No Attached Gingiva on the Lingual Side of Implants?
Posted in advice Surgical Placement of Dental Implants
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Subscribe to this PostDr. YS asks:
I placed 2 two-stage dental implants in a lower molar position. After 2 months both of them are fully integrated but the cover screws became exposed. It appears as though gingival has receded around them. The problem I have is that there is almost no attached gingiva on the lingual side of the implants. What is the probable cause of this problem? What is the best way for correcting this problem? Should I use a soft tissue graft to augment the attached gingival? Or should I do nothing and just let the implants and tissue continue to heal?
Did you have keratinized tissue at the time of placement on the lingual? How much. If you had some, but an inadequate amount, this can happen. I have has recession as you speek of, with the healing cap becomming exposed, but with adequate keratinized tissue it has never been a problem. I would recommend doing a gingival graft to give yourself a good collar of keratinized tissue 360 degrees around the implant.
I have found that the buccal is more a concern than the lingual. I think it is due to the trajectory of the crown on emergence, the muscle attachments and the food placement during mastication. I think you should be fine.
If the gum is healthy you should be in the clear.
In all probability your implant position was at the expense of Lingal Wall.There should be sufficient bone on either side at the time of placement.Anything less than 2 mm will give way.
Treatment:
Check the occlusion to relieve the stress if any to prevent further bone loss.
Ashish
Email:info@drashish.com
web:www.drashish.com
Attached gingiva is important for the quality of survival of your implants. You can create ceratinized mucosa during uncovering stage with a free epitelial graft.
If there´s no inflamation, with good higyene there should be no problem. JR
YS,
Don’t ignore the lack of keratinized tissue; Following abutment and crown placement, it will likely comeback to haunt you at a later date, with potential recession and bone loss. The easiest fix at this point is a graft using Alloderm or CT from the palate. Explain to the patient that the soft tissue around the implants, which are well integrated, is somewhat thinner then what you would like and that a small procedure is needed to increase the tissue thickness/strength. Do it at the same time that you are placing the healing or final abutments and allow a few weeks more healing time prior to final impressions. It is much easier to correct the problem now, rather then having to explain to a patient 6 months to a year later why there is recession and bone loss.
As a periodontist, I find that patients with even relatively good hygiene, fail to be able to adiquately clean the posterior lingual areas. A lack of adiquate keratinized tissue is going to be more prone to breakdown. You or the patient may not initially see the recession due to the lingual location but why risk a problem when you can correct it before it occurs.
JC, DDS
I agree with YS and the second problem is with cleaning the implants. If there isn’t keratinized tissue your patient will brush it till it bleeds and complaining of discomfort of sharp pain at that site of the implant
After 18 years of placing and restoring implants, I have found that there is no correlation between attached gingiva and implant survival. Do not worry.
There should be attached gingival all about the implant. The circular fibers are located in this area. The circular fibers will hold the tissue to the implant. The late Bob James showed this in 1976. They are important. Jim Craig and Dutchy are correct. If the fibers are not important, why do we need them about the natural teeth?
I am blown away by Dr Brooksby’s comment ..?
“No correlation between survival and attached gingivae??”
I must ask for clarification and catagorically state this goes against all perio principles in Implantology
When a tooth fails there is breakdown of these vital fibres ..CT seal is lost and pathway to pathogens opens up
Having keratinised tissue around an implant is a key fundamental concept in Implantology
To answer the original question a tissue graft is clearly needed and you can expect some bone loss on the side with the non keratinised gingivae
It is relatively easy with alloderm to change the tissue biotype. To be efficient, this can be done at implant placement when noted deficient attached mucosa exists circumferentially.
I have a couple comments here:
1.) Look at the published literature on need for KG around implants. Warrer and Buser 1995 and Chung, Misch and Wang 2006 both found that implants with little to no keratinized tissue have significantly higher incidence of peri-implant mucositis/inflammation. So based on these studies you should try to augment the lingual tissue to create some KG there. In the long-term the site may show less suceptibility to peri-implantitis development with KG.
2.) Use of alloderm will not increase Keratinized tissue. While it may thicken the biotype, the long-term maintenance of this thickened mucosa is highly questionable based on the literature.
The only way to deal with this as I see it is a KG graft from the palate
However disto lingual area is a really tough site to protect during healing
Hi,
an English persceptive now.
Implants do need sufficient attached keratinised tissue. Chapel et al quoted as needing 1-9mm on the buccal surface definately.
Otherwise you have an open pocket. For those who dont think its a problem you should radiograph your implants annually and see what happens!-bone loss!
Depends if you want a patient list with surviving implants or sucessful implants!
CT graft from the palate would work but i would take the cr off and place a long ginival former before attempting this.
Cheers