Background: The aim of this retrospective study was to assess soft tissue and esthetic outcomes at single-tooth immediate implants placed without flap elevation in maxillary central and lateral incisor sites. Methods: Photographic records of 85 consecutive patients with immediate single-tooth implants in maxillary central and lateral incisors that were placed without elevation of surgical flaps were selected. The change in mucosal level was expressed as a percent-age of the length of the reference central incisor. Results: Significant recession of the mesial papilla (-6.2% – 6.8%), distal papilla (-7.4% – 7.5%), and facial mucosa (-4.6% – 6.6%) between surgical place-ment and 1 year was observed (P 10% occurred at six of 25 thin biotype sites compared to two of 19 thick bio-type sites. Acceptable outcomes were achieved in the majority of sites; between 10% and 20% of sites had suboptimal esthetic results. Conclusions: Immediate implant placement with-out elevation of surgical flaps is associated with reces-sion of the marginal mucosa that may fall within the threshold of visually detectable change. The orofacial position of the implant shoulder and the tissue bio-type are important contributory factors. T he outcome of placing implants into tooth sockets immediately following extraction has been reported to be as predictable as placing implants into healed sites. 1,2 This technique is increasingly being applied to the replacement of teeth in the maxillary anterior region where esthetic outcomes are important. 3-7 However, recent stud-ies 4,7,8 reported that recession of the marginal peri-implant mucosa may occur, which, in turn, may have an adverse effect on the final esthetic outcome. Several factors have been reported to influence the frequency and extent of marginal mucosal recession, including tissue biotype, 9 connection of a provisional crown immediately following implant insertion, 10,11 condition and thickness of the facial bone, 12 orofa-cial position of the implant shoulder, 13,14 and graft-ing of the facial peri-implant marginal defect with bone or bone substitutes. 15,16 In addition to these parameters, an experimental study 17 showed that the facial socket wall, which is composed almost entirely of bundle bone, may be susceptible to resorption in the vertical and horizontal planes. This crestal bone resorption may lead to recession of the facial mar-ginal mucosa. It was suggested that disruption of the vascular supply to the facial bone by the elevation of surgical flaps might be an important contributory factor. 18-20 Thus, several investigators recommended placing implants into extraction sockets with minimal flap el-evation 21 or without elevation of surgical flaps 22 in an attempt to minimize marginal mucosal recession and to enhance esthetic outcomes. Recent studies 6,10 showed that despite these minimally invasive surgical approaches, marginal tissue recession may occur. It was proposed that increasing the thickness of the fa-cial mucosa by the addition of a connective tissue (CT) graft beneath the facial flap at the time of implant placement may reduce this risk for recession. 23 The aim of this retrospective study was to analyze the soft tissue and esthetic outcomes at single-tooth immediate implants placed without flap elevation in maxillary central and lateral incisor sites.
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