No keratinized tissue placed supracrestal and buccal

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Posted on By Alexander Rubinov In Periodontics

A new patient presents saying his gums always bleed around an implant placed 5 yrs ago, what can be done.
MIS MF4 4.2x16mm
#4 implant has no keratinized tissue on the buccal, angulation of implant is towards the buccal cusp. overhang on existing implant crown
I removed the implant crown and prepped the adjacent tooth.
I placed a cover screw over the implant to allow for keratinized tissue to form.

What is the best treatment modality for this case? Let tissue grow over implant, perform a buccal roll or apically repositioned flap with new keratinized tissue that fills in? As well, what is the timeframe for healing with your suggestions please?

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Hi Alex. Welcome to the forum. It's not surprising the patient exhibited persistent bleeding around #4 implant given, as you stated, no keratinized tissue and overhang of the crown. In addition, open margins on #5 certainly did not help.
My suggestions: one surgery that includes...
a) Crown lengthening #5, as depicted in attached x-ray, to re-establish a ferrule and a more cleanable environment.
b) At the same time, I would include a sub-connective tissue graft on the labial to thicken tissue and re-establish attached keratinized tissue around #4 implant.
Keep us posted... good luck

Depiction of required crown lengthening


Alex; I agree with Henry. you can also do this with 2 small separate procedures rather than all at once. 1st stage crown lengthening on natural tooth. 2nd surgery after temp with FGG. In this case, all the roads lead to success.
good luck Dr. Maurice Salama


I agree . . the patient needs tooth structure on #5 and thick tissue over buccal of #4 - I would definitely add either form of soft tissue graft and not depend solely on the tissue growing in over the implant
Time frame is 3 months after last surgery. . .
Also welcome to the Forum and please do post your follow up results as this is a problem we all so often encounter following implant surgeries


Drs Salama and Dr. Garber, thank you for welcoming me to the DentalXP Forum.

This is great advice I will certainly proceed with your recommendations and timeframe.

Dr. Maurice Salama, in your hands-on course I learned to do subconnective tissue suturing on dentate area, how do I apply that technique to an edentulous areas?
Do you have a video on XP?

Many thanks,


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