Free Gingival Graft vs. Sub-Epithelial Connective Tissue Graft: Which Do You Recommend?

Dr. MK asks:
I have treatment planned a patient for placing implants in the mandibular first molar and second molar sites. The patient presents with an inadequate zone of attached gingiva. Which would provide a more predictable therapy to augment the zone of attached gingiva – a Free Gingival Graft or a Sub-Epithelial Connective Tissue Graft procedure? Are there any other procedures that would yield a greater chance of success?

18 thoughts on “Free Gingival Graft vs. Sub-Epithelial Connective Tissue Graft: Which Do You Recommend?

  1. In my hands, in this area a free gingival graft is best. This can be accomplished niceley during a second stage, or uncovering surgery. Implants are placed using a submerged protocol. Then during the uncovering surgery, a free graft is used and guided with healing abutments. Impressions can usually be taken in 8-10 weeks.
    I am sure there are those who would do it quicker, but this technique has never failed for me.

  2. I agree with sb oral surgeon. A free gingival graft will work nicely as described.
    If the patient is very cosmetically oriented and you think may object to a graft of a different color, the connective tissue graft is the best choice then. There is also less discomfort associated with a subepithelial connective tissue graft donor site.
    As far as predictability, both are very predictable, since they would be placed on a vascular bed at the recipient site.
    Good luck!

  3. A free gingival graft is absolutely best. A subepithelial graft supposedly is kinder to the palate-but there is usually slough-so what’s the point? and you usually get a lot uglier result.

  4. As a periodontist, we mostly abandoned free gingival grafting many years ago. Subepithelial connective tissue grafts can yield a much higher percentage of success. In an area like you are describing, there have been reports in the literature about the change in surface keratinization over SECT’s. Alternatively, if you are looking for clinical “pink” tissue in addition to histologically keratinized tissue, you can apically reposition the mucosa 8 weeks after surgery.
    With an FGG in an area with a probably shallow vestibule and generally high muscle pull, it may not be easy for you to stabilize ideally. You may have better take with a fully or partially buried SECT graft.

  5. I also agree with Dr. Horowitz . I like the idea of a partially buried SECT graft with the gingival edge that has the 2 to 2.5 mm of epithelium removed with the connective tissue exposed.

  6. The question of the need of “keratinized” tissue around an implant may not be as important as non-moveable tissue. Often if I have an inadequate band of attached tissue I will do a split thickness flap, similar to the original “Branemark” incision described for the anterior mandible. Once healed a scar band forms towards the vestibule keeping immobile tissue around your fixtures and thereby reducing peri-implantis issues. (and avoiding harvest of palatal tissue). Not sure color match of the posterior molar region can be a real issue.

  7. You may want to look at PerioDerm (Dentsply) as a grafting material. It works great with no discomfort to the palate. Color is VERY good with little to no post operative pain. It works like a FGG.

  8. All good points guys.
    Dr Horowitz, could u describe your surgical technique??
    -SB oral surgeon

  9. Several years ago I completed three mandibular first molar implants. Prior to second stage a “Lip-Switch” procedure was performed, scoring the periosteum beneath the elevated flap & suturing the flap, like a mini-vestubulopasty. The resultant immobile,attached, unkeratinized mucosa required no second site procedure.
    I followed the case for two years until the patient moved out of state.
    Sincerely
    Theodore Grossman DMD

  10. Dear colleague;
    In that sight, FGG is the choice.
    Furthermore if during uncovering stage, you have 3mm of attached gingiva[mucosa], then you may perform a split thickness flap, with an apically repositioning flap. Good luck.
    Dr.Danesh from:Iran

  11. I think that both can be predictally be used. But the Free Gingival Graft can achieve the keratinized zone earlier than the connective tissue graft. I recommend that both in first and in the second stage surgery or immediate loading use the subepitelial connective tissue graft. I use the Free Gingival Graft when no keratinized mucosa is present and before the implant surgery. After tree months, the implants can be positioned.
    Aline Monnerat, DDS, MS
    From Rio de Janeiro, BRAZIL

  12. to utilise a CTG, you have to have a minimum of attached gingival band (even not sufficient) in order to achieve a proper flap closure over the graft. A FGG does not require that and in such posterior areas where 2 mm. of gain may be very useful, prefer FGG. Besides, to decide on the need for such a mucogingival surgery, waiting until uncoverage of the implants is wiser. Placing healing caps or abutments might serve as a support for periodontal dressing, which i think is essential for stabilising a non-pedicle graft and thrombus within.

  13. by the way, why do you call it as sub-epithelial, where supra-epithelial connective tissue does not exist?

  14. As a periodontist I’ve placed both types of gingival grafts over the years. I have not abandoned the use of a free gingival graft at all. The selection of graft type depends on what is to be achieved, and in this case the objective is kerratinized gingiva around proposed implants. A free gingival graft is the obvious choice and it can be performed before implants are done, and this is appropriate if the implants are to be placed together with healing abutments, or at the uncovering step if you plan a 2 step implant treatment.

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