Autogenous Free Gingival Graft to Increase Keratinized Tissue around Dental Implants

The need for keratinized tissue to ensure peri-implant tissue health is somewhat uncertain. We have all seen implants with plenty of keratinized tissue that still have alot of inflammation. At the same, there are cases with little keratinized tissue that appear healthy. Despite the debate, recent studies 1,2 have concluded that adequate keratinized tissue (KT) around implants was in fact a strong predictor of peri-implant health. As such, it seems prudent to make sure that when we are placing implants that the KT width is sufficient to maintain peri-implant tissue health and ensure the long-term success of implants.

The gold standard for increasing the width of keratinized tissue is the autogenous  free gingival graft 3. The drawback of this procedure is that it is invasive and the patient typically can have post-operative pain. However, there is usually no other alternative. In previous videos, we discussed products like Acellular Dermis for Soft Tissue Grafting (see DALI Dermis for Soft Tissue Grafting), which provide an alternative to autogenous grafts in other clinical situations. However, when it comes to  increasing the width of  keratinized tissue acellular dermis is not helpful, and free gingival grafts are indicated.

In this video, Dr. Gober reviews 2 interesting cases where free gingival grafts were performed. In the first case, following implant treatment, the patient complained of persistent discomfort. The first thing noticed when examining the patient was that the tissue quality in front of the implants was very poor. In the second case, implants were placed to facilitate an overdenture. However, the width of keratinized tissue in the areas of the lateral canines was very thin. To improve the situation in both cases, free gingival grafts were indicated. In the video, Dr. Gober provides several key clinical tips to help make this procedure successful. Some advice includes: fabricating a palatal stent with coverage over the wound post-operatively during the first week, and also using sutures to tack down the vestibular extension so it doesn't creep up during the initial healing phase. Watch the video to learn more.


1. Clin Oral Implants Res . 2022 Jun;33 Suppl 23:8-31 Influence of width of keratinized tissue on the prevalence of peri-implant diseases: A systematic review and meta-analysis Ausra Ramanauskaite et al.

Aim: To evaluate the influence of the width of keratinized tissue (KT) on the prevalence of peri-implant diseases, and soft- and hard-tissue stability....Conclusion: Reduced KT width is associated with an increased prevalence of peri-implantitis, plaque accumulation, soft-tissue inflammation, mucosal recession, marginal bone loss, and greater patient discomfort.

2. Int J Oral Maxillofac Implants . 2019 Nov/Dec;34(6):1307-1317. Effect of Peri-implant Keratinized Tissue Width on Tissue Health and Stability: Systematic Review and Meta-analysis Salvatore Longoni, et al.

Purpose: A systematic review and meta-analysis was performed to synthesize evidence on the association between peri-implant keratinization, defined as adequate (≥ 2 mm) or inadequate (0 to 2 mm), and peri-implant health and stability, measured as tissue inflammation, plaque accumulation, tendency to bleeding, and probing depth (PD)...Conclusion: The importance of having an adequate KT width around implants was confirmed by this review; adequate KT was significantly associated with less peri-implant inflammation evaluated qualitatively with mGI/GI. No difference was found for plaque accumulation and bleeding, but a positive trend was found favoring implants with adequate KT.

3. J Periodontol . 2008 Apr;79(4):587-94. doi: 10.1902/jop.2008.070414.. Free gingival grafts to increase keratinized tissue: a retrospective long-term evaluation (10 to 25 years) of outcomesGiancarlo Agudio et al.

Background: The aim of this retrospective long-term study was to evaluate changes in the amount of keratinized tissue (KT) and in the position of the gingival margin after free gingival graft procedures over a period of 10 to 25 years. Conclusion: Gingival augmentation procedures performed in sites with an absence of attached gingiva associated with recessions provide an increased amount of KT associated with recession reduction over a long period of time.

I’ve found that both suturing L-PRF membranes over the donor site and having them wear a palatal stent substantially decreases the morbidity at the donor site. For those still dragging their feet about KG need, keep in mind, the KG attaches to the bone and improves the overall attachment to the implant. I suspect the patients without KG that do well have ample bone to improve overall vascularity, to the avascular implant surface. Thicker, soft tissue does this too, yet not as well when it’s mucosa.

When I was in the Army we always made vacuform stents and after getting out I started treating patients in the transitional dentition and found it very difficult to retain a vacuform in the mixed dentition. As an act of desperation I resorted to covering the donor site with super glue and it worked great. 12 years later I cover every donor site with glue and because I have a tremendous staff they also make a vacuform stent. The combination is extremely simple and cost effective…

I started with Periacryl (super glue), then went to gluing collagen tape down. The best results I’ve seen to minimized palatal pain are 1) suture L-PRF over the donor site then 2) send them home with a vacuform stent, that they wear constantly for 3 days, then as needed for meals. The L-PRF puts out growth factors, decreases pain and speeds soft tissue healing for 2 weeks, so the more they wear the stent (2 layers of ban aids) the better. Now I rarely get complaints about FGG donor sites and i do a lot of them.