We treat the vast majority of cases of gingival recession and inadequate attached gingiva with a Subepithelial Connective Tissue Graft (SECTG). This microsurgical technique is very demanding but it yields the most predictable long-term increases in both attached gingiva and root coverage. These results have been validated by decades of clinical research. In contrast, the Free Gingival Graft (FGG) has less potential to cover exposed roots, causes more post-operative pain, and is less esthetic than the SECTG. However, there are occasionally situations where the SECTG is less predictable than an FGG.
In today’s case, the extensive loss of papillae and underlying bone (Miller Class IV), in addition to a very shallow vestibule and high frenum attachment, led us to choose an FGG. We limited the thickness of the palatal donor tissue harvested, which reduces post-operative pain and improves blending with the recipient tissue. The result was a large gain in keratinized tissue and an impressive amount of root coverage considering the anatomical limitations. Our patient was undergoing active orthodontic (Invisalign) treatment, which is a major risk factor for exacerbation of these types of mucogingival defects. We advocate grafting prior to tooth movement to minimize the likelihood of triggering more severe, less treatable recession defects.