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Francesco Mangano Single-tooth Morse taper connection

Carlo Mangano
Massimiliano Ricci
implants placed in fresh extraction
Rachel Lilian Sammons sockets of the anterior maxilla: an
Jamil Awad Shibli
Adriano Piattelli
aesthetic evaluation

Authors’ affiliations: Key words: aesthetic outcome, immediate implant placement, single-tooth Morse taper con-
Francesco Mangano, Private Practice, Gravedona nection implants
(Como), Italy
Carlo Mangano, Dental School, University of
Varese, Varese, Italy Abstract
Massimiliano Ricci, Nanoworld Institute,
University of Genoa, Genoa, Italy
Objective: The aim of this retrospective study was to evaluate the aesthetic outcome of single-
Rachel Lilian Sammons, Department of tooth Morse taper connection implants placed in fresh extraction sockets of the anterior maxilla,
Biomaterials, Dental School, University of by means of the pink aesthetic/white aesthetic score (PES/WES) index.
Birmingham, Birmingham, UK
Jamil Awad Shibli, Department of Periodontology, Materials and methods: Twenty-six adult patients (18 men, 8 women, aged between 20 and
Dental Research Division, Guarulhos University, 62 years; average: 48.7 years) who were treated with an immediate, single-tooth Morse taper
Guarulhos, Sao Paulo, Brazil connection implant (Leone Implant SystemR, Florence, Italy) in the aesthetic area of the anterior
Adriano Piattelli, Department of Oral Pathology
and Oral Medicine, Dental School, University of maxilla, were enrolled in this retrospective study. An independent calibrated examiner applied the
Chieti-Pescara, Chieti, Italy PES/WES index to 26 single-tooth implant-supported restorations, respectively, 3 months and
2 years after implant placement.
Corresponding author:
Prof. Carlo Mangano Results: No implants were lost. All 26 anterior maxillary single-tooth implants fulfilled the
P.zza Trento 4, 22015, Gravedona (Como), Italy established success criteria for dental implants with regard to osseointegration, including the
Tel.: +39-0344-85524
absence of pain, suppuration, clinically detectable implant mobility, peri-implant radiolucency and
Fax: +39-0344-85524
e-mail: prosthetic complications at the implant-abutment interface, with an overall implant-crown success
of 100.0%. At the 2-year examination, the mean DIB was 0.44 ± 0.14 mm (95% CI: 0.41–0.47); the
mean total PES/WES was 14.30 ± 2.78 (range 8–19); the mean PES was 7.30 ± 1.78 (range 4–10) and
the mean WES was 7.00 ± 1.35 (range 4–10).
Conclusions: The immediate placement of single-tooth Morse taper connection implants in the
anterior maxilla seems to represent a successful procedure, from an aesthetic point of view. Further
studies are needed to evaluate the aesthetic outcome of single-tooth Morse taper connection
implants placed in fresh extraction sockets of the anterior maxilla.

Immediate implant placement is defined as resorption of the buccal bone plate in dogs
the placement of a dental implant at the time (Araujo et al. 2006). Buccal plate resorption
of tooth extraction, into the extraction socket. and consequent fenestration of the implant
Advantages of immediate implant placement would have significant implications in soft tis-
are the reduced number of surgical procedures sues and aesthetics, such as recession and
and shortened overall treatment time, with thread platform exposure, which may result in
the resulting psychological benefit for patients visible gingival discoloration (Araujo et al.
(Koh et al. 2010). In addition, factors such as 2006). These findings were confirmed in a
ideal three-dimensional implant positioning clinical study (Botticelli et al. 2004), in which
and the presumptive preservation of alveolar 21 implants were installed in extraction sock-
bone at the site of tooth extraction have been ets in 18 patients. In this study the authors
Date: claimed as potential advantages of immediate recorded, at surgical re-entry, a horizontal
Accepted 26 July 2011 implantation (Cafiero et al. 2008). Unfortu- resorption of about 50% at the buccal aspect
To cite this article: nately, the validity of this hypothesis has been and 30% at the lingual side of the implant,
Mangano F, Mangano C, Ricci M, Sammons RL, Shibli JA, contradicted by the results of different animal corresponding to an overall horizontal width
Piattelli A. Single-tooth Morse taper connection implants
placed in fresh extraction sockets of the anterior maxilla: and clinical studies (Botticelli et al. 2004; Ara- reduction of 2.8 mm. These reported ridge
an aesthetic evaluation.
ujo et al. 2006). The placement of an implant alterations may have significant adverse
Clin. Oral Impl. Res. 23, 2012, 1302–1307
doi: 10.1111/j.1600-0501.2011.02307.x in the fresh extraction site failed to prevent effects on the final aesthetic result, especially

1302 © 2011 John Wiley & Sons A/S

Mangano et al  Morse taper connection implants placed in fresh extraction sockets

in the maxillary anterior region, where aes- mismatch. The suitability of the PES/WES Table 1. The reasons for tooth extraction
thetic outcome is of great importance (Botti- index for the assessment of the aesthetic Reason for tooth extraction N (%)
celli et al. 2004). Immediate implant dimension of anterior single-tooth implants Caries 12 (46.2)
placement in the aesthetic zone has gained has been recently confirmed (Cho et al. 2010). Root fracture 8 (30.8)
acceptance among the clinicians, with several Therefore, the aim of this retrospective study Root resorption 3 (11.5)
Non-treatable endodontic lesion 3 (11.5)
authors showing that success rates can be was to evaluate the aesthetic outcome of sin-
Total 26
achieved that are similar to those obtained for gle-tooth Morse taper connection implants
delayed implants placed into healed extraction placed in fresh extraction sockets of the ante-
sites (Chen et al. 2007; Cafiero et al. 2008). rior maxilla, by means of the PES/WES index.
Table 2. Distribution of the implants
The criteria proposed by Albrektsson & Zarb
Implant sites N (%)
(1998) are widely accepted and used as a
Central incisor 6 (23.1)
method to assess implant success. The focus Materials and methods Lateral incisor 9 (34.6)
of these criteria, however, remains osseointe- Cuspid 6 (23.1)
gration; for aesthetically sensitive cases these Patient population First premolar 5 (19.2)
osseointegration-oriented criteria are no Twenty-six patients (18 men, 8 women, aged Total 26

longer adequate (Lops et al. 2008). Nowadays, between 20 and 62 years; average: 48.7 years)
the aesthetic outcome has become the main who had been treated with an immediate,
focus of interest in aesthetically sensitive single implant in the aesthetic zone of the thetic, obtained by infiltrating articaine 4%,
areas (Raes et al. 2011). The current literature, anterior maxilla (central and lateral incisors, containing 1 : 100,000 adrenaline (Ubiste-
however, is scarce when it comes to objective cuspids, first premolars) between December sinR; 3M Espe, St. Paul, MN, USA). A mesio-
outcome evaluation from an aesthetic point of 2006 and June 2009 in one clinical centre distal crestal incision was made and a full-
view. Some studies (Jemt 1997; Schropp et al. (private practice) were identified from patient thickness flap was reflected exposing the
2005) have paid particular attention to the charts and included in the study. The follow- alveolar ridge. Care was taken to perform an
presence or absence of interproximal gingival ing information was available and included: atraumatic extraction. The hopeless tooth
papillae after implant therapy. However, more patient age and gender, previous medical and was carefully luxated and extracted avoiding
variables are responsible for the aesthetic out- dental history, oral status and oral hygiene, any lateral movement that might damage
come of implant-supported single-tooth smoking and/or parafunctional habits, rea- either buccal or palatal bone plates. Once the
replacement, and an aesthetic implant restora- sons for extraction of natural teeth (Table 1), tooth was removed, the socket was debrided
tion should resemble a natural tooth in all distribution of implants (Table 2). Inclusion with curettes and irrigated with sterile saline.
aspects (Lai et al. 2008). Several additional criteria were natural teeth present both A periodontal probe was used to scan the
attempts have been made to implement objec- mesial and distal to the implant, presence of internal surface of the alveolus for dehiscenc-
tive criteria for assessing the aesthetic dimen- four bony walls of the alveolus, adequate es and fenestrations before implant place-
sion of a fixed single-tooth implant restoration bone height and width to place an implant of ment. All sites showed the absence of
located in the anterior region of the mouth, at least 3.3 mm in diameter and 10.0 mm in fenestration and dehiscence. Preparation of
such as the pink aesthetic score (PES) (Furha- length. Exclusion criteria were uncontrolled implant sites was carried out with spiral
user et al. 2005) and the pink aesthetic/white diabetes; poor oral hygiene, active periodontal drills of increasing diameter (2.8 mm to place
aesthetic score (PES/WES) (Belser et al. 2009). infections, bruxism, heavy smoking habit an implant with 3.3 mm diameter; 2.8 and
The PES concept focused essentially on the (more than 15 cigarettes per day); presence of 3.5 mm, to place an implant with 4.1 mm
soft tissue aspects of an anterior implant resto- dehiscence or fenestration of the residual diameter; an additional 4.2 mm drill was
ration (Furhauser et al. 2005). Belser et al. bony walls; presence of a thin-scalloped gin- used to prepare the site for 4.8 mm diameter
modified the previously published PES and gival biotype (determined by the transparency implants), under constant irrigation. Implants
proposed a new implant restoration index (the of a periodontal probe through the gingival were positioned at the bone crest level. The
PES/WES index, pink aesthetic/white aes- margin while probing the buccal sulcus of implant system used in this study (Leone
thetic score index) (Belser et al. 2009). In con- the upper central incisor) (De Rouck et al. Implant SystemR, Florence, Italy) is charac-
trast to the original proposal, this modified 2009). Implant treatments including hard/soft terized by a cone Morse taper interference-fit
PES comprises five variables: mesial papilla, tissue grafting before implant placement and (TIF) locking-taper combined with an internal
distal papilla, curvature of the facial mucosa, periodontally compromised patients were hexagon. The Morse taper presents a taper
level of the facial mucosa, and root convexity/ excluded too. All patients read and signed a angle of 1.5o. Biphasic calcium phosphate
soft tissue colour and texture at the facial written consent form for immediate implant granules (MBCPR; Biomatlante, Vigneux de
aspect of the implant site. The WES specifi- placement. The study protocol was approved Bretagne, France) were used to fill the gaps
cally focuses on the visible part of the implant by the local Ethical Committee and was con- between the implant and the residual bony
restoration itself and is based on the following ducted in accordance with the Helsinki Dec- walls. The granules were mixed with tetracy-
five parameters: tooth form, volume, colour, laration of 1975, as revised in 2000. cline powder (AmbramicinaR; Scharper spa,
surface texture and translucency/characteriza- Sesto San Giovanni, Italy) to obtain a local
tion. A score of 2, 1 or 0 is assigned to all Surgical and prosthetic procedure antibiotic effect and this mixture was moist-
parameters; this can result in a maximum pos- A complete examination of the oral hard and ened with physiological saline solution so
sible combined PES/WES score of 20. All soft tissues was carried out for each patient that the composition could be more easily
parameters are assessed by direct comparison and the implant placement was planned moulded to fit into the gaps. Temporary
with the natural, contralateral reference tooth, based on clinical and radiographic evaluation. abutments were placed and all patients
estimating the degree of match or eventual Surgery was performed under a local anaes- received a temporary acrylic resin crown

© 2011 John Wiley & Sons A/S 1303 | Clin. Oral Impl. Res. 23, 2012 / 1302–1307
Mangano et al  Morse taper connection implants placed in fresh extraction sockets

cemented with a temporary cement (Temp- to establish, with adequate precision, the thetic evaluation was performed by an inde-
BondR; Kerr, Orange, CA, USA). All tempo- eventual amount of vertical bone loss at the pendent calibrated observer, who was not
rary crowns were in full contact in centric mesial and distal site of the implant. In this part of the treating team, by means of the
occlusion. The flaps were properly mobilized study, the distance between the implant PES/WES index, 1 h after seating of the defin-
and repositioned to cover the implants and shoulder and the first visible bone contact itive restoration (3 months after implant
were secured in position by interrupted (DIB) was calculated by means of an ocular placement, baseline) and 2 years after
sutures (SupramidR; Novaxa Spa, Milan, grid. The established criteria for implant- implant placement (follow-up), respectively.
Italy). All patients received oral antibiotics crown success were as follows: absence of To reduce bias and to achieve good reproduc-
(AugmentinR; Glaxo-Smithkline Beecham, pain or suppuration, absence of clinically ibility, the evaluation was carried out twice,
Brentford, UK) 2 g each day for 6 days. Post- detectable implant mobility; absence of peri- on different days; in case of diverging scores,
operative pain was controlled by administer- implant radiolucency, distance between the the observer carefully re-evaluated the photo-
ing 100 mg nimesulide (AulinR; Roche Phar- implant shoulder and the first visible bone- graphs and the study casts prior to making
maceutical, Basel, Switzerland) every 12 h for implant contact (DIB) <1.5 mm after his final decision. A score of 2, 1 or 0 was
2 days and detailed instructions about oral 12 months of functional loading and not assigned to each PES/WES parameter. The
hygiene were given, including mouth rinses exceeding 0.2 mm for each following year highest possible combined PES/WES score
with 0.12% chlorhexidine (ChlorexidineR; (Albrektsson & Zarb 1998); absence of pros- was 20, which represented a close match of
OralB, Boston, MA, USA) administered for thetic complications at the implant-abut- the peri-implant soft tissue conditions and
7 days. Suture removal was performed at ment interface. the clinical single-tooth crown compared
8–10 days. The temporary restorations with the respective features present at the
remained in situ for 3 months and after this Aesthetic follow-up examination contralateral natural tooth site. A PES/WES
period definitive restorations were placed. All To objectively examine the aesthetic out-  12 was considered as the limit for an
single crowns were ceramo-metallic and were come of the implants, intraoral photographs acceptable aesthetic outcome of implant
cemented with a temporary cement (Temp- were critically analysed using the PES/WES treatment.
BondR; Kerr, Orange, CA, USA). index (Belser et al. 2009). All implant crowns
(central, lateral incisors, cuspids and first pre- Data analysis
Clinical follow-up examination molars) were photographed with a digital For the PES/WES evaluation, descriptive sta-
Follow-up visits were scheduled for 2 weeks, camera (Nikon D100R; Nikon, Tokyo, Japan) tistics including mean values, standard devia-
1, 3 and 12 months during the first year post- and a 105 mm lens (AF micro Nikkor tions, medians and range were analysed.
operatively, and annually thereafter. Two 105 mm 1 : 2.8D; Nikon) with a ring flash Moreover, to compare the differences of PES
years after implant placement, at recall visit, (Nikon Macro Speedlight SB-29S; Nikon). For and WES assessments between the baseline
the following clinical and radiographic assessing anterior tooth replacements, the and follow-up, the Wilcoxon rank-sum test
parameters were assessed: presence/absence reference contralateral tooth had to be com- for paired data was performed. The level of
of pain or suppuration, presence/absence of pletely and symmetrically represented, to significance was set at 0.05. All statistical
clinically detectable implant mobility; pres- ensure comparability. For this purpose, the analyses were run on the statistical package
ence/absence of prosthetic complications at photographs were centred at the midline, to SPSS (SPSS 17.0; SPSS Inc., Chicago, IL,
the implant-abutment interface; presence/ facilitate the subsequent analysis, which was USA).
absence of peri-implant radiolucency; dis- primarily based on symmetry. In addition,
tance between the implant shoulder and the standardized clinical photographs were taken
first visible bone-implant contact (DIB) of each implant site and of the contralateral
(Mangano et al. 2009). Periapical radiographs tooth. These additional photographs were
Standard implant-crown success criteria
were taken at the baseline (immediately after used as tools for a more detailed evaluation.
No implants were lost. With regard to osseoin-
implant insertion) and at the 2-year follow-up For the first premolars involved in the study,
tegration, all 26 anterior maxillary single-tooth
session. Radiographs were taken using a Rinn however, the photographs could not be taken
Morse taper connection implants fulfilled the
alignment system with a rigid film-object X- at the midline; for this reason, the approach
success criteria, with an implant-crown
ray source coupled to a beam-aiming device was modified and a picture including the sec-
success of 100%. In fact, all implants showed
to achieve reproducible exposure geometry. ond premolars and the canine was taken,
stable osseointegration, with absence of pain
Customized positioners, made of polivinyl with these teeth serving as references. All
or suppuration, absence of clinically detectable
siloxane, were used for precise repositioning photographs were taken slightly superior to
implant mobility, absence of peri-implant
and stabilization of the radiographic tem- the occlusal plane, centred at the contact
radiolucency, DIB <1.5 mm during the first
plate. To calculate the distance between the region. Photographs were then viewed on a
year of function and absence of prosthetic com-
implant shoulder and the first visible bone- 42-inch monitor screen (Samsung PPM-
plications at the implant-abutment interface.
implant contact (DIB), crestal bone level 42S3Q Flat Panel Plasma MonitorR; Sam-
The 2-year mean DIB was 0.44 ± 0.14 mm
changes were recorded as changes in the ver- sung, Seoul, South Korea). Study casts, pro-
(median: 0.40; 95% CI: 0.41–0.47).
tical dimension of the bone around the duced in type IV stone, were finally
implant, so that an evaluation of peri-implant fabricated for each of the 26 patients involved
Objective evaluation of aesthetic treatment
crestal bone stability was gained with time. in the study. Study casts were fabricated to outcome (PES/WES analysis)
To correct for dimensional distortion in the facilitate a direct and objective assessment The PES and WES scores of the 26 examined
radiograph, the apparent dimension of each related to the PES/WES index. The clinical single-tooth implants were summarized in
implant (directly measured on the radiograph) photographs and the study casts were used to Table 3. At the 2-year examination, the over-
was compared with the true implant length, perform the aesthetic evaluation. The aes- all mean PES/WES was 14.30 ± 2.78 (median:

1304 | Clin. Oral Impl. Res. 23, 2012 / 1302–1307 © 2011 John Wiley & Sons A/S
Mangano et al  Morse taper connection implants placed in fresh extraction sockets

Table 3. Scores assessment for single PES/WES variables at baseline and at follow-up
Baseline assessment, N (%) Follow-up assessment, N (%)

0 1 2 0 1 2 P-value
Mesial papilla 1 (3.8) 13 (50.0) 12 (46.2) 0 (0.0) 11 (42.3) 15 (57.7) 0.157
Distal apilla 1 (3.8) 10 (38.5) 15 (57.7) 0 (0.0) 12 (46.2) 14 (53.8) 1.000
Curvature of facial mucosa 0 (0.0) 16 (61.5) 10 (38.5) 0 (0.0) 13 (50.0) 13 (50.0) 0.257
Level of facial mucosa 0 (0.0) 12 (46.2) 14 (53.8) 0 (0.0) 12 (46.2) 14 (53.8) 1.000
Root convexity/soft tissue colour/texture 3 (11.6) 18 (69.2) 5 (19.2) 2 (7.7) 18 (69.2) 6 (23.1) 0.157
PES (mean ± SD) 6.96 ± 1.77 7.30 ± 1.78 0.164
Tooth form 0 (0.0) 13 (50.0) 13 (50.0) 0 (0.0) 11 (42.3) 15 (57.7) 0.157
Tooth volume/outline 0 (0.0) 14 (53.8) 12 (46.2) 0 (0.0) 13 (50.0) 13 (50.0) 0.317
Tooth colour (Hue/Value) 2 (7.7) 14 (53.8) 10 (38.5) 2 (7.6) 12 (46.2) 12 (46.2) 0.157
Surface texture 0 (0.0) 16 (61.5) 10 (38.5) 0 (0.0) 17 (65.3) 9 (34.7) 0.317
Translucency 4 (15.3) 12 (46.2) 10 (38.5) 4 (15.3) 13 (50.0) 9 (34.7) 0.317
WES (mean ± SD) 6.88 ± 1.17 7.00 ± 1.35 0.257

14.5; range 8–19). Four (15.4%) of 26 single

implant treatments showed an almost perfect
result (PES/WES  18) (Figs 1 and 2). An
acceptable result was found for 19/26 (73.0%)
single implant cases (Figs 3 and 4). The aes-
thetic outcome was unfavourable for 3/26
(11.6%) single implant treatments (PES/WES
score <12). The overall mean PES was
7.30 ± 1.78 (median 8; range 4–10), with five
restorations with an overall PES <6. The
overall mean WES was 7.00 ± 1.35 (median:
7; range 4–10), with four restorations with an Fig. 1. Implant restoration in the upper right lateral
incisor position. Note the perfect soft tissue appearance
overall WES <6.
and restoration (PES = 9; WES = 9).
Fig. 3. Implant restoration in the upper right central
incisor position. Note the mesial papilla loss and the
Discussion attention for individual traits in the restoration
(PES = 7; WES = 8).

Patient satisfaction is a key factor in the suc-

cess of implant therapy and a successful
implant must provide an acceptable aesthetic
appearance. Recently, a novel comprehensive
index, comprising pink aesthetic score and
white aesthetic score (PES/WES) has been
applied for the objective aesthetic outcome
assessment of anterior single-tooth implants
(Lai et al. 2008; Belser et al. 2009; Cho et al.
2010). With reference to this, our retrospec-
tive study presented the aesthetic outcome of
26 anterior maxillary single-tooth Morse
taper connection implants inserted by imme-
diate placement in well-selected patients.
The goal of our study was to support aesthet-
ically pleasing soft tissue contours, avoiding
mucosal recession. In fact, although several
papers reported on optimal aesthetic out-
comes with immediate implant placement
(Cafiero et al. 2008; Tortamano et al. 2010), Fig. 2. Implant restoration in the upper right lateral
some studies warned of soft tissue complica- incisor position: the 2-year radiographic control.

tions, especially midfacial gingival recession

Fig. 4. Implant restoration in the upper right central
with exposure of the abutment or implant come. Only three restorations scored <12, incisor position: the 2-year radiographic control.
neck (Kan et al. 2003; Juodzbalys & Wang which was considered as the threshold of
2007; Ferrus et al. 2010). Our present study clinical acceptability (Belser et al. 2009). The and also the two variables of facial mucosa
on immediate implant placement, however, mean PES was 7.30 ± 1.78. The scores for the curvature and facial mucosa level showed
showed a 2-year mean total PES/WES of mesial and distal papillae (mean scores of excellent scores (mean scores of 1.50 and
14.30 ± 2.78, indicating a good aesthetic out- 1.57 and 1.53, respectively) were favourable 1.53, respectively). The combination variable

© 2011 John Wiley & Sons A/S 1305 | Clin. Oral Impl. Res. 23, 2012 / 1302–1307
Mangano et al  Morse taper connection implants placed in fresh extraction sockets

of root convexity, soft tissue colour and tex- periodontal biotype may be useful for the pre- Dibart et al. 2005). Moreover, with Morse
ture showed the lowest mean score (1.15) of vention of soft tissue complications with taper connection implants, the gap is closed
all five parameters. It is difficult to attain a immediate implant placement (Kan et al. so tightly that the abutment and the fixture
maximum score for this parameter, probably 2003; De Rouck et al. 2009). If immediate behave as a single piece, there is effectively
because it consists of three different aspects placement is performed in patients with a no microgap and therefore no bacterial leak-
to be fulfilled. The mean WES was thin biotype, there is a higher risk of soft tis- age, reducing the level of peri-implant tissue
7.00 ± 1.35. The WES analysis showed higher sue recession and underlying resorptive osse- inflammation to a minimum (Dibart et al.
scores for parameters such as tooth form and ous remodelling, exposing the metal margin 2005). In addition, with a tapered interference
volume (mean scores of 1.57 and 1.50, respec- of the implant (Kois 2004). To achieve a pre- fit, the abutment emergence geometry gives
tively), while tooth colour performed less dictable aesthetic outcome, implants must be “platform switching” advantages (Prosper
well (mean score of 1.38). Among all the placed in an optimal position and inclination. et al. 2009). The success of the platform
WES values, surface texture and tooth trans- When an implant is placed in a fresh extrac- switching design or horizontal off-set at the
lucency showed the lowest scores (mean tion socket, it seems prudent to place it in implant-abutment interface is believed to be
scores of 1.34 and 1.19, respectively). These the palatal portion of the socket, with its a consequence of the horizontal repositioning
last parameters, however, are strongly related marginal border well below the ridge of the of the microgap, and any toxin-producing
to the quality and design of prosthetic work fresh socket to compensate for the expected bacteria within it, as far away from the bone
and seem not to be related to peri-implant resorption (Kois 2004). Finally, it is essential as possible to minimize bone loss. Another
tissue dynamics. With immediate implant to maintain as much of the circumferential consequence of the platform switching design
placement, the following pre-requisites are bone height around the implant neck as pos- is the increased space for more connective
considered essential to achieve optimal aes- sible. However, when an abutment is con- tissue, to improve the biological seal. This
thetic outcome: adequate bone volume (hori- nected to a dental implant at the crestal space can guarantee excellent soft tissue
zontal, vertical, contour), stable and healthy level, bone loss around the implant always healing, with a thicker, larger, well-organized
peri-implant soft tissues and aesthetically occurs (Calvo Guirado et al. 2009). Although volume of peri-implant soft tissues, protect-
pleasing soft tissues contours (form of the the aetiological factors associated with early ing the bone crest from resorption (Prosper
periodontium, biotype of the periodontium), crestal bone loss have not been completely et al. 2009).
optimal three-dimensional (3D) implant posi- clarified, the main factors hypothesized to be
tion (mesio-distal, apico-coronal, bucco-lin- involved include surgical trauma, the forma-
gual and angulation) and ideal implant- tion of a biological width (Hermann et al.
abutment design and emergence profile (Ka- 2007), micromovements of the abutment
Based on these results and within the limits
zor et al. 2004). In immediate placement, the (Heckmann et al. 2006) and the presence and
of this study (such as the limited number of
ideal extraction socket would present little or size of a microgap between the implant and
patients and the absence of a control group),
no periodontal bone loss. Atraumatic tooth the abutment (Broggini et al. 2003). The fea-
the immediate placement of single-tooth
extraction is of key importance prior to tures of the implant-abutment connection
Morse taper connection implants in the ante-
immediate implant placement and the buccal are considered to influence not only the
rior maxilla seems to represent a successful
plate has to be intact (Evans & Chen 2008). mechanics but also the biological behaviour
procedure, with good aesthetic outcome. Fur-
Bone regeneration techniques using artificial of implants (Heckmann et al. 2006). Scien-
ther studies on a larger number of patients
bone graft substitute materials can be help- tific evidence supports the fact that the pres-
are needed to evaluate the aesthetic outcome
ful, to fill the gaps between the implant and ence of a microgap at the implant-abutment
of single-tooth Morse taper connection
the residual bony walls, reducing bone loss connection may have a direct effect on bone
implants placed in fresh extraction sockets of
(Evans & Chen 2008). The interproximal loss (Broggini et al. 2003). In implants with
the anterior maxilla.
bone height is important too, as it influences screw retained abutments, in fact, this micro-
the interdental papillae by acting as a refer- gap is of variable dimensions (40–100 lm)
ence for the soft tissue contours (Kois 2004). can be colonized by bacteria, potentially gen- Disclosure
Critical evaluation of smile line, gingival erating a chemotactic stimulus sustaining
architecture (periodontal biotype) and soft tis- the recruitment of inflammatory cells, ulti- The authors declare that they have no finan-
sue levels are essential for implant aesthetics mately resulting in inflammation and osteol- cial relationship with any commercial firm
(Juodzbalys & Wang 2007; Ferrus et al. 2010). ysis (Broggini et al. 2003). The Morse taper that may pose a conflict of interest for this
Periodontal biotype affects the periodontal interference-fit (TIF) locking-taper can avoid study. No grants, equipment or other sources
tissue dimensions, including masticatory micromovements at the implant-abutment of support were provided.
mucosa and biological width (Kan et al. interface, removing one reason for crestal
2003); for this reason, an evaluation of the bone loss around implants (Hansson 2003;

Albrektsson, T. & Zarb, G. (1998) Determinants of tion. Clinical Oral Implants Research 17: 606– cross-sectional, retrospective study in 45 patients
correct clinical reporting. The International Jour- 614. with a 2- to 4-year follow-up using pink and
nal of Prosthodontics 11: 517. Belser, U., Grutter, L., Vailati, F., Bornstein, M., white esthetic scores. Journal of Periodontology
Araujo, M.G., Wennstrom, J.L. & Lindhe, J. (2006) Weber, H. & Buser, D. (2009) Outcome evalua- 80: 140–151.
Modeling of the buccal and lingual bone walls of tion of early placed maxillary anterior single- Botticelli, D., Berglundh, T. & Lindhe, J. (2004)
fresh extraction sites following implant installa- tooth implants using objective esthetic criteria: a Hard tissue alterations following immediate

1306 | Clin. Oral Impl. Res. 23, 2012 / 1302–1307 © 2011 John Wiley & Sons A/S
Mangano et al  Morse taper connection implants placed in fresh extraction sockets

implant placement in extraction sites. Journal of ridge alterations following immediate implant dium for Continuing Education in Dentistry 25:
Clinical Periodontology 31: 820–828. placement into extraction sockets. Clinical Oral 895–900.
Broggini, N., McManus, L., Hermann, J., Medina, R. Implants Research 21: 22–29. Lai, H., Zhang, Z., Wang, F., Zhuang, L., Liu, X. &
U., Oates, T.W., Schenk, R.K., Buser, D., Mello- Furhauser, R., Florescu, D., Benesch, T., Haas, R., Pu, Y. (2008) Evaluation of soft tissue alteration
nig, J.T. & Cochran, D.L. (2003) Persistent acute Mailath, G. & Watzek, G. (2005) Evaluation of around implant-supported single-tooth restoration
inflammation at the implant-abutment interface. soft tissue around single-tooth implant crowns: in the anterior maxilla: the pink esthetic score.
Journal of Dental Research 82: 232–237. the pink esthetic score. Clinical Oral Implants Clinical Oral Implants Research 19: 560–564.
Cafiero, C., Annibali, S., Gherlone, E., Grassi, F.R., Research 16: 639–644. Lops, D., Chiapasco, M., Rossi, A., Bressan, E. &
Gualini, F., Magliano, A., Romeo, E., Tonelli, P., Hansson, S. (2003) A conical implant-abutment Romeo, E. (2008) Incidence of interproximal
Lang, N.P. & Salvi, G.E.. (2008) Immediate trans- interface at the level of the marginal bone papilla between a tooth and an adjacent immedi-
mucosal implant placement in molar extraction improves the distribution of stresses in the sup- ate implant placed into a fresh extraction socket:
sites: a 12-month prospective multicenter cohort porting bone. An axisymmetric finite element 1-year prospective study. Clinical Oral Implants
study. Clinical Oral Implants Research 19: 476– analysis. Clinical Oral Implants Research 14: Research 19: 1135–1140.
482. 286–293. Mangano, C., Mangano, F., Piattelli, A., Iezzi, G.,
Calvo Guirado, J., Ortiz-Ruiz, A., Lopez-Marı̀, L., Heckmann, S., Linke, J., Graef, F., Foitzik, C., Mangano, A. & La Colla, L. (2009) Prospective
Delgado-Ruiz, R., Matè-Sanchez, J. & Gonzalez, Wichmann, M. & Weber, H. (2006) Stress and clinical evaluation of 1920 Morse taper connection
L.. (2009) Immediate maxillary restoration of sin- inflammation as a detrimental combination for implants: results after 4-year of functional loading.
gle-tooth implants using platform switching for peri-implant bone loss. Journal of Dental Clinical Oral Implants Research 20: 254–261.
crestal bone preservation: a 12-month study. The Research 85: 711–716. Prosper, L., Redaelli, S., Pasi, M., Zarone, F., Rada-
International Journal of Oral & Maxillofacial Hermann, F., Lerner, H. & Palti, A.. (2007) Factors elli, G. & Gherlone, E.F. (2009) A randomized
Implants 24: 275–281. influencing the preservation of the peri-implant prospective multicenter trial evaluating the plat-
Chen, S., Darby, I. & Reynolds, E. (2007) A prospec- marginal bone. Implant Dentistry 16: 165–175. form switching technique for the prevention of
tive clinical study of non submerged immediate Jemt, T. (1997) Regeneration of gingival papillae post-restorative crestal bone loss. The Interna-
implants: clinical outcomes and esthetic results. after single-implant treatment. The International tional Journal of Oral & Maxillofacial Implants
Clinical Oral Implants Research 18: 552–562. Journal of Periodontics & Restorative Dentistry 24: 299–308.
Cho, H., Lee, J., Um, H. & Chang, B. (2010) 17: 326–333. Raes, F., Cosyn, J., Crommelinck, E., Coessens, P.
Esthetic evaluation of maxillary single-tooth Juodzbalys, G. & Wang, H.L. (2007) Soft and hard & De Bruyn, H. (2011) Immediate and conven-
implants in the esthetic zone. Journal of Peri- tissue assessment of immediate implant place- tional single implant treatment in the anterior
odontal and Implant Science 40: 188–193. ment: a case series. Clinical Oral Implants maxilla: 1-year results of a case series on the hard
De Rouck, T., Eghbali, A., Collys, K., De Bruyn, H. Research 18: 237–243. and soft tissue response and aesthetics. Journal of
& Cosyn, J. (2009) The gingival biotype revisited: Kan, J.Y., Rungcharassaeng, K., Umezu, K. & Kois, Clinical Periodontology 38: 385–394.
transparency of the periodontal probe through the J. (2003) Dimensions of peri implant mucosa: an Schropp, L., Isidor, F., Kostopoulos, L. & Wenzel, A.
gingival margin as a method to discriminate thin evaluation of maxillary anterior single implants (2005) Interproximal papilla levels following early
from thick gingival. Journal of Clinical Periodon- in humans. Journal of Periodontology 74: 557– versus delayed placement of single-tooth
tology 36: 428–433. 562. implants: a controlled clinical trial. The Interna-
Dibart, S., Warbington, M., Su, M. & Skobe, Z. Kazor, C.E., Al Shamari, K., Sarment, D.P., Misch, tional Journal of Oral & Maxillofacial Implants
(2005) In vitro evaluation of the implant-abut- C.E. & Wang, H.L. (2004) Implant plastic surgery: 20: 753–761.
ment bacterial seal: the locking taper system. a review and rationale. Journal of Oral Implantol- Tortamano, P., Camargo, L., Bello-Silva, M. &
The International Journal of Oral & Maxillofa- ogy 30: 240–254. Kanashiro, L. (2010) Immediate implant place-
cial Implants 20: 732–737. Koh, R., Rudek, I. & Wang, H.L. (2010) Immediate ment and restoration in the esthetic zone: a pro-
Evans, C.D. & Chen, S.T. (2008) Esthetic outcomes implant placement: positives and negatives. spective study with 18 months of follow-up. The
of immediate implant placements. Clinical Oral Implant Dentistry 19: 98–108. International Journal of Oral & Maxillofacial
Implants Research 19: 73–80. Kois, J.C. (2004) Predictable single tooth peri Implants 25: 345–350.
Ferrus, J., Cecchinato, D., Pjetursson, E., Lang, N., implant esthetics: five diagnostic keys. Compen-
Sanz, M. & Lindhe, J. (2010) Factors influencing

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