Tricky Grafting Situation: Frenum Pull, Exostoses, Thin Tissue


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Case Posted by: Surgical Master
Case By: Dr. Ziv Simon Here is a case that presented a tricky grafting situation: Frenum to the gingival margin, exostoses, thin tissue. Please share your comments.







20 Comments on Tricky Grafting Situation: Frenum Pull, Exostoses, Thin Tissue

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DrG
12/29/2015
Nice result. I do this procedure very regularly and each time I ask myself why am I not doing a FGG which always works? I'd say 1 out of 20-25 I have to redo. How do you determine when it just won't work?
ziv
12/29/2015
I agree. FGG is more straight forward and I offered this to the patient. High esthetic demands and understands the challenge with this technique. I'm with you
Dr. Nick Refahi
12/30/2015
It's good actually, the reshaping of thin muscle tissue that attaches the upper or lower lips to the gum according to give the comfortable mouth movements to the patient. Sometimes for cosmetic purpose also we have to do.
BradF
12/30/2015
Nice case and nice result. The only thing i do differently is I prefer to do the frenum release 4 weeks prior to the CTG to prevent pulling on the graft. Just personal preference though. Nice job
ziv
12/30/2015
works as well except for the scarring that develops that can challenges you at the next step. I've done it both way and no matter what lower incisors are tricky (hence the name for the post)
ziv
12/30/2015
as I mentioned in my other comment, the scarring from the frenectomy usually haunts at the second step. Lower incisors are always challenging when it comes to root coverage Thanks for the feedback
Sam Markzar
12/30/2015
Good results Ziv. I have played with different approaches for the same situation and in different locations . I generally found that removing the frenum before the grafting and coming back as early as 6 wks later to do the graft gives much better coverage, predictibility, with less tension/pull back or risk of marginal dehiscence. (BradF ...I'm applauding !)
Peter Fairbairn
12/30/2015
Hi Ziv , a good senario for the use of soft tissue screws as have better resistance to the muscle forces . David Morales -Schwartz of Spain has great research on them . Great work though as usual . Regards Peter
DrT
12/30/2015
Soft tissue screws? Could you kindly elaborate, and do you have any references I can see a clinical case? Thank you
Ziv Simon
12/30/2015
I'm not familiar. Please let me know
PeterFairbairn
12/31/2015
Look up Bioner soft tissue screws , I have done a few cases like this using them , but David has some great extreme cases using screws to stabalise the FGG as well ...he is a visitor to this site , I will get him to discuss Peter
Alex Zavyalov
12/31/2015
There is no any clinical substantiation to choose the surgical treatment approach in this case. Such minor gum recessions can be easily and highly successfully corrected with any pink composite material.
Cliff Leachman
12/31/2015
Your playing with us, right? Pink porcelain or composite is reserved for hopeless cases, no? I HATE pink porcelain or composite, third world! Great case, great pics, thanx for posting.
ziv
12/31/2015
Thanks! Minor recession but bothered the patient who was seeking a solution Thank G-D for pink porcelain for those big ridge defects... Thanks for the feedback
DrT
12/31/2015
This is NOT a restorative problem nor is it an esthetic one, so I do not see how pink composite material, or any restorative material for that matter will manage this issue. This is a periodontal problem, ie recession, thin marginal gingiva and proximal frenum; so, some form of periodontal intervention is indicated.
David Morales Schwarz
1/1/2016
As Dr. Fairbarn stated. I prefer the more straight forward Vestibuloplasty-FGG procedure to solve or at least to stabilize such cases. I almost don’t suture neither the vestibuloplasty nor the FGG. because I developed a couple of years ago for Bioner a self tapping screw set which make this procedure faster, easier and more predictable. By using screws the always difficult step of stabilizing apically the muscular fibers (Vestibuloplasty) is reduced to an easy 3 minutes procedure and the result is far more stable as if you use sutures, the later allows me to do the procedure in a single step without any fear of relapse. Screws also assist me to fix the FGG to the surgical bed, getting better immobilization and adaptation of the graft.
DrT
1/1/2016
This seems a bit more traumatic especially to the fragile soft tissue graft. Once one has done a couple of these procedures, suturing is quite straight forward both coronally to attach the graft and apically to stabilize the vestibular deepening.
David Morales Schwarz
1/2/2016
ONCE YOU GO SCREWS YOU’LL NEVER GO BACK Fixing a graft with DM Soft tissue gingival screws are far less traumatic than suturing it, because there is less manipulation of the delicate tissue graft. Only think how many times you have to grasp the tissues with a tissu forceps in order to get a well-adapted graft. I’m not talking about grafts only fixed by “thumb pressure” because absolute immobilization of the graft is the key factor for success of this procedure. Fixing the vestibulum apically is always difficult specially in posterior areas. If you want to do it right and you don’t use screws you have to suture the tissues to the thin underlying periosteum with mattress suture, this is many times a very hard task. I presented this technique many years ago Morales Schwarz D. Fixation of soft tissue grafts with miniscrews and Minipins. Clinical Oral Implants Research 2006, 17; 1xxxi and since then I teach extensively on this subject and performed hundreds of this surgeries. Thus I can tell you that Fixing either epithelial or connective tissue grafts with self- tapping gingival screws leads to a: • Much faster procedure. • Easier surgery. • Less graft trauma. • Less graft dissecation. • Less graft shrinkage. • Better graft adaptation. • Faster revascularization. • Faster graft healing. • Almost no graft necrosis. • Better general outcome.
Mahmoud sukkar
8/6/2016
Thanks David for nice technique , what are the differences between soft tissue mini screw and titanium screws which we use to fix the bone graft block . thanks a lot .
PeterFairbairn
1/2/2016
Thanks David , yes since I saw your talk in London , I have really enjoyed using the screws , makes it easier and more predictable , both nice words for me ...

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