An ageing population is increasingly associated with failing dentitions, whether due to disease or trauma, resulting in restorative cases of growing complexity. At the same time, patient expectations continue to rise, and for many, removable prostheses are no longer acceptable treatment options. Dental implants offer a predictable, long-term solution, with technological advances improving both functional and aesthetic outcomes. However, hard and soft tissue defects remain challenging considerations for clinicians. Implant success depends on adequate bone volume and favourable soft tissue architecture, and where these are lacking, augmentation becomes essential.
Recognising the need for augmentation
Following tooth loss, alveolar bone resorption and soft tissue changes are inevitable. Understanding the relationship between bone and gingival biotypes is critical for stability and aesthetics.[i] Augmentation is indicated in cases of reduced bone volume; however, soft tissue can present an even greater challenge. A thin gingival biotype, particularly in the aesthetic zone, can compromise contour, interdental papilla and emergence profile, ultimately influencing whether the final restoration appears natural.[ii] Successful implant dentistry therefore requires an integrated understanding of surgical technique, prosthetic design and tissue management.
Managing bone loss early
Even atraumatic extraction cannot prevent alveolar bone resorption, and resulting ridge deformities may compromise both function and aesthetics. Early intervention is therefore ideal. Placement of particulate bone graft material at the time of extraction helps maintain bone volume for future implant placement.[iii] However, many patients present later, often years after tooth loss, with established defects requiring more advanced augmentation strategies.
Rebuilding bone volume
Where defects already exist, guided bone regeneration (GBR) is widely used to restore adequate bone volume, with favourable long-term outcomes.[iv] The use of barrier membranes in conjunction with graft materials allows for controlled regeneration.
A range of biomaterials is available, each influencing healing, stability and clinical performance in different ways. Autogenous bone is preferred for its excellent osteogenic and biological integration properties. However, since this requires a donor site, patient discomfort and compliance are important considerations. Xenografts (derived from bovine sources) provide excellent structural support where additional volume is required. Allografts and synthetic materials offer predictable alternatives without additional surgical morbidity. Selection depends not only on defect morphology, but on how these materials behave during healing.
“Bone sets the tone, but tissue is the issue!”
Soft tissue management is critical for achieving pleasing aesthetic outcomes, particularly in anterior dental implant placement. The interface between peri-implant soft tissues and the implant restoration is essential for long-term stability and maintenance.[v] More recently this has been framed as the ‘peri-implant phenotype’, incorporating keratinised mucosa width, mucosal thickness and supracrestal tissue height, alongside underlying bone support.[vi] Together these factors influence tissue response to function, inflammation and long-term loading. Connective tissue thickness, collagen fibre orientation and vascularity around the implant influence how peri-implant tissues respond over time.
The role of keratinised mucosa remains debated; however, in practice, sites lacking adequate keratinised tissue (below 2mm) tend to present with increased recession, inflammation and reduced plaque control.[vii] Clinically, this translates to patient discomfort and more challenging maintenance, particularly in patients with suboptimal oral hygiene. Connective tissue grafts (CTG) typically harvested from the palate, remain the gold standard for increasing soft tissue thickness and keratinised mucosa.[viii] Their predictability lies in reliable vascular integration.[ix] However, this comes at the cost of donor site morbidity, scarring and colour differences, and limited tissue availability.[x]
Soft tissue substitutes, including collagen matrices and acellular dermal matrices, have been developed to reduce these limitations. These materials eliminate the need for a second surgical site and improve patient experience, with studies demonstrating comparable short-term gains in tissue thickness and keratinised mucosa.[xi] However, their long-term stability remains less favourable in comparison to autogenous grafts, particularly in high-demand aesthetic cases.
In the aesthetic ‘pink zone’, success depends on more than volume alone. Emergence profile, papilla preservation and harmonious gingival contours play a critical role in achieving a natural-looking result, particularly in patients with a high smile line. Tissue conditioning using carefully designed provisional prostheses and abutment design can help guide soft tissue healing for a more natural aesthetic integration.
From theory to clinical confidence
Given the range of techniques and materials available, clinicians must develop a thorough understanding of both biological principles and surgical application.[xii] The PG Diploma in Advanced Augmentation Techniques in Implant Dentistry from One to One Implant Education reflects this need. Delivered within an internationally recognised training centre, the programme combines theoretical foundations with practical surgical training, including GBR, soft tissue augmentation and advanced grafting techniques. A strong emphasis is placed on biomaterial selection, treatment planning and complication management, supported by ongoing mentorship to help clinicians translate learning into confident clinical practice.
Tissue augmentation is not simply technical; it is material dependent. Understanding how different grafts behave is central to achieving stable, predictable results, since implant success ultimately depends on not only how augmentation is performed, but on the biological environment those materials create.
To reserve your place or to find out more, please visit
https://121implanteducation.co.uk or call 020 7486 0000.
Author: Dr Fazeela Khan-Osborne is the founding clinician of the FACE dental implant multi-disciplinary team for the One To One Dental Clinic, London
[i] Sun TC, Chang TK. Soft tissue management around dental implant in esthetic zone–the current concepts and novel techniques. Journal of dental sciences. 2024 Jul 1;19(3):1348-58.
[ii] Tavelli L, Barootchi S, Avila-Ortiz G, Urban IA, Giannobile WV, Wang HL. Peri-implant soft tissue phenotype modification and its impact on peri-implant health: A systematic review and network meta-analysis. J Periodontol. 2021;92:21–44. https://doi.org/10.1002/JPER.19-0716
[iii] Chisci, G., Hatia, A., Chisci, E., Chisci, D., Gennaro, P., & Gabriele, G. (2023). Socket Preservation after Tooth Extraction: Particulate Autologous Bone vs. Deproteinized Bovine Bone. Bioengineering (Basel, Switzerland), 10(4), 421. https://doi.org/10.3390/bioengineering10040421
[iv] Buser, D., Urban, I., Monje, A., Kunrath, M.F. and Dahlin, C., 2023. Guided bone regeneration in implant dentistry: Basic principle, progress over 35 years, and recent research activities. Periodontology 2000, 93(1), pp.9-25.
[v] Fickl, S., Therese Kröger, A., Dietrich, T., & Kebschull, M. (2021). Influence of soft tissue augmentation procedures around dental implants on marginal bone level changes—A systematic review. Clinical Oral Implants Research, 32, 108–137. https://doi.org/10.1111/clr.13829
[vi] Wang I-C(I), Barootchi S, Tavelli L, Wang H-L. The peri-implant phenotype and implant esthetic complications. Contemporary overview. J Esthet Restor Dent. 2021;33:212–223. https://doi.org/10.1111/jerd.12709
[vii] Giannobile WV, Jung RE, Schwarz F; on behalf of the Groups of the 2nd Osteology Foundation Consensus Meeting. Evidence-based knowledge on the aesthetics and maintenance of peri-implant soft tissues: Osteology Foundation Consensus Report Part 1—Effects of Soft Tissue Augmentation Procedures on the Maintenance of Peri-implant Soft Tissue Health. Clin Oral Impl Res. 2018;29(Suppl. 15):7–10. https://doi.org/10.1111/clr.13110
[viii] Ashurko, I., Tarasenko, S., Magdalyanova, M., Bokareva, S., Balyasin, M., Galyas, A., Khamidova, M., Zhornik, M., & Unkovskiy, A. (2023). Comparative analysis of xenogeneic collagen matrix and autogenous subepithelial connective tissue graft to increase soft tissue volume around dental implants: a systematic review and meta-analysis. BMC oral health, 23(1), 741. https://doi.org/10.1186/s12903-023-03475-0
[ix] Parthasarathy, H., Ramachandran, L., Tadepalli, A. and Ponnaiyan, D., 2017. Staged hard and soft tissue reconstruction followed by implant supported restoration in the aesthetic zone: a case report. Journal of clinical and diagnostic research: JCDR, 11(4), p.ZD06.
[x] Mounssif, I., Bentivogli, V., Rendón, A., Mazzotti, C., De Rubertis, I., Zucchelli, G., & Stefanini, M. (2025). Peri-Implant Soft Tissue Augmentation with Connective Tissue Graft Substitutes. Applied Sciences, 15(18), 10178. https://doi.org/10.3390/app151810178
[xi] Wessing, B., & Boekema, B. (2025). Soft-Tissue Volume Augmentation at Dental Implant Placement Using Collagen-Based Matrix Characterized by Oriented Open Pore Structure: A Retrospective Study with a Median Follow-Up of 17 Months. Bioengineering (Basel, Switzerland), 12(12), 1324. https://doi.org/10.3390/bioengineering12121324
[xii] Bassetti, R.G., Stähli, A., Bassetti, M.A. and Sculean, A., 2016. Soft tissue augmentation procedures at second-stage surgery: a systematic review. Clinical oral investigations, 20(7), pp.1369-1387.
