Health, Maintenance, and Recovery of Soft Tissues

around Implants
Yulan Wang, MD; Yufeng Zhang, PhD; Richard J. Miron, PhD

ABSTRACT
Background: The health of peri-implant soft tissues is one of the most important aspects of osseointegration necessary for
the long-term survival of dental implants.
Purpose: To review the process of soft tissue healing around osseointegrated implants and discuss the maintenance
requirements as well as the possible short-comings of peri-implant soft tissue integration.
Materials and Methods: Literature search on the process involved in osseointegration, soft tissue healing and currently
available treatment modalities was performed and a brief description of each process was provided.
Results: The peri-implant interface has been shown to be less effective than natural teeth in resisting bacterial invasion
because gingival fiber alignment and reduced vascular supply make it more vulnerable to subsequent peri-implant disease
and future bone loss around implants. And we summarized common procedures which have been shown to be effective in
preventing peri-implantitis disease progression as well as clinical techniques utilized to regenerate soft tissues with bone
loss in advanced cases of peri-implantitis.
Conclusion: Due to the difference between peri-implant interface and natural teeth, clinicians and patients should pay more
attention in the maintenance and recovery of soft tissues around implants.
KEY WORDS: osseointegration, peri-implant soft tissue, peri-implantitis, peri-mucositis

INTRODUCTION recently, evidence has demonstrated that the long-term

When dental implants were first discovered and used to
replace missing teeth, most clinicians focused primarily
on implant stability as the biggest factor in and predictor
for future success, and this trend has in part continued
as the primary research criterion for implants.1–6
Osseointegration was and still is considered as the most
important factor in maintaining implant stability,
whereas the role of soft tissue healing and maintenance
around implants has been somewhat neglected.7–10 More
The State Key Laboratory Breeding Base of Basic Science of Stoma-
tology (Hubei-MOST), Key Laboratory of Oral Biomedicine Ministry
of Education, School & Hospital of Stomatology, Wuhan University,
Wuhan, China
Corresponding Author: Prof. Yufeng Zhang, The State Key Laboratory
Breeding Base of Basic Science of Stomatology (Hubei-MOST), Key
Laboratory of Oral Biomedicine Ministry of Education, School &
Hospital of Stomatology, Wuhan University, 237 Luoyu Road, Wuhan
430079, China; e-mail: zyf@whu.edu.cn
© 2015 Wiley Periodicals, Inc.
DOI 10.1111/cid.12343
survival of osseointegrated implants was also partly
dependent on the transmucosal healing and stability
around the implant collar, termed “peri-implant
mucosa.”11 This attachment of the soft tissue to the
coronal portion of an implant acts to provide a protec-
tive seal which prevents the development of bacterial
invasion and future inflammation.12,13 Thus, the soft
tissue seal is necessary for stable osseointegration and
long-term survival of implants.14–16
One of the key findings relating to peri-implant
mucosa was the direction of gingival fibers compared
with the natural tooth (Figure 1). This key diffe-
rence explained the increased ability of bacteria to pen-
etrate the epithelial layer and subsequent connective
tissue thus increasing the breakdown of soft tissues
around implants.17 Therefore, if patient compliance is
not fully obtained and proper oral hygiene is not
maintained, inflammatory changes in the soft tissues
surrounding dental implants will develop.18 This
inflammatory process in the peri-implant mucosa

618
1
2 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015
Figure 1 Differences between the connection of soft tissues to natural teeth and dental implants. Note the arrangement of gingival
fibers in a parallel orientation on implant surfaces.
begins with reddening and swelling, and once bleeding
on probing is initiated, the condition is then termed
peri-implant mucositis. If this condition is left
untreated, it may lead to progressive and irreversible
destruction of implant-surrounding tissues including
the loss of alveolar bone around dental implants and
ultimately lead to implant failure.19 Thus, the structure
and biological events that take place during
osseointegration and soft tissue attachment are impor-
tant components of implant survival and maintenance.
This review article aims to describe the composition of
soft tissues around implants, how to maintain their
health and survival, and how to deal with peri-mucositis
and peri-implantitis progression and its reversibility.
BIOLOGICAL EVENTS DURING
OSSEOINTEGRATION
Osseointegration, which has also been called “functional
ankylosis,”20 was initially defined as “a direct structural
and functional connection between ordered, living bone
and the surface of a load-bearing implant.”21 More
recently, authors have modified the definition of
osseointegration. In 2012, Zarb and Koka defined
osseointegration as “a time-dependent healing process
whereby clinically asymptomatic rigid fixation of
alloplastic materials is achieved and maintained in bone
during functional loading.”22 The definition explains
in more detail that the stages of osseointegration
are divided into three overlapping steps: early
immune-inflammatory response, angiogenesis, and
osteogenesis.23
Soft Tissues around Implants 619
Interestingly, more recent evidence has demon-
strated that a gap of about 60 μm between the implant
surface and host bone is created,24,25 and it may extend to
100 to 500 μm over time.26 This gap typically contains a
titanium oxide layer which comes into contact with
blood plasma proteins and body fluids and is later
adsorbed onto the implant surfaces immediately after
implantation, forming a “conditioning film.”23,27 Several
factors such as surface roughness28 as well as surface
hydrophilicity29 are key determining factors influencing
protein adsorption and are subsequently able to stimu-
late and induce cell attachment on the implant surface.30
The cell population which first occupies the implant
surface is primarily composed of inflammatory cells,
and many investigators refer to this original phase
of implant healing as the “immune-inflammatory
response.”23 Within 24 hours following implant inser-
tion, neutrophils dominate the implant site. In the 2 to 4
days following, an increasing number of infiltrating
macrophages and monocytes appear in the peri-implant
gap. These cells are responsible for removing the debris,
as well as secreting large quantities of cytokines and
growth factors responsible for stimulating future mes-
enchymal cell recruitment and proliferation, angiogen-
esis, and collagen matrix deposition.31,32
A simultaneous and equally important event that
takes place during osseointegration is the formation of a
blot clot and future stimulation of angiogenesis. On the
first day after implantation, a blood clot is formed adja-
cent to the implant surface,23 and neovascularization
begins within 24 hours. While infiltrating macrophages
620 Clinical Implant Dentistry and Related Research, Volume 18, Number 3, 2016
Figure 2 Timeline for osseointegration of dental implants with respect to changes over time.
and monocytes migrate to the bone wound by day 4, the
blood clot is gradually replaced by differentiating mes-
enchymal cells recruited from the bone marrow around
newly developing blood vessels.33 These mesenchymal
cells differentiate into osteoblasts which are influenced
by both growth factors and surface topography where
they begin to attach to the implant surface and deposit
collagen matrix.24,34 New bone formation on the implant
surface is observed in 5 to 7 days23,24 when calcification
from the host bone onto the implant surface is also
observed.35 By 4 weeks, new bone formation is observed
on the implant surface (contact osteogenesis) connect-
ing with bone formed on the host bone (distant osteo-
genesis).36,37 After 8 to 12 weeks, the peri-implant
interface is completely replaced by mature lamellar bone
in direct contact with the implant surface, thus complet-
ing the initial phase of osseointegration23,31,32 (Figure 2).
THE SHORTCOMINGS OF SOFT TISSUE
HEALING AROUND IMPLANTS
One of the issues often overlooked during implant
placement is the fact that implant insertion creates a
wound in both hard and soft tissue. It is also noteworthy
that soft tissues suffer more drastic changes than their
bony counterparts. Typically, soft tissues need to regen-
erate a greater amount of tissue, and subsequent surger-
ies and/or temporary crown changes further aggravate
soft tissues with a number of new adaptation periods
Soft Tissues around Implants 3
during healing abutments, final abutments, imprints,
and final restorations, offering numerous opportunities
for inflammation to develop during each of these pro-
cedures. Immediately after dental implant insertion, the
implant-mucosa interface also forms a blood clot that is
infiltrated by incoming neutrophils. If bacterial invasion
is not present, the initial mucosa begins forming a peri-
implant seal by the fourth day postimplantation. This
healing process takes 8 weeks to complete the peri-
mucosa seal,38–40 whereby leucocytes are typically con-
fined to the coronal portion of the implant, and
collagen-producing fibroblasts are typically found in the
apical portion of the peri-implant interface.
Histologically, the peri-implant mucosa is com-
posed of a well-keratinized oral epithelium, sulcular epi-
thelium, and a thin barrier epithelium facing the
abutment equivalent to the junctional epithelium
around teeth, termed the peri-implant junctional epi-
thelium. The height of the peri-implant junctional epi-
thelium is approximately 2 mm, and the connective
tissue underlying this junctional epithelium is around
1.0 to 1.5 mm.13 Thus, the mean biological width
(including the sulcus depth) may often exceed 3 mm.41
When biological width is reduced at any site of the peri-
implant mucosa, marginal bone resorption is typically
observed so that the biological width is adjusted to com-
pensate for these changes.42 Many factors have been
shown to influence biological width around implants.
4 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015
Various implant system (e.g., tissue-level vs bone level
implants, one-piece vs two-piece),43–45 implant material
(e.g., titanium, zirconium gold alloy),46 implant surface
characteristics (macro design, topography, hydrophilic-
ity, and surface coating),47,48 loading protocol (e.g.,
immediate vs early or delayed),49 and implant protocol
(e.g., soft tissue flap design, flapless procedure)50,51 all
have different effects on biological width. However,
more in-depth research is needed to verify the signifi-
cance of each of these factors.
With regard to the structure of the peri-implant
mucosa, the amount and distribution of fibroblasts, col-
lagen, and blood vessels is quite different from those of
a natural tooth (Figure 1). In the supra-crestal soft
connective tissue around implants, fewer fibroblasts and
collagen fibers oriented in the axis of the implant are
present than in natural teeth. Interestingly, mesenchy-
mal cells with a high number of fibroblasts are found
near the implant surface, typically interposed between
collagen fibrils.52 One of the main differences among
these collagen fibers is their orientation relative to
natural teeth. In most cases, the collagen fibers are found
oriented parallel or parallel-oblique to the smooth
implant surface, whereas in natural teeth, the fibers are
found perpendicular to the tooth embedded within
cementum as Sharpey’s fibers.13,53,54 Some research has
shown that rougher surfaces with either microgrooves
or porous plasma-sprayed surfaces form collagen fibrils
that are oriented slightly more to the perpendicular than
their smooth surface counterparts.55–57 Although more
perpendicular, these surfaces still fail to provide the pro-
tection barrier provided by natural teeth. Another dis-
cernible difference between soft tissue around natural
teeth and that of dental implants is the number of blood
vessels around both. Typically, few to no blood vessels
are found in the zone adjacent to the implant surface.53
A clearing technique visualizing carbon-stained blood
vessels showed that the vascular networks of the peri-
implant mucosa are derived from the terminal branches
of larger blood vessels originating from the periosteum
of the bone at the implant site.58 Because of the numer-
ous differences between soft tissues around natural teeth
and around implant surfaces, several key components as
listed below differ greatly between the systems.
Peri-Implant Probing
The importance of either tooth or peri-implant probing
has been well documented in the literature. One of the
Soft Tissues around Implants 621
first quantifiable differences between these two struc-
tures is the significantly deeper mean in probing depth
at implant sites compared with tooth sites.59,60 This dif-
ference occurs irrespective of probing pressure, and it is
also noted that the mean bleeding on probing percent-
age at implant sites is much higher than that of normal
teeth.59,60 Furthermore, it has been documented that
changes in probing depth forces around peri-implants
are more sensitive to slight variations, making accurate
analysis more difficult.59,60 This phenomenon may
reduce the efficacy of peri-implant probing and provide
less reliable evaluation of the inflammatory situation.
Furthermore, slight increases in pressure may some-
times result in injury when the probe goes beyond the
peri-implant seal. It is important, however, to note that
not all investigators agree with the drastic changes of
probing depth between implants and teeth,61 although
the general consensus is that probing depth is increased
in implant sites, BOP is also more sensitive to minor
changes in pressure in implant sites.
Fiber Orientation and Distribution
As noted earlier, collagen fibers in natural teeth are per-
pendicularly oriented, attaching from the tooth cemen-
tum to the alveolar bone serving as a barrier to epithelial
downgrowth and bacterial invasion.62 Since dental
implants lack a cementum layer, collagen fibers typically
orient themselves in a parallel manner to the implant
surface, making them much weaker and more prone to
periodontal breakdown and subsequent bacterial inva-
sion.17,63 The lack of a proper periodontium is also a
potential reason for faster inflammation progress, as dis-
cussed below.64
Microbiota and Inflammatory Response
When implant surfaces began to show signs of peri-
odontal plaque and biofilm accumulation, researchers
began to determine the periodontal pathogens respon-
sible for peri-implantitis.65,66 It is now well understood
that the formation of a biofilm on an implant surface is
influenced by the surface properties of the implant, such
as chemical composition, roughness, and surface free
energy.67 Studies have demonstrated that Staphylococcus
aureus is common in deep peri-implant pockets closely
linked to suppuration and bleeding on probing.68,69
Interestingly, S. aureus is not closely related to chronic
periodontitis and seems to be more specific to implant
surface contamination.70 Apart from this difference, the
622 Clinical Implant Dentistry and Related Research, Volume 18, Number 3, 2016
bacteria species found in the subgingival microbiota in
both natural tooth periodontal tissues and in peri-
implant soft tissue are similar in terms of the occurrence
and frequency of periodontal pathogens.71
Another important difference in the inflammatory
response of soft tissues in natural teeth and implant
surfaces is their different cellular responses. Inflamma-
tory lesions in peri-implant sites are infiltrated with a
high proportion of B cells and plasma cells, which
is similar to chronic periodontitis and aggressive
periodontitis.72–74 Although the development of peri-
implantitis and periodontitis follows a similar pattern,
the dynamics are quite different. Studies in human and
animals show that there is very little difference in host
response between natural and implant-supported teeth
in the initial phase,75 but disease progression occurs more
rapidly with subsequent bone loss in the peri-implant
lesions than in natural teeth.64,76 The reason might lie in
the lack of an intact supra-crestal connective tissue fiber
compartment in peri-implant soft tissue77,78 which is able
to wall off the lesions; the inflammatory cell infiltrates
generally do not penetrate the alveolar bone marrow in
periodontal tissues.79 Furthermore, the vascular supply as
discussed below is reduced, decreasing the number of
infiltrating neutrophils and B cells.
Vascular Supply
The vasculature of the periodontal soft tissues is derived
from two sources. One source is the supra-periosteal
vessels lateral to the alveolar process, and the other is the
vessels of the periodontal ligament. When the natural
tooth is extracted, the future implants have lost their
vascular supply from the periodontal ligament.58 Fur-
thermore, because of the dense fibers adjacent to the
inner zone of the implant surface, there is also less vas-
cular structure in the soft connective tissue directly adja-
cent to the implant surface compared with the natural
tooth.52 As a sufficient vascular supply is necessary for
wound healing and tissue repair by delivering numerous
cell types and growth factors, the lack of an abundant
blood supply has been suggested as one of the key reasons
for the extensive progression of inflammation and lack of
healing in soft tissues surrounding implants.80
MAINTENANCE AND RECOVERY OF SOFT
TISSUE HEALTH AROUND IMPLANTS
Because of the vast differences between natural
teeth and dental implants, their maintenance is of
Soft Tissues around Implants 5
critical importance for the longevity of successful
osseointegrated implants. A study which purposely
banned oral hygiene around dental implants for a short
period of time demonstrated a cause–effect relationship
between the accumulation of bacterial plaque and the
development of peri-implant mucositis.18 Recent studies
have shown that bacterial colonization occurrs within 30
minutes following implantation81 and becomes stable
after a 2-week period.82,83 Thus, the primary objective of
maintenance and recovery of any implant regiment is to
remove the bacterial plaque and/or calculus.
MAINTAINING THE HEALTH OF PERI-IMPLANT
SOFT TISSUE
Of course, the dental provider has a role in guiding
implant stability following osseointegration; however,
proper maintenance of the peri-implant soft tissue
health is largely in the control of the patient’s own oral
hygiene regimen. Patient self-management includes
mechanical methods and chemical ways to control
biofilm formation and subsequent plaque/calculus
accumulation.
PATIENT SELF-MANAGEMENT
Mechanical Methods
Tooth Brushing. Manual and power brushes are both
excellent and necessary means to remove dental
plaque. These include manual squish grip brushes,84,85
sonic tooth brushes, ionic toothbrushes,86 and counter-
rotational powered toothbrushes.87 Each is effective in
plaque reduction and maintaining the gingival health
of peri-implant soft tissues, and it is advised that
patients brush a minimum of twice daily. Swierkot
and colleagues88 found no significant difference
between the various brushes utilized, but other inves-
tigators found that powered brushes were more effec-
tive in reducing plaque and gingivitis.89,90 Since the
comparison of manual and powered toothbrushes does
not show a definitive advantage of one type over
another, it is typically advised that patients with good
dexterity can choose either option, but as the patient
ages, it is increasingly important to suggest powered
toothbrushes.
Interdental Cleaning. Interdental cleaning devices are
used to improve the efficacy of toothbrushes, especially
in regions with small interspaces. Traditional string
6 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015
floss and interdental brushes are useful devices, and
the width of the interdental space determines which to
use.91 Other methods to remove interdental plaque
include using water floss; however, a lack of controlled
clinical trials makes it difficult to speculate on its
effectiveness.92
Chemical Methods
Chemical agents may provide additional benefits to
mechanical plaque control. Of course, it must be borne
in mind that although they are not able to replace
mechanical brushing, they may be utilized in combina-
tion approaches.
Triclosan/Copolymer Toothpaste. Triclosan (0.3%)
together with methyl vinyl ether-maleic anhydride
polymer (2.0%) in a sodium fluoride silica-based
toothpaste has been demonstrated to reduce plaque and
gingival inflammation.93,94
Fluoride-Containing Mouth Rinses. Amino fluoride/
stannous fluoride mouth rinses are an excellent choice
as a mouthwash. In one study, it was shown that
the results for plaque control were comparable with
those for chlorhexidine gluconate mouth rinses, and the
patients enrolled in the study preferred the taste.95 Fur-
thermore, fluoride-containing mouth rinses are able to
reduce pro-inflammatory molecules in peri-implant
crevicular fluid.96
Essential Oils Mouth Rinse. Listerine, Pfizer Inc, Man-
hattan, New York, United States, used twice daily for 30
seconds directly after standard oral hygiene mechanical
brushing, has been shown to provide a reduction in
plaque index, gingival index, and bleeding index.97 More
recently, a variety of oils such as cinnamon oil and clove
oil have been studied for their long-term antibacterial
effect, although more research is necessary to character-
ize their beneficial effects on implants fully.98
Chlorhexidine. Chlorhexidine gluconate (0.12%) is
used to control plaque and maintain oral hygiene in
postrestorative phases following implant placement.87,95
Furthermore, irrigation with 0.06% chlorhexidine using
a powered oral irrigator (Water Pik, Water Pik Inc, Fort
Collins, Colorado, United States) with a special
subgingival irrigation tip has been shown to be more
effective than chlorhexidine gluconate (0.12%) mouth
Soft Tissues around Implants 623
rinses99; however, very few studies have been conducted
particularly on implants. Chlorhexidine is also available
in gel form, which has also been demonstrated as
effective.100
PROFESSIONAL MANAGEMENT
It is important that patients receiving implants be placed
on a strict recall programme so professional manage-
ment can assess changes over time, which will help
maintain the health of dental implants. Professional
management may include mechanical debridement,
application of phosphoric acid etching, or injections
with chlorhexidine.
Mechanical Debridement
A qualified dentist is required to assess the state of the
osseointegrated implant and make decisions on the
mechanical debridement program most suitable for
each placement. Typically, patients may be placed on
recall every 6 to 12 months for supra and subgingival
debridement of calculus and plaque around implants
with carbon fiber curettes. In general, patients with a
single tooth crown or bridge with two implant abut-
ments should be on recall once per year with risk factors
analyzed. Typically, if a bridge has more than two
implants, it is advised to place the patient on a 6-month
recall program which also includes patients with full
arch bridgework retained by implants or implant-
retained dentures. In patients with or at a higher risk of
developing peri-implant disease caused by systemic
factors such as smoking, personal factors such as bad
oral hygiene, or genetic factors, the recall interval should
be shorter (usually half of the suggested time). If, for
some reason, peri-implant soft tissue becomes infected
or shows signs of attachment loss, a much stricter
regimen may then be necessary for implant health, typi-
cally with recall once every 12 weeks until soft tissue
healing is observed. It is up to the healthcare provider to
make optimal decisions for the long-term survival of
implants.101
Phosphoric Acid Etching Gel
The application of phosphoric etching gel in the peri-
implant sulcus has been used as an alternate method for
improving peri-implant soft tissue. Strooker and col-
leagues have demonstrated that application of a 35%
phosphoric etching gel at pH 1 results in an instant
reduction of colony-forming units, proving that it is an
624 Clinical Implant Dentistry and Related Research, Volume 18, Number 3, 2016
effective way to fight against bacteria.102 Although long-
term clinical studies are still lacking, the use of phos-
phoric etching has been demonstrated at least in part to
counteract infected peri-implant soft tissues by decreas-
ing bacterial counts and may be a viable option in
already infected implant sites.
Chlorhexidine
Much like home mouth rinses with chlorhexidine, its
application by a professional dental provider via local
injections has also been demonstrated as a means to
improve peri-implant soft tissue healing following peri-
implant contamination. Groenendijk and colleagues
showed that a 0.2% chlorhexidine injection to the inner
part of implants at second-stage surgery demonstrated a
significant inhibition of growth and acquisition of bac-
teria by the peri-implant interface.103
RECOVERING THE HEALTH OF PERI-IMPLANT
SOFT TISSUE
Because of the growing use of dental implants, more and
more cases have now been reported as demonstrating
signs of peri-implantitis and peri-mucositis. Of primary
importance in the recovery of these implants is promot-
ing the health of the peri-implant soft tissue by elimi-
nating biofilm and calculus. Once again, this may be
achieved through oral hygiene techniques at home, but
more emphasis is now placed on the healthcare provid-
er’s efforts at disease resolution. Therefore, patient self-
management is identical to that mentioned in the
section “maintaining the peri-implant soft tissue
health”; however, we discuss next the professional means
to improve peri-implant soft tissues once peri-implant
soft tissue infection is present.
PROFESSIONAL MANAGEMENT
Mechanical Debridement
To recover periodontal soft tissues around implants fol-
lowing peri-implantitis, it becomes vital that the patient
is followed up regularly. During these appointments,
supra and subgingival debridement of the implant
surface becomes vital, as the main goal is to remove the
biofilm and calculus without altering the topography
of the implant surface. Curettes and ultrasonic devices
with polyether-etherketone-coated tips are the most
common approaches, and patients are advised to be
placed on a recall program every 12 weeks until implant
inflammatory resolution is obtained.
Soft Tissues around Implants 7
Curettes. Typically, carbon curettes are advised again for
the recovery of implants. Although metal curettes may
be acceptable for zirconia implants,104 they leave too
many scratches on the surface of titanium implants and
thus should be avoided.105 Although titanium curettes
are an option, and one study has shown less damage
observed by scanning electron microscopy,106 nonmetal
alternatives (carbon-fiber curettes, teflon curettes,
plastic curettes)107–109 are the preferred option. It is note-
worthy that a growing number of ultrasonic devices are
being used for plaque and calculus removal in peri-
implant tissues as discussed next and are therefore the
preferred method for mechanical debridement once
plaque and calculus are found subgingivally.
Ultrasonic Devices. A number of studies have shown the
efficacy of using ultrasonic devices for reducing bacterial
plaque and BOP scores. Renvert and colleagues demon-
strated that plaque scores decreased from 73% to 53%
(p < .01), and bleeding scores were also significantly
reduced following therapy (p < .01).110 Park and col-
leagues demonstrated on implants with an SLA surface
that metal scaler tips were more effective in eliminating
bacteria and reducing bacterial adherence by smoothing
the implant surface than plastic and carbon scaler tips.111
With regard to machined surfaces, the scratches caused
by a metal scaler do not significantly affect the amount
of biofilm that adheres,112 and it has been demonstrated
that a smoother surface for soft tissue attachment is
preferred since bacterial adhesion is reduced on these
surfaces. It has been demonstrated that ultrasonic
scalers do not show an increase in implant temperatures
when the cooling system is used properly.113
Adjunctive Antibiotics
When the microbial count increases during acute infec-
tions of peri-implantitis, it may become necessary to
treat with antibiotics. Antibiotics are used to enhance
the effect of the mechanical debridement and prevent
the future recolonization of bacteria. Minocycline
microspheres are used because of their sustained release
of antibacterial ingredients up to 12 months, and studies
have shown that they are effective in reducing plaque,
and probing pocket depth as well as BOP.114–116
Amoxicillin, metronidazole, and their combination are
usually delivered as local antibiotic applications. The
combination of amoxicillin and metronidazole showed
significant inhibition on the growth of adherent
8 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015 Soft Tissues around Implants 625

Streptococcus sanguinis and Porphyromonas gingivalis117 NONSURGICAL DECONTAMINATION AND

and much lower bacterial resistance.118 Furthermore,
systemic antibiotics may be used to increase the antimi-
crobial level in the peri-implant crevicular fluid to
support the effect of mechanical debridement,105 but no
sound scientific basis has been found for the use of
systemic antibiotics.119
HOW TO RECONSTRUCT THE IMPLANT SOFT
TISSUE FOLLOWING PERI-IMPLANTITIS
Peri-implantitis is accompanied with crestal bone loss,
bleeding on probing, and the possibility of suppuration.
It is very difficult for the clinician to manage such a
disease as the resulting implant surface has lower blood
supply than the natural surface, and if the disease is left
untreated, it may well lead to implant failure.120 Various
studies have revealed that the prevalence of peri-
implantitis ranges from 2.7% to 47.1%121 and that as
implants become more popular, the necessity for effec-
tive strategies to reconstruct peri-implant tissues will be
equally important.
INFECTION CONTROL
As peri-implantitis is a bacterial infectious disease, the
first thing to do before reconstructive therapy takes place
is to control infection. To this end, and prior to surgical
intervention, the peri-implantitis site should demon-
strate no bleeding on probing and exhibit no suppura-
tion.11 The mechanical decontamination methods for
peri-implantitis include mainly curettes, air-abrasive
devices, ultrasonic devices, and lasers (Table 1).
Air-Abrasive Systems
Air-abrasive systems are based on the air spray of
powders made from a variety of materials including
sodium bicarbonate, sodium hydrocarbonate,122
calcium phosphate,123 erythritol-chlorhexidine,124 and
amino acid glycine.125 They have been shown to be effec-
tive in eliminating biofilms and calculus both in vivo
and in vitro.126 Typical devices include a specially
designed nozzle, which is used for horizontal exit of air
powder mixture.127 It is recommended that the nozzle be

TABLE 1 Different Options for Decontamination of Implant Surface

Methods Kinds Introduction

Curettes Metal Efficient in reducing bacteria but causes obvious scratches on the surface of
titanium implants
Nonmetal Causes less damage to implant surface but is vulnerable and less efficient
Ultrasonic Metal Better efficiency and less bacterial adhesion, does not cause temperature change
device when cooling system is used properly
Nonmetal
Air abrasive Sodium bicarbonate, Efficient in bacterial reduction, but the high abrasiveness causes change in
system sodium hydrocarbonate microstructure of implant surface and has remnants on the implant surface
Calcium phosphate Efficient in bacterial reduction, has remnants on the implant surface
Amino acid glycine Most accepted powders, less damage to implant surface
Erythritol-chlorhexidine Newly founded method, more efficient in bacterial reduction than glycine
Lasers Diode lasers Not to cause any damage to implant surface at 980 nm but useful in destruction
of bacterial cells, cause temperature change when used continuously
Nd:YAG Effective in bacterial reduction, but it causes extensive melting and damage to the
implant surface
Er:YAG Capable of effectively removing plaque and calculus without injuring the implant
surfaces, cause temperature change when used continuously
CO2 lasers Won’t cause excessive titanium accumulation improve new bone formation by
effective decontamination, cause temperature change when used continuously
Antibiotics Local Useful adjunctive therapy for mechanical debridement, especially when it is
combined with controlled release system
Systemic May increase the antimicrobial level in the peri-implant crevicular fluid
626 Clinical Implant Dentistry and Related Research, Volume 18, Number 3, 2016
moved circumferentially around the implant surface in
equal fashion in order to decontaminate the implant
surface.128
One of the main drawbacks of the air-polishing
technique is that it increases implant surface roughness,
which in turn increases bacterial adhesion. The standard
powdered air-abrasive system (sodium-carbonate)
proved unsuitable for implant instrumentation because
of the high abrasiveness revealed by SEM examination,
whereas low-abrasive amino-acid glycine powder is rec-
ommended for debriding implant surfaces as it does no
damage to hard or soft tissues.129 Petersilka and col-
leagues compared a low abrasive air-polishing powder
with hand instruments and found that the powder
resulted in a significantly greater reduction in mean
CFU (log 1.7 1 0.98 and log 0.61 1 0.79, respectively;
p < .05) from pockets of 3 to 5 mm depth.126 Another
study showed that air-abrasive powders produced a
0.8 to 0.5 mm reduction in periodontal depth and a
reduction in bacteria (Pseudomonas aeruginosa, Staphy-
lococcus aureus and Peptostreptococcus anaerobius ) at 1
month.130 Drago and colleagues constructed a new for-
mulation consisting of erythritol and chlorhexidine
powders, and its in vitro antimicrobial and antibiofilm
effects on bacteria (S. aureus, Bacteroides fragilis, and
Candida albicans) were stronger than the standard
glycine powder used in air-polishing devices.124 Apart
from abrasiveness, another potential disadvantage of air
powder abrasive systems is the remnants. A study by
Tastepe and colleagues showed that although the powder
was effective in biofilm removal, powder particle rem-
nants were observed on and impacted on the titanium
surface.123 In the HA and HA + TCP group, a calcium
content varying between 2% and 5% was observed.
Lasers
Since their first application in dentistry in 1989,131 lasers
have gained popularity in different aspects of dentistry
and have been utilized in peri-implant decontamina-
tion. There are a variety of options for decontamination
of implant surfaces including semiconductor diode
lasers, the solid state laser Nd:YAG, Er:YAG lasers, and
gas lasers such as CO2 lasers.132–134
It was found in an in vitro study that the 980-nm
diode laser caused little or no damage to implant sur-
faces135 while still being useful for bacterial reduction of
P. gingivalis-contaminated implants.136 This result has
since been verified in clinical testing with a similar
Soft Tissues around Implants 9
810-nm diode laser.137 The CO2 laser as well as the
Nd:YAG laser have been used to a limited extent in den-
tistry. The CO2 laser has lower penetration depth in soft
tissues than the Nd:YAG lasers.138 In contrast, CO2 lasers
at an energy density of 100 J/cm2 can destroy microbial
colonies including S. sanguinis and P. gingivalis without
damage to the tooth root surface.139 Furthermore, in
another study, Deppe and colleagues found that CO2
laser-assisted therapy of ailing implants did not cause
excessive titanium accumulation in tissues, thus making
it a suitable and safe method for implant decontamina-
tion.140 Although CO2 is relatively stable for titanium
decontamination, its combination with Nd:YAG lasers
can produce the undesirable result of extensive melting
in irradiated areas and damage to the microstructure of
the implant as confirmed by SEM examination.135
Promising results have also been observed with the
Er:YAG laser in the treatment of peri-implantitis, and
it is the most popular choice at present. Kreisler and
colleagues demonstrated that the Er:YAG laser has a
high bactericidal potential regarding common implant
surfaces, even at low energy densities.141 A study by
Matsuyama and colleagues showed that an Er:YAG
laser at 30 mJ/pulse and 30 Hz with water spray was
capable of effectively removing plaque and calculus
without injuring the implant surfaces.142 Schwarz and
colleagues observed that the Er:YAG laser resulted in
a statistically significant higher reduction of BOP
than mechanical debridement with plastic curettes
and antiseptic therapy.143 Takasaki and colleagues
demonstrated that degranulation and implant surface
debridement were obtained effectively and safely by the
Er:YAG laser and that a favorable formation of new
bone was observed on the laser-treated implant surface
histologically.144
Kreisler and colleagues performed an extensive
study of numerous lasers including Nd:YAG, Ho:YAG,
Er:YAG, CO2, and diode lasers for implant decontami-
nation.138 It was found that Nd:YAG and Ho:YAG were
not suitable for implant surface decontamination
because of partial melting, cracking, and crater forma-
tion on implant surfaces irrespective of the power
output. The Er:YAG and CO2 lasers were recommended
for use at low power settings so as to avoid surface
damage. However, the diode laser did not cause surface
changes. Thus, despite their being popular choices,
care must be taken when implants are decontaminated
with either CO2 or Er:YAG lasers to avoid temperature
10 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015
increases above the critical threshold (10°C) after 10
seconds of continuous irradiation.145,146
SURGICAL TECHNIQUES
Typically, surgical techniques and reconstructive proce-
dure are more effective but limited to moderate to severe
peri-implantitis. Below is a list of various techniques
used for the treatment of peri-implantitis.
Apically Positioned Flaps
Apically positioned flap surgery is aimed at decontami-
nating the implant surface and exposing the affected
part of the implant to the oral cavity for better self-
managed oral hygiene,147 often accompanied by osteo-
plasty.148 This technique is very similar to apically
positioned flaps for natural teeth and enables reduced
pocket debts, facilitating patient hygiene. This technique
has clear drawbacks and is only recommended for
nonaesthetic regions, however.149
Access Flap Surgery
Access flap surgery is a surgical way to decontaminate
the implant surface while maintaining the soft tissues
around the affected implant. The aim of this surgery is
to maintain the soft tissue around the implant neck, and
it is recommended when bone loss is minimal. Follow-
ing the access flap, the technique may be combined with
various other methods such as curettes, air-abrasive
devices, ultrasonic devices, and lasers to enhance clean-
ing efficacy.150
A regenerative technique is mainly utilized to
support the tissue dimensions to avoid mucosa reces-
sion. After decontamination of the implant surface, a
graft may be placed around the implant, filling the peri-
implant defect. The graft commonly used is either
autologous bone151 or bone substitutes,152 and combined
with or without a resorbable or nonresorbable mem-
brane.151,153 Furthermore, the use of a connective
tissue graft with a bone graft may be advantageous
aesthetically.154
The long-term goal of a regenerative procedure
should be the re-adhesion of the peri-implant soft tissue
and further enhancement of bone regeneration around
the implant surface. The change in probing depth has
also been compared for various bone grafting materials.
Aghazadeh and colleagues demonstrated that xenografts
are better than autogenous grafts in reducing the
probing depth,155 and others have demonstrated that
Soft Tissues around Implants 627
synthetically fabricated hydroxyapatite performed worse
than xenografts.152 Although the data comparing bone
grafting materials for the treatment of peri-implantitis
remain very limited, it has been observed in numerous
studies that a xenograft in combination with a
resorbable membrane increases clinical attachment
level.152,153,156–158
ADDITIONAL CAUSES OF PERI-IMPLANT
INFLAMMATION
Although the aim of this review article was to examine
differences between soft tissues found in natural teeth
and dental implants as well as their related health and
maintenance programs, it is also vital to state that many
additional factors and etiologies are constantly being
investigated for their possible roles in peri-implantitis.
For example, recent reports have suggested that cement-
retained crowns have been more prone to peri-
implantitis when compared with their screw-retained
counterparts.159–161 Some reports suggest that when sur-
gical flaps were raised to treat peri-implant bone loss,
over 70% of cases presented excessive cement in cement-
retained crowns.162 As a result from over-contour of
cement, oral bacteria accumulation and a greater
inflammatory response leading to eventual bone loss
pose a greater risk for peri-implantitis.163 For these
reasons, it has become more mainstream to use screw-
retained implants when possible or to modify cementing
techniques to avoid excess cement in peri-implant soft
tissues.164 Another area of research which has gained
tremendous awareness over the last decade is the effect
of micro-gaps between implant components and their
effect on bacterial microleakages.165,166 Some investiga-
tors have reported that these gaps have been reported as
large as 70 um implant-abutment interface, and implant
design may affect the potential risk for invasion of oral
microorganisms into the fixture-abutment interface
microgap under dynamic loading conditions.165,167–170
Further research to improve the implant to abutment
connection will further decrease the likelihood of soft
and hard tissue inflammation around implants.
SUMMARY AND CONCLUSIONS
Osseointegration is a special kind of bone healing
process, and the intact peri-implant seal plays an impor-
tant role in protecting the alveolar bone from bacterial
invasion in the oral cavity. However, because of the
structural differences between implants and natural
628 Clinical Implant Dentistry and Related Research, Volume 18, Number 3, 2016
teeth, there are drawbacks in peri-implant soft tissue
healing compared with natural teeth such as deeper
probing depth, weaker connective tissue attachment,
faster inflammatory expansion, and reduced vascular
supply, making the implant more vulnerable to bacterial
accumulations and other external stimulations. Thus, it
is clear that implant surfaces necessitate more attention
to the maintenance of peri-implant soft tissue health. It
is also vital that patient self-management is rigorously
employed, and this should be stressed at each dental
consultation. Dentists have a variety of means to
promote soft tissue health around implants, such as
using both mechanical and chemical methods to remove
plaque and calculus. However, when the implant surface
is contaminated with peri-implantitis, the healthcare
professional must utilize methods of decontamination,
re-osseointegration, and re-adhesion of soft tissues
around implant collars. Both nonsurgical and surgical
techniques exist to facilitate this attachment; however, a
great deal of research is still necessary in terms of com-
paring the different options available to dentists to gen-
erate long-term predictable results. Future research
should better define the most predictable methods for
decontamination of implant surfaces and characterize
the effects of surface material and surface topography on
the various implant systems. An ever-increasing number
of implant companies offer various soft tissue connec-
tions either to the abutments in bone-level implants or
to the implant collar in tissue level implants. Although
new implant companies frequently demonstrate the
effects of their surface topography on bone-forming
osteoblasts, much research on the most effective
transmucosal attachment system is necessary to prevent
further peri-implant tissue inflammation. Direct com-
parisons between the various implant systems as well as
cell behavior need to be conducted which offer more
evidence on the best peri-implant tissue attachment at
the connective tissue and epithelial levels. The field of
peri-implantitis faces many upcoming challenges to
meet the large number of dental implants that is now
placed every year, and more importance should be given
to the health and maintenance of soft tissues around
implants.
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