This document discusses gingival recession, including its causes, classification, symptoms, and treatment options. It begins with an introduction that defines gingival recession and reports on its prevalence. It then covers the main causes of recession, including anatomical factors, trauma, smoking, aging, and biotype. Treatment options are separated into non-surgical approaches like prevention and desensitizing agents, and surgical options like free gingival grafts, pedicle flaps, and guided tissue regeneration. Two case reports demonstrate surgical treatments using subepithelial connective tissue grafts and Emdogain. The document concludes with a discussion of factors affecting surgical outcomes and the need for long-term maintenance.

1. Gingival recession
Presented by : Dr Eman Gsouma

2. 1 2
3 4
Causes &
classification
Case report Sugical
treatment
Introduction
Conclusions
Outline
Non-
surgical
treatment

3. Introduction
• Gingival recession in its localized or
generalized form of an undesirable
condition resulting in root exposure
where there is an apical shift in
position of gingival margin from the
CEJ occurring gradually .
* The recent surveys reported that 88% of 65 years old and 50 % of
people between 18 to 64 years old have one or more sites with
recession. (American dental association 2003 )

4. Symptoms and problems
• Sensitivity
• Esthetic complains
• Root caries
• Teeth discoloration
• Abrasion
• Difficulty maintaining plaque control

5. Causes
1- Anatomical
2-Plaque induced periodontitis
3- Trauma

6. • Trauma (con᾿t)

7. • Iatrogenic factors
• Smoking and Tobacco products

8. • Aging
was also thought to cause gum recession. However this idea was
discarded because of lack of convincing evidence that aging
cause’s shift of gingival attachment .
• Hormonal changes
Hormonal changes in women during pregnancy, menstruation
and lactation can cause gums to become more sensitive and
become more vulnerable to recession.

9. • Gingival biotype.

10. Classification

11. Treatment
Non-surgicaL Surgical
1- free soft tissue graft
a- Epithelia graft
b- Subepithelial C.T graft
2- pedicle soft tissue flap
a- rotational flap
b- advancement flap
1. Monitoring and prevention
2. Use of desensitising agents, varnishes
3. Composite restoration
4. Removable gingival veneers
5. Orthodontics

12. Monitoring and prevention
If the recession is not progressing and does not provoke
tooth sensitivity or poor aesthetics, then tooth-
brushing instructions and regular observation through
a strict maintenance program would be the optimal
treatment.

13. Desensitising agents, varnishes
• Treatment of dentine hypersensitivity is based on
blocking the dentinal tubules and preventing nerve
stimulation .
Pro-Argin™ Technology contains arginine, an amino acid naturally found in saliva, and calcium
carbonate .

14. Composite restorations
Use of composite resin to mask recession defects and eliminate
black triangles caused by recession.
Enameloplasty was carried out to even incisal plane in this case

15. Removable gingival veneers

16. Orthodontics
• In some cases surgical intervention and grafting may help to
treat the recession defect; however, if orthodontic treatment is
an option that the patient is willing to consider then any surgical
intervention should be delayed until after orthodontic tooth
movement has been completed.

17. Indications for surgical intervention
The need to improve soft tissue aesthetics
Reduce hypersensitivity
Improve plaque control
Prevent further progression of recession defect

18. Factors affecting outcome of
periodontal plastic surgery
• Condition of root surface – presence of calculus, caries,
contaminated cementum or restorations on root surface
• Prominent fraenal attachments
• Depth of vestibule
• Tissue type (Thickness of split thickness flaps raised )
• Size of the recession defect and graft material
• Smoking
• Patient oral hygiene.

19. The Free Gingival Graft
1- The epithelialised free gingival graft can be
used in either a one stage or two-stage
procedure to cover the exposed root surface
• there needs to be adequate overlap of the
graft tissue with the soft tissue around the
recession defect at the recipient site.
• Immobilisation of the graft at the recipient
site is also essential
Disadvantage : the epithelialised free
gingival graft is that it retains the colour of
the donor tissue

20. The Free Gingival Graft
2- Subepithelial connective tissue graft

21. The pedicle flap
Advancement flap

22. The pedicle flap
Lateral

23. The pedicle flap
Transpositional flap by PENNEL ET EL

24. The pedicle flap
Double papilla flap

25. Guided tissue regeneration
• The mean root coverage achieved with guided tissue
regeneration has been shown to vary between 48-94%

26. The use of Allografts and Xenografts in
management of gingival recession
• A recent systematic review concluded that these grafts
may be useful in situations where
1- A large recession defect needs to be treated .
2- Graft tissue harvested from the palate would provide an
insufficient volume of tissue.

27. Prognosis
• The subepithelial connective tissue graft has been shown to provide a
greater percentage root coverage than the epithelialised free gingival graft
• Subepithelial connective tissue graft combined with a coronally advanced
flap has been shown to provide better root coverage than the coronally
advanced flap alone over a five year follow up period
• When the subepithelial connective tissue graft is compared with guided
tissue regeneration, the subepithelial graft has shown evidence of achieving
greater root coverage

28. Criteria of successful root coverage

29. Case report 1
• A 21-year-old male was
referred to the Periodontics
Department, by his orthodontist
because of severe gingival
recession of maxillary central incisors .
Orthodontic treatment was done with no sign of recession and
during the retention phase using hawley appliance sever fast
gingival recession occurred . The orthodontist had discontinued
utilization of the appliance and had referred the patient .
Journal of Periodontology & Implant Dentistry
Periodontol Implant Dent 2010; 2(2):83-87 Tehran, Iran

30. The clinical examination revealed these findings:
• 1. Gingival recession on the labial aspect of both maxillary central incisors,
which extended apically to about one-half of the root length.
• 2. The interdental gingiva of mesial and distal aspects of both central incisors
had relatively normal appearance and was at normal position.
• 3. Both central incisors exhibited Class II mobility.
• 4. There were deep periodontal pockets on distal surfaces of central incisors;
however, pocket depth was normal on their mesial surfaces.
• 5. Oral hygiene was adequate.
• 6. Both teeth responded to electric and thermal
vitality tests.
• 7. There was no gingival inflammation, periodontal
pockets or bone loss in other areas of the mouth .

31. • Radiographic examination
disclosed severe bone loss on the
distal surfaces of central incisors,
which ex-tended to the apical third
of the roots, while bone height on
the mesial surfaces appeared
normal .
The occlusal evaluation showed no premature contacts in
centric and eccentric relations .

33. However, after completion of the surgery and detecting the elastic
band, the patient remembered that after completion of the
orthodontic treatment he had been referred to a restorative
dentist to close the residual maxillary diastema with composite
resin restorative material.
But the dentist had used latex elastics to close the diastema for
optimal esthetic results and then had restored the lateral
incisors. The patient pointed out that the elastic band had been
removed by the dentist, but it turned out that one of the elastics
had slipped under the gingival margin without the dentist
noticing it.

34. Subpedicle connective tissue graft” was selected

37. 2 -Emdogain – for gingival
recession treatment
Case by PD Dr. S. Hägewald
Assistant professor at the University of Berlin
.Berlucchi et al. J Periodontol. 2005;76:899–907.
Straumann® Emdogain leads to :an increased amount of
keratinized tissue, improved soft tissue healing and reduced
reoccurrence of the recession, making the use of the more
Traumatic connective tissue graft in many cases unnecessary

39. Conclusions
• Treatment of the gingival recession will depend
on the patient complain in the first place .
• The subepithelial connective tissue graft with a cornonally
advanced flap is gold standard grafting procedure .
• Prognosis (amount of root coverage achieved) will depend on the
severity (size )of recession .

40. References
• American Dental Association Vol 134, No 2, 220-225. © 2003 The etiology and
prevalence of gingival recession MOAWIA M. KASSAB, D.D.S., M.S. and ROBERT E.
COHEN, D.D.S., Ph.D.
• British Dental Journal 211, 353 - 358 (2011)
Published online: 21 October 2011 | doi:10.1038/sj.bdj.2011.861
• BRITISH DENTAL JOURNAL VOLUME 211 NO. 6 SEP 24 2011
• Periodontal surgery ,a clinical atlas , Naechi Sato DDS Japan 2000
• Treatment and Causes of Gum Recession . Dental hub. Leading dental consultation
• Berlin/Germany .Spahr et al. J Periodontol. 2005;76:1871–1880. 4 Moses et al. J
Periodontol. 2006;77:195–202
• Professional Education: Article Pro-Argin™ Technology Mode Of Action

41. Thank you
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