presented by:
Shahir Mitry
John Rafik
Youssef Hany
Soft tissue around dental implants plays an essential role not only in the long-term survival of
the implant but also in ensuring the aesthetics and functionality of the restoration. The
importance of adequate soft tissue thickness (STT) and keratinized mucosa (KM) around the
implant cannot be overstated, as they serve to protect against infection, improve soft tissue
stability, and provide better esthetic outcomes. Soft tissue augmentation procedures are
employed to address deficiencies in these areas, particularly when tissue volume or quality is
insufficient.
Biological Rationale:
- The biological width surrounding the implant—defined by the junctional epithelium and
connective tissue attachment—requires sufficient thickness to avoid peri-implant complications.
Thin tissues are more prone to recession, inflammation, and infection, potentially jeopardizing
the implant.
- *Keratinized mucosa (KM)* is particularly critical around dental implants since it is associated
with a reduced risk of peri-implantitis. While non-keratinized mucosa lacks the protective
barrier of keratinized tissue, it is more prone to irritation and inflammation.
2. Techniques for Soft Tissue Augmentation Around Dental Implants
Several techniques have been developed over the years for soft tissue augmentation. These vary
in terms of complexity, predictability, invasiveness, and aesthetic outcomes. Below is a more in-
depth exploration of these techniques:
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A. Free Gingival Graft (FGG)
- Description and Mechanism:
The Free Gingival Graft (FGG) technique involves harvesting a small portion of tissue from the
palatal mucosa or other donor areas, and grafting it onto the implant site. FGGs are often used
in cases where the patient requires an increase in *keratinized mucosa* around the implant
site, particularly when the implant is placed in a non-aesthetic zone or a high-stress functional
area.
- Clinical Considerations:
- The harvest site for FGG requires careful planning to avoid causing excessive discomfort or
scarring.
- *Tissue Healing: The graft lacks a direct blood supply upon placement, relying on
vascularization from the recipient site for survival. The lack of this immediate blood flow makes
FGGs prone to graft loss if there is inadequate apposition to the recipient bed.
- *Morbidity at Donor Site: FGG requires a secondary surgical site, which increases patient
discomfort and healing time. This can be particularly challenging when the palatal mucosa is
thin or scarred.
- *Advantages:
- *Predictable Outcomes: Over time, FGGs are known to provide stable and predictable results
for increasing keratinized mucosa around implants.
- *Long-Term Tissue Stability: The procedure is highly effective at creating a durable, thick band
of keratinized mucosa, which is crucial for implant success.
- *Disadvantages:
- Increased postoperative pain and potential complications due to the donor site.
- Higher chance of *partial graft loss* if the graft is not adequately vascularized or positioned.
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*B. Subepithelial Connective Tissue Graft (SCTG)
- Description and Mechanism:
The *Subepithelial Connective Tissue Graft (SCTG)* involves harvesting *connective tissue*
from beneath the palatal mucosa and grafting it to the recipient site. This technique is
frequently preferred for aesthetic zones (anterior regions) and for cases requiring significant
volume enhancement.
- *Clinical Considerations:
- *Aesthetic Outcome SCTGs are preferred in areas where *aesthetic concerns* are paramount
due to their ability to integrate seamlessly with the surrounding tissues.
- *Tissue Survival: The SCTG provides a better *blood supply* compared to FGGs, as the graft is
placed with direct access to the recipient site’svascular network, leading to improved survival
and healing rates.
- *Advantages:
- *Superior Aesthetic Results: SCTG provides a more natural result than FGG, with better color
match and texture.
- *Less Morbidity: Since the tissue harvested is from beneath the mucosa, it leads to less donor
site morbidity compared to FGG.
- *Enhanced Integration: SCTGs have better long-term integration with the surrounding tissue,
making them an ideal choice for esthetically critical cases.
- *Disadvantages:
- Requires two surgical sites (one for harvesting and one for placement), which adds
complexity.
- More technically demanding than FGG and may require greater expertise to avoid
complications.
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C. Collagen Matrices
- *Description and Mechanism:
Collagen matrices, made from either *xenogeneic* (from animals) or *allogeneic* (from
human) collagen, provide a scaffold that promotes soft tissue regeneration. These matrices are
particularly useful in cases where *autogenous tissue harvesting* may not be desirable.
- *Clinical Considerations:
- *Scaffold for Regeneration: Collagen matrices serve as a biologically inert scaffold, promoting
tissue ingrowth and angiogenesis.
- *Incorporation and Resorption: The rate of resorption and incorporation of the matrix into
the soft tissue varies and is typically slower than that ofautogenous tissue.
- *Advantages:
- *Reduced Donor Site Morbidity: There is no need for tissue harvesting, making the procedure
less invasive for the patient.
- *Shorter Surgical Time: The use of collagen matrices can reduce the overall surgical time as it
eliminates the need for harvesting tissue.
- Disadvantages:
- Less Predictable Long-Term Results: Studies suggest that while collagen matrices can enhance
soft tissue volume, they are less effective at achieving long-term thickening of the gingiva
compared to autogenous grafts like SCTG.
- Reduced Tissue Integration Collagen matrices may not integrate as well into the surrounding
tissues and could lead to greater risks of tissue collapse or failure over time.
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D. Allografts and Xenografts
- *Description and Mechanism:*
*Allografts* (human-derived grafts) and *xenografts* (animal-derived grafts) are used when
autogenous tissue is either unavailable or undesirable. These grafts are processed to remove
cells and promote tissue integration.
- *Clinical Considerations:
- *Enhanced Tissue Formation: These grafts act as a scaffold for native tissue to grow into,
promoting volume increase over time.
- *Immune Reactions: Although highly processed, there is a potential risk of immune rejection,
which can lead to graft failure.
*Advantages:
- Eliminates the need for a donor site and associated complications.
- Provides a ready-made scaffold that can assist in tissue regeneration, especially in cases
where autogenous tissue is scarc.
- Disadvantages:
- Biological Integration: Xenografts and allografts may be associated with lower integration
rates compared to autogenous grafts.
- Cost: Allografts and xenografts can be significantly more expensive, particularly when using
high-quality processed tissues.
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3. Timing of Soft Tissue Augmentation Around Implants: Insights from the Literature
The timing of soft tissue augmentation around dental implants is a critical decision-making
factor that depends on several variables, such as implant placement, tissue quality, and the
patient’s overall condition. According to Strauss et al. (2023), understanding the optimal timing
for soft tissue procedures can significantly influence the final outcome.
A. Immediate Soft Tissue Augmentation (Simultaneous with Implant Placement)
- *Advantages:
- *Reduced Treatment Time: Performing soft tissue augmentation simultaneously with implant
placement minimizes the number of surgical interventions.
- *Enhanced Aesthetic Outcomes: For patients requiring immediate esthetic restoration (such
as those with anterior implants), simultaneous procedures provide more predictable outcomes.
- *Disadvantages:
- *Increased Complexity: This approach demands that both the implant placement and the soft
tissue augmentation are executed with precision, increasing the complexity of the procedure.
- *Potential for Graft Loss:There is a higher risk of graft failure if the implant site is not
adequately prepared or if primary closure is not achieved.
*B. Delayed Soft Tissue Augmentation (After Implant Osseointegration) - Advantages:
- *Better Healing and Stability:Performing soft tissue augmentation after osseointegration
allows for stable tissue that has fully integrated with the implant.
- Customization: Delayed augmentation allows for a more personalized approach, as the
implant can be evaluated for its specific tissue needs.
- *Disadvantages:
- *Longer Treatment Duration: This approach requires a second surgical phase, which can
extend the overall treatment timeline.
- Compromised Aesthetic Outcomes: In the interim period, patients may experience aesthetic
or functional compromise due to the lack of sufficient soft tissue.
1. Importance of Soft Tissue Thickness and Keratinized Mucosa
• Biological Width:
o Soft tissue surrounding implants consists of the junctional epithelium and
connective tissue, collectively known as the biological width.
o Sufficient tissue thickness protects against complications such as recession,
inflammation, and infection.
• Keratinized Mucosa:
o Keratinized tissue offers a protective barrier, reducing the risk of peri-implantitis
and inflammation.
o Non-keratinized mucosa is more susceptible to irritation and complications.
Suggested Image: Diagram of the biological width and comparison between keratinized and non-
keratinized mucosa.
2. Techniques for Soft Tissue Augmentation
A. Free Gingival Graft (FGG)
• Mechanism:
o Tissue is harvested from the palatal mucosa or other donor areas and grafted to
the recipient site.
o Ideal for increasing keratinized mucosa, especially in non-aesthetic or high-stress
zones.
• Advantages:
o Provides stable and predictable results.
o Creates durable, thick keratinized mucosa.
• Disadvantages:
o Requires a donor site, leading to increased discomfort and longer healing time.
o Risk of graft loss due to limited blood supply.
B. Subepithelial Connective Tissue Graft (SCTG)
• Mechanism:
o Connective tissue is harvested from beneath the palatal mucosa for grafting.
o Commonly used in aesthetic zones for volume enhancement.
• Advantages:
o Superior aesthetic results with a natural appearance.
o Less morbidity at the donor site compared to FGG.
• Disadvantages:
o Requires advanced surgical skills and is more technically demanding.
C. Collagen Matrices
• Mechanism:
o Collagen-based scaffolds promote tissue regeneration.
o Useful when autogenous tissue harvesting is not feasible.
• Advantages:
o Reduced donor site morbidity.
o Shorter surgical time.
• Disadvantages:
o Less predictable long-term results compared to autogenous grafts.
o May lead to tissue collapse over time.
D. Allografts and Xenografts
• Mechanism:
o Processed grafts (human or animal-derived) act as scaffolds for tissue formation.
o Promote volume increase and integration.
• Advantages:
o No need for a donor site.
o Readily available and convenient.
• Disadvantages:
o Lower biological integration rates.
o Higher costs.
3. Timing of Soft Tissue Augmentation
A. Immediate Augmentation
• Performed simultaneously with implant placement.
• Advantages: Reduced treatment time and enhanced esthetics.
• Disadvantages: Increased complexity and risk of graft loss.
B. Delayed Augmentation
• Performed after implant osseointegration.
• Advantages: Improved healing and stability.
• Disadvantages: Longer treatment duration and potential interim aesthetic issues.
INTRODUCTION
• Periodontal and peri-implant surgery techniques that aim to increase the
amount of tissue around the teeth or implants are becoming increasingly
frequent in the dental field
The techniques to harvest CTG have undergone a large number of modifications over a period of
44 years since the time it was introduced by Edel in 1974 to increase the width of keratinized
gingiva.
CRITERIA OF SOFT TISSUE AROUND
IMPLANTS
• average of 3-4 mm thickness of mucosa is ideal
• An average of 2 mm of keratinized mucosa and 1 mm of attached gingiva in the
implant site is essential
• Contour and esthetics
WHY PALATE IS THE ROUTINELY USED
DONOR SITE?
• CTG can be procured from the edentulous ridges, maxillary tuberosity, and
palate, with palate being the most frequently used donor site due to the large
dimensions of graft that could be obtained and also the presence of
histological similarity between the palatal mucosa and keratinized attached
mucosa of alveolar ridge.
PALATAL GRAFT
• Free gingival graft
• Connective tissue graft
Pedicle graft (de epithelialized)
PROS AND CONS
ADVANTAGE DISADVANTAGE
• 1. Patient Discomfort : Postoperative pain and
discomfort at the donor site are common,
• 1. Durability:The grafted tissue is generally particularly in the initial healing phase.
resistant to further recession and provides long-
term stability, especially for implant sites. • 2. Aesthetic Considerations:There may be visible
scarring at the donor site on the palate, which
• 2. Tissue Characteristics The palatal tissue is can be a concern for some patients.
naturally thick and keratinized, offering ideal graft
material for creating durable soft tissue coverage. • 3. Healing Time: Full integration and healing can
take several months, and the donor site may
• 3. Predictability:The use of autogenous tissue require additional care during recovery.
reduces the risk of rejection or immune reaction
TECHNIQUE
• .
• Variations in the anatomy (size and shape) of the palate
may affect the proportion of graft harvested, and also the
position of the greater palatine nerve and vessel must be
known before planning any palatal surgery.
The shallower the palatal vault, the closer the palatine artery
gets to the palatal gingival margin
WHEN TO USE SOFT TISSUE GRAFTS
• A 39 year old female reported to the department of prosthodontics with a
chief complaint of missing right front tooth and wanted replacement of tooth,
which was lost due to trauma by fall two years back
