Implant aesthetics: beyond survival, the challenge of a natural result

Today, osseointegration and implant survival have become predictable in the maxillary aesthetic zone. Clinical success is no longer defined solely by mechanical stability, but by biological integration and soft tissue harmony. While the original Pink Esthetic Score (PES) remains the reference tool with its 7 parameters (mesial/distal papillae, level, curvature, alveolar process deficiency, colour and texture, scored on a 0-1-2 scale for a maximum of 14), it suffers from a major limitation: an exclusively frontal analysis that neglects the three-dimensional dimension of the emergence profile and the impact of mucosal scars.

This observational study, conducted on 30 maxillary single-tooth restorations followed for at least one year, introduces and evaluates the Extended Pink Esthetic Score (E-PES). The specific objective is to determine whether this new framework, integrating two additional clinical parameters (emergence profile and mucosal healing) and a multidirectional photographic protocol (frontal, profile, and occlusal views), provides a more comprehensive and reproducible aesthetic assessment.

The authors test the hypothesis that a multidirectional evaluation provides relevant clinical information masked by the standard frontal view, while maintaining the simplicity and reproducibility necessary for daily practice.

Study design and framework

This multidirectional observational clinical study evaluated the performance and behavior of the E-PES (Extended Pink Esthetic Score). The objective was to compare the reproducibility and clinical relevance of a three-dimensional evaluation compared to the conventional PES score.

Sampling and selection criteria

The study included 30 single implant restorations stabilized in the maxillary aesthetic zone. The inclusion criteria were as follows:

• Implant restorations in place for at least one year at the time of evaluation.
• Exclusive localization in the maxillary aesthetic zone.
• Use of purposive sampling to cover a wide spectrum of aesthetic outcomes, from optimal success to compromised cases.
• Exclusion of multiple adjacent implants and iconographic records of insufficient quality.

Photographic and experimental protocol

Data acquisition was based on a standardized multidirectional photographic protocol using a Canon EOS 600D camera body equipped with a Macro Ring Lite MR-14EX II flash system. Three views were systematically captured for each case:

• Frontal view (used for the original PES and the E-PES).
• Profile view (specific to E-PES).
• Occlusal view (specific to E-PES).

Analysis parameters

The protocol compared the classic PES (7 variables scored from 0 to 2) to the E-PES. The latter retains the original variables and adds two critical clinical parameters: the emergence profile and mucosal healing (scarring). The study was approved by the ethics committee of the Faculty of Dental Medicine at Cairo University (Approval No. 29-2-23).

Structure and parameters of the E-PES

The study introduces the Extended Pink Esthetic Score (E-PES), an evolution of the classic PES (7 parameters, maximum 14 points) aimed at overcoming the limitations of single frontal evaluation. The E-PES framework integrates two additional clinical variables for a more comprehensive assessment:

• Emergence profile: evaluation of the transition between the restoration and the mucosa.
• Mucosal healing: consideration of fibrosis lines, tissue contractions and alterations in texture/color related to scars.

The scoring system maintains the 0-1-2 ordinal scale for each variable. Unlike the original PES limited to the frontal view, the E-PES is based on a standardized multidirectional photographic protocol including frontal, profile, and occlusal views.

Methodology of the preliminary evaluation

The observational study included a sample of 30 single implant restorations in the anterior maxilla. The inclusion criteria and technical protocol were as follows:

Parameter	Protocol details
Sample	30 single implant restorations (maxillary aesthetic zone)
Clinical feedback	Minimum 1 year after the placement of the final restoration
Photography equipment	Canon EOS 600D with Canon Macro Ring Lite MR-14EX II flash system
Photographic views	Frontal (PES), Frontal + Profile + Occlusal (E-PES)

The primary objective of this experimental setup is to determine whether the addition of profile and occlusal views, combined with emergence profile and healing scores, provides reproducible and relevant clinical information that the frontal view alone might camouflage (notably vestibulo-lingual contour deficiencies or ridge collapse).

The transition to 3D: overcoming the blind spots of classic PES

The omnipresence of the original Pink Esthetic Score (PES) in implantology masks a frustrating clinical reality: its unidirectional evaluation. This study highlights that the frontal view alone creates an illusion of aesthetic success, camouflaging ridge collapses, losses of cervical convexity, or buccal volume deficiencies. For the practitioner, the challenge is no longer just osseointegration, but a three-dimensional biological and functional integration. The introduction of the E-PES (Extended Pink Esthetic Score) aims precisely to break with this 2D approach by imposing a multidirectional photographic protocol including frontal, profile, and occlusal views.

Emergence and scarring: the forgotten variables

The originality of the E-PES lies in the addition of two critical parameters: the emergence profile and mucosal scar tissue. In the practice, we know that the transition between the restoration and the peri-implant mucosa is the pillar of natural aesthetics. However, the classic PES ignores this aspect, just as it neglects fibrous bands or tissue contractions related to scars. By integrating these variables, this new assessment framework forces a more honest analysis of clinical results, where a perfect papilla is no longer sufficient if the restoration profile betrays its artificial nature.

A rigorous methodology for a preliminary assessment

This observational study focused on 30 maxillary single-unit restorations, evaluated at least one year after placement. The use of standardized equipment (Canon EOS 600D, Macro Ring Lite MR-14EX II) ensures image reproducibility, a key element for validating the E-PES score. Although the sample size remains modest (n=30) and derived from targeted sampling, this preliminary approach allows testing whether the addition of multidirectional views provides real clinical information without compromising the ease of use of the original score.

Conclusion

The E-PES transforms an often complacent aesthetic scoring into a more demanding diagnostic tool. By increasing from seven to nine variables, it captures the nuances of tissue relief often invisible on a classic photograph.

Study summary

This observational study conducted on 30 maxillary single-unit restorations at Cairo University introduces the E-PES (Extended Pink Esthetic Score). By increasing from 7 to 9 variables with the addition of emergence profile and mucosal healing, this new framework uses a multidirectional photographic protocol (frontal, profile, occlusal) to correct the blind spots of conventional frontal evaluation.

In concrete terms, for the practitioner:

• Go beyond the frontal view: Systematically adopt a photographic triplet (frontal, profile, occlusal) during your assessments. The profile view reveals vestibular volume deficiencies or unsuitable emergence profiles that a frontal photo systematically conceals.
• Scan soft tissues in 3D: Specifically evaluate cervical convexity and the absence of scar fibrosis lines. These parameters, integrated into the E-PES, impact the patient's final aesthetic perception as much as the presence of papillae.
• Objectify the prosthetic transition: No longer judge based solely on tissue height. Integrate the quality of the transition between the implant and the mucosa (emergence profile) as a major biological and aesthetic success criterion in the aesthetic zone.

In the maxillary aesthetic zone, osseointegration is no longer the sole barometer of success. For the practitioner, patient satisfaction now relies on a complex equation blending mucosal harmony, presence of papillae, and a natural emergence profile. While the Pink Esthetic Score (PES) has established itself as the reference tool since 2005, this study highlights its blind spots: an almost exclusively frontal approach that can mask ridge collapses or unsuitable emergence profiles.

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