Long-Term Esthetic Outcome of Tissue-Level and

Bone-Level Implants in the Anterior Maxilla

Carola Siebert1/Dominik Rieder, Dr Med Dent2/Jochen Eggert, Dr Med, Dr Med Dent3/
Manfred Gerhard Wichmann, Prof Dr Med Dent4/Siegfried Martin Heckmann, Prof Dr Med Dent, Dr Phil5

Purpose: The aim of this study was to assess and compare the esthetic outcome of tissue-level (TL) and bone-
level (BL) implants that had been placed as single implants in the anterior maxilla. Materials and Methods:
Between 2001 and 2008, patients were treated using TL implants (Straumann). From 2008 until 2012,
patients received the newly developed BL implant (Straumann). All patients with a single anterior maxillary
implant who came to check-ups regularly were contacted and invited to take part in the study. Standardized
photographs were taken to conduct the evaluation. Five observers analyzed the esthetic outcome using the
pink esthetic score (PES). For the purpose of statistical analysis, the Wilcoxon rank sum test was applied.
Interobserver reliability was evaluated with Krippendorff’s alpha. Results: Forty-six patients agreed to take
part in the study. The study comprised 10 immediate (TL = 6, BL = 4), 21 early (TL = 6, BL = 15), and 15
delayed implantations (TL = 11, BL = 4). All implant sites were simultaneously augmented. The prosthetic
restorations were delivered 6 to 24 weeks after implant placement in the TL group and 10 to 14 weeks after
implant placement in the BL group. Esthetic evaluation was performed after a mean period of 9.5 years for
TL implants (range: 5.5 to 12.0) and 3.7 years for BL implants (range: 2.6 to 7.1). The overall PES was 8.49
(SD: 2.35) for TL implants and 9.29 (SD: 1.90) for BL implants (P = .37). Comparison of single parameters was
between P = .24 and P = .83, indicating no statistically significant difference between the two implant types.
Conclusion: Within the limits of this study, it can be stated that both implant designs showed comparably
satisfying esthetic results. Int J Oral Maxillofac Implants 2018;33:905–912. doi: 10.11607/jomi.6419

Keywords: bone-level implant, esthetic zone, long-term esthetic outcome, pink esthetic score, single implant,
tissue-level implant

Implant restoration of single missing teeth is wide-

ly practiced, and excellent osseointegration and
long-term stability have been well documented.1,2
Ongoing research, development, and optimization,
such as improved surface properties,3,4 have led to
1Research Fellow, School of Dental Medicine, Department
of Prosthodontics, Friedrich-Alexander-University Erlangen-
Nürnberg (FAU), Erlangen, Germany.
2Private Practice, Erlangen, Germany.
3 Private Practice, Weiden, Germany.
4Professor and Chair, School of Dental Medicine, Department
of Prosthodontics, Friedrich-Alexander-University Erlangen-
Nürnberg (FAU), Erlangen, Germany.
5Professor, School of Dental Medicine, Department of
Prosthodontics, Friedrich-Alexander-University Erlangen-
Nürnberg (FAU), Erlangen, Germany.
Correspondence to: Prof Dr Dr S.M. Heckmann, School of
Dental Medicine, Department of Prosthodontics, Saarland
University, Kirrberger Straße 100, 66421 Homburg/Saar,
Germany. Fax: +49-6841-16 24952.
Email: siegfried.heckmann@uks.eu
©2018 by Quintessence Publishing Co Inc.
predictable treatment results and remarkable survival
rates of dental implants.5,6 The classical parameters
of implant success are immobility of the implant as
well as absence of periapical radiolucency, persistent
symptoms of pain, infection, and necropathies.7,8
In the anterior zone, however, mere implant survival
and the aforementioned success criteria do not imply
a satisfactory treatment outcome for the patient who
desires a pleasing appearance.5,9 The introduction of
the pink esthetic score (PES) has provided a tool to
assess the esthetic implant outcome in a comparable
way.10,11
Over time, two design variations were established
for the connection of the prosthetic abutment to the
implant body (Fig 1). In tissue-level (TL) implants, the
transition from the rough to the smooth portion is lev-
el with the bone, and this design type is characterized
by non-submerged healing. Consequently, a re-entry
is not necessary for the restoration, which means re-
duced trauma and scars at the implant site.
Bone-level (BL) implants, on the other hand, are
completely covered by a rough surface and are in-
serted level with the bone, which allows submerged

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Siebert et al
Microgap
TL implant for prosthetic BL implant for
restoration with microgap prosthetic restoration
at tissue level with microgap at bone level
Fig 1   Schematic illustration of tissue-level (TL) and bone-level
(BL) implants. In TL implants, the polished neck portion is above
the bone crest. In BL implants, the complete body is inserted
in alveolar bone.
healing. This may have the advantage of reduced bac-
terial colonization in the early phase.12,13
For TL implants, conventional titanium abutments
are available, and the microgap between the implant
and abutment is not directly located at bone level, but
a few millimeters coronally. BL implants allow the pos-
sibility of creating a natural emergence profile with
individually designed abutments. With the microgap
close to the bone crest, a certain amount of bone loss
may be expected. This results in a direct relationship
between implant configuration and peri-implant soft
tissue outcome.14 Different concepts to limit bone re-
modeling around BL implants have been developed,
and with platform switching, the crestal resorption
can be significantly reduced,15,16 and good esthetic
results in the anterior zone have been reported.11
Consequently, BL implants with a platform-switching
concept have been preferred in the esthetic zone.17
Numerous studies have investigated the esthetic out-
come of single implants in the anterior zone.18–22 In
the majority of publications, however, the measure-
ment of radiographic bone loss has been the primary
objective.23,24 Very few studies directly compare TL
and BL implants in the esthetic zone, and most of
them also emphasize radiographic bone loss rather
than esthetic appearance.17,25,26
The objective of this retrospective study was to
compare the esthetic outcome of TL and BL implants
for single-tooth restorations in the anterior maxilla and
to evaluate the clinical acceptance. It was assumed
that the implant type would have no statistically sig-
nificant influence.
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MATERIALS AND METHODS
Patients
To replace a central or lateral maxillary incisor, patients
received Straumann TL implants between 2001 and
2008. In 2008, the Straumann BL implant was launched,
and from 2008 until 2012, patients were consequently
treated with the new BL implant in the esthetic zone.
All patients with a single anterior maxillary implant
who were treated within these timeframes and came to
check-ups regularly were contacted and invited to take
part in the study. For the sake of comparison, the re-
spective contralateral incisor also had to be present in
a closed dental arch. Fillings or prosthetic restorations
of this tooth were tolerated. Only smokers, patients
with uncontrolled diabetes mellitus, or high-dose glu-
cocorticoid treatment were excluded from the study,
as these factors are known to have a disadvantageous
influence on implant treatment.
Data Collection
In order to conduct a consistent esthetic evaluation,
standardized clinical photographs27 were taken with a
digital camera (Nikon D90, Nikon). For each patient, a
set was arranged including images from three different
angles: one picture taken en face, a second focused on
the implant site, and a third centered on the contra-
lateral tooth. The soft tissue around the implant and
contralateral tooth had to be fully assessable. With the
aim of standardized evaluation in mind, each picture
set was equally arranged and printed on glossy photo
paper (240 gsm).
Esthetic Assessment
The PES was applied to evaluate the peri-implant soft
tissue situation (Fig 2). Hereby, seven variables are
specified: (1) mesial papilla, (2) distal papilla, (3) soft
tissue level, (4) soft tissue contour, (5) alveolar process,
(6) color, and (7) texture of the peri-implant mucosa.
Each parameter is rated with a 0-1-2 score, in which
0 represents the poorest and 2 the best score. Hence,
the highest total score is 14, meaning a particularly
close match of the soft tissue condition around the
implant and tooth.10 In this study, the threshold for
clinical acceptance was set at 8 for the overall PES.21,28
A maxillofacial surgeon, a prosthodontist, a general
dentist, a postgraduate dental student, and a dental
technician evaluated the cases as blinded examiners
who had not been involved in any treatment of the
patients. All evaluators scored the cases once. Prior to
the procedure, the first author of the study provided
the evaluators with a detailed explanation. All relevant
information for the evaluation process was provided as
handouts, and the ratings were taken down by the first
author of the study.

Statistical Analysis
For statistical analysis, the software R (1993, Ross
Ihaka, Robert Gentleman, R Development Core
Team) was used. Krippendorff’s alpha coefficient
was calculated to assess interreviewer reliability of
the esthetic ratings.29
For both the TL and BL groups, PES values were av-
eraged over all five observers, and mean scores and
standard deviations (SDs) were calculated to depict
the esthetic treatment outcome. Furthermore, mean
scores and SDs for every single variable of the PES
were computed for each group. The Wilcoxon rank
sum test was used to compare the overall PES scores
and each parameter in the two groups. For further
comparison within the BL group (submerged and
non-submerged healing), the two-sample t test was
applied.
RESULTS
Forty-six patients with an implant-borne single-tooth
restoration in the esthetic area fulfilled the guidelines
and were examined at the subsequent follow-up (12
men, 34 women; mean age: 49.3 years, range: 21 to 80
years). Twenty-three of them had received a TL implant
(TL group: 3 men, 20 women; mean age: 51.5 years,
range: 26 to 77 years). The BL group also consisted of
23 patients (9 men, 14 women; mean age: 47.1 years,
range: 21 to 80 years). Patient satisfaction was consis-
tently high.
Examinations and data collection were carried out
5 to 12 years after implantation for TL implants (mean:
9.5 years) and 2 to 7 years after implantation for BL im-
plants (mean: 3.7 years), respectively.
Surgical and Prosthetic Treatment
Tissue-level implants with a sand-blasted, large-grit,
acid-etched (SLA) surface and a 1.8-mm polished neck
had been inserted between 2001 and 2008. From 2008
to 2012, BL implants with a SLActive surface covering
the whole implant were used (Straumann; Fig 1). All
implants were placed by the same maxillofacial sur-
geon (J.E.). A mucoperiosteal flap was prepared, and
implants were inserted with great attention to the cor-
rect three-dimensional (3D) position.30
In all cases where labial bone had been resorbed
or marginal defects had occurred, bone augmenta-
tion was performed during surgery using autogenous
bone combined with bovine bone substitute mate-
rial (Bio-Oss, Geistlich Biomaterials). A membrane was
placed (Bio-Gide, Geistlich Biomaterials), and the surgi-
cal site was closed with single interrupted sutures. The
patients were asked to rinse with 0.1% chlorhexidine
solution twice a day and to take analgesics (Ibuprofen
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Siebert et al
6
5 7
4
3
2
1
Fig 2  Clinical photograph from the study showing the seven
pink esthetic score (PES) parameters: mesial papilla (1), distal
papilla (2), soft tissue level (3), soft tissue contour (4), alveolar
process (5), color (6), and texture of the peri-implant mucosa
(7).
Table 1   Distribution of Implantation Protocols
Immediate Early Delayed
TL 6 6 11
BL 4 15 4
400 mg) if required. Sutures were removed 7 to 10 days
after surgery.
The distribution of implantation protocols used is
depicted in Table 1. Early implantation describes place-
ment 4 to 8 weeks after extraction; an implantation
more than 8 weeks after tooth extraction is termed
conventional, standard, or delayed implant place-
ment.5 The delayed group comprised three patients
with agenesis of the lateral incisor. Lengths and diam-
eters of the implants used are provided in Tables 2 and
3. Implant insertion torque was 45 Ncm in all cases.
In the TL group with non-submerged healing, 18
patients received a removable partial denture as a pro-
visional restoration; four patients were provided with
an adhesive bridge; and for one patient, a splint was
fabricated.
In the BL group, 15 cases immediately received a
healing abutment for non-submerged healing. For the
remaining eight cases, submerged healing was cho-
sen. Thirteen patients had already been provided with
a removable prosthesis. Four patients received an ad-
hesive bridge; two patients received a splint with an af-
fixed incisor; and for four patients, a provisional crown
was placed immediately after implantation.
The dentists in charge of the restorative treatment
were advised to prevent any static or dynamic occlusal
forces during the provisional restoration phase. Per-
manent restorations were delivered 6 to 24 weeks after
implantation to the TL group, and 10 to 14 weeks after
implantation to the BL group.
The International Journal of Oral & Maxillofacial Implants 907
Siebert et al

Table 2   Specification and Allocation of Table 3   Specification and Allocation of
Tissue-Level Implants Bone-Level Implants
Central Lateral Central Lateral
incisor incisor Total incisor incisor Total
Straumann Standard Plus – 1 1 Straumann RC Bone Level – 1 1
3.3 × 12 mm 3.3 × 10 mm
Straumann Standard Plus – 1 1 Straumann RC Bone Level – 6 6
3.3 × 14 mm 3.3 × 12 mm
Straumann Esthetic Plus 2 1 3 Straumann RC Bone Level 1 – 1
4.1 × 10 mm 4.1 × 10 mm
Straumann Esthetic Plus 4 2 6 Straumann RC Bone Level 11 1 12
4.1 × 12 mm 4.1 × 12 mm
Straumann Standard Plus 3 – 3 Straumann RC Bone Level – 1 1
4.1 × 10 mm 4.1 × 14 mm
Straumann Standard Plus 4 – 4 Straumann RC Bone Level – 1 1
4.1 × 12 mm 4.8 × 12 mm
Straumann Tapered Effect 1 – 1 Straumann RC Bone Level 1 – 1
4.1 × 10 mm 4.8 × 14 mm
Straumann Tapered Effect 1 2 3 Total 13 10 23
4.1 × 12 mm
Straumann Esthetic Plus 1 – 1
4.8 × 12 mm
Total 16 7 23

Overall PES Analysis

With the PES, a maximum score of 14 points is achiev-
14 able. For the TL group, the mean value was 8.49
(SD: 2.35). The BL group showed a mean of 9.29 (SD:
12 1.90; Fig 3).
The Wilcoxon rank sum test was carried out to com-
10 pare the overall PES result of the two groups (P = .37).
For the comparison within the BL group (sub-
PES

8 merged and non-submerged healing), the two-sample

6
4 The single parameters of the PES are illustrated in Fig 4.
TL BL
Fig 3   Box-plot illustration of the overall PES result for TL (me-
dian: 9.00) and BL (median 9.20) implants. The threshold of
clinical acceptance (value: 8) is indicated by the dotted line.
Interobserver Agreement
Interassessor reliability of the five observers was inves-
tigated by applying Krippendorff’s alpha coefficient
for interval data. Considering the overall PES results,
the evaluators showed sufficient homogeneity. This
aspect was verified by the value α = .643, indicating a
substantial agreement within the Landis-Koch scale.29
t test was applied (P = .51).
Single Parameter Outcome
The TL group reached a value of 1.31 (SD: 0.65)
for the mesial papilla, and the BL group reached a
value of 1.34 (SD: 0.73). The distal papilla was rated
1.09 (SD: 0.50) for the TL and 1.17 (SD: 0.68) for the BL
group. Regarding the soft tissue margin, values of 1.20
(SD: 0.53) for the TL and 1.31 (SD: 0.52) for the BL group
were found.
The soft tissue contour scored values of 1.40 (SD:
0.48) for the TL and 1.48 (SD: 0.39) for the BL group.
The buccal contour outcome of the alveolar process
was 1.19 (SD: 0.55) for the TL and 1.37 (SD: 0.51) for the
BL group.
The gingiva color reached values of 1.03 (SD: 0.60)
for the TL and 1.17 (SD: 0.33) for the BL group. Rating
the gingiva texture, results were 1.27 (SD: 0.53) for the
TL and 1.44 (SD: 0.31) for the BL group. The statistical
analysis of the single PES parameters is illustrated in
Table 4.

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Fig 4   PES mean scores and SDs
for single parameters. 2.0
1.5
PES
1.0
0.5
0
Mesial
papilla
DISCUSSION
The objective of this study was to compare the esthetic
outcome of implant-borne single-tooth restorations
with two different implant designs. The early design
type has been termed TL implants, and in 2008, the BL
design for the esthetic zone was introduced. Both im-
plant types resulted in reliable implant survival,25 with
5.5 to 12 years for TL implants and 2.6 to 7 years for BL
implants in situ.
To evaluate the outcome with regard to hard and
soft tissues, the PES10 was applied, meeting the require-
ments of a reproducible and reliable rating tool.31,32
The five evaluators showed an acceptable level of
agreement (Krippendorff’s α = .643), and therefore,
sufficient homogeneity regarding overall PES results.
Still, there are doubts about objective parameters in
assessing dental implant esthetics.33 As shown in ear-
lier studies, however, the PES serves as a reproducible
tool, and also, the practical feasibility of the PES has
been confirmed.6,11
The overall PES results in this study corroborate the
satisfactory esthetic outcomes of TL and BL implants in
other studies.17 The comparison of the overall PES out-
come of TL implants (8.49, SD: 2.35) and BL implants
(9.29, SD: 1.90) has not shown a statistically significant
difference (P = .37). Nevertheless, there has been an
obvious tendency toward somewhat better results for
BL implants.
Regarding the PES, 65% of TL and 74% of BL im-
plants have been considered at least esthetically ac-
ceptable since scores have been above 821,28,34 (Fig 3,
Table 5). This means an unsatisfying esthetic outcome
from the clinician’s point of view in 35% (TL) and 26%
(BL) of patients. Studies that applied the same thresh-
old had respective rates of only 15% and 24% within
the cohort.34,35 Other studies showed even higher
rates of esthetically acceptable cases.6,21 As in this
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Siebert et al
TL
BL
Distal Level of Soft Alveolar Soft Soft
papilla soft tissue tissue process tissue tissue
margin contour color texture
study, inclusion criteria have been relatively broad; a
few patients with gingival soft tissue deficiencies such
as scars, lack of papilla, and unnatural gingiva color
due to inflammation or amalgam tattooing may have
been included. Consequently, because of a compro-
mised contralateral tooth site in these cases, even
with a decently reconstructed implant site, a lack of
symmetry would be evident. Furthermore, compro-
mised baseline situations at the implant site will not
necessarily improve after implant treatment.18 These
facts might be a reason for some relatively unfavor-
able PES outcomes.
To analyze PES single parameters, the Wilcoxon rank
sum test was applied. No statistically significant differ-
ences between the groups could be found, as all P val-
ues were > .05 (Table 4). However, BL implants tended
to show generally slightly superior outcomes in all pa-
rameters (Fig 4).
The mesial papilla was the most inconsistently rated
parameter in both groups, with SDs of 0.65 (TL) and
0.73 (BL), respectively, with no conclusive explanation
thus far.
Distal papilla and soft tissue color have been the
most difficult issues to solve for both implant types.
Over the years, maintenance of the distal papilla seems
to have been more delicate than preserving the mesial
papilla. So far, no explanation for this phenomenon
has been reported.21,34
The highest ratings have been found for soft tissue
contour in both implant designs. This parameter is a
result of the height of gingival margin and papilla lev-
els. A correct 3D positioning of the implant, and there-
by, the avoidance of soft tissue recession supports a
pleasing soft tissue contour outcome. By carefully
extracting the failing tooth prior to implantation, the
surrounding soft tissue has obviously been preserved,
which has led to the natural contour outcomes.
The International Journal of Oral & Maxillofacial Implants 909
Siebert et al

Table 4   Statistical Analysis of PES Single In the present study, non-submerged healing was
Parameter Values in TL and BL chosen for 15 BL implants (65%). Adequate healing
Implants abutments for soft tissue support were applied im-
mediately after surgery (Table 6). Research in recent
P values years has shown that submerged healing (widely
Mesial papilla .76 practiced with BL implants) may not be necessary for
Distal papilla .59 a predictable implant-borne tooth replacement.20,37
Level of soft tissue margin .49 Consequently, comparable esthetic outcomes have
Soft tissue contour .83 been reported for moderately augmented, submerged
Alveolar process .24 and non-submerged single implants in the esthetic
zone.38,39
Soft tissue color .42
The potentially different loading conditions with
Soft tissue texture .32
the submerged and non-submerged healing protocols
Wilcoxon rank sum test.
TL = tissue-level; BL = bone-level; PES = pink esthetic score.
in the BL group may be regarded as a confounding
variable. However, the statistical analysis of the overall
PES in these subgroups did not reveal a significant dif-
Table 5   Clinical Acceptance of TL and BL ference (P = .51).
Implants by Means of PES The preservation of bone around an implant is im-
portant for soft tissue support. Papilla formation is
PES > 8 PES < 8
based on the existence of underlying bone and de-
TL 15 (65%) 8 (35%)
cisive for a pleasing esthetic outcome. The microgap
BL 17 (74%) 6 (26%) between the implant and abutment in BL implants oc-
TL = tissue-level; BL = bone-level; PES = pink esthetic score. curs at bone level, and a platform-switching concept is
utilized to preserve the peri-implant bone.15,16 In con-
trast, the microgap is at least 1.8 mm above bone crest
Table 6   Healing Mode of TL and BL Implants in TL implants due to the smooth neck portion. Thus,
Submerged Non-submerged the principle of biologic width may be even better ac-
TL 0 23 counted for in TL implants.
BL 8 15 The relatively small sample size remains a limitation
TL = tissue-level; BL = bone-level. of the study, but nonetheless equals similar reports. A
highly experienced maxillofacial surgeon specializing
in implant surgery was entrusted with all cases, as deli-
The parameter gingiva color is notable, with rather cate interventions in the esthetic zone need a lot of ex-
low ratings for TL and BL of 1.03 (SD: 0.60) and 1.17 (SD: pertise.28,30 Obviously, the PES is basically influenced
0.33), respectively, which may be due to scar tissue for- by the surgeon’s work and capabilities.6
mation as a consequence of flap elevation. As bone and soft tissue preservation can be achieved
Furthermore, the results for soft tissue color (TL, with both immediate and early implant placement,18
SD: 0.60; BL, SD: 0.33) and soft tissue texture (TL, SD: the question arises as to whether the timing of implant
0.53; BL, SD: 0.31) have been more consistent in the placement (Table 1) has played a role in the esthetic
BL group. It can only be speculated whether the lon- outcome of this study. For immediate, early, and de-
ger in situ period of the TL implants may have created layed treatment protocols, favorable results have been
situations that have been differently judged by the found.1,5 No statistical differences in esthetic outcome
evaluators. between immediate and delayed implant treatment
The BL design allows a more individual emergence have been reported.40 Significant differences between
profile, which is regarded as an advantage of this im- immediate and early implants with immediate provi-
plant type. Customized abutments consistent with the sionalization have been stated, showing better results
natural emergence profile of the contralateral tooth for immediate implantation.11 At this point, there is no
can be fabricated. complete agreement with regard to implant insertion
TL implants are characterized by transgingival heal- time and esthetic effect. It must be mentioned that in
ing. This is an advantage insofar as a second approach this study, insertion times varied, and many more de-
to uncover the implant is unnecessary, thus avoiding layed implant placement patients are part of the TL
an additional trauma. Repeated manipulation 4 to 8 group. Hence, a comparison with studies that apply a
weeks after implantation has been associated with strict insertion protocol is questionable.
dimensional changes in peri-implant hard and soft The heterogeneity of the follow-up dates should
tissues.36 also be addressed when assessing the results of the

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study. At the time of examination, TL implants had
been incorporated for almost 10 years compared with
only 4 years for BL implants. However, the greatest di-
mensional soft and hard tissue alterations, for instance,
papilla regrowth and bone remodeling, are expected
within the first year after surgery.20,22 Consequently, it
is to be assumed that a steady state will prevail, and
therefore, no further bone remodeling may occur12
and the varying points in time might not be estheti-
cally relevant. This may be an argument for clinicians
working with TL implants in the anterior maxilla, as
even with longer in situ time, a comparable esthetic
result has been found. Finally, it should be kept in mind
that the acquisition of long-term esthetic results will
involve some compromises in the design. In the pres-
ent study, the long-term aspect of the results is em-
phasized, although in a controlled clinical trial, more
parameters would be standardized.
CONCLUSIONS
Within the limits of this study, it can be stated that with
BL and TL implants in the anterior maxilla, an accept-
able esthetic result may be achieved over the years.
These findings are valid for patients who have been
included without strict preselection.
ACKNOWLEDGMENTS
The authors thank Dr Friedrich Graef, Department of Applied
Mathematics, University of Erlangen-Nuremberg, for statistical
assistance. The present work was performed in fulfillment of
the requirements for obtaining the degree “Dr med dent”. The
authors declare no conflicts of interest.
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