Enhancement of peri-implant soft tissue is an essential factor in implant survival. As in periodontal tissue, the integrity of the attached gingiva, plus gingival contour, color, shape, size, consistency, and bleeding upon probing, is an indicator of bacterial activity that will eventually lead to gingivitis and periodontitis. The trajectory of peri-implant tissue is different from that of periodontal tissue because of periodontal ligament fibers, the absence of which makes the implant-bone interface weaker than that of natural dentition. The destruction of peri-implant tissue can be a faster and more devastating process, so maintenance of the peri-implant tissue is a must in implant therapy to avoid a potentially massive destruction of the understructure. The treatment of inadequately attached gingiva, gingiva hyperplasia, and peri-implant gingivitis is discussed with techniques that can alleviate these problems.
ORAL IMPLANTOLOGYWednesday May 14 2003 04:36 PMAllen Press x DTPro SystemMANIPULATION OF THE PERI-IMPLANTTISSUE FOR BETTER MAINTENANCE:A PERIODONTAL PERSPECTIVECLINICALMohamed A. Maksoud, DMDKEY WORDSDental implantsPeri-implant tissueImplant maintenanceMohamed A. Maksoud, DMD, is clinicalassistant professor at the College of Dentistry,University of Florida Jacksonville DentalClinic, as well as in private practice inJacksonville, Florida. Address correspondence toDr Maksoud at 9109 Baymeadows Road,Jacksonville, Fla 32256 (e-mail:firstname.lastname@example.org).120 Vol. XXIX/No. Three/2003eryday practice, influencing dentalpractitioners, including both the dentistand the dental hygienist. Eventhough the effectiveness and predictabilityof the implant treatment havesuccessfully improved, aftercare maintenancehas always been a challenge.TRAJECTORY OF PERIODONTAL VSPERI-IMPLANT TISSUEorim 29_307 Mp_120File # 07emEnhancement of peri-implant soft tissue is an essential factor in implant survival.As in periodontal tissue, the integrity of the attached gingiva, plus gingivalcontour, color, shape, size, consistency, and bleeding upon probing, is an indicatorof bacterial activity that will eventually lead to gingivitis and periodontitis. Thetrajectory of peri-implant tissue is different from that of periodontal tissuebecause of periodontal ligament fibers, the absence of which makes the implantboneinterface weaker than that of natural dentition. The destruction of periimplanttissue can be a faster and more devastating process, so maintenance ofthe peri-implant tissue is a must in implant therapy to avoid a potentiallymassive destruction of the understructure. The treatment of inadequately attachedgingiva, gingiva hyperplasia, and peri-implant gingivitis is discussed withtechniques that can alleviate these problems.ItThas become an integral part of ev- environment, the bone, and theo missing teeth in particular. is an important seal between t, rf inte e tissu o t a seal a t epl r he t d a l a erpractince of dentistryacemenin genofdental gingivthe salfttissue becauseaceithwhieformsimtdecade has altered the and Gould1-3 as similar to that oc C b ra e in scribed e th uring d e dIhNTRODUCTIONentistryevolution of implantlastplant gingivthallitetissuturee hasybeeonfhrandralhceheplant surface. Thus, the integration ofan implant necessitates the integrationof all three types of tissue: bone, connectivetissue, and epithelium. Thesame researchers, in a study utilizingnonsubmerged implants of animals,confirmed that a biological width thatis physiologically equal in dimensionto that of natural teeth should existaround implants.3 On the other hand,the biological zone of natural teeth wasOne must differentiate between periodontalvs peri-implant tissue. The im-ORAL IMPLANTOLOGYWednesday May 14 2003 04:36 PMAllen Press x DTPro Systemdescribed by Garguilo4 as a dental gingivaljunction consisting of a fibrous attachmentanchored in the cementumand gingiva. This was described as acuff of tissue that protects the understructurefrom damage. Even thoughan implant surface has no penetratinggingival fiber attachment, there is aproven proliferation of epithelial cellsthat adhere to that surface. In anotherstudy,5 it was confirmed that periodontalligament epithelial cells attached totitanium the same way as to the toothstructure in vivo. Because the majorityof implant research focuses on the implant-bone relationship, the implantgingival attachment has not been fullyexplored, and further research is needed.Although this attachment is slightlydifferent from that of the periodontalarchitecture, it is most definitely subjectto damages caused by bacterial microorganismsand its by-products, as inperiodontal disease progression.6,7 Understandingthe fragility of this sealshould dictate and alert dental practitionersto the need for light probingpressure, plastic probes and scalers,and an annual radiographic assessmentof implants.8ATTACHED GINGIVAConflicting data exist in the literatureconcerning the need for adequate keratinizedtissue around endosseous implants.A theory exists among cliniciansand researchers that bacteriamight seed from the natural toothpocket to the implant crevice and keratinizedtissue. This seeding is criticalin the partially edentulous case, withseeding from tooth to implant sulcus.The only barrier to epithelial invaginationnearing the crestal bone lies inthe gingival tissue by means of the circularfibers in the supracrestal soft tissue.These circular fibers are only presentin keratinized tissue.9 Wennstromet al10 and Mericshe et al11 documentedthat no adverse effects of implant survivaloccurred in implants that lack attachedgingiva. On the other hand, Simonet al12 presented a clinical case inwhich persistent inflammation andprogressive recession involving themucosa and implant was eliminatedwhen a free gingival graft was used toaugment the attached gingiva. Silverstein,in a different study,13 concludedthat a tenacious seal was createdaround the implant abutment whenadequate gingiva existed. He describedthis tightly adapted implant soft tissueseal as being essential to prevent thedevelopment of peri-implantitis. Severalclinicians14,15 have demonstratedthe use of free soft tissue grafts to augmentthe keratinized gingiva before orfollowing the restoration of the implant.Figure 1 shows a patient with noattached gingiva and frenum pull buccalto an implant crown on a mandibularfirst molar. The recommendedtreatment was soft tissue augmentationwith an allograft (Figure 2). After healing,an adequate zone of attached gingivawas created (Figure 3).HYPERPLASTIC GINGIVAL TISSUEHyperplasia of the gingival tissue alsohas been shown as a response to in-flammatory disease of the soft tissuearound implants. Excision of that tissuecan be accomplished via a gingivectomyprocedure using either ablade or a diamond drill. Iatrogenicdamage of the implant titanium surfaceshould be avoided because it couldharbor plaque and enhance gingivaltissue inflammation. Figure 4 shows apatient who has received a posteriormaxillary hader bar supported by twoimplants and supporting a maxillarypartial denture. Hyperplastic formationwas noticed during the recallexam and was determined to preventthe patient from maintaining good oralhygiene with a cleaning aid. Followinga gingivectomy procedure with a bladeand diamond bur, the hyperplastic tissuewas excised, and the patient wasable to maintain good oral hygiene ofthe bar. Figures 5 through 7 show thesame procedure on a similar case.MAINTENANCE RECALLFailing implants because of bacterialinfection have shown gingival microorim29_307 Mp_121File # 07emMohamed A. Maksoudbiota consistent with periodontal disease,including Prevotella intermedia, Fusobacteriumnucleatum, and Porphyromonasgingivalis.16 On the basis of thesefindings, implants should be reevaluatedduring regular recall visits. Althoughthere is no precise number ofrecommended visits, more recall visitsare recommended than with periodontaltreatment.17,18 On the other hand,the author believes that implant maintenancerecall should be designed forindividuals on the basis of several factorsthat might affect implant survival.SUMMARYSeveral techniques of soft tissue graftingand excision of hyperplastic gingivaltissue can be rendered in a dentaloffice to enhance the longevity of dentalimplants. Close monitoring of theimplant soft tissue for optimal architectureplus minor probing of the periimplantsulcus should be able to identifyincoming peri-implant disease activity.Comprehension of the anatomyand histology of the implant plateaucan aid clinicians in optimizing carefor an individual case. Improvement ofthe implant bone and soft tissue interfaceis one of the challenges for implantresearchers in discovering ways tostrengthen that bond. Perhaps ongoingresearch on implant surfaces to rendera tougher osseous integrated bond willyield some benefits. With the evolutionof dental implants in everyday practice,ongoing extensive research will resultin enhancement in the periodontal perspectivein implant dentistry. Onemust concede that the implant to boneand gingival tissue interface is muchweaker than that of natural teeth. Eventhough the bacteria that cause peri-implantitisare similar to those that causeperiodontal disease, the magnitude ofdestruction in implants can be moredevastating and more damaging. Clinically,there is a need for more frequentmaintenance visits, in addition to moremeticulous daily oral hygiene. The fastrate of bone loss dictates that early detection,diagnosis, and treatment is anJournal of Oral Implantology 121ORAL IMPLANTOLOGYWednesday May 14 2003 04:36 PMAllen Press x DTPro SystemMANAGEMENT OF SOFT TISSUE FOR IMPLANTS122 Vol. XXIX/No. Three/2003orim 29_307 Mp_122File # 07emFIGURES 1-7. FIGURE 1. Lack of attached gingiva buccal to an implant crown. FIGURE 2. Soft tissue graft placed buccal to the implantcrown. FIGURE 3. Healing of the soft tissue graft with an adequate zone of attached gingiva. FIGURE 4. Hyperplastic tissue underneath abar connecting two implants. FIGURE 5. Hyperplastic tissue excised to allow for placement of a cleaning aid. FIGURES 6, 7. Similar to thecase in Figure 4, with hyperplastic tissue excised beneath the implant bar.ORAL IMPLANTOLOGYWednesday May 14 2003 04:36 PMAllen Press x DTPro Systemessential factor in the treatment of failingimplants.REFERENCES1. Cochran DL, Simpson J, WeberHP, Buser D. Attachment and growthof periodontal cells on smooth andrough titanium. Int J Oral Maxillofac Implants.1994;9:289-297.2. Gould T, Brunette D, WestburyL. The attachment mechanism of epithelialcells to titanium in vitro. J PeriodontRes. 1981;16:611-616.3. Cochran DL, Hermann JS,Schenk W, Higginbottorn FL, Buser D.Biologic width around titanium implants.A histometric analysis of theimplanto-gingival junction around unloadedand loaded nonsubmerged implantsin the canine mandible. J Periodonol.1997;68:196-198.4. Garguilo AW, Wentz FK, OrbanB. Dimensions and relation of the dentogingivaljunction in humans. J Periodontol.1961:32:261-267.5. Gould TR, Brunette DM, WestburyL. The attachment mechanism ofepithelial cells to titanium in vitro. JPeriodont Res. 1981;16:611-616.6. Lang NP, Adler R, Joss A, NymanS. Absence of bleeding on probing.An indicator of periodontal stability.J Clin Periodontol. 1990:17:714-721.7. Salcetti JM, Moriarty JD, CooperLF, et al. The clinical, microbial andhost response characteristics of the failingimplant. Int J Oral Maxillofac Implants.1997;12:32-42.8. Misch CE. Contemporary ImplantDentistry. 2nd ed. St. Louis: Mosby;1999.9. Babbush CA. Dental Implants TheArt and Science. Philadelphia: WB Saunders;2001.10. Wennstrom JL, Bengazi F, LekholmU. The influence of the masticatorymucosa on the peri-implant softtissue condition. Clin Oral Implants Res.1994;5:1-8.11. Mericske-Stem R, Steinlin-Schaffher T, Marti P, Geering AK. Periimplantmucosal aspects of ITI implantssupporting overdenture. A 5-year longitudinal study. Clin Oral ImplantsRes. 1994;5:9-18.12. Simon AM, Darany DG, GiordanoJR. The use of free gingival graftsorim 29_307 Mp_123File # 07emMohamed A. Maksoudin the treatment of peri-implant softtissue complications. Clinical report.Implant Dent. 1993;2:27-30.13. Silverstein LH, Lefkove MD,Garnick JJ. The use of free gingival softtissue to improve the implant/soft tissueinterface. J Oral Implantol. 1994;20:36-40.14. Han TJ, Klokkevold PR, TakeiHH. Strip gingival autograft used tocorrect mucogingival problems aroundimplants. Int J Periodontics Restor Dent.1995;4:404-411.15. Rapley JW, Mills MP, Wylarn J.Soft tissue management during implantmaintenance. Int J PeriodonticsRestorative Dent 1992;12:373-381.16. Scordone L, Barone A, RamagliaL, Ciaglia RN, Iacono VJ. Antimicrobialsusceptibility of periodontopathicbacteria associated with failingimplants. J Periodontol. 1995;66:69-74.17. Scordone L, Barone A, RamagliaL, Ciaglia RN, Iacono VJ. Longitudinalstudy of dental implants in periodontallycompromised population. JPeriodontol. 1999;70:1322-1329.18. Strong S. The dental implantmaintenance. J Pract Hyg. 1995;4(5):29-31.Journal of Oral Implantology 123