With aesthetic dentistry becoming increasingly in demand, it is important to understand the soft tissue healing around implants. Continuing on from our blog on hard tissue last week, we’ll now consider the soft tissue healing process.
Our dental specialists at ARIA stress the importance of successful soft tissue healing. This provides the appearance of a natural periodontium, with the implant fully integrated into the patient’s dental arch. Below we’ll cover the basics of the soft tissue healing process.
Inflammatory
Similar to hard tissue healing, the first phase is an inflammatory process. After bleeding begins, the coagulation and complement cascades are activated. This blood coagulum separates the oral mucosa from the implant surface and alveolar bone (Villar, Huynh-Ba, Mills, & Cochran, 2011; Wang, Zhang, & Miron, 2016). Vascular permeability then allows inflammatory cells to infiltrate this coagulum, especially polymorphonuclear cells which are largely responsible for the inflammatory response. Inflammatory mediators activate these neutrophils and differentiate monocytes to macrophages (Wang et al., 2016). These macrophages secrete angiogenetic and fibroblast-stimulating cytokines, which replace the inflammatory cells with a dense fibrin network (Wang et al., 2016). This forms the initial mucosal seal, a fibrin layer, four days after implant placement.
Proliferative
Fibroblasts then invade the fibrin network. They secrete extracellular components, and in particular fibrin, collagen, fibronectin and glycosaminoglycans (Schultze-Mosgau et al., 2005). Surface receptors on adhesion molecules mediate the composition of this new matrix. This slowly replaces the initial fibrin network to form a connective tissue. By two weeks, fibroblasts are in close contact to the implant surface, and this newly formed tissue is richly vascularised (Villar et al., 2011). There are also early signs of proliferation and migration of epithelial cells from the margins of the soft tissue wound. This forms the initial junctional epithelium. Its contact with the peri-implant mucosa and implant gradually lengthens over time (Villar et al., 2011).
2 weeks after implant placement with epithelium forming at the mucosal margins. (Berglundh, Abrahamsson, Welander, Lang, & Lindhe, 2007)
Remodelling
This phase begins before the proliferative phase finishes. The collagen deposition in the wound continues from the proliferative phase, while this provisional connective tissue matrix is remodelled (Schultze-Mosgau et al., 2005). Integrin-receptor patterns play a role in the collagen and connective tissue matrix compositions to form the mucoperiosteal matrix. Maturation of this matrix includes forming a mature epithelial barrier, as well as organisation and alignment of the collagen fibres (Villar et al., 2011). This is between weeks 6 and 12, and clinically is the most important phase as it determines the quality of the regenerated tissue.
With all of this in mind, it is also important to remember that soft tissue form is largely dependent on the underlying hard tissue. To access our blog on hard tissue healing around dental implants, click here.
Specialist prosthodontists and periodontists at our Melbourne and Adelaide courses can guide you in producing the soft tissue aesthetics for implant treatment.
References
Schultze-Mosgau, S., Blatz, M. B., Wehrhan, F., Schlegel, K. A., Thorwart, M., & Holst, S. (2005). Principles and mechanisms of peri-implant soft tissue healing. Quintessence Int, 36(10), 759-769.
Berglundh, T., Abrahamsson, I., Welander, M., Lang, N. P. et Lindhe, J.. (2007). Morphogenesis of the peri-implant mucosa: an experimental study in dogs. Clinical oral implants research, 18(1), 1‑8. doi:10.1111/j.1600-0501.2006.01380.x
Villar, C. C., Huynh-Ba, G., Mills, M. P., & Cochran, D. L. (2011). Wound healing around dental implants. Endodontic Topics, 25(1), 44-62. doi:10.1111/etp.12018
Wang, Y., Zhang, Y., & Miron, R. J. (2016). Health, Maintenance, and Recovery of Soft Tissues around Implants. Clinical Implant Dentistry and Related Research, 18(3), 618-634. doi:10.1111/cid.12343
