International Journal of

Environmental Research
and Public Health

Article
Complications in the Use of Deepithelialized Free Gingival
Graft vs. Connective Tissue Graft: A One-Year Randomized
Clinical Trial
Silvestre Ripoll 1,2 , Ángela Fernández de Velasco-Tarilonte 2, *, Beatriz Bullón 2 , Blanca Ríos-Carrasco 2 and
Ana Fernández-Palacín 3

1 Clínica Dental Silvestre Ripoll, Marqués de Paradas 40 Local, 41001 Sevilla, Spain;
src@clinicasilvestreripoll.com
2 Department of Periodontology, School of Dentistry, Universidad de Sevilla, C/Avicena S/N,
41009 Sevilla, Spain; beatrizbullon@hotmail.com (B.B.); brios@us.es (B.R.-C.)
3 Departamento de Ciencias Sociosanitarias, Universidad de Sevilla, 41004 Sevilla, Spain; afp@us.es
* Correspondence: angela.fvtarilonte@gmail.com; Tel.: +34-670-438-872

Abstract: In the treatment of gingival recession, different surgical options have been described: free
gingival grafts (FGG), connective tissue Grafts (CTG), and a more recent technique, de-epithelialized



free gingival graft (DFGG). They are not procedures exempt from the appearance of complications.


Most publications refer to postoperative complications, and there is limited literature regarding the
Citation: Ripoll, S.; Fernández de development of late complications (weeks or months). Our working group carried out a study to
Velasco-Tarilonte, Á.; Bullón, B.;
describe the development of late complications associated with the use of DFGG in comparison with
Ríos-Carrasco, B.; Fernández-Palacín,
CTG, providing an incidence rate and a classification. Sixty-eight patients with mucogingival prob-
A. Complications in the Use of
lems were selected, and divided into two groups: the Test Group, for which we used DFGG + Coronal
Deepithelialized Free Gingival Graft
Advancement Flap (CAF), and the Control Group (CTG + CAF). All patients were treated at the
vs. Connective Tissue Graft: A
One-Year Randomized Clinical Trial.
University of Seville’s dental school to solve mucogingival problems for aesthetic and/or functional
Int. J. Environ. Res. Public Health 2021, reasons. A classification is proposed based on its severity; Major and Minor. Major complications
18, 4504. https://doi.org/10.3390/ included reepithelialization of the graft, epithelial bands, cul-de-sac, epithelial cysts, and bone exos-
ijerph18094504 toses. Minor complications included the graft´s color changes and superficial revascularization. Late
major complications were only associated with the use of the DFGG, and the late minor complications
Academic Editors: developed with the use of the DFGG were much higher than those associated with CTG. CTG appears
Jyothi Tadakamadla, Santosh to be a safer procedure than DFGG in terms of late complications.
K. Tadakamadla and Carlos Marcelo
da Silva Figueredo
Keywords: free gingival grafts (FGG); connective tissue grafts (CTG); de-epithelialized free gingival
graft (DFGG); late complications; reepithelialization; epithelial bands; cul-de-sac; epithelial cysts;
Received: 2 March 2021
bone exostoses; revascularization
Accepted: 21 April 2021
Published: 23 April 2021

Publisher’s Note: MDPI stays neutral

1. Introduction
with regard to jurisdictional claims in
published maps and institutional affil- Guinard and Caffesse defined a gingival recession as the displacement of the marginal
iations. gingival tissue towards the apical junction of the enamel cementum, which develops an
exposure of the root surface [1]. As a consequence, the patient may report sensitivity, suffer
a higher prevalence of caries, cervical abrasions, and the aesthetic appearance may be
compromised [2].
Copyright: © 2021 by the authors.
For its treatment, in addition to controlling the causal factors, different surgical options
Licensee MDPI, Basel, Switzerland.
have been described, such as: free gingival grafts (FGG) [3,4], connective tissue grafts
This article is an open access article
(CTG) [4,5], and pedicle flaps [6].
distributed under the terms and FGG has been used successfully for the augmentation of keratinized tissue and root
conditions of the Creative Commons coverage. However, it is associated with a lower percentage of root coverage compared
Attribution (CC BY) license (https:// with other techniques due to its reduced vascularization and its aesthetic appearance as
creativecommons.org/licenses/by/ a patch. This is, therefore, its main drawback, leading to it not being used in aesthetic
4.0/). areas [5,7].

Int. J. Environ. Res. Public Health 2021, 18, 4504. https://doi.org/10.3390/ijerph18094504 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 4504 2 of 12

Nowadays, a coronally advanced flap (CAF) with subepithelial connective tissue graft
(CTG) is considered the gold standard procedure in the treatment of gingival recession-type
defects [8]. The combination of CTG + CAF provides a greater vascularization of the graft,
achieving a double blood supply, through the supraperiosteal vessels as well as the flap
which covers it [9]. Among the benefits obtained, it found higher success rates in terms of
complete root coverage, as well as better aesthetic results, as it presents the same color as
the pre-existing mucosa compared to the FGG [10,11].
Mucogingival surgery techniques are not free from the occurrence of complications.
Early postoperative complications are most commonly described. These develop in a very
early state and could lead to bleeding, tooth sensitivity, ecchymosis, and graft necrosis
resulting from suture loosening, breakage, or other causes.
Late complications are those that appear within a few weeks or months [12–14]. There
is limited published literature regarding the development of late complications, and it
is mostly related to the use of CTG. Previous studies mainly referred to the formation
of cysts [15–18], the presence of a cul-de-sac [19], bone exostoses formation [20,21], the
development of root resorption [22–24], and the occurrence of keloids [25–27]. Although
complications related to the use of the FGG are also reported, most refer to the appearance
of cysts [28] and bone exostoses [29–32].
FGC is a valuable technique; however, some reviews reported disadvantage regarding
aesthetic concerns such as pigmentation [33,34]. In addition, some complications have
been described as the need for simultaneous augmentation of keratinized gingiva and the
requirement of increasing the vestibule depth thereof.
All these late complications refer to the use of CTG or FGG.
More recently, the use of a de-epithelialized free gingival graft (DFGG) has become
more widespread. This technique consists of obtaining a graft from a primary free gingival
graft that is subsequently deepithelialized outside the mouth to be used as an CTG [20,21].
We did not find any publications referring to the development of late complications
specifically associated with the use of DFGG. This is probably due to the fact that it is a
more recent and less used technique than the previous ones and therefore has not yet been
fully explored in the literature.
After several years of specializing in performing mucogingival surgery techniques
using DFGG, our working group at the University of Seville perceived the emergence
of some late complications not described in the scientific literature. Among them, we
identified the presence of surface reepithelization of DFGG, partial or complete, resulting
in a mucous membrane surface similar to the donor area that creates a patch effect, which
can be compared to the effect generated in a FGG. However, in these cases, a more irregular
morphology depending on the extension area of the reepithelization is present. Sometimes
this re-epithelialization is attached by epithelial bands on the graft surface. Moreover, as
less relevant complications, our group registered the appearance of multiple superficial
blood vessels that alter the aesthetics of the treatment [35].
Conducting meticulously reviews of the publications on free gingival graft and con-
nective tissue graft, we observed a great deficiency in the area of the classification of their
complications. We did not find publications that addressed it, either old or recent. Classi-
fications are necessary for the subsequent treatment of complications, and are present in
other fields such as wounds, injuries, or surgeries. Our objectives are to describe the late
complications associated with the use of the DFGG compared with the CTG, providing an
incidence rate, and to provide a classification of complications.

2. Materials and Methods

2.1. Study Design
Sixty-eight patients were selected for the study, including 39 women and 29 men with
a mean age of 39 years (ranging between 19 and 60 years). All patients were treated at the
University of Seville´s dental school to solve mucogingival problems for aesthetic and/or
functional reasons.
Int. J. Environ. Res. Public Health 2021, 18, 4504 3 of 12

To assess the effect of complications using DFGG, it was compared with the possible
drawbacks associated with the gold standard technique in the treatment of recessions
(CTG + CAF). For this purpose, we designed a Test group, where we used an DFGG + CAF
technique. On the other hand, we created a Control group using the CTG + CAF procedure.
A pilot study was designed to determine the incidence of complications and the
sample size needed. Using the N Query Advisor 7.0 program (Statistical Solutions, Cork,
Ireland), with a test based on the percentages of complications (between the two groups),
we performed a two-tailed test, with a significance of α = 0.05 and a statistical power of
80%. A detection difference of 40% more complications was estimated in the FGG group
than in the CTG group (according to a pilot study). The program reported a size of N = 28.
We sought to include at least 28 patients in each group, and accounted for the possibil-
ity of losing patients due to abandonment or change in residence. Our prospective study
increases the numbers from N = 28 per group to N = 34. Two patients in the Test group
dropped out of the study due to change of residence and the final total sample was in the
test Group (DFGG + CAF) N = 32 and in the control group N = 34.
The assignment of patients to the test group (DFGG + CAF) or control (CTG + CAF)
was performed by a balanced randomization using four sizes of blocks that were introduced
in closed envelopes. This ensured that the sample sizes in the two groups were the same
(well-adjusted), and the envelopes were given as patients arrived.
A statistic descriptive test was performed with frequencies and percentages. For
differences in proportions, chi-square contingency and test tables were performed with
95% confidence interval. The Chi Square of independence with continuity correction was
used for 2 × 2 tables or Fisher’s exact test for low populated tables.

2.2. Inclusion/Exclusion Criteria

Patients were included patients if they had healthy periodontal conditions or success-
fully treated periodontitis, were nonsmokers or light smokers (<10 cigarettes/day, had an
absence of systemic disease, and presented at least one maxillary or mandibular Miller
type I/II/III recession [36] that required treatment for aesthetic and/or functional reasons.
On the contrary, patients were excluded with poor oral hygiene, the presence of
multiple caries, teeth with active infectious disease, severe malocclusions, or those who
had undergone orthognathic surgery, as well as patients who were taking medications that
could interfere with the state of periodontal health or the healing of surgical wounds (such
as anticonvulsants, immunosuppressants, or Calcium channel blockers) [37].

2.3. Surgical Procedure

Informed consent was given by all study participants. Previously, a favorable report
from the Ethics and Research Committee of the Junta de Andalucía (Study Code 1259-N-19)
was obtained. The patients were all treated at the Seville School of Dentistry (Master of
Periodontology and Implants) by one of the main investigators, a well-known professor
with years of experience (SR), using microsurgical instruments and 8× magnifying glasses.
Prior to performing the intervention, the operator was informed of the procedure to
be performed (DFGG or CTG).
In both groups, the same procedure was carried out to prepare the root surface of the
recipient site:
Two releasing incisions were made on the teeth adjacent to the recessions to be treated,
which were followed by intrasulcular incisions around the gingival recessions, and a split-
full-split thickness flap was raised in the corono-apical direction. The flap was released
from the underlying periosteum so that it could be displaced coronally without tension
towards the level of the cementum-enamel junction.
In the donor site, the CTG was obtained from the palatal mucosa using a single hori-
zontal incision in the mesiodistal direction following the technique previously described by
Hurzeler [38]. The DFGG was obtained from a previous FGG according to the technique
reported by Holbrook and Ochsenbein [39]. It was subsequently de-epithelialized outside
Int. J. Environ. Res. Public Health 2021, 18, 4504 4 of 12

the mouth using a scalpel blade (Figure 1). Donor site closure was performed in all cases
using continuous suture. In DFGG, a collagen sponge was additionally inserted into the
donor site after suturing.

Figure 1. Deepithelialized free gingival graft.

The placement of both DFGG and CTG grafts at the recipient site was carried out
following the same procedure. In both cases, the graft was positioned at the recipient site
in a manner corresponding to its original orientation, so the DFGG was located leaving its
de-epithelialized part facing outwards. Meanwhile the CTG was positioned at the recipient
site in a more superficial location facing outwards. Afterwards, a coronal displacement
of the flap was performed to cover the graft completely without tension where there was
suturing at the interdental level. Finally, the releasing incisions were sutured.

2.4. Post-Surgical Instructions

A non-steroidal anti-inflammatory drug was prescribed every eight hours for at least
two days to prevent the appearance of pain. Chlorhexidine mouthwash was also prescribed
every 12 h for 3 weeks, starting 24 h after surgery. A soft diet and no graft mobilization for
at least 3 weeks were indicated. The sutures were removed at 3 weeks in the recipient area.

2.5. Index and Classification of Complications

An index of complications was created to speed up the selection task. To this end, a
bibliographic review was carried out, making a list of the main complications described in
the literature: epithelial cyst, cul-de-sac, bone exostoses, and color change of the grafted
area. In addition, we incorporated the main complications not described in the literature,
but were observed in our clinical experience: superficial re-epithelialization of the graft,
the presence of epithelial bands, and superficial revascularization of the graft.
A definition and description were carried out of each complication including a graphic file.
The description of the following complications was formulated as follows:
1. Epithelial cyst: chronic inflammatory lesion partially or completely delimited by tissue.
2. Cul-de-sac: invagination formation, with probing depths greater than 0.5 mm (Figure 2).
3. Bony exostoses: benign overgrowth of a pre-existing bone.
4. Color change: aesthetic alteration compared with the appearance of the surround-
ing tissues.
5. Superficial re-epithelialization: proliferation, partial or complete, of the original
superficial epithelial layer of the graft, resulting in a mucosal surface similar to the
donor area creating a patch effect comparable to the ones produces in an IGL (Figure 3).
6. Superficial epithelial bands: epithelial tissue located on the graft without being
adhered to it (Figure 4).
Int. J. Environ. Res. Public Health 2021, 18, 4504 5 of 12

7. Superficial revascularization: proliferation of multiple blood vessels modifying the

superficial aesthetics of the graft. (Figure 5).

Figure 2. Superficial re-epithelialization.

Figure 3. Cul de sac.

Figure 4. Superficial epithelial bands.

Int. J. Environ. Res. Public Health 2021, 18, 4504 6 of 12

Figure 5. Superficial revascularization.

Complications were classified based on their severity into major and minor. Major
complications were considered when additional surgical treatment was required to solve
it, or due to their location could cause a considerable alteration of aesthetics. Thus, major
complications were considered:
1. The re-epithelialization of the graft; it substantially modifies the aesthetics.
2. The presence of epithelial bands; for being non-adhered retentive areas.
3. The presence of cul-de-sac; retentive and aesthetic effect.
4. The presence of epithelial cysts.
5. Bone exostoses.
Minor complications were considered to be color changes in the grafted area and
superficial revascularization.
In this way, we created a graphical guide to complications, with a classification and
definition of them, and a graphical database associated with each heading, which we called
the Complications Index and which was used to identify and classify the complications
that could appear in our study.

2.6. Postoperative Controls

Reviews were performed at 7 days, 3 weeks, 2 months, 6 months, and one year.
Photographs were taken at each postoperative review session. All the photographs
were reviewed by an independent researcher (A.F.-P.) who did not participate in the surg-
eries. Their task was to identify and classify the presence of complications. For this purpose,
they underwent an initial training with our “Complications Index”. Subsequently, a cali-
bration was carried out to assess their reproducibility when identifying them, performing
a Kappa analysis (0.963) after evaluating [10] repeated cases with 48 h of separation.

3. Results
To ensure that the groups were analogous, three types of comparison were made:
first, by rating whether the recession was unitary or multiple (chi-square test p = 0.324);
secondly, the location (type) of tooth (chi-square test = 0.353), finally, the type of recession
(chi squared test p = 0.254). Consequently, results found no significant differences and the
groups were comparable.
Complications observed in the Test group (DFGG + CAF) included: superficial
re-epithelialization, cul-de-sac formation, appearance of epithelial bands, discoloration
changes, and superficial revascularization.
Complications detected in the Control group (CTG + CAF) included: discoloration
and superficial revascularization.
We did not find cysts or bone exostoses in either of the two groups.
Int. J. Environ. Res. Public Health 2021, 18, 4504 7 of 12

The statistics relating to the appearance of complications 1 year after the surgery can
be seen in Table 1.

Table 1. Complications observed in the study. Chi square test for independence, with continuity
correction or Fisher’s exact test.

Control Group Test Group

Confidence Interval
Complications (CTG + CAF) (DFGG + CAF)
(95%)
(n = 32 Patients) (n = 34 Patients)
Major
[3.03–28.07%]
Reepithelialization 0 (0%) 5 (15.6%)
p = 0.023
[3.03–28.07%]
Cul de Sac 0 (0%) 5 (15.6%)
p = 0.023
[3.03–28.07%]
Epithelial bands 0 (0%) 5 (15.6%)
p = 0.023
Cysts 0 (0%) 0 (0%) -
Exostoses 0 (0%) 0 (0%) -
Minor
[1.259–22.409%]
Revascularization 2 (5.9%) 10 (31.3%)
p = 0.01
[11.21–53.19%]
Discoloration 5 (14.7%) 15 (46.9%)
p = 0.007

3.1. Incidence of Major Complications

Reepithelialization of the DFGG was seen in five cases (15.6%) in the Test group
(DFGG + CAF) and in no cases in the Control group, with the differences being statisti-
cally significant.
The presence of Cul-de-sac was seen in five cases (15.6%) in the Test group (DFGG + CAF)
and in no cases in the Control group, with the differences being statistically significant.
The presence of epithelial bands was seen in five cases (15.6%) in the Test group
(DFGG + CAF) and in no cases in the Control group, with the differences being statisti-
cally significant.
Neither of the two groups experienced cysts or bone exostoses.

3.2. Incidence of Minor Complications

Discoloration of the grafted area was observed in 15 cases (46.9%) of the Test group
(DFGG + CAF), while in the Control group (CTG + CAF), this was only observed in five
cases (14.7%), and the differences were statistically significant.
Superficial graft revascularization was seen in 10 cases (31.3%) in the Test group
(DFGG + CAF), while in the Control group (CTG + CAF) it was only seen in two cases
(5.9%), and the differences were statistically significant.

4. Discussion
Mucogingival surgery procedures, as with any other surgical procedure, are not
exempt from the appearance of complications. We must make clear the separation between
disadvantages, such as aesthetic results [34] and, complications, such as incomplete healing.
Most of the publications report the presence of early postoperative complications (bleeding,
pain, inflammation, etc.) [40,41]. Late complications, appear after a few weeks to even
months or years of having performed the treatment, are scarce.
As the bibliography indicates, other minimally invasive techniques could be used
in the management of the soft tissue, such as laser systems (Er:YAG or Er,Cr:YSGG),
according to the expert’s skills, with similar results. [42–44]. Some publications suggest that
Int. J. Environ. Res. Public Health 2021, 18, 4504 8 of 12

complications can be higher in patients with HIV, and therefore the viral load (CD4/CD8
ratio) must be stable [45].
This prospective study has a double objective of assessing the development and
incidence of complications associated with the use of DFGG (Test Group) and comparing
this with the development of complications related to the use of CTG (Control Group).
Providing a classification and an incidence rate of the most common complications observed
after these types of treatments.

4.1. Major Complications: Re-Epithelialization, Epithelial Bands, and Cul-de-Sac

The re-epithelialization of the graft was observed in five cases of the Test group,
which represents an incidence rate of 15.6%. It is striking that the re-epithelialization of
the DFGG has not been described in the literature until now, despite being frequently
observed in our clinical practice. Our study considered it the most serious complication,
given the appearance of an unsightly patch that it caused. Even when it occurred in areas
where aesthetic appearance is less compromised, such as the lower incisors, the aesthetic
result was not very acceptable. The re-epithelialization generally did not cover the entire
graft, but usually occurred in a localized area and with an irregular shape, leading to
patient’s discomfort.
Another surprising finding was locating in these same cases the development of an in-
vagination or cul-de-sac, as well as the presence of epithelial bands on the re-epithelialized
graft. In all cases of graft re-epithelialization, the epithelial bands and cul-de-sac appeared
to be associated, giving the same incidence rate of 15.6% in the Test group. These complica-
tions produced non-adhered retentive areas. To eliminate them, we performed a superficial
de-epithelialization with a diamond bur under local anesthesia. The results seem to indicate
that patients undergoing an DFGG + CAF procedure are more likely to develop all these
complications. It could be suggested that these manifestations may be related. No cases in
the control group developed this type of complication. The incidence rate in the Control
group was 0% for all the major complications mentioned. These statistically significant
differences could be due to the fact that the DFGG could leave epithelial remains that block
the adhesion of CAF to the graft area, facilitating the re-epithelialization of the graft, as well
as the appearance of epithelial bands and cul-de-sac. Hence, the importance of a correct
and thorough de-epithelialization of the graft.

4.2. Major Complications: Epithelial Cysts

The appearance of epithelial remains buried under the flap and subsequently generat-
ing cysts, manifesting between 9 and 48 months after surgery, has been reported [17,28].
Cysts were one of the major complications described in the literature that we expected
to find. Nevertheless, we observed a 0% incidence rate in both the Test and Control groups.
We made three hypotheses in an attempt to explain these results. On the one hand, as
the incidence rate of epithelial cysts was so low, our sample size could be insufficient to
reveal it. Therefore, it could be necessary to work with a much larger sample. On the other
hand, it could be possible that our follow-up time of one year was not enough to reveal
this complication, and therefore that could be solved with a longer-term follow-up study.
Finally, it could be possible that the orientation of the graft could influence the for-
mation of this type of complication. In both of our study groups, the graft was sutured
in a manner corresponding to its original orientation. The DFGG was sutured with the
de-epithelialized face facing outwards, while the CTG was sutured leaving the originally
more superficial area facing outwards. This manner of the placement of the graft could be a
successful method to avoid cyst formation, since epithelial remains are not trapped underneath.
Notwithstanding, we should take into account that the orientation of the super-
ficial part of the graft towards the outside could also have favored the formation of
re-epithelialization and cul-de-sacs in the case of DFGG in the cases that experienced
superficial re-epithelialization of the graft. Epithelial cysts could have been produced
instead if we had oriented the graft with the de-epithelialized face towards the periosteum
Int. J. Environ. Res. Public Health 2021, 18, 4504 9 of 12

at the time of suturing. Although this is just conjecture, it makes sense from a biological
point of view. Zuchelli et al., 2009 [27], considered the orientation of the CTG irrelevant
at the time of the suture. The author did not refer to the appearance of complications,
only focusing in the final result, obtaining the same clinical success in both locations. In
addition to this, they did not mention the DFGG. Future research will help us to clarify
these questions.

4.3. Major Complications: Bone Exostoses

Our studies are not in line with the existing literature on the formation of bone
exostoses. These publications describe a series of cases, without providing an incidence
rate. Bone exostoses were one of the serious complications described in the literature that
we believed could be found in our work; however, we had an 0% incidence rate in both the
Test and Control groups.
To explain this event, we present two hypotheses. As in the same case of the epithelial
cysts, our sample size could be insufficient to reveal an incidence rate. Furthermore, it could
be possible that the follow-up time of 1 year was not sufficient to reveal this complication.

4.4. Minor Complications: Discoloration and Superficial Revascularization

Changes in superficial coloration of the grafted area were seen in 46.9% of the cases
treated with DFGG + CAF, compared to 14.7% in the Control group (CTG + CAF).
Color change was considered when the color of the grafted area was different from
that of the adjacent areas, as described in the Cairo RES index [46]. Cases in which re-
epithelialization had occurred were not included. This complication is more a subtle and
subjective appreciation, although the analysis carried out by the periodontist in charge of
its assessment revealed a consistent reproducibility when detecting these changes.
Although color changes are described in the literature, incidence rates have not been
provided. The obvious differences between the two groups are noteworthy, suggesting
that the DFGG achieves poorer aesthetic results compared to the CTG. This suggests that
perhaps the use of DFGG in aesthetic areas should be considered with caution.
The presence of superficial revascularization on the surface of the grafted area was
observed in ten cases in the Test group (31.3%) compared with two cases (5.9%) in the Con-
trol group. Generally, there are blood capillaries that rise from the apical to non-advanced
coronal in over half of the treated area, and are related to the graft re-vascularization
process. This revascularization also produces an unsightly effect.
Due to the postsurgical inflammation of the tissues in the first revision (seven days),
the development of complications is not well perceived. Most complications are identified
at three weeks after surgery and are maintained in subsequent check-ups at two and
six months. In the case of superficial revascularizations, they tend to diminish or even
disappear over time.
In our clinical experience, we have observed that this revascularization complication
tends to decrease or even disappear over the years, and the tissue tends to harmonize with
the rest. It is possible that with a study with a longer observation period, we would have
obtained a lower rate of these types of complications. We detected a higher incidence in
the group treated with DFGG—therefore, it should be used with caution in aesthetic areas.

5. Conclusions
Study results should always be interpreted with caution and multicenter studies with
longer-term follow-up are recommended.
A classification of complications according to their severity is proposed; major and
minor. Major complications require additional treatment for their correction or significant
alteration of aesthetics, and include re-epithelialization of the graft, epithelial bands, cul-
de-sac, epithelial cysts, and bone exostoses. In our study, the development of epithelial
cysts or bone exostoses was not detected.
Int. J. Environ. Res. Public Health 2021, 18, 4504 10 of 12

Minor complications were considered to be color changes in the grafted area and
superficial revascularization.
Regarding the incidence of complications. The presence of late major complications
was only associated with the use of DFGG, and the late minor complications that developed
with the use of the DFGG were much more common than those associated with CTG. This
incident rate may be reviewed in subsequent work.
We can conclude that CTG appears to be a more secure procedure than DFGG in
terms of the appearance of late complications. It is much more sensitive to technique, and
therefore is not recommended for less experienced clinicians.

Author Contributions: Conceptualization, S.R.; methodology, S.R., A.F.-P., and Á.F.d.V.-T.; software,
A.F.-P.; validation, B.B. and B.R.-C.; formal analysis, A.F.-P.; investigation, S.R., B.R.-C., and Á.F.d.V.-T.;
writing—original draft preparation, S.R., Á.F.d.V.-T., and B.R.-C.; writing—review and editing,
Á.F.d.V.-T., B.B.; supervision, B.B. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of a
favorable Report from the Ethics and Research Committee of the Junta de Andalucía (Study Code
1259-N-19 approved 11-06-2019).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data is contained within the article.
Conflicts of Interest: The authors declare no conflict of interest.

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