https://doi.org/10.53453/ms.2026.7.15
Stabilization strategies in free gingival graft surgery around dental
implants: a scoping review of sutures, adhesives, and mechanical
fixation techniques
Ralfas Stanevičius
1
, Inesa Stonkutė
1
, Žygimantas Petronis
1
1
Faculty of Odontology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
Abstract
Background. Adequate keratinized mucosa around dental implants is important for maintaining peri-implant
health, facilitating plaque control, and improving patient comfort. Free gingival grafts (FGGs) are commonly used
to increase keratinized tissue width; however, graft stabilization during early healing remains critical for clinical
success. Various stabilization techniques have been proposed, but no consensus exists regarding the most effective
method.
Aim. This scoping review aimed to identify and summarize stabilization techniques used for FGG procedures
around dental implants and to evaluate their associated clinical outcomes.
Methods: The review was conducted according to PRISMA-ScR guidelines. Electronic searches were performed
in PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Library, supplemented by manual screening
of reference lists. Studies published in English between 2016 and 2026 were included if they involved FGG
procedures around dental implants and reported stabilization techniques and/or clinical outcomes. Data were
extracted and synthesized descriptively.
Results. Six studies met the inclusion criteria, including one randomized clinical trial, two observational studies,
and three case reports. Conventional suturing was the most commonly used stabilization method. FGG procedures
consistently increased keratinized tissue width by approximately 2–3 mm and soft tissue thickness by 1.0–1.5
mm. Stable peri-implant conditions were maintained for up to 3 years. Graft shrinkage was commonly reported
and significantly associated with graft size (P < 0.001). Alternative techniques, including periosteal sutures,
titanium tacks, and prosthesis-assisted stabilization, demonstrated favorable outcomes in individual cases.
Conclusions. FGG procedures provide predictable improvements in peri-implant soft tissue dimensions. Suturing
remains the most evidence-supported stabilization method, while alternative techniques require further
comparative clinical research.
Keywords: Free gingival graft; dental implants; peri-implant soft tissue; graft stabilization; keratinized mucosa;
soft tissue augmentation.
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Medical Sciences 2026 Vol. 14 (5), p. 128-140, https://doi.org/10.53453/ms.2026.7.15
128
1. Introduction
Peri-implant soft tissue management plays a
critical role in maintaining implant health and
long-term stability [1]. Adequate keratinized
mucosa around dental implants has been
associated with improved plaque control,
reduced mucosal inflammation, and enhanced
patient comfort. In cases where keratinized
tissue is insufficient, surgical augmentation
procedures may be required to improve peri-
implant soft tissue conditions [2,3].
Free gingival grafts (FGGs) are commonly used
to increase the width of keratinized tissue around
dental implants and are considered a predictable
technique for peri-implant soft tissue
augmentation [4,5]. The success of this
procedure depends on several factors, among
which graft stabilization during the early healing
period is particularly important. Adequate
stabilization facilitates close adaptation of the
graft to the recipient site, promotes
revascularization, and reduces the risk of graft
displacement or necrosis [3,5,6].
Several techniques have been described to
stabilize FGGs. Conventional suturing methods
are the most widely used approach, however,
alternative techniques such as tissue adhesives
and mechanical fixation devices have also been
proposed to improve graft stability and simplify
surgical procedures [3,6].
Despite the variety of available techniques, there
is currently no clear consensus regarding the
most effective method for stabilizing FGGs
around dental implants. Moreover, most
available studies focus on procedures around
natural teeth, with limited evidence specific to
implant sites. The existing literature includes
different surgical approaches, outcome
measures, and study designs, making it difficult
to directly compare reported results.
Therefore, a scoping review is appropriate to
map the available evidence and identify
knowledge gaps in this field. The objective of
this scoping review is to identify and summarize
stabilization strategies used in free gingival graft
surgery around dental implants and to describe
the clinical outcomes associated with these
techniques.
2. Methods
This scoping review was conducted following
established methodological frameworks for
scoping reviews and was reported in accordance
with the PRISMA Extension for Scoping
Reviews (PRISMA-ScR) guidelines [7]. The
protocol for this review was registered on the
Open Science Framework (OSF) (registration
DOI: 10.17605/OSF.IO/NFGEC).
2.1 Eligibility Criteria
The eligibility criteria were defined using the
Population-Concept-Context (PCC) framework.
Population: patients undergoing FGG
procedures around dental implants, particularly
in cases with insufficient keratinized tissue
surrounding the implants.
Concept: stabilization strategies used to secure
the graft, including sutures, tissue adhesives, and
mechanical fixation techniques.
Context: peri-implant soft tissue augmentation
procedures.
Studies reporting clinical outcomes and/or
describing stabilization techniques associated
with these methods were considered eligible.
Types of Evidence Sources: eligible sources of
evidence included randomized clinical trials,
non-randomized clinical studies, cohort studies,
case-control studies, prospective and
retrospective clinical studies, case series, and
case reports describing stabilization techniques
used in FGG procedures around dental implants.
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Exclusion Criteria: studies were excluded if
they:
Involved connective tissue grafts
without fggs
Did not involve dental implants
Did not describe stabilization methods
Were review articles, systematic
reviews, editorials, or expert opinion papers
Were animal or in-vitro studies
2.2 Information Sources
Electronic searches were conducted in the
following databases: PubMed/MEDLINE,
Scopus, Web of Science, and the Cochrane
Library. In addition, publisher platforms
including Wiley Online Library, ScienceDirect,
and Springer Nature were consulted to identify
additional relevant studies.
The reference lists of all included articles were
manually screened to identify further eligible
studies that may not have been captured through
the database search.
Only studies published in English were included.
The search was limited to studies published
between January 2016 and February 2026 to
ensure inclusion of contemporary surgical
techniques. This time restriction was applied to
reflect recent developments in peri-implant
surgical techniques. The final search was
performed on February 20, 2026.
2.3 Search Strategy
The search strategy combined terms related to
free gingival grafts, dental implants, and graft
stabilization techniques. The search strategy was
initially developed for PubMed/MEDLINE and
subsequently adapted for the other databases.
An example of the search strategy used in
PubMed is shown below:
(free gingival graft OR FGG) AND (dental
implant OR implants OR peri-implant) AND
(suture OR adhesive OR cyanoacrylate OR
fibrin glue OR fixation OR stabilization)
Equivalent search strategies were adapted for
Scopus, Web of Science, and the Cochrane
Library.
The search was limited to studies published in
English between January 2016 and February
2026 to ensure inclusion of contemporary
surgical approaches and stabilization techniques
in peri-implant soft tissue augmentation.
2.4 Selection of Sources of Evidence
All records identified through the database
searches were exported to EndNote (Clarivate
Analytics), and duplicate records were removed
prior to screening.
Study selection was conducted in two stages. In
the first stage, titles and abstracts were screened
against the predefined eligibility criteria to
identify potentially relevant studies. In the
second stage, the full texts of the selected articles
were retrieved and assessed for eligibility.
Screening was performed independently by two
reviewers (R.S. and I.S.). In cases of
disagreement, consensus was reached through
discussion, and when necessary, a third reviewer
(Ž.P.) was consulted. Studies that met the
inclusion criteria were included in the final
review.
The study selection process was documented
using a PRISMA flow diagram, which illustrates
the number of records identified, screened,
excluded, and included at each stage of the
review.
2.5 Data Charting Process
Data charting was performed using a
standardized data extraction form developed by
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the authors prior to the review process. The form
was designed to systematically collect relevant
information from each included study and was
iteratively refined during the charting process as
necessary.
The following data were extracted from each
study: author and year of publication, study
design, sample size, stabilization technique used,
clinical outcomes related to graft stabilization
(including keratinized tissue gain, graft
shrinkage, healing outcomes, and
complications), follow-up period, and the main
findings reported by the authors.
2.6 Data Items
The data items included in the charting form
were predefined to capture key characteristics of
the included studies and relevant clinical
information related to graft stabilization.
The following study characteristics were
collected: author, year of publication, country of
origin, study design, and sample size.
Information related to the surgical procedure was
also extracted, including the indication for the
free gingival graft, implant location, and the
stabilization technique used.
Clinical outcomes reported in the studies were
recorded, where available, including keratinized
tissue gain, graft shrinkage, healing outcomes,
postoperative complications, patient discomfort,
and follow-up duration.
2.7 Critical Appraisal
Because the objective of this scoping review was
to map and summarize the available evidence
rather than evaluate the effectiveness of specific
interventions, a formal risk-of-bias assessment
was not performed. This approach is consistent
with the methodological purpose of scoping
reviews, which aim to provide an overview of
existing literature and identify research gaps
rather than critically appraise study quality.
2.8 Synthesis of Results
The included studies were grouped according to
the type of stabilization method used for free
gingival graft fixation. Stabilization techniques
were categorized into three main groups: sutures,
tissue adhesives, and mechanical fixation
techniques, with additional techniques described
where applicable.
The results were synthesized descriptively and
presented in tables summarizing the
characteristics of the included studies,
stabilization techniques, and reported clinical
outcomes. Findings were also described
narratively, where appropriate, to highlight
patterns in the literature and identify gaps in the
available evidence.
3. Results
3.1 Study Selection
The database search identified 643 records. After
removal of duplicates, 612 records remained and
were screened based on titles and abstracts. Of
these, 569 records were excluded.
The full texts of 43 articles were assessed for
eligibility, of which 37 were excluded, primarily
due to not meeting the inclusion criteria.
A total of six studies met the eligibility criteria
and were included in the final analysis.
The study selection process is illustrated in the
PRISMA flow diagram.
3.2 Characteristics of Included Studies
The included studies comprised a heterogeneous
body of evidence, including one randomized
clinical trial [8], two observational clinical
studies [9,10], and four case reports [11–14].
Sample sizes varied considerably, ranging from
single-patient case reports to studies involving
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up to 53 implants [10]. The duration of follow-
up also differed across studies, ranging from
short-term evaluations of 6 to 9 months [8,9,13]
to longer observation periods extending from
approximately 12 months to up to 3 years [10–
12,14].
Overall, the evidence base was characterized by
variability in study design, sample size, and
outcome measures, reflecting the limited and
diverse nature of the available literature on
stabilization strategies in free gingival graft
procedures around dental implants. The main
characteristics of the included studies are
summarized in Table 1. The stabilization
techniques identified in the included studies are
described below.
Figure 1. PRISMA flow diagram.
Table 1. Characteristics of Included Studies
Author
(Year)
Study Design
Sample Size
Stabilization
Technique
Outcomes Reported
Follow-
up
(months)
El-Sayed
et al.
(2025) [8]
Randomized
clinical trial
20 patients
(20
implants)
Sutures
KMW
STT
9
Shah &
Kothiwale
(2021) [9]
Prospective
clinical study
10 patients
(10
implants)
Sutures
KTW gain, plaque index,
gingival index, probing
depth
6
Lin et al.
(2022)
[10]
Observational
clinical study
32 patients
(53
implants)
Sutures
KMW, vertical and
horizontal tissue
thickness, marginal bone
loss
16
Liao et al.
(2023)
[11]
Case report
1 patient
(1 implant)
Periosteum sutures
Keratinized tissue gain,
graft shrinkage
36
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Lee et al.
(2023)
[12]
Case report
1 patient
(3 implants)
Titanium tacks
Keratinized mucosa gain
12
Korkis et
al. (2019)
[13]
Case report
2 patients
(4 implants)
Acrylic/composite
stents + sutures
KMW width increase,
graft stability
6
Marin et
al. (2017)
[14]
Case report
1 patient
(4 implants)
Sutures + prosthesis-
assisted stabilization
Keratinized mucosa
increase
12
KMW - keratinized mucosa width; STT - soft tissue thickness
3.3 Stabilization Techniques
Before describing specific stabilization methods,
the general surgical approach to FGG procedures
should be outlined.
The graft is typically harvested from the palatal
mucosa, most commonly in the premolar region
(between the canine and first molar), where
sufficient tissue thickness is available [15]. A
partial-thickness incision is performed, usually
at a depth of approximately 1.0-1.5 mm, to
obtain an epithelialized graft while preserving
the underlying periosteum and minimizing donor
site morbidity. The thickness of the harvested
graft generally ranges from 1.0 to 1.5 mm,
depending on the clinical indication and palatal
tissue biotype [8,16]. Care must be taken to
avoid excessive thinning, which may compro-
mise graft survival, or excessive thickness,
which may impair revascularization [15–17].
The hard palatal mucosa is primarily
vascularized by the greater palatine artery
(GPA), which arises from the descending
palatine artery within the pterygopalatine fossa.
It travels through the greater palatine canal and
exits via the greater palatine foramen, typically
located near the posterior aspect of the hard
palate [18]. The position of the GPA varies
according to the palatal region, generally lying
approximately 12-17 mm from the gingival
margin, with a depth ranging from 1.2 to 5.5 mm
beneath the palatal surface [19]. Due to its
anatomical course, inadvertent injury to this
vessel during graft harvesting may lead to
significant hemorrhage. Therefore, careful
assessment of the surgical site and precise
control of incision depth and location are critical
to minimize the risk of bleeding complications
[18].
Following harvesting, the graft is transferred to
the peri-implant recipient site, where a well-
vascularized connective tissue bed is prepared.
The graft is positioned and adapted closely to the
recipient site to ensure intimate contact with the
underlying tissue, which is critical for plasmatic
diffusion and subsequent revascularization
during the early healing phase [8,16,17].
Adequate graft stabilization during this stage is
essential to prevent micromovement, promote
revascularization, and support successful
integration of the graft [8,12].
The included studies reported a range of
stabilization strategies for FGGs around dental
implants. These techniques were categorized
into four main groups: conventional sutures,
modified suturing techniques, mechanical
fixation, and prosthesis-assisted stabilization.
3.3.1 Sutures
Conventional suturing techniques represented
the predominant method of graft stabilization
and were employed in all included clinical
studies [8–14].
Several specific suturing approaches were
described to ensure optimal graft immo-
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bilization. Initially, the graft is commonly
secured at its margins using interrupted sutures,
placed at the mesial and distal edges, as well as
along the buccal and lingual/palatal aspects.
These sutures serve to stabilize the graft
periphery and ensure precise adaptation to the
recipient bed [8]. To further enhance stability,
cross (X-shaped) sutures may be placed over the
central portion of the graft, distributing tension
evenly across the graft surface and minimizing
micromovement during the early healing phase
[10]. In addition, figure-of-eight (8-shaped)
sutures are frequently used to anchor the graft
directly to the underlying periosteum, improving
fixation and reducing dead space between the
graft and the recipient bed. This technique is
particularly useful in areas where additional
compression and immobilization are required.
In some cases, periosteal anchoring sutures are
applied by passing the needle through the graft
and engaging the periosteum, which enhances
graft stability and promotes closer contact with
the vascularized recipient site [11]. The
periosteal suturing technique is illustrated in
Figure 2, demonstrating graft stabilization
through anchorage to the underlying periosteum
(adapted from Liao et al. [11]). Continuous or
sling sutures may also be used around adjacent
teeth or implant abutments to further secure the
graft and protect it from displacement. From a
surgical perspective, proper suturing technique
aims to achieve passive, tension-free adaptation
of the graft. Excessive tension may compromise
blood supply, while insufficient fixation may
lead to graft micromovement, both of which can
negatively affect plasmatic diffusion and
revascularization.
Clinically, the use of sutures resulted in
predictable graft stabilization and favorable
outcomes. The randomized clinical trial by El-
Sayed et al. [8] demonstrated increases in
keratinized mucosa width to approximately 4.0-
4.5 mm, along with improvements in soft tissue
thickness over a 9-month follow-up period.
Similarly, Shah and Kothiwale [9] reported an
increase in keratinized tissue width to
approximately 3 mm, accompanied by improve-
ments in peri-implant clinical parameters.
In the observational study, Lin et al. [10]
reported stable peri-implant soft tissue
dimensions with a mean keratinized mucosa
width of approximately 4.08 mm at 16.7 months.
These findings indicate that suturing provides
reliable immobilization of the graft, supporting
stable integration and maintenance of augmented
tissue dimensions.
Figure 2. Periosteal suturing technique for free gingival graft stabilization.
(A) Step-by-step illustration of graft fixation using periosteal sutures.(B) Schematic representation of the operative
procedure.Adapted from Liao et al. [11].
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3.3.2 Mechanical Fixation
Mechanical fixation using titanium tacks was
identified as an alternative graft stabilization
strategy. In this approach, the graft is secured
directly to the recipient site using fixation tacks,
allowing firm immobilization without the need
for extensive suturing [12] (Figure 3). This
method provides immediate mechanical
stabilization by compressing the graft against the
underlying periosteal bed, thereby minimizing
micromovement and enhancing contact with the
vascularized recipient site.
From a clinical perspective, this technique may
simplify the surgical procedure and reduce
operative time, while ensuring stable graft
positioning during the early healing phase.
Adequate immobilization achieved through
mechanical fixation may facilitate plasmatic
diffusion and subsequent revascularization.
In the reported case, the use of titanium tacks
resulted in successful graft integration and an
increase in keratinized mucosa, with stable
outcomes observed at 12-month follow-up [12].
However, evidence regarding mechanical
fixation remains limited to case reports, and no
comparative studies have evaluated its
effectiveness relative to conventional suturing
techniques. Consequently, the clinical
advantages of this approach remain uncertain.
3.3.4 Prosthesis-Assisted Stabilization
Prosthesis-assisted stabilization techniques were
also described as alternative approaches to graft
fixation. In one case report, customized acrylic
or composite stents were fabricated and attached
to implant components to stabilize the graft
during the healing phase [13] (Figure 4). These
stents provided additional mechanical support by
maintaining constant pressure over the graft,
thereby improving adaptation to the recipient
site and protecting the graft from displacement.
In another case, prosthesis-assisted stabilization
was used in combination with conventional
suturing [14]. This combined approach allowed
for secure graft fixation while simultaneously
shielding the graft from mechanical disruption
during early healing
Clinically, these techniques may be particularly
advantageous in complex cases, such as areas
with limited access, mobile soft tissues, or where
suturing alone does not provide sufficient graft
stability.
However, similar to other alternative
stabilization methods, prosthesis-assisted
techniques have been reported only in case
reports, and their effectiveness has not been
evaluated in controlled clinical studies.
Figure 3. Mechanical fixation of a free gingival
graft using titanium tacks. The graft is stabilized
directly to the periosteal recipient bed, ensuring
firm immobilization and close adaptation to the
underlying tissue. Adapted from Lee et al. [12].
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Figure 4. Prosthesis-assisted stabilization of a free gingival graft around dental implants.
(a) Initial clinical presentation showing insufficient keratinized tissue; (b) preparation of partial-thickness flaps;
(c–d) preparation of the graft with fenestrations to accommodate implants; (e) graft positioned and sutured; (f)
stabilization using an acrylic stent secured to implant components; (g) healing at 2 weeks; (h) clinical outcome
at 2 months demonstrating increased keratinized tissue width and thickness. Adapted from Korkis et al. [13].
3.4 Clinical Outcomes
Across all included studies, FGG procedures
around dental implants demonstrated generally
favorable clinical results, although the type and
extent of reported findings varied depending on
study design. The clinical outcomes of the
included studies are summarized in Table 2.
3.4.1 Keratinized Tissue Width
All included studies reported an increase in
keratinized tissue width following FGG
procedures.
In the randomized clinical trial, keratinized
mucosa width increased from baseline values of
approximately 1.5-2.0 mm to approximately 4.0-
4.5 mm at 9 months, corresponding to a mean
gain of approximately 2.0-3.0 mm [8]. These
improvements were observed regardless of
whether the graft was performed before or after
implant placement, indicating that graft timing
did not significantly influence the magnitude of
keratinized tissue gain.
Similarly, the prospective clinical study by Shah
and Kothiwale [9] reported an increase in
keratinized tissue width to approximately 3.0-3.2
mm at 3 and 6 months postoperatively,
suggesting that most of the tissue gain occurs
during the early healing phase and remains stable
over time.
Observational data reported by Lin et al. [10]
reported a mean keratinized mucosa width of
approximately 4.08 mm at a mean follow-up of
16.7 months, demonstrating sustained stability
of the augmented tissue. In addition, this study
suggested that increased keratinized tissue width
was associated with improved peri-implant soft
tissue conditions and reduced plaque
accumulation.
Case reports further supported these findings,
demonstrating increases in keratinized tissue
following FGG procedures across different
stabilization techniques [11–14]. However, these
results were primarily descriptive and lacked
standardized quantitative measurements,
limiting direct comparison with clinical studies.
Overall, the available evidence indicates that
FGG is an effective and predictable procedure
for increasing keratinized tissue width around
dental implants, with gains of approximately 2-3
mm and stable outcomes maintained for up to 16
months and longer in individual cases.
3.4.2 Soft Tissue Thickness
Improvements in soft tissue thickness were
reported primarily in clinical studies. The
randomized clinical trial by El-Sayed et al. [8]
demonstrated a statistically significant increase
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in soft tissue thickness, with mean gains of
approximately 1.0-1.5 mm over a 9-month
follow-up period (p < 0.05). These changes were
observed in both treatment groups, indicating
consistent enhancement of peri-implant soft
tissue volume following FGG procedures.
Similarly, Lin et al. [10] reported vertical soft
tissue thickness values ranging from
approximately 2.5 to 3.7 mm around implant
sites at a mean follow-up of 16.7 months, with
statistically significant improvements compared
to baseline (p < 0.05).
From a clinical perspective, increased soft tissue
thickness may contribute to improved resistance
to mechanical trauma, enhanced tissue stability,
and a more favorable peri-implant phenotype. In
addition, thicker soft tissues may reduce
susceptibility to mucosal recession and peri-
implant inflammation.
Overall, the available evidence indicates that
FGG not only increases keratinized tissue width
but also enhances soft tissue thickness, with
measurable gains maintained over short- to
medium-term follow-up periods.
3.4.3 Graft Shrinkage
Graft shrinkage was reported as a common
postoperative phenomenon across the included
studies. The observational study by Lin et al.
[10] demonstrated that larger grafts were
associated with a significantly higher shrinkage
ratio (P < 0.001), indicating that graft
dimensions may influence postoperative
dimensional stability. This finding suggests that
graft size is an important factor in predicting the
extent of shrinkage following FGG procedures.
The case report by Liao et al. [11] also described
graft shrinkage despite successful graft
integration and increased keratinized tissue. In
this case, the use of periosteal sutures was
proposed to enhance graft stability and
potentially reduce the degree of postoperative
shrinkage by improving fixation and minimizing
micromovement.
From a clinical perspective, graft shrinkage may
partially reduce the initial gain in keratinized
tissue width, emphasizing the importance of
appropriate graft sizing and stabilization
techniques during surgery.
However, quantitative data on graft shrinkage
were inconsistently reported across studies, and
standardized measurement protocols were
lacking. This limits the ability to directly
compare outcomes and evaluate the impact of
different stabilization methods on graft
shrinkage.
3.4.4 Healing Outcomes and Complications
Healing outcomes were generally favorable
across all included studies. Clinical studies
reported uneventful postoperative healing and
stable peri-implant soft tissue conditions, with
no major complications such as graft failure,
infection, or necrosis observed [8-10]. In
addition, improvements in clinical parameters,
including plaque index and gingival index, were
reported, indicating enhanced peri-implant
tissue health following FGG procedures.
Case reports similarly demonstrated successful
graft integration and stable healing outcomes
[11-14]. Alternative stabilization techniques,
including titanium tacks and prosthesis-assisted
approaches, resulted in stable graft positioning
and uneventful healing during the postoperative
period [12-14].
Patient-related outcomes, where reported,
indicated good tolerance of the procedure, with
reduced discomfort and improved oral hygiene
following augmentation [13-14].
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Overall, the available evidence suggests that
FGG procedures around dental implants are
associated with predictable healing and a low
incidence of complications, regardless of the
stabilization technique used.
Table 2. Summary of Clinical Outcomes
Study
Keratinized
Tissue Gain
Soft
Tissue
Thickness
Graft Shrinkage
Key Clinical Findings
El-Sayed et al.
(2025) [8]
~1.5-2.0 → 4.0-
4.5 mm
1.0-1.5
mm
N/R
Significant increases in KTW and
tissue thickness
Shah & Kothiwale
(2021) [9]
~3.0-3.2 mm
N/R
N/R
Improved KTW and peri-implant
clinical indices
Lin et al. (2022)
[10]
Mean 4.08 mm
2.5-3.7
mm
Higher in larger
grafts (P < 0.001)
Stable peri-implant tissue; graft
size influences shrinkage
Liao et al. (2023)
[11]
Increased (not
quantified)
N/R
Present
Successful graft integration;
periosteal sutures may enhance
stability
Lee et al. (2023)
[12]
Increased (not
quantified)
N/R
N/R
Stable graft fixation using titanium
tacks
Korkis et al. (2019)
[13]
Increased (not
quantified)
N/R
N/R
Improved stability using stent-
assisted fixation
Marin et al. (2017)
[14]
Increased (not
quantified)
N/R
N/R
Prosthesis-assisted stabilization
supported graft protection
4. Limitations
This scoping review has several limitations that
should be considered when interpreting the
findings.
First, the included studies were heterogeneous in
design, sample size, and outcome measures,
which limited direct comparison between
studies. The evidence base consisted of a
combination of randomized clinical trials,
observational studies, and case reports, resulting
in variability in the level of evidence.
Second, a substantial proportion of the included
studies were case reports describing alternative
stabilization techniques. While these studies
provide valuable clinical insights, they offer
limited generalizability and do not allow for
robust conclusions regarding the effectiveness of
these methods.
Third, quantitative data on certain outcomes,
particularly graft shrinkage and soft tissue
thickness, were inconsistently reported across
studies. The lack of standardized outcome
measures further limited the ability to synthesize
and compare results.
Fourth, no included study directly compared
different graft stabilization techniques. As a
result, it was not possible to determine the
relative effectiveness of sutures versus
alternative fixation methods.
Finally, the search was limited to studies
published in English and within a defined time
period, which may have resulted in the exclusion
of relevant studies and introduced potential
selection bias.
5. Conclusions
Free gingival graft procedures around dental
implants are associated with favorable clinical
outcomes, including consistent increases in
keratinized tissue width and improvements in
soft tissue thickness. Across the included studies,
gains of approximately 2-3 mm in keratinized
tissue were observed, with stable peri-implant
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soft tissue conditions maintained over follow-up
periods of up to 3 years.
Conventional suturing techniques remain the
most commonly used and best-supported method
for graft stabilization, demonstrating predictable
and reproducible outcomes across clinical
studies. In contrast, alternative approaches,
including periosteal sutures, mechanical fixation
with titanium tacks, and prosthesis-assisted
stabilization, have been described as potential
adjuncts to improve graft immobilization,
particularly in complex clinical situations.
However, the current evidence is limited by the
lack of comparative clinical studies evaluating
different stabilization methods. As a result, it
remains unclear whether alternative techniques
provide clinically meaningful advantages over
conventional suturing.
Future research should focus on well-designed
randomized clinical trials to compare
stabilization strategies and to establish evidence-
based guidelines for optimizing graft stability
and long-term peri-implant soft tissue outcomes.
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