Review suggests little difference in failure rates of immediate or early loaded implants placed using a flapless technique

Cross section of a dental implant

Yesterday we considered a review which compared flapless and flapped placement of implants. (Dental Elf 8th July 2014). Today we are looking at one of the other reviews mentioned. The am of this review to evaluate the effectiveness and safety of immediate loading (within 3 days) versus early loading (after 6 weeks to 2 months) of dental implants placed by using the flapless procedure.

Searches were conducted in the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CNKI database, VIP database (Chongqing VIP information Co., Ltd.), WANFANG Database (Beijing Wanfang Data Co., Ltd.) and the World Health Organization International Clinical Trials Registry Platform Search Portal. References of identified articles were also searched. Randomised controlled trials (RCTs) that compared the efficacy of immediate loading (IL) with early loading (EL) of flapless placed implants were considered. Studies with participants who were either partially or completely edentulous, different definitions of IL or EL, and all types of implants and implant-supported prostheses were included. Study selection, data abstraction and risk of bias assessment was carried out independently by two authors.

The primary outcomes were implant failure (the presence of any mobility of implants and/or infection that dictates implant removal) and peri-implant marginal bone-level changes. Secondary outcomes were patient satisfaction and biologic or prosthetic complications.

  • 6 papers reporting 4 trials involving 180 participants were included.
  • Post loading follow up ranged from 1-4 years.
  • 1 trial reported no implant failures at 1 and 3 years of follow up
  • 3 trials reported no statistically significant differences between IL and EL groups.
  • implant failure rate in the IL and EL groups ranged from 0.0% to 3.3%.
  • No statistically significant differences were found in, peri-implant marginal bone-level changes, or complications between the 2 groups.
  • Participants in the IL group were reported to have significantly more satisfaction than those in the EL group for 2 trials.In another trial, the investigators revealed a similar trend, but with no statistically significant difference.

The authors concluded

For selected patients with sufficient bone quantity and good bone quality, success is possible with IL or EL procedures after flapless placement of dental implants. There were no differences seen in implant failure rates, peri-implant marginal bone-level changes, and complications between the 2 procedures; whereas patients preferred IL. However, because of the small sample size, the currently included evidence was insufficient to fully assess the optimal loading protocol for flapless-placed implants.


This review compares two different loading regimes following flapless implant placement. Esposito et al compared the outcomes for different implant loading times in a recent update of a Cochrane review (2013) . The Cochrane review included some 45 RCTs but although it found no convincing evidence of a clinically important difference in prosthesis failure, implant failure, or bone loss associated with different loading times of implants. The quality of the available evidence was assessed as very low due to high and unclear risk of bias of primary studies so they recommended that the findings be treated with caution.   The current review only included 4 small studies the best of which was assessed as moderate evidence by the reviewers so this evidence should also be treated cautiously.


Xu L, Wang X, Zhang Q, Yang W, Zhu W, Zhao K. Immediate versus early loading of flapless placed dental implants: A systematic review. J Prosthet Dent. 2014 May 12. pii: S0022-3913(14)00135-8. doi: 10.1016/j.prosdent.2014.01.026. [Epub ahead of print] Review. PubMed PMID: 24831750.

Esposito M, Grusovin MG, Maghaireh H, Worthington HV. Interventions for replacing missing teeth: different times for loading dental implants. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD003878. DOI: 10.1002/14651858.CD003878.pub5.

Dental Elf – 8th July 2014 -Dental implants placement flapless or not?

Dental Elf -10th April 2013 – No convincing evidence of a clinically important difference with different loading times of implants

Dental Elf -11th Nov 2013 – Same day loading for mandibular dental implants had comparable outcomes to delayed loading


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