Dental News - Interview: "Soft tissue might be even more important than the bone around the dental implant"

Dental Tribune International

Wed. 24. April 2019

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At the International Osteology Symposium, just around the corner, dental professionals will be diving into the current trends in oral regeneration. Among the speakers is PD Dr. Daniel Thoma, Head of Reconstructive Dentistry at the Clinic of Fixed and Removable Prosthodontics and Dental Material Science at University of Zurich’s Center of Dental Medicine in Switzerland. A specialist in reconstructive dentistry and a member of the Osteology Expert Council, he will deliver a lecture at the symposium, which is taking place from 25 to 27 April in Barcelona in Spain. Thoma was so kind as to talk with Dental Tribune International about the main objectives of his lecture, the importance of soft tissue for aesthetics and function in dental implant treatment, and how peri-implantitis needs more research to implement better treatment options.

Dr Thoma, you are giving a presentation titled “Shifting paradigms for soft tissue volume augmentation—From existing to novel treatment options” on Friday. What is your lecture about, and what are your intended main learning objectives?
I will start by demonstrating and talking about the indications for soft-tissue grafting. Based on RCTs [randomised controlled trials], we can clearly show that performing soft-tissue grafting procedures around dental implants increases the aesthetic outcome. There has only recently been data available that demonstrates a biological reason too: we now know that we lose less marginal bone around dental implants and thereby can maintain peri-implant health better than for implants without soft-tissue grafting. These are currently the two main reasons we perform these procedures.

I will also talk about what kinds of techniques we should be using according to the data available today. Autogenous soft-tissue grafts are considered to be the gold standard, but they are associated with an increase in patient morbidity. In the past, research has focused on the development of soft-tissue substitutes. If we look specifically into the research of the past five to ten years, the focus has been on collagen matrices, which is why I will present data on this topic. Based on an RCT, it is clear that we can achieve a volume increase around dental implants of the same level as with an autogenous soft-tissue graft using collagen matrices. However, the advantage of this treatment is that the patient’s morbidity clearly decreases. For the future, we expect that fewer dentists will be using autogenous grafts and that there will be an increase in the use of soft-tissue substitutes for dental implant procedures.

How do dentists achieve a natural texture and colour in tissue augmentation to attain aesthetic results that blend in with the surrounding tissue?
That’s a difficult question. There are two ways of doing a soft-tissue grafting procedure. Either you do it for functional purposes, for which you would mainly augment volume, but this does not really change the tissue architecture, such as the colour, and the results are way off doing such procedures to gain keratinised tissue. If you chose that procedure, you have two options: again, you can use autogenous tissue, but the aesthetic outcome will be quite poor because the colour and texture will not match with the surrounding tissue. You could also use a soft-tissue substitute which will blend much better with the neighbouring tissue.

Is it true that there is increasing concern among patients to have pleasing aesthetic results?
That’s a good question. According to some studies, or at least what we feel, is that patients are asking for aesthetics. However, if one looks into RCTs and clinical data based on studies, patients are quite often not aware of the aesthetics that dentists might be aware of. There is always a bit of a discrepancy between outcomes that dentists would like to achieve and outcomes that patients are expecting.

What materials are available to dentists for soft-tissue augmentation?
The use of autogenous grafts is considered to be the gold standard for soft-tissue graft procedures. Its main advantage lies in the fact of having certainly more clinical experience and probably also more research and long-term data available. However, these materials are associated with a higher patient morbidity, and that’s something we would like to prevent. Alternatively, we can use soft-tissue substitutes, and there are quite a good number of different ones available. If we are really looking for devices that are successful in clinical research than probably collagen matrices are the number one.

How can the prevention and treatment of peri-implantitis be addressed? What should be improved in the future?
There is a high prevalence of peri-implantitis on the patient level but also on the implant level. The main focus of all the treatments we do with dental implants should be to maintain peri-implant health. What we know for sure is that we need to have a sufficient amount of bone and soft tissue in order to do so. Only recently have we learnt that the soft tissue might be even more important than the bone around the dental implant, but of course this involves some speculation. Certainly, the goal of all the treatments is to maintain peri-implant health.

Peri-implantitis has been addressed and we are all well aware of the numbers, but maybe the problem is that we don’t have the right treatment options. Therefore, there is certainly more research needed to find a predictable way of how to treat these cases. However, prevention is much better. As already mentioned, we should make sure to have a sufficient amount of bone and soft tissue but also a good quality—not only quantity—to maintain peri-implant health because this is much easier than treating the disease.

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