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Case Series
Dimensions of Peri-Implant Mucosa: An Evaluation
of Maxillary Anterior Single Implants in Humans
Joseph Y.K. Kan,* Kitichai Rungcharassaeng,* Kiyotaka Umezu,† and John C. Kois‡
Background: Attempts have been made to evaluate
the biologic dimension of osseointegrated implants; how-
ever, most are histologic studies in animals, and the
effect of soft tissue support from adjacent teeth on the
interproximal dimension of the peri-implant mucosa for
anterior single implants has not been addressed. This
study clinically evaluated the dimensions of the peri-
implant mucosa around 2-stage maxillary anterior sin-
gle implants in humans after 1 year of function. The
influence of the peri-implant biotype was also examined.
Methods: Forty-five patients (20 males and 25
females) with a mean age of 47.3 years were included
in this study. A total of 45 maxillary anterior single
implant crowns with a mean functional time of 32.5
months (range, 12 to 78) were evaluated. The dimen-
sions of peri-implant mucosa were measured by bone
sounding using a periodontal probe at the mesial (MI),
mid-facial (F), and distal (DI) aspects of the implant
restoration and the proximal aspects (MT, DT) of adja-
cent natural teeth. In addition, the peri-implant bio-
type was evaluated and categorized as thick or thin.
Statistical analysis was performed using an inde-
pendent t test (P <0.05).
Results: The means and standard deviations of
the dimensions of peri-implant mucosa at MT, MI, F,
DI, and DT were 4.20 ± 0.77 mm, 6.17 ± 1.27 mm,
3.63 ± 0.91 mm, 5.93 ± 1.21 mm, and 4.20 ± 0.64
mm, respectively. The dimensions of peri-implant
mucosa in the thick biotype were significantly greater
than the thin biotype at MT, MI, and DT (P <0.05).
Conclusions: The mean facial dimension of peri-
implant mucosa of 2-stage implants is slightly greater
than the average dimension of the dentogingival com-
plex. The level of the interproximal papilla of the
implant is independent of the proximal bone level
next to the implant, but is related to the interproximal
bone level next to the adjacent teeth. Greater peri-
implant mucosal dimensions were noted in the pres-
ence of a thick peri-implant biotype as compared to
a thin biotype. J Periodontol 2003;74:557-562.
* Center for Prosthodontics and Implant Dentistry, Loma Linda University
School of Dentistry, Loma Linda, CA.
† Advanced Education in Implant Dentistry, Loma Linda University School
of Dentistry.
‡ University of Washington, Seattle, WA; private practice, Tacoma, WA.
J Periodontol • April 2003
KEY WORDS
Alveolar bone; biologic width; dental esthetics;
dental implants; dental papilla; dentogingival
complex; peri-implant.
Gargiulo et al.1 histologically evaluated the dimen-
sions of the gingival sulcus, epithelial attachment, and
connective tissue attachment of natural teeth, now
collectively known as the dentogingival complex.2 The
dimension and stability of the dentogingival complex,
as well as the changes due to surgical and/or restora-
tive procedures, have been extensively investigated.1-
6 The average dimension of the dentogingival com-
plex at the facial aspect has been shown to be 3 mm,
while a dimension of 4.5 mm was observed at the
interproximal aspect of natural teeth.1-4 This dimen-
sional difference may be attributed to the presence
of adjacent teeth and the size of the gingival embra-
sure.7-10 If the adjacent tooth support is removed, the
interproximal dentogingival complex dimension (4.5
mm) can be expected to collapse to a dimension sim-
ilar to that of the unsupported facial dentogingival
complex (3 mm).11 An understanding of the den-
togingival complex and its variation allows clinicians
to predictably balance the physiologic requirement
and esthetic demand of restorations in natural teeth
in the esthetic zone.
Achieving optimal gingival esthetics around ante-
rior single implants is a challenging procedure,7,12
and maintaining it over time can be an equally
demanding task. Despite the high success rates
achieved with osseointegrated implants,13 the peri-
implant mucosal response is not clearly understood.
For anterior single implants, up to 16% of gingival
recession has been reported.13 On the other hand,
spontaneous rebound of the receded gingiva has also
been observed following a few years of function.14-16
The peri-implant mucosa changes had been postu-
lated as an attempt to establish a stable biological
dimension.17 Peri-implant mucosa, like its natural
teeth counterpart (the dentogingival complex), com-
prises similar histologic components (gingival sulcus
and epithelial and connective tissue attachments)18-20
557
2141_IPC_AAP_553043 4/3/03 11:37 AM Page 558
Case Series
and dimension (
3 mm).21-27 While the dimension
of each component may change over time, these
changes do not significantly affect the overall dimen-
sion.24,26 However, the effect of the adjacent tooth
support on the interproximal dimension of the peri-
implant mucosa has not been investigated.
It has been suggested that the periodontal biotype
(thick or thin gingiva)28,29 affects the dimension of
the periodontal tissue.10,30,31 A thick biotype is
resilient and therefore prone to pocket formation,
while a thin biotype is friable and thus often subject
to gingival recession following mechanical and/or
surgical manipulation.10,30,31 The question remains as
to whether or not the biotype of the peri-implant
mucosa would behave in a similar manner.
The purpose of this study was to clinically evaluate
the dimensions of the peri-implant mucosa of 2-stage
(submerged) maxillary anterior single implants in
humans with at least 1 year of function by bone sound-
ing using a periodontal probe. The influence of the
peri-implant biotype also was examined.
MATERIALS AND METHODS
This study was approved by the Institutional Review
Board of Loma Linda University. The patients were
informed of the study procedures and provided consent.
The procedures were conducted at the Center for
Prosthodontics and Implant Dentistry, Loma Linda Uni-
versity School of Dentistry, Loma Linda, California.
Study Population
From the computer database, a list of patients who
had received 2-stage single implants in the anterior
maxilla (#6 − 11) at the Center for Prosthodontics
and Implant Dentistry, Loma Linda University School
of Dentistry between January 1995 and June 2001
was compiled. The patients were selected according
to the following inclusion criteria: 1) presence of nat-
ural teeth adjacent to the implant, with definite prox-
imal contacts; 2) the implant was placed as a 2-stage
procedure in an edentulous site; 3) the implant must
have been in function for at least 1 year; 4) in the
patient with more than one implant single crown, only
the lowest numbered implant was included in the
study (e.g., implant #6 would be selected over implant
#11); 5) at the time of clinical evaluation, the implant
had to be considered successful;32 and 6) there was
no evidence of complications that had or would have
required any exploratory and/or corrective surgical
procedures throughout the implant’s functional period.
Clinical Evaluation and Data Collection
Peri-implant mucosa dimension. After local anes-
thetic administration (2% polocaine with 1:20,000 lev-
558 Mucosa Around Anterior Implants. A Case Series
Figure 1.
Bone-sounding sites: mesial (MI), mid-facial (F), and distal (DI) aspects
of the implant restoration, and the proximal aspects (MT and DT) of
the adjacent teeth.
onordefrin)§ to the examination site, the dimensions
of peri-implant mucosa were measured by bone
sounding using a periodontal probe
at 5 sites: the
mesial (MI), mid-facial (F), and distal (DI) aspects of
the implant restoration, and the proximal aspects (MT
and DT) of the adjacent teeth (Fig. 1). The distance
from the crest of the bone to the free gingival margin
(facial aspect) or tip of the interproximal papilla (prox-
imal aspects) was recorded to the closest 0.5 mm (Fig.
1). All measurements were made by one examiner.
Peri-implant biotype. The peri-implant biotype of
each studied implant was evaluated and categorized
into a thick or thin group.28,29 To evaluate the bio-
type, a periodontal probe was placed into the facial
aspect of the peri-implant mucosa. The peri-implant
biotype was categorized as thin if the outline of the
underlying periodontal probe could be seen through
the gingiva, and thick if the probe could not be seen.
Statistical Analysis
The bone-sounding measurements at each site were
recorded and the means, standard deviations, and
frequency were calculated. The bone-sounding depths
for thick and thin peri-implant biotypes were com-
pared using the independent t test.¶ Statistical sig-
nificance was denoted when P <0.05.
RESULTS
A total of 45 single implant crowns in 45 patients (20
males and 25 females) with a mean age of 47.3 years
§ AstraZeneca LP, Wilmington, DE.

University of North Carolina color probe, Hu-Friedy, Chicago, IL.
¶ SPSS Version 10 software, SPSS Inc., Chicago, IL.
Volume 74 • Number 4
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Case Series
(range, 20 to 82) were included in this study. The
mean implant functional time was 32.5 months (range,
12 to 78). Twenty-five central incisors, 13 lateral
incisors, and 7 canine single-implant crowns were eval-
uated. The peri-implant biotype of 28 implants was
categorized as thick, and that of 17 implants as thin.
The means and standard deviations of the bone-
sounding measurements at MT, MI, F, DI, and DT
were 4.20 ± 0.77 mm, 6.17 ± 1.27 mm, 3.63 ± 0.91
mm, 5.93 ± 1.21 mm, and 4.20 ± 0.64 mm, respec-
tively (Fig. 2).
Figures 3 through 7 depict the frequencies of vari-
ous bone-sounding measurements at the evaluated
sites. A range of the most frequently recorded bone- Figure 3.
sounding measurements at these sites was also cal- Frequency of bone-sounding depths at proximal aspect of tooth
culated. Seventy-one percent (32/45) and 69% (31/45) mesial to the implant (MT).
of the bone-sounding measurements were between 4.0
to 4.5 mm at MT and DT, respectively (Figs. 3 and 7).
At F, 71% (32/45) of the bone-sounding measurements
were between 3.0 to 4.0 mm (Fig. 5). Bone-sounding
measurements between 5.0 to 7.0 mm constituted 71%
(32/45) and 75% (34/45) of the measurements at MI
and DI, respectively (Figs. 4 and 6).
The bone-sounding measurements of the thick bio-
type group were significantly greater than those of
the thin biotype group at MT, MI, and DT (P <0.05).
No significant differences were found at F or DI (Table
1 and Fig. 8)

DISCUSSION
In this bone-sounding study, the mean facial dimen-
sion (3.63 mm) of the peri-implant mucosa for
2-stage implants is slightly greater than the corre- Figure 4.
Frequency of bone-sounding depths at mesial aspect of implant (MI).

Figure 2.
Mean bone-sounding depth (mm ± SD) at each evaluated site of Figure 5.
maxillary anterior single implants. Frequency of bone-sounding depths at mid-facial aspect of implant (F).

J Periodontol • April 2003 Kan, Rungcharassaeng, Umezu, Kois 559

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Case Series
Table 1.
Bone-Sounding Measurements of Anterior
Implant Single Crowns Comparing Thick
and Thin Biotypes

Bone-Sounding Depth (mean ± SD, mm)

Site Thick Biotype (n = 28) Thin Biotype (n = 17) P Value

MT 4.46 ± 0.78 3.76 ± 0.53 0.002*

MI 6.54 ± 1.05 5.56 ± 1.40 0.011*

F 3.79 ± 0.89 3.38 ± 0.91 0.150

Figure 6. DI 6.14 ± 1.11 5.59 ± 1.31 0.137
Frequency of bone-sounding depths at distal aspect of implant (DI).
DT 4.45 ± 0.57 3.79 ± 0.56 0.001*
* Statistically significant (P <0.05).

Figure 7.
Frequency of bone-sounding depths at proximal aspect of tooth
distal to the implant (DT).
sponding histologic dimensions of the dentogingival
complex reported by Gargiulo et al.1 (2.73 mm) and
Vacek et al.3 (3.25 mm), but is comparable to the
histometric dimensions reported by others for 2-stage
(3.11 to 3.80 mm) and 1-stage implants (2.84 to
3.57 mm).21-26 Variations in facial dentogingival com-
plex dimensions have been observed and classified as
normal (3 mm), high (<3 mm), or low (>3 mm)
crest.2,33 Likewise, dimensional variations (2 to 6 mm)
in the facial aspect of peri-implant mucosa have been
noted in this study (Fig. 5). Nevertheless, unlike nat-
ural teeth, the most frequently observed facial dimen-
sion of peri-implant mucosa was between 3 to 4 mm
(normal crest, 71%) (Fig 5). Less than 3 mm of peri-
implant mucosa dimension (high crest, 9%) was
uncommon, and can be related to either thin biotype,
implants that were placed too labially, and/or an over-
Figure 8.
Comparison of bone-sounding depths (mean with 95% confidence
interval) between thick and thin biotypes using an independent t
test (P <0.05).
contoured facial prosthetic emergence. On the other
hand, a total dimension of >4 mm (low crest, 20%)
was usually associated with thick biotype.
The mean dentogingival complex dimensions at
MT and DT were both 4.20 mm, with the most
frequently observed measurements between 4 to
4.5 mm (normal crest, 71% and 69%, respectively)
(Figs. 3 and 7). These results are similar to the data
reported by van der Velden, in which a mean dis-
tance of 4.33 mm between the location of the gingi-
val margin and the bone level was observed 3 years
after denudation of the interdental alveolar bone.34
On the other hand, the mean MT and DT dimensions
(4.20 mm) are only slightly less than the reported
interproximal bone-sounding measurements of non-

560 Mucosa Around Anterior Implants. A Case Series Volume 74 • Number 4

2141_IPC_AAP_553043 4/3/03 11:37 AM Page 561
surgically involved human teeth (4.5 to 5 mm).2,4
These findings concur with clinical observations where
the interproximal papilla of 2-stage anterior single
implants is often slightly more apically located than
the papilla at corresponding sites on the contralateral
tooth.35 While minor recession of the interproximal
papilla can be expected following a 2-stage implant
surgery, the presence of considerably stable dimen-
sions at MT and DT indicates that, for an anterior
single implant, the implant papilla level is dependent
on the bone level of the adjacent natural tooth.
The overall mean peri-implant mucosa dimensions
at MI and DI were 6.17 mm and 5.93 mm, with the
most frequently recorded measurements between 5 to
7 mm (71% and 75%, respectively) (Figs. 4 and 6).
These measurements are similar to the data reported
by Garber et al., in which a mean vertical soft tissue
depth of 6.5 mm was measured interproximally imme-
diately adjacent to the implant.36 These measure-
ments (
6 mm), although substantially greater than
the facial measurements (3.63 mm), are not unex-
pected. In maxillary anterior teeth, the osseous archi-
tecture follows the cemento-enamel junction, result-
ing in an osseous scallop that is more apical at the
facial and lingual aspects and more coronal at the
interproximal aspect of the tooth.10,11,31,37,38 On the
other hand, in an anterior single implant with adjacent
teeth, the osseous architecture can only mimic the
topography of the implant platform, which is flat. The
loss of osseous scallop at the interproximal aspect of
the implant in conjunction with the existence of the
gingival scallop maintained by the bone support of
the adjacent teeth, results in pseudo-pockets at MI
and DI. This explains the wide range of MI and DI
dimensions (3 to 9 mm) when compared to other
sites (Figs. 3 through 7). Evidently, for anterior sin-
gle implants with adjacent natural teeth, the implant
papilla is independent of the bone levels at the inter-
proximal surfaces of the implant.
Studies have demonstrated that a thick mucosa has
a significantly greater periodontal probing depth than
its thin counterpart.39,40 Likewise, the dimensions of
peri-implant mucosa can also be influenced by the gin-
gival thickness.17,41,42 The greater peri-implant mucosa
dimensions of the thick biotype observed at all sites in
this study (Table 1 and Fig. 8) seem to substantiate this
assumption. Furthermore, while the bone-sounding
measurements at MT and DT (
4.5 mm) in subjects
with the thick biotype is comparable to the normal
interproximal dentogingival dimension (4.5 mm),2 it is
significantly greater than in subjects with the thin bio-
type (
3.8 mm; P <0.05). Following tooth removal,
J Periodontol • April 2003
Case Series
the interproximal papilla usually collapses due to the
loss of tooth support,7-10 and the degree of collapse
depends on the thickness of the mucosa.9 Under such
circumstances, the papilla may be restored with an
implant-tooth replacement to varying degrees depend-
ing on the peri-implant biotype. While the implant
papilla may be maintained at or reestablished to the
normal level (4.5 mm from the underlying bone) with
the thick biotype, it can seldom be recreated beyond
4 mm with the thin biotype (Table 1 and Fig. 8).
CONCLUSIONS
Within the confines of this study, the following con-
clusions can be drawn:
1. The mean facial dimension of peri-implant mucosa
of a 2-stage implant is slightly greater than the
average dentogingival complex dimension.
2. The level of the interproximal papilla of the implant
is independent of the proximal bone level next to
the implant, but is related to the interproximal bone
level next to the adjacent teeth.
3. At all evaluated sites, greater peri-implant
mucosal dimensions were noted in the presence
of the thick peri-implant biotype as compared to
the thin biotype.
ACKNOWLEDGMENTS
The authors thank Nobel Biocare, Inc., Yorba Linda,
California for partially funding this research; Mr. Shin-
ishiro Maruo for statistical analysis; Dr. Veerachai
Thumwanit for his assistance; and Dr. William Becker
and Dr. Yoon Jeong Kim for editing the manuscript.
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Correspondence: Dr. Joseph Kan, Center for Prosthodon-
tics and Implant Dentistry, Loma Linda University School
of Dentistry, Loma Linda, CA 92354. Fax: 909/558-4803;
e-mail: jkan@sd.llu.edu.
Accepted for publication September 30, 2002.
Volume 74 • Number 4