The patient is referred for the creating of a zone of keratinised mucosa, buccal of the implant crown #46.  The aim of the intervention is to create a zone of keratinised mucosa of about 2mm buccal of the implant, which will improve patient’s ability for the efficient practice of oral hygiene and maintain tissue health and stability in the long term.

Due to the think tissues buccal of the implant, but also to the fact that much of the tissues to be augmented is in close proximity with the implant abutment (thus deprived of a vascular bed on periosteum), we have selected a Hybrid Epithelial – Connective Tissue graft as intervention of choice.

After removal of the crown and placement of a healing abutment, a split-thickness, apically repositioned flap buccal of the implant is executed.  The buccal side of the flap is fixed in an apical position with lateral sutures, exposing the periosteum.  A mixed connective tissue-epithelial graft is harvested from the palate and fixed on the buccal flap, with the connective tissue component sutured against the flap, while the epithelial component is sticking out on top of the apically repositioned flap.  The grated area is stabilised with mattress and single interrupted sutures and the site is left to heal with the healing abutment for 6 weeks, after which the crown is being placed back. 

The mixed CT-epithelial tissue graft allows for better vascularisation of the graft, which is now supported by the sizeable connective tissue attached to the split-thickness pocket and not only from the periosteum of the recipient site.  This graft can allow for the predictable creation of a keratinized zone of adequate width, while mildly augmenting the volume as well.  Stabilisation of the wound while avoiding over-compression is one of the challenges of the suturing technique.

The patient is instructed Chlorexidine Mouthrinse for 4 weeks and is followed up at weeks 1,4 and 6 at which time the healing is adequate for the replacement of the implant crown. Oral Hygiene is practiced with medium hardness manual toothbrush and interdental brushes.