1

Journal of Oral Medicine and Dental

Research Genesis-JOMDR-1(1)-04
Volume 1 | Issue 1
Open Access

Evaluation of Keratinized Tissue at Peri-

Implant Mucosa and Free Gingival Graft
Application: Case Series
Emine Pirim Gorgun1*, Nilufer Altunbas1, Mustafa Kemal Erenler1

1
Cumhuriyet University, Faculty of Dentistry, Department of Periodontology, Sivas, Turkey

*
Corresponding author: Emine Pirim Gorgun, Cumhuriyet University, Faculty of Dentistry, Department of
Periodontology, Sivas, Turkey

Citation: Gorgun EP, Altunbas N, Erenler MK. (2020) Copyright© 2020 by Gorgun EP. All rights reserved.
Evaluation of Keratinized Tissue at Peri-Implant This is an open access article distributed under the
Mucosa and Free Gingival Graft Application: Case terms of the Creative Commons Attribution License,
Series. J Oral Med and Dent Res. 1(1):1-7. which permits unrestricted use, distribution, and
reproduction in any medium, provided the original
Received: July 5, 2020 | Published: July 20, 2020 author and source are credited.

Abstract
In recent years, for the restoration of lost teeth, dental implants have been used instead of fixed or
removable prosthesis that are supported by neighboring teeth. Some experimental and clinical studies
have shown that the absence of the keratinized tissue on peri-implant area, that effects the preservation
of periodontal health. Lack of the peri-implant keratinized tissue plays a critical role in the accumulation
of bacterial plaque around the dental implants, risen risk of peri-implant inflammation and contributes to
implant failure. In this case series, it is aimed to find ideal prosthesis soft tissue compliance by applying
free gingival graft that is procedure of peri-implant plastic surgery at dental implants surround placed in
the mandibula anterior region where there isn’t sufficient keratinized tissue.

Keywords
Free gingival graft; Peri-implant plastic surgery; Dental implant; Keratinized tissue

Case Report | Gorgun EP, et al. J Oral Med and Dent Res. 2020, 1(1)-04.
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Summary
In recent years, for the restoration of missing teeth, implants were used instead of the fixed or
removable prosthesis supported by neighboring teeth. Peri-implant keratinized tissue deficiency is a
critical neuroloarnacular and implant failure contributed to the enhancement of bacterial-accumulation-
implant inflammatory disease around the dental implants. In this case, the ideal prosthesis-soft tissue
was applied by applying the dental-implant plastic cerrahypyrocedural anesthetic diaphragm in dental
implants placed in the mandibular anterior region where there is not enough keratinized tissue.

Introduction
For the restoration of lost teeth in recent years, dental implants have been used instead of fixed or
removable prosthesis that are supported by neighboring teeth [1]. However, the preservation and
health of the peri-implant soft tissue is required for the longevity of dental implants [2] and prosthesis.
The soft tissue healing following implant surgery may result in the formation of a border tissue
composed of either keratinized or non-keratinized mucosa [3].

Keratinized tissue is beneficial for healthy peri-implant mucosa. Lack of the peri-implant keratinized
tissue plays a critical role in the accumulation of bacterial plaque around the dental implants, risen risk
of peri-implant inflammation and contributes to implant failure[4-6] Some experimental and clinical
studies have shown that the absence of the keratinized tissue on peri-implant area, that effects the
preservation of periodontal health [7].

In spite of that, little is known about the affect of keratinized mucosa (KM) dimension around implants
on the hard and soft tissue health. Recent studies showed that plaque accumulation and mucosal
inflammation were meaningfully higher around implants with KM < 2 mm.[8] In the same way , it was
reported that there was a negative correlation between KM and mucosal recession[9] and that
increased width of KM is related to lower alveolar bone loss.[10] More recently, Zigdon and Machtei [6]
reported that a thick mucosa (≥1 mm) was related to lesser mucosal recession compared with a thin
mucosa (≤1 mm).So that, a task of Working Group 1 of the Osteology Foundation Consensus Meeting
was to widely evaluate the effects soft tissue augmentation procedures on peri-implant health or
disease [11].

Keratinized Tissue
1. It is expected That plaque control is better relived in the presence of >2 mm of keratinized tissue.
2. When increasing the zone of keratinized tissue is requested around an implant, the clinician should
think of performing a free gingival graft.In this case series, it is aimed to find ideal prosthesis–soft tissue
compliance by applying free gingival graft that is procedure of peri-implant plastic surgery at dental
implant surround placed in the mandibula anterior region where there is not sufficient keratinized
tissue.

Case Reports

Case Report | Gorgun EP, et al. J Oral Med and Dent Res. 2020, 1(1)-04.
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Case 1: Dental implant treatment was performed in the surgical policlinic for a 35 year old, nonsmoking,
female patient with lost teeth 31 and 41 and was directed to the periodontology policlinic before
prosthetic restoration. The patient complained of increased tension and pain with localized lip
movements in the lower jaw. Intraoral and radiographic examination revealed a shallow vestibule depth
in the anterior mandibula, high frenilum attachment, inadequate keratinized tissue thickness around the
implants and approximately 2mm gingival recession around the implant placed in the tooth 41 region.
Free gingival graft obtained from palatal donor region under local anesthesia was applied to the peri-
implant region and stabilized.

Case 2: Dental implant treatment was performed in the surgical policlinic for a 56 year old, no-
nsmoking, female patient with lost teeth 33 and 43 and was directed to the periodontology policlinic
before prosthetic restoration. Intraoral and radiographic examination revealed a shallow vestibule depth
in the anterior mandibula, inadequate keratinized tissue thickness around the implant placed in the
tooth 33 region. Free gingival graft obtained from palatal donor region under local anesthesia was
applied to the peri-implant region and stabilized.

Operation Descriptions
Initially, locally anesthesia performed with articainhidroclorur 2% associated with epinephrine 1:
100,000 (Maxicaine fort-New DFL Ind. e Com. S.A., Rio de Janeiro, Brazil). Then, a horizontal incision is
made in the interdental papillae at the level of the peri-implanter marginal tissue [12,13] two vertical
incisions are performed to extend to the alveolar mucosa. The half-thickness flap is dissected up to the
apical boundaries of the vertical incision and removed.

The free gingival graft [14,15] was obtained from the palate area at a distance of about 2mm from the
teeth. The graft was sutured to the recipient area in a close contact with the periosteum bed. As
resorbable suture material (Pegelak, polyglycolide-co-lactide Dogsan Surgical Suture, Istanbul, Turkey,
USA) was used. Palate donor site sutured with, 4-0 silk suture (Silk, Cetin Surgical Suture, Adana, Turkey,
TR) for hemostasis and clot promote stabilization. The recipient area was covered with surgical cement
(coe-pack) and stabilized on mandibular teeth. As post operative patient care, rinsing 0.12%
chlorhexidine twice in the morning and evening for 2 weeks, 1000 mg amoxicillin twice daily for 7 days.
In case of possible pain, 275 mg naproxen sodium was prescribed. Surgical cement was removed on the
14th day. Sutures of donor and recipient areas were removed on the 14th day. Wound areas healed
without any discomfort after the surgery. Oral motivation training was repeated. The patient was invited
to the 1st and 3rd month follow-ups. After a 3-month follow-up period, a thickness and a 3 mm increase
in the height of the keratinized mucosa were observed, promoting good peri-implant health, facilitating
hygiene procedures and complaining of painful symptoms in the period implant area.

Case Report | Gorgun EP, et al. J Oral Med and Dent Res. 2020, 1(1)-04.
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Figure 1a, 1b, 1c: Preoperation, Postop. 14 day, Postop. 3 month of Case 1, respectively.

Figure 2a, 2b, 2c: Preoperation, Postop. , Postop. 3 month of Case 2, respectively.

Discussion
Soft tissue procedures around natural teeth can be used in two terms: mucogingival surgery and
periodontal plastic surgery. These operations can be performed around the teeth as well as in the
implant areas. It is carried out in the form of soft tissue growth or reduction procedures. The term “peri-

Case Report | Gorgun EP, et al. J Oral Med and Dent Res. 2020, 1(1)-04.
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implant plastic surgery (PiPS)” can be defined as a group of procedures aimed at correcting acquired or
pathologically derived aesthetic and / or functional, peri-implant soft and hard tissue deformities.

As with natural teeth, gingival recession may occur on the buccal side of the implants, which cause
aesthetic and functional problems. In cases where there is no interproximal tissue loss, provided that
the implant grooves are not exposed, soft tissue augmentation procedures can be used, as with natural
teeth, to improve the “peri-implant mucosa phenotype” [18]. This operation in the peri-implant mucosa
regions can provide a mechanical barrier of the area, thus reducing potential discomfort associated with
tooth brushing thanks to the KT gain.Four different time points can be distinguished to increase the
mucosal thickness around CM or dental implants: [16]
(a) Before implant placement,
(b) During implant placement,
(c) Second place After exposing the implant (healing head)
(d) Forward-looking protocol after re-entry

While the first three protocols have more predictable clinical outcomes, the prospective protocol may
face aesthetic problems or complications such as mucositis or periimplantitis [17-19]. It has been
reported in the literature that adequate CM for peri-implant health is ≥ 2 mm and that when CM <2 mm,
problems may affect peri-implant health and cause peri-implant mucocytis / peri-implantitis [3,5,20,21].

Free gingival graft is a successful and predictable technique that can prevent hard and soft tissue
problems that develop after implant surgery [22,23]. This procedure can be performed before implant
placement, as well as during the second surgical stage of the implants or after the last prosthesis has
been placed [22].When the combination of autogenous grafts and apically positioned flap (APF) /
Vestibuloplasty (V) was compared with those without any surgical procedure, it was observed that the
width of the keratinized mucosa (CM) was significantly increased. [3,5,21]. The use of autogenous or
allogeneic grafts in addition to APF / V was found to be superior to autogenous grafts. Wei et al.
Conducted a study comparing the efficacy of ADM and free gingival graft to increase the adherent
gingival width of [24,25]. The results showed that the tissue formed in the ADM treated region was not
parallel to any known mucosa and was more similar to scar tissue.

Conclusion
With the free gingival graft applied to the peri-implant mucosa, the patient’s complaints were resolved
and environment of reduced risk was provided for the long-term success as providing an adequate
keratinized tissue and vestibular depth before prosthesis restoration.

Acknowledgements
None.

Conflict of Interest
The authors deny any conflicts of interest related to this study.

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Orcid IDs of Authors

1. Emine Pirim Gorgun: 0000-0002-8867-1663
2. Nilufer Altunbas: 0000-0002-6098-2144
3. Mustafa Kemal Erenler: 0000-0002-9258-3404

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