Is Gingival Grafting a Controversial Topic?

Did you ever think that gingival grafting would be a controversial subject in dental school? In my residency program, I was always taught that if there's recession, we graft. But that's not really true. Grafting does make a difference. Patients who have had their teeth grafted are less prone to recession and inflammation around those teeth. The literature has brought this out over the years.

The Role of Keratinized Tissue

When I was first in my residency program, we were taught by Lang and Löe that we needed a minimum of 2mm of keratinized tissue around every tooth. Is that still the case today? Probably not. But what about implants? Do we need keratinized tissue on implants?

Initially, when implants were first being done, we never talked about keratinized tissue or the necessity for it. However, if you have keratinized tissue around dental implants, they're going to be less sensitive, less prone to recession, and probably less prone to peri-implantitis. So, yes—keratinized tissue on implants is very important.

Causes of Recession

The biggest cause of recession is likely a genetic predisposition. If you have thin bone, you’re more prone to recession. For example, an offensive lineman who's 300 pounds and 6'2" is less likely to have recession because they have a different bone type. I very rarely see recession in those types of patients. People who have thicker bone have less recession. If you have thin bone or a thin biotype, you're going to be more prone to recession.

Other causes include:

• Overzealous toothbrushing

• Orthodontics—moving teeth through bone

• Periodontal disease

• Iatrogenesis

• Invasion of the biologic width

• Improper use of electro-surgery or lasers

• Patient habits like snuff or tongue rings

When Do You Treat Recession?

Should you treat if there's no attached gingiva? It's not a bad indication to treat because the recession can worsen, especially if the patient has inflammation, sensitivity, or progressive recession over time.

I recommend taking clinical photos of all your patients at their initial visit and annually. This helps you track trends. For example, I had a patient with 3-4mm of recession at 27 years old. Ten years later, she returned with 7mm of recession, inflammation, and a crossbite due to tooth movement. This was a clear indication for grafting.

Indications for Grafting

• Inflammation and increasing loss of attachment

• Prior to orthodontics in patients with significant recession or thin biotypes

• Prosthetic rehabilitation where keratinized tissue is needed

• Sensitivity unresponsive to fluoride (grafting is preferable to a Class V restoration)

You can even remove a Class V restoration, clean the root down to dentin or cementum, and do a connective tissue graft. Connective tissue will attach to dentin, PDL, cementum, and bone—but not to enamel or foreign materials.

Aesthetic Considerations

Another common reason for grafting is aesthetics. Patients often dislike the appearance of recession. Today, we have several predictable procedures:

• Connective tissue grafts (autogenous or allografts like AlloDerm, often soaked in GEM 21)

• Free gingival grafts using autogenous tissue

• Xenografts like Mucograft or FibroGuide used with flaps

These alternatives are expanding, but the tried-and-true options remain the free gingival graft and the subepithelial connective tissue graft.

Vestibular Augmentation and Class V Restorations

A shallow vestibule can make brushing difficult. Vestibular augmentation and free gingival grafting can help. As my colleague and mentor Dr. P.D. Miller says, "I'd like to drive a stake through the heart of every Class V restoration." Once you place a restoration close to the gingiva, you can violate the biologic width and potentially increase recession.

If Class V restorations are needed, ensure the gingiva is healthy and there's an adequate band of keratinized tissue. Ideally, you want 2mm of keratinized tissue to reduce the risk of recession.

Final Thoughts: When to Graft

You don't need to graft every patient with recession. Understand the literature and what works. Subepithelial connective tissue grafts may look good initially but can show recession over time. Free gingival grafts, once placed, have a high success rate and can show gingival creep, where tissue moves incisally and looks better over time.

Always have a conversation with your patient about the pros and cons of treatment. Teeth won’t be lost immediately if not grafted, unlike with untreated caries or periodontal disease. Gingival recession may or may not progress, which is why documentation is crucial.

Hopefully, this overview has helped. Some of you may already know this, but for those who don't—listen again. Ask yourself: is this the right treatment for this patient? Or am I having a knee-jerk reaction to seeing recession? That way, you can truly be the gift to your patients.