Gum grafting: when it is needed, how it works and what recovery involves

When a gum graft is needed

Gum recession is common in adults, becomes more frequent with age, and occurs in populations with both high and low standards of oral hygiene. The narrative review by Cortellini and Bissada (2018), prepared for the international classification of periodontal conditions, makes that clear and then sets out the decision rule. Where there is no active disease, monitoring the site is the appropriate approach. Surgery is indicated when the risk of developing or worsening damage rises, when the exposed root surface deteriorates, and when the patient’s concern about appearance justifies it.

The same review lists what raises the risk in the first place: thin periodontal phenotypes are more likely to develop recession, and inadequate oral hygiene, orthodontic treatment and restorations placed at the neck of the tooth all increase that likelihood. In practice, three indications account for most gum grafts.

Covering a root exposed by recession

When the gum pulls back, the root comes into view. It is covered not by enamel but by cementum, a considerably softer tissue, more reactive to temperature and more prone to decay. The tooth looks longer, a step forms at the neck, and brushing becomes uncomfortable at exactly that spot, which often makes matters worse.

Root coverage aims to bring tissue back over that exposed surface. It works best where the tissue between the teeth has stayed intact, and those are the only sites where complete coverage can reasonably be expected. Once interdental attachment has been lost, the height of tissue that can be recovered falls, and a partial result becomes a matter of anatomy rather than surgical skill.

Thickening a thin gum and rebuilding keratinised tissue

Keratinised tissue is the firm, pale pink, immobile band that borders the teeth. It stands up to brushing and to friction from food in a way that the looser, mobile alveolar mucosa does not. When that band becomes too narrow, or when the gum is so thin that the root shows through it, the area turns fragile: inflammation settles in more readily and brushing hurts, so it gets skipped.

The aim of the graft then changes character. It is no longer about covering a root but about building tissue robust enough to protect the neck of the tooth for decades. A thick, stable band of gum is often worth more in the long run than a fragile cosmetic result.

Protecting the tissue around an implant

Around an implant, the question of keratinised tissue works differently from a natural tooth, and the evidence has sharpened. The meta-analysis by Dos Reis et al. (2026), pooling twelve cohort studies covering 2,646 implants in 938 patients, found no association between the width of keratinised mucosa and the incidence of peri-implant mucositis. The picture for peri-implantitis was different: incidence was significantly lower where keratinised mucosa was present than where it was absent (relative risk 0.62), and lower still above 2 mm of width (relative risk 0.56).

Those figures are why a surgeon may propose soft-tissue augmentation before or during placement of a dental implant when the available mucosa is insufficient. They describe a reduction in risk: an implant surrounded by keratinised tissue can still develop peri-implantitis, and the other known factors, plaque control and smoking foremost among them, continue to count. The risks associated with dental implants have a page of their own. It is also worth being precise about vocabulary here, because the two procedures are confused constantly: a gum graft is soft-tissue surgery and adds no bone, which is the job of a dental bone graft.

Treating the cause before grafting, or the recession returns

A graft placed over a recession whose mechanism is still active will deteriorate. Identifying that mechanism is therefore part of the treatment rather than a preliminary to it, and it is this groundwork that determines how long the result lasts.

Aggressive brushing deserves a closer look, since it is named as the obvious culprit so often. The systematic review by Heasman et al. (2015), carried out for the European Workshop on Periodontology, examined thirteen cross-sectional studies along with a meta-analysis of 159 subjects. The toothbrushing factors most frequently associated with recession were brushing frequency, a horizontal or scrub technique, bristle hardness, brushing duration and how often the brush was replaced. The authors nonetheless conclude that the data supporting or refuting the link between toothbrushing and recession remain largely inconclusive. Correcting a damaging brushing technique keeps its value, but treating the toothbrush as the single cause means overlooking plaque, tobacco and tooth position.

The sequence that follows from this is straightforward. Bring the periodontal tissues to health, establish cleaning that is effective without being traumatic, resolve any active inflammation, and only then plan the graft. Smoking belongs in the same conversation, since it is among the conditions capable of affecting root coverage outcomes.

How gum graft surgery works

Everything starts with a full periodontal assessment: probing depths, the exact height of the recession, the width of keratinised tissue still present, tissue thickness, the state of the attachment between the teeth and any wear lesion at the neck. That assessment decides which technique is used and, more importantly, what result it is reasonable to promise.

Surgery is carried out under local anaesthetic, in a practice or in a hospital department, and Cambridge University Hospitals NHS Foundation Trust puts the operation at roughly one hour. The Cleveland Clinic gives the same order of magnitude for a single graft and notes that treating several areas in one sitting takes longer. The surgeon prepares the recipient site first, disinfecting and smoothing the exposed root surface, then loosening the gum to create the space the graft will occupy. The tissue is harvested, usually from the palate, positioned and held with fine sutures. A protective dressing or a stent is sometimes placed over the donor site.

Stitches either dissolve on their own or are removed at a follow-up appointment, 7 to 21 days later according to the Cambridge guidance, and Guy’s and St Thomas’ NHS Foundation Trust puts removal of non-dissolvable sutures at two to four weeks. Surface healing takes a couple of weeks; full maturation of the tissue runs from a few weeks to a few months depending on the case.

The buried connective tissue graft

Connective tissue is harvested from beneath the surface layer of the palate, then tucked under the gum at the site being treated, most often together with a flap advanced towards the crown. The grafted tissue stays out of sight beneath the patient’s own gum, which explains the quality of the result: colour and texture blend into the surrounding tissue with no visible join.

The systematic review by Chambrone and Tatakis (2015), produced for the American Academy of Periodontology Regeneration Workshop from 234 studies selected out of 2,456 screened, concludes that procedures based on the buried connective tissue graft give the best outcomes in clinical practice, both for the mean percentage of root coverage and for the proportion of sites achieving complete coverage, with a significant gain in keratinised tissue. It is the benchmark against which the other techniques are measured.

The free gingival graft

Here the graft carries both the connective tissue and the epithelial layer covering it. It is sutured on the surface rather than buried. Its purpose is to widen the band of keratinised tissue around a tooth or an implant rather than to cover a root, and the periodontology service at Leeds Teaching Hospitals NHS Trust says so plainly in its patient information: this graft does not aim to cover the exposed root surface, some coverage may be achieved, but it is unpredictable.

The trade-off shows in the appearance. Palatal tissue keeps its own shade, paler and more opaque than the neighbouring gum, and the difference in colour can be seen. The technique is therefore kept for areas that show little when you smile, or for situations where the durability of the tissue matters more than the harmony of the gum line.

Repositioned flaps and substitute matrices

Where the gum next to the defect is healthy, thick and available in sufficient quantity, it can be mobilised to cover the area being treated. A coronally advanced flap, sometimes combined with a laterally positioned flap, removes the need for a second surgical site at the palate. That is a genuine comfort argument, and the technique combines readily with a buried connective tissue graft when both volume and an even gum line are wanted.

Substitute matrices are the third route. Acellular dermal matrix, porcine collagen matrix and enamel matrix derivatives all avoid palatal harvesting and allow several teeth to be treated in one sitting without multiplying donor sites. The consensus report by Tatakis et al. (2015) places them precisely. Used with a coronally advanced flap, acellular dermal matrix graft and enamel matrix derivative serve as alternatives to autogenous donor tissue, while the buried connective tissue graft retains the best root coverage outcomes. The choice is therefore argued case by case, between the quality of the expected result and the number of sites operated on.

Technique	What it aims at first
Connective tissue graft	Covering the exposed root
Free gingival graft	Widening the firm gum band
Repositioned flap	Coverage, no second site
Substitute matrix	Avoiding palatal harvest

What a gum graft achieves, and how much coverage is realistic

The first benefit is comfort, since an exposed root reacts to cold, heat, acid and the touch of a brush, and covering it usually removes that sensitivity or reduces it markedly. The second is protection, cementum and cervical dentine being more vulnerable than enamel both to wear and to decay. The third concerns appearance, with an even gum line and teeth that stop looking abnormally long. Chambrone and Tatakis (2015) report that all root coverage procedures significantly reduce recession depth and improve clinical attachment level in Miller Class I and II defects, those in which the interdental tissue is preserved.

Complete root coverage is not guaranteed

Covering the root entirely is possible only in certain configurations. It depends on the class of the recession, the height of interdental tissue remaining, gum thickness, the position of the tooth and the presence of cervical wear. The Leeds Teaching Hospitals NHS Trust information warns that with any grafting surgery there is a risk that it may not work, that the grafted gum may fail to heal into place and be lost, and that a connective tissue graft may not completely cover the area of recession or may be lost entirely. A perfect cosmetic outcome promised before the interdental attachment has even been measured commits to something anatomy will not always allow.

How long the result holds

The meta-analysis by Dai et al. (2019), which retained fifteen randomised controlled trials followed for at least two years, is useful on exactly this point. A coronally advanced flap used on its own loses coverage over time, with the mean percentage of root coverage falling by 7.29% between short-term and long-term measurement. When that same flap is combined with a connective tissue graft, no significant difference appears between the two time points, and the combination outperforms the flap alone both for complete root coverage and for the width of keratinised tissue gained.

That finding ties back to the section on causes. A graft holds a situation steady when inflammation is controlled, brushing is appropriate and plaque control is real. If periodontitis stays active or tooth movement continues, the recession comes back, however well the surgery was done.

Recovery after gum graft surgery

The first few days

Plan for a quiet 24 to 48 hours. Guy’s and St Thomas’ NHS Foundation Trust advises against vigorous activity such as exercise for 24 hours after surgery, and against contact sports for two to four weeks. Sleeping with your head slightly raised limits swelling, and a cold pack held against the cheek on the day of surgery, in short spells and always wrapped, helps as well.

Food stays soft for at least the first week, and eating on the opposite side of the mouth spares the operated area. Hard, crunchy, spicy, very hot or very cold items are best left alone. Smoking slows soft-tissue healing, so stopping, even temporarily, is part of standard advice.

Pain and the palatal donor site

The operation itself is painless under local anaesthetic. The question is what the following days feel like, and it is the palate, more than the grafted area, that patients tend to notice. The systematic review by Chong et al. (2025), which examined sixty-eight studies of which thirty-eight reported visual analogue scale pain scores, establishes that postoperative pain at the donor site is most pronounced in the first three days, then falls away progressively. Applying a dressing or a physical barrier over the harvested area reduces that discomfort.

The review by Figueras-Alvarez et al. (2026), covering sixteen clinical studies published between 2019 and April 2025, fills in the rest of the picture at the palate. Pain was the complication reported most often; bleeding was reported less frequently and was generally self-limiting, particularly where local haemostatic measures were used; and transient sensory disturbance was described. Several adjuncts, among them palatal stents, hyaluronic acid and platelet-rich fibrin, were associated with lower postoperative discomfort.

Practical instructions from NHS periodontology departments are consistent on the essentials. Start painkillers about an hour after surgery, before the anaesthetic wears off, and alternate paracetamol and ibuprofen for continuous cover, taking ibuprofen with food. Use a 0.2% chlorhexidine mouthwash two or three times a day for two to four weeks. Expect swelling to take two to three days to appear and up to two weeks to settle completely, and some bleeding over the first two days, controlled by firm pressure on gauze for at least thirty minutes. Pain that worsens after seven days, or bleeding that pressure does not stop, means calling the team who treated you.

Oral hygiene while healing

The grafted area is not brushed until your surgeon says otherwise. Mechanical cleaning would displace the graft before it has established a blood supply from the tissue beneath it, which happens in the first few days. Chlorhexidine mouthwash takes over on that area for as long as the department has specified.

The rest of the mouth goes on being cleaned as usual, floss and interdental brushes included, since neglecting the whole dentition on account of one operated site would produce precisely the inflammation the surgery set out to avoid. Brushing over the graft resumes with a very soft brush on your clinician’s instruction, and full cleaning of the mouth is generally permitted from the review appointment onwards.

What a gum graft costs

On the NHS

Soft-tissue grafting is performed in NHS hospital periodontology departments, which publish their own patient information about it. Access runs through a referral from your dentist, and both the criteria and the waiting times differ between trusts. Where recession is being treated mainly for the sake of appearance, the work is more often carried out privately.

NHS dental charges in England are banded. Band 1 costs £27.90 and covers examination, X-rays and simple management of gum disease such as scaling. Band 2 costs £76.60 and covers everything in Band 1 plus fillings, root canal treatment, extractions and extensive management of gum disease. Band 3 costs £332.10 and adds crowns, bridges and dentures. Charges differ in Scotland, Wales and Northern Ireland, and treatment provided in a hospital department after referral follows a different route from a course of treatment at a high street practice, so ask what you will be charged before you agree to anything.

Private treatment and treatment abroad

Private fees for periodontal surgery are set by each practice and vary widely with the number of sites, the technique and the complexity of the case. Treating one recession on a single incisor and rebuilding a band of keratinised tissue across a whole sextant are not the same operation, which is why published fee ranges are so broad.

These are the fees applied to our own periodontal procedures, quoted in euros.

Periodontal procedure	Fee
Flap surgery	€325 per quadrant
Flap with bone graft	€325 per quadrant
Guided tissue regeneration	€120 per tooth
Crown lengthening	€35 per tooth
Free gingival graft	€750 per site
Connective tissue graft	€750 per site

These amounts are per site or per quadrant treated. Only a quotation drawn up after an examination puts a figure on your own case, since the number of teeth involved and the technique chosen decide the total.

Why have a gum graft in Turkey?

The gap between UK and Turkish fees allows savings of up to 70% across a full treatment plan. That gap concerns cost, and the quality of periodontal surgery is judged elsewhere: on the precision of the assessment beforehand, on whether the technique proposed suits your type of recession, and on how follow-up is organised.

The stay is arranged from end to end, with a 5-star hotel and breakfast, VIP transfers between the airport, the hotel and the clinic, an English-speaking patient coordinator at every appointment and 12 months of post-operative follow-up. Your flight remains your own expense. The quotation is free, sent within 24 hours and carries no obligation.

This particular procedure calls for one caveat. Periodontal surgery assumes healthy tissues before the operation and durable plaque control afterwards, and both of those belong to a long-term relationship rather than to a trip. A gum grafting plan abroad is therefore prepared with your regular dentist or hygienist, who handles the periodontal treatment beforehand and the maintenance once you are back.

Sources

Chambrone, L., & Tatakis, D. N. (2015). Periodontal soft tissue root coverage procedures: A systematic review from the AAP Regeneration Workshop. Journal of Periodontology, 86(2 Suppl.), S8–S51. https://doi.org/10.1902/jop.2015.130674

Chong, W. J., Razali, M., Baharin, B., & Nik Azis, N. M. (2025). Postoperative pain and morbidity at the donor site after palatal soft tissue harvesting: A systematic review. BMC Oral Health, 25(1), 1960. https://doi.org/10.1186/s12903-025-07198-2

Cortellini, P., & Bissada, N. F. (2018). Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations. Journal of Clinical Periodontology, 45(Suppl. 20), S190–S198. https://doi.org/10.1111/jcpe.12948

Dai, A., Huang, J. P., Ding, P. H., & Chen, L. L. (2019). Long-term stability of root coverage procedures for single gingival recessions: A systematic review and meta-analysis. Journal of Clinical Periodontology, 46(5), 572–585. https://doi.org/10.1111/jcpe.13106

Dos Reis, I. N. R., Thoma, D. S., da Silva, T. E., Passos, M. Q., Feitosa, L. S., Pannuti, C. M., Jung, R. E., & Naenni, N. (2026). Keratinized mucosa width and incidence of peri-implant diseases: A systematic review with meta-analysis. Journal of Periodontal Research, 61(5), 452–472. https://doi.org/10.1111/jre.70123

Figueras-Alvarez, O., López, N. Q., Montero, J., Hernández, N. L., & Flores-Fraile, J. (2026). Postoperative complications at the palatal donor site following autologous soft tissue grafting: A systematic review. BMC Oral Health, 26(1), 716. https://doi.org/10.1186/s12903-026-07989-1

Heasman, P. A., Holliday, R., Bryant, A., & Preshaw, P. M. (2015). Evidence for the occurrence of gingival recession and non-carious cervical lesions as a consequence of traumatic toothbrushing. Journal of Clinical Periodontology, 42(Suppl. 16), S237–S255. https://doi.org/10.1111/jcpe.12330

Tatakis, D. N., Chambrone, L., Allen, E. P., Langer, B., McGuire, M. K., Richardson, C. R., Zabalegui, I., & Zadeh, H. H. (2015). Periodontal soft tissue root coverage procedures: A consensus report from the AAP Regeneration Workshop. Journal of Periodontology, 86(2 Suppl.), S52–S55. https://doi.org/10.1902/jop.2015.140376

Cambridge University Hospitals NHS Foundation Trust. (n.d.). Gum grafting procedure. Read the guidance

Cleveland Clinic. (2022, 18 July). Gum graft surgery: What it is, procedure and recovery. Read the guidance

Guy’s and St Thomas’ NHS Foundation Trust. (n.d.). Recovering from gum graft surgery. Read the guidance

Leeds Teaching Hospitals NHS Trust. (n.d.). Periodontal surgery. Read the guidance

NHS. (2025, 13 March). Understanding NHS dental charges. Read the charges