Journal of Dental and Oral Health

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Zone of Keratinized Tissue Around Implants Really Matters??

Vishal Sahayata

Correspondence Address :

Vishal Sahayata, B.D.S,M.D.S
Senior lecturer at Department of Periodontology and Oral Implantology
Faculty of Dental Science, Dharmsinh Desai University
Email: drvishalsahayata@yahoo.co.in

Received on: March 22, 2017, Accepted on: March 30, 2017, Published on: April 04, 2017

Citation: Vishal Sahayata (2017). Zone of Keratinized Tissue Around Implants Really Matters??

Copyright: 2017 Vishal Sahayata. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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The keratinized gingiva is tightly adhering to the connective tissue and bone via deep rete pegs and thought to be necessary for gingival health and prevention of periodontal disease progression. As stated by Lang and Loe, the minimum width for healthy keratinized tissue surrounding the teeth is 2mm [1]. This concept has been carried over to peri-implant keratinized tissue. The narrow zone of attached gingiva is associated with higher chance of gingival inflammation. 
However, several studies have challenged this concept as it pertains to teeth and also implants, and have stated that a minimum width of keratinized gingiva is not required provided adequate oral hygiene is maintained. Cox and Zarb in 1987 conducted a study in which they found that 80% of the implants evaluated had no keratinized gingiva but had healthy peri-implant tissue [2]. 
There is a great deal of controversy in the literature about the importance of keratinized gingiva around dental implants and the amount, if any, which is required for implant health. Some studies concluded that peri-implant health could be maintained even in the absence of keratinized gingiva providing adequate oral hygiene is employed [2,3]. Wennstrom 2012 and Esper 2012 shown in his study that no major difference in the clinical parameters like plaque control, gingivitis, bleeding on probing and probing depth between adequate and inadequate width of masticatory gingiva [4,5]. 
The absence of keratinized gingiva around dental implants does not necessarily cause peri-implant disease, but maintaining meticulous oral hygiene in areas of minimal keratinized gingiva is difficult because mobile mucosa is more susceptible to inflammatory changes. 
Greenstein, in a literature review, stated that a narrow zone of keratinized gingiva, less than 2 mm, was associated with increased inflammation, decreased tissue resistance to plaque accumulation, and recession of the gingiva, ultimately resulting in tissue destruction [6]. These findings are also supported by Chung 2006 in other similar study [3].
Warrer, et al. 1995 stated that the absence of keratinized gingiva around dental implants increase the susceptiblily of the peri-implant region to plaque induced tissue destruction [7]. As stated by Bouri in 2008 in the presence of an inflammatory response, implants placed in areas with narrow zones of keratinized gingiva have an increased susceptibility to tissue breakdown, showed earlier loss of attachment and are less resistant to insult along the implant-mucosa interface [8]. 
So the healthy keratinized gingiva around dental implants may offer more resistance to the forces of mastication and frictional contact that occurs during 
oral hygiene procedures results in more predictable success and maintenance of the implant, and also results in an improved aesthetic outcome. Keratinized gingiva 
provides stabilization to the periodontium, protects the teeth and implants from masticatory and external trauma, and provides a barrier to inflammatory infiltrate [9]. Reconstruction of the keratinized gingiva in deficient areas using techniques such as the free gingival graft, apically displaced flap or the subepithelial connective tissue graft should be employed prior or after implant placement.
Concluding attached gingiva is not the ultimate requirement for peri-implant health but as the consequences of inflammatory changes around dental implants are detrimental and sometimes not reversible, it is undoubtedly helpful.

1. Lang NP, Loe H. The relationship between the width of keratinized gingiva and gingival health. J Periodontol. 1972;43(10):623-627.
2. Cox JF, Zarb GA. The longitudinal clinical efficacy of osseointegrated dental implants: a 3-year report. Int J Oral Maxillofac Implants. 1987;2(2):91-100.
3. Chung D, Oh T, Shotwell J, Misch C, Wang HL. Significance of keratinized mucosa in maintenance of dental implants with different surfaces. J Periodontol. 2006;77(8):1410-1420.
4. Wennstrom JL, Derks J. Is there a need for keratinized mucosa around implants to maintain health and tissue stability? Clin Oral Implants Res. 2012;23(Suppl 6):136-146. 
5. Esper LA, Ferreira SB Jr, Kaizer Rde O, de Almeida AL. The role of keratinized mucosa in peri-implant health. Cleft Palate Craniofac J. 2012;49(2):167-170.
6. Greenstein G, Cavallaro J. The clinical significance of keratinized gingiva around dental implants. Compend Contin Educ Dent. 2011;32(8):24-31.
7. Warrer K, Buser D, Lang NP, Karring T. Plaque-induced peri-implantitis in the presence or absence of keratinized mucosa. An experimental study in monkeys. Clin Oral Implants Res. 1995;6(3):131-138.
8. Bouri A Jr, Bissada N, Al-Zahrani MS, Faddoul F, Nouneh I. Width of keratinized gingiva and the health status of the supporting tissues around dental implants. Int J Oral Maxillofacial Implants. 2008;23(2):323-326.
9. Paiva RBM, Mendonca JAG, Zenobio EG. Peri-implant tissues health and its association to the gingival phenotype. Dental Press Implantol. 2012;6(4):104-113.

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