Received: 3 July 2020 Revised: 27 September 2020 Accepted: 8 October 2020

DOI: 10.1002/JPER.20-0519

C O M M E N TA RY

Peri-implant marginal mucosa defects: Classification and

clinical management

Iñaki Gamborena1,2,3 Gustavo Avila-Ortiz4

1 Department of Preventive and

Restorative Sciences, University of Peri-implant marginal mucosa defects (PMMDs) are alterations of the peri-
Pennsylvania School of Dental Medicine, implant soft tissue architecture characterized by an apical discrepancy of the
Philadelphia, Pennsylvania, USA
mucosal margin respective to its ideal position with or without exposure of trans-
2Department of Restorative Dentistry at
the University of Washington School of
mucosal prosthetic components or the implant fixture surface. PMMDs may not
Dentistry, Seattle, Washington, USA only represent an esthetic concern but also predispose to biofilm accumulation
3 Private Practice, San Sebastian, Spain and subsequent initiation and progression of peri-implant inflammatory dis-
4 Department of Periodontics, University eases. A treatment-driven classification for tooth-bound, facial PMMDs in non-
of Iowa College of Dentistry, Iowa City,
molar sites, consisting of three different levels of complexity, is proposed. Clinical
Iowa, USA
recommendations pertaining to the prosthetic and surgical management of each
Correspondence type of PMMD, illustrated with practical examples, are provided with the purpose
Iñaki Gamborena, Resurrección Ma de
Azkue Kalea, 6, San Sebastián–Donostia
of facilitating decision-making processes in daily practice.
(Gipuzkoa) 28018, Spain.
Email: info@drgamborena.com KEYWORDS
clinical decision-making, dental implant, oral mucosa, plastic surgery
Sources of Support: No external funding
was received.
Disclaimers: The authors declare no
conflicts of interest pertaining to the prepa-
ration of this manuscript.

1 INTRODUCTION 2 PERI-IMPLANT SOFT TISSUE

Single tooth replacement therapy with implant-supported
prostheses has become an integral component of con-
temporary dental practice. Outstanding functional and
esthetic long-term results can be predictably achieved on
the basis of meticulous case analysis, treatment planning,
proper technical execution and a personalized mainte-
nance plan.1 On the contrary, iatrogenic dentistry, dele-
terious habits and/or inadequate supportive peri-implant
therapy may lead to the development of serious bio-
logic complications, including structural deformities of
the soft tissues that support and surround osseointegrated
implants.2
DEFORMITIES
Deformity is a congenital or acquired alteration of the nor-
mal shape, size or alignment of a biological structure. Defi-
ciencies and defects are specific types of deformities. Defi-
ciency is an insufficient or inadequate amount of a nec-
essary constituent. Defects are dysmorphic abnormalities
associated with structural alterations.
Thus, peri-implant soft tissue deficiencies and defects
can be categorized into three distinct groups:
A. Keratinized mucosa width deficiencies
Peri-implant keratinized mucosa width

J Periodontol. 2021;92:947–957. wileyonlinelibrary.com/journal/jper © 2020 American Academy of Periodontology 947

948
(KMW) is the height of keratinized soft tissue
that runs in an apico-coronal direction from the
mucosal margin to the mucosal junction.3 An insuf-
ficient amount of peri-implant keratinized mucosa
(i.e. <2 mm) has been associated with difficulty
to perform adequate oral hygiene4,5 and, therefore,
may be a predisposing factor for the occurrence of
inflammatory peri-implant diseases6 and mucosal
recession.7,8
B. Mucosal thickness deficiencies
Peri-implant mucosal thickness (MT) is the hor-
izontal dimension of the peri-implant soft tissue,
which may or may not be keratinized.3 Thin peri-
implant mucosa (i.e. <2 mm) may be associated
with tissue discoloration caused by mucosal trans-
parency of the underlying implant components.9,10
Thin peri-implant mucosa may also be a predispos-
ing factor for the development of marginal mucosa
defects secondary to peri-implant bone loss.11
C. Peri-implant marginal mucosa defects
Peri-implant marginal mucosa defects (PMMDs),
also known as peri-implant soft tissue dehiscences,
may be defined as alterations of the peri-implant
soft tissue architecture characterized by an apical
discrepancy of the mucosal margin respective to its
ideal position with or without exposure of trans-
mucosal prosthetic components or the implant
fixture surface. The etiology of PMMDs is multi-
factorial. PMMDs may be caused by actual apical
migration of the mucosal margin (i.e. reces-
sion) because of, for example, local inflamma-
tory processes, sustained trauma or iatrogenic den-
tistry (active pattern), by progressive marginal
mucosa discrepancies respective to the adjacent
teeth because of lifelong craniofacial growth (pas-
sive pattern),12,13 or by a combination of both.
PMMDs not only may represent an esthetic con-
cern, but also predispose for biofilm accumula-
tion and subsequent initiation and/or progression
of peri-implant inflammatory diseases.14,15 PMMDs
are frequently associated with underlying bone
dehiscences, KMW and/or MT deficiencies.2
3 CLASSIFICATION OF
PERI-IMPLANT MARGINAL
MUCOSA DEFECTS
To the best of our knowledge, Suzuki et al. proposed in
2012 the first classification on this topic ever published.16
However, this classification presented important limita-
tions and did not gain wide acceptance. Giovanni Zucchelli
and collaborators presented in 2019 a more comprehen-
GAMBORENA and AVILA-ORTIZ
sive classification of peri implant soft tissue dehiscences.17
This is a very granular system constituted by four classes
and three subclasses, for a total of eleven possible scenar-
ios, that relies on three essential parameters: 1) the loca-
tion of the mucosal margin relative to the ideal position of
the gingival margin of the homologous tooth, 2) the facial
contour of the implant crown respective to an imaginary
curve that connects the profile of the adjacent teeth at the
marginal level, and 3) the position of the interdental papilla
tip respective to the ideal level of the facial mucosal margin
around the implant. This classification is not exclusively
focused on PMMDs, as it also contemplates KMW and MT
deficiencies with no concomitant PMMDs under Class I.
Each category was linked to treatment recommendations
ranging from soft tissue augmentation to implant removal.
Being a valuable contribution to the literature, this
system presents some limitations. First, it is unclear how
overcontoured restorations and misaligned adjacent teeth,
if present, would influence Class determination and clin-
ical management. Second, it does not provide guidelines
to determine whether the existing implant fixture is in
a restorable position before characterizing the defect
type. This is a fundamental aspect of case selection and
treatment planning as in some clinical scenarios, instead
of solely treating the existing defect, implant removal
or submergence and secondary ridge augmentation are
required to achieve a satisfactory final outcome. Addi-
tionally, the level of detail and complexity inherent to this
classification system may be an obstacle for broad accep-
tance and implementation. Ideally, classification systems
should be suitable, exhaustive and unambiguous, whereas
also as succinct as possible to facilitate its applicability and
reproducibility in clinical practice and research settings.
It must be acknowledged that, because of the hetero-
geneity of implant systems and prosthetic designs that may
be encountered in clinical practice, as well as the lack of
robust connective tissue attachment of the peri-implant
mucosa to implant components,18 it is not feasible to estab-
lish a classification for PMMDs based on implant-related
landmarks or standard anatomical references that would
be comparable to available systems for gingival recession
defects.19–21
Taking into account these considerations, a new,
treatment-driven classification for facial PMMDs that is
primarily based on the topographic characteristics of the
marginal peri-implant mucosa is hereby proposed. This
classification applies to single, non-molar, tooth-bound
implant sites that have not been diagnosed with peri-
implantitis, according to the criteria established in the 2017
World Workshop on the Classification of Periodontal and
Peri-Implant Diseases and Conditions.2
Three categories constitute this classification, as shown
in Figure 1:
GAMBORENA and AVILA-ORTIZ
FIGURE 1 Peri-implant marginal mucosa defect (PMMD) types with clinical examples before and after treatment
∙ Type 1: Facial PMMD with no interproximal bone or
papillary height loss.
∙ Type 2: Facial PMMD with unilateral interproximal
bone and papillary height loss.
∙ Type 3: Facial PMMD with bilateral interproximal bone
and papillary height loss.
Any of these PMMD types may be accompanied with
bone dehiscences, KMW and/or MT deficiencies, but not
necessarily.
4 CLINICAL MANAGEMENT OF
PERI-IMPLANT MARGINAL MUCOSA
DEFECTS
The ultimate therapeutic goal of PMMD correction is to
reposition the mucosal margin in its ideal position by
recreating a peri-implant phenotype compatible with opti-
mal function, esthetics and long-term peri-implant health.
Proper case selection, based on a meticulous assessment
of prosthetic and surgical factors, is fundamental to maxi-
mize the predictability of treatment.
4.1 Prosthetic considerations
Implant-supported prostheses associated with facial
PMMDs frequently exhibit inadequate proportions and
949
contours. This may be the result of suboptimal prosthetic
management, an unfavorable implant position or a com-
bination of both. In these clinical scenarios, prosthetic
replacement or modification of the existing prosthesis is
often required to obtain a satisfactory final outcome, as
long as implant restorability is feasible. If restorability
is not viable, implant removal or submersion must be
considered. However, caution should be taken when
implant submersion is selected because of the risk of
secondary sinus tracts.22
First, the ideal architecture of the mucosal margin
should be envisioned according to the desired dimensions
of the implant-supported crown, which can be accom-
plished through a conventional or a digital workflow. Sub-
sequently, the spatial location of the existing implant fix-
ture relative to the ideal crown outline should be evaluated
with the purpose of determining implant restorability. This
is primarily dictated by two parameters: depth and angu-
lation.
1. Depth
It is the distance from the zenith of the mucosal mar-
gin to the implant shoulder (restorative platform). In
most single tooth replacement scenarios, the minimum
depth should be ≈ 3 mm for two reasons. First, to
prevent excessive marginal bone loss because of peri-
implant bone remodeling resulting from the establish-
ment of the physiologic supracrestal tissue height.23,24
Second, to ensure sufficient vertical space for an
950 GAMBORENA and AVILA-ORTIZ

F I G U R E 2 Implant depth should be at least 3 mm. In this case, the location of the implant shoulder is coronal to the desired mucosal
margin at baseline. Additionally, the implant was too close to the lateral incisor. In such situations, minimally traumatic implant removal is
generally recommended. Following explantation, ridge augmentation was performed via a guided bone regeneration approach, consisting of
the combination of autogenous bone and a particulate xenograft material* covered with an absorbable collagen membrane.† A new implant‡
was placed after a healing period of 6 months. Anatomic crown exposure of the left maxillary central incisor was done simultaneously to
create symmetry and allow for the fabrication of final crowns with similar proportions and shade. The patient underwent minor orthodontic
treatment to align both lateral incisors. Adjacent lateral incisors and canines were splinted lingually to the final ceramic restorations on the
central incisors using a metal wire to minimize continued natural tooth extrusion overtime. The final photograph depicts the aspect of the
facial peri-implant mucosa at ≈ 1 year after implant placement
*
Bio-Oss, Geistlich Pharma, Wolhusen, Switzerland
†
Bio-Gide, Geistlich Pharma, Wolhusen, Switzerland
‡
NobelActive, Nobel Biocare, Zürich, Switzerland

adequate crown emergence, which is particularly crit-
ical to obtain a pleasing esthetic outcome in ante-
rior sites (Figure 2).1 However, excessive implant depth
may complicate the restorative phase if the implant
platform is not easily accessible and, also, predispose
for the occurrence of peri-implant diseases because of
increased sulcular depth.25 As stated in a previous pub-
lication, “dental implants should be placed as deep as
necessary, but as shallow as possible,” accounting for
site-specific anatomic and restorative factors.3
2. Angulation
It is the degree of deviation of the long axis of the
implant fixture respective to the facial contour of
the crown in the sagittal plane. Analysis of implant
angulation should be based on a meticulous clini-
cal and radiographic examination, including advanced
imaging, such as cone-beam computed tomography
(CBCT).26 To make this assessment, the facial contour
of the ideal implant crown is divided in thirds, from
the incisal edge to the mucosal margin. If an imagi-
nary line resulting from the projection of the long axis
of the implant emerges within the two most coronal
thirds, the implant can be restored and maintained, pro-
vided depth is also adequate. On the contrary, if the
point of emergence is located within the apical third
of the crown or apical to the mucosal margin, implant
removal or submersion should be considered because
a prosthetic compensation (up to ≈ 25◦ ) compatible
with esthetics would not be feasible in most situations
(Figure 3).
4.2 Surgical considerations
Current literature pertaining to the surgical management
of single tooth PMMDs is scant and largely dominated by
case reports and prospective case series.27 Based on the
available evidence, a bilaminar approach consisting of a
coronally advanced flap (CAF) either pedicled or tunneled
in conjunction with a soft tissue graft should be considered
as the primary surgical modality in the management of
PMMDs, even if an underlying bone dehiscence is present.
In fact, data regarding the use of bone augmentation via
guided bone regeneration (GBR) as a monotherapy is very
limited28 and the predictability of this option to resolve
PMMDs is questionable.
GAMBORENA and AVILA-ORTIZ 951

F I G U R E 3 This case illustrates an example of unfavorable implant angulation. Patient presented for initial consultation seeking for an
esthetic solution. An immediate implant to replace the missing right maxillary central incisor was installed 5 years before this visit, following
a one abutment-one time protocol. According to the patient, no bone or soft tissue augmentation was done at that time. Careful clinical and
radiograph examination using CBCT imaging revealed suboptimal implant angulation. The horizontal yellow line represents the ideal
position of the mucosal margin based on a digital mock-up. The red line over the sagittal section of the implant clearly shows the suboptimal
position of the implant, as the projection of the long axis of the implant would emerge in proximity to the mucosal margin. This became more
evident on crown removal. The proposed treatment plan involved minimally traumatic implant removal, extraction of the left maxillary
central incisor because of unfavorable long-term prognosis, bone and soft tissue augmentation of the edentulous span and a tooth-supported
fixed dental prosthesis (FDP) from lateral incisor to lateral incisor. However, the patient declined to pursue further therapy at the moment

Several factors should be carefully pondered before per- 4.3 PMMD types: therapeutic
forming the surgical procedure: recommendations

- Features of the peri-implant mucosa: depth and width
of the PMMD (the larger the defect, the more challeng-
ing), characteristics of the interproximal papillae (the
more severe the papillary atrophy, the more demanding),
KMW and MT deficiencies (their presence adds more
difficulty) and local inflammatory status.
- Periodontal status of the adjacent teeth: existence of
severe attachment loss and mucogingival deformities on
the adjacent teeth may largely influence the amount
of peri-implant soft tissue correction that can be pre-
dictably achieved.
- Type of soft tissue graft: There are two alternatives, either
autogenous or exogenous (i.e. substitute). Clinical evi-
dence on the use of soft tissue substitutes for the man-
agement of PMMDs is limited to one clinical trial29 and
one case report.30 Both involved the use of acellular der-
mal matrix (ADM). Although the application of ADM
rendered relatively favorable outcomes in these reports,
autogenous subepithelial connective tissue graft (CTG)
is currently considered the gold standard for this type of
surgical interventions.31 Furthermore, deepithelialized
CTGs obtained from the tuberosity or the posterior seg-
ments of the hard palate are preferred, because of the
inherent biological properties of the lamina propria in
these locations.32,33
A clear understanding of the range of outcomes that may
result from different therapeutic alternatives is fundamen-
tal to determine what treatment plan would lead to achiev-
ing the desired goal in the most predictable and least
invasive manner. Management of PMMDs may require a
purely surgical or, in most situations, a combined surgical-
prosthetic approach, including adjustment or complete
replacement of the existing prosthesis. In some cases,
restorative work on adjacent teeth, such as modification
of the contact area, may be indicated to achieve an optimal
outcome.34,35 The following therapeutic recommendations
are based on the assumption that the existing implant is
restorable.
4.3.1 Type 1 defects
This is the most favorable PMMD type. If the features of
the existing implant-supported prosthesis are acceptable,
a purely surgical approach may be sufficient to manage
the defect. However, prosthesis replacement or modifica-
tion (i.e. abutment and/or crown) is often required because
one of the keys to maximize the chances of achieving a sat-
isfactory outcome is to ensure that there is sufficient faci-
olingual and mesiodistal space to stabilize the soft tissue
952 GAMBORENA and AVILA-ORTIZ

F I G U R E 4 Management of Type 1 defect. Patient presented with a chief complaint of esthetic dissatisfaction and discomfort on tooth
brushing on the facial aspect of the left maxillary central incisor. Intraoral exam revealed the presence of a type 1 PMMD associated to local
inflammation and accompanied by KMW and MT deficiency. Radiographic examination suggested the existence of a possible facial bone
dehiscence. Implant depth and angulation were favorable and the prosthetic crown was acceptable. Before the surgical intervention, the
crowns of both central incisors were modified using selective reduction and composite resin restorations to recreate a more harmonious look.
After local anesthesia, a facial tunnel flap was prepared. Marginal mucosa was gently retracted and abutment contour was reshaped
intraorally using a diamond bur mounted in a high speed hand piece to create more space for the graft. An autogenous connective tissue graft
was harvested from the left tuberosity (tCTG) and stabilized under the superficial mucosa. The flap was coronally positioned with no graft
exposure whatsoever. Sutures were removed after 2 weeks. The case has been followed up to 2 years. Clinical and radiographic examination at
that point revealed stable soft tissue volume gain and adequate radiographic marginal bone levels

graft in an ideal position and advance the flap coronally
without compromising wound healing. For this purpose,
intra- or extraoral modification of the facial contour of the
existing prosthesis or, if the prosthesis is to be replaced,
fabrication of a provisional restoration with a markedly
concave transmucosal profile may be required.36,37 Screw-
retained restorations offer the advantage of retrievability,
whereas cement-retained restorations can only be modi-
fied in situ, unless the crown is sectioned and removed.
Prosthetic modifications may be made during or before the
surgical intervention. When a tunnel approach is selected,
simultaneous intraoral modification of the prosthesis may
be challenging or even unfeasible depending on implant
depth and configuration of the transmucosal segment of
the abutment. Thus, in some cases, prosthesis retrieval is
inevitable, unless a conventional CAF is performed. Pros-
thetic modification before surgery to allow for a period of
soft tissue healing or maturation can be particularly advan-
tageous in sites presenting very thin mucosa, but it has the
drawback of elongating the total treatment time.
As aforementioned, the most predictable surgical
approach to manage PMMDs is a CAF+CTG. A tunnel
is recommended, whenever possible, as it provides the
advantages of preserving the integrity of the papilla and
avoiding excessive tissue thinning, which is crucial to favor
adequate wound healing and maximize esthetics. Tunnel
preparation should be initiated in marginal areas that
exhibit thicker mucosa, preserving full-thickness, to mini-
mize the possibility of tissue rupture. A partial-thickness
apical extension beyond the mucosal junction is necessary
for proper flap advancement. The facial tunnel can also
be expanded mesiodistally, following a partial-thickness
approach, over one or two teeth on each side, depending
on the amount of coronal advancement required, which
is directly related to PMMD dimensions and vestibular
depth. In cases of severe PMMDs that require the insertion
GAMBORENA and AVILA-ORTIZ 953

F I G U R E 5 Management of Type 2 defect on a right maxillary central incisor. Implant was placed ≈ 15 years before the initial visit, when
the patient was 16 years old. The discrepancy between the implant-supported crown and surrounding tissues respective to the adjacent teeth
was attributed to an unfavorable (too deep) implant position combined with the effect of continued craniofacial growth. On clinical and
radiographic examination, it was determined that the implant was restorable. This case required multiple interventions. First, the existing
crown was sectioned and the abutment was retrieved and modified circumferentially to create a more favorable transmucosal contour. A
provisional crown was fabricated. Then, a tunnel procedure using a tCTG was performed to augment the facial mucosa and the distal papilla.
Note that the papillae between #6/#7 and #9/#10 were elevated to facilitate the insertion of the graft. On tissue maturation, four months later,
it was determined that the desired amount of augmentation had not been achieved. Hence, the abutment contour was further reduced and a
second soft tissue augmentation procedure was performed. Four months later a new provisional restoration on both #7 and #8 was fabricated
and bleaching of #7 stomp was initiated. After 3 months, a new implant abutment and the final restorations were delivered. After a 12-month
follow-up period, the aspect of the peri-implant mucosa is excellent and the bone levels remained stable

of a large CTG and substantial flap displacement or in sites
with thin mucosal phenotype, a modification to the flap
design, consisting of elevation of papillae away from the
implant site or, instead, opting for a VISTA approach,38 is
advised. Following flap preparation, the soft tissue graft
can be secured in the desired location using positioning
sutures, as shown in Figure 4. Subsequently, the flap can
be coronally advanced as a second layer with simple or
double-sling sutures, trying to avoid needle engagement
in the underlying graft.39 Severe PMMDs, which are often
accompanied with KMW and/or MT deficiency, may
require more than one round of soft tissue grafting to
achieve the desired outcome.
4.3.2 Type 2 defects
These PMMDs are more difficult to manage than Type 1
defects, as reconstructing a deficient interproximal papilla
can represent a considerable clinical challenge. The added
degree of difficulty is directly related to local factors such
as the extent of interproximal bone loss and the proximity
954 GAMBORENA and AVILA-ORTIZ

F I G U R E 6 Management of Type 3 defect. Patient was referred from another practice to improve the esthetic appearance of the anterior
central sextant. Clinical and radiographic examination revealed the presence of a type 3 PMMD around a restorable implant on #9, in spite of
the unfavorable mesiodistal angulation. Existing implant-supported restoration was removed and a new undercontoured (slim) abutment was
placed. The crown on the left lateral incisor was also removed and a splinted provisional restoration was fabricated. After 2 months, soft tissue
augmentation was performed using a tCTG via a tunnel approach. The papillae between #7/#8 and #10/#11 were elevated to facilitate graft
insertion and coronal flap advancement. The provisional restoration was modified, to avoid impingement of the mucosa around the implant,
and cemented on #10. At 4 months, the amount of horizontal and soft tissue gain was evident, but not sufficient to achieve the desired
therapeutic goal. Therefore, a second soft tissue augmentation procedure was performed. This time a vestibular incision subperiosteal tunnel
access (VISTA) approach with a tCTG was followed. After another 4-months of healing, new provisional restorations were fabricated and
subsequently modified over a 2-month period until the desired mucosal architecture was achieved. The esthetic appearance of #8 was
improved with a composite resin restoration. Subsequently, final restorations on #9 and #10 were delivered and the patient was followed up at
periodic intervals of 6 months. At 1 year after delivery of the final implant-supported crown, the esthetic result is very satisfactory and
marginal bone levels remained unchanged in absence of pathosis
GAMBORENA and AVILA-ORTIZ
of the implant shoulder to the adjacent tooth, which may
result in serious space limitations to recreate an adequate
papillary anatomy.
Prosthesis removal is recommended for effective man-
agement of Type 2 defects. This allows for a more pre-
cise presurgical evaluation of the peri-implant mucosa
and also for optimal surgical access. The same surgical
principles previously described for the management of
Type 1 defects apply, including the preference for a tunnel
approach in combination with a dense CTG. However, in
Type 2 defects, tunnel preparation should be extended over
the lingual aspect of the ridge to achieve passive coronal
displacement of the whole papillae, but avoiding disrup-
tion of the interdental col. This is a fundamental technical
detail that allows to insert part of the CTG underneath the
papilla and over the underlying bone, in a saddle approach,
with the purpose of achieving soft tissue height and vol-
ume gain. Careful attention should be paid to position the
CTG crestally in a way that provides volume on the facial
aspect but, at the same time, supports the papillae from
underneath (Figure 5).
After stabilization, a crestal incision can be made on
the graft to facilitate abutment insertion. The use of an
undercontoured transmucosal abutment according to the
slim concept1 and a fixed provisional crown bonded to
the adjacent teeth is advised. This approach is intended
to maximize soft tissue volume gain on the supracre-
stal zone, which is critical to effectively manage PMMD
defects with interproximal involvement. Additional soft
tissue grafting may be required if the desired volume is
not attained after the first intervention. However, in cir-
cumstances that do not allow for additional soft tissue har-
vesting or if achieving the desired papillary morphology
through grafting procedures seems unrealistic, orthodon-
tic extrusion may be indicated to modify the interprox-
imal attachment level.40 Contrary to what is advised by
many practitioners, initiating orthodontic therapy after
soft tissue grafting and maturation, and not before, should
be considered.40 This is because, generally speaking,
orthodontic therapy is a more predictable and less inva-
sive approach to reconstruct deficient interdental papillae
compared to surgical interventions.41 That way, if surgical
therapy has not rendered the desired outcomes, orthodon-
tic extrusion can serve as a “rescue” therapy to maxi-
mize the chances of obtaining a successful esthetic out-
come. Additionally, having more volume of healthy soft tis-
sue during the orthodontic movement phase increases the
chances of achieving a satisfactory therapeutic outcome.
Implant supported provisional restorations can be used
for orthodontic anchorage purposes, which provides better
control of adjacent tooth movement. On soft tissue matu-
ration, fabrication of a new implant-supported provisional
restoration with adequate contours is recommended to
955
shape the peri-implant mucosa before delivering the final
restoration.
4.3.3 Type 3 defects
This is the most challenging type of PMMD. Although the
therapeutic principles are essentially the same as those
described above for Type 2 defects, the presence of bilat-
eral papillary deficiency makes Type 3 defects particularly
demanding (Figure 6). The more deficient the peri-implant
phenotype, the more soft tissue augmentation interven-
tions that may be necessary. As aforementioned, orthodon-
tic extrusion should be considered when the potential
to improve the papillary morphology with surgical and
restorative therapy has been exhausted in cases of severe
papillary atrophy. However, orthodontic extrusion has its
own limitations (e.g. situations in which further tooth
movement is not feasible because of local anatomic fac-
tors, such as an existing unfavorable crown-to-root ratio).
When papillary reconstruction is not possible with surgical
and orthodontic therapy, a hybrid, screw-retained implant-
supported restoration with pink composite or ceramic to
create the illusion of having papillary tissue may be indi-
cated.
5 CONCLUDING REMARKS
This treatment-oriented classification is linked to specific
recommendations for the management of each type of
PMMD. A meticulous presurgical evaluation of the site,
including assessment of implant restorability and char-
acteristics of the peri-implant mucosa, a solid treatment
plan and a refined surgical and prosthetic technique, are
the essential pillars to predictably achieve satisfactory out-
comes. Further clinical research is warranted to determine
the applicability and reproducibility of this and other clas-
sifications of PMMDs.
AC K N OW L E D G M E N T S
The authors would like to thank Drs. Leandro Cham-
brone [University of Iowa (Iowa City, USA), Ibirapuera
University (São Paulo, Brazil) and Universidad El Bosque
(Bogotá, Colombia)] and Emilio Couso-Queiruga [Univer-
sity of Iowa (Iowa City, USA)] for their critical evaluation
and feedback during the preparation of this manuscript.
AU T H O R CO N T R I B U T I O N S
Inaki Gamborena and Gustavo Avila-Ortiz conceived the
commentary and equally contributed to the writing. Both
authors agree to be accountable for all aspects of the
work.
956
ORCID
Iñaki Gamborena https://orcid.org/0000-0003-2160-
5829
Gustavo Avila-Ortiz https://orcid.org/0000-0002-5763-
0201
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How to cite this article: Gamborena I,
Avila-Ortiz G. Peri-implant marginal mucosa
defects: Classification and clinical management. J
Periodontol. 2021;92:947–957.
https://doi.org/10.1002/JPER.20-0519