Timing of gingival grafts relative to implant placement?

It's great that you are giving this matter consideration in your initial treatment planning for this case. Without the specific details it is hard to recommend one particular approach. However generally we find it best, simplest and easiest to incorporate this into the surgical procedure for implant placement. One of the simpler and most effective ways to do this is with a single stage implant procedure with placing a trans-gingival healing cap. We place Mucograft membrane under the flap and Bio-Oss Collagen around the gingivaformer before closure. This bulks up the region and has the effect of thickening and extending the zone of attached gingiva. Give it a try!

The best time for gingival augmentation is before implants are placed but there are good results if done during or very soon after implant placement.

As always, good suggestions from experienced collegues…….patients' generally prefer to have fewer surgical appointments....however, a graft can always be done after the implant(s) has been placed, and osseointegration has been achieved....and in this case you can see where you think there is a deficiency in the gingival tissues, and take your clues from there....so there is really no hard and fast rule.

Gingival grafting for keratinized tissue is easier when it is done prior to implant placement. Grafting at the time of implant placement can reduce the number of surgeries needed. Grafting after implant placement is done when it was needed but you didn't include it in your treatment plan at the begining.

Perhaps before but it could’ve after and during implant placement. Depends on your mood.

I would always try to graft before or during the implant surgery rather than after the implant is placed and restored. It can be a more difficult situation grafting onto a mucosal margin adjacent to an implant once it’s placed. Often, during implant surgery your flap design can be made in such a way to incorporate more soft tissue— if you apically position the flap on the facial you can insert a free gingival graft of some type. Or if it’s a situation where you only need a few millimeters of keratinized tissue, you can use rotational flap designs or curved incisions to push gingiva toward the facial aspect during the implant procedure. I have grafted at second stage as well at implant uncovering to tuck connective tissue under and around a healing abutment. In the case of more demanding aesthetics— I would be sure you have plenty of keratinized gingiva prior to the placement of the implant . Good luck!

1. graft at time of implant placement. The implant site may produce enough tissue to augment with 2. Graft again at time of uncovering. Once again the surgical site may have enough tissue to graft. 3 Either way , no additional surgery and you can use any graft materials in # 1 or #2

Thank you all for the responses. I would have addressed the tissue prior to implant placement if they were in esthetic zones. In the case of the 1st molar, Im just trying to think ahead for the future. I had about 3 mm to work with and wondered what Id need to do if I lost some or all of that. I definitely wouldnt wait till restoration. Ive never performed this procedure so Id like to watch my periodontist perform it before doing my first.

I think all of the comments are well thought out. I think the answer I would give is it depends on how much experience and confidence you have in placing implants and doing grafts. I would say doing the graft first minimizes the chance of potential complications and what I would recommend to someone early in their learning curve. Grafting at the time of surgery is certainly more convenient especially for the patient but there is greater risk of things going wrong and your final outcome being less predictable. I would certainly recommend sitting with an experienced clinical doing simultaneous grafting and implant placement because the general conversation during the procedure will reveal many things to you. Same thing goes for grafting after implant placement All the best

Although I don't do free gingival grafts at implant placement, it seems like another way to decrease the blood supply to the flap, that is unless you are doing a mini-flap. I prefer to time the graft 2 months after implant placement so when the implant is fully integrated the patient doesn't have to wait any longer than need be for the final restoration.

As a periodontist, I prefer to graft before or at time of implant. It's a bear to graft an edentulous arch with no keratinized gingiva after implants are in IMO. Also what is the anticipated restoration for the edentulous case. If the restoration has any tissue contact you could have a pressure related necrosis after a new graft is placed. Lastly, what does your periodontist prefer. Are you setting them up for success or failure by waiting on the grafts?