goals for FGG procedure
-increase KT
-root coverage
-increase vestibular depth
-phenotype modification
is there a difference between FGG on bone or periosteum
James and McFall:
-1.5-2 times the shrinkage when on periosteum
25% shrinkage on bone
50% shrinkage on periosteum
delayed re-vascularization if you are on bone
does the thickness of the graft matter
thicker grafts have less shrinkage
Mormann:
45% thin
38% intermediate
30% thick
thicker grafts also have more primary contraction while thin grafts have more secondary contraction
thin grafts will have more _____ ary contraction
more secondary contraction (due to cicatrization of graft, occurs 4-10 days after)
thicker grafts will have more ______ary contraction
primary contraction (due to having more lamina propria content which has more elastic fibers, occurs 2-4 days after surgery)
how does an FGG heal
by long JE
creeping attachment of FGG
Matter - 0.89mm over 1 year
how stable are the results of FGG long term
Agudio 2008 long term follow up of FGG shows increase in KT by 4mm, root coverage, no progression of recession, and additional creeping attachment
healing of an FGG
(Gargiulo and Arrocha)
0-2: plasmatic circulation
2-4: vascular invasion
4-7: CT attachment, epithelium sloughs
10: bridge of vascular channels, complete epithelialization
21: CT is well organized
28: keratinization of epithelium begins
Minimum amount of thickness for an FGG
-epi is 0.34mm according to Soehren
-lamina propria is around 1-1.5mm
so should be no less than 1.25mm to ensure adequate thickness of CT
What factors affect FGG healing
-mobility of the graft
-thickness of the graft
-infection
-trauma
-extent of host bed
-on periosteum or bone
-presence of blood clot
what is the benefit of soft tissue grafting around implants versus no soft tissue grafting
Thoma 2018-
for gain in KM width: had less GI compared to sites that were not grafted (whether they had KM or not)
for gain in thickness: had less MBL compared to sites that were not grafted
how do you choose between FGG or CTG for implants
Bassetti 2015 - FGG for KM<2mm and CTG if KM>2mm but lacking thickness
why is soft tissue important around implants
Linkevicius 2009
-thin mucosa <2mm had more MBL than thick mucosa >2mm
1.5mm vs 0.3mm
when is the best time for CTG around implants
-before implant placement:
-during implant healing phase
-at 2nd stage surgery
not recommended during implant placement (unless its an immediate) or after crown delivery
Thoma 2022
what are the pertinent clinical findings
-localized gingival recession
-lack of KT
-aberrant frenum
-shallow vestibule
-plaque and calculus
-misaligned tooth
what are your diagnoses for mucogingival deformities and conditions around teeth
1) thick flat phenotype
2) gingival recession
-facial surface
-lingual surface
-interproximal surface (RT1, RT2, RT3)
-presence of NCCL
-presence of hypersensitivity
3) lack of keratinized gingiva
4) decreased vestibular depth
5) aberrant frenum
6) gingival excess - excessive gingival display
7) root surface condition (A+-, B+-)
how do you address the cc of “sensitivity” on roots with recession
1) desensitizing toothpastes (with potassium nitrate, or stannous fluoride)
2) densitizing agents in the office (like fluoride varnishes, gluma, oxilates)
3) STA for root coverage
4) cervical restoration (has more inflammation, more recession, and worse esthetics than CTG - Leybovich)
