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Shaping And Forming Gum Around Front Teeth Dental Implants – Ramsey Amin DDS Reviews

Of the 100’s of articles I have written, this is one topic that is often not well understood by dentists or patients. So what is shaping, grooming, forming and training of gums around dental implants?

It is the process of getting the gum line around your front tooth dental implant to look as natural as possible. What makes the gum look natural? I will focus on some of the really important items:

1. The evenness of one gum line to the adjacent teeth gum line
2. The triangle of gum tissue “papilla” to be filled in. This is located between your gum.
3. The volume of gum on the outside of the implant.
4. The 3-dimensional placement of the surgical portion of the implant.
5. The health of the adjacent teeth
6. Genetically thick or thin gum and tissue

flat gum tissue without papilla or gum line before dental implant placement
flat gum tissue without papilla or gum line before dental implant placement

preoperative photograph-flat gum tissue
preoperative photograph-flat gum tissue

preoperative picture showing flat gum tissue
preoperative picture showing flat gum tissue

surgical placement of implant just slightly below bone level
surgical placement of implant just slightly below bone level

screw retained dental implant temporary interproximal view
screw retained dental implant temporary interproximal view

screw retained dental implant temporary facial view
screw retained dental implant temporary facial view

screw retained dental implant temporary, lingual view
screw retained dental implant temporary, lingual view

Implant with uneven gum line and missing papilla triangles of gum.
Implant with uneven gum line and missing papilla triangles of gum.

implant temporary and gum graft on same day as dental implant placement. Sutures visible
implant temporary and gum graft on same day as dental implant placement. Sutures visible

2 weeks after dental implant temporary. Notice that gum tissue is still open but beginning to form.
2 weeks after dental implant temporary. Notice that gum tissue is still open but beginning to form.

3 days after dental implant temporary
3 days after dental implant temporary

2 months with dental implant temporary
2 months with dental implant temporary

3 months with dental implant temporary
3 months with dental implant temporary

4 months temporary
4 months temporary

temporary after 4 months and multiple material addition to make gumline look near-perfect
temporary after 4 months and multiple material addition to make gumline look near-perfect

impression coping showing scalloped gum architecture
impression coping showing scalloped gum architecture

material added to existing temporary to modify gum level
material added to existing temporary to modify gum level

final implant after 18 months. Photograph during patient's cleaning visit.
final implant after 18 months. Photograph during patient’s cleaning visit.

custom zirconia abutment
custom zirconia abutment

final implant on day of insertion

On this particular patient I was replacing her upper right lateral incisor. I took many pictures over the course of a few months to monitor the gum healing. Read the captions to follow along the progress.  You will see how the gum changes over several months!

When you have a front tooth dental implant it is very important that you get a temporary made on the implant so that the gums can be made to follow the new shape of the tooth. If you have been missing a tooth for a long time, then the gum tissue is flat. It takes time to develop this gullwing shaped arching effect from one tooth gum line to the next. Sometimes surgical correction is needed but most of the time shaping the temporary properly and giving it 2-6 months will allow it to happen on its own.

Your implant has to be put into a good position for this to work. If the angle of the implant is too far forward and the head of the implant is too close to your lips, the implant will end up being long looking. Sometimes there are no other options because your jaw may angle outwards in the bone is so thin that there is no leeway and placing the implant closer to your tongue. But, ideally the implant should be placed just behind the edges of the upper front teeth. So, the first step in having a great gum line is having a very well placed implant in the bone in the first place!!!. Sometimes computer guided surgery helps but not always because there are errors.

There must also be a lot of bone on the outer wall of the implant. 1-2 mm or more of extra bone on the outside of the implant with good, thick gum tissue on top will allow for proper volume of gum so the tooth looks like it is coming out the gum rather than laying on top of the gum. This is not always possible and sometimes a gum graft needs to be done in combination with a bone graft in order to achieve the final volume. The implant must not be too large. Smaller, longer implants are often best in the front teeth areas.

In my practice, your dental implant gum line begins taking shape from the time the tooth is extracted. Your tooth must be very carefully extracted as to preserve as much of the gum is possible from being lost during the extraction process. Sometimes an extraction and immediate non-load dental implant is needed and sometimes staging the implant over time and doing a socket bone preservation graft is better.
If the implant is stable enough to have a same day temporary crown put directly on the implant it needs to be shaped a certain way. The implant temporary that I make for your implant usually has a “negative facial contours.” This allows the gum line not to be pushed away but rather create a thicker “cuff” of tissue around the base of the implant. If the temporaries placed on the same day that the implant is placed then thick gum training and shaping begins on that day. If the implant has to be buried or a large bone graft was done, this process will begin later on.

You can see in some of the photographs how the temporary crown is created by hand and attached by a screw to the replica green implant. This allows me to do all of the forming and shaping outside of your mouth. The sides or interproximal areas of your teeth are shaped in such a way to promote the triangle of gum tissue to grow to the proper flossing contact height. In some cases the temporary needs to be removed a few times and material either added or subtracted from it in just the right spot to move the gum line to the desired position. Most of the front teeth dental implant temporaries I make are held in with a screw rather than cement to make this easier for you.

Growing the triangle gum papilla to the proper height is often dictated by your adjacent teeth. If the tooth on either side has bone loss, even minor, the gum is much less likely to fill in completely leaving a small black triangle. This can be preplanned in advance in many situations. Oftentimes the crown can be made with a little bit of extra porcelain to fill in the black hole or sometimes the tooth right next door would need a tiny filling to close the space up. As long as it does not make your smile look asymmetric, often times this can work well. Ideally all the gum grows back to original height. It is also important that your dental implant be placed at the right depth. There is kind of a “sweet spot” or the implant is not too deep and not too shallow…..it is very much an art and can be very “touchy” and delicate.

Oftentimes front teeth require custom abutments to be made to follow the highs and lows of the scalloping gum tissue. The custom abutment also helps and supporting what is called the “emergence profile” of the tooth. This is the transition from where the implant is in the bone to where the gum line begins. In 2016, your tissue training, molding/grooming can be re-created into a 3-D printed model using an intraoral scanner like the trios 3. This prevents the gum from collapsing during the ‘molding’ digital or conventional impression.

I understand there are a lot of fine details, but it takes a lot to make a front tooth look great! It is all about the gums and not so much about the white porcelain part of the tooth. This is what separates good from great dental implants that are done right the first time. This process of shaping the gum line can take from just a few days to more than a year to complete. Each case is very unique.

Ramsey A. Amin, D.D.S.

Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

69 thoughts on “Shaping And Forming Gum Around Front Teeth Dental Implants – Ramsey Amin DDS Reviews

  1. Hello,

    I have my front tooth implant done about an year ago. The gum above my implant is higher than the rest, ever since. I tried not to complain but it bothers me time to time. I was wondering if there is a solution to lower the gum line so that I can have a shorter and equal height of the front tooth?
    Your response is very much appreciated.



  2. Why is my implant exposed after a vine grafting was done? My dentist said it’s just a matter of time before it heals, and gums to grow? Is this right? I could feel my implant with my tongue. Please help!

    1. not enough information. It is possible that this is just the healing abutment that is exposed which is completely normal. If it is not the healing abutment and the actual threads of the implant showing
      than that is not normal

  3. I am planning on getting a bridge implant on my 4 upper front teeth and was told by my perio/cosmetic dentist that due to severe bone loss, shaping and forming of the gum would be necessary and that I would need a flipper or temporary (which I assume is a temporary fixed implant) to help re-shape the gum before the final implant can be put in. I was also told that due to my high gum line, it would be difficult for the final product to “merge” and look natural with the rest of the gums and that perhaps taking out my (relatively healthy) incisors to make it a 6 teeth bridge would be advisable. What are your thoughts on this? I don’t want to have to take out health teeth if I don’t have to but esthetics is also of high concern for me since I have a high gum line.
    Also, what would be the indication for a flipper vs a temporary implant to reshape the gum line? Hearing horror stories about how uncomfortable they are, I’d much prefer something fixed in place.

    Thanks again for all the invaluable information on the process!

  4. I had two dental implants place on the upper left. Had recession after the first gum graph. Just had the second gum graphing done and I am 1 month out with the same results. I am so angry and frustrated!!! I have recession and you can see the black/metal of the implants when I smile. Would larger implants take care of the gap?//What is your advice?

    1. wait for another 2 months before doing anything else. The gum takes time to form. A larger implant will only worsen an already tough situation. Sorry you have had trouble. ;-(

  5. I have an implant placed 5 months ago and it’s almost done healing. In another month I would go in for a placement of a healing abutment. Recently, a dentist said the gum around the missing tooth is very thin and receding, and I may need gum graft. I wondering if gum graft can be done after an implant has already been placed? Thank you.

  6. Hi I just got my permanent crowns on top four teeth today I had this done more for cosmetic reasons my old feelings were discolored so my dentist recommended putting all porcelain crowns anyway I have gaps where the gum line should go he said massage them downward and they should go back within 3 days to a week is this correct its just the triangular part he said it’s due to having the plastic temporary on is tht correct as well I wish I could send a pic kinda hard to explain in writing the gums are fine where they meet my natural teeth it’s just the three middle that have gaps where the gum line should go downwards is that normal and will they go down and attach themselves in time

  7. Hi I just got my 4 permanent crowns put on my top front teeth today I had this done more for cosmetic reasons my old feelings were discolored so my dentist recommended putting all porcelain crowns anyway I have gaps where the gum line should go he said massage them downward and they should go back within 3 days to a week is this correct its just the triangle part of the gum he said its due to having the plastic temporary on is tht correct as well I wish I could send a pic kinda hard to explain in writing the gums are fine where they meet my natural teeth it just the three middle that have gaps

    1. I understand what you mean. Give it a few weeks and likely this will all go away if your dentist feels confident that it will.

  8. I wish I had looked into this exact issue before getting my front tooth implant done. My dentist pulled my front tooth about two years ago after I had my daughter due to “resorption”. I had no symptoms at all and a very nice smile. I trusted his advice. They did a bone graft at time of extraction. Before they could place the implant I fell pregnant with my son. They kept a temporary in (that kept falling out over and over again) until I had my son last July at which point they placed the implant and did another bone graft. Another temporary was put in until they exposed the implant (this is when I noticed all of the sudden my papillae on either side was gone and the gum was high) and a fixed temporary was placed. I just about a month ago got my final crown and am so unhappy. I am missing gum on either side of the implant (but there is a rounded scalloped shape at least) and the gum is mix he higher on the implant and little tooth next to it than the other front tooth and side tooth. It looks so much different than my old smile. The dentist bonded the little tooth next to it to hide the gap that was now there due to the missing gum. Will the gum grow back at all?

    1. Ugh…my guess is that you are missing bone on the teeth on either side. If that is the case than the bone will not grow back. If you do have that bone will likely come back. It should have already come back during the temporary phase. I’m hoping you had the temporary for 2-3 months.

      Another good option could be bonding pink composite or pink porcelain onto the tooth to help mask or camouflage the area.

  9. Hi Dr Amin,

    Is it possible at all to either gum graft over an implant or to raise the level of a tooth socket. There is no bone loss, but the socket of the tooth starts lower than the tooth next to it below the bone. This was done when trying to fit a crown below the gum line and was then decided to place implant instead. The extraction has not occurred yet.

  10. Hi Dr,

    I have a question about restoring the gum line between #28 and #29. Tooth #28 had a root canal when I was 13 and finally went to get a new crown on it at 30. There was further decay on the tooth beneath the gum line that had to be taken care of. Implant was recommended as necessary for long term but I requested a new crown to see how long it would last. Tooth #29 is going to have an onlay done.

    I only have the temporaries in currently but I am not happy with how I imagine the gum line is going to be.

    Did the drilling away of the decay under the gums to fit the new crown snugly cause me to lose soft tissue on #28?

    But would doing a full crown instead on #29, to match $28 better, be more cosmetically ideal? Or is it possible at all to safely lower the gingiva of #29 with a crown (it’s also above #30 a bit as #29 seems to be naturally a bit too high) or to raise the gingiva of #28 even a little?

  11. Hello Dr,

    I recently had an implant placed (final restoration) and noticed the gingiva around the implant is missing the triangles. I have healthy gums and take good oral care. Is there an average time frame for the triangles to form?

    1. As I mentioned in this post, they should be preformed before going to the final restoration. It is possible you may see some growth during the first one to 2 months but after that it begins to stabilize. Of course there are exceptions to the rule.

  12. Fantastic work. I cannot tell the difference between the implant and the real teeth at all. I myself have a bridge implant for my four front upper teeth. Had them done 14 years ago. I am not very happy with the countours of the gums, small little gaps between the gums and the impants appear. Is there a possible tratment for improving the aesthetics (gum augmentation, something else) and making the teeth look more natural? Thanks in advance.

    1. definitely (But it does depend on your unique diagnosis and treatment plan)….Thank you for your kind words.

  13. My dentist that is doing the restoration over the abutment said the implant was put in a little crooked by my oral l surgeon that nothing to worry about,he will do a custom abutment. My question to you is putting a implant a little crooked norma ?It was done by free hand so I guess it will go in little crooked .tooth number #13.could this be prevented???should I bring this up to my oral surgeon on my next visit.

    1. There are always minor variations in implant placement. As long as it is a minor position issue it will be no problem.

  14. Hi Dr. Amin. Excellent blog and great experience on implant matters. I recently got an implant done on my lower jaw where I have healthy bone and healthy gum. No periodontal disease or anything. I have got implants before, but this time around I am a bit unsatisfied with the work. Firstly, the drilling was done very excessively and harshly. The implant seems to have gone much deeper (below gingival level). Therefore, the temporary abutment base is also hiding under the bone crest. Not sure this implant has good chance of survival. Even if it survives, will it last? This is one of my main concerns. Can you please tell what should be done immediately to have a good outcome.

    1. Many implants are purposely placed under the gums to allow osseointegration to occur. Ask if it was done in a two stage technique to be sure.

  15. One week ago had my two front teeth extracted and was given a temporary pallet to wear until I have implants. My question is how long each day do I need to wear this pallet and will it help with gum line

    1. It depends on the design that your dentist gave the temporary. Most removable temporaries do not create the shapes that I am discussing in this article. The temporary must be fixed.

  16. Hi Dr. i’ve been reaching for your advice but my post keep disappeared hope this one reach you. I am 50 years old, I failed back in my young adult age and damaged four front teeth (#7,8,9 & 10) they all had root canals then a while after that i had them all crowns individually. right now they don’t have good appearance any more, #10 root canal failed got abscess more than twice of course bone loss at the root of it because of infection, tooth #8 had gum reseced #9 & #7 show a black lines, and i also lost my molars (#2, #3 & #14), still have #15 , the 1st premolars and the canines are in good condition. my 2nd premolars was pulled out way before everything had happened because of braces, and no wisdom teeth. I read almost all of your amazing experience works , now i am in the middle of like.. WHAT AM I GOING TO DO!!!.. should i have all remaining good teeth (got 5) pull out and do an ALL ON FOUR WITH 2 ZYGOMATIC & 2 REGULAR IMPLANTS permanent zirconia bridge to advoid all the problems that may happen later on or should i keep the five healthy teeth and just replace the bad and missing teeth????? then what comes next after who know. PLEASE Dr. Ramsey will you give me some advice , which is a good way to do i am so afraid and worried that i might make a wrong decision.
    THANK YOU and hope for you answer. Just want to get this don’t before my infection tooth return again.

    1. Thank you for your very kind words. The course of action for each patient is very different. Sometimes it is worth saving those remaining teeth and sometimes it is not. Sometimes zygomatic dental implants are required while other times standard implants will do. I would love to be able to guide you with exact advice, but in reality the type of questions you are asking requires a detailed clinical exam, photographs, 3-dimensional planning and a detailed medical evaluation.

      When you say to 5 teeth are healthy that is oftentimes a relative term. They may look okay to you but have issues with bone or failing restorations. You really have to weigh the pros and cons of each and get yourself aligned with a very skilled and experienced dental implant specialist. Do your due diligence!

      Ramsey A. Amin, D.D.S.
      Diplomate of the American Board of Oral Implantology /Implant Dentistry
      Fellow-American Academy of Implant Dentistry

      1. Hi there. I’m planning ahead for the future. As a voice over artist speech is very important to me. If I was in the position in say ten years time if i needed four anterior upper implants and a premolar implant would I be better getting Individual implants or all on eight. I’m thinking what would make enable my pronunciation and diction to still work well and for them to look nice at the gum line still. I have good bone. I have a couple of implants already and will need more one day as of root canals from being a teenager.

        Also if I have a few normal implants and one day may need the all on eight procedure do they replace those implants or can they be used for it?

        Thank you. You’re the best I love your site.

          1. Thanks very much. You mention it may affect in the short term. Do our mouths ultimately long term adapt to these bulkier palates? Mine did that with a temporary flipper which I know is different but then I got used to it. :0)

  17. I had#9 pulled due to external resorption. It was asymptomatic. Tooth was staged 4. Not enough bone for implant so they did a bone graph. Oak surgeon did a number 8 suture. It looked like antennas! They eventually cut into my fun, very painful. It seems the suture made my gum recede. I am concerned of gum line preservation. They have me a flipper that is very uncomfortable to wear. We talked about a Marylin bridge with an ovate tooth to shape the gum line until the bone graph heals. What are your thoughts?

    1. hmm…without seeing you and your gum type very difficult to guide you.
      It is a safe route to wait. If the temporary is shaped and formed correctly when you get to that point you should be able to regrow all of the gum back as long as the teeth on either side are healthy. The type of temporary that you have often has to do with whether or not you have a regular bite, overbite or underbite.

  18. My dentist made a custom abutment for tooth #13.I notice on the tongue side the ridge on the abutment is showing at the gum line Is this acceptable ?I assume when the crown is put on the abutment it sits on the ridge.if this is so the crown will site below the gum line instead of being in the gum socket. Showing metal
    Please give me ur recommendations, should another abutment be made?

    1. Although I am not a big fan of leaving metal exposed on the inside but sometimes a cannot be avoided. It is possible that your implant is shallow and that you are actually seeing the implant itself rather than the abutment surface. Some dentists make crowns using a metal sleeve on the tongue surface on purpose. This would be called a porcelain fused to metal crown with a lingual collar.

      On a good note, you would much rather have exposure on the inside rather than the outside. Not so much because it is visible but because the gum on the roof of the mouth is very stable and less prone to recession.

      1. Only a little exposal from the abutment is showing not the implant. He said it’s because of my period conditions and to prevent future perio problem. That’s why he made the custom abutment to be a little expose near the gum line with the metal sleeves on the crown also.
        My dentist did make a metal sleeve on the tongue side also
        Does this sound correct to you???
        Thank you

  19. Hi Dr. Amin, I really appreciate your entire blog. It has helped me understand so much more about my #9 implant I’ve had for 10 years.
    My periodontist is advising that I get a gum graft to the front of my implant, as the gum is very thin and there is a small hole in it. We at first thought it was an infection tract, but he now has changed his opinion to the gum is stretched thin and it is merely a hole, and lack of blood supply makes it difficult for the hole to heal. While I feel like this gum graft may improve the aesthetics of my implant, does the hole diagnosis make any sense? If I go through the process of getting a gum graft now, will it greatly benefit my implant’s longevity? I am 26 so I am very much interested in keeping this area of my mouth happy and healthy long term, but I also want to limit expensive surgeries that do not seem to be necessary at this time.

    1. That is a TOUGH call. The reason why I say it is tough is the possibility exists that this situation can worsen rather than improve. Without seeing you in person it would be difficult to assess but that would be my #1 concern. Typically I do this procedure through a tunnel type of incision rather than open flap.

  20. I am in need of a #9 implant. Can you recommend a prosthodontist in the westchester or Bergen county NJ area for this?
    Thank you

  21. I’m having my four front teeth extracted tomorrow because of a chronic infection in my gum line from an skateboarding accident when I was a kid. Im now 49. I’ve had some bone loss but I also had a bone graft done 6 years ago. My teeth are not lose and i take good care of them. My gums look good and range from 1-3 in depth in my front teeth. The bone loss is mostly in front. I have a gummy smile and I’m very nervous about the outcome. My dentist recommended I get two implants 7 and 10 and a bridge for my two front teeth. He recommended this because he’s afraid if they drill the holes for all four implants too close to each other the bone could collapse between the two teeth. Any recommendations for him or me?

      1. Thank you so much! I spoke to my Periodontist yesterday before my extractions about ovate pontics. He said that was the plan. He also did PRF with a bone graft. He said there had been fairly significant bone loss due to my chronic infection i had for over 20 yrs. Fyi, i had four root canals to try and resolve this problem over the years. Turns out they all were preformed on the wrong tooth.

      2. One more thing, i am wearing a four teeth “flipper” while the bone graft heals. He said the flipper is purely for aesthetics, only wear it when i have to, it’ll heal better wihout it. True? My big question is, shouldn’t we be sculpting the gums now while i heal? Otherwise it seems my gums will heal flat, no? Btw, thank you so much for your advice and replies to everyone! They’re is a lot of anxiety involved with procedures like this. I was trembling out of control in the chair yesterday just before my extraction. They couldn’t begin the extraction until i calmed down. Your blog and comments have helped to relieve a lot of my anxieties about this (long) process. THANKS AGAIN!

  22. Can your implants be reduced or reshaped after the job is fishined, if you think the implanted teeth are too long and would look better if they were a little smaller?

  23. Looks wonderful! I had a front tooth implant after years of living with a partial plate and Maryland bridge. I was never given an explanation regarding why this tooth “loosened” in the first place (?chronic periodontititis in one tooth?) but was getting ready to go to nurse in West Africa for 2 years so they removed it. That was 1977 and in 2010 had a bone graft (donorbone) and implant which I was relatively happy with but always had a bit of metal showing. But in February of this year had what seemed like an overnight appearance of a significantly more amount of metal showing. Now told that I have serious gum recession there and require connective tissue grafting and replacement. How can this happen and can it be prevented?
    What are the best options? Thanks!

    1. This was likely happening slowly over time. Your gums it would likely genetically very thin and possibly the implant is too large or too close to the outer wall.

      I often do this connective tissue graft at the same time I put the implant in so that this has an extremely low chance of ever even happening. It is a bit of an over engineering but well worth it in the long run.

      1. Thanks so very much for your feedback! I am going to have a connective tissue transplant in May; present my have had the tooth removed and wearing a temporary “tooth on a tray”!
        Unfortunate circumstances but hopefully it will all work out! Thanks again!

  24. Thanks for sharing this article.
    I had a front tooth implant placed 6 years ago.
    I was never totally happy with the slight amount of metal showing but my smile is such that it did not show, so not perfect but I accepted it. However only recently I found that slot of the metal was showing, saw my dentist and then a periodontist who tells me that the gum has receded and I now need connective tissue transplantation and replacement of the implant. How could this have happened?

    1. Gum tissue thinness was likely already present. Many women have genetically thinner gum than men. For this reason I place the implants with much thicker outside bone and all patients especially in women.

  25. I got a terrible implant in Westchester by xxxxxx. he pulled my front tooth out then bone graph waited 4 months then inserted implant waited again then tooth were he didn’t fit the gum around it and there’s a hide gap at the top so yes gum line fitting is extremely important now a year later it’s killing me and I’m just getting all my teeth pulled out I’m 58 and very discouraged

    1. It may fill in over 6-12 months as long as the bone is good. Wait for a bit before you do anything.
      Sorry for your frustrations 🙁

  26. Inspiring writings and I greatly admired what you have to say , I hope you continue to provide new ideas for us all and greetings success always for you..Keep update more information..

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About Ramsey A. Amin, DDS

Dr. Ramsey Amin has extensive experience in surgical and restorative implant dentistry. As one of only less than 400 Diplomates of the American Board of Oral Implantology/ Implant Dentistry (ABOI/ID) he is considered an expert, and board-certified in dental implants. He is a former instructor at the UCLA School of Dentistry.