GINGIVAL RECESSION AND

ITS MANAGEMENT

PRESENTER-PUNIT

Contents

Introduction

Definitions

Classifications

Etiology

Factors affecting treatment outcome

Treatment

Conclusion

Reference

INTRODUCTION

Gingival recession is characterized by the displacement of the gingival

margin apically from the cemento-enamel junction, or CEJ, or from the

former location of the CEJ in which restorations have distorted the location

or appearance of the CEJ.

Gingival recession can be localized or generalized and be associated with

one or more surfaces. The resulting root exposure is not esthetically

pleasing and may lead to sensitivity and root caries. (Smith RG-1976).

Recession is not simply a loss of gingival tissue, it is a loss of clinical

attachment and the supporting bone of the tooth that was underneath the

gingiva.

DEFINITIONS

Gingival recession is defined as the apical migration of the junctional

epithelium with exposure of root surfaces.

[Kassab MM, Cohen RE-2003].

Gingival recession is the apical shift of the marginal gingiva from its normal

position on the crown of the tooth to levels on the root surface beyond the

cemento enamel junction

[Loe H-1992].

Gingival recession is defined as “the displacement of marginal

gingiva apical to the cemento-enamel junction (CEJ).”

(American Academy of Periodontology 1992)

The term “marginal tissue recession” is considered to be more

accurate than “gingival recession,” since the marginal tissue

may have been alveolar mucosa.

Marginal tissue recession is defined as the displacement of the

soft tissue margin apical to the cemento-enamel junction (CEJ)

(American Academy of Periodontology 1996)

CLASSIFICATIONS

Sullivan and Atkins. (1968)

First classification.

Concentrated on recession involving mandibular incisor teeth, used the

descriptive terms to classify recession into four groups.

• Narrow

• Wide

• Shallow and

• Deep

Sullivan and Atkins. (1968)

Narrow Wide

Mlinek et al (1973)

Reported their results of root coverage with mucosal grafts, quantified

''shallow-narrow" clefts as being <3 mm in both dimensions,

"deep-wide'" defects as being >3 mm in both dimensions.

Liu and Solt (1980)

According to their classification,

Visual recession is measured from the cemento-enamel junction to

the soft tissue margin.

Hidden recession refers to the loss of attachment within the pocket,

i.e., apical to the tissue margin.

Miller (1985)

Class I: Marginal tissue recession not extending to the mucogingival

junction (MGJ). No loss of interdental bone or soft-tissue. 100% root

coverage

Class II: Marginal recession extending to or beyond the MGJ. No loss of

interdental bone or soft-tissue. 100% root coverage.

Class III: Marginal tissue recession extends to or beyond the MGJ.

Loss of interdental bone or soft-tissue is apical to the CEJ, but

coronal to the apical extent of the marginal tissue recession. Partial

root coverage

Class IV: Marginal tissue recession extends to or beyond the MGJ.

Loss of interdental bone extends to a level apical to the extent of

the marginal tissue recession. No root coverage .

Limitations

Although Miller’s classification has been used extensively,

there are limitations that need to be considered:

1. The reference point for classification is MGJ.

The difficulty in identifying the MGJ creates difficulties in the classification

between Class I and II.

There is no mention of presence of keratinized tissue. A certain amount of

keratinized gingiva (in the form of free gingiva) will be evident in any tooth

with the gingival recession; the marginal tissue recession cannot extend to

or beyond the MGJ. In such a case, Class II cannot be a distinct class and

Classes I and II would represent a single group.

2.In Miller’s Class III and IV recession, the interdental bone or soft-

tissue loss is an important criterion to categorize the recessions.

The amount and type of bone loss has not been specified.

Mentioning Miller’s Class III and IV doesn’t exactly specify the

level of interdental papilla and amount of loss. A clear picture of

severity of recession is hard to project.

3. Class III and IV categories of Miller’s classification stated that

marginal tissue recession extends to or beyond the MGJ with the loss of

interdental bone or soft-tissue is apical to the CEJ.

The cases, which have inter-proximal bone loss and the marginal

recession that does not extend to MGJ cannot be classified either in

Class I because of inter-proximal bone or in Class III because the

gingival margin does not extend to MGJ.

4. Miller’s classification doesn’t specify facial (F) or lingual (L)

involvement of the marginal tissue.

5. Recession of interdental papilla alone cannot be classified

according to the Miller’s classification. It requires the use of an

additional classification system.

6. Classification of recession on palatal aspect , the difficulty of the

applicability of Miller’s criteria on the palatal aspect of the maxillary

arch can be reasoned out to the fact that there is no MGJ on palatal

aspect.

Therefore, a classification is required, which specifies the type of

recession and can also quantify the amount of loss. The classification

should be able to convey the status of the gingival recession and the

severity of the condition on palatal aspect.

7. Miller’s classification, estimates the prognosis of root coverage

following grafting procedure. Miller stated that 100% coverage can

be anticipated in Class I and II recessions, partial root coverage in

Class III and no root coverage in Class IV.

This theoretical affirmation is not demonstrated by studies.

Miller also published a case report of an attempt to obtain 100%

root coverage in a class IV recession by coronally positioning a

previously free gingival graft (Miller & Binkley 1986), 1- year post-

operative root coverage was slightly <100% on the facial aspect of

the tooth.

Mahajan’s modification of Miller’s classification

(2010)

Modifications suggested:

The extent of gingival recession defect in relation to MGJ should be

separated from the criteria of bone/soft tissue loss in interdental

areas.

Objective criteria should be included to differentiate between the

severity of bone /soft tissue loss in class III and class IV

Prognosis assessment must include the profile of the gingiva as

thick gingival profile favors treatment outcome and vice versa

An outline of classification system including the above mentioned changes is

presented:

Class I GRD not extending to the MGJ.

Class II GRD extending to the MGJ/beyond it.

Class IIIGRD with bone or soft-tissue loss in the interdental area up to

cervical 1/3 of the root surface and/or mal-positioning of the teeth.

Class IV GRD with severe bone or soft- tissue loss in the

interdental area greater than cervical 1/3rd of the root surface and/or

severe mal-positioning of the teeth.

Prognosis :

BEST Class I and Class II with thick gingival profile.

GOOD Class I and Class II with thin gingival profile.

FAIRClass III with thick gingival profile.

POOR Class III and Class IV with thin gingival profile.

Francesco Cairo et al (2011)

Classification based on the assessment of clinical attachment level

at both buccal and interproximal sites.

Recession Type 1 (RT1): Gingival recession with no loss of

interproximal attachment. Interproximal CEJ was clinically not

detectable at both mesial and distal aspects of the tooth

Recession Type 3 (RT3): Gingival recession associated with loss of inter-

proximal attachment. The amount of interproximal attachment loss

(measured from the interproximal CEJ to the depth of the pocket) was

higher than the buccal attachment loss (measured from the buccal CEJ to

the depth of the buccal pocket)

Most of the classifications of gingival recession are unable to convey

all the relevant information related to marginal tissue recession. This

information is important for shaping diagnosis, prognosis, treatment

planning.

Also, with a broad variety of cases with different clinical presentations,

it is not always possible to classify all gingival recession defects

according to present classification systems.

Proposed classification of gingival recession (ASHISH

KUMAR AND SUJATHA MARIAMSETTI 2013)

This classification can be applied for facial surfaces of maxillary

teeth and facial and lingual surfaces of mandibular teeth.

Interdental papilla recession can also be classified according to this

new classification.

A distinct classification for gingival recession on palatal aspect is

also being proposed.

Class I: There is no loss of interdental bone or soft-tissue.

This is sub-classified into two categories:

Class I-A: Gingival margin on F/L aspect lies apical to CEJ, but coronal to MGJ with

attached gingiva present between marginal gingiva and MGJ

Class I-B: Gingival margin on F/L aspect lies at or apical to MGJ

with an absence of attached gingiva between marginal gingiva and

MGJ.

Class II: The tip of the interdental papilla is located between the

interdental contact point and the level of the CEJ mid- buccally/mid-

lingually. Interproximal bone loss is visible on the radiograph. This

is sub-classified into three categories:

Class II-A: There is no marginal tissue recession on F/L aspect.

Class II-B: Gingival margin on F/L aspect lies apical to CEJ but

coronal to MGJ with attached gingiva present between marginal

gingiva and MGJ.

Class II-C: Gingival margin on F/L aspect lies at or apical to MGJ

with an absence of attached gingiva between marginal gingiva and

MGJ

Class III: The tip of the interdental papilla is located at or apical to the level

of the CEJ mid-buccally/mid-lingually. Interproximal bone loss is visible on

the radiograph. This is sub-classified into two categories:

Class III-A: Gingival margin on F/L aspect lies apical to CEJ, but coronal to

MGJ with attached gingiva present

Class III-B: Gingival margin on F/L aspect lies at or apical to MGJ

with an absence of attached gingiva between marginal gingiva and

MGJ.

INDEX OF RECESSION BY SMITH 1997

Index of Recession. It would have observational and descriptive value, as well

as denoting severity and would also provide a basis for evaluating treatment

modalities and experimental studies.

Facial and lingual sites of root exposure on the same tooth are assessed

separately. The IR being proposed consists of two digits separated by a dash

(e.g F2- 4*). The first digit denotes the horizontal and the second the vertical

component of a site of recession, with the pre- fixed letter (F or L) denoting

whether the recession is on the facial or lingual aspects of the tooth, and an

asterisk (*) denoting involvement of the MGJ.

The recession is determined by the actual position of the gingiva not by its apparent position

Recession can be studied as,

VISIBLE

HIDDEN

Localised Generalised

Deep-Wide

Deep-Narrow

Shallow-Wide

Shallow-Narrow

Sullivan & Atkins classification

1968a

Mlinek, Smukler, Buchner 1973

Quantified shallow narrow clefts as being <3mm in both dimensions and deep wide defects as being > 3mm in both dimensions

P.D.MILLER (1985) CLASSIFICATION

Mahajan's modification

Class I: GRD not extending to the MGJ.

Class II: GRD extending to the MGJ/beyond it.

Class III: GRD with bone or soft-tissue loss in the interdental area upto cervical 1/3 of the root surface and/or malpositioning of theteeth.

Class IV: GRD with severe bone or soft tissue loss in the interdentalarea greater than cervical 1/3rd of the root surface and/or severemalpositioning of the teeth.

Prognosis

BEST: ClassI and Class II with thick gingival profile.

GOOD: Class I and Class II with thin gingival profile.

FAIR: Class III with thick gingival profile.

POOR: Class III and Class IV with thin gingival profile.

Class I-A.

Class I-B

Class I: There is no loss of interdental

bone or soft-tissue.

This is sub-classified into two categories:

• Class I-A: Gingival margin on F/L

aspect lies apical to CEJ, but coronal to

MGJ with attached gingiva present

between marginal gingiva and MGJ

• Class I-B: Gingival margin on F/L

aspect lies at or apical to MGJ with an

absence of attached gingiva between

marginal gingiva and MGJ.

ASHISH ET AL., 2013

Class II-A.

Class II-B.

Class II-C

Class II: The tip of the interdental papilla is

located between the interdental contact

point and the level of the CEJ midbuccally/

mid-lingually. Interproximal bone loss is

visible on the radiograph. This is sub-

classified into three categories:

• Class II-A: There is no marginal tissue

recession on F/L aspect

• Class II-B: Gingival margin on F/L aspect

lies apical to CEJ but coronal to MGJ with

attached gingiva present between marginal

gingiva and MGJ

• Class II-C: Gingival margin on F/L aspect

lies at or apical to MGJ with an absence of

attached gingiva between marginal gingiva

and MGJ.

Class III: The tip of the interdental

papilla is located at or apical to the level

of the CEJ mid-buccally/mid-lingually.

Interproximal bone loss is visible on the

radiograph.

This is sub-classified into two

categories:

Class III-A: Gingival margin on F/L

aspect lies apical to CEJ, but coronal to

MGJ with attached gingiva present

between marginal gingiva and MGJ.

Class III-B: Gingival margin on F/L

aspect lies at or apical to MGJ with an

absence of attached gingiva between

marginal gingiva and MGJ.

Either of the subdivisions can be on F or

L aspect or both (F and L).

CLASSIFICATION OF PALATAL GINGIVAL RECESSION

The position of interdental papilla remains the basis of

classifying gingival recession on palatal aspect.

The criteria of sub-classifications have been modified to

compensate for the absence of MGJ.

PR-I deals with marginal tissue recession on palatal aspect

with no loss of interdental bone or soft-tissue.

PR-II and PR-III deal with the loss of interdental bone/soft

tissue with marginal tissue recession on palatal aspect.

Palatal recession-I

There is no loss of interdental bone or soft-tissue.

This is sub-classified into two categories:

PR-I-A: Marginal tissue recession ≤3 mm from CEJ.

PR-I-B: Marginal tissue recession of >3 mm from CEJ.

Palatal recession-II

The tip of the interdentalpapilla is located between theinterdental contact point andthe level of the CEJ mid-palatally. Interproximal boneloss is visible on theradiograph.

This is sub-classified intotwo categories:

PR-II-A: Marginal tissuerecession ≤3 mm from CEJ.

PR-II-B: Marginal tissuerecession of >3 mm from CEJ

Palatal recession-III

The tip of the interdentalpapilla is located at or apical tothe level of the CEJ mid-palatally. Interproximal boneloss is visible on theradiograph.

This is sub-classified intotwo categories:

PR-III-A: Marginal tissuerecession ≤3 mm from CEJ.

PR-III-B: Marginal tissuerecession of >3 mm from CEJ.

Prevalence

According to ALBANDEN & KINGMEN(1988-1994)

1) 58 % between 30-90 yrs

2) 37.8% between 30-39 yrs

3) Women has more recession as compared to men.

4) More on buccal surface

5) Canine, premolar, molars.

• subclinical inflammation

• Clinical inflammation and proliferation of rete pegs

• Increased epithelial proliferation resulting in loss of ct core

• Merging of epithelium and resulting in separation and recession of gingival tissues.

(Susin et al.)

Inflammation of the connective tissue of free gingiva and its consequentdestruction,

where the gingival epithelium migrates into the connective tissue and getsdestroyed,

here the gingival epithelial basement membrane and sulcus epitheliumreduce the thickness of the connective tissue between them, thus reducingthe blood flow by impairing the repair of the initial injury.

As the lesion progresses, the connective tissue disappears and fusionoccurs between the gingival epithelium and the sulcular and unionepithelia, which will subsequently withdraw due to lack of blood flow

Faulty tooth brushing

Tooth malpositioning

Friction from soft tissue

Periodontal inflammation

Abnormal frenal attachment

Oral habits

Iatrogenic factors

Moscow and Bressman,1966

Aldritt,1968

Alveolar bone dehiscence

Woofer

1969

• Increases with age, 8% in children to 100% in adults over 50 yrs

• Tooth malpositioning and traumatic brushing

Stoner

1980

• prominent on mandibular 1st premolar and canine

• As width of KG decreased percentage of recession increased

Serino

1994

• Predominantly found on buccal surfaces

Clinical examination

Measurement of amount of gingival recession is made by Periodontal probe from CEJ to the gingival crest

1. Exposed root surfaces are susceptible to caries.

2. Abrasion or erosion of the cementum

Underlying dentinal suface

Sensitivity

3. Hyperemia of pulp may also result from excessive exposure of root surfaces.

4. Interproximal recession creates oral hygiene problems & resulting plaque accumulation

Clinical significance:

Index of Recession - Smith

Described by two digits separated by a dash

prefixed letter F or L –denotes facial or lingual

* denotes involvement of mucogingival junction

TreatmentNon-surgically

Surgically

Miller,1994

•Root coverage to CEJ•Adequate band of attached gingiva•An accelerated color match to surrounding tissue•An esthetic tissue contour•Minimal postop pain•No increase in sensitivity

Rationale for treatment of recession

NON – SURGICAL METHOD

1. Correction of tooth brushing technique

2. Removal of masochistic habits

3. Correction of malocclusion

4. Treating the dentinal sensitivity

Key factors in the selection of surgical procedures

Recipient Site Donor Site

1. Gingival recession is limited to

one tooth or extends to multiple

teeth

2. Degree of gingival recession

3. Amount and thickness of existing

keratinized gingiva in the area of

recession

4. Whether the area of recession

protrudes labially from the dental

arch

5. The relation between the gingival

recession area and smile line

6. Restorative/Prosthodontic

treatment after root coverage is

necessary

1. Whether area adjacent to

gingival recession can be used

as a donor site

• Amount of Keratinized

gingiva

• Thickness of keratinized

gingiva

• Size of adjacent interdental

papilla

• Thickness of the alveolar

bone covering the donor

tissue

2. Thickness of palatal soft tissue

used as donor tissue

Root coverage techniques:

1. Pedicle soft tissue graft procedures :

Rotational flapsLaterally positioned flap

Double papilla flap

Advanced flapsCoronally positioned flap

Semilunar flap

2. Free soft tissue graftsNonsubmerged graft

•One stage (free gingival graft)

•Two stage (free gingival graft + coronally positioned flap)

Submerged grafts•Connective tissue graft + laterally positioned flap

•Connective tissue graft + double papilla flap

•Connective tissue graft + coronally positioned flap

•(subepithelial connective tissue graft)

•Envelope techniques

3. Additive treatments•Root surface modification agents

• Enamel matrix proteins

•Guided tissue regeneration

•Nonresorbable membrane barriers

•Resorbable membrane barriers

Pedicle Gingival Grafts

Advantages

One surgical area

Blood supply of flap preserved

Post op color match is in harmony with surrounding tissues

Disadvantages

Applicable for single tooth

Minor and shallow recession

Contraindications

Narrow oral vestibule

Multiple teeth

Recession area extremely protrusive

Thin gingiva and bone at adjacent donor site

Preparation of recipient site

Removal of root prominence

Root biomodification

V shaped incision removing adjacent epithelium and ct

Beveling on side opposite to donor area to cause overlap

Laterally Positioned Flap

• Good vascularity

• Ability to cover denuded root surface

• One surgical siteAdvantages

• Recession at donor site,Guinard,1978

• Dehiscence or fenestration at donor site

• Limited to 1 or 2 teeth

Disadvantages

Introduced by Grupe and warren 1956

Staffileno,1964

partial thickness flap to avoid recession at donor site

Grupe,1966

submarginal incision

Pfeifer and Heller,1971

reattachment more likely with full thickness flap

VARIANTS

Advantage

Prevent recession at donor site

Submarginal pedicle flap

Dhalberg,1969

Oblique rotated pedicle flap

ADVANTAGES

1. Good tissue blend

2. Usually one surgical site

3. Pedicle to be moved over donor site without tensionand releasing incision

4. Usually complete root coverage

DISADVANTAGE

1. Possible recession at the donor site

Introduced by Bahat,1990

Advantages Disadvantages

Predictability in areas of narrow

root exposure

Possible to avoid recession at

donor site

Sufficient length and width of

interdental papilla adjacent to

recession area necessary

Not suitable for multiple teeth

It is a modification of oblique rotated flap

Transpositional flap

Goldman,1982

Split partial full thickness rotated pedicle flap

Advantage

Coverage of exposed donor site with periosteum

Introduced by Waienberg in 1964

Modified by Cohen and Ross,1968

Indications

When interdental papilla adjacent to receded area is sufficient wide

AG on approximating teeth is insufficient to cause lateral

displacement

Advantages

Risk of loss of bone is less as interdental bone is more resistant

Papilla usually supply greater width of AG

Reasons for failure

Inadequate suturing

Double papillae Laterally positioned flap

Introduced by Hatler in 1967

Requires broad interdental papilla

Horizontal lateral sliding paillary flap

Introduced by Norberg in 1956

Harvey in 1965 used it with FGG

Bernomoulin in 1975

Coined by Pini and Prato in 1999

Prerequisites

Adequate zone of AG>3mm

Advantages

• Treatment of multiple area of root exposure

• No need for involvement of adjacent teeth

• High degree of success

Disadvantages

• Need of 2 surgical procedure if zone of KG is less

Coronally advanced flap

Introduced by Tarnow in 1986

Advantages

• No vestibular shortening

• No need for sutures

Disadvantages

• Inability to treat large area of recession

• Requires FGG if underlying Dehiscence or fenestration is resent

Semilunar coronally advanced flap

2000

Coronally advanced flap for multiple recession

Introduced by Margraff,1985

Multiple gingival recession with or without adequate attached gingiva

Does not require separate

frenectomy

Increases vestibular depth

Advantages

Double Lateral sliding bridge flap

Reasons for pedicle flap failure

TensionNarrow

Flap

Bone exposed poor stabilization

The actual position of the gingiva is

the level of the attached periodontal

tissue. It is not directly visible but can

be determined by probing.

The apparent position of the gingiva is

the level of the gingival margin or crest

of the free gingiva that is seen by direct

observation.

Actual recession. The actual

recession is shown by the position of

the attachment level.The “receded

area” is from the cementoenamel

junction to the attachment.

Visible recession. The visible

recession is the exposed root surface

that is visible on clinical examination. It

is seen from the gingival margin to the

cementoenamel junction

Cut back incision- Made at apical

aspect of releasing incision and directed

towards base of the flap in laterally

positioned flap for relieving the muscle

tension.

Given with the help of 11 or 15 no.

surgical blade.

by Bjorn in 1963

Sullivan and Atkins in 1968Indications

• Covering roots in areas of gingival recession.

•For covering non pathologic dehiscence and fenestration

•Increasing the amount of keratinized tissue

•Increasing the vestibular depth

Advantages

• High degree of predictability

• Simplicity

• Ability to treat multiple teeth

• Used in cases of reduced KG

• Can be used as one site or 2site procedure

Disadvantages

• 2 operative sites

• Compromised blood supply

• Greater discomfort

• Retention of graft

Free Gingival Graft

Procedure

Preparation of recipient site

The purpose of this step is to prepare a firm connective tissue bed to

receive the graft.

Submarginal incision, either a single horizontal incision at MGJ or 2

vertical incisions joined at MGJ

Extend the incisions to approximately twice the desired width of the

attached gingiva, allowing for 50% contraction of the graft when healing

is complete.

Insert a #15 blade along the cut gingival margin

and separate a flap consisting of epithelium and

underlying connective tissue without disturbing

the periosteum.

Extend the flap to the depth of the vertical

incisions. If a narrow band of attached gingiva

remains after the pockets are eliminated, it

should be left intact.

Make an aluminum foil template of the

recipient site to be used as a pattern for the

graft.

Suture the flap where the apical portion of the

free graft will be located.

Reiser et al. in 1996 reported that theneurovascular bundle could belocated 7–17 mm from the cemento-enamel junction (CEJ) of the maxillarypremolars and molars.

According to these authors, in anaverage palatal vault the distancefrom the CEJ to the neurovascularbundle is 12 mm. That distance isshortened to 7 mm in case of ashallow palatal vault and lengthenedto 17 mm in case of a high palatalvault.

Other research has shown gender-related variations. The mean heightof the palatal vault, as measuredfrom the midline of the palate to theCEJ of the first molars, is 14.90± 2.93mm in men and 12.70 ± 2.45 mm inwomen (Redman et al 1965).

Anatomy of a donor region. Palatal vesselsand nerve running from the greater andlesser palatine foramina to theinterincisive foramen. The anterior palatalsubmucosa is mainly fatty, whereas theposterior palatal submucosa is mainlyglandular

Preparation of donor site

After measuring the denudedarea with a periodontal probe atthe recipient site, themeasurements of the palateshould be recorded and thegraft outline traced with thescalpel .

The graft thickness should beclose to 1.5 mm, whichapproximately corresponds tothe length of the bevel on a no.15 blade, and should not be toothick or too thin. The dissectionis done with a no. 15 blade keptparallel to the epithelial outerside of the graft, not the longaxis of the tooth.

.

Palatal donor site. The graft to

be harvested had been

delineated with a no. 15 blade.

Orban 1966 Raterschak,1979 minimal primary contraction

due to the presence of less elastic fibres and 25 to 45%

secondary contraction in thin to intermediate.

Davis,1966 greater primary contraction in thick to full

thickness but minimal secondary contraction due to the

presence of thicker lamina

Thorough planing of root surfaceCreating close adaptation of coronal margin of recipient

site and graft with butt jointUsing a thick graft

Stretching graft to regenerate vascularity

Advantages

• High predictability

• Dual blood supply

• Less discomfort at donor site

• Esthetic harmony

• For multiple sites

Disadvantages

• Technically demanding

• Thick graft required

Contraindications

• Broad shallow palate

• Excessive glandular or fatty palatal mucosa

Subeithelial connective tissue autograft

After anesthesia, root planing androot conditioning, horizontal incisionsare made at the level of the CEJ,preserving the interdental papillae.

This is followed by vertical incisionsat least one tooth away from eachside of the recession. This point iscritical, because the portion of thefree gingival graft placed over thedenuded root will not survive if therecipient bed is not large enough toprovide collateral vascularization.

Therefore, the bed should be as wideas possible, given the anatomicallimitation of the area. It shouldextend apically at least 3 mm belowthe margin of the denuded root.

The wider the bed, the better chancethe patient has for root coverage.

A large periosteal bed is prepared to

receive the graft. The large size of the

bed is to compensate for the avascular

area of the root to be covered and

eliminate frenum fiber attachment.

The predictability and superior aestheticsprovided by this technique make it the goldstandard for root coverage.

Harvesting the graft from the donor site

Two parallel incisions, perpendicular to the long axis of the teeth, are made in the palate, close to the CEJ (Langer & Langer 1985).

Two vertical releasing incisions help dissect the superficial flap and free the subepithelialconnective tissue graft .

Once the graft is harvested, the success rate of the procedure does not appear to be influenced by removing the epithelial collar from the graft (Bouchard et al. 1994).

The trapdoor enabling the

retrieval of the connective

tissue graft.

Donor site

Causes of failure of ct grafts

•Recipient bed too small to provide sufficient blood supply

•Flap penetration

•Inadequate root planing

•Insufficient blood supply

•Graft too small or too thick

Subepithelial connective tissue autograft

Advantages

For multiple adjacent teeth

Minimize incisions and reflection of flap

Abundant blood supply

Introduced by Zabalegui, 1999

Tunnel flap technique

This technique consists of the

following steps:

Step 1. Using a #15C or #12D blade,

a sulcular incision is made around the

teeth adjacent to the recession. This

incision separates the junctional

epithelium and the connective tissue

attachment from the root.

Step 2. Using either a curette or a

small blade such as the #15C, a

tunnel is created beneath the adjacent

buccal papilla, into which the

connective tissue is placed.

Step 3. A split-thickness pouch

is created apical to the papilla,

which has been tunneled, and

the adjacent radicular surface.

This pouch may extend 10 to

12 mm apical to the recessed

gingival margin and papilla

and 6 to 8 mm mesial and

distal to the denuded root

surface.

Step 4. The size of the pouch,

which includes the area of the

denuded root surface, is

measured so that an equivalent

size of donor connective tissue

can be procured from the

palate.

Step 5. Using sutures,curettes, and elevators, theconnective tissue is placedunder the pouch and tunnel,with a portion covering thedenuded root surface.

Step 6. The mesial and distalends of the donor tissue aresecured by gut sutures. Thegingival margin of the flap iscoronally placed and securedby horizontal mattresssutures that extend over thecontact of the two adjacentteeth

Step 7. Other holding sutures

are placed through the

overlying gingival tissue and

donor tissue to the underlying

periosteum to secure and

stabilize the donor tissue

beneath the gingiva.

Step 8. A periodontal dressing

is used to cover the surgical

site.

• Gain of new attachment

• Donor site not necessary

• Predictable root coverage

Advantages

• Technically demanding

• Costly

Disadvantages

76 to 100 % root overage

Indications

Ideal when recession is greater than 4.98mm apicoincisally(Pini Prato et

al 1992)

Cortellini et al 1993 reported 3.66mm of connective tissue attachment with 2.48mm of new cementum and 1.84mm of bone growth histologically.

GTR

Technique

After proper anesthesia, therecession is root planedthoroughly and flattened using aGracey curette or a back-actionchisel. The root is conditioned for5 min with tetracycline paste.

Two vertical releasing incisionsare made at the line angles of thetooth with the recession .

These releasing incisions mustpass the mucogingival junctionfor the flap to be mobile. Two vertical incisions are

placed, avoiding the

interproximal papillae.

GUIDED TISSUE REGENERATION

An intrasulcular incision connectsthe two verticals coronally.

A full-thickness flap is raised using aperiosteal elevator that will enablebone visibility 3 mm apical to theexposed root.

The flap is then converted to apartial thickness one apically thatwill enable coronal mobilization.

At this stage, the buccal flap, full atthe top and partial at the bottom,when moved coronally should beable to cover and lie passively onthe recession.

This is critical because any tensionwhile suturing will affect thepositive outcome of the procedure.The papillae are de-epithelialized,and the membrane is trimmed andadjusted to cover the recession.

The flap is reflected exposing the

alveolar bone.

Trimming the reabsorbable

membrane and adjusting it to fit the

site.

The membrane should extendapproximately 2 mm beyond theborders of the recession mesially,distally, and apically.

The membrane should be coronallyplaced at the level of the cemento-enamel junction and sutured inplace with a circumferential sutureand a palatally tied knot. The knot isthen palatally tucked into thegingival sulcus.

When the sulcus is shallow, a smallintrasulcular incision will helpdeepen it. Once the membrane issecured, the buccal flap is coronallymoved and secured to the papillaewith interrupted sutures .

The buccal flap is sutured

with the aim of covering as

much of the membrane as

possible.

Free gingival autograft

Horizontal suture

After making the ligature, pass the needle through the body of the graft and pull it out from the bottom

without cutting the thread. Engage the periosteum 2-3 mm from the mesial edge of the flap. Leave a slack

in the suture. Last, make a ligature and stretch to eliminate the sag. Stretching prevents primary shrinkage

of the graft (primary contraction) and regenerates graft vascularity.

Suture technique of Holbrook and Ochsenbein.

Circumferential suture

Insert the needle in the periosteum of the

recipient site slightly apical to the bottom edge

of the graft. Carry the suture around the cervical

area and tie it to the tail on the lingual aspect.

The thread presses the graft at the border of the

exposed root (dotted line).

Interdental concavity suture

Insert the needle in the periosteum at the bottom of the

interdental concavity area. Circle the needle around the

tooth, suture the graft diagonally, make a sling, and

make a ligature on the lingual aspect. Perform the

same procedure in the other Interdental area.

Subepithelial connective tissue graft

Primary incision. Make a horizontal incision with

a partial-thickness flap 3-5 mm apical to the

gingival margin in the palate (preparation of

primary flap).

Secondary incision. Make a secondary incision 1-2

mm coronal to the primary horizontal incision line. This

incision, which is perpendicular to the surface of the

gingiva, should extend to the bone.

Make a vertical incision mesiodistally approximating the width

and length of the necessary graft.

Prepare a primary partial-thickness flap (1.5-mm thick) toward

the center of the palate, parallel to the palatal gingiva. Expose

the underlying connective tissue.

Subepithelial connective tissue graft

For the secondary incision, the blade contacts the bone. Use asmall periosteal elevator or Kirkland knife to reflect the

connective tissue graft, bringing it toward the center of the

palate.

Extend the base of the primary incision to the bone.

Separate the connective tissue graft from the bone.

After harvesting of the connective tissue graft, the

bone surface is exposed.

Suture the primary flap. Close the wound with an interrupted

suture and a cross horizontal sling suture.

Make an interrupted suture in the interdental papilla with

resorbable suture material and then stabilize the graft

Displace the flap coronally, covering the graft as

much as possible, and suture

a. An interrupted suture is made on the graft

epithelium and interdental papilla with

absorbable suture thread.

b. A suture is made to cover the graft with the flap as

completely as possible

HEALING FOLLOWING FREE SOFT TISSUE GRAFTS

Healing of free soft tissue grafts placed entirely on aconnective tissue recipient bed has been studied inmonkeys and can be divided into the following threephases. (Oliver et al.1988)

0 – 3 day (Initial phase):

Plasmatic circulation

The epithelium of the free graft degenerates early inthe initial healing phase, and subsequently it becomesdesquamated.

After 4-5 days of healing, anastomoses are established betweenthe blood vessels of the recipient bed and those in the graftedtissue.

At the same time, a fibrous union is established between thegraft and the underlying connective tissue bed .

If a free graft is placed over the denuded root surface, apicalmigration of epithelium along the tooth-facing surface of thegraft may take place at this stage of healing.

2-11 day (revascularization phase)

After approximately 14 days the vascular system of the graftappears normal. Also the epithelium gradually matures with theformation of a keratin layer during this stage of healing.

Another healing phenomenon frequently observed following thefree graft procedures is “Creeping Attachment” i.e. coronalmigration of the soft tissue margin.

This occurs as a consequence of tissue maturation during a periodof about 1 year post treatment.

11-42 days (tissue maturation phase):

Silverstein and callan,1997

AlloDerm is donated human soft tissue that is processed to remove

dermal cells, leaving behind a regenerative collagen matrix.

It provides a matrix consisting of collagen, elastin, blood vessel

channels, and proteins that support

Acellular dermal grafts

After scaling and root planning, theroot surfaces are conditioned.

A partial thickness flap creating apouch is formed using a no. 15blade. The AlloDerm is rehydratedin two consecutive 10- to 15- minsterile saline baths (depending onsize and thickness of the pieceused). The graft is inserted into thepouch with the connective tissueagainst the recipient bed.

The papillae are de-epithelialized,and the graft is immobilized withresorbable sutures at the level ofthe cemento-enamel junction .

The buccal flap is then sutured over the AlloDerm to cover the graft as much as possible. It is important to not leave any AlloDerm exposed.

The buccal flap is sutured over the

AlloDerm by using a sling suture to

provide the graft with maximum

coverage.

Significant revascularizationoccurs in just over 1 week.

Allo-Derm is repopulated withcells and will begin remodelinginto the patient’s own tissue overthe next 3–6 months. Up to 41%shrinkage of the graft has beenreported during that period(Batista et al. 2001).

The material will also take thecharacteristics of the underlyingand surrounding tissues (forexample, keratinized tissue ormucosa).

[Do not be concerned by the whitishness of the graft after surgery; it is not tissue necrosis. This color reflects normal healing.]

GRAFT HEALING

By 1 week after surgery, some

of the AlloDerm is exposed. The

whitishness is a normal feature

of this healing process.

The final results are seen 2–3 yearslater.

It is important to remember that,when evaluating the results, theconcept of gain of attached gingiva orkeratinized gingiva is replaced by gainof gingival volume.

The absence of keratinized tissuewith this technique after successfulroot coverage is not uncommon, nordetrimental to the results. By 3 years after surgery, the

recessions have been covered.

Advantages

Decreases pain and bleeding as less invasive

Increases tissue thickness

Decreases infection and graft sloughing

Decreases healing time, mature tissue within 1 week

Promotes vascularization

Accelerates wound healing

Griffin, 2004 suggested use of platelet concentrate carried by

collagen sponge as graft substitute

Lien Hui,2005 used it with CAF

Yen and Jankovic,2007 used PRP with ctg and found accelerated

wound healing and attachment formation

PRP

Platelet-rich plasma (PRP)preparations

Strategy is to amplify and accelerate the effects of growth factors

contained in platelets

Modulate and up regulates one growth factor’s function in the

presence of other growth factors

Platelets play fundamental role in hemostasis and are natural source of

growth factors

Growth factors are stored in - granules of platelets

Venous blood is drawn into a tube containing an anticoagulant to avoid platelet

activation and degranulation.

The first centrifugation is called .soft spin.,of 2400rpm for 5 min which allows

blood separation into three layers, namely bottom-most RBC layer (55% of

total volume), topmost acellular plasma layer called PPP (40% of total

volume), and an intermediate PRP layer (5% of total volume) called the .buffy

coat..

Using a sterile syringe, the operator transfers PPP, PRP and some RBCs into

another tube without an anticoagulant.

This tube will now undergo a second centrifugation, which is longer and faster

than the first, called hard spin. 5600rpm for 15min. This allows the platelets

(PRP) to settle at the bottom of the tube with a very few RBCs, which explains

the red tinge of the final PRP preparation.

This PRP is then mixed with bovine thrombin and calcium chloride at the time

of application. This results in gelling of the platelet concentrate

PRP preparation

PRF

Choukroun’s PRF, is a second-generation platelet concentrate,

PRF consists of an intimate assembly of cytokines, glycanicchains, and structural glycoproteins enmeshed within a slowly polymerized fibrin network.

These biochemical components have well-known synergetic effects on healing processes.

Prior to surgery IV blood is collected in 10 ml vials without anticoagualnt & centrifuged at 2700 rpm for 10 min

Criteria for the success

Surgical site free of plaque and inflammation

Adequate blood supply to the donor tissue

Anatomy of the recipient and the donor site

Stability of the grafted tissue to the donor

site

Minimal trauma to the surgical site.

Treatment plan

Conclusion

The management of gingival recession and its sequelae is based on athorough assessment of the etiological factors and the degree ofinvolvement of the tissues. The initial part of the management of thepatient with gingival recession should be preventive and any pain shouldbe managed and disease should be treated.

The degree of gingival recession should be monitored for signs of furtherprogression. When esthetics is the priority and periodontal health is goodthen surgical root coverage is a potentially useful therapy.

Numerous therapeutic solutions for recession defects have been proposedin the periodontal literature and modified with time according to theevolution of clinical knowledge.

Careful case selection and surgical management are critical if a successfuloutcome is to be achieved.

References

Carranza’s Clinical periodontology – 10TH & 12h ed

Clinical Periodontology and Implant Dentistry – Jan Lindhe 6th ed

Periodontal Surgery – a clinical atlas - NaoshiSato

Practical periodontal plastic surgery – Serge Dibart

Chambrone L, Sukekava F, Araújo MG, Pustiglioni FE, Chambrone LA, Lima LA.

Root coverage procedures for the treatment of localised recession-type

defects (Review). The Cochrane Library 2009, Issue 2

Umberto Pagliaro, Michele Nieri, Debora Franceschi,Carlo Clauser,and Giovanpaolo Pini-Prato.

Evidence-Based Mucogingival Therapy. Part 1: A Critical Review of the Literature on Root Coverage

Procedures. J Periodontol • May 2003

The etiology and Prevalence of gingival recession – Moawia M.Kassab, Rober E. Cohen – JADA Feb

2003

The use of free gingival grafts for aesthetic purposes Paulom. Camargo, Philip R.Melnick & E. Barrie

Kenney : Periodontology 2000, Vol. 27, 2001,

Decision-making in aesthetics: root coverage revisited - Philippe bouchard, jacquesmalet & alain

borghetti - Periodontology 2000, Vol. 27, 2001