Abstract: In addressing insufficient peri-implant keratinized mucosa width (KMW)—a critical determinant of long-term implant stability and peri-implant tissue health—the peri-implant free epithelium-connective tissue grafting (FECTG) emerges as an efficacious surgical solution. This article presents technical refinements for FECTG implementation, advocating keratinized mucosa augmentation either prior to or concomitant with second-stage implant surgery to optimize surgical access and buccolingual keratinized tissue distribution. Maxillary cases benefit from palatal soft tissue transfer for buccal width enhancement, whereas mandibular cases demand meticulous technique due to lingual anatomical constraints, where improper handling may risk keratinized mucosa deficiency. The pivotal periosteal recipient bed preparation requires preservation of periosteal integrity to ensure vascularization, elimination of mobile soft tissue to enhance graft stability, and creation of a recipient bed slightly larger than the graft to facilitate suturing and promote early nutrient/oxygen diffusion. Graft fixation employs a dual-suture approach—coronal interrupted sutures coupled with external horizontal mattress sutures. Crucially, omitting sutures for apically positioned flaps streamlines the procedure, reducing operative time while lowering technical complexity. These evidence-based protocols may facilitate the broader clinical adoption of FECTG for peri-implant soft tissue augmentation.

Key words: Free epithelium-connective tissue grafting, Keratinized mucosa augmentation, Apically positioned flap