477

The Connective Tissue and Partial

Thickness Double Pedicle Graft: A
Predictable Method of Obtaining Root
Coverage*
Randall J. Harris

Obtaining predictable root coverage has been a goal of periodontal therapy for
some time. The purpose of this study is to present a technique for obtaining root coverage.
This study reports the results of 20 patients (30 defects) treated with a connective tissue
and partial thickness double pedicle graft. Root coverage of 100% was obtained in 24
of 30 defects, or 80% of the time. In all the treated defects the root coverage obtained
was to within 0.5 mm of the cemento-enamel junction. The mean percent root coverage
was 97.4%. The mean amount of exposed root surface initially was 3.6 mm. At the final
postoperative appointment the mean exposed root surface was 0.1 mm. This change
represents a net root coverage of 3.5 mm or 97.2%. The number of sites with bleeding
on probing and plaque present decreased. The esthetics, both color match and tissue
contours, were acceptable to all the patients in all cases. With this technique root coverage
can be accomplished in a predictable manner. J Periodontol 1992; 63:477-486.

Key Words: Tooth root; periodontal diseases; surgery.

Obtaining predictable root coverage of mucogingival de- of the periodontal practitioner, without requiring a number
fects has been a goal of periodontal therapy for some time. of "learning failures." Additionally, the technique should
A growing number of patients are requesting and expecting be predictable in producing a result with the following
root coverage. The desire for cosmetic dentistry will cer- characteristics:
tainly increase the demand for this service. Clinicians must 1) Root coverage to the cemento-enamel junction (CEJ) or
be ready to provide this service in a predictable manner. the height of the papilla mesial and distal to the defect; 2)
Root coverage has been shown by many practitioners and tissue tightly attached to the tooth with probing sulcus depth
researchers to be an obtainable goal.1"6 However, some of less than or equal to 2 mm; 3) no bleeding on probing;
techniques, when attempted by the clinician, produce a less 4) an "adequate" band of keratinized tissue; 5) an accept-
than acceptable result. There are many reasons for these able color match to the surrounding tissue; 6) an esthetic
failures. Strict adherence to methodology, poor case selec- tissue contour; 7) minimal pain to the patient during the
tion, improper technique selection, poor surgical technique, procedure and during the postoperative period; 8) no in-
unrealistic goals and a lack of experience in performing crease in sensitivity, preferably a decrease in sensitivity.
reconstructive periodontal plastic surgical procedures are In this article a technique, utilizing a connective tissue
potential sources of problems. and partial thickness double pedicle graft, will be presented
The techniques used to attempt root coverage include: to obtain these goals. This technique evolved from attempt-
free gingival grafts (autogenous masticatory mucosa grafts), ing to utilize various techniques now commonly used in
connective tissue grafts, and various pedicle grafts.1"8 Ex- reconstructive periodontal plastic surgery. The goal of this
amples of these pedicle grafts include: coronally positioned technique is to produce root coverage, in addition to the
flaps, laterally positioned flaps, obliquely positioned pe- other goals listed above, in a simple, predictable manner.
dicle grafts, double papilla pedicle grafts, and semilunar Miller,1 Holbrook and Ochsenbein,2 Borghetti and Gar-
pedicle grafts.7-8 Combinations of 2 or more techniques are della,5 and Ibbott et al.6 have demonstrated that root cov-
also used to attempt root coverage.8 erage can be accomplished by using free gingival grafts.
The ideal technique should be technically within the grasp The problems associated with this procedure include post-
operative pain in the palate and a color discrepancy between
*Currently, private practice, Las Vegas NV; previously, Periodontics De- the graft and the surrounding tissue. This color discrepancy
partment, Naval Dental Clinic, Orlando, FL. has been described as a "keloid-like" appearance.3-8
 J Periodontol
478 ROOT COVERAGE WITH A DOUBLE PEDICLE GRAFT May 1992

Laterally positioned grafts, coronally repositioned flaps, ticipated in this study. The age range was 18 to 41 years
and other various pedicle grafts can produce a more esthetic with a mean of 25.0 years. All defects had recession depth
result. However, these procedures are only indicated when greater than or equal to 2 mm, when measured from the

adequate donor tissue is adjacent to the defect.7'8 CEJ. The papillae, mesial and distal to the defects, showed
Edel9 has shown that connective tissue grafts can be used no signs of loss of height. By Miller's classification of
to increase the amount of keratinized tissue. The connective mucogingival defects,10 all defects were Class I or II. Class
tissue graft will induce keratinization. Utilizing these grafts III or IV defects were not included in this study.
will decrease postoperative pain. The Miller classification of marginal tissue recession is:
Langer and Langer3 reported on the use of a subepithelial Class I: Marginal tissue recession which does not extend
connective tissue graft for root coverage. The technique to the mucogingival junction. There is no periodontal loss
involved the use of a free connective tissue and epithelium (bone or soft tissue) in the interdental area. Root coverage
graft with an overlying partial thickness flap. In this tech- of 100% can be anticipated.
nique the exposed root was planed but no other treatments, Class II: Marginal tissue recession which extends to or
such as critic acid or tetracycline, were mentioned. The beyond the mucogingival junction. There is no periodontal
combined epithelium and connective tissue graft was placed loss (bone or soft tissue) in the interdental area. Root cov-
over the denuded roots and sutured to place. A partial thick- erage of 100% can be anticipated.
ness flap was then positioned coronally in a manner to cover Class III: Marginal tissue recession which extends to or
as much of the graft as possible and sutured to place. No beyond the mucogingival junction. Bone or soft tissue loss
attempt was made to completely cover the graft or the area in the interdental area is present or there is malpositioning
of the denuded root. An increase of 2 to 6 mm of root of teeth. Partial root coverage can be anticipated.
coverage was achieved in 56 cases over a 4-year period. Class IV: Marginal tissue recession which extends to or
Additionally, this technique reports less postoperative dis- beyond the mucogingival junction. The bone or soft tissue
comfort than with conventional free gingival grafts. The loss in the interdental area and/or malpositioning of the
tattoo, or "keloid-like" appearance, was much less com- teeth is so severe that root coverage cannot be anticipated.10
mon with this procedure than the free gingival graft. Oc- The teeth involved were all vital, free of restorations in
casionally, a gingivoplasty was performed to achieve more the area to be covered, and had not received periodontal
esthetic contours. surgical therapy in the past 2 years. All patients were in
Nelson4 reported on the use of a subpedicle connective good health, with no contraindications to periodontal sur-
tissue graft to obtain root coverage. This technique involved gery. The surgical procedure was thoroughly explained.
the use of a free connective tissue graft and an overlying Informed consent forms were explained and signed prior to
full thickness pedicle graft. In this technique the root was treatment.
planed to remove the outer layer of cementum and dentin. Any initial therapy deemed necessary, such as scaling
No other root preparations, such as citric acid or tetracy- and root planing or oral hygiene instruction, was generally
cline, were mentioned. When treating isolated defects, the completed prior to surgery. In some cases, it was felt that
pedicles were sutured together and then sutured over the scaling and root planing prior to surgery might result in
free connective tissue graft and the denuded root surface. excessive shrinkage of the papillae. This change of papilla
When multiple teeth were treated the pedicles were de- height could change a Class I or II defect into a Class III
signed so the interdental papillae could be transposed one defect, making 100% root coverage highly unlikely. There-
half tooth mesially. In this way the papilla would cover the fore, in some cases scaling and root planing of those defects
connective tissue graft over the denuded root surface. A was completed at the time of surgery.
total of 91% of the exposed root surface was covered with Presurgical photographs were taken (Figures 1A, 2A).
this procedure. Initial pocket depths, gingival recession depth (measured at
The difference between the articles mentioned above and the CEJ), gingival recession width (measured at the CEJ),
this article, proposing the use of connective tissue and par- and levels of keratinized tissue were recorded to the nearest
tial thickness double pedicle graft, is that this article will 0.5 mm with a standard periodontal probe. The presence
report on a practitioner's first 20 patients treated, utilizing of supragingival plaque and bleeding on probing were re-
the proposed technique. The rationale for this approach is corded in the area of the defect. The esthetic concerns of
to provide a clinician with a realistic appraisal of what the patient were recorded. Preoperative sensitivity was re-
results should be expected. Quite often it is difficult to corded on a scale of 0 to 10 (0 no sensitivity; 10
= =

accept the number of unsuccessful attempts, or "learning extreme pain). This was done by asking the patient to rate
failures," at a new procedure when attempting a different their sensitivity in the area to a 3-second stream of air from
technique. a 3-way syringe held perpendicular to the root surface and
2 cm from the defect (Table 1).
MATERIALS AND METHODS All patients received a loading dose of 2 x diflunisal,+
Twenty patients (19 male and 1 female), referred for treat-
ment of 30 isolated and multiple mucogingival defects, par- fMerck Sharp and Dohme, West Point, PA.
Volume 63
Number 5 HARRIS 479

Figure . Preoperative recession tooth #22 (patient 8). Figure IB. Incisions tooth #22 (patient 8).

Table 1. Pre- and Postoperative Clinical measures

Root Keratinized Tissue

Recess Depth Probing Depth Coverage Width Air Sensitivity
Patient Tooth Pre-op Post-op Pre-op Post-op (%) Pre-op Post-op Pre-op Post-op
1 25 3.5 0 2 1 100.0 1 6 2 0
2 24 3 0 2 1.5 100.0 1 4.5 6 1
3 24 3 0 2 2 100.0 2 5 6 0
3 25 5 0.5 2 2 90.0 2 4.5 9 0
4 21 2.5 0 3 0.5 100.0 1 6 0 0
5 20 3.5 0.5 2 1 85.7 2 3 7 1
5 21 3 0 2 1 100.0 2 3.5 5 1
6 25 3 0 2.5 1 100.0 1 5.5 2 1
7 25 3 0 2 1 100.0 7 10 2 0
8 22 3 0 2 1 100.0 1 3 3 0
9 24 4 0 2 0.5 100.0 0 4.5 4 2
9 25 3 0 2 1 100.0 1 4.5 4 2
10 26 3.5 0 2 1 100.0 3 5 4 3
11 23 4.5 0 2 0.5 100.0 1 5 3 0
11 24 5.5 0.5 2 0.5 90.9 1 5 2 0
11 25 4 0 3 0.5 100.0 1 5 4 0
12 23 3 0 2 0.5 100.0 2 4.5 1 2
12 24 2 0 1.5 0.5 100.0 2 4.5 1 2
12 25 2 0 2 1 100.0 2 4.5 0 4
13 11 3 0 2 1 100.0 1 7 2 0
14 27 7 0 3 1 100.0 0 3.5 1 1
15 21 3.5 0 3 0.5 100.0 0.5 7 2 0
16 24 3 0.5 2 0.5 83.3 1 4 1 1
16 25 5 0 3 0.5 100.0 2 4.5 1 0
17 6 4 0.5 2 0.5 87.5 2 5 2 2
18 19 5 0 2.5 1 100.0 0 3 1 3
19 5 3 0.5 2 1 83.3 2 5 0 0
19 6 3.5 0 2.5 0.5 100.0 2 5 0 0
20 12 4.5 0 2 1 100.0 1 4 0 2
20 13 2 0 2 1 100.0 2.5 4 0 0
Mean 3.6 0.1 2.2 0.9 97.4 1.6 4.8 2.5 0.9
SD* 1.1 0.2 0.4 0.4 1.2 1.4 2.3 1.1
All measurements are in mm.
*Standard deviation.

5007 mg 1 hour preoperative, then 500 mg every 8 to 12 surface was thoroughlyroot planed. The goal of this root
hours as needed for pain. After anesthesia, the exposed root planing was to remove any plaque, calculus, caries, and
 J Periodontol
480 ROOT COVERAGE WITH A DOUBLE PEDICLE GRAFT May 1992

1C. Figure IE. Pedicle flaps sutured over connective tissue graft and denuded
Figure Reflection ofpartial thickness pedicle flaps tooth #22 (patient root surface tooth #22 (patient 8).
8).

Figure IF. Postoperative 12-weeks tooth #22 (patient 8).

Figure ID. Connective tissue graft sutured into recipient site tooth #22
(patient 8).
minutes. The cotton pledget was changed approximately
"soft" root tooth structure. An attempt was made to flatten every 30 seconds. The tooth surface was rinsed with a stream
the root in areas of root prominence. Instrumentation was of water from a 3-way syringe for 10 seconds. The area
done by utilizing ultrasonic sealers, hand sealers, and cur- was then dried with air. The resulting etched surface ap-
ets. A subjective evaluation of the level of root planing peared "frosted."
revealed that all teeth were root planed to a relatively flat If there was frenum involvement in the area of the defect,
surface. The level of root planing was significantly more it was eliminated first by sharply dissecting the frenum in
pronounced than is generally done during routine root planing. the area of the defect, but only to the level required to
The root surface was then treated with a tetracycline so- eliminate the frenum pull on the gingival margin near the
lution (125 mg tetracycline/ml of sterile saline) by attempt- defect. The goal of this dissection was to eliminate the
ing to burnish, with small cotton pledgets, the tetracycline frenum involvement with as little damage as possible to the
solution into the root surface. The force applied was com- blood supply and the tissue adjacent to the defect.
parable to root planing. This root treatment was done for 3 On isolated defects, horizontal incisions were made me-
Volume 63
Number 5 HARRIS 481

Figure 24. Preoperative recession teeth #24 and #25 (patient 9). Figure 2C. Reflection ofpartial thickness pedicleflaps teeth #24 and #25
(patient 9).

Figure 2B. Incisions teeth #24 and #25 (patient 9).

Figure 2D. Connective tissue graft sutured into recipient site teeth #24
and #25 (patient 9).
sial and distal to the defect, at a level of the CEJ toward
the adjoining tooth. The incision was terminated not less
than 0.5 mm away from the gingival margin of the adjacent sure that they would remain over the defect without being
tooth. This was done to avoid creating gingival recession supported. If the pedicle flaps appeared to move with func-
on adjacent teeth. Next, vertical incisions were made per- tion, further reflection was done to free up the flaps. Any
pendicular to the horizontal incisions, starting at the ter- remaining pocket lining and tissue lags were removed. The
mination point of the horizontal incisions and extending into pedicle flaps were sutured together with 5-0 gut suture (Fig.
the alveolar mucosa. A sulcular incision was placed con- 1C).
necting the horizontal incisions (Fig. IB). Partial thickness When treating multiple recession areas the incisions were
pedicle flaps were then reflected. This was done by sharp similar, with a few modifications. The horizontal incisions
dissection as close to the periosteum as possible. The re- were extended in the interproximal regions from the CEJ
flection was carried to a level that would permit free move- of one defect to the CEJ of the next defect. They were
ment of the mesial and distal pedicle flaps. The mesial and terminated not less than 0.5 mm away from the gingival
distal pedicle flaps were placed over the defect to make margin of the teeth adjoining the teeth with the defects. At
 J Periodontol
482 ROOT COVERAGE WITH A DOUBLE PEDICLE GRAFT May 1992

Figure 2E. Pedicle flaps sutured over connective tissue graft and denuded Figure 2F. Postoperative 12-weeks tooth #24 and #25 (patient 9).
root surface teeth #24 and #25 (patient 9).

that point vertical incisions were made perpendicular to the sial-distal dimension was extended to result in a piece of
horizontal incision into the alveolar mucosa (Fig. 2B). A tissue between the parallel incisions adequate to cover the
split thickness flap was then reflected by sharp dissection recipient site. Vertical releasing incisions were used, when
as close to the periosteum as possible, similar to the isolated necessary, to provide greater access when removing the
defect. Any remaining pocket lining or tissue tags were graft. The graft was removed by incising the medial, me-
removed. Next, the interproximal tissue between the teeth sial, and distal edges between the parallel incisions. The
with defects was divided in half with a vertical incision. resulting uniform thickness piece of tissue was composed
Each half was treated as a separate pedicle flap. The pedicle of predominantly connective tissue, with an epithelial bor-
flaps from the mesial and distal of each defect were sutured der. This epithelium was then removed and discarded. Pres-
together (Fig. 2C). In doing this it was assured that blood sure was then applied, with a wet gauze, to the donor area.
flow would be available from the mesial and the distal of
all defects. Graft Knife
A connective tissue graft was then obtained from the A graft knife was used to elevate a split thickness flap by
palate. Two methods were used to obtain the connective pushing the knife, under control, distally across the palate.
tissue graft, parallel incisions and graft knife. In both meth- The flap was allowed to remain attached to the palate at its
ods, after obtaining anesthesia, the donor area was sounded distal edge. This trap door flap was retracted distally to
with a periodontal probe to be certain that there were at allow access to the connective tissue (Fig. 4A). The knife
least 3 mm of soft tissue thickness. When deciding on a was then used to elevate a connective tissue graft. This was
location, the goal was to stay away from the margin of the done by pulling the knife mesially, starting at the distal
gingiva and the palatal arteries. The donor area was usually edge of the connective tissue, under the trap door flap (Fig.
in the area palatal to the maxillary first molar to the max- 4B). After an adequate length of connective tissue was re-
illary cuspid. flected, the connective tissue graft was removed by incising
the mesial edge of the graft (Fig. 4C). The initial trap door
Parallel Incisions flap was replaced over the donor site and pressure applied
A pair of parallel incisions were made in the palate staying with a wet gauze.
at least 2 mm away from the gingival margin (Fig. 3A). In both methods the graft was inspected and trimmed, if
The goal of these incisions was to bisect the distance be- necessary. The goal was to remove as much epithelium as
tween the surface epithelium and bone of the palate while clinically possible and to inlay the connective tissue graft
into the recipient site with butt joints. The connective tissue
staying 1 to 1.5 mm apart. These incisions were extended
for 10 to 12 mm medially into the palate. To aid in making graft was sutured, with 5-0 gut suture material, at the cor-
ners of the graft to the recipient site and interproximal in
these incisions uniform throughout the entire depth of the
incision a scalpel with parallel blades* was used. The me- any multiple recession cases (Figs. ID and 2D).
The pedicle flaps were sutured with a 5-0 gut sling suture
*H & H Company, Ontario, CA. over the connective tissue graft and the original defect (Figs.
Volume 63
Number 5 HARRIS 483

Figure 3A. Parallel incisions in palate. Figure 3C. Postoperative 12-weeks donor area.

secured with piece of floss wrapped through the inter-

a
proximal of
areas the adjacent teeth. This was done to de-
crease the chances of the periodontal dressing becoming
dislodged during the early phases of healing.
All patients were placed on 0.12% Chlorhexidine glu-
conate rinse* for 4 weeks. Patients were seen at 1, 2, 4, 8
and 12 weeks for postoperative treatment. At the 1-week
postoperative appointment, the dressings and any non-re-
sorbable sutures placed in the palate were removed. At all
postoperative appointments, the involved teeth were pol-
ished and deplaqued. Plaque control instructions were given
and the necessity of excellent oral hygiene was stressed at
each appointment. During the initial 4 weeks of healing,
the incisai one-half of the crown was carefully brushed with
a soft tooth brush. Plaque control in the gingival one-half
of the tooth was accomplished with a cotton tip applicator.
Additionally, patients were instructed to lightly "comb"
the surgical area with a cotton tip applicator, twice daily,
in an apical to incisai direction. Gentle flossing was re-
Figure 3B. Sutured donor area. started as soon as possible. The patient's sensation to air,
the amount of recession, and the quantity of keratinized
IE and 2E). Light pressure was applied to the grafted area tissue were recorded in a similar manner to the preoperative
with a wet gauze for 10 to 15 seconds. recordings. Probing depths were not measured for the first
4 weeks.
The graft was usually sutured to the recipient site before
the palate was sutured to decrease the amount of time the After 12 weeks, the recession depth, recession width,
graft was without blood supply. However, the palate was probing depth, amount of keratinized tissue, presence or
sutured before the recipient site in cases where only a min- absence of supragingival plaque, bleeding on probing, and
imum number of sutures would be required to close the sensitivity to air were recorded. These final measurements
donor site (Figs. 3B and 4D). were confirmed by one or two individuals other than the

A thin layer of isobutyl cyanoacrylate dressing5 was ap- practitioner performing the surgery. Final photographs were
taken at this time (Figs. IF, 2F, 3C, and 4E). All patients
plied to the grafted area. Next, a periodontal dressing11 was were then placed on a 3-month recall maintenance schedule.
applied to the grafted area. The periodontal dressing was
Statistical analysis, utilizing a paired i-test, was done to
5Iso-Dent, Ellman International, Hewlett, NY.
"Barricaid, Dentsply, L.D. Caulk Division, Milford, DE. 'Peridex, Procter & Gamble, Cincinnati, OH.
 J Periodontol
484 ROOT COVERAGE WITH A DOUBLE PEDICLE GRAFT May 1992

Figure 4C. Graft in the process of being trimmed.

Figure 4A. Initial trap door flap retracted distally to allow access to
connective tissue.

Figure 4D. Sutured donor area.

Figure 4B. Elevation of connective tissue.

above, are presented in Table 1. The mean initial recession

determine if the surgical therapy had an effect on recession depth was 3.6 mm (range
2 to 7 mm). The final mean
depth, probing depth, width of keratinized tissue, and sen- recession depth 0.1
wasmm (range 0 to 0.5 mm). This
sitivity to air. When a patient had more than one site grafted, represents a mean root coverage of 3.5 mm, or a 97.2% of
a mean of the results was utilized. This was done to main-
total exposed root covered. This change was statistically
tain the patient as the unit of analysis. At the 0.01 level,
with 19 df, the critical value for t 2.86. Any t value
= significant (f 15.46; < 0.01). A result of 100% root
=

above that would be considered statistically significant.11 coverage was obtained in 24 of 30 sites or 80% of the time.
The mean root coverage was 97.4%. The mean recession
width decreased from 3.1 mm (range 2 to 5.5 mm) initially
RESULTS to 0.3 mm (range 0 to 2.0 mm) at the final postoperative
The results of the first 20 patients, with 30 Miller Class I appointment.
or II defects, treated with the connective tissue and partial Probing depth reduced from a mean of 2.2 mm (range
thickness double pedicle graft surgical technique described 1.5 to 3 mm) to 0.9 mm (range 0.5 to 2 mm). This change
Volume 63
Number 5 HARRIS 485

veloped adjacent to the location of the initial defect. This

was separated from the root by bound down tissue. Twelve
weeks postoperatively the area was treated with a small
pedicle flap to close the cleft.
DISCUSSION
The connective tissue and partial thickness double pedicle
graft surgical technique is proposed as an alternative to
presently available periodontal plastic surgical procedures.
The ability to produce 100% root coverage on 24 of the 30
sites (80%), in a clinician's first 20 attempts, attests to the
low number of "learning failures" with this technique. Of
the 6 defects not covered 100%, all were covered to within
0.5 mm of the CEJ. Several of the roots appeared to be
covered completely, but careful examination revealed a small
area of exposed root surface. In all cases, even those ob-
taining less than 100% root coverage, all patients viewed
the results as "clinical successes." Several of the patients
did not notice the small amount of exposed root surface
Figure 4E. Postoperative 12-weeks donor area.
until it was pointed out to them.
These root coverage results compare favorably with those
of others.15 Miller1 achieved 100% root coverage in 71 of
was statistically significant (t 8.94; < .01). In all
=
79 (90%) Class I and II defects. Additionally, Miller re-
cases the tissue was very tightly bound down. The quantity ported a 92.2% mean root coverage in these 79 defects. No
of keratinized tissue increased from a mean of 1.6 mm root coverage occurred in 4 of 79 (5%) of the defects in his
(range 0 to 7 mm) to 4.8 mm (range 3 to 10 mm). This study. Holbrook and Ochsenbein2 obtained 100% root cov-
change was statistically significant (t 11.37; < .01).
=
erage in 44% of the cases. Langer and Langer3 reported
The mean of the patient's perception of sensitivity to a increases in root coverage of 2 to 6 mm. Nelson4 achieved
stream of air initially was 2.5 (range 0 to 9) and after an average root coverage of 91% in 29 cases. His data
therapy was 0.9 (range 0 to 4). This change was statistically revealed 100% root coverage in 18 of 29 cases (62.1%).
significant (t 2.91; < .01). The sensitivity to a stream
=
Borghetti and Gardella5 reported 100% root coverage in 10
of air decreased in 18 sites (60%) and stayed the same in of 23 defects or 43.5% of the time. They reported a mean
7 sites (23.3%). Patient's sensitivity to a stream of air in- root coverage of 85.2%.
creased in 5 sites (16.7%). The change was not clinically Creeping attachment was documented by Borghetti and
significant in patients with increased sensitivity. Gardella5 for at least 1 year postoperatively when thick free
Supragingival plaque was present initially in 27, or 90%, gingival grafts were used. The creeping attachment that
of the sites. Twelve weeks postoperative 13, or 43.3%, of occurred between 1 month and 1 year was responsible for
the sites had supragingival plaque at the site in question. 28% of their total root coverage. It is unknown whether or
Bleeding on probing decreased from initially being present not the same type of creeping attachment they documented
in 28, or 93%, of the sites to 1 site, or 3.3%, at the 12- could occur in defects treated with the connective tissue
week postoperative appointment. and partial thickness double pedicle graft technique. If
Esthetic concerns were expressed preoperatively by 12 creeping attachment does occur, it may improve the results
of the 20 patients. This accounted for 20 of the 30 defects. of this study.
All were satisfied with the esthetics at the final postoper- The tissue was tightly attached to the tooth in all cases.
ative appointment. None of the sites showed the "keloid- The type of attachment present cannot be determined with-
like" appearance sometimes seen with free gingival grafts. out human histology. This information would be difficult
However, some areas did appear more bulky than the sur- to obtain because it would require the removal of a suc-
rounding tissue. A gingivoplasty was suggested to 2 pa- cessfully-treated tooth. Clinically, the tissue feels firmly
tients to improve tissue contours. Both patients stated that attached and resists probing. The mean probing sulcus depth,
they were satisfied with the esthetics and did not feel a 12 weeks postoperative, was 0.9 mm with no bleeding on
gingivoplasty was necessary. In a few cases the alveolar probing in all areas except 1 site. These findings are com-
mucosa appeared to cover a portion of the grafted area. In patible with a healthy attachment to the tooth.
one case a partial thickness reflection of alveolar mucosa The band of keratinized tissue was determined to be ad-
was done 12 weeks postoperatively to reveal more bound equate in all cases. The color match and tissue contour were
down tissue. Additionally, in one case a gingival cleft de- acceptable to the patient in all cases. In some cases the
 J Periodontol
486 ROOT COVERAGE WITH A DOUBLE PEDICLE GRAFT May 1992

color match and tissue contour match were good enough to other patient (18) stated that the initial surgery never re-
make it difficult to determine the location of the original sulted in any root coverage. In both cases, the patients were
defect. This was not true in all cases. The tissue contours very pleased with the results of this surgical therapy.
seemed to be more esthetically pleasing in those cases where Predictable root coverage is an obtainable goal. The method
a thinner connective tissue graft was used. described in this article, utilizing a connective tissue and
Pain during the procedure and postoperatively was gen- partial thickness double pedicle graft, will produce the de-
erally described as minimal. In no cases were analgesics sired results from early efforts without an extensive learning
other than diflunisal required. The only postoperative prob- curve. While the functional aspects of root coverage may
lems requiring unscheduled appointments related to the do- be controversial, the cosmetic aspect and patient satisfac-
nor areas in the palate. One patient reported eating a hard tion is not debatable. Predictable root coverage is a reality.
item which caused the palate to bleed. This was easily
managed by applying pressure to the area. A surgical stint Acknowledgments
was then constructed and the patient had no further prob-
The author would like to thank Claudia Lanktree and Terry
lems. Additionally, some of the first patients reported pal- Hart for their outstanding assistance in the clinical phase of
atal pain when eating. To alleviate this problem a palatal this study. I would also like to thank Linda Harris, my
stint was constructed for most later patients. It may be
wife, for her never-ending help and support. The author
advisable to consider the use of surgical stints when the
clinician feels they are indicated. Most patients reported
developed the scalpel with parallel blades used in this study
and at some future time may have a financial interest in
minimal discomfort and complications when using a palatal this instrument. The views expressed in this article are those
stint. However, 1 patient reported preferring not to use the of the author and do not reflect the official policy or position
stint, even in the early stages of healing. The healing of of the Department of the Navy, Department of Defense or
the palate appeared to be more rapid, with less chance of the United States Government.
tissue sloughing, when the parallel incision method was
used to obtain the connective tissue graft, rather than the
REFERENCES
graft knife method. 1. Miller PD. Root coverage using the free tissue autograft citric acid
There was concern that the use of thorough root planing
application. III. A successful and predictable procedure in deep-wide
and tetracycline treatment of the root could cause an in- recession. Int JPeriodontics Restorative Dent 1985;5(2):15.
crease in sensitivity. Quite the opposite was seen, and there 2. Holbrook , Ochsenbein C. Complete coverage of the denuded root
appeared to be an overall reduction in patient sensitivity. surface with a one stage gingival graft. Int J Periodontics Restorative
This was probably due to the amount of root coverage. Dent 1983;3(3):9.
3. Langer , Langer L. Subepithelial connective tissue graft technique
Sensitivity to air decreased in 18 defects and stayed the for root coverage. J Periodontol 1985;56:715.
same in 7 defects. Some patients reported being able to eat 4. Nelson S. The subpedicle connective tissue graft, a bilaminar recon-
certain cold foods, such as ice cream, comfortably for the structive procedure for the coverage of denuded root surfaces. J Per-
first time. Having patients rate their sensitivity to a stream iodontol 1987;58:95.
5. Borghetti A, Gardella J. Thick gingival autograft for the coverage of
of air from a 3-way syringe proved a very simple and useful
gingival recession: A clinical evaluation. Int J Periodontics Restor-
procedure in a clinical setting. ative Dent 1990;10:217.
In all cases patients expressed pleasure at the results and 6. Ibbott C, Oles R, Laverty W. Effects of citric acid on autogenous
said they would repeat the procedure to get the results ob- free graft coverage of localized recession. /Periodontol 1985;56:662.
tained. Several patients had been offered gingival grafts to 7. de Waal H, Kon S, Ruben M. The laterally positioned flap. Dent
Clin Amer 1988;32:267.
augment the amount of keratinized tissue, to "prevent fur- 8. American Academy of Periodontology. Proceedings of the World
ther recession." But they did not feel that this adequately
Workshop in Periodontics. American Academy of Periodontology:
addressed their concerns. Some had been told that treatment Chicago, IL.; 1989.; VII-l-VlI 21.
of their exposed roots was possible, but it was never sched- 9. Edel A. Clinical evaluation of free connective tissue grafts used to
uled due to a variety of reasons. More than 2 years previ- increase the width of keratinized gingiva. / Clin Periodontol 1974; 1:185.
10. Miller PD. A classification of marginal tissue recession. Int J Per-
ously, 2 patients had free gingival grafts in an attempt to iodontics Restorative Dent 1985;5(2):9.
obtain root coverage (patients 7 and 18). One patient (7) 11. Spence J, Cotton J, Underwood B, Duncan C. Elementary Statistics.
felt the graft was disappearing with time. He reported that Englewood Cliffs, NJ: Prentice-Hall Inc.; 1983;145-195.
the recession was similar to presurgical levels. There was
an adequate width of keratinized tissue, 7 mm, but the Send reprint requests to: Dr. Randall Harris, 824 E. Sahara Ave., Las
tissue was very thin. The relative thinness of the tissue is Vegas, NV 89104.
why a coronally positioned flap was not attempted. The Accepted for publication December 3, 1991.