Inadequate Zone of Attached Gingiva: Most Predictable Application?

The simplest and most conservative treatment that has worked for me in the past to gain more buccal attached gingiva on the maxilla is to make a flap incision more palatal from where the implant is and displace it bucally and then attach the healing abutment. The buccal aspect should granulate in.

Dr Dan has it there , free grafts are technique sensitive. Peter

More predictable than a CT graft is a free soft tissue graft, it will also allow you to deepen the vestibule. Take if from a periodontist.

Totally agree with Dr. Dan, but I don't do this when the soft tissue is so thin that even the 1st stage healing screw is exposed. What do you think about this?

Dr. Z If the healing abutment is already there and there isn't any attached gingiva, one approach would be to replace it with a cover screw, induce bleeding, and let the soft tissue granulate in. Once hopefully there is coverage over the cover screw, proceed with part a what i wrote originally.

Thank you Dr. Dan, so in your experience if you induce bleeding the soft tissue will cover the cover screw? How do you induce that bleeding? Pay attention Dr. C

A gingival graft is an EXTREMELY PREDICTABLE procedure...any periodontist who does them will tell you that he has over 95% success. So I find it difficult to accept that it is "technic sensitive". I also agree that another advantage of doing a gingival graft is that you will deepen the vestibule (which definitely will not happen with a CT graft). If you go ahead and do a CT graft, as you have correctly described, you will increase the thickness of the gingival tissue, but you won't have any surface keratinized tissue. Of course, you can then do a secondary procedure and remove some of the surface tissue and you will end up with a keratinized margin. But, ask yourself, why do two procedures when a single one, namely a gingival graft---which is one of the most predictable periodontal surgical procedures there is...will accomplish your objectives?

At the areas where the long junctional epithelium would be where to induce bleeding. Use a curette or blade to do it. If the implant is submerged below the gingival margin with the cover screw in place epithelium will creep and granulate across it. 6 weeks approximately you'll have more mature tissue. Epithelium loves to grow over lots of things.

I agree that grafting is a good alternative option when indicated. My experience with free gingival grafts is that the patient has terrible pain afterwards. Less with ct grafts. I agree with this option. However, in this case, if it is what i think it is, a more minimally invasive approach is what i would take.

Patients need not be in "terrible pain" after a gingival graft, especially if it is a small one, which it sounds like in this case. If your patients are experiencing this post op reaction, I suggest you refer this procedure to a periodontist who will be able to do the proper procedure without the terrible pain. This is the "new age" of periodontics...check it out. There are also MANY alternatives to palatal donor tissue. Please do some research before you perpetuate "old-time" misconceptions. Thank you

I agree with SG. Most of my patients do not have "terrible pain" after a gingival graft. I always prescribe adequate analgesics and fabricate a palatal stent which seems to give them adequate comfort. Pain should not be a contraindication to do this procedure when warranted. Bone grafts can be painful, but we still do it when it's required.

One suggestion, that works well for me in a slightly different application is to laser the area buccal to the uncovered implant in a defocused mode, and if periosteum is left in tact, the patient should grow attached tissue. How did the tissue become unattached? Bv

Congratulations to the website, thanks to all the Doctors to take time to write in this forum and give ther point of view. Next time I'll try and mix Dr. Dan and Dr. B.V. technique.

what about this problem in the edentulous under jaw with no attached gingiva left and only mobile mucosa. What is the best procedure for this to get no mobile and attached gingiva again arround the implants on the buccal and lingual side, because to have a better implant succesrate in the future? Normally there is some flabby rigde which one can use, but i have now a case there is nothing left at all and the mucosa is mobile over the knife edge causing pain at this moment!

Dr. Dutchy, this is why the split thickness skin graft was incorporated into the list of options to regain lost vestibular depth. As you probably already know, this leaves an attached zone of gingiva, perfect for stabilizing the poor fitting denture . Since the advent of co2 lasers , I have discontinued using the old technique . I personally use a wide tip laser at 6 watts ,in an uninterrupted mode with a wide tip , and allow the area to heal as per second intention. You need to have fair fitting denture , lined with Coe comfort, or have the patient wear nothing at all for about 3-4 weeks. There are probably no studies to support this technique, but anecdotally , it is hard to argue. Bv

If you don't have a laser, any hospital will let you borrow their dermatome. This is one of the few luxuries of having privelidges at a hospital. The skin graft works well, but relative to laser ablation, it's a time consuming procedure. Bv