FGG before or after

94 Rating(s).

Posted on By Wesley Latimer In Failures

Patient presented to clinic with hx of bone grafting and dental implants placed 8 years ago by post-grad perio.

#20 implant has failed and our plan is to section it from #19 and remove by reverse torque with hand ratchet. No plan for replacement at this time. Extensive vertical defect with only 4-5mm to mental foramen.

#19 and #30 implants also have bone loss and are painful for pt to carry out normal hygiene.

Treatment plan at this time is focused on disease control: Extraction of #18 and 28, sectioning hopeless implant #20 and removal. Bilateral free gingival grafts on mandibular posterior. Lower left will be treated first.

Trying to be efficient with surgical visits, should we...
A) Extract #18 and FGG #19, 20, 21 at the same time and remove #20 at another visit. (Probably my top choice)
B) Remove #20 implant and FGG at time of removal. Extract #18 later.
C) Remove #20 implant and FGG at time of #18 extraction.

This will be my first FGG after Salama's Tissue course. I have been doing quite a few palatal roll flaps on implant exposures and a few localized CTG's using split thickness pouches on implants, but am otherwise new to soft tissue work.

FGG plan consists of preparation of bed from cantilever pontic up to 21 mesial. Suturing of flap to apical with chromic. Sharp dissection of frenum. Harvest of FGG from UL maxilla with collaplug and compression sutures. Pt has RPD to cover harvest site. Suture of graft to bed at lateral and coronal, compression prevent hematoma, periopac over the top.

Any feedback would be welcome. Also if you think I should start with lower right side instead, as FGG is a new procedure to me.


Lower Left
Lower Right

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Wes. Without doubt the correct choice treatment. I feel you picked a very difficult first case. Below is a case I did 4 weeks ago. Keep in mind I have been doing this for 30 years. I hope this helps. Good luck. Regards. Chuck

FGG 4 week PO


Wesley, Just my two cents here. I am a general dentist as I am guessing you are. I think either of the plans you propose would be fine. Another consideration, and the steps as I would approach this case, would be to remove #18, remove the prosthetics on 19-21, remove the implant #20, graft #20 taking care to inspect the buccal bone. Classify the defect here whether Type 1 or 2 and be ready to place membrane and close primarily. (see Tarnow ice cream cone technique), place healing abutment or better yet cover screw #19, provisionalize #21 if restorable. Allow 4-6 weeks healing and re-evaluate soft tissue gained around #19, if any. At the subsequent appointment, #19 will need treatment for peri-implantitis, while harvesting the CT for #19, you can also ST graft #20, because the tissue was apically re-positioned with the primary closure, and also #21 as the KT is minimal. Hope that helps. Regards!!

PS. If #21 is not restorable, consider PET/SS and possible FPD implant supported 19-21.

Interesting maxillary arch!!!


Thanks for the comments. Good point on future of #21.

I have heard that posterior mandible is more difficult for FGG than anterior mandible, but don't fully understand why.

- what makes posterior mandible more challenging?
- visualization and access?
- bed prep/eliminating muscle pull?
- suturing?

I'd love to hear some ways to critically evaluate difficulty of free gingival graft sites. What makes some harder than others?

Thanks to all.



I am a periodontist( friends with Terry Council), The posterior area is a difficult site for soft tissue grafting because of the thinness of the periosteum and the ability of split thickness bed preperation in that area. proficiency in split thickness surgery is a must if you are planning this in the mandibular posterior area


Just an update on the case.

Treatment done June 14th. I was most concerned with preparation of recipient bed in premolar area due to mental foramen being 12mm from #20 implant platform. Bed prep in this area was a combo of sharp dissection with 15c and blunt dissection (supra-periosteal) of frenum attachment and submucosa with scissors to protect mental nerve branches.

I cut away part of the redundant mucosa on the flap and sutured it apically with chromic gut.

Bed prep I thought went OK, I may look into an angled scalpel holder or Orban knife. My angles felt a little clunky.

My graft seemed to be about 1mm thick, but another perio colleague commented it was likely too thin for this application. I'll definitely keep that in mind next time, as she had almost no pain from donor site.

I was not very pleased with my suturing of the graft to the site, therefore I placed a perio-pack dressing which was removed at 7 days. I'm sorry I didnt get a photo at that time, the office was very busy. My impression was that it looked like I was told to expect.

The photos are from 6 weeks followup. Some successes and some failures. We got increased vestibular depth, lessened but did not eliminate the frenum, and an increase in attached tissue of about 2-3mm.

However, NO KG INCREASE! I was disappointed, but think we gained some minor benefits. I would love some feedback on what the key cause of KG failure most likely was.

Thanks again to all,


Graft Bed
Graft Placed


6 wk followup. I seems to have functioned more as just an apically positioned flap? I think the autograft failed totally

6 wks


Augma Bio