PRACTICAL APPLICATIONS

Decision Making in Gingival Recession Treatment: Scientific Evidence and

Clinical Experience
Giulio Rasperini,* Raffaele Acunzo,* Enrico Limiroli*

The ultimate goal of root coverage procedures should be

Focused Clinical Question: What are the key complete coverage of the recession defect with a pleasing
considerations for selecting the best surgical approach color and tissue blend between the treated area and adja-
in mucogingival plastic surgery?
cent tissues, thereby achieving both biologic and esthetic
Summary: Treatment of gingival recession has
success. Thus, it is important to select the most predictable
become an important therapeutic issue due to the in-
creasing number of cosmetic requests from patients. and easy-to-perform surgical technique according to a care-
The dual goals of mucogingival treatment include com- ful evaluation of the following factors:
plete root coverage, up to the cemento-enamel junc- 1. Patient;
tion, and blending of tissue color between the treated 2. Single or multiple gingival recession defects;
area and non-treated adjacent tissues. Even though 3. Mucogingival defects localized in esthetically or non-
the connective tissue graft is commonly considered esthetic sensitive sites;
the "gold standard" for treatment of recession defects,
it may not always be the best surgical option for every 4. Defect anatomic morphology (amount of keratinized
case. tissue, periodontal biotype, and vestibule depth);
Conclusions: Under non-experimental condi- 5. Ability to enhance periodontal wound healing and sta-
tions, all root coverage procedures may be effective in bilize the flap with optimal suture technique;
terms of complete root coverage and excellent esthetics. 6. Biomaterials (connective tissue graft [CTG], enamel
Careful analyses of patient- and defect-related factors, matrix derivative, acellular dermal matrix).
however, are key considerations prior to selecting an ap-
propriate surgical technique. Clin Adv Periodontics
2011;1:41-52. Factors Affecting Complete Root
Key Words: Connective tissue graft(s); gingival recession; Coverage
mucogingival surgery; periodontitis; plastic surgery,
periodontal. Miller Class
Miller’s classification5 is based on morphologic evaluation
of the injured periodontal tissue, giving the diagnosis of the
severity of gingival lesions and the prognostic evaluation of
the treatment. According to this classification system,
which is still the most widely used, the loss of interproximal
Background bone (Class III and IV) is identified as a condition involved
In periodontal practice, root coverage requires daily in preventing CRC.
clinical decisions. Randomized clinical trials support the
potential clinical value of all proposed mucogingival
plastic surgery techniques, both in terms of mean (MRC) Post-Surgical Position of Gingival Margin (GM)
and complete root coverage (CRC), but fail to demon- Soft tissue healing pattern after root coverage procedures
strate a clear superiority of any of the tested surgical is usually linked to a shrinkage of the surgical wound. The
procedures.1,2 In addition, the clinical trials do not location of the GM relative to the cemento-enamel junc-
provide clear guidance on when to use the different tion (CEJ) after the surgery seems to affect the proba-
procedures. bility of CRC;6 the more coronal the GM after suturing,
While concerns about facial appearance have obsessed the greater the probability of achieving CRC. A coronal
humans for centuries, the systematic assessment of esthetic displacement of 2 mm of the GM relative to the CEJ is
outcomes after surgical treatment of gingival recession is suggested.
a relatively recent proposal.3,4
Flap Tension
*Unit of Periodontology, Dental Clinic, Department of Surgical, Enhanced periodontal wound healing is one of the most im-
Reconstructive and Diagnostic Science, Foundation IRCCS, Ca’ Granda portant issues for the clinical success of root coverage pro-
Policlinico, University of Milan, Milan, Italy. cedures. Even considering the different abilities of various
surgeons in tissue management, attention to blood supply
Submitted December 9, 2010; accepted for publication February 1, 2011
and suturing technique may influence the clinical outcome.
doi: 10.1902/cap.2011.100002 In particular, the use of surgical approaches that make the

Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 41

P R A C T I C A L A P P L I C A T I O N S

flap passive plays a major role in enhancing an optimal Cemento-Enamel Junction Predetermination
wound healing to achieve an adequate coronal displace- CRC is not always achievable, even in gingival recession
ment of the flap. Pini Prato et al.7 showed that the greater with no loss of interproximal attachment and bone. The
the flap tension (suggested flap tension should not exceed CEJ is the most widely used reference parameter to evaluate
4 g), the less successful the recession improvement. Thus, root coverage results; however, such conditions as 1) cervi-
periosteal incisions should be used to eliminate tension cal abrasion, 2) traumatic loss of the tip of the interdental
from the flap, and in the maxillary jaw, the periosteal inci- papilla, 3) tooth rotation, and 4) tooth extrusion with or
sion should also include careful dissection of the muscle in- without occlusal abrasion may lead to diagnostic mistakes
sertions from the flap.

Flap Thickness
The survival of the flap, and particularly the marginal gin-
giva, depends on the residual vascular system after surgical
incisions. Because of the caudo-cranial pattern of vascular-
ization, we suggest a full-thickness dissection, when possi-
ble, to avoid interrupting the supraperiosteal vessels that
enhance the survival of the flap on the avascular root sur-
face. Thus, the thicker the flap, the greater the vasculariza-
tion of the marginal gingiva and the probability of CRC
(suggested flap thickness >0.8 mm).8

Interdental Papilla Height

According to Saletta et al.,9 CRC is more likely to be
achieved in sites with a lower height of interdental papilla.
Olsson et al.10 demonstrated that individuals with a long-
narrow form of the central incisors (N biotype, scalloped-
thin) show a thin free gingiva, a narrow zone of gingiva,
and a wider height of the interdental papilla, while indi-
viduals with short-wide crowns (W biotype, flat-thick)
show a thicker free gingiva, a wider zone of keratinized
tissue, and a lower papilla height. Thus, it is possible that
the thicker gingiva of the flat-thick biotype allows
a thicker flap, which may result in a greater success rate
of CRC.

FIGURE 2 CAF procedure: suggested flap design in esthetic area. When

a single recession-type defect is present in the esthetic area, we suggest
using an envelope flap technique, avoiding vertical releasing incisions to
reduce the probability of scar tissue formation. To facilitate the coronal
repositioning of the flap, make a horizontal incision that extends
mesiodistally to include three teeth. The horizontal incision of this modified
FIGURE 1 CAF procedure: flap design. Perform two horizontal beveled envelope technique consists of oblique submarginal incisions in the
incisions (a), mesial and distal to the recession defect, and an intrasulcular interdental areas, which continue the intrasulcular incision at the recession
incision (b). Execute two beveled oblique incisions (c) coming from the two defect. Locate the starting point of oblique incisions at a distance from the
horizontal incisions, extending to the alveolar mucosa. Locate the two tip of the anatomic papilla equal to the recession depth plus 1/2 mm. A
horizontal incisions at a distance equal to the recession depth plus 1/2 mm number of disadvantages of this surgical technique can be pointed out: the
from the tip of anatomic papillae (AP) to predefine the surgical papillae (SP). need to involve healthy adjacent teeth in the procedure and the smaller
a ¼ horizontal incision; b ¼ intrasulcular incision; c ¼ vertical releasing dimension of the flap. 2a before surgery; 2b after surgery; 2c flap design.
incision; REC ¼ recession depth. REC ¼ recession depth; SP ¼ surgical papillae.

42 Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 Decision Making in Gingival Recessions
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FIGURE 3 CAFþCTG procedure: suggested flap design and harvesting FIGURE 4 DPF procedure: flap design. Mucogingival defect affecting
technique. Using a trap door technique (a) to harvest the CTG will allow tooth #11. An inadequate amount of keratinized tissue is present apically to
a primary wound closure of the donor palatal site, reducing patient the recession, and the presence of well-represented interdental papilla
postoperative morbidity. Secure the graft over the exposed root surface suggest a double papillae procedure. 4a baseline; 4b DPF; 4c 12-month
using a resorbable sling suture passing through the connective tissue of the follow-up.
interdental papilla. 3a CTG harvesting from palate; 3b suture of the graft; 3c
6-month postoperative evaluation.

Preparation of Exposed Root Surface

To the best of our knowledge, no study has been reported in
preventing CRC. Thus, in such clinical conditions, the line the literature that shows one technique to be superior to all
of root coverage may be considered the clinical CEJ, be- others. The clinician may treat the exposed root surface
cause it may substitute for the anatomic CEJ when it is mechanically, by means of curets, sonic devices, polishing
no longer clinically visible or when ideal conditions to ob- or rotary instruments, or chemically using tetracycline,
tain CRC are not fully represented.11,12 sodium hypochlorite, or EDTA. According to our clinical

Rasperini, Acunzo, Limiroli Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 43
P R A C T I C A L A P P L I C A T I O N S

FIGURE 6 LAF procedure: flap design. 6a Flap design and areas needing
to be deepithelized. An adequate amount of keratinized tissue is located
FIGURE 5 DPFþCTG procedure: surgical technique. To modify the quality
distally to the canine; 6b the LAF plus CTG correctly repositioned upon the
and amount of keratinized tissue over the exposed root surface, a DPF in
exposed root surface and stabilized with sutures; 6c 3-month follow-up.
conjunction with a CTG is performed. Use a trap door technique (Figure 3a)
as described previously to harvest the CTG and secure the graft over the
exposed root surface using a resorbable sling suture passing through the
connective tissue of the interdental papilla. 5a baseline; 5b CTG positioned
on the root surface; 5c 12-month follow-up.

Moreover, to avoid damaging any connective tissue

experience, we suggest using simple root preparation proce- fibers still embedded in cementum, it might be convenient
dures such as scaling and root planing with sonic devices and to prepare the exposed root surface prior to raising the flap,
curets. The need to flatten prominent roots may represent especially if a mechanical root preparation procedure is to
a clinical indication for the use of rotary instruments. be used.

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Restorative Approach in Mucogingival

Therapy
Gingival recession may be associated with dental abrasion
due to toothbrushing or cervical caries. In this situation,
the lack of a definable anatomic CEJ may present clinicians
with difficulties during the diagnostic phase that prevent
complete coverage of the exposed root surface. A classifica-
tion of such dental defects has been recently proposed by Pini
Prato et al.13 In cases where there is an identifiable CEJ, we
suggest predetermining the line of root coverage as described
by Zucchelli et al.11 and treating the portion of the tooth cor-
onal to the CEJ using a restorative approach. To avoid dam-
agingthegingivalmargin, wesuggestrestorationofthedental
abrasion prior to the surgical phase or during the surgery.

Treatment Strategy
Gingival recession treatment can no longer be considered
as a single treatment approach. In fact, there is evidence
to consider mucogingival plastic surgery as a multifactorial
treatment approach comprising careful selection of pa-
tients (see Decision Tree 1) and defects, different surgical
techniques, many suturing approaches, and various types
of adjunctive materials. All the cited components should
be variously combined to develop different treatment strat-
egies with different degrees of technical difficulties (see
Decision Tree 2).

Clinical Condition 1: Coronally Advanced Flap

(CAF) – Table 1
Selection of surgical flap
A distance from GM to mucogingival junction (MGJ) of at
least 2 mm should be present to enhance the stability of the
surgical flap after suturing. A CAF procedure alone should
be performed when a thick and flat periodontal biotype is
present to avoid a relapse. A moderate or deep vestibule
will allow coronal displacement of the flap without ten-
sion; a shallow vestibule does not prevent the use of a
CAF technique but requires an extensive partial-thickness

FIGURE 7 Multiple gingival recessions: surgical technique 7a Flap design;

7b multiple gingival recessions affecting teeth #4-6 (note the amount of
keratinized tissue apically to tooth #14 equal to 1.5 mm); tooth #4 is
extruded; 7c the horizontal incision of the flap consists of oblique
submarginal incisions in the interdental areas, which continue with the
intrasulcular incision at the recession defects. The oblique incisions must
be drawn starting from the mesial and distal side of the tooth to be treated
at a distance from the tip of the anatomic papilla equal to the recession
depth plus 1/2 mm; 7d the envelope flap is raised with a split-full-split
approach in the coronal-apical direction. Deepithelize the anatomic papilla
and mobilize the flap with a sharp dissection into the vestibular lining
mucosa; 7e displace coronally the flap and suture with sling suturing
technique; 7f 3 months postoperatively tooth #4 presents a residual
exposed root surface due to the extrusion condition; the patient’s
perception of an unpleasant esthetic result may be avoided by predeter-
mining the line of root coverage and performing a restoration of the portion
of the root that will not be completely covered. Moreover, the non-optimal
overall esthetic result due to the presence of visible tissue merging lines
can be corrected by performing a gingivoplasty at the end of the tissue
maturation period, about 3 to 6 months after the surgical phase.

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DECISION TREE 1 Selection of the patient.

Adapted with permission from Quintessence Pub-
lishing Co. (In: Cortellini P, Bowers GM. Periodontal
regeneration of intrabony defects: An evidence-
based treatment approach. Int J Periodontics Re-
storative Dent 1995;15:128-145.) According to the
evidence, patients with <15% of sites presenting
with plaque and residual infection, non-smokers, with
a high degree of compliance, and systemically
healthy are the best candidates for root coverage pro-
cedures. FMPS ¼ full-mouth plaque score; FMBS ¼
full-mouth bleeding score.

dissection apically to the MGJ to make the flap tension 2. Avoid making releasing incisions across the MGJ dur-
free. ing the initial phase of the surgical procedure; this will
reduce postoperative swelling and pain.
Suggested surgical management 3. Try to avoid releasing incisions when recession defect
The surgical procedure was originally described by Allen is located in esthetic area (Fig. 2).15
and Miller14 in 1989, and further modifications have been
proposed over the years. Perform a horizontal incision and
two beveled and slightly divergent releasing incisions Clinical Condition 2: Coronally Advanced Flap þ
(Fig. 1). Using a small periosteal elevator, raise a full-thick- Connective Tissue Graft (CAFþCTG) – Table 2
ness flap and treat the exposed root surface with thorough
scaling and root planing using curets and/or ultrasonic de- Selection of surgical flap
vices (Video 1: root surface conditioning by means of root A distance from GM to MGJ of at least 2 mm should be
planing). Deepithelize the anatomic papilla (Video 2: ana- present to enhance the stability of the surgical flap after
tomic papilla deepithelization using a surgical blade [15c]; suturing. A CAF procedure in conjunction with a CTG is
Video 3: use scissors to remove all the epithelium when the the technique of choice when a thin and scalloped peri-
roots are prominent) and expose the underlying connective odontal biotype is present, so that both the amount and
tissue. Extend the dissection of the flap apically to the MGJ quality of marginal soft tissue may be appropriately trans-
proceeding with a split-thickness approach (Video 4: re- formed. In the case of a thick biotype, the placement of
lease residual muscle tension, keeping the surgical blade CTG can create an impaired esthetic due to irregular gin-
[15] parallel to the flap); pay close attention to releasing gival profile or scar tissue.4 A moderate or deep vestibule
the residual muscle tension as this will enhance the coronal will allow coronal displacement of the flap without ten-
displacement of the flap (Video 5: cover the recession defect sion; a shallow vestibule does not prevent the use of
only when a completely passive coronal displacement of a CAFþCTG technique but requires an extensive partial-
the flap can be achieved). Advance the flap coronally using thickness dissection apical to the MGJ to make the flap ten-
a sling suture technique and single interrupted sutures to sion free.
close the releasing incisions.
Suggested surgical management
Surgical advice Langer and Langer18 introduced the use of subepithelial
1. Locate the horizontal incision at a distance from the CTGs for root coverage, and several modifications to the
tip of anatomic papilla equal to recession depth original technique have been published over the years. Per-
þ 1/2 mm (Fig. 1). form the CAF procedure as described above. Harvest the

46 Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 Decision Making in Gingival Recessions
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DECISION TREE 2 Selection of the treatment

strategy. Root coverage procedure should be
selected according to a careful anatomic analysis
of the recession defect; this will allow a higher
probability of complete root coverage. LAF, laterally
advanced flap; LAFþCTG ¼ laterally advanced flap
þ connective tissue graft; KT ¼ keratinized tissue;
S ¼ shallow vestibule; M ¼ moderate vestibule; D ¼
deep vestibule.

CTG from the palate using a trapdoor technique (Fig. 3a); epithelialized graft technique can be used instead of
be sure to preserve a band of keratinized tissue at least 1 a trap-door procedure to reduce the chair time and
to 2 mm from the palatal GM. To keep the graft moist, simplify the harvesting procedure.
place it on gauze soaked in physiologic saline solution. 4. Close the palatal wound using collagen sponges (to
Close the palatal wound with interrupted suture. Suture enhance secondary intention wound healing) and
the CTG at the recipient site using resorbable sling sutures criss-cross suture technique after a deepithelialized
passing through the interdental papilla connective tissue graft procedure.
(Fig. 3b).

Surgical advice
1. Locate the horizontal incision at a distance from the
tip of anatomic papilla equal to recession depth þ 1/2
Clinical Condition 3: Double Papillae Flap
mm (Fig. 1). (DPF) – Table 3
2. Avoid making releasing incisions across the MGJ dur- Selection of surgical flap
ing the initial phase of the surgical procedure; this will To perform a DPF technique, an alternative keratinized tis-
reduce postoperative swelling and pain. sue donor-site must be represented by adjacent interdental
3. Try to avoid releasing incisions when recession papillae. Periodontal biotype should be classified as thick
defect is located in esthetic area (Fig. 2).15 A de- and flat. This surgical technique is not affected by vestibule

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TABLE 1 Key Point References for CAF Technique

Reference Aim Findings Predictor

Olsson et al.10 Periodontal biotype Thin: high triangular-shaped interdental papilla, thin and narrow KT. Thin ¼ recession
(1993) classification Thick: small interdental papilla, wide and thick KT. Thick ¼ pocket

Baldi et al.8 Thickness flap Flap thickness is a significant predictor for root coverage after CAF Thickness >0.8 mm
(1999) procedure. enhances CRC

Pini Prato et al.7 Flap tension The higher the flap tension, the smaller the recession reduction. Tension <4 g enhances
(2000) CRC

Saletta et al.9 Papilla height and CRC is not correlated to the papilla area but to papilla height. Lower papilla height
(2001) area enhances CRC

Pini Prato et al.6 Distance between The location of GM relative to the CEJ following CAF procedure seems to GM-CEJ ‡2 mm
(2005) GM and CEJ affect CRC. enhances CRC

Hwang and Thickness flap A positive association exists between flap thickness and MRC and CRC.
Wang16 (2006)

Zucchelli et al.11 CEJ determination Localization of CEJ is influenced by tooth rotation, extrusion, and cervical
(2006) abrasion.

Santamaria Local anatomy The depth of non-carious cervical lesion may influence the reduction of Reduced root convexity
et al.17 (2010) gingival recession when CAF is performed. enhances CRC

CRC ¼ complete root coverage; MRC ¼ mean root coverage; GM ¼ gingival margin; KT ¼ keratinized tissue; CEJ ¼ cemento-enamel junction.

TABLE 2 Key Point References for CAFþCTG Technique

Reference Aim Findings

19
Cairo et al. Outcome of CAF CTG or EMD in conjunction with CAF enhances the probability of obtaining CRC in Miller Class I and II
(2008) procedure single gingival recession.

Cortellini et al.20 CAF versus CAFþCTG Adjunctive application of CTG under a CAF increases the probability of achieving CRC in maxillary Miller
(2009) Class I and II defects.

Zucchelli et al.21 Morbidity and clinical No differences are demonstrated in the postoperative pain and root coverage using CAFþCTG or CAF
(2010) outcomes plus deepithelized gingival graft.

CTG ¼ connective tissue graft; EMD ¼ enamel matrix derivative; CAF ¼ coronally advanced flap.

TABLE 3 Key Point References for DPF Technique

Reference Aim Findings Predictor

Kerner et al.23 Factors that may affect the clinical outcome in Under non-experimental conditions, root Miller Class, maxillary
(2008) non-experimental patients coverage procedures are effective. teeth, smoking, donor-site

TABLE 4 Key Point References for DPFþCTG Technique

Reference Aim Findings

Harris et al.24 (2005) Compare CAF, DPF, and tunneling technique All three techniques are effective in obtaining CRC.

48 Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 Decision Making in Gingival Recessions
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TABLE 5 Key Point References for LAF Technique

Reference Aim Findings

Zucchelli et al.26 Surgical The laterally moved CAF is very effective in treating isolated gingival recessions. The ideal gingival conditions must
(2004) technique be present lateral to the defect to be treated.

TABLE 6 Key Point References for Multiple Gingival Recessions Technique

Reference Aim Findings

Zucchelli and De Surgical The proposed surgical technique is effective for the treatment of multiple gingival recessions affecting teeth in
Sanctis27 (2000) technique esthetic areas of the mouth. This result may be achieved irrespective of both the number of recessions
simultaneously treated and the presence of minimal keratinized tissue prior to surgery.

Zucchelli and De Long-term At the 5-year examination, 94% of the initially exposed root surfaces are still covered, and 85% of the treated
Sanctis28 (2005) outcome recession defects showed CRC. CRC in all recessions is maintained in 15 of 22 patients (68%).

depth due to the small coronal displacement required to interdental papillae to perform DPF in conjunction with
cover the recession defect. CTG. Periodontal biotype should be classified as thin
and scalloped. This surgical technique is not affected by
Suggested surgical management vestibule depth due to the small coronal displacement re-
Cohen and Ross22 introduced the method in which bilateral quired to cover the recession defect.
interdental papilla is used as donor tissue for localized root
coverage. Perform a V-shaped incision at the buccal aspect Suggested surgical management
of the involved tooth, with an internal bevel on one side of Clean the root surface, perform the surgical flap, and harvest
the V-shaped incision and an external bevel on the other. Make the CTG as described previously (Fig. 5).
horizontal and vertical incisions as described for the CAF tech-
nique, locating the horizontal incisions closer to the tip of in- Surgical advice
terdental papilla as much as possible to include more tissue in 1. Avoid making releasing incisions across the MGJ dur-
the flap. Raise a full-thickness flap and condition the root sur- ing the initial phase of the surgical procedure; this will
face by means of scaling and root planing using curets and/or reduce postoperative swelling and pain.
sonic devices. Suture together the two surgical papillae with 2. Once the interdental papillae have been dissected, join
interrupted sutures (Fig. 4b). Extend the dissection of the flap them using interrupted sutures before proceeding with
apically to the MGJ, proceeding with a split-thickness ap- the next steps of the surgical procedure; this will make
proach (Video 4: release residual muscle tension, keeping flap manipulation simpler.
the surgical blade [15] parallel to the flap) and paying atten-
3. A deepithelialized graft technique can be used instead
tion to release the residual muscle tension (Video 5: cover the
of a trap-door procedure to reduce the chair time and
recession defect only when a completely passive coronal dis-
simplify the harvesting procedure.
placement of the flap can be achieved). Cover the recession
4. Close the palatal wound using collagen sponges (to en-
defect using a sling suture technique and use single interrupted
hance secondary intention wound healing) and criss-
sutures to close the releasing incisions (Fig. 4b).
cross suture technique after a deepithelialized graft
Surgical advice procedure.
1. Avoid making releasing incisions across the MGJ dur-
ing the initial phase of the surgical procedure; this will
reduce postoperative swelling and pain. Clinical Condition 5: Laterally Advanced
2. Once the interdental papillae have been dissected, join Flap (LAF) – Table 5
them using interrupted sutures before proceeding with
Selection of surgical flap
the next steps of the surgical procedure; this will make
To perform a LAF technique, an alternative keratinized tis-
flap manipulation simpler.
sue donor site must be represented by adjacent teeth. Peri-
odontal biotype should be classified as thick and flat. This
Clinical Condition 4: Double Papillae Flap þ surgical technique is not affected by vestibule depth due to
Connective Tissue Graft (DPFþCTG) – Table 4 the small coronal displacement required to cover the reces-
sion defect. However, a shallow or moderate vestibule may
Selection of surgical flap require more surgical operator skill to obtain a completely
As described for the DPF technique, an alternative kerati- tension-free flap; an inadequate dissection of periosteum
nized tissue donor site must be represented by adjacent and muscle insertions may lead to a relapse.

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Suggested surgical management cross suture technique after a deepithelialized graft

LAFs have been widely used since Grupe and Warren25 in- procedure.
troduced this method for the treatment of localized gingi-
val recession. In this procedure, the adjacent keratinized
gingiva is positioned laterally and the exposed root surface
covered. Over the years, several further modifications of Clinical Condition 7: Multiple Gingival
this technique have been proposed to avoid bone loss
Recessions – Table 6
and gingival recession on the donor site, the most frequent
adverse events related to this surgical procedure. Recently Another factor to consider in the surgical treatment of gin-
Zucchelli et al.26 proposed a modified approach that ap- gival recession is that mucogingival-type defects are very
pears to be more reliable and safe (Fig. 6). seldom localized to a single tooth. More frequently, gingi-
val recessions affect groups of adjacent teeth. Thus, to min-
Surgical advice imize the number of surgeries and to optimize the esthetic
1. According to muscle insertion orientation, the LAF result, all of the contiguous recessions should be treated si-
should be preferably performed when the donor site multaneously. Patient-related esthetic considerations
is localized mesial to the gingival recession defect. would suggest the use of a surgical technique that predict-
2. When the flap is moved in the distal-mesial direction, ably obtains CRC in all present recessions by using the soft
another short horizontal incision should be performed tissue adjacent to the defects.
at the most apical extension of the distal vertical re-
leasing incision in order to facilitate mesial mobiliza- Suggested surgical management
tion of the flap. Zucchelli and De Sanctis27 proposed a new surgical ap-
3. Use collagen sponges, stabilized with criss-cross su- proach for the treatment of multiple recession defects
tures, to promote wound healing of the keratinized (Fig. 7). This modified design of the envelope flap consists
tissue donor site adjacent to the recession defect. of an oblique submarginal incision in the interdental area,
which continues with an intrasulcular incision at the reces-
sion defects.
Clinical Condition 6: Laterally Advanced Flap þ
Connective Tissue Graft (LAFþCTG) Surgical advice
Selection of surgical flap 1. When performing an envelope-type flap, avoid verti-
As described for the LAF technique, an alternative kerati- cal releasing incisions to help maintain adequate
nized tissue donor-site must be available at adjacent teeth blood flow to the flap and reduce the formation of vis-
to perform LAF in conjunction with CTG. The periodontal ible white scars.
biotype and vestibule depth for the LAFþCTG should 2. Use ‘‘split-full-split’’ flap elevation, with full thickness
be the same as described for the laterally advanced flap for that portion of the flap residing over the previously
alone. exposed root surface, to increase the potential to
achieve CRC.
Suggested surgical management 3. The absence of a wide zone of keratinized tissue apical
Clean the root surface, perform the surgical flap, and har- to the defects is not considered a limitation; a CTG
vest the CTG as described previously. may be used at one single specific recession defect if
necessary.
Surgical advice 4. Suture the flap using a sling suture technique passing
1. According to muscle insertion orientation, the LAF through the connective tissue of the anatomic papilla.
should be preferably performed when the donor site
is localized mesial to the gingival recession defect.
Conclusions
2. When the flap is moved in the distal-mesial direction,
Due to an increasing public demand for cosmetic dentistry,
another short horizontal incision should be performed
the treatment of gingival recession has become an important
at the most apical extension of the distal vertical re-
therapeutic and esthetic issue for the contemporary peri-
leasing incision in order to facilitate mesial mobiliza-
odontal practice. While the efficacy of using CTGs to obtain
tion of the flap.
full coverage of root surface exposure is well supported in
3. Use collagen sponges, stabilized with criss-cross su- the literature, this cannot be the only worthy treatment goal;
tures, to promote wound healing of the keratinized surgeons must also use their skills to fulfill the demand for
tissue donor site adjacent to the recession defect. the improved esthetics their patients expect.
4. A deepithelialized graft technique can be used instead Furthermore, even as CTG is considered the gold stan-
of a trap-door procedure to reduce the chair time and dard treatment for single and multiple areas of recession,
simplify the harvesting procedure. a simpler, less invasive approach, such as a CAF, may yield
5. Close the palatal wound using collagen sponges (to en- an equally acceptable result. Each clinical situation must
hance secondary intention wound healing) and criss- be evaluated to determine the most appropriate surgical

50 Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 Decision Making in Gingival Recessions
 P R A C T I C A L A P P L I C A T I O N S

approach to achieve the esthetics expected by the patient. Acknowledgment

Therefore, to achieve the best clinical and esthetic success, The authors did not receive any financial support for this
a careful assessment of existing anatomic parameters, such study.
as the amount of keratinized tissue, the periodontal bio-
type, and vestibule depth, is a vital part of the surgical de- CORRESPONDENCE:
cision-making process. n Dr. Giulio Rasperini, Via XX Settembre, 119 - 29121 Piacenza, Italy. E-mail:
[email protected].

Rasperini, Acunzo, Limiroli Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 51
P R A C T I C A L A P P L I C A T I O N S

15. Zucchelli G, Mele M, Mazzotti C, Marzadori M, Montebugnoli L, De

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52 Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 Decision Making in Gingival Recessions