This document discusses various root coverage procedures for treating gingival recession. It begins by defining gingival recession and classifying types. Nonsurgical treatments including monitoring, desensitizing agents, and restorations are outlined. Surgical options such as laterally positioned flaps, double papilla flaps, coronally positioned flaps, free gingival grafts, and subepithelial connective tissue grafts are described in detail. Factors in selecting a procedure and modifications to techniques are also summarized. The document concludes that careful case selection and surgical management are key to achieving successful root coverage outcomes.

1. ROOT COVERAGE PROCEDURES
RIPUNJAY KR TRIPATHI
POST GRADUTE STUDENT
DEPT OF PERIODONTOLOGY

2. Contents
• Definition
• Classifications of gingival recession
• Treatment of gingival recession
Nonsurgical
Surgical
• Conclusion
• Références

3. Definition
GINGIVAL RECESSION-
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].

4.  Free Gingival Graft (FGG) - A soft tissue graft that is completely detached
from one site and transferred to a remote site. No connection with the
donor site is maintained

5. Sub-epithelial Connective Tissue Graft (CTG) - A detached connective tissue
graft that is placed beneath a partial thickness flap. This variation of the free
gingival graft provides the tissue graft with a nutrient supply on two surfaces

6. Classifications Of Gingival Recession

8. Sullivan and Atkins

9. Root Coverage Procedures
Indications:
 root sensitivity
 esthetics
 protect root surface from caries/abrasions
 improved hygiene

10. Treatment Of Gingival Recession

11. NON-SURGICAL

12. Non –surgical Treatment
Monitoring and prevention
Use of de-sensitizing agents, varnishes
Composite restoration
Removable gingival veneers
Orthodontics

13. Monitoring and prevention
If the recession is not progressing and does not provoke tooth
sensitivity or poor aesthetics, then tooth- brushing instructions
and regular observation through a strict maintenance program
would be the optimal treatment.

14. De-sensitizing agents, varnishes
Treatment of dentine hypersensitivity is based on blocking the dentinal
tubules and preventing nerve stimulation .

15. Composite restorations
Use of composite resin to mask recession defects and eliminate black
triangles caused by recession.

16. Removable Gingival Veneers

17. Orthodontics
In some cases surgical intervention and grafting may help to treat the
recession defect; however, if orthodontic treatment is an option that the
patient is willing to consider then any surgical intervention should be delayed
until after orthodontic tooth movement has been completed.

18. Indications For Surgical Intervention
The need to improve soft tissue aesthetics
Reduce hypersensitivity
Improve plaque control
Prevent further progression of recession defect

19. Key factors in the selection of surgical
procedures
RECIPIENT SITE
 Gingival recession is limited to one tooth or extends to multiple teeth
 Degree of gingival recession
 Amount and thickness of existing keratinized gingiva in the area of
recession

20.  Whether the area of recession protrudes labially from the dental arch
 Restorative/Prosthodontic treatment after root coverage is necessary

21. Donor site
 Whether area adjacent to gingival recession can be used as a donor site.
 Amount of Keratinized gingiva
 Thickness of keratinized gingiva

22.  Size of adjacent interdental papilla
 Thickness of the alveolar bone covering the donor tissue
 Thickness of palatal soft tissue used as donor tissue

23. if adequate width is present at
the donor site the following
procedures can be selected:
a. Laterally (horizontally) displaced flap.
b. Double-papilla flap.
c. Coronally-positioned flap
If the donor site is associated
with inadequate width:
Free soft tissue auto graft
Sub epithelial connective tissue grafts
are available
Depending on the width of the attached gingiva

24. Root Coverage Procedures
Pedicle soft tissue graft procedures :
Rotational flaps
 Laterally positioned flap
 Double papilla flap
Advanced flaps
 Coronally positioned flap
 Semilunar flap

25. Free soft tissue grafts
Non-submerged graft
 One stage (free gingival graft)
 Two stage (free gingival graft + coronally positioned flap)

26. 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

27. Additive treatments
•Root surface modification agents
• Enamel matrix proteins
•Guided tissue regeneration
•Non-resorbable membrane barriers
•Resorbable membrane barriers

28. Laterally Positioned flap
Advantages
a. One surgical site
b. Good vascularity of the pedicle flap.
c. Ability to cover isolated, denuded roots that have adequate donor tissue
laterally.

29. Disadvantages
a. Limited by the amount of adjacent keratinized attached gingiva.
b. Possibility of recession at the donor site.
c. Dehiscence or fenestration at the donor site.
d. Limited to one or two teeth with gingival recession.

30. 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.

31. Procedure for laterally Positioned flap:
 Step I : Preparation of the recipient site

32. Step 2: Prepare the flap of the donor site.
Step 3: Transfer the flap.
Step 4: Protect the flap and donor site.

33. VARIANTS
Satffileno, 1964
partial thickness flap to avoid
recession at donor site
Grupe,1966
Submarginal incision

34. Sub-marginal pedicle flap

35. Oblique rotated pedicle flap

36. Double papilla flap
Indications:
1. When the interproximal papillae adjacent to the mucogingival problem are
sufficiently wide.
2. When the attached gingiva on an approximating tooth is insufficient to
allow for a Lateral Pedicle Flap.
Advantages:
1. The risk of loss of alveolar bone is minimized because the interdental bone
is more resistant to loss than is radicular bone.
2. The papillae usually supply a greater width of attached gingiva than from
the radicular surface of a tooth.

38. Coronally positioned flap
Indications:
• Esthetic coverage of exposed roots.
• For tooth sensitivity owing to gingival recession.
Advantages:
• Treatment of multiple areas of root exposure.
• No need for involvement of adjacent teeth.
• High degree of success.
• Even if the procedure does not work, it does not increase the existing
problem.

39. Coronally positioned flap
First technique:
Step 1: With 2 vertical incisions.
Step 2: Root preparation

40. Step 3: Return the flap and suture it coronal to the pretreatment position.
Step 4: Cover the area with a periodontal dressing.

41. Second Technique (Semilunar flap)
Indication:
 Small localized area
Advantages:
• No vestibular shortening, as occurs with the coronally positioned flap.
• No esthetic compromise of interproximal papillae.
• No need for sutures.

42. Disadvantages:
• Inability to treat large areas of gingival recession.
• The need for a free gingival graft if there is an underlying dehiscence or
fenestration.

43. Step 1: Semilunar incision is made and ending about 2 to 3 mm short of the
tip of the papillae.

44.  Step 2: Perform a split-thickness dissection coronally from the incision, and
connect it to an intrasulcular incision.

45.  Step 3: The tissue will collapse coronally, covering the denuded root. then
held in its new position for a few minutes with a moist gauze. Many cases
do not require either sutures or periodontal dressing.

46. Double Lateral sliding bridge flap
Multiple gingival recession with or without adequate attached gingiva
Coronally
advanced
flap
Vestibular
plastic surgery

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

49. Free Gingival Autograft
that consist of epithelium and a thin layer of underlying CT completely
detached from one site and transferred to a remote site.
Advantages
 Increase keratinized tissue around teeth, implants or crowns and under
removable prostheses.
 Increase vestibular depth.

50. Surgi cal Technique
Step 1: Prepare the recipient site.
Step 2: Root preparation:
Root planing of exposed root to remove cementum and affected dentin.
Etch root surface with tetracycline (pH 2.0).

51.  Step 3: Obtain the graft from the donor site:
The ideal thickness of a graft is 1.0 - 1.5 mm.

52. Step 4: Graft transferred to recipient site.
Step 5: Protect the donor site.

53. Sub-epithelial Connective Tissue Graft
Indications:
• Where esthetics is of prime concern
• For covering multiple denuded roots
• In the absence of sufficient width of attached gingiva in the adjacent areas.
Advantages:
• High degree of cosmetic enhancement
• Incurs no additional cost for autogenous donor tissue
• Minimal palatal trauma
• Increased graft vascularity.

54. Disadvantages:
• High degree of technical skills required.
• Complicated suturing

55. I. Preparation of recipient site:
 The initial horizontal right angle incision is made into the adjacent
interdental papillae at, or slightly coronal to the cementoenamel junction of
the tooth with an exposed root surface. preserve the papillary blood
supply A partial thickness flap is raised without vertical incisions
SRP Root Conditioning with citric acid pH 1.0 or tetracycline HCl in a
concentration of 250 mg mixed in 5 ml of sterile water  approximate
mesio distal width necessary for the graft is measured with a periodontal
probe.

57. II. Excision of the donor tissue
1st incision  horizontal incision 2-3mm apical to gingival margin
2nd incision  parallel to the long axis of the teeth, 1 to 2 mm apical to the
first incision raise a full thickness periosteal connective tissue graft

58. III. Grafting to the recipient site:
 With interrupted sutures

59. Pouch and Tunnel technique
Create “pouch” using full thickness incision and maintain papilla for
bilaminar blood supply.

60.  Extend incision to adjacent teeth and undermine flap beyond MGJ, which
allows the coronal positioning of the flap.

61.  Insertion of CTG and suture.

62. Guided Tissue Regeneration
Indications
• Esthetic demand.
• Indicated for single tooth with wide, deep localized recessions.
• For areas of root sensitivity where oral hygiene is impaired.
• For repair of recessions associated with failing or unesthetic class V
restorations.

63. Advantages:
• Techniques does not require a secondary donor surgical site reducing
postoperative discomfort.
• New tissue blends evenly with the adjacent tissue, providing highly esthetic
results.
Disadvantages:
• It is sensitive technique.
• Insurance of additional cost of barrier membrane.

64. Step 1: A full-thickness flap is reflected to MGJ, continuing as a partial-
thickness flap 8 mm apical to MGJ.
Step 2: Root preparation.

65.  Step 3: A membrane is placed over the root surface and the adjacent tissue
at least 2 mm of marginal periosteum.
 Step 4: The flap is then positioned coronally and sutured.

66. The use of Allografts and Xenografts in
management
systematic review concluded that these grafts may be useful in situations
where
1- A large recession defect needs to be treated .
2- Graft tissue harvested from the palate would provide an insufficient
volume of tissue.

67. Modifications
a. Titanium–reinforced membranes  used to create the space below the
membrane.
b. Resorbable membranes have been used to prevent a second surgery

68. Criteria of successful root coverage
The gingival margin is on the CEJ in class I, Class II.
The depth of gingival sulcus is within 2mm.
There is no bleeding on probing , hypersensitivity.
Color match with adjacent tissue

69. 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.

70.  The subepithelial connective tissue graft with a cornonally advanced flap is
gold standard grafting procedure .
 Prognosis (amount of root coverage achieved) will depend on the severity
(size )of recession .
 Careful case selection and surgical management are critical if a successful
outcome is to be achieved.

71. References
 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
 Paulom. Camargo, Philip R.Melnick & E. Barrie Kenney.The use of free
gingival grafts for aesthetic purposes . Periodontology 2000, Vol. 27, 2001,

72.  Philippe bouchard, Jacquesmalet & Alain borghetti. Decision-making in
aesthetics: root coverage revisited - - Periodontology 2000, Vol. 27, 2001
 Kassab MM, Badawi H, Dentino AR. Treatment of gingival recession. Dent
Clin North Am. 2010;54:129-140.
M. Zalkind.Alternative method of conservative esthetic treatment for gingival
recession J Prosthet dent 1997 77 561-563

73. Carranza’s. Clinical Periodontology. 12th ed.New Delhi:Elsevier ;2015. pp. 628,
ch.-63