Coronally Advanced Flap Combined Witha Subepithelial Connective Tissue GraftUsing Full- or Partial-Thickness FlapReflectionFabio Mazzocco,* Luca Comuzzi,* Riccardo Stefani,* Ylenia Milan,* Giovanni Favero,*and Edoardo Stellini*

Background: Although the use of a subepithelial connectivetissue graft (SCTG) in conjunction with a coronally advancedflap (CAF) is a widely performed periodontal procedure, thecreation of a partial-thickness flap can incur a risk of perfora-tion or overthinning of the flap itself. Therefore, the aim of thepresent trial is to compare the efficacies of partial- and full-thickness flap reflections combined with an SCTG.

Methods: Twenty patients with Miller Class I or II defects (52teeth) were selected, and teeth with defects were randomlyassigned to the test group (25 teeth) for a CAF and SCTGusing a full-thickness flap reflection or to the control group(27 teeth) for a CAF associated with an SCTG and partial-thickness flap reflection. The probing depth (PD), gingival re-cession (GR), and width of the keratinized tissue (KT) wereassessed at baseline and 6 months after surgery.

Results: The mean root coverage was 97% in the test group(mean reduction in GR: 2.27 – 1.15 mm) and 95% in the con-trol group (mean reduction in GR: 1.68 – 0.74 mm). The gainin KT was 0.46 – 1.47 mm in the test group and 0.49 – 1.3 mmin the control group, the PD ranged from 1.33 to 1.55 mm inthe test group and from 1.31 to 1.64 mm in the control group;no statistically significant difference was found between thetwo groups for all of these parameters (P >0.05).

Conclusions: The elevation of a full- or partial-thicknessflap did not appear to influence the amount of KT or the per-centage of root coverage achieved post-surgically. More ex-panded studies are needed to confirm the present findings. JPeriodontol 2011;82:1524-1529.

KEY WORDS

Connective tissue; gingival recession/surgery; graft.

Gingival recession (GR) is definedas an apical displacement of thefree gingival margin (GM) from

the cemento-enamel junction (CEJ).1

This frequently encountered clinical con-dition2,3 may result in unpleasant es-thetics2 and increase the risk of rootcaries4 and dentin hypersensitivity.5 Thenumerous techniques invented for thetreatment of this condition include freegingival grafts,6,7 laterally positionedflaps,8,9 GTR (guided tissue regenera-tion),10 and coronally advanced flaps(CAFs)11,12 with or without the interpo-sition of a subepithelial connective tissuegraft (SCTG).13 The use of an SCTG isa reliable and versatile technique14-16

and involves the creation of a bilaminarvascular environment to nourish thegraft.13 In 1985, this procedure, whichwas initially designed for the correctionof ridge concavities in the pontic area,17

was first used for the treatment of GR.13

The original technique13 involved theelevation of a partial-thickness flap in-the recipient site that presented reces-sion and the creation of one mesialvertical-releasing incision and one distalvertical-releasing incision. One horizontalincision and one vertical incision in thedonor site were recommended to harvesta 1-mm thick connective tissue graft,which was then positioned on the periostealbed and covered with the mucosal flap.

* Department of Periodontology, Padua University, Padua, Italy.

doi: 10.1902/jop.2011.100586

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The original technique used a partial-thicknessflap elevation to enhance the revascularization ofthe graft, which was then stabilized on the recipientsite by using periosteal sutures. However, the eleva-tion of a partial-thickness flap can be difficult toachieve, particularly in patients with a thin peri-odontal biotype. A partial-thickness elevation deter-mines a reduction in the flap thickness, and mucosalflaps <1 mm thick were correlated with a reduction inthe percentage of root coverage in defects treatedusing CAFs.18,19

The periosteal bed was considered very importantfor the revascularization of the graft; however, thebone is a vascular surface, and even free gingivalgrafts positioned directly on it had the same long-termsurvival rates as those positioned on the perios-teum.20,21 Encouraging results were reported afterthe use of full-thickness flap reflection associated withan SCTG in the lateral sliding pedicle and the double-papilla technique in single or multiple recessions.22

Comparable findings were reported in a series of casesin which SCTG was combined with a full-thicknessflap reflection using the intramarrow perforation inthe underlying bone.23

The present preliminary study is conducted tocompare the clinical outcome after the treatmentof Miller Class I and II GRs7 using a coronally posi-tioned flap with an SCTG associated with a full-thickness flap after the use of a partial-thicknessflap reflection.

MATERIALS AND METHODS

Patient Selection and Experimental DesignPatients were selected among individuals referred tothe School of Dentistry, University of Padua, Padua,Italy from October 2008 to January 2010 for thetreatment of GR.

All selected patients gave full written informedconsent (an institutional review board consent form)to participate in the study, which was conducted inaccordance with the Helsinki Declaration of 1975,as revised in 2000.

Twenty patients with GR (nine males and 11 fe-males; age range: 21 to 57 years) were enrolled inthe study with a total of 52 treated teeth for treatment(25 in the test group, and 27 in the control group). Theinclusion criteria were: 1) Miller Class I or II recessiondefects7 involving maxillary or mandibular central orlateral incisors, canines, or premolars, 2) identifiableCEJ, 3) recession no deeper than 4 mm, 4) no signs ofcervical erosion, periodontal health, smoking habit,occlusal interferences, and/or contraindications toperiodontal surgery.

The study protocol involved a screening consul-tation followed by initial therapy to establish goodplaque control (visual plaque index <20%)24 using

appropriate dental hygiene maneuvers, surgical ther-apy, post-surgical consultations, and a post-surgicalevaluation at 6 months. The initial periodontal therapyconsisted of oral hygiene instructions, ultrasonic in-strumentation, and coronal polishing 1 to 2 monthsbefore surgery. Restorative treatment needs in non-study teeth was also addressed.

Patients were randomly divided into two groupsby using a computer-generated randomization table.Patients in test and control groups had CAFs withSCTG interpositioning, with a full-thickness flap re-flection used in the test group and a partial-thicknessflap reflection used in the control group.

One trained examiner (FM) made all clinical mea-surements on the mid-buccal aspect of each selectedsite using calipers. Because the CEJ level can bemodified during root planing, the incisal edge (IE) ofeach treated tooth was used as a reference point.The following clinical parameters were recorded be-fore surgery (baseline) and 6 months after surgery:1) clinical crown length (CCL; the distance betweenthe IE and GM), 2) anatomic crown length (ACL;the distance between the IE and CEJ, 3) probingdepth (PD; the distance from the GM to the most api-cal part of the gingival sulcus), 4) GR (the differencebetween the CCL and ACL), and 5) apico-coronalwidth of keratinized tissue (KT; the distance fromthe mucogingival junction [MGJ] to the GM). TheMGJ was located using the side of a periodontal probewith a roll technique and a visual method. ACL mea-surements, which were recorded at baseline, were alsorecorded at 6 months to evaluate the final recession asthe difference between CCL recorded at 6 months andbaseline ACL.

Surgical ProceduresAll surgical procedures were performed by two ex-perienced board-certified clinicians (FM and LC).Extraoral antisepsis was performed using a 0.2%chlorhexidine solution, and intraoral antisepsis wasperformed with a 0.12% chlorhexidine rinse. Anes-thesia was given using 2.0% lidocaine containing1:100.000 epinephrine.

Flap creation, which was started by making anintrasulcular incision with a #15 surgical blade onthe vestibular aspect of the targeted teeth, was per-formed following the principles described for thetreatment of multiple recession-type defects in pa-tients with esthetic demands,25 and no vertical re-leasing incisions were made.26 In the controlgroup (Fig. 1A), the partial-thickness flap was ele-vated with sharp dissection (Fig. 1B) and extendedas far as necessary to allow for flap advancementto the CEJ without any tension. In the test group(Fig. 2A), a full-thickness flap was obtained witha blunt dissection with periosteal elevators being

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used (Fig. 2B), and the flapwas elevated beyond the MGJ.In the most apical part of thereflection, a sharp dissectionwas performed to enable a pas-sive flap advancement to theCEJ.11 Before surgery, using arandomized table, defects wereassigned to the test group (full-thickness flap reflection) orto the control group (partial-thickness flap reflection). Thefacial epithelium of the inter-dental papillae was removedto provide an adequate bloodsupply from the wound bedfor flap repositioning. Rootsurfaces were prepared thor-oughly with manual curets toensure a smooth, cleansurface.

An SCTG with appropriatedimensions, which was har-vested from the palatal areausing a single incision tech-nique,27 was attached to therecipient site (Fig. 2C) to com-pletely cover the exposed rootsurface and was stabilized using a bioabsorbable con-tinuous suture† (Figs. 1C and 2C). The flap was posi-tioned slightly coronal to the CEJ and fixed witha continuous suture.‡ No periodontal dressing wasused.

Post-Surgical ProtocolPatients were instructed to refrain from brushing andflossing around the surgical area until suture removal(14 days post-surgery) and to consume only softfoods during the first week after surgery. Patientswere also instructed to avoid any mechanical traumato treated sites. For 4 weeks, patients used a 0.12%chlorhexidine solution rinse for 1 minute twice daily.

Statistical AnalysesFor statistical analyses, an independent sample testof location parameters was used to ascertain whetherthere was a statistically significant difference be-tween location parameters in the control and testgroups at the baseline and 6 months after surgery.For this purpose, the Mann-Whitney U test (a non-parametric alternative to the t test) was used. Thedistribution of the variable percentages of root cov-erage precluded any assumption based on t testfindings. GR and KT variables were continuous androughly symmetrical in control and test groups.Therefore, although t test assumptions might havebeen met, we chose to report the Mann-WhitneyU test P values more cautiously. However, findings

when using the t test did not differ from those whenusing the Mann-Whitney U test. A power analysiswas conducted by assuming two sample t test as-sumptions held as a power analysis within the frame-work of the Mann-Whitney U test.

RESULTS

The postoperative course for healing was uneventfulfor all patients, and no patients were excluded orwithdrew from the study.

The full-mouth gingival bleeding index and visualplaque index were maintained at <20%.24 Targetteeth were free of plaque and gingival inflammationbefore surgery and at the end of the study. Patientswere kept under a strict maintenance program, andthe overall plaque accumulation was minimal.Treated teeth were all in the anterior sextant wherethe oral hygiene maneuvers were relatively easyto accomplish, and plaque control was excellent. Thedescriptive statistics for clinical parameters, whichwere measured at baseline and 6 months post-surgery (Figs. 1D and 2D), are shown in Table 1.At baseline, no statistically significant differenceswere found between the two groups for any parame-ters evaluated. There were no statistically significantintergroup differences found for PD, GR, KT, or the

Figure 1.Control group. A) Three-millimeter recession on the canine. B) Partial-thickness flap reflection using no verticalreleasing incision. C) Connective tissue graft sutured at the level of the CEJ using a continuous sling suture. D)Final outcome at 6 months showing complete root coverage and a PD of 1 mm.

† MONOCRYL, Ethicon, Somerville, NJ.‡ MONOCRYL, Ethicon.

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percentage of root coverage at 6 months. The meanrecession at 6 months was 0.10 – 0.22 mm in thetest group and 0.09 – 0.16 mm in the control group;the mean difference in root coverage was 0.58 mm(P = 0.07), as shown in Table 1.

The mean root coverage was 97% in the test groupand 95% in the control group (P = 0.67). Complete

root coverage was accomplished in 80% (20 of25) of treated sites in the test group and in 62.9%(17 of 27) treated sites in the control group.

The mean KT at baseline was 3.05 – 1.73 mm in thetest group and 2.4 – 1.55 mm in the control group, andat 6 months, the mean KT was 3.51 – 0.86 mm in thetest group and 2.9 – 1.42 mm in the control group. The

mean difference between testand control groups for the in-crease in KT was statisticallysignificant at 0.03 mm (P =0.91), as shown in Table 1.

DISCUSSION

Various authors14,16 describedthe benefits of an SCTG for pro-moting root coverage. Theintegrity of the proximal tis-sues28 determines the extent ofroot coverage, irrespective ofwhether the SCTG is associatedwith CAF. However, increases inKT and gingival thickness areimportant clinical outcomes thatjustify the use of the SCTG.29

Furthermore, a reduced flapthickness was associated withincomplete root coverage whena CAF was used, which promp-ted an SCTG interposition inpatients with a thin gingivalbiotype.18,19

Results reported in the presentstudy demonstrate that an SCTGwas an effective means for ob-taining root coverage. The meanroot coverage at 6 months in theentire population was 96%. This

Table 1.

Clinical Parameters (mm; mean – SD) at Baseline and 6 Months After Surgery

Parameters Time

SCTG + CAF With

Partial Thickness (control group)

SCTG + CAF With

Full Thickness (test group)

Difference (mm) Between

Control and Test Groups

PD Baseline 1.32 – 0.51 1.33 – 0.72 0.01 (P >0.05)6 months 1.64 – 0.81 1.55 – 1.35 0.09 (P >0.05)Difference 0.32 – 0.82 0.22 – 0.71 0.1 (P >0.05)

GR Baseline 1.77 – 0.77 2.36 – 1.26 0.59 (P >0.05)6 months 0.09 – 0.16 0.10 – 0.22 0.01 (P >0.05)Difference 1.68 – 0.74* 2.27 – 1.15* 0.58 (P >0.05)

KT Baseline 2.40 – 1.55 3.05 – 1.73 0.65 (P >0.05)6 months 2.90 – 1.42 3.51 – 0.86 0.61 (P >0.05)Difference 0.49 – 1.37* 0.46 – 1.47* 0.03 (P >0.05)

* Statistical significance (P <0.05).

Figure 2.Test group. A) Recession of 2 mm on the first premolar, a 3-mm recession on the canine, and a 1-mmrecession on the lateral incisor. B) Full-thickness flap reflection using no vertical incision (the bone wellis visualized). C) Connective tissue graft sutured at the level of the CEJ using a continuous sling suture.D) Final outcome at 6 months showing complete root coverage.

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outcome compared well with findings made by otherauthors.30,31 Wennstrom and Zucchelli30 reportedan average mean root coverage of 89.3% whenconnective tissue was used to obtain root coverage.Harris31 obtained a mean root coverage of 97.1% andcomplete root coverage in 87.7% of treated defects.

The main purpose of this preliminary, randomizedclinical trial is to compare the use of a partial-thick-ness flap reflection with a full-thickness flap reflec-tion. Findings regarding the average root coveragein the test group (97%) and control group (95%)revealed no statistically significant difference for thisparameter. Our results appear to be in agreementwith those reported by authors22,23 who used a full-thickness flap reflection in conjunction with an SCTG.Nelson22 reported an average root coverage of 91%,with the most satisfactory results achieved in pa-tients with slight or moderate GR (a condition similarto that in our study sample), rather than in cases ofsevere recession, in which the average root coveragewas 88%. In all previous studies13,29,31 in which thetechnique used involved the use of partial-thicknessflap reflection, results appeared quite similar to thoseachieved in the present report.

In agreement with findings reported in the currentliterature, we found no difference between the use ofa full- or partial-thickness flap reflection. The findingsmade in the power analysis conducted by us showedthat this type of investigation had an 80% power to de-tect a 0.30-point difference between the two groupsfor GR depth in treated sites. Statistical findings sug-gest that neither of the two techniques has an in-fluence on the final outcome. A full-thickness flapreflection, which is a less-sensitive technique than apartial-thickness flap reflection, reduces the risk ofintraoperative complications, such as a perforationor excessive thinning of the flap with a consequent riskof necrosis of the surrounding tissue.32

The blood supply from the inner part of the flap, to-gether with that from the bone, was sufficient for thesurvival of the graft and for achieving an outcomecomparable to that achieved with a partial-thicknessflap reflection.

The difference between groups for the gain in theamount of KT was statistically significant (test group:3.05 to 3.51 mm; control group: 2.4 to 2.9 mm), butthe intergroup difference did not attain statisticalsignificance. These findings were similar to thosereported in other studies in which the SCTG was com-pletely covered by the flap.16 Harris31 found a changefrom 3.5 mm of KT preoperatively to 4.08 mm at 27months after treatment. Han et al.33 reported an aver-age increase in the width of KT of 0.9 mm when thegraft was completely covered and 1.5 mm whenthe graft was left partially exposed during healing,which also enhanced the increase in the amount of

KT. Similar results were reported by Muller et al.,34

who found an average increase of 1.1 mm in theamount of KT when using a full-thickness flap reflec-tion with an SCTG and leaving the epithelialized collarof the graft exposed.

The findings made in the present study for theamount of KT, as well as the percentage of root cov-erage achieved, are in agreement with those made byother authors16,29,33 after a procedure performed us-ing a partial- or full-thickness flap reflection.

Despite the limitations of the present study, in-cluding the short follow-up and limited sample size,encouraging results were obtained after the creationof a full-thickness flap in the root-coverage proce-dure using a CAF with an SCTG. Therefore, additionalinvestigations should be conducted to confirm ourdata.

CONCLUSIONS

The results of this study suggest that a full-thicknessflap elevation is as effective as a partial-thickness flapreflection with CAF combined with SCTG in achievingroot coverage. Full-thickness flap elevation did notcompromise the amount of KT or the percentage ofroot coverage achieved post-surgically.

ACKNOWLEDGMENT

The authors report no conflicts of interest related tothis study.

REFERENCES1. Wennstrom JL. Mucogingival therapy. Ann Periodon-

tol 1996;1:671-701.2. Albandar JM, Kingman A. Gingival recession, gingival

bleeding, and dental calculus in adults 30 years of ageand older in the United States, 1988-1994. J Peri-odontol 1999;70:30-43.

3. Susin C, Haas AN, Oppermann RV, Haugejorden O,Albandar JM. Gingival recession: Epidemiology andrisk indicators in a representative urban Brazilian pop-ulation. J Periodontol 2004;75:1377-1386.

4. Lawrence HP, Hunt RJ, Beck JD. Three-year rootcaries incidence and risk modeling in older adults inNorth Carolina. J Public Health Dent 1995;55:69-78.

5. Al-Wahadni A, Linden GJ. Dentine hypersensitivity inJordanian dental attenders. A case control study. JClin Periodontol 2002;29:688-693.

6. Miller PD Jr., Binkley LH Jr. Root coverage and ridgeaugmentation in Class IV recession using a coronallypositioned free gingival graft. J Periodontol 1986;57:360-363.

7. Miller PD Jr. A classification of marginal tissue re-cession. Int J Periodontics Restorative Dent 1985;5(2):8-13.

8. Patur B. The rotation flap for covering denuded rootsurfaces – A closed wound technique. J Periodontol1977;48:41-44.

9. Grupe HE, Warren RF Jr. Repair of gingival defects bya sliding flap operation. J Periodontol 1956;27:92-95.

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10. Trombelli L, Schincaglia GP, Scapoli C, Calura G.Healing response of human buccal gingival recessionstreated with expanded polytetrafluoroethylene mem-branes. A retrospective report. J Periodontol 1995;66:14-22.

11. Bernimoulin JP, Luscher B, Muhlemann HR. Coronallyrepositioned periodontal flap. Clinical evaluation afterone year. J Clin Periodontol 1975;2:1-13.

12. Tenenbaum H, Klewansky P, Roth JJ. Clinical eval-uation of gingival recession treated by coronallyrepositioned flap technique. J Periodontol 1980;51:686-690.

13. Langer B, Langer L. Subepithelial connective tissuegraft technique for root coverage. J Periodontol 1985;56:715-720.

14. Oates TW, Robinson M, Gunsolley JC. Surgical ther-apies for the treatment of gingival recession. Asystematic review. Ann Periodontol 2003;8:303-320.

15. Roccuzzo M, Bunino M, Needleman I, Sanz M. Peri-odontal plastic surgery for treatment of localized gingi-val recessions: A systematic review. J Clin Periodontol2002;29(Suppl. 3):178-194, discussion 195-196.

16. Chambrone L, Sukekava F, Araujo MG, Pustiglioni FE,Chambrone LA, Lima LA. Root-coverage proceduresfor the treatment of localized recession-type defects: ACochrane systematic review. J Periodontol 2010;81:452-478.

17. Langer B, Calagna LJ. The subepithelial connectivetissue graft. A new approach to the enhancement ofanterior cosmetics. Int J Periodontics Restorative Dent1982;2:22-33.

18. Baldi C, Pini-Prato G, Pagliaro U, et al. Coronallyadvanced flap procedure for root coverage. Is flapthickness a relevant predictor to achieve root coverage?A 19-case series. J Periodontol 1999;70:1077-1084.

19. Hwang D, Wang HL. Flap thickness as a predictor ofroot coverage: A systematic review. J Periodontol2006;77:1625-1634.

20. Bressman E, Chasens AI. Free gingival graft with peri-osteal fenestration. J Periodontol 1968;39:298-300.

21. Flores de Jacoby L, Stocker T. Comparative clinicaland histological studies on keratinized and non-kerati-nized tissues transplanted onto the periosteum and thedenuded alveolar bone. Dtsch Zahnarztl Z 1979;34:344-349.

22. Nelson SW. The subpedicle connective tissue graft. Abilaminar reconstructive procedure for the coverage ofdenuded root surfaces. J Periodontol 1987;58:95-102.

23. Wilcko MT, Wilcko WM, Murphy KG, et al. Full-thickness flap/subepithelial connective tissue graftingwith intramarrow penetrations: Three case reports of

lingual root coverage. Int J Periodontics RestorativeDent 2005;25:561-569.

24. Ainamo J, Bay I. Problems and proposals for re-cording gingivitis and plaque. Int Dent J 1975;25:229-235.

25. Zucchelli G, De Sanctis M. Treatment of multiplerecession-type defects in patients with esthetic de-mands. J Periodontol 2000;71:1506-1514.

26. Zucchelli G, Mele M, Mazzotti C, Marzadori M,Montebugnoli L, De Sanctis M. Coronally advancedflap with and without vertical releasing incisions for thetreatment of multiple gingival recessions: A compar-ative controlled randomized clinical trial. J Periodontol2009;80:1083-1094.

27. Lorenzana ER, Allen EP. The single-incision palatalharvest technique: A strategy for esthetics and patientcomfort. Int J Periodontics Restorative Dent 2000;20:297-305.

28. Miller PD Jr. Root coverage with the free gingival graft.Factors associated with incomplete coverage. J Peri-odontol 1987;58:674-681.

29. Harris RJ. Root coverage with connective tissue grafts:An evaluation of short- and long-term results. J Peri-odontol 2002;73:1054-1059.

30. Wennstrom JL, Zucchelli G. Increased gingival di-mensions. A significant factor for successful outcomeof root coverage procedures? A 2-year prospectiveclinical study. J Clin Periodontol 1996;23:770-777.

31. Harris RJ. Connective tissue grafts combined witheither double pedicle grafts or coronally positionedpedicle grafts: Results of 266 consecutively treateddefects in 200 patients. Int J Periodontics RestorativeDent 2002;22:463-471.

32. Edel A. Clinical evaluation of free connective tissuegrafts used to increase the width of keratinised gin-giva. J Clin Periodontol 1974;1:185-196.

33. Han JS, John V, Blanchard SB, Kowolik MJ, EckertGJ. Changes in gingival dimensions following connec-tive tissue grafts for root coverage: Comparison of twoprocedures. J Periodontol 2008;79:1346-1354.

34. Muller HP, Eger T, Schorb A. Gingival dimensions afterroot coverage with free connective tissue grafts. J ClinPeriodontol 1998;25:424-430.

Correspondence: Dr. Fabio Mazzocco, Via Cesarotti 31,Padua, Italy. Fax: 39-049-8776791; e-mail: fmazzocco@hotmail.com.

Submitted September 27, 2010; accepted for publicationFebruary 13, 2011.

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