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Immediate implant placement and restoration in the

anterior maxilla using flapless surgery and simultaneous hard tissue augmentation: Tissue dimensional changes after

2 to 5 year follow up

Journal: Clinical Implant Dentistry and Related Research

Manuscript ID Draft

Manuscript Type: Original Article

Date Submitted by the Author: n/a

Complete List of Authors: Arora, Himanshu; Griffith University, School of Dentistry and Oral Health Khzam, Nabil; Private Practice Roberts, David; Private Practice Bruce, William; Private Practice Ivanovski, Saso; Griffith University, School of Dentistry and Oral Health

Keywords: bone grafting, bone-implant interface, extraction socket, flapless implant surgery, immediate implants, immediate placement, sisingle-tooth implants

Abstract:

Background: Immediate implant placement followed by an immediate restoration has proven to be a viable technique in the anterior maxillary region. Purpose: This prospective study evaluated the long term (2-5 years) tissue changes around immediately placed restored implants in the anterior maxilla using flapless surgery and simultaneous hard tissue augmentation. Materials and methods: Thirty AstraTech implants were immediately placed in 30 patients, followed by the delivery of an immediate provisional restoration on the same day. All participating patients underwent the same treatment strategy that involved flapless removal of a failing maxillary anterior tooth, immediate implant placement, simultaneous augmentation with a deproteinized particulate xenograft and connection of a screw-

retained provisional restoration. Radiographs and photographs were used to measure hard and soft tissue changes. Aesthetic evaluation was performed using the Pink esthetic score (PES). Results: All implants remained osseointegrated during the follow up period of 2-5 years (mean 47 ± 15 months). Radiographic evaluation revealed average gains in bone levels of 0.18 mm and 0.34 mm mesially and distally, respectively. Soft tissue evaluation showed a mean tissue loss of 0.05 ± 0.64 mm and 0.16 ± 0.63 mm at the mesial and distal papillae respectively, while mid-facial mucosal recession was 0.29 ± 0.74 mm. A significant improvement in the Pink esthetic scores was seen at the final follow-up (mean PES 11.50), as compared to the baseline (mean PES 10.27) (p = 0.001).

Conclusions: In addition to a favourable implant success rate and peri-implant bony response, the soft tissue levels and overall aesthetics around

Clinical Implant Dentistry and Related Research

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single immediately placed and restored implants can also be maintained in the long term. Careful case selection, appropriate three-dimensional implant positioning, the use of an implant system that minimizes marginal bone loss, flapless surgery and the use of simultaneous particulate grafting may be important factors in achieving favourable outcomes.

Page 1 of 27 Clinical Implant Dentistry and Related Research

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Title: Immediate implant placement and restoration in the anterior maxilla using flapless

surgery and simultaneous hard tissue augmentation: Tissue dimensional changes after 2 to 5

year follow up

Himanshu Arora, MDS*; Nabil Khzam, DClindent

†; David Roberts, MDSc

‡; William L

Bruce, MDSc‡; Saso Ivanovski, MDSc, PhD

*

*: School of Dentistry and Oral Health, Griffith University, Gold Coast, QLD, Australia

†: Private practice, Perth, WA, Australia

‡: Private practice, Brisbane, QLD, Australia

Running Title: Tissue changes around anterior immediate implants

Author Contributions:

Himanshu Arora - Concept/Design, Data analysis/interpretation, Drafting article, Data

collection, Statistics, Critical revision of article.

Nabil Khzam - Concept/Design, Data analysis/interpretation, Drafting article, Data

collection.

David Roberts - Drafting article, Data collection, Critical revision of article, Approval of

article.

William L Bruce - Drafting article, Data collection, Critical revision of article, Approval of

article.

Saso Ivanovski - Concept/Design, Drafting article, Data collection, Critical revision of

article, Approval of article.

Page 2 of 27Clinical Implant Dentistry and Related Research

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Correspondence: Prof. Saso Ivanovski, School of Dentistry and Oral Health, Griffith Health

Centre, Griffith University - Gold Coast Campus, Parklands Drive, QLD 4222, Australia.

Tel: +61 7 56780741

Fax: +61 7 5678 0708

Email: [email protected]

Key Words: dental implants; osseointegration; soft tissue; aesthetics; immediate placement

and restoration.


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Abstract:

Background: Immediate implant placement followed by an immediate restoration has proven

to be a viable technique in the anterior maxillary region.

Purpose: This prospective study evaluated the long term (2-5 years) tissue changes around

immediately placed restored implants in the anterior maxilla using flapless surgery and

simultaneous hard tissue augmentation.

Materials and methods: Thirty AstraTech implants were immediately placed in 30 patients,

followed by the delivery of an immediate provisional restoration on the same day. All

participating patients underwent the same treatment strategy that involved flapless removal of

a failing maxillary anterior tooth, immediate implant placement, simultaneous augmentation

with a deproteinized particulate xenograft and connection of a screw-retained provisional

restoration. Radiographs and photographs were used to measure hard and soft tissue changes.

Aesthetic evaluation was performed using the Pink esthetic score (PES).

Results: All implants remained osseointegrated during the follow up period of 2-5 years

(mean 47 ± 15 months). Radiographic evaluation revealed average gains in bone levels of

0.18 mm and 0.34 mm mesially and distally, respectively. Soft tissue evaluation showed a

mean tissue loss of 0.05 ± 0.64 mm and 0.16 ± 0.63 mm at the mesial and distal papillae

respectively, while mid-facial mucosal recession was 0.29 ± 0.74 mm. A significant

improvement in the Pink esthetic scores was seen at the final follow-up (mean PES 11.50), as

compared to the baseline (mean PES 10.27) (p = 0.001).

Conclusions: In addition to a favourable implant success rate and peri-implant bony response,

the soft tissue levels and overall aesthetics around single immediately placed and restored

implants can also be maintained in the long term. Careful case selection, appropriate three-

dimensional implant positioning, the use of an implant system that minimizes marginal bone


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loss, flapless surgery and the use of simultaneous particulate grafting may be important

factors in achieving favourable outcomes.


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INTRODUCTION

Implant dentistry has progressed considerably since its introduction, with modifications and

enhancements being made to the surgical techniques, restorative protocols, and the implants

themselves. The initial delayed loading and placement protocols1, 2 have been modified to

expedite the treatment process. These modified protocols (immediate placement and

immediate loading) have been successfully applied in both fully and partially edentulous

patients.3, 4 Additionally, immediate implant placement has been combined with immediate

restoration to eliminate the load free healing period. Since first reported,5 the immediate

placement and restoration (IPR) technique has been widely recognized as a viable treatment

modality with survival rates equivalent to other established protocols for partially edentulous

situations.6

The nature of IPR treatment makes it particularly suited to implant treatment in the anterior

maxilla. Therefore, the focus has now shifted from hard tissue and osseointegration outcomes

to the aesthetic and soft tissue results. This increased focus towards implant aesthetics led to

the creation of various indices for evaluation of peri-implant mucosa as well as implant

supported restorations.7, 8 When evaluating aesthetic outcomes, pre-operative registration of

aesthetic status is very important in order to assess the effect of a treatment intervention over

time. Interestingly, very few studies evaluating the IPR protocol provide a baseline value of

aesthetic ratings prior to tooth loss/implant placement.9, 10

Soft tissue dimensional changes around immediately placed and restored implants have been

evaluated using standardized and non-standardized patient intra-oral photographs, study

models, as well as prefabricated stents.11 Although there are a number of studies which

analysed the effects of the IPR protocol on the soft tissue surrounding single implants in the

maxillary anterior region,12-18

most of these have a short follow-up period. Furthermore, the


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very few long-term studies that have investigated soft tissue outcomes using this protocol

have reported variable results. Cooper and colleagues19 compared immediately

provisionalized implants placed in healed ridges and extraction sockets in the maxillary

anterior region and found no difference in hard and soft tissue parameters after a period of 5

years. On the other hand, a recent study found an aesthetic complication rate of 8/17 in well-

selected patients who had been treated by experienced clinicians with the IPR protocol after 5

years,9 with the authors concluding that this treatment protocol may not be recommended in

daily practice. Even-though both of the above-mentioned studies utilized different implant

systems, they had strict patient selection criteria and included only low aesthetic risk patients.

In wake of these findings it becomes important to analyse the long-term effects of this

protocol on the peri-implant tissues.

The aim of this prospective study was to analyse the soft tissue and aesthetic changes around

implants placed with the IPR protocol in the maxillary anterior region over a follow-up

period of 2-5 years.

MATERIALS AND METHODS

Study design/Patient selection

This study included 30 patients who were recruited and treated for immediate single tooth

implants in the maxillary anterior region at a private practice in Brisbane, Australia. Patient

selection was undertaken on the basis of a specified set of inclusion and exclusion criteria.

Inclusion criteria:

1. Age at least 18 years

2. Presence of a single failing tooth in the anterior maxillary region (13-23)

3. Presence of natural teeth adjacent to the tooth being replaced


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4. Adequate bone height apical to the failing tooth to allow for placement of an implant

and to achieve a primary stability of at least 30 Ncm

Exclusion criteria:

1. Contraindications for routine implant therapy (untreated periodontitis, uncontrolled

diabetes, medical conditions that contraindicate elective surgery)

2. Smoking > 10 cigarettes per day

3. Presence of acute infection around the tooth being replaced

4. Presence of any soft tissue pathology at the gingival margin.

5. Any fenestration or dehiscence in the socket wall of the failing tooth

Informed consent was obtained from the eligible subjects, and the study was approved by the

Human Research Ethics Committee, Griffith University, Australia. The study was conducted

in accordance with the Helsinki Declaration of 1975 as revised in 2000.

Surgical and prosthetic procedures

Following the initial screening, a comprehensive clinical and radiographic examination was

undertaken by the operating surgeon. All surgical procedures were conducted by a single

operator (S.I.) under local anaesthesia. A prophylactic antibiotic dose of Amoxicillin, 500 mg

three times daily, was started a day before surgery and continued for 1 week. On the day of

the surgery, the tooth scheduled to be replaced was removed as atraumatically as possible

using periotomes and without flap elevation. This was followed by the placement of an

implant, according to the instructions of the implant manufacturer (Astra Tech®, Mölndal,

Sweden). Particular care was taken during the preparation of the osteotomy to facilitate both

primary stability and screw retained access, as well as to avoid impingement on the buccal

socket wall. Every attempt was made to engage the palatal and apical bone to achieve a high


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primary stability (30 Ncm) while placing the implant in a correct 3-dimensional position.20 In

all implant sites, the gap between the implant and the inner aspect of the buccal socket wall

was filled with deproteinized bovine bone particles (Bio-Oss®, Geistlich Pharma AG,

Wolhusen, Switzerland) (Figure 1). Postoperative instructions included Chlorhexidine rinses

twice daily, for a period of 2 weeks. For pain control Ibuprofen 400 mg was prescribed, to be

used as needed.

Implant placement was immediately followed by connection of a temporary abutment onto

which a prefabricated screw-retained temporary crown was placed. The provisional

restoration was adjusted to ensure that it was free of any contact in both centric and eccentric

positons. Patients were advised to avoid placing any pressure on the temporary crown during

the healing period. After a period of 3-4 months, the provisional restoration was replaced by a

permanent restoration. All prosthetic procedures were performed by two experienced

prosthodontists (D.R, W.B).

Hard tissue measurements

Periapical radiographs were taken with a paralleling technique after implant placement

(baseline) and follow-up appointments to measure the changes in the alveolar bone height

surrounding the implant. The radiographs were digitized, and bone level changes were

measured with the help of computer software (Image J 1.43u, NIH, Bethesda, MD, USA).

Standardization was carried out using the known implant length to calibrate the baseline and

follow-up radiographs. The implant shoulder was used as a reference level from which mesial

and distal lines were drawn in an apical direction to the first point of contact between implant

and bone, as previously described.16


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Soft tissue measurements

Intra-oral photographs were taken before extraction and implant placement (baseline) and

follow-up visits to evaluate the soft tissue changes. A digital SLR camera (Cannon 1300D,

Cannon Inc., Tokyo, Japan) was used to take photographs, at a fixed angle and magnification

ratio. Photos were taken with a periodontal probe with standardized markings to calibrate

changes in the level of soft tissues surrounding the tooth. Photographs were imported into

software (Image J 1.43u, NIH, Bethesda, MD, USA) for further measurements. A line

extending from the incisal edges of teeth adjacent to the implant was used as the reference

point for measurements. From this line, perpendicular lines were drawn extending to the tip

of the mesial papilla, distal papilla, and the mid-buccal gingival margin, as previously

described.16 The variations in the length of these lines over time were calculated to quantify

the soft tissue changes.

Aesthetic evaluation

Aesthetic evaluation was carried out using the Pink esthetic score (PES).7 PES is used to

evaluate the peri-implant soft tissue and includes seven variables: mesial papilla, distal

papilla, soft tissue level, soft tissue contour, alveolar process deficiency, soft tissue colour,

and soft tissue texture. Each parameter is assessed with a 0-1-2 score with 2 being the best

and 0 being the worst score. The score for each parameter is added to get the eventual PES

for each case (maximum possible score being 14). All the measurements were performed by

a single examiner (H. A.), who was not involved in the treatment.

Statistical analysis

Mean values and standard deviations were calculated for all parameters. Parametric data were

analysed using a paired t-test; whereas for nonparametric data, a Wilcoxon signed rank test


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was used. A frequency analysis was used to describe soft tissue quantitative changes. The

level of significance was set at 0.05. All calculations were performed with the SPSS

statistical software program (Version 16.0, SPSS Inc., Chicago, IL, USA).

Results

The study included a total of 30 OsseoSpeed™ TX implants (Astra Tech®, Mölndal,

Sweden) implants, which were placed utilizing the IPR protocol in 30 patients (9 males and

21 females) with an age range of 20 to 78 years. Sixteen implants replaced central incisors,

12 replaced lateral incisors, and 2 implants were placed in the canine region. The reasons for

tooth failure were recorded as fracture (21 cases), endodontic failure (7 cases), and root

resorption (2 cases). Implants placed had diameters ranging from 3.5 to 5.0 mm and length

ranging from 11 to 15 mm. After a mean post-operative period of 48 months (range: 2 to 5

years), all implants were stable with no loss of osseointegration resulting in a cumulative

implant survival rate of 100%.

Hard tissue measurements

Bone levels around the implants showed an overall gain in bone height at the final follow up

when compared to baseline. Mesial bone levels showed a mean gain of 0.18 ± 1.38 mm (p =

0.85), while distal bone levels showed a mean gain of 0.34 ± 1.40 mm (p = 0.22). Figure 2

shows the frequency analysis of bone level changes mesially and distally. Bone changes

ranged from >2 mm mean loss (3%) to mean gains of >2 mm (10%) with most of the values

lying (30%) between 0.5 mm loss to 0.5 mm gain (Figure 2).

Soft tissue measurements

After a follow-up period of 2 – 5 years, the mesial and distal papillae showed a mean

recession of 0.05 ± 0.64 mm and 0.16 ± 0.63 mm, respectively, while mid-facial mucosal


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margin showed a mean recession of 0.29 ± 0.74 mm, with no value reaching statistical

significance. A frequency analysis of the soft tissue dimensional changes from baseline to the

final follow-up is shown in Figure 3. Most of the changes were between 0.5 mm of tissue loss

to 0.5 mm tissue gain (Figure 1). Advanced soft tissue recession (defined as >1 mm by)21

was identified in the mid-facial mucosa of 4 patients (13%). Further evaluation revealed that

2 of these 4 patients had no soft tissue level discrepancy when compared to the contralateral

natural teeth (Figure 4).

To evaluate the effect of the IPR protocol on the soft tissue changes in the long-term, a

comparison between 1 and 5-year time points was carried out. Twelve patients who had

completed the 5-year follow-up and were included in this sub-analysis (Table 1). A

statistically significant regrowth of 0.4mm was seen in the mesial papillae (p = 0.009)

between 1 and 5 years. The distal papillary region also showed a gain in soft tissue levels of

an average of 0.19mm but this was not statistically significant (p = 0.225), whereas the mid-

facial mucosal recession was similar at 0.20 and 0.23 mm for 1 and 5 years, respectively (p =

0.776).

Aesthetic evaluation

Table 2 shows the results of various PES criteria preoperatively and at the final follow-up.

Most of the criteria showed improvement between baseline and final follow-up. The mean

PES preoperatively was 10.27 (SD 2.18; range 5-13). A significant improvement (p = 0.001)

was seen at the final follow-up appointment, with the mean PES score reaching 11.50 (SD

1.36; range 8-13). In terms of individual PES parameters, the following variables were seen

to improve significantly: soft tissue level, soft tissue contour, soft tissue colour, and soft

tissue texture (Figure 5). Once again, to evaluate the effect of the IPR protocol on the

aesthetic changes in the long-term, follow-up time points of 1 and 5 years were chosen (Table


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1). The mean PES scores improved slightly from 11.17 at 1 year to 11.25 at 5 years (p =

0.48). When looking at the individual variables, most of the variables showed an

improvement in the mean scores, except for soft tissue contour (p = 0.375) and alveolar

process deficiency (p = 0.125) showing a slight deterioration.

Discussion

The implant survival rate in this study utilizing the IPR protocol and after a follow up period

of 2 - 5 years was 100%. Comparative survival rates have also been seen in other studies

utilizing the same surgical and restorative protocol in the maxillary anterior region.5, 12, 14, 22-25

The results from the current study showed a non-significant mean bone gain of 0.18 mm and

0.34 mm mesially and distally, respectively. These results are in accordance with several

studies which have reported favourable bone levels with this technique,16, 18, 22, 26-29

albeit

after shorter follow up periods. The present study used Astra Tech implants, with a number of

features which have been shown to minimise crestal bone loss including a platform switched

design, coronal micro threads and an internal conical connection.30 Similar favourable results

have been reported in various shorter duration studies when using Astra Tech implants with

the IPR treatment protocol.15, 18, 31-33

Furthermore, the gap between the implant and the inner

walls of the extraction socket was filled with a slowly resorbing xenograft (Bio-Oss®,

Geistlich Pharma AG, Wolhusen, Switzerland) in all cases. The increase in bone levels could

be attributed to the filling of bone in the extraction socket, and could further have been

favoured by the implant design.16, 23

The positive influence of grafting the peri-implant gap

and placing an immediate provisional restoration subsequent to flapless immediate implant

placement on maintaining the ridge contour dimensions has also been previously reported.34

This study observed a mean soft tissue recession of 0.29 mm in the mid-facial region and

0.16 and 0.05 mm in the mesial and distal papillary region respectively, after a follow up


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period of 2 – 5 years. These results are similar to the previous studies reporting soft tissue

changes around implants placed with the IPR protocol in the maxillary aesthetic region.12, 14-

18, 23, 35, 36

The number of studies reporting on advanced recession (>1 mm) around immediately placed

and restored implants is very limited, especially when it comes to long term follow-ups. A 3-

year follow-up study with immediately placed and restored implants showed the incidence of

advanced mid-facial recession in 8% of cases (2/25 patients).21 Notably, these cases were

treated with a connective tissue graft. After a follow-up of 5 years, the cases treated with the

soft tissue graft maintained acceptable soft tissue levels, but the authors observed a late

advanced recession in three other cases leading to a high aesthetic complication rate.9 In our

study, advanced recession was seen in 13% of cases (4 patients), which is in accordance with

the results from the previous studies.11 No soft tissue grafting was performed in any of the

patients included in the current study. It is noteworthy that out of these 4 cases with advanced

recession, 2 had no discrepancy when compared to the contralateral tooth at the final follow-

up and were given a score of 2 for the respective PES parameter (Figure 3). This is an

interesting finding as sometimes gingival recession can be deliberately induced by the

prosthodontist to create harmony with the soft tissue level on the contralateral tooth, and this

was the case in 2/4 cases that were deemed to have experienced ‘advanced’ recession.

Aesthetic evaluation was also carried out using the PES index. The mean PES scores

increased significantly from 10.27 pre-operatively to 11.50 at the final follow-up.

Interestingly, very few studies reporting on the IPR protocol in the anterior maxilla provide a

baseline value of aesthetic ratings prior to tooth loss/implant placement.9, 10

Pre-operative

registration of aesthetic status is important in order to evaluate changes over time. Significant

improvements were seen in four of the seven PES variables, namely: soft tissue level, soft

tissue contour, soft tissue colour and soft tissue texture. Interestingly, the contour of the


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alveolar process was slightly reduced at the final follow-up as compared to the baseline

(Alveolar process contour: Baseline 1.70, follow-up 1.67). This effect was also reported in a

recent 3-year study on immediately provisionalized implants.10 Even though the shrinkage of

the alveolar process seen in this study was very slight, this variable needs further exploration.

In regards to the long-term soft tissue changes, the mesial papillary levels showed a

significant gain between 1 and 5 years. The distal papillae were also seen to improve but the

difference was not significant. A slight increase in papillary dimension following an initial

loss suggesting a papillary rebound has also been reported in a recent systematic review of

soft tissue outcomes using the IPR technique.11 Similar results have also been reported by

Cosyn and colleagues,9 who reported a significant increase in papillary height after 5-years.

The slight disparity between the mesial and distal papillary growth observed in the present

study has also been described in other studies, with authors mentioning about the difficulty to

maintain distal papilla levels.37-39

The reasons for this observation are unclear and warrant

further investigation. Interestingly, the mid-facial gingival levels were maintained between

the period of 1 to 5 years in this study, which is more favourable compared to the increased

recession reported by Cosyn et al.9 over the same timeframe. This could be attributed to the

use of a different implant system in this study.

Aesthetic evaluation with the help of PES showed a slight increase in the mean values

between 1 and 5 years (p = 0.48). Again, this is in contrast to the findings of Cosyn et al.9

who reported a significant decrease in the overall PES values between 1 and 5 years. The

significant decrease in the PES values was observed despite improved mesial and distal

papillae, with the authors pointing to soft tissue level and alveolar process deficiency as

factors leading to a poor aesthetic outcome. Even though a slight negative change in the

alveolar process was observed in the current study, the soft tissue level as well as the papillae

were maintained at acceptable levels between 1 and 5 years. Nonetheless, the current results


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should be interpreted with caution due to the small number of patients (n = 11) who

completed the 5-year follow-up. In the future, it would be interesting to see more controlled

studies exploring the long term clinical and aesthetic effects of the IPR protocol in the

maxillary anterior region.

Conclusion

This prospective 2-5 year follow-up study showed that immediately placed and restored

implants with a flapless technique in the maxillary anterior region yielded positive results in

terms of osseointegration, hard and soft tissue results, as well as aesthetic outcomes. It should

be noted that the study utilised a standardised treatment protocol using flapless surgery and

augmentation of the gap between the implant and the buccal socket wall, as well as specific

inclusion criteria including intact socket walls and absence of gingival pathology.

Acknowledgements: The authors declare no conflict of interest in relation to this manuscript.


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Figure Legends:

Figure 1: Clinical illustration of the IPR protocol. (a) Failed maxillary left central incisor to

be replaced with an implant, (b) & (c) frontal and occlusal view after flapless extraction, (d)

implant placed in the socket in an appropriate 3-dimensional position, (e) buccal gap grafted

with particulate bone graft, (f) implant restored with a provisional crown on the same day, (g,

h, i) follow-up after 1, 2, and 3 years, respectively.

Figure 2: Bone level changes from baseline to final follow-up.

Figure 3: Frequency analysis of soft tissue changes from baseline to final follow-up.

Figure 4: Case with ‘advanced’ mid-facial recession (>1mm). (a) Pre-extraction view of

maxillary right lateral incisor, (b) advanced mid-facial recession evident after definitive

restoration, (c) comparison with the contralateral natural tooth reveals no discrepancy

between the soft tissue levels after 1 year, (d) soft tissue levels maintained after 5 years.

Figure 5: Pink esthetic score results over the time course of the study. (a) Cumulative percent

scores for baseline and final follow-up, (b) average scores for individual variables.


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Table 1: Soft tissue and aesthetic changes between 1 and 5 years (baseline – pre-operative status)

1 year (n = 12) 5 years (n = 12) p-value

Soft tissue variables

Mesial papillary recession

0.34 ± 0.52

0.35 (0.05 – 0.68)

[-0.5 – 1.3]

-0.06 ± 0.66

-0.05 (-0.43 – 0.43)

[-1.2 – 1.2]

0.009*

Distal papillary recession

0.13 ± 0.47

0.1 (-0.2 – 0.55)

[-0.7 – 0.8]

-0.06 ± 0.58

-0.2 (-0.48 – 0.23)

[-0.6 – 1.4]

0.225

Mid-facial recession

0.2 ± 0.47

0.1 (-0.1 – 0.58)

[-0.5 – 1.0]

0.23 ± 0.69

0.15 (-0.35 – 0.8)

[-0.8 – 1.3]

0.776

PES variables

Mesial papilla

1.33 ± 0.49

1.0 (1.0 – 2.0)

[1.0 – 2.0]

1.58 ± 0.52

2.0 (1.0 – 2.0)

[1.0 – 2.0]

0.25

Distal papilla

1.67 ± 0.49

2.0 (1.0 – 2.0)

[1.0 – 2.0]

1.75 ± 0.45

2.0 (1.25 – 2.0)

[1.0 – 2.0]

0.25

Soft tissue level

1.42 ± 0.67

1.5 (1.0 – 2.0)

[0.0 – 2.0]

1.42 ± 0.67

1.5 (1.0 – 2.0)

[0.0 – 2.0]

1.00

Soft tissue contour

1.67 ± 0.49

2.0 (1.0 – 2.0)

[1.0 – 2.0]

1.58 ± 0.52

2.0 (1.0 – 2.0)

[1.0 – 2.0]

0.375

Alveolar process deficiency

1.5 ± 0.52

1.5 (1.0 – 2.0)

[1.0 – 2.0]

1.17 ± 0.39

1.0 (1.0 – 2.0)

[1.0 – 2.0]

0.125

Soft tissue colour

1.83 ± 0.39

2.0 (2.0 – 2.0)

[1.0 – 2.0]

1.91 ± 0.29

2.0 (2.0 – 2.0)

[1.0 – 2.0]

0.25

Soft tissue texture

1.75 ± 0.45

2.0 (1.25 – 2.0)

[1.0 – 2.0]

1.83 ± 0.39

2.0 (2.0 – 2.0)

[1.0 – 2.0]

0.99

Overall PES

11.17 ± 1.64

11.0 (9.25 – 13.0)

[9.0 – 13.0]

11.25 ± 1.36

11.0 (11.0 – 12.0)

[8.0 – 13.0]

0.48

Values in bold: Mean (SD); italic: Median (IQ range); square bracket: [Minimum; maximum].

Negative values indicate increase in soft tissue level.

*Significant change between 1 and 5 years utilizing Wilcoxon signed rank test.


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Table 2: PES change from baseline to final follow-up

Parameter Score Preoperative Final Follow-up p Value

Mesial papilla

0

1

2

0

8

22

0

6

24

0.10

Distal papilla

0

1

2

1

4

25

1

1

28

0.25

Midfacial level

0

1

2

3

12

15

2

11

17

0.03

Midfacial contour

0

1

2

3

16

11

0

13

17

0.01

Alveolar process

deficiency

0

1

2

0

9

21

1

9

20

0.09

Soft tissue colour

0

1

2

8

9

13

1

13

16

0.007

Soft tissue texture

0

1

2

5

14

11

0

10

20

0.001

Overall PES

Mean (SD) {Median

(IQR)} [Range]

10.27 (2.13)

{11.0 (9.0 – 12.0)}

[5-13]

11.50 (1.36)

{12.0 (11.0 – 12.25)}

[8-13]

0.001


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Figure 1: Clinical illustration of the IPR protocol. (a) Failed maxillary left central incisor to be replaced with an implant, (b) & (c) frontal and occlusal view after flapless extraction, (d) implant placed in the socket in an appropriate 3-dimensional position, (e) buccal gap grafted with particulate bone graft, (f) implant

restored with a provisional crown on the same day, (g, h, i) follow-up after 1, 2, and 3 years, respectively. Figure 1

254x190mm (96 x 96 DPI)


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Figure 2: Bone level changes from baseline to final follow-up. Figure 2

87x60mm (300 x 300 DPI)


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Figure 3: Frequency analysis of soft tissue changes from baseline to final follow-up. Figure 3

80x35mm (300 x 300 DPI)


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Figure 4: Case with ‘advanced’ mid-facial recession (>1mm). (a) Pre-extraction view of maxillary right lateral incisor, (b) advanced mid-facial recession evident after definitive restoration, (c) comparison with the contralateral natural tooth reveals no discrepancy between the soft tissue levels after 1 year, (d) soft tissue

levels maintained after 5 years. Figure 4

254x190mm (96 x 96 DPI)


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Figure 5: Pink esthetic score results over the time course of the study. (a) Cumulative percent scores for baseline and final follow-up, (b) average scores for individual variables.

Figure 5

100x38mm (300 x 300 DPI)


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