CASE SERIES

Focus on Epithelialized Palatal Grafts. Part 2: Implant Site Development

Joshua P. Berridge,∗ Thomas M. Johnson,† Kenneth J. Erley,† Richard B. Hill,† Jonathan D. Lane,‡ Kimberly K. Schlam,§
Daniel D. Dunham and Preston D. Miller Jr.¶

Introduction: The epithelialized palatal graft (EPG), introduced in 1963, has persisted as the gold standard for
gingival augmentation, and in the present era, mucosal augmentation around dental implants has become an important
concern. A limited body of evidence suggests peri-implant mucosal augmentation may favorably impact bone and mucosal
stability and peri-implant health under some circumstances. Although more contemporary procedures for peri-implant
mucosal augmentation are often preferred based on convenience and esthetic considerations, EPG augmentation at dental
implant sites is distinguishable from methods which do not deepen the vestibule and eliminate unfavorable superficial soft
tissue. Implant sites augmented with EPG are qualitatively distinct from sites augmented using other methods.
Case Series: Seven generally healthy patients received EPG augmentation before dental implant placement, at
implant placement, before implant uncovering, or after implant uncovering. In each case, the patient exhibited a favorable
zone of attached peri-implant mucosa following treatment.
Conclusions: Reliable mucosal augmentation with EPG is achievable at multiple phases in the course of
dental implant therapy. EPG augmentation offers distinct clinical advantages and may be preferable to other mucosal
augmentation strategies at some dental implant sites. Clin Adv Periodontics 2019;9:147–156.
Key Words: Autografts; dental implants; mucous membrane; palate; treatment outcome.

∗ Department of Periodontics, United States Army Dental Health Activ- Background

ity, Fort Bragg, NC Peri-implant mucosa functions to provide a biologic seal
† Department
around dental implants and protect underlying bone from
of Periodontics, Army Postgraduate Dental School, Uni-
the contaminated oral environment.1 – 5 Supracrestal tis-
formed Services University of the Health Sciences, Fort Gordon,
GA sue directly apposing dental implants/abutments normally
consists of an apical zone of connective tissue adhesion
‡ Department of Periodontics, United States Army Dental Health Activ- and a coronal epithelial attachment analogous to the
ity, Joint Base Lewis-McChord, WA junctional epithelium of gingiva.1,2 The oral surface of the
§ Department of Prosthodontics, United States Army Dental Health
connective tissue is often covered by an orthokeratinized
Activity, Fort Bragg, NC epithelium.2 – 4 Whether or not a minimum apicocoro-
nal keratinized mucosal width (KMW) is essential for
 Departmentof Prosthodontics, Army Postgraduate Dental School, peri-implant health remains controversial.2 – 13 Multiple
Uniformed Services University of the Health Sciences, Fort Gordon, investigators have related KMW <2 mm with plaque
GA
accumulation, bleeding on probing, discomfort, mucosal
¶ Distinguished visiting lecturer, New York University, New York, NY recession, and peri-implant mucositis,2 – 11 although con-
trary reports appear in the literature.12,13 Experts suggest
Received May 23, 2018; accepted March 31, 2019 that keratinized mucosa may not be essential when metic-
ulous oral hygiene and strict compliance with a profes-
doi: 10.1002/cap.10064 sional maintenance regimen are observed.3 Nevertheless,

Clinical Advances in Periodontics, Vol. 9, No. 3, September 2019 147

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Implant sites lacking ade-

quate KMW and MT may be
augmented using subepithe-
lial connective tissue graft
(SCTG), epithelialized palatal
graft (EPG), acellular dermal
matrix (ADM), or other
biomaterials.16,20 – 23 The graft
or biomaterial is, in most such
techniques, placed between
the periosteum and bone or
on a bed of supraperiosteal
connective tissue, with or
without advancement of a
mucoperiosteal flap.16,20 – 23
Conversely, the EPG
technique involves removal
of unfavorable superficial
tissue during recipient site
preparation,24 – 27 resulting
in peri-implant mucosa with
distinctive qualities.

Clinical Presentation,
Case Management,
and Clinical
Outcomes
Seven presented cases
illustrate use of EPG at
dental implant sites (Fig. 1)
to enhance vestibular depth
and dimensions of attached
FIGURE 1 Technique. 1a Insufficient attached mucosa present at a planned implant site (buccal view). 1b
Occlusal view demonstrating KMW deficiency. 1c Planned recipient site dimensions. 1d Vertical incisions are mucosa. Patients in cases 1
placed ≈ 1.5 to 2.0 mm from adjacent teeth. 1e Movable mucosa at the recipient site is removed to expose through 3 presented to the
alveolar bone. A butt joint is created between the EPG and the attached mucosa. 1f The EPG is fitted to the Department of Periodontics,
recipient site and placed directly on exposed bone. Simple interrupted sutures are used to stabilize the graft.
1g A mattress suture eliminates dead space and holds the EPG against the alveolar ridge during healing. 1h Army Postgraduate Dental
Sutures in place. 1i and 1j Implant placement may proceed ≈ 5 to 6 weeks following the EPG procedure. School, Uniformed Services
1k and 1l Anticipated results of therapy include establishment of a zone of attached mucosa with favorable University of the Health
dimensions, elimination of unfavorable superficial tissue, and deepening of the vestibule, if necessary.
Sciences, Fort Gordon, Geor-
gia. The patient in case 4
presented to the US Army
presence of keratinized mucosa appears to enhance effec-
Dental Health Activity, Fort Bragg, North Carolina.
tiveness of oral hygiene measures and may be protective of
Three additional cases are presented in Appendices 1
peri-implant bone, at least under some conditions.4,8,14,15
(Supplementary Figures 1 through 4), 2 (Supplementary
Separate from apicocoronal KMW, mucosal thickness
Figures 5 and 6), and 3 (Supplementary Figure 7) in
(MT) is another emerging parameter potentially influenc-
the online Clinical Advances in Periodontics. Detailed
ing bone stability and mucosal health at dental implant
treatment options were discussed in every case, and each
sites. MT <2 mm has been associated with less stable
4,16 – 19 patient completed an informed consent process with
peri-implant bone and mucosa. The 2017 World
verbal and written components.
Workshop on the Classification of Periodontal and Peri-
Implant Diseases and Conditions reported that MT may
influence peri-implant bone stability even in the absence Case 1
4
of soft tissue inflammation. Prospective human stud- In August 2017, a healthy male, aged 32 years, presented
ies and experiments in dog models indicate that peri- missing tooth #30. The #30 area demonstrated minimal
implant bone stability may improve when thin native KMW, limited vestibular depth, and minimal horizontal
peri-implant mucosa is thickened using soft tissue grafting ridge deficiency. An EPG was harvested in the manner
procedures.16,20 – 23 reported previously.27 A 2.5-mm thick EPG with “butt

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joint” margins was removed from the palate, minimally

trimmed, and stabilized at the recipient site using 5/0
dense polytetrafluoroethylene (dPTFE) sutures.# Healing
proceeded uneventfully, and a ø5 × 11.5 mm implant∗∗
was placed six weeks following the EPG procedure. Before
the restorative phase of therapy, the practitioner estab-
lished a clinically favorable zone of attached peri-implant
mucosa and improved vestibular depth in the #30 area
(Figs. 2 through 4).

Case 2
In January 2018, a healthy male, aged 33 years, pre-
sented with a history of dental implant failure in the #20
position and a submerged implant in the #19 position.
No keratinized mucosa was present at the #19 position,
and the full circumference of the submerged fixture was
visible through thin alveolar mucosa. EPG augmentation
was completed at the #19 site prior to implant exposure.
Three weeks following EPG augmentation, implant #19
was uncovered, and a ø4.3 × 10 mm implant†† was placed
in the #20 position. Clinically favorable peri-implant
mucosa was observed ten weeks following the proce-
dure. Assessment of the peri-implant mucosa with healing
abutments removed revealed tightly adherent tissue with
absence of erythema and bleeding (Fig. 5).

Case 3
In June 2018, a female, aged 49 years, presented with
history of guided bone regeneration (GBR) (#7 to #10
area) and submerged ø4.1 × 8.5 mm implants∗∗ in the #8
and #9 positions. No labial vestibule was appreciated in
the maxillary incisor region, and no keratinized mucosa
was present on the facial aspect of the implants. The
patient received vestibuloplasty and EPG augmentation
in conjunction with implant exposure. Treatment estab-
lished an acceptable labial vestibule and KMW of ≈ 6 mm
(Figs. 6 and 7).

Case 4
A male patient, aged 30 years, with an edentulous
mandible and six osseointegrated implants∗∗ was referred
in August 2018 for peri-implant mucosal augmentation in
conjunction with conversion from a removable to a provi-
sional fixed complete denture (Fig. 8). The patient’s chief
complaint was discomfort while cleansing the implants. FIGURE 2 Case 1. Occlusal view. 2a Baseline appearance, #30 area.
The recipient site was prepared, and an EPG measuring The alveolar mucosa extended to the crestal aspect of the edentulous
ridge. The mobile mucosa displayed irregular texture and pale cicatriza-
≈ 12 × 62 mm was transferred from the patient’s palate tion, possibly due to trauma during tooth extraction. Close inspection
(Figs. 9 through 11). The early postoperative period was of the mucogingival junction revealed gingival width < 2 mm at the
uneventful, and the patient reported “minimal” donor line angles of adjacent teeth. 2b Baseline appearance, #30 area. Black
arrows depict the location of the mucogingival junction. 2c Recipient
site discomfort limited to seven days. At the four-week site prepared for EPG. The graft was placed directly on bone. Since the
postoperative assessment (Fig. 12) the patient reported no mucosal and submucosal layers were removed, the possibility of graft
mobility was avoided. 2d EPG stabilized at recipient site with dPTFE
sutures.∗ 2e A favorable zone of attached keratinized mucosa was appre-
# Cytoplast, ciated 6 weeks following augmentation with EPG. 2f Clinical appearance
Osteogenics Biomedical, Lubbock, TX 4 months following implant placement.
∗∗ NanoTite ∗ Cytoplast, Osteogenics Biomedical, Lubbock, TX
Tapered Certain, Zimmer Biomet, Warsaw, IN
†† Replace Select Tapered, Nobel Biocare, Kloten, Switzerland

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C A S E S E R I E S

Discussion
The grafting technique described in this
report is not new and has undergone only
incremental changes since it appeared
in Scandinavia in 1963.25 Thirteen
years after the technique’s introduction,
Dordick et al. recommended placing EPG
directly on denuded alveolar bone—a
modification used in the present report—
to assure establishment of immobile,
firmly-attached mucosa.26 No prior
report, to the authors’ knowledge, has
documented mucosal augmentation
using EPG at multiple phases of implant
treatment.
Many dental implant sites benefit
from peri-implant mucosal augmenta-
tion. Peri-implant MT 2 mm is
desirable.2 – 6,16 – 19 However, buccal
FIGURE 3 Case 1. Occlusal view. 3a Baseline clinical appearance. The mucogingival junction gingival thickness 2 mm appears to be
(black arrows) extended almost to mid-crest. 3b Definitive restoration 5 months following uncommon in humans.28 Mean buccal
implant placement.
gingival thickness at various tooth
positions in 40 periodontally healthy
patients ranged from ≈ 0.7 to 1.8 mm, excluding third
molar sites.28 Additionally, ridge augmentation is nec-
essary at an estimated 40% of implant sites to achieve
favorable ridge dimensions.29 Hard tissue augmenta-
tion procedures such as GBR tend to alter the posi-
tion of the mucogingival junction, decrease vestibu-
lar depth, and reduce KMW due to flap advancement
over implanted biomaterials.29 Extensive alveoloplasty
to establish restorative space also commonly reduces
vestibular depth and KMW, as shown in case 4. For
these reasons, inadequate KMW and MT <2 mm may
be routine clinical findings at planned implant sites.
Mucosal augmentation appears to enhance peri-
implant tissue health and stability at sites exhibiting inad-
equate native KMW and MT,16,20 – 23 and a considerable
proportion of implant sites may be at risk for unfa-
vorable peri-implant mucosa.28,29 Thorough soft tissue
assessment at the initial evaluation allows practitioners to
establish a plan for peri-implant mucosal augmentation,
if needed. When adjacent tissue is favorable, an apically
positioned flap or rotated pedicle flap at implant exposure
may adequately develop the site. Moreover, clinicians have
devised various other techniques for leveraging adjacent
tissue to enhance KMW, MT, and mucosal contours at
implant sites.30 – 32 When adjacent tissue is inadequate
FIGURE 4 Case 1. Buccal view. 4a Baseline clinical appearance.
Black arrows depict the location of the mucogingival junction. 4b
in volume or quality, placement of a soft tissue auto-
Definitive restoration 5 months following implant placement. graft or allograft between the bone and mucoperiosteal
flap during implant placement or uncovering is a rela-
tively simple procedure. This type of augmentation may
discomfort during routine oral hygiene measures. Four thicken the peri-implant mucosa, enhance mucosal con-
months following EPG augmentation (Figs. 13 through tours, and in some cases, improve esthetics.16,21 – 23 How-
15), KMW ranged from 1 to 4 mm. The augmented area ever, these procedures will not remove unfavorable super-
exhibited pink, firmly-attached, keratinized mucosa, and ficial tissue. Implant site development with EPG favorably
clinical signs of inflammation were virtually absent. alters vestibular depth, if needed, and establishes a zone

150 Clinical Advances in Periodontics, Vol. 9, No. 3, September 2019 EPG for Implant Site Development
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FIGURE 5 Case 2. Occlusal view. 5a Baseline clinical appearance. The implant cover screw was visualized
through thin, nonkeratinizing mucosa (#19 area). Alveolar mucosa extended to the lingual aspect of the
alveolar crest. The buccal vestibule terminated at the level of the implant platform. 5b The EPG was stabilized
with 5/0 polypropylene sutures.∗ 5c Postoperative day 7. The graft appeared purplish red, consistent with
vascularization. 5d Postoperative day 14. A trace of redness persisted, and incision lines remained visible.
Favorable keratinized peri-implant mucosa was present on buccal and lingual aspects of the implant. 5e
Healing abutments† in place 10 weeks following EPG augmentation. 5f Healing abutments removed for final
impression 10 weeks following EPG augmentation.
∗ Perma Sharp polypropylene sutures, Hu-Friedy, Chicago, IL
† Nobel Replace Healing Abutment, Nobel Biocare, Kloten, Switzerland

of firmly-attached26 keratinizing mucosa bordering the ficial mucosa, prevent transmission of muscle tension to
implant. the marginal tissue, and control vestibular depth.34
In implant dentistry, there are opportunities to aug- Practitioners selecting EPG should acknowledge asso-
ment peri-implant mucosa during the course of therapy: ciated disadvantages. Relative to SCTG donor sites, EPG
before implant placement (case 1), simultaneously with donor sites can be more uncomfortable for patients.35
implant placement, at implant exposure (cases 2 and 3), Additionally, practitioners may prefer an alternative
and if necessary, following implant exposure (case 4). If mucosal augmentation method at sites where esthetic con-
increasing KMW is a surgical goal, EPG and SCTG may cerns are paramount.35 Also, if EPG augmentation is not
be superior to alternative techniques.23,33 Compared with accomplished concomitantly with implant placement, the
SCTG augmentation, EPG recipient site preparation offers time required for treatment completion may be extended
practitioners increased ability to eliminate mobile super- by ≈ 4 to 6 weeks.

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C A S E S E R I E S

FIGURE 7 Case 3. Clinical appearance postoperative week 12.

FIGURE 8 Case 4. Initial presentation. The patient was referred

to the periodontics department to address peri-implant soft tissue
deficiencies. Multi-unit abutments∗ (2-mm height) were present. The
original prosthetic plan required 15 mm between the intended incisal
edge position and implant platforms. Thus, alveoloplasty at implant
surgery placed the vertical alveolar bone height approximately 1 to 3
mm superior to the floor of the mouth. The implant sites exhibited no
facial and minimal lingual keratinized mucosa in addition to negligible
vestibular depth. Oral hygiene measures were uncomfortable for the
patient due to lack of keratinized mucosa.
∗ Certain Low Profile One-Piece Abutment, Zimmer Biomet,
Warsaw, IN

FIGURE 6 Case 3. 6a Baseline clinical appearance with provi-

sional restoration removed. 6b EPG stabilized with 4/0 dPTFE∗
and 5/0 polypropylene† sutures. 6c Provisional restoration in
place at postoperative day 7. The provisional restoration was
used to protect the EPG and maintain vestibular depth. 6d
Clinical appearance postoperative week 3.
∗ Cytoplast, Osteogenics Biomedical, Lubbock, TX
† Perma Sharp polypropylene sutures, Hu-Friedy, Chicago, IL

152 Clinical Advances in Periodontics, Vol. 9, No. 3, September 2019 EPG for Implant Site Development
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FIGURE 9 Case 4. 9a Baseline palatal appearance. 9b Palatal donor site. 9c EPG harvested. 9d Collagen membrane∗
stabilized at palatal donor site with 5/0 dPTFE† sutures and a palatal stent.‡ 9e Postoperative week 4.
∗ BioMend, Zimmer Biomet, Warsaw, IN
† Cytoplast, Osteogenics Biomedical, Lubbock, TX
‡ Invisacryl A Clear 1 mm, Great Lakes Dental Technologies, Tonawanda, NY

FIGURE 10 Case 4. 10a Baseline clinical appearance. 10b Recipient site prepared. Unfavorable superficial tissue was removed,
and alveolar bone was exposed. 10c EPG harvested (≈ 12 × 62 mm). 10d EPG stabilized at the recipient site with 5/0 dPTFE∗
and polypropylene† sutures. 10e Implant platform centers were located with a periodontal probe, and tissue overlying the fixtures was
removed with ø3-mm and ø4-mm biopsy punches.‡ Slightly stretching the EPG at punch sites allowed intimate graft-abutment approx-
imation despite undersized openings at fixture locations. Multi-unit abutments§ (4-mm height) were torqued to 20 N-cm. 10f and 10g
The conversion prosthesis was modified to accept low profile non-hexed abutment cylinders. A dental dam¶ was fitted to protect the
EPG while abutment cylinders were incorporated into the prosthesis. 10h Prosthesis in place at the conclusion of the EPG procedure.
∗ Cytoplast, Osteogenics Biomedical, Lubbock, TX
† Perma Sharp polypropylene sutures, Hu-Friedy, Chicago, IL
‡ Biopsy Punch Short, Miltex Integra, York, PA
§ Certain Low Profile One-Piece Abutment, Zimmer Biomet, Warsaw, IN
 Low Profile Abutment Non-Hexed Cylinders, Zimmer Biomet
¶ Flexi Dam Non-Latex, Coltene, Altstätten, Switzerland

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FIGURE 12 Case 4. Clinical appearance at postoperative

FIGURE 11 Case 4. EPG at conclusion of mucosal augmentation week 4.
procedure, before conversion of the prosthesis.

FIGURE 13 Case 4. Clinical appearance postoperative month 4.

FIGURE 14 Case 4. 14a and 14b Baseline clinical appearance. 14c and 14d Clinical appearance postoperative
month 4.

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FIGURE 15 Case 4. 15a Mandibular provisional fixed complete denture, occlusal surface. 15b Mandibular
provisional fixed complete denture, intaglio surface.

Summary

Why are these cases new  Although the topic remains controversial, adequate KMW, MT, and
information? vestibular depth may favorably impact peri-implant tissue health and
stability.
 EPG—the gold standard for gingival augmentation—differs
fundamentally from alternative methods and may be the technique of
choice for peri-implant mucosal augmentation at some dental implant
sites.

What are the keys to successful  The authors recommend placing EPG directly on bone to avoid the
management of these cases? possibility of mobile peri-implant mucosa following treatment.

What are the primary limitations  Depending on staging of EPG augmentation within the treatment plan,
to success in these cases? the procedure may prolong treatment by ≈ 4 to 6 weeks.

Acknowledgments Supporting Information

The views expressed in this manuscript are those of the Additional supporting information may be found online
authors and do not necessarily reflect the official pol- in the Supporting Information section at the end of the
icy of the Department of Defense, Department of Army, article.
US Army Medical Department, or Uniformed Services
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156 Clinical Advances in Periodontics, Vol. 9, No. 3, September 2019 EPG for Implant Site Development