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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?

Shaping the Implant Gums to Look Natural

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.

Implant Position is Critical

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

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

  1. Dr. Amin,

    Almost 2 years ago I knocked out my front two teeth in a bicycle accident. I had a very nice smile beforehand and desperately want one again, but what I’ve gone through since has made me doubt that it’s possible.

    Immediately after the accident, I had a flipper put in which was there for about 6 months. The reason I was given for that step is that the jaw bone needed to heal before anything else could be done. I then had posts inserted in the gums, and was given a set of temporaries (which were attached together) and stayed for approximately 4 months. The reason I was given for that is that the gums/jaw needed to get used to the posts. Almost a year later, I had the final crowns put in, which luckily were not permanently cemented (you’ll understand why that’s important below).

    I was unsatisfied almost immediately. My problems are as follows:

    1. The teeth are too high in my mouth, which I believe is because of the gum recession that took place during the post-accident process. The conclusion I’ve reached with research is that there’s not much that can be done about that. Luckily, I don’t have an extremely gummy smile anywhere in my mouth, so I can deal with the height. Is my conclusion correct about the height of the teeth being unfixable?

    2. My central concern is that there is no papilla between the front teeth, making them look obviously fake (to me at least). There was no thought given to my papilla by my dentist, and as a result there is none visible below where I naturally smile. I really feel a visible and healthy-looking papilla will fix many of my insecurities. As mentioned above, my dentist only used temporary cement, so they can be removed if necessary. Is the procedure you outlined in the article potentially a good one for me? I am willing to have the “final” crowns taken out if necessary, and go through the process outlined in this article if it will result in eventual papilla. Can you please expand on what my options are?

    I should note that I have a very healthy mouth, take very good care of my teeth, and from what I understand there is no damage to my jaw (I don’t believe there was any bone grafting done, as it was not necessary for my situation). I’m not as concerned about the expense as I am about an eventual confident smile. I have an appointment with a Prosthodontist soon to go over options, but would really, really appreciate your feedback and insight.

    Thank you so much,

    1. I should mention that when I say the final crowns were put in “almost a year later,” I mean a year after the accident.

    2. I am sorry about your bike accident. It sounds like you have been through a lot.

      If there is bone loss on the teeth on either side of the implants then it becomes very difficult to bring the gum line down. If there is not bone loss on those adjacent teeth is certainly can be done!

      Sometimes the triangle of gum can be fixed prosthetically using pink porcelain to hide the open space. This is a very delicate restorative procedure and often requires that the implant teeth are splinted. The other option is to square up the area where there is missing papilla by adding more white porcelain. Of course these are not ideal options but when done well, it is not perceptible to somebody at a conversational distance. It sounds like you have a difficult case. Without seeing you and your x-rays it would be impossible for me to tell you exactly how to correct this but this should be a starting point

  2. DR. Amin:

    My wife needs to have implants for teeth number 7 and 8 and 9.. 9 is already missing. Should she get 3 individual implants or should she get a implant bridge with 2 implants and a pontic crown in between 7 and 9? What are the advantages and disadvantages of each?

    1. This is a great question. The general answer is “it depends.” The implants have to be 3 mm apart or more. If they get too close to one another a can make for a very noncosmetic result where the triangles between the teeth disappear. The advantage to 3 implants gives her the best tooth appearance. The advantage to to implants and a bridge give the best gum appearance. I would seek out an expert for this treatment. Other factors such as gum thickness, scallop of the gum, thickness of the outer wall of bone and bite relationship have to all the factored in to make this decision. You only have one time to get right! If I had to say one method is safer than another it would be to have to implants rather than 3. Hope this helps. Stay safe during COVID 19!

  3. Hi! I recently had 4 implants completed. The ones on the left side seem good. The ones on the right seem weird. Top right teeth 3 & 4 the gum above the teeth seems to have a dip in the gum line. The teeth seem to go in a little and the teeth seem smaller than the other side and the last one has a dark line on the gum line. They just don’t seem normal and I am a little disappointed. Can this be corrected?

  4. Thank you for sharing this article. It is so helpful in understanding more about implants. I have a questions regarding my situation and hope you can give me some insight.

    I had an implant place on my upper right molar. This molar is apart of my smile line. They have placed the healing cap and have created a crown but are not adding any gum contouring. I am wondering if that is protocol and if there is a way I can request that they do. I had a follow up appointment and the crown looks so unnatural because it does not line up with the gum line but instead has a ledge on top of the tooth.

    I am so sad and disappointed and am wondering if the bone caving in is normal as well. Any guidance is appreciated. I am at a complete loss and am so embarrassed to smile. The tooth looked better when there was a whole there.

    1. Sounds like there’s a depression on the outer surface of the bone making the tooth look awkward. My guess is it looks longer than the other two rather than shorter than the other tooth?

      You may just want to see somebody for a second opinion or discuss this with the dentist and see if there are some corrected procedures that can be done such as a gum graft or trying to reshape the gum like I have discussed in this article

  5. Can you ADD a photo of the same view as “surgical placement of implant just slightly below bone level” with the FRONT TOOTH IMPLANT added so I can see what that looks like when implanted? From – SHAPING AND FORMING GUM AROUND FRONT TEETH DENTAL IMPLANTS – RAMSEY AMIN DDS REVIEWS.

    I would like to see what the gum line on the inside should look like.


  6. Dr amin, i recently had my two upper front teeth implant crowns fitted, really happy with the results, looks and feels good and the whole process has gone well, only problem now is i do have a lack of papilla on either side of the two teeth. My procedures were relatively straight forward as i was told i had healthy gums and a good amount of jaw bone. When i had the crowns fitted my dentest told me these would reform maybe not two their fullest but the gums should reform around the crown over the next year. Either way i have quite a low lip line and it is hardly noticable, but would just like a second opinion.

    Many thanks, jake

  7. I’ll recently had a zygomatic immediate implant and my gum levels are totally uneven so they gave me temporary cap for the moment. I am not sure if the gums will again get even or not?

  8. Hi. I have two separate questions: 1. I had my first top left molar extracted about 5-6years ago. I would like to get an implant, but cant afford it right now. I’m hoping by the end of the year. I’m only 39, would I still be able to get an implant with all the time that has passed? My dentist didn’t tell me I could have gotten a bone graft that same day of extraction to have enough bone later on.
    Question 2: My gums look like the picture above with the man who needed reshaping of his gum for the implant. The front 4 top triangles other than the middle are missing for me. I believe this was from abusing a teeth whitner I used years ago. Is there a procedure that can reform the triangles I lost? They make me very self conscious to the point of depression at times.

    1. Not too much time has passed. It can definitely still be done.

      As for your second question it’s likely not the teeth whitening that cause that. You likely have some sort of underlying calm disease/recession that is dissolving bone between your teeth. Unfortunately this is often impossible to correct unless you place veneers on your teeth or bonding is to close in the gaps.

      I only mean that surgery to grow them back is generally impossible but doing restorative treatments can camouflage and make your smile look nice again. 🤗

  9. I had two upper incisor implants placed several years ago after which the gum area above the implants became dark. I recently received a bone graft to improve the color and plump out the gum. However, the area is still a bit dark, and it was recommended that I have a gum graft prior to placing the healing abutment and ultimately the crowns. Is there a risk in doing this, considering I only had the bone graft 5 months ago? What are the risks associated with opening up the area again? Can it cause additional bone loss?

    1. The possibility is there but definitely it is a good procedure. Make sure that they take the gum from your palate rather then using other man-made products. having thick gum tissue is by far the best option for the upper front teeth

  10. Hi Dr. Amin, I had a bad fall onto a rock a few months ago and lost my left lateral incisor as well as some gum tissue. A few days after the fall my oral surgeon did a bone graft and reset my central incisors which had been knocked about halfway out. I got the implant a couple of months later and need to wait about another 7 weeks for the crown placement. My doctor is not allowing me to have a temporary crown until that time as he needed to use the smallest diameter implant due to the amount of bone I had. My question is about my gum healing. They were torn to the point that you could see the root of my central incisor. My doctor told me my gums would not grown back, but they are indeed growing back. They have grown back to the point where you can barely see the side of that root anymore, but they do have a way to go. Do you think they will grow back fully? They are basically flat in the back and torn on the front, but on one front side, there is obviously no triangle. So, I’m wondering if they will grow back that much, and how long should I keep a temporary in before moving to the final crown? If it takes many, many months, is it ok to keep the temporary in that long? Thank you for your help.

    1. Keeping the temp for 3-6 months is fine as long as it is well made. The body responds to trauma quite well and it may indeed regenerate completely…give it time!!

      Glad you are ok! 🤗

  11. Hi Dr. Ramsey Amin, thank you for your post, it was very helpful. It’s nice to find a blog with so much insight and detail, so thank you for uploading this information.

    I am hoping to get an opinion on some concerns I have related to this and I would greatly appreciate any help you could provide. Thank you in advance for your time.

    I have just had a temporary fitted and I have the issue outlined in this post. However, I was informed that there was nothing that could be done about this. For some background, I have had a front tooth dental implant and previously I have had both a bone graft and braces in order to place the implant as I lost the original over 15 years ago when I was very young. However, the soft tissue is still not there on each side of the tooth so I have these triangle gaps. Your post has highlighted that it is possible to correct so I will address this.

    Also, I am concerned that the gum line is too low on the implant temporary. I have seen your post on the gum line being too high, yet I was wondering if it is possible to raise the gum slightly and make the crown/tooth longer on the implant as it is not symmetrical to my other front tooth? My original front tooth is longer than the implant.

    I am also slightly concerned that the angle of the implant is ever so slightly off, being too far forward at the bottom of the temporary crown and too far back at the top of the crown. We had done some work with braces, after having the implant drilled, to bring my teeth back and I believe this is why this problem has arisen. Is it possible to fix this with a new crown that is built in a way to correct for this? And would this issue in any way affect the lengthening of the crown as previously mentioned?

    My temporary does not match my other front tooth and I am hoping to fix this before having the final fitted, so the tooth/crown is symmetrical and so the gum line is shaped to match, as well as forming the triangle papilla around the tooth.

    If you could help, that would be greatly appreciated. I am concerned that I won’t get the end result I am hoping for currently, and may potentially have to look for an alternative doctor to finish my treatment if I cannot resolve these issues.

    1. As long as the implant is deep enough you should have no problem from the standpoint that the gum line is too low. That is easily corrected as long as the implant is deep enough in relationship to the adjacent teeth

      The angle of the implant can easily be corrected within the crown or within the custom abutment shape. These types of restorations in the front of the mouth are challenging. I would suggest you see someone that has a lot of experience in front teeth dental implant restorations.

      Try to work out all the iterations in the temporary so that when you get to the final it is no surprises except for just a color and texture change. The temporary should look very nice before going to the final

      Fingers crossed!!

  12. I ham preparing do a porcelain implant on a top front tooth. I had an autoimmune issue a few years ago so I held off on an implant until now… using a flipper for 4 years. We’ve just finished a bone graft and are in the waiting period. I asked my dentist (whom I trusted and he did an excellent job with the bone graft) if I will like the end result with how the gums will look, he said it’s hard to tell and that if the gums are too flat there’s not much he can do to fill the space between the teeth with gums, and he said though there was enough there, my gums are thin. This really scares me, there was no mention of a temporary or what we can to to have my gums shaped nicely to match each other on my two front teeth. I was told grafting couldn’t fill in that space, if there is one. I would like a functional smile, but a beautiful one… I feel like I’ve been fighting for one my whole life and I don’t want to make any mistakes in my choices. How do I find a dentist like you who knows how to navigate this and has experience, especially when it comes to front teeth?

    1. You need to make sure you go through several months of healing with a temporary to make sure that the tissue has formed. Do not go straight to the final with a front tooth. This all has to be worked out and the temporary phase. I would suggest looking for a dentist that has credentials similar to mine or one that has great experience in implant dentistry

  13. My front teeth were broken and one had to be extracted because it was badly damaged.. I now have a dental bridge but the sight where they extracted the tooth my gum is now higher up then the rest of my mouth will my gum heal and grow around my crown or will I have to have my gums reshaped or cut so they can look the same.

    1. You can either regrow the gum and bone that you lost or you can cut away on the other teeth to make things look more even. Typically we re-grow the gum and bone unless you have a really gummy smile

      1. Hi,

        I have this same issue. I had an accident and fell on my tooth a year ago. I chipped my tooth in half and got a root canal filling. I have had a temporary filling since, no crown. The gum on my right top tooth has begun to recede. I had pinhole surgery on it, but it didnt work fully. What should I do next? Should I try gum grafting?

        1. Belle, if the tooth has bone loss “interproximal” the graft will not work. You may just need to “square up” the tooth a bit.

  14. So good to see this article. I had implant in october front tooth. Dentist pulled out the remains and put in an implant. February 15 th fixed a the tooth on the implant. 4 month did not have front tooth. He said better not to have it. Now the gum is not on the tooth. Ww can still see the screw. Looking not nice and both side of the tooth hollow, no triangle gum. What can be done to make it look natural again?

    1. Hopefully time will allow the gum to creep up. As long as the bone is there it should happen. This is usually known in advance of placing the implant.

  15. Just got abutments after several months from the implant placements. I see bone when I look in my mouth at the site of the abutments is this normal? And will the gums fill in ??

    1. bone can’t be visible unless something is really wrong. I have a hard time thinking you can see the bone. talk to your DDS asap

      1. I had a bridge with 1 implant and it attached to 1 good tooth, it broke after 25 years. Now my gum has receded i wanted 2 implants. Can you skin graf my gum line so i can get implants these are my back teeth

  16. 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.



  17. 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

  18. 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!

  19. 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. ;-(

  20. 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.

  21. 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

  22. 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.

  23. 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.

  24. 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.

  25. 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?

  26. 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.

  27. 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.

  28. 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.

  29. 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.

  30. 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.

  31. 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)

  32. 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.

  33. 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

  34. 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.

  35. 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

  36. 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!

  37. 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?

  38. 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!

  39. 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.

  40. 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 🙁

  41. 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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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.