appliedsciences
ArticleSoft Tissue Evaluation of an Immediate Esthetic Zone
Single Implant with a Stereolithographic Guide
Using 3D Reconstruction and a CAD/CAM
Customized Titanium Anatomic Abutment
Tae-Heung Kim 1 , You-Kyoung Oh 2 , Chang-Mo Jeong 3 , Edward Chengchuan Ko 4 ,George K. Sándor 5 and Yong-Deok Kim 6, *
1
2
3
4
5
6

*

Department of Oral and Maxillofacial Surgery, School of Dentistry, Pusan National University,
Yangsan 50612, Korea; taeheung121@gmail.com
Department of Prosthodontics, School of Dentistry, Pusan National University, Yangsan 50612, Korea;
bluesky141@hanmail.net
Department of Prosthodontics, School of Dentistry, Pusan National University, Dental and Life Science
Institute & Dental Research Institute, Yangsan 50612, Korea; cmjeong@pusan.ac.kr
Department of Oral and Maxillofacial Surgery, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
ko.edward.kaseizen@gmail.com
Department of Oral and Maxillofacial Surgery, Oulu University Hospital and Medical Research Center,
University of Oulu, 90220 Oulu, Finland; sandor_george@hotmail.com
Department of Oral and Maxillofacial Surgery, School of Dentistry, Pusan National University,
Dental and Life Science Institute & Dental Research Institute, Yangsan 50612, Korea
Correspondence: ydkimdds@pusan.ac.kr

Received: 3 January 2020; Accepted: 25 February 2020; Published: 2 March 2020


Abstract: The replacement of an unrestorable tooth with a single implant-supported prosthesis isa treatment with predictable and successful outcomes. The anterior maxilla region is a complicatedsite for such treatment, due to its esthetic, functional, and physiological sensitivity. The purpose of thisstudy was to evaluate the changes in the soft tissue following an immediate implant procedure using
guided surgery in combination with a computer-aided design and computer-aided manufacturing(CAD/CAM) customized titanium anatomic abutment in the esthetic zone. A total of 13 patients who
had been treated with an immediate post-extraction implant placement and an immediate provisional
restoration were included in the study. The changes in the soft tissue dimension, interdental papilla,and esthetic score were evaluated with a follow-up of at least one year. There was no significant
change in the midfacial mucosal status when compared to the pre-treatment situation. The recessionof the mesial papillary height was 0.32 mm and the distal papillary height was 0.10 mm. The mean
horizontal change in the labial mucosa was 0.32 ± 0.83 mm. There was no significant difference
between the mesial papilla index and the distal papilla index. The pink esthetic score value prior
to treatment was 11.16, and at one-year follow-up, 10.25. Within the limitations of this study,
the immediate post-extraction implant placement procedure with a stereolithographic guide anda provisionalization with a CAD/CAM customized titanium anatomic abutment may be a treatment
option with predictable outcomes for the replacement of teeth in the esthetic zone.
Keywords: immediate post-extraction implant placement; esthetic zone; pre-fabricated customized
abutment; immediate provisionalization; guided implant surgery; stereolithography

Appl. Sci. 2020, 10, 1678; doi:10.3390/app10051678

www.mdpi.com/journal/applsci

Appl. Sci. 2020, 10, 1678

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1. Introduction
The replacement of an unrestorable tooth with a single implant-supported prosthesis is a treatment
with predictable and successful outcomes. The esthetic outcomes, as well as the functional andphysiologic outcomes, are quintessential in the treatment of the anterior maxilla area [1–4]. After a tooth
is extracted, the loss of the periodontal ligament lowers blood supply to the alveolar bone. The buccal
plate of the alveolar bone is particularly affected, and this ultimately yields poor esthetic outcomes [5].
It is important to maintain the architecture of the fresh extraction socket for the immediate post-extraction
implant placement in the esthetic zone [6,7]. Many studies have reported that an immediate implant
placement and provisional restoration provide acceptable changes in the soft tissue and esthetic
outcomes [8–13]. A correct fixture positioning, grafting technique, and immediate provisional
restoration help achieve successful results in the esthetic zone [7,14–18].
With the advancement of computer-aided design and computer-aided manufacturing (CAD/CAM)
technology in implant dentistry, various implant techniques developed. With three-dimensional (3D)
scanning and computed tomography (CT) imaging data, a CAD program can be used to diagnose andvirtually plan an implant placement. First, the implant crown can be designed and waxed up into thedesired shape on the intraoral scanning or impression data. The virtual prosthesis is integrated with thecone beam computed tomography (CBCT) data, allowing the clinician to virtually plan the placementof the three-dimensional implant. Once the integrated plan is established, a stereolithographic surgical
guide and a customized prosthesis can be pre-fabricated by using 3D printing technology [19].
Stereolithographic guides made by using a CAD/CAM scanning program allow the computer
to transfer planned implants onto the surgical field. This can improve the precision of the implant
placement, enables a non-invasive surgical procedure, reduces the time, and allows the pre-fabricatedprosthesis to connect to the planned position immediately after a surgery [20–22].
Customized abutments can be designed with an anatomically ideal emergency profile. Recently,
various methods for improving the stability of soft tissue around implants have been developed.
For example, restoration with pre-fabricated provisionalization after immediate implant placement is
known to help maintain the anatomical structure of the extraction socket [23–25].
The purpose of this study was to evaluate the changes in the soft tissue in patients who weretreated with an immediate post-extraction implant placement using a stereolithographic guideand an immediate restoration with a CAD/CAM customized titanium anatomic abutment in theesthetic zone.
2. Materials and Methods
2.1. Patients and Materials
This retrospective clinical study was approved by the ethical committee of the Pusan National
University Dental Hospital as institutional review board (IRB) number: PNUDH-2019-017, and it
included patients treated with immediately placed dental implants and an immediate provisional
restoration using a titanium anatomic abutment, between April 2017 and May 2018. The inclusion
criteria were as listed below:
1.
2.
3.

At least 18 years old
Both adjacent teeth are intact
Followed-up for at least 1 year after final restoration

2.2. Exclusion Criteria Were as Listed Below
1.
2.
3.
4.

Systemic bone disease
Recent orthodontic treatment
Presence of an acute infection around the tooth
Less than one full year of follow-up after definitive restoration

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Appl. 4.
Sci. 2020,
1678 one full year of follow‐up after definitive restoration
Less10,than

3 of 11

Of the total 18 patients with dental implants, 13 were included in this retrospective study. The
thecollected
total 18 throughpatientsawith
dentalimplants,
13 were medical
includedrecords,
in this clinicalretrospective
data Of
were
carefulreviewof the patients’photos,study.
and
The
data
were
collected
througha
carefulreviewofthepatients’
medicalrecords,
clinical
photos,radiographs.
and radiographs.
The Osstem ® TS III fixture and OneGuide system (Osstem, Korea) were used in this study. The® TS III fixture and OneGuide system (Osstem, Korea) were used in this study.
The
fixtureis Osstema submerged
type with an internal connection and it has a tapered body. The sizes of theThe
fixtureisasubmerged
type withanhad
internal
connection
has foura tapered
The sizes
theimplant fixtures were as follows:Nine
a diameterof 4 andmm,itandhad abody.
diameterof 3.5ofmm.
implant
fixturesas follows:Nine
hada diameterof 4amm,andoffourEight
fixtureshadwerea lengthof 13 mm,andfivefixtures had
length11.5hadmm.a diameter of 3.5 mm.
Eight fixtures had a length of 13 mm, and five fixtures had a length of 11.5 mm.
2.3. Preparation for Treatment
2.3. Preparation for Treatment
The patients’ CBCT data and study cast from the alginate impression obtained at the initial visit
CBCT data
study
the alginate
impression
obtained
at abutment
the initial visit
wereThesentpatients’to a technician.
Theandstudy
castcast
wasfromscannedwith a digitalscanner
and the
was
were
sent
to
a
technician.
The
study
cast
was
scannedwithadigitalscannerandtheabutmentwasdesigned using the CAD/CAM program (Dental System, 3Shape, Copenhagen, Denmark), which was
designed using
thetheCAD/CAM
program(Dentalabutment
System, 3Shape,
Copenhagen,Denmark),
wasincorporated
into
scanner. The
customized
and provisional
restoration
werewhichdesignedincorporated
intothescanner.
The
customized
abutment
andprovisional
restorationweredesignedtoto reconstruct the original anatomic contour of the gingiva. The level of the abutment collar wasreconstruct
theoriginal
anatomic
contourofthegingiva.
The
level
of
the
abutment
collarwasplacedplaced along the gingival contour, and it rehabilitated the emergence profile of the tooth. The
along the gingival
contour,and titanium
it rehabilitatedtheAfteremergence
profilethe tooth.forTheabutment
was fabricatedusing
milling.
designing
the ofprosthesis
theabutment
plannedwasfabricatedusingtitanium
milling.
Afterdesigningtheprosthesisfortheplannedlocationwithlocation with CAD/CAM, a surgical guide was designed based on the CBCT data and manufactured
CAD/CAM,a surgicalguide
was designed
based on the CBCT
data
and manufactured
3D printingby
3D printing(Stratasys,USA).
The stereolithographic
guide
establishedthe precisebyplacementof(Stratasys,
USA).
The
stereolithographic
guide
establishedthepreciseplacementoftheimplant
fixturethe implant fixture at the intended location, which then made it possible for the abutment to connect
at theintendedlocation,asplanned(Figure1). which then made it possible for the abutment to connect as planned (Figure 1).

Figure 1.1.Designof a Stereolithographic
SurgicalGuide andCustomized
Abutment Abutment
Using Computer‐
Designof a Stereolithographic
Surgical
Guideand Customized
Using
Aided
Design andDesign
Computer‐Aided
Manufacturing(CAD/CAM).
Computer-Aided
and Computer-Aided
Manufacturing(CAD/CAM).

2.4. Surgical
Surgical Procedure
Procedure
2.4.
All surgicalsurgical procedures
procedures were
were performed
performed byby oneone oraloral andand maxillofacial
surgeon under
under local
local
All
maxillofacial surgeon
anesthesia. Before
Before thethe surgery,
surgery, 0.02%
0.02% chlorhexidine
chlorhexidine rinsing
performed. After
After obtaining
obtaining informed
informed
anesthesia.
rinsing was
was performed.
consent,
theatraumatic
tooth
extraction
was
performed
using
dentalforcepswithoutflap
elevation.
consent, the atraumatic tooth extraction was performed using dental forceps without flap elevation.
After curettage
curettage ofof thethe extraction
extraction socket,
socket, aa saline
saline irrigation
irrigation was
was done.
done. The
The preparedprepared stereolithographic
stereolithographic
Afterguide (Oneguide,
inin
thetheadjacent
teeth.
Prior
to
guide
(Oneguide, Osstem,
Osstem, Korea)
Korea)waswasplacedplacedininthe
theoraloralcavity
cavityandandfixed
fixed
adjacent
teeth.
Prior
placing
thefixture,theintegrityofthebuccalbone
wasverifiedbyanintrasocket
probing.
Basedon
to placing the fixture, the integrity of the buccal bone was verified by an intrasocket probing. BasedthetheCBCT
data,thetheimplant
fixture(TS(TS
III, III,
Osstem,Korea)
waswasplacedafterafter
drilling
accordingto the
on
CBCT
data,
implant
fixtureOsstem,Korea)
placeddrilling
accordingtoheight and diameter, as planned. Drilling was fully aided by metal sleeve components in the surgicalAppl. Sci. 2020, 10, x FOR PEER REVIEW
Appl. Sci. 2020, 10, 1678

4 of 114 of 11the height and diameter, as planned. Drilling was fully aided by metal sleeve components in thesurgicalTheguide.
Thefixture
implant
placedmmto the cementoenameltheguide.
implant
wasfixture
placedwas
2 mm
apical2totheapical
cementoenamel
junction of thejunction
adjacentof
tooth.
adjacent
A torque
30–40 Naswas
obtained
as a primarystability. The
xenograftmaterial(Bio‐A
torque tooth.
of 30–40
N wasofobtaineda primarystability.
The xenograft
material(Bio-Oss,
Geistlich,Oss,Hussen,
Geistlich,
Vol Hussen,
Switzerland)filledwhen the fixture
gap between
fixtureVol
Switzerland)wasfilled when was
the gap
betweenand thethebonewallandwas theof 2bone
mm
wall
was A
of pre-fabricated
2 mm or more. abutment
A pre‐fabricatedabutmenttowas
to surgery.
the fixture
after
surgery. Theormore.
was connected
the connected
fixture afterThe
instructionsfor
instructions forcare
post‐operative
care were
thoroughly
explained,andandamoxicillinanti-inflammatory
and nonsteroidal
post-operative
were thoroughly
explained,
and amoxicillin
nonsteroidal
anti‐inflammatory
drugs(NSAIDs)towere
prescribed
to be taken
times
daily
for five
days.
None
drugs
(NSAIDs) wereprescribedbe taken
three times
daily three
for fivedays.
Noneof thepatients
complainedof postoperative
or pain.
of the patientscomplained ofdiscomfort
postoperative
discomfort or pain.
2.5.
Restoration Protocol
Protocol2.5. Restoration
Allrestored withimplant restorations,
restorations, andand immediate
immediate provisional
provisional restorations
restorations
All teeth
teeth were
were restoredwith single
single implant
wereperformed
on
the
day
of
surgery.
Afterplacementofthefixture,apre-fabricatedwere performed on the day of surgery. After placement of the fixture, a pre‐fabricated titanium
titaniumcustomized
customized abutment
abutment waswas connected,
connected, andand thethe provisional
provisional restoration
restoration was
was cemented
cemented using
using anan interiminterimcement(TempBond
Clear;
Kerr
Corp,
Orange,Calif)(Figures
2
and
3).
All
provisional
restorations
were
cement (TempBond Clear; Kerr Corp, Orange, Calif) (Figures 2 and 3). All provisional restorations
adjustedtoavoid
occlusalcontacts
withantagonistsinthecentric
occlusionandlateralmovements
were adjusted to avoid occlusal contacts with antagonists in the centric occlusion and lateralafter
the placement.
movements
after the placement.

FigureImmediate
Post-Extraction
Implant
Placement
Using Guided
an Immediate
Figure 2.2.TheThe
Immediate
Post‐Extraction
Implant
Placement
Using Surgery
Guided with
Surgery
with anProvisionalization
(Case
1).
(A)
BeforetheExtractionoftheUnrestorable
Tooth,
(B)
After
the
Atraumatic
Immediate Provisionalization (Case 1). (A) Before the Extraction of the Unrestorable Tooth,(B) After
Tooth
Extraction,(C) Extraction,
Drilling with
Positioning
the Surgical
Guide,(D) Guide,
A Pre-Fabricatedthe Atraumatic
Tooth(C) theDrillingwith theofPositioningof theSurgical(D) A Pre‐
Customized
Titanium
Abutment,(E)
The
Abutment
SupportingtheOriginal
Anatomic
Contourof theFabricated Customized Titanium Abutment, (E) The Abutment Supporting the Original Anatomic
Gingiva,(F)
The
Provisional
Restoration
wasCemented.
Contour of the Gingiva, (F) The Provisional Restoration was Cemented.

The definitive prosthesis was made after a minimum of 6 months. The final impressions
The definitive prosthesis was made after a minimum of 6 months. The final impressions were
were obtained at the fixture level for the fabrication of the final abutments and crowns. The final
obtained at the fixture level for the fabrication of the final abutments and crowns. The final implant‐
implant-supported prosthesis was made of porcelain fused to zirconia, porcelain fused to metal,
supported prosthesis was made of porcelain fused to zirconia, porcelain fused to metal, porcelain
porcelain fused to gold, or monolithic zirconia. The material of the final prosthesis was selectedfused to gold, or monolithic zirconia. The material of the final prosthesis was selected based on thebased on the preferences of the patients and the prosthodontists, according to each patient’s situation.
preferences of the patients and the prosthodontists, according to each patient’s situation. The final
The final setting of an implant-supported prosthesis was done with an implant cement (Premiersetting of an implant‐supported prosthesis was done with an implant cement (Premier Implant
Implant Cement, Premier®Dental Products Company, Plymouth Meeting, PA, USA).
Cement, Premier® Dental Products Company, Plymouth Meeting, PA, USA).

Appl. Sci. 2020, 10, 1678
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5 of 115 of 115 of 11

Figure 3. The Immediate Post‐Extraction Implant Placement Using Guided Surgery with a Bone Graft
FigureFigure 3.
3. TheThe Immediate
Immediate Post‐Extraction
Post-Extraction Implant
Implant Placement
Placement Using
Using Guided
Guided Surgery
Surgery with
with aa Bone
Bone Graft
Graft
and an Immediate Provisionalization (Case 2). (A) Before the Extraction of the Unrestorable Tooth,and an Immediate Provisionalization
Provisionalization (Case(Case 2).
2). (A)(A) Before
Before thethe Extraction
Extraction ofof thethe Unrestorable
Unrestorable Tooth,
Tooth,(B) The Extracted Tooth and a Pre‐Fabricated Customized Titanium Abutment, (C) After Implant(B) The Extracted Tooth and a Pre-Fabricated
Pre‐Fabricated Customized Titanium Abutment, (C) After Implant
Placement, (D) The Gap Filled with Bio‐Oss Between the Fixture and the Bone Wall, with a Piece ofandthethe
Bone
Wall,
with
a PieceofPlacement,
Placement, (D)(D) The
The Gap
GapFilled
Filledwith
withBio‐Oss
Bio-OssBetween
Betweenthe
theFixture
Fixture
and
Bone
Wall,
with
a Piece
Cotton Applied for Bleeding Control, (E) The Abutment Supporting the Original Contour of the
CottonAppliedfor
Bleeding
Control,(E)
The
Abutment
SupportingtheOriginal
Contouroftheof Cotton Applied for Bleeding Control, (E) The Abutment Supporting the Original Contour ofGingiva and Capping the Grafted Material, (F) The Provisional Restoration was Cemented.
Gingiva and Capping the Grafted Material, (F) The Provisional Restoration
Restoration was
was Cemented.
Cemented.

2.6. Soft
Measurement
2.6.
Soft Tissue
Tissue Measurement
Measurement
2.6.
Thesoftsofttissue
tissuedimension
data
werecollected
fromthe study
study
casts
and follow‐up
follow‐up
casts.
The
The
dimension
data
werecollected
fromfrom
the study
casts andfollow-up
casts. ThechangesThe
soft
tissuedimension
data
werecollected
the
casts
and
casts.
The
changesinmesialpapilla,distalpapilla,andmidfacialmucosawere
measuredwithrespecttotheinmesialpapilla,distalpapilla,andmidfacialmucosawere
measuredwithrespecttotheincisalchanges in mesial papilla, distal papilla, and midfacial mucosa were measured with respect to theincisal
edge
level
of
the
adjacent
teeth.
Each
cast
was
also
digitizedusingadigitalscanner(Trios,edge level
the adjacent
teeth. Eachwas
also
digitizedusing a using
digitala scanner(Trios, 3shape,
incisaledgeoflevelof the adjacent
teeth.cast
Each
cast
was
also digitizeddigital scanner(Trios,3shape,Copenhagen,Denmark),
anddigitalcastmodelswere
superimposedusing
best‐fit
Copenhagen,Denmark),
anddigitalcastmodelswere
superimposedusingabest-fitalgorithm
on the3shape, Copenhagen, Denmark), and digital cast models were superimposed using aa best‐fit
algorithm
onthe
Geomagic
ControlX
program(version2018.0.13D
Systems,
Cary,
NC,
USA).
To
Geomagic Control
X programControl(versionX2018.0.13D
Systems, 2018.0.13D
Cary, NC, USA).
To evaluate
the labialalgorithm
on the Geomagic
program (version
Systems,
Cary, NC,
USA).softTo
evaluatethe labial
labialsoft thetissuevolumechange,thearea ofofinterest
wasanddefinedbypapillary
the mesial
mesialand distal
distaltissuevolumechange,areaof interest
wasthedefinedbyinterest
the mesial
distalmidlineandevaluatethesofttissuevolumechange,area
wasdefinedby
theandpapillary
midlineandthemucogingival
line
from
0.5
mm
to
5
mm
in
the
apicaldirection(Figure4).
themucogingival
line
from
0.5
mm
to
5
mm
in
the
apicaldirection(Figure
4).
Since
the
volumewaspapillary midline and the mucogingival line from 0.5 mm to 5 mm in the apical direction (Figure 4).
Since
the
volumewasdifferentfor
eachpatient,
the
mean
value
of
the
horizontal
distance
betweendifferenteach patient,the meanof the horizontal
the superimposed
digitalSince
theforvolumewas different
for valueeach patient,the meandistancevalue ofbetween
the horizontal
distance between
thesuperimposed
digitalcasts
wasmeasured.
The
mean
and
standard
deviationofthedistance
were
casts
was
measured.
The
mean
and
standard
deviationofthedistance
were
calculated.
the superimposed digital casts was measured. The mean and standard deviation of the distance were
calculated.
calculated.

FigureFigure 4.
4. TheThe Evaluation
Evaluation ofof thethe Labial
Labial Tissue
Tissue Volume
VolumeChange.
Change. (A)(A) TheThe Superimposed
Superimposed Digital
Digital Study
Study
Figure 4. The Evaluation of the Labial Tissue Volume Change. (A) The Superimposed Digital Study
Cast
Model
and
Follow-Up
Cast,
(B)
The
Area
of
Interest,
Where
the
Green
Area
Means
No
Change,Cast Model and Follow‐Up
Cast Model and Follow‐Up Cast, (B) The Area of Interest, Where the Green Area Means No Change,
andand thethe BlueBlue Area
Area Means
Means Loss
Loss ofof Volume.
Volume.
and the Blue Area Means Loss of Volume.

A
waswasusedused
to evaluate
the interdental
papilla between
implantthe
restoration
A clinicalclinicalphotographphotographto evaluate
evaluate
the interdental
interdental
papilla the
betweenimplantA
clinical
photographwas usedtothepapillabetweenthe implantandthe adjacentteeth
using theJemt’sindex(scoreindex
0: no papillaisnopresent,
score
1: less scorethan halfofrestorationandtheadjacent
teeth
using
the
Jemt’s(score0:papillaispresent,
1: less
lessrestoration and the adjacent teeth using the Jemt’s index (score 0: no papilla is present, score 1:
thepapillaispresent,
score
2:
more
than
half
of
the
papillaispresent,
score
3:
the
papillafills
thethan half
half ofof thethe papilla
papilla isis present,
present, score
score 2:
2: moremore than
than half
half ofof thethe papilla
papilla isis present,
present, score
score 3:
3: thethe papilla
papillathanentireinterdental
space, andspace,score 4:
thescore
papillaispresent)[26].
All measurements
were performed
by
fills
the
entireinterdental
and
4:
the
papillaispresent)[26].
All
measurements
werefills the entire interdental space, and score 4: the papilla is present) [26]. All measurements wereoneclinician.
performed
by oneone clinician.
clinician.
performedbyAppl. Sci. 2020, 10, 1678

6 of 112.7. Esthetic Outcome
The pink esthetic score (PES) was used to evaluate the esthetic outcomes with the clinicalphotographs before the treatment and after the follow-up period. The PES index includes sevenvariables (the mesial papilla, the distal papilla, the midfacial level, the midfacial contour, the alveolar
process deficiency, the soft tissue color, and the soft tissue texture), and was assessed by using
a 0-1-2 score, with 0 = lowest score, and 14 = highest score. All assessments were performed by one
clinician [27].
2.8. Statistical Analysis
The significance of the changes in soft tissue dimension, interdental papilla, and PES wasdetermined using a paired T-test for the parametric data and a Wilcoxon signed-rank test for the
nonparametric data. The analysis was performed using the SPSS ver. 23.0 (SPSS Inc.) and thesignificance level was set at 5%.
3. Results
The 13 patients who had been treated from April 2017 to May 2018 consisted of five males andeight females with a mean age of 49.6 years, and they were all included in the study. A total of 13
maxillary anterior teeth were immediately implanted and immediately restored, which included nine
central incisors, two lateral incisors, and two canine teeth. The most prevalent reason for tooth loss wascrown fracture, followed by caries, and periodontal disease. All patients were non-smokers. The meanfollow-up period was 14.7 months, and the minimum follow-up period was one year. There was noloss of implant or pathology associated with the implants observed during the follow-up period.
3.1. Soft Tissue Dimension
Table 1 depicts the changes in the soft tissue dimension before the extraction and after the recent
follow-up. There was no statistically significant change in the midfacial mucosa (p-value: 0.028).
The loss of the mesial papillary height was 0.32 ± 0.83 mm (p-value 0.203), and of the distal papillaryheight, 0.10 ± 0.060 mm (p-value: 0.594). The mean horizontal change in the midfacial soft tissue
volume was 0.32 ± 0.83 mm.
Table 1. The Changes in the Soft Tissue Dimension.
Parameters

Amounts of Change

p-Value

Midfacial mucosa level
Mesial papilla level
Distal papilla level
Horizontal change in the labial soft tissue
Mean ± standard deviation

0.27 ± 0.42
0.32 ± 0.83
0.10 ± 0.06
0.32 ± 0.83

0.028
0.203
0.594
0.060

3.2. Jemt’s Index
There was no significant difference in the mesial and distal papilla index between the measurements
made prior to the extraction and at one year of follow-up, according to the Wilcoxon signed-rank test
(p-value: 0.180, 0.157) (Table 2).
Table 2. The Jemt’s Index.
Parameters

Amounts of Change

p-Value

Mesial papilla
Distal papilla−1.342 *−1.414 *

0.180
0.157

*: Z value.

Appl. Sci. 2020, 10, 1678

7 of 113.3. PES
The mean and standard deviation of the PES and of each variable are depicted in Table 3.
The overall score was 11.16 ± 2.17 before treatment, and 10.25 ± 1.42 after the follow-up period.
There were two cases with a total score of 8 or less in both the pre-operative and follow-up periods,
which can be regarded as esthetic failures.
Table 3. The Pink Esthetic Score.
PES Parameter

Pre-Operative

Follow-Up

p-Value

Mesial papilla
Distal papilla
Midfacial mucosa level
Midfacial contour
Alveolar process deficiency
Soft tissue color
Soft tissue texture
Total score1.33 ± 0.49
1.42 ± 0.51
1.67 ± 0.65
1.58 ± 0.51
1.33 ± 0.78
1.58 ± 0.51
1.50 ± 0.52
10.58 ± 1.97

1.25 ± 0.45
1.58 ± 0.51
1.42 ± 0.51
1.33 ± 0.49
1.16 ± 0.72
1.42 ± 0.51
1.42 ± 0.51
9.83 ± 1.34

0.586
0.438
0.117
0.191
0.504
0.339
0.586
0.137

4. Discussion
The immediate tooth replacement and the provisional restoration procedures provide a physiologic
and esthetic advantage over the traditional delayed implant placement and prosthetic restoration [28].
From a clinical point of view, the post-extraction healing and osseointegration occur simultaneously,
which is advantageous in terms of time. The current study suggests that the immediate post-extraction
implant placement and provisional restoration in the esthetic zone yield acceptable changes in the soft
tissue [8–13].
The immediate provisional restoration after an implant placement in the maxillary anterior
dentition produces predictable results by maintaining the gingival papilla and facial gingival heights [29].
The gingival mucosa around the implant can heal along the contour of the interim restoration [30].
Maintaining the anatomic architecture of the existing extraction socket is an important factor inachieving esthetic results with the immediate placement and immediate restoration in the esthetic
zone. A variety of immediate provisionalization methods have been attempted to obtain desirable
emergence profiles [31–34].
With the developments in digital implant dentistry, a CAD/CAM system can be used tomake the stereolithographic guides and customized abutments, as well as the final prostheses [35].
The stereolithographic guides used in this study (Oneguide, Osstem, Korea) were designed bysuperimposing the scanned data of the cast and by CBCT imaging using a CAD/CAM software(Implant Studio, 3Shape, Copenhagen, Denmark). The implant-supported prosthesis was planned
from the scanned cast data, and the location and size of the fixture to be placed were chosen with theconsideration of the alveolar bone and its adjacent anatomical structures on the CBCT data. A titanium
customized abutment was designed by the CAD/CAM software (Dental System, 3Shape, Copenhagen,Denmark) duplicating the anatomical contours of the pre-existing tooth.
A guided surgery in combination with a pre-fabricated customized abutment can preserve theanatomic gingival architecture, minimizing the change in soft tissue. Current studies report thata peri-implanted soft tissue can heal according to the contours of the provisional restoration [36,37].
In this study, a titanium abutment replicating the original gingival shape before the extraction was
pre-fabricated using a CAD/CAM system. On the day of surgery, the titanium anatomic abutments wereconnected to allow soft tissue healing and contouring along the original gingival shape. The customized
anatomic abutment provides a reconstruction of the emergence profile and a gingival architecture to
optimize the esthetic appearance. It also provides a custom seal to allow the graft material applied
between the fixture and the bone gap to remain stable, without an exposure to the oral cavity (Figures 5
and 6). An additional advantage includes fewer complications from food retention and plaquethis study, a titanium abutment replicating the original gingival shape before the extraction was pre‐fabricated using a CAD/CAM system. On the day of surgery, the titanium anatomic abutments were
fabricated using a CAD/CAM system. On the day of surgery, the titanium anatomic abutments wereconnected to allow soft tissue healing and contouring along the original gingival shape. The
connected to allow soft tissue healing and contouring along the original gingival shape. The
customized anatomic abutment provides a reconstruction of the emergence profile and a gingival
customized anatomic abutment provides a reconstruction of the emergence profile and a gingival
architecture to optimize the esthetic appearance. It also provides a custom seal to allow the graftarchitecture
optimize the esthetic appearance. It also provides a custom seal to allow the8 of
graft
Appl.
Sci. 2020, 10,to1678
11material
applied between the fixture and the bone gap to remain stable, without an exposure tothematerial applied between the fixture and the bone gap to remain stable, without an exposure to theoral cavity (Figures 5 and 6). An additional advantage includes fewer complications from foodoral cavity (Figures 5 and 6). An additional advantage includes fewer complications from foodretention andplaquethedeposition
the gingivaInandthe abutment.
In aPeacesystematic
Peace
deposition
betweengingiva between
andthe abutment.
a systematic
review,
et al. review,
reported
that
retention andplaque deposition
betweenthe gingiva andthe abutment.
In a systematic
review, Peaceetal.
reportedthatthesurfaceoftheabutment
affectsthetissueoftheperi‐implant.
From
an
the
surfaceoftheabutment
affectsthetissueoftheperi-implant.
Fromanhistological
point
of
view,
et al. reported that the surface of the abutment affects the tissue of the peri‐implant. From anhistologicaltitanium
point of view, machinedprovidea low thatrisk of inflammatory
machined
provide atitanium
low riskabutmentsofinflammatory
reactionswith thehistological point abutmentsof view, machinedtitaniumabutments
providea low riskinterfere
of inflammatory
reactionsthatinterferewiththehealingofsoft
tissue[38].
healingofsoft
tissue[38].
reactions that interfere with the healing of soft tissue [38].

Figure 5. The Reconstruction of the Emergence Profile and Gingival Architecture with the Equi‐
FigureReconstructionof theProfileProfile
and Gingival
Architecturewith the with
Equi-Gingival
Figure5.5.The
The
Reconstructionof Emergencethe Emergenceand Gingival
Architecture
the Equi‐Gingival Abutment Margin.
Abutment
Margin. Margin.
Gingival Abutment

Figure 6. The
The Customized
Customized Titanium
Titanium Anatomic Abutment Schematic Representation.
Figure 6. The Customized Titanium Anatomic Abutment Schematic Representation.

The
results ofpresent study
stability ofsoft tissue
tissue inin thethe pre‐operative
pre-operative period
period andand after
after
The resultsof present
study show
show thethe stabilityof soft
The resultsof present
study show There
the stability
ofsignificant
soft tissue inthe pre‐operative
period mucosa;
and afteraminimum
of
one
year
of
follow-up.
wasnorecessionofthemidfaciala minimum of one year of follow‐up. There was no significant recession of the midfacial mucosa; thea minimumof follow‐up.
There wassignificantof theofmidfacialthetherecessionof
ofone
the yearmesialpapillary height
was no0.32mm, andrecession
the recession
the distalmucosa;
papillaryheight was 0.10 mm. The mean horizontal change of the labial mucosa was 0.32 ± 0.83 mm. De Roucket al. reported that the midfacial recession was 0.53mm in average in patients who received single
immediate implant and provisionalization in the anterior maxilla during the first year of function [8].
Khzam et al. evaluated the esthetic outcome by analyzing the dimensional changes of the midfacial
soft tissue as a result of using the immediate placement and restoration protocol, and reported that
advanced soft tissue recession (>1 mm) was observed in 11% of the cases [39]. Tian et al. evaluatedchanges in the contour of the labial soft tissue after an immediate post-extraction implant placement
and provisionalization. During a one-year follow-up period, the labial soft tissue contour showedAppl. Sci. 2020, 10, 1678

9 of 11a continuous alteration. The total mean change was 0.62 mm, mainly in the first three months [40].
The PES value before treatment was 11.16, and at one year of follow-up, 10.25. There was a slightdecrease in each measurement and the existing esthetic status was found to have a significant effect on
the outcome. In the present study, a favorable outcome was reported, which implies that the immediate
restoration with the anatomic abutments provides predictable results regarding the stability of thesoft tissue.
The evaluation of the stability of the soft tissue was intended to help support the scientific basis forthe immediate restoration with a CAD/CAM customized titanium anatomic abutment using a guided
surgery. With a retrospective study design, the present clinical study was limited by its small sample
size, a relatively short observation period, and a lack of hard tissue evaluation. Future studies witha larger sample size, longer follow-up periods, and a prospective clinical trial design are needed tofurther support the findings of the present study.
5. Conclusions
The immediate post-extraction placement of an implant in the esthetic zone should satisfy theesthetic and functional demands. The clinical case series in the present study provides clinicians witha scientific basis for an immediate placement procedure using a 3D reconstruction stereolithographic
guide and restoration protocols with a CAD/CAM titanium anatomic abutment. This advanced
technique provides an option with predictable outcomes for the replacement of teeth in the esthetic zone.
Author Contributions: T.-H.K. and Y.-K.O. contributed to the acquisition, analysis, and interpretation of data for
the work, E.C.K. and G.K.S., to the interpretation and critical revision, and C.-M.J. and Y.-D.K., to the conception
and design of the work, and to the analysis and interpretation. All authors have read and agreed to the publishedversion of the manuscript.
Funding: This work was supported by a 2-Year Research Grant of Pusan National University.
Conflicts of Interest: The authors declare no conflicts of interest.

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