Analyze The Attached Gingiva
A periodontal examination includes evaluation of the attached gingiva. Is the attached gingiva adequate in quantity and quality? The amount of attached gingiva necessary to maintain periodontal health has been debated. From a practical perspective, the attached gingiva is adequate if the gingival complex can remain inflammation free and there is an absence of gingival recession over time. In order to properly monitor gingival recession, accurate measurements need be taken at the initial exam. An alternative is to rely on intra-oral photographs which, to me, is easier and more accurate.
The quality of attached gingiva has to do with its thickness. Is the attached gingiva thick enough (durable enough) to withstand the trauma from normal function and proper plaque control? If it is not, the patient will complain of recurrent discomfort and there will usually be evidence of increasing recession.
If the attached gingiva is inadequate, gingival grafting will be needed. In areas where esthetics is not a concern a free gingival graft is a tried and true option. It is an easy procedure to do and has a very high success rate. However, note the graft’s unaesthetic appearance compared to the connective tissue graft below.
If esthetics is a concern, a connective graft should be done. A connective tissue graft is also the procedure of choice if root coverage is needed for the treatment of root sensitivity.
An alternative to the connective tissue graft is to use acellular dermal matrix. This tissue comes from a tissue bank. It is a much more technic sensitive procedure. I used it very little in my practice for the treatment of gingival recession.