Reports on the use of palatal soft tissue graft (harvested from “the region located behind the third molar”) were originally described in 1902 at the American Dental Club of Paris meeting and published in 1904 in Dental Cosmos [16]. Nonetheless,
the use of palatal free gingival grafts (FGG) and deepening the vestibular fornix was reported in 1963 [17], with surgical standardization occurring some years later [18].
10.3.1 Indications
The following types of defects or conditions may benefit from FGG-based procedures:
• Treatment of periodontal or peri-implant sites lacking a minimum 2 mm band of attached KT
• Treatment of periodontal or peri-implant sites presenting a “thin periodontal bio- type” (i.e., “delicate and tiny highly scalloped gingival and osseous architecture and few or non-keratinized tissue” [8, 19–21])
• Treatment of periodontal or peri-implant sites associated with toothbrushing or other environmental discomfort (i.e., pain)
10.3.2 Contraindications
The following types of defects or conditions may not benefit from FGG-based procedures:
• Treatment of periodontal or peri-implant sites located in esthetic areas—these sites may be improved by the use of FGG-based procedure, but the final tissue color will be different from adjacent gingiva.
• Treatment of sites presenting attached KT width ≥2 mm.
• Treatment of sites presenting “thick and flat” (i.e., “dense, flat gingival and osse- ous architecture and ample width of KT tissue” [8, 19–21]) or even “thick and scalloped” (i.e., “a clear thick fibrotic gingiva and narrow zone of KT” [8, 19–
21]) periodontal biotypes.
10.3.3 Principles of the Surgical Sequence
As previously reported in a prior Springer publication [8], the general basic principles involving FGG-based procedures are noted below (Figs. 10.2, 10.3, 10.4, and 10.5):
• Local anesthesia.
• A number 15C surgical scalpel blade should be used to perform a horizontal inci- sion in the interdental papillae at the level of the cement enamel junction (for marginal FGG), and an intrasulcular incision is made at the tooth/teeth receiving the graft (i.e., it should encompass the entire operative site). A submarginal approach may be used when the free gingiva is considered “thick” [5, 6].
• Two vertical incisions made at the ends of the horizontal incision and extended to the alveolar mucosa follow, and a thin, partial-thickness flap is dissected up to the apical limits of the vertical incision and afterward completely excised.
Fig. 10.2 Basics of the surgical sequence (i.e., de-epithelialization of the site and graft sutured over the recipient bed). See text for description
Fig. 10.3 Gingival recession on mandibular anterior teeth associated with advanced interproxi- mal tissue loss. The patient reported discomfort/pain during toothbrushing (note the lack of KT prior to treatment). The patient underwent nonsurgical periodontal therapy (i.e., scaling and root planning) and FGG prior to orthodontic therapy. Six months after FGG, the patient reported improvements in clinical and patient-reported outcomes
Fig. 10.4 Single gingival recession associated with fixed orthodontic retainer—(a) baseline, fron- tal view; (b) baseline, view of the location of the muscle insert following lower lip retraction; (c) free gingival graft harvested from the palatal vault; (d) graft positioned at the previously prepared recipient site; (e) flap sutured at the recipient site; (f) 2 weeks follow-up, frontal view; (g) 2 weeks follow-up, occlusal view; (h) 2 weeks follow-up, lateral view; (i) 6 months follow-up
a c
b
e
d
f h
i g
Fig. 10.4 (continued)
a c
d b
Fig. 10.5 Mandibular site presenting multiple teeth with gingival recession and a thin periodontal biotype. A free gingival graft was used to decrease recession depth and to increase the width and thickness of keratinized tissue—(a) baseline; (b) graft sutured at recipient bed; (c) 7 days follow- up; (d) 3 months follow-up
• After the recipient site/bed is completely de-epithelized, a FGG is harvested from the palate according to the size required to cover the recipient bed (Fig. 10.4c). However, the graft harvest may be influenced by the palatal vault anatomy. Reiser et al. [22] found that the average distance from the cementoe- namel junction to the neurovascular bundle varies according to the size and shapes of hard palate, from 7 mm for shallow to 17 mm for high (U-shaped) pal- ates. Usually, FGG can be harvested between the distal aspect of the canine and the midpalatal region of the second molar, in order to prevent potential damage and complications associated with severing the greater palatine artery and their major branches, such as hemorrhage.
• The graft should be sutured to the recipient site using 5-0 or 6-0 interrupted/
suspensory nylon/Teflon sutures and without leaving “dead spaces” between the lamina propria and the connective tissue side of the graft and root surface (Figs. 10.4e and 10.5b).
• The sutures may be carefully removed 7–14 days after surgery to avoid injury to the graft (Fig. 10.5c). Patients should be instructed not to perform toothbrushing of the treated area during this period and directed to rinse gently with a mouth- wash containing 0.12% chlorhexidine gluconate twice a day for 2–3 weeks, or until safe and comfortable, toothbrushing can be performed.
• Analgesics, anti-inflammatory drugs, and/or systemic antibiotics may be pre- scribed if necessary.
• Pain and bleeding may occur at the donor site during the early phase of healing due to exposure of the connective tissue layers of the palatal gingival tissue. On the other hand, these adverse effects will not promote alterations in the final anticipated outcomes.