Case report of using partially epithelialized connective tissue graft for peri-implant soft tissue augmentation simultaneously with dental implant placement
DOI:
https://doi.org/10.56569/UDJ.3.1-2.2024.162-172Keywords:
connective tissue, graft, de-epithelization, peri-implant soft tissue, dental implantAbstract
Background. The novelty of present case report is related to the fact that it represents achievement of successful results of dental implant-borne rehabilitation in means of forming appropriate pink esthetic profile and sufficient peri-implant soft tissue stability while using for such purpose partially epithelized connective tissue flap simultaneously with delayed implant placement procedure, which to the knowledge of authors have been described in the specialized literature before only in scarce manner.
Objective. To demonstrate clinical option of using partially epithelialized connective tissue graft for peri-implant soft tissue augmentation simultaneously with dental implant placement procedure to enhance peri-implant esthetic profile and optimize soft-tissue stability for further prosthetic rehabilitation.
Case report. Patient 46 years old patient referred to the dental clinic with complaints regarding condition of mandibular fixed denture, which he was using already for 9 years. Also, patient informed dentist that he wants to improve his chewing ability by restoring edentulous distal regions of mandible with implant-borne fixed dentures. Patient previous denture was gently deattached from mandibular abutment teeth while not altering periodontal conditions of any of them during procedure. All the targeted and periodontal treatment was provided based on clinical need. Tissue level implants were placed at the projection of teeth 4.5-4.6 and 3.6-3.7 due to the conventional implant placement protocol. To compensate soft tissue collapse within the implant placement region it was decided to augment such with partially epithelialized connective tissue graft. Graft was shaped, prepared and partially de-epithelialized to overcome issue of volume excess using standard technique. Partially epithelialized connective tissue graft was positioned carefully with the manner of the epithelial portion covering dental implant part, while connective tissue portion was facing inner surface of separated flap, and was covered by a flap. Modified horizontal mattress sutures were used to secure connective tissue graft at the place while retaining its primarily established positions and guaranteeing tension-free flap closure around installed healing abutments. Results of final rehabilitation outcomes with satisfactory appearance of the soft tissue condition around fixed prosthetic construction were achieved at the end of the treatment.
Conclusion. Partially epithelized connective tissue graft combines features of both connective tissue graft, which makes it suitable for mucosa thickness gain, and free gingival graft, whin in turn helps to increase width of keratinized gingiva. Such universal properties make it suitable candidate for the usage simultaneously with implant placement to enhance peri-implant esthetic profile and optimize surrounding soft-tissue stability for further prosthetic rehabilitation.
Ethical aspects
Authors confirm that they have followed all relevant ethical norms and requirements during the treatment described within present case report and preparation of present manuscript. Authors obtained full patient’s agreement regarding publication of following case report, and such was approved by corresponding consent form signed by the patient personally. No information in present case report may disclose any personal data about the patient, which further may be used for patient’s personal identification. Any information related to patient’s identity disclosure was either deleted or anonymized within present case report.
Authors confirm that they have followed CARE guidelines while preparing present case report with intention for further publication.
Conflict of Interest
Author does not have any potential conflict of interests that may influence the decision to publish this article.
Funding
No funding was received to assist in preparation and conduction of this research, as well as in composition of this article.
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29. Zangrando MS, Eustachio RR, de Rezende ML, Sant'ana AC, Damante CA, Greghi SL. Clinical and Patient‐Centered outcomes using two types of subepithelial connective tissue grafts: a Split‐Mouth randomized clinical trial. J Periodontol. 2021;92(6):814-22. doi: https://doi.org/10.1002/JPER.19-0646
30. Zucchelli G, Mele M, Stefanini M, Mazzotti C, Marzadori M, Montebugnoli L, De Sanctis M. Patient morbidity and root coverage outcome after subepithelial connective tissue and de‐epithelialized grafts: a comparative randomized‐controlled clinical trial. J Clin Periodontol. 2010;37(8):728-38. doi: https://doi.org/10.1111/j.1600-051X.2010.01550.x
31. Beymouri A, Yaghobee S, Khorsand A, Safi Y. Comparison of morbidity at the donor site and clinical efficacy at the recipient site between two different connective tissue graft harvesting techniques from the palate: A randomized clinical trial. J Adv Periodontol Implant Dent. 2023;15(2):108-116. doi: https://doi.org/10.34172/japid.2023.016
32. Naziker Y, Ertugrul AS. Aesthetic evaluation of free gingival graft applied by partial de-epithelialization and free gingival graft applied by conventional method: a randomized controlled clinical study. Clin Oral Investig. 2023;27(7):4029-38. doi: https://doi.org/10.1007/s00784-023-05029-8
33. Corrado F, Marconcini S, Cosola S, Giammarinaro E, Covani U. Immediate implant and customized healing abutment promotes tissues regeneration: A 5-year clinical report. J Oral Implantol. 2023;49(1):19-24. doi: https://doi.org/10.1563/1548-1336-49.1.19
34. Chokaree P, Poovarodom P, Chaijareenont P, Yavirach A, Rungsiyakull P. Biomaterials and clinical applications of customized healing abutment—a narrative review. J Funct Biomater. 2022;13(4):291. doi: https://doi.org/10.3390/jfb13040291alawi H, Fatani A, Almuqrin R, Aburaisi MS, Awartani F, Aburaisi M. Modifications in the free gingival graft technique: A systematic review. Cureus. 2024;16(4):e58932. doi: https://doi.org/10.7759/cureus.58932
14. Cortellini P, Tonetti M, Prato GP. The partly epithelialized free gingival graft (pe‐fgg) at lower incisors. A pilot study with implications for alignment of the mucogingival junction. J Clin Periodontol. 2012;39(7):674-80. doi: https://doi.org/10.1111/j.1600-051X.2012.01896.x
15. Park WB, Park W, Kang P, Lim HC, Han JY. Submerged technique of partially de-epithelialized free gingival grafts for gingival phenotype modification in the maxillary anterior region: a case report of a 34-year follow-up. Medicina. 2023;59(10):1832. doi: https://doi.org/10.3390/medicina59101832
16. Kinaia BM, Kazerani S, Hsu YT, Neely AL. Partly deepithelialized free gingival graft for treatment of lingual recession. Clin Adv Periodontics. 2019;9(4):160-5. doi: https://doi.org/10.1002/cap.10062
17. De Angelis P, De Angelis S, Passarelli PC, Liguori MG, Pompa G, Papi P, Manicone PF, D’Addona A. Clinical comparison of a xenogeneic collagen matrix versus subepithelial autogenous connective tissue graft for augmentation of soft tissue around implants. Int J Oral Maxillofac Surg. 2021;50(7):956-63. doi: https://doi.org/10.1016/j.ijom.2020.11.014
18. Stefanini M, Barootchi S, Sangiorgi M, Pispero A, Grusovin MG, Mancini L, Zucchelli G, Tavelli L. Do soft tissue augmentation techniques provide stable and favorable peri‐implant conditions in the medium and long term? A systematic review. Clin Oral Implants Res. 2023;34:28-42. doi: https://doi.org/10.1111/clr.14150
19. Poskevicius L, Sidlauskas A, Galindo‐Moreno P, Juodzbalys G. Dimensional soft tissue changes following soft tissue grafting in conjunction with implant placement or around present dental implants: a systematic review. Clin Oral Implants Res. 2017;28(1):1-8. doi: https://doi.org/10.1111/clr.12606
20. Aldhohrah T, Qin G, Liang D, Song W, Ge L, Mashrah MA, Wang L. Does simultaneous soft tissue augmentation around immediate or delayed dental implant placement using sub-epithelial connective tissue graft provide better outcomes compared to other treatment options? A systematic review and meta-analysis. PLoS One. 2022;17(2):e0261513. doi: https://doi.org/10.1371/journal.pone.0261513
21. Lin CY, Nevins M, Kim DM. Laser De-epithelialization of Autogenous Gingival Graft for Root Coverage and Soft Tissue Augmentation Procedures. Int J Periodontics Restorative Dent. 2018;38(3):405-411. doi: https://doi.org/10.11607/prd.3587.
22. Makker K, Yadav VS, Nayyar V, Mishra D. Histomorphometric assessment of extra-versus intra-oral de-epithelialization methods for palatal connective tissue graft: a case series. Curr Trends Dent. 2024;1(2):112-5. doi: https://doi.org/10.4103/CTD.CTD_28_24
23. Bara-Gaseni N, Jorba-Garcia A, Alberdi-Navarro J, Figueiredo R, Bara-Casaus JJ. Histological assessment of a novel de-epithelialization method for connective tissue grafts harvested from the palate. An experimental study in cadavers. Clin Oral Investig. 2024;28(6):343. doi: https://doi.org/10.1007/s00784-024-05734-y
24. Hazrati P, Baniameri S, Sabri H, Chele D, Stuhr S. Efficacy of LASER for de-epithelialization of free gingival graft: a systematic review. Lasers Med Sci. 2025;40(1):1-2. doi: https://doi.org/10.1007/s10103-025-04554-0
25. Din F, Kabalak MÖ, Yılmaz BT, Barış E, Avcı H, Çağlayan F, Keceli HG. Efficacy of different gingival graft de-epithelialization methods: A parallel-group randomized clinical trial. Clin Oral Investig. 2025 May 7;29(6):289. doi: https://doi.org/10.1007/s00784-025-06365-7
26. Frisch E, Ratka‐Krüger P. A new technique for peri‐implant recession treatment: Partially epithelialized connective tissue grafts. Description of the technique and preliminary results of a case series. Clin Implant Dent Relat Res. 2020;22(3):403-8. doi: https://doi.org/10.1111/cid.12897
27. Fawzy M, Hosny M, El-Nahass H. Evaluation of esthetic outcome of delayed implants with de-epithelialized free gingival graft in thin gingival phenotype with or without immediate temporization: a randomized clinical trial. Int J Implant Dent. 2023;9(1):5. doi: https://doi.org/10.1186/s40729-023-00468-0
28. Ripoll S, Fernández de Velasco-Tarilonte Á, Bullón B, Ríos-Carrasco B, Fernández-Palacín A. Complications in the use of deepithelialized free gingival graft vs. connective tissue graft: a one-year randomized clinical trial. Int J Environ Res Public Health. 2021;18(9):4504. doi: https://doi.org/10.3390/ijerph18094504
29. Zangrando MS, Eustachio RR, de Rezende ML, Sant'ana AC, Damante CA, Greghi SL. Clinical and Patient‐Centered outcomes using two types of subepithelial connective tissue grafts: a Split‐Mouth randomized clinical trial. J Periodontol. 2021;92(6):814-22. doi: https://doi.org/10.1002/JPER.19-0646
30. Zucchelli G, Mele M, Stefanini M, Mazzotti C, Marzadori M, Montebugnoli L, De Sanctis M. Patient morbidity and root coverage outcome after subepithelial connective tissue and de‐epithelialized grafts: a comparative randomized‐controlled clinical trial. J Clin Periodontol. 2010;37(8):728-38. doi: https://doi.org/10.1111/j.1600-051X.2010.01550.x
31. Beymouri A, Yaghobee S, Khorsand A, Safi Y. Comparison of morbidity at the donor site and clinical efficacy at the recipient site between two different connective tissue graft harvesting techniques from the palate: A randomized clinical trial. J Adv Periodontol Implant Dent. 2023;15(2):108-116. doi: https://doi.org/10.34172/japid.2023.016
32. Naziker Y, Ertugrul AS. Aesthetic evaluation of free gingival graft applied by partial de-epithelialization and free gingival graft applied by conventional method: a randomized controlled clinical study. Clin Oral Investig. 2023;27(7):4029-38. doi: https://doi.org/10.1007/s00784-023-05029-8
33. Corrado F, Marconcini S, Cosola S, Giammarinaro E, Covani U. Immediate implant and customized healing abutment promotes tissues regeneration: A 5-year clinical report. J Oral Implantol. 2023;49(1):19-24. doi: https://doi.org/10.1563/1548-1336-49.1.19
34. Chokaree P, Poovarodom P, Chaijareenont P, Yavirach A, Rungsiyakull P. Biomaterials and clinical applications of customized healing abutment—a narrative review. J Funct Biomater. 2022;13(4):291. doi: https://doi.org/10.3390/jfb13040291
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