RESULT
Statistical procedures
All data were entered into a computer by giving coding system, proofed for entry errors

Data obtained was compiled on a MS Office Excel Sheet (v 2019, Microsoft Redmond
Campus, Redmond, Washington, United States).

Data was subjected to statistical analysis using Statistical package for social sciences (SPSS v
26.0, IBM).

Descriptive statistics like frequencies and percentage for categorical data, Mean & SD for
numerical data has been depicted.
 Intra group comparison was done using paired t test (upto 2 observations)
 Comparison of frequencies of categories of variables with groups was done using chi
square test.
For all the statistical tests, p<0.05 was considered to be statistically significant, keeping α error at 5%
and β error at 20%, thus giving a power to the study as 80%.
* = statistically significant difference (p<0.05)
** = statistically highly significant difference (p<0.01)
# = non significant difference (p>0.05) … for all tables
Total ten patients were treated.Total n= 10 patient were included in this study. All
patients had immediate implant placement and provisionalized . All implants shows
100 % survival rate after 6 month. Mean age (Mean + SD) group of patients treated
was 24.7 + 8.27 years . (Table-1)
Six patient have thick gingival biotype and four patient have thin gingival
biotype. (Table-1)
Flap elevation and graft placement done in 30% patients.(Table 1)
according to Classifications for radial tooth root positions in anterior maxilla (Howard Gluckman)
30% patients fall in class 1,20% in class Class II B, 40% in Class III and 10% in Class V.(Table 1)
Table 1: Descriptive statistics
Independent variables
Sex
Male
Female
Gingival biotype
Thick
Thin
Flap elevation
Yes
No
Radial tooth root position classification
Class I
Class II B
Class III
Class V
Graft placement
Yes
No
Total
Age (Mean + SD)
Number
Percentage
7
3
70
30
6
4
60
40
3
7
70
30
3
2
4
1
30
20
40
10
3
7
10
70
30
100
24.7 + 8.27
SD= Standard deviation
Graph 1: Descriptive statistics
Sex distribution
30
Gingival biotype
Male
70
Female
Thick
40
60
Thin
Flap elevation
30
Radial tooth root position
classification
Class I
Yes
10
No
70
40
30
Class II B
Class III
20
Class V
Graft placement
30
Yes
No
70
Clinical Outcome
Peri Implant Bone Loss
Table 2 : showing mean & SD of numerical data
N
Minimum Maximum
Mean
Std. Deviation
Implant diameter(mm)
10
3.6
4.0
3.760
.2066
Implant length(mm)
10
12
18
16.00
2.667
value of periimplant Bone loss mesial(mm)
10
.10
.78
.2460
.20206
value of periimplant Bone loss distal(mm)
10
.10
.63
.2560
.17141
Implants used in the study were diameter (mm) of 3.76 + 0.21 (Mean + SD) and Implant length (mm)
of 16.00 + 2.66 (Mean + SD). (Table 2)
Mean mesial marginal bone loss after 6 month was 0.2460 mm with SD of 0.20
Mean distal marginal bone loss after 6 month was 0.25 with SD 0.17.
Table 3: Comparative assessment of probing depth at 3 months and 6 months follow up
Follow up
Probing depth (Mean + SD)
p-value
2.90 + 0.87
3 months
1.000
2.90 + 0.87
6 months
Test applied: Paired t test
Graph 2: Comparative assessment of probing depth at 3 months and 6 months follow up
3,5
Mean Probing Depth
3
2,9
2,9
3 months
6 months
2,5
2
1,5
1
0,5
0
Assessement of probing depth done at 3 month and 6 month which was stable during the follow-up period with
measuring (mm) 2.90 + 0.87 (Mean + SD). p-value found is 1 which is nonsignificant.
Plaque Index
Table 4: Comparative assessment of plaque index at 3 months and 6 months follow up
Follow up
Plaque index (Mean + SD)
p-value
0.22 + 0.11
3 months
0.412
0.18 + 0.08
6 months
Test applied: Paired t test
Graph 3: Comparative assessment of plaque index at 3 months and 6 months follow up
0,25
0,22
Mean Plaque index
0,2
0,18
0,15
0,1
0,05
0
3 months
6 months
3 month plaque score value shows a mean of 0.22 with SD of 0.11. p value was 0.412 which is non
significant.(Table 3)
6 month plaque score value shows a mean of 0.18 with SD of 0.08. p value is 0.412
which is non significant.(Table 3)
Bleeding On Probing Score
Table 5: Comparative assessment of bleeding on probing at 3 months and 6 months follow up
Follow up
Bleeding on Probing n (%)
p-value
3 (30)
3 months
1.000
2 (20)
6 months
Test applied: Mc Nemar’s test
Graph 4: Comparative assessment of bleeding on probing at 3 months and 6 months follow up
Percentage of subjects with bleeding
35
30
30
25
20
20
15
10
5
0
3 months
6 months
Bleeding on probing score 1 was found in 3 patients (30%) at 3 month and at 6 month in 2
patients(20%) with P-value 1 which is non significant. (Table 4)
PATIENT SATISFACTION SCORE
strongly agree n (%) of 10 (100) was found for size of tooth,color of gum,shape of
gum,strongly agree n(%) of 9 (90) was found with shape of tooth,position of tooth,
with smile, and strongly agree n(%) of 8 (80) was found with shape of tooth,implant
prosthesis appearance. (Table 5)
Table 6: Distribution of responses to patient satisfaction questionnaire
Questions
Strongly Disagree Neutral
Agree
disagree n (%)
n (%)
n (%)
n (%)
Satisfaction with color of tooth
0
0
0
2 (20)
Satisfaction with shape of tooth
0
0
0
1 (10)
Satisfaction with size of tooth
0
0
0
0
Satisfaction with position of tooth
0
0
0
1 (10)
Satisfaction with color of gum
0
0
0
0
Satisfaction with shape of gum
0
0
0
0
Satisfaction with smile
0
0
0
1 (10)
Satisfaction with Implant prosthesis
appearance in comparison with natural
0
0
0
2 (20)
tooth
Strongly
agree
n (%)
8 (80)
9 (90)
10 (100)
9 (90)
10 (100)
10 (100)
9 (90)
8 (80)
Percentage of subjects
Graph 5: Distribution of responses to patient satisfaction questionnaire
120
100
80
60
40
Strongly disagree
20
Disagree
0
Neutral
Agree
Strongly agree
Frequency Tables based on examiners
Table 7: Tooth#
Frequency
Percent
11
3
30.0
12
2
20.0
13
1
10.0
21
3
30.0
24
1
10.0
10
100.0
Total
Table 8: PES & WES based on examiner 1
PES Mesial papilla
PES Distal papilla
Height of gingival
margin
Soft tissue contour
Alveolar process
deficiency
color
Texture
WES Shape
WES volume
WES color
WES Texture
WES Translucency
and characterization
1
2
2
1
Frequency
3
7
10
1
Percent
30.0
70.0
100.0
10.0
2
1
2
0
9
1
9
1
90.0
10.0
90.0
10.0
1
2
2
2
1
2
1
2
2
2
2
2
7
10
10
1
9
2
8
10
10
10
20.0
70.0
100.0
10.0
90.0
20.0
80.0
100.0
100.0
100.0
Highest frequency (PES) found in score 2 is for distal papilla, soft tissue color,soft
tissue texture and in score 1 and 0 for alveolar process deficiency respectively given
by examiner 1.
highest frequency (WES) found in score 2 is for tooth color,texture,translucency and
characterization and in score 1 is for tooth volume respectively given by examiner 1.
Table 9: PES & WES based on examiner 2
PES Mesial papilla
PES Distal papilla
Height of gingival
margin
Soft tissue contour
Alveolar process
deficiency
color
Texture
WES Shape
WES volume
WES color
WES Texture
WES Translucency
and characterization
2
2
2
Frequency
10
10
10
Percent
100.0
100.0
100.0
1
2
1
1
9
2
10.0
90.0
20.0
2
2
2
2
2
1
2
2
2
8
10
10
10
10
2
8
10
10
80.0
100.0
100.0
100.0
100.0
20.0
80.0
100.0
100.0
Highest frequency (PES) found in score 2 is for mesial papilla,distal papilla,height of
gingival margin,soft tissue color and texture and in score 1 for alveolar process
deficiency respectively given by examiner 2.
Highest frequency (WES) found in score 2 is for tooth shape,tooth volume ,texture,
translucency and characterization and in score 1is for tooth color respectively given
by examiner 2.
Table 10: Average PES/WES by implant placement protocol
PES
WES
Variable
Mesial Papillary
Distal Papillary
Height of Gingival margin
Soft tissue contour
Alveolar process deficiency
Color
Texture
Total PES
Acceptability
Shape
Volume
Color
Texture
Translucency and Characterization
Total WES
Acceptability
Mean + SD
1.85 + 0.24
2.00 + 0.00
1.95 + 0.15
1.90 + 0.21
1.70 + 0.34
2.00 + 0.00
2.00 + 0.00
13.40 + 0.39
100%
1.95 + 0.15
1.90 + 0.21
1.90 + 0.21
2.00 + 0.00
2.00 + 0.00
9.75 + 0.35
100%
Mean PES found in present study is 13.40 + 0.39 with 100% acceptability
Mean WES found in present study is 9.75 + 0.35 with 100% acceptability
Table 11 : Inter examiner reliability for Pink Aesthetic score and White Aesthetic Score
Cronbach’s alpha
0.214
Pink Aesthetic Score
0.356
White Aesthetic Score
Inter examiner reliability found for PES and WES of Cronbach’s alpha was 0.214 and 0.356
respectively
DISCUSSION
The aim of the present study was to document the clinical, esthetic and patient
related outcome of immediately loaded and provisionalized single implant in anterior
maxilla with computer guided surgical template using socket shield technique. Total
10 patients included in present study with mean age group of 24.7(Table-1)
Table -1 also reveals the male and female ratio which was 7:3 (7 male and 3
female). six patients had thick while four patients had thin biotype. (Table -1)
The high survival rate of 100% found with present study which was similar to
other studies.8,29
Implant survival rate with immediate loading was found to be 82-98% which
was almost similar but slightly lower than the present study.39,41,42 Implant success
rates have also been reported when single implant placed in healed sites were either
immediately provisionalized8,40,43 or treated with delayed loading protocol,
44
showed
success rate of 97 %.
This suggest that when primary implant stability is achieved during surgery
and the provisional restoration is adjusted to clear all centric and eccentric contacts
,immediate implant placement with socket shield is not a variable that affect implant
success rate .
Clinical probing depth is an important and reliable diagnostic parameter in
continuous monitoring of both periodontal and peri implant tissue.45
Mean probing depth score of (highest probing depth score)obtained was 2.90
with SD of + 0.87 after 3 month (Table -3) and a mean probing depth of 2.90with SD
of 0.87 obtained after 6 month (Table-3) that was similar to study done by Huynh –Ba
et al 201640 and Baumer et al
2017.29 There was a very little change of reduced probing depth found after 6 month
compared to 3 month.Mean highest probing depth score obtained was stable during follow
up period. Independent t test showed a p value of 1.00 which was nonsignificant.(Table -3)
Guy Huynh-Ba et al in 2015 found the probing depth ranging from 2.59-3.06
mm in immediately placed implants cases which was similar to the present
study.40
Bleeding on probing found in present study was in 30% cases at 3 month
(table-5) and in 20% cases at 6 month (Table-5) that shows a decrease in bleeding on
probing on follow up. It shows absence of gingival inflammation. Similar results seen
with Baumer et al 2017, Huy- nh et al 2016, Cosyn et al 2012.29,40,60 P value of 1.00
was obtained which was non significant. (Table- 5)
There seemed to be no biological implant related complication which is
especially important around the root segment with its periodontal ligament. By
maintaining the ligament, also the amount of keratinized tissue width seemed to be
maintained as the inserting dento gingival fibers were preserved.
A mean plaque score obtained at 3 month in present study was 0.22 with SD of
0.11 (Table-4) and at 6 month 0.18 with SD of 0.08 (Table-4). Independent t-test
shows p value of 0.412 which was nonsignificant. (Table-4) Although the influence of
oral hygiene on implant success had been controversial.46,48 It is generally agree that
plaque accumulation may induce a negative mucosal response.47 This indicate that
good oral hygiene has been maintained around the implant . This essentially
eliminates one variable that could potentially affect the peri implant gingival stability
and tissue response in this study.
In the current study, periapical radiograph were used to measure the
interproximal bone at different time. An alternative could be cone beam CT;
however, it was shown that CBCT correlates poorly with interproximal bone level
than measured on periapical radiograph.49 Hardware and software of CBCT need to be
improved especially in the presence of image distorting metallic implant which causes
beam hardening effect. An important disadvantage of CBCT is the high dose exposure
comparison with periapical radiograph.50
In present study the mean bone loss at 6 month found on mesial side was 0.24
+ 0.20 (Table-2) while on distal side it was 0.25 + 0.17 (Table-2), similar to study
done by Baumer et al in 2017.29
Study done by Mari Veltrio et al in 2015 found that single tooth implant shows
a mean marginal bone loss of 0.96 mm and 0.83 mm on mesial and distal side
which was quite higher than present study. 57
Mean marginal bone loss found in study on immediate implant placement and
provisionalization by Kan et al
51
was 0.72 mm on mesial and 0.63mm on distal side
which was similar to study done by Jose et al52 showed a mean interproximal bone
loss of 0.83 ± 0.29 mm which was quite high than the present study .
Botticelli et al53 in study of immediate implant placement
and
provisionalization found a mean marginal bone loss of 0.2 ± 0.7 mm in mesial and 0.5
± 0.9mm distal side which was quite high. Bone loss on distal side was higher than
the mesial side which was similar to present study.
Less bone loss found in present study as in socket shield technique the part of
root fragment was preserved which maintain the bundle bone .Remaining bundle bone
prevent bone loss on buccal side .3
On titanium abutment without any later abutment manipulation helped to protect
the initially forming blood clot and presented as a template for soft tissue contouring of
already injured gingival.54 The presence of a glaze layer on the acrylic provisional
improved soft tissue attachment and this may be due to smooth surface of restoration with
low roughness that exhibit a least amount of bacterial adhesion.55
In delayed implant placement two stage surgeries are required. More marginal bone
loss is expected during flap reflection or punching soft tissue which will deprive the
already mineralizing bone from necessary blood supply .56 No second stage was required
in present study as immediate implant placement is done.
The esthetic outcome of the final restoration was evaluated at the 6-month followup visit using the PES/WES criteria previously defined by Belser et al. (2009).
Mean PES obtained in present study was 13.40 + 0.39 while WES is 9.75 +
0.35 Highest score of PES was found with distal papilla,color and texture while
lowest score found with alveolar process deficiency. Highest score for WES was
found with texture and translucency while lowest score was found with volume and
color.(Table-10)
Highest frequency (PES) found in score 2 is for distal papilla, soft tissue color,soft
tissue texture and in score 1 and 0 for alveolar process deficiency respectively given
by examiner 1. Highest frequency (WES) found in score 2 is for tooth
color,texture,translucency and characterization and in score 1 is for tooth volume
respectively given by examiner 1.(Table-8)
Highest frequency (PES) found in score 2 is for mesial papilla,distal papilla,height
of gingival margin,soft tissue color and texture and in score 1 for alveolar process
deficiency respectively given by examiner 2.Highest frequency (WES) found in
score 2 is for tooth shape,tooth volume ,texture, translucency and characterization
and in score 1is for tooth color respectively given by examiner 2.(Table-9)
All patients included in the study reported the 100% clinical acceptability both for
PES and WES score which is higher than the study done by Guy –Huynh-Ba et al.40
Tim De Rouck et al42 Mario –Ovetri et al,
57
Lai et al
58
and found a PES score of
10.9 for single tooth implant.
Yin –Xin et al59 found a PES score of 7.58 and WES of 7.29 in single implant placement
in anterior maxilla which was lower than the present study.
Guy –Huynh-Ba et al40 found that a similar score of PES of 6.96 and WES of 6.07±
0.38 found with immediate implant and a PES OF 6.71 and WES of 6.44± 0.46 with early
placed implant which was lower than the present study.
Flip Raes in 2012 found a mean PES of 10.3 and WES of 7.11 with the
implant placement done immediately, conventionally or grafted extracted sites which was
lower than the present study .49
Cosyn et al found a PES of 11.67 and WES of 8.63 after 6 month in immediate
implant placement and provisionalized site which was similar to present study.60
Preservation of bundle bone helps to preserve the bone height after implant
placement. The present bone level help to maintain soft tissue level at buccal as well as
interproximal area.
All patients showed 100% satisfaction with smile, shape and position of teeth and
color of gums. (Table- 32, 33) A high patient satisfaction was found in present study
similar to study done by Guy –Huynh-Ba et al. 40
.