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22]

Original Article

Soft‑tissue esthetic outcome of single

implants: Immediate placement
in fresh extraction sockets versus
conventional placement in healed
sockets
Nima Naddaf Pour, Baharak Ghaedi,1 Mona Sohrabi2

Department of Abstract:
Periodontology, Dental Background: Immediate implant placement has advantages such as requiring fewer surgical procedures and
School, Islamic Azad decreased treatment time; however, unpredictable soft‑ and hard‑tissue outcome is a problem. This study aimed to
University, 1Periodontist, compare the soft‑tissue esthetic outcome of single implants placed in fresh extraction sockets versus those placed
Private Practice, in healed sockets. Materials and Methods: This cross‑sectional, retrospective study was performed on 42 patients
2
Department of Pediatric who received single implants. Twenty‑two patients with a mean age of 40.14 years received immediate implants
while 18 patients with a mean age of 43.40 years were subjected to conventional (delayed) implant placement.
Dentistry, School of
The mean follow‑up time was 14.42 ± 8.37 months and 18.25 ± 7.10 months in the immediate and conventional
Dentistry, Tehran groups, respectively. Outcome assessments included clinical and radiographic examinations. The esthetic
University of Medical outcome was objectively rated using the pink esthetic score (PES). Results: All implants fulfilled the success
Science, Tehran, Iran criteria. The mean PES was 8.54 ± 1.26 and 8.10 ± 1.65 in the immediate and conventional groups, respectively.
This difference was not statistically significant (P = 0.329). The two PES parameters, namely, the facial mucosa
curvature and facial mucosa level had the highest percentage of complete score. Conclusions: Immediate and
conventional single implant treatments yielded comparable esthetic outcomes.
Key words:
Esthetics, immediate implant placement, pink esthetic score, single implant
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INTRODUCTION reported bone loss even after immediate implant
DOI: placement.[5,10]
10.4103/jisp.jisp_21_18
Quick Response Code: W ith a history of over 40 years, implant
treatment is now a standard modality of
care.[1,2] Previously, implants had to be placed
Several indexes have been proposed for esthetic
assessment of implants. The papilla index, pink
after a 6–12‑month healing period following esthetic score (PES), implant‑crown esthetic
tooth extraction. Such a long course of treatment index, and PES/white esthetic score are among
also required several surgical procedures.[2,3] the most reliable indexes for this purpose.[4,11‑13]
Advances in implant treatment have simplified
and shortened the course of treatment and Considering the significance of esthetic outcome
include flapless surgeries, immediate implant of peri‑implant soft tissue, especially in the
placement, and immediate loading.[3,4] anterior region, in acceptance or refusal of recent
treatment protocols such as immediate implant
The physiological process of healing of
extraction sockets starts immediately after tooth This is an open access journal, and articles are
Address for distributed under the terms of the Creative Commons
extraction and eventually results in a reduction Attribution‑NonCommercial‑ShareAlike 4.0 License, which
correspondence:
Dr. Mona Sohrabi, in height (vertical ridge resorption) and allows others to remix, tweak, and build upon the work
width (horizontal ridge resorption) of alveolar non‑commercially, as long as appropriate credit is given and
Department of Pediatric the new creations are licensed under the identical terms.
Dentistry, School process.[5‑7] Immediate implant placement has
of Dentistry, Tehran been suggested to preserve the crestal bone. For reprints contact: reprints@medknow.com
University of Medical Some authors have stated that immediate
Science, Tehran, Iran. implant placement in fresh extraction sockets How to cite this article: Pour NN, Ghaedi B,
E‑mail: monasohraby@ Sohrabi M. Soft-tissue esthetic outcome of single
yahoo.com
maintains the contour of the residual ridge
and prevents bone loss; therefore, it can have implants: Immediate placement in fresh extraction
sockets versus conventional placement in healed
Submission: 08‑01‑2018 favorable effects on esthetics.[5,8,9] In contrast,
sockets. J Indian Soc Periodontol 2018;22:249-53.
Accepted: 15‑04‑2018 some clinical and paraclinical studies have
© 2018 Indian Society of Periodontology | Published by Wolters Kluwer - Medknow 249
[Downloaded free from http://www.jisponline.com on Wednesday, March 6, 2019, IP: 187.54.221.22]
Pour, et al.: Soft‑tissue esthetic outcomes in immediate implant placement
placement; this study aimed to compare the esthetic outcome
of single implants placed in fresh extraction sockets versus
those placed in healed sites.
MATERIALS AND METHODS
Medical files of patients who received single implants by
immediate or delayed placement were retrieved from the
archives of a private dental clinic. This study was approved
in the ethics committee of our university (Code: 678). The
inclusion and exclusion criteria were as follows:
Inclusion criteria – (1) The presence of at least one natural tooth
at each side of the respective implant, (2) implants placed at the
site of single‑rooted teeth, and (3) minimum of 6 months had
to be passed since prosthetic delivery and loading of implant.
Exclusion criteria – (1) History of periodontal disease, (2) soft‑ or
hard‑tissue grafting before or during implant placement,
(3) systemic diseases affecting periodontal conditions such
as diabetes mellitus, (4) severe smoking, and (5) pregnancy.
The treatment process in patients who received immediate
implants was as follows:
The flap was conventionally elevated. The teeth were gently
luxated, and lateral forces were avoided to prevent damage to
buccal and lingual plates. After atraumatic extraction of tooth,
the extraction socket was debrided and rinsed with saline.
Implant was then placed in the fresh socket after ensuring
the presence of four intact bony walls without dehiscence or
fenestration. In immediate implant placement, none of the
patients received bone graft to fill the gap.
In patients who were subjected to conventional (delayed)
implant placement, the treatment process was as follows:
Patients presented at least 6 months after tooth extraction.
A mesiodistal crestal incision was made, and a full‑thickness
flap was elevated to expose alveolar bone.
Next, in both groups, implant placement site was prepared
by specific drills under continuous irrigation, and implants
were placed 0.5–1 mm beneath the bone crest according to
the principles of 3D placement of implants. In both groups,
implants were submerged and loaded after 6 months.
All clinical and radiographic examinations were carried out
by an experienced periodontist who was not involved in the
process of implant placement or prosthetic restoration. Clinical
examination of each patient included measurement of pocket
depth (PD), modified plaque index (MPI), modified bleeding
index (MBI), mobility, and PES.[14]
PD was measured by inserting a standard titanium periodontal
probe (noncolor‑coded offset probe, Nordent, USA) at six
areas of mesiobuccal, midbuccal, distobuccal, mesiolingual,
midlingual and distolingual around each implant and recorded.
MPI was measured to assess plaque accumulation around
implant. Score 0 indicated the absence of plaque, score 1
indicated plaque detectable by movement of probe in the
250 Journal of Indian Society of Periodontology - Volume 22, Issue 3, May-June 2018
sulcus, score 2 indicated visible plaque, and score 3 indicated
abundant soft plaque.
MBI was used to assess bleeding on probing in six areas around
each implant; 0 indicated no bleeding on probing, 1 indicated
bleeding in separate points, 2 indicated bleeding in gingival
margins, and 3 indicated abundant bleeding.
Mobility was graded clinically by holding the tooth firmly with
one metallic instrument and one finger. Mobility beyond the
physiologic range is termed abnormal or pathologic.
Pain, infection, neuropathy, and paresthesia were also assessed
and some questions were asked from patients in this regard.
This was done to determine the implant success rate according
to the Alberktsson’s criteria.[15]
For assessment of esthetic outcome, PES was determined for
each patient. PES included five parameters of mesial papilla,
distal papilla, facial mucosa curvature, facial mucosa level,
and last parameter including three components of root surface
convexity, soft‑tissue color, and soft‑tissue texture. Scores 0, 1,
or 2 were allocated to each parameter. Mesial and distal papilla
parameters were scored 2 in case of complete presence of papilla,
1 in case of partial presence of papilla, and 0 in case of absence
of papilla. Facial mucosa curvature was defined as visibility
of implant restoration margins over the facial soft tissue and
scored 2 in case of complete adaptation, 1 in case of presence
of small difference, and 0 in case of presence of significant
difference. Facial mucosa level was assessed by comparing the
level of mucosa relative to that of a control tooth and scored
2 in case of similarity, 1 in case of difference ≤1 mm, and 0 in
case of difference ≥1 mm. Regarding the last parameter, color
and appearance of soft‑tissue indicate presence. The absence
of inflammatory process which affects the appearance of
implant restoration. In case of complete adaptation of all
three factors with those in a control tooth, this parameter was
scored 2, adaptation of two factors scored 1, and no adaptation
was scored 0. The total score of 10 (2 × 5) for PES index was
considered optimal. The acceptable score was  ≥  6. After
scoring each PES parameter by a periodontist, standard clinical
photographs (×1 magnification) were taken of the respective
area using a digital camera (Canon).
Next, parallel radiographs were requested for each implant to
assess the presence of radiolucency around implant and bone
loss. Radiographs were scanned (300 DPI), and bone loss was
quantified by measuring the distance between the implant
shoulder and bone crest with 0.1 mm accuracy using Romexis
Viewer 2.2.9 software. Radiographic findings were used to
determine implant success rate according to the Alberktsson’s
criteria.
RESULTS
Demographics
This descriptive, analytical, cross‑sectional, and retrospective
study was conducted on 42 patients including 14 males (33.3%)
and 28 females (66.7%) with a mean age of 41.73 years (range
22–63 years); of which, 22 underwent immediate and
20 underwent conventional (delayed) implant placement. The
assessment of outcome was done 14.42 ± 8.37 months after
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Pour, et al.: Soft‑tissue esthetic outcomes in immediate implant placement

treatment in the immediate group and 18.25 ± 7.10 months The mean PD was 2.72 ± 0.81 mm in the immediate and
after treatment in the conventional group. The difference 2.56 ± 0.91 mm in the conventional group. The difference in this
in this regard between the two groups was not statistically regard was not significant between the two groups (P = 0.552).
significant (P > 0.05).
DISCUSSION
Treated sites
All teeth treated in this study were maxillary anterior teeth. Immediate implant placement following tooth extraction has
Table 1 shows the distribution of implant sites. advantages such as saving time, esthetic appearance, and
comfort for patients and disadvantages such as mid‑facial
Bone loss gingival recession.[16] Many recent studies have emphasized
The mean bone loss was 0.62 ± 0.44 mm in the immediate and that implant survival, osseointegration, and interdental crestal
0.43 ± 0.39 mm in the conventional group. The difference in bone level are not negatively affected by immediate implant
this regard was not statistically significant between the two placement protocol.[17,18] In addition, a systematic review in
groups (P = 0.779). 2014 showed better survival of crestal bone in immediate
placement of implant compared to conventional placement.[19]
Pink esthetic score Esthetic soft‑tissue outcome around immediate implants is
Table 2 compares the peri‑implant soft‑tissue esthetic outcome still a matter of debate considering no effect of this protocol
in the two groups. As shown in Table 2, the mean PES was on natural remodeling of tooth socket.
8.54 (range 6–10) in the immediate and 8.10 (range 6–10) in
the conventional group. The difference in this regard was not In the current study, none of the implants had any mobility,
statistically significant between the two groups (P > 0.05). No pain, infection, neuropathy, or paresthesia. The amount of
implant showed unacceptable PES in any of the two groups. bone loss in the two groups was within the success criterion
reported by Alberktson.[15] Assessment of soft‑tissue outcome
Modified bleeding index, modified plaque index, and pocket in the current study was done using modified PES. Both groups
depth acquired almost a complete score with no significant difference
The mean MBI was 0.49 ± 0.44 in the immediate and 0.70 ± 0.50 between the two, which was in line with the findings of similar
in the conventional group. The difference in this respect was previous studies.[20‑23]
not statistically significant between the two groups (P = 0.164).
PES did not show any significant difference between the two
Table 3 compares the MPI in the two groups. The difference groups regarding papillary height. This finding was in line with
in this regard was not statistically significant between the two that of previous studies that found no significant difference in
groups (P = 0.493). the papilla score between the two groups.[5,9,21,24,25] This finding
was also in agreement with that of previous studies showing
Table 1: Distribution of implant sites in the two groups that papilla fullness is independent of the time of implant
Treatment Implant position surgery relative to tooth extraction.[26,27] In other words, based
strategy Central Lateral Canine Premolar Total on several studies, interdental papillary height depends on the
incisor incisor bone peak of adjacent tooth, and time of implant placement
IIT 5 3 1 13 22 has no effect on bone level.[28] Cosyn et al. in 2012 conducted a
CIT 1 3 2 14 20 3‑year study on soft‑tissue status around immediately placed
IIT – Immediate implant treatment; CIT – Conventional implant treatment implants and revealed that 1 year after treatment, the papilla
had not been completely remodeled but showed significant
Table 2: Esthetic outcome regrowth especially in the mesial part over time. After 3 years,
the papilla regained its primary height.[16] Accordingly, since
IIT (n=22) CIT (n=20)
the duration of the current study was <18 months, the papillary
0 1 2 0 1 2 score still had a chance of improvement in the upcoming years.
Mesial papilla 0 6 16 0 4 16
Distal papilla 0 8 14 1 9 10 Regarding the soft tissue around immediate single implants,
Midfacial level 1 1 20 0 4 16
midfacial gingival level has gained increasing attention in
Midfacial contour 0 3 19 0 3 17
(alveolar process) the recent studies. The current study showed no significant
Soft tissue color 0 12 10 3 10 7 difference in facial mucosa level between the two groups,
(soft‑tissue texture) and 90.9% of immediate implants and 80% of conventional
Pink esthetic score, 8.54±1.26 (6‑10) 8.10±1.65 (6‑10) implants acquired a complete score in this respect. Some studies
mean±SD (range) have reported high incidence of gingival recession (30%–40%)
SD – Standard deviation; IIT – Immediate implant treatment; following immediate implant placement[27,29‑31] while some
CIT – Conventional implant treatment; n – number others have reported limited resorption in the facial mucosa
(0.5–1 mm) following immediate implant placement.[3,16,22,23,32]
Table 3: Modified plaque index in the two groups Based on Felice et  al. study, soft‑tissue levels score was
MP 0 1 2 3 significantly better at immediate implants as compared with
IIT, n (%) 21 (95.5) 1 (4.5) 0 0 delayed implants.[9] Some studies have reported that thin
CIT, n (%) 18 (90) 2 (10) 0 0 gingival biotype is an important, even the most important,
IIT – Immediate implant treatment; CIT – Conventional implant treatment; factor responsible for midfacial gingival recession.[21,33] The
MP – Modified plaque; n – number presence of labial bone with adequate thickness and height is an

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Pour, et al.: Soft‑tissue esthetic outcomes in immediate implant placement
important factor affecting long‑term stability of gingival margin
around implants.[34] Moreover, implant shoulder position also
affects mid‑facial gingival recession such that buccal shoulder
of implant can increase the risk of gingival recession by
three times. Therefore, accurate patient selection is the most
important factor in this respect.[22,29] In other words, many
factors such as technique of surgery, restorative treatment,
technical expertise, buccal bone plate status, soft‑tissue
volumetric defects, and wound healing potential significantly
affect midfacial gingiva and can compensate for the negative
effect of immediate implant placement on mid‑facial gingival
status.[34]
Also according to the Systematic Review in 2016, no
significant difference of the esthetic outcomes was reported
following immediate as compared with conventional implant
placement.[35]
In the current study, the three‑component parameter of
PES was not significantly different between the two groups
either. This parameter had the lowest frequency percentage
of acquiring a complete score compared to other parameters
in the two groups (46.5% in the immediate and 36% in the
conventional group).
In detailed assessment of findings, the most important factor
responsible for not acquiring a complete score in most cases was
found to be absence of adequate alveolar prominence (55% in
the conventional group and 46.46% in the immediate group).
Cosyn et al. in their study in 2011 evaluated immediate implants
using PES and reported that alveolar prominence was the
parameter with the highest percentage of mismatch with the
control tooth (30% mismatch).[16] The same authors in their
study in 2013 reported that alveolar prominence gained the
lowest score and great defects were noted in this parameter in
over 15% of the cases.[21] In line with these findings, evidence
shows that resorption of buccal bone plate occurs following
tooth extraction with or without implant placement.[10,32] Thus,
use of bone grafts with delayed resorption over the buccal
surface of alveolar bone, especially in the esthetic zone may
resolve this problem to some extent and help achieve more
stable esthetic results.
Only a few studies have assessed biological conditions of the
peri‑implant soft tissue.[28] Wang et  al. in 2013 showed that
peri‑implant soft tissue is an important confounding factor
in this respect.[36] In the current study, the mean MBI was
0.49 ± 0.45 in the immediate and 0.70 ± 0.50 in the conventional
group, with no significant difference between the two groups.
These findings were in agreement with those of Cosyn et al.
in 2013.[21] To put it simply, based on the current results,
36% of the areas in immediate group and 54% of those in the
conventional group showed bleeding on probing while PI was
very low in both groups such that 4.5% (one case) of samples
in the immediate group and 10% of those (two cases) in the
conventional group gained MPI score of 1. These results were
in accordance with those of similar studies.[3,16,21] Relatively
high BOP, especially in the conventional group despite low
PI is not an uncommon finding around implants,[37‑39] and is
due to infiltration of inflammatory cells, probably because
of microleakage around implant‑abutment interface[40,41] and
252 Journal of Indian Society of Periodontology - Volume 22, Issue 3, May-June 2018
subgingival placement of restoration margins.[42] Probing depth
in the current study was not significantly different between the
two groups and was within the acceptable range. This finding
was in agreement with the results of the only previous study
found on this topic.[21] In general, biological soft‑tissue findings
in this study indicated stability of soft‑tissue conditions, which
is promising for prediction of soft‑tissue outcome following
both immediate and conventional placement of single implants.
CONCLUSIONS
This study showed that immediate placement of implants
following tooth extraction is a valuable and predictable
protocol comparable to conventional placement of single
implants regarding survival rate, osseointegration, and
esthetics.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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