As teeth develop and erupt into the mouth, they emerge surrounded by two types of soft tissues.  These are the attached gingiva, and the movable mucosa. 

The movable mucosa lines the inner aspect of the lips, cheeks, and floor of the mouth.  The attached gingiva is the firm pink band of gum tissue attached to the root and bone at the base of each tooth.    The hard palate and roof of the mouth are covered with attached gingiva. Sometimes, teeth erupt into the jaw with no attached gingiva. This may be genetically determined, or affected by premature loss of deciduous (baby) teeth.  This firm tissue is necessary to stand up to frictional abrasion from chewing and brushing.  Without an adequate width of attached gingiva over the outer surface of a tooth, gum recession is likely to occur.  This can also happen on the inner aspect of lower teeth.  When gum recession occurs, it is not only the gum tissue that is being lost, but also the thin underlying bone, which may be irreplaceable.

Tooth alignment may also affect the width of attached gingiva.  If teeth are found to be tipped or protruded outward, they often have no attached gingiva.  Instead, they are covered with thin movable mucosa, which predisposes them to recession.  While orthodontic therapy is beneficial to correct tooth alignment, tooth movement during orthodontics can sometimes stimulate gum recession where there is minimal or no attached gingiva present.  It is therefore important to have these areas evaluated before beginning active orthodontic tooth movement.  Orthodontists frequently refer patients to a periodontist for this purpose.

Dr. Pechter carefully measures the width of attached gingiva on each tooth, and relates this to the level of gum recession.  This is recorded at your initial examination, and reevaluated at every recall appointment.  Depending on several factors (amount of recession, rate of recession, orthodontic status, tooth mobility, esthetic concerns, presence of crowns or bridges, patient age), treatment with gum grafting may be advised. 

There are three basic reasons why a gum graft might be needed: 

1. To establish or increase the width of attached gingiva to stop recession and protect underlying bone.
2. To cover an exposed root for cosmetic reasons or to reduce root sensitivity.
3. To thicken or plump out the gums for cosmetic reasons, such as under a false tooth on a permanent bridge.

Various surgical techniques can be used to achieve each of these objectives.

The most predictable way to establish or increase the width of attached gingiva is by means of an autogenous free gingival graft. The term “autogenous”, or “autograft”, means that the grafted tissue is derived from the same person for whom the graft is intended.  In most cases, this tissue is borrowed from the palate, which you will recall, is completely covered by attached gingiva.  Calling the graft, “free”, is not a reflection of the price charged for this procedure, but rather is an indication that the graft is detached (freed) from the donor site.  A thin superficial strip of gingiva is lifted off the palate and transplanted to the area of the mouth in need of the graft.  The palatal donor site completely regenerates itself.  The mucosa at the receptor site is released from the tooth, and allowed to naturally spring back into the cheek or inner lining of the lip.  The graft is usually protected by a periodontal dressing for one week, after which, it has become biologically adapted in its new location.  Because this is an autogenous graft, it is never rejected, and provides a maximum amount of attached gingiva, which generally lasts a lifetime.  Since this type of graft will not predictably cover an exposed root, it is most often used on lower teeth and upper back teeth, which do not have esthetic requirements because they are not visible when a person speaks or smiles.

A free gingival allograft is another technique for establishing or increasing the width of attached gingiva.  Instead of using donor tissue from the palate, the graft is purchased from a tissue bank.  This is actually skin tissue which has had the outer layer (epithelium) removed, and has been processed and sterilized to prevent rejection.  This type of graft has been used extensively to treat burn victims.  Although an allograft spares the patient from the discomfort of procuring a graft from the palate, much less attached gingiva is actually established at the recipient site.  This is because the graft is non-vital (not living tissue).  It is not actually incorporated into the new host location like an autograft, but must be replaced by new living cells from the surrounding tissue.  As a result, healing time is longer and there is considerable shrinkage of the graft during healing.  Over the long term, an allograft does not hold up as well as an autograft.  However, it is a useful procedure in specific situations.

Free gingival grafts, as described above, are chiefly done to control or prevent recession and resulting bone loss.  Their purpose is to create or restore a healthy periodontium around the tooth.  However, a free gingival graft is not the treatment of choice if covering of an exposed root surface is the desired goal.  This is because there is no blood supply available over the exposed root to nourish a freshly placed detached (free) graft during the initial stages of healing.  Covering of an exposed root surface is often indicated for cosmetic reasons or to reduce root sensitivity.  Surgical techniques to address this issue are: a pedicle graft, a sub-epithelial connective tissue graft, and a two stage approach.

A pedicle graft is the simplest way to cover an exposed root.  This involves transferring a superficial layer of attached gingiva from an adjacent location to the desired graft site.  By leaving the graft attached at its base to the underlying mucosa and loose connective tissue, the graft carries its own blood supply along with it to its new location.  Because it is an autograft, it has highly predictable, long lasting results.  However, in order to be considered, there must be an available source of adequate attached gingiva immediately adjacent to the tooth in need of grafting.  So in many cases, a pedicle graft is not an option.

A sub-epithelial connective tissue (SCT) graft involves creating a pouch by lifting the soft tissue away from the outer surface of the root, and inserting a graft in between.  The overlying soft tissue flap is then sutured back over the graft to provide the blood supply needed to nourish the graft during the initial stages of healing.  This graft is procured from the dense connective tissue underlying the palatal surface.  An allograft from a tissue bank can be used for this, as well. 

The two stage approach combines a free gingival graft with a secondary pedicle graft.  First, a free gingival graft is placed over the desired tooth without attempting to cover the root.  After about two weeks healing, the grafted tissue can be relocated over the root, maintaining its connection with the mucosa and blood supply at its base.

A frenum is a mucosal soft tissue connection originating in the inner lining of the lip, and attaching at the gum line of the upper or lower front teeth.  A frenum which is located too close to the teeth can lead to gum recession.  It can also cause a gap to form, especially between the two upper front teeth, which will not stay closed even after orthodontic therapy.  A frenectomy is a simple surgical procedure to release an adverse frenum attachment.  It is often accompanied by a free gingival graft to replace the portion of the gum where the frenum was formerly located.