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Received: 19 April 2017    Accepted: 24 December 2017

DOI: 10.1111/jicd.12325

REVIEW ARTICLE
Periodontics

Sub-­epithelial connective tissue graft for the management of

Miller’s class I and class II isolated gingival recession defect: A
systematic review of the factors influencing the outcome

Anisha P. Yadav  | Anita Kulloli | Sharath Shetty | Shruti S. Ligade | 

Santosh S. Martande  | Meenakshi J. Gholkar

Department of Periodontics, Dr D. Y.
Patil Dental College and Hospital, Pune,
Maharashtra, India
Correspondence
Dr Anisha P. Yadav, Department of
Periodontics, Dr D. Y. Patil Dental College
and Hospital, Pune, Maharashtra, India.
Email: anishayadav63@ymail.com
Abstract
The aim of the present systematic review was to analyze the factors that affect the
outcome of subepithelial connective tissue graft (SCTG) for managing Miller’s class
I and class II isolated gingival recession defect. The PRISMA (Preferred Reporting
Items for Systematic Reviews and Meta-­Analyses) guidelines for systematic reviews
were used. Quality assessments of selected articles were performed. Data on root
surface condition, recession type defect, flap thickness, different flap designs, dif-
ferent harvesting techniques, presence/absence of the epithelial collar, graft thick-
ness, flap tension, suturing techniques, and smoking-­related outcomes on root
coverage were assessed. The SCTG procedure provides the best root coverage out-
comes for Miller’s class I and class II recession. The critical threshold of flap thick-
ness was found to be 1 mm. Maximum root coverage was achieved by envelope and
modified tunnel technique. SCTG with the epithelial collar does not provide addi-
tional gains than SCTG without the epithelial collar. The thickness of SCTG for root
coverage was found to be 1.5-­2 mm. Greater flap tension and smoking adversely
affect root coverage outcomes. Analysis of the factors discussed would be of key
importance for technique selection, and a combined approach involving factors fa-
voring outcomes of SCTG could be of clinical relevance in recession coverage.

KEYWORDS
connective tissue graft, gingival recession, mucogingival junction, root coverage, systematic
review

1 |  I NTRO D U C TI O N
Gingival recession is defined as the apical displacement of the gin-
gival margin in relation to the cemento-­enamel junction (CEJ).1 It
has been associated with many factors, such as poor toothbrushing,
abnormal frenum attachment, improper restoration, tooth malpo-
sitioning, aging, and thin gingival tissue. 2,3 Gingival recession can
cause root sensitivity, root caries, and impaired esthetics. 2 Miller
proposed four classes (I-­IV) of gingival recession based on bone
and soft tissue level of the proximal sites of the tooth, of which
complete root coverage is classified as class I and class II gingival
recessions.4
Many treatment modalities have been used to achieve root cov-
erage, which include laterally-­positioned flaps, double papilla flaps,
coronally-­advanced flaps (CAF), free gingival grafts, subepithelial
connective tissue grafts (SCTG), guided tissue regeneration, acellular
dermal matrix allografts, and a combination of these.5 Among these
procedures, the SCTG is considered the gold standard because of
its high predictability for root coverage, dual blood supply, superior
esthetics, and resultant increase in the width of keratinized gingiva.6

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https://doi.org/10.1111/jicd.12325
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The factors that can influence the outcome of SCTG for predict-
ing treatment outcome have not been fully identified and needs to
7
be addressed. These include the nature of defect/cervical abrasion
defect, recession type defect, flap thickness, flap designs for the
recipient site of SCTG, harvesting techniques for SCTG, presence/
absence of the epithelial collar, graft thickness, flap tension, suturing
techniques, and effect of smoking on SCTG outcomes.
The primary clinical outcome is the percentage of root cover-
age of the previously-­exposed root surface. However, due to di-
verse study designs and techniques, there is a wide range of results.
A well-­controlled randomized, clinical trial with adequate power is
considered the ideal study design that contributes to objective re-
sults.8 Unfortunately, only limited studies have been performed in
such a manner. None of the studies evaluated the factors that were
most associated with successful outcomes. Systematic reviews of
randomized, controlled trials are key in the practice of evidence-­
based medicine. Therefore, the aim of the present systematic review
was to analyze and identify the factors in a systematic manner that
affect the outcome of SCTG for the management of Miller’s class I
and class II isolated gingival recession defect.
2 |  M ATE R I A L S A N D M E TH O DS
The review text was structured in accordance with guidelines from
PRISMA (Preferred Reporting Items for Systematic Reviews and
Meta-­Analyses).9
2.1 | Focused question
The focused question was proposed by following the PICOS
(Participant, Intervention, Comparison, Outcome, and Study Design)
principle:10,11 What are the factors which influence the outcome of
SCTG for the management of Miller’s class I and class II isolated gin-
gival recession defect?
2.2 | Eligibility criteria
The following criteria were used for selection: (a) articles in English
or those with a detailed summary in English; (b) PubMed search
which included articles published until December 2015; (c) studies
conducted on patients who underwent periodontal plastic surgery
for the treatment of Miller’s class I and class II isolated gingival re-
cession defects by using SCTG; and (d) randomized controlled, clini-
cal trials and comparative studies involving at least 10 patients per
group, which evaluated recession areas that were treated by SCTG
with at least 6 months’ follow up.
2.3 | Outcome measures
The primary outcome was the percentage of root coverage. Secondary
outcomes were as follows: (a) probing depth: distance from the gingi-
val margin to the bottom of the gingival sulcus;12 (b) recession width:
measured at the greatest width of the defect;13 (c) recession depth:
distance from the CEJ to the gingival margin;12 (d) width of kerati-
nized tissue: distance from the gingival margin to the mucogingival
junction;8 (e) gingival thickness: measured 2-­3 mm apical to the free
gingival margin (at the mid-­buccal aspect) by penetrating a #15 en-
dodontic file with a rubber stop into the tissue;14 and (f) clinical at-
tachment level: distance from the CEJ to the bottom of the sulcus.12
2.4 | Information source and search strategy
We searched the MEDLINE (PubMed), Google Scholar, Google,
and EBSCOhost electronic databases for human studies published
until December 2015. A specific search strategy was developed for
MEDLINE and revised for the other databases. Moreover, the reference
lists of selected articles were screened to find additional publications
that might fit the selection criteria. Furthermore, a hand search using the
Department of Central Library (Dr D. Y. Patil Dental College and Hospital,
Pune, Maharashtra, India) resources of the Journal of Periodontology and
Journal of Indian Society of Periodontology was executed.
2.5 | Study selection
All articles were screened independently. A standard pilot form in
Excel was initially used, and then all headings not applicable for re-
views were removed. One data extraction was done for one article,
and this form was reviewed by an expert, discussed, and final data
items were selected. Further, all the articles were reviewed and data
were extracted. The accuracy of the extracted data was confirmed
by another author. Studies that met the inclusion criteria underwent
a validity assessment and data extraction. Reasons for rejecting
studies were recorded for each study (Figure 1).
2.6 | Data collection
Data were extracted and recorded, and the following variables were
sought: (a) study identification; (b) location; (c) year of publication;
(d) author; (e) study design; (f) defects; (g) patient description; (h)
setting; (i) intervention 1; (j) intervention 2; (k) method of interven-
tion 1; (l) method of intervention 2; (m) evaluation time; (n) outcome
measures; (o) result; and (p) clinical data from root coverage studies
analyzing factors, such as nature of defect/cervical abrasion defect,
recession type defect, gingival flap thickness, flap designs for the
recipient site, harvesting techniques, presence/absence of the epi-
thelial collar, graft thickness, flap tension, suturing techniques, and
effect of smoking on outcome of SCTG were addressed (Tables 1-5).
3 | R E S U LT S
3.1 | Patient, defect, treatment and study
characteristics
The initial electronic data and journal search produced 524 arti-
cles. Thirty-­two articles qualified for additional review based on
YADAV et al.
F I G U R E   1   PRISMA Flow Diagram.
SCTG, subepithelial connective tissue
graft
titles and abstracts. Twenty-­four articles were excluded because
of incomplete data reporting. Eight studies (five randomized, con-
trolled trials and three comparative studies) corresponded to the
selection criteria. Raw data from the selected studies are presented
in Tables 1-5. Between 11 and 59 patients with 22-­78 isolated/bi-
lateral Miller’s class I and class II recession defects were included
in this review, excluding patients from three studies that did not
clearly mention whether the defects included were isolated or mul-
tiple. Four studies incorporated smokers. Follow-­up times ranged
from 3 to 12 months, although most investigations lasted 6 months
(N = 6). All studies used SCTG. Studies also differed in terms of
treatment. Of eight studies, only one discussed the nature of de-
fect/cervical abrasion defect and its influence on the outcome of
treatment of gingival recession by CAF, CAF + restoration (CAF+R),
SCTG alone (CTG) and CTG + restoration (CTG+R). For analysis,
the CTG group was considered. There was a positive association
between non-­c arious cervical lesion height (CLH) and the amount
of recession reduction, because larger recessions are associated
with a greater distance between bone crest and the incisal bor-
der of the cervical lesion. This implied that bone dehiscence does
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not negatively interfere in root coverage provided by the CTG
technique.
Six studies discussed recession type defect, and one study se-
lected Miller’s class I recession defects and the percentage of root
coverage was 75%. Five studies selected Miller’s class I and class II
recession defects and the percentage of root coverage obtained in
these studies was in the range of 54%-­97%.
Two studies discussed flap thickness. In both studies, the mean
gingival thickness did not fall below 1 mm. These studies showed
75%-­97.5% of root coverage. No study directly segregated patients
into treatment groups by tissue thickness.
Three studies discussed flap design, of which two used the
Langer and Langer technique of flap design and showed a percent-
age of root coverage of 75% and 75.53%. One study used the enve-
lope technique of flap design, and the root coverage obtained was
97.5% and 89.1%, respectively. One study used the modified tunnel
technique of flap design, and the root coverage obtained was 96.4%.
Five studies reported on the nature of harvesting SCTG, of which
two studies used a trap-­door approach, two studies used a single-­
incision technique, and one study used the Bruno technique.
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TA B L E   1   Details of included studies

Study Year of
identification Author Location publication Study design Defects Patient description Setting

1 Pini Prato et al. Italy 2000 RCT 11 patients with bilateral Miller’s class I recession. Males = 4, females = 7 age: 22-­41 years Institute
Total = 22 recessions
2 da Silva et al. Brazil 2004 RCT 11 patients with bilateral Miller’s class I recession Males = 6, females = 5 age: 18-­43 years Institute
defects, maxillary canines, premolars
3 Tozum et al. Turkey 2005 Comparative 31 patients each contributing Miller’s class I and II Males = 10, females = 21 age: Institute
study recession 21-­50  years
4 Erley et al. Germany 2006 Comparative 17 patients with 22 Miller’s class I and II recession Males = 16, females = 1 age: 27-­ Dental clinic
study defects 45 years, >10 cigarettes/day
5 Souza et al. Brazil 2008 Comparative 30 patients, each with one Miller’s class I and II 15 smokers (males = 9; females = 6), 15 Institute
study recession in non-­molar tooth non-­smokers (males = 11; females = 4)
age: 27-­47 years, >10 cigarettes/day for
a minimum of 5 years
6 Byun et al. USA 2009 RCT 20 patients with ≥1 Miller’s class I and II recession on Age: ≥18 years Institute
anterior teeth, premolars
7 Santamaria Brazil 2010 RCT 78 Miller’s class I defects with non-­c arious cervical Males = 30, females = 29 age: Institute
et al. lesion 1-­2 mm deep on maxillary canines, premolars 19-­71  years
8 Reino et al. Brazil 2015 RCT 20 patients with bilateral Miller’s class I or II recession Males = 10, females = 10, age: 35-­ Institute
in non-­molar teeth 50 years, 20 cigarettes/day for >5 years

RCT, randomized, controlled trial.

YADAV et al.
 YADAV et al.

TA B L E   2   Interventions, parameters analyzed, and evaluation time for the included studies

Study Evaluation
identification Author Intervention 1 Intervention 2 Method of intervention 1 Method of intervention 2 Parameters analyzed time (months)

1 Pini Prato et al. CAF with tension CAF without tension 6.5 g tension .4 g tension RD 3
(test group) (control group)
2 da Silva et al. CPF+SCTG (test CPF (Control group) Flap design: Langer and Langer, Flap design:Allen and Miller, RD, PD, CAL, WKT 6
group) harvesting: trap-­door, absence sutures: mattress and
of epithelial collar, graft interrupted sutures
thickness: 1.3 mm, suture:
X-­shaped sling suture
3 Tozum et al. Modified tunnel Langer and Langer Flap design: modified tunnel, Flap design: Langer and Langer, Recession, PD, CAL 6
technique harvesting: trap-­door or parallel harvesting: trap-­door or
incision, thickness of graft: parallel incision, thickness of
2 mm graft: 2 mm
4 Erley et al. SCTG in smokers SCTG in non-­smokers Harvesting: Bruno technique, Harvesting: Bruno technique, RD, RW, CAL, PD, 6
thickness of graft: 1-­2 mm thickness of graft: 1-­2 mm WKT
5 Souza et al. SCTG in smokers SCTG in non-­smokers Harvesting:single-­incision HarvestingL single-­incision PD, CAL, GR, WKT 6
technique, thickness of graft: technique, thickness of graft:
1-­1.5 mm, sling sutures 1-­1.5 mm, sling sutures
6 Byun et al. SCTGwith epithelial SCTG without epithelial Envelope flap, retained epithelial Envelope flap, no epithelial RD, WKT, CAL, PD, 6
collar + CAF collar + CAF collar, sling sutures collar, sling sutures RW, GT
7 Santamaria CAF, CAF + glass SCTG, SCTG + glass     CLH, CLW, CLD, KTT, 6
et al. ionomer ionomer KTW, BL
8 Reino et al. Barros technique Langers and Langers Harvesting: single incision, sling Harvesting:single incision, sling PD, CAL, WKT 12
(test group) technique (control sutures sutures
group)

BL, bone level; CAF, coronally-­advanced flap, CAL, clinical attachment level; CLD, cervical lesion depth; CLH, cervical lesion height; CLW, cervical lesion width; GR, gingival recession; GT, gingival thickness;
KTT, keratinized tissue thickness; KTW, keratinized tissue width; PD, probing depth; RD, recession depth; RW, recession width; SCTG, subepithelial connective tissue graft; WKT, width of keratinized
tissue.
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TA B L E   3   Baseline and postoperative evaluation for probing depth, recession width, recession depth, and WKT

Probing depth Recession width Recession depth WKT

Study Baseline Baseline Baseline Baseline

identification Author evaluation Post-­evaluation evaluation Post-­evaluation evaluation Post-­evaluation evaluation Post-­evaluation

1 Pini Prato Test: .95, Test: .68 Test: 2.82 control: Test: .64 control: .36 Test: 3.09 control: Test: 2.82 control:
et al. control: 1.09 control: .64 2.68 2.82 2.55
2 da Silva et al. CPF: 1.47 CPF: 1.89 CPF: 3.8 CPF: 1.25 CPF: 3.38 CPF: 3.17
CPF+SCTG: CPF+SCTG: CPF+SCTG: 4.20 CPF+SCTG: 1.04 CPF+SCTG: 2.79 CPF+SCTG: 3.35
1.49 2.04
3 Tozum et al. Tunnel: 1.64, Tunnel: 1.07, Tunnel: 3.50, Tunnel: .14, Langer
Langer & Langer & Langer & Langer: & Langer: .97
Langer: 1.24 Langer: 1.29 3.47
4 Erley et al. NS: 1.96, S: NS: 1.53, S: NS: 4, S: 3.50 NS: .30, S: 1.75 NS: 3.20, S: 3.33 NS: .20, S: 1.00 NS: 1.70, S: 2.42 NS: 4.50, S: 4.50
2.08 1.72
5 Souza et al. NS: 1.31, S: NS: 1.59, S: NS: 3.15, S: 3.47 NS: .52, S: 1.48 NS: 2.05, S: 1.90 NS: 3, S: 3.23
1.63 1.83
6 Byun et al. SCTGE: 1.40, SCTGE: 1.60, SCTGE: 3.55, SCTGE: 0, SCTGE: 2.45, SCTGE: .35, SCTGE: 2, SCTGE: 3.85,
SCTGN: 1.20 SCTGN: 1.30 SCTGN: 2.95 SCTGN: .60 SCTGN: 2.53 SCTGN: .10 SCTGN:1.35 SCTGN: 2.75
7 Santamaria
et al.
8 Reino et al. Langer & Langer & Langer & Langer: Langer & Langer:
Langer: 1.36, Langer: 2.21, 2.15, Barros : 1.98 2.25, Barros: 1.98
Barros: 1.32 Barros: 2.43

CPF, coronally-­positioned flap; NS, non-­smokers; S, smokers; SCTG, subepithelial connective tissue graft; SCTGE, subepithelial connective tissue graft with the epithelial collar; SCTGN, subepithelial con-
nective tissue graft without the epithelial collar; WKT, width of keratinized tissue.
YADAV et al.
TA B L E   4   Baseline and postoperative evaluation for CAL, GT, NCCL, root coverage, and results of included studies

CAL/RCAL GT NCCL
YADAV et al.

Root coverage Root coverage

Study Baseline Baseline Post-­ Baseline of intervention of intervention
identification Author evaluation Post-­evaluation evaluation evaluation evaluation 1 2 Result

1 Pini Prato Test: 3.77 Test: 1.32 78.00% 87.00% Test: recession reduction: 2.18 mm,
et al. control: 3.77 control: 1 control: recession reduction:
2.32 mm
2 da Silva CPF: 5.45, CPF: 3.15, GT1 CPF: 1.27, GT1 CPF: 75.00% 69.00% Both procedures are effective in
et al. CPF+SCTG: CPF+SCTG: CPF+SCTG: 1.28, terms of root coverage. Increase in
5.60 3.07 1.34, GT2 CPF+SCTG: gingival dimension is a desired
CPF: 1.08, 1.78, GT2 outcome CPF+SCTG should be
CPF+SCTG: CPF: 1.30, used.
1.15 CPF+SCTG:
1.96
3 Tozum Tunnel:5.14, Tunnel: 1.14 Tunnel: 96.43% Langer & Study suggests that the use of SCTG
et al. Langer & Langer & Langer: in combination with a tunnel
Langer:4.71 Langer: 2.26 75.53% procedure might result in an
increased amount of root coverage
and CAL gain compared to Langer
& Langer technique
4 Erley et al. NS: 1.93, S: NS: 1.86, S: 1.60 S: 82.30% NS: 98.30% Root coverage with SCTG appears to
1.57 be negatively associated with
cigarette smoking
5 Souza NS: 11.04, NS: 8.89, S: 10.23 S: 58.02% NS: 83.35% Root coverage with SCTG appears to
et al. S:11.67 be negatively associated with
cigarette smoking
6 Byun et al. SCTGE: 3.85, SCTGE: 1.25, SCTGE: 1.10, SCTGE: 2.10, SCTGE: SCTGN: Retained epithelial collar on SCTG
SCTGN: 3.65 SCTGN: 1.40 SCTGN: .90 SCTGN: 1.65 97.50% 89.10% might not provide significant
benefit with regard to clinical
parameters
7 Santamaria CTG CLH:3.22, Bone dehiscence does not
et al. CLW: 4.28, negatively interfere in root
CLD:.92, coverage provided by CTG
KTW: 2.38, technique
KTT:.9, BL:
6.01
8 Reino et al. Langer & Langer & Langer: 54.28% 48.60% No statistically-­significant differ-
Langer: 4.57, 3.32 Barros: ence between 2 groups in terms of
Barros: 4.77 3.71 root coverage
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BL, bone level; CAL, clinical attachment level; CPF, coronally-­positioned flap; GT, gingival thickness; KTT, keratinized tissue thickness; KTW, keratinized tissue width;NCCL, non-­c arious cervical lesion. NS,
non-­smokers; S, smokers; SCTG, subepithelial connective tissue graft; SCTGE, subepithelial connective tissue graft with the epithelial collar; SCTGN, subepithelial connective tissue graft without the epi-
thelial collar; WKT, width of keratinized tissue.
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TA B L E   5   Checklist for factors affecting final outcome and confounders (if any) in included studies

Nature of
Presence defect/
Nature of of cervical
Study Flap Flap Flap harvesting Thickness epithelial Suturing abrasion
identification Author design thickness tension SCTG of graft collar technique Smoking defect Remarks Confounder

1 Pini Prato X X ✓ X X X X ✓ X Higher flap tension, lower Root

et al. recession reduction prominence
2 da Silva et al. ✓ ✓ X ✓ ✓ X ✓ X X Success might be due to flap
design, flap thickness
3 Tozum et al. ✓ X X ✓ ✓ X X X X Success might be due to flap
design
4 Erley et al. X X X ✓ ✓ X X ✓ X Smoking affects root
coverage
5 Souza et al. X X X ✓ ✓ X ✓ ✓ X Smoking affects root
coverage
6 Byun et al. ✓ ✓ X X X ✓ ✓ X X Presence of the epithelial
collar increased the WKT
No difference in terms of
root coverage between
groups
7 Santamaria X ✓ Connective tissue graft can
et al. be performed in non-­c arious
cervical lesion and is
associated with CLH and BL
8 Reino et al. X X X ✓ X X ✓ ✓ X Smoking affects root
coverage outcomes

X, factor not included in the study; ✓, factor included in the study. BL, bone level; CLH, cervical lesion height; SCTG, subepithelial connective tissue graft; WKT, width of keratinized tissue.
YADAV et al.
YADAV et al.
One study reported on the presence/absence of the epithelial
collar; the SCTG with the epithelial collar showed a mean root cover-
age of 98% at 6 months compared to 89% in SCTG without the epi-
thelial collar. Keratinized tissue width at 6 months for SCTG with the
epithelial collar was 3.85 mm, and for SCTG without the epithelial
collar, it was 2.75 mm, which was statistically significant.
Four studies discussed graft thickness. The studies did not per-
form correlation statistics on mean or complete root coverage in re-
gards to graft thickness. Graft thickness in the studies were in the
range of 1-­2 mm. The root coverage obtained in these studies was in
the range of 58.02%-­98.3%.
One study reported on flap tension, with root coverage for the
test group (flap with tension) and control group (flap without ten-
sion) found to be 78% and 87%, respectively.
Four studies discussed the suturing technique of SCTG. One
study used mattress suture, and three studies used sling suture.
Three studies discussed smoking and its impact on root cover-
age; one study reported 82.3% and 98.3% of root coverage in smok-
ers and non-­smokers, whereas another study reported 58.02% and
83.35% of root coverage in smokers and non-­smokers, respectively.
One study evaluated root coverage outcome with connective tissue
grafts only in smokers with two techniques. Root coverage for the
test and for control groups was 54.28% and 48.6%, respectively. The
results of these studies suggest that root coverage obtained with
SCTG was reduced in smokers.
4 | D I S CU S S I O N
SCTG procedures are considered one of the most predictable meth-
ods in achieving root coverage, as well as for increasing width of
keratinized gingiva and tissue thickness.
Santamaria et al. evaluated the influence of local anatomy on
the reduction in relative gingival recession and gain of clinical at-
tachment level achieved by CAF, CAF+R, CTG, and CTG+R to treat
Miller’s class I gingival recessions associated with non-­carious cer-
vical lesions.15 It was stated that bone level was significantly asso-
ciated with a reduction of gingival recession when the CTG group
was analyzed. There was a positive association between non-­carious
CLH and the amount of recession reduction, because larger reces-
sions are associated with a greater distance between bone crest and
the incisal border of the cervical lesion. This indicated that bone de-
hiscence does not negatively interfere in root coverage provided by
the CTG technique.
da Silva et al. selected Miller’s class I recession defects, and the
percentage of root coverage was 75%,12 whereas Tozum et al., Byun
et al., Erley et al., Souza et al., and Reino et al. selected Miller’s class
I and class II recession defects, and the percentage of root cover-
age obtained in these studies was in the range of 54%-­97% by using
2,5,16,17,18
different variants of SCTG. According to Miller, class I and
class II recession defects are the most predictable for obtaining com-
plete root coverage.4 In Miller’s class I and class II recession, there
is no interproximal loss of soft tissue and bone, and thus complete
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root coverage can be anticipated in such cases. It can be stated that
great variability in terms of root coverage is seen with various SCTG
techniques.
da Silva et al. discussed baseline gingival thickness at two loca-
tions.12 At midpoint between the gingival margin and mucogingival
junction it was 1.27 mm, and 2 mm apical to the gingival margin it
was 1.08 mm. Byun et al. demonstrated a mean baseline thickness
of 1.10 mm, 3 mm apical to the gingival margin.5 Both studies indi-
cated that there was no statistically-­significant relationship between
root coverage outcomes and gingival thickness. In their systematic
review, Hwang et al. stated that for complete root coverage, the
critical threshold thickness was 1 mm.19 In both studies, the mean
gingival thickness did not fall below 1 mm. These studies showed
75%-­97.5% of root coverage. Thick gingiva in the recipient site seems
to be advantageous, as in theory, it harbors more patent vessels and
eases surgical manipulation.8
Tozum et al. and da Silva et al. performed the Langer and Langer
technique of flap design and found a percentage of root coverage of
75% and 75.53%, respectively. 2,12 Langer and Langer proposed the
use of SCTG to improve the predictability of root coverage proce-
dures. 20 The bilaminar blood supply from the overlying gingival flap
and the underlying periosteum promotes high survival potential of
SCTG.10 In the Langer and Langer technique, there is excessive cor-
onal repositioning of the mucogingival line to cover the transplanted
tissue, which could impair the esthetic results. Releasing incisions
performed in this procedure might interrupt the superficial and in-
tramural vascularization. 2
Byun et al. performed envelope flap in both groups, SCTG + with
the epithelial collar + CAF and SCTG+ without the epithelial collar
+ CAF.5 The root coverage obtained was 97.5% and 89.1%, respec-
tively. Advantages of envelope technique are the maintenance of the
blood supply to the flap, a close adaptation to the graft, and reduc-
tion in postoperative discomfort and scarring. 21.
Byun et al. stated that the difference between the Langer and
Langer technique and the envelope technique is that, in the Langer
and Langer technique, the use of vertical releasing incisions facil-
itates more coronal overcorrection and less tension of the overly-
ing flap, possibly leading to better root coverage. 5 Also, releasing
incisions provide better visualization at the recipient area, which
reduces surgical time. 2
Tozum et al. compared the modified tunnel technique and Langer
and Langer technique to examine the coverage of gingival recession
defect. 2 The percentage of root coverage obtained for the modified
tunnel technique was 96.4%, and for Langer and Langer technique
it was 75.5%. The modified tunnel procedure has a statistically-­
increased amount of root coverage and attachment gain. This could
be related to the recipient area preparation procedure, as the use
of the tunnel technique preserves intermediate papilla that provides
more blood supply and could provide a higher amount of nutrition
for the transplanted graft that might result in better initial healing.
Tozum et al. and da Silva et al. performed the trap-­door approach
for harvesting SCTG from the palate. 2,12 In 1974, Edel introduced
the trap-­door technique, using vertical incisions. This technique is
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10 of 12       YADAV et al.
popular because of the relative ease of obtaining the connective tis-
22
sue graft. Vertical incisions can also interrupt the vascular supply
to the overlying flap predisposing the palatal flap to sloughing. 22,23.
The use of the single-­incision technique allows primary closure
of the palatal wound. The primary closure of the wound increases
patient comfort, hastens healing, reduces pain, and reduces the
chances of complications at the donor site. 23–25 The single incision
technique, however, might be a little difficult to execute as com-
24,25
pared to techniques that use two or three incisions, but the end
23–25
results such as faster healing, less trauma, and less pain, make
this technique a better option.
Erley et al. performed the Bruno technique of harvesting SCTG
16
from the palate of smokers and non-­smokers. The technique is
performed by placing the first incision perpendicular on the palate,
2-­3 mm apical to the gingival margins of teeth, followed by the sec-
ond incision, which is made parallel to the long axis of the teeth and
1-­2 mm apical to the first incision. A full-­thickness connective tissue
flap is elevated. The Bruno technique minimizes postoperative se-
quela at the donor site and promotes more rapid healing. 26.
In their study, Byun et al. compared the clinical outcomes of the
two SCTG techniques, that is, with or without the epithelial col-
5
lar. The SCTG with the epithelial collar showed a mean root cov-
erage of 98% at 6 months compared to 89% in SCTG without the
epithelial collar, with no significant difference between the groups.
Keratinized tissue width at 6 months for SCTG with the epithelial
collar was 3.85 mm, and for SCTG without the epithelial collar it was
2.75 mm, which was statistically significant. Advantages of the re-
tained epithelial collar are ease of suturing, a smoother junctional
color and contour, more rapid healing to the existing epithelium, and
a significantly greater amount of keratinized gingiva. Disadvantages
include poor esthetics and slow healing at the donor site. Byun et al.
concluded that retained epithelial collar did not provide significant
benefit with regard to clinical parameters, other than a short-­term
increase in keratinized width. Limitations of their study were low pa-
tient numbers and short observation periods, the SCTG with the ep-
ithelial collar had only one mandibular tooth, and recession defects
included were relatively small.
Tozum et al. demonstrated graft thickness of 2 mm, da Silva
et al. demonstrated graft thickness of 1.3 mm, Erley et al. demon-
strated graft thickness of 1-­2 mm, and Souza et al. demonstrated
graft thickness of 1-­1.5 mm. 2,12,16,17 Root coverage was reported
by Tozum et al. (modified tunnel technique: 96.43%, Langer and
Langer technique: 75.53%), da Silva et al. (75%), Erley et al. (82.3%
in smokers, 98.3% in non-­smokers), and Souza et al. (58.02% in
smokers, 83.35% in non-­smokers). 2,12,16,17 The necessary thick-
ness of the connective tissue graft for root coverage is 1.5-­2 mm
to prevent necrosis.
Pini Prato et al. measured the tension of CAF to treat shal-
low gingival recessions and compared the recession reduction in
test (flaps with tension) and control groups (flaps without tension)
3 months after surgery.13 In the test group, the tension was 6.5 g,
while in control group it was .4 g. Three months later, the test group
showed a mean recession reduction of 2.18 mm, a mean percentage
of root coverage of 78%, and complete root coverage was achieved
on two teeth (18%). In the control group, the mean recession reduc-
tion was 2.32 mm and the mean percentage of root coverage was
87%. Complete root coverage was obtained on five teeth. It was
suggested that the higher the flap tension, the lower the recession
reduction. Increased tension of the recipient flap could cause im-
paired esthetics, disturb initial wound healing, and result in less root
coverage. 2
da Silva et al. used a X-­shaped sling suture to hold the graft in
place, and the flap was sutured with mattress sutures, while inter-
rupted sutures were placed at the vertical incisions.12 Souza et al.
stated that the reflected flap was sutured with the sling sutures.17
However, the study did not mention the suturing technique for the
graft. Byun et al. and Reino et al. stated that the graft and flap were
sutured by sling sutures.5,18
Erley et al. and Souza et al. evaluated root coverage outcome
with connective tissue graft in smokers and non-­smokers.16,17 Erley
et al. demonstrated 82.3% and 98.3% of root coverage in smok-
ers and non-­smokers, whereas Souza et al. demonstrated showed
58.02% and 83.35% of root coverage in smokers and non-­smokers,
respectively. Reino et al. evaluated root coverage outcome with con-
nective tissue grafts only in smokers with two techniques.18 Root
coverage for the test and control groups was 54.28% and 48.6%,
respectively.
For revascularization of the connective tissue graft, an adequate
blood supply is critical. Poor wound healing in cigarette smokers can
be contributed to substances, such as cyanide, carbon monoxide,
and nitrosamines. Smokers produce less hydroxyproline and colla-
gen than non-­smokers, 27 which are essential for the production and
maintenance of connective tissue. The presence of nicotine on the
root surface in smokers has also been documented. 28 Fibroblasts
can store nicotine, which alters its function and proliferation.
Cellular changes, such as transient cell vacuolization, decreased pro-
liferation, and cell death, can occur when fibroblasts are exposed to
nicotine. This could be the cause of poor periodontal wound healing
with connective tissue grafts seen in cigarette smokers.
The limitations of the present systematic review are that the
search strategy might not be complete due to limited accessibility;
few studies included in this systematic review had a small sample
size, which could have influenced the statistical analysis power; and
with the exception of one study, none of the studies included in this
systematic review performed a histologic analysis, which would have
been more significant in determining the efficacy of SCTG based on
the factors. As well as this, not all of the studies included in this sys-
tematic review evaluated all clinical parameters. Studies included in
the present systematic review did not evaluate the impact of the
suturing technique on root coverage. The effect of the harvesting
technique of SCTG on the healing of the palatal donor site was also
not addressed. Due to limited availability of studies on flap tension,
one study with only 3 months’ follow up was included in this sys-
tematic review.
SCTG is a predictable procedure to achieve root coverage in
Miller’s class I and class II recession defects. However, all of the
YADAV et al.
above-­mentioned factors have a critical role in the outcome of root
coverage.
4.1 | Conclusion
Within the limitations of this systematic review following conclu-
sions can be drawn:
• With respect to non-carious cervical lesions, it could be stated
that, whether restored or not, a considerable amount of reduction
in recession can be obtained by SCTG
• All of the studies included in this systematic review selected
Miller’s class I and class II recession defects
• In Miller’s Class I and Class II recession there is no interproxi-
mal loss of bone and soft tissue, thus complete root coverage is
possible
• With respect to flap thickness, in both studies included in this
systematic review, the mean gingival thickness did not fall below
1 mm. Data from this review implied that thicker tissue improves
clinical results, but are unable to establish conclusively a mini-
mum thickness requirement. Many more randomized, controlled
trials with concordant baseline and outcome measurements are
needed
• Considering the flap design, both the envelope technique and
modified tunnel technique impressed the importance of blood
supply, so are more predictable in terms of percentage of root
coverage when compared to the Langer and Langer technique,
which uses vertical releasing incisions
• With respect to nature of harvesting, vertical incisions used in the
trap-door technique can interrupt the vascular supply to the over-
lying flap and can dispose the palatal flap to sloughing, but is rel-
atively easy in procuring the graft. Single incision allows primary
closure of the wound, which hastens healing and reduces pain
and discomfort at the donor site, as does the Bruno technique.
Considering the limited literature available, it is not possible to
conclude anything definitive as to which technique to be used for
harvesting the graft
• The use of SCTG with the epithelial collar does not provide addi-
tional gains than SCTG without the epithelial collar, but the exist-
ing evidence is very limited
• The necessary thickness of the connective tissue graft for root
coverage is 1.5-2 mm to prevent necrosis of the palatal donor site
• With respect to flap tension, the higher the flap tension, the lower
the recession reduction
• For the graft, sling suture is preferred, as a close adaptation to
the underlying surface is obtained. Limited evidence is avail-
able for the most preferred technique for suturing the recipient
flap
• It was demonstrated that smoking could significantly decrease
the root coverage outcomes
All the above-­mentioned factors influence the treatment outcomes
in terms of root coverage.
|
      11 of 12
ORCID
Anisha P. Yadav  http://orcid.org/0000-0002-2880-0654
Santosh S. Martande  http://orcid.org/0000-0002-0772-3127
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How to cite this article: Yadav AP, Kulloli A, Shetty S, Ligade
SS, Martande SS, Gholkar MJ. Sub-­epithelial connective
tissue graft for the management of Miller’s class I and class II
isolated gingival recession defect: A systematic review of the
factors influencing the outcome. J Invest Clin Dent.
2018;e12325. https://doi.org/10.1111/jicd.12325