Free Gingival Graft Surgical Technique
The free gingival graft procedure involves creating a recipient bed, harvesting a palatal graft, securing it with interrupted sutures or fixation tacks, and following strict post-operative protocols to achieve predictable keratinized tissue augmentation. 1
Recipient Site Preparation
- Create a partial-thickness flap at the recipient site and position it apically to expose the underlying periosteum 2
- The recipient bed should be prepared to accommodate the graft dimensions needed to achieve at least 1.5mm of keratinized tissue width, which is the minimum threshold for long-term gingival margin stability 1
- Ensure the periosteal bed is clean and free of epithelial remnants to optimize graft take 3
Donor Site Harvesting
- Harvest the graft from the palate, typically using a narrow profile to minimize donor site morbidity 2
- The graft should include epithelium and a thin layer of underlying connective tissue 4
- For donor site protection, consider the patchwork technique: perform partial de-epithelialization with a lentil bur, create a partial thickness flap to harvest superficial connective tissue, place collagen sponges secured with sling sutures, apply flow composite and light-cure, then add final sling sutures for compression 5
Graft Fixation
Two validated fixation methods exist:
- Primary method: Use interrupted sutures with 5-0 or 6-0 monofilament non-absorbable sutures to secure the graft periphery 1
- Alternative method: Use 5mm fixation tacks for simplified manipulation and reduced operative time 1, 2
The fixation tack approach (sFGG technique) offers advantages in manipulation ease and may reduce operative complexity while maintaining predictable outcomes 2
Post-Operative Protocol
Dietary and hygiene restrictions:
- Restrict to soft food intake with no biting/chewing in the treated area for 1 week 1
- Prohibit mechanical cleaning of the treated area for 1 week 1
Chlorhexidine protocol:
- Begin 0.12% chlorhexidine rinses starting on day 3 (not immediately) to allow initial clot stabilization 1
- Rinse twice daily for 1 minute, continuing for at least 3 weeks 1
- Delaying chlorhexidine until day 3-5 avoids interfering with early soft tissue healing 6
Pain management:
- Prescribe analgesics as needed 6
Expected Outcomes and Predictability
- The free gingival graft is highly predictable for producing a specific dimension of keratinized mucosa 1, 4
- Expect to achieve at least 1.5mm of keratinized tissue width for long-term gingival margin stability 1
- The procedure demonstrates high success rates when proper technique and post-operative protocols are followed 4, 3
Critical Pitfalls to Avoid
Avoid using FGG for root coverage when esthetics matter - other techniques like connective tissue grafts yield more esthetic results and are more predictable for recession coverage 3
Be aware of late complications with de-epithelialized variants - if considering de-epithelialized free gingival grafts (DFGG), understand that major late complications (re-epithelialization, epithelial bands, cul-de-sac, epithelial cysts, bone exostoses) occur only with DFGG and not with standard connective tissue grafts 7
Do not create flaps or releasing incisions unnecessarily - this reduces blood supply and jeopardizes outcomes in certain applications 6