The present study was submitted and approved by the Research ethics panel of the Institution. Twenty patients were enrolled for the study. Maxillary anterior regions from canine to canine with the presence of adjacent natural teeth were included within the study. Patients with smoking habits, poor oral hygiene, parafunctional habits, multi-unit restorations, restored contralateral teeth, active oral infections, and chronic periodontitis with advanced loss of support (defined by PPD > 6mm with CAL > 4mm, radiographic evidence of bone loss, and increased tooth mobility) were excluded from the study.

This cross-sectional study evaluated 20 single-unit implants placed within the anterior maxillary region: 10 screw-retained prostheses (SP) and 10 cemented prostheses (CP). The principal investigator was blinded and each implant prosthetic crown which were already placed were randomly assigned and peri-implant soft tissue were photographed and analyzed. In each of the images , cemented or screw-retained prosthesis had to be visible for the evaluation of the peri- implant soft tissue, implant prosthesis, and therefore the contralateral tooth for comparison. PES and WES criteria introduced by Belser et al, 2009 were used for analyzing the images.

This comparative study was approved by Institutional Review Board of Rajarajeswari Dental College and Hospital, Bangalore, India ( RRDCHET/03PERIO/2020).

All patients were evaluated consistent with the pink esthetic score 5 which comprised the assessment of seven variables including the mesial papilla, distal papilla, soft tissue level, soft tissue contour, alveolar ridge deficiency, soft tissue color, and soft tissue texture [Figure 1]. Each variable is given with a score of 0, 1, or 2. A score of 0 denotes the worst and a score of 2 denotes the simplest result for every variable, therefore the very best possible score of 14 denoted perfect peri-implant soft tissues [Table 1]. The edge for clinically acceptable soft tissues was set at 8. A score of 12 or higher is accepted as almost perfect peri-implant soft tissues as previously described by Furhauser et al. 5

Figure 1

Table 1

PES
Parameters	Absent	Incomplete	Complete
Mesial papilla	0	1	2
Distal papilla	0	1	2
	Major discrepancy	Minor discrepancy	No discrepancy
Soft tissue level	0	1	2
Soft tissue contour	0	1	2
Alveolar process deficiency	0	1	2
Soft tissue colour	0	1	2
Soft tissue texture	0	1	2
Maximum total PES			14

All patients were assessed using White Esthetic Score 4 which comprised the evaluation of 5 Variables including general tooth form, tooth contour, tooth colour (hue and value, surface texture, and translucence. Each variable is given with a score of 0, 1, or 2. A score of 0 indicated the worst and a score of two indicated the simplest result for every variable. The implant-supported tooth was compared with the contralateral reference tooth to guage white esthetics [Figure 2]. A maximum score of 10 was given when the simplest mimicry of the contralateral tooth was achieved. The clinically appropriate and almost perfect implant crown thresholds were set at 6 and 9, respectively. [Table 2 ].

Figure 2

Table 2

WES
Parameters	Major discrepancy	Minor discrepancy	No discrepancy
Tooth form	0	1	2
Tooth volume / outline	0	1	2
Soft tissue level	0	1	2
Color (hue / value)	0	1	2
Surface texture	0	1	2
Translucency	0	1	2
	0	1	2
Maximum total WES			10

The statistical analysis included a descriptive and inferential characterization of the sample.

SPSS version 18 (IBM Corporation, SPSS Inc., Chicago, IL, USA) were used to analyse the Results. Results of continuous measurements were presented as Mean±SD (Min-Max) and Results of categorical measurements were presented in Frequency (Percentage). Inferential statistics just like the Mann-Whitney U test and Spearman's correlation were used. It was considered that a p - value of 0.05 was significant.

The mean PES within the CP group was 13.20 (range 11- 14, SD ±0.92) which provides an almost perfect outcome. The mean PES within the SP group was 12.50 (range 11-14, SD ±0.85 ), which also gives an almost perfect outcome. The difference between the PES in both groups was not statistically significant (p < 0.05) [Table 3, Figure 3].

Graph 1

The mean WES within the CP group was 9.50 (range 8-10, SD ±0.71), and within the SP group was 9.40 (range 8- 10. SD ±0.96). The difference between the WES in both groups was not statistically significant [Table 3, Figure 3].

Spearman's correlation test did not show any significant associations between the general mean PES or WES in both CP and SP groups (p = 0.65).

Detailed PES and WES score distribution of cemented and screw-retained prosthesis are provided in [Table 4, Table 5 and Figure 4, Figure 5].

Graph 2

Graph 3

This cross-sectional study with 20 patients showed the results of peri-implant soft tissues using PES and WES restored with screw-retained and cement-retained crowns within the maxillary anterior region. Implant restorations in the anterior aesthetic zone now focus on obtaining optimal aesthetics while also fulfilling functional rehabilitation goals. 6, 7

Pink and white esthetic scores (PES and WES) were developed to permit objective evaluation of esthetics in implant dentistry. 4, 5 PES and WES in both CP and SP groups revealed acceptable outcomes. Assessment of gingival esthetics was performed using the PES index created by Furhauser et al,5 which compares the implant to a contralateral natural tooth. The entire mean PES within the SP and CP groups showed no statistically significant differences, revealing that an esthetically satisfactory result are often obtaine`d with both sorts of prosthetic connections. Nine out of ten patients in both groups provides a mean of PES > 12, revealing 90% of the patients give almost perfect esthetic outcomes (Table 4, Figure 4). Consistent with Belser et al,4 PES scores above 60% represent a threshold of fantastic clinical acceptability. No minimum value of acceptability was established for the PES; however, the authors observed that the PES may change with time and will therefore be a useful gizmo in longitudinal monitoring of peri-implant soft tissues.

The WES leads to both the groups also showed no statistically significant differences. Ninety percentage of CP and seventy percentage of the SP group showed almost perfect outcomes (Table 5, Figure 5). This study did not show any significant correlation between PES and WES in both groups. Only a couple of studies compared esthetic outcomes of implants placed using different Protocols. 8, 9, 10 A majority of those studies compared the results of immediate implant placement (type 1) with other protocols. Type 1 and type 2 implant placement showed no difference in terms of esthetics as decribed by Huynh- Ba et al.9 Similarly, Boardman et al. observed higher PES results following implant placement, although not reached statistical significance. 8 Another analysis of patient-related outcomes of immediately loaded single implants in the anterior maxilla found no statistically relevant variations between PES and WES of implants placed immediately (type 1) and late (type 4) protocols. 10 However, there are no statistically relevant variations in PES and WES results for immediate and delayed loading protocols, according to the previous literatures.11 The type of restoration whether CP or SP did not show any difference within the esthetic outcome. However, the cemented restoration has reported the peri-implant inflammation due to overflow of cement residues resulting in peri-implant bone loss. Access hole in the cemented crowns has been able to reduce the overflow of cement residues. However due to the implant position and angulation in certain clinical situations providing access hole in the CP may not be possible. 12, 13, 14

Achieving optimum esthetics with long-term functional stability is the goal of implant therapy. The present cross-sectional study evaluated the esthetic outcome of two different types of implant prosthetic restoration. The study demonstrated that both the restoration showed no difference and achieved a favorable esthetic outcome.

PES: Pink esthetic score, WES: White esthetic score, CP: Cemented Prosthesis, SP: Screw retained prosthesis

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