Received: 7 August 2018 Revised: 5 November 2018 Accepted: 18 November 2018

DOI: 10.1002/JPER.18-0471

CASE SERIES

Significance of keratinized mucosa/gingiva on peri-implant and

adjacent periodontal conditions in erratic maintenance compliers

Alberto Monje1,2 Gonzalo Blasi2,3

1 Department of Oral Surgery and

Abstract
Stomatology, ZMK School of Dental
Medicine, University of Bern, Bern, Background: Given the fact that most patients are not regular compliers in supportive
Switzerland peri-implant maintenance programs, it is of interest to examine the significance of
2 Department of Periodontology, International
the peri-implant soft tissue characteristics in relationship to the onset of peri-implant
University of Catalonia, Barcelona, Spain
3 Division of Periodontology, University of
diseases.
Maryland School of Dentistry, Baltimore, Methods: Based on an a priori statistical power calculation, a cross-sectional study
MD, USA
was conducted on erratic peri-implant maintenance compliers (<2 times/year) to
Correspondence
Alberto Monje, DDS, MS, Department of examine the significance of keratinized mucosa (KM) and gingival tissue (KT) on
Oral Surgery and Stomatology, ZMK School peri-implant and adjacent periodontal conditions in implants restored ≥3 years. Seven
of Dental Medicine, University of Bern,
clinical parameters were recorded around implants and the adjacent buccal sites.
Freiburgstrasse 7, 3010 – Bern, Switzerland.
Email: [email protected] Radiographic assessment was performed using periapical X-rays. In addition, a visual
analog scale (VAS) was used to evaluate the impact of KM upon brushing comfort.
The case definition used for peri-implant diseases was in accordance with the 2017
World Workshop on the classification of periodontal and peri-implant diseases and
conditions.

Results: Overall, 37 patients with 45 edentulous gaps restored with 66 implants and
90 adjacent teeth were analyzed. On comparing a KM band of <2 mm versus ≥2 mm,
with the exception of suppuration (P = 0.6), all the clinical and radiographic param-
eters were significantly increased when the KM band was <2 mm (P < 0.001). A
significant correlation was observed between KM and KT (r = 0.55), though a lack of
KM did not condition a lack of KT. In the presence of peri-implantitis, only bleeding
on probing at the adjacent dentate sites was identified to be increased.

Conclusions: The presence of <2 mm of KM around dental implants in erratic main-

tenance compliers seems to be associated with peri-implant diseases. The lack of KM
constitutes a site-specific phenomenon independent of the keratinized tissue present
in the adjacent dentition (NCT03501537).

KEYWORDS
alveolar bone, dental implants, diagnostic, implant stability, peri-implant mucositis, peri-implantitis

1 I N T RO D U C T I O N claim is based on the fact that movable mucosa facilitates the

penetration of biofilm into the crevice, which in turn would
The morphological characteristics of the gingiva have been trigger the activation of neutrophils and lymphocytes.2 These
regarded as crucial for the integrity of the periodontium.1 This would cause chronification of the inflammatory response,

J Periodontol. 2019;90:445–453. wileyonlinelibrary.com/journal/jper © 2018 American Academy of Periodontology 445

 19433670, 2019, 5, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.18-0471 by Luiz Guilherme Fiorin - Universidade Estadual Paulista , Wiley Online Library on [23/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
446 MONJE AND BLASI

resulting in attachment loss.3 Hence, it has been advo- 2 M AT E R I A L S A N D M E T H O D S

cated that an adequate zone of keratinized tissue (KT)
with an attached area are decisive to maintain the sta- A cross-sectional study was conducted in accordance with the
bility of the periodontal tissues.4 This requirement is of Declaration of Helsinki on human studies, following approval
lesser relevance in patients with adequate plaque control, from the Ethics Committee of the University of Extremadura
however.5–7 (Badajoz, Spain, Ref. no. #18002909). The subjects were
The significance of keratinized mucosa (KM) border- recruited for the study from February 1 until June 15, 2018.
ing dental implants has not been without controversy, and The study was also registered and approved by Clinicaltri-
focused much debate especially during the 1990s.8–12 The als.gov (NCT03501537) and is reported according to the
reason for this academic disagreement was mainly the fact STROBE statement. Written informed consent was obtained
that the vast majority of commercial dental implants at from all patients for this study.
the time were machined/turned designs which in turn may
minimize biofilm accumulation when compared with mod-
2.1 Study population
ified surfaces. This issue is of considerable significance,
since plaque accumulation may lead to a greater inflam- All enrolled subjects had been consecutively evaluated
matory infiltrate dominated by lymphocytes and plasmatic with dental implants in function and a screw-retained fixed
cells when compared with natural teeth.13 In this regard, prosthesis for a minimum of 36 months after final pros-
a meta-analysis of recent trials revealed statistically signif- thesis delivery. All eligible patients had to fall within the
icant differences in plaque index, modified gingival index, following definition of erratic compliance: not attending to a
mucosal recession, and attachment loss, with results all favor- minimum of two times (i.e., every 6 months) for supportive
ing implants with a wide band of KM.14 In this sense, the periodontal/peri-implant maintenance therapy.24 Patients
lack of KM is positively associated with vestibular depth15 were either contacted and invited to participate in a study to
and brushing discomfort,16,17 which can condition patient identify the peri-implant/periodontal conditions or the eval-
willingness and ability to acquire adequate personal oral uation was carried out during supportive periodontal/peri-
hygiene habits. In addition, the presence of KM around dental implant treatment performed in a private practice exclusive in
implants has been shown to have an impact on immunological Periodontics and Implant Dentistry (CICOM | Periodoncia,
parameters, with a negative correlation to prostaglandin E2 Badajoz, Spain). The clinical, radiographic analyses were
levels.18 performed by one periodontist (AM) with >5 years involved
Supportive periodontal therapy (SPT) and peri-implant in clinical research accredited by the American Academy of
maintenance therapy (PIMT) have been shown to be cru- Periodontology (AAP). The baseline X-rays at the time of
cial to the longevity of both natural teeth19–23 and dental prosthesis delivery were retrospectively examined to exclude
implants.24–29 In this regard, the compliance rate has also implants with excessive early peri-implant bone loss before
been shown to potentially condition the development of function that could lead to misdiagnosis.
biological complications. Findings from a recent systematic All included patients were informed – as part of the initial
review suggest that compliance with a biannual PIMT phase – to adhere to a supportive peri-implant maintenance
program results in an approximately three-fold increased therapy program tailored to the risk profile. As such, patients
efficacy in the prevention of peri-implant diseases. In with history of periodontal disease were recommended to
agreement with this, clinical trials have underscored the attend every 3 to 4 months and patients without history of
importance of professionally providing PIMT ≥2 times/year periodontal disease were suggested to comply every 5 to
compared with less frequent recalls.24,29 Nonetheless, ≈ 60% 6 months. Supportive periodontal/peri-implant maintenance
of all patients are either erratic compliers (<2 times/year) or therapy was performed by an experienced hygienist (>5 years
non-compliers (0 times/year), and of these, roughly one out of expertise) with plastic curets and fine polishing pastes.
of five develop peri-implantitis.24 Given the fact that even Moreover, recommendations on home care were delivered
in the absence of adequate PIMT enrollment the majority stressing on the use of interproximal brush and floss with
of erratic compliers or non-compliers do not develop patho- stiffened end to cleanse the interproximal areas.
logical conditions characterized by progressive bone loss, it The prescreening was performed by reviewing the internal
seems of interest to examine the influence of KM in these records. An a priori statistical power analysis was performed
patients. to calculate the sample size. Overall, 37 patients were deter-
The present study thus assesses the significance of KM mined to be recruited assuming an intraclass correlation coef-
in erratic (<2 times/year) compliers. In addition, an eval- ficient of 0.25. All the eligible patients were consecutively
uation is made of the influence of the band of KM upon invited when attending to other departments at the same prac-
the peri-implant conditions in comparison to the periodontal tice for other reasons/concerns (i.e., prosthodontics, oral and
conditions of the adjacent teeth. maxillofacial surgery, and orthodontics) or when irregularly
 19433670, 2019, 5, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.18-0471 by Luiz Guilherme Fiorin - Universidade Estadual Paulista , Wiley Online Library on [23/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MONJE AND BLASI 447

attended to the supportive periodontal/peri-implant treatment. • Bone level ≥3 mm apical to the most coronal portion of the
Along the recruitment period, three patients resulted to be cur- intraosseous part of the implant.
rent smokers and hence were invited to adhere to a regular sup-
portive peri-implant maintenance therapy but excluded from
the study. 2.4 Clinical assessment
The following clinical parameters and indexes were recorded
2.2 Eligibility criteria at the buccal sites of the studied implants and teeth:
The following inclusion criteria were applied: implant-
• Probing depth (PD) recorded in millimeters using a North
supported single-crown and fixed prostheses, patients aged
Carolina probe.
18 to 80 years; non-smokers; absence of infectious disease
at the time of implant placement or during the maintenance • Modified sulcular bleeding index (mBI) scored from 0 to 3
program; absence of systemic disorders or medication known according to the extent and severity of bleeding on probing
to alter bone metabolism; and partially edentulous patients (BOP).31
with gaps associated to at least one mesial and one distal • Plaque index (PI) scored from 0 to 3 according to the visi-
adjacent tooth, without sign of active periodontal disease and bility and severity of plaque accumulation.32
with or without a history of chronic periodontitis. Subjects • Keratinized mucosa (KM) around dental implants, mea-
in turn were excluded for the following reasons: pregnancy; sured from the free mucosal margin to the mucogingival
lactation; past or present heavy smoking; uncontrolled med- junction at the mid-buccal, -mesial, and -distal line angles,
ical conditions such as diabetes mellitus; inadequate three- and recorded to the nearest millimeter using a North Car-
dimensional implant positioning impeding accurate recording olina probe. If unclear, Lugol iodine was used to stain the
of probing depth; cement-retained restorations or restorations mucosa to better discern the mucogingival margin. The firm
lacking KM on the lingual implant sites. and resilient KM was identified as attached mucosa (AM).
• Keratinized gingival tissue (KT) around natural dentition,
2.3 Case definition of peri-implant health, measured from the free mucosal margin to the mucogin-
mucositis, and peri-implantitis gival junction at the mid-buccal, mesial, and distal line
Based on the consensus report of Workgroup 4 of the 2017 angles, and recorded to the nearest millimeter using a North
World Workshop on the Classification of Periodontal and Carolina probe. If unclear, Lugol iodine was used to stain
Peri-Implant Diseases and Conditions,30 the diagnosis of the mucosa to better discern the mucogingival margin.
health required: • Vestibular depth (VD) measured using a North Carolina
probe from the mucosal margin to the point of greatest
• No clinical signs of inflammation. concavity of the mucobuccal fold while retracting with a
• No bleeding and/or suppuration on gentle probing bilateral retractor. Vestibular depth was rated as shallow
(0.15 Ncm). (<4 mm) or deep (≤4 mm).
• No increase in probing depth compared with previous • Suppuration (SUP) around implants and teeth, recorded by
examinations. a dichotomous (1/0) scale using a North Carolina probe.
• No bone loss beyond crestal bone level changes resulting
Moreover, the patients were interviewed by one examiner
from initial bone remodeling.
(AM) using a visual analog scale (VAS) to assess brushing
The diagnosis of peri-implant mucositis in turn was estab- comfort before assessing the clinical condition to minimize
lished from the following: bias. The VAS recorded a characteristic (comfort) ranging
across a continuum of values, and which is not easy to mea-
• Presence of bleeding and/or suppuration on gentle probing sure directly. The score ranged from 0 (maximum discomfort)
(0.15 Ncm). to 100 (maximum comfort) and was recorded around teeth and
• No bone loss beyond crestal bone level changes resulting implants.
from initial bone remodeling.
2.5 Radiographic assessment
Lastly, the diagnosis of peri-implantitis in turn was estab-
lished from the following: One examiner (AM) assessed the radiographic bone level
(intra-rater Cohen kappa value >90% – almost perfect). Peri-
• Presence of bleeding and/or suppuration on gentle probing implant radiographic marginal bone loss (MBL) was deter-
(0.15 Ncm). mined by taking linear measurements from the most mesial
• Probing depth ≥6 mm. and distal point of the implant platform to the crestal bone on
 19433670, 2019, 5, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.18-0471 by Luiz Guilherme Fiorin - Universidade Estadual Paulista , Wiley Online Library on [23/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
448 MONJE AND BLASI

each periapical radiograph, corrected according to the known Overall, 45 edentulous gaps were analyzed of which, 26
height and width of each implant using an image processing were assessed in the posterior mandible, followed by 17 in the
program (National Institutes of Health). posterior maxilla and a vast minority in the anterior regions
(2). In the posterior mandible, 53.8% accounted for <2 mm
2.6 Statistical analysis of KM, while in the posterior maxilla 17.6%. On the other
side, 82.4% and 100% of the posterior and anterior maxil-
A priori statistical power analysis was performed assuming
lary sites, respectively, and 46.2% and 0% in the posterior
an intra-class correlation coefficient (ICC) of 0.25, based on a
and anterior mandibular sites, respectively, displayed ≥2 mm
previous study.33 The Kolmogorov-Smirnov test was applied
of KM.
to assess normality between the parameters KM and KT. Pear-
son correlation coefficient was used to assess the correlations
between the presence/lack of KM in the edentulous gap and 3.2 Significance of KM in relation
the other clinical and radiographic parameters or KT of the to peri-implant condition
adjacent teeth. The Mann-Whitney U-test was applied to val-
The vast majority of the implants examined presenting a band
idate the homogeneity of the clinical parameters for teeth and
of ≥2 mm of KM displayed mucosal attachment (92%), while
implants. In the event of a non-homogeneous distribution, we
AM could not be found in implants with <2 mm of KM (0%).
used the Spearman correlation test. The Kruskal-Wallis test
When comparing a KM band of <2 mm versus ≥2 mm, with
was applied to assess homogeneity of one of the variables in
the exception of SUP, all the clinical and radiographic param-
≥3 independent samples.
eters were significantly increased when the band was < 2 mm
The inferential analysis involved estimation by generalized
(Table 1 and Fig. 1). Moreover, KM was positively associ-
estimating equations (GEEs) of multilevel logistic regres-
ated with VD. A lack of KM was significantly associated with
sion models. Calculations were made to assess any parameter
peri-implantitis (P < 0.001).
recorded at implant-level in relationship to KM. The level of
The width of the KM band was significantly associated
significance was defined as 5% (𝛼 = 0.05).
(P < 0.001) with the health and peri-implantitis rates, but
not with peri-implant mucositis (Fig. 2). Interestingly, under
the presence of KM, on comparing a band ranging from 0 to
3 RESULTS 1.99 mm versus ≥2 mm, only mucositis was found to be sig-
nificantly greater (P <0.05) in the <2 mm group. Neither peri-
3.1 Study population implantitis nor healthy implants differed between these study
Based on the a priori sample size calculation, 37 white groups.
patients (37.6% females, 32.4% males; mean age: 49.9 ± 12.9
years) with 45 edentulous gaps restored with 66 implants
3.3 Significance of KM in relation to comfort
(mean follow-up: 5.73 ± 2.89 years) and 90 adjacent teeth
upon brushing
were analyzed. Of these, 30 (81.1%), six (16.2%), and
one (16.2%) patients, respectively, had one, two, and three In the presence of a KM band of <2 mm, the VAS score
implant-supported edentulous gaps. Overall, 18 (48.6%), 11 decreased significantly (P <0.001). Interestingly, when the
29.7%), seven (18.9%), and one (2.7%) patients carried one, mean KM band was 2.5 mm, all the patients reported
two, three, and five implants, respectively. In turn, 30 (81.1%), maximum comfort (VAS = 100).
six (16.2%), and one (16.2%) patients, respectively, had two,
four, and six teeth examined. A total of 196 implants sites and
3.4 Association between KM and KT of the
360 tooth sites were recorded.
adjacent dentition
Overall, eight (21.62%) out of the 37 patients presented
with active periodontal disease (residual pockets ≥5 mm with The mean KM band width was 2.35 ± 1.83 mm (range
bleeding on probing), 16 (43.24%) were controlled individu- 0 to 6.33 mm), with a median of 2.2 mm. In 40% of the
als with history of chronic periodontitis (no residual pockets edentulous implant-supported sites, the mean KM band
≥5 mm) and 13 (35.14%) were not diagnosed with active or was <2 mm, while the remaining 60% presented a KM band
history of periodontitis (no pockets ≥5 mm). Regarding the width of ≥2 mm. On the other hand, the KT band width was
level of radiographic attachment loss, 5.40% (two patients) substantially greater, with a mean value of 3.49 ± 1.12 mm
presented advanced loss of support in the dentition (>50%), (range 1 to 6.50 mm) and a median of 3.50 mm.
24.33% (nine patients) with moderate loss (30% to 50%) and The correlation between KM and KT of the adjacent teeth
70.27% (26 patients) with mild attachment loss (<30%). The was statistically significant (P = 0.002; r = 0.55). In other
grade of attachment loss was neither associated with the width words, in scenarios characterized by a lack or narrow band
of the KT and/nor the KM (P = 0.22). of KM, the KT band of the adjacent teeth was significantly
 19433670, 2019, 5, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.18-0471 by Luiz Guilherme Fiorin - Universidade Estadual Paulista , Wiley Online Library on [23/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MONJE AND BLASI 449

TABLE 1 Descriptive analysis of the clinical and radiographic parameters according to the width of keratinized mucosa
Keratinized mucosa
<2 mm ≥2 mm Differential coefficient P value r (P value)
n 26 40
PD (mm) 4.86 ± 1.06 (5.00) 3.65 ± 1.06 (3.33) −1.21 ± 0.28 <0.001*** −0.57 (P < 0.001*** )
mBI 1.15 ± 0.69 (1.17) 0.46 ± 0.57 (0.17) −0.69 ± 0.17 <0.001*** −0.54 (P < 0.001*** )
SUP 0.08 ± 0.20 (0.00) 0.06 ± 0.18 (0.00) −0.02 ± 0.04 0.666 −0.11 (P = 0.463)
PI 1.08 ± 0.86 (1.00) 0.28 ± 0.41 (0.00) −0.79 ± 0.21 <0.001*** −0.60 (P < 0.001*** )
MBL (mm) 2.03 ± 1.65 (2.10) 0.64 ± 0.93 (0.20) −1.39 ± 0.41 0.001** −0.55 (P < 0.001*** )
VAS (%) 53.8 ± 30.7 (60.0) 97.0 ± 8.5 (100.0) 43.2 ± 6.49 <0.001*** 0.703 (P < 0.001*** )
VD <4 mm 95.7% 18.9% <0.001***
**
P < 0.01; ***
P < 0.001, in brackets: median value

FIGURE 2 Implant diagnosis according to the width of

keratinized mucosa
FIGURE 1 Clinical and radiographic parameters according to
the width of the band of keratinized mucosa (<2mm/≥2mm). Asterisks
represent the outliers
cal sites, those measuring ≥2 mm ranging from 60.6% to
61.5%. Again, significantly greater values were recorded for
narrower. When analyzed according to the location, it was PD, PI, and MBL at sites measuring <2 mm. In relation to
exhibited that the correlation was strongly associated by the mBI, although a positive trend was observed, statistical sig-
locations in the posterior maxilla (r = 0.56; P = 0.018), while nificance was not reached (P = 0.05). The statistical relation-
not in the posterior mandibular sites (r = 0.07; P = 0.71). ship became stronger at DB (disto-buccal) sites for all the
Namely, in the posterior mandible, the KM was significantly clinical and radiographic parameters (P < 0.001), except SUP
lower compared with adjacent KT sites, while in the poste- (P = 0.73).
rior maxilla, KM was significantly associated with the KT
of the adjacent teeth (median KT: 4.00 mm; median KM:
3.6 Association between KM and periodontal
3.67). However, in none of the cases was a lack of KM asso-
condition
ciated with a lack of KT of any of the adjacent teeth. This
underscore that the lack of KM constitutes a site-specific The periodontal condition was seen to be independent of KM
phenomenon. band width. However, mBI increased significantly in teeth
adjacent to peri-implantitis implants (P = 0.007).
3.5 Association of KM with implant site level
The KM was shown to be wider at the mesial (P = 0.01)
3.7 Association between peri-implant and
and distal line angles (P = 0.01) of the implants, and sig-
periodontal parameters
nificantly narrower at the medial sites. Nevertheless, on con- A positive correlation was found among PD, mBI, and PI in
sidering the median values, KM was equal at the three buc- the assessed implants and adjacent teeth (r = 0.5) (Table 2
 19433670, 2019, 5, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.18-0471 by Luiz Guilherme Fiorin - Universidade Estadual Paulista , Wiley Online Library on [23/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
450 MONJE AND BLASI

TABLE 2 Correlations between the clinical and radiographic parameters between implants and their adjacent dentition
Implants
PD mBI SUP PI MBL KM VAS
Dentition PD 0.32 (0.034* ) 0.10 (0.504) −0.10 (0.532) 0.21 (0.176) 0.19 (0.216) −0.23 (0.137) −0.26 (0.09)
mBI 0.47 (0.001** ) 0.42 (0.005** ) 0.11 (0.454) 0.38 (0.011* ) 0.25 (0.103) −0.25 (0.10) −0.16 (0.307)
SUP — — — — — — —
PI 0.39 (0.009** ) 0.37 (0.013* ) 0.16 (0.293) 0.43 (0.001** ) 0.20 (0.188) −0.10 (0.519) 0.09 (0.541)
KT −0.14 (0.367) 0.01 (0.927) −0.14 (0.358) 0.18 (0.242) −0.10 (0.520) 0.45 (0.002** ) 0.16 (0.283)
VAS (%) −0.03 (0.871) 0.15 (0.321) 0.02 (0.902) 0.05 (0.770) 0.13 (0.380) 0.20 (0.179) 0.40 (0.007** )
*
P < 0.05; **
P < 0.01

topography might play a role on biofilm development.41

Our own results partially concur with this, since in erratic
maintenance compliers, a KM band width of <2 mm was
significantly associated with more unfavorable peri-implant
conditions, discomfort while brushing, and a decrease in
VD – which in turn may decrease patient ability to correctly
implement personalized oral hygiene measures.
On the other hand, it has been shown that a lack of KM
is a site-specific condition. Nevertheless, it is remarkable that
there is a positive correlation between KM and KT of the adja-
cent teeth. In other words, when the KT band of the adjacent
teeth is narrow, it increases the probability of a narrow or inex-
istent KM on the buccal site of the implants. In any case, a lack
of KM always occurs in the presence of KT. Along these lines,
it is important to note that in scenarios characterized by a lack
of KM, mBI was found to be greater at sites adjacent to those
implants with peri-implantitis. Hence, it seems reasonable to
suggest that a lack of KM plays a limited role in relation to
FIGURE 3 Plots showing the associations corresponding to the adjacent periodontal condition.
periodontal and peri-implant parameters

4.2 Agreements and disagreements with

and Fig. 3). Nevertheless, this fact was inconsistent with the previous studies
presence (and width) or absence of KM or KT.
Our clinical findings support the view that KM around
dental implants in erratic maintenance compliers seems
necessary for maintaining peri-implant health, and are
4 DISCUSSI O N consistent with previously reported pre-clinical9,42 and clin-
ical observations.34–39 Moreover, recent data have evidenced
4.1 Principal findings the influence of the width of KM upon the peri-implant
There has been much debate on the potential impact of KM clinical parameters in relation to the onset and resolution of
upon peri-implant conditions. Based on previous clinical experimental peri-mucositis in humans.43 The data are not
trials, its influence in relation to peri-implant bone loss is fully consistent throughout the literature, however.8,10,44,45 It
equivocal.34–39 Nevertheless, it seems clear that scenarios has been speculated that these disagreements are partly due
characterized by a lack of insufficient band of KM are to the patient selection process involved. For instance, it must
more susceptible to increased signs of inflammation, includ- be noted that the patients enrolled in the aforementioned
ing erythema, bleeding on probing and tumefaction. The studies followed adequate professionally administered plaque
great disparity of the existing evidence is referred to one control measures within university settings. In comparison,
predominant aspect. Data found in the literature suggests our cohort of patients were treated and restored in private
no association between KM and peri-implant conditions practice and were erratic maintenance compliers. Hence,
in patients with adequate plaque control.40 Along these we partially concur with the findings indicating the absence
lines, it is worth mentioning that implant/restorative surface of a relationship between KM and peri-implant conditions,
 19433670, 2019, 5, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.18-0471 by Luiz Guilherme Fiorin - Universidade Estadual Paulista , Wiley Online Library on [23/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MONJE AND BLASI 451

FIGURE 4 Case showing the clinical poor oral hygiene (left) in an erratic maintenance complier, where in the presence of a wide band of
keratinized mucosa, marginal bone loss has not progressed to a pathological condition (right)

since under conditions of adequate supportive peri-implant KM. In this sense, it should be highlighted that future stud-
maintenance, the association might be negligible. ies should monitor the peri-implant clinical and radiographic
Likewise, there seems to be consensus on the brushing parameters in a longitudinal basis to assess the changes over
comfort conferred by ≥2 mm of KM.46 In the absence of time in the presence/lack of KM. Furthermore, it would be of
KM, there is a mobile lining mucosa rich in elastic fibers particular interest to evaluate the dynamics of the band of KM
and poor in collagen.47 This agrees with the findings of a according to the peri-implant condition. Moreover, it must be
recent cross-sectional comparative study in which implant noted that these findings are not applicable to good mainte-
sites with a KM band width of <2 mm were found to be nance compliers, where conflicting results have been reported
more prone to brushing discomfort, plaque accumulation regarding the significance of KM.
and peri-implant soft tissue inflammation.16 In contrast, two
recent studies failed to support the association between the
absence of KM and discomfort during brushing.33,48 This 5 CONC LU SI ON S
is certainly an area of controversy where the patient pain
threshold, brushing strength, mucosal thickness and other The presence of <2 mm of KM around dental implants in
anatomy-related factors may play important roles. erratic maintenance compliers seems to be associated with
The positive association between KM and VD is of key peri-implant diseases. The lack of KM constitutes a site-
importance, since it implies that a shallow VD could inter- specific phenomenon independent of the keratinized tissue
fere with proper oral hygiene techniques, thus leading to more present in the adjacent dentition.
plaque accumulation. This finding is in agreement with a pre-
vious clinical study reporting the association between VD and ACKNOW LEDGMENTS
a lack of KM, and also increased bone loss and mucosal reces- The authors wish to acknowledge the Foundation for the
sion around implants15 and natural dentition.49 Study and Development of Implantology and Oral and
Although a correlation was observed between KM and KT, Maxillofacial Surgery (Badajoz, Spain) for financial support
a complete absence of KM was not associated with a lack of of the statistical analysis. The authors have no direct financial
KT – thus defining the former as a site-specific condition. This interests with the products and instruments listed in the paper.
critical finding suggests that there is a remodeling of soft tis-
sues in the same way as there is a remodeling of hard tissues
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