J Clin Periodontol 2014; 41: 396–403 doi: 10.1111/jcpe.

12224

Coronally advanced flap with Giovanni Zucchelli1, Ilham Mounssif1,

Claudio Mazzotti1, Martina Stefanini1,
Matteo Marzadori1, Elisabetta Petracci2

and without connective tissue and Lucio Montebugnoli1

1
Department of Biomedical and Neuromotor

graft for the treatment of multiple

Sciences, Bologna University, Bologna, Italy;
2
Department of Statistics, University of
Bologna, Bologna, Italy

gingival recessions: a
comparative short- and
long-term controlled
randomized clinical trial
Zucchelli G, Mounssif I, Mazzotti C, Stefanini M, Marzadori M, Petracci E,
Montebugnoli L. 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. J Clin Periodontol 2014; 41: 396–403. doi:
10.1111/jcpe.12224.

Abstract
Aim: The aim of this study was to compare short- and long-term root coverage
and aesthetic outcomes of the coronally advanced flap (CAF) alone or in combi-
nation with a connective tissue graft (CTG) for the treatment of multiple gingival
recessions.
Methods: Fifty patients with multiple (≥2) adjacent gingival recessions (≥2 mm)
in the upper jaw were enrolled. Twenty-five patients were randomly assigned to
the control group (CAF), and the other 25 patients to the test group
(CAF + CTG). Clinical outcomes were evaluated at 6 months, 1 and 5 years. The
aesthetic evaluations were made 1 and 5 years after the surgery.
Results: No statistically significant difference was demonstrated between the two
groups in terms of Rec Red and complete root coverage (CRC) at 6 months and
1 year. At 5 years, statistically greater recession reduction and probability of
CRC, greater increase in buccal KTH and better contour evaluation made by an
independent periodontist were observed in the CAF + CTG group. Better post-
operative course and better colour match were demonstrated in CAF-treated Key words: aesthetics; CTG; multiple
patients both at 1 and 5 years. gingival recessions; root coverage; surgery
Conclusions: CAF + CTG provided better CRC at 5 years; keloid formation due
to graft exposure was responsible for the worse colour match evaluation. Accepted for publication 24 December 2013

Conflict of interest and source of funding statement Aesthetics is the primary indication
for root coverage surgical procedures
The authors declare that they have no conflict of interests. This study has been self-
supported by the authors.
(Wennstrom 1996). The sub-epithe-
lium CTG (SCTG) is the most
396 © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

predictable surgical procedure for the
treatment of an isolated type of reces-
sion defect, in terms of complete root
coverage (CRC) (Roccuzzo et al.
2002, Cairo et al. 2008). No reports
are available on the prevalence of
single versus multiple recession type
of defects in patients with aesthetic
demands. The envelope-type of coro-
nally advanced flap (Zucchelli & De
Sanctis 2000) (CAF) is a modality of
root coverage surgery has been dem-
onstrated to be a safe and predictable
approach (Zucchelli & De Sanctis
2005) for multiple recession-type
defects. Root coverage and aesthetic
outcomes were long term (5 years)
(Zucchelli & De Sanctis 2005) well
maintained in patients regularly
attending a recall programme.
Very few data are available
regarding the effectiveness of SCTG
in the treatment of multiple recessions
(Zabalegui et al. 1999, Carvalho
et al. 2006, Chambrone & Chamb-
rone 2006) and only one long-term
controlled study has been performed
(Pini-Prato et al. 2010). In this study,
at 6 months, no statistically signifi-
cant difference between CAF + CTG
and CAF alone was reported in terms
of recession reduction and CRC.
Conversely CAF + CTG achieved
better outcomes in terms of CRC 1
and 5 years after the surgery. The
aim of this study was to compare
short- (6 months, 1 year) and long-
term (5 years) root coverage and
aesthetic outcomes of the CAF alone
or in combination with a CTG for the
treatment of multiple Miller I and II
gingival recessions in patients under-
going to a very strict supporting care
programme.
Material and Methods
Fifty subjects, 29 females and 21
males, with aesthetic complaints were
enrolled in the study. The patients
were selected, on a consecutive basis,
among individuals referred to dental
clinic Bologna University, in the per-
iod comprised between January 2004
and January 2006. The study proto-
col, 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
committee.
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Multiple gingival recessions therapy
All participants met the study
inclusion criteria:
• Age > 18 years;
• Periodontally and systemically
healthy
• FMPS e FMBS <15%
• Multiple (≥2) Miller (1985) Class
I and II recession defects (≥2 mm
in depth) on adjacent teeth of the
same quadrant of 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);
• Presence of at least 1-mm high
keratinized tissue apical to the
root exposure.
Study exclusion criteria:
• smoking more than 10 cigarettes
a day;
• contraindications for periodontal
surgery
Study design
The study was a double-blinded,
randomized controlled clinical trial
(RCT), with parallel design, compar-
ing the CAF (Zucchelli & De Sanctis
2000) with (test group) and without
(control group) CTG for the treat-
ment of multiple recession defects.
According to the protocol of the
study, five phases were followed:
• initial screening;
• initial therapy and clinical
measurements;
• surgical therapy;
• strict maintenance phase;
• re-evaluation visit 6 months,
1 year and 5 years after the sur-
gery.
Aesthetic evaluations made by
the patients and by an independent
periodontist were performed at
1 and 5 years.
Sample size
The study was powered to detect a
minimum clinically significant differ-
ence in root coverage of 1 mm using
a = 0.05, a power = 90%, a hypoth-
esized within-group sigma of
0.9 mm, obtained from previous
studies (Aichelmann-Reidy et al.
397
2001, McGuire & Nunn 2003, da
Silva et al. 2004, Pilloni et al. 2006,
Zucchelli et al. 2009). As a mini-
mum, 23 patients per treatment arm
would have been needed.
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 sur-
gical 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 multiple recession
defects affecting adjacent teeth of one
quadrant of the upper jaw. Alloca-
tion concealment was obtained using
sealed coded opaque envelope con-
taining the treatment to the specific
subject. The sealed envelope contain-
ing treatment assignment 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
demonstrate an adequate standard
of supragingival plaque control.
All measurements were carried out
by a single masked examiner (MM) at
baseline, 6 months, 1 and 5 years after
the surgeries. MM did not perform
the surgeries and was unaware of the
treatment assignment. Measurement
of recession depth (RD), as the dis-
tance between the CEJ and gingival
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 pla-
que and bleeding (FMBS) scores were
398 Zucchelli et al.
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 the 6 months, 1 and
5 years follow-up visits at the mid-
buccal aspect of the treated teeth:
• gingival RD
• probing depth (PD)
• clinical attachment level (CAL)
• keratinized tissue height (KTH)
All measurements were performed
by means of the manual probe and
were rounded up to the nearest milli-
metre (Zucchelli et al. 2009).
Patient evaluation of post-operative
morbidity and aesthetics
A questionnaire was given to each
patient; it included dichotomous
questions and the evaluation of the
intensity of the given event on a
visual analogic scale (VAS) of
100 mm (Cortellini et al. 2009).
The questionnaire was divided in
two parts to be completed in differ-
ent time periods:
• the first part, regarding the post-
operative morbidity was com-
pleted 1 week after the surgery;
• the second part, concerning patient
satisfaction with aesthetic was
completed at the 1 and 5 years
follow-up visits.
Post-operative course (in terms of
pain/discomfort) was evaluated 1 week
following surgery based on VAS scale
(Zucchelli et al. 2010). In the
CAF + CTG treated subjects, in the
case of post-operative discomfort
patients also had to specify if it was
dependent on the palatal or buccal
wound healing. Patient’s aesthetic satis-
faction was evaluated at 1 and 5 years
follow-up visits based on a VAS.
Objective evaluation of aesthetics
Objective evaluation of colour
match, contour and degree of keloid
formation (Zucchelli et al. 2009,
2012) was scored at 1 and 5 years
post-surgical evaluation visit by an
expert periodontist (C.M.) on a
VAS. He was independent of the
clinical examiner and did not per-
form the surgeries. Keloid was
scored dichotomously.
Treatment of the root surfaces
Mechanical and chemical (EDTA)
(Del Pizzo et al. 2005) treatments of
root surfaces were performed prior
to starting the surgery.
Surgical techniques
All surgeries were performed by the
same expert periodontist (GZ).
Control group
The surgical technique adopted in
the test recession defects was the
envelope type of CAF proposed by
Zucchelli & De Sanctis (2000).
Test group
The same surgical approach was
used in the test group with the only
difference that a CTG was added.
The CTG derived from the disepi-
thelialization with the blade of a pal-
atal free gingival graft (Zucchelli
et al. 2010); graft thickness did not
exceed 1 mm. Surgical chair time
was measured with a chronometer.
Post-surgical instructions and infection
control
Post-operative pain and oedema were
controlled with Ibuprofen! (Brufen,
Ibuprofen, Abbott S.r.l., Latina, Italy).
Patients were instructed not 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 treat-
ment, the sutures were removed. Pla-
que control in the surgically treated
area was maintained by chlorhexidine
rinsing for additional 2 weeks. Patients
were again instructed in mechanical
tooth cleaning of the treated tooth. All
patients were re-called 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 subsequently
every 3 months until the final examina-
tion (5 years).
Data analysis
Descriptive statistics were expressed
as mean (95% confidence intervals).
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
CRC was evaluated after 1 and
5 years by calculating the percentage
of cases, in each treatment group,
with the gingival margin at the level
or coronal to the CEJ.
One-way ANOVA was used to eval-
uate differences between test and
control group regarding: mean age,
mean baseline values of RD, CAL,
KTH and PD, mean number of teeth
treated per patient, mean surgical
chair-time, post-operative morbidity,
patient satisfaction and independent
periodontist evaluation of colour
match and contour.
Chi-square analysis was used to
compare test and control groups
concerning keloid formation at
1 year and at 5 years, to evaluate
the relationship between graft expo-
sure and the number of treated teeth
per patient and between keloid for-
mation and graft exposure in the
CAF + CTG group.
Linear regression models were fit-
ted to evaluate the existence of any
significant difference regarding, RD,
CAL, PD, KTH, between techniques
(CAF versus CAF+CTG), times
(baseline, 6 months, 1 year and
5 years where applicable) and the
interaction between techniques and
time whereas, with the same pur-
pose, a logistic regression model was
used for the outcome CRC.
To take into account the correla-
tion in the data due to the presence
of multiple treated gingival reces-
sions per subject, the above-
mentioned regression models were
estimated following a generalized
estimating equation (GEE)
approach. We adjusted the estimates
of coefficients’ standard errors and
confidence intervals by using a
robust variance–covariance estimator
(Rogers 1993).
A multiple regression ANOVA for
repeated measures with split plot
design was used to evaluate between
techniques and times differences and
interactions with regard to patient
satisfaction, periodontist colour
match and contour. All statistical
analyses were performed using Stata
12.1 (StataCorp, College Station,
TX, USA).
Results
The search results are presented in
Figure 1. Following the initial oral
hygiene phase as well as the
 Multiple gingival recessions therapy 399

trol during the study period. Details

of patient and surgical chair time are
presented in Table 1. Healing was
uneventful for all treated cases.
In the CAF + CTG group
shrinkage of the covering flap with
graft exposure was noticed in two
patients at 6 months, six patients at
1 year and nine patients at 5 years.
Bleeding from the palatal wound
was reported in one patient for
2 days after surgery. A comparison
between baseline, 1- and 5-year
clinical outcome of patients treated
by means of the CAF and
CAF + CTG is shown in Figs 2 and
3 respectively. The descriptive statis-
tics for the clinical parameters
measured at baseline, 1 and 5 years
after surgery for both groups are
shown in Table 2. At baseline, there
were no statistically significant
differences between the two groups
for any of the considered clinical
parameters.

Clinical outcome (6 months, 1 year and 5

years)

Statistical significance was evaluated

using GEE with the robust covari-
ance estimator to account for the
correlation in the data. Tooth was
used as the unit of analysis.
RD: Significant (p < 0.01) decr-
eases were observed both in the con-
trol and in the test group at 6 months,
1 year and 5 years compared to the
baseline measurements. A significant
between-groups (p < 0.01) difference
Fig 1. Consort flowchart of the study. was found at 5 years with a higher
RD reduction in the test group
compared to the control (Table 3).
Table 1. Baseline patient-related characteristics and surgical chair time CRC: In the control group
Control group (CAF 73 teeth) Test group (CAF + CTG 76 teeth) among the 73 treated defects, CRC
was achieved in 68 (at 6 month), 65
Patient 25 (10 males and 15 females) 25 (11 males and 14 females) (at 1 year) and 57 (at 5 years) gingi-
Age (range) 34.2 ! 6.2 years (22–44) 33.2 ! 7.4 years (22–46) val defects. The difference was statis-
Number treated teeth per patient tically significant between 5 years
Mean ! SD 2.92 ! 0.9 3.04 ! 0.7
Range 2–5 2–5
and 6 months (p < 0.01) and
Type of teeth between 5 years and 1 year
Incisor 19 18 (p < 0.05), whereas no significant
Canine 22 22 difference was found between 1 year
Premolar 32 36 and 6 months.
Surgical chair time (min.) In the test group among the 76
Mean ! SD 29.8 ! 3.2 40.2 ! 6.8* treated defects, CRC was achieved
Range 25–35 36–45 in 68 (at 6 months), 66 (at 1 year)
*Between-groups statistically significant difference. and 69 (at 5 years) gingival defects;
CAF, coronally advanced flap; CTG, connective tissue graft. the differences were not statistically
significant.
post-treatment examinations, all sub- (FMPS 15%) and bleeding gingival A significant between-groups dif-
jects showed low frequencies of pla- units (FMBS 15%), indicating good ferences were observed at 5 years
que harbouring tooth surfaces standard of supragingival plaque con- with an effect of treatment in terms
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
400 Zucchelli et al.

groups at 1 year and 5 years com-

pared to the baseline measurements.
Significant (p < 0.01) between-groups
differences were found at each time
with higher values in the test group
Fig. 2. Control group: CAF. Baseline situation with multiple gingival recessions. One- with respect to the control group.
year clinical outcome: complete root coverage (CRC) was achieved in all treated teeth.
Five-year clinical outcome: CRC was maintained and significant increase in buccal
Post-operative morbidity and aesthetic
keratinized tissue height was accomplished. Good colour blending and contour of the
evaluations
treated area were obtained.
The postoperative VAS values are
reported in Table 5. Multiple regres-
sion ANOVA for repeated measures
with split plot design was used to
evaluate differences between tech-
niques and times and interactions
using patients as the unit of analysis.
Fig. 3. Test group: CAF + CTG. Baseline situation with multiple gingival recessions. The post-operative course-related
One-year clinical outcome: complete root coverage (CRC) was achieved in all treated VAS scores were high for both pro-
teeth. Five-year clinical outcome: CRC was maintained. Despite no graft exposure, the cedures indicating limited post-oper-
increased soft tissue thickness at the level on the cuspid partially jeopardizes the ative pain/discomfort for both
colour blending of the treated area. The contour of the soft tissue margin is well patient groups. However, a statisti-
restored.
cally significant better post-operative
course (p < 0.01) was reported by
the CAF group.
Table 2. Clinical parameters: mean values (95% confidential intervals) at baseline,
6 months, 1 year and 5 years post surgery. Linear regression results using GEE with the The 1-year patient aesthetic
robust covariance estimator to account for the correlation in the data. Tooth was used as assessment was high in both groups
the unit of analysis with no statistically significant differ-
ences between them as well as the
Control group (CAF) Test group (CAF + CTG)
5-year evaluation.
RD Colour match
Baseline 3.05 (2.84–3.26) 3.15 (2.94–3.37)
6 months 0.06 (0.01–0.12)† 0.10 (0.03–0.17)† Statistically significant better 1-year
1 year 0.10 (0.04–0.18)† 0.13 (0.05–0.21)† (p < 0.01) and 5 year (p < 0.01) col-
5 years 0.30 (0.17–0.47)† 0.09 (0.02–0.15)*,† our match scores were demonstrated
PD for the CAF-treated patients. No
Baseline 1.12 (1.05–1.20) 1.11 (1.04–1.19) statistically significant differences
1 year 1.02 (0.98–1.06)† 1.07 (0.01–1.14)
were demonstrated between 1- and
5 years 1.10 (1.03–1.18) 1.22 (1.13–1.32)
CAL
5-year colour match evaluations in
Baseline 4.15 (3.94–4.35) 4.19 (3.98–4.41) both patient groups.
1 year 1.10 (1.04–1.18)† 1.18 (0.09–0.27)† Contour
5 years 1.36 (1.24–1.50)† 1.32 (1.22–1.44)†
KTH The 1-year contour assessment was
Baseline 1.43 (1.32–1.55) 1.47 (1.36–1.59) high in both groups with no statisti-
6 months 1.51 (1.38–1.63) 1.84 (1.72–1.97) cally significant differences between
1 year 2.08 (1.97–2.19)† 2.47 (2.34–2.60)*,† control and group test. However,
5 years 2.75 (2.60–2.90)† 3.18 (3.02–3.34)*,† statistically significant (p < 0.01)
*Between-groups statistically significant difference compared to baseline. better 5-year contour scores were
†
Time-related within-group statistically significant difference. demonstrated for the CAF + CTG
CAF, coronally advanced flap; CAL, clinical attachment level; CTG, connective tissue graft; group. A statistically significant dif-
GEE, generalized estimating equation; KTH, keratinized tissue height; RD, recession depth; ference was demonstrated between
PD, probing depth. 1- and 5-year contour evaluations in
CAF-treated subjects (p < 0.01)
of odds ratio equals to 3.22 (the differences were found neither any while no statistically significant dif-
probability of CRC in the test group interaction with time. ferences were demonstrated between
was more than three times that in CAL: Significant (p < 0.01) 1- and 5-year contour evaluations in
the control one) (Table 4). decrease was found in both groups CAF + CTG group.
PD: Significant (p < 0.02) at 1 and 5 years compared to the Statistically greater keloid forma-
decrease was found in the control baseline measurements without sta- tion was found in the test group
group at 1 year compared to the tistically significant interactions both at 1 year (p < 0.05) and 5 years
baseline measurement, whereas no between group and time. (p < 0.01). A significant difference
significant differences were found in KTH: Significant (p < 0.01) (p < 0.01) was found in the test
the test group. No between-group increases were observed in both group concerning keloid evaluation
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Multiple gingival recessions therapy 401

Table 3. Linear regression results for RD using GEE with the robust covariance estimator at 5 years with respect to keloid
to account for the correlation in the data. Tooth was used as the unit of analysis evaluation at 1 year.
b (Robust SE) 95% CI p-value In the test group, among the 11
patients with keloid formation at
Intercept 3.055 (0.058) (2.939 to 3.171) <0.001 5 years, nine experienced graft expo-
Group sure (p < 0.01) and a statistically
Control (ref.) – – – significant relationship was found
Test 0.103 (0.092) ("0.082 to 0.288) 0.268
between graft exposure and the num-
Times
At surgery (ref.) – – –
ber of treated teeth per patient at 1
At 6 months "2.986 (0.057) ("3.101 to "2.871) <0.001 (p < 0.05;) and 5 years (p < 0.01).
At 1 year "2.945 (0.055) ("3.056 to "2.834) <0.001
At 5 years "2.753 (0.072) ("2.899 to "2.608) <0.001 Discussion
Group 9 Times
Test 9 T at 6 months "0.066 (0.089) ("0.244 to 0.112) 0.458 The purpose of the present RCT was
Test 9 T at 1 year "0.081 (0.092) ("0.265 to 0.103) 0.380 to compare short- (6 months and
Test 9 T at 5 years "0.312 (0.094) ("0.502 to "0.123) 0.002 1 year) and long-term (5 years) clini-
Group 9 Times = interactions between group and the different evaluation times. cal and aesthetic outcomes of the
b, regression coefficient estimate; 95% CI, 95% confidence intervals; GEE, generalized CAF with and without CTG in the
estimating equation; Robust SE, Robust standard error; Ref., reference category; RD, treatment of multiple gingival reces-
recession depth. sions. The study was conducted on a
carefully selected population of
Table 4. Logistic regression results for CRC using GEE with the robust covariance Miller Class I and II multiple gingi-
estimator to account for the correlation in the data. Tooth was used as the unit of analysis
val recessions presenting keratinized
b (Robust SE) 95% CI p-value tissue apical to the root exposure,
treated by a skilled periodontist with
Intercept 2.610 (0.436) (1.756 to 3.464) <0.001 well-standardized surgical procedures
Group
and in patients with high standard of
Control (ref.) – – –
Test "0.470 (0.581) ("1.610 to 0.670) 0.419
oral hygiene and undergoing to a
Times very strict regimen of post-surgical
At 6 months (ref.) – – – control visits. Results obtained from
At 1 year "0.515 (0.298) ("1.099 to 0.069) 0.084 this study indicated that both
At 5 years "1.493 (0.348) ("2.175 to "0.811) <0.001 techniques were effective in reducing
Group 9 Times RD at 6 months and 1 year
Test 9 T at 1 year 0.262 (0.349) ("0.422 to 0.947) 0.453 with no statistically significant
Test 9 T at 5 years 1.641 (0.568) (0.527 to 2.755) 0.004 difference between them. Further-
Group 9 Times = interactions between group and the different evaluation times. more, the results of fitting a logistic
b, regression coefficient estimate; 95% CI, 95% confidence intervals; CRC, complete root regression model showed no signifi-
coverage; GEE, generalized estimating equation; Robust SE, Robust standard error; Ref., cant between-groups difference at
reference category. 6 months and 1 year in terms of
CRC. A lack of statistical signifi-
Table 5. Independent periodontist evaluation of aesthetic outcomes: mean values (95% cance between groups in a trial
confidential intervals). Results from ANOVA for repeated measures with split plot design designed to demonstrate superiority
using patients as the unit of analysis does not mean that the two treat-
Control group (CAF) Test group (CAF + CTG) ment techniques are equivalent
(Gunsolley et al. 1998). In this study,
Patient evaluation VAS (0 = very bad, 50 = average, 100 = excellent) a lack of significant RD reduction
Pain (1 week) 86.4(81.1–91.7) 76.4(71.5–81.3)* and CRC between the two groups
Aesthetics might be due to the limited sample
1 year 88.4 (83.6–93.1) 84.4 (79.6–89.1)
size. This rate of successful outcome
5 years 82.8 (78.6–87.0) 81.6 (76.4–86.7)
Periodontist evaluation VAS (0 = very bad, 50 = average, 100 = excellent)
of the treatment was similar to that
Colour match reported in the literature in a case-
1 year 90.8 (86.5–96.0) 78.4 (72.2–84.5)* series study (Zucchelli & De Sanctis
5 years 85.2 (81.6–88.8) 73.6 (67.3–79.9)* 2000) where the same surgical tech-
Contour nique was used. Conversely present
1 year 87.6 (82.9–92.2) 89.6 (85.2–93.9) root coverage results were higher
5 years 76.8 (70.1–83.4)† 87.2 (82.8–91.5)* than the short-term (6 months and
Periodontist evaluation – keloids 1 year) outcomes reported in the
1 year 5 years 1 year 5 years only controlled study (Pini-Prato
,†
et al. 2010) comparing CAF with or
Keloids 4% 4% 28%* 44%* without CTG in the treatment of
*Between-groups statistically significant difference. multiple gingival recessions. Reasons
†
Time-related within-group statistically significant difference. for the differences can only be specu-
CAF, coronally advanced flap; CTG, connective tissue graft; VAS, visual analogic scale. lated on. Possible explanations can
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
402 Zucchelli et al.
be found in the different number of
operator (two versus one) or study
design (split mouth versus parallel) or
in the strict entry criteria of this
study. The present data demon-
strated that successful outcomes
achieved with both surgical
approaches can be long term main-
tained. However, 5 years after sur-
gery a higher recession reduction was
demonstrated in the test groups. Fur-
thermore, in terms of CRC, a signifi-
cant between-groups difference, with
a 3.22 times greater probability to
achieve CRC with CAF + CTG was
demonstrated. When comparing the
number of cases with CRC at differ-
ent time periods, the only statistically
significant change was the reduction
between 1 and 5 years in patients
treated with CAF alone. This ten-
dency was also reported in the Pini
Prato study (Pini-Prato et al. 2010)
where an apical relapse of the gingi-
val margin in CAF-treated sites
between the 6-month and 5-year fol-
low-ups was observed. This negative
trend following CAF was attributed
with less thickness/amount of kerati-
nized tissue achieved. It is interesting
to note that in this study the apical
relapse of the gingival margin was
observed only in eight of 25 CAF-
treated patients with the majority
(68%) of patients maintaining the
successful outcomes achieved at
6 months for the following 5 years.
The present successful overall long-
term root coverage results achieved
with CAF alone could be at least in
part ascribed to the very strict regi-
men of post-surgical control visits. It
is not uncommon, in fact, for
patients to follow the clinician’s and
hygienist’s instructions correctly for
the first year and then gradually
loose motivation (Leknes et al. 2005,
Pini-Prato et al. 2012). Long-term
marginal soft tissue relapse after
CAF, occurring in some patients
only, could be ascribed to the
decrease in patient motivation,
despite the strict control regimen,
rather than true limitations associ-
ated with the surgical technique. It
can be speculated that the adjunct of
CTG, by providing greater soft tissue
thickness/KTH, not really improve
the surgical outcomes compared to
CAF alone, but facilitates long-term
patient maintenance.
The clinical outcomes of this study
were partially confirmed by the objec-
tive aesthetic evaluation. Contour
evaluation respected faithfully the
root coverage outcomes with no dif-
ference between groups in short-term
(1 year) scores and better long-term
(5 years) results for the CAF + CTG.
Conversely, the colour match assess-
ment demonstrated better scores for
the CAF both at 1 and 5 years. This
discrepancy between root coverage
outcomes and colour match evalua-
tion could be ascribed to the greater
keloid formation in the CTG-treated
sites (Zucchelli et al. 2003, Cairo et al.
2010). In this study, keloid formation
was mainly associated with graft
exposure. It is interesting to note that
a statistically significant correlation
was found between the number of
gingival recession treated with the
CTG and graft exposure both at 1
and 5 years. It could be speculated
that large grafts can impair the vascu-
lar exchange between the covering
flap and the underlying receiving bed
and, thus, increase the risk for flap
dehiscence and unaesthetic graft
exposure. This study data showed
that patient satisfaction regarding
aesthetics was very high for both
treatment groups with no difference
between them both at 1 and 5 years.
It can be speculated that the overall
root coverage outcomes achieved in
the present patient population was so
successful that the recurrence of a
shallow gingival recession or the
keloid formation was not critical
enough to negatively influence the
mean patients aesthetic scores
although remarkable by an expert in
the field of periodontology.
Conclusions
Within the limit of this study, the
following conclusions can be drawn:
• The CAF with or without CTG
were effective in terms of RD
reduction and CRC of multiple
gingival recession defects until
the 1-year examination visit, with
no statistically significant differ-
ence between them
• The CAF + CTG was associ-
ated with an increased recession
reduction and probability of
obtaining CRC at 5 years.
• Better results in terms of post-
operative course and colour
match evaluation made by an
expert periodontist were recorded
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
in patients treated with CAF.
Conversely, better 5-year contour
assessments were reported for the
CAF + CTG treated subjects.
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© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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with the envelope type of CAF with
or without CTG. CAF alone was
associated with more comfortable
post-operative course and less keloid
formation. The adjunct of CTG
provided better long-term CRC.
Practical implications: In the treat-
ment of multiple gingival recession
the use of CAF should be suggested
403
Zucchelli, G., Mele, M., Mazzotti, C., Marzadori,
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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
because of the limited post-opera-
tive discomfort and the favour-
able improvements in periodontal
parameters, while the adjunct of
CTG should be done site specifi-
cally when the aesthetic and/or
dentine hypersensitivity patient
requests impose to more predict-
ably achieve CRC.
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