J Periodontol • July 2010

Case Series
Predetermination of Root Coverage
Giovanni Zucchelli,* Monica Mele,* Martina Stefanini,* Claudio Mazzotti,* Ilham Mounssif,*
Matteo Marzadori,* and Lucio Montebugnoli†

Background: A method to predetermine the maximum root

coverage level (MRC) achievable with surgery was recently
presented. The present study evaluates the predictability of
such a method by comparing the predetermined MRC with
that effectively achieved by means of root coverage surgical
procedures.
Methods: A total of 50 patients with single and multiple re-

G
ingival recession is defined as an
cession defects were enrolled. MRC was predetermined by an apical shift of the gingival margin
independent periodontist by assessing the ideal height of the (GM) from its position 1 mm
interdental papilla. The distance from the apical reference coronal to or at the level of the ce-
point of a stent (StRP) and the MRC was measured 7 days be- mento-enamel junction (CEJ) with ex-
fore root coverage surgery. A total of 135 Miller Class I, II, and posure of the root surface to the oral
III gingival recessions were treated with the coronally ad- environment.1 From the clinical stand-
vanced flap (CAF) or with the subepithelial connective tissue point gingival recession is measured
graft (SCTG). The distance from StRP and the gingival margin as the distance from CEJ to the most
(GM) was measured by another independent periodontist 15, apical extension of GM. Esthetics is the
30, and 90 days after surgery. primary indication for the treatment of
Results: In 97 (71.8%) of 135 treated gingival recessions, gingival recessions.2 Complete root cov-
the StRP-MRC distance coincided exactly with the StRP-GM erage, namely the proportion of treated
distance. No statistically significant difference was demon- defects with the soft tissue margin at the
strated in the cases with exact predetermination between gin- level or coronal to CEJ, is the most
gival recessions belonging to the maxilla or mandible and important outcome in patients with es-
between gingival defects treated with CAF or SCTG. The thetic requests.3 Very often the most
StRP-MRC distance measured before surgery was greater in coronal millimeter of the root exposure
24 recession defects (17.7%) and lower in 14 gingival reces- is the only visible part of the recession
sions (10.3%) than the StRP-GM distance measured 90 days when the patient smiles; therefore, its
after surgery. More cases of underestimation and fewer cases persistence after therapy, even of a shal-
with overestimation of the level of root coverage were found in low recession, may be considered an
the SCTG group compared to the CAF group. The difference esthetic failure.4 Thus, both from a di-
was statistically significant (P <0.01). agnostic and prognostic point of view the
Conclusions: The adopted method was effective in prede- identification of CEJ on a tooth with
termining the position of the soft tissue margin 90 days after gingival recession is of crucial impor-
root coverage surgery. The cases with underestimation of tance.5 Toothbrushing trauma is the
the level of root coverage should be considered clinically primary etiologic factor for gingival re-
and esthetically successful. J Periodontol 2010;81:1019-1026. cession;1 in this situation cervical abra-
sion defects are frequently associated
KEY WORDS
with the root exposures. Very seldom is
Cemento-enamel junction; connective tissue graft; hard tissue loss confined to the root
diagnosis; esthetics; gingival recession; mucogingival surface; more frequently both the crown
surgery. and the root are involved. In this case
CEJ partially or totally disappeared. In
* Department of Periodontology, School of Dentistry, University of Bologna, Bologna, Italy. the presence of an abrasive force acting
† Department of Stomatology, University of Bologna.
at the level of CEJ both the enamel and

doi: 10.1902/jop.2010.090701

1019
Root Coverage Predetermination
the root cementum are removed and thus the dentin
appears. Because there is no difference in color
between the dentin of the anatomic crown and that
belonging to the root it is not possible to define or to
measure the gingival recession. Furthermore, be-
cause of the difference in color between the dentin
(generally darker and more yellow) and the enamel,
the patient frequently confuses the line of abrasion
with CEJ. This abrasion line cannot be concealed by
root coverage surgical procedures, and the patient
infers the presence after therapy of a coronal visible
pigmented area as a failure.5
Gingival recessions are classified into four classes,
according to the prognosis of root coverage.6 In Miller
Class I and II gingival recessions, there is no loss of
interproximal periodontal attachment loss and bone
and complete root coverage can be achieved. In
Miller Class III, the interdental periodontal support
loss is mild to moderate, and partial root coverage
can be accomplished. In Miller Class IV, the interprox-
imal periodontal attachment loss is so severe that no
root coverage is feasible. More recently, other factors
than the level of interproximal attachment and bone
have been shown to limit the amount of root cover-
age,5 such as the reduction of papilla height, tooth ro-
tation, and tooth extrusion with or without occlusal
abrasion. In all these clinical situations, only partial
root coverage can be achieved. The difficulty of iden-
tifying the anatomic CEJ in a tooth with cervical abra-
sion and the presence of anatomic or clinical
conditions limiting root coverage even in Class I and
II gingival recessions stimulated clinicians to prede-
termine the level of root coverage (i.e., the level into
which the soft tissue margin will be stable after the
healing process of a root coverage surgical proce-
dure).5 Predetermination of root coverage was al-
ready performed by Aichelmann-Reidy et al.7 in
a comparative study on the treatment in single-type
gingival recession. In that study, the periodontist
made a clinical determination of the expected amount
of root coverage based on clinical experience and
clinical conditions on the test teeth and adjacent
areas. Such factors as tooth position, root promi-
nence, and recession on adjacent teeth were taken
into account in making the subjective clinical deci-
sion. However, in this article, there was no mention
of how the expected amount of root coverage was cal-
culated. More recently, a method to predetermine the
maximum root coverage level (MRC) based on the
calculation of the ideal height of the anatomic inter-
dental papilla was presented by this research group.5
This level was depicted as a line that should coincide
with the anatomic CEJ when this was not clinically de-
tectable on the tooth with Miller Class I or II gingival
recession or would be more apical than the anatomic
CEJ when the ideal anatomic conditions to obtain
1020
Volume 81 • Number 7
complete root coverage were not fully represented
(Miller Class III gingival recession). The present study
evaluates the predictability of such a method by com-
paring the predetermined MRC with that effectively
achieved by means of root coverage surgical proce-
dures.
MATERIALS AND METHODS
Fifty subjects, 22 men and 28 women (age range, 21
to 58 years; mean age, 38.7 – 9 years), were enrolled
in the study. The patients were selected, on a consec-
utive basis, among individuals referred to the Univer-
sity of Bologna, School of Dentistry, Bologna, Italy,
between January 2006 and January 2007. The pa-
tients agreed to participate in this study and gave their
written informed consent on an institutional review
board consent form. All participants met the following
inclusion criteria: 1) Age ‡18 years, 2) periodontally
and systemically healthy, 3) single or multiple Miller
Class I or II gingival recessions associated with cervi-
cal abrasion defect and with no evidence of the CEJ,
4) rotated or malpositioned and extruded teeth with
or without occlusal abrasion and teeth with some
papillae height loss were included, 5) single or mul-
tiple Miller Class III gingival recessions, 6) no con-
traindications for periodontal surgery and not
taking medications known to interfere with perio-
dontal tissue health or healing, 7) and no previous
periodontal surgery at the involved sites. Teeth in
which it was not possible to predetermine the level
of root coverage (absence of contact point in the
tooth with gingival recession and in the homolo-
gous controlateral one) or with prosthetic crown
or composite restoration extending on the buccal
root surface; smoking >10 cigarettes a day; reces-
sion defects associated with buccal caries, and
teeth with evidence of pulpal pathology; and molar
teeth were excluded.
Study Design
This was a pilot, double-masked, case-series study
comparing the predetermined MRC to that achieved
after root coverage surgical procedures: coronally ad-
vanced flap (CAF) with and without a subepithelial
connective tissue graft (SCTG). The study protocol in-
volved a screening appointment to verify eligibility,
followed by initial therapy to establish optimal plaque
control and gingival health conditions; predetermina-
tion of MRC, measurement of the apical reference
point of the stent (StRP)-MRC distance, and surgical
therapy; and early maintenance phase and postoper-
ative assessments of the StRP-GM distance 15, 30, and
90 days after the surgery. Ninety days was chosen as
the final follow-up measurement visit because at this
time the outcome of the surgery can be considered
J Periodontol • July 2010
clinically stable and not yet influenced by the mainte-
nance phase.
Initial Therapy
Following the screening examination, all subjects re-
ceived a session of prophylaxis including instruction
in proper oral hygiene measures, scaling, and profes-
sional tooth cleaning 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 to minimize toothbrushing trauma
to the GM. Surgical treatment of the recession defect
was not scheduled until the patient could demonstrate
an adequate standard of supragingival plaque con-
trol.
Stent Preparation
At baseline, a stent was fabricated using resin‡ mate-
rial directly in the mouth. A reference point (slot) was
impressed on the stent at the mid-buccal area of the
experimental tooth to allow reproducible periodontal
probe positioning. The apical margin of the stent was
linear and served as a measurement reference point
(Fig. 1).8
Predetermination of Root Coverage
The method used to predetermine the MRC in the
present study was recently published by the same re-
search group and was based on the calculation of the
ideal height of the anatomic interdental papilla.5 The
ideal height of the papilla in a tooth with gingival re-
cession was defined as the apical-coronal dimension
of the interdental papilla capable of ‘‘supporting’’
complete root coverage.5 In a non-rotated and malpo-
sitioned tooth the ideal height of the papilla was mea-
sured at the same tooth with gingival recession,
whereas in a rotated and malpositioned tooth it was
measured at the level of the homologous, controlat-
eral tooth. The ideal height of the papilla was mea-
sured as the distance between the mesial-distal line
angle of the tooth and the contact point. The line angle
is easily identifiable, even in a tooth with buccal abra-
sion defect, by elevating the interdental soft tissues
(with a probe or small spatula) and searching for
the interdental CEJ. Once the ideal papilla was mea-
sured, this dimension was replaced apically starting
from the tip of the mesial and distal papillae of the
tooth with the recession defect. The horizontal projec-
tions on the recession margin of these measurements
allowed for identification of two points that were con-
nected by a scalloped line, representing the ‘‘line of
root coverage.’’5 At the mid-buccal surface of the
teeth with gingival recessions, the distance from the
StRP and the most apical extension of the line of root
coverage, representing the MRC, was measured with
a manual pressure-sensitive probe§ equipped with
a spring devicei and measurements were rounded
Zucchelli, Mele, Stefanini, et al.
up to the nearest 0.5 mm (Fig. 1). These measure-
ments were performed by a single masked examiner
(MM) 7 days before the surgeries. She did not perform
the surgeries and did not make the clinical measure-
ments after surgery. Before the study the examiner
was calibrated to reduce intraexaminer error (k >0.75)
to establish reliability and consistency.
Clinical Measurements
Clinical measurements were carried out by a single
masked examiner (CM). He did not perform the surger-
ies and was unaware of the predetermined level of root
coverage. Before the study, the examiner was cali-
brated to reduce intraexaminer error (k >0.75) to estab-
lish reliability and consistency.
Full-mouth and local plaque scores were recorded
1 week before the surgery (baseline) and 3 months
after the surgery as the percentage of total surfaces
(four aspects per tooth) that revealed the presence
of plaque.9 Bleeding on probing was assessed dichot-
omously at a force of 0.3 N with the manual pressure-
sensitive probe. Full-mouth and local bleeding scores
were recorded as the percentage of total surfaces
(four aspects per tooth) that bled on probing. The dis-
tance from the StRP and the most apical extension of
the GM was measured at baseline, 15, 30, and 90 days
after the surgery at the mid-buccal aspect of the study
teeth (Fig. 1). Probing depth, the distance from the
GM to the bottom of gingival sulcus, was measured
at baseline and 3 months after surgery. All measure-
ments were rounded up to the nearest 0.5 mm.
Surgical Techniques
The surgeries were performed by an experienced
periodontist (GZ). He was unaware of the predeter-
mined level of root coverage and did not make the
clinical measurements.
Based on his own experience the periodontist (GZ)
decided to perform a CAF with (SCTG) or without con-
nective tissue graft. Main factors influencing the deci-
sion to add a connective tissue graft were the lack of
keratinized tissue apical to the root exposure, the need
to increase the soft tissue thickness,10 and the pres-
ence of a deep abrasion defect (Fig. 2). In the case
of single-type recession defects, the modified CAF
approach described by De Sanctis and Zucchelli11
was used, whereas the envelope-type of CAF de-
scribed by Zucchelli and De Sanctis12 was performed
in the case of multiple gingival recessions affecting
adjacent teeth in the same quadrant of the jaw.
Post-surgical Infection Control
Patients were instructed not to brush teeth in the
treated area, but rinse for 1 minute with a 0.12%
‡ Pattern Resin, GC Italy, San Giuliano Milanese, Italy.
§ PCP-UNC 15 probe tip, Hu-Friedy, Chicago, IL.
i Brodontic spring device, Dentramar, Waalwijk, Holland.
1021
Root Coverage Predetermination Volume 81 • Number 7

surgery were within the range ex-

pected for data from a normal dis-
tribution (i.e., within the range of
-2 and +2).
Thus, a general linear model
was fitted and multiple-regression
analysis of variance for repeated
measures with teeth nested in
patients was used to evaluate the
existence of any significant time-
related difference (15, 30, and
90 days after surgery) regarding
the StRP-GM distance. In case of
significance, the Bonferroni t test
was applied as a multiple compar-
ison test.
A general model, considering
teeth nested in patients, was also
fitted to relate the agreement
(presence or absence of any sig-
nificant difference in the coinci-
dence between the StRP-MRC
distance measured before the sur-
gery and the StRP-GM distance
measured 90 days after the sur-
gery) with the two techniques
Figure 1.
A) Distance between StRP and GM measured at baseline at the mid-buccal aspect of a study tooth. (CAF versus SCTG) and the jaw
B) Distance between StRP and MRC at the mid-buccal aspect of a study tooth. C) Distance between (gingival recessions belonging to
StRP and GM measured 15 days after surgery, at time of suture removal, at the mid-buccal aspect the mandible or maxilla) and to re-
of a study tooth. D) Distance between SRP and GM measured 90 days after the surgery at the mid- late the number of cases with over-
buccal aspect of a study tooth. This distance coincides with the distance SRP-MRC measured before
estimation and underestimation of
surgery.
the level of root coverage between
the two techniques (CAF versus
SCTG).
chlorhexidine solution three times a day. Fourteen RESULTS
days after the surgical treatment, the sutures were re-
Following the initial oral hygiene phase and at the
moved. Plaque control in the surgically treated area
post-treatment examinations, all subjects showed
was maintained by rinsing with chlorhexidine for an
low frequencies of plaque-harboring tooth surfaces
additional 2 weeks. After this period, patients were
(full-mouth plaque score <20%) and bleeding gingival
again instructed in mechanical tooth cleaning of the
units (full-mouth bleeding score <15%), indicating
treated tooth using an ultrasoft toothbrush and a roll
good standard of supragingival plaque control during
technique for 1 month. During this period, the chlor-
the study period.
hexidine rinse was used twice a day. Then, patients
A total of 135 (90 in the maxilla and 45 in the man-
were instructed to use a soft toothbrush and rinse with
dible) gingival recessions were treated. Ten reces-
chlorhexidine once a day for another month. All pa-
sions were treated with the single-flap approach:
tients were recalled for prophylaxis 2 and 4 weeks af-
four (three upper canines and one upper premolar)
ter suture removal and, subsequently, once a month
with CAF and six (three lower canines, one upper ca-
until the final examination (90 days).
nine, one upper premolar, and one lower incisor) with
Data Analyses SCTG. A total of 125 recession defects (in 40 patients,
A statistical software program¶ was used for the sta- mean number of treated teeth per patients was 3.12 –
tistical analyses. Descriptive statistics were ex- 0.9 with a range 2 to 5) were treated with the enve-
pressed as mean – SD. lope-type surgical approach. Sixty-six defects (58
One-way analyses were performed to see whether in the maxilla and eight in the mandible) were treated
standardized skewness and kurtosis values regard-
ing the StRP-GM distance 15, 30, and 90 days after ¶ SAS, Version 6.09, SAS Institute, Cary, NC.

1022
J Periodontol • July 2010 Zucchelli, Mele, Stefanini, et al.

were in the mandible and 65 (72.2%)

in the maxilla. The results from the gen-
eral model show no statistically signif-
icant difference in the cases with exact
predetermination between gingival
recessions belonging to the maxilla or
mandible and between gingival de-
fects treated with CAF or SCTG tech-
niques.
In 24 recession defects (17.7%) the
StRP-MRC distance measured before
surgery was greater than the StRP-GM
distance measured 90 days after sur-
gery (the difference was 1 mm in 19 re-
cessions and 0.5 mm in five; median, 1
mm). In these defects an underestima-
tion of the actual level of root coverage
was performed. Nine of the 19 reces-
sions with 1-mm underestimation of
the level of root coverage had a 90 days
probing depth (PD) of 1 mm, and the
Figure 2. remaining 10 presented a PD of 2
A) The buccal aspect of a rotated canine with a deep recession defect. In the cervical area mm. Two of five recessions with an un-
a scalloped line simulated the anatomic CEJ. B) The same tooth 3 months after SCTG surgery. derestimation of 0.5 mm presented
The soft tissue margin did not reach the scalloped line. A yellow darker area appeared between a PD of 1 mm, and the remaining three
the scalloped line and the gingival margin. C) The profile of the tooth showed the presence
of a deep abrasion defect. The scalloped line visible in the buccal aspect was not the anatomic had a PD of 2 mm. Eighteen of these 24
CEJ but the coronal step of an abrasion defect. D) The profile of the canine 3 months after gingival defects were treated with SCTG
surgery showed that the abrasion defect was not covered completely with soft tissues despite and six of these with CAF.
a connective tissue graft added below CAF (SCTG technique). In 14 gingival recessions (10.3%) the
StRP-MRC distance measured before
surgery was less than the StRP-GM dis-
tance measured 90 days after surgery
with CAF, and 59 (26 in the maxilla and 33 in the man- (the difference was 1 mm in nine recessions and 0.5
dible) were treated with SCTG. A total of 87 gingival mm in five; median, 1 mm). In these defects an esti-
recessions belonged to Miller Class I or II; the remain- mation of the actual root coverage was performed.
ing 48 gingival (26 in the maxilla and 22 in the man- Twelve of the defects were treated with CAF and
dible) fit into Miller Class III. Healing was uneventful for two with SCTG.
all cases. The results from the general linear model show that
Concerning the StRP-GM distance, one-way analy- in the SCTG group, compared to the CAF group, more
sis showed that standardized skewness and kurtosis cases of underestimation and fewer cases with over-
values 15, 30, and 90 days after surgery were within estimation of the level of root coverage are found.
the range expected for data from a normal distribution The difference is statistically significant (P <0.01)
(values always within the range of -2 and +2). The re- (Fig. 4).
sults from the general linear model show a significant
time-related difference (F = 27.20; P <0.01) regarding DISCUSSION
the StRP-GM distance. In particular, the Bonferroni Because of the difficulty of identifying the anatomic
t test showed that the mean values significantly in- CEJ in a tooth with gingival recession, especially
crease from 15 to 30 days after surgery, whereas they when associated with cervical abrasion defects and
did not change significantly between 30 and 90 days the unfeasibility of achieving complete root coverage
after surgery (Fig. 3). in Miller Class III gingival recessions, the patient may
The exact coincidence between the StRP-MRC dis- not be satisfied with the esthetic results of a surgical
tance measured before surgery and the StRP-GM dis- procedure.5 In all these situations a yellow, usually
tance measured 90 days after surgery occurred in 97 darker, coronal area of exposed dentin remains uncov-
(71.8%) of 135 treated gingival recessions. Of these, ered. Furthermore, at the end of the surgical procedure
51 (73.9%) defects were treated with CAF and 46 the soft tissues are coronally displaced to compen-
(69%) with SCTG; 32 gingival recessions (71.1%) sate for post-surgical soft tissue shrinkage.13,14

1023
Root Coverage Predetermination
Consequently, the patient is satisfied about the initial
outcome of the surgery (at time of suture removal)
because the yellow dentin area is no longer visible.
However, in a few weeks time this area appears again,
even more pigmented because of the use of chlorhex-
idine rinsing for the postoperative infection control
(Fig. 2). The patient often considers the reappear-
ance of the pigmented area as a failure of the sur-
gery.5 This is confirmed by the present study data,
which indicates a statistically and clinically signifi-
cant increase in the StRP-GM distance measured 14
(suture removal) and 30 days after the surgery. On
the contrary, there was no statistically significant dif-
ference between the StRP-GM distance measured 30
and 90 days after surgery. This indicates that most
soft tissue post-surgical contraction (shrinkage) oc-
Figure 3.
Mean and 95% Bonferroni intervals of the distance SRP-GM at 15, 30,
and 90 days after surgery.
Figure 4.
Number of cases with underestimation and overestimation of the
actual level of root coverage in the group of recessions treated with SCTG
or CAF techniques.
1024
Volume 81 • Number 7
curs in the first month; afterward the position of the
soft tissue margin is stable. This is in agreement with
previous studies,8,13 which demonstrated the ten-
dency of the CAF to experience contraction in the
early healing phase.
Knowing in advance the MRC achievable with sur-
gery should allow clinicians to increase the length of
the clinical crown by means of a composite restoration
before performing root coverage surgical procedure.5
Restoring the clinical crown might result in the pa-
tient’s esthetic satisfaction even when anatomic-
biologic conditions to obtain complete root coverage
are not fully present. In addition, in the presence of
cervical abrasion defects associated with gingival re-
cession, root coverage predetermination could make
the restorative treatment easier, and thus possibly fa-
cilitate the root coverage procedure. MRC could be
used as a guideline for the apical preparation of the
composite filling, which could be stratified and fin-
ished in an operative field adequately isolated with
a rubber dam. In fact, the rubber dam could easily
be applied to that portion of the root exposure between
MRC and GM. In turn, the composite filling could make
the mucogingival surgical procedure much easier to
perform by restoring the profile of the clinical crown
and by giving a stable, smooth, and convex hard sub-
strate for the coronal placement of the flap.5
The need for distinguishing actual versus ‘‘ex-
pected’’ amount of root coverage was already raised
by Aichelmann-Reidy et al.7 In their study, however,
predetermination of root coverage was not derived
from an ‘‘objective’’ measurement, but was based
on the clinical experience of the surgeon. Factors
such as tooth position, root prominence, and pres-
ence of recession on adjacent teeth were taken into
account in making the subjective clinical decision.
No statistically significant differences between the ex-
pected and actual root coverage were demonstrated
and, according to the authors, this suggested that
the clinician’s presurgical judgment was a reliable
predictor of the amount of attainable root coverage.
The method used to predetermine MRC in the present
study was based on the biologic and clinical concept
that interdental papillae act as the most coronal vas-
cular beds to which the soft tissues covering the root
exposure are anchored at the time of the surgery.
Thus it can be speculated that every tooth with gingi-
val recession requires an ideal papilla, so that com-
plete root coverage can be accomplished. In the
present study, the ideal papilla is measured from
the line angle to the contact point. If some papillae
height was lost because of periodontal disease (Miller
Class III) or local trauma, or if there was a reduction in
the height of papillae because of tooth malposition5
(rotation and extrusion with or without occlusal abra-
sion), complete coverage was no longer achievable.
J Periodontol • July 2010
The reduction of the papilla height decreased the po-
tential advancement of the coronally displaced flap
and reduced the vascular exchanges between the soft
tissues covering the root and the interdental connec-
tive tissue beds.
The method adopted in the present study was effec-
tive in predetermining the position of the soft tissue
margin 90 days after the healing of root coverage sur-
gical procedures: in 97 (71.8%) of the 135 treated gin-
gival recessions, the StRP-MRC distance measured by
an expert periodontist before the surgery exactly coin-
cided with the StRP-GM distance measured 90 days
after surgery by an independent periodontist. No sta-
tistically significant difference was demonstrated in
the number of cases with exact predetermination be-
tween gingival recessions belonging to the mandible
or maxilla and between gingival defects treated with
CAF or SCTG. Thus, the method was equally reliable
to predetermine the level of root coverage in the gingi-
val defects of the mandible and maxilla, treated by
means of CAF with and without connective tissue graft.
In 24 of the treated gingival recessions (17.7%) the
mean StRP-MRC distance was greater than the StRP-
GM distance measured 90 days after surgery. There-
fore, in these defects, the actual root coverage was
underestimated. Better root coverage results were
achieved with respect to those predetermined before
surgery. Present data do not allow one to discriminate
if the present method resulted in an incorrect prede-
termination or if better than expected root coverage
results were achieved with surgery. Most of these gin-
gival defects were treated with the SCTG (18 [75%] of
24) and only a few (six [25%]) with CAF alone. This is
in accordance with the data reported in the other stud-
ies,8,15 which indicated better results in terms of com-
plete root coverage achieved with SCTG compared to
CAF alone. The presence of a graft under the flap
might give stability to the coronally advanced soft tis-
sue margin and reduce soft tissue contraction.8,13
Thus, one could speculate that at least in some of
the clinical cases of the present study, the adjunctive
use of a graft permitted achievement of better root
coverage outcome than those correctly predeter-
mined. Furthermore, if one considers that the prede-
termination of root coverage is clinically used to shift
CEJ apically by means of cervical restorations and
that the difference between StRP-MRC and StRP-GM
(range, 0.5 to 1 mm) was equal or lower than the buc-
cal PD in every single treated case, all cases with bet-
ter actual than expected root coverage outcomes
should be considered clinically and esthetically suc-
cessful. In fact, in these situations the patients would
not see any exposed dentin in the cervical area and the
finishing line of the restorative material would be con-
fined within the depth of the buccal probing area and
thus easy to clean by the patient and to check by the
Zucchelli, Mele, Stefanini, et al.
clinician or dental hygienist. From a clinical stand-
point the data suggest adding a connective tissue graft
below CAF when even more than complete root cov-
erage is the desired outcome.
In 14 (10.3%) of the treated defects the mean StRP-
MRC distance measured before surgery was lower
than the StRP-GM distance measured at 90 days.
Therefore, in these gingival recessions, the soft tissue
margin did not reach the predetermined level, remain-
ing <1 mm. These should be considered failing out-
comes, especially in patients with an esthetic
request, because an exposed dentin area would ap-
pear even in the case of elongation of the clinical
crown with a restorative material. Almost all (12 of
14) of these gingival recessions were treated with
CAF alone. It is not in the scope of the present study
to distinguish if the adopted method resulted in an in-
correct predetermination or if lower than expected
root coverage results were achieved with CAF proce-
dure. However, it is interesting to note that recent
studies, by the same research group, on the use of
CAF techniques for the treatment of single11 and mul-
tiple12 Miller Class I and II gingival recessions reported
percentages of complete root coverage of 88% and
89.3%, respectively. In other words, 10% to 12% of
the gingival recessions treated in these clinical trials
were not covered with soft tissues up to CEJ. This is
very similar to the 10.3% of gingival defects of the
present study, most of them treated with CAF alone,
in which the soft tissue margin did not reach MRC.
From a clinical standpoint, present data suggest in-
creasing the length of the clinical crown (of 1 mm)
by means of the composite restoration when CAF is
used to optimize the esthetic outcome.
CONCLUSIONS
Within the limits of the present study the following
conclusions can be drawn: 1) The adopted method
was able to predict the exact position of the soft tissue
margin 90 days after root coverage surgery in about
72% of the treated gingival defects; 2) The method
was equally reliable to predetermine the level of root
coverage in the gingival defects of the mandible and
maxilla treated by means of CAF or SCTG; 3) The
maximum level of root coverage achieved with sur-
gery was underestimated in 17.7% and overestimated
in 10.3% of the treated defects, however, no data are
available to distinguish if these are incorrect predeter-
minations or variable outcomes of the surgical proce-
dures; and 4) The cases with better actual than
expected root coverage outcomes should be consid-
ered clinically and esthetically successful.
Further multicenter studies with longer-term evalu-
ations are needed to confirm the efficacy of the pres-
ent method to predetermine the maximum level of
root coverage achievable with surgery.
1025
Root Coverage Predetermination
ACKNOWLEDGMENTS
This study has been self-supported by the authors.
The authors report no conflicts of interest related to
this study.
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Correspondence: Prof. Giovanni Zucchelli, Department of
Periodontology, School of Dentistry, University of Bologna,
Via S. Vitale 59, 40125 Bologna, Italy. Fax: 39/051-
225208; e-mail: giovanni.zucchelli@unibo.it.
Submitted December 13, 2009; accepted for publication
February 6, 2010.