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Volume 72 • Number 7
Clinical Evaluation of 3 Techniques
to Augment Keratinized Tissue Without
Root Coverage*
Randall J. Harris
Background: The importance of keratinized tissue is a con-
troversial subject. However, in some situations most clinicians
would agree that surgical procedures to increase the amount of
keratinized tissue without root coverage are indicated. In this
study, 3 surgical procedures were compared in their ability to
increase the width of keratinized tissue. They are: the epithelized
autogenous masticatory mucosa graft (free gingival graft), auto-
genous predominately connective tissue graft (connective tissue
graft), and acellular dermal matrix.
Methods: Forty-five patients referred for treatment of areas
with inadequate keratinized tissue were randomly assigned into
1 of 3 groups of 15 each. Each group was treated with 1 of the
3 surgical procedures to increase the width of keratinized tissue.
The width of keratinized tissue pre- and postsurgery was eval-
uated.
Results: All 3 groups started with a similar width of kera-
tinized tissue. All of the surgical procedures resulted in a sta-
tistically significant increase in the width of keratinized tissue:
free gingival graft, 4.1 mm; connective tissue graft, 3.6 mm;
and acellular dermal matrix, 4.1 mm.
Conclusion: A statistically significant increase in the amount
of keratinized tissue was obtained with all 3 surgical procedures
evaluated. J Periodontol 2001;72:932-938.
KEY WORDS
Keratinized tissue/surgery; grafts, connective tissue; grafts,
gingival; matrix, acellular dermal.
* Private practice, Reno, NV.
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T
he importance of keratinized tissue
around natural teeth and dental
implants is a controversial topic. His-
torically, an adequate band of keratinized
tissue was viewed as important to prevent
future recession and maintain periodontal
health.1 Recently, it has been suggested that
keratinized tissue may not be needed in
many situations.2 Certainly, this debate will
continue. However, according to the 1996
Consensus Report on Mucogingival Ther-
apy, indications do still exist for increasing
the width of keratinized tissue.3 The gingi-
val augmentation procedures to increase
the width of keratinized tissue (without root
coverage) are and will continue to be per-
formed in clinical practice. The rationale
for performing the procedures include facil-
itating plaque control, improving patient
comfort, in conjunction with restorative or
prosthetic dentistry, in association with
orthodontics or natural tooth eruption which
results in alveolar bone dehiscence, and
possibly to prevent future recession.3
According to the World Workshop in 1996,
“a minimal amount or absence of gingiva
alone is not justification for gingival aug-
mentation.”2 However, indications still exist
for gingival augmentation to increase the
width of keratinized tissue.
An epithelized autogenous masticatory
mucosa graft (free gingival graft) is com-
monly used to predictably increase the
width of keratinized tissue.2 However, it cer-
tainly has its limitations and complications.
The color match is generally less than ideal
and the postoperative sequela of the donor
area can, at times, be significant.
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J Periodontol • July 2001
The use of a connective tissue graft to increase the
width of keratinized tissue has been shown to be effec-
tive. This technique seems to offer several advantages
over the conventional free gingival graft. Calura et al.4
reported, “more-rapid, less-traumatic healing and mat-
uration of the graft in the recipient site.” Additionally,
the donor area generally results in fewer postopera-
tive problems.4
Recently, the use of an acellular dermal matrix† has
been shown to be effective in root coverage procedures
as a substitute for connective tissue grafts.5,6 This tech-
nique has the advantage of not needing a donor area
and an unlimited supply of material. Reports have sug-
gested that an acellular dermal matrix can also be used
to increase the width of keratinized tissue with results
similar to free gingival grafts.7-11 However, there is a
limited amount of data presented in these studies. In a
recent study by Wei et al.,12 which did provide data to
support the claims, the acellular dermal matrix was less
effective in increasing the width of keratinized tissue
than a free gingival graft. Additionally, there are human
histological reports that suggest that placing an acellu-
lar dermal matrix on periosteum13 or bone14 is not an
effective method for increasing keratinized tissue.
The goal of this study was to evaluate and compare
the ability of these 3 surgical techniques (free gingi-
val graft, connective tissue graft, and acellular dermal
matrix) to increase the width of keratinized tissue. A
secondary goal was to examine a different technique
when using the acellular dermal matrix for gingival
augmentation, to determine if it would eliminate some
of the problems reported.12-14 Any complications that
developed would also be reported and evaluated.
MATERIALS AND METHODS
Study Population
Forty-five consecutively treated patients randomly
divided into 3 groups of 15 each were included in this
study. Group A: free gingival graft; 9 females and 6
males; mean age, 41.9 years old (range 14 to 60; sd
= 17.89). Group B: predominantly connective tissue
graft (connective tissue graft); 9 females and 6 males;
age, 39.5 years old (range 14 to 67; sd = 17.13).
Group C: acellular dermal matrix; 9 females and 6
males; mean age, 36.3 years old (range 14 to 65; sd
= 19.54).
Preoperative clinical photographs (Figs. 1A, 2A, and
3A) were taken. The width of keratinized tissue was
recorded with a standard Williams style probe rounded
off to the nearest 0.5 mm. In cases where more than
one tooth was treated, the area with the least amount
of keratinized tissue was selected as the site to be
measured. Each surgery produced one test site. All
surgical procedures and evaluations were done by the
author. The examination process was not calibrated to
measure the differences.
Harris
Surgery
The surgical procedure for all the groups was similar.
However, there were some differences. After obtain-
ing anesthesia, a releasing incision was placed between
the mucogingival junction and the marginal tissue. If
there was no keratinized tissue, the incision was made
at the margin and extended into the interproximal areas
to include some keratinized tissue. A partial thickness
flap was reflected, as close to periosteum as possible,
to create a bed preparation (Figs. 1B, 2B, and 3B). In
Group C, the periosteum was scored at the apical
extent of the bed preparation and randomly in the bed
preparation. This was not done in the other groups.
The appropriate graft was obtained or prepared.
The free gingival graft was obtained from the palate
in the molar region. The goal was to obtain a uniform
thickness graft approximately 0.75 to 1.00 mm thick.
An acrylic palatal stent was placed to cover the wound.
The connective tissue graft was obtained with a scalpel
with parallel blades (1.0 mm apart)‡ as previously
described.15-17 The epithelial border was not removed
(Fig. 2C). An acrylic palatal stent was placed to cover
the wound. The acellular dermal matrix was prepared
as directed by the manufacturer; i.e., hydrating the
material for at least 10 minutes in 2 saline washes
(Fig. 3C). Each graft was trimmed and then sutured
into the bed preparation with 5-0 gut sutures (Figs.
1C, 2D, and 3D).
In Group C the acellular dermal matrix was sutured
so the basement membrane side was in the more supe-
rior position and the connective tissue side was placed
towards periosteum.
In Groups B and C, the partial thickness flaps pre-
viously reflected to create the bed preparation were
sutured with 5-0 gut sutures to partially cover the api-
cal portion of the connective tissue graft (Fig. 2D) and
the acellular dermal matrix (Fig. 3D).
A periodontal dressing was applied in all cases and
routine postoperative instructions given. Patients were
seen at 1 to 2 weeks (Figs. 1D, 2F, and 3F) and 1
month and 3 months postoperative (Figs. 1E, 2G, and
3G). Final clinical measurements were recorded at the
3-month appointment.
Statistical Analysis
Statistical analysis was performed in 3 parts: 1) A one-
way analysis of variance (ANOVA) was used to deter-
mine if each of the groups had similar amounts of ker-
atinized tissue preoperatively. 2) A paired t test was
used to compare the pre- and postoperative mea-
surements to determine whether the surgical proce-
dures produced a statistically significant change in the
amount of keratinized tissue. 3) ANOVA was used to
† AlloDerm, LifeCell Corp., Branchburg, NJ.
‡ Harris Double Blade Graft Knife, H & H Company, Ontario, CA.
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Comparison of Techniques to Augment Keratinized Tissue
determine if one of the procedures produced more or
less keratinized tissue. An alpha of 0.01 was selected
for all evaluations. If a statistically significant F was
detected in any ANOVA, then a Fisher’s least signifi-
cant difference test would be used.18 A power analy-
sis§ was done to see if the sample size was adequate
to conclude that the results of the 3 surgical techniques
were statistically similar.
Assuming a power of 0.80, then the sample size
should be 141. Since there were only 45 subjects in
this study, one can not conclude that the results of the
3 procedures are statistically similar.
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Volume 72 • Number 7
Figure 1.
A. Preoperative free gingival graft patient (teeth #25-26). Note
progressing recession and inadequate keratinized tissue. B. Bed
preparation. C. Free gingival graft sutured. D. Postoperative (2 weeks).
E. Postoperative (12 weeks).
RESULTS
There was no statistically significant difference between
the widths of keratinized tissue present preoperatively.
Group A (free gingival graft) 0.8 mm (SD = 0.59); Group
B (connective tissue graft) 0.4 mm (SD = 0.47); and
Group C (acellular dermal matrix) 0.6 mm (SD = 0.87).
All of the surgical procedures produced statistically
significant increases in the quantity of keratinized tis-
sue. The results are summarized in Table 1.
The increase in the mean amounts of keratinized
§ PC-Size, Gerald E. Dallal, Boston, MA.
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J Periodontol • July 2001 Harris

Figure 2.
A. Preoperative connective tissue graft patient (teeth #27-28). Note:
recession that just developed and inadequate keratinized tissue.
B. Bed preparation. C. Connective tissue graft with epithelial border.
D. Connective tissue graft sutured. E. Pedicle sutured over apical
portion of graft. F. Postoperative (2 weeks). G. Postoperative (12
weeks).

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Comparison of Techniques to Augment Keratinized Tissue Volume 72 • Number 7

Figure 3.
A. Preoperative acellular dermal matrix patient (teeth #23-26). Pre-
orthodontic case that has prominent roots, thin tissue, and inadequate
keratinized tissue. B. Bed preparation. C. Acellular dermal matrix;
basement membrane side (white side) and connective tissue side (red
side) are apparent. D. Acellular dermal matrix sutured. E. Pedicle
sutured over apical portion of graft. F. Postoperative (2 weeks). G.
Postoperative (12 weeks).

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J Periodontol • July 2001 Harris

Table 1. The most obvious difference between the

procedures is the postoperative pain, which
Clinical Changes (in mm) was significantly greater in the patients treated
with a free gingival graft. These patients tended
Keratinized Group A Group B Group C Statistically
to take more pain medication and for a longer
Tissue (FGG) (CT) (ADM) F* Significant
period of time. In all cases, the pain eventu-
Preoperative ally disappeared. However, in several cases it
Mean 0.8 0.4 0.6 1.14 No was reported to have interfered with the
Range 0.0-2.0 0.0-1.5 1-3.0 patient’s lifestyle and normal activities. These
SD 0.59 0.47 0.87 problems did not occur with the connective
Postoperative tissue graft or the acellular dermal matrix. In
Mean 4.8 4.0 4.7 the future, it will be important to use some
Range 3.0-6.5 2.5-5.5 1.5-8.5 method to measure pain, rather than depend-
SD 1.16 0.99 1.92 ing on the subjective evaluations used in this
study.
Change
The esthetics of the results varied greatly in
Mean 4.1 3.6 4.1 0.79 No
all groups. The free gingival graft tended to
Range 2.5-6.5 2.5-5.0 1.5-8.5
SD 1.25 0.82 1.79 create a more “patch-like” result. The con-
nective tissue graft and acellular dermal matrix
†t (comparison of pre 12.58 16.83 8.96 seemed to produce a more esthetic result in
and postoperative) most cases; however, both these techniques
Statistically significant Yes Yes Yes produced a result that was as “patch-like” in
appearance as a free gingival graft.
* F statistic; 1-way analysis of variance.
† t statistic; t test.
Since similar clinical results can be
obtained with all 3 procedures, factors other
than clinical parameters should be consid-
tissue were: Group A (free gingival graft) 4.1 mm ered when selecting a procedure. Based on patient-
(sd = 1.25); Group B (connective tissue graft) 3.6 mm reported postoperative pain levels and the esthetics of
(sd = 0.82); and Group C (acellular dermal matrix) the results, it would seem reasonable to consider a
4.1 mm (sd = 1.79). When these results were evalu- connective tissue graft or an acellular dermal matrix
ated with an ANOVA the results were not statistically over a free gingival graft to increase the amounts of
different (F = 0.79) (Table 1). keratinized tissue. However, in certain situations, based
No major postoperative problems developed and on clinical judgement, the free gingival graft may be
there were no unscheduled appointments. Pain levels the procedure of choice.
reported by the patients postoperative were minimal The availability of adequate amounts of donor mate-
for most of the patients in Group B (connective tissue rial could limit the ability to use a connective tissue
graft) and Group C (acellular dermal matrix), and graft or free gingival graft. In these situations, an acel-
Group A (free gingival graft) patients reported higher lular dermal matrix can be an ideal material. This mate-
levels. In all cases this increased pain was from the rial permits treating larger areas than could generally
palatal donor area. be treated with a free gingival graft or a connective
tissue graft.
DISCUSSION It is unknown whether or not similar results could
In this study, it was found that all 3 surgical proce- have been obtained with a less involved technique
dures can increase the width of what appears clini- when using the acellular dermal matrix. However, the
cally to be keratinized tissue. Additionally, all 3 results of this study are contrary to the results of Wei
increased the width of keratinized tissue by a statisti- et al.12 In their study, no periosteal scoring was done
cally significant amount. However, it is not possible to and the apical portion of the acellular dermal matrix
conclude that the results are similar, due to an inade- was not covered with a flap containing keratinized tis-
quate sample size. sue. They showed that the amount that the keratinized
The free gingival graft was the simplest and least tissue increased was statistically greater with a free
time consuming procedure. The connective tissue graft gingival graft (5.57 mm) than an acellular dermal
and acellular dermal matrix required more time to matrix (2.59 mm). Further study in this area is
complete, with the increased number of sutures required.
required with these techniques probably accounting The major shortcoming of this study relates to the
for the difference. None of these procedures were tech- fact that the study was completed in a private prac-
nically challenging. tice setting. Blinded evaluations, standardized graft

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Comparison of Techniques to Augment Keratinized Tissue Volume 72 • Number 7

sizes and locations, longer term follow-ups, and a larger 10. Haeri A, Clay J, Finely JM. The use of acellular dermal
sample size could have improved the study protocol. skin graft to gain keratinized tissue. Compendium 1999;
20:233-242.
However, if one examines the literature to this point,
11. Silverstein LH, Gornstein RA, Callan DP. The similarities
in the area of gingival augmentation with an acellular between an acellular dermal allograft and a palatal graft
dermal matrix, this present study compares well in for tissue augmentation: A clinical case. Dent Today
most of these areas.6-14 1999;18(3):76-79.
It is unknown how well any of these results will main- 12. Wei P, Laurell L, Geivelis M, Lingren MW, Maddalozzo D.
Acellular dermal matrix allografts to achieve increased
tain over time. Additionally, it is unknown if the tissue
attached gingiva. Part 1. J Periodontol 2000;71:1297-
obtained from the 3 procedures is functionally equiv- 1305.
alent. Certainly, long-term follow-up will be necessary 13. Harris RJ. Gingival augmentation with an acellular der-
to determine if the results are stable. mal matrix, human histological evaluation of a case
In this study, 3 surgical procedures were evaluated. report: placement of the graft on periosteum. Int J Peri-
odontics Restorative Dent; accepted for publication.
All procedures were able to increase the width of ker-
14. Harris RJ. Gingival augmentation with an acellular der-
atinized tissue a clinically and statistically significant mal matrix, human histological evaluation of a case
amount. report: placement of the graft on bone. Int J Periodon-
tics Restorative Dent 2001;21:69-75.
ACKNOWLEDGMENTS 15. Harris RJ. The connective tissue and partial thickness
This study was funded in part by an unrestricted grant double pedicle graft: A predictable method of obtaining
root coverage. J Periodontol 1992;63:477-486.
from LifeCell Corp, Branchburg, New Jersey. The 16. Harris RJ. The connective tissue with partial thickness
author expresses his appreciation to Linda Harris, double pedicle graft: The results of 100 consecutively-
Christopher Harris, Laura Harris Miller, and Richard treated defects. J Periodontol 1994;65:448-461.
Miller for their assistance and help during the clinical 17. Harris RJ. A comparison of two techniques of obtaining
phase of this study and preparation of this manuscript. a connective tissue graft from the palate. Int J Peri-
odontics Restorative Dent 1997;17:261-271.
The Harris Double Blade Graft Knife used in this study 18. Ott L. An Introduction to Statistical Methods and Data
was designed by the author. H & H Company manu- Analysis. North Scituate, MA: Duxbury Press; 1997:354-
factured this instrument and donated it and several 392;629-638.
other instruments used in this study to the author.
Send reprint requests to: Dr. Randall J. Harris, 855 West 7th
REFERENCES St., Suite 24, Reno, NV 89503.
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2. Wennström J. Mucogingival therapy. Ann Periodontol
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4. Calura G, Mariani G, Parma-Benfenati S, De Paoli S,
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