Gum recession: when is a gum graft worthwhile?

Receding gums and gum recession: what are we talking about?

Patients describe "receding gums" or a tooth that seems to be "losing its gum": the tooth looks longer and its root becomes visible. The medical term is gingival recession: the gum margin has moved below the junction between the enamel and the root, leaving part of the root exposed. The root is covered by a softer tissue than enamel and becomes exposed to cold, wear and decay.

Receding gums actually cover two situations. In the first, the gum moves down on a tooth whose support between the teeth is intact: this is an isolated recession, often linked to brushing or thin gum tissue. In the second, the gum follows bone destroyed by periodontitis: recession then affects several teeth and comes with pockets, bleeding and sometimes loose teeth. The approach is not the same, and this is the first point the examination must settle (see recognising periodontitis).

Which signs point to a recession?

Recession develops slowly and often goes unnoticed at first. The signs that bring people to the practice fall into four groups.

• sensitivity to cold, air or sweet food, located at the neck of one or more teeth: the exposed root has no enamel to protect it;
• a tooth that looks longer than its neighbours, or a gum line that is no longer level with the teeth next to it;
• a visible root, often more yellow than the enamel, sometimes with a notch at the neck or a cavity;
• discomfort when smiling or brushing: the area hurts when the brush passes, or the gum seems to be missing in front of a tooth.

Bleeding, redness or swelling alongside these signs point instead to inflammation, gingivitis or periodontitis, which has to be treated before a graft is considered. Conversely, an isolated recession on healthy gum does not bleed and does not hurt apart from sensitivity to cold.

Why do gums recede?

Several factors are often associated with recession developing or worsening, and they usually combine. The background first: thin, shallow gum tissue (a thin gingival phenotype) and very thin or even absent bone over the root. On such fragile ground, a modest insult is enough to make the gum retreat.

The most frequent insults are forceful or horizontal brushing with a hard brush, orthodontic movement that pushes the tooth out of its bony envelope, a lip or cheek frenum that pulls on the gum with every movement, a lip or tongue piercing, and an overhanging restoration or a crown whose edge irritates the gum. Periodontitis, finally, destroys bone and attachment; the gum follows, and recession then affects the visible surfaces as well as the spaces between the teeth.

Smoking and poor plaque control do not explain a recession on their own, but they complicate the healing of a graft and weigh in the decision.

What the periodontist examines before deciding

The examination first looks for the cause, then assesses what can be achieved. Dr Hazout measures the height of the recession, the thickness of the gum and the height of keratinised gum (the firm, attached gum, as opposed to the mobile lining mucosa beyond it). He looks at the state of the exposed root (wear, notch, decay), the position of the frenum and the brushing technique, and notes whether the area shows when you smile. X-rays and pocket depth measurements define the bone present between the teeth, because that is what determines the outcome ^[1].

The 2018 international classification adopts the Cairo classification, based on the attachment (support) between the teeth on either side of the recession ^[1]:

This classification gives a prognosis even before a technique is chosen: in RT1, full root coverage can be hoped for; in RT2, coverage is often partial; in RT3, the height lost between the teeth is not rebuilt, and the aim becomes thickening the gum and stabilising the situation rather than covering the root ^[1].

Is a graft needed?

A stable recession that is barely visible, not sensitive, on healthy gum that is easy to clean, can simply be monitored. The cause is corrected first: brushing technique, a soft toothbrush, control of periodontitis through periodontal treatment. A baseline measurement, repeated at each check-up, shows whether the recession is progressing.

A graft is more likely to be discussed when:

• the recession gets worse from one measurement to the next;
• sensitivity to cold persists despite desensitising toothpastes;
• the exposed root is wearing away or decaying;
• the gum is too thin or absent and brushing becomes painful;
• orthodontic treatment is planned in a fragile area;
• the appearance bothers you.

The choice also takes into account what does not depend on the technique: a recession caused by unstabilised periodontitis is not grafted, and fragile gum in a smoker heals less well. When a tooth is too damaged or too loose to be kept, the question shifts to replacing it, which is covered on the Implants page.

Gum graft techniques

The term gum graft, or gingival graft, covers several procedures. All of them pursue one of two aims, or both: recreating a band of firm gum where it is missing, or covering an exposed root. The grafted tissue most often comes from the patient's own palate, whose thick mucosa heals over after harvesting.

What the studies suggest you can expect

The 2018 Cochrane review analysed 48 randomised trials (1,227 participants) ^[2]. Several techniques can cover roots: a coronally advanced flap alone or combined with a biomaterial, or a connective tissue graft. A connective tissue graft combined with a coronally advanced flap provides more keratinised gum than the alternatives compared. But the quality of the evidence is low to very low, and the authors remain uncertain which technique is most effective.

For the tunnel technique, a 2018 meta-analysis reports mean root coverage of about 83% for single recessions and 88% for multiple recessions; with the same graft, the coronally advanced flap more often achieved complete coverage than the tunnel ^[3].

The limits, and why follow-up matters

A graft does not put gum back where the bone between the teeth has gone: in RT2 and especially RT3, coverage remains partial, and nobody can say in advance how much height will be regained. Nor does it correct the cause. If brushing remains traumatic, if a frenum keeps pulling or if orthodontic movement moves the tooth out of its bone, recession can return, on the grafted tooth or on a neighbour.

Follow-up therefore has two purposes: checking that the grafted gum stays stable, and keeping the cause under control. For a patient treated for periodontitis, this check is part of periodontal maintenance visits. For others, a regular measurement of the recession and a look at the brushing technique are usually enough. Recessions that are part of a wider loss of support belong to periodontitis treatment or periodontal regeneration, not to an isolated graft.

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