Dealing with complications
How to prevent recessions around implants
Treatment goals should be viewed in the long-term
Our main treatment goal should be long-term aesthetic and functional success. This is closely associated with peri-implant stability of hard and soft tissues. Therefore, as well as having osseointegration as our basic objective, soft tissue integration is another pre-requisite for implant stability.
The supracrestal soft tissue – the so-called ‘biological width’ – may change with peri-implant bone remodelling.
Tissue structure around teeth and implants is different
Peri-implant tissue structure is the underlying cause for the high rate of recessions around implants. The connective tissue around an implant is more like scar tissue, with fewer fibroblasts and more collagen fibres than normal tissue. These collagen fibres are oriented parallel to the implant surface. Vascularisation of peri-implant tissues is lower than that of the periodontium. Hence, the healing and regenerative capacity of soft tissue around implants is lower than that of natural teeth; the occurrence and treatment of recessions should therefore be considered with this difference in mind.
But the main cause of recessions around implants is the dentist, as they can be at fault in the following ways:
- incorrect implant placement (too buccal)
- inadequate treatment of vestibular bone deficiencies
- discrepancy between size of implant and bony envelope
- inappropriate distance between implant(s) and teeth
- thin mucosa
- mucositis and/or peri-implantitis
The thickness of the mucosa translates to peri-implant bone loss
A mucosa thickness of 2mm is considered the parameter for predicting peri-implant bone loss. It has been shown that after one year, significantly more bone was lost in thin phenotypes (< 2mm) than thicker types (Puisys et al., 2015). Therefore, to augment mucosal thickness in cases involving thin phenotypes, reinforcing the biological seal and facilitating plaque control is recommended. The speaker uses a modified coronally advanced tunnel technique combined with a connective tissue graft to rebuild the contour of thin-tissue recessions. This surgical approach should be combined with the appropriate prosthetic procedure (Jurczyck et al., 2017) (figs 1–4).
A recent systematic review concluded that, despite the limited evidence, a lack of attached keratinised mucosa around implants makes them more prone to plaque accumulation, inflammation and recessions (Iorio-Siciliano et al., 2020).
To prevent recessions, we should consider whether the following are present:
- correct 3D implant positioning
- sufficient vestibular bone
- appropriate implant diameter in relation to the bony envelope
- adequate distance between implant(s) and teeth
- sufficient levels of attached mucosa and mucosal thickness
- infection control to prevent mucositis/peri-implantitis