Int. J. Oral Maxillofac. Surg.

2016; 45: 8592

http://dx.doi.org/10.1016/j.ijom.2015.07.014, available online at http://www.sciencedirect.com

Systematic Review
Dental Implants

Immediate versus conventional V. Moraschini,

E. Porto Barboza
Department of Periodontology, School of

loaded single implants in the Dentistry, Fluminense Federal University, Rio

de Janeiro, Brazil

posterior mandible: a meta-

analysis of randomized
controlled trials
V. Moraschini, E. Porto Barboza: Immediate versus conventional loaded single
implants in the posterior mandible: a meta-analysis of randomized controlled trials.
Int. J. Oral Maxillofac. Surg. 2016; 45: 8592. # 2015 International Association of
Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The purpose of this meta-analysis was to compare implant survival,

marginal bone loss, and complications between immediate and conventional
loading of single implants installed in the posterior mandible. An extensive
electronic search was performed of PubMed, Web of Science, and the Cochrane
Central Register of Controlled Trials to identify relevant articles published up to
January 2015. After the selection process, five studies met the eligibility criteria and
were included. The results of the meta-analysis were expressed in terms of the odds
ratio (OR) or standardized mean difference (SMD), with a confidence interval (CI)
of 95%. Results were pooled according to heterogeneity using the fixed- or random-
effects model. There was no statistically significant difference between the two
techniques (immediate loading vs. conventional loading) with regard to implant
survival (OR 1.71, 95% CI 0.40 to 7.36; P = 0.47). There was no statistically
Key words: dental implants; delayed loading;
significant difference in marginal bone loss (SMD 0.58, 95% CI 1.55 to 0.38;
immediate loading; implant survival; marginal
P = 0.24). The reported mechanical and biological complications were common to bone loss; meta-analysis.
both types of intervention, with the exception of probing depth, which was greater
following the immediate loading technique (SMD 0.13, 95% CI 0.19 to 0.44), Accepted for publication 20 July 2015
although this was not statistically significant (P = 0.43). Available online 8 August 2015

The replacement of teeth by means of protocol has been a two-stage surgery, months for the maxilla.2 However, with
single implants is a predictable treatment with the sinking of the implants followed the growing demand for less invasive and
with a high success rate.1 Historically, by a healing period free of mechanical faster procedures that optimize aesthetic
the recommended implant installation load of 3 months for the mandible and 6 requirements, single-stage surgery with

0901-5027/01085 + 08 # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
86 Moraschini and Porto Barboza

immediate prosthetic loading (immediate
loading) has been adopted.
Immediate loading can be defined as
the installation of the prosthetic crown on
the implant within 1 week of surgery.3
The single-stage installation of implants
can also be classified as functional or
non-functional, depending on the occlu-
sal contact with the opposite arch.4 The
first immediate loading protocol was per-
formed to treat edentulous patients
through four splinted implants placed
in the mandible.5 The advantages of sin-
gle-stage implant installation and the
constant development of the implants
and surgical techniques have encouraged
further research into immediate loading
of single implants in various regions of
the mouth, with high rates of success and
survival.6
The main criterion for performing im-
mediate loading of single implants is pri-
mary stability. The parameters used to
evaluate the initial stability of the implant
are usually insertion torque, measured in
Newton-centimetres (N cm), and the im-
plant stability quotient (ISQ), measured by
resonance frequency analysis (RFA). A
low initial stability necessitates long-term
osteogenesis and therefore a greater heal-
ing period.7 Moreover, a lack of contact
between the bone and the implant
increases the risk of micro-movements,
which decreases success rates.8 The inci-
dence of high masticatory forces in the
posterior mandible discourages many clin-
icians from conducting immediate pros-
thetic loading in this region. Additionally,
few clinical trials have evaluated the per-
formance of a single posterior implant
after immediate prosthetic loading.
Thus, the purpose of this meta-analysis
was to compare implant survival, mar-
ginal bone loss, and complications in
immediate and conventional loading of
single implants installed in the posterior
mandible.
Materials and methods
The methodology of this study was
adapted from the PRISMA statement (Pre-
ferred Reporting Items for Systematic
Reviews and Meta-Analyses).9 Clinical
questions were broken down and orga-
nized using the PICO10 strategy, as pro-
posed by evidence-based practice.
Objective
The purpose of the present review was to
test the null hypothesis of no difference in
the implant survival rate, marginal bone
loss, and complications in subjects who
have received immediate or conventional
loading of single implants installed in the
posterior mandible.
Focused question
What are the clinical outcomes of single
implants placed in the partially edentulous
posterior mandible between subjects who
have received an immediate restoration
and those who have received a late resto-
ration in relation to the implant survival
rate, marginal bone loss, and frequency of
complications?
Search strategy
An extensive electronic search, with no
date or language restriction, was performed
in PubMed, Web of Science, and the
Cochrane Central Register of Controlled
Trials, up to January 2015. The search
strategy and the PICO tool are shown in
Table 1. In addition, reference lists of po-
tential studies for inclusion in the meta-
analysis were explored for more studies.
Selection criteria
This review sought randomized controlled
trials (RCTs). Clinical studies in humans
with at least 12 months of follow-up data,
studies involving single implants placed in
the posterior mandible, and studies com-
paring immediate versus conventional
prosthetic loading were included. Studies
involving animals, patients with decom-
pensated metabolic diseases that could
affect bone turnover, periodontal patients
without prior treatment, and non-random-
ized clinical studies were excluded.
Screening process
Both authors/reviewers (V.M.F. and
E.P.B.) performed the search and selection
process. First, titles and abstracts were
analyzed. Next, full papers were read care-
fully and analyzed according to the eligi-
bility criteria (inclusion/exclusion) for data
extraction. Differences between the
reviewers were resolved through detailed
discussion. Concordance between the two
reviewers in relation to the search was
assessed by Cohens kappa test (k). The
authors of the studies were contacted by e-
mail for any clarification when necessary.
Quality assessment
The quality analysis was performed inde-
pendently by both authors/reviewers using
the Cochrane Collaboration tool for asses-
sing risk of bias in RCTs.11 The quality
analysis of each study was based on four
criteria: sequence generation (random se-
lection in the population), allocation con-
cealment (steps must be taken for strict
implementation of the schedule of random
assignments by preventing foreknowledge
of the forthcoming allocations), incom-
plete outcome data (clear explanation of

Table 1. Systematic search strategy (PICO strategy).

Search strategy
Population #1 (partially edentulous mandible[MeSH] OR partially edentulous implant[MeSH] OR edentulous
mandible[MeSH] OR edentulous posterior mandible[MeSH])
Intervention #2 (implant*[all fields] OR dental implant surgery[MeSH] OR mandibular implant[MeSH] OR
single implant[MeSH] OR single implant crown[MeSH] OR submerged implant[MeSH] OR
non-submerged implants[MeSH] OR immediate loading[MeSH] OR immediate single implant[MeSH] OR
immediate loading single tooth[MeSH] OR delayed load implants[MeSH] OR conventional loading
implants[MeSH])
Comparisons #3 (immediate loading single implants[MeSH] OR conventional loading single implants[MeSH])
Outcomes #4 (survival*[all fields] OR implant survival[MeSH] OR dental implant survival[MeSH] OR marginal bone
loss[MeSH] OR implant bone resorption[MeSH] OR dental implant bone loss[MeSH] OR
complication*[all fields] dental implant complication[MeSH] OR postoperative complications[MeSH] OR
randomized controlled trial[MeSH])
Search combination #1 AND #2 AND #3 AND #4
Database search
Language No restriction
Electronic databases MEDLINE/PubMed, Web of Science, and Cochrane Central Register of Controlled Trials

withdrawals and exclusions), and blinding
(measures to blind study participants and
personnel from knowledge of which inter-
vention a participant received). In addi-
tion, an analysis of conflicts of interest was
performed by reviewing the acknowledg-
ments and disclosures of each study, as
proposed by Friedman and Richter.12
Data extraction
The following parameters were extracted
from the studies: loading protocol, follow-
up period, number of subjects, gender of
subjects, age of subjects, intraoral region,
number of drop-outs, number of implants
placed, implant system, implant length
and diameter, healing period, number of
smokers, primary stability of implants,
type of occlusal contact, implant survival,
mean marginal bone loss, and implants
placed in fresh extraction sockets.
For this meta-analysis, the prosthetic
loading protocol for the implants was
classified as follows3: (1) immediate load-
ing: prostheses connected to the implant
within 1 week of implant installation; (2)
conventional loading: prostheses con-
nected to the implant more than 2 months
after implant installation.
Statistical analysis
Binary and continuous variables of the
RCTs were analyzed by meta-analysis
when at least two studies evaluated the
same data type. For binary outcomes (e.g.
implant survival), the estimation of the
Fig. 1. Flow diagram (PRISMA format) of the screening and selection process.
Immediate vs. conventional loaded single implants
intervention effect was expressed as the
odds ratio (OR) with a confidence interval
(CI) of 95%. For continuous outcomes
(e.g. marginal bone loss), the mean and
standard deviation (SD) were used to cal-
culate the standardized mean difference
(SMD) with a 95% CI. The results were
pooled using the fixed-effects model
(MantelHaenszelPeto test) or the ran-
dom-effects model (DerSimonianLaird
test). The I2 statistical test was used to
express the heterogeneity of the studies as
a percentage value. Values up to 25% were
classified as indicating low heterogeneity,
values of 50% as indicating medium het-
erogeneity, and values of 70% as indicat-
ing high heterogeneity. When significant
heterogeneity was found (P < 0.10), the
random-effects model was used. For a
low heterogeneity value, the fixed-effects
model was used. The level of statistical
significance was set at P < 0.05.
Publication bias was explored graphi-
cally through a funnel plot. Asymmetry of
the funnel plot may indicate possible pub-
lication bias.
The data were analyzed using the sta-
tistical software Review Manager version
5.2.8 (The Nordic Cochrane Centre, The
Cochrane Collaboration, Copenhagen,
Denmark; 2014).
Results
Literature search
The initial search yielded 1282 titles in
Medline/PubMed, 70 in the Cochrane
87
Central Register of Controlled Trials,
and 381 in Web of Science. After the
initial evaluation, 32 studies were select-
ed. After careful reading, 27 studies were
excluded because they did not fit the eli-
gibility criteria of this review. Thus, five
studies published between 2008 and 2014
were included in this review.1317 The
selection process and the reasons for the
exclusion of studies are presented in
Fig. 1.
The k agreement coefficient between
the reviewers for the inclusion of potential
studies (titles and abstracts) was 0.97 and
for study selection was 0.85. This demon-
strates almost perfect agreement accord-
ing to the criteria proposed by Landis and
Koch.18
Study characteristics
The characteristics of the studies included
are shown in Table 2. In the five RCTs
selected for the meta-analysis, a total of
286 implants were installed. The number
of participants in the studies ranged from
12 to 71, and totalled 177. The age range
of the participants was 2075 years. Only
two studies reported the number of smok-
ers.13,14 The follow-up period in the stud-
ies ranged from 12 to 60 months, with a
mean of 31.2 months.
The placement of immediate implants
in fresh sockets was performed in only one
study,15 with the remaining implants
placed in graft-free healed sockets. Flap
surgery was performed in all procedures.
Only one study13 described the bone
88 Moraschini and Porto Barboza

Table 2. Main characteristics of the studies selected.

Follow-up Age range No. of implants Implant size
Loading period, No. of (mean age), No. of Implant brand diameter 
Authors (year) protocol months subjects Gender years Region drop-outs Surface length, mm)
Guncu Conventional 12 12 4 M/8 F 3055 (41) Molar 0 12 4  11.5
et al. (2008)13
Immediate 12 Molar 0 12
Nobel Biocare
Rough
Schincaglia Conventional 12 15 5 M/10 F 3568 (49.2) Molar 0 15 5  8.5, 10,
et al. (2008)14 11.5
Immediate 15 4 M/11 F 3175 (51.8) Molar 0 15
Nobel Biocare
Rough
Prosper Conventional 60 71 35 M/36 F 2672 (58.3) Molar 0 60 6.5, 7.5  9,
et al. (2010)15 11, 13
Immediate Molar 0 60
WinSix
Rough
Meloni Conventional 12 20 8 M/12 F 2870 (46) Molar 0 20 4.3, 5  8, 10
et al. (2012)16
Immediate 20 Molar 0 20
Nobel Biocare
Rough
Kokovic Conventional 60 12 3 M/9 F 2062 (49) Molar, 0 36 4.1, 4.8  8,
et al. (2014)17 premolar 10
Early Molar, 0 36
premolar
Straumann
Rough
Fresh
Healing period Primary stability Occlusal contact Implant survival rate Marginal bone loss, extraction
(delayed group) Smokers (immediate group) (No. of failures) mm (mean  SD) sockets
Insertion torque,
N cm ISQ
3 months 0 NR 65 Yes 100% (0) 0.68  0.3 No
0 65 91.7% (1) 0.45  0.39
34 months 2 20 NR Yes 100% (0) 1.2  0.55 No
1 20 93.3% (1) 0.77  0.38
3 months NR NR NR Yes 96.6% (2) 1.01  0.59 Yes
NR NR NR 96.6% (2) 1.31  0.44
35 months NR 35 NR No 100% (0) 0.86  0.16 No
NR 35 NR 100% (0) 0.83  0.16
6 weeks NR NR 60 Yes 100% (0) 0.8  0.19 No
NR NR 60 100% (0) 0.4  0.24
M, male; F, female; SD, standard deviation; ISQ, implant stability quotient; NR, not reported.

quality at the location for implant instal-
lation according to the description by
Lekholm and Zarb.19 The most commonly
used implant brand was Nobel Bio-
care.13,14,16 All implants installed had un-
dergone surface treatment. Immediate
loading with temporary restorations was
applied by screwing in two studies14,16
and by cementing in two other studies.13,15
One study did not clearly describe the
method used for fixation of the temporary
crowns.17 Regarding the occlusal relation-
ship, only one study opted for non-func-
tional immediate loading.16 The healing
period for conventional loading ranged
from 3 to 5 months. The minimum primary
stability of the implant installations ranged
from 20 to 35 N cm14,16 and from 60 to 65
ISQ.13,17 One study did not provide data on
the primary stability of the implants.15
All studies included made use of pre-
and postoperative prophylactic antibiotics.
There was a recommendation for mouth
rinsing with chlorhexidine 0.12% during
the postoperative period in three stud-
ies.14,16,17
Quality assessment
The results of the quality analysis of the
RCTs included in this study are presented
in Table 3. Only one study met all criteria
described in the Cochrane Collaboration
tool for assessing risk of bias in RCTs.16
This study was also the only one that
followed the CONSORT statement guide-
lines.20 One study presented a possible
conflict of interest according to the criteria
analyzed.17
Implant survival
The survival of the implants in the imme-
diate and conventional loading groups at a
mean follow-up of 31.2 months ranged
from 91.7%13 to 100%16,17 and from
96.6%15 to 100%,13,14,16,17 respectively.
For the analysis of survival, the fixed-
effects model was used to compare
the groups, due to a lack of evidence of
heterogeneity (I2 = 0%; P = 0.75). The
 Immediate vs. conventional loaded single implants 89

Table 3. Quality assessment of studies included.

Are conflicts of
Adequate Incomplete Selective Free of interest and/or
sequence Allocation outcome data outcome other sources industrial support
Authors (year) generation concealment Blinding addressed reporting of bias present?
Guncu et al. (2008)13 Yes Unclear No Yes Yes Yes No
Schincaglia et al. (2008)14 Yes Unclear Yes Yes Yes Yes No
Prosper et al. (2010)15 Unclear Unclear Partial Yes Yes Yes No
Meloni et al. (2012)16 Yes Yes Yes Yes Yes Yes No
Kokovic et al. (2014)17 Yes Yes Yes Yes Yes No Yesa
a
The Institute Straumann supported the study with materials and instruments.

meta-analysis of the RCTs revealed an OR
of 1.71 (95% CI 0.40 to 7.36), with no
statistically significant difference between
the interventions (P = 0.47) (Fig. 2).
Marginal bone loss
All studies used peri-apical radiographs
with reference to the implant platform in
relation to the alveolar bone crest for the
evaluation of marginal bone loss. Margin-
al bone loss in the immediate and conven-
tional loading groups ranged from 0.417 to
1.31 mm15 and from 0.6813 to 1.2 mm,14
respectively. The difference in marginal
bone loss between groups was analyzed
using the random-effects model because
of considerable heterogeneity (I2 = 93%;
P < 0.00001). An SMD of 0.58 (95% CI
1.55 to 0.38) was obtained, with no
statistically significant difference between
the techniques (P = 0.24) (Fig. 3).
Complications
Mechanical complications such as frac-
tures of provisional and permanent
crowns and mobility and fractures of
abutments were reported. However, no
study included in this meta-analysis indi-
cated a higher number of mechanical
complications due to a specific tech-
nique. Furthermore, biological complica-
tions such as postoperative infection,
mucositis, abscesses, and peri-implantitis
were also observed. Only two studies
monitored peri-implant parameters be-
tween the immediate vs. the conventional
loading group.13,16 Both found greater
probing depths in the immediate loading
group; however after completion of the
meta-analysis (I2 = 23%; P = 0.25), this
difference was not statistically significant
(P = 0.43), with an SMD of 0.13 (95% CI
0.19 to 0.44) (Fig. 4). All measure-
ments of probing depth were within the
limits of peri-implant health.
Publication bias
The funnel plot did not show asymmetry
when the studies reporting the outcome
implant survival were analyzed,
indicating the possible absence of publi-
cation bias (Fig. 5).
Discussion
The presence of bias is more likely in non-
randomized studies than in RCTs.21 Thus,
the highest level of scientific evidence to
answer a clinical question comes from
systematic reviews that analyze results
from randomized clinical trials.22,23 For
this meta-analysis, five RCTs comparing
the results of single implants installed
in the mandible using immediate prosthet-
ic loading vs. conventional prosthetic
loading were selected.
The incidence of high masticatory
forces in the posterior mandible raises
questions about the predictability of single
implants with immediate loading installed
in this region. Previous studies have
shown that primary stability is a critical
factor for the indication of immediate
loading and that low initial stability is a
significant factor in early failure of single
implants with immediate loading.3,24 In
contrast, a retrospective clinical study

Fig. 2. Forest plot for the event implant survival rate.

Fig. 3. Forest plot for the event marginal bone loss.

90 Moraschini and Porto Barboza
Fig. 4. Forest plot for the event probing depth.
showed a high survival rate (95.5%) when
evaluating single implants with immediate
loading installed with low torques
(25 N cm).25 Therefore, the optimal tor-
que or ISQ value required for successful
osseointegration is still unclear, and more
clinical studies on this subject are needed.
In this review, non-functional immedi-
ate loading was performed in only one
study.16 Pilliar et al.26 observed that mi-
cro-movements above 150 mm could lead
to fibre formation around the implant and
consequently cause the premature failure
of osseointegration. This led to the theory
that non-functional immediate loading
could have a higher success rate than
functional immediate loading. However,
this theory has been questioned in two
comparative clinical studies.4,27 One
way to reduce the possible micro-move-
ments during the healing phase is to use
implants with geometric shapes and sur-
face treatments that optimize the primary
stability and accelerate the osseointegra-
tion process, especially in low quality
(type IV) bone.19,28
No study included in the analysis
showed a statistically significant differ-
ence between the two techniques regard-
ing implant survival. After completing the
Fig. 5. Funnel plot for the studies reporting the outcome event implant survival rate.
meta-analysis, and consequently increas-
ing the sample size of individual studies
and thereby enabling a more accurate
estimation of the effect of interventions,
the difference in survival of the implants
remained statistically insignificant
(P = 0.47). All implant losses in the stud-
ies reviewed occurred following less than
3 months of healing and can therefore be
classified as early losses.29
All studies prescribed prophylactic anti-
biotics before and after surgery. A recent
meta-analysis demonstrated that the use of
antibiotics reduces the failure of implants;
however their preoperative administration
does not sustain a prophylactic effect
against post-surgical infection.30 A previ-
ously published systematic review did not
find any significant effect of immediate
loading on implant survival compared to
conventional loading.3 However, unlike
the present study, the previous review
included single and splinted implants
installed in different regions of the mouth.
With regard to marginal bone loss, this
meta-analysis found no statistically signif-
icant difference between the two interven-
tions (P = 0.24). When used rationally, the
immediate loading of implants may have a
beneficial effect on marginal bone loss.31
ing technique (SMD 0.13, 95% CI 0.19
In contrast, in the case of immediate load-
ing with functional occlusion, early stim-
ulation of the boneimplant interface may
cause a functional remodelling of bone
structures, resulting in increased cell dif-
ferentiation, which may increase bone loss
around the implant.32 In a histomorpho-
metric study, Weber et al.33 demonstrated
that marginal bone loss in implants with
immediate loading occurs at a higher in-
tensity for the first 30 days, while with
conventional loading 40% of the bone
resorption occurs at the time of re-entry.
One theory that can explain this phenom-
enon is the early colonization of bacteria at
the abutmentimplant interface (micro-
gap) in immediate loading.33,34 However,
as demonstrated in a recent review, bone
loss around implants can be caused by a
combination of factors, such as the type of
implant used, surgeons skill, and patient-
related factors.35
Biological and biomechanical compli-
cations are often associated with isolated
single crowns, especially when installed
in the posterior region. Peri-implantitis,
fracture of crowns, and loose screws/
abutments are the biological and bio-
mechanical complications most common-
ly reported in previous studies.36,37 An
increase in probing depth has been
observed with the immediate loading tech-
nique. Clinically, the probing depth
around implants is multifactorial and
may be influenced by factors such as
the amount of marginal bone loss, depth
of the implant installation, type of pros-
thetic abutment, emergence profile of the
prosthetic restoration, and gingival phe-
notype at the implant installation site.38
In conclusion, the difference between
the two techniques (immediate loading vs.
conventional loading) did not affect the
survival of the implants (OR 1.71, 95% CI
0.40 to 7.36; P = 0.47). There was no
statistically significant difference in mar-
ginal bone loss (SMD 0.58, 95% CI
1.55 to 0.38; P = 0.24). The reported
mechanical and biological complications
were common to both types of interven-
tion, with the exception of probing depth,
which was greater for the immediate load-

to 0.44), although this was not statistically
significant (P = 0.43). The development of
a higher number of RCTs based on the
CONSORT statement is key to monitoring
these techniques in the future.20
Funding
The authors declare that no funding was
provided for the performance of this study.
Competing interests
The authors declare that there was no
conflict of interest during the performance
of this study.
Ethical approval
Not required the study did not involve
human subjects.
Patient consent
Not required the study did not involve
human subjects.
References
1. Wennstrom JL, Ekestubbe A, Grondahl K,
Karlsson S, Lindhe J. Implant-supported
single-tooth restorations: a 5-year prospec-
tive study. J Clin Periodontol 2005;32:
56774.
2. Albrektsson T, Branemark PI, Hansson HA,
Lindstrom J. Osseointegrated titanium
implants. Requirements for ensuring a
long-lasting, direct bone-to-implant anchor-
age in man. Acta Orthop Scand 1981;52:
15570.
3. Esposito M, Grusovin MG, Willings M,
Coulthard P, Worthington HV. Interventions
for replacing missing teeth: different times
for loading dental implants. Cochrane Data-
base Syst Rev 2013;28:CD003878.
4. Degidi M, Piatelli A. Immediate functional
and non-functional loading of dental
implants: a 2- to 60-month follow-up study
of 646 titanium implants. J Periodontol
2003;74:22541.
5. Chiapasco M, Gatti C, Rossi E, Haefliger W,
Markwalder TH. Implant-retained mandibu-
lar overdentures with immediate loading. A
retrospective multicenter study on 226 conse-
cutive cases. Clin Oral Implants Res 1997;8:
4857.
6. Esposito M, Grusovin MG, Polyzos IP,
Felice P, Worthington HV. Timing of implant
placement after tooth extraction: immediate,
immediate-delayed or delayed implants? A
Cochrane systematic review. Eur J Oral
Implantol 2010;3:189205.
7. Romanos GE. Present status of immediate
loading of oral implants. J Oral Implantol
2004;30:18997.
Immediate vs. conventional loaded single implants
8. Martinez H, Davarpanah M, Missika P,
Celletti R, Lazzara R. Optimal implant
stabilization in low density bone. Clin Oral
Implants Res 2001;12:42332.
9. Moher D, Liberati A, Tetzlaff J, Altman DG,
PRISMA Group. Preferred reporting items
for systematic reviews and meta-analyses:
the PRISMA statement. Ann Intern Med
2009;151:2649.
10. Schardt C, Adams MB, Owens T, Keitz S,
Fontelo P. Utilization of the PICO frame-
work to improve searching PubMed for clin-
ical questions. BMC Med Inform Decis Mak
2007;15:716.
11. Higgins JP, Altman DG, Gtzsche PC, Juni
P, Moher D, Oxman AD, et al. The Cochrane
Collaborations tool for assessing risk of
bias in randomised trials. BMJ 2011;18:
d5928.
12. Friedman LS, Richter ED. Relationship be-
tween conflicts of interest and research
results. J Gen Intern Med 2004;19:516.
13. Guncu MB, Aslan Y, Tumer C, Guncu GN, 27.
Uysal S. In-patient comparison of imme-
diate and conventional loaded implants in
mandibular molar sites within 12 months.
Clin Oral Implants Res 2008;19:
33541.
14. Schincaglia GP, Marzola R, Giovanni GF,
Chiara CS, Scotti R. Replacement of man-
dibular molars with single-unit restorations
supported by wide-body implants: immedi-
ate versus delayed loading. A randomized
controlled study. Int J Oral Maxillofac
Implants 2008;23:47480.
15. Prosper L, Crespi R, Valenti E, Cappare P,
Gherlone E. Five-year follow-up of wide-
diameter implants placed in fresh molar
extraction sockets in the mandible: immedi-
ate versus delayed loading. Int J Oral Max-
illofac Implants 2010;25:60712.
16. Meloni SM, De Riu G, Pisano M, De Riu
N, Tullio A. Immediate versus delayed
loading of single mandibular molars.
One-year results from a randomised con-
trolled trial. Eur J Oral Implantol 2012;5:
34553.
17. Kokovic V, Jung R, Feloutzis A, Todorovic
VS, Jurisic M, Hammerle CH. Immediate vs.
early loading of SLA implants in the poste-
rior mandible: 5-year results of randomized
controlled clinical trial. Clin Oral Implants
Res 2014;25:e1149.
18. Landis JR, Koch GG. The measurement of
observer agreement for categorical data. Bio-
metrics 1977;33:15974.
19. Lekholm U, Zarb GA. Patient selection and
preparation. In: Branemark PI, Zarb GA,
Albrektsson T, editors. Tissue-integrated
prostheses: osteointegration in clinical
dentistry. Quintessence; 1985. p. 199209.
20. Schulz KF, Altman DG, Moher D. CON-
SORT 2010 Statement: updated guidelines
for reporting parallel group randomised
trials. BMC Med 2010;8:18.
21. Higgins JP, Green S. Cochrane handbook for
systematic reviews of interventions version
91
5.1.0 [updated March 2011]. The Cochrane
Collaboration; 2011.
22. Egger M, Smith GD, Stern JA. Uses and
abuses of meta-analysis. Clin Med 2001;1:
47884.
23. Pandis N. The evidence pyramid introduc-
tion to randomized controlled trials. Am J
Orthod Dentofacial Orthop 2011;140:
4467.
24. Ottoni JM, Oliveira ZF, Mansini R, Cabral
AM. Correlation between placement torque
and survival of single-tooth implants. Int J
Oral Maxillofac Implants 2005;20:
76976.
25. Norton MR. The influence of insertion tor-
que on the survival of immediately placed
and restored single-tooth implants. Int J Oral
Maxillofac Implants 2011;26:133343.
26. Pilliar RM, Lee JM, Maniatopoulos C. Obser-
vations on the effect of movement on bone in
growth into porous-surfaced implants. Clin
Orthop Relat Res 1986;208:10813.
Degidi M, Piattelli A. Comparative analysis
study of 702 dental implants subjected to
immediate functional loading and immediate
nonfunctional loading to traditional healing
periods with a follow-up of up to 24 months.
Int J Oral Maxillofac Implants 2005;20:
99107.
28. Goiato MC, dos Santos DM, Santiago Jr JF,
Moreno A, Pellizzer EP. Longevity of dental
implants in type IV bone: a systematic re-
view. Int J Oral Maxillofac Surg 2014;43:
110816.
29. ten Bruggenkate CM, Asikainen P, Foitzik C,
Krekeler G, Sutter F. Short (6-mm) nonsub-
merged dental implants: results of a multi-
center clinical trial of 1 to 7 years. Int J Oral
Maxillofac Implants 1998;13:7918.
30. Ata-Ali J, Ata-Ali F, Ata-Ali F. Do antibio-
tics decrease implant failure postoperative
infections? A systematic review and meta-
analysis. Int J Oral Maxillofac Surg
2014;43:6874.
31. Szmukler-Moncler S, Salama H, Reinge-
wirtz Y, Dubruille JH. Timing of loading
and effect of micromotion on bonedental
implant interface: review of experimental
literature. J Biomed Mater Res 1998;43:
192203.
32. Siebers D, Gehrke P, Schliephake H.
Delayed function of dental implants: a 1-
to 7-year follow-up study of 222 implants.
Int J Oral Maxillofac Implants 2010;25:
1195200.
33. Weber HP, Buser D, Donath K, Fiorellini JP,
Doppalapudi V, Paquette DW, et al. Com-
parison of healed tissues adjacent to sub-
merged and non-submerged unloaded
titanium dental implants. A histometric
study in beagle dogs. Clin Oral Implants
Res 1996;7:119.
34. Engquist B, Astrand P, Anzen B, Dahlgren S,
Engquist E, Feldmann H, et al. Simplified
methods of implant treatment in the edentu-
lous lower jaw: a 3-year follow-up report of a
controlled prospective study of one-stage
92 Moraschini and Porto Barboza
versus two-stage surgery and early loading.
Clin Implant Dent Relat Res 2005;7:95104.
35. Qian J, Wennerberg A, Albrektsson T. Rea-
sons for marginal bone loss around oral
implants. Clin Implant Dent Relat Res
2012;14:792807.
36. Malo P, de Araujo Nobre M, Lopes A, Ferro
A, Gravito I. Single-tooth rehabilitations
supported by dental implants used in an
immediate-provisionalization protocol: re-
port on long-term outcome with retrospec-
tive follow-up. Clin Implant Dent Relat Res
2014. http://dx.doi.org/10.1111/cid.8.1227.
[Dec 23, Epub ahead of print].
37. Jung RE, Zembic A, Pjetursson BE, Zwahlen Address:
M, Thoma DS. Systematic review of the Vittorio Moraschini Filho
survival rate and the incidence of biological, Department of Periodontology
technical, and aesthetic complications of School of Dentistry
single crowns on implants reported in lon- Fluminense Federal University
gitudinal studies with a mean follow-up of 5 Rua Mario dos Santos Braga
years. Clin Oral Implants Res 2012;23 30
(Suppl. 6):221.
Centro
Niteroi
38. Moraschini V, Poubel LA, Ferreira VF, Bar-
Rio de Janeiro
boza ED. Evaluation of survival and success
Cep. 24020-140.23
rates of dental implants reported in longitu- Brazil
dinal studies with a follow-up period of at E-mail: vittoriomf@terra.com.br
least 10 years: a systematic review. Int J Oral
Maxillofac Surg 2015;44:37788.