Dr. Priya S Pungle1, Dr. Naisargi P Shah2, Dr. Sangeeta Yadav3, Dr. Anuradha B Govardhane4, Dr. Adhithi Prabhu5
2Head of Department and Professor,
3Adjunct Associate Professor,
University of Minnesota School of Dentistry, USA,
1,2,4,5Department of Prosthodontics, Crown & Bridge.
T.P.C. T’s Terna Dental College, Navi Mumbai Navi Mumbai
Aim: The aim of this scoping review was to highlight the effect of different implant placement timings on the marginal bone loss and pink esthetic score of a single implant restoration in maxillary anterior region.
Design and setting: The Arksey and O’Malley methodological framework.
Materials and methodology: The Arksey and O’Malley methodological framework was used for design and setting of this scoping review. The population, intervention, comparisons, and outcomes (PICO) format was applied to formulate a research question according to PRISMA guidelines. The outcome parameters were established in terms of marginal bone loss and pink esthetic score (PES). A systematic electronic search was conducted in the PubMed database for the related articles published from 1st January 2000 to 31st July 2020. The PICO details: Population: single implant restoration in maxillary anterior region, Intervention: different implant placement in terms of immediate, early and late implant placement, Comparison: different implant placement in terms of immediate, early and late implant placement, Outcome: marginal bone loss and pink esthetic score.
Results: Five studies were identified after applying the inclusion and exclusion criteria. In terms of marginal bone level, two studies showed immediate implant placement to have a higher bone loss than late placement. However, remaining studies showed no major difference in the bone levels
Conclusion: No difference for PES was observed with different implant placement timings in any of the studies.
Keywords: dental implants, single-tooth implants, maxillary anterior region, immediate implant placement, early implant placement, late implant placement, soft tissue alterations, pink esthetic score, marginal bone level and esthetics.
Citation: Pungle P. et al. Effect of different implant placement timings on marginal bone loss and pink esthetic score on single implant restoration in maxillary anterior region – A Scoping Review. J Prosthodont Dent Material 2022; 3(2):3-12
Esthetics is a prime concern while rehabilitating maxillary anterior region with dental implants.1 Various factors such as patient’s smile line, root location, tooth shape and position of the adjacent teeth, biotype of periodontium and tooth shape, bone anatomy of implant site and optimal implant positioning influence the subsequent esthetics.2 The high visibility and patient expectations places additional challenges during implant placement. The consideration of peri implant tissue in maxillary
anterior region becomes a significant factor due to reduced volume of buccal bone, thin biotype and
higher incidence of soft tissue defects.3
The timing of implant placement is believed to be one of the essential factors affecting the esthetic outcome.4 After tooth extraction, within the last few decades there are various classifications proposed for the timing of implant placement. The first attempt was done in 1993, where terms like immediate, recent, delayed, and mature were used.5 Third International Team for Implantology (ITI) Consensus Conference introduced recent classification which defines three basic protocols for implant placement according to the time between tooth extraction and implant placement.6 Type-1 implant placement is immediate implant placement in which implants are placed in fresh extraction sockets, to engage the remaining socket walls with the implant. In Type 2 placement,
implants are placed around 4–8 weeks (up to 16 weeks) after tooth extraction termed as early implant placement. Type-3 placement is late /conventional implant placement where the implants are placed after 16 weeks when dimensional changes in the alveolar ridge have occurred.7,8
Esthetic outcome is nothing but alterations in hard and soft tissues after implant placement. The marginal bone level and soft tissues are main determining factors in esthetic outcome. For marginal bone loss, bone is measured from platform of the implant to the alveolar crest on mesial and distal aspect. For soft tissue evaluation some easy to use index are there, such as pink esthetic score or white esthetic score. The most commonly used esthetic index is the pink esthetic score (PES).5 PES used to assess peri-implant soft tissue on the basis of some variables: soft tissue level, soft tissue contour,
mesial papilla, distal papilla, alveolar process deficiency, soft tissue color, and soft tissue texture. These variables are rated with a zero, one and two score. Two score is considered as the best and zero as the worst score. The overall PES for each case is obtained by adding score for each parameter where 16 is highest score that can be obtained.
There are several studies that have compared outcome in immediate, early and late implant placement in which soft and hard tissue augmentation was done where it was necessary. Data obtained from these studies were not very reliable to judge whether immediate, early and late implant placement in itself would result in better esthetic outcome or it was a result of quality of augmentation .9-11 Thus, a scoping review was designed with an aim to compare the effects of different implant placement timings protocol i.e. immediate implant placement, early implant placement or late implant placement on PES and marginal bone loss. This was conducted as a part of the pilot search for an anticipated systematic review with a more specific criteria.
Methodology: The Arksey and O’Malley methodological framework was followed for this scoping review (Figure 1)
Fig 1 Arksey and O’Malley methodological framework
Scoping review identify reasons such as to examine the extent, range, and nature of research activity, determine the value of undertaking a full systematic review, summarize and disseminate research findings, or identify gaps in the existing literature. This scoping review was performed applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) as described by Moher et al. 14
Stage 1: Identifying the research question.
The research question defined for this scoping review was, “Does the timings of implant placement have an effect on marginal bone loss and pink esthetic score?
PICO Criteria was established based on the research question as follows.
POPULATION: Single implant restoration in maxillary anterior region
INTERVENTION: Different implant placement in terms of immediate, early and late implant placement.
COMPARISON: Different implant placement in terms of immediate, early and late implant placement.
OUTCOME: marginal bone loss and pink esthetic score.
Stage 2: Identifying relevant studies.
An electronic search of the PubMed database for articles published from 1st January 2000 to 31st July 2020 was conducted. The search was conducted using a combination of various controlled vocabulary terms (i.e., MeSH terms) as well as free text terms related to the research question. The MeSH terms used were dental implants and single-tooth implants. The free text terms used were maxillary anterior region, immediate implant placement, early implant placement, late implant placement, soft tissue alterations, pink esthetic score, marginal bone level and esthetics. Various combinations of the MeSH terms and the free text terms were used with boolean operators such as “”AND”, “OR“, “NOT” to obtain the search term for studies. In order to detect additional trials dealing with maxillary anterior single implants, hand search of the articles of last 6 months was carried out.
Stage 3: Study selection.
Only Articles published from 1st January 2000 to 31st July 2020 were included. Only those studies pertaining to single implant restoration in maxillary anterior region with outcome measures in terms of marginal bone loss and pink esthetic score were included. In vivo studies with randomized control trials, prospective and retrospective cohort clinical studies and case series including five or more patients were selected. Also, articles published in the English language only were included.
Studies with hard and soft tissue augmentation or with any additional surgical procedure affecting the outcome during implant placement were excluded. Studies with insufficient information on the surgical protocol and timing after tooth extraction were excluded from this scoping review. After carrying out electronic search sixteen relevant articles were retrieved. (Figure 2) Ten articles were included after the title and abstract screening. Further, three articles were excluded after abstract evaluation and two articles after full text screening evaluation.20-30Thus, after detailed full text examination and agreement between examiners; remaining five articles were finally included in the review.15-19 (Figure 2)
Stage 4: Charting the data
The data was then extracted from the five selected studies and entered into a Microsoft Excel spreadsheet (Table 1, 2, 3). The data items that were extracted and charted were as follows:
- Year of publication.
- Study setting.
- Implant type.
- Surgical protocol.
- Marginal bone level
- Pink Esthetic Score
Footnote: n: number, IIP: Immediate implant placement, EIP: early implant placement, LIP: Late implant placement, PES: pink esthetic score , SD: Standard deviation . Negative value indicates bon gain
Footnote: n: number, IIP: Immediate implant placement, LIP: Late implant placement, PES: pink esthetic score, SD: Standard deviation. Negative value indicates bone gain.
Footnote: n: number, IIP: Immediate implant placement, EIP: early implant placement, LIP: Late implant placement, PES: pink esthetic score, SD: Standard deviation. Negative value indicates bone gain. GBR: guided bone regeneration, ABG: autogenous bone graft, WES: white esthetic score.
Stage 5: Collating, summarizing and reporting the results.
Following Arksey and O’Malley’s framework, included articles were charted. The data were compiled in a single spreadsheet for analysis. Mean values were utilized to describe nominal data.
For marginal bone loss, different studies showed varied results. Cooper et al. found that immediate implant placement shows more marginal bone loss than late implant placement.
In the study by Hof et al.19 lowest amount of bone loss was observed following EIP followed by late implant placement and maximum was seen with immediate implant placement. Grafted immediate implant placement showed more marginal bone loss than non-grafted immediate implant placement. Raes et al. 15 found that late implant placement showed more bone loss than immediate implant placement. Only the study by Pour et al.16 found no significant difference between immediate implant placement and late implant placement.
In terms of PES, no difference was observed in any of the studies with immediate, early and late implant placement.15, 16,18,19
Null hypothesis stating that there is no effect of different timings of implant placement and their effect on marginal bone loss and pink esthetic score is rejected. In this review no relation could be established between implant placement timings and overall esthetics of the single implant in maxillary anterior region.
Implant placement in the maxillary anterior region is a demanding treatment modality, with its success mostly observed by the absence of progressive bone loss and mobility or pain.31. In anterior maxilla the aesthetic evaluation is crucial because a small difference between the restoration and the natural teeth can lead to displeasing results. Following removal of natural tooth hard and soft tissue changes can further complicate this process. Where physiological response of bone remodeling following extraction is leading to the resorption of bundle bone. This in turn results in marked horizontal and vertical dimensional changes of the alveolar ridge.
Scoping review offers many benefits to the research process by creating a large and involving inter-professional group giving wide eye to research. Scoping review provides important summary of recent literatures and helps to provide information to perform future research. Based on revised framework by Levac et al. of Arksey and O’Malley recommendations, major tasks can be fairly divided without compromising the consistency of analysis.13 The ultimate aim of the present scoping review was to compare the effects of different implant placement timing protocol i.e. immediate implant placement, early implant placement or late implant placement in terms of parameters such as pink esthetic score and marginal bone loss.
In this scoping review, total five studies were included in the final evaluation, four had compared IIP and LIP without EIP.15-18 In two out of five studies, immediate placement sites were grafted which resulted in more marginal bone loss as compared to non-grafted immediate placement.
A systematic review done by Cosyn et al. showed more bone loss with augmented sites on long term follow up when a comparison was made between immediate and delayed implant placement in augmented and non-augmented sites which is consistent with the results of present scoping review.10
Among the studies that analysed Pink esthetic score , overall better esthetics is found following immediate implant placement which is in conjugation with results of other reviews .32 Immediate implant in anterior sites are perhaps more able to preserve hard and soft tissues after tooth extraction, helping to avoid natural collapse in the sockets, and improving esthetic results.
There are very few studies and systematic reviews focusing on esthetics in relation to implant placement in anterior region to bring any conclusion. This brings researchers and dentist to work more in this field for better esthetics.
Available evidence suggests that there is a difference on marginal bone loss and pink esthetic score due to different implant placement timings on single implant restoration in maxillary anterior region.
As esthetics in maxillary anterior region implants are crucial, we need to assess the esthetics for a period of time as bone loss and soft tissue loss can be gradual. However there is no conclusive data on absolute esthetics over a period of time.
Thus a more detailed research in this field is required, which gives us a focused research question in terms of implant placement timings according to PRISMA guidelines with a definitive systematic review and meta-analysis to come to a conclusion on the esthetics following implant placement at different times.
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