Root Coverage Procedures in the Treatment of Gingival Recession
Hend AL-Harbi, BDS , Nadir Babay, DDS,MS, DESM
Introduction:
Gingival recession can be defined as the displacement
of the gingival margin apical to the cementoenamel
junction. Exposition of the radicular surface of the
tooth due to destruction of the marginal gingival and of
the epithelial attachment that will be reestablished at a
more apical position. Its prevalence among periodontal
patients is high due to disease progression and
mechanical trauma as a result of improper use of oral
hygiene tools e.g. vigorous brushing. Buccal recessions
are most common and more advanced at single-rooted
teeth than at molars. Root coverage, 100% or partial, is
possible in Class I-III gingival recession Aesthetic
concerns are usually the reason to perform many
surgical techniques to correct labial, gingival recession
defects. Hypersensitivity and changing the tomography
of the marginal soft tissue in order to facilitate plaque
control are also indications for root coverage
procedures.
Classification of Gingival recession by Miller (1985):
Etiology:
•Uneven atrophy of the gingival margin
•Calculus deposits
•Trauma caused by tooth brushing
•Gingival lesions associated with plaque
•Direct trauma (accident, fingernails)
Predisposing Factors:
•Inadequate attached gingiva
•Malpositioning of the teeth
•Orthodontic Movements
Contraindication:
free gingival graft:
- Extensive gingival recession
- Esthetic cases
Connective tissue graft:
- High predictability
- Graft receives abundant blood supply from 2 sources
- Wound closed at palatal donor site after harvest of connective
tissue graft
- Esthetically pleasing results
- Applicable for gingival recession on multiple teeth
Case of free gingival graft:
Cl.I: Marginal tissue recession which does not extend to the
mucogingival junction
- No periodontal bone loss in the interdental area
Criteria for successful root coverage:
•Gingival margin is on the CEJ.
•Depth of gingival sulcus is within 2 mm.
•No bleeding on probing
•No hypersensitivity
•Esthetically harmonious color match with adjacent tissue
Discussion and Conclusion:
The factor most influencing the result is blood supply to the
grafted tissue. The pedicle soft tissue graft technique allows
for possible root coverage in retaining good apical blood
supply.
The free gingival graft procedure ensures thickness and
keratinization which provides a suitable housing for the
gingival margin of a tooth or crown.
The subepithelial connective tissue graft combines the
features of the pedicle and the free gingival graft.
Connective tissue grafts receives abundant blood supply from
two sources (the periostium and the overlaying flap) which
gives high predictability and successful root coverage. In
comparison to a typical free gingival graft, a connective tissue
graft produces more esthetic results and its palatal donor sites
are less invasive.
Cl.II: Marginal tissue recession which extends to or beyond the
mucogingival junction
- No periodontal loss in the interdental area
Disadvantages
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Cl.III: Marginal tissue recession which extends to or beyond the
mucogingival junction
- Bone or soft tissue loss in the interdental area or
malpositioning of the teeth, preventing 100% root coverage
Poor ability to provide blood supply to the graft for root coverage
Exposed deep and large wound on the palatal mucosa
Inferior esthetic results due to scarring
Surgery required in 2 areas
Case of connective tissue graft:
The overall aesthetic outcome depends on final color and
tissue blend of the grafted area. Nevertheless, careful decision
making prior to root coverage procedures will enhance the
success rate for these efforts.
Cl.IV: Marginal tissue recession which extends to or beyond the
mucogingival junction
- Severe bone or soft tissue loss in the interdental area and/or
malpositioning of teeth
Indication:
Cl.I and Cl.II  100% ROOT COVERAGE
Cl.III  partial root coverage
free gingival graft:
All cases where root coverage is necessary except when a graft of
sufficient thickness (1.5-2.0 mm) cannot be harvested.
Connective tissue graft:
88% root coverage in areas of severe gingival recession
Greater amount of root coverage and rate of complete coverage with the
use of connective tissue grafts as compared to free gingival grafts.
Professional evaluation of degree of root coverage, color
match of the tissues including (alveolar mucosa, preexisting
keratinized tissues and gingival graft), soft tissue appearance
and location of the mucogingival line are important factors
for successful aesthetic outcome of root coverage procedures.
Funding Source
Disadvantages:
• Technically demanding
- Gingivoplasty may be necessary postoperatively