Immediate implantation of the implant in the extraction site reduces surgical cases, the length of the treatment period, and the patient’s feeling of satisfaction with the healing process. However, using an implant immediately after extraction may cause thinning of the jawbone. This can also cause a facial recession and esthetic problems.^[1-3]

The thickness of the bone plate and gingiva play an essential role in the outcome of a successful surgery on an immediate implant. Furthermore, a suitable distance between the implant and the bone is critical in reconstructing and forming new bone around implants.^[4,5]

Filling the gap between the implant and the socket wall with bone filler compounds can benefit the aesthetic results of the immediate implant. For example, the filling materials in the gap of the extraction cavity can protect the gingiva and bone structure. Still, it may damage the temporary crown or cause problems in significant gaps.^[6,7] Based on the results of clinical studies, it is suggested to use a customized abutment similar to the structure of the new extraction socket.

The study by Choorak et al. evaluated the soft-tissue change after placing an immediate implant with a customized healing abutment on posterior teeth in a 6-month follow-up.^[8] Fernandes et al. demonstrated that the immediate use of implants, along with bone substitutes and collagen matrices, could reduce the amount of erosion in the areas surrounding the implant. Therefore, customized healing abutments can be proposed as an alternative for sealing the socket and maintaining the soft tissue contour. Fernandes et al. studied the changes in peri-implant tissues after using custom-healing abutments compared to xenogeneic collagen matrices in flapless maxillary immediate implant implantation.^[9] Hu et al. investigated the changes in the hard and soft tissue around immediate implants using two types of abutments.^[10] Menchini-Fabris et al. examined the two different methods of tissue recovery on the alveolar ridge width over 3 years after implant placement in a fresh extraction socket.^[11] Giovanni-Battista et al. compared customized and standard therapeutic abutments, evaluating alveolar bone in new socket implants.^[12] However, the results of previous studies are not in agreement with each other. In addition, there are no systematic reviews regarding this issue. The aim of this study is to systematically review the efficacy of customized healing abutments versus titanium healing abutments for peri-implant tissue healing in fresh socket implants.

Searching the databases resulted in the retrieval of 46 recorded [Figure 1]. Only 25 titles and abstracts of the paper were selected based on comparative inclusion and exclusion criteria. After reading all the articles, the other 20 studies were omitted because they lacked the required information. A diagram of the research workflow is shown in Figure 1. A total of 5 studies were included in the study for qualitative evaluation, including one randomized controlled trial study,^[9] two prospective clinical studies^[8,10] and two retrospective experiences.^[11,12] The total number of implants in these five studies involved 170 oral implants in 123 patients. Table 1 presents the main results of the surveys. In the study of Choorak et al., patients received immediate implants through bone grafting and customized healing abutment. Before, immediately, and 1, 3, and 6 months after extraction, silicone molds were prepared, scanned, and measured. The obtained data were analyzed by Friedman and Wilcoxon tests.^[8] A study by Fernandes et al. was designed as a prospective, randomized, controlled clinical trial. In this study, patients were divided into two groups depending on the socket sealing option: In one group, collagen matrix was used, and in the other group, the customized abutment was used. They took digital casts before extraction and 1, 4, and 12 months after implant placement to determine linear and volumetric changes between different time points in the peri-implant tissue areas.^[9] Hu et al. used a modified osteotomy technique to place 28 immediate implants in molar/premolar sockets in their study. They also used protein-free bovine bone minerals to bridge the implants’ gaps. The implants of the control group were connected using titanium healing abutments, and the treatment group was connected using customized healing abutments and were followed up for 6 months.^[10] In the study of Menchini-Fabris et al., the sockets were immediately implanted after tooth extraction. The implants were reviewed retrospectively in two groups. First, the conventional group was treated with a standard package with a cover screw. In contrast, in the custom group, a custom abutment made with computer-aided design (CAD)/computer-aided manufacturing (CAM) technology was immediately screwed onto the head, and the width of the alveolar ridge was measured at 3 years.^[11] Giovanni-Battista et al. immediately implanted the postextractive sockets without filling the space between the implant surface and the socket wall. In addition, they measured the width of the alveolar ridge after implant placement with or without a custom abutment up to 3 years after surgery [Table 3].^[12]

In general, for planning a suitable treatment plan for each individual, the decision to use a customized abutment is complicated. However, clinical information is needed to help practitioners decide. Therefore, the results of this systematic review may help make an appropriate treatment decision. The present study investigated the effect of two groups of implants associated with different therapeutic abutments on the initial healing process [Table 3].

Studies have shown that implant components play a role in inducing a local or systemic inflammatory reaction.^[15] Using acrylic materials in combination with customized abutments can cause allergies in sensitive people and disrupt the healing process. Therefore, there is a need to use tissue-compatible compounds in the manufacture of customized abutments. The declaration of the study by Choorak et al. was that immediate implant placement with customized healing abutment could maintain the architecture and horizontal dimension of transmucosal tissue but can keep the vertical measurement of lingual height and buccolingual width during 6 months’ follow-up.^[8]

That study also showed that the soft-tissue made the most significant changes in the 1^st month, and after that, the tissue dimensions remained constant except for the buccal side. During 3 months, the buccolingual width changed significantly. Furthermore, after 6 months of follow-up, lingual height showed a significant difference.^[8]

The findings of Fernandes et al. showed a significant difference between the average values of buccal volume in the 1^st month in both groups during 1 year of follow-up. Still, this difference was not practical for 1 year between the two groups. Furthermore, no significant difference was observed in the change of midfacial mucosa and papilla between the groups.^[9]

Hu et al. showed that the amount of buccal and lingual bone loss was comparable between the two groups. Changes in buccal bone thickness were similar between the two groups, and the soft-tissue surface of the middle face was well preserved in both groups.^[10]

The findings of the study by Menchini-Fabris et al. showed that the survival rate of 54 dental implants for all implants was reported as 100% after 36 months. However, the decrease in bone width for the customized group was significantly smaller than that of the conventional group.^[11]

Giovanni-Battista et al. reported that the survival rate of all 54 implants after 36 months was 100%. The bone width decreased in both groups, and the change in dimensions of the alveolar ridge in the customized group was insignificant compared to the standard group. Furthermosre, they observed a significant difference between the groups regarding tooth type. In comparison to the other teeth (2.57 ± 0.53 mm and 2.36 ± 0.32 in the canine and premolar sites, respectively), the incisor teeth appeared to have considerably less bone loss (with a bone loss of 1.59 ± 0.44 mm).^[12]

The study’s conclusion by Fernandes et al. was that both treatment options could be predictable solutions for sealing immediate implant sockets. However, higher volume changes can be expected in the presence of thin bone phenotypes.^[9] Hu et al. concluded that despite study limitations, for immediate implants placed in posterior sockets, customized healing abutments can facilitate the closure of large sockets. Despite more pronounced incomplete filling, healing abutments composed of ketone polyether ether and resin did not pose an increased risk of peri-implant bone loss or soft-tissue resorption during the initial healing period.^[10]

Correcting and solving the problems of healing abutments can improve their performance. When there is a need to make customized therapeutic abutments with polished surfaces in the shortest possible time, using computer tools to prepare an ideal abutment can be very helpful.^[16-18] The results of the study by Menchini-Fabris et al. showed that the CAD/CAM method could have advantages such as stabilization of bone volume in a new socket implant, and it also causes constant growth of teeth for restorative veneers. Finally, optimal prosthetic-surgical planning and minimally invasive extraction are necessary to maintain the integrity of the supporting tissue.^[11]

An abutment with convenient features can help improve gingivally and bone tissue when immediate implant placement. Therefore, it can be effective in maintaining the socket’s volume and the final restoration. During extraction, it is necessary to use customized abutments to protect the beauty and anatomy of the gingival, and it is considered the last step in implant surgery.^[19-21] Giovanni-Battista et al. stated that the customized method could help protect and support the natural appearance profile by creating a seal over the surgical site and preserving the socket volume.^[12]

Consequently, these findings illuminate the critical significance of material selection for therapeutic abutments, emphasizing the need for tissue-compatible compounds to avert allergic reactions and disruptions in the healing process, especially with immediate implant placement. Customized healing abutments, while maintaining tissue architecture and facilitating socket closure, necessitate attention to specific materials, such as ketone polyether ether and resin, to prevent adverse effects on bone loss or tissue resorption during initial healing stages. Incorporating CAD/CAM technology emerges as a promising avenue for expedited production of ideal abutments and stabilizing bone volume in new implant sockets.

This systematic review’s limitations were confined to using only indexed publications in online databases and English articles. Hence, the authors recommend evaluating articles and studies from additional sources such as gray literature, books, and articles in different languages.

The study concludes that both treatment options could be predictable solutions for sealing immediate implant sockets. However, customized healing abutments exhibit efficacy in sealing immediate implant sockets, particularly in cases with thin bone phenotypes. These abutments induce significant volume changes such as size, aiding in the closure of larger sockets and thereby preserving the socket volume.