When to consider a Gingival Graft?

When to consider an FFG (Free Gingival Graft)?

Welcome to our latest Case of the Month, this month’s issue is specifically for dental professionals interested in expanding their understanding of periodontal grafting techniques. This month’s focus is on the decision-making process involved in selecting the most appropriate graft for managing or preventing gingival recession.

Among the various grafting options, the Free Gingival Graft (FGG) stands out as a practical and gold standard choice for enhancing gum thickness, especially effective in non-aesthetic zones. Over the years, FGG has proven to be a highly predictable procedure, renowned for its stability and effectiveness in preventing further recession. It’s important to note, however, that while FGG excels in fortifying gum tissue, it is not designed for covering existing recession. Join us as we delve into the nuances of this reliable surgical option and explore how it can be integrated into your practice to benefit patient outcomes

Background

A young female patient was referred by her general dentist due to observed gingival recession. She expressed concern about the appearance of her lower teeth, which seemed elongated, and the potential risk of tooth loss. Fortunately, the patient did not experience any tooth sensitivity, nor was she particularly worried about aesthetic issues. It is also noteworthy that she has no history of orthodontic treatment

Figure 1

Clinically

The patient exhibits a generally thin gingival biotype with less than 1mm of keratinised tissue. Tissue blanching was observed upon lip movement adjacent to the LR1 and LL1, indicating the tissue’s thickness apical to the recession. There is no abnormal frenum present, and the vestibular depth is within normal limits (see figure 1). While no signs of traumatic brushing were noted on the LR1 and LL1, the patient reports increased crowding of the lower teeth in recent years. This late lower incisor crowding may contribute to the more pronounced recession observed on the LR1 and LL1 compared to other anterior teeth.

Bone levels were generally acceptable, and her mouth was periodontally stable.

 Treatment options

1. Oral Hygiene Improvement: Adjust the patient’s oral hygiene practices to minimize excessive force, using a single-tufted toothbrush, and monitor for any changes. This approach is non-invasive and suitable for maintaining current conditions, as there are no acute symptoms present. However, given the current root positioning and lack of keratinized tissue, the risk of further recession remains high, particularly in a young patient.
2. Free Gingival Graft (FGG) Surgery: This option aims to thicken the gingival tissues and reduce the risk of further recession. The FGG is known for its predictability and effectiveness, particularly in non-aesthetic zones. However, it is not intended for covering existing recession.
3. Connective Tissue Graft Surgery: Consider this option when there is adequate interdental bone and minimal papilla loss. While root coverage can be achieved, it is less predictable than FGGs, especially in cases with thin tissues or prominent roots. Often, an initial FGG is recommended to thicken tissues, followed by a second surgery for root coverage after three months.
4. Orthodontic Treatment: This involves intruding the LR1 and LL1 to reposition the roots within the arch, potentially reducing the recession’s severity. While effective, the patient expressed a preference for a minimally invasive approach, showing reluctance towards comprehensive orthodontic treatment, though it remains an option for the future.

Treatment decision

After discussing these options, the patient preferred the more predictable and less invasive approach of using a free gingival graft from her palate, while remaining open to considering orthodontic treatment at a later stage.

Treatment Protocol

1. Implement a daily oral hygiene management plan within a comprehensive prevention program to ensure optimal oral health.
2. Perform a free gingival graft surgery, utilising a palatal keratinised graft as the donor site to enhance gingival thickness and stability.
3. Schedule follow-up reviews at two weeks, one month, and subsequently at three and six months to monitor healing and progress.

Figure 2

Outcome:

Primary Outcome:

• Achieve an increase in keratinised tissue from 1mm to 5mm.
• Transform the gingival biotype from thin and vulnerable to one that is robust and thick.

Secondary Outcome:

• Enhance patient comfort during toothbrushing.
• Reduce the risk of further gingival recession.

Discussion

Graft surgery involves two concurrent surgical sites: the donor and the recipient. Patients may experience soreness at the donor site during the healing process, typically lasting up to a week. For larger donor areas, an Essix-type stent with full palatal coverage can be used to minimise discomfort. The recipient site may also experience some pain, but it is generally more manageable.

Common post-operative concerns include bleeding, infection, and bruising, though significant issues are rare. Ensuring a good blood supply to the graft is crucial for success, as proper revascularisation is needed. If the graft is not adequately sutured and secured, there is a risk of movement.

Before undergoing a Free Gingival Graft (FGG) surgery, patients are informed that the graft will likely appear a lighter shade of pink compared to the surrounding tissues (see Figure 2). FGG surgery is generally not recommended in areas where aesthetics are a priority, although it may be necessary as a preliminary step before root coverage procedures.

FGG remains the gold standard for thickening gingivae and reducing the risk of further recession, offering a predictable outcome with long-term stability. It is also highly effective for establishing stable mucosae around dental implants.

References:

Long-term stability of gingival margin and periodontal soft-tissue phenotype achieved after mucogingival therapy: A systematic review, Carbone et al. 2024

 Free Gingival Grafts to Increase Keratinised Tissue: A Retrospective Long-Term Evaluation (10 to 25 years) of outcomes,  Agudigo et al. 2008),

Refer Your Patients for Specialised Care

Encountering complex cases of gingival recession or other periodontal concerns? By referring your patients to us here at Perio and Implants, you ensure they receive advanced treatment options and personalized care, enhancing their oral health outcomes. Get in touch and arrange a referral.