The metal of my implant is showing, or there is a grey shadow in the gum

The body of the implant inside the bone and the connecting part fitted on top of it (the abutment) are most often made of titanium. In a natural tooth the root is light in colour, so it goes unnoticed even if the gum is thin; titanium, however, is grey. That is why, when the gum around the implant (in medical terms, the peri-implant mucosa) is thin, the metal can show through the tissue as a grey or bluish shadow. In this case the gum is in place and the metal is not exposed; the problem is only the colour.

In a laboratory study on pig jaws in Zurich (Ioannidis and colleagues, 2017), different materials were placed beneath mucosa 1, 2 and 3 millimetres thick and the colour was measured. All the materials caused a measurable colour change in the mucosa; this change tended to decrease as the tissue got thicker. The largest colour difference was measured with titanium under the thinnest tissue. Fluorescent zirconia and gold alloy were the materials that caused the least colour change. This is a laboratory study; it does not show the result in the mouth one-to-one, but it explains why gum thickness is decisive.

The second situation is the gum receding from the implant. Here the edge of the gum moves back and the metal connecting part beneath the crown, or the neck of the implant, becomes directly visible. A 2025 systematic review prepared for the Academy of Osseointegration and the American Academy of Periodontology, which examined 221 studies, found that this kind of recession is common even in healthy implants without inflammation: a soft tissue dehiscence on the outer surface of the implant was seen in an average of 46 per cent, and measurable gum recession in an average of 23 per cent. The rate of new recession developing within the first 5 years after loading could reach 48 per cent.

The same review also listed the risk factors for recession: thin mucosa, a lack of enough firm, immobile gum (keratinised mucosa) around the implant, an implant placed on the same day as the extraction, bone loss on the side surfaces of the implant (facing a neighbouring tooth or implant), and no soft tissue being added at the time of implant placement. The protective factors were guided surgery (done with a surgical guide), adding bone and soft tissue at the time of implant placement, and keratinised gum of sufficient thickness. In a study in Turin examining 146 patients who had had implants for an average of 13 years, a thick gum type and keratinised gum wider than 2 millimetres were also found to protect against recession.

The third and most important situation is inflammation around the implant (peri-implantitis). The 2017 World Workshop consensus report defines this as a plaque-associated disease marked by inflammation in the mucosa around the implant followed by progressive bone loss, and lists among its findings bleeding or pus on probing, deepening pockets, bone loss on X-rays and recession of the gum margin. As the bone is destroyed, the gum above it also collapses, and the rough, threaded surface of the implant can become visible. In the Turin study, implants with inflammation were about 2.2 times more likely to show a gum dehiscence.

Another cause is the position of the implant. If the implant was placed further forward than it should be, towards the lip or cheek, the bone and gum in front of it remain thin and the metal can show over time. A study classifying gum dehiscences at front teeth (Zucchelli and colleagues, 2019) takes into account, in making the classification, not only the position of the gum margin compared with the same natural tooth on the other side but also the position of the implant head between the lip and the palate, because the treatment option changes according to this. If there is a position problem, adding tissue alone may not always be enough.

Long-term follow-up shows the importance of gum structure. In a study that began with 128 patients who had implants in the back of the lower jaw and in which 64 patients could be examined at year 20, more bone loss, bleeding and gum recession were seen in those with no keratinised gum around the implant; inflammation around the implant was found in 4.2 per cent of those who had keratinised gum or gained it later with a graft, and in 25 per cent of those who did not. In a small group who later had a gum graft, the graft had a protective effect. About a third of those followed from year 10 to year 20 dropped out of the study; this should be kept in mind when interpreting these results. The 2017 consensus report also says the evidence on the effect of keratinised gum on long-term tissue health is not conclusive, but that it appears to have advantages for patient comfort and plaque removal.

The appearance itself does not show how serious it is. A grey shadow from thin gum can stay unchanged for years, while a painless inflammation can start destroying bone long before the metal shows. The European Federation of Periodontology (EFP) says peri-implant diseases are not always easy to notice, and that the warning signs are bleeding when brushing, swelling of the gum, a bad smell or taste, and looseness of the implant, bridge or denture. That is why, when metal shows, the real question is not correcting the appearance but first finding out whether there is inflammation and bone loss underneath.

The first list covers signs more consistent with gum thickness or recession without inflammation; for these, show your dentist at your usual check-up. If an item from the second list applies to you, inflammation or bone loss should be considered, and you should not wait for a routine appointment.

The assessment first rules out an emergency, then looks into whether there is inflammation, and finally into the source of the appearance problem.

1. 1

   Emergency signs are asked about

   If there is major swelling in the mouth, you cannot open your mouth, there is swelling around the eye or a problem with vision, or difficulty breathing, speaking or swallowing, the assessment is done in A&E; call 112. If none of these are present, the next steps take place at the dental practice.

2. 2

   The gum is examined

   The dentist looks for redness, swelling and pus around the implant, measures the pocket depth with a thin probe and checks for bleeding. The 2017 consensus report defines peri-implant health as the absence of redness, bleeding on probing, swelling and pus.

3. 3

   An X-ray is taken and compared with the previous one

   The X-ray shows the bone level around the implant. The consensus report recommends taking a baseline X-ray and measurements after the restoration is fitted; whether bone loss is progressing is worked out by comparing with this record. If you have old X-rays, take them with you.

4. 4

   Gum thickness and keratinised tissue are measured

   If there is no inflammation, the dentist looks at the thickness of the gum in front of the implant and the width of the band of firm, immobile gum. Some dentists roughly assess the thickness by checking whether the probe shows through the gum.

5. 5

   The position of the implant is assessed

   The dentist checks whether the head of the implant sits too far forward or too high compared with the neighbouring teeth; if needed, a 3D CBCT scan is requested. A position problem directly affects the treatment option.

6. 6

   The crown and connecting part are examined

   The shape of the part of the crown or bridge facing the gum is checked, and, if it is cemented, whether any cement residue has been left under the gum. The EFP says this kind of cement residue is often linked with inflammation around the implant.

7. 7

   A plan is made according to the cause

   If there is inflammation, it is treated first; surgery to correct the appearance is discussed once the inflammation is under control. If there is no inflammation, the option is decided according to how visible the problem is and what you expect.

Treatment depends on why the metal is showing. The options below are not alternatives to one another; they are often used in sequence or together.

The following are common wrong decisions in this situation and what they cost.

Timings vary a great deal with the procedure done. The flow below is a general framework; the plan your dentist gives you takes priority.

1. Initial assessment

   Why the metal is showing is determined with an examination, pocket measurement and an X-ray. If there is inflammation, treatment starts at this stage.

2. Treating inflammation and reassessment

   The EFP says reassessment after non-surgical treatment is usually done after 6 weeks. If bleeding has decreased and the pockets have become shallower, the intervals between check-ups are set; if not, the next step is discussed.

3. Tissue graft or correcting the restoration

   If a graft has been done, there may be tenderness in the palate and at the graft site in the first days; follow your dentist's check-up schedule for the stitches to be removed and the gum to settle. If the crown needs replacing, this is often done after the gum has healed.

4. Long-term follow-up

   The EFP recommends an X-ray of implants once a year, because in some patients inflammation around the implant can start 2–3 years after the implant. Regular professional cleaning and check-ups are also the way to prevent the appearance deteriorating again.

We do not give a single figure, because depending on why the metal is showing, treatment can range from a check-up appointment to redoing the implant. The main items that determine the scope:

Cause

Thin gum, recession without inflammation, inflammation or a wrong position: each requires a different treatment route.

Degree of inflammation and bone loss

There is a big difference between inflammation that can be controlled with non-surgical treatment and a picture that needs a bone graft or implant replacement.

Type of graft and number of sites

Tissue taken from the palate or a tissue substitute, a single implant or more than one site, change the scope.

Restorative work

Replacing or reshaping the crown, the connecting part or the full-mouth bridge requires separate laboratory work.