All patients were assessed according to the White Esthetic Score [8] which comprised the evaluation of five variables including general tooth form, tooth contour, tooth color (hue and value), surface texture, and translucence. 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. The implant-supported tooth was compared with the contralateral reference tooth in order to evaluate white esthetics (Fig. 4). A maximum score of 10 was given when the best mimicry of the contralateral tooth was achieved. The thresholds for a clinically acceptable or an almost perfect implant crown were set at 6 and 9 respectively.

Each patient was asked to rate their satisfaction regarding the overall implant treatment using a subjective outcome questionnaire. The questionnaire included five questions and a 10-cm visual analogue scale (VAS) labeled from 0 (worst possible result) to 10 (best possible result) to assess patient satisfaction. A mean VAS score was calculated for each patient based on their answers to the following questions.

How do you feel about the shape of your new implant tooth?

How do you feel about the color of your new implant tooth?

How do you feel about the shape of the gum that is around your new implant tooth?

How do you feel about the color of the gum that is around your new implant tooth?

What is your overall satisfaction with the new implant tooth?

Data were collected and analyzed according to the inclusion and exclusion criteria. The statistical analysis was performed using IBM–SPSS version 22.0 (IBM Corp, NY, USA). The type of statistical analysis was determined according to the normality of the data. Bivariate analysis using Spearman’s correlation test was utilized between VAS and PES, VAS and WES, and VAS and smile line. Associations between gingival biotypes and PES, and gingival biotypes and WES were studied using Mann-Whitney U test. Associations between placement protocols and PES, and placement protocols and WES were studied using Kruskal-Wallis test. A multivariate evaluation was performed using regression analyses. P values of < .05 were used to assess the significance for all statistical analyses.