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Original Article

Soft‑tissue esthetic outcome of single

implants: Immediate placement
in fresh extraction sockets versus
conventional placement in healed
Nima Naddaf Pour, Baharak Ghaedi,1 Mona Sohrabi2

Department of Abstract:
Periodontology, Dental Background: Immediate implant placement has advantages such as requiring fewer surgical procedures and
School, Islamic Azad decreased treatment time; however, unpredictable soft‑ and hard‑tissue outcome is a problem. This study aimed to
University, 1Periodontist, compare the soft‑tissue esthetic outcome of single implants placed in fresh extraction sockets versus those placed
Private Practice, in healed sockets. Materials and Methods: This cross‑sectional, retrospective study was performed on 42 patients
Department of Pediatric who received single implants. Twenty‑two patients with a mean age of 40.14 years received immediate implants
while 18 patients with a mean age of 43.40 years were subjected to conventional (delayed) implant placement.
Dentistry, School of
The mean follow‑up time was 14.42 ± 8.37 months and 18.25 ± 7.10 months in the immediate and conventional
Dentistry, Tehran groups, respectively. Outcome assessments included clinical and radiographic examinations. The esthetic
University of Medical outcome was objectively rated using the pink esthetic score (PES). Results: All implants fulfilled the success
Science, Tehran, Iran criteria. The mean PES was 8.54 ± 1.26 and 8.10 ± 1.65 in the immediate and conventional groups, respectively.
This difference was not statistically significant (P = 0.329). The two PES parameters, namely, the facial mucosa
curvature and facial mucosa level had the highest percentage of complete score. Conclusions: Immediate and
conventional single implant treatments yielded comparable esthetic outcomes.
Key words:
Esthetics, immediate implant placement, pink esthetic score, single implant
Access this article online
INTRODUCTION reported bone loss even after immediate implant
DOI: placement.[5,10]
Quick Response Code: W ith a history of over 40 years, implant
treatment is now a standard modality of
care.[1,2] Previously, implants had to be placed
Several indexes have been proposed for esthetic
assessment of implants. The papilla index, pink
after a 6–12‑month healing period following esthetic score (PES), implant‑crown esthetic
tooth extraction. Such a long course of treatment index, and PES/white esthetic score are among
also required several surgical procedures.[2,3] the most reliable indexes for this purpose.[4,11‑13]
Advances in implant treatment have simplified
and shortened the course of treatment and Considering the significance of esthetic outcome
include flapless surgeries, immediate implant of peri‑implant soft tissue, especially in the
placement, and immediate loading.[3,4] anterior region, in acceptance or refusal of recent
treatment protocols such as immediate implant
The physiological process of healing of
extraction sockets starts immediately after tooth This is an open access journal, and articles are
Address for distributed under the terms of the Creative Commons
extraction and eventually results in a reduction Attribution‑NonCommercial‑ShareAlike 4.0 License, which
Dr. Mona Sohrabi, in height (vertical ridge resorption) and allows others to remix, tweak, and build upon the work
width (horizontal ridge resorption) of alveolar non‑commercially, as long as appropriate credit is given and
Department of Pediatric the new creations are licensed under the identical terms.
Dentistry, School process.[5‑7] Immediate implant placement has
of Dentistry, Tehran been suggested to preserve the crestal bone. For reprints contact:
University of Medical Some authors have stated that immediate
Science, Tehran, Iran. implant placement in fresh extraction sockets How to cite this article: Pour NN, Ghaedi B,
E‑mail: monasohraby@ Sohrabi M. Soft-tissue esthetic outcome of single
maintains the contour of the residual ridge
and prevents bone loss; therefore, it can have implants: Immediate placement in fresh extraction
sockets versus conventional placement in healed
Submission: 08‑01‑2018 favorable effects on esthetics.[5,8,9] In contrast,
sockets. J Indian Soc Periodontol 2018;22:249-53.
Accepted: 15‑04‑2018 some clinical and paraclinical studies have
© 2018 Indian Society of Periodontology | Published by Wolters Kluwer - Medknow 249
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Pour, et al.: Soft‑tissue esthetic outcomes in immediate implant placement

placement; this study aimed to compare the esthetic outcome sulcus, score 2 indicated visible plaque, and score 3 indicated
of single implants placed in fresh extraction sockets versus abundant soft plaque.
those placed in healed sites.
MBI was used to assess bleeding on probing in six areas around
MATERIALS AND METHODS each implant; 0 indicated no bleeding on probing, 1 indicated
bleeding in separate points, 2 indicated bleeding in gingival
Medical files of patients who received single implants by margins, and 3 indicated abundant bleeding.
immediate or delayed placement were retrieved from the
archives of a private dental clinic. This study was approved Mobility was graded clinically by holding the tooth firmly with
in the ethics committee of our university (Code: 678). The one metallic instrument and one finger. Mobility beyond the
inclusion and exclusion criteria were as follows: physiologic range is termed abnormal or pathologic.

Inclusion criteria – (1) The presence of at least one natural tooth Pain, infection, neuropathy, and paresthesia were also assessed
at each side of the respective implant, (2) implants placed at the and some questions were asked from patients in this regard.
site of single‑rooted teeth, and (3) minimum of 6 months had This was done to determine the implant success rate according
to be passed since prosthetic delivery and loading of implant. to the Alberktsson’s criteria.[15]

Exclusion criteria – (1) History of periodontal disease, (2) soft‑ or For assessment of esthetic outcome, PES was determined for
hard‑tissue grafting before or during implant placement, each patient. PES included five parameters of mesial papilla,
(3) systemic diseases affecting periodontal conditions such distal papilla, facial mucosa curvature, facial mucosa level,
as diabetes mellitus, (4) severe smoking, and (5) pregnancy. and last parameter including three components of root surface
convexity, soft‑tissue color, and soft‑tissue texture. Scores 0, 1,
The treatment process in patients who received immediate or 2 were allocated to each parameter. Mesial and distal papilla
implants was as follows: parameters were scored 2 in case of complete presence of papilla,
1 in case of partial presence of papilla, and 0 in case of absence
The flap was conventionally elevated. The teeth were gently of papilla. Facial mucosa curvature was defined as visibility
luxated, and lateral forces were avoided to prevent damage to of implant restoration margins over the facial soft tissue and
buccal and lingual plates. After atraumatic extraction of tooth, scored 2 in case of complete adaptation, 1 in case of presence
the extraction socket was debrided and rinsed with saline. of small difference, and 0 in case of presence of significant
Implant was then placed in the fresh socket after ensuring difference. Facial mucosa level was assessed by comparing the
the presence of four intact bony walls without dehiscence or level of mucosa relative to that of a control tooth and scored
fenestration. In immediate implant placement, none of the 2 in case of similarity, 1 in case of difference ≤1 mm, and 0 in
patients received bone graft to fill the gap. case of difference ≥1 mm. Regarding the last parameter, color
and appearance of soft‑tissue indicate presence. The absence
In patients who were subjected to conventional (delayed) of inflammatory process which affects the appearance of
implant placement, the treatment process was as follows: implant restoration. In case of complete adaptation of all
three factors with those in a control tooth, this parameter was
Patients presented at least 6 months after tooth extraction. scored 2, adaptation of two factors scored 1, and no adaptation
A mesiodistal crestal incision was made, and a full‑thickness was scored 0. The total score of 10 (2 × 5) for PES index was
flap was elevated to expose alveolar bone. considered optimal. The acceptable score was  ≥  6. After
scoring each PES parameter by a periodontist, standard clinical
Next, in both groups, implant placement site was prepared photographs (×1 magnification) were taken of the respective
by specific drills under continuous irrigation, and implants area using a digital camera (Canon).
were placed 0.5–1 mm beneath the bone crest according to
the principles of 3D placement of implants. In both groups, Next, parallel radiographs were requested for each implant to
implants were submerged and loaded after 6 months. assess the presence of radiolucency around implant and bone
loss. Radiographs were scanned (300 DPI), and bone loss was
All clinical and radiographic examinations were carried out quantified by measuring the distance between the implant
by an experienced periodontist who was not involved in the shoulder and bone crest with 0.1 mm accuracy using Romexis
process of implant placement or prosthetic restoration. Clinical Viewer 2.2.9 software. Radiographic findings were used to
examination of each patient included measurement of pocket determine implant success rate according to the Alberktsson’s
depth (PD), modified plaque index (MPI), modified bleeding criteria.
index (MBI), mobility, and PES.[14]
PD was measured by inserting a standard titanium periodontal
probe (noncolor‑coded offset probe, Nordent, USA) at six Demographics
areas of mesiobuccal, midbuccal, distobuccal, mesiolingual, This descriptive, analytical, cross‑sectional, and retrospective
midlingual and distolingual around each implant and recorded. study was conducted on 42 patients including 14 males (33.3%)
and 28 females (66.7%) with a mean age of 41.73 years (range
MPI was measured to assess plaque accumulation around 22–63 years); of which, 22 underwent immediate and
implant. Score 0 indicated the absence of plaque, score 1 20 underwent conventional (delayed) implant placement. The
indicated plaque detectable by movement of probe in the assessment of outcome was done 14.42 ± 8.37 months after

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Pour, et al.: Soft‑tissue esthetic outcomes in immediate implant placement

treatment in the immediate group and 18.25 ± 7.10 months The mean PD was 2.72 ± 0.81 mm in the immediate and
after treatment in the conventional group. The difference 2.56 ± 0.91 mm in the conventional group. The difference in this
in this regard between the two groups was not statistically regard was not significant between the two groups (P = 0.552).
significant (P > 0.05).
Treated sites
All teeth treated in this study were maxillary anterior teeth. Immediate implant placement following tooth extraction has
Table 1 shows the distribution of implant sites. advantages such as saving time, esthetic appearance, and
comfort for patients and disadvantages such as mid‑facial
Bone loss gingival recession.[16] Many recent studies have emphasized
The mean bone loss was 0.62 ± 0.44 mm in the immediate and that implant survival, osseointegration, and interdental crestal
0.43 ± 0.39 mm in the conventional group. The difference in bone level are not negatively affected by immediate implant
this regard was not statistically significant between the two placement protocol.[17,18] In addition, a systematic review in
groups (P = 0.779). 2014 showed better survival of crestal bone in immediate
placement of implant compared to conventional placement.[19]
Pink esthetic score Esthetic soft‑tissue outcome around immediate implants is
Table 2 compares the peri‑implant soft‑tissue esthetic outcome still a matter of debate considering no effect of this protocol
in the two groups. As shown in Table 2, the mean PES was on natural remodeling of tooth socket.
8.54 (range 6–10) in the immediate and 8.10 (range 6–10) in
the conventional group. The difference in this regard was not In the current study, none of the implants had any mobility,
statistically significant between the two groups (P > 0.05). No pain, infection, neuropathy, or paresthesia. The amount of
implant showed unacceptable PES in any of the two groups. bone loss in the two groups was within the success criterion
reported by Alberktson.[15] Assessment of soft‑tissue outcome
Modified bleeding index, modified plaque index, and pocket in the current study was done using modified PES. Both groups
depth acquired almost a complete score with no significant difference
The mean MBI was 0.49 ± 0.44 in the immediate and 0.70 ± 0.50 between the two, which was in line with the findings of similar
in the conventional group. The difference in this respect was previous studies.[20‑23]
not statistically significant between the two groups (P = 0.164).
PES did not show any significant difference between the two
Table 3 compares the MPI in the two groups. The difference groups regarding papillary height. This finding was in line with
in this regard was not statistically significant between the two that of previous studies that found no significant difference in
groups (P = 0.493). the papilla score between the two groups.[5,9,21,24,25] This finding
was also in agreement with that of previous studies showing
Table 1: Distribution of implant sites in the two groups that papilla fullness is independent of the time of implant
Treatment Implant position surgery relative to tooth extraction.[26,27] In other words, based
strategy Central Lateral Canine Premolar Total on several studies, interdental papillary height depends on the
incisor incisor bone peak of adjacent tooth, and time of implant placement
IIT 5 3 1 13 22 has no effect on bone level.[28] Cosyn et al. in 2012 conducted a
CIT 1 3 2 14 20 3‑year study on soft‑tissue status around immediately placed
IIT – Immediate implant treatment; CIT – Conventional implant treatment implants and revealed that 1 year after treatment, the papilla
had not been completely remodeled but showed significant
Table 2: Esthetic outcome regrowth especially in the mesial part over time. After 3 years,
the papilla regained its primary height.[16] Accordingly, since
IIT (n=22) CIT (n=20)
the duration of the current study was <18 months, the papillary
0 1 2 0 1 2 score still had a chance of improvement in the upcoming years.
Mesial papilla 0 6 16 0 4 16
Distal papilla 0 8 14 1 9 10 Regarding the soft tissue around immediate single implants,
Midfacial level 1 1 20 0 4 16
midfacial gingival level has gained increasing attention in
Midfacial contour 0 3 19 0 3 17
(alveolar process) the recent studies. The current study showed no significant
Soft tissue color 0 12 10 3 10 7 difference in facial mucosa level between the two groups,
(soft‑tissue texture) and 90.9% of immediate implants and 80% of conventional
Pink esthetic score, 8.54±1.26 (6‑10) 8.10±1.65 (6‑10) implants acquired a complete score in this respect. Some studies
mean±SD (range) have reported high incidence of gingival recession (30%–40%)
SD – Standard deviation; IIT – Immediate implant treatment; following immediate implant placement[27,29‑31] while some
CIT – Conventional implant treatment; n – number others have reported limited resorption in the facial mucosa
(0.5–1 mm) following immediate implant placement.[3,16,22,23,32]
Table 3: Modified plaque index in the two groups Based on Felice et  al. study, soft‑tissue levels score was
MP 0 1 2 3 significantly better at immediate implants as compared with
IIT, n (%) 21 (95.5) 1 (4.5) 0 0 delayed implants.[9] Some studies have reported that thin
CIT, n (%) 18 (90) 2 (10) 0 0 gingival biotype is an important, even the most important,
IIT – Immediate implant treatment; CIT – Conventional implant treatment; factor responsible for midfacial gingival recession.[21,33] The
MP – Modified plaque; n – number presence of labial bone with adequate thickness and height is an

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Pour, et al.: Soft‑tissue esthetic outcomes in immediate implant placement

important factor affecting long‑term stability of gingival margin subgingival placement of restoration margins.[42] Probing depth
around implants.[34] Moreover, implant shoulder position also in the current study was not significantly different between the
affects mid‑facial gingival recession such that buccal shoulder two groups and was within the acceptable range. This finding
of implant can increase the risk of gingival recession by was in agreement with the results of the only previous study
three times. Therefore, accurate patient selection is the most found on this topic.[21] In general, biological soft‑tissue findings
important factor in this respect.[22,29] In other words, many in this study indicated stability of soft‑tissue conditions, which
factors such as technique of surgery, restorative treatment, is promising for prediction of soft‑tissue outcome following
technical expertise, buccal bone plate status, soft‑tissue both immediate and conventional placement of single implants.
volumetric defects, and wound healing potential significantly
affect midfacial gingiva and can compensate for the negative CONCLUSIONS
effect of immediate implant placement on mid‑facial gingival
status.[34] This study showed that immediate placement of implants
following tooth extraction is a valuable and predictable
Also according to the Systematic Review in 2016, no protocol comparable to conventional placement of single
significant difference of the esthetic outcomes was reported implants regarding survival rate, osseointegration, and
following immediate as compared with conventional implant esthetics.
Financial support and sponsorship
In the current study, the three‑component parameter of Nil.
PES was not significantly different between the two groups
either. This parameter had the lowest frequency percentage Conflicts of interest
of acquiring a complete score compared to other parameters There are no conflicts of interest.
in the two groups (46.5% in the immediate and 36% in the
conventional group). REFERENCES

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