Effects of immediate and delayed loading protocols on marginal bone loss around implants in unsplinted mandibular implant-retained overdentures: a systematic review and meta-analysis

Abstract

Background: Immediate loading has recently been introduced into unsplinted mandibular implant-retained overdentures for the management of edentulous patients due to their increasing demand on immediate aesthetics and function. However, there is still a scarcity of meta-analytical evidence on the efficacy of immediate loading compared to delayed loading in unsplinted mandibular implant-retained overdentures. The purpose of this study was to compare the marginal bone loss (MBL) around implants between immediate and delayed loading of unsplinted mandibular implant-retained overdentures.

Methods: Randomized controlled trials (RCTs), controlled clinical trials (CCTs), and cohort studies quantitatively comparing the MBL around implants between immediate loading protocol (ILP) and delayed loading protocol (DLP) of unsplinted mandibular overdentures were included. A systematic search was carried out in PubMed, EMBASE, and CENTRAL databases on December 02, 2020. "Grey" literature was also searched. A meta-analysis was conducted to compare the pooled MBL of two different loading protocols of unsplinted mandibular overdentures through weighted mean differences (WMDs) with 95% confidence intervals (95% CIs). The subgroup analysis was performed between different attachment types (i.e. Locator attachment vs. ball anchor). The risk of bias within and across studies were assessed using the Cochrane Collaboration's tool, the Newcastle-Ottawa scale, and Egger's test.

Results: Of 328 records, five RCTs and two cohort studies were included and evaluated, which totally contained 191 participants with 400 implants. The MBL of ILP group showed no significant difference with that of DLP group (WMD 0.04, CI - 0.13 to 0.21, P > .05). The subgroup analysis revealed similar results with Locator attachments or ball anchors (P > .05). Apart from one RCT (20%) with a high risk of bias, four RCTs (80%) showed a moderate risk of bias. Two prospective cohort studies were proved with acceptable quality. Seven included studies have reported 5.03% implant failure rate (10 of 199 implants) in ILP group and 1.00% failure rate (2 of 201 implants) in DLP group in total.

Conclusions: For unsplinted mandibular implant-retained overdentures, the MBL around implants after ILP seems comparable to that of implants after DLP. Immediate loading may be a promising alternative to delayed loading for the management of unsplinted mandibular implant-retained overdentures. PROSPERO registration number: CRD42020159124.

Keywords: Delayed loading; Immediate loading; Implant-retained overdenture; Marginal bone loss; Meta-analysis; Systematic review.

Fig. 1

PRISMA flow program for study selection of this systematic review and meta-analysis process

Fig. 2

Quality assessment and risk of bias of the included RCTs assessed by review authors with the RevMan v.5.3 software: a risk of bias summary showing review authors' judgments about risk of bias items for each included RCT; b risk of bias graph showing review authors' judgments about each item's risk of bias presented as percentages for all included RCTs

Fig. 3

Forest plot generated by Stata MP v.14 software for comparison of immediate loading protocol versus delayed loading protocol with regard to marginal bone loss. ILP, immediate loading protocol; DLP, delayed loading protocol

Fig. 4

Forest plot generated by Stata MP v.14 software for subgroup comparison of immediate and delayed loading protocols with regard to marginal bone loss in Locator attachments subgroup and ball anchors subgroup. ILP, immediate loading protocol; DLP, delayed loading protocol

Fig. 5

Sensitivity analyses generated by Stata MP v.14 software for comparison between immediate and delayed loading protocols with regard to marginal bone loss