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Objective The gold standard for a soft tissue augmentation around implants is a subepithelial connective tissue graft (CTG), but the xenogeneic collagen matrices (XCM) started to be used as an alternative. This systematic review aimed to assess the effectiveness XCM in comparison to CTG for the increasing the thickness of the soft tissue around implants. Data All studies included at least two parallel groups comparing the use of CTG and XCM with a minimum follow-up of 3 months. As the primary outcome, the amount of soft tissue thickness gain after soft tissue augmentation with XCM or CTG was assessed. Secondary outcomes were clinical and patient-related outcomes; evaluation of aesthetic outcomes, patient-reported outcomes measures (PROMs) and complications. Eligible studies were selected based on the inclusion criteria. Meta-analysis was applied whenever possible. The quality of the evidence of studies including in meta-analysis was assessed using the GRADE approach. Source A systematic literature search up to January 2022 was conducted using the following electronic databases: PubMed (MEDLINE), Scopus, Cochrane Library, LILACS, eLIBRARY.RU. Unpublished researches, the gray literature, nonprofit reports, government studies and other materials were reviewed electronically using an EASY search. An additional manual search was carried out in November 2022. Study selection Of the 1376 articles from the initial search, 8 randomized controlled trials (RCTs) (306 patients and 325 implants) were included in this systematic review, and 7 studies were part of the meta-analysis. Meta-analysis revealed that XCM is less effective than the CTG in increasing soft tissue thickness around dental implants. However, XCM also provides soft tissue thickness gain and can be recommended for use in various clinical situations. Clinical significance Previous systematic reviews and meta-analyses have shown that autologous grafts are more effective than collagen matrices in increasing soft tissue thickness, however, the latter can be used as an alternative. Studies included in previous systematic reviews varied in design, which could lead to limitations. The present systematic review and meta-analysis includes for the first time only randomized controlled clinical trials with collagen matrix of xenogeneic origin in the test group. Tight eligibility criteria were established, and the main parameter studied was soft tissue thickness. It was found that xenogeneic collagen matrix is effective for increasing soft tissue thickness around dental implants, however, the results obtained using an autogenous connective tissue graft are superior.

The vascularized tunneled combine epithelialize‐subepithelialize connective tissue graft may yield biological outcomes superior to those achieved separately by rotated vascularization or combination interposition onlay tissue graft. This technique may provide clinicians with pathway to improve socket seal by improving the vascularity and the volume of the tissue seal, which would be paramount for the definitive esthetic and functional outcome for modern demand of our patients. The vascularized tunneled combine epithelialize‐subepithelialize connective tissue graft may yield biological outcomes superior to those achieved separately by rotated vascularization or combination interposition onlay tissue graft. This technique may provide clinicians with pathway to improve socket seal by improving the vascularity and the volume of the tissue seal, which would be paramount for the definitive esthetic and functional outcome for modern demand of our patients.

Dehiscence and fenestration are commonly confronted alveolar defects. But the combined mucosal and alveolar fenestration is uncommonly reported in the literature as they less often cause pain, and in majority of the cases, only aesthetic complaint is present. This article highlights the case report of a 28-year-old female patient who presented with aesthetic concern about gingival/mucosal fenestration in her right lower central incisor. She had a history of surgical endodontic treatment in the same tooth. In this case, mucosal fenestration was treated with regenerative therapy using bioactive glass with platelet-rich fibrin and free connective tissue graft. The treatment resulted in excellent aesthetic outcome and satisfactory bone healing.

Achieving symmetry of the soft-tissue margins between anterior maxillary dental-implant restorations and adjacent teeth is a therapeutic challenge for both the implant surgeon and the restorative dentist. This article describes a modified procedure utilizing autogenous connective-tissue grafts to improve primarily buccal soft-tissue margins and secondarily inter-proximal tissues around tooth-bound single dental implants. This technique has the advantage of allowing for coronal augmentation of the peri-implant soft tissue while maximizing the blood supply to the area by using tunneling-technique principles. A detailed description of the technique and a case with a stable result over 24 months after crown placement is presented.

Acellular dermal matrix (ADM) is an alternative to autologous tissue grafts that are commonly utilized in soft tissue augmentation procedures. This randomized clinical trial evaluated the clinical effectiveness of allogeneic ADM versus connective tissue graft (CTG) in treating multiple recession type (RT) 2 gingival recessions using a modified tunnel technique. A total of 40 patients were randomly assigned to either the CTG group (n=20) or the ADM group (n=20). Clinical parameters, including the plaque index (PI), gingival index (GI), probing depth (PD), clinical attachment level (CAL), keratinized tissue width (KTW), recession depth (RD), and gingival thickness (GT), were assessed at baseline and 12 months. Both groups showed significant improvements in CAL, KTW, RD, and GT at 12 months compared to baseline. No significant differences in PI, GI, PD, mean root coverage (MRC), complete root coverage (CRC) or the Root Coverage Esthetic Score (RES) were observed between the CTG and ADM groups. The CTG group demonstrated greater gains in GT and KTW ( p <0.05), whereas the ADM group reported significantly lower postoperative pain ( p <0.05). ADM and CTG yielded comparable root coverage and aesthetics. CTG provided superior tissue augmentation, whereas ADM offered better patient comfort. In conclusion, allogeneic ADM is a promising alternative for the treatment of RT2 gingival recessions.

Objective The primary objective of this review is to compare autogenous soft tissue grafts (connective tissue graft – CTG and free gingival graft—FGG) with different type of matrices (acellular dermal matrix—ADM, xenograft collagen matrix—XCM, volume-stable collagen matrix—VCMX) used to increase peri-implant soft tissues. Materials and methods A search on electronic databases was performed to identify randomized and non-randomized controlled trials (RCTs and CCTs, respectively) with either parallel or split-mouth design, and treating ≥ 10 patients. A network meta-analysis (NMA) was used to compare different matrices. Soft tissue thickness dimensional changes and keratinized width (KMW) changes were the primary outcome measures. The secondary outcomes were to evaluate: a) PROMs; b) volumetric changes; c) surgical operating time; and d) different periodontal measurements. Results A total of 23 studies were included in the qualitative analysis, and 16 studies (11 RCTs and 5 CCTs) in the quantitative analysis. A total of N = 573 sites were evaluated for NMA. CTG resulted the best material for increasing peri-implant soft tissue thickness, at 180 and 360 days after surgery. The use of an ADM showed good results for buccal thickness increase, primarily in the first three months after surgery. Vestibuloplasty + FGG resulted in the most effective technique for peri-implant KMW augmentation, after 180 days. Conclusions While CTG demonstrated better performance in all the comparison and FGG showed to be the best graft to increase keratinized mucosa up to 90 days, ADM and VCMX may be used to increase soft tissue horizontal thickness with lower patients’ morbidity. Limitations The limits of this NMA are the following: a) limited number of included studies; b) high heterogeneity among them (number of patients, treatment sites, surgical techniques, outcome measures, and follow-ups). Clinical Relevance Many studies compared the efficacy of autogenous and non-autogenous grafts in terms of gingival thickness, volume, and keratinized width increase. However, there is still not clear overall evidence on this topic. This NMA helps clinicians to choose the right material in different peri-implant soft tissue procedures. Recommendations for future studies are mandatory.

Background: Multiple approaches have been used to replace lost, damaged or diseased gingival tissues. The connective tissue graft (CTG) procedure is the golden standard method for root coverage. Although multiple sites often need grafting, the palatal mucosa supplies only a limited area of grafting material. To overcome this limitation, expanded mesh graft provides a method whereby a graft can be stretched to cover a large area. The aim of this study was to evaluate the effectiveness and the predictability of expanded mesh CTG (e-MCTG) in the treatment of adjacent multiple gingival recessions. Materials and Methods: Sixteen patients aged 20-50 years contributed to 55 sites, each site falling into at least three adjacent Miller's Class 1 or Class 2 gingival recession. The CTG obtained from the palatal mucosa was expanded to cover the recipient bed, which was 1.5 times larger than the graft. Clinical measurements were recorded at baseline and 3 months, 12 months postoperatively. Results: A mean coverage of 1.96 mm ± 0.66 mm and 2.22 mm ± 0.68 mm was obtained at the end of 3rd and 12th month, respectively. Twelve months after surgery a statistically significant increase in CAL (2.2 mm ± 0.68 mm, P < 0.001) and increasing WKT (1.75 ± 0.78, P < 0.001) were obtained. In 80% of the treated sites, 100% root coverage was achieved (mean 93.5%). Conclusions: The results of this study demonstrated that multiple adjacent recessions were treated by using e-MCTG technique can be applied and highly predictable root coverage can be achieved.

Background: Tooth loss results in hard- and soft-tissue volume loss over time. We compared the handling of three different soft tissue substitutes (STS) to the subepithelial connective tissue graft (SCTG) for soft tissue volume augmentation in a pig ex vivo model. Methods: Five dentists simultaneously shaped, placed and sutured randomized four graft types in single-tooth soft tissue defects created in pig mandibles. The STS, produced from slightly crosslinked collagen fibres (VCMX), were either 3 mm or 6 mm thick blocks or a newly developed pre-customized saddle-shape. Each graft type was handled 20 times. The time required for shaping, placement, and suturing was recorded. Dentists reported outcomes on the grafts’ handling were evaluated with a visual-analogue-scale (VAS). Statistical analysis included calculating means and medians and testing significance. Results: The mean time of 0.72 min for shaping the pre-customized saddle-shape STS was significantly lower than 1.31 min for SCTG, 1.73 min for 3 mm STS and 2.17 min for 6 mm STS. Placement/suturing time was similar for all grafts. The dentists mainly preferred the saddle-shape STS and the SCTG. Conclusions: The saddle-shape STS required less time for graft-shaping and, therefore, reduced the overall treatment time, suggesting a more efficient and less invasive workflow for soft tissue augmentation.

Background: Different extracellular matrix (ECM)-based technologies in periodontal and peri-implant soft tissue augmentation have been proposed in the market. The present review compared the efficacy of soft tissue substitutes (STSs) and autogenous free gingival grafts (FGGs) or connective tissue grafts (CTGs) in mucogingival procedures to increase keratinized tissue (KT) width around teeth and implants. Methods: Two independent examiners performed an electronic search on MEDLINE and the Cochrane Library based on the following PICOS format: (P) adult patients; (I) soft tissue substitutes and FGGs/CTGs; (C) STSs vs. CTGs; STSs vs. FGGs; STSs vs control; (O) KT width gain; (S) systematic reviews, randomized controlled trials. Studies published before November 2023 were included. Results: Around teeth, all biomaterials showed superior performance compared to a coronally advanced flap (CAF) alone for treating gingival recessions. However, when compared to CTGs, acellular dermal matrices (ADMs) yield the most similar outcomes to the gold standard (CTGs), even though in multiple recessions, CTGs continue to be considered the most favorable approach. The use of STSs (acellular matrix or tissue-engineered) in combination with apically positioned flaps (APF) resulted in significantly less gain in KT width compared to that achieved with FGGs and APFs. Around dental implants, free gingival grafts were deemed more effective than soft tissue substitutes in enhancing keratinized mucosa width. Conclusions: Based on the available evidence, questions remain about the alternative use of soft tissue substitutes for conventional grafting procedures using free gingival grafts or connective tissue grafts around teeth and implants.