Evaluation of Pink and White Esthetic Scores for

Immediately Placed and Provisionally Restored

Implants in the Anterior Maxilla
Guaracilei Maciel Vidigal, Jr, DDS, MSc, PhD1/Mario Groisman, DDS, MSc2/
Victor Grover Rene Clavijo, DDS, MS, PhD3/Igor Guimarães Barros Paulinelli Santos, DDS, MSc4/
Ricardo Guimarães Fischer, DDS, MSc, PhD5

Purpose: To evaluate the esthetic result of immediately placed implants with immediate provisional restorations
in the anterior maxilla using the pink esthetic score (PES) and white esthetic score (WES). Materials and
Methods: The records of patients were evaluated retrospectively. The evaluation was carried out by two
examiners using 12 evaluation criteria. Results: The average PES value from the evaluation of 53 images
obtained from the 53 selected patients (22 men and 31 women) was 8.63 ± 2.4 (range, 1–14), whereas the
average WES value was 6.92 ± 1.67 (range, 2–10). The mesial papilla had the highest average PES (1.39 ± 0.4)
and the distal papilla had the lowest PES (0.87 ± 0.54). Texture had the highest average WES (1.54 ± 0.34)
and tooth shape had the lowest average WES (1.25 ± 0.43). Conclusion: Treatment with immediate implants
providing immediate provisional restoration in the anterior maxilla yields good clinical esthetic outcomes, as
assessed by PES/WES values. The PES and WES values showed strong intraexaminer agreement, but weak
interexaminer agreement. Int J Oral Maxillofac Implants 2017;32:625–632. doi: 10.11607/jomi.5149

Keywords: esthetic zone, immediate implants, immediate restoration, pink esthetic score, white esthetic score

C omparing the results of different studies of imme-

diately placed implants is challenging. A previous
systematic review of the outcomes of implants placed
immediately after tooth extraction and those placed
in healed areas concluded that it was not possible to
compare the results because of the heterogeneity of
the studies.1 Immediately placed implants have high
survival rates.2–4 However, with the progress in sur-
gical and prosthetic techniques for osseointegrated
implants and the development of novel materials, the
treatment results for immediately placed implants
can no longer be assessed solely on the basis of the
1 Adjunct Professor, Faculty of Dentistry, Rio de Janeiro State
University, Rio de Janeiro, Rio de Janeiro, Brazil.
2Private Practice, Rio de Janeiro, Rio de Janeiro, Brazil.
3Visiting Professor, Advanced Operative and Adhesive
Dentistry, Division of Restorative Sciences, University of
Southern California, Los Angeles, California, USA.
4Private Practice, Niterói, Rio de Janeiro, Brazil.
5Dean, Faculty of Dentistry, Rio de Janeiro State University, Rio
de Janeiro, Rio de Janeiro, Brazil.
Correspondence to: Dr Guaracilei Maciel Vidigal, Jr, Adjunct
Professor, Faculty of Dentistry, Rio de Janeiro State University,
Av. 28 de setembro 157, Vila Isabel, Rio de Janeiro,
RJ, Brazil, 22050-002. Fax: +55 21 22559512.
Email: vidigaljr@globo.com
©2017 by Quintessence Publishing Co Inc.
success/survival rate, as this progress has been accom-
panied by an increased demand for optimal esthetics.
This has raised scientific interest in the evaluation of
the esthetic outcomes of these treatments.5,6
Several factors can affect peri-implant tissues and
the esthetic outcomes of immediate implant therapy,7
including the morphology of the area,8,9 the shape
of the alveolar bone defect,10 the surgical technique
used,11 the material composition and design of the im-
plants and abutments used,12,13 and the use of bone
substitutes14 and connective-tissue grafts.15 These
critical factors should be evaluated by the clinician/
surgeon when determining the appropriateness of de-
layed or immediate implant placement. When consid-
ering immediate implant placement and provisional
restoration, the risk factors for this loading protocol
should also be analyzed. Potentially deleterious effects
may result from parafunctional habits,16 initial inser-
tion torque,17 and the patient compliance level.18
In 2005, Fürhauser et al19 proposed an index—the
pink esthetic score (PES)—to evaluate the esthetic re-
sults of treatments involving single implants. The PES
provides a rating of seven soft tissue parameters: the
mesial and distal papilla, contour and margin level, al-
veolar process deficiency, and mucosal color and tex-
ture. Belser et al20 proposed combining the PES with
a score that assesses the quality of prosthetic restora-
tion of the mucosa over the implant: the white esthetic

The International Journal of Oral & Maxillofacial Implants 625

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Vidigal et al
Fig 1  PES/WES parameters. PES parameters: 1–Mesial
papilla; 2–Distal papilla; 3–Height of the gingival margin; 4–
Soft tissue contour; 5–Alveolar process deficiency; 6–Color;
7–Texture; WES parameters: 1–Shape; 2–Volume; 3–Soft tis-
sue contour; 4–Height of gingival margin; 5–Translucency and
characterization.
score (WES). The WES evaluates the following param-
eters of the clinical crown: form, color, texture, volume,
translucency, and characterization. All parameters
of the PES/WES (Fig 1) scores are evaluated via direct
comparison of the mucosa and the implant-supported
crown with the contralateral homologous tooth, and
a value of 0, 1, or 2 is assigned to each parameter. A
score of 0 indicates large discrepancies, a score of 1 in-
dicates small discrepancies, and a score of 2 indicates
a high similarity with the contralateral tooth. The PES
has been used to evaluate implants placed in the an-
terior maxillary area,21 as well as to evaluate surgical
procedures in periodontics in terms of esthetics.22,23
Since publication of the classic study by Wöhrle,24
direct placement of a provisional crown on an implant
placed immediately after tooth extraction was shown
to be a reliable procedure that does not compromise
osseointegration.24,25 In addition, such immediate
loading of the implant decreases the number of sur-
gical steps and the treatment period and increases
patient satisfaction.26 However, one possible benefit
of treatment, the preservation of pre-existing bone
structure and the consequences thereof, has been
questioned in the literature.27
Thus, a review of the clinical and biologic aspects of
the technique is important. Although several studies
have evaluated differences in clinical parameters using
continuous variables, such as the degree of gingival re-
cession28 or marginal bone loss and probing depth,29
few studies have evaluated the esthetic results in this
context. Therefore, the aim of this study was to evalu-
ate the esthetic outcomes of immediately placed im-
plants providing immediate provisional restoration in
the anterior maxilla using objective criteria (PES and
WES scores).
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MATERIALS AND METHODS
Sample Selection
In this study, the records of patients who received
single immediately placed implants with provisional
restoration in the anterior maxilla were evaluated retro-
spectively. The following exclusion criteria were used:
alcohol and drug abuse, poor oral hygiene, dental his-
tory of bruxism or parafunctional habits, presence of
systemic disease that could interfere with healing, and
bone loss of greater than 5 mm in the facial aspect (in
the mesiodistal and apicocoronal directions) of the
compromised tooth. The inclusion criteria for implant
placement surgery were as follows: gingival architec-
ture in harmony with the neighboring teeth, with at
least 2 mm of keratinized tissue; absence of previous
periodontal surgery; and good oral hygiene. Any infec-
tion or acute inflammation was treated before surgery.
Surgical Procedures
All patients were evaluated using cone-beam com-
puted tomography (Newtom 3G, Quantitative Radiol-
ogy). Before surgery, the gingival biotype was assessed
using a periodontal probe, as proposed by Kan et al30
(Colorvue Probe #12, Hu Friedy). A periotome was
used to cut the fibers of the periodontal ligament on
the mesial, distal, and palatal aspects of the compro-
mised tooth during extraction. Care was taken to pre-
vent damage to the surrounding tissues, particularly
the buccal bone plate. For transsurgical evaluation, a
North Carolina probe (Hu-Friedy) was used after tooth
extraction to assess the presence and dimensions of
the bone defect on the facial aspect. All surgical proce-
dures were performed by the same surgeon (M.G.) us-
ing standard protocols and without releasing incisions.
Implants were placed with the aid of a prefabricated
surgical guide. The initial osteotomy was performed
on the palatal aspect to avoid contact of the buccal
bone plate with the implant. The ideal position of the
implant was determined to be 3 mm below the facial
gingival margin and 2 mm palatal to the buccal bone
plate. Initial stability of the implant was achieved via
contact with the mesial, distal, and palatal aspects of
the alveolar bone. All implants were placed with a mini-
mum insertion torque of 35 Ncm. The space between
the implant and the facial bone was filled with mineral-
ized bovine bone (Bio-Oss, Geistlich). A total of 16 pa-
tients (30.19%) received a connective-tissue graft.
The systemic antibiotic amoxicillin (500 mg every 8
hours for 7 days; Medley Pharmaceuticals) and the an-
ti-inflammatory drug ibuprofen (600 mg every 8 hours
for 3 days; Alivium, Mantecorp Chemical and Pharma-
ceutical Industry) were prescribed, along with topical
use of 0.12% chlorhexidine mouthwash (Perioxidin,
Gross Laboratory) twice a day for 14 days.

Restorative Procedures
Restorative treatment was initiated immediately after
implant placement. A transfer coping was coupled to the
implant and an impression was taken using polyvinyl si-
loxane. Immediately after surgery, provisional crowns
were cemented onto a prefabricated screw-retained ti-
tanium abutment. The crowns were adjusted in centric
occlusion and lateral excursive movement of the man-
dible to prevent occlusal contact, and splinting of the
antagonist tooth was performed when necessary. The
final impression was taken, on average, 4 months later.
Esthetic Evaluation
Intraoral photographs were taken after placement of
the provisional crowns and again at all follow-up vis-
its. All photographs were taken using a digital photo-
graphic setup with a macro lens (D90 camera, 105-mm
lens, SBR 200 flash, Nikon). All intraoral photos were
standardized by symmetrically framing the homolo-
gous contralateral tooth and the six anterior teeth
under the same lighting conditions to allow objective
evaluation of the esthetic outcomes of treatment. Im-
ages were analyzed on the same 42-inch television
(Panasonic) by two examiners (GMV and VC) who had
previously calibrated the assessment procedure and
who were not involved in treating the patients. To cal-
culate the degree of intraexaminer and interexaminer
agreement (kappa), the examiners evaluated the im-
ages again after 10 days.
Statistical Analysis
The descriptive statistical analysis of the results involved
calculation of the mean and standard deviation of each
PES/WES variable, analysis per variable and per ex-
amination of the highest and lowest possible values,
and the results of the total PES/WES scores in the first
and second assessments. The degree of intraexaminer
and interexaminer agreement for the seven PES vari-
ables and the five WES variables was calculated using
the weighted kappa statistic (κ). Values of κ ≥ 0.8 indi-
cate very strong agreement, values from 0.6 to 0.7 in-
dicate moderately strong agreement, values from 0.3
to 0.5 indicate intermediate agreement, and values
< 0.3 indicate poor agreement. Kappa was calculated us-
ing statistical software (SPSS, version 20, IBM), and the
weighted κ was calculated using VassarStats software
(swMATH).
RESULTS
Of the 53 patients selected, 22 were men and 31 were
women. Their average age was 46 years (range, 26–73
years). The follow-up period varied from 4 months to
162 months, with an average follow-up of 51 months.
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Vidigal et al
Good primary stability was achieved for the imme-
diately placed implants with provisional restorations.
Of the 53 implants placed, 51 became osseointegrated
and 2 were lost; in these cases, new implants were re-
placed by implants with larger diameters. Of these two
failed implants, one was lost as a result of trauma (the
patient reported that he chewed hard food a few days
after surgery). The cause of failure of the other implant
is unknown. All other patients were compliant.
Biologic complications observed after osseointegra-
tion included the need for connective-tissue graft surgery
in two cases—6 months after surgery in one case and 5
years after surgery in the other—and the need for a bone
graft 8 years after surgery in one case. Mechanical compli-
cations included screw loosening from a prosthetic abut-
ment and screw fracture (one each), two definitive crowns
that were redone, and seven that were recemented.
The 53 images were examined by both examiners
using 12 evaluation criteria, which generated 1,272
scores for analysis.
Variables of the PES/WES Score and Total
PES/WES Score
The average PES was 8.63 ± 2.4 (range, 1–14), and the
average WES was 6.92 ± 1.67 (range, 2–10) (Table 1).
The esthetic outcome of treatment as evaluated using
the total PES/WES score was 15.55 ± 3.45 (Table 1). PES
results indicated a clinically favorable outcome in 31
(58.49%) cases, an optimal outcome in 5 (9.43%) cases,
and an unfavorable outcome in 17 (32.07%) cases. WES
results indicated that the outcome was clinically favor-
able in 36 (67.92%) cases, optimal in 4 (7.55%) cases,
and unfavorable in 13 (24.52%) cases. Analysis of the
PES/WES indicated that outcomes were favorable in 32
(60.38%) cases, optimal in 2 (3.77%) cases, and unfa-
vorable in 19 (35.85%) cases.
Analysis of Highest and Lowest Possible
Scores per Variable and per Examination
The highest possible PES value (2) was observed
most frequently for the height of the gingival margin
(45.28% and 42.45% for the first and second examin-
ers, respectively; Table 2), with an average PES of 1.32
± 0.62 (Table 1). The distal papilla received the lowest
score and, consequently, the highest percentage of
0 scores (31.13% and 21.70% for the first and second
examiners, respectively; Table 3) and the lowest av-
erage PES (0.87 ± 0.54; Table 1). The highest possible
WES value (2) was observed most frequently for sur-
face texture (49.06% and 61.32% for the first and sec-
ond examiners, respectively; Table 2), with an average
score of 1.54 ± 0.34 (Table 1). Tooth shape received the
lowest average WES: 1.25 ± 0.43 (Table 1) and a high
frequency of 0 scores (10.38% and 4.72% for the first
and second examiners, respectively; Table 3).
The International Journal of Oral & Maxillofacial Implants 627
Vidigal et al

Table 1  Means and Standard Deviations (SDs) Table 2  Distribution of Highest Possible Score
of Each Variable of the Pink Esthetic for Each Variable of the Pink Esthetic
Score (PES) and White Esthetic Score Score (PES) and White Esthetic Score
(WES) (WES), by Examination
Score Variable Mean ± SD Score Variable Examiner 1 Examiner 2
PES Mesial papilla 1.39 ± 0.40 PES Mesial papilla 40.57 41.51
Distal papilla 0.87 ± 0.54 Distal papilla 16.04 10.38
Height of the gingival margin 1.32 ± 0.62 Height of the 45.28 42.45
Soft tissue contour 1.25 ± 0.53 gingival margin
Alveolar process deficiency 1.34 ± 0.40 Soft tissue contour 37.73 36.79
Color 1.19 ± 0.36 Alveolar process 36.79 39.62
Texture 1.28 ± 0.42 deficiency
Total PES 8.63 ± 2.4 Color 27.36 22.64
WES Shape 1.25 ± 0.43 Texture 34.90 33.02
Volume 1.35 ± 0.41 WES Shape 28.30 37.73
Color 1.36 ± 0.43 Volume 38.68 40.57
Texture 1.54 ± 0.34 Color 35.85 43.40
Translucency and 1.42 ± 0.42 Texture 49.06 61.32
characterization Translucency and 47.17 46.23
Total WES 6.92 ± 1.67 characterization
PES/WESa 15.55 ± 3.45
aPES/WES is the sum of the two esthetic scores.

Table 3  Distribution of the Lowest Possible Table 4  Assessment of Intraexaminer

Score for Each Variable of the Pink Agreement Using the Weighted Kappa
Esthetic Score (PES) and White (κ) Statistic
Esthetic Score (WES), by Examination Score Variable Examiner 1 Examiner 2
Score Variable Examiner 1 Examiner 2 PES Mesial papilla 0.532 0.919
PES Mesial papilla 1.89 1.89 Distal papilla 0.602 0.783
Distal papilla 31.13 21.70 Height of the 0.765 0.871
Height of the 12.26 12.26 gingival margin
gingival margin Soft tissue contour 0.529 0.740
Soft tissue contour 14.15 10.38 Alveolar process 0.629 0.922
Alveolar process 4.72 3.77 deficiency
deficiency Color 0.440 0.651
Color 2.83 8.49 Texture 0.555 0.756
Texture 4.72 6.60 WES Shape 0.316 0.549
WES Shape 10.38 4.72 Volume 0.496 0.678
Volume 6.60 2.83 Color 0.653 0.724
Color 2.83 4.72 Texture 0.458 0.769
Texture 0.94 0.94 Translucency and 0.543 0.876
Translucency and 4.72 5.66 characterization
characterization

Intraexaminer Agreement Interexaminer Agreement by Percentage and

In the intraexaminer assessment of PES, the variable
with the lowest agreement was color (κ = 0.440 and
0.651 for the first and second examiners, respectively),
whereas in the WES evaluation, the variable with the
lowest agreement was tooth shape (κ = 0.316 and
0.549 for the first and second examiners, respectively).
In contrast, there was no marked intraexaminer agree-
ment between the variables with the highest κ values
(height of the gingival margin and alveolar process de-
ficiency according to PES score, color, and translucency
according to WES score; Table 4).
Weighted 𝛋 Statistic
The interexaminer agreement for PES varied from
poor—for evaluation of the mesial papilla (κ = 0.153,
64.2% agreement)—to moderately strong—for evalu-
ation of the distal papilla (κ = 0.614, 75.5% agreement).
The interexaminer agreement for WES varied from
poor—for evaluation of tooth shape (κ = 0.145, 51%
agreement)—to moderately strong—for evaluation
of color (κ = 0.307, 56.6% agreement). For PES, there
was a marked disagreement in evaluation of the mesial
papilla in six cases and in evaluation of the soft tissue

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 Vidigal et al

Table 5  Assessment of Agreement Between Examiner 1 (Ex 1) and Examiner 2 (Ex 2) Using the
Weighted Kappa (κ) Statistic and the Percentage of Agreement (%)
Ex 1 Ex 1 Ex 1
Score Variable Value score = 0 score = 1 score = 2 κ %
PES MP Ex 2, score = 0 1 19 6 0.153 64.2
Ex 2, score = 1 0 16 11
Ex 2, score = 2 1 35 17
DP Ex 2, score = 0 9 4 0 0.614 75.5
Ex 2, score = 1 5 25 2
Ex 2, score = 2 0 2 6
HGM Ex 2, score = 0 5 2 0 0.543 71.7
Ex 2, score = 1 0 15 8
Ex 2, score = 2 0 5 18
STC Ex 2, score = 0 3 5 1 0.231 43.4
Ex 2, score = 1 2 9 18
Ex 2, score = 2 0 4 11
APD Ex 2, score = 0 1 2 0 0.154 39.6
Ex 2, score = 1 1 14 29
Ex 2, score = 2 0 0 6
Color Ex 2, score = 0 1 0 0 0.178 62.3
Ex 2, score = 1 1 30 19
Ex 2, score = 2 0 0 2
Texture Ex 2, score = 0 0 2 0 0.233 56.6
Ex 2, score = 1 2 23 19
Ex 2, score = 2 0 0 7
WES Shape Ex 2, score = 0 0 3 1 0.145 51.0
Ex 2, score = 1 2 19 17
Ex 2, score = 2 1 2 8
Volume Ex 2, score = 0 0 3 0 0.213 47.2
Ex 2, score = 1 3 15 22
Ex 2, score = 2 0 0 10
Color Ex 2, score = 0 1 0 0 0.307 56.6
Ex 2, score = 1 2 17 20
Ex 2, score = 2 0 1 12
Texture Ex 2, score = 0 0 0 0 0.151 54.7
Ex 2, score = 1 1 8 19
Ex 2, score = 2 0 4 21
T and C Ex 2, score = 0 1 0 1 0.196 49.1
Ex 2, score = 1 1 13 23
Ex 2, score = 2 0 2 12
In the 3 × 3 table generated for each variable, the third cell of the first row and the first cell of the third row indicate the largest discrepancies,
and the imaginary line formed by the first cell of the first row, second cell of the second row, and third cell of the third row indicate interexaminer
agreement.
PES = pink esthetic score; MP =mesial papilla; DP = distal papilla; HGM = height of the gingival margin; STC = soft tissue contour; APD = alveolar
process deficiency; WES = white esthetic score; T and C = translucency and characterization.

contour in one case. The WES evaluation of tooth shape
varied markedly between examiners in two cases and
that of translucency in one case (Table 5).
DISCUSSION
The PES/WES scores for immediate implants with im-
mediate provisional restorations were higher in this
study than those found in the literature. Pieri et al31 es-
tablished a PES of ≥ 8 as clinically acceptable, whereas
the average PES in the present study was 8.63. Using
the same PES/WES methodology, Cosyn et al32 sug-
gested the following values as unfavorable: PES < 8,
WES < 6, and PES/WES < 14. PES from 8 to 12, WES from
6 to 9, and PES/WES from 14 to 21 were considered fa-
vorable, and PES ≥ 12, WES ≥ 9, and PES/WES ≥ 21 were
considered close to optimal. Cosyn et al32 reported an
average PES of 10.48, which is higher than the aver-
age PES obtained in the study by Pieri et al.31 However,
in the study by Cosyn et al,32 the patient sample was
selected from among only those with a thick gingival

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Vidigal et al
phenotype and without bone defects. Furthermore,
a systematic review by Shi et al33 indicated that there
were no significant differences in PES between the im-
mediate and delayed implants (placed from 12 to 16
weeks after tooth extraction) placed in patients with a
thick gingival phenotype and intact facial bone, over
a short follow-up period (≤ 4 years). This may explain
the different results of the present study, as the patient
sample was not selected on the basis of the gingival
phenotype.
Belser et al20 suggested that a PES/WES ≥ 12 is clini-
cally acceptable; however, their study combined three
parameters of the original PES established by Fürhaus-
er et al19 (convexity, color, and texture of the mucosa)
into a single parameter, and they assigned a weight of
0.33 for each variable. In this study, we used the PES
proposed by Fürhauser et al,19 and the total PES/WES
value was 15.55. Using the methodology proposed by
Belser et al,20 the average PES/WES value in the pres-
ent study would have been 13.07, which is still above
the score designated as clinically acceptable in their
study. In the present study, only patients with an ad-
equate amount of bone palatal to the root position34
and with bone loss of no more than 5 mm in the fa-
cial aspect were selected to avoid inadequate implant
angulation, as implants angulated too far facially have
been associated with a higher risk of midfacial mucosa
recession.35
Evaluation of the esthetic outcomes of treatment,
despite being a relatively simple process, is not trivi-
al from the point of view of reproducibility. Only one
study to date,23 to the present authors’ knowledge, has
used the κ statistic to analyze interexaminer agree-
ment in PES/WES evaluation. The results of the pres-
ent study indicate that interexaminer agreement was
lower than intraexaminer agreement. Hof et al6 evalu-
ated the esthetic outcomes of single implants placed
in the anterior maxilla assessed by means of the PES,
and used the κ statistic and Kendall’s concordance co-
efficient to calculate the intraexaminer and interexam-
iner agreements, respectively. Other studies have used
Spearman’s correlation coefficient to analyze PES/WES
values.36,37 However, correlation is not always associat-
ed with agreement,38 and agreement will appear high-
er when using Spearman’s correlation coefficient than
when using the κ coefficient. Therefore, the present
study used the κ coefficient to calculate interexaminer
and intraexaminer agreement, revealing an intermedi-
ate to moderately strong level of intraexaminer agree-
ment for examiner 1 and a moderately strong to very
strong level of intraexaminer agreement for examiner
2, justifying use of the PES/WES value.
However, the interexaminer agreement was poor to
intermediate. This may suggest either the need for bet-
ter interexaminer calibration or an intrinsic difficulty
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related to the subjective perception of esthetics. Dif-
ferences in interexaminer agreement could also be
due to differences in the expertise of the examiners; in
this case, one of the examiners was an expert in peri-
odontology and the other was an expert in prosthetics.
Gehrke et al36 also observed differences in PES evalu-
ations made by different examiners when evaluating
the esthetic outcomes of single implant-supported
restorations.
Furthermore, the statistical treatment of ordinal
variables of the PES/WES value can lead to differences.
Liberal or pragmatic statisticians have accepted the
mathematical treatment of these variables,39 whereas
purists or conservative statisticians have argued that
these operations should not generate results in the
form of means and standard deviations.40 In the pres-
ent study, the liberal position was adopted because
the authors consider average values important for un-
derstanding differences in the variables that make up
the PES/WES score.
Cosyn et al41 observed a statistically significant
difference in PES between immediate implant place-
ments (10.88) and implants placed in previously graft-
ed areas (9.00), underscoring how surgical technique
can influence treatment results. In a comparison of the
PES of areas that received implants with and without
connective tissue grafts in the same patients, Wiesner
et al42 observed significantly higher scores in areas that
had received grafts. These studies offer evidence of the
approaches that result in a better esthetic outcome.
In the present study, patients who had a thin gin-
gival biotype were treated with a connective-tissue
graft to prevent future gingival marginal recession.43
Therefore, the 16 patients (30.19%) who received a
connective-tissue graft may have influenced the PES/
WES findings. This result is similar to the observations
of Cosyn et al.44 In a similar study of immediate implant
restorations, these authors found that connective-
tissue grafts may be necessary in about one-third of
patients. Furthermore, the decision to use zirconia or
titanium abutments was clearly based on the gingival
biotype. Only patients with a thick gingival biotype re-
ceived titanium abutments.
The distal papilla may have received low average
scores because the majority of implants (34 of 53)
were placed in the regions of the maxillary central in-
cisors. Considering that the contralateral homologous
tooth served as a reference for comparison in PES/WES
evaluation, the mesial papilla of these teeth becomes
single, limiting the comparison. Another important
factor to consider is the position of the cementoenam-
el junction (CEJ) in the distal aspects of the maxillary
central incisors and the mesial aspects of the maxillary
lateral incisors. In the same tooth, the amplitude of
curvature of the CEJ is higher in the mesial aspect than

in the distal aspect, and it decreases in the posterior
direction of the jaws.45 Therefore, the CEJ in the mesial
aspect of the maxillary lateral incisors is located in a
slightly more apical position than the CEJ in the distal
aspect of the central incisors. Therefore, and consider-
ing that the position of the papilla is influenced by the
periodontal position of the neighboring tooth,46,47 the
loss of a central incisor often leads to loss of height in
the distal papilla. The interdental papilla strongly in-
fluences the esthetic outcome of treatment, primarily
because patient esthetic dissatisfaction is often associ-
ated with absence of this structure.20 The importance
of the papilla cannot be underestimated, because it is
visible in 91% of patients with a low smile line. Gingi-
val papillae remain among 87% of older patients, al-
though to a lesser extent than in younger patients.48,49
Using the PES/WES, Vanlioğlu et al50 compared the
esthetic outcomes of maxillary anterior single-tooth
implants with metal or ceramic abutments and ceramic
crowns and found no statistically significant difference
between all-ceramic crowns with metal versus those
with ceramic abutments. Gallucci et al51 compared the
esthetic outcomes of porcelain-fused-to-ceramic and
all-ceramic single-implant crowns using the PES/WES
values. They observed no statistically significant dif-
ferences and concluded that the material chosen for
fabricating an implant crown does not guarantee an
optimal esthetic outcome if other esthetic parameters
are not favorable.
Cement-retained implant crowns can result in un-
predictable retention of cement in the soft tissues,
which can be difficult to remove and can cause swell-
ing, bleeding on probing, and marginal bone loss;
however, no case of cement-induced peri-implantitis
was observed. To prevent cement retention in the sul-
cular area, the excess cement was removed with a plas-
tic scaler. A systematic review compared the marginal
peri-implant bone loss around cement- and screw-re-
tained prostheses but revealed no greater bone loss in
cement-retained than in screw-retained prostheses.52
Although a patient’s evaluation of the esthetics
of implants is crucial in assessing the success of such
treatment, obtaining this evaluation was not possible
because of the retrospective nature of the present
study. Cho et al53 and Hof et al6 compared patients’ es-
thetic perceptions of maxillary single-tooth implants
in the esthetic zone using the subjective visual ana-
log scale with dentists’ perceptions using the objec-
tive PES/WES index. Their results showed a statistically
significant correlation between the evaluations of the
two groups. However, Fava et al54 reported that factors
(ie, magnification) other than the esthetic outcome it-
self appear to influence patients’ satisfaction with the
results. Subjective patient satisfaction with implant
esthetics is nevertheless important, and its objective
© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Vidigal et al
quantification requires further development. One limi-
tation of the present study relates to the retrospective
design. New studies evaluating the PES/WES prospec-
tively may allow capture of the long-term outcomes of
immediately placed implants with immediate provi-
sional restorations.
CONCLUSIONS
Treatment with immediately placed implants with im-
mediate provisional restoration in the anterior maxilla
showed good clinical esthetic outcomes, as assessed
by PES/WES values. In addition, the PES/WES values
showed strong intraexaminer agreement, but weak in-
terexaminer agreement.
ACKNOWLEDGMENTS
The authors reported no conflicts of interest related to this study.
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