Background/Objectives: Implant treatment in patients who require teeth extraction due to periodontitis presents a significant challenge. The consideration of peri-implantitis is crucial when planning the placement of dental implants. The predictability of implant treatment relies on the suitability of both hard and soft tissue quality. The aim of this article is to present a case report demonstrating a secure treatment protocol for implant procedures in patients with periodontitis requiring the extraction of all teeth, soft tissue management targeted at increasing the keratinized mucosa zone, and the provision of a reliable prosthetic solution. The secondary objective is to review the relevant literature regarding the significance of keratinized mucosa surrounding dental implants and its association with the occurrence of peri-implantitis. Case presentation: A 65-year-old female with generalized periodontitis, stage IV grade C and very poor oral hygiene came for treatment and rehabilitation of the lower jaw. CBCT revealed periodontal lesions and labio-lingual ridge dimensions in the region of teeth 34-44 from 8.0 to 10.2 mm. The first surgery included teeth extraction and periodontal lesions enucleation with simultaneous placement of four implants in the positions of teeth 32, 34, 42, 44. The second-stage surgery involved increasing the keratinized mucosa using two free gingival grafts. Conclusions: The present case report described the treatment process of the patient with periodontitis, including immediate implantation in the infected region, soft tissue augmentation using free gingival grafts and the ultimate placement of a bar-retained overdenture for final restoration. After two years of observation, despite questionable hygiene, no symptoms of gingival inflammation were detected. Furthermore, there is limited information in the literature regarding the correlation between inadequate keratinized gingiva and the occurrence of peri-implantitis.

BACKGROUND: Free gingival graft is commonly used to augment the keratinized mucosa and vestibular depth around dental implants. The proper suturing technique is fundamental to achieve a successful result following free gingival graft. However, there are limited studies that focus on the details of the suturing methods to optimize graft adaptation. The purpose of this technical note is to describe a new suturing technique for optimal approximation and stabilization of free gingival graft around dental implants.
METHODS: Here, we present a 53-year-old Persian female with peri-implantitis and lack of keratinized mucosa around mandibular implants who was a candidate for free gingival graft. A new suturing technique, double vertical interrupted suture, was conducted in the interimplant areas. In addition, the suspensory cross-mattress sutures were added to ensure the adaptation of the graft over the implants. The proposed suturing technique is useful for soft tissue augmentation around multiple implants with concave or uneven recipient bed.
CONCLUSIONS: The present article describes a novel suturing technique for good adaptation and fixation of free gingival graft around dental implants.

BACKGROUND: The presence of adequate keratinized mucosa (KM) around dental implants and natural dentition is pivotal for the long-term success of dental restorations. Despite various techniques to augment KM, challenges persist in achieving stable, keratinized, and adherent mucosa, especially in the context of significant muscle pull or compromised tissue conditions. This study introduces a novel application of titanium pins for the fixation of free gingival grafts (FGG) and apically repositioned flaps (APF) during vestibuloplasty, aiming to overcome important limitations associated with traditional suturing methods and shorten the treatment time and patient morbidity.
METHODS: Three patients with insufficient KM width, presenting discomfort during oral hygiene and inflammation around implant restorations and natural teeth, underwent soft tissue augmentation using titanium pins traditionally used in guided bone regeneration (GBR) for the stabilization of FGGs and APFs. This method ensures intimate contact between the graft and the periosteum, facilitating proper graft perfusion and revascularization, minimizing shrinkage and the risk for necrosis of the graft.
RESULTS: Postoperative follow-up revealed successful integration of the grafts, with minimal shrinkage and increased width and depth of KM. The use of titanium pins allowed for reliable fixation in challenging surgical sites, where traditional suturing methods were impractical due to the presence of extensive muscle pull and an unstable recipient bed.
CONCLUSIONS: The application of titanium pins for the fixation of FGGs and APFs during vestibuloplasty provides a promising alternative to traditional suturing techniques, particularly in complex cases where the recipient bed is suboptimal for suturing. This method simplifies and shortens the procedure, offering a predictable outcome with increased mechanical stability and minimal shrinkage of the graft. Randomized clinical trials are recommended to further evaluate the efficacy of this technique.

OBJECTIVE: This study aimed to investigate the viability of free gingival grafts (FGG) and assess clinical and radiographic changes in the alveolar ridge following socket seal surgery with or without freeze-dried bone allograft (FDBA).
METHODS: Twenty-eight anterior and premolar tooth extractions were randomly allocated to 2 groups: socket graft of FDBA sealed with FGG (n = 15) and control with empty sockets sealed solely with FGG (n = 13). Photographs taken at 3, 7, 14, and 30 days post-surgery assessed FGG viability. Alveolar ridge volume was clinically evaluated via intraoral scanners before surgery and at 1 and 3 months post-surgery. CBCT scans taken immediately post-surgery and 3 months later assessed alveolar ridge dimensions.
RESULTS: FGG viability in both groups increased from day 3 and reached the maximum score on day 14. Alveolar ridge volume reduction at 3 months in the FDBA group was comparable to the control group. Buccal alveolar bone height reduction was significantly higher in the FDBA group than the control group, while palatal alveolar bone height was comparable. Alveolar bone width reduction was evident but not statistically significant between the groups. The FDBA group exhibited a significant alteration in bone volume compared to the control group.
CONCLUSIONS: Viability of FGG was not affected by graft filling materials. Sealing the socket with FGG effectively preserved socket integrity and ridge volume in minor socket defects using either graft filling material or not. This study was registered on 4 January 2021 on Thai Clinical Trials Registry (TCTR20210104001).

OBJECTIVE: This study aimed to provide the latest updates on the therapeutic effectiveness of keratinized mucosa (KM) augmentation using autogenous soft tissue grafts for dental implants retaining prostheses.
METHODS: A systematic search of electronic databases was conducted on autogenous soft tissue grafts to create and/or augment KM for functioning dental implants. Two investigators independently extracted data from the selected 11 clinical studies, including 290 participants, from the initially retrieved 573 publications.
RESULTS: A lack of KM surrounding dental implants was associated with greater mucosal inflammation. A free gingival graft (FGG) was used to increase the KM width, and a connective tissue graft (CTG) was used to manage peri-implant mucosal recession (MR). The weighted mean gain in KM was 2.6 mm from the selected FGG studies, with a significant reduction in mucosal inflammation and no changes in crestal bone levels for up to 4 years. The weighted mean reduction in MR was 2 mm in selected CTG studies.
CONCLUSIONS: A lack of KM negatively affects soft tissue health around dental implants. FGG was effective in increasing KM and reducing mucosal inflammation, whereas CTG was effective in decreasing MR.

UNASSIGNED: A successful management of a mandibular recession with creeping attachment using free gingival graft. This case highlights the \"wait-and-see\" approach in the treatment plan, emphasizing the root coverage.
UNASSIGNED: This clinical report describes the case of a 23-year-old female patient with gingival recession of the mandibular left central incisor. The patient\'s symptoms included hypersensitivity and cosmetic improvements. After thorough examination, the patient was diagnosed with plaque-induced gingivitis on a reduced periodontium with acquired mucogingival deformities. Gingival recession was classified as Miller class II or Cairo Recession Type 1. The treatment plan consisted of a nonsurgical phase, followed by a surgical phase using a free gingival graft. The surgical procedure involved harvesting the graft from the palatal mucosa and placing it in the recipient site. Post-operative care and instructions were provided and a comprehensive follow-up schedule was established. At the 12-month evaluation, the patient exhibited healthy periodontal conditions with creeping attachment and complete root coverage. The success of the treatment approach demonstrates its effectiveness in addressing hypersensitivity and cosmetic concerns, while improving periodontal health. Factors influencing the achievement of creeping attachment are discussed, including recession width, graft position, bone support, tooth position, patient hygiene, graft thickness, and root surface treatment.

OBJECTIVE: This study compared the effects of leukocyte platelet-rich fibrin (L-PRF) and advanced platelet-rich fibrin (A-PRF) on patients\' quality of life and the healing of palatal wounds after free gingival graft harvesting.
METHODS: After free gingival graft harvesting, palatal donor sites of 36 patients were assigned to one of three groups: L-PRF group, A-PRF group, or palatal stent + periodontal pack group (control group). Wound healing was evaluated by H2O2 test. Pain was evaluated by visual analog scale and number of analgesics consumed. For patient quality of life, the Oral Health Impact Profile-14 (OHIP-14) questionnaire was utilized.
RESULTS: Complete epithelialization was higher in the control group on day 7 than in the test groups (P < .05). Complete epithelialization was achieved in all groups 14 days postoperatively. Visual analog scale scores for pain and the number of analgesic tablets consumed were similar in all groups (P > .05). OHIP-14 total scores were similar in all study groups at 7 days postoperatively (P > .05). OHIP-14 total and physical pain score was lower in the L-PRF group than the A-PRF group at 14 days postoperatively (P < .05).
CONCLUSIONS: Aside from the slight superiority of L-PRF over A-PRF, it can be concluded that both PRF procedures have similar effects on palatal wound healing and quality of life.

The most challenging and time-consuming step in the free gingival graft (FGG) for keratinized mucosa augmentation is the compression suture anchoring the FGG to the periosteum. This article proposed a novel \"microscrew with tie-down sutures\" technique to anchor the FGG to the recipient site without the traditional trans-periosteum suture. This patient\'s keratinized mucosa width (KMW) around the healing abutments of teeth #29 and #30 was less than 1 mm. After an apically positioned flap (AFP) was prepared, 2 microscrews were placed at the buccal plate of the alveolar ridge bone, which is the coronal margin of the AFP. Then, the sutures winded between the microscrews and the healing abutments to anchor the FGG. In conclusion, the \"microscrew with tie-down sutures\" technique offers a feasible and straightforward alternative for the trans-periosteum compression suture, mainly when the periosteum is fragile, thin, or injured.

Free gingival grafts (FGGs) have developed beyond covering exposed roots to improve the width and thickness of gingival tissue. While traditional FGGs have shown a high success rate and are easy to apply, they have some drawbacks, such as potential aesthetic concerns and bulky appearance. Recent advancements in FGGs have been explored, with different modifications proposed to overcome these limitations, including partly epithelialized FGGs (PE-FGG), gingival unit grafts, and epithelialized subepithelial connective tissue grafts. This systematic review aims to evaluate published case reports that discuss the utilization of modified approaches to FGG treatment and their outcome.

BACKGROUND: Different extracellular matrix (ECM)-based technologies in periodontal and peri-implant soft tissue augmentation have been proposed in the market. The present review compared the efficacy of soft tissue substitutes (STSs) and autogenous free gingival grafts (FGGs) or connective tissue grafts (CTGs) in mucogingival procedures to increase keratinized tissue (KT) width around teeth and implants.
METHODS: Two independent examiners performed an electronic search on MEDLINE and the Cochrane Library based on the following PICOS format: (P) adult patients; (I) soft tissue substitutes and FGGs/CTGs; (C) STSs vs. CTGs; STSs vs. FGGs; STSs vs control; (O) KT width gain; (S) systematic reviews, randomized controlled trials. Studies published before November 2023 were included.
RESULTS: Around teeth, all biomaterials showed superior performance compared to a coronally advanced flap (CAF) alone for treating gingival recessions. However, when compared to CTGs, acellular dermal matrices (ADMs) yield the most similar outcomes to the gold standard (CTGs), even though in multiple recessions, CTGs continue to be considered the most favorable approach. The use of STSs (acellular matrix or tissue-engineered) in combination with apically positioned flaps (APF) resulted in significantly less gain in KT width compared to that achieved with FGGs and APFs. Around dental implants, free gingival grafts were deemed more effective than soft tissue substitutes in enhancing keratinized mucosa width.
CONCLUSIONS: Based on the available evidence, questions remain about the alternative use of soft tissue substitutes for conventional grafting procedures using free gingival grafts or connective tissue grafts around teeth and implants.