Free Gingival Graft Research Articles

Surgical Management of Gingival Recession Using Free Gingival Autograft: A Case Report

Gingival recession leads to dentinal hypersensitivity, aesthetic problems, root caries, cervical abrasion and difficulty in oral hygiene maintenance. Managing gingival recession often is a great challenge for practitioners. Different surgical techniques have been advocated for root coverage like free soft tissue graft procedures free gingival graft and sub-epithelial connective tissue graft, pedicle soft tissue graft rotational flap and flap advancement, pouch and tunnel technique and guided tissue regeneration. This case report displays use of free gingival graft for management of patient of age 22 years with Miller’s Class I recession defect in lower left mandibular central incisor.

Operculum from Erupting Third Molar: An Alternative Donor Site for an Epithelialised-Free Soft-Tissue Autograft

Gingival augmentation technique is used to increase the thickness of attached gingiva and arresting the progress of recession. Autogenous epithelialised free gingival graft obtained from palate is a well-established periodontal plastic procedure for root coverage and increasing the width of attached gingiva. This case report shows augmentation of attached gingiva from operculum of erupting third molar as an alternative donor site in marginal tissue recession not extending beyond the mucogingival junction with soft and hard tissue loss interdentally of 31 and 41 in a 20-year-old female.

Evaluation of Color and Width of Attached Gingiva Gain in Two Surgical Techniques: Free Gingival Graft and Connective Tissue Graft Covered By Thin Mucosal Flap, a Clinical Trial.

Statement of the Problem:The periodontal health and marginal stability of gingiva can be negatively affected by a number of dental conditions in association with deficiency of attached gingiva. Purpose:This study aimed to compare the color and width of tissue grafted by two surgical techniques of keratinized gingival augmentation, namely free gingival graft(FGG) and connective tissue graft (CTG) covered by thin mucosal flap . Materials and Method: This clinical trial was performed on 15 adult individuals. The patients showed less than 2mm keratinized gingiva on two different recipient sides. One side was to be treated with CTG as the test group and the other side to be treated with FGG as the control group. The amount of keratinized gingiva before the surgery, size of grafted tissue during the surgery and 6 month after the surgery was documented. Six months after healing, the test and control sides were compared in terms of the width of generated gingiva on both sides, and the color match of the grafted areas with the surrounding gingiva or mucosa. The color of the grafted areas was determined and compared by using both professional evaluation and digital evaluation. Results: In digital evaluation, ∆E (which shows color mismatch) was higher in FGG. In professional evaluation, visual analogue scale (VAS) was used by two blinded periodontists. The mean VAS in FGG was less than CTG. The mean increase of gingival width was higher in CTG. The increased width in CTG technique was more than that in FGG technique. This difference was statistically, but not clinically, significant. Conclusion:Higher ∆E in control side and higher mean VAS CTG both showed better color adaptation of CTG side. FGG can be used in case of increasing keratinized gingiva, vestibular depth, and in patients with low smile line without esthetic concerns. However, using connective tissue in the underlying thin mucosal layer is preferred for gingival augmentation if there are adequate vestibule depth and esthetic concerns, like in maxillary canine.

Prosthetic Rehabilitation in Older Adult with Free Gingival Graft: Case Report

Aim: The aim of the present study was to perform the clinical evaluation of the thickness of the soft tissue around dental implants using a free gingival graft obtained from the palate.
 Background: Rehabilitation in elderly patients improves physiological functions and quality of life, and when this rehabilitation involves a surgical stage, it becomes a challenge, even for more experienced surgeons.
 Methods: a 64-year-old, white, female patient with a complaint of difficulty chewing and discomfort stemming from her dental status. Rehabilitation was proposed involving a multidisciplinary approach to reestablish esthetics, function and wellbeing. For such, 4.1 Bone Level Tapered® implants were installed. During the presurgical preparation, a free gingival graft was planned to increase the gingival area using the Miller technique. After establishing the suitability of the oral environment, impressions were made in alginate for the fabrication of an acrylic surgical stent to protect the donor site on the hard palate and minimize the morbidity of the surgical intervention.
 Conclusion: In the case reported, the increase in the gingival tissue using a free gingival graft provided satisfactory peri-implant health in an older patient throughout annual follow-up for 15 years.

Augmentation of keratinized tissue at tooth and implant sites by using autogenous grafts and collagen-based soft-tissue substitutes.

To investigate the effect of three treatment modalities on the gain of keratinized tissue (KT) at tooth and implant sites in dogs. In five dogs, the distal roots of the mandibular second, third and fourth premolars were extracted, while the mesial roots were maintained. After 2months of healing, implants were placed with KT excision. After another 2months of healing, free gingival grafts, collagen-based matrices and apically positioned flap only were applied. The height of KT was measured during implant placement, immediately before soft-tissue grafting and after 10, 30 and 60days. Two months after KT excision, spontaneous KT regrowth was greater at tooth sites than at implant sites (median, 2.0mm vs. 1.1mm). The outcomes of soft-tissue grafting at implant sites favoured the free gingival graft treatment, with a greater final median height (5.0-5.5mm) and increase in KT (4.0-4.2mm). Locations of the recipient sites significantly influenced KT regeneration at both tooth and implant sites. At implant sites, the free gingival graft treatment led to higher KT regeneration. At tooth sites, however, the differences between the three treatment modalities seemed clinically irrelevant.

Autogenous soft tissue grafting for periodontal and peri-implant plastic surgical reconstruction.

This state-of-the-art review presents the latest evidence and the current status of autogenous soft tissue grafting for soft tissue augmentation and recession coverage at teeth and dental implant sites. The indications and predictability of the free gingival graft and connective tissue graft (CTG) techniques are highlighted, together with their expected clinical and esthetic outcomes. CTGs can be harvested from the maxillary tuberosity or from palate with different approaches that can have an impact on graft quality and patient morbidity. The influence of CTGs on soft tissue thickness and keratinized tissue width are also discussed.

Evaluation of the Effects of Er:YAG Laser for the De-Epithelialization of the Palatal Graft in the Treatment of Multiple Gingival Recessions: A Randomized Clinical Trial.

Objective: The purposes of this split-mouth pilot study were to investigate the efficacy of the Er:YAG laser use for the de-epithelialization of the palatal graft in the treatment of the multiple gingival recessions using the bilaminar procedure and also to evaluate the patient-reported esthetic outcomes after 6 months. Materials and methods: Five systemically healthy participants with total 28 bilateral-multiple adjacent maxillary Miller I recessions were included. The treatment was performed with the bilaminar technique [coronally advanced flap (CAF)+de-epithelialized free gingival graft]. De-epithelialization procedure was done with scalpel (control site) or Er:YAG laser (Versawave, Hoya ConBio, San Francisco, CA; 40 hz, 50 mJ/pulse), under water irrigation, noncontact mode (∼1 mm away from the target tissue) in sweeping motion with chisel-type laser (test site). Root coverage and patient-reported outcomes were evaluated at 6 months after the operations. Results: Clinical outcomes of the both treatment sites did not show any statistically significant differences except for the gingival thickness parameter. However, patient-reported outcomes regarding the esthetic appearance of the gingiva was detected in favor of the Er:YAG laser applied sites. Conclusions: Within the limits of the study, it can be concluded that both de-epithelialization techniques were highly effective at 6 months. However, Er:YAG laser-applied grafted sites revealed more uniform and esthetic gingival appearance compared with scalpel-used grafted sites.

Comparison of platelet-rich fibrin and cellulose in palatal wounds after graft harvesting.

The aim of the present study was to compare patient morbidity and healing outcomes of free gingival graft (FGG) harvesting at palatal donor sites and after using platelet-rich fibrin (PRF) and oxidized regenerated cellulose (ORC). FGG harvesting leaves open palatal wounds, which heal by secondary intention. Patients might experience discomfort or pain during the first 2weeks of healing. Eighteen participants requiring two FGG were recruited. The test and control sites were covered with PRF membrane and ORC. The complete epithelialization of the palatal wound, the percentage of wound healing, and postoperative pain were evaluated, 1, 3, and 7days and 2, 3, and 4weeks after surgery. Similar wound size reduction at 1week (test: 36.87%, control: 38.78%) was found. At 2weeks, the majority of the test group (88.89%) showed complete epithelialization, whereas 66.67% of the control group had complete epithelialization (P=.228). Pain was more prevalent in the control group (27.77%) than in the test group (11.1%) on day 1. None of the participants reported any pain or discomfort at the test sites on day 3. PRF seems to reduce patient morbidity, but there is no difference in palatal wound healing (P>.05).

Clinical study of the effect of free gingival graft and apically repositioned flap surgery on peri‐implant keratinized gingival augmentation

Background Peri-implant disease is defined in two forms- mucositis and peri-implantitis. It is estimated that peri-implant mucositis affects up to 48% of implants during 9–14 years follow-up, and peri-implantitis was observed in up to 20% of patients with dental implants 5–10 years after implant placement. Lack of keratinized mucosa has been investigated as a potential contributing factor to peri-implant disease, however, the implant survival and maintenance has not been studied systematically. Aim/Hypothesis The objective of this study is compare and analyze the clinical outcomes of apically repositioned flap surgery and free gingival graft on keratinized gingival augmentation around implants with limited keratinized mucosa. Material and Methods Totally 13 partially edentulous patients treated with submerged implant surgery in mandibular molar area were recruited and divided into three groups- group 1(mean age- 62 years – 5 patients) and group 2 (mean age- 34 years – 4 patients) received free gingival graft 1 month after submerged implant surgery and second stage implant surgery 3 months after submerged implant surgery+ group 3(mean age- 42 years – 4 patients) received apically repositioned flap and second stage implant surgery 3 months after submerged implant surgery. The widths of keratinized gingiva were measured respectively at the time before the apically repositioned flap surgery free gingival graft and 1 month, 6 months after the surgery. The thickness of keratinized gingiva was measured during the operation. Results The widths of peri-implant keratinized gingiva of group 1 and group 2 were (3.3 ± 1.1) mm and (3.4 ± 1.0) mm 1 month after the free gingival graft surgery, (3.1 ± 1.2) mm and (3.5 ± 1.0) mm 6 months after the free gingival graft surgery, respectively. The widths of peri-implant keratinized gingiva in group 1 and group 2 demonstrated no statistically significant differences (P > 0.05). The widths of peri-implant keratinized gingiva of group 3 was (2.4 ± 0.5) mm 1 month after the apically repositioned flap surgery, (1.9 ± 0.3) mm 6 months after the apically repositioned flap surgery, respectively. The widths of peri-implant keratinized gingiva(1 month and 6 months after the apically repositioned flap surgery) in group 3 showed statistically significant differences when compared with group 1 and group 2 (P = 0.008, P = 0.000). Conclusion and Clinical Implications The implant area treated with free gingival graft or apically repositioned flap exhibited increased width of the keratinized gingiva. The implants treated with free gingival graft exhibited more increased width of the keratinized gingiva compared with those treated with apically repositioned flap. Age showed little impact on keratinized gingival augmentation. Both techniques proved to be efficient and a viable treatment option to reduce mucosal inflammation, and avoid possible peri-implantitis.

The histological changes of soft tissue reconstruction in palate and peri‐implant after free gingival graft

The histological changes of soft tissue reconstruction in palate and peri‐implant after free gingival graft

Surgical treatment of peri-implantitis – Consensus report of working group 4

The following consensus report is based on four background reviews (Keeve etal., Implant Dent 2019 28(2): 177-186; Ramanauskaite etal., Implant Dent 2019 28(2): 187-209; Koo etal., Implant Dent 2019 28(2): 173-176; Sculean etal., Implant Dent 2019 210-216). The surgical treatment of peri-implantitis is indicated in the cases where the first choice of treatment, the non-surgical one, failed with recurrence of bleeding and suppuration. The aim of this review was to systematically screen the literature for possible surface decontamination techniques and material during surgical treatment, the surgical regenerative and non-regenerative treatments of peri-implantitis, radiological and clinical outcomes, the importance of the presence of fixed and or keratinised peri-implant gingiva, and to determine predictable therapeutic options for the clinical surgical management of peri-implantitis lesions. Existent clinical, radiographic and microbiological data do not favour any decontamination approaches and fail to show the influence of a particular decontamination protocol on surgical therapy. Using implantoplasty in surgical non-regenerative treatment leads to a significant decrease in bleeding on probing and probing depth, and may result in improvement of clinical and radiographic parameters, up to 3years after surgery compared with mechanical debridement alone. Surgical augmentative peri-implantitis therapy resulted in improved clinical and radiographic treatment outcomes compared with the baseline in the majority of studies with 6 months to 7-10 years of follow-up. There is no evidence to support the superiority of a specific material, product or membrane in terms of long-term clinical benefits. The best treatment modality to improve the width of keratinised attached mucosa and bleeding and plaque scores, and to sustain the peri-implant marginal bone level, is the use of an apically positioned flap combined with a free gingival graft.

A minimal invasive periodontal surgery around implant

Background Various soft tissue manipulations during bone augmentation surgeries, in particular in order to obtain primary and watertight closure of the flaps, weaken the soft tissues. This modification is accompanied by a severe loss of keratinized tissue (KT) and vestibular depth and thereby with displacement of the mucogingival line. The aesthetic and biological integration of implant-prosthesis is directly related to the presence of favorable mucosal conditions. Aim/Hypothesis This case series study was performed to evaluate the quantity and quality of keratinized tissue in 13 sites following the combination of the strip gingival graft technique described by Urban with the use of a xenogeneic collagen matrix over a period of 36 months. Material and Methods 13 sites where selected on healthy and non-smoker 11 patients with a mean age of 59.13 years (range- 22 to 78.5 years, 1 male, 10 females). A combination technique using a free strip gingival graft sutured to the apical end of the recipient bed and a xenogeneic collagen matrix sutured on the coronal bed was done. The strip was harvested from the palate and had only 3 mm wide. The primary outcome measurement was the increase in the width of KT between baseline (T0 at 10 days after surgery) and 36 months post-surgery (T36). The augmented tissue was assessed with a calibrated periodontal probe from the apical extension of the strip graft to the established reference point at T0 and T36. The secondary outcome was the degree of graft shrinkage, expressed in percentage and calculated by measuring the graft contours with the probe in place at T0 and T36. The patient's pain was recorded through a visual analog scale. Postoperative complications, such as infection and bleeding was recorded. Results After 36 months, significant gain in KTW, with an average width at 36 months of 6.15 mm was observed (range between 4 and 9). The percentage of shrinkage was 48.70%. The regenerated soft tissue demonstrated a good healing and homogeneity with the neighboring tissues in 6 sites whereas in 7 sites there where a significant difference of color and texture. Coral pink color was the main color of the gum. Some pale pink white color was observed at the contour. Bridles were observed in 7 sites specially at the contour and the apical end of the strip graft. No postoperative complications, such as intense pain, infection, or bleeding where noticed. No patient complained of pain on the donor site which rapidly epithelialize. All patient required continuous pain medication during the first post-operative 3 days. The score from VAS varies from 1 to 7 (mean 2.61). Paracetamol codeine was the main prescribed molecule. Only one patient needed tramadol. No problem on chewing was noticed. Conclusion and Clinical Implications The strip gingival graft is minimal invasive and seems effective muco-gingival surgery to restore severe loss of keratinized tissue with a minimum of post-operative complications. This gingival graft technique is promising to better the comfort for the patient and reduce morbidity. However, due to unpredictable aesthetic result, it is better to limit this muco-gingival graft on posterior sites. Larger group of patients and long term assessment must be conducted in order to confirm these results.

The comparison of free gingival graft operations around implant or teeth on quality of life

The comparison of free gingival graft operations around implant or teeth on quality of life

The influence of palatal harvesting technique on the donor site vascular injury: A split-mouth comparative cadaver study.

The aim of this study was to evaluate the influence of two harvesting approaches on the donor site vascular injury. A split-mouth cadaver study was designed on 21 fresh donor heads. Every hemi-palate was assigned to receive the trap-door harvesting technique (TDT) or the epithelialized free gingival graft harvesting technique (FGGT). A soft tissue graft was harvested from each side for histology analyses. Betadine solution was used to inject the external carotid artery and a collagen sponge was positioned over the harvested area to compare the amount of "leakage." The mean leakage observed was 16.56±3.01 µL in the FGGT-harvested sites, and 69.21±7.08 µL for the TDT group, a ratio of 4.18 (P<0.01). Regression analyses demonstrated a trend for more leakage at thinner palatal sites for the FGGT group (P=0.09), and a statistically significant correlation for the TDT-harvest sites (P=0.02). Additionally, a shallow palatal vault height (PVH) was associated with a higher leakage in both harvesting groups (P=0.02). The histomorphometric analyses revealed that grafts harvested with TDT exhibited a significantly higher mean number of medium (ø=0.1 to 0.5mm, P=0.03), and large vessels (ø ≥ 0.5mm, P=0.02). Within the limitations of the present research, the TDT resulted in a significantly higher leakage than the FGGT, which was also correlated with the histology analyses where a greater number of medium and large vessels were observed in the harvested grafts.

Early changes of interproximal ridge height with alveolar ridge preservation of maxillary single anterior teeth

This study aimed to provide foundation for interproximal bone preservation to improve esthetic effects of inter-implant papillar by alveolar ridge preservation following tooth extraction of maxillary single anterior teeth. A total of 30 patients requiring maxillary single anterior teeth extraction were randomly divided into test and control groups (15 cases in each group). The test group underwent alveolar ridge preservation after tooth extraction (Bio-Oss bone powder was implanted in alveolar fossa and fixed with surface free gingival graft suture). No other treatment was performed on the control group after tooth extraction. All patients were scanned using cone beam computed tomography with personalized digital radiographic template at 7 days and 6 months after tooth extraction. Then, measurement of height changes at the interproximal and middle buccal was performed. At the mesial and distal interproximal site, ridge height reduction in the test group measured (0.358±0.151) mm, (0.322±0.180) mm, whereas that of control group reached (0.653±0.260) mm, (0.667±0.274) mm, indicating statistical significance (P<0.05). At the middle buccal site, the ridge height reduction of test group amounted to (0.826±0.307) mm, whereas that of control group totaled (1.510±0.625) mm, also presenting statistical significance (P<0.05). Alveolar ridge preservation can reduce absorption of alveolar crest height after tooth extraction, which could improve esthetic effects of inter-implant papillae gingiva.

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.

Free gingival graft and acellular dermal matrix for gingival augmentation: a 15-year clinical study.

This study evaluated clinical outcomes of acellular dermal matrix (ADM) allograft compared with autogenous free gingival graft (FGG) for gingival augmentation after 15years. Twenty-two patients were originally included and evaluated by de Resende et al. (Clin Oral Investig 23:539-550, 2019), and 12 accepted to participate in this longitudinal evaluation. Clinical parameters evaluated were recession depth (RD), probing depth (PD), clinical attachment level (CAL), keratinized tissue width (KTW), and soft tissue thickness (TT). In addition, esthetic perception was evaluated by patients and by a calibrated periodontist. Data were evaluated by ANOVA complemented by Tukey tests (p < 0.05). After 15years, both treatments provided a significant increase in KTW and TT but with superior results for the FGG group (p < 0.05). No differences were observed between groups for PD and CAL. In the ADM group, RD significantly increased in long term, as well as the rate of tissue contraction. The percentage of shrinkage for the ADM group was 59.6%. Conversely, the FGG group presented a creeping attachment of 17.6% and RD significantly decreased in long term. The ADM group presented superior results considering professional esthetic perception. Both treatments longitudinally promoted significant gain of keratinized tissue width and thickness with superior outcomes for the FGG group. The ADM group demonstrated more tissue contraction and gingival recession whereas the FGG group presented creeping attachment. Professional esthetic perception was superior for the ADM group. This study added important clinical data with long-term evaluation of ADM compared with FGG.

A New Approach for Root Surface Biomodification Using Injectable Platelet-Rich Fibrin (I-PRF).

BackgroundThis study investigated the potential effects of Injectable Platelet-Rich Fibrin (I-PRF) on root coverage of free gingival graft surgery.Material/MethodA total of 40 patients with Miller class I or II gingival recession were included. The patients who participated in this study were randomly divided into 2 groups, including the control and experiment groups. The patients in the control group were treated only with free gingival graft (FGG). The patients in the experiment group were treated with free gingival graft and injected with I-PRF as a root surface biomodification agent (FGG+I-PRF). The patients were called back after 3 months, and the amount of exposed root surface was determined and compared to the preoperative findings.ResultsThe mean initial exposed root surface was 4.7±1.49 mm for the FGG+I-PRF group, 4.1±1.07 mm for the FGG group, and 4.4±1.31 mm for all subjects. Three months after the operation, the mean root surface coverage values of the 2 groups were 3.5±1.05 and 3.9±0.78 mm in the control and experiment groups, respectively.ConclusionsThe findings showed that the injection of Injectable Platelet-Rich Fibrin (I-PRF) had a positive effect on root coverage in free gingival graft surgery.

Morphological and Molecular Characterization of Human Gingival Tissue Overlying Multiple Oral Exostoses

Gingival and osseous augmentations are reported as hypertrophic or hyperplastic reactions to different factors including chronic traumatisms and surgeries such as free gingival graft (FGG) that induce an abnormal growth of both hard and soft tissues in genetically predisposed subjects. Since an imbalance in collagen turnover plays a key role in the development of gingival overgrowth leading to an accumulation of collagen in gingival connective tissue, in this study we described the histological and molecular features of three oral overgrowths obtained from a 34-year-old woman previously operated for FGG in order to evaluate a possible relationship between exostoses and overgrown tissue. Healthy and overgrown gingiva were analyzed by histological methods, and the expression of genes and proteins involved in collagen synthesis, maturation, and degradation was assessed in cultured fibroblasts obtained from gingival fragments at the molecular level. Our results show that general morphology and collagen content were similar in healthy and overgrown gingivae. However, fibroblasts obtained from the overgrown gingiva revealed an anabolic phenotype characterized by an increased collagen turnover and maturation. These findings indicate that an exostosis could act as a mechanical stimulus stretching the overlying connective tissue and triggering an anabolic phenotype of gingival fibroblasts and suggest to use minimally invasive surgical techniques to avoid traumatizing the periosteal tissues for the eradication of the exostosis with minimal relapses.

THE USE OF PLATELET-RICH FIBRIN COMBINED WITH FREE GINGIVAL GRAFT IN THE MANAGEMENT OF INSUFFICIENT ATTACHED GINGIVA AT TEETH WITH GINGIVAL RECESSION

Aim: This study was carried to evaluate the effect of the placement of PRF membrane beneath the free gingival graft in gingival augmentation surgeries regarding the changes by time in graft horizontal dimension, vertical dimension and total surface area.Subjects and Methods: Sixteen patients were selected. All the patients showed gingival recession with insufficient attached gingiva. The gingival augmentation surgery was decided to be performed as a primary surgery to increase the attached gingiva with no attempt to cover the recession during this study. Group 1 (test group) included eight patients where the gingival augmentation was performed using a free gingival graft in combination with a platelet rich fibrin membrane placed beneath the graft at the recipient site. Group 2 (control group) included eight patients where the gingival augmentation was performed using a free gingival graft only. The graft vertical dimension (GVD) and the graft horizontal dimension (GHD) were measured using William’s graduated periodontal probe. Plaque index, gingival bleeding index and probing depth were used to monitor the oral hygiene status and gingival health condition throughout the study. All the measures were obtained at 2 occasions; the day of the surgery and 1.5 months after the surgery.Results: Regarding the changes in GVD, a statistically significant greater mean and median percent decrease was noted in group 2 after 1.5 month. The same was obtained with the changes in GHD and graft surface area.Conclusion: Using platelet-rich fibrin beneath free gingival graft in gingival augmentation surgery resulted in successful increase in the attached gingiva with less dimensional changes by time in the transplanted free gingival graft compared to using free gingival graft alone.