Review Article Jun-Yu Shi* Ren Wang* Long-Fei Zhuang Ying-Xin Gu Shi-Chong Qiao Hong-Chang Lai
Authors’ affiliations: Jun-Yu Shi*, Ren Wang*, Long-Fei Zhuang, Ying-Xin Gu, Shi-Chong Qiao, Hong-Chang Lai, Department of Oral and Maxillo-facial Implantology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
Esthetic outcome of single implant crowns following type 1 and type 3 implant placement: a systematic review
Key words: dental implants, immediate implant placement, pink esthetic score, soft-tissue
esthetic outcome, systematic review Abstract Objective: The aim of the current review was to systematically appraise the esthetic outcome of soft tissue around single implant crowns following type 1 and type 3 implants placement in
Corresponding author: Hong-Chang Lai Department of Oral and Maxillo-facial Implantology Shanghai Ninth People’s Hospital, School of Medicine Shanghai Jiaotong University 639 Zhizaoju Road, Shanghai, 200011, China Tel.: +86 21 23271699 (ext. 5298) Fax: +86 21 53073068 e-mail: [email protected]
published dental literature. Materials and methods: A PubMed, Embase, and the Cochrane Central Register of Controlled Trials search up to March 2013 was conducted for articles published in the dental literature and limited to human trials with no language restricted. Furthermore, the reference lists of related articles were systematically screened, and additional manual searches were also performed. The primary outcome was pink esthetics score (PES). Results: The electronic search in the database of PubMed, Embase, and the Cohrane Central Register of Controlled Trials resulted in the identification of 463 titles. These titles were initially screened by the two independent reviewers for possible inclusion. Screening the abstracts and titles led to 28 articles for future full-text consideration. From these articles, 18 studies were excluded. Manual search identified one article. After quality assessment, eight studies were included in this review. This review showed that no significant difference of PES index could be found between type 1 and type 3 implant placement. Conclusion: According to the current evidence, short-term esthetic outcomes of peri-implant soft tissue did not show significant difference following type 1 and type 3 implants placement with well-selected patients. However, caution should be taken for clinicians to extrapolate this result to all types of patients, as more randomized clinical trials are needed for long-term soft-tissue esthetic outcome in patients with high esthetic risk following type 1 implant placement. PES frequency, peri-implant condition and other risk factors for peri-implantitis are recommended to be reported for future studies.
*These authors contributed equally to this work The authors claim that none of the material in the paper has been published or is under consideration for publication elsewhere. Date: Accepted 11 December 2013 To cite this article: Shi J-Y, Wang R, Zhuang L-F, Gu Y-X, Qiao S-C, Lai H-C. Esthetic outcome of single implant crowns following type 1 and type 3 implant placement: a systematic review. Clin. Oral Impl. Res. 00, 2014, 1–7 doi: 10.1111/clr.12334
In recent years, oral rehabilitation of partially and fully edentulous patients with oral implants has become a routine treatment with high survival and success rates (Pjetursson et al. 2007, 2012; Jung et al. 2008). Immediate implant placement is widely applied for the sake of shorter treatment time span and fewer surgical interventions. Immediate implant placement (type 1) is defined as the placement of a dental implant immediately after tooth extraction in a fresh socket. Similar survival and success rates of singletooth implants can be achieved following different timing of implant placement (Knoernschild 2012; Lang et al. 2012; OrtegaMartinez et al. 2012). Several studies have reported hard tissue remodeling following immediate implant
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
placement. It has been demonstrated that the immediate implant placement failed to prevent resorption of the buccal bone plate (Botticelli et al. 2004; Araujo & Lindhe 2005). In addition, the hard tissue remodeling and buccal bone plate resorption will occur whether or not bone substitutes are used (Benic et al. 2012a,b; Novaes et al. 2012). However, the esthetic outcome following type 1 implant placement has still remained controversial. Two reviews have reported the impact of type 1 implant placement on softtissue esthetic outcome remained inconclusive (den Hartog et al. 2008; Benic et al. 2012a,b). While another review reported limited recession of interdental papillae and facial mucosa can be achieved following immediate restoration with those patients
1
Shi et al Esthetic assessment of implant treatment
who have intact buccal bone and thick gingival biotype (Cosyn et al. 2012a). The success of implant treatment should not be limited to achieving osseointergration. The visual appearance of the reconstructions is also an important factor for clinical success especially in esthetic area (Belser et al. 2004; Papaspyridakos et al. 2012). For clinical esthetic assessment, both implant crown features and peri-implant soft-tissue stability should be considered (Chang et al. 1999). To achieve optimal esthetic outcomes, the following prerequisites are considered essentially: optimal implant 3D position, adequate bone volume, stable level of bone support and ideal soft-tissue dimensions around the implant-supported restoration (Belser et al. 2004; Belser et al. 1998). It is worth mentioning that peri-implant soft tissue meets most clinical challenge from the esthetic aspect. The complete and incomplete loss of interproximal papillae, disharmonious mucosal color or texture and poor emergence profile are the most common reasons for esthetic failure (Jung et al. 2012). Thus, stable peri-implant soft tissue is very important to achieving clinical esthetic success. Aiming at objectively assessing esthetic outcome of soft tissue, several indices have been proposed. Furhauser et al. (2005) introduced pink esthetic score (PES) to assess the appearance of soft tissue in esthetic area with seven parameters including mesial and distal papilla, level of soft-tissue margin, soft-tissue contour, alveolar process, soft-tissue color and texture. Each parameter was assessed with a 2-1-0 scale, with 2 being the best and 0 being the poorest score (Furhauser et al. 2005). Belser et al. (2009) modified the PES index by combining three specific soft-tissue parameters, that is, alveolar process, mucosal color, and mucosal texture, making these three parameters 33% of their original relative “weight.” White esthetics score (WES), assessing tooth form, tooth volume, color, surface texture and translucency, was used in combination with the modified PES to assess the restorations. A threshold for clinical acceptability was defined as PES ≥ 8 and modified PES ≥ 6 by Cosyn et al. (2012b) and Belser et al. (2009). Unfavorable mucosal esthetics was defined as PES < 8 and modified PES < 6. Also, perfect mucosal esthetics was defined as PES ≥ 12 and PES ≥ 9. Up to now, many studies focus on the influence of type 1 implant placement on interdental papillae and mid-facial mucosa. However, other factors, such as alveolar
2 |
Clin. Oral Impl. Res. 0, 2014 / 1–7
process deficiency, mucosal contour, color and texture, also impact the stability of periimplant soft tissue. The PES index can assess the soft-tissue esthetic outcome more comprehensively. And the index has been proved to be reliable and reproducible, so it was chosen as the main variable in this review (Cho et al. 2010; Vilhjalmsson et al. 2011; Hof et al. 2013). The aim of the present review is to systematically analyze the scientific literature regarding the esthetic outcome of periimplant soft tissue following type 1 and type 3 implant placement. Type 3 implant placement (conventional group) named early placement with partial bone healing is defined as the placement of a dental implant 12– 16 weeks after tooth extraction. This type of implant placement is most widely used in the world with sufficient evidence to achieve high success rate and favorable peri-implant soft tissue. So it was chosen as the control group in this review.
Material and methods Search strategy
A PubMed, Embase, and the Cochrane Central Register of Controlled Trials search up to March 2013 was conducted for articles published in the dental literature, and limited to human trials with no language restricted, using search term (esthetics or esthetics or PES or “pink esthetics score” or PES/WES) and (“dental implants” or “dental implantation” or implant) and (“single implant” or “single tooth” or “single crown” or “single restoration”). Additional manual searches of bibliographies of full-text articles and related reviews were also performed. Furthermore, manual searching was conducted in the following journals from 2005 up to March 2013: Clinical Oral Implants Research, Clinical Implant Dentistry and Related Research, International Journal of Oral Maxillofacial Implants, European Journal of Oral Implantology, Journal of Oral Implantology, Journal of Oral Rehabilitation, Journal of Prosthetic Dentistry.
4. Studies reporting mean PES value or PES frequency of the implant-supported crown; 5. Studies with a minimum of 10 patients; 6. Publications in the dental literature, based on human trials, without language restriction. Exclusion criteria
Studies not conforming to the inclusion criteria and study with multiple publications on the same patient cohort were excluded in this review. Selection of studies
Titles and abstracts of the searches were initially screened by two independent reviewers (S. J. Y. & G. Y. X). Any disagreement regarding the inclusion criteria was resolved by discussion. Full-text articles of all papers that were considered eligible for inclusion by two reviewers. The k values were 0.82 and 0.77 at the abstract and full-text article levels, respectively. After manual searching, one study was added into this review. Finally, the full-text articles were assessed by a qualityassessment checklist (Fig. 1). Assessment of the Methodological quality
The methodological quality of the studies was assessed by two independent investigators, focusing on description of patient demographics, intervention procedures, outcome measurement and follow-up assessment. A quality-assessment checklist designed by den Hartog et al. (2008) was used to assess the included studies. It was decided that studies scoring 5 or more plusses were finally included in this review. Date extraction
Two independent reviewer extracted data using a data extraction form. Any disagree-
Inclusion criteria
The additional inclusion criteria for study selection were: 1. Studies with implants in esthetic area; 2. Studies reporting type 1 or 3 implant placement; 3. Studies reporting restorations supported by single implants only;
Fig. 1. Search strategy.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Shi et al Esthetic assessment of implant treatment
ment regarding data extraction was resolved by discussion. General information, eligibility criteria, study characteristics, interventions and outcomes, mean PES value and PES frequency was retrieved. The primary outcome was mean PES value. The secondary outcomes were PES frequency and parameters in PES or modified PES. Statistical analysis
As only limited studies described short-term outcomes with type 1 and type 3 implants placement, descriptive analysis was performed in this review instead of a quantitative meta-analysis.
Table 1. Study and patient characteristics of the reviewed studies for implants in esthetics area
Study (year)
Study design
Follow-up (months)
Felice et al. (2011)
RCT
Cosyn (2013)
Retrosp.
24–36
Raes et al. (2012)
Prosp.
12
Mangano et al. (2013)
Retrosp.
Lai et al. (2008) Cosyn et al. (2011) Mangano et al. (2012) Chen et al. (2009)
Prosp. Prosp. Retrosp Retrosp.
31.09 34.44 6–8 36 24 36–48
8
NO. of implants (failed implants excluded) 52 52 26 41 15 23 22 18 29 25 24 85
Mean age
Implant timing
Implant systems
Drop-out (in percent)
NR
I III I III I III I III III I I I
MegaGen
0 0 7.1 6.8 0 0 0 0 0 16.7 0 0
NR 44 49 44.9 46.7 31 54 48.7 43.2
Nobel Astra Sesto ITI Nobel Florence ITI
NR, not reported.
Result Included studies
Four hundred and sixty-three titles and abstracts were retrieved from the electronic search for possible inclusion in the review. Twenty-eight articles were selected for fulltext evaluation. After manual searching, one study was added into full-text evaluation (Traini et al. 2011). Eight studies were excluded because of not reporting timing of implant placement or reporting other types of implant placement (Buser et al. 2008a,b; Li et al. 2008; De Angelis et al. 2011; Vilhjalmsson et al. 2011; Furze et al. 2012; Santing et al. 2012; Pieri et al. 2013). Four studies were excluded because of involving multiple implant-supported restorations (Juodzbalys & Wang 2007; Hof et al. 2013; Noelken et al. 2007, 2012). One study was excluded because of insufficient number of patients (Traini et al. 2011). Two studies were excluded because of reporting the same patient cohort (Buser et al. 2009; Raes et al. 2011). Two studies were excluded because the implants were not in esthetic area (den Hartog et al. 2011; Paul & Held 2012). After quality assessment, three studies were excluded because of not reporting details of intervention procedures (Gallucci et al. 2011; Luo et al. 2011; Cutrim et al. 2012). Finally, eight studies were included in this review (Table 1; Cosyn et al. 2011; Cosyn et al. 2013; Felice et al. 2011; Lai et al. 2008; Mangano et al. 2012; Raes et al. 2012; Chen et al. 2009; Mangano et al. 2013). Table 2 shows the details on clinical procedures of the eight studies included in present review. Mean PES value with type 1 and type 3 implant placement
Four studies reported mean PES values following type 1 implant placement compared with type 3 implant placement. None of four
Table 2. Details on clinical procedures of the reviewed studies Study (year)
Clinical procedures
Felice et al. (2011)
Bio-oss was used to fill the gap between implant and bone wall in type 1 group; pocket preservation was performed using Bio-oss and Bio-Gide and 4 months later implant surgery was performed in type 3 group. Nonoccluding provisional crowns were immediately installed and replaced by definitive crowns after 4 months. No bone grafting materials were used. Nonoccluding provisional crowns were immediately installed and replaced by definitive crowns after 3 months. No bone grafting materials were used. Provisional crowns were immediately installed and replaced by definitive crowns after 8 weeks. No bone grafting materials were used. Provisional crowns were immediately installed and replaced by definitive crowns after 3 months. No bone grafting materials were used. Definitive crowns were installed after 3 months. Bio-oss was used to fill the gap between implant and bone wall. Provisional crowns were immediately installed and replaced by definitive crowns after 6 months Biphasic calcium phosphate granules were used to fill the gap between implant and bone wall. Provisional crowns were immediately installed and replaced by definitive crowns after 3 months No bone grafting materials were used and connective tissue graft was performed in part of patients. Removable dental prostheses or vacuum-formed overlay bridges were provided and replaced by definitive crowns after 4 months.
Cosyn (2013)
Raes et al. (2012)
Mangano et al. (2013)
Lai et al. (2008) Cosyn et al. (2011)
Mangano et al. (2012)
Chen et al. (2009)
studies reported significant difference between type 1 and 3 group. All studies reported the parameters in PES index, and they were also analyzed individually. None of the parameters showed significant difference between type 1 and 3 implant group (Table 3). Three studies used Mann–Whitney U-tests for comparison of type 1 and type 3 implant groups (Mangano et al. 2012; Raes et al. 2012; Cosyn et al. 2013), and one study used a t test (Felice et al. 2011). PES frequency with type 1 and type 3 implant placement
One study reported PES frequency in type 1 group compared with type 3 group: unfavor-
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
able outcome rate (UR, 9% vs. 11%), acceptability outcome rate (AR, 77.3% vs. 55.6%) and perfect outcome rate (PR, 13.7% vs. 33.4%). One study reported PES frequency following type 3 implant placement: UR 22.36%, AR 58.62%, PR 18.97%. Three studies reported PES frequency following type 1 implant placement: UR ranged from 0% to 21%, AR ranged from 58% to 73.0%, PR ranged from 15.4% to 38.9% (Table 4).
Discussion The present systematic review is focused on the soft-tissue esthetic outcome around
3 |
Clin. Oral Impl. Res. 0, 2014 / 1–7
Shi et al Esthetic assessment of implant treatment
Table 3. Mean pink esthetics score value and parameters of the reviewed studies Mesial papilla
Distal papilla
Soft-tissue level
Soft-tissue contour
Alveolar process
Soft-tissue color
Soft-tissue texture
PES
Study
Immediate
Conventional
Difference
Cosyn Felice Raes Mangano Cosyn Felice Raes Mangano Cosyn Felice Raes Mangano Cosyn Felice Raes Mangano Cosyn Felice Raes Mangano Cosyn Felice Raes Mangano Cosyn Felice Raes Mangano Cosyn Felice Raes Mangano (modified)
1.46 1.85 1.60 1.64 1.45 1.75 1.33 1.59 1.69 2.00 1.40 1.55 1.54 1.75 1.53 1.55 1.42 1.94 1.53 NR 1.65 1.75 1.53 NR 1.62 1.71 1.40 NR 10.88 12.75 10.33 7.45
1.54 1.75 1.57 1.61 1.50 1.73 1.52 1.67 1.51 2.00 1.52 1.56 1.44 1.81 1.70 1.67 1.27 1.96 1.48 NR 1.44 1.69 1.41 NR 1.42 1.67 1.17 NR 10.07 12.62 10.35 7.83
0.08 0.10 0.03 0.03 0.05 0.02 0.19 0.08 0.18 0.00 0.12 0.01 0.10 0.06 0.17 0.12 0.15 0.02 0.05 NR 0.21 0.06 0.12 NR 0.20 0.04 0.23 NR 0.81 0.13 0.02 0.38
NR, not reported; PES, pink esthetics score.
Table 4. Pink esthetics score frequency of the reviewed studies PES frequency
Study Mangano et al. (2013) Lai et al. (2008) Cosyn et al. (2011) Mangano et al. (2012) Chen et al. (2009)
Implant timing
Mean PES
Unfavorable (%)
Acceptable (%)
Perfect (%)
I III III I I I
7.45 7.83 9.55 10.48 7.3 11.0
9 11 22.36 21 11.60 0
77.3 55.6 58.62 58 73.00 61.10
13.7 33.4 18.97 21 15.40 38.90
Remark Modified PES
Modified PES
Table 5. Additional exclusion criteria for immediate group Raes Mangano
Cosyn Felice
Thin-scalloped gingival biotype, poor soft tissue level and contour at the facial aspect, intact extraction socket The presence of less than 4 bony walls of the alveolus, dehiscence of fenestration of the residual bony walls and a thin-scalloped gingival biotype, natural teeth present both mesial and distal to the implant Incomplete buccal wall, bone height apical to the socket
Authors’ affiliations: Jun-Yu Shi*, Ren Wang*, Long-Fei Zhuang, Ying-Xin Gu, Shi-Chong Qiao, Hong-Chang Lai, Department of Oral and Maxillo-facial Implantology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
Esthetic outcome of single implant crowns following type 1 and type 3 implant placement: a systematic review
Key words: dental implants, immediate implant placement, pink esthetic score, soft-tissue
esthetic outcome, systematic review Abstract Objective: The aim of the current review was to systematically appraise the esthetic outcome of soft tissue around single implant crowns following type 1 and type 3 implants placement in
Corresponding author: Hong-Chang Lai Department of Oral and Maxillo-facial Implantology Shanghai Ninth People’s Hospital, School of Medicine Shanghai Jiaotong University 639 Zhizaoju Road, Shanghai, 200011, China Tel.: +86 21 23271699 (ext. 5298) Fax: +86 21 53073068 e-mail: [email protected]
published dental literature. Materials and methods: A PubMed, Embase, and the Cochrane Central Register of Controlled Trials search up to March 2013 was conducted for articles published in the dental literature and limited to human trials with no language restricted. Furthermore, the reference lists of related articles were systematically screened, and additional manual searches were also performed. The primary outcome was pink esthetics score (PES). Results: The electronic search in the database of PubMed, Embase, and the Cohrane Central Register of Controlled Trials resulted in the identification of 463 titles. These titles were initially screened by the two independent reviewers for possible inclusion. Screening the abstracts and titles led to 28 articles for future full-text consideration. From these articles, 18 studies were excluded. Manual search identified one article. After quality assessment, eight studies were included in this review. This review showed that no significant difference of PES index could be found between type 1 and type 3 implant placement. Conclusion: According to the current evidence, short-term esthetic outcomes of peri-implant soft tissue did not show significant difference following type 1 and type 3 implants placement with well-selected patients. However, caution should be taken for clinicians to extrapolate this result to all types of patients, as more randomized clinical trials are needed for long-term soft-tissue esthetic outcome in patients with high esthetic risk following type 1 implant placement. PES frequency, peri-implant condition and other risk factors for peri-implantitis are recommended to be reported for future studies.
*These authors contributed equally to this work The authors claim that none of the material in the paper has been published or is under consideration for publication elsewhere. Date: Accepted 11 December 2013 To cite this article: Shi J-Y, Wang R, Zhuang L-F, Gu Y-X, Qiao S-C, Lai H-C. Esthetic outcome of single implant crowns following type 1 and type 3 implant placement: a systematic review. Clin. Oral Impl. Res. 00, 2014, 1–7 doi: 10.1111/clr.12334
In recent years, oral rehabilitation of partially and fully edentulous patients with oral implants has become a routine treatment with high survival and success rates (Pjetursson et al. 2007, 2012; Jung et al. 2008). Immediate implant placement is widely applied for the sake of shorter treatment time span and fewer surgical interventions. Immediate implant placement (type 1) is defined as the placement of a dental implant immediately after tooth extraction in a fresh socket. Similar survival and success rates of singletooth implants can be achieved following different timing of implant placement (Knoernschild 2012; Lang et al. 2012; OrtegaMartinez et al. 2012). Several studies have reported hard tissue remodeling following immediate implant
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
placement. It has been demonstrated that the immediate implant placement failed to prevent resorption of the buccal bone plate (Botticelli et al. 2004; Araujo & Lindhe 2005). In addition, the hard tissue remodeling and buccal bone plate resorption will occur whether or not bone substitutes are used (Benic et al. 2012a,b; Novaes et al. 2012). However, the esthetic outcome following type 1 implant placement has still remained controversial. Two reviews have reported the impact of type 1 implant placement on softtissue esthetic outcome remained inconclusive (den Hartog et al. 2008; Benic et al. 2012a,b). While another review reported limited recession of interdental papillae and facial mucosa can be achieved following immediate restoration with those patients
1
Shi et al Esthetic assessment of implant treatment
who have intact buccal bone and thick gingival biotype (Cosyn et al. 2012a). The success of implant treatment should not be limited to achieving osseointergration. The visual appearance of the reconstructions is also an important factor for clinical success especially in esthetic area (Belser et al. 2004; Papaspyridakos et al. 2012). For clinical esthetic assessment, both implant crown features and peri-implant soft-tissue stability should be considered (Chang et al. 1999). To achieve optimal esthetic outcomes, the following prerequisites are considered essentially: optimal implant 3D position, adequate bone volume, stable level of bone support and ideal soft-tissue dimensions around the implant-supported restoration (Belser et al. 2004; Belser et al. 1998). It is worth mentioning that peri-implant soft tissue meets most clinical challenge from the esthetic aspect. The complete and incomplete loss of interproximal papillae, disharmonious mucosal color or texture and poor emergence profile are the most common reasons for esthetic failure (Jung et al. 2012). Thus, stable peri-implant soft tissue is very important to achieving clinical esthetic success. Aiming at objectively assessing esthetic outcome of soft tissue, several indices have been proposed. Furhauser et al. (2005) introduced pink esthetic score (PES) to assess the appearance of soft tissue in esthetic area with seven parameters including mesial and distal papilla, level of soft-tissue margin, soft-tissue contour, alveolar process, soft-tissue color and texture. Each parameter was assessed with a 2-1-0 scale, with 2 being the best and 0 being the poorest score (Furhauser et al. 2005). Belser et al. (2009) modified the PES index by combining three specific soft-tissue parameters, that is, alveolar process, mucosal color, and mucosal texture, making these three parameters 33% of their original relative “weight.” White esthetics score (WES), assessing tooth form, tooth volume, color, surface texture and translucency, was used in combination with the modified PES to assess the restorations. A threshold for clinical acceptability was defined as PES ≥ 8 and modified PES ≥ 6 by Cosyn et al. (2012b) and Belser et al. (2009). Unfavorable mucosal esthetics was defined as PES < 8 and modified PES < 6. Also, perfect mucosal esthetics was defined as PES ≥ 12 and PES ≥ 9. Up to now, many studies focus on the influence of type 1 implant placement on interdental papillae and mid-facial mucosa. However, other factors, such as alveolar
2 |
Clin. Oral Impl. Res. 0, 2014 / 1–7
process deficiency, mucosal contour, color and texture, also impact the stability of periimplant soft tissue. The PES index can assess the soft-tissue esthetic outcome more comprehensively. And the index has been proved to be reliable and reproducible, so it was chosen as the main variable in this review (Cho et al. 2010; Vilhjalmsson et al. 2011; Hof et al. 2013). The aim of the present review is to systematically analyze the scientific literature regarding the esthetic outcome of periimplant soft tissue following type 1 and type 3 implant placement. Type 3 implant placement (conventional group) named early placement with partial bone healing is defined as the placement of a dental implant 12– 16 weeks after tooth extraction. This type of implant placement is most widely used in the world with sufficient evidence to achieve high success rate and favorable peri-implant soft tissue. So it was chosen as the control group in this review.
Material and methods Search strategy
A PubMed, Embase, and the Cochrane Central Register of Controlled Trials search up to March 2013 was conducted for articles published in the dental literature, and limited to human trials with no language restricted, using search term (esthetics or esthetics or PES or “pink esthetics score” or PES/WES) and (“dental implants” or “dental implantation” or implant) and (“single implant” or “single tooth” or “single crown” or “single restoration”). Additional manual searches of bibliographies of full-text articles and related reviews were also performed. Furthermore, manual searching was conducted in the following journals from 2005 up to March 2013: Clinical Oral Implants Research, Clinical Implant Dentistry and Related Research, International Journal of Oral Maxillofacial Implants, European Journal of Oral Implantology, Journal of Oral Implantology, Journal of Oral Rehabilitation, Journal of Prosthetic Dentistry.
4. Studies reporting mean PES value or PES frequency of the implant-supported crown; 5. Studies with a minimum of 10 patients; 6. Publications in the dental literature, based on human trials, without language restriction. Exclusion criteria
Studies not conforming to the inclusion criteria and study with multiple publications on the same patient cohort were excluded in this review. Selection of studies
Titles and abstracts of the searches were initially screened by two independent reviewers (S. J. Y. & G. Y. X). Any disagreement regarding the inclusion criteria was resolved by discussion. Full-text articles of all papers that were considered eligible for inclusion by two reviewers. The k values were 0.82 and 0.77 at the abstract and full-text article levels, respectively. After manual searching, one study was added into this review. Finally, the full-text articles were assessed by a qualityassessment checklist (Fig. 1). Assessment of the Methodological quality
The methodological quality of the studies was assessed by two independent investigators, focusing on description of patient demographics, intervention procedures, outcome measurement and follow-up assessment. A quality-assessment checklist designed by den Hartog et al. (2008) was used to assess the included studies. It was decided that studies scoring 5 or more plusses were finally included in this review. Date extraction
Two independent reviewer extracted data using a data extraction form. Any disagree-
Inclusion criteria
The additional inclusion criteria for study selection were: 1. Studies with implants in esthetic area; 2. Studies reporting type 1 or 3 implant placement; 3. Studies reporting restorations supported by single implants only;
Fig. 1. Search strategy.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Shi et al Esthetic assessment of implant treatment
ment regarding data extraction was resolved by discussion. General information, eligibility criteria, study characteristics, interventions and outcomes, mean PES value and PES frequency was retrieved. The primary outcome was mean PES value. The secondary outcomes were PES frequency and parameters in PES or modified PES. Statistical analysis
As only limited studies described short-term outcomes with type 1 and type 3 implants placement, descriptive analysis was performed in this review instead of a quantitative meta-analysis.
Table 1. Study and patient characteristics of the reviewed studies for implants in esthetics area
Study (year)
Study design
Follow-up (months)
Felice et al. (2011)
RCT
Cosyn (2013)
Retrosp.
24–36
Raes et al. (2012)
Prosp.
12
Mangano et al. (2013)
Retrosp.
Lai et al. (2008) Cosyn et al. (2011) Mangano et al. (2012) Chen et al. (2009)
Prosp. Prosp. Retrosp Retrosp.
31.09 34.44 6–8 36 24 36–48
8
NO. of implants (failed implants excluded) 52 52 26 41 15 23 22 18 29 25 24 85
Mean age
Implant timing
Implant systems
Drop-out (in percent)
NR
I III I III I III I III III I I I
MegaGen
0 0 7.1 6.8 0 0 0 0 0 16.7 0 0
NR 44 49 44.9 46.7 31 54 48.7 43.2
Nobel Astra Sesto ITI Nobel Florence ITI
NR, not reported.
Result Included studies
Four hundred and sixty-three titles and abstracts were retrieved from the electronic search for possible inclusion in the review. Twenty-eight articles were selected for fulltext evaluation. After manual searching, one study was added into full-text evaluation (Traini et al. 2011). Eight studies were excluded because of not reporting timing of implant placement or reporting other types of implant placement (Buser et al. 2008a,b; Li et al. 2008; De Angelis et al. 2011; Vilhjalmsson et al. 2011; Furze et al. 2012; Santing et al. 2012; Pieri et al. 2013). Four studies were excluded because of involving multiple implant-supported restorations (Juodzbalys & Wang 2007; Hof et al. 2013; Noelken et al. 2007, 2012). One study was excluded because of insufficient number of patients (Traini et al. 2011). Two studies were excluded because of reporting the same patient cohort (Buser et al. 2009; Raes et al. 2011). Two studies were excluded because the implants were not in esthetic area (den Hartog et al. 2011; Paul & Held 2012). After quality assessment, three studies were excluded because of not reporting details of intervention procedures (Gallucci et al. 2011; Luo et al. 2011; Cutrim et al. 2012). Finally, eight studies were included in this review (Table 1; Cosyn et al. 2011; Cosyn et al. 2013; Felice et al. 2011; Lai et al. 2008; Mangano et al. 2012; Raes et al. 2012; Chen et al. 2009; Mangano et al. 2013). Table 2 shows the details on clinical procedures of the eight studies included in present review. Mean PES value with type 1 and type 3 implant placement
Four studies reported mean PES values following type 1 implant placement compared with type 3 implant placement. None of four
Table 2. Details on clinical procedures of the reviewed studies Study (year)
Clinical procedures
Felice et al. (2011)
Bio-oss was used to fill the gap between implant and bone wall in type 1 group; pocket preservation was performed using Bio-oss and Bio-Gide and 4 months later implant surgery was performed in type 3 group. Nonoccluding provisional crowns were immediately installed and replaced by definitive crowns after 4 months. No bone grafting materials were used. Nonoccluding provisional crowns were immediately installed and replaced by definitive crowns after 3 months. No bone grafting materials were used. Provisional crowns were immediately installed and replaced by definitive crowns after 8 weeks. No bone grafting materials were used. Provisional crowns were immediately installed and replaced by definitive crowns after 3 months. No bone grafting materials were used. Definitive crowns were installed after 3 months. Bio-oss was used to fill the gap between implant and bone wall. Provisional crowns were immediately installed and replaced by definitive crowns after 6 months Biphasic calcium phosphate granules were used to fill the gap between implant and bone wall. Provisional crowns were immediately installed and replaced by definitive crowns after 3 months No bone grafting materials were used and connective tissue graft was performed in part of patients. Removable dental prostheses or vacuum-formed overlay bridges were provided and replaced by definitive crowns after 4 months.
Cosyn (2013)
Raes et al. (2012)
Mangano et al. (2013)
Lai et al. (2008) Cosyn et al. (2011)
Mangano et al. (2012)
Chen et al. (2009)
studies reported significant difference between type 1 and 3 group. All studies reported the parameters in PES index, and they were also analyzed individually. None of the parameters showed significant difference between type 1 and 3 implant group (Table 3). Three studies used Mann–Whitney U-tests for comparison of type 1 and type 3 implant groups (Mangano et al. 2012; Raes et al. 2012; Cosyn et al. 2013), and one study used a t test (Felice et al. 2011). PES frequency with type 1 and type 3 implant placement
One study reported PES frequency in type 1 group compared with type 3 group: unfavor-
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
able outcome rate (UR, 9% vs. 11%), acceptability outcome rate (AR, 77.3% vs. 55.6%) and perfect outcome rate (PR, 13.7% vs. 33.4%). One study reported PES frequency following type 3 implant placement: UR 22.36%, AR 58.62%, PR 18.97%. Three studies reported PES frequency following type 1 implant placement: UR ranged from 0% to 21%, AR ranged from 58% to 73.0%, PR ranged from 15.4% to 38.9% (Table 4).
Discussion The present systematic review is focused on the soft-tissue esthetic outcome around
3 |
Clin. Oral Impl. Res. 0, 2014 / 1–7
Shi et al Esthetic assessment of implant treatment
Table 3. Mean pink esthetics score value and parameters of the reviewed studies Mesial papilla
Distal papilla
Soft-tissue level
Soft-tissue contour
Alveolar process
Soft-tissue color
Soft-tissue texture
PES
Study
Immediate
Conventional
Difference
Cosyn Felice Raes Mangano Cosyn Felice Raes Mangano Cosyn Felice Raes Mangano Cosyn Felice Raes Mangano Cosyn Felice Raes Mangano Cosyn Felice Raes Mangano Cosyn Felice Raes Mangano Cosyn Felice Raes Mangano (modified)
1.46 1.85 1.60 1.64 1.45 1.75 1.33 1.59 1.69 2.00 1.40 1.55 1.54 1.75 1.53 1.55 1.42 1.94 1.53 NR 1.65 1.75 1.53 NR 1.62 1.71 1.40 NR 10.88 12.75 10.33 7.45
1.54 1.75 1.57 1.61 1.50 1.73 1.52 1.67 1.51 2.00 1.52 1.56 1.44 1.81 1.70 1.67 1.27 1.96 1.48 NR 1.44 1.69 1.41 NR 1.42 1.67 1.17 NR 10.07 12.62 10.35 7.83
0.08 0.10 0.03 0.03 0.05 0.02 0.19 0.08 0.18 0.00 0.12 0.01 0.10 0.06 0.17 0.12 0.15 0.02 0.05 NR 0.21 0.06 0.12 NR 0.20 0.04 0.23 NR 0.81 0.13 0.02 0.38
NR, not reported; PES, pink esthetics score.
Table 4. Pink esthetics score frequency of the reviewed studies PES frequency
Study Mangano et al. (2013) Lai et al. (2008) Cosyn et al. (2011) Mangano et al. (2012) Chen et al. (2009)
Implant timing
Mean PES
Unfavorable (%)
Acceptable (%)
Perfect (%)
I III III I I I
7.45 7.83 9.55 10.48 7.3 11.0
9 11 22.36 21 11.60 0
77.3 55.6 58.62 58 73.00 61.10
13.7 33.4 18.97 21 15.40 38.90
Remark Modified PES
Modified PES
Table 5. Additional exclusion criteria for immediate group Raes Mangano
Cosyn Felice
Thin-scalloped gingival biotype, poor soft tissue level and contour at the facial aspect, intact extraction socket The presence of less than 4 bony walls of the alveolus, dehiscence of fenestration of the residual bony walls and a thin-scalloped gingival biotype, natural teeth present both mesial and distal to the implant Incomplete buccal wall, bone height apical to the socket
