Clinical context and challenges of mandibular recession

The management of localized gingival recessions in the mandibular anterior zone represents a unique therapeutic challenge for the clinician. This region is frequently characterized by unfavorable anatomical constraints, such as a shallow vestibule, high labial frenum attachment, and a thin gingival phenotype. These factors, when associated with a lack of keratinized tissue, create an environment conducive to the progression of attachment loss and complicate conventional root coverage procedures.

This case report documents the treatment of a 38-year-old female patient presenting with a Type I recession (RT1) on the left mandibular central incisor. Faced with a precarious periodontal environment, the objective of this study is to evaluate the effectiveness of a free gingival graft (FGG) not only to reduce the recession depth, but above all to predictably increase the keratinized tissue band and deepen the vestibule.

The approach is based on the clinical hypothesis that strengthening the biotype and modifying the vestibular environment through a free gingival graft allow for long-term tissue stability. The study thus aims to demonstrate the viability of this technique over a three-year long-term follow-up, prioritizing overall periodontal health over the sole aesthetic criterion of root coverage.

Clinical protocol and case evaluation

This case report documents the surgical management of a 38-year-old female patient presenting with a localized Miller Class I (RT1) gingival recession on the mandibular left central incisor. The initial clinical diagnosis highlighted the following parameters:

• An initial recession depth of 3 mm.
• A band of keratinized tissue (KT) limited to 1 mm.
• A thin gingival phenotype, a high labial frenum attachment and a shallow vestibule.

The experimental protocol consisted of performing a free gingival graft (FGG). Unlike approaches aimed solely at root coverage, the primary therapeutic objective here was the augmentation of keratinized tissue and the deepening of the vestibule to ensure long-term periodontal stability.

The analysis of the results was carried out according to the following methodology:

• Follow-up: Clinical follow-up examinations were performed at one year and three years postoperatively.
• Evaluation criteria: Comparative measurement of the KT width (increasing from 1 mm to 4 mm) and the recession depth (reduced from 3 mm to 0.4 mm).
• Qualitative observation: Evaluation of graft integration and tissue maturation.

As this is a single case report (n=1), no comparative statistical analysis or control group was used.

Clinical results and long-term stability

The free gingival graft (FGG) procedure in this 38-year-old patient achieved the set clinical objectives, namely the increase of keratinized tissue and vestibular deepening at the lower left central incisor.

The clinical measurements recorded during follow-up show a significant evolution of periodontal parameters between the initial state and the examinations at one and three years post-operatively:

Qualitatively, the authors report the following observations:

• Graft integration: Tissue integration considered satisfactory with harmonious maturation of the gingival tissue over time.
• Tissue stability: The results obtained immediately after the healing phase remained stable during the 12-month and 36-month follow-ups, without recurrence of recession or loss of the acquired keratinized tissue width.
• Vestibular morphology: The objective of vestibular deepening was achieved, correcting the impact of the labial frenum attachment that initially complicated the case.

As this is a single case report (n=1), no comparative statistical analysis or p-value is reported. However, the study highlights that, despite the inherent limitations of this format, the FGG demonstrated high predictability for the management of RTI-type recessions associated with a thin phenotype in the anterior mandibular zone.

Discussion on the clinical efficacy of FGG in RT1 recessions

The clinical results obtained in this 38-year-old patient confirm that the free gingival graft (FGG) remains a predictable technique for securing the anterior mandibular periodontium. Beyond the reduction of the recession — which decreased from 3 mm to 0.4 mm — the major contribution lies in the substantial gain of keratinized tissue (KT), tripling from 1 mm to 4 mm. In this specific anatomical context (thin phenotype, shallow vestibule, and high labial frenum), the objective was not solely aesthetic, but aimed at creating a tissue barrier capable of resisting muscle traction.

The tissue stability observed during the one and three-year follow-ups highlights the relevance of the functional approach. While other techniques such as the coronally advanced flap with connective tissue graft are often preferred for their superior aesthetic mimicry, the FGG stands out here for its ability to deepen the vestibule, an essential environmental correction in this area of high labial mobility. The graft showed satisfactory integration and maturation, proving its long-term viability.

However, the limitations of this case report lie in its single sample size (n=1). Although the results are convincing, they cannot be universally extrapolated without larger-scale studies. Nevertheless, this case demonstrates that for RT1-type recessions associated with an unfavorable anatomical environment, the increase of keratinized tissue is a key factor for long-term success.

In concrete terms, for the practitioner:

• Prioritise keratinised tissue gain: In the presence of a shallow vestibule and a thin phenotype in the mandible, FGG remains the technique of choice for stabilising the periodontium, even if root coverage is not complete.
• Ensure long-term stability: This protocol offers predictable tissue maturation, the benefits of which (stable recession depth at 0.4 mm) persist for at least 3 years after the intervention.
• Manage unfavorable anatomy: Grafting allows for the simultaneous repositioning of high labial frenum attachments, thereby eliminating the mechanical tensions responsible for the progression of recessions.

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