Why the firm gum around implants and teeth matters

Two different tissues: firm gum and movable lining

If you gently pull your lower lip down and look at your front teeth, you will see a pale pink, matt, firm band at the base of the teeth and, below it, redder, shiny tissue that moves with the lip. The upper band is keratinised tissue: gum with a tough protective surface layer, bound firmly to the bone underneath. Around teeth, the part of this band that is anchored to bone is called attached gingiva. The tissue below it is the movable mucosa that lines the inside of the cheeks and lips.

A similar band can surround an implant, where it is called keratinised mucosa. After tooth loss, however, this band may narrow, or the implant may emerge straight through movable tissue. How wide the band is varies from person to person and from one area of the mouth to another.

What can happen when the band is narrow

Movable mucosa does not cope well with friction; it can hurt and bleed easily when the brush touches it. Often without realising it, people then brush that area less, or more lightly. A firm band, by contrast, is thought to form a sturdier collar around an implant against bacteria and rubbing. Problems commonly reported with a narrow band include:

• Soreness or stinging in that area when brushing.
• The brush not reaching easily, and plaque building up at the base of the implant or tooth.
• Redness of the gum and bleeding when brushing.
• The edge of the tissue gradually moving downwards over time.

What the evidence says

For teeth, the picture is clearer. According to a consensus report from the American Academy of Periodontology, a minimum band width is not needed to prevent loss of the tissues supporting a tooth when plaque control is very good; when plaque control falls short, a band of at least 2 mm is considered necessary.

For implants, the picture is more mixed. One systematic review found more plaque, inflammation, tissue recession and loss of support around implants with too little firm gum. A more recent review found no link between the band and peri-implant mucositis, where inflammation stays in the soft tissue; however, having no band at all, or one narrower than 2 mm, was associated with more frequent peri-implantitis, which involves bone loss. The same review notes that the 2 mm threshold has been criticised as arbitrary. Where the reviews agree more clearly is the patient's own experience: pain and discomfort when brushing are consistently reported around implants with too little firm gum.

Daily care with a narrow band

Not everyone with a narrow band needs a graft. If the area is free of inflammation, brushing does not hurt and the tissue edge stays put from one check-up to the next, adapting your routine is often enough:

• Use a soft-bristled brush and clean that area with small movements, without pressing.
• Clean the sides of the implant or tooth with an interdental brush; let your dentist choose the right size.
• If a spot hurts when you brush, clean it gently rather than skipping it, and mention it at your check-up.
• Keep up with implant check-ups and professional cleaning.

When a gum graft is discussed

A graft moves tissue from another part of the mouth to widen the band of firm gum. It usually comes up when brushing hurts so consistently that cleaning suffers, when inflammation keeps returning despite careful care, when the tissue edge moves down from one check-up to the next, or when there is no firm gum at all where an implant is planned.

The method with the strongest evidence is a free gingival graft: a thin piece of gum taken from the palate and stitched onto the prepared area. Systematic reviews report that this and a connective tissue graft from the palate widen the band most predictably. Collagen matrices, which do not require tissue from the palate, are also used: the procedure is shorter and patients report less discomfort, but the band gained is usually narrower.

Healing after a graft

The donor site on the palate heals like an open wound that closes on its own; burning and tenderness when eating are common in the first days. Your dentist may give you a thin plate to protect the palate during this period. The grafted area may swell and bleed slightly; it is not brushed until it has healed, and a mouthwash is usually used to keep it clean instead. The graft shrinks somewhat in the first months and gradually blends in, but it may stay slightly paler than the surrounding gum. In visible areas, this difference in appearance is worth discussing beforehand.

This content is for general information only and does not replace an examination.