J Clin Periodontol 2016; 43: 609–617 doi: 10.1111/jcpe.

12547

Soft tissue volume alterations Christian M. Schmitt1, Ragai E.

Matta2, Tobias Moest1, Julia
Humann1, Lisa Gammel1, Friedrich

after connective tissue grafting W. Neukam1 and Karl A. Schlegel1

1
Department of Oral and Maxillofacial

at teeth: the subepithelial

Surgery, University of Erlangen-Nuremberg,
Erlangen, Germany; 2Department of
Prosthodontics, University of Erlangen-
Nuremberg, Erlangen, Germany

autologous connective tissue

graft versus a porcine collagen
matrix – a pre-clinical volumetric
analysis
Schmitt CM, Matta RE, Moest T, Humann J, Gammel L, Neukam FW, Schlegel KA.
Soft tissue volume alterations after connective tissue grafting at teeth: the subepithelial
autologous connective tissue graft versus a porcine collagen matrix – a pre-clinical
volumetric analysis. J Clin Periodontol 2016; 43: 609–617. doi: 10.1111/jcpe.12547.

Abstract
Aim: This study evaluates a porcine collagen matrix (CM) for soft tissue thicken-
ing in comparison to the subepithelial connective tissue graft (SCTG).
Material and Methods: In eight beagle dogs, soft tissue thickening was performed
at the buccal aspects of the upper canines (SCTG and CM). Impressions were
taken before augmentation (i1), after surgery (i2), after one (i3), three (i4) and ten
month (i5). Casts were optically scanned with a 3D scanner and each augmented
region (unit of analysis) evaluated (primary outcome variable: volume increase in
mm3; secondary outcome variables: volume increase in percent, mean and maxi-
mum thickness increases in mm).
Results: 3D tissue measurements after surgery revealed a significant higher vol-
ume increase in the CM (86.37 mm3  35.16 mm3) than in the SCTG group Key words: CAD CAM; collagen matrix;
(47.65 mm3  17.90 mm3). After 10 months, volume increase was non-significant collagen-based matrix; dental implants;
between groups (SCTG:11.36 mm3  9.26 mm3; CM: 8.67 mm3  13.67 mm3). gingiva thickening; gingival biotype;
mucodermâ; porcine collagen matrix; soft
Maximum soft tissue thickness increase (i1-i5) was 0.66 mm  0.29 mm (SCTG)
tissue augmentation; soft tissue volume;
and 0.79 mm  0.37 mm (CM) with no significant difference. subepithelial connective tissue graft;
Conclusions: Ten months after soft tissue thickening, the CM is statistically non- volumetric measurement
inferior to the SCTG in terms of soft tissue volume and thickness increase.
Further 3D studies are needed to confirm the data. Accepted for publication 11 March 2016

Conflict of interest and source of funding statement

The authors declare no conflicts of interest related to this study. This study was supported by a grant from botiss biomaterials
GmbH, Zossen, Germany.

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 609
610 Schmitt et al.
Soft tissue volume augmentation
procedures have been proposed to
surgically correct localized alveolar
defects as pre-prosthetic site develop-
ment or ridge preservation proce-
dures, and have been used for soft
tissue contouring around implants
(Studer et al. 2000, Jung et al. 2004,
Schneider et al. 2011, Vignoletti
et al. 2014, Akcali et al. 2015).
Subepithelial connective tissue grafts
(SCTG) are currently the gold stan-
dard of care for soft tissue volume
augmentation procedures (Sanz &
Simion 2014, Thoma et al. 2014,
Zuhr et al. 2014).
As alternative to SCTGs, xeno-
geneic soft tissue substitutes such as
porcine-derived 3D collagen-based
matrices are currently in the focus,
with the intention to avoid postoper-
ative patient morbidities and risks
associated with autologous tissue
grafting (Sanz et al. 2009, Ghanaati
et al. 2011, Schmitt et al. 2013,
Nocini et al. 2014). Originally, such
collagen matrices were introduced to
promote keratinized tissue regenera-
tion and in the further course subse-
quently used for root coverage
procedures (Sanz et al. 2009, Her-
ford et al. 2010, McGuire & Scheyer
2010, Nevins et al. 2011, Zuhr et al.
2014). Due to its potential to
increase the gingival thickness in
terms of recession coverage, further
research focused on its use as SCTG
substitute for soft tissue volume aug-
mentations (Thoma et al. 2010,
2011). To our knowledge the study
of Thoma et al. (2010) is currently
the only study that has examined
volume alterations after soft tissue
augmentation with a 3D collagen
matrix (CM) compared to the SCTG
with a three-dimensional measuring
method (Thoma et al. 2010). Volu-
metric outcomes revealed statistically
non-significant thickness and volume
increases in the augmented regions
after 84 days, indicating that the
CM might be suitable as alternative
to the SCTG to augment localized
alveolar ridge defects (Thoma et al.
2010). Long-term volumetric pre-
clinical and clinical data with the use
of 3D collagen matrices for soft tis-
sue thickening does not exist in the
literature.
Therefore, in clinical practice,
autologous tissues are mainly used
for soft tissue volume augmentations
today (Thoma et al. 2014, Zuhr
et al. 2014, Akcali et al. 2015). The
usage of collagen matrices as alter-
native cannot be recommended at
this time point due to the lacking
evidence about the volume loss that
occurs during integration and degra-
dation and the uncertainty of the
volumetric long-term stability of
augmented soft tissues (Thoma et al.
2014).
The aim of this study was to test
whether or not soft tissue augmenta-
tion with a native porcine CM leads
to a soft tissue volume and thickness
increase around teeth similar to out-
comes obtained by the SCTG. The
soft tissue volume augmentation was
simulated by thickening attached
peridental soft tissues in a pre-clini-
cal dog model including a clinical
three-dimensional and morphologic
follow-up of 10 months. This partic-
ular model was chosen to eliminate
tissue changes of the surrounding
hard and/or soft tissues, that may
have be arisen in terms of edentulous
ridges (Thoma et al. 2010, 2011), the
presence of dental implants or gingi-
val recessions around teeth. It is
hypothesized, that volumetric tissue
changes are solely attributed to the
soft tissue augmentation procedure
and will not be masked by further
influencing factors.
Material and Methods
Study design
The present paper reports on a pre-
clinical animal study with a follow-
up of 10 months (May 2014–January
2015) including eight healthy beagle
dogs in a split-mouth design. The
aim of the current research was to
evaluate the natural porcine 3D col-
lagen matrix (CM, mucodermÒ,
botiss biomaterials GmbH, Zossen,
Germany) for soft tissue thickening
in a dog model and compare it to
the current gold standard of care,
the SCTG. Each animal received an
autologous SCTG (control group)
from the palate and a CM (test
group) in a randomized split-mouth
allocation. The sample size consider-
ation was based on the increase in
the gingival thickness (mm) after
10 months. An equivalence test of
means using two groups of eight
augmented sites (total 16 augmented
sites, eight animals) achieved a
power of 0.91 at a significance level
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
a of 0.05 when the means are truly
equivalent. Gingival thickness
increase was assumed to be
1.00 mm  0.3 mm and the equiva-
lence margin was set to be 0.5 mm.
The study was approved by the
Pest county government department
for food safety and animal health,
Hungary, number 54-2532.1-45/12.
The manuscript was prepared in
accordance to the Animal Research:
Reporting In Vivo Experiments
(ARRIVE) Guidelines Checklist
(Kilkenny et al. 2010).
Outcome variables
Primary outcome variable
The primary outcome variable was
the Integrated Distance (volume
increase in mm3) in the region of
interest (ROI).
Secondary outcome variables
The secondary outcome variables
were the Integrated Distance in %
(postoperative Integrated Distance
defined as 100%), the Maximum
Distance (mm) and the Mean Dis-
tance (mm) in the ROI.
The Maximum Distance describes
the maximum deviation (mm) of the
surface comparison of two objects.
The Mean Distance describes the
arithmetic mean deviation (mm) of
all points of the surface comparison
of two objects.
Sedation, anaesthesia and animal care
Eight healthy female beagle dogs, at
the age of at least 12–18 months,
were selected by a veterinarian prior
to study start from a local animal
breeder. After a 1-month period of
acclimatization animals were exam-
ined and judged as healthy by the
veterinarian and included in the
study. Prior to the study start all
animals received a transponder
(AlvicÒ complete Alvetra GmbH,
Neum€ unster, Germany) to guarantee
a clear allocation of the animals to
the experimental protocol. All surg-
eries were performed under general
anaesthesia. Pre-treatment sedation
(midazolam 0.05–0.1 mg/kg and
ketanest 1–2 mg/kg intramuscularly)
was given 10–15 min. prior to
administration of the general anaes-
thesia. The animals were anaes-
thetized with thiopental sodium
(20 mg/kg body weight). Inhalation
 Porcine CM versus SCTG for gingiva augmentation 611

was performed with oxygen, nitrous of the buccal soft tissues tunnelled in sion was made from P1 to P4 and a
oxide and isoflurane (1.5–2.0% a mesiodistal direction with a split- subepithelial split-flap sharply dis-
isoflurane in 2 l/min. flow of oxy- flap. The resulting tunnel was either sected towards the midline of the
gen). After surgery animals received augmented with a SCTG from the palate. The SCTG was harvested
post-surgical antibiotics (Strepto- palate or the CM (after rehydrating with the periosteum and the wound
mycin 0.5 g/day, Gr€unenthal GmbH, with sterile saline solution) (Fig. 1). bed immediately treated with local
Stolberg, Germany) for 3 days. The graft size was standardized: haemostatic measures such as elec-
Immediately after surgery animals 20 mmx 10 mmx 1.2–1.7 mm in the trocoagulation and suturing with
were monitored and kept warm until CM group prior rehydrating (thick- resorbable sutures (Vicryl 5.0, Ethi-
full recovery. Post-surgical care ness ranging from 1.2 to 1.7 mm as con GmbH & Co KG, Norderstedt,
included daily observations docu- it is commercially available) and Germany).
menting any adverse events, i.e. 20mmx 10mmx 1.5–2 mm in the After surgery, an additional
bleedings, pain, swelling, discomfort SCTG group. The mesial vertical impression (i2) was taken in the
and appetite. incision was sutured with resorbable ROI. Follow-up measures were per-
At each of the further investiga- sutures (Vicryl 5.0, Ethicon GmbH formed 1, 3 and 10 months after sur-
tion time points (one, three and & Co KG, Norderstedt, Germany). gery. The augmented region was
10 months) animals were sedated The SCTG was harvested from clinically examined detecting any
with midazolam 0.05–0.1 mg/kg and the palate. After local anaesthesia of kind of wound healing complica-
ketanest 1–2 mg/kg intramuscularly. the palate in the region of the tions. At all the time points, impres-
canine, mandibular premolars (P1– sions (i3, 1 month; i4, 3 months and
Surgical procedure and follow-up
P4) and the first molar, a para- i5, 10 months) were taken as previ-
marginal palatal subepithelial inci- ously described.
Impressions and assessments prior
surgeries as well as the surgeries
were performed by the first and the
last author (CMS: surgeon, KAS:
surgical assistance). Follow-up treat-
ments and measurements were per-
formed by the co-authors (blinded
examiners). Surgeons and examiners
were calibrated prior start of the
corresponding procedure.
After general anaesthesia an
impression (i1) was taken with a
polyether impression material
A B
(ImpregumTM PentaTM Polyether
Impression Material, 3M Deutsch-
land GmbH, Neuss, Germany) and a
prefabricated impression tray.
Soft tissue thickness of the kera-
tinized mucosa was clinically mea-
sured with the bone mapping
method (transgingival probing of
gingival thickness) at the buccal
aspect of each canine (Wilson 1989).
This was standardized performed C D
2 mm below the most coronal extend
of the keratinized mucosa and 2 mm
coronal to the mucogingival junction
in the central longitudinal axis of the
canine with a thin gauge. Measure-
ments in whole millimetres were
recorded. Each of the two treatments
(CM and SCTG) were then ran-
domly assigned to either the right or
left upper canine by simple random-
ization flipping a coin. After local E F
anaesthesia (UltracainÒ DS forte;
Fig. 1. Exemplary pictures of the augmentation procedure with the use the collagen
adrenaline 1:100,000; Sanofi-Aventis matrix (CM) for peridental soft tissue thickening in the region of the upper canine.
GmbH, Frankfurt, Germany) at the After a mesial submucosal vertical incision, the soft tissues were tunnelled in a distal
buccal aspect of the canine, a mesial direction with a microsurgical blade (A and B), the CM inserted (C) and the wound
vertical subepithelial incision was sutured with resorbable sutures (D). (E) showing the clinical situation of a grafted site
performed and the keratinized part with the use of the CM after 1 month and (F) after 10 months.

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
612 Schmitt et al.
Three-dimensional measurements
For three-dimensional volume mea-
surements, impressions were poured
out with a scannable Super Hard
Plaster (GC Fujirock EP OptiXscan,
GC EUROPE N.V., Leuvena, Bel-
gium) especially developed for sensi-
tive CAD/CAM technology.
Dental models were optically
scanned with an industrial scanner
(ATOS II SO4, Gom mbH, Braun-
schweig, Germany). The ATOS Pro-
fessional software (Gom mbH) was
used to match the virtual models in
one coordinate system. Adjacent
teeth were then used to superimpose
the three-dimensional data of two
virtual dental models. A ROI was
individually selected for each aug-
mented site. The augmented region
was detected by matching the base-
line model (i1) with the one obtained
directly after surgery (i2). By this
procedure, we were able to define
the margins of each graft and pre-
cisely set the ROIs in the augmented
regions (individually for each aug-
mented site). The set ROIs were
standardized used for all further fol-
low-up measurements of the corre-
sponding sites by comparing the
virtual models of the different time
points with the baseline situation (i1-
i2, i1-i3, i1-i4 and i1-i5) (Fig. 2). The
following data were measured and
recorded: (1) The Integrated Dis-
tance (volume increase in mm3), (2)
The Maximum Distance (mm) and
(3) The Mean Distance (mm).
Statistical analyses
Results were entered into Excel 2013
(Microsoft Corp., Redmond, WA,
USA). Data were analysed with
SPSS version 22.0 for Windows
(SPSS Inc., Chicago, IL, USA).
Descriptive statistics included the
frequency (absolute and relative
abundances, %), arithmetic mean,
median and standard deviation.
Clinical measurements at baseline
(transgingival probing of gingival
thickness) were statistically evaluated
as follows: The mean thickness of the
keratinized mucosa (mm) was calcu-
lated for each region (canine). Result-
ing mean values for the groups were
statistically compared with a non-
parametric Mann–Whitney U-test to
detect statistically significant differ-
ences at baseline, defined as p < 0.05.
A B
C D
Fig. 2. Exemplary case showing the soft tissue volume alterations over time after peri-
dental soft tissue thickening in the region of the upper canine with the collagen matrix.
A (i1-i2): Comparing the baseline situation (i1) with the situation directly after surgery
(i2); B (i1-i3): Comparing the baseline situation (i1) with the situation 1 month after
surgery (i3); C (i1-i4): Comparing the baseline situation (i1) with the situation
3 months after surgery (i4); D (i1-i5): Comparing the baseline (i1) with the situation
10 months after surgery (i5). The thickness differences in the soft tissues (mm) are dis-
played on the coloured scale at the bottom of the figure. Blue areas represent a
decrease in thickness, green areas a comparable thickness and yellow and red areas an
increase in thickness.
The three-dimensional measure- period in both groups (Fig. 1). The
ments were statistically evaluated as CM showed excellent clinical tissue
follows: The mean Integrated Dis- integration. In total n = 8 aug-
tance (mm3), the mean Maximum mented regions were available for
Distance and the mean Mean Dis- evaluation per group. Baseline mea-
tance (mm) were compared within surements of the gingiva thickness
the group over time and between the (mm) in the ROI revealed no statisti-
groups at different examination time cally significant differences in inter-
points. Data of the Integrated Dis- group comparison (SCTG group:
tance were additionally expressed as 1.63 mm  0.6 mm; CM group
percentages relative to the immediate 1.56 mm  0.61 mm, p = 0.20).
postoperative measurement (defined
as 100%) to calculate percentage Three-dimensional measurements
volume changes over time. For inter-
group comparisons, we separately Outcomes of three-dimensional mea-
used a non-parametric Man–Whit- surements are displayed in Table 1
ney U-test at each examination time and Figs 2–6. Statistical analyses
point to determine statistical signifi- revealed statistically significant dif-
cance, defined as p < 0.05. For intra- ferences in the mean Integrated Dis-
group comparisons a non-parametric tance (mm3) (SCTG: 47.65 mm3 
Wilcoxon signed rank test was used, 17.90 mm3; CM: 86.37 mm3  35.16
with a significance level of p < 0.05. mm3, p = 0.038), the mean Maxi-
mum Distance (mm) (SCTG: 1.57
mm  0.28 mm; CM: 2.0 mm 
Results 0.22 mm, p = 0.005) and the mean
Mean Distance (mm) (SCTG:
Clinical outcomes
0.65 mm  0.26 mm; CM: 0.96 mm
There was no wound healing compli-  0.22 mm, p = 0.028) comparing
cation observed in the whole study the SCTG and the CM group
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Porcine CM versus SCTG for gingiva augmentation 613

Table 1. Showing the outcomes of the three-dimensional analyses for the control (subepithelial connective tissue graft; SCTG) and the test
group (collagen matrix; CM). Mean, median and standard deviation (SD) is given for each parameter
Outcomes of three-dimensional measurements comparing the situation directly after surgery (i2),
1 month after surgery (i3), 3 month after surgery (i4) and 10 month after surgery (i5) with the
situation prior surgery (i1)

i1-i2 i1-i3 i1-i4 i1-i5

Mean Median SD Mean Median SD Mean Median SD Mean Median SD

SCTG Integrated Distance (mm3) 47.65 48.61 17.90 25.12 21.16 23.36 7.64 6.60 8.56 11.36 13.03 9.26
Integrated Distance % 100.00 100.00 .00 45.27 44.06 32.06 28.40 21.10 36.49 27.08 29.74 18.75
Maximum Distance (mm) 1.57 1.54 0.28 1.05 0.91 0.48 0.70 0.67 0.42 0.66 0.67 0.29
Mean Distance (mm) 0.65 0.56 0.26 0.37 0.24 0.37 0.05 0.05 0.25 0.13 0.19 0.26
CM Integrated Distance (mm3) 86.37 90.32 35.16 15.15 12.38 13.83 5.57 1.93 7.79 8.67 0.74 13.67
Integrated Distance % 100.00 100.00 0.00 16.99 12.82 13.98 9.47 2.68 11.80 11.33 0.57 17.10
Maximum Distance (mm) 2.00 2.01 0.22 1.12 0.90 0.91 0.65 0.60 0.47 0.79 0.88 0.37
Mean Distance (mm) 0.96 0.98 0.22 0.20 0.18 0.19 0.04 0.02 0.14 0.01 0.01 0.26

directly after soft tissue thickening
(i1-i2) (Table 1, Figs 3, 5 and 6).
Further inter-group comparisons
were statistically non-significant at
all investigation time points and for
all measured parameters (Table 1,
Figs 3–6). The mean Integrated Dis-
tance (augmented tissue volume;
mm3 and %) and the mean Maxi-
mum and mean Mean Distances
(mm) decreased in both groups over
time. The highest volume and thick-
ness decrease occurred in the early
phase of healing (first month follow-
ing surgery, i1-i3). This resulted in a
mean Integrated Distance of
25.12 mm3  23.36 mm3 in the
SCTG group and 15.15 mm3 
13.83 mm3 in the CM group after
1 month (i1-i3) with a statistically
significant decrease in both groups
(intra-group comparisons of i1-i2
with i1-i3, SCTG: p = 0.018; CM:
0.012). From the first (i1-i3) to the
third month (i1-i4), the soft tissue
decrease was lower and afterwards
relatively stable up to 10 months (i1-
i5). The mean Integrated Distances
after 3 months (i1-i4) were
7.64 mm3  8.56 mm3 (SCTG) and
5.57 mm3  7.79 mm3 (CM). Intra-
group comparisons revealed a statis-
tically significant decrease between
the 1 month (i1-i3) and the 3 months
(i1-i4) evaluation time points in both
groups (SCTG: p = 0.043; CM:
0.043) (Fig. 3). After 10 months (i1-
i5) the mean Integrated Distance was
11.36 mm3  9.26 mm3 in the SCTG
and 8.67 mm3  13.67 mm3 in the
CM group. Maximum soft tissue
thickness increase after 10 months
(i1-i5) was 0.66 mm  0.29 mm
(SCTG) and 0.79 mm  0.37 mm
(CM) with no significant inter-group
difference (i1-i5).

Discussion
This study aimed to evaluate a por-
cine CM for soft tissue thickening in
a dog model. With a three-dimen-
sional measuring method, the vol-
ume and thickness alterations of the
augmented soft tissues could be mea-
sured and directly compared to the
soft tissues augmented with the
autologous SCTG. The volume gain,
achieved directly after surgery, was
significantly higher (86.37 mm3 
35.16 mm3) in the CM group than in
the SCTG group (47.65 mm3 
17.90 mm3). This was also reflected
in the thickness of the grafted soft
tissues with a mean maximum thick-
ness increase of 2.00 mm  0.22 mm
for the CM and 1.57 mm 
0.28 mm for the SCTG (significant
difference p = 0.005). The integra-
tion of both grafts was associated
Fig. 3. Showing the primary outcome of the study, the mean Integrated Distance with a high degree of shrinkage
(mm3) in the augmented region over time for the test (CM) and control group (especially in the first month). After
(SCTG). Statistical significant differences are given for inter- and intra-group compar- 3 months, soft tissue dimensions
isons (p < 0.05). were stable in both groups, resulting
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
614 Schmitt et al.
Fig. 4. Showing the secondary outcome of the study, mean Integrated Distance in per-
cent (%) in the augmented region over time for the test (CM) and control group
(SCTG). Statistical significant differences are given for inter- and intra-group compar-
isons (p < 0.05).
Fig. 5. Showing the secondary outcome of the study, the Mean Distance in mm in the
augmented region over time for the test (CM) and control group (SCTG). Statistical
significant differences are given for inter- and intra-group comparisons (p < 0.05).
in a mean maximum thickness gain
of 0.66 mm  0.29 mm for the
SCTG and 0.79 mm  0.37 mm for
the CM after 10 months with no sta-
tistically significant difference.
The animal model used in this
study is a widely used model in den-
tal research. It has especially been
used in numerous publications to
simulate treatment modalities for
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
hard and/or soft tissue augmenta-
tions as well as the osseointegration
of dental implants (Persson et al.
2001, Berglundh et al. 2003, Schwarz
et al. 2014, Sculean et al. 2015). The
canine animal model has shown a
good ability to detect subtile differ-
ences between different hard and/or
soft tissue augmentation procedures
and grafts (Rothamel et al. 2007,
Thoma et al. 2010, 2011).
Soft tissue thickening can clini-
cally be indicated in combination
with root coverage procedures, as
pre-prosthetic site development or in
the context of implant therapy as
implant site preservation and/or soft
tissue contour augmentation
(McGuire & Scheyer 2010, Aroca
et al. 2013, Jepsen et al. 2013, Mol-
nar et al. 2013, Akcali et al. 2015).
In this study, attached peridental
soft tissues were augmented to simu-
late a mucosal soft tissue volume
augmentation procedure. This setup
was not implemented to create a
specific clinical treatment scenario. It
was rather considered to be the most
accurate one to exclude further tis-
sue alterations of the surrounding
tissues that can modulate the total
volume change in the ROI and mask
the actual effect of the soft tissue
augmentation procedure. This espe-
cially refers to edentulous ridges
were an augmentation procedure of
the soft tissues can lead to a hard
tissue thickness increase as shown in
the study by Thoma et al. (2011).
The soft tissue volume augmentation
of chronic alveolar ridge defects with
a collagen-based matrix resulted in
new bone and connective tissue for-
mation. The subperiosteal placed
CM must have interacted with the
underlying bone (Thoma et al.
2011). In our study, we assume that
the epiperiosteal and submucosal
placement of the grafts around teeth
did neither lead to a bone increase
nor a bone decrease, and the volume
alterations are solely attributed to
the soft tissue changes.
This study had a randomized
split mouth design. This design elim-
inated the influence of inter-indivi-
dual differences between the test
animals. In addition, the applied
standardized surgical procedure and
the randomized placement of the
grafts ensured the greatest possible
comparability between the experi-
mental groups. No healing complica-
 Porcine CM versus SCTG for gingiva augmentation
Fig. 6. Showing the secondary outcome of the study, the mean Maximum Distance
(mm) in the augmented region over time for the test (CM) and control group (SCTG).
Statistical significant differences are given for inter- and intra-group comparisons
(p < 0.05).
tion occurred in the entire study per- simply resorbed when used for soft
iod in both groups, showing a suffi- tissue thickening. Results of this
cient tissue integration of the used study show, however, that this does
CM. This is consistent with out- not seem to be the case. After the
comes of other studies also indicat- degradation process, some tissue
ing a sufficient integration process of gain was encountered which was
collagen matrixes used for soft tissue stable after 3 months and resulted in
thickening, root coverage procedures a mean maximum soft tissue thick-
and for the regeneration of kera- ness increase of 0.66 mm  0.29 mm
tinized mucosa (McGuire & Scheyer in the SCTG and
2010, Thoma et al. 2010, 2011, Sch- 0.79 mm  0.37 mm in the CM
lee et al. 2014, Schmitt et al. 2015). group with no significant inter-group
Concerning the CM used in this difference. Interestingly, also the vol-
study, Rothamel et al. 2014 have ume dimensions of the used SCTGs
already demonstrated in their rat decreased significantly during the
model, that the matrix shows a fast healing process. Concerning the
tissue integration and vascularization thickness increase as outcome vari-
with almost no signs of ingrowing able after soft tissue grafting with
inflammatory cells and a resorption SCTGs, data of our study are in
time of approximately 8–12 weeks. accordance to data published by
In most of the studies investigat- other working groups (Schneider
ing the degradation and integration et al. 2011, Akcali et al. 2015).
mode of such biomaterials, authors Akcali et al. 2015 reported of a soft
conclude that after total degradation tissue thickness increase after graft-
the matrix is replaced by newly ing with a free SCTG of edentulous
formed connective tissue. However, ridges of (median, range) 1 mm,
the real amount of connective tissue 0.37–1.45 measured directly after
that can be encountered after graft- soft tissue augmentation and
ing was not measured in most of the 0.63 mm, 0.28–1.22 after 6 months
studies. The degradation obviously of healing. The vascularized inter-
leads to a significant amount of vol- positional periosteal-connective tis-
ume loss as demonstrated by the sue graft showed significant higher
outcomes of this study. The question thickness increases than the free
arises, whether the entire matrix is SCTG (1.21 mm, 0.74–2.47 (after
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
615
augmentation); 1.18 mm, 0.16–1.75
(after 6 month)). It was speculated
that this might have been attributed
to the better perfusion of the pedicu-
lated graft (Akcali et al. 2015). Also
Schneider et al. 2011 three-dimen-
sionally measured volumetric
changes after hard tissue grafting in
the context of implant placement
and soft tissue grafting 6 month
later with the free SCTG in the aes-
thetic zone (Schneider et al. 2011).
The mean increase in 1 month after
soft tissue grafting was
+0.55 mm  0.53 mm (range: 0.09
to +1.74 mm), which is comparable
to outcomes of our study with a
mean maximum soft tissue thickness
increase of 1.05 mm  0.48 after
1 month. Augmented tissues in the
study by Schneider et al. were rela-
tively stable over time and showed
only a mean loss of the facial promi-
nence within the first year after
crown insertion of 0.04  0.31 mm
(range: 0.57 to +0.56 mm). Impor-
tantly, they observed large inter-indi-
vidual variations regarding the tissue
alterations after grafting (Schneider
et al. 2011) and it has to be consid-
ered, that tissue alterations measured
in this study are due to hard and
soft tissue contour augmentation
procedures and do not exclusively
reflect the soft tissue volume
increases. In summary, outcomes of
this study can hardly be compared
to the outcomes of our study.
In terms of the used CM as pro-
claimed alternative to the autologous
SCTG, only one study investigated
soft tissue changes with the use of a
matrix made of porcine collagen in
an animal model. Only slight volu-
metric decreases were observed in a
follow-up period of 84 days. The
soft tissue gain of 1.4 mm  1.1 mm
for the CM and 1.4 mm  0.4 mm
for the SCTG were statistically sig-
nificant different compared to the
control without grafting with a loss
of 0.3 mm  0.3 mm (Thoma et al.
2010). Results indicate much higher
tissue volume increases than mea-
sured in our study. However, we
know from the histological outcomes
of the augmented regions published
in another paper by Thoma et al.
(2011), that the thickness increase in
the augmented region was not solely
attributed to the increase in the soft
tissue thickness, but also the forma-
tion of new bone. We speculate that
616 Schmitt et al.
the total tissue thickness increases
measured in our study were solely
attributed to the soft tissue volume
increase achieved by the soft tissue
thickening procedure. This knowl-
edge can be helpful in clinical prac-
tice, and make outcomes of soft
tissue thickening procedures more
predictable.
Some limitations exist with
respect to the present animal study.
First of all, a relatively small number
of animals were treated. This may
have influenced the outcome of the
statistical comparisons between the
groups. In addition, the used grafts
(SCTG and the CM) were not of the
same size after rehydrating the CM,
leading to significant greater graft
volumes and thicknesses in the CM
group directly after surgery. Rehy-
drating the CM obviously leads to a
minimal increase in volume. In this
study, one should have trimmed the
CM after the rehydration process
avoiding this shortcoming. However,
expressing the augmented volume in
percent eliminated the difference
between the groups concerning the
absolute augmented volume and a
comparison could be performed.
Another limitation of this study
is that we did not create a real clini-
cal treatment scenario and the treat-
ment applied in this study is not
directly transferable to the clinical
practice. Outcomes of this study will
certainly contribute to better charac-
terize the used CM and judge its
potential for soft tissue thickening.
In addition, it can be helpful to
know the properties of such grafts to
indicate its use for a specific treat-
ment. Further clinical research
should focus more on real clinical
treatment scenarios with the use of
the CM as possible alternative to
autologous grafts.
Results of this study are valuable
since we applied a three-dimensional
measuring method to detect volume
changes over time. Due to the lack-
ing evidence with respect to the mea-
suring device, it is difficult to
compare the outcomes of this study
to other studies applying two-dimen-
sional measuring techniques (Batista
et al. 2001) to different three-dimen-
sional volumetric assessments
(Thoma et al. 2010). There is one
shortcoming of the technique
because optical scans were per-
formed on study casts in this study.
The accuracy of the method is highly
influenced by the accuracy of the
impressions and the casts. Further
three-dimensional scanning systems
will probably eliminate the need for
impressions by an intra-oral in vivo
scan.
Since it is not entirely clarified
until today, what happens exactly by
the integration of the free SCTG
and collagen based matrices, further
research should keep on focusing on
the integration and degradation pro-
cess of used grafts and investigate
the biological processes that might
lead to volume increase or decrease
in the course of healing.
Conclusion
Within the limitations of the study,
outcomes indicate that the porcine
CM used in this study is statistically
non-inferior after 10 months for the
volume augmentation of the kera-
tinized gingiva than the gold stan-
dard of care, the SCTG. Graft
shrinkage, which seems to be associ-
ated with the healing process after
soft tissue grafting needs to be con-
sidered in clinical practice. With the
knowledge of the properties of the
CM, practitioners should consider its
clinical use indication-dependent.
Still, further research in a variety of
animal models and clinical trials is
needed to confirm the outcomes of
this study and make treatment out-
comes more predictable.
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Clinical Relevance
Scientific rationale for the study:
To evaluate the potential of a
native collagen matrix (CM) for
soft tissue thickening (simulated
around teeth in a dog model) as
alternative to the autologous
subepithelial connective tissue graft
(SCTG).
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617
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S142.
Address:
Christian M. Schmitt
Department of Oral and Maxillofacial
Surgery
University of Erlangen-Nuremberg
Gl€
uckstr. 11, 91054 Erlangen
Germany
E-mail: Christian.Schmitt@uk-erlangen.de
Practical implications: With suffi-
cient integration and augmentation
properties, the tested collagen
matrix could serve as an alternative
to the SCTG for soft tissue thick-
ening. Further clinical research
should focus on its regeneration
potential in specific treatment sce-
narios.