How would you manage this case of advanced soft tissue recession?

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Posted on By Toni Salama In Soft Tissue Enhancement

My first post to the dental forum! 30-year old patient presents to our clinic due to the severe gingival recession noted on #25. Recession extends into the mucosa with no keratinized tissue present at the base of the defect. Also note high frenum attachment present. How would you manage this case? FGG? SECTG? ADM? Looking forward to hearing your opinions!

Pre-surgical photo
Pre-surgical photo

CTG + Coronally Advanced Flap


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18 Comments

Interesting post. Which technique would provide for maximum root coverage and release of frenum muscle pull? I think this to be a most challenging area and see so many different concepts discussed. FGG, standard CTG, Zuchelli CTG, Tunnel, VISTA or Pinhole etc. What woukd you choose here and why? MAS


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Not similar but I did CAF with CTG


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Different schools all are working according to clinician:
If this case came to Master of CAF he is go for it, other one he will go for tunneling with CTG
Traditional school to do FGG and do second surgery to cover the roots
In my opinion : CAF with CTG in this case will give good result 👌☺️


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Nice one Toni. This to me is a classic case for a FGG to enhance the zone of attached gingiva and orthodontics. Between the two, root coverage will take care of itself once the etiology is corrected . Maurice, thoughts?


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Traditional surgery comsmatically not acceptable and why orthodontic ??


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Of course, many options like Maurice pointed out to start. The question is the etiology and how to prevent recurrence. In my opinion, the FGG is the first step. I'sve seen several cases, where the recession corrects itself after the FGG to increase Attached tissue. in this case the tooth looks like its outside the alveolar envelope, hence the Ortho after FGG. If necessary after allthis, the CTG with its various application techniques , be it CAF or tunnel , is always available.


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Well thought and CONSERVATIVE-PREDICTABLE old school approach. regards Maurice


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As dr salama said of course one of the most challenging areas to decide for you might consider a lateral pedicled graft from mesial?


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Clever thinking...with or without additional CTG?


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Welcome to the forum toni!!
I used to do what we were taught in the residency in these cases. FGG with frenectomy. Followed by a CAF with possible CTG. Ive also tried to tunnel these sites with a ctg but noted some difficulty in advancing the tissue.

Now i go for a tunneling approach and leave the ctg exposed over the root surface. It has to be a large enough ctg though, and i still coronally advance the flap but not fully to cover the graft. A frenectomy at a later phase to eliminate muscle pull.

Good luck and let us know how u managed it.

Regards,
Sherif


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Clever thinking Sherif, well thought out. regards Dr. S


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Toni; Please explain the way you managed and SUTURED this CTG and how this is so different from other approaches...Also, please speak about the root coverage achieved on the lower right 1st bicuspd. Fantastic!! We want more from you now. MAS


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Hi everyone! Thanks for all of your replies and amazing insight! So many different ways to manage this challenging area but I chose Standard CTG with coronally advanced flap. I was able to internally release the muscle attachment in order to allow for adequate coronal advancement and utilized an alternating tunnel technique when possible! Harvested the CTG from the palate and used for site #25, but also utilized CTG at site #28 in order to address the clefting that was present pre-surgically. In regards to the suturing technique, I utilized the vertical mattress sling sutures with 5-0 monofilament sutures in order to stabilize my graft and flap. Looking forward to hear your thoughts on my choice of treatment and continue our discussions! Best, Toni


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Perfect outcome and it will even further improve with time. I usually go with FGG for this cases in order to achieve KG/AG zone and frenum displacement. Lots of times we also get vestibular depth improvement which is a common finding for these cases. Maybe it is time to revisit CTG for these cases :) Ioannis


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I think the same as you my friend....but here no denying the result. regards Dr. Salama


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Fabulous outcome! Congratulations. How do you manage the advanced mucosa and shortened vestibule? Dd you subsequently do a slit thickness apically positioned flap to exose the underlying CT? Or does the area keratinize on its own despite being covered by mucosa?


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Steven; Over time the area becomes keratinized on it's own. If you want to see it sooner then a gingivoplasty can be performed. Dr. Salama


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Gran posteo para su inicio en el forum !!!! Mis felicitaciones por el resultado !!! Que piensa con la perdida te tejido queratinizado que se observa en las piezas 42y 31 con respecto a la situación inicial ? De todas maneras un excelente resultado !! A controlarlo en el tiempo !! Saludos desde Uruguay Eduardo !


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