Periodontology

Enhanced CPD DO C

Joshua Hudson

Ulpee Darbar

Gingival Recession.
Part 2: Treatment Options and
When to Intervene Surgically
Abstract: This is the second article in a two-part series on gingival recession. The first article covered the aetiology and prevalence of
gingival recession, while this article focuses on the factors affecting decision making and the management, including treatment of gingival
recession alongside the evidence base. With more than half of the population suffering from gingival recession, the clinician should be
aware of the different options and treatment modalities available to manage gingival recession. This will enable them to engage with the
patient, giving them the necessary and required information to make a patient-centred decision about the most suitable treatment option
that will address their concerns.
CPD/Clinical Relevance: The clinician should be aware of the different options and treatment modalities available to manage
gingival recession.
Dent Update 2024; 51: 243–250

The first article of this two-part series complain of compromised aesthetics and
discussed the prevalence, aetiology and hypersensitivity, usually exacerbated by an
classification of gingival recession. In this associated habit, such as traumatic tooth
article, the different treatment options for brushing. The recession may also contribute
managing gingival recession are discussed to compromised plaque control especially
with an option appraisal of the different when there are high muscle attachments
treatment modalities and when intervention (Figure 1). However, it has been reported that
should be considered. irrespective of good patient motivation and
Gingival recession usually affects the plaque control, untreated gingival recession Figure 1. High muscle attachment inhibiting
buccal surfaces of teeth, with recession does have the tendency for further apical effective plaque control and subsequent
of 1 mm or more involving at least one or displacement over time.2 gingival recession.
more sites in more than half the population.1 This article provides an overview
Gingival recession per se tends to remain of the decision-making process for the
asymptomatic; however, some patients may management of patients with gingival
recession not caused by periodontal
disease, and covers the different types of
surgical procedures available.
Joshua Hudson, BDS, MFDS, RCPS (Glasg), FHEA, PGCert Specialty Registrar in
Restorative Dentistry, Charles Clifford Dental Hospital, Sheffield. Ulpee Darbar, BDS, Decision to treat
MSc, FDS (Rest Dent), RCS FHEA, PGCert Consultant in Restorative Dentistry; Eastman
The decision to treat gingival recession is
Dental Hospital, London.
driven by patient expectations and site/
email: joshua.hudson@nhs.net
tooth-related factors that will determine

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 Periodontology
Figure 2. Treatment decision-making algorithm for patients with gingival recession.
Dentine sensitivity
Aesthetic concerns
Non-carious tooth surface loss
Inability to maintain adequate oral
hygiene around the defect
Progression of recession defect over time
Table 1. Indications for the treatment of
gingival recession.
the risk and rate of deterioration of the
recession (Table 1). Patients with gingival
recession fall into two categories, those
who are asymptomatic and those who are
symptomatic. Asymptomatic patients will
either be aware or unaware of the recession
and are often unconcerned by its presence.
Symptomatic patients on the other hand
will have specific needs dictated by their
symptoms, i.e. sensitivity or aesthetics.
The presence of predisposing factors
and precipitating factors should be
considered for all patients with gingival
recession. In addition to the normal clinical
parameters, such as plaque control and
probing depths that are recorded as part
of their clinical assessment, for all patients,
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Identification of key aetiological agents
Patient education on the condition
Oral hygiene instruction and correction of
tooth brushing technique
Smoking cessation
Application of desensitizing agents
Removal of sources of trauma (e.g.
piercings and poor toothbrush technique)
Management of periodontal disease
Table 2. List of gingival recession
prevention strategies.
irrespective of their category, the following
should also be considered:
 Generalized or localized recession: if
localized how many sites?
 Is there keratinized gingival tissue
present? i.e. none or <2 mm;
 Gingival tissue biotype: thin vs thick;
 Are there any site-related factors?
e.g. root position, muscle attachments
 Are there any habits? e.g. picking at
the gingivae;
 Are there any other factors?
e.g. tongue studs;
 Is there any periodontal disease?
Once this information has been
gathered as part of the history, the patients’
expectations should be established and a
preventive care plan, outlined in Table 2,
agreed with the patient. This plan should
be established for both asymptomatic
and symptomatic patients, with the
preventive strategy aiming to improve
patient awareness about their gingival
recession and their role in managing it.
There should also be a focus on managing
and correcting any modifiable aetiological
factors, including traumatic brushing
techniques or habits that are exacerbating
the recession, with adjunctive scaling and
polishing and application of desensitizing
agents where necessary.
The role of traumatic tooth brushing in
recession has been reported, and correcting
the brushing technique is a vital first step in
the management of the gingival recession
even when there are no obvious signs
of toothbrush trauma.3 The preventive
phase will also provide the opportunity of
evaluating the patient’s expectations and
their compliance. Once this phase has been
completed an appraisal of the options,
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Figure 3. Digital scans, such as this scan of the
mandible, can allow review of the recession
around these lower incisors over time.
a managed satisfactorily non-surgically
c study casts offer a more reliable means of
Figure 4. (a–c) Use of a gingival mask to treat
generalized recession defects.
whether to monitor the recession or
surgically intervene, should be undertaken.
A patient-centred decision should be
made so that the patient’s expectations
and aspirations can be met. Figure 2
suggests the decision-making algorithm to
be followed.
Monitoring the
gingival recession
This option is usually undertaken when
there are no symptoms from the recession,
the patient decides not to have anything
done, or there is a low risk of progressive
deterioration over time. The risk of
deterioration will be dependent on the
patient’s habits and the local factors,
such as the tooth position, gingival tissue
biotype and presence of keratinized tissue
and muscle attachments.
Monitoring is usually undertaken
following patient education, and includes
recording recession charts, photographs
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Indications5,24
Documented evidence of progressing gingival
recession despite appropriate advice and
therapeutic intervention
Anatomical variation, such as shallow vestibular
depth, aberrant frenum position, absence or a
narrow band of keratinized tissue (<2 mm) where
poor oral hygiene has induced gingival inflammation
despite therapeutic intervention being undertaken
The patient has aesthetic concerns that cannot be
Orthodontic or restorative treatment is to be
undertaken on a tooth with predisposing factors or
the presence of any of the above
Table 3. Indications and contraindications for surgical intervention.
and study casts. The recording of recession
can be an unreliable measure, especially
due to the variation in the probe angulation
and position, and thus photographs and
monitoring the recession over time.
The recession should be monitored
annually and, along with the above
parameters, should include a
comprehensive periodontal examination
and any changes in the patient’s history
and symptoms. Digitally scanned images,
which allow the superimposition of the
previous and up-to-date images, can also
be used with the key advantage of these
providing a direct comparison of the
change in the recession defects (Figure 3).
Treatment of
gingival recession
In cases where there is a risk of progressive
deterioration due to various factors listed
above, or there are symptoms or concerns
raised by the patient, intervention using
a non-surgical or surgical approach may
need to be considered.
Non-surgical approach
Different non-surgical options can be
considered to treat gingival recession and
their use will be dictated by the extent and
location of the recession and its severity.
Different restorative options, including
veneers, crowns or gingival masks, can be
used to treat gingival recession however,
such options are usually not suitable for
localized recession defects. The gingival
mask is beneficial in cases where there
Periodontology
Contraindications25
Smoking
Poor oral hygiene and active
periodontal disease
Large defects where surgery
outcomes are unpredictable
(e.g. Millers Class IV)
is generalized recession as a result
of periodontal disease with residual
recession and ‘black triangles’ (Figure 4).
Orthodontic intervention can also be
used to treat gingival recession, however,
in such cases, further surgical intervention
is often required.4
Surgical approach
The surgical approach to treating gingival
recession aims to address concerns the
patient may have about the appearance,
or alternatively to manage any local
anatomical factors that may influence
the future progression of the recession.
These include thin gingival tissue biotype,
absence or presence of a narrow band
(<2 mm) of keratinized tissue, and
recession extending beyond the depths
of the mucogingival junction.5 A full list
of indications and contraindications is
presented in Table 3.
In patients who have aesthetic
concerns, the rationale for the surgical
intervention is to obtain root coverage.
Flap thickness >0.8 mm is reported to
be a stronger indicator of complete
root coverage, and where this is not
achievable, biotype modification has
been proposed.6,7 Thus, when any surgical
intervention is being considered, it is
critical that the clinician is clear about
the objective of the surgical intervention
and the anticipated endpoint. This
clarity will help ensure that effective
communication with the patient takes
place, thus ensuring that the patient
expectations are managed, especially in
situations where complete root coverage
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 Periodontology
a a
b Figure 7. Harvesting a CTG with an epithelial
c prevent progression?
Figure 5. (a–c) Patient with recession defect
treated with CTG and coronal advancement flap
with the aim of achieving root coverage. Courtesy
of Hong Jin Tan
is not achievable. When surgical treatment
is being planned the clinician must ask the
following questions:
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pg243-249 Hudson Pt2.indd 246
Figure 6. Patient with a narrow band of
keratinized tissue (a) before and (b) after
FGG procedure.
b
 Is there enough keratinized tissue?
 Are there any muscle attachments?
 What is the gingival tissue biotype,
thin or thick?
 How prominent is the root in the
alveolar housing?
 Are there any cervical restorations?
 What do I want to do – achieve
root coverage or increase the
band of keratinized tissue to
Depending on the answers to the
above questions, the clinician will be
able to plan the appropriate surgical
treatment and communicate this with
the patient. This ensures that the patient
fully understands the proposed surgery
and the anticipated endpoint, especially
if this is at variance to what the patient
is expecting. Root coverage procedures
are planned to cover root surfaces when
hypersensitivity and/or aesthetics are of
concern. In contrast, when there is lack
of keratinized tissue, the objective of the
surgical intervention will be to increase
the band of keratinized tissue in the first
instance, and not necessarily cover the
root surface.
Root coverage techniques are
undertaken with either a coronally
advanced flap alone, or more commonly
with a connective tissue graft (CTG) taken
from the palate (Figure 5). In contrast,
free gingival grafts (FGG) are taken when
increased keratinized tissue is needed and
collar can not only increase the band of
keratinized tissue present at the recipient site, but
also improve graft handling.
Figure 8. (a,b) This patient has undergone FGG
to increase the band of keratinized tissue, but
creep of the gingival margin over time has also
led to increased root coverage.
usually have unpredictable results when
considered for root coverage (Figure 6).
Alternative materials are also available
instead of the autogenous grafts for root
coverage and enhancing tissue thickness.
These off-the-shelf materials help overcome
the disadvantages associated with
second-site morbidity and quantity. These
materials act as scaffolds for fibroblasts
and endothelial cells to build up new
connective tissue and promote epithelial
cell migration from the borders of the
adjacent tissue over the matrix.
Autogenous material demonstrates
better outcomes in relation to mean
root coverage and the percentage of
sites exhibiting complete coverage than
alternative materials.8 While guided tissue
regeneration using barriers has been
proposed for root coverage procedures,
owing to the risks with membrane
exposure and adverse outcomes, the
technique has not gained widespread
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a tissue stability and long-term outcome
b
c terms of keratinized tissue gain as well as
Figure 9. (a–c) Use of a CTG with epithelial collar
to concurrently increase keratinized tissue, tissue
thickness, as well as achieve metal coverage
around a dental implant.
use.9 Other materials, such as enamel
matrix-derived proteins, have also been
advocated; however, the evidence
base behind the use of these and their
outcomes remains limited.9
Techniques
Coronally advanced flap (CAF)
This is the most widely used flap design for
root coverage, first described by Norberg
in 1926,10 and has since undergone several
modifications. The flap uses a split-full-
split approach to overcome issues with
scar tissue formation and blood supply.
The procedure was modified with no
vertical releasing incisions for use with
multiple recession defects by Zuchelli and
De Sanctis.11 In cases where there is at
least 2 mm of keratinized tissue beyond
the recession defect, and at least 1 mm
of gingival tissue thickness with no other
anatomical factors, then the CAF on its
own will give good results. However,
for most cases, predictability, gingival
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is improved when a CTG is used with the
CAF.12 This is especially relevant if there
are muscle attachments or thin to no
keratinized tissue. In these cases, harvesting
a CTG with an epithelial collar should be
considered to enable a concurrent increase
in both keratinized tissue width and overall
tissue thickness, while also improving the
graft handling properties (Figures 7–9).
The CAF with a CTG has been reported
to be the gold standard for root coverage
for both single and multiple recession
defects.12,13 The European Federation of
Periodontology (EFP) suggest that CTG
with enamel matrix derivatives (EMD)
have better outcomes than CTG alone;
however, CTG with CAF demonstrates
significantly better outcomes than both in
recession reduction.9
Tunnelling techniques
Tunnelling techniques have also been used,
either full thickness or partial thickness,
depending on the gingival tissue biotype,
for root coverage with a CTG. Studies have
shown no significant differences between
the tunnelling technique and CAF and
connective tissue in terms of root coverage;
however, others have indicated a superior
clinical outcome with a CAF.14–16 Tunnelling
techniques are challenging, and both
operator- and technique-sensitive.
Other techniques
The double papilla flap and laterally
sliding flaps with a CTG have also been
used for root coverage procedures;
however, these flaps tend to be technique-
sensitive and in the authors’ experience,
often some unzipping of the flap occurs
during the healing phase with suboptimal
outcomes.8,17,18 A full range of techniques,
their indications advantages and
disadvantages are presented in Table 4.
Increasing keratinized tissue
Techniques using FGG are aimed at
increasing the band of keratinized/
attached gingivae, and removing aberrant
frenal/muscle attachments or shallow
vestibules. Although it has been shown that
keratinized tissue is not needed for health,
the lack of keratinized tissue compromises
the patient’s ability to maintain plaque
control, thereby leading to inflammation.19
The FGG, in small recession defects can
be placed directly over the denuded root
Periodontology
surface to obtain increased keratinized
tissue and coverage.20 For deep recession
defects where there is <2 mm or lack of
keratinized tissue, the FGG is placed to
obtain an increase in the keratinized tissue.
If root coverage is subsequently desired, a
CAF with a CTG, as described above, can
then be undertaken. The success rate of
FGG varies widely, between 11% and 100%,
when success is defined by root coverage,
with an average increase in keratinized
tissue width in the year post surgery
of 4.2 mm.21,22
Creeping attachment is often seen
after FGG are placed and is a result of the
coronal migration of the grafted gingivae.
This can take place over several years
following the surgery.23 The amount of
creep that takes place is determined by the
width of the recession, the positions of the
graft and the tooth, and the oral hygiene
of the patient.23 Narrow recession defects,
where the graft has been placed over
the denuded zone, show the most creep
leading to complete root coverage. Figure 8
shows a case where a FGG was used in a
narrow recession defect to increase the
keratinized tissue with coronal creep taking
place over a period of time.
Dehiscences/recession defects
around dental implants
Peri-implant soft tissue dehiscences or
recession defects have been reported,
and while the techniques outlined above
can be considered to treat these, it is
important to appreciate that the outcome
will be dependent on several factors. These
include the bucco-lingual position of the
implant, the shape of the implant-retained
crown, and the height of the anatomical
papillae. These factors will need to be taken
into consideration when establishing the
objective for intervention to ensure that
the correct choice has been adopted for
treatment. The benefit of keratinized tissue
around dental implants has been reported,
and has been shown to reduce the risk of
peri-implant mucositis and inflammation.24
Figure 9 shows the use of CTG with an
epithelial collar to concurrently increase
keratinized tissue, tissue thickness and
achieve exposed metal coverage around a
dental implant.
Long-term maintenance
Once the treatment for the gingival
recession has been completed, the patient
should be followed up and documented
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 Periodontology

Surgery type Indications Advantages Disadvantages

Laterally Single site recession defects  Retains its own blood supply  Adequate width of adjacent
repositioned flap18 with adequate thickness of  Single-site surgery so less morbidity tissue needed (twice the
keratinized tissue adjacent width of the recession defect)
to the defect  Cannot be used to treat
multiple recession defects
 Not possible if there is
inadequate keratinized tissue
width or thin gingival biotype
unless completed alongside
another procedure
Free gingival graft20 Where there is an  Predictably increases keratinized tissue  Second surgical site with
inadequate thickness width increased morbidity
of keratinized tissue or  Able to be undertaken even if thin gingival  Poorer aesthetic outcome
inadequate vestibular depth tissues +/- lack of width of keratinized owing to differences in
tissue graft colour
 Can increase vestibular depth  Unpredictable root coverage
 Does not retain its own
blood supply
Coronally Single or multiple recession  High predictability  Not possible if there is
advanced flap27 defects where root  Single-site surgery so less morbidity inadequate keratinized tissue
coverage is the desired  High percentage of root coverage width or a thin gingival
outcome and there is  Can treat multiple defects biotype unless completed
an adequate width of  Can be combined with: CTG; GTR; ADMG; alongside another procedure
keratinized gingivae and a EMD; XMG; or other biomaterials  Requires adequate
deep vestibule  Good aesthetics vestibular depth
 Retains its own blood supply
Connective This can be combined  High predictability  Second surgical site with
tissue graft28 with coronal advancement  High percentage of root coverage increased morbidity
surgery to increase the  Allows coronal advancement surgery to be when compared to
thickness of the gingival used even with thin gingival biotype alloplastic biomaterials
tissue covering the  Good aesthetics  Not suitable if thin width
recession defects in thin of keratinized tissue
gingival biotypes  Requires adequate
vestibular depth
Tunnelling Multiple recession defects  Can be used to treat multiple recession  Technique sensitive
technique14 where root coverage is defects  Requires large donor
the treatment aim and  Produces less scaring due to no relieving site resulting in
early aesthetic healing incisions, improving aesthetics increased morbidity
is essential  Faster healing as fewer surgical incisions
 High percentage of root coverage and
predictability if undertaken successfully
Modified coronally Multiple recession defects  Envelope flap design reduces scarring as no  Requires thick
advanced flap11 where root coverage is the relieving incisions, improving aesthetics gingival biotype
treatment aim and aesthetic  Can be used to treat multiple  Technique-sensitive
healing is essential recession defects
 Single site so less morbidity
 Retains its own blood supply
Table 4. Indications, advantages and disadvantages for each surgery type. CTG: connective tissue graft; GTR: guided tissue regeneration; ADMG: acellular
dermal matrix grafts; EMD: enamel matrix derivatives; XMG: xenogenic matrix graft.

on a regular basis to monitor the stability the outcome achieved against this desired noted and these parameters should be
of the grafted sites. This should include objective. Aetiological factors, including evaluated when monitoring the site during
a summary of the treatment completed, the patient’s brushing technique and the recall period. Over time other patient-
the objective of treatment and a record of correction of these factors, should also be related factors, as well as the ongoing tooth

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brushing technique, should continue to
be monitored, and the patient reminded
of the influence of these on the treatment
outcome. Predictable and successful
treatment outcomes can be achieved when
recession is managed effectively; however,
patient engagement and understanding is
of key importance for long-term outcomes
to be sustained.
Conclusion
This article highlights the importance of
the clinician being aware of the factors that
influence the presence of gingival recession
and the role the clinician plays in raising
the patient’s awareness of these factors if
the treatment of the gingival recession is to
be successful. The role of the first phase of
treatment, with prevention and correction
of the modifiable and susceptibility factors,
has been highlighted with the different
options for treatment underpinned by the
evidence base. Successful outcome of the
surgical treatment is dependent on careful
and structured planning, with the objective
of the treatment being considered to
ensure that the patient is given the correct
information to aid their decision making.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Kassab MM, Cohen RE. The etiology and
prevalence of gingival recession. J Am Dent
Assoc 2003; 134: 220–225. https://doi.
org/10.14219/jada.archive.2003.0137
2. Chambrone L, Tatakis DN. Long-term
outcomes of untreated buccal gingival
recessions: a systematic review and meta-
analysis. J Periodontol 2016; 87: 796–808.
https://doi.org/10.1902/jop.2016.150625
3 Khocht A, Simon G, Person P, Denepitiya
JL. Gingival recession in relation to history
of hard toothbrush use. J Periodontol 1993;
64: 900–905. https://doi.org/10.1902/
jop.1993.64.9.900
4.. Jati AS, Furquim LZ, Consolaro A. Gingival
recession: its causes and types, and the
importance of orthodontic treatment.
Dental Press J Orthod 2016; 21: 18–29.
https://doi.org/10.1590/2177-6709.21.3.018-
029.oin
5. Chan HL, Chun YH, MacEachern M, Oates
TW. Does gingival recession require surgical
treatment? Dent Clin North Am 2015;
April 2024
pg243-249 Hudson Pt2.indd 249
59: 981–996. https://doi.org/10.1016/j.
cden.2015.06.010
6. Baldi C, Pini-Prato G, Pagliaro U et al.
Coronally advanced flap procedure for
root coverage. Is flap thickness a relevant
predictor to achieve root coverage? A
19-case series. J Periodontol 1999; 70:
1077–1084. https://doi.org/10.1902/
jop.1999.70.9.1077
7. Hwang D, Wang HL. Flap thickness as a
predictor of root coverage: a systematic
review. J Periodontol 2006; 77: 1625–1634.
https://doi.org/10.1902/jop.2006.060107
8. Cairo F. Periodontal plastic surgery of
gingival recessions at single and multiple
teeth. Periodontol 2000 2017; 75: 296–316.
https://doi.org/10.1111/prd.12186
9. Cairo F, Nieri M, Pagliaro U. Efficacy of
periodontal plastic surgery procedures in
the treatment of localized facial gingival
recessions. A systematic review. J Clin
Periodontol 2014; 41 Suppl 15: S44–62.
https://doi.org/10.1111/jcpe.12182. PMID:
24641000.
10. Norberg O. Ar en utlakning utan
vovnadsfortust otankbar vid kirurgisk
behandling av. S. K. Alveolarpyorrhoe?
Svensk Tandlaekare Tidskrift 1926; 19: 171.
11. Zucchelli G, De Sanctis M. Treatment of
multiple recession-type defects in patients
with esthetic demands. J Periodontol 2000;
71: 1506–1514. https://doi.org/10.1902/
jop.2000.71.9.1506
12. Chambrone L, Ortega MAS, Sukekava F et
al. Root coverage procedures for treating
single and multiple recession-type defects:
an updated Cochrane systematic review. J
Periodontol 2019; 90: 1399–1422. https://doi.
org/10.1002/JPER.19-0079
13. Buti J, Baccini M, Nieri M et al. Bayesian
network meta-analysis of root coverage
procedures: ranking efficacy and
identification of best treatment. J Clin
Periodontol 2013; 40: 372–386. https://doi.
org/10.1111/jcpe.12028
14. Allen AL. Use of the supraperiosteal
envelope in soft tissue grafting for root
coverage. I. Rationale and technique. Int
J Periodontics Restorative Dent 1994; 14:
216–227.
15. Salem S, Salhi L, Seidel L et al. Tunnel/pouch
versus coronally advanced flap combined
with a connective tissue graft for the
treatment of maxillary gingival recessions:
four-year follow-up of a randomized
controlled trial. J Clin Med 2020; 9: 2641.
https://doi.org/10.3390/jcm9082641
16. Santamaria MP, Neves FLDS, Silveira CA et
al. Connective tissue graft and tunnel or
trapezoidal flap for the treatment of single
maxillary gingival recessions: a randomized
Periodontology
clinical trial. J Clin Periodontol 2017;
44: 540–547. https://doi.org/10.1111/
jcpe.12714
17. Cohen DW, Ross SE. The double papillae
repositioned flap in periodontal therapy.
J Periodontol 1968; 39: 65–70. https://doi.
org/10.1902/jop.1968.39.2.65
18. Grupe HE, Warren RF. Repair of gingival
defects by a sliding flap operation. J
Periodontol 1956. https://doi.org/10.1902/
jop.1956.27.2.92
19. Wennström J, Lindhe J, Nyman S. Role of
keratinized gingiva for gingival health.
Clinical and histologic study of normal and
regenerated gingival tissue in dogs. J Clin
Periodontol 1981; 8: 311–328. https://doi.
org/10.1111/j.1600-051x.1981.tb02041.x
20. Sullivan HC, Atkins JH. Free autogenous
gingival grafts. I. Principles of successful
grafting. Periodontics 1968; 6: 121–129.
21. Wennström JL. Mucogingival therapy. Ann
Periodontol 1996; 1: 671–701. https://doi.
org/10.1902/annals.1996.1.1.671
22. Agudio G, Nieri M, Rotundo R et al. Free
gingival grafts to increase keratinized
tissue: a retrospective long-term
evaluation (10 to 25 years) of outcomes. J
Periodontol 2008; 79: 587–594. https://doi.
org/10.1902/jop.2008.070414
23. Matter J, Cimasoni G. Creeping attachment
after free gingival grafts. J Periodontol.
1976; 47: 574–579. https://doi.
org/10.1902/jop.1976.47.10.574
24. Souza AB, Tormena M, Matarazzo
F, Araújo MG. The influence of peri-
implant keratinized mucosa on brushing
discomfort and peri-implant tissue health.
Clin Oral Implants Res 2016; 27: 650–655.
https://doi.org/10.1111/clr.12703
25. Merijohn GK. Management and prevention
of gingival recession. Periodontol
2000 2016; 71: 228–242. https://doi.
org/10.1111/prd.12115
26. Chambrone L, Chambrone D, Pustiglioni FE
et al. The influence of tobacco smoking on
the outcomes achieved by root-coverage
procedures: a systematic review. J Am Dent
Assoc 2009; 140: 294–306. https://doi.
org/10.14219/jada.archive.2009.0158
27. Bernimoulin JP, Lüscher B, Mühlemann
HR. Coronally repositioned periodontal
flap. Clinical evaluation after one year. J
Clin Periodontol 1975; 2: 1–13. https://doi.
org/10.1111/j.1600-051x.1975.tb01721.x
27. Langer B, Langer L. Subepithelial
connective tissue graft technique for root
coverage. J Periodontol 1985; 56: 715–720.
https://doi.org/10.1902/jop.1985.56.12.715
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