Root coverage

hi dear naresh. because of thin gingiva biotype in lateral areas and loss of keratinized tissue in apical site, you can first augment kt with FGG or FCTG then coronally positiond that( a technique was introduced by dr bernimoulin ). fgg alone seems to cant coverage this area compeletly because of recession size. also lateraly pedicle graft in this case is with some risk in adjacent marginal gingiva.
best regard
Ali

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hello. i agree with ali, one stage procedure is too risky, because of the thin biotype (flap necrosis), lack of keratinized tissue and shallow vestibule. So maybe FGG to extend your KT and on a second stage coronally advanced flap would be a right decision. But is it really Miller class III? because the adjacent papilla are not recessive. i think you meant class II?
greets

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Hi Christos, wie geht es dir? Ich bin domi der Halb -Syrer - war Student in Freiburg als du noch in Weiterbildung warst. Mache jetzt auch den FA in Oralchirurgie - schöne Überraschung dass du auch hier bist.

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Here is link to similar case for 17 yr female.
Tunnel technique and CTG, one stage
GOOD LUCK
Paul Kozy
http://kozydds.com/KozyDDS_Home/Periodontal_Plastic_Surgery.html

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I think straight CTG on this one Paul. Do not really need to Tunnel here. Just my thoughts.
Dr. Salama

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I would dissect a sub-ep pocket around periphery of recession area and slip in CTG. This will also relaxation of tissue and allow suturing and closure of recession area to help with initial nourishment of CTG.

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The connective tissue graft would have to cover a great amount of space in this case - about 4mm. There is a risk for a partial necrosis even though there is lateral nutrition because it is just a class II miller class as christos mentioned before. There is a good possibility that the envelope technique has to be performed a 2nd time to cover the remaining recession - no problem but tell the patient and get a signature. As an alternative a coronal positioned flap has to be performed simultaneously with the CTG. Risky but possible and elegant. If one goes for a two stage solution with FGG the risk of failure is being doubled in my opinion. If a FGG is being used one would have to secure space and disconnect muscular fibres apically simultaneously in an area of at least 2 cm because otherwise the graft - after a certain period of time - will be too small. I think it is not a good case for FGG indeed.

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Double papilla design with Connective Tissue Graft is what has worked for me in similar cases

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2 stage surgery for root coverage was documented in litretures before and predictable for this case that patient want complete coverage. FGG or CTG because less adequate blood supply are not first indication for root coverage. indeed we have in this case some hidden recession that is bigger than of this recession on photo. in sullivan & atkins recession grade this recession is wide and deep that means you may have partial coverage only, but you can try one stage procedure.otherwise with other techniques like envelope you cannot augment kt in apical site of recession because there is no keratinized and attached gingiva and we see mocugingival problem

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Thanks guys, I will personally carryout a pouch technique. Relying on the CT receiving blood supply from the sites either side of the recession, as I doubt that I will be able to completely advance the tissue due to the lack of vestibular depth. Hopefully I will post some successful follow up pictures. Many thanks for all your comments and opinions.

Naresh

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Don't forget root preparation.
Reduce prominence. EDTA.

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What a friendly and useful discussion on this board. Nice input from all. Thank you to all.
Dr. Salama

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Maurice.. you nailed it.. dont over think this one... nice zones of keratinized tissue all around lead to a very predictable outcome with CTG... i wish all of my "thin" biotype patients looked like this....

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Dear Naresh
in this case i am gonna go with free connective tissue graft as my first choice and subepithelial connective tissue graft as second choice.also as other collegues have stated we can do stage procedure but i dont think it would be necessary.
best regards.

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DEAR NARESH I HAD EXACTLY THE SAME CASE AND I TREATED WITH THE TECHNIQUE DESCRIBED IN DENTAL XP BY DR SONICK WITH ALLODERM AND THE RESULTS WERE FANTASTIC.BELIEVE ME IT WAS VERY DIFFICULT BECAUSE I HAD TO DEAL WITH VERY THIN BIOTYPE-IMAGINE THAT I USED OPHTALMIC SCALPEL TO RELEASE THE FLAP-BUT IF YOU FOLLOW EXACTLY THE PROTTOCOL THAT IS DESCRIBED-TYPE OF FLAP,SUTURE MATERIAL,EDTA,TECHNIQUE OF SUTURING BACK THE FLAP,ETC YOU WILL HAVE FANTASTIC RESULTS.AND OF COURSE IF YOU COMBINE IT AND WITH BIOMODIFIERS EVEN BETTER.I WILL TRY TO POST MY CASE-PRE OP AND POST OP-FOR THOSE THAT THEY DON T BELIEVE.ALL THE BEST

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Beautiful and enriching discussion. Thanks dentalxp.

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