One of the main criteria for long‐term implant success has always been related to the limitation of marginal bone loss (MBL) around implant necks (Albrektsson, 1986). However, peri‐implant bone loss of 1.5–2.0 mm during the first year of loading and an annual bone loss thereafter of <0.2 mm has generally been considered acceptable for two‐piece implants. (Adell, Lekholm, Rockler, & Brånemark, 1981; Albrektsson et al., 1986). Despite numerous explanations, the multifactor etiology of MBL is not yet well understood (Oh, Yoon, Misch, & Wang, 2002; Tatarakis, Bashutski, Wang, & Oh, 2012).

Early marginal bone loss may be influenced by both surgical factors (overheating during site preparation, excessive cortical compression, insufficient crestal bone width and/or implant malpositioning, and implant crest module characteristics) and by prosthetic variables (type of implant/abutment connection, entity and location of implant/abutment microgap, multiple abutment disconnections, and cement remnants; Canullo, Bignozzi, Cocchetto, Cristalli, & Iannello, 2010; Oh et al., 2002; Qian, Wennerberg, & Albrektsson, 2012; Tatarakis et al., 2012). An important additional influence upon MBL around healthy implants is biologic width establishment following abutment connection (Broggini et al., 2006; Cochran, Hermann, Schenk, Higginbottom, & Buser, 1997; Eriksson, Nilner, Klinge, & Glantz, 1996; Hermann et al., 2001). More recent findings even suggest that early marginal bone resorption is influenced more by prosthetic rehabilitation characteristics than by the post‐surgical bone remodeling process, significantly increasing up to 6 months after functional loading before stabilizing (Galindo‐Moreno et al., 2015).

The influence of mucosal thickness upon MBL around implant necks was discussed by Cochran et al. (1997), suggesting that soft tissue creates a protective barrier against inflammatory infiltration toward the underlying alveolar bone. Later studies suggested that the vertical mucosal thickness necessary for biological width establishment around two‐piece dental implants should be at least 2 mm to avoid MBL (Linkevicius, Apse, Grybauskas, & Puisys, 2009; Suárez‐López Del Amo, Lin, Monje, Galindo‐Moreno, & Wang, 2016). Other studies suggested that a variable amount of MBL may occur to provide the necessary space for biological width establishment (Berglundh, Abrahamsson, & Lindhe, 2005; Hermann et al., 2001).

More recently, this concept has been re‐elaborated by Linkevicius, Apse, Grybauskas, and Puisys (2010), specifically stating that vertical keratinized mucosal thickness is a significant factor in limiting peri‐implant marginal bone loss around platform‐ switched implants placed at crestal level. One year after loading, implants with an initial vertical mucosal thickness greater than 2 mm maintained marginal bone levels more successfully than implants with an initial mucosal thickness ≤2 mm (Linkevicius, Puisys, Steigmann, Vindasiute, & Linkeviciene, 2015). Indirect confirmation of this concept was then provided by Vervaeke, Collaert, Cosyn, and Bruyn (2016), who concluded that initial peri‐implant bone remodeling was affected by mucosal thickness, even though initial mucosal thickness was not measured in their case series study. The authors postulated that abutment height was determined by mucosal thickness, as abutments were chosen at the time of implant insertion and their height was adapted to site‐specific mucosal thickness.