J Clin Periodontol 2014; 41: 708–716 doi: 10.1111/jcpe.

12256

Does the dimension of the graft Giovanni Zucchelli, Ilham Mounssif,

Claudio Mazzotti, Lucio
Montebugnoli, Matteo Sangiorgi,

influence patient morbidity and Monica Mele and Martina Stefanini

Department of Biomedical and Neuromotor
Sciences, Bologna University, Bologna, Italy

root coverage outcomes? A

randomized controlled clinical
trial
Zucchelli G, Mounssif I, Mazzotti C, Montebugnoli L, Sangiorgi M, Mele M,
Stefanini M. Does the dimension of the graft influence patient morbidity and root
coverage outcomes? A randomized controlled clinical trial. J Clin Periodontol
2014; 41: 708–716. doi: 10.1111/jcpe.12256

Abstract
Aim: Primary aim of this study was to evaluate if patient morbidity was
improved by diminishing graft thickness and height; secondary objective was to
evaluate if such graft modifications influence root coverage and aesthetic out-
comes.
Methods: 60 Miller class I and II gingival recessions (GR) (≥3 mm in depth) were
treated with the coronally advanced flap plus extraoral de-epithelialized free gingi-
val graft (FGG). In 30 randomly selected control GRs (“big graft group”), the
FGG thickness was ≥2 mm and the height was equal to bone dehiscence (BD); in
the other 30 test defects (“small graft group”), the thickness of the FGG was
<2 mm and the height was 4 mm. The post-operative patient morbidity was
assessed 1 week after the surgery. The clinical and aesthetic evaluations were
performed 1 year after the surgery.
Results: Lower analgesic assumption, better post-operative course evaluations,
better patient colour match scores and better periodontist aesthetic assessments
were reported in the “small graft” group. No statistically significant differences were
demonstrated between the two groups in terms of recession reduction, CRC and
Key words: aesthetics; connective tissue
increase in KTH. Greater GT increase was obtained in the control-treated sites. graft; free gingival graft; gingival recessions;
Conclusions: Coronally advanced flap plus CTG of reduced thickness and height patient’s morbidity; root coverage
was associated with less patient morbidity, better aesthetic evaluations with no
difference in RC outcomes. Accepted for publication 1 April 2014

Treatment of buccal gingival reces-
sion is a common requirement due
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests. This study has
been self-supported by the authors.
708
to aesthetic concern or root sensitiv-
ity in patients with high standards of
oral hygiene (American Academy of
Periodontology 1996). The ultimate
goal of a root coverage procedure is
the complete coverage (CRC) of the
recession defect with good appear-
ance related to adjacent soft tissues
and minimal probing depth (PD)
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
(Miller 1985, Roccuzzo et al. 2002,
Clauser et al. 2003). The recent sys-
tematic reviews (Cairo et al. 2008,
Chambrone et al. 2010) showed that
coronally advanced flap (CAF) is a
safe and predictable approach for
root coverage and the adjunct of
connective tissue graft (CTG)
enhances the probability to obtain
 Patient morbidity and root coverage after different connective tissue grafts
CRC in Miller Class I and II single
gingival recession, but can jeopardize
the aesthetic outcome. The aesthetic
appearance of the bilaminar-treated
area can be in contrast with that of
adjacent soft tissues for a number of
reasons: the chromatic difference
between the uncovered epithelized
portion of the graft and the adjacent
soft tissues (Langer & Langer 1985,
Raetzke 1985, Allen 1994); the dis-
chromy associated with the uninten-
tional exposure of CTG due to
covering flap dehiscence (Nelson
1987, Bruno 1994, Wennstromm &
Zucchelli 1996); the difference in
thickness between the grafted area
and adjacent soft tissues.
During the last two decades, cli-
nicians have introduced several mod-
ifications to the original bilaminar
procedure described by Raetzke
(1985), resulting in more predictable
outcomes, in terms of root coverage
and greater aesthetic satisfaction for
the patients. These modifications
related both the type of graft (par-
tially or completely de-epithelialized)
harvested from the palate and the
design (envelope-type or with verti-
cal releasing incisions) of the cover-
ing flap. More recently, it was
suggested (Zucchelli et al. 2003) that
the reduced apical–coronal dimen-
sion of the CTG, together with its
positioning apical to the CEJ, facili-
tated graft coverage by the CAF and
improved the aesthetic outcome.
Moreover, it was demonstrated that
patient pain killer assumption after
bilaminar procedures (Zucchelli
et al. 2010) increased by increasing
the depth and height of the palatal
withdrawal. The primary aim of this
study was to evaluate if patient mor-
bidity could be improved by dimin-
ishing graft thickness and height;
secondary objective was to evaluate
if such modifications influence root
coverage and aesthetic outcomes.
Material and Methods
Subject and site selection
Sixty subjects with aesthetic and/or
hypersensitivity complaints due to
the presence of single-type gingival
recession were enrolled in the study.
The patients were selected, on a con-
secutive basis, among individuals
referred to the University of Bolo-
gna, Dental School in the period
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
comprised between February 2010
and September 2011. The study pro-
tocol, questionnaires, and informed
consent in full accordance with the
ethical principles of the Declaration
of Helsinki of 1975, as revisited in
2000, was approved by the Institu-
tional Review Board and received
the approval by the local ethic com-
mittee. All participants met the study
inclusion criteria:
• Age >18 years
• Periodontally and systemically
healthy
• FMPS e FMBS <15%
• Single Miller Class I and II
(Miller 1985) recession defects
(≥3 mm in depth) in the upper
jaw
• Presence of identifiable CEJ (a
step ≤1 mm at CEJ level and/or
presence of a root abrasion, but
with an identifiable CEJ, were
accepted)
Study exclusion criteria:
• Smoking more than 10 cigarettes
a day.
• Contraindications for periodontal
surgery, taking medications
known to interfere with peri-
odontal tissue health or healing;
previous periodontal surgery on
the involved sites.
Study design
This pilot study was a double-
masked, randomized, controlled clin-
ical trial, with a parallel design, com-
paring CTGs of different thickness
and height, in association with the
CAF, for the treatment of single-
type gingival recession (Fig. 1). The
CTGs resulted from the extraoral
de-epithelialization, with the knife
blade, of a free gingival graft
(FGG). In the control group (“big
graft”), the height of the FGG was
equal to the depth of bone dehis-
cence (BD) and its thickness ≥2 mm;
in the test group (“small graft”) the
height of the free graft was 4 mm
and its thickness was <2 mm.
According to the protocol of the
study, six phases were followed:
• Initial screening
• Initial therapy and clinical mea-
surements
• Surgical therapy
709
• Strict maintenance phase
• Evaluation of post-operative
morbidity 1 week after the sur-
gery
• Clinical and aesthetic (made by
the patient and by an indepen-
dent periodontist) evaluations
visit 1 year after the surgery.
Sample size
As a minimum, 30 patients per treat-
ment arm would have been required,
using a = 0.05 and a power = 85%,
to detect a minimum clinically signif-
icantly different pain killer consump-
tion of 1200 mg with a hypothesized
within-group sigma of 1500 mg
obtained from a previous study
(Zucchelli et al. 2010).
Investigator training
All participating investigators were
required to attend two training and
calibration meetings. Aims of the
meetings were to review the objec-
tives of the study and the protocol,
standardize the case selection, the
measurement techniques, and the
surgical procedures.
Randomization
Patients were assigned to one of the
two treatment groups with the use of
computer-generated randomization
table. Each patient participated in
the study with a single recession
defect. Allocation concealment was
obtained using sealed coded opaque
envelope containing the treatment to
the specific subject. The sealed enve-
lope containing treatment assign-
ment was opened at time of the
surgery immediately after treatment
of the root surfaces.
Initial therapy and clinical measurements
Following the screening examina-
tion, all subjects received a session
of prophylaxis including instructions
in proper oral hygiene measures,
scaling and professional tooth clean-
ing with the use of a rubber cup and
a low abrasive polishing paste. A
coronally directed “roll technique”
was prescribed for teeth with reces-
sion type defects. Surgical treatment
of the recession defects was not
scheduled until the patient could
710 Zucchelli et al.
Fig. 1. Consort flowchart of the study.
demonstrate an adequate standard
of supragingival plaque control.
All clinical measurements were
carried out by a single masked
examiner (MM) at baseline and
1-year after the surgeries. MM did
not perform the surgeries and was
unaware of the treatment assign-
ment. Measurement of RD, as the
distance between the CEJ and gingi-
val margin, was repeated three times
by the examiner for a total of 50
defects with a K coefficient of 0.86.
Full mouth (FMPS) and local
plaque and bleeding (FMBS) scores
were recorded as the percentage of
total surfaces (four per tooth), which
revealed the presence of plaque
(O’Leary et al. 1972) and bleeding
respectively.
The following clinical measure-
ments were taken 1 week before the
surgery and at 1-year follow-up
visits:
• Gingival recession depth (RD)
• Probing depth (PD)
• Clinical attachment level (CAL)
• Keratinized tissue height (KTH).
All measurements were performed
by means of the manual probe, at
the midbuccal aspect of the treated
teeth and were rounded up to the
nearest millimetre (Zucchelli et al.
2009).
• Gingival thickness (GT) was
determined 1.5 mm apical to the
gingival margin with a short
needle for anaesthesia and a
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
3-mm-diameter silicon disk stop.
The penetration depth was mea-
sured with a digital calliper accu-
rate to the nearest 0.1 mm
(Paoloantonio et al. 2002, Zucch-
elli et al. 2010).
Intra-surgical measurement
The depth of bone dehiscence (BD)
was measured as the distance from
the cemento-enamel junction (CEJ)
to the most apical extension of
buccal bone crest.
The width (FGG width) (mesial-
distal dimension) and the height
(FGG height) (apical-coronal dimen-
sion) of the FGG were measured,
after being harvested, with the
 Patient morbidity and root coverage after different connective tissue grafts
manual probe and rounded up to
the nearest millimetre.
The thickness of the FGG (FGG
thickness) was measured immediately
after being harvested, 1.5 mm apical
to the coronal border with the digi-
tal calliper (Zucchelli et al. 2010).
The thickness of the CTG (CTG
thickness) was measured, in the same
way, after de-epithelialization and
removal of fatty tissue when present
(Zucchelli et al. 2010).
Graft measurements were per-
formed by a different examiner
(CM) independent from the clinical
examiner. Graft measurements were
repeated three times by the examiner
for a total of 50 defects with a K
coefficient of 0.80 for FGG thickness
and 0.86 for FGG height and width.
He also evaluated, dichotomously,
the presence of early, at time of
suture removal (14 days), and 1-year
graft exposure.
Patient morbidity
Post-operative pain was indirectly
evaluated on the basis of the mean
assumption (in mg) of analgesics
(Ibuprofenâ) (Zucchelli et al. 2010).
Patient’s post-operative discom-
fort, bleeding, and inability to chew
(Zucchelli et al. 2010) was evaluated
with a questionnaire given to
patients 1 week following surgery.
Questionnaire included the evalua-
tion of the intensity of the given
event on a visual analogical scale
(VAS) of 100 mm (Cortellini et al.
2009).
Patient evaluation of aesthetics
Patient satisfaction with aesthetics in
terms of root coverage and colour
match was evaluated at the 1-year
follow-up visits based on a VAS
(Zucchelli et al. 2009, 2012).
Objective evaluation of aesthetics
Objective evaluation of colour
match, root coverage and degree of
keloid formation (Zucchelli et al.
2009, 2012) were scored at 1-year
post-surgical evaluation visit by an
expert periodontist (I.M.) on a VAS.
He was independent of the clinical
examiner and did not perform the
surgeries. Keloid was scored dichoto-
mously. The expert periodontist
examiner was asked three times,
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
within a month, to judge and score
the 1-year healing of all patients.
The intra-observer coefficient of
agreement (K) was 0.83.
Treatment of the root surfaces
Mechanical and chemical (EDTA)
treatments of root surfaces were per-
formed, prior to starting the surgery.
Surgical techniques
All surgeries were performed by the
same expert periodontist (GZ). All
gingival recessions were treated with
the trapezoidal CAF described by
De Sanctis & Zucchelli in 2007, with
the adjunct of a CTG resulting from
the extraoral de-epithelialization,
with the knife blade, of a FGG
(Zucchelli et al. 2010). The width of
the FGG was 6 mm greater than the
width of the recession measured at
the level of the CEJ. The differences
between control and test groups
resided in the height and thickness
of the free gingival graft.
Big graft group. The height of the
FGG was equal to the BD. The
thickness was ≥2 mm.
Small graft group. The height of
the free graft was 4 mm. The thick-
ness was <2 mm.
After de-epithelialization (under
49 magnification vision) with the
15c knife blade the CTG was posi-
tioned at the level of the CEJ and
anchored at the base of the anatomic
de-epithelialized papillae with two
interrupted sutures. Care was taken
to completely cover the graft with
the CAF at time of suturing. The
palatal wound was protected in both
groups with equine-derived collagen*
maintained in situ with compressive
sling 5-0 sutures.
Post-surgical instructions and infection
control
Post-operative pain and oedema
were controlled with Ibuprofenâ.
Patients received 600 mg at the
beginning of the surgical procedure.
Subsequent doses were taken only if
necessary to control pain. Patients
had to record the quantity of analge-
sics taken during the first week post-
surgery. Patients were instructed not
*GABA Vebas, San Giuliano Milanese, MI,
Italy.
711
to brush their teeth in the treated
area but to rinse with chlorhexidine
solution (0.12%) three times a day
for 1 min. Fourteen days after the
surgical treatment, the sutures were
removed. Plaque control in the surgi-
cally treated area was maintained by
chlorhexidine rinsing for additional
2 weeks. Patients were again
instructed in mechanical tooth clean-
ing of the treated tooth. All patients
were recalled for prophylaxis and
reinforcement of motivation and
instruction for a-traumatic tooth
brushing technique 2 and 4 weeks
after suture removal, once a month
for the following 3 months and sub-
sequently every 3 months until the
final examination.
Data analysis
After controlling that standardized
skewness and standardized kurtosis
values for pain, discomfort, bleeding,
inability to chew, root coverage and
colour match were all within the
range expected for data from a nor-
mal distribution, general linear mod-
els were fitted to describe the impact
of FGG height, width, thickness and
surgical procedure on pain killer
consumption (mg), discomfort
(VAS), bleeding (VAS), and inability
to chew (VAS), and multiple regres-
sion ANOVA with step-wise selec-
tion was applied to find the best
model that contained only statisti-
cally significant variables.
A multifactorial ANOVA was
performed to evaluate the inter-
group difference between GT
increase at 1 year and GRTs with
GRTs as a covariate.
The v2 test was used to compare
the two groups with regard to early
and 1-year graft exposure as well as
root coverage and keloids as evalu-
ated by the independent periodon-
tist.
General linear models were also
fitted and multiple regression ANO-
VA for repeated measures with split
plot design was used to evaluate the
existence of any significant difference
regarding RD, PD CAL, KT and
GT between techniques, time, and
the interaction between techniques
and time. In case of significance,
Bonferroni t test was applied as a
multiple comparison test.
A logistic regression model was
fitted to relate CRC as the outcome
712 Zucchelli et al.

variable and groups, including

baseline RD as a confounding
factor.

Results
Following the initial oral hygiene
phase as well as at the post-treat-
ment examinations, all subjects
showed low frequencies of plaque
harbouring tooth surfaces (FMPS
<15%) and bleeding gingival units
(FMBS <15%), indicating good
standard of supragingival plaque
control during the study period.
Healing was uneventful for all trea-
ted cases.
Early (2 weeks) shrinkage of the
covering flap with graft exposure
was assessed in eight control and
two test patients. The difference was
statistically significant (p < .05).
The baseline situation, the sur-
gery and the 1-year clinical outcome
are shown in Figs 2 and 3 for the
control group and in Figs 4 and 5
for the test group.
The descriptive statistics for the
clinical parameters measured at
baseline and 1 year after surgery for
both groups, as well as the mean dif-
ferences within and between groups
are shown in Table 1.
At baseline, there were no statisti-
cally significant differences between
the two groups for any of the con-
sidered clinical parameters.
Intra-surgical measurements
The thickness of FGG (FGGT) and
CTG (CTGT), as well as FGG
height and FGG width in the two
groups is reported in Table 2.
(a) (b) (c)
Fig. 3. “Big graft” group (lateral view). (a) Baseline gingival recession. (b) Thick CTG
full covering the bone dehiscence. (c) 1 year healing. Note that the grater increase in
gingival thickness is more apical with respect to the previously exposed root surface.
A statistically significant differ- (p < .01), bleeding (p < .05) and
ence (p < .01) between test and con- inability to chew (p < .01), were dem-
trol groups in FGG thickness, CTG onstrated in test compared to control
thickness and FGG height, whereas patients.
no difference in FGG width was FGG thickness and FGG height
demonstrated. were the two predictive factors sig-
nificantly related to pain killer
Patient morbidity
assumption (p < .01). FGG thickness
was the only predictive factor related
Mean pain killer consumption (in to discomfort (p < .01) and inability
addition to the 600 mg Ibuprofenâ to chew (p < .01).
given before the surgery) in the con-
trol and test groups was 2520 mg
Subjective aesthetic assessment
and 1100 mg respectively (Table 3).
The difference was statistically sig- The 1-year patient root coverage aes-
nificant (p < .01): greater analgesic thetic assessment was high in both
assumption was demonstrated in groups with no statistically signifi-
patients treated with bigger grafts. cant differences between them. Sta-
Statistically significant lower VAS tistically significant better (p < .01)
scores (better post-operative course) colour match scores were demon-
in terms of post-operative discomfort strated for the test-treated patients.

(a) (b) (c) (d) (e)

Fig. 2. “Big graft” group (frontal view). (a) Baseline gingival recession. (b) Bone dehiscence after elevation a trapezoidal flap. (c)
CTG sutured at the CEJ, full covering the bone dehiscence. (d) CAF covering in excess the CTG. (e) 1 year healing.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Patient morbidity and root coverage after different connective tissue grafts
(a) (b) (c) (d)
Fig. 4. “Small graft” group (buccal view). (a) Baseline gingival recession. (b) Bone dehiscence after elevation a trapezoidal flap. (c)
4 mm high CTG sutured at the CEJ. Note that the most apical extension of the bone exposure is not covered by the CTG. (d)
CAF covering in excess the CTG. (e) 1 year healing.
(a) (b) (c)
Fig. 5. “Small graft” group (lateral view). (a) Baseline gingival recession. (b) Thin
CTG not completely covering the bone dehiscence. (c) 1 year healing. Note the site-
specific increase in gingival thickness limited to the area of previous gingival recession.
Periodontist aesthetic assessment subjects. The difference was statisti-
Root coverage: The 1 year assess- cally significant (p < .01).
ment was high in both groups with Concerning RD, CAL, PD and
no statistically significant difference KT, no significant relationship was
between them. found regarding the type of tech-
Colour match: Statistically signifi- nique but only regarding the time-
cant greater (p < 0.5) colour match related changes (p < .01).
scores were demonstrated in the test Complete coverage was achieved
compared to the control groups. Colour in 25 and 24 of 30 gingival reces-
match was significantly related to graft sions in the test and control groups
exposure only in the control group. respectively. The difference was not
Statistically greater (p < .05) statistically significant.
keloid formation was found in the GT: significantly (p < .01)
control group. Keloid was signifi- increased in both groups compared
cantly (p < .01) related with graft to the baseline measurements with a
exposure in both groups. statistically significant (p < .01)
greater increase in the control group.
The difference between GT
1-year clinical outcome increase at 1-year and CTGT was
Graft exposure was observed in 5 statistically significant (p < .01)
(17%) test and 16 (53%) control between the two groups indepen-
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
713
(e)
dently of the thickness of the CTG
at the time of suturing. A greater
difference (0.22 versus 0.02) was
demonstrated in the control group.
Discussion
Bilaminar procedure was demon-
strated the most predictable root
coverage surgical technique (Cairo
et al. 2008, Chambrone et al. 2010)
but very few studies have measured
the size of the CTG used in combi-
nation with the CAF. Efforts have
been made to improve palatal heal-
ing and to decrease patient morbid-
ity by making first (Edel 1974) and
then modifying (Bruno 1994, Hurzel-
er & Weng 1999, Lorenzana & Allen
2000) CTG harvesting techniques
characterized by primary intention
palatal wound healing. Nevertheless,
no attempts have been made to
reduce the size and thickness of the
palatal withdrawal, despite it was
demonstrated that post-operative
pain and discomfort were related to
the apical-coronal dimension and
depth of the palatal withdrawal
(Zucchelli et al. 2010). In the only
comparative study (Zucchelli et al.
2003) where CTG with reduced api-
cal coronal dimension were com-
pared to bigger CTG no statistically
significant differences in terms of
mean percentage and complete root
coverage were observed. Conversely
better patient aesthetic evaluations
and post-operative course were
reported for smaller CTG. In this
study apical-coronal dimension of
the CTG was that of the bone dehis-
cence minus the pre-surgical height
714 Zucchelli et al.

Table 1. Clinical parameters: mean values
SD (95% confidential intervals) que control and tooth-brushing tech-
Test group (n = 30) Control group (n = 30) nique with no or minimal
(CAF + SMALL CTG) (CAF + BIG CTG) unaesthetic dis-alignment of the
mucogingival line.
RD This study demonstrated that the
Baseline 3.80
0.96 (3.44–4.16) 3.93 (3.59–4.27) use of small graft was associated
1 year 0.13
0.35 (0.01–0.26)† 0.17 (0.02–0.31)† with less painful and more conform-
Change 3.66
0.96 (4.02–3.31) 3.80
0.92 (4.14–3.45)
able post-operative course with no
PD
Baseline 1.17
0.38 (1.02–1.31) 1.20
0.39 (1.05–1.35)
difference in root coverage outcomes
1 year 1.33
0.48 (1.15–1.51)† 1.40
0.51 (1.21–1.59)† with respect to bigger graft. Further-
Change 0.16
0.53 (0.03–0.36) 0.20
0.54 (0.03–0.37) more, better aesthetic results,
CAL assessed by an expert periodontist,
Baseline 4.73
0.74 (4.45–5.01) 5.13
0.96 (4.78–5.48) in terms of colour match and keloid
1 year 1.47
0.57 (1.25–1.68)† 1.53
0.59 (1.32–1.74)† formation were reported for smaller
Change 3.26
0.78 (3.56–2.97) 3.60
1.06 (4.03–3.23) CTG. These differences could be
KTH ascribed to the lower tendency of
Baseline 1.33
0.71 (1.07–1.60) 1.13
0.73 (0.86–1.40) small CTG to expose during the
1 year 3.50
0.63 (3.26–3.73)† 3.63
0.67 (3.38–3.88)†
healing process. The reduced thick-
Change 2.17
0.59 (1.94–2.39) 2.50
0.73 (2.22–2.77)
GT ness and height of the CTG allowed
Baseline 0.75
0.15 (0.69–0.80) 0.72
0.13 (0.66–0.77) minimizing the obstacle hindering
1 year 1.47
0.16 (1.41–1.53)† 2.11
0.17 (2.04–2.17)†,‡ the blood supply from the receiving
Change 0.72
0.12 (0.67–0.77) 1.39
0.14 (1.34–1.44) connective tissue bed to the covering
Graft exposure CAF. Conversely, bigger and thicker
Early 7% 27%‡ CTG, increase the risk of covering
1 year 17% 53%‡ flap dehiscence and consequently
CRC graft exposure. This is confirmed by
1 year 83% 80%
the present data, which indicated a
SD, standard deviation higher percentage of early (2 week)
†
Time related within-group statistically significant difference. and late (1 year) graft exposures in
‡
Between-groups statistically significant difference. the control with respect to the test
group. When the CTG is exposed, it
rapidly becomes covered by a kerati-
Table 2. Intra-surgical measurements: mean values
SD (95% confidential intervals) nized epithelium and its colour and
Parameter Test group (n = 30) Control group (n = 30) texture becomes similar to that of
(CAF + SMALL CTG) (CAF + BIG CTG) the patient’s palate. The consequence
might be a poor camouflaging of the
FGG thickness 1.12
0.14 (1.07–1.17) 2.14
0.16 (2.08–2.20)† treated area with respect to the adja-
CTG thickness 0.73
0.10 (0.69–0.77) 1.61
0.16 (1.54–1.67)† cent soft tissues. It interesting to
FGG height 3.80
0.40 (3.64–3.95) 6.43
1.16 (5.99–6.86)† note that also the patient was aware
FGG width 11.13
0.82 (10.82–11.43) 10.90
0.72 (10.63–11.16)
of the different in colour between
FGG thickness, free gingival graft thickness at the time of harvesting; CTG thickness, con- the two groups. This confirms the
nective tissue graft thickness at the time of suturing; FGG height, free gingival graft height data of previous studies (Zucchelli
at the time of harvesting; FGG width, free gingival graft width at the time of harvesting; et al. 2003, 2011, Zucchelli et al.
SD, standard deviation. 2014 in press) demonstrating the
†
Between-groups statistically significant difference. importance of colour match in the
patient’s aesthetic assessment of a
surgical outcome.
of keratinized tissue remaining apical thick) or big (≥2 mm-thick and The results of a pilot study must
to the root exposure and the better reaching the buccal bone crest) de- be taken with caution and longer
aesthetic outcome was attributed to epithelialized FGGs in association term and multicenter randomized tri-
the lower tendency of the covering with the CAF in the treatment of als are needed to confirm them. Nev-
flap to relapse and consequently to deep gingival recessions. A 4 mm ertheless, it can be speculated that
leave the graft exposed. Another height of the graft, in the test group, the successful aesthetic and root cov-
aspect that was not previously inves- was arbitrarily chosen for technical, erage outcome achieved with the
tigated was the need to cover the clinical and aesthetic reasons. From small graft used in this study is
whole buccal root exposure, up to a technical standpoint smaller graft strictly related to the quality of the
the bone crest, with the CTG, espe- would have been more difficult to CTG. In this study, in fact, only the
cially in the presence of deep bone de-epithelialized and to suture and subepithelial palatal connective tis-
dehiscence. The purpose of this with a greater risk to be traumatized sue was included in the CTG. This
study was to compare post-operative during surgical manipulation. From connective tissue is denser firm, sta-
patient morbidity and root coverage a clinical stand point 3–4 mm of ker- ble and less prone to resorption with
and aesthetic outcomes after the use atinized tissue can be considered respect to the connective tissue closer
of small (4 mm-high and <2 mm- adequate for facilitating patient pla- to the palatal bone which is looser
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Patient morbidity and root coverage after different connective tissue grafts 715

Table 3. Patient and periodontist evaluation: mean values
SD (95% confidential evaluations were reported after
intervals) the use of small CTG.
Test group (n = 30) Control group (n = 30)
(CAF + SMALL CTG) (CAF + BIG CTG)
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•
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Clinical Relevance
Scientific rationale for the study:
No reports are available to com-
pare patient morbidity and root
coverage outcomes after the use of
CTGs of different height and thick-
ness.
Principal findings: This randomized
comparative clinical study demon-
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tematic review. Journal of Clinical Periodontol-
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The American Academy of Periodontology (1996)
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Zucchelli, G., Mele, M., Mazzotti, C., Marzadori,
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strated that the use of de-epithelial-
ized FGG of reduced height and
thickness was associated with better
post-operative course and aesthetic
evaluations with no difference in the
root coverage outcomes
Practical implications: In the bilami-
nar treatment of single-type gingival
recession the use of thin (<2 mm)
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Coronally advanced flap with and without ver-
tical releasing incisions for the treatment of
multiple gingival recessions: a comparative con-
trolled randomized clinical trial. Journal of
Periodontology 80, 1083–1094.
Zucchelli, G., Mele, M., Stefanini, M., Mazzotti,
C., Marzadori, M., Montebugnoli, L. & de
Sanctis, M. (2010) Patient morbidity and root
coverage outcome after subepithelial connective
tissue and de-epithelialized grafts: a compara-
tive randomized-controlled clinical trial. Jour-
nal of Clinical Periodontology 37, 728–738.
Zucchelli, G., Mounssif, I., Mazzotti, C., Stefa-
nini, M., Marzadori, M., Petracci, E. & Monte-
bugnoli, L. (2014). Coronally advanced flap
with and without connective tissue graft for the
treatment of multiple gingival recessions: a
comparative short- and long-term controlled
randomized clinical trial. Journal of Clinical
Periodontology 41, 396–403.
Address:
Giovanni Zucchelli
Department of Biomedical and Neuromotor
Sciences
University of Bologna
Via S. Vitale 59, 40125 Bologna, Italy
E-mail: giovanni.zucchelli@unibo.it
and 4 mm-high de-epithelialized
FFG should be suggested, in com-
bination with the CAF, because of
the better post-operative course
and aesthetic outcomes.