Received: 8 November 2017 | Revised: 14 March 2018 | Accepted: 21 March 2018

DOI: 10.1111/cid.12613

ORIGINAL ARTICLE

A long-term prospective cohort study on immediately restored

single tooth implants inserted in extraction sockets and healed
ridges: CBCT analyses, soft tissue alterations, aesthetic ratings,
and patient-reported outcomes

Stefanie Raes DDS, MSc, PhD Student1 | Aryan Eghbali DDS, MSc, PhD2 |
Vivianne Chappuis DDS, Dr. Med. Dent3 | Filiep Raes DDS, MSc, PhD1 |
Hugo De Bruyn DDS, MSc, PhD1,4,5 | Jan Cosyn DDS, MSc, PhD1,2

1
Department of Periodontology and Oral
Implantology, Dental School, Faculty of
Abstract
Medicine and Health Sciences, Ghent
Background: Although many studies have been published on single implants, long-term data
University, Ghent, Belgium
2
remain scarce.
Oral Health Research Group (ORHE),
Faculty of Medicine and Pharmacy, Vrije Purpose: To evaluate immediately restored single implants after at least 8 years of follow-up in
Universiteit Brussel, Brussels, Belgium
terms of buccal bone, soft tissue alterations, aesthetic ratings, and patient-reported outcomes.
3
Department of Oral Surgery and
Stomatology, School of Dental Medicine, Materials and Methods: This prospective cohort study included patients who were consecutively
University of Bern, Bern, Switzerland treated with an immediately restored single implant installed in an extraction socket (IIT) or a
4
Department of Prosthodontics, Faculty of healed ridge (CIT) in the anterior maxilla. Biomaterials were never used. CBCTs were taken at study
Odontology, Malmo€ University, Malmo€,
termination, soft tissue alterations, and Pink Esthetic Score were evaluated between 1 year and
Sweden
5
study termination using standardized clinical images. Patient satisfaction was also registered.
Department Periodontology and
Implantology, College of Dental Science, Results: About 11/16 initially treated patients in the IIT cohort (10 men, 6 women; mean age 45)
Radboud University Medical Center,
and 18/23 initially treated patients in the CIT cohort (12 men, 11 women; mean age 40) could be
Nijmegen, The Netherlands
evaluated after more than 8 years. A buccal bone wall less than 2 mm was found at all implant
Correspondence sites. A thin buccal bone wall less than 1 mm was found at 42% of the implant sites. In the CIT
Stefanie Raes, DDS, MSc, PhD Student, cohort, 8 patients had a missing buccal bone in the crestal area, although bone was present at the
Department of Periodontology and Oral
time of surgery. Alveolar process deficiency significantly deteriorated (P  .046), whereas vertical
Implantology, Dental School, Faculty of
Medicine and Health Sciences, Ghent soft tissue levels and PES remained stable over time in both cohorts. Patients expressed high over-
University, C. Heymanslaan 10, Ghent, all satisfaction.
Belgium.
Email: stefanie.raes@ugent.be Conclusions: Substantial dimensional changes may be expected at the buccal aspect of single
implants inserted in the premaxilla. As a result, contour augmentation procedures at the time of
implant placement should be considered to counteract these bone alterations, even when implants
are fully embedded in bone upon insertion.

KEYWORDS
buccal bone, long-term study, patient satisfaction, single-tooth implants, soft tissue alterations

Clin Implant Dent Relat Res. 2018;1–9. wileyonlinelibrary.com/journal/cid V

C 2018 Wiley Periodicals, Inc. | 1
2 | RAES ET AL.

1 | INTRODUCTION 2. Minimum 20 teeth present.

3. Good oral hygiene defined as a full mouth plaque score 25%.12

Ample systematic reviews have indicated high survival rates for single
4. Presence of a single failing tooth or a single tooth gap in the ante-
tooth implants in the aesthetic area irrespective of the timing of
rior maxilla (15–25) with both neighboring teeth present.
implant placement.1–5 Immediate restoration has become a convenient
5. Ideal soft tissue level and contour at the facial aspect of the
way to reduce the time span for a patient to function with a removable
failing tooth or the single tooth gap, implying no visible disparity
partial denture. Providing proper primary implant stability immediate
between the latter and the contra-lateral tooth and adjacent
restoration does not seem to hamper osseointegration.6
teeth.
Although many studies have been published on single tooth
implants, the available literature remains scarce when it comes to long- 6. Appropriate bone volume as assessed by standard radiographs or
term prospective studies with data on midfacial alterations, aesthetics, CBCT scans to ensure primary implant stability of at least 25 Ncm.
2,7,8
and patient-reported outcomes. Buser et al (2013) demonstrated 7. Signed informed consent.
stable hard and soft tissues, and pleasing aesthetics at 6 years of
Exclusion criteria were as follows:
follow-up for early implant placement (type II) and concomitant contour
augmentation with guided bone regeneration.9 The low risk for midfa-
1. Pregnancy at the time of inclusion.
cial recession and the maintenance of the buccal bone wall may be
2. Uncontrolled diabetes mellitus.
considered pivotal findings of this approach. Low risk for midfacial
recession has also been reported for ridge preservation and single 3. Smoking.
10
implant treatment in a delayed approach. 4. Non-treated periodontal disease and/or caries.
Five-year prospective studies on immediate implant placement 5. IIT in high-risk patients with an incomplete buccal bone wall upon
(type I) have indicated higher risk for midfacial recession with prevalen- extraction or a thin-scalloped gingival biotype. The latter was
ces of advanced midfacial recession (>1 mm) up to 21%.11,12 In addi- determined by the transparency of the periodontal probe through
tion, Benic et al (2012) demonstrated an incomplete buccal bone wall the gingival margin while probing the buccal sulcus of the upper
in 5/14 patients who had been treated with an immediate implant 7 central incisors13).
13
years earlier. These findings are in accordance with a recent random-
6. CIT when the failing tooth had been extracted less than 3 months
ized controlled study on the timing of implant placement.14
earlier.
To the best of our knowledge long-term prospective studies with
7. CIT in sites that had been treated by guided bone regeneration or
data on midfacial alterations, aesthetics, and patient-reported out-
bone grafts before.
comes have not been published for delayed implant placement (type
IV). Given the fact that this approach is by many still considered the 8. Primary implant stability less than 25 Ncm.
golden standard, such information is of key importance.
The study was conducted in accordance with the Helsinki declaration
The objective of the present prospective cohort study was to
of 1975 as revised in 2000 and the protocol was approved by the ethi-
document midfacial hard and soft tissue alterations, aesthetics, and
cal committee of the University Hospital in Ghent (UZ Ghent, no.
patient-reported outcomes between 1 and at least 8 years of follow-up
2004/439).
following type I (immediate implant treatment [IIT]) and type IV place-
ment (conventional implant treatment [CIT]).
2.2 | Surgical and prosthetic procedures
2 | MATERIALS AND METHODS Surgical and prosthetic procedures have been described extensively in
an earlier article pertaining to the same study material with 1-year
2.1 | Patient cohorts results.15 In brief, flapless surgery was performed for IIT when deemed
appropriate by the implant surgeon. A minimal mucoperiosteal flap
This prospective cohort study included patients who were consecu-
extending to the midfacial aspect of both neighboring teeth was raised
tively treated with a single chemically modified moderately rough tita-
for CIT. Implants were placed in a correct three-dimensional position as
nium implant (Astra Tech Implant System, OsseoSpeed, Dentsply
described by Buser et al (2004). All implants were immediately restored
€ lndal, Sweden) in the University Hospital in Ghent
Sirona Implants, Mo
with a provisional crown, cleared of all contact in centric occlusion and
between May 2005 and December 2006 by one experienced perio-
during eccentric movements prior to cementation with temporary
dontist (FR) and one prosthodontist (PC). They underwent either IIT if
cement (Temp-Bond NE, Scafati, Kerr, Italy). After 10 weeks, a defini-
the failing tooth was still in situ, or CIT if the tooth had already been
tive crown was cemented using glasionomer cement (Ketac Cem, 3M
lost at the time of inclusion. Patients were selected during a screening
Espe, Zoeterwoude, the Netherlands).
visit based on inclusion and exclusion criteria.
The results on implant survival, marginal bone loss, and complica-
Inclusion criteria were as follows:
tions for the cohorts described in this article have been published else-
1. At least 18 years old. where (Raes et al, Accepted).
RAES ET AL. | 3

2.3 | Outcome variables Oral Radiology, Ghent University, Belgium. All scans were made at
96 kV and 11.0 mA for 12 s (voxel size: 200 mm; grey scale: 15 bit;

 Facial bone and soft tissue thickness was measured on CBCT images focal spot: 0.5 mm; field of view: 100 3 55 mm). Image reconstruc-

after at least 8 years of follow-up at the implant site and the contra- tion for visual analysis was obtained by the use of OnDemand 3D

lateral tooth (Figure 1). CBCTs were taken at the Department of software (Cybermed, Seoul, Korea). Facial bone and soft tissue

F I G U R E 1 (A) IIT in region 12: (a) Clinical evaluation at 1 year of follow-up; (b) Clinical evaluation after at least 8 years of follow-up; (c)
Soft tissue thickness evaluation on CBCT after at least 8 years of follow-up; (d) Buccal bone thickness evaluation on CBCT after at least 8
years of follow-up. (B) CIT in region 12: (a) Clinical evaluation at 1 year of follow-up; (b) Clinical evaluation after at least 8 years of follow-
up; (c) Soft tissue thickness evaluation on CBCT after at least 8 years of follow-up; (d) Buccal bone thickness evaluation on CBCT after at
least 8 years of follow-up
4 |
FIGURE 2 Vertical soft tissue measurements at the mesial, distal,
and midfacial aspect
thickness was assessed to the nearest 0.01 mm at 1–3-5 mm from
the implant shoulder (reference line A, Figure 1) at the midfacial
aspect of each implant perpendicular to the axis of the implant (ref-
erence line B, Figure 1). Facial bone and soft tissue thickness on the
contra-lateral tooth was assessed accordingly, at 1–3-5 mm from
the alveolar crest. Soft tissue thickness was calculated by subtract-
ing buccal bone thickness of the total buccal thickness. All sites
were measured by two clinicians (AE and SR).
 Vertical soft tissue changes at the mesial, distal, and midfacial aspect
of the implant restoration between 1 year and after at least 8 years
of follow-up (Figure 2). Measurements were performed on clinical
photographs taken perpendicular to the implant crown. With desig-
nated software (GS 1.0.0.2.) a reference yellow line was drawn con-
necting incisal lines of both adjacent teeth. Three yellow lines,
representing the mesial papilla, distal papilla, and midfacial level
were drawn perpendicular to this reference line. The width of the
mesial neighboring tooth was measured on study casts with a slide
ruler to the nearest 0.1 mm. This distance was transferred to the
digital slide by means of a blue line in order to calibrate distances on
digital slides.
 Pink Esthetic Score (PES)16 was evaluated at 1 year and after at least
8 years of follow-up.
 Oral Health Impact Profile-14 (OHIP-14)17,18 was evaluated at 1 year
and after at least 8 years of follow-up.
 Patient satisfaction was assessed after at least 8 years of follow-up.
Ad hoc questions with visual analogue scales were used for this pur-
pose and related to general satisfaction, comfort, speech, aesthetics,
function, and cleansability.
2.4 | Statistical analysis
Data analysis was performed using the patient as the experimental unit
and descriptive statistics were calculated for all variables. Changes
between 1 year and after at least 8 years of follow-up were examined
using the Wilcoxon Signed Ranks Test. The same test was used to
compare buccal soft tissue thickness between implant and contra-
lateral tooth. The possible association between missing buccal bone in
the crestal area and midfacial recession was evaluated using the
Mann–Whitney U test. The possible association between missing
RAES ET AL.
buccal bone in the crestal area and alveolar process deficiency at
implants was evaluated using the Fisher’s exact test. The level of signif-
icance was set at 0.05.
3 | RESULTS
3.1 | Patient cohorts
About 11 out of the 16 (69%) treated patients in the IIT cohort (10
men, 6 women; mean age 45; age range 22–68) and 18 out of the 23
(78%) treated patients in the CIT cohort (12 men, 11 women; mean age
40; age range 19–75) could be evaluated after more than 8 years of
follow-up. Ten patients dropped out due to various reasons (implant
failure 5 1; patient not willing to return 5 2; patient unreachable 5 6;
patient deceased 5 1). From 26 out of the remaining 29 patients a
CBCT was taken. In 3 patients, this could not be done due to various
reasons (patient evaluated at home since he/she was not willing to
come to the clinic 5 2; patient refused CBCT 5 1). For further details
regarding reasons for tooth loss, implant positions, length, and diameter
we wish to refer to an earlier article.15
3.2 | Facial bone and soft tissue thickness
Table 1 shows facial bone thickness at the implant and contra-lateral
tooth for both cohorts. Irrespective of the treatment concept, a buc-
cal bone wall less than 2 mm was found at almost all implant sites
(overall interquartile range of [0–1.35], [0.26–1.92], and [0.26–1.83]
at 1-3-5 mm level from the implant shoulder, respectively). A thin
buccal bone wall less than 1 mm was found at 42% of the implant
sites. Facial bone was missing in the crestal area in 8 patients of the
CIT cohort after at least 8 years of function (47%). Similarly, a buccal
bone wall of less than 2 mm at 1-3-5 mm from the CEJ was
observed at all tooth sites.
Table 1 also shows buccal soft tissue thickness at the implant and
contra-lateral tooth. Soft tissues were significantly thicker at
implant sites at 1 mm from the implant shoulder/CEJ (P 5 .001). At
3 mm (P 5 .058) and 5 mm (P 5 .325) the difference was not statisti-
cally significant.
3.3 | Vertical soft tissue changes
Table 2 shows vertical soft tissue changes in both cohorts between 1
year and after at least 8 years of follow-up. For none of the parame-
ters statistical significance was reached indicating stable soft tissue
levels in the long-term. One patient in the IIT cohort showed
advanced midfacial recession (>1 mm) after at least 8 years. No
patient demonstrated this magnitude of midfacial recession in the CIT
cohort.
The possible association between missing buccal bone in the
crestal area and midfacial recession was further explored. Mean
midfacial recession amounted to 0.13 mm in patients with an intact
buccal bone wall and to 20.08 mm in patients with missing buccal
bone wall in the crestal area. The difference was not statistically sig-
nificant (P 5 .738).
 RAES
ET AL.

TA BL E 1 Buccal bone and soft tissue thickness at implant site and corresponding tooth site

Implant Implant Implant Tooth Tooth Tooth Implant Implant Implant Tooth Tooth Tooth
bone bone bone bone bone bone soft tissue soft tissue soft tissue soft tissue soft tissue soft tissue
21 mm 23 mm 25 mm 21 mm 23 mm 25 mm 21 mm 23 mm 25 mm 21 mm 23 mm 25 mm

IIT Mean (SD) 1.12 1.32 0.95 1.29 1.30 0.92 1.26 1.32 2.15 0.68 0.90 1.67
(0.44) (0.54) (0.61) (0.45) (0.62) (0.63) (0.40) (0.55) (1.81) (0.38) (0.66) (1.08)
Median 1.19 1.26 1.16 1.24 1.03 0.80 1.24 1.16 1.57 0.66 0.59 1.33
[IQ Range] [0.85; [1.03; [0.40; [0.90; [0.87; [0.55; [0.93; [0.97; [1.31; [0.35; [0.40; [0.77;
1.37] 1.74] 1.40] 1.59] 1.75] 1.00] 1.57] 1.62] 1.78] 1.05] 1.65] 2.67]
0 mm N50 N50 N51 N50 N50 N50
<0.5 mm N51 N51 N53 N50 N50 N51 N50 N50 N50 N53 N53 N50
0.5-0.99 mm N51 N51 N51 N52 N53 N56 N54 N52 N50 N54 N52 N52
1.0–1.49 mm N56 N54 N54 N55 N53 N51 N53 N54 N53 N52 N50 N53
1.50 mm N51 N53 N51 N52 N53 N51 N52 N53 N55 N50 N53 N53

CIT Mean (SD) 0.78 1.22 1.27 1.00 1.10 1.03 1.25 1.24 1.52 0.74 0.92 1.13
(0.85) (1.02) (1.04) (0.42) (0.56) (0.44) (0.71) (0.77) (0.77) (0.27) (0.63) (0.40)
Median 0.50 1.52 1.52 0.97 0.91 0.99 1.17 1.21 1.33 0.73 0.80 1.17
[IQ Range] [0.00; [0.00; [0.00; [0,73; [0,71; [0.69; [0.69; [0.73; [1.06; [0.53; [0.48; [0.72;
1.49] 1.95] 1.95] 1.39] 1.41] 1.37] 1.97] 1.62] 1.76] 0.84] 1.04] 1.49]
0 mm N58 N56 N55 N50 N50 N50
<0.5 mm N58 N56 N55 N52 N51 N52 N52 N52 N50 N51 N54 N51
0.5-0.99 mm N51 N50 N52 N56 N 5 10 N58 N54 N54 N52 N 5 11 N57 N53
1.0–1.49 mm N54 N52 N51 N57 N53 N54 N54 N54 N55 N53 N52 N58
1.50 mm N54 N59 N59 N52 N53 N53 N54 N54 N56 N50 N52 N52

IIT, immediate implant treatment; CIT, conventional implant treatment.

Mean (SD).
Median [IQ Range].
N 5 number of cases with no buccal bone at given distance from implant shoulder.
|
5
6 | RAES ET AL.

TA BL E 2 Vertical soft tissue changes between 1 year and >8 years of follow-up

Immediate implant treatment Conventional implant treatment

(n 5 11) (n 5 18)
Parameter Difference between 1 year and >8 years P valueb Difference between 1 year and >8 years P valueb

Mesial papillary recessiona 0.44 (1.04) .166 0.05 (0.56) .652

0.35 [20.20; 0.60] 0.10 [20.40; 0.50]

Distal papillary recessiona 0.27 (0.55) .130 0.02 (0.83) .977

0.40 [20.20; 0.50] 20.05 [20.33; 0.45]

Midfacial recessiona 0.09 (0.62) .905 0.01 (0.61) .670

20.10 [20.30; 0.50] 0.15 [20.33; 0.50]

Mean (SD).
Median [IQ range].
a
Positive value indicates recession; negative value indicates regrowth.
b
Comparison between 1 and >8-year data using the Wilcoxon Signed Ranks test.

3.4 | Pink esthetic score 3.6 | Patient satisfaction

Tables 3 and 4 show details on the PES in both cohorts at 1 year and
after at least 8 years of follow-up. At study termination, the mean PES
amounted to 10.36 and 9.22 in the IIT and CIT cohort, respectively.
There was no statistically significant difference between 1 year and at
least 8 years of follow-up in either cohort (P  .470).
Table 4 shows frequency distributions on the three criteria of the
PES relating to midfacial tissues. Midfacial soft tissue level and midfa-
cial soft tissue contour were stable over time (P  .405). Alveolar pro-
cess deficiency significantly deteriorated in both cohorts between 1
year and at least 8 years of follow-up (P  .046).
The possible association between missing buccal bone in the cres-
tal area and alveolar process deficiency at implants was further
explored. Of the 8 patients with missing buccal bone, 5 (62.5%) demon-
strated major alveolar process deficiency (score 0). Of the 18 patients
with an intact buccal bone wall, only 6 (33%) demonstrated major alve-
olar process deficiency (score 0). The difference was not statistically
significant (P 5 .218).
3.5 | Oral health related quality of life
As can be seen in Table 3 the mean OHIP-14 score was 0.11 in the IIT
cohort and 0.21 in the CIT cohort at study termination. There was a
slight, yet significant deterioration between 1 year and at least 8 years
of follow-up in the CIT cohort (P 5 .042).
Visual analogues scales for general satisfaction, comfort, speech, aes-
thetics, functional outcome, and cleansability ranged between 87 and
97. High scores were given for all parameters indicative of high patient
satisfaction.
4 | DISCUSSION
In the past several years, attempts were made to relate the thickness
of the buccal bone wall to the aesthetic outcome of single
implants.19,20 Based on a limited number of short-term studies, Merheb
et al (2014) suggested that a thickness of at least 2 mm would be
needed to avoid bone resorption.19 Given the results of the present
study, it is clear that a 2 mm thick buccal bone wall is highly unusual at
implants. The same may apply to teeth as shown in many other
studies.21–24 In spite of that, the present study demonstrated stable
soft tissue levels over at least 8 years of follow-up. Hence, it seems
that the mere presence of a bony wall at the buccal aspect of an
implant may be more relevant to consider than its thickness when aim-
ing for soft tissue preservation.
In the present study, all patients in the IIT cohort demonstrated a
buccal bone wall and stable midfacial soft tissues at implant sites.
These findings seem to contradict the available literature on type I
placement showing high risk for incomplete facial bony walls and mid-
facial recession.12–14 Possible explanations may be a stringent selection

TA BL E 3 Pink Esthetic Score and OHIP-14 at 1 year and >8 years of follow-up

Immediate implant treatment Conventional implant treatment

1 year > 8 years 1 year >8 years

Parameter (n 5 15) (n 5 11) P-valuea (n 5 20) (n 5 18) P-valuea

Pink Esthetic Score (/14) 10.33 (2.29) 10.36 (2.11) 0.470 9.70 (1.72) 9.22 (2.31) 0.763
11.00 [9.00; 12.00] 11.00 [10.00; 12.00] 10.00 [9.00; 10.75] 9.00 [7.00; 11.25]

OHIP-14 0.24 (0.04) 0.10 (0.21) 0.068 0.14 (0.37) 0.21 (0.38) 0.042
(/4) 0.00 [0.00; 0.07] 0.00 [0.00; 0.07] 0.00 [0.00; 0.00] 0.00 [0.00; 0.30]

Mean (SD).
Median [IQ range].
a
Comparison between 1 and >8-year data using the Wilcoxon Signed Ranks test.
RAES ET AL. | 7

TA BL E 4 Details on the Pink Esthetic Score relating to midfacial tissues

Immediate implant treatment Conventional implant treatment

1 year (n 5 15) >8 years (n 5 11) 1 year (n 5 20) >8 years (n 5 18)
Number Number Number Number
Parameter Score of cases Score of cases P-valuea Score of cases Score of cases P-valuea

Midfacial soft 0 2 0 1 0.655 0 2 0 3 0.763

tissue level
1 5 1 5 1 6 1 2
2 8 2 5 2 12 2 13

Midfacial soft 0 0 0 0 0.655 0 1 0 1 0.405

tissue contour
1 7 1 4 1 6 1 9
2 8 2 7 2 13 2 8

Alveolar process 0 1 0 2 0.046 0 0 0 10 0.008

deficiency
1 5 1 4 1 9 1 3
2 9 2 5 2 11 2 5

Comparison between 1 and >8-year data using the Wilcoxon Signed Ranks test.
a

of ideal, low-risk patients with an intact facial socket wall at implant
placement, and a strict palatal position of implants in the present study.
Eight patients in the CIT cohort demonstrated missing buccal
bone in the crestal area after at least 8 years of follow-up. Unfortu-
nately, CBCTs were only seldom taken prior to implant placement at
the time, making it impossible to compare buccal bone over time. On
the other hand, all implants had been installed by an experienced
periodontist in a correct 3D position as described by Buser et al
(2004)25 ensuring complete embedding of all implants in alveolar
bone at the time of surgery. As a result, relevant buccal bone changes
must have taken place leading to at least partial loss of the buccal
bone wall over time. In this respect, Vera et al (2012) also described
relevant buccal bone changes following implant placement in healed
ridges, yet only short-term data were published.26 Our findings may
question CIT as the golden standard approach. As indicated by at
least two long-term studies, maintenance of the buccal bone wall is
possible when combining implant placement to guided bone regenera-
tion.9,27 Hence, clinicians should consider contour augmentation
procedures at the time of implant placement to compensate for
dimensional changes at the buccal aspect in the long term, even
when implants are fully embedded in bone upon insertion.
Another finding of the present study was that buccal soft tissues
were significantly thicker at implants when compared with contra-
lateral teeth, at least in the crestal area. This is in agreement with ear-
lier studies showing thickening of the buccal soft tissues following
tooth extraction in patients with a thin bone wall phenotype and also
28–30
following abutment connection.
The present study showed stable vertical soft tissue levels in both
cohorts after at least 8 years of follow-up. Interestingly, patients with
missing buccal bone did not demonstrate more midfacial recession
than those with intact buccal bone. There are two possible explana-
tions for this observation. First, bone resorption can be physiologic. In
that case, healthy connective tissue adheres to the implant surface
without pocket formation, which may help to support soft tissue levels
in the vertical dimension. Second, a type II statistical error may have
occurred (a true difference was overlooked) due to a limited sample
size.
The PES was another important outcome variable in this study.
With a mean PES of 10.36 at study termination, IIT resulted in a
slightly better aesthetic outcome than CIT (mean PES of 9.22).
Possibly selection bias may account for this disparity. After all, only
ideal low-risk patients received an immediate implant, whereas also
high-risk patients with a thin-scalloped gingival biotype and thin
bone wall phenotype were included in the CIT cohort. This should
be kept in mind when comparing the results of both cohorts under
investigation.
An important observation was that alveolar process deficiency sig-
nificantly deteriorated in both cohorts between 1 year and at least 8
years of follow-up. This finding may be considered a logical conse-
quence of ongoing buccal bone resorption in the long-term, even
though a significant association between missing buccal bone and alve-
olar process deficiency could not be sustained. There are two possible
explanations for this observation. First, alveolar process deficiency is
evaluated in a subjective way using a 0–1-2 scoring method. This
method may only allow for the identification of obvious deficiencies.
Second, the sample size may have been too limited to demonstrate the
difference as being statistically significant.
Another factor that could have an impact on the outcome, other
than the treatment protocol is the implant position. Of all the implants
that could be re-examined in the long term, 17 had been placed in the
incisor/cuspid area and 12 in the premolar area. There was no statisti-
cally significant difference in any of the outcome variables between the
areas. Interestingly, a statistically significant deterioration in alveolar
process deficiency was observed in the incisor/cuspid area (P 5 .008),
which could not be shown in the premolar area (P 5 .083). This finding
seems to indicate more pronounced buccal resorption in the anterior
segment; however, the sample sizes are clearly too small to draw
robust conclusions.
8 |
Finally, the OHIP-14 questionnaire as well as the ad hoc questions
on patient satisfaction indicated that patients were satisfied with the
long-term outcome on a number of domains. This is in accordance with
other studies on single implants.31,32
In conclusion, this prospective cohort study demonstrated a thin
buccal bone wall at all implant sites after at least 8 years of follow-up.
In the CIT cohort, 8 patients (47%) had missing buccal bone in the cres-
tal area, although bone was present at the time of surgery. These find-
ings are indicative of buccal bone resorption in the long-term, which
was clinically supported by a significant deterioration in alveolar pro-
cess deficiency. As a result, contour augmentation procedures at the
time of implant placement should be considered to counteract these
dimensional changes, even when implants are fully embedded in bone
upon insertion. With respect to soft tissues, vertical levels as well as
aesthetic ratings remained stable over time in both cohorts. Patients
were not that critical for the alterations that occurred at the buccal
aspect of their implant as they expressed high overall satisfaction.
AC KNOW LEDG MENT S
This study was supported by departmental funds and by Dentsply
€ lndal, Sweden. Prof. De Bruyn has on behalf of
Sirona Implants, Mo
the university a research and educational collaboration agreement
with Dentsply Sirona Implants. Prof. Cosyn has a collaboration
agreement with Nobel Biocare, Gothenburg, Sweden.
CONFLIC T OF I NTE R ES T
Vivianne Chappuis has no conflict of interest.
ORCI D
Stefanie Raes DDS, MSc, PhD Student http://orcid.org/0000-0003-
4838-3859
Vivianne Chappuis DDS, Dr. Med. Dent https://orcid.org/0000-
0003-1227-7587
RE FE RE NCE S
[1] Creugers NH, Kreulen CM, Snoek PA, de Kanter RJ. A systematic
review of single-tooth restorations supported by implants. J Dent.
2000;28(4):209–217.
[2] den Hartog L, Slater JJ, Vissink A, Meijer HJ, Raghoebar GM.
Treatment outcome of immediate, early and conventional single-
tooth implants in the aesthetic zone: a systematic review to
survival, bone level, soft-tissue, aesthetics and patient satisfaction.
J Clin Periodontol. 2008;35(12):1073–1086.
[3] Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M, Lang NP.
A systematic review of the 5-year survival and complication rates of
implant-supported single crowns. Clin Oral Implants Res. 2008;19(2):
119–130.
[4] Jung RE, Zembic A, Pjetursson BE, Zwahlen M, Thoma DS.
Systematic review of the survival rate and the incidence of biologi-
cal, technical, and aesthetic complications of single crowns on
implants reported in longitudinal studies with a mean follow-up of 5
years. Clin Oral Implants Res. 2012;23(Suppl 6):2–21.
RAES ET AL.
[5] Chen ST, Buser D. Esthetic outcomes following immediate and early
implant placement in the anterior maxilla–a systematic review. Int J
Oral Maxillofac Implants. 2014;29(Supplement):186–215.
[6] Benic GI, Mir-Mari J, Hammerle CH. Loading protocols for single-
implant crowns: a systematic review and meta-analysis. Int J Oral
Maxillofac Implants. 2014;29(Supplement):222–238.
[7] De Bruyn H, Raes S, Matthys C, Cosyn J. The current use of
patient-centered/reported outcomes in implant dentistry: a system-
atic review. Clin Oral Implants Res. 2015;26(Suppl 11):45–56.
[8] Slagter KW, den Hartog L, Bakker NA, Vissink A, Meijer HJ,
Raghoebar GM. Immediate placement of dental implants in the
esthetic zone: a systematic review and pooled analysis. J Periodontol.
2014;85(7):e241–e250.
[9] Buser D, Chappuis V, Kuchler U, et al. Long-term stability of early
implant placement with contour augmentation. J Dent Res. 2013;92
(12_suppl):176S–182S.
[10] Roccuzzo M, Gaudioso L, Bunino M, Dalmasso P. Long-term stabil-
ity of soft tissues following alveolar ridge preservation: 10-year
results of a prospective study around nonsubmerged implants. Int J
Periodont Restor Dent. 2014;34(6):795–804.
[11] Cooper LF, Reside GJ, Raes F, et al. Immediate provisionalization of
dental implants placed in healed alveolar ridges and extraction sock-
ets: a 5-year prospective evaluation. Int J Oral Maxillofac Implants.
2014;29(3):709–717.
[12] Cosyn J, Eghbali A, Hermans A, Vervaeke S, De Bruyn H, Cleymaet
R. A 5-year prospective study on single immediate implants in the
aesthetic zone. J Clin Periodontol. 2016;43(8):702–709.
[13] Benic GI, Mokti M, Chen C-J, Weber H-P, Hämmerle CHF, Gallucci
GO. Dimensions of buccal bone and mucosa at immediately placed
implants after 7 years: a clinical and cone beam computed tomogra-
phy study. Clin Oral Implants Res. 2012;23(5):560–566.
[14] Tonetti MS, Cortellini P, Graziani F, et al. Immediate versus delayed
implant placement after anterior single tooth extraction: the timing
randomized controlled clinical trial. J Clin Periodontol. 2017;44(2):
215–224.
[15] Raes F, Cosyn J, Crommelinck E, Coessens P, De Bruyn H.
Immediate and conventional single implant treatment in the anterior
maxilla: 1-year results of a case series on hard and soft tissue
response and aesthetics. J Clin Periodontol. 2011;38(4):385–394.
[16] Furhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek
G. Evaluation of soft tissue around single-tooth implant crowns:
the pink esthetic score. Clin Oral Implants Res. 2005;16(6):
639–644.
[17] McGrath C, Bedi R. Measuring the impact of oral health on
life quality in two national surveys - functionalist versus herme-
neutic approaches. Community Dent Oral Epidemiol. 2002;30(4):
254–259.
[18] Slade GD. Assessing change in quality of life using the Oral Health
Impact Profile. Community Dent Oral Epidemiol. 1998;26(1):52–61.
[19] Merheb J, Quirynen M, Teughels W. Critical buccal bone dimen-
sions along implants. Periodontol 2000. 2014;66(1):97–105.
[20] Teughels W, Merheb J, Quirynen M. Critical horizontal dimensions
of interproximal and buccal bone around implants for optimal aes-
thetic outcomes: a systematic review. Clin Oral Implants Res. 2009;
20(Suppl 4):134–145.
[21] El Nahass H, Naiem SN. Analysis of the dimensions of the labial
bone wall in the anterior maxilla: a cone-beam computed tomogra-
phy study. Clin Oral Implants Res. 2015;26(4):e57–e61.
[22] Januario AL, Duarte WR, Barriviera M, Mesti JC, Araujo MG, Lindhe
J. Dimension of the facial bone wall in the anterior maxilla: a cone-
RAES ET AL.
beam computed tomography study. Clin Oral Implants Res. 2011;22
(10):1168–1171.
[23] Nowzari H, Molayem S, Chiu CH, Rich SK. Cone beam computed
tomographic measurement of maxillary central incisors to determine
prevalence of facial alveolar bone width >/52 mm. Clin Implant
Dent Relat Res. 2012;14(4):595–602.
[24] Younes F, Eghbali A, Raes M, De Bruyckere T, Cosyn J, De Bruyn
H. Relationship between buccal bone and gingival thickness
revisited using non-invasive registration methods. Clin Oral Implants
Res. 2016;27(5):523–528.
[25] Buser D, Martin W, Belser UC. Optimizing esthetics for implant
restorations in the anterior maxilla: anatomic and surgical considera-
tions. Int J Oral Maxillofac Implants. 2004;19(Suppl):43–61.
[26] Vera C, De Kok IJ, Chen W, Reside G, Tyndall D, Cooper LF.
Evaluation of post-implant buccal bone resorption using cone beam
computed tomography: a clinical pilot study. Int J Oral Maxillofac
Implants. 2012;27:1249–1257.
[27] Buser D, Chappuis V, Bornstein MM, Wittneben JG, Frei M,
Belser UC. Long-term stability of contour augmentation with
early implant placement following single tooth extraction in the
esthetic zone: a prospective, cross-sectional study in 41 patients
with a 5- to 9-year follow-up. J Periodontol. 2013;84:1517–
1527.
[28] Chappuis V, Engel O, Shahim K, Reyes M, Katsaros C, Buser D. Soft
tissue alterations in esthetic postextraction sites: a 3-dimensional
analysis. J Dent Res. 2015;94(9_suppl):187S–193S.
| 9
[29] Henriksson K, Jemt T. Measurements of soft tissue volume in asso-
ciation with single-implant restorations: a 1-year comparative study
after abutment connection surgery. Clin Implant Dent Relat Res.
2004;6(4):181–189.
[30] Chappuis V, Araujo MG, Buser D. Clinical relevance of dimensional
bone and soft tissue alterations post-extraction in esthetic sites.
Periodontol 2000. 2017;73(1):73–83.
[31] Gjelvold B, Kisch J, Chrcanovic BR, Albrektsson T, Wennerberg A.
Clinical and radiographic outcome following immediate loading and
delayed loading of single-tooth implants: randomized clinical trial.
Clin Implant Dent Relat Res. 2017;19(3):549–558.
[32] Topcu AO, Yamalik N, Guncu GN, et al. Implant-site related and
patient-based factors with the potential to impact patients’ satisfac-
tion, quality of life measures and perceptions toward dental implant
treatment. Implant Dent. 2017;26:581–591.
How to cite this article: Raes S, Eghbali A, Chappuis V, Raes F,
De Bruyn H, Cosyn J. A long-term prospective cohort study on
immediately restored single tooth implants inserted in extrac-
tion sockets and healed ridges: CBCT analyses, soft tissue alter-
ations, aesthetic ratings, and patient-reported outcomes. Clin
Implant Dent Relat Res. 2018;00:1–9. https://doi.org/10.1111/
cid.12613