Description of a Free gingival graft technique. Goals: - Recession coverage
- Establishment of thick keratinized and attached gingival zone
- Elimination of muscle fibers that might be "pulling away" the free gingival margin.
Creating an ideal implant site is not always achievable. Sometimes the patient himself will not wish to undergo full treatment in order to achieve a result that will be nice for our pictures. However, it is important for the clinician to understand the biologics behind the decisions he will have to make for the best interest of his patient.
Creating adequate hard and soft tissue anatomy around an implant is proven to be critical for long term stable results.
In this case the presence of interproximal bone loss on the distal of tooth 2.1 is the detrimental factor that would not allow the establishment of gingival symmetry between R and L side. The tooth had already been extruded with no additional benefit. Any further attempt to improve its bone levels, would put in risk its longevity since C:R is already compromised.
Upon evaluating the patient's smile and discussing with him his options, it was concluded that symmetry will not longer be one of our primary goals in this case.
However, good hard and soft tissue quality is important to prevent future breakdown. This is particularly important in post-ortho cases where the anatomy of the alveolus and the position of the teeth has been changed compared to the genetic information of the patient.
Another interesting point is the interproximal bone stability (this is all you can evaluate from regular PA or BW xrays) around the implant. This was a Legacy implant, an implant with no platform shift design for the implant diameter used (3.75mm) and short conical connection (internal hex, 45') and it still shows very stable bone levels.
Possible reasons for the observed crestal bone stability:
1. Bone width around the implant (>2mm)
2. Soft tissue quality and thickness
3. Subgingival material
(no porcelain, only titanium abutment with a 3mm collar. Titanium is a biocompatible material, porcelain is not!)
4. Microgap position (crown-abutment interface) slightly subgingivally and away from the crest of bone
5. Biologic width component - if there is such a thing around implants- (different tissue structure around teeth and implants. There is no real attachment on implant or abutment surface up to this time point).
This is a post-orthodontic treatment case that required esthetic crown lengthening due to inappropriate gingival position and contours. The appropriate steps prior to this procedure in cases where the teeth will not be restored, are the following: 1. evaluate radiographically and clinically the interproximal bone position 2. evaluate, with bone sounding, the position of the bone in relation to the CEJ of the teeth 3. evaluate the presence and extension of frenums in the area 4. evaluate the crown and root position in relation to the bony envelope 5. evaluate the root shape and color All of the above are factors that can influence your results. Always tell the patient in advance that a second small procedure (touch up) such as gingivectomy with either blade or laser, might be necessary in order to achieve an optimal result. Best, Ioannis
This patient presented with a failed anterior bridge and huge aesthetic concern. We proceeded with extractions of the remaining teeth and immediate implant placement. A temporary titanium re-inforced acrylic prosthesis was placed within 24 hours. Utilizing the described protocol in the video, this type of treatment option can be very easy and predictable for the doctor and very satisfactory for the patient.
In this case we describe the indications of doing a Free Gingival Graft in order to cover a recession, increase the thickness of the tissue and create a zone of attached gingival in the lower central incisors.
It is very important to identify the cause of the problem:
1. Thin tissue biotype
2. Absence of attached gingiva
3. High Frenum insertion
4. Root position post orthodontic treatment
The free gingival graft in combination with plasty of the root during the procedure will eliminate the above causes and will offer a good and stable long term result.
Disadvantage of the technique:
1. Morbidity of the donor site ( use a stent and/or mouthwash NSAID)
2. No good color match of the graft with the adjacent tissue (even though is not really an aesthetic area but you have to inform the patient in advance)
Bottom-line:
Very predictable technique for this area of the mouth to treat muccogigival defects.
In this case we showed how important is to evaluate the edentulous space and to perform bone reconstruction of the whole area and not only of the extraction sockets. At the end, the quality of regenerated bone was very good, the initial stability of the implants was very high, therefore we decided to place only 2 and not 3 dental implants as original planned, to be restored with a 3-unit bridge.
It is my belief that bone manipulation techniques like ERE can give more long-term stable results than regular GBR techniques. No evidence is available in the literature, however we could start a debate on this matter.
This is a very old case of mine. The video shows the technique I utilized to augment the bone in height and width. It also shows the result of the surgical procedure and the 4 year follow up of the case.
I will be happy to answer any questions you might have!
We would like to thank you for participating on our blog.
The goal of this blog is to create a community of dentists who are interested on sharing experiences and learning with us about dental treatment.
In this blog we would like all the participants to share opinions openly in order to help each other achieving high quality treatment protocols in their offices.
The goal is to share opinions based on our true opinion as it has been developed by our experience.
We will start by posting clinical cases from our clinic. We will, openly and for no cost, post the treatment protocols we use along with any pitfalls and complications.
Our hope is that by sharing our experiences and expertise we will be helping each other to find better treatment options that best suit our patients.
We are looking forward to your participation.
Ioannis Vergoullis, DDS, MS
Diplomate American Boards of Periodontology
Visiting Clinical assistant Professor, Periodontics,
Louisiana State University, New Orleans, USA
Catherine Badell, DDS
Diplomate American Boards of Periodontology
Assistant Professor, Periodontics,
Louisiana State University, New Orleans, USA
