Dentistry Review 2 (2022) 100008

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Dentistry Review
journal homepage: www.elsevier.com/locate/dentre

Review article

“Gingival Recession And Root Coverage Up To Date, A literature Review”

Diana Mostafa a,∗, Nikhat Fatima b
a
Periodontology and Oral Medicine Department. Alexandria University, Faculty of Dentistry, Egypt
b
Department of Periodontics Reader, Daswani Dental College and Research center. Kota, Rajasthan, India

a r t i c l e i n f o a b s t r a c t

Keywords: Background: As gingival recession (GR) becomes a more common condition, root coverage becomes a crucial
Gingival recession aspect of aesthetic and periodontal treatment. In general, gingival recession refers to an apical movement away
Root coverage from the cementoenamel junction (CEJ) that exposes root surfaces. The root coverage (RC) procedures are in-
Periodontal plastic surgeries
dicated for aesthetic purposes, for reducing hypersensitivity, for treating gingival margin inconsistency, and for
Gingival recession treatments
enhancing keratinized tissue. Numerous techniques have been established to treat the GR either single or multi-
ple defects including restorative, orthodontic, and surgical options. The surgical RC modalities are free gingival
autograft, subepithelial connective tissue graft, lateral repositioned flap, double papilla flap, semilunar flap, coro-
nally advanced flap, guided tissue regeneration (GTR), tunnel technique, and pinhole technique. The management
choice depends on the size and number of the recession defects, quantity and quality of keratinized tissues, the
width and height of the interdental papillae, the presence of frenum pull, and the depth of the vestibule, as well
as the patient aesthetic and functional demands. In our study, we discussed the causative factors and treatment
modalities for gingival recession. Furthermore, we highlighted the indications and feasibility of each invasive
and non-invasive technique for treating gingival recession. However, we concluded that the selection of the ap-
propriate technique for GR management is related to the proper assessment of the case which in turn will deliver
successful predictable results.

1. Introduction equate mucogingival complex is fundamental to sustain morphological

integrity and enhance gingival attachment.
Today, modern dentistry is more concerned with aesthetic patient’s In this presented review, we highlighted the indications and treat-
expectations. For instance, root coverage for gingival recession (GR) ment modalities of root coverage as well as their advantages and disad-
has become an essential requirement in aesthetic and periodontal fields. vantages. However, first, we need to understand the causes and classi-
However, GR is characterized as an apical migration of gingival tissues fications of GR to consider its management.
away from the cementoenamel junction (CEJ) causing exposure of the
root surfaces. Two main influences have been implicated for GR, the in- 2. Etiology of gingival recession
flammatory periodontal condition and mechanical trauma. In addition,
risk factors such as the presence of a thin biotype, lack of attached gin- It can be divided into the following: direct causes and predisposing
giva, presence of bone deficiencies, tooth malposition, and high frenum factors.
or muscle attachment are also reported. While GR is observed in al-
most all populations around the globe, it is more commonly observed 2.1. Direct causes of gingival recession
among the elderly. The ageing process may increase the possibility of
GR, but not relative as a cause,1 which makes it age-associated and not 2.1.1. Periodontal diseases
age-related. It involves interaction between plaque bacteria and host immune
The GR is characterized by a reduction in the volume and cell pop- response resulting in periodontal tissue destruction and bone loss ulti-
ulation of the gingival tissues, resulting from sublethal cell aggression mately leading to apical gingival migration and root exposure laterally
due to compression and reduced local vascularization of the gingiva, (Figure 1-a -c). Initially, a loss of tissues is compensated by gingival
which may affect single or multiple root surfaces.1 Nonetheless, an ad- inflammation driven by inflammatory exudates and infiltrate accumu-
lation, then, the persistence of bacterial plaque promotes inflammatory
mediators secretion which is responsible for periodontal destruction.

∗
Corresponding author: Periodontology and Oral Medicine Department. Alexandria University, Faculty of Dentistry, Egypt. Mailing address: 5 str. Abdsalam street,
Alhadaia, Alexandria, Egypt, Mob:00966502197814
E-mail address: [email protected] (D. Mostafa).

https://doi.org/10.1016/j.dentre.2021.100008
Received 26 September 2021; Received in revised form 16 November 2021; Accepted 18 November 2021
2772-5596/© 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
D. Mostafa and N. Fatima Dentistry Review 2 (2022) 100008

In addition, the gingival recession is associated with overlying to inadequate brushing associated with chronic periodontal disease as
supragingival and subgingival calculus which are mineralized by min- depicted in figure 1-h.
erals of either saliva or gingival fluid. Due to the presence of adjacent -Narrow zone of keratinized gingiva(KG) is commonly associated
salivary ducts, supragingival calculus is most commonly found on lin- with GR and is considered as one of the most important mucogingival
gual surfaces of lower anterior teeth and buccal surfaces of upper molars. conditions. However, studies have shown no relationship between ker-
Sometimes the gingival margins remain in their place despite the bone atinized gingiva and GR when optimal periodontal tissues and hygiene
loss, this is due to the presence of intrinsic gingival fibers, but if the maintenance are maintained.6
gingival margins are removed apically and GR occurs, it becomes chal- -Thin biotype of periodontium, is usually associated with the pap-
lenging to regenerating due to the deficiency of the supporting bone.1 , 2 illary and facial recession commonly found in maxillary canines and
Despite the purpose of the periodontal treatment being to eradicate mandibular incisors.1 This type of periodontium has a thin alveolar bone
the local causes of periodontal disease, the mechanical therapy leads to crest in conjunction with a delicate scalloped gingival margin which
the migration of inflammatory cells and the reduction of gingival tissues, is prone to dehiscence and fenestrations formation even with minimal
resulting in root exposure, once the treatment has been completed.1 , 2 brushing force, also bacterial plaque accumulation, which may trigger
early root exposure.
2.1.2. Occlusal trauma/ traumatic occlusal forces
If the occlusal forces exerted by the tooth are greater than the peri- 2.2.2. Improper orthodontic forces
odontal capacity, the periodontal tissues will gradually be destroyed. A It is an iatrogenic factor that induces GR especially in cases of the
traumatic occlusion may cause pain, infra-bony pockets, and bone loss thin, delicate biotype periodontium. Orthodontic tooth movement can
at first, as well as an increase in tooth mobility. Additionally, a widen- disturb the marginal and the papillary tissues generating dehiscence
ing periodontal space, thickening of the lamina dura, and angular bone which are commonly presented in the lower incisors (Figure 1-g) and
loss may be observed radiographically. It is clinically identified by wear the mesiobuccal root of first molars, particularly in premolar extraction
patterns associated with occlusal/incisal surfaces, V-shaped recession, cases. Besides, the extreme proclination of incisors and expansion of the
abfraction, and cracked cervical enamel surfaces (chipped teeth). In se- arch are considered great risk factors for GR.7
vere consequences, trauma from occlusion may cause root resorption,
cementum tearing and tooth fracture. 2.2.3. Systemic and environmental factor
This process is unrelated to plaque amount or accumulation but a Gingival recession occurs more frequently among smokers partic-
tooth that has periodontal diseases may exhibit aggressive destruction ularly on the buccal surfaces of maxillary molars, premolars, and
of periodontium as the ability of periodontal tissues to withstand the mandibular central incisors.8 Heavy smoker patients are characterized
occlusal forces are much lesser than a tooth with healthy periodontium, by pink-coloured gingiva with a minimal amount of gingival inflam-
this is called “ secondary trauma from occlusion” (Figure 1-c). mation and bleeding on probing, due to nicotine’s vasoconstriction ef-
fect along with an overall reduction of oxygen amounts in their blood
2.1.3. Traumatic injury (Figure 1-b). Despite low levels of appearing inflammation, smokers ex-
It is also referred to as chronic mechanical or chemical trauma. hibit changes in bacterial flora, decrease in PMNs and increase in host re-
Commonly, it is caused by inappropriate and aggressive tooth brush- sponse mediators, all of which contribute to more aggressive periodontal
ing or flossing over delicate gingival margins resulting in GR gradually destruction compared to their non-smoking counterparts. This destruc-
developing.3 In addition, finger infliction is described as self-injurious tion includes bone loss and connective tissue break down which results
behaviour when the patients used their nails to push the gingiva api- in GR.
cally and cause irritation, resulting in GR4 as shown in figure 1-f. Fur- Additionally, immunocompromised individuals and those who take
ther, tongue and lip rings or accessories can cause continual mechanical immunosuppressive medications (ex: steroids and methotrexate) have
trauma causing facial or lingual recession defects. an impaired immune system which lead to suppression of the inflamma-
tory process and host response making patients prone to more infection
2.1.4. Protheses related factors and the progression of the periodontal diseases.9 Besides, poor dietary
Also, subgingival restorative margins, overhanging amalgam, sub- intake and malnutrition especially vitamins A, C and zinc affect the im-
gingival prosthetic margins and improper partial denture design may mune response and delay the repair and regenerative processes of the
cause pressure on supracrestal attached tissues (biological width vio- periodontium, contributing to progression of periodontal diseases and
lation), this is in turn potentially leads to mechanical irritations and GR.10 Furthermore, the incidence of gingival recession regardless of the
formation of plaque retentive areas which cause bone loss and GR.5 cause also increases with age, so it can be considered as a risk factor for
both the extent and severity of the recession.11

2.1.5. Direct stimulus and carcinogenic substance

3. Classifications of gingival recession
Using chemical irritants involving smokeless tobacco, betel leaf,
lime, areca nut, and cocaine influence the sulcular microflora, affect
Among various classifications which have been proposed to classify
the host response, and inhibit the synthesis of fibroblasts developing
the gingival recession, Miller’s classification system is the most broadly
GR (Figure 1-e).
used, which focuses on the extension of the recession to a mucogingival
junction (MCJ), interdental soft tissue loss and proximal bone loss.12
2.2. Predisposing factors of gingival recession
• Class I: recession of gingival marginal tissue, which does not extend
2.2.1. Anatomic factors to the MGJ. There is no bone or soft tissue in the interdental area,
-Bone dehiscence refers to a morphological defect of the bone crest and 100% root coverage can be predicted.
where there is a reduction in the buccal bone thickness associated with • Class II: recession of gingival marginal tissue, which extends to or
the absence of the marginal bone. Dehiscence and fenestration signif- beyond the MGJ. There is no bone or soft tissue in the interdental
icantly increase the chance of gingival recession, especially in mal- area, and 100% root coverage can be expected.
positioned teeth as illustrated by figure 1-d. • Class III: recession of gingival marginal tissue, which extends to or
-Aberrant Frenal attachment near the cervical region of the gin- beyond the MGJ. Bone or soft tissue loss in the interdental area is
giva, pulls labial and lingual gingival margins apically causing gingi- present or there is a malpositioning of the teeth, which prevents
val retraction and plaque formation, especially in the areas subjected 100% root coverage. Partial root coverage can be expected. The

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D. Mostafa and N. Fatima Dentistry Review 2 (2022) 100008

Figure 1. Different factors that cause or predispose gingival recession.

amount of root coverage can be estimated using a periodontal probe The facial GR displays an aesthetic problem, whereas the lingual and
pre-surgically. palatal ones don’t own this problem, but it should still be considered
• Class IV: recession of gingival marginal tissue, which extends to or since it can lead to root caries and hypersensitivity. However, GR may
beyond the MGJ. The bone or soft tissue loss in the interdental area be represented in single or multiple defects. The localized gingival reces-
and/or malpositioning of teeth is so severe that root coverage cannot sion is divided into two categories; V-shaped gingival recession which
be predicted. is associated with teeth exposed to occlusal trauma, especially the para-
functional habits such as grinding, clenching and bruxism, also referred
However, this classification has significant limitations, counting the as Stillman’s cleft. While U-shaped gingival recession is associated with
proximal bone and soft tissue loss and the mucogingival junction as a chronic periodontal diseases (characterized by the presence of local fac-
landmark for measuring recession depth which can be difficult to iden- tors and periodontal inflammation), improper tooth brushing (charac-
tify. It also lacks evidence on tooth-related conditions to adequately pre- terized by abrasion, intact interdental papillae and a minimal amount
dict RC.

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of plaque) and mucogingival problems such as high frenal attachment.9 4.5. Decrease in the width of keratinized tissue
n 1983, Bengue et al.13 made a prognosis for both types giving; “U”
type recession a poor prognosis, and for the “V” type recession a fair KT provides fibrotic collar strength and attachment around the tooth
prognosis. that increase the capacity of the periodontium to withstand the occlusal
The 2017 World Workshop on the Classification of Periodontal and forces. When it becomes inadequate, it impacts the tooth capacity, aes-
Peri-Implant Diseases and Conditions introduced a new classification thetic appearance and plaque control maintenance. Hall identified that
for gingival recession which involves the gingival phenotype, the in- keratinized attached gingiva with less than 2 mm should be monitored
terproximal attachment loss and the characteristics of the exposed root for active recession.21
surface.5
Cario et al.14 in 2011 had classified recession type (RT) into 3 types; 5. Treatment modalities

• RT1: GR has no interproximal clinical attachment loss (CAL) and CEJ Recent decades, numerous techniques have been established to treat
is not noticed proximally. the GR with either single or multiple defects including restorative, or-
• RT2: GR with interproximal CAL equal or less than the buccal CAL. thodontic and surgical options. GR treatments are based on the assess-
• RT3: GR with interproximal CAL greater than the buccal CAL. ment of the causative factor, degree of involvement and a class of reces-
sion defect.
Alternatively, the generalized or horizontal gingival recession is as-
sociated with chronic destructive periodontal disease, as loss of bone
5.1. Restorative and prosthodontic treatment
and destruction of tissues generate the apical migration of gingival mar-
gins with or without interdental papillae involvement. Bone height and
Localized recession defects with wear or root caries can be camou-
bone width are the main factors that determine the height of soft tis-
flages by direct or indirect restorations or full coverage or resin based
sue. Other factors such as dental morphology, location of contacts and
material, but dentists should be aware of not creating plaque-retentive
quality of soft tissue can also influence its appearance.15 As a result, the
margins to avoid further GR.22 While several GR and loss of the inter-
greater the gingival recession, the lower the probability of achieving
dental papillae cause open embrasures (black triangles), create unaes-
complete root coverage.16
thetic appearance and altered speech due to air escaping through these
spaces interproximally.23 In these cases, surgical procedures are not the
4. Indications of root coverage management appropriate choice, but silicone removable gingival veneers can restore
the soft tissue and fill the interproximal spaces.23
The root coverage (RC) procedures are indicated for aesthetic pur-
poses, reduction of hypersensitivity, treatment of the inconsistency of 5.2. Orthodontic treatment
the gingival margin, oral hygiene maintenance and augmentation of ker-
atinized tissue.17 , 18 In case of teeth crowding, orthodontic management can position the
teeth towards the center of the bone allowing alveolar bone growth on
4.1. Root sensitivity the buccal aspect which in turn thickens the gingival tissues causing a
coronal shift of the gingival margin.23 As well, orthodontic intervention
Due to the exposed dentin of the root surface, it causes short sharp recedes GR in cases of V-shaped localized GR associated with occlu-
pain when eating or drinking, or when opening the mouth. In the ab- sion trauma without any surgical interference.1 However, orthodontic
sence of aesthetic concerns, topical fluoride may be applied to root sur- movements may not completely cure all cases of GR particularly if a
faces to enhance mineral precipitation and relieve pain. If pain persisted, periodontal surgical approach is needed.
a restorative treatment may be performed. If dentine hypersensitivity
is associated with aesthetic complaints, treatment should involve sur- 5.3. Frenectomy
gical and /or restorative approaches.19 In such situations, periodontists
should be cautious when performing mechanical debridement20 to avoid In the case of the high frenal attachment that pulls the gingival mar-
removing the surface layer of the enamel and exposing underlying denti- gins downwards and hinders the plaque control procedures, a surgical
nal tubules, which could lead to increased hypersensitivity, biofilm ac- removal of the frenum is advised. 24
cumulation, and caries.
5.4. Periodontal surgeries for root coverage
4.2. Unaesthetic appearance
The main objective of periodontal plastic surgery is the establish-
Patients typically seek treatment for GR because they dislike their ment of homogenous pink aesthetics by the regeneration of gingival
smile or may have issues with phonation due to air that passes through margins. Prior to any root coverage surgery, root planning and condi-
open embrasures (black triangles). tioning should be achieved. Root conditioning is often performed with
chemical agents such as citric and phosphoric acids, ethylenediaminete-
traacetic acid and tetracycline hydrochloride. The procedure involved
4.3. Inconsistency of gingival margin soaking in the chemical solution and applying it to the exposed root
surface for 2-5 minutes. This process involves detoxification, decontam-
Disharmonies in the marginal gingiva affect the appearance and ination, and demineralization of the root surface so that the smear layer
oral hygiene performance, it can only be managed by root coverage is removed exposing the collagenous matrix that covers dentin and ce-
surgery.18 mentum.25
The most common surgical root coverage modalities are free gin-
4.4. Cleansing and plaque control gival autograft,26 subepithelial connective tissue graft(SCTG),27 lateral
positioned flap (LPF),28 double papilla flap (DPF),29 semilunar flap,
GR traps food debris, which acts as a plaque retentive area, affecting coronally advanced flap (CAF),30 guided tissue regeneration (GTR),31
oral hygiene maintenance and making it difficult for patients to clean vestibular incision subperiosteal tunnel access(VISTA) technique and
their teeth. Thus, increases the progression of periodontal destruction pinhole technique (PST).32 The management choice depends on the size
and intensifies the GR situation. and number of the recession defects as well as the quantity and quality

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D. Mostafa and N. Fatima Dentistry Review 2 (2022) 100008

of keratinized tissues, the width and height of the interdental papillae, lope type flap is done to combine the advantages of FGGs and SCTGs.
the presence of frenum pull, the depth of the vestibule16 and the pa- In this technique, the epithelialized grafts are placed to cover the ex-
tient’s aesthetic and functional demands. There is a schematic for root posed root surfaces while the SCTG is adapted to the recipient bed and
coverage techniques for class I,II,III recessions which was introduced by is covered by the flap. This procedure increases the resistance against the
Carlo et al.33 as follows; mucosal tension, decreases the risk of MGL displacement and increases
-If the pocket depth is less than 5mm (shallow) with adequate ker- the amount of KT.36
atinized tissues (KT), a pedicle graft such as coronally advanced flap Also, there are different procedures for harvesting the subepithelial
(CAF), Laterally positioned flap (LPF) or Double papilla flap (DPF), is connective tissue including the trap door procedures and the envelope
recommended. But in case of inadequate KT, soft tissue augmentation is techniques with single or double incisions.37 These procedures involve
indicated using free gingival graft with CAF or subepithelial connective a split-thickness flap elevation, followed by the withdrawal of connec-
tissue graft with CAF/LPF/DPF. tive tissue graft and then complete closure of the palatal flap by su-
-If there are deep periodontal pockets more than 5mm, and KT is ad- tures. However, the size of the graft should be with adequate thickness
equate then the guided tissue regeneration (GTR) technique with CAF is to avoid desquamation of the undermined superficial flap as a result of
the choice. Conversely, if inadequate KT presents apically to the reces- compromised vascularization, also should exceed the bone dehiscence
sion, a free soft tissue graft with a membrane and CAF will be indicated. and suture at the level or coronal to the cementoenamel junction.38 , 39
However, periodontal surgery for root coverage is indicated when aes- The advantages of this procedure include the primary intention of
thetics are the prime concern and periodontal health is good.34 healing the donor site, predictability, long-term stability and acceptable
aesthetic results. Although root coverage (RC) is more predictable, the
5.4.1. Soft tissue graft procedure aesthetic appearance of the treated recipient site was somehow differ-
5.4.1.1. Free epithelized soft tissue autograft. This is the most widely used ent from that of the neighbouring tissues. This is due to the chromatic
surgical technique for increasing the width of the attached gingiva. It is difference between the uncovered epithelialized part of the graft and
indicated in the presence of a thin biotype of gingiva and insufficient the adjacent soft tissues, or maybe partial exposure and dehiscence of
apicocoronal gingiva that can’t be placed coronally. But it is not indi- the connective tissue graft or maybe the difference in tissue thickness
cated for recession defects in aesthetic zone. between the grafted site and the adjacent tissues.25 Besides, the require-
Technique: The procedure starts after root planning and condition- ment of technical skills is a critical disadvantage of this technique.
ing, where the split-thickness flap is performed to prepare the recipient
periosteal bed for the free gingival graft (FGG), which is harvested from 5.4.1.3. Pedicle autograft procedures. It is known as a soft tissue auto-
a remote donor site (hard palate or maxillary tuberosity) with irrelevant graft that covers the exposed root surface while it is not completely
aesthetic requirements to the recipient site. The graft should be a mini- detached from the donor site and transferred to the adjacent recipient
mum of 1.25 mm in thickness as mentioned by Sullivan and Atkins35 to site. It is contraindicated in the narrow oral vestibule and thin biotype
assure the presence of blood supply in connective tissues, sutured coro- of donor site. Its advantages are preserved blood supply, harmonious
nally to the cementoenamel junction (CEJ) to compensate for the soft colour match and one surgical site while its disadvantages include lim-
tissue shrinkage and adapted to the convexity of the crown to minimize itation of single tooth treatment and minor shallow recessions only can
coagulum exposure and destabilization. After the suturing of FGG, the be managed.
flap is apically positioned underneath the FGG (One-stage procedure). -Coronally advanced flap (CAF)
While in the two-stage procedure, the FGG is adapted to the periosteal It is indicated when treating patients with shallow recession defects
bed apically to widen the KT, then after 2 months as a minimum period less than 4mm and thick periodontal biotype. It is contraindicated when
for graft integration, a coronally advanced flap is used to reposition the there is inadequate KT apical to the recession defect, the presence of a
sufficient KT coronally covering the gingival recession.36 gingival cleft (Stillman cleft) extending into the alveolar mucosa, a high
One of its important disadvantages is that the healing of the donor frenum pull, a prominent root and a very shallow vestibule.
site occurs by secondary intention within 2–4 weeks, which is usually Technique: It is done by shifting coronally the gingival tissues to
associated with patient discomfort. In addition, the graft placed on the cover the exposed root surface. This technique was modified using a
denuded root surface does not receive adequate blood supply, causing trapezoidal flap design and a split–full–split-thickness flap elevation
partial necrosis of the grafted tissue which is considered to be the main approach where split-thickness preparation is done in the interdental
obstacle. Also, the unfavourable aesthetic outcome could happen due to papillae and beyond the MGJ while the full-thickness flap in the kera-
the inadequate root coverage, the scar appearance of the grafted tissue tinized gingiva40 as shown in figure 3. Another alternative to CAF is a
(contrasts the adjacent tissues) and the malalignment of the mucogin- semilunar coronally advanced flap (SCAF) that can be used when the
gival line (GML), this is why it is not recommended for the aesthetic recession is less than 3mm, thick biotype of the periodontium, and suf-
zone.37 ficient KT at the apex of the defect.36 It is done by horizontal semilu-
nar incision at the MGJ, then a split-thickness flap is elevated starting
5.4.1.2. Subepithelial connective tissue autograft (Figure 2). It is indicated from the sulcus where the tissues are moved coronally then sutured36
for patients with aesthetic demands, inadequate KT, deep root abrasion, as shown in figure 4.
root prominence and root pigmentation (a dark/orange root surface) The advantages of this treatment are the simplicity and well toler-
and gingival recession associated with prosthetic crowns or implants. ance of the technique, in which the surgical area is limited, does not
But it is contraindicated when GR is caused by a high muscle pull, a involve donor tissues and delivers aesthetic results. Due to the coronal
gingival cleft extending in alveolar mucosa and a shallow vestibule.38 , 39 shift of gingival margins after CAF, CT increases; however, mucogingi-
Technique: A partial‑thickness flap is reflected to ensure a blood val line (MGL) tendencies to regain its genetically determined position
source for the graft. It was reported that the bilaminar techniques are limits the processes. Nevertheless, periodontal biotype influences the
the most predictable procedures for root coverage25 since a high blood width of KT as patients with a more apical position of the MGL experi-
supply is provided by the covering flap. This enhances the survival of ence a greater increase of KT when compared to those with more coronal
the graft above the avascular surface of roots and improves the aesthetic MGL.41
results. -Laterally Positioned flap (LPF)
Some modifications have been done concerning the type of graft This technique is indicated for narrow, isolated recession defects
(partially or completely de-epithelialized) and the flap design (enve- with thick biotype periodontium and sufficient interdental papilla. It
lope type or with a vertical releasing incision). However, epithelialized- is contraindicated in case of excessive root prominence and insufficient
subepithelial connective tissue graft (ESCTG) combined with an enve- vestibular depth. A modification was done to LPF design involving dif-

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D. Mostafa and N. Fatima Dentistry Review 2 (2022) 100008

Figure 2:. Subepithelial connective tissue graft used for gingival recession treatment.

Figure 3. Coronally advanced flap was used to increase the keratinized gingiva and cover the exposed root.

Figure 4. Using of semilunar technique to cover the exposed root.

ferent thicknesses of the flap elevation; split-thickness at the papillae 5.4.1.4. Allograft. It is indicated in large and multiple recession de-
level, full-thickness in the flap covering the avascular root surface and fects. It is a processed dermal allograft of extracted cell components
then split-thickness again apical to the MGL to permit the coronal move- and the epidermis, where the remaining dermal layer is washed in de-
ment of the flap, then coronal sling sutures anchoring the tooth cingu- tergent solutions to inhibit viruses and minimize tissue rejection. It is
lum are done to hold the flap coronally.41 then cryoprotected and rapidly freeze-dried in a proprietary process in
Its advantages include the well-tolerance by patients because it does order to maintain its biochemical and structural integrity.42 The allo-
not involve a second surgical donor site, is less time consuming and has graft acts as a collagenous scaffold, facilitating the vascular endothe-
excellent postoperative healing results, but it is not desired to be used in lial cells and fibroblasts to repopulate the connective tissue matrix
patients with high aesthetic demands as scar tissue forms in the donor and encourage the epithelial cells to migrate from the adjacent tissue
site as it heals with the secondary intention.41 Also, it may have the risk margins.
of recession observation in the lateral donor site (Figure 5). However, the comparison between alloderm matrix graft (ADMG)
Double papillae flap (DPF) and SCTG using CAF was done by several studies and concluded no
It is indicated for a single recession defect in patients with thick gin- statistically significant differences for complete root coverage and re-
gival biotype. It has been suggested to be done when the papillae of both cession reduction but KT was increased significantly with the use of the
sides have sufficient width and height.Technique: Two partial-thickness connective tissue graft.42 On the other hand, experiments on collagen
flaps are raised and rotated obliquely so that the adjacent papillae of matrix from the porcine origin (Mucografts) were performed in com-
both sides are sutured together covering the exposed root. The benefit parison with SCTG, showing that Mucograft provided new widths of
of this procedure is to decrease the amount of tissues exposed of the formed KT, as well as predictable results similar to the connective tissue
donor site, giving more aesthetic results. graft.43 , 44 In addition, the ADMG with CAF gave better overall aesthetic

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D. Mostafa and N. Fatima Dentistry Review 2 (2022) 100008

Figure 5. Laterally repositioned flap to cover the adjacent recession defect.

Figure 6. Pinhole surgical technique.

outcomes and patient satisfaction, even though it showed less com- nor grafts41 , allowing the treatment of an unlimited number of gingi-
plete root coverage.45 Despite this, Chambrone & Tatakis46 concluded val recession defects with high predictability and high aesthetic results
that patients were concerned with covering exposed roots safely and ef- within one appointment.48 , 49 However, its disadvantages include the
fectively, with a preference for techniques involving only one surgical technique sensitivity and the use of especial instruments to elevate the
site. flap elevation without exposure of the inside tissue, increaseing the risk
of flap proliferation.48
5.4.1.5. Tunnel technique. Technique: It is done by elevation of the mu-
coperiosteal envelope (partial-thickness flap) to the level of the MGJ at 5.4.2. Regenerative procedures
each gingival recession site using tunnelling knives with the exclusion of 5.4.2.7. Guided tissue regeneration(GTR). It can be done with resorbable
the interdental papillae, then the graft either SCTG or ADMG is placed and non-resorbable membranes where membranes act as a barrier that
inside the envelope and sutured. It is termed the supraperiosteal enve- helps tissues to heal in their proper place resulting in the regeneration
lope technique (SET) where the interdental papillae are left intact the of new connective tissue attachment and reconstruction of the bone as
graft is placed in the tunnel, the graft does not need to be completely shown in figure 7. This technique is indicated for wide deep recession
covered as long as the dimension of the graft is satisfactory to ensure defects with aesthetic demand. Its advantages include blending with ad-
graft survival. However, the tunnel technique has been modified by in- jacent tissues giving the desired colour results, the gain of new attach-
cluding a coronal placement of the marginal tissue, allowing complete ment and the absence of a secondary donor surgical site, which reduce
coverage of the graft by dissecting more deeply the facial tissue and by postoperative discomfort. However, the membrane exposure or contam-
lifting the papillae of the interproximal septum from the facial and lin- ination, technical difficulties and the possibility of improper healing are
gual aspects.47 This technique is called vestibular incision subperiosteal the drawbacks of this procedure that make this procedure considered
tunnel access (VISTA) that secures coronal position of gingival margin inadvisable.19 , 27
preventing relapse in early healing stage. Its advantages involve mini-
mally invasive surgery as there are no vertical incisions, no flap to be
elevated and minimal sutures. Besides, there is no compromise of blood 5.4.2.8. Enamel matrix derivative (EMD). Using the EMD in combina-
circulation resulting in proper healing and negligible postoperative dis- tion with a CAF provides positive results in the RC because it improves
comfort in the recipient site, also, it increases the KT width and displays KT height and reduces the recession by enhancing periodontal regener-
excellent aesthetic results due to the secondary epithelialization of the ation. McGuire50 endorsed the application of EMD during mucogingival
graft.36 surgery in cases with a wider extension of new attachment formation
between the soft tissue and the root surface. This may be a result of the
size of root exposure (a very wide and deep recession defect), or the
5.4.1.6. Pinhole surgical technique (PST). Technique: It is done by mak-
tooth position (buccally dislocated root) or attachment and bone loss.
ing a small hole in alveolar mucosa tissues using a needle. Through this
pinhole, special instruments are used to loosen gently the gingival tis-
sues and slide them over the denuded root surface.32 As a result, all 6. Healing after root coverage procedures
the muscular and fibrous adhesions are released until the flap can move
freely coronally without being constrained, then collagen strips are in- It would be preferable to have a truly new connective tissue attach-
serted into the interdental papillae to hold the flap coronally (figure 6). ment rather than a long junctional epithelium. Whether FGG or SCTG is
The advantages of this technique are that it only involves coronal ad- successful depends on the survival of the connective tissue and its blood
justment of the existing gingival tissues, so there are neither incisions supply.

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D. Mostafa and N. Fatima Dentistry Review 2 (2022) 100008

Figure 7. Guided tissue regeneration procedure.

6.1. Initial phase (0-3 days) 7.3. Technique related factors

Following graft application, the epithelium begins to shed, while the This includes flap design, flap reflection, root surface treatment, type
connective tissue survival and ability to adapt and grow in the recipi- of graft, the thickness of the graft and position of gingival margin coro-
ent bed determine the outcome of the graft. It becomes edematous and nal to CEJ,
disorganized within the first few days and undergoes degeneration, re-
sulting in new granulation tissue.49
7.4. Periodontist related factors
6.2. Revascularizing phase (2-11 days)
Experience and knowledge of surgeons are very important to make
a proper treatment plan and determine the proper technique for each
The graft is revascularized by the transfer of hydration and nutrients
case as well as the skills to master the case during surgery.
from the recipient bed to the connective tissues, forming new blood ves-
However, Miller’s classification was significant in the prediction of
sels. However, if the graft was thick, blood clots might form, preventing
final root coverage after the surgical augmentation 12 as it stated 100%
the plasmatic circulation producing graft necrosis. The survival of the
root coverage for classes I and II, partial root coverage for class III and
part of the graft that is placed over the avascular root surface depends
no achievable root coverage for class IV. In addition, Bengue et al.9
on the graft nature, diffusion of plasma,and subsequent revasculariza-
made a prognosis for U and V gingival recession types giving; the "U"
tion. On day 4, anastomoses are established and a fibrous interface is
type recession a poor prognosis, and for the "V" type recession a fair
formed between the graft and recipient bed to allow adequate circula-
prognosis. Moreover, the prognosis of RC of maxillary teeth is better
tion. Collagen attachment begins on the fourth day and becomes firm on
than that of mandibular teeth.53 This could be explained by the dif-
day 10 after surgery. Moreover, the heterotopically placed grafts main-
ference in the gingival papilla and bone type between maxillary and
tain their structure (keratinized epithelium) even if it is only connective
mandibular teeth as the maxillary teeth have larger and wider papil-
tissue graft.51
lae and more porous cortical plate of bone which increase the blood
supply. Besides, mandibular teeth have stronger muscle attachment and
6.3. Tissue maturation phase (11-42 days)
shallower vestibular sulcus than maxillary teeth. To my mind, gravity
nature makes maxillary gingiva heal downward easily while mandibular
The tissue maturation begins from day 1 until 42 days while epithe-
gingiva is opposite to gravity forces.
lium maturation and keratin layer formation are established after 14
days.51 After day 14, the vascular system of the graft appears normal.,
also epithelium matures with the formation of the keratin layer. In the 8. Conclusion
case of the FGG, a “creeping attachment phenomenon” is observed at
the recipient site where coronal migration of the soft tissue margin is Some patients with GR can be treated non-surgically without surgical
noticed until 1 year.52 However, in case of ADMG healing, it begins its intervention or in conjunction with plastic surgery, while others require
remodeling with the patient’s own tissues after 3-6 months. surgical intervention. RC evaluation depends on numerous factors such
as the cause of the recession, periodontal biotype, degree of recession
7. Prognosis of the surgical root coverage involvement, width of keratinized mucosa and the class of recession de-
fect as well as the aesthetic and functional demands.
The main objective of the surgical options is to achieve complete FGG is indicated for narrow, isolated recession defects in non-
root coverage which has been accepted as the best indicator of suc- aesthetic areas with inadequate keratinized mucosa. While SCTG with
cess.53 However, there are various factors that affect the prognosis of a bilaminar technique is the gold standard for RC especially in the aes-
the treatment including; thetic zone in terms of predictability and long-term stability. Although
soft tissue graft procedures are predictable, harvesting the palatal area
7.1. Patient-related factors increases patient morbidity, technical difficulty and time-consuming.
Thus, ADMG has been used as a substitute for SCTG in RC management.
Poor oral hygiene, immunocompromised health, systemic diseases LPF is indicated for narrow, isolated recession defects with thick bio-
and smoking affect periodontal surgery negatively. type periodontium. In addition, the CAF technique is used when treating
patients with shallow recession defects and thick periodontal biotype.
7.2. Gingiva related factors SET and PST are minimally invasive techniques that are used in multiple
recession defects and indicated in any periodontal biotype but both of
The cause of the recession, class of recession defect, periodontal them have technical sensitivity. However, selection of the appropriate
biotype, degree of recession involvement, the width of the keratinized technique for GR management based on the proper assessment of the
mucosa, tooth location, vestibular depth and interproximal attachment case which in turn will deliver successful predictable results. Figure 8
level as well as the aesthetic and functional demands are considered shows a decision tree of different surgical techniques for gingival reces-
critical factors. sion.

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D. Mostafa and N. Fatima Dentistry Review 2 (2022) 100008

Figure 8. A decision tree of different surgical techniques for gingival recession treatment.

Funding [4] Mostafa D, Koppolu P, Tarakji B. A Self-Injurious Behavior Causing Unusual Bilateral
Recession And Affecting The Periodontal Treatment: A Case Report. J Med. Cases
2017;8:42–7.
None [5] Jepsen S, Caton JG, et al. Periodontal manifestations of systemic diseases and de-
velopmental and acquired conditions: consensus report of workgroup 3 of the 2017
Conflict of interest statement World Workshop on the Classification of Periodontal and Peri-Implant Diseases and
Conditions. J Clin Periodontol. 2018;45:S219–29.
[6] Kennedy JE, Bird WC, Palcanis KG, Dorfman SH. A longitudinal evaluation of varying
The authors declare no potential conflict of interest with respect to widths of attached gingiva. J Clin Periodontol 1985;12:667–75.
the authorship and/or publication of this article. [7] Årtun J, Krogstad O. Periodontal status of mandibular incisors following exces-
sive proclination A study in adults with surgically treated mandibular prognathism.
American Journal of Orthodontics and Dentofacial Orthopedics 1987;91:225–32.
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