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The “One Abutment - One Time” Protocol: A Systematic Review and Meta-
Analysis

Article in Journal of Periodontology · June 2017

DOI: 10.1902/jop.2017.170238

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Journal of Periodontology; Copyright 2017 DOI: 10.1902/jop.2017.170238

The “One Abutment - One Time” Protocol: A Systematic Review

and Meta-Analysis
Momen A. Atieh, BDS, MSc, DClinDent PhD*, Andrew Tawse-Smith, DDS,
CertPeriodontology*, Nabeel H. M. Alsabeeha, DMD, MSc, MFDS RCPS (Glasg), PhD†,
Sunyoung Ma, BDS, DClinDent*, Warwick J. Duncan, BDS, MDS, FRACDS, PhD*

*Oral Implantology Research Group, Sir John Walsh Research Institute, Department of Oral
Sciences, Faculty of Dentistry, University of Otago, Dunedin, New Zealand.
†
Prosthetic Section, Ras Al-Khaimah Dental Center, Ministry of Health, Ras Al-Khaimah,
United Arab Emirates.
Background: The use of definitive abutments (DAs) at the time of implant placement has been
introduced to overcome the limitations of dis/reconnection of healing / provisional abutments (PAs). With little
and inconsistent information in the literature regarding the effectiveness of using DAs, the aim of this
systematic review was to examine marginal bone and soft tissue level changes, technical and biological
complications and implant failure associated with the use of DAs and PAs.
Methods: This systematic review was prepared according to the guidelines of Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. MEDLINE, EMBASE, The Cochrane
Central Register of Controlled Trials (CENTRAL), and online trial registers were searched for studies
comparing the use of DAs with PAs. The Cochrane Collaboration risk of bias tool was used to assess the
selected studies and meta-analyses were performed using statistical software.
Results: A total of 1124 citations were identified. Of these, seven trials with 363 dental implants in
262 participants were included in the analysis. The pooled estimates for the marginal bone level changes
showed significant differences between the two prosthetic techniques in favor of using DAs. No significant
differences in soft tissue level changes, technical, biological complications or implant failure rate were found.
Conclusions: Within the limitations of this review, DAs appear to be viable alternative to PAs at the
time of implant placement. The favorable changes in peri-implant marginal bone level associated with use of
DAs should, however, be viewed with caution as its clinical significance is still uncertain.

KEY WORDS:
dental abutments, dental implant – abutment design, meta-analysis, review.
The outcomes of dental implant treatment are amongst the most studied and most predictable
of therapeutic options in modern dentistry. Although the validity of titanium to bone
osseointegration has been established beyond any doubt, the long-term stability of peri-
implant hard and soft tissues remains one of the main challenges in implant treatment.1 In this
context, different micro- and macro- implant designs,2-7 surgical and prosthodontic
protocols,8-11 prosthetic superstructures, implant-abutment connections and platform-
switching concepts have been developed to minimize marginal bone loss and maintain peri-
implant soft tissue levels, although without clear evidence of the superiority of one design
over the other.12-14
One of the limitations of the standard prosthetic protocol for implant treatment is the need
to disconnect and reconnect the prosthetic components. Such frequent exchange of abutments
may disturb the surrounding peri-implant mucosal barrier and subsequently cause marginal
bone loss.15, 16 In the current era of increased emphasis on minimizing soft and hard tissue
trauma, the “one abutment - one time” protocol was introduced as minimally invasive
prosthetic protocol.17, 18 It involves the use of one definitive abutment (DA) instead of cover
screw or healing / provisional abutment (PA) at the time of implant placement to overcome

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Journal of Periodontology; Copyright 2017 DOI: 10.1902/jop.2017.170238

the potential limitations of repeated changes of cover screw or healing / provisional abutment
(PA).17, 18
Nevertheless, there is still limited information available on the effects of repeated changes
of abutments. In an experimental study, Abrahamsson and co-workers15 showed that the
repeated changes of prosthetic components (five times) caused an apical positioning of
connective tissue and underlying bone. When the same research group limited the number of
changing the abutments to two times in another study, no differences in soft and hard tissues
were observed between repeated and single abutment dis/reconnection.19 Further pre-clinical
studies20-22 have evaluated the “one abutment - one time” protocol and indicated that repeated
manipulation of abutments caused dimensional changes in soft and hard tissues regardless of
the abutment material.20 It was argued that the radiographic marginal bone loss at platform-
switched implants was less than platform-matched implants when subjected to comparable
times of abutment dis/reconnections.21, 22
The earliest clinical use of DAs was reported by Romanos and colleagues,23, 24 who
showed that immediate functional loading and the use of DAs did not negatively influence
the long-term prognosis of platform-switched implants in the posterior mandible. In a human
autopsy study,25 the authors evaluated the peri-implant soft tissue dimensions around
immediately loaded implants with platform-switched DAs. The non-removal of abutments
was considered one of the determinant factors in minimizing the trauma to peri-implant
tissues and preventing subsequent bone resorption. Clinical studies have also evaluated the
same concept using implants placed in extraction sockets17, 26 and healed sites18, 27 but with
controversial and limited data on the clinical relevance of the observed hard and soft tissue
level changes and the impact of the number of abutment removal on the peri-implant tissue
interface. One strand in the controversy is whether examining the clinical relevance of this
concept is possible without considering the influence of other factors such as implant-
abutment connection and its location in relation to the crestal bone loss. Therefore, the aim of
the present systematic review was to evaluate the clinical effects of using DAs for dental
implant restorations in comparison with PAs that require repeated dis/reconnections.

MATERIALS AND METHODS

The current systematic review was prepared in accordance with the guidelines provided by
the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
statement,28 and the Cochrane Collaboration.29 The present review attempts to answer a
clearly focused question using the participant, intervention, comparison, outcome approach:30
Participant: Patients that require dental implants.
Intervention: Definitive abutment (DA) at the time of implant placement.
Comparison: Healing / provisional abutment (PA) that require repeated dis/reconnection.
Outcomes: Peri-implant marginal bone level changes, peri-implant soft tissue parameters,
biological and technical complications, and implant failure rate.

Types of Studies

Inclusion criteria. This review included randomized controlled trials (RCTs) that
compared DAs with PAs that require repeated dis/reconnection and that reported on peri-
implant hard and soft tissue changes, biological and technical complications and implant
failure. No language restrictions were imposed.

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Exclusion criteria. Non-RCTs, retrospective studies, case series and case reports were
excluded. Studies that lacked a control group, or that did not provide sufficient data were also
excluded.

Outcome Measures

Primary outcomes. Peri-implant marginal bone level changes.

Secondary outcomes.
Peri-implant soft tissue parameters.
Biological complications.
Technical complications.
Implant failure rate.

Search Strategy
The following electronic databases were searched for ongoing and unpublished trials up to
January 12 2017: MEDLINE, EMBASE, The Cochrane Central Register of Controlled Trials
(CENTRAL), MetaRegister, ClinicalTrials.gov, and the system for information on Grey
literature in Europe (Table 1). The search was performed independently and in duplicate by
two authors (M.A. and A.T.). The bibliographies of all eligible papers were scrutinized for
additional studies. The last five years of relevant dental journals (Clinical Implant Dentistry
and Related Research, Clinical Oral Implants Research, Implant Dentistry, International
Journal of Oral and Maxillofacial Implants, International Journal of Periodontics and
Restorative Dentistry, Journal of Clinical Periodontology, Journal of Oral Implantology, and
Journal of Periodontology) were hand-searched to identify any potentially relevant papers.

Selection of Studies
Two reviewers (M.A. and A.T.) independently screened the retrieved citations in duplicate to
identify human studies. The initial citations were assessed on the basis of the title, abstract,
and keywords. The relevant papers were then obtained in full and assessed for inclusion by
using an eligibility form. Any disagreements were resolved by reaching a consensus. The
reasons for excluding irrelevant papers were reported.

Data Collection
Two authors (M.A. and A.T.) independently extracted the following information from the
selected studies: 1) Study characteristics: title, authors’ names, contact address, study
location, language of publication, year of publication, published or unpublished data, source
of study funding, study design (parallel group or split mouth), method of randomization,
allocation concealment and blinding (participants, investigators, outcome examiners). 2)
Participants: demographic characteristics, inclusion/exclusion criteria, number of participants
in test and control groups, number of withdrawals and reasons for dropouts. 3) Interventions:
the use of DA. 4) Comparison: the use of PA. 5) Outcomes: peri-implant marginal bone level
changes, peri-implant soft tissue parameters, biological complications, technical
complications and implant failure rate. 5) Length of the observation period. Additional
information was obtained by contacting corresponding authors of the included studies.

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Quality Assessment of Included Studies

The Cochrane Collaboration’s Risk of Bias tool29 was used by two reviewers (M.A. and
A.T.) to independently assess the selected human studies in duplicate to determine the risk of
bias. The tool consists of seven domains (sequence generation, allocation concealment,
blinding of participants and investigators, blinding of outcome assessment, incomplete data
outcome, selective outcome reporting, and potential sources of bias). The first part of the tool
describes each domain while the second part categorizes studies into those having (i) low risk
of bias if all the criteria were met, (ii) unclear risk of bias if one or more criteria were
partially met, or (iii) high risk of bias if one or more criteria were not met.

Data Synthesis
Meta-analyses for comparable trials that reported the same outcome measures were
conducted using a statistical software program‡. Continuous data such as marginal bone and
soft tissue level changes were expressed as mean difference (MD) or standardized mean
difference (SMD) and 95% confidence intervals (CIs). Dichotomous data such as
complications and implant failure were expressed as risk ratio (RR) estimates and 95% CIs.
Random-effects model was used to pool the results from more than one study as
heterogeneity between studies was expected. Split-mouth and parallel group studies were
combined using the generic inverse variance option in the statistical software program‡. As
there were fewer than 10 studies, publication bias was not formally assessed because the
power to detect publication bias is limited.29 The statistical heterogeneity across different
studies was assessed by means of the Cochran’s test for heterogeneity and I2 statistic.31 An I2
value of > 50 indicated significant heterogeneity. The unit of analysis was the implant rather
than the participant as the outcomes may vary amongst the two prosthetic techniques.

RESULTS
Description of Studies
A total of 1124 citations were retrieved from the initial search (Figure 1). After reviewing the
titles and abstracts, 1115 were excluded. The full-text of the remaining nine articles17, 18, 26, 27,
32-36
were scrutinized for eligibility. Seven articles17, 26, 27, 32-35 fulfilled the inclusion criteria
and were included in the review (Table 2). All the trials were of parallel-group design. Two
trials34, 35 were undertaken in university settings while the remaining trials17, 26, 27, 32, 33 took
place in private practice.

Characteristics of Participants at Baseline

Inclusion criteria.
- Systemically healthy adults.17, 26, 27, 32-35
- Full mouth plaque score and full mouth bleeding score < 25%17 or plaque index of ≤
2.26, 27
- Presence of opposing natural and adjacent teeth.17, 26, 27, 33, 34
- Presence of intact alveolar bone walls and minimum of four millimeters of bone
beyond the root apex for immediate implant placement.17, 26, 33
- Sufficient bone height and width in which bone augmentation was not required.27, 32,
34, 35

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Exclusion criteria.
- History of systemic disease and/or radiation therapy that contraindicated surgery
and/or impaired bone and wound healing.17, 26, 27, 32-35
- Pregnant or lactating females.17, 32, 33
- Smoking more than 10 cigarettes17, 27, 32, 34, 35 or 20 cigarettes per day.26
- Parafunctional habits such as bruxism.27, 32, 34
- Alcohol or drug abuse.26, 33, 34
- Narrow interproximal spaces (less than nine millimeters).17
- Presence of acute infection, or interproximal or intra-bony defects.17, 32-34
- Insertion torque of < 32 Ncm.33
- Lack of primary stability at surgery.34
- History of implant failure.34

Surgical and Prosthetic Technique

In five trials, all the participants received prophylactic antibiotic therapy prior to the surgical
procedure in five trials.17, 26, 27, 32, 33 The clinicians in one trial34 prescribed prophylactic
antibiobic in cases where it was deemed necessary. Minimally traumatic extractions, which
preserved the integrity of the socket walls, were used in trials that employed an immediate
implant placement protocol.17, 26, 32, 33 Implants with a platform-switched design were placed
in all the trials, by either an open-flap33-35 or a flapless approach.17, 26, 27, 32, 33 An implant
stability quotient of more than 60 for the included implants was recorded in one trial32 while
an insertion torque of 25 to 45 Ncm was recorded in five trials.17, 26, 27, 32, 33 All the
immediately-placed implant studies used bone graft substitutes to fill the gap between the
implant and socket walls, with the exception of one.32 Provisional restorations without any
occlusal centric and eccentric contacts were provided immediately after implant placement in
six trials.17, 26, 27, 32, 33, 35 In one study,34 immediate provisionalization was not attempted.
Instead, conventional healing abutments were placed in the control group during the healing
period.
Postoperative care included instructions to maintain a soft diet,17, 26, 27, 32 the use of
antibiotics26, 27, 32, 33, 35 and non-steroidal anti-inflammatory drugs.33, 34 Participants were
asked either to use soft brushing17 or to avoid brushing at the surgical site.33, 34 Trial
participants rinsed with chlorhexidine gluconate, either 0.12%17, 34, 35 or 0.2%26, 27, 33 for the
first one to two weeks.
All the trials recorded the peri-implant marginal bone level changes using either
periapical radiographs17, 26, 27, 33-35 or cone-beam computed tomography.32 Clinical changes in
peri-implant soft tissue parameters were recorded in four studies.17, 32, 34, 35 The definitive
implant crown was delivered at various intervals following implant placement: after two to
four months,34 three months,17, 27, 35 four months,26, 33 or six months.32

Risk of Bias in Included Studies

Two trials33, 34 were judged to be at low risk of bias. Two trials32, 35 were rated at unclear risk
of bias, and the remainder17, 26, 27 were at high risk of bias (see Supplementary Figure 1 and
Supplementary Table 1 in online Journal of Periodontology).

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Other Potential Sources of Bias

Two trials did not receive any specific grant or funding.26, 27 Information regarding the source
of funding was missing in two trials17, 32 while the remaining three,33-35 declared support from
dental implant manufacturers. Power analysis was carried out to calculate the required sample
size in three trials.17, 33, 34 One trial26 stated that sample size calculation was not attempted,
whereas it was not clear whether any of the remaining studies27, 32, 35 conducted a priori
power analysis.

Outcomes and Pooled Estimates

In total, 262 participants with 363 dental implants were included in the analysis, of which,
173 implants (47.7%) were restored using DAs.

Peri-implant Marginal Bone Level Changes

The peri-implant marginal bone level changes were reported in all trials.17, 26, 27, 32-35 The
marginal bone loss at the PAs, which required repeated dis/reconnection of more than one
time, was significantly higher than around implants restored using DAs. The overall meta-
analyses found a statistically significant difference in peri-implant marginal bone levels
favouring DAs (MD -0.20; 95% CI -0.35, -0.06; p = 0.006; Figure 2). Heterogeneity across
the trials was noted (Chi2 = 179.65, df = 6; p < 0.0001; I2 = 97%). When analysis was limited
to trials where the PA was only removed one to two times, the difference remained
statistically significant in favour of DAs (MD -0.18; 95% CI -0.32, -0.05; p = 0.009; Figure
2).

Peri-implant Soft Tissue Parameters

Two trials17, 34 reported on modified bleeding and plaque indices as well as probing pocket
depths. The meta-analysis found no significant differences between DA and PA groups in
terms of modified bleeding index (SMD 0.47; 95% CI -0.63, 1.57; p = 0.40; Figure 3a),
modified plaque index (SMD -0.82; 95% CI -1.94, 0.29; p = 0.15; Figure 3b), or probing
pocket depth (SMD 0.08; 95% CI -0.36, 0.52; p = 0.72; Figure 3c). The marginal soft tissue
level changes were more favorable for DAs. The meta-analysis, however, showed no
significant differences between the two groups (SMD -0.41; 95% CI -1.67, 0.84; p = 0.52;
Figure 3d). Only one trial35 reported on changes in the width of keratinised tissue and found
no significant differences (Figure 3e). No heterogeneity was noted across the trials that
reported on peri-implant soft tissue changes.

Biological Complications
The number of reported biological complications was higher among implants that had PAs
prior to definitive restorations. In the PA group, fistulae, palatal wound dehiscence and loss
of bone graft were reported in one trial.33 Another study26 reported one case of peri-implant
soft tissue inflammation in the DA group. Overall, no statistically significant differences
were oberved between the two groups (RR 0.71; 95% CI 0.04, 12.89; p = 0.82; Figure 4a).

Technical Complications
A total of three incidents of abutment screw loosening in each group were reported in two
trials.26, 34 A high incidence of misfit was reported in one study;33 nine provisional and
definitive restorations in both groups had to be remade, mainly due to deviation from the
protocol and the use of non-engaging abutments. Almost similar rates of technical

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complications for both groups were observed, with no significant differences (RR 1.36; 95%
CI 0.52, 3.57; p = 0.54; Figure 4b).

Implant Failure Rate

The implant survival rate was reported in all trials,17, 26, 27, 32-35 with only one failed implant in
the DA group.34 The pooled estimates did not show any statistically significant differences in
implant failure rate between the two groups (p = 0.45; Figure 4c).

DISCUSSION
Summary of the Main Findings
This review evaluated and compared the use of DAs and PAs with respect to peri-implant
marginal bone and soft tissue level changes, biological and technical complications, and
implant failure. Despite the small number of included trials, the present review suggests that
a minimally invasive prosthetic protocol using DAs could minimise peri-implant marginal
bone loss, but it was not clear whether this difference is clinically relevant when compared
with use of PAs. The subgroup analysis indicated that the reducing the number of
dis/reconnections of PAs did not influence peri-implant bone level changes between the two
techniques. In terms of peri-implant soft tissue parameters, the differences again favored
using DAs but did not reach statistical significance. In addition, the overall analysis showed
that the rate of biological and technical complications as well as implant failures were almost
similar in both groups.

Quality of Evidence
Two trials33, 34 reported sufficient methodological details to be judged at low risk of bias. On
the other hand, three trials17, 26, 27 were rated at high risk of bias due to the lack of allocation
concealment and blinding of outcome assessors whilst the remaining two trials32, 35 did not
provide sufficient information on allocation concealment and thus assessed as having an
unlcear risk of bias. It is difficult to estimate the extent to which heterogeneity across the
included trials, along with confounding factors such as variations in operator experience,
methods of assessment, implant systems, implant locations, bone quality and initial gingival
tissue thickness, could have affected the estimation of treatment effect.
This review suggested that even for cases following the platform-swtiching concept,
frequent dis/reconnection of PAs may cause more marginal bone loss than DAs. It is possible
that the use of DAs enhanced the soft tissue adaptation, prevented possible contamination at
the implant-abutment interface and subsequently reduced marginal bone loss. However, the
clinical relevance of less than 1 mm reduction in marginal bone loss remains debatable.
The subgroup analysis was limited to trials with either repeated abutment
dis/reconnection of at least three times or minimal frequency of up to two times to evaluate
the cumulative effects of abutment dis/reconnection. We hypothesized that more frequent
dis/reconnection in abutments would mean greater disturbance to the peri-implant interface
and hence more bone loss would be expected. It was also anticipated that variations in the
number of abutment removals, which ranged from one34 up to four times27, 32 could be
considered an important potential source of clinical heterogeneity. However, the subgroup
analysis showed that the differences between the two groups remained statistically significant
in favor of DAs.
A limitation of the current review is that only a small number of trials with short
observation periods could be analysed. The review included studies of implants supporting

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both single and multiple units, and trials in which implants were placed subcrestally or in
extraction sockets. It is prudent to mention that most of the soft and hard tissue changes occur
in the first three months following implant placement,37 but the changes associated with
immediate implant protocols are often unpredictable and might have been a confounding
factor that affected the results of this review.
As the decision to place DAs at the time of surgery would subsequently result in the use
of cement-retained implant restorations, clinicians should be aware of the potential
complications associated with residual excess cement.38, 39 In one study,35 the authors
recorded lower bleeding score in the PA group and attributed the findings to the ease of
removing plaque when PAs were changed compared to placing DAs, which required careful
removal of residual cement. Another study26 referred to the use of DAs as stressful and time-
consuming procedure when compared to the use of PAs. In contrast, the same research
group27 suggested that the use of DAs would optimise the soft and hard tissue architecture
and recommended their use when thin gingival biotype is present. Therefore, clinical
subjective judgement that weighs the potential advantages and possible drawbacks is
required.
Furthermore, the future impact of such small differences in hard and soft tissue levels on
the long-term implant success rate is yet to be determined. Therefore, further properly
designed RCTs, that not only report hard and soft tissue parameters but also aesthetic and
patient outcomes and take into consideration all confounding factors, particularly the
frequency of PA exchange, are required to confirm or refute the present findings.

CONCLUSIONS
Within the limitations of this review, DAs appear to be viable alternative to PAs at the time
of implant placement. The favorable changes in peri-implant marginal bone level associated
with use of DAs should, however, be viewed with caution as the clinical significance is still
uncertain.

ACKNOWLEDGMENT
The authors report no conflicts of interest related to this study.

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27. Grandi T, Guazzi P, Samarani R, Garuti G. Immediate positioning of definitive abutments versus repeated
abutment replacements in immediately loaded implants: effects on bone healing at the 1-year follow-up of a
multicentre randomised controlled trial. Eur J Oral Implantol 2012;5:9-16.
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meta-analyses: the PRISMA statement. Ann Int Med 2009;151:264-269, W264.
29. Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. In. vol.
updated March 2011: The Cochrane Collaboration, 2011.
30. Miller SA, Forrest JL. Enhancing your practuce through evidence-based decision making: PICO, learning
how to ask good questions. J Evid Based Dent Pract 2001;1:136-141.
31. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002;21:1539-1558.
32. Degidi M, Nardi D, Daprile G, Piattelli A. Nonremoval of immediate abutments in cases involving
subcrestally placed postextractive tapered single implants: a randomized controlled clinical study. Clin
Implant Dent Relat Res 2014;16:794-805.
33. Luongo G, Bressan E, Grusovin MG, et al. Do repeated changes of abutments have any influence on the
stability of peri-implant tissues? Four-month post-loading preliminary results from a multicentre
randomised controlled trial. Eur J Oral Implantol 2015;8:129-140.
34. Molina A, Sanz-Sanchez I, Martin C, Blanco J, Sanz M. The effect of one-time abutment placement on
interproximal bone levels and peri-implant soft tissues: a prospective randomized clinical trial. Clin Oral
Implants Res 2017;28:443-452.
35. Koutouzis T, Koutouzis G, Gadalla H, Neiva R. The effect of healing abutment reconnection and
disconnection on soft and hard peri-implant tissues: a short-term randomized controlled clinical trial. Int J
Oral Maxillofac Implants 2013;28:807-814.
36. Degidi M, Daprile G, Nardi D, Piattelli A. Immediate provisionalization of implants placed in fresh
extraction sockets using a definitive abutment: the chamber concept. Int J Periodontics Restorative Dent
2013;33:559-565.
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Correspondence: Dr. Momen A. Atieh, Oral Implantology Research Group, Sir John Walsh
Research Institute, Department of Oral Sciences, Faculty of Dentistry, University of Otago,
310 Great King Street, Dunedin 9016, New Zealand, Email: maatieh@gmail.com
Submitted April 10, 2017; accepted for publication June 04, 2017.

Figure 1:
Flowchart of the search strategy

Figure 2:
Forest plot of random effects meta-analysis evaluating the peri-implant marginal bone level changes: Definitive
abutment (DA) versus provisional abutment (PA)

Figure 3:
Forest plots of random effects meta-analyses evaluating the peri-implant soft tissue parameters: (a) modified
bleeding index, (b) modified plaque index, (c) probing pocket depth, (d) marginal tissue level changes, and (e)
changes in the width of keratinized tissue: Definitive abutment (DA) versus provisional abutment (PA)

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Journal of Periodontology; Copyright 2017 DOI: 10.1902/jop.2017.170238

Figure 4:
Forest plot of random effects meta-analysis evaluating (a) the biological complications, (b) technical
complications, and (c) implant failure rate: Definitive abutment (DA) versus provisional abutment (PA)
Table 1
Databases and search terms
Databases Keywords
Published studies
PubMed (1965 – January 12, 2017) ((definitive OR provisional) abutment* OR repeated
abutment change* OR abutment reconnection OR
healing abutment) AND (dental implant* OR oral
implant*)
EMBASE via Ovid (1947 – January 12, 2017) (dental adj abutment$).mp OR (definitive adj
abutment$).mp. OR (provisional adj abutment$).mp.
OR repeated abutment change$.mp. OR abutment
reconnection.mp.) AND ((dental OR oral) adj
implant$).mp.
Cochrane Central Register of Controlled Trials (dental adj abutment$).mp OR (definitive adj
(CENTRAL) via Ovid (January 12, 2017) abutment$).mp. OR (provisional adj abutment$).mp.
OR repeated abutment change$.mp. OR abutment
reconnection.mp.) AND ((dental OR oral) adj
implant$).mp.
Unpublished studies (dental abutment or defintive abutment or provisional
MetaRegister of controlled trials abutment or repeted abutment changes or abutment
OpenGrey reconnection and (dental implant or oral implant))
ClinicalTrials.gov
(January 12, 2017)

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Journal of Periodontology; Copyright 2017 DOI: 10.1902/jop.2017.170238

Table 2
Characteristics of the included trials
Canullo et al. Degidi et al. 2014 Grandi et al. 2012 Grandi et al. 2014 Koutouzis et al. Luongo et al. Molina et al. 2016
2010 2013 2015
Study design RCT (parallel RCT (parallel RCT (parallel RCT (parallel RCT (parallel RCT (parallel RCT (parallel
group) group) group) group) group) group) group)
Location Private practices, Private practice, Private practices, Private practice, University of Private practices, University
Italy Italy Italy Italy Florida, USA Italy Complutence of
Madrid, Spain
Number randomised 32/32 68/68 28/56 28/28 16/21 80/128 39/60
(participants/implants)
DA 16/16 33/33 14/28 14/14 8/10 40/58 18/29
PA 16/16 35/35 14/28 14/14 8/11 40/70 21/31
Number evaluated 25/25 53/53 28/56 25/25 16/21 80/128 35/55
(participants/implants)
DA 15/15 24/24 14/28 12/12 8/10 40/58 16/26
PA 10/10 29/29 14/28 13/13 8/11 40/70 19/29
Age (years)
DA 51.0 ± 7.7 40.1 ± 12.5 53.2 ± 5.3 56.0 ± 7.8 59.1 ± 12.6 55.6 ± 13.6 52.61 ± 10.93
PA 55.0 ± 13.5 37.7 ± 14.3 50.3 ± 5.3 57.1 ± 7.8 54.2 ± 13.6 57.6 ± 12.9 51.62 ± 8.65
Methods of assessment Periapical CBCT Periapical Periapical Periapical Periapical Periapical
radiograph radiograph radiograph radiograph radiograph radiograph
Periodontal probe Periodontal probe Periodontal probe Periodontal probe Periodontal probe
Digital
photographs
Implant placement Immediate Immediate Delayed Immediate Delayed Immediate and Delayed
protocol delayed
Implant location Maxillary Anterior maxilla Anterior and Anterior maxilla Anterior maxilla Partially Posterior maxilla
premolars posterior maxilla and mandible and mandible edentulous and mandible
and mandible maxilla and
mandible
Implant system * † ‡ ‡ § † ‖
Implant diameter (mm) 5.5 3.5, 4.5 3.7, 4.3, 5 3.7, 4.3 4.1, 4.8 3.5, 4.5, 5.5 3.8, 4.3
Implant length (mm) 13 14, 17 10, 11.5, 13 11.5, 13 8, 10 8, 9.5, 11, 14 9, 11, 13
Number of abutment At least three Four Four At least three Two At least three Once
disconnection in the times ≥ 3 times times times

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Journal of Periodontology; Copyright 2017 DOI: 10.1902/jop.2017.170238

control group
Postoperative care CHX Antibiotics Antibiotics and Antibiotics and Antibiotics and Antibiotics and NSAID and CHX
CHX CHX CHX CHX
Peri-implant marginal
bone level changes (mm)
DA 0.33 ± 0.08 0.13 ± 0.22 0.09 ± 0.03 0.11 ± 0.06 0.13 ± 0.20 0.08 ± 0.16 0.01 ± 0.54
PA 0.43 ± 0.12 0.17 ± 0.21 0.44 ± 0.03 0.58 ± 0.11 0.28 ± 0.16 0.09 ± 0.20 0.32 ± 0.58
¶
Modified bleeding index
DA 0.67 ± 0.08 NR NR NR NR 0.69 ± 0.53
PA 0.56 ± 0.12 NR NR NR NR 0.71 ± 0.49
¶
Modified plaque index
DA 1.53 ± 0.11 NR NR NR NR 0.24 ± 0.25
PA 1.69 ± 0.10 NR NR NR NR 0.35 ± 0.41
¶
Probing pocket depth
(mm)
DA 2.79 ± 0.24 NR NR NR NR 3.19 ± 0.55
PA 2.82 ± 0.33 NR NR NR NR 3.08 ± 0.77
Marginal tissue level
changes (mm)
DA NR 0.33 ± 0.12 NR NR 0.33 ± 0.70 NR 0.55 ± 0.85
PA NR 0.57 ± 0.17 NR NR 0.31 ± 0.64 NR 0.24 ± 1.00
Changes in width of
keratinised tissue (mm)
DA NR NR NR NR -0.11 ± 0.3 NR NR
PA NR NR NR NR 0.06 ± 0.2 NR NR
Biological complications
DA 0 0 0 1# 0 0 0
PA 0 0 0 0 0 3** 0
Technical complications
DA 0 0 0 0 0 5‡‡ 3††
PA 0 0 0 1†† 0 4§§ 2††
Implant failure rate (%)
DA 0 0 0 0 0 0 3.4
PA 0 0 0 0 0 0 0
DA: definitive abutment; PA: provisional abutment; CBCT: cone beam computed tomography; CHX: Chlorhexidine; NSAID: non-steroidal anti-inflammatory drug; AB:
antibiotics; NR: not reported

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*
Sweden & Martina, Padua, Italy
†
ANKYLOS®, DENTSPLY Friadent, Mannheim, Germany
‡
JDEvolution®, JDentalCare, Modena, Italy
§
Straumann AG, Basel, Switzerland
‖
Camlog Biotechnologies AG, Basel, Switzerland
¶
Percentages instead of mean and standard deviations were reported
#
Peri-implant mucositis
**
loss of graft, palatal wound dehiscence, fistula
††
Screw loosening
‡‡
One definitive and four provisional restorations remade
§§
Three debonding and one provisional restoration remade
‡
Review Manager (RevMan) Version 5.0, The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark

14
Ide Total studies identified from Total studies identified through
ntifi database searching (N = 1124) other sources (N = 0)
cati PubMed (N = 495)
on EMBASE (N = 407)
CENTRAL (N = 222)
MetaRegister (N = 0)

Scr
eeni
ng Studies excluded after title and abstract screening (N = 1115)

Full-text articles retrieved for

Elig
detailed evaluation (N = 9)
ibili Full-text excluded (N = 2) for
ty
the following reasons:
- Lack of randomization
(Degidi et al. 2011)
- Lack of control group
(Degidi et al. 2013)
Final number of studies
Incl included in the review (N = 7)
usio
n
Journal of Periodontology; Copyright 2017 DOI: 10.1902/jop.2017.170238

IV: inverse variance; SD: standard deviation; CI: confidence interval; τ: Kendall tau; z: z test

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Journal of Periodontology; Copyright 2017 DOI: 10.1902/jop.2017.170238

(a)

(b)

(c)

(d)

(e)

IV: inverse variance; SD: standard deviation; CI: confidence interval; τ: Kendall tau; z: z test

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Journal of Periodontology; Copyright 2017 DOI: 10.1902/jop.2017.170238

(a)

M-H: Mantel-Haenzel; SE: standard error; CI: confidence interval; τ: Kendall tau; z: z test
(b)

M-H: Mantel-Haenzel; SE: standard error; CI: confidence interval; τ: Kendall tau; z: z test

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 Journal of Periodontology; Copyright 2017 DOI: 10.1902/jop.2017.170238

(c)

M-H: Mantel-Haenzel; SE: standard error; CI: confidence interval; τ: Kendall tau; z: z test

19

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