Ever since the introduction of dental implants in the 1960s, they have been used worldwide with high success rates and accepted predictability [13]. Initial efforts of implant treatment mainly focused on osseointegration and function, whereas today, esthetics is also regarded as an essential component, which is commonly addressed together with functional goals of rehabilitation with dental implants [15]. In the anterior maxilla, the definition of success embodies several factors in addition to absence of pain, bleeding, or other morbidities [3].

Pink and white esthetic scores (PES and WES) were developed in an attempt to allow objective evaluation of esthetics in implant dentistry [8, 9]. However, esthetic outcomes should measure both an objective assessment by the clinician and a subjective evaluation by the patient [13]. Only a limited number of studies have previously reported on the correlation between the objective evaluation of implants placed in the esthetic zone with patient-reported outcomes [2, 10, 13, 15,16,17].

The results of this study revealed acceptable outcomes in both PES and WES analyses. The mean PES in this study was 10.7, a score that is similar to the one previously reported by Cosyn et al. and higher than those from several other studies [2, 10, 16, 18]. The WES results on the other hand revealed an almost perfect outcome with a mean of 8.6, which was similar to studies by Angkaew et al. and Beekmans et al. and higher than the ones reported by Cho et al. and Gjelvold et al. [2, 10, 15, 16]. Even though variable overall PES and WES were reported on different studies, on a clinical basis, these indices not only reveal a patient-specific objective evaluation for the esthetic outcome but may aid in record-keeping and over-time assessment of anterior implant treatment. Angkaew et al. who also used VAS to determine patients’ perception of the outcomes reported higher VAS scores than our findings, although they found acceptable but lower PES and WES values. It is noteworthy that, as in the present study, they found no significant relationship between PES/WES and VAS scores [2]. On the contrary, similar results in VAS scores were achieved by Cho et al. who reported poor PES and almost acceptable WES results with a statistically significant correlation of VAS [10]. The outcomes of this study did not reveal a significant correlation between PES/WES results and patient satisfaction, which may be attributed to subjective nature of esthetics and the incompatibility of patient perspective with what is considered as an “objectively perfect clinical result”. Therefore, when our findings are considered together with the previous literature, it can be concluded that the outcomes from objective evaluations may not always fall in line with the patients’ satisfaction levels. An implant with perfect pink and white esthetic scores may in fact prove to be unsatisfactory for the patient, which emphasizes the significance of subjective evaluation by the patient when assessing esthetic outcomes.