591

S u b e p ith e lia l C o n n e c tiv e T is s u e G r a ft in C o m b in a tio n w ith a

T u n n e l T e c h n iq u e f o r th e T re a tm e n t o f M ille r C lass II a n d III
G in g iv a l R e c e s s io n s in M a n d ib u la r In c is o rs :
C lin ic a l a n d E s th e tic R e su lts

Gingival recession (GR) is defined as

an apical displacement of the gingi­
val margin from the cementoenamel
junction (CEJ) with oral exposure
of the root surface.1 The primary
objectives of mucogingival surgery
There is limited evidence regarding the effect o f the subepithelial connective have changed with time. During the
tissue graft (SCTG) on root coverage in the mandibular anterior region. A 1960s and 1970s, the rationale for
sample o f 15 Miller Class II and III recessions were treated in 15 patients using
increasing the width of keratinized
a SCTG with a tunnel technique. After a mean follow-up o f 20.53 months,
tissue (KT) and/or deepening the
the mean percentage o f root coverage was 83.25% for all treated recessions.
Furthermore, a statistically significant increase o f keratinized tissue was observed vestibule was to maintain gingival
at the end o f the evaluation period (2.66 mm; P = .001). The combination o f health2 by facilitating oral hygiene,
tunnel technique and SCTG should be considered a treatment option to obtain and to prevent GR.3 More recently,
root coverage in mandibular incisors with Class II and III recession defects. esthetic concerns are an indication
Int J Periodontics Restorative Dent 2016;36:591-598. doi: 10.11607/prd.2748
for surgical treatment,1 and the most
appropriate soft tissue grafting pro­
cedure must be carefully selected.
Coronally advanced flap (CAF),4
free gingival graft (FGG),5 guided tis­
sue regeneration,6 acellular dermal
matrix allograft,7 and subepithelial
connective tissue graft (SCTG)8 have
been reported to be effective in re­
ducing the extent of exposed root
surface, with a concomitant gain in
clinical attachment level (CAL) and
in width of KT.9 For many years, the
FGG was the most widely used mu­
'Chairman, Department of Periodontology, School of Dentistry, Universitat Internacional de cogingival surgical procedure.10 Lim­
Catalunya, Barcelona, Spain; Private Practice, Barcelona, Spain. ited data supports the use of FGG
"Clinical Research Coordinator and Associate Professor, Department of Periodontology, when root coverage is indicated,
School of Dentistry, Universitat Internacional de Catalunya, Barcelona, Spain; Private
Practice, Barcelona, Spain.
and complete root coverage ap­
pears to be an uncommon outcome
Correspondence to: Dr Cristina Valles, Department of Periodontology, Universitat with this technique.11 Furthermore,
Internacional de Catalunya. Universitat Internacional de Catalunya, C/ Josep Trueta s/n,
FGG is usually associated with an
Sant Cugat del Valles, 08195 Barcelona, Spain. Fax: 935042001.
unsatisfactory final esthetic appear­
Email: [email protected]
ance.12 Flowever, recently a partly
©2016 by Quintessence Publishing Co Inc. epithelialized FGG at the mandibular

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incisors showed a high percentage tients. After a mean follow-up of 11.7 December 2012 and January 2014.
of complete root coverage and an months, 90.22% ± 12.36% of root The GR defects were Miller Class
appreciable esthetic outcome.13 coverage was achieved. When com­ II or III5 > 2 mm and involved one
The results of meta-analyses parisons were made between Miller tooth. All defects were located in
have shown that SCTG could be Class II and III recession defects, no mandibular central incisors. Cases
considered the gold standard pro­ statistically significant differences were chosen according to the fol­
cedure in the treatment of GR.9-11-14 in root coverage were observed lowing inclusion criteria: (1) age > 18
However, the predictability of this (94.04% ± 10.45% and 86.41% ± years; (2) noncompromised systemic
procedure is influenced by a variety 13.70%, respectively). Complete health and no contraindication for
of defect, patient, and surgical fac­ root coverage was achieved at five periodontal surgery; (3) no active
tors, such as tooth to be treated,15 (71.42%) Class II sites compared with periodontitis; (4) no pregnancy;
tension of the flap,16 smoking hab­ three (42.85%) Class III defects. (5) no previous surgery at the de­
its,17 and Miller classification.5 The increasing interest in es­ fect site; and (6) good oral hygiene
Most studies evaluating root thetics has led to the development (Visible Plaque Index [VPI] < 20%).22
coverage with SCTG report on of new and m odified surgical tech­ Subjects were excluded from the
the type of teeth included in the niques. Different procedures and study if they were taking drugs caus­
study, but not the mean root cover­ flap designs have been proposed ing gingival enlargement, smoked
age obtained by tooth type.18 The for the treatment of GR, such as > 10 cigarettes a day, had restora­
mean root coverage observed for lateral pedicles, double pedicles, tions and/or periapical radiolucen-
the mandibular incisors (95.7%) was tunneling techniques, and combi­ cies at the defect site, or were using
lower than that obtained for the nations of various techniques. The fixed orthodontic or removable ap­
other tooth types (97.1% to 100%) tunneling approach eliminates the pliances.
except maxillary molars (90%).15 Fur­ need for horizontal or vertical inci­
thermore, the mean root coverage sions, providing less scarring and
for the mandibular anterior region better esthetic results.20 Moreover, C lin ica l m e a surem ents
seems to be influenced by surgical creating a pouch to contain the
procedure.18 The decreased success SCTG provides an excellent blood All participants signed a consent
rate could be caused by many fac­ supply to the gingival papillae.21 form and completed a baseline ex­
tors related to the anatomy of the The aim of this case series was amination. The following clinical pa­
area: thin papillae, thin tissue for the to describe, after a mean follow-up rameters were assessed at baseline
pedicle, prominent roots, frenum period o f 20.53 months, the clini­ and at the final postoperative evalu­
attachments, minimal vestibular cal and esthetic outcomes following ation after surgery by the same cali­
depth, lip muscles, and crowding of treatment of Miller Class II and III re­ brated examiner (J.N.): (1) probing
teeth. While many of these aspects cessions in mandibular central inci­ depth (PD), measured from the free
are not supported by the literature, sors using an SCTG in combination gingival margin to the most apical
a number of clinicians have their with a tunnel technique. part of the sulcus; (2) CAL, recorded
own personal list of factors18 and from the CEJ to the deepest point
select the FGG when treating man­ of the gingival sulcus; (3) width of KT,
dibular incisors. M a te ria ls and m e th o d s measured from the mucogingival
In 2012, Nart et al,19 in a case junction to the free gingival margin;
series study, described a technique A sample of 15 patients, 12 women and (4) recession depth (RD), mea­
using SCTG with CAF for the treat­ and 3 men (age range 21-60 years; sured as the distance from the CEJ
ment of GR in mandibular central in­ mean age: 36.27 ± 12.03 years), was to the gingival margin. Intraexam­
cisors. A to ta l of 14 Miller Class II and selected consecutively from a pri­ iner reproducibility was determined
III recessions were treated in 10 pa­ vate periodontal practice between by measuring PD and RD in five

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different patients on two occa­ with the use of Gracey curettes and taken, pressure was applied to the
sions 48 hours apart. Calibration ultrasonic instruments to remove donor area. The graft was trimmed
was accepted if 90% of the record­ bacterial contaminants. The more to achieve a thickness between 1.5
ings could be reproduced within 1 apically located area of the root was and 2.0 mm and enough width to
mm. Baseline measurements were not planed to avoid damaging un­ extend to one tooth on each side.
performed on the day of surgery. contaminated cementum and the The graft was gently placed into
All clinical measurements were connective tissue attachment. The the pouch with the same tunneling
made on the midbuccal aspect area was irrigated with sterile saline. instrument, covering the recessions
of each tooth with a periodontal Initial sulcular incisions were at the level of the CEJ. A continuous
probe (PCP-UNC 15, Hu-Friedy) and made with a 15C blade around each sling 6-0 poliglecaprone 25 suture
rounded up to the nearest millime­ tooth, and full-thickness flap separa­ (Monocryl, Ethicon) was used to se­
ter. An area of GR was considered tion was then carried out with a tun­ cure the graft to the interproximal
completely covered when no root nel knife (TKN1, Hu-Friedy) to help papilla and then the flap was su­
surface was visibly detected (or CEJ prevent perforations of the flap. tured coronally, leaving 1 to 2 mm of
seen) at the clinical examination. Care was taken to conserve as much the graft exposed (Fig 1b).
The final esthetic outcome of gingival tissue as possible to nourish Postsurgically, ibuprofen 600
the grafted sites was assessed by the graft. The mucoperiosteal dis­ mg three times a day was pre­
the patients using a visual analog section was extended beyond the scribed to control postoperative
scale (VAS) ranging from 0 (poor es­ mucogingival junction and under discomfort. To control swelling,
thetic result, below the initial expec­ each papilla. Finally, the most api­ corticosteroids (prednisone) were
tations) to 10 (very pleasing result, cal portion of the flap was elevated given daily in a regression mode
fulfilling the initial expectations). in a split-thickness manner to facili­ (30 mg to 10 mg) from the day of
tate the coronal displacement of the surgery until 4 days postoperative-
flap. A dissection into the vestibular ly. Amoxicillin 500 mg every 8 hours
P re s u rg ic a l p ro c e d u r e s mucosa with a 15C blade was car­ for 6 days was recommended to
ried out to eliminate muscle tension prevent infection. All patients were
All subjects underwent a hygienic in the apical portion of the flap to prescribed 0.12% chlorhexidine
phase, which included oral hygiene obtain a passive coronal positioning gluconate mouthrinse (Perio-Aid)
instructions, a session of prophylax­ of it and the papilla. At this stage, all twice daily for 2 weeks starting the
is, and if needed, scaling and root the buccal tissues and papillae were day after surgery. Sutures were re­
planing. Subjects were instructed to undermined and connected. moved after 15 days, at which time
use the modified Stillman brushing Preparation of the donor site professional plaque control was
technique. was performed immediately be­ performed and an extra-soft tooth­
fore starting with the envelope flap brush was given to each patient to
to avoid dehydration of the recipi­ be used for 1 week. No flossing at
S u rg ic a l te c h n iq u e ent site and minimize surgical time. the surgical site was performed for
Dense connective tissue was har­ 3 weeks.
All surgical procedures were per­ vested from the palate using a single All patients were then recalled
formed by the same experienced incision23 between the distal aspect every 6 months for evaluation, over
clinician (J.N.). Before surgery, a of the canine and the mesial aspect a mean follow-up period of 20.53
0.12% chlorhexidine gluconate of the first molar with a number 15 ± 8.89 months. At every follow-up
mouthrinse (Perio-Aid, Dentaid) blade. The donor site was sutured visit, subjects received one session
was used for 1 minute. Following with a single continuous 4-0 glycolic of prophylaxis, including reinforce­
local anesthesia, the exposed root acid suture (AP7 Rapid, Ancladen). ment of oral hygiene, supragingival
surfaces were mechanically treated Immediately after the graft was debridement, and tooth polishing.

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Fig 1a (left) Miller Class II gingival

recession o f 6 mm on the mandibular left
central incisor.

Fig 1b (right) Connective tissue graft

sutured at the level of the CEJ using a
continuous sling suture. The graft was left
exposed 2 mm, and both sides o f the flap
were sutured apically.

Fig 1c (left) Healing 15 days after surgery.

Fig 1d (right) Final outcome at 18 months

showing complete root coverage and
3 mm o f KT.

S ta tistica l analysis Results A statistically significant de­

crease in RD was observed at the end
The Shapiro-Wilk test was used to The study population consisted of of the evaluation period (P = .001).
determine whether data followed a 15 patients treated for single reces­ The mean recession at baseline was
Gaussian distribution. Descriptive sions (8 Miller Class II and 7 Class III 4.33 ± 1.50 mm (range: 3 to 7 mm)
statistics were expressed as mean ± defects). All patients included were and at the final examination it was
standard deviation (SD). The change healthy and nonsmokers. The post­ 0.77 ± 0.73 mm (range: 0 to 2 mm)
from baseline to final examination operative course for healing was un­ (Table 1). The mean percentage of
was determined using the Wilcoxon eventful for all patients. root coverage was 83.25 ± 14.96%
signed-rank test. The comparisons All subjects showed a good level for all treated recessions. When com­
of variables between Miller Class II of plaque control (VPI < 20%) during parisons were made between Miller
and III recession defects were per­ the study period. All clinical param­ Class II and III recession defects, sta­
formed using Mann-Whitney U test. eters had changed significantly be­ tistically significant differences in root
The percentage of root coverage tween the beginning of the study coverage were observed (90.92 ±
was calculated as: [(GR at baseline and the final examination, with the 13.53% and 74.49 ± 11.86%, respec­
- GR at the final examination)/GR at exception of PD. At baseline, no sta­ tively; P = .039) (Table 2).
baseline] X 100. The proportion of tistically significant differences were Complete root coverage was
complete root coverage (root cov­ found between Miller Class II and achieved at five (62.5%) o f the Miller
erage = 100%) was also calculated. III recession defects for any of the Class II defects compared with one
P < .05 was considered statistically parameters evaluated. The clinical (14.3%) of the Class III gingival de­
significant. All statistical analysis was parameters at tooth level at baseline fects. These values were not sta­
perform ed using a statistical soft­ and after therapy are summarized in tistically different between groups
ware package (SPSS 17.0, IBM). Table 1 and shown in Fig 1. (P = .066) (Table 2).

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Table 1 Comparison of clinical variables at baseline and final exam ination of

M iller Class II and III gingival recessions

Between-group
Class II defects (n = 8) Class III defects (n = 7) difference (P)
Initial Final Difference Initial Final Difference Initial Final
examination examination (P) examination examination (P) examination examination
PD (mm) 1.00 ± 0.00 1.00 ± 0.00 1.000 1.14 ± 0.38 1.14 ± 0 .3 8 1.000 .285 .285
RD (mm) 4.13 ± 1 .3 6 0.38 ±0.52 .011* 4.57 ± 1.72 1.21 ± 0 .7 0 .018* .762 .026*
KT (mm) 0.13 ±0.35 2.87 ± 0.35 .008* 0.00 ± 0.00 2.57 ± 0 .5 4 .015* .350 .200
CAL (mm) 5.13 ± 1.36 1.38 ± 0 .5 2 .011* 5.71 ± 1.89 2.36 ±0.75 .017* .716 .017*
PD = probing depth; RD = recession depth; KT = keratinized tissue; CAL = clinical attachment level.
Data are presented as mean ± SD.
“ Statistically significant difference, P < .05.

Treatment resulted in a sig­

nificant CAL gain at the end of the Comparison of root coverage and com plete root
1 coverage of M iller Class II and III gingival recessions
clinical evaluation period (from
5.40 ± 1.59 mm to 1.83 ± 0.79 mm; Class II defects Class III defects
P = .001). There were statistically sig­ (n = 8) (n = 7) P

nificant differences in CAL between Root coverage (%) 90.92 ± 13.53 74.49 ± 11.86 .039*
Miller Class II and III recession de­ Complete root coverage (%) 62.50 14.30 .066
fects at the final examination (1.38 ± “ Statistically significant difference, P < .05.

0.52 mm and 2.36 ± 0.75 mm, re­

spectively; P = .017) (Table 1). reported in a recent systematic re­ a mean root coverage of 95% after
A statistically significant increase view, which showed that while the treatment of Miller Class II GR using
in KT was observed at the end of ideal treatment for GR has not yet a tunnel technique with full-thickness
the evaluation period (P = .001). been identified, compared with the flap and SCTG, while Allen27 and
The mean KT at baseline was 0.07 ± traditional CAF approach the use of Zabalegui et al28 obtained a mean
0.26 mm and at the final examina­ additional grafting, modifications of root coverage of 84% and 92%, re­
tion was 2.73 ± 0.46 mm (Table 1). the flap technique, or tunnel varia­ spectively, using SCTG by partial­
Finally, the mean score of the tion with SCTG may improve clinical thickness dissection in the tunnel
final esthetic outcome evaluated by results.24 Furthermore, the combina­ procedure.
patients was 9.07 ± 1.03 out of 10. tion o f SCTG and tunnel technique In this investigation, a full-thick­
represents a valuable approach for ness flap reflection was performed
the treatm ent of Miller Class III re­ to avoid the reduction in the flap
Discussion cessions.25 thickness. It should be noted that
After a mean follow-up period Mazzocco et al29 compared the use
The results reported demonstrate of 20.53 months, the mean root cov­ of CAF combined with SCTG using
that a SCTG in conjunction with erage was 83.25% (90.92% for Class a partial-thickness reflection (con­
a tunnel technique is a treatment II and 74.49% for Class III recession trol group) with a full-thickness flap
option to consider for root cover­ defects). These outcomes compare reflection (test group). The authors
age in mandibular incisors. These well with findings from other re­ concluded that the elevation o f a
results are in agreement with those searchers. Tozum and Dini26 showed full-thickness or partial-thickness

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596

flap does not appear to influence were observed (94.04% ± 10.45% bination of a SCTG with the tunnel
the percentage of root coverage and 86.41% ± 13.70%, respectively). technique produced a statistically
achieved postsurgically. This investigation achieved less root significant increase in KT. Harris et
Some investigators have re­ coverage in both Class II and III re­ al18 observed a statistically greater
ported that in the mandibular cession defects (90.92 ± 13.53% and increase in KT for a SCTG + double
areas maximum coronal mobiliza­ 74.49 ± 11.86%, respectively). Mini­ pedicle papilla flap than for a SCTG
tion of the undermined tissue and mal efforts were made in coronally combined with tunnel/laterally po­
subsequent complete coverage of advancing the flap with the tunnel sitioned pedicle or CAF (2.9 mm,
the SCTG is often difficult due to technique; most of the root cover­ 2.0 mm, and 1.4 mm, respective­
factors such as minimal vestibular age occurred through vasculariza­ ly), whereas the mean gain in KT
depth and lip muscles, which could tion of the exposed graft. Likewise, obtained in theses cases was ap­
result in partial graft necrosis and the surgical management of flap ad­ proximately 2.5 mm. One possible
incomplete root coverage.30 Harris vancement seems to be easier with explanation for this could be that, in
et al18 compared three variations of an envelope flap compared with a these cases, the SCTG was left ex­
a SCTG for root coverage to treat tunnel flap. Important differences posed 1 to 2 mm, while in the study
mandibular incisors. These authors can be observed in root coverage by Harris et al18 the flap covered
showed that defects treated with a between Class II and III recessions in the connective tissue graft com­
SCTG in combination with a double this case series. Class III recessions pletely. Han et al34 reported a mean
pedicle papilla flap or tunnel/later- might have different degrees of in- increase in KT of 0.9 mm when the
ally positioned pedicle procedures terproximal bone and tissue loss, graft was covered completely and
had greater mean root coverage and according to Cairo's classifica­ 1.5 mm when the graft was left par­
than defects treated with a SCTG tion31 these recessions could be RT2 tially exposed during healing. This
in combination with CAF (95.5%, or RT3, possibly with different per­ fact is related to the inductive sig­
90.5%, and 80.2%, respectively). centages of root coverage. Most of nals from the connective tissue graft
The authors indicated that in cases the treated Class III recessions in this on epithelial differentiation during
treated with CAF, coronal reposi­ series were RT3. the early period of wound healing.35
tioning of the pedicle to cover the In the present study, the SCTG In this context, Zucchelli et al32 re­
connective tissue graft was neces­ was also left exposed 1 to 2 mm. In ported that the greater graft expo­
sary to a greater extent, which re­ contrast with Zucchelli et al,32 the sure could be responsible for the
sulted in greater tension in the flap. thickness of the graft was approxi­ greater increase in KT.
It should be noted that tunnel/later- mately 1.5 to 2.0 mm. However, Patient esthetic demands have
ally positioned pedicle procedure there is limited evidence in the litera­ become more stringent; thus, root
was similar to double pedicle tech­ ture regarding thickness of the graft coverage procedures should pro­
nique. In the present study, leaving and its relation to root coverage vide soft tissue anatomy compa­
the graft partially exposed avoided when it is left partially exposed. In a rable with the adjacent tissue.36
undue tension in the overlaying flap. recent retrospective study, Esteibar The results of this study indicated
In 2012, Nart et al19 obtained et al33 reported that the thickness of optimum patient satisfaction re­
90.22% ± 12.36% of root coverage the graft is an important factor for garding the appearance of treated
in the treatment of GR in mandibu­ treatment success predictability. A teeth. Using a visual analog scale,
lar central incisors using SCTG with graft greater than 2 mm in thickness the results showed a mean score of
CAF, leaving 1 to 2 mm of the graft is a relevant predictor, among oth­ 9 out of 10. Zucchelli et al37 evalu­
exposed. When comparisons were ers, of complete root coverage in ated whether graft dimensions in­
made between Miller Class II and III Miller Class III recessions. fluence root coverage and esthetic
recession defects, no statistically sig­ Another interesting outcome of outcomes. Sixty Miller Class I and
nificant differences in root coverage the present study is that the com­ II GR were treated with CAF plus

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 597

extraoral de-epithelialized FGG. In C onclusions 8. Langer B, Langer L. Subepithelial con­

nective tissue graft technique for
30 randomly selected control GR,
root coverage. J Periodontol 1985;56:
the FGG thickness was > 2 mm It was concluded that the SCTG with 715-720.
and the height was equal to bone a tunnel technique seems to be an 9. Chambrone L, Chambrone D, Pustiglioni
FE, Chambrone LA, Lima LA. Can sub­
dehiscence; in the other 30 test adequate technique to treat Miller epithelial connective tissue grafts be
defects, the thickness of the FGG Class II and III recessions and mu- considered the gold standard procedure
in the treatment of Miller Class I and II
was < 2 mm and the height was cogingival deformities in the man­
recession-type defects? J Dent 2008;
4 mm. After 1 year, better patient dibular anterior region. The mean 36:659-671.
color-match scores and better peri­ percentage of root coverage was 10. Zucchelli G, De Sanctis M. Long-term
outcome following treatment of multiple
odontist esthetic assessments were 83.25%, with a statistically signifi­ Miller class I and II recession defects in
reported in the test group. These cant increase of keratinized tissue of esthetic areas of the mouth. J Periodon­
tol 2005;76:2286-2292.
authors reported that bigger and 2.5 mm. The combination of tunnel
11. Roccuzzo M, Bunino M, Needleman I,
thicker grafts created greater ob­ technique and SCTG provides an Sanz M. Periodontal plastic surgery for
stacles for blood supply and faced excellent esthetic treatment when treatment of localized gingival reces­
sions: A systematic review. J Clin Peri­
a higher risk of flap dehiscence evaluated by patients. odontol 2002;29:S178-S194.
and, consequently, graft exposure, 12. Kerner S, Sarfati A, Katsahian S, et al.
Qualitative cosmetic evaluation after
leading to a poor esthetic result.
root-coverage procedures. J Periodon­
In this study, grafts were trimmed A c k n o w le d g m e n ts tol 2009;80:41-47.
to a thickness of approximately 1.5 13. Cortellini P, Tonetti M, Prato GP. The
partly epithelialized free gingival graft
to 2.0 mm in all defects, and mean The authors reported no conflicts of interest
(pe-fgg) at lower incisors. A pilot study
patient satisfaction was 9 out of related to this study. with implications for alignment of the
mucogingival junction. J Clin Periodon­
10 at the end of the study. Thus, it
tol 2012;39:674-680.
could be speculated that the use of 14. Chambrone L, Sukekava F, Araujo MG,
thicker grafts in certain cases, such R e fe ren c e s Pustiglioni FE, Chambrone LA, Lima
LA. Root-coverage procedures for the
as mandibular incisors, does not treatment of localized recession-type
jeopardize the esthetics resulting 1. Wennstrom JL. Mucogingival therapy. defects: A Cochrane systematic review.
Ann Periodontol 1996;1:671-701. J Periodontol 2010;81:452-478.
from treatment and might actually
2. Lang NP, LoeH. The relationship between 15. Harris RJ. The connective tissue with
improve the chances of root cover­ the width of keratinized gingiva and partial thickness double pedicle graft:
age when left exposed. gingival health. J Periodontol 1972;43: The results of 100 consecutively-treated
623-627. defects. J Periodontol 1994;65:448-461.
The major limitations of this 3. Nabers JM. Free gingival grafts. Peri­ 16. Pini Prato G, Pagliaro U, Baldi C, et al.
study are a limited sample and lack odontics 1966;4:243-245. Coronally advanced flap procedure for
4. Bernimoulin JP, Luscher B, Muhlemann root coverage. Flap with tension ver­
of a blinded examination. The re­
HR. Coronally repositioned periodontal sus flap without tension: A randomized
sults should be interpreted with flap. Clinical evaluation after one year. controlled clinical study. J Periodontol
caution, and further investigations J Clin Periodontol 1975;2:1-13. 2000;71:188-201.
5. Miller PD Jr. A classification of marginal 17. Martins AG, Andia DC, Sallum AW, Sal-
are needed to confirm these find­ tissue recession. Int J Periodontics Re­ lum EA, Casati MZ, Nociti Junior FH.
ings. Nevertheless, within the limits storative Dent 1985;5:8-13. Smoking may affect root coverage out­
of the present study, the combina­ 6. Trombelli L, Schincaglia GP, Scapoli come: A prospective clinical study in hu­
C, Calura G. Healing response of hu­ mans. J Periodontol 2004;75:586-591.
tion of a 1.5- to 2.0-mm SCTG and man buccal gingival recessions treated 18. Harris RJ, Miller LH, Harris CR, Miller RJ.
tunnel technique, as well as partial with expanded polytetrafluoroethylene A comparison of three techniques to
membranes. A retrospective report. obtain root coverage on mandibular inci­
exposure (1 to 2 mm) of the graft, J Periodontol 1995;66:14-22. sors. J Periodontol 2005;76:1758-1767.
can be successfully applied in the 7. Tal H, Moses O, Zohar R, Meir H, Nem-
treatment of Miller Class II and III covsky C. Root coverage of advanced
gingival recession: A comparative study
recession defects in mandibular in­ between acellulardermal matrix allograft
cisors, with a significant gain in KT and subepithelial connective tissue
grafts. J Periodontol 2002;73:1405-1411.
and excellent patient satisfaction.

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19. Nart J, Valles C, Mareque S, Santos A, 26. Tozum TF, Dini FM. Treatment of adja­ 32. Zucchelli G, Marzadori M, Mounssif I,
Sanz-Moliner J, Pascual A. Subepithelial cent gingival recessions with subepi­ Mazzotti C, Stefanini M. Coronally ad­
connective tissue graft in combination thelial connective tissue grafts and the vanced flap + connective tissue graft
with a coronally advanced flap for the modified tunnel technique. Quintes­ techniques for the treatment of deep
treatment of Miller Class II and III gin­ sence Int 2003;34:7-13. gingival recession in the lower incisors.
gival recessions in mandibular incisors: 27. Allen AL. Use of the supraperiosteal A controlled randomized clinical trial.
A case series. Int J Periodontics Restor­ envelope in soft tissue grafting for root J Clin Periodontol 2014;41:806-813.
ative Dent 2012;32:647-654. coverage. II. Clinical results. Int J Peri­ 33. Esteibar JR, Zorzano LA, Cundin EE,
20. Modaressi M, Wang HL. Tunneling pro­ odontics Restorative Dent 1994;14: Blanco JD, Medina JR. Complete root
cedure for root coverage using acel­ 302-315. coverage of Miller Class III recessions.
lular dermal matrix: A case series. Int J 28. Zabalegui I, Sicilia A, Cambra J, Gil J, Int J Periodontics Restorative Dent 2011;
Periodontics Restorative Dent 2009;29: Sanz M. Treatment of multiple adjacent 31:e1-e7.
395-403. gingival recessions with the tunnel sub­ 34. Han JS, John V, Blanchard SB, Kowolik
21. Aroca S, Keglevich T, Nikolidakis D, et epithelial connective tissue graft: A clini­ MJ, Eckert GJ. Changes in gingival di­
al. Treatment of class III multiple gingival cal report. Int J Periodontics Restorative mensions following connective tissue
recessions: A randomized-clinical trial. Dent 1999;19:199-206. grafts for root coverage: Comparison
J Clin Periodontol 2010;37:88-97. 29. Mazzocco F, Comuzzi L, Stefani R, Mi­ of two procedures. J Periodontol 2008;
22. Ainamo J, Bay I. Problems and proposals lan Y, Favero G, SteMini E. Coronally 79:1346-1354.
for recording gingivitis and plaque. Int advanced flap combined with a subepi­ 35. Karring T, Lang NP, Loe H. The role of
Dent J 1975;25:229-235. thelial connective tissue graft using gingival connective tissue in determin­
23. Hurzeler MB, Weng D. A single-incision full- or partial-thickness flap reflection. ing epithelial differentiation. J Periodon­
technique to harvest subepithelial con­ J Periodontol 2011;82:1524-1529. tal Res 1975;10:1-11.
nective tissue grafts from the palate. Int 30. Fischer KR, Alaa K, Schlagenhauf U, Fickl 36. Cairo F, Rotundo R, Miller PD, Pini Prato
J Periodontics Restorative Dent 1999; S. Root coverage with a modified lateral GP. Root coverage esthetic score: A sys­
19:279-287. sliding flap - a case series. Eur J Esthet tem to evaluate the esthetic outcome
24. Graziani F, Gennai S, Roldan S, et al. Ef­ Dent 2012;7:120-128. of the treatment of gingival recession
ficacy of periodontal plastic procedures 31. Cairo F, Nieri M, Cincinelli S, Mervelt through evaluation of clinical cases.
in the treatment of multiple gingival J, Pagliaro U. The interproximal clini­ J Periodontol 2009;80:705-710.
recessions. J Clin Periodontol 2014;41: cal attachment level to classify gingival 37. Zucchelli G, Mounssif I, Mazzotti C,
S63-S76. recessions and predict root coverage et al. Does the dimension of the graft
25. Hofmanner P, Alessandri R, Laugisch outcomes: An explorative and reliabil­ influence patient morbidity and root
O, et al. Predictability of surgical tech­ ity study. J Clin Periodontol 2011 ;38: coverage outcomes? A randomized con­
niques used for coverage of multiple 661-666. trolled clinical trial. J Clin Periodontol
adjacent gingival recessions—A system­ 2014;41:708-716.
atic review. Quintessence Int 2012;43:
545-554.

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