REVIEW ARTICLE

Implanto-gingival complex: An indispensable junctional

complex for the clinical success of an implant
Inderpreet S Narula, Krishna K Chaubey, Vipin K Arora, Rajesh K Thakur, Zeba Jafri

ABSTRACT

Meticulous assessment of gingival and periodontal status around a future implant site is must for
optimizing healthy esthetic gingival appearance and to establish a functionally successful implant-
supported restoration. A successful osseointegrated implant requires a direct bone-to-implant interface
to provide long-term support for a prosthesis. However a cause–effect relationship between bacterial
plaque accumulation and the development of inflammatory changes in the soft tissues surrounding
oral implants has been shown and known to exist. Thus maintaining a healthy peri-implant status
becomes an integral component for the success of implant-supported restorations.

KEY WORDS: Biologic-width, interfacial micro-gap, osseointegration, osteopreservation, peri-implantitis

INTRODUCTION which may compromise its future and ultimately lead

Meticulous assessment of gingival and periodontal status
around a future implant site is must for optimizing
healthy esthetic gingival appearance and to establish a
functionally successful implant-supported restoration.
It entails to achieve psychologically, esthetically, and
functionally successful implant supported restoration.
Early osseointegration research concentrated on the
adaptation of bone to the alloplastic implant surface
and on the clinical survival of implants. A successful
osseointegrated implant requires a direct bone-to-
implant interface to provide long-term support for
a prosthesis. A cause–effect relationship between
bacterial plaque accumulation and the development of
inflammatory changes in the soft tissues surrounding
oral implants has been shown.[1] If this condition is left
untreated, it may lead to the progressive destruction
of the tissues supporting an implant (peri-implantitis),
Department of Periodontics, Kothiwal Dental College Research
Centre, Kanth Road, Moradabad, Uttar Pradesh, India
Address for correspondence: Dr. Inderpreet Singh Narula,
Senior Lecturer, Kothiwal Dental College Research Centre, Mora Mustaqueem,
Moradabad, Uttar Pradesh, India. E-mail: dr.ipsnarula@gmail.com
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to its failure.[2]
Peri-implant soft tissues: The keratinized tissue and
its significance
Relationship has been studied several times between
periodontal health and width of attached gingiva. As
stressed and concluded by Lang and Loe,[3] 2 mm of
keratinized gingival with 1 mm of attached gingival
was sufficient to preserve periodontal health. On the
contrary, Berglundh et al.[4] concluded that gingival
health could be maintained in the absence of keratinized
tissue, provided patient maintained proper home care or
if the keratinized gingiva was augmented by soft tissue
grafting around teeth or dental implants. However it
has been found that regardless of plaque control, width
of keratinized tissue either around teeth or implant
does not influence periodontal or peri-implant or peri-
implant health.[5]
Few studies have evaluated soft tissue around dental
implants. Presence of keratinizing mucosa surrounding
an implant is thought to be a positive factor in
maintaining soft-tissue health.[6-9]
However, at present evidence-based format has failed
to show any correlation between the reduced width of
keratinized gingiva and peri-implant health.

DOI: The connective tissue and epithelium may actually

10.4103/0974-6781.102225 integrate with the titanium surfaces of dental implants,
suggesting that the health and resistance to peri-

110 Journal of Dental Implants | Jul - Dec 2012 | Vol 2 | Issue 2

 Narula, et al.: Implanto-gingival complex
implant disease states may be a reflection of the overall
integration process contributing to the functional and
esthetic success of implant.[10-13]
CHEMISTRY OF BONE-IMPLANT INTERFACIAL
HEALING
The integrating and investing peri-implant tissues
during implant healing includes cortical and cancellous
bone, marrow collagenous tissue and the neurovascular
structures, as observed at the healing interface at
microscopic level.[14]
Alveolar bone housing around a natural teeth serves
to provide tooth integrity and transmit the stress
of occlusal forces to absorbed by force-dissipating
periodontal ligament and surrounding bone. New
bone and collagenous investing tissues are laid down
to become part of the healed tissue around the implant.
The biomechanical stress pattern at the bone-implant
interface determines the amount and distribution of
collagenous connective tissue during healing and under
subsequent loading of implant superstructures. One stage
hypofunctional healing with controlled micromovement
is believed to promote the controlled deposition of a
collagenous, osteogenic peri-implant ligament, and the
osteopreservation mode of tissue integration.[15,16]
The surface oxide thickness has been found to increase
much faster at the implant position in bone than in air.[17]
The mechanism involved may include metal atom/
ion diffusion out of the oxide surface followed by
oxidation or oxygen diffusion from an oxygen carrying
species at the oxide surface to the metal oxide interface.
Other components that can contribute to the growth
and modification of the oxide include hydrogen atoms
(forming hydroxide) mineral ions of calcium and
phosphorus.
When in contact with air or water, titanium quickly
forms and surface oxide layer of thickness 3 to 5 nm at
room temperature owing to which titanium is one of
the most resistant metals contributing to its high bio-
compatibility.
However, there also exists possibility of dissolution of
oxide layer termed as corrosion.
Adequate host tissue response at the bone-implant
interface involves bone remodeling with a gradual
functional adaptation to the loads applied at the host
site.
Implanto-gingival complex
The implanto-gingival tissues serve as barrier function
and necessitate the integration of three types of tissues:
Journal of Dental Implants | Jul - Dec 2012 | Vol 2 | Issue 2 111
bone, soft connective tissue, and epithelium. The
morphology of the healthy soft tissue adjacent to teeth
has many features in common with that adjacent to
implants: Both types of tissue have (a) a well-keratinized
oral epithelium, (b) a junctional epithelium, and (c) a
connective tissue lateral to the junctional epithelium and
between the bone crest and the most apical extension of
the junctional epithelium.
Whenever the oral mucosa is pierced by any structure,
be it tooth during eruption or an implant, the epithelial
cells are known to proliferate and migrate over the
structure. Epithelial cells have the ability to synthesize
basal lamina and form hemidesmosomal attachment.
Several experimental studies have demonstrated a
satisfactory epithelial attachment between oral mucosa
and a dental implant.
DENTO-GINGIVAL UNIT V/S IMPLANT-
GINGIVAL COMPLEX
The tooth and its supporting tissues have a precise
embryological origin from dental follicle and therefore
the investing tissue cells are genetically determined
to form periodontium and its surrounding structures.
Thus formed periodontal ligament has unique feature of
adaptive remodeling owing to the presence of fibroblast
population remodeling the collagen and ground
substance. On the other hand, the soft tissues formed
around the implant surface are not directly derived
from the dental follicle, and thus do not have the ability
to remodel and adapt to the stresses exerted upon the
implant.
It is currently accepted that the implant–soft-tissue
interface has certain similarities with that of natural
teeth, including an oral epithelium, a sulcular epithelium,
and a junctional epithelium with underlying connective
tissue. [18] The most striking difference from the natural
dentition is in the structure of the underlying connective
tissue, which has been studied in vitro and in vivo.
Berglundh et al.[4] have demonstrated a cuff-like barrier
of well-keratinized oral epithelium adhering to both teeth
and implants. One difference was that collagen fibers of
the peri-implant mucosa appeared to run parallel with
the surface of the transmucosal abutment. Berglundh
et al.[19] observed that the peri-implant tissues may have
an impaired defense system, due to the finding that peri-
implant tissues are virtually devoid of vascular supply.
The vascular topography of the soft tissues around
implants demonstrates that the soft tissue blood supply
is derived from terminal branches of larger vessels from
the bone periosteum at the implant site. Blood vessels
adjacent to junctional epithelium around implants reveal
a characteristic “crevicular plexus”, but blood vessels
 Narula, et al.: Implanto-gingival complex
adjacent to the connective tissue are sparse and often
lacking.
Moon et al . [20] postulated that the fibroblast-rich
layer adjacent to the titanium surface has a role in
the maintenance of a proper seal between the oral
environment and the peri-implant tissue.
Several weeks are required to obtain sufficient soft
tissue dimensions and connective tissue quality of the
peri-implant mucosa as well as an adequate degree
of osseointegration. [21-23] Soft tissue healing around
implants results in the establishment of a barrier
epithelium and a zone of connective tissue integration,
the dimensions of which constitutes the biological
width. [24-26] Repeated abutment disconnection and
reconnection resulted in an apical shift of the barrier
epithelium and connective tissue attachment as well
as loss of marginal bone. A single shift from a healing
abutment to a permanent abutment, however, did
not cause apparent effects on the soft and hard tissue
integration to the implant.[27]
Buser et al.[28] concluded that the different surface textures
of the dental implants did not influence the healing
pattern of the soft tissues and found nonkeratinized
sulcular epithelium with a zone of dense circular fibers
close to the implant surface.
The depth of the implant in the bone affects the peri-
implant soft tissues. Todescan et al.[29] placed implants
at varying heights in the bone: 1 mm above the crest,
even with the crest, and 1 mm below the crest of
alveolar bone and found that there was a tendency for
the epithelium and connective tissue to be longer when
the implants were placed deeper. Abrahamsson et al.[30]
and Berglundh et al.[31] that the epithelium establishes an
attachment of approximately 2 mm, and the connective
tissue, an attachment of approximately 1 mm around
dental implants.
Implant-abutment interfacial “Micro-Gap”.
Implant-abutment interface creates a small micro-gap
that has been implicated in the ongoing health of soft
tissue surrounding implants.[31-37] In two-part implants,
the interface or “gap” between the transmucosal and
intraosseous components was suggested to have a
detrimental effect on the marginal bone level. Thus,
results from animal experiments indicated that crestal
bone loss of about 2 mm occurred around custom-
made two-part implants with a gap size of about
50 mm.[25,26]
Hermann et al.[26] in an experimental study in dogs
evaluated healing around one- and two-part implants.
112 Journal of Dental Implants | Jul - Dec 2012 | Vol 2 | Issue 2
The two-part implants were placed in such a way that
the interface or “gap” between the two components
was located either in level with 1 mm above or 1 mm
below the crestal bone. Histological examinations
made 6 months after implant installation revealed that
the presence of a ”gap” or interface between implant
components had a significant effect on the resulting
bone level. Thus, at two-part implants crestal bone
loss in combination with an apical shift of the soft
tissue margin was more pronounced than at one-part
implants. However, marginal bone support at level
with or even above the abutment–implant borderline,
with osseointegration coronal to the abutment-implant
interface has also been reported.[38]
Peri-implant probing
An increased probing depth is a sign of reduced tissue
resistance to probing, which in turn is interpreted as
an indication of the presence of an inflammatory cell
infiltrate in the gingival tissue.[39] Periodontal probing
is commonly used to monitor tissue heights. Quirynen
et al.[40] assessed various types of periodontal probes
to determine which was the most reliable method
to measure clinical attachment level and whether a
relationship between bone and attachment levels around
dental implants exists. The authors concluded that for
implants with healthy gingiva, the clinical attachment
level is a reliable indicator of bone level. Etter et al.[41]
determined that healing of the epithelial attachment after
probing around dental implants is complete after 5 days
and does not appear to have any detrimental effects on
the soft-tissue seal and the longevity of oral implants. In
the periodontium, connective tissue fibers insert more
or less perpendicular into the root surface. This type
of attachment does not exist between the peri-implant
mucosa and the implant; instead, the collagen fibers
of the supracrestal connective tissue at implants lack a
true attachment and have an orientation parallel to the
implant surface.[4,42] This different type of supracrestal
fiber arrangement could be one source of difference in
probe penetration.
Inter-implant distance
Tarnow et al.[43] noted the amount of space between
implants and the relationship to bone height. Tarnow
suggested that dental implants should have at least
3 mm between them and noted that implants placed
closer than 3 mm had increased amounts of crestal
bone loss. Implants should be placed in the optimal
position mesio-distally, apico-coronally, and bucco-
palatally. The mesio-distal dimension between adjacent
teeth should be 6 to 9 mm to ensure minimal (1.5 mm)
distance between implant fixture and adjacent teeth.[44,45]
Natural buccal and proximal restorative contour can be
ensured by correctly orienting the implant in a bucco-
 Narula, et al.: Implanto-gingival complex
palatal position. A minimum space of 2 mm should be
maintained on the buccal side in front of the external
implant collar surface.
Criteria of success
Albrektsson et al.[46] included the following: absence of
persistent subjective complains, such as pain, foreign
body sensation, and/or dysestesia; absence of peri-
implant infection with suppuration; absence of mobility;
absence of a continuous radiolucency around the
implant; and vertical bone loss less than 1.5 mm in the
first year of function.
“Biologic Width” around implant
A biologic width has been reported in several studies
which demonstrated that the mean height of the
supra alveolar soft tissue at implant sites was 3 to
4 mm. The dimensions of the peri-implant soft tissues
(i.e. the Biologic Width), as evaluated by histometric
measurements, are significantly influenced by the
presence/ absence of a microgap (interface) between
the implant and the abutment, and the location of this
microgap (interface) in relation to the crest of the bone.
Biologic-width around one-piece implants is more
similar to natural teeth dimensions as compared to
two-piece implants, either being placed according to a
submerged or a nonsubmerged technique.[26] Cochran
et al.[25] showed that an area of epithelial attachment
with the implant surface occurs similar in morphology
to that which is found around natural teeth. In addition,
an area of connective tissue contact was found between
the apical extension of the junctional epithelium and
the alveolar bone comprising the first bone-to-implant
contact. The dimensions of these tissues, the biologic
width, for nonsubmerged, one-piece implants were
demonstrated to be similar to the dimensions for the
same tissues described for natural teeth.[47,48] Sicher[49]
indicated that the connective tissue attachment was
the most stable component of the soft tissue unit
while the junctional epithelium was more variable
in its dimension. Weber et al . [50] found significant
differences between implant types. Epithelium
had a mean length of 1.18 mm for nonsubmerged
implants and a 1.71 mm length around submerged
implants.
SUMMARY
Early osseointegration research concentrated on the
adaptation of bone to the alloplastic implant surface
and on the clinical survival of implants. A successful
osseointegrated implant requires a direct bone-to-implant
interface to provide long-term support for a prosthesis.
A cause–effect relationship between plaque and implant
may lead to the progressive destruction of the supporting
tissues (peri-implantitis), which may compromise its
Journal of Dental Implants | Jul - Dec 2012 | Vol 2 | Issue 2 113
future and ultimately lead to its failure. Hence a pre-
treatment planning of a future implant-supported
restoration requires an insight into the factors governing
the restoration which includes the implanto-gingival
complex, inter-implant distance, peri-implant probing
depth, the interfacial micro-gap and the biologic width.
ACKNOWLEDGMENT
It takes me immense pleasure to acknowledge the hard-work of
my collegues and my seniors including Dr. KK Chaubey, Prof.
(Periodontics), Dr. VK Arora Prof. (Periodontics), Dr. Rajesh
Thakur, Asso. Prof. (Periodontics), and Dr. Zeba Jafri, Senior
Lecturer (Periodontics) without whom this work would not
have been possible to carry out.
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How to cite this article: Narula IS, Chaubey KK, Arora VK, Thakur RK,
Jafri Z. Implanto-gingival complex: An indispensable junctional complex for
the clinical success of an implant. J Dent Implant 2012;2:110-4.
Source of Support: Nil, Conflict of Interest: None.
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