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Evaluation of Soft Tissue Around Single-Tooth Implant Crowns: The Pink Esthetic Score
Evaluation of Soft Tissue Around Single-Tooth Implant Crowns: The Pink Esthetic Score
Dionisie Florescu
Thomas Benesch
single-tooth implant crowns: the pink
Robert Haas esthetic score
Georg Mailath
Georg Watzek
Authors’ affiliations: Key words: esthetic score, peri-implant soft tissue, single-tooth implant
Rudolf Fürhauser, Dionisie Florescu, Department of
Prosthodontics, Dental School, Medical University
of Vienna, Vienna, Austria Abstract
Thomas Benesch, Department of Medical Statistics, Aim: In this study, the reproducibility of a newly developed pink esthetic score (PES) for
Medical University of Vienna, Vienna, Austria
Robert Haas, Georg Mailath, Georg Watzek, evaluating soft tissue around single-tooth implant crowns was assessed. The effect of
Department of Oral Surgery, Dental School, observer specialization was another point of interest.
Medical University of Vienna, Vienna, Austria
Material and methods: Twenty observers (five prosthodontists, five oral surgeons, five
Correspondence to: orthodontists and five dental students) were given photographs of 30 single-tooth implant
Rudolf Fürhauser crowns. Seven variables were evaluated vs. a natural reference tooth: mesial papilla, distal
Cottagestrasse 9
A-1140 Vienna papilla, soft-tissue level, soft-tissue contour, alveolar process deficiency, soft-tissue color and
Austria texture. Using a 0-1-2 scoring system, 0 being the lowest, 2 being the highest value, the
Tel.: þ 43 676 705 64 06
e-mail: rudolf@fuerhauser.at
maximum achievable PES was 14. Each observer was requested to make two assessments at
an interval of 4 weeks. At the second assessment, the photographs were scored in the
reverse order.
Results: The mean PES of evaluations at the first assessment (n ¼ 600) was 9.46 ( 3.81 SD),
and 9.24 ( 3.8 SD) at the second one. The difference between these two means was not
significant statistically (P ¼ 0.6379). Implant-related mean PES for single-tooth implants
varied from 2.28 to 13.8, with standard deviations between 0.46 and 3.51. Very poor and
very esthetic restorations showed the smallest standard deviations. The mean total PES was
10.6 for the prosthodontists, 9.2 for the oral surgeons, 9.9 for the dental students and 7.6
for the orthodontists.
Conclusions: The PES reproducibly evaluates peri-implant soft tissue around single-tooth
implants. Thus, an objective outcome of different surgical or prosthodontic protocols can
be assessed. Orthodontists were clearly more critical than the other observers.
Single-tooth implants have become a stan- tion (de Lange 1995; Phillips & Kois 1998).
dard in dentistry and are considered state of Ideally, successful implant-supported re-
the art (Tarnow & Eskow 1995) and stan- storations should imitate the appearance
Date: dard care (Newman 1999). As implant of natural teeth (Belser et al. 2004). The
Accepted 4 April 2005 survival and success rates are high (Avivi- condition of the peri-implant soft tissue
To cite this article: Arber & Zarb 1996; Scheller et al. 1998; appears to be the critical determinant (Gar-
Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G,
Watzek G. Evaluation of soft tissue around single-tooth Haas et al. 2002), the esthetic outcome has ber 1996). The implant-supported restora-
implant crowns: the pink esthetic score. become the main focus of interest in esthe- tion should be in symmetry with the
Clin. Oral Impl. Res. 16, 2005; 639–644
doi: 10.1111/j.1600-0501.2005.01193.x tically sensitive areas. To achieve an opti- reference tooth. The level of the peri-im-
mal esthetic outcome, implants must be plant soft tissue, which influences the
Copyright r Blackwell Munksgaard 2005 placed in an optimal position and inclina- crown length, and its color and texture
639
Fürhauser et al . Esthetic score
are decisive for the ‘natural’ appearance of (Nobel Biocare AB, Gothenborg, Sweden),
s
implant-supported single-tooth replace- with nine CeraOne -titanium and 18 Cer-
s
ments (Chang et al. 1999). Adapt -aluminaoxide abutments, two
s
Albrektsson’s criteria of success (Al- were Replace implants (Nobel Biocare
s
brektsson et al. 1986) were extended by AB), with CerAdapt abutments, and one
s
Smith and Zarb: ‘To be considered a suc- was a Semados implant (Bego Goldschlä-
cess, an implant must allow placement of a gerei, Bremen, Germany), with a gold alloy
restoration with adequately esthetic appear- abutment. At the time of the study, the
ance’ (Smith & Zarb 1989). But objective implants had been in place for 15–143
criteria defining what is ‘adequately es- months. Fig. 1. Pictorial view of pink esthetic score vari-
thetic’ have so far not been available. The Each single-tooth implant was photo- ables.
range of subjective impressions of the be- graphed with a digital camera (D100, Nik-
holder is well known and depends on the kor Medical Objective circular flash; Statistical analysis
specialization (Kokich et al. 1999; Rosen- Nikon Corporation, Tokyo, Japan). For Differences between the two assessments
stiel et al. 2000). While criteria for assessing assessing anterior tooth replacements, the were evaluated with the w2 test. Simple
bone quality (Lekholm & Zarb 1985; Nor- reference tooth had to be visible well en- analysis of variance with the Tukey test
ton & Gamble 2001), bone loss (Fallschüs- ough to ensure comparability. The im- was used for assessing observer specializa-
sel 1986; Cawood & Howell 1991), plant-supported restorations in the region tion. Po0.05 was considered to be signifi-
perception of bone drilling procedures of the right first premolars were photo- cant. All statistical analyses were run on
(Misch 1993; Enquist et al. 1998) and a graphed to ensure comparison with the the Statistics Package SAS (SAS System for
papilla score (Jemt 1997) are used in im- second premolar. The photographs were Windows, Cary, NC, USA).
plant dentistry, an overall score for evaluat- magnified to twice the original size and
ing peri-implant soft tissues has so far not printed out on DIN A4 sheets together
been available. In the Consensus State- with the list of variables. Implant-sup- Results
ments and Recommended Clinical Pro- ported crowns were marked by arrows.
cedures Regarding Esthetics in Implant All photographs were developed and pro- In each of the two assessments, 20 obser-
Dentistry (Belser et al. 2004), measurement cessed by the same person. The question- vers rated 30 cases, i.e. a total of 600 PESs/
of esthetic outcomes is ‘proposed for use in naire was handed to 20 individuals of assessments. All in all, 1200 PESs with
clinical studies’. A selective assessment of variable specialization (five prosthodon- 8400 single variables were available for
peri-implant soft tissues with an objective tists, five oral surgeons, five orthodontists analysis. The mean PES was 9.46
score would help to evaluate implant-sup- and five dental students), in order to assess ( 3.81 SD) in the first assessment and
ported restorations and to objectify the soft- the potential effects of observer specializa- 9.24 ( 3.8 SD) in the second assessment.
tissue esthetic outcome of different surgical tion on PES scoring. Assessments were The difference was not significant statisti-
or prosthodontic treatment protocols. made twice at an interval of 4 weeks. To cally (P ¼ 0.6479). An analysis of the 1200
In the current study, the peri-implant reduce any bias from the first viewing, the PESs showed that the highest achievable
soft tissue of 30 maxillary single-tooth order of the photographs was reversed for score of 14 was assigned 94 times in the
replacements was evaluated by 20 dentists the second viewing. first assessment (15.67%) vs. 70 times in
using a new defined pink esthetic score the second assessment (11.67%) (Table 2).
(PES). The reproducibility of the score and A score of 13 was assigned 66 times in the
a potential effect of observer specialization Assessment criteria – PES first assessment (11%) vs. 74 times in the
on evaluating the esthetic outcome were The PES is based on seven variables: mesial second assessment (12.33%). The lowest
the points of interest. papilla, distal papilla, soft-tissue level, soft- score of 0 was assigned eight times in the
tissue contour, alveolar process deficiency, first assessment (1.33%) vs. 10 times in
soft-tissue color and texture (Fig. 1). Each the second one (1.67%). A score of 1 was
Material and methods variable was assessed with a 2-1-0 score, assigned 13 and 17 times, respectively
with 2 being the best and 0 being the (2.17% vs. 2.83%).
Photographs of 30 single-tooth implants in poorest score.
the esthetically sensitive area of the max- The mesial and distal papilla were eval- Single-variable analysis
illa (including the first premolars) were uated for completeness, incompleteness or The highest possible score of 2 was as-
evaluated. Of these, 10 replaced the right absence. All other variables were assessed signed to the mesial papilla in 62% of cases
and five the left central incisor, five the by comparison with a reference tooth, i.e. and 58.8% in the second assessment, to
right and six the left lateral incisor and four the corresponding tooth (anterior region) the distal papilla in 56% and 51.67%,
the right first premolar. For the sake of or a neighboring tooth (premolar region) respectively (Table 3). The alveolar process
statistical correctness, both poor and esthe- (Table 1). was rated as well restored in 54% (49.17%)
tically satisfactory restorations were in- The highest possible score reflecting a of cases. The soft-tissue texture was rated
cluded in the assessment. Twenty-seven perfect match of the peri-implant soft tis- as indistinguishable from the reference
s
of the implants were Brånemark fixtures sue with that of the reference tooth was 14. tooth, and was assigned a score of 2 in
53.1% (49.17%) of cases. Comparable score of 0 was most often assigned to the (0.38) for the mesial papilla followed by the
percentages for the other variables were peri-implant soft-tissue level (19.8% and distal papilla (0.45), the soft-tissue contour
48% (47.6%) for soft-tissue contour, 21.8% of cases) and soft-tissue color (0.51), the soft-tissue level (0.51), bone loss
45.3% (37.1%) for soft-tissue color and (21.8% and 18.8% of cases) as shown in (0.54), soft-tissue color (0.55) and soft-tis-
42.3% (44.5%) for soft-tissue level. A Table 4. The standard deviation was lowest sue texture (0.57).
reference tooth in no more than 44% of the outcome of implant-supported tooth repla- standards. Le PES total moyen était de 10,6 pour
les spécialistes en prothèse, 9,2 pour les chirurgiens,
implant-supported replacements. In 20% cements. Prosthodontists, surgeons and
9,9 pour les étudiants et 7,6 pour les orthodontistes.
of cases, the difference vs. the reference dental students, who all scored the out- Le PES évalue donc les tissus mous paraı̈mplantaires
tooth was more than 2 mm. This factor is come significantly more generously, autour des implants uniques. Un aboutissement
of special interest, as both pre- and post- should make sure to heed this point. Cri- objectif de différents protocoles chirurgicaux ou
treatment soft-tissue height and recession tical assessment of peri-implant soft tissues prothétiques peut donc être estimé. Les orthodon-
tistes étaient clairement plus critiques que les autres
need consideration. Scheller et al. (1998) with an objective score would help to
observateurs.
reported stable soft tissues in 75% of the evaluate the esthetics of implant-supported
implant-supported single-tooth replace- single tooth restorations and optimal surgi-
ments that they evaluated, and recessions cal and prosthodontic treatment strategies.
in 10%. Thus, the PES may change over Zusammenfassung
time and can be a useful tool for monitor-
ing long-term soft-tissue alterations. The Conclusions Ziel: In dieser Arbeit wird die Reproduzierbarkeit
eines neu entwickelten Pink Esthetic Index (PES)
color of the peri-implant soft tissue zur Evaluation vom Weichgewebe um Kronen auf
matched that of the reference tooth in no The PES is a tool for reproducibly evaluat-
Einzelzahnimplantaten untersucht. Zusätzlich in-
more than just over one-third of cases, and ing the esthetic appearance of the soft teressierte der Einfluss des Spezialisierungsgrades
showed major discrepancies in 20%. The tissue around single-tooth implant crowns. eines Untersuchers.
level of the soft-tissue margin and the color Very good and very poor outcomes were Material und Methoden: Man gab zwanzig Unter-
associated with low standard deviations, suchern (5 Prothetiker, 5 Oralchirurgen, 5 Orthodon-
of the peri-implant soft tissue fared worst ten und 5 Zahnmedizinstudenten) Fotoaufnahmen
in the assessments. Consequently, tooth- suggesting better reproducibility. Restoring
von 30 Kronen auf Einzelzahnimplantaten. Sie hat-
colored ceramic abutments would appear to the papilla, which ranks prominently in ten 7 Variabeln gegenüber einem natürlichen Refer-
play an important role. But as the higher the literature, fared best in the assess- enzzahn zu beurteilen: mesiale Papille, distale
standard deviations (0.55 and 0.57) suggest, ments, while the level of the soft-tissue Papille, Niveau der Weichgewebe, Form der Weich-
margin and the color of the peri-implant gewebe, Defizit an Alveolarkamm, Farbe und
reproducible assessments of color and tex- Struktur der Weichgewebe. Man definierte eine Be-
ture are problematic. soft-tissue fared worst. The latter two vari-
wertungsskala 0-1-2, wobei 0 für den schlechtesten
Esthetically very good and very poor ables should, therefore, be given more at- und 2 für den besten Wert stehen, so dass man einen
outcomes presented fewer assessment pro- tention. Unbiased by an awareness of the maximalen PES von 14 erreichen konnte. Jeder
blems than intermediate outcomes. This problems encountered in achieving ‘nat- Untersucher war angehalten, im Abstand von 4
ural-looking’ implant-supported restora- Wochen zwei Beurteilungen durchzuführen. Anläs-
was reflected by the low standard devia- slich des zweiten Untersuchungstermins wurden die
tions for high and low PESs (Figs 2b and 3), tions, orthodontists were the most critical
Fotoaufnahmen in ungekehrter Reihenfolge beurteilt.
and the high standard deviations for PESs observers. Resultate: Der mittlere PES bei den Untersuchun-
in the intermediate range. The example in gen im ersten Umgang (n ¼ 600) betrug 9.46
( 3.81 SD) und 9.24 ( 3.8 SD) im zweiten
Fig. 4 with the highest standard deviation
Résumé Umgang. Der Unterschied zwischen diesen zwei
illustrates the problems inherent in the Mittelwerten war statistisch nicht signifikant
score and in an unbiased assessment: Dans cette étude la reproduction d’un nouveau (P ¼ 0.6379). Der mittlere implantatspezifische
asymmetry at baseline with aplasia of Score d’Esthétique Rose (PES) pour l’évaluation PES für die Einzelzahnimplantate variierte zwischen
tooth 12, diasthemas and midline shift. In des tissus mous autour des couronnes d’implants 2.28 und 13.8 mit Standardabweichungen zwischen
uniques a été évaluée. L’effet de la spécialisation de 0.46 und 3.51. Sehr schlechte und sehr schöne
the presence of diasthemas, an evaluation
l’observateur était un autre point d’intérêt. Vingt Rekonstruktionen zeigten die kleinesten Standar-
of the completeness and shape of the pa- dabweichungen. Der mittlere Gesamt-PES war bei
observateurs (cinq spécialistes en prothèse, cinq
pilla is fraught with problems. Ideally, a chirurgiens, cinq orthodontistes et cinq étudiants den Prothetikern 10.6, bei den Oralchirurgen 9.2,
score should help to address critical pro- en médecine dentaire) ont reçu des photographies bei den Zahnmedizinstudenten 9.9 und bei den
blems that are easily overlooked in a gen- de 30 couronnes sur implant unique. Sept variables Orthodonten 7.6.
ont été évaluées vs une dent de référence naturelle : Zusammenfassung: Der Pink Esthetic Index
eral assessment. These include recessions,
papille mésiale, papille distale, niveau du tissu mou, untersucht die periimplantären Weichgewebe um
and the color and texture of the peri-im- Einzelzahnimplantate und wird auf seine Re-
couleur du tissu mou, perte du processus alvéolaire,
plant soft tissue. couleur du tissu mou et texture. En utilisant un produzierbarkeit überprüft. Damit kann man die
The comparison of specialty groups re- système 0–1–2, zéro étant le plus bas et deux étant la Ergebnisse von verschiedenen chirurgischen und
vealed what effect specialization has. plus haute valeur, le score maximum PES était donc prothetischen Protokollen objektivieren. Die Ortho-
de 14. Chaque observateur a reçu comme instruc- donten waren deutlich kritischer bei ihrer Beurtei-
Orthodontists, who are at best marginally
tion de réaliser deux évaluations à un intervalle de lung als die anderen Behandler.
involved in implant-supported restorations,
quatre semaines. A la seconde évaluation les photo-
were clearly more critical in their judg- graphies ont été évaluées dans un ordre inverse. Les
ments. Unaware of the problems en- PES moyens des évaluations de la première fois
countered in achieving an esthetically (n ¼ 600) étaient de 9,46 3,81 et 9,24 3,80 la Resumen
satisfactory appearance of the peri-implant seconde fois. La différence entre ces deux moyennes
n’était pas significative (P ¼ 0,6379). Le PS moyen Intencion: En este estudio se valoró la reproductibi-
tissue, they approach its assessment with-
en relation pour les implants sur dent unique variait lidad de una nueva Valor de Rosado Estético (PES)
out bias. As they are trained to focus on de 2,28 à 13,8 avec des déviations standards de 0,46 para evaluar el tejido blando alrededor de coronas de
‘natural’ esthetics, orthodontists could à 3,51. Les restaurations de moindre qualité et les implantes unitarios. El efecto de la especialización
thus serve as critical arbiters of the esthetic excellentes affichaient les plus petites déviations del observador fue otro punto de interés.
Material y metodos: Se entregó a veinte observa- total fue de 10.6 para los prostodoncistas, 9.2 para
dores (5 prostodoncistas, 5 cirujanos orales, 5 orto- los cirujanos orales, 9.9 para los estudiantes dentales
doncistas y 5 estudiantes dentales) fotografı́as de 30 y 7.6 para los ortodoncistas.
coronas de implantes unitarios. Se evaluaron 7 vari- Conclusiones: Las Puntuaciones de Estética Rosa
ables frente a dientes naturales de referencia: papila evalúa reproduciblemente el tejido blando periim-
mesial, papila distal, nivel de tejido blando, contorno plantario alrededor de implantes unitarios. De este
de tejido blando, deficiencia del proceso alveolar, modo, se puede valorar un resultado objetivo de
color y textura del tejido blando. Usando un sistema diferentes protocolos quirúrgicos o prostodónticos.
de puntuación de 0-1-2, siendo 0 el valor más bajo, 2 Los ortodoncistas fueron claramente más crı́ticos
el valor más alto, el PES más alto alcanzable era de que los otros observadores.
14. Se solicitó a cada observador que llevara a cabo
dos valoraciones en un intervalo de 4 semanas. En la
segunda valoración las fotografı́as se valoraron en
orden inverso.
Resultados: El PES medio de evaluaciones a la
primera valoración (n ¼ 600) fue 9.46 ( 3.81 SD)
y 9.24 ( 3.8 SD) en la segunda. La diferencia entre
estas dos medias no fue estadı́sticamente significa-
tivo (P ¼ 0.6379). El PES medio relacionado al im-
plante para implantes unitarios varió desde 2.28 a
13.8 con desviaciones estándar entre 0.46 y 3.51.
Las restauraciones más pobres y más estéticas mos-
traron las desviaciones estándar más bajas. El PES
References
Albrektsson, T., Zarb, G.A., Worthington, P. & Fallschüssel, G.K.H. (1986) Untersuchungen zur computerized tomography scan. Clinical Oral
Eriksson, A.R. (1986) The long-term efficacy of Anatomie des zahnlosen Oberkiefers. Fortschritte Implants Research 12: 79–84.
currently used dental implants: a review and der Zahnärztliche Implantologie 2: 64–72. Phillips, K. & Kois, J.C. (1998) Aesthetic peri-
proposed criteria of success. Journal of Oral & Garber, DA. (1996) The esthetic dental implant: implant site development. The restorative con-
Maxillofacial Implants 1: 11–25. letting restoration be the guide. Journal of Oral nection. Dental Clinics in North America 42:
Avivi-Arber, L. & Zarb, G.A. (1996) Clinical effec- Implantology 22: 45–50. 57–70.
tiveness of implant-supported single-tooth repla- Haas, R., Pollak, Ch., Fürhauser, R., Mailath-Po- Rosenstiel, S.F., Ward, D.H. & Rashid, R.G. (2000)
cement: the toronto study. International Journal korny, G., Dörtbudak, O. & Watzek, G. (2002) A Dentists’ preferences of anterior tooth proportion
of Oral & Maxillofacial Implants 11: 311–321. long term follow up of 76 Branemark single tooth – a Web-based study. Journal of Prosthodontics 9:
Belser, U., Buser, D. & Higginbottom, F. (2004) implants. Clinical Oral Implants Research 13: 123–136.
Consensus statements and recommended clinical 38–43. Scheller, H., Urgell, J.P., Kultje, C., Klineberg, I.,
procedures regarding esthetics in implant dentis- Jemt, T. (1997) Regeneration of gingival papillae Goldberg, P.V., Stevenson-Moore, P., Alonso,
try. International Journal of Oral & Maxillofacial after single-implant treatment. International Jour- J.M., Schaller, M., Corria, R.M., Engquist, B.,
Implants 19 (Suppl): 73–74. nal of Periodontics and Restorative Dentistry 17: Toreskog, S., Kastenbaum, F. & Smith, C.R.
Cawood, J.I. & Howell, R.A. (1991) Reconstructive 327–333. (1998) A 5-year multicenter study on implant-
preprosthetic surgery. I. Anatomical considera- Kokich, V.O. Jr, Kiyak, H.A. & Shapiro, P.A. (1999) supported single crown restorations. International
tions. International Journal of Oral and Maxillo- Comparing the perception of dentists and lay Journal of Oral & Maxillofacial Implants 2:
facial Surgery 2: 75–82. people to altered dental esthetics. Journal of Es- 212–218.
Chang, M., Wennstrom, J.L., Odman, P.A. & An- thetic Dentistry 11: 311–324. Smith, D.E. & Zarb, G.A. (1989) Criteria for suc-
dersson, B. (1999) Implant supported single-tooth Lekholm, U. & Zarb, G.A. (1985) Patient selection cess of osseointegrated endosseous implants. Jour-
replacements compared to contralateral natural and preparation. In: Branemark, P.I., Zarb, G.A. & nal of Prosthetic Dentistry 62: 567–572.
teeth. Clinical Oral Implants Research 10: Albrektsson, T., eds. Osseointegration in Clinical Tarnow, D.P. & Eskow, R.N. (1995) Considerations
185–194. Dentistry, 199–209 pp. Chicago: Quintessence. for single-unit esthetic implant restorations.
De Lange, G.L. (1995) Aesthetic and prosthetic Misch, C.E. (1993) Density of bone: effect on treat- Compendium of Continuing Education in Den-
principles for single tooth implant procedures: an ment planning, surgical approach, and healing. In: tistry 16: 778.
overview. Practical Periodontics and Aesthetic Misch, CE, ed. Contemporary Implant Dentistry, Trisi, P. & Rao, W. (1999) Bone classification:
Dentistry 7: 51–61. 469–485. St Louis: Mosby-Year Book, Inc. clinical-histomorphometric comparison. Clinical
Enquist, B., Bergendal, T., Kallis, T. & Linden U. Newman, M.G. (1999) The single-tooth implant as Oral Implants Research 10: 1–7.
(1998) A retrospective multicenter evaluation of a standard of care (editorial). International Journal
osseointegrated implant supporting overdentures. of Oral & Maxillofacial Implants 14: 621–622.
International Journal of Oral & Maxillofacial Norton, M.R. & Gamble, C. (2001) Bone classifica-
Implants 3: 129–134. tion: an objective scale of bone density using the