Journal of Periodontology; Copyright 2010

DOI: 10.1902/jop.2010.100408

Stability of Contour Augmentation and Esthetic Outcomes of Implant Supported Single Crowns in the Esthetic Zone. 3-Year Results of a Prospective Study With Early Implant Placement Post Extraction
Daniel Buser, DMD, Dr. med. dent.*, Julia Wittneben, DDS, Dr. med. dent. , Michael M. Bornstein, DMD, Dr. med. dent.*, Linda Grtter, DMD, Dr. med. dent., Vivianne Chappuis, DMD, Dr. med. dent.*, Urs C. Belser, DMD, Dr. med. dent. * Department of Oral Surgery and Stomatology, School of Dental Medicine, University of Bern, Switzerland

Department

Background: Early implant placement is one of the treatment options following extraction. Implant surgery is performed after a healing period of 48 weeks, and combined with a simultaneous contour augmentation using the GBR technique to rebuild stable esthetic facial hard and soft tissue contours. Methods: In this prospective study, 20 patients were treated with an implant-borne single crown and followed for 3 years. Clinical, radiologic and esthetic parameters were recorded to assess treatment outcomes.

KEY WORDS

Implantology, bone regeneration, clinical trial, gingival recession, bone graft(s), guided bone regeneration

Today, implant placement following extraction of a single tooth is common in daily clinical practice. The clinician can choose from various treatment options, such as immediate, early or late implant placement.1,2 Objectives of implant therapy can be divided into primary and secondary. Primary objectives of implant therapy are successful outcomes from a functional and esthetic point of view and a low risk of complications. Secondary objectives are to offer implant therapy with the least number of surgical procedures, low morbidity for patients, and a short treatment period from extraction to restoration. These secondary objectives are meant to improve the attractiveness of implant therapy for patients, but should not compromise primary objectives. Thus, clinicians must carefully weigh these aspects of treatment, particularly in the esthetic zone, where esthetic outcomes are of utmost importance. This esthetic challenge is based on a variety of local risk factors which are often present in the

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Conclusions: This prospective study evaluating the concept of early implant placement demonstrated successful tissue integration for all 20 implants and stable bone crest levels around the implant-abutment interface according to the platform-switching concept. The mid-term 3-year follow-up revealed pleasing esthetic outcomes and stable facial soft tissues. The risk of mucosal recession was low, with only one patient showing minor recession of the facial mucosa. These encouraging results need to be confirmed with a 5-year follow-up examination.

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Results: At the 3-year examination, all 20 implants were successfully integrated, demonstrating ankylotic stability and healthy peri-implant soft tissues as documented by standard clinical parameters. The esthetic outcomes assessed by a Pink and White Esthetic Scores (PES and WES) confirmed pleasing results overall. The WES values were slightly superior to the PES values. The periapical radiographs showed minimal crestal bone loss around the utilized bone-level implants, with mean bone loss of 0.18 mm at 3 years. Only two implants revealed bone loss between 0.5 and 1.0 mm. One of these had minor mucosal recession of less than 1.0 mm.

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of Fixed Prosthodontics and Occlusion, School of Dental Medicine, University of Geneva, Switzerland

Department of Crown and Bridge Prosthetics, School of Dental Medicine, University of Bern, Switzerland

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DOI: 10.1902/jop.2010.100408

anterior maxilla.3,4 A recent literature review clearly showed that immediate implants are associated with an increased risk of esthetic complications.5 Several clinical studies have demonstrated that the recession of the facial mucosa is the main complication observed with immediate implants.6-12 Early implant placement following a soft tissue healing period of 4-8 weeks is a valuable treatment alternative. The main objective of this approach is to get an intact mucosa at the future implant site to allow a predictable contour augmentation on the facial aspect.13 Contour augmentation using the guided bone regeneration (GBR) technique with a resorbable collagen membrane combined with autogenous bone grafts and a low-substitution bone filler is considered important for the esthetic outcome, since it compensates for ridge alterations following extraction. These alterations are a physiologic tissue reaction following extraction due to the interruption of blood supply of the bundle bone through blood vessels of the periodontal ligament.14 At present, the concept of early implant placement is only documented with short- to mid-term studies showing favorable esthetic outcomes on the facial aspect with a low risk of mucosal recession.15-18

MATERIAL & METHODS

Between November 2005 and July 2006, 20 partially edentulous patients were consecutively admitted to this case series examining the concept of early implant placement post extraction. The study protocol was approved by the standing ethical committee for clinical studies of the State of Bern (approval number 30/05), and all patients signed an informed consent. Details of case selection, surgical and restorative procedures have been reported in a previous publication.16 The most important aspects of the surgical procedures for contour augmentation included flapless tooth extraction, a soft tissue healing period of 4-8 weeks, and the insertion of a bone level implant in a correct 3-dimensional position with an implant platform diameter of 4.1 mm and an implant length of either 10 or 12 mm*. These implants are characterized by a chemically modified, sandblasted and acid-etched surface in the endosseous portion. Contour augmentation was performed with locally harvested autogenous bone chips to cover the exposed implant surface, followed by a superficial layer of deproteinized bovine bone mineral (DBBM). The augmentation material was then covered with a non-crosslinked porcine-derived collagen membrane, followed by tension-free primary wound closure. The reopening procedure with a flapless excision of the mucosa was performed after 8-12 weeks of healing, and was followed by the prosthetic procedures for a screw-retained full ceramic crown bonded with composite resin to the titanium milling abutment. For all 20 crowns, the same ceramic material has been usedII. Follow-up Examinations Following completion of surgical and prosthetic therapy, the 20 patients were recalled at various time points for the assessment of the following parameters: Standard soft tissue parameters which have been routinely used in prospective long-term studies for roughly 20 years19-21: modified plaque index (mPLI)19, modified sulcus bleeding index (mSBI)19, probing depth (PD, in mm)20, all assessed at four aspects around the implants. In addition, the width of keratinized mucosa (KM) was assessed on the facial aspect in millimeters. These parameters were assessed with the crowns in place at 3, 6, 12, and 36 months.

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The purpose of the present prospective study was to follow up on the 12-month results of a case series study with 20 consecutive patients15 and to evaluate the stability of contour augmentation and esthetic outcomes 3 years following restoration.

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DIM values. At the same time intervals, the screw-retained crowns were removed and the distance from the mucosal margin to the implant shoulder (DIM) was measured with a periodontal probe to the nearest millimeter at four locations in the implant site20. This was only feasible in 19 crowns, since one implant was restored with a cemented all-ceramic crown. DIB values. Periapical radiographs were taken with the longcone technique and individual bite blocks at day 0 (baseline) and at 3, 6, 12, and 36 months, and subsequently analyzed to assess the distance from the implant shoulder to the first bone-to-implant contact (DIB) on the mesial and distal aspects.22 For each implant and each examination period, one DIB value was calculated as the average of the obtained mesial and distal values. Analysis was done using the distance between the tips of the implant threads (0.8 mm) for calibration. The radiographic readings were performed by one experienced examiner not involved in the surgical or prosthetic treatment of the patients. Cast analysis. Impressions were taken at 1, 12, and 36 months to produce study casts of the maxilla. The casts were photographed with a standardized technique using a millimeter grid as reference.16 On these digital pictures, the mid-facial height of the implant crown (IC) and the corresponding height of the contra-lateral tooth crown (TC) were both measured to identify potential changes in crown height or mucosal recession. Esthetic parameters. To objectively examine the esthetic outcomes of the implant crowns at the 12- and 36-month examination, the respective casts and intraoral pictures were critically analyzed by two examiners (J.W. and U.B.) to assess the pink esthetic score (PES) and white esthetic score (WES).17

Statistical Analysis

The esthetically relevant facial DIM values (DIMf) were tested separately in comparison to the interproximal and oral values of the 36-month examinations (DIMm, DIMo and DIMd) using Wilcoxon paired signed rank tests to avoid pooling data of dependent variables. Data sets of the cast analysis were evaluated descriptively, and the difference between IC and TC was calculated for each time point separately. To detect statistically significant differences between the IC-TC values, the Wilcoxon signed-rank test was used. The level of significance for all tests was p < 0.05. All analyses were performed using a computer software program. The p value adjustment was done using the Internet-based program R 2.9.2 (http://www.R-project.org).

RESULTS
Standard Soft Tissue Parameters In general, the patients performed good oral home care. During the 3-year observation period, the mean mPLI remained at low levels, with a mean value of 0.40 at the 3-year examination

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First, all data were analyzed with descriptive methods using box plots. To analyze potential differences in the gingival parameters and radiographic findings over the time period, the Wilcoxon signed-rank test was used. To compensate for multiple testing situations, the p values were adjusted according to the method of Holm23, which allowed them to be compared to the usual alpha level of 0.05.

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(Table 1). The peri-implant soft tissues revealed little tendency to bleed following probing and appeared clinically healthy. The mean mSBI was 0.20 at the 3-year examination. The mean PD was 4.00 mm at the 3-year examination, slightly increasing from 3.69 mm at the 3-month examination during the follow-up period. The difference, however, was statistically not significant. The mean KM value at the 3-year examination was 4.10 mm, indicating a wide band of keratinized mucosa on the facial aspect of the implant crowns. Radiographic Findings/DIB Values The radiographs obtained of each implant did not reveal any signs of continuous peri-implant radiolucency during the observation period. At baseline (reopening = day 0), the mean DIB was 0.00 mm for the 20 implants. The peri-implant crestal bone showed a remodeling pattern during the first 12 months with functional loading. The mean DIB values increased from 0 to 0.18 mm at 12 months of loading (Table 2), and remained stable thereafter with a mean value of 0.18 mm (+/- 0.24 mm) at the 3-year examination. The frequency analysis of DIB36mos-day0 (Fig. 1) demonstrated minimal bone resorption (<0.25 mm) for 15 of 20 implants, as shown by the radiographs of all 20 implants at the 36-month examination (Fig. 2). Of 20 implants, only two showed bone loss between 0.5 and 1.0 mm. DIM Values at the 12-Month and 36-Month Examinations The DIM values were measured following the removal of the definitive crowns at 12 and 36 months. The analysis demonstrated a mean value of -3.68 mm for the facial DIM. This value was significantly different (p=0.0004 for all tests) from the mesial and distal values when analyzed using Wilcoxon paired signed rank tests (Table 3). No difference was found in comparison with the mean value at 12 months (-3.53 mm). Summarizing these clinical and radiographic parameters, all 20 implants could be considered successfully integrated at the 3-year follow-up examination according to strict success criteria which have been used in implant dentistry for almost 20 years.20 Cast Analysis

Esthetic Parameters: PES/WES Values Esthetic parameters at 12 and 36 months are depicted in Table 5. At 3 years, the analysis revealed a mean PES score of 8.10 and a mean WES score of 8.65, resulting in a total mean score of 16.75. These values were stable when compared to the 1-year results. Overall, the esthetic outcomes were favorable, as demonstrated in Fig. 3, showing the clinical photographs of all 20 crowns at the 3-year examination. Within the five parameters of the PES index, the papilla height showed the lowest mean values, with 1.50 mesially and distally, whereas the level of the facial mucosa performed best, with a mean value of 1.8. One implant crown still showed the lowest total score, with a slightly compromised esthetic outcome. The mucosal margin of this specific implant restoration demonstrated minimal recession between 0.5 and 1.0 mm (Fig. 3L). It was the same implant that showed bone resorption of 0.70 mm at the 3-year examination (Fig. 2L). No severe recession of 1 mm or more was observed in any of the 20 implants. Among the five parameters of the WES index, surface texture and

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IC and TC values performed similarly over the 3-year study period, not showing any statistically significant changes over time (Table 4). The highest mean crown length values 10.03 mmwere obtained in the IC group at the 12-month examination. No significant differences were seen either between the two groups (IC-TC values) or within one of the groups over time.

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translucency had excellent mean values of 1.95 and 2.0, respectively, whereas color showed the lowest mean value, 1.4.

DISCUSSION
The 3-year results of this prospective study with 20 consecutive patients confirmed favorable clinical and radiographic 1-year results for implant-borne single-tooth crowns in the anterior maxilla.16 The examined 20 implants were placed according to the concept of early implant placement eight weeks following extraction. The 3-year data demonstrated that all 20 implants achieved and maintained successful tissue integration over the study period, documented by routine clinical and radiographic parameters. The standard clinical parameters such as plaque and sulcus bleeding indices as well as probing depth values indicated healthy peri-implant soft tissues. The mean values obtained were all in line with previous prospective studies utilizing the same parameters.21, 24 All 20 implants fulfilled strict success criteria utilized in prospective studies for almost 20 years20, resulting in a survival and success rate of 100% at the 3-year follow-up examination. The main focus of this study was the long-term stability of the esthetic outcome using this treatment approach. Three different methods were applied in an attempt to objectively assess the esthetic outcomes in these 20 patients. First, the esthetic outcomes were evaluated with pink esthetic score (PES) and a white esthetic score (WES).17 In the present study, the overall results were highly satisfactory, with a mean total score of 16.75 for both indices. The 3-year mean WES score was again slightly better than the mean PES score, similar to the 1-year examination. This is not surprising, since the WES index is mainly dependent on the quality and experience of the dental technician. In the present study, all 20 ceramic implant crowns were produced by one technician with excellent expertise in esthetic restorations. Its also not surprising that the WES score did not change between the two examinations, since none of the ceramic crowns had to be repaired or replaced due to technical complications, and since contemporary ceramic crowns are very stable over time concerning mechanical resistance, volume and optical properties. Surface texture and translucency were highly rated by the two examiners, whereas color, with a mean score of 1.4, rated the lowest among the 5 different parameters. The PES index evaluates soft tissue esthetics, including the height of the mesial and distal papillae, the level and curvature of the facial mucosa, as well as the root convexity and tissue color. Compared to the 1-year results, the PES values remained stable, with a mean value of 8.1. Among the five parameters of the PES index, the papillae height showed a mean value around 1.5 and was stable. A further reduction in papilla height could potentially be caused by a loss of interproximal bone height at adjacent teeth, since the papilla height around an implant-supported single crown primarily depends on this anatomical structure25. Such a change in bone height can be caused either by a local infection such as periodontitis or a fractured root, or by the extraction of an adjacent tooth. None of these complications were observed between the 1-year and 3-year examinations in the present study. Changes in papilla height are unlikely to be influenced by the surgical technique at this time point. They might be influenced during the initial healing phase, as pointed out by a clinical study using various incision techniques26. The applied surgical technique seems to have a greater influence on the esthetic outcome on the facial aspect. The level of the facial mucosa is an important soft tissue parameter for the esthetic outcome of implant-supported crowns.3, 27 To achieve a correct mucosal level on the facial aspect, two prerequisites need to be fulfilled. First, an implant has to be correctly positioned in the oro-facial and corono-apical directions, and second, the mucosa must be

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Journal of Periodontology; Copyright 2010

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supported by a facial bone wall of sufficient height and thickness, since the peri-implant mucosa has a rather constant dimension of 3.5 to 4.5 mm on the facial aspect.28 In postextraction sites, significant ridge alterations do occur on the facial aspect, as documented in experimental and clinical studies.29, 30 As a consequence, contour augmentation is strongly recommended in post-extraction sites in the anterior maxilla.13 In the present study, the esthetic outcomes on the facial aspect were reflected by rather high PES values with regard to the level of the labial mucosa. Of 20 patients, only one (5%) demonstrated minor mucosal recession between 0.5 and 1.0 mm. No severe recession of 1 mm or more was observed at the 3-year examination. These results confirm favorable data of a previous retrospective study in 45 patients using the same surgical approach15; that study also showed a low risk for facial recession after 24 years of follow-up. The stability of the facial mucosal margin was confirmed by two additional measurements, the DIM values and the comparison of IC and IT values on casts. These measurements corroborate that the facial mucosa remained stable over the period between the 1-year and 3-year examinations. This is in contrast to various clinical studies utilizing immediate implant placement, as summarized in a recent systematic review.5 These studies all reported a rather high incidence of mucosal recession, in the range of 2040%, and identified potential risk factors for such complications.7-10, 31 Based on a recent ITI Consensus Conference, a group of experts recommended that immediate implant placement should only be used in well-selected patients with a low risk profile and carried out by master clinicians with sufficient clinical experience.32 In addition to the applied treatment quality of the involved surgeon, contour augmentation depends on the characteristics of the biomaterials utilized. Based on the promising results of the present study, it seems that a resorbable collagen membrane, in combination with autogenous bone grafts and deproteinized bovine bone mineral (DBBM), is able to provide successful contour augmentation on the facial aspect of the implants, and soft tissue stability for up to 3 years. The use of DBBM granules seems important for the long-term stability of a facial bone wall of sufficient height and thickness, since DBBM granules have a low substitution rate.33-36 It can be speculated that these bone fillers will not be resorbed during the natural bone remodeling process, and thus will help maintain the dimensions of the facial bone wall. This hypothesis needs to be confirmed by long-term studies using cone beam computed tomography (CBCT), since this new radiologic technique is able to visualize and assess the facial bone wall at implants with excellent resolution and low radiation exposure.37,38 Results of an ongoing radiologic study will be reported soon. In the present study, so-called bone-level implants were utilized which follow the concept of a platform-switching design. This implant design has gained a lot of attention in recent years, since it is believed to be associated with minimal bone resorption at the crest level during functional loading.39,40 The present study confirms this hypothesis, since the 20 implants showed on average a bone loss of only 0.18 mm from the day of loading up to 3 years of follow-up. The frequency distribution showed bone loss between 0.5 and 1.0 mm for only two implants. This rate of bone loss is much lower than the one already cited in a retrospective study with 45 implants using the same surgical approach. In this study, so-called soft-tissue-level implants were used, and the mean bone loss was 2.18 mm after a follow-up period of 24 years. To definitively confirm the superiority of bone-level implants with regard to crestal bone stability, the results of large multicenter studies seem necessary. ACKNOWLEDGMENTS
The authors thank Mrs. Claudia Moser and Mrs. Olivia Schrag for the organization of all follow-up examinations. Both are employed by the Department of Oral Surgery and Stomatology, University of Bern.

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DOI: 10.1902/jop.2010.100408

CONFLICT OF INTEREST
The study was supported by departmental funds of the Universities of Bern and Geneva, and by a research grant from Institut Straumann AG, Basel. The authors report no conflict of interest related to this study.

SOURCES OF SUPPORT
The study was supported by departmental funds of the Universities of Bern and Geneva, and by a research grant from Institut Straumann AG, Basel.

CONFLICT OF INTEREST
The authors report no conflicts of interest related to this study.

REFERENCES
1.

2.

3. 4.

Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants 2004;19 Suppl:43-61. Martin WC, Morton D, Buser D. Diagnostic factors for esthetic risk assessment. In: Buser D, Belser U, Wismeijer D, eds. ITI Treatment Guide Vol 1: Implant therapy in the esthetic zone - single-tooth replacements. Berlin: Quintessence Publishing Co., Ltd., 2006:11-20. Chen ST, Buser D. Clinical and esthetic outcomes of implants placed in postextraction sites. Int J Oral Maxillofac Implants 2009;24 Suppl:186-217. Chen ST, Darby IB, Adams GG, Reynolds EC. A prospective clinical study of bone augmentation techniques at immediate implants. Clin Oral Implants Res 2005;16:176-184. Chen ST, Darby IB, Reynolds EC. A prospective clinical study of non-submerged immediate implants: clinical outcomes and esthetic results. Clin Oral Implants Res 2007;18:552-562.

5. 6. 7. 8. 9.

Lindeboom JA, Tjiook Y, Kroon FH. Immediate placement of implants in periapical infected sites: a prospective randomized study in 50 patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:705-710.

10. Kan JYK, Rungcharassaeng K, Sclar A, Lozada JL. Effects of the facial osseous defect morphology on gingival dynamics after immediate tooth replacement and guided bone regeneration: 1-year results. J Oral Maxillofac Surg 2007;65:13-19. 11. 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;35:649-657. 12. Chen ST, Darby I, Reynolds EC, Clement JG. Immediate implant placement post-extraction without flap elevation: A case series. J Periodontol 2009;80:163-172. 13. Buser D, Chen ST, Weber HP, Belser UC. Early implant placement following single-tooth extraction in the esthetic zone: biologic rationale and surgical procedures. Int J Periodontics Restorative Dent 2008;28:441451. 14. Araujo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 2005;32:212-218. 15. Buser D, Bornstein MM, Weber HP, Grutter L, Schmid B, Belser UC. Early implant placement with simultaneous guided bone regeneration following single-tooth extraction in the esthetic zone: A crosssectional, retrospective study in 45 subjects with a 2- to 4-year follow-up. J Periodontol 2008;79:1773-1781.

un

Evans CJD, Chen ST. Esthetic outcomes of immediate implant placements. Clin Oral Implants Res 2008;19:73-80.

ed

ite

Chen ST, Buser D. Advantages and disadvantages of treatment options for implant placement in postextraction sites. In: Buser D, Wismeijer D, Belser U, eds. ITI Treatment Guide: Implant placement in postextraction sites: Treatment options, Volume 3. Berlin, Chicago: Quintessenz Publishing Co. Inc., 2008: 2937.

Hammerle CH, Chen ST, Wilson TG, Jr. Consensus statements and recommended clinical procedures regarding the placement of implants in extraction sockets. Int J Oral Maxillofac Implants 2004;19 Suppl:2628.

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16. Buser D, Hart C, Bornstein M, Grtter L, Chappuis V, Belser UC. Early implant placement with simultaneous GBR following single-tooth extraction in the esthetic zone: 12-month results of a prospective study with 20 consecutive patients. J Periodontol 2009;80:152-162. 17. Belser UC, Grutter L, Vailati F, Bornstein MM, Weber HP, Buser D. Outcome evaluation of early placed maxillary anterior single-tooth implants using objective esthetic criteria. A cross-sectional, retrospective study in 45 patients with a 2-4 year follow-up using pink and white esthetic scores (PES/WES). J Periodontol 2009;80:140-151. 18. Cosyn J, De Rouck T. Aesthetic outcome of single-tooth implant restorations following early implant placement and guided bone regeneration: crown and soft tissue dimensions compared with contralateral teeth. Clin Oral Implants Res 2009;20:1063-1069. 19. Mombelli A, van Oosten MA, Schurch E, Jr., Land NP. The microbiota associated with successful or failing osseointegrated titanium implants. Oral Microbiol Immunol 1987;2:145-151. 20. Buser D, Weber HP, Lang NP. Tissue integration of non-submerged implants. 1-year results of a prospective study with 100 ITI hollow-cylinder and hollow-screw implants. Clin Oral Implants Res 1990;1:33-40. 21. Bornstein MM, Schmid B, Belser UC, Lussi A, Buser D. Early loading of non-submerged titanium implants with a sandblasted and acid-etched surface. 5-year results of a prospective study in partially edentulous patients. Clin Oral Implants Res 2005;16:631-638.

23. Holm S. A simple sequentially rejective multiple test procedure. Scand J Statist 1979;6:65-70. 24. Bornstein MM, Wittneben JG, Bragger U, Buser D. Early loading at 21 days of non-submerged titanium implants with a chemically modified sandblasted and acid-etched surface: 3-year results of a prospective study in the posterior mandible. J Periodontol 2010;81:809-818.

26. Gomez-Roman G. Influence of flap design on peri-implant interproximal crestal bone loss around singletooth implants. Int J Oral Maxillofac Implants 2001;16:61-67. 27. Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant relationship on esthetics. Int J Periodontics Restorative Dent 2005;25:113-119.

29. Araujo MG, Sukekava F, Wennstrom JL, Lindhe J. Ridge alterations following implant placement in fresh extraction sockets: an experimental study in the dog. J Clin Periodontol 2005;32:645-652. 30. Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations following immediate implant placement in extraction sites. J Clin Periodontol 2004;31:820-828. 31. Cordaro L, Torsello F, Roccuzzo M. Clinical outcome of submerged vs. non-submerged implants placed in fresh extraction sockets. Clin Oral Implants Res 2009; 20:1307-1313. 32. Chen ST, Beagle J, Jensen SS, Chiapasco M, Darby I. Consensus statements and recommended clinical procedures regarding surgical techniques. Int J Oral Maxillofac Implants 2009;24 Suppl:272-278. 33. Schlegel AK, Donath K. BIO-OSS- a resorbable bone substitute? J Long Term Eff Med Implants 1998;8:201-209. 34. Jensen SS, Broggini N, Hjorting-Hansen E, Schenk R, Buser D. Bone healing and graft resorption of autograft, anorganic bovine bone and beta-tricalcium phosphate. A histologic and histomorphometric study in the mandibles of minipigs. Clin Oral Implants Res 2006;17:237-243. 35. Jensen SS, Yeo A, Dard M, Hunziker E, Schenk R, Buser D. Evaluation of a novel biphasic calcium phosphate in standardized bone defects. A histologic and histomorphometric study in the mandibles of minipigs. Clin Oral Implants Res 2007;18:752-760.

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28. Kan JY, Rungcharassaeng K, Umezu K, Kois JC. Dimensions of peri-implant mucosa: an evaluation of maxillary anterior single implants in humans. J Periodontol 2003;74:557-562.

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25. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region. J Periodontol 2001;72:1364-1371.

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22. Weber HP, Buser D, Fiorellini JP, Williams RC. Radiographic evaluation of crestal bone levels adjacent to nonsubmerged titanium implants. Clin Oral Implants Res 1992;3:181-188.

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36. Jensen SS, Bornstein MM, Dard M, Bosshardt DD, Buser D. Comparative study of biphasic calcium phosphates with different HA/TCP ratios in mandibular bone defects. A long-term histomorphometric study in minipigs. J Biomed Mater Res B Appl Biomater 2009;90:171-181. 37. Loubele M, Van Assche N, Carpentier K, et al.. Comparative localized linear accuracy of small-field conebeam CT and multislice CT for alveolar bone measurements. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:512-518. 38. Loubele M, Bogaerts R, Van Dijck E, et al.. Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications. Eur J Radiol 2009;71:461-468. 39. Lazzara RJ, Porter SS. Platform switching: a new concept in implant dentistry for controlling postrestorative crestal bone levels. Int J Periodontics Restorative Dent 2006;26:9-17. 40. Atieh MA, Ibrahim HM, Atieh AH. Platform switching for marginal bone preservation around dental implants: A systematic review and meta-analysis. J Periodontol 2010; (e-pub)

Submitted July 4, 2010; accepted for publication August 22, 2010. Fig. 1

Frequency distribution of bone loss around the 20 implants using the DIB36mos-0mos values.

Fig. 2A-L Radiographic examination of all 20 implants at the 3-year follow-up. Overall, minimal bone loss is observed. Fig. 3A-L Clinical status of all 20 implant restorations at the 3-year follow-up. Note the stability of the facial mucosa. Only one implant showed minor mucosal recession of between 0.5 and 1.0 mm (Fig. 3L).

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Correspondence to: Prof. Dr. Daniel Buser, Department of Oral Surgery and Stomatology, Freiburgstrasse 7, CH-3010 Bern, Switzerland, Phone: +41-31-632 25 63, Fax: +41-31-632 98 84, e-mail: daniel.buser@zmk.unibe.ch

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Table 1:

Soft tissue parameters of the 20 implants (mean standard deviation)

Exam

mPLI

mSBI

PD (mm)

3 months (n = 20)

0.08 (0.24)a,v

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3.69 (0.62)a 3.75 (0.46)b 4.43 (0.57)a,b 4.00 (0.56)

0.26 (0.29)

6 months (n = 20)

0.08 (0.20)c,d

0.16 (0.23)

1 year (n = 20)

0.36 (0.33)a,c

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0.21 (0.17)

3 years (n = 20)

0.40 (0.27)c,d

0.20 (0.20)

Statistically significant differences between the gingival parameter scores are marked with the same letters mPLI = modified plaque index; mSBI = modified sulcus bleeding index; PD = probing depth; KM = keratinized mucosa

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KM (mm)

4.06 (1.43)

4.10 (1.41)

4.50 (1.54)

4.10 (1.17)

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Table 2:

Radiographic parameters (DIB) of the 20 implants analyzed over the course of 3 years.

Exam

0 mos

3 mos

6 mos

12 mos

36 mos

Mean Median Maximum Minimum STD Significance

0 0 0 0 0.00 a, b

0.09 0 0.54 0 0.16

0.14 0 0.9 0 0.25

0.18 0.17 0.76 0

0.18 0.14 0.70 0

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0.20 a

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0.23 b

Statistically significant differences between the radiographic parameter values are marked

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with the same letters

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Table 3:

DIM values at 12 and 36 months (n = 19)

Parameters Mean Median Maximum Minimum STD Significance

DIMm -6.68 -7 -9 -5 1.16 a, b

DIMd -6.00 -6 -8 -5 0.94 c, d

DIMf -3.53 -3 -5 -2

DIMo -3.84 -4 -6 -2

d
DIMm -6.74 -7 -9 -5 0.97 e, f

Timepoint

12 months

36 months

DIMd -6.21 -6 -8 -4 1.13 g, h

DIMf -3.68 -4 -5 -3 0.97 e, g

DIMo -4.16 -4 -7 -3 1.17 f, h

0.84 a, c

un

Statistically significant differences between the soft tissue parameter values are marked with the same letters m = mesial value; f = facial value; d = distal value; o = oral value; n = number of examined implants

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0.90 b, d

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Journal of Periodontology; Copyright 2010

DOI: 10.1902/jop.2010.100408

Table 4:

Cast analysis regarding the length of the implant crown (IC) and the contralateral tooth crown (TC) in mm (mean standard deviation).

Exam

IC

TC

1 month

9.99 (0.95)

9.90 (1.12)

1 year

10.03 (1.05)

9.85 (1.23)

3 years

ed
9.84 (1.21)

9.94 (1.04)

Statistically significant differences between the gingival parameter scores are marked with the same letters IC = implant crown; TC = contralateral tooth;

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d
IC-TC
0.09 (0.58) 0.18 (0.58) 0.09 (0.33)

Journal of Periodontology; Copyright 2010

DOI: 10.1902/jop.2010.100408

Table 5.

PES and WES values of the 20 implant-supported single crowns after 12 and 36 months

Pink Esthetic Score (PES)

Timepoint

Mesial Papilla

Distal Papilla

Curvature labial Mucosa

Level labial Mucosa

Root convexity Soft tissue colour and texture

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Tooth Form 1.75 1.55 1.8 1.5

d
Mean PES Tooth Volume/ Outline

White Esthetic Score (WES)

Colour

Surface Texture

Translucency

Mean WES

Total PES & WES

1 year

1.45

1.5

1.75

1.9

ed
1.5 8.1

1.4

1.95

8.65

16.75

3 years

1.5

1.5

1.7

1.8

1.6

8.1

1.4

1.95

8.65

16.75

un

Journal of Periodontology; Copyright 2010

DOI: 10.1902/jop.2010.100408

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Journal of Periodontology; Copyright 2010

DOI: 10.1902/jop.2010.100408

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Journal of Periodontology; Copyright 2010

DOI: 10.1902/jop.2010.100408

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