Immediate Placement and Restoration of Dental Implants in the Esthetic Region: Clinical Case Series

Transcription

1 RESEARCH ARTICLE Immediate Placement and Restoration of Dental Implants in the Esthetic Region: Clinical Case Series NABIL KHZAM, BDS, MPhil, DClinDent*, NIKOS MATTHEOS, DDS, MASc, PhD, DAVID ROBERTS, BDSc, MDSc, WILLIAM L BRUCE, BDSc, MDSc, SASO IVANOVSKI, BDSc, BDentSt, MDSc, PhD ABSTRACT Aim: The objective of this study was to assess the hard and soft tissue changes following immediate placement and provisional restoration of single-tooth implants in the aesthetic zone. Methods: Thirteen patients with immediately placed and restored implants were included in this study. All participating patients underwent the same treatment strategy that involved removal of the failed tooth, flapless surgery, immediate implant placement, and connection of a screw-retained provisional restoration. Three months following implant placement, the temporary crowns were replaced by the definitive restorations. Implant survival rates, and hard and soft tissue changes were measured using periapical X-rays and photographs. The range of the observation period was between 12 and 37 months with a mean period of 23.2 ± 7.6 months. Results: At the time of follow-up, all implants were present with no complications. Radiographic evaluation revealed a mean mesial bone gain of 1.20 ± 1.01 mm and a mean distal bone gain of 0.80 ± 1.14 mm, which reached statistical significance. The mean mid-buccal recession was 0.20 ± 0.78 mm, whereas the mesial and distal papillae height loss was 0.50 ± 1.26 mm and 0.30 ± 0.82 mm, respectively. The changes in the soft tissues did not reach statistical significance. Conclusion: Notwithstanding the limitation of a small sample size, this study shows that immediate implant placement and provisional restoration in the maxillary aesthetic zone can result in favorable treatment outcomes with regards to soft and hard tissues changes over a follow-up period of 23.2 ± 7.6 months. CLINICAL SIGNIFICANCE Most clinical trials investigating immediate implant placement and immediate restoration in the maxillary anterior zone have focused on implant survival and implant success, with particular emphasis on radiographically assessed hard tissues changes. However, this study assesses the soft tissue changes associated with this procedure, which is an important area of study given the esthetic demands of implant therapy in the maxillary anterior region. (J Esthet Restor Dent :, 2013) INTRODUCTION Single tooth replacement with an implant supported crown is often the treatment of choice for missing teeth in the anterior maxilla. The original implant treatment protocol described by Branemark involved 3 months of healing following extraction of a failed tooth, and an additional 3 to 6 months of a load-free period following implant placement. 1,2 In the last 20 years, implant dentistry has evolved dramatically, with the original two-stage protocol modified to include one-stage surgery, 3 immediate implant placement into a fresh *Specialist Periodontist, Private Practice, University of Tripoli, Libya Associate Professor, The University of Hong Kong, Hong Kong Specialist Prosthodontist, Private Practice, Brisbane, Qld, Australia Specialist Prosthodontist, Private Practice, Brisbane, Qld, Australia Professor of Periodontology, School of Dentistry and Oral Health, Griffith University, Gold Coast, Qld, Australia 2013 Wiley Periodicals, Inc. DOI /jerd Journal of Esthetic and Restorative Dentistry Vol No

2 extraction socket and immediate implant restoration. 4,5 These three approaches have been combined in an attempt to further expedite the restorative process. 6 Clinical trials have shown high levels of implant survival and success for single tooth implants placed directly into fresh extraction sockets. 6,7 Furthermore, it has been shown that immediately placed implants may be provisionally restored with a temporary crown that is placed out of occlusion (immediate provisional restoration). This one-stage surgical and restorative procedure has the advantage of an immediate esthetic outcome with a fixed restoration, while eliminating the need for temporary fixed and/or removable partial dentures, and potential second-stage surgical intervention. It also allows for shorter treatment times as post-extraction socket-healing events coincide with implant osseointegration. However, case selection is critical for this treatment approach, with multiple contraindications such as the presence of infection at the extraction site, inadequate soft tissue profile, and the requirement for sufficient bone apical to the socket in order to achieve appropriate primary stability. From a surgical point of view, good primary stability appears to be critical for the one-stage surgical procedure, as it has been shown that there is a strong relationship between the placement torque and the survival of single tooth-implants. 8 Adequate primary stability is of additional importance in cases where the implant is provisionally restored in order to withstand various forces that may be exerted on the restored implant during the early stages of healing. From a restorative point of view, the implant temporary crown must be out of occlusion in both centric and eccentric positions of the lower jaw. 6 Indeed, the immediate implant placement and restoration protocol is technically challenging and can be considered a technique sensitive procedure. 9 A major consideration in the maxillary anterior region is the loss of buccal tissue contour following tooth extraction. In order to minimize this loss of buccal tissue, the placement of a grafting material in the space between the implant and the buccal socket wall has been advocated and is supported by histological evidence that this approach significantly decreases bone loss following immediate implant placement The use of antibiotic prophylaxis in patients undergoing routine implant placement to minimize complication is supported by the literature and hence are indicated in more challenging clinical protocols such as that described in this study. 14 Most clinical trials investigating immediate implant placement and immediate restoration in the maxillary anterior zone have focused on implant survival and implant success, with particular emphasis on radiographically assessed hard tissues changes. However, few studies have assessed the soft tissue changes associated with this procedure, although this is an important consideration given the esthetic demands of implant therapy in the maxillary anterior region. Therefore, the objectives of the current study were to assess the soft and hard tissue dimensional changes associated with immediately placed and provisionally restored implants replacing single teeth in the anterior maxillary region after a minimum follow-up of 12 months. METHODS The research protocol was reviewed and granted ethical approval by the Griffith University Human Research Ethics Committee (DOH/09/09/HREC). Patient selection Thirteen patients who received 15 immediately placed and provisionally restored implants in the esthetic zone between March 2007 and December 2008 were included in this study. Two of the patients had two implants each. Patients were included in this study based on their willingness to attend 6 monthly review visits following their treatment. The sample included four males and nine females, mean age 44.7 ± 18.7 years, with 15 implants (13 incisors, 1 canine, and 1 premolar) (Table 1). None of the patients were smokers. No patients were lost at the final follow-up. 2 Vol No 2013 Journal of Esthetic and Restorative Dentistry DOI /jerd Wiley Periodicals, Inc.

3 TABLE 1. Tooth types and reason for tooth extraction Tooth type/ reason for extraction Inclusion and Exclusion Criteria The decision to progress with immediate implant placement and provisional restoration was determined following a comprehensive clinical and radiographic examination (using a cone-beam computed tomography [CBCT] scan), and detailed consultation between the surgical and restorative clinician. Aside from the usual contraindications for routine implant therapy (untreated periodontitis, uncontrolled diabetes, medical conditions that contraindicate elective surgery), specific contraindications for the immediate implant placement and restoration protocol included the presence of any pathological bone loss around the tooth or any gingival margin pathology or irregularity. Furthermore, the immediate implant placement and provisional restoration protocol was not implemented unless the tooth socket walls were completely intact (no fenestrations or dehiscences) following extraction, and a minimal implant torque insertion of 30 Ncm (maximum of 40 Ncm) was obtained. Surgical Protocol Endodontic Fracture Root resorption Incisors Canines Premolars Total Total All surgical procedures were conducted under local anesthesia. Preoperative antibiotics were given to all patients. This prophylactic dose was 500 mg Amoxicillin three times daily (20 caps) for 1 week, starting 1 day before surgery. Diagnostic evaluation of the site of placement included clinical examination, radiographic analysis using a cone-beam CT scan and occlusal analysis with study models. After informed consent was obtained from the patient, atraumatic tooth extraction using a periotome without flap elevation was performed (Figure 1B). Surgical implant placement followed, according to the instructions of the implant manufacturer (Astra Tech, Mölndal, Sweden) (Figure 1C). Primary stability was achieved to a minimum insertion torque of 30 Ncm using a motor-driven surgical handpiece. In all implants sites, the buccal space between the implant and the socket wall was filled using a xenogenic particulate bone grafting material (Bio-Oss; Geistlich Pharma AG, Wolhusen, Switzerland). Postoperative instructions included chlorhexidine mouthwash (20 ml) use for 2 minutes twice daily for 2 weeks. Patients were instructed to not brush the implant site for at least 2 weeks. For pain control, patients were advised to use either 1 g of Paracetamol or 400 mg of Ibuprofen as needed. Restorative Protocol After connection of a temporary abutment (Figure 1D), a prefabricated screw-retained temporary crown was adjusted and placed (Figure 1E). Appropriate adjustment of the occlusal scheme was carried out in order to ensure that the temporary restoration was free of any contact in both centric and eccentric excursions (Figure 1F). Final finishing of the provisional crown was carried out with rubber cups and pumice. The patients were advised to avoid placing any pressure on the provisional restoration, especially during eating. After 3 to 4 months, the temporary restoration was replaced with a custom zirconia abutment (Procera, Nobel Biocare, Göteborg, Sweden) and a permanent all-ceramic restoration by a prosthodontist. Hard Tissue Measurements Periapical X-rays were used to measure the changes in alveolar bone height surrounding the implant from the time of placement of the temporary restoration (baseline) to the follow-up assessment, which was at least 12 months later. The parallel technique was used in order to obtain comparable X-rays, and standardization was carried out by using the known implant length to calibrate the baseline and follow-up measurements. The implant shoulder was used as a reference level from which mesial (Mbc) and distal (Dbc) lines were drawn in an apical direction to the 2013 Wiley Periodicals, Inc. DOI /jerd Journal of Esthetic and Restorative Dentistry Vol No

4 A B C G D E F FIGURE 1. A, Failed tooth due to improper root canal treatment (12) before the extraction. B, Minimal traumatic tooth extraction. C, Implant placed in final position. D, E, and F, Temporary crown in place. G, A radiograph. first point of contact between bone and the implant (Figure 2). Computer software (Image J 1.43u; National Institute of Health, Bethesda, MD, USA) was used to calculate the length of these lines (Mbc and Dbc) and express it as an absolute measurement in millimeters. Soft Tissue Measurements The soft tissue data were collected from photographs taken with a fixed angle and zoom ratio prior to tooth extraction (baseline) and at the follow-up visit (at least 12 months later). The crown length of the tooth mesial to the implant measured from the margin of the gingiva was set as the reference length. This allowed comparisons of the changes that occurred before and after the treatment with regard to the position of the gingiva and the amount of recession. A line extending from the incisal edges of the teeth adjacent to the implant (Ocl) was the starting point for the measurements. From this line, perpendicular lines were drawn extending to the tip of the mesial (Mp) and distal (Dp) papilla, as well as the middle of the mid-buccal gingival margin (Bm) (Figure 3). The length of these lines was calculated based on the clinical photographs using a software program (Image J 1.43u), and variations over time were calculated in millimeters. Other Measurements Implant survival rate: defined as the percentage of implants that were present at the final follow-up. Implant success rate: defined as the percentage of symptom and pathology free implants at the final follow-up. Assessment of interdental papilla: The triangular interdental papillae occupying the space between the implant retained restoration and the adjacent teeth were assessed using Jemt s index. 15 Jemt s Index comprises of: score 0 (no papilla present), score 1 (<1/2 of papilla present), score 2 (1/2 of papilla present), score 3 (papilla fills entire interdental space), and score 4 (hyperplastic papilla present). Statistical Analysis The primary hypothesis of this study was that there is no significant change between tooth extraction/implant placement and follow-up with regards to the hard and 4 Vol No 2013 Journal of Esthetic and Restorative Dentistry DOI /jerd Wiley Periodicals, Inc.

5 A B FIGURE 3. Illustration of the measurements of soft tissue on photographs. Bm = distance to middle of buccal gingival margin; Dp = distance to distal papilla; Mp = distance to mesial papilla; Ocl = occlusal line. FIGURE 2. Illustration of hard tissue measurements on periapical X-ray. Cl = coronal line; Dbc = distal bone contact; Mbc = mesial bone contact. A set of paired radiographs used for measurements. A = baseline radiograph; B = follow-up radiograph. soft tissues changes. In case of parametric data, a paired t-test was used, whereas in nonparametric data a Wilcoxon signed-rank test was used. A frequency analysis was used to describe the distribution of hard and soft tissue changes among the patients. All calculations were performed with the SPSS statistical software program (version 16.0, SPSS, Inc., Chicago, IL, USA). demographics, implant characteristics and follow-up intervals are shown in Table 2. No implant loss or implant associated pathology was observed at the final follow-up visit. Representative outcomes of the treatment are illustrated in Figures 4 to 6. Hard Tissue Measurements Radiographic evaluation revealed a mean mesial bone gain of 1.20 ± 1.01 mm (p < ), which reached statistical significance. The mean distal bone gain was 0.80 ± 1.14 mm (p = 0.01), which also reached statistical significance. Table 3 shows that there was a significant change in both the mesial and distal bone level between the time of implant placement and the follow-up assessment. Table 4 shows the distribution of bone gain and loss in millimeters for individual patients. The majority of the readings demonstrated bone gain 0.5 mm (13/15 cases). RESULTS The reasons for tooth loss of the 15 implants (13 incisors, 1 canine, and 1 premolar) included in this study are outlined in Table 1. The patient Soft Tissue Measurements The mean mid-buccal gingiva recession was 0.20 ± 0.78 mm (p = 0.44). The mesial papillary height loss was 0.50 ± 1.12 mm (p = 0.24), whereas the distal papillary height loss was 0.30 ± 0.82 mm (p = 0.27) Table 5. The 2013 Wiley Periodicals, Inc. DOI /jerd Journal of Esthetic and Restorative Dentistry Vol No

6 TABLE 2. Overview of clinical data Patient No. Sex Age (years) Follow-up (months) Site of implant Length (mm) Diameter (mm) 1 M M F F F F M M F F M F F F F M = male, F = female. mesial papilla showed the highest amount of tissue loss. The changes in the soft tissues did not reach statistical significance. Table 6 shows the distribution of soft tissue changes on the mesial, distal, and mid-facial aspects of individual implants. Most of the readings remain within ±10% of the baseline value except for the mesial changes which reach up to 35% in the patients that had two implants placed adjacent to each other. Jemt s Index Wilcoxon signed-rank test did not reveal any significant difference in the Jemt s index score for either mesial or distal papilla between implant placement and follow-up observations (p-values and 0.171, respectively) (Table 7). At follow-up, 50% of the mesial papillae received a score of 3, which means that the full height of the interdental papillae was present (normal), whereas the same score was recorded in 60% of distal papillae. The rest of the results showed scores of 1, 2, and 4. No score of 0 was recorded. DISCUSSION In this case series report, immediately placed and restored single-tooth implants in the maxillary anterior zone were found to osseointegrate and remain complication-free after 23.2 ± 7.6 months of follow-up. This result is in accordance with outcomes presented in other similar studies, demonstrating the high predictability of osseointegration when a very specific set of selection criteria is applied, and a strict surgical and restorative protocol is observed. This study utilized the Astra Tech implant system, which has several abutment-implant interface characteristics common to contemporary implant 6 Vol No 2013 Journal of Esthetic and Restorative Dentistry DOI /jerd Wiley Periodicals, Inc.

7 FIGURE 4. Illustration of soft tissue on photographs, (22)-baseline and follow-up. FIGURE 5. Illustration of soft tissue on photographs, (21)-baseline and follow-up. systems. Astra Tech implants have a rough surface, an internal connection, a platform switch at the abutment-implant interface and microthreads at the coronal aspects of the implant. These design features are incorporated primarily to enhance the stability of the hard and soft tissues, although it is unclear if, and to what extent, each of these features may contribute to tissue stability. It is likely that some or all of the features of the Astra Tech system, many of which it shares with other currently available implant designs, has contributed to the positive outcomes of this study. This study showed a mean mesial bone gain of 1.20 mm and a mean distal bone gain of 0.80 mm over the duration of the follow-up period (23.2 ± 7.6 months). The changes in the hard tissues reached statistical significance compared with baseline suggesting that there was bone gain in a coronal direction at the interproximal aspects over the duration of the study. This is not surprising because the implants were placed in extraction sockets, and there was subsequent bone fill in the space between the implant and the socket walls, resulting in the coronal repositioning of the bone-implant contact over the course of the study. The bone gain was also assisted by the use of a slowly resorbing particulate bone graft. Knowing the exact implant length and diameter allowed for precise measurement of the bone level in millimeters, compensating for any distortion of the radiograph. This was an important element of the methodology in contrast with much of the literature, where measurements are only made with the use of the apical 20,22 or the coronal end 23 of the implant shoulder as a reference point. Other studies have used the contact point of the restoration to the adjacent tooth as a reference point. However, the use of these landmarks 2013 Wiley Periodicals, Inc. DOI /jerd Journal of Esthetic and Restorative Dentistry Vol No

8 TABLE 4. Frequency analysis of hard tissue changes in millimeters Bone changes in mm/patients 2.5 and 2 mm and 1.5 mm and 1 mm and 0.5 mm and 0 mm and 0.5 mm and 1 mm 0.63 TABLE 5. Soft tissue level changes (presented as millimeters change) Parameters Change in mm p-value Mesial papilla level 0.50 ± Distal papilla level 0.30 ± Mid-buccal ginigval level 0.20 ± FIGURE 6. Illustration of soft tissue on photographs, (21)-baseline and follow-up. Mean ± standard deviation. TABLE 3. Bone level changes (presented as millimeters change) Parameters Change in mm p-value Mesial bone level 1.20 ± * Distal bone level 0.80 ± * Mean ± standard deviation. *Significant. has some limitations, namely that the restorative contact point is not going to be constant as the provisional crowns will undergo replacement with permanent restorations, whereas the radiographic location of the apical/coronal shoulder is easily affected by image distortion. 24 The results of the present study, which showed a relatively high amount of bone gain, compares favorably with other studies involving implant therapy in the maxillary anterior zone. 18,19,22,25 28 Using the immediate placement and restoration protocol, Kan and colleagues showed a mean marginal bone loss ranging from 0.26 to 0.40 mm on the mesial and 0.22 to 0.28 mm on the distal aspect of the implant at 1-year follow-up. 23 Several other investigators have shown even greater amounts of bone loss. The study by De Rouck and colleagues revealed a mean bone loss of 0.98 mm on the mesial aspect of the implant and 0.78 mm distally at 1-year follow-up. 6 Other studies using the immediate implant placement and immediate restoration approach have shown similar outcomes. 23,24,29 31 On the other hand, Kan and colleagues reported that scalloped shaped implants placed into extraction sites showed a mean bone gain of 1.0 mm after 1 year of follow-up. 7 The amount of bone gain in this study was attributed to the placement of a bone graft into the gap between the implant and walls of the extraction socket that subsequently resulted in radiographically assessed bone fill. Our study used a platform switching implant 8 Vol No 2013 Journal of Esthetic and Restorative Dentistry DOI /jerd Wiley Periodicals, Inc.

9 TABLE 6. Frequency analysis of soft tissue changes in percentage Soft tissue changes in percentage/patients 10% and 5% 5.96 (DP) 5.90 (MP) 5.12 (MP) 7.70 (MF) 5.95 (MF) 5% and 0% 1.02 (DP) 2.06 (DP) 1.79 (MP) 0.11 (MP) 1.83 (MF) 4.58 (MF) 0.95 (MF) 4.5 (MF) 0% and 5% 2.57 (DP) 1.62 (DP) 1.13 (DP) 1.82 (DP) 0.36 (DP) 2.31 (DP) 0.72 (MP) 1.14 (MP) 0.96 (MP) 0.39 (MF) 1.09 (MF) 4.72 (MF) 5% and 10% 8.98 (DP) 9.55 (DP) 7.43 (DP) 9.03 (DP) 9.55 (MF) 8.05 (MF) 9.99 (MF) 10% and 15% (MP) (MP) (MP) (MF) (MF) 15% and 20% (DP) 20% and 25% (MP) 25% and 30% (MP) 30% and 35% (MP) DP = distal papilla; MF = mid-facial gingival; MP = mesial papilla. TABLE 7. Changes in the interdental papilla Parameters Amount of change p-value Mesial papilla level 1.342* Distal papilla level 1.242* *Z value design, flapless surgery, and applied a particulate bone graft between the tooth socket and the implant, which may account for the reported increase in interproximal bone height over the observation period. Soft tissue measurements have been reported in only a few studies utilizing immediate placement and immediate provisional restoration of implants in the anterior maxilla. This study showed mean mid-buccal gingival recession of 0.20 mm, whereas the mesial and distal papillae were apically positioned by 0.50 and 0.30 mm respectively, compared with baseline. Overall, no statistically significant changes in the aesthetically important mid-buccal soft tissue profile were found compared with baseline. Furthermore, no statistically significant changes in papilla levels were noted when the results were accurately measured in millimeters. This indicates a short-medium term stability of the soft tissue architecture around immediately placed and restored implants. The soft tissue loss noted in this study was of minimal clinical significance and did not appear to influence the esthetic outcome. This is further supported by the fact that there were no 2013 Wiley Periodicals, Inc. DOI /jerd Journal of Esthetic and Restorative Dentistry Vol No

10 differences in Jemt s index indicating no changes in the papillary fill of the interdental embrasure, which is of importance in terms of the esthetic outcome. 15 It should also be noted that there was apical drift of the mesial papillae more than that of the distal papillae and mid-facial tissue. The greater mesial papilla tissue loss can be attributed to the fact that the sample included four implants replacing both central incisors in two patients. In this case, the mesial papillae were bordered by implants on both sides, and it is widely recognized that greater soft tissue loss occurs between two implants compared with an implant and an adjacent natural tooth. 32 The method being used for this study to record soft tissue measurements is different from other studies, 23,25,27 which used a reference line connecting the mid-facial gingival level of the two teeth adjacent to the implant restoration. However, flap elevation was used for access in these studies, which may lead to variability of the position of the reference line connecting the mid-facial gingiva of the adjacent teeth, as some soft tissue recession generally occurs following the elevation of a full mucoperiosteal flap. The reference line used in our study extended from the incisal edges of the teeth adjacent to the implant, and this acted as a fixed and stable reference. The soft tissue outcomes reported in this study compare favorably with the available literature. In a study that assessed 35 patients with single immediately placed and restored maxillary implants, the soft tissue loss from the facial aspect was greater than that reported in our study, with 0.55 mm loss at the follow-up period of 1 year. 23 Similar results were reported by De Rouck and colleagues with an average mid-buccal recession of 0.53 mm in the first year of function. 6 Another study by Cornelini and colleagues reported 0.75 mm mid-facial tissue loss after 1 year. 27 The somewhat superior outcomes reported in this study may be attributable to differences in implant design (platform switch versus regular platform, internal versus external attachment) and surgical protocols (flap elevation versus flapless, augmentation of gap between implant and socket walls). In terms of longer term changes, a recent paper published by Cosyn and colleagues revealed a mean mesial and distal papilla height loss of 0.05 and 0.08 mm, respectively. 30 The mid-facial soft tissue recession was 0.34 mm. The mesial papillae showed significant regrowth between the 1- and 3-year follow-ups. Advanced midfacial recession was found in 2/25 (8%) cases. 30 Kan and colleagues showed that following a 4-year follow-up period, the changes in mean mesial and distal papilla levels ( 0.22 and 0.21 mm, respectively) were significantly less than those observed at the 1-year follow-up. However, the mean overall facial gingival level change ( 1.13 mm) was significantly greater than that observed at the 1-year follow-up ( 0.55 mm), which means that papillary height may improve over time, although changes in the position of the labial margin may deteriorate. 32 Therefore, long-term studies are required to document the long-term esthetic outcomes of implant treatment in the anterior maxillary region. In comparison with other treatment protocols, studies with data on the soft tissue changes following single tooth implant placement in healed sockets reveal around 0.6 mm of mid-facial recession within the first year of placement. 33,34 In a study using the conventional technique (two stages) with a follow-up period of 3 years, the mean recession on the mid-facial aspect of the implant was found to be 1 mm. 35 Overall, the results of the present investigation demonstrate a relatively limited loss of soft tissue on the mid-facial aspect. This fact can be attributed to atraumatic extraction of the failed teeth, flapless surgical approach, and the use of a particulate xenograft. It is noteworthy that flapless surgery presents increased risk for perforation of the alveolar bone, and the experience of the surgeon is an important factor that minimizes that risk. 36 Insertion of bone grafting material (Bio-Oss) into the gap between the implant and the walls of the extraction socket assists in preserving a stable level of the hard tissues, 13 and hence the overlying soft tissue profile, as the Bio-Oss particles would not significantly resorb over the duration of the study. Finally, the use of screw-retained instead of cemented temporary restorations may contribute to the 10 Vol No 2013 Journal of Esthetic and Restorative Dentistry DOI /jerd Wiley Periodicals, Inc.

11 absence of complications during the initial stages of wound healing and maturation. In contrast, fistula formation was reported in a study conducted by Kan and his associates using a cemented type of temporary crowns. 19 It is important to note that mid-facial recession does not necessarily imply an esthetic compromise. An interesting finding in one case (FR) was that the recession at the mid-facial aspect actually improved the patient esthetic, as the level of the adjacent tooth buccal soft tissue was already apically displaced (Figure 6). The papillary height changes observed in this study appear to be in accordance with other studies. Kan and colleagues reported a mean loss of 0.50 mm for the mesial papillae and 0.30 mm mean loss of the distal papillae. 23 De Rouck and his associates showed a reduction in the papillae height loss of 0.41 mm on average for mesial papillae and 0.31 mm for distal papillae. 6 No statistically significant differences were found between the papillae levels at baseline and follow-up in terms of Jemt s index. 15 A study by Cornelini and colleagues found no scores of 0, 1, or 4 in their sample, with 60% of papillae receiving a score of 2, with the remainder scoring a In another study by Kan and colleagues the papilla index was measured at pretreatment and 3, 6, and 12 months following implant placement with no differences noted between baseline and any of the follow-up observations. 7 Therefore, the findings of our study in relation to Jemt s index are consistent with the published literature. This clinical investigation was limited by the retrospective nature, the small sample size, the inability to secure a fully standardized follow-up examination protocol for all patients and the relatively small length of the observation period. All of these factors can have a significant impact on the results obtained from this study, which should be interpreted with caution. Nevertheless, the study has provided some indications as to the nature and extent of soft and hard tissue changes that may be expected with this protocol, although it remains unclear if the soft tissue outcomes would remain stable over time. A longer observation period and a larger sample size are needed to support more definite conclusions. Notwithstanding the limitations of the study, the results indicate that the immediate placement and provisional restoration of a single tooth implant in the anterior maxilla can result in predictable implant osseointegration, as well as stable peri-implant tissues, for up to 23.2 ± 7.6 months. DISCLOSURE The authors have no financial interest in any of the companies whose products are mentioned in this paper. REFERENCES 1. Albrektsson T, Branemark PI, Hansson HA, Lindstrom J. Osseointegrated titanium implants. Requirements for ensuring a long-lasting, direct bone-to-implant anchorage in man. Acta Orthop Scand 1981;52: Branemark PI, Adell R, Albrektsson T, et al. Osseointegrated titanium fixtures in the treatment of edentulousness. Biomaterials 1983;4: Becker W, Becker BE, Israelson H, et al. One-step surgical placement of Branemark implants: a prospective multicenter clinical study. Int J Oral Maxillofac Implants 1997;12: Lazzara RJ. Immediate implant placement into extraction sites: surgical and restorative advantages. Int J Periodontics Restorative Dent 1989;9: Gomes A, Lozada JL, Caplanis N, Kleinman A. Immediate loading of a single hydroxyapatite-coated threaded root form implant: a clinical report. J Oral Implantol 1998;24: De Rouck T, Collys K, Cosyn J. Immediate single-tooth implants in the anterior maxilla: a 1-year case cohort study on hard and soft tissue response. J Clin Periodontol 2008;35: Kan JY, Rungcharassaeng K, Liddelow G, et al. Periimplant tissue response following immediate provisional restoration of scalloped implants in the esthetic zone: a one-year pilot prospective multicenter study. J Prosthet Dent 2007;97(6 Suppl): Esposito M, Grusovin G, Achile H, et al. Interventions for replacing missing teeth: Different times for loading dental implants. Cochrane Database Syst Rev 2009;(1):CD Wiley Periodicals, Inc. DOI /jerd Journal of Esthetic and Restorative Dentistry Vol No

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13 to single-tooth dental implants. A retrospective study in the maxillary anterior region. J Periodontol 2001;72: Oh TJ, Shotwell J, Billy E, et al. Flapless implant surgery in the esthetic region: advantages and precautions. Int J Periodontics Restorative Dent 2007;27: Reprint requests: Saso Ivanovski, School of Dentistry and Oral Health, Griffith University, High Street, Southport, Qld 4215, Australia; Tel.: ; Fax: ; s.ivanovski@griffith.edu.au 2013 Wiley Periodicals, Inc. DOI /jerd Journal of Esthetic and Restorative Dentistry Vol No