Key opinion leaders ( that I heard over 4 days of soft tissue training by several of the big names in perio) all agree on the essential role adequate soft tissue plays for both teeth and implants). With Periodontally Assisted Orthodontics (PAO), researchers have studied jaw size changes over centuries and note that as we’ve evolved, our jaws have gotten smaller, and hence we have more recession than centuries ago. I see this on teeth all the time. I regularly see teeth with little to no buccal bone on a CBCT, because of this. Yes tooth brush abrasion contributes to this, yet thick tissue doesn’t recede. 78% of recession on teeth is progressive and leads to loss of keratinized tissue attachment. Without that 2-3mm of tissue height around teeth and adequate thickness along with the recession, the soft tissue doesn’t attach to the bone and problems develop: the bone is lost with the recession, root sensitivity, avoidance of through brushing because the thin tissue is tender, inflammation, and worst of all root decay.
All too often a connective tissue graft will stop the progress of this and a crownally advanced flap can cover the exposed root partially or completely. Stopping the recession around implants and teeth is essential to dental health. Around a tooth, I start to talk about treatment when the recession is 3mm.
After 37 years of implant surgery I’ve grown to also know that without 2-3mm of height of attached keratinized tissue around implants and tissue that is 2mm thick, that the bacteria have no trouble invading and resorbing the bone. You likely already know that the attached keratinized tissue around an implant gives tissue attachment to the bone which gives greater resistance to bacterial invasion and tissue thickness is essential since the implant has no PDL blood supply and the thickness help provide adequate vascularity. Without these the bacteria have no trouble invading and resorbing the bone. I’ve seen a lot of cases where the patient has pus on probing, yet a shallow PPD and associated bone loss. Always these cases don’t have the required tissue.
Watch for metal showing which is due to resorption associated with lack of bone volume, buccal implant placement and/or lack of adequate tissue. For me the real underlying problem is that just below that shiny metal is the rough implant. Attempting to grow soft tissue on that is much tougher than catching it early. Also watch for tissue that you can see the perio probe through the tissue. That tissue is too thin and it will resorb long term. The mandibular anterior is the most frequent site this occurs and sadly people that have a thin phenotype (biotype) often have generalized recession.
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