PERIODONTIC DENTISTRY: The Subepithelial Connective Tissue Graft

by Russell Leve, DDS, BSc., Ed.M.

The ability to cover denuded root surfaces has been a long-time goal of periodontists. Procedures available today allow us to achieve root coverage predictably. While marginal tissue recession seldom results in tooth loss, it is often associated with root sensitivity, predisposes to root caries, may cause frenal involvement with marginal tissue irritation and are perceived as aesthetic impairment by our patients. It is important that our patients are aware that these surgical periodontal plastic procedures are both available and predictable.

After a brief review of the issues related to root coverage and gingival recession the subepithelial connective tissue technique will be presented.

The term “mucogingival surgery” was introduced into the periodontal literature in the 1950s and was defined as a surgical procedure to preserve gingiva, remove aberrant frenulum and muscle attachments and to increase the depth of the vestibule.1 Since then the definition has been changed to refer to periodontal surgical procedures designed to correct defects in the morphology, position, and amount of gingiva surrounding the teeth.2 The term “periodontal plastic surgery procedure” may be more appropriate since mucogingival surgery now encompasses not only the treatment of problems associated with the amount of gingivae and recession type defects but also includes correction of ridge form and soft tissue aesthetics.3

The gingivae is composed of dense connective tissue covered with keratinized epithelium and extends from the gingival margin to the mucogingival junction. The gingivae has been divided into a free segment, the part of the gingivae that corresponds to the probing depth, and the attached segment that is determined clinically by subtracting the probing depth from the entire width of the gingival tissue.

Gingival recession occurs when the location of the marginal gingivae is positioned apically to the cemento-enamel junction.

A number of procedures have been utilized for the augmentation of gingival tissues. These include:

1. Rotational flaps (laterally sliding flaps, papilla and double papilla flaps).

2. Coronally positioned flap, (flaps without rotation or lateral movement).

3. Pedicle soft tissue graft with the use of a membrane (Guided Tissue Regeneration).

4. Free soft tissue grafts (epithelialized free gingival grafts, subepithelial connective tissue grafts).

The most widely-used plastic surgery procedure today is the subepithelial connective tissue graft because its high predictability in achieving root coverage. This procedure was first introduced by Langer and Langer in 19854 and has been refined over the last few years. This technique represents a major improvement over the Free Gingival Graft for a number of reasons:

1. Leads to more predictable root coverage.

2. It is less traumatic surgery and has fewer and less severe post-operative complications.

3. Results in a better aesthetic outcome allowing superior tissue-colour match.

Before considering root coverage procedures, it is helpful to refer to a classification of gingival recession. The most accepted one today is the Miller5 classification because its ability to predict success or failure or root coverage. The classification is as follows:

Class 1. Marginal tissue recession, which does not extend to the mucogingival junction. There is no periodontal loss in the interdental area.

Class 2. Marginal tissue recession, which extends to or beyond the mucogingival junction. There is no periodontal loss in the interdental area.

Class 3. Marginal tissue recession, which extends to or beyond the mucogingival junction. Bone or soft tissue loss in the interdental area is present or there is malpositioning of teeth.

Class 4. Marginal tissue recession which extends to or beyond the mucogingival junction. The bone or soft tissue loss in the interdental area or the malpositioning of teeth is severe.

A skillful operator can anticipate full root coverage in Class 1 and Class 2 cases; partial root coverage in Class 3 cases; very little or no coverage in Class 4 cases.

The subepithelial connective tissue graft — Technique:

After a complete examination and consultation and after obtaining informed consent local anaesthesia is achieved.

Preparation of the Recipient Site: Teeth # 22 and 23 (Fig. 1). The exposed root surface is thoroughly root planed. Then, a horizontal incision is made through the interdental papillae on both sides of the tooth at the level of the cementoenamel junction or at the level of the height of the crest of bone; whichever is more coronal (Fig. 2). The incisions traversing the interdental papilli are joined together with a sulcular incision. Then, a split thickness flap is raised extending to and beyond the mucogingival junction. There are no releasing incisions. The interdental papillae are left intact (Fig. 3). The epithelial surface layer of the papilli is removed, achieving de-epithelialization of the papilli.

Harvesting the Graft: A second surgical site, the Donor Site is planned on the hard palate. Two parallel incisions, 1.5 mm to 2.0 mm apart, are made at approximately 3.0 mm distance from the gingival margin. The length of the incisions equals the combined width of the recession and the two interdental papilli. The two palatal incisions are joined at both ends. The tissue between the two incisions is “dissected out” (Fig. 4) and the soft tissue edges are sutured together (Fig.5). The excised tissue is thinned and shaped extra-orally and the epithelial layer is removed.

Securing the Graft to the Recipient Site: The excised graft tissue is inserted into the space between the root and the previously prepared flap (Fig. 6). It is placed so that it covers the denuded root surface up to the cementoenamel junction or the crest of bone. The graft is sutured into place with a 5.0 sling suture through the graft and the interdental papilli. The flap is then sutured into place with a similar 5.0 sling suture (Fig. 7).

The recipient and donor sites are covered with a periodontal dressing. This author prefers to remove the sutures in two weeks’s time and invite the patient back for a final post-operative evaluation six weeks following the initial procedure.

Several pre- and post-surgical pictures illustrate the predictable nature of the Subepithelial Connective Tissue Graft.OH

Dr. Leve is a Periodontist in private practice with Cumberland Periodontics in Toronto. He has taught at Temple University, University of Toronto, and was head of Periodontics at Mount Sinai Hospital in Toronto.

Oral Health welcomes this original article.


1.Friedman N. Mucogingival surgery Texas Dent. Jr. 1957; 75:358-362

2. The American Academy of Periodontology Glossary of Periodontal Terms 3rd edition Chicago The American Academy of Periodontolgy

3.Miller PD. Regenerative and reconstructive periodontal surgery. Mucogingival surgery. Dent. Clin. North Am. 1988; 32:287-306

4. Langer, B and Langer, L: Subepithelial Connective Tissue Graft Technique for Root Coverage, J. Periodont., Dec. 715,1985

5.Miller, P.D., Jr.: A Classification of Marginal Tissue Recession, Int. J. Periodont. Rest. Dent, 5: 9, 1985