Clinical Assessment of the Gingiva and Alveolus

  • Yung-Ting Hsu
  • Hom-Lay WangEmail author


The first step heading to successful implant outcomes is a meticulous clinical examination. It provides implantologists a clear picture for diagnosis, treatment plan, and prevention of possible complications. This chapter suggests a guideline for comprehensive clinical evaluation on both gingiva and alveolus as well as general checking via palpation, probing, and visual perception. Prior to evaluation of future implant sites, an overall investigation is mandatory to verify the locations of anatomic structures, occlusion, esthetic, and pathologic conditions. Periodontal charting is of the essence in recording current soft tissue conditions to analyze periodontal/peri-implant health. Clinicians should also be aware of individual tissue biotype, keratinized mucosa, and biologic width for better soft tissue management. In addition to soft tissue, ridge dimension and ridge deformities should be entailed. With the aids of both clinical and radiographic examinations, these data found the basis for the precise diagnosis and comprehensive treatments, leading to uneventful outcomes and successful implant therapy.


Gingiva Alveolar bone atrophy Clinical assessments Anatomic landmarks 


  1. Abrahamsson I, Berglundh T et al (1997) The mucosal barrier following abutment dis/reconnection. An experimental study in dogs. J Clin Periodontol 24(8):568–572CrossRefGoogle Scholar
  2. Allen EP, Gainza CS et al (1985) Improved technique for localized ridge augmentation. A report of 21 cases. J Periodontol 56(4):195–199CrossRefGoogle Scholar
  3. Apostolakis D, Brown JE (2012) The anterior loop of the inferior alveolar nerve: prevalence, measurement of its length and a recommendation for interforaminal implant installation based on cone beam CT imaging. Clin Oral Implants Res 23(9):1022–1030CrossRefGoogle Scholar
  4. Bengazi F, Botticelli D et al (2013) Influence of presence or absence of keratinized mucosa on the alveolar bony crest level as it relates to different buccal marginal bone thicknesses. An experimental study in dogs. Clin Oral Implants Res. 25(9):1065–1071CrossRefGoogle Scholar
  5. Berglundh T, Lindhe J (1996) Dimension of the periimplant mucosa. Biological width revisited. J Clin Periodontol 23(10):971–973CrossRefGoogle Scholar
  6. Berglundh T, Lindhe J et al (1991) The soft tissue barrier at implants and teeth. Clin Oral Implants Res 2(2):81–90CrossRefGoogle Scholar
  7. Bouri A Jr, Bissada N et al (2008) Width of keratinized gingiva and the health status of the supporting tissues around dental implants. Int J Oral Maxillofac Implants 23(2):323–326PubMedGoogle Scholar
  8. Boynueğri D, Nemli SK et al (2013) Significance of keratinized mucosa around dental implants: a prospective comparative study. Clin Oral Implants Res 24(8):928–933CrossRefGoogle Scholar
  9. Brånemark P-I, Zarb GA et al (1985) Tissue-integrated prostheses: osseointegration in clinical dentistry. Quintessence, ChicagoGoogle Scholar
  10. Bragger U, Burgin WB et al (1997) Associations between clinical parameters assessed around implants and teeth. Clin Oral Implants Res 8(5):412–421CrossRefGoogle Scholar
  11. Cardaropoli D, Re S et al (2004) The Papilla Presence Index (PPI): a new system to assess interproximal papillary levels. Int J Periodontics Restor Dent 24(5):488–492CrossRefGoogle Scholar
  12. Carlsson GE, Persson G (1967) Morphologic changes of the mandible after extraction and wearing of dentures. A longitudinal, clinical, and x-ray cephalometric study covering 5 years. Odontol Revy 18(1):27–54PubMedGoogle Scholar
  13. Cawood JI, Howell RA (1988) A classification of the edentulous jaws. Int J Oral Maxillofac Surg 17(4):232–236CrossRefGoogle Scholar
  14. Chan HL, Brooks SL et al (2011) Cross-sectional analysis of the mandibular lingual concavity using cone beam computed tomography. Clin Oral Implants Res 22(2):201–206CrossRefGoogle Scholar
  15. Chan HL, Leong DJ et al (2010) The significance of the lingual nerve during periodontal/implant surgery. J Periodontol 81(3):372–377CrossRefGoogle Scholar
  16. Chung DM, Oh TJ et al (2006) Significance of keratinized mucosa in maintenance of dental implants with different surfaces. J Periodontol 77(8):1410–1420CrossRefGoogle Scholar
  17. Claffey N, Shanley D (1986) Relationship of gingival thickness and bleeding to loss of probing attachment in shallow sites following nonsurgical periodontal therapy. J Clin Periodontol 13(7):654–657CrossRefGoogle Scholar
  18. Cook DR, Mealey BL et al (2011) Relationship between clinical periodontal biotype and labial plate thickness: an in vivo study. Int J Periodontics Restorative Dent 31(4):345–354PubMedGoogle Scholar
  19. De Rouck T, Eghbali R et al (2009) The gingival biotype revisited: transparency of the periodontal probe through the gingival margin as a method to discriminate thin from thick gingiva. J Clin Periodontol 36(5):428–433CrossRefGoogle Scholar
  20. Eghbali A, De Rouck T et al (2009) The gingival biotype assessed by experienced and inexperienced clinicians. J Clin Periodontol 36(11):958–963CrossRefGoogle Scholar
  21. Eke PI, Page RC et al (2012) Update of the case definitions for population-based surveillance of periodontitis. J Periodontol 83(12):1449–1454CrossRefGoogle Scholar
  22. Ericsson I, Lindhe J (1984) Recession in sites with inadequate width of the keratinized gingiva. An experimental study in the dog. J Clin Periodontol 11(2):95–103CrossRefGoogle Scholar
  23. Evans CD, Chen ST (2008) Esthetic outcomes of immediate implant placements. Clin Oral Implants Res 19(1):73–80Google Scholar
  24. Fu JH, Hasso DG et al (2011) The accuracy of identifying the greater palatine neurovascular bundle: a cadaver study. J Periodontol 82(7):1000–1006CrossRefGoogle Scholar
  25. Fu JH, Hsu YT et al (2012) Identifying occlusal overload and how to deal with it to avoid marginal bone loss around implants. Eur J Oral Implantol 5(Suppl):S91–103PubMedGoogle Scholar
  26. Fu JH, Yeh CY et al (2010) Tissue biotype and its relation to the underlying bone morphology. J Periodontol 81(4):569–574CrossRefGoogle Scholar
  27. Garaicoa-Pazmino C, Suarez F et al (2014) Influence of crown-implant ratio upon marginal bone loss. A systematic review. J Periodontol 85:1214CrossRefGoogle Scholar
  28. Goodacre CJ, Bernal G et al (2003) Clinical complications with implants and implant prostheses. J Prosthet Dent 90(2):121–132CrossRefGoogle Scholar
  29. Grunder U, Gracis S et al (2005) Influence of the 3-D bone-to-implant relationship on esthetics. Int J Periodontics Restor Dent 25(2):113–119Google Scholar
  30. Hsu YT, Fu JH et al (2012) Biomechanical implant treatment complications: a systematic review of clinical studies of implants with at least 1 year of functional loading. Int J Oral Maxillofac Implants 27(4):894–904PubMedGoogle Scholar
  31. Jacobs R, Schotte A et al (1992) Posterior jaw bone resorption in osseointegrated implant-supported overdentures. Clin Oral Implants Res 3(2):63–70CrossRefGoogle Scholar
  32. Jemt T (1997) Regeneration of gingival papillae after single-implant treatment. Int J Periodontics Restor Dent 17(4):326–333Google Scholar
  33. Johnson K (1969) A study of the dimensional changes occurring in the maxilla following tooth extraction. Aust Dent J 14(4):241–244CrossRefGoogle Scholar
  34. Juodzbalys G, Wang HL et al (2013) Inferior alveolar nerve injury associated with implant surgery. Clin Oral Implants Res 24(2):183–190CrossRefGoogle Scholar
  35. Kan JY, Morimoto T et al (2010) Gingival biotype assessment in the esthetic zone: visual versus direct measurement. Int J Periodontics Restor Dent 30(3):237–243Google Scholar
  36. Kan JY, Rungcharassaeng K et al (2003) Dimensions of peri-implant mucosa: an evaluation of maxillary anterior single implants in humans. J Periodontol 74(4):557–562CrossRefGoogle Scholar
  37. Kent JN, Quinn JH et al (1983) Alveolar ridge augmentation using nonresorbable hydroxylapatite with or without autogenous cancellous bone. J Oral Maxillofac Surg 41(10):629–642CrossRefGoogle Scholar
  38. Kois JC (2004) Predictable single-tooth peri-implant esthetics: five diagnostic keys. Compend Contin Educ Dent 25(11):895–896 898, 900 passim; quiz 906–897Google Scholar
  39. Lang NP, Loe H (1972) The relationship between the width of keratinized gingiva and gingival health. J Periodontol 43(10):623–627CrossRefGoogle Scholar
  40. Lekholm U, Zarb G (1985) Patient selection and preparation. In: Brånemark P-I (ed). Tissue-Integrated Prostheses: Osseointegration in Clinical Dentistry.Quintessence, Chicago 199–209Google Scholar
  41. Lin GH, Chan HL et al (2013) The significance of keratinized mucosa on implant health: a systematic review. J Periodontol 84(12):1755–1767CrossRefGoogle Scholar
  42. Malchiodi L, Cucchi A et al (2014) Influence of crown-implant ratio on implant success rates and crestal bone levels: a 36-month follow-up prospective study. Clin Oral Implants Res 25(2):240–251CrossRefGoogle Scholar
  43. Mardinger O, Namani-Sadan N et al (2008) Morphologic changes of the nasopalatine canal related to dental implantation: a radiologic study in different degrees of absorbed maxillae. J Periodontol 79(9):1659–1662CrossRefGoogle Scholar
  44. Maurer S, Hayes C et al (2000) Width of keratinized tissue after gingivoplasty of healed subepithelial connective tissue grafts. J Periodontol 71(11):1729–1736CrossRefGoogle Scholar
  45. Misch C (1990) Classifications and treatment options of the completely edentulous arch in implant dentistry. Dent Today 9(8):26 28-30PubMedGoogle Scholar
  46. Misch CE (2008) Contemporary implant dentistry. Mosby/Elsevier, St. LouisGoogle Scholar
  47. Miyata T, Kobayashi Y et al (2000) The influence of controlled occlusal overload on peri-implant tissue. Part 3: a histologic study in monkeys. Int J Oral Maxillofac Implants 15(3):425–431PubMedGoogle Scholar
  48. Neiva RF, Gapski R et al (2004) Morphometric analysis of implant-related anatomy in Caucasian skulls. J Periodontol 75(8):1061–1067CrossRefGoogle Scholar
  49. Neugebauer J, Ritter L et al (2010) Evaluation of maxillary sinus anatomy by cone-beam CT prior to sinus floor elevation. Int J Oral Maxillofac Implants 25(2):258–265PubMedGoogle Scholar
  50. Nisapakultorn K, Suphanantachat S et al (2010) Factors affecting soft tissue level around anterior maxillary single-tooth implants. Clin Oral Implants Res 21(6):662–670CrossRefGoogle Scholar
  51. Nordland WP, Tarnow DP (1998) A classification system for loss of papillary height. J Periodontol 69(10):1124–1126CrossRefGoogle Scholar
  52. Park YB, Jeon HS et al (2011) Analysis of the anatomy of the maxillary sinus septum using 3-dimensional computed tomography. J Oral Maxillofac Surg 69(4):1070–1078CrossRefGoogle Scholar
  53. Pietrokovski J, Starinsky R et al (2007) Morphologic characteristics of bony edentulous jaws. J Prosthodont 16(2):141–147CrossRefGoogle Scholar
  54. Pyun JH, Lim YJ et al (2013) Position of the mental foramen on panoramic radiographs and its relation to the horizontal course of the mandibular canal: a computed tomographic analysis. Clin Oral Implants Res 24(8):890–895CrossRefGoogle Scholar
  55. Reiser GM, Bruno JF et al (1996) The subepithelial connective tissue graft palatal donor site: anatomic considerations for surgeons. Int J Periodontics Restor Dent 16(2):130–137Google Scholar
  56. Sarver D, Jacobson RS (2007) The aesthetic dentofacial analysis. Clin Plast Surg 34(3):369–394CrossRefGoogle Scholar
  57. Schropp L, Wenzel A et al (2003) Bone healing and soft tissue contour changes following single-tooth extraction: a clinical and radiographic 12-month prospective study. Int J Periodontics Restor Dent 23(4):313–323Google Scholar
  58. Seibert JS (1983) Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part I. Technique and wound healing. Compend Contin Educ Dent 4(5):437–453PubMedGoogle Scholar
  59. Spray JR, Black CG et al (2000) The influence of bone thickness on facial marginal bone response: stage 1 placement through stage 2 uncovering. Ann Periodontol 5(1):119–128CrossRefGoogle Scholar
  60. Tallgren A (1972) The continuing reduction of the residual alveolar ridges in complete denture wearers: a mixed-longitudinal study covering 25 years. J Prosthet Dent 27(2):120–132CrossRefGoogle Scholar
  61. Tan WL, Wong TL et al (2012) A systematic review of post-extractional alveolar hard and soft tissue dimensional changes in humans. Clin Oral Implants Res 23(Suppl 5):1–21CrossRefGoogle Scholar
  62. Tozum TF, Guncu GN et al (2012) Evaluation of maxillary incisive canal characteristics related to dental implant treatment with computerized tomography: a clinical multicenter study. J Periodontol 83(3):337–343CrossRefGoogle Scholar
  63. von Arx T, Matter D et al (2011) Evaluation of location and dimensions of lingual foramina using limited cone-beam computed tomography. J Oral Maxillofac Surg 69(11):2777–2785CrossRefGoogle Scholar
  64. Wang HL, Al-Shammari K (2002) HVC ridge deficiency classification: a therapeutically oriented classification. Int J Periodontics Restor Dent 22(4):335–343Google Scholar
  65. Watanabe H, Mohammad Abdul M et al (2010) Mandible size and morphology determined with CT on a premise of dental implant operation. Surg Radiol Anat 32(4):343–349CrossRefGoogle Scholar
  66. Wen SC, Chan HL et al (2013) Classification and management of antral septa for maxillary sinus augmentation. Int J Periodontics Restor Dent 33(4):509–517CrossRefGoogle Scholar
  67. Wennstrom JL, Bengazi F et al (1994) The influence of the masticatory mucosa on the peri-implant soft tissue condition. Clin Oral Implants Res 5(1):1–8CrossRefGoogle Scholar
  68. Worthington P (2004) Injury to the inferior alveolar nerve during implant placement: a formula for protection of the patient and clinician. Int J Oral Maxillofac Implants 19(5):731–734PubMedGoogle Scholar
  69. Yildirim YD, Guncu GN et al (2014) Evaluation of mandibular lingual foramina related to dental implant treatment with computerized tomography: a multicenter clinical study. Implant Dent 23:57CrossRefGoogle Scholar
  70. Zetu L, Wang HL (2005) Management of inter-dental/inter-implant papilla. J Clin Periodontol 32(7):831–839CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Department of Periodontology and Dental Hygiene, School of DentistryUniversity of Detroit MercyDetroitUSA
  2. 2.Department of Periodontics and Oral Medicine, School of DentistryUniversity of MichiganAnn ArborUSA

Personalised recommendations