8/17/2019 2014 - RS - YING -XIN GU - Esthetic Outcome and Alterations of Soft Tissue Around Single Implant
1/6
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
8/17/2019 2014 - RS - YING -XIN GU - Esthetic Outcome and Alterations of Soft Tissue Around Single Implant
2/6
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
8/17/2019 2014 - RS - YING -XIN GU - Esthetic Outcome and Alterations of Soft Tissue Around Single Implant
3/6
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
Gu et al Evaluation of soft tissue alteration
8/17/2019 2014 - RS - YING -XIN GU - Esthetic Outcome and Alterations of Soft Tissue Around Single Implant
4/6
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.
4 | 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
8/17/2019 2014 - RS - YING -XIN GU - Esthetic Outcome and Alterations of Soft Tissue Around Single Implant
5/6
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.
References
Al-Nsour, M.M., Chan, H.L. & Wang, H.L. (2012)
Effect of the platform-switching technique on
preservation of peri-implant marginal bone: a sys-
tematic review. International Journal of Oral
Maxillofacical Implants 27: 138 – 145.
Annibali, S., Bignozzi, I., Cristalli, M.P., Graziani,
F., La Monaca, G. & Polimeni, A. (2012) Peri-implant marginal bone level: a systematic review
and meta-analysis of studies comparing platform
switching vs. conventionally restored implants.
Journal of Clinical Periodontology 39: 1097 – 1113.
Belser, U., Buser, D. & Higginbottom, F. (2004)
Consensus statements and recommended clinical
procedures regarding esthetics in implant den-
tistry. International Journal of Oral Maxillofaci-
cal Implants 19(Suppl): 73 – 74.
Belser, U.C., Grutter, L., Vailati, F., Bornstein,
M.M., Weber, H.P. & Buser, D. (2009) Outcome
evaluation of early placed maxillary anterior sin-
gle-tooth implants using objective esthetic crite-
ria: a cross-sectional, retrospective study in 45
patients with a 2- to 4-year follow-up using pink
and white esthetic scores. Journal of Periodontol-
ogy 80: 140 – 151.
Buser, D., Chappuis, V., Bornstein, M.M., Wittne-
ben, J.G., Frei, M. & Belser, U.C. (2013) Long-
term stability of contour augmentation with early
implant placement following single tooth extrac-tion in the esthetic zone a prospective, cross-sec-
tional study in 41 patients with a 5- to 9-year
follow-up. Journal of Periodontology 84: 1517 –
1527.
Buser, D., Halbritter, S., Hart, C., Bornstein, M.M.,
Grutter, L., Chappuis, V. & Belser, U.C. (2009)
Early implant placement with simultaneous
guided bone regeneration following single-tooth
extraction in the esthetic zone: 12-month results
of a prospective study with 20 consecutive
patients. Journal of Periodontology 80: 152 – 162.
Buser, D., Martin, W. & Belser, U.C. (2004)
Optimizing esthetics for implant restorations
in the anterior maxilla: anatomic and surgical
considerations. International Journal of Oral
Maxillofacical Implants 19(Suppl): 43 – 61.
Buser, D., Wittneben, J., Bornstein, M.M., Grutter,
L., Chappuis, V. & Belser, U.C. (2011) Stability of
contour augmentation and esthetic outcomes of
implant-supported single crowns in the esthetic
zone: 3-year results of a prospective study withearly implant placement postextraction. Journal
of Periodontology 82: 342 – 349.
Cabello, G., Rioboo, M. & Fabrega, J.G. (2013) Imme-
diate placement and restoration of implants in the
aesthetic zone with a trimodal approach: soft tis-
sue alterations and its relation to gingival biotype.
Clinical Oral Implants Research 24: 1094 – 1100.
Chang, M., Wennstrom, J.L., Odman, P. & Anders-
son, B. (1999) Implant supported single-tooth
replacements compared to contralateral natural
teeth. Crown and soft tissue dimensions. Clinical
Oral Implants Research 10: 185 – 194.
Chiapasco, M., Casentini, P. & Zaniboni, M. (2014)
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
Gu et al Evaluation of soft tissue alteration
8/17/2019 2014 - RS - YING -XIN GU - Esthetic Outcome and Alterations of Soft Tissue Around Single Implant
6/6
study on the outcome of straumann(R) tissue
level and bone level implants placed in vertically
deficient alveolar ridges treated by means of
autogenous onlay bone grafts. Clinical Implant
Dentistry and Related Research 16: 32 – 50.
Cho, H.L., Lee, J.K., Um, H.S. & Chang, B.S. (2010)
Esthetic evaluation of maxillary single-tooth
implants in the esthetic zone. Journal of Peri-
odontal Implant Science 40: 188 – 193.
Chow, Y.C. & Wang, H.L. (2010) Factors and tech-niques influencing peri-implant papillae. Implant
Dentistry 19: 208 – 219.
Cosyn, J., De Bruyn, H. & Cleymaet, R. (2013) Soft
tissue preservation and pink aesthetics around
single immediate implant restorations: a 1-year
prospective study. Clinical Implant Dentistry
and Related Research 15: 847 – 857.
Cosyn, J., Eghbali, A., De Bruyn, H., Dierens, M. &
De Rouck, T. (2012) Single implant treatment in
healing vs. healed sites of the anterior maxilla: an
aesthetic evaluation. Clinical Implant Dentistry
and Related Research 14: 517 – 526.
Degidi, M., Nardi, D. & Piattelli, A. (2011) One
abutment at one time: non-removal of an imme-
diate abutment and its effect on bone healingaround subcrestal tapered implants. Clinical Oral
Implants Research 22: 1303 – 1307.
Dierens, M., de Bruecker, E., Vandeweghe, S., Kis-
ch, J., de Bruyn, H. & Cosyn, J. (2013) Alterations
in soft tissue levels and aesthetics over a 16-
22 year period following single implant treatment
in periodontally-healthy patients: a retrospective
case series. Journal of Clinical Periodontology 40:
311 – 318.
Furhauser, R., Florescu, D., Benesch, T., Haas, R.,
Mailath, G. & Watzek, G. (2005) Evaluation of
soft tissue around single-tooth implant crowns:
the pink esthetic score. Clinical Oral Implants
Research 16: 639 – 644.
den Hartog, L., Raghoebar, G.M., Slater, J.J., Stel-
lingsma, K., Vissink, A. & Meijer, H.J. (2013) Sin-
gle-tooth implants with different neck designs: a
randomized clinical trial evaluating the aesthetic
outcome. Clinical Implant Dentistry and Related
Research 15: 311 – 321.
Hermann, J.S., Buser, D., Schenk, R.K., Schoolfield,
J.D. & Cochran, D.L. (2001) Biologic width around
one- and two-piece titanium implants. Clinical
Oral Implants Research 12: 559 – 571.
Hof, M., Pommer, B., Strbac, G.D., Suto, D., Watzek,
G. & Zechner, W. (2013) Esthetic evaluation of sin-
gle-tooth implants in the anterior maxilla follow-
ing autologous bone augmentation. Clinical Oral
Implants Research 24(Suppl A100): 88 – 93.
Jung, R.E., Pjetursson, B.E., Glauser, R., Zembic,
A., Zwahlen, M. & Lang, N.P. (2008) A system-
atic review of the 5-year survival and complica-
tion rates of implant-supported single crowns.
Clinical Oral Implants Research 19: 119 –
130.Lai, H.C., Zhang, Z.Y., Wang, F., Zhuang, L.F., Liu, X.
& Pu, Y.P. (2008) Evaluation of soft-tissue alteration
around implant-supported single-tooth restoration
in the anterior maxilla: the pink esthetic score.
Clinical Oral Implants Research 19: 560 – 564.
Lang, N.P., Zitzmann, N.U. & Working Group 3 of
the, V. E. W. o. P. (2012) Clinical research in
implant dentistry: evaluation of implant-sup-
ported restorations, aesthetic and patient-reported
outcomes. Journal of Clinical Periodontology 39
(Suppl 12): 133 – 138.
Lee, A., Fu, J.H. & Wang, H.L. (2011) Soft tissue
biotype affects implant success. Implant Den-
tistry 20: e38 – e47.
Mangano, F., Mangano, C., Ricci, M., Sammons,R.L., Shibli, J.A. & Piattelli, A. (2012) Single-
tooth Morse taper connection implants placed in
fresh extraction sockets of the anterior maxilla:
an aesthetic evaluation. Clinical Oral Implants
Research 23: 1302 – 1307.
Mombelli, A., van Oosten, M.A., Schurch, E., Jr &
Land, N.P. (1987) The microbiota associated with
successful or failing osseointegrated titanium
implants. Oral Microbiology and Immunology 2:
145 – 151.
Muller, H.P., Heinecke, A., Schaller, N. & Eger, T.
(2000) Masticatory mucosa in subjects with dif-
ferent periodontal phenotypes. Journal of Clinical
Periodontology 27: 621 – 626.
Pieri, F., Aldini, N.N., Marchetti, C. & Corinaldesi,
G. (2013) Esthetic outcome and tissue stability of
maxillary anterior single-tooth implants follow-
ing reconstruction with mandibular block grafts:
a 5-year prospective study. International Journal
of Oral Maxillofacical Implants 28: 270 – 280.
Pjetursson, B.E., Bragger, U., Lang, N.P. & Zwahlen,
M. (2007) Comparison of survival and complica-
tion rates of tooth-supported fixed dental prosthe-
ses (FDPs) and implant-supported FDPs and
single crowns (SCs). Clinical Oral Implants
Research 18(Suppl 3): 97 – 113.
Pjetursson, B.E., Thoma, D., Jung, R., Zwahlen, M.
& Zembic, A. (2012) A systematic review of the
survival and complication rates of implant-sup-
ported fixed dental prostheses (FDPs) after a mean
observation period of at least 5 years. Clinical
Oral Implants Research 23(Suppl 6): 22 – 38.
Priest, G. (2003) Predictability of soft tissue form
around single-tooth implant restorations. Interna-tional Journal of Periodontics Restorative Den-
tistry 23: 19 – 27.
Santing, H.J., Raghoebar, G.M., Vissink, A., den
Hartog, L. & Meijer, H.J. (2013) Performance of
the Straumann bone level implant system for
anterior single-tooth replacements in augmented
and nonaugmented sites: a prospective cohort
study with 60 consecutive patients. Clinical Oral
Implants Research 24: 941 – 948.
Schropp, L., Isidor, F., Kostopoulos, L. & Wenzel, A.
(2005) Interproximal papilla levels following early
vs. delayed placement of single-tooth implants: a
controlled clinical trial. International Journal of
Oral Maxillofacical Implants 20: 753 – 761.
Shi, J.Y., Wang, R., Zhuang, L.F., Gu, Y.X., Qiao,S.C. & Lai, H.C. (2014) Esthetic outcome of sin-
gle implant crowns following type 1 and type 3
implant placement: a systematic review. Clinical
Oral Implants Research. doi: 10.1111/clr.12334.
Epub ahead of print.
Singh, V.P., Uppoor, A.S., Nayak, D.G. & Shah, D.
(2013) Black triangle dilemma and its manage-
ment in esthetic dentistry. Dental Research Jour-
nal (Isfahan) 10: 296 – 301.
Vilhjalmsson, V.H., Klock, K.S., Storksen, K. &
Bardsen, A. (2011) Aesthetics of implant-sup-
ported single anterior maxillary crowns evalu-
ated by objective indices and participants’ per-
ceptions. Clinical Oral Implants Research 22:
1399 –
1403.
Weinlander, M., Lekovic, V., Spadijer-Gostovic, S.,
Milicic, B., Wegscheider, W.A. & Piehslinger, E
(2011) Soft tissue development around abutments
with a circular macro-groove in healed sites of
partially edentulous posterior maxillae and man-
dibles: a clinical pilot study. Clinical Oral
Implants Research 22: 743 – 752.
6 | 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
Top Related