Multiple Recession defects around teeth & Implants

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Posted on By Maurice Salama In Soft Tissue Enhancement

A patient presents after implants were restored in 2009 post extraction. Very typical recession and resorption pattern of labial bone and contours. Additionally, teeth in the same mouth display a propensity to recession, abfraction, erosion and and lack of KT as well as a black triangle formation in the anterior area.
What are your initial thoughts on diagnosis? What treatment options would you propose for implant sites, teeth and missing papilla?
Thanks Dr. Salama

Mandibular right with Implant in molar site
PA of mandibular implant area

Maxillary left with implant in 2nd premolar area
PA of maxillary left implant site

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Thoughts on each site and should be a good educational discussion. I look forward to hearing different ideas and approaches from our community. regards Dr. Salama


2009 tells a different story..."Dual zone Approach"

2009 Implant placement Dual Zone
2009 Immediate Provisional after healing


How thick was a buccal bone? The flap was elevated - do you think that resorption would be less mid- and long-term with a flap less approach?


Snjezana; that is my point....this case started downhill trajectory at 6-7 yrs. We see continued resorption many years later. regards Maurice


Soft block on the 4Q. Soft block on the 2Q if the bicuspid doesn't show on the smile line. 3Q wedge palatal graft. Front upper teeth modified VISTA or wedge palatal graft or free ctg & coronal advancement.


Nice thinking....I am sending to Portugal. regards Mo


Here is what I would do for the sites (I would also look to thicken the gingiva on adjacent teeth):

Mandibular right implant: FGG (also for the second premolar). Often I place CTG like FGG - it causes less donor site morbidity. May be later CAF or VISTA and CTG.
2nd premolar: CTG in VISTA approach
Mandibular left teeth: CTG in Tunnel or VISTA , also Zucchelli
Maxillary anterior: CTG in VISTA , composite restauration on the right lateral incisor to mask a missing papilla

I am sure that you are going to do occlusion control and adjustment, ev. ortho? At least a night guard, OH and diet instructions...

Thank you for sharing...looking forward to discussion!
Best regards


Nice thinking, solid. Dr. S


This is an eye opener case. Unfortunately 10years+ follow ups are the ones saying the true story with implants. On the other hand teeth are not doing that much greater either. We cannot win the battle against jaw changes with aging, especially in female dolicephalic patients.

I would stage the case and go for CTG on implant sites and alloderm for tissue thickening on the natural teeth (due to limitations on amount of CTG that can be harvested and utilised).

All of the above after radiographic and occlusal evaluation.


Well stated my friend. regards


No one talks about diagnosis...
What is the reason for the thinning of the buccal bone, recessions and buccal bone loss around implants?
Besides the parafunction, there is something else.
BTW, Do some people still place implants at the crest?


Andon could you please elaborate more and help us identify what we are missing?
On crestal, spracrestal or subcrestal placement issue, I believe the choice depends on the connection and surface of the collar of the implant you use. Zimmer implants that have been used in this case and still continue to be widely used require crestal (full treated surface) or supracrestal (smooth collar) placement. These implants have been around for decades with excellent results documented long term. Am I missing something?
I would really appreciate your input.


Yes, I am interested as well. Dr. Salama


KLS Martin