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Free Gingival Graft

Mucogingival surgery procedure transferring autogenous keratinized tissue (most commonly from palatal donor site) to recipient site to increase attached gingiva width, prevent further recession, and improve oral hygiene access; gold standard for keratinized tissue augmentation since Bjorn (1963) and Sullivan and Atkins (1968).

Written by: Saygı Hospital Health Guide Editorial Board
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This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

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What is Free Gingival Graft?

Free gingival graft (FGG, autogenous gingival graft) is a mucogingival surgical procedure to increase the width of attached keratinized gingiva at sites with mucogingival deficiency. Originally described by Bjorn in 1963 and refined by Sullivan and Atkins in 1968, FGG transfers a free piece of keratinized masticatory mucosa from a donor site (most commonly hard palate) to a recipient site without maintaining vascular pedicle connection — graft survives by initial plasmatic diffusion (24-48 hours), then revascularization (3-7 days) and organic union (10-14 days).

Indications: 1) Inadequate keratinized tissue width (< 1-2 mm attached gingiva, especially around abutment teeth, restorations, orthodontic appliances); 2) Shallow vestibule with mucogingival problems impairing oral hygiene; 3) Aberrant frenum attachment (high frenum pull causing recession); 4) Prevention of progressive recession in thin gingival biotype (Maynard and Wilson type 4); 5) Pre-prosthetic vestibuloplasty (denture-bearing area enhancement); 6) Peri-implant soft tissue augmentation (keratinized peri-implant mucosa associated with reduced peri-implantitis risk per Lin et al meta-analysis).

Donor site: hard palate from second premolar to mid-second molar, 2-3 mm from gingival margin to avoid greater palatine artery (which exits greater palatine foramen at second/third molar level), depth 1-1.5 mm to avoid fat and glandular tissue; alternative donor sites include edentulous ridges, retromolar pad, tuberosity. Recipient site preparation: split-thickness flap reflection (partial-thickness preserving periosteum on bone), apical positioning, immobile periosteal bed without muscle attachments, graft adaptation with periosteal sutures (5-0 or 6-0 nylon, polypropylene), tight stabilization without dead space (clot formation prevents revascularization).

Symptoms

Visible gingival recession with sensitivity (cold, brushing) — Miller class I-III
Insufficient attached gingiva less than 2 mm at restorations, abutment teeth, or implant sites
Frenum pulling on marginal gingiva causing recession progression
Shallow vestibule preventing adequate oral hygiene
Pre-orthodontic treatment in thin biotype patients (prevention of orthodontic recession)
Peri-implantitis risk in implants without keratinized peri-implant mucosa
Plaque accumulation due to mucogingival junction discomfort (sensitive, mobile alveolar mucosa at gingival margin)
Pre-prosthetic preparation for removable or fixed prosthesis

Risk Factors

Anticoagulant therapy (warfarin INR 2-3, aspirin 100 mg) — coordinate with physician for bleeding risk
Bisphosphonate therapy (medication-related osteonecrosis MRONJ risk in IV bisphosphonates, oral risk minimal)
Diabetes mellitus uncontrolled (HbA1c > 8 percent) — impaired wound healing
Active periodontitis or gingivitis (treat before surgery)
Smoking (impairs revascularization, increases failure rate to 20-30 percent vs 5-10 percent in non-smokers)
Donor site complications: bleeding (greater palatine artery), pain (palatal sensory nerve injury), prolonged healing 3-4 weeks
Recipient site complications: graft necrosis (5-15 percent), color mismatch (palatal tissue color contrast with surrounding gingiva), incomplete root coverage (FGG inferior to connective tissue graft for root coverage)
Patient compliance with postoperative instructions (no smoking, soft diet, no brushing surgical site for 2 weeks, palatal stent wearing)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Visible gingival recession with progressively exposed root surface
  • Tooth sensitivity to cold, sweet, brushing especially in canines and premolars
  • Visible 'long teeth' appearance (esthetic concern)
  • Difficulty maintaining oral hygiene at recession site (plaque accumulation)
  • Pre-orthodontic consultation in thin biotype patient (recession prevention)
  • Implant treatment with insufficient keratinized peri-implant mucosa
  • Frenectomy needed (orthodontic referral for high frenum)
  • Pre-prosthetic preparation for full or partial denture

Treatment Methods

01
Comprehensive periodontal examination: probing depths, attachment levels (CAL), Miller recession classification (Class I — recession not extending to mucogingival junction MGJ, no interproximal bone or soft tissue loss; Class II — extends to/beyond MGJ; Class III — extends to/beyond MGJ with interproximal loss; Class IV — severe interproximal loss with malposition), Cairo recession type (RT1, RT2, RT3), gingival biotype (thin < 1 mm, thick > 1 mm), keratinized tissue width measurement
02
Treatment planning: identify root coverage need vs only keratinized tissue augmentation; FGG ideal for thin attached gingiva increase, suboptimal for esthetic root coverage (use connective tissue graft CTG with coronally advanced flap CAF instead); informed consent (palatal donor pain, color mismatch with FGG)
03
Donor site preparation (palatal harvest): local anesthesia (2 percent lidocaine with 1:80,000 epinephrine, greater palatine nerve block), trace template of recipient site dimensions on palate (1-2 mm from gingival margin to avoid greater palatine artery), incise outline with #15 blade, harvest split-thickness graft 1-1.5 mm thickness using Buser blade or microblade, careful preserving epithelium and lamina propria without fat/glands; achieve hemostasis with collagen plug, gelfoam, or palatal stent
04
Recipient site preparation: local anesthesia (infiltration), horizontal incision at mucogingival junction (or coronal to MGJ if root coverage), split-thickness flap reflection with periosteal elevator, apical positioning, immobile periosteal bed without muscle/frenum attachments; debride root surface (root planing, EDTA conditioning 17 percent for 2 minutes to expose collagen fibrils for graft attachment, root surface biomodification)
05
Graft adaptation and suturing: place graft on prepared periosteal bed, ensure intimate contact (no dead space — clot formation prevents revascularization), suture with 5-0 or 6-0 nylon or polypropylene; circumferential sutures (sling sutures around adjacent teeth), periosteal anchor sutures, gentle digital pressure for 5 minutes to express any blood between graft and bed; periodontal pack (Coe-Pak, COE-PAC) optional for protection
06
Postoperative care: palatal stent (essilon, vacuum-formed) to protect donor site for 2 weeks, prescribe analgesics (ibuprofen 400-600 mg q6h), 0.12 percent chlorhexidine mouthwash 2x daily for 2 weeks, soft diet for 1 week, no brushing surgical sites for 2 weeks (use chlorhexidine swab); avoid smoking strictly (smokers have 20-30 percent failure rate); 7-10 day suture removal
07
Healing and outcomes: graft initial pale white from plasmatic circulation (24-48 hours), pink color returns by day 7-10 from revascularization, organic union by 14 days, complete maturation 4-6 weeks; expected outcomes include keratinized tissue width increase 3-5 mm (FGG), root coverage 35-65 percent (FGG, less than CTG/CAF 80-95 percent), reduced recession progression, improved oral hygiene access; long-term stability 10+ years; failure causes include hematoma under graft (revascularization failure), graft mobility, smoking, infection, palatal nerve injury (rare permanent paresthesia)

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