Abstract
To describe a novel free gingival graft (FGG) technique, the ‘M–saddle FGG technique’ for treating non-keratinized tissue distal to a mandibular second molar associated with a suprabony periodontal pocket, inflammation, and patient discomfort. A 30-year-old patient presented with persistent discomfort, bleeding, food impaction, a 6-mm suprabony periodontal pocket distal to tooth #3.7, 1 mm of keratinized tissue width (KTW), and reduced vestibular depth (VD). A modified horseshoe-shaped FGG was harvested from the palate and adapted over the distal crest and buccal periosteum. Outcomes were assessed after 3 months. At 3 months, discomfort, inflammation, and soft tissue trauma during function were completely resolved. KTW and VD both increased by 4 mm, and periodontal probing depths reduced by 3 mm. The ‘M-Saddle FGG technique’ improved KTW, periodontal parameters, VD, and patient comfort, representing a promising novel treatment option for selected mandibular second molar mucogingival defects and suprabony periodontal pockets.
Introduction
The role of keratinized tissue width (KTW) around teeth and implants remains widely discussed. Gingival augmentation is recommended when KTW is <2 mm and adequate biofilm and bleeding control cannot be achieved [1, 2]. The free gingival graft (FGG) is indicated for gingival recession, inadequate KTW (<2 mm), reduced vestibular depth (VD) (<4 mm), aberrant frenum/muscle pull, localized alveolar defects pre-prosthetic treatment, and pre-/post-orthodontic therapy [1, 3–5].
Sites lacking keratinized tissue (KT) are more mobile, elastic, permeable, and lack protective structures such as the stratum corneum, increasing susceptibility to biofilm accumulation, inflammation, and gingival disease [6]. This means sites, especially around teeth, with non-KT, are more prone to inflammation, biofilm accumulation and gingival diseases. An FGG can increase KTW and VD while converting non-KT distal to the mandibular second molar (M2M) into KT. This case report describes the clinical application and outcomes of this novel approach, termed the ‘M-Saddle FGG technique,’ to improve patient comfort and oral hygiene (OH).
Case report
A 30-year-old, ASA II, patient with a medical history of anxiety, which was treated with Venlafaxine and had quit smoking 4-years previously. The chief complaints were, ‘pain on biting the tissue behind the lower left back molar and persistent bleeding and discomfort as food gets stuck behind this tooth. It has been getting harder to clean’.
All horizontally impacted M3Ms were extracted at the age of 15 years.
Following multiple rounds of unsuccessful non-surgical treatment, 6 mm suprabony PPDs distal to the #3.7 persisted (Fig. 1). In addition to this local periodontal factor, where the epithelium was non-KT, there were mucogingival defects, as there was 1 mm of buccal KTW, a thin phenotype and no VD (<4 mm) (Fig. 2).
Pre-operative left bitewing radiograph.
(a) Intra-oral photo of #3.7. (b) Intra-oral occlusal photo of #3.7 showing no vestibular depth. (c) Intra-oral occlusal photo showing no keratinized tissue width buccal and distal to #3.7.
Following written and verbal informed consent, local anaesthesia was achieved using two cartridges of 2% lidocaine with 1:100000 epinephrine and one cartridge of 2% lidocaine with 1:50 000 epinephrine. A #15 scalpel was used to create a partial-thickness flap extending from the mesial line angle of tooth #3.7 along the buccal aspect to a depth of approximately 7 mm. The incision continued 7 mm distal to the distolingual cusp. A full-thickness crestal incision from the distobuccal to distolingual cusp ensured complete removal of the non-KT from the crest. The distal non-KT was excised using a Kirkland knife following scalpel incisions. The buccal flap was apically positioned, while the distal flap was displaced further distally (Fig. 3).
Buccal and distal incisions at #3.7.
A template of the recipient site was used to outline a 1.5-mm-thick FGG from the palatal donor site (Fig. 4). Because the horseshoe-shaped graft covered both the denuded bone on the crest, distal to #3.7 and the buccal periosteum, this modification was termed the ‘M–saddle FGG technique.’ The ‘M’ represents the distal location at the M2M, and the ‘saddle’ is the horseshoe-shape of the FGG.
FGG harvested from the palate.
The graft was stabilised with 5 polyglycolic acid (PGA) sutures: one horizontal mattress and one simple interrupted suture securing the distal aspect to the lingual mucosa, two simple interrupted sutures at the mesial buccal extension, and one periosteal suture to improve graft adaptation and compression against the recipient bed (Fig. 5).
FGG in situ with PGA 5-0 sutures.
The ‘Sandwich dressing technique’ was used on the palate for haemostasis [7]. Postoperative instructions included avoiding brushing at the surgical site for 8 days, rinsing twice daily with 30 ml (0.12% chlorhexidine), and a soft diet. Ibuprofen (600 mg) and acetaminophen (1 g) were prescribed every 4–6 h as required, up to maximum daily doses of 2.4 and 4 g, respectively. The patient required analgesics for only 4 days.
At the 8-day review, OH was given with a soft and end-tuft toothbrush, suture removal, and a normal diet was recommenced (Fig. 6). Healing was uneventful, with no postoperative complications.
3.7 at 8 days PO.
At the 3-month re-evaluation, the patient reported complete resolution of discomfort, bleeding, mucosal biting, and food impaction, with improved quality of life. Clinically, the non-KT distal to #3.7 was replaced by 4 mm of KT (Fig. 7). KTW increased from 1 to 5 mm, VD from 1 to 5 mm, and the suprabony probing depth decreased from 6 to 3 mm, supported by radiographic improvement (Fig. 8). Bleeding on probing and biofilm accumulation were no longer present.
Three-month photo showing an increase in KT.
Three-month post-treatment left bitewing radiograph.
Discussion
Local periodontal factors, especially the distal of mandibular molars, can present challenges for clinicians. Prevention is the best option and removal of impacted M3Ms has been recommended ≤25 years to reduce the biofilm, periodontal pockets, and periodontal diseases [8].
Treating suprabony pockets distal to the M2M when non-KT is present is unpredictable. A preventative option is completion of a distal wedge at the time of M3M extraction [9] or laser therapy when a decision tree is followed [10, 11].
The graft thickness of 1.5 mm and the width of 7 mm was important as graft shrinkage occurs on the bone crest distal to the #3.7 as well as on the periosteum, but less on bone [12]. The majority of graft shrinkage occurs early with the timeline ranging from within the first 6 weeks [13] to within the first 3 months [14, 15]. Therefore, the graft can be expected to be stable pending good OH and due to the extension of the graft from the more vascular buccal periosteum to the denuded crestal bone. The horseshoe shape design maximizes resistance to occlusal forces.
This case report presents a new indication for an FGG, at the site distal to M2M when the epithelium is non-KT with a suprabony pocket ≥6 mm and inflammation, especially when the epithelium is at the level of the occlusal plane. The novel technique shown was also due to the 1 mm of buccal KTW, a thin phenotype, and no VD (<4 mm) in addition at the site, enabling the ‘M-Saddle FGG technique’ to be shown. Although this is a single case report, further studies with more patients, clinicians, and follow-up will help confirm efficacy, predictability, and reproducibility.
Conclusion
The ‘M–saddle FGG technique’ is a novel technique to treat non-KT distal to the M2M by changing the epithelium from non-KT to KT. The technique decreases PPDs, increases VD, improves gingival indices and biofilm scores, which improves patient comfort, OH, and function.
Conflicts of interest
There were no conflicts of interest.
Informed consent for the publication was obtained by the anonymized patient included in the study.
Artificial intelligence was solely used for manuscript formatting.
The case report adheres to the CARE and Process 2025 guidelines.
Funding
None declared.
