Received: 30 November 2020 Accepted: 4 January 2021

DOI: 10.1111/jerd.12709

REVIEW ARTICLE

The peri-implant phenotype and implant esthetic

complications. Contemporary overview

I-Ching (Izzie) Wang DDS, MS | Shayan Barootchi DMD |

Lorenzo Tavelli DDS, MS | Hom-Lay Wang DDS, MSD, PhD

Department of Periodontics and Oral

Medicine, University of Michigan School of Abstract
Dentistry, Ann Arbor, Michigan, USA Objective: To provide a contemporary and comprehensive overview of the hard and
Correspondence soft tissue biological structures surrounding an osseointegrated dental implant (peri-
Hom-Lay Wang, DDS, MSD, PhD, Department implant referred to as the peri-implant phenotype), in the context of peri-implant
of Periodontics and Oral Medicine, University
of Michigan School of Dentistry, 1011 North esthetic complications.
University Avenue, Ann Arbor, Overview: The individual components of the peri-implant phenotype (keratinized
MI 48109-1078, USA.
Email: [email protected] mucosa width, mucosal thickness, supracrestal tissue height, and the peri-implant
buccal bone) have been linked to different aspects of implant esthetics, as well as
health-related aspects. At the time of implant therapy, respecting the biology of the
peri-implant hard and soft tissues, and anticipating their remodeling patterns can alle-
viate future esthetic complications.
Conclusions: While the current literature may not allow for a point-by-point evi-
dence based-recommendation for the required amount of each peri-implant struc-
ture, bearing in mind the proposed values for the components of the peri-implant
phenotype, at the time of and prior to implant therapy can lead to more predictable
treatment outcomes, and the avoidance of esthetic complications.
Clinical Significance: Knowledge of hard and soft tissue components surrounding
and osseointegrated dental implant, and their underlying biological remodeling pro-
cess is crucial for carrying out a successful therapy and alleviating possible future
esthetic challenges.

KEYWORDS
alveolar process, dental implants, esthetics, evidence-based dentistry, gingival recession,
periodontics, phenotype

1 | I N T RO DU CT I O N increasing interest in dental implant therapy among both patients and

clinicians, there has also been a rise in the incidence of their complica-
Dental implants have become a common and reliable tool for replace- tions and adverse events.4-6
ment of missing teeth. Ever since their introduction in the dentistry, In the case of an osseointegrated dental implant, complications
an abundance of research has been conducted to investigate different can be categorized as technical/prosthetic-related factors (such as
aspects related to their survival and success.1-3 Nonetheless, with the screw loosing of an implant crown or chipping of a prosthetic
component),2,7 or biologic-related aspects that directly affect the
health of the implant (such as the emergence of peri-implant
Thorough knowledge and assessment of the peri-implant phenotype is critical for
management and avoidance of implant esthetic complications. diseases),8,9 and finally patient-related components, some of which

212 © 2021 Wiley Periodicals LLC wileyonlinelibrary.com/journal/jerd J Esthet Restor Dent. 2021;33:212–223.
WANG ET AL. 213

are subjective (e.g., post-surgical morbidity), and others that can be volume around implants, which is significantly related to the peri-
assessed both by the clinicians and the patients themselves (such as a implant health.
treatment's esthetic result).
In the scope of biological complications, peri-implantitis which is
an irreversible pathological condition characterized by loss of 3 | IMPLANT ESTHETIC COMPLICATIONS
implant's supporting bone, is an increasing challenge for dentists A ND C OM M ON C A U SE S
around the world.9 According to the 2017 World Workshop on the
Classification of Periodontal and Peri-implant Diseases and Condition Although an esthetically pleasing outcome may be subjective in
control,10 the major risk factors associated with this condition are: a nature, several objective assessment tools have been developed over
history of periodontitis, poor plaque control, as well as non-compliant the years to evaluate the esthetic outcome of an implant in the
maintenance. At the implant level, the effect of the peri-implant soft esthetic zone. These include the Pink Esthetic Score (PES),20,21
tissues on the long-term maintenance of implant health has also the Papilla Index (PI),22 the Implant Crown esthetic Index (ICAI),21 and
gained considerable interest. While the evidence in this topic remains the modified-ICAI.23
equivocal, it appears that keratinized mucosa may present advantages The PES and PI have been correlated with the patients' responses
10,11
relative to patient comfort and ease of plaque control. Another in relation to the peri-implant soft tissues. In addition, the ICAI and
risk indicator for the onset of peri-implantitis is an improperly posi- mod-ICAI have also shown a correlation between their objective and
tioned implant, or an inadequate design of its suprastructure,9,12,13 subject assessment relative to peri-implant mucosa and implant-
which may also lead to other implant-related complications, such as supported crown assessment.24
an adverse esthetic outcome. The peri-implant esthetic result is It is hardly surprising that a patient's subjective perception would
influenced by the esthetic appearance of the soft tissues as well as be less critical than an objective assessment by a dentist.23,24 The rat-
the esthetics of the prosthetic reconstruction.14 Other than prosthetic ing of a peri-implant mucosa by clinicians and patients was reported
components (e.g. marginal integrity, contour, color, and shape), to be less satisfactory when compared to the contour or color of an
esthetic complications are essentially the manifestation of hard and/or implant-supported crown, especially in areas which has received an
soft tissue deficiencies that have occurred following implant place- augmentation procedure prior to the implant therapy.25 In other
ment, many of which may not be revealed in the short-term. words, it is more challenging to reach a satisfactory esthetic result in
A hard tissue deficiency after implant placement can be as a result the case of a pre-existing hard and/or soft tissue defect.
of a pre-existing alveolar ridge deficiency, a peri-implant inflammation, The most prevalent implant esthetic complication is an asymmet-
implant malpositioning, and inadequate soft tissue thickness.15 A soft ric appearance of the peri-implant mucosa level, followed by an
tissue deficiency however, can be related to the absence of the buccal incomplete fill or lack of papilla, as well as an unnatural color of the
bone, reduced papilla height, and the lack of keratinized mucosa.15 soft tissues, and an esthetic void (e.g., volume deficiency/concavity,
Collectively, the hard and soft tissues that surround a dental mesial open contact, etc). Commonly, a mid-facial mucosal defect
implant comprise the peri-implant phenotype.16 In the current article, which has been defined as a peri-implant soft tissue dehiscence/defi-
we present a contemporary narrative of the individual components of ciency (PSTD),26 particularly in the case of immediate implant place-
the peri-implant phenotype, and their implication to peri-implant ment is one of the main esthetic concerns (Figure 1). It has been
health and esthetics. reported that a volumetric change within 1 mm is typically not notice-
able by the patients.27-29 However, when even a minimal PSTD is
concomitant with/characterized by the exposure of the metallic com-
2 | THE PERI-IMPLANT PHENOTYPE ponent of the abutment or the fixture, patients tend to be unsatisfied
about the overall implant treatment.26,30
The 2017 World Workshop suggested the universal adoption of the A deficient papillary fill is also not a rare event with implant ther-
term “periodontal phenotype” to describe the traditional term “peri- apy, especially when multiple implants are position in the anterior
odontal biotype”, which is a composed of the gingival phenotype area. While for patients with a low smile line this may not necessarily
(gingival thickness and the keratinized tissue width), as well as the pose a significant challenge, in those with a high smile line, however
bone morphotype (thickness of the buccal bone plate).17 The term this can be a major esthetic concern.31
“peri-implant phenotype” was recently described analogous to the
periodontal phenotype as the morphologic and dimensional features
of an osseointegrated dental implant, comprising a soft tissue com- 4 | T H E SO F T T I S S U E C O M P O N E N T S OF
ponent, including the peri-implant keratinized mucosa width (KMW), T H E P E R I - I M P L A NT P H E N O T Y P E A N D T H E I R
the mucosal thickness (MT), and the supracrestal tissue height (STH), IMPACT ON IMPLANT ESTHETICS
and an osseous component, which is the peri-implant bone thickness
(PBT).16 Similar to the periodontal phenotype, the peri-implant 4.1 | Keratinized mucosa width
phenotype is site-specific and vulnerable to change due to environ-
mental factors18 or clinical interventions.11,19 In essence, the peri- The peri-implant KMW is the dimension of keratinized soft tissue in
implant phenotype can be referred to as the three-dimensional tissue an apico-coronal direction measured from the mucosal margin to the
214 WANG ET AL.

F I G U R E 1 Illustrates an example of assessing components of the peri-implant phenotype in the case of an implant placement, and the 1-year
outcome of the treatment

mucogingival junction.16 In the scientific literature, the threshold to esthetics of an implant with a zone of keratinized mucosa over
define an “adequate” KWM for maintaining optimal peri-implant implants without.45
health has frequently been defined as 2 mm.16,32-34 Despite existing In conclusion, a lack of KMW may not directly lead to an esthetic
35
controversies in this field, the absence of an adequate KMW concerns while, its presence can maintain a more natural soft tissue
around implants has been associated with higher likelihood of architecture and color, similar to that of its contralateral natural denti-
plaque accumulation, gingival inflammation, and mucosal reces- tion, and reduce the risk for the occurrence of peri-implant inflamma-
sions.33,36-41 KMW augmentation with apically positioned flap and tion, and avoid progression of a mucosal recession.
free gingival graft procedure can result in probing depth reduction,
as well as lower plaque scores and less chance for future mucosal
recession.11 4.2 | Mucosal thickness
However, an abundance of keratinized mucosa may not be as rel-
evant to peri-implant esthetics, as it is to peri-implant health. In other The peri-implant MT refers to the horizontal dimension of the peri-
words, the natural appearance of soft tissues around a dental implant implant soft tissue, which may or may not be keratinized (Figure 3). It
is mainly dictated by the position, color, and texture of the peri- is commonly measured at 1–2 mm apical to the mucosal margin,
implant mucosa.42,43The typical appearance of a limited or lack of depending on its measurement method; and may vary according to
KMW is commonly caused by a severely deep implant placement different implant locations (e.g., buccal versus lingual).16 In the past
(likely due to the an underlying hard tissue deficiency at the time of decade, a great deal of the published research has focused on the hor-
placement) followed by the lack of apically positioning the keratinized izontal measurement of the mid-facial peri-implant mucosa (at the
tissue at the time of implant uncover (second stage), or simply exces- most coronal segment on the implant shoulder) for assessing the
sive localized trauma from previous surgical procedures. esthetic outcomes of implant therapy.46-51 Mainly the “masking”
Arguably, in such cases, the challenge to the esthetics predomi- effect of the peri-implant soft tissues on the shade of different abut-
nantly arises from an inaccurate crown height or the alteration of the ment materials have been evaluated, and it has been reported that
mucosal margin; that is to say, that an asymmetric gum line is often ≈2 mm of tissue is the minimal thickness required for having the least
what attracts attention and is often the underlying cause of the noticeable color changes on zirconia abutments.50 While an in vitro
esthetic concern, rather than an unnatural soft tissue appearance study, it was found that a MT of 3 mm was capable of masking all
(Figure 2). Nevertheless, the color and texture of peri-implant mucosa restorative materials,52 the current recommendation is that MT should
on the facial aspect can be significantly influenced by the amount of be of at least 2 mm for avoiding discoloration of the soft tissue due to
keratinized mucosa, tissue thickness, and the inflammatory edema the restorative materials.
which may be exacerbated by an insufficient keratinized tissue, espe- The presence of a thick biotype, as determined by probe visibility
cially in patients who tend to comply less with maintenance recalls.44 (>1 mm)53 was also demonstrated to have a higher resilience towards
Finally, it has to be mentioned that patients typically prefer the the incidence of a mucosal recession following immediate
WANG ET AL. 215

F I G U R E 2 Clinical demonstration of two implants in the anterior region with esthetic complications. Note that both implants were placed
deeper relative to the adjacent dentition, and show reduced keratinized mucosa width (KMW). The left image (A) shows an implant in the #8
region with a narrow band of KMW caused by the implant deep placement, showing an unnatural color and altered mucogingival junction due to
the previous bone regenerative procedures. Case on the right (B) shows an implant complication in the #8 area with a peri-implant soft tissue
dehiscence/deficiency (PSTD), as well as a limited band of KMW, likely caused by a deep positioning, as well as transparency of the abutment
through the mucosal margin. The unesthetic and unnatural color of the mucosal margin is also due to the chronic localized inflammation (triggered
by an inadequate KMW). The frenum may further impair self-performance of oral hygiene as well

review and network meta-analysis have confirmed the benefit of phe-

notype modification in augmenting the peri-implant MT, relative to
marginal bone level stability.11 While up to this day, a consensus on
the minimal required amount of MT for achieving predictable long-
term functional and esthetic outcomes is still missing,61 a threshold of
2 mm in thickness has been proposed for reducing the impact on the
esthetic outcomes in the daily practice.16
The term “peri-implant mucosa thickness” or “peri-implant soft
tissue thickness” has also been used to incorrectly refer to the vertical
dimension of soft tissues on the crestal bone62-65 or the distance of
the peri-implant mucosal margin to the level of bone to implant con-
tact.66 Later on, as researchers have explored the influence of soft tis-
sues to crestal bone stability around implants; the term was redefined
as the “vertical soft tissue thickness on crestal bone” to distinguish it
from the horizontal dimension.67,68 Today, this dimension is collec-
tively referred to as the “supracrestal tissue height”,16 and a positive
correlation has been shown between this soft tissue component and a
thick peri-implant phenotype (greater “supracrestal tissue height”

F I G U R E 3 Example of lack of a thin peri-implant phenotype associated with the thicker peri-implant phenotype).69
(keratinized mucosa width, inadequate mucosal thickness, and thin In conclusion, the peri-implant MT is significantly related to a risk
peri-implant bone thickness). Multiple implant-supported crown/ for esthetic complications. Not only does a thin mucosal margin pre-
bridges in the anterior maxilla with multiple peri-implant soft tissue dispose the site to a more drastic bone remodeling, but also the pres-
dehiscence/deficiencies (PSTDs), and interproximal bone loss. #9
ence of a minimal amount of MT (2 mm) can diminish the possibility
implant exhibits a suspicious fibroma at the buccal aspect potentially
of appearance of the shade of the abutment. Additional soft tissue
induced by the foreign body reaction to the titanium particles and
chronic inflammation around the exposed threads, associated with the grafting procedures are recommended to overcome visibility of the
lack of KMW. Thin mucosal thickness, allows for the grayish metallic shade of titanium abutments or for compensation of a thin
transparency to show through the margin, and mucosal tattooing was MT for immediate placement of dental implants, or in the case of a
evident which made the deficient ridge volume more obvious pre-existing bone deficiency.

placement.54 Thus, MT augmentation has been advocated for com- 4.3 | Supracrestal tissue height
pensating an underlying bone deficiency, or the expected bone remo-
deling in the case of an immediate implant placement, for promoting a The peri-implant STH refers to the vertical dimension of the soft tis-
more stable facial soft tissue profile over time.55-60 A recent systemic sue surrounding a dental implant, which is from the mucosal margin to
216 WANG ET AL.

F I G U R E 4 Example of a deep mucosal tunnel and tall supracrestal tissue height (STH). #12 implant presented with an acceptable peri-implant
mucosal margin, but an unnatural color which suffered from persistently chronic inflammation and bleeding on probing, occasional suppuration,
and patient discomfort (peri-implant mucositis). The cause of such biological and esthetic complication is the significantly deep placement of the
implant which created a deep mucosal tunnel with a tall STH

the crestal bone.16 Clinically, it can be circumferentially determined by a thin STH (≤2 mm).81 However, recent evidence suggests that a short
transmucosal sounding with the periodontal probe, and its dimension prosthetic abutment is the true predisposing factor of early MBL
includes the sulcular epithelium, the junctional epithelium, and the despite vertical MT.82-84
supracrestal connective tissue. It is greater in interproximal areas and To evaluate the risk of esthetic complications, it is important to
is usually 1–1.5 mm higher than the corresponding gingiva.70 In an realize the correlation between peri-implant tissue dimensions and
animal model, it was found to average about 3.4 mm and tends to be the “periodontal phenotype”. It was reported that a “flat-thick” peri-
71
shorter in the case of epicrestal bone-level implants. odontal phenotype combined with a more square-shaped tooth con-
STH is usually assessed during the surgery, either at the time of tour exhibited a greater STH than a “scalloped-thin” phenotype with a
implant placement or at second stage, by using a probe. However, this slender triangular crown form.85,86 In addition, STH is strongly associ-
method is not feasible for follow-up visits. Ultrasonography has ated with greater papillary volume, which is usually ≤5 mm between
shown to be a non-invasive and reliable tool for assessing peri-implant an implant-supported crown and a natural tooth in case of a complete
soft and hard tissues in real-time.72-74 fill87-89 and is dictated by the connective tissue adhesion level at the
Unlike natural teeth, the STH reflects the fact that the adjacent interproximal tooth surface.69,90 It was averaged to about
supracrestal connective tissue is not attached to the implant abutment 3 mm between two adjacent implant restorations, and its regeneration
surface; hence, STH should not be used interchangeably with the term has proven to be unpredictable, due to its dependence on the under-
“supracrestal tissue attachment” around natural teeth, which has lying supporting bone.89,91,92 As such, to predict the esthetic of the
recently been proposed to replace the classical term “biologic papilla, the morphology of an interproximal space should be evaluated
width”.17 The principle of “biologic width” had comprised the junc- prior to the implant placement, including assessment of STH.93,94 In
75
tional epithelium and the supracrestal connective tissue to be asso- the management of esthetic complications commonly induced by a
ciated with the physiologic establishment of the peri-implant biologic “deep implant placement”, “mucosal thickening” or “phenotype medi-
space to protect the bone level.76-78 It not only dictates the dimension cation” to cover the peri-implant dehiscence by multiple layers of con-
of the facial bone crest, but may also explain the findings that a thin nective tissue grafts, or an acellular dermal matrix with a bilaminar
tissue height at the time of implant placement tends to be associated approach has been proven effective control.11,95 The key ingredient
67,68,79,80
with the marginal bone loss (MBL). This rationale is of success relies on the abutment design with a reduced-diameter to
supported by current evidence irrespective of the implant design preserve the adhesion of a good-quality connective tissue; and subse-
(e.g., bone or tissue level implant), or the restorative modality quent manipulation of the emergence architecture of peri-implant soft
16
(e.g., platform switching or laser modification). A recent systemic tissue volume.
review confirmed that a thick STH (>2 mm) could have a protective In addition, orthodontic extrusion can also be supplemented to
effect on the MBL around crestally-positioned implants, compared to re-establish the ideal height of supracrestal tissues between implants
WANG ET AL. 217

F I G U R E 5 Clinical- and ultrasonographic view of anterior implants with and without soft tissue dehiscence (peri-implant soft tissue
dehiscence/deficiency [PSTD]). (A) Implants without PSTD. (B) Implant with PSTD without exposure of the abutment. (C) Implant with PSTD with
exposure of both abutment and fixture. The dotted black lines in the clinical photographs illustrate the reference (gingival margin of the
homologous tooth) for the peri-implant soft tissue margin, while the white lines indicate that is presented in each ultrasound scan.
Ultrasonography shows the implant supported crown (C), abutment (A), implant fixture (I), crestal bone (CB) and soft tissue (ST). This technology
allows to assess and calculate supracrestal tissue height (from the crown margin to the crestal bone) and MT at different levels

and adjacent teeth. However, the long-term (>5 years) outcomes of In conclusion, the STH to re-establish a biologic space for the
soft tissue augmentation around implants, especially in the presence implant-supporting apparatus is essential to protect and maintain the
of a buccal bone dehiscence, has yet to be elucidated.96,97 peri-implant bone. The risk of esthetic complications can be avoided
Recent evidence indicates that when implants are placed deeper by prudent examination of the interproximal periodontal attachment
with a mucosal tunnel depth ≥3 mm (above the implant-restorative of adjacent teeth, and possibly by “modified” by soft tissue augmenta-
platform), the resolution of peri-implant mucositis can take longer, tion. Yet, the long-term stability of soft tissue augmentation warrants
and proper oral hygiene can be hindered, compared to a shallower more evidence. Ultimately, the best way to prevent esthetic complica-
implant position with a mucosal tunnel ≤1 mm.98 The tunnel refers to tions is ensuring an ideal 3D implant positioning and proper abutment
the distance between the bottom of sulcus and the mucosal margin, design for the STH establishment around dental implants to minimize
and taking into account the smooth 1.8 mm collar of the implant, STH the peri-implant bone loss.
≥5 mm presented with higher risk for peri-implant mucositis com-
pared to STH < 3 mm (Figure 4). Similarly, a recent study showed that
an excessive STH in patients with previous history of periodontitis 4.4 | Level of the soft tissue margin
was correlated with increased pocket depth and MBL, with the risk
for peri-implantitis that increased 1.5 times for 1 mm increase of The level of the soft tissue margin (STM) in the midfacial aspect plays
STH.99 Given the anatomic and restorative variations, Avila-Ortiz a crucial role on the esthetic appearance and health of the
et al. proposed the threshold of 3 mm for definition of a “short STH” implant.26,95 When the STM is not at the level of the homologous nat-
(<3 mm) versus “tall STH” (≥3 mm) to avoid esthetic complications ural tooth, a PSTD is diagnosed. The term PSTD includes conditions
that dental implants should be placed “as deep as necessary, but as with: (a) deficient peri-implant soft tissue volume compared to the
shallow as possible”.16 adjacent sites, or thin MT that makes the color of the abutment/
218 WANG ET AL.

F I G U R E 6 Example of thin peri-

implant bone thickness in the area of
#8 implant, which required additional
grafting procedure

implant fixture visible through the mucosa, (b) apical shifting of the homologous tooth, with an adequate peri-implant soft tissue pheno-
peri-implant STM compared to the homologous natural tooth with type and volume.26,103 Our group recently proposed a classification of
concomitant exposure of the abutment and/or the implant fixture PSTDs based on the level of the STM and the bucco-lingual position
(with the implant-supported crown having the same height as the of the implant crown and platform.26 While evidence for PSTD treat-
crown of the homologous tooth), (c) apical shifting of the peri-implant ment is still limited in the literature and mainly based on case series, it
STM as a consequence of an implant-supported crown longer than seems that coronally advanced flap and connective tissue graft, either
the one of the homologous tooth, (d) a combination of these scenarios with the combined surgical-prosthetic approach104 or with a sub-
(Figure 5).26,95,100 merge technique,105 is the approach of choice for these conditions.
While discrepancies between the level of the peri-implant STM
and/or the height of the implant-supported crown compared to the
gingival architecture of the adjacent teeth are mainly esthetic compli- 5 | O S S E O U S CO M P O N E N T A N D TH E
cations that may affect patients' perception of the overall implant IMPACT ON THE IMPLANT ESTHETIC
therapy, PSTDs with exposure of the abutment or implant fixture can COMP LIC A TI ONS
impair peri-implant health. Indeed, the exposure of the rough surface
of the implant to the oral cavity creates an environment for bacterial 5.1 | Peri-implant bone thickness
colonization, drastically increasing the change of developing peri-
implant diseases. The PBT is the horizontal dimension of the osseous tissues supporting
Several etiological factors for PSTDs have been identified, includ- an osseointegrated implant. The alveolar bone housing around the
ing inadequate KMW and/or MT, buccally positioned implant plat- osseointegrated implant is the foundation to support the soft tissues
form, overcontoured prosthesis and traumatic toothbrushing.95,101,102 which is considered a necessity for obtaining esthetic outcomes in the
Bearing in mind that the etiology must be eliminated before treating anterior zone. There is a wealth of studies investigating the peri-
these conditions, the primary goal for the treatment of PSTD is to implant bone volume, and the evidence indicates that PBT varies at
reposition the STM (and the crown margin) at the same level of the different heights relative to the bone crest106 and that a thicker bone,
WANG ET AL. 219

particularly at the coronal level, favors the esthetic and functional out- periodontal tissues and allow the re-establishment of the traditional
comes of implant therapy.107 A study reported that without guided concept of “biologic width” (currently referred to as supracrestal tis-
bone regeneration (GBR) of bone dehiscences around implants, the sue attachment).
probability of future bone loss increased to two folds.108 The efficacy As such, implants should be placed:
of lateral augmentation to increase bone thickness around implants
was confirmed by a recent systematic review, which also found a 1. At least 1.5 mm from adjacent teeth in the mesiodistal direction.
reduction of 0.15 mm in mucosal recession at sites undergoing 2. 3–4 mm apical to the anticipated mucosal margin in the
GBR.109 Interestingly, it was shown that even with significant coronoapical direction.
dehiscence-type bone loss long after GBR was performed around 3. At least 3 mm palatal to the facial curvature of the arch in an orofacial
immediate implants, the mucosal levels remained relatively direction, and at the level of mucosal margin considering 2 mm bone
110,111
unchanged ; while larger dehiscence defects, increased the likeli- thickness and 1 mm MT; or alternately at a cingulum position.
hood of mucosal recessions and peri-implant diseases.111,112
Despite limited evidence for distinguishing a clinical threshold of By understanding the underlying tissue characteristics and the
bone thickness to sustain the peri-implant tissue stability, esthetic and phenotype, we should predict the direction of tissue remodeling that
health, findings from a prospective study indicates that a bone thick- is associated with thin hard and soft tissue phenotypes, and proac-
ness ≥2 mm leads to significantly less bone loss after implant tively compensate the estimated remodeling to reduce esthetic
uncovering.113 A recent preclinical study further explored the concept complications.
of “critical bone thickness” and concluded that a minimum thickness
of 1.5 mm was needed to avoid further physiological bone remodeling ACKNOWLEDG MENTS AND DISCLOS URE
and to have less pathologic bone loss.114 Therefore, in the meantime All authors have equally contributed to the conception, design, the
a threshold of 2 mm can be used for categorization of a thin versus literature search, and collection of figures, as well as the scientific
thick PBT (<2 mm: thin; ≥2 mm: thick), for clinical guidelines. writing.
Taking into account the surrounding bone volume when placing The authors declare that they do not have any financial interest in
implants in the restoratively-driven position can aid in determining the companies whose materials are included in this article.
the need for potential ancillary bone grafting. As a thin bone mor-
photype around an implant may accompany a more aggressive bone
OR CID
resorption pattern due to disturbance of the surrounding blood
Shayan Barootchi https://orcid.org/0000-0002-5347-6577
supply,115 particularly when implants are placed far too buccal relative
Lorenzo Tavelli https://orcid.org/0000-0003-4864-3964
to the bony housing (Figure 6). Thus, thorough assessment of the sag-
Hom-Lay Wang https://orcid.org/0000-0003-4238-1799
ittal root position in the anterior maxilla is crucial when planning an
immediate implant placement.116 When an unfavorable root position
RE FE RE NCE S
(e.g., when majority of the root is engaging both buccal and palatal
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