J Clin Periodontol 2016; 43: 849856 doi: 10.1111/jcpe.

12590

Clinical efficacy of coronally Francesco Cairo1, Pierpaolo

Cortellini2, Andrea Pilloni3, Michele
Nieri1, Sandro Cincinelli1, Franco

advanced flap with or without Amunni4, Gabriella Pagavino5 and

Maurizio S. Tonetti6
1
Section of Periodontology, Department of

connective tissue graft for the Surgery and Translational Medicine, A.O.U.
Careggi, University of Florence, Florence,
Italy; 2Accademia Toscana di Ricerca

treatment of multiple adjacent Odontostomatologia (ATRO), Florence, Italy;

3
Section of Periodontology, University La
Sapienza of Rome, Rome, Italy; 4Unit of
Special Care Dentistry, A.O.U. Careggi,
gingival recessions in the University of Florence, Florence, Italy;
5
Section of Endodontics, Department of
Surgery and Translational Medicine, A.O.U.

aesthetic area: a randomized Careggi, University of Florence, Florence,

Italy; 6European Research Group on
Periodontology (ERGOPERIO), Berne,

controlled clinical trial Switzerland

Cairo F, Cortellini P, Pilloni A, Nieri M, Cincinelli S, Amunni F, Pagavino G,

Tonetti MS. Clinical efficacy of coronally advanced flap with or without connective
tissue graft for the treatment of multiple adjacent gingival recessions in the
aesthetic area: a randomized controlled clinical trial. J Clin Periodontol 2016; 43:
849856. doi: 10.1111/jcpe.12590.

Abstract
Background: The aim of this study was to assess the clinical efficacy of coronally
advanced flap (CAF) with or without connective tissue graft (CTG) for the treat-
ment of multiple adjacent gingival recessions in the upper arch.
Material and Methods: Thirty-two patients with a total of 74 gingival recessions
were randomly allocated to the two groups. Outcome measures, collected by a
blind examiner, included complete root coverage (CRC), recession reduction
(RecRed), keratinized tissue (KT) gain, increase in gingival thickness (GT),
patient satisfaction and root coverage esthetic score (RES).
Results: An interaction between treatment and baseline GT was detected. At
1 year, CAF + CTG resulted in better outcomes in terms of CRC (p = 0.0016) and
RecRed (p < 0.0001) than CAF alone at sites with thin gingiva (thick-
ness 0.8 mm). No difference was found between CAF alone and CAF + CTG at
sites with thick gingiva (>0.8 mm). CAF resulted in higher aesthetic scores (RES)
Key words: aesthetics; connective tissue
than CAF + CTG at sites with thick gingiva. CAF + CTG was associated with
graft; coronally advanced flap; gingival
greater KT gain (p < 0.0001) and greater post-operative morbidity (p < 0.0001). recession; multiple gingival recessions; root
Conclusion: Connective tissue graft under CAF results in increased probability of coverage
CRC only at sites with thin baseline gingiva. CAF alone is associated with similar
clinical outcomes and better aesthetics at sites with thick baseline gingiva. Accepted for publication 17 June 2016

Conflict of interest and source of funding statement

The authors have stated explicitly that there are no conflicts of interest in connection with this article.
The study was self-funded by the authors and their institution.

2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 849
850 Cairo et al.
In modern medicine, the treatment
of aesthetic problems is a common
and increasing patient compliant. A
recent survey of the American Soci-
ety of Plastic Surgeons reports that
the total number of cosmetic proce-
dures in the United States is
increased by 98% compared with the
previous decade (American Society
of Plastic Surgeons 2012). In den-
tistry, gingival recessions are a very
common problem (L oe et al. 1992)
often requiring treatment for aes-
thetic reasons (Nieri et al. 2013).
Young age, deep recessions and
location at anterior teeth are signifi-
cantly associated with patient
request for treatment (Nieri et al.
2013).
Robust evidence supports the effi-
cacy of various periodontal plastic
surgical techniques to achieve root
coverage of isolated gingival reces-
sion demonstrated that a connective
tissue graft (CTG) under coronally
advanced flap (CAF) is associated
with the highest probability to
obtain complete root coverage
(CRC; Cairo et al. 2008, 2012, 2014,
Chambrone et al. 2012, Chambrone
& Tatakis 2015). Conversely, data
regarding treatment of multiple
gingival recessions is more limited
(Graziani et al. 2014, Tonetti et al.
2014).
The aim of this RCT was to test
the clinical efficacy of CAF with or
without the additional placement of
CTG for the treatment of multiple
adjacent gingival recessions
(MAGR) in the aesthetic area.
Material and Methods
Participants
The present study is a parallel, ran-
domized single centre clinical trial
on the treatment of MAGR accord-
ing to the CONSORT statement
(http://www.consort-statement.org/).
Two different treatment modalities
were compared: the CAF plus CTG
(test group) and the CAF alone
(control group). The flow chart of
the study is presented in Fig. 1.
The study protocol was approved
by the University Ethical Board
(Ref. 981/14). Informed consent was
obtained from all the subjects
included in the study. The study was
conducted according to the princi-
ples outlined in the Declaration of
Fig. 1. CONSORT flow chart of the study.
Helsinki on experimentation involv-
ing human subjects, as revised in
2000.
Participants satisfying the follow-
ing entry criteria were recruited:
Age 18 years.
No systemic diseases or preg-
nancy.
Self-reported smoking 10 ci-
garettes/day.
Full-mouth plaque score and
full-mouth bleeding score 15%
(measured at four sites per
tooth).
Presence of at least two adjacent
RT1 (Cairo et al. 2011) buccal
gingival recessions 2 mm of
depth. Only gingival recessions
localized in the anterior area of
the upper jaw (central and lateral
incisors, canine, first and second
pre-molars, first molar) and asso-
ciated with aesthetic complains
were enclosed.
No history of mucogingival or
periodontal surgery at experimen-
tal sites.
Exclusion criteria were:
Prosthetic crown at experimental
teeth.
Gingival recessions presenting
minimal amount (<1 mm) of
keratinized tissue (KT) apical to
recession area.
2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Teeth presenting abrasion of the
cementoenamel junction (CEJ) were
previously treated with a composite
filling to reconstruct the CEJ before
surgery. Anatomic landmarks at
adjacent or contralateral teeth were
used to identify the correct CEJ
position in cases with abrasion; care
was taken to limit the extension of
the restorative material within 1 mm
apical to the ideal CEJ level (Cairo
& Pini-Prato 2010).
Each patient (experimental unit)
contributed with a single experimen-
tal area consisting of 23 adjacent
gingival recessions. When patients
presented bilateral MAGR at upper
arch, the experimental site was
selected by tossing a coin. When
more than three adjacent gingival
recessions were present, the deepest
ones were selected as experimental
recessions. The adjacent recessions
not included into the study, how-
ever, were treated with CAF alone
within the same procedure.
Interventions/Operator/Investigators
All surgical procedures were per-
formed by a single expert clinician
(F.C.) with more than 10 years of
experience in periodontal plastic sur-
gery. Two examiners, blinded with
respect to the surgical procedures,
assessed all the clinical and aesthetic

outcomes of treatments. The first
blind examiner evaluated clinical
outcomes and attended a preliminary
calibration session reporting intra-
class correlation coefficient of 0.87
(CI 95% 0.82; 0.91). The second
blind examiner evaluated the final
aesthetic outcomes of the surgical
procedures using the root coverage
esthetic score (RES; Cairo et al.
2009, 2010).
Clinical measurements
The following measurements were
taken at baseline for each treated
tooth by a blind examiner, using a
periodontal probe (PCP UNC 15,
Hu-Friedy):
Rec 0: Recession depth at the
mid buccal site measured from
CEJ to the gingival margin.
PD 0: probing depth at the mid
buccal site.
CAL 0: clinical attachment level
was calculated as Rec 0 + PD 0.
IM-CEJ 0: distance from incisal
margin (IM) to the CEJ.
IM-GM 0: distance from gingival
margin (GM) to incisal margin
(IM).
IM-GMJ 0: distance from incisal
margin to mucogingival junction
(MGJ).
KT 0: keratinized tissue mea-
sured from the gingival margin
to the MGJ at the mid buccal
point.
GT 0: gingival thickness at base-
line was measured 1.5 mm apical
to the gingival margin using an
injection needle, perpendicular to
the tissue surface and a silicon
stop over the gingival surface.
The silicon disc stop was then
placed in tight contact with the
soft tissue surface and fixed with
a drop of cyanocrylic adhesive
(Zucchelli et al. 2010). After nee-
dle removal, the distance between
needle tip and the silicon stop
was estimated using a digital cal-
liper with 0.01 mm of accuracy.
Sens: teeth for which the patient
reported dental hypersensitivity.
Sens VAS: dental hypersensitivity
tested using the air spray and
quantified by the patients on a
visual analogue scale (VAS).
All variations in the position of
the gingival margin were monitored
considering the incisal margin (IM)
2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Multiple gingival recession treatment
as fixed reference point at 3-month,
6-month and 1-year follow-ups.
Intra-operatory measurements
The following measurements were
taken during the surgical procedure
at each experimental tooth.
CEJ-BC: distance between
cementenamel junction and
bone crest after flap elevation.
IM-GM1: distance between inci-
sal margin and gingival margin
after suture.
In addition, chair time of the sur-
gical procedure was measured from
the end of local anaesthesia until the
completion of the sutures.
Clinical measurements to monitor
early healing
At suture removal, 10 days after sur-
gery, the following measures were
evaluated: Rec, IM-GM, IM-GMJ,
KT. In addition, data on soft tissue
complications (necrosis, oedema,
bleeding), general discomfort and
pain (measured by VAS from 0 to
100) were also collected.
Demographic data and patient ques-
tionnaires (baseline, end of surgery,
10 days, 1 year)
At baseline, age, gender, smoking
habits, number of cigarettes/day and
presence root sensitivity (VAS from
0 to 100) were registered.
After 10 days, data on post-
operative pain and possible side
effects or complications were regis-
tered. Patient discomfort was mea-
sured by VAS.
At the 1-year follow-up, patient
report on aesthetic satisfaction
(VAS) and dental hypersensitivity
(VAS) were collected. In case of
drop out, the reason related was reg-
istered.
Pre-treatment procedures
Patients received oral hygiene
instructions (roll technique) with a
soft-bristled toothbrush to correct
wrong habits related to the aetiology
of the recession at least 2 months
before surgery.
Treatment procedures
A flap design with a split (interden-
tal papilla)full (until MGJ)split
thickness (beyond MGJ) approach
was used to treat the multiple
851
recessions without vertical realising
incisions (Zucchelli & De Sanctis
2000). Details of the surgical proce-
dures are presented in the Appendix.
The randomization sealed and opa-
que envelope was opened after flap
elevation. In the test group (Fig. 2),
a single CTG (involving at least two
adjacent recessions) was applied in
the dehiscence areas (Fig. 2). In the
control group, the CAF alone was
used (Fig. 3).
Post-surgical instructions
Patients were instructed to avoid
mechanical trauma and tooth brush-
ing for 2 weeks and to intermittently
apply an ice bag for the first 4 h.
Patients received ibuprofen 600 mg
at the end of the surgical procedure
and were instructed to take another
tablet 6 h later; they were also
instructed to take additional doses if
needed. Chlorhexidine mouth rins-
ings (0.12%) were prescribed twice
daily for 1 min. Smokers were
reminded to quit smoking in the first
2 weeks after surgery. Ten days after
surgery, sutures were removed and
prophylaxis dental paste was applied
using a rubber cup at teeth in the
surgical area. Two weeks after sur-
gery, patients were instructed to
resume mechanical tooth cleaning
using a soft post-surgical toothbrush.
Patients were recalled at 1, 2, 3, 6, 9
and 12 months after surgery for pro-
fessional oral hygiene procedures
and scheduled clinical measurements.
The use of soft toothbrush was
maintained until the 3-month follow-
up, when a medium-sized bristle
toothbrush was prescribed.
Sample size
The sample dimension was calcu-
lated using a = 0.05 and the power
(1 b) of 90%. For the variability
(r = SD), the value of 0.383 mm
obtained in a previous paper
(Pini-Prato et al. 2010) was used
considering Rec T0 as covariate and
applying a multilevel model. The
minimum clinically significant value
(d) considered was 0.5 mm. Consid-
ering possible dropouts, the number
of patients was also increased of
15% for each arm. On the basis
of these data, the needed number of
patients to be enroled in this study
resulted 16 for the test group
(CAF + CTG) and 16 for the con-
trol group (CAF).
852 Cairo et al.

the operator. Blinding of examiners

was maintained throughout all
experimental procedures.

Statistical analysis

Statistical analysis was performed

(a) (b) using JMP 11.0 (SAS Institute Inc.,
Cary, North Carolina, United States),
and MLWIN 2.26 Centre for
Multilevel (Modelling University of
Bristol, Bristol, United Kingdom).
Descriptive statistics were performed
using mean  standard deviation for
quantitative variables and frequencies
and percentage for qualitative vari-
(c) (d) ables. The primary outcomes vari-
ables were the presence of CRC and
Fig. 2. Patient allocated in the test group. (a) Baseline gingival recessions from central RecRed, measured as a difference
incisors to first molar. Abrasion of cementoenamel junction (CEJ) involving cuspid, between baseline distance between
premolars and first molar was previously treated with restorative procedures. Cuspid IM-GM 0 and IM-GM1. Secondary
and first premolar were the experimental teeth. (b) After flap elevation, connective tis-
sue graft (CTG) was secured at the dehiscence area of the experimental teeth. (c) The
variables included RES values, KT,
flap is sutured. (d) Final healing at the 1-year follow-up with complete root coverage surgical time, intake of anti-inflam-
at all treated teeth. matory tablets, post-operative dis-
comfort (VAS) and final aesthetic
satisfaction (VAS).
Multilevel models considering
both patient and tooth levels were
performed in order to investigate
factors influencing the outcomes
variables (CRC, RecRed, KT gain
and RES). A logistic multilevel
model was used for CRC. Explica-
(a) (b)
tive variables were the treatment
(CAF + CTG and CAF), the base-
line recession (Rec 0), the baseline
gingival thickness (GT 0) and the
interaction between the treatment
and GT. The interaction was main-
tained in the model only when it was
significant.
General linear multilevel models
(c) (d) were applied for RecRed, KT gain
and RES. Regressors were the same
Fig. 3. Patient allocated in the control group. (a) Baseline gingival recessions from of the previous model. All the analy-
central incisors to first molar. Abrasion of cementoenamel junction (CEJ) involving ses were defined a priori.
first premolar was previously treated with restorative procedures. Premolars were the
experimental teeth. (b) Flap elevation. (c) The flap is sutured. (d) Final healing at the
1-year follow-up with complete root coverage at all treated teeth. Results

Experimental population, patients and

Randomization/Allocation conceal-
ment/Masking of examiners
Each experimental subject was ran-
domly assigned to one of the two
treatment regimens. A blocked ran-
domization in order to obtain the
same number of patients in each
arm was used. Treatment assignment
was noted in the registration and
treatment assignment form that was
kept by the study registrar (M.N.,
statistician). Allocation concealment
was performed by opaque sealed
envelopes, sequentially numbered.
The statistician generated the alloca-
tion sequence by means of a com-
puter-generated random list and
instructed a different subject to
assign a sealed envelope containing
the treatments (CAF + CTG and
CAF). The opaque envelope was
opened after flap elevation and treat-
ment assignment communicated to
2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
defect characteristics at baseline
An original sample of 36 patients
showing multiple gingival recessions
at upper arch and satisfying the
entry criteria were identified; four of
36 declined to participate into the
experimental study. A total of 32
patients were enrolled in the study
and randomized (Fig. 1); 16 patients
were treated with CAF + CTG (test
group) and 16 with CAF alone (con-
trol group).
 Multiple gingival recession treatment 853

In the CAF + CTG group, 13
out of 16 were females (81%), and
the mean age was 33.4  7.0 years
(minimum: 26; maximum: 48). Two
patients were smokers. A total of 36
upper teeth were treated: 4 incisors
(11%), 8 canines (22%), 22 premo-
lars (61%) and 2 first molars (6%).
The baseline buccal recession (Rec
Buc 0) was 3.2  0.8 mm (2; 6). In
the CAF group, 10 out of 16 were
females (62%), and the mean age
was 35.1  10.4 years (minimum:
20; maximum: 53). Three patients
were smokers. A total of 38 upper
teeth were treated: 11 incisors
(29%), 11 canines (29%), 15 premo-
lars (39%), and 1 first molar (1%).
The baseline buccal recession (Rec
Buc 0) was 3.0  0.9 mm (2; 5).
Details of baseline data are pre-
sented in Table 1. There was no clin-
ical difference at baseline between
the two groups.
Evaluation of the surgical procedure and
post-operative period (10 days)
The mean duration of the surgical
procedure was 79.4  5.6 min. for
the test group and 54.7  4.2 min.
for the control group (p < 0.0001).
After 10 days, patients from the
CAF group reported an intake of
3.1  0.7 anti-inflammatory tablets
that compared with 4.2  1.2 for the
CAF + CTG group (p = 0.0023).
Patients allocated in the test group
experienced also significantly higher
intensity of post-surgical discomfort
than the control group (44.0  9.3
versus 28.9  7.0 VAS values,
p < 0.0001).
Clinical outcomes (3, 6 and 12 months)
All patients attended all follow-up
visits and no significant complication
was reported. At the final visit all
patients were satisfied, with
93.5  5.9 mean VAS value in the
test group and 86.6  13.1 in the
control group. The difference was
not significant (6.9; 95% CI from
0.4 to 14.3; p = 0.0633).
At the 3-month follow-up visit,
the number of sites with CRC was 34
(89%) in the CAF group and 30
(83%) in the CAF + CTG group.
The number of sites with CRC
decreased to 47% at the 6-month fol-
low-up visit in the control group,
while remained stable in the test
group. No difference in term of sites
with CRC was observed between 6-
and 12-month follow-ups in both
groups. Details of the clinical
outcomes at 6 and 12 months are pre-
sented in Table 1. At the final follow-
up, CRC (p = 0.0016) and RecRed
(p < 0.0001) were significantly higher
in the test group. Furthermore, the
additional use of CTG yielded to
greater KTgain (p < 0.0001) and GT
gain (p < 0.0001). No significant dif-
ference was observed in term of final
RES score between the two groups
(Table 1). After 12 months, 69% of
patients treated with CAF + CTG
showed the complete coverage of all
the treated recessions while in the
CAF group only 25% of patients
obtained the full coverage of all the
recessions.
Multilevel analyses considering
patient and tooth levels were per-
formed to explore factors associated
with the clinical outcomes. For the
outcome variable RecRed, baseline
recession (p < 0.0001), GT (p <
0.0001), the treatment CAF + CTG
(p < 0.0001) and the interaction
between GT and treatment
(p < 0.0001) were associated with
improved final RecRed. For values of
thickness, 0.85 mm adding CTG
was associated with higher final
RecRed, while for values >0.85 mm
the use of CAF alone was associated
with better outcomes. Similar obser-
vations were reported for the analysis
in which CRC was the outcome vari-
able (Table 2). The greater was Rec 0
the smaller was the probability to
obtain CRC (p = 0.0164). Further-
more, GT (p = 0.0020), the treatment
CAF + CTG (p = 0.0016) and the
interaction between GT and treat-
ment (p = 0.0028) were associated
with improved probability of CRC.
In Fig. 4, an explorative model

Table 1. Baseline data and mean clinical outcomes at 6 and 12 months

Variable CAF (baseline) CAF + CTG CAF (6 months) CAF + CTG CAF CAF + CTG p-value
N = 38 (baseline) N = 38 (6 months) (12 months) (12 months)
N = 36 N = 36 N = 38 N = 36

Rec (mm) 3.0 (0.9) 3.2 (0.8) 0.6 (0.6) 0.2 (0.4) 0.6 (0.6) 0.2 (0.4)
RecRed (mm) 2.4 (0.7) 3.0 (0.7) 2.4 (0.7) 3.0 (0.7) <0.0001*
IM-GM (mm) 13.5 (1.4) 13.6 (1.5) 11.1 (1.0) 10.5 (1.1) 11.1 (1.0) 10.5 (1.1)
Diff. IM-GM (mm) 2.4 (0.8) 3.1 (0.7) 2.4 (0.8) 3.1 (0.7)
CRC (n/%) 18 (47) 30 (83) 18 (47) 30 (83) 0.0016*
PD (mm) 1.0 (0.0) 1.0 (0.0) 1.0 (0.0) 1.1 (0.2) 1.0 (0.0) 1.1 (0.2)
CAL (mm) 4.0 (0.9) 4.2 (0.8) 1.6 (0.6) 1.2 (0.4) 1.6 (0.6) 1.2 (0.4)
KT (mm) 3.1 (1.0) 2.8 (0.8) 2.7 (1.2) 4.7 (0.9) 2.7 (1.2) 4.7 (0.9)
KT Gain (mm) 0.4 (0.9) 1.8 (0.6) 0.4 (0.9) 1.8 (0.6) <0.0001*
GT (mm) 0.76 (0.09) 0.73 (0.08) 0.76 (0.10) 1.39 (0.18) 0.76 (0.10) 1.39 (0.18)
GT Gain (mm) 0.002 (0.05) 0.66 (0.17) 0.002 (0.05) 0.66 (0.17) <0.0001*
Sens (n/%) 5/13 10/28 3 (8) 0 (0) 3 (8) 0 (0)
Sens VAS (0100) 5.3 (14.5) 15.6 (26.7) 1.4 (5.3) 0.0 (0.0) 1.4 (5.3) 0.0 (0.0)
RES (010) 7.9 (1.4) 7.9 (1.4) 7.9 (1.4) 7.9 (1.4)

CAF, coronally advanced flap; CAF + CTG, coronally advanced flap plus connective tissue graft; CAL, clinical attachment level; CRC,
complete root coverage; CTG, connective tissue graft; GT, gingival thickness; GT Gain, gain in gingival thickness; IM-GM, distance from
gingival margin (GM) to incisal margin (IM); KT, width of keratinized tissue; KT Gain, gain in width of keratinized tissue; PD, probing
depth; Rec Red, recession reduction; RES, root coverage esthetic score; Sens, number of tooth with hypersensitivity; Sens VAS, tooth hyper-
sensitivity measured by visual analogue scale.
*p-value favouring CAF + CTG.

2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
854 Cairo et al.

Table 2. Multilevel analysis (patient and tooth level) evaluating factors associated with recessions associated with thick peri-
complete root coverage (CRC) odontal biotype (>0.8 mm). The
Term Estimate Std. error p-value model suggested that the additional
use of CTG under the flap was asso-
Intercept 23.962 9.017 ciated with higher efficacy in term of
Rec 0 2.016 0.840 0.0164 CRC and RecRed in sites presenting
GT 38.838 12.553 0.0020 with thin gingiva (0.8 mm). The
CAF + CTG (versus CAF) 39.974 12.658 0.0016
reported model, thereby, confirming
Interaction (CAF + CTG 9 GT) 49.261 16.484 0.0028
r2Patient 1.305 1.599
on the one side the benefit of graft-
ing procedure in thin biotypes
CAF, coronally advanced flap; CAF + CTG, coronally advanced flap plus connective tissue (Ahmedbeyli et al. 2014), supports
graft; CRC, complete root coverage; CTG, connective tissue graft; GT, gingival thickness; on the other side the critical role of
Rec 0, baseline recession. the baseline GT in root coverage
procedures (Baldi et al. 1999, Hwang
& Wang 2006). The observation of
similar outcomes obtained with or
without the additional use of CTG
might help clinicians in the decision-
making process for MAGR treat-
ment suggesting to restrict the use of
CTG at sites with thin residual gin-
giva only.
The analysis of the gingival mar-
gin positions at the different obser-
Fig. 4. The explorative model considering the interaction between surgical procedures vation points shows a tendency in
and baseline gingival thickness is shown. Considering a baseline Rec 0 = 3 mm, for apical shift of the gingival margin in
value of thickness 0.8 mm adding CTG was associated with higher probability of
CRC, while CTG seems to be not useful for value >0.8 mm since CAF alone was
CAF-treated group between 3 and
associated with optimal likelihood of CRC. CRC: complete root coverage (1 = 100% 6 months. In this group, CRC was
of recessions with CRC); Thick: gingival thickness; CTG: coronally advanced flap plus observed in 89% of the sites
connective tissue graft; CAF: coronally advanced flap; Rec: gingival recession. 3 months after surgery, while it was
reduced to 47% at 6 months. Con-
considering the interaction between greater KT gain for CAF + CTG versely, CAF + CTG treated sites
surgical procedures and baseline GT (mean difference 2.2 mm; 95% CI showed a consistent stability in the
is presented. For values of thickness from 1.8 to 2.7; p < 0.0001) compared same time frame, with a similar
0.8 mm the use of CTG under a with control group. number of sites with CRC at 3- and
CAF was associated with higher An explorative model to investi- 6-month follow-ups. This finding
probability of CRC, while the addi- gate the interaction between surgical corroborates the observation that
tional use of CTG did not make a sig- procedures and baseline GT in term the placement of CTG under CAF
nificant difference when the GT was of final RES values was also per- improves the clinical stability of the
>0.8 mm; in these cases, in fact, CAF formed. The use of CTG was associ- gingival margin during healing. The
alone was associated with optimal ated with higher RES values better hypothesis is that CTG might act as
likelihood of CRC. Multilevel analy- outcomes at sites with thin gingiva biological filler improving the flap
sis for KT gain (Table 3) showed (p < 0.0001), while for baseline GT adaptation over root surface, thus
>0.75 mm CAF alone was associated limiting the post-operative shrinkage
with better RES outcomes with of the gingival margin in apical
respect to CAF + CTG. direction. This outcome confirms
Table 3. Multilevel analysis (patient and
previous observations provided by
tooth level) evaluating factors associated
with keratinized tissue gain (KT gain) Discussion studies on treatment of single gingi-
val recessions (Pini-Prato et al. 2005,
Term Estimate Std. p-value The present randomized clinical trial Cortellini et al. 2009, Cairo et al.
error compared the use of CAF with or 2012). It has to be underlined that in
without CTG for the treatment of both test and control groups, the
Intercept 0.479 0.823
KT 0 0.292 0.126 0.0025 MAGR in the aesthetic area of the number of sites with CRC remained
GT 1.286 1.330 0.3336 upper jaw. At the 1-year follow-up, stable between 6- and 12-month fol-
CAF + CTG 2.211 0.224 <0.0001 CAF + CTG results more effective low-ups, thus suggesting that clinical
(versus CAF) than CAF alone, thus confirming healing of root coverage may be
r2Patient 0.268 0.102 previous outcomes (Cairo et al. considered complete after 6 months.
r2Tooth 0.287 0.063 2014). A specific multilevel analysis Data from this study confirm that
CAF, coronally advanced flap;
applied to test the potential effect of the use of CTG is associated with
CAF + CTG, coronally advanced flap plus the interaction between the type of significant improvements of apico-
connective tissue graft; CTG, connective tis- treatment and GT shows that CAF coronal KT dimension (mean
sue graft; GT, gingival thickness; KT 0, alone is similarly effective to difference 2.2 mm; p < 0.0001). In
keratinized tissue at the baseline. CAF + CTG in the treatment of addition, the group treated with
2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

CAF plus CTG resulted in a consis-
tent increase in KT thickness of
~0.7 mm; this increase in thickness is
the result of the positioning of a
graft ~1-mm thick during surgery.
This study, thereby, confirms that
CTG is a predictable approach to
improve soft tissue dimensions in
width and thickness (Zuhr et al.
2014). The increased dimensions in
KT may explain, at least in part, the
greater long-term stability of the gin-
gival margin at CAF + CTG treated
sites compared with CAF alone
(Pini-Prato et al. 2010, Zucchelli
et al. 2014, Cairo et al. 2015).
Superior clinical outcomes of the
CAF + CTG approach were, how-
ever, associated with longer chair
time and greater morbidity than
CAF alone (Cortellini et al. 2009,
Cairo et al. 2012). Surgical time was
about 25 min. longer than CAF
alone (p < 0.0001) and patients expe-
rienced significantly higher post-sur-
gical discomfort (p < 0.0001) and
reported greater anti-inflammatory
tablets consumption (p = 0.0023).
Overall, both the test and control
procedure did not cause major post-
operative complication, indicating
that surgical treatment of MAGR is
well tolerated by patients if a specific
post-operative protocol is applied.
All treated patients were highly
satisfied (mean VAS > 85) in terms
of aesthetic outcomes after both
treatments with no significant differ-
ence between the two groups. This is
a very important finding because all
patients were treated for pure aes-
thetic reasons. Furthermore, profes-
sional evaluation of the aesthetic
outcomes showed no significant dif-
ference between the two procedures
with final RES values ~8 for both
groups. Multilevel models also show
an interaction between the type of
treatment and final RES values, indi-
cating that CAF alone is associated
with better aesthetics at sites with
thick periodontal biotype. The anal-
ysis of single RES variables revealed
that the combination treatment
including CTG resulted with more
sites completely covered (primary
variable of RES score), but CAF-
treated sites resulted in higher scores
in terms of gingival colour, marginal
contour and gingival texture (sec-
ondary variables) than CAF + CTG.
These findings corroborate the
hypothesis that, considering a similar
2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Multiple gingival recession treatment
baseline mean recession, the use of
CTG could be avoided at sites with
KT thickness > 0.8 mm, where the
use of CAF alone is associated with
similar clinical outcomes and better
aesthetics.
Within the limit of this study, the
following conclusions can be drawn:
CAF + CTG overall is more
effective than CAF alone to
obtain root coverage, especially
in multiple gingival recessions at
upper arch with thin periodontal
biotype (0.8 mm).
Adding a CTG provides better
stability of the gingival margin at
the 3-month follow-up than
CAF. CAF + CTG also show
higher increase in KT and GT
than CAF alone.
CAF + CTG is associated with
longer surgical time, higher post-
operative morbidity and anti-
inflammatory tablets consumption.
Interaction between baseline GT
and type of treatment shows that
CAF alone is associated with
similar clinical outcomes and bet-
ter final aesthetics than
CAF + CTG at sites with thick
periodontal biotype (>0.8 mm).
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Clinical Relevance
Scientific rationale for the study:
The treatment of multiple recession
defects in the aesthetic area is
poorly investigated and the indica-
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(CTG) under multiple coronally
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Appendix: Treatment Procedures
An envelope flap design with a split
fullsplit thickness approach was
used to treat the multiple recessions
(Zucchelli & De Sanctis 2000).
Briefly, intra-sulcular incisions were
performed involving at least one
tooth mesial and at least one tooth
distal to the teeth with gingival
recessions. Oblique incisions were
performed at the inter-dental soft tis-
sue level in order to elevate with
split-thickness approach each surgi-
cal papilla. A full-thickness flap was
then raised up until the MGJ with a
periosteal elevator. Soft tissue was
then mobilized with a horizontal
supra-periosteal incision beyond the
MGJ to relieve muscular tension and
allow the coronal advancement of
GM in the absence of tension at
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with and without connective tissue graft for the
baseline gingival thickness was
demonstrated. CAF + CTG resulted
in better outcomes in terms of com-
plete root coverage (p = 0.0016) and
RecRed (p < 0.0001) than CAF
alone only at sites with thin peri-
odontal biotype (thick-
ness 0.8 mm).
Practical implications: Use of CTG
under CAF is strongly indicated at
each treated tooth. Exposed root
surfaces corresponding to the area of
CAL loss were carefully instru-
mented with gentle root-planing and
the inter-dental papillae were care-
fully de-epithelialized.
The randomization sealed and opa-
que envelope was opened at this time
and the clinician was instructed
whether or not to apply a connective
tissue graft (CTG) under the flap. In
the test group (Fig. 2), a CTG (in-
volving at least two adjacent reces-
sions) was harvested from the palatal
side with a single incision approach
(Lorenzana & Allen 2000) or a de-
epithelialized free gingival graft (Zuc-
chelli et al. 2010) according to the
baseline soft tissue availability and
number of experimental teeth allo-
cated to the use of CTG. The CTG
2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
treatment of multiple gingival recessions: a
comparative short- and long-term controlled
randomized clinical trial. Journal of Clinical
Periodontology 41, 396403.
Zuhr, O., Rebele, S. F., Schneider, D., Jung, R.
E. & H urzeler, M. B. (2014) Tunnel technique
with connective tissue graft versus coronally
advanced flap with enamel matrix derivative
for root coverage: a RCT using 3D digital mea-
suring methods. Part I. Clinical and patient-
centred outcomes. Journal of Clinical Periodon-
tology 41, 582592.
Address:
Francesco Cairo
via fra Giovanni Angelico 51
Firenze 50121
Italy
E-mail: cairofrancesco@virgilio.it
sites with keratinized tissue (KT)
thickness 0.8 mm. Conversely,
the use of CTG could be avoided
at sites with KT thickness > 0.8,
where CAF alone was associated
with similar clinical outcomes and
better aesthetics than CAF + CTG.
was approximately 1 mm in thick-
ness, with the height similar to the
depth of the bone dehiscence and cov-
ering all exposed experimental root
surface. The CTG was carefully
secured using resorbable sutures
(Vycril 7-0; Ethicon, Johnson & John-
son, New Brunswick, New Jersey,
United States) at apical or adjacent
periosteum. The splitfullsplit thick-
ness flap was then passively posi-
tioned coronal the cementoenamel
junction of all involved teeth and
sling sutures engaging anatomic
papillae were used to stabilize the
flap. The graft was completely cov-
ered by the gingival margin in all
cases. In the control group the coro-
nally advanced flap alone was used
(Fig. 3).