Journal of Interdisciplinary Dentistry

: 2022  |  Volume : 12  |  Issue : 2  |  Page : 65--69

A novel application of partially epithelized-subepithelial connective tissue graft for management of complex mucogingival condition

Deepak Sharma, Pravesh Jhingta 
 Department of Periodontology, HP Government Dental College and Hospital, Shimla, Himachal Pradesh, India

Correspondence Address:
Dr. Deepak Sharma
Department of Periodontology, HP Government Dental College and Hospital, Shimla - 171 001, Himachal Pradesh


Multiple adjacent gingival recessions in the mandibular anterior region are frequently associated with critical anatomic factors such as inadequate attached gingiva, high frenum insertion, or shallow vestibule. In addition, the loss of interdental soft and hard tissues make these mucogingival conditions more complex and challenging for the clinician. Multiple periodontal plastic surgical procedures are often required to treat such conditions which increase patient discomfort and surgical morbidity. The cases present for the first time a novel application of the bilaminar technique of reverse partially epithelized-subepithelial connective tissue graft (PESCTG) with bridge flap to treat severe multiple contiguous recessions and augment gingiva and vestibular depth in mandibular anterior teeth as a single-staged surgical approach. The technique achieved good esthetics and clinical outcomes in terms of recession coverage, increase in width and thickness of gingiva, and vestibular depth.

How to cite this article:
Sharma D, Jhingta P. A novel application of partially epithelized-subepithelial connective tissue graft for management of complex mucogingival condition.J Interdiscip Dentistry 2022;12:65-69

How to cite this URL:
Sharma D, Jhingta P. A novel application of partially epithelized-subepithelial connective tissue graft for management of complex mucogingival condition. J Interdiscip Dentistry [serial online] 2022 [cited 2023 Jan 28 ];12:65-69
Available from:

Full Text

 Clinical Relevance to Interdisciplinary Dentistry

Multiple contiguous severe gingival recessions in mandibular anterior teeth frequently present with composite mucogingival condition of loss of interdental soft and hard tissues and inadequate width and thickness of attached gingiva and shallow vestibular depthThe presented novel bilaminar reverse PESCTG technique is a promising and predictable treatment to manage such situationsCareful surgical graft harvesting and its firm stability at the recipient site improve success outcomes in the presented technique.


Gingival recession is the exposure of the root surface resulting from migration of the gingival margin apical to the cementoenamel junction (CEJ). It may be limited to a single tooth or affect many teeth and can be associated with one or more tooth surfaces.[1] Patients seek treatment for gingival recession because of esthetic reasons, dentin hypersensitivity, inability to perform oral hygiene, or for associated carious or carious and noncarious cervical lesions.[2],[3]

Multiple adjacent gingival recessions are more commonly observed and they present a number of crucial anatomic features such as large surgical field, frequently shallow vestibules and prominent roots, variation in the size of defects, and reduced keratinized tissue making the treatment challenging for clinicians.[4][5],[6]

The authors planned and performed a novel “Sharma Jhingta” bilaminar technique of reverse partially epithelized-subepithelial connective tissue graft with bridge flap for the composite mucogingival condition of severe multiple contiguous recessions and deficient keratinized and attached gingiva and shallow vestibular depth in mandibular anterior teeth.

 Case Report

A 28-year-old systemically healthy female presents with a chief complaint of “gum recessions and inability to maintain oral hygiene in the lower front teeth.” Examination reveals multiple Miller's Class III and IV gingival recession defects of 3–6 mm depth with interdental papillary loss in mandibular anterior teeth. Other significant findings were inadequate vestibular depth and limited attached gingiva and gingival thickness in central and lateral incisors [Figure 1].{Figure 1}

Another female patient, aged 32 years, complained of “sensitivity and lowering of gums in lower front teeth and inability to maintain good oral hygiene.” On clinical examination, generalized multiple recessions were observed and Class III recession in mandibular lateral incisors and Class IV recessions with severe interdental papillary loss in mandibular central incisors were present. No attached gingiva was present in the right mandibular right central incisor [Figure 1]. There was no contributory medical history. Both the patients had esthetic concerns about the procedure and wanted single-visit treatment for their problem. After written informed consent was obtained from both the patients, a bilaminar technique of reverse partially epithelized-subepithelial connective tissue graft with bridge flap was performed for severe multiple contiguous recessions and deficient gingival width and thickness.

Before surgical procedure, meticulous Phase I periodontal therapy was completed where all exposed root surfaces were thoroughly scaled and root planed with hand and ultrasonic curettes. The clinical parameters were recorded in a standardized sequence at the selected sites using UNC-15 probe and preoperatively and 6 months after surgery, as shown in [Table 1]. An initial horizontal incision was made with 15 c blade in the alveolar mucosa apically to the mocogingival junction (MGJ), incision extended to the distal surfaces of neighbouring teeth bilaterally [Figure 2]. A crevicular incision was made through each recession and also in one tooth on each side without dissecting interdental papillae. Tunneling was done interdentally with tunneling knives and the soft-tissue tunnel was joined with horizontal incision. A full-thickness flap was raised in the apical–coronal direction starting from the horizontal incision. Passive coronal advancement of the flap was confirmed.{Figure 2}{Table 1}

The partially epithelized-subepithelial connective tissue graft (PESCTG) dimensions were determined with a template and corresponded to the dimensions of the recipient site. PESCTG was harvested from the palate by means of the double-incision technique. The connective tissue portion of harvested graft was placed coronally under the bridge flap and epithelised portion apically for the intended purposes [Figure 3]. The flap with the graft was repositioned at the level coronal to CEJ using a 5-0 Vicryl sutures bonded to composite restorations on facial tooth surfaces. Periosteal anchoring 4-0 silk sutures were done apically to secure the graft and to ensure firm adaptation at recipient area [Figure 4]. Eugenol-free, surgical periodontal dressing was given at the grafted site. Ibuprofen 800 mg tid for analgesia as needed was prescribed. Instructions to avoid brushing at the operated site for 1 month and the use of 0.2% chlorhexidine mouthwash were advised for plaque control. Sutures were removed on the 10th postoperative day. Six months postoperatively, partial root coverage and augmented gingival and vestibule dimensions were observed [Figure 5]. The intraoperative steps and 1- and 6-month postoperative clinical presentations of the second case are shown in [Figure 6],[Figure 7],[Figure 8],[Figure 9], respectively.{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Figure 8}{Figure 9}

Both the cases showed a significant improvement in recession dimensions, attached gingiva width and thickness, and vestibular depth with a “Sharma Jhingta” bilaminar PESCTG technique, as shown in [Table 1]. The PESCTG graft blended in color and texture with recipient gingiva. Patients and clinicians were satisfied with esthetic appearance of graft and reduction of dentin sensitivity. With an increase in width and thickness of attached gingiva and vestibular fornix, the oral hygiene efficiency of patients was considerably improved [Figure 5] and [Figure 9]. The patients reported high levels of esthetic and function satisfaction with the results and experienced no postoperative discomfort or difficulty in resuming daily activities. In addition, performing the single-step surgery instead of two or more reduced patients' dental office visits and postoperative complications.


Various perioplastic surgical approaches have been recommended for the treatment of multiple adjacent gingival recessions, either derived from the coronally advanced flap or from tunneling techniques.[7],[8] The predictability of these procedures in the treatment of multiple contiguous recessions of Miller's Class I and Class II is high and improved clinical results were observed when graft-based subepithelial connective tissue procedures were performed.[9],[10]

A flat vestibule, cervical insertion of the frenulum, and a thin periodontal phenotype are common in the mandibular anterior region.[11] Limited keratinized gingiva, interdental soft tissue, and bone loss further complicate the treatment of Class III multiple recession defects in mandibular anterior teeth. Limited data are available for the treatment of multiple Miller's Class III and IV gingival recessions. The loss of interproximal bone and soft tissues and reduced interproximal periosteal bed make them challenging defects to treat mainly because of compromised vascularity.[5]

In cases with inadequate keratinized tissue adjacent to the recession defect and shallow vestibule, the free gingival graft (FGG) is the treatment of choice. It is effective in extending the vestibule and in increasing the width and thickness of the keratinized mucosa.[12],[13] However, the disadvantages of FGG are unpredictable complete root coverage and poor esthetic appearance.[14]

The presented technique utilizes the benefits of FGG for augmenting the keratinized gingiva, removing the frenal insertions, and improving the phenotype whereas the connective tissue graft attempts to cover exposed roots and improve gingival thickness as well. Being a single-step approach, it reduces the operator's chair time and enhances patients' acceptance. The treatment of multiple contiguous recessions with combination soft-tissue grafts and bridge flap has been shown to be a predictable treatment in such complex mucogingival conditions in mandibular anterior teeth.[15]


The described novel application of reverse PESCTG for multiple gingival severe recession coverage in mandibular anterior teeth provides the advantage of FGG and connective tissue graft. It gives the dual benefit of esthetic root coverage and interdental papillary fill because of bilaminar approach of bridge flap and connective tissue and augments width and thickness of gingiva due to apical epithelized portion of the graft. The epithelized portion was able to prevent frenal and muscle pull on marginal gingiva and stabilized augmented thickness and width of keratinized gingiva till the present 1½-year follow-up visits. The technique avoids multiple surgical procedures of augmenting gingiva or deepening vestibule in initial surgery and recession coverage procedures later. This considerably reduces patient postoperative discomfort or restriction in daily activities.


The authors would like to thank patients who participated in the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent Assoc 2003;134:220-5.
2Cortellini P, Bissada NF. Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations. J Clin Periodontol 2018;45 Suppl 20:S190-8.
3Zucchelli G, Testori T, De Sanctis M. Clinical and anatomical factors limiting treatment outcomes of gingival recession: A new method to predetermine the line of root coverage. J Periodontol 2006;77:714-21.
4Zucchelli G, De Sanctis M. Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol 2000;71:1506-14.
5Aroca S, Barbieri A, Clementini M, Renouard F, de Sanctis M. Treatment of class III multiple gingival recessions: Prognostic factors for achieving a complete root coverage. J Clin Periodontol 2018;45:861-8.
6Bethaz N, Romano F, Ferrarotti F, Mariani GM, Aimetti M. A mucogingival technique for the treatment of multiple recession defects in the mandibular anterior region: A case series with a 2-year follow-up. Int J Periodontics Restorative Dent 2014;34:345-52.
7Chambrone L, Lima LA, Pustiglioni FE, Chambrone LA. Systematic review of periodontal plastic surgery in the treatment of multiple recession-type defects. J Can Dent Assoc 2009;75:203a-f.
8Zabalegui I, Sicilia A, Cambra J, Gil J, Sanz M. Treatment of multiple adjacent gingival recessions with the tunnel subepithelial connective tissue graft: A clinical report. Int J Periodontics Restorative Dent 1999;19:199-206.
9Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13.
10Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: A systematic review from the AAP Regeneration Workshop. J Periodontol 2015;86:S8-51.
11Stimmelmayr M, Allen EP, Gernet W, Edelhoff D, Beuer F, Schlee M, et al. Treatment of gingival recession in the anterior mandible using the tunnel technique and a combination epithelialized-subepithelial connective tissue graft – A case series. Int J Periodontics Restorative Dent 2011;31:165-73.
12Pini Prato G, Pagliaro U, Baldi C, Nieri M, Saletta D, Cairo F, et al. Coronally advanced flap procedure for root coverage. Flap with tension versus flap without tension: A randomized controlled clinical study. J Periodontol 2000;71:188-201.
13Agudio G, Nieri M, Rotundo R, Cortellini P, Pini Prato G. Free gingival grafts to increase keratinized tissue: A retrospective long-term evaluation (10 to 25 years) of outcomes. J Periodontol 2008;79:587-94.
14Clauser C, Nieri M, Franceschi D, Pagliaro U, Pini-Prato G. Evidence-based mucogingival therapy. Part 2: Ordinary and individual patient data meta-analyses of surgical treatment of recession using complete root coverage as the outcome variable. J Periodontol 2003;74:741-56.
15Windisch P, Molnar B. Surgical management of gingival recession using autogenous soft tissue grafts. Clin Dent Rev 2019;3:18.