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Immediate Placement and Restoration of Dental Implantsin the Esthetic Region: Clinical Case SeriesNABIL KHZAM, BDS, MPhil, DClinDent*, NIKOS MATTHEOS, DDS, MASc, PhD†, DAVID ROBERTS, BDSc, MDSc‡,

WILLIAM L BRUCE, BDSc, MDSc§, SASO IVANOVSKI, BDSc, BDentSt, MDSc, PhD¶

ABSTRACT

Aim: The objective of this study was to assess the hard and soft tissue changes following immediate placement andprovisional restoration of single-tooth implants in the aesthetic zone.Methods: Thirteen patients with immediately placed and restored implants were included in this study. All participatingpatients underwent the same treatment strategy that involved removal of the failed tooth, flapless surgery, immediateimplant placement, and connection of a screw-retained provisional restoration.Three months following implantplacement, the temporary crowns were replaced by the definitive restorations. Implant survival rates, and hard and softtissue changes were measured using periapical X-rays and photographs.The range of the observation period wasbetween 12 and 37 months with a mean period of 23.2 ± 7.6 months.Results: At the time of follow-up, all implants were present with no complications. Radiographic evaluation revealed amean mesial bone gain of 1.20 ± 1.01 mm and a mean distal bone gain of 0.80 ± 1.14 mm, which reached statisticalsignificance.The mean mid-buccal recession was 0.20 ± 0.78 mm, whereas the mesial and distal papillae height loss was0.50 ± 1.26 mm and 0.30 ± 0.82 mm, respectively.The changes in the soft tissues did not reach statistical significance.Conclusion: Notwithstanding the limitation of a small sample size, this study shows that immediate implant placementand provisional restoration in the maxillary aesthetic zone can result in favorable treatment outcomes with regards tosoft and hard tissues changes over a follow-up period of 23.2 ± 7.6 months.

CLINICAL SIGNIFICANCE

Most clinical trials investigating immediate implant placement and immediate restoration in the maxillary anterior zonehave focused on implant survival and implant success, with particular emphasis on radiographically assessed hard tissueschanges. However, this study assesses the soft tissue changes associated with this procedure, which is an importantarea of study given the esthetic demands of implant therapy in the maxillary anterior region.

(J Esthet Restor Dent ••:••–••, 2013)

INTRODUCTION

Single tooth replacement with an implant supportedcrown is often the treatment of choice for missing teethin the anterior maxilla. The original implant treatmentprotocol described by Branemark involved 3 months of

healing following extraction of a failed tooth, and anadditional 3 to 6 months of a load-free period followingimplant placement.1,2 In the last 20 years, implantdentistry has evolved dramatically, with the originaltwo-stage protocol modified to include one-stagesurgery,3 immediate implant placement into a fresh

*Specialist Periodontist, Private Practice, University of Tripoli, Libya†Associate Professor, The University of Hong Kong, Hong Kong‡Specialist Prosthodontist, Private Practice, Brisbane, Qld, Australia§Specialist Prosthodontist, Private Practice, Brisbane, Qld, Australia¶Professor of Periodontology, School of Dentistry and Oral Health, Griffith University, Gold Coast, Qld, Australia

RESEARCH ARTICLE

© 2013 Wiley Periodicals, Inc. DOI 10.1111/jerd.12083 Journal of Esthetic and Restorative Dentistry Vol •• • No •• • ••–•• • 2013 1

extraction socket and immediate implant restoration.4,5

These three approaches have been combined in anattempt to further expedite the restorative process.6

Clinical trials have shown high levels of implant survivaland success for single tooth implants placed directlyinto fresh extraction sockets.6,7 Furthermore, it has beenshown that immediately placed implants may beprovisionally restored with a temporary crown that isplaced out of occlusion (immediate provisionalrestoration). This one-stage surgical and restorativeprocedure has the advantage of an immediate estheticoutcome with a fixed restoration, while eliminating theneed for temporary fixed and/or removable partialdentures, and potential second-stage surgicalintervention. It also allows for shorter treatment timesas post-extraction socket-healing events coincide withimplant osseointegration. However, case selection iscritical for this treatment approach, with multiplecontraindications such as the presence of infection atthe extraction site, inadequate soft tissue profile, andthe requirement for sufficient bone apical to the socketin order to achieve appropriate primary stability.

From a surgical point of view, good primary stabilityappears to be critical for the one-stage surgicalprocedure, as it has been shown that there is a strongrelationship between the placement torque and thesurvival of single tooth-implants.8 Adequate primarystability is of additional importance in cases where theimplant is provisionally restored in order to withstandvarious forces that may be exerted on the restoredimplant during the early stages of healing. From arestorative point of view, the implant temporary crownmust be out of occlusion in both centric and eccentricpositions of the lower jaw.6 Indeed, the immediateimplant placement and restoration protocol istechnically challenging and can be considered a“technique sensitive” procedure.9

A major consideration in the maxillary anterior regionis the loss of buccal tissue contour following toothextraction. In order to minimize this loss of buccaltissue, the placement of a grafting material in the spacebetween the implant and the buccal socket wall hasbeen advocated and is supported by histological

evidence that this approach significantly decreases boneloss following immediate implant placement.10–13 Theuse of antibiotic prophylaxis in patients undergoingroutine implant placement to minimize complication issupported by the literature and hence are indicated inmore challenging clinical protocols such as thatdescribed in this study.14

Most clinical trials investigating immediate implantplacement and immediate restoration in the maxillaryanterior zone have focused on implant survival andimplant success, with particular emphasis onradiographically assessed hard tissues changes.However, few studies have assessed the soft tissuechanges associated with this procedure, although this isan important consideration given the esthetic demandsof implant therapy in the maxillary anterior region.

Therefore, the objectives of the current study were toassess the soft and hard tissue dimensional changesassociated with immediately placed and provisionallyrestored implants replacing single teeth in the anteriormaxillary region after a minimum follow-up of12 months.

METHODS

The research protocol was reviewed and granted ethicalapproval by the Griffith University Human ResearchEthics Committee (DOH/09/09/HREC).

Patient selection

Thirteen patients who received 15 immediately placedand provisionally restored implants in the esthetic zonebetween March 2007 and December 2008 wereincluded in this study. Two of the patients had twoimplants each. Patients were included in this studybased on their willingness to attend 6 monthly reviewvisits following their treatment. The sample includedfour males and nine females, mean age 44.7 ± 18.7years, with 15 implants (13 incisors, 1 canine, and 1premolar) (Table 1). None of the patients were smokers.No patients were lost at the final follow-up.

IMMEDIATE PLACEMENT AND RESTORATION OF DENTAL IMPLANTS Khzam et al.

DOI 10.1111/jerd.12083 © 2013 Wiley Periodicals, Inc.Vol •• • No •• • ••–•• • 2013 Journal of Esthetic and Restorative Dentistry2

Inclusion and Exclusion Criteria

The decision to progress with immediate implantplacement and provisional restoration was determinedfollowing a comprehensive clinical and radiographicexamination (using a cone-beam computed tomography[CBCT] scan), and detailed consultation between thesurgical and restorative clinician. Aside from the usualcontraindications for routine implant therapy(untreated periodontitis, uncontrolled diabetes, medicalconditions that contraindicate elective surgery), specificcontraindications for the immediate implant placementand restoration protocol included the presence of anypathological bone loss around the tooth or any gingivalmargin pathology or irregularity. Furthermore, theimmediate implant placement and provisionalrestoration protocol was not implemented unless thetooth socket walls were completely intact (nofenestrations or dehiscences) following extraction, and aminimal implant torque insertion of 30 Ncm(maximum of 40 Ncm) was obtained.

Surgical Protocol

All surgical procedures were conducted under localanesthesia. Preoperative antibiotics were given to allpatients. This prophylactic dose was 500 mgAmoxicillin three times daily (20 caps) for 1 week,starting 1 day before surgery. Diagnostic evaluation ofthe site of placement included clinical examination,radiographic analysis using a cone-beam CT scan andocclusal analysis with study models. After informedconsent was obtained from the patient, atraumatictooth extraction using a periotome without flapelevation was performed (Figure 1B). Surgical implant

placement followed, according to the instructions of theimplant manufacturer (Astra Tech®, Mölndal, Sweden)(Figure 1C). Primary stability was achieved to aminimum insertion torque of 30 Ncm using amotor-driven surgical handpiece. In all implants sites,the buccal space between the implant and the socketwall was filled using a xenogenic particulate bonegrafting material (Bio-Oss; Geistlich Pharma AG,Wolhusen, Switzerland). Postoperative instructionsincluded chlorhexidine mouthwash (20 mL) use for2 minutes twice daily for 2 weeks. Patients wereinstructed to not brush the implant site for at least2 weeks. For pain control, patients were advised to useeither 1 g of Paracetamol or 400 mg of Ibuprofen asneeded.

Restorative Protocol

After connection of a temporary abutment (Figure 1D),a prefabricated screw-retained temporary crown wasadjusted and placed (Figure 1E). Appropriateadjustment of the occlusal scheme was carried out inorder to ensure that the temporary restoration was freeof any contact in both centric and eccentric excursions(Figure 1F). Final finishing of the provisional crown wascarried out with rubber cups and pumice. The patientswere advised to avoid placing any pressure on theprovisional restoration, especially during eating. After3 to 4 months, the temporary restoration was replacedwith a custom zirconia abutment (Procera, NobelBiocare, Göteborg, Sweden) and a permanentall-ceramic restoration by a prosthodontist.

Hard Tissue Measurements

Periapical X-rays were used to measure the changes inalveolar bone height surrounding the implant from thetime of placement of the temporary restoration(baseline) to the follow-up assessment, which was atleast 12 months later. The parallel technique was usedin order to obtain comparable X-rays, andstandardization was carried out by using the knownimplant length to calibrate the baseline and follow-upmeasurements. The implant shoulder was used as areference level from which mesial (Mbc) and distal(Dbc) lines were drawn in an apical direction to the

TABLE 1. Tooth types and reason for tooth extraction

Tooth type/reason forextraction

Endodontic Fracture Rootresorption

Total

Incisors 6 6 1 13

Canines 0 1 0 1

Premolars 0 1 0 1

Total 6 8 1 15



first point of contact between bone and the implant(Figure 2). Computer software (Image J 1.43u; NationalInstitute of Health, Bethesda, MD, USA) was used tocalculate the length of these lines (Mbc and Dbc) andexpress it as an absolute measurement inmillimeters.

Soft Tissue Measurements

The soft tissue data were collected from photographstaken with a fixed angle and zoom ratio prior to toothextraction (baseline) and at the follow-up visit (at least12 months later). The crown length of the tooth mesialto the implant measured from the margin of the gingivawas set as the reference length. This allowedcomparisons of the changes that occurred before andafter the treatment with regard to the position of thegingiva and the amount of recession. A line extendingfrom the incisal edges of the teeth adjacent to theimplant (Ocl) was the starting point for themeasurements. From this line, perpendicular lines weredrawn extending to the tip of the mesial (Mp) anddistal (Dp) papilla, as well as the middle of themid-buccal gingival margin (Bm) (Figure 3). The length

of these lines was calculated based on the clinicalphotographs using a software program (Image J 1.43u),and variations over time were calculated in millimeters.

Other Measurements

Implant survival rate: defined as the percentage ofimplants that were present at the final follow-up.Implant success rate: defined as the percentage ofsymptom and pathology free implants at the finalfollow-up. Assessment of interdental papilla: Thetriangular interdental papillae occupying the spacebetween the implant retained restoration and theadjacent teeth were assessed using Jemt’s index.15 Jemt’sIndex comprises of: score 0 (no papilla present), score 1(<1/2 of papilla present), score 2 (1/2 of papillapresent), score 3 (papilla fills entire interdental space),and score 4 (hyperplastic papilla present).

Statistical Analysis

The primary hypothesis of this study was that there isno significant change between tooth extraction/implantplacement and follow-up with regards to the hard and

A B C

D E F

G

FIGURE 1. A, Failed tooth due to improper root canal treatment (12) before the extraction. B, Minimal traumatic toothextraction. C, Implant placed in final position. D, E, and F,Temporary crown in place. G,A radiograph.



soft tissues changes. In case of parametric data, a pairedt-test was used, whereas in nonparametric data aWilcoxon signed-rank test was used. A frequencyanalysis was used to describe the distribution of hardand soft tissue changes among the patients. Allcalculations were performed with the SPSS statisticalsoftware program (version 16.0, SPSS, Inc., Chicago, IL,USA).

RESULTS

The reasons for tooth loss of the 15 implants (13incisors, 1 canine, and 1 premolar) included in thisstudy are outlined in Table 1. The patient

demographics, implant characteristics and follow-upintervals are shown in Table 2. No implant loss orimplant associated pathology was observed atthe final follow-up visit. Representativeoutcomes of the treatment are illustrated inFigures 4 to 6.

Hard Tissue Measurements

Radiographic evaluation revealed a mean mesial bonegain of 1.20 ± 1.01 mm (p < 0.0001), which reachedstatistical significance. The mean distal bone gain was0.80 ± 1.14 mm (p = 0.01), which also reached statisticalsignificance. Table 3 shows that there was a significantchange in both the mesial and distal bone level betweenthe time of implant placement and the follow-upassessment. Table 4 shows the distribution of bone gainand loss in millimeters for individual patients. Themajority of the readings demonstrated bone gain≥0.5 mm (13/15 cases).

Soft Tissue Measurements

The mean mid-buccal gingiva recession was 0.20 ± 0.78mm (p = 0.44). The mesial papillary height loss was0.50 ± 1.12 mm (p = 0.24), whereas the distal papillaryheight loss was 0.30 ± 0.82 mm (p = 0.27) Table 5. The

A B

FIGURE 2. Illustration of hard tissue measurements onperiapical X-ray. Cl = coronal line; Dbc = distal bone contact;Mbc = mesial bone contact.A set of paired radiographs usedfor measurements. A = baseline radiograph; B = follow-upradiograph.

FIGURE 3. Illustration of the measurements of soft tissue onphotographs. Bm = distance to middle of buccal gingival margin;Dp = distance to distal papilla; Mp = distance to mesial papilla;Ocl = occlusal line.



mesial papilla showed the highest amount of tissue loss.The changes in the soft tissues did not reach statisticalsignificance. Table 6 shows the distribution of soft tissuechanges on the mesial, distal, and mid-facial aspects ofindividual implants. Most of the readings remain within±10% of the baseline value except for the mesialchanges which reach up to 35% in the patients that hadtwo implants placed adjacent to each other.

Jemt’s Index

Wilcoxon signed-rank test did not reveal any significantdifference in the Jemt’s index score for either mesial ordistal papilla between implant placement and follow-upobservations (p-values 0.180 and 0.171, respectively)(Table 7). At follow-up, 50% of the mesial papillaereceived a score of 3, which means that the full heightof the interdental papillae was present (normal),whereas the same score was recorded in 60% of distal

papillae. The rest of the results showed scores of 1, 2,and 4. No score of 0 was recorded.

DISCUSSION

In this case series report, immediately placed andrestored single-tooth implants in the maxillary anteriorzone were found to osseointegrate and remaincomplication-free after 23.2 ± 7.6 months of follow-up.This result is in accordance with outcomes presented inother similar studies,16–22 demonstrating the highpredictability of osseointegration when a very specificset of selection criteria is applied, and a strict surgicaland restorative protocol is observed.

This study utilized the Astra Tech implant system,which has several abutment-implant interfacecharacteristics common to “contemporary” implant

TABLE 2. Overview of clinical data

Patient No. Sex Age(years)

Follow-up(months)

Site ofimplant

Length(mm)

Diameter(mm)

1 M 39 30 11 15 5.0

2 M 39 30 21 13 4.0

3 F 23 16 11 15 5.0

4 F 33 20 11 13 4.5

5 F 33 20 21 15 4.5

6 F 62 21 21 13 5.0

7 M 66 26 14 13 4.0

8 M 64 17 12 13 3.5

9 F 27 28 13 15 4.0

10 F 44 31 21 13 4.5

11 M 27 30 22 15 4.0

12 F 83 37 22 15 4.0

13 F 62 12 11 13 4.0

14 F 32 15 21 13 5.0

15 F 66 18 22 15 4.0

M = male, F = female.



systems. Astra Tech implants have a rough surface, aninternal connection, a “platform switch” at theabutment-implant interface and microthreads at thecoronal aspects of the implant. These design featuresare incorporated primarily to enhance the stability ofthe hard and soft tissues, although it is unclear if, andto what extent, each of these features may contribute totissue stability. It is likely that some or all of thefeatures of the Astra Tech system, many of which itshares with other currently available implant designs,has contributed to the positive outcomes of thisstudy.

This study showed a mean mesial bone gain of 1.20 mmand a mean distal bone gain of 0.80 mm over theduration of the follow-up period (23.2 ± 7.6 months).The changes in the hard tissues reached statisticalsignificance compared with baseline suggesting thatthere was bone gain in a coronal direction at the

interproximal aspects over the duration of the study.This is not surprising because the implants were placedin extraction sockets, and there was subsequent bonefill in the space between the implant and the socketwalls, resulting in the coronal repositioning of thebone-implant contact over the course of the study. Thebone gain was also assisted by the use of a slowlyresorbing particulate bone graft.

Knowing the exact implant length and diameter allowedfor precise measurement of the bone level inmillimeters, compensating for any distortion of theradiograph. This was an important element of themethodology in contrast with much of the literature,where measurements are only made with the use of theapical20,22 or the coronal end23 of the implant shoulderas a reference point. Other studies have used thecontact point of the restoration to the adjacent tooth asa reference point. However, the use of these landmarks

FIGURE 4. Illustration of soft tissue on photographs,(22)-baseline and follow-up.




has some limitations, namely that the restorativecontact point is not going to be constant as theprovisional crowns will undergo replacement withpermanent restorations, whereas the radiographiclocation of the apical/coronal shoulder is easily affectedby image distortion.24

The results of the present study, which showed arelatively high amount of bone gain, compares favorablywith other studies involving implant therapy in the

maxillary anterior zone.18,19,22,25–28 Using the immediateplacement and restoration protocol, Kan and colleaguesshowed a mean marginal bone loss ranging from 0.26 to0.40 mm on the mesial and 0.22 to 0.28 mm on thedistal aspect of the implant at 1-year follow-up.23

Several other investigators have shown even greateramounts of bone loss. The study by De Rouck andcolleagues revealed a mean bone loss of 0.98 mm on themesial aspect of the implant and 0.78 mm distally at1-year follow-up.6 Other studies using the immediateimplant placement and immediate restoration approachhave shown similar outcomes.23,24,29–31 On the otherhand, Kan and colleagues reported that “scalloped”shaped implants placed into extraction sites showed amean bone gain of 1.0 mm after 1 year of follow-up.7The amount of bone gain in this study was attributed tothe placement of a bone graft into the gap between theimplant and walls of the extraction socket thatsubsequently resulted in radiographically assessed bonefill. Our study used a “platform switching” implant


TABLE 3. Bone level changes (presented as millimeterschange)

Parameters Change in mm p-value

Mesial bone level 1.20 ± 1.01 0.001*

Distal bone level 0.80 ± 1.14 0.01*

Mean ± standard deviation.*Significant.

TABLE 4. Frequency analysis of hard tissue changes inmillimeters

Bone changes inmm/patients

2.5 and 2 mm 2.23 2.19 2.18

2 and 1.5 mm 1.79 1.75 1.58

1.5 and 1 mm 1.29 1.04 –

1 and 0.5 mm 0.82 0.71 –

0.5 and 0 mm 0.22 0.2 0.01

0 and −0.5 mm 0.09 – –

−0.5 and −1 mm 0.63 – –

TABLE 5. Soft tissue level changes (presented as millimeterschange)

Parameters Change in mm p-value

Mesial papilla level −0.50 ± 1.12 0.24

Distal papilla level −0.30 ± 0.82 0.27

Mid-buccal ginigval level −0.20 ± 0.78 0.44

Mean ± standard deviation.



design, flapless surgery, and applied a particulate bonegraft between the tooth socket and the implant, whichmay account for the reported increase in interproximalbone height over the observation period.

Soft tissue measurements have been reported in only afew studies utilizing immediate placement and

immediate provisional restoration of implants in theanterior maxilla. This study showed mean mid-buccalgingival recession of 0.20 mm, whereas the mesial anddistal papillae were apically positioned by 0.50 and0.30 mm respectively, compared with baseline. Overall,no statistically significant changes in the aestheticallyimportant mid-buccal soft tissue profile were foundcompared with baseline. Furthermore, no statisticallysignificant changes in papilla levels were noted whenthe results were accurately measured in millimeters.This indicates a short-medium term stability of the softtissue architecture around immediately placed andrestored implants. The soft tissue loss noted in thisstudy was of minimal clinical significance and did notappear to influence the esthetic outcome. This isfurther supported by the fact that there were no

TABLE 6. Frequency analysis of soft tissue changes in percentage

Soft tissue changes inpercentage/Patients

10% and 5% 5.96 (DP) – – – – –

5.90 (MP) 5.12 (MP) – – – –

7.70 (MF) 5.95 (MF) – – – –

5% and 0% 1.02 (DP) 2.06 (DP) – – – –

1.79 (MP) 0.11 (MP) – – – –

1.83 (MF) 4.58 (MF) 0.95 (MF) 4.5 (MF) – –

0% and −5% 2.57 (DP) 1.62 (DP) 1.13 (DP) 1.82 (DP) 0.36 (DP) 2.31 (DP)

0.72 (MP) 1.14 (MP) 0.96 (MP) – – –

0.39 (MF) 1.09 (MF) 4.72 (MF) – – –

−5% and −10% 8.98 (DP) 9.55 (DP) 7.43 (DP) 9.03 (DP) – –

9.55 (MF) 8.05 (MF) 9.99 (MF) – – –

−10% and −15% 10.76 (MP) 10.63 (MP) 14.95 (MP) – – –

13.41 (MF) 12.86 (MF) – – – –

−15% and −20% 18.52 (DP) – – – – –

−20% and −25% 24.68 (MP) – – – – –

−25% and −30% 25.92 (MP) – – – – –

−30% and −35% 33.17 (MP) – – – – –

DP = distal papilla; MF = mid-facial gingival; MP = mesial papilla.

TABLE 7. Changes in the interdental papilla

Parameters Amount of change p-value

Mesial papilla level −1.342* 0.180

Distal papilla level −1.242* 0.171

*Z value



differences in Jemt’s index indicating no changes in thepapillary fill of the interdental embrasure, which is ofimportance in terms of the esthetic outcome.15 It shouldalso be noted that there was apical drift of the mesialpapillae more than that of the distal papillae andmid-facial tissue. The greater mesial papilla tissue losscan be attributed to the fact that the sample includedfour implants replacing both central incisors in twopatients. In this case, the mesial papillae were borderedby implants on both sides, and it is widely recognizedthat greater soft tissue loss occurs between twoimplants compared with an implant and an adjacentnatural tooth.32

The method being used for this study to record softtissue measurements is different from otherstudies,23,25,27 which used a reference line connecting themid-facial gingival level of the two teeth adjacent to theimplant restoration. However, flap elevation was usedfor access in these studies, which may lead to variabilityof the position of the reference line connecting themid-facial gingiva of the adjacent teeth, as some softtissue recession generally occurs following the elevationof a full mucoperiosteal flap. The reference line used inour study extended from the incisal edges of the teethadjacent to the implant, and this acted as a fixed andstable reference.

The soft tissue outcomes reported in this studycompare favorably with the available literature. In astudy that assessed 35 patients with single immediatelyplaced and restored maxillary implants, the soft tissueloss from the facial aspect was greater than thatreported in our study, with 0.55 mm loss at thefollow-up period of 1 year.23 Similar results werereported by De Rouck and colleagues with an averagemid-buccal recession of 0.53 mm in the first year offunction.6 Another study by Cornelini andcolleagues reported 0.75 mm mid-facial tissue loss after1 year.27 The somewhat superior outcomes reported inthis study may be attributable to differencesin implant design (platform switch versus regularplatform, internal versus external attachment) andsurgical protocols (flap elevation versus flapless,augmentation of gap between implant andsocket walls).

In terms of longer term changes, a recent paperpublished by Cosyn and colleagues revealed a meanmesial and distal papilla height loss of 0.05 and0.08 mm, respectively.30 The mid-facial soft tissuerecession was 0.34 mm. The mesial papillae showedsignificant regrowth between the 1- and 3-yearfollow-ups. Advanced midfacial recession was found in2/25 (8%) cases.30 Kan and colleagues showed thatfollowing a 4-year follow-up period, the changes inmean mesial and distal papilla levels (−0.22 and−0.21 mm, respectively) were significantly less thanthose observed at the 1-year follow-up. However, themean overall facial gingival level change (−1.13 mm)was significantly greater than that observed at the1-year follow-up (−0.55 mm), which means thatpapillary height may improve over time, althoughchanges in the position of the labial margin maydeteriorate.32 Therefore, long-term studies are requiredto document the long-term esthetic outcomes ofimplant treatment in the anterior maxillary region.

In comparison with other treatment protocols, studieswith data on the soft tissue changes following singletooth implant placement in healed sockets revealaround 0.6 mm of mid-facial recession within the firstyear of placement.33,34 In a study using the conventionaltechnique (two stages) with a follow-up period of 3years, the mean recession on the mid-facial aspect ofthe implant was found to be 1 mm.35

Overall, the results of the present investigationdemonstrate a relatively limited loss of soft tissue onthe mid-facial aspect. This fact can be attributed toatraumatic extraction of the failed teeth, flaplesssurgical approach, and the use of a particulatexenograft. It is noteworthy that flapless surgery presentsincreased risk for perforation of the alveolar bone, andthe experience of the surgeon is an important factorthat minimizes that risk.36 Insertion of bone graftingmaterial (Bio-Oss) into the gap between the implantand the walls of the extraction socket assists inpreserving a stable level of the hard tissues,13 and hencethe overlying soft tissue profile, as the Bio-Oss particleswould not significantly resorb over the duration of thestudy. Finally, the use of screw-retained instead ofcemented temporary restorations may contribute to the



absence of complications during the initial stages ofwound healing and maturation. In contrast, fistulaformation was reported in a study conducted by Kanand his associates using a cemented type of temporarycrowns.19 It is important to note that mid-facialrecession does not necessarily imply an estheticcompromise. An interesting finding in one case (FR)was that the recession at the mid-facial aspect actuallyimproved the patient esthetic, as the level of theadjacent tooth buccal soft tissue was already apicallydisplaced (Figure 6).

The papillary height changes observed in this studyappear to be in accordance with other studies. Kan andcolleagues reported a mean loss of 0.50 mm for themesial papillae and 0.30 mm mean loss of the distalpapillae.23 De Rouck and his associates showed areduction in the papillae height loss of 0.41 mm onaverage for mesial papillae and 0.31 mm for distalpapillae.6

No statistically significant differences were foundbetween the papillae levels at baseline and follow-up interms of Jemt’s index.15 A study by Cornelini andcolleagues found no scores of 0, 1, or 4 in their sample,with 60% of papillae receiving a score of 2, with theremainder scoring a 3.27 In another study by Kan andcolleagues the papilla index was measured atpretreatment and 3, 6, and 12 months following implantplacement with no differences noted between baselineand any of the follow-up observations.7 Therefore, thefindings of our study in relation to Jemt s’ index areconsistent with the published literature.

This clinical investigation was limited by theretrospective nature, the small sample size, the inabilityto secure a fully standardized follow-up examinationprotocol for all patients and the relatively small lengthof the observation period. All of these factors can havea significant impact on the results obtained from thisstudy, which should be interpreted with caution.Nevertheless, the study has provided some indicationsas to the nature and extent of soft and hard tissuechanges that may be expected with this protocol,although it remains unclear if the soft tissue outcomeswould remain stable over time. A longer observation

period and a larger sample size are needed to supportmore definite conclusions.

Notwithstanding the limitations of the study, the resultsindicate that the immediate placement and provisionalrestoration of a single tooth implant in the anteriormaxilla can result in predictable implantosseointegration, as well as stable peri-implant tissues,for up to 23.2 ± 7.6 months.

DISCLOSURE

The authors have no financial interest in any of thecompanies whose products are mentioned in this paper.

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