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Journal of Oral Science & Rehabilitation Volume 2 | Issue 3/2016 21 H a r d - a n d s o f t - t i s s u e c h a n g e s w i t h a s u p e r i m p o s i t i o n t e c h n i q u e Introduction Esthetic outcomes and patient satisfaction have become the main focus of interest in esthetical- lysensitiveareas.1,2 Thelevelandthicknessofthe soft tissue, as well as its color and texture, are decisive for the natural appearance of an implant-supported restoration.3 Over the last 20 years, the evaluation of the success oftooth- and implant-supported resto- rations has shifted from judging only the survi- val rate of the restoration itself to additionally assessingwhetheran esthetic appearance simi- lar to the adjacent teeth has been achieved. Today,themainconcerniswhetherthesurround- ingbonearchitectureandsoft-tissuetextureand color can precisely and biomimetically emulate nature.4 Assessment of esthetically successful treatment outcomes is validated clinically by several objective periodontal and esthetic para- meters.5–7 However, there is still a lack ofclinical comparative studies in the current literature regarding objective outcome evaluation from an esthetic perspective.8–13 In 2004, the InternationalTeam for Implant- ology presented a treatment guide to provide clinicians with practical and evidence-based clinical instructions for implant restorations in the esthetic zone.14 Successfultissue integration and pleasing esthetic outcomes after the appli- cation of this treatment protocol have been re- ported in retrospective15 and prospective16 case series studies. Jemt proposed an index, termed the Papilla Index, to assess the size and volume of the interproximal papillae adjacent to a single tooth. The index defines five distinct levels, ranging from the complete absence of papillarytissue (index score of0)to hyperplastic papillae (index score of 4).17 Meijer et al. publis- hed the Implant Crown Aesthetic Index, which stipulates criteria related to the implant restor- ation itself and those associated with the sur- rounding soft tissue.5 Fürhauser et al. proposed an index, termed the Pink Esthetic Score (PES), focusing essentially on the soft-tissue aspects associated with an anterior single implant- supported restoration.6 Seven distinct soft- tissue parameters are considered: the presence orabsence ofmesial and distal papillae,the level and curvature of the line of emergence of the implant restoration from the mucosa at the facial aspect, the facial soft-tissue convexity (in analogy to a root eminence), and the color and texture of the facial marginal periimplant mucosa. Each parameter score can range from 0 to 2, which results in a maximum score of 14. Finally, Belser et al. proposed a five-variable in- dex, termed the White Esthetic Score (WES), focusing on thevisible part ofthe implant resto- ration itself and usable in combination with the previously reported PES.15 The aim ofthis prospective case series study was to propose a novel comprehensive method using digitized model casts and a superimpos- ition technique to allow an objective evaluation ofthe hard- and soft-tissue parameters for both tooth- and implant-supported restorations. Materials and methods Any patients requiring all-ceramic restoration of the anterior maxillary teeth were recruited and treated betweenJanuary2014 and Decem- ber 2014. All of the patients were treated in a private dental center in Rome, Italy, bythe same clinician (EX). No inclusion or exclusion criteria were considered. Initial photographs and radio- graphs were taken (Fig. 1). Diagnostic casts were obtained from polyvinyl siloxane impres- sions (Aquasil Putty DECA and Aquasil Ultra LV/ XLV Regular Set, DENTSPLY International, Mil- ford, Del., U.S.) taken with customized light- curing acrylic impression trays (Elite LC Tray, Zhermack, Badia Polesine, Italy) fabricated from preliminary casts. A diagnostic wax-up was performed (Fig. 2) and used to fabricate a sili- cone guide. Acrylic duplication of the wax-up was performed directly in the patient’s mouth, using the silicone guide (direct mock-up; Fig. 3) in orderto test the function and esthetics ofthe envisioned restorations. Dental preparationwas carried out according to a minimally invasive approach (Fig. 4) based on the silicone guide, to avoid over-reducing areas of the teeth. A new cast was obtained for the fabrication of the all-ceramic veneer restorations. The all- ceramic veneer restorations were bonded ac- cording to a previously published technique.18 One year after delivery of the definitive resto- rations (Fig.5), a newpolyvinyl siloxane impres- sion was taken for each patient to allow direct comparison with the pre-treatment scenario. Pre- and post-treatment model casts were poured using a conventional single-pouring technique. Vacuum-mixed, low-expansion (0.09%) Type IV dental stone was vibrated into theimpression(CAM-base,Dentona,Dortmund, Volume 2 | Issue 3/201621