Esthetic Outcomes of Immediately Placed Implants Receiving Immediate Provisionalization and Delayed Restoration
Phase: NA
Conditions: Tooth Diseases, Tooth Extraction, Dental Implant
Sponsor: University of Michigan

 
 
Study Title:  A Randomized Controlled Trial Comparing Esthetic Outcomes of Immediately 
Placed Implants Receiving Immediate Provisionalization and Delayed Restoration 
 
 
NCT Number:  NCT01925339 
 
 
IRB Approval Date:  08-23-2017 

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A Randomized Controlled Trial Comparing Esthetic Outcomes of 
Immediately Placed Implants Receiving Immediate Provisionalization 
and Delayed Restoration  
 
Sponsor: Neobiotech, South Korea 
 
Principal Investigator:  
Hom-Lay Wang, D.D.S., PhD 
 
Co-Investigators:  
Hsun-Liang Chan, D.D.S., M.S. 
Furat George B.D.S., M.S. 
 
Study Coordinator: 
Janet Kinney, RDH, MS 
 
Study Site: 
Graduate Periodontics 
Department of Periodontics and Oral Medicine 
University of Michigan School of Dentistry 
1011 N. University Ave., Ann Arbor, MI 48109-1078 
 
 
 
 
Table of Contents  
  

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Introductory Statement 
General Investigational Plan 
Study Protocol 
I. 
Introduction 
II. 
Objectives 
III. 
Treatment 
IV. 
Statistical analysis 
V. 
References 
 
 

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Introductory Statement  
Implant therapy is a highly predictable treatment option for replacing missing 
teeth; however, long waiting time for the conventional implant placement 
protocol (3-6 months) discourages many patients who are considering implant 
therapy. With improvement in technology, the immediate implant placement 
protocol (IIP) has become more popular, especially in the esthetic zone. The 
obvious advantage is to save the waiting time patients have to suffer through. 
Soft tissues might be preserved when the immediately placed implant is also 
restored immediately, following the immediately implant restoration protocol 
(IIR).1,2 Limited evidence is present to demonstrate the esthetic advantages of 
the combination protocol (IIP + IIR).3 Therefore, this study is aimed at 
investigating the esthetic outcome of single-tooth implants immediately placed 
and immediately restored, comparing to those immediately placed and 
restored after 4 months in the pre-maxilla. . 
General Investigational Plan 
A single center, randomized, controlled, parallel-arm study is planned to 
investigate esthetic outcomes after IIP + IIR in the esthetic zone. Forty adult 
patients who have a hopeless maxillary anterior or premolar tooth, with intact 
adjacent teeth will be enrolled. A signed written informed consent will be 
obtained after he or she has been given verbal and written information 
describing the nature and duration of the study. Subjects will not be screened or 
treated until an informed consent has been obtained. Patient information will be 
protected according to the privacy regulations of the federal Health Insurance 
Portability and Accountability Act of 1996 (HIPAA). 
Enrolled patients will be randomly placed into one of two treatment groups, 
immediate implant placement and restoration group (IIR) or the IIP + delayed 
restoration group (DR). For all patients, the tooth will be extracted and an 
implant placed immediately. The subject will be randomly assigned before the 
surgery visit to either restoring the implant immediately (Test group) with a 
provisional crown or restoring the implant at 4 ± 1 month after implant 
placement (Control). Outcome analyses will be clinical and radiographic 
parameters to determine the esthetic outcomes of immediately restored IIP 
implants, in comparison to those immediately placed but restored in a delayed 
approach.  

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 Study Protocol  
I. 
Introduction 
Immediate implant placement (IIP) is becoming a prevailing treatment modality 
because of improvement in implant surfaces and understanding of implant 
healing. The propelling force for the popularity of IIP is probably from patients’ 
desire for faster dental rehabilitation. Numerous clinical trials3-6 have proved 
predictability of this approach, with survival rate similar to the conventional 
approach, provided with prudent case selection and treatment planning. 
Without being satisfied by high success rate in terms of implant function, we are 
now striving to achieve esthetic success. IIP was supposed to preserve soft 
and hard tissues around the implant, but this statement failed to hold true, as 
suggested by preclinical7 as well as clinical studies.8 Bone and peri-implant 
mucosa continue to remodel after an implant is placed in a fresh socket. A 
recent long-term follow-up study9 further pointed out there might be an 
increased risk of continued facial mucosa recession that is associated with IIP. 
On the other hand, some studies 1-3 suggested IIP might actually reduce the 
amount of facial mucosa recession, especially when the implants are also 
immediately restored. The effect of IIP on facial soft tissues remains unsolved. 
Looking into this interesting and clinically relevant issue more closely, some 
factors might have contributed to the controversy that was observed in the 
literature. First and foremost is probably the implant position. Immediately 
placed implant has a tendency to shift to the buccal plate because it follows the 
pathway with the least resistance.10 Buccally placed implants have three times 
the amount of mucosal recession.11 Therefore, it is advisable to use a surgical 
guide and guide the implant in the cingulum position. Second, the tissue 
biotype might determine the amount of recession after implant placement. It 
has been long known that a thin tissue is more prone to recess.12 Patients with 
a thin tissue biotype are at a higher risk for esthetic failures after receiving 
immediately placed implants.9 Surgical modifications have been proposed to 
overcome potential recession, e.g. connective tissue graft and a flapless 
surgery. Placing a connective tissue graft has increased the buccal soft tissue 
by 1.1mm,13 although its effect on recession has never been investigated. 
Last but not the least, buccal plate thickness seems to be a determining factor 
for the stability of its overlying soft tissue. A thicker buccal plate might resist 
bone resorption more effectively.14 Furthermore, it is suggested at least 2 mm 

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thick crestal bone might be necessary for a stable dimension of facial 
mucosa.15 Unpredictable bone remodeling after immediate implant placement, 
especially in situations where there is a buccal wall defect, might be one of the 
reasons for seeing advanced soft tissue recession.16  
Immediate implant restoration (IIR) is defined when an implant is restored 
within 48 hours after implant placement.17 With adequate implant primary 
stability, an implant can be restored immediately, however, it might be wise to 
leave it out of occlusion during the healing phase to allow for proper formation 
of osseointegration. The greatest advantage of this approach is to restore 
esthetics immediately. The responses of soft and hard tissues to this approach 
have been studied to some extent. A recent systematic review18 suggested that 
the timing of the restoration does not influence marginal bone level around 
implants. However, IIR might preserve the height of papilla19 and the level of 
mucosal margin.3 Therefore, IIR of immediately placed implants might improve 
the esthetic outcomes. 
 
II. Objectives  
The primary objective of this study is to evaluate the effect of IIR on clinical 
outcomes (mucosal recession and esthetics) of IIP implants, compared with the 
effect of DR on clinical outcomes of IIP implants. Essentially, we are testing 
whether a temporary crown placed right after the surgery will have better 
clinical outcomes than not placing one. Secondary outcomes will include 
radiographic marginal bone changes. 
 
III. Treatment  
A. Patient selection 
Forty patients will be randomized into two experimental groups: 20 in the test 
group (IIR) and 20 in the control group (DR). In both groups, the hopeless 
tooth will be extracted atraumatically without raising a flap. The tooth is 
replaced by an immediately placed implant. The test implants will be restored 
with a provisional crown immediately, which will be replaced by a permanent 
crown at 4 ± 1 month (crown impression visit) after implant placement. The 

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control implants will be restored at 4 ± 1 month (crown impression visit) after 
the surgery.  
 
Subjects can be considered a screen fail at any study visit prior to the surgery 
and up until the time that the implant is placed and deemed stable. All screen 
failed subjects will be replaced. 
Inclusion and exclusion criteria 
Inclusion Criteria 
• 
Male or female, aged ≥ 21 
• 
A minimum dentition of 20 permanent teeth (including natural rooted teeth 
or dental implants; pontic of a fixed bridge is not considered a tooth) 
• 
A maxillary premolar, canine, lateral incisor or central incisor with a 
hopeless prognosis 
• 
Presence of adjacent teeth and enough clearance for an implant crown 
• 
Presence of sufficient bone apical to the root apex of the hopeless tooth  
 
Exclusion Criteria 
Systemic criteria: 
• 
Current heavy smokers (>10 cigarettes per day) or heavy smoker who 
quit less than 1 year ago 
• 
Pregnant or plan to get pregnant or lactating mothers 
• 
Current alcoholism or drug abuse  
• 
Diseases of the immune system or any medical condition that may 
influence the outcome (uncontrolled diabetes (HbA1c >7), neurologic or 
psychiatric disorders, systemic infections, …) 
• 
Radiation therapy in the head and neck area within 3 years 
• 
Current use of oral bisphosphonates for >3 years 
• 
History of IV bisphosphonates use 
• 
Other medical conditions that may contradict an implant surgery 
Intraoral criteria:  
• 
Area of study is adjacent to an existing implant 
• 
Acute infection at/or adjacent to the extraction site (e.g., sinus tract, 
swelling) 
• 
Observable gingival changes due to use of medications known to affect 
the periodontal status (calcium antagonists, anticonvulsives, 
immunosuppressants, anti-inflammatory medications…) 

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• 
Untreated deep carious lesions or defective restorations that can 
potentially exacerbate during the course of the experiment 
• 
Uncontrolled periodontal disease 
• 
Poor oral hygiene (>20% FMPS) 
CBCT criteria: 
• 
More than 4mm of buccal plate dehiscence is present on the CBCT scans 
Intraoperative criteria: 
• 
More than 4 mm of buccal plate dehiscence is present once the tooth is 
extracted 
The screening visit (V1) 
All participants will receive an informed consent form that explains the aims, 
courses, and potential benefits/risks of this study. They will be given no limit of 
time to read through it. The research team members will answer any questions 
regarding this study. Any research related activity will not be initiated unless 
they sign the consent form.  
Medical history will be reviewed by system, using the School of Dentistry 
Medical History Questionnaire. Relevant health history information will be 
highlighted. Eligibility screen will be performed, including systemic and 
intraoral criteria. Blood pressure and heart rate will be measured. A peri-apical 
(intraoral) film will be taken if the patient doesn’t have one within 3 months 
available to the research team at the screening. 
CBCT scans (V2 and V8) 
Two CBCT scans will be taken by a trained technician under supervision of a 
board-certified oral radiologist at the University Of Michigan School Of 
Dentistry. The Dental School only does CBCT scans on certain days and at 
certain times. For subject convenience the first CBCT scan may be scheduled 
at the pre-implant visit and the second CBCT scan may be scheduled before 
the preparation and placement of crowns. However, one or both, may be done 
at separate visits due to dental school CBCT scan scheduling. Eligibility 
screening will be performed on the scan; subjects with more than 4 mm buccal 
bone dehiscence will be excluded. 
 
Peri-apical radiographs 
Peri-apical radiographs, including standardized radiographs, will be taken at 
the screening if unavailable, pre-implant placement, implant surgery, 
placement of restoration, and crown follow-up (final visit). At the 

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abovementioned visits, usually only one peri-apical film will be taken; however, 
if not of acceptable quality, it might be necessary to take another one. Likewise, 
if an x-ray was taken recently with good quality, a new x-ray might not be 
required at the screening visit. In the baseline surgery, 2 to 4 films may be 
taken to assure safety of the implant placement procedure. Custom-made 
stents will be fabricated from plastic film holders and blue mousse to ensure 
standardization of the radiographs.  
Pre-implant placement visit (V3) 
The informed consent will be checked (the purpose of checking the consent is 
to assure that the subject is still interested in the study and they are still eligible 
to be in the study which will also be another form of an AE screening) along with 
a review of the medical history. Impressions of the subject upper and lower jaws 
will be taken with alginate for preparation of study models and surgical guides. 
Bite registration will be taken with a silicone material. Clinical measurements 
will be taken, including probing depth, gingival recession, plaque index, gingival 
index, keratinized mucosa width, and the PES score. A standardized 
peri-apical film will be taken along with clinical photos. Eligible subjects will be 
randomly assigned to one of the two groups after V3. 
 
Implant and bone surgery (V4) 
The informed consent will be checked along with a review of the medical 
history. The blood pressure and heart rate will be checked before surgery. The 
area selected for surgery will be locally anesthetized and examined. The 
hopeless tooth will be extracted under local anesthesia, without raising a flap. 
If necessary, a small flap might be elevated to facilitate the extraction. For 
subjects with intact buccal plate (equal or less than 4 mm loss), an implant will 
be placed according to the manufacturer’s protocol for both groups. The 
implant position follows the computerized surgical guides (Neoguide, 
Neobiotech, South Korea) that are designed based on the CBCT scans. The 
gap between the implant and socket wall will be filled with bone allografts (The 
tooth root dimension is most of the time larger than the implant). In cases with a 
small buccal wall defect, a collagen membrane will be used. The test implants 
will be restored immediately with a provisional crown, which will be replaced by 
a permanent crown. A healing abutment and collatape to contain bone grafts 

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will be placed for control implants but without immediate restoration during the 
healing period. A removable temporary denture may be provided at subject 
request. All surgical procedures will be performed by a periodontist. Implant 
stability will be assessed at the time of placement. Any adverse events such as 
no implant stability, etc. during the surgery will be reported. Clinical 
measurements will be taken including: socket-related and implant-related 
parameters. A standardized peri-apical radiograph will be taken, as well as 
clinical photos. 
Subjects who lose more than 4mm of buccal plate after extraction will be 
excluded from the study at this time. They will receive bone allografts and 
collagen membrane as a socket grafting material. The test implant that does 
not achieve 30 N-cm will be treated as a control implant and excluded from the 
study. 
 
 
Post-op visits after implant and bone surgery (V5, V6, V7 if necessary) 
Post-op visits will be scheduled at 14 ± 3 days, 28 ± 3 days, and varied date 
upon subject oral condition, if needed. The informed consent along with a 
review of the medical history will be checked at each visit. Clinical 
measurements will be taken, including: mid-facial mucosal level, papilla height 
and labial ridge contour. Clinical photos will be taken during the visit. The 

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wound will be gently debrided and disinfected. Sutures, if any, will be removed. 
 
Additional post-op visits (V7) may be necessary for conditions that require 
additional care for subject safety, such as premature wound exposure, minor 
infection, and slower healing. They are based on per subject needs for a visit, 
not for every subject and will be followed as adverse events. No clinical 
measurements will be taken at this visit.  
Management of adverse events 
If the dental implant does not achieve primary stability (10-20 % of prevalence 
rate) due to infection or other reasons, the implant will be removed in a brief 
surgery. The osteotomy site will be grafted with allograft bone and covered by 
a collagen membrane. The wound will be closed with sutures. The participants 
with the abovementioned conditions will be withdrawn from the study. 
Alternative treatments will be given. All adverse events will be reported.  
Crown impression (V9) 
The impression visit will be at 4 (+/- 1) months after the baseline surgery, 
depending on the healing of the bone graft and implant. The informed consent 
will be checked along with a review of the medical history. Any adverse events 
will be screened and reported. If the implant fails, it will be removed and the site 
will be grafted at no charge. The subjects with a failed implant will be excluded. 
Impressions will be taken for upper and lower jaws with alginate and silicone 
materials, along with a bite registration. 
Crown placement (V10) 
The final crown placement will be within several weeks from the impression. 
The informed consent will be checked along with a review of the medical 
history. Any adverse events will be screened and reported. If the implant is 
loose then the subject will be taken out of the study. The implant will be 
removed and bone placed where the implant was at no charge to the subject. 
Their participation in the study will be over at this time. 
Clinical measurements, including PES/WES, mid-facial mucosal level, papilla 
height, and labial ridge contour will be taken. All components to be used will be 
commercially available from Neobiotech. A standardized radiograph and 

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intraoral photos will be taken.  Multiple visits may be required to assure the 
quality of crowns. 
Crown follow-up/Final visit (V11) 
One crown follow-up visit will be scheduled at 10 (+/- 2) months after the 
baseline surgery. A standardized peri-apical film, clinical measurements, 
clinical photos and impressions/bite registration will be done. The clinical 
measurements include probing depth, plaque index, gingival index, keratinized 
mucosa width, PES/WES, mid-facial mucosal level, papilla height and labial 
ridge contour. The informed consent will be checked along with a review of the 
medical history. Any adverse events will be screened and reported.  

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Schedule of Events 
Event 
Screening 
CBCT scan 
Pre-implant 
placement  
Implant and bone 
surgery  
Post-Op visit 1 
Post-Op visit 2 
Additional post-Op 
visits (if necessary) (c) 
CBCT 
scan 
Crown impression (IP) 
Crown Placement 
Crown follow-up/ Final 
Visit 
 
V1 
V2 
V3 
V4 
V5 
V6 
V7 
V8 
V9 
V10 
V11 
Timeline 
 
 
 
Baseline (BL) 
14 D (+/- 3D) 
28 D (+/- 3D) 
Varied 
 
4 (+/- 1) M after BL 
3+ wks after IP 
10 (+/- 2) M after BL 
Informed consent 
SIGN 
 
X 
X 
X 
X 
X 
 
X 
X 
X 
Check BP, HR 
X 
 
 
X 
 
 
 
 
 
 
 
Med history review 
X 
 
X 
X 
X 
X 
X 
 
X 
X 
X 
Screen for adverse events 
 
 
 
X 
X 
X 
X 
 
X 
X 
X 
Eligibility Screen 
X 
X 
 
X 
 
 
 
 
 
 
 
Impression and bite registration 
 
 
X 
 
 
 
 
 
X 
 
X 
CBCT Scan (a) 
 
X 
 
 
 
 
 
X 
 
 
 
Clinical measurements (b) 
 
 
X 
X 
X 
X 
 
 
 
X 
X 
Periapical radiograph/ (S = Standardized) 
X (optional) 
 
X (S) 
X (S) 
 
 
 
 
 
X (S) 
X (S) 
Clinical photographs 
 
 
X 
X 
X 
X 
X 
 
 
X 
X 
Wound disinfection & suture removal (if any) 
 
 
 
 
X 
X 
X 
 
 
 
 
Subject withdrawn by PI 
 
Inadequate Bone 
 
Inadequate Bone 
Implant Loose 
Implant Loose 
Implant Loose 
 
Implant Loose 
Implant Loose 
 
Temp Crown for Test Group Only 
 
 
 
X 
 
 
 
 
 
 
 
Bone Allograft 
 
 
 
X 
 
 
 
 
 
 
 
Control Group – Temp Denture (at subject request) 
 
 
 
X 
 
 
 
 
 
 
 
(a) The dental school only does CBCTs on certain days and at certain times. For subject convenience the first CBCT may be scheduled at the pre-implant visit and the second CBCT may be scheduled at the implant 
uncover surgery. However, one or both, may be done at separate visits due to dental school CBCT scheduling. Additionally, for the convenience of the subject, the Screening, first CBCT Scan and Pre-implant visit can be 
combined on the same day. 
 
 
 
 
 
 
 
 
 
 
(b) Clinical measurements consist of plaque Index, gingival Index, probing depth, recession, PES/WES, width of keratinized tissue, thickness of keratinized tissue, gingival margin level and socket- and implant-related 
features. Not all measurements will be made in each visit. Specific parameters for each visit will be listed in CRF. 
 
 
 
 
 
 
 
 
 
(c) Schedule for these visits is based on a per subject need for a visit, not for every subject. Conditions that require additional care for subject safety, such as premature wound exposure and slower healing might require 

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additional visits and will be followed as adverse events 
 

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IV. Statistical Analysis 
Sample Size 
A power analysis was performed using a statistical power calculator. This study 
will have a sample size of 40 subjects, 20 in each of the two groups. We 
estimate to have 80% power (with a Type I error rate of 5%) to detect a mean 
difference of 0.8mm mucosal recession, with the estimated standard deviation 
of 0.8mm.22 This power calculation takes into account the estimated 10% of 
subjects drop out. A “p” value of less than 0.05 will be considered statistically 
significant. 
 
Data Analysis 
Mean values, standard deviations, and medians will be calculated for clinical 
and radiographic measurements.  We will examine the univariate association 
of the defect size with the success of treatment using logistic regression.  We 
will also attempt to examine the association of implant success with various 
combinations of clinical and radiographic parameters using multiple logistic 
regression, but acknowledge that we will be restricted by our sample size to at 
most two or three predictors in any model. Changes of the parameters over 
time within each group as well as differences between groups will be analyzed 
using the repeated measure of analysis of variance.  
 
 
 

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V. References 
1. 
Cosyn J, De Bruyn H, Cleymaet R. Soft Tissue Preservation and Pink 
Aesthetics around Single Immediate Implant Restorations: A 1-Year 
Prospective Study. Clin Implant Dent Relat Res 2012. 
2. 
Cosyn J, Hooghe N, De Bruyn H. A systematic review on the frequency 
of advanced recession following single immediate implant treatment. J 
Clin Periodontol 2012;39:582-589. 
3. 
Cosyn J, Eghbali A, De Bruyn H, Collys K, Cleymaet R, De Rouck T. 
Immediate single-tooth implants in the anterior maxilla: 3-year results of 
a case series on hard and soft tissue response and aesthetics. J Clin 
Periodontol 2011;38:746-753. 
4. 
Chen ST, Wilson TG, Jr., Hammerle CH. Immediate or early placement 
of implants following tooth extraction: review of biologic basis, clinical 
procedures, and outcomes. Int J Oral Maxillofac Implants 2004;19 
Suppl:12-25. 
5. 
Kan JY, Rungcharassaeng K, Lozada JL. Bilaminar subepithelial 
connective tissue grafts for immediate implant placement and 
provisionalization in the esthetic zone. J Calif Dent Assoc 
2005;33:865-871. 
6. 
Rungcharassaeng K, Kan JY, Yoshino S, Morimoto T, Zimmerman G. 
Immediate implant placement and provisionalization with and without a 
connective tissue graft: an analysis of facial gingival tissue thickness. 
Int J Periodontics Restorative Dent 2012;32:657-663. 
7. 
Araujo MG, Linder E, Lindhe J. Bio-Oss collagen in the buccal gap at 
immediate implants: a 6-month study in the dog. Clin Oral Implants Res 
2011;22:1-8. 
8. 
Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations following 
immediate implant placement in extraction sites. J Clin Periodontol 
2004;31:820-828. 
9. 
Kan JY, Rungcharassaeng K, Lozada JL, Zimmerman G. Facial gingival 
tissue stability following immediate placement and provisionalization of 
maxillary anterior single implants: a 2- to 8-year follow-up. Int J Oral 
Maxillofac Implants 2011;26:179-187. 
10. 
Koticha T, Fu JH, Chan HL, Wang HL. Influence of thread design on 
implant positioning in immediate implant placement. J Periodontol 
2012;83:1420-1424. 
11. 
Evans CD, Chen ST. Esthetic outcomes of immediate implant 

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placements. Clin Oral Implants Res 2008;19:73-80. 
12. 
Claffey N, Shanley D. Relationship of gingival thickness and bleeding to 
loss of probing attachment in shallow sites following nonsurgical 
periodontal therapy. J Clin Periodontol 1986;13:654-657. 
13. 
Grunder U. Crestal ridge width changes when placing implants at the 
time of tooth extraction with and without soft tissue augmentation after a 
healing period of 6 months: report of 24 consecutive cases. Int J 
Periodontics Restorative Dent 2011;31:9-17. 
14. 
Ferrus J, Cecchinato D, Pjetursson EB, Lang NP, Sanz M, Lindhe J. 
Factors influencing ridge alterations following immediate implant 
placement into extraction sockets. Clin Oral Implants Res 
2010;21:22-29. 
15. 
Miyamoto Y, Obama T. Dental cone beam computed tomography 
analyses of postoperative labial bone thickness in maxillary anterior 
implants: comparing immediate and delayed implant placement. Int J 
Periodontics Restorative Dent 2011;31:215-225. 
16. 
Kan JY, 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. 
17. 
Cochran DL, Morton D, Weber HP. Consensus statements and 
recommended clinical procedures regarding loading protocols for 
endosseous dental implants. Int J Oral Maxillofac Implants 2004;19 
Suppl:109-113. 
18. 
Suarez F, Chan HL, Monje A, Galindo-Moreno P, Wang HL. Effect of the 
timing of restoration on implant marginal bone loss: a systematic review. 
J Periodontol 2013;84:159-169. 
19. 
Oh TJ, Shotwell JL, Billy EJ, Wang HL. Effect of flapless implant surgery 
on soft tissue profile: a randomized controlled clinical trial. J Periodontol 
2006;77:874-882. 
20.   Furhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G. 
Evaluation of soft tissue around single-tooth implant crowns: the pink 
esthetic score. Clin Oral Implants Res 2005;16:639-44.  
21.   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 crosssectional, retrospective 
study in 45 patients with a 2- to 4-year follow-up using pink and white 
esthetic scores. J Periodontol 2009;80:140-51. 

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22. Raes F, Cosyn J, Crommelinck E, Coessens P, De Bruyn H. Immediate 
and conventional single implant treatment in the anterior maxilla: 1-year results 
of a case series on hard and soft tissue response and aesthetics. J Clin 
Periodontol 2011;38:385-394.