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Keywords:

  • Dental implant;
  • immediate;
  • papilla;
  • recession;
  • single tooth

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and Methods
  5. Results
  6. Discussion
  7. References

Purpose

It has been stated that midfacial recession is common following immediate implant treatment (IIT). The objective of this systematic review was to assess the frequency of advanced recession (>1 mm) following single IIT.

Material and methods

An electronic search in Pubmed, Web of Science and the Cochrane Oral Health Group Specialized Trials Register database was performed using a search algorithm. Reference lists of relevant articles were also scrutinized to identify prospective studies on ≥10 implants installed in patients with an intact buccal bone wall and followed for ≥12 months. Study eligibility and quality were independently assessed by two investigators. Primary outcome variables were advanced inter-proximal and midfacial recession defined as soft tissue loss surpassing 1 mm between the pre- or postoperative status and the final re-assessment.

Results

Thirteen of 171 papers were selected. Inter-examiner agreement on eligibility (κ = 0.879; p < 0.001) and quality (κ = 0.788; p < 0.001) was high. Advanced inter-proximal recession was described in 0–27% of the cases. However, these data were only based on two studies. Mean inter-proximal recession was frequently reported (11/13) and was <1 mm in all studies suggesting limited risk for advanced inter-proximal recession. Advanced midfacial recession was described in 0–64% of the cases. Again, few papers provided such information (4/13). Only one of these studies demonstrated high risk for advanced midfacial recession (>10%). This could be attributed to the fact that implants had not been restored with an immediate implant crown, which seems of pivotal importance given the results of a randomized controlled trial reporting on the preserving effect of immediate provisionalization on midfacial mucosa level. There is limited evidence to support an increased risk for midfacial recession following flap surgery and in patients with a thin-scalloped gingival biotype. The impact of implant-specific parameters on inter-proximal and midfacial soft tissue level seems conflicting.

Conclusions

Soft tissue recession may be expected following IIT and multiple factors seem to contribute to the phenomenon. Taking into account the paucity of papers, patients with an intact buccal bone wall and thick gingival biotype, treated by means of flapless surgery and an immediate implant crown may demonstrate limited risk for advanced midfacial recession (<10%). Proper risk assessment addressing diagnostic, surgical and restorative aspects is mandatory to avoid compromised outcome of IIT.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and Methods
  5. Results
  6. Discussion
  7. References

According to a number of systematic reviews single implant treatment is predictable and successful, at least in terms of classical outcome variables following conventional implant surgery (Creugers et al. 2000, Berglundh et al. 2002, den Hartog et al. 2008, Jung et al. 2008). Still, data on clinical response parameters, complications and bone remodelling may be considered limited to describe the overall outcome of single implants. Society is evolving with more and more patients focusing on aesthetic aspects of treatment outcome. This may explain the growing interest by scientists for soft tissue dynamics, objective aesthetic ratings and patient-centred outcomes.

The progressive shortening of the healing time from tooth loss to implant installation finally resulting in immediate implant placement, may be the ultimate reflection of patient's expectations. Apart from the time gain it is clear, however, that this procedure is potentially risky especially from a surgical point of view. The ideal three-dimensional implant position usually deviates from the alveolar socket, therefore requiring highly experienced and skilled surgeons to overcome incorrect positioning. Also diagnostic considerations need to be properly addressed as it has been shown that immediate implantation may not avert post-extraction remodelling (Botticelli et al. 2004, Araújo et al. 2005). In this respect an intact buccal bone wall seems mandatory. Indeed, high risk for advanced midfacial recession has been described following immediate implant treatment (IIT) and simultaneous guided bone regeneration of buccal bone defects (Kan et al. 2007). In addition, midfacial recession may not be avoided by a thick gingival biotype, flapless surgery or connective tissue grafting in these patients, stressing the pivotal importance of an intact buccal bone wall for IIT (Kan et al. 2007).

In a recent review article midfacial recession was found common following IIT (Chen & Buser 2009). However, studies were not selected on the basis of eligibility and quality criteria, making conclusions possibly biased. The purpose of this study was to systematically review the available literature on the occurrence of advanced recession (>1 mm) based on the following focused research question: ‘what is the frequency of advanced recession in patients who received an immediate single implant’?

Material and Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and Methods
  5. Results
  6. Discussion
  7. References

Study selection

The PRISMA checklist (Moher et al. 2011) was consulted and used as a guide for quality reporting of a systematic review. Only full-text reports in English on clinical studies pertaining to IIT for single-tooth replacement were considered. In this context IIT was defined as the installation of a dental implant into an extraction socket.

Inclusion criteria were:

  1. Prospective case series or randomized controlled trial (RCT)
  2. Results on at least 10 cases
  3. Follow-up of at least 12 months
  4. Results on at least 1 outcome variable of interest

Exclusion criteria were:

  1. Retrospective case series or cross-sectional study
  2. Molar replacements
  3. Missing natural teeth adjacent to the implant restoration
  4. Regeneration or augmentation of the alveolar process prior to or during implant surgery
  5. Soft tissue grafting

Socket grafting, that is the application of autogenous bone and/or biomaterials within the confines of the extraction socket, was not considered an exclusion criterion.

Outcome variables

In the context of the present study advanced recession was defined as soft tissue loss surpassing 1 mm between the pre- or postoperative status and the final re-assessment.

Advanced inter-proximal recession and advanced midfacial recession were considered primary outcome variables and results were expressed as proportions, given the aforementioned focused research question.

Secondary outcome variables were mean inter-proximal and midfacial recession, fill of the embrasure space, aesthetic soft tissue ratings by clinicians and patient's aesthetic satisfaction.

Search strategy

An electronic search was performed in Pubmed, Web of Science and the Cochrane Oral Health Group Specialized Trials Register database by two investigators (JC, NH) until the 31th of July 2011. The following search algorithm was used: Dental implants, single tooth [MeSH] AND (papilla [free text word] OR recession [free text word]). In addition, reference lists of relevant articles were scrutinized to include as much studies as available.

Assessment of study quality

Following the selection of eligible papers on the basis of inclusion and exclusion criteria, studies were rated on their quality. Specific study-design related forms designed by the Dutch Cochrane Collaboration were used as a basis. For each study type a checklist was developed focusing on randomization (if applicable), patient and site characteristics, patient selection, intervention, evaluation method, outcome and follow-up (Table 1). Two investigators (JC, NH) independently generated a score for all selected articles, expressed in the numbers of plusses given. A score of at least 8 plusses was considered to be methodologically acceptable for RCTs and 7 plusses for case series. To reduce the risk for bias as much as possible, studies showing poor quality on the basis of this assessment were excluded.

Table 1. Checklist for quality assessment
Quality assessment of randomized controlled trialsQuality assessment of prospective case series
  1. N/A, not applicable.

RandomizationN/A
1. Were adequate methods used for randomization?
Patient and site characteristicsPatient and site characteristics
1. Were patient characteristics well described for both groups?1. Were patient characteristics well described?
2. Were site characteristics well described for both groups?2. Were site characteristics well described?
3. Were there no disparities in terms of patient or site characteristics between the groups?
Patient selectionPatient selection
1. Were the inclusion and exclusion criteria well described and the same for both groups?1. Were the inclusion and exclusion criteria well described?
2. Did the study report on consecutively treated patients?2. Did the study report on consecutively treated patients?
InterventionIntervention
1. Were interventions for both groups clearly described?1. Was the intervention clearly described?
2. Were all patients of the same group treated according to the same intervention?2. Were all patients treated according to the same intervention?
Evaluation methodEvaluation method
1. Was blinding used to assess the outcome?1. Was the outcome assessed by an investigator who had not been involved in the treatment?
2. Were adequate methods used to assess the outcome?2. Were adequate methods used to assess the outcome?
3. Were reproducibility data reported on the outcome variable(s)?3. Were reproducibility data reported on the outcome variable(s)?
Outcome & follow-upOutcome & follow-up
1. Was the outcome clearly described?1. Was the outcome clearly described?
2. Was an intention-to-treat analysis performed and was there low risk for selective loss to follow-up?2. Was the response rate acceptable and was the number of patients lost to follow-up clearly described?

Statistical analysis

Given the limited number of selected studies and the heterogeneity among them in terms of possible factors affecting recession, the data were analysed from a descriptive point of view. κ statistics were used to evaluate inter-examiner agreement on study eligibility and quality.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and Methods
  5. Results
  6. Discussion
  7. References

Search results

All search strategies provided 171 papers after eliminating titles that were present in different searches. Two investigators (JC, NH) independently identified 18 eligible papers. Inter-examiner agreement on study eligibility was high (κ = 0.879; p < 0.001). Disagreement mainly related to aspects of hard tissue augmentation, which could be resolved by discussion. Eligible studies were methodologically assessed by the same investigators with high agreement (κ = 0.788; p < 0.001). Five studies did not meet the quality requirements and were excluded (Norton 2004, Ferrara et al. 2006, Chen et al. 2007, Block et al. 2009, Cooper et al. 2010). Reasons for exclusion are depicted in Table 2. One examiner (NH) extracted all data from the selected papers.

Table 2. Studies excluded after quality assessment and reasons for exclusion
AuthorsStudy designReasons for exclusion
  1. RCT, randomized controlled trial; AB, autogenous bone; AL, allograft.

Norton (2004), Case seriesSite characteristics incomplete (gingival biotype not described); patients not treated according to same intervention (flap or flapless surgery); outcome possibly assessed by an investigator involved in the treatment; methods used to assess the outcome unclear; no reproducibility data; no actual data on the outcome
Ferrara et al. (2006), Case seriesSite characteristics incomplete (gingival biotype not described); outcome possibly assessed by an investigator involved in the treatment; no reproducibility data; methods used to assess the outcome unclear; no actual data on the outcome
Chen et al. (2007), RCTPatients not treated according to same intervention (with or without connective tissue graft); no blinding described; methods used to assess the outcome unclear; no reproducibility data; no actual data on the outcome at the final re-assessment; no significance testing; high risk for selective loss to follow-up
Block et al. (2009), RCTPatients characteristics incomplete (age not described); site characteristics incomplete (reasons for tooth loss, gingival biotype not described); disparities between the groups in terms of patient or site characteristics not evaluated; patients not treated according to same intervention (flap or flapless surgery, AB or AL); outcome not clearly described; unclear whether an intention-to-treat analysis was performed; high risk for selective loss to follow-up
Cooper et al. (2010)Case seriesSite characteristics incomplete (reasons for tooth loss, gingival biotype not described); unclear whether patients were consecutively treated; patients not treated according to same intervention (flap or flapless surgery); outcome possibly assessed by an investigator involved in the treatment; inadequate methods used to assess the outcome (clinical crown length measured on provisional and permanent restoration); no reproducibility data; outcome not clearly described

Finally, 13 papers could be identified (Kan et al. 2003, 2011, Canullo & Rasperini 2007, De Rouck et al. 2008, 2009, Lops et al. 2008, Romeo et al. 2008, Canullo et al. 2009, Cordaro et al. 2009, Tortamano et al. 2010, Cosyn et al. 2011, Pieri et al. 2011, Raes et al. 2011).

The papers by Kan et al. (2003, 2011) related to the same study sample with different follow-up. The same applied to the studies by De Rouck et al. (2008) and Cosyn et al. (2011).

Nine studies were case series (Kan et al. 2003, 2011, Canullo & Rasperini 2007, De Rouck et al. 2008, Lops et al. 2008, Romeo et al. 2008, Tortamano et al. 2010, Cosyn et al. 2011, Raes et al. 2011) and four were RCTs (Canullo et al. 2009, Cordaro et al. 2009, De Rouck et al. 2009, Pieri et al. 2011).

Only Canullo & Rasperini (2007) did not provide information on the reasons for tooth loss. Cases where the tooth had been extracted because of advanced periodontal disease were specifically excluded in the study by Lops et al. (2008), Romeo et al. (2008) and Tortamano et al. (2010).

All studies related to maxillary implants. Three studies related to maxillary as well as mandibular implants (Lops et al. 2008, Romeo et al. 2008, Cordaro et al. 2009). Pieri et al. (2011) only included premolar replacements in the upper jaw.

Altogether data pertaining to six different implant systems were available. The most frequently used system was Replace Select® by Nobel Biocare (Göteborg, Sweden) (Kan et al. 2003, 2011, De Rouck et al. 2008, 2009, Cosyn et al. 2011).

In all but two studies (Tortamano et al. 2010, Pieri et al. 2011) information on the gingival biotype was provided. In all papers surgical (flap/flapless surgery, socket grafting) and restorative procedures (immediate implant crown) were described.

Inter-proximal recession

Only in two studies the frequency of advanced inter-proximal recession was reported (Canullo et al. 2009, Cosyn et al. 2011) (Table 3). For mesial and distal papillae this occurred in 0–18%, 0–27% respectively, of the cases.

Table 3. Experimental characteristics and results of prospective clinical studies on single immediate implant treatment
AuthorsStudy designImplant systemFollow-up (mo)No of implants/No of patientsGingival biotypeFlap/flaplessSocket graftingImmediate implant crownFill of the embrasure spaceInter-proximal recession (mean)Midfacial recession (mean)Pink aesthetic scorePatient's aesthetic appreciation
  1. a

    Negative value indicates tissue gain.

  2. b

    Percentage of cases showing complete fill of the embrasure space at study termination.

  3. RCT, randomized controlled trial; RPD, removable partial denture; mo, months; Membr, membrane; X, xenograft; AB, autogenous bone; M, mesial; D, distal; NS, non significant.

Kan et al. 2003, Case seriesReplace select1235/35Thin & thickFlaplessNoYes/M: 0.55 mm D: 0.39 mm0.55 mm/Mean 9.9/10
Kan et al. 2011, Case seriesReplace select24–9635/35Thin & thickFlaplessNoYes/M: 0.22 mm D: 0.21 mm1.13 mm/11% unsatisfied
Canullo & Rasperini 2007, Case seriesDefcon18–3610/9Thin & thickFlaplessYes (AB & X if gap >1 mm)Yes/M: −0.40 mma D: NSNS//
De Rouck et al. 2008, Case seriesReplace select1230/30ThickFlapYes (X)Yes/M: 0.41 mm D: NS0.53 mm/Mean 93/100
Cosyn et al. 2011, Case seriesReplace select3625/25ThickFlapYes (X)Yes/M: NS 4% >1 mm D: NS 16% >1 mm0.34 mm 8% >1 mmMean 10.48 16% ≤7/
Lops et al. 2008, Case seriesAstra tech1246/46ThickFlapNoNoM+D: 68%b ////
Romeo et al. 2008, Case seriesStraumann1248/48Thin & thickFlapNoNoM+D: 67%b ////
Canullo et al. 2009, RCT: conical connection & platform switchGlobal24–2711/11Thin & thickFlaplessYes (X if gap >1 mm)Yes/M: NS 0%>1 mm D: NS 0%>1 mmNS 0%>1 mm//
Flat-to-flat connectionGlobal24–2711/11Thin & thickFlaplessYes (X if gap >1 mm)Yes/M: 0.77 mm 18%>1 mm D: 1 mm 27%>1 mm0.45 mm 0%>1 mm//
Cordaro et al. 2009, RCT: Non-submergedStraumann1216/16Thin & thickFlapNoNo/M: 0.83 mm D: 0.63 mm0.73 mm 53%>1 mm//
SubmergedStraumann1214/14Thin & thickFlapNoNo/M: 0.96 mm D: 0.82 mm0.82 mm 64%>1 mm//
De Rouck et al. 2009, RCT: Non-submerged & crownReplace select1224/24ThickFlapYes (X)Yes/M: 0.44 mm D: 0.31 mm0.41 mm/Mean 93/100
Submerged & RPDReplace select1225/25ThickFlapYes (X & membr)No/M : 0.43 mm D : 0.53 mm1.16 mm/Mean 91/100
Tortamano et al. 2010, Case SeriesStraumann1812/12?FlaplessNoYes/M: NS D: NSNS//
Pieri et al. 2011, RCT: conical connection & platform switchSamo smiler1220/20?FlaplessYes (AB & X)Yes/M: 0.24 mm D: 0.28 mm0.61 mm//
Flat-to-flat connectionSamo smiler1220/20?FlaplessYes (AB & X)Yes/M: 0.33 mm D: 0.33 mm0.73 mm//
Raes et al. 2011 Case seriesAstra tech1216/16Thick5 flap/11 flaplessNoYes/M: NS D: NSNS 7% >1 mmMean 10.33 13% ≤7/

Mean inter-proximal recession was frequently reported (11/13) and was low in all studies (<1 mm) suggesting limited risk for advanced inter-proximal recession. In one study even some tissue gain was observed (Canullo & Rasperini 2007). The few results on fill of the embrasure space also indicated limited risk for advanced inter-proximal recession with complete fill in nearly 70% of the cases (Lops et al. 2008, Romeo et al. 2008).

Two studies showed a key impact of the tooth-to-implant distance and the level of the contact point in relation to the bone crest on papilla height (Lops et al. 2008, Romeo et al. 2008). One study demonstrated significantly more incomplete papillae in patients with a thin-scalloped gingival biotype (Romeo et al. 2008). However, the changes in papilla height over time were found to be comparable for patients with a thick and thin-scalloped gingival biotype (Kan et al. 2011). Finally, Canullo et al. (2009) demonstrated in a RCT significantly less inter-proximal recession for implants with a conical connection and platform switch when compared with implants with a flat-to-flat connection and without abutment diameter reduction. However, this could not be confirmed by another RCT (Pieri et al. 2011).

Midfacial recession

Immediate implant crown

In four studies the frequency of advanced midfacial recession was actually reported (Canullo et al. 2009, Cordaro et al. 2009, Cosyn et al. 2011, Raes et al. 2011) (Table 3). Advanced midfacial recession was an infrequent finding affecting <10% of the implants in all but one study. Cordaro et al. (2009) demonstrated high risk (≥53%). The fact that an immediate implant crown was not installed in that particular study in contrast with the others, may explain the disparity. There is evidence from a RCT to support a preserving effect of an immediate implant crown on midfacial mucosa level following IIT (on average 0.75 mm less midfacial recession) (De Rouck et al. 2009).

Flapless surgery

Midfacial mucosa level was not affected by implant surgery in four studies (Canullo & Rasperini 2007, Canullo et al. 2009, Tortamano et al. 2010, Raes et al. 2011) (Table 3). In two of these investigations the gap between the implant and bone wall was not filled with a grafting material (Tortamano et al. 2010, Raes et al. 2011). Hence, the need for socket grafting to limit the amount of midfacial recession seemed inconclusive. On the other hand, all four studies were related to immediate implant installation via flapless surgery. Raes et al. (2011) demonstrated significantly less midfacial recession following a flapless approach when compared with flap surgery.

Gingival biotype

Mean midfacial level showed acceptable shrinkage (<1 mm) following IIT in all but one study (Table 3). In the paper by Kan et al. (2011) mean midfacial recession amounted to 1.13 mm. A significant difference could be demonstrated between patients with a thick gingival biotype (mean 0.56 mm) and thin-scalloped gingival biotype (mean 1.50 mm). This is in accordance with Cordaro et al. (2009) showing advanced midfacial recession in 38% and 85% of the patients with a thick and thin-scalloped gingival biotype respectively.

Implant-specific parameters

The impact of implant-specific parameters on midfacial recession was investigated in two RCTs (Table 3). Canullo et al. (2009) demonstrated significantly less midfacial recession for implants with a conical connection and platform switch when compared with implants with a flat-to-flat connection and without abutment diameter reduction. However, this could not be confirmed by another RCT (Pieri et al. 2011).

Aesthetic aspects of treatment outcome

In two studies soft tissue aesthetics were rated using the pink aesthetic score by Fürhauser et al. (2005) (Cosyn et al. 2011, Raes et al. 2011) (Table 3). In both papers mean pink aesthetic score was 10/14. A score of 7 or less was considered an aesthetic failure as earlier proposed (Cosyn et al. 2010) and was found in 13–16% of the cases.

In three studies patient's aesthetic appreciation was assessed using a questionnaire with a 0–10 score (Kan et al. 2003) or visual analogue scales (De Rouck et al. 2008, 2009) (Table 3). Mean appreciation values were high in these studies (mean 9.9/10 or ≥91/100). On the other hand, 11% of the patients were unsatisfied because of advanced midfacial recession in a recent paper by Kan et al. (2011).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and Methods
  5. Results
  6. Discussion
  7. References

The purpose of this study was to systematically review the available literature on the frequency of advanced recession following single IIT.

Although the frequency of advanced inter-proximal recession was clearly underexposed in research, mean inter-proximal recession was <1 mm in all studies indicating limited risk following IIT. Two studies identified the tooth-to-implant distance and the level of the contact point in relation to the bone crest as key factors for maintaining papillae (Lops et al. 2008, Romeo et al. 2008). Since periodontal disease affects the level of the bone crest, periodontitis patients may be considered at risk for papilla loss. In a recent study on various modalities of single implant treatment, tooth loss because of periodontal disease was found a major risk factor for incomplete papillae (Cosyn et al. 2012). Note that cases where the tooth had been extracted because of advanced periodontal disease were only specifically excluded in 3 of 13 studies (Lops et al. 2008, Romeo et al. 2008, Tortamano et al. 2010).

Another primary outcome variable of the present study was the frequency of advanced midfacial recession. In a recent review article Chen & Buser (2009) concluded that advanced midfacial recession is common following IIT. In three of four studies with data on the parameter of interest, advanced midfacial recession was an infrequent finding affecting <10% of the implants (Canullo et al. 2009, Cosyn et al. 2011, Raes et al. 2011). However, in contrast with Chen & Buser (2009), we only included prospective studies on IIT in patients with an intact buccal bone wall. As shown earlier, patients with a facial osseous defect may not be considered candidates for IIT as advanced midfacial recession seems inevitable (Kan et al. 2007). Even in case of an intact buccal bone wall, proper diagnosis remains important. In this respect, patients with a thin-scalloped gingival biotype have been shown to be at risk for midfacial recession as reported in two studies (Cordaro et al. 2009, Kan et al. 2011). This may not be surprising because this biotype reflects the limited underlying bone support. As the buccal bone wall in these patients is predominantly built up by bundle bone that entirely resorbs following tooth loss and regardless of implant placement, midfacial recession may be a logic consequence. Hence, IIT should be avoided in patients with a thin-scalloped gingival biotype.

Apart from diagnostic considerations, clinicians should also take into account aspects specifically relating to implant surgery in extraction sockets. A correct three-dimensional implant positioning has been considered important for predicable soft tissue levels (Buser et al. 2004), which may be hampered by the alveolar socket. An association of buccal malpositioning and midfacial recession has been described (Chen et al. 2007, 2009) and calls for experienced and skilled surgeons when pursuing IIT. Another surgical aspect relates to the opening procedure. Remarkably, midfacial mucosa level was not affected by implant surgery in four studies and in all these a flapless approach was used (Canullo & Rasperini 2007, Canullo et al. 2009, Tortamano et al. 2010, Raes et al. 2011). One study demonstrated significantly less midfacial recession following flapless surgery (Raes et al. 2011), which is in line with a pre-clinical study by Blanco et al. (2008) showing a trend towards less recession and smaller biologic width dimensions for flapless procedures.

Finally, restorative aspects may also have an impact on the development of midfacial recession following IIT. There is evidence from a RCT demonstrating a preserving effect of an immediate implant crown on midfacial mucosa level (De Rouck et al. 2009). This could be confirmed by four studies with data on the frequency of advanced midfacial recession (Canullo et al. 2009, Cordaro et al. 2009, Cosyn et al. 2011, Raes et al. 2011). In three of these studies an immediate implant crown was installed and advanced midfacial recession was found in <10% of the implants (Canullo et al. 2009, Cosyn et al. 2011, Raes et al. 2011). Immediate provisionalization was not performed in another study demonstrating high risk (≥53%) (Cordaro et al. 2009).

In 2005, an objective rating system was introduced for the aesthetic evaluation of peri-implant tissues (Fürhauser et al. 2005) around single implants and two studies could be identified using this method (Cosyn et al. 2011, Raes et al. 2011). In spite of the fact that in these studies patients had been carefully selected and treated by experienced clinicians according to delineated protocols, 13–16% of the cases could be considered aesthetic failures. As shown by a recent study (Cosyn et al. 2012), this may also apply to other modalities of single implant treatment. Interestingly, patients seem less critical in terms of aesthetics as demonstrated by high aesthetic appreciation scores.

It would be interesting from a scientific and clinical point of view to have information on recession following single implant treatment in healed bone with the status prior to tooth extraction as a reference. Only as such the total amount of recession, being the result of post-extraction remodelling and implant treatment, may be properly assessed and compared with the amount of recession following IIT. Even though implant surgery in healed bone may be considered the standard approach, only two studies provided such information to our knowledge (Block et al. 2009, van Van Kesteren et al. 2010). As one of these studies was excluded in this review because of quality concerns (Block et al. 2009) and the other only demonstrated 6-month data (Van Kesteren et al. 2010), definitive conclusions may be premature. Future research should focus on soft tissue dynamics following conventional implant treatment with appropriate baseline registration. Long-term RCTs would be meaningful to investigate the impact of the treatment concept on recession.

In this systematic review eligible studies were rated on their quality using specific study-design related forms designed by the Dutch Cochrane Collaboration. This method was also used by den Hartog et al. (2008) to evaluate the outcome of immediate, early and conventional single implant treatment. Note that other checklists based on the CONSORT statement for RCTs (Moher et al. 2010) or STROBE statement for case series (Von Elm et al. 2007) could also have been used to evaluate methodological background. Albeit one method may be considered more detailed than another, we believe that the papers we excluded would have been omitted in any quality assessment as clear data on the outcome were missing in all five.

In conclusion, this systematic search identified 13 of 171 papers on the basis of eligibility and quality criteria with data on inter-proximal and/or midfacial recession following single IIT. Few studies reported on the primary outcome variables of interest (4/13). Hence, the results of this systematic review should be interpreted within this context. On the other hand, mean inter-proximal recession was frequently reported (11/13) and was <1 mm in all studies suggesting limited risk for advanced inter-proximal recession. Low risk (<10%) for advanced midfacial recession was found in patients with an intact buccal bone wall and thick gingival biotype, treated by means of flapless surgery and an immediate implant crown. Proper risk assessment addressing diagnostic, surgical and restorative aspects is mandatory to avoid compromised outcome.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and Methods
  5. Results
  6. Discussion
  7. References
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Clinical Relevance

Scientific rationale for the study: Since it has been stated that midfacial recession is common following immediate implant treatment (IIT), the purpose of this systematic review was to study the frequency of advanced midfacial recession (>1 mm).

Principal findings: The frequency of advanced midfacial recession was low (<10%) in patients with an intact buccal bone wall and thick gingival biotype, treated by means of flapless surgery and an immediate implant crown.

Practical implications: IIT may be considered a predictable procedure when proper risk assessment is performed addressing diagnostic, surgical and restorative aspects.