what is gingival recession classification etiology treatment

1. GINGIVAL RECESSION AND
ITS MANAGEMENT
PRESENTER-PUNIT

2. Contents
 Introduction
 Definitions
 Classifications
 Etiology
 Factors affecting treatment outcome
 Treatment
 Conclusion
 Reference

3. 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.

4. 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].

5.  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)

6. CLASSIFICATIONS

7. 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

8. Sullivan and Atkins. (1968)
Narrow Wide

9. 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.

10. 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.

11. 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


12. Class II: Marginal recession extending to or beyond the MGJ. No loss of
interdental bone or soft-tissue. 100% root coverage.

13. 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

14.  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 .

15. Limitations
 Although Miller’s classification has been used extensively,
there are limitations that need to be considered:

16. 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.

17. 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.

18.  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.

19.  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.

20.  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.

21.  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.

22. 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

23. 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.

24.  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.

25. 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

26.  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)

27.  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.

28. 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.

29.  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


30.  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.

31.  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.

32.  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.

33.  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

34.  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

35.  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.

36. 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.

40. The recession is determined by the actual position of the
gingiva not by its apparent position
Recession can be studied as,
VISIBLE
HIDDEN

41. Localised Generalised

42.  Deep-Wide
 Deep-Narrow
 Shallow-Wide
 Shallow-Narrow
Sullivan & Atkins classification
1968a

43. Mlinek, Smukler, Buchner 1973
 Quantified shallow narrow clefts as being <3mm in both dimensions and deep
wide defects as being > 3mm in both dimensions

44. P.D.MILLER (1985) CLASSIFICATION

46. 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 up
to cervical 1/3 of the root surface and/or malpositioning 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
malpositioning 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.

47. 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

48. 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.

49.  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).

50. 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.

51. 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.

52. Palatal recession-II
The tip of the interdental
papilla is located between the
interdental contact point and
the level of the CEJ mid-
palatally. Interproximal bone
loss is visible on the
radiograph.
This is sub-classified into
two categories:
PR-II-A: Marginal tissue
recession ≤3 mm from CEJ.
PR-II-B: Marginal tissue
recession of >3 mm from CEJ

53. Palatal recession-III
The tip of the interdental
papilla is located at or apical to
the level of the CEJ mid-
palatally. Interproximal bone
loss is visible on the
radiograph.
This is sub-classified into
two categories:
PR-III-A: Marginal tissue
recession ≤3 mm from CEJ.
PR-III-B: Marginal tissue
recession of >3 mm from CEJ.

54. 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.

55. • 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.

56. (Susin et al.)
 Inflammation of the connective tissue of free gingiva and its consequent
destruction,
 where the gingival epithelium migrates into the connective tissue and gets
destroyed,
 here the gingival epithelial basement membrane and sulcus epithelium
reduce the thickness of the connective tissue between them, thus reducing
the blood flow by impairing the repair of the initial injury.
 As the lesion progresses, the connective tissue disappears and fusion
occurs between the gingival epithelium and the sulcular and union
epithelia, which will subsequently withdraw due to lack of blood flow

57. 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

59. 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

60. Clinical examination
Measurement of amount of gingival recession is
made by Periodontal probe from CEJ to the gingival
crest

61. 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:

62. 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

65. Treatment
Non-surgically
Surgically

66. 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

67. NON – SURGICAL METHOD
1. Correction of tooth brushing technique
2. Removal of masochistic habits
3. Correction of malocclusion
4. Treating the dentinal sensitivity

68. 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

69. Root coverage techniques:
1. Pedicle soft tissue graft procedures :
Rotational flaps
Laterally positioned flap
Double papilla flap
Advanced flaps
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
3. Additive treatments
•Root surface modification agents
• Enamel matrix proteins
•Guided tissue regeneration
•Nonresorbable membrane barriers
•Resorbable membrane barriers

70. 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

71. Contraindications
 Narrow oral vestibule
 Multiple teeth
 Recession area extremely protrusive
 Thin gingiva and bone at adjacent donor site

72. 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

74. Laterally Positioned Flap
• Good vascularity
• Ability to cover denuded root surface
• One surgical site
Advantages
• 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

76. 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

77. Advantage
Prevent recession at donor site
Submarginal pedicle flap

78. Dhalberg,1969
Oblique rotated pedicle flap

79. 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
1. Possible recession at the donor site

80. 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

82. Goldman,1982
Split partial full thickness rotated pedicle flap
Advantage
Coverage of exposed donor site with periosteum

83. 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

87. Introduced by Hatler in 1967
Requires broad interdental papilla
Horizontal lateral sliding paillary flap

89. 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

91. 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

94. 2000
Coronally advanced flap for multiple recession

95. 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

98. Reasons for pedicle flap failure
Tension
Narrow
Flap
Bone exposed poor stabilization

99. 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

100. 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.

101. by Bjorn in 1963
Sullivan and Atkins in 1968
Indications
• 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

102. 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.

103.  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.

104.  Reiser et al. in 1996 reported that the
neurovascular bundle could be
located 7–17 mm from the cemento-
enamel junction (CEJ) of the maxillary
premolars and molars.
 According to these authors, in an
average palatal vault the distance
from the CEJ to the neurovascular
bundle is 12 mm. That distance is
shortened to 7 mm in case of a
shallow palatal vault and lengthened
to 17 mm in case of a high palatal
vault.
 Other research has shown gender-
related variations. The mean height
of the palatal vault, as measured
from the midline of the palate to the
CEJ of the first molars, is 14.90± 2.93
mm in men and 12.70 ± 2.45 mm in
women (Redman et al 1965).
Anatomy of a donor region. Palatal vessels
and nerve running from the greater and
lesser palatine foramina to the
interincisive foramen. The anterior palatal
submucosa is mainly fatty, whereas the
posterior palatal submucosa is mainly
glandular
Preparation of donor site

105.  After measuring the denuded
area with a periodontal probe at
the recipient site, the
measurements of the palate
should be recorded and the
graft outline traced with the
scalpel .
 The graft thickness should be
close to 1.5 mm, which
approximately corresponds to
the length of the bevel on a no.
15 blade, and should not be too
thick or too thin. The dissection
is done with a no. 15 blade kept
parallel to the epithelial outer
side of the graft, not the long
axis of the tooth.
.
Palatal donor site. The graft to
be harvested had been
delineated with a no. 15 blade.

106. 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

107. Thorough planing of root surface
Creating close adaptation of coronal margin of recipient
site and graft with butt joint
Using a thick graft
Stretching graft to regenerate vascularity

108. 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

109.  After anesthesia, root planing and
root conditioning, horizontal incisions
are made at the level of the CEJ,
preserving the interdental papillae.
 This is followed by vertical incisions
at least one tooth away from each
side of the recession. This point is
critical, because the portion of the
free gingival graft placed over the
denuded root will not survive if the
recipient bed is not large enough to
provide collateral vascularization.
 Therefore, the bed should be as wide
as possible, given the anatomical
limitation of the area. It should
extend apically at least 3 mm below
the margin of the denuded root.
 The wider the bed, the better chance
the 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 aesthetics
provided by this technique make it the gold
standard for root coverage.

110. 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 subepithelial
connective 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.

111. Donor site

112. 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

113. Advantages
For multiple adjacent teeth
Minimize incisions and reflection of flap
Abundant blood supply
Introduced by Zabalegui, 1999
Tunnel flap technique

114.  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.

115.  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

116.  Step 5. Using sutures,
curettes, and elevators, the
connective tissue is placed
under the pouch and tunnel,
with a portion covering the
denuded root surface.
 Step 6. The mesial and distal
ends of the donor tissue are
secured by gut sutures. The
gingival margin of the flap is
coronally placed and secured
by horizontal mattress
sutures that extend over the
contact of the two adjacent
teeth

117.  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.

119. • 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

120. Technique
 After proper anesthesia, the
recession is root planed
thoroughly and flattened using a
Gracey curette or a back-action
chisel. The root is conditioned for
5 min with tetracycline paste.
 Two vertical releasing incisions
are made at the line angles of the
tooth with the recession .
 These releasing incisions must
pass the mucogingival junction
for the flap to be mobile. Two vertical incisions are
placed, avoiding the
interproximal papillae.
GUIDED TISSUE REGENERATION

121.  An intrasulcular incision connects
the two verticals coronally.
 A full-thickness flap is raised using a
periosteal elevator that will enable
bone visibility 3 mm apical to the
exposed root.
 The flap is then converted to a
partial thickness one apically that
will enable coronal mobilization.
 At this stage, the buccal flap, full at
the top and partial at the bottom,
when moved coronally should be
able to cover and lie passively on
the recession.
 This is critical because any tension
while suturing will affect the
positive outcome of the procedure.
The papillae are de-epithelialized,
and the membrane is trimmed and
adjusted to cover the recession.
The flap is reflected exposing the
alveolar bone.
Trimming the reabsorbable
membrane and adjusting it to fit the
site.

122.  The membrane should extend
approximately 2 mm beyond the
borders of the recession mesially,
distally, and apically.
 The membrane should be coronally
placed at the level of the cemento-
enamel junction and sutured in
place with a circumferential suture
and a palatally tied knot. The knot is
then palatally tucked into the
gingival sulcus.
 When the sulcus is shallow, a small
intrasulcular incision will help
deepen it. Once the membrane is
secured, the buccal flap is coronally
moved and secured to the papillae
with interrupted sutures .
The buccal flap is sutured
with the aim of covering as
much of the membrane as
possible.

124. Free gingival autograft

126. 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.

127. 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.

129. Subepithelial connective tissue graft

130. 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

131. For the secondary incision, the blade contacts the bone. Use a
small 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.

132. 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

133. 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

134. 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):
 Plasmatic circulation
 The epithelium of the free graft degenerates early in
the initial healing phase, and subsequently it becomes
desquamated.

135.  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.
2-11 day (revascularization phase)

136. 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.
11-42 days (tissue maturation phase):

138. 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

140.  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 .

141. 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.

142.  Significant revascularization
occurs in just over 1 week.
 Allo-Derm is repopulated with
cells and will begin remodeling
into the patient’s own tissue over
the next 3–6 months. Up to 41%
shrinkage of the graft has been
reported during that period
(Batista et al. 2001).
 The material will also take the
characteristics of the underlying
and surrounding tissues (for
example, keratinized tissue or
mucosa).
[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.

143.  The final results are seen 2–3 years
later.
 It is important to remember that,
when evaluating the results, the
concept of gain of attached gingiva or
keratinized gingiva is replaced by gain
of gingival volume.
 The absence of keratinized tissue
with this technique after successful
root coverage is not uncommon, nor
detrimental to the results. By 3 years after surgery, the
recessions have been covered.

144. 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

145. 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

146. 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

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

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

150. 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.

151. Treatment plan

152. 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.
 Numerous therapeutic solutions for recession defects have been proposed
in the periodontal literature and modified with time according to the
evolution of clinical knowledge.
 Careful case selection and surgical management are critical if a successful
outcome is to be achieved.

153. 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

154.  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