J Clin Periodontol 2012; 39: 582–589 doi: 10.1111/j.1600-051X.2012.01888.

A systematic review on the Jan Cosyn1,2, Nele Hooghe1 and

Hugo De Bruyn1
1
Department of Periodontology and Oral

frequency of advanced recession Implantology, University of Ghent, Faculty of

Medicine and Health Sciences, Dental
School, Ghent, Belgium; 2Dental Medicine,

following single immediate Free University of Brussels (VUB), Brussels,

Belgium

implant treatment
Cosyn J, Hooghe N, De Bruyn H. A systematic review on the frequency of
advanced recession following single immediate implant treatment. J Clin Periodontol
2012; 39: 582–589. doi: 10.1111/j.1600-051X.2012.01888.x.

Abstract
Purpose: It has been stated that midfacial recession is common following immedi-
ate implant treatment (IIT). The objective of this systematic review was to assess
the frequency of advanced recession (>1 mm) following single IIT.
Material and methods: An electronic search in Pubmed, Web of Science and the
Cochrane Oral Health Group Specialized Trials Register database was performed
using a search algorithm. Reference lists of relevant articles were also scrutinized
to identify prospective studies on  10 implants installed in patients with an intact
buccal bone wall and followed for  12 months. Study eligibility and quality were
independently assessed by two investigators. Primary outcome variables were
advanced inter-proximal and midfacial recession defined as soft tissue loss surpass-
ing 1 mm between the pre- or postoperative status and the final re-assessment.
Results: Thirteen of 171 papers were selected. Inter-examiner agreement on eligi-
bility (j = 0.879; p < 0.001) and quality (j = 0.788; p < 0.001) was high.
Advanced inter-proximal recession was described in 0–27% of the cases. However,
these data were only based on two studies. Mean inter-proximal recession was fre-
quently reported (11/13) and was <1 mm in all studies suggesting limited risk for
advanced inter-proximal recession. Advanced midfacial recession was described in
0–64% of the cases. Again, few papers provided such information (4/13). Only
one of these studies demonstrated high risk for advanced midfacial recession
(>10%). This could be attributed to the fact that implants had not been restored
with an immediate implant crown, which seems of pivotal importance given the
results of a randomized controlled trial reporting on the preserving effect of imme-
diate provisionalization on midfacial mucosa level. There is limited evidence to
support an increased risk for midfacial recession following flap surgery and in
patients with a thin-scalloped gingival biotype. The impact of implant-specific
parameters on inter-proximal and midfacial soft tissue level seems conflicting.
Conclusions: Soft tissue recession may be expected following IIT and multiple
factors seem to contribute to the phenomenon. Taking into account the paucity
of papers, patients with an intact buccal bone wall and thick gingival biotype,
treated by means of flapless surgery and an immediate implant crown may dem- Key words: Dental implant; immediate;
onstrate limited risk for advanced midfacial recession (<10%). Proper risk assess- papilla; recession; single tooth
ment addressing diagnostic, surgical and restorative aspects is mandatory to
avoid compromised outcome of IIT. Accepted for publication 26 March 2012

582 © 2012 John Wiley & Sons A/S

 Recession at immediate implants 583

Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests. The study was
self-funded by the authors and their
institution.
According to a number of systematic
reviews single implant treatment is
predictable and successful, at least in
terms of classical outcome variables
following conventional implant sur-
gery (Creugers et al. 2000, Bergl-
undh et al. 2002, den Hartog et al.
2008, Jung et al. 2008). Still, data on
clinical response parameters, compli-
cations and bone remodelling may
be considered limited to describe the
overall outcome of single implants.
Society is evolving with more and
more patients focusing on aesthetic
aspects of treatment outcome. This
may explain the growing interest by
scientists for soft tissue dynamics,
objective aesthetic ratings and
patient-centred outcomes.
The progressive shortening of the
healing time from tooth loss to
implant installation finally resulting
in immediate implant placement,
may be the ultimate reflection of
patient’s expectations. Apart from
the time gain it is clear, however,
that this procedure is potentially
risky especially from a surgical point
of view. The ideal three-dimensional
implant position usually deviates
from the alveolar socket, therefore
requiring highly experienced and
skilled surgeons to overcome incor-
rect positioning. Also diagnostic
considerations need to be properly
addressed as it has been shown that
immediate implantation may not
avert post-extraction remodelling
(Botticelli et al. 2004, Araújo et al.
2005). In this respect an intact buc-
cal bone wall seems mandatory.
Indeed, high risk for advanced mid-
facial recession has been described
following immediate implant treat-
ment (IIT) and simultaneous guided
bone regeneration of buccal bone
defects (Kan et al. 2007). In addition,
midfacial recession may not be
avoided by a thick gingival biotype,
flapless surgery or connective tissue
grafting in these patients, stressing
the pivotal importance of an intact
buccal bone wall for IIT (Kan et al.
2007).
In a recent review article midfacial
recession was found common follow-
ing IIT (Chen & Buser 2009). How-
ever, studies were not selected on the
basis of eligibility and quality criteria,
making conclusions possibly biased.
The purpose of this study was to sys-
tematically review the available litera-
ture on the occurrence of advanced
recession (>1 mm) based on the fol-
lowing focused research question:
‘what is the frequency of advanced
recession in patients who received an
immediate single implant’?
Material and Methods
Study selection
The PRISMA checklist (Moher et al.
2011) was consulted and used as a
guide for quality reporting of a sys-
tematic review. Only full-text reports
in English on clinical studies pertain-
ing to IIT for single-tooth replace-
ment were considered. In this
context IIT was defined as the instal-
lation of a dental implant into an
extraction socket.
Inclusion criteria were:
1 Prospective case series or random-
ized controlled trial (RCT)
2 Results on at least 10 cases
3 Follow-up of at least 12 months
4 Results on at least 1 outcome vari-
able of interest

Table 1. Checklist for quality assessment

Quality assessment of randomized controlled trials Quality assessment of prospective case series

Randomization
1. Were adequate methods used for randomization?
Patient and site characteristics
1. Were patient characteristics well described for both groups?
2. Were site characteristics well described for both groups?
3. Were there no disparities in terms of patient or site characteristics
between the groups?
Patient selection
1. Were the inclusion and exclusion criteria well described and
the same for both groups?
2. Did the study report on consecutively treated patients?
Intervention
1. Were interventions for both groups clearly described?
2. Were all patients of the same group treated according to
the same intervention?
Evaluation method
1. Was blinding used to assess the outcome?
2. Were adequate methods used to assess the outcome?
3. Were reproducibility data reported on the outcome variable(s)?
Outcome & follow-up
1. Was the outcome clearly described?
2. Was an intention-to-treat analysis performed and was there
low risk for selective loss to follow-up?
N/A
Patient and site characteristics
1. Were patient characteristics well described?
2. Were site characteristics well described?
Patient selection
1. Were the inclusion and exclusion criteria well described?
2. Did the study report on consecutively treated patients?
Intervention
1. Was the intervention clearly described?
2. Were all patients treated according to the same
intervention?
Evaluation method
1. Was the outcome assessed by an investigator
who had not been involved in the treatment?
2. Were adequate methods used to assess the outcome?
3. Were reproducibility data reported on the outcome
variable(s)?
Outcome & follow-up
1. Was the outcome clearly described?
2. Was the response rate acceptable and was the number
of patients lost to follow-up clearly described?

N/A, not applicable.

© 2012 John Wiley & Sons A/S

584 Cosyn et al.

Exclusion criteria were: Search strategy bias as much as possible, studies

1 Retrospective case series or cross-
sectional study
2 Molar replacements
3 Missing natural teeth adjacent to
the implant restoration
4 Regeneration or augmentation of
the alveolar process prior to or
during implant surgery
5 Soft tissue grafting
Socket grafting, that is the appli-
cation of autogenous bone and/or
biomaterials within the confines of
the extraction socket, was not con-
sidered an exclusion criterion.
Outcome variables
In the context of the present study
advanced recession was defined as
soft tissue loss surpassing 1 mm
between the pre- or postoperative
status and the final re-assessment.
Advanced inter-proximal reces-
sion and advanced midfacial reces-
sion were considered primary outcome
variables and results were expressed as
proportions, given the aforementioned
focused research question.
Secondary outcome variables were
mean inter-proximal and midfacial
recession, fill of the embrasure space,
aesthetic soft tissue ratings by
clinicians and patient’s aesthetic
satisfaction.
An electronic search was performed
in Pubmed, Web of Science and the
Cochrane Oral Health Group Spe-
cialized Trials Register database by
two investigators (JC, NH) until the
31th of July 2011. The following
search algorithm was used: Dental
implants, single tooth [MeSH] AND
(papilla [free text word] OR reces-
sion [free text word]). In addition,
reference lists of relevant articles
were scrutinized to include as much
studies as available.
Assessment of study quality
Following the selection of eligible
papers on the basis of inclusion and
exclusion criteria, studies were rated
on their quality. Specific study-
design related forms designed by the
Dutch Cochrane Collaboration were
used as a basis. For each study type
a checklist was developed focusing
on randomization (if applicable),
patient and site characteristics,
patient selection, intervention, evalu-
ation method, outcome and follow-
up (Table 1). Two investigators (JC,
NH) independently generated a score
for all selected articles, expressed in
the numbers of plusses given. A
score of at least 8 plusses was
considered to be methodologically
acceptable for RCTs and 7 plusses
for case series. To reduce the risk for
showing poor quality on the basis of
this assessment were excluded.
Statistical analysis
Given the limited number of selected
studies and the heterogeneity among
them in terms of possible factors
affecting recession, the data were
analysed from a descriptive point of
view. j statistics were used to evalu-
ate inter-examiner agreement on
study eligibility and quality.
Results
Search results
All search strategies provided 171
papers after eliminating titles that
were present in different searches.
Two investigators (JC, NH) indepen-
dently identified 18 eligible papers.
Inter-examiner agreement on study
eligibility was high (j = 0.879;
p < 0.001). Disagreement mainly
related to aspects of hard tissue aug-
mentation, which could be resolved
by discussion. Eligible studies were
methodologically assessed by the
same investigators with high agree-
ment (j = 0.788; p < 0.001). Five
studies did not meet the quality
requirements and were excluded
(Norton 2004, Ferrara et al. 2006,
Chen et al. 2007, Block et al. 2009,

Table 2. Studies excluded after quality assessment and reasons for exclusion
Authors Study design Reasons for exclusion

Norton (2004), Case series Site characteristics incomplete (gingival biotype not described); patients not treated according to
same intervention (flap or flapless surgery); outcome possibly assessed by an investigator
involved in the treatment; methods used to assess the outcome unclear; no reproducibility data;
no actual data on the outcome
Ferrara et al. (2006), Case series Site characteristics incomplete (gingival biotype not described); outcome possibly assessed by an
investigator involved in the treatment; no reproducibility data; methods used to assess the
outcome unclear; no actual data on the outcome
Chen et al. (2007), RCT Patients not treated according to same intervention (with or without connective tissue graft); no
blinding described; methods used to assess the outcome unclear; no reproducibility data; no
actual data on the outcome at the final re-assessment; no significance testing; high risk for
selective loss to follow-up
Block et al. (2009), RCT Patients characteristics incomplete (age not described); site characteristics incomplete (reasons
for tooth loss, gingival biotype not described); disparities between the groups in terms of
patient or site characteristics not evaluated; patients not treated according to same intervention
(flap or flapless surgery, AB or AL); outcome not clearly described; unclear whether an
intention-to-treat analysis was performed; high risk for selective loss to follow-up
Cooper et al. (2010) Case series Site characteristics incomplete (reasons for tooth loss, gingival biotype not described); unclear
whether patients were consecutively treated; patients not treated according to same intervention
(flap or flapless surgery); outcome possibly assessed by an investigator involved in the
treatment; inadequate methods used to assess the outcome (clinical crown length measured on
provisional and permanent restoration); no reproducibility data; outcome not clearly described

RCT, randomized controlled trial; AB, autogenous bone; AL, allograft.

© 2012 John Wiley & Sons A/S

 Table 3. Experimental characteristics and results of prospective clinical studies on single immediate implant treatment
Authors Study Implant Follow-up No of Gingival Flap/ Socket Immediate Fill of the Inter- Midfacial Pink Patient’s
design system (mo) implants/ biotype flapless grafting implant embrasure proximal recession aesthetic aesthetic
No of crown space recession (mean) score appreciation
patients (mean)

Kan et al. Case Replace 12 35/35 Thin & Flapless No Yes / M: 0.55 mm 0.55 mm / Mean 9.9/10
2003, series select thick D: 0.39 mm
Kan et al. Case Replace 24–96 35/35 Thin & Flapless No Yes / M: 0.22 mm 1.13 mm / 11%
2011, series select thick D: 0.21 mm unsatisfied

© 2012 John Wiley & Sons A/S

Canullo & Case Defcon 18–36 10/9 Thin & Flapless Yes Yes / M: 0.40 mm* NS / /
Rasperini series thick (AB & D: NS
2007, X if gap
>1 mm)
De Rouck Case Replace 12 30/30 Thick Flap Yes (X) Yes / M: 0.41 mm 0.53 mm / Mean
et al. series select D: NS 93/100
2008,
Cosyn Case Replace 36 25/25 Thick Flap Yes (X) Yes / M: NS 0.34 mm Mean /
et al. series select 4% >1 mm 8% >1 mm 10.48
2011, D: NS 16%
16% >1 mm 7
Lops Case Astra tech 12 46/46 Thick Flap No No M+D: / / / /
et al. series 68%§
2008,
Romeo Case Straumann 12 48/48 Thin & Flap No No M+D: / / / /
et al. series thick 67%§
2008,
Canullo RCT: Global 24–27 11/11 Thin & Flapless Yes Yes / M: NS NS / /
et al. conical thick (X if 0%>1 mm 0%>1 mm
2009, connection & gap D: NS
platform >1 mm) 0%>1 mm
switch
Flat-to-flat Global 24–27 11/11 Thin & Flapless Yes Yes / M: 0.77 mm 0.45 mm / /
connection thick (X if 18%>1 mm 0%>1 mm
gap D: 1 mm
>1 mm) 27%>1 mm
Cordaro RCT: Straumann 12 16/16 Thin & Flap No No / M: 0.83 mm 0.73 mm / /
et al. Non- thick D: 0.63 mm 53%>1 mm
2009, submerged
Submerged Straumann 12 14/14 Thin & Flap No No / M: 0.96 mm 0.82 mm / /
thick D: 0.82 mm 64%>1 mm
Recession at immediate implants
585
586 Cosyn et al.

Cooper et al. 2010). Reasons for

appreciation
Patient’s
aesthetic exclusion are depicted in Table 2.

93/100

91/100
One examiner (NH) extracted all

Mean

Mean
data from the selected papers.

RCT, randomized controlled trial; RPD, removable partial denture; mo, months; Membr, membrane; X, xenograft; AB, autogenous bone; M, mesial; D, distal; NS, non significant.
/

/
Finally, 13 papers could be iden-
tified (Kan et al. 2003, 2011, Canullo
aesthetic
score
Pink

10.33
13%
Mean
& Rasperini 2007, De Rouck et al.

7
2008, 2009, Lops et al. 2008, Romeo
/

/
et al. 2008, Canullo et al. 2009,

7% >1 mm
Cordaro et al. 2009, Tortamano
Midfacial
recession
(mean)

et al. 2010, Cosyn et al. 2011, Pieri

0.41 mm

1.16 mm

0.61 mm

0.73 mm
et al. 2011, Raes et al. 2011).
NS

NS
The papers by Kan et al. (2003,
2011) related to the same study sam-
ple with different follow-up. The same
proximal
recession

applied to the studies by De Rouck

(mean)
Inter-

0.31 mm

0.53 mm

0.28 mm

0.33 mm
mm D :

et al. (2008) and Cosyn et al. (2011).

mm D:

mm D:

mm D:
M: 0.44

M: 0.24

M: 0.33
D: NS

D: NS
M: NS

M: NS
Nine studies were case series
0.43
M:

(Kan et al. 2003, 2011, Canullo &

Rasperini 2007, De Rouck et al.
embrasure
Fill of the

2008, Lops et al. 2008, Romeo et al.

space

2008, Tortamano et al. 2010, Cosyn

et al. 2011, Raes et al. 2011) and
/

/
four were RCTs (Canullo et al.
2009, Cordaro et al. 2009, De Rouck
Immediate
implant
crown

et al. 2009, Pieri et al. 2011).

Only Canullo & Rasperini (2007)
Yes

Yes

Yes

Yes

Yes
No

did not provide information on the

reasons for tooth loss. Cases where
(AB & X)

(AB & X)

the tooth had been extracted because

Yes (X &
grafting

membr)
Socket

Yes (X)

of advanced periodontal disease were

Yes

Yes

specifically excluded in the study by

No

No

Lops et al. (2008), Romeo et al.

(2008) and Tortamano et al. (2010).
5 flap/11
flapless
Flapless

Flapless

Flapless
flapless
Flap/

§Percentage of cases showing complete fill of the embrasure space at study termination.

All studies related to maxillary

Flap

Flap

implants. Three studies related to

maxillary as well as mandibular
Gingival

implants (Lops et al. 2008, Romeo

biotype

Thick

Thick

Thick

et al. 2008, Cordaro et al. 2009).

Pieri et al. (2011) only included pre-
?

molar replacements in the upper jaw.

implants/

patients

Altogether data pertaining to six

No of

No of

24/24

25/25

12/12

20/20

20/20

16/16

different implant systems were avail-

able. The most frequently used sys-
tem was Replace Select® by Nobel
Follow-up

Biocare (Göteborg, Sweden) (Kan

(mo)

12

12

18

12

12

12

et al. 2003, 2011, De Rouck et al.

2008, 2009, Cosyn et al. 2011).
In all but two studies (Tortamano
Straumann

Astra tech

et al. 2010, Pieri et al. 2011) infor-

Implant
system

Replace

Replace

mation on the gingival biotype was

smiler

smiler
select

select

*Negative value indicates tissue gain.

Samo

Samo

provided. In all papers surgical (flap/

flapless surgery, socket grafting) and
restorative procedures (immediate
& platform

implant crown) were described.

connection

connection
submerged

Submerged

Flat-to-flat
design
Study

& crown

& RPD

conical

switch
Series

series
Non-
RCT:

RCT:
Table 3. (Continued)

Case

Case

Inter-proximal recession

Only in two studies the frequency of

advanced inter-proximal recession
Tortamano
De Rouck

was reported (Canullo et al. 2009,

Authors

2009,

2010,

2011,
et al.

et al.

et al.

et al.
2011

Cosyn et al. 2011) (Table 3). For

Raes
Pieri

mesial and distal papillae this

© 2012 John Wiley & Sons A/S

occurred in 0–18%, 0–27% respec-
tively, of the cases.
Mean inter-proximal recession
was frequently reported (11/13) and
was low in all studies (<1 mm) sug-
gesting limited risk for advanced
inter-proximal recession. In one
study even some tissue gain was
observed (Canullo & Rasperini
2007). The few results on fill of the
embrasure space also indicated lim-
ited risk for advanced inter-proximal
recession with complete fill in nearly
70% of the cases (Lops et al. 2008,
Romeo et al. 2008).
Two studies showed a key impact
of the tooth-to-implant distance and
the level of the contact point in
relation to the bone crest on papilla
height (Lops et al. 2008, Romeo
et al. 2008). One study demonstrated
significantly more incomplete papil-
lae in patients with a thin-scalloped
gingival biotype (Romeo et al. 2008).
However, the changes in papilla
height over time were found to be
comparable for patients with a
thick and thin-scalloped gingival
biotype (Kan et al. 2011). Finally,
Canullo et al. (2009) demonstrated
in a RCT significantly less inter-
proximal recession for implants with
a conical connection and platform
switch when compared with implants
with a flat-to-flat connection and
without abutment diameter reduc-
tion. However, this could not be
confirmed by another RCT (Pieri
et al. 2011).
Midfacial recession
Immediate implant crown
In four studies the frequency of
advanced midfacial recession was
actually reported (Canullo et al.
2009, Cordaro et al. 2009, Cosyn
et al. 2011, Raes et al. 2011)
(Table 3). Advanced midfacial reces-
sion was an infrequent finding affect-
ing <10% of the implants in all but
one study. Cordaro et al. (2009)
demonstrated high risk (  53%).
The fact that an immediate implant
crown was not installed in that par-
ticular study in contrast with the
others, may explain the disparity.
There is evidence from a RCT to
support a preserving effect of an
immediate implant crown on midfa-
cial mucosa level following IIT (on
average 0.75 mm less midfacial
recession) (De Rouck et al. 2009).
© 2012 John Wiley & Sons A/S
Recession at immediate implants
Flapless surgery
Midfacial mucosa level was not
affected by implant surgery in four
studies (Canullo & Rasperini 2007,
Canullo et al. 2009, Tortamano et al.
2010, Raes et al. 2011) (Table 3). In
two of these investigations the gap
between the implant and bone wall
was not filled with a grafting material
(Tortamano et al. 2010, Raes et al.
2011). Hence, the need for socket
grafting to limit the amount of mid-
facial recession seemed inconclusive.
On the other hand, all four studies
were related to immediate implant
installation via flapless surgery. Raes
et al. (2011) demonstrated signifi-
cantly less midfacial recession follow-
ing a flapless approach when compared
with flap surgery.
Gingival biotype
Mean midfacial level showed accept-
able shrinkage (<1 mm) following IIT
in all but one study (Table 3). In the
paper by Kan et al. (2011) mean mid-
facial recession amounted to 1.13 mm.
A significant difference could be dem-
onstrated between patients with a
thick gingival biotype (mean
0.56 mm) and thin-scalloped gingival
biotype (mean 1.50 mm). This is in
accordance with Cordaro et al. (2009)
showing advanced midfacial recession
in 38% and 85% of the patients with a
thick and thin-scalloped gingival bio-
type respectively.
Implant-specific parameters
The impact of implant-specific
parameters on midfacial recession
was investigated in two RCTs
(Table 3). Canullo et al. (2009) dem-
onstrated significantly less midfacial
recession for implants with a conical
connection and platform switch
when compared with implants with a
flat-to-flat connection and without
abutment diameter reduction. How-
ever, this could not be confirmed by
another RCT (Pieri et al. 2011).
Aesthetic aspects of treatment outcome
In two studies soft tissue aesthetics
were rated using the pink aesthetic
score by Fürhauser et al. (2005) (Co-
syn et al. 2011, Raes et al. 2011)
(Table 3). In both papers mean pink
aesthetic score was 10/14. A score of
7 or less was considered an aesthetic
failure as earlier proposed (Cosyn
587
et al. 2010) and was found in 13–
16% of the cases.
In three studies patient’s aesthetic
appreciation was assessed using a
questionnaire with a 0–10 score (Kan
et al. 2003) or visual analogue scales
(De Rouck et al. 2008, 2009)
(Table 3). Mean appreciation values
were high in these studies (mean 9.9/10
or  91/100). On the other hand, 11%
of the patients were unsatisfied because
of advanced midfacial recession in a
recent paper by Kan et al. (2011).
Discussion
The purpose of this study was to
systematically review the available
literature on the frequency of
advanced recession following single
IIT.
Although the frequency of
advanced inter-proximal recession
was clearly underexposed in
research, mean inter-proximal reces-
sion was <1 mm in all studies indi-
cating limited risk following IIT.
Two studies identified the tooth-to-
implant distance and the level of the
contact point in relation to the bone
crest as key factors for maintaining
papillae (Lops et al. 2008, Romeo
et al. 2008). Since periodontal dis-
ease affects the level of the bone
crest, periodontitis patients may be
considered at risk for papilla loss. In
a recent study on various modalities
of single implant treatment, tooth
loss because of periodontal disease
was found a major risk factor for
incomplete papillae (Cosyn et al.
2012). Note that cases where the
tooth had been extracted because of
advanced periodontal disease were
only specifically excluded in 3 of 13
studies (Lops et al. 2008, Romeo
et al. 2008, Tortamano et al. 2010).
Another primary outcome vari-
able of the present study was the fre-
quency of advanced midfacial
recession. In a recent review article
Chen & Buser (2009) concluded that
advanced midfacial recession is com-
mon following IIT. In three of four
studies with data on the parameter
of interest, advanced midfacial reces-
sion was an infrequent finding affect-
ing <10% of the implants (Canullo
et al. 2009, Cosyn et al. 2011, Raes
et al. 2011). However, in contrast
with Chen & Buser (2009), we only
included prospective studies on IIT
in patients with an intact buccal
588 Cosyn et al.
bone wall. As shown earlier, patients
with a facial osseous defect may not
be considered candidates for IIT as
advanced midfacial recession seems
inevitable (Kan et al. 2007). Even in
case of an intact buccal bone wall,
proper diagnosis remains important.
In this respect, patients with a thin-
scalloped gingival biotype have been
shown to be at risk for midfacial
recession as reported in two studies
(Cordaro et al. 2009, Kan et al.
2011). This may not be surprising
because this biotype reflects the lim-
ited underlying bone support. As the
buccal bone wall in these patients is
predominantly built up by bundle
bone that entirely resorbs following
tooth loss and regardless of implant
placement, midfacial recession may
be a logic consequence. Hence, IIT
should be avoided in patients with a
thin-scalloped gingival biotype.
Apart from diagnostic consider-
ations, clinicians should also take
into account aspects specifically
relating to implant surgery in extrac-
tion sockets. A correct three-dimen-
sional implant positioning has been
considered important for predicable
soft tissue levels (Buser et al. 2004),
which may be hampered by the alve-
olar socket. An association of buccal
malpositioning and midfacial reces-
sion has been described (Chen et al.
2007, 2009) and calls for experienced
and skilled surgeons when pursuing
IIT. Another surgical aspect relates
to the opening procedure. Remark-
ably, midfacial mucosa level was not
affected by implant surgery in four
studies and in all these a flapless
approach was used (Canullo &
Rasperini 2007, Canullo et al. 2009,
Tortamano et al. 2010, Raes et al.
2011). One study demonstrated sig-
nificantly less midfacial recession fol-
lowing flapless surgery (Raes et al.
2011), which is in line with a pre-
clinical study by Blanco et al. (2008)
showing a trend towards less reces-
sion and smaller biologic width
dimensions for flapless procedures.
Finally, restorative aspects may
also have an impact on the develop-
ment of midfacial recession following
IIT. There is evidence from a RCT
demonstrating a preserving effect of
an immediate implant crown on mid-
facial mucosa level (De Rouck et al.
2009). This could be confirmed by
four studies with data on the fre-
quency of advanced midfacial reces-
sion (Canullo et al. 2009, Cordaro
et al. 2009, Cosyn et al. 2011, Raes
et al. 2011). In three of these studies
an immediate implant crown was
installed and advanced midfacial
recession was found in <10% of
the implants (Canullo et al. 2009,
Cosyn et al. 2011, Raes et al. 2011).
Immediate provisionalization was
not performed in another study dem-
onstrating high risk (  53%) (Cord-
aro et al. 2009).
In 2005, an objective rating sys-
tem was introduced for the aesthetic
evaluation of peri-implant tissues
(Fürhauser et al. 2005) around single
implants and two studies could be
identified using this method (Cosyn
et al. 2011, Raes et al. 2011). In
spite of the fact that in these studies
patients had been carefully selected
and treated by experienced clinicians
according to delineated protocols,
13–16% of the cases could be con-
sidered aesthetic failures. As shown
by a recent study (Cosyn et al.
2012), this may also apply to other
modalities of single implant treat-
ment. Interestingly, patients seem
less critical in terms of aesthetics as
demonstrated by high aesthetic
appreciation scores.
It would be interesting from a sci-
entific and clinical point of view to
have information on recession fol-
lowing single implant treatment in
healed bone with the status prior to
tooth extraction as a reference. Only
as such the total amount of reces-
sion, being the result of post-extrac-
tion remodelling and implant
treatment, may be properly assessed
and compared with the amount of
recession following IIT. Even though
implant surgery in healed bone may
be considered the standard approach,
only two studies provided such infor-
mation to our knowledge (Block
et al. 2009, van Van Kesteren et al.
2010). As one of these studies was
excluded in this review because of
quality concerns (Block et al. 2009)
and the other only demonstrated
6-month data (Van Kesteren et al.
2010), definitive conclusions may be
premature. Future research should
focus on soft tissue dynamics follow-
ing conventional implant treatment
with appropriate baseline registra-
tion. Long-term RCTs would be
meaningful to investigate the impact
of the treatment concept on reces-
sion.
In this systematic review eligible
studies were rated on their quality
using specific study-design related
forms designed by the Dutch Coch-
rane Collaboration. This method
was also used by den Hartog et al.
(2008) to evaluate the outcome of
immediate, early and conventional
single implant treatment. Note that
other checklists based on the CON-
SORT statement for RCTs (Moher
et al. 2010) or STROBE statement
for case series (Von Elm et al. 2007)
could also have been used to evalu-
ate methodological background.
Albeit one method may be consid-
ered more detailed than another, we
believe that the papers we excluded
would have been omitted in any
quality assessment as clear data on
the outcome were missing in all five.
In conclusion, this systematic
search identified 13 of 171 papers on
the basis of eligibility and quality
criteria with data on inter-proximal
and/or midfacial recession following
single IIT. Few studies reported on
the primary outcome variables of
interest (4/13). Hence, the results of
this systematic review should be
interpreted within this context. On
the other hand, mean inter-proximal
recession was frequently reported
(11/13) and was <1 mm in all studies
suggesting limited risk for advanced
inter-proximal recession. Low risk
(<10%) for advanced midfacial
recession was found in patients with
an intact buccal bone wall and thick
gingival biotype, treated by means of
flapless surgery and an immediate
implant crown. Proper risk assess-
ment addressing diagnostic, surgical
and restorative aspects is mandatory
to avoid compromised outcome.
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Address:
J. Cosyn
Department of Periodontology and Oral
Implantology
University of Ghent, Faculty of Medicine and
Health Sciences, Dental School
De Pintelaan 185
B-9000 Ghent
Belgium
E-mail: jan.cosyn@ugent.be
flapless surgery and an immediate
implant crown.
Practical implications: IIT may be
considered a predictable procedure
when proper risk assessment is per-
formed addressing diagnostic, sur-
gical and restorative aspects.