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Gingival grafting
Gingival grafting
Gingival grafting
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Gingival graft
ICD-9-CM24.2-24.3

In periodontology, gingival grafting, also called gum grafting or periodontal plastic surgery,[1][2] is a generic term for the performance of any of a number of surgical procedures in which the gingiva (gum tissue) is grafted. The aim may be to cover exposed root surfaces or merely to augment the band of keratinized tissue.

Anatomy

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Gums showing recession

The soft tissue in the oral cavity is classified as either keratinized or nonkeratinized based on the presence of keratin in the epithelium.[3] In health, the soft tissue immediately around the teeth is keratinized and is referred to as keratinized tissue or gingiva. Alveolar mucosa is non keratinized oral epithelium and is located apical to the keratinized tissue, delineated by the mucogingival junction (MGJ). It should also be pointed out that mucosa can surround a tooth in health.[4] Nonkeratinized tissue also lines the cheeks (buccal mucosa), underside of the tongue and floor of the mouth. The lips contain both non-keratinized tissue (on the inside) and keratinized tissue on the outside, demarcated by the vermillion border. The dorsum of the tongue is keratinized and features many papillae, some of which contain taste buds.[5]

Exposure of the tooth root due to loss of keratinized tissue around the neck of a tooth is referred to as gingival recession. This can result in sensitivity or pain from the exposed tooth root surface (dentin is more permeable and soft compared to enamel and dentin is what makes up the tooth root).[6] Recession may also cause an unasthetic appearance especially if located in the anterior dentition (front teeth). While not all cases of gingival recession require surgical correction, there are various options if that is what the patient desires.[7] It should be reinforced that recession left untreated will not result in tooth loss, contrary to popular belief. Also, recession that is left untreated can be maintained and the inflammation kept at bay with proper brushing and oral hygiene technique.[4][needs update] On the other hand, if one desires to pursue corrective therapy, there are a wide variety of techniques ranging from autograft (one's own tissue, usually taken from the palate), allograft (another's tissue, cadaver tissue), xenograft (animal tissue, usually porcine or bovine) or simply repositioning of the tissue native to the site.[8]

Rationale

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Gum grafting, also known as a gingival graft or periodontal plastic surgery, is a surgical procedure to reverse gum recession. Gum recession exposes the roots of teeth,[9] which can lead to sensitivity and put teeth at a higher risk of damage or disease[10] due to the loosening of their attachment within the gums and bones of the jaw. Should gum recession continue, bone and keratinized tissue will be at greater risk of being damaged and permanently lost around the teeth. The aim of a gum graft is to extend keratinized tissue of the gums to cover tooth roots,[11] which restores their firm placement within the jaw and prevents further damage.

Options in gum grafting

[edit]

Traditional gum grafting will have a piece of the gums harvested from the roof of the mouth and sutured facing the exposed root to increase the lost keratinized tissue.[11] The limitation in quantity and the morbidity are the limiting factor of this technique. Allografting techniques (skin from cadavers bought from tissue banks) are used as well to supply the surgeon with larger amount of tissues when needed in larger cases,[12] but the type of healing and the risk of possible disease transmission should be considered and disclosed to the patient when opting for such technique.[13]

Advantages of APRF in gum grafting

[edit]

Blood-derived growth factors have been used in medicine and oral surgery for more than twenty years with an abundance of scientific data supporting its role in soft and hard tissue regenerations. APRF introduced by Dr. Choukroun represents the fourth improved generation of such technology and has been widely used in the field of dentistry and oral surgery. The advantages of APRF are of multiple folds: Unlimited amount (only 10 millilitres (0.35 imp fl oz; 0.34 US fl oz) per tube harvested), no risk of rejection or disease transmission (using your own blood), high noble type of healing (autogenous growth factors, hematopoietic or mesenchymal stem cells).[14]

Technique

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Platelet-rich fibrin clots being prepared for use
Gums sutured during a graft

A small amount of blood (10 millilitres (0.35 imp fl oz; 0.34 US fl oz) per tube) is harvested and spun in a centrifuge for eight minutes at 1300 RPM. A fibrin clot packed with blood-derived growth factors, extra cellular matrix and hematopoietic stem cells is fabricated and implanted into the gums above the area of gum recession. Advanced platelet-rich fibrin will promote the patient's own gums to fabricate more gum thus eliminating the need to harvest gums from the roof of the mouth or the use of allografting tissue.

Post-gingival graft

Following this procedure, patients have an improved quality of recovery and require less recovery time due to enhanced healing factors.[15][16][17][18]

Specific procedures

[edit]

Coronally and apically positioned flaps, although technically not grafting procedures, are other forms of a pedicle grafts in that gingival tissue is freed up and moved either coronally or apically. This requires adequate thickness and width of gingival tissue at the base of the recession defect.[citation needed]

A free gingival graft is a dental procedure where a small layer of tissue is removed from the palate of the patient's mouth and then relocated to the site of gum recession. It is sutured (stitched) into place and will serve to protect the exposed root as living tissue. The donor site will heal over a period of time without damage. This procedure is often used to increase the thickness of very thin gum tissue.[citation needed]

A subepithelial connective tissue graft takes tissue from under healthy gum tissue in the palate, which may be placed at the area of gum recession. This procedure has the advantage of excellent predictability of root coverage,[19] as well as decreased pain at the palatal donor site compared to the free gingival graft. The subepithelial connective tissue graft is a common procedure for covering exposed roots.[citation needed]

A lateral pedicle graft, or pedicle graft, takes tissue from the area immediately adjacent to the damaged gingiva. This is not always an option, as the constraint that there must be sufficient tissue immediately lateral to the area of interest is an onerous one. When this procedure is performed, the transplant tissue is cut away and rotated over the damaged area. This can place the donor area at risk of recession as well.[citation needed]

An acellular dermal matrix (such as Alloderm) graft uses donated medically processed human skin tissue as a source for the graft. The advantage of this procedure is no need for a palatal donor site, and though some periodontists consider it equally successful as a subepithelial connective tissue graft,[20] others consider it less successful.[21]

Guided bone reconstruction is a technique in which bone growth is enhanced by preventing soft tissue ingrowth into the desired area and utilizes either resorbable or nonresorbable membranes.[22] Both metallic membranes[23] and membranes supported by a titanium frame[24][25][26] have been tested and have been successful.

Through the advent of micro-surgical procedures these procedures have become more predictable and comfortable for the patients. Gum grafts are usually performed by periodontists who are trained in these procedures, though general-purpose dentists may offer the procedures themselves. Outcome comparisons between both are highly variable, though with periodontists being specially-trained, periodontists generally recommend patients seeking their services over general-practice dentists. A literature review in 2018 showed that the amount of gum recession patients had was reduced after most types of root coverage periodontal surgery procedures. Reported unwanted outcomes were discomfort and pain, mostly related to the site where the tissue graft was taken.[27] This usually occurred in the first week after surgery and had no influence on root coverage outcomes. Currently, more research is needed to determine whether one root coverage technique is more effective than others.[27]

See also

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References

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Revisions and contributorsEdit on WikipediaRead on Wikipedia

Gingival grafting

View on Grokipedia
from Grokipedia
Gingival grafting, also known as gum graft surgery, is a periodontal surgical procedure used to treat gum recession, a condition in which the gingival tissue pulls away from the teeth, exposing the underlying root surfaces. This recession can result from factors such as periodontal disease, aggressive toothbrushing, or genetic predisposition, leading to increased tooth sensitivity, higher risk of root decay, and potential bone loss if untreated. The procedure involves harvesting soft tissue—typically from the patient's palate or a donor source—and transplanting it to the affected area to cover exposed roots, restore gum thickness, and prevent further recession. The primary goals of gingival grafting are to reduce tooth sensitivity, protect against bacterial invasion and caries on exposed , enhance the aesthetic appearance of the gum line, and promote long-term periodontal health. Performed under , the surgery typically lasts about one hour per graft site and has a success rate exceeding 90%, though multiple sessions may be required for extensive . Common techniques include pedicle grafts, such as the coronally advanced flap or laterally positioned flap, which reposition adjacent gingival tissue without detaching it completely; and free grafts, notably the subepithelial connective tissue graft—considered the gold standard for root coverage due to its reliable blood supply and esthetic outcomes—and the free gingival graft, which primarily augments keratinized tissue width. Gingival recession is classified using systems like Miller's (1985), which grades severity from Class I (marginal recession without interdental loss) to Class IV (severe recession with significant bone and soft tissue loss), guiding the choice of grafting method. While traditional autografts from the palate remain the most effective, alternatives like acellular dermal matrix allografts are increasingly used to avoid donor site morbidity. Post-operative care involves avoiding hard foods, maintaining , and monitoring for complications such as or graft failure, with full healing typically occurring within 1-2 weeks.

Background

Definition and Overview

Gingival grafting is a periodontal surgical procedure designed to augment or repair gingival tissue, primarily to cover exposed tooth roots caused by recession. This intervention addresses the apical migration of the gingival margin, which exposes dentin and can lead to hypersensitivity, root caries, and aesthetic concerns. By increasing the width and thickness of attached gingiva, the graft stabilizes the periodontal environment and prevents further tissue loss. The procedure originated in the mid-20th century, with J.M. Nabers introducing free gingival grafts in 1966 as a method to increase keratinized tissue around teeth. Building on this, H.C. Sullivan and J.H. Atkins detailed principles for successful autogenous grafting in 1968, emphasizing donor site selection and vascular integration. Since then, techniques have advanced from basic free gingival grafts to subepithelial grafts, which provide superior root coverage and color blending with surrounding tissues. Gingival recession necessitating such grafts affects 50% of adults aged 18-64 and up to 88% of those over 65, with mandibular showing the highest prevalence due to their thin biotype and mechanical stresses. The fundamental process entails preparing the recipient site by root planing, harvesting donor tissue—typically autogenous from the or using allogeneic/xenogeneic substitutes—and suturing it over the defect to promote and integration.

Relevant Anatomy

The gingiva, or , consists of several key components that surround and protect the . The free gingiva forms the coronal border around the , creating a collar-like structure that includes the , a shallow crevice between the surface and the gingiva. The attached gingiva lies coronal to the mucogingival junction and is firmly bound to the underlying and cementum via fibers, providing stability during mastication. Marginal gingiva refers to the unattached edge of the free gingiva, which is the most coronal portion visible clinically, while interdental papillae are the triangular-shaped soft tissue projections filling the spaces between adjacent , both facially and lingually/palatally. The encompasses the supportive structures around the , including the gingiva, , periodontal ligament, and alveolar bone. is a mineralized layer covering the , serving as the attachment site for the periodontal ligament fibers. The periodontal ligament is a specialized that anchors the to the alveolar bone, containing fibers, fibroblasts, and blood vessels that facilitate support and sensory functions. Alveolar bone forms the , providing bony support, and its crestal portion underlies the attached gingiva; alterations in these components, such as loss of attachment, contribute to by exposing underlying surfaces. The gingiva is divided into distinct zones based on epithelial characteristics and attachments. Keratinized gingiva, including both free and attached portions, features a with a parakeratinized or orthokeratinized surface layer, offering resistance to mechanical stress and microbial invasion. In contrast, non-keratinized mucosa lines the inner aspects of the , cheeks, and floor of the mouth, presenting a smoother, more flexible without surface . The mucogingival junction marks the irregular boundary where the keratinized gingiva meets the more mobile, non-keratinized alveolar mucosa, delineating the transition in tissue texture and attachment. Gingival recession involves the apical migration of the gingival margin, leading to denudation of the tooth root as the junctional epithelium detaches from the . This exposure removes the protective gingival covering over the root's and , resulting in heightened due to direct of dentinal tubules and an elevated risk of root caries from bacterial colonization on the less mineralized root surface.

Causes of Gum Recession

Gingival recession refers to the apical displacement of the gingival margin, resulting in exposure of the root surface. Primary causes include , such as periodontitis, which leads to progressive loss of attachment and support through chronic inflammation induced by bacterial plaque accumulation. Traumatic toothbrushing, often characterized by vigorous horizontal strokes, mechanically abrades the gingival tissues, contributing to recession in approximately 42.7% of cases according to epidemiological data. Orthodontic forces, particularly those involving labial tooth movement beyond the alveolar envelope, can exacerbate recession by stretching or compressing the gingival fibers, especially in susceptible individuals. Contributing factors encompass anatomical and behavioral elements that predispose tissues to . A thin gingival biotype, with minimal keratinized tissue thickness, offers less resistance to inflammatory or traumatic insults, increasing . Aging naturally leads to cumulative tissue remodeling and , with studies showing a progressive rise in prevalence over time. use, particularly , impairs vascular and , significantly elevating incidence through heightened plaque retention and inflammatory response. influences gingival thickness and susceptibility to periodontitis, thereby indirectly promoting in affected individuals. Epidemiologically, gingival recession affects a substantial portion of the adult population, with prevalence rates often exceeding 50% in those over 30 years. It occurs more frequently in males than females, attributed to differences in practices and behavioral factors. Smokers exhibit up to twice the risk compared to non-smokers, while poor —manifested as high plaque and levels—correlates strongly with recession severity across diverse s. Recession defects are classified using Miller's system, proposed in 1985, which categorizes severity based on the extent of gingival margin displacement relative to the mucogingival junction and interdental or loss. Class I involves marginal tissue not extending to or beyond the mucogingival junction, with no interdental or loss, allowing potential for complete root coverage. Class II features extending to or beyond the mucogingival junction but without interdental loss. Class III includes to or beyond the junction with partial interdental or loss, limiting full coverage. Class IV denotes severe extending beyond the junction with greater than 2 mm of interdental or loss in multiple teeth, often precluding complete resolution.

Indications and Preparation

Rationale for Grafting

Gingival grafting is primarily performed to achieve root coverage, which addresses key functional concerns associated with , such as hypersensitivity, progression of recession, and compromised periodontal stability. Exposed surfaces often lead to heightened sensitivity due to the lack of protective enamel and , causing discomfort during eating, brushing, or temperature changes. By covering the root, grafting reduces this hypersensitivity and halts further recession, which can otherwise exacerbate attachment loss over time. Additionally, root coverage enhances aesthetics by restoring the natural contour of the gingival margin, particularly in visible areas like the . Beyond functional restoration, gingival grafting offers significant benefits by improving plaque control and mitigating risks to the exposed . Recession exposes to bacterial plaque, facilitating accumulation that is harder to remove compared to enamel surfaces, thereby increasing the likelihood of root caries and non-carious cervical lesions from abrasion during practices. Grafting augments the keratinized tissue band, creating a more resilient barrier that supports effective plaque removal and reduces the incidence of these complications, ultimately promoting long-term periodontal . Clinical evidence supports the efficacy of gingival grafting, with studies demonstrating mean root coverage rates of 70-90% in mild to moderate cases, contributing to sustained periodontal stability over years. For instance, subepithelial grafts combined with coronally advanced flaps have shown mean root coverage of 74% at one year, with approximately 68% persisting after 20 years. These outcomes underscore the procedure's role in achieving predictable tissue regeneration and preventing disease progression. Grafting is preferred over non-surgical options, such as or orthodontic corrections, when causes persistent symptoms like sensitivity or aesthetic deficits that non-invasive measures cannot adequately resolve, or when there is evidence of ongoing tissue loss despite plaque control. While non-surgical approaches effectively manage and etiologic factors like trauma from brushing, they do not provide the physical coverage needed for protection in progressive cases.

Patient Selection and Contraindications

Patient selection for gingival grafting prioritizes individuals with stable periodontal health, defined as the absence of active , probing depths ≤4 mm, and effective plaque control to support graft integration and long-term stability. Adequate alveolar bone support is essential, particularly in Miller Class I or II defects where interproximal bone levels are preserved to minimize progression of post-grafting. motivation plays a critical role, as success depends on compliance with and follow-up care to prevent complications like graft sloughing or recurrent . Diagnostic evaluation begins with periodontal probing to measure recession depth, clinical attachment levels, and gingival thickness, typically using a calibrated probe to identify defects suitable for grafting. Radiographs, such as periapical or panoramic views, assess underlying bone morphology and support, ensuring no significant osseous defects that could compromise outcomes. Recession measurements, including vertical and horizontal dimensions, further classify the defect and guide technique selection. Contraindications include active periodontal infection, which hinders healing and graft viability, necessitating resolution prior to . Uncontrolled systemic diseases, such as , impair and increase infection risk, making them relative or absolute barriers depending on glycemic control. substantially elevates failure risk, with studies showing complete root coverage rates approximately half in smokers (30%) compared to non-smokers (60%), due to and delayed . is contraindicated owing to potential hormonal influences on healing and ethical considerations for elective procedures. Pre-operative preparation emphasizes , ideally at least two weeks prior, to optimize vascular supply and reduce failure odds. Antibiotic prophylaxis is recommended for patients with specific risk factors, such as , to prevent , though it is not routine for all cases.

Types of Grafts

Autogenous Tissue Grafts

Autogenous tissue grafts utilize the patient's own oral tissues to treat and augment the gingival architecture, offering biological compatibility and reduced risk of rejection compared to donor-derived materials. These grafts are harvested from intraoral sites and transplanted to the recipient area, promoting tissue regeneration through vascularization and integration. The primary subtypes include the free gingival graft, graft, and pedicle graft, each selected based on the clinical objectives such as coverage or increasing keratinized tissue width. The free gingival graft (FGG), typically harvested as an epithelialized full-thickness graft from the , is indicated primarily for augmenting the width of keratinized gingiva in areas with insufficient attached tissue, particularly in shallow or to stabilize progressive . This subtype achieves reliable increases in keratinized tissue, with success rates for root coverage ranging from 9% to 87% mean coverage, though complete coverage is less predictable at 9% to 72%. The donor site is most commonly the , providing thick, robust tissue, but harvesting can lead to morbidity such as postoperative pain and bleeding, which is generally managed with analgesics and protective dressings. Limitations include potential color mismatch with surrounding tissues and variable esthetic outcomes due to the epithelial component. The connective tissue graft (CTG), obtained as a subepithelial connective tissue harvest from the palate, serves as the gold standard for root coverage in Miller Class I and II recessions, addressing both functional and esthetic concerns by providing a natural tissue blend. It is particularly effective for single or multiple adjacent defects, yielding mean root coverage rates of 88% to 98.4% and complete coverage in up to 97% to 100% of cases when combined with techniques like the coronally advanced flap. Palatal donor sites are preferred for their accessibility and thickness, though risks include donor site pain, necrosis, or infection, mitigated by analgesics and hemostatic measures. Key limitations encompass limited donor tissue availability in some patients and the need for a second surgical site, increasing overall morbidity. Pedicle grafts, derived from adjacent gingival tissue without a separate donor site, include variants such as the laterally positioned flap and coronally advanced flap, indicated for shallow s (less than 5 mm) where sufficient neighboring keratinized gingiva is available. These grafts promote root coverage through preserved blood supply from the pedicle base, achieving mean coverage of 55% to 99% and complete coverage in 24% to 95% of cases. Morbidity is minimized as no remote harvest is required, though potential donor site or dehiscence may occur if adjacent tissue is thin. Limitations involve dependency on adequate local tissue volume, restricting use in widespread or severe defects. Overall, autogenous grafts excel in long-term stability but are constrained by donor site availability and the dual-surgical-site morbidity inherent to free grafts, influencing patient selection and procedural planning.

Allogeneic and Xenogeneic Grafts

Allogeneic grafts in gingival grafting involve the use of human cadaver-derived acellular dermal matrices (ADMs), such as AlloDerm, which is processed to remove cellular components and the epidermal layer while preserving the to support host cell migration and vascularization. These materials serve as substitutes for autogenous in root coverage procedures, particularly when combined with techniques like the coronally advanced flap, to treat defects. AlloDerm, introduced for periodontal applications in the late , has been FDA-approved as a human tissue banked product under strict regulations (21 CFR Parts 1270 and 1271), ensuring sterilization and processing to eliminate risks of disease transmission. Xenogeneic grafts, derived from animal sources such as porcine or bovine , provide another off-the-shelf alternative, with materials like non-cross-linked matrices (e.g., Copios® from bovine ) engineered to minimize through and purification. These grafts act as scaffolds that integrate with recipient , promoting , keratinized tissue formation, and gingival thickness augmentation in treatment. Like allogeneic options, xenogeneic materials are FDA-regulated as Class II devices or human/animal tissue products, with approvals dating back to the for dental use, emphasizing rigorous sterilization protocols to prevent adverse immune responses or infections. Both allogeneic and xenogeneic grafts offer key advantages over autogenous tissue by eliminating donor site morbidity—such as , , and scarring—and simplifying , allowing single-stage treatment for multiple sites. Clinical studies report mean root coverage rates of 70-97% for these materials, often comparable to autogenous grafts in short-term outcomes (e.g., 86.7% with bovine matrix at 6 months), though long-term stability (12-18 months) may show slightly lower mean coverage (around 80-88%) versus the gold standard graft's 91-92%. These alternatives are particularly valuable when autogenous harvesting is limited by patient anatomy or preferences, with reduced surgical time (e.g., 36 minutes versus 49 for autogenous) and postoperative discomfort.

Surgical Techniques

General Procedure Steps

Gingival grafting commences with preoperative site preparation, which involves to mechanically debride the exposed root surfaces using ultrasonic or hand instruments and irrigate with sterile saline, ensuring a plaque-free environment for graft adherence. This step addresses underlying etiologies such as or trauma prior to . Local anesthesia is then administered, commonly 2% lidocaine with 1:100,000 epinephrine, to numb the recipient and donor sites, enabling the outpatient procedure without the need for general or in most cases. Anxiolytics may be provided preoperatively for patients with dental anxiety, and an rinse is used to minimize microbial load. Intraoperatively, a precise incision is made at the recipient site, typically a split-thickness envelope flap along the mucogingival junction, to access the area without compromising adjacent papillae. The flap is elevated using periosteal elevators to form a pouch, exposing the root while preserving the for graft stabilization. The prepared graft—sourced from autogenous, allogeneic, or xenogeneic tissues—is positioned over the denuded root surface and secured with interrupted or mattress sutures, such as 5-0 , to promote intimate contact and vascularization. A periodontal dressing is often applied over the sutured site to protect the graft during initial healing. The procedure generally requires including scalpels for incisions, periosteal elevators for tissue reflection, and suture materials for fixation, with the entire process lasting approximately 30 to 90 minutes per site depending on the extent of .

Specific Graft Procedures

The graft (CTG) procedure involves harvesting subepithelial from the using a technique, where a partial-thickness flap is raised via horizontal and vertical incisions to access and excise the graft without including , minimizing donor site morbidity. At the recipient site, a tunnel flap is created by making intrasulcular incisions and undermining the gingival margin to form a pouch, into which the graft is inserted and secured with sutures for tension-free adaptation, promoting minimal scarring and enhanced esthetics. This approach is particularly suited for multiple or esthetically demanding s, with administered as in standard periodontal surgery. The free gingival graft (FGG) entails a full-thickness from the , typically between the premolars, where a rectangular piece of and underlying is obtained using a after outlining the graft dimensions, ensuring adequate thickness for vascularization. The recipient bed is prepared by removing epithelium to expose , and the graft is placed as an onlay, sutured over the denuded root surface to augment keratinized tissue width, though it may result in color mismatch compared to surrounding gingiva. This technique is indicated for shallow recessions with insufficient keratinized gingiva. The pedicle graft encompasses techniques that utilize adjacent gingival tissue while preserving its blood supply. One common method is the laterally positioned flap, which involves raising a split-thickness pedicle flap from the neighboring , rotating it over defect, and suturing it in place without requiring a separate donor site, which simplifies the procedure for localized defects. Adequate donor tissue thickness and no interproximal loss are prerequisites for success, as the flap's blood supply is preserved through its pedicle base. Another pedicle technique is the coronally advanced flap (CAF), where intrasulcular incisions are made around the recession, and a split-thickness flap is elevated apical to the defect, then advanced coronally to cover the exposed and secured with sutures to the or adjacent tissue. This method is suitable for areas with sufficient apical gingiva and is often combined with grafts for better outcomes. In clinical application, a pedicle graft is commonly selected for Miller Class I recessions, where no loss of interproximal bone or occurs, achieving approximately 95% root coverage in treated cases. For Miller Class III recessions involving interproximal bone loss, a graft via tunnel technique yields substantial root coverage, often exceeding 90% in suitable candidates.

Adjuncts and Innovations

Role of Platelet-Rich Fibrin (PRF)

(PRF) is an autologous fibrin matrix derived from a patient's own blood through , forming a natural scaffold rich in platelets, leukocytes, and growth factors such as (PDGF) and transforming growth factor-beta (TGF-β). These components promote tissue regeneration by facilitating slow, sustained release of bioactive molecules that support , , and extracellular matrix formation. Introduced by Choukroun et al. in 2001 as a second-generation platelet concentrate, PRF simplifies preparation compared to earlier methods and avoids the need for exogenous biochemical additives. Preparation of PRF involves drawing 5–40 mL of venous blood into anticoagulant-free tubes, followed by a single centrifugation step at 2700–3000 rpm for 10–12 minutes, yielding a solid clot or compressible that can be manipulated during . This process leverages natural to create a three-dimensional structure without anticoagulants, distinguishing PRF from (PRP), which requires additives that may interfere with polymerization and stability. The resulting PRF serves as a biocompatible barrier and reservoir, enhancing in periodontal applications. In gingival grafting procedures, such as coronally advanced flap (CAF) for root coverage in Miller class I or II recessions, PRF is typically placed over the exposed surface or beneath the flap to accelerate vascularization, reduce , and promote epithelial attachment. Clinical studies demonstrate that PRF adjunctive use improves relative coverage by 10–15% and clinical attachment level compared to CAF alone, while also minimizing postoperative pain and supporting gingival thickness gain. Unlike PRP, PRF's lack of anticoagulants allows for a more natural healing environment, potentially leading to superior long-term tissue integration in periodontal .

Emerging Techniques

Recent advancements in gingival grafting have incorporated integration to enhance tissue regeneration. Dental pulp s (DPSCs) combined with scaffolds, such as hydrogels, have shown promise in regenerating periodontal tissues, including gingival structures, by promoting and formation. Early clinical trials since 2015, including studies such as Ferrarotti et al. in 2018, reported 60-80% success rates in treating intrabony defects with DPSC micrografts, highlighting their potential for gingival augmentation in periodontal defects. As of November 2025, ongoing phase II trials (e.g., NCT03386877) confirm DPSCs' efficacy in stage III periodontitis, with significant periodontal regeneration observed in human subjects. Laser-assisted techniques have emerged as a minimally invasive alternative in gingival grafting procedures. The use of Er,Cr:YSGG lasers for deepithelialization of free gingival grafts enables precise incisions with reduced thermal damage to surrounding tissues. In a randomized split-mouth involving 46 gingival recessions, this method achieved 95% mean root coverage at six months, comparable to techniques, while significantly increasing keratinized tissue width to 3.98 mm versus 3.44 mm (p < 0.05). Benefits include hemostatic effects that minimize intraoperative bleeding and postoperative pain, as supported by studies showing improved comfort and graft integration without sutures. These lasers facilitate faster and enhanced esthetic outcomes in recession treatment. Three-dimensional (3D) printing technologies are advancing the customization of scaffolds for gingival grafting, particularly for complex defects. Biodegradable matrices, such as those fabricated from or composites, are designed using patient-specific to mimic natural periodontal architecture, including gingival and components. Recent developments in have improved scaffold precision and bioactivity, enabling controlled release of regenerative factors for enhanced tissue integration. In periodontal applications, these scaffolds support bone- complex regeneration, with preclinical models demonstrating superior defect filling compared to traditional grafts. As of 2025, hybrid 3D-printed constructs show promise for alveolar ridge preservation, reducing the need for autologous harvesting. Gene therapy holds potential for gingival tissue engineering through targeted delivery of growth factors via viral or nonviral vectors. Adeno-associated viruses (AAV) and plasmids encoding factors like platelet-derived growth factor (PDGF) and bone morphogenetic proteins (BMPs) promote sustained expression to stimulate gingival fibroblast proliferation and matrix synthesis in preclinical models. These approaches address limitations of direct protein delivery by extending bioactivity, with animal studies in dogs and rabbits showing enhanced periodontal regeneration, including gingival coverage. As of 2025, applications remain preclinical, focusing on gene-activated scaffolds for localized therapy, though phase I/II trials for related growth factors indicate safety for future gingival grafting integration. Challenges include optimizing vector specificity to avoid off-target effects in oral environments.

Outcomes and Aftercare

Success Rates and Advantages

Subepithelial connective tissue grafts (SCTG), often combined with coronally advanced flaps, achieve high success rates in root coverage for gingival recession, with mean root coverage percentages of 80% to 95% reported at one year post-surgery in meta-analyses. Complete root coverage occurs in 64.4% to 96.6% of cases treated with SCTG techniques, establishing them as a gold standard for predictable outcomes in localized defects. Long-term stability is favorable, with approximately 85% root coverage maintained at five years for SCTG procedures, though slight increases in recession depth may occur over time due to ongoing tissue remodeling. Gingival grafting provides key advantages, including enhanced through restoration of the natural gumline and , which improves patient satisfaction and smile appearance. It effectively reduces dentin , with meta-analyses showing suppression in 70.8% of cases (95% CI: 64.4%-76.6%) following surgical root coverage, primarily via coverage of exposed dentin tubules. Furthermore, grafting supports long-term periodontal health by increasing keratinized tissue width and halting progressive , thereby reducing risks to stability and supporting structures. Factors influencing success include operator skill in technique execution, patient compliance with postoperative oral hygiene and maintenance, and the initial defect classification, such as Miller Class I or II recessions, which predict higher complete coverage rates compared to advanced classes. Comparative evidence from Cochrane reviews up to 2018 confirms that procedures outperform non-surgical therapies for moderate s, yielding greater reductions in recession depth (mean difference -0.37 mm versus guided tissue regeneration alternatives) and superior gains in keratinized tissue.

Risks, Complications, and Recovery

Gingival grafting procedures, while generally safe, carry risks including postoperative , which occurs in approximately 2% of cases due to oral bacterial . Graft , often partial sloughing from inadequate vascularization, affects up to 5-10% of cases, with smokers experiencing higher rates owing to impaired and increased shrinkage. Proper patient selection, such as avoiding heavy smokers or those with uncontrolled systemic conditions, can help minimize these risks. Common complications include donor site morbidity at the , where pain and tenderness persist for 7-14 days in most patients, accompanied by swelling and in 25-40% of free gingival graft cases. Suture dehiscence may occur within the first 14 days if tension is excessive, leading to partial graft exposure, while esthetic mismatches such as color or texture discrepancies arise in free gingival grafts due to the palatal tissue's distinct characteristics. Less frequent issues encompass formation, prolonged sensitivity, and rare abscesses, often managed conservatively to prevent progression. Recovery typically involves a soft diet for the first week to protect the graft site, with mouth rinses initiated 24 hours post-surgery to reduce bacterial load and promote healing. Brushing should be avoided near the surgical area for 2 weeks, with gentle saline rinses encouraged thereafter; full epithelialization and maturation occur in 4-6 weeks. Pain and swelling, peaking at 2-3 days, are controlled with analgesics like ibuprofen (400-600 mg every 6 hours) combined with acetaminophen, and ice packs for the initial 48 hours. In cases of , systemic antibiotics such as amoxicillin are prescribed, while dehiscence or requires monitoring for 3-6 months before considering revision. Routine follow-up visits at 1, 3, and 6 months assess integration and address any residual sensitivity or esthetic concerns, ensuring optimal long-term outcomes.

References

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