Gingival recession is characterized by apical displacement of the gingival margin, resulting in exposure of the root surface. It may be associated with dentin hypersensitivity, root caries, non-carious cervical lesions, aesthetic concerns, and progressive loss of soft-tissue coverage.
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✅ What Is the Current Treatment for Gingival Recession?
Treatment can be divided into non-surgical management and periodontal plastic surgery.
| Clinical Situation | Current Management |
|---|---|
| Mild recession without symptoms or progression | Risk-factor control and periodontal maintenance |
| Dentin hypersensitivity | Desensitizing agents and exposure control |
| Plaque-related inflammation | Professional periodontal therapy and optimized plaque control |
| Root caries or cervical lesion | Restorative management when indicated |
| Aesthetic concern or progressive recession | Periodontal plastic surgery |
| Localized recession suitable for root coverage | Coronally advanced flap ± connective tissue graft |
| Multiple adjacent recessions | Tunnel or coronally advanced techniques, usually with connective tissue graft |
| Limited donor tissue or avoidance of palatal surgery | Collagen or other soft-tissue substitutes may be considered |
Not every gingival recession requires surgery. The initial approach should identify and control factors that may contribute to progression or symptoms.
Management may include:
▪️ Improvement of plaque control without traumatizing the marginal tissues.
▪️ Correction of inappropriate oral-hygiene practices when clinically relevant.
▪️ Management of periodontal inflammation or periodontitis.
▪️ Treatment of dentin hypersensitivity with appropriate desensitizing agents.
▪️ Evaluation and treatment of non-carious cervical lesions or root caries.
▪️ Periodic periodontal monitoring to determine whether the recession remains stable.
The evidence regarding traumatic toothbrushing as a direct cause of recession is not completely consistent. Therefore, clinicians should avoid attributing every recession solely to brushing technique and should evaluate the entire clinical context.
2. Connective Tissue Graft With a Coronally Advanced Flap
For a suitable localized gingival recession, the combination of a subepithelial connective tissue graft (CTG) and coronally advanced flap (CAF) remains one of the most predictable approaches for root coverage.
A systematic review and network meta-analysis involving 38 studies found that CTG + CAF ranked highest for mean root coverage, complete root coverage, and gain in keratinized tissue for single recession defects. The authors concluded that this combination can be considered the current gold-standard approach for these indications.
The technique is particularly valuable when the objectives include:
▪️ Root coverage
▪️ Increased gingival thickness
▪️ Increased keratinized tissue
▪️ Reduction of dentin hypersensitivity
▪️ Improvement of gingival aesthetics
▪️ Long-term soft-tissue stability
3. Tunnel Techniques
Tunnel procedures combined with a connective tissue graft are another important option, particularly for multiple adjacent recessions.
Evidence indicates that tunnel and coronally advanced flap approaches can provide comparable overall root-coverage outcomes in appropriately selected cases, although the optimal technique depends on defect morphology, tissue thickness, interdental anatomy, and operator expertise.
4. Collagen Matrices and Other Alternatives
When harvesting an autogenous graft is undesirable or contraindicated, xenogeneic collagen matrices, acellular dermal matrices, and other soft-tissue substitutes can be considered.
These materials may reduce the need for a palatal donor site and can reduce postoperative morbidity. However, current evidence generally continues to support autogenous connective tissue grafts as the most predictable option, particularly when maximum root coverage and soft-tissue augmentation are priorities.
5. Enamel Matrix Derivative
Enamel matrix derivative (EMD) may be used as an adjunct to selected root-coverage procedures. A systematic review and meta-analysis found a statistically significant improvement in root coverage when EMD was added to CAF + CTG, although the magnitude of the additional benefit was relatively modest.
Therefore, EMD should generally be regarded as an adjunct rather than a replacement for the fundamental surgical technique.
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Modern diagnosis should consider the interproximal clinical attachment level, rather than relying exclusively on the traditional Miller classification.
The Cairo classification distinguishes:
▪️ RT1: recession without interproximal attachment loss.
▪️ RT2: interproximal attachment loss that is equal to or less than the buccal attachment loss.
▪️ RT3: interproximal attachment loss greater than the buccal attachment loss.
The amount of interproximal attachment is clinically important because it influences the predictability of complete root coverage.
A complete periodontal assessment should also consider:
▪️ Recession depth and width
▪️ Gingival phenotype
▪️ Keratinized tissue
▪️ Interproximal attachment
▪️ Root prominence
▪️ Tooth position
▪️ Periodontal inflammation
▪️ Presence of cervical lesions
▪️ Patient symptoms and aesthetic expectations
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Root-coverage surgery should be considered when the recession produces significant aesthetic concerns, persistent hypersensitivity, progressive tissue loss, root caries risk, or other clinically relevant problems that cannot be adequately managed with conservative measures.
However, surgery should not be performed simply because a recession is visible. Stable, asymptomatic recession without functional or aesthetic concerns may be managed conservatively with monitoring and risk-factor control.
Untreated recession can progress over time in some patients; therefore, periodic assessment is appropriate even when surgery is not initially indicated.
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The current evidence supports an individualized, defect-based approach to gingival recession. Conservative management remains appropriate for stable and asymptomatic defects, whereas surgical root coverage is indicated when symptoms, aesthetics, progression, or tissue-management objectives justify intervention.
For appropriately selected single recession defects, coronally advanced flap combined with a subepithelial connective tissue graft remains the most predictable reference treatment. Tunnel techniques provide an important alternative for multiple recessions, while collagen matrices and other substitutes can be considered when an autogenous graft is unsuitable or when reduced donor-site morbidity is prioritized.
The presence of a non-carious cervical lesion should also be identified before surgery because the altered cemento-enamel junction and root-surface anatomy can affect the predictability of root coverage and may require a combined restorative-periodontal approach.
✍️ Conclusion
The current treatment of gingival recession begins with accurate diagnosis and control of modifiable risk factors. Non-surgical management is appropriate for many stable defects, while periodontal plastic surgery is indicated when root coverage, symptom control, tissue augmentation, or aesthetic improvement is required.
For suitable localized defects, connective tissue grafting combined with a coronally advanced flap remains the most evidence-supported and predictable approach. Alternative techniques and biomaterials should be selected according to defect characteristics, patient preferences, donor-site considerations, and the clinician's surgical expertise.
🎯 Clinical Recommendations
1. Classify the recession and assess interproximal attachment before selecting a root-coverage technique.
2. Control periodontal inflammation and modifiable risk factors before surgery.
3. For predictable root coverage of appropriate localized defects, consider CAF + subepithelial connective tissue graft as the reference approach.
4. For multiple adjacent recessions, consider tunnel or coronally advanced techniques combined with soft-tissue grafting according to anatomy and operator expertise.
5. Consider collagen matrices or other substitutes when an autogenous donor site is undesirable or contraindicated, recognizing that clinical outcomes may differ from those obtained with CTG.
6. Evaluate non-carious cervical lesions before surgery and consider coordinated restorative-periodontal treatment when indicated.
7. Maintain long-term periodontal supportive care and clinical monitoring, even after successful root-coverage therapy.
📚 References
✔ Chambrone, L., Botelho, J., Machado, V., Mascarenhas, P., Mendes, J. J., & Avila-Ortiz, G. (2022). Does the subepithelial connective tissue graft in conjunction with a coronally advanced flap remain as the gold standard therapy for the treatment of single gingival recession defects? A systematic review and network meta-analysis. Journal of Periodontology, 93(9), 1336–1352. https://doi.org/10.1002/JPER.22-0167
✔ Chapple, I. L. C., Mealey, B. L., Van Dyke, T. E., Bartold, P. M., Dommisch, H., Eickholz, P., Geisinger, M. L., Genco, R. J., Glogauer, M., Goldstein, M., Griffin, T. J., Holmstrup, P., Johnson, G. K., Kapila, Y., Lang, N. P., Meyle, J., Murakami, S., Plemons, J., Romito, G. A., Shapira, L., Teughels, W., Trombelli, L., Walter, C., Wimmer, G., & Xenoudi, P. (2018). Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop. Journal of Clinical Periodontology, 45(Suppl. 20), S68–S77. https://doi.org/10.1111/jcpe.12940
✔ Cairo, F., Nieri, M., Pagliaro, U. (2008). Treatment of gingival recession with coronally advanced flap procedures: A systematic review. Journal of Clinical Periodontology, 35(8 Suppl.), 136–162. https://doi.org/10.1111/j.1600-051X.2008.01267.x
✔ Gennai, S., Ben Guiza, Z., Orsolini, C., & Gosset, M. (2022). The influence of non-carious lesions in the surgical treatment of gingival recession: A systematic review and meta-analysis. Journal of Dentistry, 117, 103922. https://doi.org/10.1016/j.jdent.2021.103922
✔ Kasaj, A., & Willershausen, B. (2021). Treatment of gingival recession: When and how? International Dental Journal, 71(3), 178–187. https://doi.org/10.1111/idj.12617
✔ Rajapakse, P. S., McCracken, G. I., Gwynnett, E., Steen, N. D., Guentsch, A., & Heasman, P. A. (2007). Does tooth brushing influence the development and progression of non-inflammatory gingival recession? A systematic review. Journal of Clinical Periodontology, 34(12), 1046–1061. https://doi.org/10.1111/j.1600-051X.2007.01149.x
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