The healthy soft tissue surrounding the natural dentition is composed of the gingiva and alveolar mucosa, which are clearly demarcated into clinically identifiable zones. The free gingiva begins at the gingival margin, which is normally located 1 to 3 mm coronal to the cemento-enamel junction and extends to the base of the gingival sulcus. The attached gingiva refers to the tissue that is firmly bound by Sharpey’s fibers to the cementum of the tooth and underlying bone and begins at the base of the gingival sulcus in health—or periodontal pocket in disease—and extends to the mucogingival junction. The apical migration of the gingival margin results in gingival recession, which may lead to root exposure that not only may be aesthetically unacceptable to the patient, but more importantly, is always accompanied by bone loss. This migration can also result in tooth sensitivity, difficulty in plaque removal, root caries, and cervical abrasion and erosion. Gingival recession is a common clinical finding that affects almost 90% of the American population.1
(1) Areas of minimal or no attached gingiva where the movable alveolar mucosal margins interfere with plaque control. These areas become chronically inflamed and may be further compromised by a frenum pull or shallow vestibule.9,10
(2) Areas of progressive recession.4,11
(3) Areas in which orthodontic procedures may position the roots of a tooth in a prominent part of the arch, or when a tooth is tipped lingually, resulting in buccal displacement of the roots.12
(4) Areas where there is a need for restorative treatment, and the margins of the restorations will be placed subgingivally and impinge upon the biologic width of connective tissue attachment.13 It is generally accepted that 5 mm of keratinized gingiva are required prior to restorative procedures (2 mm is the average width of the free gingiva plus approximately 3 mm of attached keratinized gingiva). Soft-tissue grafting procedures may also be indicated if the clasps of a removable prosthesis irritate the marginal tissues.14
(5) Areas where recession presents an aesthetic concern to the patient.
(6) Areas where root exposure has resulted in tooth sensitivity.
In younger patients who present with any of the factors mentioned above (especially orthodontics), soft-tissue grafting should be considered to help reduce future complications.
GINGIVAL GRAFTING TECHNIQUES
(1) Free Gingival Graft
The free gingival graft is an autograft obtained from a palatal donor site, an edentulous ridge, or tuberosity. After transplantation to the recipient site, the graft benefits from plasmic diffusion from the adjacent tissue. This helps sustain the graft over avascular root surfaces. The graft’s connective tissue will determine the surface appearance of the new gingiva. If it is obtained from the palate, the mature graft may resemble palatal tissue, resulting in aesthetic complications.19,20
Case Report No. 1
|Figure 1. Preoperative view of the mandibular anterior sextant in a patient requiring orthodontic treatment. Note recession and lack of attached gingiva associated with tooth No. 24.||
Figure 2. Free gingival graft secured in position.
A 19-year-old female patient presented for a periodontal evaluation prior to orthodontic treatment. Of concern was the lack of attached gingiva in the area of tooth No. 24. The remainder of the sextant had a very thin layer of keratinized attached gingiva that could be susceptible to recession, especially if the roots of the teeth were to be torqued buccally during the orthodontic treatment (Figure 1). After preparing the recipient bed for the free gingival graft, the donor tissue was harvested from the palate (Figure 2). The free gingival graft was secured using interrupted sutures and periosteal sling sutures. The graft must remain immobile and firmly bound to the periosteum (Figure 3). Two years after treatment, the increased zone of keratinized attached gingiva has protected the roots of the mandibular anterior teeth from dehiscences or fenestrations that could result from buccal displacement of the roots during orthodontic movement (Figure 4).
(2) Subepithelial Connective Tissue Graft
The subepithelial connective tissue graft (SCTG) is one of the most versatile and predictable periodontal plastic surgical procedures. It consists of a bilaminar reconstruction of the gingiva using both free and pedicle connective tissue layers to preserve graft viability over denuded root surfaces.24-27 Because of the dual blood supply to the graft (from the underlying connective tissue and the overlying flap), the SCTG results in improved root coverage.28 The results are limited by the amount of avascular root surface and the interdental periodontal attachment levels.18 Based on Miller’s classification, virtually 100% root coverage can be anticipated in class I and class II defects where there is no interproximal loss of bone or gingiva, but is limited in class III and IV defects where there is interdental periodontal attachment loss.18
Case Report No. 2
|Figure 3. One-week postoperative view of the palatal donor site. Because the surface epithelium was removed with the graft, the site is healing through secondary intention.||Figure 4. Two-year postoperative view of graft. Complete root coverage is observed. Note “patch-like” appearance of graft and rugae transplanted with the palatal tissue.|
|Figure 5. Preoperative view of area of recession associated with teeth Nos. 5 and 6.||Figure 6. Partial thickness flap elevation at the recipient site.|
|Figure 7. Primary intention closure and suturing of palatal flap after removal of connective tissue graft.|
A 27-year-old female patient presented with complaints of temperature sensitivity and aesthetic concerns in the areas of gingival recession. Teeth Nos. 5 and 6 had gingival recession and tooth No. 6 had a minimal zone of attached gingiva (Figure 5). The patient did not have any interproximal bone loss, the interdental gingival level was normal, and the recession did not extend beyond the mucogingival junction (Miller class I). Complete root coverage could therefore be anticipated.
(3) Acellular Dermal Connective Tissue Allografts
The acellular dermal connective tissue (ADCT) allograft permits grafting multiple sites without the need for a donor tissue surgical site. This results in decreased discomfort and morbidity associated with the donor surgical site. Human clinical studies have shown that connective tissue allografts result in root coverage comparable to autogenous tissue grafts.29-32
The ADCT allograft can be used as a flap extender over bone grafts and extraction sockets, and can also be used for ridge augmentation, to increase the depth of the vestibule, and for soft-tissue augmentation around dental implants.
Case Report No. 3
|Figure 8. Interpositional SCTG placed on recipient site and covered with a gingival flap.||Figure 9. Complete root coverage and enhanced gingival aesthetics observed 8 months after grafting.|
|Figure 10. Preoperative view of patient with advanced recession on the buccal surface of teeth Nos. 8 and 9.||
Figure 11. The flap was coronally advanced to cover the connective tissue allograft and sutured in place with interrupted sutures.33
|Figure 12. Nine months postoperative healing.|
A 26-year-old male patient presented with advanced recession on the buccal aspect of teeth Nos. 8 and 9. The recession extended to or beyond the mucogingival junction, but there was no loss of interdental bone or soft tissue (Miller classification class II)18 (Figure 10). The site was prepared, a gingival flap elevated, and an acellular dermal connective tissue allograft was placed on teeth No. 8 and 9. The graft was sutured in place with resorbable, single, interrupted 5.0 sutures, and the gingival flap was coronally re-positioned to cover the graft (Figure 11). At 9 months, there was complete root coverage and maturation of the graft (Figure 12).
Most studies indicate that with adequate plaque control, minimal to no attached gingiva may be maintained in a state of health over long periods of time.2,5,7,8 However, there are clear indications for augmenting the zone of keratinized gingiva. Numerous periodontal plastic surgical procedures have been developed to correct mucogingival defects and to increase the zone of keratinized attached gingiva. Three of the commonly used procedures—the free gingival graft, the subepithelial connective tissue graft, and acellular dermal connective tissue allograft procedures—were described. Each procedure has clear advantages and disadvantages that need to be evaluated according to the patient’s needs. In addition, all procedures are limited by the amount of avascular root surface, the height of the interproximal papillae, and the alveolar bone. Moreover, several mucogingival conditions may occur concurrently, necessitating the consideration of combining or sequencing surgical techniques.
The author would like to thank Drs. Vincent Iaconno and Barry Wagenberg for their editorial contributions, and Dr. Louis F. Rose for providing Figures 10 to 12.
- Miller A, Brunelle J, Carlos J, et al. Oral Health of United States Adults: The National Survey of Oral Health in U.S. Employed Adults and Seniors, 1985-1986: National Findings. Bethesda, Md: US Dept of Health and Human Services, Public Health Service; 1987. NIH publication 87-2868.
- Lang NP, Loe H. The relationship between the width of keratinized gingiva and gingival health. J Periodontol. 1972;43:623-627.
- Hangorsky U, Bissada NF. Clinical assessment of free gingival graft effectiveness on the maintenance of periodontal health. J Periodontol. 1980;51:274-278.
- de Trey E, Bernimoulin JP. Influence of free gingival grafts on the health of the marginal gingiva. J Clin Periodontol. 1980;7:381-393.
- Wennstrom JL. Lack of association between width of attached gingiva and development of soft tissue recession. A 5-year longitudinal study. J Clin Periodontol. 1987;14:181-184.
- Wennstrom J, Lindhe J. Plaque-induced gingival inflammation in the absence of attached gingiva in dogs. J Clin Periodontol. 1983;10:266-276.
- Salkin LM, Freedman AL, Stein MD, et al. A longitudinal study of untreated mucogingival defects. J Periodontol. 1987;58:164-166.
- Freedman AL, Green K, Salkin LM, et al. An 18-year longitudinal study of untreated mucogingival defects. J Periodontol. 1999;70:1174-1176.
- Gottsegen R. Frenum position and vestibule depth in relation to gingival health. J Oral Surg (Chic). 1954;7:1069-1078.
- Gorman WJ. Prevalence and etiology of gingival recession. J Periodontol. 1967;38:316-322.
- Baker DL, Seymour GJ. The possible pathogenesis of gingival recession. A histological study of induced recession in the rat. J Clin Periodontol. 1976;3:208-219.
- Maynard JG Jr, Ochsenbein C. Mucogingival problems, prevalence and therapy in children. J Periodontol. 1975;46:543-552.
- Ericsson I, Lindhe J. Recession in sites with inadequate width of the keratinized gingiva. An experimental study in the dog. J Clin Periodontol. 1984;11:95-103.
- Maynard JG Jr, Wilson RD. Physiologic dimensions of the periodontium significant to the restorative dentist. J Periodontol. 1979;50:170-174.
- Friedman N. Mucogingival surgery. Tex Dent J. 1957;75:358-362.
- Bjorn H. Free transplantation of gingival propria. Odontol Revy. 1963;14:523.
- King K, Pennel B. Evaluation of attempts to increase the width of attached gingiva. Presented at the Philadelphia Society of Periodontology; 1964.
- Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent. 1985;5(2):8-13.
- Karring T, Lang NP, Loe H. Role of connective tissue in determining epithelial specificity. J Dent Res. 1972;51:1303-1304.
- Karring T, Lang NP, Loe H. The role of gingival connective tissue in determining epithelial differentiation. J Periodontol Res. 1975;10:1-11.
- Nabers JM. Free gingival grafts. Periodontics. 1966;4:243-245.
- Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Principles of successful grafting. Periodontics. 1968;6:121-129.
- Sullivan HC, Atkins JH. Free autogenous gingival grafts. III. Utilization of grafts in the treatment of gingival recession. Periodontics. 1968;6:152-160.
- Nelson SW. The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol. 1987;58:95-102.
- Langer B, Calagna L. The subepithelial connective tissue graft. J Prosthet Dent. 1980;44:363-367.
- Langer B, Calagna LJ. The subepithelial connective tissue graft. A new approach to the enhancement of anterior cosmetics. Int J Periodontics Restorative Dent. 1982:2(2):22-33.
- Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol. 1985;56:715-720.
- Harris RJ. Root coverage with connective tissue grafts: an evaluation of short- and long-term results. J Periodontol. 2002;73:1054-1059.
- Harris RJ. A comparative study of root coverage obtained with an acellular dermal matrix versus a connective tissue graft: results of 107 recession defects in 50 consecutively treated patients. Int J Periodontics Restorative Dent. 2000;20:51-59.
- Aichelmann-Reidy ME, Yukna RA, Evans GH, et al. Clinical evaluation of acellular allograft dermis for the treatment of human gingival recession. J Periodontol. 2001;72:998-1005.
- Henderson RD, Greenwell H, Drisko C, et al. Predictable multiple site root coverage using an acellular dermal matrix allograft. J Periodontol. 2001;72:571-582.
- Wei PC, Laurell L, Geivelis M, et al. Acellular dermal matrix allografts to achieve increased attached gingiva. Part 1. A clinical study. J Periodontol. 2000;71:1297-1305.
- Alloderm acellular tissue. Available at http://www.biohorizons.com/alloderm.htm. Accessed on June 8, 2004.
- Harris RJ. Root coverage with a connective tissue with partial thickness double pedicle graft and an acellular dermal matrix graft: a clinical and histological evaluation of a case report. J Periodontol. 1998;69:1305-1311.
- Harris RJ. Clinical evaluation of 3 techniques to augment keratinized tissue without root coverage. J Periodontol. 2001;72:932-938.
- Paolantonio M, Dolci M, Esposito P, et al. Subpedicle acellular dermal matrix graft and autogenous connective tissue graft in the treatment of gingival recessions: a comparative 1-year clinical study. J Periodontol. 2002;73:1299-1307.
- Tal H, Moses O, Zohar R, et al. Root coverage of advanced gingival recession: a comparative study between acellular dermal matrix allograft and subepithelial connective tissue grafts. J Periodontol. 2002;73:1405-1411.
Dr. Minsk received her degree from Temple University School of Dentistry. She completed advanced graduate training in periodontics at the University of Pennsylvania School of Dental Medicine, and then a 1-year fellowship in implant dentistry at the University of Pennsylvania Implant Center. She is a diplomate of the American Board of Periodontology. Dr. Minsk is clinical assistant professor of periodontics at the University of Pennsylvania School of Dental Medicine. She maintains a private practice limited to periodontics and implant dentistry. She can be reached at email@example.com.