Received: 25 April 2022 | Accepted: 1 May 2022

DOI: 10.1111/clr.13956

CONSENSUS REPORT

Importance of keratinized mucosa around dental implants:

Consensus report of group 1 of the DGI/SEPA/Osteology
Workshop

Mariano Sanz1 | Frank Schwarz2 | David Herrera1 | Pamela McClain3,4 |

Elena Figuero1 | Ana Molina1 | Alberto Monje5,6 | Eduardo Montero1 |
Andrés Pascual7 | Ausra Ramanauskaite2 | Franck Renouard8 | Robert Sader2 |
Eik Schiegnitz9 | Itsvan Urban10,11 | Lisa Heitz-­Mayfield12
1
ETEP (Etiology and Research of Periodontal and Peri-­implant Diseases) Research Group, University Complutense of Madrid, Madrid, Spain
2
Department of Oral Cranio-Maxillofacial and Facial Plastic Surgery, Madical Center of the Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
3
Private Practice, Aurora, Colorado, USA
4
School of Dentistry, University of Colorado Health Sciences Center, Denver, USA
5
Department of Periodontology, School of Dentistry, International University of Catalonia (UIC), Barcelona, Spain
6
Department of Periodontology and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, Michigan, USA
7
Department of Periodontology, School of Dentistry, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
8
Private Practice, Paris, France
9
Department of Oral and Maxillofacial Surgery, University Medical Center of the Johannes‑Gutenberg University, Mainz, Germany
10
Department of Periodontics & Oral Medicine, Ann Arbor, Michigan, USA
11
Urban Regeneration Institute, Budapest, Hungary
12
International Research Collaborative –­Oral Health and Equity, School of Anatomy, Physiology and Human Biology, The University of Western Australia,
Crawley, Western Australia, Australia

Correspondence
Mariano Sanz, ETEP (Etiology and Abstract
Research of Periodontal and Peri-­implant
Objectives: To assess the literature on (i) the relevance of the presence of a minimum
Diseases) Research Group, University
Complutense of Madrid, Madrid, Spain. dimension of keratinized peri-­implant mucosa (KPIM) to maintain the health and sta-
Email: [email protected]
bility of peri-­implant tissues, and; (ii) the surgical interventions and grafting materials
used for augmenting the dimensions of the KPIM when there is a minimal amount or
absence of it.
Material & Methods: Two systematic reviews complemented by expert opinion from
workshop group participants served as the basis of the consensus statements, impli-
cations for clinical practice and future research, and were approved in plenary session
by all workshop participants.
Results: Thirty-­four consensus statements, eight implications for clinical practice,
and 13 implications for future research were discussed and agreed upon. There is
no consistent data on the incidence of peri-­implant mucositis relative to the pres-
ence or absence of KPIM. However, reduced KPIM width is associated with increased
biofilm accumulation, soft-­tissue inflammation, greater patient discomfort, mucosal

© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Clin Oral Impl Res. 2022;33(Suppl. 23):47–55.  wileyonlinelibrary.com/journal/clr | 47

48 | SANZ et al.

recession, marginal bone loss and an increased prevalence of peri-­implantitis. Free

gingival autogenous grafts were considered the standard of care surgical intervention
to effectively increase the width of KPIM. However, substitutes of xenogeneic origin
may be an alternative to autogenous tissues, since similar results when compared to
connective tissue grafts were reported.
Conclusion: Presence of a minimum width of KPIM should be assessed routinely in
patients with implant supported restorations, and when associated with pathological
changes in the peri-­implant mucosa, its dimensions may be surgically increased using
autogenous grafts or soft-­tissue substitutes with evidence of proven efficacy.

KEYWORDS
autogenous grafts, connective tissue attachment, dental implants, keratinized mucosa, oral
epithelium, soft-­tissue substitutes, xenogeneic grafts

1 | I NTRO D U C TI O N dimension of keratinized peri-­implant mucosa (KPIM) to maintain

the health and stability of peri-­implant tissues. Furthermore, this
Peri-­implant mucosa (PIM) refers to the soft tissue that surrounds report has evaluated the main surgical interventions and grafting
dental implants. The PIM is established during the early stages of materials used for augmenting the dimensions of the KPIM in situ-
wound healing following implant surgery or abutment connection ations where there is a minimal amount or absence of KPIM.
and serves as a seal that prevents the downgrowth of the biofilm
and other macro molecules from the oral cavity. The PIM is com-
posed of an epithelial compartment, in which most of the time the 2 | S YS TE M ATI C R E V I E W 1: I N FLU E N C E
outer surface consists of a keratinized oral epithelium that extends O F K E R ATI N IZE D TI S S U E O N PE R I -­
apically to the mucosal junction, where it continues as alveolar mu- I M PL A NT TI S S U E H E A LTH O R D I S E A S E
cosa. However, the epithelium around an implant may also be non-­
keratinized lining mucosa. Coronally, it connects at the mucosal This systematic review aimed to evaluate the influence of the width
margin with a thin sulcular epithelium that faces the abutment part of keratinized tissue (KT) in the PIM on the prevalence of peri-­implant
of the implant, forming a barrier epithelium. This barrier epithelium diseases and on the stability of the peri-­implant soft and hard tissues
extends apically and adheres to the abutment/implant surface via (Ramanauskaite et al., 2022). Clinical studies including ≥10 patients
hemidesmosomes. The connective tissue compartment forms the with dental implants in function for at least 6 months, reporting on
implant surface–­tissue interface separating the bone from the ep- the prevalence of peri-­implant diseases (primary outcome), plaque
ithelial compartment, and it is mainly composed of fibroblasts and index (PI), modified plaque index (mPI), bleeding index (mBI), bleeding
collagen fibres that extend between the periosteum to the mucosal on probing (BOP), probing depths (PD), mucosal recession (MR), and
margin in directions parallel to the surface of the implant/abutment marginal bone loss (MBL) and/or patient-­reported outcomes meas-
(Araujo & Lindhe, 2018). ures (PROMs), (secondary outcomes), published until September
This connective tissue component is consistently reported with a 2020 were searched. An additional search for relevant articles pub-
dimension of about 1.5 mm. However, the barrier epithelium compo- lished between October 2020 and January 31, 2022, was performed.
nent may vary, depending on the thickness of the mucosa, between
2–­3 mm. While the structure and dimensions of the PIM are well
established and the stability of the soft-­tissue attachment around 2.1 | PECO question/Outcomes
implants has been associated with the maintenance of stable mar-
ginal bone levels, the clinical significance of the width of keratinized In patients with dental implants (Population), what is the influence
tissue and its attachment to the underlying bone is still a matter of of a reduced width of KT in the peri-­implant mucosa (i.e. KT < 2 mm)
controversy. (Exposure) compared to peri-­implant sites with a width of KT ≥ 2 mm
Therefore, the purpose of this consensus report was to evalu- (Comparison), on the prevalence of peri-­implant diseases (Outcome),
ate the scientific evidence from two systematic reviews elaborated and on the stability of peri-­implant soft-­and hard-­tissues, as re-
for the present workshop (Montero et al., 2022; Ramanauskaite ported in cross-­sectional, case–­control, cohort, controlled clinical
et al., 2022), complemented by expert opinion from the partici- trials (CCTs) and randomized clinical trials (RCTs),
pants, regarding the clinical relevance of the presence of a minimum Population: Patients with dental implants.
SANZ et al. | 49

Exposure: Presence of peri-­implant mucosa KT < 2 mm. 3.2 | How often should the PIKM measurements
Comparison: Presence of peri-­implant mucosa KT ≥ 2 mm. be performed?
Outcomes: primary outcome: Occurrence of peri-­implant muco-
sitis and/or peri-­implantitis based on case definitions used in respec- Measurements of PIKM should be made routinely during the pa-
tive studies. tient's follow-­up since changes might be expected over time.
As secondary outcomes: PI, PD, BOP/BI, MBL changes, and
PROMs.
3.3 | What is the minimum width of peri-­implant
keratinized tissue suggested to reduce the risk of peri-­
2.2 | Results implant diseases?

Twenty-­t wo articles describing 21 studies (15 cross-­sectional, five To define inadequate PIKM, the studies from this systematic re-
longitudinal comparative studies, and one case series with pre–­ view have used different threshold values ranging from 0 mm (n = 4
post design) with an overall high to low risk of bias were included. studies) to 1 mm (n = 1 study) and 2 mm (n = 18 studies). Based on
Peri-­implant mucositis affected 20.8% to 42% of implants and peri-­ the meta-­analyses, the presence of KT < 2 mm was associated with
implantitis affected 10.5% to 44% of implants with a reduced amount a higher frequency of clinical signs of inflammation and marginal
(<2 mm) or absence of KT. The corresponding values for implant sites bone loss as opposed to sites exhibiting a KT ≥ 2 mm. However, the
with KT width ≥2 or >0 mm were 20.5% to 53% for peri-­implant mu- incidence of peri-­implant mucosal inflammation does not seem to
cositis and 5.1% to 8% for peri-­implantitis. Significant differences be markedly influenced by wider bands of KT (i.e. 2 up to 11 mm)
between implants with KT <2 mm and those with KT ≥ 2 mm were (Schwarz et al., 2018).
revealed for weighted mean differences (WMD) for BOP, mBI, PI,
MBL, and MR all favouring implants with KT ≥2 mm.
An updated literature search, following acceptance of the sys- 3.4 | Is inadequate PIKM associated with increased
tematic review and prior to the consensus meeting, yielded 2 mucosal inflammation?
cross-­sectional studies with an overall low risk of bias, of which one
reported on a significantly higher prevalence of peri-­implant muco- Peri-­implant mucosal inflammation appears to be increased when
sitis and peri-­implantitis at implants with KM < 2 mm when compared the KT width is <2 mm. However, these results are inconclusive due
with control sites exhibiting KT ≥2 mm (46.6% vs. 34.1%, and 42.1% to variations in the reported indices (BOP, mBI, suppuration).
vs. 17%, respectively).

3.5 | Is inadequate PIKM associated with an

2.3 | Conclusions increased incidence and prevalence of peri implant
mucositis?
Reduced KT width is associated with an increased prevalence of
peri-­implantitis, biofilm accumulation, soft-­tissue inflammation, mu- There is no data on the incidence of peri-­implant mucositis relative
cosal recession, marginal bone loss, and greater patient discomfort. to the presence or absence of KT. The prevalence of peri-­implant
mucositis (n = 5 studies) ranged between 20.8% to 46.6% at im-
plants exhibiting a reduced KT width (defined as absence of KT or
3 | CO N S E N S U S R E P O RT presence of KT <2 mm), and between 20.5% to 53% at implants
in the control group (defined as presence of KT or presence of
3.1 | How should the width of PIKM be measured KT ≥ 2 mm). Due to heterogeneity in methodologies (i.e. different
in the clinic? threshold values and case definitions), the available evidence re-
mains inconclusive regarding the role of KT on the occurrence of
Based on the studies investigated (n = 17 studies), PIKM width was peri-­implant mucositis.
commonly measured at the mid-­buccal aspect of the implant site by
means of a periodontal probe. Assessments were conducted from
the peri-­implant mucosal margin to the mucosal junction. Only a few 3.6 | Is inadequate PIKM associated with increased
studies (n = 4) addressed the KT width at the lingual aspect employ- incidence and prevalence of peri-­implantitis?
ing the same reference points.
In daily clinical practice, measurements of KT width should be as- There are no data reporting on the incidence of peri-­implantitis
sessed using a millimetre scaled periodontal probe at buccal and lingual relative to the presence or absence of KT. The prevalence of peri-­
aspects. If identification of the peri-­implant mucosal margin is ham- implantitis in the studies (using different case definitions) evaluated
pered by the prosthesis, removal of the prosthesis may be considered. in the systematic review (n = 5 studies) ranged between 10.5% to
44% at implants with a reduced width of KT (defined as absence
50 | SANZ et al.

of KT or presence of KT < 2 mm), while a lower prevalence of peri-­ This was particularly noted in the posterior regions of the mandible
implantitis (5.1% to 17% of the implants) was reported in the control in one study.
group (defined as presence of KT or presence of KT ≥ 2 mm).

3.13 | Is inadequate PIKM associated with

3.7 | Is inadequate PIKM associated with higher patient's oral health-­related quality of life?
plaque scores?
There is no evidence associating reduced KT and patient's oral
Plaque scores were significantly higher at implants exhibiting a KT health-­related quality of life (n = 5 studies).
width of <2 mm, as shown by longitudinal (n = 3) and cross-­sectional
(n = 6) studies.
3.14 | What is the association between vestibular
depth and KT width?
3.8 | Is inadequate PIKM associated with increased
probing depths? Evidence from one cross-­sectional study suggested a positive as-
sociation between a deep vestibulum of >4 mm and an increased
The reduced width of KT (i.e. <2 mm) was not associated with dif- width of KT.
ferences in PDs, as shown by longitudinal (n = 3) and cross-­sectional
(n = 10) studies.
3.15 | Is the lingual band of KT equally relevant
as the buccal band in reducing the risk for peri-­
3.9 | Is inadequate PIKM associated with increased implant diseases?
mucosal recession?
None of the included studies specifically addressed the relevance
During a follow-­up period of 4–­5 years, longitudinal studies (n = 2) of lingual KT on the occurrence of peri-­implant diseases. However,
revealed no differences between groups regarding the extent of mu- based on expert opinion there, is a suggestion that the presence of a
cosal recession. Cross-­sectional studies (n = 6) showed a significant band of KT on the lingual aspect is of equal clinical relevance.
association between the presence of KT <2 mm and increased mu-
cosal recession.
3.16 | Does the location of the implant correlate
to the amount of keratinized tissue and occurrence of
3.10 | Is inadequate PIKM associated with the peri-­implant diseases?
level of the marginal bone?
Evidence from the systematic review did not reveal any informa-
A KT width of <2 mm was shown to be significantly associated with tion on the implant location and preservation of peri-­implant health.
bone loss, based on longitudinal (n = 2) and reduced MBL in cross-­ However, one cross-­sectional study (Monje et al., 2019) suggested
sectional studies (n = 6). that posterior areas (i.e. molars and premolars) in the mandible lack-
ing KT were more frequently associated with peri-­implantitis com-
pared to anterior sites.
3.11 | Is inadequate PIKM associated with
increased mobility of the peri-­implant mucosa?
3.17 | Implications for clinical practice
The studies included in this systematic review have measured KT
width rather than the presence of mucosal attachment. However, • Presence of keratinized tissue should be an important consider-
there is some evidence that associates KT > 2 mm with absence of ation during the surgical therapy of dental implants. Particular
mucosal mobility (Monje et al., 2019). attention should be placed on the establishment of a proper peri-­
implant mucosal seal.
• Presence of keratinized tissue and attached mucosa should be
3.12 | Is inadequate PIKM associated with assessed once the tissue remodelling around dental implants is
increased pain and brushing discomfort? completed.
• Evaluation of the width of PIKM should be part of the regular oral
The level of brushing discomfort and pain appears to be higher at im- examination of peri-­implant hard and soft tissues.
plants lacking KT or presenting a KT width of <2 mm (n = 4 studies). • Maintenance care should be intensified at implants exhibiting an
SANZ et al. | 51

inadequate PIKM, since those sites are more prone to plaque ac- 4.2 | Outcomes
cumulation and subsequent peri-­implant mucosal inflammation.
The primary outcome was the change in width of the peri-­implant
keratinized mucosa (PIKM) around dental implants, expressed in
3.18 | Implications for future research mm. Secondary outcome variables were: (i) implant and prosthe-
ses survival (%); (ii) changes in clinical and radiographic peri-­implant
• Appropriate primary and secondary outcome measures defining outcomes (PIs, BOP, PD, MBLs, keratinized mucosa [KM] thickness,
peri-­implant health and disease should be established and glob- marginal bone levels); (iii) incidence of biological complications; (iv)
ally agreed. surgical time; and (v) PROMs, aesthetic evaluation, and economic
• Precise KT threshold levels associated with peri-­implant tissue factors.
stability should be established.
• The clinical relevance of PIM mobility, together with an adequate
appraisal of attached versus non-­attached mucosa should be es- 4.3 | Results
tablished, thus allowing a clear definition of adequate or inade-
quate PIKM. Eleven articles corresponding to ten investigations were selected.
• The application of imaging technologies to allow for the assess- For the PICOS #1, five RCTs and one CCT were included, all of
ment of the PIKM volume and changes during follow-­up, should them with an unclear or high risk of bias. For the PICOS #2, in
be considered. addition to the previous studies, three prospective case series
• The corresponding lingual KT values should be reported in addi- and one retrospective case series were included. Overall mean
tion or separately to the buccal KT values. risk of bias was 3.0 (ranging from 2.0 to 4.0) for the case series
• The influence of relevant factors, such as the implant location, the according to the Newcastle-­O ttawa scale. KM augmentation was
vestibular depth, and the type and design of the suprastructure significantly greater for autogenous grafts than for soft-­t issue sub-
should be investigated. stitutes (n = 6; WMD = 0.9 mm; 95% confidence interval (CI) [−1.4;
−0.3]; p < .001). However, when only xenografts were compared
with autogenous grafts no significant differences were observed
4 | S YS TE M ATI C R E V I E W # 2 : E FFI C AC Y (n = 5; WMD = -­0 .8 mm; 95% CI [−1.6; 0.0]; p = .062). Considering
O F G R A F TI N G TO I N C R E A S E TH E W I DTH all studies, soft-­t issue substitutes led to a statistically significant
O F PE R I - ­I M PL A NT K E R ATI N IZE D M U COSA . increase of KM (n = 9; weighted mean effect, WME = 3.0 mm; 95%
AU TO LO G O U S V E R S U S S O F T-­T I S S U E CI [2.2; 3.7]; p < .001). If only xenografts (n = 7) were considered
S U B S TIT U TE S the WME was 3.5 mm (95% CI [2.4; 4.5]; p < .001). Surgical time
and post-­surgical pain seemed to be reduced using soft-­t issue
The aim of this systematic review was to compare the efficacy of substitutes.
soft-­tissue substitutes compared with autogenous grafts (FGG, CTG)
in surgical interventions aiming at increasing the width of the PIKM
around dental implants (Montero et al., 2022). Secondarily, this sys- 4.4 | Conclusions
tematic review aimed to assess the impact of soft-­tissue substitutes
on peri-­implant health (i.e. PIs, BOP, PD, and MBLs) and PROMs. Free gingival grafts (FGG) are more effective in the augmentation
of PIKM than soft-­tissue substitutes. However, substitutes of xeno-
geneic origin may be an alternative to autogenous tissues, as they
4.1 | PICOS questions provided similar results to connective tissue grafts (CTG) and were
able to increase the width of KM by more than 2 mm. Furthermore,
PICOS #1: “In patients with dental implants (Population), what surgical time and post-­operative pain were significantly reduced,
is the efficacy of surgical interventions using soft-­tissue substi- and aesthetic appearance improved.
tutes (Intervention), as compared to those using autogenous grafts
(Comparison), to increase the amount of PIKM (Outcome), in rand-
omized clinical trials (RCTs) and controlled clinical trials (CCTs) with 5 | CO N S E N S U S R E P O RT
at least 6 months of follow-­up (Study design)?”
PICOS #2: “In patients with dental implants (Population), what 5.1 | Which surgical intervention is the standard of
is the effectiveness of soft-­tissue substitutes (Intervention and care to increase the width of the PIKM?
Comparison), to increase the amount of peri-­implant keratinized
mucosa (Outcome), in RCTs, CCTs, prospective/retrospective cohort Based on a previous systematic review (Thoma et al., 2014) and a
studies or prospective/retrospective case series, with a minimum consensus report (Tonetti & Jepsen, 2014), the standard of care for
follow-­up time of 6 months (Study design)?” PIKM augmentation is a combination of apically positioned flaps/
52 | SANZ et al.

vestibular extension procedures along with autogenous soft-­tissue 5.7 | What is the percentage of shrinkage of soft-­
grafts. tissue substitutes compared to autogenous grafts?

Based on five studies (RCTs/CCTs), the difference in the percent-

5.2 | What is the efficacy of the autogenous free age of shrinkage (measured apico-­coronally) between 1 to 6 months
gingival graft to increase the width of the peri-­implant post-­operatively after autogenous grafts compared to soft-­tissue
mucosa? substitutes was not statistically significant (WMD = −3.7%; 95%
[−10.1; 2.7]; p = .256). While no significant differences were ob-
Based on the systematic review, the range of PIKM augmentation ob- served between xenogeneic soft-­tissue substitutes and autogenous
served after grafting with a FGG in comparative studies (RCTs and CCTs) grafts (n = 4; WMD = 0.0%; 95% CI [−6.6; 6.5]; p = .990), based on
ranged between 1.5–­6.5 mm. Two comparative studies evaluating the one study, the shrinkage of allogeneic soft-­tissue substitutes was sig-
gain of PIKM after a connective tissue graft reported a gain of 2.3–­2.6 mm nificantly higher than autogenous grafts (mean difference = −19.5%;
(Lorenzo et al., 2012; Sanz et al., 2009). 95% CI [−24.3; −14.7%]; p = .009).

5.3 | What is the percentage of shrinkage in 5.8 | What is the difference between
autogenous gingival grafts when used to augment the xenogeneic and autogenous soft-­tissue grafts in
width of peri-­implant keratinised mucosa? terms of attaining an attached (non-­mobile) PIKM?

Based on four studies (Sanz et al., 2009; Monje et al., 2022; Urban Based on this systematic review, there is no evidence to compare
et al., 2015, 2019) not included in the systematic review, the percent- attaining an attached (non-­mobile) peri-­implant mucosa between
age of shrinkage of surface area in autogenous grafs or combination autogenous grafts and soft-­tissue substitutes. Based on expert opin-
of autogenous and xenogeneic grafts ranged between 42.4%–­60% ion, the attainment of an attached (non-­mobile) peri-­implant mucosa
from baseline up to 12 months. should be an objective of these surgical interventions.

5.4 | What is the efficacy of the soft-­tissue 5.9 | What is the difference between
substitutes to increase the width of the peri-­implant xenogeneic and autogenous soft-­tissue grafts in
mucosa compared to autogenous grafts? terms of increasing the vestibular depth?

PIKM augmentation with autogenous grafts resulted in signifi- Based on this systematic review, there is no evidence on the effect of
cantly greater width compared with soft-­tissue substitutes (n = 6; autogenous grafts versus soft-­tissue substitutes in terms of increas-
WMD = 0.9 mm; 95%, (CI) [0.3; 1.4]; p = .001). ing the vestibular depth. Based on an expert opinion, in situations
with lack of PIKM and a shallow vestibule, deepening the vestibule
should be considered in combination with autogenous grafting.
5.5 | What is the efficacy of allogenic
soft-­tissue substitutes to increase the
width of the peri-­implant mucosa compared to 5.10 | What is the difference between
autogenous grafts? xenogeneic and autogenous soft-­tissue grafts in
terms of patient's morbidity?
One study included in the systematic review reported a significantly
greater width of PIKM after grafting with autogenous grafts when Based on five studies, soft-­tissue substitutes led to significantly
compared to allogenic soft-­tissue substitutes (WMD = 1.0 mm; 95% lower post-­operative pain (visual analogue scales) than autogenous
CI [0.7; 1.3]; p < .001). grafts. Furthermore, two studies reported a lower consumption of
analgesics after the use of soft-­tissue substitutes compared to au-
togenous grafts.
5.6 | What is the efficacy of xenogeneic soft-­tissue
substitutes to increase the width of the peri-­implant
mucosa compared to autogenous grafts? 5.11 | What is the difference between
xenogeneic and autogenous soft-­tissue grafts in
Based on five studies (RCTs/CCTs) PIKM augmentation with autog- terms of patient's preferences?
enous grafts resulted in no significant differences when compared
to soft-­tissue substitutes of xenogeneic origin (WMD = 0.8 mm; 95% Based on this systematic review, there is no evidence relating to
CI [0.0; 1.6]; p = .062). patient's preferences. Three studies professionally evaluating the
SANZ et al. | 53

aesthetic appearance provided better results for soft-­tissue substitutes etc.) have been reported. Evidence from four studies in the system-
when compared to FGG, while no differences were observed with CTG. atic review comparing autogenous graft with soft-­tissue substitutes
did not report a significantly higher probability of surgical complica-
tions (e.g. loss of the graft, paraesthesia, etc.)
5.12 | What is the difference between
xenogeneic and autogenous soft-­tissue grafts in
terms of surgical time? 5.17 | What is the performance of soft-­tissue
substitutes to augment the PIKM?
Based on two studies, surgical time was significantly lower for
soft-­tissue substitutes when compared to autogenous grafts Evidence from the systematic review evaluating pre-­post results
(WMD = 18.5 min; 95% CI [10.3; 26.8]; p ≤ .001). The range of surgi- from nine studies, reported a weighted mean gain of 3.0 mm (95%
cal time for soft-­tissue substitutes was 20–­87 min while for autog- CI [2.3; 3.8]) when assessing all soft-­tissue substitutes. From seven
enous grafts it was 40–­87 min. studies, the xenogeneic soft-­tissue substitutes reported a weighted
mean gain of 3.5 mm (95% CI [2.5; 4.6]) while the two studies assess-
ing allogeneic soft-­tissue substitutes reported a weighted mean gain
5.13 | Are there any graft-­less surgical of 1.6 mm (95% CI [1.4; 1.7]). Five studies using soft-­tissue substi-
interventions that can provide an increase in tutes have reported 16.5% (95% CI [8.4; 24.6]) shrinkage between
keratinized peri-­implant mucosa? one to 6 months, while two studies reported 52.5% (95% CI [37.2;
67.8]) shrinkage between baseline and 12 months, which implies that
Different surgical interventions as the apically positioned flap and most of the shrinkage occurred during the first month.
the vestibule extension procedure have been indicated for increasing
the amount of PIKM, but there is no evidence of predictable results.
A previous systematic review (Thoma et al., 2014), including compar- 5.18 | What is the performance of combining
ative studies between these surgical interventions and the addition autogenous grafts and soft-­tissue substitutes to
of a graft resulted in significantly wider band of PIKM with the ad- augment the PIKM?
dition of an autogenous graft or a xenogeneic soft-­tissue substitute.
There is no evidence on the outcome of combining autogenous
grafts and soft-­tissue substitutes from studies included in this
5.14 | Is the surgical procedure to use an systematic review. However, two case series evaluating the com-
autogenous graft more difficult than using a soft-­ bination of autogenous grafts (strip gingival grafts) and soft-­tissue
tissue substitute? substitutes (collagen matrices) have shown enhanced amounts of
PIKM (mean differences from baseline to 12 months ranging from
Based on expert opinion, the avoidance of harvesting an autogenous 6–­7 mm) (Urban et al., 2015, 2019).
graft would imply an easier surgical intervention; however, the han-
dling of the substitute and its suturing may be more cumbersome
and technique sensitive. 5.19 | Implications for clinical practice

• When there is <2 mm of PIKM a surgical intervention to augment

5.15 | Do we need a minimum amount of KT to the width of keratinized tissue could be considered, especially
augment PIKM using soft-­tissue substitutes? when there is recurrent inflammation of the peri-­implant mucosa,
pain or disturbance on brushing, increased recession of the peri-­
Based on expert opinion, a minimum amount of keratinized tissue implant mucosa, lack of attached mucosa or a shallow vestibular
with the ability to induce keratinization is needed for cell migration depth.
into the matrix. This keratinization may be induced from the marginal • Although the apically positioned flap in combination with an au-
borders of the surgical bed. togenous graft is the standard of care intervention to increase the
width of PIKM, the decision to select the type of grafting mate-
rial should be based on a variety of factors, such as the residual
5.16 | What is the difference in surgical amount of PIKM, the extension of the surgical area and the abil-
complications associated with autogenous grafting ity of apically repositioning the flap, the aesthetic demand, the
versus soft-­tissue substitutes? patient's preferences, the operator surgical skills and limitations
from the donor area.
Surgical complications related to the donor site and healing compli- • Autogenous grafting should be favoured in sites with complete
cations in the grafted site (loss of the graft/ soft-­tissue substitute, absence of keratinized tissue.
54 | SANZ et al.

• Soft-­tissue substitutes could be considered in patients with lim- on file. Declared potential dual commitments included having re-
itations in the donor area, or when a limited amount of KT is ceived research funding, consultant fees and speaker fee from the
needed. The initial size of the graft should account for the ex- industries with economic interests in the interventions dealt in this
pected shrinkage rates. workshop.

DATA AVA I L A B I L I T Y S TAT E M E N T

5.20 | Implications for future research Data sharing is not applicable to this article as no new data were cre-
ated or analyzed in this study.
• New knowledge in wound healing and neo-­vascularization, with
development of effective soft-­tissue constructs without the need ORCID
of harvesting autogenous grafts Mariano Sanz https://orcid.org/0000-0002-6293-5755
• New knowledge in wound healing and neo-­vascularization, with Frank Schwarz https://orcid.org/0000-0001-5515-227X
development of biologically active molecules that improve our David Herrera https://orcid.org/0000-0002-5554-2777
current surgical techniques Lisa Heitz-Mayfifield https://orcid.org/0000-0001-5755-8265
• Development of new soft-­tissue substitutes, easy to handle sur- Andres Pascual https://orcid.org/0000-0002-1223-7764
gically, volume stable, easily integrated with the adjacent tissues Elena Figuero https://orcid.org/0000-0002-3129-1416
and resulting in minimal shrinkage
• Development of new soft-­tissue substitutes able to promote not
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