The free gingival graft (FGG) is one of the oldest and most predictable procedures in periodontal plastic surgery. Originally developed to increase the width of attached gingiva and stabilize the mucogingival junction, the technique remains highly relevant today despite the growing popularity of connective tissue grafts and soft tissue substitutes. In recent years some clinicians have viewed FGG as a “lost art,” largely because other grafting techniques may offer superior esthetic integration in certain situations. However, the ability of FGG to reliably create a durable band of keratinized tissue continues to make it an essential procedure in periodontal and implant surgery.
At its core, a free gingival graft involves harvesting a thin epithelialized graft—usually from the palate—and transferring it to a recipient site where additional keratinized tissue is needed. Because the graft contains both epithelium and underlying connective tissue, it can generate new keratinized tissue that integrates with the surrounding mucosa during healing. This biologic property is what makes FGG uniquely effective for situations where the primary goal is not root coverage or tissue thickening, but rather the creation of stable, resilient keratinized gingiva.
Why Keratinized Tissue Matters
Keratinized gingiva plays an important role in maintaining periodontal and peri-implant health. Sites with insufficient keratinized tissue can be uncomfortable for patients during brushing, which may lead to plaque accumulation and inflammation. Thin, mobile mucosa can also be more prone to mechanical trauma, recession, and marginal instability. For these reasons, many clinicians aim to maintain or create an adequate zone of keratinized tissue around teeth and implants when deficiencies are present.
Although implants can function in sites with minimal keratinized tissue, increasing evidence suggests that a broader zone of keratinized mucosa may improve patient comfort, plaque control, and long-term soft tissue stability. In particular, sites lacking keratinized mucosa have been associated with increased inflammation and patient-reported discomfort during oral hygiene. Free gingival grafting is one of the most predictable ways to address this deficiency.
What a Free Gingival Graft Is Designed to Do
The primary objective of an FGG is to increase the width of keratinized tissue. Unlike connective tissue grafts, which are often used to thicken tissue or cover exposed roots, FGG procedures are typically performed to establish a stable band of attached gingiva in areas where the existing tissue is inadequate. The graft integrates with the recipient site during healing and forms new keratinized tissue that is firmly attached to the underlying bone.
Because of this biologic behavior, FGG is particularly effective in sites with shallow vestibules, minimal attached gingiva, or thin and mobile mucosa. It is also useful for stabilizing soft tissue margins around teeth that are prone to recession or inflammation due to inadequate keratinized tissue.
Typical Indications for Free Gingival Grafts
Increasing Keratinized Tissue Around Teeth
One of the most common indications for FGG is the treatment of sites with minimal attached gingiva around natural teeth. In these cases, patients may experience discomfort when brushing or difficulty maintaining oral hygiene. Increasing the width of keratinized tissue with a free gingival graft can make plaque control easier and reduce inflammation associated with inadequate soft tissue support.
Stabilizing the Mucogingival Junction
Free gingival grafts are also used to stabilize the mucogingival junction and improve tissue resistance to mechanical trauma. When mucosa extends too close to the gingival margin, it can be more susceptible to movement and recession. FGG creates a more stable band of attached tissue that helps resist these forces.
Preparing Sites for Orthodontic or Restorative Treatment
In patients with thin periodontal phenotype or limited keratinized tissue, FGG may be performed before orthodontic movement or restorative treatment. Increasing the width of attached gingiva can help reduce the risk of recession when teeth are moved or when restorations are placed in areas with thin tissue.
The Role of FGG Around Dental Implants
Free gingival grafting is particularly valuable around dental implants when keratinized mucosa is limited. Unlike natural teeth, implants lack a periodontal ligament and rely heavily on the surrounding soft tissue environment for protection against inflammation. A narrow zone of keratinized mucosa around implants may contribute to patient discomfort, plaque accumulation, and difficulty with oral hygiene.
Several studies have suggested that increasing keratinized tissue around implants can improve soft tissue health and reduce mucosal inflammation. FGG is often used in these situations because it reliably increases the width of keratinized mucosa and creates a more stable peri-implant tissue environment. This procedure may be performed before implant placement, during implant surgery, or after restoration depending on the clinical situation.
Around implants, the goal of FGG is not primarily esthetic enhancement but rather the creation of durable tissue that can tolerate mechanical stress and daily hygiene. For this reason, many experienced clinicians still rely on free gingival grafts to establish keratinized mucosa in implant sites with deficient tissue.
Healing and Expected Outcomes
Healing after an FGG occurs through revascularization and integration of the graft with the recipient site. During the early healing phase, the graft receives nutrients through plasmatic diffusion before new blood vessels begin to grow into the tissue. Over time, the graft becomes incorporated into the surrounding tissue and develops the characteristics of keratinized gingiva.
Some shrinkage of the graft during healing is expected, and clinicians typically compensate for this by harvesting a graft slightly larger than the final desired dimensions. Despite this contraction, free gingival grafts consistently produce reliable increases in keratinized tissue width and long-term stability at treated sites.
One limitation of FGG is esthetics. Because the graft is epithelialized, the final tissue may appear lighter or slightly different in texture compared with adjacent gingiva. In highly visible areas, connective tissue grafts may provide superior esthetic blending. However, when the primary objective is functional improvement rather than cosmetic integration, FGG remains extremely effective.
Potential Complications
Donor Site Discomfort
Because free gingival grafts require harvesting tissue from the palate, postoperative discomfort at the donor site is one of the most common patient concerns. Protective stents and careful surgical technique can help reduce bleeding and improve healing during the postoperative period.
Graft Shrinkage
Some contraction of the graft during healing is normal and should be anticipated during surgical planning. Despite this shrinkage, the procedure typically produces a meaningful increase in keratinized tissue width.
Esthetic Differences
The color and texture of the grafted tissue may differ slightly from adjacent gingiva. While this difference is usually acceptable in posterior areas or functional sites, clinicians should carefully consider esthetic expectations when planning FGG procedures in the anterior maxilla.
Why Free Gingival Grafts Still Matter
In an era where connective tissue grafts and biomaterials dominate many discussions of periodontal plastic surgery, free gingival grafting is sometimes overlooked. However, the procedure remains one of the most reliable methods for increasing keratinized tissue and stabilizing mucogingival defects. For this reason, many experienced periodontists consider FGG a foundational surgical skill that should remain part of modern periodontal practice.
Rather than viewing FGG as outdated, it is more accurate to see it as a specialized tool. When the clinical objective is to create a durable band of keratinized tissue, few procedures match the predictability of a free gingival graft. Maintaining proficiency in this technique ensures that clinicians have the full range of surgical options available when managing soft tissue deficiencies around teeth and implants.
Want to See Free Gingival Graft Surgery Step by Step?
Understanding the principles of FGG is important, but seeing the surgical workflow—from graft harvesting to stabilization and healing—provides a much clearer picture of how this procedure is performed in real clinical cases.
Watch Medavue Learning surgical videos to see free gingival graft procedures demonstrated step by step.
References
- Lang NP, Löe H. The relationship between the width of keratinized gingiva and gingival health. J Periodontol. 1972;43(10):623-627.
- Thoma DS, Naenni N, Figuero E, et al. Effects of soft tissue augmentation procedures on peri-implant health or disease: a systematic review. Clin Oral Implants Res. 2018;29(suppl 15):32-49.
- Wennström JL, Derks J. Is there a need for keratinized mucosa around implants to maintain health and tissue stability? Clin Oral Implants Res. 2012;23(suppl 6):136-146.
- Zucchelli G, Mounssif I. Periodontal plastic surgery. Periodontol 2000. 2015;68(1):333-368.
- Cairo F, Nieri M, Pagliaro U. Efficacy of periodontal plastic surgery procedures in the treatment of localized gingival recessions. J Clin Periodontol. 2014;41(suppl 15):S44-S62.
- Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: a systematic review. J Periodontol. 2015;86(8):S8-S51.
