Progression of Gingival Recession with or Without Therapy

Multiple lines of evidence have suggested that gingival recession defects are progressive in nature. A longitudinal study with 12-year follow-up demonstrated that gingival recession increases with age and sites with existing gingival recession are at the greater risk of progression.

In a retrospective 10- to 27-year follow-up split-mouth study, gingival recession defects, lacking attached gingiva treated with free gingival graft on one side of the mouth, were compared with untreated contralateral sites. 

Results demonstrated that treatment was effective, since all treated sites exhibited reduced gingival recession and increased stable keratinized gingiva. In contrast, untreated sites showed increased gingival recession during follow-up period.

A systematic review and meta-analysis of untreated gingival recession defects has indicated increased risk of progression of recession during long-term follow-up. There is also some limited evidence to support a protective role for keratinized gingiva in reducing the likelihood of gingival recession progression. 

As a result, the surgical correction of these defects via soft tissue augmentation and root coverage appears as an important intervention to be considered during the clinical decision-making process. 

There are four main indications for the surgical treatment of gingival recession: 

1. Esthetic purposes 
2. To reduce dentinal hypersensitivity 
3. To augment a deficient keratinized tissue 
4. To correct root abrasion defects or caries 

Esthetic Reasons

The main reason that drives many patients to seek periodontal treatment are esthetic concerns. Patients demand treatment when excessively long teeth and/or a lack of harmony in the gingival margins are evident while smiling. The most feasible treatment to correct this esthetic gingival imbalance is root coverage procedures. 

A recent systematic review of randomized controlled trials demonstrated that periodontal plastic surgery procedures for the treatment of single and multiple gingival recessions improve esthetics, both perceived by patients and objectively assessed by professionals. 


Teeth with gingival recession often experience pain in response to thermal, chemical, and tactile stimuli to the exposed dentine. This phenomenon is known as “dentinal hypersensitivity.” The pain is commonly sharp, short, and localized and can severely affect performance of proper oral hygiene. The treatment for dentinal hypersensitivity can be complex and may include local application of desensitizing agents to occlude exposed dentinal tubules for mild cases with no esthetic concerns. Cervical restoration can be performed in cases where there has been enamel loss, exposing dentine coronal to the CEJ. 

Surgical intervention to achieve root coverage is another strategy, primarily indicated when complete root coverage can be predicted. A systematic review has suggested that there is not enough evidence to prove that mucogingival surgical procedures can resolve dentinal hypersensitivity. This is attributed to the fact that dentinal hypersensitivity has not been consistently evaluated in clinical studies. Nonetheless, several studies have demonstrated improvement in dentinal hypersensitivity. 

One reason why dentinal hypersensitivity is not consistently resolved is because incomplete root coverage can be associated with residual dentinal hypersensitivity. Therefore, root coverage can be proposed as a viable therapeutic option for patients who complain of dentinal hypersensitivity, only if complete root coverage is technically feasible. 

Keratinized Tissue Augmentation 

Gingival recession defects with thin, minimal, or no keratinized gingiva have been considered to be at greatest risk of progression. Therefore, keratinized tissue gain has been considered one of the therapeutic objectives of periodontal plastic surgery. 

However, it may be debatable whether gingival thickness or the keratinized phenotype of the gingiva is the most important element of risk. The fact that many types of grafting, which do not necessarily mediate clinically significant increase in keratinized gingival zone, are associated with periodontal attachment level stability may argue that gingival margin thickness is more important than keratinization phenotype. 

Moreover, some of the therapies aimed at increasing keratinized gingival zone, such as free gingival graft, are associated with diminished esthetic and suggest a secondary role for keratinized gingiva in periodontal plastic surgery. 

Cervical Caries and Non-carious Cervical Lesions 

In the elderly population, radicular caries and/or deep root abrasion are common findings and can pose oral hygiene challenges for patients. These can lead to dentinal hypersensitivity and/or endodontic involvement. 

The combination of root coverage surgery and restorative treatment in these teeth can help prevent future caries development and render an easier situation for plaque control for the patient. 

However, one needs to consider that dentinal bonding is not as predictable as enamel bonding. Therefore, bonded restorations in dentin may be more prone to leakage or failure.

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