Gum Grafting Procedure: CTG, Free Gingival and Pedicle Flaps

Gum grafting is an umbrella term, not a single operation. The technique determines where the tissue comes from, how the root is prepared, how much coverage is realistic and what the bill looks like. Two patients with the same amount of recession can leave with different procedures for good reasons.

The decision starts with the defect

Before choosing a technique, the periodontist measures:

• Recession depth and width — how much root is exposed and how wide the gap is.
• Attached gum width — the band of firm, keratinized tissue around the tooth.
• Gum thickness (biotype) — thin gums behave differently from thick ones.
• Interdental papilla height — whether the gum between the teeth is intact.
• Root surface condition — caries, wear, restorations or a frenum pull.
• Blood supply — whether the site can support a graft.

The same measurements also determine whether a graft is the right treatment at all. Shallow, stable recession with no symptoms may be monitored. Deep recession with sensitivity, caries or a thin biotype is more likely to be grafted.

1. Connective tissue graft (CTG)

What it is. The surgeon harvests a strip of subepithelial connective tissue from the palate and places it over the root, usually under a flap of existing gum.

How it is done. A small incision is made in the palate, the connective tissue layer is separated, and a strip is removed. The palate surface is closed with sutures, often with a protective stent. On the recipient side, a flap is raised around the recession, the root is planed, and the graft is positioned and sutured.

Best for. A single exposed root, or two adjacent teeth, with enough donor tissue. CTG is the most commonly taught and studied root-coverage technique.

Trade-offs. There is a second surgical site, and the palate can be sore for one to two weeks. The amount of tissue available limits how many teeth can be treated in one visit.

2. Free gingival graft (FGG)

What it is. A piece of the palate’s surface — epithelium plus a thin layer of connective tissue — is removed and placed directly on the recipient site.

How it is done. The graft is shaped to the recipient bed and sutured in place. The palate wound is left to heal by secondary intention or covered with a dressing.

Best for. Increasing the band of attached, keratinized gum, especially on lower front teeth, around implants, or where a denture or orthodontic appliance irritates the gum.

Trade-offs. The graft often looks paler and thicker than the surrounding gum, at least initially. The palate wound is a surface wound and can be uncomfortable. Root coverage is less predictable than with CTG.

3. Pedicle or laterally positioned flap

What it is. Gum next to the recession is partially released and moved over the root while keeping its blood supply attached.

How it is done. The surgeon makes a flap adjacent to the defect, rotates or slides it sideways, and sutures it over the root. No tissue is removed from the palate.

Best for. A single narrow defect with healthy, thick gum next to it.

Trade-offs. Limited by how much neighbouring tissue can be moved. It can pull the gum line of the donor tooth and is not suitable for wide or multiple defects.

4. Donor tissue (acellular dermal matrix)

Not a technique in itself, but a material choice. A processed dermal matrix can replace the patient’s own connective tissue. It avoids a palate harvest and allows a larger area to be treated, but it adds a material fee and may be less predictable in thin biotypes. Some surgeons use it with a tunnel technique rather than a flap.

Technique comparison

Does the technique change the price?

Yes. In the US, a pedicle flap typically sits at the lower end ($450–$1,100), a free gingival graft in the middle ($550–$1,200), and a connective tissue graft at the upper end ($700–$1,600). Donor matrix adds a material charge. The cost per tooth guide compares the bands, and the cost hub explains what the fee includes.

The technique is not the only price driver. The number of teeth, the city, sedation and whether a bone graft is combined all move the total.

What to ask your surgeon

1. Which technique are you recommending, and what makes it right for this tooth?
2. What root coverage do you expect — complete, partial, or uncertain?
3. Will you use my palate or donor tissue, and why?
4. How many of these procedures do you perform in a month?
5. What is the plan if the graft contracts or fails?

A surgeon should be able to explain the trade-off between coverage, donor-site discomfort and cost without promising a perfect result.

Recovery is similar across techniques

The first week is about protecting the graft and the donor site. Soft food, no brushing at the site, no smoking, and no pulling on the lip. Sutures come out at 7 to 14 days. The tissue matures over two to three months. The recovery guide has the day-by-day version.

Bottom line

Connective tissue graft, free gingival graft and pedicle flap are tools for different problems. The right question is not “which is best” but “which one fits this defect, this biotype and this patient’s healing capacity.” A periodontist who measures before recommending is doing the job correctly.