[Soft tissue management of severe bone defect in the maxillary anterior area: a clinical guideline on the decision-making process].

Vertical bone augmentation (VBA) in the anterior maxilla is a technically and biologically challenging technique with high complication rates and unpredictable outcomes. Selecting appropriate soft tissue management strategies is crucial to avoid short-term and long-term complications. This article aims to assist clinicians in making treatment decisions based on different soft tissue conditions during VBA. It is divided into two parts. Incision and flap design based on the quality and quantity of different soft tissues during VBA. For mucosa of good quality and quantity, a trapezoidal flap incision design is adopted, and the periosteum extension technique is applied for tension reduction. For a shallow vestibular sulcus, a larger trapezoidal flap is used, and the tension reduction method of mucosa-oralis muscle separation is applied, along with papilla transposition suture to ensure primary wound closure. For thin mucosa or with perforating defects, a pedicled periosteal flap is used for repair. Selection of appropriate soft tissue augmentation techniques during the second-stage surgery based on the soft tissue status to improve esthetic outcomes. For horizontal soft tissue defects, free connective tissue graft (CTG) or palatal pedicled flap can be used for treatment; for vertical soft tissue defects, techniques such as the iceberg technique or customized CTG with bowtie-like shape can be used for vertical augmentation; for combined horizontal and vertical defects, the connective tissue platform technique can be used for three-dimensional soft tissue reconstruction.