Received: 29 December 2016 | Revised: 19 March 2017 | Accepted: 3 April 2017

DOI: 10.1111/cid.12487

ORIGINAL ARTICLE

Immediate implant placement and restoration in the anterior

maxilla: Tissue dimensional changes after 2-5 year follow up

Himanshu Arora, MDS1 | Nabil Khzam, DClinDent2 | David Roberts, MDSc3 |

William L Bruce, MDSc3 | Saso Ivanovski, MDSc, PhD1

1
School of Dentistry and Oral Health,
Griffith University, Gold Coast, Queensland,
Abstract
Australia
Background: Immediate implant placement followed by an immediate restoration has proven to
2
Private practice, Perth, Western Australia,
be a viable technique in the anterior maxillary region.
Australia
3
Private practice, Brisbane, Queensland, Purpose: This prospective study evaluated the mid-long term (2-5 years) tissue changes around
Australia immediately placed and restored implants in the anterior maxilla using flapless surgery and simulta-
Correspondence neous hard tissue augmentation.
Saso Ivanovski, School of Dentistry and
Oral Health, Griffith Health Centre, Griffith Materials and methods: Thirty AstraTech implants were immediately placed in 30 patients, fol-
University - Gold Coast Campus, Parklands lowed by the delivery of an immediate provisional restoration on the same day. All participating
Drive, Queensland 4222, Australia.
30 patients underwent the same treatment strategy that involved flapless removal of a failing max-
Email: s.ivanovski@griffith.edu.au
illary anterior tooth, immediate implant placement, simultaneous augmentation with a
deproteinized particulate xenograft, followed by the connection of a screw-retained provisional
restoration. Radiographs and photographs were used to measure hard and soft tissue changes.
Aesthetic evaluation was performed using the Pink Esthetic Score (PES).

Results: All implants remained osseointegrated during the follow up period of 2-5 years (mean
47 6 15 months). Twelve of the thirty patients completed the 5 year follow up. Radiographic eval-
uation revealed average gains in bone levels of 0.18 and 0.34 mm mesially and distally,
respectively. Soft tissue evaluation showed a mean tissue loss of 0.05 6 0.64 mm and 0.16 6
0.63 mm at the mesial and distal papillae, respectively, while mid-facial mucosal recession was
0.29 6 0.74 mm. A significant improvement in the Pink Esthetic Scores was seen at the final
follow-up (mean PES 11.50), as compared to the baseline (mean PES 10.27) (P 5 .001).

Conclusions: In addition to a favorable implant success rate and peri-implant bony response, the
soft tissue levels and overall aesthetics around single immediately placed and restored implants
can also be maintained in the mid-long term.

KEYWORDS
aesthetics, dental implants, immediate placement and restoration, osseointegration, soft tissue

1 | INTRODUCTION both fully and partially edentulous patients.3,4 Additionally, immediate

Implant dentistry has progressed considerably since its introduction,
with modifications and enhancements being made to the surgical tech-
niques, restorative protocols, and the implants themselves. The initial
delayed loading and placement protocols1,2 have been modified to
expedite the treatment process. These modified protocols (immediate
placement and immediate loading) have been successfully applied in
implant placement has been combined with immediate restoration to
eliminate the load free healing period. Since first reported,5 the imme-
diate placement and restoration (IPR) technique has been recognized
as a viable treatment modality for partially edentulous situations.6
The nature of IPR treatment makes it particularly suited to implant
treatment in the anterior maxilla. Therefore, the focus has now shifted
from hard tissue and osseointegration outcomes to the aesthetic and

Clin Implant Dent Relat Res. 2017;1–9. wileyonlinelibrary.com/journal/cid V

C 2017 Wiley Periodicals, Inc. | 1
2 |
soft tissue results. This increased focus toward implant aesthetics led
to the creation of various indices for evaluation of peri-implant mucosa
as well as implant supported restorations.7,8 When evaluating aesthetic
outcomes, preoperative registration of aesthetic status is very impor-
tant in order to assess the effect of a treatment intervention over time.
Interestingly, very few studies evaluating the IPR protocol provide a
baseline value of aesthetic ratings prior to tooth loss/implant
placement.9–11
Soft tissue dimensional changes around immediately placed and
restored implants have been evaluated using standardized and non-
standardized patient intraoral photographs, study models, as well as
12
prefabricated stents. Although there are a number of studies which
analyzed the effects of the IPR protocol on the soft tissue surround-
ing single implants in the maxillary anterior region,13–19 most of these
have a short follow-up period. Furthermore, the very few long-term
studies that have investigated soft tissue outcomes using this proto-
col have reported variable results. Cooper et al.20 compared immedi-
ately provisionalized implants placed in healed ridges and extraction
sockets in the maxillary anterior region and found no difference in
hard and soft tissue parameters after a period of 5 years. Interest-
ingly, about 21% of the cases treated with immediate placement and
provisionalization showed advanced mid-facial recession of >1 mm.
A recent study found an aesthetic complication rate of 8/17 in well-
selected patients who had been treated by experienced clinicians
9
with the IPR protocol after 5 years, with the authors concluding that
this treatment protocol may not be recommended in daily practice.
Although both of the above-mentioned studies utilized different
implant systems, they had strict patient selection criteria and included
only low aesthetic risk patients. In wake of these findings it becomes
important to analyse the long term effects of this protocol on the
peri-implant tissues.
The aim of this prospective study was to analyse the soft tissue
and aesthetic changes around implants placed with the IPR protocol in
the maxillary anterior region over a follow-up period of 2-5 years.
2 | MATERIALS AND METHODS
2.1 | Study design/patient selection
This study included 30 patients who were recruited and treated for
immediate single tooth implants in the maxillary anterior region at a pri-
vate practice in Brisbane, Australia. Patient selection was undertaken
on the basis of a specified set of inclusion and exclusion criteria.
Inclusion criteria:
1. Age at least 18 years
2. Presence of a single failing tooth in the anterior maxillary region
(13-23)
3. Presence of natural teeth adjacent to the tooth being replaced
4. Adequate bone height apical to the failing tooth to allow for place-
ment of an implant and to achieve a primary stability of at least 30
Ncm
ARORA ET AL.
Exclusion criteria:
1. Contraindications for routine implant therapy (untreated periodon-
titis, uncontrolled diabetes, medical conditions that contraindicate
elective surgery)
2. Smoking >10 cigarettes per day
3. Presence of acute infection around the tooth being replaced
4. Presence of any soft tissue pathology at the gingival margin.
5. Any fenestration or dehiscence in the socket wall of the failing
tooth
Informed consent was obtained from the eligible subjects, and the
study was approved by the Human Research Ethics Committee, Griffith
University, Australia. The study was conducted in accordance with the
Helsinki Declaration of 1975 as revised in 2000.
2.2 | Surgical and prosthetic procedures
Following the initial screening, a comprehensive clinical and radio-
graphic examination was undertaken by the operating surgeon. All sur-
gical procedures were conducted by a single operator (S.I.) under local
anaesthesia. A prophylactic antibiotic dose of Amoxicillin, 500 mg three
times daily, was started a day before surgery and continued for 1
week. On the day of the surgery, the tooth scheduled to be replaced
was removed as atraumatically as possible using periotomes and with-
out flap elevation. This was followed by the placement of an implant,
according to the instructions of the implant manufacturer (Astra Tech,
€ lndal, Sweden). Particular care was taken during the preparation of
Mo
the osteotomy to facilitate both primary stability and screw retained
access, as well as to avoid impingement on the buccal socket wall.
Every attempt was made to engage the palatal and apical bone to
achieve a high primary stability (30 Ncm) while placing the implant in a
correct three-dimensional position.21 In all implant sites, the gap
between the implant and the inner aspect of the buccal socket wall
was filled with deproteinized bovine bone particles (Bio-Oss, Geistlich
Pharma AG, Wolhusen, Switzerland) (Figure 1). Postoperative instruc-
tions included Chlorhexidine rinses twice daily, for a period of 2 weeks.
For pain control, Ibuprofen 400 mg was prescribed, to be used as
needed.
Implant placement was immediately followed by connection of a
temporary abutment onto which a prefabricated screw-retained tem-
porary crown was placed. The provisional restoration was adjusted to
ensure that it was free of any contact in both centric and eccentric
positons. Patients were advised to avoid placing any pressure on the
temporary crown during the healing period. After a period of 3-4
months, the provisional restoration was replaced by a permanent resto-
ration. All prosthetic procedures were performed by two experienced
prosthodontists (D.R., W.B.).
2.3 | Hard tissue measurements
Periapical radiographs were taken with a paralleling technique after
implant placement (baseline) and follow-up appointments to measure
ARORA ET AL. | 3

F I G U R E 1 Clinical illustration of the IPR protocol. (A) Failed maxillary left central incisor to be replaced with an implant, (B) and (C) frontal
and occlusal view after flapless extraction, (D) implant placed in the socket in an appropriate three-dimensional position, (E) buccal gap
grafted with particulate xenograft, (F) implant restored with a provisional crown on the same day, (G-I) follow-up after 1, 2, and 3 years,
respectively

the changes in the alveolar bone height surrounding the implant. The 2.5 | Aesthetic evaluation
radiographs were digitized, and bone level changes were measured
Aesthetic evaluation was carried out using the Pink Esthetic Score
with the help of computer software (Image J 1.43u, NIH, Bethesda,
(PES).7 PES is used to evaluate the peri-implant soft tissue and includes
Maryland). Standardization was carried out using the known implant
seven variables: mesial papilla, distal papilla, soft tissue level, soft tissue
length to calibrate the baseline and follow-up radiographs. The implant
contour, alveolar process deficiency, soft tissue color, and soft tissue
shoulder was used as a reference level from which mesial and distal
texture. Each parameter is assessed with a 0-1-2 score with 2 being
lines were drawn in an apical direction to the first point of contact
the best and 0 being the worst score. The score for each parameter is
between implant and bone, as previously described.17
added to get the eventual PES for each case (maximum possible score
being 14). All the measurements were performed by a single examiner
2.4 | Soft tissue measurements (H.A.), who was not involved in the treatment.

Intraoral photographs were taken before extraction and implant place-

ment (baseline) and follow-up visits to evaluate the soft tissue changes.
A digital SLR camera (Cannon 1300D, Cannon Inc., Tokyo, Japan) was
used to take photographs, at a fixed angle and magnification ratio. Pho-
tos were taken with a periodontal probe with standardized markings to
calibrate changes in the level of soft tissues surrounding the tooth.
Photographs were imported into software (Image J 1.43u, NIH,
Bethesda, Maryland) for further measurements. A line extending from
the incisal edges of teeth adjacent to the implant was used as the refer-
ence point for measurements. From this line, perpendicular lines were
drawn extending to the tip of the mesial papilla, distal papilla, and the
17
mid-buccal gingival margin, as previously described. The variations in
the length of these lines over time were calculated to quantify the soft
tissue changes.
2.6 | Statistical analysis
Mean values and standard deviations were calculated for all parame-
ters. Parametric data were analyzed using a paired t-test; whereas for
nonparametric data, a Wilcoxon signed rank test was used. A fre-
quency analysis was used to describe soft tissue quantitative changes.
The level of significance was set at .05. All calculations were performed
with the SPSS statistical software program (Version 16.0, SPSS Inc.,
Chicago, Illinois).
3 | RESULTS
The study included a total of 30 OsseoSpeed TX implants (Astra Tech,
€ lndal, Sweden) implants, which were placed utilizing the IPR
Mo
4 | ARORA ET AL.

FIGURE 3 Frequency analysis of soft tissue changes from

baseline to final follow-up

the frequency analysis of bone level changes mesially and distally.

FIGURE 2 Bone level changes from baseline to final follow-up
protocol in 30 patients (9 males and 21 females) with an age range of
20-78 years. Sixteen implants replaced central incisors, 12 replaced lat-
eral incisors, and 2 implants were placed in the canine region. The rea-
sons for tooth failure were recorded as fracture (21 cases), endodontic
failure (7 cases), and root resorption (2 cases). Implants placed had
diameters ranging from 3.5 to 5.0 mm and length ranging from 11 to
15 mm. After a mean postoperative period of 48 months (range: 2-5
years), all implants were stable with no loss of osseointegration result-
ing in a cumulative implant survival rate of 100%.
3.1 | Hard tissue measurements
Bone levels around the implants showed an overall gain in bone height
at the final follow up when compared to baseline. Mesial bone levels
showed a mean gain of 0.18 6 1.38 mm (P 5 .85), while distal bone lev-
els showed a mean gain of 0.34 6 1.40 mm (P 5 .22). Figure 2 shows
Bone changes ranged from >2 mm mean loss (3%) to mean gains of
>2 mm (10%) with most of the values lying (30%) between 0.5 mm
loss to 0.5 mm gain (Figure 2).
3.2 | Soft tissue measurements
After a follow-up period of 2-5 years, the mesial and distal papillae
showed a mean recession of 0.05 6 0.64 mm and 0.16 6 0.63 mm,
respectively, while mid-facial mucosal margin showed a mean recession
of 0.29 6 0.74 mm, with no value reaching statistical significance. A
frequency analysis of the soft tissue dimensional changes from baseline
to the final follow-up is shown in Figure 3. Most of the changes were
between 0.5 mm of tissue loss to 0.5 mm tissue gain (Figure 1).
Advanced soft tissue recession (defined as >1 mm by)22 was identified
in the mid-facial mucosa of four patients (13%). Further evaluation
revealed that two of these four patients had no soft tissue level dis-
crepancy when compared to the contralateral natural teeth (Figure 4).
To evaluate the effect of the IPR protocol on the soft tissue
changes in the long-term, a comparison between the 1- and 5-year

FIGURE 4 Case with “advanced” mid-facial recession (>1 mm). (A) Pre-extraction view of maxillary right lateral incisor, (B) advanced mid-
facial recession evident after definitive restoration, (C) comparison with the contralateral natural tooth reveals no discrepancy between the
soft tissue levels after 1 year, (D) soft tissue levels maintained after 5 years
ARORA ET AL. | 5

TA BL E 1 Soft tissue and aesthetic changes between 1 and 5 years 3.3 | Aesthetic evaluation
(baseline—preoperative status)
Table 2 shows the results of various PES criteria preoperatively and at
1 year (n 5 12) 5 years (n 5 12) P-value
the final follow-up. Most of the criteria showed improvement between
Soft tissue variables baseline and final follow-up. The mean PES preoperatively was 10.27
Mesial papillary recession 0.34 6 0.52 –0.06 6 0.66 .009* (SD 2.18; range 5-13). A significant improvement (P 5 .001) was seen
0.35 (0.05-0.68) –0.05 (–0.43-0.43) at the final follow-up appointment, with the mean PES score reaching
[–0.5-1.3] [–1.2-1.2]
11.50 (SD 1.36; range 8-13). In terms of individual PES parameters, the
Distal papillary recession 0.13 6 0.47 –0.06 6 0.58 .225 following variables were seen to improve significantly: soft tissue level,
0.1 (–0.2-0.55) –0.2 (–0.48-0.23) soft tissue contour, soft tissue color, and soft tissue texture (Figure 5).
[–0.7-0.8] [–0.6-1.4]
Once again, to evaluate the effect of the IPR protocol on the aesthetic
Mid-facial recession 0.2 6 0.47 0.23 6 0.69 .776 changes in the long-term, follow-up time points of 1 and 5 years were
0.1 (–0.1-0.58) 0.15 (–0.35-0.8) compared (Table 1). The mean PES scores remained unchanged from
[–0.5-1.0] [–0.8-1.3]
11.17 at 1 year to 11.25 at 5 years (P 5 .48). When evaluating the indi-
PES variables vidual variables, no statistically significant change was seen between
Mesial papilla 1.33 6 0.49 1.58 6 0.52 .25 the 1 and 5-year time points.
1.0 (1.0-2.0) 2.0 (1.0-2.0)
[1.0-2.0] [1.0-2.0]
4 | DISCUSSION
Distal papilla 1.67 6 0.49 1.75 6 0.45 .25
2.0 (1.0-2.0) 2.0 (1.25-2.0) The implant survival rate in this study utilizing the IPR protocol and
[1.0-2.0] [1.0-2.0]
after a follow up period of 2-5 years was 100%. Comparative
Soft tissue level 1.42 6 0.67 1.42 6 0.67 1.00 survival rates have also been seen in other studies utilizing the
1.5 (1.0-2.0) 1.5 (1.0-2.0) same surgical and restorative protocol in the maxillary anterior
[0.0-2.0] [0.0-2.0]
region.5,10,11,13,15,23–26
Soft tissue contour 1.67 6 0.49 1.58 6 0.52 .375 The results from the current study showed a nonsignificant mean
2.0 (1.0-2.0) 2.0 (1.0-2.0) bone gain of 0.18 mm and 0.34 mm mesially and distally, respectively.
[1.0-2.0] [1.0-2.0]
These results are in accordance with several studies which have
Alveolar process 1.5 6 0.52 1.17 6 0.39 .125 reported favorable bone levels with this technique,17,19,23,27–30 albeit
deficiency 1.5 (1.0-2.0) 1.0 (1.0-2.0)
after shorter follow up periods. The present study used Astra Tech
[1.0-2.0] [1.0-2.0]
implants, with a number of features which have been shown to mini-
Soft tissue color 1.83 6 0.39 1.91 6 0.29 .25 mize crestal bone loss including a platform switched design, coronal
2.0 (2.0-2.0) 2.0 (2.0-2.0)
micro threads, and an internal conical connection.31 Similar favorable
[1.0-2.0] [1.0-2.0]
results have been reported in various shorter duration studies when
Soft tissue texture 1.75 6 0.45 1.83 6 0.39 .99 using Astra Tech implants with the IPR treatment protocol.11,16,19,32,33
2.0 (1.25-2.0) 2.0 (2.0-2.0)
[1.0-2.0] [1.0-2.0]
Furthermore, the gap between the implant and the inner walls of the
extraction socket was filled with a slowly resorbing xenograft (Bio-Oss,
Overall PES 11.17 6 1.64 11.25 6 1.36 .48
Geistlich Pharma AG, Wolhusen, Switzerland) in all cases. The increase
11.0 (9.25-13.0) 11.0 (11.0-12.0)
[9.0-13.0] [8.0-13.0] in bone levels could be attributed to the filling of bone in the extraction
socket, and could further have been favored by the implant design.17,24
Values in bold: Mean (SD); italic: Median (IQ range); square bracket:
The positive influence of grafting the peri-implant gap and placing an
[Minimum; maximum].
Negative values indicate increase in soft tissue level. immediate provisional restoration subsequent to flapless immediate
*Significant change between 1 and 5 years utilizing Wilcoxon signed implant placement on maintaining the ridge contour dimensions has
rank test.
also been previously reported.34
This study observed a mean soft tissue recession of 0.29 mm in
the mid-facial region and 0.16 and 0.05 mm in the mesial and distal
time points was carried out. Twelve patients had completed the 5-year papillary region, respectively, after a follow up period of 2-5 years.
follow-up and were included in this subanalysis (Table 1). A statistically These results are similar to the previous studies reporting soft tissue
significant regrowth of 0.4 mm was seen in the mesial papillae changes around implants placed with the IPR protocol in the maxillary
(P 5 .009) between 1 and 5 years. The distal papillary region also aesthetic region.13,15–19,24,35,36
showed a gain in soft tissue levels of an average of 0.19 mm but this The number of studies reporting on advanced recession
was not statistically significant (P 5 .225), whereas the mid-facial muco- (>1 mm) around immediately placed and restored implants is very
sal recession was similar at 0.20 and 0.23 mm for 1 and 5 years, limited, especially when it comes to long term follow-ups. A 3-year
respectively (P 5 .776). follow-up study with immediately placed and restored implants
6 | ARORA ET AL.

TA BL E 2 PES change from baseline to final follow-up

Parameter Score Preoperative Final follow-up P value

Mesial papilla 0 0 0 .10

1 8 6
2 22 24

Distal papilla 0 1 1 .25

1 4 1
2 25 28

Midfacial level 0 3 2 .03

1 12 11
2 15 17

Midfacial contour 0 3 0 .01

1 16 13
2 11 17

Alveolar process 0 0 1 .09

deficiency
1 9 9
2 21 20

Soft tissue color 0 8 1 .007

1 9 13
2 13 16

Soft tissue texture 0 5 0 .001

1 14 10
2 11 20

Overall PES Mean (SD) {Median (IQR)} [Range] 10.27 (2.13) 11.50 (1.36) .001
{11.0 (9.0-12.0)} {12.0 (11.0-12.25)}
[5-13] [8-13]

reported the incidence of advanced mid-facial recession in 8% of
22
cases (2/25 patients). Another study by the same group evaluating
the effect of the IPR technique found early aesthetic complications
(advanced mid-facial recession) in 5/22 cases after 3 months, which
37
were treated with a connective tissue graft. After a follow-up of 5
years, the cases treated with the soft tissue graft maintained
acceptable soft tissue levels, but the authors observed a late
advanced recession in three other cases leading to a high aesthetic
complication rate.9 In our study, advanced recession was seen in
13% of cases (four patients), which is in accordance with the results
from previous studies.12 No soft tissue grafting was performed in
any of the patients included in the current study. It is noteworthy
that out of these four cases with advanced recession, two had no
discrepancy when compared to the contralateral tooth at the final
follow-up and were given a score of 2 for the respective PES param-
eter (Figure 3). This is an interesting finding as sometimes gingival
recession can be deliberately induced by the prosthodontist to cre-
ate harmony with the soft tissue level on the contralateral tooth,

F I G U R E 5 Pink esthetic score results over the time course of the study. (A) Cumulative percent scores for baseline and final follow-up, (B)
average scores for individual variables
ARORA ET AL.
and this was the case in 2/4 cases that were deemed to have expe-
rienced “advanced” recession.
Aesthetic evaluation was also carried out using the PES index. The
mean PES scores increased significantly from 10.27 preoperatively to
11.50 at the final follow-up. Interestingly, very few studies reporting
on the IPR protocol in the anterior maxilla provide a baseline value of
aesthetic ratings prior to tooth loss/implant placement.9–11 Preopera-
tive registration of aesthetic status is important in order to evaluate
changes over time. Significant improvements were seen in four of the
seven PES variables, namely: soft tissue level, soft tissue contour, soft
tissue color, and soft tissue texture. Interestingly, the contour of the
alveolar process was slightly reduced (nonsignificant) at the final
follow-up as compared to the baseline (Alveolar process contour: Base-
line 1.70, follow-up 1.67). This effect has also been reported in two
previous studies on immediately placed and provisionalized single-
tooth implants.10,11 The authors of both studies reported improved
overall PES outcomes using autogenous bone chips for filling the
implant-bone gap without any soft-tissue grafting, but a deterioration
of the alveolar process was observed after a period of 2-11 and 3-
years.10 Although the shrinkage of the alveolar process seen in this
study was not statistically significant, this variable needs further
exploration.
An important consideration is the utilization of cone beam com-
puted tomography (CBCT) to radiographically evaluate the bone pres-
ent on the buccal surface of implants. The presence or absence of a
bony lamella can affect the level of mid-facial soft tissue around
implants. Implants without any visible bone on a CBCT have been
reported to have their mucosal level 1 mm apically placed as compared
38
to implants with radiographically evident buccal bone. Noelken
et al.10 observed the changes in the thickness of buccal bone using
CBCT following the immediate placement and restoration technique.
The authors reported an improvement in the thickness of buccal bone
over a period of 3-years, which was attributed to strict control over
implant positioning, flapless placement, and the use of autogenous
bone for grafting. The authors avoided the use of nonautogenous
materials due to concerns over impaired resorption resulting from a
foreign body reaction, which is interesting in the context of the use of
a xenograft in our study. Notwithstanding the fact that this xenograft
has been widely studied and documented, the possibility of a foreign
body reaction cannot be ruled out and the possible role in peri-implant
tissue loss may warrant further investigation.
In regards to the long-term soft tissue changes, the mesial papillary
levels showed a significant gain between 1 and 5 years. The distal pap-
illae were also seen to improve but the difference was not significant.
A slight increase in papillary dimension following an initial loss, suggest-
ing a papillary rebound, has also been reported in a recent systematic
review of soft tissue outcomes using the IPR technique.12 Similar
9
results have also been reported by Cosyn et al., who reported a signif-
icant increase in papillary height after 5 years. The disparity between
the mesial and distal papillary growth observed in the present study
has also been described in other studies, with authors noting the diffi-
culty in maintaining distal papilla levels.39–41 The reasons for this obser-
| 7
vation are unclear and warrant further investigation. Interestingly, the
mid-facial gingival levels were maintained between the period of 1-5
years in this study, which is favorable when compared to the increased
recession reported by Cosyn et al.9 over the same timeframe, although
this finding was based on fewer cases that completed the 5-year fol-
low-up (12 compared to 17).
Aesthetic evaluation with the help of PES showed no significant
changes in the mean values between 1 and 5 years (11.17 vs. 11.25;
P 5 .48). Cosyn et al.9 reported a significant decrease in the overall PES
values between 1 and 5 years. The significant decrease in the PES val-
ues was observed despite improved mesial and distal papillae, with the
authors pointing to soft tissue level and alveolar process deficiency as
factors leading to a poor aesthetic outcome. No statistically significant
changes in the alveolar process were observed in the current study,
and the soft tissue level as well as the papillae were maintained at
acceptable levels between 1 and 5 years. Nonetheless, the current
results should be interpreted with caution due to the small number of
patients (n 5 12) who completed the 5-year follow-up. In the future, it
would be interesting to see more controlled studies exploring the long
term clinical and aesthetic effects of the IPR protocol in the maxillary
anterior region.
5 | CONCLUSION
This prospective 2-5 year follow-up study showed that immediately
placed and restored implants with a flapless technique in the maxillary
anterior region yielded positive results in terms of osseointegration,
hard, and soft tissue results, as well as aesthetic outcomes. It should be
noted that the study utilised a standardised treatment protocol using
flapless surgery and augmentation of the gap between the implant and
the buccal socket wall, as well as specific inclusion criteria including
intact socket walls and absence of gingival pathology.
CONFLIC T OF I NTE RE ST
The authors declare no conflict of interest in relation to this
manuscript.
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