Francesco Mangano Single-tooth Morse taper connection

Carlo Mangano
Massimiliano Ricci
implants placed in fresh extraction
Rachel Lilian Sammons sockets of the anterior maxilla: an
Jamil Awad Shibli
Adriano Piattelli
aesthetic evaluation

Authors’ affiliations:
Francesco Mangano, Private Practice, Gravedona
(Como), Italy
Carlo Mangano, Dental School, University of
Varese, Varese, Italy
Massimiliano Ricci, Nanoworld Institute,
University of Genoa, Genoa, Italy
Rachel Lilian Sammons, Department of
Biomaterials, Dental School, University of
Birmingham, Birmingham, UK
Jamil Awad Shibli, Department of Periodontology,
Dental Research Division, Guarulhos University,
Guarulhos, Sao Paulo, Brazil
Adriano Piattelli, Department of Oral Pathology
and Oral Medicine, Dental School, University of
Chieti-Pescara, Chieti, Italy
Corresponding author:
Prof. Carlo Mangano
P.zza Trento 4, 22015, Gravedona (Como), Italy
Tel.: +39-0344-85524
Fax: +39-0344-85524
e-mail: camangan@gmail.com
Key words: aesthetic outcome, immediate implant placement, single-tooth Morse taper con-
nection implants
Abstract
Objective: The aim of this retrospective study was to evaluate the aesthetic outcome of single-
tooth Morse taper connection implants placed in fresh extraction sockets of the anterior maxilla,
by means of the pink aesthetic/white aesthetic score (PES/WES) index.
Materials and methods: Twenty-six adult patients (18 men, 8 women, aged between 20 and
62 years; average: 48.7 years) who were treated with an immediate, single-tooth Morse taper
connection implant (Leone Implant SystemR, Florence, Italy) in the aesthetic area of the anterior
maxilla, were enrolled in this retrospective study. An independent calibrated examiner applied the
PES/WES index to 26 single-tooth implant-supported restorations, respectively, 3 months and
2 years after implant placement.
Results: No implants were lost. All 26 anterior maxillary single-tooth implants fulfilled the
established success criteria for dental implants with regard to osseointegration, including the
absence of pain, suppuration, clinically detectable implant mobility, peri-implant radiolucency and
prosthetic complications at the implant-abutment interface, with an overall implant-crown success
of 100.0%. At the 2-year examination, the mean DIB was 0.44 ± 0.14 mm (95% CI: 0.41–0.47); the
mean total PES/WES was 14.30 ± 2.78 (range 8–19); the mean PES was 7.30 ± 1.78 (range 4–10) and
the mean WES was 7.00 ± 1.35 (range 4–10).
Conclusions: The immediate placement of single-tooth Morse taper connection implants in the
anterior maxilla seems to represent a successful procedure, from an aesthetic point of view. Further
studies are needed to evaluate the aesthetic outcome of single-tooth Morse taper connection
implants placed in fresh extraction sockets of the anterior maxilla.

Date:
Accepted 26 July 2011
To cite this article:
Mangano F, Mangano C, Ricci M, Sammons RL, Shibli JA,
Piattelli A. Single-tooth Morse taper connection implants
placed in fresh extraction sockets of the anterior maxilla:
an aesthetic evaluation.
Clin. Oral Impl. Res. 23, 2012, 1302–1307
doi: 10.1111/j.1600-0501.2011.02307.x
Immediate implant placement is defined as
the placement of a dental implant at the time
of tooth extraction, into the extraction socket.
Advantages of immediate implant placement
are the reduced number of surgical procedures
and shortened overall treatment time, with
the resulting psychological benefit for patients
(Koh et al. 2010). In addition, factors such as
ideal three-dimensional implant positioning
and the presumptive preservation of alveolar
bone at the site of tooth extraction have been
claimed as potential advantages of immediate
implantation (Cafiero et al. 2008). Unfortu-
nately, the validity of this hypothesis has been
contradicted by the results of different animal
and clinical studies (Botticelli et al. 2004; Ara-
ujo et al. 2006). The placement of an implant
in the fresh extraction site failed to prevent
resorption of the buccal bone plate in dogs
(Araujo et al. 2006). Buccal plate resorption
and consequent fenestration of the implant
would have significant implications in soft tis-
sues and aesthetics, such as recession and
thread platform exposure, which may result in
visible gingival discoloration (Araujo et al.
2006). These findings were confirmed in a
clinical study (Botticelli et al. 2004), in which
21 implants were installed in extraction sock-
ets in 18 patients. In this study the authors
recorded, at surgical re-entry, a horizontal
resorption of about 50% at the buccal aspect
and 30% at the lingual side of the implant,
corresponding to an overall horizontal width
reduction of 2.8 mm. These reported ridge
alterations may have significant adverse
effects on the final aesthetic result, especially

1302 © 2011 John Wiley & Sons A/S


in the maxillary anterior region, where aes-
thetic outcome is of great importance (Botti-
celli et al. 2004). Immediate implant
placement in the aesthetic zone has gained
acceptance among the clinicians, with several
authors showing that success rates can be
achieved that are similar to those obtained for
delayed implants placed into healed extraction
sites (Chen et al. 2007; Cafiero et al. 2008).
The criteria proposed by Albrektsson & Zarb
(1998) are widely accepted and used as a
method to assess implant success. The focus
of these criteria, however, remains osseointe-
gration; for aesthetically sensitive cases these
osseointegration-oriented criteria are no
longer adequate (Lops et al. 2008). Nowadays,
the aesthetic outcome has become the main
focus of interest in aesthetically sensitive
areas (Raes et al. 2011). The current literature,
however, is scarce when it comes to objective
outcome evaluation from an aesthetic point of
view. Some studies (Jemt 1997; Schropp et al.
2005) have paid particular attention to the
presence or absence of interproximal gingival
papillae after implant therapy. However, more
variables are responsible for the aesthetic out-
come of implant-supported single-tooth
replacement, and an aesthetic implant restora-
tion should resemble a natural tooth in all
aspects (Lai et al. 2008). Several additional
attempts have been made to implement objec-
tive criteria for assessing the aesthetic dimen-
sion of a fixed single-tooth implant restoration
located in the anterior region of the mouth,
such as the pink aesthetic score (PES) (Furha-
user et al. 2005) and the pink aesthetic/white
aesthetic score (PES/WES) (Belser et al. 2009).
The PES concept focused essentially on the
soft tissue aspects of an anterior implant resto-
ration (Furhauser et al. 2005). Belser et al.
modified the previously published PES and
proposed a new implant restoration index (the
PES/WES index, pink aesthetic/white aes-
thetic score index) (Belser et al. 2009). In con-
trast to the original proposal, this modified
PES comprises five variables: mesial papilla,
distal papilla, curvature of the facial mucosa,
level of the facial mucosa, and root convexity/
soft tissue colour and texture at the facial
aspect of the implant site. The WES specifi-
cally focuses on the visible part of the implant
restoration itself and is based on the following
five parameters: tooth form, volume, colour,
surface texture and translucency/characteriza-
tion. A score of 2, 1 or 0 is assigned to all
parameters; this can result in a maximum pos-
sible combined PES/WES score of 20. All
parameters are assessed by direct comparison
with the natural, contralateral reference tooth,
estimating the degree of match or eventual
© 2011 John Wiley & Sons A/S
Mangano et al
Morse taper connection implants placed in fresh extraction sockets
mismatch. The suitability of the PES/WES
index for the assessment of the aesthetic
dimension of anterior single-tooth implants
has been recently confirmed (Cho et al. 2010).
Therefore, the aim of this retrospective study
was to evaluate the aesthetic outcome of sin-
gle-tooth Morse taper connection implants
placed in fresh extraction sockets of the ante-
rior maxilla, by means of the PES/WES index.
Materials and methods
Patient population
Twenty-six patients (18 men, 8 women, aged
between 20 and 62 years; average: 48.7 years)
who had been treated with an immediate,
single implant in the aesthetic zone of the
anterior maxilla (central and lateral incisors,
cuspids, first premolars) between December
2006 and June 2009 in one clinical centre
(private practice) were identified from patient
charts and included in the study. The follow-
ing information was available and included:
patient age and gender, previous medical and
dental history, oral status and oral hygiene,
smoking and/or parafunctional habits, rea-
sons for extraction of natural teeth (Table 1),
distribution of implants (Table 2). Inclusion
criteria were natural teeth present both
mesial and distal to the implant, presence of
four bony walls of the alveolus, adequate
bone height and width to place an implant of
at least 3.3 mm in diameter and 10.0 mm in
length. Exclusion criteria were uncontrolled
diabetes; poor oral hygiene, active periodontal
infections, bruxism, heavy smoking habit
(more than 15 cigarettes per day); presence of
dehiscence or fenestration of the residual
bony walls; presence of a thin-scalloped gin-
gival biotype (determined by the transparency
of a periodontal probe through the gingival
margin while probing the buccal sulcus of
the upper central incisor) (De Rouck et al.
2009). Implant treatments including hard/soft
tissue grafting before implant placement and
periodontally compromised patients were
excluded too. All patients read and signed a
written consent form for immediate implant
placement. The study protocol was approved
by the local Ethical Committee and was con-
ducted in accordance with the Helsinki Dec-
laration of 1975, as revised in 2000.
Surgical and prosthetic procedure
A complete examination of the oral hard and
soft tissues was carried out for each patient
and the implant placement was planned
based on clinical and radiographic evaluation.
Surgery was performed under a local anaes-
1303 |
Table 1. The reasons for tooth extraction
Reason for tooth extraction N (%)
Caries 12 (46.2)
Root fracture 8 (30.8)
Root resorption 3 (11.5)
Non-treatable endodontic lesion 3 (11.5)
Total 26
Table 2. Distribution of the implants
Implant sites N (%)
Central incisor 6 (23.1)
Lateral incisor 9 (34.6)
Cuspid 6 (23.1)
First premolar 5 (19.2)
Total 26
thetic, obtained by infiltrating articaine 4%,
containing 1 : 100,000 adrenaline (Ubiste-
sinR; 3M Espe, St. Paul, MN, USA). A mesio-
distal crestal incision was made and a full-
thickness flap was reflected exposing the
alveolar ridge. Care was taken to perform an
atraumatic extraction. The hopeless tooth
was carefully luxated and extracted avoiding
any lateral movement that might damage
either buccal or palatal bone plates. Once the
tooth was removed, the socket was debrided
with curettes and irrigated with sterile saline.
A periodontal probe was used to scan the
internal surface of the alveolus for dehiscenc-
es and fenestrations before implant place-
ment. All sites showed the absence of
fenestration and dehiscence. Preparation of
implant sites was carried out with spiral
drills of increasing diameter (2.8 mm to place
an implant with 3.3 mm diameter; 2.8 and
3.5 mm, to place an implant with 4.1 mm
diameter; an additional 4.2 mm drill was
used to prepare the site for 4.8 mm diameter
implants), under constant irrigation. Implants
were positioned at the bone crest level. The
implant system used in this study (Leone
Implant SystemR, Florence, Italy) is charac-
terized by a cone Morse taper interference-fit
(TIF) locking-taper combined with an internal
hexagon. The Morse taper presents a taper
angle of 1.5o. Biphasic calcium phosphate
granules (MBCPR; Biomatlante, Vigneux de
Bretagne, France) were used to fill the gaps
between the implant and the residual bony
walls. The granules were mixed with tetracy-
cline powder (AmbramicinaR; Scharper spa,
Sesto San Giovanni, Italy) to obtain a local
antibiotic effect and this mixture was moist-
ened with physiological saline solution so
that the composition could be more easily
moulded to fit into the gaps. Temporary
abutments were placed and all patients
received a temporary acrylic resin crown
Clin. Oral Impl. Res. 23, 2012 / 1302–1307
Mangano et al
Morse taper connection implants placed in fresh extraction sockets
cemented with a temporary cement (Temp-
BondR; Kerr, Orange, CA, USA). All tempo-
rary crowns were in full contact in centric
occlusion. The flaps were properly mobilized
and repositioned to cover the implants and
were secured in position by interrupted
sutures (SupramidR; Novaxa Spa, Milan,
Italy). All patients received oral antibiotics
(AugmentinR; Glaxo-Smithkline Beecham,
Brentford, UK) 2 g each day for 6 days. Post-
operative pain was controlled by administer-
ing 100 mg nimesulide (AulinR; Roche Phar-
maceutical, Basel, Switzerland) every 12 h for
2 days and detailed instructions about oral
hygiene were given, including mouth rinses
with 0.12% chlorhexidine (ChlorexidineR;
OralB, Boston, MA, USA) administered for
7 days. Suture removal was performed at
8–10 days. The temporary restorations
remained in situ for 3 months and after this
period definitive restorations were placed. All
single crowns were ceramo-metallic and were
cemented with a temporary cement (Temp-
BondR; Kerr, Orange, CA, USA).
Clinical follow-up examination
Follow-up visits were scheduled for 2 weeks,
1, 3 and 12 months during the first year post-
operatively, and annually thereafter. Two
years after implant placement, at recall visit,
the following clinical and radiographic
parameters were assessed: presence/absence
of pain or suppuration, presence/absence of
clinically detectable implant mobility; pres-
ence/absence of prosthetic complications at
the implant-abutment interface; presence/
absence of peri-implant radiolucency; dis-
tance between the implant shoulder and the
first visible bone-implant contact (DIB)
(Mangano et al. 2009). Periapical radiographs
were taken at the baseline (immediately after
implant insertion) and at the 2-year follow-up
session. Radiographs were taken using a Rinn
alignment system with a rigid film-object X-
ray source coupled to a beam-aiming device
to achieve reproducible exposure geometry.
Customized positioners, made of polivinyl
siloxane, were used for precise repositioning
and stabilization of the radiographic tem-
plate. To calculate the distance between the
implant shoulder and the first visible bone-
implant contact (DIB), crestal bone level
changes were recorded as changes in the ver-
tical dimension of the bone around the
implant, so that an evaluation of peri-implant
crestal bone stability was gained with time.
To correct for dimensional distortion in the
radiograph, the apparent dimension of each
implant (directly measured on the radiograph)
was compared with the true implant length,
1304 | Clin. Oral Impl. Res. 23, 2012 / 1302–1307
to establish, with adequate precision, the
eventual amount of vertical bone loss at the
mesial and distal site of the implant. In this
study, the distance between the implant
shoulder and the first visible bone contact
(DIB) was calculated by means of an ocular
grid. The established criteria for implant-
crown success were as follows: absence of
pain or suppuration, absence of clinically
detectable implant mobility; absence of peri-
implant radiolucency, distance between the
implant shoulder and the first visible bone-
implant contact (DIB) <1.5 mm after
12 months of functional loading and not
exceeding 0.2 mm for each following year
(Albrektsson & Zarb 1998); absence of pros-
thetic complications at the implant-abut-
ment interface.
Aesthetic follow-up examination
To objectively examine the aesthetic out-
come of the implants, intraoral photographs
were critically analysed using the PES/WES
index (Belser et al. 2009). All implant crowns
(central, lateral incisors, cuspids and first pre-
molars) were photographed with a digital
camera (Nikon D100R; Nikon, Tokyo, Japan)
and a 105 mm lens (AF micro Nikkor
105 mm 1 : 2.8D; Nikon) with a ring flash
(Nikon Macro Speedlight SB-29S; Nikon). For
assessing anterior tooth replacements, the
reference contralateral tooth had to be com-
pletely and symmetrically represented, to
ensure comparability. For this purpose, the
photographs were centred at the midline, to
facilitate the subsequent analysis, which was
primarily based on symmetry. In addition,
standardized clinical photographs were taken
of each implant site and of the contralateral
tooth. These additional photographs were
used as tools for a more detailed evaluation.
For the first premolars involved in the study,
however, the photographs could not be taken
at the midline; for this reason, the approach
was modified and a picture including the sec-
ond premolars and the canine was taken,
with these teeth serving as references. All
photographs were taken slightly superior to
the occlusal plane, centred at the contact
region. Photographs were then viewed on a
42-inch monitor screen (Samsung PPM-
42S3Q Flat Panel Plasma MonitorR; Sam-
sung, Seoul, South Korea). Study casts, pro-
duced in type IV stone, were finally
fabricated for each of the 26 patients involved
in the study. Study casts were fabricated to
facilitate a direct and objective assessment
related to the PES/WES index. The clinical
photographs and the study casts were used to
perform the aesthetic evaluation. The aes-
thetic evaluation was performed by an inde-
pendent calibrated observer, who was not
part of the treating team, by means of the
PES/WES index, 1 h after seating of the defin-
itive restoration (3 months after implant
placement, baseline) and 2 years after
implant placement (follow-up), respectively.
To reduce bias and to achieve good reproduc-
ibility, the evaluation was carried out twice,
on different days; in case of diverging scores,
the observer carefully re-evaluated the photo-
graphs and the study casts prior to making
his final decision. A score of 2, 1 or 0 was
assigned to each PES/WES parameter. The
highest possible combined PES/WES score
was 20, which represented a close match of
the peri-implant soft tissue conditions and
the clinical single-tooth crown compared
with the respective features present at the
contralateral natural tooth site. A PES/WES
 12 was considered as the limit for an
acceptable aesthetic outcome of implant
treatment.
Data analysis
For the PES/WES evaluation, descriptive sta-
tistics including mean values, standard devia-
tions, medians and range were analysed.
Moreover, to compare the differences of PES
and WES assessments between the baseline
and follow-up, the Wilcoxon rank-sum test
for paired data was performed. The level of
significance was set at 0.05. All statistical
analyses were run on the statistical package
SPSS (SPSS 17.0; SPSS Inc., Chicago, IL,
USA).
Results
Standard implant-crown success criteria
No implants were lost. With regard to osseoin-
tegration, all 26 anterior maxillary single-tooth
Morse taper connection implants fulfilled the
success criteria, with an implant-crown
success of 100%. In fact, all implants showed
stable osseointegration, with absence of pain
or suppuration, absence of clinically detectable
implant mobility, absence of peri-implant
radiolucency, DIB <1.5 mm during the first
year of function and absence of prosthetic com-
plications at the implant-abutment interface.
The 2-year mean DIB was 0.44 ± 0.14 mm
(median: 0.40; 95% CI: 0.41–0.47).
Objective evaluation of aesthetic treatment
outcome (PES/WES analysis)
The PES and WES scores of the 26 examined
single-tooth implants were summarized in
Table 3. At the 2-year examination, the over-
all mean PES/WES was 14.30 ± 2.78 (median:
© 2011 John Wiley & Sons A/S
 Mangano et al
Morse taper connection implants placed in fresh extraction sockets

Table 3. Scores assessment for single PES/WES variables at baseline and at follow-up
Baseline assessment, N (%) Follow-up assessment, N (%)

0 1 2 0 1 2 P-value
Mesial papilla 1 (3.8) 13 (50.0) 12 (46.2) 0 (0.0) 11 (42.3) 15 (57.7) 0.157
Distal apilla 1 (3.8) 10 (38.5) 15 (57.7) 0 (0.0) 12 (46.2) 14 (53.8) 1.000
Curvature of facial mucosa 0 (0.0) 16 (61.5) 10 (38.5) 0 (0.0) 13 (50.0) 13 (50.0) 0.257
Level of facial mucosa 0 (0.0) 12 (46.2) 14 (53.8) 0 (0.0) 12 (46.2) 14 (53.8) 1.000
Root convexity/soft tissue colour/texture 3 (11.6) 18 (69.2) 5 (19.2) 2 (7.7) 18 (69.2) 6 (23.1) 0.157
PES (mean ± SD) 6.96 ± 1.77 7.30 ± 1.78 0.164
Tooth form 0 (0.0) 13 (50.0) 13 (50.0) 0 (0.0) 11 (42.3) 15 (57.7) 0.157
Tooth volume/outline 0 (0.0) 14 (53.8) 12 (46.2) 0 (0.0) 13 (50.0) 13 (50.0) 0.317
Tooth colour (Hue/Value) 2 (7.7) 14 (53.8) 10 (38.5) 2 (7.6) 12 (46.2) 12 (46.2) 0.157
Surface texture 0 (0.0) 16 (61.5) 10 (38.5) 0 (0.0) 17 (65.3) 9 (34.7) 0.317
Translucency 4 (15.3) 12 (46.2) 10 (38.5) 4 (15.3) 13 (50.0) 9 (34.7) 0.317
WES (mean ± SD) 6.88 ± 1.17 7.00 ± 1.35 0.257

14.5; range 8–19). Four (15.4%) of 26 single

implant treatments showed an almost perfect
result (PES/WES  18) (Figs 1 and 2). An
acceptable result was found for 19/26 (73.0%)
single implant cases (Figs 3 and 4). The aes-
thetic outcome was unfavourable for 3/26
(11.6%) single implant treatments (PES/WES
score <12). The overall mean PES was
7.30 ± 1.78 (median 8; range 4–10), with five
restorations with an overall PES <6. The
overall mean WES was 7.00 ± 1.35 (median:
7; range 4–10), with four restorations with an Fig. 1. Implant restoration in the upper right lateral
incisor position. Note the perfect soft tissue appearance
overall WES <6.
and restoration (PES = 9; WES = 9).
Fig. 3. Implant restoration in the upper right central
incisor position. Note the mesial papilla loss and the
Discussion attention for individual traits in the restoration
(PES = 7; WES = 8).

Patient satisfaction is a key factor in the suc-

cess of implant therapy and a successful
implant must provide an acceptable aesthetic
appearance. Recently, a novel comprehensive
index, comprising pink aesthetic score and
white aesthetic score (PES/WES) has been
applied for the objective aesthetic outcome
assessment of anterior single-tooth implants
(Lai et al. 2008; Belser et al. 2009; Cho et al.
2010). With reference to this, our retrospec-
tive study presented the aesthetic outcome of
26 anterior maxillary single-tooth Morse
taper connection implants inserted by imme-
diate placement in well-selected patients.
The goal of our study was to support aesthet-
ically pleasing soft tissue contours, avoiding
mucosal recession. In fact, although several
papers reported on optimal aesthetic out-
comes with immediate implant placement
(Cafiero et al. 2008; Tortamano et al. 2010), Fig. 2. Implant restoration in the upper right lateral
some studies warned of soft tissue complica- incisor position: the 2-year radiographic control.

tions, especially midfacial gingival recession

with exposure of the abutment or implant
neck (Kan et al. 2003; Juodzbalys & Wang
2007; Ferrus et al. 2010). Our present study
on immediate implant placement, however,
showed a 2-year mean total PES/WES of
14.30 ± 2.78, indicating a good aesthetic out-
come. Only three restorations scored <12,
which was considered as the threshold of
clinical acceptability (Belser et al. 2009). The
mean PES was 7.30 ± 1.78. The scores for the
mesial and distal papillae (mean scores of
1.57 and 1.53, respectively) were favourable
Fig. 4. Implant restoration in the upper right central
incisor position: the 2-year radiographic control.
and also the two variables of facial mucosa
curvature and facial mucosa level showed
excellent scores (mean scores of 1.50 and
1.53, respectively). The combination variable

© 2011 John Wiley & Sons A/S 1305 | Clin. Oral Impl. Res. 23, 2012 / 1302–1307
Mangano et al
Morse taper connection implants placed in fresh extraction sockets
of root convexity, soft tissue colour and tex-
ture showed the lowest mean score (1.15) of
all five parameters. It is difficult to attain a
maximum score for this parameter, probably
because it consists of three different aspects
to be fulfilled. The mean WES was
7.00 ± 1.35. The WES analysis showed higher
scores for parameters such as tooth form and
volume (mean scores of 1.57 and 1.50, respec-
tively), while tooth colour performed less
well (mean score of 1.38). Among all the
WES values, surface texture and tooth trans-
lucency showed the lowest scores (mean
scores of 1.34 and 1.19, respectively). These
last parameters, however, are strongly related
to the quality and design of prosthetic work
and seem not to be related to peri-implant
tissue dynamics. With immediate implant
placement, the following pre-requisites are
considered essential to achieve optimal aes-
thetic outcome: adequate bone volume (hori-
zontal, vertical, contour), stable and healthy
peri-implant soft tissues and aesthetically
pleasing soft tissues contours (form of the
periodontium, biotype of the periodontium),
optimal three-dimensional (3D) implant posi-
tion (mesio-distal, apico-coronal, bucco-lin-
gual and angulation) and ideal implant-
abutment design and emergence profile (Ka-
zor et al. 2004). In immediate placement, the
ideal extraction socket would present little or
no periodontal bone loss. Atraumatic tooth
extraction is of key importance prior to
immediate implant placement and the buccal
plate has to be intact (Evans & Chen 2008).
Bone regeneration techniques using artificial
bone graft substitute materials can be help-
ful, to fill the gaps between the implant and
the residual bony walls, reducing bone loss
(Evans & Chen 2008). The interproximal
bone height is important too, as it influences
the interdental papillae by acting as a refer-
ence for the soft tissue contours (Kois 2004).
Critical evaluation of smile line, gingival
architecture (periodontal biotype) and soft tis-
sue levels are essential for implant aesthetics
(Juodzbalys & Wang 2007; Ferrus et al. 2010).
Periodontal biotype affects the periodontal
tissue dimensions, including masticatory
mucosa and biological width (Kan et al.
2003); for this reason, an evaluation of the
References
Albrektsson, T. & Zarb, G. (1998) Determinants of
correct clinical reporting. The International Jour-
nal of Prosthodontics 11: 517.
Araujo, M.G., Wennstrom, J.L. & Lindhe, J. (2006)
Modeling of the buccal and lingual bone walls of
fresh extraction sites following implant installa-
1306 | Clin. Oral Impl. Res. 23, 2012 / 1302–1307
periodontal biotype may be useful for the pre-
vention of soft tissue complications with
immediate implant placement (Kan et al.
2003; De Rouck et al. 2009). If immediate
placement is performed in patients with a
thin biotype, there is a higher risk of soft tis-
sue recession and underlying resorptive osse-
ous remodelling, exposing the metal margin
of the implant (Kois 2004). To achieve a pre-
dictable aesthetic outcome, implants must be
placed in an optimal position and inclination.
When an implant is placed in a fresh extrac-
tion socket, it seems prudent to place it in
the palatal portion of the socket, with its
marginal border well below the ridge of the
fresh socket to compensate for the expected
resorption (Kois 2004). Finally, it is essential
to maintain as much of the circumferential
bone height around the implant neck as pos-
sible. However, when an abutment is con-
nected to a dental implant at the crestal
level, bone loss around the implant always
occurs (Calvo Guirado et al. 2009). Although
the aetiological factors associated with early
crestal bone loss have not been completely
clarified, the main factors hypothesized to be
involved include surgical trauma, the forma-
tion of a biological width (Hermann et al.
2007), micromovements of the abutment
(Heckmann et al. 2006) and the presence and
size of a microgap between the implant and
the abutment (Broggini et al. 2003). The fea-
tures of the implant-abutment connection
are considered to influence not only the
mechanics but also the biological behaviour
of implants (Heckmann et al. 2006). Scien-
tific evidence supports the fact that the pres-
ence of a microgap at the implant-abutment
connection may have a direct effect on bone
loss (Broggini et al. 2003). In implants with
screw retained abutments, in fact, this micro-
gap is of variable dimensions (40–100 lm)
can be colonized by bacteria, potentially gen-
erating a chemotactic stimulus sustaining
the recruitment of inflammatory cells, ulti-
mately resulting in inflammation and osteol-
ysis (Broggini et al. 2003). The Morse taper
interference-fit (TIF) locking-taper can avoid
micromovements at the implant-abutment
interface, removing one reason for crestal
bone loss around implants (Hansson 2003;
tion. Clinical Oral Implants Research 17: 606–
614.
Belser, U., Grutter, L., Vailati, F., Bornstein, M.,
Weber, H. & Buser, D. (2009) Outcome evalua-
tion of early placed maxillary anterior single-
tooth implants using objective esthetic criteria: a
Dibart et al. 2005). Moreover, with Morse
taper connection implants, the gap is closed
so tightly that the abutment and the fixture
behave as a single piece, there is effectively
no microgap and therefore no bacterial leak-
age, reducing the level of peri-implant tissue
inflammation to a minimum (Dibart et al.
2005). In addition, with a tapered interference
fit, the abutment emergence geometry gives
“platform switching” advantages (Prosper
et al. 2009). The success of the platform
switching design or horizontal off-set at the
implant-abutment interface is believed to be
a consequence of the horizontal repositioning
of the microgap, and any toxin-producing
bacteria within it, as far away from the bone
as possible to minimize bone loss. Another
consequence of the platform switching design
is the increased space for more connective
tissue, to improve the biological seal. This
space can guarantee excellent soft tissue
healing, with a thicker, larger, well-organized
volume of peri-implant soft tissues, protect-
ing the bone crest from resorption (Prosper
et al. 2009).
Conclusions
Based on these results and within the limits
of this study (such as the limited number of
patients and the absence of a control group),
the immediate placement of single-tooth
Morse taper connection implants in the ante-
rior maxilla seems to represent a successful
procedure, with good aesthetic outcome. Fur-
ther studies on a larger number of patients
are needed to evaluate the aesthetic outcome
of single-tooth Morse taper connection
implants placed in fresh extraction sockets of
the anterior maxilla.
Disclosure
The authors declare that they have no finan-
cial relationship with any commercial firm
that may pose a conflict of interest for this
study. No grants, equipment or other sources
of support were provided.
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