الفهرس 
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Abstract
D
ental implants are widely and frequently used as a treatment option to replace missing teeth in patients with single or multiple missing teeth. Treatment of missing teeth by dental implant are highly successful and highly durable.
Immediate implant placement, a technique provides a satisfactory protocol for replacing missing teeth in addition to reduced treatment time, immediate implant placement offers easier definition of implant position and reduced treatment costs.
Also, flap elevation may not be necessary in order to minimize marginal mucosal recession and to enhance esthetic outcomes. Tooth extraction or tooth loss is often followed by facial soft and hard tissue resorption. This may eventually lead to gingival recession around subsequently placed implants.
Recent studies show that with proper three-dimensional implant positioning and bone grafting into the implant-socket, the facial gingival level can be maintained after connective tissue grafting simultaneously with, immediate implant placement.
this study was conducted to evaluate the use of combined epithelial-subepithelial connective tissue graft in increasing soft tissue volume at implant sites and enhance pink esthetic score (PES) and to compare it with sub epithelial connective tissue graft using same tunneling approach.
20 patients involved in this study and were randomly allocated into one of the two groups equally. Patient recruited were between 20-40
years old with a healthy medical condition and no systemic or local factors that would contraindicate any surgical procedure. Additional exclusion criteria as the occurrence of residual untreated periodontal disease, insufficient bone volume to place implants( At least 4 mm of bone beyond the root apex) and extraction sockets type II and III.
group I: this group received immediate implant, bone grafting and socket closure by combined epithelized-subepithelial connective tissue graft using tunneling technique
group II: this group received immediate implant ,bone grafting and socket closure by simple connective tissue graft using tunneling technique
Pink esthetic score (PES)assessment was based on seven variables; mesial papilla, distal papilla ,soft-tissue level ,soft- tissue contour, alveolar process deficiency , soft-tissue color and texture
Each variable was assessed with a 2-1-0 score, with 2 being the best and 0 being the poorest score.
The combined connective tissue graft group showed (Mean±SD) value of (PES) (12.50±0.52) was recorded at (Baseline), then it decreased by (3 months) to (11.70±0.48) then at (6 months) it increased again to (12.20±0.63). while sub epithelial connective tissue group showed (Mean±SD) value of (PES) (12.60±0.51) was recorded at (Baseline), then it decreased by (3 months) to (10.70±0.48) then at (6 months) it increased again to (11.10±0.31).
The other outcome of this study was Volumetric changes. Impressions were obtained before tooth extraction (baseline) , 3months after surgery and 6months after surgery. Cast models were optically scanned, digitally super- imposed and horizontal measurements of the contour alterations between time points were performed using digital imaging analysis
The combined connective tissue graft group showed (Mean±SD) value of volumetric changes (0.50±0.09) recorded at the difference between (3-6 months), followed by the difference between (Baseline- 6 months) (0.11±0.46). While the difference between (Baseline- 3 months) (-0.39±0.47) while sub epithelial connective tissue group showed
(Mean±SD) value of volumetric changes (0.27±0.08) recorded at the difference between (3-6 months), followed by the difference between (Baseline- 6 months) (-0.65±0.40). While the difference between (Baseline- 3 months) (-0.93±0.42)
Data was collected, tabulated and statistically analyzed to compare between the combined technique at different time points and also to compare it with the SCTG.
Statistical analysis of the result of current study showed that combined epithelial-sub epithelial connective tissue graft group had a significantly higher value than SCTG group for both volumetric gain and preserving esthetics (PES) through follow-up intervals.
The results revealed that the combined group had no significant difference in PES score 6 months post-operatively than the pre-operative score, also there was a significant higher value of PES score for the combined group than the SCTG group
The results obtained showed that volumetric changes were significantly different with more favorable results in the combined group than the SCTG group.