journal of dentistry 42 (2014) 10521059

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Review

Immediate nonfunctional versus immediate

functional loading and dental implant failure rates:
A systematic review and meta-analysis
Bruno Ramos Chrcanovic a,*, Tomas Albrektsson b, Ann Wennerberg a
a
b

Department of Prosthodontics, Faculty of Odontology, Malmo University, Malmo, Sweden

Department of Biomaterials, Goteborg University, Goteborg, Sweden

article info

abstract

Article history:

Objectives: The purpose of the present review was to test the null hypothesis of no difference

Received 20 March 2014

in the implant failure rates, postoperative infection, and marginal bone loss for patients

Received in revised form

being rehabilitated using dental implants with immediate nonfunctional loading (INFL)

19 June 2014

compared to immediate functional loading (IFL), against the alternative hypothesis of a

Accepted 24 June 2014

difference.
Methods: An electronic search without time or language restrictions was undertaken in
March 2014. Eligibility criteria included clinical human studies, either randomized or not.

Keywords:

The estimates of relative effect were expressed in risk ratio (RR) and mean difference (MD) in

Dental implants

millimeters.

Immediate loading

Results: 1059 studies were identified and 11 studies were included, of which 7 were of high

Nonfunctional loading

risk of bias, whereas four studies were of low risk of bias. The results showed that the

Functional loading

procedure used (nonfunctional vs. functional) did not significantly affect the implant failure

Implant failure rate

rates (P = 0.70), with a RR of 0.87 (95% CI 0.441.75). The wide CI demonstrates uncertainty

Marginal bone loss

about the effect size. The analysis of postoperative infection was not possible due to lack of

Meta-analysis

data. No apparent significant effects of non-occlusal loading on the marginal bone loss (MD
0.01 mm, 95% CI -0.040.06; P = 0.74) were observed.
Conclusions: The results of this study suggest that the differences in occlusal loading
between INFL and IFL might not affect the survival of these dental implants and that there
is no apparent significant effect on the marginal bone loss.
Clinical Significance: There has been a controversy concerning whether dental implants
should be subjected to immediate functional or nonfunctional loading. As the philosophies
of treatment may alter over time, a periodic review of the different concepts is necessary to
refine techniques and eliminate unnecessary procedures. This would form a basis for
optimum treatment.
# 2014 Elsevier Ltd. All rights reserved.

* Corresponding author. Department of Prosthodontics, Faculty of Odontology, Malmo University, Carl Gustafs vag 34, SE-205 06, Malmo,
Sweden. Tel.: +46 725 541 545; fax: +46 40 6658503.
E-mail addresses: bruno.chrcanovic@mah.se, brunochrcanovic@hotmail.com (B.R. Chrcanovic).
http://dx.doi.org/10.1016/j.jdent.2014.06.010
0300-5712/# 2014 Elsevier Ltd. All rights reserved.

journal of dentistry 42 (2014) 10521059

1.

Introduction

The desire for fewer surgical interventions and shorter

implant treatment times has led to the development of
revised placement and loading protocols. A healing period of
46 months was initially proposed to ensure osseointegration
of endosseous dental implants.1 With the improvements in
oral implantology resulting in improved prognosis and outcomes, the traditional protocol for implant dentistry has been
constantly reevaluated. Recent steps include reduction of the
treatment time through immediate placement of implants
into fresh extraction sockets2 and by loading the implants
immediately.3 Immediate loading protocols have since been
extensively discussed in the literature and found to be a viable
treatment approach in selected cases.3
Two types of immediate loading have been described in the
literature. One is the immediate functional loading (IFL), or
immediate occlusal loading, which refers to the use of a
temporary or definitive prosthesis seated the same day as the
surgery in occlusal contact with the opposing arch.4 An
alternative approach consists modifying the immediate
temporary restoration to avoid occlusal contacts in centric
and lateral excursions, in order to reduce the early risks of
mechanical overload caused by functional or parafunctional
forces, the immediate nonfunctional loading (INFL), or
immediate non-occlusal loading.5 Thus, the modified restoration would still be involved in the masticatory process, but the
mechanical loading stress is reduced.6
Theoretically, it has been suggested that IFL could be
associated with an increased rate of implant failure. Thus,
the aim of this systematic review and meta-analysis was to
compare the survival rate of dental implants submitted to IFL
and INFL protocols, in order to test the hypothesis that the
immediate full occlusal load would compromise or jeopardize the osseointegration process. This study presents a
more detailed analysis of the influence of IFL and INFL
protocols on the implant failure rates, previously assessed in
a systematic review addressing the reasons for failures of
oral implants.7

2.

Materials and methods

This study followed the PRISMA Statement guidelines.8 A

review protocol does not exist.

2.1.

Objective

The purpose of the present review was to test the null

hypothesis of no difference in the implant failure rates,
postoperative infection, and marginal bone loss for patients
being rehabilitated by dental implants with INFL compared to
IFL, against the alternative hypothesis of a difference.

2.2.

Search strategies

An electronic search without time or language restrictions was

undertaken in March 2014 in the following databases: PubMed,
Web of Science, and the Cochrane Oral Health Group Trials

1053

Register. The following terms were used in the search strategy

on PubMed:
{Subject AND Adjective}
{Subject: (dental implant OR dental implant failure OR
dental implant survival OR dental implant success [text
words])
AND
Adjective: (immediate occlusal loading OR immediate nonocclusal loading OR immediate functional loading OR immediate nonfunctional loading [text words])}
The following terms were used in the search strategy on
Web of Science:
{Subject AND Adjective}
{Subject: (dental implant OR dental implant failure OR
dental implant survival OR dental implant success [title])
AND
Adjective: (immediate occlusal loading OR immediate nonocclusal loading OR immediate functional loading OR immediate nonfunctional loading [title])}
The following terms were used in the search strategy on the
Cochrane Oral Health Group Trials Register:
(dental implant OR dental implant failure OR dental
implant survival OR dental implant success AND (immediate occlusal loading OR immediate non-occlusal loading OR
immediate functional loading OR immediate nonfunctional loading))
A manual search of dental implant-related journals,
including British Journal of Oral and Maxillofacial Surgery, Clinical
Implant Dentistry and Related Research, Clinical Oral Implants
Research, European Journal of Oral Implantology, Implant Dentistry,
International Journal of Oral and Maxillofacial Implants, International Journal of Oral and Maxillofacial Surgery, International Journal
of Periodontics and Restorative Dentistry, International Journal of
Prosthodontics, Journal of Clinical Periodontology, Journal of Dental
Research, Journal of Dentistry, Journal of Oral Implantology, Journal of
Craniofacial Surgery, Journal of Cranio-Maxillofacial Surgery, Journal
of Maxillofacial and Oral Surgery, Journal of Oral and Maxillofacial
Surgery, Journal of Oral Rehabilitation, Journal of Periodontology, and
Oral Surgery Oral Medicine Oral Pathology Oral Radiology and
Endodontology, was also performed.
The reference list of the identified studies and the relevant
reviews on the subject were also scanned for possible
additional studies. Moreover, online databases providing
information about clinical trials in progress were checked
www.centerwatch.com/clinicaltrials;
(clinicaltrials.gov;
www.clinicalconnection.com).

2.3.

Inclusion and exclusion criteria

Eligibility criteria included clinical human studies, either

randomized or not, comparing implant failure rates in any
group of patients receiving dental implants with non-occlusal
immediate loading compared to occlusal immediate loading.
For this review, implant failure represents the complete loss of
the implant. The exclusion criteria were case reports,
technical reports, animal studies, in vitro studies, and reviews
papers.

1054

2.4.

journal of dentistry 42 (2014) 10521059

Study selection

The titles and abstracts of all reports identified through the

electronic searches were read independently by the three
authors. For studies appearing to meet the inclusion criteria,
or for which there were insufficient data in the title and
abstract to make a clear decision, the full report was obtained.
Disagreements were resolved by discussion between the
authors.

2.5.

Quality assessment

The quality assessment was performed by using the recommended approach for assessing risk of bias in studies included
in Cochrane reviews.9 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 implementation of the schedule of random
assignments by preventing foreknowledge of the forthcoming
allocations), incomplete outcome data (clear explanation of
withdrawals and exclusions), and blinding (measures to blind
study participants and personnel from knowledge of which
intervention a participant received). The incomplete outcome
data will also be considered addressed when there are no
withdrawals and/or exclusions. A study that met all the
criteria mentioned above was classified as having a low risk of
bias, whereas a study that did not meet one of these criteria
was classified as having a moderate risk of bias. When two or
more criteria were not met, the study was considered to have a
high risk of bias.

2.6.

Data extraction and meta-analysis

From the studies included in the final analysis, the following

data was extracted (when available): year of publication, study
design, unicenter or multicenter study, number of patients,
patients age, follow-up, days of antibiotic prophylaxis, mouth
rinse, implant healing period, failed and placed implants,
postoperative infection, marginal bone loss, and implant
surface modification. Contact with authors for possible
missing data was performed.
Implant failure and postoperative infection were the
dichotomous outcomes measures evaluated. Weighted mean
differences were used to construct forest plots of marginal
bone loss, a continuous outcome. The statistical unit for
implant failure and marginal bone loss was the implant, and
for postoperative infection was the patient. 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 random-effects or fixed-effects model.
Where statistically significant (P < .10) heterogeneity is
detected, a random-effects model was used to assess the
significance of treatment effects. Where no statistically
significant heterogeneity was found, analysis was performed
using a fixed-effects model.10 The estimates of relative effect
for dichotomous outcomes were expressed in risk ratio (RR)

and in mean difference (MD) in millimeters for continuous

outcomes, both with a 95% confidence interval (CI). Only if
there were studies with similar comparisons reporting the
same outcome measures was meta-analysis to be attempted.
In the cases where no events (or all events) were observed in
both groups, the study provides no information about relative
probability of the event and is automatically omitted from the
meta-analysis. In such cases, the term not estimable is
shown under the RR column of the forest plot table. The
software used here automatically checks for problematic zero
counts and adds a fixed value of 0.5 to all cells of study results
tables where the problems occur.
A funnel plot (plot of effect size versus standard error) will
be 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 analyzed using the statistical software
Review Manager (version 5.2.8, The Nordic Cochrane Centre,
The Cochrane Collaboration, Copenhagen, Denmark, 2014).

3.

Results

3.1.

Literature search

The study selection process is summarized in Fig. 1. The

search strategy resulted in 1059 papers. The three reviewers
independently screened the abstracts for those articles
related to the focus question. The initial screening of titles
and abstracts resulted in 51 full-text papers; 33 were cited in
more than one search of terms. The full-text reports of the
remaining 18 articles led to the exclusion of 9 articles
because they did not meet the inclusion criteria: 6 articles

Fig. 1 Study screening process.

Table 1 Detailed data of the included studies.

Authors

Study
design

Patients (n)

Patients age
range (average)
(years)

Follow-up
visits (or
range)

Antibiotics/
mouth
rinse (days)

Fully occluding
final restoration
after

Failed/
placed
implants
(n)

Implant
failure
rate (%)

P value
(for
failure
rate)

Marginal
bone loss
(mean  SD)
(mm)

Implant surface modification

(brand)

Observations

Degidi and
Piattelli4

2003

CCT
(unicenter)

151 (116, G1;

65, G2)

1875 (NM)

1, 2, 12, 18,
24, 36, 48, and
60 months

NM

NM

2/224 (G1)
6/422 (G2)

0.9 (G1)
1.4 (G2)

NM

NM (G1)
1.1  0.2
(G2) (n = 87)

Severala

Degidi and
Piattelli16

2005

CCT
(unicenter)

97 (253b) (63,
G1; 34, G2)

2078 (53)

1, 3, 5, 12, 18,
and 24 months

NM

NM

1/135 (G1)
2/253 (G2)

0.7 (G1)
0.8 (G2)

NM

0.7  0.2
(G1 + G2)

Degidi et al.17

2006

CCT
(unicenter)

29 (12, G1;
17, G2)

2365 (52)

12 and 36
months

5 / NM

Mean of 28
weeks

0/23 (G1)
0/119 (G2)

0 (G1)
0 (G2)

NM

1.0  NM
(G1 + G2)

Grit-blasted and acid-etched

(XiVe, Dentsply-Friadent,
Mannheim, Germany)
Porous anodized surface (TiUnite,
Nobel Biocare, Goteborg, Sweden)

Lindeboom
et al.11

2006

RCT
(unicenter)

48 (24, G1;
24; G2)

1978
(42.3  13.1)

1, 2, 4, and 6
weeks, 2, 3, 4,
5, and 6 months,
1 year

Only before
surgery / NP

6 months

3/25 (G1)
2/25 (G2)

12 (G1)
8 (G2)

NM

Machtei
et al.18

2007

CCT
(unicenter)

20 (NM)

3168 (55.7)

7-10 days, 1,
2, 3, 6, and
12 months

7 / 21

12 months

1/26 (G1)
4/23 (G2)

3.8 (G1)
17.4 (G2)

0.2755

Mesial
0.28  0.22 (G1)
0.27  0.2 (G2)
Distal
0.2  0.11 (G1)
0.19  0.15 (G2)
0.91  0.17
(G1 + G2)

No grafted patients
Implants placed in fresh
extraction sockets: 97 (G1),
187 (G2)
No grafted patients
Some implants placed in
fresh extraction sockets
No grafted patients
Some implants placed in
fresh extraction sockets
Only in maxilla (excluding
molar regions)
32 implants grafted (16 from
each group)

Degidi
et al.12

2009

RCT
(unicenter)

82 (155c) (63,
G1; 19, G2)

1878 (54)

3/7

46 months

3/132 (G1)
0/130 (G2)

2.3 (G1)
0 (G2)

NMd

0.5  NM (G1)
0.6  NM (G2)

Cannizzaro
et al.13

2010

RCT
(multicenter)

40 (20, G1;
20, G2)

1855 (39)

4 and 6 months,
1, 2, 3, 4, and 5
years
3, 10, and 14
days, 4/5
months, 1 year

45 months

2/20 (G1)
3/20 (G2)

10 (G1)
15 (G2)

1.0

0.72  0.59 (G1)

0.90  0.48 (G2)

Degidi et al.6

2010

RCT
(unicenter)

50 (25, G1;
25, G2)

3554
(45.1  9.1)

Only before
surgery
(6 days
for the
grafted) / 14
5 / NP

6 months

1/50 (G1)
1/50 (G2)

2 (G1)
2 (G2)

NM

0.987  0.375 (G1)

0.947  0.323 (G2)

Siebers
et al.19

2010

CCT
(unicenter)

45 (76e) (NM)

2285
(52  13)

NM

68 months

4/47 (G1)
1/64 (G2)f

8.5 (G1)
1.6 (G2)

0.083f

NM

Margossian
et al.14

2012

RCT
(unicenter)

80 (117g) (40,
G1; 40, G2)

NM

Only before
surgery / 14

4 months

0/105 (G1)
7/104 (G2)

0 (G1)
6.7 (G2)

NM

NM

Vogl et al.15

2013

RCT
(unicenter)

20 (11, G1;
9, G2)

3370
(54  11.9)

5 / only before
surgery

68 months

0/34 (G1)
0/21 (G2)

0 (G1)
0 (G2)

NM

0.4  0.5 (G1)

0.4  0.4 (G2)

5 and 7 weeks,
6, 12, 24, and
36 months
Mean of 38
months

2, 4, 8, 12, 20,
and 24 weeks,
1 and 2 years
1 week, 1, 2, 3,
6, and 12 months

Sandblasted and etched

(BioComp, BioComp Industries
BV, Vught, The Netherlands)

Acid-etched (Osseotite TG, 3i

Implant Innovations, Palm Beach
Gardens, USA)
Blasted with calcium phosphate
(Maestro, BioHorizons,
Birmingham, USA)
Zirconia sandblasted (Z-Look3, ZSystems, Oensingen, Switzerland)

Grit-blasted and acid-etched

(XiVe Plus, Dentsply-Friadent,
Mannheim, Germany)
Sandblasted and acid-etched
(Camlog Rootline and Screw Line,
Camlog Biotechnologies, Basel,
Switzerland), acid-etched
(Osseotite, Biomet 3i, Palm Beach
Gardens, USA), blasted with HA
and calcium phosphate (Restore
RBM, Lifecore Biomedical,
Chaska, USA)
Acid-etched (Osseotite NT, 3i
Implant Innovations, Palm Beach
Gardens, USA)
Grit-blasted and acid-etched
(XiVe, Dentsply-Friadent,
Mannheim, Germany)

Implants placed in
periodontally susceptible
patients. Xenograft in some
patients
No grafted patients
Some implants placed in
fresh extraction sockets
Use of zirconia implants, 10
patients grafted (5 of each
group), 10 implants placed in
fresh extraction sockets (5 of
each group)
Only in posterior mandible
No grafted patients
No grafted patients
46 implants placed in fresh
extraction sockets

journal of dentistry 42 (2014) 10521059

Published

No grafted patients

Only in posterior mandible.

Use of stereolithographic
tooth-supported guides. No
grafted patients

Frialit 2, IMZ, Frialoc (Friadent, Mannheim, Germany), Branemark (Nobel Biocare, Goteborg, Sweden), Restore (Lifecore Biomedical, Chaska, USA), Maestro (Biohorizons, Birmingham, USA), 3i (Implant Innovations, West Palm Beach, USA).

There were 253 patients in the study, however, in 156 patients the implants were inserted using the traditional technique.
There were 155 patients in the study, however, only in 82 of them the implants were inserted in immediate function.
A P value was 0.196 when a comparison of the implant survival rate between the immediately loaded group and delayed loaded group was performed, but not between the INFL and IFL groups.
e
There were 76 patients in the study, however, only in 45 of them the implants were inserted in immediate function.
f
Unpublished information was obtained by personal communication with one of the authors.
g
There were 117 patients in the study, however, in 37 patients the implants were inserted using the traditional technique.
NMnot mentioned; CCTcontrolled clinical trial; RCTrandomized controlled trial; G1group immediately nonfunctional loaded implants (INFL); G2group immediately functional loaded implants (IFL); NP - not performed.
c

1055

1056

journal of dentistry 42 (2014) 10521059

were conducted in animals, and 3 articles compared nonocclusal vs. occlusal loading, but only in one group the
loading was immediate. Additional hand-searching of the
reference lists of selected studies yielded 2 additional
papers. Thus, a total of 11 publications were included in
the review.

3.3.

Each trial was assessed for risk of bias, and the scores are
summarized in Table 2. Seven studies4,11,12,1619 were judged to
be at high risk of bias and four studies6,1315 of low risk of bias.

3.4.
3.2.

Quality assessment

Meta-analysis

Description of the studies

Detailed data of the eleven included studies are listed in Table

1. Six RCTs,6,1115 and five CCT4,1619 were included in the
meta-analysis. In two studies6,13 both patients and operators/
outcome assessors were blinded to the tested intervention,
whereas in three studies12,14,15 it was unclear whether
blinding was performed. Four studies11,13,15,18 had a followup of up to 1 year.
All studies with available data of patients age included
only adult patients. Eight studies4,6,12,1417,19 did not perform
grafting procedures in any of the patients. One study13 used
only zirconia implants, in another study18 the implants were
inserted in periodontally susceptible patients, in two studies6,15 the implants were inserted only in the posterior
mandible, and in one study11 the implants were inserted only
in the maxilla.
Not every article provided information about the number of
failed implants by group. Unpublished information concerning the number of failed implants in each group was obtained
by personal communication with one of the authors in one
study.19 From the eleven studies, a total of 821 dental implants
received non-occlusal immediate loading, with 17 failures
(2.1%), and 1231 implants received occlusal immediate
loading, with 26 failures (2.1%). Eight studies4,6,11,12,1417 did
not inform whether there was a statistically significant
difference or not between the techniques concerning implant
failure, whereas the other three studies13,18,19 did not find
statistically significant difference. There were no implant
failures in two studies.15,17 Only three studies13,15,17 informed
of the incidence of postoperative infection, all with no
occurrences in a total of 89 patients receiving 237 implants.
Nine studies provided information about the marginal bone
loss.4,6,1113,1518

In this study, a fixed-effects model was used to evaluate the

implant failure, since statistically significant heterogeneity
was not found (P = 0.26; I2 = 21%). The results showed a RR of
0.87 (95% CI 0.441.75; Fig. 2) for the INFL, suggesting that
implant failures in patients receiving implants under the INFL
protocol are 0.87 times likely to happen when compared to
implant failures in patients receiving implants under the IFL
protocol (relative risk reduction of 13% for INFL). However, the
procedure used (INFL vs. IFL) did not significantly affect the
implant failure rates (P = 0.70).
As only three studies13,15,17 informed of the incidence of
postoperative infection, and all with no events, no metaanalysis was possible for this outcome.
Only four studies6,11,13,15 (245 implants) provided information about the marginal bone loss with standard deviation,
necessary for the calculation of comparisons in continuous
outcomes (Fig. 3). A fixed-effects model was used to evaluate
this outcome, since statistically significant heterogeneity was
not found (P = 0.84; I2 = 0%). There was no statistically
significant difference (P = 0.74) between the different techniques concerning the marginal bone loss.

3.5.

Publication bias

The funnel plot did not show asymmetry when the studies
reporting the outcome implant failure were analyzed (Fig. 4),
indicating absence of publication bias.

4.

Discussion

The present study proposed to test the null hypothesis of no

difference in the implant failure rates, postoperative infection,

Table 2 Results of quality assessment.

Authors

Degidi and Piattelli4

Degidi and Piattelli16
Degidi et al.17
Lindeboom et al.11
Machtei et al.18
Degidi et al.12
Cannizzaro et al.13
Degidi et al.6
Siebers et al.19
Margossian et al.14
Vogl et al.15
a

Published

Sequence
generation
(randomized?)

Allocation
concealment

Incomplete
outcome data
addressed

Blinding

Estimated
potential
risk of bias

2003
2005
2006
2006
2007
2009
2010
2010
2010
2012
2013

No
No
No
Yes
No
Yes
Yes
Yes
No
Yes
Yes

Inadequate
Inadequate
Inadequate
Inadequate
Inadequate
Unclear
Adequate
Adequate
Inadequate
Adequate
Adequate

Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes

No
No
No
No
No
Unclear
Yes
Yes
No
Yesa
Yesa

High
High
High
High
High
High
Low
Low
High
Low
Low

Unpublished information was obtained by personal communication with one of the authors.

journal of dentistry 42 (2014) 10521059

1057

Fig. 2 Forest plot of comparison of INFL versus IFL for the event implant failure.

and marginal bone loss for patients being rehabilitated with

dental implants comparing INFL to IFL, against the alternative
hypothesis of a difference.
Concerning the implant failure rates, the idea behind the
concept of keeping the temporary restoration out of occlusion
is to control the load on the prosthesis in order to allow
undisturbed healing. The role of tongue pressure and perioral
musculature may be an underestimated factor in immediately
provisionalized but unloaded implants. Moreover, occlusion
might not be the only determinant of implant survival.11 The
results of the present meta-analysis showed that there was no
statistically significant difference between the INFL and IFL
concerning implant failures. The increase of load, applied to
the prosthesis caused by the presence of the normal occlusal
contact, seems to be unable to jeopardize or alter the healing
process of the implant.6 Some factors may have contributed to
such outcome in some studies, that include the use of a
resilient acrylic resin for the fabrication of the temporary
restoration, the exclusion of parafunctional bruxist patients
from the study, and the splinting of the temporary prosthetic
work. It has been suggested that it is not the absence of loading
per se that is critical for osseointegration, but rather the
absence of excessive micromotion at the interface.17 Micromotion consists of a relative movement between the implant
surface and surrounding bone during functional loading and it
is believed that, above a certain threshold, excessive interfacial micromotion early after the implantation interferes with
local bone healing, predisposing to a fibrous tissue interface,
preventing the fibrin clot from adhering to the implant surface

during healing.20 Splinting the provisional restoration might

have protected the implants from micromotion.15
The small sample size in many studies6,11,13,15,1719 may
also have affected the results concerning implant failure. Even
though the importance of meta-analyses is to increase sample
size of individual trials to reach more precise estimates of the
effects of interventions, in this particular analysis no statistically significant difference was found when comparing these
two techniques concerning the implant failure rates (P = 0.70).
As there is a wide CI for the RR (RR 0.87; 95% CI 0.441.75), the
uncertainty about the effect size is greater than if the CI was
narrower, although there might still be enough precision to
make decisions about the utility of the intervention.9
In four studies11,13,15,18 the patients were followed for a
short period (1 year). Thus, only early failures could be
assessed. A longer follow-up period may lead to an increase in
the failure rate. Moreover, the results found in the studies
differed from each other, and such discrepancies could be due
to factors such as differences in the patients included in the
study or the between clinicians placing and restoring the
implants.
Only three studies13,15,17 provided information regarding
the incidence of postoperative infection, all of them with no
events. Therefore, no meta-analysis was possible for this
outcome.
The third outcome analyzed was the marginal bone loss.
Marginal bone levels might vary with load distribution
patterns between natural teeth and implants, with access
for hygiene instruments in splinted provisional restorations21

Fig. 3 Forest plot of comparison of INFL versus IFL for the event marginal bone loss.

1058

journal of dentistry 42 (2014) 10521059

Fig. 4 Funnel plot for the studies reporting the outcome

event implant failure.

or with iatrogenic manipulation of the implant during initial

healing.22 Early functional loading during the healing phase
may have a positive effect on marginal bone levels. Early
loading stimuli at the bone-implant interface leads to
functional adaptation of the bone (remodeling) and to an
improved differentiation of the bone structures, resulting in a
higher marginal bone level.22,23 However, the present metaanalysis did not find a statistically significant difference
(P = 0.74) between the techniques in what concerns the
marginal bone loss. The reason for that may be the short
postoperative follow-up period of 1 year found in three11,13,15
of the four studies with available data to produce a comparison, and/or the small sample size in all four studies.6,11,13,15
The biological differences in peri-implant tissue responses
between IFL and INFL implants have been analyzed in animal
models, where no differences were observed between the
ultrastructural morphology of the cells at the interface of
implants from both groups in the early phases of osseointegration in minipigs,24 and no statistically significant differences in the bone-to-implant contact percentages were found
between groups, in a study performed in dogs.25
The present meta-analysis included non-RCT studies,
which is not usually performed. Potential biases are likely
to be greater for non-randomized studies compared with
RCTs, so results should always be interpreted with caution
when they are included in reviews and meta-analyses.9 So
what was the reason to include non-randomized studies in the
present meta-analysis? The issue is important because metaanalyses are frequently conducted on a limited number of
RCTs.26 Shrier27 reviewed a random 1% sample of metaanalyses published by the Cochrane Collaboration in 2003 and
found that 6 of 16 reviews included two studies or fewer.
Furthermore, 158 of 183 analyses conducted in 7 additional
studies were limited to two or fewer studies. In meta-analyses
such as these, adding more information from observational
studies may aid in clinical reasoning and establish a more
solid foundation for causal inferences.26 In a meta-analysis,
homogeneity implies a mathematical compatibility between
the results of each individual trial. Narrowing the inclusion

criteria increases homogeneity but also excludes the results of

more trials and thus risks the exclusion of significant data.
One of the strengths of meta-analysis as a technique for
synthesizing research findings on the effectiveness of intervention programs is that it allows those findings to be
systematically compared and contrasted across studies.28
What complicates the investigation is the presence of
confounding variables in the analyzed studies. The use of
grafting in some studies11,13,18 is a confounding factor, as well
as inserting the implants only in periodontally susceptible
patients,18 in particular regions of the mouth, such as only in
the posterior mandible6,15 or only in the maxilla,11 the insertion
of some implants in fresh extraction sockets,4,12,13,16,17,19 the
use of zirconia implants,13 and the insertion of implants from
different brands and surface treatments. Titanium implants
with different surface modifications show a wide range of
chemical, physical properties, and surface topographies and
morphologies, depending on how they are prepared and
handled,2931 while it is not clear whether, in general, one
surface modification is better than the other.32
The results of the present study should be interpreted with
caution considering its limitations. The presence of confounding factors may have affected the long-term outcomes,
regardless of whether the implants were submitted to INFL or
IFL. The impact of such variables on the implant survival rate,
postoperative infection and marginal bone loss outcomes is
difficult to estimate if these factors are not identified
separately between the two different procedures in order to
perform a meta-regression analysis. Therefore, lack of control
of the confounding factors limited the potential to draw robust
conclusions.

5.

Conclusions

The results of this meta-analysis suggest that the differences

in occlusal loading between INFL and IFL might not affect the
survival of these dental implants. There was also no
statistically significant difference between the two techniques
concerning the marginal bone loss.

Acknowledgements
This work was supported by CNPq, Conselho Nacional de
Desenvolvimento Cientfico e TecnologicoBrazil. The authors
would like to thank Dr. Derk Siebers, Dr. Patrice Margossian,
and Dr. Marlene Stopper, who provided us some missing
information about their studies.

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