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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 3-9

Comparative clinical evaluation of esthetic parameters of immediately provisionalized implants in the esthetic zone with their natural counterparts


Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth Dental College and Hospital, Pune, Maharasthtra, India

Date of Submission13-Aug-2019
Date of Acceptance11-Nov-2019
Date of Web Publication08-Jul-2020

Correspondence Address:
Dr. Vrushika Mahajan
Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth Dental College and Hospital, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdi.jdi_18_19

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   Abstract 

Background: An anterior single implant-supported crown restoration in the maxillary anterior region must meet a particularly high standard of esthetic quality. The standard of care for edentulous space in esthetic zone therefore would be the placement of an implant with immediate provisionalization.
Aims and Objecectives: The aim of this study is to evaluate the esthetic parameters of immediately provisionalized implants in the esthetic zone and compare patients opinion with blinded clinicians opinion of the outcome of esthetics of implant in esthtic zone.
Materials and Methods: In our study, we placed 10 maxillary anterior single-tooth implants in fully healed maxillary anterior sites in esthetic zone. All the implants were provisionalized within 24 hours. Zirconia prosthesis was delivered as definitive prosthesis after three months of implant placement. The esthetic zone was photographed three months after delivering the definitive prosthesis. The esthetic outcome was then evaluated objectively using Pink Esthetic Score (PES) and White Esthetic Score (WES) by a blinded clinician. In addition, we used a triple score technique Visual Analogue Scale(VAS) wherein the patients commented on the soft tissue, prosthetic as well as the overall esthetic outcome.
Results: A mean PES of 9.2± 1.03 and a mean WES of 8.7± 1.16 recorded showed an acceptable peri-implant soft tissue outcome and an acceptable prosthetic outcome respectively. The statistical analysis revealed statistically significant correlation between patients' esthetic perception and dentists' perception of the anterior tooth.
Conclusion: The PES/WES is an objective tool in rating the esthetics of implant supported single crowns and adjacent soft tissues. Orthodontists were the most critical observers, while periodontists were more generous than other observers. The statistical analysis revealed a statistically significant correlation between patients' esthetic perception and dentists' perception of the anterior tooth.

Keywords: Esthetic outcome, esthetic zone, immediate provisionalization


How to cite this article:
Mahajan V, Kshirsagar R, Singh V, Pawar S. Comparative clinical evaluation of esthetic parameters of immediately provisionalized implants in the esthetic zone with their natural counterparts. J Dent Implant 2020;10:3-9

How to cite this URL:
Mahajan V, Kshirsagar R, Singh V, Pawar S. Comparative clinical evaluation of esthetic parameters of immediately provisionalized implants in the esthetic zone with their natural counterparts. J Dent Implant [serial online] 2020 [cited 2020 Sep 19];10:3-9. Available from: http://www.jdionline.org/text.asp?2020/10/1/3/289232


   Introduction Top


Patients today place a high demand for esthetics and want not only improved function but also early restoration of normal appearance. Esthetics plays an important role in any implant placement but is crucial for implants placed in the anterior maxilla.[1],[2],[3],[4],[5] An anterior single implant-supported crown restoration in the maxillary anterior region must meet a particularly high standard of esthetic quality because the adjacent natural teeth provide an immediate comparison. Overall, implant dentistry in the esthetic zone is challenging because the implant restoration and surrounding tissues will be visible when the patient smiles.[6],[7]

The main esthetic objectives of implant therapy from a surgical point of view are the achievement of a harmonious gingival margin without abrupt changes in tissue height, maintaining intact papillae, and obtaining or preserving a convex contour of the alveolar crest.[8],[9],[10],[11],[12],[13],[14],[15]

Objective methods of esthetic evaluation have been found to be largely superior to subjective evaluation methods using questionnaire-based assessment.[9],[16],[17],[18] However, many researchers have suggested that from an esthetic standpoint, the perception of the patient measured using subjective parameters is paramount.[19],[20],[21],[22],[23] Hence, we propose to use a combination of objective (White Esthetic Score [WES] and Pink Esthetic Score [PES]) subjective methods (Visual Analog Scale [VAS]) to assess the esthetic outcomes of our methods.

To provide consistent superlative results, the successful implant surgeon working in the esthetic zone should have a good understanding of biologic tissue response to implant placement, a thorough surgical education enabling performance of precise and low-trauma surgical procedures, and a large patient pool providing sufficient surgical experience with esthetic implant placement.[9],[24],[25],[26],[27],[28] The standard of care for edentulous space in the esthetic zone, therefore, would be the placement of an implant with immediate restoration/provisionalization.[29],[30],[31] A definitive prosthesis would be prepared after a delay of 3–4 months.

Few studies have considered a comparison between implant-supported prosthesis and their natural counterparts using objective esthetic parameters of assessment along with subjective parameters of assessment using a VAS to consider patient esthetic satisfaction.[32],[33],[34],[35]

This prospective study was designed to clinically evaluate the effects of immediate provisionalization on peri-implant soft-tissue status (PES) and esthetic appeal of the definitive prosthesis (WES) after definitive restoration compared to its healthy counterpart using objective esthetic parameters of assessment by a blinded clinician. In addition, subjective parameters of assessment by the patient with regard to esthetics were also considered.


   Materials and Methods Top


A total of ten (n = 10) implants were selected fulfilling the inclusion criteria, and the implants were immediately provisionalized. All cases were performed in the Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth (Deemed to be University) Dental College and Hospital, Pune, during the period from December 2016 to June 2018.

At the first visit, a detailed clinical examination of the patient was performed and consisted of an assessment of general and oral health status of the patient. Necessary laboratory investigations were advised. An orthopantomogram and intraoral periapical radiographs were made of all the patients included in the study.

Study models of the upper and lower jaws were made to facilitate the fabrication of surgical guiding stents. To prevent infection, preoperative antibiotic cover was prescribed and the surgical procedure was performed under strict aseptic conditions with the greatest attention paid for the preservation of implant. Local anesthesia with adrenaline (1:200,000) was administered. A surgical guiding stent was used to mark the approximate position for the implant placement. A full-thickness mucoperiosteal flap was reflected. A hole was drilled using the pilot drill in orientation with the adjacent tooth. The implant site was prepared using final twist drills. Implant placement was completed at a subcrestal level (0.5 mm below alveolar bone height). To eliminate the bias of using additional measures, namely bone graft and membrane, the study was designed to exclude the cases requiring bone graft and membrane. Implants having a stability of minimum 35 N-cm as measured using a torque wrench were provisionalized (acrylic provisional restoration) within 24 h. (All the implants were BioHorizons®, titanium abutment).

Zirconia prosthesis was delivered as a definitive restoration after 3 months. The esthetic zone was photographed using a structured methodology 3 months after delivering the definitive restoration. The esthetic outcome was then evaluated objectively using PES and WES by a single-blinded clinician who was not involved in the treatment procedure. VAS was used to record the perception of the patient about the soft-tissue, prosthetic as well as the overall esthetic outcome.

Statistical analysis

Spearman's rank correlation test was carried out to evaluate the relationship between the VAS and total PES/WES. To provide a graphic description of the results, scatter plots were created. Spearman's rank correlation coefficient is a nonparametric measure to study the relationship (strength and direction) between two variables (PES/WES and VAS) described using qualitative data. The “r” value was calculated, and the level of significance was fixed at P < 0.05.


   Results Top


This study was designed to evaluate the esthetic outcome of immediately provisionalized implants in the esthetic zone. Evaluation criteria included soft-tissue parameters (PES) and esthetic appeal of the definitive prosthesis (WES) assessed by a blinded clinician. In addition, the patients' perception with regard to esthetic outcome was also recorded subjectively using a VAS. We also compared PES and WES to the patient's perception of esthetic outcome using Spearman's rank correlation test.

Pink Esthetic Score

We applied the PES to ten (n = 10) implants in the esthetic zone. PES includes assessment of five variables, namely mesial papilla, distal papilla, curvature of facial mucosa, level of facial mucosa, and root convexity/soft-tissue color/soft-tissue texture. Of the parameters evaluated “mesial papilla” and “distal papilla” are scored independent of the conditions of the contralateral tooth.

Each variable was rated on the same 2-1-0 scale, with 2 as the best score and 0 as the poorest, for a maximal possible score of 10. The threshold of clinical acceptability was set at 6.

White Esthetic Score

Similarly, we used the WES which focused on the visible part of the implant restoration and assessed five variables, namely tooth form, tooth volume, tooth color, surface texture, and tooth translucency, which were assessed by comparison with a reference tooth. We have used the healthy natural contralateral tooth as a reference. Each variable was rated on the same 2-1-0 scale, with 2 as the best score and 0 as the poorest, for a maximal possible score of 10.

The threshold of clinical acceptability for PES and WES was set at 6 independently on each scale. Any score lower than 6 on either scale or lower than 12 on the combined index was assessed as an esthetic failure. A score higher than 6 on both scales and therefore higher than 12 on the combined index was assessed as an esthetic success. Acceptability was based on a score of 6 for each scale separately and not on a combined score of 12.

Visual Analog Scale

We used a horizontal VAS with the left anchor labeled “0” and the right anchor labeled “10.” Total two questions specifically addressing the patient's satisfaction with the treatment outcome from an esthetic point of view were asked; the range of possible answers went from totally unsatisfied = 0 to completely satisfied = 10.

Assessment by a blinded clinician

A photographed esthetic zone along with a scoring card was presented to the blinded clinician for assessment of the esthetic outcome at the conclusion of the study using the PES and WES.


   Discussion Top


Esthetic outcome assessment has been an emerging area of focus in implant dentistry. Clinicians today are concerned with the peri-implant soft-tissue result and the natural appearance of the definitive restoration that is in harmony with the surrounding dentition and soft tissue.[4],[5],[36],[37] Numerous controlled clinical trials showed that the respective overall implant survival and success rates are similar to those reported for other segments of the jaws.[7],[8],[38] However, most of the published studies do not include well-defined esthetic parameters for objective evaluation of soft-tissue outcomes and implant-supported prosthesis. Most of the analyses primarily focus on implant survival and rarely do they evaluate elements of anterior implant success such as re-establishment of harmoniously scalloped soft-tissue lines, natural contours, and esthetic merits of the prosthesis.[6],[7],[8],[11],[12]

Early assessment of soft-tissue outcomes was measured by a method proposed by Jemt et al.[39] (1997) which assessed the size and volume of interproximal papillae with respect to single-tooth implants, termed the papilla index (PI). Meijer et al.[40] (2005) gave an esthetic implant crown index to assess the implant restoration. Subsequently, Furhauseret al.[41] developed the PES for evaluating the soft tissue around single-tooth implant crowns.[7],[19],[21] This score had seven variables which objectively assessed the esthetic outcome of the soft tissues contouring a dental implant restoration, addressing crucial problems that are easily overlooked in a general assessment. Comprehensive objective assessment of soft-tissue and prosthetic parameters was eventually proposed by Belser et al. that included the PES with a WES (PES/WES). They modified Furhauser's PES by decreasing the number of variables from 7 to 5 to include mesial papilla, distal papilla, curvature of the facial mucosa, level of the facial mucosa, and root convexity/soft-tissue color and texture at the facial aspect of the implant site. All variables except the mesial and distal papilla were assessed by comparison with a natural counterpart. The authors' objective was to develop an index that evaluates the relevant peri-implant soft tissues and specifically evaluates the parameters inherent to the restoration.[13],[19],[23] The WES focused on the visible part of the implant restoration and assessed five variables: general tooth form, outline/volume of the clinical crown, color (hue/value), surface texture, and translucency/characterization. All variables were assessed by comparison with a natural counterpart. The PES and WES provided the most comprehensive objective esthetic evaluation; hence, we used PES/WES in our study for evaluation of the esthetic outcome of implants placed in the esthetic zone.

This prospective study was designed to evaluate the esthetic outcome of implants in the esthetic zone (anterior maxilla). A total of ten (n = 10) patients were selected fulfilling the inclusion criteria. The implants were immediately provisionalized within 24 h of implant placement. Zirconia prosthesis was delivered as a definitive prosthesis after 3 months of implant placement. The esthetic zone was photographed using a structured standardized methodology 3 months after delivering the definitive prosthesis. The esthetic outcome was then evaluated objectively using PES and WES. The PES/WES scoring was done by a blinded clinician to eliminate operator bias. All variables for PES/WES except the mesial and distal papilla were assessed by comparison with a natural counterpart. In addition, the patient's perception with regard to esthetic outcome was also recorded subjectively using a VAS.

In our study, we found evidence that the PES/WES index is indeed a suitable instrument for evaluating the esthetics of peri-implant conditions and the implant-supported prosthesis in the esthetic zone. The PES/WES index could also give a more objective insight into esthetic results in daily practice if performed preferably by the blinded clinician. Furthermore, the index could be a very useful tool in scientific research.

Pink Esthetic Score

PES has a maximum score of 10. Each variable was rated on the same 2-1-0 scale, with 2 as the best score and 0 as the poorest, for a maximal possible score of 10. The threshold of clinical acceptability was set at 6.

Belser et al. applied PES to 45 early placed maxillary anterior single-tooth implants. The mean score recorded for the mesial papilla was 1.6 ± 0.5 and 1.3 ± 0.5 for the distal papilla, whereas the mean root convexity/soft-tissue color and texture was 1.2 ± 0.53. The mean facial mucosa curvature was 1.9 ± 0.29; the mean facial mucosa level was 1.8 ± 0.42. The mean total PES of 7.8 ± 0.88 documents favorable overall peri-implant soft-tissue conditions.[14]

Nicholas Boardman (2016) applied PES to 98 single-tooth implants in the anterior maxilla. The median PES was 11, and 94% of implants were deemed esthetically acceptable. The PES was positively influenced by the use of a connective tissue graft (CTG), adding 1 to the score (P = 0.002) and negatively influenced by membrane use (P = 0.026). The use of CTG improved the esthetic outcome mainly by increasing the alveolar process contour. Less variation in outcomes was observed with early implant placement compared to immediate implant placement.

Emerson Souza Cutrim et al. (2012) applied PES to forty single-tooth implants in the anterior maxilla restored with cemented prostheses (CP) and screw-retained prostheses (SP). The mean mesial papilla was 1.73/1.82 (SP/CP). The mean distal papilla was 1.13/1.88 (SP/CP). The mean soft-tissue level was 1.73/1.52 (SP/CP). The mean soft-tissue shape was 1.69/1.52 (SP/CP). The mean alveolar process was 1.47/1.17 (SP/CP). The mean soft-tissue color was 1.52/1.35 (SP/CP). The mean soft-tissue texture was 1.43/1.35 (SP/CP). The total mean PES for SP was 10.73 and 10.41 for CP which concluded that both types of prosthetic restorations (screw and cement retained) may achieve satisfactory results regarding peri-implant esthetics in the anterior maxilla.[24]

Furthermore, Jones and Martin (2014) applied PES to 27 single-tooth implant restorations in the esthetic zone. They achieved a mean PES of 6.8 which was a successful peri-implant tissue outcome.[29]

In our prospective study, we applied PES for 10 maxillary anterior single-tooth implants in fully healed maxillary anterior sites in the esthetic zone. The mean score recorded for mesial papilla was 1.8 ± 0.42. The mean score recorded for distal papilla was 2. The mean score recorded for curvature of facial mucosa was 2. The mean score recorded for level of facial mucosa was 1.6 ± 0.52, and the mean score recorded for soft-tissue color and texture was 1.8 ± 0.42. Similar to Belser et al., we too recorded a mean PES of 9.2 ± 1.03 providing evidence of a successful peri-implant soft-tissue outcome. The highest scores were recorded for the distal papilla and the curvature of facial mucosa. According to the scores recorded by the blinded clinician, only one patient achieved a minimum score of 7, whereas one patient achieved a score of 8, three patients achieved a score of 9, and five patients achieved a maximum score of 10.

Our study showed a median PES of 9.5; all the implants were esthetically acceptable. Unlike Nicholas Boardman, we did not use CTG, bone grafts, and membrane in our study. As per the study design, all the cases requiring bone grafts and membranes were excluded from the study to exclude the influence of additional measures. Hence, we could not comment on the influence of CTG, bone grafts, and membrane on PES.

In contrast to the study by Emerson Souza Cutrim et al., ours was an evaluation study and did not attempt to compare outcomes using different methods of implant placement, provisionalization, and method of prosthesis retention or material of the final prosthesis. All the definitive prostheses provided were cement retained in our study. We too recorded a mean PES of 9.2 ± 1.03 showing a successful peri-implant soft-tissue outcome with a cement-retained prosthesis.

White Esthetic Score

WES has a maximum score of 10. Each variable was rated on the same 2-1-0 scale, with 2 as the best score and 0 as the poorest, for a maximal possible score of 10. The threshold of clinical acceptability was set at 6.

Belser et al. (2009) applied WES to 45 early placed maxillary anterior single-tooth implants. The mean score for tooth form was 1.3 ± 0.46. The mean score for tooth volume was 1.2 ± 0.40. The mean score for the tooth color was 1.6 ± 0.55. The mean score for surface texture was 1.3 ± 0.50. The mean score for tooth translucency was 1.6 ± 0.50. The total mean WES was 6.9 ± 1.47.

In our prospective study, we applied WES to ten maxillary anterior single-tooth implants in the esthetic zone. The mean score recorded for tooth form was 1.8 ± 0.42. The mean score recorded for tooth volume was 2. The mean score recorded for the tooth color was 1.5 ± 0.53. The mean score for recorded surface texture was 1.7 ± 0.48. The mean score recorded for tooth translucency was 1.7 ± 0.48. A mean WES recorded was 8.7 ± 1.16 showing a successful prosthetic outcome.[24]

Nicholas Boardman (2016) applied WES to 98 single-tooth implants in the anterior maxilla. The median WES was 9, and 98% of implants were deemed esthetically acceptable.

Similarly, Jones and Martin (2014) applied WES to 27 single-tooth implant restorations in the esthetic zone. The mean WES of 6.2 was achieved which was considered as a successful prosthetic outcome.[29]

We placed ten implants in fully healed maxillary anterior sites in the esthetic zone. All the implants were immediately provisionalized with an acrylic crown within 24 h. All the definitive prostheses were delivered 3 months after the implant placement. All the definitive prostheses were made in zirconia. A mean WES of 8.7 ± 1.16 recorded by the blinded clinician showing a successful prosthetic outcome. The highest scores were recorded for tooth volume followed by tooth form. According to the scores recorded by the blinded clinician, two patients achieved a minimum score of 7, whereas two patients achieved a score of 8, three patients achieved a score of 9, and three patients achieved a maximum score of 10.

We recorded a total mean PES/WES of 17.9 ± 1.28 showing a successful esthetic outcome of the implants.

In similar studies, Buser et al., Cosyn et al., and Raes et al. documented 7%–35% of esthetic success of implants placed in the esthetic zone.[10],[25],[36],[38] Meijndert et al., Belser et al., Buser et al., Cosyn et al., and Raes et al. documented 5%–34% of esthetic failures of implants placed in the esthetic zone.[10],[14],[36],[38]

Visual Analog Scale

Many studies have objectively evaluated the esthetic outcome using scoring criteria, but few studies have considered the patients' perception of esthetic outcome.

Kan et al. (2002), Jan Cosyn et al. (2009), and Cosyn et al. (2010) found no significant correlation between objective PES and WES ratings and the patient's esthetic satisfaction as determined by a VAS, whereas Jones et al. (2015) found a statistically significant correlation between objective PES and WES ratings and the patient's esthetic satisfaction. However, in the above studies, general questions about the overall esthetic outcome were asked to the patient. Patients' perception of soft-tissue and prosthetic outcome was not addressed. Our study considered the patients' perception of esthetic outcome using a VAS. We compared the scoring by the blinded clinician with a patient's perception of esthetic outcome using the Spearman's correlation test.

Ours is among few studies to solicit the patients' opinion on the soft-tissue as well as the prosthetic outcome. We used a triple score technique, wherein the patients commented on the soft-tissue, prosthetic replacement as well as the overall esthetic outcome.

A strong positive correlation was recorded on comparing the clinician's observations of PES with patients' perception about the peri-implant soft-tissue outcome (R = 0.70, P < 0.05). In effect, the scores of the blinded clinician and the patients' perception were similar with regard to soft-tissue parameters (PES).

A weak positive correlation was recorded on comparing the clinician's observations of WES with patients' perception about the prosthetic outcome (R = 0.36, P > 0.05). This study highlighted that the clinician perceived white deficiencies in greater detail than the patient.

We found a strong positive correlation between clinician's rating and patient's perception about the overall esthetic outcome (R = 0.51, P < 0.05).

This study has limitations due to the number of blinded clinicians involved and small sample size. The follow-up duration period was short. Therefore, further studies encompassing a larger number of blinded clinicians from every dental specialty group along with a larger number of sample sizes with a long-term follow-up could help in obtaining more accurate outcomes. As the focus in implant dentistry has turned to achieving natural-appearing outcomes, implant survival alone is no longer considered a successful outcome. It is also important to note that the esthetic outcomes can be perceived differently by the clinicians and patients.

Our study suggests that patients' perception of soft-tissue outcome (VAS Q 1) is similar to that of a blinded clinician (PES). However, with regard to prosthetic outcome (VAS Q 2), the blinded clinician tends to score less than the patient, suggesting that the blinded clinician's perception of prosthetic outcome is more detailed than that of the patient.

In our series of 10 patients, the patients reported their experience with the overall esthetic outcomes to meet or be above their expectation. The average score of VAS Q 3 was 9.4 suggestive of higher acceptability and satisfaction with the esthetic outcome. We strongly support the placement of implants with immediate provisionalization, and the use of metal-free definitive prosthesis should be standard of care.


   Conclusion Top


We strongly support the placement of implants with immediate provisionalization, and the use of metal-free definitive prosthesis should be standard of care.

This study has limitations due to the number of blinded clinicians involved and small sample size. Furthermore, the blinded clinician was not aware about the preoperative status of the patient. The follow-up duration period was short. Therefore, further studies encompassing a larger number of blinded clinicians from every dental specialty group along with a larger number of sample sizes with a long-term follow-up could help in obtaining more accurate outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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