Effectiveness of Mucogingival Surgery for the Treatment of Gingival Recessions and Root Hypersensitivity

Abstract

Treatment of gingival recessions with hypersensitivity could be quite challenging for clinical practice and includes: establishing optimal plaque control, removal of plaque-retentive subgingival restorations, elimination of risk factors, removal of parafunctions and occlusal trauma, and use of desensitizing agents. If a surgical approach is indicated, coronary displaced flap or tunnel technique procedures, combined with connective tissue grafting (with or without Emdogain or hyaluronic acid gel), are considered as most predictable treatment options for single and multiple gingival recessions. If the patient or clinician considers to avoid a second surgery in the donor site area by taking a connective tissue graft from the palate, acellular dermal matrices and collagen matrices can be used as an alternative treatment option. In cases of gingival recessions associated with non- carious cervical lesions (NCCL), a combined restorative surgical approach may provide favorable clinical outcomes. In case patient refuses surgical intervention or has other contraindications for a surgical approach, gingival recessions with hypersensitivity could be treated by prophylactic and conservative methods.

1. Introduction

Mucogingival surgery involves various invasive procedures with the aim to correct defects in the morphology, position, and/or amount/quality of soft tissues surrounding teeth or implants [1]. “Mucogingival surgery” was originally introduced by Friedman in 1957 [2] and includes surgical interventions designed to preserve gingival tissues, correct abnormal frenulums or muscle attachments, and increase the keratinized gingiva and vestibule depth. However, this term is often used to describe some approaches to periodontal pocket elimination, and in 1993, Miller [3] introduced the term “periodontal plastic surgery”, given credence by the international scientific society in 1996, which is defined as “surgical procedures performed to prevent or correct anatomical, congenital, traumatic, or disease-induced defects of the gingiva, alveolar mucosa, or bone” [4]. This definition includes numerous soft tissue and bony interventions designed to achieve gingival augmentation, root coverage, plastic correction of mucosal defects around implants, clinical crown lengthening, preservation or providing of a sufficient amount of keratinized gingiva in case of ectopic tooth eruption, correction of abnormal frenulum, socket preservation, and alveolar ridge augmentation. Most of the reviewed publications in the specialized scientific literature focus on the mechanisms leading to gingival recessions, the defects resulting from them, their precise diagnosis, and prognosis over time, as well as the various treatment methods—conservative approach—antisensitive gel in the case of hypersensitivity and invasive approach including various surgical root coverage procedures.

The increasing esthetic demands of patients in recent years play a decisive role in the development of plastic periodontal surgery. One of the serious problems associated with periodontal health is gingival recession, which is the apical migration of the gingival margin with subsequent exposure of the buccal or lingual root surface. It can cause esthetic disturbances, root hypersensitivity, as well as the patient’s fear of subsequent/future tooth loss.

Gingival recession is a frequent clinical finding in daily practice in nowadays. Various problems can be related with apical migration of the gingival margin as dentin hypersensitivity, caries of root surface, non-carious cervical lesions (NCCL), and disrupted esthetics. What is initial in treatment and prevention of GR is to identify the predisposition and anatomical and physiological conditions leading to GR.

The etiology of the condition dentin sensitivity (DS) or root sensitivity (RS) is multifactorial and not fully understood, although it has been detected (via scanning and electron transmission microscopy) by some researchers that the dentin structure in sensitive areas of the tooth is altered as containing more and with a wider diameter dentin tubules than insensitive areas. These observations appear to be consistent with the hydrodynamic theory of Braennstrom and Astroem [5] which give information that DS is because of the hydrodynamic movement of fluids through exposed dentin with open tubules, which mechanically triggers nerve endings located at the inner ends of dentinal tubules or in the outer surface of pulp of the tooth. According to Dababneh et al. [6], the evolution of a “hypersensitive” lesion may be result from two factors: exposure and initiation of the lesion.

Dentin exposure can result from one of the following processes: (1) Anatomical features at the cementoenamel junction (CEJ); (2) Absent/removal or of the crown enamel covering; (3) Denudation of the root surface because of loss of cementum and overlying periodontal soft tissues [7, 8, 9].

Root surface denudation can be caused by increasing/expanding the gingival recession with age, chronic periodontal disease, misaligned teeth, periodontal surgery, and chronic trauma related to the patient’s habits and orthodontic treatment. The sensitivity of GR is initiated only when erosive factors expose and affect the openings of the dentinal tubules. Erosion can be caused by an overly acidic environment. Increased acidity can be due to occupational and medical factors or disease, such as bulimia, gastric regurgitation, or dietary features, such as excessive use of carbonated drinks, fruits, and mouthwash, which can act alone or in combination. DS/RS may also be due to iatrogenic damage, for example, inadequate coverage of the tooth. Occlusal trauma can also lead to DS. Vigorous brushing with an abrasive paste can cause abrasion, and subsequently, an acidic diet can lead to erosion of the hard tooth structures. Previous exposure to an acidic drink or a low pH in the oral cavity, which can be explained by a demineralization process and subsequent aggressive tooth brushing, can lead to an actual loss of hard tooth tissue [7, 8, 9].

“Abfraction” as term has been included to the list of risk factors, and it is suggested that just as the cervical region of a tooth can be subjected to unique stresses, torques, and moments as a result of chronic occlusal trauma, bruxism, or other parafunctional activity, so these bending forces can ruin the précised ordered crystalline structure of the enamel and dentin through cyclic prolonged fatigue and lead to disintegration and microfractures. Piezoelectric effects and stress corrosion could be as well theoretically relevant for disrupting the enamel structure and provoking DS. All of these mechanisms, alone or in combination, can cause enamel destruction [7, 8, 9].

2. Etiology of gingival recessions (GR)

Recession may exist in case of the presence of a normal gingival sulcus and the absence of interdental bone loss, or it may be due to chronic periodontal disease associated with bone loss.

2.1 Anatomical factors

Anatomical factors associated with gingival recessions include fenestration and dehiscence of alveolar bone, abnormal/incorrect tooth position, irregular tooth eruption, and individual tooth shape [9, 10].

2.2 Physiological factors

Physiological factors may include the orthodontic treatment and movement of teeth to buccal and lingual to alveolar base position, resulting in dehiscence effect [11], which may act as a “locus minoris resistenciae” for the development of GR [12].

GR may appear as a deep and intrusive lesion similar to a “Stillman’s cleft” where personal oral hygiene is very difficult to be performed, and bacterial or viral infection/lesion/may cause additionally a buccal gingival pocket of sufficient depth to form.

Buccal soft tissue volume may be a predictable factor whether gingival recession may occur during or after orthodontic treatment with different devices. In the presence of inflammation (associated with dental biofilm), a thin gingival phenotype may be a greater risk factor for progression of GR. More often isolated deep gingival recessions can occur in the lower incisors several years after orthodontic treatment. Common features associated with these GR are the presence of rounded canine-to-canine engagement, a different axial inclination of the affected tooth relative to adjacent teeth, and presence of gingival inflammation near the root exposure [11, 12, 13]. The etiological factors may also be found as well in the patient’s chronic habits as nail biting, sucking objects such as pens/pencils, piercing devices, or toothpicks, which can exert prolonged pressure on the affected tooth.

2.3 Pathological factors

2.3.1 Brushing the teeth

Tooth brushing is often associated with gingival recessions and partly explains the correlation between the low plaque levels found at recession sites. The clinical signs of gingival recession caused by brushing are soft tissue injuries (without tenderness) and cervical abrasions of dental tissues (NCCL). Soft tissue trauma can destroy keratinized gingiva. Prolonged mechanical trauma and the additional use of whitening agents can cause cervical abrasions after the initiation and progression of recession [13].

2.3.2 Improper use of dental floss

Flossing trauma may contribute to tooth abrasion and gingival damage. These often occur in highly motivated strict patients who have not been precisely instructed in interdental cleaning technique. The diagnosis of these impairments/disorders can often be clarified by asking patients to explain and show their oral hygiene routines. The initial lesion may look like a symptomatic ulcerated, highly inflamed, linear, or V-shaped cleft [14]. When there is flossing trauma, the superficial fissures of the gingival tissues are “red” because the damage is limited to the connective tissue and the lesion is reversible: for patients flossing procedures should be ceased for at least 14 days, and only chemical plaque inhibitor control (i.e., chlorhexidine rinse) should be performed. If the fissure appears “white”, the entire thickness of the gingival tissue is affected, and the radicular surface becomes apparent. In this case, the gingival lesion is irreversible [14].

2.3.3 Perioral and intraoral piercing

The piercing of lips and tongue is a popular expression of the so-called body art nowadays [15]. Tongue piercing is directly associated to local dental and gingival damage on the lingual surfaces of the mandibular frontal teeth [15], and buccal gingival recession can be observed vestibular in case of lip piercing [16]. Often, lingual gingival lesions are narrow, and thin and plaque control is difficult to achieve; especially in deep lingual recession which may be associated with local inflammation and an increased probing depth to reach the periapical region.

2.3.4 Direct trauma associated with malocclusion

Class II malocclusions have deep coverage, and often the upper front teeth are tilted back (retroclined). In severe cases, this can lead to local chronic trauma to the vestibular gingiva of the lower frontal teeth or to the palatal marginal gingiva of the upper frontal teeth [7, 17]. As a result, gingival recession may develop. Sometimes in young people, proper orthodontic/orthognathic management of the malocclusion and accurate tooth brushing can resolve GR and surgical therapy is not necessary [11].

2.3.5 Gingival recessions associated with the use of partial dentures

Poorly made or maintained partial dentures and the placement of restorative margins subgingival can not only cause direct tissue trauma, but also facilitate the accumulation of subgingival plaque, leading to inflammatory changes in the adjacent gingiva and recession of the soft tissue margin [18].

2.3.6 Bacterial plaque

Gingival recession can be caused or progress by a localized accumulation of bacterial plaque on the buccal surface of the tooth [19, 20, 21]. This should be differentiated by GR related to chronic periodontal pocket disease. In this case, the accumulated bacterial plaque enriched with specific periodontal pathogens and with altered immunological response can cause a loss of connective tissue attachment, which can clinically demonstrate with GR not only on the buccal surface, but as well as in the interdental areas. Plaque-induced gingival recession is caused by local bacterial plaque accumulation at the buccal tooth surface without interdental loss of attachment, and successful treatment can be achieved with root-covering procedures and patient’s motivation of efficient plaque control [21, 22].

3. Classification, diagnosis, and prognosis of gingival recessions

GR may be treated with a variety of surgical interventions, and good root coverage can be achieved regardless of the chosen surgical technique. Clinical attachment and alveolar bone level determine the height of the interdental periodontal support and are the most important prognostic factors for root coverage interventions [23, 24].

Gingival recessions were classified by Miller [23, 24] into four classes according to the prediction of root coverage level. In Class I and Class II gingival recessions, there is no loss of interproximal periodontal attachment and bone, and full root coverage (just up to the cementoenamel border) can be expected. The difference between the two classes is due to the height of the root exposure, which reaches (class II) or does not reach (class I) the mucogingival line. In Class III gingival recessions, the loss of interdental periodontal tissue is mild to moderate, and partial root coverage can be achieved; in addition, tooth/root malposition limits the possibility of root coverage. In Class IV recessions, interproximal periodontal attachment loss (or tooth/root malposition) is severe, and root coverage is impossible to achieve.

Cairo et al. [25] have recently introduced a new classification system for gingival recessions using the interproximal clinical attachment level as an identification criterion as they highlight the predictive value of the classification system for final outcome of root coverage surgery. Three different types of recession (RT) have been identified: grade RT1 includes GR without interproximal attachment loss; class RT2 includes gingival recessions with loss of interproximal attachment less than or equal to the buccal exposed surface; and grade RT3 indicates loss of interproximal attachment greater than the buccal exposed surface [25].

4. Indications for root coverage surgical procedures

Treatment of defects due to GR is indicated for esthetic concerns and to reduce RH and to create or augment keratinized tissue [4, 26, 27, 28, 29]. Indications for root planning procedures before coverage are root abrasion/caries and gingival margin discrepancy/disharmony.

4.1 Esthetic grounds/reasons

For most of cases, initiating for GR correction is patient concern. Esthetic concerns as excessive length of the tooth(s) (i.e., those with recession) may be visible when smiling and sometimes when speaking. Esthetic correction can be accomplished only with different root coverage procedures.

4.2 Hypersensitivity

Some patients with GR complain of hypersensitivity to heat or cold stimuli. This causes discomfort and/or pain and makes it very difficult to practice good personal oral hygiene. If there are no accompanying esthetic concerns, a less invasive approach is indicated. Different desensitizing agents are used topically. If this is not effective, composite restorations can be performed. When dentin hypersensitivity is associated with an esthetic complaint from the patient, treatment of GR should be surgical or combined restorative-surgical (e.g., a combined restorative mucogingival surgical approach [8, 9]).

4.3 Increase of keratinized tissue

Indications for treatment of GR may arise from the patient’s site-specific difficulty or inability to achieve adequate plaque control due to deep and narrow recession or lack of keratinized tissue [4, 29].

4.4 Root abrasion/caries

Treatment of GR may be indicated in the additional presence of root demineralization or caries, or deep wedge-shaped defects/abrasion, which may cause hypersensitivity and/or make personal plaque control more difficult. Management of radicular caries/abrasion in combination with gingival recession can be surgical or combined restorative-surgical, related to the possibility of coverage or not of the area affected by tooth abrasion or caries [4].

4.5 Irregular contour/disharmony of the gingival margin

Gingival margin incompatibility/disharmony can be resulted in the morphology of GR, even in the absence of DH/RH, which may not allow the patient to perform an effective brushing technique, especially when gingival recessions are isolated and deep or very narrow with triangular-shaped fissures (so-called Stillman fissures), or when they cross the mucogingival border. The only feasible therapy is surgical approach [30].

5. Surgical procedures for root coverage

The ultimate goal of the root planning is complete root coverage of the exposed root surface with good esthetics compared to the adjacent gingival tissues, as well as minimal probing depth after healing and minimizing RS [4, 27, 28, 29, 30, 31].

Surgical procedures used to treat recessions can be classified as follows [19, 32].

Procedures with pedicled soft tissue grafts:

• Procedures with rotated flaps (laterally displaced flap, double papilla flap, and obliquely rotated flap).

• More complex flap procedures: coronary repositioned flap (coronally advanced flap CAF) and semilunar coronary repositioned flap.

• Regenerative procedures (with resorbable barrier membrane or application of enamel matrix proteins).

• Procedures with soft tissue grafts (STG):

• Epithelialized graft (FGG).

• Subepithelial connective tissue graft (CTG).

The specialized scientific literature supports the fact that GR can be treated successfully with various surgical interventions and techniques [19] and regardless of the chosen technique can provide good biological conditions for achieving a good root coverage (without loss of height of interdental soft tissues and bone).

The choice of one surgical technique over another depends on various factors, some of which are related to the characteristic of the defect (size and number of recessions, presence/absence, quantity/quality of keratinized tissue lateral, and apical to the defect, width, and height of interdental soft tissues (papillae), presence of frenulum or muscle attachments, and vestibular depth) [31, 33, 34, 35]. Esthetic requirements and minimization of intraoperative and postoperative discomfort are the most important patient-related factors to consider when selecting a surgical technique. In addition, the clinician must have good theoretical and practical training as well as analytical and critical thinking in order to choose the most predictable surgical approach from those possible in a clinical situation. The individual clinical approach is decisive for the favorable outcome of the treatment and is determined by anatomy, presence of parafunctions, occlusal trauma, hygiene habits, orthodontic consideration, general condition and comorbidity, patient’s wishes, and skills and knowledge of the clinician.

Non-surgical treatment options for recessions include: establishing optimal plaque control, removing plaque retention subgingival restorations, removal of parafunctions and occlusal trauma, and use of desensitizing agents if hypersensitivity is presented. If a surgical approach is indicated, coronary repositioned flap and tunnel technique procedures, combined with or without connective tissue grafting, are known as most predictable treatment options for single and multiple gingival recessions [33, 34, 35]. If there is a contraindication to take a connective tissue graft from the palate or if the patient or clinician wants to avoid a second surgery in the donor site area, acellular grafts can be used dermal matrices and collagen matrices. Additionally Hyaluronic acid products [34, 35, 36, 37, 38] and/or enamel matrix derivate could be applied [39, 40]. In gingival recessions associated with NCCL, a combined restorative surgical approach may provide favorable clinical outcomes. If the patient refuses surgical intervention or has other contraindications for a surgical approach, the condition of the gums should be maintained with prophylactic and conservative methods. Treatment of single and multiple gingival recessions can be performed with periodontal plastic surgery techniques [41, 42, 43, 44]. These include displacement of the flap in the coronal and/or lateral direction alone or in combination with gingival grafts. The goal is complete root coverage with satisfactory esthetics for the patient with reduction or elimination of dentin hypersensitivity.

The risk factors leading to failure of surgical treatment may be the following (Figure 1).

Figure 1.

Risk factors leading to failure of surgical treatment.

Patient side—patient selection criteria—high risk profile, comorbidity, low compliance, and no eliminated risk factors.

Patient compliance and motivation are important for a successful outcome.

Local risk factors—loss of the interdental papilla and/or bone, risk anatomical structures and anatomical features (periodontal phenotype and dentofacial deformity).

From the operator’s side—theoretical training, knowledge of tissue biology, and surgical skills.

On the side of operating procedure—indications, planning, instruments, execution technique, choice of suture material, choice of sutures, strict adherence to the post-operative regimen, good awareness to make an informed decision to avoid a result that does not meet the patient’s expectations, and infection control (Figure 1).

The use of microinvasive techniques promotes atraumatic work, a faster healing process, and a faster return of the patient to daily activities.

The aim of periodontal plastic surgery is the coverage of roots exposed to gingival recession. Currently, exposed root coverage is a predictable and effective procedure, usually with high esthetic results. However, the relationship between the graft tissue and the root surface is still not well understood. One potential weak point of the technique is that a pocket could be created where the recession is covered. It is preferable to achieve a new connective tissue attachment rather than a long connective epithelium [19, 33, 34, 35].

A critical review of the literature reveals different problems such as:

1. The problem of gingival recessions with root sensitivity is a common problem in daily clinical practice and is treated by the dentist or periodontologist. Treatment aims to fast and fully restore the quality of life of patients affected by this condition.

2. The doctor of dental medicine must be familiar with the etiological factors and correct diagnosis of gingival recessions with root hypersensitivity, as well as with the indications for the various methods of their treatment.

3. Modern periodontal surgery is represented by a wide range of operative interventions that provide better oral health, prevention, and restoring the quality of life and self-esteem of patients.

Gingival recessions with hypersensitivity can have different effective methods of treatment as surgical or non-surgical approach. Operative interventions are delicate and require mastery of a different range of operative interventions, but there is no standardized approach in the treatment of GR.

Surgical coverage of gingival recession is a relatively predictable procedure. The currently accepted gold standard is the bilaminar technique, which basically consists of a coronary displaced flap/tunnel technique covering and connective tissue graft [27, 31, 41, 42]. The graft increases the likelihood of achieving complete root coverage compared to the use of a coronary displaced flap alone, especially in the long term. When considering a treatment strategy, clinicians should focus on hypersensitivity and tissue-modifying conditions while increasing patient awareness of gingival recession. In cases where a surgical approach is indicated and accepted by the clinician and the patient, techniques with the most predictable results are preferred for the treatment of single and multiple recessions. If there is a contraindication or disagreement from the patient to take a graft, an alternative approach using allografts, Fibro-Gide, Emdogain, and Hyaluronic acid gel should be discussed. If the patient refuses surgical intervention or has other contraindications for a surgical approach, adequate plaque control should be maintained with preventive measures.

One of the most important features in treatment of GR is the individual approach to the treatment of the patient, including the expectations of the result (complete root coverage, esthetics, root hypersensitivity, and attitude to operative intervention) from patient side (patient-centered outcome). This would certainly change the current criteria for evaluating the success of the procedure and establish itself as a decisive matrix for the surgical management of gingival recession. The modern literature is still debating, there is no unified opinion on a standardized method in the treatment of gingival recessions with hypersensitivity, and also the data on the results of the different techniques are contradictory. This gives reason to carry out and clarify the discussed topic which will enrich the experience of dental doctors in making clinical decisions in the treatment of patients with gingival recessions with hypersensitivity.

The treatment of gingival recessions with hypersensitivity as an individual-oriented treatment of the modern patient can be surgical or non-surgical, the purpose of which is to improve quality of life without affecting a lot of a patient’s daily activities. Surgical techniques prevent (with patient follow-up) the progression of recession and the development of root caries. Timely surgical treatment of gingival recessions improves periodontal health by creating an opportunity to maintain good plaque control esthetic result. An evaluation of the treatment plan can be made on the basis of hypersensitivity reduction, root coating, and esthetic satisfaction. The major risk factors are related to the correct selection of patients, knowledge of the anatomy and biology of the tissues, the operative technique and instruments, and the knowledge and skills of the clinician.

6. The algorithm of clinical behavior for gingival recessions

The algorithm of clinical behavior for gingival recessions according to Miller’s classification, accompanied by root hypersensitivity, was developed by us in connection with the work with 120 patients and the results obtained from it.

The two main groups into which they are divided are based on the gingival recession with root sensitivity (GRRS): class—Class I and Class II.

In patients who have Miller Class I GRCS and slight/mild hypersensitivity, the algorithm offers two courses of action depending on whether the patient has esthetic disturbances from gingival recession with root sensitivity (GRRS). For those who have such and high esthetic requirements, we suggest the direction of action to be CAF + CTG, because based on our study, it provides very high esthetic satisfaction from patients, and also the technique shows a very high rate of complete root coverage and resolution of RS (root sensitivity) (Figure 2). For the patients who do not have esthetic disturbances and do not have very high esthetic requirements, we suggest starting the treatment with an anti-sensitizing gel 2 times a day, for 14 days. When this is associated with a lack of satisfactory effect, free gingival graft (FGG) technique could be used. If a satisfactory effect is achieved with the gel, maintenance and regular control visits are planned.

Figure 2.

Algorithm of clinical behavior Class I and Miller Class II gingival root hypersensitivity recessions.

In patients who have Miller Class I GRRS and strong hypersensitivity, the algorithm again offers two directions of action depending on whether the patient has esthetic disturbance from GRRS. For those who have both of them and have high esthetic expectations from the treatment, we recommend applying coronally advanced flap (CAF) + CTG, because based on our study, it provides very high esthetic satisfaction from patients, and also, the technique shows a very high rate of complete root coverage and resolution of RS. For the rest of them who do not have esthetic disturbances and do not have very high esthetic requirements, we suggest that the treatment be with an individualized approach, which may include FGG or CAF + CTG (Figure 2).

In patients who have Miller Class II GRRS and mild hypersensitivity, the algorithm offers two courses of action depending on whether the patient has esthetic disturbances from GRRS. Those who have such and high esthetic requirements, we suggest the direction of action to be CAF + CTG, because based on our study, it provides very high esthetic satisfaction from patients, and also, the technique shows a very high rate of complete root coverage and resolution of DH/RS. For the rest of them who do not have esthetic disturbances and do not have very high esthetic requirements, we suggest that the treatment be chosen between the two FGG surgical techniques or CAF + CTG, bearing in mind that when choosing FGG it is possible not to achieve complete root coverage, but partially.

In patients who have Miller Class II GRRS and moderate or severe hypersensitivity, the algorithm again offers two courses of action depending on whether the patient has esthetic disturbance from GRRS. For those who have them and have high esthetic expectations from the treatment, we recommend applying CAF + CTG, because based on our study, it provides very high esthetic satisfaction from patients, and also, the technique shows a very high rate of complete root coverage and resolution of RS. For the rest of them who do not have esthetic disturbances and do not have very high esthetic requirements, we suggest that the treatment be with the CAF + CTG or FGG technique, combined with an anti-sensitizing gel.

Following a clinical behavior protocol may help the work of the periodontist and the doctors of dental medicine in patients with GRRS. In treatment it is necessary to initially eliminate the risk factors, achieving a good plaque control and making a clinical decision about the right treatment approach. The treatment should be personalized and targeted to the requirement of the patient with adequate consideration of the possible treatment outcome. Following this algorithm directs the clinician to a correct clinical approach and obtaining a predictable result of the treatment, taking considering the type of sensitivity, Miller class, and esthetic risk. The detailed assessment, analysis of the risk factors, patient demand, and stratification would lead to a favorable outcome of the treatment and sustainability of the result.

7. Conclusion

Management of single or multiple gingival recessions with root hypersensitivity is individually oriented and depends on the clinical features, the skills of the clinician, and the wishes of the patient.

If the surgery is contraindicated, a conservative approach is indicated.

Successful treatment of gingival recessions with hypersensitivity can be performed with periodontal plastic surgery techniques. These include displacement of the flap or tunneling technique in the coronal and/or lateral direction alone or in combination with gingival grafts. Additional enamel matrix derivative application or hyaluronic acid gel could be applied to provide additional clinical benefits while treating gingival recessions. With this treatment approach, a good root coverage with long-term stability and satisfactory esthetics could be achieved for a patient with reduced or eliminated dentin sensitivity.