Connective Tissue Graft

Dr. Romanita Ghilzon
Authored by:
Dr. Romanita Ghilzon
Dr. Jim Lai
Authored by:
Dr. Jim Lai


The gingival margin is typically located at or slightly coronal to the cementoenamel junction. Gingival recession occurs when the gingival margin migrates apical to the cementoenamel junction. Consequently, the root of the tooth is exposed. Gingival recession is found in populations with both high and low oral hygiene levels.

Gingival recessions generally are associated with four types of clinical situations:

1. Recessions associated with mechanical factors, predominantly toothbrushing trauma:

  • Clinically healthy sites where recession developed due to improper toothbrushing techniques. Typically the exposed root is a clean, smooth, polished and wedge shape.

2. Recessions associated with localized plaque-induced inflammatory lesions:

  • Presence of plaque, calculus, class V caries and iatrogenic factors, such as a subgingival restoration, contribute to the development of a localized inflammatory lesion. This inflammation leads to cumulative destruction of the alveolar bone and/or gingival tissue which results in gingival recession.
  • These sites typically involve inadequate thickness of alveolar bone and/or gingival tissue. The alveolar bone may be thin which results in mostly cortical bone with minimal amount of cancellous bone. Consequently the regenerative potential of the bone is low. Thin gingival tissue has minimal amount of connective tissue and similarly, there is low potential of regeneration. Another clinical situation involves the absence of alveolar bone (dehiscence) which may also lead to recession.

3. Recessions associated with generalized forms of periodontitis:

  • Periodontitis leads to the destruction of supporting structure around the tooth. The apical migration of the attachment leads to gingival recession.

4. Recessions associated with orthodontic tooth movement:

  • If the tooth is orthodontically moved within the alveolar bone, gingival recession will not occur. However, if the tooth is moved to the point where the cortical bone is thin or is beyond the bone, then gingival recession may occur.

Treatment of recession

Elimination of the etiology is the first and most critical step in management of gingival recession. This may include modifying oral hygiene techniques, treating the inflammation and/or periodontitis, eliminating structures that are plaque retentive and tooth repositioning. Often, eliminating the cause is adequate treatment and no further treatment is required.

However, certain clinical situations may need surgical intervention, especially if the goal is to correct the defect and attain root coverage where the gingiva is regenerated over the exposed root surface.

Indications for root coverage procedures include:

  • Aesthetic demand
  • Gingival discomfort where the lack of attached keratinized tissue leads to continuous plaque accumulation and inflammation
  • Evidence of progressive apical migration of the gingival margin, despite elimination of the etiology
  • Management of shallow root caries and cervical abrasions
  • Root hypersensitivity (when all other desensitizing methods have been unsuccessful)

The challenge of root coverage is due to the avascular surface of the exposed root. Any successful outcome of these root coverage procedures is dependent on proliferation of blood vessels and progenitor cells such as gingival fibroblasts over the root surface.

Predictability of attaining root coverage is dependent on the type of recession. The recession defects are classified as:

Miller Classification (1985):

Class I:

  • Marginal tissue recession which does not extend to the mucogingival junction (MGJ). There is no periodontal loss (bone or soft tissue) in the interdental area, and 100% root coverage can be anticipated.

Class II:

  • Marginal tissue recession which extends to or beyond the MGJ. There is no periodontal loss (bone or soft tissue) in the interdental area, and 100% root coverage can be anticipated. 

Class III:

  • Marginal tissue recession which extends to or beyond the MGJ. Bone or soft tissue loss in the interdental area is present or there is malpositioning of the teeth which prevents the attempt of 100% root coverage. Partial root coverage can be anticipated.

Class IV:

  • Marginal tissue recession which extends to or beyond the MGJ. The bone or soft tissue loss in the interdental area and/or malpositioning of teeth is so severe that root coverage cannot be anticipated. 

Root coverage procedures in treatment of recession defect are classified into:

  1. Pedicle soft tissue graft procedures (laterally positioned pedicle flap, double papilla flap, coronally repositioned flap, semilunar coronally repositioned flap).
  2. Free soft tissue graft procedures (epithelialized graft such as free gingival graft and subepithelial connective tissue graft. Both are harvested from the masticatory mucosa of the palate).
  3. Guided Tissue Regeneration for Root Coverage.
  4. Acellular Dermal Matrix Allograft (Alloderm) for Root Coverage
Table 1 Root Coverage Procedure Mean % of Initial Recession Range Mean% of Teeth Range
Rotational Flaps 68 41-74 43 -
Coronal Advance Flap 80 55-99 50 9-95
Guided Tissue Regeneration 75 48-94 36 0-75
Free Connective Tissue Graft 86 53-98 61 0-93
Free Gingival Graft 63 11-87 28 0-93


In comparison to the other root coverage procedures, connective tissue graft surgery is the most predictable in achieving the greatest amount of root coverage and has a better success in attaining 100% root coverage. 

Connective Tissue Graft

Connective tissue graft is a technique that utilizes the connective tissue from the palate. The tissue from the hard palate is keratinized masticatory mucosa with a dense lamina propria. If this tissue is transplanted to another site, the phenotypic expression of the tissue is maintained by the graft’s connective tissue (Karring 1972, 1975, Edel 1974).

Indications for the connective tissue graft (Langer 1985)

  • Inadequate donor site for a horizontal sliding flap.
  • Isolated wide gingival recession.
  • Multiple root exposures.
  • Multiple root exposures in combination with minimal attached gingiva.
  • Recession adjacent to an edentulous area that also requires ridge augmentation.

Advantage of connective tissue graft

  • Easier to establish and maintain blood supply.
  • Dual blood supply source from the periosteum and flap. Over the avascular root surface, the flap provides the blood supply.
  • Minimal palatal denudation, less invasive, less prone to hemorrhage, more rapid healing.
  • Closer colour blend of the graft with the adjacent tissue; no “keloid” healing as with the free gingival graft.
  • The connective tissue graft results in two sutured closed wound sites, while the free gingival graft results in two open exposed wounds.

Technique for Connective Tissue Graft

Technique: after proper local anesthesia, the following steps are recommended in sequence to perform a connective tissue graft surgery:

  1. Preparation of the exposed root surface.
  2. Preparation of the recipient bed.
  3. Harvest the connective tissue graft from the palate.
  4. Stabilize and suture the connective tissue graft to the recipient.
  5. Management of the donor site.              

1. Preparation of the exposed root surface:

The exposed root surface is carefully scaled and root planed. If the plan is to obtain root coverage over existing caries or class V restoration, the caries and restoration must be completely removed. Significant convexity of the root may be reduced with diamond burs on high speed and with hand instruments. Historically, chemical root surface modifiers such as citric acid, tetracycline, or EDTA had been used to demineralize and decontaminate the root surface to expose the collagen fibers. The theory is this will facilitate attachment of fibers to the root surface. However, recent evidence demonstrates that the use of these chemical modifiers provides no benefit of clinical significance (Mariotti 2003).

2. Preparation of the recipient bed:

The recipient bed is prepared to accommodate the connective tissue graft. A split thickness flap is performed where the periosteum remains attached to the underlying osseous structure. The split thickness flap is prepared by sharp dissection and the presence of any muscle fibers or attachment is eliminated. The flap should be mobile so that it can be coronally repositioned without any tension.

3.  Harvest the connective tissue graft from the palate:

The connective tissue graft is harvested from the hard palate. The ideal location is 5-6 mm apical to the gingival margin of the palatal aspects of the maxillary premolars and the mesial half of the maxillary first molar. Incisions are made to gain access to the connective tissue. The incisions create a trap door effect where a flap is raised on the palate and then the connective tissue is harvested. The ideal thickness of the graft should be 1-1.5 mm thick. During harvesting the connective tissue, the vital structure that needs to be avoided is the greater palatine artery. Depending on the depth of the palatal vault, typically, the artery is about 12 mm apical to the gingival margin (Reiser 1996, Monnet-Corti 2006).

4. Placement of the Graft:

The harvested connective tissue graft is immediately placed in the recipient site and secured into position with sutures. The typical size of the sutures are 5-0 or 6-0. Optimized healing requires the graft to be in intimate contact with the recipient bed with the absence of any dead space.

5. Management of the donor site:

Positive hemostasis is required in the donor site. The first step is application of pressure. A variety of hemostatic agents such as collagen sponges may be used to aid with hemostasis. If there is significant bleeding, then ligation of the greater palatine artery with a suture may be required. For patient comfort, a periodontal dressing may be placed or palatal stent that was pre-surgically fabricated may be inserted.

Post-operative maintenance

Patient should be seen no more than 2 weeks following surgery for a post-operative visit and suture removal (if necessary). Toothbrushing and flossing are not recommended around the surgical site for first 2 weeks. Gentle rinsing with chlorhexidine gluconate (0.12%) should be used. Professional prophylaxis is recommended every 2 weeks until healing is complete and the patient is able to maintain acceptable oral hygiene in the surgically-treated areas. 

Healing Following Connective Tissue Graft

Histologic studies of sites with connective tissue graft demonstrate that some regeneration of new bone, cementum and connective tissue attachment have occurred, but the predominant healed site is mostly long junctional epithelium (Harris 1999a, Harris 1999b, Bruno 2000, Goldstein 2001, Majzoub 2001).  

As the connective tissue matures, creeping attachment may occur where the gingival margin migrates coronally. A group of 155 consecutively treated Miller Class I or Class II defects were treated with the connective tissue. Recession was observed in 22 defects in 19 patients at 4 weeks postoperatively. The patients were seen at 1, 2, 4, 8, and 12 weeks postoperatively and were then placed on a 3-6 month recall. All defects were evaluated for 1 year. The mean amount of creeping attachment which occurred by 12 months was 0.8 mm. 21 of the 22 defects (95.5%) and 18 of 19 patients (94.7%) had some creeping attachment. Complete root coverage as a result of creeping attachment occurred in 17 of 22 defects (77.3%), in 15 of 19 patients (78.9%) (Harris 1997).

With respect to the donor site, regeneration of the connective tissue occurs in about 2-3 months.  If the patient requires multiple grafting, the same donor site can be re-entered and more tissue is harvested every 2-3 months (Tarnow 1992).

Summary and Conclusions

Management of gingival recession requires the identification and elimination of the etiology. Many recessions do not require treatment. In some cases, the decision may be to treat the recession with a root coverage procedure. One of the most predictable techniques is the connective tissue graft.



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Article Reviewed By

Dr. Michael Goldberg & Dr. Howard Tenenbaum