An exposed root in the area of the front teeth. Sensitivity that does not go away, and an increasingly visible difference in tooth length when you smile. The question that brings patients to our clinic: "Can this gum be restored?"
CTG?
CTG (connective tissue graft) is a surgical procedure in which the periodontist harvests a small piece of connective tissue from the palate and transplants it to the area of the gum recession. The transplanted tissue provides volume and a biological scaffold for new gum growth.
In the periodontological literature CTG has for years been regarded as one of the most effective procedures for recession coverage — especially in combination with the tunnel or coronally advanced flap technique.
CTG is a routine surgical procedure within the scope of gum surgery. We propose it to patients with recessions that cause aesthetic, functional or sensitivity problems.
Indications for CTG — when does it make sense?
Not every gum recession qualifies for surgical treatment, and among those that do, not all carry an equally good prognosis.
Indications for the procedure
- Cairo RT1 recession — no attachment loss in the interdental spaces. Prognosis very good; complete coverage frequent.
- Root sensitivity that does not respond to other methods (desensitising toothpastes, varnishes, composite restorations).
- Progression of recession despite removal of the cause (correction of brushing technique, change of toothbrush).
- Planned orthodontic treatment in the area of thin gum — prevention of further recession.
- Aesthetics of the smile zone, where the recession is clearly visible.
Limited or no indication
- RT3 recession — complete coverage usually not possible; partial coverage may be attempted.
- Active smoking — significantly reduces the efficacy of the procedure.
- Poorly controlled diabetes (HbA1c above 7%).
- Failure to remove the cause of recession — the procedure without changing habits will give a short-lived result.
- Poor home hygiene — the graft is sensitive to bacterial plaque.
- Recession caused by unstabilised periodontitis — primary treatment first
Course of the procedure — step by step
Stage 1: Preparation
The procedure is performed under local anaesthesia. Anaesthesia is administered both at the recipient site (where the recession will be covered) and at the donor site (the palate).
Stage 2: Harvesting tissue from the palate
The periodontist makes a small incision on the palate and harvests a piece of connective tissue — the layer beneath the surface, without taking epithelium. The wound on the palate is sutured or covered with a collagen sponge.
Stage 3: Preparation of the recipient site
At the recession site the periodontist prepares a tunnel or a soft-tissue flap — creating a "pocket" beneath the existing gum in which the graft will be placed. The root surface is prepared (planed) and in some cases treated with a bioactive agent (e.g. enamel matrix derivative — Emdogain).
Stage 4: Grafting and closure
The harvested tissue is placed in the prepared site and secured with sutures. The existing gum is then advanced coronally (towards the crown of the tooth) so that it covers the graft and the root as much as possible.
Stage 5: Post-operative protection
A periodontal dressing or protective gel is often placed at the surgical site. The palate after harvesting is also protected — some operators use a palatal plate, others rely on a collagen sponge and sutures.
Pain from the palate — what you need to know
| The greatest discomfort after CTG comes not from the recession coverage site but from the palate, from which the tissue was harvested. The palate is more sensitive and heals more slowly. Most patients describe the palatal discomfort as "moderate to marked" for the first 3–5 days. |
Practical tips for the first days after CTG:
- For 3–5 days eat only soft, cool foods (yoghurts, cool soups, bananas, custard). Avoid hot, hard and acidic foods.
- Analgesics: usually paracetamol or ibuprofen. In the first 48 hours these can be taken regularly, without waiting for severe pain.
- Do NOT brush the surgical area — use chlorhexidine mouthwash or gel for 10–14 days.
- Avoid sucking through a straw, forceful spitting and smoking — all of these can damage the sutures or impair healing.
- Sleep with the head slightly elevated for the first 2–3 nights — this reduces swelling.
- If using a palatal plate — wear it as instructed.
Timeline
| Stage | Time | What happens |
|---|---|---|
| Day 0 | Procedure | Harvesting, grafting, sutures |
| Days 1–5 | Acute phase | Greatest discomfort, particularly from the palate |
| Day 7 | Check-up | Preliminary assessment, possible removal of some sutures |
| Day 14 | Suture removal | Initial picture of coverage; healing continues |
| Weeks 3–4 | Resumption of hygiene | A soft toothbrush returns to the area |
| 3 months | Early stabilisation | Preliminary results assessment; tissues are maturing |
| 6 months | Final assessment | Stable result, photographic documentation, coverage measurement |
The definitive assessment of the outcome is made at 6 months. Before then the tissues are still changing — gum colour may differ (lighter or darker) and the gum margin may shift slightly. Patience is key.
Prognosis: what can realistically be achieved?
The efficacy of CTG depends on several factors. The table below shows the average outcomes from the literature for different recession types.
| Cairo recession type | Mean coverage | Chance of complete coverage |
|---|---|---|
| RT1 (no interdental loss) | 85-95% | High (60–75% of cases) |
| RT2 (partial interdental loss) | 60-80% | Moderate (30–50%) |
| RT3 (significant interdental loss) | 40-60% | Low (complete coverage rarely possible) |
Practical implications for the patient:
- If you have RT1 — there is a good chance the recession will be virtually invisible after the procedure.
- If you have RT2 — significant improvement can be achieved, but some recession may remain.
- If you have RT3 — the goal is usually to increase gum thickness and halt progression, not complete coverage. This is a valuable goal, but it must be understood realistically.
Alternatywy dla CTG
If, for various reasons, CTG is not the optimal choice, there are alternatives worth considering.
Collagen matrix
Instead of harvesting tissue from the palate, a ready-made collagen matrix of animal origin can be used. Advantages: no second wound, less pain, shorter procedure. Disadvantage: slightly lower efficacy in full coverage compared with CTG in some studies.
Free gingival graft (FGG)
A different technique in which epithelium together with connective tissue is harvested. Used mainly to increase the width of keratinised gingiva, not for aesthetic coverage of recessions.
Coronally advanced flap (without a graft)
In selected situations — when the gum surrounding the recession is already sufficiently thick — the recession can be covered by advancing the existing tissues alone. Less pain (no donor site), but less predictable in thin tissue.
Composite filling
Does not replace CTG, but is a good symptomatic solution (reduces sensitivity, improves aesthetics) for patients who do not want or cannot undergo surgery.
The most frequently asked questions from patients
Can multiple teeth be treated at once?
Yes. When recessions involve several adjacent teeth, we usually perform the procedure for the entire group in a single session (2–4 teeth). Tissue is harvested from the palate once, so the patient has only one donor wound.
Can the recession return after the procedure?
Yes, if the cause has not been removed. That is why before and after the procedure we discuss with the patient: brushing technique, type of toothbrush, habits and the need for regular monitoring.
Does the procedure leave scars?
At the recession site — no. The tissues heal cleanly and the result is usually aesthetic. At the donor site (palate) the incision heals within 2–3 weeks, and ultimately no scar is visible.
Read more:
- Periodontist Warsaw — Klinika MDO services
- Gum recession — why the gum recedes and when surgical treatment is needed
- Surgical crown lengthening — when is it necessary and how is it performed
Sources
Source 1
Links
https://pubmed.ncbi.nlm.nih.gov/36594482
https://doi.org/10.1111/prd.12468
Mazzotti C, Mounssif I, Rendón A, Mele M, Sangiorgi M, Stefanini M, Zucchelli G. „Complications and treatment errors in root coverage procedures.” Periodontology 2000. 2023 Jun;92(1):62-89.
Source 2
Links
https://pubmed.ncbi.nlm.nih.gov/41498281
https://doi.org/10.1002/jper.70049
Santamaria MP, Mathias-Santamaria IF, Tavelli L, Barootchi S, Pini Prato GP. „An updated evidence-based recommendation for the treatment of gingival recession associated with non-carious cervical lesions.” Journal of Periodontology. 2026 Jan 7. doi:10.1002/jper.70049. Online ahead of print.
Source 3
Links
https://pubmed.ncbi.nlm.nih.gov/35451068
https://doi.org/10.1002/JPER.22-0167
Chambrone L, Botelho J, Machado V, Mascarenhas P, Mendes JJ, Avila-Ortiz G. „Does the subepithelial connective tissue graft in conjunction with a coronally advanced flap remain as the gold standard therapy for the treatment of single gingival recession defects? A systematic review and network meta-analysis.” Journal of Periodontology. 2022 Sep;93(9):1336-1352.
Source 4
Links
https://pubmed.ncbi.nlm.nih.gov/34024328
https://doi.org/10.1111/idj.12617
Imber J-C, Kasaj A. „Treatment of Gingival Recession: When and How?” International Dental Journal. 2021 Jun;71(3):178-187.