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Table of Contents
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 109-113

Thick soft tissues around implant-supported restoration; stable crestal bone levels?

Division of Periodontics, Faculty of Dental Sciences, IMS BHU, Varanasi, Uttar Pradesh, India

Date of Submission05-Nov-2020
Date of Decision04-Aug-2021
Date of Acceptance05-Aug-2021
Date of Web Publication14-Dec-2021

Correspondence Address:
Dr. Farhan Durrani
D 37/40 Baradeo Godowlia, Varanasi - 221 005, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdi.jdi_29_20

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The peri-implant tissue remodeling just after implant surgery forms a coagulum that occupies the space between mucosa and implant. This is invaded by neutrophils and a barrier forms around implant consisting of dense fibrin network. In another 2 weeks post surgery, it is replaced by connective tissue and vascular structures. In the crestal area, the proliferation of epithelium takes place and forms a junctional epithelium. The barrier epithelium around the implant matures in 6–8 weeks. Formation of biological width begins when the implant gets exposed to the oral environment. This could be through healing screw or prosthetic abutment depending on connection to the implant. It is said that thin or thick tissues have different approaches to healing as the blood supply is varied. Flap is raised during the second stage of implant surgery damaging the blood supply of surrounding tissues. Thin mucosa present around the implant crestal area might lead to more bone loss but not thick tissues as more blood vessels are present here. Bone turnover can lead to crestal bone loss up to 3.2 mm apical to soft-tissue margin. The thickness of the tissues may be a recognized biological factor that might lead to crestal bone stability. In this report, we describe three cases where bone remodeling was camouflaged by thick soft tissues around implant-supported restorations.

Keywords: Crestal bone stability, definitive abutment, esthetics, soft-tissue thickness, supracrestal implants

How to cite this article:
Durrani F, Pandey S, Nahid R, Singh P, Pandey A. Thick soft tissues around implant-supported restoration; stable crestal bone levels?. J Dent Implant 2021;11:109-13

How to cite this URL:
Durrani F, Pandey S, Nahid R, Singh P, Pandey A. Thick soft tissues around implant-supported restoration; stable crestal bone levels?. J Dent Implant [serial online] 2021 [cited 2022 Aug 7];11:109-13. Available from:

   Introduction Top

Crestal bone stability around implants had been the goal for every clinician. Various treatment options proposed for the same are platform switching, laser-micro-textured surface of abutment, and thick soft tissues. The etiology behind bone loss is multifactorial and can be attributed to microgap between abutment and implant, overload, and biological width formation. It is said that if the peri-implant soft-tissue thickness is <2 mm, the biological width formation causes bone loss.[1] Slight supracrestal implant placement (0.5 mm above the bone) has the negative influence of microgap and may decrease early bone changes along with the presence of thick soft tissues.[2] Another cautious approach for further reducing marginal bone loss could be the use of definitive abutment during implant placement.[3] This prevents regular connection and disconnection during prosthetic phase which further provides stability to thick peri-implant soft tissue. We present three cases where the crestal bone around restorations looked stable after 3 years of implant function. The reason could be the presence of thick soft tissues around crestal area of implant restorations. With our report, it can be assumed that vertical soft-tissue thickness is one of the important variables for the longevity of implant restorations.

Soft-tissue evaluations for each patient were termed thick on visual probe inspection.

   Case Series Top

Clinical case 1

A healthy male patient, 22 years-old, presented with a missing right upper front tooth. Computed tomography showed an anterior maxillary ridge with a width of 4.6 mm.[Figure 1] The soft tissue when measured with transgingival probing was found thick [Figure 2]. The vertical height was 11.5 mm. Ridge expansion was done through osseodensification (Versah burs) [Figure 3] followed by augmentation with a 1:1 mixture of autogenous bone and bovine graft covered with collagen membrane [Figure 4]. No soft-tissue surgery was performed at any stage. The anterior implant restoration was followed for 3 years [Figure 5]a and [Figure 5]b.
Figure 1: Cross-sectional view of the ridge

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Figure 2: Partial edentulous ridge with thick biotype of soft tissue

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Figure 3: Ridge expansion through osseodensification (Versah burs)

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Figure 4: Guided bone regeneration

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Figure 5: (a) Implant-supported restoration surrounded by thick tissues. (b) Cross-sectional view after 3 years

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Clinical case 2

A healthy 55-year-old male patient presented with missing lower front teeth. Clinical and radiographic examination revealed ridge resorption with remaining buccolingual width of 6.4 mm and height 11 mm [Figure 6]a. On evaluation, the soft tissue was found thick [Figure 6]b. The treatment plan had two implants with a four-unit fixed prosthesis. Two implants of 3.3 mm × 10 mm were placed supracrestally (0.5 mm) followed by placement of a definitive abutment [Figure 7] and [Figure 8]. Screw retained four-unit implant prosthesis was delivered after 3 months [Figure 9]. The patient was on regular follow-up of every 6 months for the last 3 years [Figure 10].
Figure 6: (a) Three-dimensional view of the partial edentulous lower anterior ridge. (b) Clinical picture depicting thick soft tissue in lower edentulous space

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Figure 7: Two implants with definitive abutments and thick soft tissues surrounding them

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Figure 8: Postoperative orthopantomogram

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Figure 9: Implant-supported bridge

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Figure 10: Orthopantomogram after 3 years with stable crestal bone around implant prosthesis

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Clinical case 3

A healthy male patient, 20 year old, presented with a missing right upper front tooth. Clinical examination revealed thick soft tissue in the partial edentulous space. Dentascan revealed atrophic bone defect in the maxillary anterior region [Figure 11]a and [Figure 11]b. Bone augmentation was done through autogenous block harvesting from ramus without any soft-tissue surgery at any stage [Figure 12]. After complete maturation of the grafted bone, 3.3 mm × 11.5 mm implant was placed. Implant-supported esthetic restoration was given after 9 months [Figure 13]. The stability of crestal bone was evident in regular follow-ups of 3 years [Figure 14] and [Figure 15].
Figure 11: (a) Cross-sectional view showing a defect in missing tooth area (computed tomography). (b) Clinical picture depicting thick soft tissues in the missing tooth area

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Figure 12: Cross-sectional view showing a bone gain in missing tooth area (computed tomography)

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Figure 13: Esthetic implant restoration with thick soft tissue

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Figure 14: Stable crestal bone (intraoral periapical radiograph)

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Figure 15: Stable crestal bone (intraoral periapical Radiograph) after 3 years

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   Discussion Top

The outcome of any implant treatment largely relies on the stability of the crestal bone for long term. The current report emphasizes that there was minimal crestal bone loss in the presence of thick tissues around implant-supported restorations. In one of our patients (clinical case 2), the supracrestal location of abutment–implant microgap and a definitive abutment placement during surgery may have decreased persistent bone remodeling with stable marginal bone levels even after 3 years. The reason could be reduced possible bacterial leakage and avoidance of repeated disconnection and reconnection at the implant–abutment interface. Thick tissue surroundings around the cervical part of restorations were an added factor. Suárez-López et al. in a systematic review said that peri-implant soft-tissue thickness plays a role in minimizing marginal bone loss when implants are placed supracrestally.[4] In a systematic review and meta-analysis, Tallarico et al. concluded that repeated abutment disconnections and reconnections considerably increased marginal bone loss and caused buccal soft-tissue recession.[5] Peri-implant tissues react similarly as tissues surrounding natural tooth for the establishment of biological width. The tissue biotype may play a key role in its formation. This is measured as thickness of mucosa covering implant–abutment junction.[6] First and third cases had stable crestal bone around anterior esthetic implant-supported restorations. The broader bone width after guided bone regeneration lead to crater formation around the implants, but the outer facial wall seemed unaffected Linkevicius et al. suggested that vertical soft-tissue thickness should be 3 mm in height to prevent bone loss during biological width formation.[7] The other two anterior implant restorations in clinical case 2 showed initial crestal bone loss followed by remineralization around implants. Sometimes, this occurrence looks like bone loss in periapical X-ray.[8] Inflammation and overproduction of cytokines and bone cells lead to demineralization and release of hydroxyapatite mineral ions from hard tissues.[9] Bone mineralization would have occurred around these restorations after loading. Further, evidence-based long-term studies are needed for accurate results.

   Conclusion Top

It brings us to a conclusion that thick biotype of soft tissues plays a vital role in averting or hiding the crestal bone remodeling. This assumption needs proper research and evaluation for a definite answer with a randomized control trial approach.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Berglundh T, Lindhe J. Dimension of the periimplant mucosa. Biological width revisited. J Clin Periodontol 1996;23:971-3.  Back to cited text no. 1
Linkevicius T, Apse P, Grybauskas S, Puisys A. The influence of soft tissue thickness on crestal bone changes around implants: A 1-year prospective controlled clinical trial. Int J Oral Maxillofac Implants 2009;24:712-9.  Back to cited text no. 2
Atieh MA, Tawse-Smith A, Alsabeeha NH, Ma S, Duncan WJ. The one abutment-one time protocol: A systematic review and meta-analysis. J Periodontol 2017;88:1173-85.  Back to cited text no. 3
Suárez-López Del Amo F, Lin GH, Monje A, Galindo-Moreno P, Wang HL. Influence of soft tissue thickness on peri-implant marginal bone loss: A systematic review and meta-analysis. J Periodontol 2016;87:690-9.  Back to cited text no. 4
Tallarico M, Caneva M, Meloni SM, Xhanari E, Covani U, Canullo L. Definitive abutments placed at implant insertion and never removed: Is it an effective approach? A systematic review and meta-analysis of randomized controlled trials. J Oral Maxillofac Surg 2018;76:316-24.  Back to cited text no. 5
Linkevicius T, Apse P. Biologic width around implants. An evidence-based review. Stomatologija 2008;10:27-35.  Back to cited text no. 6
Linkevicius T, Puisys A, Svediene O, Linkevicius R, Linkeviciene L. Radiological comparison of laser-microtextured and platform-switched implants in thin mucosal biotype. Clin Oral Implants Res 2015;26:599-605.  Back to cited text no. 7
Abou Neel EA, Aljabo A, Strange A, Ibrahim S, Coathup M, Young AM, et al. Demineralization-remineralization dynamics in teeth and bone. Int J Nanomedicine 2016;11:4743-63.  Back to cited text no. 8
Xiao W, Wang Y, Pacios S, Li S, Graves DT. Cellular and molecular aspects of bone remodeling. Front Oral Biol 2016;18:9-16.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]


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