Gingival Recession Treatment Guidelines
Primary Recommendation
Perform coronally advanced flap (CAF) with autogenous connective tissue graft (CTG) as the definitive surgical treatment for gingival recession, as this achieves 70-92% root coverage with superior long-term stability (89.35% coverage at 5 years) and is the gold standard approach. 1, 2
Treatment Algorithm
Step 1: Initial Non-Surgical Management (All Patients)
- Modify toothbrushing technique to Bass or modified Bass method using a soft toothbrush, replaced monthly, with mild fluoride-containing, non-foaming toothpaste to prevent progression 1
- Remove overhanging subgingival restorations and establish optimal plaque control 3
- Apply desensitizing agents if dentine hypersensitivity is present 3
- Monitor for progression at regular intervals 4
Step 2: Determine Surgical Candidacy
Proceed to surgical evaluation when:
- Non-surgical measures fail to prevent progression 4
- Patient experiences persistent sensitivity, root caries risk, or aesthetic concerns 5, 3
- Recession threatens long-term tooth retention due to clinical attachment loss 4
Surgical Protocol: CAF with CTG (Gold Standard)
Incision Design
- Create horizontal beveled incisions (±3mm length) mesial and distal to recession, positioned at distance from papillae tips equal to recession depth plus 1mm 6, 1
- Extend beveled oblique, slightly divergent incisions from horizontal incision endpoints to alveolar mucosa 6, 1
Flap Elevation
- Elevate trapezoidal flap using split-full-split approach: split thickness for surgical papillae, full thickness at root exposure area, split thickness for vertical incisions and apical to exposed bone 6, 1
- De-epithelialize papillae and complete thorough root planing 6, 1
Graft Placement (Critical for Success)
- Place autogenous CTG to achieve minimum 1.5mm gingival thickness, as this is the primary determinant of long-term stability 1, 2
- Position graft to ensure at least 1.5mm keratinized tissue width, which is necessary to prevent recession recurrence 1, 2
- Coronally advance flap to cover graft completely 6, 1
Suturing
- Secure with modified vertical mattress sutures combined with interrupted sutures using 5-0 or 6-0 monofilament non-absorbable sutures 6, 1
- Ensure flap remains passively in position without tension 6
- Use sling sutures at most coronal aspect of papillae for additional stability 6
Alternative Approaches (When CTG Contraindicated)
L-PRF Membrane Technique
- Use 3-4 L-PRF membranes with CAF when palatal harvesting is contraindicated or patient refuses donor site surgery 6, 2
- Suture membranes together with absorbable 6-0 sutures before placement 6
- Place with face portion of deepest membrane oriented toward exposed root 6
- Suture membranes to periosteum for graft stability before coronally advancing flap 6
- Note: Clinical benefits are slightly inferior to CTG, but significant reduction in post-operative pain is a major advantage 6
Growth Factor Approaches (Limited Long-Term Data)
- Consider rhPDGF-BB with soft tissue matrices only when CTG and L-PRF are not options 6, 2
- Be aware that coverage decreases significantly from 89.85% at 6 months to 74.10% at 5 years, substantially inferior to CTG's 89.35% at 5 years 2
Critical Success Factors
Tissue Thickness Requirements (Non-Negotiable)
- Achieve minimum 1.46mm gingival thickness at 6 months, as this is the main determinant of long-term gingival margin stability 6, 1, 2
- Ensure at least 1.5mm keratinized tissue width is present, regardless of surgical approach used 6, 1, 2
- Soft tissue phenotype is more important than periodontal regeneration or buccal bone for preventing long-term relapse, since thin tissue is prone to recede with inflammation or traumatic brushing 6
Post-Operative Management
Week 1 (Critical Period)
- Restrict to soft food intake with absolutely no biting/chewing in treated area 6, 1, 2
- Prohibit all mechanical cleaning of treated area 6, 1
- Prescribe analgesics for pain management 6, 1
Weeks 1-3
- Begin 0.12% chlorhexidine rinses twice daily for 1 minute starting day 3, continue minimum 3 weeks 6, 1, 2
Common Pitfalls to Avoid
Critical Errors
- Never proceed with CAF alone in thin phenotype cases, as this results in long-term recession recurrence 1, 2
- Never accept insufficient graft thickness (<1.5mm), as failure to achieve adequate thickness leads to significant recession over 5 years 1, 2
- Never rely solely on growth factor approaches without addressing soft tissue thickness, as this leads to significant recession recurrence 2
Technical Considerations
- Avoid vertical releasing incisions when possible, as they increase morbidity 6
- Do not use collagen membranes designed as barriers for phenotype modification, as they do not promote gingival thickness changes 6
- Recognize that thin soft tissue will recede regardless of buccal bone level if adequate thickness is not achieved 6