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Effectiveness of Contour Augmentation with Guided Bone Regeneration: 10-

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Regeneration: 10-Year Results DOI: 10.1177/0022034517737755

https://doi.org/10.1177/0022034517737755
journals.sagepub.com/home/jdr

V. Chappuis1, L. Rahman1, R. Buser2, S. Janner1, U. Belser2,

and D. Buser1[AQ: 1][AQ: 2][AQ: 3][AQ: 4]

Abstract
In aesthetic sites, the integrity of the facial bone wall dimension in the anterior maxilla is jeopardized by physiologic and structural changes
postextraction. An effective regenerative protocol is key to reestablish and maintain the hard and soft tissue dimensions over time. The
present prospective case series study examined the effectiveness of early implant placement with simultaneous contour augmentation
through guided bone regeneration with a 2-layer composite graft in postextraction single-tooth sites over an observation period of 10 y
among 20 patients. The median peri-implant bone loss was 0.35 mm between the 1- and 10-y examination. A success rate of 95% was
obtained, with pleasing aesthetic outcomes and a high median Pink Esthetic Score (8). Implant crowns (ICs) revealed significant median
facial recession between IC10y and IC1y (0.10 mm). The facial bone wall dimensions were assessed by preoperative cone beam computed
tomography and 2 subsequent scans taken at 6 and 10 y. The median facial bone wall thickness increased significantly from 0 mm at
surgery to 1.67 mm at the 10-y examination. The facial vertical bone wall peak (DIC [distance from the implant shoulder to the facial
crest]) was located at a median distance of 0.16 mm coronal to the implant shoulder. The facial vertical bone loss of DIC amounted to
0.02 mm between 6 and 10 y. Equivalence testing was performed for the null hypothesis of a difference of >0.2 mm per year between
2 respective time points, showing stable bone conditions. Modulating factors influencing the regenerative outcomes at 10 y were the
preoperative proximal crest width and soft tissue thickness. In conclusion, the present study confirmed the long-term effectiveness of
early implant placement with simultaneous contour augmentation through guided bone regeneration with a 2-layer composite graft in
postextraction single-tooth sites offering stable bone conditions with low risks of mucosal recessions over an observation period of 10 y
(ClinicalTrials.gov NCT03252106).

Keywords: clinical trial, guided tissue regeneration, osseointegration, bone substitutes, aesthetics, endosseous dental implantation

Introduction
In the anterior maxilla, the establishment and maintenance of
sufficient hard and soft tissue volume are important to achieve
pleasing aesthetic outcomes. The peri-implant soft tissues need
to be supported by an adequate 3-dimensional osseous volume
of the alveolar ridge, including an intact facial bone wall of suf-
ficient thickness and height in combination with a correct
restoration-driven implant placement (Buser, Martin, and Belser
2004; Grunder et al. 2005). Deficiency of the facial bone anat-
omy has a negative impact on aesthetics and is often a critical
causative factor for aesthetic implant complications and failures
(Chen and Buser 2014). The integrity of the facial bone wall
and the soft tissue dimensions are altered by physiologic and
structural changes following tooth extraction in the aesthetic
zone (Chappuis et al. 2013; Chappuis et al. 2015). Therefore, a
thorough understanding of the underlying biological processes
postextraction and following implant placement is required to
select the most appropriate treatment approach to achieve pleas-
ing aesthetic outcomes (Berglundh and Giannobile 2013).
In postextraction sites, the clinician has various treatment
options, including immediate, early, or late implant placement
(Morton et al. 2014; Buser et al. 2017). One of these treatment
options is the early implant placement protocol, with a 4- to
8-wk soft tissue healing period postextraction. The complete
soft tissue healing provides an increased amount of keratinized
mucosa (KM), which facilitates flap closure and favors bone
regeneration (Zitzmann et al. 1999; Buser et al. 2008). In addi-
tion, the boost in osteoclastic activity due to bundle bone
resorption during the initial healing phase decreases after 4 to
8 wk (Araujo and Lindhe 2005), providing a favorable envi-
ronment for regenerative procedures, mostly needed in aesthetic
implant sites to compensate for dimensional ridge alterations on
the facial aspect (Buser et al. 2009; Sanz et al. 2012; Tonetti
1
Department of Oral Surgery and Stomatology, School of Dental
Medicine, University of Bern, Bern, Switzerland
2
Department of Reconstructive Dentistry and Gerodontology, School of
Dental Medicine, University of Bern, Bern, Switzerland
Corresponding Author:
V. Chappuis, Department of Oral Surgery and Stomatology, School
of Dental Medicine, University of Bern, Freiburgstrasse 7, 3010 Bern,
Switzerland.
Email: vivianne.chappuis@zmk.unibe.ch
2 Journal of Dental Research 00(0)
et al. 2017). Thus, this protocol has been recommended as the
treatment of choice in sites lacking an intact facial bone wall or
with a thin bone wall phenotype (Morton et al. 2014; Buser
et al. 2017).
The primary objective of the present study is to assess the
integrity and long-term stability of the facial bone wall after 10 y
of function in single-tooth replacement within the aesthetic
zone to examine the effectiveness of early implant placement
with simultaneous contour augmentation with guided bone
regeneration (GBR). The secondary objective is to evaluate
potential factors modulating the regenerative outcomes of the
facial bone dimensions after a 10-y follow-up period.
Materials and Methods
Study Design
The present study was designed as a monocenter prospective
case series study to investigate the effectiveness of early implant
placement with simultaneous contour augmentation following
single-tooth extractions as described previously (Buser et al.
2009). The study is in accordance with the 2013 Declaration of
Helsinki and has been approved by the standing ethical commit-
tee of the state of Bern, Switzerland (KEK-BE-No. 30/05,
180/11). It has been registered on clinicaltrials.gov (NCT032
52106) and conforms to the STROBE guidelines.
Surgical Procedure
The surgical procedures included flapless tooth extraction
without any applied modality of ridge preservation, a soft tis-
sue healing period of 8 wk, and the subsequent placement of a
bone-level implant with a chemically modified, sandblasted,
and acid-etched surface (SLActive, Straumann AG; Buser,
Broggini, et al. 2004). Simultaneous contour augmentation
was performed via GBR with a 2-layer composite graft with
locally harvested autogenous bone chips to cover the exposed
implant surface on the facial aspect, combined with a superfi-
cial layer of deproteinized bovine bone mineral (DBBM; Bio-
Oss, Geistlich Pharma) and subsequent covering with a
noncrosslinked collagen membrane (Bio-Gide; Geistlich
Pharma), followed by tension-free primary wound closure.
Follow-up Examination at 10 y
Clinical Parameters, Cast Analysis, and Aesthetic Score Assess-
ment. The same clinical parameters previously described
(Buser et al. 2009) were applied for the present 10-y examina-
tion: peri-implant suppuration, modified plaque index (mPLI),
modified sulcus bleeding index (mBLI), probing depth, DIMfacial
(distance from the implant shoulder to the mucosal margin in
the facial aspect), and width of the KM. Clinical examinations
were taken by 1 examiner throughout the 10-y follow-up
period (U.B.).
The cast analysis monitored the levels of the peri-implant
mucosa over time. The midfacial height of the implant crown
(IC) and the corresponding height of the contralateral tooth
crown were both measured on digitized images to identify the
recession rate of the facial mucosa (Buser et al. 2009).
Aesthetic score assessment was based on the respective
casts and intraoral photographs, which were critically analyzed
by 2 examiners to determine the modified Pink Esthetic Score
(Belser et al. 2009).
Radiographic Analysis.  On the 2-dimensional periapical radio-
graphs, the linear distance from the implant shoulder to the
first visible bone-to-implant contact (DIB; in millimeters) was
assessed (Buser et al. 2009). The mean DIB value per implant
was calculated as the average of the mesial and distal values.
Three-dimensional radiographic analysis was based on
cone beam computed tomography (CBCT) and included a pre-
operative analysis of the surgical site and the 2 follow-up
examinations at 6 and 10 y. The preoperative analysis exam-
ined the facial soft and socket wall thickness, the facial bone
wall height, and the crest width proximal to the extraction
socket (Fig. 1A, B). The measurements were taken 4 mm api-
cal to the cementoenamel junction of adjacent teeth. In the
follow-up examinations, the facial bone wall thickness was
analyzed at 4 levels (Buser et al. 2013), and the peak of the
facial bone wall height (DIC [distance from the implant shoul-
der to the facial crest]) was defined as the distance to the
implant shoulder (Chappuis et al. 2016; Fig. 1C, D). The radio-
graphic analysis was performed by 1 observer (L.R.), carefully
calibrated by an experienced clinician (D.B.).
Assessment of Biological and Technical Complications. Episodes
of biological, prosthetic, and aesthetic complications were
retrieved from the patients’ charts. Mechanical complications
were defined as failures of prefabricated components, whereas
technical complications consisted of failures of the laboratory-
fabricated crowns (Salvi and Bragger 2009).
Statistical Analysis
All data were expressed as median, minimum, and maximum
values. Statistical significance for the clinical and radiographic
data over the follow-up period was determined with the global
nonparametric Brunner-Langer model for longitudinal data in
factorial experiments (Brunner et al. 2002). A P value <0.05
was considered statistically significant. For significant interac-
tions, post hoc analyses were performed with Wilcoxon signed-
rank tests for the paired cases and Mann-Whitney-Wilcoxon
tests for the nonpaired cases. The Holm-Bonferroni method
was used for the adjustment of multiple comparisons. To iden-
tify possible factors influencing the outcomes, a robust analy-
sis of variance and a Spearman’s correlation coefficient were
performed (Hettmansperger and McKean 2011). Equivalence
testing was performed for the null hypothesis of a difference of
>0.2 mm per year between 2 respective time points. All statisti-
cal analyses were calculated with an open source software
package (R 3.3.3; R Development Core Team, http://www.r-
project.org).
Contour Augmentation with Guided Bone Regeneration 3

Figure 1.  Three-dimensional radiographic analysis, based on cone beam computed tomography, included a preoperative analysis of the surgical site
(A, B) and 2 follow-up examinations at 6 and 10 y (C, D). The preoperative analysis included the facial soft tissue thickness (s), preoperative socket
wall thickness (b), facial socket wall height (h) and proximal crest width (p). The measurements were taken 4 mm apical to the cementoenamel
junction at the future implant site. In the follow-up examinations, the facial bone wall integrity was characterized by 2 parameters: first, the peak of the
facial bone wall height was analyzed as the distance from the implant shoulder to the facial crest (DIC) (C); second, the facial bone wall thickness was
assessed at 4 levels (shoulder level at 0, 2, 4 and 6 mm) (D).

Results Clinical Parameters

Study Sample
The group consisted of 5 men and 15 women with a median
age of 53 y (range, 35 to 71 y; Fig. 2). The median observation
period was 10.5 y (range, 10 to 11 y). Thirteen patients were
healthy, and 7 suffered from preexisting medical conditions
(cardiovascular disease, n = 4; osteoporosis, n = 1; diabetes,
n = 1; brain tumor, n = 1). The treatment sites included 14 cen-
tral incisors, 3 lateral incisors, 1 canine, and 2 first premolars.
No dropout occurred up to the 10-y follow-up period.
Overall, the patients exhibited good oral hygiene, documented
by a median mPLI of 0.3 and mBLI of 0.1 at 10 y. None of the
patients presented with suppuration at the 10-y examination.
The median probing depth showed a significant decrease over
the 10-y period, from 4.5 to 4.0 mm at the 10-y examination in
the Brunner-Langer analysis (P = 0.009). The subsequent post
hoc tests showed a significant decrease from 1 to 3 y, from 6 to
10 y, and from 1 to 10 y (Fig. 3C). The remaining parameters
(mPLI, mBLI, DIMfacial, KM) revealed no significant changes
over time (Table; Figs. 2, 3A–E).
4 Journal of Dental Research 00(0)

Table.  Results of the 10-y Observation Period.

Parameters 3 mo 1y 3y 6y 10 y P Value

Clinical parameters (n = 20)

Modified plaque index 0.0, 0.3, 1.0 0.0, 0.5, 1.0 0.0, 0.4, 1.5 0.0, 0.3, 1.5 0.3738
Modified sulcus bleeding index 0.0, 0.3, 0.5 0.0, 0.1, 0.8 0.0, 0.3, 0.5 0.0, 0.1, 0.8 0.0703
Probing depth, mm 3.8, 4.5, 5.8 2.8, 4.0, 5.0 3.0, 4.3, 5.3 3.3, 4.0, 5.0 0.0090
Distance from gingival margin to implant 5.0, 3.0, 2.0 5.0, 4.0, 3.0 5.0, 4.0, 3.0 6.0, 3.5, 2.0 0.3364
shoulder, mm
Keratinized mucosa, mm 2.0, 5.0, 7.0 3.0, 4.0, 7.0 2.0, 4.0, 7.0 2.0, 3.5, 5.0 0.1182
Modified Pink Esthetic Score analysis (n = 20)
Mesial papilla 1.0, 1.0, 2.0 1.0, 1.5, 2.0 1.0, 1.5, 2.0 1.0, 1.5, 2.0 0.7147
Distal papilla 1.0, 1.5, 2.0 1.0, 1.5, 2.0 1.0, 1.5, 2.0 1.0, 2.0, 2.0 0.7864
Curvature labial mucosa 1.0, 2.0, 2.0 1.0, 2.0, 2.0 1.0, 2.0, 2.0 1.0, 2.0, 2.0 0.7288
Level labial mucosa 1.0, 2.0, 2.0 1.0, 2.0, 2.0 1.0, 2.0, 2.0 1.0, 2.0, 2.0 0.5777
Root convexity soft tissue color and texture 1.0, 1.5, 2.0 1.0, 2.0, 2.0 1.0, 2.0, 2.0 1.0, 1.0, 2.0 0.0812
Total modified Pink Esthetic Score 5.0, 8.0, 10.0 5.0, 8.0, 10.0 5.0, 8.0, 10.0 6.0, 8.0, 10.0 0.4441
Cast model analysis (n = 18; in mm)
Height of implant crown 8.4, 9.8, 12.1 8.1, 9.8, 11.6 8.3, 10.0,11.9 8.4, 9.9, 12.7 0.0286
Height of contralateral tooth crown 7.4, 9.9, 12.1 7.8, 9.9, 12.0 8.0, 10.1, 12.6 8.2, 9.8, 12.6 0.4473
Difference between tooth crown and –1.8, 0.0, 0.6 –1.4, –0.2, 0.6 –0.8, –0.1, 0.8 –1.4 , –0.2, 1.2 0.9569
implant crown
2-dimensional radiographic analysis (n = 20; in mm)
Distance from implant shoulder to the first 0.00, 0.00, 0.54 0.00, 0.18, 0.76 0.00, 0.14, 0.70 0.00, 0.48, 1.09 0.35, 0.49, 1.05 0.0030
bone-to-implant contact
3-dimensional radiographic analysis (n = 19; in mm)
Facial soft tissue thickness at implant 0.87, 1.71, 2.78 0.86, 1.70, 2.76 0.1793
shoulder
Facial bone wall thickness 1.01, 1.79, 2.58 0.98, 1.67, 2.48 0.0870
Facial bone wall height as distance from –0.90, 0.22, 1.49 –1.26, 0.16, 1.48 0.3391
implant shoulder to the facial crest

All data are expressed as minimum, median (bold), and maximum values. Statistical significance for the clinical and radiographic data over the follow-up
period was determined through the nonparametric Brunner-Langer model for longitudinal data in factorial experiments (Brunner et al. 2002). P < 0.05
was considered statistically significant. For significant interactions, post hoc analyses were performed with Wilcoxon signed-rank tests for the paired
cases and Mann-Whitney-Wilcoxon tests for the nonpaired cases, as presented in Figures 3 and 4. The Holm-Bonferroni method was used for the
adjustment of multiple comparisons.

Aesthetic Score Parameters and Cast Two-dimensional Radiographic Analysis

Assessment
The overall modified Pink Esthetic Score did not significantly
change over time and revealed pleasing outcomes (P = 0.4441).
Among the 5 parameters evaluated, the level and curvature of
the mucosal margin maintained the high values of 2.0. Lower
values were obtained for the root convexity (1.0), whereas the
mesial and distal papillae both improved by 0.5 as compared
with the 1-y examination without reaching statistical signifi-
cance (Table; Figs. 2, 3F, 3G).
Prosthetic analysis revealed that 2 ICs were replaced: 1
crown due to fracture (Fig. 2S) and 1 to an adjacent implant
insertion (Fig. 2F),[AQ: 5] in which the existing IC had to be
replaced as well to achieve a harmonious aesthetic outcome for
both ICs (Fig. 2T, F, respectively). Therefore, these 2 patients
were excluded from the cast analysis (n = 18). ICs revealed
significant median facial recession between IC10y and IC1y
(0.10 mm, P = 0.0286). The crown length of the contralateral
tooth did not change over time (P = 0.4473). Interestingly, the
recession rate between IC and tooth crown showed no signifi-
cant differences (P = 0.9569; Table, Fig. 4A).
During the 10-y period, significant peri-implant bone-level
changes were observed in the global analysis (P = 0.0030), but
none of the 20 implants demonstrated a continuous peri-implant
radiolucency. In the paired post hoc tests, the values at 6 and 10 y
were significantly greater than those at 3 mo, 1 y, and 3 y. The
median peri-implant bone loss between the 1- and 10-y exami-
nation amounted to 0.35 mm (P = 0.002; Table; Figs. 2, 4B).
Three-dimensional Radiographic Analysis
The CBCT analysis of the facial bone wall demonstrated that
19 of 20 implants (95%) had a detectable facial bone wall (Fig.
2). The remaining implant already had no facial bone wall at
the 6-y CBCT analysis. In addition, the implant developed an
acute infection after an implant surgery at an adjacent site in
the eighth year of follow-up. The patient had a history of smok-
ing and was taking bisphosphonates due to osteoporosis. At the
10-y examination, the implant was clinically healthy without
signs of infection but revealed no detectable facial bone wall
and a vertical bone loss of 5.92 mm (Fig. 2L)[AQ: 6]. This
Contour Augmentation with Guided Bone Regeneration 5

Figure 2.  Clinical images of all 20 patients (A–T)[AQ: 7] revealed healthy peri-implant tissues, with minor changes in the peri-implant bone levels
in the 2-dimensional radiographs at 6 and 10 y. The median peri-implant bone loss between the 1- and 10-y examinations amounted to
0.35 mm (range, –0.57 to 0.15 mm). The median DIC (distance from the implant shoulder to the facial crest) was located 0.16 mm coronal to the
implant shoulder level. In 15 implants, the facial bone wall extended coronal to the platform. The median facial bone wall thickness amounted to
1.67 mm. One implant already had no facial bone wall at the 6-y cone beam computed tomography analysis (M). In addition, the implant developed
an acute infection after implant surgery at an adjacent site in the eighth year of follow-up. The patient had a history of smoking and was taking
bisphosphonates due to osteoporosis. At the 10-y examination, the implant was clinically healthy, without signs of infection, but revealed no detectable
facial bone wall and a vertical bone loss of 5.92 mm. This implant was classified as a regenerative failure, leading to the success rate of 95%.
6 Journal of Dental Research 00(0)

Figure 3.  Clinical parameters (A–E): Overall, the patients exhibited good oral hygiene, documented by a median mPLI of 0.3 (modified plaque index;
A) and a mBLI of 0.1 at 10 y (median modified sulcus bleeding index; B). None of the patients presented with suppuration at the 10-y examination. The
median PD (probing depth) showed a significant decrease over the 10-y period, from 4.5 to 4.0 mm at the 10-y examination (P = 0.009; C) in the global
testing, whereas the remaining parameters revealed no significant changes over time: mPLI (A), mBLI (B), KM (keratinized mucosa; D), and DIM in the
facial aspect (distance from the implant shoulder to the mucosal margin; E). Paired post hoc test were performed for PD (C). The values at 6 and 10 y
were significantly greater than those at 3 mo, 1 y, and 3 y. The graphs represent the median, including the maximum and minimum values. Aesthetic
scores (F, G): the overall modified Pink Esthetic Score (PES) did not significantly change over time and revealed pleasing outcomes (P = 0.4441)
(F; showing the median with the maximum and minimum values). Among the 5 parameters evaluated, the level and curvature of the mucosal margin
maintained the high values of 2.0. Lower values were obtained for the root convexity (1.0), whereas the mesial and distal papillae both improved
by 0.5 when compared with the 1-y examination, without reaching statistical significance (G; showing the median with the maximum).

implant was classified as a regenerative failure, leading to the
success rate of 95%. This implant was therefore excluded from
the subsequent CBCT analysis.
The preoperative analysis at 8 wk postextraction revealed a
median facial socket wall thickness of 0 mm (range, 0 to 0.69
mm) at the 4-mm level apical to the cementoenamel junction of
adjacent teeth. Twelve sites revealed no facial socket wall at
the future implant shoulder site, whereas the remaining 8 sites
exhibited a median thickness of 0.43 mm. The peak of the
facial socket wall was located at a median height of –3.16 mm
apical to the future level of the implant shoulder (range, 0.64 to
10.27 mm). The proximal ridge was intact in all sites, exhibit-
ing a median crest width of 6.58 mm (range, 5.06 to 8.11 mm).
In the 10-y follow-up analysis, the soft tissue thickness at the
implant shoulder did not significantly change in the global test-
ing (P = 0.1793). The median facial bone wall thickness was
1.67 mm showing no significant changes to the 6-y examination
(P = 0.0870). The peak of the facial bone wall (DIC) was
located at a median distance of 0.16 mm coronal to the implant
shoulder. Of the 19 implants, 15 (79%) had a positive DIC
value, with the peak of the bone wall being located coronally to
the implant shoulder. The facial vertical bone loss of DIC
amounted to 0.02 mm between 6 and 10 y, showing no signifi-
cance in the global testing (P = 0.3391; Table; Fig. 4C, D).
Correlations
The facial bone wall thickness was significantly correlated
with the proximal crest width (P = 0.0487) and with the soft
tissue thickness (P = 0.0203), whereas no correlation was
found with the preoperative facial bone wall thickness (P =
0.4900; Fig. 4E). The peak of the facial bone wall (DIC)
showed no significant correlation between the preoperative
proximal crest and facial bone wall thickness, but a significant
correlation with the soft tissue thickness was observed (P =
0.0359; Fig. 4F).
Contour Augmentation with Guided Bone Regeneration 7

Figure 4.  Cast analysis (A): In the global testing, implant crowns (ICs) revealed significant median facial recession between IC10y and IC1y (0.10 mm,
P = 0.0286). The crown length of the contralateral tooth (TC) did not change over time (P = 0.4473). Interestingly, the recession rate between IC
and TC showed no significant differences (P = 0.9569; Table). The graph represents the median, including the maximum and minimum values. Two-
dimensional radiographic analysis (B): Overall, significant peri-implant bone loss was observed in the global test (P = 0.003). In the paired post hoc
tests, the values at 6 and 10 y were significantly greater than those at 3 mo, 1 y, and 3 y. The median peri-implant bone loss between the 1- and 10-y
examination amounted to 0.35 mm (P = 0.002). The graph represents the median including the maximum and minimum values. DIB, linear distance
from the implant shoulder to the first visible bone-to-implant contact. Three-dimensional radiographic analysis based on cone beam computed
tomography (C, D): The median facial bone wall thickness was 1.67 mm at 10 y (range, 0.98 to 2.48 mm), showing no significant changes to the 6-y
examination (P = 0.0870) and a significant increase in comparison with the facial socket wall thickness at surgery (P ≤ 0.0001) in the global testing (C).
The peak of the facial bone wall (DIC [distance from the implant shoulder to the facial crest]) was located at a median distance of 0.16 mm coronal
to the implant shoulder. The facial vertical bone loss of DIC amounted to 0.02 mm between 6 and 10 y, showing no significance in the global testing
(P = 0.3391; D). The graphs represent the median including the maximum and minimum values. pre-OP, preoperative. Correlation analysis (E, F): The
facial bone wall thickness was significantly correlated by the proximal crest width (P = 0.0487) and by the soft tissue thickness (P = 0.0203), whereas
no correlation was found for the preoperative facial bone wall thickness (P = 0.4900) (E). The peak of the facial bone wall (DIC) showed no significant
correlation between the preoperative proximal crest and facial bone wall thickness, but a significant correlation for the soft tissue thickness was
observed (P = 0.0359; F).

Equivalence Testing graft in aesthetic postextraction single-tooth sites over an

Equivalence testing was performed for the null hypothesis of a
difference of >0.2 mm per year between 2 respective time
points, according to the definition of Albrektsson et al. (1981),
which showed stable bone conditions for the parameters DIB,
DIC, and facial bone wall thickness (P ≤ 0.001).
Discussion
The present study is the first prospective case series to assess
the effectiveness of early implant placement with simultaneous
contour augmentation through GBR with a 2-layer composite
observation period of 10 y. The dropout rate was 0% over the
10-y period. Contour augmentation was successful in 19 of 20
patients (95%). High aesthetic scores with healthy peri-implant
soft tissue conditions and stable bone crest levels were observed
at the 10-y examination. The deficient facial socket wall height
at surgery was regenerated from a vertical defect of –3.16 mm
apical to the shoulder level to a facial bone wall height of
0.16 mm coronal to the implant shoulder. The deficient facial
socket wall thickness increased from 0 to 1.67 mm. The 10-y
implant survival rate was 100%. The 10-y success rate amounted
to 95% with 1 regenerative failure, when the strict success cri-
teria of Buser et al. (1991) were applied.
8 Journal of Dental Research 00(0)
The critical analysis of long-term outcomes is an important
milestone to identify potential factors affecting success of regen-
erative procedures. However, long-term studies reporting on
regenerative outcomes of the facial tissues are scarce. A recent
10-y study on immediate implants in 17 patients observed a
reduced facial bone wall height of 1.6 mm apical to the implant
shoulder. In addition, 24% of the implants showed no visible
facial bone wall in CBCT (Kuchler et al. 2016). Similar results
were observed in a 7-y study on 14 patients with immediate
implants (Benic et al. 2012). In 35.7% of the sites, no detectable
facial bone wall was visible in CBCT. Vertical bone loss of the
facial bone wall was 3.1 mm, with a mean facial bone wall thick-
ness of 0.4 mm. A recent 5-y clinical study of 17 patients with
immediate implants and immediate restoration showed an aes-
thetic complication rate of 47%, since 8 of 17 patients developed
mucosal recession >1 mm (Cosyn et al. 2016). The mean muco-
sal recession was 0.53 mm at the 5-y period. Short-term data are
also available for a recent randomized clinical trial on immediate
versus delayed implant placement (Tonetti et al. 2017). The 1-y
clinical results showed an increased rate of wound-healing com-
plications (26% vs. 5%) for immediate implants and inadequate
Pink Aesthetic Scores (42% vs. 19%) when compared with
delayed implant placement. These studies confirmed the
increased risk of aesthetic complications of immediate implants,
as shown recently (Chen and Buser 2014). In the present study,
the median midfacial recession was 0.10 mm after 10 y, and the
aesthetic complication rate was 5%. The favorable DIC mea-
surements—with the peak of the facial bone wall 0.16 mm coro-
nal to the implant shoulder—can also be attributed to the implant
design. The bone-level implant has a platform switching design,
which offers less crestal bone remodeling when compared with
a butt-joint interface on facial and proximal aspects (Chappuis
et al. 2016).
There are several potential reasons for the favorable regen-
erative outcomes in the present study. First, it can be hypothe-
sized that the underlying biological concept of early implant
placement leads to decreased activity in macrophages and
increased levels of osteocalcin and bone morphogenetic pro-
teins, with high activity of endothelial cells after 8 wk of soft
tissue healing, which may provide a favorable environment for
bone regeneration (Trombelli et al. 2008; Chappuis et al.
2012). Second, the environment is favorable not only due to
the high cellular activity but also due to the advantage of a
2-wall defect morphology. An early implant placement proto-
col offers minimal bone resorption proximal to the extraction
socket, as shown in a recent CBCT study following flapless
single-tooth extraction (Chappuis et al. 2013). This resorption
pattern preserved the proximal crest width. The proximal crest
width of ≥6 mm provides on the facial aspect a 2-wall bone
defect morphology offering a stabile environment for applied
bone biomaterials and a high osteogenic potential for new bone
formation (Kan et al. 2007; Chen and Darby 2017). Such
mechanical cues are able to modulate neoangiogenesis by the
expression of VEGF (Mammoto et al. 2009). Therefore, the
2-wall defect morphology in a site with low osteoclastic activ-
ity may provide an advantageous environment for neoangio-
genesis and subsequent bone formation. Third, the locally
harvested autogenous bone chips contain noncollagenous pro-
teins in the bone matrix, growth factors, and numerous osteo-
cytes providing a high osteogenic potential (Colnot 2009;
Nudelman et al. 2010). Finally, osteocytes have been identified
as important regulators in bone metabolism, acting on osteo-
clasts and osteoblasts (Bonewald 2011). A proteomic analysis
revealed that cortical autogenous bone chips release >150 pro-
teins, acting mostly over the TGFβ pathway (Caballe-Serrano
et al. 2014), which clearly accelerated the rate of new bone
formation in membrane-protected bone defects during the ini-
tial healing phase in preclinical studies (Jensen et al. 2007).
Besides the utilization of autograft chips, the selection of an
appropriate bone substitute also influences the long-term treat-
ment outcome. Contour augmentation is based on a 2-layer
composite graft, with a first layer of locally harvested autoge-
nous bone chips having osteogenic potential (Caballe-Serrano
et al. 2014) and a second layer of DBBM particles acting as an
osteoconductive scaffold. This DBBM scaffold not only
improves the volume but also provides long-term stability of
the regenerated bone wall due to its low substitution rate. When
embedded in bone, DBBM is almost not resorbed during bone
remodeling, as demonstrated in preclinical and clinical studies
with histomorphometric analysis (Jensen et al. 2007; Jensen
et al. 2014). In the present study, a resorbable, noncrosslinked
collagen membrane was utilized to eliminate the need for mem-
brane removal and to ensure a low risk of complications (von
Arx and Buser 2006). The favorable long-term regenerative
outcome indicates that the rather short barrier function of non-
crosslinked collagen membranes during early healing is suffi-
cient for successful bone regeneration (Chappuis et al. 2017).
Finally, the tension-free primary soft tissue closure, with an
increased amount of KM and spontaneous thickened soft tissue
in a thin bone wall phenotype, may also have contributed to the
favorable regenerative and aesthetic outcomes (Nemcovsky
and Artzi 2002; Buser et al. 2008; Chappuis et al. 2015).
The present study has several limitations. First the sample
size of 20 patients is small. Therefore, the statistical power may
be low to detect a difference in the outcome. Second, in the
radiographic analysis, different observers were involved in the
1-, 3-, 6-, and 10-y study. Even though observers were carefully
calibrated by an experienced clinician (D.B.), slight variations
may have occurred. Finally, the facial bone wall thickness may
be influenced by further parameters that were not taken into
consideration in the present investigation, such as the horizontal
defect depth from the facial bone wall to the implant surface.
Therefore, the results need to be interpreted with caution.
In conclusion, the present study confirmed the long-term
effectiveness of early implant placement with simultaneous
contour augmentation through GBR with a 2-layer composite
graft in postextraction single-tooth sites offering stable bone
conditions with low risks of mucosal recessions over an obser-
vation period of 10 y.
Author Contributions
V. Chappuis, U. Belser, D. Buser, contributed to design,
data acquisition, analysis, and interpretation, drafted and
 Contour Augmentation with Guided Bone Regeneration 9
critically revised the manuscript; L. Rahman, R. Buser, S.
Janner, contributed to the radiographic data acquisition, the
cast analysis, the esthetic score analysis, or their interpreta-
tion, critically revised the manuscript. All authors gave final
approval and agree to be accountable for all aspects of the
work.
Acknowledgments
The authors thank Gabriel Fischer of significantis GmbH Herzwil,
Switzerland, for the statistical analysis. The study was supported
by departmental funds from the universities of Bern and Geneva
and by a research grant from Straumann AG. The authors declare
no potential conflicts of interest with respect to the authorship and/
or publication of this article.
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