The literature pertaining to immediate implant placement and immediate loading/restoration (Type 1a protocol) is continually expanding due to the appeal of this treatment approach. The advancement of dental implants, a more comprehensive understanding of bone biology, and the healing process following tooth extraction, together with the introduction of improved surgical and prosthetic protocols, have established the Type 1a protocol as a clinically and scientifically validated treatment option. Nevertheless, it is crucial to understand in which situations the protocol can be considered both safe and predictable. Following an extensive literature review that culminated in two systematic reviews prepared in advance of the Consensus Conference and in detailed on-site group discussions, Group 5 of the 7th ITI Consensus Conference was able to affirm that case selection is a fundamental factor in achieving successful outcomes. For low-risk patients/sites, the Type 1a protocol exhibits a high level of clinical performance. For medium-risk patients/sites, it may still be considered as an option, provided that additional regenerative procedures are undertaken. However, for high-risk patients/sites, this protocol cannot be recommended as a routine procedure. Furthermore, certain pre-operative factors must be taken into consideration when implementing such a protocol, with the use of digital technologies in data acquisition and interpretation being highly recommended. During implant placement, the presence of a gap between the implant and the facial bone greater than 2 mm in dimension that is also grafted is associated with improved clinical results. As for the prosthetic phase, it is advisable to ensure an appropriate emergence profile, light interproximal contacts, and the absence of any eccentric contacts. In the current article, we present a comprehensive overview of all the details discussed regarding the Type 1a protocol during the 7th ITI Consensus Conference in Lisbon, Portugal in 2023.
Historically, implants were placed only in healed ridges, mostly in edentulous arches and loaded after a minimum healing period of 3 - 4 months (Branemark et al. 1977; Adell et al., 1981; Albrektsson et al. 1981). However, with the fast development and evolution of implant dentistry, different timings for implant placement and loading protocols were suggested to increase the indications and pool of patients for which implant rehabilitation could be helpful (Buser et al. 2017). Such suggestions aim to identify the best possible treatment with predictable outcomes and with low morbidity and risk of complications.
The timing of implant placement and implant loading has been of interest to the ITI since it was first considered in 2003 at the 3rd ITI Consensus Conference (Cochran et al. 2004; Hämmerle et al. 2004; Chen et al. 2009; Weber et al. 2009; Gallucci et al. 2014; Morton et al. 2014; Feine et al. 2018; Gallucci et al. 2018; Morton et al. 2018). Definitions and terminology related to the timing of implant placement and loading protocols were proposed, followed by the documentation of esthetic complications, identification of risk factors, and inclusion criteria for each treatment option. Immediate implant placement proved to be an approach that received increased attention (Schulte et al. 1978). Some years later immediate placement was described in combination with immediate restoration or loading (Wohrle 1998). One of the most recent additions to the literature was the recognition that the surgical and restorative phases are strongly linked and highlight the importance of evaluating the outcome by combining the placement and loading protocols (Gallucci et al. 2018).
By definition, immediate implant placement is related to dental implants placed in a fresh extraction socket on the same day as tooth extraction (during the same procedure), while immediate loading/restoration is related to a prosthesis connected to the dental implants and placed in occlusion (loading) or held out of occlusion (restoration) with the opposing arch within one week of implant placement. The combination of such procedures is categorized as the Type 1a protocol (Gallucci et al. 2018). This protocol has been considered an attractive treatment option for clinicians and patients mainly due to reduced treatment time, clinical appointments and number of interventions as well as the potential to avoid removable provisional prostheses and treatment morbidity. The recent literature has shown high survival rates when applying such protocols (Gallucci et al. 2018; Cosyn et al. 2019; Pommer et al. 2021; Zhou et al. 2021; Garcia Sanchez et al. 2022).
This treatment protocol was considered in detail by Group 5 (implant placement and loading protocols) at the 7th ITI Consensus Conference. Prior to the ITI Consensus Conference 2023, two systematic reviews were conducted focusing on the clinical performance (Wittneben et al. 2023) and selection criteria related to patients as well as site factors (Hamilton et al. 2023) in cases where the Type 1a protocol was the treatment approach employed. At the Consensus Conference itself, both systematic reviews were then meticulously analyzed by an expert group composed of professionals from different backgrounds and specialities (Morton et al. 2023), with the primary aim of generating a series of statements and clinical guidelines for the dental community.
With all these dynamics in mind, this narrative review aims to summarize the content of the two systematic reviews and consider the consensus statements and recommendations made by the group in order to provide clinicians with the most up to date and evidence-based information related to immediate implant placement and immediate loading/restoration (Type 1a protocol).