This study was conducted in accordance with the Declaration of Helsinki on medical protocol and was approved by the Akdeniz University Ethical Review Board.

The patients rehabilitated with a single implant-supported fixed prosthesis in the maxillary esthetic zone at the departments of Oral and Maxillofacial Surgery and Prosthetic Dentistry of Akdeniz University between June 2015 and April 2017 were included in this study. Maxillary esthetic zone was considered from and including canine to canine. All patients included in the study had only one missed tooth, rehabilitated with dental implant, in the esthetic zone, and all adjacent teeth were natural (Fig. 1). Patients with parafunctional habits, multi-unit restorations, restored contralateral tooth, or acute infection at the implant region were excluded. Patients that met the criteria were recalled for an esthetic outcome evaluation and given a subjective assessment questionnaire.

Demographic information of each patient along with the details of the intraoral evaluation to assess the gingival biotype and the radiographic evaluation, and details regarding implants and surgical procedures were obtained from hospital records.

Peri-implant tissues were examined with a Williams probe to determine the inflammatory status and the peri-implant sulcus depth. Gingival biotypes were recorded and classified as thick or thin using a periodontal probe (Fig. 2). The smile lines of each patient were observed during function (i.e., talking or smiling) and categorized as low, medium or high, according to the criteria set by Tjan et al. [14]. Digital periapical radiographs were obtained using the paralleling technique and Planmeca Romexis dental imaging software (Helsinki, Finland) was used to measure the distance between implant shoulder and alveolar crest.

All patients were evaluated according to the pink esthetic score [9] which comprised the assessment of seven variables including the mesial papilla, distal papilla, soft tissue level, soft tissue contour, alveolar process deficiency, soft tissue color, and soft tissue texture (Fig. 3). Each variable was given a score of 0, 1, or 2. A score of 0 indicated the worst and a score of 2 indicated the best result for each variable, therefore the highest possible score of 14 denoted perfect peri-implant soft tissues. The threshold for clinically acceptable soft tissues was set at 8. A score of 12 or higher was accepted as almost perfect peri-implant soft tissues as previously described by Fürhauser et al. [9]