Muhammet Bahattin Bingül(1), Belgin Gülsün(2)
1Harran University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Şanlıurfa
2Dicle University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Diyarbakır
SUMMARY
OBJECTIVE: In our study, to reveal the effect of different implant
surfaces on gingival tissues with PES and BES.
MATERIAL AND METHOD: A total of 117 dental implants were followed clinically. Gingival index (loe-silness), PES (Pink Aesthetic Score) and WES (White Aesthetic Score) values were evaluated, recorded 1 week after the healing head was placed, 3, 6 and 12 months after the end of the prosthesis. The data were analyzed with IBM SPSS Statistics Version 22 package program.
RESULTS: There is no statistically significant difference between the groups in terms of gingival index values (p> 0.05). While there was no statistically significant difference between the times in terms of gingival index values in the micro-roughened surface group (p> 0.05), there was a statistically significant difference between the times in terms of gingival index values in the nano laser excimer technology group (p <0.05). There was no statistically significant difference between the groups in terms of total PES values at all times (p> 0.05), but there was an increase in PES values in both groups over time. In the nano laser excimer technology group, although no statistically significant difference was found between times in terms of total WES values, a statistically significant difference was found between the times in terms of total WES values in the micro- roughened surface group (p <0.05).
CONCLUSION: In our study, it was concluded that the surface properties of dental implants used missing dental rehabilitation have effect on marginal tissues.
Keywords: Dental implant, PES, WES. INTRODUCTION
Since dental implants are biocompatible materials, their use in dentistry has become widespread in order to regain function and aesthetics in missing teeth rehabilitation (1). The healing processes begin with the placement of dental implants produced from the titanium element by modifying the shape and surface properties of the alveolar bone. Following the initial resorption in the surrounding bone, new bone tissue formation and mineralization occurs around the implant in about 3/6 months. This period is the "osseointegration" process of the implant. If this period is completed without any problems, prosthetic treatments of dental implants are performed (2).
To be able to evaluate an implant as successful, it must be clinically non-mobile and osseointegrated. The concept of osseointegration is a histological term and has been defined by Branemark and his colleagues as "direct structural and functional connection between the living bone tissue and the implant surface under loading" (3, 4).
Since implants compensate for tooth loss, dental implants made of various materials, with many different designs and surface properties have been put on the market (5). This is important in order to be able to compare the results of clinical studies on different implants and to evaluate the success of the treatment. Undoubtedly, in order to show the accuracy and success of the data obtained as a result of these scientific researches, objective and evidence-based information is required (6).
The density or quality of the existing bone in the areas of tooth loss, implant design and surface features, treatment protocol, surgical
approach options, are among the factors that determine the healing time and loading during the prosthetic phase (7).
Another issue that is closely related to patient satisfaction in dental implant applications in recent years is aesthetics. As a result of the treatment, patients should be aesthetically satisfied. Therefore, Pink Aesthetic Score / White Aesthetic Score (PES / BES, Pink Esthetic Score / White Esthetic Score, PES / WES) data have been used more frequently in recent years (8). Fürhauser et al. Stated that when evaluating the aesthetics of single-tooth implants, it is not sufficient to evaluate only the gingival papillae, but also the soft tissue color, contour, surface feature and marginal gingival level (9). In this study, we aim to reveal the effect of different implant surfaces on gingival tissues with PES and BES values.
MATERIAL AND METHOD
Our research was supported by Dicle University Scientific Research Projects Coordinator with the project number DİŞ.17.025. Before starting this study, ethics committee approval was obtained from Dicle University Faculty of Dentistry Local Ethics Committee with the protocol number 2017/11 dated 31.05.2017.
The study groups consisted of individuals in Dicle University Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, where 2 different dental implant models with micro-roughened surface feature with nano laser excimer technology were applied. A total of 117 dental implants were placed in these individuals.
The parameters we use in our research; The data were gingival index (loe-silness), Pink Aesthetic Score / White Aesthetic Score (PES / BES, Pink Esthetic Score / White Esthetic Score, PES / WES) data. These parameters were evaluated 1 week after the healing cap was put on, 3 months, 6 months and 12 months after the end of the prosthesis.
Material Used
In this study, 2 different implant models with nano laser excimer technology (Biohorizons®, Bone Level, USA) and micro-roughened surface properties (Zimmer®, Bone Level, Germany) were used.
Treatment Procedure
Panoramic and periapical x-rays were taken from the patients before the procedure in order to make appropriate treatment. In addition, patients were informed extensively possible complications before implant application.
Clinical Follow-up
Gingival Index (Silness and Löe)
This index system was developed in 1963 by Silness and Löe. The main sign of inflammation in the system is bleeding. It is determined by giving values to the gums in the mesial, distal, vestibule and lingual of the teeth according to the edema and bleeding status. These values are then summed and divided by four. These measurements were made with the aid of a periodontal probe (Hu-Friedy®). In this way, gingival index is calculated.
0: Healthy gums, no inflammation.
1: There is mild inflammation, discoloration and mild edema in the
gums, there is no bleeding in the peeling.
2: There is moderate inflammation, edema and redness in the gums, there is bleeding at the end.
3: There is severe inflammation, edema and redness in the gums, there is spontaneous bleeding.
Criteria Recorded When Evaluating Peri-Implant Aesthetics
While determining the score according to PES, 7 criteria out of the photographs are evaluated as 0-1-2:
•Mesial and distal papillae: 0 = no papillae, 1 = no papillary filling, 2 = complete papillary filling
• Soft tissue level: 0 = There is> 2mm difference with natural teeth, 1 = There is 1-2 mm difference with natural teeth, 2 = <1mm difference with natural teeth.
•Soft tissue contour: 0 = Unnatural contour, 1 = Quite natural contour, 2 = Natural contour
• Alveolar process: 0 = Significant insufficiency compared to natural tooth, 1 = Mild insufficiency, 2 = No difference
•Soft tissue color: 0 = Significant difference compared to natural teeth, 1 = Slight difference, 2 = No difference
•Soft tissue surface structure: 0 = Significant difference compared to natural teeth, 1 = Slight difference, 2 = No difference
BES, on the other hand, examines 5 basic criteria that should be considered when evaluating the aesthetics of conventional fixed restorations, which are based on implant restorations. The criteria are calculated over 10 points, and having 6 points or more indicates an acceptable aesthetic.
•Crown form: 0 = Significant difference with natural teeth, 1 = Slight difference, 2 = No difference
•Crown contour / volume: 0 = Significant difference with natural tooth, 1 = Slight difference, 2 = No difference
• Crown color: 0 = Significant difference with natural teeth, 1 = Slight difference, 2 = No difference
•Crown surface structure: 0 = Significant difference with natural teeth, 1 = Slight difference, 2 = No difference
•Crown translucency and characterization: 0 = Significant difference with natural tooth, 1 = Slight difference, 2 = No difference
Statistical Analysis
The data obtained in this study were analyzed with IBM SPSS Statistics Version 22 package program. Shapiro Wilk's was used while investigating the status of variables coming from normal distribution.
Mann Whitney U Test was used to examine the differences between groups. While examining the relationships between groups of nominal variables, Chi-Square analysis was applied. Kappa Fit analysis was applied to measure the fit between dependent nominal variables. 0.05 was used as the significance level while interpreting the results; It was stated that there is a significant relationship when p <0.05, and there is no significant relationship when p> 0.05.
RESULTS
There was no loss in the implants included in the study, but complications occurred in 4 out of 59 implants in the nano laser excimer technology group. All of the complications that occurred were periimplantitis. Complications developed in 6 out of 58 implants in the micro-roughened surface group. Soft tissue loss developed in 4 of these 6 implants and free gingiva graft operation was applied to these patients. There was an abutment fracture in one of the other implants, and a prosthesis fracture in the other.
There is no statistically significant difference between the groups (micro-roughened surface and nano laser excimer technology) in terms of gingival index values (p> 0.05) (Figure-1).
There is no statistically significant difference between the times in terms of gingival index values in the micro-roughened surface group (p> 0.05) (Figure-2).
There is a statistically significant difference between times in terms of gingival index values in the nano laser excimer technology group (p <0.05). In the nano laser excimer technology group, gingival index 12 month value is significantly lower than gingival index 0 month and gingival index 3 month value (Figure-2).
There is no statistically significant difference between the micro- roughened surface and the nano laser excimer technology surface in terms of the total pink aesthetic score values at all times (p> 0.05) (Figure-3).
There is a statistically significant difference between the times in terms of total pink aesthetic score values in the micro-roughened surface and nano laser excimer technology group (p <0.05). In the micro-roughened surface group, the total pink aesthetic score at 3 months and 6 months was significantly lower than the 12 month value. In the nano laser excimer technology group, the total pink aesthetic score was significantly lower than the 0th month value compared to the 6th and 12th month values (Figure-4). It is seen that PES scores increase over time in both groups.
A statistically significant difference was found between micro- roughened surface and nano laser excimer technology in terms of total white aesthetic score values at all times (0, 3, 6, and 12 months) (p <0.05). The BES scores of dental implants with nano laser excimer technology are higher at all times than the micro-roughened surface group (Figure-5).
Although there is no statistically significant difference between times in terms of total white aesthetic score values in the nano laser excimer technology group (p> 0.05), there is a statistically significant difference between times in terms of total white aesthetic score values in the micro-roughened surface group (p <0, 05). In the micro- roughened surface group, the total white aesthetic score was significantly lower than the 0th month value compared to the 6th and 12th month values (Figure-6).
DISCUSSION
Due to the high success rate, the use of dental implants in dentistry has increased and therefore many implant systems have been developed. In order to receive long years of service from dental implants, it is necessary to perform routine controls. In order to be able to treat any
adverse events in the early period, the patient should be kept under control by using all kinds of clinical and radiological diagnostic methods (10). In our study, we also followed up patients at regular intervals.
In our study, we did not experience implant loss in both nano laser excimer technology and dental implants with micro-roughened surfaces. Among the implant surface preparation methods, there are studies reporting that morphological methods are more successful than physico-chemical methods (11).
In their retrospective study by Halperin-Sternfeld et al, in which they examined the effect of vestibular depth on peri-implanter parameters, they used Loe & Silness and periodontal probe (Hu-Friedy®) for gingival index (12). In our study, we used Loe & Silness scoring for gingival index and Hu-Friedy® as periodontal probe in accordance with the literature. Gültekin et al. Compared 56 dental implants with neck design features and 47 dental implants with nano laser excimer technology neck design, and recorded the gingival index values in the 12th, 24th and 36th month periods. After three years of study, they could not find a significant difference between the groups in terms of gingival index values. They explained this situation with oral hygiene control (13). Similar results have emerged in our study. We believe that oral hygiene motivation and routine periodic controls set the ground for this situation.
In a study followed for 5 years, they found that gingival index values decreased until the 2nd year, while these values increased in the following years. Researchers have suggested that oral care motivation and diet may cause this condition (14). In our study; No statistically significant difference was found between the groups in terms of gingival index values (p> 0.05). In obtaining similar results in both groups; We attribute the effectiveness of routine control appointments to short intervals and increasing patient motivation at each check-up.
Although there was no statistically significant difference between times in terms of gingival index values in the MTX surface group (p> 0.05), a statistically significant difference was found between times in terms of gingival index values in the nano laser excimer technology group (p <0.05). In the nano laser excimer technology group, the gingival index is significantly lower than the 12th month (0.28 ± 0.28), 0th month (0.47 ± 0.44) and 3rd month (0.44 ± 0.38) values. While the MTX surface in dental implants in the micro-roughened surface group only increases bone apposition, we believe that such a result is obtained because the micro cavities in the implants with nano laser excimer technology restrict the migration of the gingival tissues to the apical. Because dental implants with nano laser excimer technology have a design that is roughened with 0.7 mm long 8 microns in the middle of the neck area and aims to create a gingival attachment. Thus, we think that the collagen fibers found in natural teeth will act as an epithelial barrier in dental implants with nano laser excimer technology, and plaque accumulation will be prevented from going deeper.
As a result of the treatment, patients should be aesthetically satisfied. Therefore, Pink Aesthetic Score / White Aesthetic Score (PES / BES, Pink Esthetic Score / White Esthetic Score, PES / WES) data have been used more frequently in recent years (15).
In accordance with the reviewed literature, dental implants; Crown surface structure, color, soft tissue contour, exit profile, papilla filling, compatibility of the restoration with neighboring and contralateral teeth are among the important factors in terms of aesthetics. In 2005, a newly defined PES test was found for soft tissue evaluations in the periimplanter area. In this study, the authors argued that PES is an appropriate method for evaluating the soft tissues of implant restorations (9).
In our study, no statistically significant difference was found between micro-roughened surface and nano laser excimer technology in terms of total PES at all times (p> 0.05). In the micro-roughened surface group, the PES value in the 0th month was 8.71 ± 1.08, the PES value
in the 3rd month was 8.61 ± 1.1, the 6th month PES value was 8.89 ± 1.23, the 12th month PES value was 9.11 ± 1.29; In the group of nano laser excimer technology, we found these values as 8.63 ± 1.45, 8.89 ± 1.40, 9.04 ± 1.43, 9.04 ± 1.43, respectively. However, a statistically significant difference was found in terms of total pink aesthetic score values between dental implants with micro-roughened surface and nano laser excimer technology (p <0.05). In addition, an increase in PES scores was observed in both groups over time. In a study by Belser; The PES and BES scores were evaluated at an acceptable level, and the reason for this was explained by the choice of implant with ideal design to protect bone tissues during surgical application (15). In parallel with the work of the researcher named Belser, we can achieve acceptable PES values; We can interpret it as applying gingival-sparing surgical techniques, determining the correct implant loading time and choosing the correct implant surface.
The researcher named Cosyn suggested that the amount of buccal bone may cause changes in PES values (16). The increase in PES scores over time in both groups can be explained by the fact that crestal bone resorption remains at the physiological limit, and thus soft tissue migration does not shift to the apical. In other words, more aesthetic results have been found in soft tissue with bone support. In addition, we can interpret this situation as the feature of the dental implants we prefer to create periodontal attachments or systems that can protect this attachment. On the other hand, we think that the geometric structure of dental implants may also affect the amount of bone remaining in the buccal region, because we believe that the amount of buccal bone may cause changes in the PES values, in line with the study of the researcher named Cosyn.
Guarnieri et al., In a study in which they evaluated 46 laser-lok (Biohorizons®, Bone Level, USA) implants, found the total PES and BES values as 12.25 and 8.81, respectively. In addition, they argued that the acceptable PES values were 8-11 and the BES values were 6- 8, as a result of the studies they examined (17).
In our study, there was a statistically significant difference between the groups in terms of BES values at all times (p <0.05). ± 1.27, and the BES value at the 12th month was 5.75 ± 1.27; In the group of nano laser excimer technology, we found these values as 6.70 ± 1.32, 6.70 ± 1.32, 6.67 ± 1.30, 6.67 ± 1.30, respectively. In line with the literature, we can interpret our results as an acceptable value since the BES scores of dental implants with nano laser excimer technology are in the range of 6-8, but the BES scores in the micro-roughened surface group are below
6. BES scores of dental implants with nano laser excimer technology are higher than MTX surface group at all times. We think that laser microwaves in dental implants with nano laser excimer technology affect the alignment of fibroblasts and consequently position the connective tissue at the ideal point for restorations. Due to this positive development in soft tissue, we can say that better restorations are made. Although there was no statistically significant difference between times in terms of BES values in the nano laser excimer technology group, there was a statistically significant difference between times in terms of total BES values in the MTX surface group (p <0.05). In the dental implant group with MTX surface, the increasing BES score value over time may be more compatible with natural teeth depending on the color selection of the restorations, and the periodontal or endodontic origin of the tooth extracted from the dental implant application area may also be affected.
CONCLUSION
Patients who have undergone dental implant treatment do not want to worry about long-term function and aesthetics. We found that the surface properties of the dental implant materials used in the rehabilitation of tooth deficiencies can affect the marginal tissues as well as the aesthetics of dental implant rehabilitation.