Free Gingival Graft Procedures Research Articles

Palatal Graft Harvesting Site Healing and Pain Management: What Is the Best Choice? An Umbrella Review

The use of free gingival graft (FGG) and connective tissue graft (CTG) from the palate are among the most predictable periodontal and peri-implant plastic surgery procedures. However, palatal harvesting causes severe discomfort in the palatal area in patients undergoing harvesting. The aim of this umbrella review is to evaluate which products or techniques can result in fewer side effects and less morbidity in patients. Systematic reviews, with meta-analysis or not, about postoperative pain and wound healing in patients undergoing surgery to remove a free gingival graft or connective tissue graft from the palatal region, published only in the English language, were electronically searched for on BioMed Central, Scopus, MEDLINE/PubMed, the Cochrane library databases, and PROSPERO register. Of 1153 titles, only 7 articles were included in this review. The reviews included suggest that the more effective interventions for patient-reported outcomes, particularly for pain management, are cyanoacrylate adhesives, platelet-rich fibrin, hyaluronic acid, and the use of palatal stents. Low-level laser therapy also demonstrated good results in palatal wound healing speed after FGG procedures. Also, topical agents were also described. Future studies and more high-quality randomized clinical trials are needed to provide clear descriptions and standardized procedures of interventions to obtain clear results.

Effectiveness of the periodontal dressing upon periodontal parameters during treatment of gingival recession by free gingival graft

Background:Various grafting procedures have been used to convert a thin periodontal phenotype to a thick phenotype, including free gingival graft.Objective:To evaluate the effectiveness of the periodontal dressing upon periodontal parameters such as Pocket depth, width of keratinized gingiva and recession depth during treatment of the Miller class I, II or III gingival recession of the lower anterior teeth. Materials andMethods:34 lower anterior teeth with Miller class I, II or III gingival recession were selected and randomly grouped into two groups. The first group included 19 teeth and was treated with a single-step free gingival graft procedure with the application of the periodontal dressing. The second group had 15 teeth and was treated with a single-step free gingival graft (FGG) procedure without applying the periodontal dressing. Clinical parameters such as probing depth, the width of keratinized gingiva and recession depth were recorded before surgery (B0), two weeks (B1) and three months (B2) after surgery. Results:No significant differences (P>0.05) in PD were observed in both groups at different time intervals and between both groups at two weeks and three months after surgery. However, a significant reduction (P<0.05) in RD in both groups at two weeks and three months after the surgery was seen. Also, both groups saw a significant decrease (P<0.05) at two weeks and three months after surgery. WKG was significantly (P<0.05) increased at two weeks and three months after the surgery in both groups. The difference in the increase was highly significant (P<0.001) between both groups at 2-weeks and 3-months after the surgery.Conclusions:The group that used periodontal dressing at 2-weeks and 3-months after surgery reported greater improvements in root coverage and increased width of keratinized gingiva compared to those who did not use periodontal dressing.

The perspectives of a novel operative procedure for free gingival graft

Graft shrinkage, epithelial disintegration, and even necrosis are the well-known clinical complications during initial healing stage of free gingival graft (FGG) procedure. This article presented a novel operative prodecure for FGG in a dental implant with insufficient keratinized tissue over a 3-year follow-up period. Briefly, donor site for FGG harvested from maxillary tuberosity would minimize the volume of graft shrinkage. The new periosteum suture technique could secure FGG firmly adapted on the recipient site. With 1 mm gap between FGG and muco-gingival junction may improve plasmatic circulation and revascularization. The clinical findings of case report demonstrated that this novel operative procedure may provide a viable therapeutic alternative for FGG.

Evaluation of the significance of keratinized mucosa on peri-implant tissue health: a prospective clinical trial.

The effect of keratinized mucosa on peri-implant tissue health is still inconclusive. This study aimed to evaluate the importance of keratinized mucosa and investigate the impact of the free gingival graft procedure on peri-implant health. At prosthesis delivery, the implants were allocated into three groups, based on the width of keratinized mucosa (KM) and patients' agreement on the free gingival graft procedure: KMS (KM ≥2 mm), KMD (KM <2 mm), and FGG (KM <2 mm initially and having surgically increased keratinized mucosa). Modified plaque index (mPI), probing depth (PD), modified bleeding index (mBI), KM, and marginal bone loss (MBL) were assessed at the baseline, 6-, 12-, and 24-month follow-up periods. Of the 47 patients, 17 belonged to the KMS group, 17 belonged to the KMD, and the remaining 13 patients belonged to the FGG. KMD demonstrated significantly fewer mPI and higher mBI than KMS and FGG at 6 and 12 months. At 24 months, MBL did not differ between the groups; however, PD was significantly greater in the KMD group. Implants with inadequate keratinized mucosa had higher bleeding and pocket depth values despite less plaque accumulation. According to the results, soft tissue grafting should be performed as early as possible. © 2023 Australian Dental Association.

Physiological reaction of anxious patients taking sedative medications before and after periodontal surgery

Clinicians use sedatives for anxiety patients at times in daily practice, but the direct influence of the medication on the wound healing of periodontal tissues is unknown. The aim of this study was to analyze the influence of the short-term administration of diazepam to patients with dental anxiety undergoing free gingival graft (FGG) procedures. A total of 51 FGG procedures in 39 patients were included. Twenty-six anxious patients medicated with 5mg of diazepam from the night before surgery to 7 days after surgery served as the medication group, and the rest served as the control group. Direct examination, photographs and H2O2 were used to evaluate the healing of palatal wounds. Stress levels and sleep quality, and salivary melatonin levels were assessed. On Day 14, complete epithelization of the wounds was noted in 48.39% of the patients in the medication group and 35.29% of the patients in the control group. Regardless of whether they receive medication or not, groups with complete epithelialization by Day 14 had higher levels of preoperative melatonin than those without, with a P value of 0.02. The postoperative melatonin in the medication group tended to present higher levels than the control group. Higher preoperative melatonin levels can accelerate wound healing. The short-term administration of the diazepam seemed to facilitate palatal wound healing by reducing stress and maintaining postoperative melatonin levels. This is the first time the relationships between sedatives, melatonin levels and palatal wound healing has been reported.

Effect of aloe vera hydrogel on the scarring and healing of free gingival graft: Randomized controlled trial

Objective: Several studies have used aloe vera hydrogel to enhance various tissues regeneration to reduce scar formation in wounds. This study aimed to prepare a hydrogel specified for the oral cavity and observe scar formation and healing of free gingival graft after its application compared with the natural healing and scaring of the graft without any material.Design: This study is a randomized controlled clinical trial that included 22 patients with a width of attached gingiva less than 2 mm. after preparing the aloe vera hydrogel and completing the laboratory stage, the hydrogel was randomly applied for 11 patients after the free gingival graft procedure while the other 11 patients did not use any material after the same surgery. Landry’s scale was used to assess the healing index, scarring was evaluated using Mucosal Scarring Index.Results: The healing index was higher in the intervention group with a statistical difference P&lt;0.05 than the control group after three weeks. Moreover, Scar formation in the intervention group was less in the intervention group with a significant difference P&lt;0.05 after 1,2,3,6 months.Conclusion: Within the limitations of our study, the aloe vera hydrogel can be considered as a good topical treatment after oral surgery due to its ability to reduce scar formation and speeding up the healing in the receiving area in free gingival graft procedures.

Simplified Free Gingival Graft Around Implants Using Medical Grade Tissue Cyanoacrylate: A Case Series Report.

The free gingival graft (FGG) procedure using suturing techniques has been widely utilized to effectively increase the amount of attached keratinized gingiva. However, conventional suturing procedures are time-consuming and technique-sensitive. Simplified FGG procedure around teeth and dental implants using medical grade tissue adhesive (cyanoacrylate) is known to overcome drawbacks of traditional suture techniques. However, the clinical application of cyanoacrylate as a means of stabilizing the graft has not been a common practice. The aim of this report demonstrates simplified FGG procedures around dental implants using cyanoacrylate with follow-up results.

Optimized Healing of the Donor Wound Area with Ora-Aid, the Miracle Mix Containing Polymers and Vitamin E: A Case Series

Aim: To assess the donor site (in the palate) wound healing in free gingival graft (FGG) procedures after the placement of Ora-aid wound dressing. Methods: A total of five patients who underwent treatment for isolated gingival recession with free gingival graft procedure were enrolled for the study. The palatal donor site was covered with Ora-aid instead of the traditional acrylic stent.The various parameters assessed were: thickness of palate, pain using the visual analogue scale (VAS), measurement of size of surgical wound, wound healing assessment, direct visual assessment of oedema, suppuration, haemorrhage and necrosis and patient satisfaction through direct interaction/communication. Thus, the purpose of this case series was an objective observation of the donor site after the placement of Oraaid dressing. Results: All of the enrolled subjects showed significant improvement of the wound healing parameters. No untoward post-operative complications were reported. Conclusion: Ora-aid can contribute to a substantial reduction in patient discomfort and thus can be a substitute for the acrylic stent

Clinical Outcomes of Free Gingival Graft Following Recipient Bed Preparation with Er,Cr:YSGG Laser Versus Scalpel: A Split-Mouth Randomized Clinical Trial

Objective: Free gingival graft (FGG) procedure is accompanied with a considerable rate of graft shrinkage. This study was aimed to assess the dimensional changes of FGG after recipient site preparation with Er,Cr:YSGG laser and surgical scalpel. Materials and methods: This split-mouth randomized clinical trial evaluated 11 patients with bilateral lack of keratinized gingiva in mandibular premolars. The test side in each patient was prepared with Er,Cr:YSGG laser (3 W power, 300 mJ energy, 10 Hz frequency, long-pulsed mode), whereas the control side was prepared by surgical scalpel. All FGGs were harvested from the palate with standard dimensions of 14 × 9 mm. The graft width, length, surface area, and shrinkage and color match were measured after 1, 3, and 6 months. Postoperative complications, including pain and bleeding were also evaluated using a questionnaire. Results: In both groups, the surface area and width of graft significantly decreased at all time points compared with baseline but the difference in this respect was not significant between the two groups (p > 0.05). In both groups, maximum shrinkage occurred within the first 3 months. In control group, the surface shrinkage in 3 months was significantly greater than the first month (p = 0.025) without significant difference between groups (p = 0.79). The two groups were not significantly different regarding pain score and bleeding score either. On the day of surgery, the test group had slightly lower pain score and higher bleeding score in comparison to the control group without significant difference. The pain and bleeding scores reduced in both groups with no significant difference (p > 0.05). Conclusions: Er,Cr:YSGG laser has promising results for preparation of FGG recipient site and yields results comparable to those of surgical scalpel.

Palatal pre-suturing for perioperative hemostasis at free gingival graft donor sites: A randomized, controlled clinical trial.

The palatal suture has been well known in literature as a method for palatal hemostasis but has not been validated for its efficacy. The aim of this parallel-arm randomized controlled clinical trial was to evaluate the efficacy of palatal pre-suturing using the greater palatine compression suture (GPCS) in reducing the perioperative hemorrhage associated with the palatal free gingival graft (FGG) procedure. Twenty-four patients requiring the FGG procedure for recession coverage or augmentation of keratinized tissue were recruited in the study and randomized to the GPCS group and the control group. The GPCS was placed using a previously described protocol by a single operator in all the participants in the GPCS group. Perioperative blood loss was estimated by weighing the gauze used to mop the palatal hemorrhage, before and after the procedure. The time required for the surgery was also recorded by an independent observer. Significantly lesser blood loss was observed in the GPCS group (4.33 ± 0.89g) as compared with the control group (8.91 ± 4.16g). The difference in the time taken for the surgical procedure for the GPCS group (73.25 ± 22.35 minutes) was not significantly different from that required for the control group (76.08 ± 14.47 minutes). This study demonstrates that pre-suturing of the palate using the GPCS is an effective technique to reduce the perioperative blood loss associated with the palatal FGG procedure.

Treatment of Gingival Recession with Hypersensitivity using Free Soft-tissue Graft Procedures

Background The main goal of root coverage procedure is complete coverage of the recession defect with a good esthetic result related to the adjacent soft tissues and minimal probing depth after the healing process. Purpose The aim of this study was to compare the efficiency of surgical and nonsurgical treatment options in patients with gingival recession and dentin hypersensitivity (DH). Material and methods 60 patients with gingival recession Miller Class I and II with hypersensitivity and esthetic concerns were included. 30 of them were treated with free soft-tissue graft procedures and control group of 30 people were treated with anti-hypersensitivity gel. Surgically treated patients were separated in two groups: 20 of them- with coronally advanced flap with sub-epithelial connective tissue graft and 10 of them- with free gingival graft. Results We achieved full coverage on the exposed root surfaces in 18 patients treated with coronally advanced flap and de-epithelized graft and partial root coverage in two of them. Patients treated with free gingival graft procedure achieved full root coverage in 6 of them and partial on 4 of them (GR=1 mm after surgery). Surgical treatment led to resolution of the esthetic issues of the patients and elimination or reduction of the DH. In control group there were partial elimination of root sensitivity. Conclusion: In surgical treated group with both techniques we achieved resolution of DH and coverage of the root surface with healthy keratinized tissues. Surgery may be considered for treatment options of DH depending on the indications.

Evaluation of Connective Tissue Grafts Versus Free Gingival Grafts

Root coverage is one of the important aims of periodontal therapy. The aim of the study was to evaluate the connective-tissue grafts (CTG) and free gingival grafts (FGG) in root coverage procedures. A retrospective study of sample size 32 was conducted. These patients underwent a root coverage procedure done using grafts. The details on which graft was obtained from patient records were reviewed and analysed between June 2019 to March 2020. Excel tabulation was done, analysed and transferred to SPSS for statistical analysis. The p value was set at 0.05. In the study, it was found that CTG was used in 56.25% of the patients and FGG was used in 43.75% of the patients undergoing root coverage procedure. It was found that Free gingival grafts (25%) were placed more commonly in females when compared to connective tissue grafts (18.75%). However, in males, connective tissue grafts (37.5%) were placed more commonly than free gingival grafts. (18.75%) The prevalence of connective tissue graft was more when compared to free gingival graft at 36-55 years of age. Connective tissue graft was done more commonly in the age group of 15-35 years. Prevalence of connective tissue grafts was more in males than in females. Within the limits of the study, it was found that connective tissue graft (CTG) procedures performed more than free gingival graft (FGG) procedures following the gold standard for root coverage in gingival recession treatment.

Keratinized tissue gain after free gingival graft augmentation procedures around teeth and dental implants: A prospective observational study.

The primary goal was to compare the amount of keratinized tissue width (KTW) gain after free gingival graft (FGG) procedures around implants and teeth after 6 and 12months of healing. Patients with mucogingival defects (<2mm of KT) around teeth and implants underwent a gingival augmentation procedure by means of a FGG. Clinical measurements were performed with an individual stent to determine keratinized tissue width (KTW), length (KTL), graft shrinkage (GS) and gingival margin position (GMP) at 2weeks, 6weeks, 3months, 6months and 12months after surgery. Twenty-nine patients (35 sites) participated in this prospective study. After surgery, KTW decreased and GS increased significantly in both treatment groups during the whole follow-up period, but the biggest changes were observed at 6weeks. When comparing both treatment groups, implant sites showed significantly more reduction in KTW and more GS. Thus, at 12months, KTW and GS reduced 2.03±2.1mm and 36.74±38.2% in the teeth group and 2.91±12.03mm and 61.8±36.25% around implants, respectively. A significantly greater reduction in KTW and more GS might be expected at implant sites.

Efficacy of free gingival graft in treatment of localized gingival recession in smokers and non-smokers: donor site healing, graft shrinkage and success

Background:Because smoking is harmful to free gingival graft procedures,donor site healing, graft shrinkage and success of root coverage,so The present study was designed to evaluate effect of light smoking(≤10 cigarettes per day)and number of years of cigarettes smoking on free gingival graft procedures (donor site healing and graft shrinkage, success). Methods: A total of 22 patients with miller classI,II gingival recession consist of two group,groupI was 12 non-smokers and groupII 10 smokers(≤10 cigarettes per day,less than five years on smoking habits) . All patients treated with free gingival graft. Phase I therapy was performed for all patients to provide an oral environmental more favorable to wound healing.. The following clinical indices measurements of plaque index, gingival index, probing depth clinical attachment level, recession height ,recession width, width of keratinized gingiva, gingival thickness, graft shrinkage (length, width),immediate and delayed bleeding, complete epithelization and discomfort, sensibilty disorder all were recorded at 1 month,3month and 6month. Results: the non smokers group showed significant decrease of recession width and graft shrinkage area compared to smokers group, The clinical parameters showed improvement in non-smoker group more than smokers group but the difference was not statistically significant.probing depth,clinical attachment level, Recession height, keratinzation tissue width , gingival thickness, the improvement occurs at all follow up periods was more in non smokers than smokers Conclusion: following free gingival graft procedures,free gingival graft undergoes graft shrinkage which decrease amount root coverage ,light and young smokers showed increased in recession width and graft shrinkage area .

A Modified Technique of Tacking Acellular Dermal Matrix to Increase Keratinized Mucosa Around Dental Implants as an Alternative to a Free Gingival Graft: A Case Report

Free autogenous graft was the gold standard to increase the keratinized mucosa (KM) and vestibular depth. The major downfall of this technique is the postoperative morbidity at the donor site. The purpose of this case report is to demonstrate a modified technique using acellular dermal matrix (ADM) to increase the KM around implants to achieve faster healing with less postoperative morbidity. Patient presented with inadequate keratinized tissue band and shallow vestibule at submerged implant sites bilaterally. Initially, surgical procedure of vestibuloplasty in conjunction with free gingival graft (FGG) was performed at one side. However, patient opted for the allograft as a substitute for the other side due to the postoperative discomfort from palatal donor site. On the left side, the FGG procedure was performed in a conventional way stabilizing with sutures. On the right side, the ADM was stabilized with tacks only at recipient site and left exposed. The new vestibule was established and stabilized with tacks. A significant gain of KM and vestibule depth was observed at the site of using ADM when compared with baseline. For the site of using FGG, KM was increased. However, the vestibule was rebounded compared with the site of using ADM with tacks. The use of ADM stabilized with tacks is a predictable procedure that can increase KM and establish stable vestibule around dental implants. It can lead to less chair time, faster healing, and reduced postoperative morbidity compared with autogenous soft tissue graft.

Platelet Rich Fibrin Versus Hyaluronic Acid as palatal wound Dressings following epithelialized free gingival graft harvest: A randomized controlled clinical trial

Introduction: Patient centered outcome became of great interest nowadays. Patient’s pain and discomfort following free gingival graft procedure are common complain. Different palatal dressings are suggested to cover and protect the palatal donor site as stents, collagen gelatin scaffolds, platelet rich fibrin (PRF), hyaluronic acid (HA) and Alvogyl. However, in the literature no ideal agent has been emphasized. Objectives: This randomized controlled clinical trial compares for the first-time the effect of PRF versus HA palatal wound dressings on postoperative pain, post-surgical bleeding, and wound healing. Materials and methods: Following sample size calculation, 30 systemically healthy patients requiring palatal mucosal graft harvesting were randomized to receive either PRF or HA (intervention groups) or gelatin sponge (control group) as palatal dressings. Patient-reported visual analogue score (VAS) pain scores as primary outcome. Post-surgical bleeding and wound healing were considered as secondary outcomes. Results: VAS pain scores were reported minimal in PRF group throughout follow up intervals, PRF was statistically significant when compared to HA group at 3 and 7 days postoperative, PRF was statistically significant when compared to control group from 3 to 30 days postoperative and VAS in PRF was nearly 0 in day 14. PRF group showed the highest value of healing index during all the follow up intervals with mean 4.4 at 30 days that indicates a full healing of palatal wound area. Conclusions: Within this study’s limitations, PRF had better outcomes than both HA and gelatin sponge in means of cost, pain reduction, hemostasis and healing properties.

The effect of low-level laser therapy as an adjunct to periodontal surgery in the management of postoperative pain and wound healing: a systematic review and meta-analysis.

The meta-analysis and systematic review aimed to evaluate the effect of low-level laser therapy (LLLT) as an adjunct to periodontal surgery in the management of postoperative pain and wound healing. An electronic search in 4 databases (PubMed, Embase, Cochrane, and OpenGrey) was conducted for randomized clinical trials reporting the effectiveness of LLLT used as an adjunct to periodontal surgery to alleviate pain and accelerate wound healing compared with surgery alone. Finally, 13 studies were eligible and included. The results showed a significant difference of pain relief between groups at day 3 post-surgery, whereas no difference was found at day 7. Moreover, a significant reduction was observed in the mean analgesic intake during the first week in the LLLT group. On day 14, the adjunctive use of LLLT showed significantly faster re-epithelialization and better wound healing in palatal donor sites following free gingival graft procedures. Based on the results, LLLT used as an adjunct to periodontal surgery positively influenced postsurgical pain control. Low power (≤ 500mW) combined with energy density ≥ 5J/cm2 might be more appropriate for postoperative pain relief. Moreover, adjunctive LLLT to free gingival grafts could significantly accelerate wound healing of palate sites at early healing phase. Multicenter studies using different LLL parameters without postsurgical analgesics are needed to determine optimal laser settings.

Quality of free gingival graft content in youtube videos: Usability in patient information and student education.

The aim of our study is to evaluate the usability of the Free Gingival Graft (FGG) procedure, which is included in YouTube videos, in both patient information and student education. A search was performed on YouTube on December 1, in 2022, using the search term ''Free Gingival Graft''. First 150 videos were pre-evaluated, and 67 videos were included in the study. The length of the videos, the number of views, the number of likes, the presence of animation and the number of months after uploading were evaluated. The quality of the videos was evaluated and analyzed with The Global Quality Score (GQS), Usefulness Score (US) and The Journal of American Medical Association (JAMA) scores. A positive correlation was found between viewer interaction, video duration and quality scores. The median values of the quality scores were 2 for the GQS, 2 for the JAMA score and 1 for the Usefulness score. The level of quality scores was found to be insufficient (poor quality). There is a high level, positive and statistically significant correlation between the GQS and the Usefulness score (r=0.858 and p<0.001). YouTube videos containing the FGG procedure were found to be insufficient for both student education and patient information purposes.

Management of inadequate keratinized gingiva and millers class III or IV gingival recession using two-stage free gingival graft procedure.

Background:Prognosis in the management of Millers Class III or IV gingival recession is often fair to poor, which is further decreased by factors such as inadequate keratinized gingiva. Very few modalities show long-term success in the management of gingival recession with inadequate keratinized gingiva, free gingival graft (FGG) being one such technique.Materials and Methods:Ten individuals with Millers Class III or IV recession and inadequate keratinized gingiva were recruited for the study. The first surgical procedure involved the FGG procedure to increase the width of keratinized gingiva (WOKG). Patients were recalled after 3 months for the second surgical procedure, where the flap was coronally advanced. They were recalled 9 months after the second surgery. WOKG was examined at baseline and 3 months (before the second surgical procedure). Recession depth (RD) and clinical attachment level (CAL) was examined at baseline, at 3 months (before the second surgical procedure) and at 12 months (9 months after the second surgical procedure). The percentage of root coverage was measured at 12 months from baseline.Results:Significant increase in WOKG was seen at 3 months. Significant decrease in RD and CAL was observed at 12 months from baseline. The percentage of root coverage was 76.4%.Conclusion:Two-stage FGG procedure can be a successful modality in the management of Millers Class III or IV recession with inadequate keratinized gingiva. This technique improves the prognosis of such compromised cases.

The role of periodontal plastic surgery in the aesthetic management of localized gingival overgrowth

The localized gingival overgrowths are often a broad clinical expression of an inflammatory response that occurs against the long-standing irritation and/or chronic trauma in the affected gingival site. These reactive gingival overgrowths have a high inclination for the anterior maxillary region. Management of such a lesion is more challenging in the anterior region due to an unaesthetic outcome after surgical excision. Various surgical procedures have been applied for the management of post-excisional unaesthetic mucogingival complications. The free gingival graft (FGG) procedure is an excellent and predictable surgical approach in the root coverage aesthetic procedures. The aesthetic outcome can be enhanced if the periodontal plastic surgical procedure is combined with excisional procedures at the same visit. The purpose of the present case report is to discuss and management of peripheral ossifying fibroma (POF) by combining immediate excision and an FGG for coverage of gingival defect for the best functional and aesthetic outcome. Keywords: Aesthetic, Free gingival graft, Periodontal plastic surgery, Peripheral ossifying fibroma, Reactive gingival lesions.