What is a gum graft, and how does it work?

What is a gum graft?

A gum graft is a surgical procedure that adds gum tissue at a site of recession to cover exposed root and stabilise the gum margin (also called a soft-tissue graft or root coverage procedure). The goal is one or more of:

• Cover the exposed root surface so the root is again protected by tissue.
• Increase the amount of attached gum so the recession does not progress further.
• Thicken the existing tissue so it is more resilient to future challenge.
• Improve the appearance of the gum margin (particularly important in the front teeth).

The procedure has been performed in modern periodontics for over four decades; outcomes are documented in a substantial body of clinical research. The 2015 AAP Regeneration Workshop systematic review by Chambrone and Tatakis remains a useful synthesis of the evidence.¹

What are the main techniques?

The gold-standard root-coverage procedure is a coronally advanced flap combined with a connective tissue graft (CAF + CTG) — the coronally advanced flap with or without a subepithelial connective tissue graft is the most documented approach for localised recessions (review).² The CAF is the flap technique; the CTG is the graft material delivered under it. The flap can also be used alone where the existing keratinised tissue is adequate.

1. Coronally advanced flap with connective tissue graft (CAF + CTG)

The gold-standard combination. A piece of connective tissue is harvested from beneath the surface of the palate (the roof of the mouth, which has a thick layer of connective tissue under its surface gum). The harvested tissue is placed over the exposed root, and the patient's existing gum is moved over it as a coronally advanced flap to cover the graft.

Why it works well: connective tissue from the palate has the right biological properties to integrate with the site and form new attached gum. The thickness and predictability of root coverage are favourable.

Trade-offs:

• The palate is a second surgical site. It takes 1–2 weeks to heal and is the most uncomfortable part of the procedure for most patients.
• The procedure itself takes 60–90 minutes per treated area.

CAF + CTG is suitable for Cairo RT1 and many RT2 recessions and is the first-line approach where significant root coverage is the goal.⁵

2. Coronally advanced flap alone (CAF)

The existing gum tissue is reflected up off the bone, mobilised to allow it to be moved upward (towards the crown of the tooth), and re-positioned to cover the exposed root — without a graft. No second surgical site. Sometimes combined with biologic adjuncts such as enamel matrix derivative or growth factors to enhance the healing response.

Why it works: when there is enough keratinised tissue below the recession to be moved up over the root, the patient's own tissue is the best material.

Trade-offs:

• Requires adequate existing keratinised tissue below the recession (the procedure cannot create tissue from nothing).
• The technique is most predictable for single-site recession; multiple-site recession needs a more involved flap design (Zucchelli's modified coronally advanced flap is the published reference technique).⁴
• Tissue thickness gain is usually less than with a connective tissue graft.

3. Acellular dermal matrix (ADM) or xenograft alternatives

Donor-derived processed tissue (acellular dermal matrix, from human tissue banks) or animal-derived collagen matrices are used in place of the patient's own palatal tissue. Placed under a coronally advanced flap, the matrix provides scaffolding for the patient's own tissue to populate.

Why some patients prefer this: no second surgical site (the palate is left untouched); shorter overall recovery; the option to treat multiple sites in one visit with less morbidity.

Trade-offs:

• Long-term outcomes are good in published studies but the body of evidence is smaller than for autogenous grafts.
• Material costs are added to the procedure fee.
• Not all cases are suitable.

What happens on the day of a gum graft?

A single-site root-coverage procedure typically proceeds:

1. Local anaesthetic at the recession site and (if needed) at the palate.
2. Site preparation: the specialist cleans the exposed root and assesses the recession and adjacent tissue.
3. When a connective tissue graft is used: the palatal harvest — a small incision on the roof of the mouth, careful harvest of connective tissue from under the surface, and closure of the harvest site (a small dissolving suture or a palatal stent).
4. Recipient site preparation: a small flap is reflected at the recession site, the root surface is cleaned and conditioned.
5. Graft placement: the graft is positioned over the root and secured with fine sutures.
6. Closure: the patient's existing gum is positioned to cover the graft and sutured in place.
7. Post-operative instructions and follow-up plan.

The procedure takes 60–120 minutes depending on the technique and the number of sites. Most patients return to normal activities the next day; the palate is typically the most uncomfortable area in the first few days.

How long does a gum graft take to heal?

Initial healing takes about one to two weeks, with tissue maturation continuing over several weeks and the final result judged at six months.

• Days 1–3: mild to moderate discomfort, particularly at the palate. Managed with over-the-counter pain medication in most cases. Cold packs help with swelling. Soft-food diet.
• Week 1–2: progressive comfort improvement. Sutures usually removed at 1–2 weeks. Soft brushing of unaffected teeth; the surgical site is cleaned with a chlorhexidine mouthwash instead of brushing.
• Week 3–6: gentle brushing of the surgical site can usually resume, with care. The tissue is still maturing; the final aesthetic result is judged at 6 months, not at 6 weeks.
• Month 6: review of the final result. Most of the tissue contour is settled by this point.

What outcomes can you realistically expect?

For a Cairo RT1 case with adequate planning:

• Significant root coverage, often complete root coverage at the treated site.
• A measurable increase in keratinised tissue width.
• Improved tissue thickness (greater for a connective tissue graft than for acellular dermal matrix or flap-only).
• Reduced sensitivity at the treated site.

For Cairo RT2: complete root coverage is achievable in a meaningful proportion of cases — around half at six months in systematic reviews — particularly with a connective tissue graft under a coronally advanced flap when interproximal attachment loss is limited (broadly 3 mm or less); long-term stability is less predictable (Sangiorgio et al., BMC Oral Health).³

For Cairo RT3: full root coverage is not predictably achievable; the goal becomes stabilisation and partial improvement rather than complete restoration, because the interproximal tissue level limits what can be achieved.

Published systematic reviews report high mean root coverage for suitable recessions, with results largely stable at long-term follow-up where studies have looked (Chambrone & Tatakis, AAP Regeneration Workshop systematic review).¹

Can a gum graft fail or go wrong?

The procedure is generally well-tolerated. Possible complications:

• Graft failure (the graft does not integrate) — uncommon with good technique.
• Bleeding from the palatal harvest — usually controlled at the time of surgery.
• Post-operative discomfort that exceeds expectation — managed with stronger pain medication where needed.
• Incomplete root coverage — sometimes the result is less than aimed for; revision surgery is possible in selected cases.
• Aesthetic mismatch — uncommon when the procedure is performed by experienced hands.

Who should perform a gum graft?

Periodontal plastic surgery — including gum grafting — is core periodontal specialist training. For predictable results we recommend it be performed by a periodontist or a clinician with specific training in periodontal plastic surgery; in our view, experience materially affects results in this technique-sensitive field.

Common questions

Is a gum graft painful?

The procedure is done under local anaesthetic (intraoral injections), so it is not painful at the time. Afterwards most patients have mild to moderate discomfort for a few days, particularly at the palate where a connective tissue graft is taken, and this is usually managed with over-the-counter pain medication.

How long does a gum graft take to heal?

Initial healing takes about one to two weeks, when sutures are usually removed. The tissue keeps maturing for several weeks; the final aesthetic result is judged at around six months, not at six weeks.

Do gum grafts last, and can recession come back?

A successful graft is generally stable long-term, and published systematic reviews report results largely maintained at long-term follow-up (Chambrone & Tatakis).¹ Lasting stability depends on correcting the original cause — gentle brushing technique and good plaque control — so the same factors do not act again.

Can a gum graft fail?

Graft failure (the graft not integrating) is uncommon with good technique. The most common shortfall is incomplete root coverage, where the result is less than aimed for; revision surgery is possible in selected cases.

This article is general educational content. The right surgical approach for your specific recession pattern is determined by a clinical examination by a registered specialist.