How do you stage FGG/later bone graft/implant placement?

A pt's lower first and second molars are missing on one side. tx planned to have two implants for the missing teeth. 3rd molar stable. He needs a lateral bone graft (thin alveolar ridge) and FGG (inadequate keratinized gingiva) for the lower molar area. How would you stage the above tx procedures?

Drtoast comments:

Consider doing the FGG first which will make the soft tissue easier to manage when you do the bone graft

Greg Kammeyer, DDS, MS comments:

If there is enough keratinized tissue that it will hold a suture, do the bone graft first, second stage the implant and while the implant is integrating, do the FGG. That optimizes the amount of keratinized tissue. When I do the FGG first, I have less net kert. tissue. Be sure to have tension free closure when you release the flap, stay 5mm from the mental foramen, and use vertical mattress sutures with closure.

Bro Mike comments:

Doesn't the non-keratinized tissue hold the tissue well?

Tim Carter comments:

Pros and cons either way... The easiest way would be to do the FGG first for the previously mentioned reason as well as the fact/theory that thick soft tissue provides better stability for bone healing and maintenance. The issue will likely come later because when you do the lateral ridge augmentation you will advance the buccal flap and obliterate the vestibule thus setting up the possibility for an additional graft to recreate the vestibule. Another approach would be to augment first with the understanding that the mucossa will be delicate. If you choose this route I would recommend paying careful attention to your choice of "collagen" membrane. I say "collagen" because it provides an additional benefit of some soft tissue augmentation (demonstrated in the Pin Hole protocol) and clot stability not possible with the teflon products. I hope this helps.

Greg Kammeyer, DDS, MS comments:

great comment. If you want thicker tissue to hold an advanced flap in place, do an Allograft first. Less explaining why you are harvesting palatal tissue twice.

Dr. Jennifer Watters comments:

Might be able to do subepithelial CTG at same time as bone graft leaving most coronal area exposed for keratinized margin at the alveolar ridge. PRF and sticky bone with PRF could assist. Can you post a photo? Doesn't always have to be FGG