Soft Tissue Grafting for Dental Implants: Clinical Guide

Graft around implants when keratinized tissue width (KTW) falls at or below 2 mm, or when mucosal thickness is insufficient for biological stability and esthetic outcomes. For mucosal thickness augmentation, the subepithelial connective tissue graft (SCTG) is the gold standard. For KTW gain, an apically positioned flap combined with a free gingival graft (APF+FGG) produces the most reliable increases. Xenogeneic collagen matrices (XCM) and acellular dermal matrices (ADM) are reasonable when reducing donor-site morbidity is a priority, but expect less predictable long-term volume stability.

• KTW threshold: KTW ≤ 2 mm is the widely accepted clinical benchmark for augmentation; sites with inadequate keratinized tissue show higher plaque indices and greater marginal bone loss over time.
• Mucosal thickness target: Aim for at least 2 mm of peri-implant mucosal thickness; sites below this threshold are associated with increased marginal bone resorption and compromised esthetics.
• Timing shortline: Grafting before or during implant placement simplifies stabilization; second-stage surgery is a practical window when the site was not addressed earlier.

Pro Tip: Before any implant procedure, record baseline KTW and mucosal thickness with a calibrated probe and stent. You cannot track what you did not measure.

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Key Takeaways

Soft tissue grafting around implants is indicated when KTW falls at or below 2 mm or mucosal thickness drops below approximately 2 mm, with SCTG as the gold standard for thickness gain and APF+FGG as the most reliable approach for KTW augmentation.

Point	Details
KTW and MT thresholds	Graft when KTW ≤ 2 mm or MT < 2 mm; both thresholds are linked to marginal bone loss and hygiene compromise.
Material hierarchy	SCTG produces 0.8–2.5 mm thickness gains; APF+FGG yields 1.4–3.3 mm KTW gains; XCM/ADM reduce morbidity but produce smaller, less stable gains.
Plan for shrinkage	SCTG shrinkage of 0.2–1.1 mm is expected within 6–12 months; augment slightly beyond the minimum target when long-term stability is required.
Timing is secondary to technique	Technique and material choice drive outcomes more than timing, but second-stage surgery is a practical and evidence-supported grafting window.
Onewd training pathway	Onewd’s hands-on implant and soft tissue grafting courses provide supervised live-patient experience to translate this evidence into predictable clinical outcomes.

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When should you perform soft tissue grafting around implants?

Peri-implant soft tissue deficiencies fall into two distinct clinical problems, and conflating them leads to the wrong treatment plan. The first is inadequate keratinized tissue width, which compromises oral hygiene access and long-term mucosal stability. The second is insufficient mucosal thickness, which predisposes the site to marginal bone loss and esthetic failure regardless of how much keratinized tissue is present.

Keratinized tissue width: the 2 mm benchmark

The Osteology Foundation Consensus Report identifies KTW ≤ 2 mm as the commonly used clinical threshold for augmentation. Sites below this mark tend to accumulate more plaque, bleed more readily on probing, and show higher rates of peri-implant mucositis. Patients with thin, mobile mucosa also report greater discomfort during brushing, which compounds hygiene compliance problems over time.

Measuring KTW is straightforward: use a periodontal probe with a fixed reference stent to record the distance from the mucosal margin to the mucogingival junction. Reproducibility improves when the same clinician uses the same stent at each recall. For anterior sites where esthetics drive the decision, CBCT-to-soft-tissue overlay or transgingival probing with a caliper can add volumetric context, though probe-based measurement remains the clinical standard.

Mucosal thickness: why 2 mm matters biologically

A mucosal thickness below approximately 2 mm is associated with greater marginal bone resorption in multiple systematic reviews. The mechanism is straightforward: thin mucosa cannot buffer the biologic width demands of the implant-abutment interface, and the body compensates by resorbing crestal bone. Meta-analytic data confirm that connective tissue grafting for mucosal thickness is associated with significantly less marginal bone loss compared to non-grafted controls.

Transgingival probing under local anesthesia gives the most direct thickness measurement. Ultrasonic devices and CBCT-based soft-tissue proxies are emerging but not yet standard in most practices.

Clinical scenarios: mapping phenotype to action

Phenotype	Location	Patient Priority	Recommended Action
Thin mucosa, KTW ≤ 2 mm	Anterior esthetic zone	Esthetics + stability	Stage SCTG before or at implant placement
Thin mucosa, KTW ≤ 2 mm	Posterior functional zone	Hygiene access	APF+FGG at second-stage or before placement
Adequate KTW, thin mucosa	Anterior esthetic zone	Esthetics	SCTG bilaminar approach; consider timing with provisionalization
Adequate KTW, adequate mucosa	Any	Maintenance	No graft; monitor at recall
Thin mucosa, limited palatal tissue	Any	Reduced morbidity	XCM or ADM with informed consent on predictability limits

When soft-tissue deficiency is severe enough to compromise primary implant stability or flap closure, staging the graft before implant placement is the safer path. Attempting simultaneous bone and soft-tissue augmentation at a site with minimal attached mucosa increases the risk of membrane exposure and graft failure.

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What graft materials and techniques are available for implant sites?

Each technique in the oral soft tissue grafting toolkit has a distinct indication, and none of them is universally superior across all clinical goals.

Subepithelial connective tissue graft (SCTG)

Harvested from the palate via a partial-thickness trap-door or single-incision technique, the SCTG is placed beneath a split-thickness or coronally advanced buccal flap. It is the gold standard for mucosal thickness augmentation, producing thickness gains of approximately 0.8–2.5 mm at 6–12 months across RCTs. Color match is excellent because the graft is covered by native epithelium. The trade-off is a palatal donor site, which is the primary source of postoperative morbidity.

Pros: Best long-term volume stability; superior esthetic integration; well-documented marginal bone preservation.
Cons: Two surgical sites; longer operative time; palatal healing discomfort for 2–4 weeks.

Free gingival graft (FGG)

The FGG is an epithelialized graft, also harvested from the palate, placed directly on a periosteal bed. It is most effective for increasing KTW, particularly in posterior sites where color match is less critical. Used with an apically positioned flap, it produces the largest KTW gains in the literature.

Pros: Technically straightforward; reliable KTW increase; durable long-term.
Cons: Color mismatch (pale, opaque appearance); not suitable for anterior esthetic zones; donor-site morbidity similar to SCTG.

Apically positioned flap (APF) and vestibuloplasty

The APF repositions existing mucosa apically to expose periosteum and create a new zone of attached tissue. Used alone, it increases KTW but does not add volume. Combined with FGG or SCTG, it becomes the most effective approach for KTW gain. A systematic review reports APF+FGG or APF+SCTG producing KTW gains of approximately 1.4–3.3 mm, outperforming APF alone or no treatment.

Vestibuloplasty is essentially an APF extended across a broader edentulous span, often used in full-arch implant cases where the vestibular depth is inadequate.

Bilaminar approaches

Bilaminar techniques combine a CTG with a coronally advanced flap (CAF) or split-thickness flap. These are preferred in anterior esthetic sites where root or implant surface coverage and volume augmentation are both needed. The two-layer design protects graft vascularity while allowing coronal advancement without tension.

Xenogeneic collagen matrix (XCM)

Products like Mucograft (Geistlich) are porcine-derived collagen matrices used as autograft substitutes. They eliminate the palatal donor site entirely, reducing surgery time and patient morbidity. RCT data consistently show lower morbidity scores with XCM compared to SCTG, but gains in KTW and mucosal thickness are smaller and more variable. Long-term volume stability is less predictable.

Pros: No donor site; shorter surgery; lower early morbidity.
Cons: Less predictable volume gain; higher shrinkage variability; greater cost per unit.

Acellular dermal matrix (ADM)

ADM products (such as AlloDerm) are human-derived processed dermis. They behave similarly to XCM in clinical outcomes: reduced morbidity versus autograft, but generally inferior long-term thickness gains. ADM may be preferred when palatal tissue is genuinely insufficient or when the patient declines a second surgical site.

Pre-operative planning checklist

1. Confirm KTW and MT measurements with a calibrated probe and stent.
2. Assess palatal tissue thickness and donor-site availability (minimum 1.5 mm palatal tissue for safe harvest).
3. Select flap design based on esthetic zone, implant position, and keratinization goal.
4. Choose suture material (e.g., 5-0 or 6-0 chromic gut or PTFE for graft stabilization).
5. Plan stabilization method around implant hardware (mattress sutures, periosteal sutures, or tacking).
6. Confirm provisionalization plan if grafting occurs at abutment connection.

Stabilization around implant hardware

Implant hardware complicates flap advancement and suturing. When the healing abutment or provisional crown is present, use interrupted periosteal sutures to anchor the graft apically and sling sutures around the abutment to prevent coronal displacement. Avoid placing sutures directly over the graft center, where tension can compromise vascularity.

Pro Tip: For SCTG around implants, a horizontal mattress suture placed 3–4 mm from the graft margin, combined with a periosteal anchor suture at the base, provides the most reliable stabilization without compressing the graft’s blood supply.

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When is the right time to graft: before, during, or after implant placement?

Timing is often treated as a secondary decision, but it directly affects graft stabilization feasibility, the number of surgical entries, and patient morbidity.

Timing options and their trade-offs

• Before implant placement: Allows full soft-tissue healing before implant surgery; simplifies flap design at placement; adds a surgical visit. Best when the site has severe KTW deficiency or inadequate vestibular depth that would compromise flap closure at placement.
• Simultaneous with implant placement: Reduces total surgical entries; graft stabilization is feasible when primary implant stability is achieved and no extensive bone augmentation is required simultaneously. Evidence supports adding SCTG at immediate implant placement to thicken the buccal contour and limit midfacial recession, provided the graft does not interfere with osseous grafting or primary stability.
• At second-stage/abutment connection: A practical and commonly used window. The surgical access needed for abutment connection allows simultaneous soft-tissue augmentation without an additional visit. This timing addresses both KTW and mucosal thickness while leveraging necessary access.
• Delayed/after loading: Technically more demanding because the restoration is in place; flap advancement is restricted; graft stabilization is harder. Reserve for cases where earlier grafting was not performed and a deficiency is identified at recall.

Timing decision matrix

Phenotype	Procedure Complexity	Recommended Timing
Thin mucosa, adequate KTW	Immediate implant, no bone graft	Simultaneous SCTG at placement
KTW ≤ 2 mm, thin mucosa	Delayed implant, staged site	Graft before implant placement
KTW ≤ 2 mm, adequate mucosa	Standard delayed implant	APF+FGG at second-stage
Any deficiency, missed earlier	Restored implant	Delayed graft with modified flap design
Thin mucosa, bone graft needed	Complex simultaneous GBR	Stage graft before or after GBR; avoid simultaneous

The evidence from a 2026 network meta-analysis suggests that technique and material choice have a greater influence on outcomes than timing alone, but individualized timing decisions based on anatomy and stabilization feasibility remain clinically important.

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What does the evidence actually show for KTW and MT gains?

The literature on soft tissue grafting around implants has grown substantially, though heterogeneity in study design, follow-up duration, and measurement methods limits direct comparisons.

Key findings from systematic reviews and RCTs

Source	Intervention	Outcome	Result	Evidence Notes
Zucchelli et al. / JCPE systematic review	APF+FGG vs. APF alone	KTW gain	1.4–3.3 mm with APF+FGG	Moderate heterogeneity; short follow-ups in some studies
Osteology Consensus (CLR 2019)	Autogenous grafting (KTW)	Plaque/bleeding indices	Significant improvement vs. control	Consensus-level; RCT base
Thoma et al. meta-analysis (CLR)	CTG for mucosal thickness	Marginal bone level	Significantly less bone loss vs. no graft	Moderate evidence; varied follow-up
Cafasso et al. NMA 2026	APF+FGG vs. CTG vs. XCM	KTW and MT	APF+FGG best KTW; CTG best MT; XCM lower gains	Network meta-analysis; largest synthesis to date
SCTG vs. XCM RCTs (pooled)	SCTG vs. collagen matrix	MT gain	SCTG: 0.8–2.5 mm; XCM: 0.3–1.2 mm	Lower morbidity with XCM; less gain

Clinically meaningful thresholds

A thickness gain of at least 1 mm is generally considered clinically meaningful for marginal bone preservation. Meta-analytic data confirm that even modest thickness increases reduce marginal bone loss and improve esthetic outcomes across multiple studies. The pink esthetic score (PES) improves most reliably with SCTG in anterior sites, where papilla fill and mucosal contour are the dominant esthetic parameters.

For KTW, the systematic review evidence shows APF+autogenous grafts outperform APF alone or no treatment by a clinically significant margin. Sites treated with APF alone gain some KTW but less reliably, and without the volume benefit.

Shrinkage: plan for it

SCTG shrinkage of approximately 0.2–1.1 mm in thickness (or roughly 10–40 mm³ volumetrically) occurs within 6–12 months of placement. This is not failure; it is expected remodeling. The practical implication: target slightly greater initial augmentation than the minimum threshold when long-term stability is the priority. XCM shrinkage is variable and in some RCTs exceeds that of SCTG in proportional terms, which partly explains the lower net gains at follow-up.

Evidence caveats

Short follow-up periods (often 3–6 months) dominate the literature, and few studies track outcomes beyond 12 months. Measurement methods vary widely, from probe-based KTW to volumetric scanning, making pooled analyses imprecise. The 2026 network meta-analysis by Cafasso et al. is the most comprehensive synthesis available, but the authors note residual heterogeneity and call for standardized outcome reporting in future trials. Interpret numeric ranges as guidance, not guarantees.

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Practical operative guidance for implant-related soft tissue grafting

Technical execution determines whether the evidence-based gains you expect actually materialize in your patient.

Operative checklist

1. Confirm anesthesia adequacy at both donor and recipient sites before incision.
2. Achieve hemostasis at the recipient bed before graft placement; a bleeding bed compromises visibility and graft contact.
3. Harvest CTG to a target thickness of 1.5–2 mm; thinner grafts shrink more; thicker grafts risk necrosis at the center.
4. Design the buccal flap with 2–3 mm of full-thickness periosteal release at the base, then transition to split-thickness for coronal advancement. This preserves vascularity while allowing tension-free closure.
5. Place the graft with the connective tissue surface against the periosteal bed; orient the graft so its thickest portion is at the mid-buccal.
6. Suture in sequence: periosteal anchor sutures first, then sling sutures around the abutment, then interrupted sutures at the coronal margin.
7. Apply a periodontal dressing or collagen sponge at the palatal donor site.
8. Confirm tension-free closure by releasing the patient’s lip; the flap should not retract.

Flap management principles

Partial-thickness palatal flap harvest with careful de-epithelialization of the recipient bed improves graft revascularization. On the buccal side, combining 2–3 mm of full-thickness release with split-thickness advancement reduces tension while preserving perfusion. These two principles together account for most of the difference between a graft that integrates and one that partially necroses.

When implant hardware is present, the healing abutment height affects flap advancement. A shorter healing abutment facilitates coronal advancement; a tall abutment may require a custom provisional to support the graft margin.

Donor-site management

The palate between the canine and first molar is the primary harvest zone. Avoid harvesting within 2 mm of the gingival margin to preserve palatal gingival integrity. When palatal tissue is thin (less than 3 mm total thickness including epithelium), consider a single-incision technique rather than a trap-door to reduce the risk of palatal artery injury. If palatal tissue is genuinely insufficient, XCM or ADM becomes the practical alternative rather than a preference.

Pro Tip: A pre-operative CBCT or ultrasonic measurement of palatal tissue thickness at the harvest site takes under two minutes and prevents the unpleasant intraoperative discovery of a thin palate. Target a harvest zone with at least 3.5 mm total tissue thickness.

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What complications should you anticipate, and how do you manage them?

Complications after soft tissue grafting around implants are manageable when anticipated, but they require a systematic approach rather than reactive improvisation.

Common complications and prevention

• Graft destabilization: The most common early failure. Caused by tension at closure, inadequate suturing, or patient non-compliance with soft diet. Prevention: tension-free closure confirmed intraoperatively; sling sutures around abutment hardware; clear post-op instructions.
• Infection: Uncommon but serious. Signs include purulent exudate, fever, and rapid graft discoloration beyond the expected pallor of the first 48 hours. Management: chlorhexidine rinses, systemic antibiotics (amoxicillin 500 mg TID or clindamycin 300 mg TID for penicillin-allergic patients), and early re-evaluation.
• Excessive bleeding: Most often from the palatal donor site. Prevention: careful flap design avoiding the greater palatine artery; hemostatic dressing at closure. Management: direct pressure, resorbable hemostatic agents, or re-suturing if persistent.
• Edema and ecchymosis: Expected and self-limiting. Cold compresses for the first 24 hours reduce severity. Patients should be counseled that swelling peaks at 48–72 hours.
• Impaired healing at the donor site: More common in smokers and patients on anticoagulants. Counsel patients to cease smoking at least two weeks before surgery; coordinate with the prescribing physician regarding anticoagulant management.

Expected healing timeline

Initial epithelialization of the graft surface takes approximately two weeks. During this phase, the graft appears pale and slightly raised; this is normal. Progressive integration and vascular ingrowth continue through 4–12 weeks, during which the graft softens and begins to match surrounding tissue color. Final volumetric stability is not reached until 6–12 months, which is why outcome measurements taken at 3 months underestimate shrinkage.

Patient counseling points

1. Explain the difference in expected morbidity: SCTG patients typically experience 7–14 days of palatal discomfort; XCM/ADM patients have less donor-site pain but should understand the trade-off in predictability.
2. Prescribe analgesics proactively (ibuprofen 600 mg every 6–8 hours with food for the first 3–5 days unless contraindicated).
3. Soft diet for two weeks; no hard, crunchy, or spicy foods near the surgical site.
4. Chlorhexidine 0.12% rinse twice daily for two weeks; no mechanical brushing at the graft site for the same period.
5. Schedule follow-up at 1 week (suture check), 4 weeks (early integration assessment), and 3 months (interim volumetric review).

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How to decide: a practical clinical decision algorithm

Work through these steps in sequence for every implant patient with a potential soft-tissue deficiency.

Step-by-step decision process

1. Measure baseline KTW and MT at the implant site using a calibrated probe with a fixed stent. Record both values in the chart.
2. Classify the zone: anterior esthetic zone (maxillary incisors through first premolars, mandibular anterior) vs. posterior functional zone.
3. Assess patient priorities: esthetics, hygiene access, reduced morbidity, or cost sensitivity.
4. Apply the KTW branch:
   • KTW ≤ 2 mm → consider APF+FGG (highest KTW gain, best long-term durability) or APF+ADM (if patient declines donor site).

• KTW > 2 mm → proceed to MT assessment.

5. Apply the MT branch:
   • MT < 2 mm or esthetic zone with visible implant shadow → favor SCTG bilaminar approach if patient accepts donor-site morbidity.
   • Patient declines donor site or palatal tissue is insufficient → XCM or ADM with explicit informed consent about lower predictability and possible need for re-grafting.
6. Determine timing:
   • Severe deficiency before implant placement → stage graft first.
   • Moderate deficiency, primary stability achievable → simultaneous grafting.
   • Deficiency identified at second-stage → graft at abutment connection.
   • Deficiency identified after loading → delayed graft with modified flap design.
7. Check staging criteria: if simultaneous bone augmentation (GBR) is required, stage the soft-tissue graft separately to avoid competing for flap tension and membrane stability.

Factors that push toward staging

• Less than 1 mm of attached mucosa at the planned implant site.
• Simultaneous GBR with a non-resorbable membrane.
• High-risk esthetic case where graft failure would compromise the final restoration.
• Patient with systemic factors (uncontrolled diabetes, active smoking) that reduce graft predictability.

Treatment plan documentation checklist

• Baseline KTW (mm) and MT (mm) recorded with measurement method noted.
• Esthetic zone classification confirmed.
• Material selected and rationale documented (autograft vs. substitute, with morbidity discussion).
• Timing decision recorded with clinical justification.
• Informed consent covering expected gains, shrinkage range, donor-site morbidity, and possibility of re-grafting.

Pro Tip: Photograph the site with a calibrated ruler at baseline, immediately post-op, and at 3 and 6 months. Volumetric photo documentation is the fastest way to identify early shrinkage before it becomes a clinical problem.

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How should clinicians build competence in implant soft tissue grafting?

Soft tissue grafting around implants is a technique-sensitive procedure. Reading the evidence is necessary but not sufficient; the gap between knowing the algorithm and executing it predictably closes only through structured, progressive hands-on training.

Recommended training sequence

• Didactic foundation: Start with a structured review of anatomy, indications, and evidence. Online webinar-based courses provide flexible access to this layer before committing to hands-on time.
• Simulation and model practice: Pig-jaw or typodont models allow flap design, suturing, and graft stabilization practice without patient risk. Focus on tension-free closure and suture sequence before moving to live cases.
• Supervised hands-on courses: Short-format labs (one to two days) focused on flap management, CTG harvest, and suturing technique provide the density of repetition needed to build muscle memory. Suturing technique courses are a practical prerequisite for anyone new to graft stabilization.
• Live surgery observation and mentored cases: Watching an experienced surgeon manage a bilaminar SCTG around an implant in real time reveals intraoperative decisions that no textbook captures. Mentored live-patient modules, where you perform the procedure under direct supervision, are the highest-value training format.
• Progressive independent practice: Begin with lower-complexity cases (posterior FGG for KTW gain) before advancing to anterior bilaminar SCTG. Track your outcomes with photographs and measurements.

When to refer

Refer to a periodontist or oral surgeon when the case involves a failed previous graft, active peri-implant disease requiring concurrent treatment, a severely limited tissue envelope (less than 1 mm attached mucosa with no vestibular depth), or a complex anterior esthetic case where a single graft failure would compromise the final restoration. Recognizing the limits of your current skill level is a clinical competency, not a shortcoming.

For clinicians building this skill set, hands-on implant training that integrates soft tissue management into the implant placement workflow is the most efficient path to predictable outcomes. The implants and surgery course catalog at Onewd covers the full procedural arc from site development through soft-tissue management.

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The evidence is good, but it does not operate the instruments

The literature on soft tissue grafting around implants is more consistent than it was a decade ago. APF+FGG for KTW, SCTG for mucosal thickness, XCM when morbidity is the constraint: the hierarchy is reasonably clear. What the systematic reviews cannot tell you is how to manage the moment when your flap advancement is 1 mm short of tension-free closure, or when the palatal harvest comes out thinner than planned.

The clinicians who produce the most predictable outcomes are not necessarily those who have read the most meta-analyses. They are the ones who have done enough supervised cases to have internalized the tactile feedback of a well-placed periosteal suture and the visual cue of a graft that is adequately vascularized versus one that is not. Evidence sets the target; technique gets you there.

There is also a tendency in the field to treat material selection as the primary decision and technique as secondary. The data suggest the opposite: a well-executed SCTG with proper flap design outperforms a poorly executed XCM placement every time, even accounting for the morbidity difference. Invest in the technique first, then optimize the material choice.

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Hands-on training that closes the gap between evidence and execution

Knowing the indications and the algorithm is the starting point. Executing a bilaminar SCTG or an APF+FGG predictably in a live patient requires a different kind of preparation, and that is exactly where structured, mentorship-driven training pays off.

Onewd’s hands-on implant training programs are built around the principle that supervised repetition, not passive observation, is what converts clinical knowledge into reliable outcomes. The soft tissue grafting course covers flap design, CTG harvest, graft stabilization around implant hardware, and suturing sequences, with live-patient modules that put you in the operator’s seat under direct mentorship. Courses are available in both online and in-person formats, with CE credits upon completion.

If you are ready to move from reading the evidence to applying it, browse the full training course catalog and find the format that fits your schedule and current skill level.

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Recommended

• Xenograft vs. Allograft: Which Bone Graft is Best? | One World
• Soft Tissue Grafting: Principles & Techniques (On-Demand)
• 41-50 Archives – One World Dental
• 51-60 Archives – One World Dental