Received: 6 March 2018 | Accepted: 17 April 2018

DOI: 10.1111/cid.12623

REVIEW

Stability of tapered and parallel-walled dental implants:

A systematic review and meta-analysis

Momen A. Atieh BDS, MSc, DClinDent, PhD1 |

Nabeel Alsabeeha DMD, MSc, MFDS RCPS (Glasg), PhD2 |

Warwick J. Duncan BDS, MDS, FRACDS, PhD3

1
Senior Lecturer in Periodontology, Sir John
Walsh Research Institute, Department of
Abstract
Oral Sciences, Faculty of Dentistry,
Background: Clinical trials have suggested that dental implants with a tapered configuration have
University of Otago, Dunedin, New Zealand
2
improved stability at placement, allowing immediate placement and/or loading. The aim of this sys-
Head of Prosthetic Section, Ras Al-Khaimah
Dental Center, Ministry of Health, Ras tematic review and meta-analysis was to evaluate the implant stability of tapered dental implants
Al-Khaimah, United Arab Emirates compared to standard parallel-walled dental implants.
3
Professor in Periodontology, Sir John
Materials and Methods: Applying the guidelines of Preferred Reporting Items for Systematic
Walsh Research Institute, Department of
Oral Sciences, Faculty of Dentistry, Reviews and Meta-analyses (PRISMA) statement, randomized controlled trials (RCTs) were
University of Otago, Dunedin, New Zealand searched for in electronic databases and complemented by hand searching. The risk of bias was
assessed using the Cochrane Collaboration’s Risk of Bias tool and data were analyzed using statisti-
Correspondence
cal software.
Dr. Momen A. Atieh, Oral Implantology
Research Group, Sir John Walsh Research Results: A total of 1199 studies were identified, of which, five trials were included with 336 dental
Institute, Department of Oral Sciences,
implants in 303 participants. Overall meta-analysis showed that tapered dental implants had higher
Faculty of Dentistry, University of Otago,
310 Great King Street, Dunedin 9016, New implant stability values than parallel-walled dental implants at insertion and 8 weeks but the differ-
Zealand. ence was not statistically significant. Tapered dental implants had significantly less marginal bone
Email: [email protected] loss compared to parallel-walled dental implants. No significant differences in implant failure rate
were found between tapered and parallel-walled dental implants.

Conclusions: There is limited evidence to demonstrate the effectiveness of tapered dental

implants in achieving greater implant stability compared to parallel-walled dental implants. Superior
short-term results in maintaining peri-implant marginal bone with tapered dental implants are pos-
sible. Further properly designed RCTs are required to endorse the supposed advantages of tapered
dental implants in immediate loading protocol and other complex clinical scenarios.

KEYWORDS
dental implants, meta-analysis, resonance frequency analysis, review

1 | INTRODUCTION survival of dental implants.5 This stability can be influenced by variables

related to the patient, the surgical site, the surgical technique, or to the
The use of dental implants is considered one of the most reliable and implant specific design features.
predictable treatment options to restore partially and fully edentulous Implant stability is a measure of osseointegration and denotes the
patients. High implant survival rates are well demonstrated in the litera- absence of implant movement at the time of measurement. Implant
ture.1,2 However, implants placed in sites with poor quality bone or stability may be classified as primary or secondary.6,7 Primary implant
implants immediately placed or loaded have shown lower survival stability is measured at the time of implant placement, whereas second-
rates.3,4 Achieving implant stability is mandatory for success and ary implant stability reflects the ongoing process of osseointegration.

Clin Implant Dent Relat Res. 2018;1–12. wileyonlinelibrary.com/journal/cid V

C 2018 Wiley Periodicals, Inc. | 1
2 | ATIEH ET AL.

Primary implant stability is thought to promote bone cell differentia- 2.2 | Outcome measures
tion; lack of stability may result in micromotion leading to fibrous tissue
2.2.1 | Primary outcome
formation and early implant failure.8,9 Implant stability, whether primary
or secondary, can be influenced by site related factors such as bone Implant stability measurements.
quality and quantity as well as the surgical instrumentation and implant
macro- and micro-design features.10,11 2.2.2 | Secondary outcomes
The role of implant macro and microstructures in improving Insertion torque; marginal bone level changes; changes in CALs;
implant stability has been controversial in the evidence-based litera- changes in PPDs; implant failure rate.
ture. Several reports have shown improved primary implant stability
with implants of specific surface modifications,12 cutting thread config-
urations,13,14 and with implants of tapered designs15 compared with 2.3 | Search strategy
standard implants. It has also been demonstrated that implants with
The following electronic databases were searched for ongoing and
tapered design and surface modifications can increase implant stability
unpublished trials up to November 29 2017: MEDLINE, EMBASE, The
due to the high bone compression generated during insertion16 and
Cochrane Central Register of Controlled Trials (CENTRAL), MetaRegis-
high contact osteogenesis.5,17 Implant sites with poor bone quality and
ter, ClinicalTrials.gov, and the system for information on Grey literature
immediate implant placement, where primary stability is a prerequisite,
in Europe (http://www.opengrey.eu) (Table 1). The search was per-
seem to be the primary indications for the use of implants with such
formed independently and in duplicate by two authors (M.A. and N.A.).
designs.18
The bibliographies of all eligible papers were scrutinized for additional
The influence of tapered and parallel-walled implant designs on
studies. A hand-search of the last five years of relevant dental journals
implant biomechanics has been scarcely investigated in the literature
(Clinical Implant Dentistry and Related Research, Clinical Oral Implants
and the results remain inconsistent.19–21 The aim of the present sys-
Research, Implant Dentistry, International Journal of Oral and Maxillofacial
tematic review was to compare the influence of tapered and parallel-
Implants, International Journal of Periodontics and Restorative Dentistry,
walled implant design on the primary and secondary implant stability.
Journal of Clinical Periodontology, Journal of Oral Implantology, Journal of
Implant failure and peri-implant soft and hard tissue changes were also
Periodontal Research, Journal of Periodontology, and Quintessence Inter-
evaluated with the aim to provide evidence based decision on the
national) was carried out to identify potential papers.
validity of the use of such implant designs.

2.3.1 | Selection of studies

2 | MATERIALS AND METHODS
Two reviewers (M.A. and N.A.) independently screened the retrieved
This systematic review was prepared according to the guidelines of citations in duplicate to identify relevant studies. The eligibility of initial
Preferred Reporting Items for Systematic Reviews and Meta-analyses citations was assessed on the basis of the title, abstract, and keywords.
(PRISMA) statement,22 and the Cochrane Collaboration.23 The current The full texts of potentially relevant papers were then obtained and
review addresses a clearly focused question by using the participant, assessed for inclusion using an eligibility form. Any disagreements on
24,25
intervention, comparison and outcome method: the selection of studies were resolved by discussion and the reasons
Participant: Patients that require dental implants. for excluding irrelevant papers were reported.
Intervention: Tapered dental implants
Comparison: Parallel-walled dental implants. 2.3.2 | Data collection
Outcomes: Implant stability measurements, insertion torque,
The following information was extracted independently by the two
implant failure rate, changes in marginal bone levels, probing pocket
authors (M.A. and N.A.) using a predesigned data extraction form: (1)
depths (PPDs), and clinical attachment levels (CALs).
Study details: title, authors’ names, contact address, study location, lan-
guage of publication, year of publication, published or unpublished
2.1 | Types of studies data, source of study funding, study design (parallel group or split-
2.1.1 | Inclusion criteria mouth), method of randomization, duration of study, allocation con-

Randomized controlled trials (RCTs) that compared tapered with cealment and blinding (participants, investigators, outcome assessors).

parallel-walled dental implants for replacing missing teeth and reported (2) Participants: demographic characteristics, inclusion/exclusion crite-

on implant stability measurements. No language restrictions were ria, number of participants in test and control groups, number of with-

applied. drawals and reasons for dropouts. (3) Intervention: the system,
diameter and length of tapered dental implants. (4) Comparison: the
2.1.2 | Exclusion criteria system, diameter and length of parallel-walled dental implants. (5) Out-
Non-randomized controlled trials, retrospective, cross-sectional, case comes. (6) Length of observation period. Any disagreements were
series, and case reports and those that did not have a control group or resolved by reaching a consensus. Additional data was obtained by
did not provide enough information on the above parameters. contacting corresponding authors of the included studies.
ATIEH ET AL. | 3

TA BL E 1 Databases and search terms

Databases Keywords

Published studies
PubMed (1965 – November 29, 2017) (tapered OR conical OR cylindrical OR parallel walled OR straight) AND
(dental implant* OR oral implant*)
EMBASE via Ovid (1974 – November 29, 2017) (tapered.mp. OR conical.mp. OR cylindrical.mp. OR parallel walled.mp. OR
straight.mp.) AND ((dental OR oral) adj5 implant$)).mp.
Cochrane Central Register of Controlled Trials (CENTRAL) (exp tapered OR conical.mp. OR cylindrical.mp. OR parallel walled.mp. OR
via Ovid (November 29, 2017) straight.mp.) AND ((dental OR oral) adj5 implant$)).mp.

Unpublished studies
MetaRegister of controlled trials (tapered OR conical OR cylindrical OR parallel walled OR straight) AND
OpenGrey (www.opengrey.eu) (dental implant OR oral implant)
ClinicalTrials.gov
(November 29, 2017)

2.3.3 | Assessment of quality and risk of bias The remaining five trials33–37 were included for the present review

The two reviewers (M.A. and N.A.) independently assessed the selected (Table 2). The hand search did not provide any further studies. Of the

studies in duplicate to determine the risk of bias using the Cochrane five included studies, three were conducted in the United States,33–35

Collaboration’s Risk of Bias tool.23 The tool comprises seven domains one in Spain,36 and one in Brazil.37

(sequence generation, allocation concealment, blinding of participants Study designs were described as split-mouth in two trials;36,37 and

and investigators, blinding of outcome assessment, incomplete data out- parallel-group in three trials.33–35 All the trials were conducted in uni-

come, selective outcome reporting, and potential sources of bias). The versity setting and were supported by implant manufacturers.

first part of the tool described each domain while the second part cate-
gorized the studies into those having (1) low risk of bias if all the criteria 3.2 | Characteristics of participants at baseline
were met, (2) unclear risk of bias if one or more criteria were partially
3.2.1 | Inclusion criteria
met, or (3) high risk of bias if one or more criteria were not met.
1. Age  18 35 or > 21 years of age.34
2.3.4 | Data analysis
2. Periodontally and systemically healthy participants.33–37
Data was analyzed using a statistical software program (Review Man-
3. Adequate plaque control with full-mouth plaque scores and full-
ager (RevMan) software, version 5.3, The Nordic Cochrane Center, The
mouth bleeding scores of  25%.34
Cochrane Collaboration, Copenhagen, Denmark). Continuous data such
as implant stability measurements, insertion torque and marginal bone 4. Fully edentulous mandible,36 partially edentulous anterior maxilla,33,34

level changes were expressed in mean difference (MD) and 95% confi- anterior mandible,33 posterior maxilla35 or posterior mandible.37

dence intervals (CIs). Dichotomous data such as implant failure were 5. Adequate quantity and quality of native bone34–37 or grafted
reported as risk ratio (RR) estimates and 95% CIs. bone.35
A fixed-effects model was used to pool the results from more than 6. Presence of sufficient zones of keratinized tissue  2 mm.34
one study except where notable heterogeneity was present in which
7. Compliance with study requirements and follow-up appointments.35
case the random-effects model was used. The generic inverse variance
option in the statistical software program was used to combine both
3.2.2 | Exclusion criteria
split-mouth and parallel group trials. With fewer than 10 studies, publi-
cation bias was not formally assessed because the power to detect 1. Uncontrolled medical conditions33,35–37 or need for systemic anti-
publication bias is limited.23 The statistical heterogeneity between trials biotic for endocarditis prophylaxis.35
was tested by means of the Cochran’s test for heterogeneity and I2 sta- 2. Use of medications during the last month.35
26
tistic. An I value of > 50 indicated a significant heterogeneity.
2
3. History of therapeutic radiation to the head and neck.33,35–37
4. History of chemotherapy.33
3 | RESULTS
5. Presence of acute abscess or chronic sinus tracts in the area
intended for surgery.34–37
3.1 | Characteristics of the trial settings and
investigators 6. Absence of neighboring teeth.34
7. Patient taking bisphosphonates.36,37
A total of 1199 publications were identified from the databases
(Figure 1). Titles and abstracts were assessed independently and in 8. Pregnant or lactating females.36,37

duplicate by two review authors (M.A. and N.A.). Only 11 studies were 9. Smokers,35 smoking more than 10 cigarettes per day33,34,36 or
27–32
eligible for full-text evaluation, of which, six studies were excluded. smoking more than 5 cigarettes per day.37
4 | ATIEH ET AL.

FIGURE 1 Flowchart of the search process

10. Parafunctional habits such as bruxism.36  Implant stability at 8 weeks.33,37

11. Drug and alcohol abuse.33  Implant stability at 12 weeks.33,34,36,37

3.4.2 | Secondary outcome measures

3.3 | Characteristics of the interventions
Tapered and parallel-walled dental implants were immediately placed into  Insertion torque.36,37
extraction sockets in two trials33,34 and into healed sites in three  Changes in peri-implant marginal bone level changes.35,36
35–37 35
trials. In one delayed-placement study implant were left sub-
 Implant failure rate.33–37
merged for six weeks, whereas healing abutments were placed at the
 None of the included trials reported on the changes in PPDs and CALs.
time of implant placement in the other two delayed-placement trials.36,37
Pre- and postoperative oral antibiotics were prescribed in two tri-
als.34,37 One study34 reported on a standard post-operative care regi- 3.5 | Risk of bias in included studies
men which involved applying an ice pack to the surgical area for the
One trial was judged to be at low risk of bias37 while the remaining
first two hours, using chlorhexidine mouth rinse for the first two weeks
four trials33–36 were considered to be at high risk of bias due to a lack
and brushing using a soft toothbrush with light vertical strokes.
of information concerning randomization, allocation and blinding
(Figure 2, Table 3).
3.4 | Characteristics of the outcome measures
3.4.1 | Primary outcome measure 3.5.1 | Allocation (selection bias)
The random sequence generation and concealment of allocation were
 Implant stability at implant placement. 33–37
clearly described in two trials34,37 and were assessed at low risk of bias
TA BL E 2 Characteristics of the included studies
ATIEH

Torroella-Saura Waechter West and

Lang et al. (2007) Simmons et al. (2017) et al. (2015) et al. (2017) Oates (2007)
ET AL.

Study design RCT (parallel group) RCT (parallel group) RCT (split-mouth design) RCT (split-mouth design) RCT (parallel group)

Location Nine centres: Louisiana State University School of Dentistry, Univer- School of Dentistry, Federal University of Texas Health
Zurich, Switzerland Bern, Health Sciences Center sitat Internacional de Cat- University of Pelotas (Pe- Science Center at San An-
Switzerland School of Dentistry, New alunya, Barcelona, Spain lotas, RS, Brazil) tonio, Texas, USA
Geneva, Switzerland Orleans, USA
Athens, Greece, Copenhagen,
Denmark
Gothenburg, Sweden
London, UK
Boston, USA
Connecticut, USA

Number evaluated (participants/ 208/208 20/20a 10/40 40/40 25/28

implants)

Tapered implants 104/104 11/11 10/20 40/20 13/13

Parallel-walled implants 104/104 9/9 10/20 40/20 12/15

Age (years) 48.8 6 15.9 NR NR 50.8 6 12.5 54.6 6 12.8

b b b b
Method of assessment RFA RFA RFA RFA RFAb
Periodontal probe Calibrated torque wrench Surgical micromotor to Surgical torque wrenchd
Periapical radiograph evaluate ITc Peri-apical radiograph
Periapical radiograph Periodontal probe

Implant location Anterior / premolar maxilla and Posterior maxilla Anterior and posterior Posterior mandible Anterior maxilla, posterior
mandible mandible maxilla and mandible
e f g h e
Implant system

Implant diameter (mm) NR 4.0 3.75, 4.2 4.0, 4.6 4.1

Implant length (mm) NR 8.0 11.5, 13.0 10.0 8, 10, 12, 14

Insertion torque (Ncm)

Tapered implants NR NR 51.5 6 3.6 59.7 6 14.0 NR

Parallel-walled implants 48.75 6 4.83 54.3 6 13.8

Implant stability at insertion (ISQ)

Tapered implants 56.7 6 7.6 67.90 6 8.43 72.92 6 2.54 67.86 6 12.28 57.47 6 1.66

Parallel-walled implants 55.8 6 9.4 74.94 6 5.12 72.35 6 5.79 62.82 6 16.99 58.77 6 1.69

Implant stability at 8 weeks (ISQ)

Tapered implants NR NR NR 73.58 6 8.58 55.24 6 1.18

Parallel-walled implants 70.87 6 7.94 56.25 6 1.25

|

(Continues)
5
 6
|

TA BL E 2 (Continued)

Torroella-Saura Waechter West and

Lang et al. (2007) Simmons et al. (2017) et al. (2015) et al. (2017) Oates (2007)

Implant stability at 12 weeks

(ISQ)

Tapered implants 61.1 6 10.5 NR 71.42 6 0.40 78.61 6 8.85 58.27 6 1.22

Parallel-walled implants 59.4 6 9.3 69.81 6 0.14 76.62 6 8.52 58.62 6 1.17

Implant stability at 52 weeks

(ISQ)

Tapered implants 82.74 6 4.03 NR NR NR

Parallel-walled implants NR 83.61 6 2.04

Peri-implant marginal bone level

changes (mm)

Tapered implants NR 20.11 6 0.58 0.42 6 0.45 NR NR

Parallel-walled implants 20.30 6 0.28 0.91 6 0.78

Implant failure rate (%)

Tapered implants 0 9 0 10 0

Parallel-walled implants 0 0 10 15 7

Follow-up period (months) 3 12 3 3 6

Abbreviations: RCT, randomized controlled trial; NR, not reported; ISQ, implant stability quotient.
a
Only two groups were included in the analysis.
b
Osstell, Integration Diagnostics, Gothenburg, Sweden.
c
Implantmed, W&H, Bu €rmoos, Austria.
d
Signo Vinces, Campo Largo-PR, Brazil.
e
Straumann AG, Basel, Switzerland.
f
Astra Tech Implant System, DENTSPLY Implants System, Mo € lndal, Sweden.
g
MIS Implants Technologies, Shlomi, Israel.
h
Signo Vinces, Campo Largo-PR, Brazil.
ATIEH
ET AL.
ATIEH ET AL. | 7

dental implants. The remaining 138 participants were treated with con-
ventional parallel-walled implants.

3.6.1 | Implant stability measurements

Resonance frequency analysis (RFA) was used to measure implant sta-
bility in all trials. Implant stability was measured at three time-points
(implant placement, 8 and 12 weeks). In two trials,33,37 implant stability
was measured at implant placement, 8 and 12 weeks post placement.
One trial35 reported on implant stability measurement at implant place-
ment only. The remaining two trials34,36 measured implant stability at
placement and 12 weeks. The stability measurements of tapered
implants were higher than that of parallel-walled implants at time of
placement and 8 weeks but the differences were insignificant. At 12
weeks, the stability measurements of tapered implants were lower
than that of parallel-walled implant and the difference remained
insignificant.
The overall meta-analyses did not find statistically significant dif-
ferences in implant stability quotient (ISQ) values between tapered and
parallel-walled dental implants at time of implant placement (MD
20.51; 95% CI 22.54 to 1.53; P 5 0.63) (Figure 3A), 8 weeks
(MD 20.04, 95% CI 23.24 to 3.17, P 5 0.98) (Figure 3B) and 12 weeks
(MD 0.95, 95% CI 20.54 to 2.44, P 5 0.21) (Figure 3C). Moderate het-
erogeneity across the trials was detected at two time-points: placement
(Chi2 5 9.31, df 5 4; P 5.05; I2 5 57%) and 8 weeks (Chi2 5 1.97,
df 5 1; P 5 0.16; I2 5 49%) while significant heterogeneity was
observed at 12 weeks (Chi2 5 18.28, df 5 3; P 5.0004; I2 5 84%).
FIGURE 2 Risk of bias summary For the secondary outcomes, the overall meta-analysis showed
that tapered dental implants required significantly higher insertion tor-
for this domain. The remaining three studies33,35,36 did not provide suf-
que (MD 22.98, 95% CI 25.51 to 20.45, P 5.02) (Figure 4A), and suf-
ficient information to enable a clear judgment and hence considered
fered less peri-implant marginal bone loss (MD 20.28, 95% CI 20.55
under high risk of bias.
to 20.01, P 5.04) (Figure 4B) than parallel-walled dental implants, with

3.5.2 | Blinding moderate heterogeneity (Chi2 5 2.06, df 5 1, P 5 0.15, I2 5 52%). No

significant differences between tapered and parallel-walled dental
Blinding of clinicians to the selected intervention was not possible due
implants were detected with regard to implant failure rate (RR 0.61,
to the nature of intervention, which required either placing tapered or
95% CI 0.18 to 2.07, P 5 0.43) (Figure 4C). No substantial heterogene-
parallel-walled dental implant. On the other hand, blinding of outcome
ity was detected (Chi2 5 1.44, df 5 3, P 5 0.70, I2 5 0%).
assessment was both, possible and essential to reduce the risk of
detection bias. Only two trials35,37 clearly reported blinded assessment
3.7 | Sample size
of marginal bone level changes and therefore were assessed at low risk
of bias for this domain. Three trials33,36,37 reported a priori calculation for the sample size.

3.5.3 | Incomplete outcome data and selective reporting

4 | DISCUSSION
In all trials, the outcome data were reported in full without any with-
drawals and the risks of attrition and reporting bias were assessed as low. 4.1 | Summary of main results
3.5.4 | Other potential sources of bias The present review included five RCTs that evaluated the stability of

None of the five included trials were self-funded. All the trials declared tapered and parallel-walled dental implants. Moderate to lower-quality
evidence on the use of tapered dental implants was revealed due to
full or partial funding and support from dental implant research founda-
the limited number of implants/participants and to the low-to-
tion and manufacturers.
moderate quality of the included trials.
The review showed that tapered dental implants required signifi-
3.6 | Effects of interventions
cantly higher insertion torque at placement and demonstrated improved
In total, 303 participants with 336 dental implants were included in this implant stability both at the time of implant placement and 8 weeks
review. Of these, 165 participants were treated with 168 tapered postoperatively. The differences in implant stability, however, were not
8 | ATIEH ET AL.

TA BL E 3 Assessment of risk of bias of the included studies

Lang et al. Simmons Torroella-Saura Waechter West and

(2003) et al. (2017) et al. (2015) et al. (2017) Oates (2007)

Random sequence Low risk High risk High risk Low risk High risk
generation Reported in the article “all Insufficient information No information Reported in the article No information
(selection bias) subjects were randomly in the article “Brown envelopes con- in the article
assigned to one of the taining two colored
two treatment regimens labels were used to
according to pre- randomize the alloca-
defined randomization tion sequence of the
tables and using a bal- implant types”
anced random-
permuted block
approach”

Allocation concealment Low risk High risk High risk Low risk High risk
(selection bias) Reported in the article Insufficient information No information Reported in the article No information
“Assignment was con- in the article “These SNOSE schemes in the article
cealed from the investi- (Sequentially Numbered
gator until the time Opaque Sealed Enve-
during the surgical lopes) were used to
procedure” reduce randomization
bias” “Envelope manip-
ulation was always per-
formed in the presence
of at least two of the
researchers”

Blinding of outcome High risk Low risk High risk Low risk High risk
assessment Insufficient information Reported in the article No information Reported in the article No information
(detection bias) “Changes to the bone in the article “The marginal bone in the article
level heights were level was assessed by
measured at 6 and 12 an independent, single,
months by two blinded calibrated blinded
examiners” examiner”

Incomplete outcome Low risk Low risk Low risk Low risk Low risk
data (attrition bias) All data presented All data presented All data presented All data presented All data presented

Selective reporting Low risk Low risk Low risk Low risk Low risk
(reporting bias) All outcomes appear to be All outcomes appear to be All outcomes All outcomes appear to be All outcomes appear
detected detected appear to be detected to be detected
detected

Other bias None detected None detected None detected None detected None detected

significant when compared with parallel-walled dental implants. Peri- underestimated the intervention effect and limited the evidence for
35,36
implant marginal bone loss was evaluated based on two studies and the use of tapered implant design.
found to be higher around parallel-walled dental implants, but again did The included trials had short-term observation periods ( 12
not reach a significant level. Similarly, the short-term implant failure rate months) and therefore the long-term stability of tapered dental
of parallel-walled dental implants was higher than the tapered implant implants could not be determined in this meta-analysis. In the present
design but the difference was not statistically significant. review, only one trial was considered to be at low risk of bias.37 The
remaining trials were judged to be at high risk of bias because of lack
of sufficient information on method of randomization, allocation con-
4.2 | Quality of evidence
cealment or blinding. Therefore the findings of the present review
In an attempt to limit heterogeneity amongst the included trials, strin- should be considered with caution.
gent selection criteria were used in the present review. In addition, the The fact that all trials had commercial affiliation may favor the pub-
inclusion criteria used to recruit participants were rigid and uniform lication of trials with positive outcomes. However, the impact of publi-
across all included trials and the same diagnostic instrument was used cation bias is not clear, as formal testing for such bias was not possible
to measure implant stability, which further reduced the heterogeneity due to the limited number of included trials.
amongst the included trials. On the other hand, the application of these
stringent inclusion criteria resulted in the exclusion of trials that were
4.3 | Applicability of evidence
not randomized or lacked sufficient data required for analysis, hence,
only a small number of the trials could be included in the meta- The selection of appropriate implant design should largely depend on
analyses. The inclusion of different implant diameters may also have the bone quality and quantity available at the surgical site rather than
ATIEH ET AL. | 9

F I G U R E 3 Comparison: tapered versus parallel-walled dental implants. Primary outcome: Implant stability measurements (ISQ) at (A) implant
insertion. (B) 8 weeks. (C) 12 weeks. Abbreviations: IV, inverse variance; τ, Kendall tau; CI, confidence interval; SE, standard error; z, z test

F I G U R E 4 Comparison: tapered versus parallel-walled dental implants. Outcomes: A, insertion torque (Ncm). B, peri-implant marginal bone
level changes (mm). C, Implant failure rate. Abbreviations: IV, inverse variance; τ, Kendall tau; CI, confidence interval; M-H, Mantel-Haenszel;
SE, standard error; z, z test
10 | ATIEH ET AL.

the placement or loading protocol. From the findings of the present term RCTs that include a large sample size are required to confirm or
review, it remains unclear whether a tapered implant design is the refute the prognostic accuracy of RFA.
design of choice for immediate placement or loading/restoration. The
primary prerequisite for immediate loading/restoration is achieving
5 | CONCLUSIONS
high primary implant stability and the present review demonstrated
that both tapered and parallel-walled implants have adequately satis-
There is limited evidence to support the effectiveness of tapered dental
fied this requirement. It seems therefore that implant stability is not
implants in achieving higher implant stability compared to parallel-
solely dependent on the specific implant design but rather on the inter-
walled dental implants. Superior short-term results in reducing marginal
play between several factors known to influence implant stability such
bone loss with tapered dental implants are possible. Further properly
as bone quality and quantity, the drilling sequence, and the implant sur-
designed RCTs are required to validate the use of tapered dental
face characteristics and design.
implants in immediate loading protocol or in other complex clinical
The tapered implant design was introduced to improve the primary
scenarios.
implant stability based on the assumption that bone compression
would increase the bone density. Nevertheless, the high insertion tor-
que and bone compression are not always associated with high levels CON FLICT OF INT E RE ST
of implant stability.38 The required high insertion torque and the exces- The authors report no conflicts of interest related to this review
sive bone compression caused by the tapered implant design may
exceed the physiologic tolerance, which in turn can initiate bone
ORC ID
resorption.39,40 Moreover, no substantial differences were found
Momen A. Atieh http://orcid.org/0000-0003-4019-9491
between undersized and conventional drilling protocols despite the
favorable outcomes with the former.41,42
This review showed that the marginal bone levels around tapered R EFE R ENC E S
dental implants were lower than parallel-walled dental implants. These [1] Buser D, Janner SFM, Wittneben J-G, Brägger U, Ramseier CA, Salvi
findings are in accordance with other studies.27,43 The degree of GE. 10-year survival and success rates of 511 titanium implants
with a sandblasted and acid-etched surface: a retrospective study in
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