Pierpaolo Et Al-2012-Periodontology 2000

Periodontology 2000, Vol.
59, 2012, 158–184 2012 John Wiley & Sons A/S

Printed in Singapore. All rights reserved PERIODONTOLOGY 2000
Coronally advanced flap and

combination therapy for root
coverage. Clinical strategies
based on scientific evidence
and clinical experience
PIERPAOLO CORTELLINI & GIOVANPAOLO PINI PRATO
Gingival recession is defined as the displacement of oral hygiene habits of patients and ⁄ or by applying
the soft tissue margin apical to the cemento–en- mucogingival surgical procedures (6). A long-term
amel junction (5) and is a frequent clinical feature clinical study recently reported that shallow
in populations with both good (69, 113) and poor recessions showed a tendency for further apical
(9, 69, 131) standards of oral hygiene. Localized loss displacement of the gingival margin in highly moti-
of attachment with gingival recession is located vated patients with high standards of oral hygiene
mainly at the interdental spaces in patients with and enrolled in a stringent supportive periodontal
plaque-induced periodontal inflammation and at care system (4–6 months) over a period ranging from
the buccal surfaces of teeth in patients with high 10 to 27 years (1). In the same population of patients,
standards of oral hygiene (69, 113) and may affect contralateral grafted sites showed stability or even a
single or multiple root surfaces. It has historically coronal shift of the gingival margin over the same
been associated with mechanical factors such as time frame. The study concluded that untreated
traumatic toothbrushing impacting on predisposed gingival recessions show a negative prognosis over
thin soft tissues (108), even though a recent time in spite of good patient motivation, while the
systematic review (99) concluded that data to prognosis is improved after applying mucogingival
support or refute the association between tooth- procedures. Gingival recession remains a highly
brushing and gingival recession are still inconclu- prevalent problem (57, 105) and potentially impacts
sive. This is a severe Ôblack holeÕ in our knowledge, on both esthetics and dentine hypersensitivity. Pa-
because knowing the cause of recession would tients therefore commonly ask about treatment op-
greatly help in the planning of an appropriate tions for both single and multiple buccal recession
clinical approach directed to improve the prognosis defects.
of this type of periodontal lesion. In fact, prognosis The ultimate goal of root-coverage procedures is
is defined as Ôprediction of the future course of a the complete resolution of the recession defect, with
disease in terms of disease outcomes following its minimal probing depths after treatment, along with a
onset and ⁄ or treatmentÕ and might be positively nice chromatic and texture integration of the cover-
modified if the causative agents are controlled; in ing tissues with the adjacent resident soft tissues (20,
other words, if periodontitis is properly treated 21, 31, 78, 102). Clinicians are challenged to achieve
and if the traumatic toothbrushing technique is outcomes that meet these exacting standards, and
corrected. therefore need a sound, clinically oriented and sci-
A long-standing debate in the scientific community entifically supported decision-making process to
relates to whether it is possible to halt the progres- plan the therapeutic approach, to predict the out-
sion of gingival recession defects by modifying the come and, finally, to achieve it.
158
Coronally advanced flap and combination therapy for root coverage
During the last three decades, several surgical sues ⁄ materials, from a clinical perspective with the
techniques have been proposed to treat single and aim of helping clinicians in their decision-making
multiple gingival recessions. In the 1970s and 1980s, process. The review will include: (i) analysis of the
the main treatment goals were achieving recession potential prognostic factors (patient, tooth ⁄ site and
reduction and increasing keratinized tissue. The technique-related factors), (ii) discussion of the
proposed surgical techniques were pedicle flaps surgical procedures, (iii) comparison of different
(laterally or coronally positioned) and free gingival coronally advanced flap-based approaches, (iv)
grafts. During the 1980s and 1990s, new approaches, evaluation of the healing dynamics and long-term
such as bilaminar techniques or regenerative proce- stability of outcomes, and (v) a discussion of the
dures, were proposed to achieve the goal of complete patient-related outcomes and side effects of therapy.
root coverage. In the last decade, because of the ever- The review will end with referenced flow charts.
increasing esthetic demands from patients, surgical Single or multiple gingival recessions and patientsÕ
techniques have been further developed to obtain requests for root coverage challenge the clinicianÕs
complete root coverage associated with a perfect ability to choose the best approach and to predict the
integration of the grafted tissue with the adjacent soft outcome. Ideally, a clinician should first discuss with
tissues (20, 31). the patient the desired ⁄ expected outcome(s), then
In broad terms, three different approaches can be select the best option to reach those outcome(s).
identified from the published literature: (i) the free Interestingly, very few studies have considered
gingival graft (117), (ii) the coronally advanced flap Ôpatient satisfactionÕ and this should be the true
(3), and (iii) combined procedures, based on a coro- outcome of a procedure that mainly addresses the
nally advanced flap with tissue ⁄ material interposed goal of esthetic improvement. A study was performed
between the flap and the root surface. The most to investigate the perceived esthetic outcomes of
common of the latter approaches are based on a simulated root-coverage procedures using three dif-
coronally advanced flap plus a connective tissue graft ferent groups of ÔevaluatorsÕ: patients, dentists and
(coronally advanced flap + connective tissue graft) periodontists (104). Complete root coverage was
(63), a nonresorbable barrier (91), a bio-resorbable perceived as the most desirable outcome by the three
barrier (92, 101), enamel matrix derivative (25, 41, 89, groups.
100, 115), platelet-rich gel (62), acellular dermal Similarly, information about changes in dentinal
matrix (51), or living tissue-engineered human hypersensitivity, another important outcome for
fibroblast-derived dermal substitute (129). patients, is seldom reported. A recent multicenter
Although all the proposed techniques have shown randomized clinical study reported that coronally
potential for root coverage, meta-analyses from sev- advanced flap therapy alone and coronally advanced
eral systematic reviews (20, 29, 31, 85, 102) showed flap therapy associated with a connective tissue graft
the greatest potential for recession reduction and were both effective in reducing dental hypersensi-
complete root coverage when applying coronally tivity (37).
advanced flap or combined procedures. These are Most studies have reported surrogate outcomes,
therefore the approaches of choice to date. such as complete root coverage, amount of root
The aim of this review was to provide a critical coverage, per cent root coverage and changes in the
analysis of clinical studies and controlled clinical amount of keratinized tissue. Therefore, this review
trials performed either with coronally advanced flap will focus on patient outcomes when available, but
therapy alone or with coronally advanced flap ther- will mainly use surrogate outcomes to draw conclu-
apy in combination with tissues ⁄ materials, and to sions.
propose sound, clinically oriented and scientifically An additional problem has to be highlighted and
supported flow charts to help clinicians in their should be taken into account when comparing results
decision-making processes for the treatment of from different studies: understanding how Ôcomplete
localized and multiple gingival recessions. root coverageÕ or Ôper cent root coverageÕ are defined
by different authors. The issue is especially relevant
when teeth with large abrasion cavities and ⁄ or deep
Overview steps involving the cemento–enamel junction are
included (Fig. 1A–C). In these instances, the cemen-
From a methodological point of view, this review will to–enamel junction is no longer detectable and the
consider published evidence on coronally advanced record of root coverage becomes a guess. There is, in
flap therapy, alone, or in combination with tis- fact, a tendency to declare a root to be Ôcompletely
159
Cortellini & Pini Prato
A B C
Fig. 1. Coronally advanced flap on multiple gingival (B) An envelope flap has been coronally advanced to cover
recessions associated with root abrasions. (A) Severe a connective tissue graft, positioned on the abraded root
multiple gingival recessions on the maxillary right quad- surfaces. (C) The 1-year clinical outcome. Note that the
rant, associated with severe steps and abraded cemento– abraded cemento–enamel junction is visible making
enamel junction. The residual gingiva is thick and wide. evaluation of the outcome difficult.
coveredÕ when the gingival margin reaches a position root coverage and do not provide a comparison be-
that the clinician ÔfeelsÕ is the maximum possible tween smokers and nonsmokers.
coverage obtainable in that specific case. This might
in reality reflect the true maximum potential out-
Tooth ⁄ site-related factors
come, but it still is not an ÔobjectiveÕ measure.
Interestingly, many of the tooth ⁄ site-specific factors
that are believed to be, and are frequently cited as,
Potential prognostic factors relevant prognostic factors, have never been tested in
sound clinical studies. For example, there is no
Prognostic factors are defined as the characteristics information as to whether tooth position (buccal or
of a particular patient that can be used to predict, lingual), tooth vitality and depth of the vestibule
with greater accuracy, the patientÕs eventual out- might influence the outcome of mucogingival pro-
come. Prognostic factors do not predict the outcome cedures. Limited, and often conflicting, information
completely, but do influence the outcome of treat- is available on the results of root coverage procedures
ment (64). Potential prognostic factors for root cov- performed on different tooth types or on maxillary or
erage can be divided into three different categories: mandibular teeth (14, 73, 81, 82).
patient-related factors, tooth ⁄ site-related factors and Cervical dental caries and ⁄ or abrasions are often
technique-related factors. associated with gingival recessions. Various ap-
proaches have been attempted to treat gingival
recession associated with cervical lesions, and
Patient-related factors
excellent clinical results have been achieved, both in
Few articles in the periodontal literature are available terms of root coverage and cosmetic outcomes (42,
that debate the possible influences of age, gender, race 44, 72, 76, 90), showing that superficial caries lesions
and systemic disease on the outcomes of root coverage or abrasion defects do not seem to impair the pos-
procedures. There is weak evidence that poor oral sibility to cover a root.
hygiene will negatively influence the success of root Root curvature might potentially influence the
coverage (19). Similarly, there is little information on outcome of root coverage. This hypothesis is based
the influence of traumatic toothbrushing in the on the size of the avascular area, which is larger in
recurrence of recession after treatment (127). Smoking prominent root surfaces. A study (107), performed to
is a controversial issue. Some papers report less compare the root curvature of four different dental
favorable outcomes in terms of root coverage in morphotypes (central incisors, lateral incisors, cus-
smokers (78, 81, 114, 124, 133), whereas other studies pids and bicuspids), showed statistically significant
do not find differences between smokers and non- differences among the tested teeth. To date, no
smokers (4, 16, 50, 54, 73, 120). A recent systematic studies have reported a difference in root coverage in
review (28) concluded that smoking may negatively different morphotypes. However, given the hypothe-
influence gingival recession reduction and clinical sis of an impact of root curvature on outcomes, it
attachment gain, and smokers may exhibit fewer sites would be of interest to test such an influence in a
with complete root coverage. In reality, most of the controlled study.
studies cited in the review by Chambrone et al. (28) The level of interdental periodontal support (77) is
were not designed to test the influence of smoking on universally recognized to be of paramount impor-
160
tance for the outcome of root coverage and is one of (3, 127). However, there is limited evidence to sup-
the clinical ÔindicatorsÕ generally used to predict port this approach.
outcome. According to the Miller classification, A clinical study (10) tested the influence of flap
Class I and II type defects, in which the interdental thickness following coronally advanced flap proce-
bone support is intact, have the best potential for dures. The results indicate that flap thickness is sig-
complete root coverage. Conversely, only partial nificantly (P < 0.0001) associated with root coverage.
root coverage is thought to be achievable in Miller A flap thickness of >0.8 mm was associated with
Class III and IV type defects: these are associated complete root coverage, while a flap thickness of
with some (from mild to severe) loss of interdental <0.8 mm was associated with partial root coverage. In
bone support. This hypothesis (or is it a dogma?), addition, linear regression analysis showed that with
however, has been challenged in a recent study (8) each increase in thickness of 0.1 mm, recession was
on Miller Class III recessions. The authors reported reduced by approximately 0.2 mm in all treated sites.
complete root coverage in 38% of patients treated Therefore, 0.8 mm can be considered as the critical
with a modified tunnel ⁄ connective tissue graft flap thickness above which the expected clinical
technique, with or without the additional use of outcome should be complete root coverage when
enamel matrix derivative. Evidence on treating using a coronally advanced flap alone.
Miller Class III and IV defects is both scarce and Another study (136) evaluated the relationship be-
weak and does not provide any clear indications on tween root coverage and the baseline amount of
the potential of interproximal bone loss to impact keratinized tissue in laterally positioned and coro-
on root coverage. nally advanced flaps. Multiple logistic regression
The dimension of the interdental papilla was also analysis showed a statistically significant relationship
investigated in terms of total area and height (apico- between complete root coverage and the amount of
coronal dimension). Two published studies reached keratinized tissue lateral to the gingival defects: the
completely different outcomes. One study, on 33 greater the amount of keratinized tissue, the greater
Miller Class I recessions treated with a coronally ad- the percentage of root coverage.
vanced flap, demonstrated that the area of the Many studies and recent systematic reviews
interdental papillae adjacent to the recession defect showed the importance of baseline recession depth
does not influence the amount of recession reduction in the treatment outcome. The results of the meta-
and the likelihood of complete root coverage. On the analyses of controlled and randomized clinical trials
other hand, the height of the papilla does influence published by Roccuzzo et al. (102) and Clauser et al.
complete root coverage: the shorter the papilla, the (31) showed a relationship between the initial reces-
greater the probability of obtaining complete root sion depth and the final outcome of the surgical
coverage (106). Other authors have hypothesized that procedure, reporting that Ôgreater baseline recession
short papillae could favor coverage because they are depths were always associated with decreased com-
normally associated with a flat and thick gingival plete root coverageÕ.
biotype (88). A second study compared two root-
coverage techniques: subepithelial connective tissue
graft and acellular dermal matrix allograft. The study
reported significant, positive correlations between
Technique-related factors
papilla height and width, and mean root coverage:
Root surface
the higher and wider the papilla, the greater the ob-
served mean root coverage. In addition, a papilla There is a general consensus in the scientific com-
height of 5 mm was consistently associated with munity that treatment (particularly mechanical
complete coverage of the root using both surgical treatment) of the exposed root surface is an impor-
approaches (47). tant component of root-coverage procedures. Various
The amount and thickness of keratinized tissue is mechanical and ⁄ or chemical approaches have been
generally thought to influence the outcome of root reported in the periodontal literature.
coverage: thick tissues and large amounts of residual Mechanical root instrumentation (such as root
keratinized tissue are ÔperceivedÕ as favorable. Many planing or root surface debridement) is first aimed to
clinicians select a coronally advanced flap or a sliding remove the microbial biofilm and has been at-
flap when the residual keratinized tissue is well rep- tempted with hand and machine-driven instruments.
resented, or place a graft under the flap when kera- It is important to remember that most Miller Class I
tinized tissue is insufficient in thickness and width and II recession defects are caused by toothbrushing
161
trauma in patients with good oral hygiene. These fibrin glue associated with tetracycline-HCl (123) and
recessions are normally associated with low levels of sodium hypochlorite (87), in combination with scal-
plaque, the presence of clinically healthy gingiva and ing and root planing, have been tested in animal and
clean root surfaces. Therefore, the relevance of clinical studies. These agents have been used to re-
planing the root surface might be questioned, and move the smear layer produced by root instrumen-
more conservative approaches should be adopted tation, to expose the collagen fibrils of the dentin
(128). A recent randomized, controlled split-mouth matrix facilitating the formation of new connective
clinical study (139) was performed to compare the tissue attachment and to remove cytopathic sub-
efficacy of hand and ultrasonic instrumentation in stances from infected cementum that inhibit human
combination with coronally advanced flap therapy in gingival fibroblast growth. Two systematic reviews
11 patients with bilateral Miller Class I single reces- (85, 102) concluded that there are no significant dif-
sions. Control root surfaces were planed with ferences in terms of root coverage between sites
curettes, while test roots were instrumented with treated with root planing alone and sites treated with
ultrasonic piezoelectric devices. Hand and ultrasonic combined chemical ⁄ mechanical treatment. There-
root instrumentation were equally effective in terms fore, chemical root surface conditioning cannot be
of root coverage and clinical attachment gain at considered as beneficial for root coverage.
6 months postsurgery. A particular root surface-conditioning approach
A randomized controlled clinical study compared consists of chemical treatment of the exposed root
two mechanical treatment modalities: root planing surface with ethylenediaminetetraacetic acid (EDTA)
with curettes vs. polishing with a rubber cup and before the application of enamel matrix derivative.
prophylaxis paste (93). The experimental population This approach is part of the clinical protocol for en-
consisted of 10 patients with bilateral similar Miller amel matrix derivative application suggested by the
Class I and II single recessions treated with the cor- manufacturer, even if its efficacy is unknown (25, 41,
onally advanced flap procedure. At 3 monthsÕ re- 46, 74, 79, 89, 115).
evaluation, the difference in terms of recession A classification of dental surface defects associated
reduction between the test and control groups was with gingival recession (cervical dental caries and ⁄ or
not statistically significant. In addition, residual abrasions) has recently been published (97). This
hypersensitivity was experienced only in sites treated classification is based on the evaluation of two mor-
with root planing. This study suggests that planing of phological conditions that may be observed on hard
the exposed root surface may be not necessary when dental tissues associated with the occurrence of gin-
shallow recessions caused by traumatic toothbrush- gival recession: the presence (Class A) or absence
ing are treated with the coronally advanced flap (Class B) of an identifiable cemento–enamel junction;
procedure in patients with high levels of oral hygiene. and the presence (+) or absence ()) of a dental sur-
Heavy mechanical root instrumentation has been face discrepancy (step). The study was carried out on
suggested to modify the root surface with the aim of 1,010 recession defects. Only 469 had an identifiable
achieving different end results, such as minimizing cemento–enamel junction without any associated
cementum toxicity (13), smoothing irregularities and step (Class A): 46%), while 144 sites showed an
grooves in the exposed surface (128), removing root identifiable cemento–enamel junction associated
caries lesions (42) and reducing the convexity of the with a root surface step (Class A+: 14%), 244 had an
root and the mesio–distal distance between the unidentifiable cemento–enamel junction with a step
interproximal spaces (55, 76). Saletta et al. (107) (Class B+: 24%) and 153 had an unidentifiable
measured the root curvature before and after cemento–enamel junction without any associated
mechanical instrumentation: vigorous root planing step (Class B): 15%).
(40 curette strokes) did not substantially modify root The high prevalence of sites with an unidentifiable
curvature, only slightly reduced (3%) the mesio–dis- cemento–enamel junction and ⁄ or with a step re-
tal dimensions and slightly flattened (6%) the root quire the adoption of clinical strategies to overcome
surface. Therefore, the use of vigorous root planing is these problems. In daily practice, clinicians should
questionable and none of the cited studies report first identify the coronal limit of the potential root
evidence to prove a beneficial influence of extensive coverage: this becomes difficult when the cemento–
root instrumentation on the outcomes of root enamel junction is not identifiable. Predicting and
coverage (128). measuring the true and surrogate outcomes becomes
The adjunctive effects of different chemical agents, impossible if the reference point (i.e. the cemento–
such as citric acid (18, 68), tetracycline-HCl (49), enamel junction) is not present. A potential solution
162
might be the ÔreconstructionÕ of the cemento–enamel provide a stable and detectable ÔreferenceÕ for both
junction with restorative dentistry prior to surgery the clinician and the patient. Another potential
(22, 138). The cemento–enamel junction can be solution is the reconstruction of the cemento–enamel
reconstructed with composite resin mimicking a junction after the complete healing of the coronally
Ônormal cemento–enamel junctionÕ (Fig. 2A–D). The positioned gingival margin (Fig. 3A–F).
methods suggested by the cited authors are obviously The presence of a step might impair the stabiliza-
based on a ÔguessÕ of the shape and position of the tion of the flap ⁄ graft on a flat or concave root
pre-existing cemento–enamel junction, but finally surface, thereby requiring a modified treatment
A B
Fig. 2. Root abrasions associated

with multiple gingival recessions are
restored before root coverage with a
C D coronally advanced flap. (A) Multiple
gingival recessions on the maxil-
lary left sextant. The cemento–
enamel junction of the cuspid is
abraded. (B) Composite restoration
of the cemento–enamel junction,
performed before surgery. (C)
Envelope-type of coronally ad-
vanced flap. (D) Clinical outcome
after 6 months.
A B
Fig. 3. Coronally advanced flap +

connective tissue graft applied on a
gingival recession associated with a
C D severe abrasion. (A) Severe recession
on the maxillary left cuspid, associ-
ated with a severe root step and
abrasion of the cemento–enamel
junction. The residual gingiva is
thick and wide. (B) A connective
tissue graft has been sutured on the
abraded root surface. (C) A trape-
zoidal flap with vertical releasing
incisions has been coronally
E F advanced. (D) The 1-year clinical
outcome. Note that the abraded ce-
mento–namel junction is visible and
has yet to be restored. The root is
over-covered and the flat surface
determines a flat gingival contour.
(E) Clinical appearance after
restoration of the cemento–enamel
junction with composite resin. (F)
Eight-year clinical stability.
163
approach. Some authors propose the use of barrier advanced flap. The authors speculated that thick
membranes on the abraded root surface: the root marginal tissues could be associated with a more
concavity under a bent barrier is perceived as a stable vascular system. Another study (136) con-
benefit because it provides extra space for peri- cluded that wider residual keratinized tissue was
odontal regeneration (90). Other authors suggest the associated with greater root coverage in sites treated
application of a thick connective tissue graft posi- with laterally positioned, coronally advanced flaps.
tioned to fill the root concavity and finally covered The importance of blood supply during healing
with a coronally advanced flap (22, 75). Lucchesi et al. has been stressed by Burkhardt & Lang (17), who
(70) proposed the reconstruction of the abraded evaluated, in a split-mouth study, the degree of
root surface with glass ionomer composite combined vascularization of connective tissue grafts following
with a coronally advanced flap approach. Two ran- the creation of double papilla flaps using microsur-
domized clinical studies compared coronally gical or macrosurgical approaches. The angiographic
advanced flap plus connective tissue graft (109) or evaluation performed immediately after the surgical
coronally advanced flap alone (110) positioned over a treatment revealed better vascularization of micro-
carefully planed root surface against the coronally surgically treated sites compared with macrosurgi-
advanced flap plus connective tissue graft or cally treated sites. The authors assumed that Ôthe
coronally advanced flap alone positioned over glass sharper and the finer surgical blades, together with
ionomer restorations applied during surgery to finer suture material used in the microsurgical
completely fill the root abrasion. According to the approach, were responsible for the reduced tissue
authors, both surgical procedures provide similar soft damageÕ. Similar conclusions were drawn by Franc-
tissue coverage either on planed or restored root etti et al. (43).
surfaces. The presence of a restoration does not The vascularization of the pedicle flap when per-
necessarily prevent root coverage but also does forming a coronally advanced flap can be further
not improve the outcome. improved if vertical releasing incisions are avoided.
Zucchelli & De Sanctis (134) proposed a surgical
technique to treat multiple adjacent recession defects
Soft tissue
based on an envelope type of flap without vertical
Soft tissue handling is another factor affecting clinical releasing incisions. The authors reported excellent
outcomes in mucogingival surgery. Design of the clinical results in terms of complete root coverage
flap, mesio–distal extension, vertical releasing inci- and optimal esthetic integration of the covering tis-
sions, split-thickness or full-thickness elevation, ten- sue. The same authors have published a study com-
sion of the flap and coronal positioning of the flap paring coronally advanced flap therapy, with and
should all be planned by the surgeon before surgery. without vertical releasing incisions, in the treatment
One of the relevant aspects strictly associated with of multiple recessions (140). Both coronally advanced
flap design is the preservation of a sufficient vascular flap techniques were effective in reducing recession
system to ensure survival of the flap and in particular depth but the envelope type of coronally advanced
of the marginal gingiva, which is the farthest part of flap (without vertical releasing incisions) was asso-
the flap from the base of the pedicle and lies on an ciated with an increased probability of achieving
avascular root surface. Wound healing of pedicle complete root coverage and with a better postoper-
flaps on exposed root surfaces depends on the pa- ative course. Nevertheless, a recent systematic review
tency of the blood vessels and on anastomoses be- reported that data on this issue are still insufficient
tween capillaries of the flap ⁄ recipient area and ⁄ or (27).
capillaries of connective tissue graft and recipient An angiographic study on humans supports the
area ⁄ flap. In order to minimize circulatory altera- hypothesis that the best clinical outcomes, in terms
tions during root coverage procedures Mörmann & of root coverage, are achievable when the flap is
Ciancio (80) suggested that Ôflaps should be broad passively adapted and sutured without tension over
enough at their base to include major gingival vessels the exposed root surface (80). Vestibule depth, root
and flap preparations to cover avascular areas should prominence, presence of frena and recession depth
not be too thin so that more blood vessels are in- may influence the passive surgical shift of the cor-
cluded in themÕ. A clinical study (10) reported that onally advanced flap towards the cemento–enamel
thick gingiva was consistently associated with better junction. If the flap is not completely released, the
outcomes in terms of recession reduction and com- sutures are positioned to overcome the residual
plete root coverage in sites treated with a coronally tension to stabilize the flap at the cemento–enamel
164
junction. As a consequence, sutures that are too taken into account to explain, at least in part, the high
tight may damage the residual vascular system of degree of variability frequently observed when stud-
the flap: vessel patency is reduced and neo-vascu- ies performed by different clinicians or groups of
larization is impaired. In addition, the residual ten- clinicians are evaluated and statistically analysed, as
sion of the flap could favor a postoperative apical observed in the meta-analyses from four systematic
shift of the gingival margin during the early phase of reviews on root coverage procedures (20, 31, 85, 102).
healing. Coronally advanced flaps, with or without the use of a
This hypothesis was confirmed by a randomized graft, are technique-sensitive procedures that require
controlled clinical study (94) performed to measure specific and refined training and a high level of skills
the tension of the coronally advanced flap before to be properly applied.
suturing and to compare the reduction in recession
following coronally advanced flap therapy with or
without tension. The statistical analysis showed that Surgical procedures
minimal flap tension (ranging from 0.0 to 0.4 g) fa-
vored recession reduction, while higher tension of the Coronally advanced flap
flap (ranging from 4 to 7 g) was associated with lower
Single recessions
recession reduction.
The position of the gingival margin in relation to The coronally advanced flap is based on the coronal
the cemento–enamel junction was proven to be an shift of soft tissues apical to the exposed root surface
important factor in achieving complete root coverage (3). The original procedure was described for cover-
with coronally advanced flap therapy. In a pilot ing isolated gingival recessions. The design of the flap
study, Pini Prato et al. (93) positioned and sutured included Ôvertical incisions lateral to the recessed area
the gingival margin 2 mm coronal to the cemento– beginning at a point apical to the papilla tip and
enamel junction, obtaining complete root coverage. extending well into the alveolar mucosaÕ (3). A sul-
Recently, the same group (95) investigated the cular incision and sharp dissection close to the
influence of the postsurgical position of the gingival periosteum allowed a split-thickness flap elevation to
margin relative to the cemento–enamel junction on be performed, reaching the alveolar mucosa. Epi-
the clinical outcomes of coronally advanced flap thelium was removed from the papillae adjacent to
therapy. Coronal displacement of the flap of ‡2 mm the recession and the flap was coronally positioned
was associated with complete root coverage in 100% and stabilized with interproximal sutures and apico–
of the patients. The results of the logistic regression coronal interrupted sutures to close the vertical
showed that the greater the coronal displacement releasing incisions. The area was dressed with a
of the flap, the greater the recession reduction (P < periodontal pack.
0.0001) and the greater the probability of obtaining This overall design of the coronally advanced flap
complete root coverage (P = 0.0003). has been developed over time with relevant modifi-
Operator skill is another important factor that can cations ⁄ improvements coming from animal and
affect the outcomes of periodontal surgery. A con- human research. Following the suggestion of Mör-
sistent center effect has been demonstrated in several mann & Ciancio (80), Pini Prato et al. (91) described a
studies of periodontal regeneration in intrabony de- flap with divergent releasing incisions to obtain a
fects (36, 111, 121, 122). Regarding root coverage, a broad base that included major gingival vessels. The
recent multicenter study, comparing coronally design of the vertical incisions was a Ôgolf club designÕ
advanced flap therapy with coronally advanced to achieve enough mesio–distal extension of the
flap + connective tissue graft therapy in single coronal part of the flap and obtain perfect adaptation
recession defects, revealed relevant differences be- to the cemento–enamel junction and the interproxi-
tween centers (37). In this study, the center effect was mal vascular recipient bed. The starting point of the
significant in spite of the fact that surgery was per- vertical incisions should be determined before sur-
formed by skilled periodontists who were specifically gery (134): the amount (in mm) of coronal shift of the
trained and calibrated to perform the surgical ap- gingiva necessary to cover the exposed root will
proaches tested; in addition, the patient population indicate the distance from each papilla tip and the
was well balanced and carefully selected according to starting point of the vertical incisions. This accurate
stringent entry criteria and randomization processes, design will allow for a perfect adaptation of the coronal
and the procedures were conducted within a com- part of the flap to the interdental recipient bed. Pini
mon and strict protocol. The center effect should be Prato et al. (91) also suggested a full-thickness elevation
165
of the gingiva. The clinical study of Baldi et al. (10) interdental interrupted sutures or sling sutures. The
proved the relevance of gingival thickness, as thick application of a periodontal pack is today broadly
gingiva was consistently associated with improved avoided.
outcomes. Flap elevation should therefore be
Multiple recessions
performed through a buccal intrasulcular incision to
the bone crest followed by a full-thickness flap When multiple gingival recessions are located on
elevation beyond the mucogingival junction. Then, adjacent teeth, root coverage should be undertaken
sharp horizontal dissection of the periosteum with one surgical procedure. The coronally advanced
reaching the vertical incisions has to be performed for flap described above can be extended to treat mul-
flap mobilization. Pini Prato et al. (94) demonstrated tiple recession defects. The pedicle flap should be
that flap tension is key to root coverage: tension-free broad enough to include all of the individual reces-
flaps have a higher chance of achieving complete root sion defects and the vertical releasing incisions will
coverage. Effort should be made to obtain complete constitute the mesio–distal limits of the flap. Zucch-
relaxation of the flap through proper apical under- elli & De Sanctis (134) proposed a modified technique
mining of the alveolar mucosa. The relaxed flap has to to treat multiple recessions; this technique was based
be positioned and stabilized to cover the exposed root on an envelope flap, aiming to avoid vertical releasing
surface (Fig. 4A–C). The position of the gingival incisions and to better preserve the vascular system
margin influences the final outcomes. Pini Prato et al. and reduce potential scars caused by the vertical
(95) showed that complete root coverage following incisions (Fig. 5A–D). The design of the envelope flap
coronally advanced flap therapy was consistently requires the involvement of one extra tooth mesial,
obtained when the flap was positioned 1–2 mm and one extra tooth distal, to the treatment area to
coronal to the cemento–enamel junction. Flap adap- allow for sufficient flap mobility. A modified oblique
tation and stabilization can be achieved through papilla incision is performed to obtain proper adap-
A B C
Fig. 4. Coronally advanced flap on a single gingival residual gingiva. (B) The trapezoidal flap has been sutured
recession associated with thick residual gingiva. (A) Single coronally to the cemento–enamel junction. (C) One-year
gingival recession on the maxillary left bicuspid with thick clinical outcome.
A B
Fig. 5. Coronally advanced flap on

multiple gingival recessions associ-
C D ated with thick residual gingiva. (A)
Multiple gingival recessions on the
maxillary left quadrant. The residual
gingiva is thick and wide. (B) An
envelope flap has been coronally
advanced to cover the cemento–en-
amel junction of all the involved
teeth. (C) The 1-week healing of the
flap. (D) The 1-year clinical out-
come.
166
tation of the surgical papilla to the recipient bed. A the graft, of about 1 mm, was also suggested. The graft
full-thickness flap, followed by a split-thickness is sutured apical to the cemento–enamel junction at a
incision beyond the mucogingival junction, is elevated distance equal to the height of the preoperative kera-
and coronally positioned to cover the cemento– tinized tissue. It has been speculated that this limited
enamel junction. A comparison between the coro- thickness and size could improve nutritional exchange
nally advanced flap, with or without vertical incisions between the recipient site, graft and covering pedicle
in multiple recessions, demonstrated that both ap- flap as well as the esthetic outcomes. In a randomized
proaches were effective in providing root coverage, controlled clinical study, Zucchelli et al. (135) com-
but the envelope flap was associated with an pared the conventional bilaminar approach with the
increased probability of obtaining complete root described novel grafting technique. Outcomes were
coverage and with a better postoperative result (140). similar in terms of root coverage, but esthetics and
perceptions of patients were much more favorable in
the sites treated with the novel approach based on the
Combined approaches
use of small grafts. The need to open a second surgical
Coronally advanced flap therapy has been proposed site to harvest the graft from the palate adds morbidity
in combination with connective tissue graft, barrier to this approach. This approach can be used to treat
membrane, enamel matrix derivative, acellular der- either single (Fig. 6A–C) or multiple (Fig. 7A–D)
mal matrix, platelet concentrated graft and living recession defects.
tissue-engineered human fibroblast-derived dermal
Barrier membranes
substitute.
Barrier membranes have been proposed and tested
Connective tissue graft
by many authors (4, 15, 33, 34, 59, 65, 67, 90, 91, 118,
Historically, the use of connective tissue grafts, either 119, 133). Both animal (33) and human histology
partially (63) or completely (40, 49, 83, 127) covered by studies (35) demonstrate the potential of this ap-
a coronally advanced flap, was suggested. These approach to regenerate periodontium with formation of
proaches consisted of thick and large connective tissue cementum, bone and periodontal ligament coronal
grafts sutured close to the cemento–enamel junction to the baseline position of the gingival margin. The
and resulted in a high prevalence of complete root barriers were positioned and fixed coronal to the
coverage. However, even if consistent root coverage cemento–enamel junction and fully covered with a
occurred, often the esthetic appearance of the treated coronally advanced flap. The barrier was bent, when
area was unsatisfactory because of the excessive possible, to provide space for clot formation on the
thickness of the grafted tissue. Recently, some surgical root surface. Some authors proposed the use of bar-
modifications to the original technique have been rier membranes on abraded root surfaces: the root
proposed to improve esthetic outcomes (135). The concavity under a bent barrier provided extra space
size, thickness and positioning of the connective tissue for periodontal regeneration (90). Comparative
graft have been modified accordingly. It has been studies demonstrated no difference between resorb-
proposed that a connective graft, 6 mm larger than the able and nonresorbable barriers in terms of root
recession width, should be applied at the cemento– coverage (102).
enamel junction; its apico–coronal dimension is cal-
Enamel matrix derivative
culated as the distance from the cemento–enamel
junction to the bone crest minus the preoperative Animal (48) and human (24, 100) histology studies
height of the keratinized tissue. An ideal thickness of have proven the potential of enamel matrix deriva-
A B C
Fig. 6. Coronally advanced flap + connective tissue graft bicuspid with thin residual gingiva. (B) The trapezoidal
on a single gingival recession associated with thin residual flap has been coronally positioned to fully cover a con-
gingiva. (A) Single gingival recession on the maxillary left nective tissue graft. (C) One-year clinical outcome.
167
A B

connective tissue graft on multiple
gingival recessions associated with a
narrow band of residual gingiva. (A)
Severe multiple gingival recessions
C D on the maxillary right quadrant. The
residual gingiva is thick but narrow.
(B) A connective tissue graft has been
sutured on top of the denuded root
surfaces. (C) A flap with a mesial-
releasing incision has been coronally
advanced to cover the connective
tissue graft and the cemento–enamel
junction of all the involved teeth. (D)
The 1-year clinical outcome.
tive associated with coronally advanced flap therapy Living tissue-engineered human fibroblast-derived
to induce periodontal regeneration. This technique dermal substitute
has been proposed and tested in several controlled
studies (25, 41, 46, 74, 79, 89, 115). Application of Another proposal to avoid the use of connective tis-
enamel matrix derivative is generally accomplished, sue grafts for the treatment of gingival recession de-
according to the manufacturer, on the planed and dry fects was published by Wilson et al. (129). The living
root surface. Application of EDTA is generally in- tissue-engineered human fibroblast-derived dermal
cluded in the procedure. The coronally advanced flap substitute is a tissue-engineered human dermal
procedure is performed in order to completely cover replacement graft manufactured through the three-
the enamel matrix derivative-treated root surface. dimensional culture of human diploid fibroblast cells
on a polymer scaffold. In this clinical randomized
Acellular dermal matrix controlled feasibility study, the effectiveness and
Acellular dermal matrix has been proposed to treat safety of human fibroblast-derived dermal substitute
recession defects in combination with advanced flaps compared with connective tissue graft for root cov-
(51) to avoid the need to harvest connective graft erage was evaluated. At 6 months, there were no
from the palate, thereby eliminating the second sur- statistically significant differences between the two
gical site and consequently decreasing morbidity. groups and it was concluded that human fibroblast-
Acellular dermal matrix is an acellular biocompatible derived dermal substitute may offer potential as a
human connective tissue matrix; this allograft of substitute for connective tissue graft in the treatment
human skin is processed to eliminate the epithelium of Miller Class I and II recession defects. This needs
and all cellular components of the connective tissue to be confirmed in independent studies and cost–
and then freeze-dried. The basal membrane is benefit analyses performed.
maintained. Several clinical studies have docu-
Platelet concentrated graft
mented root coverage and good esthetic results using
acellular dermal matrix (2, 12, 52, 53, 130). A histology Platelets contain many autogenous growth factors
study in human samples (39) compared therapy with (including platelet-derived growth factor, insulin-like
connective tissue grafts, acellular dermal matrix growth factor and transforming growth factor-beta)
grafts and coronally advanced flap, and identified the that regulate several biologic activities at both genetic
formation of a dense layer of collagen attached to the and cellular levels. Platelet-rich plasma is highly
root surface and unaffected underlying alveolar bone concentrated in platelets and hence there are many
in the three groups. On the basis of these observa- growth factors in a limited volume of plasma (71).
tions the authors concluded that connective tissue In vitro studies have demonstrated that growth
graft and acellular dermal matrix grafts can be factors contained in the platelet-rich plasma are
successfully and safely used to treat exposed root involved in the regulation of expression of osteoblast-
surfaces. associated genes (116), regulate the expression of
168
mineral-associated genes in cementoblasts (112), Table 1 presents a summary of the meta-analyses

modulate the proliferation of periodontal cells in conducted with coronally advanced flap as the con-
vitro (86) and stimulate collagen synthesis in peri- trol treatment. Coronally advanced flap + connective
odontal ligament and osteoblastic cells in vitro (61). tissue graft and coronally advanced flap + enamel
Marx et al. (71) demonstrated that a concentration of matrix derivative were associated with a higher
1 · 106 platelets ⁄ ml favors the early stages of wound probability of obtaining complete root coverage and
healing. Several clinical studies showed that platelet- greater amounts of recession reduction than coro-
rich plasma may enhance early graft maturity, bone nally advanced flap alone. Coronally advanced flap +
density and new bone formation (7, 23, 32, 66, 132). barrier membrane, coronally advanced flap + acel-
Different modes of application of platelet concen- lular dermal matrix and coronally advanced flap +
trated graft under a coronally advanced flap have platelet concentrated graft were not any more likely
been proposed in mucogingival surgery. Griffin & than coronally advanced flap alone to obtain com-
Cheung (45) and Cheung & Griffin (30) used a colla- plete root coverage and were not associated with
gen resorbable sponge soaked with platelet-rich greater amounts of recession reduction.
plasma, and others (58, 62) applied platelet-rich For keratinized tissue gain, the adjunctive use of
plasma to a collagen graft, while Huang et al. (56) connective tissue graft or enamel matrix derivative
applied platelet-rich plasma directly onto the planed under a coronally advanced flap was associated with
root surface. A coronally advanced flap is performed a gain of keratinized tissue compared with coronally
in all instances to cover the platelet concentrated advanced flap alone, while combinations of coronally
graft or platelet-rich plasma. advanced flap + barrier membrane, coronally ad-
vanced flap + acellular dermal matrix and coronally
advanced flap + platelet concentrated graft did not
Clinical outcomes of coronally result in any significant differences compared with
advanced flap and coronally coronally advanced flap alone.
advanced flap-based approaches As coronally advanced flap + connective tissue
graft showed the best outcomes, Cairo et al. (20)
A recent meta-analysis from a systematic review (20) performed additional comparisons considering cor-
evaluated a total of 794 Miller Class I and II gingival onally advanced flap + connective tissue graft as the
recession defects in 530 patients from 25 randomized control surgical procedure (Table 2). Single studies
controlled trials. Coronally advanced flap was se- compared coronally advanced flap + enamel matrix
lected as the reference treatment and was compared derivative and coronally advanced flap + human
with the possible combinations (coronally advanced fibroblast-derived dermal substitute vs. coronally
flap + connective tissue graft, coronally advanced flap + advanced flap + connective tissue graft, and reported
enamel matrix derivative, coronally advanced flap + no significant differences in terms of complete root
barrier membrane, coronally advanced flap + acel- coverage. No significant differences in complete
lular dermal matrix, coronally advanced flap + root coverage were reported when comparing coronally
platelet concentrated graft and coronally advanced advanced flap + barrier membrane and coronal-
flap + human fibroblast-derived dermal substitute). ly advanced flap + acellular dermal matrix vs.
Complete root coverage was considered as the pri- coronally advanced flap + connective tissue graft,
mary outcome variable; recession reduction and although a trend favoring coronally advanced flap +
keratinized tissue changes were secondary outcomes. connective tissue graft was detected. In terms of
This systematic review confirmed that coronally ad- recession reduction, the meta-analyses reported
vanced flap is a safe and reliable approach and is better results for coronally advanced flap + connec-
consistently associated with complete root coverage tive tissue graft vs. coronally advanced flap + barrier
and recession reduction. Results from meta-analyses, membrane, but no significant differences were re-
however, showed that two combinations (coronally ported vs. coronally advanced flap + acellular dermal
advanced flap + connective tissue graft and coronally matrix; for this comparison, however, the test for
advanced flap + enamel matrix derivative) provided heterogeneity was statistically significant (P = 0.002).
better results than coronally advanced flap alone Comparisons in terms of recession reduction
and no other therapy provided better results than between coronally advanced flap + enamel matrix
coronally advanced flap + connective tissue graft in derivative and coronally advanced flap + human
terms of complete root coverage and recession fibroblast-derived dermal substitute vs. coronally
reduction. advanced flap + connective tissue graft were not
169
Table 1. Outcomes from meta-analyses conducted with coronally advanced flap as the control treatment (20)
Coronally advanced flap alone vs.
Coronally Coronally Coronally Coronally Coronally

advanced flap + advanced flap + advanced advanced flap + advanced
connective enamel matrix flap + barrier acellular dermal flap + platelet
tissue graft derivative membranes matrix concentrated
graft
Complete root coverage

No. of randomized clinical trials Two Four One Two One
Significance (P-value) 0.03 0.003 0.41 0.31 0.79

Odds ratio 2.49 3.89 0.58 4.83 1.25
95% confidence interval 1.10–5.68 1.59–9.50 0.16–2.08 0.23–99.88 0.23–6.71

Recession reduction
No. of randomized clinical trials Two Five Two Two One

Mean difference (mm) 0.49 0.58 )0.27 0.60 )0.20

95% confidence interval 0.14–0.83 0.14–0.83 )0.60 to 0.06 )0.52 to 1.73 )0.89 to 0.49
Keratinized tissue
No. of randomized clinical trials Two Five Two Two One

Mean difference (mm) 0.73 0.42 0.15 0.31 )0.30
95% confidence interval 0.35–1.10 0.18–0.66 )0.13 to 0.42 )0.15 to 0.78 )0.97 to 0.37
Comparative test treatments were connective tissue graft + coronally advanced flap, coronally advanced flap + enamel matrix derivative, coronally advanced
flap + barrier membranes, coronally advanced flap + acellular dermal matrix and coronally advanced flap + platelet concentrated graft.
possible owing to the methods of data presentation the original articles (74, 129). However, McGuire &
in the original articles (74, 129), even if no statisti- Nunn (74) reported greater gain of keratinized tissue
cally significant difference was reported by the for coronally advanced flap + connective tissue graft
authors. Therefore, no combined therapy was more than for coronally advanced flap + enamel matrix
effective than coronally advanced flap + connective derivative (P < 0.001) 1 year following therapy, while
tissue graft for achieving complete root coverage and Wilson et al. (129) reported no difference. Therefore,
recession reduction. no therapy was more effective than coronally ad-
Only two comparisons were possible for kerati- vanced flap + connective tissue graft in achieving
nized tissue gain. Coronally advanced flap + con- keratinized tissue gain.
nective tissue graft resulted in better outcomes when
compared with coronally advanced flap + barrier
membrane and coronally advanced flap + acellular Healing dynamics and long-term
dermal matrix. For the comparison with coronally outcomes after coronally advanced
advanced flap + barrier membrane, the test for het- flap or combination therapy
erogeneity was statistically significant (P < 0.00001).
Comparisons in terms of keratinized tissue gain be- What happens to the gingival margin shortly after a
tween coronally advanced flap + enamel matrix root coverage procedure? Following coronally ad-
derivative and coronally advanced flap + human vanced flap therapy of single recession defects, Pini
fibroblast-derived dermal substitute vs. coronally Prato et al. (93) reported that the gingival margin,
advanced flap + connective tissue graft were not sutured, on average, 1 mm coronal to the cemento–
possible because of the data-presentation methods in enamel junction, remained stable at week 1, but
170
Table 2. Outcomes from meta-analyses conducted with coronally advanced flap + connective tissue graft as the
control treatment (20)
Coronally advanced flap + connective tissue graft vs.
Coronally Coronally Coronally Coronally

advanced advanced advanced advanced
flap + enamel flap + barrier flap + acellular flap + human
matrix derivative membranes dermal matrix fibroblast-derived
dermal substitute
Complete root coverage

No. of randomized clinical trials One Six Four One
Significance (P-value) 0.31 0.06 0.06 1.00

Odds ratio 2.31 0.45 0.49 1.00
95% confidence interval 0.45–11.74 0.20–1.04 0.23–1.03 0.02–50.40

Recession reduction
No. of randomized clinical trials One Six Four* One

Significance (P-value) – 0.008 0.24 –
Mean difference (mm) – )0.38 )0.40 –

95% confidence interval – )0.65 to )0.10 )1.07 to 0.26 –
Keratinized tissue
No. of randomized clinical trials – Six* Four –
Significance (P-value) – 0.004 0.004 –

Mean difference (mm) – )1.18 )0.90 –
95% confidence interval – )1.98 to )0.39 )1.51 to )0.28 –

Comparative test treatments were coronally advanced flap + enamel matrix derivative, coronally advanced flap + barrier membranes, coronally advanced
flap + acellular dermal matrix and coronally advanced flap + human fibroblast-derived dermal substitute.
*Test for heterogeneity was statistically significant.
shifted apically from weeks 2 to 4, uncovering the vanced flap-treated sites and with 17 exposed ce-
cemento–enamel junction in 60% of the sites with an mento–enamel junctions out of 42 coronally ad-
average shift of 1.5 ± 0.6 mm. From week 4 to week vanced flap + connective tissue graft-treated sites
12 after the procedure, the gingival margin remained (Fig. 8). The tendency for an apical shift of the gin-
stable. Cortellini et al. (37) tested the stability of the gival margin to occur after surgery was confirmed in
gingival margin in a controlled clinical trial compar- two case series on single recession defects published
ing the potential benefit of adding a graft under a flap by Baroffio et al. (11) in coronally advanced
with coronally advanced flap therapy alone, in single flap + connective tissue graft cases and published by
gingival recession defects. At week 1, the cemento– Centra & Gionso (26) in cases of coronally advanced
enamel junction was visible in five (12%) of the pa- flap therapy alone.
tients treated with a coronally advanced flap and in Long-term studies show different patterns in the
three (7%) of the patients treated with a coronally tendency for recurrence of recession following dif-
advanced flap + connective tissue graft. There was a ferent root coverage procedures. Leknes et al. (65)
steady increase in the number of patients with a reported severe recurrence of gingival recession in a
visible cemento–enamel junction over the following 6-year study of sites treated either with coronally
3 weeks. The increase in the number of sites with a advanced flap or with coronally advanced flap +
visible cemento–enamel junction was greater in the bioresorbable barriers. At 6 months, five sites trea-
coronally advanced flap-treated sites; this trend was ted with coronally advanced flap + barrier mem-
further confirmed at the 3- and 6-month examination brane and 10 sites treated with coronally advanced
time-points, ending at 6 months with 27 exposed flap alone were completely covered in a population
cemento–enamel junctions out of 43 coronally ad- of 11 bilateral single recession defects. At 6 years,
171
30 27 60
Coronally advanced flap
cemento-enamel junction
No. of sites with exposed
25
Complete root coverage (%)

25 Coronally advanced flap
50
+connective tissue graft
20 40
16
17
15 13 17 30
10
10
20 Coronally advanced flap
5 8
5 7 Coronally advanced flap+connective tissue graft
2 10
4
3 1
0
0 1 2 3 4 12 24 0
6 months 1 year 5 year
Weeks
Follow-up
Fig. 8. Number of sites with exposed cemento–enamel
junction (indicated as numbers next to points in the Fig. 9. Number of sites with complete root coverage in
graph) in patients treated with coronally advanced flap patients treated with coronally advanced flap (blue) and
(blue) and coronally advanced flap + connective tissue coronally advanced flap + connective tissue graft (red).
graft (red). The graph shows a tendency for a progressive The graph shows a tendency of a progressive apical shift
increase in the number of sites with exposed cemento– through time in the coronally advanced flap-treated sites,
enamel junction through time for both groups. The sites whereas the sites receiving a connective tissue graft
receiving a connective tissue graft demonstrate greater demonstrate a tendency for improved root coverage.
stability. Modified from Cortellini et al. (37). Modified from Pini Prato et al. (98).
only two sites treated with barriers and one site crease the stability of the gingival margin over time.
treated with coronally advanced flap alone were still Interestingly, a trend of the so-called Ôcreeping
completely covered. Nickles et al. (84) compared attachmentÕ of grafted sites was reported in a 27-year
sites treated with coronally advanced flap + a bio- follow-up study (1). The authors reported a signifi-
resorbable barrier to sites treated with coronally cant coronal shift of the gingival margin in grafted
advanced flap + connective tissue graft. After sites, while observing an apical shift of the gingival
10 years, stability of root coverage was significantly margin at contralateral nongrafted sites.
better in the sites treated with coronally advanced In summary, it is apparent that the position of the
flap + connective tissue graft. In other words, the gingival margin tends to shift apically after surgery in
sites treated with a barrier membrane underwent a the short term after coronally advanced flap therapy
greater apical shift of the gingival margin over alone or in combination with other procedures. The
time. A 14-year study of 22 single recession defects greatest recurrence of recession seems to occur after
treated with coronally advanced flap alone similarly coronally advanced flap therapy alone, while the
reported a consistent apical shift of the gingival interposition of a graft seems to enhance the stability
margin in 39% of the cases (96). In a 5-year eval- of the gingival margin. Grafted sites, over the long
uation of a case series treated with the envelope term, show a tendency for a coronal shift of the
type of coronally advanced flap on multiple gingival margin, while the coronally advanced flap-
recession defects, Zucchelli & De Sanctis (137) treated sites confirm a tendency for recurrence of
reported a slight shift of the gingival margin com- recession similar to sites treated with coronally ad-
pared with the 1-year data. The amount of long- vanced flap + barrier membrane.
term recurrence, however, was very limited. In fact,
complete root coverage was observed in 88% of
the patients at 1 year, and was reduced to 85% at Patient-related outcomes and side
5 years. In contrast, a long-term comparative study
(98) of multiple recession defects treated with
effects
coronally advanced flap alone or with coronally
Dentinal hypersensitivity
advanced flap + connective tissue graft showed a
consistent shift of the gingival margin over time in Very few studies have evaluated dentinal hypersen-
the coronally advanced flap-treated sites, whereas sitivity following root coverage procedures. Cortellini
the coronally advanced flap + connective tissue et al. (37) compared coronally advanced flap + con-
graft-treated sites showed a tendency for a coronal nective tissue graft vs. coronally advanced flap alone,
shift of the gingival margin (Figs 9, 10A–E, 11C–D). and reported no statistically significant differences
The reported studies seem to indicate a possible for dental hypersensitivity (12% in the test group
beneficial role of adding a graft under a flap to in- and 12% in the control group) 6 months following
172
A B
C D

connective tissue graft on multiple
gingival recessions associated with a
narrow band of residual gingiva and
stability over time. (A) Recessions on
the upper maxillary cuspid and
bicuspid. The residual gingiva is thin
E and narrow. (B) A connective tissue
graft has been sutured on top of the
denuded root surfaces. (C) A trape-
zoidal flap has been coronally
advanced to cover the connective
tissue graft and the cemento–en-
amel junction of all the involved
teeth. (D) The 1-year clinical out-
come. (E). Clinical stability after
5 years.
A B
Fig. 11. Coronally advanced flap on

multiple gingival recessions associ-
ated with a narrow band of residual
gingiva and recurrences over time.
(A) Contralateral side of the patient
C D described in Fig. 10, presenting with
gingival recessions on the maxillary
right cuspid and bicuspid. The
residual gingiva is thin and narrow.
(B) An envelope flap has been
coronally advanced to cover the
cemento–enamel junction of all the
involved teeth. (C) The 1-year clini-
cal outcome. (D) Gingival recession
recurrence after 5 years.
therapy. McGuire & Nunn (74) reported dentinal

Esthetics
hypersensitivity in only one patient treated with
coronally advanced flap + enamel matrix derivative Some studies have evaluated esthetic satisfaction
and no dentinal hypersensitivity for a coronally ad- following therapy. Romagna-Genon (103) compared
vanced flap + connective tissue graft 1 year following coronally advanced flap + barrier membrane vs.
therapy. Pini Prato et al. (93) reported reduced coronally advanced flap + connective tissue graft in a
hypersensitivity in sites treated with prophylaxis split-mouth study, and reported that one patient was
compared to sites treated with root planing following not satisfied with either treatment. In a study by
coronally advanced flap therapy. Wang et al. (126) a double esthetic evaluation was
173
performed by a periodontist blinded to the treatment vanced flap + connective tissue graft group, and these
and by the patients. The periodontist rated treatment differences were statistically significant (coronally ad-
outcomes at 6 months, concluding that 15 out of 16 vanced flap + connective tissue graft: 32.2 ± 28.4; and
barrier membrane sites and 11 connective tissue graft coronally advanced flap, 17.8 ± 19.9; data obtained
sites had an excellent colour match. Patient satis- using a visual analog scale; P = 0.0068). No statistically
faction with esthetics (colour match, overall satis- significant difference for pain was reported between
faction and amount of root coverage) was the same the two groups (23.8 ± 19.4 for coronally advanced flap
for both treatments, even if greater overall satisfac- and 31.4 ± 24.6 for coronally advanced flap + con-
tion was expressed for barrier membrane sites. nective tissue graft; data obtained using a visual analog
Aichelmann-Reidy et al. (2) compared coronally scale; P = 0.0811). In studies using barrier membranes,
advanced flap + acellular dermal matrix vs. coronally a frequent complication was membrane exposure: A-
advanced flap + connective tissue graft in a split- marante et al. (4) reported the exposure of several
mouth study in 22 patients, performing a double membranes in coronally advanced flap + barrier
esthetic evaluation (blinded clinician and patients). membrane sites, while Lins et al. (67) reported the
The clinician considered that sites with coronally exposure of all membranes in all treated sites (10 ⁄ 10).
advanced flap + acellular dermal matrix were asso- In studies comparing coronally advanced flap + bar-
ciated with better results in 11 patients, while the rier membrane and coronally advanced flap + con-
outcomes in the other 11 patients were similar to nective tissue graft, membrane exposure was reported
those of coronally advanced flap + connective tissue as a possible complication in seven of 15 patients
graft. Nine patients out of 22 considered coronally (Jepsen et al. (59)), in two of 12 patients (Trombelli
advanced flap + acellular dermal matrix to be asso- et al. (125)) and in five of 12 patients (Tatakis &
ciated with better esthetics; in 12 patients outcomes Trombelli (118)). Jepsen et al. (59) reported a similar
were considered similar to coronally advanced incidence of postoperative pain for both treatments
flap + connective tissue graft and the remaining (five of 15 patients). Tatakis & Trombelli (118) reported
patient preferred the side treated with coronally seven cases of swelling in 12 patients treated with a
advanced flap + connective tissue graft. Keloid for- coronally advanced flap + barrier membrane but none
mation was reported in one patient treated with a for patients treated with a coronally advanced
coronally advanced flap + connective tissue graft. flap + connective tissue graft. No complications for a
Zucchelli et al. (135) compared the esthetic outcome coronally advanced flap + barrier membrane were
of a conventional thick connective tissue graft asso- reported by Wang et al. (126). Instead, they reported
ciated with coronally advanced flap with the outcome one swelling and one ecchymosis in the coronally ad-
after treatment with a thinner and smaller graft. Both vanced flap + connective tissue graft group. Romagna-
procedures resulted in similar root coverage, but the Genon (103) described postoperative discomfort at the
esthetic appearance of the sites treated with the thin palatal donor site for the connective tissue graft. Sites
graft got a higher score. The same authors (140) treated with barrier membrane were more frequently
compared two types of coronally advanced flaps on symptom-free. None of the patients reported exposure
multiple recession defects: the envelope type vs. the of the membrane. No complications were reported in
flaps with vertical releasing incisions. Root coverage comparisons between coronally advanced flap +
was similar with both procedures but the envelope enamel matrix derivative vs. coronally advanced flap
type resulted in better esthetics. (79), coronally advanced flap + acellular dermal ma-
trix vs. coronally advanced flap (38, 130) and coronally
advanced flap + acellular dermal matrix vs. coronally
Adverse side effects
advanced flap + connective tissue graft (60). When
Pain and complications are unusual following root comparing coronally advanced flap + enamel matrix
coverage procedures. Da Silva et al. (40) reported no derivative vs. coronally advanced flap + connective
complications when comparing coronally advanced tissue graft, McGuire & Nunn (74) reported higher
flap + connective tissue graft vs. coronally advanced discomfort for the connective tissue graft procedure
flap. Cortellini et al. (37) reported three cases of (P = 0.011) 1 month after therapy.
haematoma in 43 patients treated with coronally ad- No statistically significant differences for compli-
vanced flap and five cases of haematoma in 42 patients cations were reported when comparing coronally
treated with coronally advanced flap + connective advanced flap + platelet concentrated graft vs. coro-
tissue graft. A higher number of patients with postop- nally advanced flap (56), using a wound healing
erative swelling was reported for the coronally ad- index.
174
A reasonable starting point for a flow chart is to set

Flow charts and discussion the outcomes of therapy (Fig. 12). Treatment of
recession is often undertaken to satisfy the esthetic
In the era of evidence-based medicine, clinicians are demands of patients: the main outcome should
invited to adopt evidence-based decisions for ther- therefore be esthetic satisfaction of the patient (37,
apy. However, it is apparent that evidence-based 74, 93). However, scientific background on this ÔtrueÕ
decision-making is lacking in many areas of peri- outcome is very scarce. A number of research groups
odontal therapy, including decisions about achiev- are now proposing novel Ôevaluation scalesÕ of
ing root coverage at recession defects. The lack of esthetics that need validation and adoption in con-
evidence means that clinical experience is used trolled studies (21, 104): these will probably help
when making clinical decisions. The literature sur- clinicians in the future to choose the proper ap-
vey performed in this review attempts to provide proach and acknowledge patient desires. Owing to
clinicians with enough scientific and clinical support this lack of information, we are therefore forced to
to take proper decisions. References to support the make decisions based on Ôsurrogate outcomesÕ.
following flow charts have been reported earlier in Complete root coverage is the one mostly used, along
this review. with recession reduction. Another commonly re-
A B Amount of KT C
Cost–benefit
Root coverage
CAF + CTG CAF+BM CAF
CAF+CTG CAF+EMD CAF+BM CAF
CAF+CTG CAF CAF+ADM CAF+EMD
CAF+EMD CAF+BM CAF+ADM CAF+PRC

CAF+PRC
CAF+ADM Increased morbidity and chair-time

Increment over Reduction over
CAF+PCG baseline baseline
Increased outcomes
D Cost–benefit E F
CAF+BM CAF Long term

Esthetics
CAF+ADM CAF+CTG CAF+CTG CAF CAF+BM
CAF+PRC CAF CAF + thin CTG CAF + EMD Greater stability
CAF+EMD
Increased financial costs
Fig. 12. Objectives of therapy. (A) When the objective of respect to a coronally advanced flap, alone or together with
therapy is root coverage, meta-analyses demonstrate that enamel matrix derivative (EMD) (green). These results were
the combinations of coronally advanced flap (CAF) + supported by controlled studies. (D) When evaluating the
connective tissue graft (CTG) and coronally advanced cost–benefit ratio, clinicians should consider that increased
flap + enamel matrix derivative (EMD) (green) result in the financial costs are associated with the combinations in red
best clinical outcomes. (B) When the objective of therapy is with respect to a coronally advanced flap, alone or with a
increased keratinized tissue (KT), meta-analyses demon- connective tissue graft (green). These results were
strate that adding a graft or even enamel matrix derivative supported by expert opinions. (E) According to existing
under a flap (green) results in increased keratinized tissue. evidence, the three suggested procedures (green) do result
The amount of keratinized tissue is slightly reduced over in the best esthetic outcomes. These results were supported
time when a coronally advanced flap alone or with platelet- by controlled studies. (F) Considering the long-term sta-
rich concentrate (PRC) (red) is used. There is a minor bility of therapy, results obtained with coronally advanced
reduction in keratinized tissue when a barrier membrane flap + connective tissue graft (green) are reportedly more
(BM) or an acellular dermal matrix (ADM) (orange) is stable over time than results obtained with coronally
added to a coronally advanced flap. (C) When considering advanced flap or coronally advanced flap + barrier mem-
the cost–benefit ratio, greater morbidity and chair-time are brane (red). These results were supported by controlled
associated with some combinations (red and orange) with studies. PCG, platelet concentrated graft.
175
ported outcome of interest is an increase in kerati- flap + barrier membrane (65, 84, 96). This evidence
nized tissue. adds strong support to the placement of a graft under
Overall, the results of meta-analyses showed that a coronally advanced flap to improve both short-term
two treatment combinations – coronally advanced and long-term outcomes (Fig. 12F).
flap + connective tissue graft and coronally advanced Figure 12A–F is mainly supported by meta-analy-
flap + enamel matrix derivative – provide the best ses based on randomized controlled trials that pro-
clinical outcomes for both complete root coverage vide substantial support for our decision-making
and recession reduction (Fig. 12A), while coronally process (20). However, we should remember that the
advanced flap + connective tissue graft results in the random assignment of a therapy cannot satisfy the
greatest gain of keratinized tissue, followed by coro- requirements of each single clinical case. In other
nally advanced flap + enamel matrix derivative words, the presurgical analysis of every patient
(Fig. 12B) (20). In other words, coronally advanced should incorporate information that cannot be fully
flap + connective tissue graft Ôwins the gameÕ for all exploited by the meta-analytic process of random-
the most common surrogate outcomes and should ized controlled trials. This individual, clinically ori-
therefore be considered the treatment of choice. ented analysis is presented in Figs 14 and 15.
Coronally advanced flap + enamel matrix derivative The second step in our decision-making process is
therapy is a potential alternative. The other combi- trying to forecast the outcomes by assessing patient,
nations tested do not offer advantages over coronally tooth and defect ⁄ site prognostic factors. Figure 13
advanced flap therapy alone (20). lists the factors that researchers and clinicians believe
Our decision-making process, however, should are relevant to root coverage. Most of these are not
include clinical considerations regarding patient supported by evidence (yellow).
morbidity and potential side effects that are inherent Among the potential patient factors, only smoking
to the second surgical site required when harvesting has sufficient evidence to indicate a clear, negative
a graft from the palate (Fig. 12C) (37, 40, 103). The effect on root coverage (28). The potential influence
desire to reduce morbidity, side effects and also the of oral hygiene habits (19) relies on the hypothesis
surgical chair-time creates challenges and suggests that improper toothbrushing can cause recession: the
adoption of the second-best combination therapy same aggressive oral hygiene habit might impair the
(coronally advanced flap + enamel matrix derivative) short-term and long-term outcomes of surgery. Age,
or of one of the other tested combinations with gender and race have not been explored in well-de-
acellular dermal matrix, barrier membrane or
platelet-rich plasma (4, 38, 56, 59, 60, 67, 74, 79,
130).
All of these combinations, however, are based on Patient Tooth Defect/site
factors factors factors
the use of commercial products that will increase the
financial cost of the treatment (Fig. 12D). Consider- 100%
Smoke Abrasion Miller class I, II
ations about cost–benefit should therefore be intro-
Root coverage
duced into our decision-making process; however, Thicker KT
cost–benefit analyses are still absent in the published 50%

Papilla morphology
literature. Adoption of coronally advanced flap ther-
apy alone would slightly compromise the outcomes, Deeper Recession
0
but would reduce morbidity, surgical chair-time and
Age Type Miller class III, IV
costs (37).
Gender Maxillary-Mandibular KT width
Looking at the limited evidence on esthetics, it is
apparent that coronally advanced flap alone, coro- Race Position Vestibule depth
nally advanced flap + enamel matrix derivative and Oral hygiene Vitality
coronally advanced flap + thin connective tissue graft Fig. 13. Factors affecting root coverage. Patient, tooth and
are the techniques which achieve the best esthetic defect ⁄ site factors are clustered at two levels. The factors
outcomes (Fig. 12E) (2, 103, 126, 135, 140). supported by evidence are shown in violet boxes. Some of
Other relevant information for the choice of which the factors generally perceived as relevant by experts, but
without evidence, are shown in yellow boxes. The col-
procedure to use comes from long-term studies
oured arrows indicate the impact of each supported factor
indicating a greater stability of coronally advanced on root coverage, according to the existing literature: red
flap + connective tissue graft compared with coro- arrow = negative impact; blue arrow = no difference;
nally advanced flap alone or coronally advanced green arrow = positive impact; KT = keratinized tissue.
176
signed studies: in other words, we do not know their Tooth structure

influence.
Among the tooth factors, there is evidence to indi- CEJ Step
cate that the presence of abrasions does not impair

root coverage. Most clinicians believe that tooth po- Detectable Not detectable Absent Present
sition has an influence on root coverage: rotated and

buccally positioned teeth could make it more difficult Reconstruction Barrier Graft Composite
with composite under flap under flap under flap
to perform the procedure. There are also hypotheses
that a poorer outcome might be achieved with man-
Surgery
dibular teeth and larger units (such as molars). There
is no real evidence regarding the influence of tooth Fig. 14. Analysis of the tooth structure. If the cemento–
vitality on outcomes (14, 73, 81, 82). enamel junction (CEJ) is detectable (green) and no steps
Among the defect ⁄ site factors, there is evidence to are present (green), surgery can be undertaken without
any additional treatment. If the cemento–enamel junction
indicate the potential for complete root coverage of
is not detectable (red) and ⁄ or a step is present (red), an
Miller Class I and Class II defects (77). Evidence additional approach is suggested before flap suturing.
indicates that thicker gingiva is associated with a Supported by controlled studies.
greater probability of obtaining complete root cov-
erage by therapy with a coronally advanced flap (3,
127). There is limited evidence indicating that even in solutions have been proposed and successfully tes-
Class III defects, complete root coverage might be ted: (i) placement of a connective tissue graft (22, 75)
achieved (8). There is conflicting evidence on papilla or (ii) a barrier (90) under a coronally advanced flap
height and width (47, 88, 106): some authors report or (iii) the presurgical reconstruction of the missing
better outcomes with shorter papillae (with coronally root structure with composite (109, 110). In many
advanced flap), whereas others report better out- instances, a missing cemento–enamel junction is
comes with longer papillae (with coronally advanced associated with a step (24% prevalence) (96). This
flap + connective tissue graft). Recession depth is condition requires the adoption of one of the sug-
inversely correlated with root coverage: the deeper gested measures to correct both the anatomical
the recession defect, the more difficult it is to achieve deformities.
the root coverage. Vestibule depth is indicated as The nature of the periodontal soft tissues is rele-
relevant by most of the experts: the shallower the vant to the surgical approach. There is a common
vestibule, the more difficult the coronal positioning clinical ÔfeelingÕ that thick and wide residual gingiva
of the flap. favors root coverage (Fig. 15). The experts tend to
In summary, reduced outcomes are to be expected suggest the use of coronally advanced flap alone in
in smokers with aggressive oral hygiene habits, and at this instance. When the residual soft tissue is
deep recessions with thin gingiva, located in the narrow and thin, the adjunctive use of a graft is
lower jaw in buccally positioned and rotated teeth generally advocated. One study (10) has supported
with shallow vestibules. the importance of flap thickness when undertaking
Analysis of the tooth structure is first directed to a coronally advanced flap procedure, but no stud-
check for the presence of the cemento–enamel ies have directly tested the impact of the width
junction (Fig. 14). If the cemento–enamel junction is of the residual gingiva and the outcomes of coro-
intact or only slightly abraded, no presurgical treat- nally advanced flap alone or combination therapy.
ment is required. If the cemento–enamel junction is Observations from short-term and long-term studies
missing (39% prevalence) (97), we do not have the discussing the healing dynamics and the long-term
coronal reference available to indicate the level of stability of the gingival margin, however, seem to
maximum potential root coverage. In this instance, it confirm that the additional use of a graft under a flap
is suggested that the cemento–enamel junction improves the short-term and long-term outcomes
should be rebuilt with composite before surgery (11, 26, 37, 93). Other combination therapies (enamel
(ensuring that this is not plaque-retentive) (22, 138). matrix derivative, acellular dermal matrix and plate-
A second, frequent, observation (38% prevalence) is let-rich plasma) might help to achieve the same
the presence of a step (97). The step, caused by the additive effect. The use of barrier membranes does
aggressive brushing habit of the patient, can be very not improve the outcomes over and above those
deep, causing a problem of adaptation of the coro- achieved by the coronally advanced flap procedure
nally advanced flap. In this instance, three potential alone (20).
177
Residual KT
Published evidence on single recession defects
suggests a design of the flap with divergent vertical-
releasing incisions to produce a trapezoidal shape
with a large apical base (Fig. 17) (3, 80, 91). Full-
Thick Thin
thickness elevation to the mucogingival junction is
generally preferred (10). An even periosteal incision
CAF CAF + is produced beyond the mucogingival junction,
followed by careful undermining of the alveolar
mucosa to release tension. The gingival margin has to
be passively positioned and sutured 1–2 mm coronal
Graft EMD ADM PRP to the cemento–enamel junction (93, 95). The same
rules can be extended to procedures involving mul-
Fig. 15. Analysis of periodontal tissues. If residual kera-
tiple recessions. In these cases, however, an envelope
tinized tissue (KT) is thick (green), coronally advanced
flap (CAF) therapy alone can result in predictable root type of flap is also suggested to avoid vertical inci-
coverage. If keratinized tissue is thin (red) a combination sions, when possible (134). Among the different
therapy might be indicated. Supported by expert opinions. combinations proposed in the published literature,
EMD, enamel matrix derivative; ADM, acellular dermal the coronally advanced flap + connective tissue graft
matrix; PRP, platelet-rich plasma.
procedure demonstrates the best outcomes, followed
by treatment with the coronally advanced flap +
enamel matrix derivative (20). Esthetic appearance
Mechanical treatment of root surfaces at surgery is using a coronally advanced flap + connective tissue
the treatment of choice (Fig. 16). Evidence indicates graft is a concern, probably because of the habit of
that either hand instruments or powered instru- grafting thick connective tissues (40, 49, 83, 127). The
ments, including prophylaxis, result in similar use of thin and small-sized grafts has been proposed
outcomes (93, 128, 139). There is no evidence to to improve esthetics (135). Barriers, acellular dermal
support any beneficial effect of chemical root con- matrix, platelet concentrated graft and human
ditioning in addition to mechanical debridement fibroblast-derived dermal substitute do not provide
(85, 102). benefits in addition to coronally advanced flap alone
Root surface treatment
Mechanical Chemical Fig. 16. Root surface treatment.

treatment treatment Mechanical instrumentation (green)
performed with different ap-
proaches is considered the treat-
Hand Sonic/ Tooth EDTA Citric acid Sodium Fibronectin &
instrument ultrasonic cleaning hypochlorite tetracycline ment of choice. Chemical therapy
(red) does not provide any adjunc-
tive benefit. Supported by controlled
Similar No adjunctive effect studies. EDTA, ethylenediaminetetra-
outcomes
acetic acid.
CAF CAF
single multiple
Trapezoidal flap Trapezoidal flap Envelope flap

with vertical with vertical
incisons incisons Fig. 17. Surgical procedure. Techni-
cal tips to perform a coronally ad-
Full thickness flap
vanced flap (CAF) either on single or
Release
with periosteal
tension
multiple recession or a combination
incision therapy. Supported by controlled
Graft Barrier ADM EMD PRP
studies. ADM, acellular dermal
matrix; EMD, enamel matrix deriva-
Coronal position tive; PRP, platelet-rich plasma; CEJ,
above the CEJ
cemento–enamel junction.
178
(20). From a surgical standpoint, all these materials morbidity and chair-time, but increases the financial
or products are applied on the denuded and debrided cost of therapy.
root surface, sutured when indicated and fully cov- Clinicians should make their decisions after
ered with the coronally advanced flap. defining the desired short-term and long-term out-
comes, having completed a careful presurgical anal-
ysis and having discussed with the patient the impact
Conclusions of morbidity and biologic ⁄ economic costs in addi-
tion to the potential benefits of therapy.
It is clear that much relevant information is still
missing in the published literature.
Evidence indicates that the use of a graft under a Acknowledgments
coronally advanced flap results in the best short-term
and long-term outcomes in terms of root coverage This study was supported by the Accademia Toscana
and gain in keratinized tissue with the highest prev- di Ricerca Odontostomatologica (ATRO) and the Euro-
alence of success. It would therefore appear easy to pean Research Group on Periodontology (ERGOPerio).
suggest that clinicians adopt coronally advanced
flap + connective tissue graft for root coverage. On
the other hand, harvesting a graft from the palate References
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Periodontology 2000, Vol.

59, 2012, 158–184 2012 John Wiley & Sons A/S

Coronally advanced flap and

Fig. 2. Root abrasions associated

Fig. 3. Coronally advanced flap +

Fig. 5. Coronally advanced flap on

Fig. 7. Coronally advanced flap +

mineral-associated genes in cementoblasts (112), Table 1 presents a summary of the meta-analyses

Coronally advanced flap alone vs.

Coronally Coronally Coronally Coronally Coronally

Complete root coverage

Significance (P-value) 0.03 0.003 0.41 0.31 0.79

95% confidence interval 1.10–5.68 1.59–9.50 0.16–2.08 0.23–99.88 0.23–6.71

No. of randomized clinical trials Two Five Two Two One

Mean difference (mm) 0.49 0.58 )0.27 0.60 )0.20

Significance (P-value) 0.0001 0.0007 0.30 0.19 0.38

Coronally advanced flap + connective tissue graft vs.

Coronally Coronally Coronally Coronally

Complete root coverage

Significance (P-value) 0.31 0.06 0.06 1.00

95% confidence interval 0.45–11.74 0.20–1.04 0.23–1.03 0.02–50.40

No. of randomized clinical trials One Six Four* One

Mean difference (mm) – )0.38 )0.40 –

Significance (P-value) – 0.004 0.004 –

95% confidence interval – )1.98 to )0.39 )1.51 to )0.28 –

Complete root coverage (%)

Fig. 10. Coronally advanced flap +

Fig. 11. Coronally advanced flap on

therapy. McGuire & Nunn (74) reported dentinal

A reasonable starting point for a flow chart is to set

CAF+EMD CAF+BM CAF+ADM CAF+PRC

CAF+ADM Increased morbidity and chair-time

CAF+BM CAF Long term

CAF+ADM CAF+CTG CAF+CTG CAF CAF+BM

CAF+PRC CAF CAF + thin CTG CAF + EMD Greater stability

Increased financial costs

duced into our decision-making process; however, Thicker KT

cost–benefit analyses are still absent in the published 50%

signed studies: in other words, we do not know their Tooth structure

cate that the presence of abrasions does not impair

sition has an influence on root coverage: rotated and

Root surface treatment

Mechanical Chemical Fig. 16. Root surface treatment.

Trapezoidal flap Trapezoidal flap Envelope flap

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