Abstract
Titanium is widely used for dental implant abutments due to its mechanical strength, biocompatibility, and corrosion resistance; however, its gray coloration can compromise esthetic outcomes, particularly in patients with thin or translucent gingival biotypes. Anodization, a surface modification technique altering the titanium oxide layer, has been proposed to improve soft tissue aesthetics by producing abutments with warmer tones (eg, pink or gold) that harmonize with the surrounding gingiva. This systematic review aimed to evaluate the clinical and aesthetic outcomes of anodized titanium abutments compared to non-anodized titanium and other materials, with a focus on peri-implant soft tissue health and visual integration. Following PRISMA 2020 guidelines, a comprehensive search was conducted in Scopus, PubMed, and ScienceDirect for Randomized Controlled Trials (RCTs) published between 2013 and 2024. Eligibility followed the PICOS framework. Nine RCTs with parallel or split-mouth designs and follow-ups from six weeks to two years were included. Esthetic outcomes were assessed using CIELab spectrophotometry and the Pink Esthetic Score (PES), while clinical parameters included mucosal recession, probing depth, plaque accumulation, gingival inflammation, and bleeding on probing. Study quality was appraised using the Cochrane Risk of Bias 2.0 tool. Anodized titanium abutments demonstrated enhanced aesthetic outcomes, especially in thin gingival biotypes, by improving colour harmony and reducing grayish shine-through. Pink-anodized abutments also showed better soft tissue integration compared to controls. However, clinical improvements such as reductions in inflammation, plaque, or recession were modest, inconsistent, and often statistically insignificant across studies. While anodization appears safe and beneficial for visual outcomes, its functional clinical advantages remain uncertain. These findings call for cautious interpretation and highlight the need for further well-powered, standardized long-term RCTs to validate the broader clinical relevance.