esthetic assessment of implants placed into fresh ... · peri-implant mucosa,15–18 and that it...

Esthetic Assessment of Implants Placed intoFresh Extraction Sockets for Single-ToothReplacements Using a Flapless ApproachRoni Kolerman, DMD;* Eitan Mijiritsky, DMD;† Eitan Barnea, DMD;‡ Areeje Dabaja, DMD;§

Joseph Nissan, DMD;¶ Haim Tal, DMD, PhD**

ABSTRACT

Background: To validate the concept of immediate implant placement and nonfunctional loading for use in the

esthetically sensitive anterior maxilla, clinical trials should ideally include objective esthetic criteria.

Purpose: This study analyzed procedural results as graded by the pink esthetic score and white esthetic score (PES/WES).

Methods: Thirty-nine suitable patients (mean follow-up 44.82 6 28 months) were evaluated.

Results: Thirty-eight implants fulfilled stringent criteria for successful osseointegration: absence of peri-implant

radiolucency, implant mobility, suppuration, and pain. The mean total PES/WES was 15.50 6 2.67 (range: 10–20). The

mean total PES of 7.92 6 1.60 (range: 5–10) indicated favorable overall peri-implant soft-tissue conditions. Root

convexity and texture (1.63 6 0.54) and curvature of the facial mucosa (1.68 6 0.47) and distal papilla (1.66 6 0.48) had

the highest mean values, whereas acceptable levels of facial tissue (1.53 6 0.73) and mesial papilla (1.42 6 0.64) were the

most difficult to fully achieve. The mean mesial and distal bone loss at data collection was, was 1.19 6 0.54 and

1.15 6 0.51, respectively. Periodontal disease severity (advanced chronic and aggressive periodontitis) was significantly

associated with a low total PES (p 5 .048).

Conclusions: Objective PES/WES assessment validated immediate anterior maxillary single-tooth replacement and

restoration as being a successful and esthetically predictable treatment modality in sites where the buccal bone had been

preserved during the extraction at 1 year of follow-up.

KEY WORDS: flapless implant surgery, immediate placement, radiographic data, single-tooth implants

INTRODUCTION

Advances in biomaterial technology over the past

three decades have led to redefinitions of the term

“osseointegration” based on patients’ increasing

expectations for reduced treatment time and

improved esthetics and comfort. The advantages asso-

ciated with reduction of healing time by immediate

implant placement into fresh extraction sockets has

been previously described.1–6 It has been claimed that

survival rates of immediate implants are comparable

to those of delayed implants providing that good pri-

mary stability is achieved.1–6 In addition to reducing

the number of surgical procedures, immediate

implantation reduces or even eliminates the load-free

healing period following implant placement. The

promising results reported thus far have led to further

studies that concentrated on the progressive shorten-

ing of the healing period for maxillary multiunit

implant reconstruction7–10 and for single-tooth

implants, resulting in the immediate connection of an

*Lecturer, Department of Periodontology, Dental Implantology Tel-

Aviv University, Tel-Aviv, Israel; †Senior Lecturer, Department of Oral

Rehabilitation Tel-Aviv University, Tel-Aviv, Israel; ‡Prosthodontist,

private clinic, Tel-Aviv, Israel; §Student, DMD Thesis, The Maurice

and Gabriela Goldschleger School of Dental Medicine, Tel-Aviv Uni-

versity, Israel; ¶Professor, Department of Oral Rehabilitation, Tel-Aviv

University, Israel; **Professor, Head of Department of Periodontology,

Dental Implantology Tel-Aviv University, Tel-Aviv, Israel

Reprint requests: Dr. Roni Kolerman, Department of Periodontology

and Dental Implantology, The Maurice and Gabriela Goldschleger

School of Dental Medicine, Tel-Aviv University, Klachkin 5, Israel;

e-mail: [email protected] or [email protected]

The authors have no conflict of interest.

VC 2016 Wiley Periodicals, Inc.

DOI 10.1111/cid.12458

351

implant-retained provisional restoration.11–14 Howev-

er, it has been claimed that immediate implantation

and restoration may lead to recession of the marginal

peri-implant mucosa,15–18 and that it may have an

adverse effect on the final esthetic outcome. Several

factors have been reported to influence the frequency

and extent of marginal mucosal recession, including

tissue biotype,18 connection of a provisional crown

immediately following implant insertion,19,20 condi-

tion and thickness of the facial bone,21 orofacial posi-

tion of the implant shoulder,22,23 and grafting of the

facial peri-implant marginal defect with bone or bone

substitutes.24,25 The biological explanation for the

hard- and soft-tissue loss is that following extractions,

the facial socket wall, which is composed almost

entirely of bundle bone, is more susceptible to resorp-

tion both horizontally and vertically.26 If this crestal

bone resorption occurs after immediate implantation,

it may lead to recession of the facial marginal muco-

sa. It was further suggested that disruption of the vas-

cular supply to the facial bone by the elevation of

surgical flaps might be an important contributory

factor.26 Thus, several investigators27–29 recommended

placing implants into extraction sockets with minimal

flap elevation or without any elevation of surgical

flaps30,31 in an attempt to not only enhance esthetic

outcomes but to also minimize marginal mucosal

recession. Despite these minimally invasive surgical

approaches, marginal tissue recession may neverthe-

less occur.

Apart from time gain, another rationale for

immediate implantation and provisionalization is

the potential of maximizing the preservation of

hard and soft tissue, which may be beneficial to

the esthetic treatment outcome.32,33 The achieve-

ment of successful aesthetic results, however,

requires an ideal three-dimensional implant position

within optimal bone configuration and dimen-

sions,21,22 particularly that of the buccal and inter-

proximal bone. The use of connective tissue grafts

for stabilizing soft tissue and for the prevention of

recessions in patients with a thin tissue biotype was

also described.34,35 Implant positioning in relation

to the bucco-oral and mesio-distal dimensions of

the alveolar ridge is a factor believed to influence

the degree of bone remodeling.36,37

The aim of this study was to objectively ana-

lyze the esthetic outcomes of single-tooth immediate

implants placed and restored without flap eleva-

tion in the anterior maxilla. The working hypoth-

esis of the present study is that flapless extraction,

which preserves the integrity of the residual bone

walls after extraction and allows immediate im-

plant placement, is a predictable treatment modal-

ity in terms of both osseointegration and esthetic

outcome.

MATERIALS AND METHODS

Patient Selection

Thirty-nine consecutive patients who had undergone

maxillary anterior single-tooth immediate implants

according to the concept of immediate nonfunctional

loading between 2004 and 2013 were included in this

retrospective case-control study. The senior author

(R.K.) carried out all surgical procedures. The study

was approved by the ethics committee of the Tel-Aviv

University, and all the participating patients signed an

informed consent form, giving permission to use

their medical files and records.

The inclusion criteria were the need for extrac-

tion of a single tooth in the anterior esthetic zone of

the upper jaw (central/lateral incisors or canines), the

presence of both adjacent teeth, perfect symmetry of

the pre-extraction soft tissue contours, (or excess of

soft tissue) at least 18 years of age, good oral hygiene

(after initial preparation) with a plaque score

�10%,38 integrity of the residual bone walls after

extraction (three wall defects were acceptable if the

buccal dehiscence did not exceeded 3 mm), and at

least 5 mm of bone apical or palatal to the alveolus

of the failing tooth to ensure primary insertion tor-

que of at least 32 Ncm.

The exclusion criteria were heavy use of tobacco

(more than 10 cigarettes a day), a past history of

radiotherapy to the head and neck region or treat-

ment with bisphosphonates, untreated or uncon-

trolled periodontal disease, poor oral hygiene mucosal

diseases (e.g., lichen planus) in the areas to be

treated, para-functional habits (e.g., bruxism), uncon-

trolled diabetes, acute infection (with the presence of

pus or fistula) around the failing tooth, failure to

achieve a stabilizing insertion torque of at least 32

Ncm, and failure to maintain integrity of the bony

socket during the extraction.

352 Clinical Implant Dentistry and Related Research, Volume 19, Number 2, 2017

Surgical Protocol

A thorough presurgical evaluation included a peri-

odontal examination and chart, clinical images,

smoking habits, full-mouth periapical radiographs,

and periodontal diagnosis. Initial periodontal therapy

included oral hygiene instructions and training until

a hygiene index38 of <10% was achieved. Scaling and

root planing were carried out whenever indicated, fol-

lowed by additional periodontal therapy (e.g., open

flap debridement), aiming to reduce the periodontal

probing depth and bleeding on probing. The mor-

phology of the alveolar process at the implant site,

the location of the incisive foramen, and the root to

be extracted, as well as the presence of periapical

pathologies were evaluated preoperatively by means

of computed tomography (Figure 1). Special attention

was given to the trabecular pattern between the buc-

cal and palatal plates and to the presence of bony

contour undercuts. Light smokers were instructed to

follow a smoking cessation protocol of 1 week before

and at least 1 month after implant placement. Pre-

medication with 875 mg amoxicillin and clavulanic

acid (Augmentin, Glaxo Smith Klein, Brentford, UK)

was administered orally 1 hour before surgery.

Penicillin-sensitive patients were premedicated with

clindamycin HCL (Dalacin-C, Pfizer NV/SA, Bel-

gium) 150 mg bid starting 1 hour before surgery. The

patients rinsed their mouths for 1 minute with chlor-

hexidine solution 0.2% (Tarodent mouthwash, Taro

Pharmaceutical Industries Ltd., Haifa, Israel) prior to

surgery. Antibiotic treatment consisting of 875 mg

oral amoxycillin-clavulonate potassium (Augmentin,

Glaxo Smith Klein, Brentford, UK) was continued for

one week (replaced by Dalacin 150 mg 3 4 per day

in penicillin-sensitive patients), and analgesic treat-

ment (naproxen sodium 275 mg; Narocin, Teva Phar-

maceutical Industries Ltd., Petah-Tikva, Israel) was

provided for pain relieve. The patients were instructed

to rinse their mouths twice daily for 2 weeks with

0.2% chlorhexidine.

All surgical procedures were performed by the

same practitioner (R.K).

Surgical Procedure

After the surgical site was anesthetized intracrevicular

incisions limited to the circumference of the hopeless

tooth or retained root were performed using a 15c

blade. This was followed by an atraumatic tooth

extraction taking care to maintain the integrity of the

socket bone walls, especially the buccal bone, using

periotomes (Hu- Friedy, Chicago, IL, USA). Granula-

tion tissue was removed using a spoon curette and a

3 mm diamond bur (Strauss Company, Raanana,

Israel). The socket walls were then inspected for the

presence of fenestration or dehiscence defects. At this

stage, a decision was made as to whether or not to

proceed with implant placement without flap eleva-

tion. To be included in the current study, the facial

socket walls had to be intact or to contain only small

defects, that is, �3 mm affecting the height of the

crestal bone. Patients with dehiscence defects of the

facial bone wall greater than those dimensions were

treated with surgical flaps to allow for bone augmen-

tation procedures and their data were excluded.

Site preparation was performed along the palatal

socket wall. The osteotomy was designed to achieve

as much implant engagement as possible with the

apical and palatal borders of the extraction socket.

Depending on the residual bone density, final drilling

was performed using a drill measuring at least 1 mm

less than the implant diameter Screw-type sand-

blasted, and acid-etched surface bone level titanium

implants that were used (Lans, MIS-Bar Lev Industri-

al Zone, Israel) or a conical type (Seven, MIS-Bar

Lev). Final seating was done at an insertion torque of

at least 32 Ncm, performed by means of a torque-

controlled ratchet (MIS-Bar Lev).

Proper implant positioning was considered as

being of pivotal importance, with the adjacent teeth

serving as reference for optimal implant positioning

(Figure 2). A minimum distance of 1 mm (measured

with a periodontal probe) between the implant shoul-

der and neighboring tooth was achieved in all cases.

The implant shoulder was flush with the palatal bone,

2 to 3 mm apical to the cemento-enamel junction or

the crown cervical margin of the adjacent teeth, if

present. In the orofacial dimension, the buccal neck

of the implant was placed at least 2 mm palatal to

the buccal contour of neighboring teeth. After adapta-

tion of an appropriate abutment (0–258), with a gin-

gival neck 1–3 mm in height and torqued with 15

Ncm (Anthogyr, torque-controlled ratchet, Botzer

Ergonomics, Israel), 0.25 to 1 mm particle allograft

material (FDBA-Raptos–Citagenix Toronto, Canada)

was applied in the residual gap in all cases.

Esthetic Assessment of Flapless Implants 353

Reconstructive Treatment Protocol

Abutment connection was followed by adaptation of

a prefabricated nonfunctional acrylic temporary

crown (no occlusal contacts with the implant crown

[IC] or during protrusive and lateral movements)

(Figure 3). Six months after implant placement, the

temporary crown and abutments were removed, and

color-coded transfers (MIS-Bar Lev, Israel) were

adapted. Transfer adaptation was radiographically ver-

ified, and impressions were taken by means of the

putty-wash one-step technique (Express, 3M. ESPE

Dental Products, St. Paul, MN, USA) using the closed

tray technique with metal stock trays. A master model

with a silicon image of the marginal gingiva was

prepared, and interarch relations were recorded.

Abutments were connected, and the Zirconia base

was adjusted at the following visit. The permanent

Zirconia crown was cemented after occlusal adjust-

ment and glazing with temporary cement (Temp-

Bond Kerr Corporation, Orange, CA, USA). The

abutments were tightened to 35 Ncm using a pros-

thetic ratchet. The implants were considered suc-

cessful if they fulfilled the criteria of Alberktsson

et al.39

Clinical Follow-up Examination

Patients were clinically followed at 1, 2, and 4 weeks,

at 3, 6, and 12 months postoperatively, and annually

Figure 1 CT scan demon-strating intact buccal bone ofhopeless left central incisor.


thereafter. They received personal oral hygiene

instructions and were seen and treated when neces-

sary and at least once every 3-6 months. Periodical

maintenance examinations were performed by super-

vised dental hygienists and included recording of pla-

que index, probing depth and presence of gingival

bleeding.

Radiographic Evaluation

Periapical radiographs were performed before extrac-

tion and immediately after implant placement, at the

time of impression taking, at final crown installation,

at the annual follow-up examinations and at the time

of data collection (during 2014). The radiographs

were standardized, with the film kept parallel (Schick

Technologies, Long Island, NY, USA) by means of

plastic film holders and maintaining the x-ray beam

perpendicular to the digitalized film.

Follow-up and Criteria for Surgical Success

The mesial and distal alveolar bone crest-to-implant

shoulder distance was digitally measured using

computerized dental radiography (Schick Technolo-

gies) (Figure 4). Radiographic distortion was calculat-

ed by dividing the radiographic implant length by the

actual one. Measurements were made at 12 to 108

months after the final crown adaptation, that is, at

the time of data collection. Successful implants were

those with bone loss not >1.5 mm during the first

year and not >0.2 mm for each successive year.39 The

radiographic readings were performed by one experi-

enced examiner not involved in the surgical or pros-

thetic treatment of the patient (EB).

Esthetic Assessment

Distance from the mucosal margin to the implant

shoulder (DIM).

At 7 months after crown adaptation, the distance

from the mucosal margin to the implant shoulder

(DIM) was measured with a periodontal probe (Hu–

Friedy, Chicago, IL, USA) on the master model (type

IV stone and pink silicone imitation of the gingiva)

after removal of the prefabricated new abutment and

final crown to the nearest millimeter at four

locations.

Figure 3 Temporary nonfunctional acrylic crown.Figure 4 Final x-ray at data at 42 month after crownadaptation.

Figure 2 Flapeless extraction and parallel pin.


Cast Analysis

Impressions were taken at 12 months after crown

adaptation and study models were produced by

means of a type IV stone. The casts were photo-

graphed with a standardized technique using a milli-

meter grid as reference. The mid-facial height of the

implant crown (IC) and the corresponding height of

the reference contralateral tooth (CT) crown were

measured on these digital pictures with Image J

(image processing and analysis in Java) (Figure 5) in

order to identify potential changes in crown height or

mucosal recessions. In cases in which the incisal edge

of the IC or the CT crown were longer than the con-

tralateral – the measurement was adapted to a line

traced along the incisal edge of the shorter crown.

The length (in mm) of the hopeless tooth before

extraction was calculated with the Image J program

in the following manner: the relative hopeless tooth

length was divided by the relative length of the con-

tralateral teeth multiplied by the absolute length of

the contralateral teeth.

The Pink Esthetic Score and White Esthetic Score

(PES/WES) Index

All patients were examined 12 months after the

final crown was adapted. They underwent a clinical

examination and frontal photographs were taken

(Canon EOS 650 D, Japan with a 100 mm Canon

macro lens and a ring flash) at these visits. The pho-

tograph was centered slightly superior to the occlusal

plane at the contact region of the central incisors at

the midline to facilitate the subsequent analysis,

which is primarily based on symmetry. Care was tak-

en that the CT was also completely and symmetrically

represented (Figure 6). The technique described by

Belser et al.40 was adopted in order to comprehensively

assess the esthetic outcome and performance. For the

esthetic outcome of the implant crowns at the 12-

month examination, the respective casts and intraoral

pictures were critically analyzed by three examiners

(EM, EB, and DA), none of whom were involved in

the surgical procedure. Their examination was con-

ducted according to two specific indices, the PES and

the WES.40 The PES is comprised of the following var-

iables: mesial papilla, distal papilla, curvature of the

facial mucosa, level of the facial mucosa, root convexi-

ty, and soft tissue color and texture at the facial aspect

of the implant site. The WES includes five variables:

tooth form, tooth volume, tooth color (including

assessment of hue and value), tooth texture and trans-

lucency, each with five parameters. A score of 2, 1, or

0 is assigned to each parameter. The parameters are

assessed by direct comparison with the natural, refer-

ence CT, estimating the degree of match or eventual

mismatch. A maximum score of 10 is applied for each

index in the case of an optimum duplication of the

esthetically relevant features of the reference tooth. As

a result, the highest possible combined PES/WES score

is 20, which represents optimal match of the peri-

implant soft-tissue conditions and the single-tooth

implant crown compared to the respective features of

the natural CT site. The examiners used the study casts

to facilitate the objective assessment of some of the

parameters, and the threshold of clinical acceptability

was 6/10 for each index.

Statistical Analysis

Statistical analysis was performed using the SPSS

20.0; statistical analysis software (SPSS Inc., Chicago,

Figure 5 Measurement of implant crown length versuscontralateral.

Figure 6 Final Zirconia crown 12 month after adaptation thetotal PES-WES was 19.


IL, USA). The Wilcoxon signed rank test with the

Bonferroni correction for multiple comparisons was

applied for the analysis of the differences within

the PES and WES parameters (five parameter in each

group). The differences between the lengths of

implant crowns and natural CTs were analyzed by

the paired t-test. A p value <.05 was accepted as

significant.

RESULTS

Thirty-nine consecutive patients (16 males and 23

females, age range: 24–82 years [mean 47.51 6 18.09])

who had undergone a simultaneous flapless extrac-

tion, immediate implant placement, and restoration

procedure during 2004 to 2013 comprised the study

group. They were followed-up for a mean of

44.82 6 28 months (Table 1). Twenty (51%) of the

patients were diagnosed as having gingivitis and/or

mild adult chronic periodontitis, and 19 (49%) as

having chronic moderate/advanced adult periodontitis

or aggressive periodontitis. Eleven teeth (28%) were

extracted due to periodontal disease, 17 (44%) due to

root fracture, 8 (21%) due to severe carious lesions,

and 3 (7%) due to external root resorption. Three

patients had a narrow and shallow (�3 mm) buccal

dehiscence. The relevant details of the study group

(gender, smoking status, implant length and width,

abutment type and site of each implant) are pre-

sented in Table 1. The implant diameter varied

between 3.3 and 5 mm, and the implant length varied

between 13 and 16 mm. Data were collected at 12 to

108 months (mean 44.82 6 28 months) after implant

placement and all but one implant had survived (the

single failed implant was removed one month after

installation in a 63-year-old light smoking female

whose data were excluded from the final analysis).

The mean mesial and distal bone loss was 1.19 6 0.54

and 1.15 6 0.51 mm (Table 2).

Analysis of the DIM values demonstrated a mean

value of 3.34 6 0.71 mm (range: 2–5 mm) for the

buccal DIM (Table 3). The length of the hopeless

tooth was similar to the length of the contralateral

tooth (9.75 vs 9.76 mm) (Table 3). Cast analyses of

the IC and CT values performed over the 1-year

study period showed a 0.41 mm (range: 0–2.34 mm)

(p 5 .004) difference between the IC and the CT

(recession during the first year) (Table 3).

Esthetic Parameters: PES/WES

The esthetic parameters at 1 year after crown adapta-

tion of the final restoration revealed a mean PES of

7.92 6 1.60 (range: 5–10) and a mean WES of

7.66 6 1.48 (range: 5–10), resulting in a total PES/

WES score of 15.50 6 2.67 (Tables 3 and 4). The

cumulative total PES/WES demonstrated that good or

acceptable esthetics (�12) had been achieved in 35/38

patients (89.7%). Overall, the esthetic outcomes were

favorable (Table 4). Of the five parameters of the

PES index, the mesial papilla height had the lowest

mean value (1.42) whereas the curvature of facial

mucosa had the highest mean value (1.68) (Table 2).

Twenty-five implants (66%) had an optimal level of

the facial mucosa, eight implants (21%) had reces-

sions <1 mm and five implants (13%) had reces-

sions �1 mm (Table 4). Among the five parameters

of the WES index, color had the highest score (1.76)

while the surface texture had the lowest score (1.26)

(Table 4).

DISCUSSION

The success rate for the immediate tooth replacement

procedure in the present study was 94.7% (36/38

TABLE 1 Included Patients, Sites and Implant Used

No %

Gender

Female 23 59

Male 16 41

Smokers

< 10 cigarettes per day 7 17.9

Non smokers 32 82.1

No’ of Implants 39 100

Implant length

13 mm 7 18

16 mm 32 82

Implant platform

3.3 8 20.5

3.75 22 56.4

4.2 7 18

5 2 5.1

Implant site, Maxilla

Central Incisor 19 48.7

Lateral Incisor 15 38.5

Canine 5 12.8


TABLE 2 Radiographic Data

Sex Age

Follow Up

Months Smoking

Distal

Bone Loss

Mesial

Bone Loss Mean

Permitted

Bone Loss

M 48 12 No 1.9 1.9 1.90 1.5 *

M 70 72 No 1.4 1.6 1.50 2.5

F 32 36 No 1.7 1.7 1.70 1.9

F 34 24 No 1.3 1.2 1.25 1.7

M 23 60 No 1.2 1.4 1.3 2.3

M 52 60 Yes 1.6 1.8 1.70 2.3

M 31 42 No 1 1 1.00 2

F 65 12 No 1.2 1.9 1.55 1.5 *

M 51 40 No 1.3 1 1.15 1.96

M 51 12 No 0.8 1.1 0.95 1.5

M 20 60 No 0.3 0.2 0.25 2.3

F 25 72 No 2.6 2.1 2.35 2.5

M 76 108 Yes 0.3 0.2 0.25 3.1

F 23 108 No 0.9 1.2 1.05 3.1

F 22 84 No 0.5 0.4 0.45 2.7

F 53 60 No 1.2 1.1 1.15 2.3

F 30 72 No 1.3 1 1.15 2.5

F 34 84 No 0.8 0.7 0.75 2.7

F 26 72 Yes 0.7 0.9 0.80 2.5

M 27 48 No 1.1 0.6 0.85 2.1

M 67 60 Yes 0.7 1.2 0.95 2.3

F 25 60 No 0.6 1.8 1.20 2.3

F 72 18 No 1.5 1.1 1.30 1.6

M 41 12 No 1.2 1.8 1.50 1.5

F 35 36 Yes 1.6 1.2 1.40 1.9

F 54 36 No 0.9 1 0.95 1.9

F 81 40 No 1.7 1.9 1.80 1.96

F 63 0 Yes

F 52 48 No 1.8 2 1.90 2.1

F 55 12 No 1.1 1.6 1.35 1.5

F 65 12 Yes 1.4 1.1 1.25 1.37

F 45 60 No 1.8 2 1.90 2.3

M 68 36 No 1.6 1.2 1.40 1.9

M 72 24 No 0.7 0.6 0.65 1.7

M 72 60 No 1.3 1.1 1.20 2.3

M 72 60 No 0.6 0.5 0.55 2.3

F 45 12 No 0.6 0.5 0.55 1.5

F 39 12 No 1.1 1.2 1.15 1.5

F 37 12 No 0.3 0.4 0.35 1.5

47.51 44.82 1.15 1.19 1.17 Mean

18.33 27.98 0.51 0.54 0.49 SD

48.00 42.00 1.20 1.15 1.18 Median

81.00 108.00 2.60 2.10 2.35 Max

20.00 0.00 0.30 0.20 0.25 Min

*Survival


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22

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91

0.5

10

.69

10

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55

5

12

12

22

22

21

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22

22

10

20

9.4

58

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9.2

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65

4

13

12

11

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27

11

22

28

15

8.6

58

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8.6

46

55

14

22

22

21

29

22

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29

18

8.0

59

.41

7.8

63

43

4

15

12

22

22

21

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22

22

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8.7

8.0

38

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35

43

16

22

22

12

18

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17

15

9.2

59

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9.2

72

44

3

17

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22

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19

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29

18

9.6

71

0.1

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35

43

18

21

22

12

18

11

21

16

14

9.5

9.6

69

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45

45

19

11

12

22

29

22

21

29

18

9.9

61

0.1

99

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46

54

20

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3

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43

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81

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1.3

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43

3

23

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25

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8.8

10

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8.7

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53

4

24

12

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26

21

11

16

12

9.5

61

1.4

89

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34

43

25

11

22

22

08

22

21

29

17

9.7

51

0.1

59

.75

45

54

26

21

02

12

27

21

21

17

14

9.7

21

0.5

29

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43

55

27

23

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10

15

11

11

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10

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12

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10

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34

54

28

22

fail

ure

lig

ht sm

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ing

29

11

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20

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11

11

15

10

10

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2.4

81

0.7

55

64

5

30

12

11

22

28

22

21

18

16

7.9

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8.8

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55

4

31

11

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28

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9.8

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54

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53

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17

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9.8

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3

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27

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11

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45

55

35

22

22

21

18

22

21

18

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8.4

58

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9.4

34

45


implants), and the cumulative survival rate after a 12-

to 108-month follow-up period (mean: 45 months)

was 97.4% (38/39). Operative success was defined as

a maximum 1.5 mm of marginal bone loss in the first

year and not >0.2 mm of bone loss in each of the

successive years. The results were esthetically pleasing

and considered “esthetic successes” as defined in the

present investigation.

A recent systematic review41 showed better crestal

bone preservation around immediately (concomitant

with extraction) placed implants compared with

implants placed in healed/native bone at 12 months

of follow-up. The difference between the crestal bone

level changes of immediately loaded and delayed

loaded implants did not reach a level of statistical sig-

nificance.41 The findings of the current study indicat-

ed that success was comparable to those reported data

when single implants were used to replace failing teeth

in the esthetic zone using a flapless approach and

immediate restoration (100%).42,43 The relatively low

mean marginal bone loss of 1.17 mm (range: 0.25–

2.35 mm) that had been measured 45 months after

implant placement in the present study may be attrib-

uted to the placement of bone grafts which enhanced

the bone fill and preserved the buccal bone, as well as

to the compliance of the patients in terms of personal

plaque control and compliance with the maintenance

appointments.44,45

The concomitant placement of slow resorbing

bone grafts in the present study had the potential to

reduce the remodeling of the facial bone plate which is

characterized by bone fill from the inside and resorp-

tion of the facial plate from the outside.29 Without

bone grafting, this usually results in significant hori-

zontal and vertical facial bone loss and subsequent

recession.29 Chu and colleagues noted that the gain in

soft-tissue height and thickness was greater for immedi-

ately restored implants in which the gap was filled

(grafted) compared to nongrafted sites.46

The present study results showed that immediate

implant placement for single-tooth replacement in

the anterior maxilla yields successful treatment out-

comes with high predictability and low risk of com-

plications. The patients in this study had a mean

follow-up of 45 months during which all 38 implants

achieved and maintained successful tissue integration,

as documented by standard clinical and radiographic

parameters.

TA

BLE

3.

con

tin

ued

.

N

imp

lan

t

site

PES-

pin

kest

heti

csW

ES-

wh

ite

est

heti

cs

To

tal

PES

6W

ES

DIM

Mesi

al

Pap

illa

Dis

tal

pap

illa

Cu

rvatu

re

of

Faci

al

Mu

cosa

Leve

l

of

Faci

al

mu

cosa

Ro

ot

Co

nve

xity

,

Soft

Tis

sue

Co

lor

an

d

Text

ure

To

tal

PES

To

oth

Form

To

oth

Vo

lum

e/

Ou

tlin

e

Co

lor

(hu

e/

valu

e)

Surf

ace

Text

ure

Tra

nsl

uce

ncy

an

d

Ch

ara

cteri

zati

on

To

tal

WES

base

lin

e

ho

pele

ss

too

th

len

gth

imp

lan

t

cro

wn

len

gth

mm

con

trala

tera

l

len

gth

mm

BM

DP

36

22

12

21

28

22

22

21

01

89

.51

0.8

49

.55

33

44

37

12

22

21

29

22

21

18

17

99

.45

9.0

14

67

4

38

11

11

12

27

11

22

28

15

11

.91

2.5

01

1.8

45

55

39

12

22

21

18

22

11

17

15

8.6

8.9

38

.63

44

5

40

Ave

rage

1.4

21

.66

1.6

81

.53

1.6

37

.92

1.6

61

.66

1.7

61

.26

1.3

27

.66

15

.50

9.7

51

0.1

79

.76

3.3

44

.79

4.4

54

.08

41

SD

0.6

40

.48

0.4

70

.73

0.5

41

.60

0.4

80

.48

0.4

30

.45

0.4

71

.48

2.6

71

.01

1.2

00

.96

0.7

10

.87

0.8

60

.78

42

Med

ian

1.5

22

22

82

22

11

81

69

.62

10

.27

9.6

53

54

4

43

Min

imu

m0

11

00

51

11

11

51

07

.95

8.0

37

.86

23

33

44

Max

22

22

21

02

22

22

10

20

12

12

.48

12

56

75

58

Del

ta0

.41


The main focus of this study was documentation

of the esthetic outcome of this treatment approach.

Three different methods were applied to objectively

assess the esthetic outcomes in the 38-patient cohort.

First, the esthetic outcomes were evaluated with

PES40 and WES.40 Each index has a total score of 10

points, and the minimal threshold for esthetic accept-

ability was set at 6 for each index. The overall esthetic

results of a mean total score of 15.50 for both indices

were satisfying and better than those of a group of

patients treated by the same group that carried out

immediate implant placement and restoration using

soft- and hard-tissue augmentation (guided bone

regeneration [GBR] and connective tissue grafts

(mean total score of 14.44) aimed to compensate for

compromised buccal plate.45 The cumulative total

PES/WES of the 38 current cases showed that accept-

able or good esthetics was achieved (�12) in 34 of

them (89.4%).

The score of 7.92 for the PES in the present study

was in the range of 7 to 8.1 reported for delayed or

immediate implant placement and restoration47using

the same modified PES index comparison with other

studies. The current total PES/WES score is similar

to that reported by Belser and colleagues40 who eval-

uated 45 implants placed 6 to 12 weeks postextrac-

tion together with augmentation of the anterior

maxillary teeth. In contrast, the current mean score

is lower than the mean of 16.75 reported by Buser

and colleagues48 who used the same scoring system

to evaluate the esthetic outcome of implants placed

in combination with GBR 4 to 8 weeks after tooth

extraction. In the present study, the extraction socket

walls were intact (a dehiscence of up to 3 mm was

permitted). The level of facial mucosa had a score of

2 in 25 out of 38 cases (65.8%), while eight cases

had a score of 1 (21%) and five had a score of

0 (13.2%) (a discrepancy of more than 1 mm). The

papilla height had a score of 2 in 19 (50%) of the

mesial papillae and in 25 (65.8%) of the distal

papillae.45

The result of 13.2% major discrepancies

(>1 mm) for buccal recessions occurring between

the time of the immediate provisionalization phase

and the 1-year esthetic evaluation is lower than that

reported by others who claimed that a high inci-

dence of mucosal recession (30–40%) is a common

observation following immediate implant place-

ment.16,23,49,50 Potential causes of this esthetic com-

plication are thin gingival biotype and a U-shaped

defect morphology, thus underscoring the impor-

tance of preoperative risk assessment and proper

case selection to avoid malpositioning of the

implant. Having a thin-tissue biotype was identified

as a risk factor for mucosal recession.35 In a study

on immediate implant placement and provisionaliza-

tion using a flapless approach, thin biotype sites had

significantly more recession than thick biotype sites

after 1 year, respectively, Furthermore, Kan and col-

leagues reported no differences between thick and

thin tissue biotype sites when CT grafts were incor-

porated in the surgical protocol of flapless implant

TABLE 4 1-Year Assessment, N (%)

0 1 2 Average

Mesial Papilla 3(7.9) 16(42.1) 19(50) 1.42

Distal papilla 0(0) 13(34.2) 25(65.8) 1.66

Curvature of Facial Mucosa 0(0) 12(31.6) 26(68.4) 1.68

Level of Facialmucosa 5(13.2) 8(21) 25(65.8) 1.53

Root Convexity/Soft tissue Color/Texture 1(2.6) 12(31.6) 25(65.8) 1.63

PES (Mean 6 SD) 7.92 6 1.6

Tooth Form 0(0) 13(34.2) 25(65.8) 1.66

Tooth Volume/Outline 0(0) 13(34.2) 25(65.8) 1.66

Tooth Color(hue/value) 0(0) 9(23.7) 29(76.3) 1.76

Surface texture 0(0) 28(73.7) 10(26.3) 1.26

Translucency 0(0) 26(68.4) 12(31.6) 1.32

WES (Mean 6 SD) 7.66 6 1.48

Total PES/WES 15.5 6 2.67


placement and restoration.35 In the present study,

the pre-extraction soft-tissue contours were in per-

fect symmetry with the surrounding teeth. As such,

there was no need for soft-tissue augmentation or

flap elevation, unlike situations in which the

extracted teeth had a pre-existing gingival recession

whose correction required connective tissue grafts in

conjunction with coronally advanced flaps.

Evans and Chen noted that recession of the

mucosa was three times greater in facially malposi-

tioned implants compared to implants placed more

palatal in the socket.23

As for the severity of recessions, the finding of a

mean of 0.41 mm in the present study is in agreement

with the reported mean recession of <1 mm.47 In con-

trast to the current results, some studies reported no

changes51,52 or a gain in mucosal height.42,52,53 Notably,

all of those studies used the flapless approach and

immediate provisional restoration42,53 as well as con-

comitant incorporation of a connective tissue graft.51,52

In the present study, attempts were made to minimize

mid-facial recessions by the use of low resorbing bone

grafts,47 palatal placement of the implant,53 and convex

emergence profiles of the provisional restoration.34,45,47

Moreover, cases with a thin tissue biotype were not

excluded, a fact that may explain the relatively high rate

of recession in comparison to other flapless cases.52

The mean DIM value on the buccal aspect of the

implant among the current cases was 3.34 mm. This

confirmed that the technique permitted the formation

of a normal mucosal height.45

The third method of objective esthetic assessment

was the measurement of IC and the CT on study

casts. One limitation of the present study is that the

findings can be applied solely to a very strictly select-

ed group of implants, that is, implants placed in sites

where the buccal bone was preserved during the

extraction (no more than 3 mm of narrow dehiscence

allowed). The second limitation is that the reported

esthetic outcome was evaluated at 1 year since crown

adaptation. It is possible that further buccal bone/soft

tissue recession might occur with time, due to resorp-

tion of the bone graft.

The comparison of these values at 12 months

showed a significant difference (0.41 mm) between

them. The results of the present study indicate that

while the flapless approach may help to maintain the

level of buccal marginal tissue, it could not prevent

the occurrence of recession. Moreover, the result pre-

sented herein (0.41 mm) is similar to that reported

for 34 patients with compromised buccal plate treated

by immediate restoration of implants combined with

guided tissue regeneration and connective tissue graft

(0.54 mm).45

In conclusion objective PES/WES assessment vali-

dated immediate anterior maxillary single-tooth

replacement and restoration as being a successful and

esthetically predictable treatment modality in the

short term (1 year), although the occurrence of buc-

cal recessions is inevitable, even in patients with opti-

mal soft- and hard-tissue configuration. The

technique may be implemented in a selected group of

implants: specifically, implants placed in sites where

the buccal bone had been preserved during the

extraction. More data are needed regarding the main-

tenance of the esthetic results in the medium and

long terms.

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esthetic assessment of implants placed into fresh ... · peri-implant mucosa,15–18 and that it...

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