YIJOM-3044; No of Pages 14

Int. J. Oral Maxillofac. Surg. 2014; xxx: xxxxxx

http://dx.doi.org/10.1016/j.ijom.2014.11.011, available online at http://www.sciencedirect.com

Dental implants

Immediately loaded B. R. Chrcanovica,, T. Albrektssona,b,

A. Wennerberga
a
Department of Prosthodontics, Faculty of

non-submerged versus delayed Odontology, Malmo University, Malmo,

Sweden; bDepartment of Biomaterials,
Goteborg University, Goteborg, Sweden

loaded submerged dental

implants: A meta-analysis
B.R. Chrcanovic, T. Albrektsson, A. Wennerberg: Immediately loaded
non-submerged versus delayed loaded submerged dental implants: A meta-analysis.
Int. J. Oral Maxillofac. Surg. 2014; xxx: xxxxxx. # 2014 International Association of
Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The purpose of the present meta-analysis was to test the null hypothesis of
no difference in the implant failure rate, postoperative infection, and marginal bone
loss for patients being rehabilitated with immediately loaded non-submerged dental
implants or delayed loaded submerged implants, against the alternative hypothesis
of a difference. An electronic search without time or language restrictions was
undertaken in March 2014. Eligibility criteria included clinical human studies,
either randomized or not. The search strategy resulted in 28 publications. The
inverse variance method was used for a random- or fixed-effects model, depending
on the heterogeneity. The estimates of an intervention were expressed as the risk
ratio (RR) and mean difference (MD) in millimetres. Twenty-three studies were
judged to be at high risk of bias, one at moderate risk of bias, and four studies were
considered at low risk of bias. The difference between procedures (submerged vs.
Keywords: Dental implants; Submerged; Non-
non-submerged implants) significantly affected the implant failure rate (P = 0.02),
submerged; One-stage implant; Two-stage im-
with a RR of 1.78 (95% confidence interval (CI) 1.122.83). There was no apparent plant; Implant failure rate; Postoperative infec-
significant effect of non-submerged dental implants on the occurrence of tion; Marginal bone loss; Meta-analysis.
postoperative infection (P = 0.29; RR 2.13, CI 0.528.65) or on marginal bone loss
(P = 0.77; MD 0.03, 95% CI 0.23 to 0.17). Accepted for publication 19 November 2014

Introduction
Historically, the original Branemark pro-
tocol for placing dental implants pre-
scribed a two-stage surgery with a
submerged healing period of at least 3
months in the mandible and 6 months in
the maxilla,1 allowing the implant to
osseointegrate without being exposed to
external forces. After bone healing, a sec-
ond surgery is performed to connect a
healing abutment. One of the main reasons
for implant insertion in the two-stage pro-
cedure was to minimize the risk of infec-
tion, since the peri-implant tissue is
allowed to heal separate from the oral
microbial environment.2 Extended treat-
ment times, the requirement for two sur-
gical interventions, and the need for
interim prostheses during healing are dis-
advantages of conventional implant treat-
ment.3
Over time, the concepts of implant
placement in fresh extraction sockets,4,5
immediate loading, and non-submerged
implants were introduced, focusing on
shorter and less invasive procedures. To
reduce the treatment time and offer the
patient early function and aesthetics, it is
necessary to use a one-stage surgical pro-
cedure and to load the implants as soon as
possible. In the one-stage surgical approach
(non-submerged implant), the coronal part
of the implant is positioned above the gin-
giva level in the case of single-part implants,
or transmucosal healing abutments are

0901-5027/000001+014 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Chrcanovic BR, et al. Immediately loaded non-submerged versus delayed loaded submerged dental
implants: A meta-analysis, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.11.011
YIJOM-3044; No of Pages 14
2 Chrcanovic et al.
placed in the case of two-part implants. In
the one-stage surgical approach, the implant
can be loaded immediately or not. The
encouraging early experiences of immedi-
ate loading in the mandible and the devel-
opment of new implant designs and surfaces
have inspired researchers to further explore
applications of immediate loading.6
Inserting implants in one stage has sev-
eral advantages. Only one surgical inter-
vention is required, which is convenient
for the patient, especially for the medically
compromised patient. In addition, there is
a considerable cost-benefit advantage. The
prosthetic phase can start earlier because
there is no wound-healing period related to
a second surgical procedure. Furthermore,
the implants are accessible for clinical
monitoring during the osseointegration
period.7 It allows for a healed peri-implant
mucosa at the time of prosthetic rehabili-
tation. Although immediate loading of
implants shortens the treatment duration
and also provides patients with an accept-
able aesthetic appearance, there is concern
that immediate loading may increase the
risk of implant failure.
The aim of this meta-analysis was to
compare the survival rate, postoperative
complications, and marginal bone loss of
non-submerged immediately loaded dental
implants with those of submerged delayed
loaded implants. The present study presents
a more detailed and in-depth analysis of the
influence of the submerged and non-sub-
merged approaches on implant failure rates
previously assessed in a published system-
atic review.8
Materials and methods
This study followed the PRISMA State-
ment guidelines.9 A review protocol does
not exist.
The purpose of the present meta-analy-
sis was to test the null hypothesis of no
difference in implant failure rate, postop-
erative infection, and marginal bone loss
for patients rehabilitated with immediately
loaded non-submerged dental implants or
delayed loaded submerged implants,
against the alternative hypothesis of a
difference.
Search strategies
An electronic search without time or lan-
guage restrictions was undertaken in
March 2014 in the following databases:
PubMed, Web of Science, and the
Cochrane Oral Health Group Trials Reg-
ister. The following terms were used in the
search strategy on PubMed, refined by
selecting the term dental journals in
the filter journal categories: {Subject
Please cite this article in press as: Chrcanovic BR, et al. Immediately loaded non-submerged versus delayed loaded submerged dental
implants: A meta-analysis, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.11.011
AND Adjective} {Subject: (dental implant
[title]) AND
Adjective: (submerged OR nonsub-
merged OR non-submerged OR one-stage
OR single-stage OR two-stage [title])}.
The following terms were used in the
search strategy on Web of Science, refined
by selecting the term dentistry oral sur-
gery medicine in the filter research area:
{Subject AND Adjective} {Subject: (den-
tal implant [title]) AND
Adjective: (submerged OR nonsub-
merged OR non-submerged OR one-stage
OR single-stage OR two-stage [title])}.
The following terms were used in the
search strategy for the Cochrane Oral
Health Group Trials Register: (dental im-
plant OR dental implant failure OR dental
implant survival OR dental implant suc-
cess AND (submerged OR nonsubmerged
OR non-submerged OR one-stage OR sin-
gle-stage OR two-stage)).
A manual search of journals covering
dental implant research was also done,
including British Journal of Oral and Max-
illofacial Surgery, Clinical Implant Den-
tistry and Related Research, Clinical Oral
Implants Research, European Journal of
Oral Implantology, Implant Dentistry, In-
ternational Journal of Oral and Maxillofa-
cial Implants, International Journal of Oral
and Maxillofacial Surgery, International
Journal of Periodontics and Restorative
Dentistry, International Journal of Prostho-
dontics, Journal of Clinical Periodontolo-
gy, Journal of Dental Research, Journal of
Oral Implantology, Journal of Craniofacial
Surgery, Journal of Cranio-Maxillofacial
Surgery, Journal of Dentistry, Journal of
Maxillofacial and Oral Surgery, Journal of
Oral and Maxillofacial Surgery, Journal of
Oral Rehabilitation, Journal of Periodon-
tology, and Oral Surgery Oral Medicine
Oral Pathology Oral Radiology and Endo-
dontology.
The reference lists of the studies identi-
fied and relevant reviews on the subject
were also scanned for possible additional
studies. Moreover, online databases pro-
viding information on clinical trials in
progress were checked (http://clinical-
trials.gov; http://www.centerwatch.com/
clinical-trials; http://www.clinicalconnec-
tion.com).
Inclusion and exclusion criteria
Eligibility criteria included clinical human
studies, either randomized or not, compar-
ing implant failure rates in any group of
patients receiving submerged versus im-
mediately loaded non-submerged dental
implants. Only the studies immediately
loading all non-submerged implants were
considered. For the studies publishing
more than one paper but with different
follow-up periods, only the publication
with the longest (the last) follow-up period
was considered, as long as the sample size
had remained the same. For this review,
implant failure represents the complete
loss of the implant. Exclusion criteria were
case reports, technical reports, animal
studies, in vitro studies, and review
papers.
Study selection
The titles and abstracts of all reports iden-
tified through the electronic searches were
read independently by the three authors.
For studies appearing to meet the inclusion
criteria, or for which there were insuffi-
cient data in the title and abstract to make a
clear decision, the full report was
obtained. Disagreements were resolved
by discussion between the authors.
Quality assessment
The quality assessment was performed
using the recommended approach for
assessing risk of bias in studies included
in Cochrane reviews.10 The classification
of the risk of bias potential for each study
was based on the four following criteria:
sequence generation (random selection in
the population), allocation concealment
(steps must be taken to secure strict im-
plementation of the schedule of random
assignments by preventing foreknowledge
of the forthcoming allocations), incom-
plete outcome data (clear explanation of
withdrawals and exclusions), and blinding
(measures to blind study participants and
personnel from knowledge of which inter-
vention a participant received). Incom-
plete outcome data would also be
considered addressed when there were
no withdrawals and/or exclusions. A study
that met all the criteria mentioned above
was classified as having a low risk of bias,
a study that did not meet one of these
criteria was classified as having a moder-
ate risk of bias, and when two or more
criteria were not met, the study was con-
sidered to have a high risk of bias.
Data extraction and meta-analysis
The following data were extracted from
the studies included in the final analysis,
when available: year of publication, study
design, single centre or multi-centre study,
number of patients, patient age, follow-up,
days of antibiotic prophylaxis, use of
mouth rinse, implant healing period, failed
and placed implants, and postoperative
YIJOM-3044; No of Pages 14
Immediately loaded non-submerged versus delayed loaded submerged dental implants: A meta-analysis
infection. Contact was made with authors
to obtain possible missing data.
Implant failure and postoperative infec-
tion were the dichotomous outcome mea-
sures evaluated. Weighted mean differences
were used to construct forest plots of mar-
ginal bone loss, a continuous outcome. The
statistical unit for the outcomes was the
implant. Whenever outcomes of interest
were not clearly stated, the data were not
used for analysis. The I2 statistic was used to
express the percentage of the total variation
across studies due to heterogeneity, with
25% corresponding to low heterogeneity,
50% to moderate and 75% to high. The
inverse variance method was used for the
random-effects or fixed-effects model. In
the case of statistically significant
(P < 0.10) heterogeneity, a random-effects
model was used to assess the significance of
treatment effects. Where no statistically
significant heterogeneity was found, analy-
sis was performed using a fixed-effects
model.11 The estimates of an intervention
were expressed as the risk ratio (RR) and as
the mean difference (MD) in millimetres for
continuous outcomes, both with a 95% con-
fidence interval (CI). Statistical significance
was set at P< 0.05. Only if there were
studies with similar comparisons reporting
Fig. 1. Study screening process.
Please cite this article in press as: Chrcanovic BR, et al. Immediately loaded non-submerged versus delayed loaded submerged dental
implants: A meta-analysis, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.11.011
the same outcome measures was a meta-
analysis to be attempted.
A funnel plot (plot of effect size versus
standard error) was drawn. Asymmetry of
the funnel plot may indicate publication
bias and other biases related to sample
size, although the asymmetry may also
represent a true relationship between trial
size and effect size.
The data were analysed using the statis-
tical software Review Manager (version
5.2.8; The Nordic Cochrane Centre, The
Cochrane Collaboration, Copenhagen,
Denmark, 2014).
Results
Literature search
The study selection process is summarized
in Fig. 1. The search strategy resulted in
1328 papers. One hundred and eighty-four
were cited in more than one research of
terms. The three reviewers independently
screened the abstracts to identify articles
related to the focus question. The initial
screening of titles and abstracts resulted in
1144 full-text papers; 1050 were excluded
for not being related to the topic. Assess-
ment of the full-text reports of the remain-
ing 94 articles led to the exclusion of 66
3
because they did not meet the inclusion
criteria: 39 reported the non-submerged
group being submitted to early or delayed
loading, nine did not report the number of
failures and/or the number of implants in
each group, eight comprised earlier fol-
low-up of the same study, four were ani-
mal studies, two were reviews, one was a
finite element analysis study, one applied
extraoral implants, one did not evaluate
implant failure, and one reported two-stage
implants being inserted in a one-stage pro-
cedure. Thus, a total of 28 publications
were included in the review.
Description of the studies
Detailed data of the 28 studies included
are listed in Tables 1 and 2. Six random-
ized clinical trials (RCT),3,1216 14 con-
trolled clinical trials (CCT),6,1729 and
eight retrospective analyses3037 were in-
cluded in the meta-analysis. Only three of
them were multi-centre studies.15,19,21
Nine studies had a maximum follow-up
of 12 months,3,6,13,15,19,20,25,29,35 eight
studies had a maximum follow-up ranging
from 13 to 36 months,12,14,16,17,2124 nine
studies had a maximum follow-up ranging
from 37 to 120 months,18,2628,3032,34,36
and one study had a follow-up of more
than 10 years;37 one study did not report
the follow-up period.33 Three studies did
not report patient age.18,28,31 Of the studies
with data available for patient age, three
included non-adults patients.22,35,37 Only
seven studies provided information on
postoperative infection,12,15,16,18,23,28,36
with six occurrences in a total of 663
patients receiving 1530 implants.
Some of the patients were smokers in 16
studies.6,12,13,15,17,19,2124,26,27,29,32,35,36
Ten studies inserted some of the implants
in fresh extraction sockets,17,22,25,26,28,29,
32,34,36,37
whereas in another, all implants
were inserted in fresh extraction sockets.16
Four studies included only patients who
received single-implant restorations3,1315
and two included only patients who re-
ceived overdentures.12,36 Some14,33,36 or
all16 implant sites underwent grafting pro-
cedures in some studies. Seven studies
included only edentulous patients,12,18,19,
21,24,27,33
five inserted implants only in the
maxilla,3,6,13,14,27 five studies inserted
implants only in the mandible,15,19,21,23,24
and one study only in the pterygomaxillary
region using a stereolithographic surgical
guide.37 Some patients17,26,32 or all
patients16,25 had periodontal disease in
some studies. Diabetic patients were in-
cluded in three studies.17,29,36
The most common period of healing
before the loading of implants in the
 4

YIJOM-3044; No of Pages 14
Table 1. Detailed data of the studies included.
implants: A meta-analysis, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.11.011
Please cite this article in press as: Chrcanovic BR, et al. Immediately loaded non-submerged versus delayed loaded submerged dental

Number of Patient age Antibiotics/ Failed/ Implant

Chrcanovic et al.
Year Study patients range (average) Follow-up mouth placed failure P-value (for Postoperative
Authors published design (n per group) (years) visits (or range) rinse (days) implants (n) rate (%) failure rate) infection
Schnitman et al.30 1990 RA (single 7a 4871 (NM) 42 Months NM 3/20 (G1) 15 (G1) NM NM
centre) 0/26 (G2) 0 (G2)
31
Dietrich et al. 1993 RA (single 535 NM 10 Years NM 75/421 (G1) 17.8 (G1) NM NM
centre) (106 G1; 429 G2)b 150/1137 (G2) 13.2 (G2)
Balshi and 1997 CCT (single 10a 4570 (55) 12 And 18 NM 8/40 (G1) 20 (G1) NM NM
Wolfinger17 centre) months 4/90 (G2) 4.4 (G2)
Schnitman et al.32 1997 RA (single 10 (NM) 4878 (NM) 10 Years NM 4/28 (G1) 14.3 (G1) 0.022 NM
centre) 0/35 (G2) 0 (G2)
Tarnow et al.18 1997 CCT (single 10 (G1 + G2) NM 1, 2, 3, 4, NM 2/69 (G1) 2.9 (G1) NM 0 (G1)
centre) And 5 years 1/38 (G2) 2.6 (G2) 1 (G2)
33
Horiuchi et al. 2000 RA (single 14 (NM) 4083 (NM) NM NM 4/140 (G1) 2.9 (G1) NM NM
centre) 0/17 (G2) 0 (G2)
Chiapasco et al.12 2001 RCT (single 20 (10 G1; 10 G2) 4473 (58.4) 6, 12, And 3/4 1/40 (G1) 2.5 (G1) >0.05 1 (G1)
centre) 24 months 1/40 (G2) 2.5 (G2) 0 (G2)
Engquist et al.19 2002 CCT (multi- 82 (52 G1; 30 G2) NM (64.9) 1 Year 710/710 14/208 (G1) 6.7 (G1) NM NM
centre) 3/120 (G2) 2.5 (G2)
Lorenzoni et al.20 2003 CCT (single 7a 5072 (60) 6 Months 4/post- 0/14 (G1) 0 (G1) NM NM
centre) operatively 0/28 (G2) 0 (G2)
21
Engquist et al. 2005 CCT (multi- 108 (78 G1; 30 G2) NM (64.9) 2 And 3 years 710/710 21/312 (G1) 6.7 (G1) NM NM
centre) 3/120 (G2) 2.5 (G2)
Ostman et al.6 2005 CCT (single 40 (20 G1; 20 G2) 5887 (73) (G1) 3, 6, And 12 10/10 1/123 (G1) 0.8 (G1) NM NM
centre) 5080 (64) (G2) months 0/120 (G2) 0 (G2)
Degidi et al.22 2006 CCT (single 371 1783 (53) 1 And 2 years 5/NM 6/484 (G1) 1.2 (G1) 0.267 NM
centre) (130 G1; 241 G2) 3/521 (G2) 0.6 (G2)
3
Hall et al. 2006 RCT (single 28 (14 G1; 14 G2) 2371 (43) 1 Year NM 1/14 (G1) 7.1 (G1) NM NM
centre) 0/14 (G2) 0 (G2)
Romanos and 2006 CCT (single 12 (Split-mouth) NM (51) 6 Weeks, 3, 6, 9, 0/7 0/36 (G1) 0 (G1) NM 0 (G1)
Nentwig23 centre) 12, 18, and 24 0/36 (G2) 0 (G2) 0 (G2)
months
Balshi et al.34 2007 RA (single 39 (NM) 2982 (58.5) 6 Months to 11 NM 1/15 (G1) 6.67 (G1) not NM
centre) years (4.05 years) 7/29 (G2)c 24.14 (G2) statistically
significant
at this
sample size
De Smet et al.24 2007 CCT (single 30 (10 G1; 10 G2, 4468 (58) (G1) 1 Week, 1, 3, NM 2/30 (G1) 6.7 (G1) NM NM
centre) 1 week; 10 G2, 4 5786 (69) and 6 months, 2/20 (G2, 10 (G2,
months) (G2, 1 week) 1 and 2 years 1 week) 1 week)
3372 (64) 2/20 (G2, 10 (G2,
(G2, 4 months) 4 months) 4 months)
Horwitz et al.25 2007 CCT (single 19 (NM) 3479 (NM) 2, 4, And 8 7/7 10/42 (G1) 23.8 (G1) NM NM
centre) weeks, 3, 6, 2/23 (G2) 8.7 (G2)
and 12 months
Susarla et al.35 2008 RA (single 855 1591 (53) (G1) 12 Months NM 46/477 (G1) 9.6 (G1) <0.01 NM
centre) (178 G1; 677 G2) 1792 (53) (G2) 106/2349 (G2) 4.5 (G2)
De Rouck et al.13 2009 RCT (single 49 (24 G1; 25 G2) NM (55 G1; 52 G2) 3, 6, And 12 NM 1/24 (G1) 4.2 (G1) NM NM
centre) months 2/25 (G2) 8 (G2)
 YIJOM-3044; No of Pages 14

Immediately loaded non-submerged versus delayed loaded submerged dental implants: A meta-analysis 5

The authors evaluated 459 implants, but made a separate evaluation for non-submerged and submerged implants only in the group of implants without rotational primary stability (n = 44). These
CCT, controlled clinical trial; G1, immediately loaded non-submerged implants group; G2, delayed loaded submerged implants group; NM, not mentioned; RA, retrospective analysis; RCT,

A total of 690 patients were included in the study, but only those patients for whom it was clearly stated that implants were inserted using one technique or the other (non-submerged vs. submerged)
non-submerged group was 3 months in 10
studies,13,14,16,17,19,21,23,31,32,34 followed

(G2)e
0 (G1)
1 (G2)

(G1)
(G2)
(G1)

0 (G1)
1 (G2)
by loading after 6 months of healing in
NM

NM

NM

NM

NM
three studies6,20,25 and 4 months of healing

0
0
2
0
in one study.30 One study did not report
the period of healing before loading.22 In
most other studies, loading of the sub-
0.00007

merged implants was performed within

>0.05
0.024

0.42

0.29
a range of time (e.g., between 3 and 6
NM

NM

NM

NM
months).
In the 28 studies comparing the proce-
17.1 (G1)

14.1 (G2)
dures, a total of 3918 dental implants were
4.5 (G1)

3.4 (G2)
3.2 (G1)

6.1 (G1)
4.1 (G2)

4.2 (G1)

3.3 (G1)
6.7 (G2)

4.1 (G1)

3.8 (G1)
1.9 (G2)
0 (G2)

0 (G2)

0 (G1)
0 (G2)

0 (G2)

non-submerged and immediately loaded,

with 263 failures (6.71%), and a total of
7194 implants were submerged, with 446
failures (6.20%). There was no implant
35/1015 (G2)

116/825 (G2) failure in three studies.15,20,23

10/163 (G1)

32/783 (G1)
5/111 (G1)
0/111 (G2)

7/184 (G1)
3/160 (G2)
0/97 (G2)e
6/35 (G1)

1/31 (G1)
0/31 (G2)

4/97 (G2)
0/20 (G1)
0/20 (G2)
1/24 (G1)

1/30 (G1)
2/30 (G2)

The most commonly used implants were

the Branemark (Nobel Biocare, Goteborg,
Sweden) in 13 studies,6,12,1719,21,24,30,3234,
36,37
but not exclusively in five stud-
ies,6,18,34,36,37 and the TiUnite (Nobel Bio-
care, Goteborg, Sweden) with an oxidized
surgery/
Before

surface in nine studies.6,1316,28,34,36,37 Ten

5/NM
10/14
7/14
NM

NM

NM

NM

NM

NM

studies reported whether there was a

statistically significant difference or not
in the implant failure rate between the
3 And 6 months,
3, 6, 9, And 12

7 And 10 days,
1, 2, 3, 4, 5, 6,

procedures;12,14,22,26,27,29,32,3436
7, 8, 9, and 10
3647 Months

four
3, 6, 12, and
(mean 40.5)

39 Months
Mean of 38

Mean of 88

found a statistically significant difference

24 months
6 And 18

16 Years

favouring submerged implants.26,32,35,36

The patients received both non-submerged and submerged implants, but not in a split-mouth design.
months

months

months

months

Twelve studies provided information

years

on the use of prophylactic antibio-

tics6,12,15,16,1923, 25,28,29 and nine studies
Unpublished information was obtained by personal communication with one of the authors.

about the use of chlorhexidine mouth rinse

by the patients.6,12,15,16,1921,23,25
2285 (52  13)

1866 (38) (G1)

1867 (40) (G2)

2594 (NM)
2870 (46)

1490 (58)
NM (60.8)

NM (58.2)

NM (47.5)

Quality assessment
Each trial was assessed for risk of bias; the
NM

scores are summarized in Table 3. Twen-

ty-three studies were judged to be at high
76 (45 G1; 51 G2)d

62 (31 G1; 31 G2)

49 (34 G1; 15 G2)

60 (30 G1; 30 G2)

risk of bias, whereas one study was con-

and who were followed up for 10 years were considered (n = 535).
(24 G1; 471 G2)

20 (Split-mouth)

sidered at moderate risk of bias and four

studies at low risk of bias.
981 (NM)

155 (NM)
46 (NM)

Some patients received implants from both groups.

Meta-analysis
495

In this study, a random-effects model was

used to evaluate implant failure in the
RCT (multi-
CCT (single

RCT (single

CCT (single

CCT (single

RCT (single

CCT (single
RA (single

RA (single

comparison between the procedures, since

centre)

centre)

centre)

centre)

centre)

centre)

centre)

centre)

centre)

statistically significant heterogeneity was

observed (P < 0.00001; I2 = 76%). The
insertion of dental implants through the
are the implants considered here.

two different techniques statistically af-

fected the implant failure rate in favour of
randomized controlled trial.
2010

2010

2011

2011

2012

2012

2012

2013

2014

the submerged procedure (P = 0.02;

Fig. 2). The RR of 1.78 (95% CI 1.12
2.83) implies that failures are 1.78 times
den Hartog et al.14

more likely to happen when implants are

Ostman et al.28
Siebers et al.26

Meloni et al.15
27

Shibly et al.16

immediately loaded than when implants

Balshi et al.37

Meizi et al.29
Tealdo et al.
Vercruyssen

are submerged. Thus, the relative risk

et al.36

reduction (RRR) is 78%. The RRR is

negative, i.e. immediately loaded non-
b

d
a

submerged implants increase the risk of

Please cite this article in press as: Chrcanovic BR, et al. Immediately loaded non-submerged versus delayed loaded submerged dental
implants: A meta-analysis, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.11.011
 6

YIJOM-3044; No of Pages 14
Table 2. Further details of the studies included.
implants: A meta-analysis, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.11.011
Please cite this article in press as: Chrcanovic BR, et al. Immediately loaded non-submerged versus delayed loaded submerged dental

Healing Marginal bone loss

Chrcanovic et al.
Authors period/loading (G2) (mean  SD), (mm) Implant surface modification (brand) Observations
Schnitman et al.30 4 Months NM Turned (Branemark, Nobel Biocare, Goteborg,
Sweden)
Dietrich et al.31 3 Months NM Sandblasted (IMZ, Friedrichsfeld AG,
Mannheim, Germany), TPS (?)
Balshi and 3 Months NM Turned (Branemark, Nobel Biocare, Goteborg, Only in the mandible. 8 patients with moderate
Wolfinger17 Sweden) to advanced periodontal disease, 4 with
bruxism, 2 smokers, 1 diabetic. 58 implants
were inserted in fresh extraction sites
Schnitman et al.32 3 Months NM Turned (Branemark, Nobel Biocare, Goteborg, 9 patients with periodontal disease. Some
Sweden) implants were inserted in fresh extraction
sockets and some patients were smokers, but
the exact number was not reported
Tarnow et al.18 46 Months NM Several (Branemark, Nobel Biocare, Goteborg, Only in totally edentulous jaws, minimum of 10
Sweden; Bonefit, ITI, Waldenburg, implants were placed in each patients arch
Switzerland; TiOblast, Astra Tech, Molndal,
Sweden; 3i, Implant Innovations, West Palm
Beach, USA)
Horiuchi et al.33 4 Months (mandible), NM Turned (Branemark, Nobel Biocare, Goteborg, 11 implants with bone grafting (all in G2), only
6 months (maxilla) Sweden) edentulous patients
12
Chiapasco et al. 48 Months 1 Year: 0.7 (G1), 1.5 (G2) Turned (Branemark System MKII, Nobel Edentulous mandibles, overdentures. Patients
2 Years: 0.8 (G1), 1.2 (G2) Biocare, Goteborg, Sweden) who smoked <10 cigarettes/day were also
included, but the exact number was not
reported
Engquist et al.19 3 Months 0.09  0.05 (G1) Turned (Branemark, Nobel Biocare, Goteborg, Only in edentulous mandibles. Patients who
0.32  0.06 (G2) Sweden) smoked <20 cigarettes/day were also included,
but the exact number was not reported
Lorenzoni et al.20 6 Months 0.9  0.4 (G1) Sandblasted and acid-etched (Frialit-2, 12 implants inserted 68 weeks after tooth
0.33  0.34 (G2) Dentsply-Friadent, Mannheim, Germany) extraction
Engquist et al.21 3 Months 1.33  0.15 (G1; n = 120) Turned (Branemark, Nobel Biocare, Goteborg, Only in edentulous mandibles. Patients who
1.42  0.17 (G1; n = 88) Sweden) smoked <20 cigarettes/day were also included,
1.24  0.17 (G1; n = 104)a but the exact number was not reported
1.68  0.12 (G2; n = 120)
Ostman et al.6 6 Months 0.78  0.90 (G1) Turned (Branemark, Nobel Biocare, Goteborg, Only in maxilla, 2 smokers
0.91  1.04 (G2) Sweden; n = 11), oxidized (TiUnite, Nobel
Biocare, Goteborg, Sweden; n = 232)
Degidi et al.22 NM 0.9 (G1) Sandblasted and acid-etched (XiVE, Dentsply- Patients who smoked <20 cigarettes/day were
1.0 (G2) Friadent, Mannheim, Germany) also included and some implants were inserted
in fresh extraction sockets, but the exact
numbers were not reported
Hall et al.3 26 Weeks Mesial Sandblasted (Southern Implants, Irene, South Only in the anterior maxilla, only single
0.69  1.36 (G1) Africa) implant crowns
0.56  1.90 (G2)
Distal
0.58  0.95 (G1)
0.99  1.18 (G2)
Romanos and 3 Months Information was provided, Sandblasted and acid-etched (Ankylos, Only in the posterior mandible, 6 smokers
Nentwig23 but not in mean  SD Dentsply-Friadent, Mannheim, Germany)
 Balshi et al.34

YIJOM-3044; No of Pages 14
3 Months NM Turned (Branemark, Nobel Biocare, Goteborg, Some implants were placed in fresh extraction
implants: A meta-analysis, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.11.011
Please cite this article in press as: Chrcanovic BR, et al. Immediately loaded non-submerged versus delayed loaded submerged dental

Sweden; n = 20) sockets, but the exact number was not reported
Oxidized (TiUnite, Nobel Biocare, Goteborg,
Sweden; n = 24)
De Smet et al.24 1 Week (n = 20) 1 year Turned (Branemark, Nobel Biocare, Goteborg, Edentulous mandible, 7 smokers
4 Months (n = 20) 1.53  0.1 (G1) Sweden)
1.07  0.2 (G2, 1 week)

Immediately loaded non-submerged versus delayed loaded submerged dental implants: A meta-analysis
0.47  0.2 (G2, 4 months)
2 years
1.67  0.1 (G1)
1.26  0.1 (G2, 1 week)
0.49  0.2 (G2, 4 months)
Horwitz et al.25 6 Months NM Sandblasted and acid-etched (MIS Implant Only in patients diagnosed with moderate to
Technologies, Shlomi, Israel) severe generalized chronic periodontitis. 40
implants in fresh extraction sockets (26 in G1,
14 in G2)
Susarla et al.35 36 Months NM Hydroxyapatite (Bicon, Boston, MA, USA) 73 smokers (16 in G1, 57 in G2)
De Rouck et al.13 3 Months Mesial Oxidized (TiUnite, Nobel Biocare, Goteborg, Only in the anterior maxilla, only single
0.92  0.49 (G1) Sweden) restorations. Patients who smoked <10
0.96  0.25 (G2) cigarettes/day were also included, but the exact
Distal number was not reported
0.79  0.54 (G1)
0.97  0.35 (G2)
Siebers et al.26 46 Months NM Sandblasted and acid-etched (Camlog Root- No grafted patients, 58 implants placed in fresh
Line and Screw-Line, Camlog extraction sockets, almost 20% of the patients
Biotechnologies, Basel, Switzerland), acid- were smokers, almost 30% were bruxers, and
etched (Osseotite, Biomet 3i, Palm Beach almost 60% were treated for periodontal
Gardens, FL, USA), blasted with HA and disease
calcium phosphate (Restore RBM, Lifecore
Biomedical, Chaska, MN, USA)
Vercruyssen et al.36 35 Months Information was provided, Turned (Branemark, Nobel Biocare, Goteborg, Only two-implants-supported mandibular
but not comparing G1 and G2 Sweden; 95.5%), oxidized (TiUnite, Nobel overdentures. 11.8% of the patients were
Biocare, Goteborg, Sweden, 4.5%) smokers, 23 diabetic patients. Insertion in fresh
extraction sockets and GBR were performed in
some cases, but the exact numbers were not
reported
den Hartog et al.14 3 Months 0.91  0.61 (G1) Oxidized (NobelReplace Tapered Groovy, Only single implants in the maxillary aesthetic
0.90  0.57 (G2) TiUnite, Nobel Biocare, Goteborg, Sweden) zone. All implants placed in healed sites at least
3 months after tooth removal. GBR was
performed in some cases, but the exact number
was not reported. No smokers
Tealdo et al.27 Mean 8.75 months 12 Months Acid-etched (Osseotite, 3i Implant Only maxillary full-arch treatment. No graft.
0.8  0.8 (G1) Innovations, Palm Beach Gardens, FL, USA) Patients who smoked were also included, but
1.4  0.8 (G2) the exact number was not reported
24 Months
1.0  0.9 (G1)
1.7  0.9 (G2)
36 Months
1.1  0.9 (G1)
1.8  1.1 (G2)

7
YIJOM-3044; No of Pages 14

8 Chrcanovic et al.

not reported. Use of stereolithographic surgical

but the exact number was not reported. No graft

G1, immediately loaded non-submerged implants group; G2, delayed loaded submerged implants group; GBR, guided bone regeneration; HA, hydroxyapatite; NM, not mentioned; SD, standard

The non-submerged implants were divided into three groups: those treated with one-stage surgery, those treated with one-piece implants, and those treated with the early loading procedure.
smoked <10 cigarettes/day were also included,

7% of the patients were diabetics and 8% were

Only implants placed in the pterygomaxillary

extraction sockets, but the exact number was

region. Some implants were inserted in fresh
implant failure by 78%. The number need-

33 implants were placed in fresh extractions

sockets, 237 flapless surgery, 107 open flap

Only first mandibular molars. Patients who

periodontal disease. GBR used in all cases

ed to treat (NNT) to prevent one patient

smokers, 215 implants in fresh extraction

sockets in patients with a past history of
Only implants placed in fresh extraction
sockets or 3 to 6 weeks after extraction
having an implant failure is 50 (95% CI
25100).
Only seven studies provided information
on postoperative infection.12,15,16,18,23,28,36

guide in 136 implants of G1

A fixed-effects model was used due to the
lack of statistically significant heterogene-
ity (P = 0.16; I2 = 39%). The insertion of
dental implants did not statistically affect
the incidence of postoperative infection
Observations

(P = 0.29; Fig. 3). A RR of 2.13 (95% CI

0.528.65) was observed.

surgery
Eleven studies provided information on
marginal bone loss with the standard devi-
ation, which is necessary for comparisons
of continuous outcomes (Fig. 4).3,6,1316,
1921,24,27
A random-effects model was used
Turned (Branemark, Nobel Biocare, Goteborg,
Oxidized (TiUnite, Nobel Biocare, Goteborg,

Sandblasted and acid-etched (Saturn, Cortex

TiUnite, Nobel Biocare, Goteborg, Sweden)

TiUnite, Nobel Biocare, Goteborg, Sweden)

Sweden; n = 710), oxidized (TiUnite, Nobel

to evaluate marginal bone loss, since sta-

Oxidized (Nobel Replace Tapered Groovy,

Oxidized (NobelReplace Straight Groovy,

tistically significant heterogeneity was

found (P < 0.00001; I2 = 99%). There
Biocare, Goteborg, Sweden; n = 898)
Implant surface modification (brand)

was no statistically significant difference

between the groups concerning marginal
bone loss (P = 0.77; MD 0.03, 95% CI
0.23 to 0.17).
Dental, Shlomi, Israel)

Publication bias
The funnel plot showed asymmetry when
the studies reporting the outcome implant
Sweden)

failure were analysed (Fig. 5), indicating

the possible presence of publication bias.

Discussion
Potential biases are likely to be greater for
non-randomized studies compared with
RCTs, so results should always be inter-
0.7  1.35 (G1 + G2)

preted with caution when they are included

(mean  SD), (mm)

0.75  0.17 (G2)b

Marginal bone loss

0.99  0.22 (G1)

in reviews and meta-analyses.10 However,

0.83  0.16 (G1)
0.86  0.16 (G2)

narrowing the inclusion criteria increases

homogeneity but also excludes the results
of more trials and thus risks the exclusion of
significant data.38 This was the reason for
NM

NM

the inclusion of non-randomized studies in

the present meta-analysis. The issue is im-
portant because meta-analyses are fre-
quently conducted on a limited number
of RCTs. In meta-analyses such as these,
period/loading (G2)

adding more information from observation-

deviation; TPS, titanium plasma-sprayed.

al studies may aid in clinical reasoning and

45 Months

36 Months

68 Months

36 Months

to establish a more solid foundation for

3 Months

causal inferences.38
Healing

Gain of marginal bone level.

The relevant question is whether the

lack of a difference in failure rates be-
tween the immediately loaded non-sub-
merged implant and delayed loaded
Table 2 (Continued )

submerged implant procedures in some

studies is a real finding or is due to the
Ostman et al.28
Meloni et al.15

16

lack of statistical power, given the small

Balshi et al.37

Meizi et al.29
Shibly et al.

number of patients per group in many

studies.3,6,13,14,1618,20,23,25,28,3234 A sta-
Authors

tistically and clinically significant differ-

b
a

ence (P = 0.02) favouring the submerged

Please cite this article in press as: Chrcanovic BR, et al. Immediately loaded non-submerged versus delayed loaded submerged dental
implants: A meta-analysis, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.11.011
YIJOM-3044; No of Pages 14

Immediately loaded non-submerged versus delayed loaded submerged dental implants: A meta-analysis 9

Table 3. Results of the quality assessment.

Sequence Incomplete Estimated
generation Allocation outcome data potential
Authors Published (randomized?) concealment addressed Blinding risk of bias
Schnitman et al.30 1990 No Inadequate No No High
Dietrich et al.31 1993 No Inadequate No No High
Balshi and 1997 No Inadequate Yes No High
Wolfinger17
Schnitman et al.32 1997 No Inadequate No No High
Tarnow et al.18 1997 No Inadequate No No High
Horiuchi et al.33 2000 No Inadequate Yes No High
Chiapasco et al.12 2001 Yes Inadequate Yes Unclear High
Engquist et al.19 2002 No Inadequate Yes No High
Lorenzoni et al.20 2003 No Inadequate No No High
Engquist et al.21 2005 No Inadequate Yes No High
Ostman et al.6 2005 No Inadequate Yes No High
Degidi et al.22 2006 No Inadequate No No High
Hall et al.3 2006 Yes Adequate Yes Unclear Moderate
Romanos and 2006 No Inadequate Yes No High
Nentwig23
Balshi et al.34 2007 No Inadequate Yes No High
De Smet et al.24 2007 No Inadequate Yes No High
Horwitz et al.25 2007 No Inadequate Yes No High
Susarla et al.35 2008 No Inadequate No No High
De Rouck et al.13 2009 Yes Adequate Yes Yes Low
Siebers et al.26 2010 No Inadequate No No High
Vercruyssen et al.36 2010 No Inadequate No No High
den Hartog et al.14 2011 Yes Adequate Yes Yes Low
Tealdo et al.27 2011 No Inadequate No No High
Meloni et al.15 2012 Yes Adequate Yes Yes Low
Ostman et al.28 2012 No Inadequate Yes No High
Shibly et al.16 2012 Yes Adequate Yes Yes Low
Balshi et al.37 2013 No Inadequate Yes No High
Meizi et al.29 2014 No Inadequate No No High

Fig. 2. Forest plot for the event implant failure.

Please cite this article in press as: Chrcanovic BR, et al. Immediately loaded non-submerged versus delayed loaded submerged dental
implants: A meta-analysis, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.11.011
YIJOM-3044; No of Pages 14

10 Chrcanovic et al.

Fig. 3. Forest plot for the event postoperative infection.

Fig. 4. Forest plot for the event marginal bone loss.

implant procedure was found after meta-
analysis, stressing the importance of meta-
analyses to increase the sample size of
individual trials to reach more precise
estimates of the effects of interventions.
Fig. 5. Funnel plot for the studies reporting the outcome event implant failure.
Concerning immediate loading, which
might have influenced the results, Pilliar
et al.39 observed that a micro-movement
of 150 mm may be the critical level above
which healing will undergo fibrous repair
rather than the desired osseous regenera-
tion. Micro-motion or motion of the im-
plant surface relative to the bone can result
from functional overloading immediately
after implantation. It has long been be-
lieved that micro-motion can also disturb
the early remodelling phase, and a critical
degree of micro-motion caused by over-
load can result in fibrous repair at the
interface rather than osseous regeneration
and osseointegration.33 However, reports
have shown that immediate loading can
lead to clinical and histological osseointe-
gration.40,41 It is therefore justifiable to
question whether this healing period is
an absolute prerequisite to obtaining
osseointegration, or if under certain cir-
cumstances this period can be shortened
without jeopardizing osseointegration and
long-term results.12 Moreover, several im-
plant features, such as geometry of
the implant body specially designed for
critical bone conditions and implant sur-
faces combined with high insertion tor-
ques during bone healing, may have
minimized the risk of early failure of
immediately loaded implants. The imme-
diate loading of implants installed accord-
ing to the non-submerged procedure
might inhibit osseointegration, although

Please cite this article in press as: Chrcanovic BR, et al. Immediately loaded non-submerged versus delayed loaded submerged dental
implants: A meta-analysis, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.11.011
YIJOM-3044; No of Pages 14
Immediately loaded non-submerged versus delayed loaded submerged dental implants: A meta-analysis
implants inserted in the submerged way
sometimes fail to osseointegrate as well.
Thus, the true reason for the failure to
osseointegrate remains largely obscure.2
Concerning postoperative infection, the
present meta-analysis showed no statisti-
cally significant difference (P = 0.29) be-
tween the different techniques on its
occurrence, even though it was observed
that the non-submerged procedure in-
creased the risk of postoperative infection
by 113% (RR 2.13, RRR 113%) in com-
parison with the submerged technique. This
may be due to the fact that in the non-
submerged procedure the peri-implant tis-
sues are exposed to the oral environment
following implant insertion and during
healing.
The present meta-analysis showed no
statistically significant difference between
the two techniques compared here with
regard to marginal bone loss (P = 0.77).
One might think that immediate loading
may cause a greater marginal bone loss in
comparison with delayed loading. Howev-
er, early functional loading to a determined,
controlled extent during the healing phase
may have a positive effect on marginal
bone levels.42 Early loading stimuli at the
boneimplant interface lead to functional
adaptation of the bone to the loading situa-
tion (remodelling) and to an improved dif-
ferentiation of the bone structures, resulting
in a higher marginal bone level.26
A potential explanation for any possible
difference could be that the trauma of the
second operation is avoided with preser-
vation of the biological width by means of
a more superficial placing of implants.21 A
less extensive countersinking in the non-
submerged implants may also contribute
to less bone resorption.21 The presence
of a microgap between the implant and
the prosthetic abutment when two-part
implants are used is another hypothesis.
It has been observed that bacteria colonize
the inner region of two-part implants fol-
lowing abutment connection and that this,
in turn, may result in marginal bone
loss.43,44 Weber et al.45 demonstrated that
in one-stage implants a large percentage of
initial bone loss occurred during the first
months, whereas in two-stage implants,
40% of initial bone resorption was found
after re-entry. The authors explained their
findings as being related to bacterial col-
onization of one-stage implants and the
additional surgical trauma of the two-stage
protocol. However, a comparison of mar-
ginal bone loss between one- and two-
piece implants was performed in the study
of Engquist et al.21 and the results suggest
that the micro-gap has no obvious effect
on the clinical outcome.
Please cite this article in press as: Chrcanovic BR, et al. Immediately loaded non-submerged versus delayed loaded submerged dental
implants: A meta-analysis, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.11.011
Putative periodontal pathogens have
been implicated in the onset and progres-
sion of peri-implantitis, but it remains
unclear whether these bacteria always
constitute a risk factor for the maintenance
of dental implants.46 In fact, in some
studies47,48 no correlation was established
between the frequency of any group of
microorganisms and the clinical parame-
ters of peri-implantitis. Although sus-
pected periodontal pathogens were
identified at implant sites in these latter
studies, the clinical parameters were not
indicative of deteriorating support, sug-
gesting that the presence of potential peri-
odontal pathogens around implants may
not always be associated with future at-
tachment loss or implant failure. As ob-
served in a recent review, there are many
original reasons for marginal bone loss
around oral implants, reasons not associ-
ated with any primary infection or over-
loading alone, but instead coupled with the
hardware used, clinical handling, and dif-
ferent patient factors or foreign body reac-
tions.49
Furthermore, the peri-implant bone
reactions around delayed and immediately
loaded implants have been evaluated in an
animal study. Histological and histomor-
phometric observations and data have al-
ready been published50 and have shown no
histological differences in the two loading
groups. It should be noted that the lack of a
statistically significant difference between
the two loading groups does not mean that
the peri-implant conditions are the same,23
because the sample sizes in most of the
studies with available information on mar-
ginal bone loss were relatively small.
It is possible that surface properties
played a role in the clinical outcome in
these studies. Surface properties such as
topography physics and chemistry may
affect protein adsorption, cell-surface
interactions, and peri-implant tissue de-
velopment, which are all relevant to the
functionality of the implant or device and
may have an influence on osseointegra-
tion, the host response to the implant, and
subsequent treatment outcomes.8 This in-
fluence on the results may be related to the
fact that some transmucosal implants have
a rough surface topography (e.g. titanium
plasma-sprayed surface, TPS), whereas
implants placed for submerged healing
have a turned surface with minimal rough-
ness. Increases in surface roughness and
surface free energy have been shown to
facilitate microbial biofilm formation on
dental implant and abutment surfaces.51,52
The outcomes reported from experimental
studies in dogs suggest that the progres-
sion of peri-implantitis, if left untreated,
11
differs among implant types53,54 and is
more pronounced for implants with a mod-
erately rough surface (e.g. sand-blasted
and acid-etched) compared with implants
with a turned surface.55 However, ligature
studies such as those referred to here, add
the possibility of a foreign body reaction
to the ligature and, therefore, these find-
ings may not be clinically relevant at all.
Moreover, the results of clinical studies in
partially edentulous patients have shown
that implants with a rough surface yield
higher rates of peri-implantitis and late
failures compared with implants with
moderately rough or turned surfaces.56,57
It is worth mentioning that titanium with
different surface modifications shows a
wide range of chemical and physical prop-
erties and surface topographies or
morphologies, depending on how they
are prepared and handled,5860 and it is
not clear whether, in general, one surface
modification is better than another.61
The fact that some of the studies
reviewed here had a short follow-up is
also a confounding factor. Nine of the
28 studies had a maximum follow-up of
only 12 months. A longer follow-up period
could lead to an increase in the failure rate,
especially if it is extended beyond func-
tional loading, because other prosthetic
factors can influence implant failure from
that point onwards. This might have led to
an underestimation of actual failures in
some studies. However, it is hard to define
what would be considered a short follow-
up period to evaluate implant failures
when comparing these techniques.
The placement of implants in fresh ex-
traction sockets may also be considered a
confounding factor. However, even
though the immediate loading of implants
in post-extraction sites has been hypothe-
sized to increase the risk of failure most
likely due to residual infection, this pro-
cedure can be successful, provided that
thorough preoperative care is given.5
Moreover, primary closure over immedi-
ately placed implants is another variable
that could influence the outcome, due to
the fact that the socket may have had
exposure to the oral environment during
healing,62 even though one of the proce-
dures analysed here was immediate load-
ing.
A valuable observation here is that
papers are often written by experienced
clinicians and the surgical novice may
have more reliable results in a slow,
delayed procedure. After all, immediate
loading is a challenge, and the results may
to some degree be compensated for if
experienced clinicians work with the
implants. A recent review8 observed that
YIJOM-3044; No of Pages 14
12 Chrcanovic et al.
three of the four available studies evaluat-
ing the influence of surgeon surgical ex-
perience on implant failure rates indicated
that inexperienced surgeons tend to have
more failures than more experienced sur-
geons.
The splinting of the implants in the
prosthetic work could be considered an-
other confounding factor, and this was
performed in some studies .6,18,20,21,32,33
By splinting, the implants work as a group
rather than as single units, thereby com-
pensating for lateral forces .6 The bilateral
splinting action among several implants
that are themselves stable at placement,
along with other stabilizing factors, such
as optimal distribution of implants and a
protective occlusal scheme, may resist
the theoretically critical degree of mi-
cro-movement at the boneimplant inter-
face .33
It is no less important to mention smok-
ing habits. Smoking is one of the promi-
nent risk factors affecting success rates
and marginal bone loss related to dental
implants,63 and some of the patients were
smokers in 16 of the 28 studies included
here.
The results of the present study have to
be interpreted with caution because of its
limitations. First, all confounding factors
may have affected the long-term out-
comes and not just the difference be-
tween the procedures; the impact of
these variables on the implant survival
rate, postoperative infection, and margin-
al bone loss is difficult to estimate if
these factors are not identified separately
for the two different procedures in order
to perform a meta-regression analysis.
This lack of control of the confounding
factors limited the potential to draw ro-
bust conclusions. Second, some of the
studies included had a retrospective de-
sign, and the nature of a retrospective
study inherently results in flaws. These
problems were manifested by the gaps in
information and incomplete records. Fur-
thermore, all data rely on the accuracy of
the original examination and documenta-
tion. Items may have been excluded in
the initial examination or not recorded in
the medical Charts .6466 Third, much of
the research in the field is limited by
small cohort sizes.
In conclusion, the difference between
immediately loaded non-submerged den-
tal implants and delayed loaded sub-
merged implants statistically affected the
implant failure rate. No statistically sig-
nificant effects on the occurrence of post-
operative infection or on marginal bone
loss were observed between the two dif-
ferent techniques.
Please cite this article in press as: Chrcanovic BR, et al. Immediately loaded non-submerged versus delayed loaded submerged dental
implants: A meta-analysis, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.11.011
Funding
This work was supported by CNPq, Con-
selho Nacional de Desenvolvimento Cien-
tfico e TecnologicoBrazil.
Conflict of interest statement
None declared.
Ethical approval
Not required.
Patient consent
Not required.
Acknowledgements. The authors would
like to thank Linda W. Maroney for send-
ing us the article by Balshi and Wolfinger
(1997), Dr Cecilia Larsson Wexell and Dr
Marco Tallarico for sending us their arti-
cles, and Dr Cecilia Larsson Wexell, Dr
Lars Sennerby, and Dr Par-Olov Ostman,
who provided some of the missing infor-
mation about their studies.
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Corresponding author
Tel.: +46 725 541 545
fax: +46 40 6658503
E-mails: bruno.chrcanovic@mah.se,
brunochrcanovic@hotmail.com