Best technique for Gingival Grafting?

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Posted on By bruce birchenough In Soft Tissue Enhancement

Came to me for first visit from another GP after the surgeon had extracted and bone grafted #8. Photos and pa from previous office and with 5 month post surgery photo from me. Wondering what the best would be to gain keratinized tissue, and timing also for implant placement and provisional?

Presurg smile
Presurg closeup

post surg photo
presurg pa
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One option may be to de-epithelialize the crestal portion down to the mucogingival junction and then perform a "frenectomy" apical to that. The hope would be to re-establish the mucogingival junction with the granulation tissue in the frenectomy area and the exposed connective tissue will be appropriately keratinized. Another options or secondary procedure could be to do an onlay connective tissue graft in the coronal aspect. Just some ideas... Good luck! Looking forward to seeing what you decide to go with. Jason Nicholson DDS, MS


Bruce; Add healed site PA. I would plan for implant after CBCT evaluation, check for bone volume and location/size of nasopalatine canal. Soft Tissue can be managed by Palatal pedicle or apically repositioned flap from palate or FGG taking KT from palatal aspect. regards Mo


These are 5 month healing scan images. I was wondering if there is a good way to preserve the gingival tissues during the surgery? The surgeon stated that the defect was so extensive that after cleaning out the site he had no tissue left and was worried about the graft so he advanced the flap to create primary closure. Is there a less aggressive technique to preserve the soft tissue or in some cases this is what your left with and deal with gaining keratinized tissue later? I keep hearing in my head Maurice saying the tissue is the issue.

Screenshot of CBCT
Screenshot of CBCT


Bruce, fortunately papillae are present, there is hard tissue for implant placement- gaining keratinised tissue is a minor problem.
Regarding your question about less agressive tecniques-there is mIVAN technique. It is basically hard tissue augmentation utilizing ice cone technique and closure with pediculated CTG inserted in the buccal tunnel. The whole procedure is flap less. There are some cases posted on this forum.
Best regards


If you use a mucosal pouch procedure to place a free gingival graft you will not have to worry about the frenum. Reflect a mucosal flap, place a free gingival graft suture it at the crestal margin and cover the graft with the mucosal pouch for three days. Then remove the sutures and the mucosal tissue will migrate apically below the apical margin of the graft. The mucosal tissue will not heal over the surface since the surface is epithelialized.

gfart placement with sutures to the crestal marginal tissue
mucosal pouth pulled up over the graft to stabilize it for three days


Just you have any follow ups? Dr. Salama


Pretty innteresting I want to know about the results.


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