Single implant treatment in healing versus healed sites of the anterior maxilla: an aesthetic evaluation

Patient-reported outcomes for bone regenerative procedures

Evidence-based dentistry used for decision-making and assessment of treatment includes three components: evidence from the literature, clinical expertise, and patient expectations. Patient satisfaction embraces affability, availability, and ability and can be examined using questionnaires or structured questions to the patient to evaluate patient perception of the treatment. The questions can be quantified using dichotomous, point, or visual analog scales. This would be a straightforward patient-reported outcome measure (PROM). Validated and specific oral health-related quality of life (OHRQoL) questionnaires such as the oral health impact profile (OHIP), oral impact on daily performance (OIDP), or the dental impact on daily living (DIDL) can be used as PROMs, and these measures are appropriate for population studies, where you can measure changes over time and differences between treatment groups. PROMs have shown to enhance patient engagement when integrated into clinical care. PROMs for bone regenerative procedures are mainly used as secondary outcome and are concentrating on the prosthetic outcome more than the pain, discomfort, anxiety, and cost of the surgical procedures. Surprisingly, most patients are satisfied and willing to have the procedures performed again. Whether this is recall bias or not and how the information's from the dentist and the team influence the patients answers to PROMs questionnaires are discussed. The importance of patient perspectives in bone regeneration procedures is obvious and combined with clinical outcome measures, it increases our ability to provide better care. Studies using PROMs as a primary outcome variable are required.

The peri-implant mucosa color: A systematic appraisal of methods for its assessment and clinical significance

BACKGROUND

Peri-implant mucosa color (PMC) seems to be one of the main parameters affecting the esthetic outcome of implant therapy. However, more emphasis should be given to its assessment and reporting.

PURPOSE

To describe the available evidence on methods to assess and report the color of the peri-implant mucosa (PMC) and the respective clinical relevance.

MATERIAL AND METHODS

A comprehensive electronic and manual search was performed to identify clinical studies reporting on PMC.

RESULTS

A total of 121 studies were included. PMC was evaluated at the time of the follow-up visit (chairside) in 45.5% studies. PMC assessment was performed qualitatively, by comparing PMC with adjacent and/or contralateral gingiva (78.6%) or quantitatively, using spectrophotometry (20.7%) or a software on clinical photographs (0.8%). The most performed method to assess PMC was through esthetic indices (76.9%), either at the time of the follow-up visit (chairside) or at later time point using photographs. Quantitative reporting of PMC included averages of points from esthetic indices or color differences to natural gingiva expressed with the CIELAB color system. PMC assessment allowed describing color discrepancies compared to natural gingiva, evaluating color changes over time, and comparing the outcomes of different treatment modalities. PMC assessment through spectrophotometry was additionally utilized to assess the role of mucosal thickness (MT) on PMC.

CONCLUSIONS

Various methods for PMC assessment and reporting were described, including visual assessment, mainly through esthetic indices, and spectrophotometry. PMC evaluation has allowed to demonstrate the factors affecting the color of the peri-implant soft tissue, such as the type of abutment/restoration, MT, and soft tissue augmentation.

Immediate implant placement vs. early implant treatment in the esthetic area. A 1-year randomized clinical trial

OBJECTIVES

To assess the impact of implant placement and temporization timing on esthetic outcomes of single maxillary anterior implants with intact bone walls and interproximal bone.

MATERIALS AND METHODS

Test group patients received an immediate implant with immediate provisional restoration and socket preservation, while patients in the control group received an early implant placement with guided bone regeneration and delayed loading. Patients were followed for 1 year after final prosthetic and pink esthetic score (PES), mid-buccal mucosal level (MBML), crestal bone changes (CBC), and peri-implant soft tissue parameters, and patient chair time was recorded.

RESULTS

Fifty patients received the intended treatment (25 test and 25 control). No implants failed. PES after 1 year was 12.8 ± 1.19 for the test group and 12.5 ± 1.36 for the control group (p = .362). MBML difference between baseline (after final crown delivery) and the 1-year follow-up was gain of 0.2 ± 1.02 mm for the test group (p = .047) and no change in the control group. CBC after 1 year were 0.1 mm ± 0.21 mm (mesial) and 0.2 mm ± 0.22 mm (distal) for the test group and 0.2 mm ± 0.25 mm (mesial) and 0.3 mm ± 0.19 mm (distal) for the control group, p = .540 (mesial) and p = .462 (distal). Test group required half the chair time (127 ± 13 min) when compared to the control group (259 ± 15 min, p < .001).

CONCLUSIONS

Within the limits of this trial, both treatment protocols resulted in excellent esthetic outcomes with PES >12 after 1-year follow-up.

Clinical esthetic comparison between monolithic high-translucency multilayer zirconia and traditional veneered zirconia for single implant restoration in maxillary esthetic areas: Prosthetic and patient-centered outcomes

Background/purpose

Clinical esthetic evidence for the performance of monolithic high-translucency multilayer zirconia is lacking. The aim of this study was to compare monolithic high-translucency multilayer zirconia with traditional veneered zirconia in clinical situation.

Material and methods

A total of 30 participants who were provided with both monolithic zirconia crowns (Group 1) and traditional veneered crowns (Group 2) for single implant restoration in maxillary esthetic areas were enrolled. Patients' subjective outcome (Visual Analog Scale, VAS) were recorded. Photos were taken and then evaluated by 9 evaluators with Pink and White Esthetic Score (WES). Wilcoxon signed rank test was used for comparison between Group 1 and Group 2 in VAS, WES and five variables in WES. Kendall's coefficient of concordance test was used to calculate inter-rater reliability of WES variables. Spearman correlation was used to analyze association between patients' outcome and evaluators' scores.

Results

There was no significant difference in patients' subjective outcome between monolithic zirconia and traditional veneered crowns: overall VAS were 9.0 (8.0–9.0) and 9.0 (8.5–9.5), respectively (P > 0.05). However, in professional view, significant difference between Group 1 and Group 2 in WES was observed: 7.5 (6.0–8.0) and 8.0 (6.5–8.5), respectively (P < 0.05). Kendall's test showed, among WES variables, translucency demonstrated the highest agreement. Professionally reported evaluations did not correlate with patient-reported outcomes (Spearman correlation were 0.246 and 0.224 for Group 1 and Group 2, respectively).

Conclusion

Within the limitation of this study, it can be concluded that monolithic high-translucency multilayer zirconia restoration might be a treatment modality.

Efficacy of bone-substitute materials use in immediate dental implant placement: A systematic review and meta-analysis

OBJECTIVE

To assess the efficacy of using a bone substitute material (BSM) in the fixture-socket gap in patients undergoing tooth extraction and immediate implant placement.

MATERIALS AND METHODS

MEDLINE, EMBASE, and CENTRAL databases were searched for randomized controlled trials (RCTs). RCTs were screened for eligibility, and data were extracted by two authors independently. Risk of bias (ROB) was assessed using Cochrane's ROB tool 2.0. Primary outcomes were implant failure, overall complications, and soft-tissue esthetics. Secondary outcomes were vertical buccal bone resorption, vertical interproximal bone resorption, horizontal buccal bone resorption, and mid-buccal mucosal recession. Meta-analysis was performed using random-effects model with generic inverse variance weighing. GRADE was used to grade the certainty of the evidence.

RESULTS

After screening 19 544 potentially eligible references, 20 RCTs were included in this review, with a total of 848 patients (916 sites). Most included RCTs were deemed of some concerns (53%) or at low (38%) risk of bias, except for overall complications (high ROB). Implant failure did not differ significantly RR = 0.92 (confidence intervals [CI] 0.34 to 2.46) between using a BSM compared with not using a BSM (NoBSM). BSM use resulted in less horizontal buccal bone resorption (MD = -0.52 mm [95% CI -0.74 to -0.30]), a higher esthetic score (MD = 1.49 [95% CI 0.46 to 2.53]), but also more complications (RR = 3.50 [95% CI 1.11 to 11.1] compared with NoBSM. Too few trials compared types of BSMs against each other to allow for pooled analyses. The certainty of the evidence was considered moderate for all outcomes except implant failure (low), overall complications (very low), and vertical interproximal bone resorption (very low).

CONCLUSION

BSM use during immediate implant placement reduces horizontal buccal bone resorption and improves the periimplant soft-tissue esthetics. Although BSM use increases the risk of predominantly minor complications.

Esthetic Outcome and Oral Health-Related Quality of Life after Restoration with Single Anterior Maxillary Implants

Background/Aim: To evaluate the esthetic outcome of single implant restorations and the correlation of these esthetic results between patient satisfaction and oral health-related quality of life (OHRQoL).

Material and Methods: 15 patients with single-tooth implants in the anterior maxilla region were included in this study. Patients were clinically followed to evaluate the esthetic outcomes of implant prostheses and photographs of the implant site were obtained using a digital camera. A researcher evaluated the photographs according to the pink esthetic score/white esthetic score (PES/WES) index. Patients were asked to complete a questionnaire including 13 questions to evaluate their satisfaction with the overall implant and restoration treatments using by visual analogue scale (VAS). OHRQoL was evaluated by patients with the questionnaire Oral Health Impact Profile-14 (OHIP-14).

Results: The mean PES/WES was 13.6. In Ohip-14 questionnaire, the questions were answered ‘never’ generally. The mean VAS score was 9.01±0.9 and ranged from 7.6 to 9.7. There was no correlation between VAS and PES/WES (p= 0.484), similarly, there was no correlation between OHIP-14 and PES/WES (p= 0.763).

Conclusions: All of the implant restorations’ PES/WES scores were clinically acceptable. Professionals evaluated the esthetic outcome more suspicious than patients. Patients were satisfied with the esthetic results.

Zirconium dioxide implants as an alternative to titanium: A systematic review

Background

This systematic review evaluates the available scientific literature to demonstrate the aesthetic and clinical benefits and to determine the survival and the success of zirconium dioxide implants concerning titanium implants.

Material and Methods

The electronic databases were searched until January 2020. Outcome measures were pink aesthetic score (PAS), white aesthetic score (WAS), bleeding on probing (BOP) and probing depth (PD). The addressed PICO question was: In partially edentulous patients in the upper-anterior sector, do zirconium dioxide implants provide aesthetic benefits over conventional titanium implants?

Results

In the 15 articles included after the screening were evaluated respectively, the pink aesthetic score, white aesthetics score, the peri-implant, and crown index, bleeding on probing, plaque index, probing pocket depth, radiographic bone loss, papilla height, and survival and success rate. The results show how the aesthetic and clinical benefits and the survival and success rate of zirconium dioxide implants are, in general, better than titanium implants.

Conclusions

Despite the optimal aesthetics, clinical and survival results obtained in the review, more studies are needed to confirm these data.

Key words:Ceramic dental implants, zirconia implants, esthetics, zirconium dioxide and zirconia.

A Randomized Clinical Trial Comparing Immediate Loading and Delayed Loading of Single-Tooth Implants: 5-Year Results

The aim of this prospective randomized clinical study was to compare the clinical treatment outcome for single dental implants submitted to either immediate loading (IL) or delayed loading (DL) after 5 years of follow-up. Fifty patients with a missing maxillary tooth (15–25) were randomly allocated to either the IL or DL. The treatment procedures included implant installation in healed sites, temporary screw-retained crown and replacement with a permanent single implant crown. The two groups were evaluated with regard to implant survival, marginal bone level, papillae index, pink and white esthetic score (PES, WES). At the 5-year follow-up the implant survival rate was 100% and 95.8% for IL and DL, respectively. Implant success rate was 91.7% and 83.3% for IL and DL, respectively. The mean ± SD marginal bone loss for IL and DL was −0.50 ± 0.73 mm and −0.54 ± 0.65 mm, respectively. (p = 0.782). Statistically significant less marginal bone loss was found non-smokers (p = 0.021). No statistically significant differences were found for IL and DL concerning papillae index PES and WES after 5 years. This study suggests that implant-supported single crowns in the maxillary aesthetic zone can present similar results with respect to either IL or DL after 5 years.

Prosthodontic Principles in Dental Implantology: Adjustments in a Coronavirus Disease-19 Pandemic-Battered Economy

More patients are requesting fixed prosthesis to replace missing teeth. More than 5 million dental implants are placed annually in the United States. This number will decrease in 2020 owing to the coronavirus disease-19 pandemic. The edentulous patient has a decreased quality of life. Prosthodontic rehabilitation/reconstruction of edentulism improves overall quality of life. Patient-reported outcome measures are subjective reports of patients' perceptions of their oral health status and the impact that it has on their quality of life. This chapter contains a variety of prosthodontic principles for the reader to help satisfy the needs and expectations of the patient.

Reproducibility and validity of anterior implant esthetic indices: A review

Background:

The purpose of this review was to narrate about the reproducibility and validity of different indices evaluating esthetic aspects in anterior single implant-supported restorations.

Materials and Methods:

An electronic search of Medline, Scopus, Embase, Cochrane Central, and Web of Science databases was performed using the keywords “dental implants,” “anterior esthetics,” “esthetic score,” and “esthetic index.” Besides, a manual search of dental implant journals was carried out.

Results:

The electronic search revealed 932 titles. After further review, 14 articles fulfilled the eligibility criteria and were included in this review. Because of the heterogeneity of the study designs, interventions, and parameters used for assessment of esthetics, no meta-analysis could be performed.

Conclusion:

Many indices have been proposed for the evaluation of the esthetic aspects of single implant-supported reconstructions in the anterior maxilla. All of them have some advantages and drawbacks that this review pointed out. The evidence level of studies used for the validation of these indices is poor. It is necessary to achieve a consensus on the tools for assessment of the esthetic aspect and perform evidence-based studies to validate an appropriate index.

Two bone blocks sandwich technique for horizontal reconstruction of severely atrophic alveolar ridge in anterior maxilla: A case report

BACKGROUND

Severe horizontal bone deficiency of the maxillary anterior region is considered a major challenge in reconstruction and successful implant placement. Various approaches have been developed to augment bone volume. Of these approaches, onlay bone graft, alveolar bone splitting, and guided bone regeneration have been suggested.

CASE SUMMARY

A 22-year-old female patient, with no previous medical history, presented to the Department of Oral Implantology, Wuhan University due to a missing right maxillary incisor. The X-ray results showed severe horizontal bone deficiency, with an available bone width of 3.1-4.0 mm. The two bone blocks sandwich technique was performed to augment the bone volume. After 6 months healing, X-ray results showed that the newly formed alveolar ridge dimension increased to 4.7-9.5 mm horizontally. Implant insertion surgery was performed and all-ceramic restorations were fabricated. The implant was stable at the 1-year follow-up visit after restoration, and the X-ray showed a stable bone level around the dental implant. The scores for the pink esthetic score and white esthetic score were 12 and 8, respectively, and the patient was satisfied with the esthetic outcome.

CONCLUSION

The two bone blocks sandwich technique may be an alternative treatment option in augmenting severe horizontal bone deficiency of the anterior maxilla.

A randomized controlled study comparing guided bone regeneration with connective tissue graft to re-establish buccal convexity: One-year aesthetic and patient-reported outcomes

OBJECTIVES

To compare guided bone regeneration (GBR) with connective tissue graft (CTG) in terms of aesthetic and patient-reported outcomes (PROMs).

MATERIALS AND METHODS

Patients with a single tooth gap in the anterior maxilla and horizontal alveolar defect were enrolled in a single-blind RCT. All sites had a buccopalatal bone dimension of at least 6 mm, received a single implant and were randomly allocated to the control (GBR) or test group (CTG) to re-establish buccal soft tissue convexity. Primary outcomes were Pink Esthetic Score (PES) and Mucosal Scarring Index (MSI) assessed after 1 year. Secondary outcomes included PROMs registered during the early stages of healing and after 1 year.

RESULTS

Twenty-one patients were included per group (control: 11 females, mean age 51; test: nine females, mean age 48). Although there was no significant difference in the PES between the groups (control: 10.11; test: 10.48; p = .577), the MSI was significantly lower in the test (1.10) than in the control group (2.53) (p = .017). Based on descriptive statistics, the latter demonstrated wider scars, more colour mismatch and slightly more suture marks. However, these were not considered disturbing by the patients given similar VAS on soft tissue aesthetics (control: 84; test: 87). Oedema and haematoma were rated twice as high in the control group on at least two postoperative time points, and patients took more painkillers (7.10 vs. 4.86). OHIP-14 decreased in both groups between baseline and 1-year follow-up, indicative of less discomfort in daily life. Differences in MSI and PROMs between the groups may be explained by the need of a vertical releasing incision in order to achieve sufficient access for GBR, periosteal incisions and the use of biomaterials that may induce inflammation.

CONCLUSION

GBR and CTG resulted in favourable aesthetic outcomes as assessed by professionals and patients. However, given additional vertical and periosteal incisions, GBR resulted in more scarring, postoperative discomfort and a higher need for painkillers.

Esthetic evaluation of single implant restorations, adjacent single implant restorations, and implant-supported fixed partial dentures: A 1-year prospective study

BACKGROUND

Peri-implant soft tissues esthetics varies and depends on the restoration type such as implant-supported single crowns, adjacent multiple single crowns, and fixed partial dentures (FPD).

PURPOSE

The aim of this prospective study was to assess the esthetic outcome of the peri-implant soft tissues of (NobelBiocare™) implant-supported single crowns, adjacent multiple single crowns, and FPD. A potential association between the esthetic risk profile and the esthetic outcome was assessed.

MATERIALS AND METHODS

Between 03/11 and 03/17, 300 NobelActive implants were installed in 153 partially edentulous patients. Prior to the fabrication of the final restoration, the esthetic risk profile (ERP) of the patient was determined. The pink esthetic score (PES) and white esthetic score (WES) were assessed by three investigators at 6 and 12 months post-insertion of the final restoration. Patients' appreciation was assessed on a visual analogue scale (VAS) at the 1-year follow-up.

RESULTS

The clinical acceptable limit for PES (≥6) was achieved in 56% to 68% of the single crowns at 6 and 12 months, respectively. Clinically unacceptable PES scores were recorded for 48% of the adjacent multiple single crowns and 63% of the FPDs at both time points. The association of a high ERP with WES and PESWES was noticed for single implant-supported crowns. For the latter restoration type, a ≤5 mm distance between the crestal bone level and the proximal contact positively influenced the PES and combined PESWES scores. No correlation was found between PES or WES and patient satisfaction. Mesial papilla formation was more pronounced compared to the distal one for the single implant crowns and for implant-supported FPD.

CONCLUSION

When high esthetic demands are expected, assessment of ERP prior to implant treatment is advised in order to estimate a realistic outcome.

Effectiveness and clinical performance of early implant placement for the replacement of single teeth in anterior areas: A systematic review

AIM

To assess the effectiveness and clinical performance of early implant placement, 4-8 (Type 2) or 12-16 weeks (Type 3) after extraction, in single anterior sites.

METHODS

Studies reporting on Type 2 and Type 3 implant placement were identified. Findings were summarized in evidence tables. Main outcome was implant survival. Peri-implant soft and hard tissues changes, periodontal parameters, aesthetics and patient-reported outcomes were also evaluated. Quality of reporting of the included studies was evaluated through Consort, Newcastle-Ottawa scale and IHE quality appraisal checklist.

RESULTS

Nineteen eligible articles (seven from one RCT, three from two CCTs and nine from three case series) reporting on 140 patients and 140 implants were included. Type 3 implants showed comparable results to Type 4: 95% vs. 100% survival rates. Studies reported high values of implant survival, minimal technical and biological complications and high aesthetic scores in both short and long-term follow-ups for both Type 2 and Type 3 implant placement. Quality evaluation highlighted important weaknesses in the included trials.

CONCLUSIONS

Limited data on Type 2 and Type 3 implant placement appear to indicate that they can perform well both short and long term. However, the limited number of cases, the significant heterogeneity of the included studies and the high risk of biases importantly reduce the generalizability of the findings. CRD42018117363.

Patient-reported outcome measures focusing on aesthetics of implant- and tooth-supported fixed dental prostheses: A systematic review and meta-analysis

OBJECTIVES

The aim of this systematic review and meta-analysis was to summarize the existing evidence on patient-reported aesthetic outcome measures (PROMs) of implant-supported, relative to tooth-supported fixed dental prostheses.

MATERIAL AND METHODS

In April 2017, two reviewers independently searched the Medline (PubMed), EMBASE, and Cochrane electronic databases, focusing on studies including patient-reported aesthetic outcomes of implant- and tooth-supported fixed dental prostheses (FDPs). Human studies with a mean follow-up period of at least 1 year, a minimum of ten patients, and English, German, or French publication were included. For the comparison of subgroups, random-effects meta-regression for aggregate-level data was used.

RESULTS

The systematic search for implant-supported prostheses focusing on patient-reported outcomes identified 2,675 titles, which were screened by two independent authors. Fifty full-text articles were analyzed, and finally, 16 publications (including 19 relevant study cohorts) were included. For tooth-supported prostheses, no studies could be included. A total of 816 implant-supported reconstructions were analyzed by patients. Overall aesthetic evaluation by the patients' visual analogue scale (VAS) rating was high in implant-supported FDPs (median: 90.3; min-max: 80.0-94.0) and the surrounding mucosa (median: 84.7; min-max: 73.0-92.0). Individual restorative materials, implant neck design (i.e., tissue or bone level type implants), and the use of a fixed provisional had no effect on patients' ratings of the definitive implant-supported FDPs.

CONCLUSIONS

Aesthetics is an important patient-reported measure, which lacks in standardized methods; however, patients' satisfaction was high for implant- supported FDPs and the surrounding mucosa.

The clinical performance of all-ceramic implant-supported single crowns: A systematic review and meta-analysis

OBJECTIVE

This review aimed at evaluating the survival and technical complication rates of all-ceramic implant-supported single crowns (SC).

MATERIAL AND METHODS

Three electronic databases were searched for clinical studies conducted at ≥ 15 patients examining implant-supported all-ceramic SCs over ≥ 12 months. Survival rates of implants and restorations plus technical complication rates of SCs were calculated and tested for statistical correlation with confounding variables. Statistical analysis was performed using a negative binomial distribution model to calculate 5- and 10-year survival and complication estimates.

RESULTS

Forty-one included studies reported on implant-supported SCs made of veneered and monolithic high-strength oxide ceramics, monolithic, and veneered glass-based ceramics and of a monolithic resin-nano-ceramic (RNC). Survival estimates for SCs of 93% (95% CI: 86.6%-96.4%) after 5 years and 94.4% (95% CI: 91.1%-96.5%) after 10 years were calculated, corresponding values for implant survival were 95.3% (95% CI: 90.6%-97.7%) and 96.2% (95% CI: 95.1%-97.1%). Technical complication rates after 5/10 years were as follows: chipping 9.0% (95% CI: 5.4%-14.8%)/2.7% (95% CI: 2.1%-3.5%), framework fractures 1.9% (95% CI: 0.7%-4.9%)/1.2% (95% CI: 1%-1.5%), screw loosening 3.6% (95% CI: 1.6%-8.4%)/5.2% (95% CI: 3.6%-7.5%), and decementations with 1.1% (95% CI: 0.4%-2.8%) after 5 years. Some confounding variables influenced the above-mentioned estimates significantly.

CONCLUSIONS

All-ceramic implant-supported SCs showed-with the exception of a RNC material-high survival rates. However, failures and technical complications occurred which have to be considered when informing patients on the treatment with implant-supported all-ceramic SCs.

Esthetic evaluation of implant-supported single crowns: a comparison of objective and patient-reported outcomes

Background

This study investigated objective and patient-reported esthetic outcomes and their correlation for single-tooth implant restorations in the maxillary anterior region.

Methods

Nineteen patients were included. Gingival biotypes and smile lines were evaluated. Esthetic evaluation was performed according to the pink and white esthetic scores (PES and WES). Patients rated their satisfaction regarding the implant treatment using a subjective outcome questionnaire and a 10-cm visual analogue scale (VAS).

Results

The mean PES and WES were 10.7 (range 5–13, SD ± 2.24) and 8.6 (range 8–10, SD ± 0.60), respectively. The overall mean VAS was 8.54 ± 0.36 (range 3.8–9.8). No significant correlation was found between VAS and PES or WES (p = 0.475, p = 0.984, respectively). PES and WES scores for gingival biotypes failed to show any statistically significant difference (p = 0.701, p = 0.831). There was a significant negative correlation between the smile line and VAS; indicating that patients with lower smile lines expressed higher patient satisfaction (p = .001).

Conclusions

Professionally reported esthetic outcomes (PES and WES results) may not correlate with patient-reported outcomes. Smile line is a significant factor in patient satisfaction, which should be evaluated thoroughly prior to implant placement in the anterior maxilla.

Outcome of early dental implant placement versus other dental implant placement protocols: A systematic review and meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to compare the clinical efficacy of the early dental implant placement protocol with immediate and delayed dental implant placement protocols.

METHODS

An electronic and manual search of literature was made to identify clinical studies comparing early implant placement with immediate or delayed placement. Data from the included studies were pooled and quantitative analyses were performed for the implant outcomes reported as the number of failed implants (primary outcome variable) and for changes in peri-implant marginal bone level, peri-implant probing depth, and peri-implant soft tissue level (secondary outcome variables).

RESULTS

Twelve studies met the inclusion criteria. Significant difference in risk of implant failure was found neither between the early and immediate placement protocols (risk difference = -0.018; 95% confidence interval [CI] = -0.06, 0.025; P = 0.416) nor between early and delayed placement protocols (risk difference = -0.008; 95% CI = -0.044, 0.028; P = 0.670). Pooled data of changes in peri-implant marginal bone level demonstrated significantly less marginal bone loss for implants placed using the early placement protocol compared with those placed in fresh extraction sockets (P = 0.001; weighted mean difference = -0.14 mm; 95% CI = -0.22, -0.05). No significant differences were found between the protocols for the other variables.

CONCLUSIONS

The available evidence supports the clinical efficacy of the early implant placement protocol. Present findings indicate that the early implant placement protocol results in implant outcomes similar to immediate and delayed placement protocols and a superior stability of peri-implant hard tissue compared with immediate implant placement.

Esthetic evaluation of natural teeth in anterior maxilla using the pink and white esthetic scores

BACKGROUND

Natural teeth in the anterior maxilla are critical in determination the esthetic outcome of single implant prosthesis.

PURPOSE

The present study aimed to explore aesthetics of natural teeth in the anterior maxilla using the Pink Esthetic Score/White Esthetic Score (PES/WES) index. Additionally, inherent weak spots of natural teeth and high-risk parameters of prostheses were also considered.

MATERIAL AND METHODS

This cross-sectional study was performed by photographic analysis.

RESULTS

A total of 102 subjects and 306 teeth (the right incisor, lateral incisor and canine) were included. The grand means of the PES and WES were 12.92 and 8.75, respectively. The score of soft tissue margin, soft tissue contour and outline/volume of the crown were significantly lower than other variables. The PES and WES showed a downward trend with age. Most of the PES/WES values of the females exceeded those of the males.

CONCLUSION

The average level of natural teeth in PES and WES assessment were around 13 and 9, respectively. The soft tissue margin, soft tissue contour and outline/volume of the crown were high-risk parameters for the esthetic outcomes of implant reconstructions. Underlying factors, such as age and gender, contributed to the esthetics of natural teeth change.

Evaluation of the influence of implant placement timing on the esthetic outcomes of single tooth implant treatment in the anterior maxilla: A retrospective study

OBJECTIVES

The purpose of this retrospective study was to investigate the influence of implant placement timing on the esthetic outcomes for single implants in the anterior maxilla.

MATERIALS AND METHODS

One hundred and ten patients (48 males; 62 females) who received a single-tooth implant after extraction either immediately (Type 1); after 4-8 weeks (Type 2); after 8-16 weeks (Type 3); or more than 16 weeks (Type 4) were evaluated in terms of esthetic outcomes after a mean post-placement interval of 26.3 months (range 12-116). Esthetic outcomes were measured using the Pink and White Esthetic Score (PES; WES). Stepwise regression analysis was performed to analyze the effect of timing of placement, as well as patient demographics and other clinical parameters on the esthetic outcomes.

RESULTS

No statistically significantly differences in PES were found between the various treatment modalities with Type 1 implants (n = 33) scoring 10.58 ± 1.65 (median: 11), followed by 10.36 ± 2.09 (median: 10.5), 9.68 ± 2.43 (median: 10), and 9.63 ± 2.21 (median: 10) for Type 2 (n = 14), Type 3 (n = 19), and Type 4 (n = 44), respectively. For immediate implants, a trend towards better esthetic outcomes was observed when implant placement was done flaplessly in cases with intact buccal bone (Type 1A, median PES 11) as compared to cases with partial/complete missing buccal plates where a flap was raised (Type 1B, median PES 10). Overall, the only parameter that influenced esthetic outcomes (as measured by PES) was gender, with females having significantly superior results. The median WES was 8 and 96% of the crowns were deemed esthetically acceptable, with crowns placed by specialist prosthodontists yielding higher scores than those placed by general practitioners.

CONCLUSIONS

Single tooth implants in the anterior maxilla showed satisfactory outcomes when measured with objective esthetic criteria. Timing of implant placement did not significantly influence the esthetic outcomes, although a trend towards better outcomes was seen with immediate implant placement as observed by higher median PES values.

CLINICAL SIGNIFICANCE

Single tooth implant placement in the anterior maxilla is a predictable treatment modality for achieving acceptable esthetic outcomes regardless of the timing of placement.

Clinical and radiographic outcome following immediate loading and delayed loading of single-tooth implants: Randomized clinical trial

BACKGROUND

Immediate loading of single implants is generally considered a reliable procedure.

PURPOSE

The objective of the present prospective randomized clinical study was to compare the overall treatment outcome following immediate loading (IL) and delayed loading (DL) of single implants after 1 year of follow-up.

MATERIALS AND METHODS

Patients with a missing maxillary tooth (15-25) were randomly assigned to IL or DL. The protocol included implant installation in healed sites, immediate loading, delayed loading, temporary screw-retained restoration, and replacement with a permanent single implant crown. Outcome measures were implant survival, marginal bone level, soft tissue changes, papillae index, pink, and white esthetic score (PES and WES), patient judged aesthetics, and oral health impact profile (OHiP-14).

RESULTS

Implant survival rate was 100% and 96% for IL and DL, respectively. Implant success rate was 96% and 88% for IL and DL, respectively. Statistically significant lower papilla index scores were found in the IL group at temporary crown and definitive crown placement. An overall statistically significant improvement after 12 months for PES, WES and OHIP-14 was found.

CONCLUSION

This prospective randomized study showed that single implants in the maxilla can present satisfactory results with respect to either immediate loading or delayed loading after 12 months.

Evaluation of the papilla level adjacent to implants placed in fresh, healing or healed sites: A systematic review

A better understanding of factors that can lead to papilla formation or recession, such as the type of site where the implant was placed, is of fundamental importance to the aesthetic success of the rehabilitation. The aim of this study was to perform a systematic review of the literature regarding the formation or recession of papilla adjacent to implants placed in fresh, healing or healed sites. The protocol for this study was registered in the PROSPERO database (registration number CRD 42016033784). An electronic search was performed by two independent reviewers who applied the inclusion and exclusion criteria on the PubMed/MEDLINE, Scopus, and Embase databases from January 2005 up to February 2016. The initial screening yielded 1,065 articles, from which 15 were selected for a systematic review after applying the inclusion and exclusion criteria. Nine studies compared fresh and healed sites, four studies compared healing and healed sites, one study compared fresh and healing sites, and one study analysed all three sites. The majority of studies identified by this systematic review showed no difference between groups after the longer follow-up period. The sites where the implants were placed did not have a long-term influence on papilla formation or recession.

Clinician assessments and patient perspectives of single-tooth implant restorations in the esthetic zone of the maxilla: A systematic review

STATEMENT OF PROBLEM

Esthetic outcomes associated with implant dentistry are important to both clinicians and patients. However, esthetic satisfaction may vary between the 2 groups. In order to evaluate the current publications relating to this topic, the following focused question was developed, "what are the quantitative and qualitative differences between clinician evaluations and patient perspectives in the assessment of single-tooth implant outcomes in the esthetic zone?"

PURPOSE

The purpose of this systematic review was to identify differences in esthetic satisfaction between clinicians and patients when evaluating single-tooth implant-supported restorations.

MATERIAL AND METHODS

An electronic search of the Medline database and Cochrane Central Register of Controlled Trials (2000 to 2014) was performed. The search was supplemented by a manual search of specific journals. A quality assessment of full-text articles was performed according to Cochrane Collaboration's tool and Newcastle-Ottawa scale for risk of bias assessment. Information regarding outcomes was collected and compared.

RESULTS

The search term combinations identified 555 titles. Subsequent to further review, 11 publications, including 2 randomized controlled trials, were selected for inclusion. Because of the heterogeneity of the study designs, study interventions, and esthetic assessment methods, no meta-analysis was performed. The clinicians identified a satisfactory outcome in 51% to 100% for peri-implant soft tissue and 62% to 90% for implant restorations. Patients showed a mean range score of 43% to 93% for peri-implant soft tissue and 81% to 96% for implant restorations. The visual analog scale score of the dentists was always lower than that of the patients. The review identified correlations between subjective and objective assessments for the Pink Esthetic Score (PES), the Papilla Index (PI), the Implant Crown Aesthetic Index (ICAI), and the modified (mod-ICAI) indices.

CONCLUSIONS

Clinicians are more critical of esthetic outcomes than patients. The PES and the PI correlated with the patients' responses concerning the peri-implant soft tissue. The ICAI and the mod-ICAI showed a correlation of both the peri-implant mucosa and implant-supported crown satisfaction. Thus, a comprehensive and practical index should be developed to assess the esthetic outcomes for single-tooth implant restorations in the esthetic zone.

Clinical Application of the PES/WES Index on Natural Teeth: Case Report and Literature Review

The use of reliable indices to evaluate the aesthetic outcomes in the aesthetic area is an important and objective clinical aid to monitor the results over time. According to the literature various indices were proposed to evaluate aesthetic outcomes of implant-prosthetic rehabilitation of the anterior area like Peri-Implant and Crown Index [PICI], Implant Crown Aesthetic Index [ICAI], Pink Esthetic Score/White Esthetic Score [PES/WES], and Pink Esthetic Score [PES] but none of them was related to prosthetic rehabilitation on natural teeth. The aim of this study is to verify the validity of PES/WES index for natural tooth-prosthetic rehabilitation of the anterior area. As secondary objective, we proposed to evaluate the long-term predictability of this clinical application, one of which is presented below, following the analysis of the most currently accepted literature.

Long-term Stability of Soft Tissue Esthetic Outcomes Following Conventional Single Implant Treatment in the Anterior Maxilla: 10-12 Year Results

Purpose:

The present study aimed to evaluate the long-term stability of esthetic outcomes of soft tissue around maxillary anterior single-tooth implants after 10-to-12 years of loading.

Methods:

Patients who had been treated for single-tooth implants in the anterior maxilla between February 2000 and July 2002 were invited to participate in the study. All implants had been placed according to delayed implant placement and conventional loading protocols without any connective tissue graft or papilla preservation flaps. Pink Esthetic Score (PES) was rated using standardized clinical photographs to assess the esthetic outcomes of the implant treatment at the time of crown placement and at time of follow-up examination which was at least 10 years after the crown placement.

Results:

A total of 19 patients were included. The mean score of PES was 11.63 (SD 1.61; range 7-14) at baseline. After 10-to-12 years of function, a mean PES score of 11.05 (SD 2.09; range 6–14) was recorded. No significant differences were found in the esthetic outcomes, categorized based on clinically relevant levels, between the baseline and follow-up session (p>0.05).

Conclusion:

Within limitation of the present study, it can be concluded that the esthetic outcomes of soft tissue around the maxillary anterior single-tooth implants placed using conventional implant placement technique remained stable in the long-term.

Esthetic outcome for maxillary anterior single implants assessed by different dental specialists

PURPOSE

The aim of this study was to assess the esthetic outcome of maxillary anterior single implants by comparing the esthetic perception of dental professionals and patients.

MATERIALS AND METHODS

Twenty-three patients with single implants in the esthetic zone were enrolled in this study. Dentists of four different dental specialties (Three orthodontists, three oral surgeons, three prosthodontists, and three periodontists) evaluated the pink esthetic score (PES)/white esthetic score (WES) for 23 implant-supported single restorations. The satisfactions of the patients on the esthetic outcome of the treatment have been evaluated according to the visual analog scale (VAS).

RESULTS

The mean total PES/WES was 12.26 ± 4.76. The mean PES was 6.45 ± 2.78 and mean WES was 5.80 ± 2.82. There was a statistically significant difference among the different specialties for WES (P<.01) and Total PES/WES (P<.01). Prosthodontists were found to have assigned poorer ratings among the other specialties, while oral surgeons gave the higher ratings than periodontists, orthodontists, and prosthodontists.

CONCLUSION

Prosthodontists seemed to be stricter when assessing aesthetic outcome among other specialties. Moreover, a clear correlation existed between dentists' and patients' esthetic perception, thereby providing rationales for involving patients in the treatment plan to achieve higher levels of patient satisfaction.

Rehabilitation of the severely atrophied dentoalveolar ridge in the aesthetic region with corticocancellous grafts from the iliac crest and dental implants

Background

The aim of this study was to assess changes in bone volume after block bone augmentation and placement of dental implants and further evaluate the aesthetic outcome of the treatment.

Material and Methods

9 Patients with atrophied anterior maxilla were included in this study. They received total of 21 implants. Dimensions of the alveolar ridge were measured from cone-beam computed tomography x-rays. The bone level at the implant sites was analysed from intraoral x-rays and the aesthetic outcome was assessed from clinical photographs using a pink aesthetic score (PES) scaling.

Results

The mean gained horizontal bone width at the marginal crest and 5 mm apically was accordingly 2.7mm and 5.0 mm. The mean PES rating was 9.8/14. The survival rate of.

Conclusions

Reconstruction of the atrophied anterior maxilla with bone blocks and dental implants is a safe procedure with high survival rate and acceptable aesthetic outcome.

Key words:Dental implants, aesthetic region, corticocancellous bone grafts, pink aesthetic score, survival rate.

The Impact of Buccal Bone Defects and Immediate Placement on the Esthetic Outcome of Maxillary Anterior Single-Tooth Implants

This study aimed to evaluate the impact of buccal bone defects and immediate placement on the esthetic outcome of maxillary anterior single-tooth implants. The archives of the Department of Dental Implants & Tissue Regeneration at Hygeia Hospital during a 5-year period (2010–2014) were retrospectively analyzed, in search of patients treated with a single-tooth implant after extraction of a maxillary incisor. The status of the buccal bone plate and the time of implant placement were recorded. The pink esthetic score (PES) of each case was evaluated, with a maximum score of 14. In total, 91 patients were included in the study. The mean PES was 10.5. The outcome was considered satisfactory (PES ≥ 8) in 89% and (almost) perfect (PES ≥ 12) in 35% of the cases. Immediate implant placement had no impact on PES (P &gt; .05), even though it demonstrated slightly greater variability. On the other hand, buccal bone defects had a negative effect on PES (P &lt; .0001). In conclusion, a satisfactory esthetic outcome can be achieved in single-tooth implants in the anterior maxilla. The presence of buccal bone defects is considered a negative prognostic factor, whereas immediate implant placement does not affect the esthetic outcome.

Aesthetic perception of single implants placed in the anterior zone. A cross-sectional study

BACKGROUND

Several aesthetic indexes have been described to assess implant aesthetics. The aim of this study was to compare the aesthetic assessment made by dental professionals and students of single-tooth implants placed in the upper incisors.

MATERIALS AND METHODS

A cross-sectional survey study using a subjective questionnaire to assess the aesthetics in 3 implant supported single-tooth cases in the anterior maxilla was performed. The interviewed subjects were divided into 4 groups: dentist with experience in implant treatment, dentists without experience in implants and 3rd and 5th year dental students. The questionnaire consisted of 2 visual analogue scales (VAS) to evaluate aesthetics, the pink esthetic score (PES), the white esthetic score (WES) and the simplified papilla index (PI).

RESULTS

One-hundred dentists and one-hundred dental students filled the aesthetic assessment questionnaire. The results showed that the subjects were more critical than reference values, specially concerning prosthetic issues. The differences between groups were more obvious in the case with the best result. On the other hand, few differences were detected in the remaining cases. Regarding soft tissue and crown features, experienced dentists in implant dentistry were the most demanding. Cronbach's Alpha showed values ≥ 0,8 in the questionnaire in every case, which indicates an adequate reliability.

CONCLUSIONS

Dentists and dental students have different opinions when assessing aesthetics of single tooth implant supported cases. Experience and area of expertise seem to influence the evaluation of aesthetics in the anterior region.

Clinical, radiographic, and esthetic evaluation of immediately loaded laser microtextured implants placed into fresh extraction sockets in the anterior maxilla: a 2-year retrospective multicentric study

OBJECTIVES

To assess the clinical, radiographic, and esthetic outcomes of implants with a laser microtextured collar placed in the anterior region of the maxilla at the time of tooth extraction and immediately temporized.

METHODS

Forty-six Tapered Internal Laser-Lok BioHorizons implants were immediately placed and immediately restored with nonfunctional loading in 46 patients (24 men and 22 women) with a thick gingival biotype, ideal gingival level/contour, and postextraction intact walls. Survival rate, cortical bone loss, and periimplant mucosal responses were evaluated at 6, 12, and 24 months.

RESULTS

Survival rate was 95.6%. Mean mesial and distal marginal bone loss, 24 months after installation, were 0.58 mm (SD = 0.53; range, 0.17-1.15) and 0.57 mm (SD = 0.70; range, 0.42-1.10), respectively. A mesial and distal papilla regrowth mean of 1.8 and 1.5 mm, respectively, were found. The midfacial soft tissue levels showed 0.12 mm of mean recession after 24 months.

CONCLUSION

Immediate implants with a laser microtextured surface restored at the day of surgery, may be considered as a predictable procedure in terms of implant survival and hard and soft tissue remodeling.

The influence of professional competence on the inter- and intra-individual esthetic evaluation of implant-supported crowns in the anterior maxilla

OBJECTIVES

Evaluation of the influence of professional competence on esthetic predictability of implant-supported crowns in the anterior maxilla and identification of objective factors allowing predictable planning for esthetic results.

MATERIALS AND METHODS

Sixty patients with 82 implants in the esthetic zone were included in this study. Width of keratinized mucosa, biotype, recessions, and papilla index according to Jemt as well as radiological bone loss were assessed. Study casts and photographs were obtained. Each patient as well as people with different level of expertise (laypersons, students and dentists) rated the esthetic satisfaction after final restoration on a scale (1-10). Correlations between esthetic assessments and previously documented clinical parameters were tested.

RESULTS

The study failed to show a significant relationship between the raters' level of dental expertise and their subjective esthetic evaluation. However, patients rated themselves much more favorable than the three evaluator groups did. A comparison of the clinical parameters with the esthetic evaluation revealed significantly more favorable ratings by the lay group in the presence of a wide attached gingiva (P = 0.021) than by the other groups and by the laypersons (P = 0.002), the dentists (P = 0.003), and students (P = 0.009) in the absence of recessions. The ratio of the implant crown length to the length of the contralateral crown had a negative effect on ratings for all three groups ([laypersons P < 0.001], [students P < 0.001] and [dentists P = 0.001]). The papilla index of the mesial papilla correlated significantly with laypersons' ratings (P = 0.036).

CONCLUSION

Earlier investigations are confirmed. Width of keratinized mucosa is a risk factor for esthetic predictability of implant-supported crowns in the anterior maxilla in laypersons' ratings. Furthermore, there is an association between the discrepancy of lengths of implant-supported single crowns to their contralateral natural teeth and esthetic satisfaction for all expertise levels.

Esthetic Evaluation of Implant Crowns and Peri-Implant Soft Tissue in the Anterior Maxilla: Comparison and Reproducibility of Three Different Indices

BACKGROUND

A successful implant reconstruction with optimal esthetics consists of a visually pleasing prosthesis and complete and healthy surrounding soft tissue. In the current literature, numerous indices used to qualitatively assess esthetics have been described. However, studies comparing the indices and their reproducibility are scarce.

PURPOSE

The aim of this study was to compare three different esthetic indices for the evaluation of single implant-supported crowns.

MATERIALS AND METHODS

A total of 10 prosthodontists (P), 10 orthodontists (O), 10 general dentists (G), and 10 lay people (L) independently performed the same assessment using 30 photographs and corresponding casts with three different esthetic indices (Peri-Implant and Crown Index [PICI], Implant Crown Aesthetic Index [ICAI], "Pink Esthetic Score/White Esthetic Score [PES/WES]) and repeated the evaluations 4 weeks later.

RESULTS

The PES/WES and the PICI showed significantly higher esthetic scores (pink, white, total) and clinical acceptance compared with the ICAI in all four groups and in both assessments. The highest intraobserver agreement was achieved using the PES/WES and the least with the ICAI. The mean Kappa per group ranged from 0.18 (group L with ICAI) to 0.63 (group G with PICI).

CONCLUSION

In comparison with the ICAI, the PES/WES and PICI were more reproducible. Therefore, PES/WES and PICI seem to be more suitable as esthetic indices for single implant crowns.