2014 - RS - YING -XIN GU - Esthetic Outcome and Alterations of Soft Tissue Around Single Implant

8/17/2019 2014 - RS - YING -XIN GU - Esthetic Outcome and Alterations of Soft Tissue Around Single Implant

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Ying-Xin Gu*Jun-Yu Shi*Long-Fei ZhuangShi-Chong Qiao

You-You XuHong-Chang Lai

Esthetic outcome and alterations ofsoft tissue around single implantcrowns: a 2-year prospective study

Authors’ affiliations:Ying-Xin Gu, Jun-Yu Shi, Long-Fei Zhuang,Shi-Chong Qiao, You-You Xu, Hong-Chang Lai,

Department of Oral and Maxillo-facialImplantology, Shanghai Key Laboratory ofStomatology, Shanghai Ninth People’s Hospital,School of Medicine, Shanghai Jiaotong University,Shanghai, China

Corresponding author:Hong-Chang Lai

Department of Oral and Maxillo-facialImplantology Shanghai Ninth People’s Hospital,School of Medicine Shanghai Jiaotong University639 Zhizaoju Road, Shanghai, 200011, ChinaTel.: +86 21 23271699Fax: +86 21 53073068e-mail: [email protected]

Key words: dental implants, pink esthetic score/white esthetic score, soft tissue esthetic out-

come, tissue level

Abstract

Objective: The aim of this prospective study was to assess the esthetic outcome and alterations of

peri-implant soft tissue using tissue-level implants. Furthermore, the influencing factors, including

grafting and gingival biotype, of esthetic outcome of peri-implant soft tissue were also evaluated.

Materials and methods: Of 38 patients with single missing anterior tooth in maxilla were treated

with a Straumann Standard Plus SLA implant. Bone augmentation was performed in 24 patients.

Follow-up was conducted at 12 and 24 months after definitive crowns placement. Esthetic outcome

using the pink esthetic score/white esthetic score (PES/WES) and clinical parameters were evaluated.

Results: The mean PES/WES value at baseline, 1-year, and 2-year examination was 13.79, 14.87,

and 14.96. Significant improvement was found between baseline and 1-year examination

(P < 0.01). And the improvement between 1-year and 2-year examination was not significant

(P = 0.40). The mean PES changing value in patients with thick biotype was significantly higher

than those with thin biotype at 2-year after definitive crowns placement ( P = 0.03). Graft

procedure had an unfavorable effect on mean PES value both at baseline and at follow-up

(P < 0.01). No implants were lost at 2-year examination. Three patients experienced peri-implant

infection. No significant difference was found with the passage of time in modified plaque index

(mPI), probing pocket depth (PPD), and modified bleeding index (mBI).

Conclusion: According to the present prospective clinical study, it can be concluded that it is

feasible to use tissue-level implant to support single crowns in esthetic area. Favorable short-term

esthetic outcome and stability of soft tissue around single implant crowns can be expected in

patients with or without graft. However, graft procedures might have an unfavorable effect on

the esthetic outcome. Gingival biotype can be considered as prognostic factor for esthetic

outcome. RCTs with long-term follow-up are needed to provide evidence for the long-term

stability of peri-implant soft tissue using tissue-level implant systems.

In recent years, rehabilitation of single-tooth

gaps by means of dental implants has become

a routine treatment with high survival and

success rates (Pjetursson et al. 2007, 2012;

Jung et al. 2008). However, the success of

implant treatment should not be limited to

achieving osseointegration. The esthetic

outcome of the reconstruction also becomes

an important parameter for clinical success

especially for esthetically sensitive cases.

For clinical esthetic assessment, both

implant crown features and peri-implant soft

tissue stability should be taken into consider-

ation (Chang et al. 1999). However, peri-

implant soft tissue meets most clinical chal-

lenges from the esthetic aspect. The most

common reasons for esthetic failure

include disharmonious mucosal color or tex-

ture, complete or incomplete loss of inter-

proximal papillae, and recession of soft tissue

level. So the soft tissue esthetic outcome is

of paramount importance to achieving clini-

cal esthetic success (Belser et al. 2004).

Pink esthetic score (PES) (Furhauser et al

2005) or pink esthetic score/white esthetic

score (PES/WES) (Belser et al. 2009) is now

adopted by more and more studies to assess

esthetic outcome and alterations of peri-

implant soft tissue. Connective tissue graft

might be necessary in about one-third of the

patients following type 1 (immediate after

tooth extraction) implants placement to

*These authors contributed equally to this work.

The authors claim that none of the material in the articlehas been published or is under consideration for publica-tion elsewhere.

Date:Accepted 21 March 2014

To cite this article:Gu Y-X, Shi J-Y, Zhuang L-F, Qiao S-C, Xu Y-Y, Lai H-C.Esthetic outcome and alterations of soft tissue around singleimplant crowns: a 2-year prospective study.Clin. Oral Impl. Res. 00, 2014, 1–6

doi: 10.1111/clr.12408

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1


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achieve steady improvement in PES score (Co-

syn et al. 2013). Following type 2 (4 – 8 weeks

after tooth extraction) and type 3 (12 –

16 weeks after tooth extraction) implants

placement, spontaneous improvements of

PES score might occur in the short-term fol-

low-up, and then the PES score will likely

reverse to the baseline level when the obser-

vational time was prolonged to at least

3 years after crown installation (Buser et al.

2011, 2013; Weinlander et al. 2011; Pieri

et al. 2013).

It is worth mentioning that only bone-level

implant systems were used in the above stud-

ies. Bone-level implant systems were widely

used in patients needed implant treatment in

esthetic area because of more concise surgi-

cal procedures and less bone resportion espe-

cially when platform-switching technology

was used (Al-Nsour et al. 2012; Annibali

et al. 2012).

Meanwhile, tissue-level implant systems

are also widely used in clinical practices, and

few studies have reported the esthetic evalua-

tion using tissue-level implant systems. A

previously published study by our group has

proved that tissue-level implant systems can

also achieve predictable soft tissue appear-

ance on the premise of accurate implant

placement depth (Lai et al. 2008). How-

ever, the follow-up was relatively short

(6 – 8 months), and patients in need of graft

procedures were excluded. To our knowledge,

this is the first prospective study reporting

the PES index of soft tissue using tissue-level

implants in patients with and without bone

augmentation.

Therefore, the aims of the present study

were (i) to assess the esthetic outcome and

alterations of peri-implant soft tissue using

tissue-level implants after 2-year follow-up

and (ii) to study the influencing factors,

including grafting and gingival biotype, of

esthetic outcome of peri-implant soft tissue.

Material and methods

Study design and patient data

This study was design as a prospective study

with 2-year follow-up. The study was

conducted at the Department of Oral and

Maxillofacial Implant of the Shanghai Ninth

People Hospital. From May 2010 to May

2012, 40 generally healthy patients (18

women and 22 men), aged from 19 to

58 years (mean 31.3 years), were included in

this study. All patients signed the informa-

tion consent from and received oral hygiene

instructions before the implant surgery was

performed. Fig. 1 shows the flow of clinical

procedures. The inclusion criteria were as fol-

lows:

1. Patients in need of single-tooth restora-

tion in the anterior maxilla;

2. Tooth extraction at least three months

before implant surgery;

3. No severe vertical bone defect and

enough primary stability to achieve

simultaneous implant placement;

4. Not be heavy smokers (>10 cigarettes/

day);

5. Not require restorative treatment of the

adjacent teeth.

Intervention

Implant placement

All the implants used in this study were

Straumann Standard Plus SLA implants

(Institut Straumann AG, Waldenburg, Swit-zerland). The implant placement was planned

based on pre-surgical clinical and radio-

graphic assessment. The implants were placed

in a three-dimensional position described by

Buser and colleagues (Buser et al. 2004). A

bone augmentation procedure was carried out

if (i) implant neck remained uncovered or (ii)

the buccal bone plate was

PES ≥ 6), and unfavorable rate (PES < 6) (Bel-

ser et al. 2009; Cosyn et al. 2012).

Clinical assessment

The survival rate was defined as the percent-

age of the implants remained in the oral cav-

Fig. 1. Flow chart of clinical procedures.Fig. 2. The fabrication of provisional plastic crowns.

2 | Clin. Oral Impl. Res. 0, 2014 / 1–6 © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Gu et al Evaluation of soft tissue alteration


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ity. Both biological and mechanical complica-

tions were recorded. In addition, the follow-

ing clinical variables were assessed: gingival

biotype (Muller et al. 2000), modified plaque

index (mPI), probing pocket depth (PPD),

modified bleeding index (mBI). All the mea-

surements were made by the same dentist

using a periodontal probe (15 UNC/CP-11.5B

Screening Color-Coded Probe, Hu-Friedy)

(Mombelli et al. 1987).

Follow-up assessment

Patients were re-called for clinical and

esthetic assessment at 1-year and 2-year after

crown placement, and the indices of mPI,

PPD, mBI, and PES/WES were recorded.

Statistical methods

Data analysis was performed using a statisti-

cal software package STATA (version 11.0;

StataCorp, College Station, TX, USA). Non-

normally distributed data (mBI, mPI, PPD,and PES/WES) were analyzed using Wilcoxon

signed-rank test. The intraclass correlation

coefficient was used to determine the interex-

aminer reliability. Wilcoxon rank-sum test

was used to analyze the mean PES value and

PES changing in patients with different graft

procedures and gingival biotypes. The

reported P values were two-sided. Statistical

significance was set at 5%.

Results

After two-year follow-up, two patients were

excluded because they declined to come back

for the follow-up examination. At last,

38 patients were included in this analysis.

Table 1 shows the demographic features of

all the subjects.

The interclass correlation coefficient of the

mean PES/WES value given by two orthodon-

tists was 0.85 at baseline, 0.82 at 1-year fol-

low-up, and 0.82 at 2-year follow-up.

Table 2 shows the mean PES/WES value

from baseline to 1-year follow-up. PES/WES

significantly increased from 13.79 to 14.87 at1-year follow-up (P < 0.01). In detail, the

mean value of mesial and distal papilla, cur-

vature and PES also increased significantly at

1-year follow-up. The mean value of margin

level and root convexity/color/texture sligh-

tly increased, but both did not reach

statistically significance.

Table 3 shows the mean PES/WES value

from 1-year follow-up to 2-year follow-up.

PES/WES showed steady improvement (from

14.87 to 14.96) at 2-year follow-up (P = 0.40).

In detail, the mean value of mesial and distal

papilla, curvature, root convexity/color/tex-

ture, and PES showed steady improvement at

2-year follow-up. The mean value of margin

level decreased slightly. And none parameters

showed statistically significantly difference

from 1-year follow-up to 2-year follow-up.

Fig 3 shows one typical example of all the

subjects included in the study.

Table 4 shows PES frequency at baseline,

1-year, and 2-year follow-up. The perfect rate

(PR) increased from 2.63% to 34.21% after 2-

year follow-up. The acceptable rate (AR)

decreased from 78.95% to 59.21%. The unfa-

vorable rate (UR) decreased from 18.42% to

6.58%.

Table 5 shows influence of variables on

esthetic outcome of peri-implant soft tissue.

Mean PES value did not show significant

difference between patients with thick and

thin biotype at baseline (P = 0.27). However,

patients with thick biotype could achieve sig-

nificantly higher mean PES value at follow-

up (P = 0.02). In addition, PES changing value

was higher in patients with thick biotype

(P = 0.03). Graft procedure had an unfavor-

able effect on mean PES value both at base-

line and at follow-up (P < 0.01). However,

similar PES changing value was found in

patients with or without graft (P = 0.44).

No implants were lost during the observa-

tion period, representing the survival rate

was 100%. Three patients experienced peri-

implant infection. All the three patients had

undergone guided bone regeneration (GBR

procedure due to the insufficient bone vol-

ume. Thus, the biological complication rate

was 7.9%. Two patients showed significant

improvement after debridement. One patient

showed recession of mid-facial mucosa and

exposure of neck metal. No mechanical com-

plications have occurred during the observa-

tion period.

Table 6 shows the change of clinical

parameters from baseline to follow-up. No

significant difference was found with the

Table 1. Summary of patient characteristics

Mean age in years 31.3(19 – 58)

Male/female ratio 22/16

Patient need graft/not graft 24/14

Implant site location: I1/I2/C 12/18/8

Implant diameter: 3.3 mm/4.1 mm 20/18

Implant length: 10 mm/12 mm 12/26

I1, first incisor; I2, second incisor; C, cannine.

Table 2. Mean pink esthetic score/white esthetic score value from baseline to 1-year follow-upmean (median) SD

Baseline(n = 38) 1-year (n = 38)

Mesial papilla 1.34 (1) 0.48 1.68 (2) 0.47 P < 0.01*

Distal papilla 1.03 (1) 0.16 1.42 (1) 0.50 P < 0.01*

Margin level 1.34 (1) 0.58 1.39 (1) 0.68 P = 0.53

Curvature 1.58 (2) 0.50 1.84 (2) 0.37 P = 0.02*Root/color/texture 1.16 (1) 0.37 1.24 (1) 0.59 P = 0.41

PES 6.45 (7) 1.16 7.58 (8) 1.51 P < 0.01*

Form 1.58 (2) 0.50 1.55 (2) 0.49 P = 0.96

Outline 1.34 (1) 0.48 1.32 (1) 0.53 P = 0.32

Color 1.29 (1) 0.46 1.28 (1) 0.45 P = 0.99

Texture 1.50 (1) 0.51 1.49 (1) 0.53 P = 0.57

Translucency 1.63 (2) 0.49 1.66 (2) 0.48 P = 0.16

WES 7.34 (8) 1.26 7.29 (8) 1.11 P = 0.94

PES/WES 13.79 (14) 2.25 14.87 (15) 2.21 P < 0.01*

*Statistically significant difference from baseline to follow-up.

Table 3. Mean pink esthetic score/white esthetic score value from 1-year follow-up to 2-year fol-low-up mean (median) SD

1-year (n = 38) 2-year (n = 38)

Mesial papilla 1.68 (2) 0.47 1.72 (2) 0.43 P = 0.08

Distal papilla 1.42 (1) 0.50 1.46 (1.5) 0.50 P = 0.18

Margin level 1.39 (1) 0.68 1.38 (1) 0.65 P = 0.99

Curvature 1.84 (2) 0.37 1.87 (2) 0.40 P = 0.33

Root/color/texture 1.24 (1) 0.59 1.28 (1) 0.49 P = 0.19

PES 7.58 (8) 1.51 7.71 (8) 1.38 P = 0.07

Form 1.55 (2) 0.49 1.54 (2) 0.50 P = 0.46

Outline 1.32 (1) 0.53 1.29 (1) 0.50 P = 0.55

Color 1.28 (1) 0.45 1.32 (1) 0.45 P = 0.32

Texture 1.49 (1) 0.53 1.47 (1) 0.51 P = 0.98

Translucency 1.66 (2) 0.48 1.63 (2) 0.50 P = 0.32

WES 7.29 (8) 1.11 7.25 (8) 1.18 P = 0.71

PES/WES 14.87 (15) 2.21 14.96 (16) 2.12 P = 0.40

None parameters showed statistically significant difference.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 3 | Clin. Oral Impl. Res. 0, 2014 / 1–6



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passage of time in all three parameters. The

gingival biotype assessment showed thick/

thin ratio was 28/10.

Discussion

The present study used PES/WES to evaluate

the esthetic outcome and alterations of peri-implant soft tissue using tissue-level implant

system. Several studies have demonstrated

the reliability and reproducibility of the PES/

WES index in clinical esthetic assessment

(Vilhjalmsson et al. 2011; Hof et al. 2013). In

addition, it has also been proved that the

changing of mean PES value is suitable to

assess the stability of peri-implant soft tissue

(Cho et al. 2010; Dierens et al. 2013).

In present study, the implant shoulder was

positioned about 1 mm apical to the cement –

enamel junction of the contralateral tooth.

Implant position is believed to play an impor-tant role in implant esthetic outcomes. This

may contribute to the favorable mean PES/

WES value (7.71/7.25) at 2-year examination

in this study. 26 patients received an imme-

diate, single-tooth Morse taper connection

implant (Leone implant System, Florence,

Italy) in esthetic area (Mangano et al. 2012).

At the 2-year examination, the mean PES/

WES value was 14.30 (7.30/7.00). 20 patients

received a bone-level implant treatment in

esthetic area (Buser et al. 2009). At the 1-year

examination, the mean PES/WES value was

16.75 (8.10/8.65). This may indicate that tis-

sue-level implant systems can also achieve

favorable short-term esthetic outcome of sin-

gle implant treatment on the premise of

accurate implant placement depth.

Implant crown features were assessed by

WES score. The parameters of form,

outline, color, texture, and translucency were

assessed respectively. Good visual appearance

had been achieved (WES > 7). As the WES

score is strongly related to the prosthetic

design and quality, we pay more attention to

the PES score.

In this study, baseline assessment was

performed two days later to avoid the inter-

ference of pressure caused by immediately

crowns placement. Spontaneous improve-

ment in mean PES value was observed after

one year follow-up and the slowdown of the

improvement was observed at the second

year follow-up.

Mesial and distal papilla showed signifi-

cant improvement during the observation

period. This observation may be due to the

relatively high bone level at the adjacent nat-

ural teeth as only patients with single gap

were included, for it is strongly believed that

the extent of papillae fill surrounding an

implant-supported restoration is principally

decided by the bone level at the adjacent

teeth (Chow & Wang 2010; Singh et al.

2013).

The curvature of soft tissue also showed

significant improvement during the observa-

tion period. It has been proven that peri-

implant soft tissue is still in remodeling

phase after abutment and crown attachment

(Priest 2003; Schropp et al. 2005). With the

relief of the pressure, the soft tissue may

become relatively more mature and healthier

with the time. This may probably explain

why the soft tissue curvature score increased

significantly.

The margin level and root convexity/color/

texture of soft tissue did not show significant

difference during the observation period. The

score of margin level even slightly decreased

at 2-year follow-up compared with score at 1-

year follow-up. This result is a little different

from our previous study using the same

implant systems (Lai et al. 2008). Only

patients with sufficient bone volume were

included in that study. Significant improve-

ment in margin-level score was reported after

6 – 8 months follow-up. Recession of mid-

facial mucosa caused by peri-implant infec-

tion in three subjects may explain the differ-

Table 4. Pink esthetic score frequency (in percent)

PES score

Baseline 1 year 2 years

No. % No. % No. %

0 0 0 0 0 0 0

1 0 0 0 0 0 0

2 0 0 0 0 1 1.32

3 2 2.63 0 0 1 1.32

4 2 2.63 4 5.26 0 0

5 10 13.16 4 5.26 3 3.95

6 22 28.95 6 7.89 2 2.63

7 26 34.21 12 15.79 19 25.00

8 12 15.79 30 39.47 24 31.58

9 2 2.63 16 21.05 24 31.58

10 0 0 4 5.26 2 2.63

Total 76 100 76 100 76 100

Perfect rate 2 2.63 20 26.32 26 34.21

Acceptable rate 60 78.95 48 63.16 45 59.21

Unfavorable rate 14 18.42 8 10.52 5 6.58

(a)

(b)

(c)

Fig 3. (a) Baseline, (b) One year, and (c) 2-year result of

a representative case. The pink esthetic score/white

esthetic score score was (a) 7/9, (b) 9/9, (c) 9/9.

Table 5. Influence factors of pink esthetic score index mean (median) SD

PES at bas eline PES at 2 years PES changing

Patients with thick biotype (n = 28) 6.57 (7) 1.26 8.18 (8) 0.85 1.61 (1.5) 0.95

Patients with thin biotype (n = 18) 6.20 (6) 0.79 6.75 (6) 2.00 0.55 (0) 1.55

P = 0.27 P = 0.02* P = 0.03*

Patients with graft (n = 24) 5.92 (6) 1.06 7.31 (7) 1.45 1.40 (1) 1.47

Patients without graft (n = 14) 7.43 (7) 0.51 8.64 (8) 0.72 1.21 (1) 0.54

P < 0.01* P < 0.01* P = 0.44

PES changing = PES at 2-year follow-up – PES at baseline.*Statistically significant difference between groups.




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ence. This agreed with the findings in previ-

ous studies that higher biological complica-

tion rate was found in patients with grafting

(den Hartog et al. 2013; Santing et al. 2013).

Among 38 patients in this study, 24 patients

experienced grafting procedures combined

with implant placement. The mean PES value

in patients with grafting was significantly

lower in those without grafting both at base-

line and at follow-up. This implied that the

grafting procedures might have an unfavorable

effect on the esthetic outcome of peri-implant

soft tissue. The less favorable pre-surgical sit-

uation, scar tissue caused by additional surgi-

cal procedures, higher complication rate, and

resorption of graft materials may be the possi-

ble reason for this result.

However, similar alterations of mean PES

value were found in patients with or without

GBR in this study, and the mean PES value

increased from 5.92 to 7.31 after 2-year fol-

low-up. This indicated tissue-level implant

systems could achieve spontaneous improve-

ment in soft tissue visual appearance also in

patients with GBR.

It is believed that biologic width around

one-piece tissue-level implants was more sim-

ilar to natural teeth than that around two-

piece bone-level implants (Hermann et al.

2001). The disconnections and reconnections

of abutments which are necessary in bone-

level implant systems may disturb connec-

tive tissue interaction and result a more api-

cally positioned zone of connective tissue

(Degidi et al. 2011). In addition, a recent pub-

lished study showed tissue-level implants

may present better long-term results in terms

of peri-implant bone maintenance, as com-

pared with bone-level implants (Chiapasco

et al. 2014). This may explain the favorable

outcome in our study and demonstrate that

tissue-level implants are also suitable to sup-

port single implant crowns in esthetic area.

Several studies have demonstrated that

thick gingivae have lower risk of recession of

mid-facial margin-level and interdental papilla

(Lee et al. 2011; Cabello et al. 2013). In this

study, similar mean PES value was found in

patients with thick or thin gingival biotype

at baseline. After 2-year follow-up, patients

with thick gingival biotype achieved more

favorable esthetic outcome of peri-implant

soft tissue. This means gingival biotype can

be considered as prognostic factors for

esthetic assessment.

Besides the mean value, the existing indi-

ces that categorize single features should also

be analyzed with frequency analysis (Lang &

Zitzmann 2012). It should be noted that PES/

WES index should be classified as an ordinal

data instead of a continuous data. Frequency

analysis which reflects the discrete distribu-

tion of data is important for ordinal data (Shi

et al. 2014). In this study, the perfect rate at

2-year follow-up was almost thirteen times

as much as it at baseline. And the unfavor-

able rate decreased after 2-year follow-up.

The result of frequency analysis also con-

firmed the improvement in esthetic out-

come.

Conclusion

The results of the present study indicate that

it is feasible to use tissue-level implant to

support single crowns in esthetic area. Favor-

able short-term esthetic outcome and stability

of soft tissue around single implant crowns

can be expected in patients with or withoutgraft. However, graft procedures might have

an unfavorable effect on the esthetic out-

come. Gingival biotype can be considered as

prognostic factor for esthetic outcome. RCTs

with long-term follow-up are needed to pro-

vide evidence for the long-term stability of

peri-implant soft tissue using tissue-level

implant systems.

Acknowledgement

We would like to thank Sheng-hui Li (Shang-

hai Jiaotong University, College of Medicine)

for statistics consultation.

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Implants in reconstructed bone: a comparative

Table 6. Summary of patient’s gingival biotype and clinical parameters mean (median) SD

Biotype: thick/thin mBI PPD(mm) mPI

Baseline (n = 38) 28/10 0.58 (1) 0.50 4.16 (4) 0.68 0.37 (0) 0.49

1-year follow-up (n = 38) 28/10 0.63 (1) 0.67 4.32 (4) 0.57 0.45 (0) 0.50

P = 0.59 P = 0.11 P = 0.37

2-year follow-up (n = 38) 28/10 0.66 (1) 0.67 4.39 (4) 0.70 0.47 (0) 0.51

P = 0.44 P = 0.06 P = 0.25

mPI, modified plaque index; PPD, probing pocket depth; mBI, modified bleeding index.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 5 | Clin. Oral Impl. Res. 0, 2014 / 1–6



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2014 - RS - YING -XIN GU - Esthetic Outcome and Alterations of Soft Tissue Around Single Implant

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