Achieving optimal peri-implant soft tissue esthetics and stability is a key goal in implant dentistry, as it significantly influences patient satisfaction and long-term implant success (1). Soft tissue deficiencies around dental implants can result in compromised esthetic outcomes, increased plaque accumulation, and peri-implant inflammation, potentially leading to biological complications (2). Various soft tissue grafting techniques, such as subepithelial connective tissue grafts (SCTG), free gingival grafts (FGG), and acellular dermal matrix (ADM), have been employed to enhance peri-implant tissue volume, improve contour, and establish a stable band of keratinized mucosa (3).

Subepithelial connective tissue grafts (SCTG) are widely regarded as the gold standard due to their predictable outcomes in increasing soft tissue thickness and improving esthetic integration (4). They provide excellent vascularization and blend well with adjacent tissues, leading to long-term peri-implant stability (5). Free gingival grafts (FGG), though effective in augmenting keratinized tissue width, may lead to less favorable esthetic outcomes due to color and texture mismatches (6). Acellular dermal matrix (ADM) has emerged as a viable alternative to autogenous grafts, eliminating the need for a secondary surgical site while still providing acceptable soft tissue enhancement (7). However, its long-term stability and esthetic performance compared to autogenous grafts remain controversial (8).

Despite advancements in soft tissue grafting techniques, the selection of an optimal approach remains challenging. Factors such as peri-implant mucosal thickness, keratinized tissue width, and pink esthetic score (PES) are critical in determining the success of these procedures (9). This study aims to compare the influence of different soft tissue grafting techniques on peri-implant esthetics and stability by evaluating clinical outcomes and patient satisfaction over a six-month period.

Study Design and Patient Selection

This randomized clinical study was conducted to evaluate the impact of different soft tissue grafting techniques on peri-implant esthetics and stability. A total of 60 patients requiring soft tissue augmentation around single anterior maxillary implants were selected based on specific inclusion and exclusion criteria. The inclusion criteria consisted of systemically healthy individuals aged 20–50 years, non-smokers, and patients with adequate bone volume for implant placement. Patients with systemic conditions affecting wound healing, those with a history of periodontal disease, or individuals on long-term medications influencing soft tissue healing were excluded.

Grouping and Surgical Protocol

Patients were randomly allocated into three groups (n = 20 per group) based on the grafting technique used:

• Group A: Subepithelial Connective Tissue Graft (SCTG)
• Group B: Free Gingival Graft (FGG)
• Group C: Acellular Dermal Matrix (ADM)

All patients underwent implant placement using a standardized surgical protocol. After osseointegration, soft tissue augmentation was performed in the assigned groups. In Group A, SCTG was harvested from the palatal donor site and positioned in the peri-implant region using a tunnel technique. In Group B, FGG was obtained from the palatal mucosa and sutured in the recipient site. In Group C, a commercially available ADM was trimmed and placed over the peri-implant mucosa without the need for a donor site.

Clinical and Esthetic Evaluation

The primary outcome measures included peri-implant mucosal thickness (PMT), keratinized tissue width (KTW), and pink esthetic score (PES). These parameters were recorded at baseline, three months, and six months postoperatively.

Peri-implant mucosal thickness (PMT): Measured using a periodontal probe under local anesthesia.

Keratinized tissue width (KTW): Assessed by measuring the distance from the mucogingival junction to the gingival margin.

Pink Esthetic Score (PES): Evaluated using standardized digital photographs and assessed by two independent periodontists.

Statistical Analysis

All data were analyzed using SPSS software. Intragroup and intergroup comparisons were performed using repeated-measures ANOVA and post-hoc Bonferroni tests. A significance level of p < 0.05 was considered statistically significant.

Peri-implant Mucosal Thickness (PMT)

The peri-implant mucosal thickness (PMT) showed a significant increase in all three groups over time. At baseline, the mean PMT was 1.2 mm in Group A (SCTG), 1.3 mm in Group B (FGG), and 1.1 mm in Group C (ADM). At three months, Group A showed the highest increase to 2.1 mm, followed by Group B (1.8 mm) and Group C (1.6 mm). At six months, Group A maintained the highest PMT (2.5 mm), significantly higher than Group B (2.1 mm) and Group C (2.0 mm) (Table 1).

Keratinized Tissue Width (KTW)

The width of keratinized tissue (KTW) improved in all groups. At baseline, Group A had a mean KTW of 3.2 mm, Group B had 3.4 mm, and Group C had 3.1 mm. At three months, KTW increased to 4.5 mm in Group A, 4.8 mm in Group B, and 4.0 mm in Group C. By six months, the highest KTW was observed in Group B (5.1 mm), followed by Group A (5.0 mm) and Group C (3.8 mm) (Table 2).

Pink Esthetic Score (PES)

The pink esthetic score (PES) was assessed at all time points. Initially, Group A had a mean PES of 7.0, Group B had 6.8, and Group C had 6.5. After three months, PES increased to 9.5 in Group A, 9.0 in Group B, and 8.2 in Group C. At six months, the highest PES was recorded in Group A (11.2), followed by Group B (9.8) and Group C (9.2), indicating superior esthetic outcomes in the SCTG group (Table 3).

Table 1: Peri-implant Mucosal Thickness (PMT)

Table 2: Keratinized Tissue Width (KTW)

Table 3: Pink Esthetic Score (PES)

Soft tissue augmentation plays a pivotal role in optimizing peri-implant esthetics and stability, particularly in the anterior maxilla, where esthetic demands are high (1). This study compared three commonly used grafting techniques—subepithelial connective tissue graft (SCTG), free gingival graft (FGG), and acellular dermal matrix (ADM)—to determine their effectiveness in improving peri-implant soft tissue characteristics. The results demonstrated that SCTG was superior in increasing peri-implant mucosal thickness (PMT) and pink esthetic score (PES), while FGG provided the greatest enhancement in keratinized tissue width (KTW).

Peri-implant mucosal thickness is crucial for long-term implant success as it influences the stability of the soft tissue seal and reduces crestal bone loss (2). The findings of this study align with previous research indicating that SCTG results in the greatest improvement in PMT due to its ability to integrate well with surrounding tissues and promote enhanced vascularization (3,4). This supports studies by Thoma et al. (5) and Huber et al. (6), who reported that SCTG significantly increases mucosal thickness compared to other techniques. The improved PMT in the SCTG group is likely due to the high amount of connective tissue components, which enhance soft tissue volume and resilience (7).

The keratinized tissue width (KTW) is another critical factor affecting peri-implant health, as it provides a protective barrier against bacterial invasion and mechanical trauma (8). This study observed the greatest increase in KTW in the FGG group, consistent with findings by Lin et al. (9), who demonstrated that FGG is particularly effective in augmenting keratinized tissue due to its epithelial component. However, FGG has been associated with esthetic drawbacks, such as color mismatches and increased postoperative discomfort, which were also noted in this study (10). In contrast, ADM, while providing a moderate increase in KTW, offers the advantage of eliminating the need for a donor site, reducing patient morbidity (11).

The pink esthetic score (PES) is widely used to evaluate peri-implant esthetics by assessing soft tissue contours, color, and overall appearance (12). SCTG exhibited the highest PES improvement, which correlates with its superior ability to create a natural-looking soft tissue architecture (13). The study results are consistent with those of Fürhauser et al. (14), who found that SCTG produced the most esthetically pleasing results, particularly in cases requiring papillary enhancement. ADM, although less effective than SCTG, provided acceptable esthetic outcomes, making it a viable alternative when avoiding a second surgical site is a priority (15).

Despite the positive outcomes observed in all groups, certain limitations should be acknowledged. The follow-up period of six months may not be sufficient to evaluate long-term stability, as soft tissue remodeling continues beyond this timeframe. Additionally, patient-reported esthetic satisfaction was not assessed, which could provide valuable insights into the perceived success of each technique. Future studies should incorporate longer follow-up durations and patient-centered evaluations to enhance clinical recommendations.

In conclusion, SCTG proved to be the most effective technique for improving peri-implant mucosal thickness and esthetics, while FGG was superior for increasing keratinized tissue width. ADM, though less effective in comparison, remains a suitable option for patients seeking a minimally invasive approach. The choice of grafting technique should be based on clinical indications, patient preferences, and long-term stability considerations.

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