There are two types of epithelial tissues in the mouth: Gingiva and Mucosa.

Gingiva is what we normally refer to as the gums. Mucosa is the epithelial tissue which lines the cheeks and lips, and is also the type of tissue that lines the eye sockets and gastrointestinal tract. Mucosa and gingiva are usually easily distinguished from one another in the mouth. Mucosa appears smooth, while gingiva has a coarse or stippled appearance similar to that of an orange peel. The gingiva normally surrounds all of the teeth and covers the hard palate (roof of the mouth.) If you look into your mouth you can usually see a line where the gingiva ends, and the mucosa begins. This line is called the mucogingival junction, and can usually be easily identified near the lower front teeth by gently pulling outward on the lower lip. The mucosa, which is very loosely attached to the underlying bone, pulls away easily, but is stopped at the mucogingival junction where the gingiva are very firmly attached to the underlying bone. It is this firm attachment to the bone and around the neck of each tooth which affords a strong barrier against bacterial invasion. It is generally accepted that each tooth should be surrounded by usually at least a two millimeter broad zone of gingival attachment in order to adequately protect the underlying bone. On a microscopic level, the factor which causes the differentiation of gingival tissue from mucosal tissue is actually the underlying connective tissue.

Simply stated, gingiva is distinguished by the presence of underlying dense connective tissue, while mucosa is distinguished by the presence of underlying loose connective tissue.

For a variety of reasons, some individuals only have a very narrow band or zone of gingiva around a portion of one or more teeth. This can present a significant problem, because the presence of the tightly attached gingiva is necessary to prevent bacterial infiltration under the gumline, the absence of which would eventually lead to disintegration of the bone, which in turn leads to gum recession. Often the most severe cases of gum recession are a result of insufficient gingival attachment, because the loosely-attaching mucosa is taking the place of the tightly-attaching gingiva. Unfortunately, we have seen many patients who believe that they themselves are causing the recession by brushing too hard, when in fact there exists an anatomic defect which can be repaired.

Treatment:
Treatment of what is often referred to as a mucogingival defect involves the grafting of tissue to the affected area. The generally accepted criteria indicative for performing a graft is evidence of recession, plus gingival attachment width of 2 or less millimeters.

If an adjacent tooth has enough gingiva around it, some can be borrowed and slid into the area of the defect. This is called a Pedicle Graft, or sometimes simply called a Sliding Graft.

More often, however, the adjacent teeth do not have enough gingival tissue from which to borrow. This necessitates the use of a different donor source for the graft. Most commonly, gingiva is borrowed from the roof of the mouth, and transplanted into the affected area. This is called a Free Gingival Graft.

Or, similarly, dense connective tissue may be borrowed from the roof of the mouth, and placed under the mucosa at the site of the defect. The presence of dense connective tissue under the mucosa causes it to differentiate into gingiva. This is called a Connective Tissue Graft.

In severe cases, where the area requiring grafting is very extensive, actual skin may be used, although this is rarely necessary.

In our office the success rate of these grafts is close to 100%.
Gingival grafting is often necessary to prevent the loss of a tooth, and/or to prevent development of severe recession on a front tooth which would be cosmetically undesirable. It is important to note that these grafting techniques usually only prevent further gum recession, rather that reversing it. This is because the level of the gumline is primarily dependent upon the level of the underlying bone, which has probably already receded. There are procedures designed to encourage the gums to attach at a higher level and thus reverse the recession, but this usually needs to be performed as two separate surgical procedures, and the long term success is variable.