Periodontal Plastic Surgery and Soft Tissue Grafts A Road Map for Assessment and Recommendation

Newsletter Article

by Kyle H. Trammell, DMD

My purpose for this article is to support your co-diagnostic process with an overview of soft tissue grafting procedures, as well as share a few tools and indicators to assist in the development of treatment recommendations for patients with gingival recession (GR).

Meet Patient A: (See Figure 1). As we would expect, Patient A presented with esthetic concerns and complained about sensitivity when brushing. It was fair to assume that this condition would worsen over time, with a reasonable risk of tooth loss. Developing a treatment plan and addressing the underlying cause was our mission for this patient, as I am sure it would be in your practice.

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The Decision Process for Soft Tissue Grafts
The type of soft tissue grafting procedure selected is based on the diagnostic criteria and necessary healing to achieve the best outcome. Patient A clearly has severe gingival with no keratinized gingiva (KG) orattached tissue. In this case, a connective tissue graft with a coronally advanced flap was recommended. (See Figure 2).

Following are some of the methodologies used to arrive at this recommendation:

In 1985, periodontist, author and clinical researcher Dr. P.D. Miller, Jr. developed a system that applies the criteria of both diagnosis and prognosis for classification of gingival recession defects. The Miller classification system is one of the most widely used evaluation tools today.

A key determinant of Miller classification is to assess the adjacent interproximal bone level for bone loss before any soft tissue grafting procedure. (1 See Table 1 below; note that root coverage is not expected with the presence of interproximal bone loss and predictability of root coverage diminishes with increased bone and tissue loss.


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Along with Miller classification, site specific factors are considered, including: depth of defect, presence of frenum attachment, root prominence, root-surface caries, presence of non-carious cervical lesion, vestibular depth and thin or thick tissue biotype. (2

The problem with recession is…
The longer we wait to treat gingival recession defects, the less favorable the
expected treatment outcome. In Patient A’s case, if left untreated, neither you nor
I would make any promises to this patient that they would not lose these teeth or
develop an infection. Using Miller Classification, Patient A was Miller Class II.

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The treatment process begins with identifying the etiology of the gingival recession
defect and plotting a course of action to prevent reoccurrence. Common
etiologies include toothbrush trauma, abfraction, poor plaque control of
subgingival restorations, high frenal attachment, tooth malalignment, calculus,
gingival inflammation and orthodontic tooth movement. (1
Having addressed the etiology, the next step is to consider the objectives of soft
tissue grafting, which may be a combination of root coverage, increased
keratinized gingiva or increased tissue thickness. (See the decision tree diagram,
Figure 5). (1

  • For Miller Class I or II patients, if root coverage is required, soft tissue procedures may include connective tissue graft (CT), free gingival graft (FG), lateral pedicle
    graft, coronally advanced flap procedures, guided tissue regeneration (GTR),
    acellular dermal matrix (ADM), or a combination of procedures.
  • For Miller Class III or IV patients, root coverage is not predictable. The first choices
    are typically free gingival graft or connective tissue graft (CT) procedures. Other
    soft tissue procedures may be indicated. A restorative plan may also be needed
    to meet the patient’s expectations. (2


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Free Gingival Grafts (FG)
Free gingival grafts (FG) have been in use since the 1960s with a good history of success. They are harvested from the patient’s palatal tissue; the most prevalent use is in the lower anterior region for Miller Class I or II recession defects. In addition to treating recession, FG grafts may sometimes be used to increase keratinized tissue (KT) around a dental implant. (3

FG grafts are generally best suited for non-esthetic areas because the grafted tissue often does not blend seamlessly with the surrounding areas; full root coverage should not be expected. (4

Connective Tissue Grafts (CT)
Subepithelial connective tissue grafts (CT) provide the best outcomes for root coverage in Miller Class I and II defects for most patients, along with an increase in keratinized tissue. 2 CT grafts are limited to the amount of tissue that can be obtained from the palate or other intraoral site(s). They provide a better esthetic result than free gingival grafts as they tend to blend very well with surrounding tissues. For Miller Class III and IV GR defects, CT procedures provide significant benefits such as GR reduction and CAL (clinical attachment level) gain, however, root coverage is not predictable. (2

Pedicle Grafts
A pedicle graft is a coronal flap tissue repositioning procedure. Site selection is the most critical factor with this type of soft tissue graft; if the connective tissue is thin, the graft can fail and make the recession worse. They are effective in cases of mild recession with no bone loss and adequate tissue height on adjacent teeth. (5

Esthetic Crown Lengthening
Periodontal plastic surgery is probably best known for esthetic improvement in the anterior region. Crown lengthening procedures are used to reduce excessive gingiva, “gummy smile”, or to create a more symmetrical appearance in the gumline. Crown lengthening procedures may also be used to move the gingival margin apically and expose more of the anatomic crown, thus providing the opportunity for supragingival restoration margins.

Autogenous Grafts vs. Allografts
Using the patient’s own tissue (autograft) is well supported in research for the benefits of healing and integration. Harvesting autograft tissue, however, does create an additional surgical site, so post-surgical discomfort is a common patient concern. Availability of adequate intraoral donor tissue must also be considered; treatment of multiple sites raises the question of alternative graft options.

Acellular dermal matrix or allograft (trade name Alloderm®, Dermis®, etc.) has been used for many years in medicine for graft treatment of burn victims and other reconstructive procedures. In recent years, it has taken a viable position for use in periodontal soft tissue procedures as an alternative to autogenous tissue.

Allograft tissue is increasing in use to meet patient comfort needs, and it is delivering comparable results to autograft procedures in well planned treatment cases, although the clinical data is not as extensive. (4


Patient education to address plaque control and counseling to quit smoking help enhance the success of gingival surgical procedures.(4 Smoking has been reported to be one of the most common reasons for failure after mucogingival surgery.(4

Recall compliance is crucial for healing, studies show that poor plaque control contributes to less than optimal surgical outcomes and can lead to loss of clinical
attachment, further gingival recession and infection.

Candidates for periodontal soft tissue grafting procedures should be medically screened for systemic health conditions that negatively affect wound healing, such as uncontrolled diabetes. Medical consultation is recommended for these patients. (4

The goals of periodontal plastic surgery and soft tissue grafting procedures include improving the long term prognosis of tissue health, tooth stabilization, intervening and stopping future gingival recession and facial bone loss, and eliminating inflammation and recession for planned and existing subgingival restorations. The grafting approach selected is based on critical analysis of key factors, including Miller’s Classification, surgical site condition, patient health and smoking habits, esthetic requirements and comfort.

Our objective as a periodontal specialty practice is to support these goals and to educate the patient in the importance of continual periodontal maintenance through professional hygiene visits and diligent home care.  We strive to partner with the restorative dentist to achieve an oral health condition for our shared patients that is manageable, comfortable, functional and esthetically appealing.

If you have questions about periodontal plastic surgery procedures or possible outcomes, please do not hesitate to contact myself or my team.
Kyle Trammell

1. The International Journal of Periodontics & Restorative Dentistry. A Decision Tree for Soft Tissue Grafting, Daylene Jack-Min Leong, BDS, Hom-Lay Wang, DDS, MSD, phd, Volume 31, Number 3, 2011. Quintessence Publishing Company.
2. Enhancing Periodontal Health Through Regenerative Approaches Periodontal Soft Tissue Root Coverage Procedures: Practical Applications From the AAP Regeneration Workshop Christopher R. Richardson,* Edward P. Allen,† Leandro Chambrone,‡ Burton Langer,x Michael K. Mcguire,‖ Ion Zabalegui,{ Homayoun H. Zadeh,# and Dimitris N. Tatakis*
3. Is it time to retire the free gingival graft procedure in light of new alternative tissue grafting materials?
By Alessandro Geminiani, DDS, MS 2013-05-06, Surgical Restorative Resource, online

4. Periodontal Soft Tissue Non–Root Coverage Procedures: Practical Applications From the AAP Regeneration Workshop Vanchit John,* Laureen Langer,† Giulio Rasperini,‡ David M. Kim,x Rodrigo Neiva,‖ Henry Greenwell,{ Serge Dibart,# Mariano Sanz,** and E. Todd Scheyer††
0051 Clinical Advances in Periodontics, Vol. 5, No. 1, February 2015

5. Practical Periodontal Plastic Surgery
Serge Dibart, Mamdouh Karima
ISBN: 978-1-118-70493-6
May 2013, Wiley-Blackwell, Hoboken, NJ
Chapter 8: Pedicle Grafts: Coronally Advanced Flaps