Soft Tissue-implant Interface Research Articles

Dynamics of Mucosal Integration of Machined versus Anodized Titanium Implants.

The long-term success of dental implants depends on the ability of soft tissues to form a protective barrier, limiting pathogen infiltration into peri-implant tissues. Here, we investigated the impact of an anodized surface modification on mucosal integration. Scanning electron microscopy and surface chemistry characterization were carried out on miniaturized implants. Following placement in fresh extraction sockets of mice, peri-implant tissues were examined at 4 time points. Histology along with quantitative immunohistochemistry for Keratin14, Vimentin, Laminin5, and CD68 were carried out on postimplant day (PID) 3 to assess early events in soft-tissue repair; on PID7, when peri-implant epithelialization was complete; at PID14, when osseointegration was complete; and at PID28, when soft-tissue maturation was nearing completion. In all cases, an intact junctional epithelium served as a reference. These analyses supported 3 conclusions: first, maturation of the peri-implant epithelium (PIE) is a protracted process, consistent with clinical observations. Second, maturation of the soft tissue-implant interface is slower than maturation of the bone-implant interface. Third, there is a benefit, albeit transient, to soft-tissue maturation around an anodized implant surface. Given its prolonged time course, strategies to improve and/or accelerate PIE maturation are likely to have significant clinical benefit.

Dynamic analyses of a soft tissue-implant interface: Biological responses to immediate versus delayed dental implants.

To qualitatively and quantitatively evaluate the formation and maturation of peri-implant soft tissues around 'immediate' and 'delayed' implants. Miniaturized titanium implants were placed in either maxillary first molar (mxM1) fresh extraction sockets or healed mxM1 sites in mice. Peri-implant soft tissues were evaluated at multiple timepoints to assess the molecular mechanisms of attachment and the efficacy of the soft tissue as a barrier. A healthy junctional epithelium (JE) served as positive control. No differences were observed in the rate of soft-tissue integration of immediate versus delayed implants; however, overall, mucosal integration took at least twice as long as osseointegration in this model. Qualitative assessment of Vimentin expression over the time course of soft-tissue integration indicated an initially disorganized peri-implant connective tissue envelope that gradually matured with time. Quantitative analyses showed significantly less total collagen in peri-implant connective tissues compared to connective tissue around teeth around implants. Quantitative analyses also showed a gradual increase in expression of hemidesmosomal attachment proteins in the peri-implant epithelium (PIE), which was accompanied by a significant inflammatory marker reduction. Within the timeframe examined, quantitative analyses showed that connective tissue maturation never reached that observed around teeth. Hemidesmosomal attachment protein expression levels were also significantly reduced compared to those in an intact JE, although quantitative analyses indicated that macrophage density in the peri-implant environment was reduced over time, suggesting an improvement in PIE barrier functions. Perhaps most unexpectedly, maturation of the peri-implant soft tissues was a significantly slower process than osseointegration.

Construction of silver-coated high translucent zirconia implanting abutment material and its property of antibacterial

High translucent zirconia (HTZ) has excellent mechanical properties, biocompatibility, and good semi-translucency making it an ideal material for aesthetic anterior dental implant abutments without antibacterial properties. In the oral environment, the surface of the abutment material is susceptible to microbial adhesion and biofilm formation, which can lead to infection or peri-implantitis and even implant failure. This study aims to promote the formation of a biological seal at the implant-soft tissue interface by modifying the HTZ surface, using the load-bearing capacity of the aluminosilicate porous structure and the broad-spectrum antibacterial effect of silver nanoparticles to prevent peri-implant bacterial infection and inflammation and to improve the success rate and prolong the use of the implant. FE-SEM (field emission scanning electron microscopes), EDS (energy dispersive spectroscopy), and XPS (X-ray photoelectron spectroscopy) results showed that aluminosilicate non-vacuum sintering can form open micro- and nanoporous structures on HTZ surfaces, and that porous aluminosilicate coatings obtain a larger number, smaller size, and more uniformly shaped silver nanoparticles than smooth aluminosilicate coatings, and could be deposited deeper in the coating. The ICP-AES (inductively coupled plasma-atomic emission spectroscopy) results showed that the early silver ion release of both the smooth silver coating and the porous silver coating was obvious, the silver ion concentration released by the former was higher than that of the latter. However, the silver ion concentration released by the porous silver coating was higher than that of the smooth coating when the release slowed down. Both smooth and porous silver coatings both inhibited E. coli (Escherichia coli), S. aureus (Staphylococcus aureus), and L. acidophilus (L. acidophilus), and porous silver coatings had stronger antibacterial properties. The silver coating was successfully constructed on the surface of HTZ, through aluminium silicate sintering and silver nitrate solution impregnation. It was found that the high concentration environment of silver nitrate solution was more advantageous for nano-Ag deposition, and the non-vacuum sintered porous surface was able to obtain a larger number of nano-Ag particles with smaller sizes. The porous Ag coating exhibited superior antibacterial properties. It was suggested that the HTZ with silver coating had clinical application, and good antibacterial properties that can improve the survival rate and service life of implants.

Influence of Surface Characteristics of TiO2 Coatings on the Response of Gingival Cells: A Systematic Review of In Vitro Studies.

The soft tissue-implant interface requires the formation of epithelium and connective tissue seal to hinder microbial infiltration and prevent epithelial down growth. Nanoporous titanium dioxide (TiO2) surface coatings have shown good potential for promoting soft tissue attachment to implant surfaces. However, the impact of their surface properties on the biological response of gingival cells needs further investigation. This systematic review aimed to investigate the cellular behavior of gingival cells on TiO2-implant abutment coatings based on in vitro studies. The review was performed to answer the question: "How does the surface characteristic of TiO2 coatings influence the gingival cell response in in vitro studies?". A search in MEDLINE/PubMed and the web of science databases from 1990 to 2022 was performed using keywords. A quality assessment of the studies selected was performed using the SciRAP method. A total of 11 publications were selected from the 289 studies that fulfilled the inclusion criteria. The mean reporting and methodologic quality SciRAP scores were 82.7 ± 6.4/100 and 87 ± 4.2/100, respectively. Within the limitations of this in vitro systematic review, it can be concluded that the TiO2 coatings with smooth nano-structured surface topography and good wettability improve gingival cell response compared to non-coated surfaces.

Optimization of Lactoferrin-Derived Amyloid Coating for Enhancing Soft Tissue Seal and Antibacterial Activity of Titanium Implants.

A poor seal of the titanium implant-soft tissue interface provokes bacterial invasion, aggravates inflammation, and ultimately results in implant failure. To ensure the long-term success of titanium implants, lactoferrin-derived amyloid is coated on the titanium surface to increase the expression of cell integrins and hemidesmosomes, with the goal of promoting soft tissue seal and imparting antibacterial activity to the implants. The lactoferrin-derived amyloid coated titanium structures contain a large number of amino and carboxyl groups on their surfaces, and promote proliferation and adhesion of epithelial cells and fibroblasts via the PI3K/AKT pathway. The amyloid coating also has a strong positive charge and possesses potent antibacterial activities against Staphylococcus aureus and Porphyromonas gingivalis. In a rat immediate implantation model, the amyloid-coated titanium implants form gingival junctional epithelium at the transmucosal region that resembles the junctional epithelium in natural teeth. This provides a strong soft tissue seal to wall off infection. Taken together, lactoferrin-derived amyloid is a dual-function transparent coating that promotes soft tissue seal and possesses antibacterial activity. These unique properties enable the synthesized amyloid to be used as potential biological implant coatings.

The response of soft tissue cells to Ti implants is modulated by blood-implant interactions.

Titanium-based dental implants have been highly optimized to enhance osseointegration, but little attention has been given to the soft tissue-implant interface, despite being a major contributor to long term implant stability. This is strongly linked to a lack of model systems that enable the reliable evaluation of soft tissue-implant interactions. Current in vitro platforms to assess these interactions are very simplistic, thus suffering from limited biological relevance and sensitivity to varying implant surface properties. The aim of this study was to investigate how blood-implant interactions affect downstream responses of different soft tissue cells to implants in vitro, thus taking into account not only the early events of blood coagulation upon implantation, but also the multicellular nature of soft tissue. For this, three surfaces (smooth and hydrophobic; rough and hydrophobic; rough and hydrophilic with nanostructures), which reflect a wide range of implant surface properties, were used to study blood-material interactions as well as cell-material interactions in the presence and absence of blood. Rough surfaces stimulated denser fibrin network formation compared to smooth surfaces and hydrophilicity accelerated the rate of blood coagulation compared to hydrophobic surfaces. In the absence of blood, smooth surfaces supported enhanced attachment of human gingival fibroblasts and keratinocytes, but limited changes in gene expression and cytokine production were observed between surfaces. In the presence of blood, rough surfaces supported enhanced fibroblast attachment and stimulated a stronger anti-inflammatory response from macrophage-like cells than smooth surfaces, but only smooth surfaces were capable of supporting long-term keratinocyte attachment and formation of a layer of epithelial cells. These findings indicate that surface properties not only govern blood-implant interactions, but that this can in turn also significantly modulate subsequent soft tissue cell-implant interactions.

Fabrication and evaluation of antimicrobial biomimetic nanofiber coating for improved dental implant bioseal: An in vitro study.

A weak implant-soft tissue interface may lead to bacterial ingression, breakdown of underlying tissues, and eventually implant failure. This study proposes a surface modification technique of titanium alloy (Ti), using a nano-biopolymer scaffold to enhance soft tissue attachment in dental implants. Gelatin (20% w/v) embedded with 10 ± 2nm silver nanoparticles (AgNPs) was electrospun to form a gelatin electrospun mat (GEM) scaffold, bonded to Ti alloy surface using chemical surface functionalization. Antimicrobial activity of AgNPs was tested against representative Gram-positive (Staphylococcus aureus) and Gram-negative bacteria (Escherichia coli) at 4, 24, and 48hours and after embedding in scaffold at 48 hours. Cytotoxicity analysis (MTT assay) was performed using the 3T3 mouse fibroblast cell line at 24 and 72 hours for two groups: control (unmodified Ti disc) and experimental (GEM embedded with AgNPs); and further validated by scanning electron microscopy. The AgNPs-embedded GEM showed good antimicrobial activity at 48 hours, with the AgNPs showing complete (99.99%) inhibition of bacterial colony counts at 24 and 48 hours. Cell viability and proliferation over the GEM modified Ti discs were seen to be significantly increased (P<0.05) at 72 hours as compared with control. SEM images revealed intimate spreading of fibroblasts, with differentiated cell morphology and pseudopodial processes, indicative of enhanced fibroblastic adhesion, growth, and differentiation over the scaffold. Results show good antifouling properties and biocompatibility of the fabricated coating, making it a promising strategy to reduce postoperative infections and peri-implant diseases in Ti dental implants.

Periodontal Evaluation of One-Piece and Two-Piece Single Implant Loaded in Esthetic Zone

Background: Soft tissue around dental implant is an important anatomical feature contributing to the long-term implant success and esthetics, different factors may influence the soft tissue-implant interface. The purposes of the current study were to evaluate the soft tissue profile around one-piece and two-piece implants loaded in esthetic zone. Method: Totally thirty patients who had single missing tooth in premaxillary region were included in the study. Fifteenth patients’ group-A were assigned to immediate loading one-piece implant and fifteen patients’ group-B were assigned to early loading two-piece implant protocol. Flapless approach was performed for both groups. In group-A, implants were loaded immediately with a temporary crown within 48h, while group-B, were loaded after two months following conventional impression for metal ceramic crown. Clinical outcomes were evaluated after two and six months in terms of success rate, papillary index, plaque index and width of keratinized mucosa. Results: The success rate in group-A found to be 80%, which was lower than the success rate in group-B (100%). On comparison, there was no statistically significant difference in success rate between the two study groups. There was no statistically significant difference between both groups over time in clinical parameters like plaque index, width of keratinized gingiva and papillary index. Conclusion: The results of this study indicated that using either immediately loading one-piece implants or early loaded two-piece implants protocol demonstrated the same enhancements of implant esthetics

Advances in implant therapy in North America: Improved outcomes and application in the compromised dentition

Advances in dental implant therapy have strengthened our understanding of the management of the implant-soft tissue interface, with site-specific implications ranging from marginal tissue management and esthetics to immediate placement and restoration, and extend to patient-level implications of systemic conditions. The advancements in implant therapy have placed an increased emphasis on patient-centered outcomes. In this paper, the following conclusions can be drawn: improvements in both esthetics and long-term maintenance have been guided by the study of the marginal peri-implant tissues leading to innovations in implant design along the implant-abutment interface. Patient expectations for simple and realistic time intervals for treatment have promoted the use of immediate implant placement and restoration. The expansion of implant therapy offers implant options for patients with medical conditions, with one in particular, diabetes mellitus a focus of this paper. Studies on patients with diabetes are supporting the development of evidence-based treatment considerations with broader application and greater benefits for the use of implant therapy across a larger patient population. This paper is not intended to offer a comprehensive review, but offers a representative review of some of the many contributions of USA and North American clinicians to the global scientific dialogue that has guided the development of dental implant therapy.

Titanium surface modifications and their soft-tissue interface on nonkeratinized soft tissues-A systematic review (Review).

In this systematic review, the authors explored the surface aspects of various titanium (Ti) or Ti alloy medical implants, examining the interface formed between the implant and surrounding nonkeratinized soft tissues (periosteum, muscles, tendons, fat, cicatrix, or dura mater). A comprehensive search undertaken in July 2019 used strict keywords in relevant electronic databases to identify relevant studies. Based on the authors' inclusion criteria (restricted to in vivo studies), 19 of 651 publications qualified, all pertaining to animal models. The syrcle's risk of bias tool for animal studies was applied at study level. Given the broad nature of the reported results and the many different parameters measured, the articles under scrutiny were assigned to five research subgroups according to their surface modification types: mechanical surface modifications, oxidative processes (e.g., acid etching, anodization, microarc oxidation), sol-gel derived titania (TiO2) coatings, biofunctionalized surfaces, and a subgroup for other modifications. The primary outcome was a liquid space at the interface (e.g., seroma formation) that was reported in six studies. Machining Ti implants to a roughness between Ra = 0.5 and 1.0 μm was shown to induce soft-tissue adhesion. Smoother surfaces, with the exception of acid polished and anodized Ti (Ra = 0.2 μm), prevented soft-tissue adhesion. A fibroblast growth factor 2 apatite composite coating promoted soft-tissue attachment via Sharpey-like fibers. In theory, this implant-soft tissue interface could be nearly perfect.

Strategies for Optimizing the Soft Tissue Seal around Osseointegrated Implants.

Percutaneous and permucosal devices such as catheters, infusion pumps, orthopedic, and dental implants are commonly used in medical treatments. However, these useful devices breach the soft tissue barrier that protects the body from the outer environment, and thus increase bacterial infections resulting in morbidity and mortality. Such associated infections can be prevented if these devices are effectively integrated with the surrounding soft tissue, and thus creating a strong seal from the surrounding environment. However, so far, there are no percutaneous/permucosal medical devices able to prevent infection by achieving strong integration at the soft tissue-device interface. This review gives an insight into the current status of research into soft tissue-implant interface and the challenges associated with these interfaces. Biological soft/hard tissue interfaces may provide insights toward engineering better soft tissue interfaces around percutaneous devices. In this review, focus is put on the history and current findings as well as recent progress of the strategies aiming to develop a strong soft tissue seal around osseointegrated implants, such as orthopedic and dental implants.

Ultrastructural analysis of implant-soft tissue interface on a three dimensional tissue-engineered oral mucosal model

Ultrastructural analysis of implant-soft tissue interface on a three dimensional tissue-engineered oral mucosal model

Biologic Width around Dental Implants: An Updated Review

Soft tissue-implant interface is an important anatomical feature contributing to the long-term success of dental implants. Based on the available evidence, different factors may influence biological width around implants including the surgical technique, implant loading, implant surface properties, abutment materials, implant position, and width of the peri-implant mucosa. The purpose of the present review was critical evaluation of the available data, regarding the factors that may influence the biologic width around implants and their subsequent effect on clinical performance of implants. Available literature on this subject published primarily in English from 1921 to 2014, was found by searching several electronic databases and by hand searching relevant journals as well. Totally, 70 relevant articles were selected for this narrative review. The structure of peri-implant mucosa has many similarities, as well as differences with its periodontal counterpart. Most studies report larger values for peri-implant biologic width compared to that of natural teeth. This literature review yielded contradictory data regarding the dimensions of the biologic width when different influential factors were taken into account. .

Using QCM-D to study the adhesion of human gingival fibroblasts on implant surfaces.

Sealing the soft tissue-implant interface is one of the key issues in preventing transcutaneous implant-associated infections. A promising surface modification for improving osseointegration and possibly soft tissue integration is to coat the implant surface with hydroxyapatite (HA) nanoparticles. When new implant materials are developed, their ability to facilitate cell attachment and spreading are commonly investigated in vitro to establish their potential for good in vivo performance. However, commonly used techniques, such as microscopy methods, are time consuming, invasive, and subjective. This is the first study using quartz crystal microbalance with dissipation monitoring, where the real-time adhesion of biopsy-derived human gingival fibroblasts onto titanium and nanostructured HA was investigated. Experiments were performed for at least 16 h, and we found that cellular attachment and spreading kinetics can be followed in situ by observing the change in dissipation and frequency with time. Interestingly, a correlation between cell coverage and the magnitude of dissipation shift reached at the end of the experiment was found, but no such trend was observed for the frequency. Furthermore, the level of cell coverage was found to influence the cellular attachment and spreading behavior. No difference in cell response to the two surface types, Ti and nanostructured HA, was found.

Dependence of macrophage superoxide release on the pulse amplitude of an applied pressure regime: a potential factor at the soft tissue-implant interface

Failure of soft tissue implants has been largely attributed to the influence of biomaterial surface properties on the foreign body response, but some implant complications, e.g. macrophage accumulation and necrosis, are still not effectively addressed with surface treatments to minimize deleterious biomaterial effects. We explored an alternative explanation for implant failure, linking biocompatibility with implant micromotion-induced pressure fluctuations at the tissue-biomaterial interface. For this purpose, we used a custom in vitro system to characterize the effects of pressure fluctuations on the activity of macrophages, the predominant cells at a healing implant site. Initially, we quantified superoxide production by HL60-derived macrophage-like cells under several different pressure regimes with means of 5-40 mmHg, amplitudes of 0-15 mmHg and frequencies of 0-1.5 Hz. All pressure regimes tested elicited significantly (p < 0.05) reduced superoxide production by macrophage-like cells relative to parallel controls. Notably, pressure-sensitive reductions in superoxide release correlated (r(2) = 0.74; p < 0.01) only with pulse pressures. Based on the connection between superoxide production and cell viability, we also explored the influence of cyclic pressure on macrophage numbers and death. Compared to controls, adherent macrophage-like cells exposed to 7.5/2.5 mmHg cyclic pressures for 6 h exhibited significantly (p < 0.01) reduced cell numbers, independent of cell death. A similar effect was observed for cells treated with 10 U/ml superoxide dismutase. Collectively, our results suggest that pressure pulses are a putative regulator of macrophage adhesion via a superoxide-related effect. Pressure fluctuations, e.g. due to implant micromotion, may, therefore, potentially modulate macrophage-dependent wound healing.

Contour analysis of an implant-soft tissue interface

Studies of peri-implant soft tissue on invivo models are commonly based on histological sections prepared using undecalcified or 'fracture' techniques. These techniques require the cutting or removal of implant during the specimen preparation process. The aim of this study is to explore a new impression technique that does not require any cutting or removal of implant for contour analysis of soft tissue around four types of titanium (Ti) surface roughness using an invitro three-dimensional oral mucosal model (3D OMM). The 3D OMM was constructed by co-culturing a keratinocyte cell line TR146 and human oral fibroblasts on to an acellular dermis scaffold. On the fourth day, a Ti disk was placed into the model. Four types of Ti surface topographies, i.e. polished, machined, sandblasted and anodized were tested. After 10d of culture, the specimens were processed based on undecalcified (ground sectioning), electropolishing and impression techniques for contour analysis of the implant-soft tissue interface. Under light microscopic examination of the ground and electropolishing sections, it was found that the cell line-based oral mucosa formed a peri-implant-like epithelium attachment on to all four types of Ti surfaces. In contour analysis, the most common contour observed between the cell line-based oral mucosa and Ti surface was at an angle ranging between 45° and 90°. The invitro cell line-based 3D OMM formed a peri-implant-like epithelium at the implant-soft tissue interface. The contour of the implant-soft tissue interface for the four types of Ti surface was not significantly different.

Magnetoelastic vibrational biomaterials for real-time monitoring and modulation of the host response

Magnetoelastic (ME) biomaterials are ferromagnetic materials that physically deform when exposed to a magnetic field. This work describes the real-time control and monitoring capabilities of ME biomaterials in wound healing. Studies were conducted to demonstrate the capacity of the materials to monitor changes in protein adsorption and matrix stiffness. In vitro experiments demonstrated that ME biomaterials can monitor cell adhesion and growth in real-time, and a long-term in vivo study demonstrated their ability to monitor the host response (wound healing) to an implant and control local cell density and collagen matrix production at the soft tissue-implant interface. This approach represents a potentially self-aware and post-deployment activated biomaterial coating as a means to monitor an implant surface and provide an adjuvant therapy for implant fibrosis.

Changes in soft tissues around immediate full‐arch rehabilitations: a prospective study

Nowadays, aesthetic appearance is receiving more and more attention from clinicians and patients. Therefore, it is of paramount importance for the surgeon to maintain or to improve the quality and the stability of the soft tissue-implant interface. The scientific literature supports the idea that the immediate placement and provisionalization of endosseus implants and abutments can indeed offer additional clinical control over the peri-implant tissue architecture. On this basis, this prospective study aims to evaluate the changes in soft tissues around immediately loaded dental implants in full-arch rehabilitations, over a period of 3 months. Fifteen subjects were treated for immediate full-arch rehabilitations. Following implant placement, provisional rehabilitations made of bisphenol-A-glycidyldimethacrylate (BIS-GMA) and resin were placed. All records were made using a periodontal probe. The facial soft-tissue level was measured evaluating the distance between the soft-tissue margin and the incisal edge of the crown. Moreover, papilla levels were measured at the mesial and distal sites from a reference line connecting the occlusal edge of the crowns. The average value at the mesial site was -0.035 mm (±1, median 0 mm), while at the midfacial site, it was 0 mm (±0.76, median 0 mm) and at the distal site, -0.05 mm (±0.92, median 0 mm). The plaque score index showed a reduction during the follow-up period. Our data indicate that no differences at the midfacial point were detectable over the observation period. This is in agreement with several studies; it is plausible that these results are linked to a correct position of the implant in the alveolar socket. Moreover, comparing our results with what has been reported by other authors, it is surprising that while other studies highlight that papilla loss at the mesial and distal aspect is an expected consequence of immediate implant restorations, our data do not show any changes. The explanation of these results remains unclear. Further studies are needed to support our data and to clarify what mechanisms are involved in the maintenance of soft tissue.

Ultrastructural analysis of implant–soft tissue interface on a three dimensional tissue‐engineered oral mucosal model

A three dimensional tissue-engineered human oral mucosal model (3D OMM) used in the investigation of implant-soft tissue interface was recently reported. The aim of this study was to examine the ultrastructural features of soft tissue attachment to various titanium (Ti) implant surfaces based on the 3D OMM. Two techniques, that is, focus ion beam (FIB) and electropolishing techniques were used to prepare specimens for transmission electron microscopic (TEM) analysis of the interface. The 3D OM consisting of both epithelial and connective tissue layers was constructed by co-culturing human oral keratinocytes and fibroblasts onto an acellular dermis scaffold. Four types of Ti surface topographies were tested: polished, machined (turned), sandblasted, and TiUnite. The specimens were then processed for TEM examination using FIB (Ti remained) and electropolishing (Ti removed) techniques. The FIB sections showed some artifact and lack of details of ultrastructural features. In contrast, the ultrathin sections prepared from the electropolishing technique showed a residual Ti oxide layer, which preserved the details for intact ultrastructural interface analysis. There was evidence of hemidesmosome-like structures at the interface on the four types of Ti surfaces, which suggests that the tissue-engineered oral mucosa formed epithelial attachments on the Ti surfaces.

A review of histomorphometric analysis techniques for assessing implant-soft tissue interface

A review of histomorphometric analysis techniques for assessing implant-soft tissue interface