This presentation describes the diagnostic and different treatment procedures for gingival recession.

1. DR. MANISHA SINHA
II nd yr PG
DEPT OF
PERIODONTOLOGY
GINGIVAL
RECESSION
PART- II
RAJARAJESWARI DENTAL COLLEGE AND HOSPITAL

2.  Diagnosis
HISTORY
RADIOGRAPHIC ASSESSMENT
 Treatment
 Conclusion
 References

3. DIAGNOSIS

4. Chief Complaint, Specific Reason for the Visit or
Referral

5. Dental History
 Orthodontic treatment
 Oral appliances
 A history of periodontitis, or necrotizing ulcerative gingivitis/periodontitis
or mechanical/chemical trauma
 Periodontal treatment or surgical procedures
 Aesthetic dentistry/splinting/filling on anterior teeth
 Oral (hygiene) habits

6. Personal History
 Tobacco use (duration, daily consumption):
 Dietary habits:
 Recreational drugs (cocaine, meth, smokeless tobacco, bethel nut, etc.)
either

7. Mucosa
 Special attention should be given to:
 Depth of vestibulum: adequate space for oral hygiene procedures.
 Frenula: possible frenum pull at place of insertion.
 Scar tissue might exert tension.
 Piercings: position of the intraoral disc in relation to the gingiva

8. Gingiva
Thin scalloped: association with triangular-shaped crown, subtle
cervical convexity, interproximal contacts close to incisal edge,
narrow zone of KT, thin delicate gingiva, and relatively thin alveolar
bone
Thick scalloped: associated with slender teeth, thick fibrotic gingiva,
narrow zone of KT, and a high gingival scallop
Thick flat: associated with more square-shaped tooth crowns,
pronounced cervical convexity, large interproximal contact located
more apically, broad zone of KT, thick, fibrotic gingiva, and thick
alveolar bone

12. • Aberrant frenal insertions: Ankyloglossia? Blanching?
• Oral hygiene-induced or self-induced lesions
–– Stilman’s clefts? Incomplete (red) or complete (white) lesions
–– McCall’s festoons
–– Gingival erosion

19. Radiographic
Assessment
 Periapical Radiograph
 Bitewing Radiograph
 Cone Beam Computed Tomography
 Panoramic Radiograph

20. Periapical Radiograph

21. Cone Beam Computed Tomography

23. Miller,1994
•Root coverage to CEJ
•Adequate band of attached gingiva
•An esthetic tissue contour
•Minimal post op pain

24. METHODS:
Non-Surgical treatment
Surgical treatment

25. 1. Correction of tooth brushing technique
2. Removal of masochistic habits
3. Correction of malocclusion
4. Treating the dentinal sensitivity

26. Correction of tooth brushing technique

27. Removal of masochistic habits

28. Correction of malocclusion

29. Treating the dentinal sensitivity

30. 1. Pedicle soft
tissue graft
procedures :
• Rotational flaps
• Laterally positioned flap
• Double papilla flap
• Coronally positioned
flap
• Semilunar flap
2. Free soft tissue grafts
• Nonsubmerged 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
ROOT COVERAGE TECHNIQUES

31. 3. Additive treatments
• Root surface modification agents
• Enamel matrix proteins
• Guided tissue regeneration
• Nonresorbable membrane barriers
• Resorbable membrane barriers

32. Recipient 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/Prosthodonti
c treatment after root
coverage is necessary

33. • Thickness of the
alveolar bone
covering the donor
tissue
2. Thickness of palatal soft
tissue used as donor
tissue
Donor Site
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

35. Presurgical preparation
Mechanical modification of the root surface as well as root conditioning
procedures have been used prior to the surgical root coverage
techniques to achieve improved results (Miller, 1985).
Root surface modification using agents such as citric acid or tetracycline
hydrochloride has been advocated in an effort to promote the healing
response following root surface coverage, although clinical studies have
failed to show any improvement in root surface coverage when using
such agents (Tolmie et al., 1991; Zucchelli et al., 2009; Pini-Prato et al.,
1999)

36. Laterally Positioned Flaps
Indications:
1. Sufficient width, length, and thickness of keratinised tissue exist
adjacent to the area of gingival recession.
2. Coverage of the exposed root is limited to one or two teeth.
3. This method is most suitable for root coverage in gingival
recession with narrow mesiodistal dimension.( mandibular
anterior region)
Introduced by Grupe and warren 1956

37. Contraindications:
1. Insufficient width and thickness of keratinised tissue in the adjacent
donor site.
2. Extremely thin bone in the donor site or an osseous defect such as a
dehiscence or fenestration.
3. Gingival recession area extremely protrusive.
4. Deep periodontal pocket and remarkable loss of interdental alveolar
bone in the adjacent area.
5. Narrow oral vestibule.
6. Multiple teeth involved.

40. • Good vascularity
• Ability to cover denuded root surface
• One surgical site
Recession at donor site,Guinard,1978
• Dehiscence or fenestration at donor site
• Limited to 1 or 2 teeth
Advantages
Disadvantages

41. VARIANTS Staffileno,1964 and Pfeifer
and Heller,1971
partial thickness flap to
avoid dehiscence at donor
site
Grupe,1966
submarginal incision
to avoid recession

42. Submarginal pedicle flap

43. Oblique rotated pedicle flap
Dhalberg,1969

44. ADVANTAGES :
1. Good tissue blend
2. Usually one surgical site
3. Pedicle to be moved over donor site
without tension and releasing incision
4. Usually complete root coverage
DISADVANTAGE :
Possible recession at the donor site

45. Transpositional Flaps
Bahat et al" modified the oblique rotated flap. This
is called the transpositional flap.
Advantages
1. Predictability in areas of narrow root exposure
2. Possible to avoid gingival recession at the donor site
Disadvantages
1. Sufficient length and width of the interdental papilla adjacent to
the gingival recession area necessary
2. Not suitable for multiple tooth root coverage

47. Disadvantages
1. Technically demanding.
2. Limited application. The technique is
generally used for multiple interdental papilla
grafting, not for root coverage. The objective
is to increase the width of the attached
gingiva.
Indication
1. Sufficient width and
length of the interdental
papilla on both sides of the
area of gingival recession.
Advantages
1. The amount of donor tissue is
small because interdental papilla
adjacent to the gingival recession
area is displaced. Therefore,
the procedure can be achieved with
less tension to the pedicle flap.
2. While interdental bone is
exposed if a full-thickness pedicle
flap including interdental papilla is
used, there is little damage to
the alveolar bone because
interdental alveolar bone is thick.
Double Papilla Flap

50. Coronally advanced flap
Indications
1. Esthetic coverage of
exposed roots
2. For tooth sensitivity
owing to gingival
recession

52. 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

53. Semilunar coronally advanced flap
Introduced by Tarnow in 1986

54. Advantages
• No vestibular shortening
• No need for sutures
Disadvantages
• Inability to treat large area of
recession
• Requires FGG if underlying
Dehiscence or fenestration is present

55. Free autogenous gingival graft
This method was not indicated for root coverage of deep and wide gingival recession areas
because of insufficient blood supply to graft.
However, a series of procedures modified by Miller and Holbrook and Oschenbein
demonstrated successful root coverage using free autogenous gingival graft.
The common techniques are:
1. Through planing of the root surface to reduce the thickness of cementum , thereby
reducing the mesiodistal dimension of the root surface.
2. Creating close adaptation of the coronal margin of the recipient site and the graft with a
butt joint.
3. Using a graft of 1.5-2.0 mm thickness.
4. Stretching the graft to regenerate vascularity.

56. Indications:
All cases where root coverage is necessary except where a graft of sufficient thickness
(1.5-2.0 mm) cannot be harvested. (palatal tissue).
Disadvantages:
1. Method with poorest ability to provide blood supply to the graft for root coverage.
2. Because a large and thick graft is necessary, a deep and large wound is exposed on
the palatal mucosa( donor tissue). Various problems may occur, such as difficulty
achieving hemostasis and patient pain and discomfort due to slow healing( healing
by secondary intention).
3. Scarring occurs with wound healing, therefore, esthetic results may be inferior to
other methods.
4. Surgery is required in two areas.

57. Preparation of Recipient Site.

58. . Make a partial-thickness incision.
Complete recipient site preparation.
• Prepare recipient site 3-5 mm or more apical to the
most apical part of the exposed root.

59. Obtaining Graft Tissue.
Donor tissue, although obtainable from various sites—the edentulous ridge, the
tuberosity area, gingivectomy tissue— is most often secured from palatal
tissue.
The area of choice is the gingival zone distal to the anterior ruga on the
posterior portion of the palate .
This has the widest gingival zone with the least amount of submucosa . The
submucosal tissue is fatty anteriorly and glandular posteriorly.

61. a. Tinfoil is placed over the
recipient site to determine the
size. The tinfoil is then placed
over the palatal area.
b. An incision is made to the
palatal tissue with a depth of
about 2 mm. The incision should be
about 1 mm larger than the outline
of the tinfoil to accommodate graft
shrinkage.
c. Small tissue pliers are used to lift
the graft's edge. The graft is
separated along the outline and a
uniform-thickness graft (about 2 mm)
is harvested.

62. d. After harvest, the donor site is immediately sutured
and an absorbable hemostat gauze is placed.
e. The harvested graft is placed onto a gauze soaked
with physiologic saline solution. The thickness of the
adipose tissue and glandular tissue is checked.
f. The graft thickness necessary for root coverage is
1.5-2.5 mm.

63.  Holbrook and Ochsenbein (1983) noted that when grafts are used for root
coverage and underlying anatomic osseous factors must be taken into account,
the teeth with the most prominent roots generally exhibit the least amount of
bone over them, the most dehiscences and fenestrations, the greatest gingival
scalloping, the thinnest type of periodontium, the most esthetic form, and the
most mucogingival problems.
 They pointed out that prominent, bulging roots produce deep interproximal
valleys , which require close adaptation of the grafts.
 These interradicular concavities necessitate graft stabilization to promote
intimate graft contact and prevent dead space and hematoma formation.
Suture of graft
Suture technique of Holbrook and Ochsenbein

64. 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.
Horizontal suture

65. 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).

66. 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.
Interdental concavity suture

67.  Insert the needle from outside of the distal aspect of the papilla flap and
then insert the needle from the inside of the mesial aspect of the papilla
flap.
 Join the distal aspect of the papilla flap and the bevel of the mesial papilla
flap. Make an interrupted suture to overlap each connective tissue surface.
 If the flap edge is not straight after suture of the bilateral papilla, make a
releasing incision of the periosteum to relieve flap tension.
 Place the flap edge on the enamel coronal to the CEJ and stabilize the
overlapped bilateral papilla with a sling suture.
 Next, make a horizontal suture onto the flap mesiodistally for close
adaptation of the flap to the root surface.
Suturing in double papilla flap

68. Connective Tissue Grafts
Inroduced by Langer and Langer in 1985
• The techniques utilizing a subepithelial soft tissue graft, i.e. the connective tissue, involve the
placement of the graft directly over the exposed root and the mobilization of a mucosal flap
coronally or laterally for coverage of the graft (Langer & Langer 1985; Nelson 1987; Harris 1992;
Bruno 1994; Zucchelli et al. 2003).
• An alternative technique is to place the base of the connective tissue graft within an “envelope”
prepared by an undermining partial-thickness incision from the soft tissue margin, i.e. part of the
graft will rest on the root surface coronal to the soft tissue margin (Raetzke 1985; Allen 1994).
• For the treatment of multiple adjacent recessions, a multi-envelope recipient bed (“tunnel”) may
be prepared (Zabalegui et al. 1999).

69.  Indications
Root coverage necessary in the gingival recession area.
 Contraindications
Inadequate thickness of donor tissue. The necessary thickness of the
connective tissue graft for root coverage is 1.5-2.0 mm, and the
thickness of the palatal flap should be 1.5-2.0 mm after graft harvest to
prevent necrosis. Therefore, at least 3-mm thickness is necessary in the
palatal soft tissue of the donor site.

70. Connective tissue graft
combined with a coronally advanced flap
a. Make a trapezoidal partial-thickness flap with two vertical incisions mesiodistally. Vertical incision should be
at least 0.5 mm from the gingival margin of the adjacent teeth.
b. In the interdental papilla, make a horizontal i ncision at the CEJ or slightly coronal to it.

71. c. Prepare a partial-thickness flap. The interdental papillae should be de-epithelialized to allow for
maximum coronal positioning of the tissue fl ap over the exposed root surface at suturing
d. Reflect the partial-thickness flap. Make a releasing incision of the periosteum at the base of the
flap for easy coronal migration.

72. Harvesting of graft
Subepithelial connective tissue graft of masticatory
mucosa is harvested on the palatal aspect of the
maxillary premolars/first molar (or from the retromolar
pad) by the use of a “trap door” approach. Before
incisions are placed, the available thickness of the
mucosa is estimated
by the use of the tip of the syringe.
. 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.

73. 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.

74. For the secondary incision, the blade contacts the
bone. Use a small periosteal elevator or Kirkland 'S/6
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.

75. After harvesting of the connective tissue graft, the
bone surface is exposed.

76. I. Suture the primary flap. Close the wound with an
interrupted suture and a cross horizontal sling suture.

77. In subepithelial connective tissue grafts, place the thin border of the
epithelium, left on the marginal area of graft, coronal to the CEJ.
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.

78. Free connective tissue graft combined with a
coronally advanced fl ap procedure – single
recession
(a) Deep gingival recession at a cuspid with
minimal height of keratinized tissue apical
to the root exposure.
(b) The graft has been sutured to leave an area
between the cemento-enamel junction and the
graft available for the marginal keratinized
tissue of the flap.
(c) The flap has been advanced coronally and
sutured.
(d) Clinical healing at 1 year.

79. Advantages
1. High predictability.
2. The graft receives abundant blood supply from both the inside of the flap and the periosteum-
connective tissue.
3. Wound closed at palatal donor site after harvest of connective tissue graft. Therefore, hemostasis is
easy and healing is rapid. There is also less discomfort and pain during healing.
4. The graft fits the surrounding tissue on the recipient site, therefore, results are esthetically pleasing.
5. Applicable for gingival recession on multiple teeth.
Disadvantages
1. Technically demanding.
2. Because a thick graft is used, the grafted tissue is
thick. Gingivoplasty may be necessary
postoperatively to obtain better morphology.

80. Modified Technique of Langer and Langer
 Do not use a vertical incision when preparing a recipient site to:
• Ensure excellent blood supply to flap.
• Alleviate postoperative discomfort.
• Avoid scarring.
 Make a partial-thickness horizontal incision perpendicular to the interdental papilla of the
recipient site.
 Close adaptation to donor tissue is obtained with a butt joint.

81. a. Make a partial-thickness horizontal incision on the CEJ or slightly
coronally and perpendicular to the interdental papilla.
b. Connect each horizontal incision with a sulcular incision. Extend the
incision mesiodistally and prepare a large flap for proper access.
After reflecting a partial-thickness flap, prepare a periosteum-connective
tissue recipient site. Extend the partial-thickness incision apically
for coronal migration of the flap.

82. d. Cover the exposed root with a connective tissue graft and suture.
Cover the graft completely with the flap and suture.

83. Connective Tissue Graft Using an Envelope
Flap
Raetzke introduced a connective tissue graft using an envelope technique. A
partial-thickness envelope flap is prepared on the soft tissue adjacent to the
gingival recession area from the gingival sulcus. No horizontal or vertical
incision is made.

84. Prepare the envelope flap. With the use of the
“envelope” technique the recipient
site is prepared by fi rst eliminating the sulcular
epithelium by an internal beveled incision
an “envelope” is prepared apically
and laterally to the recession by split incisions.
The depth of the preparation should
be 3–5 mm in all directions. In an apical direction,
the preparation of the site should extend beyond
the mucogingival junction to facilitate the placement
of the connective tissue graft and to allow for
coronal advancement of the mucosal fl ap at time
of suturing.

85. • A foil template may be used for the
harvest of an appropriately sized
connective tissue graft.
The graft, , is inserted into the prepared “envelope” and
positioned to cover the exposed root surface.
• Sutures are placed to secure graft in position
. A crossed sling suture may be placed to
advance the mucosal fl ap coronally. Pressure is
applied for 5 minutes to adapt the graft closely to
the root surface and covering soft tissue.

86.  The advantages of this technique are: simplicity, minimal surgical invasiveness, and good esthetics
because the interdental papilla is preserved.
 One limitation of the envelope flap is that it cannot be displaced coronally.
 The envelope flap is also not applicable in areas of extensive gingival recession because there is a limit
to the size of the graft that can be placed in the envelope flap.

87. Pouch and Tunnel Technique
 In case multiple adjacent recessions are to be treated,
“envelopes” are prepared for each tooth.
 However, the lateral split incisions are extended so that
the multi-envelopes are connected mesially and distally to
form a mucosal tunnel.
 Care should be taken to avoid detachment of the papillae.
• The graft is gently positioned inside the tunnel and its
mesial and distal extremities are fixed with two
interrupted sutures.
 Sling sutures may be placed to advance the mucosal fl ap
coronally over the exposed portions of the connective
tissue graft.
 Pressure is applied for 5 minutes to closely adapt the graft
to the root surface and covering soft tissue. Application of
a periodontal dressing is often not required.
Introduced by Zabalegui, 1999

88. Subpedicle Connective Tissue Grafts
a. Double papilla flap design in recipient site.
b. Prepare the partial-thickness pedicle flap, which includes
mesiodistal interdental papilla.

89. c. Prepare the recipient site, which consists of periosteum-connective
tissue.
d. Suture and stabilize the connective tissue graft.
e. Connect each papilla flap to make a double papilla flap.
f. Cover the connective tissue graft on the root surface with the double
papilla flap. Make a sling suture.

90. CAUSES OF FAILURE OF CONNECTIVE TISSUE
GRAFTS
• Insufficient height of interdental bone and soft tissue.
• Horizontal incision placed apical to the CEJ.
• Reflection of all interdental papilla.
• Inadequate root planing.
• Insufficient blood supply from surrounding tissue due to inadequate
recipient site preparation.
• Connective tissue graft too small.
• Connective tissue graft too thick.
• Connective tissue graft inadequate for root coverage and coronal
placement.
• Insufficient coronal migration of flap covering the graft.

91. Advantages
1. High predictability.
2. The graft receives abundant blood supply from both the
inside of the flap and the periosteum-
connective tissue.
3. Wound closed at palatal donor site after harvest of
connective tissue graft. Therefore, hemostasis
is easy and healing is rapid. There is also less discomfort
and pain during healing.
4. The graft fits the surrounding tissue on the recipient site,
therefore, results are esthetically
pleasing.
5. Applicable for gingival recession on multiple teeth.
 Disadvantages
1. Technically demanding.
2. Because a thick graft is used, the
grafted tissue is thick. Gingivoplasty
may be necessary postoperatively to
obtain better morphology.

92. Healing of pedicle soft
tissue grafts
 1. The adaptation stage (from 0–4 days).
 The laterally repositioned flap is separated from
the exposed root surface by a thin fibrin layer.
The epithelium covering the transplanted tissue
flap starts to proliferate and reaches contact
with the tooth surface at the coronal edge of
the flap after a few days.

93.  The proliferation stage (from 4–21 days).
 In the early phase of this stage the fibrin layer between the root
surface and the flap is invaded by connective tissue proliferating
from the subsurface of the flap.
 After 6–10 days a layer of fibroblasts is seen in apposition to the
root surface. These cells are believed to differentiate into
cementoblasts at a later stage of healing.
 At the end of the proliferation stage, thin collagen fibers are
formed adjacent to the root surface, but a fibrous union between
the connective tissue and the root has not been observed. From
the coronal edge of the wound, epithelium proliferates apically
along the root surface.

94.  The attachment stage (from 27–28 days).
 During this stage of healing thin collagen fibers
become inserted in a layer of new cementum
formed at the root surface in the apical portion of
the recession.
 The maturation stage.
 This last stage of healing is characterized by
continuous formation of collagen fibers. After 2–3
months bundles of collagen fibers insert into the
cementum layer on the curetted root surface in
the apical portion of the recession.

95. HEALING FOLLOWING FREE SOFT TISSUE GRAFTS
 Healing of free soft tissue grafts placed entirely on a connective tissue recipient bed has been studied
in monkeys and can be divided into the following three phases. (Oliver et al.1988)
 0 – 3 day (Initial phase): During these fi rst days of healing a thin layer of exudate is present
between the graft and the recipient bed. During this period the grafted tissue survives with an
avascular “plasmatic circulation” from the recipient bed. Therefore, it is essential for the
survival of the graft that a close contact is established to the underlying recipient bed at the
time of operation. A thick layer of exudate or a blood clot may hamper the “plasmatic
circulation” and result in rejection of the graft.
 The epithelium of the free graft degenerates early in the initial healing phase, and subsequently it
becomes desquamated.

96. 2-11 day (revascularization phase)
 After 4-5 days of healing, anastomoses are established between the blood vessels of the
recipient bed and those in the grafted tissue.
 At the same time, a fibrous union is established between the graft and the underlying
connective tissue bed .
 If a free graft is placed over the denuded root surface, apical migration of epithelium along
the tooth-facing surface of the graft may take place at this stage of healing.

97. 11-42 days (tissue maturation phase):
 After approximately 14 days the vascular system
of the graft appears normal. Also the epithelium
gradually matures with the formation of a keratin
layer during this stage of healing.
 Another healing phenomenon frequently
observed following the free graft procedures is
“Creeping Attachment” i.e. coronal migration of
the soft tissue margin. This occurs as a
consequence of tissue maturation during a
period of about 1 year post treatment.

98. Guided Tissue Regeneration for
Gingival Recession
The use of a barrier membrane, according to the principles of guided tissue regeneration, in
conjunction with pedicle soft tissue graft procedures was introduced as a treatment modality for
root coverage by Pini Prato et al. (1992).
In order create space for tissue formation between the facial root surface and the membrane
Pini Prato et al. (1992) suggested that extensive root planing should be carried out to produce
concave root morphology.
Specially designed membranes for the treatment of recession type defects are available, such
as nonabsorbable titanium-reinforced expanded polytetrafluoroethylene (e-PTFE) membranes.

99. Guided Tissue Regeneration for Gingival Recession

100. a. Prepare a full-thickness trapezoidal flap
• Horizontal incision to the mesiodistal interdental papilla at the
level of the CEJ.
• Two vertical incisions.
b. Connect the horizontal and vertical incisions with a sulcular incision.

101. c. Prepare a full-thickness flap 3-4 mm apical to the crest of the osseous
dehiscence. Apically, prepare a partial thickness flap.
d. Remove the epithelial tissue in the interdental papilla area.

102. e. Perform root planing and preparation of root concavity. If a titanium-reinforced membrane is
used, the root profile may not need to be changed to establish the required space between the
root and the
membrane
f. Bend the membrane in a tentlike fashion with suture thread.
The titanium frame is bent to create space
under the membrane.
g. Stabilize the membrane
with a sling suture.

103. h. Displace the flap coronally and cover the membrane completely. The use of non-biodegradable membrane barriers
requires a second surgery for membrane removal, usually after 5–6 weeks. A partial thickness trapezoidal fl ap is raised to
expose the membrane.
Following its removal, the flap is repositioned at the level of the CEJ to completely cover the newly formed tissue.
Mechanical plaque control is reinstituted 4 weeks after membrane removal

104. Pedicle soft tissue graft procedures
combined with enamel matrix proteins
 Abbas et al. (2003) described a surgical procedure for periodontal regenerative therapy of
recession defects utilizing enamel matrix derivative bioactive material (Emdogain®)
 Following preparation of the coronally advanced flap, the exposed root surface is conditioned with
PrefGelTM (24% EDTA-gel, pH 6.7; Straumann Biologics, Switzerland) for 2 minutes to remove the
smear layer.
 After thorough rinsing with sterile saline, the enamel matrix protein gel (Emdogain®Straumann
Biologics, Switzerland) is applied to the exposed root surface. The pedicle graft is advanced
coronally and secured at a level slightly coronal to the CEJ by suturing the flap to the de-
epithelialized papilla regions.

105. Acellular dermal grafts
 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 vessels.
Silverstein and callan,1997

106.  After scaling and root planning, the root
surfaces are conditioned.
 A partial thickness flap creating a pouch is
formed using a no. 15 blade. The AlloDerm
is rehydrated in two consecutive 10- to 15-
min sterile saline baths (depending on size
and thickness of the piece used). The graft
is inserted into the pouch with the
connective tissue against the recipient
bed.
 The papillae are de-epithelialized, and the
graft is immobilized with resorbable
sutures at the level of the cemento-enamel
junction .

107.  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.

108. PRP
 Griffin, 2004 suggested use of platelet concentrate carried by collagen sponge as graft
substitute
 Yen and Jankovic,2007 used PRP with CTG and found accelerated wound healing and
attachment formation.
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

109. PRF
 Choukroun’s PRF, is a second-generation platelet concentrate.
 PRF consists of an intimate assembly of cytokines, glycamic chains, and structural
glycoproteins enmeshed within a slowly polymerized fibrin network.
 These biochemical components have well-known synergetic effects on healing
processes.

110.  Prior to surgery IV blood is collected in 10 ml vials without
anticoagulant & centrifuged at 2700 rpm for 10 min

112. Factors influencing the degree of root
coverage
Patient-related factors.
 Poor oral hygiene is a factor that will negatively influence the success of root coverage
procedures (Caffesse et al. )
 Further, the predominant causative factor in the development of gingival recession is toothbrushing
trauma, and hence this factor has to be corrected to secure an optimal outcome of any root coverage
procedure.
 Treatment outcome in terms of root coverage is usually less favorable in smokers than in nonsmokers
(Trombelli & Scabbia 1997; Zucchelli et al. 1998; Martins et al. 2004; Erley et al. 2006; Silva et al.
2006)

113. Site related factors.
 Among site-specific factors, the level of interdental periodontal support may
be of greatest significance for the outcome of root coverage procedures. From a biological point
of view complete root coverage is achievable in class I–II recession defects , while when loss of
connective tissue attachment also involves proximal tooth sites (class III–IV recession defects),
only partial facial root coverage is obtainable (Miller 1985b)
 An additional factor shown to influence the degree of attainable root coverage is the
dimensions of the recession defect. Less favorable treatment outcome has been reported
at sites with wide (>3 mm) and deep (≥5 mm) recessions (Holbrook & Ochsenbein 1983;
Pini Prato et al. 1992; Trombelli et al. 1995).

114. Technique-related factors.
 Several technique-related factors may influence the treatment outcome of a pedicle graft
procedure. In a systematic review including data from 15 studies (Hwang & Wang
2006) a positive correlation was demonstrated between the thickness of the tissue flap and
recession reduction. For complete root coverage the critical threshold thickness was found to be
about 1 mm. However, whether a full- or split-thickness pedicle graft is used for root coverage
may not influence the treatment outcome (Espinel & Caffesse 1981).

115.  Elimination of flap tension is considered an important factor for the outcome of the coronally
advanced flap procedure. Pini Prato et al. (2000a) measured the tension in coronally
advanced flaps to compare the amount of root coverage in sites with and without residual flap
tension. At sites that had residual tension (mean 6.5 g) the root coverage amounted to 78% 3
months post-surgically and 18% of the treated sites showed complete root coverage. Sites
without tension demonstrated mean root coverage of 87% and complete root coverage in
45% of the cases.
 Pini Prato et al. (2005) demonstrated that for 100% predictability of complete root coverage
in the treatment of Miller class I recessions with a coronally advanced flap procedure the flap
margin has to be positioned at least 2 mm coronal to the CEJ.

117. CONCLUSION
The management of gingival recession and its sequelae
is based on a thorough assessment of the etiological
factors and the degree of involvement of the tissues.
The initial part of the management of the patient with
gingival recession should be preventive and any pain
should be managed and disease should be treated.
The degree of gingival recession should be monitored
for signs of further progression. When esthetics is the
priority and periodontal health is good then surgical root
coverage is a potentially useful therapy. Careful case
selection and surgical management are critical if a
successful outcome is to be achieved.

118.  Carranza’s Clinical periodontology – 9th & 10th ed
 Clinical Periodontology and Implant Dentistry – Jan Lindhe 5th ed
 Periodontal surgery, Sato
 Atlas of cosmetic and reconstructive periodontal surgery- cohen
 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

119.  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
 Surgical management of gingival recession: A clinical update Hamdan, The Saudi
Dental Journal (2009) 21, 83–94
 Gingival Recession: Clinical Examination 4 and Diagnostics Corinna Bruckmann
and Gernot Wimmer

120.  THANK YOU