The extended pink esthetic score (E-PES): a reliability and multidirectional score-behavior study for peri-implant...

The Pink Esthetic Score (PES) is widely used to assess peri-implant soft-tissue esthetics around single-tooth implant restorations; however, frontal-view assessment may incompletely capture three-dimensional peri-implant features such as buccolingual contour, emergence profile, and mucosal scarring. This study introduced the Extended Pink Esthetic Score (E-PES), a multidirectional assessment framework incorporating frontal, profile, and occlusal views.

Thirty single-tooth implant restorations in the maxillary esthetic zone were evaluated using standardized photographs. Twenty blinded evaluators (five periodontists, five prosthodontists, five orthodontists, and five general practitioners) scored each case using two assessment systems. The traditional frontal-view assessment using the seven-variable PES, then the multidirectional E-PES assessment using frontal, profile, and occlusal views with nine variables. The E-PES retained the seven core PES variables, with emergence profile and mucosal scarring added to the variables to give a multidirectional view. Assessments were repeated after a three-week washout period with randomized image order. Reliability, agreement, and score-distribution analyses were performed.

A total of 600 first-round assessments were completed for each scoring system and included in the paired frontal-view versus multidirectional score analysis. Original PES and multidirectional E-PES-compatible total scores averaged 9.98 ± 3.96 and 9.76 ± 3.52, respectively, yielding a small but statistically significant mean paired difference of 0.22 points (P < 0.001). Scores differed in 442 of 600 paired assessments (73.67%). Agreement between frontal-view and multidirectional total scores remained excellent (ICC = 0.919; ICC = 0.958). The alveolar process/buccal contour parameter showed the greatest mean shift, decreasing from 1.31 ± 0.69 to 1.10 ± 0.74 (P < 0.001). Inter-examiner reliability for multidirectional total scores was moderate at the individual-rater level (single-measure ICC = 0.633) and high at the group level (average-measure ICC = 0.972).

E-PES preserved the reliability of the original PES while identifying clinically relevant esthetic differences not fully captured by frontal-view assessment alone. Multidirectional evaluation particularly enhanced assessment of alveolar-process/buccal-contour morphology, supporting E-PES as a practical refinement of PES for more comprehensive peri-implant esthetic evaluation.