Free gingival graft

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The free gingival graft technique, initially introduced by Bjorn in 1963 and subsequently refined by Sullivan and Atkins in 1968, was intended for the treatment of recession defects. [1] The degree of root coverage achieved has been reported to vary between 11% and 100%.The free gingival graft is a simple, predictable technique for increasing the zone of attached gingiva. [2]

Contents

Free gingival grafting (FGG) is considered the gold standard technique for predictable augmentation of deficient keratinized mucosa (KM) around natural teeth and dental implants. At the 2017 World Workshop, jointly convened by the American Academy of Periodontology and the European Federation of Periodontology, “keratinized mucosa” was defined as the tissue extending from the peri-implant mucosal margin to the movable lining mucosa. [3]

Surgical Steps

  1. Preparing the recipient site: Horizontal papillary incisions are placed at right angles to the papilla at the level of the cementoenamel junction (CEJ). Two vertical releasing incisions extend from the gingival margin to the alveolar mucosa, and a split-thickness flap is elevated without disturbing the periosteum. This intact periosteum provides the vascular bed essential for graft survival. [4] The recipient bed is refined to create a stable, immobile surface capable of supporting graft uptake.
  2. Harvesting the graft: A free gingival graft is typically harvested from the palate due to its thick keratinized tissue. A template matching the recipient site is used to outline the donor area, ensuring proper dimensions. The graft comprising epithelium and a thin layer of connective tissue is carefully removed and trimmed to fit the intended location. [5]
  3. Placement and suturing: The harvested graft is adapted to the recipient bed and sutured at its lateral borders and, when necessary, directly to the periosteum to prevent movement. Digital pressure is applied for several minutes to enhance close contact between the graft and the bed, promoting vascular inosculation and reducing clot space. [6] A periodontal dressing is commonly placed to protect both donor and recipient sites.
  4. Postoperative care: Which is critical for successful healing. Dressings are applied to protect the surgical areas, and patients are instructed to avoid brushing the graft region, maintain good oral hygiene elsewhere, and use antimicrobial rinses as prescribed. Dietary modifications, pain control, and monitoring for complications such as bleeding or graft necrosis support optimal healing. [4]

Advantages and Disadvantages

Advantages

Success rate is calculated by the mean percentage of root coverage over the total initial recession. FGG was able to achieve a success rate of 73%, [7] which is a moderately satisfactory result among the other modalities such as rotational flaps, coronally advanced flaps, guided tissue regeneration and connective tissue graft with percentages ranging between 68% and 91%.

Predictability, on the other hand, refers to the mean percentage of teeth where total root coverage was successfully established. FGG was able to score a result of 57%, with the aforementioned modalities ranging between 30% and 66%. [7]

The relatively high success rate and predictability of FGG denotes it as a favorable choice for increasing the width of keratinized tissue and halting progression of gingival recession, especially in the lower front teeth area. [8]

FGG is a relatively simple procedure as compared to other modalities such as guided tissue regeneration, as the tissue handling is easier [8] and the length of the procedure is considerably shorter. In addition, FGG can be done for multiple teeth at the same time, which is often required in most cases.

Disadvantages

Multiple complications such as post-operative bleeding, pain and discomfort have been reported in majority of the cases, consequently leading to more research into alternative methods or possible modifications that can be made to the conventional FGG. For instance, a study report has shown that the usage of maxillary tuberosity donor graft instead of the conventional palatal donor graft resulted in less post-operative pain and also improved gingival thickness. [9]

The presence of 2 surgical sites namely the donor site (where the graft was acquired) and the receptor site plays a significant role in contributing to the post-operative discomfort and patient’s morbidity. This is mainly due to the risk of hemorrhage and infection of the large wound at the donor site if left untreated. [8]

Graft necrosis and dimensional shrinkage is also a commonly reported complication. Studies have shown a percentage range of 12% to 58%. This significant amount of discrepancy largely depends on the quality of revascularization available. A relationship has been established between an increased number of sutures and reduced revascularization due to the damage imposed on the periosteum in the receptor site [10] Hence, it is advisable to minimize the number of sutures to diminish the risk of hematomas and subsequently reduce the risk of graft necrosis.

FGG may lead to aesthetic concerns due to the unsatisfactory color match between the lighter color of the grafted tissue and the surrounding gingival tissue at the receptor site. As a result, usage of FGG is commonly restricted to non-aesthetic areas. [8] Though, as mentioned above, FGG is a relatively simple procedure, a notable amount of expertise and precision is required to achieve a good aesthetic outcome.

See also

References

  1. ↑ Nibali, Alaa Guni,Luigi (2023-01-02). "The free gingival graft". Dental Update. Retrieved 2025-12-30.{{cite web}}: CS1 maint: multiple names: authors list (link)
  2. ↑ Hall, W. B.; Lundergan, W. P. (April 1993). "Free gingival grafts. Current indications and techniques". Dental Clinics of North America. 37 (2): 227–242. doi:10.1016/S0011-8532(22)00278-6. PMID   8477866.
  3. ↑ Lee, Won-Pyo; You, Jae-Seek; Oh, Ji-Su (2023-11-22). "Technical Note on Simplified Free Gingival Graft Using Tack Fixation (sFGG)". Medicina. 59 (12): 2062. doi: 10.3390/medicina59122062 . PMC   10745066 . PMID   38138164.
  4. 1 2 Goyal, Lata; Gupta, Narender Dev; Gupta, Namita; Chawla, Kirti (January 2019). "Free Gingival Graft as a Single Step Procedure for Treatment of Mandibular Miller Class I and II Recession Defects". World. 8 (1): 12–17. PMC   6409142 . PMID   30873357.
  5. ↑ Srinivas, B. V. V.; Rupa, N.; Halini Kumari, K. V.; Rajender, A.; Reddy, M. Narendra (August 2015). "Treatment of gingival recession using free gingival graft with fibrin fibronectin sealing system: A novel approach". Journal of Pharmacy & Bioallied Sciences. 7 (Suppl 2): S734–739. doi: 10.4103/0975-7406.163524 . PMC   4606698 . PMID   26538956.
  6. ↑ "Gingival Graft Treatment: Procedure and Its Benefits". 2024-11-12. Retrieved 2025-12-31.
  7. 1 2 Camargo, Paulo M.; Melnick, Philip R.; Kenney, E. Barrie (2001). "The use of free gingival grafts for aesthetic purposes". Periodontology 2000. 27 (1): 72–96. doi:10.1034/j.1600-0757.2001.027001072.x. PMID   11551301.
  8. 1 2 3 4 Lahham, Cezar; Ta'a, Mahmoud Abu (2022-08-01). "Clinical comparison between different surgical techniques used to manage advanced gingival recession (Miller's class III & IV)". Heliyon. 8 (8) e10132. Bibcode:2022Heliy...810132L. doi: 10.1016/j.heliyon.2022.e10132 . PMC   9404267 . PMID   36033300.
  9. ↑ Liao, Tsung-Hsuan; Hsu, Min-Hsun; Liao, Yu-Tsung; Chang, Yu-Chao (2023-07-01). "The perspectives of a novel operative procedure for free gingival graft". Journal of Dental Sciences. 18 (3): 1368–1371. doi:10.1016/j.jds.2023.05.013. PMC   10316494 . PMID   37404611.
  10. ↑ Shakiliyeva, Sanubar; Sahin, Demet; Gunpinar, Sadiye; Gursel, Mihtikar (2025). "Comparison of conventional and modified sling suture techniques in free gingival graft operations-a randomized controlled clinical trial". BMC Oral Health. 25 (1) 279. doi: 10.1186/s12903-025-05456-x . PMC   11846402 . PMID   39984903.

Further reading

  1. Guni A, Nibali L. The free gingival graft [Internet]. Dental Update. 2023. Available from: https://www.dental-update.co.uk/content/periodontics/the-free-gingival-graft
  2. >Hall, WB; Lundergan, WP (April 1993). "Free gingival grafts. Current indications and techniques". Dental Clinics of North America. 37 (2): 227–42. doi:10.1016/S0011-8532(22)00278-6. PMID   8477866.
  3. Lee, Won-Pyo; You, Jae-Seek; Oh, Ji-Su (22 November 2023). "Technical Note on Simplified Free Gingival Graft Using Tack Fixation (sFGG)". Medicina. 59 (12): 2062. doi: 10.3390/medicina59122062 . PMID   38138164.
  4. Bur. (2025, March 5). Gingival Graft Techniques Compared: Free Gingival, Pedicle, and Connective Tissue Grafts Explained. Mr Bur. https://www.mrbur.com/blogs/education/comparing-gingival-graft-techniques-free-gingival-grafts-pedicle-grafts-and-connective-tissue-grafts#:~:text=Free%20Gingival%20Graft%20(FGG),without%20a%20second%20donor%20site.
  5. Yu, Miao; Wang, Xiaoying; Wu, Yaping; Sun, Ying (18 February 2025). "The top 100 most cited publications on free gingival graft between 2000 and 2023: a bibliometric and visualized analysis". BMC Oral Health. 25 (1) 251. doi: 10.1186/s12903-025-05622-1 .
  6. Implants, P. (2024, November 19). When to consider a Gingival Graft? Perio & Implant Dental Referral Centre. https://perionimplant.co.uk/when-to-consider-a-gingival-graft/
  7. Guni, Alaa; Nibali, Luigi (2 January 2023). "The free gingival graft". Dental Update. 50 (1): 34–39. doi:10.12968/denu.2023.50.1.34.
  8. Parra, C., Kormas, I., Afouxenides, P., & Foyle, D. (2024). Soft tissue conditioning around teeth: A narrative review. Dentistry Review, 4(3), 100144. https://doi.org/10.1016/j.dentre.2024.100144
  9. Lahham, C., & Ta’a, M. A. (2022). Clinical comparison between different surgical techniques used to manage advanced gingival recession (Miller’s class III & IV). Heliyon, 8(8), e10132. https://doi.org/10.1016/j.heliyon.2022.e10132
  10. Ramanauskaite, A., Obreja, K., Müller, K. M., Schliephake, C., Wieland, J., Begic, A., ... & Schwarz, F. (2023). Three-dimensional changes of a porcine collagen matrix and free gingival grafts for soft tissue augmentation to increase the width of keratinized tissue around dental implants: a randomized controlled clinical study. International Journal of Implant Dentistry, 9(1), 13.
  11. Saad, E. (2023). Clinical Efficacy of Xenogeneic Collagen Matrix as a Comparative Alternative to Free Gingival Graft in Augmenting Keratinized Mucosa Width Around Dental Implants: A Systematic Review and Meta-Analysis. Temple University.
  12. Rokn, A., Zare, H., & Haddadi, P. (2020). Use of mucograft collagen matrix versus free gingival graft to augment keratinized tissue around teeth: a randomized controlled clinical trial. Frontiers in dentistry, 17, 5.
  13. Wei, D., Wang, Q., Sui, H., Qin, Y., Zhang, H., Meng, H., & Han, J. (2025). Efficacy of Collagen Matrix for Establishing Keratinized Mucosa at Dental Implants: A 5‐Year Randomized Controlled Trial. Clinical Implant Dentistry and Related Research, 27(1), e13422.
  14. Augustine D. What is Gingival Graft Treatment? Understanding the Procedure and Its Benefits.Available from: https://draugustine.com/what-is-gingival-graft-treatment-understanding-the-procedure-and-its-benefits/
  15. Zucchelli G, Mounssif I. Periodontal plastic surgery. Periodontal 2000. 2015;68(1):333–68.Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6409142/
  16. Khuller N, Sharma N. Oral mucosal grafting for root coverage: A review. J Indian Soc Periodontol. 2014;18(6):703–9. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4606698/
  17. aiagent completesmilesbv. Gum Grafting Healing Stages: Day-by-Day Guide - Complete Smiles [Internet]. Complete Smiles. 2025 [cited 2025 Dec 10]. Available from :https://completesmilesbv.com.au/gum-grafting-healing-stages-day-by-day-guide/#:~:text=Recovering%20from%20gum%20grafting%20involves,this%20time%20to%20monitor%20progress.
  18. How Long Does it Take for a Free Gingival Graft to Heal? [Internet]. NORTHEAST TEXAS PERIODONTAL SPECIALISTS |. 2024 [cited 2025 Dec 10]. Available from: https://ntxperioandimplants.com/how-long-does-it-take-for-a-free-gingival-graft-to-heal/
  19. Babalı, Selin; Doğan, Başak; Kuru, Leyla; Güngörmek, Hatice Selin (October 2024). "Free Gingival Graft Healing in Young and Adult Individuals". International Dental Journal. 74: S161 –S162. doi:10.1016/j.identj.2024.07.1068.
  20. Tavelli, Lorenzo; Barootchi, Shayan; Stefanini, Martina; Zucchelli, Giovanni; Giannobile, William V.; Wang, Hom-Lay (June 2023). "Wound healing dynamics, morbidity, and complications of palatal soft-tissue harvesting". Periodontology 2000. 92 (1): 90–119. doi:10.1111/prd.12466.
  21. Themes U. Complications, Adverse Effects, and Patient-Centered Outcomes of soft tissue augmentation procedures and the use of gingival soft tissue substitutes [Internet]. Pocket Dentistry. 2015. Available from: https://pocketdentistry.com/complications-adverse-effects-and-patient-centered-outcomes-of-soft-tissue-augmentation-procedures-and-the-use-of-gingival-soft-tissue-substitutes/
  22. Jankowski T, Jankowska A, Palczewska-Komsa M, Jedliński M, Kazimierczak W, Janiszewska-Olszowska J. Patient experience and wound healing outcomes using different palatal protection methods after free gingival grafts: a systematic review. Journal of Functional Biomaterials [Internet]. 2024 Nov 27;15(12):360. Available from: https://pubmed.ncbi.nlm.nih.gov/39728160/
  23. Choi D, Choi D. Gum graft complications - North Texas dental Surgery [Internet]. North Texas Dental Surgery - Wisdom Teeth Removal, All-on-4, Dental Implants and more - Dental Surgery in North Texas. 2025. Available from: https://northtexasdentalsurgery.com/blog/gum-graft-complications/
  24. Castro-Rodríguez Y, Garay KA. Adverse effects of free gingival grafts. Journal of Oral Research [Internet]. 2020 Oct 30;9(5):356–8. Available from: https://www.researchgate.net/publication/348923354_Perspective_Adverse_effects_of_free_gingival_grafts
  25. Camargo PM, Melnick PR, Kenney EB. The use of free gingival grafts for aesthetic purposes. Periodontology 2000 [Internet]. 2001 Oct 1;27(1):72–96. Available from: https://doi.org/10.1034/j.1600-0757.2001.027001072.x
  26. Lahham C, Ta’a MA. Clinical comparison between different surgical techniques used to manage advanced gingival recession (Miller’s class III & IV). Heliyon [Internet]. 2022 Aug 1;8(8):e10132. Available from: https://doi.org/10.1016/j.heliyon.2022.e10132
  27. Liao TH, Hsu MH, Liao YT, Chang YC. The perspectives of a novel operative procedure for free gingival graft. Journal of Dental Sciences [Internet]. 2023 May 17;18(3):1368–71. Available from: https://doi.org/10.1016/j.jds.2023.05.013
  28. Shakiliyeva S, Sahin D, Gunpinar S, Gursel M. Comparison of conventional and modified sling suture techniques in free gingival graft operations-a randomized controlled clinical trial. BMC Oral Health [Internet]. 2025 Feb 21;25(1):279. Available from: https://doi.org/10.1186/s12903-025-05456-x


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