Free Gingival Graft vs Connective Tissue Graft: Which One, and Why

Patients come in having read about “a gum graft” as if it were one procedure. In practice Dr. Verrett chooses between two, and they are different enough that being offered the wrong one for your situation is worth avoiding.

Connective Tissue Graft

Tissue is taken from beneath the surface of the palate, so the palate’s own surface layer stays intact and heals faster. The graft is placed under the existing gum, against the exposed root, usually through a tunnel technique with small openings rather than a long incision. The gum is then moved up over it. Langer and Langer described the technique in 1985 and attributed its success to the double blood supply at the recipient site, from the connective tissue base underneath and the flap laid over the top, which is the reason the graft goes under the gum rather than on it.

Its strengths are root coverage and appearance. Because the graft sits under your own gum, the result blends in, which matters on the upper teeth and anywhere in the smile. It also thickens the tissue. This is the graft for recession that shows, for sensitivity from an exposed root, and for thin tissue around an implant in the front of the mouth. The systematic review Chambrone and Tatakis prepared for the AAP Regeneration Workshop reached the same conclusion from 234 included studies: connective tissue graft procedures gave the best outcomes for clinical practice, with superior percentages of mean and complete root coverage and a significant increase in keratinized tissue. Several cases in the gallery show it at two weeks, one month, and one year.

Free Gingival Graft

A piece of the surface tissue of the palate is placed directly onto the site and sutured in, not tucked under the gum. It heals as a visible patch of firm, pale tissue that blends in over months but never completely matches. It is the older of the two techniques: Sullivan and Atkins set out the principles of free autogenous gingival grafting in 1968, and were the first to describe placing such a graft directly onto an exposed root.

Its strength is building a wide, durable band of attached gum where there is none, and deepening a shallow vestibule so the lip stops pulling. It is the more predictable choice on the lower front teeth when the goal is to stop recession rather than to cover a root that shows, and it is the usual choice around implants that have no firm tissue at all. Root coverage with a free gingival graft is possible but less reliable than with connective tissue. In the companion AAP Regeneration Workshop review on non-root-coverage grafting, Kim and Neiva call autogenous gingival grafts the gold standard for gingival augmentation, and report that widening the band of keratinized tissue may prevent recession from developing and progressing.

Donor Tissue Instead of Your Own

Processed human donor tissue can substitute for connective tissue from the palate. It avoids a second surgical site, which matters when several teeth are treated at once or when a patient would rather not have the palate involved. Your own tissue gives the thickest and most stable result, and Dr. Verrett recommends it for the hardest cases: severe recession, very thin tissue, and sites with a history of failed grafting. Kim and Neiva report that viable alternatives to palatal harvesting are available for augmenting keratinized tissue, and that patients treated without a palatal donor site appeared to report more satisfaction and less discomfort afterward. The trade-off is discussed at the consult, and the choice is yours.

How Each Heals

The connective tissue graft site is sore for a few days and the palate feels like a pizza burn for a week or two; the graft looks pale and swollen at the two-week visit and settles over two to three months. The free gingival graft’s palate site is more tender, because the surface layer is gone, and takes a little longer; the graft itself looks white at first, then pink, then like gum, over about two months. Neither should be brushed until Dr. Verrett has checked it. Gum graft recovery, day by day goes through it in detail.

The Short Version

Root showing, in the smile, or thin tissue around an implant: connective tissue. No firm gum at all, lower teeth, shallow vestibule, implants with loose tissue: free gingival. Several teeth at once, or no palate involvement: donor tissue, with the trade-off explained. If you have been quoted one and the reasoning was not clear, ask why that one; the answer should be about your tissue, not about convenience.

How gum grafting works at Austin Periodontal Associates is performed by Dr. Andrew Verrett, a board-certified periodontist in North Austin.

Which graft suits a particular tooth is settled at a consult, with the recession measured and the reasoning explained before anything is scheduled. Request a consult or call (512) 346-6097.