Gum grafting: What to know about gum recession, surgery and alternatives

May 9, 2019
Gum grafting: What to know about gum recession, surgery and alternatives

If your dentist or periodontist has uttered the words gum recession — or worse — gum grafting surgery, your receding gums may have brought you on a deep dive into gingival territory — an often dark and scary place.

Don’t worry, we’ve got you covered, even if the gums surrounding your teeth do not. We asked Dr. Jaffer A. Shariff, an instructor of dental medicine at Columbia University College of Dental Medicine, specializing in periodontics, for an oral (no pun intended) download of information on the topic, so you can be informed should you decide to opt for surgery.

Read on for a full breakdown of gum recession and gum grafting surgery.

What is gum recession and how is it identified?

In dental speak, receding gums are a “mucogingival defect,” according to Shariff, who works within the section of oral, diagnostic and rehabilitation sciences at Columbia. In layman's terms, this means recession is when the root of your tooth becomes exposed due to your gums moving back.

“When you look at the tooth itself, the tooth has the crown portion and the root portion,” he says. “The crown portion is what’s exposed to the oral environment. The root is covered by the bone and then the gums. What happens is, the root does not have enamel. It has something called cementum which is the protective layer. Recession is when the root starts to get exposed.”

The protective cementum, which covers the root of your tooth, is no match, sadly, for a lot of the stuff we put in our mouths, like soda, coffee and even our toothbrushes, which many of us wield around like a rake on leaves.

“Cementum is really thin, it gets worn off because of the food that we eat,” he says. “When that layer goes off, that’s when the complications start.”

Recession is typically first identified by us when we feel a certain tinge of soreness in the area.

“Sensitivity, that’s the biggest, biggest reason why people have a problem,” he says. “Sensitivity and aesthetics are the two major problems that we see. Some people don’t even realize that they have recession even a small amount because they are not sensitive enough, the cementum has not worn off yet. But once it’s worn off the dentine inside, when it’s exposed, that’s when the sensitivity starts.”

Why does recession happen?

In case you haven’t noticed, lots of things tend to happen to our bodies as we age. In a 2015 study by the National Institutes of Health, which focused on 710 individuals, the frequency of gum recession was found to increase with age, and the most common causes were dental plaque accumulation and faulty tooth brushing.

“There are a lot of reasons for it,” Shariff says.

Here are some of the common causes he sees.

Aggressive brushing

If you brush like you’re scrubbing the inside of a toilet — with entirely too much elbow grease — that’s a problem.

“[It’s] very common with people across all age groups,” he says. “We do see people with aggressive brushing only on one side. If they are right-handed, some patients tend to be rougher on their right side.”

Shariff suggests holding your toothbrush like a pen and using the “modified bass technique” for brushing, which involves positioning the brush at a 45-degree angle, with the bristles pointed at the gum line and moving the toothbrush back and forth with short strokes.

Tooth position

The positioning of your teeth can play a role in recession, especially if the tooth is positioned more toward the face. It’s “a buccally positioned tooth, as we call it,” he says. “The tooth is positioned outside of the dental arch toward the cheeks/lips (either maxillary/upper or mandibular/lower). In some cases, this is the cause of recession and it can be first corrected with orthodontic treatment, and if needed, gum surgery.”

Periodontal disease

Periodontal disease is described as inflammation or an infection of the areas surrounding the teeth — that’s the important stuff like gums and bone that hold your teeth in place.

“People who don’t take care of their gums, that leads to the destruction of the bone, which supports the gums,” he says. “Because you lose a lot of bone, you have this recession.”

With older individuals “it [often] has to do with previous history with periodontal disease, the way they brush, and also based on the tooth position in their mouth,” Shariff says.

Orthodontic treatment

If you’ve had braces, you may notice that in addition to the gift of straighter teeth, you now have some recession.

“Sometimes when you move the tooth, there’s a little bit of recession that you see,” Shariff says.

Your hereditary

Just like Lady Gaga said, we were born this way — with gums that are more likely to recede.

“Some people are a little more prone,” Shariff says. “When I say genetic, everybody’s gum type is different. Some people have thinner gums, which are more prone to aggressive brushing, and because of that you get recession.”

Your frenum

Grab your mirror and take a look at your gums.

“When you lift your upper lip you see something like a tag between your tooth incisors, it’s called frenum,” Shariff says. “Sometimes it’s so lower, it’s toward the gums, the gingiva. It has a pull on it and some studies have shown that it’s because of that that causes recession.”

Are you a candidate for gum grafting?

Here’s the bad news: There is no easy fix. If you’re noticing recession or feeling sensitivity, it’s important to discuss your situation with a professional as soon as you’re seeing signs — early treatment is definitely a good thing.

“This is where I want to make it clear, especially for older individuals, not all gum recession can be managed by doing any common form of gum surgery or gum therapy; we call them gingival therapies,” Shariff says. “Because once you’ve lost the supporting bone structure, there’s only so much you can do to pull those gums up or pull them up to the normal level.”

Tooth positioning is also important, Shariff adds, when determining whether a patient is a good candidate.

“We also have to look at where the tooth position is, which is one of the causes,” he says. “So after addressing all that, after diagnosing all those things, then we can treat them.”

Shariff says, ideally, they’ll get 100 percent coverage after a successful gum grafting surgery. But in most cases, he says, it’s really about 50 percent to 70 percent coverage.

“The greater the recession and the more teeth affected, the poorer the prognosis of the surgery,” he says. “Specifically the height and the width of the recession: a narrow and shallow recession shows better results compared to a deep and wide one.”

If the recession is accompanied with bone loss between the teeth, this may limit the amount of coverage that can be achieved with any of the available periodontal mucogingival therapies, Shariff says. In other words, recession should be evaluated on a case by case basis, taking into account three things:

  1. The patient’s chief complaint

  2. The patient’s expectations

  3. The anatomical limitations

According to Shariff, good candidates will be:

  • Medically healthy or stable

  • Non-smokers, as smokers show lower success rates, due to its negative effect in the post-operative healing

  • Good quality home care, which is key also for the long-term success of the surgery

  • No or minimal gingival inflammation/bleeding (at time of surgical procedure)

  • Healthy patient or controlled periodontal disease status

  • No or minimal bone loss around teeth

  • Preferably thick gingival phenotype

  • The type of recession is of great importance, as mentioned above

What happens during gum grafting surgery?

Gum grafting is one of the most common gingival therapies used to treat recession.

“Gum grafting is the term that everybody Googles,” he says. “Gum grafting is basically taking the patient’s own gum from the palate. We take a piece of your tissue, we overlay it on the root surface with the aim of covering the recession.”

While you’re under local anesthesia, a connective tissue graft, as it’s called, is taken from the palate by cutting a flap on the roof of your mouth, taking tissue from inside it, and stitching it back up. Another kind is a gingival graft, which is taken directly from the top layer of the palate.

“The grafts that you take from the palate, it needs a blood supply for it to reattach in that [receding] area,” he says. “So the only blood supply that you get is when we expose the bone. We open the gums away from the bone, place the graft over the bone, which has blood supply, and then cover it over with the gums which also has blood supply.”

By doing so it “gives all the nutrition the graft needs to be stable and be accepted by the body,” he says. “It’s a graft, so it shrinks a little bit. That’s called primary shrinkage. That’s the most common way of doing it. That’s the best way of doing it, because it’s your own graft.”

Another method is using tissue, or allograft, from a cadaver.

“You’re basically using a small piece of skin grafts [from a cadaver], we do the same thing,” he says, adding that this can be preferable because there’s only one surgery site, the area of the receding gums, versus also having the palate involved when you use your own tissue.

Just as they do with your own tissue, the allograft is put over the recession area and the gums in that area are pulled over it, he explains, so surgery consists of “cutting the gums open, putting the skin graft on, or the patient’s own tissue, and then covering the graft over with the patient’s gums or whatever remaining gums he or she has.”

Besides having just one surgical site, there are other benefits to using an allograft.

“Another reason for using the [cadaver tissue] is because some people’s palate might be really thin, might be really shallow, might be close to the nerve,” he says.

What is the recovery from gum grafting surgery like?

It takes about three to five days for the initial healing process to start, Shariff says, barring any sort of infection. It takes about six to eight weeks for all the connective tissue inside the mouth to heal. Your periodontist will give you detailed instructions regarding your post-operative care, including pain management, recommendations for physical activity like strenuous exercise and what you should and should not eat.

You won’t be brushing or flossing for four to six weeks, so you’ll likely be given an oral rinse prescribed for use two times a day to help keep the mouth clean. But only use it for as long as it is prescribed because it can stain the teeth.

“The post-op instructions are very important,” he says. “After surgery, the patient is explained about dos and don’ts. You removed this piece of tissue from there, now that part is kind of exposed to all the elements and it’s very thin now. It was thick for a reason because it was protecting all the vessels and nerves underneath. Now if you drink anything too hot or too cold you can feel it. So I always tell my patients you’ve got to be careful what you’re eating, nothing too hot, nothing too spicy, because it’s just going to aggravate that.”

Surgery is surgery — and when it takes place in your mouth, there will be challenges, like:

  • Expect to be numb after surgery.

  • Don’t be surprised if while rinsing your mouth for the first time or beyond, you spit out stitches.

  • You may also see some blood. If you’re noticing a lot of blood, call your doctor.

  • If your graft came from your palate, soft foods like applesauce or oatmeal are best. Crunchy foods will hurt the area.

  • Smiling will be hard. Depending on where your graft is, moving your mouth — and even talking — may be difficult for several days.

  • Certain people will experience facial swelling or bruising. Ice packs are recommended.

Shariff explains that when it comes to recovery, less is more.

“Some people have [asked] ‘Can I apply clove on it or should I put some garlic on it?’ So I’m like, OK, please don’t do that, things will aggravate it,” he says. “This is like the plastic surgery of dentistry, that’s what periodontists do. So it’s very delicate. Do not do anything that is not recommended.”

To make eating easier, Shariff sometimes gives a denture-like cover to patients for their palate.

“[It’s] a small denture with no teeth that snaps onto the palate, just as a protective layer, just for a week,” he says. “Just so that whatever you eat you’re more comfortable.”

Shariff believes most of the post-op pain will be felt on the palate.

“The surgical site, where the recession was, yes, you will have a little bit of pain maybe the first 24 hours, 48 hours,” he says. “The annoying part I think is the sutures.”

Lindsay Tyler, an executive producer from Chicago, had gum surgery on one tooth in 2014. Her surgeon used another kind of graft, a pedicle graft, which is gum taken from near the area of recession.

“They actually cut my gum and flopped it down instead of taking it from my palate,” she says. “They said I was lucky I had gums because it was much less painful.”  

Even still, her two-week recovery was intense.

“Right after the procedure was super painful, and then it was just gross,” she says. “I couldn’t eat or drink very well, my gums were really raw and irritated, and then I was spitting stitches for a few weeks.”

Susan Spann, a mortgage loan originator from Davis, California, had gum grafting surgery in 2001 on four teeth. She says her recession was part hereditary, part aggressive brushing and that the procedure worked well to cover her problem areas.

“The surgery was quite painful when I had it done,” Spann says. “I had stitches in my mouth and gums for some time, and it took time for the gum line to heal and gums to look normal. With some healing and time, I felt better and my gums took on a more natural look.”

How effective is gum grafting?

You won’t see brand, spanking new gums right away — and it will be a little grotesque before you do, with the sutures and gums being pretty tender and raw. But don’t despair, what you see the first few days is not the final product. It could take six months or longer to see full results of the procedure. You will see the best results, Shariff says, if it’s done right and you have carefully followed the post-op instructions.

“Keep it comfortable,” he says. “The healing process will take its time. The body wants to heal.”

Spann is happy with the results, which she says have held up well since 2001.

“It is still far better than where it was before,” she says, referring to her root exposure and sensitivity. “There has been some additional recession over time that my dentist monitors. He continually watches and measures the area, and it’s a possibility in the future that I will have an additional surgery.”

As for Tyler, she is seeing more signs of recession in her mouth but hopes she never has to go through the procedure again.

“I would do whatever I needed to do to avoid it,” she says. “I was told it was a less painful version because of not needing to take it from my palate, and it was still pretty awful.”

Shariff notes that more than one surgery may be needed in some cases.

“It’s also important to keep in mind that to treat recessions, [the] patient might need a second and/or third surgical procedure in order to achieve the desired result,” he says.

Are there alternatives to gum grafting?

Depending on what’s going on with your gums and the bone underneath them, you may be a candidate for another, less invasive procedure to treat your recession.

“It’s all depending on the type of case it is [and] the amount of recession,” Shariff says, adding that “the most common and the best [technique] is using the person’s own graft to cover it. That’s been proven by a lot of research.”

Schedule an appointment with your periodontist and discuss whether any of the following three techniques would work for you.

Coronally advanced flap technique

Some patients can avoid grafts with this technique in which incisions are made in thick gum and they are pulled over the recession.  “We’ll advance your gums in order to cover the recession without the use of a gum graft,” Shariff explains.

Semilunar technique

This technique generally works well for the top teeth, and the canines or molars, where you have mild recession, he says.

“You don’t use any grafts, you just make a semilunar incision on top of the tooth and you push the gums down, so it stays there,” Shariff explains. “Another good thing about that is that you don’t need to put any sutures, you basically use a glue. You just glue it on top and you can avoid stitches.”

Pinhole technique

Dr. John Chao has had some success with this less invasive technique that he invented which involves collagen graft material. “He makes a hole on top of your gums, he goes in from that hole and tries to move your gums more towards the crown,” says Shariff. “And he packs it with some collagen material. He has shown to have good results but it’s still new, [but] people say that the results are pretty good.”

Read next: Do you need a health care proxy if you’re married?

Tips and stories from parents and caregivers who’ve been there.

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