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Free gingival graft: An effective technique to create healthy keratinised gingiva

Article  in  Indian Journal of Mednodent and Allied Sciences · January 2018

DOI: 10.5958/2347-6206.2018.00006.7

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 Indian Journal of Mednodent and Allied Sciences
Vol. 6, No. 1, February 2018, pp- 30-34
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DOI : 10.5958/2347-6206.2018.00006.7

Case Report

Free Gingival Graft: An Effective Technique to Create Healthy

Keratinised Gingiva
Sowmya Nettem1*, Sunil Kumar Nettemu2, Vijendra P. Singh1 and Sangeeta Umesh Nayak3

ABSTRACT
The high labial frenal attachment in mandibular anterior segment is most commonly associated with inadequate width
of attached gingiva. Insufficient attached gingiva contributed to the difficulty in oral hygiene maintenance and
ultimately poor gingival health. Frenectomy, vestibular extension and gingival augmentation procedures either alone
or in combination are often required to maintain adequate health of the gingiva. Clinical relevance: Inadequate width
of keratinised gingiva contributed to the difficulty in oral hygiene maintenance and ultimately poor gingival health.
Frenotomy with free gingival graft (FGG) technique is most predictable in these situations. Objective: To highlight
the importance of keratinised gingiva and overview of the FGG technique.
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KEYWORDS: Gingival, Frenotomy, Free gingival graft, Non-smoker oral hygiene, Harvesting the free gingival graft,
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Adequate nutrition
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INTRODUCTION technique was originally introduced in 1966, by Nabers

The keratinised gingiva extends from the gingival margin
to the mucogingival junction. The function of keratinised
gingiva has the support to the alveolar mucosa and free
gingival margin as well as resistant to traumatic
procedures such as toothbrushing [1] and orthodontic
forces [2]. Periodontal plastic surgery is the branch of
periodontology, focused primarily on the improvement
or elimination of mucogingival problems associated with
inadequate attached gingiva, a shallow vestibule and
aberrant frenum [3,4]. In the past, various authors
considered that the ‘ideal’ amount of attached gingiva
plays an important role for periodontal health [3, 5].
Lindhe et al. [6] have proven that the periodontal health
is not related to the amount of attached gingiva, but the
plaque is the main aetiological factor of periodontal
disease. Free gingival graft (FGG) is a surgical procedure
frequently used in periodontics to increase the amount
of keratinised tissue surrounding a tooth. This surgical
and further described by the extensive work of Sullivan
and Atkins [7]. This technique accomplishes the
following objectives: enhances plaque removal around
the gingival margin, reduces gingival inflammation and
improves aesthetics [8].
Here in this case report, we are presenting the
management of a case of inadequate attached gingiva,
with high frenal attachment and shallow vestibule using
the free gingival autograft.
CASE DESCRIPTION
A 32-year-old male patient reported to the clinic with
the complaint of difficulty in maintaining oral hygiene
and root exposure in the buccal aspect mandibular
anterior segment. Medical history was insignificant and
the patient was a non-smoker. On clinical examination,
moderate amount of plaque and calculus, and lack of

1
Associate Professor, 2Associate Professor & Head, Assistant Professor, Department of Periodontics, Faculty of Dentistry,
Melaka-Manipal Medical College, Melaka, Malaysia
3
Assistant Professor, Department of Periodontics, Manipal College of Dental Sciences, Mangalore, Karnataka, India
*Corresponding author email id: nettemsunil@gmail.com

30
 Free Gingival Graft: An Effective Technique to Create Healthy Keratinised Gingiva
adequate room to place the toothbrush in the lower
buccal vestibule were found. The tension test was
positive due to the high frenal attachment. Intraoral
periapical radiograph revealed around 30% bone loss in
relation to the mandibular incisor teeth. There was no
clinical mobility detected in the incisor teeth. After
thorough clinical examination, a detailed treatment plan
was explained to the patient, which included thorough
scaling and root planing and FGG surgery. A written
informed consent was obtained from the patient.
After professional oral prophylaxis, the patient was
motivated and instructed to use vertical brushing
technique and interdental cleaning aids according to
interdental architecture. Four weeks after phase 1
therapy, the oral hygiene was examined and the gingival
recession, probing pocket depth and width of attached
gingiva were measured before surgery.
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SURGICAL PROCEDURE
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After administration of local anaesthesia, 2% lignocaine
with epinephrine (1:200,000), at planned recipient and
donor site, the following steps were performed:
Preparation of Recipient Site
The recipient site was prepared with initial incision using
#15 blade at the existing mucogingival junction, and a
mucosal (split-thickness) flap was elevated. Muscle
insertions of the frenum were completely released
(Figures 1 and 2).
Harvesting the Free Gingival Graft
The partial thickness graft consisted of epithelium and
a thin layer of underlying connective tissue was
harvested from the first molar–premolar area of the
palate. A band of 2–3 mm of tissue was left around the
gingival margin of the teeth to avoid recession. The
thickness of the graft between 1.0 and 1.5 mm is
important for survival of the graft [10–12]. Haemostasis
(blood clot) is achieved by applying pressure with a
sterile gauze (Figures 3–5).
Immobilisation of the Graft
The gingival graft was adapted to the recipient bed and
finally sutured to the periosteum to secure it in position.
Indian Journal of Mednodent and Allied Sciences
Absolute immobilisation of the graft is the key factor
for the success of this procedure. The labial flap was
sutured to the periosteum apically. The graft was
covered by the periodontal dressing for 10 days (Figures
6 and 7).
Protecting the Donor Site
The donor site was compressed and protected by the
acrylic stent, which was prepared on the preoperative
dental cast. Sutures were removed 10 days after
surgery. After initial healing, the subjects were recalled
every 3 months for supportive periodontal treatment
(Figure 8).
DISCUSSION
FGG consists of gingival epithelium and underlying
connective tissue. Surgical procedure for FGG consists
the removal of the gingival tissue from the donator site
and its transference to the area with lack of keratinised
tissue (receptor site). The advantages of FGG are related
to the increase of the keratinised gingival tissue area
and thickness, graft predictability, technique simplicity
and no post-operative pain at the receptor site (Figure
2). The major limitation of FGG to use is the need of a
second surgical donor site (usually palate) but also from
the edentulous ridge and maxillary tuberosity (Figure
3). Some disadvantages of this procedure included the
second intention healing of the palate, in addition post-
operative discomfort and risks for complications. The
discomfort can be reduced by protecting the area with
a stent or a periodontal dressing (Figure 8).
Adequate dimension of the graft is necessary the
longevity of the graft; it must be sufficiently thin to
enable its adequate nutrition (through propagation of the
fluids) through the receptor site. The chances of necrosis
and exposure of the receptor area will increase with
very thinner graft [9,10]. However, the excess of tissue
in a thicker graft will hinder an adequate nutrition [11].
The harvested gingival graft should be 15–25% larger
than the desired final size. This is to overcome primary
(immediate) and secondary (during healing) contraction.
An average of ~20% of shrinkage is expected during
healing. A thin graft will have less primary, but more
31
 Sowmya Nettem et al.

Figure 4: Harvested free gingival graft

Figure 1: Preoperative frenum position
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Figure 2: Preparation of recipient site

Figure 5: Donor site after FGG harvested

Figure 3: Donor site Figure 6: Adaptation and suturing of FGG

32 Vol. 6, No. 1, February 2018

 Free Gingival Graft: An Effective Technique to Create Healthy Keratinised Gingiva

Figure 7: Graft covered by periodontal dressing Figure 10: Healing at donor site
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Figure 11: Two-month post-operative

Figure 8: Donor site protected by acrylic stent

Figure 9: Two-week post-operative Figure 12: Six-month post-operative

Indian Journal of Mednodent and Allied Sciences 33

 Sowmya Nettem et al.
secondary contraction [10]. A thick gingival graft will
have more primary and less secondary contraction [11].
The sub epithelial tissue of the harvested graft is mostly
composed by a thin connective tissue layer, adipose and
glandular tissue. Adipose and glandular tissue should be
removed from the connective tissue surface of the graft
using a new #15 blade, before placement on the recipient
site.
The healing [12] of the FGG comprises three phases:
(1) stage of plasmatic circulation, in the first 3 days, the
grafted tissue survives by diffusion of nutrients from
the receptor site; (2) revascularisation phase, from 2 to
11 days, new blood vessels proliferate from the
surrounding areas and anastomose to the pre-existing
vessels, in addition to the beginning of the new re-
epithelisation; (3) maturation and functional integration
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phase, from 11 to 42 days, the ‘maturation’ of the vessels
and complete renewal of epithelium occur with keratin
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deposition (Figures 9–12).
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In the presented case, the FGG technique was very
effective. In fact, one procedure achieved three
purposes: frenotomy, vestibular extension (creating more
space to fit the toothbrush) and increase of attached
keratinised mucosa.
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keratinized gingiva during orthodontic treatment: its
significance and impact on periodontal status. Journal
of Periodontology 1981;52(6):307–13.
34
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