C ase L etter

A New Technique for Increasing Keratinized Tissue Around

Dental Implants: The Partially Epithelialized Free
Connective Tissue Graft. Retrospective Analysis of
a Case Series
Eberhard Frisch, Dr med dent, MSc1,2*
Petra Ratka-Kruger, Prof Dr*2
Dirk Ziebolz, Priv Doz, Dr med dent, MSc3

I ntroduction This article describes a novel technique developed by the

authors to increase the width of KM around dental implants
or decades, it has been known that the absence of

F
and presents results of a case series with up to 15 years of
keratinized gingiva around teeth and the resulting
follow-up.
mobility of marginal tissues promote bacterial invasion
of the gingival sulcus.1 In particular, the presence of
The partially epithelialized free connective tissue graft
keratinized gingiva improves the long-term prognosis of
technique
restored teeth.2 However, the relationship between a suffi­
ciently wide zone of keratinized mucosa (KM) and the long­ The procedure is performed under local anesthesia using four­
term success rate of oral implants remains controversial. A fold magnification loupes. A partial thickness incision is made
causal relationship has been postulated between the accumu­ along the implant's sulcus and extended approximately 5 mm
lation of bacterial plaque on implants and the progression of both mesially and distally, following the mucogingival junction
inflam m atory processes in the peri-im plant soft tissue.3 and separating the vestibular mucosa from the KM. The
Mucositis around implants is very similar to gingivitis around vestibular mucosal flap is then dissected from the periosteum
natural teeth, a fact that has been demonstrated in humans.4* to create an envelope that is approximately 15 mm deep
Some studies have shown that with adequate plaque control, (Figure la and b).
peri-implant tissues can be maintained in a healthy state. In Using a scalpel w ith tw o parallel blades, grafts are
those studies, no correlation was found between implant harvested from the palate between the distal aspect of the
survival or success and the presence o f KM.5,6 Other studies, lateral incisor and the mesial aspect of the first molar18 in the
however, have noted that in clinical practice, consistently good following manner. With a minimal distance of 2 mm to the
oral hygiene around restorations is difficult to maintain if no gingival margins, tw o parallel incisions are made to a depth of
keratinized gingiva is present.7,8 Several studies have demon­ approximately 10 mm. With a single-blade scalpel, the graft is
strated increased levels of plaque and inflammation around then dissected at the mesial, distal, and apical edges w ithout
implants in the absence of KM9" 11 More recent studies have removing the epithelium on top of the graft (Figure 2a through
shown that in spite of good oral hygiene and maintenance
d).
therapy, implants with less than 2 mm of KM in the peri-implant
The donor area is sutured and covered with a previously
region were significantly more prone to bleeding and exhibited
fabricated stent (Erkodent 1.5 mm, Erkodent GmbH, Pfalzgra-
greater radiologic bone loss, as well as buccal soft tissue
fenweiler, Germany) to facilitate wound healing. The partially
recession.12-16 Moreover, elevated values of immunologicpara-
epithelialized free connective tissue graft (PECTG) is placed into
meters (eg, PGE2) were observed in these implants.17 In order to
the envelope that was created at the recipient site, positioning
minimize these risks, various proposals have been made
the keratinized portion near the incision line (Figure 3a). The
regarding a potential surgical extension of the zone of KM
KM graft portion is then sutured to the local keratinized tissues
around implants.
(Figure 3b). To optimize the blood supply to the graft, the
mucosal flap is sutured to cover the connective tissue part of
' Northern Hessia Implant Center, Hofgeismar, Germany. the graft, and the grafted site is protected with periodontal
2 Department of Operative Dentistry and Periodontology, University of dressing.
Freiburg, Freiburg, Germany.
Postoperatively, patients may be provided with analgesics
3 Department of Carioiogy, Endodontology, and Periodontology, Univer­
sity of Leipzig, Leipzig, Germany. (ibuprofen 400 mg), and they are advised to rinse with
* Corresponding author, e-mail: [email protected] chlorhexidine 0.2% for up to 4 weeks. The stent is left in place
DOI: 10.1563/AAID-JOI-D-13-00006 for 48 hours at the donor site, and thereafter applied during

Journal of Oral Implantology 467

F igures 1 and 2. F igure 1. (a) Before surgery, the implant had thin tissues, recession, and a high inserting buccal frenulum, (b) Placement of
a partially epithelialized free connective tissue graft (PECTG) began by creating a partial thickness incision along the implant's sulcus,
following the mucogingival junction. The vestibular mucosa was then separated from the keratinized mucosa. F igure 2. (a) The PECTG is
harvested from the palate, at least 2 mm from the gingival margins with a double blade scalpel. The grade of scalpel angulation defines
the width of the keratinized part, (b) The parallel superficial incisions, (c) After a slight change of the scalpel's axis towards the teeth axes,
the incision can be performed to the final depth to harvest a sufficient connective tissue part, (d) The PECTG after harvesting.

meals and at night for 5 additional days. Sutures can normally All of the PECTGs survived, no implant was lost, and no
be removed after 7 days. Figure 4a through d illustrates healing peri-implantitis was recorded. The implant survival rate and
of tw o PECTGs from day 7 through 1 year. implant success rate thus were both 100%. All implants showed
a gain of keratinized tissue; the mean score changed from 0.24
mm KM preoperatively to 1.94 mm KM (mean KM gain of 1.7
C ase S eries mm) 5 years after PECTG surgery. Out of 23 implants, a majority
of 74% (n = 17) exhibited a KM w idth o f >2 mm after surgery,
Between January 1997 and June 2012, a total of 42 implants in
while none of the implants showed more than 0.75 mm before
22 patients were treated by an experienced periodontist (E.F.)
surgery (Table 3). The rate of peri-implant mucositis decreased
with PECTGs to increase the amount of vestibular tissue around
from 73.9% before PECTG to 30.4% after PECTG was performed.
the implants. Peri-implant outcomes for patients who met the
Because a relatively small group of patients with a wide range
inclusion criteria were evaluated. In all cases, the indication for
of observation periods was included, only descriptive statistics
surgery was <1 mm of KM at the buccal aspect of an implant.
were applied.
The inclusion criteria were met by 12 nonsmoking patients (9
women, 3 men), with a mean age of 58.4 ± 10 years at the time
of surgery (Table 1). Excluded were 3 patients who moved
D iscussion
away, 2 patients who had a PECTG performed for treatment of
peri-implantitis, and 5 patients who did not reach the minimum The goal o f this study was to evaluate a new technique for
follow-up period (at least 1 year). increasing keratinized tissue around dental implants. As all the
The mean follow-up period was 5 years (range: 1 to 15 grafts were successful after a mean follow-up period of 5 years,
years). In the 12 included patients, PECTGs were performed for the study revealed the feasibility of PECTG surgery. After
23 implants: 14 maxillary (60.9%) and 9 mandibular (39.1%) compliance with a supportive therapy program in a private
(Table 2). Different roughened-surface implant systems were practice, 100% implant survival and success rates (no diagnosis
included, and the included implants were restored with single of peri-implantitis) were found, along with a considerable gain
crowns (2 = 8.7%), fixed bridges (8 = 34.8%), and removable of KM in 23 implants. Weak points of the study were the
dentures (13 = 56.5%) made of noble (n = 9/39.1 %) or base (n = relatively small number of treated patients and implants,
14/60.9%) alloys, and retained with both screws (n = 11/47.8%) inclusion of different implant systems, and different types of
and cement (n = 12/52.2%). prosthodontic rehabilitations. Furthermore, no control group

468 Vol. XLI/No. Four/2015

 Frisch et al

Figures 3 - 5 . Figure 3 . (a) The keratinized p o rtio n o f th e partially epithelialized free connective tissue graft (PECTG) is positioned near the
incision line in the envelope th a t was created at the recipient site, (b) The partially covered PECTG after suturing. F igure 4 . (a) Two anterior
m andibular PECTGs, 7 days after surgery, (b) A t th e 7 day ap p ointm e n t, th e healing abutm ents were rem oved fo r impression m aking, (c)
The sites, 2 weeks after PECTG surgery w ith im p la nt abutm ents, (d) The graft sites, 1 year postoperatively, bo th im plants are surrounded by
a zone o f keratinized mucosa (KM). F igure 5. (a) PECTG at th e tim e o f placem ent at 2 m andibular im p la nt sites, (b) This m agnified view o f
th e same site 15 years later shows th a t th e graft surface is indistinguishable from the local KM surfaces.

c o u ld be prese n te d . Therefore, no s tro n g co n clu sio n s can be im p la n titis d e v e lo p e d . A re c e n t re v ie w w ith o b s e rv a tio n

d ra w n . p e rio d s > 1 0 years in c lu d in g 2652 im p la n ts in 904 subjects
As th e re are no e v id e n c e -b a s e d g u id e lin e s fo r th e fo u n d survival rates o f 94.8% -99.6% and success rates o f
tr e a tm e n t o f p e ri-im p la n titis , p re v e n tio n s tra te g ie s have 83.1% -94.2% .24 Patients w h o d o n o t s u ffic ie n tly c o m p ly w ith
b e c o m e in crea sin g ly im p o rta n t. On th e o n e hand, in sta lla tio n re g u la r im p la n t m a in te n a n c e m ay be e x p e c te d to sh o w
o f p o s tim p la n t m a in te n a n ce p ro g ra m s m ay c o n trib u te to lo n g ­ sig n ific a n tly h ig h e r values o f p la q u e and p e ri-im p la n t disease.
te rm s ta b ility o f p e ri-im p la n t tissues. Several studies have This sh o u ld be co n sid e re d in th e in te rp re ta tio n o f o u r results.
d e m o n s tra te d a p o s itiv e in flu e n ce o f re g u la r p a rtic ip a tio n in a On th e o th e r hand, th e q u a lity and th ickn e ss o f p e ri-
p ro fe ssio n a l SIT p ro g ra m .19-23 The fin d in g s o f th e p re se n t stu d y im p la n t tissue also m ay in flu e n ce th e genesis o f p e ri-im p la n t
c o n firm th e se results, as n o case o f im p la n t loss o r peri- diseases. C o n tro ve rsy has su rro u n d e d th e q u e stio n o f w h e th e r

Journal of Oral Implantology 469

New Technique for Increasing Keratinized Tissue

T able 1
that initial gingival tissue thickness at the crest has a significant
influence on marginal bone stability around implants.38 In
P a tie n t ch a ra cte ristics (n = 12) implant restorations, the thick flat tissue biotype was found to
Total be an important factor for a successful esthetic treatment
Age, mean ± SD, y 62.7 ± 9.4
outcome.35
Gender, n (%) It can be summarized that implants in individuals with
Female 9 (75%) buccal position of the implant shoulders, implants in individuals
Male 3 (25%) with a thin biotype, implants with only a thin coverage of soft
Smoking habits, n (%) tissue, and implants with little to no keratinized tissue may be
Nonsmoker 12 (100%) prone to mucosal recession, esthetic problems, and peri-
Smoker 0
implant bone loss. Therefore, in order to increase mucosal
General illnesses, n (%)
thickness and KM width in those cases, peri-implant soft tissue
Diabetes mellitus 0
Coronary heart disease 3 (25%) augmentation should be considered. The PECTG was created
Observation period, mean ± SD (median) 5.1 ± 5.6 (1.25) with the aim of at least partially overcoming these problems.
implants, n 23 The hope was that patients could benefit by reducing the risk
Maxilla, n {%) 14 (61%)
of esthetic problems, midfacial mucosal recession, and inflam­
Mandible, n (%) 9 (39%)
matory peri-implant diseases that could lead to progressive
bone loss and implant failure in the long term.
Many years ago, Harris,18 recommended a double-blade
the presence or absence of KM affects peri-implant disease scalpel for harvesting connective tissue graft material for root-
rates. Some studies have revealed significantly higher scores for coverage procedures. Such a scalpel also can be effectively
peri-implant mucositis (bleeding on probing positive) at used to harvest PECTGs with a defined thickness of approxi­
implants with <2 mm of KM w idth.14-17,25,26 Other studies mately 1.5 mm and an approximately 2-mm wide band of KM.
have not confirmed this.9,13 In the present study, the mucositis Because all grafted tissues are cut off from their original blood
rate was 38.9%. This is in accordance with a review of Roos- supply, a primary goal in developing the PECTG procedure was
Jansaker et al,27 who found mucositis rates between 39.6% and to create maximal vascular adjacency to help ensure the
52.3%. An actual systematic review with meta-analyses revealed maximum number of cells would survive until new blood
significant differences in several periodontal parameters (ie, vessels were able to form. An advantage of the PECTG has been
mucosal recession and attachment loss) depending on the KM its position mostly in direct contact with vascularized tissue, the
width.28 underlying periosteum, and the covering alveolar mucosa. This
An adequate peri-implant soft tissue level has been facilitates early nourishment of the graft cells from both sides,
essential to achieving long-term esthetic success in implant as does the recently proposed partly epithelialized free gingival
therapy. Therefore, preventing peri-implant mucosal recession graft.39
has increasingly been a focus of attention. Marginal tissue Free gingival grafts, while used for many years in cases
recession around natural teeth can occur even in populations requiring KM around natural teeth, are nourished only from the
with high oral hygiene standards.29,30 Correspondingly, reces­ underlying periosteum. Esthetic outcomes of this mucogingival
sion may be expected in implant sites too, but data on this surgical technique have been less than optimal because the
topic have been scarce. Bianchi and Sanfilippo31 investigated color and texture of the palate are transposed to the operation
22 implants in 22 individuals after submerged implant site. A recent study of esthetic outcomes of different root-
placement using connective tissue grafts (CTG). Another 20 coverage procedures found the soft tissue appearance was a
implants were placed immediately in 20 patients w ithout using significant factor in cosmetic assessments. Submerged and
CTG. They served as a control. After 6-9 years, mucosal envelope techniques had esthetic outcomes that were superior
recession of >1 mm was found in 5% of the CTG group and to nonsubmerged grafts.40 In line with that finding, PECTGs
20% of the control group. Evans and Chen32 found >1 mm of typically do not result in a different appearance between the
midfacial recession to be a common phenomenon that may be graft and local tissue surfaces (Figure 5a and b). A recent review
expected in 40.5% of sites. Individuals with a thin biotype and found weak evidence that peri-implant augmentation with soft
buccal positioning of the implant shoulders were more prone tissue grafts may result in increased soft tissue thickness and
to recession. Several recent studies have found the soft tissue improved esthetics. However, there is insufficient evidence
biotype to be an important parameter in achieving esthetics regarding the best soft tissue augmentation technique and the
and preventing mucosal recession.33-37 Another study revealed benefits of an increased width of KM for implants.41

Table 2

Distribution of implants and teeth according to tooth and jaw position (American Dental Association notation)
Implants in the maxilla 0 0 1 3 1 2 1 0 0 1 1 2 0 1 1 0
Tooth position 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
Implants in the mandible 0 o 0 0 1 1 2 0 0 2 1 1 1 0 0 0

470 Vol. XLI/No. Four/2015

 Frisch et al

Table 3

Clinical parameters and outcomes of patients/implants (n = 12 patients)*

Parameters Preoperative (n = 18 Implants) Postoperative (n = 23 Implants)
PPD, mean ± SD (range), mm NA 3.4 ± 0.8 (2.5-5.5)
BOP-positive (peri-implant mucositis), n (%) 17 (94.4%) 7 (30.43%)
KM, mean ± SD (range), mm 0.24 ± 0.26 (0-0.75) 1.9 ± 0.7 (0.5-3.0)

*PPD indicates pocket depth; BOP, bleeding on probing; KM, width of keratinized mucosa; and NA, not applicable.

C onclusions keratinized mucosa in maintenance of dental implants with different

surfaces. J Periodontol. 2006;77:1410-1420.
High survival and high success rates and a low prevalence of 10. Warrer K, Buser D, Lang NP, Karring T. Plaque-induced peri-
peri-implant diseases over long periods of time may be implantitis in the presence or absence of keratinized mucosa. An
experimental study in monkeys. Clin Oral Implants Res. 1995;6:131-138.
expected in patients attending professional SIT programs. Use
11. Zarb GA, Schmitt A. The longitudinal clinical effectiveness of
of the PECTG proved to be feasible and resulted in an increased osseointegrated dental implants: the Toronto study. Part III: problems and
KM width around implants. However, due to the lack of a complications encountered. J Prosthet Dent. 1990;64:185-194.
control group, no strong conclusions can be drawn. Future 12. Esper LA, Ferreira SB Jr, de Oliveira Fortes Kaizer R, de Almeida AL.
The role of keratinized mucosa in peri-implant health. Cleft Palate Craniofac
independent and prospective evaluations should compare
J. 2012;49:167-170.
horizontal and vertical tissue dimensional changes following 13. Kim BS, Kim YK, Yun PY, et al. Evaluation of peri-implant tissue
use of the PECTG with other surgical approaches. response according to the presence of keratinized mucosa. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2009;107:e24-e28.
14. Adibrad M, Shahabuei M, Sahabi M. Significance of the width of
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A bbreviations implants supporting overdentures. J Oral Implantol. 2009;35:232-237.
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BOP: bleeding on probing keratinized gingiva and the health status of the supporting tissues around
CTG: connective tissue grafts dental implants. Int J Oral Maxillofac Implants. 2008;23:323-326.
KM: keratinized mucosa 16. Schrott AR, Jimenez M, Hwang JW, Fiorellini J, Weber HP. Five-year
PECTG: partially epithelialized free connective tissue graft evaluation of the influence of keratinized mucosa on peri-implant soft-tissue
health and stability around implants supporting full-arch mandibular fixed
PPD: pocket depth
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Periodontol. 1992;63:477-486.
Dragoo, Escondido, Calif, for different study club lectures
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