What Is Keratinised Tissue and Why Does It Matter for Implants?

If you have been told you have "not much keratinised tissue" around an implant, the phrase probably arrived without much explanation. It sounds like a diagnosis. It is closer to a description of the terrain.

This article takes a deliberately practical angle: what the two kinds of gum tissue actually are, how you can recognise which one you have around your implant, and — the part that matters day to day — what it changes about cleaning and comfort. The tissue biology behind it, including how gum fibres attach differently around implants than around teeth, is covered separately in our article on keratinised tissue and long-term implant health.

Look inside your own mouth and there are two visibly different tissues.

Around the necks of your teeth there is a band of pale pink, firm, slightly stippled gum. It does not move when you pull your lip. This is keratinised tissue — so called because its surface layer contains keratin, the same structural protein that makes the outer layer of skin tough. It is built to take abrasion: chewing, brushing, the friction of food passing over it.

Further away from the teeth, towards the lip and cheek, the tissue changes. It becomes darker red, shinier, thinner and noticeably mobile. This is alveolar mucosa, and it is built for flexibility rather than resilience. You can often see small blood vessels through it. The boundary between the two is a reasonably distinct line called the mucogingival junction.

Around a natural tooth there is usually a comfortable band of the firm type. Around an implant, that band is far less reliably present, particularly if the tooth was lost long ago, if the ridge has resorbed, or if surgical flaps were repositioned during placement.

There is a simple test used in the surgery and you can approximate it yourself with a mirror.

Gently pull your lip or cheek outwards and watch the gum at the implant. If the tissue right at the collar of the restoration stays completely still, you have keratinised tissue there. If the tissue tugs and moves with the lip — if a small fold or crease travels right up to the edge of the crown — then the mucosa is attaching close to or at the implant margin and there is little or no firm band.

The visual clues support this. Keratinised tissue is matt, pale pink and firm. Mucosa is glossy, redder and moves.

A commonly cited working figure is that roughly two millimetres of keratinised width, with at least one millimetre of it firmly attached to underlying bone, gives the tissue enough resilience to handle daily function comfortably. Less than that, and the collar around the implant is essentially mobile lining tissue.

Here is the part that is usually left out.

The evidence about whether a narrow band of keratinised tissue independently causes implant disease is genuinely mixed. Plenty of implants with minimal keratinised tissue remain stable for many years in people who clean well. What the evidence agrees on far more consistently is this: where the band is narrow, patients report more discomfort during brushing, more bleeding, and more plaque accumulation.

The mechanism is straightforward. Mobile mucosa does not resist a toothbrush. It gets pushed, it stretches, and it becomes sore. A sore area is an area people brush more cautiously, or avoid. Plaque accumulates where the brush does not reach properly. Inflammation follows, and inflamed mucosa bleeds more readily and feels worse, which reinforces the avoidance.

So the chain runs from tissue quality through comfort to cleaning behaviour, and it is the cleaning behaviour that determines what happens to the implant. That is a more accurate framing than saying thin tissue causes disease, and it is more actionable, because it identifies where to intervene.

There is a related point about the shape of the tissue rather than its type, covered in our article on how gum shape affects implant results.

If the tissue around your implant is mobile and tender, technique changes are usually more effective than trying harder.

Use a soft or extra-soft brush and reduce pressure. Brushing harder on mobile tissue produces soreness without improving plaque removal, a point made more generally in our article on whether brushing harder cleans better.

Angle the brush along the margin rather than into it. Small circular or short horizontal movements parallel to the gum line are better tolerated than scrubbing towards the tissue.

Consider a powered brush with a pressure sensor. The value here is not superior cleaning so much as consistent, limited force, which is exactly what sensitive mucosa needs. Our guide to using an electric toothbrush on an implant covers the practical points.

Favour interdental brushes sized correctly over forcing floss. Where the tissue is delicate, a correctly sized interdental brush is usually gentler and more effective than sawing floss through a tight contact. The comparison is set out in interdental brushes versus floss around implants.

A water flosser is a reasonable adjunct. It is not a replacement for mechanical cleaning, but it reaches areas around implant restorations that are awkward to access and it applies no abrasive force at all. Our article on water flossers for implants covers settings and technique.

• Keratinised tissue is firm, pale and immobile; mucosa is red, shiny and moves with the lip.

• Pulling the lip and watching whether the tissue at the implant moves is a reasonable self-check.

• Around two millimetres of width is the commonly cited working threshold.

• The strongest evidence links narrow bands to discomfort and plaque accumulation rather than directly to implant loss.

• Grafting is usually considered for comfort and cleanability, not as an emergency measure.

Adding keratinised tissue is a well-established procedure, most commonly a free gingival graft taken from the palate and placed around the implant to widen the firm band.

It is worth discussing in specific circumstances: where brushing the area is consistently uncomfortable; where the tissue bleeds readily despite reasonable cleaning; where the margin is progressively receding and exposing metal; where a removable denture rubs against the area; and where the implant supports a larger restoration that is harder to clean, such as a full-arch bridge.

It is less clearly indicated where the implant is comfortable, the tissue is stable over successive reviews, and cleaning is being managed well. A narrow band that has caused no problems for eight years is not automatically a problem now.

Timing is worth mentioning too. It is generally easier to augment tissue before or at the time of implant placement than afterwards, once a restoration is in place and access is limited. If you are still in the planning stage and this has been raised, it is a reasonable question to ask about explicitly. Our article on soft tissue architecture around implants covers how this fits into overall planning.

If the gum around your implant is tender to brush, bleeds easily or looks as though it is receding, arrange an assessment through our contact page so the tissue type and stability can be measured properly rather than guessed at.

You can read more on our dental implants page, our receding gums page for tissue loss around teeth and implants, our gum disease treatment page, and our dental hygiene page for maintenance appointments.

This article is for general information only and does not constitute dental or medical advice. Tissue quality around an implant, and whether grafting is appropriate, can only be assessed by clinical examination. Always consult a registered dental professional about your own circumstances. If you have pain, swelling or bleeding around an implant, please arrange an appointment.

Next review due: 6 August 2027