What is attached (keratinised) gum around an implant?
Attached gum is the firm, pale pink tissue that is bound to the bone directly around a tooth or implant; the technical term is keratinised mucosa. Below it begins the darker, mobile and thinner lining of the mouth. The plain-language summary of the Cochrane review calls it “firm gum”.
According to the consensus report of the 2017 World Workshop, defects of bone and soft tissue can arise after tooth loss, which is why the attached gum around some implants is wide and around others very narrow or absent. Cleveland Clinic adds that some people are genetically prone to thin gums. The International Team for Implantology (ITI) counted the width of attached gum on the lip side among the measures of soft tissue around an implant in 2003, and the 2023 S3 guideline of the European Federation of Periodontology (EFP) recommends recording it at every check-up.
Does little attached gum harm the implant?
The evidence is mixed: little attached gum goes with more plaque and more gum recession, but its influence on the long-term health of the implant is not proven. The systematic review by Lin and colleagues (2013, eleven studies) compared implants with wide (mostly 2 millimetres or more) and narrow attached gum:
| Measure | At implants with wide attached gum |
|---|---|
| Plaque accumulation | Significantly less |
| Gum inflammation | Significantly less on one index |
| Gum recession | On average 0.6 mm less |
| Attachment loss | On average 0.35 mm less |
| Bleeding on probing | No significant difference |
| Bone loss | No significant difference |
The authors stress that most studies were cross-sectional with a high risk of bias. The 2017 World Workshop consensus report (Berglundh and colleagues, 2018) rates the evidence on long-term benefit as inconclusive but sees possible advantages for comfort and cleaning. The 2023 EFP guideline lists a lack of attached gum among possible risk factors whose role still needs research. The other risk factors for inflammation around implants are explained in our guide peri-implantitis.
Is a graft always needed when there is little attached gum?
No. Lin and colleagues call for the benefit of widening to be shown first in intervention studies, and the 2012 Cochrane review found no study on whether increasing firm gum improves long-term outcomes. The decision therefore depends less on the measurement than on your situation. The following are usually assessed:
- pain or discomfort when brushing at the implant
- whether plaque can be removed regularly and whether inflammation keeps returning
- gum recession or a visible implant surface
- whether the site shows when you smile
- the type of teeth on the implant and how easy they are to clean
With cleaning problems it is also worth looking at your brush and interdental brushes; see our guide caring for teeth on implants.
Free gingival graft or connective tissue graft: what is the difference?
Both techniques usually use tissue from the palate, but they have different aims and leave different wounds:
| Feature | Free gingival graft | Connective tissue graft |
|---|---|---|
| Main aim | Widen the attached gum | Thicken the gum, gain volume and aesthetics |
| Harvest from the palate | Thin piece of tissue including the surface | Tissue from beneath the surface; the top layer stays |
| Palate wound | Left open, heals on its own | Usually stitched |
According to the Erciyes University consent form, a free gingival graft uses tissue about 1 to 1.5 millimetres thick from the palate; the key difference from the connective tissue graft is that the donor site is stitched in the latter. Cleveland Clinic describes a small wedge taken from inside the palate, with the outer layer preserved, and the palate site closed. In a small ten-patient study from the Cochrane review, palate grafts improved the thickness and appearance of the gum around implants. How important gum thickness is in the visible area is explained in our guide dental implants for front teeth.
How is a gum graft done?
According to the consent forms of Erciyes University and Kahramanmaraş Sütçü İmam University, the procedure usually runs like this:
- The recipient site at the implant and the donor site on the palate are numbed with local anaesthetic.
- The bed for the graft is prepared at the implant.
- Tissue of the right size is taken from the palate or a toothless area.
- The graft is placed and stitched.
- If needed, both sites are covered with a protective dressing; a soft protective plate can be made for the palate.
The Kahramanmaraş Sütçü İmam University form gives 60 to 90 minutes as the duration; Cleveland Clinic says a single graft usually takes about an hour. According to the Erciyes University form, the stitches on the palate are usually removed after a week and those at the graft, on the dentist’s advice, on day 10 to 14.
How does the palate heal after harvesting?
The palate usually heals on its own within a few weeks, but in the first days it is often more uncomfortable than the recipient site. According to the Kahramanmaraş Sütçü İmam University form, the donor site heals within a month; a soft palate plate is worn for the first ten days to give comfort, prevent bleeding and protect the wound. The Erciyes University form gives at least 4 to 6 weeks for complete healing and notes that the unstitched palate wound can heal slowly and be painful.
Possible complications listed in the forms are infection, bleeding, swelling, pain, herpes-like blisters on the palate, irritation at the corners of the mouth, colour differences and failure of the graft to take. Cleveland Clinic says complications are uncommon but can happen, and in one study from the Cochrane review, noticeable pain was reported after procedures to widen the attached gum.
What does this have to do with gum recession at an implant?
Missing attached gum is one of several factors in gum recession at an implant, not the only one. The 2017 World Workshop consensus report names as main causes an unfavourable implant position, missing bone on the lip side, thin gum, missing attached gum, the condition of the neighbouring teeth and surgical trauma. Recession can also be part of inflammation around the implant, so the cause is sought first.
In the visible area, recession that has already occurred is hard to correct. According to the 2013 ITI consensus statement, soft tissue augmentation in this situation brings only limited improvement, and the results vary widely. That is why gum thickness and width are worth considering at the planning stage.
What should you bear in mind after a gum graft?
- Take prescribed medicines and follow the oral hygiene instructions.
- Leave the graft, dressing and palate plate alone until you are cleared; do not brush the graft.
- According to the Erciyes University form, do not smoke for 3 to 4 weeks; smoking raises the risk of failure.
- Report anything unusual; Cleveland Clinic advises contacting the surgeon for heavy bleeding, pus or fever. From home you can send us photos on WhatsApp, and for acute symptoms a dentist near you is the first port of call.
- Keep your appointments for stitch removal and check-ups, whether before your flight or with your dentist at home.
How do we assess the gum around an implant at Rönesans?
At the examination at our clinic in Serdivan, the gum around the implant or the planned implant site is assessed; the bone beneath it is shown by the cone-beam CT (CBCT) scan. We carry out bone grafting and sinus lifts at the clinic. Whether a gum graft is necessary and sensible in your case, and during which stay it could take place, is assessed at the examination.
Our dentists discuss your case together, and one dentist accompanies you throughout. Before treatment starts you receive a written treatment and cost plan with the procedures for each tooth. After implant treatment, check-ups are planned; if you notice pain, bleeding or gum recession at the implant when brushing, send us a photo on WhatsApp at +90 532 363 49 54. How care continues after you return is described on our aftercare and follow-up page.