Soft tissue at implants: autografts still lead, substitutes hurt less

How should we thicken the mucosa around an implant, or widen its band of keratinised tissue: with the patient's own tissue, or with a substitute? This systematic review, commissioned for the AAP/Osteology Foundation/SEPA workshop on new technologies in oral reconstructive medicine, tries to put the question in order.

The authors followed PRISMA 2020 and registered the protocol in PROSPERO. Only randomised controlled trials were included: forty in total, judged by RoB 2 to be of generally high methodological quality. Clinician-reported and patient-reported outcomes were extracted. Because the trials reported their results inconsistently, a network meta-analysis was feasible only for two variables, mucosal thickness (MT) and keratinised mucosa width (KMW), across five sets of comparisons.

The answer is clear on two points. For mucosal thickness, an autogenous connective tissue graft placed with a bilaminar approach ranked best, regardless of when soft tissue augmentation was performed. For keratinised mucosa width, a free mucosal graft placed on a partial-thickness vascular bed was generally the most effective option.

Substitute scaffolds (collagen matrices, dermal grafts and similar materials) did not disappear from the picture. Some specific types performed similarly to autogenous grafts, particularly for thickness gain. They also had a consistent advantage: lower postoperative discomfort, because there is no palatal donor site.

The authors' conclusion is cautious. Autogenous grafts remain the first choice when a predictable gain in thickness or keratinised width is the goal. A selected substitute can achieve similar results with less morbidity. The evidence has limits: patient-reported outcomes were reported unevenly, follow-up was mostly short, and long-term stability, especially for newer materials, is still under-studied.

Clinical relevance: the choice between autograft and substitute is not a contest with one winner. It depends on the target (thickness or keratinised tissue), on how much predictability the case requires, and on how much postoperative morbidity the patient is willing to accept. This review gives the decision a solid, trial-based starting point.