Gingival recession aries

GINGIVAL RECESSION
PRESENTED BY
R ANIL KUMAR PG-II
GUIDED BY
Dr K REKHA RANI (PROF & HOD)

CONTENTS
• Introduction
• Definition
• Classification
• Etiology
• Factors affecting treatment outcome
• Treatment
• Root coverage techniques
• Pedicle grafts
• Free gingival autografts
• Subepithelial connective tissue graft
• Guided tissue regeneration
• Healing of the graft
• Conclusion
• References.

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 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)
• Gingival recession is defined as the apical migration of the junctional
epithelium with exposure of root surfaces.
[Kassab MM, Cohen RE-2003].

CLASSIFICATION
Several classifications have been proposed in literature to facilitate the
diagnosis of gingival recessions.
 Sullivan and Atkins (1968)
 Mlinek (1973)
 Liu and Solt (1980)
 Bengue (1983)
 Miller (1985)
 Smith (1990)
 Nordland and Tarnow (1998)
 Mahajan (2010)
 Cairo et al. (2011)
 Rotundo et al. (2011)
 Ashish Kumar and Masamatti (2013)
 Prashant et al. (2014)

Sullivan and Atkins (1968)
It was 1st classifications proposed for gingival recession.Based on depth &
width of the defect,They 4 categories were.
 Deep wide
 Shallow wide
 Deep narrow
 Shallow narrow.

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
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 softtissue
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 postoperative root coverage
was slightly

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.
• FAIR Class III with thick gingival profile.
• POOR Class III and Class IV with thin gingival profile.

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
Francesco Cairo et al (2011)

Recession Type 2 (RT2):Gingival recession associated with loss of
interproximal attachment.
 The amount of interproximal attachment loss (measured from the
interproximal CEJ to the depth of the pocket) was less than the buccal
attachment loss (measured from the buccal CEJ to the depth of the buccal
pocket).

Recession Type 3 (RT3): Gingival recession associated with loss of
interproximal 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).

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 subclassified 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
Either of the subdivisions can be on
F or L aspect or both (F and L).

 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.
INDEX OF RECESSION BY SMITH(1997)

Swathi Ravipudi et al /J. Pharm. Sci. & Res. Vol. 9(2), 2017, 215-220

 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
CLASSIFICATION OF PALATAL
GINGIVAL RECESSION

Palatal recession-I
There is no loss of interdental bone or softtissue. 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 interdental papilla is located between the interdental contact
point and the level of the CEJ midpalatally. 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

Palatal recession-III
The tip of the interdental papilla is located at or apical to the level of the CEJ
midpalatally. 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.

According to ALBANDEN & KINGMEN(1988-1994)
 youngest age (30 to 39 years), the prevalence was 37.8%.
 In oldest , aged 80 to 90 years, had a prevalence of 90.4%.
 extent of recession were significantly higher in males than females
 gingival recession was most prevalent for the maxillary first molars and the
mandibular central incisors.
 buccal sites exhibited much higher prevalence and more severe recession
than mesial sites within each age, gender, and race/ethnic group.
PREVELANCE

DEVELOPMENT OF RECESSION
(GOLDMAN, 1973, BAKER, 1976)
A. subclinical inflammation B. Clinical inflammation & proliferation of rete pegs.
C.Increased epithelial proliferation resulting in loss of connective
tissue core.
D. Merging of epithelium and resulting in separation and recession of
gingival tissues.

ETIOLOGY OF GINGIVAL RECESSION
Moscow and Bressman (1966)
 Faulty tooth brushing;
 Tooth malpositioning;
 Friction from soft tissue;
 Periodontal inflammation;
 Abnormal frenal attachment;
 Oral habits;
 Iatrogenic factors.
Aldritt (1968)
 Alveolar bone dehiscence.

Inadequate attached gingiva
Malpositioning of teeth
Osseous dehiscence (or) thin facial plate
Predisposing
factors
Vigorous brushing
Lacerations
Recurrent inflammation
Iatrogenic factors
(1)Precipitating
factors
HALL(1977)
WOOFER (1969)
 Increases with the age , 8% in children to 100% in adult over 50 yrs.
 Tooth malpositiong and traumatic bleeding.
STONER (1980)
 Prominent on mandibular 1st premolars and canines.
 As width of keratinized gingiva decreases gingival recession increases.
SERINO (1994)
 predominantly found on buccal surface.

McCall Festoons & Stillman’s clefts
Mc Call Festoons:
 Rolled, thickened band of gingiva usually seen adjacent to the cuspids when
recession approaches MGJ.
Stillman’s clefts
A narrow triangular shaped recession.
As the recession progress apically, the cleft becomes broader exposing
the cementum of the root surface When the lesion reaches mucogingival
junction the boarder of the oral mucosa is usually inflamed because of the
difficulty in maintaining adequate plaque control at this site.

CLINICAL EXAMINATION
 Measurement of amount of gingival recession is made by
Periodontal probe from CEJ to the gingival crest.

CLINICAL SIGNIFICANCE
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

TREATMENT
NON
SURGICAL
TREATMENT
SURGICAL
TREATMEN
T
RATIONALE FOR TREATMENT OF RECESSION (Miller,1994)
 Root coverage to CEJ;
 Adequate band of attached gingiva;
 An accelerated color match to surrounding tissue;
 An esthetic tissue contour;
 Minimal post-op pain;
 No increase in sensitivity.

NON–SURGICAL METHOD
• Monitoring and prevention
• Use of desensitizing agents, varnishes.
• Composite restoration.
• Removable gingival veneers.
• Orthodontics.

Decision tree providing clinical guidance for patient care in the
treatment of GR defects
Christopher R. et al.Clin Adv Periodontics 2015;5:2-10.

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
1. Whether area adjacent to gingival
recession can be used as a donor site
2. Degree of gingival recession  Amount of Keratinized gingiva
3. Amount and thickness of existing
keratinized gingiva in the area of
recession
 Thickness of keratinized gingiva
4. Whether the area of recession protrudes
labially from the dental arch
 Size of adjacent interdental papilla
5. The relation between the gingival
recession area and smile line
 Thickness of the alveolar bone
covering the donor tissue
6. Restorative/Prosthodontic treatment
after root coverage is necessary
2. Thickness of palatal soft tissue used as
donor tissue

Christopher R. et al.Clin Adv Periodontics 2015;5:2-10.

SURGICAL ROOT COVERAGE TECHNIQUE

PEDICLE GINGIVAL GRAFT
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
Pedicle gingival grafts are classified according to the direction of' flap migration.
1. Rotational flap- flap rotated or displaced laterally
• Laterally positioned flap
• Transpositional flap
• Double papilla flap
2. Advanced flap-flap placed without rotation or lateral migration
• Coronally positioned flap

 Introduced by Grupe and warren 1956.
Advantages:
• Good vascularity
• Ability to cover denuded root surface
• One surgical site
Disadvantages:
• Recession at donor site,Guinard,1978
• Dehiscence or fenestration at donor site
• Limited to 1 or 2 teeth
LATERALLY POSITIONED FLAP

Indications:
a. For covering the isolated denuded root.
b. When there is sufficient width of interdental papilla in the adjacent
teeth, and Sufficient vestibular depth.
Contraindications:
a. Presence of deep interproximal pockets.
b. Excessive root prominence.
c. Deep or extensive root abrasion or erosion

Procedure for laterally positioned flap
• Step I : Preparation of the recipient site:
Epithelium is removed around the denuded root surface.
Exposed connective tissue will be the recipient site for
laterally displaced flap. The root surface will be thoroughly scaled and
root planed.

Step II: Prepare the flap of the donor site:
The periodontium of the donor site should have satisfactory
width of the attached gingiva and minimal bone loss without
fenestration or dehiscence.
A full thickness or partial thickness flap may be used.
With a # 15 blade , a vertical incision is made extending from marginal
gingiva in to the mucogingival junction.
A crevicular incision is then made from the vertical incision to the
defect.
A flap is then raised utilizing either partial thickness or full thickness
reflection.

• Step III: Transfer the flap: Slide the flap laterally on to the adjacent
root, making sure it lies flat, firm with out excess tension on the base.
• Fix the flap with adjacent gingiva with interrupted sutures.
• Step IV: Protect the flap and donor site.:
• cover the area with aluminum foil and periodontal dressing

COMPLICATIONS
• Slight recession at the donor site – Most common;
• Necrosis or loosening of the flap;
• The flap will loosen if the dissection was insufficient, and the flap was
sutured with tension.
VARIANTS
• Staffileno,1964 Partial thickness flap to avoid recession at donor site.
• Pfeifer and Heller,1971 Reattachment more likely with full thickness
flap.
• Ruben et al demonstrated partial and full thickness pedicle flap

Transpositional Flaps
• Bahat et al" modified the oblique rotated flap introduced by Pennel et.
al., 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.

Double papillae Laterally positioned flap
• 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

CORONALLY ADVANCED FLAP
 In these procedure , a partial thickness flap is created apical to the
area of recession and is then repositioned coronally to cover the root.
 Introduced by Norberg in 1956
 Harvey in 1965 used it with FGG
 Bernomoulin in 1975 first reported the coronally positioned graft
succeeding grafting with a free gingival autograft.
 Coined by Pini and Prato in 1999
Two-stage procedure:
 In the first stage, a free gingival graft placed apical to the margins of
the recession to be treated.
 The second stage occurred a few months later, when the graft was
coronally positioned over the denuded root surfaces.

Maynard (1977) outlined the following requirements as criteria for
success when using coronally positioned flaps:
 Shallow crevicular depths on proximal surfaces
 Normal interproximal bone heights
 Tissue height within 1 mm of the cemento-enamel junction of
adjacent teeth
 Six-week healing of the free gingival graft prior to coronal
positioning
 Reduction in root prominence
 Adequate release of the flap during the second-stage surgery to
prevent retraction during healing

TECHNIQUE
STEP I:
With two vertical incisions, delineate the flap. These incisions
should go beyond the mucogingival junction.
Make an internal bevel incision from the gingival margin to the
bottom of the pocket to eliminate the diseased pocket wall.
Elevate a mucoperiosteal flap using careful sharp dissection.
Step II:
Scale and plane the root surface, and the root is treated with citric
acid.
The papillae are de-epithelialized

Step III:
Return the flap and suture it at a level coronal to the pretreatment
position.
Cover the area with a periodontal pack, which is removed along
with the sutures after 1 week.
The pack is replaced for an additional week if necessary.
Complications
Results with the coronally displaced flap technique are not often favorable
owing to the presence of insufficient keratinized gingiva.
To solve this and increase the chance of success, a gingival extension
operation with a free autogenous graft can be performed.
This creates several millimeters of attached keratinized gingiva apical to the
denuded root .

Semilunar coronally positioned flap
(Tarnow -1986)
INDICATIONS
It is designed primarily for attaining esthetic root covrage wher only 2-3
mm of root coverage is required.
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

This is a one-stage, no-suture, coronally repositioned flap aimed at
correcting mild gingival recessions.
A semilunar incision is made following the curvature of the free
gingival margin that extends into the papillae.
A split-thickness dissection coronally from the incision to connect it to
an intra sulcular incision
The loosened flap, is connected at the papillae, is coronally
repositioned to cover the recession.
No sutures are placed.
The healing is uneventful.

Coronally advanced flap for multiple recession
• Zucchelli & de Sanctis (2000) have recently introduced a
modification of this procedure to treat multiple recession defects.
• A split–full–split approach was used to elevate the flap; this
permitted to maintain the maximum soft tissue thickness above the root
exposure.

Sneha W et al. Zucchelli’s Modified Coronally Advanced Flap Technique for the Treatment of Multiple Recession Defects.
IOSR Journal of Dental and Medical Sciences. 2017:16; 4; 57-61.

STUDIES REGARDIND COMPARISON OF CAF AND OTHER TECHNIQUES AND DIFFERENT TYPES OF GRAFTS
& MEMBRANE USED FOR ROOT COVERAGE CAF TECHNIQUE
Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures: a systematic review. J
Clin Periodontol 2008; 35 (Suppl. 8): 136–162.

Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures: a systematic review. J Clin Periodontol 2008; 35
(Suppl. 8): 136–162.

Free gingival Autografts
 Most common techniques used for gingival augmentation apical to the area
of recession.
 Bjorn in 1963, and Sullivan & Atkins in 1968, were the first to describe the
free gingival autograft.
 Later it was used to attempt coverage of exposed root surfaces (Sullivan &
Atkins 1968; Holbrook & Ochsenbein 1983; Miller 1985).
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

CONTRAINDICATIONS.
• Lack of donar tissue thickness.
• Medically compromised patients( uncontrolled diabetes, hypertension,bleeding
disorders, anticoagulant therapy).
• When the mesiodistal width of denuded roor is significantly larger than the
interproximal periosteal bloodsupply, so that the graft would not rceive an adequate
blood supply.
• An unaccepetable color mismatch between the grafted site and adjacent gingiva.
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

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.
Procedure

 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.

Preparation of donor site
 Reiser et al. in 1996 reported that the neurovascular bundle could be located
7–17 mm from the cementoenamel 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
 Other research has shown genderrelated 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
 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

 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

Subepithelial connective tissue grafts
 First described in the literature in 1985 (Langer & Langer1985; Raetzke
1985).
 Later on the technique was modified by NELSON(1967).
INDICATIONS
 Root coverage in areas of gingival recession (mild, moderate, or severe)
 Gingival coverage of exposed implant abutment or metal collar.
 Increase in the width of attached gingiva
 Ridge augmentation (edentulous area)

CONTRAINDICATION
 Broad shallow palate
 Excessive glandular or fatty palatal mucosa
ADVANTAGES
 High predictability
 Dual blood supply
 Less discomfort at donor site
 Esthetic harmony
 For multiple sites
DISADVANTAGES
 Technique sensitive
 Complicate suturing

 Edel (1974) Trapdoor technique. The palatal portion opposite to the molars
is selected for harvesting the graft. A primary incision is made along the
long axis of the teeth, near the gingival margin. A total of 1 horizontal and 2
vertical incisions are made, the flap is raised, and the graft is harvested. The
undersurface of an edentulous region can also be used for harvesting the
graft. Complete wound closure is achieved
Techniques for harvesting a subepithelial connective tissue
graft (SCTG) from the palate.

 Langer & Calagna (1980) If the periodontium is normal, a horizontal bevel
incision is made on the palate 1 mm apical to the free gingival margin of the
posterior teeth. This is followed by vertical incisions at either end, and the
graft is harvested from the palatal side

 Langer & Langer (1985) A rectangular design, with 2 horizontal and 2
vertical incisions, results in an SCTG with an epithelial collar of 1.5-2.0 mm
in width
 Raetzke (1985) this technique employs no vertical incisions but 2 converging
horizontal, crescent-shaped incisions that intersect deep within the palate,
just shy of bone, producing a wedge of SCTG with an epithelial collar.
a,b: Two incisions 1-2mm apart carried to depth of palatal mucosa, where they converge just short
of bone; c: A wedge of tissue with epithelium at its edge is dissected

Hürzeler & Weng (1999) Single-incision technique. A single horizontal
incision is made on the palate, 2 mm from marginal gingiva. Initially the blade
is angled to 90 degrees, and then it is angled to 135 degrees to undermine the
flap. The SCTG is removed by making the incision to the bone on all sides of
the uncovered SCTG. This approach has several advantages: Sloughing of
epithelium due to an unfavorable relationship between the flap base and
pedicle length will be avoided, postoperative healing is better, and patient
morbidity is decreased

Bruno (1994)Double-incision technique. The first incision is made
perpendicular to the long axis of the teeth about 2-3 mm apical to the gingival
margin of the maxillary teeth, falling just short of the bone. The second incision
is made parallel to the long axis of the teeth but 1-2 mm apical to the first
incision. A small periosteal elevator is used to raise a full-thickness periosteal
SCTG

Advantages and disadvantages of connective tissue graft harvest techniques

Puri K, Kumar A, Khatri M, Bansal M, Rehan M, Siddeshappa ST. 44-year journey of palatal connective tissue graft harvest: A
narrative review. J Indian Soc Periodontol 2019;23:395-408.

1. Insufficient height of interdental bone and soft tissue.
2. Horizontal incision placed apical to the CEJ.
3. Reflection of all interdental papilla.
4. Flap penetration.
5. Inadequate root planing.
6. insufficient blood supply from surrounding tissue due to inadequate
recipient site preparation.
7. Connective tissue graft too small. Connective tissue graft too thick.
8. Connective tissue graft inadequate for root coverage and coronal
placement.
9. Insufficient coronal migration of flap covering the graft.
Causes of Failure of Connective Tissue Grafts

Pouch and Tunnel Technique
 Introduced by Zabalegui, 1999.
 The pouch and tunnel technique is also referred to as the coronally
 advanced tunnel technique.
 To minimize incisions and the reflection of flaps and to provide
abundant blood supply to the donor tissue, placement of the
subepithelial donor connective tissue into pouches beneath papillary
tunnels allows intimate contact of donor tissue with the recipient site.

 Positioning of the graft in the pouch and through the tunnel and
coronal placement of the recessed gingival margins completely
covers the donor tissue.
 The technique is especially effective for the anterior maxillary area in
which vestibular depth is adequate and there is good gingival
thickness.
Advantages
 For multiple adjacent teeth
 Minimize incisions and reflection of flap
 Abundant blood supply

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.

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.

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.

Guided Tissue Regeneration
 Guided tissue regeneration (GTR) is defined by the American Academy of
Periodontology as a procedure attempting to regenerate lost periodontal
structures through differential tissue responses.
 It involves the use of resorbable or non resorbable barriers (membranes) to
exclude epithelial and connective tissue cells from the root surface during
wound healing.
 This is believed to facilitate the regeneration of lost cementum, periodontal
ligament, and alveolar bone.

 In1950 Hurley used barrier membrane to develop a gap between soft and hard
tissue and this described GTR.
 Melsher in 1976 hypothesis - certain cells in periodontium have create new
periodontal apparatus, if they get crowd the wound
 The term Guided Tissue Regeneration 1986 by Gottlow.
 Pini-Prato et al. (1992) and Tinti & Vincenzi (1994) reported the use of an ePTFE
membrane to treat gingival recessions.
 Cortellini et al 1993 reported 3.66mm of connective tissue attachment with
2.48mm of new cementum and 1.84mm of bone growth histologically.
HISTORY

MEMBRANES CAN BE NON ABSORBABLE OR ABSORBABLE
Non absorbable membrane
 Cellulose filters
 Expanded poly tetrafluoro ethylene membranes.
Absorbable membranes
 Collagen membranes
 Polylactic acid
 Polyglycolic acid and polylactic acid
 Synthetic liquid polymer Polyglactin.
 Calcium sulfate
 Acellular dermal allografts
 Oxidized cellulose mesh

INDICATIONS
 Intra bony or two or three walled vertical defects. (deeper than 4mm).
 Class II furcation involvement.
 Class III furcation involvement.
 Treatment for receeded gingiva.
 Bone augmentation.
 Repair of apicocectomy defects.
CONTRATINDICATIONS
 Very severe defect where periosteum is minimally remained.
 Horizontal defect.
 In case of flap perforation
ADVANTAGES
 Gain of new attachment
 Donor site not necessary
 Predictable root coverage
DISADVANTAGES
 Technically demanding
 Costly

Qualities and patterns for membranes was stated by Scantlebury in 1993.
 Biocompatibility.
 Cell exclusion.
 Space maintenance.
 Tissue integration and simple to use.
 Mechanical strength.
 Degradability
CHARACTERISTICS OF MEMBRANE

 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.
TECHNIQUE

 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.
 The papillae are de-epithelialized, and the membrane is trimmed and adjusted to
cover the recession.

 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 cementoenamel junction
and sutured in place with a circumferential sutureand 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

Acellular Dermal Matrix Graft
(AlloDerm)
 AlloDerm is donated human soft tissue that is processed to remove dermal
cells, leaving behind a regenerative collagen matrix.
 This allograft is a freeze-dried, cellfree, dermal matrix comprised of a
structurally integrated basement-membrane complex and extracellular
matrix in which collagen bundles and elastic fibers are the main components
HISTORY.
 Originally intended to cover burn wounds (Wainwright 1995)
 Has been introduced as a less invasive alternative to soft tissue grafting
(Silverstein & Callan 1997).
 Is a freeze-dried, cell free, dermal matrix

TECHNIQUE
 After scaling and root planning, the root surfaces are conditioned.
 A partial thickness flap creating a pouch is formed using a no. 15 blade.
 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 .
 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.

GRAFT HEALING
 Significant revascularization occurs in just over 1 week.
 AlloDerm 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.

 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.

platelet concentrates
 Platelet concentrates have been in use for the past 30 years, and its use stems
from the ability of the fibrin glue to enhance healing.
 Fibrin, the activated form of the plasmatic molecule fibrinogen, plays a
determining role in the platelet aggregation during hemostasis.
 Fibrin glue is a human-derived tissue adhesive that can be used for
hemostasis and healing of tissues, and is derived from two components, the
first containing human fibrinogen and coagulation factors IX and varying
amounts of plasma proteins, and the second component containing the
thrombin (Burnouf et al. 2008, Choukroun et al. 2006)

Classification of platelet concentrates
FIRST GENERATION
P-PRP Without leucocytes,low density fibrin Liquid or gel solutions
L-PRP With leucocytes , low density fibrin Liquid or gel solutions
SECOND GENERATION
P-PRF Without leucocytes ,high density fibrin strong gel forms,solid material
L-PRF With leucocytes ,high density fibrin strong gel forms,solid material
I-PRF Injectable form
A-PRF Advanced form
T-PRF Titanium tubes

PLATELET RICH PLASMA
 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
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

Rachita Dhurat et al.Principles and Methods of Preparation of Platelet-Rich Plasma. Journal of Cutaneous and Aesthetic Surgery
.2014: 7;4.

PLATLET RICH FIBRIN
 Platelet-Rich Fibrin (PRF) consists of a strictly autologous fibrin matrix rich
in platelets, leukocyte cytokines, and various growth factors.
 It was described in France by Choukroun in 2001(Choukroun et al. 2006), it is
a second-generation platelet concentrate used for its ability to enhance tissue
repair and regeneration.

PREPARATION OF PRF
10 ml sample collection sample in collecting tubes centrifugation at 3000 rpm
for 10 min
After centrifugation
PRF Prf in sterile metal
cup
PRF is placed on the grid
in the PRF Box
PRF Box
PRF Box® is used to create PRF membranes.
Serum exudate collects in the bottom of the box
beneath the grid

 No biochemical handling of blood.
 Simplified and cost effective process.
 No use of bovine thrombin and anticoagulants.
 Favorable healing due to low polymerization.
 More efficient cell migration and proliferation.
 Supportive effect on immune system.
 Helps in haemostasis.
ADVANTAGES OF PRF OVER PRP

Moraschini, V., & Barboza, E. dos S. P. (2016). Use of Platelet-Rich Fibrin Membrane in the Treatment of Gingival Recession: A Systematic
Review and Meta-Analysis. Journal of Periodontology, 87(3), 281–290.
STUDIES RELATED TO
PRF

Amniotic Membrane
 The amniotic membrane used in various fields in medicine including eye
surgery, burns, and temporary biologic dressings for full thickness wounds,
to decrease postoperative pain, reconstruction of damaged or malformed
organs, and prevention of tissue adhesion.
 Human amniotic membrane is the innermost layer of the placenta and lines
the amniotic cavity.
 It is composed of a single layer of epithelial cells, a basement membrane,
and an avascular connective tissue matrix.

 The basement membrane contains collagen Types III, IV, V, and
cell-adhesion bioactive factors including glycoproteins, fibronectin, and
laminins (laminin-5 plays a role in the cell adhesion of gingival cells).
 It also contains stem cells and growth factors such as epidermal growth
factor, transforming growth factor beta, fibroblast growth factor, and
platelet-derived growth factor aid in the formation of granulation tissue
Authors Studies Results
Ankita Jain et al (2017) PRF v/s AMNIOTIC MEMBRANE by
CAF
PRF and dehydrated AM proved to be
equally
Effective.
Bolla Vet al (2019) CAF+Amniotic membrane increase in height and thickness of
keratinized gingiva from 3
to 3.5 mm and 1.5 to 2 mm, respectively

ROOT BIOMODIFICATION
ROOT PREPARATION:
 Use of instruments or chemicals on roots to eliminate irritants, prevent
bacterial accumulation, and encourage wound healing.
 Many root conditioners have been introduced to facilitate detoxification,
decontamination and the removal of smear layer, to promote the exposure
of the collagenous matrix of dentin and cementum for the attachment of
collagen fibres.

 1833 Marshall presented a case of pocket eradication after the use of
aromatic sulfuric acid.
 1890s Stewart described the use of acids in conjunction with the mechanical
removal of calculus and cementum.
 Register, et al. in (1973) to perform the first controlled study on the use of
acid on root surfaces.
 Terranova, et al. in 1986 have shown that the tetracycline treatment of root
surface suppresses laminin binding and epithelial cell growth and
attachment.
HISTORY

CLASSIFICATION OF ROOT SURFACE
BIOMODIFICATION AGENTS
Bhushan K, Chauhan G, Prakash S (2016) Root Biomodification in Periodontics - The Changing Concepts. J Dent Oral Care
Med 2(1): 105.

CITRIC ACID- RATIONALE FOR USE
 Antibacterial effect (Daly et al. 1982)
 Root detoxification (Aleo et al. 1974)
 Exposure of root collagen and opening of dentinal tubules (Polson et al.
1984)
 Removal of smear layer (Polson et al. 1984)
 Initial clot stabilization (Wikesjo et al. 1991)
 Demineralization prior to cementogenesis (Register, 1975)
 Enhanced fibroblast growth and stability (Boyko et al. 1980)

RECOMMENDED TECHNIQUE
 Raise a mucoperiosteal flap
 Thoroughly instrument the root surface-removing calculus & underlying
cementum.
 Apply cotton pellets soaked in saturated solution of citric acid. *20-30%
concentration PH1(61 gm of citric acid per 100 ml of distilled water is added
to achieve pH of 1)
 Leave for 2-4 minutes. Remove pellets. Irrigate root surface profusely with
water.
 Replace the flap & suture it.

DRAWBACK OF CITRIC ACID
 Formation of extremely acidic environment in the surrounding
tissues, which may result in unfavorable wound healing responses
 Its low pH has also been shown to induce cytotoxic effects when in
direct contact with periodontal cells .
 The factors influencing the effects of citric acid on root surface
include concentration of the acid, duration of application and mode
of application.

EVIDENCES RELATED TO DIFFERENT ROOT
CONDITIONERS
REFERENCE SUBJECTS
/SAMPLES
PROCEDURE/
INTERVENTION OBSERVATION
INFERENCE
CAFESSE et al,1987 Human in vivo study .6
months duration
N=25
Lateral sliding flap, root
planing and citric acid
application
Improvement in clinical
parameters but
nonsignificant findings
The lateral sliding flap
provides satisfactory
root coverage with or
without citric acid
Dalhouse et al 1995 Human in vivo study. 8
Weeks duration.
N=7
Flap, scaling and root
planing, tetracycline
Reduction in probing
depth and gain in
clinical attachment level
Tetracycline root
conditioning shows
improvement in all
clinical parameters
Cafesse et al 1988 Human in vivo study.
N=29
Modified Widman
flap+Citric
acid+Fibronectin
Reduction in Probing
pocket depth,gain in
clinical attachment level
Changes observed after
MWF with citric acid +
fibronectin is
significantly greater
than modified Widman
flap alone.
Blomlof et al 2000 Human in vivo study,6
Months duration
N=68
Flap, root planing and
EDTA
No staitistically
significant differences
observed after 3 and 6
months
EDTA etching of root
surfaces did not
contribute to
elimination of
Periodontal pockets or
increase in CAL

Microsurgery
 Daniel RK. (1979) broadly defined microsugery as surgery performed under the
magnification provided by operating microscope.
 In 1978, Apotheker and Jako first introduced the microscope to dentistry.
 In 1993, Shanelec and Tibbetts presented a continuing education course on
periodontal microsurgery at the annual meeting of the American Academy of
Periodontology.
Principles of Microsurgery
1. Improvement of motor skills, thereby enhancing surgical ability.
2. An emphasis on passive wound closure with exact primary apposition of the wound
edge.
3. The application of microsurgical instrumentation and suturing to reduce tissue
trauma.

Indications
 Periodontal plastic surgery,
 Cosmetic restorative
 Gingival augmentation procedures,
 Soft and hard tissue ridge augmentation,
 Dental implant placements,
 Double papilla flaps.
 Apical or coronal repositioned flaps.
 Connective tissue grafts.
 Pedicle or sliding flaps.
 Microsurgical techniques are especially
beneficial to mucogingival procedures

(Burdhardt& Lang 2005)
concluded that performing root coverage techniques microsurgically versus
macrosurgically substantially improved the vascularization of connective
tissuegrafts and the percentage of additional root coverage.
Sandro Bittencourt et al 2012.
concluded that microsurgical and conventional surgical procedures were capable of
producing root coverage, but use of surgical microscope was associated with
additional clinical benefits in the treatment of teeth with gingival recession
Thankkappan et al 2012.
compared 2 different types of root coverage procedures using periodontal
microsurgical approach. It showed that use of microsurgical instruments helped to
deliver precise incision , better visual acuity and improved illumination which
facilitates to gain a better final outcome

Kian Jian et al Microsurgery for root coverage: A systematic review. Pak J Med Sci. 2015 Sep-Oct; 31(5): 1263–1268

 The management of gingival recession and its sequelae is based on athorough
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
Conclusion

REFERENCES
 Carranza’s Clinical periodontology – 10TH & 12h ed
 Clinical Periodontology and Implant Dentistry – Jan Lindhe 6 th ed
 Periodontal Surgery – a clinical atlas – Naoshi Sato
 Practical periodontal plastic surgery – Serge Dibart
 Textbook of Periodontology and Oral Implantology - Dilip G. Nayak.
 Color Atlas of Dental Hygiene Periodontology by Herbert F. Wolf, Thomas M
 Hall's Critical Decisions in Periodontology 4 edition.
 Mucogingival esthetic surgery – Zucchelli.
 PERIODONTICS_Medicine_Rose_Genco.
 Deepalakshmi D, Arunmozhi U. Root coverage with free gingival autografts--a clinical study. Indian J Dent
Res 2006;17:126.
 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.
 Swathi Ravipudi et al.JGingival Recession: Short Literature Review on Etiology, Classifications and Various
Treatment Options. . Pharm. Sci. & Res. Vol. 9(2), 2017, 215-220.
 Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U. The interproximal clinical attachment level to classify
gingival recessions and predict root coverage outcomes: an explorative and reliability study. J Clin
Periodontol 2011; 38: 661–666.
 Mythri S, Arunkumar SM, Hegde S, Rajesh SK, Munaz M, Ashwin D. Etiology and occurrence of gingival
recession – An epidemiological study. J Indian Soc Periodontol 2015;19:671-5.
 Rathi M, Jha AK, Singh S, Prakash P. Periodontal microsurgery using Zucchelli’s modification of coronally
advanced flap with PRF membrane for root coverage. Int J Case Rep Images 2018;9:10.
 de Sanctis M, Zucchelli G. Coronally advanced flap: a modified surgical approach for isolated recession type
defects. Three-year results. J Clin Periodontol 2007; 34: 262–268.
 Shah, et al.: Amnion membrane for coverage of gingival recession. Contemporary Clinical Dentistry | Jul-Sep
2014 | Vol 5 | Issue 3.
 Bhushan K, Chauhan G, Prakash S (2016) Root Biomodification in Periodontics - The Changing Concepts. J
Dent Oral Care Med 2(1): 105.
 Agarwal SK, Jhingran R, Bains VK, Srivastava R, Madan R, Rizvi I. Patient-centered evaluation of
microsurgical management of gingival recession using coronally advanced flap with platelet-rich fibrin or
amnion membrane: A comparative analysis. Eur J Dent 2016;10:121-33

• Thamaraiselvan, et al.: PRF membrane in the treatment of gingival recession. Journal of Indian
Society of Periodontology - Vol 19, Issue 1, Jan-Feb 2015.
• Avhad R, Laddha R, Sewane S, Agrawal S, Sharma D, Upadhye K. Microsurgery in Periodontics: A
Review. J Adv Med Dent Scie Res 2019;7(6): 41-47.
• Padmaja rajan et al. Hyaluronic Acid as an Adjunct to Scaling and Root Planing in Chronic
Periodontitis. A Randomized Clinical Trail . J Clin Diagn Res. 2014 Dec; 8(12): ZC11–ZC14.
• Gayathri GV, Choudary S, Bharath N,Shilpa E, Mehta DS. Treatment of gingival recession with
coronally advanced flap combined with connective tissue graft/alloderm: A systematic review. Int J
Oral Health Sci 2014;4:70-80.
• G. Zucchelli et al .Laterally Moved, Coronally Advanced Flap: A Modified Surgical Approach for
Isolated Recession-Type Defects. J Periodontol 2004;75:1734-1741.
• Sneha Walkar et al .Zucchelli’s Modified Coronally Advanced Flap Technique for the Treatment of Multiple
Recession Defects – A Case Report. Volume 16, Issue 4 Ver. VI (April. 2017), PP 57-61.
• Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures: a
systematic review. J Clin Periodontol 2008; 35 (Suppl. 8): 136–162.
• Karthikeyan B.V etal .The versatile subepithelial connective tissue graft: a literature update. GENERAL
DENTISTRY November/December 2016.
• B, Belazelkoska Z. Exploring the Gingival Recession Surgical Treatment Modalities: A Literature Review. Open
Access Maced J Med Sci. 2018 Apr 15;6(4):698-70.

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