Dental implants are considered a predictable and suitable option for replacing single or multiple teeth. Implant success is determined by the rate of implant survival as well as the esthetic and functional results. Implant placement plays a critical role in the final outcome of a case, and it should be based on a throughout análisis and planification. As of today, placing an implant in the ideal position is crucial to achieve an esthetic and functional result. It is well documented that an implant placed on its proper position will also decrease the possibility of bone resorption and posible recession or soft tissue deficiencies. Although we have a good amount of diagnostic tools to plan an implant case in a very complete way, there are cases in which the final result does not achieves the esthetic outcome that the patient and the dentist were planning to achieve. What is the main cause for this to occur? How is esthetic success measured? This is something very subjective. Nevertheless from the patients perspective, the success of an implant is given not only by long-term function but also by the esthetic result. In the eyes of a patient, one of the first parameters that deviates from a successful implant is an apical shift of the peri-implant mucosal margin. This could be presented as a softtissue recession, a soft-tissue deficit or a mucosal recession. When we have a situation where there is a soft tissue recession or absence, the patient recognizes this as a lack of success in her implant. Different studies have analyzed the presence of gingival dehiscence Cosyn et al. [1-7] this and other studies have encountered gingival recessions very commonly. There are reasons why soft-tissue dehiscence occurs on implants once they are restored. The most common reasons we have observed in the last years are : thin biotype prior to implant placement, inadequate keratinized attached mucosa, a bucally positioned implant, a deficient osseous surrounding of an implant, a high frenum or muscle pull. From all the previously mentioned factors, the 2 most strongly associated with a gingival recession around implants are a bucally placed implant and a lack of keratinized tissue on the buccal aspect of the implant. Therefore we usually prefer to work on implant cases taking into consideration a list of the so called “riskfactors surrounding implant soft tissue esthetics”. This list of risk factors are: Lack of keratinized tissue on the bucal aspect of the implant, inadequate 3-D implant placement, thin Biotype, High frenum pull in the buccal area of a recently placed implant. All this factors play a key role in maintaining a stable soft tissue margin around implants.

    This scenario becomes more risky when we are treating a case involving extractions combined with immediate implant placement. When an extraction procedure is added to the event of placing an implant, the wound healing process will be more complex with a high probability of experiencing a soft tissue dehiscence in the early weeks of wound healing. In such cases a flapless atraumatic extraction combined with the maintenance of the thin buccal wall play a key role in the final esthetic success of the case. Other factors such as implant form, implant platform switch, prosthetic abutment selection, implant restoration shoulder, play as well important roles on the esthetic final outcome, as does the patient maintenance. Last but not least, a very precise surgical planning will definitely enhance the avoidance of a soft tissue deficiency time after the prosthetic restoration of the implant. Dr. Iñaki Gamborena has disrupted the implant surgical protocol with a new approach which is based on a minimally invasive split thickness flap with minimal bone exposure, no vertical releasing incisions and a Tuberosity Connective Tissue Graft [8-11]. This technique enhances the most soft tissue response and allows a case to be closer to a naturael scenario with no remnants of an implant placement, giving the appearance of a natural perfect tooth. So as time advances and as we more in depth understand the language of the tissues, the famous quote by Dr. David Garber “The bone sets the tone, but the tissue is the issue” is more than present today and plays the most important role in Implant Esthetics. Tissue is still the issue today and will be for years to come!

1. Cosyn J, Hooghe N, De Bruyn H (2012) A systematic review on the frequency of advanced recession following single immediate implant treatment. J Chin Periodontal 39(6): 582-589.

2. Cosyn J, Sabzevar MM, De Bruyn H (2012) Predictors of inter proximal and mid facial recession following single implant treatment in the anterior maxilla: a multivariate analysis. J Chin Periodontal 39(9): 895-903.

3. Evans CD, Chen ST (2008) Esthetic outcomes of immediate implant placements. Colin Oral Implants Res 19(1): 73-80.

4. Grunder U (2000) Stability of the mucosal topography around single-tooth implants and adjacent teeth: 1-year results. Int J Periodontics Restorative Dent 20(1): 11-17.

5. Oates TW, West J, Jones J, Kaiser D, Cochran D (2002) Long-term changes in soft tissue height on the facial surface of dental implants. Implant Dent 11(3): 272-279.

6. Khzam N, Arora H, Kim P, Fisher A, Mattheos N, et al. (2015) Systematic review of soft tissue alterations and esthetic outcomes following immediate implant placement and restoration of single implants in the anterior maxillae. J Periodontal 86(12): 1321-1330.

7. Grunder U (2011) Crestal ridge width changes when placing implants at the time of tooth extraction with and without soft tissue augmentation after healing period of 6 months: report of 24 consecutive cases. Int J Periodontics Restorative Dent 31(1): 9-17.

8. Garber DA (1995) The esthetic dental implant: letting the restoration be the guide. J Am Dent Assoc 126(3): 319-25.

9. Gamborena I, Blatz MB (2008) Current clinical and technical protocols for single-tooth immediate implant procedures. IN Duarte S, editor QDT: Quintessence of Dental Technology. Honover Park (IL): Quintessence Pub 31: 49-60.

10. Gamborena I, Blatz MB (2011) The Gray zone around Dental Implants: Keys to Esthetic Success. American Journal of Esthet Dent 1(1): 26-46.

11. Gamborena I, Sasaki Y, Blatz MB (2020) Updated clinical and technical protocols for predictable immediate implant placement. Journal of Cosmetic Dent 35: 36-53.