gingival recession

Surgical Procedures for gingival recession are usually performed by Periodontist. C D A J O U R N A L , V O L 4 6 , Nº 1 0

As a general Dentist, you should be aware of the etiology of gingival recession, classification and basic knowledge about Grafts.

Gingival Recession:
What Is It All About?
Debra S. Finney, DDS, MS, and Richard T. Kao, DDS, PhD

A B S T R A C T Gingival recession is a common dental problem that escalates with

increasing age. From the patient’s perspective, this may be associated with intensified
symptoms of dentinal hypersensitivity, impaired aesthetics, plaque retention with
increased localized inflammation and greater susceptibility to root caries. This article
reviews factors that enhance the risk for gingival recession, describes at what stage
interceptive treatment should be recommended and expected outcomes.

AUTHORS

Debra S. Finney, DDS,
MS, a board-certified
periodontist, practices in
Folsom, Calif. She was
president of the California
Dental Association in 2004
and has held numerous
positions with the CDA and
the ADA.
Conflict of Interest
Disclosure: None reported.
Richard T. Kao, DDS,
PhD, is a clinical professor
at the University of
California, San Francisco,
School of Dentistry and
is in private practice in
Cupertino, Calif.
Conflict of Interest
Disclosure: None reported.
G
ingival recession is one of
the most common forms of
mucogingival deformities.
It is a prevalent but often
overlooked problem. The
2012 National Health and Nutrition
Examination Survey study reported a
prevalence of gingival recession in 50
percent of those aged 18 to 64 and that 88
percent of those 65 and older have at least
one site. It increases with age and males
have more recession defects than females.1
Once recession is present, a 3-mm recession
will worsen 67 percent of the time and a
4-mm recession will worsen 98 percent
of the time.2 In the clinical evaluation
and monitoring process, determining the
causes of gingival recession is important in
defining if the mucogingival defects need to
be addressed. Etiologic causes for gingival
recession include traumatic oral hygiene
habits, chronic periodontal inflammation,
malposition of the tooth, orthodontic
movement, regional frenum pull,
biological width invasion and underlying
bony dehiscence. Experience, careful
observation of the dental environment
and good history intake will help the
clinician discern the true etiology.
Mucogingival Assessment
and Phenotype
Gingival recession results when the
marginal tissue migrates apical to the
cementoenamel junction (CEJ), exposing
the root surface. Recession is measured
from the CEJ to the coronal tissue margin.
In addition, it is important to measure and
monitor the width of attached gingiva,
which can be determined by measuring
the distance from the coronal margin of
the gingiva to the mucogingival junction
(MGJ) and subtracting the sulcular
probing depth. At times, especially if
the gingiva is thin, it can be challenging
to identify the MGJ. Gently rolling the
mucosa with an instrument such as a
periodontal probe (FIGURE 1 ) can be
helpful in locating the apical extent of the
attached gingiva. The position of frenum
attachments should also be noted as part
of the mucogingival evaluation. A frenum
attachment at or near the gingival margin
may contribute to recession (FIGURE 2 ).
Another significant parameter in
assessing mucogingival health and
treatment planning for restorative
procedures is the tissue type. Ochsenbein
and Ross first described the concept
O C T O B E R 2 0 1 8  617
 gingival recession
C D A J O U R N A L , V O L 4 6 , Nº 1 0

of thick and thin gingival biotypes.3

More recently, the 2017 American
Academy of Periodontology World
Workshop on Disease Classification
has described this not as biotypes but FIGURE 1. Gently rolling the mucosa can FIGURE 2 . A frenum attachment close to the
as gingival phenotypes.4 Appreciating help to demarcate the mucogingival junction gingival margin may contribute to gingival recession if
the gingival phenotype will help the when assessing the width of attached gingiva. lip movement pulls on the marginal gingiva.
clinician predict how fast recession or
attachment loss may occur. Employing
gingival phenotype as a prognostic
indicator for further gingival recession/
attachment loss is a skill that clinicians
learn over time with clinical experience.
In defining and identifying the gingival a
a
b b
phenotype, the components of the
b
mucogingival complex that should be
considered include the gingival thickness FIGURE 3A . Thin scalloped tissue may appear
(GT), keratinized tissue width (KTW), translucent; notice the roots are apparent under the
gingival morphotype (GM), bone thin tissue.
morphotype (BM) and tooth dimension. FIGURE 3B. When the gingiva is thin, the underlying
Utilizing these parameters, one recent alveolar bone often has dehiscences (a) and fenestrations (b).
classification system categorized gingival
phenotypes into three categories:5 KT
■ Thin scalloped phenotype —

Teeth that are associated with

a gingival phenotype with a
narrow zone of KT, clear thin
delicate gingiva and a relatively
thin alveolar bony housing.
This is usually associated with
narrow triangular crowns with a
buccal profile that is more subtly
convex and with interproximal
contacts that are proximal to
the incisive edge (FIGURES 3 ).
■ Thick flat phenotype — Teeth that
are associated with a broad zone
of KT, thick fibrotic gingiva and
a comparatively thick alveolar
bony housing. The coronal
tooth morphology tends to be
squarer in design with increased
cervical convexity and a
proximal contact that is located
more apically (FIGURES 4 ).
■ Thick scalloped phenotype —
Teeth that are associated with
618 O C T O B E R 2 01 8
FIGURE 4A . A thick flat phenotype has a broad
zone of keratinized gingiva (KT) and teeth that tend to
be more square.
a narrow coronal band of
thick fibrotic gingiva and a
pronounced gingival scallop.
This phenotype is a hybrid of
the two phenotypes described
above with the coronal aspect
having characteristics consistent
with a thick phenotype and
the apical aspect having
mucogingival characteristics
that are more similar to a
thin phenotype (F I G U R E 5 ).
F I G U R E 4 B . The alveolar housing is
thicker with a thick flat phenotype and
contacts are located more apically.
Though there are average parameters
for each of the mucogingival components
in each of these phenotypes, it is
more important to appreciate how the
phenotypes behave in the presence
of inflammation, trauma, restorative
treatment, exodontia and orthodontic
movement. Each of the phenotypes
will respond to these conditions in
a different fashion as first described
by Kao and Pasquinelli.6 In general,
the biological responses are:

FIGURE 5 . A thick scalloped phenotype has a
narrow coronal band of thick gingiva with thin tissue
more apically.
FIGURE 8A . Pulling dental floss into the tissue
instead of wrapping it around the tooth can create
clefts that lead to recession.
FIGURE 9A . The lateral incisor is tipped to the distal
and is positioned more labially in the alveolus resulting
in thin overlying bone and gingiva that contributed to
gingival recession.
■ Thin scalloped phenotype condition:
• Inflammation: Marginal inflam-
mation with the hallmark being
gingival recession with no/minimal
periodontal pocketing. There will
be increasing clinical attachment
loss (CAL) as recession progresses.
• Restorative treatment: Delicate
tissue management is essential as
trauma due to tooth preparation
and/or tissue retraction may
result in gingival recession.
FIGURE 6 . A thin phenotype and chronic
inflammation often result in gingival recession.
FIGURE 8B . Flossing clefts on the lingual.
FIGURE 9B . The same patient demonstrating
the malposition on the lingual and resulting
mucogingival defects.
• Exodontia: Due to the thin bony
housing, the surrounding bundle
bone would be lost with removal
of the periodontal ligament and
extensive ridge resorption is likely.
• Orthodontic treatment: The
bony housing is thin and often
associated with dehiscence and/
or fenestration. Orthodontic
movement is often associated
with further bone remodeling.
Though gingival recession may
C D A J O U R N A L , V O L 4 6 , Nº 1 0
FIGURE 7. A history of vigorous brushing with a
firm brush resulted in recession defects.
not be readily apparent, it can
occur years after the treatment.
• Surgical consideration: With
extraction, the loss of bundle
bone results in extensive alveolar
remodeling. The resulting
thin alveolar ridge is often a
challenge for the restorative
dentist. It may be difficult to
achieve an optimum aesthetic
result and a ridge lap pontic
design may be necessary. For
the implant surgeon, these
are challenging cases in that
ridge preservation and/or ridge
augmentation is often needed
for implant site development.
■ Thick flat phenotype condition:
• Inflammation: Chronic gingival
inflammation tends to be a
hallmark for this phenotype. As
inflammation persists, pocket
formation with intrabony and
furcation defects forms.
• Restorative treatment: This
tissue phenotype is the ideal tissue
to work with for the restorative
dentist. It tends to rebound well
from reasonable restorative trauma.
• Exodontia: There is less
post-extraction remodeling
but the extent is dependent
on the thickness/volume of
pre-existing buccal bone.
• Orthodontic treatment:
Generally, no recession with
conventional orthodontic
movement unless excessive
force moves the tooth out of the
thicker coronal bony housing.
O C T O B E R 2 0 1 8  619
 gingival recession
FIGURE 10 . The first premolar is displaced toward
the buccal making it more prominent and more likely to
incur toothbrush trauma resulting in gingival recession.
• Surgical consideration: Though
this is the ideal gingival phenotype
to work with both from a restorative
and surgical perspective, ridge
preservation strategy should be
taken when there is concern for
extensive ridge remodeling post-
extraction. This is so the ideal ridge
for an ovate pontic or implant
placement can be developed.
■ Thick scalloped phenotype condition:
The behavior of this phenotype is
dependent on whether the problem
area is limited to the thicker coronal
band. If this is the case, the tissue
behaves similar to the thick flat
phenotype. If recession is present
or the trauma spreads to the more
apical thinner phenotype, recession
and mucogingival remodeling
may occur at a much more rapid
rate. With implant placement, the
surgeon must take caution in that
the apical portion is quite thin
and care must be taken to avoid
buccal plate perforation. This is
easy to do because the coronal
aspect gives the false image that
there is a thick bony housing.
While it is not the purview of
this paper, it should be mentioned
that these characteristics also
apply to the mucogingival complex
around implants. The conclusion of
a systematic review indicated that
based on current evidence, a lack of
adequate keratinized gingiva around
implants is associated with more plaque
accumulation, tissue inflammation,
gingival recession and attachment loss.7
620 O C T O B E R 2 01 8
FIGURE 11A . Premolar and first molar roots are
prominent and have more recession defect.
These mucogingival parameters are an
important component of a comprehensive
periodontal evaluation and should be
obtained as a baseline on adult patients and
anyone who presents with a mucogingival
defect.8 Mucogingival abnormalities
should be evaluated at each exam to
determine if there has been progression.
Etiology and Contributing Factors
Etiologic factors must also be identified
to allow them to be addressed as part of
the corrective treatment if indicated. The
most common causes of gingival recession
are plaque-induced inflammation and
mechanical trauma.2,9 Chronic periodontal
inflammation can result in gingival
recession and attachment loss, especially
with thin anatomy (FIGURE 6 ). Mechanical
trauma may occur as a result of brushing
with a hard toothbrush10 especially with
a vigorous brushing technique and/or
using an abrasive dentifrice (FIGURE 7 ).
Buccal gingival recession is noted more
frequently on the left side of the jaw,
most likely related to the fact that most
people are right-handed and brush more
thoroughly on the left sides of their mouths.
In patients with dentin hypersensitivity,
more gingival recession and sensitivity are
found on the left side of the mouth and the
lowest amount of plaque is seen on teeth
with recession and sensitivity.11 Improper
flossing technique can lead to flossing clefts
in the gingiva (FIGURES 8 ), which may
contribute to gingival recession. Improper
and aggressive use of other interproximal
aids may also lead to mucogingival defects.
Anatomical abnormalities often result
in teeth with a thin phenotype because
C D A J O U R N A L , V O L 4 6 , Nº 1 0
FIGURE 11B . Canines commonly have prominent
roots that exhibit recession.
they are positioned more buccal or lingual
in the alveolar bone (FIGURES 9 ). Such
teeth may incur greater forces during oral
hygiene because they are more prominent
(FIGURE 10 ). Canines and the mesial buccal
root of first molars are often prominent
in the arch and may be subject to heavier
brushing forces contributing to recession
defects (FIGURES 11 ). Patients should
be made aware of these conditions and
educated in proper oral hygiene to reduce
the possibility of gingival recession.
Mechanical trauma leading to gingival
recession may also be the result of oral
piercings. A tongue piercing can rub on
the lingual aspect of the lower incisors
(FIGURE 12 ) and lip piercings may affect
the buccal aspect. Other contributing
factors include chemical erosion from
acid reflux or bulimia (FIGURE 13 ) or
the combined chemical and mechanical
action of smokeless tobacco (FIGURE 14 ).
Gingival recession is typically
the result of several factors but not
necessarily simultaneously or equally.
Disease Progression and
Modifying Factors
Once the putative etiologic contributing
factor(s) and the gingival phenotype have
been identified, the greatest challenge to
the clinician is to define the rate of disease
progression. To define how fast the disease is
progressing, clinical records must provide a
history of the progress of gingival recession.
This may at times prove challenging in
that it would require diligent monitoring of
attachment loss (AL), pocket depth (PD)
and gingival recession (GR). This challenge
has been previously described.12 Each of

FIGURE 12 . Lingual recession on lower
incisors as a result of a tongue piercing rubbing
against the gingival margin.
the aforementioned gingival conditions
will have different parameters changing
depending on the gingival phenotype. For
the thin scalloped phenotype, one would
notice an increase in AL and GR but the
PD will generally remain 2–3 mm deep.
With a thick flat gingival phenotype, one
would note an increase in AL and PD but
GR will not increase until periodontitis
has reached the moderate-advanced
stage associated with tissue recession.
In a thick scalloped phenotype, the
AL and PD will progress at a moderate
rate; once it is past the mucogingival
junction, the rate of progression will
increase quite rapidly for both of these
parameters. In this latter condition, GR
is generally a late disease phenomenon.
Systemic modifying factors that will
affect treatment outcomes include smoking
and uncontrolled diabetes mellitus,
both of which are consistent with poor
wound healing. An important reason
for a less than ideal outcome is smoking.
Miller reported that heavy smoking (≥
10 cigarettes) is highly correlated with
gingival root-coverage failures.13 Poor
wound healing due to uncontrolled diabetes
or immunosuppression can negatively
affect gingival augmentation procedures.14
Systemic and parafunctional habits such
as smoking and health issues that would
compromise wound healing should be
considered in the patient selection process.
Local modifying factors include
patient compliance with treatment
recommendations, poor plaque control
(high localized plaque scores), the
periodontal phenotype for the affected
area, defining if aesthetics is an issue
FIGURE 13 . Acid erosion in a bulimic patient with a
thin phenotype contributed to generalized recession.
and the number of affected areas.
Consideration of these decision-
making factors is further elaborated
on in two recent articles.15,16
Indications for Increasing Keratinized
Tissue Around Natural Dentition
Indications for gingival
augmentation procedures include:
■ The presence of gingival
recession extending to/beyond
the mucogingival junction.
■ Minimal/lack of attached gingiva.
■ Persistence of gingival
inflammation.
■ The need for subgingival placement
of a restorative margin.
■ High frenum attachment associated
with gingival recession.
■ History of progressive
gingival recession.
■ Prerestorative/pre-orthodontic
procedure to increase keratinized
tissue around the treatment area.
It is important for the clinician
to appreciate how the mucogingival
characteristics can influence the rate of disease
progression. The classic study by Lang and
Loe suggested that a minimum of 2 mm of
keratinized gingiva is needed to maintain
gingival health.17 However, in the presence of
good to excellent oral hygiene, it is possible
to maintain periodontal health with minimal
or lack of keratinized gingiva. If there is a lack
of good hygiene, inflammation may occur
and result in progression of the recession.
This study further noted that if restorative
treatment is involved, 5 mm of attached
gingiva composed of 2 mm of free gingiva
and 3 mm of attached gingiva would be ideal.
C D A J O U R N A L , V O L 4 6 , Nº 1 0
FIGURE 14 . A smokeless tobacco habit contributed
to recession and leukoplakia (a).
As recession occurs, there is a decrease in the
width of the attached gingiva. If a restoration
is to be placed onto the root surface, it is
important to first re-establish the normal
gingival contour by correction of the recession
with a gingival graft procedure to reduce the
need for apical extension of the restorative
margin as seen in FIGURE 15. When a
restoration is placed onto the root surface,
it compromises the ability to achieve tissue
attachment to the root and to increase the
keratinized and attached gingiva. Extension
of a restorative margin onto the root also
makes it more difficult to achieve good
marginal fit and aesthetics. A subgingival
margin placed on a tooth surface with a
lack of keratinized gingiva will most likely
result in a biologic width violation such as
that seen in FIGURE 15 , which will result
in further inflammation and recession.
The amount of attached gingiva
necessary for periodontal health has been
debated but it appears to be a function
of the patient’s oral hygiene.18 Therefore,
the presence of a wide band of keratinized
and attached gingiva is advantageous.
Classification of Recession Defects
and Outcome Prediction
Several classifications of tissue
recession have been described in the
literature to assist in diagnosis and
prediction of treatment outcomes.
One of the most widely accepted
classifications was introduced by Miller
in 1985.19 The level of the interproximal
bone and soft tissue are evaluated first
followed by the extent of the recession.
The defect can be classified as a Miller
Class I if there is no loss of interproximal
O C T O B E R 2 0 1 8  621
 gingival recession
FIGURE 15. A biologic width violation most likely
occurred when the crown was placed on tooth No. 5
due to close proximity of the crown margin to the
gingival margin and inadequate attached gingiva,
both of which may result in increased inflammation
and further recession.
bone or tissue and the recession does
not extend to the MGJ (FIGURES 16 ). If
there is no loss of interproximal bone
or tissue and the recession extends
beyond the MGJ, it would be considered
a Miller Class II defect (FIGURES 17 ).
Complete root coverage is often possible
with gingival augmentation performed
on Miller Class I and II defects. Once
interproximal bone and tissue loss
have occurred in conjunction with
recession to or beyond the MGJ, the
predictability of complete root coverage
diminishes. A Miller Class III defect has
minor interproximal attachment loss
(FIGURES 18 ) and may have minor tooth
malpositioning. Partial root coverage
(50–70 percent) can be anticipated
with corrective procedures. If the bone
loss or tooth malpositioning is severe
(FIGURES 19 ), the defect would fall into a
Miller Class IV and less than 10 percent
root coverage would be predicted.
Mucogingival Corrective Treatment
In treatment planning, the clinician
must initially define factors influencing
patient selection for treatment. This
is essential whether the clinician will
be doing the corrective procedure or
referring the case to a specialist. This
initial assessment and conversation
with the patient is essential so that
the patient’s expectation can be set
at a reasonable level in regard to
the complexity of the problem, the
difficulties that may be encountered
622 O C T O B E R 2 01 8
MGJ
FIGURE 16A . Miller Class I recession has no loss
of interproximal tissue and recession does not extend
beyond the mucogingival junction (MGJ).
MGJ
FIGURE 17A . Miller Class II recession extends
beyond the MGJ.
FIGURE 18A . Miller Class III recession; note loss of
interproximal tissue height.
during the corrective procedure and
the anticipated clinical outcome.
Once the etiologic factors have been
identified, it is important to educate
the patient and provide instruction in
any corrective behavior indicated. In
addition to informing patients of their
responsibility, they should be given the
treatment options and alternatives with
expected outcomes. The consequences
of no treatment should be explained so
that patients can make informed decisions
about their treatment. A recent long-
C D A J O U R N A L , V O L 4 6 , Nº 1 0
FIGURE
16B .
No loss of
interproximal
bone.
FIGURE
17B .
No underlying
bone loss.
FIGURE
18B .
Underlying
bone loss.
term study demonstrated that 83 percent
of sites receiving gingival augmentation
maintained a reduction in recession for
up to 35 years and 48 percent of untreated
sites had an increase in recession.20 This
study showed that thin biotypes remain
more stable over time if grafting procedures
are performed to thicken the tissue as
compared to thin biotypes; however,
highly motivated patients can prevent
the development/progression of gingival
recession and inflammation for more than
20 years. FIGURE 20A depicts a young

FIGURE 19A . Miller Class IV recession with loss of
interproximal tissue.
FIGURE 20A . Connective tissue grafting was
recommended for this young patient with a thin
phenotype and lack of keratinized gingiva.
patient with a thin phenotype and a lack
of keratinized gingival. Connective tissue
grafting was recommended but the patient
did not return for one year (FIGURE 20B ),
at which time recession had occurred.
Several treatment modalities exist to
treat gingival recession. These include
gingival grafting techniques utilizing
autogenous tissue, allograft or xenograft
materials. Autogenous grafting may
involve lateral sliding flaps, coronally
positioned flaps or autogenous donor
tissue. In more severe defects, guided
tissue regeneration may be desired.
Orthodontic movement may be
recommended to move malpositioned
teeth into a more desirable location. In
cases with a thin phenotype or existing
mucogingival defect, it is preferable
in most cases to perform gingival
augmentation prior to tooth movement
to prevent initiation or progression of
gingival recession. It is also preferable
to perform corrective treatment prior
to restorative procedures on exposed
root surfaces to allow for new gingival
attachment as coronal as possible.
FIGURE 19B .
Underlying
advanced
bone loss.
FIGURE 20B . No treatment was performed and one
year later there is gingival recession.
Interdisciplinary communication
and collaboration are important to
optimize outcomes for patients.
Conclusion
Gingival recession is a common
periodontal defect. In this review, we
described how to identify gingival
recession that is at risk for further
deterioration, the possible etiologies
involved, the various strategies for the
surgical management and the potential
treatment outcome that may result. Like
many dental and periodontal problems,
early identification will generally result
in a simple correction with a predictable
outcome. Clinicians are encouraged
to train their dental team members,
especially dental hygienists, to identify
recession problems, to be familiar
with the symptomatic complaints that
patients may report and both surgical
and nonsurgical solutions for correcting
these problems. To do so will result in
a more effective periodontal screening
and maintenance program that will
result in better patient care. ■
C D A J O U R N A L , V O L 4 6 , Nº 1 0
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THE CORRESPONDING AUTHOR, Debra S. Finney, DDS, MS, can
be reached at dfinney@folsomperio.com.
O C T O B E R 2 0 1 8  623
 SOFT TISSUE GRAFTING
C D A J O U R N A L , V O L 4 6 , Nº 1 0

Autogenous Soft Tissue

Grafting for the Treatment
of Gingival Recession
Elissa Green, DMD; Soma Esmailian Lari, DMD; and Perry R. Klokkevold, DDS, MS

A B S T R A C T Gingival recession is prevalent. It can adversely affect the health, stability

and appearance of the involved teeth. Exposed root surfaces may be susceptible to caries,
root sensitivity or result in aesthetic concerns. A variety of procedures are described
in the literature for the treatment of gingival recession. This article reviews the use
of autogenous soft tissue grafting for root coverage. Advantages and disadvantages of
techniques are discussed. Case types provide indications for selection and treatment.

AUTHORS

Elissa Green, DMD,
earned a bachelor’s degree
in molecular cell biology at
the University of California,
Berkeley in 2009. She
earned her doctor of dental
medicine degree at Tufts
University in 2015 and
recently completed the
periodontics residency
and a master’s degree
in periodontics and oral
biology at the University of
California, Los Angeles.
Conflict of Interest
Disclosure: None reported.
Soma Esmailian Lari,
DMD, earned a bachelor’s
degree in biomedical
engineering at the University
of California, Los Angeles,
in 2011 and her doctor of
dental medicine degree at
the Western University of
Health Sciences, School
of Dentistry in 2015. She
recently completed the
periodontics residency at
UCLA.
Conflict of Interest
Disclosure: None reported.
Perry R. Klokkevold,
DDS, MS, earned a
doctor of dental science
degree at the University of
California, San Francisco,
in 1986. His postdoctoral
training at UCLA includes
the hospital-based general
practice residency, the
periodontics residency
and the surgical implant
fellowship at UCLA. He
earned a master’s degree
in oral biology concurrently
with his specialty training.
He is a diplomate of
the American Board of
Periodontology and a
fellow of the American
College of Dentists. He is
professor of clinical dentistry
and currently serves as
the periodontics residency
program director at UCLA.
Conflict of Interest
Disclosure: None reported.
G
ingival recession is a
prevalent condition that can
adversely affect the health,
stability and appearance of
the involved teeth. Exposed
root surfaces may increase susceptibility to
caries and root sensitivity and/or result in
aesthetic concerns for the patient. There
are a variety of periodontal plastic surgery
procedures that have been developed and
described in the literature for the treatment
of gingival recession. This article reviews
the use of autogenous soft tissue grafting as
a predictable and effective treatment when
indicated for gingival recession, focusing
on the goal of root coverage. Various
procedures are presented in a historical
context. Advantages and disadvantages
of each technique are discussed and
gingival recession case types are defined to
provide indications and guidelines for case
selection. A completed case with long-
term follow-up is presented to demonstrate
the use of the subepithelial connective
tissue graft with a tunnel approach and
coronally advanced flap as a predicable
technique for aesthetic root coverage.
Introduction
Gingival recession is a prevalent
condition, reported to affect about 50
percent of the adult population aged
18–64 and 88 percent of those over 65
years old.1 It is described as the apical
displacement of the gingival margin
away from the cementoenamel junction
(CEJ) resulting in exposed root structure.
Depending on the extent of periodontal
attachment and bone loss, gingival
recession can adversely affect the health,
stability and appearance of involved teeth.
It may increase susceptibility to caries,
root sensitivity and, based on the location,
gingival recession may cause significant
aesthetic concerns for the patient.
Topical agents are available to reduce
root sensitivity and aid in the prevention
of caries. However, these medicaments
tend to be palliative and do not correct
the anatomical defects. Class V composite
restorations have also been advocated
as a treatment to mask root sensitivity,
correct cervical abrasion, cover dark,
unsightly roots and repair tooth structure
lost to caries or abrasion/abfraction.
O C T O B E R 2 0 1 8  625
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C D A J O U R N A L , V O L 4 6 , Nº 1 0

FIGURE 1B .

However, this treatment fails to correct

the periodontal anatomical defect. The
authors contend that, when possible,
class V composite restorations should be
avoided as a treatment for root coverage FIGURE 1A .
because cervical restorations place margins
in close proximity to or slightly below
the gingival margin and contribute to FIGURE 1D.
increased biofilm accumulation and an
altered subgingival microbiota, which can
perpetuate the inflammatory response.2–4
Diligent biofilm removal and control
of inflammation can prevent further
gingival recession. Surgical correction of
gingival recession with autogenous soft
tissue grafting is indicated for sites that are
FIGURE 1C .
difficult to clean, chronically inflamed,
progressively receding, highly sensitive and/
or aesthetically unacceptable to the patient.
FIGURE 1F.
There are a variety of periodontal
plastic surgery procedures that have been
developed and used to treat gingival
recession as well as other mucogingival
problems such as a lack of keratinized
attached gingiva, a shallow vestibule or an
aberrant frenum attachment.5 Identifying
and selecting appropriate cases for root
FIGURE 1E .
coverage and determining the predictability
of success for a given case depends on a
number of factors including the etiology of
recession, severity of tissue destruction and FIGURE 1H .
control of contributing factors. Selecting
the best procedure to treat gingival
recession will depend on presenting factors.
This article describes the etiology
of gingival recession, reviews the
variety of root-coverage procedures and
provides guidelines for case selection
and treatment of gingival recession. FIGURE 1G.

Etiology of Gingival Recession

The etiology of gingival recession
is primarily attributed to biofilm and/or
trauma-induced inflammation superimposed
on a susceptible anatomy. Namely, teeth
that are prominent in the arch with thin
labial bone and/or soft tissue (i.e., thin
FIGURES 1. Clinical view of Miller Class I recession with radiograph demonstrating good interdental soft tissue and
bone height (1A, 1B). Clinical view of Miller Class II recession with radiograph demonstrating good interdental soft
tissue and bone height (1C, 1D). Clinical view of multiple Miller Class III gingival recessions demonstrating some
loss of interdental soft tissue and bone height (1E, 1F). Notice class V composite restorations with leaking, rough
margins near the gingiva (courtesy of Travis Steinberg, DDS). Clinical view of Miller Class IV recession defect with
radiograph demonstrating severe loss of interdental soft tissue and bone height (1G, 1H).

626 O C T O B E R 2 01 8

periodontal biotype) are more susceptible
to gingival recession than teeth in a normal
or lingual/palatal position with a thick
biotype. Factors that increase the risk
of gingival recession include aggressive
toothbrushing, tooth malposition, alveolar
bone dehiscence, high muscle/frenum
attachment, plaque-induced inflammatory
lesions, iatrogenic habits and factors related
to restorative and periodontal treatments.5,6
Classification of Gingival Recession
In 1985, P.D. Miller published a
classification scheme for gingival recession
and associated the prognosis for root
coverage with each type.7 He correlated
the predictability of therapeutic success
(i.e., root coverage) with the extent of the
recession defect and the height of adjacent
interdental soft and hard tissues. Miller
Class I defects are defined as gingival margin
recession that does not extend beyond
the mucogingival junction with no loss of
interdental tissues. Miller Class II defects
are defined as gingival margin recession
that extends to or beyond the mucogingival
junction with no loss of interdental tissues.
Miller Class III defects are defined as
gingival margin recession that extends to
or beyond the mucogingival junction with
some loss of interdental bone or soft tissues
and/or malpositioning of teeth. Miller Class
IV defects are defined as gingival margin
recession that extends to or beyond the
mucogingival junction with severe loss
of interdental bone or soft tissues and/
or malpositioning of teeth (FIGURES 1 ).
According to Miller, complete root
coverage can be anticipated in Miller Class
I and Miller Class II recession defects where
there is no interproximal attachment loss,
partial root coverage can be expected in
Miller Class III defects where there is some
loss of interproximal bone and soft tissue
height and no root coverage is expected
in Miller Class IV defects where there is
severe interproximal attachment loss.
Root-Coverage Procedures
The methods used to treat gingival
recession have progressively advanced
over time from early basic attempts to
transplant gingival soft tissue from one
site to another to more sophisticated
techniques of creating recipient sites
with an envelope, pouch or tunnel
approach and the use of subepithelial
connective tissue grafts with or without
biologic mediators and biomaterials.
Regardless of surgical techniques or
materials used for root coverage, all
procedures share the common endpoint
While all soft tissue
grafting techniques provide
reduction in gingival
recession, some are more
effective than others.
objective to cover exposed roots
with tissues that are stable, healthy
and aesthetic. In a patient with high
aesthetic demands, obtaining complete
root coverage is the primary objective.8
Secondary objectives, depending on
specific case findings, may be to increase
the amount of keratinized tissue and/
or to decrease dentin hypersensitivity.
Root-coverage procedures must also
result in tissue coverage that is well
adapted and adherent to the previously
exposed root surface. It would be
problematic, and considered a failure,
if the soft tissue grafting resulted in
periodontal pocket formation. The ideal
outcome of soft tissue grafting for root
coverage would be a true regeneration
of the periodontal attachment with
new cementum, periodontal ligament,
C D A J O U R N A L , V O L 4 6 , Nº 1 0
inserting connective tissue fibers and new
bone; this can only be determined with
histology. Although true periodontal
regeneration seems to be an elusive
goal, there is limited human histologic
evidence that it has been achieved
with autogenous soft tissue grafting
over exposed root surfaces.9–12 The
periodontal regeneration achieved in
these cases always formed at the apical
extent of the grafted site from the existing
periodontium with the more coronal
aspect consisting of closely adapted
connective tissue fibers running parallel
to the root surface (i.e., not inserting
perpendicular) and a long junctional
epithelial attachment above it. The
most likely and predominant form
of attachment following autogenous
soft tissue grafting for root coverage
will be an apical zone of connective
tissue adherence with fibers running
parallel to the root surface, little or no
new cementum or bone and a coronal
zone of long junctional epithelial
attachment.13 This attachment will be
predictable and stable long term.14,15
Autogenous soft tissue grafting
techniques are reviewed here in the
order that they were first described in
the literature. Procedures include the
laterally positioned flap16 (Grupe and
Warren, 1956), free gingival grafts17
(Sullivan and Atkins, 1968), free
connective tissue grafts18 (Edel, 1974),
coronally advanced flaps19 (Bernimoulin
et al., 1975), subepithelial connective
tissue grafts in combination with
coronally advanced flaps20 (Langer and
Langer, 1985) and variations of these
techniques. While all soft tissue grafting
techniques provide reduction in gingival
recession, some are more effective
than others. See other articles in this
issue regarding the use of biomaterials,
allografts and biologic mediators as
adjuncts to root-coverage procedures.
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FIGURE 2A . FIGURE 2B . FIGURE 2C .

FIGURES 2 . Miller Class III recession of mandibular central incisor (2A ). There is slight loss of interdental papilla height. Notice the lack of keratinized tissue and high
frenum attachment at the gingival margin. There is also evidence of calculus on the root surface. Recipient site was prepared by de-epithelializing the adjacent tissues and
resecting the mucosa/frenum (2B ). Healed site more than five years later (2C ). Notice the incomplete root coverage with increased zone of keratinized, attached tissue. There
is also a clear color demarcation outlining the free gingival graft.

Laterally Positioned Pedicle Graft

The laterally positioned pedicle
graft technique was introduced by
Grupe and Warren in 1956.6 It utilizes a
split-thickness flap design with vertical
incisions directed apically toward the
recipient site thereby allowing keratinized
tissue from an adjacent location to be
repositioned over an exposed root surface FIGURE 3A . FIGURE 3B .
while remaining attached at the base.
Tissues adjacent to the area of recession
are de-epithelialized with a split-thickness
flap to expose a connective tissue bed
for attachment and nutrients (blood
supply) of the laterally positioned flap.
Tissue survival and root coverage depends
on a flap design with a wide base that
allows good blood supply, adequate
flap (periosteum) release, connective FIGURE 3C . FIGURE 3D.

tissue exposure for blood supply at the
recipient site, intimate adaptation and flap
stabilization with sutures. Advantages of
the laterally positioned pedicle graft are
relative ease of procedure, time efficiency,
excellent aesthetic results and avoidance
of a second surgical site. Disadvantages
are the limited applicability to isolated
recession defects and the possible risk of
creating gingival recession, dehiscence or
fenestration at the adjacent donor site.
There is also a requirement for adequate
keratinized tissue at a neighboring
donor site along with a deep vestibule.
The success rate of the laterally
positioned pedicle graft for root
coverage is limited, ranging from
61 percent to 77 percent.21,22 The
628 O C T O B E R 2 01 8
FIGURES 3 . Miller Class I recession affecting several maxillary incisors (3A ). Split-thickness flap preparation of
recipient site with vertical releasing incisions on the distal aspect of the papilla adjacent to recession defects (3B ).
Periosteum is released at the base of the flap. Coronally advanced flap to cover recession defects (3C ). Flap is
secured coronally with interrupted and mattress sutures. Healed site about six months after surgery. Root coverage
of the treated sites is nearly complete (3D ).
predictability of this technique has Free Gingival Graft
not been evaluated in a systematic The free gingival graft (FGG)
review or meta-analysis. technique was introduced by Sullivan
Variations of the laterally and Atkins in 1968.17 The FGG
positioned flap procedure include is harvested from the surface of a
the double papilla graft (Cohen keratinized area on the palate and placed
and Ross, 1968)23 and the obliquely on a de-epithelialized recipient bed
rotated graft (Pennel et al., 1965).24 at the defect site (FIGURES 2). Survival
It is important to recognize that all of of the graft depends on the intimate
these rotational pedicle grafts work contact of the graft with an adequate
best when the adjacent donor papilla area of exposed connective tissue/
and zone of keratinized tissue is wide. vascular bed and stabilization of the

FIGURE 4A .
F I G U R E S 4 . Miller Class I recession affecting the maxillary premolars, cuspid and lateral incisor (4A ). The maxillary lateral incisor is treated with a semilunar
coronally advanced flap (4B ). Notice the semilunar incision and coronal advancement of the existing tissue to cover the recession defect at the lateral incisor. The
other recession defects are treated with SCTG and pouch technique. Healed sites about four months after surgery (4C ). Root coverage of all sites, including the
lateral incisor, is nearly complete.
graft by sutures. The free gingival graft,
which is separated from its original
blood supply, survives initially via
plasmatic circulation and over time by
neovascularization. Hence, the critical
importance of graft stabilization during
the initial healing phase. Advantages of
this technique are that it is a relatively
less sensitive technique, it can be
applied to both single and multiple
recession defects and it has the potential
to increase the width of keratinized
tissue, deepen the vestibular depth
and modify the periodontal biotype.
Disadvantages are palatal donor sites
that heal by secondary intention with
increased susceptibility to bleeding
and pain and the unfavorable color
match of an FGG at the recipient
site. Thin free gingival grafts are
susceptible to necrosis and sloughing
while thick free gingival grafts have
higher survival rates but result in deeper,
slow-healing donor sites. Thicker
grafts also tend to be more noticeable
at the recipient site after healing.
The success rate of this root-coverage
procedure is limited, ranging from
12 percent to 66 percent, with mean
root coverage of 41 percent for thin
grafts.25–27 The success rate is higher
for thicker grafts (≥ 2mm) ranging
from 39 percent to 100 percent with a
mean root coverage of 69 percent.28–31
Predictability data indicates that 90
percent or greater root coverage was
achieved only 16 percent of the time.25,27
FIGURE 4B .
Free Connective Tissue Graft
The free connective tissue graft
technique was introduced by Edel in
1974.18 Similar to the free gingival graft,
the free connective tissue graft was utilized
to increase the width of keratinized
tissue with less donor site morbidity and
improved aesthetics. The procedure is
performed identically to the traditional
free gingival graft at the recipient site but
varies at the donor site where subepithelial
connective tissue is harvested from below
the surface rather than harvesting the graft
with the surface epithelium. The primary
advantage of this technique is the ability
to obtain wound closure at the donor site
resulting in less postoperative discomfort
to the patient. This technique also
provides enhanced aesthetics compared to
the FGG due to improved color matching
with the adjacent tissues because the
epithelium grows over the graft from
the recipient site. This technique can
be used for the same applications as the
FGG because the genetic specificity for
keratinization comes from the dense
connective tissue close to the epithelial
layer.32 The connective tissue must be
harvested from beneath a keratinized
zone of epithelium. Disadvantages of the
free connective tissue graft may include
more shrinkage at the recipient site and
more susceptibility to surface necrosis
due to a lack of epithelial covering.
The success rate and predictability
of free connective tissue grafts for root
coverage has not been reported. However,
C D A J O U R N A L , V O L 4 6 , Nº 1 0
FIGURE 4C .
as with FGGs, the free connective tissue
graft for root coverage probably has limited
success due to the lack of blood supply
over the root surface and limited blood
supply from only one side (recipient bed)
of the graft. For this reason, various flap
techniques have been developed and
described to cover free connective tissue
grafts for better circulation and graft
survival. See the section on subepithelial
connective tissue grafts on page 630.
Coronally Advanced Flap
The coronally advanced flap
(CAF) is a form of pedicle graft that
was introduced by Bernimoulin et al.
in 1975.19 This procedure does not
require a palatal donor site. It can be
used to treat shallow recession defects
(≤ 4 mm) when the existing tissue
biotype is thick (≥ 1 mm) and a broad
zone of keratinized tissue (≥ 3 mm)
exists apical to the recession defect. The
flap design is created with two vertical
incisions on the papillae adjacent to the
recession area and reverse-bevel sulcular
incisions along the gingival margin.
These incisions are connected with two
horizontal, reverse-bevel incisions made
in the papillae adjacent to the recession
defect. The coronal surface of the
adjacent papillae are de-epithelialized
over a length that is equivalent to
the depth of the gingival recession.
A full-thickness flap is elevated. The
periosteum of the flap is released at
the base with a horizontal incision
O C T O B E R 2 0 1 8  629
 SOFT TISSUE GRAFTING
FIGURE 5A .
FIGURES 5 . Free gingival graft donor site (5A ). Free gingival graft harvested (5B ). Donor site healing at one week (5C ).
and the flap is coronally positioned to
cover the recession. Alternatively, a
partial-thickness flap can be used. Tissue
adjacent to the area of recession is de-
epithelialized with a split-thickness flap
to expose connective tissue and provide
a blood supply for the advanced flap.
The coronally advanced flap is sutured
at a level to cover exposed root surfaces
(FIGURES 3 ). This procedure can be
applied at single or multiple recession
sites with adequate keratinized tissue
apical to the root exposure. With this
approach, the soft tissue used to cover
the root exposure is similar in color,
texture and thickness to that originally
present at the labial aspect of the tooth
with the recession defect, providing a
satisfactory aesthetic result. Advantages
of the coronally advanced flap procedure
include relative ease, good aesthetics
and no secondary donor site required.
Disadvantages are that this procedure
does not increase the zone of keratinized
tissue and may be susceptible to flap
retraction and relapse of the recession if
the flap is not adequately released and
sutured. The CAF procedure cannot
be used if there is a lack of keratinized
tissue, a cleft through the gingival
margin, a high frenum attachment at the
gingival margin or a shallow vestibule.
The coronally advanced flap
procedure for root coverage was shown
to be successful with mean root coverage
of 79 percent.33 Predictability data
showed that complete root coverage was
achieved 40 percent of the time.34,35
630 O C T O B E R 2 01 8
FIGURE 5B .
Semilunar Coronally Advanced Flap
Several variations of the coronally
advanced flap have been proposed.
Tarnow described the semilunar
coronally repositioned flap in 1986.36
This technique uses a semilunar
incision that is parallel to the gingival
margin above the recession defect.
A split-thickness incision is made
through the sulcus to elevate and
coronally advance the tissue over the
denuded root (FIGURES 4 ). Advantages
include no tension, no shortening of
the vestibule and no manipulation of
interdental papilla. Disadvantages are
similar to the CAF procedure. Namely,
it does not increase the zone of
keratinized tissue, may be susceptible
to retraction and cannot be used in
cases with a gingival cleft, high frenum
attachment or shallow vestibule.
Modified Coronally Advanced Flap
De Sanctis and Zucchelli (2007)
proposed a modified surgical approach of
split-full-split-thickness flap compared
to the conventional CAF procedure
with vertical releasing incisions for
the treatment of localized gingival
recessions.37 For multiple recession types,
Zucchelli and de Sanctis (2000, 2007)
presented further changes to the CAF
procedure to improve the predictability
of multiple recession-type defects.38,39
The authors proposed the use of a
horizontal incision and a split-full-split
approach to create an “envelope flap”
with no vertical releasing incisions in
C D A J O U R N A L , V O L 4 6 , Nº 1 0
FIGURE 5C .
order to preserve the maximum soft tissue
thickness above the root exposure. This
incision should be extended laterally
to include at least one adjacent tooth
on each side of the gingival recession.
Subepithelial Connective Tissue Graft
With Flap Coverage
The use of a “submerged” subepithelial
connective tissue graft (SCTG) for root
coverage was originally introduced by
Langer and Langer in 1985.20 The technique
utilized an SCTG and split-thickness CAF
with releasing vertical incisions that is
repositioned over the connective tissue
graft to partially cover it. Advantages of
this technique are the dual blood supply
contributing to the high predictability
and improved aesthetics compared to the
free gingival graft or the free connective
tissue graft. The SCTG with CAF provides
more tissue thickness than the CAF alone.
Furthermore, harvesting SCTG from
the donor site involves less postoperative
morbidity as compared to the donor site for
free gingival grafts. In situations where the
overlying flap does not completely cover
the connective tissue, the exposed tissue
becomes keratinized thereby potentially
increasing the zone of keratinized tissue.
The disadvantage of this technique is the
use of vertical releasing incisions, which
may compromise vascularization in wound
healing and result in fibrotic scars.
Following the introduction of the
original Langer and Langer technique,
several modifications of the recipient
site preparation have been proposed.

FIGURE 6A .
FIGURES 6 . Strip gingival autograft donor site (6A ). Strip gingival grafts (6B ). Donor site healing at one week (6C ). Notice the shallow depth and rapid
re-epithelialization as compared to the typical FGG donor site.
Envelope flaps were introduced to avoid
the use of vertical incisions with the SCTG
either completely covered or left partially
exposed.40 Further modifications include
combining the free connective tissue graft
with partial- or full-thickness flaps, single-
tooth tunnel or pouch technique, subpedicle
flaps and double papilla pedicle flaps.41
All of these techniques offer a bilaminar
blood supply increasing the chance for
revascularization of the graft and complete
root coverage. In 2005, Harris compared
various recipient site flap designs used to
cover SCTG and found them all to be
equally effective in obtaining root coverage
and improving clinical parameters.42
Another bilaminar technique using a
dual blood supply was introduced by Zadeh
in 2011.43 He proposed a variation of the
SCTG that used a midline vestibular
incision and subperiosteal tunnel approach
(VISTA) to prepare the recipient site.
The VISTA technique utilizes a vertical
incision in the vestibule, away from the
recession area, to provide access for full-
thickness, tension-free soft tissue elevation
and insertion of graft materials (i.e.,
subepithelial connective tissue or acellular
dermal matrix). The outer “flap” tissue is
coronally advanced along with the graft
and stabilized with suspensory sutures that
are tacked to the crowns with composite.
Subepithelial connective tissue grafts
with flap coverage have clearly been
established as a highly effective means of
covering recession defects providing the
most significant gains in root coverage
and the greatest long-term stability.44 It is
FIGURE 6B .
reported to be a highly successful method
with mean root-coverage outcomes of
91.1 percent and 95.8 percent for molar
and non-molar sites, respectively.45,46
Predictability data indicates that complete
root coverage and long-term success of
the SCTG with flap coverage for Miller I
and II recession defects is 98.4 percent.47
This is the gold standard for root coverage
in terms of predictability, percentage
of coverage and long-term stability.
See the following case presentation.
Recipient Site Considerations
Recipient Site Preparation
Recipient site preparation includes
soft tissue flap design and root surface
treatment. The primary purpose of the
recipient site soft tissue flap preparation
is to expose stable connective tissue that
serves to provide nutrients (blood supply)
and an area for attachment (suturing and
healing) of the graft. In the case of free
gingival grafts or free connective tissue
grafts, the recipient site is prepared by
dissecting the epithelium, connective tissue
and muscle fibers, leaving the periosteum
as the base. The recipient bed should be
nonmobile. It should be even and the
donor tissue should be well adapted to
prevent blood pooling, which can lead to
a hematoma and subsequent necrosis.17 In
the case of subepithelial connective tissue
graft with flap coverage, the recipient site
is prepared by elevating a full- or partial-
thickness flap with or without vertical
incisions and repositioning the flap over
C D A J O U R N A L , V O L 4 6 , Nº 1 0
FIGURE 6C .
the graft either completely or partially. In
the case of a tunnel or pouch technique,
incisions are made through the sulcus and
horizontal incisions across interdental
papilla are avoided; the flap is extended
beyond the mucogingival junction and
under each papilla to allow passive, tension-
free coronal mobilization of the overlying
flap. The tissues are less likely to retract
when using this flap design because the
interdental tissues are not severed. Incisions
and flap reflection are accomplished
entirely through the gingival sulcus.
The etiology of the lesion must be
identified and addressed prior to surgical
therapy. This may include the removal
and control of biofilm, modification of
oral hygiene techniques, orthodontic
tooth movement, surgical reduction of
prominent root surfaces and complete
removal of class V restorations.
Root surfaces must be thoroughly
cleaned prior to surgical preparation of
the recipient site. Typically, roots are
scaled and root planed. Root surface
biomodification may be performed,
although the clinical benefit is unclear.48
The purpose, in conjunction with
scaling and root planing, is to remove
the smear layer, expose collagen fibers
within the dentin and eliminate any toxic
substances on the root surface. Citric acid,
tetracycline, sodium hypochlorite and
ethylenediaminetetraacetic acid (EDTA)
are chemical agents commonly used to
remove the smear layer and prepare the
root surface. The use of lasers to clean
and prepare root surfaces has also been
O C T O B E R 2 0 1 8  631
 SOFT TISSUE GRAFTING
reported but without advantages.49,50
In fact, root surface biomodification
with the Nd:YAG laser was found to
be detrimental to the success of root-
coverage procedures.49 No particular root
surface biomodification technique has
been shown to produce any advantage
over another, including no treatment.51
Donor Site Considerations
Donor Site: Harvesting Free
Gingival Graft
The free gingival graft must be
harvested from an area of keratinized
epithelium with a dense lamina propria.
This can include edentulous ridge tissue,
attached gingiva and palatal mucosa.17
A minimum palatal thickness of 3 mm
is recommended for this technique.
Graft thickness relates to graft survival,
shrinkage and appearance. Thinner grafts
blend better than thicker grafts but may
not survive as well over root surfaces.
An FGG for root coverage requires a
thicker graft than for gaining attached
gingiva.52 Overall, a graft thickness
of 1–1.5 mm has been reported to be
functionally optimal5 (FIGURES 5 ).
The strip gingival autograft technique
has been described as a technique to
address the disadvantage of large, slow
healing palatal donor sites with the
traditional FGG.53,54 Donor tissue is
harvested in thin and narrow (2 mm
wide) strips from multiple separate
sites to create small, shallow donor site
wounds with more wound edges and
less exposed connective tissue area for
rapid epithelialization and decreased
discomfort for the patient (FIGURES 6 ).
This technique cannot be used for root
coverage because the donor tissue is
too thin to survive over root surfaces;
it may be used in combination with
a subsequent coronally advanced flap
procedure to cover exposed roots.
632 O C T O B E R 2 01 8
FIGURE 7A .
FIGURE 7C .
FIGURES 7. Trap door technique donor site with vertical incisions at both ends (7A ). Harvesting SCTG from trap
door (7B ). SCTG harvested from trap door (7C ). Trap door donor site sutured with mattress and interrupted sutures (7D ).
Donor Site: Harvesting Subepithelial
Connective Tissue Graft
There are important anatomical
structures that must be considered when
electing to harvest SCTGs from the
palate. The depth of the palatal vault
must be evaluated prior to surgery. The
primary concern is violation of the
neurovascular bundle that extends from
the greater palatine foramen anteriorly
in the palatal vault. It has been reported
that the greater palatine vascular bundle
is located 7 mm apical to the free gingival
margin in shallow palates, 12 mm apical to
the free gingival margin in average palates
and 17 mm apical to the free gingival
margin in steep palates.55 In shallow
palates, the harvest site must be restricted
to a position closer to the teeth and
limited in depth. The optimal location
for harvesting SCTGs is palatal to the
maxillary premolars and first molar sites.
Harvesting of SCTGs must be limited to
the depth that avoids injury to the major
vessels. Based on the estimated position
C D A J O U R N A L , V O L 4 6 , Nº 1 0
FIGURE 7B .
FIGURE 7D.
of the greater palatine artery in 198
periodontally healthy individuals, it was
determined that it is possible to harvest a
connective tissue graft measuring 5 mm
in height for all cases and approximately
8 mm in height for 93 percent of cases in
the premolar region.56 Direct evaluation
of the greater palatine artery in 41 human
cadavers confirmed that it is possible to
harvest a connective tissue graft measuring
at least 5 mm in height.57 Palatal tissue
thickness is thinner in younger individuals
and females as compared to older
individuals and males, respectively. The
amount of tissue that can be harvested
varies depending on the height of the
palatal vault and thickness of tissue.56,58
There are multiple methods for the
harvesting of subepithelial connective tissue
grafts. The overall goals are to achieve a
graft of desired dimensions while respecting
anatomical landmarks and minimizing tissue
sloughing during healing. The overlying
flap tissue must remain thick enough to
survive and to be sutured adequately for

FIGURE 8A .
FIGURES 8 . Parallel incision technique donor site (8A ). SCTG harvested from parallel incisions (8B ). Parallel incision donor site sutured with mattress sutures (8C ).
(Photos courtesy of Charlene Pham, DDS, UCLA periodontics resident.)
FIGURE 9A .
FIGURES 9. Single-incision technique donor site. SCTG harvested from single incision (9A ). Single-incision donor
site sutured with mattress sutures (9B ). Notice primary closure achieved with this technique.
stabilization. Flap designs for harvesting
SCTGs include trap door, parallel
incisions and single-incision approaches.
The trap door technique, advocated
by Edel,18 uses a horizontal incision
parallel to the gingival margin and vertical
releasing incisions at one or both ends. A
partial thickness flap is raised (FIGURES 7 ).
This technique is easier to use because it
creates increased access to the underlying
connective tissue. However, the vertical
incision interrupts the vascular supply,
which predisposes the tissue to sloughing,
especially if the flap is too thin.
The parallel incision technique,
introduced by Langer and Langer,20 uses a
horizontal incision made 2–3 mm apical
to the gingival margin of the maxillary
teeth perpendicular to the palatal surface.
A second parallel incision is made 1–2 mm
apically but directed parallel to the long
axis of the teeth to create a split thickness
flap to harvest a connective tissue graft with
an epithelial collar (FIGURES 8 ). Raetzke
introduced a similar procedure with two
FIGURE 8B .
FIGURE 9B .
incisions that converged at each end to
harvest a CTG wedge with an epithelial
collar.40 Alternatively, Harris developed
a double-blade knife to create parallel
incisions between the palatal surface
and the bone with a single stroke, which
helps to harvest a graft of uniform 1.5 mm
thickness.59 Internal vertical incisions are
required at the mesial and distal ends to
join the incisions. A horizontal incision
is then made at the base to release the
graft apically. The graft is removed with
a narrow collar of epithelium, which can
be excised after harvesting if desired. Due
to the removal of epithelium with the
graft, complete primary closure of the
palatal wound is not predictably obtained
(i.e., there is usually a 1–2 mm gap of
exposed connective tissue after closure).
The single-incision technique,
introduced by Hurzeler and Weng,60
uses a single horizontal incision made
perpendicular to the palatal tissue surface
2–3 mm apical to the gingival margin of
the maxillary teeth (FIGURES 9 ). A partial
C D A J O U R N A L , V O L 4 6 , Nº 1 0
FIGURE 8C .
thickness dissection is made within this
incision, leaving adequate flap thickness
to minimize sloughing. The incisions are
extended as long and apically as needed
for the desired graft size while respecting
anatomical limitations. The connective
tissue is then elevated from the bone
with a blunt instrument for a graft of
maximum thickness with periosteum or
with a second incision closer to the bone
for a graft of desired thickness without
periosteum. Internal vertical incisions are
required at the mesial and distal ends to
join the incisions. A horizontal incision is
then made at the base to release the graft
apically. The advantage of this technique
compared to the parallel incision
technique is primary closure of the palatal
wound, which allows for accelerated
healing and decreased patient discomfort.
Once a graft is harvested, it must be
kept in a sterile, moist environment and
should be sutured to the recipient bed as
soon as possible with resorbable sutures.
Case Presentation
A 42-year-old healthy female
presented with the complaint of
moderate to severe gingival recession
affecting most of her maxillary teeth.
She wanted to improve her smile as she
did not like the uneven tooth length
and gingival asymmetry (FIGURES
10 ). She also complained about root
sensitivity. The most likely etiology of
the gingival recession was trauma from
aggressive toothbrushing habits with
a medium- or stiff-bristled brush on a
susceptible, thin periodontal biotype
with labially prominent teeth. Biofilm
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