Received: 1 July 2020 | Revised: 9 October 2020 | Accepted: 3 January 2021

DOI: 10.1111/clr.13706

ORIGINAL RESEARCH

Implant soft tissue Dehiscence coverage Esthetic Score (IDES):

A pilot within- and between-rater analysis of consistency in
objective and subjective scores

Giovanni Zucchelli1,2 | Shayan Barootchi1 | Lorenzo Tavelli1 |

Martina Stefanini2 | Giulio Rasperini3 | Hom-Lay Wang1

1
Department of Periodontics & Oral
Medicine, University of Michigan School of Abstract
Dentistry, Ann Arbor, MI, USA Objectives: To introduce an esthetic index for assessing the outcomes of peri-implant
2
Department of Biomedical and Neuromotor
soft tissue dehiscence/deficiency (PSTD) coverage and test its within- and between-
Sciences, University of Bologna, Bologna,
Italy reviewer reliability.
Materials and Methods: Photographs of 51 single PSTDs at baseline and after treat-
3
Department of Biomedical, Surgical and
Dental Sciences, University of Milan,
Foundation IRCCS Ca’ Granda Polyclinic,
ment were provided to four periodontists from three centers. The examiners were
Milan, Italy asked to rate each case at two timepoints with the Implant soft tissue Dehiscence/

Correspondence
deficiency coverage Esthetic Score (IDES) that involved the evaluation of the post-
Shayan Barootchi, Department of treatment level of the soft tissue margin, peri-implant papillae height, mucosa color,
Periodontics and Oral Medicine, University
of Michigan School of Dentistry, 1011 North
and mucosa appearance (summing up to a total score of 10). Variance components
University Avenue, Ann Arbor, MI 48109- analysis was conducted using multilevel regression fit in a Bayesian framework for
1078, USA.
Email: [email protected]
obtaining uncertainty intervals for fractional variance contributions and intraclass
correlation values (ICC) of the IDES, and for each of its four clinical variables.
Results: Regression models showed reproducible esthetic evaluation among the ex-
aminers (inter-reliability) and negligible intra-reviewer variability (assessment of the
same case at different timepoints). The ICC for the variability in the assessment of
the overall IDES was 0.86, and for the individual components ranged from 0.78 to
0.87. Additionally, there was a strong similarity between the raters’ IDES values, and
their subjective esthetic response, by the same raters.
Conclusion: The IDES showed persistent judgment among the 4 reviewers, and only
a slight intra-reviewer variability across timepoints. Within its limitations, this study
suggests that the proposed novel score can be a reliable tool for evaluating the es-
thetic outcomes of PSTD coverage, which can aid in standardization of esthetic as-
sessments following the treatment of a PSTD.

KEYWORDS

connective tissue, dental implant, esthetics, evidence-based dentistry, gingival recession,

periodontics

© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Clin Oral Impl Res. 2021;32:349–358.  wileyonlinelibrary.com/journal/clr | 349

350 | ZUCCHELLI et al.

1 | I NTRO D U C TI O N & Wang, 2010), and the pink, or white esthetic scores (Belser
et al., 2009; Furhauser et al., 2005; Zucchelli et al., 2018). These
Peri-implant soft tissue dehiscence/deficiencies (PSTD) have be- indices, however, have been suggested for evaluating the out-
come an emerging concern in the last decade. While this condition comes of implant therapy, and not the correction of an esthetic
had already been observed in the early 1990s and in the beginning complication, such as a PSTD.
of the 2000s (Bengazi et al., 1996; Small et al., 2001), it is recently In this scenario, the large number of utilized esthetic scores and
patients’ esthetic demands have increased such that even a minimal the lack of consensus and uniformity among the authors indicate
appearance of the grayish color of the implant component or an im- the need of introducing a specific Implant soft tissue Dehiscence/
plant-supported crown that is longer than its homologous contralat- deficiency coverage Esthetic Score (IDES). Therefore, the aim of
eral tooth can be considered unacceptable, especially when it comes the present study was as follows: (a) to propose a score for eval-
to the esthetic region (Roccuzzo et al., 2014; Tavelli et al., 2020; uating the esthetic outcomes following the treatment for a PSTD
Zucchelli et al., 2019). The relatively high and heterogenous inci- at single implant sites in the esthetic area, and (b) to test the intra-
dence of PSTD, ranging from 9% to 64% (Chen & Buser, 2014; and inter-rater reliability/consistency of this rubric among expert
Cosyn et al., 2012; Khzam et al., 2015; Mazzotti et al., 2018), is periodontists.
likely due to the large variety of factors that have been suggested
to be associated with this condition (Mazzotti et al., 2018; Zucchelli
et al., 2019). The bucco-palatal implant position (especially when 2 | M ATE R I A L S A N D M E TH O DS
combined with a thin soft tissue phenotype) can be one the most
significant determinants of a PSTD (Cosyn et al., 2012; Sanz-Martin 2.1 | Study design
et al., 2020; Zucchelli et al., 2019), with an odds ratio of 34 as re-
ported by Sanz-Martin et al. (2020). The current study was designed as a preliminary analysis for presen-
Several techniques have been proposed for the treatment of tation of a novel esthetic score for the objective evaluation of PTSD
PSTDs, including coronally advanced flap (CAF) or tunnel tech- coverage, and for testing the reliability of its application among ex-
nique in combination with a connective tissue graft (CTG) or other aminers from different centers, and for the same examiners between
substitutes (Anderson et al., 2014; Burkhardt et al., 2008; Happe different timepoints. For this purpose, photographs of 51 previously
et al., 2013), a prosthetic-surgical approach (Zucchelli et al., 2013, treated cases of the coverage of a PSTD were utilized.
2018; Zucchelli, Mazzotti, Mounssif, Mele, et al., 2013) or soft tis- The inclusion criteria comprised patients with at least 18 years of
sue augmentation with a submerged healing (Chu & Tarnow, 2013; age with one PSTD in the esthetic zone (from the first right premolar
Lai et al., 2010; Stefanini et al., 2020). Nonetheless, most of the to the first left premolar) that was bounded by two natural teeth.
available literature includes case reports and case series (Mazzotti The patients must have been periodontally and systemically healthy
et al., 2018; Zucchelli et al., 2019); therefore, a comparison among without any contraindications for periodontal surgery or under any
different techniques, in terms of clinical and esthetic outcomes, is medication known to interfere with periodontal/peri-implant tissue
currently not feasible. In addition, the inclusion of different types of health or healing. Also, the treated cases must have had a follow-up
PSTDs in the aforementioned studies leads to large heterogeneity in of at least 6 months. Conversely, patients who had reported smok-
their reporting of the percentage of mean or complete coverage of ing more than 10 cigarettes per day were excluded, along with im-
these defects. plants that were diagnosed with a peri-implant disease (Berglundh
Recently, our group proposed a classification of PSTD for sin- et al., 2018).
gle implant sites in the esthetic zone, with recommendation of All patients had provided their informed consent prior to the
the appropriate treatment protocols for each category (Zucchelli study, and the protocol of the study was approved by the University
et al., 2019). One of the aims behind this classification was to of Michigan Medical School Institutional Review Board (IRBMED,
provide a uniform and standardized reporting of PSTDs, to en- HUM00146261), and in accordance with the Declaration of Helsinki
hance communication among clinicians, improve research, and of 1975, revised in Tokyo in 2004. The current manuscript abides
aid in comparison of the relative efficacy of different surgical ap- by the EQUATOR guidelines Standards for Reporting Qualitative
proaches (Zucchelli et al., 2019). Nonetheless, as the treatment Research (SRQR) (O'Brien et al., 2014).
of PSTDs is mainly carried out with the aim of improving esthetic
concerns (Mazzotti et al., 2018), a specific index evaluating the
esthetic outcomes following the surgical correction of PSTDs 2.2 | The IDES
should also be set forward for properly and objectively evaluat-
ing its results. Some authors have utilized visual analogue scales The IDES was evaluated at least 6 months following the treatment
(Roccuzzo et al., 2014, 2019; Zucchelli, Mazzotti, Mounssif, Mele, of a PSTD.
et al., 2013) for evaluating the final esthetic outcomes, while oth- While weighted differently, four individual components give
ers used previously proposed indices for implant therapy, such rise to the IDES, which can range from 0 at lowest to 10 which rep-
as the complex esthetic index (Anderson et al., 2014; Juodzbalys resents the highest esthetic outcome (Table 1):
ZUCCHELLI et al. | 351

TA B L E 1 Summary of the Implant Soft Tissue Dehiscence/Deficiency coverage Esthetic Score (IDES)

Peri-Implant soft tissue Dehiscence coverage Esthetic Score (IDES)

Assigned
Parameter (points) Condition at least 6 months after treatment points

Soft Tissue Margin (STM) No improvement of the PSTD 0

(0–5) Partial coverage of the PSTD but the metallic components are still visible 1
Complete coverage of the metallic components (or abutment) only, but the implant-supported crown 2
is still longer than the homologous tooth
Complete coverage of the metallic components with the mucosal margin at the same level of the 5
homologous tooth
Peri-implant papillae height Both papillae are more apical than the healthiest papilla tip of the homologous tooth 0
(PPH) (0–3) Only one papilla is at the same level (or more coronal) of the healthiest papilla tip of the homologous 1
tooth
Both papillae are at the same level (or more coronal) of the healthiest papilla tip of the homologous 3
tooth
Peri-implant Mucosa Color Distinguishable from the adjacent soft tissue 0
(PMC) (0–1) Not distinguishable from the adjacent soft tissue 1
Peri-implant Mucosa Presence of at least one of these conditions: scar tissue, MGJ not-aligned, tissue volume too thin or 0
Appearance (PMA) (0–1) too thick compared to the adjacent soft tissue or tissue texture not similar to the adjacent soft tissue
Absence of scar tissue, MGJ well aligned, tissue volume in line with the adjacent soft tissue or tissue 1
texture similar to the adjacent soft tissue

Abbreviations: MGJ, mucogingival junction; PSTD, peri-implant soft tissue dehiscence.

1. The level of the soft tissue margin (STM). The PMC is evaluated by comparing the color of the peri-implant
2. The peri-implant papillae height (PPH). soft tissue to the adjacent soft tissues. When the PMC is distinguish-
3. The peri-implant mucosa color (PMC). able from the adjacent soft tissues, 0 is assigned (Figure 1d), while
4. The peri-implant mucosa appearance (PMA). if the PMC is not distinguishable from the adjacent tissues, 1 point
is given.
The score for the STM ranges between 0 and 5 based on the The PMA includes the evaluation of scar tissues, level of the mu-
amount of soft tissue dehiscence coverage of the PSTD that was ob- cogingival junction (MGJ), soft tissue volume, and soft tissue tex-
tained, compared to the baseline, using the homologous unrestored ture using the adjacent teeth as references. Zero point is assigned if
tooth as the reference (Mazzotti et al., 2018; Zucchelli, Mazzotti, any of the following conditions are present: scar tissue, MGJ of the
Mounssif, Mele, et al., 2013; Zucchelli et al., 2019). If the surgical treat- peri-implant soft tissue not aligned with the MGJ of the adjacent
ment after 6 months failed to reduce the vertical depth of the PSTD a teeth, soft tissue volume too thin or thick compared to the adjacent
score of 0 is assigned, while a situation with a coronal advancement of soft tissue or tissue texture not similar to the adjacent soft tissue.
the STM in a way that the depth of the PSTD is reduced (but a com- When none of these conditions is observed, 1 point is given.
plete coverage of the PSTD is not achieved) is assigned with a score Figure 1 presents the esthetic evaluation of 3 PTSDs with IDES.
of 1. Treatment resulting in a complete coverage of the metallic com-
ponents (or abutment) but the implant-supported crown is still longer
than the homologous natural tooth is given 2 points. Five points are 2.3 | Assessment of Intra- and inter-rater
attributed to situations with complete coverage of the metallic com- reliability of IDES
ponents with the soft tissue margin positioned at the same level of the
ideal gingival margin of the homologous natural tooth. Four periodontists with expertise in periodontal and peri-implant
The PPH is assessed by comparing the level of the tip of the papil- plastic surgery (L.T., M.S, G.R, and HLW) from 3 centers without
lae to the one at the homologous natural tooth. A clinical situation in previous knowledge of the treated cases or patients were asked to
which both peri-implant papillae are more apical than the healthiest participate in the study. Standardized clinical photographs (a single
papilla tip of the homologous tooth is assigned 0 points, while cases camera; Nikon D7200, Nikon Corporation) and photographer (A.R.),
with only one peri-implant papilla at the same level (or more coronal) with the same settings, and shooting protocol (perpendicular to the
of the healthiest papilla tip of the homologous tooth are given 1 point long axis of the treated implant) of all cases at pre-op (prior to the
(Figure 3). When both peri-implant papillae are at the same level (or procedure), and at a single follow-up timepoint (at least 6 months
more coronal) of the healthiest papilla tip of the homologous tooth, 3 post-op) were gathered. All clinical photographs were compiled
points are assigned. in a single document (Adobe Acrobat Pro DC for Mac©, version
352 | ZUCCHELLI et al.

(a) (b) (e)

(c) (d) (f)

F I G U R E 1 Utilization of IDES for esthetic assessment of three PSTDs (a, c, and e) for their 1-year outcomes (b, d, and f). (a) Baseline
and (b) follow-up of a case that resulted in complete coverage of the soft tissue dehiscence (STM = 5 points). White dotted lines show the
difference in the level of the soft tissue margin compared to the homologous tooth. Black arrows and dotted lines demonstrate the change
in the level of the papilla (PPH = 1 point in this case since only one papilla is at the same level of the healthiest papilla tip of the homologous
tooth). The peri-implant mucosa appearance and color are not distinguishable from the adjacent soft tissues in terms of color, texture, and
volume (PMC = 1, and PMA = 1). (c) Baseline and (d) follow-up of the second case that resulted in a complete coverage of the soft tissue
dehiscence (STM = 5 points, white dotted lines show the change in the levels of the soft tissue margin). Both papillae of the implant are
more apical to the healthiest papilla tip of the homologous tooth (black arrows) (PPH = 0). The peri-implant mucosa color is distinguishable
from the adjacent soft tissue (PMC = 0), and the peri-implant mucosa appearance is different from the adjacent sites in terms of texture
and volume (PMA 0 points). (e) Baseline and (f) 1-year results of the third cases in which a partial coverage of the soft tissue dehiscence
is obtained relative to the homologous tooth, as the soft tissue margin of the implant site is more apical to the gingival margin of the
homologous tooth (dotted white line) (STM = 2 points). The peri-implant papillae are more apical than the than the healthiest papilla tip of
the homologous tooth (black arrows) (PPH = 0 point), while PMC and PMA were not distinguishable from the adjacent sites (1 point each)

2020.009.20067, Adobe Incorporated) with no specific order to pre- observe for vast differences, or correlations between the IDES-
sent each of the pre- and post-operative images of the treated cases based objective assessment, and the initial SES.
side-by-side in a single slide, with its designated number. Meticulous
attention was paid to maintain the original standardized 1:1 ratio of
the clinical photographs, without any adjustments to the pictures 2.4 | Data and statistical analysis
(change in color, contract, brightness, etc.). The files were checked
for any distortion to the images prior to distribution to the raters. The gathered IDES responses were first descriptively assessed in
The reviewers were asked to provide their subjective esthetic terms of means per item and overall, and for crude agreement be-
evaluation (subjective esthetic score, SES) of the PTSD treatment, tween pairs of raters. Next, we used variance components analysis
on a 0 (lowest) to 10 (highest) numeric scale, without any guidance to decompose the variation in IDES values into variance contribu-
or criteria. To eliminate potential biases no other information was tions for cases, examiners, and case by examiner pairs. The analysis
provided to the raters (including the type of surgical approach/tech- was conducted using multilevel regression, fit in a Bayesian frame-
nique, or the exact follow-up timepoint [6/12 months]). work in order to facilitate construction of uncertainty intervals for
Subsequently, the examiners were instructed on the IDES rubric fractional variance contributions and intraclass correlation values.
and provided with examples of preliminary cases along with their The multilevel regression produces estimates of the variance
corresponding IDES values for clarification. Next, they were pro- explained by cases, examiners, case by examiner pairs, and the
vided with two specifically designed spreadsheets (Microsoft Excel variance that is unexplained. The case variance reflects true es-
for Mac®, version 16.23, Microsoft) and were asked to rate the thetic differences among the cases. The examiner variance re-
cases according to the IDES criteria at two different occasions (one flects systematic differences among the examiners in scale usage,
spreadsheet at a time, and with at least 1 week apart). The raters for example, if it is inflated by an examiner who consistently gives
were provided as much time as they needed to complete this task. higher scores than the others. The case by examiner variance re-
The aim was to assess the reliability and consistency of IDES flects reproducible (across the two repeated assessments) differ-
among different examiners (inter-reliability) and among the same ences in the ratings given by one reviewer to one case, that are not
examiner at different timepoints (intra-reliability). Additionally, to explained by either a systematic behavior of the rater, or by the
ZUCCHELLI et al. | 353

true esthetic score for the case. The unexplained variance reflects TA B L E 2 Characteristics of the included patients and implant
differences between the two ratings provided by one examiner sites at baseline

for one case. Characteristic Value

The intraclass correlation coefficient (ICC) was defined by divid-
Age (mean ± SD) (years) 35.86 ± 4.45
ing the variance from one source by the variance from that source
Females (n) 28
along with one or more additional sources. Most relevant here is
Smokers (less than 10 cigarettes/day) (n) 4
the variance of cases relative to the combined variance from all
Maxillary sites (n) 43
sources. It is desirable for this ICC to be high (Koo & Li, 2016; Landis
& Koch, 1977; Liljequist et al., 2019). Conversely, it is desirable for Mandibular sites (n) 8

the case by examiner variance to be small, as this reflects persistent Central incisor sites (n) 24

differences in judgments about the esthetics for the same case by Lateral incisor sites (n) 19
different raters. The variance contribution for raters should also be Canine sites (n) 2
small, as it reflects systematic differences in usage of the rating scale First premolar sites (n) 4
by different raters. All of these fractional variance contributions Second premolar sites (n) 2
were presented using a Bayesian approach to obtain 95% credible PSTD class II (n) 13
intervals (CI). PSTD class III (n) 22
Lastly, a regression approach was used to assess the relation-
PSTD class IV (n) 16
ship between the objective esthetic score (IDES as the dependent
PSTD subclass a (n) 13
variable) and the SES (independent variable) for the assessment
PSTD subclass b (n) 21
of the treated PTSDs. Similarly, random effects were included for
PSTD subclass c (n) 17
case, examiner, and case by examiner pairs. The estimated inter-
cept and slope parameters indicate the fitted relationship, and the Abbreviations: n, number; PSTD, peri-implant soft tissue dehiscence/
deficiency; SD, standard deviation.
variance parameters reflect the degree of scatter around the fitted
relationship.
TA B L E 3 Average response of the ratings by reviewers
All data analysis, distribution of cases and preparations were according to IDES at each timepoint
performed by a separate investigator (S.B) with experience in data
management and biostatistics who had not taken part in the exam- Examiner # Attempt Mean SD Range

inations. The packages lme4 (Signorell, 2019), lmerTest (Kuznetsova 1 1 8.27 2.18 2–10
et al., 2017), Rcpp (Eddelbuette, 2013; Eddelbuette & Balamuta, 2017; 2 8.16 2.20 2–10
Eddelbuette & Francois, 2011), brms (Bürkner, 2017, 2018), arm 2 1 8.13 2.04 2–10
(Wickham & Henry, 2020), tidyr (Wickham & Henry, 2020), and tidy- 2 8.45 2.14 2–10
bayes (Kay, 2020) in Rstudio (Version 1.3.959) were used for the sta- 3 1 8.23 1.96 2–10
tistical analyses. The plots were produced using the ggplot2 package
2 8.53 1.98 2–10
(Wickham, 2016).
4 1 8.63 1.93 3–10
2 8.48 1.74 3–10

3 | R E S U LT S
IDES (soft tissue margin, peri-implant papillae height, peri-implant
Fifty-one PSTDs were treated in 51 patients. Table 2 describes the mucosa color, and peri-implant mucosa appearance), as well as the
characteristics of the included patients and the treated implants. All overall IDES. All models presented with a high absolute case vari-
the interventions were performed by the same experienced operator ance conveying true esthetic differences among the treated PTSDs,
(G.Z) using CTG either with CAF (14 cases), a combined surgical-pros- and small examiner, and case by examiner variances demonstrating
thetic approach (33 cases), or with a submerged healing (four cases; minor systematic variability among raters, and reproducible esthetic
Mazzotti et al., 2018; Stefanini, Marzadori, et al., 2020; Zucchelli, evaluations (persistent judgment) of the observed cases with IDES.
Mazzotti, Mounssif, Mele, et al., 2013; Zucchelli et al., 2019). Thirteen Additionally, only a slight intra-reviewer variability between differ-
PSTDs were class II, 22 were class III, and 16 were class IV cases ent timepoints was observed across all models (between evaluation
(Zucchelli et al., 2019). attempts 1 and 2). This was demonstrated by a negligible residual
Table 3 and Figure 2 present the mean, median, SD, and range for (unexplained variance of only 2% of the total variance) that rep-
the evaluated IDES among the four examiners at both evaluation at- resents the changes between the two repeated measures (examiner
tempts. Overall, only minor discrepancies existed among the raters scores for the same case). Results of the variability in assessment
and between different timepoints for the same rater. of IDES in terms of ICC for the evaluated cases are presented in
Table 4 shows the absolute and fractional variance contribu- Table 5. As shown, a high level of agreement for evaluation of the
tions of each source in the model, and for the four components of PTSDs with IDES was observed among the reviewers.
354 | ZUCCHELLI et al.

Lastly, when testing the relationship between the raters’ objec- stable examiner effects, 5.06% attributable to examiner by case in-
tive and subjective esthetic responses (IDES vs. SES, respectively), teractions, 45.5% attributable to stable case effects, and 8.86% un-
results from the regression model showed that the estimated in- attributable. Figure 3 plots the reviewers’ final IDES evaluation and
tercept parameter was not significantly different from 0, and the the SES of the same cases at every observed value of IDES, showing
estimated slope parameter, 0.97, was nearly equal to 1, reflecting a strong similarity between the two types of scores (both on a 0–10
a near identity in the mean trend relating the two scores. The total scale) when provided by the same rater.
unexplained variance was 0.79 ± 0.88 (less than 1 point on the 0–10
rating scale). This unexplained variance was 40.5% attributable to
4 | D I S CU S S I O N

The importance of incorporating a professional esthetic evaluation

in dentistry has been extensively highlighted (Belser et al., 2009;
Cairo et al., 2009; Dueled et al., 2009; Furhauser et al., 2005; Meijer
et al., 2005; Stefanini et al., 2018). According to Stefanini et al.,
the main advantages of objective methods for evaluating esthetic
outcomes after single tooth-implant rehabilitation in the esthetic
area are as follows: (a) the possibility of assessing improvements in
patient appearance following implant therapy, (b) education of stu-
dents and/or technicians for providing certain standard and objec-
tive esthetic parameters, and (c) the comparison between different
approaches and studies in the literature (Stefanini et al., 2018).
Several esthetic scores have been proposed for evaluating the
outcomes of implant therapy, including the papilla index (Jemt, 1999),
the Pink Esthetic Score/White Esthetic score (PES/WES) (Belser
et al., 2009; Furhauser et al., 2005), the Implant Crown Aesthetic
Index (Meijer et al., 2005), the Complex Esthetic Index (Juodzbalys &
Wang, 2010), and the Copenhagen Index Score (Dueled et al., 2009).
Most of these indices focus on the outcome of implant rehabilitation
including the appearance of the implant-supported crown, using the
healthy homologous contralateral tooth and/or the adjacent teeth
as references (Benic et al., 2012; Stefanini et al., 2018). Interestingly,
there is no consensus on the most reproducible or accurate esthetic
score for describing the esthetic outcomes after rehabilitation
of a single implant site in the esthetic area (Stefanini et al., 2018;
Tettamanti et al., 2016).
F I G U R E 2 Boxplots demonstrating the reviewers’ final IDES
assessment for the PTSDs at both occasions The present article introduces a new esthetic score specifi-
cally for the treatment of PSTDs. Given their rising incidence, and

TA B L E 4 The absolute and fractional variance contributions of IDES and the 4 individual constituents of the score

Absolute variance contributions Fractional variance contributions

Case by Case by
Variable Case examiner Examiner Residual Case examiner Examiner Residual

IDES 1.95 0.66 0.17 0.27 0.86 0.21 0.009 0.002

Soft tissue margin (STM) 1.04 0.26 0.17 0.21 0.87 0.05 0.03 0.03
Peri-implant papilla height 0.88 0.45 0.08 0.05 0.78 0.20 0.01 0.002
(PPH)
Peri-implant mucosa color 0.89 0.45 0.07 0.05 0.79 0.21 0.009 0.002
(PMC)
Peri-implant mucosa 0.88 0.45 0.08 0.05 0.78 0.20 0.013 0.002
appearance (PMA)

Note: Note that the absolute variance contributions are shown as SDs, the fractional contributions are calculated from variances.
Abbreviation: IDES, Peri-Implant soft tissue Dehiscence coverage Esthetic Score.
ZUCCHELLI et al. | 355

the notion that these esthetic complications are completely differ- appreciated. Especially considering the lack of a standardized or spe-
ent from edentulous sites or hopeless teeth restored with dental cifically designed tool for their esthetic assessment has led studies
implants, the need for a novel and exclusive index can be readily reporting on PTSDs to utilize a large variety of indices with different
criteria, hence rendering a direct or indirect comparison among the
TA B L E 5 ICC results for the variability in the assessment of the studies, or the treatments almost impossible (Anderson et al., 2014;
overall IDES, and the individual components among the evaluated Roccuzzo et al., 2014; Zucchelli et al., 2018; Zucchelli, Mazzotti,
cases Mounssif, Mele, et al., 2013).
The IDES is based on the evaluation of the final position of the
95% CIs (lower–upper
Variable ICC bound) soft tissue margin compared to the homologous tooth, the height of
the peri-implant papillae, the peri-implant mucosa color, and its ap-
IDES 0.86 0.78–0.91
pearance, as it has been shown that the surgical treatment of PSTDs
Soft tissue margin (STM) 0.87 0.68–0.93
can improve these parameters (Mazzotti et al., 2018; Zucchelli
Peri-implant papilla height 0.78 0.67–0.85
et al., 2018, 2019; Zucchelli, Mazzotti, Mounssif, Marzadori,
(PPH)
et al., 2013; Zucchelli, Mazzotti, Mounssif, Mele, et al., 2013). Our
Peri-implant mucosa color 0.79 0.68–0.86
(PMC) analysis showed that the IDES is an overall objective score for evalu-
ating the esthetic outcomes of PSTD treatment among different op-
Peri-implant mucosa 0.78 0.67–0.85
appearance (PMA) erators, with an overall ICC for the final IDES of 0.86, which indicates
very high (and almost perfect) agreement (Landis & Koch, 1977). This
Abbreviations: CI, credible intervals; ICC, intraclass correlation
coefficient; IDES, Peri-Implant soft tissue Dehiscence coverage Esthetic result is in line with the ICC reported by previous studies in peri-
Score. odontal plastic surgery assessing the reliability of new methods for

F I G U R E 3 Comparison between
reviewers’ objective evaluation of treated
PTSDs with IDES and their subjective
esthetic scores (SES) for all cases. The
Loess curve (dark blue line) shows the
estimated conditional mean relationship
between the two scores
356 | ZUCCHELLI et al.

classifying gingival recessions (Cairo et al., 2011), or a new index for clinicians. Also, given the current pilot study design, we deem neces-
assessing root coverage esthetic outcomes (Cairo et al., 2010; Isaia sary future investigations with a larger number of examiners, as well
et al., 2018). as assessments by less experienced audience to test the consistency
The highest ICC among the four IDES parameters was obtained in ratings with the IDES, and indeed the relationship with a subjective
by the STM (0.87). It is reasonable to assume that a partial coverage approach.
of the PSTD can be easily identifiable, particularly when the metallic
component is still visible or with the implant-supported crown still lon-
ger than the homologous tooth. Thus, leading to less variability in the 5 | CO N C LU S I O N S
assessment of this component and its scoring. Additionally, only a slight
intra-reviewer variability between different timepoints was observed The present article introduces a novel esthetic score for evaluating
among the same examiners, further corroborating the reproducibility the outcomes of the treatment of PSTDs. A high level of agreement
of the IDES. for evaluating the treatment of PSTDs was observed with IDES
Similar to the root coverage esthetic score for natural teeth among examiners, and within the same examiner between different
(Cairo et al., 2009), the final IDES is largely dependent upon the timepoints. These results, together with a strong correlation found
STM (5 points out of 10). This highlights the negative impact of a between the final IDES and the subjective esthetic assessments,
partial coverage, and the exposure of the metallic components, suggest that the proposed IDES is a reliable tool for evaluating the
or a longer implant-supported crown on the esthetic outcomes esthetic outcomes of PSTD coverage. This newly introduced system
of the treatment (Roccuzzo et al., 2014; Zucchelli et al., 2019). can aid in standardization of esthetic assessments following the
Additionally, the present esthetic score emphasizes the impor- treatment of PSTDs and encourage the incorporation of clinical and
tance of the level of the interproximal soft tissues/peri-implant esthetic outcomes.
papillae (3 out of 10 points), as shallow papillae that give rise to
“black triangles” are frequent findings at implant sites that lead to AC K N OW L E D G E M E N T S
compromised esthetics (Stefanini, Marzadori, et al., 2020; Urban The authors would like to express their gratitude to Prof. Kerby
et al., 2016). It has been shown that during the treatment of a Sheddan (Department of Biostatistics, University of Michigan, Ann
PTSD, along with improvement in the level of the STM, the im- Arbor) for his valuable feedback and guidance on the statistical
plant papillae can also be augmented, even at sites with periodon- methods, as well as Alexandra Rendon for serving as the photogra-
tal attachment loss on the adjacent teeth (Stefanini, Marzadori, pher in this study, and Claudio Mazzotti for their valued assistance.
et al., 2020). The authors declare no potential conflict of interest with respect
Another important finding from our analysis was the strong to the publication of this article, or any of the materials utilized
correlation between the SES and the final IDES in all examiners. throughout the study.
This result suggests that the IDES may be a valid alternative to
subjective esthetic assessment among periodontists, with the AU T H O R S ’ C O N T R I B U T I O N
advantage of providing an esthetic evaluation for each individual G. Z involved in contribution to the study design, provided all clin-
parameter of interest at the same time. This can be very bene- ical aspects of the work, gave final approval of the version to be
ficial when comparing different surgical techniques or grafting published with critical manuscript reviewal, and accountable for all
materials. aspects of the work. S. B involved in conception and design of the
The present study, despite bearing the advantage of having a study; analysis and interpretation of data; initial and final drafting
large sample of treated cases, and all by a single experienced op- of the work; final approval of the version to be published, account-
erator, may inadvertently also carry a limitation as a result of these able for all aspects of the work. L. T involved in design of the study,
components. We emphasize that all the treated cases had been per- served as an examiner, manuscript preparation and the initial draft,
formed by an expert clinician and involved the use of a CTG. While final reviewal of the work, accountable for all aspects of the work.
the importance of an experienced surgeon in treatment of PTSDs M. S and G. R served as an examiner, manuscript preparation and the
cannot be overstated, with regard to the use of a CTG, indeed its initial draft, final reviewal of the work, accountable for all aspects
properties of enhancing blood clot, flap stability, increasing kerati- of the work. H-L.W involved in design of the study, critical review
nized tissue width/soft tissue thickness, and the possibility of creep- of the draft of the manuscript, served as one of the 4 case examin-
ing attachment (Tavelli et al., 2019, 2020) have rendered it the gold ers, final review and approval of the work and accountable for all
standard for root coverage (Barootchi et al., 2019, 2020; Mazzotti aspects.
et al., 2018; Zucchelli et al., 2019). Therefore, future studies are
needed for further validation of IDES, including different flap de- ORCID
signs (e.g., the tunnel approach; Aroca et al., 2013; Tavelli et al., 2018; Shayan Barootchi https://orcid.org/0000-0002-5347-6577
Zuhr et al., 2014) and grafting materials (e.g., acellular dermal or col- Lorenzo Tavelli https://orcid.org/0000-0003-4864-3964
lagen matrices; Barootchi, Tavelli, Gianfilippo, et al., 2020; Stefanini, Martina Stefanini https://orcid.org/0000-0002-9154-637X
Mounssif, et al., 2020), as well as execution by less proficient Hom-Lay Wang https://orcid.org/0000-0003-4238-1799
ZUCCHELLI et al. | 357

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