as compared to DIP result
in different implant survival?’
The PICO elements relating to this focused research question
were as follows:
Patient Adult patients in need of a single implant
Intervention Immediate implant placement (within 24 hours
post-extraction)
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226
Comparison Delayed implant placement (≥3 months post-extraction)
Outcome Implant survival (defined as the mere presence of the im-
plant regardless of its clinical condition).
Secondary objectives related to the same comparison; yet focus-
ing on the following variables: need for additional bone augmenta-
tion, wound healing complications, marginal bone loss, probing depth,
bleeding on probing, papillary recession, pink aesthetic score, patient-­
reported outcomes, technical and biological complications.
2.2 | Inclusion criteria
• Human clinical studies published in English.
• At least 18-year-old patients.
• Systemically healthy patients.
• Single implant site in any position.
• Studies reporting on titanium implants.
• Randomized controlled trials (RCTs) and non-randomized con-
trolled studies (NRSs) allowing for a direct comparison of IIP (within
24 hours post-extraction) and DIP (≥3 months post-extraction).
• Data on at least the primary outcome variable (implant survival).
• At least 10 cases in each treatment arm at intake.
• At least 1 year of follow-up after implant placement.
2.3 | Exclusion criteria
• Case series (prospective as well as retrospective).
• Cross-sectional studies.
• Letters to editors.
• Reviews.
• Studies reporting on zirconia implants.
• Studies involving sinus floor elevation procedures.
• Studies reporting on alveolar ridge preservation before implant
placement.
• Studies reporting on implant placement in previously augmented
sites.
• Studies reporting bone ring techniques.
• Studies reporting on alveolar socket shield technique.
• Studies involving vertical ridge augmentation.
• Studies reporting on distraction osteogenesis.
• Studies reporting on alveolar ridge splitting.
• Studies reporting on subperiosteal implants.
• Studies reporting on bicortical implants.
• Studies reporting on patients taking medications/therapy affect-
ing bone metabolism (i.e. bisphosphonates, radiation therapy).
• Studies reporting on patients with pathologies affecting bone me-
tabolism (i.e. osteoporosis, osteopenia, rheumatoid arthritis).
• Studies reporting on implants placed in sites affected by tumours.
• Lack of information on whether augmentation procedures were
performed or not.
• Studies involving the application of any additional therapy that
could have affected healing outcomes (e.g. use of healing en-
hancers, such as PRP, PRF, growth factors).
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COSYN et al.
• Insufficient information on the surgical protocol and timing after
tooth extraction.
2.4 | Information sources and search strategy
An electronic literature search as well as a hand search was
performed by 2 independent reviewers (LDL and LS) to identify
eligible clinical studies.
The electronic search was performed in PubMed, Web of
Science, EMBASE and Cochrane databases until May 2018 using the
following search terms:
Patient Dental implant [MeSH Terms] OR dental implant, single tooth
[MeSH Terms] OR dental implantation [MeSH Terms] OR dental
implant OR oral implant
Intervention Immediate placement OR immediately placed OR imme-
diate installation OR immediately installed OR immediate inser-
tion OR immediately inserted OR extraction, tooth [MeSH Terms]
OR fresh extraction socket
Primary Outcome Implant survival.
The final search string included a combination of these search
items as follows: Patient AND Intervention AND Primary outcome.
The two reviewers (LDL and LS) independently evaluated all
studies on their eligibility based on inclusion and exclusion criteria as
listed below. First, this was performed at title level, then at abstract
level. Articles that still qualified at the abstract level were printed
and full texts were read. If doubt arose at title or abstract level, stud-
ies were further scrutinized in the next level to avoid overlooking of
appropriate studies. Any disagreement that arose at full-­text level
was resolved by discussion with a third reviewer (JC). To assess inter-­
rater reliability in the selection of appropriate studies, kappa coeffi-
cients were calculated at title and abstract level.
All reference lists of the studies that had been selected by the
electronic search were checked for cross-­references. Finally, the
following journals were hand searched up to May 2018: Journal of
Clinical Periodontology, Journal of Periodontology, Journal of Periodontal
Research, Journal of Dental Research, Journal of Prosthetic Dentistry,
Journal of Prosthodontics, Journal of Prosthodontic Research, Clinical
Implant Dentistry and Related Research, Clinical Oral Implants Research,
Clinical Oral Investigations, European Journal of Oral Implantology,
Implant Dentistry, International Journal of Oral & Maxillofacial Implants,
International Journal of Oral & Maxillofacial Surgery, International
Journal of Periodontics and Restorative Dentistry, International Journal
of Prosthodontics, Oral Surgery Oral Medicine Oral Pathology and Oral
Radiology. An attempt was made to search for grey literature by con-
tacting researchers who published on immediate implant placement.
2.5 | Data extraction
The same reviewers (LDL, LS) extracted all relevant data from the
finally selected articles and possible errors were excluded by a third
reviewer (JC). In case the results of a study were published more

COSYN et al.
than once due to different follow-­up, only the paper with the longest
follow-­up data was included. Authors were contacted by email to
provide missing or incomplete data.
2.6 | Risk of bias assessment
A quality assessment of the included RCTs and NRSs was independently
performed by 2 other reviewers (RD and SV) following the Cochrane
Handbook for Systematic Reviews of Interventions (Higgins and
Green, 2011). This quality assessment included the following criteria:
random sequence generation (selection bias), allocation concealment
(selection bias), blinding of participants and personnel (performance
bias), blinding of outcome assessment (detection bias), incomplete out-
come data (attrition bias), selective reporting bias and other sources of
bias. All criteria were rated as low, unclear or high risk of bias. To assess
inter-­rater reliability in quality assessment, a kappa coefficient was cal-
culated. Disagreement that arose following the quality assessment was
resolved by discussion with a third reviewer (JC).
2.7 | Statistical analysis
®
Data analysis was performed in Review Manager 5.3 (Cochrane
Collaboration, Oxford, UK). The I2 index was used to express the
percentage of the total variation across studies due to heterogeneity
(Higgins, Thompson, Deeks, & Altman, 2003). The GRADE guidelines
were adopted to categorize heterogeneity with <40% corresponding
to low, 30%–60% to moderate, 50%–90% to substantial and 75%–
100% to considerable heterogeneity (Guyatt et al., 2011).
For dichotomous outcome variables, the Mantel–Haenszel
method was used in an a priori fixed-­effects model with effect sizes
expressed as risk ratios (RRs) and 95% confidence intervals (CIs). If
FIGURE 1 Flow chart on the search
strategy
|
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227
significant heterogeneity was observed or when deemed relevant
from a clinical point of view, subgroup analyses were performed.
Where heterogeneity remained unexplained, a random-­effects
model was chosen using the Dersimonian Laird estimator.
For continuous outcome variables, the same process was fol-
lowed, however using the inverse variance method with effect sizes
expressed as mean differences or standardized mean differences
and 95% CIs. Forest plots were created to illustrate effect sizes in
the overall analysis and subgroup analyses. A funnel plot was drawn
for the primary outcome variable to assess publication bias across
studies. The level of significance was set at 0.05.
3 | R E S U LT S
3.1 | Search
The search strategy is illustrated in Figure 1. The electronic search
rendered 2,589 titles in total (874 in PubMed, 936 in Web of Science,
675 in EMBASE and 104 in Cochrane). Inter-­rater agreement in the
selection of appropriate studies at title level was very high given a
kappa value of 0.829 (p < 0.001). At abstract level, kappa was 0.707
(p < 0.001) indicative of substantial agreement. After removing
duplicates across databases, 95 abstracts remained for full-­text
analysis. Of those, 6 articles fully met the inclusion and exclusion
criteria. Based on scrutinizing the reference lists of these articles
and by additional hand search, 3 appropriate articles were added
resulting in a total number of 9 eligible articles. These articles
corresponded to 8 clinical studies since 2 articles pertained to the
same study material. The reasons for exclusion of the remaining
articles are described in Table 1. The search for grey literature did
not result in extra data.
 |
228
TA B L E 1 Reasons for exclusion
Inappropriate study design (NO Not reporting on single
RCT/NRS) implants
Bahat & Sullivan, 2010
Chuang & Cai, 2006
Correia, Gouveia, Felino, Costa,
& Almeida, 2017
Cosyn et al., 2012
Crespi, Cappare, Gherlone, &
Romanos, 2008
Da Silva et al., 2014
Degidi, Piattelli, & Carinci, 2007 Kim, Kim, Kim, Yi, & Yun,
Jemt, 2017
Levin, Laviv, & Schwartz-­Arad,
2006
Lopez et al., 2016
Minichetti, D’Amore, & Hong,
2018
Misch et al., 2008
Mundt, Mack, Schwahn, &
Biffar, 2006
Payer et al., 2010
Penarrocha-­Diago et al., 2012
Penarrocha-­Oltra, Demarchi,
Maestre-­Ferrin, Penarrocha-­
Diago, & Penarrocha-­Diago,
2012
Perry & Lenchewski, 2004
Schwartz-­Arad, Mardinger,
Levin, Kozlovsky, & Hirshberg,
2005
Schwartz-­Arad, Laviv, & Levin,
2008
Siepenkothen, 2007
Smith, Ng, Grubor, & Chandu,
2009
Wilson, Roccuzzo, Ucer, &
Beagle, 2013
Balshi, Allen, Wolfinger, &
Balshi, 2005
Buchs, Levine, & Moy, 2001
Cavallaro, 2011
Degidi, Nardi, & Piattelli,
2012
Degidi, Nardi, & Piattelli,
2016
Duda et al., 2016
2012
Kim, Lee, & Kim, 2015
Negri et al., 2014
Ormianer & Palti, 2006
Ormianer & Palti, 2008
Ormianer et al., 2012
Ostman, Wennerberg,
Ekestubbe, & Albrektsson,
2013
Penarrocha-­Diago,
Carrillo-­Garcia, Boronat-­
Lopez, & Garcia-­Mira,
2008
Piek et al., 2013
Pozzi & Mura, 2016
Rodrigo, Martin, & Sanz,
2012
Stanley, Braga, & Jordao,
2017
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COSYN et al.
No comparison DIP Insufficient number of
with IIP Bone graft prior to IP cases
de Souza et al., 2018 Aguirre-­Zorzano, Rodriguez-­ Chaushu, Chaushu,
Andres, Estefania-­Fresco, & Tzohar, & Dayan, 2001
Fernandez-­Jimenez, 2011
Degasperi, Andersson, de Moraes & Rao Genovese, Dhanrajani & Al-­Rafee,
Verrocchi, & 2013 2005
Sennerby, 2014
Degidi, Piattelli, & Guarnieri et al., 2014 Han, Mangano,
Carinci, 2006 Mortellaro, & Park, 2016
Esposito et al., 2016 Kohen, Matalon, Block, & Mayer, Hawley, Gunsolley,
Ormianer, 2016 & Feldman, 2002
Guruprasada, Kolinski et al., 2018 Ottoni, Oliveira, Mansini,
Thapliyal, & Pawar, & Cabral, 2005
2013
Hasan et al., 2015 Laviv, Levin, Usiel, & Oxby, Oxby, Oxby, Saltvik,
Schwartz-­Arad, 2010 & Nilsson, 2015
Henningsen et al., Vandeweghe et al., 2012
2017
Lindeboom et al., Zembic et al., 2012
2006a,b
Luongo et al., 2014 Zwaan, Vanden Bogaerde,
Sahlin, & Sennerby, 2016
Maiorana et al., 2015
Malo et al., 2003
Mangano et al., 2017
Norton, 2004
Pettersson &
Sennerby, 2015
Sato et al., 2014
Schiegnitz, Noelken,
Moergel, Berres, &
Wagner, 2017
Yildiz, Zortuk, Kilic,
Dincel, & Albayrak,
2016
(Continues)
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COSYN et al. 229

TA B L E 1 (Continued)

Inappropriate study design (NO Not reporting on single No comparison DIP Insufficient number of
RCT/NRS) implants with IIP Bone graft prior to IP cases

Yoo, Chuang, Erakat, Weed, &

Dodson, 2006
Insufficient information on Not dealing with DIP and/ Longer follow-­up Insufficient healing period Othera
timing after tooth extraction or IIP available
Balshi, Wolfinger, Wulc, & Anitua, Pinas, & Alkhraisat, Cooper et al., 2010 Grunder et al., 1999 Kim & Yoon, 2017
Balshi, 2011; 2016
Andreasi Bassi et al., 2016; Norton, 2017 De Bruyn et al., 2013 Schropp, Kostopoulos, & Slagter, Raghoebar,
Wenzel, 2003 Bakker, Vissink, & Meijer,
2017
Evian et al., 2004; Payer et al., 2008 Raes, Cosyn, & De Soydan, Cubuk, Oguz, & Prati et al., 2017
Bruyn, 2013 Uckan, 2013
Raes et al., 2018a,b

DIP: delayed implant placement; IIP: immediate implant placement; IP: implant placement; NRS: non-­randomized controlled study; RCT: randomized
controlled trial.
a
Other: Patients taking medications or undergoing therapy affecting bone metabolism, or no survival data available, or not reporting on titanium
implants.

3.2 | Description of selected studies
The characteristics of the included studies are reported in Table 2.
Of the 8 finally selected studies, 3 were RCTs (Cucchi et al., 2017,
Lindeboom et al., 2006, Tonetti et al., 2017) and 5 were NRSs (Atieh
et al., 2013; Cooper et al., 2014; Mangano et al., 2013; Raes, Cosyn,
Noyelle, Raes, & De Bruyn, 2018a; Raes et al., 2018b; Siciliano et al.,
2009). The present systematic review pooled data of 512 patients
with a mean age ranging from 40 to 55 years, treated with a total of
517 single implants. Follow-­up ranged from 12 to 96 months. At study
termination, 468 patients who had been treated with a total of 473
single implants (IIP: 233, DIP: 240) remained available for evaluation
corresponding to an overall dropout rate of 9%. Selective loss to fol-
low-­up was observed in one study (dropout 33.3% following IIP versus
16.7% following DIP) (Atieh et al., 2013). Also in the study of Raes et al.
(2018), high dropout was observed, especially following IIP (31.3%).
Smokers were only included in three studies and accounted
for 13.7%–14.5% of the patients (Cucchi et al., 2017; Tonetti et al.,
2017). Mangano et al. (2013) excluded heavy smokers (more than
15 cigarettes per day) but provided no actual numbers of smokers.
Studies were heterogeneous in the inclusion of cases with in-
complete buccal bone walls at the time of tooth extraction. Cucchi
et al. (2017) only included cases with intact alveolar sockets in both
groups. Cooper et al. (2014), Mangano et al. (2013) and Raes et al.
(2018a,b) excluded cases with incomplete buccal bone walls in the
IIP group. In contrast, Siciliano et al. (2009) included such cases in
the IIP group, but not in the DIP group. Lindeboom et al. (2006)
and Tonetti et al. (2017) did not select patients on the basis of this
criterion including cases with incomplete buccal bone walls in both
groups. Atieh et al. (2013) did not provide this information.
Authors rarely reported on the gingival phenotype at the surgical
site. Mangano et al. (2013) and Raes et al. (2018a,b) excluded cases
with a thin phenotype for IIP. In both studies, the transparency of a
periodontal probe through the gingival margin while probing the buccal
sulcus of the upper central incisor, was used to discriminate a thin from
thick phenotype (De Rouck, Eghbali, Collys, De Bruyn, & Cosyn, 2009b).
Postoperative antibiotics were administered in 4 studies
(Siciliano et al., 2009; Mangano et al., 2013; Tonetti et al., 2017, Raes
et al., 2018). In one study, this was unclear (Cooper et al., 2014).
The majority of articles related to single implants installed in the
anterior segment of the dentition, either in the maxilla (Cooper et al.,
2014, Lindeboom et al., 2006, Mangano et al., 2013; Raes et al.,
2018a,b) or in both jaws (Tonetti et al., 2017). Atieh et al. (2013) and
Siciliano et al. (2009) exclusively reported on molar replacement,
whereas Cucchi et al. (2017) studied single implant placement in
premolar and molar sites. Lindeboom, Tjiook, and Kroon (2006a),
Lindeboom et al. (2006b) only included periapically infected sites.
Half of the studies combined implant placement with immedi-
ate provisional restoration (Atieh et al., 2013; Cooper et al., 2014;
Mangano et al., 2013; Raes et al., 2018a,b). Siciliano et al. (2009) and
Tonetti et al. (2017) aimed for transmucosal healing around a heal-
ing cap, whereas Cucchi et al. (2017) and Lindeboom et al. (2006a,b)
pursued submerged healing.
3.3 | Risk of bias assessment
The risk of bias of the included studies is given in Table 3. A kappa
coefficient of 0.673 (p < 0.001) was found, indicating good inter-­
rater agreement in quality assessment. The study of Tonetti et al.
(2017) demonstrated the highest quality since high risk of bias was
not found for any of the criteria and 5 criteria were rated as low
risk of bias. The studies of Cucchi et al. (2017) and Lindeboom et al.
(2006a,b) showed high risk of bias for one criterion. The remaining
five studies were NRSs. All demonstrated high risk of bias for 3 cri-
teria (Atieh et al., 2013; Cooper et al., 2014; Mangano et al., 2013;
Raes et al., 2018a,b; Siciliano et al., 2009).
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230 COSYN et al.

TA B L E 2 Characteristics of included studies

No. of Cases with Cases with thin

patients/No. of Mean age incomplete buccal phenotype Postoperative
Author Study design implants (years) No. of smokers bone wall included included antibiotics

Atieh et al., Single-­centre IIP: 12/12 IIP: 52 IIP: 0 IIP: NR IIP: NR

2013 NRS DIP: 12/12 DIP: 54 DIP: 0 DIP: NR DIP: NR No
Cooper Multi-­centre IIP: 55/55 IIP: 45 IIP: 0 IIP: No IIP: NR
et al., 2014 NRS DIP: 58/58 DIP: 42 DIP: 0 DIP: Unclear DIP: NR NR
Cucchi et al., Multi-­centre IIP: 48/49 IIP: 51 IIP: 7 IIP: No IPP: NR
2017
RCT DIP: 44/48 DIP: 51 DIP: 8 DIP: No DIP: NR No
Lindeboom Single-­centre IIP: 25/25 IIP: 40 IIP: 0 IIP: Yes IIP: NR
et al., RCT DIP: 25/25 DIP: 40 DIP: 0 DIP: Yes DIP: NR No
2006a,b
Mangano Single-­centre IIP: 22/22 IIP: 45 IIP: Unclear IIP: No IIP: no
et al., 2013 NRS DIP: 18/18 DIP: 47 DIP: Unclear DIP: Unclear DIP: yes Yes
Raes et al., Single-­centre IIP: 16/16 IIP: 45 IIP: 0 IIP: No IIP: no
2018a,b NRS DIP: 23/23 DIP: 40 DIP: 0 DIP: Unclear DIP: yes Yes
Siciliano Single-­centre IIP: 15/15 IIP: 48 IIP: 0 IIP: Yes IIP: NR
et al., 2009 NRS DIP: 15/15 DIP: 50 DIP: 0 DIP: No DIP: NR Yes
Tonetti et al., Multi-­centre IIP: 62/62 IIP: 50 IIP: 9 IIP: Yes IIP: NR
2017 RCT DIP: 62/62 DIP: 55 DIP: 9 DIP: Yes DIP: NR Yes

ant: anterior; DIP: delayed implant placement; IIP: immediate implant placement; mand: mandible; max: maxilla; NR: not reported;
NRS: non-­randomized controlled study; post: posterior; RCT: randomized controlled trial.

survival was observed following IIP when postoperative antibiotics

3.4 | Primary outcome variable: implant survival
Altogether, 16 implant failures (3.1%) occurred among 517 installed
single implants. Twelve arose within 6 months after placement (Atieh
et al., 2013; Cooper et al., 2014; Lindeboom et al., 2006a,b, Raes
et al. 2018, Tonetti et al., 2017) and two were identified at 1 year
(Atieh et al., 2013). In the study of Cucchi et al. (2017), two implant
failures occurred, yet the time point was not reported. Of the fail-
ing implants, 13 had been immediately placed into a fresh extraction
socket and 3 in a healed site pointing to an implant failure rate of
5.1% for IIP and 1.1% for DIP. Conversely, implant survival amounted
to 94.9% for IIP and 98.9% for DIP (Table 4). This 4% difference in
implant survival between IIP and DIP appeared statistically signifi-
cant as shown by the meta-­analysis (RR 0.96, 95% CI [0.93; 0.99],
p = 0.02) (Figure 2). Heterogeneity across studies was low, given an
I2 of 0% (p = 0.84). Even though the number of studies was limited,
the funnel plot demonstrated a fairly symmetrical distribution indi-
cating low risk of publication bias (Figure 2). In addition, all but one
study appeared accurate given the low variation that was observed
(SE close to 0).
Subgroup analyses were performed pooling studies in which post-
operative antibiotics had and had not been administered, RCTs and
NRSs, anterior and posterior sites, studies with ≤ 1-­year follow-­up and
studies with >1-­year follow-­up. There was no statistically significant
difference in terms of implant survival between IIP and DIP among
studies including the administration of postoperative antibiotics (RR:
0.98, 95% CI [0.94; 1.02], I2 = 0%). A trend towards lower implant
had not been administered (RR: 0.93, 95% CI [0.86; 1.00], I2 = 0%).
The difference in terms of implant survival between IIP and DIP did
not seem to be affected by the study design (RCTs: RR: 0.96, 95% CI
[0.93; 1.00], I2 = 0% – NRSs: RR: 0.95, 95% CI [0.90; 1.01], I2 = 0%),
implant position (anterior sites: RR: 0.96, 95% CI [0.93; 1.00], I2 = 0%
– posterior sites: RR: 0.92, 95% CI [0.76; 1.11], I2 50%) or follow-­up
(≤1-­year follow-­up: RR: 0.96, 95% CI [0.90; 1.01], I2 = 0% – >1-­year
follow-­up: RR: 0.96, 95% CI [0.92; 1.01], I2 = 0%).
3.5 | Secondary outcome variables
Table 4 depicts all relevant outcomes as described in the included
studies.
3.5.1 | Need for additional bone augmentation
In half of the studies, bone augmentation procedures were never
performed at the time of implant installation (Atieh et al., 2013;
Cooper et al., 2014; Mangano et al., 2013; Raes et al., 2018a,b).
Cucchi et al. (2017) performed bone augmentation following IIP
and DIP but did not specify in how many cases nor in total, neither
per group. Given the specific context of only including periapically
infected sites, Lindeboom et al. (2006a,b) performed bone aug-
mentation in every patient, regardless of the treatment modality.
Siciliano et al. (2009) always performed bone augmentation fol-
lowing IIP since the presence of a buccal self-­contained dehiscence
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COSYN et al. 231

No. of patients/No. of implants at % patients lost

Implant position Immediate restoration Follow-­up (months) study termination to follow-­up

IIP: post/mand IIP: yes IIP: 12 IIP: 8/8 IIP: 33.3%

DIP: post/mand DIP: yes DIP: 12 DIP: 10/10 DIP: 16.7%
IIP: ant/max IIP: yes IIP: 60 IIP: 45/45 IIP: 18.2%
DIP: ant/max DIP: yes DIP: 60 DIP: 49/49 DIP: 15.5%
IIP: ant+post/max+mand IIP: no IIP: 24.5 IIP: 48/49 IIP: 0%

DIP: ant+post/max+mand DIP: no DIP: 24.3 DIP: 44/48 DIP: 0%

IIP: ant/max IIP: no IIP: 12 IIP: 25/25 IIP: 0%
DIP: ant/max DIP: no DIP: 12 DIP: 25/25 DIP: 0%

IIP: ant/max IIP: yes IIP: 31.09 IIP: 22/22 IIP: 0%

DIP: ant/max DIP: yes DIP: 34.44 DIP 18/18 DIP: 0%
IIP: ant/max IIP: yes IIP: 96 IIP: 11/11 IIP: 31.3%
DIP: ant/max DIP: yes DIP: 96 DIP: 18/18 DIP: 21.7%
IIP: post/max+mand IIP: no IIP: 12 IIP: 15/15 IIP: 0%
DIP: post/max+mand DIP: no DIP: 12 DIP: 15/15 DIP: 0%
IIP: ant/max+mand IIP: no IIP: 12 IIP: 58/58 IIP: 6.5%
DIP: ant/max+mand DIP: no DIP: 12 DIP: 57/57 DIP: 8%

upon tooth extraction was an inclusion criterion. However, molar
sites with only intact alveolar walls were used for DIP. Hence,
bone augmentation was not performed in this group. Tonetti et al.
(2017) included cases with and without intact buccal bone walls
following tooth extraction in both groups. The need for additional
bone augmentation procedures was considerably higher following
IIP (72%) than following DIP (43.9%).
aspects of wound healing were evaluated in the various studies,
Cucchi et al. (2017), Mangano et al. (2013) and Siciliano et al. (2009)
described optimal healing for all cases following both treatment con-
cepts. In contrast, Tonetti et al. (2017) found five times more wound
healing complications following IIP when compared to DIP (26.1%
vs. 5.3%).

3.5.3 | Marginal bone loss

3.5.2 | Wound healing complications
Four studies reported on wound healing following IIP and DIP as
assessed by clinicians (Cucchi et al., 2017; Mangano et al., 2013;
Siciliano et al., 2009; Tonetti et al., 2017).Even though different
In the majority of studies, data on marginal bone loss (MBL) were
described (Atieh et al., 2013; Cooper et al., 2014; Cucchi et al.,
2017; Lindeboom et al., 2006a,b; Raes et al., 2018a; Tonetti
et al., 2017). A subgroup meta-­a nalysis was performed pooling

TA B L E 3 Risk of bias assessment of included studies

Selection bias: Selection bias:

Random sequence Allocation Performance Attrition Selective Other sources
Author generation concealment bias Detection bias bias reporting bias of bias

Atieh et al., 2013 High High Low High Low Low Unclear
Cooper et al., 2014 High High Low High Low Unclear Low
Cucchi et al., 2017 Low Low Low High Low Unclear Low
Lindeboom et al., 2006a,b Low Unclear Low High Low Low Low
Mangano et al., 2013 High High Low High Low Low Low
Raes et al., 2018a,b High High Low High Low Unclear Low
Siciliano et al., 2009 High High Low High Low Unclear Low
Tonetti et al., 2017 Low Low Low Low Unclear Unclear Low
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232 COSYN et al.

TA B L E 4 Outcomes of included studies

Sites requiring bone Sites with wound

augmentation % (N°/ complications % (N°/ Implant survival % (N°/ Marginal bone loss Probing depth Bleeding on
Author total N°) total N°) total N°) mean (SD) mean (SD) probing %

Atieh et al., IPP: Not performed IPP: NR IIP: 66.7% (8/12) IIP: -­0.41 (0.57) IIP: NR IIP: NR
2013 DIP: Not performed DIP: NR DIP: 83.3% (10/12) DIP: -­0.04 IIP: NR DIP: NR
(0.46)baseline:
crown
Cooper et al., IPP: Not performed IIP: NR IIP: 94.5% (52/55) IIP: -­2.06 (2.38) IIP: NR IIP: 7.2%
2014 DIP: Not performed DIP: NR DIP: 98.3% (57/58) DIP: -­0.10 (1.29) DIP: NR DIP: 6.6%
baseline: surgery

Cucchi et al., IPP: Yes, No. of sites IIP: 0% (0/49)a IIP: 95.9% (47/49) IIP: 0.4 (0.4) IIP: no data IIP: 13.6%
2017 NR
DIP: Yes, No. of sites DIP: 0% (0/48)a DIP: 100% (48/48) DIP: 0.5 (0.4) DIP: no data DIP: 9.4%
NR baseline: crown

Lindeboom IPP: 100% (25/25) IIP: NR IIP: 92% (23/25) IIP: 0.51 (0.11) IIP: NR IIP: NR
et al., DIP: 100% (25/25) DIP: NR DIP: 100% (25/25) DIP: 0.52 (0.15) DIP: NR DIP: NR
2006a,b

Mangano IPP: Not performed IIP: 0% (0/22)b IIP: 100% (22/22) IIP: NR IIP: NR IIP: NR
et al., 2013 DIP: Not performed DIP: 0% (0/18)b DIP: 100% (18/18) DIP: NR DIP: NR DIP: NR

Raes et al., IPP: Not performed IIP: NR IIP: 93.8% (15/16) IIP: -­0.98 (1.71) IIP: 2.7 (0.5) IIP: 18.2%
2018a,b DIP: Not performed DIP: NR DIP: 100% (23/23) DIP: 0.49 (1.89) DIP: 3.4 (1.7) DIP: 44.4%
baseline: surgery

Siciliano et al., IIP: 100% (15/15) IIP: 0% (15/15)c IIP: 100% (15/15) IIP: NR IIP: 4.13 (0.98) IIP: NR
2009 DIP: 0% (0/15) DIP: 0% (0/15)c DIP: 100% (15/15) DIP: NR DIP: 3.06 (0.58) DIP: NR
d
Tonetti et al., IIP: 72% (45/62) IIP: 26.1% (16/62) IIP: 98.4% (61/62) IIP: 1.5 (0.5) IIP: 4.1 (1.2) IIP: 32%
2017 DIP: 43.9% (27/62) DIP: 5.3% (3/62)d DIP: 100% (62/62) DIP: 0.3 (0.4) DIP: 3.3 (1.1) DIP: 24%
after 36 months
baseline: crown

DIP: delayed implant placement; IIP: immediate implant placement; NR: not reported.
a
Neurological or vascular injuries, infection, fistula, suppuration. bPain, suppuration. cInfection. dWound dehiscence, oedema, suppuration.
e
Chipping, screw loosening. fAbutment or crown loosening, chipping, crown fracture. gFistula, progressive bone loss, pain.

the studies with and without bone augmentation (Figure 3). MBL
was not statistically significantly different between IIP and DIP
in the studies where bone augmentation was performed at the
time of implant installation (WMD 0.33 mm, 95% CI [−0.37; 1.09],
p = 0.33) (Cucchi et al., 2017; Lindeboom et al., 2006a,b; Tonetti
et al., 2017). However, heterogeneity across studies was consid-
erable given an I 2 of 99% (p < 0.001). In contrast, statistically sig-
nificantly more marginal bone gain was found following IIP when
compared to DIP (WMD 1.23 mm, 95% CI [0.08; 2.37], p = 0.04)
in the studies where bone augmentation was never performed
(Atieh et al., 2013; Cooper et al., 2014; Raes et al., 2018a). Again,
heterogeneity across studies was considerable given an I 2 of 87%
(p < 0.001).
3.5.4 | Probing depth and bleeding on probing
Probing depth was registered by Raes et al. (2018a,b), Siciliano et al.
(2009) and Tonetti et al. (2017). Raes et al. (2018a,b) found deeper
pockets following DIP, whereas Siciliano et al. (2009) and Tonetti
et al. (2017) described deeper pockets following IIP. The meta-­
analysis failed to demonstrate a statistically significant difference in
favour of one or the other treatment modality (WMD 0.43 mm, 95%
CI [−0.47; 1.33], p = 0.35) (Figure 3).
Four studies provided data on bleeding on probing (Cooper et al.,
2014; Cucchi et al., 2017; Raes et al., 2018a; Tonetti et al., 2017).
Low bleeding scores with percentages below 15% for IIP and DIP
were described by Cucchi et al. (2017) and Cooper et al. (2014). High
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COSYN et al. 233

No. of technical No. of biological

Papillary recession Pink aesthetic score mean Post-­op pain mean Patient satisfaction complications % (N°/total complications % (N°/
mean mm (SD) (SD) (SD) VAS N°) total N°)

IIP: NR IIP: NR IIP: NR IIP: NR IIP: 33.3% (4/12)e IIP: NR

e
DIP: NR DIP: NR DIP: NR DIP: NR DIP: 25% (3/12) DIP: NR

IIP: mesial 0.13 (1.61) IIP: NR IIP: NR IIP: NR IIP: NR IIP: NR

Distal 0.21 (1.61) DIP: NR DIP: NR DIP: NR DIP: NR DIP: NR
DIP: mesial -­0.39
(1.52)
distal -­0.50 (1.35)
IIP: no data IIP: NR IIP: NR IIP: NR IIP: 0% (0/49) IIP: 0% (0/49)

DIP: no data ‘no DIP: NR DIP: NR DIP: NR DIP: 0% (0/48) DIP: 0% (0/48)
visible recession’

IIP: 18 score 3 IIP: NR IIP: NR IIP: NR IIP: NR IIP: NR

Jemt’s papilla index DIP: NR DIP: NR DIP: NR DIP: NR DIP: NR
DIP: 18 score 3
Jemt’s papilla index
IIP: NR IIP: 7.45/10 IIP: no data IIP: NR IIP: 0% (0/22) IIP: NR
DIP: NR (1.62) DIP: no data DIP: NR DIP: 0% (0/18) DIP: NR
DIP: 7.83/10 ‘absence of pain
in all cases’
(1.58)
IIP: mesial 0.44 (1.04) IIP: 10.36/14 IIP: no data IIP + DIP: IIP: 37.5% (6/16)f IIP: 0% (0/16)g
Distal 0.27 (0.55) (2.11) DIP: no data 87–97 DIP: 21.7% (5/23)f DIP: 13% (3/23)g
DIP: mesial 0.05 DIP: 9.22/14 ‘absence of pain
(0.56) in all cases’
distal 0.02 (0.83) (2.31)

IIP: NR IIP: NR IIP: NR IIP: NR IIP: NR IIP: NR

DIP: NR DIP: NR DIP: NR DIP: NR DIP: NR DIP: NR
IIP: NR IIP: 7.1/10 IIP: 1.3/10 IIP: >85 IIP: NR IIP: NR
DIP: NR (1.8) (1.6) DIP: >85 DIP: NR DIP: NR
DIP: 7.5/10 DIP: 0.8/10
(1.8) (0.9)

bleeding scores with percentages above 30% for IIP or DIP were re-
ported by Raes et al. (2018a,b) and Tonetti et al. (2017). Since none
of the authors provided standard deviations for bleeding on probing,
a meta-­analysis could not be performed.
3.5.5 | Papillary recession
Only Cooper et al. (2014) and Raes et al. (2018a,b) described vertical
changes in papilla height following IIP and DIP. Both provided separate
data for the mesial and distal aspect (Figure 3). Overall, statistically
significantly more papillary recession was found following IIP when
compared to DIP (WMD 0.44 mm, 95% CI [0.18; 0.70], p = 0.001).
Heterogeneity across studies was low, given an I2 of 0% (p = 0.92).
3.5.6 | Pink aesthetic score
Mangano et al. (2013), Raes et al. (2018a,b) and Tonetti et al.
(2017) assessed the aesthetic outcome by rating the pink aes-
thetic score (PES). Raes et al. (2018a,b) used the original index
generating a score on a total of 14 (Furhauser et al., 2005).
Mangano et al. (2013) and Tonetti et al. (2017) used a modified
index generating a score on a total of 10 (Belser et al., 2009).
Raes et al. (2018a,b) demonstrated a slightly superior aesthetic
outcome for IIP, whereas Mangano et al. (2013) and Tonetti
et al. (2017) described slightly higher PES scores for DIP. The
meta-­a nalysis failed to demonstrate a statistically significant
difference in favour of one or the other treatment concept
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234 COSYN et al.

(standardized WMD -­0 .03, 95% CI [−0.46; 0.39], p = 0.88)

(Figure 3).

3.5.7 | Patient-­reported outcomes

Quantitative data on post-­o perative pain and overall patient sat-
isfaction were seldom described (Raes et al., 2018b; Tonetti et al.,
2017). IIP and DIP seemed well tolerated by the patients given
low pain scores (<2/10) (Tonetti et al., 2017) and high patient
appreciation scores (VAS >85) (Raes et al., 2018b; Tonetti et al.,
2017).

3.5.8 | Complications
Four studies provided data on technical complications (Atieh et al.,
2013; Cucchi et al., 2017; Mangano et al., 2013; Raes et al., 2018a).
There were no technical complications in the studies of Cucchi et al.
(2017) and Mangano et al. (2013). In contrast, technical complica-
tions occurred in over 20% of the cases irrespective of the treatment
concept as reported by Atieh et al. (2013) and Raes et al. (2018a,b).
The most frequent technical complications were veneer chipping
and screw loosening.
Biological complications were only described in 2 studies (Cucchi
et al., 2017; Raes et al., 2018a). There were no biological complica-
tions in the study of Cucchi et al. (2017). In the study of Raes et al.
(2018a,b), 2 patients experienced progressive bone loss (> 2 mm) and
deep pockets (> 6 mm) indicative of peri-­implantitis. Another patient
developed a fistula.
Left: Forest plot on implant survival; right: funnel plot on implant survival

4 | D I S CU S S I O N

This systematic review was based on 8 clinical studies on single im-

plants comparing IIP to DIP.
After a follow-­up ranging from 12 to 96 months, data from 473
out of 517 installed implants were available for evaluation, pointing
to an overall dropout rate of 9%. Although strict inclusion and ex-
clusion criteria were adopted, heterogeneity across studies was still
observed mainly in terms of the inclusion of cases with incomplete
buccal bone walls at the time of tooth extraction, implant position,
healing and restoration protocol.
Altogether, 16 implant failures (3.1%) occurred among 517 in-
stalled single implants. All were early failures, thus resulting from a
lack of osseointegration. Meta-­analysis showed significantly lower
survival rates for implants installed into fresh extraction sockets
when compared to implants placed into healed sites (RR 0.96, 95%
CI [0.93; 0.99], p = 0.02). Given a good model fit, nihil heterogene-
ity and low risk of publication bias, this conclusion applies to ideal
sites as well as to sites where additional augmentation is needed,
to anterior as well as to posterior sites, to immediately restored im-
FIGURE 2

plants as well as to conventionally restored implants. A subgroup

meta-­analysis demonstrated a trend towards more implant loss fol-
lowing IIP as compared to DIP among studies in which postoperative

COSYN et al.
F I G U R E 3 Upper left: Forest plot on marginal bone loss (MBL); upper right: forest plot on probing depth; lower left: forest plot on
papillary recession at mesial and distal aspect; lower right: forest plot on pink aesthetic score
antibiotics had not been administered (RR: 0.93, 95% CI [0.86; 1.00])
(Atieh et al., 2013; Cucchi et al., 2017; Lindeboom et al., 2006a,b).
In contrast, similar implant survival was observed among studies in-
cluding the use of postoperative antibiotics (RR: 0.98, 95% CI [0.94;
1.02]). This finding suggests that postoperative antibiotics mainly
reduce early implant loss following IIP, which is in line with earlier
findings (Lang, Pun, Lau, Li, & Wong, 2012). Another reason for the
higher failure for IIP may be less bone-­to-­implant contact at the time
of implant installation and possibly lower primary implant stability in
a fresh extraction socket.
The need for additional bone augmentation is an important vari-
able that has never been evaluated in systematic reviews before. This
need is closely related to the inclusion of patients with incomplete
buccal bone walls at the time of tooth extraction. Such patients were
excluded for IIP in 4 studies (Cooper et al., 2014; Cucchi et al., 2017;
Mangano et al., 2013; Raes et al., 2018a,b). In all but one (Cucchi
et al., 2017), the authors decided not to fill the gap between the im-
plant and intact buccal bone wall. Today, evidence is available show-
ing a significant reduction in buccal bone resorption at immediately
installed implants when placing a demineralized bovine bone mineral
in the gap as compared to using no augmentation material (Sanz,
Lindhe, Alcaraz, Sanz-­Sanchez, & Cecchinato, 2017). Clearly, the
need for additional bone augmentation in routine practice can only
be assessed in studies where all patients have been included. After
all, a lot of teeth are removed because of root fractures or periodontal
disease in daily practice, usually resulting in bone resorption at the
buccal aspect. In addition, the criteria for bone augmentation should
be same for IIP and DIP for an unbiased comparison, as in the study
of Tonetti et al. (2017). They described a considerably higher need for
additional bone augmentation following IIP (72%) when compared to
DIP (43.9%). The other studies reporting on bone augmentation pro-
cedures demonstrated high risk of reporting bias (Cucchi et al., 2017)
|
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235
or selection bias (Lindeboom et al., 2006a,b; Siciliano et al., 2009) and
have to be interpreted with caution in this respect.
An interesting finding was the five times higher wound heal-
ing complications rate following IIP when compared to DIP (26.1%
versus 5.3%) in the study of Tonetti et al. (2017). This can be partly
explained by the higher need for bone augmentation following IIP.
Indeed, bone augmentation requires tension-­free primary wound
closure and this can be difficult to accomplish, especially when
soft tissues are lacking as is the case immediately following tooth
extraction. Cucchi et al. (2017) also performed bone augmentation
when deemed necessary and even used a submerged healing ap-
proach in all cases. Interestingly however, optimal wound healing
was observed in all cases, which seems to be in conflict with the
results from Tonetti et al. (2017). The fact that Cucchi et al. (2017)
only included ideal cases with intact buccal bone walls, whereas
Tonetti et al. (2017) included all cases could have an impact on the
extent of the bone augmentation procedure and therefore on wound
healing. Also Siciliano et al. (2009) provided data on wound healing.
However, due to a high risk of selection bias, these findings should
be interpreted with caution.
Marginal bone loss was frequently reported, yet yielded highly
heterogeneous data (Atieh et al., 2013; Cooper et al., 2014; Cucchi
et al., 2017; Lindeboom et al., 2006a,b; Raes et al., 2018a; Tonetti
et al., 2017). Therefore, a subgroup meta-­analysis was performed
pooling the studies with and without bone augmentation. This anal-
ysis showed similar MBL following IIP and DIP in the studies where
bone augmentation was performed at the time of implant installa-
tion (Cucchi et al., 2017; Lindeboom et al., 2006a,b; Tonetti et al.,
2017). However, statistically significantly more marginal bone gain
was observed following IIP when compared to DIP (WMD 1.23 mm,
95% CI [0.08; 2.37], p = 0.04) in the studies where bone augmenta-
tion was never performed (Atieh et al., 2013; Cooper et al., 2014;
 |
236
Raes et al., 2018a). From a biological point of view, this seems logic
taking into account that in many IIP cases the first bone-­to-­implant
contact may be far away from the implant shoulder at the time of
implant installation. In the months thereafter, bone formation occurs
in this area and interproximal bone gain will be registered (Cooper
et al., 2014; Raes et al., 2018a). In contrast, in a healed ridge an im-
plant is fully embedded in bone from the day of implant installation.
When it comes to comparing MBL between IIP and DIP without
bone augmentation, MBL should be interpreted with caution as the
changes following IIP merely reflect physiological bone formation
that occurs in an extraction socket, regardless of the immediate in-
stallation of an implant. The disparity between the subgroup analy-
ses can be explained by the use of a bone replacement graft in the
gap between the implant shoulder and alveolar socket. By doing so,
the initial marginal bone level will be assessed in close proximity to
the implant shoulder even though the true bone-­to-­implant contact
may be much more apical. In this regard, it is important to realize
that even in case of bone augmentation, the comparison between
IIP and DIP is highly biased because one basically assesses the level
of bone replacement grafts following IIP. Given all this, we believe
that MBL can only be objectively compared between IIP and DIP
when the initial bone remodelling has taken place, thus with the in-
stallation of the permanent crown as a reference time point. Only
Atieh et al. (2013), Cucchi et al. (2017) and Tonetti et al. (2017) used
permanent crown installation as a baseline, yet with conflicting re-
sults (0.37 mm extra bone gain for IIP versus DIP (Atieh et al., 2013),
1.2 mm extra bone loss for IIP versus DIP (Tonetti et al., 2017)). It
can be concluded that the available information comparing IIP with
DIP in terms of MBL is conflicting and highly biased.
The results of the present study failed to show a significant dif-
ference in clinical outcome between IIP and DIP. A meta-­analysis
could be performed indicating similar probing depth following IIP
and DIP. In this context, it is important to note that the difference
in follow-­up among the studies could be a source of bias. Indeed,
Siciliano et al. (2009) and Tonetti et al. (2017) reported on 1-­year
data and found deeper pockets following IIP, whereas Raes et al.
(2018a,b) described 8-­year data and found deeper pockets following
DIP.
Bleeding on probing demonstrated quite high variation across
studies, yet the available data did not support a plausible impact of
the treatment concept.
Meta-­analysis showed significantly more papillary recession fol-
lowing IIP when compared to DIP (WMD 0.44 mm, 95% CI [0.18;
0.70], p = 0.001). The analysis was performed with limited material
since vertical soft tissue changes were only evaluated in two stud-
ies combining implant placement to immediate restoration in the
anterior segment of the dentition (Cooper et al., 2014; Raes et al.,
2018b). In these studies, the moment of provisional crown installa-
tion was used as baseline. Consequently, papillary re-­growth could
have been anticipated following DIP given the re-­establishment of
a contact point, as shown by Cooper et al. (2014). Hence, the com-
parison between IIP and DIP may be misleading. Papillary and also
midfacial recession can only be objectively compared between IIP
1600051x, 2019, S21, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13054, Wiley Online Library on [10/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
COSYN et al.
and DIP when baseline registrations occur with the original tooth
still in situ. To the best of our knowledge, there are no such compar-
ative studies.
Meta-­analysis showed similar aesthetic outcomes following IIP
and DIP on the basis of the pink aesthetic score. Again, the analysis
was performed with limited material since the PES was only evalu-
ated in three studies reporting on anterior implants (Mangano et al.,
2013; Raes et al., 2018b; Tonetti et al., 2017).
The available data on patient-­reported outcomes were very
scarce (Raes et al., 2018b; Tonetti et al., 2017). Given this limitation,
both treatment concepts seemed well tolerated by the patients.
Large variation was observed across studies in terms of technical
complications (Atieh et al., 2013; Cucchi et al., 2017; Mangano et al.,
2013; Raes et al., 2018a). However, the available data did not sup-
port a plausible impact of the treatment concept. Only in one study
3 biological complications were reported (Raes et al., 2018a).
This systematic review has clear limitations when it comes to
the amount and quality of the study material. One RCT showed
unclear risk of bias (Tonetti et al., 2017), whereas all other studies
demonstrated high risk. This information becomes of critical impor-
tance when secondary outcome variables are compared between
IIP and DIP, since such comparisons are usually based on very few
studies.
The lack of CBCT analyses at different time points and the lack
of data on midfacial recession with the preoperative status as base-
line may be considered basic flaws in available studies comparing
IIP to DIP. This is surprising knowing multiple prospective and ret-
rospective clinical studies have been published demonstrating a
loss of buccal convexity and midfacial recession following IIP (Chen
et al., 2007, 2009; Cordaro et al., 2009; Cosyn et al., 2016; De Rouck
et al., 2009a; Kan et al., 2011). To counteract these dimensional al-
terations, bone augmentation (Sanz et al., 2017) and connective tis-
sue grafting have been proposed. RCTs demonstrated significantly
less midfacial recession following the application of a connective
tissue graft in the buccal mucosa following IIP (Frizzera et al., 2018;
Yoshino, Kan, Rungcharassaeng, Roe, & Lozada, 2014; Zuiderveld,
Meijer, den Hartog, Vissink, & Raghoebar, 2018). Connective tissue
grafts also appear beneficial to restore buccal convexity following
DIP (D'Elia et al., 2017; De Bruyckere, Eghbali, Younes, De Bruyn, &
Cosyn, 2015; De Bruyckere et al., 2018; Eghbali, De Bruyn, Cosyn,
Kerckaert, & Hoof, 2016; Eghbali et al., 2018; Hanser & Khoury,
2016; Stefanini et al., 2016). Clearly, state-­of-­the-­art implant ther-
apy often requires soft tissue grafting following IIP as well as fol-
lowing DIP. The need for soft tissue grafting should therefore be
evaluated in future RCTs comparing IIP to DIP.
Information on the horizontal and vertical implant position would
be valuable in future RCTs. Tonetti et al. (2017) described that im-
plants had been slightly deeper installed into fresh extraction sock-
ets, which could have an impact on aesthetic parameters. Especially
buccal shoulder positions should be identified as these have been
clearly associated with midfacial recession (Chen et al., 2007, 2009;
Cosyn et al., 2012b). In order to avoid misplacement, guided surgery
should be considered (Younes et al., 2018).

COSYN et al.
Finally, RCTs comparing IIP with DIP are of pivotal importance
to refine clinical decision-­making. The fact that only few have been
published may be partly explained by ethical concerns that some
investigators may have for conducting such trials. After all, ran-
domization implies that the same selection criteria are used for IIP
and DIP. In clinical practice however, a lot of clinicians only per-
form IIP for strictly selected cases. In this respect, it is important to
realize that even if IIP demonstrates inferior outcomes when com-
pared to DIP in general as assessed in RCTs, this does not imply
that the concept should be abandoned for treating ideal cases.
5 | CO N C LU S I O N
After a follow-­up ranging from 12 to 96 months, IIP resulted in sig-
nificantly lower implant survival than DIP (94.9% vs. 98.9%). All were
early failures, thus resulting from a lack of osseointegration. Although
based on few studies, probing depth and aesthetic outcomes were
similar. Results were inconclusive for all other outcomes.
C O N FL I C T O F I N T E R E S T
The authors have stated explicitly that there are no conflicts of in-
terest in connection with this article. Prof. Dr. Jan Cosyn has a col-
laboration agreement with Nobel Biocare (Kloten, Switzerland) and
Straumann (Basel, Switzerland).
ORCID
Jan Cosyn http://orcid.org/0000-0001-5042-2875
Stijn Vervaeke http://orcid.org/0000-0002-1416-6787
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The effectiveness of immediate implant placement for single
tooth replacement compared to delayed implant placement: A
systematic review and meta-­analysis. J Clin Periodontol.
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