Esthetic Evaluation of Anterior Single-Tooth Implants with

Different Abutment Designs—Patients’ Satisfaction

Compared to Dentists’ Observations
Ratnadeep Patil, BDS,1,2 Marco M.M. Gresnigt, DDS, PhD,2 Kavita Mahesh, BDS,1 Anjali Dilbaghi, BDS,1
& Marco S. Cune, DDS, PhD2,3
1
Department of Clinical Dentistry, Smile Care Clinic Pvt Ltd, Mumbai, India
2
Rijksuniversiteit Groningen, University Medical Center Groningen, Center for Dentistry and Oral Hygiene, Department of Fixed and Removable
Prosthodontics and Biomaterials, Groningen, The Netherlands
3
Department of Oral-Maxillofacial Surgery, Prosthodontics and Special Dental Care, St. Antonius Hospital, Nieuwegein, The Netherlands

Keywords
Implant esthetics; patient satisfaction; PES;
VAS; curved abutment; single-tooth dental
implants.
Correspondence
Ratnadeep Patil, Smile Care Clinic Pvt
Ltd—Department of Clinical Dentistry, 1/C
3-3, Sujata Niwas, S V Road, Bandra,
Mumbai, Maharashtra 400050, India. E-mail:
ratnadeeppatil@gmail.com
The authors deny any conflicts of interest.
Accepted August 21, 2015
doi: 10.1111/jopr.12423
Abstract
Purpose: To correlate patients’ satisfaction and dentists’ observations regarding two
abutment designs used for single crowns in the esthetic zone: a divergent one (control)
and a curved one (experimental), with special emphasis on muco-gingival esthetics.
Materials and Methods: Twenty-six patients with nonadjacent missing teeth in the
esthetic zone were enrolled in a randomized clinical trial (within-subject comparison).
Two implants placed in each were restored using abutments of different geometry.
Patients’ appreciation was assessed on a visual analog scale (VAS) by recording
answers to three questions, and dentists’ appreciation was determined by means of
the Pink Esthetic Score (PES) at T0 (crown cementation, baseline) and at T12 (1 year
post-cementation). ANOVA with post hoc analysis was used to identify differences
between groups and at different moments in time. Pearson correlations were calculated
between all variables, both at T0 and at T12.
Results: No statistically significant differences were found at any time between the
control and experimental abutment design, either for the PES or for the VAS score.
PES slightly improved after 1 year, as did the VAS rating related to functioning with the
implant-crown compared to the natural teeth. All PES and VAS scores demonstrated
highly significant correlation. Both patient satisfaction and professional appreciation
of muco-gingival conditions after single implant treatment in the esthetic zone were
high; however, the curved, experimental abutment design performed no better than
the conventional, divergent type.
Conclusion: Curved abutment design does not significantly impact crown or gingival
esthetics as assessed by PES and VAS scored by dentists and patients, respectively.

Implant dentistry has been constantly evolving in terms of
materials and surgical protocols over the last few decades with
the objective of improving patient-oriented results. Initially,
success and survival rates for dental implants were measured
only in terms of osseointegration. Albrektsson’s criteria for
success1 were considered to be well established and were
widely used in clinical studies as a “rule” for analyzing success
rates; however, these osseointegration-oriented criteria were
not adequate to holistically assess the success and survival
of the outcomes and, hence, other factors such as gingival
and crown esthetics were incorporated. The appearance of the
peri-implant soft tissue was recognized as a crucial factor in
the success of implant therapy.2 With osseointegration and
restoration in function, patient satisfaction was also considered
as a key factor in the success of implant therapy in the anterior
maxilla.3 Therefore, Smith and Zarb4 extended the criteria by
emphasizing that a successful implant must factor in optimal
esthetic outcome. In 2005, Furhauser et al5 proposed an index
termed the Pink Esthetic Score (PES), focusing essentially on
the soft tissue aspects of anterior implant restorations. Success
in implant dentistry should ideally evaluate the long-term
primary outcome of an implant-prosthetic complex as a whole.6
Despite the importance of esthetic outcomes, only a few stud-
ies included in a recent systematic review evaluated the esthetics
of implant-supported single crowns.6 Some studies asked pa-
tients to rate overall satisfaction with the implant-supported
crowns, and others were asked to rate only crown shape
and color. Some studies had the practitioner, not the patient,

Journal of Prosthodontics 0 (2016) 1–4 

C 2016 by the American College of Prosthodontists 1
PES vs. VAS Score for Anterior Modified Abutment Design
Figure 1 Experimental grooved (left) and control conventional abut-
ments (right, Nobel Biocare).
evaluate the implant restoration esthetics. It has been proven
that the practitioner’s perspective is different than that of
the patients.7-9 The importance of using computer-aided de-
sign and computer-aided manufacturing (CAD/CAM) to repro-
duce a favorable shape of the abutment that would support
the peri-implant soft tissue and ensure better esthetics was
discussed.10,11
The aim of this study was to assess patients’ satisfaction
after implant therapy and correlate patients’ perception with
professional observers’ opinion on the esthetics of maxillary
single-tooth implants in the esthetic zone when a variation in
the abutment design was used.
Materials and methods
A randomized clinical trial (within-subject comparison) was
set up. Necessary ethical approval and written informed
consent were obtained for the study. Twenty-six patients with
nonadjacent missing teeth in the esthetic zone, namely between
the second premolar bilaterally and in the same arch, received
52 tapered implants (Replace Select; Nobel Biocare, Goteborg,
Sweden). All sites were completely healed at the time of
surgery. After 17 to 19 weeks they were randomly assigned
a conventional divergent abutment (control, Esthetic; Nobel
Biocare) or a curved abutment (experimental, Curvy; Nobel
Figure 2 Intraoral photographs (1:1.5 ratio) for PES and VAS scoring. Control (divergent) and experimental (curved) abutment at T0 (A and B,
post-cementation) and at T12 (C and D, after 1 year).
2 Journal of Prosthodontics 0 (2016) 1–4 
Patil et al
Biocare).The experimental abutment had an additional macro
groove of about 0.5 mm in depth, and the total height of the con-
cave profile was 1.25 mm (Fig 1). Such a macro groove has been
hypothesized to increase the interface between the abutment
and the soft tissue, creating an “O-ring connective tissue.”12
Frontal view intraoral photographs at a 1:1.5 ratio were taken
with a Rebel XT camera (Canon, Tokyo, Japan) under standard
light conditions for all implant restorations at the day of
cementation (T0) and 1 year post-cementation (T12) (Fig 2).
A questionnaire to record patients’ satisfaction was based
on a visual analog scale (VAS) for all 26 patients at T0 and
T12. A horizontal VAS bar, 100 mm long, with the left anchor
labeled "much less than natural teeth" and the right anchor la-
beled "much more” was used. Three questions were formulated
to record patients’ satisfaction in terms of functionality and
from an esthetic point of view (Fig 3). The questionnaires were
accompanied by simple and precise instructions. Participants
looked in a mirror and also viewed a photograph before record-
ing their answers on the horizontal, calibrated line. The same
photograph was assessed by a dentist who was not involved in
the treatment and was blinded with respect to the group the pa-
tient belonged to. The PES was calculated for all 52 sites, both
at T0 and T12.PES evaluated seven variables: mesial papilla,
distal papilla, soft-tissue level, soft-tissue contour, alveolar pro-
cess deficiency, soft-tissue color, and soft-tissue texture. Using
a 0-1-2 scoring system,6 0 being the lowest, 2 being the highest
value, the maximum achievable PES was 14.
ANOVA with post hoc analysis (Student-Newman-Keuls)
was used to compare mean PES and VAS scores for both groups
at baseline and after 1 year. Pearson correlations were calcu-
lated to identify correlations between patient and dentist appre-
ciation. All computations were performed in SPSS v.23 (SPSS
inc., Chicago, IL).
Results
Overall patient satisfaction levels were high at both moments in
time. No statistically significant differences were found at any
time between the control and experimental abutment designs,
neither for the PES nor for the VAS scores. PES scores had
slightly improved after 1 year, as did the VAS rating related to
question 2, which referred to the functioning with the implant-
crown compared to the natural teeth (Table 1). All PES and VAS
scores correlated highly significantly with each other, although
correlation coefficients were sometimes low (Table 2).
C 2016 by the American College of Prosthodontists
Patil et al PES vs. VAS Score for Anterior Modified Abutment Design

Table 1 Mean VAS answers to three questions PES values for control (divergent) and experimental (curved) abutments compared at T0 and T12
(standard deviation between parentheses, ANOVA with post hoc analysis by means of Student-Newman-Keuls test)

at T0 at T12 p-value
Control (a) Experimental (b) Control (c) Experimental (d)

VAS
Q1 9.5 (0.6) 9.6 (0.5) 9.7 (0.5) 9.5 (1.2) F(3,100) = 0.68, p = 0.57
Q2 9.4 (0.6) 9.5 (0.7) 9.8 (0.4) 9.9 (0.3) F(3,100) = 5.31, p = 0.002;a = b<c = d
Q3 9.6 (0.6) 9.5 (0.6) 9.6 (0.6) 9.5 (1.3) F(3,100) = 0.12, p = 0.95
PES 9.0 (1.4) 8.7 (1.5) 10.2 (1.5) 10.0 (1.8) F(3,100) = 5.48, p = 0.002;a = b<c = d

sidered for the overall patient satisfaction at two time points in

Figure 3 Questionnaire consisting of three questions on a VAS.
Table 2 Pearson correlations between mean VAS answers to three
questions and PES values for control (divergent) and experimental
(curved) abutments at T0 and T12
PES VASq1 VASq2
PES 1 0.31 0.29
VASq1 1 0.3
VASq2 1 0.29
VASq3
All correlations are significant at the 0.01 level (2-tailed), n=104.
Discussion
Esthetics around implants depends upon several factors from
anatomical and surgical perspectives.3 In this study the esthetic
benefit of a curved abutment over a conventional divergent
abutment was tested.
The ultimate goal of the therapy is to satisfy the patient’s
desire to replace a lost tooth with a functional and esthetic so-
lution. Hence, criteria for successful implant therapy should
always incorporate the patient’s view. If objective indices by
clinicians are not correlated with the patients’ esthetic percep-
tion, the practitioner may be overlooking potential treatments
or materials that could better satisfy the patients needs. In this
study, the patients were presented with three simple but specific
questions, and the scores of the combined answers were con-
the study.
The results to the question on muco-gingival esthetics and
the PES recorded by a trained observer were tabulated, and the
trends of the observations were compared. Although it is impos-
sible to directly compare the patient and dentist perspectives,
as they used different scoring systems, a substantial agreement
between the two groups was observed in relation to the muco-
gingival esthetics. Both patient satisfaction and professional
appreciation of muco-gingival conditions after single implant
treatment in the esthetic zone were high. Both groups showed
no difference in the mucogingival esthetic results using abut-
ments of different geometries.
Studies involving modification in implant abutments by
CAD/CAM to manage the peri-implant soft tissue11,12 have
indicated a favorable esthetic outcome. This is contrary to the
results seen in our study. Further studies with larger sample
sizes are recommended to ascertain the influence of abutment
design on peri-implant gingival esthetics.
Conclusion
The results of the study indicated that the curved experimental
VASq3 abutment design performed no better than the conventional,
0.31 divergent type with respect to gingival esthetics as assessed by
0.74 PES and VAS score by dentists and patients, respectively.
1 Acknowledgments
We are grateful for the support of Nobel Biocare who pro-
vided the implants and abutments without cost. We especially
thank Mrs. Seema Tolani for her valuable contribution in record
maintenance.
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