Clinical and histologic evaluation of different approaches to gain keratinized tissue prior to implant placement in fully edentulous patients

Clin Oral Investig. 2018 Jun;22(5):2111-2119. doi: 10.1007/s00784-017-2319-4. Epub 2017 Dec 22.


Objectives: This work aimed to investigate the effectiveness and predictability of different treatment modalities for gain of keratinized tissue (KT) in fully edentulous jaws prior to dental implant placement: apically positioned flap (APF), APF plus xenogeneic collagen matrix (XCM), and APF plus free gingival graft (FGG).

Materials and methods: In fully edentulous patients with insufficient zones of KT at the prospective implant positions, four treatment modalities were performed in the lower jaw: APF, XCM, FGG, and an untreated control group (control). APF and XCM were applied in the first molar positions, FGG and control in the canine positions. Assessed outcomes up to 3 months post-surgery included changes in width of KT (over a 3-month period), histomorphometric analysis of harvested soft-tissue biopsies (at 3 months postoperatively), and patient-reported outcomes measures (PROMs).

Results: For the primary outcome, changes in KT width demonstrated an increase of 1.93 ± 1.6 mm (APF), whereas XCM and FGG showed an increase of 4.63 ± 1.25 mm and 3.64 ± 2.01, respectively. Histomorphometric analyses revealed a thickness of the epithelium ranging between 375 ± 122 μm (APF), 410 ± 116 μm (XCM), 336 ± 122 μm (FGG), and 413 ± 109 μm (control). All biopsies showed a regular muco-periosteal structure with a keratinized epithelium of comparable thickness in all groups.

Conclusion: All three methods were suitable to increase the width of KT, although APF alone rendered roughly 50% less gain compared to XCM and FGG.

Clinical relevance: The use of XCM in conjunction with an APF represents a valuable treatment option for the gain of keratinized tissue in edentulous sites.

Keywords: Augmentation; Autologous; Collagen; Gingival graft; Keratinized mucosa; Keratinized tissue; Matrix; Patient-reported outcome measures; Transplantation.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Biopsy
  • Connective Tissue / transplantation*
  • Dental Implants*
  • Female
  • Gingivoplasty / methods*
  • Humans
  • Keratins
  • Male
  • Middle Aged
  • Mouth, Edentulous / rehabilitation*
  • Patient Reported Outcome Measures
  • Pilot Projects
  • Surgical Flaps*
  • Vestibuloplasty / methods*


  • Dental Implants
  • Keratins