Soft tissue grafting to improve the attached mucosa at dental implants: A review of the literature and proposal of a decision tree

Background: Scientific data and clinical observations appear to indicate that an adequate width of attached mucosa may facilitate oral hygiene procedures thus preventing peri-implant inflammation and tissue breakdown (eg, biologic complications). Consequently, in order to avoid biologic complications and improve long-term prognosis, soft tissue conditions should be carefully evaluated when implant therapy is planned. At present the necessity and time-point for soft tissue grafting (eg, prior to or during implant placement or after healing) is still controversially discussed while clinical recommendations are vague. Objectives: To provide a review of the literature on the role of attached mucosa to maintain periimplant health, and to propose a decision tree which may help the clinician to select the appropriate surgical technique for increasing the width of attached mucosa. Results: The available data indicate that ideally, soft tissue conditions should be optimized by various grafting procedures either before or during implant placement or as part of stage-two surgery. In cases, where, despite insufficient peri-implant soft tissue condition (ie, lack of attached mucosa or movements caused by buccal frena), implants have been uncovered and/or loaded, or in cases where biologic complications are already present (eg, mucositis, peri-implantitis), the treatment appears to be more difficult and less predictable. Conclusion: Soft tissue grafting may be important to prevent peri-implant tissue breakdown and should be considered when dental implants are placed. The presented decision tree may help the clinician to select the appropriate grafting technique. Keywords: peri-implant keratinized attached mucosa, peri-implantitis, soft tissue recession