Interview: “Can we achieve disease-free longevity in peri-implant tissues?”: Dr Alberto Miselli

The Umbrella Concept brings together prosthetic design, three-dimensional implant positioning and the biological requirements of the supracrestal tissue complex. When you first began developing this concept, what clinical observations or recurring challenges led you to look beyond osseointegration and consider these elements as an interconnected system? What were you hoping clinicians would begin to understand differently?

The Umbrella Concept™ emerged from a recurring clinical observation: osseointegration alone does not guarantee long-term peri-implant health.

Throughout my clinical experience, I observed successfully osseointegrated implants developing marginal bone loss, soft-tissue inflammation and biological complications.

These observations led me to recognise that implant longevity depends on the interaction between three-dimensional implant positioning, prosthetic design, the emergence profile and the biological stability of the Implant Supracrestal Complex (ISC).

I came to understand that bone, soft tissues and prosthetic components must be planned as an interconnected biological and functional system rather than as independent elements.

The concept progressively evolved to incorporate tissue vascularisation, oxygenation, osteoimmunology and the maintenance of peri-implant homeostasis.

My goal was to encourage clinicians to move beyond implant survival and focus on Disease-Free Longevity (DFL).

The fundamental message of the Umbrella Concept™ is simple:

“Osseointegration is the foundation, but biological homeostasis is the key to disease-free longevity.”

An implant can achieve osseointegration and still encounter biological or restorative complications over time. In your clinical reasoning, when does a successfully integrated implant become a genuinely successful long-term restoration? Which parameters do you consider essential when making that distinction?

From my perspective, an implant is a successful long-term restoration when it remains functional and free from peri-implant inflammation and progressive pathological marginal bone loss, while maintaining the stability of the surrounding tissues and the prosthetic restoration. Osseointegration is essential, but it is not sufficient.

Within the Umbrella Concept™, I evaluate five fundamental parameters:

1. Implant Supracrestal Complex (ISC): the integrity of the biological barrier formed by the peri-implant sulcus, junctional epithelium and supracrestal connective tissue.
2. Marginal bone stability: the absence of pathological progressive bone loss, assessed through comparative radiographic examinations.
3. Peri-implant health: the absence of clinical signs of inflammation, suppuration and bleeding on probing, together with stable probing depths.
4. Prosthetic design and function: appropriate three-dimensional implant positioning, a tissue-compatible emergence profile, mechanical stability and accessibility for effective oral hygiene.
5. Long-term monitoring: preservation of these parameters through regular follow-up and individualised management of risk factors.

The fundamental difference between implant survival and implant success lies in the clinical course over time. It is not enough for an implant to remain osseointegrated; its biological, structural and functional condition must remain stable.

This perspective leads to the central objective of the Umbrella Concept™: Disease-Free Longevity (DFL), defined as the long-term functional preservation of an implant without active peri-implant disease or progressive deterioration of its supporting structures.

“Implant survival is not the ultimate goal. Disease-free longevity is.”

The supracrestal peri-implant tissue complex is not simply a measurement of soft-tissue thickness. Its vertical dimension, volume, quality, vascularity and distribution may all influence the biological environment. How do you interpret these characteristics together when assessing a site, and how has this understanding influenced your approach to peri-implant tissue management?

From the perspective of the Umbrella Concept™, peri-implant stability depends on the interaction of three essential elements: soft-tissue architecture, bone support and implant-prosthetic design.

The Implant Supracrestal Complex (ISC) consists of the peri-implant sulcus, junctional epithelium and supracrestal connective tissue, which together form a protective biological barrier.

Clinically, I evaluate tissue thickness, vertical dimension, phenotype, keratinisation and vascularity, as well as marginal bone architecture, particularly the buccal bone plate.

I use approximately 4 mm from the bone crest to the mucosal margin as an individualised clinical planning reference, not as a universal biological requirement.

Equally important are implant positioning, placement depth, transmucosal abutment height and the emergence profile, since prosthetic design directly influences the surrounding tissues.

My philosophy is simple: tissues should not be forced to adapt to the prosthesis; the prosthesis must be designed to respect tissue biology.

This balance between soft tissues, bone and prosthetic design is central to the Umbrella Concept™ and our goal of achieving Disease-Free Longevity (DFL).

Implant positioning is often discussed in terms of bone availability and prosthetic alignment. However, the available restorative space and the tissue envelope can impose additional biological and restorative considerations. When these requirements compete with one another, how do you prioritise implant depth, platform position and the intended prosthetic transition? What clinical compromises do you consider acceptable, and which would make you reconsider the plan?

Treatment planning begins with the definitive restoration, following a clear order of priorities: anatomical safety and bone support, supracrestal biological space, three-dimensional implant positioning and prosthetic feasibility. All these factors must be evaluated as an integrated system.

I consider it essential to preserve the Implant Supracrestal Complex (ISC), consisting of the peri-implant sulcus, junctional epithelium and supracrestal connective tissue. I use approximately 4 mm between the bone crest and the mucosal margin as a clinical planning reference, individualised according to tissue phenotype and anatomy.

The subcrestal depth of the implant platform represents a separate dimension. In certain implant systems, placing the implant approximately 2 mm below the bone crest may facilitate an appropriate transmucosal transition, but it does not, by itself, increase the vertical dimension of the ISC.

In the buccolingual dimension, I prioritise preservation of the buccal bone plate and an emergence profile without excessive contours. In the mesiodistal dimension, I respect biological distances, using approximately 1.5 mm between an implant and an adjacent tooth and 3 mm between neighbouring implants as general clinical references.

The available restorative space must provide sufficient prosthetic height, mechanical stability, a progressive emergence profile and adequate access for oral hygiene.

I consider it acceptable to modify implant dimensions, select alternative prosthetic components or perform regenerative procedures when necessary. However, I would reconsider the treatment plan if the proposed implant position compromised bone support or supracrestal tissue stability, or required a biomechanically unfavourable restoration that would be difficult to maintain.

My guiding principle is that the ideal implant position must simultaneously meet biological and prosthetic requirements without compromising either.

This balance represents one of the fundamental principles of the Umbrella Concept™ and contributes to achieving Disease-Free Longevity (DFL).

“The ideal implant position is not simply where bone is available, but where biology and prosthetics can coexist in long-term stability.”

The emergence profile is commonly used to shape peri-implant tissues and achieve an appropriate restorative contour. You have also emphasised its relationship with tissue support, hygiene access and biological stability. How do you decide what the emergence profile should accomplish in an individual case, and how do you balance tissue conditioning and aesthetic demands against the restoration's long-term cleanability?

The emergence profile is designed on an individual basis, considering the three-dimensional position of the implant, the mucosal phenotype, the available transmucosal height, and the aesthetic and functional requirements.

I use the Esthetic Biological Contour (EBC) Concept, proposed by Gómez-Meda, Esquivel and Blatz, as a reference. This concept distinguishes three zones: E (Esthetic), which supports the mucosal margin; B (Biological), which allows a gradual prosthetic transition; and C (Crestal), where the space required for the supracrestal tissues must be respected.

In the anterior region, I prioritise aesthetic integration and adequate support of the mucosal margin. I use provisional restorations to condition the tissues progressively while avoiding excessive compression.

In the posterior region, where functional and maintenance requirements predominate, I favour less convex contours, smooth transitions and adequate access for oral hygiene, avoiding bulky emergence profiles that could interfere with biofilm control.

In both regions, the design must respect the Implant Supracrestal Complex (ISC) and its biological stability.

My clinical principle is to provide support where needed and preserve space where biology requires it. The goal is to balance aesthetics, function, and ease of maintenance, promoting long-term peri-implant health.

Soft-tissue thickness, keratinised tissue and mucosal positioning can present different clinical challenges around implants. Rather than treating every deficiency in the same way, how do you determine which tissue characteristic actually requires intervention in a particular patient? How do you weigh tissue thickening, keratinised tissue augmentation and flap repositioning against the possibility that a different prosthetic or restorative strategy may address the underlying problem?

From the perspective of the Umbrella Concept™, my decision depends on identifying the specific clinical problem that needs to be addressed.

If the patient has a thin mucosal phenotype, I consider soft-tissue thickening with connective tissue grafts to improve tissue volume and mucosal margin stability.

If keratinised mucosa is insufficient and compromises oral hygiene or contributes to discomfort and inflammation, I consider augmentation using free gingival grafts.

If the problem involves mucosal positioning or inadequate vestibular depth, I evaluate flap repositioning.

Before performing any surgery, I determine whether the problem can be resolved by modifying the emergence profile or prosthetic design.

My principle is to address the underlying clinical cause rather than automatically treating every anatomical deficiency, preserving the stability of the Implant Supracrestal Complex (ISC) and promoting long-term peri-implant health.

The biological and restorative decisions made during implant healing and provisionalisation can influence the final peri-implant tissue architecture. How do you approach the transition from the healing phase to provisionalisation and then to the definitive restoration? What do you consider most important to preserve during this process, and where do you find that continuity is most often lost in clinical practice?

I consider healing, provisionalisation and definitive restoration to be interconnected phases of a single biological and prosthetic process.

During healing, my priority is to preserve mucosal architecture, vascularity and the stability of the Implant Supracrestal Complex (ISC), avoiding unnecessary tissue manipulation.

During provisionalisation, I condition the tissues progressively through controlled adjustments of the transmucosal contour, respecting their biological response and maintaining adequate access for oral hygiene.

Accurate transfer of the emergence profile is a critical step. Once a stable mucosal architecture has been achieved, I record the subgingival geometry of the provisional restoration using a customised impression coping or an individualised scan body, preventing standard components from altering or collapsing the established tissue contour during registration.

This information allows the definitive restoration to reproduce the clinically validated transmucosal contour without introducing excessive convexity or additional tissue pressure.

Continuity is most often lost when the provisional emergence profile is not recorded accurately, when its geometry is modified in the laboratory, or when too much time elapses between removal of the provisional restoration and tissue registration, allowing soft-tissue changes to occur.

My principle is to preserve the tissue architecture established during provisionalisation in the definitive restoration, without compromising biological stability or cleanability.

This continuity is an essential component of the Umbrella Concept™ and helps achieve Disease-Free Longevity (DFL).

Long-term peri-implant health requires more than identifying disease once clinical signs become apparent. From your perspective, what should clinicians establish as a meaningful baseline after restoration, and which changes in tissue condition, prosthetic contour or patient-level factors deserve particular attention during follow-up? How should these observations influence subsequent clinical decisions?

Within the Umbrella Concept™, peri-implant maintenance begins by establishing a clinical and radiographic baseline after placement of the definitive restoration.

I record probing depths, bleeding on probing, the presence of suppuration, mucosal margin position and marginal bone levels. I also evaluate the emergence profile, access for oral hygiene and the patient’s systemic risk factors.

During follow-up, I pay particular attention to changes from baseline, especially increasing probing depths, bleeding or suppuration, mucosal recession and progressive marginal bone loss.

I also assess whether the prosthetic design interferes with biofilm control and whether factors such as smoking, glycaemic control or oral hygiene have changed.

My principle is to identify and address risk factors before irreversible deterioration occurs. Based on the findings, I adjust the maintenance schedule, reinforce biofilm control, modify the restoration when necessary or initiate appropriate peri-implant treatment.

The goal of the Umbrella Concept™ is to maintain biological stability and achieve Disease-Free Longevity (DFL).

As your experience with the Umbrella Concept and peri-implant tissue management has grown, have you encountered clinical outcomes that differed from what you initially expected? How did you interpret those situations, and did they lead you to modify any aspect of your clinical reasoning?

Yes. Throughout my clinical experience, I have observed that successful osseointegration does not always guarantee long-term peri-implant tissue stability.

In some cases, despite excellent initial implant stability, marginal bone remodelling, inflammation, or soft-tissue changes may occur.

These observations led me to pay greater attention to the Implant Supracrestal Complex (ISC), the mucosal phenotype, the three-dimensional position of the implant and the prosthetic design, particularly the emergence profile and transmucosal height.

I also came to understand that marginal bone remodelling should not automatically be interpreted as failure. It must be assessed in the context of biological adaptation, inflammation, and the clinical and radiographic course over time.

My reasoning has evolved from focusing primarily on osseointegration to prioritising long-term biological stability.

This evolution is one of the foundations of the Umbrella Concept™: achieving integration is not enough; we must create the conditions that keep the implant healthy and support Disease-Free Longevity (DFL).

Peri-implant tissue stability is influenced by several interacting factors, including tissue characteristics, implant positioning, prosthetic design, inflammation and patient-related variables. In a clinical situation where more than one factor could explain an unfavourable outcome, how do you avoid overemphasising a single variable? Has this way of thinking changed how you approach treatment planning over the years?

From my perspective, one of the greatest mistakes in implant dentistry is attributing a complication to a single factor. Peri-implant stability results from the interaction between the patient’s biology, bone and mucosal conditions, surgical technique and prosthetic design.

Therefore, when I encounter an unfavourable outcome, I do not immediately look for a single cause. I evaluate the Implant Supracrestal Complex (ISC), the implant's three-dimensional position, bone support, the emergence profile, oral hygiene, and the patient’s systemic and inflammatory factors.

My approach is to identify which factors are contributing to the problem and which can be modified, while avoiding the confusion of clinical association with a causal relationship.

Over the years, my reasoning has evolved from a primarily mechanical view centred on osseointegration towards a more comprehensive understanding of peri-implant biology.

This is precisely the foundation of the Umbrella Concept™: integrating biological, surgical, prosthetic and systemic factors to make individualised decisions.

My principle is simple: we do not treat isolated variables; we treat a biological system in which all the factors interact.

The Umbrella Concept brings together several interdependent factors, from implant positioning and prosthetic design to the characteristics of the surrounding tissues. When multiple variables contribute to the same clinical outcome, how would you distinguish the influence of each individual factor from the effect of their interaction? What would you consider the most meaningful way to test whether this integrated approach offers an advantage over evaluating these factors separately?

The Umbrella Concept™ is based on a fundamental principle: peri-implant stability does not depend on a single variable, but on the interaction of biological, surgical, prosthetic and systemic factors.

To distinguish the influence of each factor, I believe prospective studies are necessary to evaluate individual variables such as mucosal phenotype, the Implant Supracrestal Complex (ISC), three-dimensional implant positioning and prosthetic design. Multivariable statistical analyses could then help identify their independent effects and potential interactions.

However, validating the Umbrella Concept™ must show that its integrated application produces better clinical outcomes than conventional approaches.

To do so, I would propose comparative clinical studies, ideally across multiple centres, with standardised protocols and long-term follow-up. These studies should assess marginal bone stability, soft-tissue health, the incidence of peri-implant diseases and prosthetic complications.

My goal is not simply to show that each variable matters individually, but to determine whether integrating them improves treatment predictability and promotes Disease-Free Longevity (DFL).

I believe the Umbrella Concept™ must remain open to scientific evaluation, critical review and continuous refinement as new evidence emerges.

Looking at the evolution of implant dentistry, what do you believe clinicians still underestimate about achieving long-term peri-implant health? If you were developing the Umbrella Concept today, with the current understanding of tissue biology, biomaterials and digital restorative workflows, what would you investigate or approach differently?

I believe clinicians still underestimate the importance of vascularisation, tissue oxygenation, the osteoimmunological response and the interaction between the Implant Supracrestal Complex (ISC) and prosthetic design.

Looking ahead, I would investigate how inflammatory biomarkers, bioactive biomaterials and digital technologies could be integrated to develop more individualised and predictable treatments.

The future of implant dentistry is not simply about achieving osseointegration, but about understanding, preserving and maintaining the biological environment that allows implants to remain healthy throughout life.

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