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ABSTRACT
Background:
Along the years, a remarkable variety of periodontal surgical protocols has been proposed, the focus of which has shifted
from the mere resolution of a soft tissue defect to the performance of predictable and minimally invasive procedures. Initially,
the free gingival graft was used. Subsequently, many different techniques were experimented, including those using soft
tissue substitutes, such as the Alloderm membrane.
Nowadays, the association of the connective tissue graft with the coronally advanced ap is considered the gold standard.
Finally, the Pinhole technique, being a more conservative method in terms of tissue preservation and aesthetic outcome, was
proposed.
Objectives:
The aim of this review was the comparison of the updated techniques for the treatment of multiple periodontal recessions,
affecting both maxilla and mandible. The procedure outcome was assessed in terms of complete root coverage, recession
reduction, gain in height and volume, aesthetic outcome, patient’s post-operative pain and morbidity of donor and recipient
sites.
Material and methods:
Electronic and hand searches were performed to collect split- mouth studies, randomized controlled clinical trials, case series,
pilot studies, periodontal books, case studies, systematic reviews and meta-analysis, including maxillary and mandibular
multiple gingival recession defects of all four Miller’s classes, for its extensive evidence.
Results:
Thirty-four publications were included and data regarding the surgical techniques outcome were extracted from eighteen
articles. The clinical evaluation analyzed the amount of complete root coverage, recession reduction and gain in height
and volume, while the patient’s perspective was expressed in terms of aesthetic satisfaction and possible postoperative
complications. Procedures in the last ten years showed better results in all the above-mentioned factors.
Conclusion:
Procedural predictability and long-lasting treatment stability embody the factors driving the technique election process and
adding value to more updated procedures. Progress was observed both at an aesthetic level, by reducing the discrepancies
between the surgical region and the surrounding tissue, and at a postoperative level, by reducing patient discomfort. The
challenges inherent to this branch could soon nd answers thanks to its prompt evolution, which allows for further advances
to be conceived.
Update of techniques for the treatment of periodontal recessions.
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Actualización de las técnicas para el tratamiento
de las recesiones periodontales.
Débora Scandola DDS1 https://orcid.org/0009-0006-9914-2763, Marta Muñoz Corcuera DDS, PhD, MSc2 https://orcid.org/0000-0001-5033-4680,
Gabriela Gil-Abando, DDS, PhD3 https://orcid.org/0009-0008-4998-5900 Emilio González Ibarguren DDS4 https://orcid.org/0009-0008-2562-3737
1. Residente de Máster Periodoncia y Osteointegración en Universidad Europea de Madrid, Madrid, España scandoladebora98@gmail.com
2. Profesora Universidad Europea de Madrid, España. PhD y MSc en Odontología, marta.munoz@universidadeuropea.es
3. Departamento de Odontología Clínica, PhD en Odontología, Universidad Europea de Madrid, Madrid, España
4. Departamento de Odontología Preclínica, Universidad Europea de Madrid, Madrid, España
Recibido: 2023-03-22
Aceptado: 2023-07-04
Scandola, D., Muñoz-Corcuera, M., Gil-Abando, G., Gonzalez, E. (2024) Update of techniques for the treatment of periodontal recessions. Odontología Vital No. 40, Vol 1, 18-29, https://doi.
org/10.59334/ROV.v1i40.602
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Key words:
Dentistry, gingival recession, periodontal plastic surgery, root coverage, connective tissue graft. Key words: Dentistry, gingival
recession, periodontal plastic surgery, root coverage, connective tissue graft.
INTRODUCTION
A gingival recession is dened as the migration
of the gingival margin apically to the cemento-
enamel junction, with the consequent
tooth’s root exposure. Due to the periodontal
components involved in this process, the term
periodontal recession is regarded as a synonym
of this term (Dominiak et al., 2014). Depending
on the etiological factors, a gingival defect can
present itself as asymptomatic or as a variety of
impairments in need of clinical interventions.
Any manifestation of the periodontal disease,
such as a soft tissue defect, is treated by
following an established therapeutic protocol,
which indicates the non-surgical basic
periodontal procedures as the starting point.
When these actions are insufcient to restore the
physiological conditions, a surgical approach
is required. It will intend to achieve the root
coverage through the soft tissue displacement,
as well as to improve the quality of the recipient
site, increasing the tissue volume. However,
even when the further necessity of a surgical
procedure can be foreseen, a basic treatment
must always be performed rst, as it comprises
the only means through which a baseline
stability can be achieved (Imber et al., 2021;
Caton et al., 2014).
Along the years, a remarkable variety of surgical
protocols has been proposed. Their focus has
shifted from the mere resolution of a soft tissue
defect to the performance of highly predictable
and minimally invasive procedures (De Sanctis
et al., 2014). Some of these are listed below.
Free gingival graft (FGG):
It was the most widely used mucogingival
technique during 70’s and 80’s. Commonly
obtained from the hard palate, at the level of the
rst and the second molar.
The graft was made of connective and epithelial
tissues, leaving part of the former covering the
donation site. This process was designed to
increase the amount of keratinized tissue in the
recipient site (De Sanctis et al., 2014; Cairo et al.,
2014).
Coronally advanced ap (CAF):
First described by Allen and Miller in 1989, it
consisted of two divergent vertical releasing
incisions, performed together with a sulcular
incision. Finally, a full thickness ap was raised
and relocated in a coronal position (De Sanctis
et al., 2014; Cairo et al., 2014; Alghamdi et al.,
2009).
Envelope ap:
It is the coronally advanced ap technique
modication, proposed by De Sanctis and
Zucchelli in 2007. It implied the reduction of the
vertical releasing incisions to a horizontal cut. It
also involves a new ap dissection approach,
consisting of split thickness elevation of the
surgical papillae, full thickness ap elevation
3 to 4 mm apical to the bottom of the gingival
recession and split thickness ap elevation in
its most apical portion. De-epithelization of the
anatomical papillae was performed, for the
surgical papillae to be sutured over and the
muscle insertions were eliminated to favour the
ap mobilization (Alghamdi et al., 2009; Zucchelli
et al., 2009; Cortellini et al., 2012).
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Coronally advanced ap with connective tissue
graft (CAF + CTG):
Described by Zucchelli and De Sanctis, it implied
the placement of a 4 mm height and among 1,5
and 2 mm width of connective tissue graft. It did
not reach the apical portion of the defect, as it
did not aim to achieve complete root coverage
in the recession site, but the purpose was the
stabilization of the coronal ap, improving in the
long-term (Stefanini et al., 2018; Pini-Prato et al.,
2010; Zucchelli et al., 2014; Azaripour et al., 2016).
Both the European Federation of Periodontology
and the American Association of Periodontology
indicated this approach was the gold-standard
(Tian et al., 2021; Dodge et al., 2018; Skurska et al.,
2015; Tavelli et al., 2019).
Tunnelling technique:
Proposed by Raetzke, it consisted of an
intrasulcular incision, which left the interdental
papillae untouched. Also, a continuous split
thickness ap elevated up to the mucogingival
junction and the undermined dissection of the
buccal mucosa, to obtain the ap mobilization
coronally to the cementoenamel junction
(Skurska et al., 2015; Ozenci et al., 2015; Zhur et al.,
2020; Gobbato et al., 2016; Osorio et al., 2022).
Vestibular incision subperiosteal tunnel access
(VISTA):
It consisted of a single vestibular incision,
performed about 3 mm from the gingival
margin, split thickness elevation of the attached
gingiva and a tunnel carried out in the papillary
areas. Finally, the whole complex was advanced
coronally (Rajeswari et al., 2021; Mansouri et al.,
2019).
Pinhole technique:
It consisted of a horizontal incision, extended for
2 to 3 mm, a supraperiosteal dissection of the
muscular and brous adhesions and the tissue
elevation in an apicocoronal direction, involving
the interdental papillae.
A collagen membrane was placed, through
the hole, increasing the amount of tissue in the
interproximal areas.
This promoted the coronal self-holding of
the complex, since the muscular insertions
elimination favoured its passive mobilization
(Agarwal et al., 2020; Reddy, 2017).
An accurate case selection is of paramount
importance, before starting to act. The
identication of the etiological factor implied
in the gingival margin migration, as well as the
recession type (single or multiple), its location
and associated aesthetic affectation, along
with the patient’s gingival phenotype are the
elements that drive the professional’s choice of
a specic technique rather than the other.
The main objective was to compare the updated
techniques for the treatment of periodontal
recession, following their historical development,
and to analyse the advantages inherent in the
more recent approaches with respect to the
older ones.
The secondary objective was to examine the
treatment outcome in terms of CRC (complete
root coverage), RecRed (recession reduction), KT
gain (keratinized tissue gain), aesthetic outcome,
patient’s post-operative pain and morbidity, to
justify the advantages of one technique over
another.
MATERIALS AND METHODS
A literature review was conducted considering
the publications obtained from the following
databases: Medline, through PubMed, Wiley
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Online Library and Cochrane Library Advance
Search. Additionally, hand searching directed
at Journal of Clinical Periodontology, Journal
of International Academy of Periodontology,
Journal of Periodontology, The International
Journal of Periodontics and Restorative Dentistry
was performed.
The inclusion criteria consisted of the following:
• Publications in English language.
• Released between 2006 and 2021.
• Articles including multiple gingival recession
defects, affecting both maxilla and
mandible.
• Publications including all four gingival
recession Miller’s Classes, thanks to the
evidence extension.
• Split-mouth-studies, randomized controlled
clinical trials, case series, pilot studies,
periodontal books, case studies, systematic
reviews and meta-analysis.
• Two publications of a single case report for
the treatment analysis of Miller’s Class III
and IV, due to the limited available literature.
The exclusion criteria consisted of the following:
• Preclinical studies.
• Publications including periodontal
treatment associated to implant surgery.
• Studies analysing localized gingival
recession defect only.
• Research without a post-operative
assessment during a specied follow-up
period.
• Publications that did not include the term
“gingival recession”.
Information sources and search equations:
• The MEDLINE, through PubMed, on December
5, 2021. The search equations were:
(“Gingival recession”) AND (“Etiology”)
[catalog]; (“Gingival recession”) AND
(“Etiology”) AND (“Occurrence”) [full text];
(“Gingival recession”) AND (“Classication”)
AND (“Miller”) [full text]; (“Coronally
advanced ap”) AND (“Zucchelli”) [full text];
(“Tunnel technique”) AND (“Connective
tissue graft”) [full text]. Additionally,
the advanced search was limited to
publications in English language and
between the year 2000 and 2021.
• Wiley Online Library, on December 5, 2021.
The search equations were: (“Periodontal
recession”) AND (“Connective tissue graft”)
NOT (“Free gingival graft”) [full text journal];
(“Root coverage”) AND (“Prediction”) [full text
journal]; (“Root coverage”) AND (“Connective
tissue graft”) AND (“Meta-analysis”) [full
text journal]. Additionally, the advanced
search was limited to publications in English
language and between the year 2000 and
2021.
• Cochrane Library Advance Search on
November 8, 2021. The search equations
were: (“Comparison”) AND (“Surgical
techniques”) AND (“Gingival recession”)
[Review]; (“Root coverage”) AND (“Patient’s
morbidity”) [trial]. Additionally, the advanced
search was limited to publications in English
language and between the year 2000 and
2021.
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• Hand searching included: Journal of Clinical
Periodontology, Journal of International
Academy of Periodontology, Journal of
Periodontology, The International Journal of
Periodontics and Restorative Dentistry.
Data extracted from eighteen publications were
examined, to offer a visual comparison between
the different surgical techniques, confronting
their outcome in terms of complete root
coverage (CRC), recession reduction (RecRed)
and keratinized tissue augmentation (KT gain).
CRC was expressed in percentages. Every
percentage was calculated by making the
average of the values expressed in the different
publications and referred to the same technique.
RecRed and KT gain were expressed in mm.
Every value was extracted from numbers
expressed using the standard deviation and
calculated by making the average of the
measures shown in the different publications
and referred to the same technique.
Additionally, values related to aesthetics
and possible post-operative complications
were considered, in the attempt to provide a
data analysis that considered the patient’s
perspective as well.
The level of patient’s satisfaction, in terms of
aesthetic outcome and postoperative pain and
morbidity was expressed according to the Visual
Analogue Scale (VAS), including values from 1 to
100, and where a higher number was associated
to a better result.
Data depicted according to the Root Coverage
Aesthetic Score (RES) were converted to
their equivalent in the VAS, while publications
reporting the patient’s point of view with words
were excluded, as they could not be represented
with numerical values.
RESULTS
Through a hand search and the analysis of
three different databases, 105 publications
were collected and progressively screened
down to 34 (Figure 1). Afterwards, limited to 24,
considering only those publications indexed in
PubMed.
The data extraction process considered
18 publications, examined in terms of CRC,
RecRed, KT gain, aesthetic outcome, patient’s
postoperative pain and morbidity of the
donation and recipient site.
The comparison between one technique
with the other was carried out facing clinical
situations that differed for some characteristics,
such as the recession depth, the keratinized
tissue volume in the recipient site or the soft
tissue defect location. Each surgical protocol
is indicated to treat cases with specic
characteristics. For example, a coronally
advanced ap or an envelope ap is not
indicated if the area to be treated has an
insufcient vestibular sulcular depth, as well
as the tunneling technique is not suggested to
treat very deep recessions, due to the reduced
coronal mobility of this type of ap.
Amongst the surgical techniques considered,
the percentage of CRC varied from 9%, being the
lowest achieved value, and 93%, representing the
highest.
The worst outcome was linked to the free
gingival graft procedure, while the tunneling and
the VISTA technique turned out to be equally
effective in showing the best result (Figure 2).
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The prot, expressed in mm, relatively to the KT
gain and the RecRed varied respectively from
0.57 mm to 3.03 mm for the former, and from 1.40
mm to 3.43 mm for the latter. The envelope ap
technique showed the worst outcome for the
KT gain, as the VISTA did for the RecRed. On the
contrary, the VISTA achieved the best result in
terms of KT gain, as the free gingival graft did in
terms of RecRed (Figure 3).
According to the VAS scale and following the
historical evolution of the analyzed surgical
techniques, the aesthetic outcome and the
postoperative pain and morbidity varied from
a value of 60, reported from those patients that
underwent the free gingival graft procedure,
to a value of 95 and 75 respectively, as the
Pinhole technique is performed. Nevertheless,
in terms of aesthetics, the highest value was
associated with the envelope ap and with the
tunneling procedure. Instead, considering the
postoperative pain and morbidity, the highest
value presented with the envelope ap, while
a negative result appeared with the VISTA
technique (Figure 4).
Publications excluded by screening of title and abstract
and elimination of papers selected by more than one
source
Publications excluded by screening of full text
Medline Wiley Cochrane Hand Search
51 32
105
17 5
18 11
34
3 2
31
40
Medline Wiley Cochrane Hand Search
Figure 1. Study selection process.
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FGG
CAF
Envelope flap
CAF + CTG
Tunneling
VISTA
Pinhole
9%
75%
76%
85%
93%
93%
75%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
CRC (%)
CRC (%)
Figure 2. Surgical techniques comparison in terms of complete root coverage (CRC).
Figure 3. Surgical techniques comparison in terms of keratinized tissue gain (KT gain) and recession reduction (RecRed).
KT gain AND RecRed
KT gain (mm) RecRed (mm)
FGG CAF ENVELOPE
FLAP CAF + CTG TUNNELING VISTA PINHOLE
3
3.43
0.92
2.46
0.57
2.2
2
2.5
3.03
1.56
1.4
2.94
2.49
3.1
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Figure 4. Surgical techniques comparison in terms of aesthetic outcome and patient’s postoperative complications.
100
90
80
70
60
50
40
30
20
10
0
FGG CAF Envelope flap CAF + CTG Tunneling VISTA Pinhole
Aesthetics Postoperative pain and morbidity
Aesthetic outcome VS Postoperative pain and morbidity
DISCUSSION
The focus of this review lied in the identication
of the oldest techniques’ limitations and in their
compensation through the improvements
introduced with the newer procedures.
The formerly predominant idea of a direct
association between abundant amount of
keratinized tissue and healthy periodontal
status led to the setting of the free gingival
graft procedure as the golden standard for the
achievement of KT gain (3 mm) at the recession
site. Nevertheless, the frequent relapses,
associated to its short-term stability, caused this
technique to occupy the worst position in the
historical perspective concerning the amount of
CRC (9%) and RecRed (3.43 mm).
Moreover, the disparities in tissue colour and
texture blending between the treated area and
the surrounding resulted in an aesthetically
unacceptable outcome (VAS 60). This was
aggravated by a difcult postoperative due to
a double surgical site (VAS 60), which lead to a
progressive disregard of such procedure (De
Sanctis et al., 2014; Cairo et al., 2014).
Hence, the CAF technique was introduced,
eliminating the solution of continuity between
the ap and its base and thus providing an
almost identical appearance to the surrounding
area. As demonstrated by Cairo et al. (2014), it
showed a greater potential for CRC (75%), as well
as for RecRed (2.46 mm), which allowed for an
elevation of the aesthetic degree (VAS 70).
Additionally, the presence of a single surgical
site limited the morbidity and the patient’s
discomfort (VAS 67) (De Sanctis et al., 2014; Cairo
et al., 2013; Alghamdi et al., 2009).
For minimal invasiveness, Zucchelli and de
Sanctis (2009) enhanced the previously
modied CAF procedure, derived from the
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elimination of the vertical releasing incisions,
with the split-full-split thickness ap technique,
which lead to the development of the envelope
ap. The tissue manipulation was reduced, by
limiting the full thickness approach to the tissue
apical to the recession defect, resulting in a
better postoperative for the patient (VAS 87).
Despite sharing the same procedural drawback
of the traditional CAF, identied in the sufcient
amount of keratinized tissue needed close to the
recession site, the envelope technique proved a
higher rate of success in terms of CRC (76%) and,
therefore, a superior aesthetic outcome (VAS 92).
Nevertheless, remaining limited by a very low
value of KT gain (0.57 mm) (Alghamdi et al., 2016;
Zucchelli et al., 2009; Cortellini et al., 2012).
In the attempt to broaden the indications for
the coronally advanced ap, along with its
modication, the association with the harvesting
of connective tissue was proposed. It increased
the amount of KT gain at the recession site (2.49
mm), enhanced the RecRed (3.10 mm) and
provided an additional source of blood supply,
preventing the marginal shrinkage (Pini -Prato
et al., 2010; Azaripour et al., 2016; Tian et al., 2018;
Dodge et al., 2018).
Firstly, intended to accommodate the
accomplishment of CRC (85%), it was lately
demonstrated by Zucchelli et al. (2018) that the
real enhanced benet was the considerable
degree of treatment stabilization reached
in the long term, once the lack of tissue was
compensated through the graft. Thanks to
its efciency, the association of CAF with CTG
established as the gold standard technique,
despite its worse morbidity derived from a
double surgical site (VAS 76) (Stefanini et al.,
2018; Zucchelli et al., 2014). In the clinical practice,
patients subjected to this type of surgery most
commonly refer to the donation site as the main
cause of their postoperative pain.
Aiming at enhancing the patient’s comfort,
the visible cuts on the tissue surface and
the anatomical papillae detachment were
eliminated with the tunneling technique, leading
to an uneventful healing (VAS 72).
As demonstrated by Tian et al.(Tian et al., 2021),
this technique allowed an optimal CRC (93%), a
greater recession reduction (2.5 mm), a better
aesthetic outcome (VAS 94) and an increased
keratinized tissue gain (2 mm). Apart from
exhibiting a signicant long-term stability,
this procedure admitted the reduced gingival
amount at the recession site as one of its
indications (Tian et al., 2021; Gobbato et al., 2016;
Osorio et al., 2022).
With the repurposing of a ap elevation that
followed the same fashion as the tunnelling
technique, while changing for a single vertical
incision, gave way to the development of the
the vestibular incision subperiosteal tunnel
access technique. Such modication led to
an improvement of the aesthetic outcome, in
terms of post-surgical colour, tissue contour
and shape. For those reasons it became the
procedure of choice for situations with high
aesthetic demand (VAS 91).
This technique gained relevance as it:
accomplishes a greater CRC (93%), compared to
that reported by the CAF technique (even in its
association with a CTG), minimizes invasiveness,
eases the procedure and reduces the surgical
chair time, decreases the patient’s pain
perception and discomfort during and after the
treatment, (Rajeswari et al., 2021; Mansouri et al.,
2019).
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Culminating this historical excursus is the Pinhole
technique, associated to the least invasive
tissue manipulation and therefore achieving the
highest tissue preservation.
This procedure usually manifests a minimal
discomfort during the surgical procedure, as
well as a negligible pain after the intervention
(VAS 75). It allowed for an immediate CRC (75%),
clinically evident, and also granted aesthetic
improvement from the patients’ perspective.
This, in turn, increased their satisfaction (VAS 95)
(Agarwal et al., 2020; Reddy, 2017).
It must be pointed out that a decrease in
the numeric values representing the clinical
outcomes of this procedure, when compared to
the other surgical techniques, may be related
to the short spectrum of accessible scientic
literature, currently limited to a few case reports
and, therefore, yet not sufcient to be considered
fully reliable.
CONCLUSION
As the aesthetic concern increases amongst
patients, the historical evolution in the eld of
periodontal surgery has made advancements to
cover their demand.
The minimization of the differences between
the treated site and the surrounding area and
physiological gingival prole reestablishment,
have been the main achievements so far.
Minimal patient discomfort, limited post-
operative pain and reduced morbidity are
the additional elements driving the process
for choosing the right technique. Procedural
predictability and long-lasting treatment
stability embody the factors clinicians look for as
they add value to the updated techniques.
To date, considerable improvements, in the
above-mentioned aspects, have been made
through the development of renovated
surgical procedures. Nevertheless, despite
the signicant progress that has taken place,
this exciting branch of periodontal surgery is
still to be regarded as a quickly evolving eld.
Many challenges remain, therefore further
advancements are to be expected.
Conicts of interest:
The authors declare that they have no conicts
of interest.
Funding:
No funding was received to assist with the
preparation of this manuscript.
Author contribution statement
Conceptualization and design:
DS, EGI, MMC, GGA
Literature review: DS
Methodology and validation: DS, EGI
Formal analysis: DS
Investigation and data collection: DS
Resources: DS, EGI
Data analysis and interpretation: DS, EGI
Writing-original draft preparation: DS, MMC, GGA
Writing-review & editing: DS, MMC, GGA
Supervision: MMC
Project administration: MMC
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