Title Soft Tissue Substitutes Reduce Post-Operative Morbidity Compared to Subepithelial Connective Tissue Grafts in Peri-Implant Soft Tissue Augmentation
Clinical Question In adults undergoing peri-implant soft tissue augmentation, does the use of soft tissue substitutes result in reduced post-operative morbidity compared to subepithelial connective tissue grafts?
Clinical Bottom Line For adults undergoing peri-implant soft tissue augmentation, soft tissue substitutes, including xenogeneic collagen matrices, acellular dermal matrix (ADM), and volume-stable collagen matrices, are associated with significantly reduced postoperative morbidity compared to subepithelial connective tissue grafts (SCTG). These benefits include less postoperative pain, shorter surgical time, and decreased need for analgesics, as demonstrated in recent systematic reviews and meta-analyses involving over 1,400 patients across multiple randomized controlled trials. By eliminating the need for a palatal donor site, soft tissue substitutes offer a less invasive and more comfortable treatment approach. While connective tissue grafts remain the benchmark for long-term stability, substitutes present a viable and evidence-based option in appropriately selected patients.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
39953082Yadav/2025Adult patients undergoing peri-implant soft tissue augmentation procedures across 29 clinical studies Systematic Review and Meta-Analysis
Key resultsThe study reported that patients who received soft tissue substitutes experienced significantly less postoperative discomfort compared to those treated with subepithelial connective tissue grafts. The reduction in pain was observed across both 0-100 and 0-10 visual analog scales (VAS), with mean differences of 14.91 VAS units (95% CI: 6.42-23.40; P < 0.0006) and 1.62 units (95% CI: 0.01-3.23; P = 0.05), respectively. Patients in the soft tissue substitute group used fewer analgesics (mean difference = 1.56 tablets; 95% CI: 1.22-1.91; P < 0.00001) and shorter procedure times (mean difference = 10.9 minutes; 95% CI: 4.60-17.19; P < 0.00001). These findings suggest that compared to autogenous grafts, soft tissue substitutes are associated with reduced postoperative pain, lower analgesic use, and shorter surgical times, making them a more comfortable and efficient option for peri-implant soft tissue augmentation.
36914299Afrashtehfar/2023911 patients in various randomized control trials (RCTs) of peri-implant soft tissue proceduresSystematic Review and Meta-Analysis
Key resultsThis systematic review and meta-analysis assessed patient-reported outcomes following peri-implant soft tissue augmentation using soft tissue substitutes versus subepithelial connective tissue grafts. Soft tissue substitutes were associated with significantly reduced postoperative pain, analgesic use, and surgical time. Specifically, pain perception favored substitutes on both the 0-100 VAS scale (n = 4; P < 0.001) and 0-10 scale (n = 4; P = 0.05), while analgesic consumption (n = 6; P < 0.001) and procedure duration (n = 5; P < 0.001) were also lower. Risk of bias among the included RCTs was mixed: 7 were low, 6 moderate, and 6 high. While evidence quality was rated moderate to low due to methodological concerns, results suggest soft tissue substitutes may improve postoperative morbidity compared to SCTGs.
31889581Lu/2020511 systemically healthy adult patients across 28 RCTsSystematic Review and Meta-Analysis
Key resultsThis systematic review analyzed 28 RCTs involving 511 adult patients and 750 soft tissue sites. Acellular dermal matrix (ADM) demonstrated comparable outcomes to subepithelial connective tissue grafts (CTG) in terms of soft tissue thickness and gingival recession coverage. However, CTG resulted in significantly greater long-term keratinized tissue width gain (mean difference =−0.86 mm; 95% CI: −1.54 to −0.17 mm; P = 0.01). ADM was associated with reduced postoperative morbidity, including less pain and discomfort, although patient-reported outcomes were inconsistently measured. The risk of bias varied across studies, with only 4 trials rated as low risk, and moderate to high heterogeneity was noted in several comparisons.
Evidence Search Database: PubMed Search Strategy: (“soft tissue substitute” OR “connective tissue graft” OR “collagen matrix” OR “acellular dermal matrix”) AND (“peri-implant” OR “dental implant”) AND (“pain” OR “morbidity” OR “postoperative discomfort” OR “healing complications” OR “surgical time” OR “analgesic use”)
Comments on
The Evidence		 The three systematic reviews evaluated offer useful insights but vary in the strength of their evidence. Lu et al. (2020) included 28 RCTs, though only a small number were considered low risk of bias, and many showed moderate to high variability, which affects how confidently the results can be applied. Afrashtehfar et al. (2023) summarized findings from a paper done by Thoma et al. (2022), which included 29 studies and focused on patient reported outcomes. While soft tissue substitutes showed benefits in terms of pain and recovery, the overall quality of evidence was rated as moderate to low due to inconsistencies in study design and risk of bias. Yadav et al. (2025) provided a commentary on the same Thoma (2022) review and emphasized the clinical relevance of soft tissue substitutes in enhancing patient comfort. Meta-analyses within that review showed significantly lower postoperative pain scores, decreased analgesic use, and reduced surgery time with soft tissue substitutes compared to autogenous grafts. However, Yadav et al. also noted methodological limitations in the systematic review, including substantial heterogeneity, missing demographic data, and the absence of publication bias assessment. The overall confidence in the review was rated as “critically low” using the AMSTAR-2 tool, and the certainty of the evidence was graded as “low” using GRADE. Despite these limitations, all three sources collectively support the potential of soft tissue substitutes as a less invasive alternative to autogenous grafts, particularly for improving patient-reported outcomes like pain, surgical experience, and satisfaction.
Applicability The evidence from the three systematic reviews is generally applicable to adult patients in need of peri-implant soft tissue augmentation, particularly those who are medically healthy and present with mucogingival deficiencies. Most subjects studied were adults with adequate oral hygiene and without significant systemic conditions, which aligns well with typical implant patients seen in general or specialty practice. The use of soft tissue substitutes such as acellular dermal matrix (ADM) or xenogeneic materials may be especially beneficial for patients who prefer to avoid donor site morbidity, experience dental anxiety, or have limited palatal tissue availability. These materials offer reduced postoperative discomfort, shorter surgical time, and potentially improved patients’ satisfaction, making them attractive alternatives to connective tissue grafts in appropriate cases. However, considerations such as higher material costs and limited long term data for some substitutes may limit their routine use. Overall, for patients where autogenous grafting is contraindicated or poorly tolerated, soft tissue substitutes represent a viable and patient-centered treatment option.
Specialty (General Dentistry) (Periodontics)
Keywords Peri-implant soft tissue, connective tissue graft, collagen matrix, surgical morbidity, pain, dental implants
ID# 3583
Date of submission 06/24/2025
E-mail sophie.hung3@gmail.com
Author Sophia Hung
Co-author(s) Alexandria I. Tan
Co-author(s) e-mail lexi.tan21@yahoo.com
Faculty mentor Kelly C. Lemke, DDS, MS
Faculty mentor e-mail LemkeK@uthscsa.edu
   
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
None available
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Comments and Evidence-Based Updates on the CAT
(FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs)
None available