Peri-Implant Plastic Surgical Approaches to Increasing Keratinized Mucosa Width: Which to Use and When?
The long-term efficacy of adequate keratinized mucosa (>2 mm) in dental implants is controversial. Peri-implant plastic surgeries are currently used because they increase keratinized mucosa width (KMW), helping to regain peri-implant health and maintaining it over the long-term. We present the clinical findings using free-gingival-graft (FGG) and free-periosteal-graft (FPG) techniques in peri-implant plastic surgery for implant rehabilitation patients. We included 20 patients with implant indications of inadequate KMW (KMW < 2 mm for postimplantation) in the maxilla and mandible. All underwent clinical and radiographic measurements and a treatment protocol was prepared for implant rehabilitation and subsequent peri-implant plastic surgery. A decision as to whether and when FGG or FPG techniques would be used was made. FGG/FPG was performed pre-implantation (before monocortical block-bone augmentation) or postimplantation (before/during/after stage 2 surgery). KMW was ≥ 2 mm after application of FGG/FPG pre- or post-implantation. Moreover, peri-implant tissue health was regained/maintained in all cases from 6 months to 4 years. Peri-implant plastic surgery techniques can prevent hard- and soft-tissue problems after implant rehabilitation and during treatment of developing problems. However, surgical design and timing, and an interdisciplinary perspective determine the success of peri-implant plastic surgery.

Figure 1. (a, b, c) Obtaining a free periosteal graft in the palatal area. Figure 2. FGG application to the left posterior mandibular area prior to stage 2 surgery. (a) Clinical view prior to FGG. (b,c) FGG and FGG operation. (d) 12 months after FGG.

FGG application to the right posterior mandibular area with implant abutment during stage 2 surgery. (a) Radiographic appearance. (b) Clinical view prior to FGG. (c) Incision borderline. (d) Semilunar incision. (e) Immediately after FGG operation. (f) 6 months after FGG.

FPG application to the right anterior mandibular area following stage 2 surgery. (a) Radiographic appearance. (b) Clinical view prior to FPG (peri-implantitis and shallow vestibule). (c,d) FGG operation (cleaning of granulation tissues with an Er,Cr:YSGG laser). (e) 6 months after FPG.
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