Gum recession and grafting, explained

What gum recession is

Gum recession is the migration of the gum margin down the root of a tooth, exposing root surface that is normally covered. Healthy gum tissue covers the root and meets the crown at the cemento-enamel junction — the small visible line where enamel ends and root begins. Recession is the apical migration of that margin, exposing some of the root surface.

Recession is common and increases with age: around 50% of adults aged 18-64 and roughly 88% of people 65 and older have at least one site of recession (Kassab & Cohen, JADA).¹ It is not, on its own, a disease — it is a finding that can have several different causes.

Recession is visible to the patient in two ways:

• The tooth looks "longer" than it used to.
• The exposed root surface, which is darker and less smooth than enamel, is now visible at the gum line.

Recession is also functional: exposed root surface is more sensitive to cold, more prone to decay (because root is softer than enamel and accumulates plaque more readily), and harder to clean.

Why it happens

Recession has multiple causes, often present in combination:

1. Anatomical predisposition. A thin periodontal/gingival phenotype (previously called thin biotype) — thin gum over a thin layer of bone on the root surface — is common, particularly in patients with prominent canines. Once that thin bone resorbs, the overlying gum has nothing to support it and follows.
2. Mechanical trauma. Aggressive brushing with a hard brush and a horizontal scrubbing motion is widely regarded as a contributing factor, but the best systematic-review evidence finds that the direct evidence that brushing alone causes recession is inconclusive (Heasman et al.).² It is best understood as one mechanical stressor acting on thin, susceptible tissue rather than a proven sole cause.
3. Periodontal disease. Severe gingival inflammation and bone loss from periodontitis can present as recession, particularly in middle-aged and older patients.
4. Orthodontic movement — moving teeth outside the bony envelope of the jaw can produce recession at the moved sites.
5. Lip and tongue habits — strong frenum attachments pulling on the gum, tongue thrust.
6. Aging. Some gradual gum migration is normal over decades.

Most patients in our practice have recession from a combination of (1) and (2) — they have thin tissue anatomically and they brush vigorously. Treatment that does not address both factors tends not to last.

How a specialist classifies recession

Specialists classify recession using the Cairo (RT) system, adopted in the 2017/2018 World Workshop classification of periodontal conditions as the current international standard.³⁴ It uses the level of the interdental tissue to predict the likely outcome of root coverage surgery:

• RT1: gingival recession with no loss of interproximal tissue. Best prognosis for full root coverage.
• RT2: gingival recession with loss of interproximal tissue that is less than the buccal (cheek-side) recession.
• RT3: gingival recession with loss of interproximal tissue equal to or greater than the buccal recession. Full root coverage is not predictably achievable; partial coverage is the realistic goal.

This classification is what guides the conversation about what surgery can and cannot achieve for your specific case.

When recession actually needs treatment

Not every case of gum recession requires surgery. The clinical thresholds for considering surgical treatment are typically:

• Progressive recession. Stable recession that has been the same for years is usually managed by addressing the cause (brushing technique, plaque control) and monitoring.
• Inadequate keratinised tissue. Less than about 2 mm of keratinised gum below the recession is associated with greater risk of progression, especially where plaque control is imperfect (Lang & Löe).⁷ The augmentation indication is tied to progression and hygiene, not the number alone — surgical augmentation is more often indicated here.
• Severe sensitivity that is not responding to non-surgical measures.
• Aesthetic concern in the front teeth.
• Cervical decay or wear on the exposed root.

Many patients with mild, stable recession in non-aesthetic areas are best managed with no surgery — just better brushing technique and ongoing monitoring.

What surgical treatment involves

Several techniques are in current use, all variants of moving tissue to cover the exposed root. The gold-standard root-coverage procedure is a coronally advanced flap combined with a connective tissue graft (CAF + CTG) — the CAF is the flap technique and the CTG is the graft material delivered under it. The flap can also be used alone where the existing keratinised tissue is adequate.

Coronally advanced flap with connective tissue graft (CAF + CTG)

A small piece of connective tissue is harvested from the palate (the roof of the mouth) and placed under the gum at the recession site, then covered by a coronally advanced flap of the patient's existing gum. The graft thickens the tissue and provides material for root coverage.

Advantages: substantial evidence base; can produce significant root coverage and tissue thickness gain. Trade-offs: a second surgical site at the palate (which takes 1–2 weeks to heal); two sites of post-operative discomfort.

Coronally advanced flap alone (CAF)

The patient's existing gum is reflected and re-positioned higher up the tooth to cover the exposed root, sometimes combined with biologic adjuncts.

Advantages: no second surgical site; good aesthetic results in single-site recession. Trade-offs: works best where some keratinised tissue already exists below the recession.

Acellular dermal matrix or xenograft alternatives

In some cases, donor-derived tissue (acellular dermal matrix) or animal-derived collagen substitutes can be used instead of harvesting from the patient's palate.

Advantages: no second surgical site; faster overall recovery. Trade-offs: somewhat different long-term outcomes than autogenous (own-tissue) grafts; not suitable for all cases.

Chambrone and Tatakis's systematic review for the AAP Regeneration Workshop summarises the evidence on root-coverage outcomes across these techniques.⁵ In summary: the techniques are all effective in suitable cases; the choice depends on the recession pattern, the site, and the patient's clinical situation.

What you can realistically expect

For a typical Cairo RT1 case with adequate planning and execution:

• Significant root coverage, often complete coverage at the treated site.
• A measurable gain in keratinised tissue.
• Improved tissue thickness.
• Reduced sensitivity at the treated site.
• Healing over 4–6 weeks; final tissue maturation over 6 months.

In RT2, complete root coverage is achievable in a meaningful proportion of cases — around half at six months in systematic reviews — particularly with a connective tissue graft under a coronally advanced flap when interproximal attachment loss is limited (broadly 3 mm or less); long-term stability is less predictable (Sangiorgio et al., BMC Oral Health).⁶ In RT3, full root coverage is not predictably attainable and the goal is stabilisation and partial improvement, because the proportion of root that can be covered is limited by the level of interproximal tissue, which surgery cannot regenerate.

Recovery and timeline

Recovery from gum graft surgery is generally manageable:

• Local anaesthetic (intraoral injections) for the procedure itself.
• Mild to moderate discomfort for 3–7 days, managed with over-the-counter pain medication in most cases.
• Soft-food diet for 1–2 weeks.
• Avoiding brushing the surgical site directly for 2–3 weeks (a chlorhexidine mouthwash is used instead).
• Most patients return to normal activities the next day.
• Sutures removed at 1–2 weeks; review at 4–6 weeks and 3–6 months.

What it costs

Gum graft surgery in South Africa is performed per site. The fee depends on:

• The technique chosen (autogenous vs xenograft).
• Whether the procedure addresses one tooth or several.
• Whether the patient needs separate surgical visits.

A written estimate is provided after the consultation. See how-much-does-gum-graft-cost-south-africa for the detail. Medical aids usually cover a portion of gum surgery from the major-dental or specialist-dental sub-limit; pre-authorisation is typically required.

This pillar links to three L3 pages: what causes gum recession, what a gum graft is and how it works, and gum graft cost in South Africa.