Periodontology ZOOO, Vol.

1, 1993 118-127 Copyright 0 Munksgaard 1993

Printed in Denmark All righrs reserved
PERIODONTOLOGY 2000
ISSN 0906-6713

Root coverage grafting for

regeneration and aesthetics
PRESTON
D. MILLER,
JR.

One of the long term-desires of periodontists was to allow cells from the periodontal ligament space to
be able to cover denuded root surfaces. Beginning repopulate the wound may offer not only root cover-
with the 1980s, this dream became a reality (12-17). age but also a connective tissue attachment. In this
While marginal tissue recession seldom results in case, the color match of the tissue would be ideal
tooth loss, it is often associated with sensitivity, frenal since the new tissue comes from the cells apical to
involvements, marginal tissue irritation because of the recession.
the patient’s inability or unwillingness to properly Root coverage procedures fit philosophically into
remove plaque, aesthetic concerns and tendency to the area of mucogingival surgery, a term introduced
dental caries. by Friedman (9) in the 1950s. Mucogingival surgery
Some feel that if marginal tissue health can be is, however, a dated term, and is currently known
maintained free of inflammation, treatment of re- as periodontal plastic surgery (20). The concept of
cession need not be considered (8). This statement mucogingival surgery originally included 2 pro-
is predicated on the concept that recession is not cedures that are less frequently done (deepening the
necessarily progressive. Unfortunately, this line of vestibule and the frenectomy) plus treatment of an
thought does not take into consideration either the inadequate zone of attached gingiva. Although peri-
desires of the patient or the potential to regenerate odontal plastic surgery includes treatment of these
lost oral tissue. Since root coverage procedures are mucogingival problems, it has a much broader scope,
quite predictable (18) and produce patient satisfac- including surgical procedures for:
tion, the therapist should make patients aware of this
treatment modality. 0 root coverage;
For root coverage to be successful the following 0 ridge augmentation;
criteria must be met: maintenance of ridge form following extraction of
periodontally involved teeth;
0 The tissue margin must be at the cementoenamel 0 correction of excessive gingival display (gummy
junction in Class I and Class I1 recession. smile);
0 The sulcus depth should be 2 mm or less. exposing teeth for orthodontic movement;
There should be no bleeding on probing. 0 maintenance of interdental papilla; and
0 There should be no sensitivity. 0 reconstruction of lost papilla.
The color match of the tissues should be accept-
able.
Definition of terms
The nature of the new gingival attachment remains
undetermined. Although a long junctional epithelial The terminology used in this chapter may vary from
attachment is acceptable, a connective tissue attach- the popular terminology. For example, the term free
ment remains the treatment goal. Given the current gingival graft is not used. It is incorrect in 2 aspects.
climate in human research, it is unlikely that ade- First, the anatomical term free gingival groove differ-
quate human histological data will soon be available entiates free gingiva from attached gingiva. This free
for researchers to make this determination. Addition- gingiva is not used in root coverage grafting. Second,
ally, the importance of root biomodification using gingiva is defined as the masticatory mucosa sur-
citric acid or tetracycline HCI remains a question. rounding the teeth (2). Palatal masticatory mucosa
Barrier membranes that exclude epithelium and used in grafting is technically not gingiva since it does

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not surround the teeth. The ideal term, free palatal mined pre-surgically using a periodontal probe. The
masticatory mucosal autograft, is not only awkward probe is placed horizontally on an imaginary line
but now must be modified to include the subepith- connecting the tissue level on the midfacial of the
elial connective tissue graft! Therefore, the two free teeth on either side of the recession. Root coverage
grafts will be described as the classic epithelialized can be anticipated to that level. If this line is marked
palatal graft as contrasted to the sub-epithelial con- with a pencil, the patient can graphically see the level
nective tissue graft. Additionally, the term marginal of root coverage attainable. Additionally, the
tissue recession (16) is used rather than gingival re- cementoenamel junction should be outlined inter-
cession since marginal tissue recession covers both dentally when there is interdental recession so that
gingival recession and alveolar mucosal recession. the patient might better understand the limitations
of treatment.
Clinically, different classes of recession may be
Classification of recession found on adjacent teeth. For example, one mandibu-
lar incisor may exhibit Class I1 recession while the
Sullivan & Atkins (28) initially classified marginal adjacent central incisor may exhibit Class I recession.
tissue recession into 4 morphologic categories - the Obviously, if partial root coverage is planned, gross
shallow-narrow, the shallow-wide, the deep-narrow instrumentation coronal to the graft height only in-
and the deep-wide. This classification was used from creases and prolongs root sensitivity.
1968 until 1985 when Miller (19) presented an ex-
panded classification.
Many areas of recession fail to fall into one of the
4 classic categories presented by Sullivan & Atkins The effect of smoking on root
(28). Anatomical considerations, such as extruded coverage
teeth or the loss of bone or soft tissue in interproxi-
mal areas, may make it physically impossible to posi- Surgeons have long been aware that smoking nega-
tion the graft at the cementoenamel junction. tively affects tissue in general and healing in particu-
Root coverage can further be grouped into two lar. Clinically, tissue tone and color improve when
categories - primary root coverage found initially patients quit smoking. It has been observed that
after grafting and secondary root coverage (18) complete root coverage is not attainable in the
(creeping attachment). smoker using the epithelialized palatal graft (18).
The 4 classes of recession according to Miller (19) Tissue alterations caused by smoking do not appear
are: to be a factor, since root coverage is attainable if pa-
Class I. Marginal tissue recession that does not ex- tients stop smoking immediately before surgery and
tend to the mucogingival junction. There is no peri- do not smoke for 3 weeks following surgery.
odontal loss (bone or soft tissue) in the interdental Smoking impairs circulation by constricting ves-
area, and 100% root coverage can be anticipated. sels and thus reducing blood flow to the graft site
Class ZZ. Marginal tissue recession that extends to or (3). In the smoker, that portion of the graft on the
beyond the mucogingival junction. There is no peri- avascular root surface generally will slough, resulting
odontal loss (bone or soft tissue) in the interdental in recession. The subepithelial connective tissue graft
area, and 100% root coverage can be anticipated. offers greater hope for root coverage in the smoker
Class ZZI. Marginal tissue recession that extends to or than does the epithelialized palatal graft. Not only is
beyond the mucogingival junction. Bone or soft the subepithelial connective tissue graft thinner but
tissue loss in the interdental area is present, or there it also has a blood supply from two sides (facially
is malpositioning of the teeth that prevents the from the flap and from the periosteum) rather than
attempting of 100% root coverage. Partial root cover- one side (periosteum) as in the case of the epi-
age can be anticipated. thelialized palatal graft. Coronally positioned flaps
Class ZV. Marginal tissue recession that extends to or and laterally positioned pedicle grafts, although
beyond the mucogingival junction. The bone or soft probably compromised by smoking, are not as com-
tissue loss in the interdental area andlor the malpo- promised as the free grafts, since they have their own
sitioning of the teeth is so severe that root coverage blood supply. In any event, it is imperative that the
cannot be attempted. surgeon point out the negative effects of smoking in
In Class 111 recession, partial root coverage can be any periodontal surgical procedure and especially in
expected. The amount of root coverage can be deter- grafting for root coverage.

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Root biomodification in root of the orifice of dentinal tubules, creating a “blunder-

coverage buss” effect that, on healing, allowed cementum to
form within this orifice. Register & Burdick referred
to this cementum that formed within the dentinal
It has never been established exactly how roots tubules as cementum pins.
should be modified prior to attempting root cover- Register & Burdick speculated that these ce-
age. Obviously, the longer roots have been exposed mentum pins may form a mechanical or molecular
to bacteria and oral fluids the more surface changes attachment that may be stronger than a normal con-
(26)occur, which could impact root biomodification. nective tissue attachment. They further speculated
Root biomodification may be mechanical or that citric acid may expose the collagen fibrils in the
chemical or a combination of the two. Mechanical root surface and that these fibrils may splice with the
biomodification in its simplest form involves scaling collagen fibrils in a flap or graft. Codelli et al. (5) gave
and root planing. This may include cementum re- credibility to the theory of collagen splicing. Regis-
moval, removal of softened dentin or the smoothing ter & Burdick (25) further noted accelerated healing
of surface irregularities. In more involved cases, and accelerated cementogenesis as well as a connec-
mechanical biomodification may involve the use of tive tissue attachment when citric acid was used.
rotary instruments to remove deep grooves resulting Register & Burdick’s technique (25) included rubbing
from abrasion or the removal of restorations. the roots with pH 1 citric acid for 3 min.
Early on in using the epithelialized palatal graft for Polson et al. (23) found that citric acid removed
root coverage, Miller (17) advocated flattening the the smear layer normally found after root planing.
root, especially at the cementoenamel junction. He Polson felt that the crystalline debris that compro-
felt this enhanced the “fit” of the butt joint margin mised the smear layer may interfere with attachment.
of the graft with the cementoenamel junction. Hol- Fear of pulpal changes proved unfounded, since cit-
brook & Ochsenbein (12) advocated flattening the ric acid produced root surface changes only a few
root but for a different reason. They felt this reduced microns deep. Citric acid may precipitate root re-
the surface area of the root mesiodistally and thus sorption in animals, but this has never been reported
decreased the amount of avascular root surface that in humans either experimentally or clinically.
required covering. Currently, neither is a reason for Tanaka et al. (29) found that citric acid may demin-
exaggerated root reduction. eralize subclinical bits of residual calculus left follow-
Chemical biomodification has centered on acid ing root planing. Perhaps the removal of residual en-
therapy to supposedly demineralize an overly min- dotoxins may produce a root more amenable to
eralized root (25).Acid therapy, though controversial, attachment.
has centered on two acids, citric and hydrochloric At this point, no negative effects have been dem-
(tetracycline HC1). Citric acid has been used clini- onstrated in humans when roots have been treated
cally for over 15 years; tetracycline HCl has only been with citric acid. By the same token, the positive ef-
used recently. A lingering antimicrobial action fects on root surfaces and ultimately on healing are
(substantivity) of tetracycline is often mentioned as well documented and can be summarized in the fol-
the reason for selecting tetracycline HC1 over citric lowing statement:
acid. In animals, the changes produced on root sur-
faces by citric acid with subsequent connective tissue Citric acid has been shown to remove the “smear
attachment are well documented (4, 25). The results layer,” thus opening dentinal tubules, allowing ce-
in humans, however, remain controversial (21, 27). mentum to form within these tubules resulting in
Isolated instances of connective tissue attachment in “cementum pins.” This could be associated with ac-
humans following citric acid application have been celerated cementogenesis as well as accelerated heal-
reported (71, but there are no reports on tetracycline ing. This accelerated healing may take place at such
HCl producing a connective tissue attachment. a rate that either a connective tissue attachment or a
Although acid therapy was used in the early nine- collagen adhesion without cementum formation may
teenth century, Register & Burdick (25) are credited occur before epithelium migrates, thus indirectly
with the revival of this technique. Having tested sev- preventing epithelial migration. Citric acid has been
eral acids, including citric acid and hydrochloric acid, shown to expose collagen fibrils in the root surface,
they concluded that citric acid was the most effective which may splice with collagen fibrils in a soft tissue
and least toxic of all the acids tested. In animals they graft or flap (collagen splicing), again perhaps result-
noted root surface changes. These included widening ing in collagen adhesion without cementum forma-

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 Root coverage grafting

Fig. 1. a. Preoperative view of 43-year-oldwoman with 3- coverage and excellent color match of tissue. Note level of
m m Class I1 recession on maxillary canine. b. Laterally tissue maturity 2 weeks postoperatively.
positioned pedicle graft sutured. Note that the donor site Fig. 2. a Preoperative view of 32-year-old man with
is in an interproximal area and not over a root promi- multiple Class I or early Class I1 recessions on lower in-
nence. c. Two-week postoperativeview with complete root cisors and canine.

tion and accelerated healing. Additionally, citric acid this often resulted in recession on the donor tooth,
may demineralize small bits of residual calculus, dis- the procedure was later modified so that a collar of
infect the root, and aid in removing endotoxins. gingiva remained on the donor tooth. For over 25
years this was the only surgical procedure available
This statement represents a possible scenario based that could predictably produce root coverage. The
on research findings reported in the periodontal laterally positioned pedicle graft, however, has cer-
literature over a period of nearly 20 years. Whether tain limitations that may contraindicate its use:
these individual findings are clinically significant or
whether the scenario is correct is speculative. an insufficient amount of gingiva available for posi-
tioning;
a shallow vestibule;
The laterally positioned 0 secondary frenal attachment(s) at the donor site;

pedicle graft and

0 multiple adjacent recessions.

Grupe &Warren (10) introduced contiguous (as con-

trasted to free) soft tissue autografts under the term Variations of the laterally positioned pedicle graft in-
lateral sliding flap. This procedure is currently known clude the double papilla graft (6) and the oblique
as the laterally positioned pedicle graft (Fig. 1). Lat- rotated graft (22). These latter two procedures
eral gingiva is freed by 1 horizontal and 2 vertical evolved in an attempt to use minimal amounts of
incisions and transferred to the recipient tooth. Since gingiva for root coverage. Since other techniques for

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Miller

Fig. 2 b. Appearance of roots after biomodification, which proximal positioning sutures, apical stretching sutures
included root planing to remove residual cementum. Cit- and vertical stabilizing sutures. e. Three-week postopera-
ric acid was burnished into the roots until the roots took tive view. Note tissue maturity as well as the presence of
on a “mat” finish as well as a white “milk glass” look. The masticatory mucosa at the depth of the vestibule. The
time of burnishing was less than 30 s. c. Recipient site presence of this masticatory mucosa at the depth of the
prepared with butt joint margins created in the papillae. vestibule results in a match of tissues that is less than
d. Epithelialized palatal graft sutured to place using inter- ideal.

root coverage are readily available, the laterally posi- to produce a soft tissue margin that would enable
tioned pedicle graft should only be used under ideal the patient to practice a high level of plaque re-
conditions. It thus becomes a highly predictable pro- moval without traumatizing the soft tissue; and
cedure resulting in an ideal color match of tissues 0 as an adjunctive treatment when margins of res-
(Fig. lc). torations necessarily were to be placed in the gingi-
val sulcus.

Epithelialized palatal Based on surgical criteria drawn from the plastic

(free gingival graft) surgery literature, it was assumed that root coverage
(with attachment) was not possible using the epi-
The classic epithelialized palatal graft was originally thelialized palatal graft. Miller (181, however, in a
presented (13)as a gingival augmentation procedure study involving 100 cases, graphically demonstrated
with the following treatment goals: that this was not only possible but also quite predict-
able (Fig. 2). The root coverage achieved, although
0 to establish a soft tissue margin of keratinized functional, results in a graft that is readily dis-
tissue; tinguishable. On healing, the grafted palatal tissue
0 to prevent further recession; tends to be whiter and more opaque than gingiva
0 to negate the effects of an aberrant frenum; and generally extends deeper into the vestibule. The

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 Root coverage grafting

Fig. 3. a. Fifty-four year-old woman with Class 11 recession epithelial connective tissue graft taken from the palate.
on mandibular central incisor. b. Recipient site prepared d. The connective tissue graft sutured to place. Note that
for connective tissue graft. Note that there are no vertical the majority of the connective tissue graft is beneath the
incisions and the pouch is being held laterally for pho- flap, and only that portion over the denuded root is left to
tography purposes using two scalpel blades. c. The sub- re-epithelial&.

presence of grafted masticatory mucosa at the depth Subepithelialconnective

of the vestibule results in a match of tissues that is tissue graft
less than ideal (Fig. 2e). The major drawbacks to root
coverage using the epithelialized palatal graft are:
The subepithelial connective tissue graft (Fig. 3) rep-
The technique is difficult to perform. resents the next stage in the evolution of free grafting
0 The technique is time-consuming. for root coverage. Originally presented as a ridge aug-
0 A blood supply to the graft is more difficult to mentation technique in 1980 (14), it was subsequent-
achieve when compared with a subepithelial con- ly presented in 1985 (15) as a technique to be used
nective tissue graft. for root coverage. As a root coverage technique, it
The palatal wound (donor site) is more invasive, offers several advantages over the epithelialized pala-
more prone to hemorrhage and heals slower. It is tal graft:
'
also more annoying to the patient.
0 The match of tissues is less than ideal. 0 not as technically demanding;
0 less time-consuming;
Although the epithelialized palatal graft is still used 0 easier to establish and maintain a blood supply;
for gingival augmentation, the subepithelial connec- 0 a palatal wound that is less invasive, less prone
tive tissue graft has become increasingly popular for to hemorrhage, more rapidly healing and generally
root coverage. less annoying to the patient; and

123
MUler

Fig. 3 e. Eighteen-month postoperative view showing ex- restoration was removed during the surgery. b. Coronally
cellent tissue match and root coverage. positioned flap sutured to place. Note the oblique incision
Fig. 4. a Preoperative view of 38-year-old woman. Maxil- on the mesial so as to avoid severing the frenum. c. Six-
lary central incisor exhibiting recession. Note that a bon- month postoperative view showing complete root cover-
ded restoration has been placed on the root surface. This age and excellent tissue match.

0 match of tissues is generally better than that ob- Coronally positioned flap
tained with the epithelialized palatal graft.

The fact that the subepithelialized connective tissue The coronally positioned flap (Fig. 4) has been in
graft is placed beneath the flap enables the graft to periodontics for many years with several different
have a blood supply on 2 surfaces rather than a single variations (1, 11,301. Originally described in the early
surface. Quite often, the subepithelial connective part of this century ( l l ) , it was popularized in the
tissue graft can be done without vertical incisions by 1980s by Tarnow (30) under the term semi-lunar cor-
simply making a sulcular incision, creating a pouch onally repositioned flap. Allen & Miller (1) presented
into which the connective tissue can be placed (Fig. a further modification.
3b). This procedure is limited by the height and thick-
Both the palatal epithelialized graft and the sub- ness of the gingiva apical to the recession. Although
epithelial connective tissue graft offer a more versa- there is no scientific basis, 3 mm of gingival height
tile solution for root coverage procedures than the is generally felt to be a minimum height of gingiva
laterally positioned pedicle graft, since the amount necessary if coronal positioning of the gingiva is to
of donor tissue is not a problem and multiple re- be considered. The- gingiva should also be relatively
cessions can be treated. Furthermore, neither a shal- thick. This procedure can only be done on Class I
low vestibule nor an aberrant frenal attachment pres- recession, and if a Class I1 or 111 recession is present,
ents a problem. then either a subepithelial connective tissue graft or

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 Root coveraue grafting

Fig. 5. a. Twenty-seven-year-oldman exhibiting Class I re- the connective tissue. Note that the flap completely covers
cession but with very thin gingiva.b. Subepithelialconnec- the connective tissue. d. One-year postoperative view.
tive tissue that will be placed under a coronally positioned Note excellent color match of tissue as well as thickness
flap. c. The flap has been coronally positioned over of the gingiva over both maxillary central incisors.

a coronally positioned flap augmented by connective either case the resultant tissue is a functional masti-
tissue should be considered. catory mucosa that presents an excellent cosmetic
tissue match.
Although the surgical procedure is quite similar to
Coronally positioned flap the subepithelial connective tissue graft presented by
augmented by connective tissue Langer & Langer (151, there is one subtle difference.
Rather than allowing the sub-epithelial connective
This technique was developed to meet the short- tissue to be coronal to the flap, the coronally posi-
comings of the previously mentioned coronally posi- tioned tissue completely covers the grafted connec-
tioned flap: an inadequate height or thickness of tive tissue (Fig. 5c). Therefore, on initial healing the
existing gingiva. By placing connective tissue com- thickness and color match of the tissue is excellent
pletely beneath the coronally positioned tissue (Fig. 5d) since “native” tissue covers the connective
(gingiva or alveolar mucosa), the surgeon can pro- tissue. When the coronal portion of a conventional
duce not only a functional but also a most aesthetic subepithelial connective tissue is left exposed, the
result (Fig. 5). graft tends to thicken on re-epithelialization and the
If the connective tissue extends beneath alveolar aesthetic result may be compromised.
mucosa, the connective tissue on healing may ulti-
mately become the dominant tissue. On long-term Technical considerations
healing, the alveolar mucosa may persist but with a
connective tissue base or the alveolar mucosa may In addition to a routine surgical set-up including an-
be lost exposing the underlying connective tissue. In esthetic syringes, scalpel blades (15+ 12B), curettes,

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Miller

etc., the following items are added for periodontal Today, root coverage procedures produce a more
plastic surgery procedures: aesthetic result and are simpler to do than they were
10 years ago. This trend will continue. Although the
0 SurgiceP wound incurred in harvesting palatal tissue for graft-
0 cyanoacrylate ing is less invasive, a future goal would be to have
Castro Viejho needle holders commercially available a substitute for subepithelial
0 4-0 chromic gut sutures with a P-3 cutting needle connective tissue which would negate the need for a
0 separating medium palatal wound at all.
neosporin ointment The concept of guided tissue regeneration offers
tetracycline powder mixed with Vaseline. hope for an ideal color match of tissue without the
need of taking tissue from the palate. These native
Typically 2 to 3 scalpel blades are used for most peri- cells, either from the periodontal ligament space or
odontal plastic surgical procedures. For example, any gingival connective tissue cells, may repopulate the
procedure requiring removal of palatal tissue uses a wound, thus producing not only adequate tissue but
new 15 blade for harvesting that tissue. 12B blades an ideal color match.
are used for de-epithelialization of the papilla in cor-
onally positioned flap procedures as well as under-
mining papilla via inverse bevel incisions in other Acknowledgement
root coverage procedures.
I prefer chromic gut sutures because of their re- I wish to thank Mrs. Peggy Speck for typing and
sorbability and to avoid the wicking phenomenon proofreading.
experienced with silk. Also, with gut sutures the heal-
ing process is not disrupted, as may occur when silk
or other nonresorbable sutures are removed. Sutur- References
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