Tricky Grafting Situation: Frenum Pull, Exostoses, Thin Tissue

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?

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.

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

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 !)

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

Soft tissue screws? Could you kindly elaborate, and do you have any references I can see a clinical case? Thank you

I'm not familiar. Please let me know

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

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.

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.

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.

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.

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.

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 ...