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| Title |
Free Gingival Grafts Provide Greater Keratinized Tissue Gain Than Soft-Tissue Alternatives, but Allografts Offer Comparable Clinical Augmentation With Decreased Donor-Site Morbidity |
| Clinical Question |
In patients with limited keratinized tissue, does an autogenous free gingival graft, compared with an allograft, result in greater gain and stability of keratinized tissue and improved clinical outcomes? |
| Clinical Bottom Line |
For patients with limited keratinized tissue requiring gingival augmentation, free gingival grafts (FGG) provide greater keratinized tissue gain than allograft and other soft-tissue alternatives, although these alternatives can provide clinically meaningful augmentation without donor site morbidity. This is supported by systematic reviews and network meta-analyses of randomized clinical trials, with FGGs showing greater KT gain compared with allografts and other soft-tissue alternatives. The evidence is applicable to patients requiring keratinized tissue augmentation, although differences in graft materials, techniques, populations, and follow-up limit direct comparison with specific allografts, and additional long-term direct comparisons are needed. |
| Best Evidence |
(you may view more info by clicking on the PubMed ID link) |
| PubMed ID |
Author / Year |
Patient Group |
Study type
(level of evidence) |
| #1) 38704784 | Tommasato, 2024 | 573 sites in 16 studies | Meta-Analysis | | Key results | FGG demonstrated significantly greater keratinized mucosa gain at 180 days than CTG (treatment ratio 2.83; 95% CI: 1.06–7.47) and XCM (2.83; 95% CI: 1.50–5.32). Most importantly, FGG produced a significantly greater keratinized mucosa outcome than ADM, with ADM vs FGG = 0.23 (95% CI: 0.06–0.87), corresponding to approximately 4.35-fold greater KT gain with FGG (95% CI: 1.15–16.67). At 90 days, differences between FGG and other materials were not statistically significant. | | #2) 32392401 | Barootchi, 2020 | 699 treated sites in 10 studies | Meta-Analysis | | Key results | In the non-root-coverage network meta-analysis of 10 RCTs (699 sites), FGG + APF resulted in 4.72 mm of KT gain (95% CI: 4.24–5.21; P < .001) compared with untreated sites, while ADM + APF resulted in 2.54 mm (95% CI: 1.67–3.41; P = .007); when directly compared within the network, FGG produced 1.58 mm greater KT gain than ADM (95% CI: 0.88–2.27; P = .01). | | #3) 29197438 | Dragan, 2017 | 232 adult patients in 7 studies | Meta-Analysis | | Key results | Soft-tissue alternatives resulted in 1.39 mm less KT gain than FGG (weighted mean difference −1.39 mm; 95% CI −1.82 to −0.96; P < .001; I² = 70.89%). The authors noted that all alternative-treatment groups still achieved >2 mm of KT gain, so the clinical significance of the additional 1.39 mm achieved with FGG remains uncertain. | |
| Evidence Search |
("keratinized tissue"[Title/Abstract] OR "keratinized gingiva"[Title/Abstract] OR "attached gingiva"[Title/Abstract] OR "keratinized mucosa"[Title/Abstract]) AND ("free gingival graft"[Title/Abstract] OR "free gingival autograft"[Title/Abstract] OR FGG[Title/Abstract]) AND ("acellular dermal matrix"[Title/Abstract] OR allograft*[Title/Abstract] OR AlloDerm [Title/Abstract] OR "dermal allograft"[Title/Abstract]) |
Comments on
The Evidence |
Regarding validity, all three articles had a similar clearly defined question regarding keratinized tissue gain with free gingival graft versus soft-tissue substitutes. All concluded that FGG produced more KT gain. Systematic reviews with meta-analyses were utilized for all the studies, which are the highest level of evidence for research type. Limits in validity were due to heterogeneity in the included studies, short-term follow up, and the Tommasato study evaluated peri-implant soft tissue, while the other two studies looked at natural teeth.
The results show that FGG produced more KT gain than ADM and other substitutes. While these studies do show that there is gain in KT, the reviews use different materials, techniques, compare different sites, and few of the included trials compared FGG directly to allograft. Additionally, patients receiving alternatives to autogenous soft tissue grafting still showed a gain in KT of 2 mm or more, so it is not clear whether the additional gain with FGG is clinically important. The confidence interval, particularly for the Tommasato study, was very wide, making the true advantage uncertain.
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| Applicability |
The studies apply to adult patients with limited or absent KT who need gingival augmentation. The reviews do not clearly separate results by baseline KT width, or by patient risk factors, so applying them to a particular patient is not highly reliable. The evidence covers both natural teeth (Barootchi, Dragan) and dental implants (Tommasato), so the site type should be considered when applying these findings.
One of the main considerations is the post-operative recovery/pain for the patient. FGG gives the largest and most predictable gain, but it requires a second surgical donor site, which may increase post-operative pain, bleeding, and total healing time. Allografts are more expensive than autograft and seem to produce less KT gain, though the gain was still above 2 mm in the studies reviewed. Patient preferences about donor-derived material may also be a consideration. Both approaches are technique-sensitive and, because the included studies used varied materials and techniques, the clinician should use their discretion in making the ultimate treatment decision.
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| Specialty/Discipline |
(Periodontics) |
| Keywords |
Free gingival graft; FGG; allograft; acellular dermal matrix; keratinized tissue; keratinized mucosa; gingival augmentation; soft tissue augmentation; gingival phenotype; limited keratinized tissue
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| ID# |
3771 |
| Date of submission: |
10/18/2026 |
| E-mail |
gawey@uthscsa.edu, rectorl@uthscsa.edu |
| Author |
Ashley Gawey, Lauren Rector |
| Co-author(s) |
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| Co-author(s) e-mail |
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| Faculty mentor/Co-author |
Dr. Brian Mealey |
| Faculty mentor/Co-author e-mail |
mealey@uthscsa.edu |
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) |
post a rationale |
| None available | |
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Comments and Evidence-Based Updates on the CAT
(FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) |
post a comment |
| None available | |
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