Immediate single-tooth implants in the anterior maxilla: 3-year results of a case series on hard and soft tissue response and aesthetics.

PURPOSE: The objective of this prospective study was to assess the overall outcome of immediate single implant treatment in the anterior maxilla after a 3-year observation period. MATERIAL AND METHODS: Thirty consecutively treated patients with a thick gingival biotype, ideal gingival level/contour and intact socket walls at the time of tooth extraction were treated for single-tooth replacement in the aesthetic zone by two experienced clinicians. Treatment included minimal mucoperiosteal flap elevation, immediate implant placement (NobelReplace TiUnite(®)), insertion of a grafting material between the implant and the socket wall and connection of a screw-retained provisional restoration. The latter was replaced by a cemented crown 6 months thereafter. Patients were clinically and radiographically re-examined after 3 years to assess implant survival, complications and hard and soft tissue conditions. The aesthetic outcome was objectively rated using the Pink Esthetic Score (PES) and White Esthetic Score (WES) by a blinded clinician who had not been involved in the treatment. RESULTS: Twenty-five patients could be re-evaluated after 3 years. One early implant failure had occurred resulting in an implant survival rate of 96%. Radiographic examination yielded on average 1.13 mm mesial, respectively 0.86 mm distal bone loss. The clinical conditions showed fairly low peri-implant plaque (18%) and bleeding (24%) and mean probing depth was 3.17 mm. Mean mesial/distal papilla shrinkage and midfacial soft tissue recession in reference to the pre-operative status accounted for 0.05, 0.08 and 0.34 mm, respectively. Between the 1- and 3-year reassessment mesial papillae showed significant re-growth (0.36 mm; p=0.015). Advanced midfacial recession (>1 mm) was found in 2/25 (8%) cases. Five (21%) cases were aesthetic failures (PES<8 and/or WES<6) and 5/24 (21%) showed an (almost) perfect outcome (PES≥12 and WES≥9). The remainder (14/24 or 58%) demonstrated acceptable aesthetics. CONCLUSIONS: The proposed strategy seems a valuable and predictable treatment option for well-selected patients in the mid-long term as shown by almost full papillary re-growth and a low risk for advanced midfacial recession.

The gingival biotype revisited: transparency of the periodontal probe through the gingival margin as a method to discriminate thin from thick gingiva.

AIM: To detect groups of subjects in a sample of 100 periodontally healthy volunteers with different combinations of morphometric data related to central maxillary incisors and surrounding soft tissues. MATERIAL AND METHODS: Four clinical parameters were included in a cluster analysis: crown width/crown length ratio (CW/CL), gingival width (GW), papilla height (PH) and gingival thickness (GT). The latter was based on the transparency of the periodontal probe through the gingival margin while probing the buccal sulcus. Every first volunteer out of 10 was re-examined to evaluate intra-examiner repeatability for all variables. RESULTS: High agreement between duplicate recordings was found for all parameters, in particular for GT, pointing to 85% (kappa=0.70; p=0.002). The partitioning method identified three clusters with specific features. Cluster A1 (nine males, 28 females) displayed a slender tooth form (CW/CL=0.79), a GW of 4.92 mm, a PH of 4.29 mm and a thin gingiva (probe visible on one or both incisors in 100% of the subjects). Cluster A2 (29 males, five females) presented similar features (CW/CL=0.77; GW=5.2 mm; PH=4.54 mm), except for GT. These subjects showed a clear thick gingiva (probe concealed on both incisors in 97% of the subjects). The third group (cluster B: 12 males, 17 females) differed substantially from the other clusters in many parameters. These subjects showed a more quadratic tooth form (CW/CL=0.88), a broad zone of keratinized tissue (GW=5.84 mm), low papillae (PH=2.84 mm) and a thick gingiva (probe concealed on both incisors in 83% of the subjects). CONCLUSIONS: The present analysis, using a simple and reproducible method for GT assessment, confirmed the existence of gingival biotypes. A clear thin gingiva was found in about one-third of the sample in mainly female subjects with slender teeth, a narrow zone of keratinized tissue and a highly scalloped gingival margin corresponding to the features of the previously introduced "thin-scalloped biotype" (cluster A1). A clear thick gingiva was found in about two-thirds of the sample in mainly male subjects. About half of them showed quadratic teeth, a broad zone of keratinized tissue and a flat gingival margin corresponding to the features of the previously introduced "thick-flat biotype" (cluster B). The other half could not be classified as such. These subjects showed a clear thick gingiva with slender teeth, a narrow zone of keratinized tissue and a high gingival scallop (cluster A2).

Instant provisionalization of immediate single-tooth implants is essential to optimize esthetic treatment outcome.

OBJECTIVE: The immediate single-tooth implant has become a viable treatment option. However, the impact of the restorative procedure on esthetics is currently unclear. The goal of this study was to compare the soft tissue outline at immediate implants following two restorative protocols: immediate connection of a temporary crown or submerged healing during which a removable partial denture is used. MATERIAL AND METHODS: A 1-year single-blind randomized clinical study was performed in 49 patients. Twenty-four patients were assigned to the immediate restoration group and 25 to the delayed restoration group. Clinical and radiographic evaluations of soft and hard tissues were carried out after 3, 6 and 12 months. RESULTS: Implant survival, bone remodeling, probing depth and bleeding tendency were not influenced by the restorative protocol. Delayed restoration resulted in initial papilla loss taking up to 1 year to attain comparable height as for immediate restoration. Midfacial recession was systematically 2.5-3 times higher following delayed restoration pointing to a 0.75 mm additional loss in comparison with immediate restoration after 1 year. CONCLUSIONS: If the primary implant stability permits it, immediate single-tooth implants should be instantly provisionalized in the interest of optimal midfacial esthetics.

Immediate single-tooth implants in the anterior maxilla: a 1-year case cohort study on hard and soft tissue response.

AIM: The objective of the present study was to assess implant survival rate, hard and soft tissue response and aesthetic outcome 1 year after immediate placement and provisionalization of single-tooth implants in the pre-maxilla. All patients underwent the same strategy, that is mucoperiosteal flap elevation, immediate implant placement, insertion of a grafting material between the implant and the socket wall and the connection of a screw-retained provisional restoration. MATERIAL AND METHODS: Thirty consecutive patients were treated for single-tooth replacement in the aesthetic zone by means of immediate implant placement and provisionalization. Reasons for tooth loss included caries, periodontitis or trauma. At 6 months, provisional crowns were replaced by the permanent ones. Clinical and radiographic evaluation was completed at 1, 3, 6 and 12 months to assess implant survival and complications, hard and soft tissue parameters and patient's aesthetic satisfaction. RESULTS: One implant had failed at 1 month of follow-up, resulting in an implant survival rate of 97%. Radiographic examination yielded 0.98 mm mesial, respectively, 0.78 mm distal bone loss. Midfacial soft tissue recession and mesial/distal papilla shrinkage were 0.53, 0.41 and 0.31 mm, respectively. Patient's aesthetic satisfaction was 93%. CONCLUSIONS: The preliminary results suggest that the proposed strategy can be considered to be a valuable treatment option in well-selected patients.

Single-tooth replacement in the anterior maxilla by means of immediate implantation and provisionalization: a review.

OBJECTIVES: The objective of this study was to assess to what extent the outcome of immediate implantation and provisionalization for replacing single maxillary teeth in the esthetic zone is favorable and predictable from biologic and esthetic points of view. MATERIAL AND METHODS: An electronic search (MEDLINE and Cochrane Oral Health Group Specialized Trials Register) and a manual search were performed to detect studies concerning maxillary single-tooth replacements by means of dental implants immediately placed into fresh extraction sockets and provisionalized within the first 24 hours. Only full-text reports on clinical studies published in English up to June 2006 were included. Case reports and reviews on the topic of interest were excluded. RESULTS: Eleven studies were selected. Based on a qualitative data analysis, implant survival and even management of papilla levels seem predictable following immediate implantation and provisionalization. However, maintaining the midfacial gingival margin may be more problematic, since postextraction bone remodeling and therefore marginal gingival changes will occur irrespective of the timing of the placement of an implant. The long-term impact of this remodeling is currently unclear and needs to be elucidated in future research. CONCLUSION: The clinician is recommended to be reserved when considering immediate implant placement and provisionalization for replacing single maxillary teeth in the anterior zone. At the very least, a number of guidelines and prerequisites need to be taken into consideration.