PRD 12059

Periodontology 2000, Vol.
68, 2015, 333368

Printed in Singapore. All rights reserved
2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
Periodontal plastic surgery

GIOVANNI ZUCCHELLI & ILHAM MOUNSSIF
Mucogingival therapy is a general term used to

describe periodontal treatment involving procedures
for the correction of defects in the morphology, position and/or amount of soft tissue and underlying
bone support around teeth and implants (12). At the
beginning, mucogingival surgery, introduced by
Friedman in 1957 (69), included surgical procedures
designed to preserve gingival tissue, remove aberrant
frenal or muscle attachments and increase the depth
of the vestibule. Frequently, however, this term
was used to describe certain pocket elimination
approaches. Therefore, in 1993, Miller (132) introduced the term periodontal plastic surgery,
accepted by the international scientic community
in 1996, which was dened as surgical procedures
performed to prevent or correct anatomic, developmental, traumatic or disease-induced defects of the
gingiva, alveolar mucosa or bone (203). This denition includes various soft- and hard-tissue procedures aimed at gingival augmentation, root coverage,
correction of mucosal defects at implants, crown
lengthening, gingival preservation at ectopic tooth
eruption, removal of aberrant frena, prevention of
ridge collapse associated with tooth extraction and
augmentation of the edentulous ridge. This paper
focuses on gingival recession defects, their diagnosis
and prognosis and the surgical procedures for root
coverage.
Etiology of gingival recessions

The gingival margin is clinically represented by a scalloped line that follows the outline of the cemento
enamel junction, 12 mm coronal to it. Gingival
recession is an apical shift of the gingival margin with
exposure of the root surface to the oral cavity (205)
(Fig. 1). Gingival recession is often found in populations with good oral hygiene (173, 177), when it is
most commonly located at the buccal surfaces (117)
and may be associated with wedge-shaped defects in
the cervical area of one or more teeth (173). However,
gingival recession is also found in populations with

poor standards of oral hygiene in which it may affect
other tooth surfaces (16, 117). Recession may exist in
the presence of normal sulci and nondiseased interdental crestal bone levels, or it may occur as part of
the pathogenesis of periodontal disease during which
alveolar bone is lost. One etiological factor that may
be associated with gingival recession is a pre-existing
lack of alveolar buccal bone at the site (202) (Fig. 1).
These deciencies in alveolar bone may be developmental (anatomical) or acquired (physiological or
pathological) (72).
Anatomical factors
Anatomical factors that have been related to gingival recession include fenestration and dehiscence of
the alveolar bone, abnormal tooth position in the
arch, an aberrant path of eruption of the tooth and
the shape of the individual tooth (7). These anatomical factors are inter-related and may result in an
alveolar osseous plate that is thinner than normal
and that may be more susceptible to resorption.
Anatomically, a dehiscence may be present because
of the direction of tooth eruption or as a result of
other developmental factors, such as buccal placement of the root relative to adjacent teeth, so that
the cervical portion protrudes through the crestal
bone (119). One surgical study found a correlation
between gingival recession and bone dehiscence
(21). A correlation between the pattern of eruption
and gingival recession has also been suggested
(134). Dehiscence may be present where the buccolingual thickness of a root is similar to or exceeds
the crestal bone thickness (144). The same authors
postulated that individuals with morphological biotypes characterized by narrow, long teeth are more
prone to dehiscences than are individuals with
broad, short teeth. Where gingival recession has
developed, the underlying presence of dehiscences
may be considered, and possibly discovered during
ap procedures.
333
Zucchelli & Mounssif

A
Fig. 1. Gingival recession and bone

dehiscence. (A) Gingival recession
extending from the cementoenamel
junction (dotted line) to the soft-tissue margin. (B) Gingival recession in
the lateral view: the distinction
between the anatomic crown and
the root (cementoenamel junction)
becomes more evident. (C) Bone
dehiscence (from the cemento
enamel junction to the buccal
bone crest) associated with gingival
recession.
Localized gingival recession may be associated with

the position of the teeth on the arch (106, 144). The
position in which a tooth erupts through the alveolar
process affects the amount of gingiva that will be
established around the tooth. If a tooth erupts close
to the mucogingival line there may be very little, or
no, keratinized tissue labially and localized recession
may occur (214). In the developing dentition of preteenage children, buccal displacement of the lower
incisors is common and is often associated with gingival recession. Follow-up studies reveal spontaneous
reversal of recession as the child matures (13).
Physiological factors
Physiological factors may include the orthodontic
movement of teeth to positions outside the labial or
lingual alveolar plate, leading to dehiscence formation (105, 206) that may act as locus minoris resistentiae for gingival recession development (172, 206).
The gingival recession may appear as a deep and narrow lesion, similar to a Stillman cleft, in which domiciliary oral hygiene becomes very difcult to perform,
and bacterial or viral infection may induce the formation of a buccal probing pocket of sufcient depth to
reach the periapical environment of the tooth. Sometimes a delayed diagnosis is made only when an endodontic abscess occurs.
The volume of the facial soft tissue may be a factor
in predicting whether gingival recession will occur
during or after active orthodontic treatment. A thin
gingiva may be a greater risk factor for progression in
the presence of plaque-induced inammation or
toothbrushing trauma (206). Therefore, the active
orthodontic movement of the teeth outside the alveolar bone may be considered as an etiological factor.
334
When, during the postorthodontic retention phase,

wide and deep multiple gingival recessions occur, it is
toothbrushing trauma that acts as an etiological factor on gingival tissue that has been thinned as a result
of tooth malposition (buccal dislocation). In such a
clinical situation, orthodontic therapy acts as a predisposing factor for gingival recession. Sometimes,
isolated deep gingival recessions occur in the lower
incisors a few years after orthodontic therapy. Common characteristics associated with these gingival
defects are the presence of a round-wire lingualbonded retainer from canine to canine, a different
axial (faciallingual) inclination of the affected tooth
with respect to the adjacent incisors and the presence
of inammatory tissue lateral to the root exposure
(Fig. 2). In such a case, the etiological factor can be
found in a patients chronic habits, such as ngernail
biting, digit sucking, or sucking on objects such as
pens, pencils or toothpicks, that exert continuous
pressure on the biting edge of the affected tooth
(Fig. 2). As any lingual-crown movement is prevented
by the round-wire lingual-bonded retainer, the
applied force leads to buccal displacement of the
root, bone dehiscence and gingival recession.
Pathological factors
Toothbrushing
Toothbrushing is commonly associated with gingival
recession and partly explains the correlation between
low plaque levels found at sites of recession (2).
Trauma can be caused by improper toothbrushing
or by a number of potentially confounding variables,
such as pressure, time, bristle type and the dentifrice
used (108, 164). Clinical signs of gingival recession
caused by toothbrushing are soft-tissue ulcers (with-

A
Fig. 2. Postorthodontic gingival recession. (A) Buccal view:

note the presence of inamed, red, highly vascularized
tissue lateral to the deep root exposure. (B) Occlusal
view: note the presence of the round-wire lingual-bonded
retainer from canine to canine and the different axial

buccallingual inclination of the affected tooth with
respect to the adjacent incisors.
out pain) and hard-tissue cervical abrasions (noncarious cervical lesions). Sometimes, soft-tissue trauma
may destroy all keratinized gingival tissue. The cervical abrasions are caused by continued mechanical
trauma after recession manifestation.
of epithelialization (87). Often patients use a ossing

technique with a sawing motion (126) while advancing the oss apically into the gingival crevice (200).
When ossing trauma is involved, supercial gingival
tissue clefts are red because the injury is conned
within connective tissue. In this case the lesion is
reversible: ossing procedures have to be stopped for
at least 2 weeks and chemical plaque control (i.e.
chlorexidine rinses) only should be performed
(Fig. 3). If the cleft appears white the whole connective tissue thickness is involved and the radicular surface becomes evident; in this case the gingival lesion
is irreversible (87, 140) (Fig. 3).
Improper ossing techniques

Flossing trauma can contribute to tooth abrasion and
gingival injury (1, 66, 74). These lesions often occur in
highly motivated patients who have not been properly instructed in the technique of ossing. Diagnosis
of these injuries can often be conrmed by asking
patients to demonstrate their oral hygiene procedures
(200). The initial injury may appear as an acutely
inamed, ulcerated linear or V-shaped cleft that is
symptomatic (74, 87) (Fig. 3). Chronic lesions are
often asymptomatic and may not appear to be ulcerated or clinically inamed. The clefts may traverse
the width of the interdental space and extend into the
adjacent facial and lingual gingivae. At the histological level, gingival clefts are often lined by stratied
squamous epithelium. The base of the cleft may have
a bifurcated appearance and exhibit varying degrees
Perioral and intraoral piercing

Piercing of the tongue and perioral regions is becoming an increasingly popular expression of so-called
body art (79, 126). Tongue piercing has been directly
related to dental and gingival injuries on the lingual
aspect of the anterior lower teeth (24, 37), and buccal
gingival recession may occur in subjects in whom the
lip stud is located such that it can traumatize the gingiva (37, 63). Frequently, the lingual gingival lesion is
Fig. 3. Gingival cleft. (A, B) Red

cleft: the interruption of the soft-tissue margin is not full thickness. The
lesion can be reversed by interrupting
the trauma. (C, D) White cleft: the
root surface is evident at the bottom
of the ssure. Re-epithelization of the
lesion is complete.
335
narrow and thin and plaque control is difcult to perform; when particularly deep, lingual recession can
be associated with a probing pocket depth that can
reach the periapical region. Removal of the stud is
desirable to eliminate the etiological factor (175). Further therapy (such as mucogingival surgery) (179)
may be necessary when keratinized tissue is lost and
the periodontal attachment compromised.
Direct trauma associated with malocclusion
Class II, division two, malocclusions have a deep overbite and often a reduced overjet with retroclination of
the upper anterior teeth. In some severe cases this can
result in direct trauma to the labial gingiva of the
lower anterior teeth or to the palatal marginal gingiva
of the upper anterior teeth (97). This may result in
indentations in the gingiva and can result in recession
at the site (195). In rare cases in young people, the
orthodontic/orthognatic management of malocclusion and appropriate toothbrushing can solve gingival
recession without the need for surgical interaction.
Partial denture/restorative therapy
Poorly designed or maintained partial dentures and
the placement of restoration margins subgingivally
may not only result in direct trauma to the tissues
(55), but may also facilitate subgingival plaque accumulation, with resultant inammatory alterations in
the adjacent gingiva and recession of the soft-tissue
margin (85, 111, 147). Experimental and clinical data
suggest that the thickness of the marginal gingiva
(182), but not the apicocoronal width of the gingiva
(64), may inuence the magnitude of recession taking
place as a result of direct mechanical trauma during
tooth preparation and bacterial plaque retention. If
gingival recession is caused only by trauma from partial dentures, complete root coverage is possible by
mucogingival surgery; however, if recession is caused
by interdental attachment loss during tooth preparation, root coverage is not achievable. In both cases a
new partial denture is suggested.
Bacterial plaque
Gingival recession may be caused by localized accumulation of bacterial plaque on the buccal surface of
the tooth (17, 117, 168, 195, 196). This should not be
confused with gingival recession caused/associated
with periodontal disease. In the latter, bacterial
plaque (specic periodontal pathogens) causes connective tissue attachment loss that may clinically
manifest with gingival recession not only at buccal
surfaces but also at the interproximal tooth surfaces.
Bacterial plaque-induced gingival recessions are
336
caused by plaque accumulation localized to the buccal surface with no severe interdental attachment
loss; thus, they can be successfully treated with
root-coverage procedures. Patients with bacterial
plaque-induced recessions must be motivated on the
importance of oral hygiene, and mucogingival surgery
must not be performed until good plaque control has
been achieved. The presence of microbial deposits on
the exposed root surface and/or clinical signs of
inammation in the surrounding tissues are useful
for reaching the correct diagnosis. Buccal probing
pocket depths apical to the root exposure are
frequently associated with bacteria-induced gingival
recessions.
Herpes simplex virus
Gingival recession may be associated with herpes
simplex virus type 1. The lesions consist of multiple
vesicles that rupture, rapidly giving rise to ulcers (62,
68). They are often accompanied with pain and sometimes with fever and regional lymphadenopathy. The
lesion can be found in all areas of the mouth because
of diffusion of the infection with toothbrushing; frequently, associated mucocutaneous lesions can be
found. In the early phase ulcers do not involve the
gingival margin and it is suggested that toothbrushing
is responsible for their evolution (159). In the presence of virus-induced gingival lesions, toothbrushing
and dental ossing should be stopped and chemical
plaque control (with chlorexidine rinsing) should be
performed. Surgical procedures are indicated only if
and when gingival recession becomes irreversible.
Classication, diagnosis and

prognosis of gingival recessions
Gingival recession can be treated with various surgical procedures, and root coverage can be obtained
irrespective of the surgical approach adopted. The
most important prognostic factor for root coverage
following surgery is the height of the interdental periodontal support (clinical attachment and alveolar
bone levels) (131). In the case of a periodontally
healthy tooth the papillae completely lls the interdental spaces and there is no clinical attachment loss
or bone loss; periodontal probing and intraoral X-ray
may be helpful to conrm the healthy condition. Gingival recessions have been classied by Miller (131)
into four classes (an illustration of Millers classication is reported in Fig. 4), according to the prognosis
of root coverage. In Class I and Class II gingival recessions, there is no loss of interproximal periodontal

A
Fig. 4. Miller classication of gingival recession. (A) Class I: the interdental periodontal support is intact
and the gingival recession does not
reach the mucogingival line. Complete root coverage can be achieved.
(B) Class II: the interdental periodontal support is intact and the
gingival recession reaches the mucogingival line. Complete root coverage can be achieved. (C) Class III:
there is some interdental attachment
and bone loss and the gingival recession reaches the mucogingival line.
Partial root coverage can be
achieved. (D) Class IV: bone and
attachment loss are so severe that no
root coverage can be accomplished.
attachment and bone, and complete (up to the cementoenamel junction) root coverage can be
achieved. The difference between the two classes lies
in the height of the root exposure reaching (Class II)
or not reaching (Class I) the mucogingival junction.
In Class III gingival recessions, the loss of interdental
periodontal support is mild to moderate, and partial
root coverage can be accomplished; in addition,
tooth/root malposition limits the possible amount of
root coverage. In Class IV gingival recessions, the loss
of interproximal periodontal attachment (or tooth/
root malposition) is so severe that no root coverage is
feasible.
Some questions/doubts about the classication of
gingival recession, not claried in Millers classication, have recently been highlighted (160). One of
these doubts relates to the Millers class of gingival
recession (Class I or Class II) extending beyond the
mucogingival line, but conserving a small, probable
height of keratinized tissue apical to the root exposure (Fig. 5). The distinction, even if not signicant
from a prognostic point of view, could be useful for
A
selecting the most successful root-coverage surgical

approach. Other criticisms of Millers classication
relate to the unclear procedures to ascertain the
amount of soft-/hard-tissue loss in the interdental
area to differentiate Class III and Class IV (Fig. 6) and
the unclear inuence of tooth malpositioning (160)
(Fig. 7). Cairo et al. (35) recently introduced a new
classication system of gingival recessions using the
level of interproximal clinical attachment as an identication criterion; they also explored the predictive
value of the resulting classication system on nal
root coverage outcomes following surgery. Three
recession types (RT) were identied: class RT1
included gingival recession with no loss of interproximal attachment; class RT2 comprised recession with
loss of interproximal attachment less than or equal to
the buccal site; and class RT3 showed interproximal
attachment loss higher than the buccal site. The
results of this study show that the recession type class
is a strong predictor of the nal recession reduction
after different surgical procedures. The authors
hypothesized that the level of interproximal clinical
Fig. 5. Criticisms of Millers classication of gingival recession. (A, B)

Distinction between Class I and
Class II is not clear for gingival
recessions extending beyond the
mucogingival line but a small height
of probable keratinized tissue is conserved apical to the exposed root.
337

A
Fig. 6. Criticisms of Millers classication of gingival recession. (A, B) Distinction between Class III and Class IV: partial root coverage can be accomplished in supposed Class
IV gingival recessions.
attachment loss is the coronal limit of the achievable

amount of root coverage at the buccal site after surgery. The RT1 class showed a higher mean reduction
of recession compared with the RT2 class, highlighting the importance of baseline interproximal clinical
attachment loss for the prognosis of gingival recession treatment. The same authors (34) recently published a randomized clinical trial evaluating the
adjunctive benet of connective tissue grafts compared with coronally advanced aps for the treatment
of gingival recession associated with interdental clinical attachment loss the same as or smaller than buccal attachment loss (RT2). They concluded that
complete root coverage can be achieved in RT2
affecting the upper anterior teeth with both coronally
advanced ap alone and coronally advanced ap plus
connective tissue grafts; however, the additional use
of a connective tissue graft resulted in a greater number of sites with complete root coverage: >80% of the
sites when the baseline amount of interdental clinical
attachment loss was 3 mm (34). Further longer-term
studies are advocated to evaluate root coverage in
Miller Class III and Class IV gingival recessions.
Another criticism of Millers classication regards the
difculty of identifying the cementoenamel junction
338
on teeth affected by gingival recession and noncarious cervical lesions (Fig. 8). Pini-Prato et al. (161)
recently proposed a clinical classication of surface
defects in teeth associated with gingival recession.
Four classes of dental-surface defects in areas of gingival recession were identied on the basis of the
presence (Class A) or absence (Class B) of the cementoenamel junction and of the presence (Class+) or
absence (Class ) of surface discrepancy (a step). Of
1010 exposed root surfaces, 144 (14%) showed an
identiable cementoenamel junction associated
with a root surface step (Class A+), 469 (46%) showed
an identiable cementoenamel junction without any
associated step (Class A ), 244 (24%) demonstrated
an unidentiable cementoenamel junction with a
step (Class B+) and 153 (15%) showed an unidentiable cementoenamel junction without any associated step (Class B ). According to the authors, the
classication of dental surface defects in conjunction
with the classication of periodontal tissues is useful
for reaching a more precise diagnosis in areas of gingival recession, and the condition of the exposed root
surface may also be important for the prognostic
evaluation of mucogingival surgery. In the literature
(169, 203), predictability of root coverage was measured in terms of the mean percentage of root coverage (indicating the percentage of the root exposure
covered with soft tissues) and the percentage of complete root coverage (showing the percentage of teeth
with the soft-tissue margin covering the cemento
enamel junction). For the correct evaluation of both
of these parameters, it is necessary to recognize the
cementoenamel junction, which anatomically separates the crown from the root, on the tooth with the
recession defect. Therefore, the clinical healing pattern only of those gingival recessions in which the cementoenamel junction is clinically detectable could
be evaluated in terms of percentage and/or complete
root coverage. When the cementoenamel junction is
not recognizable, it is no longer possible to measure
the depth (and width) of the recession and/or to
assess the efcacy of a surgical technique in terms of
root coverage, as a result of the lack of the reference
parameter (226). Furthermore, other tooth/gingival
Fig. 7. Criticisms of Millers classication of gingival recession. (A, B)

The role of tooth malposition in preventing complete root coverage:
complete root coverage can be
accomplished in supposed Class III
gingival recession (caused by buccal
dislocation of the root).

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A
Fig. 9. Predetermination of root coverage. (A) The ideal

papilla is measured as the distance between the cemento
enamel junction angular point and the contact point. This
distance is replaced apically starting from the tip of the
papillae. The horizontal projections of these measurements allow the identication of two points (blue points)
that are connected by the line of root coverage. (B) This
line can be used as a guide for composite lengthening of

the clinical crown. (C) Three months after root-coverage
surgery the soft-tissue margin is located at the level of, or
slightly coronal to, the composite lling. Esthetically
complete root coverage can be achieved, even in Class III
gingival recessions. CAP, cemento-enamel junction angular point; IP, interproximal.
level of root coverage was located within the abrasion

defect (using the restorativemucogingival approach).
Conservative treatment (with or without access ap
surgery) was performed when the maximal line of
root coverage was located at the level or apical to the
most apical extension of the abrasion area (221).
teeth affected by gingival recession. This is a cause of

discomfort and/or pain and can make proper oral
hygiene very difcult to perform. If there is no concomitant esthetic complaint related to the excessive
tooth length, a less invasive (and patient-appreciated)
treatment is the local application of chemical desensitizing agents. If this is not effective, a restorative
treatment (composite llings) may be performed. If
and when dentine hypersensitivity is associated with
a patient complaint about esthetics, treatment of
gingival recession should be surgical or combined
restorativesurgical (e.g. a combined restorative
mucogingival approach).
Indications for root coverage

surgical procedures
The treatment of gingival recession defects is indicated for esthetic reasons, to reduce root hypersensitivity and to create or augment keratinized tissue (36,
48, 78, 136, 169, 203, 205). Indications for root coverage procedures are root abrasion/caries and the
inconsistency/disharmony of the gingival margin.
Esthetic reasons
The main indication for treatment of gingival recessions is patient demand. The excessive length of
the tooth/teeth (i.e. those with recession) may be
evident when smiling and sometimes during
phonation. Esthetic shortening of the tooth can
only be accomplished with root coverage surgical
procedures.
Hypersensitivity
Sometimes the patient complains of hypersensitivity
to thermal stimuli (especially to cold) at the level of
340
Keratinized tissue augmentation

The indication for treatment of gingival recession
may also result from the site-specic patient difculty/inability to maintain adequate plaque control
because of the deep, narrow nature of the recession
defect or the absence of keratinized tissue.
Root abrasion/caries
The indication for treatment of gingival recession
may also derive from the concomitant presence of
root demineralization/caries or deep abrasion defects
that can cause hypersensitivity and/or may render
the patients plaque control difcult. Treatment of
radicular caries/abrasion associated with gingival
recession can be surgical or combined restorative
surgical, depending on the potential to cover with soft
tissue, or not cover, the area affected by abrasion or

caries (see the prognosis of root coverage) (205).
Inconsistency/disharmony of gingival
margin
Inconsistency/disharmony of the gingival margin
may be caused by the morphology of the gingival
recession, even in the absence of dentin hypersensitivity, which may prevent the patient performing an
effective toothbrushing technique. This is especially
true when gingival recessions are isolated and deep,
when they are very narrow with triangular-shape vertices (the so-called Stillman cleft) or when they
extend beyond the mucogingival junction. The only
feasible treatment is root coverage surgery.
Root coverage surgical procedures

The ultimate goal of a root coverage procedure is
complete coverage of the recession defect with a good
appearance related to the adjacent soft tissues and
minimal probing depth following healing (36, 48, 49,
131, 169).
Surgical procedures used in the treatment of recession defects may basically be classied as follows
(115).
Pedicle soft-tissue graft procedures:
Rotational ap procedures (laterally sliding ap,
double papilla ap, oblique rotated ap);
Advanced ap procedures (coronally repositioned
ap, semilunar coronally repositioned ap);
Regenerative procedures (with barrier membrane
or application of enamel matrix proteins)
Free soft-tissue graft procedures:
Epithelialized graft;
Subepithelial connective tissue graft
The international literature has thoroughly documented that gingival recession can be successfully
treated using several surgical procedures (205), irrespective of the technique utilized, provided that the
biological conditions for accomplishing root coverage
are satised (no loss in height of interdental soft and
hard tissue) (131).
The selection of one surgical technique over
another depends on several factors, some of which
are related to the defect (the size and number of the
recession defects, the presence/absence, quantity/
quality of keratinized tissue apical and lateral to the
defect, the width and height of the interdental soft tissue (papillae), the presence of frenum or muscle pull
and the depth of the vestibulum), whereas others are
related to the patient (219). The esthetic request and

the need to minimize postoperative discomfort are
the most important patient-related factors to be considered in the selection of the root coverage surgical
approach. Furthermore, the clinician must consider
data from the literature in order to select the most
predictable surgical approach, among those feasible
in a given clinical situation.
In a patient with esthetic requests, pedicle ap surgical techniques (coronally advanced or laterally
moved aps) are recommended if there is adequate
keratinized tissue apical or lateral to the recession
defect (10, 32, 81, 83, 84, 187, 204). In these surgical
approaches the soft tissue utilized to cover root exposure is similar to that originally present at the buccal
aspect of the tooth with the recession defect and thus
the esthetic result is satisfactory. Furthermore, the
postoperative discomfort is minimal as second surgical sites (palate) far from the tooth with the recession
defect are not involved.
Conversely, when the keratinized tissue apical or
lateral to the gingival defect is not adequate, free graft
procedures have to be performed (25, 96, 124, 130,
133, 184, 190). The use of free gingival grafts to treat
recession defects in patients with esthetic requests is
not recommended because of the poor esthetic outcome and the low root coverage predictability (205).
The use of a pedicle ap to cover the graft (i.e. the bilaminar technique) improves the root coverage predictability (by providing an additional blood supply
to the graft) and the esthetic result (through hiding
the white-scar appearance of the graft and masking
the irregular outline of the mucogingival junction that
frequently occurs after a free graft procedure) (8, 9,
28, 29, 92, 112, 137, 163, 204). This paper will focus in
particular on those surgical procedures that have
been reported to be more predictable in achieving
root coverage. From a clinical standpoint it can be
useful to classify them in root coverage surgical procedures for single and for multiple recession-type
defects.
Pedicle soft tissue graft procedure for

single recession defects
Coronally advanced ap
The coronally advanced ap procedure is a very common approach for root coverage. This procedure is
based on the coronal shift of the soft tissues on the
exposed root surface (10, 156). It is the technique of
choice for the treatment of isolated gingival recession. It is technically simple, well tolerated by the
patient [because the surgical area is limited and does
341
the splitfullsplit-thickness ap elevation (219): the

split-thickness elevation at the level of the wide
(3 mm) surgical papilla provided anchorage and
blood supply to the interproximal areas mesial and
distal to the root exposure. Furthermore, the partial
thickness of the surgical papillae facilitated the nutritional exchanges between them and the underlying
de-epithelialized anatomical papillae and improved
the blending (in terms of color and thickness) of the
surgically treated area with respect to the adjacent
soft tissues. The full-thickness elevation of the soft tissue apical to the root exposure conferred more thickness and some periosteum, and thus better
opportunity to achieve root coverage (18) to that portion of the ap residing over the exposed avascular
root surface. The more apical split-thickness ap elevation facilitated the coronal displacement of the
ap. Although the technique included vertical releasing incisions, these did not result in unesthetic scars.
In fact, these incisions were beveled in such a way
that the bone and periosteal tissues were not
included in the supercial cut and thus did not participate in the healing process. Another important
modication of the present surgical technique, with
respect to the previously proposed techniques (10,
150, 204), was that the coronal advancement of the
ap was not obtained by periosteal incisions, but
rather by cutting the muscle insertions included in
the thickness of the ap. A deep incision (with the
not require removal of tissue far from the tooth with

the gingival recession (palate)] and provides optimal
results from an esthetic point of view (Fig. 10). The
conditions required to perform the coronally
advanced ap are the presence of keratinized tissue, apical to the root exposure, of an adequate
height (1 mm for shallow recessions and 2 mm for
recessions 5 mm) (57, 203) and thickness. The technique was initially described by Norberg (138) and
subsequently reported by Allen & Miller (10).
Recently, it was modied (57) using a trapezoidal ap
design and a splitfullsplit-thickness ap elevation
approach (Fig. 10). This technique resulted in a very
high mean percentage (99%) and complete (88%) root
coverage at 1 year; these outcomes were similar (59,
204, 217, 218), or even higher (6, 33, 155, 193), than
those reported in the literature for other root coverage procedures. The 3-year outcomes showed only a
slight decrease compared with those at 1 year: 97% of
root coverage and 85% of complete root coverage. A
recent systematic review (36) concluded that the coronally advanced ap procedure is a safe and predictable root coverage surgical procedure for the
treatment of single type gingival recessions. The
mean percentage and the percentage of complete
root coverage of the articles comprised in the systematic review (36) are summarized in Table 1. The modied coronally advanced ap (57) technique (Fig. 11)
presented some clinical and biologic advantages over
Fig. 10. Predetermination of root coverage. (A) Lateral

view of the same tooth shown in Fig. 9. The coronal step of
the noncarious cervical lesion cannot be covered with the
soft tissues. (B) Enamel plastic and composite restoration
nished at the level of the line of root coverage. (C) The
ap is coronally advanced to cover in excess the composite
prole. Note the thickness of the coagulum that forms
between the root surface and the coronally displaced soft
342
tissue. (D) The sling coronal suture anchored to the palatal

cingulum permits precise adaptation of the ap marginal
tissue to the convexity of the clinical crown restored in
composite. There is no space for coagulum exposure. (E)
Two years after the root coverage procedure. The increase
in buccal soft-tissue thickness, together with the composite lling, provides the treated tooth with good esthetics
and a correct emergence prole.
Table 1. Mean root coverage and complete root coverage (%) with coronally advanced ap technique
Study
Flap procedure
Mean root
coverage (%)
Complete root
coverage (%)
da Silva et al. (54)
68.8
11.0
P. Cortellini (unpublished data)
62.0
Not available
Lins et al. (116)
60.0
Not available
Leknes et al.(114)
34.0
Not available
Modica et al. (135)
80.9
58.3
Del Pizzo et al. (59)
67.0
60.0
Spahr et al. (180)
86.7
23.0
Castellanos et al. (41)
62.2
36.3
Pilloni et al. (152)
65.5
31.2
Woodyard et al. (212)
67.0
33.3
de Queiroz Cortes et al. (56)
55.9
23.1
Huang et al. (98)
83.5
58.3
Fig. 11. Coronally advanced ap. (A, B) Comparison of the smile before and after placement of a coronally advanced ap
at the level of the left upper canine. The esthetic outcome was satisfactory for the patient.
blade parallel to the bone) detached the lip muscle

from the periosteum and permitted the performance
of a supercial incision (with the blade parallel to
the lining mucosa) that allowed for coronal advancement of the ap. These incisions minimized lip tension on the ap and permitted passive displacement
of the ap soft-tissue margin in a coronal position. A
further technical aspect that was considered critical
for the success of the modied coronally advanced
ap procedure related to the coronal sling suture.
The anchorage to the palatal cingulum permits precise adaptation of the keratinized tissue of the ap to
the convexity of the crown of the treated tooth. This
minimizes exposure of the coagulum, which forms
between the soft tissue and the root exposure, to the
detrimental microbiological and traumatic agents of
the oral environment. The increased stability of the
coagulum may play a role in preventing early ap
dehiscence and thus favor root coverage. The need
for a tight coronal adaptation of the keratinized tissue

of the aps at the time of suturing (Fig. 12C,D) represented another indication (221), together with the
esthetic indication, for a composite reconstruction,
before surgery, of the convexity of the tooth crown
interrupted by the presence of noncarious cervical
lesions (Figs 9 and 12).
A large increase in keratinized tissue height was
demonstrated after coronally advanced ap surgery
in the study by De Sanctis & Zucchelli (57) (Fig. 13):
in fact, 3 years after the surgery, the mean increase of
keratinized tissue was 1.78 mm, and this increase was
greater in sites with deeper recession and a lower
amount of residual keratinized tissue at baseline. Very
similar results were obtained in a previous study evaluating the 5-year outcomes of the coronally positioned ap for multiple gingival recessions (218).
Some hypotheses were made in an attempt to explain
the increase of keratinized tissue after coronally
343

A
Fig. 12. Coronally advanced ap surgical technique of the

tooth shown in Fig. 11. (A) Baseline gingival recession. (B)
Trapezoidal splitfullsplit ap elevation. Note the bone
exposure apical to the bone dehiscence. The periosteum
has been left in that portion of the ap covering the avascular root surface. There is no bone exposure along the
vertical releasing incisions to minimize keloid formation
after the healing process. (C) The ap has been coronally

advanced and secured with interrupted sutures along the
vertical releasing incisions and a coronal sling suture
anchored to the palatal cingulum. (D) At 2 years of follow
up, complete root coverage and an increase in keratinized
tissue height have been accomplished.
Fig. 13. Increase in keratinized tissue height after placement of a coronally advanced ap in different patient biotypes. (A) Gingival recession in a patient with an apical
location of the mucogingival line (compare with healthy
tooth, i.e. the lateral incisor). (B) Three years after placement of a coronally advanced ap: the great increase in
keratinized tissue height could be ascribed to the tendency
of the mucogingival line to regain its genetically deter-
mined position. (C) Gingival recession in a patient with a

more coronal location of the mucogingival line (see the lateral incisior). (D) Three years after placement of a coronally advanced ap: the small increase in keratinized tissue
height could be explained with the lower excursion threat
which the mucogingival line had to make to reach the
genetically determined position.
advanced ap surgery: the tendency of the mucogingival line, coronally displaced during the surgery, to
regain its original, genetically determined position
(5); or the capability of the connective tissue, deriving
from the periodontal ligament, to participate in the
healing processes taking place at the dentogingival
interface (107, 121, 149). The observation that the
increase in keratinized tissue height was greater
when, before surgery, there was a greater recession
depth and narrower residual band of attached gingiva
apical to the defects seems to support the hypothesis

of the tendency of the mucogingival junction to
regain its genetically determined position. In fact,
these were the clinical situations in which a greater
coronal displacement of the mucogingival line was
performed during the surgery. The repositioning of
the mucogingival line could also explain the great variability among patients (and studies) in the increase
of keratinized tissue height after coronally advanced
ap procedures. One can speculate that patient bio-
344
type might inuence the increase in keratinized tissue

after surgery: patients with a more apical position of
the mucogingival line will experience a greater
increase of keratinized tissue height after coronally
advanced ap surgery relative to patients with a more
coronal location of the mucogingival junction. Randomized comparative clinical trials of different
patient biotypes are advocated to test this hypothesis.
Recently, Pini Prato et al. (157) evaluated, in a longterm 14-year randomized split-mouth study, the
outcomes of two different methods of root-surface
modications (root-surface polishing compared with
root planing) used in combination with a coronally
advanced ap performed for the treatment of single
type gingival recessions. The authors (157) observed
that, during the 14-year follow-up period, an apical
shift of the gingival margin occurred in 39% of the
patients treated in both groups, showing a progressive worsening of the gingival recessions with time.
The observed relapse of the soft-tissue defects could
be ascribed to a resumption of traumatic toothbrushing habits in patients with high levels of oral hygiene,
even if they were included in a stringent maintenance
protocol with recall every 46 months. Regarding the
keratinized tissue width, the results of Pini Prato et al.
(157) showed its tendency to decrease over time.
The same authors (162) evaluated the outcomes of
coronally advanced ap for the treatment of single
gingival recessions in another long-term 8-year case
series study. They reported that an apical shift of the
gingival margin occurred in 53% of the cases and that
this was associated with a reduction of keratinized tissue; furthermore, the baseline amount of keratinized
tissue was indicated as a prognostic factor for recession reduction: the greater the width of keratinized
tissue, the greater the reduction of the recession.
The main contraindications for performing the coronally advanced ap as a root coverage procedure are
the absence of keratinized tissue apical to the recession defect, the presence of a gingival cleft (Stillman
cleft) extending into the alveolar mucosa, high frenulum pull at the soft-tissue margin, deep root-structure
loss, buccally dislocated root and a very shallow vestibulum depth.
Laterally repositioned (rotational) ap

The laterally repositioned ap is advocated when the
local anatomic conditions may render the coronally
advanced ap contraindicated. It is not the technique
of choice in patients with high esthetic demands (as
scar tissue forms in the secondary intention healing
at the donor site) but it is well accepted by the patient
because it does not involve the withdrawal of tissue
from a distant area (the palate) and has an excellent
postoperative healing course. In the literature, most
reports on the laterally repositioned ap technique
are quite dated. Various authors suggested several
modications to the original laterally sliding ap
described by Grupe & Warren in 1956 (82) in order to
reduce the risk of gingival recession at the donor site:
Stafleno (181), proposed the use of a partial-thickness ap, instead of a full-thickness ap, to cover the
root exposure. Grupe, in 1966 (81), suggested performing a submarginal incision at the donor site in
order to preserve the marginal integrity of the tooth
adjacent to the recession defect. Ruben et al., in 1976
(171), introduced a mixed-thickness ap that consisted of a full-thickness ap, performed close to the
recession defect for covering the root exposure, and a
split-thickness ap created laterally to the full-thickness ap, for covering the bone exposure occurring at
the donor site of the full-thickness ap. The most
recent publication, before 2004, on the laterally repositioned ap as a root coverage surgical technique,
dates back to 1988 (143). The reason for the lack of a
more recent interest is related to the low predictability and efcacy of the laterally repositioned ap as a
root coverage surgical procedure. In the literature,
the reported mean percentage of root coverage
ranges between 34% and 82% (31, 33, 65, 84, 109, 142,
171, 199, 215). Complete root coverage data are lacking, with only one study (31, 143) (Table 2) reporting
data ranging between 40% and 50%. All techniques
reported in the literature consisted of the lateral shift
of the pedicle ap only. More recently, Zucchelli et al.
(217) suggested a modication of the surgical
approach, which added coronal advancement to the
lateral movement of the pedicle ap (laterally moved
Table 2. Mean root coverage and complete root coverage (%) with laterally repositioned ap technique
Study
Flap procedure
Mean root
coverage (%)
Complete root
coverage (%)
Oles et al. (143)
Laterally repositioned ap
Not available
40.050.0
Zucchelli et al. (217)
96.0
80.0
Chambrone & Chambrone (44)
93.8
62.5
345

A
Fig. 14. Laterally moved coronally advanced ap. (A) Baseline gingival recession affecting a buccally dislocated lower
lateral incisor. The keratinized tissue mesial to the root
exposure was adequate in width and height. (B) Splitfull
split ap elevation, de-epithelialization of the receiving
bed and root treatment. (C) The ap has been coronally
advanced and the keratinized tissue secured to the de-epi-
thelialized anatomic papillae with the sling suture

anchored to the lingual cingulum. Equine-derived collagen
(gingistat) was sutured to cover the secondary intention
wound-healing donor area. (D) At 1 year of follow up.
Complete root coverage and increase in keratinized tissue
height have been accomplished. Scar tissue formed in the
donor site.
Fig. 15. Laterally moved coronally advanced ap. (A) Baseline gingival recession affecting the mesial root of an upper
rst molar. The keratinized tissue distal to the root exposure is adequate in width and height. (B) Splitfullsplit
ap elevation and de-epithelization of the receiving bed.
Note the depth of the bone dehiscence. Graft techniques

would require large withdrawal from the palate. (C) The
ap has been coronally advanced and sutured. (D) At
1 year of follow-up. Root coverage and a large increase in
keratinized tissue height have been accomplished.
coronally advanced ap) (Figs 14 and 15). In this

study, precise measurements of the keratinized tissue
lateral to the root exposure were requested: the
mesialdistal dimension was 6 mm more than the
width of the recession measured at the level of the cementoenamel junction, whilst the apicalcoronal
dimension was 3 mm more than the facial probing
pocket depth of the adjacent donor tooth. The main
surgical modications (Figs 14 and 15) consisted of
the different thickness during ap elevation; split at
the level of the surgical papillae, full in that portion of
the ap covering the avascular root surface and split
again apical to the mucogingival line; the deep and
supercial cuts of the muscle insertions to permit
coronal advancement of the ap; the de-epithelialization of the anatomical papillae to provide coronal
anchorage to the surgical papillae of the ap; and the
coronal sling suture anchored to the palatal cingulum
of the treated tooth. This technique resulted in a very
high mean percentage of root coverage (96%), and
complete root coverage was accomplished in the
great majority (80%) of patients treated. A recent
24-month study (44) assessed the clinical results

obtained with full-thickness laterally positioned ap
and citric acid root conditioning for the treatment of
localized gingival recession; the mean percentage of
root coverage was 94% and complete root coverage
was 63%. The laterally moved coronally advanced ap
is mainly indicated for the treatment of deep single
type gingival recession defects affecting a lower incisor (Fig. 14) or the mesial root of the upper rst molar
(Fig. 15). In the latter case the presence of very deep
bone dehiscence must be expected. Graft techniques
would require withdrawal of a very large (in apical
coronal dimension and thickness) amount of tissue
from the palate, with an unpleasant postoperative
course for patients.
346
Regenerative procedures
Barrier membranes
Guided tissue regeneration with resorbable and nonresorbable membranes has been used for the treatment of gingival recessions. This procedure has been
shown to offer a predictable modality for root coverage (158, 188, 189), especially in deep recessions,
resulting in the regeneration of new connective tissue
attachment and bone. The root coverage obtained by
polytetraethylene membranes or bioresorbable membranes ranges from 54% to 87% (with a mean of 74%).
However, the use of the membrane technique also
resulted in several problems such as membrane exposure and contamination, technical difculties in placing the barrier and possible damage of the newly
formed tissue as a result of membrane removal or
absorption. Furthermore, recent literature (36, 48,
124) shows that the use of a barrier membrane, in
conjunction with a coronally advanced ap, does not
improve the result of the coronally advanced ap
alone in terms of complete root coverage and recession reduction. At present, the use of a barrier membrane for root coverage procedures appears to be
inadvisable, especially considering the high incidence
of complications (i.e. membrane exposure) (11, 102,
116, 187, 194).
Enamel matrix derivate
Enamel matrix derivative, in combination with a coronally advanced ap, was introduced to treat gingival
recession (135) with the double objective of enhancing root coverage results and inducing periodontal
regeneration (59). Recent literature reviews (36, 47,
169) showed that enamel matrix derivative, in conjunction with a coronally advanced ap, improved
the percentage of complete root coverage, increased
keratinized tissue height and provided better reduction of recession. Histological studies are contradictory, reporting either predominant attachment
consisting of collagen bers running parallel to the
root surface without new cementum or Sharpeys
bers (39) and with new bone and new cementum
forming only in the most apical portion of root surface, or periodontal regeneration with connective tissue attachment, new bone and new cementum (127,
165). The true clinical rationale to choose this
approach with respect to the coronally advanced ap
alone or other techniques is unclear; thus, routine
use of enamel matrix derivative associated with a coronally advanced ap is not recommended. One may
speculate that the application of enamel matrix derivative during mucogingival surgery may be recommended in situations in which a wider extension of
new attachment formation between the soft tissue
and the root surface could be of clinical relevance.
This may be a result of the size of root exposure (a
very wide and deep recession defect), or the tooth
position (buccally dislocated root) or a concomitant
buccolingual attachment and bone loss (see histological healing after root coverage surgery). Clinical
and histological studies are advocated to conrm
such a hypothesis.
Free soft-graft procedures

Epithelialized graft
The free gingival graft is the most widely used surgical
technique for increasing the width of attached gingiva. Nevertheless, several authors (20, 23, 151, 166)
observed a low degree of predictability of favorable
results with this technique in the coverage of exposed
root surfaces. In fact, a portion of the graft placed on
the denuded root surface does not receive an adequate blood supply, with consequent partial necrosis
of the grafted tissue. The literature on free gingival
grafts is contradictory and reports percentages of root
coverage ranging from 11% to 100% (22, 27, 96, 100,
101, 123125, 130, 133, 145, 176, 190). This variation
may be attributed to differences in the severity of the
gingival lesion and in surgical techniques. Nowadays,
free autogenous gingival grafts are the last resort
when the main goal is root coverage or particularly to
meet the esthetic demands of patients. An unfavorable esthetic outcome is related to incomplete root
coverage, the white-scar appearance of the grafted
tissue that contrasts with the adjacent soft tissues and
the malalignment of the mucogingival line. Free gingival grafts can still be used when the main goal of
the surgical procedure is to augment keratinized tissue height (especially in mandibular incisors without
attached gingiva and with aberrant frenuli), the thickness of gingival tissue and the vestibulum depth.
When used for root coverage purposes (Fig. 16), the
graft should be sutured coronally to the cemento
enamel junction (to compensate for soft-tissue
shrinkage); its thickness should be >1 mm (to
increase root coverage predictability) (3, 190); and it
should be adapted to the convexity of the crown (to
minimize coagulum exposure and destabilization).
The free gingival graft is contraindicated in patients
with esthetic demands, in deep and wide recession
defects and in the presence of deep facial probing
pockets associated with gingival recession. Free
autogenous gingival grafts can be used as the rst surgical procedure in the two-stage technique described
by Bernimoulin et al. in 1975 (20). This consists of a
rst stage of surgery, in which a free gingival graft is
performed to increase the keratinized tissue height
apical to the gingival recession, and a second stage in
which the grafted tissue is coronally advanced to
cover the exposed root surface (Fig. 17). A mean per-
347

A
Fig. 16. Free gingival graft for root coverage. (A) Shallow
gingival recession affecting a lower incisor with absence of
keratinized tissue apical to the exposed root. (B) Suture of
the graft. Two coronal interrupted sutures are used to
anchor the graft to the base of the papillae. Two apical
interrupted sutures stabilize the graft to the periosteum
and adjacent soft tissue. A compressive horizontal mattress suture is anchored to the periosteum apical to the
graft and suspended around the lingual cingulum. (C) The

thickness of the graft must exceed 1 mm. No space should
be left between the graft and the convexity of the tooth
crown. (D) At 1 year of follow up. Complete root coverage
and a signicant increase in keratinized tissue height have
been accomplished. Note the difference in color between
the grafted area and the adjacent soft tissue, and the malalignment of the mucogingival line.
Fig. 17. Two-stage surgical technique for root coverage.

(A) A free gingival graft was positioned apical to a deep
gingival recession defect affecting a lower central incisor;
the image shows the graft after 3 months of healing. Note
that the mesialdistal length of the graft has been extended
in order to improve the quality/quantity of keratinized tissue of the adjacent central incisor. (B) Second-stage coronally advanced surgery: the grafted tissue has been
elevated; only the root of the affected tooth has been
mechanically treated and the receiving bed has been deepithelized. (C) The grafted tissue has been coronally
advanced and sutured with interrupted sutures along the
vertical-releasing incisions and a double sling suture has
been anchored to the lingual cinguli of the treated teeth.
(D) One year of follow up. Root coverage and an increase
in keratinized tissue height have been accomplished in
both teeth. Note the difference in color between the grafted
area and the adjacent soft tissue.
centage of root coverage ranging from 65% (31, 123)

to 72% (155) was reported for the two-stage
technique. This procedure is not well accepted by the
patient because of the two surgical stages. However,

there could be a combination of unfavorable
conditions at the tooth with gingival recession that
348
render this technique as indispensable: the lack of

keratinized tissue apical and/or lateral to the root
exposure; gingival cleft extending beyond the mucogingival line; and the presence of a shallow vestibulum depth. A recent case report (220) introduced a
modied two-stage surgical procedure aiming to
improve the esthetic outcome and reduce the
patients morbidity. The main modication of the
rst stage of surgery consisted of harvesting a free
gingival graft of the same height as the keratinized
width of the adjacent teeth and suturing it on the
periosteum apical to the bone dehiscence. During the
second stage of surgery the coronal advancement of
the grafted tissue led to root coverage and realignment of the mucogingival line. Zucchelli and De
Sanctis (220) showed that by minimizing the apical
coronal dimension of the free graft and standardizing
the surgical techniques, successful results (in terms of
root coverage, increase in keratinized tissue and
achieving a color similar to that of the adjacent soft
tissues) could be obtained in the treatment of gingival
recessions characterized by local conditions, which
otherwise preclude, or render unpredictable, the use
of one-step root coverage surgical techniques. Randomized controlled studies are advocated to test the
efcacy and predictability of the two-stage root coverage surgical technique.
Subepithelial connective tissue graft (bilaminar
technique)
The recent literature indicates the bilaminar techniques as the most predictable root coverage surgical
procedures (36, 4749, 51, 141, 169, 205). The biological rationale for these techniques is to provide the
graft with an increased blood supply from the covering ap. This will increase the survival of the graft
above the avascular root surface (112) and improve
the esthetic outcome by hiding, partially or completely, the white-scar appearance of the grated tissue. The mean percentage and the percentage of
complete root coverage in the articles of the systematic review of Cairo et al. (36) are summarized in
Table 3. During the last two decades clinicians have
introduced several modications to the original bilaminar technique described (163), resulting in more
predictable outcomes, in terms of root coverage, and
greater esthetic satisfaction for patients. These modications were related to the type of graft (partially or
completely de-epithelialized) harvested from the palate and to the design (envelope type or with a vertical
releasing incision) of the covering ap. Some authors
used an envelope ap (8, 163) or a repositioned ap
(112) to partially cover epithelial connective tissue
grafts. Others utilized coronally advanced aps, with

(137, 204) or without (29) vertical releasing incisions,
or a laterally moved papillae ap (92) to cover
connective tissue grafts. In all surgical approaches
reported, the size of the graft exceeded that of the
bone dehiscence and it was positioned (and sutured)
at the level of, or mainly coronal to, the cemento
enamel junction. Although root coverage became
increasingly more predictable, the esthetic appearance of the surgically treated area was often different
from that of the adjacent soft tissues. This was caused
by the chromatic difference between the uncovered
epithelialized portion of the graft and the adjacent
soft tissues (8, 112, 163), the dischromy associated
with partial exposure of the connective tissue graft as
a result of early dehiscence of the covering ap (29,
137, 204), or the difference in thickness between the
grafted area and adjacent soft tissues. More recently,
in a comparative study by Zucchelli et al. (216), a further modied approach was proposed to improve the
esthetic outcome of the bilaminar root coverage procedure (Fig. 18). The main surgical modications
related to the size and positioning of the connective
tissue graft: the apicocoronal dimension of the graft
was equal to the depth of the bone dehiscence (measured from the cementoenamel junction to the most
apical extension of the buccal bone crest) minus the
preoperative height of keratinized tissue apical to the
recession defect. The thickness of the graft was
<1 mm. The connective tissue graft was positioned
apical to the cementoenamel junction at a distance
equal to the height of keratinized tissue originally
present apical to the root exposure. This approach
was able to improve patient esthetic satisfaction and
postoperative course (as a result of the lower dimension of the withdrawal), whereas no difference in
terms of root coverage outcomes (mean percentage
and percentage of complete root coverage) were
reported with respect to a more traditional approach.
The successful root coverage outcome of this
approach could be explained by the capacity of connective tissue grafts to reduce the apical relapse of
the coronally positioned gingival margin during the
healing phase of the coronally advanced ap procedure (153). The main indications for the use of a bilaminar root coverage surgical technique are gingival
recession in patients with a high esthetic demand in
whom the coronally advanced ap is contraindicated
as a result of the absence/inadequacy of keratinized
tissue apical to the root exposure; gingival recession
associated with deep root abrasion, root prominence
and root pigmentation (a dark/orange root surface);
and gingival recession associated with prosthetic
349
Table 3. Mean root coverage and complete root coverage (%) with subepithelial connective tissue graft plus coronally
advanced ap technique
Study
Flap procedure
Mean root
coverage (%)
Complete root
coverage (%)
Zucchelli et al. (216)

plus coronally advanced ap
80.0
97.0
da Silva et al. (54)

75.3
18.1
P. Cortellini (unpublished data)

76.0
Not available
Jepsen et al. (102)

86.9
Not available
Trombelli et al. (194)

81.0
Not available
Borghetti et al. (26)

76.0
28.6
Tatakis & Trombelli (186)

96.0
83.0
Romagna-Genon (170)

84.8
Not available
Wang et al. (201)

84.0
43.7
McGuire & Nunn (128)

93.8
79.0
Aichelmann-Reidy et al. (4)

74.1
Not available
Paolantonio et al. (146)

88.8
46.6
Tal et al. (185)

88.7
42.8
Joly et al. (104)

79.5
Not available
Wilson et al. (210)

64.4
Not available
crowns or implants. Contradictions for the bilaminar

techniques are those anatomic situations limiting the
possibility to perform pedicle covering aps (marginal frenuli, high muscle pull, gingival cleft extending
in alveolar mucosa and a very shallow vestibulum
depth), especially when these unfavorable conditions,
in fact, occur more frequently in the lower incisions
zone.
Connective tissue graft-harvesting procedures
Different connective tissue graft-harvesting procedures, with the purpose of achieving primary intention palatal wound healing, have been described in
the literature: the most common are the trap-door
procedures (60) and the envelope techniques with
single (99, 118) or double (29) incisions. These procedures have the following common characteristics:
350
a primary split-thickness access ap elevation; the

withdrawal of connective tissue graft; and complete
closure of the palatal wound with the access ap.
The primary objective of these techniques is to
reduce patient morbidity by obtaining primary closure of the wound and primary intention healing;
however, they need an adequate thickness of the
palatal bromucosa to avoid desquamation of the
undermined supercial ap as a result of compromised vascularization (60, 101, 112). The free gingival graft surgical wound heals by secondary
intention within 24 weeks (67) and has been consistently associated with greater discomfort for the
patient as a result of postoperative pain and/or
bleeding (58, 67, 101). However, this technique is
easy to perform and can be utilized even in the
presence of a thin palatal bromucosa.

A
Fig. 18. Bilaminar technique for root coverage. (A) Gingival recession affecting a buccally prominent upper canine
(lateral view). (B) A small (<1 mm) height of probable keratinized tissue remained apical to the exposed root. The
root prominence and the inadequacy of the remaining keratinized tissue suggest that a connective tissue graft should
be added to the coronally advanced ap. (C) The graft covered the bone dehiscence and is sutured slightly apical to
the cementoenamel junction. The papillae coronal to the
graft are de-epithelized and provide anchorage to the surgical papillae of the covering ap. (D) The trapezoidal ap
is coronally advanced to completely cover the graft. The

sling coronal suture was anchored to the palatal cingulum
to permit precise adaptation between the keratinized tissue of the ap and the convexity of the tooth crown. (E)
One year of follow up. Complete root coverage has been
achieved. The keratinized tissue remaining apical to the
root exposure characterizes the new soft-tissue margin.
There was no sign of graft exposure. (F) The lateral view
showed the increase in buccal soft-tissue thickness. A good
tooth-emergence prole has been achieved despite the
prominence of the root.
The evidence in the literature evaluating differences in patient outcomes and morbidity following
use of the connective tissue graft and free gingival
graft for root coverage procedures, is minimal. A few
prospective comparative studies (58, 80, 207) reported
poorer patient outcomes, specically a greater incidence of postoperative pain, for free gingival grafts
compared with connective tissue graft procedures.
Recently, a clinical randomized controlled study (223)
was performed to compare the postoperative morbidity and root coverage outcomes in patients treated
with trap-door connective tissue (control group) and
epithelialized (test group) graft-harvesting techniques
for the treatment of gingival recession using the bilaminar procedure. In the test group the connective tissue graft was obtained after de-epithelialization of
the epithelialized graft with a scalpel blade. No statistically signicant differences in painkiller consumption, postoperative discomfort and bleeding
(recorded using the visual analog scale) were found
between the two groups. By contrast, necrosis of the
primary ap in the control patients resulted in a sixfold increase of the intake of anti-inammatory
drugs. The reasons for the lack of differences between
the two patient groups are open to speculation; however, a possible explanation may be found in the surgical techniques and, in particular, in the reduced
dimensions of the graft or in the protection of the
wound area with equine-derived collagen in the test
group. At present, study data demonstrate that the
height (the apicalcoronal dimension) and depth of
the harvesting graft, but not the type (primary
compared with secondary) of palatal wound healing
inuence postoperative analgesic consumption. The

results of the study also indicate that both types of
connective tissue graft can be successfully used under
a coronally advanced ap to cover gingival recession,
with no statistically signicant difference in root
coverage outcomes between the grafts. One year
post-treatment, 92% of the control gingival defects
and 97% of the test gingival recessions were covered
with the soft tissue. Furthermore, complete root
coverage was achieved in 70% of the controls and in
85% of the test subjects. The only statistically signicant difference in the clinical outcomes between the
two treatment groups was the greater increase in
gingival thickness in the patients treated with the
de-epithelialized graft. Any attempt to explain this
difference is speculative in nature, but it may be
related to the better quality (greater stability and less
shrinkage) of the more supercial connective tissue
resulting from the de-epithelialization of a free gingival graft with respect to the deeper connective tissue
harvested using the trap-door approach (223).
Surgical procedures for multiple

recession defects
Gingival recession is rarely localized to a single tooth,
and no reports are available on the prevalence of single recession defects compared with multiple recession defects; nevertheless, clinical experience
indicates a greater incidence of multiple gingival
recessions (219). In the presence of multiple defects,
the attempt to reduce the number of surgeries and
intraoral surgical sites, together with the need to sat-
351
isfy the patients esthetic demands, must always be

taken into consideration. Thus, when multiple recessions affect adjacent teeth they should be treated at
the same time and, if possible, the removal of soft tissue from distant areas of the mouth (palate) should
be minimized to reduce patient discomfort (46).
To date, extensive evidence reports positive outcomes following the use of root coverage procedures
in the treatment of localized gingival recessions (36,
48), whilst few studies are currently available reporting the outcomes for the treatment of multiple gingival recessions (46, 154, 218, 222). The coronally
advanced ap for multiple recessions was introduced
by Zucchelli & De Sanctis (219) as a novel approach
to treat more than two adjacent teeth with gingival
recession. This technique (Fig. 19) comprises an
envelope type of ap (with no vertical releasing incisions); an innovative ap design that anticipates the
rotational movement of the surgical papillae during
the coronal advancement of the ap; a split (at the
level of the surgical papillae) full (at the soft tissue
apical to the root exposure) split (apical to bone
exposure) approach during ap elevation; a double
incision (one to dissect muscle insertions from the
periosteum and the other to cut muscle from the
inner connective tissue lining the mucosa of the ap)
to permit coronal advancement of the ap; the
de-epithelization of the anatomic papillae; and a various number of sling sutures anchored to the palatal
cingulum of the treated teeth. This case series reported

97.1 5.1% mean root coverage and 88.6 20.3%
complete root coverage (219). A long-term study
(5 years) (218) conducted by the same authors
reported stability of the successful outcomes obtained
at 1 year of evaluation: 94% of the root surfaces initially exposed by gingival recession were still covered
with soft tissue and 85% of the treated recession
defects showed complete coverage (218).
A recent systematic review (46) evaluated the
results obtained with different root-coverage procedures in the treatment of multiple recession type
defects; only four studies were included in this paper:
coronally advanced ap (218); coronally advanced
ap plus subepithelial connective tissue (42, 45); and
subepithelial connective ap with a modied coronally advanced ap (40). A mean percentage of root
coverage of 96% was reported, with 73% of complete
root coverage. The authors concluded that all the
periodontal plastic surgery procedures evaluated (i.e.
a coronally advanced ap, either alone or in combination with a subepithelial connective tissue graft)
led to improvements in recession depth, clinical
attachment level and width of keratinized tissue; further multicenter studies may be required to increase
the number of patients and to achieve adequate
statistical power.
A recent randomized clinical trial comparing coronally advanced ap, with or without vertical releasing
Fig. 19. Coronally advanced ap for multiple gingival

recessions. (A) Multiple gingival recessions affecting the
anterior teeth in a patient with esthetic demands. Coronally advanced ap surgeries, in the right and left upper
sides, were performed. (B) Baseline clinical situation in the
rst quadrant. (C) An envelope ap from the central incisor to the rst molar was elevated using a splitfullsplit
approach. The papillae are de-epithelialized. (D) The ap
was anchored coronal to the cementoenamel junctions of
352
all teeth present in the ap design using sling sutures

anchored to the palatal cinguli. (E) One year of follow up.
Complete root coverage has been achieved in all treated
teeth. An increase in the height of the buccal keratinized
tissue can be observed. (F) One year after the same coronally advanced ap treatment of the gingival recessions
affecting teeth of the second quadrant. Complete root
coverage and good esthetic outcome were achieved in all
treated teeth.
of multiple recessions (40, 45) and only two longterm studies have been published (155, 225). This
trial compared the clinical outcomes of coronally
advanced ap alone with those of coronally
advanced ap plus connective tissue graft in the
treatment of multiple gingival recessions with
5 years of follow-up. Six months after surgery, no
statistically signicant difference between coronally
advanced aps plus connective tissue grafts and
coronally advanced aps alone was reported in
terms of recession reduction and complete root coverage. A different trend was noted over time at the
6-month and 5-year follow-up time points. A slight
coronal shift of the gingival margin occurred in the
coronally advanced ap plus connective tissue graft,
whilst a slight apical shrinkage of the margin was
observed in the coronally advanced ap group
(154). The progressive coronal improvement of the
gingival margin level and the increased percentage
of sites with complete root coverage observed at
5 years in the sites treated with coronally advanced
ap plus connective tissue graft were explained with
the creeping attachment effect over time (124).
According to the authors, this effect was facilitated
by the thick gingival tissue obtained after healing of
the connective tissue graft (154). Conversely, the
apical shift of the gingival margin of the coronally
advanced ap-treated sites at 5 years was ascribed
to the lower thickness/amount of keratinized tissue
achieved (36), leading to possible apical relapse of
incisions, for the treatment of multiple recession, did

not report differences in terms of the mean percentage of root coverage between both approaches (222).
However, the envelope type of coronally advanced
ap was associated with an increased probability of
achieving complete root coverage and with a greater
increase of buccal keratinized tissue height. Patient
satisfaction with esthetics (overall satisfaction, color
match and amount of root coverage) was very high
for both treatments, with no signicant difference
observed between them; better results, in terms of
postoperative healing and esthetic evaluation, as
judged by an independent expert periodontist, were
obtained for patients treated with the envelope type
of coronally advanced ap. Keloids, which may form
along the vertical releasing incisions, were responsible for the worst esthetic evaluation made by the
expert periodontist (222).
The coronally advanced ap for multiple gingival
recessions should not be considered only as a root
coverage surgical procedure but also as a covering
ap for connective tissue grafts (subepithelial connective tissue graft) should the keratinized band of
tissue apical to the root exposure for root coverage
be absent or inadequate (Fig. 20). This inadequacy
may be a result of the small height and/or thickness
of the keratinized tissue itself or the presence of
deep root abrasion (221) or root prominence. Very
little data are available on the effectiveness of subepithelial connective tissue grafts in the treatment
Fig. 20. Coronally advanced ap plus connective tissue

graft for multiple gingival recessions. (A) Multiple gingival
recessions in a patient with esthetic demands. (B) An envelope ap from the central incisor to the rst molar was elevated using a splitfullsplit approach. A de-epithelized
connective tissue graft was sutured at the level of the
canine and rst premolar, teeth with smaller amounts of
residual buccal keratinized tissue. (C) The ap was
anchored coronal to the cementoenamel junctions of all
teeth present in the ap design using sling sutures

anchored to the palatal cinguli. (D) One year of follow up.
Complete root coverage has been achieved in all treated
teeth. An increase in the height of the buccal keratinized
tissue can be observed in all treated teeth. The increase in
soft-tissue thickess was greater for the teeth treated with
the adjunct of connective tissue graft. There was no sign of
graft exposure.
353
the gingival margin during the maintenance phase.

These data underline, to an even greater extent, the
importance of renewing (refreshing) patient motivation for plaque control and an atraumatic toothbrushing technique in the rst year(s) postsurgery.
Data of the study carried out by Pini Prato et al.
(154) could be interpreted as showing that the
adjunct use of connective tissue does not really
improve the surgical outcomes (until 6 months)
compared with the coronally advanced ap procedure alone, but facilitates long-term patient maintenance. A recent randomized controlled trial (225)
compared short-term (6 months and 1 year) and
long-term (5 years) clinical and esthetic outcomes
of the coronally advanced ap, with and without
connective tissue grafts, in the treatment of multiple
gingival recessions. The authors (225) showed that,
in patients with high standards of oral hygiene and
undergoing a very strict regimen of postsurgical
control visits, both techniques were effective in
reducing recession depth and achieving complete
root coverage at 6 months and 1 year, with no statistically signicant differences between these time
points. Better results, in terms of postoperative
course and color-match evaluation made by an
independent expert periodontist, were obtained in
patients treated with the coronally advanced ap
procedure. Conversely, the coronally advanced ap
plus connective tissue graft procedure was associated with an increased probability of obtaining
complete root coverage at 5 years. Further investigations are advocated.
Tunnel technique
The tunnel procedure for root coverage was introduced in 1994 and termed the supraperiosteal envelope technique (8, 9). The unique characteristic of
this procedure is that the interdental papillae are left
intact. A connective tissue graft is placed in the tunnel
and it does not need to be completely covered as long
as the dimension of the graft is sufcient to ensure
graft survival. An advantage of not covering the graft
completely is that additional keratinized tissue is
gained, whereas a disadvantage is that the exposed
tissue might not be an exact color match. Conversely,
the absence of vertical incisions has a tendency to
produce better esthetics. Probably the main advantage of the technique is the minimally invasive nature
of the surgery, which results in negligible postoperative discomfort at the recipient site. Recently, the tunnel technique was modied to include coronal
positioning of the marginal tissue, which allows complete coverage of the graft (E. P. Allen, Center for
Advanced Dental Education, Dallas, Texas; course
manual) (Fig. 21). This was accomplished by dissecting more deeply to free up the facial tissue and by lifting the papillae off the interproximal septum from
the facial and lingual aspects. These two features
allow greater coronal mobilization of the tissue margin. Successful execution of the technique requires
almost a microsurgical approach, using smaller, specially designed instruments, small sutures and a
unique suturing technique. Aroca et al. (14) tested, in
a controlled randomized split-mouth study, the ef-
Fig. 21. (A) Baseline. Multiple Miller Class 1 recessions.

(B) Use of the tunnel instrument to completely mobilize
the ap. (C) The ap was completely mobilized. Note
that a tension-free ap was obtained. (D) The palatal
connective tissue graft was placed in the tunnel and xed
with mattress and sling sutures. (E) The tunnel was
354
sutured coronally to the cementoenamel junction in

such a way that the connective tissue graft and the recession defects were completely covered. (F) At 12 months
following surgery, complete coverage of the recessions
was achieved. Courtesy of Anton Sculean (University of
Bern).
cacy of a modied tunnel plus connective tissue graft

technique in the treatment of multiple Class III gingival recessions. The data showed predictable results at
1 year (14). Recently, the same author (15), in a
split-mouth randomized controlled trial, showed the
ndings of treatment of Miller Class I and II multiple
adjacent gingival recessions with a modied coronally
advanced tunnel technique in conjunction with a
connective tissue graft. At 12 months this technique
resulted in statistically signicant improvements in
complete root coverage (85%), mean root coverage
(90 18%) and mean keratinized tissue width
(2.7 0.8 mm) compared with baseline (P < 0.05).
The favorable root coverage results of the tunnel procedure and its modication are summarized in
Table 4.
Allograft
The subepithelial connective tissue graft is a predictable and versatile technique in which a bilaminar vascular environment is created to nourish the graft.
However, harvesting the palatal area increases postoperative morbidity and is time consuming (104). The
need for a second surgical procedure to harvest donor
tissue is a disadvantage of the connective tissue graft
procedure because only a limited amount of donor
tissue is available for multiple recession defects. Thus,
there has been a desire to nd a substitute for the
autogenous donor tissue (19). As a response, acellular
dermal matrix graft has been used as a substitute for
connective tissue grafts in root coverage procedures
(Fig. 22). The acellular dermal matrix graft is a dermal
allograft processed to extract cell components and
the epidermis, whilst maintaining the collagenous
scaffolding (43). The remaining dermal layer is

washed in detergent solutions to inactivate viruses
and to reduce rejection and then is cryoprotected and
rapidly freeze dried in a proprietary process to
preserve its biochemical and structural integrity. The
allograft acts as a scaffold for the vascular endothelial
cells and broblasts to repopulate the connective tissue matrix and encourage the epithelial cells to
migrate from the adjacent tissue margins (211). The
healing process observed in the allograft is similar to
that seen in autogenous grafts (178, 183, 184). Similar
root coverage outcomes have been reported in several studies (4, 36, 48, 52, 56, 70, 95, 104, 139, 141, 146,
212) that compared coronally advanced aps plus
acellular dermal matrix grafts with coronally
advanced aps plus connective tissue grafts.
Recent systematic reviews (36, 48) did not show a
statistically signicant difference between the coronally advanced ap plus the acellular dermal matrix
graft compared with the coronally advanced ap
alone in terms of complete root coverage, recession
reduction and keratinized tissue gain, suggesting no
additional benet with the use of the acellular dermal matrix graft. Surprisingly, even the comparison
between coronally advanced ap plus acellular dermal matrix graft and coronally advanced ap plus
connective tissue graft showed no statistically signicant differences for complete root coverage and
recession reduction, even though a tendency favoring connective tissue grafts was observed for both
variables. A statistically signicant difference in gain
of keratinized tissue was detected with use of the
connective tissue graft. Furthermore, a meta-analyses of two studies (52, 212) showed large heterogeneity in recession reduction for both comparisons
Table 4. Mean root coverage and complete root coverage (%) with subepithelial connective tissue graft plus tunnel
technique
Study
Flap procedure
Mean percentage
root coverage
Mean percentage
complete root coverage
Allen (8)
Subepithelial connective tissue graft plus

tunnel technique
84.0
Not available
Zabalegui et al. (213)

tunnel technique
91.6
66.7
Tozum & Dini (191)

tunnel technique
95.0
Not available
Tozum et al. (192)

tunnel technique
96.0
Not available
Georges et al. (73)

tunnel technique
85.0
Not available
Aroca et al. (15)
Connective tissue graft plus modied

coronally advanced tunnel technique
90.0
85
355

A
Fig. 22. Coronally advanced ap for multiple gingival

recessions plus collagen matrix. (A) Multiple gingival
recessions affecting lower teeth. (B) Lateral view of the
lower incisor and canine, showing minimal height of keratinized tissue and gingival thickness. (C) An envelope ap
from the central incisor to the second premolar was elevated using a splitfullsplit approach. Collagen matrix
was applied site-specically at the level of the lateral inci-
sor and canine and sutured at the base of the de-epithelialized papillae. (D) The ap was anchored coronal to the
cementoenamel junctions of all teeth present in the ap
design using sling sutures anchored to the lingual cinguli.
(E) One year of follow up. Lateral view of the lower incisor
and canine showing an increase in gingival height and
thickness. (F) One year of follow up. Complete root coverage has been achieved in all treated teeth.
(coronally advanced ap plus acellular dermal matrix

graft vs. coronally advanced ap alone), thus indicating the possible inuence of patient-related factors,
operator skill and severity of recession on the clinical
outcomes. However, the coronally advanced ap
plus acellular dermal matrix graft gave better overall
esthetic outcomes, as reported by both clinicians
and patients, when compared blind with the coronally advanced ap plus connective tissue graft, even
though it showed less complete root coverage (4).
This nding may be related to different color
matches with adjacent tissues for the acellular dermal matrix graft and connective tissue graft, or
poorer healing for the connective tissue graft, in
which size exceeds the bone dehiscence (216). The
data from the literature on the use of acellular dermal matrix grafts for root coverage is not conclusive
and its use may be associated with ethical concerns
and risk of disease transmission.
Recently, a new collagen matrix of porcine origin
(Mucografts Prototype) has been developed. Its
intended mechanism of action is through acting as a
three-dimensional scaffold that allows the ingrowth
and repopulation of broblasts, blood vessels and
epithelium from surrounding tissues, eventually

being transformed into keratinized tissue. Only one
clinical trial investigating the use of collagen matrix is
available in the literature (174); in this trial, the
authors tested the efcacy of Mucograft to build up a
clinically sufcient width of newly formed keratinized
tissue and assessed the esthetic outcomes and postoperative morbidity in comparison with the connective tissue grafts technique. The collagen matrix,
when used as a soft-tissue substitute aiming to
increase the width of keratinized tissue or mucosa,
appears to be as effective and predictable as the connective tissue graft.
McGuire & Scheyer (129) proposed a study to test
whether the xenogeneic collagen matrix could be useful for covering recession defects compared with the
gold-standard coronally advanced ap plus connective tissue graft. The single-masked, randomized-controlled split-mouth trial showed an average of 84%
root coverage at 6 months and 89% at 1 year with collagen matrix plus coronally advanced ap; better
results were achieved with coronally advanced ap
plus connective tissue graft: 97% of root coverage at
6 months and 99% at 1 year. The authors underlined
356
that the measures, evaluated statistically, were different but balanced with subject-reported outcomes
(subjects assessments of pain/discomfort and esthetics), and that collagen matrix plus coronally advanced
ap presented an intriguing comparison with the traditional connective tissue graft gold standard. A
recent randomized controlled trial (38) evaluated the
use of a porcine collagen matrix plus coronally
advanced ap as an alternative to coronally advanced
ap plus connective tissue graft for the treatment of
gingival recessions. At 12 months, porcine collagen
matrix plus coronally advanced ap resulted in a
mean root coverage of 94% compared with a mean
root coverage of 97% for coronally advanced ap plus
connective tissue graft. From a statistical point of
view, these measures are different but, according to
the authors, the outcomes achieved by the porcine
collagen matrix plus coronally advanced ap procedure were clinically comparable with those of the coronally advanced ap plus connective tissue graft
group and similar to those expected from the coronally advanced ap plus connective tissue graft, as
stated in previous literature reviews. A recent singleblinded, randomized, controlled, split-mouth multicenter trial (103) evaluated the clinical outcomes of
the use of a xenogeneic collagen matrix (test group)
plus the coronally advanced ap or coronally
advanced ap alone in the treatment of localized
recession defects. At 6 months, root coverage (primary outcome) was 76% for test defects and 73% for
control defects (P = 0.169), with 36% of test defects
and 31% of control defects exhibiting complete root
coverage. The increase in the mean width of keratinized tissue was higher in test defects (from 1.97 to
2.90 mm) than in control defects (from 2.00 to
2.57 mm) (P = 0.036). Likewise, test sites had more
gain in gingival thickness (0.59 mm) than did control
sites (0.34 mm) (P = 0.003). Larger (3 mm) recessions (n = 35 patients) treated with collagen matrix
showed higher root coverage (72% vs. 66%, P = 0.043),
as well as more gain in keratinized tissue and gingival
thickness. The authors (103) concluded that coronally
advanced ap plus collagen matrix was not superior
with regard to root coverage, but enhanced gingival
thickness and width of keratinized tissue when compared with coronally advanced ap alone. For the
coverage of larger defects, coronally advanced ap
plus collagen matrix was more effective.
Root conditioning
Chemical root-surface conditioning using a variety of
agents has been introduced in order to detoxify,
decontaminate and demineralize the root surface,

thereby removing the smear layer and exposing the
collagenous matrix of dentin and cementum (8891).
Various acids have been used for chemical root-surface conditioning, including citric and phosphoric
acids (167), ethylenediaminetetraacetic acid (113) and
tetracycline hydrochloride (110). In an animal model,
these procedures are believed to be able to induce cementogenesis and enhance attachment by connective
tissue ingrowth and/or demineralization (71, 209).
However, in human studies, no clinical advantages
were observed (61, 120). The clinical relevance of root
conditioning with an acid agent in routine periodontal surgery is still uncertain and there is no evidence
that these products will improve root coverage
(36, 48).
Healing after root coverage

procedures
The major goal of periodontal plastic surgery is the
coverage of roots exposed by gingival recession (203).
These days, the covering of denuded roots is a predictable and effective procedure, usually with highly
esthetic results. However, the nature of the attachment between the grafted tissue and the root surface
is not well understood. A potential weakness of the
technique is that a pocket may be created where the
recession has been covered (86) A true new connective tissue attachment would be preferable to a long
junctional epithelium (86). The aim of the present
section is to summarize current knowledge about the
regenerative events following the surgical treatment
of recession defects. Specically, the character of histological healing involved will be discussed. Histological evaluation of the nature of the interface between
the newly covered root surface and overlying gingival
tissues is based on animal studies and isolated case
reports.
Animal studies
Animal studies in dogs and monkeys were undertaken as long ago as 1950, using different periodontal
plastic surgery procedures: lateral (32, 208) and coronal (77) displaced aps, coronal ap associated with
membranes (76) and connective tissue grafts were
performed to achieve root coverage in experimental
gingival recession. Similar histological and histomorphometrical ndings were reported: connective tissue
attachment (bers functionally inserted or parallel to
the root) with new bone and cementum was found in
357
about 50% of the most apical portion of the root; and

long junctional epithelium was observed in the other
50% of the most coronal root surface. Better results
were reported following guided tissue-regeneration
procedures (76), with an average of 73% of newattachment formation. As the periodontal ligament is
the source of granulation tissue capable of being
transformed into connective tissue attachment, it is
plausible that the topographic distribution along the
root exposure between connective tissue attachment
and long junctional epithelium is concentric. The
connective tissue attachment should be more peripheral and close to the periodontal ligament and the
long junctional epithelium located in the center of
the lesion. This may explain why narrow defects may
heal with a complete new-attachment formation,
whereas, in wider defects, the same area of the new
attachment fails to cover the central portion of the
defect (77). A recent randomized controlled study
(197) in minipigs evaluated the histological and
clinical outcomes of the use of a xenogeneic collagen
matrix in combination with a coronally advanced
ap in the treatment of localized Miller Class I gingival recessions. The authors showed that the matrix
was completely incorporated into the adjacent host
connective tissues in the absence of a signicant
inammatory response. The healing was characterized by the formation of new cementum and new
connective tissue attachment in the apical aspect
of the defect and by a junctional epithelium in its
most coronal third. When compared with the coronally advanced ap alone, both techniques rendered
similar clinical outcomes, although the collagen
matrix graft attained more tissue regeneration, with
a shorter epithelium and a larger new-cementum
formation (197).
Human studies
A number of human histological studies (30, 75, 93,
94, 122, 127, 149) (Table 5) have been performed on
the use of autogenous free tissue grafts or connective
tissue grafts with pedicle aps as root coverage procedures. A combination of long junctional epithelium
and connective tissue attachment was demonstrated;
the deeper the recession and the greater the patients
compliance, the larger the amount of new connective
tissue attachment with newly formed cementum and
bone that was generated. Other studies (50, 148, 198)
(Table 6) investigated the histological assessment of
new attachment following treatment of human buccal recession with a guided tissue-regeneration procedure. Higher amounts of periodontal regeneration
358
and a satisfactory percentage of root coverage were

reported.
Three studies used a combination of conventional
mucogingival surgery (connective tissue graft and
coronally advanced ap procedures) and enamel
matrix protein derivative to treat a buccal gingival
recession (39, 127, 165) (Table 7). Contradictory histological outcomes were reported. The study, by
Carnio et al. (39), reported a predominant attachment consisting of collagen bers running parallel
to the root surface without new cementum or Sharpeys ber formation. New bone and new cementum were found only in the most apical portion of
the root surface. By contrast, Rasperini et al. (165)
and McGuires and Cochran (127) studies showed
periodontal regeneration with connective tissue
attachment and new-bone and new-cementum
formation.
A human histological case series (53) comparing
connective tissue grafts and acellular dermal matrix
grafts after 6 months of healing indicated comparable
gingival attachment to the root surface (a combination of long junctional epithelium and connective tissue adhesion). The acellular dermal matrix graft
seemed well incorporated with new broblasts,
vascular elements and collagen, whilst retaining its
elastic bers throughout.
The ndings of the literature are not conclusive
and are sometimes controversial; very few studies,
mainly case reports, are available. However, within
the limits of the reported studies, it is possible to
afrm that the combination of a long junctional epithelium and connective tissue attachment is created
when gingival recessions are treated with periodontal
plastic surgical procedures. The concentric distribution between connective tissue attachment and long
junctional epithelium suggests that regenerative procedures (guided tissue regeneration or enamel matrix
derivate) could be appropriate, preferably in wide
defects or in the case of a buccally dislocated root
with larger root exposure with respect to bone position. The variability of the results in the reported
studies indicates that further histological investigations are needed.
Conclusions
The present article reviews the most recent knowledge in terms of the etiology, diagnosis, classication,
prognosis and surgical treatment of gingival recessions. The etiology of gingival recession is well
dened: toothbrushing trauma and bacterial plaque
McGuire &
2
Cochran (127)
Majzoub
et al.(122)
1.80
1.0
2.5
4.24
1.0
1.0
3.0
5.0
Not
available
1.5
0.5
3.0
10
Yes
No
No
No
Subepithelial 0.29
connective
tissue graft
Subepithelial 0.5
connective
0.0
tissue graft
Subepithelial 1.0
connective
tissue graft
Subepithelial 1.0
connective
tissue graft
Subepithelial 0.0
connective
tissue graft
0.5
1.0
1.0
1.0
1.0
1.0
Not
available
5.0
3.0
5.0
4.0
4.0
No
No
Yes
Yes
0.7
3.05.0
Yes
Yes
Yes
Yes
3.4
3.8
No
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
4.0 No
2.0
No
5.0
3.0
2.6
Goldstein
et al. (75)
8.0
2.0
0.5
0.5
4.4
1.0
Subepithelial 0.0
connective
0.5
tissue graft
5.0
Bruno &
Bowers (30)
4.0
Yes
Yes
1.0
0.0
1.0
5.0
Harris (94)
2.0
2.0
2.0
3.0
Connective
tissue graft
No
Harris (93)
0.0
Pasquinelli
(149)
2.0
Gingival Periodontal Keratinized Connective Long

New New
recession pocket
tissue
tissue
junctional
bone cementum
(mm)
depth
(mm)
(mm)
epitheliummm) (mm) (mm)
(mm)
No. of Gingival Periodontal Keratinized Notches Surgical

teeth recession pocket
tissue
technique
(mm)
depth
(mm)
(mm)
Study
6.0
Postoperative
Baseline
Table 5. Characteristics of human histological studies: connective tissue graft or subepithelial or connective tissue graft
359
360
7.0
4.0
0.0
Not
available
Yes
Yes
Guided tissue 4.0
regeneration
Guided tissue 2.0

regeneration
1.0
2.0
1.0
1.0
Not
available
3.0
McGuire &
2
Cochran (127)
2.0
1.0
6.0
6.0
1.80
(mean)
2.0
5.0
4.25
(mean)
5.0
4.0
Not
available
1.0
0.0
0.0
0.0
Yes
Yes
Yes
3.0
2.0
1.0
0.0
4.0
Coronally advanced 0.29

ap plus enamel
(mean)
matrix derivate
Subepithelial
connective tissue
graft plus enamel
matrix derivate
Subepithelial
connective tissue
graft plus enamel
matrix derivate
0.5
1.0
2.0
2.0
1.0
1.0
Not
available
4.0
5.0
4.0
4.0
3.0
Yes
Yes
2.2
Yes
No
No
Yes
No
No
No
Yes
Yes
No
No
No
Yes
1.80 Yes
0.0
Carnio
et al. (39)
1.0
Rasperini
et al. (165)
6.0

New New
recession pocket
tissue
tissue
junctional bone cementum
(mm)
depth
(mm)
(mm)
epithelium (mm) (mm)
(mm)
(mm)
5.6
Yes
2.48

tissue
technique
(mm)
depth
(mm)
(mm)
6.7
Yes
1.84
Study
No
No
No
Postoperative
5.6
2.3
3.6
Baseline
Table 7. Characteristics of human histological studies: subepithelial connective tissue graft plus enamel matrix derivate
Parma-Benfenati 1
& Tinti (148)
Not
Not
available available
Guided tissue 4.0

regeneration
Yes
Vincenzi
et al. (198)
0.0
Cortellini
et al. (50)
1.0

New New
recession pocket
tissue (mm) tissue
junctional bone cementum
(mm)
depth (mm)
(mm)
epithelium (mm) (mm)
(mm)

tissue (mm)
technique
(mm)
depth (mm)
Study
8.0
Postoperative
Baseline
Table 6. Characteristics of human histological studies: guided tissue regeneration
are the most frequent causative factors for gingival

recessions acting on an existing lack of alveolar
buccal bone that may be anatomical or acquired.
Conversely, diagnosis, prognosis and, especially, classication of gingival recession will need to be revisited on the basis of the recent ndings. Major
difculties arise when the main reference parameter
for diagnosing, measuring and evaluating the treatment outcome of gingival recession is lack of the
cementoenamel junction. This occurs quite frequently when toothbrushing trauma also creates
noncarious cervical lesions, together with gingival
recession. A criticism of Millers classication and the
prognosis of gingival recessions relates to the unclear
procedures used to ascertain the amount of soft/hard
tissue loss in the interdental area to differentiate Class
III and IV and the unclear inuence of tooth malpositioning. Until new knowledge better denes these
aspects, the use of clinical methods to predetermine
the level of root coverage is recommended, at least to
improve the patients perception of their esthetic outcome. Surgical coverage of gingival recession is very
predictable, at least for a single type of defect. The
gold standard is the bilaminar technique, which
mainly consists of a coronally advanced ap covering
a connective tissue graft because the adjunctive use
of connective tissue grafts increases the likelihood of
achieving complete root coverage, with respect to use
of the coronally advanced ap alone, especially in
long-term follow-up. Although because of the limited
dimension in single type recession defects the
adjunctive use of connective tissue grafts is quite
often indicated to improve complete root coverage
predictability, the same cannot be assumed for multiple gingival recessions. This is because of the limited
amount of tissue that can be harvested from the palate, the increased patient morbidity and the
enhanced possibility of dehiscence in the covering
ap as a result of increasing the dimension of the
connective tissue grafts. This last factor is particularly
unacceptable in patients with esthetic demands as a
result of the difference in color, texture and surface
characteristic of the exposed grafted area with respect
to the adjacent soft tissue. Studies are needed to clarify, in greater detail, which, and how many, gingival
recessions should be treated with the adjunctive use
of connective tissue grafts when treating multiple gingival recessions. In this view, the utilization of substitutes for the connective tissue grafts would be
strongly encouraged. Unfortunately, despite recent
improvements, none of the available allograft materials can be considered as a true substitute for connective tissue grafts.
One of the most important innovations in gingival

recession treatment, which has already started but
needs future development and improvement, is the
design of clinical trials with the patients outcome,
esthetics and morbidity in particular, as primary
outcome measures. This is likely to change current
success evaluation criteria and perhaps also the decisional matrix in the surgical management of gingival
recession.
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Periodontology 2000, Vol.

68, 2015, 333368

Periodontal plastic surgery

Mucogingival therapy is a general term used to

Etiology of gingival recessions

gingival recession is also found in populations with

Zucchelli & Mounssif

Fig. 1. Gingival recession and bone

Localized gingival recession may be associated with

When, during the postorthodontic retention phase,

Periodontal plastic surgery

Fig. 2. Postorthodontic gingival recession. (A) Buccal view:

retainer from canine to canine and the different axial

of epithelialization (87). Often patients use a ossing

Improper ossing techniques

Perioral and intraoral piercing

Fig. 3. Gingival cleft. (A, B) Red

Zucchelli & Mounssif

Classication, diagnosis and

Periodontal plastic surgery

selecting the most successful root-coverage surgical

Fig. 5. Criticisms of Millers classication of gingival recession. (A, B)

Zucchelli & Mounssif

attachment loss is the coronal limit of the achievable

Fig. 7. Criticisms of Millers classication of gingival recession. (A, B)

Zucchelli & Mounssif

matrix: a multicenter randomized clinical trial. J Clin

Zucchelli & Mounssif

Fig. 9. Predetermination of root coverage. (A) The ideal

line can be used as a guide for composite lengthening of

level of root coverage was located within the abrasion

teeth affected by gingival recession. This is a cause of

Indications for root coverage

Keratinized tissue augmentation

Periodontal plastic surgery

tissue, or not cover, the area affected by abrasion or

Root coverage surgical procedures

related to the patient (219). The esthetic request and

Pedicle soft tissue graft procedure for

Zucchelli & Mounssif

the splitfullsplit-thickness ap elevation (219): the

not require removal of tissue far from the tooth with

Fig. 10. Predetermination of root coverage. (A) Lateral

tissue. (D) The sling coronal suture anchored to the palatal

Periodontal plastic surgery

da Silva et al. (54)

P. Cortellini (unpublished data)

Lins et al. (116)

Modica et al. (135)

Del Pizzo et al. (59)

Spahr et al. (180)

Castellanos et al. (41)

Pilloni et al. (152)

Woodyard et al. (212)

de Queiroz Cortes et al. (56)

Huang et al. (98)

blade parallel to the bone) detached the lip muscle

for a tight coronal adaptation of the keratinized tissue