Immediate versus early loading of flapless

placed dental implants: A systematic review

Lin Xu, BDS, MDSc,a Xiaodong Wang, BDS, MDSc,b
Qin Zhang, BDS,c Wen Yang, BDS,d Wenjun Zhu, BDS, MDSc,e and
Ke Zhao, BDS, PhDf
Guanghua School of Stomatology, Hospital of Stomatology, Sun
Yat-sen University, Guangzhou, China
Statement of problem. The flapless implant technique is a predictable procedure with several advantages and a high overall
implant survival rate. Immediate loading and early loading have been widely used in dental implant therapies and provide
improved esthetics, with enhanced function and comfort. However, the scientific support for immediate or early loading
approaches for flapless-placed dental implants is unclear.

Purpose. The purpose of this systematic review was to assess the effectiveness and safety of the immediate versus early loading
of dental implants with flapless placement.

Material and methods. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CNKI database, VIP
database, WANFANG Database, and World Health Organization International Clinical Trials Registry Platform Search Portal
were searched (up to October 2012). The systematic review included clinical randomized controlled trials that compared
immediate with early loading of flapless-placed dental implants to replace missing teeth in adult participants who were
partially or completely edentulous. The selection of included studies, data extraction, and assessment of the quality of the
studies and evidence were conducted independently by 2 reviewers.

Results. Six articles that reported on 4 randomized controlled trials that involved 180 selected participants were included. The
implant failure rate was from 0.0% to 3.3% in both immediate and early loading groups with flapless implantation. No
statistically significant differences were found in implant failure rates, periimplant marginal bone-level changes, or
complications between the 2 groups. More participants preferred immediate loading rather than waiting for nearly 2 months.

Conclusions. Within the limitation of needing additional high-quality evidence, immediate and early loading of dental
implants after flapless placement both demonstrated an acceptable short- to medium-term survival rate. Immediate loading
seems more acceptable because of the time benefit. (J Prosthet Dent 2014;112:760-769)

Clinical Implications
Immediate or early loading of dental implants placed by using the
flapless procedure is widely used for replacing missing teeth due to its
reduction of discomfort, treatment time, and costs. This study revealed
that the immediate loading option seems more acceptable because of
the time benefit.

Tooth loss of any kind usually been a common treatment option, with and partially edentulous.3,4 The flapless
leads to problems of esthetics, comfort, favorable survival rates, for replacing implant surgery technique is an alter-
and function.1,2 Currently, implant- missing teeth and improving the quality native and minimally invasive technique
supported dental rehabilitation has of life of patients who are completely that does not require soft-tissue flaps

a
Resident, Department of Prosthodontics.
b
Resident, Department of Prosthodontics.
c
Resident, Department of Prosthodontics.
d
Resident, Department of Prosthodontics.
e
Resident, Department of Prosthodontics.
f
Professor, Department of Prosthodontics.

The Journal of Prosthetic Dentistry Xu et al

October 2014 761
and suturing. This technique has gained clinical results.23-27 The conclusions of that dictates implant removal) and
popularity since its introduction in a 3-year follow-up randomized con- periimplant marginal bone-level changes.
2000.5-7 The flapless approach has trolled trial (RCT) determined that The secondary outcomes consisted
several advantages over conventional there were no statistically significant of patient satisfaction and biologic or
flap elevation, including the preserva- differences in failure rates and bone prosthetic complications.
tion of hard tissues; maintenance of levels between IL and EL implants with Two reviewers (L.X., X.W.) indepen-
vascular supply; decreased surgical the flapless approach.28 This result dently searched the following electronic
procedure time; lower intensity; and has wide consensus in other RCT databases: Cochrane Central Register of
reduction of postoperative complica- studies.24,29 Nevertheless, Cannizzaro Controlled Trials (CENTRAL) (accessed
tions, for example, pain, swelling, et al30 showed more failed implants in October 2012), MEDLINE (1966-2012),
infection, necrosis, or dehiscence.5,8-13 the flapless placement and EL group EMBASE (1980-2012), CNKI database
Furthermore, the available data indi- than in the flapless placement and IL (1976-2012), VIP database (Chongqing
cate that the flapless technique is an group. Some studies revealed that com- VIP information Co., Ltd.) (1986-2012),
effective and predictable procedure with plications developed more frequently in and WANFANG Database (Beijing
high overall implant survival rates.6,8-10 the flapless placement and IL group Wanfang Data Co., Ltd.) (1994-2012).
The success rate has been reported to than in the EL group.24,28,29 When A detailed search strategy was prepared
be 98.6% in prospective cohort studies, considering periimplant bone changes, for each database. Search terms were
whereas retrospective and case studies Moon et al31 observed that the bone the following: flapless, incisionless inva-
have indicated survival rates of 95.9%.8 formation rate was high and that a de- sive, minimally invasive, implant*, im-
In addition, the survival rate of the gree of bone contact was indicated for IL mediate*, early. In addition, the World
flapless technique is comparable with and EL. Currently, the recommendation Health Organization International Clin-
the conventional surgical protocol when for IL or EL approaches for flapless ical Trials Registry Platform Search
performed with patients who have an placed implants is still premature. Portal for ongoing studies also was
adequate quantity of bone.10,14 Reviews have been published on the retrieved. To increase the yield of relative
Immediate loading (IL) and early topic of flapless surgery or different studies, the references of all identified
loading (EL) has been widely used loading protocols17,32-34; however, no studies were searched manually. Initially,
in implant therapies, particularly in study has focused on the flapless tech- 2 review authors independently scanned
mandibles with good bone quality. nique with IL or EL. Therefore, the all titles and abstracts of the potential
The protocols provide good esthetics, objective of this study was to conduct studies identified through the electronic
enhanced function, and almost imme- a systematic review to evaluate the searches. The full-text articles were
diate comfort, and have a favorable effectiveness and safety of IL (within analyzed when the title or abstracts
implant survival rate.15-20 IL has been 3 days) versus EL (after 6 weeks to indicated that the eligibility criteria
defined as the placement of an interim 2 months) of dental implants placed were fulfilled. Two reviewers (L.X., X.W.)
prosthesis within 72 hours of implant by using the flapless procedure for independently extracted the data of
placement,21,22 whereas EL has been replacing missing teeth and to assess included studies by using a special data
defined as the loading of the implants the quality of retrieved evidence and collection form. Any discrepancy was
after a 6-week to 2-month healing the strength of recommendations by resolved by discussion, and, if resolu-
period.20,22 Esposito et al17 indicated using the Grades of Recommendations tions were impossible, then a third
that both IL and EL implants were Assessment, Development and Evalua- reviewer (K.Z.) was consulted. When
successful in selected patients, with no tion (GRADE) system. necessary, the original investigator (L.X.
statistically significant differences in or X.W.) was contacted for further clar-
the outcomes. However, the results of MATERIAL AND METHODS ification of relevant information.
that study suggested a trend that IL The risk of bias for each included
implants might fail more often than This review used RCTs, which study was assessed independently by
conventionally loaded implants but less compared the efficacy of IL with EL 2 review authors (L.X., X.W.) according
commonly than EL implants. of dental restorations supported by to the recommended approach sug-
Patients are assumed to prefer the flapless placed implants. Studies with gested by the Cochrane Collaboration,
delivery of a functional and esthetic participants who were either partially which included the following specific
prosthesis on the same day as implant or completely edentulous, different aspects: sequence generation, alloca-
placement, which reduces discomfort, definitions of IL or EL, and all types tion concealment, blinding, incomplete
treatment time, and costs; flapless sur- of implants and implant-supported outcome data, selective reporting bias,
gery, combined with IL or EL to replace prostheses were included. The primary and other sources of bias. When the
missing teeth, is then considered. outcomes of this review consisted of possibility of a reporting bias existed,
Some studies have demonstrated that implant failure (the presence of any the original study investigators were
this procedure could provide excellent mobility of implants and/or infection contacted to provide further outcome
Xu et al
762 Volume 112 Issue 4
data, if possible. If the study protocol reliability of evidence, sensitivity anal- included trials were conducted in Italy.
was available, then its outcomes were ysis was performed by comparing the The 4 studies involved 180 participants
compared with the published article; difference between a fixed-effect model (77 men and 103 women), with ages
if not, then the outcomes listed in and a random-effects model. The sub- between 18 and 80 years. Sixty-four of
the methods section of an article and group analysis was performed for the the participants were smokers. The
reported in the results section were following groups: different follow-up participants were recruited and treated
compared. time and different types of prosthesis. in private dental clinics in Italy. In 2
For continuous data, outcomes trials, the participants were required to
were expressed as the mean difference RESULTS have bone volumes in which implants
(MD) if measured in the same scale or of no less than 3.7 mm in diameter and
as the standardized MD if measured There were 62 references that were 10 mm in length could be placed.29,30
in different methods with a calculated identified by following the search stra- The other 2 trials included partici-
95% confidence interval (CI). For di- tegies. Title and abstract analyses ob- pants with at least 5.5 mm of bone at
chotomous data, a risk ratio or odds tained 7 potentially relevant articles the implant sites: one of the studies
ratio (OR) with a 95% CI was used. (Fig. 1).22-25,28-30 Full-text analyses required bone that allowed placement
The I2 statistic was used to quantify indicated 3 articles that discussed an of 6.5-mm-long implants,24,25 whereas
the statistical heterogeneity among identical trial published by the same the other study required the placement
the studies for all outcomes. For an I2 investigator22,23,28; the preliminary ar- of implants at least 9.5-mm long.23,28
of not more than 50%, a fixed-effect ticle was excluded because the data In all 4 of the trials, the partici-
model was performed regarding no were reported in 1 of the other 2 in- pants were randomly allocated to 2
or moderate heterogeneity. When sub- cluded articles,22,23,28 which discussed groups: the test group was loaded
stantial heterogeneity (I2 > 50%) was different follow-up periods. Overall, 6 immediately after flapless implanta-
presented, possible explanations were articles about 4 trials were included in tion, and the control group was
explored, and a random-effects meta- this review (Table I).23-25,28-30 All of the EL after flapless implantation pro-
analysis was performed or a descriptive included studies were RCTs with a sin- cedures. Two trials used definitive
analysis was performed. To test the gle center, parallel design. All of the metal ceramic crowns.23-25,28 One

Initial electronic search results:

CENTRAL (n=6); PubMed (n=14);
EMBASE (n=13); CNKI (n=16);
WANFANG (n=3); VIP (n=10)

19 duplicates removed

43 potentially relevant records

Non dental implants related

(n=17)
Not clinical trials (n=4)
No articles added by Retrospective studies (n=2)
manual search Trials without random or
control (n=4)
Not immediately versus early
loading (n=8)
Not flapless implantation (n=1)

7 potentially appropriate records

to be obtained full texts

1 article excluded for its datum

were parts of results in another
article

6 articles included

1 Search and selection flow of articles.

The Journal of Prosthetic Dentistry Xu et al
October 2014 763
Table I. Characteristics of included studies
Study Method Participants Interventions Outcomes

Cannizzaro et al,29 RCT, (1) Total no., 60 (IL, (1) Test group: flapless implantation and IL (the Implant failure,
2008 (spring) parallel M/F¼11/19; EL, same day as placement); (2) control group: prosthesis failure,
design M/F¼14/16); (2) age flapless implantation and EL (6 wk after patient satisfaction,
range, 36-80 y; (3) placement); (3) no. inserted implants: IL/EL complications
diagnosis: 60/60; (4) prosthesis: mandibular bar-
mandibular retained overdentures; (5) implants: tapered
completely SwissPlus; (6) time of follow-up: 1 y;
edentulous arches (7) dropouts: none

Cannizzaro et al,30 RCT, (1) Total no. 30 (IL: (1) Test group: flapless surgery and IL (the same Implant failure,
2008 (summer) parallel M/F¼8/7; EL: M/ day as placement); (2) control group: flapless prosthesis failure,
design F¼7/8); (2) age implantation and EL (2 mo after placement); periimplant
range, 42-75 y; (3) (3) no. inserted implants: IL/EL 90/87; (4) marginal bone-level
diagnosis: maxillary prosthesis: maxillary full-arch prostheses; (5) changes,
completely implants: tapered SwissPlus (Zimmer Dental): complications,
edentulous arches (6) time of follow-up: 1 y; (7) dropouts: none patient satisfaction

Cannizzaro et al,24 RCT, (1) Total no.: 30 (1) Test group: flapless implantation and IL (the Implant failure,
2008 (winter) parallel (M/F¼15/15; IL: 29; same day as placement); (2) control group: prosthesis failure,
design EL: 31); (2) age flapless implantation and EL (6 wk after periimplant
range, 18-57 y; (3) placement); (3) no. inserted implants: IL/EL marginal bone-level
diagnosis: maxillary 29/31; (4) prosthesis: metal-ceramic crowns; changes, patient
or mandibular (5) implants: NanoTIte parallel-walled satisfaction,
partially edentulous titanium alloy dental implants with discrete complications
arches crystalline deposited surface; (6) time of
follow-up: 1 y; (7) dropouts: none

Cannizzaro et al,25 RCT, (1) Total no.: 30 (1) Test group: flapless implantation and IL (the Implant failure,
2012 parallel (M/F¼15/15; IL: 29; same day as placement); (2) control group: prosthesis failure,
design EL: 31); (2) age flapless implantation and EL 6 wk (after periimplant
range, 18-57 y; (3) placement); (3) no. inserted implants: IL/EL marginal bone-level
diagnosis: maxillary 29/31; (4) prosthesis: metal ceramic crowns; changes, patient
or mandibular (5) implants: NanoTIte parallel-walled satisfaction,
partially edentulous titanium alloy dental implants with discrete complications
arches crystalline deposited surface (Biomet 3i); (6)
time of follow-up: 4 y; (7) dropouts: none

Merli et al,23 2008 RCT, (1) Total no.: 60 (IL: (1) Test group: flapless implantation and IL Implant failure,
parallel M/F¼10/20; EL: (within 72 h after placement); (2) control prosthesis failure,
design M/F¼12/18); (2) age group: flapless implantation and EL (after 6 complications
range, 19-72 y; (3) wk of placement); (3) no. inserted implants:
diagnosis: partially IL/EL 35/34; (4) prosthesis: metal ceramic
edentulous arches crowns; (5) implants: threaded cylindrical
titanium implants with sand-blasted acid-
etched surface; (6) time of follow-up: 1 y; (7)
dropouts: none

Merli et al,28 2012 RCT, (1) Total no.: 60 (IL: (1) Test group: flapless implantation and IL Implant failure,
parallel M/F¼10/20; EL: (within 72 h after placement); (2) control prosthesis failure,
design M/F¼12/18); (2) age group: flapless implantation and EL (after periimplant
range, 19-72 y; (3) 6 wk of placement); (3) no. inserted implants: marginal bone-level
diagnosis: partially IL/EL 35/34; (4) prosthesis: metal ceramic changes,
edentulous arches crowns; (5) Implants: threaded cylindrical complications
titanium implants with sand-blasted acid-
etched surface; (6) time of follow-up: 3 y;
(7) dropouts: 4 participants with 4 implants
(IL 1; EL 3)

RCT, randomized clinical trial; IL, immediate loading; EL, early loading.

trial used mandibular bar-retained The postloading follow-ups were 1 years in 2 reports of the remain-
overdentures.29 One trial made use year in 2 trials,29,30 1 year and 4 years ing study.23-25,28 All of the 6 arti-
of maxillary complete-arch prostheses.30 in 1 report of 1 trial, and 1 and 3 cles reported implant failures and
Xu et al
764 Volume 112 Issue 4
complications.23-25,28-30 Four of the implantation ended. At that point, the interest was available for any of the
articles published the periimplant surgeon needed to know the allocation articles.
marginal bone-level changes.23,25,28,30 to decide the loading time of the im- According to the trials, the implant
Four articles showed participant satis- plants, and the participants knew their failure rate in the IL and EL groups
faction.24,25,29,30 The reviewers’ as- study group upon receipt of their allo- ranged from 0.0% to 3.3%. One trial
sessment of the risk of bias in cation.23-25,28-30 When considering the that used metal-ceramic crowns with a
the included studies is presented in little impact of the blinding method, a 4-year follow-up showed that IL and EL
Table II; the summarization is shown low risk of performance bias was indi- rates of failure were similar (OR1.0
in Figure 2. Computer software was cated. All of the trials mentioned that [95% CI, 0.06-16.76).25 Another trial
used to generate a restricted ran- dentists who had assessed the compli- reported no implant failure with both
domization list in 3 trials. The pro- cations knew of the group allocation, 1 year and 3 years of follow-up.23,28 In
cedures of allocation concealment but the dentists in charge of the a 1-year follow-up report of a trial that
were described clearly and adequately assessment of other outcomes and the used overdentures, the implant failure
in those studies.24,25,29,30 Therefore, biostatistician were blinded.23-25,28-30 rate of IL was not statistically signifi-
the risk of selection bias was judged to Therefore, the risk of detection bias cantly different from EL (OR 0.19 [95%
be low. One trial used a “manually was considered to be unclear. Five ar- CI, 0.01-4.11]).29 In a trial with fixed
generated randomization list” and ticles reported no loss of partici- full-arch prostheses, the participants in
was referred to in a 1-year follow-up pants.23-25,28-30 One article reported 4 the IL group presented with a lower
report23; however, the 3-year follow- participants who failed to return for implant failure rate when compared
up article for the same study follow-up, and intention-to-treat ana- with the EL group in a 1-year follow-up,
described computerized randomly gen- lyses and sensitivity per-protocol ana- without any statistically significant dif-
erated numbers.28 Because a current lyses were performed.28 All 6 articles ferences (OR 0.31 [95% CI, 0.03-3.08])
reviewer had sent an e-mail to the reported implant failure and some (Fig. 3).30 Three trials reported periim-
investigator of that study for details types of complications.23-25,28-30 How- plant marginal bone-level changes, with
without reply, its risk of selection ever, no protocols could be obtained all 3 indicating no statistically sig-
bias was unclear. In all of the in- that compared the planned outcome nificant difference between IL and
cluded studies, participants and treat- measures with the reported measures. EL.25,28,30 IL resulted in a loss of more
ment dentists were blinded until No information about a conflict of marginal bone than EL in a trial with

Table II. Risk of bias

Random Blinding of Blinding of Incomplete
Sequence Allocation Participants Outcome Outcome Selective
Generation Concealment and Personnel Assessment Data Reporting
(selection (selection (performance (detection (attrition (reporting Other
Study bias) bias) bias) bias) bias) bias) Bias

Cannizzaro Low risk Low risk Low risk Unclear Low risk Unclear Unclear
et al,29 2008
(spring)

Cannizzaro Low risk Low risk Low risk Unclear Low risk Unclear Unclear
et al,30 2008
(summer)

Cannizzaro Low risk Low risk Low risk Unclear Low risk Unclear Unclear
et al,24 2008
(winter)

Cannizzaro Low risk Low risk Low risk Unclear Low risk Unclear Unclear
et al,25 2012
(summer)

Merli et al,23 Unclear Low risk Low risk Unclear Low risk Unclear Unclear
2008

Merli et al,28 Unclear Low risk Low risk Unclear Low risk Unclear Unclear
2012

The Journal of Prosthetic Dentistry Xu et al

October 2014 765
a 4-year follow-up (MD 0.06 [95% Participants in the IL group were re- reported no intraoperative biologic
CI, 0.13 to 0.25]) and a trial with a ported to have significantly more satis- complications and successful treat-
3-year follow-up (MD 0.06 [95% faction than those in the EL group ments; however, several postoperative
CI, 0.75 to 0.87]).25,28 However, in for 2 trials.29,30 In another trial, the complications occurred in both the IL
a trial with a 1-year follow-up, the investigators revealed a similar trend, and EL groups, including biologic and
trend was the opposite (MD 0.07 but with no statistically significant prosthetic complications.23-25,28-30 All
[95% CI, 0.14 to 0.00) (Fig. 4).30 difference.24,25 All of the 4 trials of the included studies declared that
the differences in complications were
not statistically significant between the

Blinding of participants and personnel (performance bias)

2 interventions. Table III shows the list
of complications.

Blinding of outcome assessment (detection bias)

Random sequence generation (selection bias) DISCUSSION

Incomplete outcome data (attrition bias)

Allocation concealment (selection bias)
This present systematic review in-

Selective reporting (reporting bias)

cluded 4 trials that fulfilled the inclu-
sion criteria. When considering the
great variation in the type of implants
and implant-supported prostheses and
the various postloading follow-up pro-

Other bias
tocols, neither primary nor secondary
outcomes could be performed with
a pooled analysis. For the significant
Cannizzaro G, 2008, Spring + + + ? + clinical heterogeneity, outcomes were
Cannizzaro G, 2008, Summer + + + ? + assessed with qualitative methods. Be-
cause implant failure is a time-sensitive
Cannizzaro G, 2008, Winter + + + ? + variable, all periods of follow-up were
Cannizzaro G, 2012 + + + ? + included in this current review to show
how the failure rate changed over time.
Merli M, 2008 ? + + ? + All of the included trials reported a high
Merli M, 2012 ? + + ? + implant success rate (96.5%-100%)
for both IL and EL methods. When
2 Risk of bias summary: review authors’ judgments about considering the current recommenda-
each risk of bias item for each included study. tion that insertion torque should be

Immediate Loading Early Loading Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total M-H, Fixed [95% Cl] M-H, Fixed [95% Cl]
1.1.1
3-year follow-up (crowns)
Merli M, 2012 0 35 0 34 Not estimable
1.1.2
4-year follow-up (crowns)
Cannizzaro G, 2012,
Summer 1 30 1 30 1.00 [0.06, 16.76]
1.1.3
1-year follow-up
(overdentures)
Cannizzaro G, 2008, Spring 0 60 2 60 0.19 [0.01, 4.11]
1.1.4
1-year follow-up
(fixed full-arch prostheses)
Cannizzaro G, 2008, Summer 1 90 3 87 0.31 [0.03, 3.08]

0.001 0.1 1 10 1000

Favors experimental Favors control
3 Implant failure rate.
Xu et al
766 Volume 112 Issue 4
Immediate Loading Early Loading Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total IV, Fixed [95% Cl] IV, Fixed [95% Cl]
1.2.1
4-year follow-up (crowns)
Cannizzaro G, 2012,
Summer 0.37 0.35 28 0.31 0.36 28 0.06 [–0.13, 0.25]
1.2.2
1-year follow-up
(fixed full-arch prostheses)
Cannizzaro G, 2008,
Summer 0.55 0.22 90 0.62 0.25 87 –0.07 [–0.14, –0.00]
1.2.3
3-year follow-up (crowns)
Merli M, 2012 1.6 1.63 30 1.54 1.58 30 0.06 [–0.75, 0.87]

–0.5 –0.25 0 0.25 0.5

Favors experimental Favors control
4 Periimplant marginal bone-level changes.

Table III. Types of complications in included studies

Study Immediate Loading Group Early Loading Group
29
Cannizzaro et al, 2008 (spring) Periimplantitis; soft-tissue ulcers; Soft-tissue ulcers, clip lost retention
clip loss of retention

Cannizzaro et al,30 2008 (summer) Periimplant tissue complications; soft-tissue Periimplant tissue complications;
ulcers; temporomandibular joint, occlusal, temporomandibular joint, occlusal,
mastication problems; fracture or loosening mastication problems; fracture or
of the provisional prostheses; fracture of the loosening of the provisional prostheses
ceramic of definitive prosthesis

Cannizzaro et al,24 2008 (winter) Periimplantitis, periimplant tissue complications, Periimplantitis

fracture of the ceramic of definitive crown

Cannizzaro et al,25 2012 (summer)a Periimplantitis, mucositis Periimplantitis, mucositis

Merli et al,22 2008 Loosening of the screw that connects Fistula, fracture of abutment screw
the provisional crown

Merli et al,28 2012 No complications occurred from 1- to 3-y follow-up after loading
a
Between 9 mo and 4 y after loading.

more than 32 Ncm,34 one of the con- failure rate is that implant sites with studies was extremely low. In addition,
tributing factors may be that the high adequate bone volume were required by smoking, which is widely considered to
insertion torques at the time of place- all of the included trials. have an adverse effect on implant sur-
ment (>40 Ncm in 2 trials, >48 Ncm in No included reports demonstrated vival,37 was not in the exclusion criteria of
the other 2 trials).23-25,28-30 Insertion statistically significant differences for all of the included studies. A total of five-
torque was regarded as an indicator of implant failure rates between IL and EL eighths of the participants with failed
primary stability.35 More significantly, procedures after flapless surgery. Two of implants were smokers. Therefore, the
a high degree of primary stability at the studies indicated slightly higher failure current evidence was not sufficient to
implant insertion is considered to be a rates in the EL groups.29,30 The original confirm that the EL procedure is more
key prerequisite for obtaining successful investigators of those studies hypothe- likely to fail.
osseointegration.36 A systematic review sized that EL generated unfavorable No apparent differences in periim-
indicated that the quality and quantity forces, which disturbed implant healing plant marginal bone changes between
of bone plays an important role in pri- when bone remodeling decreased the the IL and EL groups were observed
mary stability.34 Therefore, another initial high stability of implants.30 How- in the included articles.24,25,28,30 One
possible reason for the relatively low ever, the number of participants in those investigator indicated that the degree of
The Journal of Prosthetic Dentistry Xu et al
October 2014 767
Table IV. Summary of findings
Illustrative Comparative Risks
(95% CI)a
Assumed Corresponding Relative No. Quality
Risk Risk Effect, Participants of the Evidence
Outcome EL IL OR (95% CI) (no. studies) (GRADE)

Implant failure
removal of implants
Crowns, High risk population Not estimable 69 (1) Not estimable
follow-up: mean 3 y
Not estimable Not estimable
Low risk population

Crowns, Study population 1.00 (0.06-16.76) 60 (1) 4422, lowb,c

follow-up: mean 4 y
33/1000 33/1000 (2-366)
Low risk population
33/1000 33/1000 (2-364)

Overdentures, High risk population

follow-up: mean 1 y
33/1000 7/1000 (0-124) 0.19 (0.01-4.11) 120 (1) 4442 moderateb,d,e
Low risk population
33/1000 6/1000 (0-123)

Fixed full-arch, High risk population 0.31 (0.03-3.08) 177 (1) 4422, lowb,f,g
follow-up: mean 1 y
34/1000 11/1000 (1-99)
Low risk population
34/1000 11/1000 (1-98)

Periimplant marginal
bone-level changes
intraoral radiographs
Crowns, 0.62 mm 0.07 lower (0.14 177 (1) 4442, moderateb,g,h
follow-up: mean 3 y lower to 0 higher)

Crowns, 0.31 mm 0.06 higher (0.13 56 (1) 4422, lowi

follow-up: mean 4 y lower to 0.25
higher)

Fixed full-arch 1.54 mm 0.06 higher (0 to 60 (1) 4422, lowj

prostheses, 0.87 higher)
follow-up: mean 1 y

CI, confidence interval; OR, odds ratio; GRADE, Grading of Recommendations, Assessment, Development and Evaluation; EL, early loading; IL, immediate
loading; MD, mean difference.
1. Patient or population: patients with flapless-placed dental implants; 2. Settings: Italy; 3. Intervention: immediate loading; 4. Comparison: early loading.
a
Basis for the assumed risk (such as median control group risk across studies) is provided in footnotes. Corresponding risk (and its 95% CI) is based on
assumed risk in comparison with group and relative effect of intervention (and its 95% CI).
b
Unclear risk of detection bias.
c
95% CI is very wide: OR 1.00 (95% CI, 0.06-6.76).
d
95% CI is very wide: OR 0.19 (95% CI, I0.01-4.11).
e
OR 0.19.
f
95% CI is very wide: OR 0.31 (95% CI, 0.03-3.08).
g
OR 0.31.
h
Unclear risk of selection bias.
i
95% CI is very wide: MD 0.06 (0.13 to 0.25).
j
95% CI is very wide: MD 0.06 (0.75 to 0.87).

Xu et al
768 Volume 112 Issue 4
periimplant bone loss was not affected evidence was downgraded to moderate 2. Mamai-Homata E, Margaritis V, Koletsi-
Kounari H, Oulis C, Polychronopoulou A,
by the loading differences.24 This was or even low, mainly because of its risk
Topitsoglou V. Tooth loss and oral
in agreement with the results of other of bias and imprecision. When con- rehabilitation in Greek middle-aged adults
clinical trials.38,39 In conclusion, when sidering the variables involved in the and senior citizens. Int J Prosthodont
taking into account the insufficient decision-making process on therapy, 2012;25:173-9.
3. Ravindran DM, Sudhakar U,
number of included trials, this current decisions cannot be solely based on the Ramakrishnan T, Ambalavanan N. The
review does not draw a definitive con- quality of the evidence. Nevertheless, efficacy of flapless implant surgery on
clusion as to which method (IL or EL the GRADE concept may be helpful for soft-tissue profile comparing immediate
loading implants to delayed loading
after flapless placement of implants) is improving the transparency regarding implants: a comparative clinical study.
more clinically favorable. judgment and explicit acknowledgment J Indian Soc Periodontol 2010;14:245-51.
All of the studies included in this of values and preferences that underlie 4. Jung RE, Pjetursson BE, Glauser R,
Zembic A, Zwahlen M, Lang NP.
review were performed in Italy. Data the recommendations. When consid-
A systematic review of the 5-year
from other populations is required to ering the problem of non-English lan- survival and complication rates of
make the results applicable interna- guages, non-English regional databases implant-supported single crowns. Clin
tionally. For all of the included trials, were not searched, except for the Chi- Oral Implants Res 2008;19:119-30.
5. Bidra AS. Consequences of insufficient treat-
the implant sites were required to pro- nese electronic databases. In addition, ment planning for flapless implant surgery for
vide at least 5.5 mm in bone width to gray literature was unavailable; there- a mandibular overdenture: a clinical report.
place an implant with a diameter of at fore, selection bias may be considered. J Prosthet Dent 2011;105:286-91.
6. Jeong SM, Choi BH, Kim J, Xuan F, Lee DH,
least 3.7 mm. As a result, the evidence Mo DY, et al. A 1-year prospective clinical
of this review only applies to selected CONCLUSIONS study of soft tissue conditions and marginal
participants with a sufficient quantity bone changes around dental implants after
flapless implant surgery. Oral Surg Oral
of bone. The variability of prosthesis For selected patients with sufficient Med Oral Pathol Oral Radiol Endod
types and length of follow-up present bone quantity and good bone quality, 2011;111:41-6.
high clinical diversity; therefore, only 1 success is possible with IL or EL pro- 7. Kan JY, Rungcharassaeng K, Ojano M,
trial is included in each subgroup Goodacre CJ. Flapless anterior implant surgery:
cedures after flapless placement of a surgical and prosthodontic rational. Pract
without a pooled analysis. Otherwise, dental implants. There were no differ- Periodontics Aesthet Dent 2000;12:467-74.
not all of the included trials reported ences seen in implant failure rates, peri- 8. Brodala N. Flapless surgery and its effect
the whole 4 outcomes required by the on dental implant outcomes. Int J Oral
implant marginal bone-level changes,
Maxillofac Implants 2009;24:118-25.
present review. The insufficient sample and complications between the 2 pro- 9. Turkyilmaz I. Immediate provisional restora-
size had an effect on reducing the cedures; whereas patients preferred IL. tion of implant placed using flapless surgery
robust nature of the evidence. However, because of the small sample and ridge mapping. N Y State Dent J
The methodologic limitations of the 2011;77:21-3.
size, the currently included evidence was 10. Becker W, Goldstein M, Becker BE, Sennerby L.
4 trials led to potential detection bias insufficient to fully assess the optimal Minimally invasive flapless implant surgery:
that may affect the assessment of loading protocol for flapless-placed im- a prospective multicenter study. Clin Implant
complications. In addition, the impre- Dent Relat Res 2005;7:S21-7.
plants. Consequently, more high-quality
11. Sclar AG. Guidelines for flapless surgery.
cision of most results is another reason evidence is needed to make a definite J Oral Maxillofac Surg 2007;65:20-32.
for downgrading the evidence. Howev- conclusion. Non-European populations 12. Fortin T, Bosson JL, Isidori M, Blanchet E.
er, some results presented a large effect should be included in future compari- Effect of flapless surgery on pain experienced
that helped upgrade the quality of the in implant placement using an image-guided
sons of IL with EL after placing flapless system. Int J Oral Maxillofac Implants
evidence. Therefore, through utilization dental implants. Outcomes from trials 2006;21:298-304.
of the GRADE approach, the evidence that used maxillary overdentures, 13. Komiyama A, Klinge B, Hultin M. Treatment
regarding implant failure from 1 trial mandibular complete-arch prostheses, outcome of immediately loaded implants
installed in edentulous jaws following
was of moderate quality, with 2 other and partial fixed dental prostheses are computer-assisted virtual treatment planning
trials graded as low quality.25,29,30 The needed. The measurement of patient and flapless surgery. Clin Oral Implants Res
quality of evidence regarding periim- satisfaction should be consistent and 2008;19:677-85.
plant marginal bone-level changes were 14. Berdougo M, Fortin T, Blanchet E, Isidori M,
quantifiable. In addition, future trials Bosson JL. Flapless implant surgery using
low in 2 trials,25,30 and moderate in should involve large sample sizes and an image-guided system. A 1- to 4-year
another study (Table IV).28 The pur- long-term follow-up (5 years or longer). retrospective multicenter comparative clinical
pose of the GRADE approach, when study. Clin Implant Dent Relat Res 2010;
12:142-52.
taking into account many factors, is
REFERENCES 15. Brånemark PI, Engstrand P, Ohrnell LO,
to grade the quality of evidence Gröndahl K, Nilsson P, Hagberg K, et al.
and strength of recommendations. The 1. Koller B, Att W, Strub JR. Survival rates of Brånemark Novum: a new treatment concept
teeth, implants, and double crown-retained for rehabilitation of the edentulous
system clearly separates evaluations
removable dental prostheses: a systematic mandible. Preliminary results from a pro-
regarding the quality of evidence from literature review. Int J Prosthodont 2011; spective clinical follow-up study. Clin Implant
the strength of recommendations. The 24:109-17. Dent Relat Res 1999;1:2-16.

The Journal of Prosthetic Dentistry Xu et al

October 2014 769
16. Ozan O, Turkyilmaz I, Yilmaz B. A preliminary 25. Cannizzaro G, Leone P, Leone M, Ferri V, 34. Chung S, McCullagh A, Irinakis T. Immediate
report of patients treated with early loaded Viola P, Esposito M. Immediate versus early loading in the maxillary arch: evidence-based
implants using computerized tomography- loading of 6.5-mm-long flapless-placed guidelines to improve success rates: a review.
guided surgical stents: flapless versus single implants: a 4-year after loading J Oral Implantol 2011;37:610-21.
conventional flapped surgery. J Oral Rehabil report of a split-mouth randomized 35. Wang HL, Boyapati L. “PASS” principles for
2007;34:835-40. controlled trial. Eur J Oral Implantol 2012; predictable bone regeneration. Implant Dent
17. Esposito M, Grusovin MG, Achille H, 5:111-21. 2006;15:8-17.
Coulthard P, Worthington HV. Interventions 26. Van de Velde T, Sennerby L, De Bruyn H. The 36. Robling AG, Turner CH. Mechanical
for replacing missing teeth: different times for clinical and radiographic outcome of im- signaling for bone modeling and remodeling.
loading dental implants. Cochrane Database plants placed in the posterior maxilla with a Crit Rev Eukaryot Gene Expr 2009;19:
Syst Rev 2009;21:CD003878. guided flapless approach and immediately 319-38.
18. De Bruyn H, Raes F, Cooper LF, Reside G, restored with a provisional rehabilitation: a 37. Shibli JA, Piattelli A, Iezzi G, Cardoso LA,
Garriga JS, Tarrida LG, et al. Three-years randomized clinical trial. Clin Oral Implants Onuma T, de Carvalho PS, et al. Effect of
clinical outcome of immediate provisionali- Res 2010;21:1223-33. smoking on early bone healing around
zation of single Osseospeed(
) implants in 27. Cannizzaro G, Felice P, Leone M, Checchi V, oxidized surfaces: a prospective, controlled
extraction sockets and healed ridges. Clin Esposito M. Flapless versus open flap study in human jaws. J Periodontol 2010;
Oral Implants Res 2013;24:217-23. implant surgery in partially edentulous 81:575-83.
19. Margossian P, Mariani P, Stephan G, patients subjected to immediate loading: 38. Capelli M, Esposito M, Zuffetti F, Galli F,
Margerit J, Jorgensen C. Immediate loading 1-year results from a split-mouth Del Fabbro M, Testroi TA. 5-year report
of mandibular dental implants in partially randomised controlled trial. Eur J Oral from a multicentre randomised clinical trial:
edentulous patients: a prospective random- Implantol 2011;4:177-88. immediate non-occlusal versus early loading
ized comparative study. Int J Periodontics 28. Merli M, Moscatelli M, Mariotti G, of dental implants in partially edentulous
Restorative Dent 2012;32:e51-8. Piemontese M, Nieri M. Immediate versus patients. Eur J Oral Implantol 2010;3:
20. Cochran DL, Jackson JM, Bernard JP, ten early non-occlusal loading of dental implants 209-19.
Bruggenkate CM, Buser D, Taylor TD, placed flapless in partially edentulous pa- 39. Zembic A, Glauser R, Khraisat A,
et al. A 5-year prospective multicenter tients: a 3-year randomized clinical trial. Hämmerle CH. Immediate vs. early
study of early loaded titanium implants J Clin Periodontol 2012;39:196-202. loading of dental implants: 3-year
with a sandblasted and acid-etched sur- 29. Cannizzaro G, Leone M, Esposito M. results of a randomized controlled clinical
face. Int J Oral Maxillofac Implants Immediate versus early loading of two im- trial. Clin Oral Implants Res 2010;21:481-9.
2011;26:1324-32. plants placed with a flapless technique sup-
21. Testori T, Galli F, Capelli M, Zuffetti F, porting mandibular bar-retained
Esposito M. Immediate nonocclusal versus overdentures: a single-blinded, randomised Corresponding author:
early loading of dental implants in partially controlled clinical trial. Eur J Oral Implantol Dr Ke Zhao
edentulous patients: 1-year results from a 2008;1:33-43. Department of Prosthodontics
multicenter, randomized controlled clinical 30. Cannizzaro G, Torchio C, Leone M, Guanghua School of Stomatology
trial. Int J Oral Maxillofac Implants 2007;22: Esposito M. Immediate versus early loading Hospital of Stomatology
815-22. of flapless-placed implants supporting Sun Yat-sen University
22. Merli M, Bernardelli F, Esposito M. Immedi- maxillary full-arch prostheses: a randomised No. 56 Lingyuan West Rd
ate versus early nonocclusal loading of dental controlled clinical trial. Eur J Oral Implantol 510055 Guangzhou
implants placed with a flapless procedure in 2008;1:127-39. CHINA
partially edentulous patients: preliminary 31. Moon SY, Kim SG, Lim SC, Ong JL. Histo- E-mail: [email protected]
results from a randomized controlled logic and histomorphometric evaluation of
clinical trial. Int J Periodontics Restorative early and immediately loaded implants in the Acknowledgments
Dent 2008;28:453-9. dog mandible. J Biomed Mater Res 2008; The authors thank Dr Taixiang Wu and
23. Merli M, Merli A, Bernardelli F, Lombardini F, 86:1122-7. Dr Guanjian Liu (Evidence-Based Medicine and
Esposito M. Immediate versus early non- 32. Alsabeeha N, Atieh M, Payne AG. Loading Clinical Epidemiology Centre, West China
occlusal loading of dental implants placed protocols for mandibular implant over- Hospital, Sichuan University, Chengdu, China) for
flapless in partially edentulous patients. dentures: a systematic review with meta- their help and advice on writing a systematic
One-year results from a randomised analysis. Clin Implant Dent Relat Res review and dealing with data; and Dr Ronald E.
controlled trial. Eur J Oral Implantol 2008; 2010;12(suppl 1):e28-38. Jung (Department of Fixed and Removable
1:207-20. 33. Esposito M, Maghaireh H, Grusovin MG, Prosthodontics and Dental Material Science,
24. Cannizzaro G, Leone M, Torchio C, Viola P, Ziounas I, Worthington HV. Soft tissue University of Zurich, Zurich, Switzerland) for his
Esposito M. Immediate versus early loading of management for dental implants: what are excellent advice on this article.
7-mm-long flapless-placed single implants: the most effective techniques? A Cochrane
a split-mouth randomised controlled clinical systematic review. Eur J Oral Implantol Copyright ª 2014 by the Editorial Council for
trial. Eur J Oral Implantol 2008;1:277-92. 2012;5:221-38. The Journal of Prosthetic Dentistry.

Xu et al