Section 8
Mucogingival Therapy
Jan L. Wennström*
"Department of Periodontology, School of Dentistry, University of Göteborg, Göteborg, Sweden
Question Set
1. What are the therapeutic endpoints of
success?
2. What are the indications/contraindi-
cations for mucogingival therapy?
3. Which procedures are justified in mu-
cogingival therapy?
a. for augmenting the dimensions of gin-
gival tissue
b. for root coverage
c. for augmenting the edentulous ridge
4. Is root coverage a predictable outcome of
mucogingival surgery?
5. What is the role of root surface modifi-
cation in mucogingival procedures aimed at
root coverage?
6. What dento-gingival anatomy will be-
come established following root coverage pro-
cedures?
7. What is the long-term stability of the
healing result following mucogingival proce-
dures?
Ann Periodontol 1996;1:671-701.
INTRODUCTION
The goal of this review on mucogingival
therapy was primarily to cover the literature
published after 1988. However, in order to
achieve a more complete overview of the
topic, articles providing significant informa-
tion published prior to 1989 have been in-
cluded. For further details on the literature
published before 1989 the reader is referred
to the section on mucogingival surgery in the
Proceedings of the 1989 World Workshop in
Clinical Periodontics.1 A total of 590 articles
were reviewed. The papers reviewed were
ranked according to the instructions given
by the Organizing Committee for the 1996
World Workshop.
The final bibliography includes 216 arti-
cles. Single case reports were not consid-
ered to qualify for inclusion in the bibliog-
raphy unless the paper provided some
important information in relation to a spe-
cific question. Evidence tables include only
studies from which clearly defined descrip-
tive variables for the treatment outcome
were retrievable.
The review follows the outline below:
Definitions of Terms
What Are the Therapeutic Endpoints of Suc-
cess?
Increased Gingival Dimensions
Root Coverage
Improved Esthetics
What are the Indications/Contraindications
for Mucogingival Therapy?
Vol. 1, No. 1, November 1996
672
Augmentation of the Dimensions of Gin-
gival Tissue
RootCoverage
Augmentation of the Endentulous Ridge
Frenectomy
General Considerations
Which Procedures Are Justified inMucogin-
gival Therapy?
Augmentation of the Dimensions of Gin-
gival Tissue
Root Coverage Procedures
Augmentation of the Edentulous Ridge
Is Root Coverage a Predictable Outcome of
Mucogingival Surgery?
Rotational Flaps
Coronally Advanced Flaps
Guided Tissue Regeneration
Full Thickness Free Soft Tissue Graft
Free Connective Tissue Graft
What is the Role of Root Surface Modifica-
tion in Mucogingival Procedures Aimed at
Root Coverage?
Root Planing
Root Surface Conditioning
What Dento-Gingival Anatomy Will Become
Established Following Root Coverage Proce-
dures?
What Is the Long-Term Stability of the Heal-
ing Result Following Mucogingival Proce-
dures?
Augmentation of the Dimensions of Gin-
gival Tissue
Root Coverage Procedures
Augmentation of the Edentulous Ridge
Definition of Terms
The term "mucogingival surgery" was in-
troduced in the periodontal literature in the
1950s and was at that time defined as "sur-
gical procedures designed to preserve gin-
giva, remove aberrant frenulum or muscle
attachments, and increase the depth of the
vestibule."2 Since then the definition has
been changed and according to the Glos-
sary of Periodontal Terms,3 mucogingival
surgery refers to "periodontal surgical pro-
cedures designed to correct defects in the
morphology, position and/or amount of
gingiva" surrounding the teeth. It has been
Annals of Periodontology
Wennström
suggested45 that the term "periodontal
plastic surgery" may be more appropriate,
since mucogingival surgery has moved be-
yond the traditional treatment of problems
associated with the amount of gingiva and
recession type defects to also include cor-
rection of ridge form and soft tissue esthet-
ics. Periodontal plastic surgery would be
defined as "surgical procedures performed
to correct oreliminate anatomic, develop-
mental, or traumatic deformities of the gin-
giva or alveolar mucosa."4
The gingiva (keratinized tissue), which is
composed of a dense, collagen rich connec-
tive tissue and covered by a keratinizing ep-
ithelium, extends from the soft tissue mar-
gin (gingival margin) to the mucogingival
line. Traditionally, the gingiva has been di-
vided into 1) a free portion; i.e., that part of
the gingiva which corresponds to the prob-
ing depth and 2) an attached portion, deter-
mined clinically by subtracting the probing
depth from the measure describing the en-
tire width (height) of the gingiva.
The supracrestal soft tissue adjacent to
implants is usually referred to as "peri-im-
plant mucosa," which may consist of either
masticatory or lining mucosa.
Recession (gingival recession) is defined
as "location of the marginal tissue apical to
the cemento-enamel junction."3 Since the
soft tissue margin may not always be com-
posed of gingiva, the terms "soft tissue re-
cession" and "marginal tissue recession" are
also commonly used.
WHAT ARE THE THERAPEUTIC
ENDPOINTS OF SUCCESS?
The variables to be used as descriptors of
the therapeutic endpoint of success may
vary depending on the specific goal of the
mucogingival therapy.
Increased Gingival Dimensions
The gingival dimension commonly as-
sessed is the width (height); i.e., the distance
between the soft tissue margin and the mu-
cogingival line measured in mm. An in-
creased width of gingiva, independent of the
number of mm, is considered as a successful
outcome of augmentation procedures. Also
 Review: Mucogingivai Therapy
an increased thickness of the marginal tis-
sue may in certain situations be considered
as an endpoint of success.
Root Coverage
To obtain root coverage in areas with lo-
calized or generalized soft tissue recessions
associated with esthetic problems, root sen-
sitivity, and /or shallow root carries lesions
is one of the major therapeutic goals in mu-
cogingivai surgery. The amount of recession
is clinically assessed through measuring the
distance in mm between the cemento-en-
amel junction (CEJ) and the soft tissue mar-
gin. This assessment is the primary outcome
variable for the therapeutic endpoint of suc-
cess. An additional variable is reduction in
root sensitivity.
Probing depth (PD) and clinical attach-
ment level (CAL) assessments may also be
used as descriptors of the success of root
coverage procedures. A shallow probing
depth and gain of clinical attachment would
be considered as successful treatment out-
come. Although gain of clinical attachment
is a positive therapeutic outcome, it does
not disclose the quality of attachment es-
tablished.6
Histologie evaluation is the only reliable
method by which the nature of attachment
of the tissue to the root can be determined.
However, only limited histological data from
humans on the healing following mucogin-
givai surgery are available. A critical point
in the histologic evaluation of the quality of
healing against the previously detached
root surface is that proper markings have
been made of the extension of the defect.
Improved Esthetics
Improved esthetics is one of the major in-
dications for mucogingivai surgery. This is
a subjective parameter which only can be
determined by the patient. Variables deter-
mining improvements in esthetics following
mucogingivai surgery have so far rarely
been included in studies reported in the lit-
erature.
673
WHAT ARE THE
INDICATIONS/CONTRAINDICATIONS
FOR MUCOGINGIVAL THERAPY?
Augmentation of the Dimensions of
Gingival Tissue
The position in which a tooth erupts
through the alveolar process and its eventual
position in relation to the bucco-lingual di-
mension of the alveolar process have pro-
found influence on the amount of gingiva that
will be established around the tooth.7 In chil-
dren, the gingival dimensions will increase
due to growth in the alveolar process, as well
as changed position of the teeth.8-10 Longi-
tudinal monitoring of the gingival dimen-
sions at the facial aspect of anterior teeth in
the developing dentition has shown that a
significant increase of the gingival height will
take place.811 Also, the spontaneous change
of the tooth position in bucco-lingual direc-
tion that often takes place during develop-
ment will affect the gingival height.12 A more
lingual positioning of the tooth results in an
increase of the gingival height on the facial
aspect with a coronal migration of the soft
tissue margin. The opposite will occur when
changing to a more facial position in the al-
veolar process. Furthermore, in the growing
child mucogingivai defects may be elimi-
nated spontaneously, provided an adequate
plaque control is established and main-
tained. 13~15 In one 3-year prospective study15
it was suggested that, based on the obser-
vation that 25 out of 35 (71%) recession de-
fects with an initial depth of 0.5 mm to 3.0
mm were spontaneously eliminated follow-
ing improved oral hygiene standards, repar-
ative surgical treatment of soft tissue
recessions in the developing dentition may
not be necessary and should preferably be
postponed until the growth is completed.
Data on gingival dimensions in adults in-
dicate that there is a tendency of increased
apico-coronal width with age.16
Gingival dimensions and periodontal
health. The early development of mucogin-
givai surgery was based on the clinical im-
pression that a certain apico-coronal width
of gingiva was required for maintenance of
Vol. 1, No. 1, November 1996
674 Wennström
periodontal health and prevention of soft tis-
sue recession.17-27 Based on observations
made in young individuals it was suggested
that 2 mm of gingiva, corresponding to 1 mm
of attached portion of gingiva, is adequate to
maintain gingival health.28 Subsequent clin-
ical29-39 and experimental studies40-41 all
failed, however, to generate support for the
concept of a minimal width of gingiva for
maintenance of periodontal health. Further-
more, longitudinal, prospective studies showed
that the incidence of soft tissue recession
was not greater at buccal tooth surfaces with
a minimal band of gingiva, or lack of at-
tached portion of gingiva, than at tooth sites
with a broad zone of properly attached gin-
giva.35-3942'43 Other studies32-33 show that
minimal bands of gingiva and even mucosal
margins can be maintained in periodontal
health without progressive recession pro-
vided that traumatic toothbrushing and in-
flammation are controlled.
It has been proposed that the movability
of the soft tissue margin at sites with a min-
imal attached portion of gingiva (< 1 mm)
may favor the establishment of subgingival
plaque and, hence, make the periodontal tis-
sues more vulnerable to destruction.28 How-
ever, an experimental gingivitis study29 re-
vealed no differences in the development of
clinical signs of inflammation between areas
with minimal (< 1 mm) and appreciable (> 2
mm) width of gingiva. A controlled clinical
trial on the effect of gingival augmentation in
patients who were not recalled for supportive
treatment during 5 years did not show any
differences in loss of clinical attachment or
recession during the follow-up period after
active treatment between control sites with
< 1 mm or complete lack of attached gingiva
and grafted sites.42 Also, experimental stud-
ies44-46 including histological examinations
failed to lend support to the view that a mo-
bile marginal tissue offers an inferior protec-
tion of the periodontium.
Gingival dimensions and orthodontic tooth
movement. Recession of the marginal tissue
may occur during orthodontic therapy. 7,26,47-49
Clinical studies have shown that a narrow
band of gingiva is capable of withstanding
the stress caused by orthodontic forces.5051
Additionally, alterations occurring in gingi-
Annals of Periodontology
val dimensions are related to the direction of
tooth movement; facial movement results in
reduced facial gingival dimensions, while an
increase is observed following lingual move-
ment.12-50'51 Results from experimental stud-
ies indicate that as long as the tooth is
moved within the envelope of the alveolar
process, the risk of harmful side-effects on
the marginal soft tissue is minimal, irre-
spective of its dimensions and quality.52 If la-
bial tooth movement results in the establish-
ment of an alveolar bone dehiscence, the
risk for development of a recession defect is
evident,50 53 34 particularly if the marginal tis-
sue is composed of lining mucosa.50 Clinical
and experimental studies32 54-55 have indi-
cated that the volume (thickness) of the soft
tissue may be a factor in predicting if gingi-
val recessions will occur during and/or after
the phase of active orthodontic therapy. A
thin gingiva may serve as a locus minorus re-
sistentia to developing recession defects in
the presence of plaque-induced inflamma-
tion or toothbrushing trauma.52
Gingival dimensions and restorative den-
tistry. It has been proposed that in segments
of the dentition involved in restorative ther-
apy there is a particular demand for gin-
giva.5657 The placement of restoration mar-
gins subgingivally not only creates a direct
operative trauma to the tissues58 but may
also facilitate plaque accumulation, with re-
sultant inflammatory alterations in the ad-
jacent gingiva.59 Subgingival restorations
will create more pronounced inflammation
in areas with (< 2 mm) band of gin-
a narrow
giva than in with a wide gingiva, but
areas
not necessarily loss of attachment.60 An ex-
perimental study in the beagle dog, in which
metallic strips were inserted subgingivally in
areas with varying dimensions of gingiva,
showed that in sites with a thin gingival
margin, recession was a more likely conse-
quence of the combined tissue trauma
caused by the insertion of the strip and sub-
sequent plaque accumulation than in sites
with a broad gingival zone.61 It has been sug-
gested that in a thin free gingiva the inflam-
matory lesion will occupy and degrade the
entire connective tissue portion, resulting in
a collapse of the free gingiva.62 However,
whether an increase in thickness of the mar-
 Review: Mucogingival Tnerapy
ginaltissue will reduce the risk for soft tis-
sue recession as a consequence of inflam-
reactions related to the subgingival
matory
placement of restoration margins has not
been evaluated.
Soft tissue quality and implant ther-
apy. There is a fundamental difference be-
tween the periodontal and the peri-implant
tissues with regard to the anchorage of the
bordering soft tissue, which might have in-
fluence on the stability of the soft tissue
margin. While the periodontal mucosa is at-
tached to the tooth with collagen fibers in-
serting into the supracrestal portion of the
root, the peri-implant mucosa lacks such an
attachment,63 resulting in the possibility
that a marginal tissue composed of movable
lining mucosa easily can be detached from
the implant surface. However, the high long-
term success rate of implant therapy,64-67 de-
spite high prevalence of implant sites lack-
ing firmly attached masticatory mucosa as
marginal border tissue (46% to 74%),68-72 in-
dicates that the lining mucosa may not be
inferior to the keratinized and collagen-rich
mucosa as a protective tissue.
masticatory
Recent clinical studies addressing the ques-
tion of the significance of the quality of the
mucosa in implant therapy have also failed
to generate support for the concept that the
lack of masticatory mucosa may jeopardize
the maintenance of healthy implant sup-
porting tissues.71-73 Furthermore, an experi-
mental study in dogs showed that an in-
crease of the width of masticatory mucosa
around dental implants had no effect on the
conditions of the peri-implant soft tissue.74
Alterations in the position of the soft tis-
sue margin at implants, a factor that may be
of concern from an esthetic point of view,
have been focused on to some extent in the
past.6871 76 It was reported that apical dis-
placement of the tissue margin will occur
over time, but if differences depend on qual-
ity or mobility of the peri-implant mucosa,
have not been addressed. However, results
from a recent experimental study indicate
that, in presence of plaque-induced inflam-
mation, a border tissue composed of lining
mucosa may be more prone to the develop-
ment of recession than one composed of
masticatory mucosa.76
675
Summary
A minimal amount or absence of gingiva
alone is not justification for gingival augmen-
tation.1 Evidence suggests that the gingival
height is not a critical factor for the preven-
tion of marginal tissue recession.32 39 42 There
is also evidence that in the growing child an
increase in gingival height will occur,8-12 and
that gingival defects may be eliminated
spontaneously provided an adequate plaque
control program is established and main-
tained.15 However, gingival augmentation
may be considered in situations where a
change in the morphology of the mucogin-
gival complex may facilitate proper plaque
control. This may be the case in the presence
of a high frenulum attachment, a deep and
narrow recession defect, and where a reces-
sion extends to the level of the vestibulär for-
nix. Additionally, in conjunction with facial
tooth movement resulting in the establish-
ment of alveolar bone dehiscences, there is
evidence that gingival dimensions can influ-
ence the development of marginal tissue re-
cession.49525455 The presence of masticatory
mucosa around implants is not a decisive
factor for the prognosis of implant ther-
apy.68-73
Root Coverage
Soft tissue recession; i.e., displacement of
the gingival margin apical to the cemento-
enamel junction with oral exposure of the
root surface, is a common feature in popu-
lations with high standards of oral hy-
giene,77-80 as well as in populations with poor
oral hygiene.79-81-82 While loss of attachment
and gingival recession are predominantly
found at the buccal surface of the teeth in
populations maintaining high standards of
oral hygiene,79-80-83 all tooth surfaces are usu-
ally affected in periodontally untreated pop-
ulations.7981 It has therefore been suggested
that at least two different types of gingival re-
cessions may exist: one related to mechanical
factors (toothbrushing) and one associated
with destructive periodontal disease.79 80
Besides toothbrushing trauma and Per-
iodontitis,7779-83-87 factors such as 1) tooth
Vol. 1, No. 1, November 1996
676 Wennström
malposition;85-89-91 2) alveolar bone de-
hiscences;92-93 3) high muscle attachment
and frenal pull;94 and 4) iatrogenic factors
related to restorative and periodontal treat-
ment procedures85-95 have been associated
with the development of gingival recessions.
The main indications for root coverage
procedures areesthetic demands, root sen-
sitivity, and shallow root caries lesions.1
Recession defects can be classified into 4
groups taking into consideration the antici-
pated root coverage that can be obtained:96
Class I: Marginal tissue recession not ex-
tending to the mucogingival junction. No
loss of interdental bone or soft tissue.
Class II: Marginal tissue recession ex-
tends to or beyond the mucogingival junc-
tion. No loss of interdental bone or soft
tissue.
Class III: Marginal tissue recession ex-
tends to or beyond the mucogingival junc-
tion. Loss of interdental bone or soft tissue
is apical to the cemento-enamel junction,
but coronal to the apical extent of the mar-
ginal tissue recession.
Class IV: Marginal tissue recession ex-
tends beyond the mucogingival junction.
Loss of interdental bone extends to a level
apical to the extent of the marginal tissue
recession.
While complete root coverage can be
achieved in Class I and II defects, only par-
tial coverage may be expected in Class III.
Class IV recession defects are not amenable
to root coverage. Thus, the critical clinical
variable to assess to determine the possible
outcome of a root coverage procedure is the
level of periodontal tissue support at the
proximal surfaces of the tooth.
Augmentation of the Edentulous
Ridge
The major indication for soft tissue aug-
mentation of the edentulous ridge is esthet-
ics. Phonetic considerations may also be an
indication. Lack of appropriate donor tissue
with respect to amount and/or quality is a
contraindication for soft tissue augmenta-
tion. Various procedures for hard tissue
augmentation may offer alternatives to soft
tissue augmentation in such situations.
Annals of Periodontology
Ridge deformities can be classified into 3
groups:97 1) Class I, bucco-lingual loss of tis-
sue with normal apico-coronal ridge height;
2) Class II, apico-coronal loss of tissue with
normal bucco-lingual ridge width; and 3)
Class III, combination type with loss of both
width and height of the ridge. Several factors
should be considered regarding indications
for ridge augmentation:97 1) the lip line; 2)
type and extent of deformity; 3} general arch
form, tooth form, and position of teeth; and
4) the proposed relationship of the pontics
to the abutment teeth and gingiva.
Frenectomy
In the Consensus Report on mucogingival
surgery from the 1989 World Workshop,1 the
following situations were identified as pos-
sible indications for frenectomy as a single
mode of therapy: 1) restrictive problems as-
sociated with lip or tongue movement; 2) clo-
sure of a midline diastema via orthodontic
treatment; and 3) location of attachment in
edentulous ridge compromising prostheses.
Frenum attachment positioned close to the
soft tissue margin, particularly if obstruct-
ing mechanical tooth cleaning, may also be
considered as an indication. Gingival aug-
mentation may be considered when a fre-
nectomy is accomplished.3
In relation to diastema closure it is usu-
ally advocated to delay the surgical treat-
ment until the orthodontic tooth movement
is completed.4-98 The removal of an abnormal
frenulum has been shown to markedly re-
duce the incidence of relapse.98
General Considerations
Plaque control measures/compliance. Two
of the major causative factors in the devel-
opment of soft tissue recessions are trauma
caused by toothbrushing and plaque-in-
duced periodontal inflammation.79-80-88 The
control of these factors, therefore, is of great
importance both in preventing the develop-
ment of soft tissue recessions and in suc-
cessful long-term outcome of root coverage
procedures. Poor plaque control has been re-
ported to result in less favorable treatment
outcome of root coverage procedures.99
 Review: Mucogingival Therapy
Smoking. The evidence that smoking may
have a detrimental effect on periodontal
wound healing is accumulating in the liter-
ature.100 Few studies on mucogingival sur-
gery have analyzed the effect of smoking on
the treatment outcome. In one study exces-
sive smoking was indicated to be strongly
correlated to the failure in obtaining root
coverage using free soft tissue grafts, while
"light" or "occasional" smokers (< 5 ciga-
rettes/day) showed similar healing response
as nonsmokers.101 Other clinical studies
have reported no significant effect of smok-
ing on the healing result following the use of
free soft tissue graft procedures.102 103 Fur-
ther studies are needed to determine the po-
tential negative effect of smoking on the
healing following various procedures used in
mucogingival therapy.
Age. There is no evidence in the literature
that patient age has an influence on the suc-
cess of mucogingival therapy.
WHICH PROCEDURES ARE
JUSTIFIED IN MUCOGINGIVAL
THERAPY?
Augmentation of the Dimensions of
Gingival Tissue
The earliest techniques proposed for in-
creasing the apico-coronal dimension of the
gingiva are the gingival extension procedu-
res, which were designed mainly with the
objective of extending the depth of the ves-
tibulär sulcus.104-106 With the "denudation
technique" all soft tissue was removed with-
inan area extending from the alveolar bone
crest to a level apical to the mucogingival
junction, leaving the alveolar bone completely
exposed.104 Healing following this type of treat-
ment resulted often in an increased width of
the gingival zone, although in some cases only
a very limited effect was observed. The expo-
sure of alveolar bone, however, produced se-
vere bone resorption with permanent loss of
bone height.107-109 In addition, the recession of
marginal tissue in the surgical area often ex-
ceeded the gain of gingiva obtained in the ap-
ical portion of the wound.110-111 Moreover, the
relapse of the vestibulär depth gained as a
677
consequence of the displacement of the soft
tissue at surgery were reported to be as much
as 50% within 6 months.112-113
With the "periosteal retention procedure" or
"split flap procedure" only the superficial por-
tion of the oral mucosa within the wound area
was removed leaving the bone covered by per-
iosteum.114-117 Although the preservation of
the periosteum resulted in less severe bone re-
sorption than following the "denudation tech-
nique," loss of crestal bone height was also
observed following this type of operation un-
less a relatively thick layer of connective tissue
was retained on the bone surface.109
The apically repositioned flap procedure,22
which involved the elevation of full thickness
soft tissue flaps and their displacement dur-
ing suturing in an apical position, often leav-
ing 3 to 5 mm of alveolar bone denuded in
the coronal part of the surgical area, may in
fact be considered as a modification of the
"denudation" technique. Although it was
stated that a predictable postsurgical result
with respect to increase of the width of the
gingiva was obtained following the "apically
repositioned flap,"22 other studies showed
mostly only retained presurgical width or a
slight increase.24118 Furthermore, a long-
term follow-up study of the location of the
mucogingival junction following the apically
positioned flap procedure revealed that the
procedure fails to create a permanent apical
shift of the mucogingival junction.118
The procedures discussed above can
hardly be justified today as a means for wid-
ening the gingival zone. The use of trans-
plants offers a better potential to predict the
postsurgical result, since gingival and pala-
tal soft tissues will maintain their original
tissue characteristics after transplantation
to areasof alveolar mucosa.119 A number of
pedicle and free graft techniques as treat-
ment modalities for gingival extension have
been described in the literature.27 120-127 Lon-
gitudinal studies revealed that these proce-
dures are effective means for augmentation
of the gingival dimensions.30-33 128 129 Also,
with free graft procedures a more predictable
increase of the vestibulär depth can be
achieved as compared to the previously dis-
cussed techniques, although some relapse of
the surgically gained depth may be expected
Vol. 1, No. 1, November 1996
678
due to shrinkage of the tissue graft during
healing.113 If a periosteal retention or a de-
nudation procedure was used to prepare the
recipient bed for a free tissue graft, or if bone
fenestrations or dehiscences were present at
the recipient site, no significant influence
was observed on the healing result.130-131
Summary
There is evidence that the most predicta-
ble procedures for gingival augmentation are
those utilizing pedicle or free autogenous
grafts of gingiva or masticatory mucosa from
the palate. It is a consensus that under or-
dinary circumstances "denudation" proce-
dures are not justified as a means for
widening the gingival zone]
Root Coverage Procedures
Mucogingival procedures used for root
coverage may be classified as 1) pedicle soft
tissue grafts; 2} free soft tissue grafts; or 3)
combinations of the two.
Pedicle soft tissue grafts. Depending on
the direction of transfer pedicle soft tissue
grafts can be divided into 1) rotational flaps
(e.g., laterally sliding flap, papilla flap, dou-
ble papilla flap) and 2) advanced flaps with-
out rotation or lateral movement (e.g.,
coronally positioned flap).132
One of the first surgical procedures for cov-
ering a localized recession defect, the laterally
sliding flap procedure, was described in the
literature in 1950s.133 A full-thickness flap
was mobilized on the adjacent tooth and the
flap was then positioned laterally and su-
tured to cover the exposed root surface. The
technique was later modified not to include
the marginal soft tissue on the donor tooth in
order to reduce the risk for recession.134 To
reduce the potential risk for dehiscence at the
donor tooth due to denudation of the bone
plate, the use of a split thickness flap was
proposed.135-136 Other modifications of the
procedure are the double papilla flap,137 the
oblique rotational flap,138 the rotation flap,126
and the transpositioned flap.139
As an alternative to lateral transposition of
soft tissue pedicle grafts, a coronally posi-
tioned flap to cover exposed root surfaces may
AnnaLs of Periodontology
Wennström
be used.140-144 In situations with only shallow
recession defects the semilunar coronally re-
positioned flap offers an alternative approach.
It was originally presented in 1907145 and
reappeared in the literature in the 1980s.146
The pedicle soft tissue graft procedure
combined with the use of a membrane bar-
rier according to the principles of guided tis-
sue regeneration (GTR) has recently been
introduced as a treatment procedure for root
coverage.147-148 In most studies a nonab-
sorbable expanded polytetrafluorethylene
(ePTFE) membrane has been used in com-
bination with a coronally advanced flap pro-
cedure. One critical factor in the use of GTR
barriers in mucogingival surgery is the
maintenance of a space for tissue regenera-
tion between the membrane and the facial
root surface. With the use of titanium rein-
forced ePTFE membranes, an adequate
space can be maintained during the healing
period.149-150 Also specially designed bioab-
sorbable polylactic acid and citric acid ester-
based membranes have been used in the
treatment of recession type defects.151-152
From a patient comfort point of view, bio-
degradable membranes should be prefera-
ble, since only one surgical session is re-
quired. General considerations on the use of
GTR membranes to restore defects in the
periodontium are reviewed in Section 8 Re-
generation-Natural Teeth.
Free soft tissue grafts. The free soft tissue
graft procedure can be performed as 1) an
epithelialized soft tissue graft or 2) a subep-
ithelial connective tissue graft, both usually
taken from the palate. Because the differ-
entiation of the covering epithelium is con-
trolled by morphogenetic stimuli from the
underlying connective tissue,119153 it is not
necessary to include the epithelial lining in
the free graft. However, there is evidence
that the deep connective tissue of the palate
may not possess the full potential to induce
keratinization of an overlaying epithelium.154
Case reports on the use of free soft tissue
grafts can be found in the dental literature
as early as in the beginning of this century.155
However, it was first in the 1960s that the
procedure became commonly used in mu-
cogingival surgery.120'123 156 Initially the pri-
mary goal of the free soft tissue graft pro-
 Review: Mucogingival Therapy
cedure was not root coverage but rather to
prevent progression the recession by in-
of
creasing the width of gingiva.129 To achieve
root coverage a 2-stage procedure was ad-
vocated by which the graft was initially
placed apical to the recession and allowed to
heal before a second surgical procedure to
coronally position the grafted tissue over the
exposed root surface.157 158 In the 1980s
modifications of the 1-stage grafting tech-
nique were presented, which from a root cov-
erage point of view was more successful and
predictable than the previous grafting pro-
cedure.159160 Acid conditioning of the ex-
posed root surface before the placement of
the graft was advocated as a critical treat-
ment component for the successful outcome
of the 1-stage procedure.101
The subepithelial connective graft125161 is
usually harvested from the palate by the use
of a "trap door" approach. The graft can be
placed directly on the exposed root and cov-
ered with a coronally or laterally moved mu-
cosal flap,161-165 or placed within an "enve-
lope" prepared by an undermining partial
thickness incision from the soft tissue mar-
gin.166 This grafting technique generally re-
sults in improved esthetics as compared to
the use of an epithelialized soft tissue. Com-
pared to the epithelialized graft the subepi-
thelial connective tissue graft may be pref-
erable from the patient's point of view due to
a less invasive palatal wound and improved
esthetic result.
Summary
Pedicle grafts as well as free soft tissue
grafts, as single or combined procedures,
can be considered justified in the treatment
of recession type defects. Several factors
may influence the selection of a specific
treatment procedure for the individual case;
e.g., the depth and width of the recession de-
fect, the availability of donor tissue, muscle
attachment, and esthetics.
of the Edentulous
Augmentation
Ridge
Reconstruction of alocalized defect in an
edentulous ridge can be achieved by soft tis-
679
sue as well as hard tissue augmentation.
While minor deformities in the ridge may be
successfully restored by the use of pedicle167
or free soft tissue grafts,97 168 larger defects
may today preferably be treated with bone
augmentation procedures such as guided
bone regeneration, with or without the com-
bination with allogenic bone grafts or hy-
droxyapatite.169 The literature on these pro-
cedures is reviewed in Section 11 Implant
Therapy.
IS ROOT COVERAGE A
PREDICTABLE OUTCOME OF
MUCOGINGIVAL SURGERY?
As discussed above, complete root cover-
age may be achievable in Class I and II type
recession defects, while only partial coverage
may be expected in Class III.96 In the major-
ity of studies evaluating the therapeutic ef-
fect of root coverage procedures only Class I
and II defects have been included.
Rotational Flaps
Table 1 presents an overview of clinical
studies on the use of rotational flaps (later-
ally positioned flap and double papilla flap)
for the treatment of exposed root sur-
faces.99128170"177 The follow-up period in the
majority of the studies is 3 to 6 months, al-
though one study reports 36 months of fol-
low-up.171 At teeth with a mean recession
depth of 3 to 5 mm the average percent root
coverage achieved with rotational flaps in
these studies varied between 34% and 74%.
With consideration given to the number of
teeth treated in each study, the calculated
average percentage of root coverage for all
the listed studies is 64%. A closer analysis
of the data indicates that the differences in
amount of root coverage reported in the
studies may to a certain extent be due to dif-
ferences in the width of the recession: less
favorable treatment outcome at sites with
wide recessions (> 3 mm).
To determine the predictability of the pro-
cedure, the percent of treated teeth at which
complete root coverage is achieved is an im-
portant variable. However, only one study
provides such information.176 This study,
Vol. 1, No. 1, November 1996
680 Wennström

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Annals of Periodontology
 Review:
which used the laterally positioned flap in
combination with various forms of root sur-
face treatment, reported 40% to 50% of
treated teeth with complete root coverage.
In terms of probing assessments, all stud-
ies report shallow post-treatment probing
depth, with a mean gain in clinical attach-
ment level varying from 1.7 to 5.1 mm. In the
studies which reported data describing the
gingival dimensions,99 an increase in
170 172 174
gingival height 2.2 4.0 mm was evident
of to
at the follow-up examination. One study
compared the use of full and split thickness
laterally positioned flaps and reported no dif-
ferences between the procedures.172
Coronally Advanced Flap
In Table 2 pertinent data from clinical stud-
ies on the effect of coronally advanced flap for
root coverage are summarized.140178"181 The fol-
low-up period in the listed studies varied
from 5 to 77 months. The mean depth of the
recession defects treated was 2.2 to 4.1 mm.
On average 70% to 99% coverage of the ex-
posed root surface was achieved. Consider-
ing the number of teeth treated in each
study, the calculated average percentage of
root coverage for all the listed studies is
83%. The percent of teeth with complete root
coverage in these studies varied between
24% and 95%. The amount of root coverage
was not found to correlate to the preopera-
tive gingival height.179
Similar to observations reported following
the use of rotational flaps, all studies evalu-
ating the effect of coronally advanced flap for
root coverage revealed shallow residual prob-
ing depth and gain of clinical attachment (Ta-
ble 2). The average gain of clinical attachment
reported amounted to 2.5 to 3.7 mm. A slight
increase in gingival height may also be ex-
pected.
Guided Tissue Regeneration
Clinical data reported in studies on the
use of GTR-barriers in root coverage proce-
dures are presented in Table 3.147-152,182,183 jn
most of the studies an expanded polytetra-
fluorethylene (ePTFE) membrane was used
in combination with a coronally advanced
Mucogingival Therapy 681
flap procedure.147150 Two studies used
182 183
a biodegradable membrane.151152 The mean
depth of the recession defects treated varied
from 4.6 to 6.3 mm, and the time of follow-
up from 6 to 18 months. The mean percent
root coverage achieved in the studies was
54% to 83%. Considering the number of
teeth treated in each study, the calculated
average percentage of root coverage for all
the listed studies is nearly 74%. The per-
cent of treated sites showing complete root
coverage is only reported in 4 of the stud-
ies,148151152182 and ranged from 0 to 42%.
The initial recession depth was not reported
to negatively influence the amount of root
coverage.147 183 However, initial recession
width and membrane exposure had a sig-
nificant negative effect on the treatment
outcome.183 Shallow post-treatment prob-
ing depth was reported in all studies, and
the mean gain in clinical attachment level
varied between 2.8 and 5.5 mm.
One controlled study on the treatment
outcome following coronally advanced flap
with and without the inclusion of a GTR
barrier has been reported.147 The mean per-
cent root coverage at the 18 month follow-
up examination revealed similar degree of
root coverage, but the clinical attachment
gain was significantly greater with the use
of the GTR barrier. In addition, the data
showed a more favorable result with re-
spect to root coverage with the GTR pro-
cedure in sites with deep (> 5 mm)
recession defects as compared to the co-
ronally advanced flap.
Epithelialized Free Soft Tissue Graft-
the 2-Stage Procedure
Table 4 presents an overview of clinical
studies on the use of the 2-stage procedure
for the treatment of exposed root sur-
faces.128147158171184-187 The follow-up period
varied from 2 to 36 months. Mean percent
root coverage established ranged from 36%
to 74%. When considering the number of
teeth treated in each study, the calculated av-
erage percentage of root coverage for the
studies is nearly 63%. Minimal residual prob-
ing depth as well as improved clinical attach-
ment level were observed in all studies.
Vol. 1, No. 1, November 1996
682 Wennström

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Annals of Periodontology
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Annais of Periodontology
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Voi. J, No. J, November 1996

686
Epithelialized Free Soft Tissue Graft
An overview of studies on the effect of the free
soft tissue graft as a means for root coverage is
presented Table 5.102,159,160,177,187-197 ^ mean
in
initial depth of the recessions included was
2.1 mm to 5.1 mm. The mean percent root
coverage obtained with the free soft tissue
graft procedure varied between 11% and
87%, with the greatest success in narrow
and shallow recession defects. Considering
the number of teeth treated in each study,
the calculated average percentage of root
coverage studies is 72%. The predictability
of complete root coverage ranged from 0% to
90%, with an average of 57%. In one study159
a predictability of 100% was reported for
Class I recession. The procedure consis-
tently resulted in minimal probing depth.
The mean gain in clinical attachment level
ranged from 1.6 to 5.3 mm.
Free Connective Tissue Graft
Table 6 describes studies on the effect of
free connective tissue grafts in the treatment
of recession defects.103'162'164'166'181'194-196'198-201
The mean initial depth of the treated reces-
sions ranged from 3.3 mm to 5.9 mm. The
outcome of this mode of surgical treatment
in terms of mean percent root coverage was
52% to 98%. When considering the number
of teeth treated in each study, the calculated
average percentage of root coverage for all
the listed studies is 91%. In 9 of the 12 stud-
ies, the predictability of complete root cov-
erage was reported, showing a range of 27%
to 89%, with an average of 66%.
Short-term clinical studies comparing the
treatment effect of the connective tissue
graft and epithelialized soft tissue graft (Ta-
ble 6) demonstrate significant difference in
terms of root coverage between the two pro-
cedures.194"196 In all three studies the con-
nective tissue graft was found to be superior
to the epithelialized soft tissue graft.
Summary
Evidence suggest that root coverage is a
predictable outcome of mucogingival surgery
in Class I and II recession defects. Shallow
Annals of Periodontology
Wennström
probing depth will be the result following all
procedures. No single treatment procedure
is superior to all the others. Results pre-
sented from comparative studies on the use
of free grafts for root coverage favor the con-
nective tissue grafts over epithelialized soft
tissue grafts.194"196 Further studies are
needed to define factors that may be critical
for the predictability of the treatment out-
come for the various procedures. Also, the
development of treatment procedures for im-
proved possibilities for root coverage in
Class III recession defects are highly desir-
able.
WHAT IS THE ROLE OF ROOT
SURFACE MODIFICATION IN
MUCOGINGIVAL PROCEDURES
AIMED AT ROOT COVERAGE?
Root Planing
Before root coverage is attempted, the de-
tached portion of the root should be ren-
dered free from bacterial plaque. Whether
extensive root planing has to be performed
is more doubtful, particularly on root sur-
faces that have been exposed due to tooth-
brushing trauma. Controlled experimental202
and clinical studies203 have demonstrated no
differences in the healing result following
periodontal surgery with or without root
planing. In a controlled clinical trial on the
treatment of recession type defects, no sta-
tistical differences were found in terms of
root coverage or residual probing depth be-
tween teeth which had been instrumented
(root planing) and controls.176 Hence, evi-
dence suggests that intentional removal of
root structures through root planing is not a
critical factor for the outcome of mucogin-
gival surgery. However, root planing is indi-
cated for removal of surface irregularities
and grooves as well as shallow root caries
lesions.
Extensive root planing or grinding, in or-
der to reduce the convexity of the root and
to minimize the mesiodistal avascular recip-
ient bed in free graft procedures has been
suggested.159 160 In GTR, grinding has been
performed to produce a flattened or concave
 Review: Mucogingival Therapy 687

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VoL j, JVo. j, November 1996

688
profile of the root surface to create space for
tissue regeneration.148 With the use of tita-
nium-reinforced membranes grinding may
not be necessary for establishing the re-
quired space for tissue regeneration.150
Whether or not reduction of root convexity
may influence the long-term stability of sur-
gically-achieved root coverage has not been
evaluated.
Root Surface Conditioning
The of root surface demineralization
use
agents has been advocated as an important
treatment component in root coverage pro-
cedures, particularly in conjunction with
free soft tissue grafts.159204 Citric acid has
been the most commonly used agent, but
tetracycline HCl has been used in some
studies.103 164 In addition to the removal of
the smear layer, the use of acid deminerali-
zation of the root surface is intended to fa-
cilitate the formation of a new fibrous
attachment through exposure of collagen fi-
brils of the dentin matrix and allow subse-
quent interdigitation of these fibrils with
those in the covering connective tissue.205'206
Articles on the use of root conditioning in
conjunction with root coverage procedures are
summarized in Table 7.99.102-103,140,159464,175,180,
182,185,187,188,193,196,197,201 Controlled clinical trials
comparing the effect of free gingival graft pro-
cedures with and without root condition-
ingis7,193,197,201 <jid not demonstrate any
beneficial clinical effect from the use of cit-
ric acid. Also controlled studies comparing
the211 effect of laterally positioned flap with
and without root conditioning showed no
statistically significant positive effect with
the use of citric acid.99 175 No controlled
studies on the effect of tetracycline HCl are
available.
The healing following treatment of local-
ized gingival recessions with coronally posi-
tioned flaps and citric acid was evaluated in
a controlled study in dogs.207 Histological
analysis after 3 months of healing disclosed
no differences in the amount of root coverage
or new connective tissue attachment be-
tween citric acid treated sites and saline
treated control sites, but root resorption was
Annals of Periodontology
Wennström
a common finding among the citric acid
treated teeth. From a study with similar de-
sign performed in monkeys, it was con-
cluded that citric acid application did not
result in enhanced clinical root coverage, al-
though significantly greater amount of new
connective tissue attachment was noted.208
There is no report showing that root re-
sorption is a common finding in humans fol-
lowing the use of citric acid root biomodifi-
cation.
Summary
The evidence suggests that there is no
beneficial clinical effect of the use of root
conditioning with citric acid in conjunction
with root coverage procedures.
WHAT DENTO-GINGIVAL ANATOMY
WILL BECOME ESTABLISHED
FOLLOWING ROOT COVERAGE
PROCEDURES?
For obvious reasons evaluation of the type
of healing against previously detached root
surfaces following root coverage procedures
cannot be studied in humans except in iso-
lated case reports. Animal studies providing
information on the healing following root cov-
erage procedures are listed in Table 8.207-212
Healing where a pedicle graft was placed
in contact with the denuded root surface has
been studied in dogs211 and in monkeys.212
After 2 to 3 months of healing, bundles of
collagen fibers were found inserting into a
cementum layer on the curetted root surface
in the apical portion of the recession in
dogs.211 Retraction of the gingival margin
amounted to 50% of the initially covered por-
tion of the defect, while a new connective tis-
sue attachment of about 2 mm (50%), and
an epithelial attachment of the same height
had formed in the portion of the defect suc-
cessfully covered by soft tissue.211 The monkey
study212 reported that 44% of the successfully
covered recession in monkeys demonstrated
new connective tissue attachment after 35
days of healing. These observations are in ac-
cordance with results from a study in dogs us-
ing a coronally advanced flap for coverage of
experimentally-produced recession type de-
 Review: Mucogingival Therapy 689

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690 Wennström

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Annais of Periodontology
 Review: Mucogingival Therapy 691

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Vol. J, Wo. J, November 1996

692 Wennström
fects.207 The authors found after 3 months of
healing that, on average, 20% of the apico-co-
ronal length of the original defect had been ex-
posed due to recession (i.e., about 80% root
coverage was achieved), 40% was covered by
epithelium, and 40% demonstrated new con-
nective tissue attachment. The newly formed
cementum was consistently in continuity with
the original cementum in the apical, non-in-
strumented portion of the roots, indicating
that the newly formed attachment was pro-
duced by cells originating from the periodontal
ligament. In a study performed in monkeys,209
38% of the successfully covered recession de-
fects using a coronally advanced flap demon-
strated formation of new connective tissue
attachment. The use of a GTR membrane be-
tween the root surface and the coronally ad-
vanced flap was found to generate significantly
more new connective tissue attachment (79%
of the covered recession defect).209
A few case reports with human block sec-
tions following treatment of recession de-
fects with pedicle or free graft procedures are
available in the literature (Table 9),213-216 pro-
viding evidence that new connective tissue
attachment may be formed following root
coverage procedures. Histological evaluation
of two teeth treated with a laterally posi-
tioned flap213 showed that about 26% of the
covered root surface showed connective tis-
sue attachment, but partly without evidence
of cementum formation. In surgically cre-
ated recession defects new cementum for-
mation with parallel oriented connective
tissue fibers was observed after citric acid
root demineralization but not on control
roots.214 Histological evaluation of a tooth
treated with GTR procedure demonstrated
connective tissue attachment formation
amounting to 74% of the length of the suc-
cessfully covered root portion.215 New ce-
mentum with inserting collagen fibers; i.e.,
new connective tissue attachment, covered
48% of the distance between the apical bor-
der of the root instrumentation and the soft
tissue margin.
Although new connective tissue attach-
ment may only be formed in a limited part of
the recession defect, pedicle graft proce-
dures evidently rarely result in the formation
of a deep periodontal pocket. Furthermore,
Annals of Periodontology
evidence suggests that GTR results in
greater amounts of new attachment forma-
tion, but the outcome in terms of root cov-
erage and pocket closure does not appear
superior to that achieved by traditional ped-
icle graft procedures (Tables 2 and 3). How-
ever, whether a connective tissue attach-
ment is more favorable than an epithelium
attachment for the long-term stability of the
position of the soft tissue margin, and
whether GTR procedures can improve the
clinical result in Class III recessions need to
be evaluated.
The nature of the attachment following
the use of free grafts also remains a ques-
tion. It is likely, however, that a healing pat-
tern similar to the one discussed above
following pedicle graft procedures will result,
namely that new connective tissue attach-
ment will be established in the apical and
lateral parts of the recession defect, while an
epithelial attachment is formed in the coro-
nal and mid-buccal portion of the root. His-
tological evaluation 42 weeks after treatment
of a narrow recession defect with root bio-
modification (tetracycline HCl) and an epithe-
lialized free soft tissue graft was recently
reported (Table 9).216 The root coverage
amounted to 5 mm or 83% of the original re-
cession. The epithelial lining was found to
terminate 2.6 mm below the gingival margin,
and the most coronally positioned new ce-
mentum with inserting connective tissue fi-
bers was seen 3.4 mm apical to the gingival
margin. No histological reference for the ap-
ical extension of the original defect was
available, but based on extrapolations from
pretreatment probing assessments, the au-
thor216 estimated that 3.6 mm of new attach-
ment had formed, corresponding to 51% of
the apico-coronal length of the covered, pre-
viously detached root portion.
Summary
There is histological evidence that healing
following both pedicle and free graft root cov-
erage procedures results in the formation of
some new connective tissue attachment. The
clinical significance of a possible enhanced
healing through the formation of new con-
nective tissue attachment with the use of
 Review: Mucogingival Therapy 693

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Vol. 1, No. 1, November 1996

694 Wennström
root biomodifications and GTR barriers re-
mains to be evaluated.
WHAT IS THE LONG-TERM
STABILITY OF THE HEALING
RESULT FOLLOWING
MUCOGINGIVAL PROCEDURES?
Augmentation of the Dimensions of
Gingival Tissue
follow-up periods of up 4 to
Studies with
5 years3342 have reported long-term
129 191
stability surgically increased apico-coro-
of
nal width of gingiva. Whether also an in-
creased gingival thickness will demonstrate
clinical stability over time has not been eval-
uated.
Root Procedures
Coverage
The majority of the reports on the effect of
various root coverage procedures have a fol-
low-up of less than 1 year (Tables 1 to 6).
One study on the treatment with laterally
positioned flap (Table 1) reports 3 years of
follow-up.171 The mean root coverage was re-
ported to be more or less unchanged when
compared to the 6 months post-treatment
evaluation. With regard to the coronally ad-
vanced flap procedure (Table 2), one study
with a 3-year171 and one study with a 5- to
8-year179 maintenance interval are available.
These studies report 70% to 74% root cov-
erage, a figure which is comparable to data
from studies of shorter duration. GTR pro-
cedures in the treatment of recession type
defects have only been used since the early
1990s, and so far no study with follow-up of
more than 18 months is available. Data from
long-term studies on the use of free grafts
indicate maintained root coverage over per-
iods of 4 to 5 years with epithelialized191192
as well as with connective tissue grafts.162199
The results from the long-term studies
discussed suggest stability over time irre-
spective of the surgical procedure used to
achieve root coverage. Of importance for the
long-term outcome of root coverage proce-
dures is that the major etiologic factors for
the development of recessions; i.e., tooth-
Annals of Periodontology
brushing trauma and plaque-induced in-
flammation, are kept under control.
Augmentation of the Edentulous
Ridge
There are no data available in the litera-
ture regarding the long-term stability of lo-
calized ridge augmentation with soft tissue
grafts.
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21. Corn H. Periosteal separation—Its clinical signifi-
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