Abstract:

Statement of Problem: Pink Esthetic Score has established its reliability in Objective assessment of esthetics till premolars. However its application to implant prosthesis replacing molars placed by flapless technique needs to be evaluated especially for patients having a wide smile.

Purpose: This study aims to assess the Pink Esthetic Score for single Implant crowns in the region of mandibular first molars.

Material and Methods: 20 single implant crowns in mandibular first molar region were evaluated for Pink Esthetic Score using 7 evaluation criteria 6 months post rehabilitation.

Results: The mean PES value obtained after evaluating 20 images from 20 patients was 12.9 ± 2.37. The alveolar process deficiency (2.00±0.00) had highest score and distal papilla the lowest (1.55± 0.69).

Conclusions: Flapless implants with single implant crowns in molars placed in optimal conditions lead to a favorable esthetic outcome in terms of PES value.

Clinical Implication: A carefully selected posterior implant sites for flapless implant placement which should be free of any alveolar bone deficiency, having Division a bone type and adequate interocclusal space leads to an esthetically pleasing posterior implant restoration.

1. Introduction

With the progress in modern day implantology, the implant success criteria gradually shifted from just survival rates to optimal esthetics [1]. To objectively quantify esthetics, Furhauser in 2005 published the Pink Esthetic Score [2]. With the passing years PES established itself as a gold standard in objectively assessing single implants esthetics. Seven soft tissue parameters are assessed: the mesial and distal papilla, contour, margin level, alveolar process deficiency, mucosal colour and texture. For each one of the seven variables a 2-1-0 score is assessed, with 2 being the best and 0 being the poorest score [2] (Table 1).

Most of the studies involving PES evaluate the score in anterior maxilla or up to the premolars. However, these esthetic parameters are also of pertinent importance in posterior areas. If these parameters are not fulfilled these can create place for food entrapment leading to periimplant mucositis and eventually periimplantitis.

The objective of the current article is to show the results of PES of 20 flapless single molar implants.

2. Material and Methods

20 Patients with single missing mandibular first molars (14 males and 06 females) were selected with a minimum age of 22 years and maximum age of 56 years. The mean age of the patients was 38 years. The Inclusion criteria were:

• Division A bone with interocclusal space 7 mm or more.
• Thick gingival phenotype.
• Absence of any tilting of the adjacent teeth.
• Tooth loss not over 6 months.

Implants of 4.0mm or 5.0mm width (Bioner Top DM, Spain) and optimal lengths were placed in the sites as planned on CBCT. Implant osteotomies were prepared without raising a flap via punch (Figure 1). Implants were placed 0.5 to 1mm subcrestally (Figure 2) and a transmucosal healing protocol was followed. Healing abutments flush with soft tissue were placed to avoid the need for a stage 2 surgery after 3 months (Figure 3). Post-operative IOPA X rays were taken (Figure 4).

Restorative phase was initiated after 3 months. The healing abutment was removed and epithelial cuff was evaluated (Figure 5). An intraoral scan (Trios 3, 3 Shapes) of the entire arch was done without the healing abutment followed by a placement of a scan body and another scan of the arch. The scan body was verified for the fit via an intraoral periapical X ray. The opposing arch and bite were also captured digitally.

Premilled titanium abutments were used to mill the desired abutment profile and a CAD PFM crown was fabricated over it (Figure 6). The cementation was done using a resin cement (3M RelyX U200). The entire prosthesis was tried and torqued with a calibrated torque wrench to 30 N cm into the patients´ mouth and PES was evaluated at 6 months recall visit. (Figure 7). Iopa X rays at the time of PES evaluation were taken (Figure 8).

3. Results

The mean PES value obtained after evaluating 20 images from 20 patients was 12.9 ± 2.37. The alveolar process deficiency (2.00±0.00) had highest score and distal papilla the lowest (1.55± 0.69) (Table 2).

Individual parameters showed varying results. The scores for mesial papilla and distal papilla were comparatively lower, while alveolar crest deficiency and soft tissue texture showed consistently high scores.

4. Discussion

The results of this study suggest that flapless implants in the posterior mandible can achieve favorable esthetic outcomes as assessed by PES. The high scores for alveolar crest deficiency and soft tissue texture suggest that these parameters are less influenced by the implant placement technique.

One of the limitations of this study is the relatively small sample size and the short follow-up period. Further research with larger sample sizes and longer follow-up periods is needed to validate these findings.

5. Conclusion

Flapless implants with single implant crowns in molars placed in optimal conditions lead to a favorable esthetic outcome in terms of PES value.

Clinical Implication: A carefully selected posterior implant sites for flapless implant placement which should be free of any alveolar bone deficiency, having Division a bone type and adequate interocclusal space leads to an esthetically pleasing posterior implant restoration.