What is the recommended flap and incision design for a free gingival graft of a tooth with little keratinised (keratinized) gingiva?

Free Gingival Graft Technique for Tooth 41 with Minimal Keratinized Gingiva

For a free gingival graft on tooth 41 with little keratinized gingiva, create a horizontal partial-thickness recipient bed extending apically into the alveolar mucosa, harvest a thin palatal graft (1-1.5mm thick), and secure it with either interrupted sutures or fixation tacks for simplified manipulation. 1, 2

Recipient Site Preparation

Incision Design

• Make a horizontal incision at the mucogingival junction extending mesially and distally beyond the area requiring augmentation by approximately 3-5mm 2
• Create a partial-thickness (split-thickness) dissection extending apically into the alveolar mucosa to create an immobile, well-vascularized bed 3, 2
• The apical extent should provide adequate surface area to accommodate the graft dimensions needed (typically 10-15mm apicocoronally for mandibular incisors) 2
• Leave periosteum exposed at the recipient site—this is critical for graft revascularization and survival 3

Critical Technical Points

• Avoid full-thickness flap elevation, as the periosteal bed is essential for graft take 3
• In areas with pre-existing alveolar mucosa at the margin (which is your scenario with minimal keratinized tissue), the free gingival graft is specifically indicated over apically positioned flap alone 3
• Ensure the recipient bed is completely immobile—any muscle pull will compromise graft stability 2

Donor Site Harvesting

Palatal Graft Harvest

• Harvest from the palate between the canine and first molar, typically 2-3mm apical to the gingival margin 2
• Use a narrow profile graft (approximately 8-10mm mesiodistally for a single lower incisor) to minimize donor site morbidity 1
• Graft thickness should be 1-1.5mm—thin enough to ensure predictable revascularization but thick enough to provide adequate keratinized tissue 2
• Create a template of the recipient site dimensions before harvesting to ensure proper sizing 2

Donor Site Protection

• Place collagen sponges into the palatal wound and secure with sling sutures for hemostasis 4
• Consider flow composite coverage or other protective dressing to reduce postoperative pain and improve healing 4

Graft Fixation

Traditional Suturing Approach

• Use interrupted sutures with 5-0 or 6-0 monofilament non-absorbable sutures to secure the graft periphery 5
• Suture the graft under slight tension to ensure intimate contact with the periosteal bed 2
• Place sutures at 2-3mm intervals around the entire graft perimeter 2

Simplified Tack Fixation Alternative

• Use 5mm fixation tacks as an alternative to suturing for simplified manipulation and reduced operative time 1
• This technique eliminates suturing requirements while maintaining graft stability 1
• Particularly useful when conventional suturing is technically challenging in the anterior mandible 1

Post-Operative Protocol

Immediate Care (Week 1)

• Restrict to soft food intake with no biting/chewing in the treated area 5
• Prohibit mechanical cleaning of the treated area for 1 week 5
• Prescribe analgesics for pain management 5

Oral Hygiene Protocol

• Begin 0.12% chlorhexidine rinses starting day 3, twice daily for 1 minute, continuing for at least 3 weeks 5, 6
• This timing (day 3 start) allows initial clot stabilization before chemical rinses 5

Suture Removal

• Remove non-absorbable sutures at 10-14 days post-operatively 2

Expected Outcomes and Long-Term Considerations

Success Metrics

• The free gingival graft is highly predictable for producing a specific dimension of keratinized mucosa 7, 2
• Expect to achieve at least 1.5mm of keratinized tissue width, which is the minimum threshold for long-term gingival margin stability 5, 6
• Graft shrinkage of approximately 25% should be anticipated, so oversize the graft accordingly 2

Critical Pitfall to Avoid

• Do not use free gingival graft if root coverage is the primary goal—other techniques (coronally advanced flap with connective tissue graft) are more predictable and esthetic for recession coverage 2
• In your case with tooth 41 and minimal keratinized tissue, the goal is keratinized tissue augmentation, not root coverage, making FGG the appropriate choice 2

Alternative Consideration

If you want to avoid palatal harvesting entirely, L-PRF membranes (3-4 layers) can substitute for the free gingival graft, though this is more commonly described for recession coverage procedures rather than pure keratinized tissue augmentation 5, 6