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Inside Dentistry
December 2023
Volume 19, Issue 12
Peer-Reviewed

Ensuring Sufficient Attached Gingiva Around an Implant

A simple surgical procedure to resolve a common problem

Timothy Kosinski, DDS | Stephanie Tilley, DMD

As teeth are lost, it is common for bone loss to occur, which can be followed by the loss of mucosal tissue and result in a lack of attached gingiva on the facial aspect of edentulous sites. Oftentimes, a band of attached gingiva can be repositioned with a simple surgical procedure using a sling suture around a healing abutment. In this procedure, the gingiva is sutured around the healing abutment and not onto the lingual tissue at all.

Stable gingival margins are critical to the health of dental implants. The attached gingiva provides protection from external trauma, creates stability for the adjacent soft tissue, and is essential for proper tissue healing around dental implants. Without sufficient keratinized attached gingiva, food impaction may occur as well as tissue shrinkage, which can affect the long-term prognosis and esthetics of an implant-supported restoration. In addition, the penetration of bacteria can compromise the long-term health of dental implants; therefore, sufficient keratinized tissue is critical in areas of the mouth where plaque control may be challenging.

The gingiva around dental implants needs to be firm and attached, otherwise the physiologic pattern of health may be broken. Hemidesmosomal fibers, which are normally about 1-mm long, attach the junctional epithelium to the teeth or implants, and the oral sulcular epithelium is connected to the junctional epithelium. Subjacent to the junctional epithelium is a layer of connective tissue that is approximately 1-mm thick. Unlike around teeth, where the connective tissue fibers are perpendicular to the root surfaces and insert into the cementum, around implants, the fibers are parallel or oblique and do not insert into the implant surface. The blood supply around implants is also less than around teeth because there is no periodontal ligament around implants. Learning to control the positioning of attached gingiva, such as how it is managed in this case report, is a significant treatment modality that facilitates a natural emergence profile, correct function, and appropriate hygiene while delivering restorative excellence.

About the Authors

Timothy Kosinski, DDS
Master
Academy of General Dentistry
Diplomate
International Congress of Oral Implantologists
Affiliated Adjunct Clinical Professor
University of Detroit Mercy
School of Dentistry
Detroit, Michigan
Private Practice
Bingham Farms, Michigan

Stephanie Tilley, DMD
Fellow
International College of Dentists
Fellow
International Congress of Oral Implantologists
Private Practice
Pensacola, Florida

(1.) Radiograph acquired following extraction of a non-restorable mandibular first molar and site grafting with a calcium apatite material (OsteoGen® Bioactive Resorbable Calcium Apatite Graft, Impladent Ltd.). Note the radiolucency of the graft material immediately following placement.

Figure 1

(2.) Radiograph of the site after 3 months of integration demonstrating that the graft material is visually more opaque, especially in the apical third, and ready for dental implant placement.

Figure 2

(3.) The edentulous space was evaluated for tooth replacement, which included measuring the mesial-distal dimension for an implant-supported crown while ensuring appropriate interocclusal space.

Figure 3

(4.) It is imperative that a band of attached gingiva of at least 2 mm is present on the facial aspect of any implant restoration. This can be determined by infiltrating anesthesia and monitoring the mucogingival line. The attached gingiva will remain fixed, whereas the mucosa will elevate from the underlying bone.

Figure 4

(5.) It is imperative that a band of attached gingiva of at least 2 mm is present on the facial aspect of any implant restoration. This can be determined by infiltrating anesthesia and monitoring the mucogingival line. The attached gingiva will remain fixed, whereas the mucosa will elevate from the underlying bone.

Figure 5

(6.) Marking the most facial aspect of the adjacent teeth and the mucogingival line with a permanent marker can help in determining the proper angulation of the implant and its eventual emergence profile.

Figure 6

(7.) An Orban knife was used to make a precise incision slightly lingual to the center of the crest in order to harvest a band of attached gingiva that would later be repositioned to the facial aspect of a tall healing abutment. No vertical incisions were made into the mucosa. When incisions are limited to the attached gingiva, prostaglandins and histamine are not released, and thus, there is nominal postoperative discomfort for the patient.

Figure 7

(8.) An Orban knife was used to make a precise incision slightly lingual to the center of the crest in order to harvest a band of attached gingiva that would later be repositioned to the facial aspect of a tall healing abutment. No vertical incisions were made into the mucosa. When incisions are limited to the attached gingiva, prostaglandins and histamine are not released, and thus, there is nominal postoperative discomfort for the patient.

Figure 8

(9.) The band of attached gingiva was reflected facially, but the lingual tissue was not elevated. The facial reflection revealed graft maturation and a site ready for implant placement.

Figure 9

(10.) The band of attached gingiva was reflected facially, but the lingual tissue was not elevated. The facial reflection revealed graft maturation and a site ready for implant placement.

Figure 10

(11.) Following implant planning protocols, an osteotomy was made that would maximize the emergence profile. The selected implant (Hahn™ Tapered Implant, Glidewell) was positioned in the center of the ridge in line with the central grooves of the adjacent teeth.

Figure 11

(12.) The dental implant was torqued to an initial stability of 45 Ncm with its 1-mm machined collar positioned at the height of the crest.

Figure 12

(13.) Because an insertion torque greater than 25 Ncm was achieved, a 5-mm tall healing abutment was threaded into the implant, making this a single-stage implant surgical procedure and eliminating the need for secondary uncovering after integration of the implant.

Figure 13

(14.) An intrasurgical radiograph was acquired to assess the final position of the implant and healing abutment.

Figure 14

(15.) A periodontal sling suture was used to reposition the band of attached gingiva on the buccal flap from the slightly lingual aspect of the crest to the facial aspect of the healing abutment. To accomplish this, a reverse cutting, 3/8-circle needle was engaged on the mesial-facial aspect of the attached gingiva. After the suture was wrapped around the healing abutment without engaging the lingual tissue at all, the needle was reversed, engaging the distal-facial aspect of the attached gingiva, and again the suture was wrapped around the healing abutment without engaging the lingual tissue. A knot was tied on the mesial facial aspect. The exposed bone at the crestal aspect of the site was left untouched. Epithelium will fill that space at a rate of approximately 0.5 mm per day.

Figure 15

(16.) A periodontal sling suture was used to reposition the band of attached gingiva on the buccal flap from the slightly lingual aspect of the crest to the facial aspect of the healing abutment. To accomplish this, a reverse cutting, 3/8-circle needle was engaged on the mesial-facial aspect of the attached gingiva. After the suture was wrapped around the healing abutment without engaging the lingual tissue at all, the needle was reversed, engaging the distal-facial aspect of the attached gingiva, and again the suture was wrapped around the healing abutment without engaging the lingual tissue. A knot was tied on the mesial facial aspect. The exposed bone at the crestal aspect of the site was left untouched. Epithelium will fill that space at a rate of approximately 0.5 mm per day.

Figure 16

(17.) A periodontal sling suture was used to reposition the band of attached gingiva on the buccal flap from the slightly lingual aspect of the crest to the facial aspect of the healing abutment. To accomplish this, a reverse cutting, 3/8-circle needle was engaged on the mesial-facial aspect of the attached gingiva. After the suture was wrapped around the healing abutment without engaging the lingual tissue at all, the needle was reversed, engaging the distal-facial aspect of the attached gingiva, and again the suture was wrapped around the healing abutment without engaging the lingual tissue. A knot was tied on the mesial facial aspect. The exposed bone at the crestal aspect of the site was left untouched. Epithelium will fill that space at a rate of approximately 0.5 mm per day.

Figure 17

(18.) A periodontal sling suture was used to reposition the band of attached gingiva on the buccal flap from the slightly lingual aspect of the crest to the facial aspect of the healing abutment. To accomplish this, a reverse cutting, 3/8-circle needle was engaged on the mesial-facial aspect of the attached gingiva. After the suture was wrapped around the healing abutment without engaging the lingual tissue at all, the needle was reversed, engaging the distal-facial aspect of the attached gingiva, and again the suture was wrapped around the healing abutment without engaging the lingual tissue. A knot was tied on the mesial facial aspect. The exposed bone at the crestal aspect of the site was left untouched. Epithelium will fill that space at a rate of approximately 0.5 mm per day.

Figure 18

(19.) Occlusal and buccal views of the site after 7 days of healing and removal of the sutures, respectively. The tissue was evaluated. Note the closure of the crestal defect with new epithelium.

Figure 19

(20.) Occlusal and buccal views of the site after 7 days of healing and removal of the sutures, respectively. The tissue was evaluated. Note the closure of the crestal defect with new epithelium.

Figure 20

(21.) Occlusal and buccal views of the site after 7 days of healing and removal of the sutures, respectively. The tissue was evaluated. Note the closure of the crestal defect with new epithelium.

Figure 21

(22.) Occlusal and buccal views of the site after 7 days of healing and removal of the sutures, respectively. The tissue was evaluated. Note the closure of the crestal defect with new epithelium.

Figure 22

(23.) Occlusal and buccal views of the site following an additional 3 weeks of healing, during which time the implant crown was fabricated. A sufficient band of attached gingiva was apparent, so the final implant supported, screw-retained prosthesis could be predictably seated.

Figure 23

(24.) Occlusal and buccal views of the site following an additional 3 weeks of healing, during which time the implant crown was fabricated. A sufficient band of attached gingiva was apparent, so the final implant supported, screw-retained prosthesis could be predictably seated.

Figure 24

(25.) Occlusal and buccal views of the final implant crown (BruxZir® Zirconia, Glidewell) demonstrating excellent periodontal health.

Figure 25

(26.) Occlusal and buccal views of the final implant crown (BruxZir® Zirconia, Glidewell) demonstrating excellent periodontal health.

Figure 26

(27.) The final digital radiograph illustrates an implant-supported restoration in a healthy position with an excellent long-term prognosis.

Figure 27

Timothy Kosinski, DDS

Stephanie Tilley, DMD

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