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Implantology

2 C E C r e d i t s

Implant Soft-Tissue Complications

Risk Indicators and Prevention of Implant Soft-Tissue

Complications: Interproximal Papillae Loss and
Midfacial Implant Mucosal Recessions
James Mailoa, DDS; Richard J. Miron, DMD, DDS, MSc, PhD; and Hom-Lay Wang, DDS, MSD, PhD

2 C E C r e d i t s

Periodontal Probing

Risks and Benefits of Probing Around Natural

Teeth and Dental Implants
Stuart J. Froum, DDS; and Wendy C.W. Wang, BDS, MSc

SUPPORTED BY AN UNRESTRICTED GRANT FROM CARESTREAM DENTAL • Published by AEGIS Publications, LLC © 2018
continuing education 1 Implant Soft-Tissue Complications

Risk Indicators and Prevention

of Implant Soft-Tissue
Complications: Interproximal
Papillae Loss and Midfacial
Implant Mucosal Recessions
James Mailoa, DDS; Richard J. Miron, DMD, DDS, MSc, PhD; and
Hom-Lay Wang, DDS, MSD, PhD

Abstract: Achieving a long-term esthetic implant restoration in the maxillary anterior

area is sometimes unpredictable. This article reviews several risk indicators of implant
mucosal recession and loss of interproximal papillae, and how to prevent these risks.
Results obtained from the literature suggest that the following factors are strongly related
to implant soft-tissue complications: buccally positioned implant placement, a thin gingi-
val biotype, lack of an adequate amount of keratinized mucosa, implant placement after
ridge augmentation procedures, an increased distance of tooth bone peak to the contact
point, and an inadequate horizontal implant–tooth distance. Factors that have been shown
to favor long- term stability and improve implant esthetic outcomes include implant place-
ment in an ideal 3-dimensional position, use of platform-switching implant/abutment
designs, and performing soft-tissue grafting. Careful assessment of the above factors and
adoption of suggested guidelines are critical to executing successful implant placement
with favorable esthetic outcomes while minimizing soft-tissue complications.

learning objectives

• D
 escribe the etiologic
factors related to soft-
tissue problems such as
loss of interproximal papillae
and midfacial implant
mucosal recessions
• Evaluate how to avoid • D
 iscuss how to predictably
common implant soft-tissue achieve long-term
complications esthetically pleasing
implant restorations

DISCLOSURE: The authors report no conflicts of interest associated with this work.
www.compendiumlive.com March 2018 COMPENDIUM EBOOK SERIES 3
 continuing education 1
S
atisfactory long-term survival rates
of endosseous implants as treat-
ment options for partially and fully
edentulous patients have been well-
documented.1,2 However, achiev-
ing esthetically pleasing peri-implant tissues
long term after implant placement in the ante-
rior area is not always predictable. The most
common implant soft-tissue complications
encountered in the esthetic zone are interprox-
imal papillae and midfacial implant mucosal
recessions.3 Rates of these complications have
been reported as high as 7.1% after 5 years in
function.1 Kan et al reported that the overall
cumulative implant success rate after immedi-
ate implant placement and provisionalization
was 100% after a mean follow-up of 4 years;
however, continuing implant midfacial reces-
sion was found over time after 1 year of function,
and 11% of these patients expressed dissatis-
faction with the esthetic outcomes because of
marginal soft-tissue recession and unesthetic
final restorations.4 These findings demonstrate
that despite high implant survival rates, implant
soft-tissue complications in the esthetic zone
are not uncommon; patients not only expect
implants that are functional but that also have
long-term esthetic stability in harmony with
the surrounding dentition.
Several factors have been reported as the
etiology for implant midfacial mucosal reces-
sions and loss of interproximal papillae, includ-
ing buccally positioned implants,5 thin gingi-
val biotypes,4 lack of adequate keratinized
mucosa,6 implant placement with horizon-
tal bone augmentation, implant placement
after horizontal onlay block grafting, inade-
quate horizontal implant–tooth distance, and
increased distance of the tooth bone peak to
the contact point.3 Thus, it is prudent for clini-
cians to address these factors before perform-
ing implant therapy to improve predictability of
attaining esthetic results and provide a compre-
hensive treatment plan to meet the patient’s
esthetic expectations.
4 COMPENDIUM EBOOK SERIES March 2018
Implant Soft-Tissue Complications
Surgical and restorative interventions, such
as bone-grafting procedures,7 connective-
tissue grafting,8,9 and implant provisionaliza-
tion,10,11 have also been reported as treatment
options for mucosal recessions around implants.
However, a recent systematic review evaluat-
ing the effect of several treatment modalities
for implant midfacial mucosal recessions failed
to find a benefit of using bone-grafting materi-
als to reduce implant recession; nor was there
enough evidence to demonstrate the beneficial
effect of connective-tissue grafting to improve
implant mucosal levels.12 Peri-implant mucosa
and gingival tissue around teeth are different
in several ways. Compared with gingiva, peri-
implant tissue shows absence of root cementum
and collagen fiber insertion on implant surfaces.
Moreover, the collagen and fibroblast composi-
tion of the peri-implant mucosa is different from
that of gingival tissue; a study indicated that the
tissue turnover of peri-implant mucosa is less
rapid than in gingiva.13 Therefore, periodontal
procedures, particularly those related to soft-
tissue augmentation, may have less-predictable
long-term results for treating mucosal recession
around implants.14
Hence, it has been suggested that the key
determinant to prevent implant esthetic compli-
cations is identifying, before implant therapy,
all possible etiologies that may cause implant
mucosal recession and loss of interproximal
papillae, combined with thorough presurgical
planning.15 The aim of this article is to review
several risk indicators of implant mucosal reces-
sion and loss of interproximal papillae, and how
to prevent these risks.
Risk Indicators of Implant
Mucosal Recession and
Interproximal Papillae Loss
Buccally Positioned Implant
A minimum of 2 mm of facial bone thickness
has been proposed as the “critical bone thick-
ness” for the prevention of vertical height loss
of the facial plate. It has been reported that
continuing education 1 Implant Soft-Tissue Complications

Fig 1.

Fig 1. Clinical photograph showing significant issues related to implant

midfacial mucosal recession and loss of interdental papillae. This is
attributed to incorrect implant positioning (too buccal and too deep);
several corrective surgeries resulted in interproximal bone loss, then
loss of interdental papillae. Fig 2. Radiograph showing implant was
placed too deep and the diameter of the implant may be slightly Fig 2.
larger than what was needed.

when the distance of the buccal shoulder posi-
tion of the implant to facial bone plate is below
this critical thickness, an increased amount of
facial bone resorption may be observed, which,
in turn, may increase the chance of implant
mucosal recession and failure (Figure 1). When
the facial bone thickness is more than 2 mm
from the implant buccal shoulder position, the
likelihood of facial bone loss is decreased and
the chance for alveolar bone stability is, there-
fore, increased.16
Chen and coworkers evaluated the soft-
tissue and radiographic outcomes of implants
placed in extraction sockets using a nonsub-
merged protocol. The result showed statisti-
cally significantly higher marginal tissue reces-
sion at sites when implants were placed 1.1 mm
from the inner buccal socket wall compared
with implants placed 2.3 mm from the inner
buccal socket wall. Six of the eight implant cases
that were buccally positioned had unsatisfac-
tory post-restorative esthetic outcomes. The
authors concluded that position of the implant
shoulder within the socket is a critical factor for
ideal esthetic outcomes; thus, a minimum of 2
mm distance from the implant shoulder to the
inner buccal shoulder wall was recommended
to prevent implant marginal tissue recession.5
Caneva et al also suggested placing implants in
a lingual (eg, cingulum) position to achieve opti-
mal esthetic outcomes. The authors assessed
the effect of implant positioning on resorptive
patterns of the alveolar bone crest and demon-
strated the importance of placing implants in a
lingual position to minimize buccal bone resorp-
tion and thus prevent exposure of the implant. In
their study, an average of 0.6 mm more buccal
bone resorption was seen on implants that were
placed in the center of the socket when heal-
ing after 4 months was compared histologically
with implants that were positioned toward the
lingual bony wall.17 In addition, placing a wider-
diameter cylindrical implant in the extraction
socket with the aim of filling the void between
the implant and the inner socket wall was also
shown to present greater buccal alveolar bone
resorption (Figure 2).18,19 Based on these findings,
it has been suggested that implant placement be

www.compendiumlive.com March 2018 COMPENDIUM EBOOK SERIES 5

 continuing education 1
performed in the palatal position of the socket
to allow the formation of a gap between the
implant surface and the inner buccal bone wall
surface.19 More recently, in a retrospective
cohort study, Cosyn and coworkers evaluated
115 patients who underwent implant place-
ment with function. At 31 months, the buccal
shoulder position of the implant was signifi-
cantly associated with an increased likelihood
of midfacial recession.3
Thin Gingival Biotype
While it has been suggested that peri-implant
mucosa needs to be only a certain thickness to
prevent bone resorption after implant place-
ment, a thin tissue biotype may have an adverse
effect on peri-implant soft-tissue stability
and esthetic outcomes.20 Kois described thick
tissue biotypes as more fibrotic and resistant
to recession, whereas a thin tissue biotype is
more friable and has less vascularization, or
blood supply, and, thus, an increased risk of
recession after implant surgery is observed.21
In an animal study, sites with a thin mucosa
(≤ 2 mm) displayed consistent bone resorp-
tion and angular defects around implants,
suggesting that a certain thickness of the peri-
implant mucosa was required to favor stabil-
ity.22 Similarly, Abrahamsson et al, using a dog
model, demonstrated that sites with a thin
mucosa had an angulated pattern of bone
defects, whereas sites with an even pattern of
the alveolar crest had an adjacent mucosa that
was consistently thick.23
A human prospective clinical trial evaluated
whether tissue/mucosa thickness may affect
crestal bone stability around implants. This study
showed that implants with initially thin tissue
(< 2 mm) had bone loss up to 1.45 mm occurring
within the first year of function. Contrarily, thick
tissues (≥ 2 mm) showed only 0.2 mm of bone
loss.24 Moreover, an incomplete filling of the space
under the contact point by the interdental papil-
lae was also reported more frequently at implant
sites developed with a thin tissue biotype.20
6 COMPENDIUM EBOOK SERIES March 2018
Implant Soft-Tissue Complications
In conclusion, some major differences were
noted between implants with thin and thick
gingival biotypes regarding marginal bone loss,
buccal probing depth, buccal recession, and
papilla index. Statistically higher amounts of
peri-implant marginal bone loss and buccal
recession were noted in a thin gingival biotype
than in a thick biotype. Therefore, a thin gingi-
val biotype may be considered a risk factor for
implant marginal tissue recessions.14,20
Lack of Adequate Amount of
Keratinized Mucosa
In 1972, Lang and Loe reported that at least 2
mm of keratinized gingiva, including 1 mm of
attached gingiva, is needed to maintain gingi-
val health and prevent bacterial entry into the
gingival crevice.25 Keratinized mucosa around
implants acts as a protective tissue seal to cope
with bacterial challenge. In an animal exper-
iment, Warrer and coworkers showed that
implants placed in the lining (nonkeratinized)
mucosa resulted in higher susceptibility for
tissue breakdown due to bacterial plaque accu-
mulation, leading to significantly higher attach-
ment loss and higher mucosal recession than
implants placed in areas with adequate keratin-
ized mucosa.26 Similarly, Chung et al evaluated
339 endosseous implants in 69 patients that
were in function for 3 years and demonstrated
that implants with an absence of adequate
keratinized mucosa or attached mucosa were
associated with higher plaque accumulation
and gingival inflammation, regardless of the
implant surface configurations.27
Bouri et al, in a cross-sectional study, analyzed
76 patients with 200 implants and found that
implants with narrow zones of keratinized tissue
(< 2 mm) had significantly more plaque, bleed-
ing on probing, and alveolar bone loss compared
with implants with wider zones of keratinized
tissue (≥ 2 mm). With a wider zone of keratin-
ized tissue, implants may display an epithelial
seal that is more resistant to the forces of masti-
cation and frictional contact that occur during
continuing education 1
oral hygiene procedures, whereas implants with
a lack of keratinized tissue have been shown to
be more susceptible to irritation and inflam-
mation.28 Shrott and coworkers also noted that
at least 2 mm of keratinized mucosa around
implants was beneficial for reducing lingual
peri-implant plaque accumulation, bleeding,
and buccal soft-tissue recession over a 5-year
period.29 In contrast, Wennstrom et al showed
that a lack of keratinized mucosa and marginal
soft tissue had no significant effect on the health
conditions of dental implants. However, the
authors also reported that there were more clini-
cally visible signs of inflammation in areas with
narrow keratinized tissue (< 2 mm) compared
with areas with wider zones of keratinized tissue
(≥ 2 mm).30 Furthermore, in a recent systematic
review, it was concluded that more plaque accu-
mulation, tissue inflammation, mucosal reces-
sion, and attachment loss were found in implants
with no keratinized mucosa.6
Implant Placement After Ridge
Augmentation Procedures
Implant surgery with ridge recontouring has
been suggested as a significant predictor of
interproximal recession (ie, loss of interproxi-
mal papillae), which has been particularly seen
in implants placed after block-grafting proce-
dures. Thus, it has been suspected that multiple
surgeries and/or papillae openings increase
the risk for incomplete wound closure, result-
ing in soft-tissue recession. Furthermore, an
increase in surgery time during ridge recon-
touring procedures was found to cause 0.2 mm
of additional bone loss at the distal aspect of the
adjacent tooth.3
In another report, Tymstra et al evaluated 10
patients who had maxillary anterior implants
and had undergone multiple surgeries, includ-
ing separate bone augmentation procedures
with autogenous bone harvested from the chin
region before implant placement. The authors
reported that the inter-implant papilla was
present in only one patient and 30% of the
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Implant Soft-Tissue Complications
patients lost the papilla between the implant
and its neighboring tooth, resulting in six
moderate esthetic outcomes and four poor
esthetic outcomes based on the clinician’s crite-
ria. The authors concluded that the low esthetic
index scores of the sites could be attributed to
the patients having been through several trau-
matic surgeries, such as ridge recontouring by
an augmentation procedure before implant
placement.31 Thus, it was recommended to limit
flap (eg, papilla) opening procedures to opti-
mize soft-tissue esthetics around implants.3
Increased Distance of Tooth Bone Peak
to the Contact Point
In 1992 Tarnow and coworkers reported the
effect the distance from the contact point to the
crest of bone has on the presence or absence
of interproximal dental papilla. The data
demonstrated that the presence of papilla was
decreased when the distance of the bone peak
(ie, crest of bone on the adjacent tooth surfaces)
to the contact point increased. Incidence of
complete interproximal papilla was observed
when the distance between contact point and
bone crest was ≤ 5 mm.32 Presence of papilla
between a tooth and an implant depends on
the proximal bone crest level of the adjacent
tooth, whereas papilla presence between two
adjacent implants is associated with inter-
implant distance at the implant shoulder and
the distance from the base of the contact point
to the bone crest between adjacent implants.
A similar observation was observed by
Choquet et al, who reported that the papilla was
almost fully present when the distance from the
base of the contact point to the bone crest was 3
mm to 4 mm. However, when the distance was
5 mm to 6 mm, some papilla was missing 50%
of the time.33 In a prospective study, Andersson
et al found a correlation between the marginal
bone loss at tooth surfaces facing implants and
vertical implant–tooth distance. The results
showed that higher mean bone loss at implant-
facing surfaces was noted when the vertical
March 2018 COMPENDIUM EBOOK SERIES 7
 continuing education 1 Implant Soft-Tissue Complications

Fig 3. Fig 4. Fig 5.

Fig 6. Fig 7.

Fig 3. Initial buccal view of tooth No. 7. Fig 4. Radiograph showing root fracture and apical lesion of the
tooth (No. 7). Fig 5. Atraumatic extraction without raising the flap, with the intention of minimizing bone
loss, especially in the interproximal area. Fig 6. Implant was placed in an ideal 3-dimensional position.
Fig 7. Human bone allograft was placed in the gap.

distance between the implant–abutment junc-
tion and cementoenamel junction (CEJ) of the
adjacent tooth was 5.49 mm.34 Another retro-
spective study, by Cardaropoli et al, evaluat-
ing 28 patients with 35 fixed partial prosthe-
ses, also showed that implants positioned 6
mm below the CEJ of the adjacent tooth had
0.5-mm mean marginal bone loss at the implant
site at the 3-year follow-up period.35
Concurring with these previous studies,33,36
Gastaldo and coworkers evaluated 48 patients
who had implant-supported fixed prostheses
for a minimum of 18 months and found that the
papilla was always present when the distance
from the base of the contact point to the bone
crest was ≤ 3 mm. However, when the distance
increased to ≥ 5 mm, papilla was absent in 60%
to 75% of cases.37 Cosyn et al also reported that
only 13% of the cases demonstrated a full distal
papilla when the distance of the bone peak to
the contact point exceeded 5 mm.3
Inadequate Horizontal Implant–
Tooth Distance
Regarding placement of dental implants
adjacent to natural teeth, careful consid-
eration of available bone coupled with the
implant dimension and insertion position
is needed. Previous studies38,39 have indi-
cated an increased amount of periodontal
bone loss associated with a decrease in hori-
zontal distance to the implant. Esposito et
al analyzed the bone modification at teeth
facing a single-tooth implant in the maxil-
lary anterior region and reported a strong
correlation between bone loss at the tooth
site and a decreasing distance between the
implant and tooth.38 It was also reported that

8 COMPENDIUM EBOOK SERIES March 2018

continuing education 1
soft- and hard-tissue alterations occurred
predominantly within the first 6 months
after one-stage implant placement surgery,
and it was found that the presence of a tooth
next to the implant positively affects the
maintenance of the proximal bone crest level
and the topography of the tooth–implant
unit soft tissues.40
Vela et al also showed that there was a corre-
lation between bone peak resorption and hori-
zontal implant–tooth distance when platform-
switched implants were placed closer than
1 mm to the adjacent tooth.41 Furthermore,
Cosyn et al observed that when the implant–
tooth distance was < 2.5 mm, there was a signif-
icant drop in the incidence of complete distal
papilla,3 which is in agreement with previous
reports.37,42 The closer the approximation of
roots, the more complex the relationship will
be between the interproximal tissue, which
may be compromised, and the thinner the
interproximal bone will be, which can poten-
tially lead to greater risk of lateral resorption
of the osseous crest and cause an absence of
interdental papilla.21,43
Prevention of Implant Mucosal
Recession and Interproximal
Papillae Loss
To predict peri-implant esthetic outcomes,
Kois described five essential diagnostic keys
that need to be assessed before removing a
periodontally hopeless tooth (Figure 3 and
Figure 4): (1) relative tooth position; (2) form
of the periodontium; (3) periodontal biotype;
(4) tooth shape; and (5) position of the osse-
ous crest. Failing teeth that have a thick, flat
gingival biotype, are square shaped, and have <
3 mm vertical distance from the position of the
facial and interproximal crest have the lowest
risk of developing recessions after implant
placement.23 Therefore, implant surgery may
be performed by either an open flap or flap-
less approach. However, teeth with a thin
soft-tissue biotype, a highly scalloped gingival
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Implant Soft-Tissue Complications
architecture, and a triangular shape that are
positioned facially have less-predictable peri-
implant esthetic outcomes. When a tooth
presents with these unfavorable anatomi-
cal features, grafting procedures should be
considered both before and after tooth extrac-
tion to prevent vertical loss and facial collapse
of the gingival architecture.21 Flapless tooth
extraction should be attempted in the esthetic
zone to maintain blood supply from the peri-
osteum and endosteum and maximize heal-
ing potential (Figure 5).44 In addition, several
surgical protocols have been proposed to avoid
peri-implant mucosal recessions, including
3-dimensional implant positioning,45,46 the
use of platform-switching implants,47,48 and
soft-tissue augmentation.8,49,50
Three-dimensional Implant
Positioning
When placing an implant in the esthetic zone,
ideal 3-dimensional positioning, including
mesio-distal, apico-coronal, and orofacial
dimensions, is essential to achieve favorable
esthetic outcomes, regardless of the implant
system used (Figure 6).45 With respect to
the orofacial dimension, implants should
be placed in a more palatal or lingual posi-
tion to allow the presence of at least 2 mm
of buccal bone thickness from the implant
buccal shoulder.45,46 When the distance of the
buccal bone wall and implant buccal shoulder
is < 2 mm, a significantly higher incidence
of midfacial recession has been previously
reported.3,12 Placement of bone graft (Figure
7) and immediate restoration (Figure 8 and
Figure 9) at the time of implant placement
has also been suggested to increase peri-
implant soft-tissue height and thickness.51
In the apico-coronal dimension, the implant
head should be at least 3 mm apical to an
imaginary line connecting the CEJ of the
adjacent teeth and 1 mm to 2 mm apical to
the interproximal and crestal bone to ensure
a proper implant emergence profile and
March 2018 COMPENDIUM EBOOK SERIES 9
 continuing education 1 Implant Soft-Tissue Complications

the bone crest in areas with an inter-implant

distance of ≤ 3 mm compared with areas with >
3 mm between the implants and suggested that
this difference may be the result of lateral bone
loss at the implants.53 Finally, management of
subgingival abutment contour and definitive
crown restoration shape that is harmonious
with the surrounding periodontium is needed
Fig 8. to maintain long-term soft-tissue health and
stability (Figure 11 and Figure 12).

Use of Platform-switching Implant

Designs
The platform-switching implant concept was
introduced to reduce or minimize post-restora-
tion crestal bone remodeling that was normally
seen around a two-piece implant. The mismatch
between the diameter of implant platform and
the prosthetic component results in an increased
Fig 9. circumferential horizontal tissue from 0.45 mm
to 0.95 mm.54 The increased soft-tissue attach-
Fig 8. Immediate ment around platform-switched implants thus
provisionalization may potentially reduce the incidence of dehis-
was fabricated to
preserve the soft-
cence defects and prevent midfacial recessions
tissue contour to around implants.47
prevent midfacial Canullo et al investigated soft-tissue changes
implant mucosal around platform-switching implants placed
recession. Fig 9.
Occlusal view
into extraction sockets with a 2-year follow-
showing excellent up and found 0.18 mm of soft-tissue gain and
soft-tissue contour. 0.045 mm of interproximal papillae gain in the
Fig 10. Periapical platform-switching group; in the platform-
radiograph showing
implant placement matching implant group, interproximal papil-
with abutment in lae recession of 0.88 mm and buccal mucosal
Fig 10. place for fabrication recession of 0.45 mm were noted. The authors
of provisional crown.
described that in the group in which implants
were restored with the platform-switching
facilitate proper implant restoration (Figure protocol, there was an additional 0.85 mm of
10). Regarding the horizontal implant–tooth horizontal biologic width formation around
distance, implants should be placed no closer the implant collar, which may have provided
than 1.5 mm from the adjacent root surface additional peri-implant tissue stability.47 In
to minimize resorption of the interproximal contrast, Pieri and coworkers failed to show any
alveolar crest, which causes a reduction in the difference regarding marginal soft-tissue level
papillary height.46,52 change and papilla height between platform-
When placing multiple implants in the esthetic switching implants and platform-matching
zone, Tarnow et al reported a lower height of implants. However, the results demonstrated a

10 COMPENDIUM EBOOK SERIES March 2018

continuing education 1
Fig 11.
Fig 11. Four months after healing, a final crown was placed. An esthetically pleasing outcome was achieved.
Fig 12. Final periapical x-ray showing excellent bone level and implant positioning.
0.3 mm greater marginal bone loss at platform-
matching implants compared with platform-
switching implants after 12 months of loading.
This difference was found to be statistically
significant. Moreover, the data also showed
that 60% of platform-matching implants had
a marginal bone resorption > 0.5 mm, whereas
only 11% of platform-switching implants had
bone resorption > 0.5 mm.55
Soft-tissue Augmentation
Several studies have reported the use of connec-
tive-tissue grafting during immediate implant
placement to prevent marginal soft-tissue
recession.8,49,56,57 Kan and coworkers studied
20 patients, eight with a thick gingival biotype
and 12 with a thin gingival biotype, who under-
went immediate implant placement with simul-
taneous connective-tissue grafting, and found
comparable mean marginal bone levels in each
group. The authors also reported statistically
insignificant outcomes regarding facial gingival
levels and the presence of papillae in each group,
suggesting that connective-tissue grafting in
conjunction with immediate implant placement
in the esthetic zone may minimize potential
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Implant Soft-Tissue Complications
Fig 12.
future facial gingival recessions. Moreover, it
was concluded that a thin gingival biotype can
be converted to a thick gingival biotype morpho-
logically and behaviorally with this procedure,
which may be beneficial for long-term stability
of facial gingival tissues.8
Conclusion
Buccally positioned implants, thin tissue
biotype, lack of keratinized tissue around
implants, inadequate horizontal implant–
tooth distance, increased distance of tooth
bone peak to the contact point, and implant
placement after surgical recontouring have
all been described as risk indicators for peri-
implant mucosal recessions. Careful assess-
ment of the position of osseous crest and tissue
biotype before tooth extraction and implant
placement is critical for predictable esthetic
outcomes. Lastly, ideal implant position in all
three dimensions is critical to prevent poten-
tial recessions around implants. The use of
platform-switching implants in conjunction
with connective-tissue grafting procedures
may be beneficial for the long-term stability
of soft tissues around implants.
March 2018 COMPENDIUM EBOOK SERIES 11