Consensus Statement on Mucogingival Conditions
This paper was developed by experts in the field and approved by the AAP Board of Trustees in May 2009.
The 2000 American Academy of Periodontology Parameters of Care
defined mucogingival conditions as “deviations from the normal anatomic
relationship between the gingival margin and the mucogingival
junction.” This relationship may be affected by tooth position,
frenulum insertions, and vestibular depth. The most common
manifestations are gingival recession and associated loss of supporting
bone, absence or reduction of keratinized tissue, and probing depths
extending beyond the mucogingival junction. This mucogingival pathology
often results in root sensitivity, loss of tooth structure (abrasion),
increased length of the clinical crown, and inflammation and bleeding
of the marginal tissue.
Most adults have some form of a mucogingival pathosis. There are a
number of evidence-based procedures available to predictably correct
these anatomic abnormalities and pathoses. However, there is
disagreement on criteria for determining the need for that treatment.
The decision whether or not to treat a particular patient involves
consideration of the factors noted above plus the need for orthodontic
or restorative care.
In the absence of evidence-based studies to determine the need for
treatment, clinical practice guidelines are used in a number of health
care disciplines. These guidelines should be based upon explicit
criteria to ensure consensus regarding their validity. However, it must
be remembered that the use of guidelines must always be in the context
of a dentist’s best clinical judgment in the care of a particular
patient. It is the patient, together with his or her dentist, who has
the final responsibility for making treatment decisions after all
therapeutic options have been explained and carefully considered.
In presenting those options to the patient, consideration must be given to:
- 2 mm or more of gingival recession with inadequate keratinized tissue*
- less than 1 mm of attached gingiva
- root abrasion
- class V caries or defective restorations
- aberrant frenum attachment
to maintain the marginal tissue in periodontal health** with atraumatic
plaque removal techniques using a manual or mechanical toothbrush with
- orthodontics – planned, in progress, or completed
- need for restorative care of the tooth
- progression of recession
- root sensitivity
- age of patient
- presence of periodontitis
- abnormal tooth position relative to the alveolar ridge
It is important to emphasize that the amounts of gingival recession
and attached gingiva should not be the sole determinants of the need
for treatment of mucogingival pathology.
*Inadequate keratinized tissue is defined as <2 mm in width of which less than 1 mm is attached gingiva
** Periodontal health is defined as minimal probing depth with no bleeding or inflammation
Surgical Clinical Crown Lengthening
There should be adequate exposure of a sound tooth structure for the tooth to be restored.
Caries, fracture of a tooth, external or internal root resorption,
uneven occlusal planes, or excessive occlusal or incisal wear may
result in insufficient clinical crown length or tooth volume to support
a restoration without impinging upon the biologic width of the
periodontal attachment to the tooth. The combined measurement of the
sulcus depth and biologic
width is minimally three millimeters. Placement of a restoration that
invades the biologic width may result in inflammation and loss
of support. In order to maintain periodontal health and restorative
retention form, there should be adequate exposure of sound tooth
structure for the restoration of the tooth.
Surgical clinical crown lengthening is often necessary to obtain adequate sound tooth structure. This procedure involves
surgical reflection of mucoperiosteal flaps with osseous recontouring through ostectomy and osteoplasty. Clinical crown
lengthening is performed in a healthy periodontal environment, in contrast to osseous surgery, which is performed to treat periodontal osseous defects. When there are adjacent teeth, surgical
clinical crown lengthening of a single tooth involves a minimum of three teeth in order to avoid unhealthy, inconsistent
gingival margins and alveolar bone contours.