Received: 24 March 2020 Revised: 23 May 2020 Accepted: 19 June 2020

DOI: 10.1111/cid.12934

ORIGINAL ARTICLE

A randomized controlled study comparing guided bone

regeneration with connective tissue graft to reestablish buccal
convexity at implant sites: A 1-year volumetric analysis

Thomas De Bruyckere DDS, MSc1,2 | Ricardo Garcia Cabeza DDS2 |

Aryan Eghbali DDS, MSc, PhD1,2 | Faris Younes DDS, MSc, PhD2 |
Roberto Cleymaet DDS, PhD1 | Jan Cosyn DDS, MSc, PhD1,2

1
Faculty of Medicine and Pharmacy, Oral
Health Research Group (ORHE), Vrije Abstract
Universiteit Brussel (VUB), Brussels, Belgium Objectives: To volumetrically compare guided bone regeneration (GBR) with connec-
2
Department of Periodontology and Oral
tive tissue graft (CTG) to reestablish convexity at the buccal aspect of single implants.
Implantology, Faculty of Medicine and Health
Sciences, Dental School, Ghent University, Materials and methods: Patients with a single tooth gap in the anterior maxilla and
Ghent, Belgium
horizontal alveolar defect were enrolled in a single-blind randomized clinical trial
Correspondence (RCT). All sites had a buccopalatal bone dimension of at least 6 mm, received a single
Thomas De Bruyckere, Department of
implant, and were randomly allocated to the control (GBR) or test group (CTG) to
Periodontology and Oral Implantology, Faculty
of Medicine and Health Sciences, Dental reestablish buccal soft tissue convexity. Patients received a provisional crown at
School, Ghent University, Corneel
3 months and a permanent crown at 6 months. Primary outcomes were volumetric
Heymanslaan 10, Ghent B-9000, Belgium.
Email: [email protected] increase (mm3) and linear increase (mm) in buccal soft tissue profile (BSP) within a
well-defined area of interest at fixed time points. Alveolar process deficiency was a
secondary outcome.
Results: Twenty-one patients were included per group (control: 11 females, mean
age 51; test: 9 females, mean age 48). After 1 year, GBR resulted in a significant volu-
metric increase of 20.74 mm3 (P < .001) corresponding to linear increase in BSP of
1.30 mm (P < .001). For CTG, this was 15.86 (P < .001) and 1.19 mm (P < .001),
respectively. The changes over time in volume (P = .173) and BSP (P = .241) were not
significantly different between the groups. Twenty-nine percentage and 26% of the
final volumetric increase was the result of installing and altering prosthetic compo-
nents in the control and test groups, respectively. Alveolar process deficiency signifi-
cantly reduced from pre-op to 1 year following GBR (P < .001) and CTG (P < .001).
The difference between the groups was not significant (P = .342). However, 58% of
the patients treated with GBR and 38% treated with CTG failed to show perfect soft
tissue convexity at the buccal aspect.
Conclusion: GBR as well as CTG are effective in reducing horizontal alveolar defects
for aesthetic purposes. However, in about half of the cases, either strategy failed to
optimally reestablish buccal convexity.

KEYWORDS

connective tissue graft, dental implant, guided bone regeneration, single tooth

Clin Implant Dent Relat Res. 2020;1–9. wileyonlinelibrary.com/journal/cid © 2020 Wiley Periodicals LLC 1
2 DE BRUYCKERE ET AL.

1 | I N T RO DU CT I O N Inclusion criteria were the following:

Systematic reviews based on human reentry studies and study casts dem- • At least 18 years
onstrate substantial dimensional changes of the alveolar ridge following • Good oral hygiene defined as full-mouth plaque score ≤25%19
tooth extraction. 1-3
At 6 months postextraction, horizontal and vertical • Presence of a single tooth gap in the anterior maxilla (15–25) with
shrinkage of the alveolar ridge amounts to 29% to 63% and 11% to 22%, both neighboring teeth present
respectively. The magnitude of these changes is clinically relevant as • Failing tooth at least 3 months earlier removed
these create a clear buccal concavity in the alveolar ridge. Especially in • Class I defect at the single tooth gap as clinically assessed
the premaxilla, such a horizontal defect may hamper an aesthetic rehabili- (buccopalatal loss of tissue with a normal apicocoronal ridge
tation. Therefore, tissue augmentation procedures are often needed as an height)20
adjunct to single implant placement in this area of the dentition, regard- • Signed informed consent
less of the timing of implant placement.4 Interestingly, the need for such • Buccopalatal bone dimension of at least 6 mm at the central and
procedures is supported by data on patients' preference comparing aug- crestal aspect of the single tooth gap to ensure complete embed-
mented to nonaugmented sites in terms of aesthetics.5 ding of an implant by bone
Guided bone regeneration (GBR) has shown to be effective in
reducing horizontal defects that remain after implant installation.6 In Exclusion criteria were the following:
addition, thick and stable buccal bone walls have been demonstrated
up to 10 years after lateral bone augmentation on the basis of cone • Systemic diseases
beam computed tomography (CBCT) analyses. 7-9
The main disadvan- • Smoking
tage of GBR is the invasiveness of the approach including at least one • (History of) periodontal disease
vertical releasing incision, release of the periosteum and muscle inser- • Untreated caries lesions
tion. Less invasive alternatives have been explored to treat minor hor- • Need for horizontal bone augmentation at the time of implant
10-12
izontal defects in the anterior maxilla. Such defects are eliminated placement
by thickening the buccal soft tissues using a connective tissue graft
(CTG) or collagen matrix. Although the latter seems promising,13,14 The study was approved by the Ethical Committee of the Univer-
CTG is still considered the gold standard.15 Long-term data are avail- sity Hospital in Brussels (B.U.N. 143201523186) and conducted in
able on CTG at the buccal aspect of single implants pointing to 85% accordance with the ethical standards of the Declaration of Helsinki
relative horizontal stability after 5 years.16 In another 5-year clinical in 1975, as revised in 2013.
study, the originally concave buccal alveolar contour was still convex
in all implants.17 Main disadvantages of CTG relate to the need of a
donor site and the dimension of the graft, which has an obvious 2.2 | Randomization and allocation concealment
impact on the soft tissue thickness that can be achieved.
Recently, an randomized clinical trial (RCT) has been published Patients were randomly assigned to the control group (GBR) or test
comparing GBR with CTG to treat minor horizontal defects at the group (CTG). Simple randomization was applied using sealed enve-
18
buccal aspect of single implants. Both increased the buccal soft tis- lopes with an equal number of envelopes for every treatment group.
sue profile (BSP) between 0.7 and 1.5 mm depending on the vertical Group allocation was revealed just prior to surgery by the surgeon
distance from the implant shoulder, without a significant difference and remained concealed for the evaluating investigator during the
between the groups. However, these results are based on sup- analytical stage of the project.
erimposed CBCT slides, which may lack accuracy, since soft tissue
outlines may be difficult to assess even when lip retractors are used.
Superimposed digital surface models overcome this shortcoming and 2.3 | Surgical and prosthetic procedures
allow for a volumetric analysis. Hence, the primary objective of this
study was to volumetrically compare GBR with CTG when applied at Details on the surgical and prosthetic procedures can be found in an
single implant sites demonstrating a minor horizontal alveolar defect. earlier paper.18
In brief, a mucoperiosteal flap was raised in the control group by
means of a midcrestal incision, sulcular incisions at both neighboring
2 | MATERIAL AND METHODS teeth, and a vertical parapapillary releasing incision at the distal neigh-
boring tooth. Following implant installation (NobelActive TiUnite,
2.1 | Patient groups Nobel Biocare AB, Göteborg, Sweden), the buccal concavity was aug-
mented with deproteinized bovine bone mineral (DBBM) (Bio-Oss;
Patients in need of a single maxillary implant restoration were 0.25-1 mm; Geistlich Biomaterials, Wolhusen, Switzerland) and a col-
selected between 2014 and 2016 in two private practices and the lagen membrane (Creos xenoprotect; 15 × 20 mm2; Nobel Biocare
University Hospital in Brussels to participate in a single-blind RCT. AB). Following apical release of the tissues, a cover screw (Nobel
DE BRUYCKERE ET AL. 3

Biocare AB) was placed and primary wound closure was achieved for higher up (Figure 1). The AOI was determined at T4 with the permanent
submerged healing (Seralon 5/0, Serag Weissner, Naila, Germany). crown in situ to avoid invalid superimposition as a result of midfacial
Aftercare included the use of a chlorhexidine rinse, systemic antibiotics recession. Each time point was compared to T0 by using the best-fit
(amoxicilline 1 g, two times a day) and anti-inflammatory medication algorithm to superimpose digital surface models. Unchanged neighbor-
(ibuprofen 600 mg) as deemed necessary by the patient. After 3 months, ing tooth surfaces were used as a reference for proper superimposition.
the implant was uncovered by means of a pouch procedure. A screw- In each patient, the AOI was kept constant for all pairwise comparisons.
retained provisional crown was placed as described by De Rouck et The volumetric analysis software (Swissmeda/SMOP, Zürich, Switzer-
al,21 which was replaced by a screw-retained permanent restoration land) calculated a mean volumetric change (mm3) within the AOI for
(Procera on ASC abutment, Nobel Biocare AB) 3 months later. each patient at T1, T2, T3, and T4. The mean volumetric change per area
The flap design in the test group was identical to the one in the was also transformed to a mean linear change in BSP in mm (Figure 2).22
control group, yet without a vertical parapapillary releasing incision.
Instead of augmenting with DBBM, an appropriately sized CTG
harvested from the palatal flap or palatal mucosa in the premolar area, 2.5 | Secondary outcomes
was pulled into the envelope and immobilized (Seralon 5/0, Serag
Weissner, Naila, Germany). Transmucosal healing with a healing abut- Midfacial recession was calculated at 1 year. The distance from the
ment was respected. Aftercare and prosthetic procedures were identi- incisal edge of the permanent crown to the buccal mucosal margin
cal in both groups. Figure 1 gives an overview of the time frame of (so-called midfacial soft tissue level) was determined at the center of
both protocols. each implant. This was performed in the same software (Swissmeda/
All surgical treatments and provisional restorations were per- SMOP, Zürich, Switzerland) to the nearest 0.01 mm at 6 months and
formed by one practitioner (TDB). Referring dentists made permanent 1 year. Midfacial recession was calculated by subtracting 6-month
restorations. midfacial soft tissue levels from 1-year midfacial soft tissue levels.
Positive values indicated recession; negative values indicated vertical
regrowth.
2.4 | Primary outcome: Volumetric change Alveolar process deficiency was evaluated at T0 and T4 on the
basis of occlusal slides as described by Fürhauser and co-workers.23 A
Conventional impressions (Cavex ColorChange, Haarlem, The Nether- score of 0 was given when “obvious alveolar process deficiency” was
lands) were taken at T0 (pre-op), T1 (suture removal), T2 (3 months prior observed; 1 was given in case of “slight alveolar process deficiency”
to the installation of the provisional crown), T3 (6 months with provi- and 2 was attributed when the alveolar process was not deficient.
sional crown in situ), and T4 (1 year with permanent crown in situ). Probing depth was registered at four locations (mesiobuccal, buc-
These were poured in dental stone (Sheraplaster Hartgips White, cal, distobuccal, and palatal) around the implant at 1 year of function
SHERA Werkstoff-Technologie, Lemförde, Germany) within 2 hours and to the nearest 0.5 mm. A mean value was calculated per implant.
stone casts were optically scanned (LS 3 scanner, Kavo, Biberach an der Plaque and bleeding on probing were assessed at four locations
Riss, Germany) to produce digital surface models in STL format. For (mesiobuccal, buccal, distobuccal, and palatal) around the implant at
each patient, all STL files were imported in designated software 1 year of function. Each location was scored 0 or 1 (absence or pres-
(Swissmeda/SMOP, Zürich, Switzerland). The study-relevant area of ence of plaque or bleeding on probing, respectively). Both parameters
interest (AOI) was mesio-distally delineated by the mesial and distal line were expressed as a percentage.
angle of the implant crown, respectively. The coronal border was
located 0.5 mm below the mucosal margin and the apical border 4 mm
2.6 | Sample size calculation

The sample size calculation was based on BSP and was performed in SAS
Power using the Satterthwaite t-test.18 The calculation was based on
finding a mean difference of at least 0.5 mm between these groups with
an SD of 0.5 mm. This SD was arbitrarily chosen given the lack of com-
parative studies. Alpha was set at .05 and the power was set at 0.80. This
resulted in the inclusion of at least 17 patients per group. To compensate
for possible dropouts, 21 patients were included in each group.

2.7 | Statistical analysis

F I G U R E 1 T0 digital surface model (yellow) and T4 digital surface
model (blue) were superimposed. The area of interest (black box) was
determined on the T4 model and was kept constant for each patient Statistical analysis was performed in SPSS Statistics 25 (SPSS Inc., Chi-
while superimposing other time points to T0 cago, Illinois) with the patient as the unit of analysis. Volumetric
4 DE BRUYCKERE ET AL.

F I G U R E 2 A-D, Case illustrating a patient of the control group (GBR). A, Occlusal view of the preoperative situation: Seibert Class I alveolar
ridge defect. B, T0 digital surface model with volumetric changes in the area of interest between T0 and T4. C, Result after 1 year with the
permanent restoration. D, Outline of the superimposed buccal soft tissue profile at the different timepoints in the center of the grafted area. E-H,
Case illustrating the above-mentioned for a patient of the test group (CTG)

changes and linear changes in BSP over time within each group and been described in the same paper. None of the patients were lost to
the impact of the treatment strategy were examined by means of follow-up.
repeated measures ANOVA. Treatment strategy, time, and their inter-
action were modeled as fixed factors and the patient as a random fac-
tor. The model included the two main effects of treatment and time 3.2 | Primary outcome: Volumetric changes
together with the two-way interaction of these factors. The indepen-
dent samples' t-test was used to compare AOI, midfacial recession, Mean AOI amounted to 16.65 (SD 7.15) and 15.09 (SD 3.75) mm2 in
probing depth, plaque, and bleeding on probing between the groups. the control group and test group, respectively. The difference
Kappa statistics were calculated to assess intra- and inter-assessor between the groups was not significant (P = .382).
reliability on alveolar process deficiency. Therefore, 20 cases were The results on volumetric changes are summarized in Table 1. A
randomly selected for duplicate registration. Within each group, significant time effect (within group difference) was observed in both
changes in alveolar process deficiency between T0 and T4 were eval- groups indicating that GBR and CTG were effective in increasing buc-
uated by means of the Wilcoxon signed ranks test. Between the cal volume (P < .001). The highest volumetric increase was observed
groups, alveolar process deficiency was compared using the Fisher's at T1 as a result of postoperative edema. An obvious decline was
exact test. The level of significance was set at 0.05. observed at T2 followed by a slight increase thereafter in both groups
pointing to a final volumetric increase of 20.74 mm3 in the control
group (P < .001) and 15.86 mm3 in the test group (P < .001). Volumet-
3 | RESULTS ric increase was slightly higher in the control group, yet only at T3
(P = .020) (between group difference). There was no significant
3.1 | Patient groups treatment*time interaction (P = .173) indicating that the volumetric
changes over time were not significantly different between the
The sample size calculation resulted in the inclusion of at least 17 groups.
patients per group. To compensate for possible dropouts, 21 The results on linear changes in BSP are also summarized in
patients were included in each group (Figure 3). In the control group, Table 1. They followed a similar pattern as volumetric changes. The
10 males and 11 females with a mean age of 51 (SD 13) years partic- final linear increase in BSP was 1.30 mm in the control group
ipated. The test group consisted of 12 males and 9 females with a (P < .001) and 1.19 mm in the test group (P < .001). Volumetric
mean age of 48 (SD 15) years. Details on implant sites, diameter, increase was slightly higher in the control group, yet only at T3
length and horizontal defect dimension per group can be found in an (P = .030) (between group difference). There was no significant
earlier paper.18 One-year clinical outcomes and CBCT analyses have treatment*time interaction (P = .241).
DE BRUYCKERE ET AL. 5

FIGURE 3 CONSORT flow diagram

TABLE 1 Volumetric and linear changes at the buccal aspect

Volumetric increase of buccal soft tissues sorted per time point and treatment group (mm3)

T1 (2 wk) without T2 (3 mo) without T3 (6 mo) with T4 (1 y) with permanent Within group difference
crown crown provisional crown crown (P-value)
Guided bone regeneration (GBR) 29.47 (18.68)a 14.78 (8.73)a 19.95 (9.59)a 20.74 (9.22) <.001
[6.19; 86.19] [2.36; 34.16] [4.47; 37.82] [4.80; 41.46]
Connective tissue graft (CTG) 23.07 (8.07)a 11.78 (6.34)a 13.55 (6.73)a 15.86 (8.08) <.001
[9.68; 41.93] [1.81; 23.41] [1.16; 25.80] [1.82; 34.36]
Between group difference (P-value) 0.162 0.218 0.020 0.090
Linear increase in buccal soft tissue profile sorted per time point and treatment group (mm)
GBR 1.87 (0.82)a 0.95 (0.50)a 1.30 (0.37)a 1.30 (0.42) <.001
[0.80; 4.15] [0.23; 2.23] [0.45; 1.84] [0.25; 1.97]
CTG 1.73 (0.71)a 0.83 (0.52)a 0.99 (0.50)a 1.19 (0.57)a <.001
[0.91; 3.65] [−0.06; 1.75] [−0.06; 1.77] [0.00; 2.19]
Between group difference (P-value) 0.582 0.452 0.030 0.515

Note: Differences against T0 shown: positive values indicate increase, negative values indicate loss. The values are represented in the format: mean (SD)
[min; max].
a
Within group difference when compared to preceding time point.
6 DE BRUYCKERE ET AL.

3.3 | Secondary outcomes ≤25%. There were no significant differences between the groups for
any of the parameters (P ≥ .184).
Midfacial recession at 1 year was 0.27 (SD 0.42) mm in the control
group and 0.22 (SD 0.43) mm in the test group. The difference
between the groups was not significant (P = .702). 4 | DI SCU SSION
Kappa for intra- and inter-assessor reliability on alveolar process
deficiency was, respectively, 0.667 (P < .001) and 0.741 (P < .001) In the past, many patients were treated with a single implant in fully
suggesting good agreement between duplicate measurements. The healed bone without hard or soft tissue grafting. Although satisfying
results are illustrated in Figure 4. Given the inclusion of class I defects from a clinical and radiographical point of view,24 aesthetics was poor
at baseline, all patients demonstrated slight to obvious alveolar pro- in those days.25 The lack of buccal soft tissue convexity appeared the
cess deficiency prior to surgery. There was no significant difference in most common problem with nearly one third of the patients presenting
the frequency distribution between the groups at T0 (P = .758). Due with obvious alveolar process deficiency prior to implant placement.25
to surgical treatment, alveolar process deficiency significantly reduced Today, patients expect an implant restoration to resemble a natural
in the control group (P = .001) as well as in the test group (P < .001). tooth in all aspects. More studies on patient-reported outcomes are
26
Obvious alveolar process deficiency was never observed at T4 neither emerging and patients have expressed a clear preference of aug-
in the control group, nor in the test group. Interestingly, however, 11/ mented over nonaugmented sites.5 This creates a huge indication for
19 (58%) patients in the control group and 8/21 (38%) patients in the surgery to reestablish convexity at the buccal aspect of implants.
test group still demonstrated slight alveolar process deficiency at In addition, technological advancement made it possible to accu-
study termination. There was no significant difference in the fre- rately assess tissue alterations over time on the basis of superimposed
quency distribution between the groups at T4 (P = .342). digital surface models. Ample studies have been published using this
Table 2 shows clinical outcomes at 1 year sorted per group. technology producing data on volumetric soft tissue changes follow-
Implants demonstrated healthy clinical conditions in both groups ing implant surgery.14,27-30
given probing depth <4 mm, plaque <15%, and bleeding on probing In this RCT, two well-established treatment concepts were com-
pared to restore buccal convexity. Given a buccopalatal bone dimension
of at least 6 mm ensuring complete embedding of all implants by bone,
it is important to realize that none of the cases required GBR for the
purpose of bone augmentation. After 1 year, GBR resulted in a signifi-
cant volumetric increase of 20.74 mm3 (P < .001). The volumetric
increase was also significant following CTG and amounted to
15.86 mm3 (P < .001) at T4. The difference between the groups was
not significant at study termination, although a trend toward slightly
more volume gain was observed in favor of the control group (P = .090).
Besides GBR and CTG, it is important to realize that volumetric
changes at T3 and T4 were affected by the installation of prosthetic
components, as these may displace soft tissues to the buccal aspect.
Since provisional crowns were installed between T2 and T3, their
impact on buccal tissues could be assessed at T3, pointing to a signifi-
cant volumetric increase of 5.17 mm3 (P = .005) in the control group
and 1.77 mm3 in the test group (P = .033). Permanent crowns were
installed between T3 and T4; therefore, their impact on buccal tissues
could be assessed at T4. In both groups, however, permanent crowns
F I G U R E 4 Bar chart on alveolar process deficiency at T0 and T4
failed to significantly increase buccal tissue volume. Altogether, the
sorted per treatment group. In two patients of the control group
(GBR), the permanent crown was not installed onto the implant due volumetric increase that was observed after T2 due to the installation
to financial restrictions. These patients were not evaluated at T4 and alteration of prosthetic components amounted to 5.96 mm3

TABLE 2 Clinical outcomes at 1 year

Guided bone regeneration Connective tissue graft P-value

Probing depth (mm) 3.27 (0.75) 3.53 (0.40) .184
Plaque (%) 13.16 (17.42) 10.71 (20.27) .686
Bleeding on probing (%) 22.37 (20.23) 25.00 (20.92) .689

Note: The values are represented in the format: mean (SD).

DE BRUYCKERE ET AL. 7

(29%) in the control group and 4.08 mm3 (26%) in the test group. demonstrated significant reduction in alveolar process deficiency
These findings demonstrate that prosthetic components had an influ- between pre-op and 1-year follow-up. In addition, there was no signif-
ence on volumetric changes, yet GBR and CTG contributed substan- icant difference in the final outcome between the groups. However,
tially more to those changes. When it comes to comparing GBR with 58% of the patients treated with GBR still demonstrated slight alveo-
CTG over time, it is relevant to scrutinize treatment*time interactions. lar process deficiency at 1-year follow-up. Following CTG, 38% of the
Significant treatment*time interactions were not observed in this patients failed to show perfect soft tissue convexity at the buccal
study, implying that the changes over time in volume and BSP were aspect. In this context, the study by Schneider et al38 reveals interest-
not significantly different between GBR and CTG. Thus, clinical deci- ing information. They consecutively performed GBR and CTG at the
sion-making should be based on aspects other than effectiveness. buccal aspect of single implants and found that the former was
These include aesthetic outcomes and patient-reported outcomes and responsible for 57% of the increase in BSP, whereas CTG amounted
31
have been recently published on the same patient material. to 43% of that increase. Given all this, it seems necessary to perform
In this study, volumetric changes were expressed as alterations in both hard and soft tissue augmentation in about half of the cases to
mm3 within an AOI that was kept constant within each patient. Since achieve an optimal outcome with respect to buccal tissue support.
one tooth position may require wider augmentation than another (eg, The need for hard and soft tissue grafting in a relatively high number
lateral incisor positions are smaller than central incisor positions), the of cases may not only apply to implant surgery in healed sites, but also
AOI was individualized and therefore varied between patients. This to immediate implant placement.39,40
could potentially hamper a volumetric comparison between the The software that was adopted to assess volumetric changes was
groups. However, since the mean AOI did not differ significantly also used to calculate midfacial recession between T3 and T4. Given
between the control group and test group, valid volumetric comparisons mean values of 0.27 mm in the control group and 0.22 mm in the test
were made in this study. Apart from that, volumetric changes have two group, midfacial recession was low in both groups. Evidently, longer
major drawbacks. First, it is difficult to compare volumes between stud- follow-up is needed to assess the stability of these findings. Interest-
ies, since details on the AOI are frequently missing and the AOI may dif- ingly, all implants demonstrated healthy clinical conditions at study
fer substantially. Second, the ultimate goal of GBR and CTG is to termination, irrespective of the group.
increase tissue volume in the horizontal aspect. From a clinical point of When interpreting the results of the present study, several limita-
view, volumetric changes in mm3 do not accord with that treatment tions should be acknowledged. First, this concerns an RCT with lim-
objective. This can be overcome by dividing volumetric changes to the ited follow-up. Long-term evaluation is of utmost importance to
AOI, resulting in mean linear changes in BSP. The results on these fol- evaluate the stability of the buccal tissues. Second, the results on both
low the same pattern than those on volumetric changes. After 1 year, treatment concepts may be affected by procedural aspects. In this
GBR resulted in a significant linear increase in BSP of 1.30 mm study, GBR was performed as most clinicians perform it, using DBBM
(P < .001). The linear increase in BSP was also significant following CTG particles and a collagen membrane. Recent studies have shown that
and amounted to 1.19 mm at T4 (P < .001). The difference between the the use of membrane fixation pins and a collagen-enriched DBBM block
groups was not significant at study termination (P = .515). increases the augmented volume in the cervical area.41-43 Third, intra-
The results on BSP were slightly superior to those recently oral scans are preferred over conventional impressions to produce digi-
reported on the basis of the same patient material, yet using sup- tal surface models. Impressions were poured in dental stone within
18
erimposed CBCT slides. The explanation for this may be twofold. 2 hours in this study, yet it is conceivable that some dimensional alter-
First, soft tissue outlines may be difficult to assess on CBCT even when ations still occurred rendering the superimpositioning of digital surface
lip retractors are used making the technique less accuracy. Second, the models less accurate. Unfortunately, an intra-oral scanner was not avail-
CBCT data only pertain to the center of the implant site, whereas the able yet in our center at the time this study was started. Fourth, CTG is
volumetric data of the present study pertain to a well-defined AOI. always limited by the amount of tissue that can be harvested. Given the
It is difficult to compare our results on GBR to other studies, since donor-site associated morbidity, additional research is needed on viable
these only relate to hard tissue changes. Several volumetric studies alternatives such as collagen matrices. Finally, high interindividual varia-
have been published on CTG when applied at pontic sites,32 as an tion was observed in volumetric increase and linear increase in BSP
33
adjunct to immediate implant placement and as an adjunct to irrespective of the treatment concept. This indicates that increasing the
implant placement in healed sites.14,34-37 CTGs are still considered the volume at the buccal aspect of implants is a challenging procedure. In
gold standard for soft tissue augmentation at implant sites and the future, multicenter RCTs need to be conducted, since only such
increase soft tissue thickness with about 1 mm in the short term,15 studies demonstrate good external validity.
which is in line with our observations.
When it comes to the clinical effectiveness of GBR and CTG in
reestablishing buccal convexity, the linear increase in BSP is the main 5 | CONC LU SION
outcome. However, this parameter does not provide information on
the optimal outcome, which is complete elimination of the horizontal GBR as well as CTG significantly increased BSP up to 1 year, pointing
alveolar defect. In this respect, the results on alveolar process defi- to a mean gain of 1.30 and 1.19 mm, respectively. There was no sig-
ciency become important. Both treatment concepts obviously nificant difference between the groups. Although alveolar process
8 DE BRUYCKERE ET AL.

deficiency significantly reduced following GBR and CTG, 58% of the 12. Eghbali A, De Bruyn H, Cosyn J, Kerckaert I, Van Hoof T. Ultrasonic
patients treated with GBR and 38% treated with CTG failed to show assessment of mucosal thickness around implants: validity, reproduc-
ibility, and stability of connective tissue grafts at the Buccal aspect.
perfect soft tissue convexity at the buccal aspect.
Clin Implant Dent Relat Res. 2016;18(1):51-61. https://doi.org/10.
1111/cid.12245.
CONF LICT OF IN TE RE ST 13. Thoma DS, Naenni N, Benic GI, Hämmerle CHF, Jung RE. Soft tissue
There are no conflicts of interest. Dental implants and prosthetic com- volume augmentation at dental implant sites using a volume stable
three-dimensional collagen matrix—histologic outcomes of a preclini-
ponents were supplied free of charge by Nobel Biocare Services AG
cal study. J Clin Periodontol. 2017;44(2):185-194. https://doi.org/10.
(Kloten, Switzerland). Prof. Cosyn has collaboration agreements with 1111/jcpe.12635.
Nobel Biocare (Kloten, Switzerland) and Straumann (Basel, 14. Zeltner M, Jung RE, Hämmerle CHF, Hüsler J, Thoma DS. Random-
Switzerland). ized controlled clinical study comparing a volume-stable collagen
matrix to autogenous connective tissue grafts for soft tissue augmen-
tation at implant sites: linear volumetric soft tissue changes up to 3
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How to cite this article: De Bruyckere T, Cabeza RG,
Volumetric and linear changes at dental implants following grafting
with volume-stable three-dimensional collagen matrices or autoge- Eghbali A, Younes F, Cleymaet R, Cosyn J. A randomized
nous connective tissue grafts: 6-month data. Clin Oral Investig. 2018; controlled study comparing guided bone regeneration with
22(3):1185-1195. https://doi.org/10.1007/s00784-017-2210-3. connective tissue graft to reestablish buccal convexity at
36. Rojo E, Stroppa G, Sanz-Martin I, Gonzalez-Martín O, Alemany AS,
implant sites: A 1-year volumetric analysis. Clin Implant Dent
Nart J. Soft tissue volume gain around dental implants using autoge-
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eral palate or tuberosity area. A randomized controlled clinical