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 307

A Decision Tree for Soft Tissue Grafting

Daylene Jack-Min Leong, BDS* Mucogingival surgery is a term

Hom-Lay Wang, DDS, MSD, PhD** first introduced in 1957 by Fried-
man1 and was defined as surgical
procedures designed to preserve
gingiva, remove aberrant frenulum
Periodontal plastic surgery is commonly performed for esthetic and physiologic or muscular attachments, and in-
reasons, such as alleviating root sensitivity, root caries, and cervical abrasion crease the depth of the vestibule.
and facilitating plaque control at the affected site. Currently, there is a lack These procedures were performed
of information regarding the most appropriate treatment method for the to maintain an adequate mucogin-
various clinical situations encountered. The aims of this paper are to review gival complex, with emphasis on
and discuss the various clinical situations that require soft tissue grafting and the amount of attached gingiva.
to attempt to provide recommendations for the most predictable technique. However, techniques were later de-
Using MEDLINE and The Cochrane Library, a review of all available literature signed not only for health reasons
was performed. Papers published in peer-reviewed journals written in English
but also for cosmetic purposes.
were chosen and reviewed to validate the decision-making process when
Subsequently, Miller not only intro-
planning for soft tissue grafting. A decision tree was subsequently developed to
duced a classification of marginal
guide clinicians to choose the most appropriate soft tissue grafting procedure
tissue recession,2 he also coined the
by taking into consideration the following clinical parameters: etiology,
purpose of the procedure, adjacent interproximal bone level, and overlying term periodontal plastic surgery
tissue thickness. The decision tree proposed serves as a guide for clinicians in 1988,3 which was accordingly
to select the most appropriate and predictable soft tissue grafting procedure defined at the Proceedings of the
to minimize unnecessary mistakes while providing the ultimate desired World Workshop in Periodontics in
treatment outcome. (Int J Periodontics Restorative Dent 2011;31:307313.) 19964 as surgical procedures per-
formed to prevent or correct ana-
tomic, developmental, traumatic or
disease-induced defects of the gin-
*Resident, Department of Periodontics and Oral Medicine, School of Dentistry, University
of Michigan, Ann Arbor, Michigan. giva, alveolar mucosa or bone.
**Professor and Director of Graduate Periodontics, Department of Periodontics and Oral Today, periodontal plastic sur-
Medicine, School of Dentistry, University of Michigan, Ann Arbor, Michigan. gery is not only performed for
physiologic reasons, but also for es-
Correspondence to: Dr Hom-Lay Wang, Department of Periodontics and Oral Medicine,
University of Michigan School of Dentistry, 1011 North University Avenue, Ann Arbor, MI thetic purposes. This paper focuses
48109-1078; fax: (734) 936-0374; email: homlay@umich.edu. on the management of soft tissue

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308
defects and discusses situations in
which a clinician would consider a
soft tissue plastic surgery proce-
dure. In addition, the authors at-
tempt to provide recommendations
as to the appropriate technique in
different clinical scenarios to mini-
mize unnecessary mistakes through
providing the predictability and
overall success of treatment.
Decision tree for
soft tissue grafting
Soft tissue grafting is a type of
periodontal plastic surgery, and a
decision tree for performing soft
tissue grafting is herein proposed
to guide clinicians in making a pru-
dent choice of the most appropri-
ate and predictable techniques in
managing different goals and clini-
cal situations (Fig 1). This decision
tree takes into consideration the
following important influencing
factors: identifying and removing
the etiology of the problem, estab-
lishing the purpose of treatment,
and then determining the poten-
tial of root coverage by examining
the adjacent interproximal bone
level and overlying tissue thick-
ness. By adopting this decision-
making process, predictable treat-
ment outcomes would increase
and unnecessary complications and
failures would be reduced. The ra-
tionale and evidence in support of
this decision-making process are
discussed.
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Etiology
First and foremost, it is of para-
mount importance to identify the
etiology of the soft tissue defect
and remove the associated etiol-
ogy to achieve long-term stability
of the treatment outcome. Some
common etiologies for gingival re-
cession include toothbrush trauma,
tooth malalignment, calculus, gingi-
val inflammation, and orthodontic
tooth movement.5,6 By addressing
these etiologies, one can prevent
the problem from recurring. If mal
aligned teeth or orthodontic treat-
ment led to the gingival recession
and mucogingival problems, the
dentist or periodontist should com-
municate with the orthodontist prior
to initiation of surgical correction to
ensure proper treatment outcomes.
Treatment purpose
Next, one should question the pur-
pose of the procedure. Soft tissue
grafting can be done for augment-
ing the zone of keratinized gingiva
(KG), increasing tissue thickness, or
achieving root coverage.
Augmenting the zone of KG
In situations where increasing the
zone of KG is desired, procedures
such as the apically positioned
flap (APF),7 free soft tissue (FST)
grafting,8,9 laterally positioned flap
(LPF),10 and two-stage connective
tissue (CT) grafts are all feasible,
with the possibility of using tissue-
engineered or biologic agents as
well. When a two-stage CT graft is
used, deepithelialization is required
at 12 weeks after healing so that the
conversion of the overlying tissue to
keratinized tissue by the underlying
CT can occur.11,12 Some studies have
used acellular dermal matrix (ADM)
as an alternative to an autogenous
palatal mucosal graft with a certain
degree of success,13,14 but the gain
in the width of KG and amount of
root coverage using these allografts
and other biologic agents or tissue-
engineered products is generally
not as predictable as compared to
CT grafts or FST graft.15,16
Increasing tissue thickness
On the other hand, if increasing tis-
sue thickness is the ultimate goal of
treatment, then procedures using
CT grafts, ADM, or bone augmenta-
tion techniques may be carried out.
Studies have reported that although
both CT grafts and ADM produced
an increase in gingival thickness,
greater improvement was observed
when using the CT graft.17 Other
experimental studies comparing a
coronally advanced flap (CAF) with
or without ADM in the treatment
of gingival recessions showed suc-
cessful outcomes in gaining gingival
thickness with the adjunctive use of
ADM.18,19 However, the long-term
stability of both procedures remains
to be determined. For CT grafts,
deepithelialization is recommend-
ed11,12; more studies are needed
for ADM because of the lack of ca-
pacity of converting to KG.20 Bone
augmentation using nonresorbable
bone grafts has also been advocat-
ed for this purpose and has shown
some success.21
 309

Identify etiology

Remove etiology

Purpose of procedure

Increase KG Increase tissue

thickness

APF, free soft tissue, LPT,

tissue engineering (biologic agents), CT, ADM,
or CT graft first then deepithelialize at bone augmentation
Root coverage 12 weeks after

Check interproximal bone level

No bone loss Bone loss

(Miller Class I or II) (Miller Class III or IV)

100% root
coverage
possible Root coverage is unpredicatable

Check tissue thickness

Class III: Class IV:

70% to 75% No root
root coverage coverage

New attachment with

Thin (< 1 mm) Thick ( 1 mm)
root coverage

CT graft preferably Any soft tissue procedures: GTRC, tissue

(deepithelialization CT graft, CAF, GTR, ADM, engineeering
at 12 weeks after) LPF, or combination (biologic agents)

Fig 1 Decision tree for selecting a soft tissue grafting procedure. CT = connective tissue; CAF = coronally advanced flap; GTR = guided
tissue regeneration; ADM = acellular dermal matrix; KG = keratinized gingiva; LPF = laterally positioned flap; APF = apically positioned flap;
GTRC = GTR-based root coverage.

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310
Root coverage
If the goal of treatment is to attain
root coverage so that esthetics can
be improved and hypersensitivity
can be reduced, factors to consider
that can influence the predictabil-
ity of root coverage procedures
include the interproximal bone
level of the involved tooth or teeth
as well as gingival tissue thickness
(also known as tissue biotype).
To predict the amount of root
coverage obtainable, it would be
useful to understand the type of
gingival recession according to the
Miller classification.2 Based on the
Miller classification, one has to as-
sess the adjacent interproximal
bone level for any bone loss before
any soft tissue grafting procedure.2
In general, complete root coverage
can be achieved in Class I and II
defects, only partial root coverage
(70% to 75%) can be accomplished
in Class III defects, and Class IV de-
fects are not amenable to root cov-
erage.2 As such, it was the authors
objective to focus on the manage-
ment of Miller Class I and II defects,
while Miller Class III and IV defects
are not described in this paper.
In deciding the soft tissue graft-
ing procedure for root coverage,
the next parameter to assess is gin-
gival tissue thickness. In Miller Class
I and II recession defects with thin
gingival thickness (< 1 mm), the
treatment of choice would be a CT
graft. In the presence of thick tissue
( 1 mm), any soft tissue procedure
may be selected, such as a CT graft,
CAF, guided tissue regeneration
(GTR), ADM, LPF, or a combination
of these procedures and materials.
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While gingival thickness was
not considered an influencing fac-
tor in achieving 100% root cov-
erage with the CT procedure, it
proved to be so for the CAF2225
and GTR procedures.26 In a recent
systematic review, a critical thresh-
old flap thickness of > 1.1 mm was
found to be associated with com-
plete root coverage for GTR and
CT grafting.25
For a CAF procedure, an aver-
age thickness of 0.8 to 1.2 mm has
been suggested as the minimal tis-
sue thickness to achieve complete
root coverage.22-25 The thickness of
the marginal tissue (eg, 0.8 mm)
has been credited as a primary
attribute for the success of root
coverage for a CAF procedure.24
Another study investigating the
factors affecting the outcomes of
CAF procedures reported that an
initial gingival thickness > 1.2 mm
was highly associated with com-
plete root coverage.22 When the
criteria mentioned previously were
adhered to or when a CT graft was
placed under a CAF, the amount of
mean defect coverage was almost
100%.22,27,28 Therefore, if the gingi-
val biotype is thick, root coverage
can be achieved with a CAF alone
or other types of grafting proce-
dures (eg, GTR, ADM). On the oth-
er hand, defects should be treated
in combination with a CT graft at
sites with a thin gingival biotype.
This is in agreement with a recent
multicenter, randomized, double-
blind clinical trial that showed that
additional placement of a CT graft
beneath a CAF increased the prob-
ability of achieving complete root

coverage in Miller Class I and II de-
fects in maxillary teeth.29
Using GTR, sites with a tissue
thickness of > 0.5 mm obtained
a mean root coverage of 95.6%;
at thin areas of 0.5 mm, a mean
root coverage of only 26.7% was
obtained.26 This may lead one
to speculate that the membrane
placed between the bone and full-
thickness flap may have acted as
a barrier preventing blood circula-
tion. This is especially detrimental
for a thin flap.
Techniques used for root cov-
erage include CT grafts, FST grafts,
pedicle autografts (rotational and
advanced flaps), GTR, and, more
recently, acellular dermal matrix.
The use of a CT graft for root cov-
erage has been shown to be a
highly predictable and successful
procedure. Studies have shown a
mean defect coverage of 84%3032
and a predictability of achieving
90% defect coverage 68% of
the time.30,33,34 The CAF is another
technique often used alone or in
combination26 with other soft tis-
sue grafting procedures to cover
exposed roots. However, the re-
sults can only be predictable un-
der specified conditions27,28: Miller
Class I recession defect, shallow re-
cession 4 mm, keratinized tissue
width 3 mm, gingival thickness
0.8,22,24,27 and overcorrection of the
defect.23,35 The LPF technique has
been advocated for coverage of lo-
calized recession defects. In gener-
al, clinical studies on humans have
reported a range of 61% to 74%
reduction in recession depth,10,36,37
representing a mean 67% defect
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311
coverage for these studies.34 GTR
procedures using both absorbable
and nonresorbable membranes
have been performed for root cov-
erage, with no apparent significant
differences in treatment outcome.38
The mean root coverage has been
found to be approximately 72% to
73%, with a 35% to 39% predict-
ability of achieving 90% root cov-
erage.34,39,40 Some factors affecting
the success of root coverage in-
clude the initial recession depth,41
gingival thickness,25,26 and mem-
brane exposure.42
In a recent systematic review
comparing CT grafts, ADM, and
GTR with absorbable membranes,
results showed that CT grafts can
be considered the gold standard
in treating Miller Class I and II re-
cession defects with respect to ob-
taining substantial root coverage,
clinical attachment, and keratinized
tissue gain.43 Similar results in favor
of CT grafts were also reported in
other systematic reviews.44,45
Another factor that may influ-
ence the final treatment outcome
is the final position of the gingival
margin. It has been demonstrated
that the more coronal the level of
the gingival margin postsuturing,
the higher the probability of achiev-
ing complete root coverage.35
Huang and Wang23 introduced a
sling and tag technique in 2007
for the CAF procedure, and in the
study, the flap was repositioned cor-
onally beyond the cementoenamel
junction by at least 1 mm. At 1 year
postsurgery, a mean root cover-
age of 93% 15% was obtained,
indicating very successful results.
Volume 31, Number 3, 2011
312
Therefore, to increase the predict-
ability of complete root coverage
with a CAF procedure, it is gener-
ally recommended that the flap be
repositioned at least 1 mm beyond
the cementoenamel junction.
If the objective of root coverage
is to obtain new attachment, proce-
dures such as GTR-based root cov-
erage and use of tissue-engineered
or biologic agents may be consid-
ered. GTR and other techniques,
such as root surface conditioning
procedures and root biomodifi-
cation with biologic agents (eg,
enamel matrix derivatives), have
shown varying results with uncer-
tain predictability in obtaining new
attachment and root coverage.46
Histologic evidence showing re-
generation of the periodontium at
6 months has been shown in stud-
ies using EMD and certain growth
factors.47,48 However, more studies
are warranted in this area to ascer-
tain the effectiveness and predict-
ability of attaining new attachment
with various biologic agents.
Conclusion
The decision tree proposed serves
as a guide for clinicians to select
the most appropriate and predict-
able soft tissue grafting procedure
to minimize unnecessary mistakes
while providing the ultimate de-
sired treatment outcome.
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Acknowledgments
This study was supported by the Periodontal
Graduate Student Research Fund, University
of Michigan, Ann Arbor, Michigan.
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