Tsao and WangInt Chin J Dent 2003; 3: 13-30.

Periodontal considerations in implant therapy
Yi-Pin Tsao, DDS, and Hom-Lay Wang, DDS, MSD
Department of Periodontics/Prevention/Geriatrics, School of Dentistry, Universityof Michigan, Ann Arbor, MI, USA
Purpose: This paper is aimed to address periodontal considerations around dental implants. Tools used to
identify disease/infection and techniques developed to correct peri-implant infection were thoroughly
discussed. Procedures that have been successful used in maintaining/correcting soft/hard tissue problems
around dental implants were explored.
Materials and Methods: Critical appraisal of the current techniques regarding the soft/hard tissue grafts is
performed. Techniques that have shown predictable outcomes were selected and discussed. Guidelines fortreating peri-implant infection and dealing with different soft/hard tissue defects were provided.
Results: Peri-implant infection can be early identified and treated. Ridge preservation as well as guided
bone regeneration prior to implant placement had been widely adopted as the predictable treatment
methods. Soft tissue grafting such as connective tissue graft, ovate pontic site development, and othercommon soft tissue grafts (e.g., roll, pouch, interpositional grafts, onlay grafts and combination grafts) canbe successfully applied in augmenting peri-implant tissue height and width while achieving esthetics
around dental implants. In addition, implant maintenance care is necessary for the overall success.
Conclusion: To maintain implant long-term success, the interface between soft and hard tissues should beclearly understood. Several procedures such as ridge preservation and guided bone regeneration haveshown promising results in restoring/maintaining the alveolar bone height and width to facilitate ideal
implant placement. Many soft tissue grafts, for example connective tissue graft, have been used to augment
soft tissue thickness while provide esthetic results around dental implants.
(Int Chin J Dent 2003; 3: 13-30.)
Clinical Significance: This paper provides ways of maintaining/correcting soft/hard tissue defects arounddental implants.
Key Words: dental implant, guided bone regeneration, implant maintenance, implant plastic surgery,peri-implant mucosa, soft tissue graft.

Introduction
Dental implants have been shown to successfully replace missing teeth while provide all restorative
functional needs. Techniques and materials have been developed over the years to facilitate a high degreeof clinical success. Nonetheless, the ultimate long-term success of implants is largely relied upon the13Tsao and WangInt Chin J Dent 2003; 3: 13-30.

interface between implants and their surrounding tissues, both soft and hard tissues. Dental implants have
two distinct interfaces with oral tissues. First, the soft tissue-implant interface is where the peri-implantmucosa meets the implant creating a biological seal to prevent future disease invasion. Due to the naturalof the tissue components, soft tissues surrounding the dental implants are called peri-implant mucosa
instead of gingiva. And second, the hard tissue-implant interface is where the alveolar bone contact withimplant surface. This integration provides stability and rigidity that implant needs.

To achieve andmaintain long-term success of dental implants, it is necessary to understand how these interfaces are andhow they can be maintained. Therefore, the aims of this paper are to discuss these interfaces and torecommend ways of promoting/maintaining these implant biological structures.

Implant/Soft Tissue Interface
Epithelial Attachment
The peri-implant mucosa, similar to the natural gingival, can be divided into two parts: epithelium andconnective tissue. Table 1 summarizes the differences between implants and natural teeth. Briefly, theepithelial tissues around implants move more in apico-coronal direction and as a result it is average 1 mm
longer when compared to natural teeth.1-3 The attachment of epithelial cells to implant surface occurred
directly via basal lamina (<200 nm) and hemidesmosomes which was the same as natural teeth.4-7
The implant surface topography has been shown to play a role in influencing how soft tissue attached todental implant. It is generally agreed that polished surfaces are more compatible to fibroblasts than roughsurfaces.8-12

Obtaining a peri-implant mucosal seal to prevent bacterial invasion is suggested as a

pre-requirement for maintaining long-term success of dental implants.13,14 When the seal is not achieved, it
often leads to apical migration of the epithelium, thus cause partially or completely encapsulation of theendosseous implant.15,16 In natural teeth, the junctional epithelium provides a seal at the base of the sulcus
against the penetration of chemical irritants and bacterial by-products. Once disruption of the seal and/or
destruction of the fibers apical to the epithelium take place, the epithelium migrates apically, forming aperiodontal pocket. Due to the lack of cementum and fiber insertion into the implant surface, the biologic
seal was important in preventing formation of a "peri-implant pocket" extending into the osseous structures.
Connective Tissue Attachment
The average length of connective tissue attachment around implant ranges from 1.3 to 1.8 mm.2,17
Majority of the studies showed a parallel-oriented fiber’s orientation instead of perpendicular as thoseformed in natural teeth.18 In addition, the connective tissue around implants had been shown to possess lessvascularities, more collagen and less fibroblasts when compared to natural teeth. The connective tissue ofthe peri-implant mucosa can be further divided into outer and inner zone. The outer zone located under thejunctional epithelium, is composed of collagen Types I and III and is responsible for the transformation ofcollagen. The inner supracrestal connective tissue zone is composed mainly of Type I collagen and is
responsible for mechanical resistance and stability of the peri-implant mucosa.18,19 The origins of the blood
supplies around implants are terminal branches of large vessels originating from the periosteum and they14

Tsao and WangInt Chin J Dent 2003; 3: 13-30.

differ from that around natural teeth that come from supra-periosteal vessels and the vessels of theperiodontal ligament.
Table 1. Differences between implants and natural teeth.
Natural teeth

Dental implants

Connection

Cementum, PDL, Bone

Osseointegration, Functional ankylosis

Junctional epithelium

Basal lamina and hemidesmosome Basal lamina and hemidesmosome

Connective tissue (fiber orientation)

Perpendicular

Parallel

Vascularity

More

Less

CollagenMore (85%)

Less (65%)

Fibroblasts

Less (1-3%)

More (5-10%)130

Biological width

JE+CT (Fig. 1)
1.91 mm131

2.04 mmSD+JE+CT132

3.09 mm23.80 mm130

JE: Junctional epithelium, CT: Connective tissue, SD: Sulcus depth.

Fig. 1. Biological width in natural teeth.

Fig. 2. Implant thread designs.

Biological Width
The biological width around dental implants acts as a protective barrier against potential bacterial
infection, food debris entrapment into the implant/soft tissue interface. It had been shown in animal andhuman studies that an adequate biological width/seal can only be achieved if there is a supra-crestal smoothtitanium surface of at least 3 mm long in the apico-coronal direction.2,15,20-23 Approximately 2 mm of thesurface was occupied by the junctional epithelium, while the rest 1mm is connective tissue.

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Tsao and WangInt Chin J Dent 2003; 3: 13-30.

Biological width has been reported composed of 2.0 mm of junctional epithelium and 1.3 to 1.8 mm
connective tissue for a two-part implant.17 Similar dimensions were also observed around one-part implant
before and after 12 months loading.2 Recent evidence has suggested that reformation of biological width
may be the primary etiology contributing to early implant crestal bone loss.24 Nevertheless, some authors
have speculated that biological width/seal increases approximately 1 mm after implant loading, possibly
due to crestal bone resorption.25
Keratinized Mucosa to Maintain Implant Health
The need of keratinized mucosa around dental implants to maintain implant mucosa health remains
controversial, since healthy peri-implant tissues can be observed regardless of the amount of keratinizedmucosa.26 It has been reported 90% of overall fixture survival rate even only 67% of these cases had
keratinized mucosa in the facial aspect and 51% in the lingual surfaces.3,26 Hence, it had been challenged
that keratinized mucosa is not the pre-requisite for peri-implant health and movable tissue surrounding
dental implant does not contribute to more implant failure.27,28 On the other hand, some papers havereported increased implant failure rate in the areas of insufficient peri-implant mucosa width.29 Although
the conflicted results existed, it is desirable to have keratinized mucosa around the implant since
keratinized tissue not only promotes resistance to mechanical trauma but also facilitates personal home careand professional maintenance procedure.30,31 Different procedures including connective tissue grafts, freegingival grafts, and others have been described to augment keratinized mucosa around dental implants
successfully.32,33

Implant/Hard Tissue Interface
Successful implant therapy is based on osseointegration, which has been characterized as “a direct
structural and functional connection between ordered living bone and the surface of a load-bearing
implant”.34 Most long-term clinical trials have demonstrated the success of cylindrical, screw-type, smoothsurface titanium implants.
Osseointegration and long-term stability of implant depends on the early interactions between theimplant surface and various cell populations. The early events of optimal bone healing around implant sites
are: protein adsorption, cellular adherence, local factor production, proliferation, matrix production, andcalcification. Ideally, dental implants should have surfaces that result in precise control over these types oftissue activities.
Implant Macrostructure
Thread-designed dental implants have been shown to possess higher surface contact areas, moremechanical retention to maximize initial contact and improve initial stability, and better force distribution
when compared to cylinder-type implants.35,36 The greater the number and the deeper depth of threads, themore functional surfaces are available. Three thread shapes: square, V-shape, and buttress have been usedin implant dentistry (Fig. 2). The face angle of the thread changes the direction of load from the prosthesis
to a different force direction at the bone.

Under axial loading to an implant, a V-threaded face is16

Tsao and WangInt Chin J Dent 2003; 3: 13-30.

comparable to the buttress thread when the face is similar, usually is 30 degree.37 It had been demonstrated
to have 10 times greater shear loads on bone compared with a square thread.37 A square thread had been
proposed to reduce the shear force by transferring a more axial load along the implant body to compress thebone. A buttress thread is optimized for pull-out loads.38 Although the differences in force transfer to bone
was suggested in different thread design, no controlled clinical studies comparing the three designs areavailable.
Implant Microstructure
To improve the clinical success of dental implants, modification of implant surfaces microstructures has
been attempted. Roughened implant surfaces often showed higher adhesive strength than smooth surfaces.
This is supported by most of animal and human biopsy studies where bone-to-implant contact (BIC) andresistance to shear forces by removal-torque values were used to show the differences.39-45 However,controversial remains with regard to the BIC and its clinical relevance. In a study comparing BIC in six
different implant surfaces, HA-coated and sandblasted/acid-etched surfaces showed the highest BIC.46
Similar results were also reported in other studies.39,40,47

Implant Infections and Their Management
Microbiology and occlusal overload are two most common etiologies for implant failure. Nonetheless,bacterial plaque is often regarded as the primary responsible reason for implant failure after loading.48,49
The imbalance between host and parasite causes a series of inflammatory changes, thus leads to two
distinct clinical syndromes; 1) Mucositis is a reversible inflammatory lesion confined to the superficial
peri-implant mucosal tissues. Generally, the prevalence is around 28% after 2 year implant loading.50 2)
Peri-implantitis is a lesion involving the marginal portion of the bone-implant interface besides theperi-implant soft tissues. Five to 10% of overall prevalence has been reported.50
Peri-implant mucositis has the similar clinical characteristics as those of in gingivitis, similar relationshipwas also noted between peri-implantitis and periodontitis.51

Therefore, it has been suggested thatconventional periodontal therapy should be instituted if inflammation develops around implants, as those
happened to natural dentition.52,53

The ailing implants had been defined as problems limited to theperi-implant mucosa and not involving the supporting bone, more recently, as biological complications.48,54
Peri-implant probing depth, mucosal recession, bleeding upon probing, and peri-implant exudation haveall been suggested as useful diagnostic tools for detecting biological complications.55-57 The emergenceprofile of the final restoration influences the accuracy of peri-implant probing depth, since assessing
probing depth around overcontoured crowns is largely irrelevant unless the superstructure is removed toallow parallel probing to the long axis of implant fixture.

In addition, the presence or absence of

inflammation influences the outcome of probing, since probe often penetrates deeper (e.g. close to alveolarbone) in presence of mild to moderate mucositis.58 Stable implants usually present approximately 3 mm ofprobing depth, while diseased implants had deeper penetration of the probe. The deeper implant probing
depth resulted in a shift of microflora (e.g., to more gram negative anaerobics) to induce more disease17

Tsao and WangInt Chin J Dent 2003; 3: 13-30.

invasion.2,57
The microbiological findings related to healthy and failing implants are similar as those in healthy andperiodontally compromised teeth.55,57

Increased levels of subgingival Porphyromonas gingivalis,

Prevotella intermedia, and Fusobacterium nucleatum may lead failure of dental implants. However, failing
implants with a traumatic etiology may have a microflora predominant in streptococci which is consistent
with periodontal health.59 The microbiota present in the remaining dentition may serve as a reservoir forbacterial colonization around implants.60,61 Therefore, it is often recommended to control patient’s overall
periodontal problems before initiate complex implant therapy. Increased levels of PGE2, IL-1ß, and PDGF
were also formed in failing implant sites which indicated that not only the microbiota but also the host
response is similar to those of periodontally diseased teeth.62
Table 2. Implant infections and their proposed treatments.

133

Ailing implant
Definition: Soft tissue inflammation without bone loss
Proposed treatment
Non-surgical treatment: Mechanical debridement, Antibiotic: systemically or locally
Failing implant
Definition: Inflammation with bone loss but without mobility
Proposed treatment
Vertical defect:<2 mm: GBR; Osteoplasty-convert to horizontal defect>2 mm but <1/2 Implant height: GBR; Autogenous bone wedge grafting>1/2 Implant height: Implant removal
Horizontal defect: <1/2 Implant height: APF; Osteoplasty; GBR>1/2 Implant height: Implant removal
Failed implant
Definition: Inflammation with bone loss and with mobility
Proposed treatment: Implant removal
APF: Apically positioned flap, GBR: Guided bone regeneration.

The clinical features of peri-implantitis include: radiographic evidence of vertical destruction of thecrestal bone, not dependant on implants mobility, formation of a peri-implant pocket in association withradiographic bone loss, bleeding after gentle probing, suppuration might also be present, mucosal swelling
and redness, pain is not a typical feature of peri-implantitis.51 Peri-implantitis can lead to ailing implant,
failing implant and failed implant. Treatments of ailing and failing implant remain a challenge to many
clinicians. Once infected, implant surface is contaminated with endotoxin, it must be detoxified before any
regenerative therapy can be performed. The goals of non-surgical and surgical therapies are to re-establish
healthy peri-implant soft and hard tissues. Table 2 listed current available diagnostic criteria for implantfailures as well as their proposed treatment. Occlusal therapy is indicated if occlusal overload is one of
etiologic factors for peri-implant bone loss. Antiseptic non-surgical therapy (e.g. antibiotics) is suggested
by some authors for treating deep pockets more than 5 mm.63,64 Surgical procedures such as regenerative18

Tsao and WangInt Chin J Dent 2003; 3: 13-30.

approaches have been tried and shown promising outcomes after surface is being detoxified. Air powder
abrasions as well as acid (e.g. citric or tetracycline) had been shown to be effective in detoxifying
contaminated implant surfaces.65,66

Esthetic Management Around Dental Implants
Success of implant therapy not only depends on fixture osseointegration and restoration of function, butalso esthetic requirements which arise in recent years. The procedures available for esthetic regenerations
are not as predictable as implant placement procedure. However, esthetic plastic surgical techniques forcorrection of various soft tissue defects including recession, mucogingival defects, and improper gingival
contours have been considered routine procedures during implant therapy.
In attempting to achieve optimal esthetic results after implant therapy, following requirements are
essential: adequate bone volume (discussed in previous section), optimal implant position and angulation,
stable and healthy peri-implant soft tissues (discussed in previous section), proper soft tissue contours, andideal emergence profile.67 After verifying the tissue and ridge defects, modification of the soft tissues canbe performed prior to implant placement, at stage I and II surgery, or after implant placement.
Pre-placement Soft Tissue Modification
Soft tissue modification prior to implant placement to provide proper tissue contour and support canincrease the predictability of the treatment outcome, however additional surgical procedure is necessary toachieve the goal (Tables 3 and 4). Ridge preservation procedure using bone graft, barrier membrane inextraction socket had been shown to be predictable.68-70 Although longitudinal data was still lacking forevaluating the net effect from ridge preservation procedure, it is still preferred by many clinicians.68,69
Atraumatic removal of the tooth with preserving most of the bone architecture is the key to successful ridge
preservation.

Modified techniques for ridge retention were also been described including: Bio-col

technique, modified graft preservation, and spontaneous in-situ gingival augmentation.
Table 3. Techniques for soft tissue modification.
Ridge preservation
Bone grafts plus barrier membranes (e.g., Bio-Col technique)
Combinations of soft and hard tissue graft
Ovate pontic site development (Spontaneous in situ gingival augmentation)
Nature healing of extraction socket (minimal 6 months of healing)
Orthodontic forced eruption
Slow eruption (less than 1 mm/month)
Controlled tissue expansion
Expand soft tissue by placing silicon balloon expander first. After space is obtained then bone grafts
will be placed with primary wound coverage to ensure better healing.
Common soft tissue grafting procedures
Roll technique, Pouch procedure, Interpositional graft, Onlay graft, Combination grafts

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Tsao and WangInt Chin J Dent 2003; 3: 13-30.

Utilization of orthodontics in erupting hopeless teeth to augment bone and soft tissue support prior to
extraction had been demonstrated successfully in proposed implant site.71-73 Increased treatment time andcost are the drawbacks.74,75 The controlled tissue expansion was to expand soft tissue by placing siliconballoon expander to expand existing soft tissue in ridge deficiency to enhance primary coverage ofsubsequent osseous graft.76 However, additional soft tissue grafting to gain keratinized tissue is often
required. Soft tissue grafting procedures such as roll technique, pouch technique, interpositional grafts,
onlay grafts and combination grafts can be successfully applied in augmenting peri-implant tissue height
and width.
Table 4. HVC ridge deficiency classification and therapy.
Classification
Horizontal (H)Vertical (V)Combination (C)89

Therapy
S
M
L
S
M
L
S
M
L

Roll, Pouch, Inlay CT graft
Pouch, Inlay CT graft
Inlay CT graft, Interpositional graft
Interpositional graft
Interpositional graft, Onlay graft
Interpositional graft, (Onlay graft)
Combination of ST grafts
Combination of ST grafts
Not applicable

CT: Connective tissue, ST: Subepithelial connective tissue.

Stage I and II Soft Tissue Modification
The previously discussed soft tissue modification techniques can be performed at the time of implant
placement or abutment connection. Soft tissue augmentation performed at abutment connection eliminatedadditional surgical procedure. In the non-esthetic areas, apically positioned flap to increase keratinizedtissue can be employed at stage II surgery. The underlying bony support and contours can be evaluated forthe need of augmentation procedure.
The presence/absence of interdental papilla had been described and classified.77,78 The vertical distance
between the contact point and crest of bone was significant in determining the presence of papilla between
implants and adjacent teeth.79 When the distance was ≤5 mm, the papilla was present almost 100% of thetime. However, when the measurement was ≥6 mm, the papilla was only present ≤50% of the time. It was
further speculated that remaining bone crest influenced on the presence or absence of papillae either in
implants or teeth. This should be taken into consideration when performing esthetic implant surgeries. In
addition, when the distance between two implants is <3 mm, it often resulted in more horizontal bone loss
thus caused in loss of inter-implant papilla.80 The techniques such as papilla regeneration technique,81
coronally repositioned flap, soft tissue graft, gingival recontrouring,82,83 guided soft tissue augmentation84
have been developed to correct deficient papillae contours at stage one/two surgery.

20

Tsao and WangInt Chin J Dent 2003; 3: 13-30.

Post-placement Soft Tissue Modification
As previously described in the GBR section, it is mainly composed of hard tissue regeneration or hard
and/or soft tissue resective procedure to restore the health of the peri-implant tissue.

Ridge Deficiency and Its Management
Adequate bone volume pre-requisites the implant therapy and proper esthetic result. Inadequate alveolarbone height and width often requires bone augmentation procedures either performed prior to, at the time of,or after the implant surgery.
Ridge Deficiency
Alveolar ridge defects resulting from tooth extraction, trauma or periodontal disease are recommended tohave surgical corrections prior to their comprehensive prosthodontic reconstruction, especially implant
prosthesis. Without careful consideration and proper treatment planing, hard and/or soft tissue defects maylead to functional, structural or esthetic compromised in the final prosthesis. Several classification systemsof alveolar ridge deformities have been proposed.85-88 We recently published a therapeutically oriented
HVC ridge deficiency classification.89 Table 4 lists the proposed classification as well as its suggested
treatment.
The techniques that had been described for ridge augmentation include guided bone regeneration, blockgraft, particulate graft, ridge expansion technique, and distraction osteogenesis.90-94

Extra-oral

cortico-cancellous bone grafts for ridge augmentation was primarily used for the reconstruction of atrophic
arches.95-98 However, extra-oral graft sources have the disadvantages of great morbidity and expense.
Therefore, the use of intra-oral graft sites have been suggested for ridge augmentation procedures insmaller defects.99-103 Intra-oral sources of block grafts include the symphysis, body, and ramus of mandible.
Decreased morbidity, convenient surgical access, lack of cutaneous scar formation, and favorable bonequality are the advantages of intra-oral graft sources. The application of distraction osteogenesis in alveolar
ridge augmentation prior to implant placement had been evaluated and provided promising outcomes.
However, long-term evaluations and refinements in methodology are needed for establishing this techniquein ridge augmentation.
The principle of guided bone regeneration (GBR) was first examined in animal studies.104,105 It had been
demonstrated that GBR improves new bone formation by excluding fibrous tissue migration into thedefects with absorbable or non-absorbable membranes.104-106 Utilization of GBR technique to regenerate
deficient ridge to allow implant placement and to correct osseous defects around implants had been
evaluated.107,108

GBR with cell-occlusive barrier membranes used for horizontal or vertical ridge

augmentation with or without bone grafts showed varying degrees of success.70,90,104,109,110 When proper
surgical techniques are used and principles are followed, GBR procedures provide a fairly predictableoutcome (Fig. 3).

Regenerated bone has been shown to respond like non-regenerated bone inbearing/sustaining implant functional load.111

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Tsao and WangInt Chin J Dent 2003; 3: 13-30.

a

b

d

g

c

e

f

h

i

Fig. 3. Biologic width in natural teeth and dental implants.
a Pre-treatment maxillary occlusal view.
b Ridge preservation (demineralized free-dried boneallograft plus collagen plug with cross mattress suture)
was performed right after tooth extraction.
c Implants were placed and fenestration wound was noted in all three implants.

jd Autograft and demineralized free-dried bone allograft were placed to act as space creater andmaintainer.
e Collagen membrane (BioMend, Centerpulse Inc., Carlsbad, CA) was placed around the defect.
f Flap was sutured with three vertical modified mattress sutures.
g One month healing.
h Implant un-covery surgery showed newly regenerated bone around fenestration defects.
i Apically positioned flap was used to augment soft tissue thickness.
j Final results.
The benefit of GBR for correcting dehisced alveolar ridge was investigated for the use of GBR in threads
exposed implants in deficient ridges.112-116 Both absorbable and non-absorbable membranes were evaluated22

Tsao and WangInt Chin J Dent 2003; 3: 13-30.

and reported to be successful in treating dehiscence defects.112-116 Bone grafting materials were combinedin treating dehiscence defects with GBR and had shown successful regenerative results.115,116
An alternative to ridge augmentation procedure is to use expansion techniques to increase the width ofthe existing ridge. Several techniques had been proposed including osteotome, ridge expansion, and thepiezoelectric scalpel expansion technique.90,117-122 The aim of these expansion techniques is to reduce
surgical morbidity and complications associated with grafting procedures while providing similar successrates.117,121
At the time of abutment connection, the stage two procedure, GBR or hard and/or soft tissue resective
procedures need to be considered if implant related defects was discovered. The guidelines for treating
vertical and horizontal alveolar defects were listed in Table 2.

Implant MaintenanceImplant maintenance can be divided into professional maintenance and personal home care.
essential aspect of any maintenance program is patient compliance, which is dependent upon:

123

The

the relative

simplicity of the procedure; the time required; minimum number of devices.
Oral hygiene instructions should be performed and modified according to each patient’s condition. The
devices such as regular toothbrush, some types of floss (G-floss, Oral-B Superfloss), yarn, or tape havebeen shown capable of cleaning the interproximal implant areas. Interproximal brushes can also be used insome areas, however it should be plastic-coated to avoid any metal damage or contaminate to the titanium
implant surface.123 The important message is to use whatever patient felt comfortable so they can use them
regularly and effectively. Different mouthrinses such as 0.12% chlorhexidine or Listerine have beensuggested as adjuncts to aid in the personal oral hygiene in maintaining implant health. No clinical or
microbiological effects could be demonstrated in these studies.124,125 One week after abutment placement,
the patient should be recalled for evaluation and oral hygiene instructions.
Implant is like a tooth, regular professional cleaning is needed in order to maintain its long-term stability.
Professional cleaning will facilitate: removal of existing plaque, prevent early plaque attachment, inhibit
future plaque accumulation/formation as well as to avoid bacterial pathogen shift.

Three months

prophylaxis is often recommended as those observed in the natural dentition.126 Due to the natural oftitanium implant surface, it is often recommended not to use metallic instruments since it may scratch theimplant surface as well as causing metal corrosion.127 Metal ultrasonic scalers severely disrupt the titanium
dioxide surface, create the multitude of grooves and roughened surfaces. This often leads to further plaqueretention, and therefore may compromise longevity success of dental implants.

However, when an

ultrasonic scaler covered with a plastic tip, the titanium surface was uncharged and plaque can beeffectively removed from the implant surfaces.128 Various forms of plastic scalers have been advocated forremoving calculus deposits from the surfaces of abutments, but these have not been particularly
effective.128 Gold-plated Gracey curettes do not affect the titanium surface examined by scanning electron
microscopy and hence it was recommended by some authors for clinical usage.123 Gold-alloy-tipped scaler,plastic scaler, graphite-reinforced scaler, air powder-abrasive system, and rubber cup with tin oxide slurry

23

Tsao and WangInt Chin J Dent 2003; 3: 13-30.

have all been suggested to clean the implant surface. Among these, air abrasive system has been shown tobe the most effective method in removing plaque from implant surfaces.129 Rubber-cup polishing with avery fine abrasive paste is another method for deplaquing of implant surfaces in the dental office.123

Conclusion
Dental implants have been successfully used in the treatment of partially or fully edentulous patients. To
facilitate ideal implant placement, procedures attempted to restore/maintain the alveolar bone height andwidth have been developed and have shown promising results. Ridge preservation as well as guided boneregeneration prior to implant placement had been widely adopted as the predictable treatment methods.
Soft tissue grafting to enhance esthetic outcomes had also been addressed in many recent literatures.
Techniques such as connective tissue graft, ovate pontic site development, and other common soft tissue
grafts (e.g., roll, pouch, interpositional grafts, onlay grafts and combination grafts) can be successfully
applied in augmenting peri-implant tissue height and width.
To maintain implant long-term success, the interface between soft and hard tissues should be clearly
understood. When the implants are infected, surface should be detoxified and treatment should be provided
accordingly.

In addition, implant maintenance care is necessary for the overall success.

It affords

clinicians an opportunity, over time, to continuously diagnose, modify treatment, re-evaluate potential
pathogenic disease or identify disease recurrence. With professional maintenance care and effective homecare habits, post-treatment peri-implant health can be maintained for an undetermined period of time.

Acknowledgment
This work was partially supported by the University of Michigan Periodontal Graduate Student Research
Fund.

References
1. Listgarten MA. Soft and hard tissue response to endosseous dental implants. Anat Rec 1996; 245: 410-25.
2. Cochran DL, Hermann JS, Schenk RK, et al. Biologic width around titanium implants. A histometric analysis of theimplanto-gingival junction around unloaded and loaded nonsubmerged implants in the canine mandible. J Periodontol
1997; 68: 186-98.
3. Lindhe J, Berglundh T. The interface between the mucosa and the implant. Periodontol 2000 1998; 17: 47-54.
4. Gould TR, Brunette DM, Westbury L. The attachment mechanism of epithelial cells to titanium in vitro. J Periodontal
Res 1981; 16: 611-6.
5. Hansson HA, Albrektsson T, Branemark PI. Structural aspects of the interface between tissue and titanium implants. J
Prosthet Dent 1983; 50: 108-13.
6. McKinney RV Jr, Steflik DE, Koth DL. Evidence for a junctional epithelial attachment to ceramic dental implants. A
transmission electron microscopic study. J Periodontol 1985; 56: 579-91.
7. Donley TG, Gillette WB. Titanium endosseous implant-soft tissue interface: a literature review. J Periodontol 1991; 62:
153-60.
8. Schroeder A, van der Zypen E, Stich H, Sutter F. The reactions of bone, connective tissue, and epithelium to endosteal
implants with titanium-sprayed surfaces. J Maxillofac Surg 1981; 9: 15-25.

24

Tsao and WangInt Chin J Dent 2003; 3: 13-30.

9. Wennstrom J, Lindhe J. Plaque-induced gingival inflammation in the absence of attached gingiva in dogs. J Clin
Periodontol 1983; 10: 266-76.
10. Jansen JA, de Wijn JR, Wolters-Lutgerhorst JM, van Mullem PJ. Ultrastructural study of epithelial cell attachment toimplant materials. J Dent Res 1985; 64: 891-6.
11. Fitton JH, eDalton BA, Beumer G, Johnson G, Griesser HJ, Steele JG. Surface topography can interfere with epithelial
tissue migration. J Biomed Mater Res 1998; 42: 245-57.
12. Lauer G, Wiedmann-Al-Ahmad M, Otten JE, Hubner U, Schmelzeisen R, Schilli W. The titanium surface texture effects
adherence and growth of human gingival keratinocytes and human maxillar osteoblast-like cells in vitro. Biomaterials
2001; 22: 2799-809.
13. Liljenberg B, Gualini F, Berglundh T, Tonetti M, Lindhe J. Some characteristics of the ridge mucosa before and after
implant installation. A prospective study in humans. J Clin Periodontol 1996; 23: 1008-13.
14. Liljenberg B, Gualini F, Berglundh T, Tonetti M, Lindhe J. Composition of plaque-associated lesions in the gingiva andthe peri-implant mucosa in partially edentulous subjects. J Clin Periodontol 1997; 24: 119-23.
15. Ericsson I, Lindhe J. Probing depth at implants and teeth. An experimental study in the dog. J Clin Periodontol 1993;
20: 623-7.
16. Ericsson I, Persson LG, Berglundh T, Marinello CP, Lindhe J, Klinge B. Different types of inflammatory reactions inperi-implant soft tissues. J Clin Periodontol 1995; 22: 255-61.
17. Berglundh T, Lindhe J. Dimension of the periimplant mucosa. Biological width revisited. J Clin Periodontol 1996; 23:971-3.
18. Chavrier CA, Couble ML. Ultrastructural immunohistochemical study of interstitial collagenous components of thehealthy human keratinized mucosa surrounding implants. Int J Oral Maxillofac Implants 1999; 14: 108-12.
19. Chavrier C, Couble ML, Hartmann DJ. Qualitative study of collagenous and noncollagenous glycoproteins of thehuman healthy keratinized mucosa surrounding implants. Clin Oral Implants Res 1994; 5: 117-24.
20. Ericsson I, Nilner K, Klinge B, Glantz PO. Radiographical and histological characteristics of submerged andnonsubmerged titanium implants. An experimental study in the Labrador dog. Clin Oral Implants Res 1996; 7: 20-6.
21. Abrahamsson I, Berglundh T, Wennstrom J, Lindhe J. The peri-implant hard and soft tissues at different implantsystems. A comparative study in the dog. Clin Oral Implants Res 1996; 7: 212-9.
22. Abrahamsson I, Berglundh T, Lindhe J. The mucosal barrier following abutment dis/reconnection. An experimental
study in dogs. J Clin Periodontol 1997; 24: 568-72.
23. Berglundh T, Lindhe J. Healing around implants placed in bone defects treated with Bio-Oss. An experimental study inthe dog. Clin Oral Implants Res 1997; 8: 117-24.
24. Oh TJ, Yoon J, Misch CE, Wang HL. The causes of early implant bone loss: myth or science? J Periodontol 2002; 73:
322-33.
25. Wallace SS. Significance of the 'biologic width' with respect to root-form implants. Dent Implantol Update 1994; 5: 25-9.
26. Wennstrom JL, Bengazi F, Lekholm U. The influence of the masticatory mucosa on the peri-implant soft tissue condition.
Clin Oral Implants Res 1994; 5: 1-8.
27. Adell R, Lekholm U, Rockler B, et al. Marginal tissue reactions at osseointegrated titanium fixtures (I). A 3-year
longitudinal prospective study. Int J Oral Maxillofac Surg 1986; 15: 39-52.
28. Becker W, Becker BE, Newman MG, Nyman S. Clinical and microbiologic findings that may contribute to dental implantfailure. Int J Oral Maxillofac Implants 1990; 5: 31-8.
29. Kirsch A. Ackermann KL. The IMZ osteointegrated implant system. Dent Clin North Am 1989; 33: 733-91.
30. Block MS, Kent JN. Factors associated with soft- and hard-tissue compromise of endosseous implants. J Oral
Maxillofac Surg 1990; 48: 1153-60.
31. Zarb GA, Schmitt A. The longitudinal clinical effectiveness of osseointegrated dental implants: the Toronto study. Part
III: Problems and complications encountered. J Prosthet Dent 1990; 64: 185-94.
32. Silverstein LH, Lefkove MD, Garnick JJ. The use of free gingival soft tissue to improve the implant/soft-tissue interface.
J Oral Implantol 1994; 20: 36-40.

25

Tsao and WangInt Chin J Dent 2003; 3: 13-30.

33. Becker W. Esthetic soft-tissue augmentation adjacent to dental implants. Compend Contin Educ Dent 2001; 22: 250-2,
254, 256 passim.
34. Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study of osseointegrated implants in the treatment of theedentulous jaw. Int J Oral Surg 1981; 10: 387-416.
35. Brunski JB. Biomechanical considerations in dental implant design. Int J Oral Implantol 1988; 5: 31-4.
36. Ivanoff CJ, Grondahl K, Sennerby L, Bergstrom C, Lekholm U. Influence of variations in implant diameters: a 3- to
5-year retrospective clinical report. Int J Oral Maxillofac Implants 1999; 14: 173-80.
37. Misch CE, Qu Z, Bidez MW. Mechanical properties of trabecular bone in the human mandible: implications for dental
implant treatment planning and surgical placement. J Oral Maxillofac Surg 1999; 57: 700-6; discussion 706-8.
38. Misch CE, Bidez MW, Sharawy M. A bioengineered implant for a predetermined bone cellular response to loading
forces. A literature review and case report. J Periodontol 2001; 72: 1276-86.
39. Gotfredsen K, Wennerberg A, Johansson C, Skovgaard LT, Hjorting-Hansen E. Anchorage of TiO2-blasted, HA-coated,and machined implants: an experimental study with rabbits. J Biomed Mater Res 1995; 29: 1223-31.
40. Wennerberg A, Albrektsson T, Andersson B, Krol JJ. A histomorphometric and removal torque study of screw-shaped
titanium implants with three different surface topographies. Clin Oral Implants Res 1995; 6: 24-30.
41. Wennerberg A, Albrektsson T, Lausmaa J. Torque and histomorphometric evaluation of c.p. titanium screws blasted
with 25- and 75-microns-sized particles of Al2O3. J Biomed Mater Res 1996; 30: 251-60.
42. Wennerberg A, Ektessabi A, Albrektsson T, Johansson C, Andersson B. A 1-year follow-up of implants of differing
surface roughness placed in rabbit bone. Int J Oral Maxillofac Implants 1997; 12: 486-94.
43. Carr AB, Beals DW, Larsen PE. Reverse-torque failure of screw-shaped implants in baboons after 6 months of healing.
Int J Oral Maxillofac Implants 1997; 12: 598-603.
44. Pebe P, Barbot R, Trinidad J, et al. Countertorque testing and histomorphometric analysis of various implant surfaces incanines: a pilot study. Implant Dent 1997; 6: 259-65.
45. Buser D, Nydegger T, Oxland T, et al. Interface shear strength of titanium implants with a sandblasted and acid-etchedsurface: a biomechanical study in the maxilla of miniature pigs. J Biomed Mater Res 1999; 45: 75-83.
46. Buser D, Schenk RK, Steinemann S, Fiorellini JP, Fox CH, Stich H. Influence of surface characteristics on bone
integration of titanium implants. A histomorphometric study in miniature pigs. J Biomed Mater Res 1991; 25: 889-902.
47. Ericsson I, Johansson CB, Bystedt H, Norton MR. A histomorphometric evaluation of bone-to-implant contact onmachine-prepared and roughened titanium dental implants. A pilot study in the dog. Clin Oral Implants Res 1994; 5:
202-6.
48. Esposito M, Hirsch J, Lekholm U, Thomsen P. Differential diagnosis and treatment strategies for biologic complications
and failing oral implants: a review of the literature. Int J Oral Maxillofac Implants 1999; 14: 473-90.
49. Esposito M, Thomsen P, Ericson LE, Lekholm U. Histopathologic observations on early oral implant failures. Int J Oral
Maxillofac Implants 1999; 14: 798-810.
50. Smedberg JI, Lothigius E, Bodin I, Frykholm A, Nilner K. A clinical and radiological two-year follow-up study of maxillary
overdentures on osseointegrated implants. Clin Oral Implants Res 1993; 4: 39-46.
51. Mombelli A. Prevention and therapy of peri-implant infections. Proceedings of the 3rd European Workshop on
Periodontology. Implant Dentistry 1999; 1: 281-98.
52. Sbordone L, Barone A, Ramaglia L, Ciaglia RN, Iacono VJ. Antimicrobial susceptibility of periodontopathic bacteria
associated with failing implants. J Periodontol 1995; 66: 69-74.
53. Sbordone L, Ramaglia L, Barone A, Ciaglia RN, Tenore A, Iacono VJ. Periodontal status and selected cultivableanaerobic microflora of insulin-dependent juvenile diabetics. J Periodontol 1995; 66: 452-61.
54. Cochran D. Implant therapy I. Ann Periodontol 1996; 1: 707-91.
55. Mombelli A, Buser D, Lang NP. Colonization of osseointegrated titanium implants in edentulous patients. Early results.
Oral Microbiol Immunol 1988; 3: 113-20.
56. Mombelli A, Lang NP. The diagnosis and treatment of peri-implantitis. Periodontol 2000 1998; 17: 63-76.
57. Mombelli A. Microbiology and antimicrobial therapy of peri-implantitis. Periodontol 2000 2002; 28: 177-89.

26

Tsao and WangInt Chin J Dent 2003; 3: 13-30.

58. Schou S, Holmstrup P, Stoltze K, Hjorting-Hansen E, Fiehn NE, Skovgaard LT. Probing around implants and teeth withhealthy or inflamed peri-implant mucosa/gingiva. A histologic comparison in cynomolgus monkeys (Macaca
fascicularis). Clin Oral Implants Res 2002; 13: 113-26.
59. Mombelli A, van Oosten MA, Schurch E Jr, Land NP. The microbiota associated with successful or failing
osseointegrated titanium implants. Oral Microbiol Immunol 1987; 2: 145-51.
60. Lee KH, Maiden MF, Tanner AC, Weber HP. Microbiota of successful osseointegrated dental implants. J Periodontol
1999; 70: 131-8.
61. Lee KH, Tanner AC, Maiden MF, Weber HP. Pre- and post-implantation microbiota of the tongue, teeth, and newly
placed implants. J Clin Periodontol 1999; 26: 822-32.
62. Salcetti JM, Moriarty JD, Cooper LF, et al. The clinical, microbial, and host response characteristics of the failing
implant. Int J Oral Maxillofac Implants 1997; 12: 32-42.
63. Mombelli A, Lang NP. Antimicrobial treatment of peri-implant infections. Clin Oral Implants Res 1992; 3: 162-8.
64. Mombelli A, Feloutzis A, Bragger U, Lang NP. Treatment of peri-implantitis by local delivery of tetracycline. Clinical,
microbiological and radiological results. Clin Oral Implants Res 2001; 12: 287-94.
65. Zablotsky MH, Diedrich DL, Meffert RM. Detoxification of endotoxin-contaminated titanium and hydroxyapatite-coatedsurfaces utilizing various chemotherapeutic and mechanical modalities. Implant Dent 1992; 1: 154-8.
66. Dennison DK, Huerzeler MB, Quinones C, Caffesse RG. Contaminated implant surfaces: an in vitro comparison of
implant surface coating and treatment modalities for decontamination. J Periodontol 1994; 65: 942-8.
67. Jovanovic SA. Bone rehabilitation to achieve optimal aesthetics. Pract Periodontics Aesthet Dent 1997; 9: 41-51; quiz52.
68. Bahat O, Koplin LM. Pantographic lip expansion and bone grafting for ridge augmentation. Int J Periodontics
Restorative Dent 1989; 9: 344-53.
69. Nevins M, Mellonig JT. Enhancement of the damaged edentulous ridge to receive dental implants: a combination ofallograft and the GORE-TEX membrane. Int J Periodontics Restorative Dent 1992; 12: 96-111.
70. Buser D, Dula K, Belser U, Hirt HP, Berthold H. Localized ridge augmentation using guided bone regeneration. 1.
Surgical procedure in the maxilla. Int J Periodontics Restorative Dent 1993; 13: 29-45.
71. Salama H, Salama M. The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles
prior to implant placement: a systematic approach to the management of extraction site defects. Int J Periodontics
Restorative Dent 1993; 13: 312-33.
72. Salama H, Salama M, Kelly J. The orthodontic-periodontal connection in implant site development. Pract Periodontics
Aesthet Dent 1996; 8: 923-32; quiz 934.
73. Spear FM, Mathews DM, Kokich VG. Interdisciplinary management of single-tooth implants. Semin Orthod 1997; 3(1):45-72.
74. Ingber JS. Forced eruption. I. A method of treating isolated one and two wall infrabony osseous defects-rationale andcase report. J Periodontol 1974; 45: 199-206.
75. Ingber JS. Forced eruption: part II. A method of treating nonrestorable teeth--Periodontal and restorative considerations.
J Periodontol 1976; 47: 203-16.
76. Bahat O, Handelsman M. Controlled tissue expansion in reconstructive periodontal surgery. Int J Periodontics
Restorative Dent 1991; 11: 32-47.
77. Jemt T. Regeneration of gingival papillae after single-implant treatment. Int J Periodontics Restorative Dent 1997; 17:326-33.
78. Nordland WP, Tarnow DP. A classification system for loss of papillary height. J Periodontol 1998; 69: 1124-6.
79. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and radiographic evaluation of
the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region. J
Periodontol 2001; 72: 1364-71.
80. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-implant bone crest. J
Periodontol 2000; 71: 546-9.

27

Tsao and WangInt Chin J Dent 2003; 3: 13-30.

81. Nemcovsky CE, Moses O, Artzi Z. Interproximal papillae reconstruction in maxillary implants. J Periodontol 2000; 71:
308-14.
82. Adriaenssens P, Hermans M, Ingber A, Prestipino V, Daelemans P, Malevez C. Palatal sliding strip flap: soft tissue
management to restore maxillary anterior esthetics at stage 2 surgery: a clinical report. Int J Oral Maxillofac Implants
1999; 14: 30-6.
83. Tinti C, Benfenati SP. The ramp mattress suture: a new suturing technique combined with a surgical procedure toobtain papillae between implants in the buccal area. Int J Periodontics Restorative Dent 2002; 22: 63-9.
84. Salama H, Salama M, Garber D, Adar P. Developing optimal peri-implant papillae within the esthetic zone: guided soft
tissue augmentation. J Esthet Dent 1995; 7: 125-9.
85. Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part II.
Prosthetic/periodontal interrelationships. Compend Contin Educ Dent 1983; 4: 549-62.
86. Allen EP, Gainza CS, Farthing GG, Newbold DA. Improved technique for localized ridge augmentation. A report of 21
cases. J Periodontol 1985; 56: 195-9.
87. Lekholm U, Zarb G. Tissue-integrated prosthesis: Osseointegration in clinical dentistry. Chicago: Quintessence; 1985.
p. 199-209.
88. Misch CE, Judy KW. Classification of partially edentulous arches for implant dentistry. Int J Oral Implantol 1987; 4: 7-13.
89. Wang, HL, Al-Shammari K. HVC ridge deficiency classification: a therapeutically oriented classification. Int J
Periodontics Restorative Dent 2002; 22: 335-43.
90. Buser D, Bragger U, Lang NP, Nyman S. Regeneration and enlargement of jaw bone using guided tissue regeneration.
Clin Oral Implants Res 1990; 1: 22-32.
91. Buser D, Dula K, Belser UC, Hirt HP, Berthold H. Localized ridge augmentation using guided bone regeneration. II.
Surgical procedure in the mandible. Int J Periodontics Restorative Dent 1995; 15: 10-29.
92. Hermann JS, Buser D. Guided bone regeneration for dental implants. Curr Opin Periodontol 1996; 3: 168-77.
93. Misch CM. Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac
Implants 1997; 12: 767-76.
94. Oda T, Sawaki Y, Ueda M. Experimental alveolar ridge augmentation by distraction osteogenesis using a simple device
that permits secondary implant placement. Int J Oral Maxillofac Implants 2000; 15: 95-102.
95. Breine U, Branemark PI. Reconstruction of alveolar jaw bone. An experimental and clinical study of immediate andpreformed autologous bone grafts in combination with osseointegrated implants. Scand J Plast Reconstr Surg 1980;
14: 23-48.
96. Keller EE, Desjardins RP, Tolman DE, Laney WR, Van Roekel NB. Reconstruction of the severely resorbed mandibularridge using the tissue-integrated prosthesis. Int J Oral Maxillofac Implants 1986; 1: 101-9.
97. Listrom RD, Symington JM. Osseointegrated dental implants in conjunction with bone grafts. Int J Oral Maxillofac Surg
1988; 17: 116-8.
98. Keller EE, Tolman DE. Mandibular ridge augmentation with simultaneous onlay iliac bone graft and endosseous
implants: a preliminary report. Int J Oral Maxillofac Implants 1992; 7: 176-84.
99. Misch CM, Misch CE, Resnik RR, Ismail YH. Reconstruction of maxillary alveolar defects with mandibular symphysis
grafts for dental implants: a preliminary procedural report. Int J Oral Maxillofac Implants 1992; 7: 360-6.
100.

Misch CM, Misch CE. The repair of localized severe ridge defects for implant placement using mandibular bone

grafts. Implant Dent 1995; 4: 261-7.
101.

Misch CM. Ridge augmentation using mandibular ramus bone grafts for the placement of dental implants:

presentation of a technique. Pract Periodontics Aesthet Dent 1996; 8: 127-35; quiz 138.
102.

Pikos MA. Facilitating implant placement with chin grafts as donor sites for maxillary bone augmentation--Part I.

Dent Implantol Update 1995; 6: 89-92.
103.

Pikos MA. Block autografts for localized ridge augmentation: Part I. The posterior maxilla. Implant Dent 1999; 8:

279-85.

28

Tsao and Wang104.

Int Chin J Dent 2003; 3: 13-30.

Dahlin C, Linde A, Gottlow J, Nyman S. Healing of bone defects by guided tissue regeneration. Plast Reconstr Surg

1988; 81: 672-6.
105.

Seibert J, Nyman S. Localized ridge augmentation in dogs: a pilot study using membranes and hydroxyapatite. J

Periodontol 1990; 61: 157-65.
106.

Kostopoulos L, Karring T. Guided bone regeneration in mandibular defects in rats using a bioresorbable polymer.

Clin Oral Implants Res 1994; 5: 66-74.
107.

Dahlin C, Ge Sennerby L, Lekholm U, Linde A, Nyman S. Generation of new bone around titanium implants using amembrane technique: an experimental study in rabbits. Int J Oral Maxillofac Implants 1989; 4: 19-25.
108.

Nyman S, Lang NP, Buser D, Bragger U. Bone regeneration adjacent to titanium dental implants using guided tissue

regeneration: a report of two cases. Int J Oral Maxillofac Implants 1990; 5: 9-14.
109.

Linde A, Alberius P, Dahlin C, Bjurstam K, Sundin Y. Osteopromotion: a soft-tissue exclusion principle using amembrane for bone healing and bone neogenesis. J Periodontol 1993; 64(11 Suppl): 1116-28.
110.

Buser D, Lat Dula K, Hirt HP, Schenk RK. Lateral ridge augmentation using autografts and barrier membranes: aclinical study with 40 partially edentulous patients. J Oral Maxillofac Surg 1996; 54: 420-32; discussion 432-3.
111.

Buser D, Ruskin J, Higginbottom F, Hardwick R, Dahlin C, Schenk RK. Osseointegration of titanium implants inbone regenerated in membrane-protected defects: a histologic study in the canine mandible. Int J Oral Maxillofac
Implants 1995; 10: 666-81.
112.

Zablotsky M, Meffert R, Caudill R, Evans G. Histological and clinical comparisons of guided tissue regeneration on

dehisced hydroxylapatite-coated and titanium endosseous implant surfaces: a pilot study. Int J Oral Maxillofac Implants
1991; 6: 294-303.
113.

Jovanovic SA, Spiekermann H, Richter EJ. Bone regeneration around titanium dental implants in dehisced defectsites: a clinical study. Int J Oral Maxillofac Implants 1992; 7: 233-45.
114.

Sevor JJ, Meffert RM, Cassingham RJ. Regeneration of dehisced alveolar bone adjacent to endosseous dental

implants utilizing a resorbable collagen membrane: clinical and histologic results. Int J Periodontics Restorative Dent
1993; 13: 71-83.
115.

Fugazzotto PA, Shanaman R, Manos T, Shectman R. Guided bone regeneration around titanium implants: report of

the treatment of 1,503 sites with clinical reentries. Int J Periodontics Restorative Dent 1997; 17: 292-9.
116.

Hammerle CH, Lang NP. Single stage surgery combining transmucosal implant placement with guided boneregeneration and bioresorbable materials. Clin Oral Implants Res 2001; 12: 9-18.
117.

Scipioni A, Bruschi GB, Calesini G. The edentulous ridge expansion technique: a five-year study. Int J Periodontics

Restorative Dent 1994; 14: 451-9.
118.

Summers RB. The osteotome technique: Part 2--The ridge expansion osteotomy (REO) procedure. Compendium

1994; 15: 422, 424, 426, passim; quiz 436.
119.

Summers RB. The osteotome technique: Part 4--Future site development. Compend Contin Educ Dent 1995; 16:1080, 1092 passim; quiz 1099.
120.

Scipioni A, Bruschi GB, Giargia M, Berglundh T, Lindhe J. Healing at implants with and without primary bone contact.

An experimental study in dogs. Clin Oral Implants Res 1997; 8: 39-47.
121.

Sethi A, Kaus T. Maxillary ridge expansion with simultaneous implant placement: 5-year results of an ongoingclinical study. Int J Oral Maxillofac Implants 2000; 15: 491-9.
122.

Vercellotti T. Piezoelectric surgery in implantology: a case report--a new piezoelectric ridge expansion technique. Int

J Periodontics Restorative Dent 2000; 20: 358-65.
123.

Garber D. Implants-The name of the game is still maintenance. Compend Contin Educ Dent (II) 1992; 12: 876-884.

124.

Ciancio SG, Lauciello F, Shibly O, Vitello M, Mather M. The effect of an antiseptic mouthrinse on implantmaintenance: plaque and peri-implant gingival tissues. J Periodontol 1995; 66: 962-5.
125.

Felo A, Shibly O, Ciancio SG, Lauciello FR, Ho A. Effects of subgingival chlorhexidine irrigation on peri-implantmaintenance. Am J Dent 1997; 10: 107-10.
126.

Miyata H. Osseointegrated implants in clinical dentistry. Follow up maintenance phase. Shigaku 1989; 77: 1235-45.

29

Tsao and Wang127.

Int Chin J Dent 2003; 3: 13-30.

Rapley JW, Swan RH, Hallmon WW, Mills MP. The surface characteristics produced by various oral hygiene

instruments and materials on titanium implant abutments. Int J Oral Maxillofac Implants 1990; 5: 47-52.
128.

Gantes BG, Nilveus R. The effects of different hygiene instruments on titanium surfaces: SEM observations. Int J

Periodontics Restorative Dent 1991; 11: 225-39.
129.

Brookshire FV, Nagy WW, Dhuru VB, Ziebert GJ, Chada S. The qualitative effects of various types of hygiene

instrumentation on commercially pure titanium and titanium alloy implant abutments: an in vitro and scanning electron
microscope study. J Prosthet Dent 1997; 78: 286-94.
130.

Berglundh T, Lindhe J, Ericsson I, Marinello CP, Liljenberg B, Thomsen P. The soft tissue barrier at implants andteeth. Clin Oral Implants Res 1991; 2: 81-90.
131.

Vacek JS, Gher ME, Assad DA, Richardson AC, Giambarresi LI. The dimensions of the human dentogingival

junction. Int J Periodontics Restorative Dent 1994; 14: 154-65.
132.

Gargiulo A, Wentz F, Orban B. Dimensions and relations of the dentogingival junction in humans. J Periodontol

1961; 32: 261-8.
133.

Meffert RM. Maintenance and treatment of the ailing and failing implant. J Indiana Dent Assoc 1994; 73(3): 22-4;

quiz 25.

Reprint request to:
Dr. Hom-Lay Wang
Department of Periodontics/Prevention/Geriatrics, University of Michigan School of Dentistry1011 North, University Avenue, Ann Arbor, MI 48109-1078, USA
FAX: +1-734-936-0374 E-mail: homlay@umich.edu
Received on December 31, 2002. Revised on February 21, 2003. Accepted on March 1, 2003.
Copyright ©2003 by the Editorial Council of the International Chinese Journal of Dentistry.

International Chinese Journal of Dentistry 2003 Outstanding Article AwardInternational Chinese Journal of Dentistry announces the second Outstanding Article Award.
Award:A cash prize of US$ 600 and a certificate of commendation are awarded for the most outstanding article published in
the International Chinese Journal of Dentistry.
Criteria:
Original articles, clinical reports, and dental technology articles published in the Journal between issue 1 and issue 4
are considered for the award. The winning article will be selected by a committee on the basis of scientific impact on
the dental professional communities, and interest to the readers. The 2003 Award is sponsored by the International
Chinese Journal of Dentistry and the following award sponsors.
Award Sponsors:
Kuraray Medical Inc., Tokyo, Japan, http://www.kuraray.co.jp/dental
Sun Medical Co., Ltd., Moriyama, Japan, http://www.sunmedical.co.jp
Toho Dental Products, Saitama, Japan
Tokuyama Dental Corp., Tokyo, Japan, http://www.tokuyama-dental.co.jp
3M Health Care Limited, Sagamihara, Japan, http://www.3m.com/espe/
2002 Award Winner:
Miyazaki M, Onose H, Hirohata N, Nishizawa O, Moore BK.
Influence of cutting of enamel surface with Er: YAG laser on bond strength. Int Chin J Dent 2002; 2(2): 75-85.

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