Gingival augmentation around natural teeth and dental implants

Figure 1. Pre-operative view of gingival recession tooth #24.
Figure 2. Partial thickness flap outlined.
Figure 3. The connective tissue graft sutured in place and the flap is coronally-positioned.
Figure 4. 12 months post-operatively.

Multifactorial etiological factors can lead to gingival recession including anatomical, physiological and pathological factors. The denuded root surface or a dehisced implant is disturbing to patients because of both sensitivity and appearance. Treating gingival recession includes different surgical techniques and flap designs with emphasis on regenerating the periodontium.
By Dr Moawia M. Kassab


Anticipating the success rate of root coverage procedures is often difficult, since coverage may depend on several factors, including location, classification of the gingival recession, the technique used and the amount of bone present to support the soft tissue. Gingival height (distance between the soft tissue margin and the mucogingival line measured in millimetres) is commonly assessed; an increase in gingival height independent of the number of millimetres is considered a successful outcome of gingival augmentation procedures [1].


Autogenous grafting

Achieving root coverage has inspired many clinicians to use various flap designs and different surgical techniques to accomplish that goal; some of the techniques do not require a donor site (pedicle flaps) while others require a donor site (free soft tissue grafts). Pedicle grafts differ from free autogenous soft tissue grafts in that the base of the pedicle flap contains its own blood supply, which nourishes the graft and facilitates the re-establishment of vascular union with the recipient site.


A classical pedicle flap technique is the laterally positioned pedicle graft (LPPG), which cannot be performed unless there is significant gingiva lateral to the site of recession. A shallow vestibule may also jeopardise outcomes. Although the use of the LPPG provides an ideal colour match, it is often inadequate for the treatment of multiple recessions [2,3].


Cohen and Ross proposed a double-papilla repositioned flap to cover defects where an insufficient amount of gingiva was present. The papillae from each side of the tooth are reflected and rotated over the mid-facial aspect of the recipient tooth and sutured. The only advantage of this technique is the dual blood supply and denudation of interdental bone only [4].


Coronally-positioned flaps

Initially clinicians utilised the coronally-positioned flap subsequent to grafting with a free graft (in a two stage procedure). First, a free autogenous soft tissue graft is placed apical to an area of denuded root. After healing, the flap is coronally repositioned. The requirements for the success of coronally-positioned grafts include

  1. the presence of shallow crevicular depths on proximal surfaces;
  2. approximately normal interproximal bone heights;
  3. tissue height within 1mm of the cementoenamel junction (CEJ) on adjacent teeth; 
  4. adequate healing of the free graft prior to coronal positioning; 
  5. reduction of any root prominence within the plane of the adjacent alveolar bone; 
  6. adequate release of the flap to prevent retraction during healing. The second stage procedure utilises a split-thickness dissection with mesial and distal vertical releasing incisions until adequate flap mobility is obtained. The flap is sutured 0.5 to 1mm coronal to the CEJ and covered with a periodontal dressing.


Allen and Miller used single stage coronally-positioned flaps in the treatment of shallow marginal recession. The Miller Class I defects had a minimum keratinised tissue width of 3mm, with recession between 2.5 to 4mm, a split-thickness flap extending into the vestibule, and surface gingivoplasty of the papillae to produce a bleeding bed. Flaps were sutured into position and dressed. Complete root coverage was attained in 84% of the sites, with a mean root coverage gain of 3.2mm. Similarly, Harris reported a 98% success rate of root coverage in Class I defects by using the coronally-positioned graft technique [5].


Tarnow described the semilunar coronally-positioned flap technique. An incision is made that follows the curvature of the free marginal gingiva and extends into the papillae, staying at least 2mm from the papilla tip on either side. The incision is made far enough apically to ensure that the apical portion of the flap rests on bone after repositioning. A split-thickness dissection of the flap is made and the flap is repositioned and held in place with light pressure and a periodontal dressing. The advantages of that technique include no tension on the flap after repositioning, no shortening of the vestibule, no reflection of the papillae (thereby avoiding esthetic compromise), and no suturing [6].


Free autogenous soft tissue grafts

Both the epithelialised palatal graft and the subepithelial connective tissue graft offer a more versatile solution for root coverage than do laterally-positioned or coronally-positioned pedicle flaps. There is usually adequate donor tissue, a shallow vestibule does not compromise the procedure, and multiple recessions can be treated. Two kinds of autogenous grafts can be used for root coverage. One consists of an epithelialised layer, while the other does not.


Free epithelialised autogenous gingival grafts:

Sullivan and Atkins were the first to explore the feasibility and healing of the free gingival graft (FGG). This procedure involves the preparation of a recipient site, which is accomplished by supraperiosteal dissection to remove epithelium and connective tissue in
the periosteum.


Some of the common areas for donor material include edentulous ridges, attached gingiva, and palatal gingiva. Free gingival grafts were also found to be a predictable means of increasing the width of the attached gingiva [7].


Miller described a technique for root coverage using a free soft tissue autograft with citric acid treatment. Predictable root coverage depended upon the severity and classification of gingival recession. After root planing, citric acid application was performed, followed by horizontal incisions at the level of the CEJ to preserve the interdental papillae. Vertical incisions at proximal line angles of adjacent teeth facilitate completion of bed preparation. A thick palatal graft with a thin layer of submucosa was placed on a moderately bleeding bed and stabilised with sutures at the papillary and apical ends of the graft extending into the periosteum. Results of 100 consecutively placed grafts showed 100% root coverage in Class I defects and 88% coverage in Class II. The average root coverage for all sites was 3.8mm with a mean clinical attachment gain of 4.5mm [8].


Connective tissue autogenous grafts

The use of connective tissue grafts for root coverage was first reported by Langer and Langer. A partial thickness flap with two vertical incisions was elevated on the recipient site, followed by placement of the graft (which is collected from the palate by a double parallel incision technique). The flap is coronally-positioned to attempt to cover the graft and benefit from a double blood supply. An increase of 2 to 6mm of root coverage in 56 cases over four years was reported [9].


Jahnke et al. compared the results of free gingival and connective tissue grafts for root coverage in nine patients. Paired defects were selected and assessed pre-operatively, as well as three and six months post-operatively. Root coverage averaged 43% for the free gingival graft group, and 80% for the connective tissue graft group [10]. When the connective tissue graft was compared to the free gingival graft for root coverage, Paolantonio et al. found, in a five-year post-operative study, that the connective tissue graft provided a predictable percentage of root coverage (85%), while the free gingival graft had only a 53% success rate. They concluded that connective tissue grafting for root coverage requires a long term predictable procedure [11].


A variety of techniques have been used to collect the connective tissue graft, including via parallel incisions and free gingival knife methods, with no significant difference in the percentage of root coverage being demonstrated.


Combination of one or more techniques

In an attempt to obtain higher success rate of root coverage, many clinicians have attempted to combine different procedures. Nelson used connective tissue grafting with a double pedicle graft. A free connective tissue graft was first placed over the denuded root surface, followed by a double pedicle graft to partially cover the connective tissue graft. Harris modified Nelson’s technique with a split thickness pedicle graft to cover the connective tissue graft. Thirty Miller Class I and II defects were selected and the mean root coverage was 97% [12,13].


Wennström and Zucchelli compared a coronally-positioned flap to a combination of a coronally-positioned and a connective tissue graft procedure. The treatment of 103 (Miller class I and II) defects was performed. The success rate for the combination group was 98.9%, while 97% was accomplished for the control group after a two-year post-operative evaluation. The authors concluded that the previous combination of coronally-positioned flap and connective tissue graft was the treatment of choice to achieve root coverage [14].


Soft tissue allografting

Acellular Dermal matrix (ADM) is a processed de-epithelialised human skin-derived dermal allograft with retained basement membrane complex. ADM has gained acceptance in periodontal plastic surgery for grafting around natural teeth and dehisced dental implants to improve esthetics. One of its advantages is it eliminates need for a donor site and thus allows treatment of multiple areas of recession or augment the gingival tissue around multiple implants. The outcomes appear to be contradictory, possibly due to the fact that the procedure is technique-sensitive, especially when used for root coverage [15]. Enamel Matrix derivative and other tissue engineering techniques have been used to enhance root coverage, however minimal clinical significance has been reported in terms of root coverage [16]. Recent studies report that the addition of platelet-rich plasma to the combination of connective tissue grafting and coronally-positioned grafts revealed no additional clinical benefits [17].



1. Kassab MM, Cohen RE. The etiology and preference of gingival recession. J Am Dent Assoc. 2003 Feb;134(2):220-5.

2. Grupe HE, Warren RF. Repair of gingival defects by a sliding flap operation. J Periodontol 1956; 27:290-295.

3. Miller PD, Allen EP. The development of periodontal plastic surgery. Periodontology 1996; 11:7-17.

4. Cohen DW, Ross SE. The double papilla repositioned flap in periodontics. J Periodontol 1968; 39:65-70.

5. Allen EP, Miller PD. Coronal positioning of existing gingiva: Short-term results in the treatment of shallow marginal tissue recession. J Periodontol 1989; 60:316-319.

6. Tarnow DP. Semilunar coronally-repositioned flap. J Clin Periodontol 1986; 13:182-185.

7. Sullivan HC, Atkins JH. Free autogenous gingival grafts, III utilization of grafts in the treatment of gingival recession. J Periodontol 1968; 6:152-159.

8. Miller PD. Root coverage using the free soft tissue autograft following citric acid application. III. A successful and predictable procedure in areas of deep wide recession. Int J Periodontics Restorative Dent 1985; 5(2): 15-37.

9. Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985; 56:715-720.

10. Jahnke PV, Sandifer JP, Gher ME, Gray JL, Richardson CA. Thick free gingival graft and connective tissue autografts for root coverage. J Periodontol 1993; 64:315-322.

11. Paolantonio M, Muro C, Cattabriga A, Cattabriga M. Subpedicle connective tissue graft versus free gingival graft in the coverage of exposed root surfaces. A 5-year clinical study. J Clin Periodontol 1997; 24:51-56.

12. Nelson S. The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1986; 95:102.

13. Harris RJ. The connective tissue and partial thickness double pedicle graft: A predictable method of obtaining root coverage. J Periodontol 1992; 63:477-486.

14. Wennström JL. Zucchelli J. Increased gingival dimensions. A significant factor for successful outcome of root coverage procedures. A 2-year prospective clinical study. J Clin Periodontol 1996; 23:770-777

15. Papageorgakopoulos G, Greenwell H, Hill M, Vidal R, Scheetz JP. Root Coverage Using Acellular Dermal Matrix and Comparing a Coronally-Positioned Tunnel to a Coronally-Positioned Flap Approach. Journal of Periodontology 2008; 79: 6 1022-1030.

16. McGuire MK, Scheyer ET, Nunn ME, Lavin PT. A Pilot Study to Evaluate a Tissue-Engineered Bilayered Cell Therapy as an Alternative to Tissue from the Palate. Journal of Periodontology 3 Jun 2008: 1847-1856.

17. Huang LH, Neiva RE, Soehren SE, Giannobile WV, Wang HL. The effect of platelet-rich plasma on the coronally advanced flap root coverage procedure: A pilot human trial. J Periodontol 2005; 76:1768-1777.


The author

Moawia M. Kassab, DDS, MS

Assistant Professor,

Department of Surgical Sciences

School of Dentistry

Marquette University,

Milwaukee, WI 53132, USA

Tel +1 414 288 0771

e-mail :


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