although even the complete absence of attached gingiva is compatible with oral health , certain clinical situations require definitive gingival augmentation . an epithelized autogenous masticatory mucosal graft procured from palate is preferred by most of the clinicians to increase the zone of keratinized tissue . leading to compromised esthetics , also postoperative sequela on palate at times can be significant . this procedure aimed at investigating the potential of buccal marginal gingiva as a donor tissue to augment gingiva . two patients ( 25-year - old male , female aged 32 years ) with miller 's class iii gingival recession along with narrow keratinized gingiva in the mandibular anterior region reported to the department of periodontics , post graduate institute of dental sciences , rohtak , india in may 2010 [ figure 1a and b ] . initial periodontal therapy included sessions of oral hygiene instructions , scaling , and root planing . despite their efforts and professional guidance , as both the patients had shallow palatal valves , it was decided to procure donor tissue from maxillary buccal marginal gingiva . preoperative view ( case 1 ) : gingival recession with shallow vestibular depth and narrow band of keratinized gingiva in respect to 31 , 41 ( a ) . preoperative situation ( case2 ) : gingival recession along with shallow vestibular and narrow band of keratinized gingiva depth in respect to 41 ( b ) . recipient bed preparation apical to the available keratinized tissue ( case 1 ) ( c ) . donor tissue was harvested from buccal marginal gingiva of maxillary first molar ( case 1 ) ( d ) . graft was sutured on the recipient bed with silk sutures ( case 1 ) ( e ) following local anesthesia ( 2% lignocaine , adrenaline 1:80,000 ) the exposed root surfaces were planed using gracey 12 curette . a horizontal incision was made with no 15 scalpel apical to the available keratinized tissue to prepare recipient bed [ figure 1c ] . muscle and loose connective tissue ( ct ) fibers were thoroughly scraped to prevent subsequent graft mobility . a horizontal incision was given at the base of gingival sulcus and at least 1 mm coronal to alveolar crest in relation to right and left maxillary first molars ( 16 , 26 ) for case 1 and case 2 respectively [ figure 1d ] to harvest donor tissue . tissue measuring 3 mm  9 mm was made free by sulcular incision and was trimmed to remove sulcular epithelium and to standardize its thickness . it was positioned on the recipient bed and secured in place with silk sutures ( 3 - 0 ethicon non absorbable silk suture ) [ figure 1e ] and covered with coe pack . patients were refrained from brushing at the surgical sites and were instructed not to pull the lip or manipulate operated area for 2 weeks . patients were recalled at 2 and 4 week and then after every 3 months to monitor healing . parameters recorded at recipient sites included plaque index ( pi ) , gingival index ( gi ) , width of keratinized tissue ( wkt ) that is , corono apical width of graft at baseline ; increased width of keratinized gingiva on recalls . at donor site pi , gi , probing depth and location of the gingival margin with respect to cementoenamel junction were recorded using williams probe . esthetics was evaluated at the end of 3 years using a qualitative questionnaire given to five masked examiners who rated the result as excellent , very good , good , fair , and poor . at 3 months postoperatively when keratinization is expected to be complete , graft blended well with the adjacent tissues and was not clearly distinguishable [ figure 2a and b ] . increased gingival width following surgical procedure [ table 1 , figure 2c and d ] improved oral hygiene and decreased gingival inflammation [ tables 2 and 3 ] . gingiva at donor sites regained its normal form and contour at 3 months [ figure 3a and b ] . evaluation of esthetics demonstrated acceptable esthetic results wherein 80% and 60% examiners rated results as excellent for case 1 and case 2 , respectively , while rest rated it as very good [ table 4 ] . ( a ) final healing at 36 months ( case 1 ) : note the presence of increased keratinized tissue and color match . ( b ) final healing at 36 months ( case 2 ) : note the presence of enough keratinized tissue and color match . ( c ) 2 mm gain in the width of keratinized gingiva following soft tissue graft at 36-month follow - up ( case 1 ) . ( d ) a gain of 2.5 mm in the width of keratinized gingiva following gingival augmentation was recorded at 36-month follow - up ( case 2 ) ( a ) healing at donor site at 36 months : note the normal form and harmony of gingiva with the adjacent teeth ( case 1 ) . ( b ) maxillary first molar on the contralateral site : note the comparable contour of the gingival margin ( case 1 ) wkt ( mm ) at baseline and subsequent recall visits pi scores at recipient sites at baseline and various follow - up gi scores at recipient sites at baseline and various follow - up color evaluation at the recipient site at 3 years two patients ( 25-year - old male , female aged 32 years ) with miller 's class iii gingival recession along with narrow keratinized gingiva in the mandibular anterior region reported to the department of periodontics , post graduate institute of dental sciences , rohtak , india in may 2010 [ figure 1a and b ] . initial periodontal therapy included sessions of oral hygiene instructions , scaling , and root planing . despite their efforts and professional guidance , as both the patients had shallow palatal valves , it was decided to procure donor tissue from maxillary buccal marginal gingiva . preoperative view ( case 1 ) : gingival recession with shallow vestibular depth and narrow band of keratinized gingiva in respect to 31 , 41 ( a ) . preoperative situation ( case2 ) : gingival recession along with shallow vestibular and narrow band of keratinized gingiva depth in respect to 41 ( b ) . recipient bed preparation apical to the available keratinized tissue ( case 1 ) ( c ) . donor tissue was harvested from buccal marginal gingiva of maxillary first molar ( case 1 ) ( d ) . graft was sutured on the recipient bed with silk sutures ( case 1 ) ( e ) following local anesthesia ( 2% lignocaine , adrenaline 1:80,000 ) the exposed root surfaces were planed using gracey 12 curette . a horizontal incision was made with no 15 scalpel apical to the available keratinized tissue to prepare recipient bed [ figure 1c ] . muscle and loose connective tissue ( ct ) fibers were thoroughly scraped to prevent subsequent graft mobility . a horizontal incision was given at the base of gingival sulcus and at least 1 mm coronal to alveolar crest in relation to right and left maxillary first molars ( 16 , 26 ) for case 1 and case 2 respectively [ figure 1d ] to harvest donor tissue . tissue measuring 3 mm  9 mm was made free by sulcular incision and was trimmed to remove sulcular epithelium and to standardize its thickness . it was positioned on the recipient bed and secured in place with silk sutures ( 3 - 0 ethicon non absorbable silk suture ) [ figure 1e ] and covered with coe pack . patients were refrained from brushing at the surgical sites and were instructed not to pull the lip or manipulate operated area for 2 weeks . patients were recalled at 2 and 4 week and then after every 3 months to monitor healing . parameters recorded at recipient sites included plaque index ( pi ) , gingival index ( gi ) , width of keratinized tissue ( wkt ) that is , corono apical width of graft at baseline ; increased width of keratinized gingiva on recalls . at donor site pi , gi , probing depth and location of the gingival margin with respect to cementoenamel junction were recorded using williams probe . esthetics was evaluated at the end of 3 years using a qualitative questionnaire given to five masked examiners who rated the result as excellent , very good , good , fair , and poor . at 3 months postoperatively when keratinization is expected to be complete , graft blended well with the adjacent tissues and was not clearly distinguishable [ figure 2a and b ] . increased gingival width following surgical procedure [ table 1 , figure 2c and d ] improved oral hygiene and decreased gingival inflammation [ tables 2 and 3 ] . gingiva at donor sites regained its normal form and contour at 3 months [ figure 3a and b ] . evaluation of esthetics demonstrated acceptable esthetic results wherein 80% and 60% examiners rated results as excellent for case 1 and case 2 , respectively , while rest rated it as very good [ table 4 ] . ( a ) final healing at 36 months ( case 1 ) : note the presence of increased keratinized tissue and color match . ( b ) final healing at 36 months ( case 2 ) : note the presence of enough keratinized tissue and color match . ( c ) 2 mm gain in the width of keratinized gingiva following soft tissue graft at 36-month follow - up ( case 1 ) . ( d ) a gain of 2.5 mm in the width of keratinized gingiva following gingival augmentation was recorded at 36-month follow - up ( case 2 ) ( a ) healing at donor site at 36 months : note the normal form and harmony of gingiva with the adjacent teeth ( case 1 ) . ( b ) maxillary first molar on the contralateral site : note the comparable contour of the gingival margin ( case 1 ) wkt ( mm ) at baseline and subsequent recall visits pi scores at recipient sites at baseline and various follow - up gi scores at recipient sites at baseline and various follow - up color evaluation at the recipient site at 3 years in past few years , esthetic results for augmentation procedures have become a prime concern for many patients and clinicians . in both the cases , the boundary between grafted tissue and surrounding gingiva could not be easily distinguished as can be seen by comparing pre and postoperative photographs . whereas the color match of free gingival graft ( fgg ) from palate is not always predictable and often appears whitish and thick ; with characteristic tire - patch appearance . subepithelial connective tissue graft ( sectg ) often results in bulky tissue contour which mostly demands post healing gingivoplasty . research also suggests that deep palatal ct lack the full potential of inducing transformation to keratinized epithelium . allografts ( adma ) offer the advantage of predictable color match but suffer poor predictability owing to considerable postoperative shrinkage and inconsistent quality of tissue gained . it has been suggested that most of the graft shrinkage occurs within the 1 year of healing . in the documented cases , most of the postoperative shrinkage was complete by 3 months after which the results were maintained . a total shrinkage of 33.33% and 17.6% was observed for case 1 and case 2 , respectively . postoperative shrinkage using donor tissue harvested from the palate has been reported to vary between 30% and 50% while significant shrinkage up to 89.5% is reported with adma . patients in the presented cases did not complain of any postoperative discomfort at both recipient and donor sites at any point of time . on the other hand , patients treated with fgg harvested from the palate frequently experience postoperative pain and discomfort as a palatal wound is most of the times painful and slow to heal . another finding which supports this procedure is that the gingiva gained its normal form at donor sites in both the cases . this could be attributed to the inherent characteristic of periodontium to form a new  physiological  supracrestal gingival unit . gingiva in documented cases was of a thick biotype which is known to predictability grow coronally to acquire healthy gingival sulcus . chief limitation of this technique is limited availability of harvestable tissue ; also tissue biotype should be cautiously evaluated . it may be concluded that buccal marginal gingiva may provide a useful substitute to other donor tissues to augment gingiva .