Soft Tissue Substitutes: Current Biomaterials and Indications at Teeth and Implant Sites

Soft tissue augmentation around teeth and dental implants is a central aspect of periodontal and peri-implant plastic surgery. Autogenous soft tissue grafts are generally regarded as the gold standard for increasing keratinized mucosa, mucosal thickness, and soft tissue height, supported by extensive long-term evidence. However, limitations such as restricted tissue availability, increased surgical time, and donor-site morbidity have encouraged the development of soft tissue graft substitutes, including xenogeneic and allogeneic matrices, and collagen derivatives, among other biomaterials. Over the past two decades, these alternatives have shown promising results, particularly in sites with favorable anatomical conditions, including optimal bone support, tall and wide papillae, and adequate hard and soft tissue phenotype; although their predictability remains variable across the literature and is often lower than that of autogenous grafts in complex defects and esthetically demanding areas. Nevertheless, the growing emphasis on patient-reported outcomes has led several authors to explore the use of graft substitutes in different clinical scenarios, sometimes in combination with smaller autogenous grafts. This manuscript aims to summarize the current state-of-the-art on soft tissue graft substitutes for managing deficiencies at both teeth and implant sites. A comprehensive literature review is provided, together with clinical decision trees designed to guide clinicians in selecting autogenous grafts versus substitutes across different scenarios. These tools highlight the main factors influencing treatment selection, including baseline keratinized mucosa, buccal bone conditions, site anatomy, esthetic requirements, and patient preference. By integrating current evidence with practical algorithms, this review seeks to support clinicians in making informed, patient-centered decisions regarding soft tissue augmentation at teeth and implants.