J Stomatol Oral Maxillofac Surg 124 (2023) 101385

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Review

Influence of using collagen on the soft and hard tissue outcomes of

immediate dental implant placement: A systematic review and meta-
analysis
Jingmei Liua, Fang Huab,c, Haiwen Zhanga, Jian Hua,*
a
Department of Prosthodontics Dentistry, Hubei-MOST KLOS & KLOBM, School & Hospital of Stomatology, Wuhan University, Wuhan, China
b
Centre for Evidence-Based Stomatology, Hubei-MOST KLOS & KLOBM, School & Hospital of Stomatology, Wuhan University, Wuhan, China
c
Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester Academic Health Science
Centre, Manchester, UK

A R T I C L E I N F O A B S T R A C T

Article History: Objective: To compare the effects of bone grafting materials, collagen-infused grafting materials, and no graft-
Received 8 November 2022 ing materials on the soft and hard tissue outcomes when an immediate implant is placed.
Accepted 12 January 2023 Materials and Methods: In addition to hand searching, electronic searches were performed in Pubmed,
Available online 13 January 2023
Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL). Only RCTs were included in our
review. The Cochrane ROB 2.0 tool was used to assess the risk of bias (ROB). Two subgroups were used to
Keywords:
evaluate implant failure rate, buccal bone resorption, soft tissue thickness, and esthetic scores. In the meta-
Dental implants
analysis, both the fixed-effects model and the random-effects model were employed.
Immediate implant
Guided tissue regeneration
Result: 7 RCTs were selected after screening 580 studies, and 205 patients were included in the review, with
Collagen 279 implants. Two RCTs were at low bias of risk, three were at moderate bias, and two were deemed at high
Tooth extraction risk of bias. The failure rate (95% CI: 0.17 to 11.84) and soft tissue thickness were not significantly different
between collagen with bone grafting materials and without bone grafting materials. On the basis of the fail-
ure rate and buccal bone thickness, there was no significant difference between collagen with bone grafting
materials and bone grafting materials. While we found collagen with bone grafting materials could have a
significant advantage on the buccal bone thickness (MD: 0.43,95% CI 0.72 to 0.41) and esthetic outcome
(MD: 1.23,95% CI 1.90 to 0.55).
Conclusion: In the statement of immediate implant implantation, the thickness of the buccal bone and
esthetic outcomes did significantly benefit from bone grafting materials with collagen inserted in the “jump-
ing gap”.
© 2023 The Author(s). Published by Elsevier Masson SAS. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

1. Introduction
Immediate implant placement refers to the placement of an
implant on the day of tooth extraction and within the same surgical
procedure [1]. Several clinical and experimental studies reported that
immediate implant placement is a predictable procedure, [2] it might
prevent post-extraction bone loss [3] under the selection criteria [4].
Tooth extraction could disrupt vascular structures and damage the
associated periodontal ligament, also osteoclastic activity remains
high at the early period, and these why the buccal bone, mainly com-
posed of bundle bone, would have the bone loss [5]. Immediate
implant placement can reduce treatment time and lower the risk of
the absorption of the buccal bone plate by grafting materials.
* Corresponding author.
E-mail address: 00008460@whu.edu.cn (J. Hu).
Considering that there are obvious tooth extraction sockets after
tooth extraction [6] that immediate implant placement in the
esthetic area is often accompanied by bone defect [7]. And the extrac-
tion sockets often create a wide space between the wall of the
implant and the buccal bone plate, the wide space can be named as
“jumping gap” [8]. So it needs particular requirements on the place-
ment site [6,9]. Previous studies showed that immediate implant
placement with bone grafting could positively affect ridge preserva-
tion. John Zaki et al. showed that bone-substitute materials used dur-
ing immediate implant placement could reduce horizontal buccal
bone resorption and improve the peri‑implant soft-tissue esthetics
[10]. Lorenz et al. came to the same conclusion, so they suggested
socket grafting should be considered as an adjunct to immediate
implant placement in clinical practice [11]. It could be suggested that
the use of grafting can be helpful in particular a slowly resorbed bio-
material [12]. With bone grafting, newly formed bone and some

https://doi.org/10.1016/j.jormas.2023.101385
2468-7855/© 2023 The Author(s). Published by Elsevier Masson SAS. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
J. Liu, F. Hua, H. Zhang et al.
remained grafting materials could be seen around the implant during
socket healing [13]. But different materials did not show different
results on the survival rate and the esthetic outcome [10].
Collagen was widely used in oral implantology, and it has been
confirmed that collagen can help reduce the alveolar bone of the
respective region undergoing resorption and atrophy [14]. In addi-
tion, collagen has been approved to treat peri‑implant bone defects
in vivo animal models [15] and promote osseointegration [16]. Bone
substitute materials were widely used in the “jumping gap” and alve-
olar ridge preservation [17], studies have reported superior outcomes
ascribed to xenogeneic bone substitutes in combination with colla-
gen [18,19]. Bone grafting mixed with collagen was widely used in
alveolar ridge preservation and could be helpful to reduce the resorp-
tion of the buccal plate [20,21].
The main objective of our review is to assess when placing the
immediate implant, the effect of grafting materials mixed with colla-
gen placed in the gap compared to bone grafting materials or no
materials on the soft and hard tissue outcomes.
2. Material and methods
2.1. Reporting
The protocol of this systematic review was registered in the PROS-
PERO database (CRD42022322578), and the present review was
reported by following the PRISMA (Preferred Reporting Items Sys-
tematic review and Meta-Analyses) statement [22].
2.2. Criteria for considering studies for this review
We included all randomized controlled trials (RCTs) in which:
2.2.1. Types of participants
1) Participants were at least 18 years old, required one or more per-
manent teeth extraction, and met the requirement of immediate
implant placement.
2) The studies should have been at least a 3-month follow-up.
2.2.2. Types of interventions
Bone grafting materials mixed with collagen are placed peri‑im-
plant under the condition of immediate implant placement.
2.2.3. Types of control
Other bone grafting materials or no material are placed peri‑im-
plant under the condition of immediate implant placement.
2.2.4. Types of outcome measures
Data on at least one outcome variable of interest.
1) Implant failure rate.
2) Buccal plate width changes of the alveolar ridge.
3) Change of soft tissue width
4) Pink esthetic scores
2.3. Exclusion criteria
1) Patients with severe bone defects after tooth extraction were
immediate implant placement or other techniques which could
be helpful to bone augmentation were required at the same time
as implant implantation.
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Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101385
2) Studies are not trying to compare bone grafting materials mixed
with collagen placed peri‑implant in immediate implant place-
ment, compared to other bone grafting materials, or no material
was placed peri‑implant under the condition of immediate
implant placement.
3) Studies are not doing immediate implant placement, rather than
the implant placement after alveolar ridge preservation.
2.4. Search strategy and selection of studies
Electronic searches were conducted in Pubmed, Embase, and
Cochrane Central Register of Controlled Trials (CENTRAL) databases
without language or publication date restrictions to April, 23, 2022
(Table 1) listed the detailed search strategy for MEDLINE, which was
tailored to the syntax and topics of other databases. Additionally,
Table 1
Search strategy for MEDLINE.
Search Number Query
1 ("Dental Implants" [Mesh] OR Implant, Dental [Title/Abstract]
OR Implants, Dental [Title/Abstract] OR "Dental Implant*"
[Title/Abstract] OR "Dental Implantation" [Mesh] OR" den-
tal implantation" [Title/Abstract]) OR (Dental Implants
[Title/Abstract])
2 Immediate [Title/Abstract]
3 #1 and #2
4 ("immediate implant*" [Title/Abstract]) or ("immediate
implant placement" [Title/Abstract]) OR ("immediate place-
ment" [Title/Abstract])
5 ("immediate post extraction" [Title/Abstract]) OR ("immedi-
ate fixture" [Title/Abstract]) OR ("immediate postextrac-
tion" [Title/Abstract]) OR ("fresh socket" [Title/Abstract]) OR
("extraction socket" [Title/Abstract]) OR ("tooth socket"
[Title/Abstract]) OR ("tooth extraction" [Title/Abstract] )OR
("teeth extraction" [Title/Abstract]) OR ("tooth extraction"
[MeSH Terms])
6 ("peri implant gap" [Title/Abstract]) OR (jumping distance
[Title/Abstract])
7 (prei-implant [Title/Abstract]) OR (jump [Title/Abstract]) OR
(jumping [Title/Abstract]) OR (periimplant [Title/Abstract])
OR (jump* [Title/Abstract])
8 (gap [Title/Abstract] )or( distance [Title/Abstract])
9 #7 and #8
10 #3 or #4 or #5 or #6 or #9
11 ("Bone Substitutes" [Mesh]) OR ("Bone Substitutes" [Title/
Abstract])
12 ("bone substitutes" [Title/Abstract]) OR ("bone substitute"
[Title/Abstract]) OR (Replacement Material, Bone [Title/
Abstract]) OR (Replacement Materials, Bone [Title/
Abstract]) OR (Materials, Bone Replacement [Title/
Abstract]) OR (Substitute, Bone [Title/Abstract]) OR (Substi-
tutes, Bone [Title/Abstract]) OR ("Bone Replacement Mate-
rial" [Title/Abstract]) OR (Material, Bone Replacement
[Title/Abstract]) OR ("Bone Replacement Materials" [Title/
Abstract])
13 (allografting [Title/Abstract]) OR (alloplast [Title/Abstract]) OR
(xenografting [Title/Abstract]) OR (bio-oss [Title/Abstract])
OR(biooss [Title/Abstract]) OR(autografting [Title/Abstract])
OR ("autogenous bone" [Title/Abstract]) OR(biomaterials
[Title/Abstract]) OR ("equine bone" [Title/Abstract])OR
("bovine bone" [Title/Abstract]) OR ("porcine bone" [Title/
Abstract])
14 #11 or #12 or #13 or #13
15 collagen [Title/Abstract]
16 #14 and #15
17 (randomized controlled trial [Publication Type]) OR (con-
trolled clinical trial [Publication Type]) OR (randomized
[Title/Abstract]) OR (placebo [Title/Abstract]) OR (randomly
[Title/Abstract]) OR (trial [Title/Abstract]) OR (groups [Title/
Abstract])
18 (animals [MeSH Terms]) NOT (humans [MeSH Terms])
19 #17 not #18
20 #10 and #16 and #19
J. Liu, F. Hua, H. Zhang et al.
hand searching was used in the Journal of Clinical Periodontology,
Journal of Periodontology, Journal of Periodontal Research, International
Journal of Periodontics and Restorative Dentistry, Clinical Implant Den-
tistry and Related Research, Clinical Oral Implants Research, European
Journal of Oral Implantology, Implant Dentistry, Journal of Oral and
Maxillofacial Surgery, International Journal of Oral and Maxillofacial
Surgery, International Journal of Oral and Maxillofacial Implants, Journal
of Oral Implantology, International Journal of Prosthodontics, and Jour-
nal of Prosthetic Dentistry up to April 2022. The subject search was
linked with the highly sensitive search strategy designed by Cochrane
for identifying RCTs [23]. The literature search was conducted by two
reviewers independently (JL and HZ). When there was any disagree-
ment, the senior author (FH) was consulted to reach a consensus.
We followed the guidance provided in the Cochrane Handbook for
Systematic Reviews to select the studies [23]. Two authors (JL and
HZ) carried out the selection of studies and made decisions about the
eligibility of all reports identified through the electronic and manual
searches independently, then first screened titles and abstracts of
articles and subsequently assessed full-texts of the articles for inclu-
sion in the review. The studies included in this review used bovine
bone as bone graft materials, and they came from different compa-
nies, but there were not enough studies to support the opinion that
different xenogenic graft materials had obvious different effects on
the bone graft. Any disagreements were settled down by discussion
and consultation with a third review author (HF) (Table 1).
2.5. Risk of bias assessment
The risk of bias assessment for the included trials was performed
independently and in duplicate by two review authors by using the
Cochrane Risk of Bias tool 2.0(ROB2.0) [23]. The tool addresses the
seven following key domains: sequence generation, allocation con-
cealment, blinding of participants and personnel, blinding of assess-
ment, incomplete outcome data, selective reporting, and other
biases. After judgment was given for each study, RCTs were judged as
having a low, moderate, or high risk of bias. We compared and dis-
cussed the independent assessment of deviation risk with the third
author to resolve any differences.
The Grading of Recommendation, Assessment, Development, and
Evaluation (GRADE) framework was used to assess the quality of support-
ing evidence behind each major comparison [24,25]. RCTs began with a
high certainty of evidence. Thereafter, five factors (risk of bias, impreci-
sion, inconsistency, indirectness, and publication bias) might lead to
downgrading the certainty of the evidence, and three factors (a large
effect, dose-response, and all plausible confounding would reduce a dem-
onstrated effect) might lead to upgrading the certainty of evidence.
2.6. Data analyses
After we identified an adequate sample of studies with homoge-
neous populations and characteristics, we got a meta-analysis of pri-
mary and secondary results. Changes from baseline within each
treatment group were expressed as mean difference (MD) for the
continuous outcome variable results. We expressed dichotomous
outcomes as risk ratios (RR) with 95% confidence interval (Cis) and
expressed continuous outcomes as MD with 95% CIs.
As recommended by the Cochrane Collaboration, data synthesis was
conducted using Review Manager software (RevMan V.5.3). Meta-analy-
sis was conducted for trials of similar comparisons reporting the same
outcome measures. We mixed MDs or standardized mean differences
(SMDs) for continuous data and RRs for dichotomous data. In the pres-
ence of four or more trials, mean differences for continuous data using a
random-effects model was conducted. Otherwise, a fixed-effect model
was used for combining three or fewer trials [26].
Subgroup analysis was to be conducted to explore possible sour-
ces of heterogeneity [27]. We tried to perform subgroup analyses
3
Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101385
based on the following groups:1) Bone grafting materials with colla-
gen and no materials; 2) Bone grafting materials with collagen and
bone-substitute materials.
2.7. Clinical relevance
A summary of the variables included in the studies found that
patients in the groups with higher implant retention, less buccal
bony plate change, more stable soft tissue width, and better esthetic
scores had better long-term outcomes, including better masticatory
function, longer implant retention and use, and greater recovery or
reconstruction of esthetic function. It can help the surgeon choose
more suitable materials for immediate planting.
3. Result
3.1. Study selection
A total of 579 works of literature were obtained by electronic and
manual search, of which PubMed had 165 articles, EMBASE had 190
articles, and CENTRAL 224 articles, and literature was obtained by
hand searching. After importing all the data into EndnoteX9 software
for repeated elimination, 314 articles were obtained. Two review
authors (JL and HZ) excluded 202 articles through an independent
review of titles and abstracts, 3 of the 10 articles were screened out
by full-text review according to the pre-established criteria, and
finally, we included 7 articles (Fig. 1).
3.2. Description of studies
Two review authors (JL and HZ) independently extracted data and
resolved discrepancies by consensus. The basic characteristics of the
included study are shown in characteristics of included studies
(Table 2).
3.3. Risk of bias in included studies
The assessment of the risk of bias is presented in Fig. 2. Some addi-
tional information was provided by the corresponding authors. In sum-
mary, the randomization process, missing outcome data, and selection of
the reported results of the five studies included were all rated as low
risk. Girlanda et al. [28] and Sanz et al. [29] were judged to be at low risk
of bias overall. Bittner et al. [30] Mastrangelo et al. [31] and Jacobs et al.
[32] were judged to be at some concerns, while Chen et al. [33] and Dai
et al. [34] were judged to be at high risk of bias overall.
3.4. Results of individual studies
3.4.1. Bone grafting materials mixed with collagen versus no grafting
materials
(1) Implant failure rate.
A total of two studies were included. Filiberto et al. (2018) and
Sanz et al. (2016) had the failure implants during the procedures.
There was no significant difference in the survival rate between the
two groups (95%CI:0.17 to 11.84), with no heterogeneity (I2= 0%)
between trials (Fig. 3).
(2) Buccal plate width changes of the alveolar ridge.
As shown in Fig. 4, a total of five studies were included. Bittner et
al. (2018) measured at 4 and 8 mm from the free gingival margin.
Chen et al. (2007) and Girlanda et al. (2019) measured the buccal
bone width based on the width between the margin of the implant
J. Liu, F. Hua, H. Zhang et al.
Fig. 1. Study flow diagram.
and the buccal plate. Sanz et al. (2016) chose to measure the bucco-
lingual dimension from implant to buccal bone plate 1 mm below the
crest while Jacobs et al. (2020) combined the following points:1 mm
subcrestal, at midroot, and 1 mm from the apex of the tooth. There
were significantly fewer buccal bone thickness changes in the graft-
ing group (MD: 0.27,95% CI 0.48 to 0.07), with no heterogeneity
(I2= 0%) between trials (Fig. 4).
(3) Change of soft tissue width.
Only Bittner et al. had the results of soft tissue outcome, measur-
ing the thickness at 3, 4, and 8 mm from the free gingiva margin, but
there were no statistically significant differences between groups
(Fig. 5).
(4) Pink esthetic scores.
Two studies chose the PES scores [35] to evaluate the esthetics
outcome, and it showed the grafting group had the better esthetics
scores (MD: 1.23,95% CI 1.90 to 0.55), with no heterogeneity
(I2= 0%) (Fig. 6).
3.4.2. Bone grafting materials mixed with collagen versus only bone
grafting materials
(1) Implant survival rate.
The survival rate of implants in the collagen group and only the
bone grafting group was 100% with no statistical difference.
(2) Buccal plate width changes of the alveolar ridge.
As shown in Fig. 7, a total of two studies were included. The
width-changing data of the buccal bone plate between the two
4
Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101385
groups showed no significant difference(MD=0.11; 95%CI 0.20 to
0.41), with no heterogeneity (I2= 0%) between trials (Fig. 7).
4. Discussion
The purpose of this review is to discuss the impact of using colla-
gen during immediate implant placement. The survival rate of
implants does not differ significantly between bone grafting materi-
als mixed with collagen and bone grafting materials or no materials.
Given the broad confidence intervals and the limited number of
investigations, collagen mixed with grafting materials may either
increase or decrease the absorption of the buccal plate.
We found no significant difference between using collagen on the
survival rate of the immediate implant placement. That could be
accounted for all studies included had the strict inclusion criteria for
patients who would do the immediate implant placement: intact
facial bone wall with thick wall phenotype (> 1 mm), thick soft tissue
biotype, no acute infection in the socket and sufficient bone volume
apically to stabilize the implant in a correct three dimensional posi-
tion [4]. The short-term survival rate of immediate implant place-
ment is similar to that of implants placed in healed sites with longer
follow-ups [12]. Lang et al. showed the factor which could affect the
failure of the implants is the regimen of antibiotics only. One study
reported the reasons for loss to follow, one of them was a lost implant
during the healing period, and it was not included in the final results,
[28] we speculated it would have an impact on the real survival rate.
Four patients were excluded from the study [28] because they did
not present adequate insertion torque, but the writer did not explain
which group they were first included in, also we thought it would
have an impact on the final results.
By using collagen combined with grafting materials, we found the
advantage of reducing the absorption of the buccal bone. Sanz et al.
[29] and Chen et al. [33] thought putting materials in the “jumping
gap” could be helpful for the stability of the thickness of the buccal
bone, while Bittner et al. [30], Girlanda et al. [28] and Jacobs et al.
[32] came to the opposite results.
 J. Liu, F. Hua, H. Zhang et al.
Table 2
Characteristics of included studies.

Author (year) Bittner et al. Chen et al. Dai et al. Girlanda et al. [28] Jacobs et al. Mastrangelo et al. [31] Sanz et al.
[30] [33] [34] [32] [29]

Country (setting) USA(Educational) Australia(private China(Educational) Brazil(Educational) USA(Educational) Italy (private practice) Spain, Sweden, Italy
practice) (Educational)
M: F ratio Intervention 9:23 7:13 18:17 4:18 8:11 31:20 22:21
Control 3:7 6:8 32:19 19:24
Mean age in years § SD Intervention 52.3 § 4 46.8 § 10.8 40.1 § 12.3 21 to 58 53§20 44§6.7
or (range) Control 42.1 § 11.0 65§14
Follow-up in months (reference) 12 36 12 6 10 36 4
Sample size (patients Intervention 16 10 35 11 19 51 45
randomized) Intervention-2 10
Control 16 10 35 11 14 51 46
Number of implants Intervention 16 10 40 11 19 64 44
Intervention-2 10
Control 16 10 40 11 14 51 43
Maxilla or mandible (anterior or posterior) Maxilla Maxilla Maxilla Maxilla Maxilla Maxilla Maxilla
Intervention Deproteinized bovine Anorganic bovine bone Mineralized collagen Deproteinized bovine Xenograft(Bio- Xenograft(Bio- Xenograft(Bio-oss
bone mineral with (Bio-Oss) (MC bone-derived with oss) + Collagen dress- oss) + Resorbable Collagen)
10% collagen (DBBM- collagen (Bio-Oss ing(Collagen plug)) membrane(BioGuide)
C; Bio-Oss Collagen) Collagen)
Intervention-2 Anorganic bovine bone
and resorbable colla-
gen membrane(Bio-
Oss)
Control No biomaterial No biomaterial Anorganic bovine bone No biomaterial No biomaterial No biomaterial or No biomaterial
(Bio-Oss membrane
Implants Certain, ITI XIVEÒ Biomet 3i Full Osseotite OsseoSpeed TX Profile, tioLogic Implant System, (Fixture MicrothreadTM
5

Zimmer Biomet Implant System; Insti- And Tapered Certain— Dentsply Sirona Dentaurum, Germany OsseoSpeedTM;
tut Straumann AG, Nobel ActiveÒ Palm Beach Dentsply, Mo€ lndal,
Waldenberg, Gardens, FL) Sweden
Switzerland
Outcomes used in the meta-analysis Horizontal change (buc- Oral hygiene and tissue Survival, complications, Soft tissue height Soft-tissue esthetics, Implant failures, Implant
colingual change), health, complications, vertical labial bone (mesiobuccal, buccal, vertical buccal bone peri-implant marginal failure,horizontal

Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101385

Vertical Dimensional Vertical labial bone resorption, horizontal and distobuccal), buc- resorption, horizontal bone loss, buccal bone
Changes, and soft tis- resorption Horizontal labial bone resorption, colingual distance buccal bone resorp- patient satisfaction resorption
sue thickness. labial bone resorption, Soft-tissue esthetics, (1 mm, 3 mm, and tion,mid-buccal evaluated with the
Mid-buccal mucosal Patient satisfaction 5 mm apical to the mucosal recession pink esthetic score
recession bone crest), the dis- (PES),
tance between the probing pocket depth,
buccal bone surface biological complica-
and implant platform tions (fistulas, mucosi-
(GAP) tis, and
periimplantitis)
Failure number of Intervention 0 0 0 0 0 1 1
implants Intervention-2 0
Control 0 0 0 0 0 1 0
J. Liu, F. Hua, H. Zhang et al. Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101385

Fig. 2. Risk of bias summary: review authors’ judgments about each risk of bias item for each included study.

Fig. 3. Analysis 1.1 Comparison 1: Bone grafting materials mixed with Collagen versus no grafting materials, Outcome 1: the implant failure rate.

Fig. 4. Analysis 1.2 Comparison 1: Bone grafting materials mixed with Collagen versus no grafting materials, Outcome 2: Buccal plate width changes of the alveolar ridge.

Fig. 5. Analysis 1.3 Comparison 1: Bone grafting materials mixed with Collagen versus no grafting materials, Outcome 3: change of soft tissue width.

Fig. 6. Analysis 1.3 Comparison 1: Bone grafting materials mixed with Collagen versus no grafting materials, Outcome 4: pink esthetic scores.

Fig. 7. Analysis 2.2 Comparison 2: Bone grafting materials mixed with Collagen versus only bone grafting materials, Outcome 2: Buccal plate width changes of the alveolar ridge.

6
J. Liu, F. Hua, H. Zhang et al.
The previous reviews showed that bone-substitute materials used
during immediate implant placement could reduce the buccal bone
loss caused by the high activity of osteoclastic [10,36]. Lorenz et al.
thought socket grafting may contribute to horizontal bone preserva-
tion, the studies included used different bone grafting materials, and
different materials are different manifestations in guide bone regen-
eration [37]. The buccal gap width could affect the thickness of the
newly formed buccal wall, and with appropriate gap width, could
promote a thicker buccal bone wall [38]. Even for the damaged buccal
socket wall, grafting materials would achieve favorable esthetic out-
comes [39].
The width and height of the alveolar ridge changed because it had
 jo et al. provided
been remodeled after the teeth extraction [40]. Arau
the placement of an implant in the fresh extraction site failed to pre-
vent the re-modeling that occurred in the walls of the socket [41].
Also, they have found that immediate implant installation failed to
prevent dimensional reduction of the alveolar bone and buccal bone
loss [3]. Ridge preservation techniques with or without immediate
implant placement could help to reduce the horizontal bone mor-
phology because the grafting material promoted de novo hard tissue
formation and the walls of the fresh extraction socket somewhat
counteracted the contraction of the buccal hard tissue plate [42].
While it did not show significant improvement in the horizontal lin-
ear and volumetric changes at the buccal soft tissue and it was due to
a significant increase in soft tissue thickness in spontaneously healing
sites [43].
Esthetic outcomes might be improved by putting collagen com-
pared with bone materials around the immediate implant. Because
the materials might be helpful to the contour of the buccal bone and
the maintenance of gingival height [32,31]. Also the previous studies
showed the collagen material was used in the soft tissue grafting
[44,45].
Type I collagen is the main component of the extracellular matrix
(ECM) of bone and plays an important role in the bone cellular net-
work. Type I collagen can induce osteoid formation and mineraliza-
tion and enhance mRNA expression of cellular proteins.so it can do
favor to bone healing [46] with the nonirritating integration, excel-
lent tissue compatibility and help to volume stability, collagen can be
wildly used in dental implant. Bone graft materials combined with
collagen could prevent the displacement of bone particles. Collagen
can also be an alternative to the subepithelial connective tissue graft
(SCTG) because it serves as a scaffold for ingrowing blood vessels and
cells [46].
Besides the grafting materials in the “jumping gap”, there were
still some factors that could affect clinical outcomes including ana-
tomical factors and surgical and restorative factors [12]. The root
position will affect the difficulty of the surgery [47] and the implant
site for immediate placement [48].
The thickness of the buccal bone, [49] the horizontal gap, [50,51]
the gingival phenotype [51,52] the flapless technique [36] will affect
the clinical outcomes by affecting the surgical procedures. And with
or without immediate provisionalization influenced the esthetic out-
come [53,54].
Following a summary analysis of the included research, it was
shown that patients with thicker buccal bone plates experienced less
shape alterations during postoperative recovery and might attain
superior esthetic outcomes. Perhaps because the thick buccal bone
plate is formed of dense bone and cancellous bone, the blood supply
is less likely to cause bone loss after tooth extraction with the thick
buccal bone plate than with the thin buccal bone plate composed of
just dense bone. In investigations employing flapless method, there
is no statistically significant difference between the two groups.
Unlike those who underwent conventional surgery, those who did
not receive a bone graft were more likely to experience buccal bone
loss [29, 33]. In addition, the flapless approach can be advantageous
for retaining the buccal plate. In studies of postoperative wound
7
Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101385
closure employing temporary provisionalization or tailored abut-
ment, it was also discovered that there are fewer changes in soft and
hard tissue in the immediate postoperative period.
The studies included in this review were limited, some of them
had a high risk of bias, and the heterogeneity among the studies was
not uniform. At present, the research on the influence of using colla-
gen for guided bone regeneration is mainly reflected in alveolar ridge
preservation [55−58].
5. Conclusion
Bone grafting materials with collagen could not be demonstrated
to affect the survival rate of the immediate implant. And it turned out
that bone grafting materials with collagen placed in the jumping gap
did have significant advantages on the thickness of the buccal bone
and the esthetic outcomes in the statement of immediate implant
placement, but we did not find any significant advantages in the
other areas. While in the immediate implant placement, the studies
on the advantages of collagen combined with bone grafting materials
over bone substitute materials are limited. In the future, more basic
studies may be needed to explore the effect of collagen addition on
gap osteogenesis, and to talk about the clinical outcome of using col-
lagen.
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