There are predominantly two types of soft tissue that can surround the neck of a tooth: keratinized gingiva and alveolar mucosa. Keratinized gingiva is the resilient tissue that protects the underlying bone during the normal functioning of the dentition (such as eating). Alveolar mucosa is the smooth tissue that lines the inside of your cheek; it is not nearly as resilient as keratinized gingiva and cannot withstand the long-term trauma of chewing when directly adjacent to teeth. Teeth with alveolar mucosa directly adjacent to them are more prone to recession.
In looking at the pictures below, there is a fairly clear delineation between keratinized gingiva and alveolar mucusa just below the teeth. ￼
Keratinized tissue is slightly whiter and not as shiny, whereas alveolar mucosa is a darker red color (if you look closely, you can see small blood vessels in the thin, stretched alveolar mucosa, hence the darker red color of the tissue as a whole).
The height and thickness of keratinized gingiva one has is largely genetically predetermined, although the position of a tooth within the jaw bone may also determine the amount of gingiva. When individuals have too little keratinized gingiva
(a general rule is less than 2mm), a free gingival graft can be performed to increase the amount of this type of tissue. A small piece of tissue is removed from the roof the the patient’s mouth (palate) and placed at the area where tissue is needed (the recipient site). This donor tissue integrates with the surrounding tissues and increases the height of keratinized gingiva adjacent to the previously deficient tooth or teeth.
￼The clinical pictures presented above are of a 16 year-old male who was midway though his orthodontic treatment. The orthodontist was concerned by the minimal height of keratinized gingiva adjacent to the lower right canine (the prominent tooth in the middle of Both pictures). A free gingival graft was performed, and the picture to the left was taken three months following the grafting procedure. The patient now has a greater height of and more resilient tissue adjacent to his lower right canine, decreasing his chances of future recession on that tooth.
Patients must understand that although thicker keratinized gingiva is functionally more stable than alveolar mucosa, the tissue harvested from the roof of the mouth is often slightly different in color than the tissue native to the tooth site. For this reason, teeth that show gum tissue upon smiling are often poor candidates for free gingival grafting. Periodontists often consider subepithelial connective tissue grafting in sites where esthetics are important.
BOTH THE DONOR AND THE RECIPIENT SITES CREATED DURING FREE GINGIVAL GRAFTING TEND TO HEAL QUITE WELL. PATIENTS STATE THAT THE DISCOMFORT FELT DURING THIS HEALING PERIOD IS SIMILAR TO A PIZZA BURN. THIS DISCOMFORT, OFTEN LASTING LESS THAN A WEEK, IS MINIMIZED WITH OVER-THE-COUNTER ANALGESICS, SUCH AS IBUPROFEN AND ACETAMINOPHEN.