Notes

ttached gingiva and dental implants
May 6, 2014
ByAlbert Yoo, DDS, and Adam Bear, DDS
The free gingival graft (FGG) (Fig. 1) is an age-old periodontal procedure first
described by Sullivan & Atkins in 1968. (9) It has long been the gold standard
for increasing attached gingiva around the natural dentition. Connective tissue
grafting (CTG) (Fig. 2) provides many of the same benefits along with root cover
age, without the accompanying discomfort from the donor site, making the FGG les
s desirable. However, the FGG procedure has its advantages over CTG for both the
natural dentition and, more recently, dental implants.
ALSO BY DR. ALBERT YOO | 'My implant is too shallow and now I'm getting food stu
ck between my teeth'
Attached gingiva and dental implants by Albert Yoo, DDS, and Adam Bear, DDS At
tached gingiva and dental implants by Albert Yoo, DDS, and Adam Bear, DDS
Anatomy
(Fig. 3) In a healthy periodontium, there exists the free gingival margin (FGM)
along with a zone of attached/keratinized gingiva (AG). The mucogingival junctio
n (MGJ) forms the boundary between the attached tissue and alveolar mucosa (AM),
which continues to form the vestibule becoming confluent with the cheek or lip.
Literature supports a minimum of 2 mm AG for long-term stability and maintenanc
e. (7) Note: not all keratinized gingiva is attached. The free gingival margin,
which forms the external border of the periodontal sulcus, is usually keratinize
d, but certainly not attached to the underlying bone.
Attached gingiva and dental implants by Albert Yoo, DDS, and Adam Bear, DDS
Loss of attached gingiva
Gingival recession is the result of loss of alveolar bone and tissue, specifical
ly AG. A high number of recession cases result in less than the minimum required
amount of AG. (Fig. 4) Similarly, following tooth extraction or long-standing e
dentulism (without bone preservation), loss of alveolar dimension is accompanied
with diminishing AG. (Fig. 5) Note: specific cases may also be attributed to gi
ngival biotype and genetic predisposition.
Reconstruction
Surgical reconstruction of a deficient ridge/site begins with bone augmentation
(i.e., lateral ridge graft, sinus augmentation, etc.), closely followed by soft-
tissue augmentation (i.e., onlay graft, pedicle graft, etc.) When either cannot
produce adequate ridge form for esthetics, prosthetic solutions are used to comp
ensate for this deficiency. Soft-tissue augmentation, particularly those procedu
res to increase AG, is often overlooked.
Fig. 6: Implants placed in lateral window sinus graft with no augmentation of at
tached tissue.
Fig. 7: Failing implants for mandibular overdenture were placed in atrophic mand
ible with inadequate attached tissue.
Comparison
There is an abundance of literature showing increased gingival inflammation arou
nd natural dentition (exacerbated when a fixed restoration is present) when ther
e is less than 2 mm AG. (Figs. 8, 9: post grafting) There is an abundance of lit
erature showing increased incidence of peri-implant mucositis when there is inad
equate attached tissue a weaker connective tissue adhesion and lack of Sharpey s f
ibers make the peri-implant tissue even more susceptible to bacterial challenge.
(1-6, 8, 10) And as periodontitis is always preceded by gingivitis, peri-implan
titis will be preceded by peri-implant mucositis. If we can decrease the inciden
ce of peri-implant mucositis by providing a better and more resilient tissue phe
notype, we can lower the incidence of peri-implantitis.
The FGG procedure is indicated in cases of implant therapy where this is less th
an 2 mm of attached tissue present. Sometimes, a FGG is preferred over CTG becau
se: (1) the FGG results in greater gain of attached tissue, (2) the FGG alleviat
es frenum/muscular pull whereas the connective tissue may increase muscular tens
ion after the flap is coronally advanced, and (3) creeping attachment is often a
positive byproduct of the FGG procedure.
Refer to Case Nos. 1 & 2.
Case No. 1
Fig. A: Four weeks following immediate implant placement, FGG recommended. Note
exposed implant collar.
Fig. B: Suturing of graft.
Fig. C: Two-year post-placement with final restoration, <3 mm PD. Creeping attac
hment noted implant collar or abutment NOT visible.
tached gingiva and dental implants by Albert Yoo, DDS, and Adam Bear, DDS Attac
hed gingiva and dental implants by Albert Yoo, DDS, and Adam Bear, DDS
Figs. A1 to C1: Radiographic evaluation demonstrating increasing bone mineraliza
tion/density with stable crestal bone levels at placement (A1), Stage II surgery
(B1) and two-year follow-up (C1).
Case No. 2
Fig. M & N: Preop and radiographic condition of hopeless tooth No. 14. Note lack
of attached gingiva.
Fig. O: Immediately following extraction and degranulation of socket.
Fig. P: Four months reentry following extraction and bone graft. Good bone augme
ntation, but insufficient AT.
Fig. Q: Implant placement with internal sinus lift; final position/emergence.
Fig. R: Two-week postop following implant placement with thin overlying tissue a
nd inadequate attached gingiva.
Fig. S: Suturing of palatal graft.
Fig. T: Final screw-retained restoration with increased attached tissue and alle
viated frenum pull.
Fig. U: Final radiograph (six-months post-placement) demonstrating excellent bon
e level.
References
1. Adibrad M, Shahabuei M, Sahabi M. Significance of the width of keratinized mu
cosa on the health status of the supporting tissue around implants supporting ov
erdentures. J Oral Implantol.2009;35(5):232-237.
2. Artzi Z, Tal H, Moses O, Kozlovsky A. Mucosal considerations for osseointegra
ted implants. J Prosthet Dent. Nov. 1993;70(5):427-432.
3. Bouri A Jr, Bissada N, Al-Zahrani MS, Faddoul F, Nouneh I. Width of keratiniz
ed gingiva and the health status of the supporting tissues around dental implant
s. Int J Oral Maxillofac Implants. Mar.-Apr. 2008;23(2):323-326.
4. Boynuegri D, Nemli SK, Kasko YA. Significance of keratinized mucosa around de
ntal implants: a prospective comparative study. Clin Oral Implants Res. Aug. 201
3;24(8):928-933.
5. Chung DM, Oh TJ, Shotwell JL, Misch CE, Wang HL. Significance of keratinized
mucosa in maintenance of dental implants with different surfaces. J Periodontol.
Aug. 2006;77(8):1410-1420.
6. Kim BS, Kim YK, Yun PY, Yi YJ, Lee HJ, Kim SG, Son JS. Evaluation of peri-imp
lant tissue response according to the presence of keratinized mucosa. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. Mar. 2009;107(3).
7. Lang, N.P. & Loe, H. The relationship between the width of keratinized gingiv
a and gingival health. Journal of Periodontology 43;623-627.
8. Schrott AR, Jimenez M, Hwang JW, Fiorellini J, Weber HP. Five-year evaluation
of the influence of keratinized mucosa on peri-implant soft-tissue health and s
tability around implants supporting full-arch mandibular fixed prostheses. Clin
Oral Implants Res. Oct. 2009;20(10):1170- 1177.
9. Sullivan H., Atkins J. Free Autogenous Grafts. I. Principals of successful gr
afting. Periodontics 1968; 6(1) 5-13.
10. Warrer K, Buser D, Lang NP, Karring T. Plaque-induced peri-implantitis in th
e presence or absence of keratinized mucosa. An experimental study in monkeys. C
lin Oral Implants Res. Sept. 1995;6(3):131-138.
Albert Yoo, DDSAlbert Yoo, DDS, completed his predoctoral training at the Stony
Brook School of Dental Medicine in 2005. He received his certificate in periodo
ntics and implantology in Stony Brook in 2008. He is in full-time private practi
ce and has lectured to numerous study clubs, with special interest in perio-pros
thetics, advanced bone grafting, and sinus lift procedures, and immediate implan
t placement. He is a clinical assistant professor in the Department of Periodont
ics at Newark Beth Israel Hospital, Stony Brook School of Dental Medicine, and N
ew York Hospital of Queens. He maintains a private practice in Bayside, N.Y.
Adam Bear, DDSAdam Bear, DDS, received his Doctorate of Dental Surgery with dis
tinction in research in May of 2011 from the Stony Brook University School of De
ntal Medicine. Currently, he is a chief resident at Stony Brook University's Dep
artment of Periodontology. Dr. Bear has lectured and presented on numerous perio
dontal and implant topics for the 2013 American Academy of Osseointegration Annu
al Meeting, the Suffolk County Dental Society and the Bay Study Club.
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