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Dental Medicine and Oral Health Sciences

No clinically meaningful difference in implant survival rates between immediate vs delayed protocols

Clinical Question: In partly edentulous/edentulous adults, what is the effect of implants placed in molar sites immediately after extraction on bone osseointegration compared to implant placement in 3-6 months after extraction?

Clinical Bottom Line:  The evidence for the two systematic reviews indicate that there is no clinically meaningful difference in implant survival between immediate and delayed implant placement protocols within the follow up period ranging from 12-120 months. This suggests that clinically the implant survival rate between these two implant placement protocols are essentially similar. The evidence is compromised by lack of clinical precision of the results (Cosyn et al.) and by unclear or clearly defined reporting bias, detection bias, selection bias due to random sequence generation, selection bias due to allocation concealment, selective reporting bias as well as long range of follow up time. Given these limitations, however, these results are highly applicable to the Canadian population considering all factors such as costs, benefits and harms, and esthetics.  In the future, we need more studies with rigorous methodology and less risk of biases. Additionally, more studies are needed that look specifically at molar implant sites (rather than molar and premolar, or molar and anterior, sites).

Evidence search:

("Immediate Dental Implant Loading"[Mesh] OR (immediate[tiab] AND (loading[tiab] or placement[tiab]) and implant[tiab])) AND ("Molar"[Mesh] or molar[tiab])

Search date: 18 Feb 2020; PubMed yield: 16 evidence sources; Additional search: TRIP Database, Journal of Evidence-based Dentistry

Author, year Source of evidence Population Characteristics Methods
1.

Canellas et al., 2019

PMID: 31522823

Systematic review & meta-analysis

(16 RCTs)

Population: Healthy patients requiring tooth extractions

Age/Gender: Not reported

Sample size, total:  N=444; 580 implant surgeries

Location/Setting: Not reported

Search: Pubmed/Medline, Cochrane Library, EMBASE, Web of Science, Scopus, LILACS

Intervention: immediate implant placement (IIP)

Control: delayed implant placement (DIP)

Primary Outcome: implant survival; implant esthetic

Follow up: at least 1 year (ranging 12-120 months)

 

Key Results

MD =0.03 (95% CI 0.0025-0.0647)

Evidence Quality

There is a 3% increased risk of failure in patients receiving implants via immediate vs delayed implant placement protocol within 12-120 months period. The results are statistically significant, not clinically meaningful (threshold of clinical meaningfulness of 4%) and not clinically precise.

Strengths: six databases and grey literature, arbitrator present, no language or date restrictions, MeSH terms and key words, blinding of reviewers, PRISMA flow diagram (with reasons of study exclusion), validated risk assessment tool (Cochrane Collaboration of bias), meta-analysis, nine RCTs. Regarding heterogeneity, (1) all parameters of the PICOT in the studies included where in accord with the PICOT of the systematic review, (2) the effect sizes varied between studies but were consistently located on the same side of the forest plot, (3) the confidence intervals  overlapped for most studies, and (4) the I2 estimate is 3% (indicates low heterogeneity).

Limitations: eight studies had unclear or high risk of reporting bias; four studies either had unclear or clearly defined selection bias; two studies had attrition bias; unclear if publication bias was assessed.

Perspectives: more RCTs with rigorous methodology, bigger sample sizes, and lower risks of bias are needed.

 

Author, year Source of evidence Population Characteristics Methods
 

2. Cosyn et al., 2019


PMID: 30624808

Systematic review & meta-analysis
(3 RCTs; 5 NRSs)

Population: Adult patients in need of a single implant

Age/Gender: mean age of 40-55 years

Sample size: N=512; 517 total implants

Location/Setting: Not reported

Search: Pubmed, Web of Science, EMBASE, Cochrane library

Intervention: immediate implant placement (IIP)

Control: delayed implant placement (DIP)

Primary Outcome: implant survival

Follow up: at least 1 year (ranging 12-96 months)

 

Key Results

MD =-0.0396 (95% CI - 0.0693, 0.0297)

Evidence Comments

There is a 4% increased risk of failure in patients receiving implants via immediate vs delayed implant placement protocol within 12-96 months period. The results are not statistically significant, not clinically meaningful (threshold of clinical meaningfulness of 4%) and not clinically precise.

Strengths: four databases, hand search, grey literature search, arbitrator present, MeSH terms and key words, flow chart of search strategy, well-defined exclusion/inclusion criteria, two independent reviewers, validated tool for risk of bias assessment (Cochrane Collaboration), meta-analysis, eight included studies, publication bias assessed. Heterogeneity: (1) there is no heterogeneity among included studies with regards to the study design (PICOT), (2) the effect sizes of individual studies (mapped on forest plots) show a significant degree of overlap, (3) the confidence intervals of most included studies have a similar range, and (4) the I2 estimate is 0% for all survival rate comparisons (indicating low statistical heterogeneity).

Limitations: Seven studies had a high risk of detection bias; five studies had a high risk of selection bias due to random sequence generation; six studies had a high/unclear risk of selection bias due to allocation concealment; and five studies had an unclear risk of selective reporting bias. Huge variation in follow up time: 12 to 96 months.

Perspectives: more RCTs with rigorous methodology, bigger sample sizes, and lower risks of bias are needed.

Applicability

These results are applicable to healthy partly edentulous/edentulous adults seeking implant intervention in Canada. The intervention is feasible in the local setting as the instruments/equipment, personal needed and training do not differ from the ones practiced in Canada. All patient important outcomes were considered, and no clear adverse effects were noted. The follow up time was at a minimum of one-year post-operation, which is sufficient to see effect and consistent to the guidelines in Canada, where implants should be monitored after one year, and ideally at every recall.
The results did not address the costs associated with the intervention and comparison. For both IIP and DIP costs are individualized based on the case. The steps associated with DIP may include additional bone graphing as well as an additional interim restoration. These steps / procedures infer additional charges, whether these expenses will be absorbed by the clinician or charged to the patient will depend on the clinician.
IPP has it’s advantages by being cheaper, requiring less appointments, having similar esthetics to DIP, and a shorter time for the patient to receive their final restoration. However, IIP may be associated with a 3-4% higher risk of failure (which is not clinically meaningful) and may be associated with a greater papillary recession. Since IPP has a lower success rate (greater chance for the implant to fail), and implant failure requires costly treatment, the pros/cons must be discussed with the patient. Overall immediate implant placement is a viable option to patients and has already been implemented into many Canadian practices.
 
Authors:  Danny Kim, John Hyun, Zenas Kuate-Defo, Keelan O’Malley (DMD3 students)

Faculty mentor(s):  Dr. Doaa Taqi, Dr. Raphael de Souza, Dr. Svetlana Tikhonova

Acknowledgments: Martin Morris (McGill librarian)

Date: April 02, 2020

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