Would you consider this a successful soft tissue augmentation result??

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Posted on By Maurice Salama In Soft Tissue Enhancement

Would you consider this a successful soft tissue augmentation result?? Patient presents with recession in maxillary anterior region. No occlusal issues and wearing a nightguard. A Semi-lunar Approach was performed with addition of A-PRF Fibrin membranes and CAF. Comments and discussion. Dr. Salama

Semi-lunar approach
Preop image

A-PRF Fibrin
Packing of Fibrin into labial tunnel


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12 Comments

Same patient same day same surgeon with Tunnel and ACDM/PRF.

preop recession
post op root coverage 100%


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Why have you chosen semi-lunar approach?
Thank you so much for this topic, I`m looking forward to learn more! Would love to get access to hands-on courses.
Best regards
Snjezana


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Snjezana; I look forward to seeing you in a few weeks at NYU. You have the best correspondence and enthusiasm to learn like many on this Forum. Nice renderings. As for discussion, I performed Semi-lunar because I find the access to be easy to navigate line angle to line angle BUT I honestly do not think it matters if you use a "little hole" in the tissue, a "gum drop" access or even a VISTA access, they to me are all VESTIBULAR approaches IMHO!
No significant difference.
The access here is for SHARP supra-periosteal dissection into the sulcus and lifting of the papillae. Multiple A-PRF fibrins are placed which provides space and thickness to support the flap coronally. I still prefer a couple of 6.0 PTFE or monofilament sutures to stabilize the CAF.
I do NOT add I-PRF?? Not sure how it would benefit the surgical result?
As for me, the LONG TERM results of any vestibular approach with Fibrin alone has had more relapse at 2 years plus than cases where CTG or ACDM has been added. Also, there remains much more tissue THICKNESS and KT in those cases.....regards Maurice

Vestibular approach with collagen strips and PRF
2 yrs post op


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I agree with your results using PRF as a graft material. The results are never as good as CTG in my cases. I have personally found like your cases you end up with flap retraction. The tissues do get thicker. I don't know if the fibrin itself interferes with the tissue attachment somehow or prolongs the re-attachment possibly? What I find is I get poor results and more retraction of the flap when the marginal existing gingiva is not in contact with the tooth instead has fibrin in between the root surface and the gingiva. When the marginal gingiva is in direct contact with the root surface and the fibrin is tucked more apically the results seem to be a little better. However IMHO nothing is better than autogenous connective tissue and it is my primary choice for graft material. Would be curious to know if any others have similar results or experiences as I have? I personally have not done many cases with PRF because like your cases the results do not compare to connective tissue. Regards... Naheed


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Dr. Salama,
Lovely discussion with solid answers from a highly experienced clinician like yourself. I have two questions:
1- You mentioned that for the lower you used Alloderm and PRF, can you explain where was each placed? Also what is the goal of the mix?

2- The maxilla with semilunar approach as you mentioned it is only a vestibular access, however do you think that after coronally repositioning the tunnel prep will leave this area for secondary intention healing, like Tarnow's technique will end up with shrinkage and recession of the margins?

Naheed- I am partially convinced with your idea that the fibrin sometimes retard the attachment.

Best,
Michel


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Michael;
I hydrate my ACDM in PRF or PRGF and then tuck the fibrins into the vestibular areas and only then place the ACDM on top of the fibrins in location with the remaining KT and closer to the gingival margin positions I desire in my outcome.
As for Semi-lunar, yes I leave the area open partial thickness and allow it to granulate in....like Tarnow but unlike Tarnow I always utilize sutures for the CAF stability.
Dr. Salama


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World class Dr. Salama.

Thanks


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Dr Salama,

Beautiful surgery and spectacular images. I do love the use of semilunar in the anterior maxilla. However, in class 3 defects with interdental attachment loss I prefer to always add a graft, preferably CTG. I've also found this to be the recommendation in latest AAP systematic review on RC.
Must admit though, result here is impressive :)

See you in NY.
Ehab


Reply

Ehab; I agree. I do believe that this will perform BEST with addition of CTG...
As to type of Vestibular Approach it does not truly matter to me BUT I do prefer predominantly SHARP dissection SUPRA-Periosteal over SUB-Periosteal dissection.
Semi-Lunar, VISTA, Apical Stab, Gum Drop, P-hole simply is NOT the KEY to success by itself IMHO.
Dr. Salama


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Totally agree. All tunnels are created equal 😊😊


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Remarkably the focus has been on access, instrumentation and growth factors alone....


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Hi Maurice,
Hope all's well with you and your family. Please give them my best regards.
It's fascinating to see and read about how you treated this case with such impressive results. What prompted this response was your comment that "......P-hole is simply NOT the KEY to success by itself, IMHO." I would assume that "P-hole" means Pinhole...not Pinkhole ( a short-lived knock off which is now re-dupped Gum Drop).
A picture is worth a thousand words. Two pictures below can save even more boring words.
It's a full mouth case treating 24 teeth all in one appointment in two hours and 15 minutes. As of the date of the second photo, the case is 2 years and 11 months.
Question: Would you be comfortable and confident in doing a full mouth case with any of the methods you named, including the go-to golden standard, SCTG? Other than Pinhole(R)-trained doctors, do you know of anyone who has done a full-mouth case involving 24 teeth with a 24-month follow-up?
I am not saying it is impossible. At my presentation to the International Society of Periodontal Plastic Surgeons, one of the co-speakers actually harvested enough palatal tissue to be able to show a full mouth case. It was Herculean and had everyone gasping.
But it is entirely possible for a Pinhole-trained doctor with some experience to routinely do full arches and even once in a while full-mouth cases in the first few months of practice. Should you be interested in seeing their results, I'd happy to share them with you on this Forum.
In any case, my invitation to you to attend the Pinhole(R) seminar still stands. I have been looking forward to seeing you for quite some time now. I certainly can share more with you when you come.
Cheers!
John



Pinhole


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