The International Journal of

Esthetic Dentistry
Official publication of the Editors-in-Chief:
European Academy of Esthetic Dentistry
Martina Stefanini

02/24 Volume 19 Vincent Fehmer

Issue 2 • Summer 2024 Alfonso Gil
CLINICAL RESEARCH

Peri-implant soft tissue volume

changes after microsurgical
envelope technique with a
connective tissue graft
A 5-year retrospective case series

Behnam Shakibaie, DDS, MSc, OMFS

Specialized Clinic in Microscopic Dentistry, Tehran, Iran

Hamoun Sabri, DMD, PgC

Department of Periodontics & Oral Medicine, University of Michigan School of Dentistry,
Ann Arbor, MI, USA

Center for clinical Research and evidence synthesis In Oral Tissue Regeneration
(CRITERION), Ann Arbor, Michigan, USA

Huthaifa Abdulqader, DDS

General Practice, Amman, Jordan

Hans-Juergen Joit, BDT, MDT

Dental Technician, Düsseldorf, Germany

Markus B. Blatz, DMD, PhD

Chairman, Department of Preventive and Restorative Science, School of Dental Medicine,
University of Pennsylvania, PA, USA

Correspondence to: Dr Behnam Shakibaie

Specialized Clinic in Microscopic Dentistry, Unit 23, No 122, West Soleimani Street, Andarzgou Boulevard,
Farmanieh, Tehran, Iran; Email: [email protected]

126 | The International Journal of Esthetic Dentistry | Volume 19 | Number 2 | Summer 2024
 Shakibaie et al

Abstract

Aim: The aim of the present retrospective case series 4.59 ± 0.62 mm), then dropped slightly to 4 ± 0.85 mm,
was to longitudinally assess soft tissue volume changes after which it maintained at 4 ± 0.36 mm until the
on the vestibular aspect of implants in relation to kera- 2-year time point. Between the second and third years
tinized mucosa thickness (KMT) and width (KMW) after after surgery, a further decrease of 3.59 ± 0.42 mm
the application of the microsurgical envelope tech- was recorded for KMT, which then remained constant
nique combined with a connective tissue graft (CTG). until the end of the 5-year research period. The obser-
Materials and methods: A total of 12 healthy patients vations regarding KMW were slightly different, with the
received 12 dental implants placed either in the pos- measurements demonstrating the greatest decrease
terior maxilla or mandible. The study involved the har- in first 6 weeks (from 2.5 ± 0.42 to 1.5 ± 0.42 mm),
vesting of 12 CTGs with a minimally invasive single-in- which was maintained until the 1-year time point. Be-
cision technique, grafted to the vestibular peri-implant tween the first and second years after surgery, the
soft tissue utilizing the envelope technique, followed KMW increased to 2 ± 0.60 mm and remained level
by the insertion of 12 screw-retained IPS e.max crowns. for the next 3 years, at 2 ± 0.85 mm.
Results: The healing process was uneventful across all Conclusions: The current research demonstrated the
areas, and all patients were followed up for a period of advantages of using a combination of a minimally in-
5 years. The evaluation of KMT showed the highest vasively harvested CTG and the microsurgical enve-
decrease in the first 6 weeks after surgery (5.5 ± 0.79 to lope technique for a duration of 5 years.

 (Int J Esthet Dent 2024;19:126–138)

Keywords

connective tissue graft, envelope technique, implantology, microsurgery, peri-implant soft tissue

Submitted: July 10, 2023; accepted: August 14, 2023

The International Journal of Esthetic Dentistry | Volume 19 | Number 2 | Summer 2024 | 127
Clinical Research

Introduction of the implant and the health of the sur-

rounding tissue.14,15
Over the past decade, considerable discus- Extensive research has been conducted
sion has focused on the crucial importance regarding the MT, keratinized mucosa width
of peri-implant soft tissue in the long-term (KMW), and supracrestal tissue height (STH)
health of implant therapy.1-3 There has been to enhance the peri-implant soft tissue
controversy surrounding whether peri-im- phenotype (PSP).16 Due to the positive out-
plant health requires a sufficient amount of comes observed around natural teeth, au-
keratinized tissue (KT), which can range togenous soft tissue grafts were the initial
from zero to several millimeters in width grafting methods examined historically.17
and can aid in plaque control. While some Connective tissue grafts (CTGs) obtained
authors have suggested that a circumferen- from the lateral palate or tuberosity have
tial sealing effect is necessary for long-term been considered the gold standard in ves-
success, this remains a topic of debate.1,4 tibular peri-implant augmentation.18 Accord-
Nevertheless, the most recent evidence, in- ing to the 6th EAO Consensus Conference
cluding consensus statements,1,5,6 suggests Report, it was recommended that augment-
the implementation of phenotype modifica- ing the KT may be advised to enhance sev-
tion and soft tissue augmentation proced- eral clinical parameters that play a signifi-
ures in cases where there is a lack of suffi- cant role in maintaining peri-implant
cient KT around dental implants, and there health.19 Therefore, the aim of the present
is general agreement on this point. There retrospective case series was to evaluate
are well-documented plastic surgery peri-­ the volume changes of vestibular peri-im-
implant procedures that aim to enhance the plant soft tissue in terms of keratinized mu-
amount of KT and boost the soft tissue vol- cosa thickness (KMT) and KMW after apply-
ume.7 Peri-implant soft tissue volume aug- ing the envelope technique combined with
mentation is primarily recommended for a CTG over the course of 5 years.
esthetic purposes in addition to promoting
oral hygiene in pontic areas in order to Materials and methods
make up for deficiencies in both hard and
soft tissue in localized defects.1,8,9 Such pro- Study design and recruitment
cedures have been recommended to in-
crease the soft tissue thickness simultan- The present retrospective case series was
eously with implant surgery or during the conducted in full accordance with ethical
healing phase.10-12 principles, including the Declaration of Hel-
Despite the scientific evidence, it re- sinki of 1965, as revised in Tokyo in 2013.
mains unclear whether thicker peri-implant Moreover, all patients provided their written
soft tissue contributes to improved long- informed consent prior to all treatments,
term success and the survival rates of dental and the current article was prepared follow-
implants from a functional perspective. In ing the items presented in the STROBE
2017, it was declared at the World Workshop statement (www.strobe-statement.org).
that there was uncertain evidence regarding Between March 2014 and July 2017,
the lasting impact of the width of KT on the 50 healthy nonsmoker patients with no
maintenance and health of dental im- periodontal disease in their history received
plants.13 Mucosa thickness (MT), which may a single-tooth implant (Straumann Bone
or may not be keratinized, is considered a Level Tapered Implant; Institut Straumann,
crucial factor that affects both the esthetics Basel, Switzerland) of 4.1-mm diameter and

128 | The International Journal of Esthetic Dentistry | Volume 19 | Number 2 | Summer 2024
 Shakibaie et al

10- to 14-mm length in the posterior maxilla

or mandible. As all implants had a primary
stability of a minimum of 30 Ncm, a wide-
body healing screw was inserted simultan-
eously without further plastic surgery or
periodontal measures to manipulate the
vestibular soft tissue volume. Every patient
had undergone minimally invasive tooth ex-
traction with socket preservation in the
same region using Bio-Oss (size large) bone
substitute granules (Geistlich Pharma, Wol-
Fig 1 Using a microsurgical blade for Fig 2 Further preparation of the
husen, Switzerland) and a Stypro gelatine
the vestibulo-marginal incision and vestibular envelope with a micro
sponge (Curasan, Kleinostheim, Germany) preparation of a vestibular envelope. elevator in the mobile gingival zone.
4 months prior to implantation. Six weeks
later, at the time of the first impression for
prosthetic treatment, a vestibular peri-im-
plant soft tissue thickness of 1.5 mm or less
was observed in 12 out of 50 study cases.
These patients were informed about the in-
sufficient amount of soft tissue and the as-
sociated high risk for future complications.
This led to the consent of all 12 patients to
undergo further treatment to increase the
soft tissue volume prior to prosthetic ther-
apy and the integration of all 12 patients into
the present study.
Fig 3 Fixation of the graft into the Fig 4 The graft is stabilized using
Surgical technique prepared vestibular envelope using additional microsurgical sutures.
6-0 Seralon suture material.
To follow a minimally invasive protocol, all
steps – from tooth extraction and socket
preservation, implant insertion, implant ex-
posure, and grafting, to the prosthetic pro-
cedures – were performed with the utiliza-
tion of an operating microscope (Zeiss
OPMI PROergo; Carl Zeiss Meditec, Oberko-
chen, Germany).
Figures 1 to 6 illustrate the entire vestibu-
lar envelope technique with a CTG from the
palate.20,21 A vestibulo-marginal incision was
initiated in the fixed gingival zone of tooth
46 using a micro blade to prepare the ves-
tibular envelope, and a micro elevator fur-
thered the preparation into the mobile gin- Fig 5 Occlusal view of the augment- Fig 6 Occlusal aspect after the
gival zone. The single-incision technique22 ed peri-implant soft tissue, vestibular immediate insertion of a wide-body
was utilized to harvest the CTG from the to implant 46. healing screw on implant 46.

The International Journal of Esthetic Dentistry | Volume 19 | Number 2 | Summer 2024 | 129
Clinical Research

Fig 7 Occlusal aspect 10 days after surgery Fig 8 Occlusal aspect 6 weeks after surgery Fig 9 Occlusal aspect confirming the
and before suture removal showing slight demonstrating progressing vestibular soft significant volume gain compared with
thickness reduction despite optimal healing. tissue volume loss compared with the 10-day baseline after removal of the healing
follow-up. However, significant soft tissue abutment. The impression tool is inserted.
volume gain can be observed compared
with baseline, despite the resorption
process.

palate according to the prepared envelope with flowable composite for a more precise
size, and tension-free wound closure was forming of the emergence profile (Figs 9
obtained. Then, the harvested CTG was to 14). In all cases, screw-retained IPS e.max
placed and fixated into the prepared vestib- crowns (Ivoclar Vivadent, Schaan, Liechten-
ular envelope using 6-0 suture material (Ser- stein) were fabricated and inserted intra-
alon; Mettler, Boennigheim, Germany). Fol- orally 4 weeks after the impression (Fig 15).
lowing the fixation of the graft, it remained
partially exposed from its occlusal surface Study outcomes and reporting
and within the limits of the junctional epi-
thelium. After 10 days, a slight shrinkage oc- The aim of the present study was to evalu-
curred despite optimal healing of the vestib- ate the changes in peri-implant soft tissue in
ular soft tissue (Fig 7), and a progressive terms of the vestibular thickness and width
volume loss was observed 6 weeks after (KMT and KMW, respectively) on the vestib-
surgery (Fig 8). ular aspect of the implant at seven different
time points: 1) Immediately after surgery;
Prosthetic phase 2) 2 months after surgery, immediately after
crown insertion; 3) 1 year after surgery;
Six weeks after soft tissue augmentation, the 4) 2 years after surgery; 5) 3 years after sur-
closed-tray impression technique was ap- gery; 6) 4 years after surgery; 7) 5 years after
plied after customizing an impression tool surgery.

130 | The International Journal of Esthetic Dentistry | Volume 19 | Number 2 | Summer 2024
 Shakibaie et al

Fig 10 Injection of flowable composite around the Fig 11 Following curing of the composite, the
impression tool for the precise forming of the impression tool is removed.
emergence profile.

Fig 12 The sharp edges of the composite are Fig 13 The custom-prepared impression tool is
removed extraorally and the composite stamp is replaced and double checked for fit.
optimized.

Fig 14 Following the fit test, the impression cap is Fig 15 Vestibular aspect 4 weeks after the impression
installed and an impression taken. and immediately after the delivery of the screw-re-
tained IPS e.max crown.

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Clinical Research

Table 1 Demographic characteristics of individuals included in the study

Characteristics Value
Participants 12
Age, mean ± SD [years] 38 ± 13.5
Male (N) 4
Female (N) 8
Total implants (N) 12
Maxillary first molar (N) 3
Maxillary second molar (N) 1
Mandibular first molar (N) 5
Mandibular second molar (N) 2
Total utilized envelope technique (N) 12
Total harvested CTG from palate (N) 12
Harvested CTG thickness [mm]: mean (minimum, maximum) 4 (3–5)
Total inserted screw-retained IPS e.max crowns (N) 12
SD: standard deviation; N: number, CTG: connective tissue graft

Table 2 Measurements of soft tissue variables throughout the duration of the 5-year study period

Time point KMT [mm] KMW [mm]

Surgery day 5.5 ± 0.79 2.5 ± 0.42
6 weeks 4.59 ± 0.62 1.5 ± 0.42
1 year 4 ± 0.85 1.5 ± 0.42
2 years 4 ± 0.36 2 ± 0.60
3 years 3.59 ± 0.42 2 ± 0.73
4 years 3.45 ± 0.45 2 ± 0.85
5 years 3.5 ± 0.42 2 ± 0.85
KMT: keratinized mucosa thickness; KMW: keratinized mucosa width

In order to evaluate changes in the ves- plant. The measurement of KMW was taken
tibular peri-implant soft tissue, two param- with the same probe and microscope in dir-
eters were measured – vestibular KMT and ect view from buccal, defined as the short-
vestibular KMW. The measurement of KMT est perpendicular keratinized soft tissue
was taken with a 1-mm scaled periodontal width line, middle-marginal to the healing
probe (Zepf Dental, Seitingen-Oberflacht, screw/implant crown. All clinical measure-
Germany) in perpendicular indirect occlusal ments were taken by the same examiner
view (mirror) with the operating microscope, (BS) at all the time points, and the mean
defined as the shortest transversal soft tissue value of both parameters (KMT and KMW)
thickness line, middle-vestibular to the im- was generated and reported descriptively.

132 | The International Journal of Esthetic Dentistry | Volume 19 | Number 2 | Summer 2024
 Shakibaie et al

Results
Mean keratinized mucosa thickness (KMT)
6
Tables 1 and 2 depict the characteristics 5.5 (4.5-6.5)
of the included subjects and implants. 5
4.5 (3-5.5)
Briefly, 12 systemically healthy nonsmoker 4 4 (3-5) 4 (3.5-4.5)

Millimeters
patients (8 females, 4 males; mean age 3.5 (3-4) 3.5 (3-4) 3.5 (3-4)
35 ± 13.5 years) with 12 dental implants ei- 3

ther in the posterior maxilla or mandible 2

were successfully treated and included in
the present research study. In total, the 1

study included four implants in the maxilla 0

(three in first molar and one in second mo- Surgery 6 weeks 1 year 2 years 3 years 4 years 5 years
day
lar sites), and eight implants in the mandible
(six in first molar and two in second molar Fig 16 Changes in mean keratinized mucosa thickness (KMT) throughout the
sites). In addition, 12 CTGs were harvested 5-year study duration.
from the palate, 12 envelope techniques
were utilized, and 12 screw-retained IPS
e.max crowns were inserted. The average Mean keratinized mucosa width (KMW)
6
thickness of the harvested tissue was 4 mm.
Postoperative healing was uneventful at all 5 2.5 (2-3)

sites, and no adverse events or major com-

4 2 (1-3) 2 (1-3) 2 (1-3) 2 (1-3)
Millimeters

plications were reported. Moreover, the sur-

vival rate of the implants at the 5-year fol- 3 1.5 (1-2) 1.5 (1-2)

low-up was 100%, without the occurrence

2
of peri-implant diseases.
Tables 1 and 2 as well as Figures 16 and 1

17 present the data regarding the changes

0
in the main study outcomes. On the day of Surgery 6 weeks 1 year 2 years 3 years 4 years 5 years
day
surgery, the mean KMT was 5.5 ± 0.79 mm,
and it decreased to 4.59 ± 0.62 mm at
Fig 17 Changes in mean keratinized mucosa width (KMW) throughout the
6 weeks, which is a predictable volume
5-year study duration.
loss. Similarly, the mean KMW decreased
from 2.5 ± 0.42 mm on the day of surgery
to 1.5 ± 0.42 at 6 weeks. At 1 year, the mean
KMT decreased to 4 ± 0.85 mm, and the
mean KMW maintained its volume at
1.5 ± 0.42 mm. The reason for this is that
bone resorption within the first year of
implant function is often relatively high due
to bone remodeling (Fig 18). At the 2-year
follow-­ up, the mean KMT was still
4 ± 0.36 mm; however, the mean KMW had
increased to 2 ± 0.60 mm (Fig 19). At the
3-year follow-up, the mean KMT had de-
creased to 3.59 ± 0.42 mm, while the mean Fig 18 Occlusal aspect at the 1-year Fig 19 Occlusal aspect at the 2-year
KMW still measured 2 ± 0.73 mm, demon- follow-up. follow-up.

The International Journal of Esthetic Dentistry | Volume 19 | Number 2 | Summer 2024 | 133
Clinical Research

Fig 20 Occlusal aspect at the 3-year Fig 21 Occlusal aspect at the 4-year Fig 22 Occlusal aspect at the 5-year
follow-up. follow-up. follow-up.

Fig 23 Vestibular aspect at the 5-year

follow-up with the IPS e.max crown in
place, demonstrating a stable implant–pros-
thetic interface.

Fig 24 Vestibular-frontal aspect at the Fig 25 Occlusal aspect at the 5-year

5-year follow-up after sealing the internal follow-up after sealing the internal screw
screw hole with composite. hole with composite.

strating a stable implant-prosthetic interface The same was seen at the 5-year follow-up,
(Fig 20). At the 4-year follow-up, all meas­ with no changes in measurements ob-
urements (KMT and KMW) showed the served (Fig 22). Figures 23 to 25 depict sev-
same amount as previous records with the eral aspects (vestibular, vestibular-frontal,
same standard deviations, demonstrating a and occlusal) with the IPS e.max crown in
stable implant-prosthetic interface (Fig 21). place.

134 | The International Journal of Esthetic Dentistry | Volume 19 | Number 2 | Summer 2024
 Shakibaie et al

Discussion ducing keratinization of the epithelium in

the natural dentition,26 this does not appear
The results of the present 5-year retrospec- to hold true when a CTG is employed as a
tive case series demonstrated that the vol- component of a bilaminar approach around
ume of vestibular peri-implant soft tissue dental implants. The bilaminar technique
could successfully be augmented using the was found to be effective in increasing MT,
envelope technique in combination with a but not KMW.27 The procedure used in the
CTG. Within 2 years following the augmen- present study utilized a CTG in combination
tation procedure, the augmented volume with the envelope technique.
reached stability on average, with a slight While the value of 2 mm of KTW has
shrinkage that caused a decrease in the vol- commonly been used as the cutoff point in
ume of KT during the first few months. This research, it is important to note that this
fast drop in volume could partly be due to number is arbitrary and may not adequately
partial exposure of the new graft to the oral account for the complex nature of peri-im-
cavity, which after the initial healing and re- plant health and disease. There is limited
sorption reached a steady range throughout evidence supporting 2 mm as the optimal
the long-term follow-ups. cutoff point in comparison with other pos-
The crucial factor to consider when sible values.4 It is possible to hypothesize
choosing soft tissue grafting materials and that the minimal amount of keratinized mu-
techniques for periodontal and peri-implant cosa (KM) necessary to maintain healthy
plastic surgery is the blood supply source of peri-implant tissue may vary depending on
the grafts and the presence of vital cells other individual case-specific factors, in-
within them.23,24 By taking into account cluding MT, STH, peri-implant bone thick-
these two primary biologic characteristics, ness, probing depth, and superstructure de-
clinicians can choose the most suitable ma- sign.4
terial in order to attain the desired surgical To expand further on this point, several
outcome. CTG-based procedures have studies suggest that having sufficient
demonstrated the most favorable results for peri-implant KMW measuring over 2 mm is
enhancing root coverage and increasing linked to better overall soft tissue health
the width of KT of natural teeth.24 According around implants.28,29 Insufficient KMW
to Obreja et al, peri-implant soft tissue vol- (< 2 mm) has been demonstrated to elevate
ume grafting procedures utilizing a CTG the vulnerability of peri-implant tissue to de-
were found to have a positive impact on the struction caused by plaque.29 In addition,
preservation of peri-implant health when Gharpure et al demonstrated in a cross-sec-
applied simultaneously.23 However, both tional study that the presence of insufficient
simultaneous and staged soft tissue aug- KMW in implants was linked to a higher
mentations during implant treatment have prevalence of peri-implantitis and peri-im-
been found to significantly improve both plant mucositis.30 Moreover, patients with
KMT and KMW, and there is no distinguish- < 2 mm of KM exhibited increased levels of
able difference between the two ap- plaque, peri-implant inflammation, and dis-
proaches.25 Clinically, the decision to aug- comfort during tooth brushing.31 Neverthe-
ment and the timing of the procedure less, it is important to note that there is a
depend on the clinician’s preference, the strong positive association between exces-
patient’s willingness to undergo the proced- sive soft tissue thickness and peri-implant
ure, and the clinical necessity.1,25 In addition, probing depth as well as peri-implant bone
although CTG has been associated with in- loss.32

The International Journal of Esthetic Dentistry | Volume 19 | Number 2 | Summer 2024 | 135
Clinical Research

The results of the present study indicated from 3 to 12 months.34 In another study by
approximately 35% shrinkage of the aug- Roccuzzo et al, this technique was applied
mented site at the 1-year follow-up while to cover the peri-implant dehiscence; 86%
gaining approximately 2 mm of MT at the of mean coverage was achieved in that
3- to 5-year follow-ups. In this regard, study, along with high patient satisfaction.35
Schmitt et al reported 56.39% shrinkage us- Moreover, it should be noted that there are
ing the same technique, while gaining several other techniques such as omega roll
1.1 ± 0.49 mm in thickness at the 6-month envelope flap,36 roll-in-envelope flap,12 and
follow-up.33 These differences might be due several modifications37 to the original roll
to various factors such as harvested graft flap technique. Bear in mind that, currently,
thickness, adipose tissue composition, fol- evidence is still lacking regarding compari-
low-up period, and measurement tech- sons of all these techniques. However, the
niques. Similarly, in a 3-year follow-up study, overall results indicate relatively acceptable
Thoma et al reported a gain of 0.8 mm in outcomes for all. This is in line with Thoma
thickness.19 Nevertheless, none of these et al, who concluded that there was an in-
studies reported graft thickness, thereby sufficient number of randomized controlled
rendering it impossible to conduct a mean- trials (RCTs) specifically addressing the in-
ingful comparison with the present study. A crease in soft tissue volume.24 Due to such
similar soft tissue augmentation approach considerations, it was not feasible to con-
was performed in a study by Hosseini et al, duct RCTs on this particular subject matter.
where the cases were followed up in a simi- Recruiting patients from private dental
lar way to that of the present study, for up to clinics instead of university clinics has the
5 years.14 The long-term results of that study advantage of yielding data on the “effective-
showed an average thickness gain of 1.02, ness” rather than just the “efficacy” of im-
1.51, and 1.63 mm at different reference plant therapy. The outcome of the present
points coronoapically.14 study can be understood as an association
A network meta-analysis was used to rather than a causal relationship. To better
conduct a thorough evaluation of the avail- determine the impact of KM on peri-implant
able evidence on the effectiveness of vari- health, it would be more meaningful to
ous interventions targeting PSP modifica- study changes in peri-implant tissue over
tion and their impact on peri-implant health.1 time in relation to the thickness and width
The analysis recommended that the combi- of the KM.
nation of a free gingival graft with an apically Finally, the limitations of the present
positioned flap is the most effective tech- study include the lack of patient-reported
nique for augmenting KMW. In addition to outcome measures (PROMs) as well as a
these commonly used techniques, various possibility that inherent biases could have
other minimally invasive and microsurgical arisen due to the clinician and clinical meas­
approaches have also been introduced and urer being the same person. Furthermore, it
implemented in this regard. De Bruyckere et should also be noted that several recent
al utilized the same technique as in the pres- studies8,38 implemented 3D volumetric as-
ent study in the anterior maxilla and fol- sessment of soft tissue augmentation
lowed up the subjects for 1 year.34 Similarly around implants. The common conclusion
to the present findings, these authors re- of these studies proves the feasibility of this
ported a reduction in initial (immediate) tis- technology in such cases. Nonetheless, it is
sue gain up to 3 months after surgery; important to acknowledge that the absence
nonetheless, they reported stable outcomes of this assessment in the present study can

136 | The International Journal of Esthetic Dentistry | Volume 19 | Number 2 | Summer 2024
 Shakibaie et al

be considered a limitation. Another crucial combination with the envelope technique

topic to study with regard to peri-implant over a period of 5 years. It was demon-
soft tissue augmentation procedures is the strated that this microsurgical approach
prevalence/incidence analyses of peri-im- could achieve a stable implant-prosthetic
plant diseases and the estimation of risk interface. Whenever indicated, it is recom-
ratios regarding these as well as revealing mended to utilize the envelope technique
any possible negative correlation between with a CTG from the palate to increase the
soft tissue augmentation and the occur- volume of peri-implant soft tissue in terms
rence of disease in the long term. There- of KMT and KMW.
fore, it is strongly suggested to take these
points into account for future research in Disclaimer
dental implantology. Additionally, conduct-
ing a follow-up over an extended period The authors declare no conflicts of interest
would be advantageous in evaluating regarding this research study. No funding
whether the increase in soft tissue volume is was received for this study.
sustained over time.
Data availability
Conclusions
The study data can be provided upon rea­
Within its limitations, the present study de- sonable request from the corresponding
picted the benefit of applying a CTG in author.

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138 | The International Journal of Esthetic Dentistry | Volume 19 | Number 2 | Summer 2024