Clinical and Experimental Dental Research

ORIGINAL ARTICLE OPEN ACCESS

Association of Peri‐Implant Mucosa Dimensions With

Emergence Profile Angles of the Implant Prosthesis
Piboon Rungtanakiat1 | Natchaya Thitaphanich1 | Martin Janda2 | Franz Josef Strauss3,4 | Mansuang Arksornnukit1 |
Nikos Mattheos5,6
1
Department of Prosthodontics, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand | 2Department of Prosthodontics, Faculty of Odontology,
Malmoe University, Malmö, Sweden | 3Clinic of Reconstructive Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland | 4Faculty of
Dentistry, Universidad Finis Terrae, Santiago, Chile | 5Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn University,
Bangkok, Thailand | 6Department of Dental Medicine, Karolinska Institute, Stockholm, Sweden

Correspondence: Nikos Mattheos ([email protected])

Received: 31 March 2024 | Revised: 2 July 2024 | Accepted: 11 July 2024

Funding: The authors received no specific funding for this work.

Keywords: dental implants | emergence angle | implant supracrestal complex | peri‐implant tissue

ABSTRACT
Objectives: The primary aim of this cross‐sectional study was to investigate the association between prosthesis design and peri‐
implant mucosa dimensions and morphology. The secondary aim was to investigate associations between mucosal dimensions
and the presence of mucositis.
Materials and Methods: Forty‐seven patients with 103 posterior bone level implants underwent clinical and radiographic
examination, including cone beam computer tomography and intraoral optical scanning. Three‐dimensional models for each
implant and peri‐implant mucosa were constructed. Vertical mucosa height (TH), horizontal mucosa width at implant platform
(TW), and 1.5 mm coronal of the platform (TW1.5), as well as mucosal emergence angle (MEA), deep angle (DA), and total
contour angle (TA) were measured at six sites for each implant.
Results: There was a consistent correlation between peri‐implant mucosa width and height (β = 0.217, p < 0.001), with the
width consistently surpassing height by a factor of 1.4–2.1. All three angles (MEA, DA, TA) were negatively associated with
mucosa height (p < 0.001), while DA was negatively associated with mucosa width (TW1.5) (p < 0.001, β = −0.02, 95% CI:
−0.03, −0.01). There was a significant negative association between bleeding on probing (BoP) and mucosa width at platform
(OR 0.903, 95% CI: 0.818–0.997, p = 0.043) and 1.5 coronal (OR 0.877, 95% CI: 0.778–0.989, p = 0.033). Implants with less than
half sites positive for BoP (0–2/6) had significantly higher mucosa height (OR 3.51, 95% CI: 1.72–7.14, p = 0.001).
Conclusions: Prosthesis design can influence the dimensions of the peri‐implant mucosa, with wider emergence profile angles
associated with reduced peri‐implant mucosa height. In particular, a wider deep angle is associated with reduced mucosa width
in posterior sites. Reduced peri‐implant mucosa height and width are associated with more signs of inflammation.
Trial Registration: Registered in Thai Clinical Trials Registry: http://www.thaiclinicaltrials.org/show/TCTR20220204002.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly
cited.

© 2024 The Author(s). Clinical and Experimental Dental Research published by John Wiley & Sons Ltd.

Clinical and Experimental Dental Research, 2024; 10:e939 1 of 13

https://doi.org/10.1002/cre2.939
1 | Introduction profile angles of the implant prosthesis (deep angle [DA], mucosal
emergence angle [MEA], contour angle [CA]). A secondary aim of
Several morphological features and dimensions of the peri‐implant the study was to investigate associations between peri‐implant
mucosa have been associated with clinical outcomes related to mucosa dimensions, morphology, and the presence of mucositis.
aesthetics, tissue morphology, as well as risk for inflammation. The
vertical height of the peri‐implant mucosa has been assessed in
humans both in histological studies (Glauser et al. 2005, Romanos 2 | Materials and Methods
et al. 2010, Tomasi et al. 2014) and clinical studies with
measurements conducted on tissue impressions (Nozawa et al. 2006, This study was approved by the Ethics Committee at the Faculty
Farronato et al. 2019). The vertical or supracrestal height of the peri‐ of Dentistry, Chulalongkorn University (HREC‐DCU 2022‐024)
implant mucosa is a critical anatomic feature, directing the and was registered at the Thai Clinical Trials Registry
establishment of the critical biological zone of mucosal attachment (TCTR20210709003). The study followed the STROBE statements.
(Mattheos, Vergoullis, et al. 2021, Monje, González‐Martín, and
Ávila‐Ortiz 2023). The horizontal width of the peri‐implant mucosa
has also been assessed in clinical studies, albeit commonly by
2.1 | Patient Sample
means of lower precision. Traditional assessments of horizontal
tissue “thickness” were mainly conducted by assessing the
Healthy patients (ASA classification I and II) aged 20 years or
transmucosal visibility of a colored probe (Kan et al. 2003, Evans
older, having received implant therapy at the postgraduate
and Chen 2008, Nisapakultorn et al. 2010), ultrasonic devices
clinics of Prosthodontics or the clinic of Implants and
(Cardaropoli, Lekholm, and Wennström 2006) or endodontic files
Aesthetics, Faculty of Dentistry, Chulalongkorn University
(Strauss et al. 2024). More recent studies have employed measure-
and in maintenance for at least 3 months between July 4 and
ments in three‐dimensional radiographic and optical imaging
November 30, 2022, were considered for the study, as presented
(Kheur et al. 2015, Khorshed et al. 2023) in a noninvasive, reliable,
in detail by Rungtanakiat et al. (2023).
and reproducible manner (Strauss et al. 2024). The width of the
peri‐implant mucosa has been associated with aesthetic outcomes
Patients were invited to participate in the study if the following
(Bienz et al. 2022), recession (Nozawa et al. 2006, Chen et al. 2009),
conditions were met:
and papilla fill (Romeo et al. 2008). Interestingly, clinical studies
have identified a correlation between peri‐implant mucosa height
1. Posterior implant supported single crown.
and horizontal width at the implant platform, with researchers
suggesting the width surpasses height by a ratio of 1.5 (Nozawa 2. Prosthesis axis no more than 10° divergence from
et al. 2006, Cardaropoli, Lekholm, and Wennström 2006) or implant axis.
1.19 ± 0.55 (Farronato et al. 2019). Longitudinal studies have further 3. At least 3 months post restoration.
suggested that changes in the height of the mucosa could be
regulated by the width (Nozawa et al. 2006, Bengazi, Wennström, Upon informed consent, the patients received clinical and
and Lekholm 1996). The width‐to‐height ratio of peri‐implant radiographic (cone beam computed tomography [CBCT]) exam-
mucosa appears inverted to what was measured on free gingiva ination (Figure 1), as described in further detail in Rungtanakiat
around teeth, where the height was found to surpass width by a et al. (2023). In the cases where the excessive contour of the
ratio of 1.5 (Wenstrom et al. 1996) albeit the anatomic location of prosthesis prevented the insertion of the probe in the reasonably
the measurements in teeth and implants might not be directly vertical direction, probing depth was not recorded.
comparable. The lack of keratinized mucosa is another morpholog-
ical feature of the peri‐implant mucosa that has been associated
with an increased risk for mucositis (Mancini et al. 2024) and peri‐
implantitis (Mahardawi et al. 2023).
2.2 | Measurements

The DICOM file of CBCT and the intraoral optical scan (STL
Although the dimensions of the peri‐implant mucosa and its
file) were imported and transposed in the treatment planning
relation to clinical outcomes have been investigated in multiple
software (coDiagnostiX version 9.7, Dental Wings Inc.).
studies, it has scarcely been assessed in parallel to the design of the
prosthesis. Siegenthaler et al. (2022) in a prospective study showed
The implant axis and the perpendicular axis of the implant
that alterations in the contour of the prosthesis could have
platform were defined. Thereafter, four axial planes (parallel to
significant implications for the peri‐implant mucosa height,
the implant axis) were identified (Figure 2):
increasing the occurrence of recession when the contour was
switched from concave to convex. The peri‐implant tissue remains
i. Midline (buccolingual plane).
a tissue formed as a direct consequence of the implant placement
and restoration. Thus its formation, maturation, morphology, and ii. Interproximal (mesiodistal), perpendicular to the midline
dimensions should be best understood in relation to the conditions plane.
that lead to their creation, that is, the surgical placement of the
iii. 45° lateral oblique mesiobuccal.
implant‐prosthesis complex (Mattheos, Vergoullis, et al. 2021).
iv. 45° lateral oblique distobuccal.
The primary aim of this cross‐sectional study was to investigate
associations between peri‐implant mucosa dimensions and mor- Each plane included two side views of the Implant Supracrestal
phology (height and width, keratinized zone) with the emergence Complex, so a total of eight sites were identified for each

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FIGURE 1 | Eight sites (mesial [M], distal [D], mesiobuccal [MB], buccal, distobuccal [DB], and respective lingual/palatal) were defined based on
three horizontal planes for each implant crown. Plaque index, bleeding on probing, and probing depth were recorded in six of them (yellow dots), but
not for the two directly mesial and distal points (M&D, blue dots). Likewise, mucosal emergence and total and deep angles were calculated for the six
sites, but only deep angle was measured for sites M and D. Width of keratinized Mucosa was recorded only at the three buccal sites (MB, B, DB).

implant (Figure 1). The following horizontal levels (perpendic-

ular to the implant axis) were defined for each site:

i. Implant platform.
ii. 1.5 mm coronally of the implant platform.
iii. Mucosal margin.
iv. 0.5 mm apically of mucosal margin.

Thereafter, the following points were identified for each level:

A. Point of implant abutment nearest to the implant

platform.
B. Point of implant abutment 1.5 mm coronally of point A
(projected on implant axis).
C. Most coronal points of soft tissue (mucosal margin).
D. Point of prosthesis 0.5 mm apically of mucosal margin
(projected on implant axis).
E. Point of the prosthesis at maximum convexity/
prominence.

Three angles were defined as follows:

i. Deep angle (DA): angle of the abutment ascending

directly from the implant platform. Defined by the
FIGURE 2 | Schematic representation (not in scale) of the horizon-
implant axis and the line connecting A–B.
tal measurements of mucosa dimensions at platform level on the basis
of the six defined planes from the bone margin (white dashed line) to ii. Mucosal emergence angle (MEA): angle of the prosthesis
the outer margin of the oral mucosa (red dashed line) at six sites per emerging through the soft tissue. Defined by the implant
implant. axis and the line connecting C–D.

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 iii. Total contour angle (CA): angle of the overall contour of iii. TH: Mucosa height: The vertical dimension of the
the prosthesis. Defined by the implant axis and the line mucosa from the implant platform level to the most
connecting A–E. coronal point of the mucosa, as measured in a
perpendicular line (Figures 3 and 4).
Peri‐implant mucosa dimensions were measured as follows
(Figures 3 and 4): All radiographic measurements were conducted by two
calibrated examiners, blinded to the clinical examination
i. TwP: Mucosa width at platform. The horizontal dimen- measurements. Both examiners contributed to the definition
sion of the mucosa is in mm at the implant platform of the planes and points of measurement for the study.
level. Thereafter interrater agreement was assessed using a calibra-
tion exercise where the two examiners conducted indepen-
ii. Tw1.5: Mucosa width. The horizontal dimension of the
dently a set of 10 measurements. The intraclass correlation
mucosa is in mm, 1.5 mm coronal of the implant platform
coefficient was 0.998 (0.995–0.999), p < 0.001.
level.

2.3 | Clinical Examination

All clinical examinations were conducted by one specialist

periodontist and included among others dichotomous registration
of the plaque index (O'Leary et al. 1972), dichotomous registration
of bleeding on probing (BoP), and presence of suppuration, probing
depth rounded to nearest mm at six points per crown with plastic
periodontal probe (Hu‐Friedy) and keratinized mucosa width in
mm, at three points per crown (Figure 1), as per previously
published protocol (Rungtanakiat et al. 2023). Intrarater agreement
was assessed by measuring peri‐implant probing depth in four
patients at two subsequent visits, 48 h apart. Intraclass correlation
coefficient was ICC = 0.931 (95% CI: 0.840−0.970, p < 0.001).

2.4 | Clinical Diagnoses

FIGURE 3 | Schematic representation (not in scale) of the mea- Diagnosis at the implant level was based on the condition of the
surements conducted for the mucosa height and mucosa width at the peri‐implant tissue upon clinical and radiographical examination.
platform and 1.5 mm, at six sites per implant. Mucositis was defined as bleeding and/or suppuration on gentle

FIGURE 4 | Schematic representation (in scale) of the mucosa dimensions (height, width at platform, and width at 1.5 mm) as directed by the
mean of the respective measurement points at mid‐buccal (left) and 45° oblique lateral (right).

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probing and was reported at implant level per site from a total of six presented with somewhat higher values than the midbuccal/
sites (0/6–6/6). Three case definitions were used for peri‐implantitis: lingual sites, without this difference reaching statistical signifi-
cance (Table 1). The trend for vertical mucosal height was to
a. increase from first premolar to second molar. Mean mucosal
– Bleeding and/or suppuration on gentle probing. width at platform ranged from 2.1 to 5.6 mm, with the mean
– Probing depth ≥ 6 mm. values between 3.0 and 4.6 mm at the six measurement points.
– Bone loss ≥ 3 mm apical of the most coronal portion of The mucosa at lateral lingual/palatal measuring points was
the intra‐osseous part of the implant (day‐to‐day significantly thicker than the respective midbuccal/lingual. There
practice, Berglundh et al. 2018). was a clear trend for the mucosal width to increase at the
platform from first premolar to second molar, which was
b.
statistically significant for three out of six sites. At 1.5 mm higher
– Bleeding and/or suppuration on gentle probing.
than the platform the mean width decreased by an average of 52%
– Bone loss ≥ 3 mm apical of the most coronal portion of
to 1.5–2.4 mm. Again, there was a trend for the mucosal width to
the intra‐osseous part of the implant (epidemiological
increase at this level from first premolar to second molar, which
studies, Berglundh et al. 2018).
reached statistical significance at one of the six sites.
c.
– Bleeding and/or suppuration on gentle probing.
– Bone loss ≥ 2 mm apical of the most coronal portion of the 3.2 | Height/Width Ratio
intra‐osseous part of the implant (Romandini et al. 2021).
The mucosa width/height ratio collectively for all measurement
points ranged from 1.4 to 2.1 for the width at the platform and
2.5 | Statistical Analysis 0.6–0.8 for the width at 1.5 mm (Table 2). There was no association
between the width/height ratio and bleeding on probing or any of
Descriptive statistics analysis was conducted using mean, the case definitions for the clinical diagnosis of peri‐implantitis.
standard deviation (SD), median, interquartile range (IQR), and
percentages as appropriate. Differences of keratinized mucosa
dimensions were analyzed using a one‐way repeated measures
3.3 | Differences at Molar/Premolar Sites and
analysis of variance (ANOVA) while differences between sites
Maxillary/Mandibular Sites
with a one‐way ANOVA. Differences in mucosal height and
width and exploration of the associations between prosthetic
When molars and premolars were analyzed separately, the
angles and tissue dimensions or conditions were investigated
mucosal width at the platform was significantly greater for
using a linear mixed model and adjustment for the site as a fixed
three of the six sites of molars, and two out of six at 1.5 mm
factor. Patient level and implant level were random intercepts
(Table 3). There was no significant difference in mucosa height
and random slope of implant level on site. A logistic mixed model
between premolar and molar sites.
was performed to explore the association between tissue width,
tissue height, and the presence of BOP, adjusting for sites and
The mucosal width was significantly more at maxillary than
patient level as a random intercept. Statistical testing was done
mandibular corresponding sites, but the difference was less
within an exploratory framework at a two‐sided significance level
pronounced with regard to mucosal height, which reached
of α = 0.05. No correction of the multiple testing was applied. The
significance for only one of the six sites (Table 4).
nature of this study was exploratory and no sample size
calculation was conducted. All statistical tests were performed
using Stata IC15 (StataCorp, 2017, College Station, TX, USA).
3.4 | Association of Tissue Height and Width

3 | Results There was a positive correlation between mucosal width at the

platform and mucosal vertical height (β = 0.217, p < 0.001)
Measurements from 47 patients (24 male and 23 female) with (Table 5). There was also a strong correlation between tissue width
103 bone level implant crowns in molar and premolar positions at the platform and tissue width at 1.5 mm (β = 1.06, p < 0.001). It is
were analyzed. Patients' average age was 61 years (range: 32–81) noteworthy that the average mucosal width at 1.5 mm coronally
and the average time with prosthesis in function was 39 months decreases to only 52% of the width at the platform, with this width
(3 years, 3 months) (SD 28.05 months, range 3–120 months). being around 50% for premolars, 51% for the first and 55% for the
Eighty‐eight crowns were screw‐retained (85.5%) and 15 were second molar. At the same time, the mucosal width increases on
cement‐retained (14.5%), with the screw‐retained being splited average from 3.25 mm mid‐buccal/lingual to 4.15 at oblique lateral
almost equally to porcelain fused to metal (n = 42) and mesio/distal at platform (127% increase) and from 1.6 mm to
monolithic Zirconia on Ti‐base abutment (n = 45). 2.225 mm at 1.5 mm (139% increase).

3.1 | Mean Tissue Dimensions 3.5 | Mucositis/Peri‐Implantitis

The mucosal height ranged from 2.1 to 3.3 mm with the mean Mucositis at the implant level was assessed by the number of
value at all six sites between 2.5 and 2.7 mm. The lateral sites bleeding sites out of a total of six (Vianna et al. 2018), as seen in

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TABLE 1 | Mean and standard deviation of peri‐implant mucosa dimensions for first (x4), second (x5) premolar, and respective molar (x6, x7)
sites.

Implant site
x4 (N = 13) x5 (N = 19) x6 (N = 54) x7 (N = 17) p value between positiona
TP BM 3.1 (1.3) 3.0 (1.1) 3.7 (1.8) 4.6 (1.7) 0.147
TP BB 2.1 (1.1) 2.9 (1.3) 2.8 (1.2) 4.6 (1.7) 0.040
TP BD 2.9 (1.2) 3.4 (1.4) 4.2 (2.1) 5.6 (2.4) 0.206
TP LM 4.8 (2.9) 4.3 (3.4) 4.7 (3.3) 4.4 (2.5) 0.001
TP LL 3.7 (2.7) 3.6 (2.6) 3.2 (1.9) 3.9 (2.9) 0.192
TP LD 4.1 (2.9) 4.2 (2.6) 4.3 (3.6) 4.1 (2.6) 0.045
p value between sitesa 0.001 0.810 0.221 < 0.001
T1.5 BM 1.5 (1.2) 1.6 (1.2) 2.0 (1.6) 2.4 (1.4) 0.679
T1.5 BB 1.2 (0.8) 1.4 (1.4) 1.3 (1.1) 2.7 (1.4) 0.124
T1.5 BD 1.4 (0.9) 1.6 (1.7) 2.0 (1.7) 3.2 (2.2) 0.642
T1.5 LM 2.6 (2.8) 2.2 (2.9) 2.5 (2.7) 2.4 (1.9) 0.0.50
T1.5 LL 1.7 (2.2) 1.8 (2.4) 1.6 (1.5) 2.2 (2.1) 0.509
T1.5 LD 2.1 (2.6) 2.3 (2.1) 2.5 (3.2) 2.3 (2.0) 0.143
a
p value between sites 0.103 0.977 0.812 0.058
TH BM 2.6 (1.2) 2.5 (1.2) 2.5 (1.1) 3.0 (1.0) 0.471
TH BB 2.2 (1.0) 2.3 (1.2) 2.4 (1.0) 3.3 (1.2) 0.406
TH BD 2.6 (1.0) 2.4 (1.4) 2.5 (1.2) 3.2 (1.5) 0.960
TH LM 2.8 (0.9) 2.6 (1.5) 2.8 (1.4) 2.9 (1.0) 0.394
TH LL 2.3 (1.1) 2.6 (1.4) 2.3 (1.1) 2.8 (1.3) 0.522
TH LD 2.1 (1.0) 2.8 (1.5) 2.6 (1.4) 3.0 (1.5) 0.389
a
p value between sites 0.192 0.304 0.655 0.161
Abbreviations: BM, BB, BD = bucco‐mesial, ‐midbuccal, and ‐distal; LM, LL, LD = lingual‐mesial, ‐midlingual, and ‐distal; T1.5 = tissue width at 1.5 mm; TH = vertical
tissue height; TP = tissue width at the platform.
a
p values for the site and position effects were estimated using a linear mixed model, including patient and implant levels as a random effect.

Rungtanakiat et al. (2023). When divided into two groups, 3.7 | Correlation Between Tissue Dimensions and
implants with 0–2/6 bleeding sites were 37 (37%) while those Peri‐Implantitis/Mucositis
with half or more bleeding sites out of six were 66 (63%)
(Table 6). The prevalence of peri‐implantitis for the three case There was no correlation between mucosa dimensions and
definitions used (a: PD ≥ 6 and BL ≥ 3, b: BL ≥ 3 mm, and c: diagnosis of peri‐implantitis, but there was a significant
BL ≥ 2 mm was 2 (1.9%), 8 (7.8%), and 10 (9.7%), respectively negative association between mucosal width and dichotomous
(Rungtanakiat et al. 2023). bleeding on probing, with an odds ratio of 0.903 (95% CI:
0.818–0.997, p = 0.043) for width at platform level and 0.877 at
1.5 mm level (95% CI: 0.778–0.989, p = 0.033). This indicates
3.6 | Correlation Between Prosthetic Angles and that an increase in the mucosa width reduced the odds of
Tissue Dimensions presenting bleeding on probing.

The adjusted linear mixed model revealed that all prosthetic Furthermore, implants presented with no more than two
angles (deep angle, total contour angle, and mucosal emergence bleeding sites out of the six assessed had significantly higher
angle) were negatively associated with vertical mucosal height mucosa height than implants with three or more sites found to
(p < 0.001, Table 5, Figure 5). Expressed differently, the increase be bleeding on probing (OR 3.51, 95% confidence interval
in any of the aforementioned angles was significantly associated [1.72–7.14], p = 0.001).
with a decrease in soft tissue height.

There was also a negative correlation between deep angle and tissue 3.8 | Keratinized Mucosa
width at 1.5 mm (p < 0.001, β = −0.02, 95% CI: −0.03, −0.01)
(Figure 6). The deep angle had a significant positive correlation with The mean keratinized tissue width at buccal sites (KBM, KBB,
the ratio of tissue width/tissue height—at the platform (β = 0.36, KBD) was 2.6 ± 1.6, 2.0 ± 1.5, and 2.4 ± 1.7 mm, respectively
95% CI: 0.03–0.04), but not at the 1.5 mm height. (Table 7) and it was significantly wider at lateral oblique points

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TABLE 2 | Mean peri‐implant mucosa width/height ratio and standard deviation for width at platform and 1.5 mm. Mean per respective implant
site first (x4), second (x5) premolar and first (x6) and second molar (x7).

Implant site
Width/height x4 (N = 13) x5 (N = 19) x6 (N = 54) x7 (N = 17) p valuea
At implant platform
BM 1.4 (0.9) 1.3 (0.4) 1.7 (0.9) 1.5 (0.6) 0.719
BB 1.5 (2.1) 1.4 (0.5) 1.4 (1.4) 1.4 (0.6) 0.728
BD 1.2 (0.7) 2.1 (2.6) 2.4 (2.8) 1.9 (0.6) 0.007
LM 1.8 (1.0) 1.5 (0.7) 1.9 (1.4) 1.7 (1.0) 0.741
LL 1.7 (1.0) 1.5 (1.0) 1.5 (0.9) 1.4 (0.9) 0.869
LD 1.9 (0.8) 1.5 (0.6) 1.7 (1.0) 1.4 (0.8) 0.823
a
p value between sites 0.715 0.450 0.113 0.662
At 1.5 mm platform
BM 0.5 (0.3) 0.6 (0.4) 0.7 (0.6) 0.8 (0.5) 0.655
BB 0.8 (1.3) 0.5 (0.5) 0.5 (0.3) 0.8 (0.4) 0.049
BD 0.5 (0.3) 0.7 (0.8) 0.7 (0.6) 0.9 (0.6) 0.957
LM 0.8 (0.9) 0.7 (0.6) 0.8 (0.7) 0.8 (0.4) 0.391
LL 0.6 (0.8) 0.5 (0.4) 0.6 (0.4) 0.7 (0.5) 0.345
LD 0.8 (0.8) 0.7 (0.5) 0.7 (0.8) 0.7 (0.5) 0.491
a
p value between sites 0.244 0.577 0.123 0.334
a
p values for the site and position effects were estimated using a linear mixed model, including patient and implant levels as a random effect.

of measurement than midbuccal. Also, it was significantly The presence of a width/height ratio in the peri‐implant
higher at the first premolar with a trend to decrease toward the mucosa is something that has been previously reported in
molars and being the lowest at the second molar. An association clinical studies, albeit with smaller and less homogenous
of keratinized mucosa and tissue height only reached the level samples. Nozawa et al. analyzed the volume of soft tissue
of significance for the buccal‐mesial sites. None of the implant around internal hexagon single implants with a flat‐to‐flat
sites presented with 0 width of keratinized mucosa at all three connection on 14 patients after an average period of 3 years
buccal sites, 12 implants had no keratinized mucosa at two of and 5 months. The ratio between the height and width of peri‐
the three sites while 12 implants at one site, respectively, with implant mucosa was 1.58. Farronato et al. (2019) studied
the mid‐buccal point most likely to present with no keratinized mucosa width/height on 20 patients with 32 bone level,
mucosa (19 implants). No association was found between the platform switching implants and reported a significant
width of keratinized mucosa and bleeding on probing for the association between width and height and a ratio of 1.19 ±
corresponding sites. 0.55. This trend was confirmed by the present data as well, as
in all cases the width of the peri‐implant mucosa at the
platform was higher than the vertical mucosa height in the
4 | Discussion
corresponding site. Nevertheless, the results of this study add
two new important parameters: First, the ratio between width
This cross‐sectional study aimed to describe and explore
and height presents with variation between anatomic locations
associations between the design of implant‐supported
and can vary even within a relatively limited group, such as
prosthesis and peri‐implant mucosa dimensions in a sample
posterior premolars and molars. Second, peri‐implant tissue
of posterior platform switching implants in patients under
dimensions as well as the ratio of width/height can vary
maintenance. To achieve this, the study utilized reproduc-
depending on the anatomic location within the same implant
ible measurements in a three‐dimensional imaging model
site. As previous research has been conducted using two‐
based on specific planes and angles, as previously described
dimensional imaging, tissue measurements have been mainly
by Rungtanakiat et al. (2023). This study predominantly
focused in the mid‐buccal and at times mid‐palatal points,
revealed:
which in this study are shown to be the sites with the lowest
values in terms of both height and width of the mucosa. The
− A consistent correlation between peri‐implant mucosa
thickness of the tissue at the mesial and distal lateral
width and height.
measurement points is significantly more than at the mid‐
− A significant association between the design features of buccal point, not only at the platform level but also 1.5 mm
the implant‐supported prosthesis (deep angle, mucosal higher, where the abutment/prosthesis inevitably widens. This
emergence angle, and total contour angles) and the “geometrical” bias induced by the overreliance on two‐
dimensions of the peri‐implant mucosa. dimensional imaging for understanding a three‐dimensional

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TABLE 3 | Mean and standard deviation of peri‐implant mucosa dimensions for implants at premolar and molar sites.

Premolars (x4, x5) (N = 32) Molars (x6, x7) (N = 71) p valuea

At implant platform
BM 3.1 (1.2) 3.9 (1.8) 0.137
BB 2.6 (1.3) 3.2 (1.6) 0.031
BD 3.2 (1.3) 4.6 (2.2) 0.102
LM 4.5 (3.2) 4.6 (3.1) < 0.001
LL 3.7 (2.6) 3.4 (2.2) 0.054
LD 4.2 (2.7) 4.2 (3.4) 0.026
a
p value between sites < 0.001 0.024
At 1.5 mm platform
BM 1.6 (1.2) 2.1 (1.6) 0.400
BB 1.3 (1.2) 1.7 (1.3) 0.115
BD 1.5 (1.4) 2.3 (1.9) 0.693
LM 2.4 (2.8) 2.5 (2.5) 0.021
LL 1.8 (2.3) 1.7 (1.6) 0.207
LD 2.2 (2.3) 2.5 (3.0) 0.066
a
p value between sites 0.013 0.459
Tissue height
BM 2.5 (1.2) 2.6 (1.1) 0.945
BB 2.3 (1.1) 2.6 (1.1) 0.468
BD 2.5 (1.2) 2.6 (1.3) 0.981
LM 2.7 (1.3) 2.8 (1.3) 0.348
LL 2.5 (1.3) 2.5 (1.2) 0.374
LD 2.5 (1.3) 2.7 (1.4) 0.953
a
p value between sites 0.500 0.843
a
p values for the site and position effects were estimated using a linear mixed model, including patient and implant levels as a random effect.

structure such as the Implant Supracrestal Complex, might in keratinized mucosa at midfacial buccal sites, neglecting mesial
the past have influenced our understanding and definitions of and distal sites as well as lingual sites.
tissue “thickness.” In the future, it might be essential to review
and expand our definitions of peri‐implant tissue phenotype Past studies have observed that the width‐to‐height ratio in the
and thickness, to better represent the three‐dimensional case of free gingiva around natural teeth is inverted to this
complexity of the peri‐implant mucosa taking advantage of around implants, showing height surpassing width by a ratio of
new imaging technologies (Strauss et al. 2024). 1.5 (Wennström 1996). Such measurements, taken at the
margin of free gingiva, might not be anatomically directly
The same might be true for the width of the keratinized comparable with those in the peri‐implant mucosa and can only
mucosa, which was the lowest at the midbuccal point of serve as a reminder of the important structural differences
measurement. Nevertheless, even if the mid‐buccal point was between two fundamentally different tissues. The clinical
the site most likely to have no keratinized mucosa (18% of significance of the width‐to‐height ratio might not be at its
implants), there were no implants in this sample that had no absolute value. The results of this study suggest an underlying
keratinized mucosa at all three measured points. This might geometrical architecture of the peri‐implant mucosa, with the
explain why the keratinized mucosa width had no impact on essential establishment of a wide base to support the essential
bleeding on probing in the sample. Indeed, a recent 10‐year tissue height. In the case of the peri‐implant mucosa, this base
prospective study revealed that the absence of buccal kerati- might have to be much wider than in physiological periodontal
nized mucosa around implants was associated with higher risks tissue. The width of the peri‐implant mucosa at the implant site
of presenting buccal bleeding on probing (Mancici et al. 2024). depends on many factors, such as the local site anatomic
However, the association between a lack of keratinized mucosa conditions and the position of the implant. However, the results
and bleeding on probing seems weak (Ravidà et al. 2022). of this study suggest that the prosthesis design might be another
Future studies might need to look closer into the importance of important determinant of the peri‐implant mucosa dimensions.
the three‐dimensional arrangement of the keratinized mucosa In particular, the association of the deep angle with mucosal
around implants as most studies have only evaluated the width is something that has not been presented before. From a

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TABLE 4 | Mean and standard deviation of peri‐implant mucosa dimensions for implants at mandibular and maxillary sites.

Maxillary Mandibular Maxillary Mandibular p value

premolars premolars molars molars between
(N = 10) (N = 22) (N = 13) (N = 58) positiona
TP BM 3.7 (1.0) 2.8 (1.1) 5.5 (1.8) 3.6 (1.7) 0.007
TP BB 2.8 (0.9) 2.5 (1.4) 3.0 (1.2) 3.3 (1.6) < 0.001
TP BD 3.9 (1.1) 2.9 (1.3) 4.0 (1.9) 4.7 (2.3) < 0.001
TP LM 6.7 (1.8) 3.5 (3.2) 8.1 (4.1) 3.8 (2.2) < 0.001
TP LL 5.0 (1.3) 3.1 (2.8) 5.8 (2.5) 2.8 (1.7) 0.029
TP LD 5.6 (2.5) 3.5 (2.5) 8.2 (5.1) 3.3 (2.0) < 0.001
a
p value between sites < 0.001 0.001 0.081 < 0.001
T1.5 BM 1.9 (0.9) 1.4 (1.3) 3.2 (1.8) 1.9 (1.4) 0.128
T1.5 BB 1.5 (0.6) 1.2 (1.4) 1.3 (1.1) 1.7 (1.3) 0.003
T1.5 BD 2.0 (1.1) 1.3 (1.5) 1.9 (1.9) 2.4 (1.9) 0.017
T1.5 LM 4.0 (1.4) 1.6 (3.0) 5.1 (3.9) 1.9 (1.7) < 0.001
T1.5 LL 2.2 (1.2) 1.6 (2.6) 3.1 (2.2) 1.4 (1.3) 0.379
T1.5 LD 3.5 (1.9) 1.7 (2.2) 5.4 (5.1) 1.8 (1.7) < 0.001
p value between sitesa < 0.001 0.004 0.040 < 0.001
TH BM 2.6 (0.9) 2.5 (1.3) 2.8 (0.8) 2.6 (1.2) 0.688
TH BB 2.3 (1.1) 2.3 (1.1) 2.4 (1.1) 2.7 (1.1) 0.478
TH BD 2.7 (1.0) 2.4 (1.3) 2.1 (1.0) 2.8 (1.3) 0.137
TH LM 3.6 (1.0) 2.3 (1.3) 3.6 (1.6) 2.6 (1.2) 0.001
TH LL 3.0 (0.9) 2.2 (1.4) 3.0 (1.1) 2.3 (1.2) 0.126
TH LD 3.1 (1.1) 2.3 (1.4) 3.1 (1.7) 2.6 (1.3) 0.367
p value between sitesa 0.002 < 0.001 0.406 0.001
Abbreviations: BM, BB, BD = bucco‐mesial, ‐midbuccal, and ‐distal; LM, LL, LD = lingual‐mesial, ‐midlingual, and ‐distal; T1.5 = tissue width at 1.5 mm; TH = vertical
tissue height; TP = tissue width at the platform.
a
p values for the site and position effects were estimated using a linear mixed model, including patient and implant levels as a random effect.

TABLE 5 | Unstandardized coefficient (β) and confidence intervals TABLE 6 | Presence of positive sites for bleeding on probing (BoP),
(CI) between mucosa height and deep angle (DA), mucosal emergence organized according to the number of bleeding on probing sites per
angle (MEA), total contour angle (TA), mucosa width (n = 618). Linear implant (Rungtanakiat et al. 2023).
mixed model and adjustment for the site as a fixed factor. Patient level
Implants (n = 103)
and implant level are random intercepts and random slope of implant
level on site. Bleeding BoP+, 0–2 of 6 sites 37 (35.92%)
on probing BoP+, 3 of 6 sites 27 (26.21%)
β [95% CI] p value
Tissue width at the platform 0.217 < 0.001 BoP+, 4 of 6 sites 14 (13.59%)
BoP+, 5 of 6 sites 13 (12.62%)
[0.185, 0.248]
Tissue width at 1.5 mm 0.323 < 0.001 BoP+, 6 of 6 sites 12 (11.65%)
above the platform
[0.286, 0.360]
Deep angle −0.018 < 0.001 purely geometrical point of view, the peri‐implant mucosa
[−0.024, −0.011] appears to fill a pyramid shape, supplementary to the trapezoid
shape of the implant prosthesis, when the prosthetic contour
Total contour angle −0.015 < 0.001 remains within 30°, as recommended by Puisys et al. (2023).
[−0.021, −0.008] The deep angle has a critical importance for the marginal bone,
Mucosal emergence angle −0.011 < 0.001 as studies have shown increased marginal bone remodeling
(Valente et al. 2020) and early marginal bone loss when this
[−0.015, −0.006]
angle exceeds 28°–34° (Han et al. 2023). Although defining a

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FIGURE 5 | Correlation between prosthetic angles and vertical mucosa height. Linear mixed model and adjustment for the site as a fixed factor.
Patient level and implant level are random intercepts and random slope of implant level on site.

provisional crown are used to invoke changes in the dimensions

and morphology of the peri‐implant mucosa. Furthermore,
these results could indirectly explain clinical outcomes such as
the increased recession observed when switching from concave
to convex contour in anterior implant crowns (Siegenthaler
et al. 2022).

Two more associations emerged as the results of this study with

regard to clinical outcomes: First, mucosal width was negatively
associated with bleeding on probing, especially in the 1.5 mm
level coronally of the platform, but not mucosal height. When the
implant sites were further stratified in those with no or relatively
few bleeding points (0–2/6) and those with half or more of the
measured points showing bleeding (3–6/6), there was a signifi-
cant association of the first with higher vertical tissue height.
Such results should be interpreted with caution in a cross‐
sectional study since causality cannot be determined. Therefore,
they should be seen as preliminary findings that warrant
validation through longitudinal studies. Nevertheless, these
observations might be well aligned with current research
FIGURE 6 | Correlation between deep angle (DA) and width at understanding and hint toward wider observed associations
1.5 mm coronal of the platform. Linear mixed model and adjustment for (Mattheos, Janda, et al. 2021). With regard to mucosal width,
the site as a fixed factor. Patient level and implant level are random cross‐sectional studies have suggested an increased prevalence of
intercepts and random slope of implant level on site. mucositis in the presence of “thin” peri‐implant mucosa
(Gharpure et al. 2021, Tur and Sarıbaş 2023). In fact, soft tissue
augmentation at implant sites has been advocated as an
cut‐off point has not been attempted in this study and might not intervention to promote peri‐implant health over time (Tavelli
be meaningful in clinical terms, the clear negative correlation of et al. 2021, Thoma et al. 2018). Conversely, other prospective
the deep angle with the width of the peri‐implant mucosa could clinical studies have failed to find any association between
suggest further implications of this critical design feature phenotype and mucositis (Fernandes‐Costa et al. 2019). This
extending beyond marginal bone remodeling. The relation of contrast results might be explained by the case definition of
the prosthetic angles with the peri‐implant mucosa dimensions mucositis at the implant level. For example, bleeding on probing
might come as no surprise to anyone who has been conducting could differ between thin and thick mucosa because thin mucosa
post‐implant placement “tissue conditioning” using prospective might be more prone to trauma during probing, while the
contour modifications of provisional prosthesis (Furze et al. contour of the prosthesis might also interfere with our ability to
2019). Thus, the results of this study might be well aligned with probe and the consequent registration of bleeding and probing
tissue manipulation techniques such as “dynamic compression” depth (Rungtanakiat et al. 2023). The 2017 World Workshop
(Wittneben et al. 2013), where contour adjustments of a defined mucositis as the presence of bleeding and/or pus on

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TABLE 7 | Mean keratinized mucosa dimensions (mm) and standard deviation for each of the three buccal sites were measured.

Position
Keratinized Total p value between
mucosa width (N = 103) x4 (N = 13) x5 (N = 19) x6 (N = 54) x7 (N = 17) positionb
BM 2.6 (1.6) 4.0 (1.8) 2.7 (1.2) 2.5 (1.5) 1.7 (1.2) < 0.001
BB 2.0 (1.5) 3.3 (1.7) 1.7 (1.3) 2.1 (1.5) 1.2 (1.3) 0.001
BD 2.4 (1.7) 4.0 (1.6) 2.4 (1.4) 2.4 (1.6) 1.1 (1.2) < 0.001
p value between sitesa < 0.001 0.006 < 0.001 0.005 0.003
Abbreviations: BM, BB, BD = bucco‐mesial, ‐midbuccal, and ‐distal; x4 = first premolar, x5 = second premolar, x6 = first molar, x7 = second molar.
a
One‐way repeated ANOVA.
b
One‐way ANOVA.

gentle probing, with or without increased probing depth The major strength of the current study is the detailed and
compared to previous exams, and no bone loss beyond initial reproducible measurements, defined by points on specific planes,
remodeling changes (Berglundh et al. 2018). The bleeding on following the model of analysis of cephalometric radiographs.
probing was in addition characterized as “profuse” (line or drop, Furthermore, although no specific attempt was made to assess the
not “dot”) (Renvert et al. 2018), to distinguish inflammation from appropriateness of the implant position, restorations were excluded
potential traumatic bleeding, especially when dichotomous when the axis of the crown differed from that of the implant by
scoring is used. Other case definitions proposed later, appeared more than 10°. Thus, the great majority of the implant crowns were
to focus on dichotomous bleeding on probing in isolation of other screw‐retained. Nevertheless, this method also has limitations.
signs and qualitative features, where mucositis was defined as Although four axial planes were defined leading to eight distinct
probing resulting in two or more bleeding “dots” after probing six sites for each implant, the peri‐implant mucosa margin was only
sites around an implant (Herrera et al. 2023). Nevertheless, even visible in six of them. The outline of the peri‐implant mucosa was
with consistent force the prevalence of bleeding on probing is not visible directly mesial and distal (under the contact point), the
influenced by many factors (Dukka et al. 2021), such as the point which was also not accessible to clinical examination. Thus
operator and the probing force (Gerber et al. 2009), the values for MEA, bleeding on probing, probing depth, and plaque
morphology and characteristics of the tissue (Ravidà et al. 2022), score were not recorded for these points, while values for deep angle
and the contour of the prosthesis (Rungtanakiat et al. 2023). and total contour angle were not included in the analysis.
There is a high likelihood of false positives when relying on Furthermore, one should interpret the results of this study in light
dichotomous scoring of bleeding. Common sense would suggest of the limitations of the sample, which albeit rather homogenous,
that if one bleeding “dot” can be attributed to traumatic probing, was collected from the patient pool of one university department.
then a second one should be at least as likely in the same implant
under the same conditions. Two traumatic “dots” would not
equal one inflammatory. Thus the authors have chosen to report
Author Contributions
the frequency of bleeding sites out of six per implant, allowing for
wider interpretations of the dichotomous bleeding data. In the Piboon Rungtanakiat: data curation, formal analysis, investigation,
future, case definitions of mucositis based on qualitative features writing – original draft preparation. Natchaya Thitaphanich: data
curation, investigation. writing – review and editing. Martin Janda:
of bleeding on probing in combination with other signs of
conceptualization, methodology, validation, visualization, writing –
inflammation (Dukka et al. 2021) might offer a better diagnostic review and editing. Franz Josef Strauss: validation, writing – review
potential to epidemiological studies. and editing. Mansuang Arksornnukit: conceptualization, formal
analysis, funding acquisition, methodology, project administration,
The variation in mucosal height in this sample of posterior resources, software, supervision, validation, writing – review and editing.
implants was rather narrow, with the great majority of sites Nikos Mattheos: conceptualization, formal analysis, methodology, project
falling within 2.4–2.8 mm. Implants with peri‐implant mucosa administration, resources, software, supervision, validation, visualization,
writing – original draft preparation, writing – review and editing.
toward the upper margin of this range were associated with
significantly fewer bleeding sites. An optimal range of mucosa
height facilitating peri‐implant tissue health cannot be easily Acknowledgments
defined based on a cross‐sectional study, it is however
reasonable to expect that an adequate soft tissue height may The authors would like to acknowledge the contribution of Dr. Stavros
Pelekanos, Dr. Ioannis Vergoullis, and Dr. Alberto Miselli in the
enhance the structural seal around the implant, potentially
development of this research protocol, and Professor Atiphan Pim-
better coping with the bacterial challenge and facilitating oral khaokham for his help with the radiography.
hygiene measures. Furthermore, a larger soft tissue height may
relate to the presence of attached (non‐mobile) mucosa
Conflicts of Interest
(Tarnow et al. 2021). Together, these factors emphasize the
importance of the establishment of the essential vertical The authors declare no conflicts of interest.
attachment zone (Mattheos, Janda, et al. 2021). However, this
may be influenced by other factors, such as the mucosal Data Availability Statement
emergence angle. A wider angle has been linked to both a The data that support the findings of this study are available from the
higher prevalence of mucositis and a reduced mucosal height. corresponding author upon reasonable request.

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