Influence of Attached Gingiva Width on Peri-implant Bone Loss: A 5-year Retrospective Study

Influence of Attached Gingiva Width on Peri-implant Bone Loss: A 5-year Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Influence of Attached Gingiva Width on Peri-implant Bone Loss: A 5-year Retrospective Study Merve Tekelioğlu, Aysun AKPINAR, Hakan Özdemir This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8673286/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 18 You are reading this latest preprint version Abstract Background This study aimed to assess the demographic, clinical, and radiographic characteristics of patients who received dental implants over a five-year period, and to explore the relationship between the width of attached gingiva and peri-implant marginal bone loss.. Methods A total of 107 patients with 330 dental implants placed at the Department of Periodontology, Faculty of Dentistry, Eskişehir Osmangazi University, were retrospectively evaluated. Recorded parameters included age, sex, smoking habits, plaque index (PI), gingival index (GI), probing depth, and width of attached gingiva. Marginal bone loss was measured on standardized panoramic radiographs, and implants were grouped according to attached gingiva width (< 2 mm or ≥ 2 mm) and bone loss severity ( 3 mm). Statistical analyses were performed using chi-square and independent samples t-tests, with the significance level set at p < 0.05. Results Among the implants examined, 79.7% had an attached gingiva width of ≥ 2 mm, while 45.8% exhibited less than 1 mm of bone loss. Mean bone loss was significantly greater in implants with < 2 mm gingiva (2.17 mm) compared to those with ≥ 2 mm (1.64 mm). Decreased gingiva width was associated with older age and smoking, and implants with narrower gingiva showed higher PI and GI scores. Conclusion A limited width of attached gingiva appears to be linked to greater peri-implant bone loss. Preserving at least 2 mm of keratinized attached gingiva around implants may be important for maintaining peri-implant tissue health and long-term stability. Prospective multicenter studies are recommended to further substantiate these findings and establish optimal soft tissue management strategies. Dental implants attached gingiva peri-implantitis marginal bone loss smoking BACKGROUND Dental implants have become a well-established and predictable option for the restoration of oral function, esthetics, speech, and overall quality of life, with consistently high long-term success rates [ 1 , 2 ]. Despite these advantages, biological complications such as peri-implant mucositis and peri-implantitis remain significant challenges, with reported prevalence rates ranging from 20% to 45% [ 3 , 4 ]. These peri-implant diseases share many etiological factors with periodontitis, in which bacterial biofilm accumulation and patient-related risk factors—such as inadequate oral hygiene and smoking—play key roles in disease initiation and progression [ 5 , 6 ]. The importance of keratinized mucosa and attached gingiva surrounding dental implants has long been a subject of discussion and, at times, controversy in the field of implant dentistry. While osseointegration forms the biological foundation of implant success, the stability of the soft tissue interface is equally critical for the long-term maintenance of peri-implant health. Several investigations have suggested that the presence of at least 2 mm of keratinized mucosa plays a protective role by enhancing peri-implant tissue stability, minimizing plaque accumulation, and facilitating effective oral hygiene procedures by patients [ 7 , 8 ]. From a clinical standpoint, sufficient attached gingiva also improves patient comfort during tooth brushing and reduces mechanical irritation of the peri-implant mucosa caused by functional and masticatory movements. On the other hand, some authors have argued that implants can remain healthy even in the absence of keratinized mucosa, provided that optimal plaque control is maintained [ 9 ]. According to this view, the quality of patient-performed oral hygiene and professional maintenance visits may outweigh the quantitative width of keratinized tissue. Nevertheless, maintaining adequate tissue thickness and width may offer a biological advantage by providing resistance against mechanical stress, microbial insult, and inflammatory extension toward the alveolar bone. Recent systematic reviews have further highlighted that insufficient keratinized mucosa is often associated with higher levels of inflammation, increased plaque accumulation, mucosal recession, and greater patient-reported discomfort during oral hygiene practices [ 10 ]. However, despite these clinical correlations, the direct effect of attached gingiva width on marginal bone loss remains controversial. This uncertainty largely stems from methodological differences between studies—including variations in sample size, follow-up duration, measurement techniques, and criteria for defining “adequate” keratinized tissue. Consequently, the literature still lacks a clear consensus regarding whether a specific minimum width of attached gingiva is necessary to prevent peri-implant bone resorption and to maintain long-term peri-implant tissue health. Given these inconsistencies in the literature, additional evidence is needed to clarify whether a reduced width of attached gingiva predisposes to greater peri-implant bone loss over time. Therefore, the present retrospective study aimed to evaluate the demographic, clinical, and radiographic characteristics of patients who received dental implants during a five-year period, and to investigate the relationship between attached gingiva width and peri-implant marginal bone loss. It was hypothesized that implants with narrower attached gingiva would demonstrate greater peri-implant bone loss compared with those surrounded by adequate keratinized tissue. MATERIALS AND METHODS Ethical approval and patient selection This study was approved by the Non-Interventional Clinical Research Ethics Committee of Eskişehir Osmangazi University, Eskişehir, Turkey (Approval No: E-25403353-050.99-77333). The study was conducted in accordance with the principles of the Declaration of Helsinki (2013). Written informed consent was obtained from all participants prior to inclusion in the study. Study design A total of 107 patients with 330 implants were evaluated in this study. Demographic, clinical, and radiographic data were systematically recorded and analyzed. To ensure consistency and reliability of the measurements, all assessments were performed by a single calibrated examiner. The intra-examiner agreement was verified using Cohen’s kappa coefficient (κ = 0.89), indicating excellent reproducibility. Clinical examination Demographic variables included age, sex, smoking status, and systemic conditions. Clinical parameters included plaque index [ 11 ] (PI), gingival index [ 12 ] (GI), probing depth, and width of attached gingiva. Measurements were performed at six sites per implant using a Williams periodontal probe. In line with previous studies, attached gingiva was categorized as < 2 mm or ≥ 2 mm [ 13 , 14 ] Smoking status was defined as < 10 cigarettes/day versus ≥ 10 cigarettes/day for at least five years [ 15 , 16 ]. Radiographic evaluation Standardized panoramic radiographs were obtained using a Planmeca Promax 2D system (Planmeca, Helsinki, Finland; 68 kVp, 16 mA, 13 s). Marginal bone loss was measured as the vertical distance from the implant shoulder to the most apical bone-to-implant contact point. All radiographic measurements were performed using ImageJ software (National Institutes of Health, Bethesda, MD, USA) to ensure precision and reproducibility. To minimize potential positioning errors, both baseline and follow-up radiographs were standardized by calibrating the measurements according to the known implant length. Bone loss values were categorized as 3 mm [ 17 , 18 ]. Statistical Analysis Data analysis was performed using IBM SPSS Statistics version 22.0 (IBM Corp., Armonk, NY, USA). The normality of continuous variables was assessed using the Shapiro–Wilk test. Categorical variables such as sex, age group, smoking status, and width of attached gingiva were analyzed with the chi-square test, while comparisons of continuous variables between two groups were carried out using independent samples t-tests. When multiple comparisons were made, Bonferroni correction was applied to adjust for type I error. A p-value of < 0.05 was considered statistically significant. Post hoc power analysis demonstrated a statistical power of 97.7% for group comparisons, based on an effect size of 0.5 and a significance level of α = 0.05. RESULTS A total of 330 implants placed in 107 patients were assessed over a 5-year follow-up period. Of these, 263 implants had an attached gingiva width ≥2 mm, while 67 implants had <2 mm. Regarding bone loss, 151 implants showed 3 mm. Mean bone loss was significantly greater in implants with <2 mm gingiva compared with those with ≥2 mm. (p=0.045) (Table 1). Sex distribution In the 3 mm was more frequent in females (63.2%) compared with males (36.8%), although the difference was not statistically significant. (p=0.059) (Table 1) Table 1. Distribution of attached gingiva with and marginal bone loss according to sex WAG n (%) p MBS n (%) p <2 mm. ≥2mm. 3mm. Gender Female 25 (37.3) 131 (49.8) 0.067 68 (45) 28 (45.2) 24 (40) 36 (63.2) 0.059 Male 42 (62.7) 132 (50.2) 83 (55) 34 (54.8) 36 (60) 21 (36.8) Total (n) 67 263 151 62 60 57 WAG: Width of attached gingiva, MBL: Marginal bone loss, N: Number of implant Age distribution Patients were categorized into three age groups: 30-51, 52-61, and 62-75 years. In the 30-51 group, 94.2% of implants had ≥2 mm attached gingiva width, whereas this decreased to 70.2% in the 52-61 group. (p<0.05) Bone loss distribution across age groups was not statistically significant (p=0.468) (Table 2) Table 2. Distribution of attached gingiva with and radiological bone loss according to age groups WAG n (%) p RBL n (%) p <2 mm. ≥2mm. 3mm. Age group (years) 30-51 6 (9) 97 (36.9) 0.000* 43 28.5) 25 (40.3) 17(28.3) 18 (31.6) 0.468 52-61 39 (58.2) 92 (35) 59 (39.1) 22 (35.5) 29 (48.3) 21 (36.8) 62-75 22 (32.8) 74 (28.1) 49(32.5) 15 (24.2) 14(23.3) 18 (31.6) Total (n) 67 263 151 62 60 57 *p<0.001 WAG: Width of attached gingiva, RBS: Radiological bone loss, n: Number of implant Smoking status Among patients smoking <10 cigarettes/day, 77% of implants had ≥2 mm gingiva width, compared with only 3% in the heavy-smoking group (≥10 cigarettes/day). This difference was statistically significant (p=0.003) Bone loss was also significantly higher in heavy smokers: while 92.1% of implants with 3 mm loss were found in the heavy smoking group. (p=0.011) (Table3) Table 3. Relationship between smoking status, width of attached gingiva, and marginal bone loss Width of Attached Gingiva N (%) P value Radiological Bone Loss N (%) P value <2 mm. ≥2mm. 3mm. Cigarette <10 cigarettes/day ≥10 cigarettes/day 65(97) 2 (3) 217(82.5) 46 (17,5) 0.003* 139(92.1) 12 (7,9) 52(83.9) 10(16,1) 46(76.7) 14(23,3) 45(78.9) 12(21,1) 0.011* Total (N) 67 263 151 62 60 57 *p<0.05 WAG: Width of attached gingiva, MBL: Marginal bone loss, n: Number of implant Jaw region Implants were most frequently placed in the mandibular posterior region. Gingiva width differed significantly among regions, with lower values in the anterior sites. (p=0.005) However, bone loss distribution did not differ significantly by jaw region (p=0.381) (Table 4) Table 4. Relationship between jaw region, width of attached gingiva, and marginal bone loss. WAG n (%) p MBL n (%) p <2 mm. ≥2mm. 3mm. Jaw Region Maxillary anterior 2 (3) 35 (13.3) 0.005* 14(9.3) 9 (14.5) 8 (13.3) 6 (10.5) 0.381 Maxillary posterior 21 31.3) 108(41.1) 59(39.1) 26(41.9) 28(46.7) 16(28.1) Mandibular anterior 9 (13.4) 15 (5.7) 13 (8.6) 4 (6.5) 1 (1.7) 6 (10.5) Mandibular posterior 35(52.2) 105 (39.9) 65(43.0) 23(37.1) 23(38.3) 29(50.9) Total (n) 67 263 151 62 60 57 *p<0.05 WAG: Width of attached gingiva, MBL: Marginal bone loss, n: Number of implant Plaque Index, Gingival Index, and Probing Depth PI scores were significantly lower in implants with ≥2 mm gingiva. (p=0.010) For example, only 3% of implants with a PI of 0 showed >3 mm bone loss, compared with 20% of those with a PI score of 3. (p=0.007) GI scores were also higher in the <2 mm gingiva group (83.5% had GI=2 vs. 68.4% in the ≥2 mm group, p=0.049), although no significant association was observed between GI and bone loss. (p=0.254) Probing depth increased significantly with bone loss: only 3.3% of implants with 3 mm loss. (p<0.001) (Table 5) Table 5. Relationship between plaque index (PI), gingival index (GI), probing depth, width of attached gingiva, and marginal bone loss WAG n (%) p MBL n (%) p <2 mm. ≥2mm. 3mm. PI 0 9 (13.4) 67(25.5) 0.010* 47(31.1) 14 (22.6) 14 (23.3) 1 (1.8) 0.007* 1 3 (44.8) 128(48.7) 67 (44.4) 30(48.4) 26(43.3) 35(61.4) 2 25(37.3) 66 (25.1) 34 (22.5) 18 (29.0) 19 (31.7) 20(35.1) 3 3 (4.5) 2 (0.8) 3 (2.0) 0 (0.0) 1 (1.7) 1 (1.8) GI 0 4 (6) 27 (10.3) 0.049* 18 (11.2) 8 (13) 4 (6.6) 1 (1.7) 0.254 1 7 (10.4) 56 (21.2) 32 (21.2) 10 (16) 10 (16.7) 11 (19.3) 2 56 (83.5) 180 (68.4) 101(66.9) 44 (71) 46 (76.7) 45 (79.0) PD <3mm. 9 (13.4) 38 (14.4) 0.915 29 (19.2) 7 (11.3) 7 (11.7) 4 (7.0) 0.000* 3-6 mm. 53 (79.1) 202 (76.8) 117 (77.5) 51 (82.3) 49 (81.7) 38 (66.7) ≥6 mm. 5 (7.5) 23 (8.7) 5 (3.3) 4 (6.5) 4 (6.7) 15 (26.3) Total (n) 67 263 151 62 60 57 *p<0.05 WAG: Width of attached gingiva, MBL: Marginal bone loss, n: Number of implant PD: Probing Depth Table 6. Mean marginal bone loss according to width of attached gingiva WAG n Average p MBL (mm) <2mm. 67 2.1709 0.045* ≥2 mm. 263 1.6373 *p<0.05 WAG: Width of attached gingiva, MBL: Marginal bone loss, n: Number of implant Mean Bone Loss by Gingiva Width As shown in Table 6, mean bone loss was significantly greater in the <2 mm gingiva group (2.17 ± SD mm) compared with the ≥2 mm group (1.64 ± SD mm) (p=0.045). DISCUSSION This retrospective study demonstrated that a narrower width of attached gingiva was significantly associated with greater peri-implant bone loss. Specifically, the mean bone loss was 2.17 mm in implants with < 2 mm of attached gingiva compared to 1.64 mm in those with ≥ 2 mm, thereby supporting our initial hypothesis. These findings are in line with several previous investigations suggesting that insufficient keratinized mucosa may predispose to greater peri-implant tissue breakdown. Block and Kent [ 19 ] reported that minimal bone loss occurred in the presence of adequate attached gingiva, whereas reduced keratinized tissue was correlated with bleeding on probing, probing depths exceeding 3 mm, and crestal bone loss of 2 mm or more. Similar observations were made by Bouri et al. [ 20 ] and Hanisch et al. [ 21 ], who noted greater peri-implant bone loss in the absence of sufficient keratinized mucosa. Likewise, Fernandes-Costa et al. [ 22 ] and Chung et al. [ 23 ] emphasized that a limited band of keratinized tissue can negatively influence peri-implant health and maintenance. However, the literature is not unanimous on this issue. Wennström and Derks [ 7 ], as well as Kim et al. [ 18 ], found no significant association between keratinized mucosa width and peri-implant bone levels, reflecting the ongoing debate in this area. Such discrepancies may stem from variations in study design, follow-up duration, sample selection, patient compliance, or differences in oral hygiene practices across studies. Most systematic reviews have nonetheless adopted a threshold of approximately 2 mm as the minimum width required to maintain peri-implant tissue stability. In this context, Brito et al. [ 17 ] highlighted that the absence of keratinized mucosa may compromise peri-implant health, reinforcing the concept that maintaining at least 2 mm of keratinized tissue contributes to long-term implant success and stability. In the present study, patients with < 2 mm of attached gingiva also presented with higher plaque index (PI) and gingival index (GI) values, indicating that sufficient keratinized tissue may play a crucial role in facilitating plaque control and minimizing inflammation, thereby helping to preserve peri-implant bone levels. These findings align well with the reports of Gobbato et al. [ 13 ], Orellana-Bustos et al. [ 24 ], and Van der Weijden et al. [ 25 ], who consistently demonstrated that a reduced width of keratinized gingiva is associated with increased plaque accumulation, greater inflammatory response, and a higher risk of compromised periodontal status. Moreover, in our cohort, the prevalence of implants surrounded by ≥ 2 mm of attached gingiva tended to decline with advancing age, particularly in the 52-61-year age group. This trend may reflect physiological aging processes, such as alveolar bone resorption, mucogingival recession, and soft tissue remodeling following tooth loss. Similar observations have been reported in previous studies. [ 16 ] It is generally recognized that keratinized mucosa tends to decrease with age due to passive eruption, bone remodeling, and soft tissue contraction. These age-related changes highlight the importance of considering soft tissue augmentation procedures in elderly implant patients to enhance peri-implant tissue stability and ensure long-term success. Smoking also emerged as a key factor influencing both attached gingiva width and peri-implant bone levels. Heavy smokers (≥ 10 cigarettes/day) exhibited narrower keratinized tissue and significantly greater bone loss compared with non-smokers and light smokers. This observation is consistent with prior evidence identifying smoking as a strong risk factor for peri-implantitis [ 5 , 14 , 15 ]. Although smoking is known to induce epithelial keratinization, the resulting mucosa is histologically altered, often displaying reduced vascularity due to chronic vasoconstriction. Such compromised tissue perfusion may impair healing capacity and structural resilience, which could account for the greater peri-implant bone loss observed in smokers [ 24 , 25 ]. Clinically, while some researchers argue that meticulous plaque control can compensate for an inadequate width of keratinized mucosa, [ 7 , 26 ] others emphasize that the absence of sufficient keratinized tissue can lead to discomfort during oral hygiene practices, increased plaque accumulation, and a higher risk of inflammation. Long-term cohort studies, such as those by Roos-Jansåker et al. [ 27 ], have also demonstrated that inadequate keratinized mucosa is associated with a greater likelihood of developing peri-implant lesions over time. Taken together, these findings reinforce the notion that evaluating the width of attached gingiva should be an integral part of implant treatment planning. In cases where the keratinized tissue is insufficient, periodontal surgical interventions—such as free gingival grafts or apically positioned flaps—may be considered to augment the soft tissue and promote peri-implant health [ 28 ]. CONCLUSION Within the limitations of this retrospective study, reduced attached gingiva width was significantly associated with increased peri-implant bone loss. Maintaining at least 2 mm of keratinized gingiva around dental implants appears to be essential for plaque control, peri-implant tissue stability, and long-term implant success. Therefore, evaluation of keratinized gingiva width should be incorporated into implant treatment planning, and soft tissue augmentation procedures should be considered when deficiencies are present. LIMITATIONS This study has several limitations that should be acknowledged when interpreting the results. First, the retrospective design inherently limits the ability to establish causal relationships between attached gingiva width and peri-implant bone loss. Although retrospective analyses are valuable for identifying long-term trends, they rely on previously recorded data that may lack full control over potential confounding variables. Second, all radiographic assessments were performed using panoramic radiographs. While panoramic imaging provides a broad overview of the maxillofacial region, it offers lower spatial resolution and may introduce magnification or distortion compared with periapical radiographs or cone-beam computed tomography (CBCT). These limitations could affect the precision of bone level measurements despite efforts to standardize radiographic calibration using implant length. Third, several patient-related factors—such as oral hygiene practices, systemic health conditions, medication use, and compliance with maintenance visits—could not be completely standardized or controlled due to the retrospective nature of the study. Variations in these factors may have influenced both gingival tissue stability and peri-implant bone levels. Additionally, all data were obtained from a single academic center and a relatively homogeneous patient population, which may limit the generalizability of the findings to broader or more diverse clinical settings. The study also did not account for the possible effects of implant design, surface characteristics, or prosthetic loading protocols, which may have influenced the observed bone remodeling patterns. FUTURE DIRECTIONS Future prospective, multicenter studies with larger sample sizes and standardized radiographic protocols are warranted to validate these findings. Longitudinal research should evaluate the role of soft tissue augmentation procedures in patients with < 2 mm of keratinized gingiva. Additionally, randomized controlled trials are needed to determine the optimal clinical threshold for keratinized gingiva width and to establish evidence-based guidelines for peri-implant soft tissue management. Declarations Ethics approval and consent to participate: Ethics approval and consent to participate: This study was approved by the Non-Interventional Clinical Research Ethics Committee of Eskişehir Osmangazi University, Eskişehir, Turkey (Approval No: E-25403353-050.99-77333). The study was conducted in accordance with the principles of the Declaration of Helsinki (2013). Written informed consent was obtained from all participants prior to inclusion in the study. Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: The authors declare that no funding was received for this study. Authors’ contributions: MT and HÖ conceived and designed the study. MT performed data collection. MT, HÖ, and AA analyzed the data. MT and AA drafted the manuscript. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8673286","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":592498809,"identity":"53d66a6f-10c6-4944-8aa2-71cadc771704","order_by":0,"name":"Merve Tekelioğlu","email":"","orcid":"","institution":"Unlü Akademi Private Oral and Dental Health Clinic","correspondingAuthor":false,"prefix":"","firstName":"Merve","middleName":"","lastName":"Tekelioğlu","suffix":""},{"id":592498810,"identity":"97eb7cea-77a4-4804-a3ca-7ccfc9d8f65b","order_by":1,"name":"Aysun AKPINAR","email":"data:image/png;base64,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","orcid":"","institution":"Bursa Uludağ University","correspondingAuthor":true,"prefix":"","firstName":"Aysun","middleName":"","lastName":"AKPINAR","suffix":""},{"id":592498811,"identity":"356f9c52-bb5f-4e61-b15b-12bd7a6282f1","order_by":2,"name":"Hakan Özdemir","email":"","orcid":"","institution":"Eskişehir Osmangazi University","correspondingAuthor":false,"prefix":"","firstName":"Hakan","middleName":"","lastName":"Özdemir","suffix":""}],"badges":[],"createdAt":"2026-01-22 21:38:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8673286/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8673286/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102928809,"identity":"8aaa3dca-1b34-42dd-99ac-fa9e2995e5d3","added_by":"auto","created_at":"2026-02-18 14:27:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":717014,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8673286/v1/7f87d45f-f27d-4971-8f51-efed3694c8ae.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eInfluence of Attached Gingiva Width on Peri-implant Bone Loss: A 5-year Retrospective Study\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eDental implants have become a well-established and predictable option for the restoration of oral function, esthetics, speech, and overall quality of life, with consistently high long-term success rates [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite these advantages, biological complications such as peri-implant mucositis and peri-implantitis remain significant challenges, with reported prevalence rates ranging from 20% to 45% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These peri-implant diseases share many etiological factors with periodontitis, in which bacterial biofilm accumulation and patient-related risk factors\u0026mdash;such as inadequate oral hygiene and smoking\u0026mdash;play key roles in disease initiation and progression [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe importance of keratinized mucosa and attached gingiva surrounding dental implants has long been a subject of discussion and, at times, controversy in the field of implant dentistry. While osseointegration forms the biological foundation of implant success, the stability of the soft tissue interface is equally critical for the long-term maintenance of peri-implant health. Several investigations have suggested that the presence of at least 2 mm of keratinized mucosa plays a protective role by enhancing peri-implant tissue stability, minimizing plaque accumulation, and facilitating effective oral hygiene procedures by patients [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. From a clinical standpoint, sufficient attached gingiva also improves patient comfort during tooth brushing and reduces mechanical irritation of the peri-implant mucosa caused by functional and masticatory movements.\u003c/p\u003e \u003cp\u003eOn the other hand, some authors have argued that implants can remain healthy even in the absence of keratinized mucosa, provided that optimal plaque control is maintained [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. According to this view, the quality of patient-performed oral hygiene and professional maintenance visits may outweigh the quantitative width of keratinized tissue. Nevertheless, maintaining adequate tissue thickness and width may offer a biological advantage by providing resistance against mechanical stress, microbial insult, and inflammatory extension toward the alveolar bone.\u003c/p\u003e \u003cp\u003eRecent systematic reviews have further highlighted that insufficient keratinized mucosa is often associated with higher levels of inflammation, increased plaque accumulation, mucosal recession, and greater patient-reported discomfort during oral hygiene practices [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, despite these clinical correlations, the direct effect of attached gingiva width on marginal bone loss remains controversial. This uncertainty largely stems from methodological differences between studies\u0026mdash;including variations in sample size, follow-up duration, measurement techniques, and criteria for defining \u0026ldquo;adequate\u0026rdquo; keratinized tissue. Consequently, the literature still lacks a clear consensus regarding whether a specific minimum width of attached gingiva is necessary to prevent peri-implant bone resorption and to maintain long-term peri-implant tissue health.\u003c/p\u003e \u003cp\u003eGiven these inconsistencies in the literature, additional evidence is needed to clarify whether a reduced width of attached gingiva predisposes to greater peri-implant bone loss over time. Therefore, the present retrospective study aimed to evaluate the demographic, clinical, and radiographic characteristics of patients who received dental implants during a five-year period, and to investigate the relationship between attached gingiva width and peri-implant marginal bone loss. It was hypothesized that implants with narrower attached gingiva would demonstrate greater peri-implant bone loss compared with those surrounded by adequate keratinized tissue.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003ch2\u003eEthical approval and patient selection\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Non-Interventional Clinical Research Ethics Committee of Eskişehir Osmangazi University, Eskişehir, Turkey (Approval No: E-25403353-050.99-77333). The study was conducted in accordance with the principles of the Declaration of Helsinki (2013). Written informed consent was obtained from all participants prior to inclusion in the study.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy design\u003c/h2\u003e\n \u003cp\u003eA total of 107 patients with 330 implants were evaluated in this study. Demographic, clinical, and radiographic data were systematically recorded and analyzed. To ensure consistency and reliability of the measurements, all assessments were performed by a single calibrated examiner. The intra-examiner agreement was verified using Cohen\u0026rsquo;s kappa coefficient (\u0026kappa;\u0026thinsp;=\u0026thinsp;0.89), indicating excellent reproducibility.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch2\u003eClinical examination\u003c/h2\u003e\n\u003cp\u003eDemographic variables included age, sex, smoking status, and systemic conditions. Clinical parameters included plaque index [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e] (PI), gingival index [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e] (GI), probing depth, and width of attached gingiva. Measurements were performed at six sites per implant using a Williams periodontal probe. In line with previous studies, attached gingiva was categorized as \u0026lt;\u0026thinsp;2 mm or \u0026ge;\u0026thinsp;2 mm [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e] Smoking status was defined as \u0026lt;\u0026thinsp;10 cigarettes/day versus \u0026ge;\u0026thinsp;10 cigarettes/day for at least five years [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\n\u003ch2\u003eRadiographic evaluation\u003c/h2\u003e\n\u003cp\u003eStandardized panoramic radiographs were obtained using a Planmeca Promax 2D system (Planmeca, Helsinki, Finland; 68 kVp, 16 mA, 13 s). Marginal bone loss was measured as the vertical distance from the implant shoulder to the most apical bone-to-implant contact point. All radiographic measurements were performed using ImageJ software (National Institutes of Health, Bethesda, MD, USA) to ensure precision and reproducibility. To minimize potential positioning errors, both baseline and follow-up radiographs were standardized by calibrating the measurements according to the known implant length. Bone loss values were categorized as \u0026lt;\u0026thinsp;1 mm, 1\u0026ndash;2 mm, 2\u0026ndash;3 mm, and \u0026gt;\u0026thinsp;3 mm [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n \u003cp\u003eData analysis was performed using IBM SPSS Statistics version 22.0 (IBM Corp., Armonk, NY, USA). The normality of continuous variables was assessed using the Shapiro\u0026ndash;Wilk test. Categorical variables such as sex, age group, smoking status, and width of attached gingiva were analyzed with the chi-square test, while comparisons of continuous variables between two groups were carried out using independent samples t-tests. When multiple comparisons were made, Bonferroni correction was applied to adjust for type I error. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant. Post hoc power analysis demonstrated a statistical power of 97.7% for group comparisons, based on an effect size of 0.5 and a significance level of \u0026alpha;\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 330 implants placed in 107 patients were assessed over a 5-year follow-up period. Of these, 263 implants had an attached gingiva width \u0026ge;2 mm, while 67 implants had \u0026lt;2 mm. Regarding bone loss, 151 implants showed \u0026lt;1 mm loss, 62 implants had 1-2 mm, 60 implants had 2-3 mm, and 57 implants had \u0026gt;3 mm. Mean bone loss was significantly greater in implants with \u0026lt;2 mm gingiva compared with those with \u0026nbsp;\u0026ge;2 mm. (p=0.045) (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSex distribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the \u0026lt;2 mm gingiva group, 62.7% of implants were placed in male patients, whereas in the \u0026ge;2 mm group, distribution was nearly equal between sexes. Bone loss \u0026gt;3 mm was more frequent in females (63.2%) compared with males (36.8%), although the difference was not statistically significant. (p=0.059) (Table 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Distribution of attached gingiva with and marginal bone loss according to sex\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"625\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eWAG n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; p\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eMBS n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;2 mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;2mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;1mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1-2mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2-3mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;3mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25 (37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e131 (49.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e68 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28 (45.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36 (63.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42 (62.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e132 (50.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83 (55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34 (54.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21 (36.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWAG: Width of attached gingiva, MBL: Marginal bone loss, \u0026nbsp;N: Number of implant\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAge distribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were categorized into three age groups: 30-51, 52-61, and 62-75 years. In the 30-51 group, 94.2% of implants had \u0026ge;2 mm attached gingiva width, whereas this decreased to 70.2% in the 52-61 group. (p\u0026lt;0.05) Bone loss distribution across age groups was not statistically significant (p=0.468) (Table 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Distribution of attached gingiva with and radiological bone loss according to age groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"666\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eWAG n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eRBL n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;2 mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;2mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;1mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1-2mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2-3mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;3mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eAge group (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30-51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e97 (36.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43 28.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25 (40.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17(28.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e0.468\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52-61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39 (58.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e92 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e59 (39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22 (35.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29 (48.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21 (36.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62-75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22 (32.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e74 (28.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49(32.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (24.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14(23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.001 \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWAG: Width of attached gingiva, RBS: Radiological bone loss, n: Number of implant\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSmoking status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong patients smoking \u0026lt;10 cigarettes/day, 77% of implants had \u0026ge;2 mm gingiva width, compared with only 3% in the heavy-smoking group (\u0026ge;10 cigarettes/day). This difference was statistically significant (p=0.003) Bone loss was also significantly higher in heavy smokers: while 92.1% of implants with \u0026lt;1 mm loss belonged to the low-smoking group, 20% of implants with \u0026gt;3 mm loss were found in the heavy smoking group. (p=0.011) (Table3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Relationship between smoking status, width of attached gingiva, and marginal bone loss\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"621\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eWidth of Attached Gingiva N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eRadiological Bone Loss\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;2 mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ge;2mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;1mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1-2mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2-3mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026gt;3mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCigarette\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10 cigarettes/day \u0026ge;10 cigarettes/day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65(97)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e217(82.5)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e46 (17,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.003*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e139(92.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (7,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52(83.9)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10(16,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46(76.7)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14(23,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45(78.9)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12(21,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.011*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal (N)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.05 \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWAG: Width of attached gingiva, MBL: Marginal bone loss, n: Number of implant\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJaw region\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImplants were most frequently placed in the mandibular posterior region. Gingiva width differed significantly among regions, with lower values in the anterior sites. (p=0.005) However, bone loss distribution did not differ significantly by jaw region (p=0.381) (Table 4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e Relationship between jaw region, width of attached gingiva, and marginal bone loss.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"610\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eWAG \u0026nbsp;n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eMBL n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;2 mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;2mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;1mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1-2mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2-3mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;3mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eJaw\u003c/p\u003e\n \u003cp\u003eRegion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMaxillary anterior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e0.005*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14(9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (14.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e0.381\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMaxillary posterior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21 31.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e108(41.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e59(39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26(41.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28(46.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16(28.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMandibular anterior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (8.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMandibular posterior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35(52.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e105 (39.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65(43.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23(37.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23(38.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29(50.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal \u0026nbsp;(n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.05 \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWAG: Width of attached gingiva, MBL: Marginal bone loss, n: Number of implant\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlaque Index, Gingival Index, and Probing Depth\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePI scores were significantly lower in implants with \u0026ge;2 mm gingiva. (p=0.010) For example, only 3% of implants with a PI of 0 showed \u0026gt;3 mm bone loss, compared with 20% of those with a PI score of 3. (p=0.007) GI scores were also higher in the \u0026lt;2 mm gingiva group (83.5% had GI=2 vs. 68.4% in the \u0026ge;2 mm group, p=0.049), although no significant association was observed between GI and bone loss. (p=0.254)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProbing depth increased significantly with bone loss: only 3.3% of implants with \u0026lt;1 mm loss had probing depth \u0026ge;6 mm, compared with 26.3% of implants with \u0026gt;3 mm loss. (p\u0026lt;0.001) (Table 5)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5.\u003c/strong\u003e Relationship between plaque index (PI), gingival index (GI), probing depth, width of attached gingiva, and marginal bone loss\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"665\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eWAG \u0026nbsp;n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eMBL n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;2 mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026ge;2mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt;1mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1-2mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2-3mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026gt;3mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003ePI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e9 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e67(25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.010*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e47(31.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e14 (22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e14 (23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e0.007*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3 (44.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e128(48.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e67 (44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e30(48.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e26(43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e35(61.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e25(37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e66 (25.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e34 (22.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e18 (29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e19 (31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e20(35.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e3 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eGI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e4 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e27 (10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.049*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e18 (11.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e4 (6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e0.254\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e7 (10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e56 (21.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e32 (21.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e10 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e10 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e11 (19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e56 (83.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e180 (68.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e101(66.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e44 (71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e46 (76.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e45 (79.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003ePD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;3mm.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e9 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e38 (14.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.915\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e29 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e7 (11.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e7 (11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e4 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3-6 mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e53 (79.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e202 (76.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e117 (77.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e51 (82.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e49 (81.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e38 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026ge;6 mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e5 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e23 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e5 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e4 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e4 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e15 (26.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eTotal (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.05 \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWAG: Width of attached gingiva, MBL: Marginal bone loss, n: Number of implant PD: Probing Depth\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6.\u0026nbsp;\u003c/strong\u003eMean marginal bone loss according to width of attached gingiva\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"572\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eWAG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eMBL (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026lt;2mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e2.1709\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.045*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026ge;2 mm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.6373\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.05 \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWAG: Width of attached gingiva, MBL: Marginal bone loss, n: Number of implant\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean Bone Loss by Gingiva Width\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 6, mean bone loss was significantly greater in the \u0026lt;2 mm gingiva group (2.17 \u0026plusmn; SD mm) compared with the \u0026ge;2 mm group (1.64 \u0026plusmn; SD mm) (p=0.045).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis retrospective study demonstrated that a narrower width of attached gingiva was significantly associated with greater peri-implant bone loss. Specifically, the mean bone loss was 2.17 mm in implants with \u0026lt;\u0026thinsp;2 mm of attached gingiva compared to 1.64 mm in those with \u0026ge;\u0026thinsp;2 mm, thereby supporting our initial hypothesis.\u003c/p\u003e \u003cp\u003eThese findings are in line with several previous investigations suggesting that insufficient keratinized mucosa may predispose to greater peri-implant tissue breakdown. Block and Kent [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] reported that minimal bone loss occurred in the presence of adequate attached gingiva, whereas reduced keratinized tissue was correlated with bleeding on probing, probing depths exceeding 3 mm, and crestal bone loss of 2 mm or more. Similar observations were made by Bouri et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and Hanisch et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], who noted greater peri-implant bone loss in the absence of sufficient keratinized mucosa. Likewise, Fernandes-Costa et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and Chung et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] emphasized that a limited band of keratinized tissue can negatively influence peri-implant health and maintenance.\u003c/p\u003e \u003cp\u003eHowever, the literature is not unanimous on this issue. Wennstr\u0026ouml;m and Derks [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], as well as Kim et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], found no significant association between keratinized mucosa width and peri-implant bone levels, reflecting the ongoing debate in this area. Such discrepancies may stem from variations in study design, follow-up duration, sample selection, patient compliance, or differences in oral hygiene practices across studies.\u003c/p\u003e \u003cp\u003eMost systematic reviews have nonetheless adopted a threshold of approximately 2 mm as the minimum width required to maintain peri-implant tissue stability. In this context, Brito et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] highlighted that the absence of keratinized mucosa may compromise peri-implant health, reinforcing the concept that maintaining at least 2 mm of keratinized tissue contributes to long-term implant success and stability.\u003c/p\u003e \u003cp\u003eIn the present study, patients with \u0026lt;\u0026thinsp;2 mm of attached gingiva also presented with higher plaque index (PI) and gingival index (GI) values, indicating that sufficient keratinized tissue may play a crucial role in facilitating plaque control and minimizing inflammation, thereby helping to preserve peri-implant bone levels. These findings align well with the reports of Gobbato et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], Orellana-Bustos et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and Van der Weijden et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], who consistently demonstrated that a reduced width of keratinized gingiva is associated with increased plaque accumulation, greater inflammatory response, and a higher risk of compromised periodontal status.\u003c/p\u003e \u003cp\u003eMoreover, in our cohort, the prevalence of implants surrounded by \u0026ge;\u0026thinsp;2 mm of attached gingiva tended to decline with advancing age, particularly in the 52-61-year age group. This trend may reflect physiological aging processes, such as alveolar bone resorption, mucogingival recession, and soft tissue remodeling following tooth loss. Similar observations have been reported in previous studies. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] It is generally recognized that keratinized mucosa tends to decrease with age due to passive eruption, bone remodeling, and soft tissue contraction. These age-related changes highlight the importance of considering soft tissue augmentation procedures in elderly implant patients to enhance peri-implant tissue stability and ensure long-term success.\u003c/p\u003e \u003cp\u003eSmoking also emerged as a key factor influencing both attached gingiva width and peri-implant bone levels. Heavy smokers (\u0026ge;\u0026thinsp;10 cigarettes/day) exhibited narrower keratinized tissue and significantly greater bone loss compared with non-smokers and light smokers. This observation is consistent with prior evidence identifying smoking as a strong risk factor for peri-implantitis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Although smoking is known to induce epithelial keratinization, the resulting mucosa is histologically altered, often displaying reduced vascularity due to chronic vasoconstriction. Such compromised tissue perfusion may impair healing capacity and structural resilience, which could account for the greater peri-implant bone loss observed in smokers [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClinically, while some researchers argue that meticulous plaque control can compensate for an inadequate width of keratinized mucosa, [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] others emphasize that the absence of sufficient keratinized tissue can lead to discomfort during oral hygiene practices, increased plaque accumulation, and a higher risk of inflammation. Long-term cohort studies, such as those by Roos-Jans\u0026aring;ker et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], have also demonstrated that inadequate keratinized mucosa is associated with a greater likelihood of developing peri-implant lesions over time. Taken together, these findings reinforce the notion that evaluating the width of attached gingiva should be an integral part of implant treatment planning. In cases where the keratinized tissue is insufficient, periodontal surgical interventions\u0026mdash;such as free gingival grafts or apically positioned flaps\u0026mdash;may be considered to augment the soft tissue and promote peri-implant health [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eWithin the limitations of this retrospective study, reduced attached gingiva width was significantly associated with increased peri-implant bone loss. Maintaining at least 2 mm of keratinized gingiva around dental implants appears to be essential for plaque control, peri-implant tissue stability, and long-term implant success. Therefore, evaluation of keratinized gingiva width should be incorporated into implant treatment planning, and soft tissue augmentation procedures should be considered when deficiencies are present.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLIMITATIONS\u003c/h2\u003e \u003cp\u003eThis study has several limitations that should be acknowledged when interpreting the results. First, the retrospective design inherently limits the ability to establish causal relationships between attached gingiva width and peri-implant bone loss. Although retrospective analyses are valuable for identifying long-term trends, they rely on previously recorded data that may lack full control over potential confounding variables.\u003c/p\u003e \u003cp\u003eSecond, all radiographic assessments were performed using panoramic radiographs. While panoramic imaging provides a broad overview of the maxillofacial region, it offers lower spatial resolution and may introduce magnification or distortion compared with periapical radiographs or cone-beam computed tomography (CBCT). These limitations could affect the precision of bone level measurements despite efforts to standardize radiographic calibration using implant length.\u003c/p\u003e \u003cp\u003eThird, several patient-related factors\u0026mdash;such as oral hygiene practices, systemic health conditions, medication use, and compliance with maintenance visits\u0026mdash;could not be completely standardized or controlled due to the retrospective nature of the study. Variations in these factors may have influenced both gingival tissue stability and peri-implant bone levels.\u003c/p\u003e \u003cp\u003eAdditionally, all data were obtained from a single academic center and a relatively homogeneous patient population, which may limit the generalizability of the findings to broader or more diverse clinical settings. The study also did not account for the possible effects of implant design, surface characteristics, or prosthetic loading protocols, which may have influenced the observed bone remodeling patterns.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eFUTURE DIRECTIONS\u003c/h2\u003e \u003cp\u003eFuture prospective, multicenter studies with larger sample sizes and standardized radiographic protocols are warranted to validate these findings. Longitudinal research should evaluate the role of soft tissue augmentation procedures in patients with \u0026lt;\u0026thinsp;2 mm of keratinized gingiva. Additionally, randomized controlled trials are needed to determine the optimal clinical threshold for keratinized gingiva width and to establish evidence-based guidelines for peri-implant soft tissue management.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eEthics approval and consent to participate:\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Non-Interventional Clinical Research Ethics Committee of Eskişehir Osmangazi University, Eskişehir, Turkey (Approval No: E-25403353-050.99-77333). The study was conducted in accordance with the principles of the Declaration of Helsinki (2013). Written informed consent was obtained from all participants prior to inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors declare that no funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003eMT and H\u0026Ouml; conceived and designed the study. MT performed data collection. MT, H\u0026Ouml;, and AA analyzed the data. MT and AA drafted the manuscript. H\u0026Ouml; critically revised the manuscript. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLang NP, Lindhe J. Clinical Periodontology and Implant Dentistry. 6th ed. Oxford: Wiley Blackwell; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuser D, Sennerby L, De Bruyn H. Modern implant dentistry based on osseointegration: 50 years of progress. Periodontol 2000. 2017;73(1):7\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerglundh T, Armitage G, Araujo MG, et al. Peri-implant diseases: Consensus report of the Sixth European Workshop on Periodontology. J Clin Periodontol. 2018;45(Suppl 20):S286\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDerks J, Tomasi C. Peri-implant health and disease. A systematic review of current epidemiology. J Clin Periodontol. 2015;42(Suppl 16):S158\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwarz F, Derks J, Monje A, Wang HL. Peri-implantitis. J Clin Periodontol. 2018;45(Suppl 20):S246\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJepsen S, Caton JG, Albandar JM, et al. Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report. J Clin Periodontol. 2018;45(Suppl 20):S219\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWennstr\u0026ouml;m JL, Derks J. Is there a need for keratinized mucosa around implants to maintain health and tissue stability? Clin Oral Implants Res. 2012;23(Suppl 6):136\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin GH, Chan HL, Wang HL. The significance of keratinized mucosa on implant health: A systematic review. J Periodontol. 2013;84(12):1755\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBengazi F, Souza AB, Gobbato L, Warrer K, Giannobile WV, Lang NP. Lack of keratinized mucosa and peri-implant tissue health. J Periodontal Res. 2016;51(6):679\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSouza AB, Tormena M, Matarazzo F, Ara\u0026uacute;jo MG. The influence of peri-implant keratinized mucosa on brushing discomfort and peri-implant tissue health. Clin Oral Implants Res. 2016;27(6):650\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilness J, L\u0026ouml;e H. Periodontal disease in pregnancy II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand. 1964;22:121\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eL\u0026ouml;e H, Silness J. Periodontal disease in pregnancy I. Prevalence and severity. Acta Odontol Scand. 1963;21:533\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGobbato L, Avila-Ortiz G, Sohrabi K, Wang C-W, Karimbux N. The effect of keratinized mucosa width on peri-implant health: A systematic review. Int J Oral Maxillofac Implants. 2013;28(6):1536\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlQahtani MA, Alayad AS, Alshihri A, Correa FOB, Akram Z. Clinical peri-implant parameters and inflammatory cytokine profile among cigarette-, e-cigarette-, and waterpipe-smokers. Clin Implant Dent Relat Res. 2018;20(6):1016\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilva CO, Ribeiro EDP, Sallum AW, Tatakis DN. Free gingival grafts: Graft shrinkage and donor-site healing in smokers and non-smokers. J Periodontol. 2010;81(5):692\u0026ndash;701.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrito C, Tenenbaum HC, Wong BK, Schmitt C, Nogueira-Filho G. Is keratinized mucosa indispensable to maintain peri-implant health? A systematic review. J Biomed Mater Res B Appl Biomater. 2014;102(3):643\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChrcanovic BR, Kisch J, Albrektsson T, Wennerberg A. A retrospective study on clinical and radiological outcomes of oral implants in patients followed up for a minimum of 20 years. Clin Implant Dent Relat Res. 2018;20(2):199\u0026ndash;207.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim B-S, Kim Y-K, Yun P-Y, Yi Y-J, Lee H-J, Kim S-G, Son J-S. Evaluation of peri-implant tissue response according to the presence of keratinized mucosa. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107(3):e24\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlock MS, Kent JN. Factors associated with soft- and hard-tissue compromise of endosseous implants. J Oral Maxillofac Surg. 1990;48(11):1153\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBouri A Jr, Bissada N, Al-Zahrani MS, Faddoul F, Nouneh I. Width of keratinized gingiva and the health status of the supporting tissues around dental implants. Int J Oral Maxillofac Implants. 2008;23(2):323\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHanisch O, Cortella CA, Boskovic MM, James RA, Slots J, Wikesj\u0026ouml; UM. Experimental peri-implant tissue breakdown around hydroxyapatite-coated implants. J Periodontol. 1997;68(1):59\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernandes-Costa AN, Menezes KM, Borges SB, Roncalli AG, Calderon PS, de Gurgel V. Clinical outcomes of peri-implant tissues in patients treated for peri-implant mucositis and followed up for 54 months: A prospective study. Clin Implant Dent Relat Res. 2019;21(5):1099\u0026ndash;105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChung DM, Oh TJ, Shotwell JL, Misch CE, Wang HL. Significance of keratinized mucosa in maintenance of dental implants with different surfaces. J Periodontol. 2006;77(8):1410\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrellana-Bustos AI, Espinoza-Santander IL, Franco-Mart\u0026iacute;nez ME, Lobos-James-Freyre N, Ortega-Pinto AV. Evaluation of keratinization and AgNORs count in exfoliative cytology of normal oral mucosa from smokers and non-smokers. Med Oral. 2004;9(3):197\u0026ndash;203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan der Weijden G, De Slegte C, Timmerman M, Van der Velden U. Periodontitis in smokers and non-smokers: Intra-oral distribution of pockets. J Clin Periodontol. 2001;28(10):955\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePranskunas M, Poskevicius L, Juodzbalys G, Kubilius R, Jimbo R. Influence of peri-implant soft tissue condition and plaque accumulation on peri-implantitis: A systematic review. J Oral Maxillofac Res. 2016;7(3):e5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoos-Jans\u0026aring;ker AM, Renvert H, Lindahl C, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part III: factors associated with peri-implant lesions. J Clin Periodontol. 2006;33(4):296\u0026ndash;301.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDorfman HS, Kennedy JE, Bird WC. Longitudinal evaluation of free autogenous gingival grafts: A four-year report. J Periodontol. 1982;53(6):349\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Dental implants, attached gingiva, peri-implantitis, marginal bone loss, smoking","lastPublishedDoi":"10.21203/rs.3.rs-8673286/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8673286/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study aimed to assess the demographic, clinical, and radiographic characteristics of patients who received dental implants over a five-year period, and to explore the relationship between the width of attached gingiva and peri-implant marginal bone loss..\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 107 patients with 330 dental implants placed at the Department of Periodontology, Faculty of Dentistry, Eskişehir Osmangazi University, were retrospectively evaluated. Recorded parameters included age, sex, smoking habits, plaque index (PI), gingival index (GI), probing depth, and width of attached gingiva. Marginal bone loss was measured on standardized panoramic radiographs, and implants were grouped according to attached gingiva width (\u0026lt;\u0026thinsp;2 mm or \u0026ge;\u0026thinsp;2 mm) and bone loss severity (\u0026lt;\u0026thinsp;1 mm, 1\u0026ndash;2 mm, 2\u0026ndash;3 mm, \u0026gt;\u0026thinsp;3 mm). Statistical analyses were performed using chi-square and independent samples t-tests, with the significance level set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong the implants examined, 79.7% had an attached gingiva width of \u0026ge;\u0026thinsp;2 mm, while 45.8% exhibited less than 1 mm of bone loss. Mean bone loss was significantly greater in implants with \u0026lt;\u0026thinsp;2 mm gingiva (2.17 mm) compared to those with \u0026ge;\u0026thinsp;2 mm (1.64 mm). Decreased gingiva width was associated with older age and smoking, and implants with narrower gingiva showed higher PI and GI scores.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eA limited width of attached gingiva appears to be linked to greater peri-implant bone loss. Preserving at least 2 mm of keratinized attached gingiva around implants may be important for maintaining peri-implant tissue health and long-term stability. Prospective multicenter studies are recommended to further substantiate these findings and establish optimal soft tissue management strategies.\u003c/p\u003e","manuscriptTitle":"Influence of Attached Gingiva Width on Peri-implant Bone Loss: A 5-year Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 14:26:03","doi":"10.21203/rs.3.rs-8673286/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-06T07:37:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-04T07:35:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-26T12:33:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-18T14:11:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-16T09:45:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39090234136931345898997814710508639620","date":"2026-02-16T03:23:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19171727053700285935941286484944219413","date":"2026-02-15T14:30:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190014269580843691727015296422455883390","date":"2026-02-14T14:54:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98525010686909100456673944360483901955","date":"2026-02-14T12:32:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291888920963142908790789020132021449943","date":"2026-02-14T12:01:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"295919256082485432825653855432170009672","date":"2026-02-13T18:50:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"257567574423004062694437214424204125078","date":"2026-02-12T19:27:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22564406596601881258154895913833380137","date":"2026-02-12T14:21:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-12T11:31:57+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-30T09:51:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-30T02:09:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-30T02:09:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2026-01-22T21:21:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f76f3daf-3662-42ba-8693-79659d854c07","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T06:56:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-18 14:26:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8673286","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8673286","identity":"rs-8673286","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}