Gingival Grafting: Free Gingival vs Connective Tissue Graft

The gingival graft is the surgical procedure that the periodontist performs to restore the keratinized tissue and to cover the exposed root, and the choice between the free gingival graft and the connective tissue graft determines the outcome that the patient receives. The free gingival graft har...

The gingival graft is the surgical procedure that the periodontist performs to restore the keratinized tissue and to cover the exposed root, and the choice between the free gingival graft and the connective tissue graft determines the outcome that the patient receives. The free gingival graft harvests the strip of the epithelium and the connective tissue from the palate and transplants it to the recipient site, while the connective tissue graft harvests the connective tissue alone and places it under the recipient flap, which preserves the colour and the contour of the tissue that surrounds the graft. The clinician who understands the biology, the indications, and the limitations of each technique selects the graft that the case requires rather than the graft that the habit favours. This article reviews the recession, the two techniques, the comparison, and the maintenance that the long-term result demands.

The Gingival Recession and the Rationale for Grafting

The gingival recession is the exposure of the root surface that follows the loss of the gingival tissue, and the recession that progresses threatens the tooth with the sensitivity, the caries, and the loss of the attachment. The inadequate keratinized tissue that the thin biotype provides is the predisposing factor that the clinician identifies before the recession advances, and the grafting that the clinician performs restores the tissue that the tooth requires for the protection and the stability. The rationale that the graft follows is the coverage of the root, the increase of the keratinized tissue, and the prevention of the further recession.

The Free Gingival Graft

The free gingival graft is the technique that the clinician uses when the goal is the increase of the keratinized tissue rather than the coverage of the root alone, and the graft that the clinician harvests from the palate carries both the epithelium and the connective tissue. The recipient site that the clinician prepares receives the graft that is sutured and stabilised, and the healing that follows the plasmatic circulation and the revascularisation determines whether the graft survives. The drawback that the technique presents is the colour mismatch, because the graft that the clinician harvests from the palate retains the keratinization that the adjacent tissue may not share.

The Connective Tissue Graft

The connective tissue graft is the technique that the clinician uses when the goal is the root coverage with the aesthetic result, and the graft that the clinician harvests from the palate includes the connective tissue alone and the epithelial layer that the clinician removes before the placement. The graft that the clinician inserts under the recipient flap receives the blood supply from the flap and the bed, and the healing that follows produces the coverage that the patient sees and the tissue that blends with the adjacent gingiva. The aesthetic advantage that the technique offers is the colour and the contour that the epithelial layer preserves, which is the reason the technique is the standard for the anterior site.

The Comparison of the Two Techniques

The comparison that the clinician makes between the two techniques follows the indication, the aesthetic demand, the donor site, and the patient preference, and the clinician who matches the technique to the case achieves the result that the patient expects. The free gingival graft that the clinician selects for the thin biotype with the narrow recession delivers the keratinized tissue that the tooth requires, while the connective tissue graft that the clinician selects for the anterior site delivers the coverage and the colour that the patient notices.

The Surgical Technique and the Healing

The surgical technique that the clinician follows decides the healing that the graft achieves, and the clinician who respects the vascular supply, the graft adaptation, and the immobilization gives the graft the environment that the revascularisation requires. The recipient bed that the clinician prepares must expose the bone and the tissue that the plasmatic circulation reaches, and the graft that the clinician sutures with the tension-free adaptation receives the early nutrition from the bed before the new vessels form. The patient who follows the post-operative instruction and avoids the trauma during the first weeks protects the graft that the surgeon has placed.

The Patient Selection

The patient selection that the clinician performs considers the biotype, the recession, the aetiology, the systemic status, and the compliance, and the patient who understands the reason for the surgery cooperates with the plan. The patient who has the plaque and the gingival inflammation must be treated before the graft, because the inflammation that the infection maintains compromises the healing. The smoking that the patient continues reduces the vascular supply that the graft requires, and the clinician who advises the cessation before the surgery improves the outcome that the patient can expect.

The Maintenance and the Home Care

The longevity of the graft depends on the maintenance that the patient provides at home and the clinician supervises at the recall, and the routine that the patient establishes protects the tissue that the surgery has restored. A soft electric brush such as the BrushO cleans the grafted area at the controlled pressure without the abrasion of the delicate margin, and the interdental cleaning that the clinician demonstrates reaches the interproximal surface that the graft has covered. The patient who keeps the recall interval allows the clinician to monitor the tissue and to intervene when the marginal inflammation returns.

Clinical Key Points

- Assess the biotype and the recession before the graft.

- Select the free gingival graft for the increase of the keratinized tissue.

- Select the connective tissue graft for the root coverage in the anterior site.

- Stabilise the graft and protect the vascular supply.

- Maintain the home care and the recall for the long-term result.

Conclusion

The gingival grafting is the procedure that the periodontist applies to the recession, and the choice between the free gingival graft and the connective tissue graft follows the indication, the aesthetic demand, and the tissue that the case requires. The clinician who plans the technique and maintains the result gives the patient the coverage and the stability that the exposed root demands.