e103

Introduction of a Novel Anatomic Recession Ratio

in the Treatment of Gingival Recession:
A Proof-of-Principle Study

Serhat Aslan, DDS, PhD1 Gingival recession (GR) is defined as

Nurcan Buduneli, DDS, PhD2 the apical shift of the gingival margin
Lorenzo Tavelli, DDS, MS3 with respect to the cementoenamel
Giulio Rasperini, DDS4 junction (CEJ), associated with at-
Pierpaolo Cortellini, MD, DDS5 tachment loss and exposure of the
root surface to the oral cavity.1 Vari-
ous surgical techniques have been
The present study introduces a novel “anatomic recession ratio” (ARR) and proposed in the literature that at-
evaluates the clinical outcomes of using a tunnel technique (TUN) with a tempt to provide root coverage (RC),
connective tissue graft (CTG) for root coverage (RC). Sixteen systemically healthy improve esthetics, and minimize pa-
patients contributing a total of 33 recession types 1 and 2 were treated with
tient discomfort.2 Recent technical
TUN + CTG. The predictive value of a panel of baseline clinical parameters
(ARR) on RC was evaluated 12 months postoperatively. At 12 months, mean developments have increased the
recession depth decreased from 2.74 ± 0.22 mm to 0.46 ± 0.13 mm (P < .0001); interest for tunneling flap procedures
19 sites (58%) showed complete RC, and the mean RC rate was 88.85% ± in reconstructive surgery.3–6 A series
2.73%. The mean ARR value was 0.74 ± 0.3, revealing a positive correlation with of randomized clinical trials report
RC (r2: 0.73, P < .0001). The 12-month esthetic evaluation resulted in a score similar RC outcomes when compar-
of 8.52 ± 1.75 using the root coverage esthetic score. TUN + CTG is effective
ing coronally advanced flap (CAF)
in reducing recession depth and obtaining good esthetic outcomes. Within
the limits of the present study, it may be suggested that ARR has potential and coronally advanced tunneling
as an analytical baseline parameter for RC outcomes with TUN + CTG. Int J technique (TUN).7–11 All TUN tech-
Periodontics Restorative Dent 2022;42:e103–e112. doi: 10.11607/prd.5574 niques aim to maintain interdental
papilla integrity by avoiding any kind
of incision through the interproximal
soft tissues, thereby reducing the
risk for scar formation and favoring a
potential improvement in esthetics.
Application of TUN in combination
Private Practice, İzmir, Turkey; Department of Biomedical, Surgical, and Dental Sciences,
1

University of Milan, Milan, Italy. with connective tissue graft (CTG)

2Department of Periodontology, Faculty of Dentistry, Ege University, İzmir, Turkey. have been proposed with various
3Department of Periodontics and Oral Medicine, University of Michigan, Ann Arbor,
technical solutions. Complete cover-
Michigan, USA.
4Department of Biomedical, Surgical, and Dental Sciences, University of Milan, Milan,
age of CTG12 or, alternatively, partial/
Italy; Department of Periodontics and Oral Medicine, University of Michigan, Ann Arbor, complete exposure of the graft to
Michigan, USA. increase the keratinized tissue width
5Accademia Toscana di Ricerca Odontostomatologica (ATRO), Florence, Italy; European
(KTW),13,14 has been suggested. In
Research Group on Periodontology (ERGOPERIO), Berne, Switzerland.
isolated deep GR cases, TUN based
Correspondence to: Dr Serhat Aslan, Meksika Sk. No: 13/4, 35220 - Alsancak, Izmir / Turkey. on coronal advancement has a lim-
Email: perio@drserhataslan.com ited potential to cover the entire CTG
despite the apical split-flap prepara-
Submitted November 27, 2020; accepted March 21, 2021.
©2022 by Quintessence Publishing Co Inc. tion, and therefore some parts of the

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e104
CTG may be left exposed.8 This ex-
posure entails potential risks for graft
integration and revascularization,
and eventually reduces the probabil-
ity for complete RC (CRC).15 To over-
come this problem, a laterally closed
TUN technique was recently devel-
oped for the treatment of isolated
deep mandibular GRs to reduce the
risk of graft necrosis by approximat-
ing the two margins of the pouch.16
At 1 year, CRC was obtained in 17 of
the 24 defects (70.83%). Obviously,
the choice of the appropriate surgi-
cal technique is dependent, at least
partially, on the recession depth17
(RD) and other anatomical param-
eters, but there is no available guide-
line for the decision-making process.
A comprehensive, site-specific analy-
sis for TUN may help to identify the
possible factors associated with RC
outcomes.18
It is hypothesized that a novel
clinical parameter formulated using
multiple measurements may reliably
predict the outcomes of RC proce-
dures. The aim of this preliminary
study was twofold: (1) to introduce a
novel clinical parameter, the anatomic
recession ratio (ARR), and (2) to evalu-
ate the clinical outcomes with applica-
tion of TUN + CTG in GRs with reces-
sion types (RTs) RT1 and RT2.19
Materials and Methods
Study Population
All participants gave informed con-
sent, and all the study procedures
were performed according to the
Declaration of Helsinki on experi-
mentation involving human subjects.
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The study protocol was approved
by the Institutional Review Board of
Faculty of Medicine, Ege University
in İzmir, Turkey. Inclusion criteria for
patients were as follows: (1) age ≥ 18
years; (2) being systemically healthy;
(3) having clinically healthy peri-
odontium (no clinical sign of active
periodontal disease) with full-mouth
plaque and bleeding scores ≤ 20%;
(4) presence of detectable CEJ; (5)
presence of at least one buccal RT1
or RT2 GR with RD < 5 mm at anteri-
or maxillary and mandibular sextants
(incisors and canines); and (6) no his-
tory of mucogingival or periodontal
surgery at the experimental sites. Pa-
tients with the self-report/detection
of the following criteria were exclud-
ed: (1) smoking habit; (2) pregnancy
or lactation; (3) extrusion, protru-
sion, presence of cervical restora-
tion, or noncarious cervical lesion at
the experimental teeth; (4) increased
tooth mobility; (5) shallow vestibulum
depth; and (6) sites with RT3 GR.
Clinical Parameters
Using a manual periodontal probe
(PCP UNC 15, Hu-Friedy), the fol-
lowing clinical measurements were
recorded at baseline and 12 months
postsurgery for each treated tooth:
(1) Probing depth (PD) at the
midbuccal site; (2) clinical attach-
ment level (CAL) at the midbuccal
site, calculated as the sum of PD and
RD; (3) CAL at interproximal sites
(iCAL); (4) RD at the midbuccal site;
(5) recession width (RW), measured
as the horizontal distance between
the gingival margins of the recession
at the CEJ level; (6) KTW, measured
as the distance between the gingi-
val margin and the mucogingival
junction; (7) baseline gingival thick-
ness (GT), measured 1.0 mm apical
to the gingival margin using an in-
jection needle perpendicular to soft
tissue and a silicon stop over gingiva
fixed with cyanoacrylate,20 and the
distance between the needle tip
and the inner surface of the silicon
stop was measured with a digital
caliper having 0.01 mm of accuracy.
Digital photographs of the
experimental teeth were taken at
baseline and 12 months postsur-
gery, taking special care to posi-
tion the camera perpendicular to
the long axis of the teeth as much
as possible. An examiner (N.B.) was
calibrated to assess the following
parameters using a digital software
(ImageJ Mac OS X, National Insti-
tutes of Health). Following the ana-
tomic reference point selection (Fig
1), components of ARR were traced
and calculated as follows:
• Anatomic line: curve between
the GR contacts (GC), traced
along the CEJ
• GR line: curve between GC,
traced along the gingival margin
• mP: distance from tip of the
mesial papilla to the point where
GR contacts CEJ
• dP: distance from tip of the
distal papilla to the point where
GR contacts CEJ
• ARR was calculated as follows
(Fig 2):
(mP) + (anatomic line) + (dP)
ARR = ____________________________
(mP) + (GR line) + (dP)
Before starting the study, intra-
examiner calibration was performed
 e105

Gingival contact Gingival contact Gingival contact

Gingival contact Gingival contact

Mesial tip of papilla Mesial tip of papilla Mesial tip of papilla

Distal tip of papilla Distal tip of papilla Distal tip of papilla

a b c
Fig 1  Selection of the reference points on (a) RT1 and (b and c) RT2 gingival recessions. (a and b) All reference points are present and
can be calculated. (c) This recession is missing a gingival contact reference point, and thus the anatomic recession ratio (ARR) cannot be
calculated.

by measuring the distance from the Fig 2  Reference points and

lines needed to calculate the
CEJ to the most apical extension of ARR. ARR= [(mesial papilla) +
the gingival margin and calculating (anatomic line) + (distal papilla)]
/ [(mesial papilla) + (gingival
the ARR three times for a total of 20
recession line) + (distal papilla)].
defects not included in the present Mesial papilla Distal papilla
study (k coefficient > 0.85). Esthetic
Anatomic line
outcomes were assessed using the (CEJ)
root coverage esthetic score (RES).21
RES uses a five-point ordinal scale
(poor, fair, good, very good, excel-
lent), which has shown satisfactory
reproducibility among periodon-
tists. A total of 10 points is the ideal
Gingival recession line
esthetic score, comprising the eval-
uation of gingival margin position,
marginal tissue contour, soft tis-
sue texture, mucogingival junction
alignment, and gingival color.

and 4) according to the modified dent). A tunneling elevator (TKN1

Surgical Procedures
All surgical procedures were per-
formed by a single experienced
periodontal surgeon (S.A.) (Figs 3
TUN, as previously described by
Sculean et al.22,23 Following local
anesthesia, a buccal intracrevicular
incision was performed using micro-
surgical blades (Micro Blades, Key-
and TKN2, Hu-Friedy) was used to
raise a buccal mucoperiosteal flap,
extended at least one tooth me-
sial and distal to the experimental
tooth/teeth. The pouch was then

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e106

Fig 3  Representative images from a man-

dibular site in Case 1 treated with TUN +
CTG. (a) The baseline recession depth was
4.4 mm, with a calculated ARR of 0.72.
(b) Transparency of the soft tissue. (c) Pro-
file view of the soft tissue thickness during
tunnel flap preparation. (d) Harvested
connective tissue graft was placed at
the recipient site. (e) Primary closure was
achieved at the surgical site. (f) Facial and
(g) profile views at 12 months. Partial root
coverage is seen.

a b c

d e f g

a b c
Fig 4  Representative images from Case 2 treated with TUN + CTG. (a) The baseline recession depth was 2.1 mm, with a calculated ARR of
0.87. (b) Primary closure was achieved at the surgical site. (c) Complete root coverage was seen at 12 months.

mobilized beyond the mucogingi-
val junction. Muscles and inserting
fibers inside the flap were detached
with microsurgical blades by keep-
ing the blade parallel to the external
mucosal surface to attain tension-
free flap closure. An angled tunnel
elevator (Stoma) facilitated the in-
terdental tunnel preparation under
the papillary tissue. Utmost care
was taken to elevate the interdental
papilla in a full-thickness manner up
to the intact interdental bone crest.
Subsequently, a CTG (1 to 1.5 mm
thick) was harvested with the single-
incision technique.24 The CTG was
inserted into the pouch using posi-
tioning sutures, then stabilized in a
mesiodistal direction. The graft was
tightly adapted to the CEJ of the ex-
perimental tooth/teeth with sling su-
tures (6-0 polypropylene, SurgiPro II,
Covidien). Then, the margins of the
pouch were advanced coronally with

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sling sutures (6-0 polypropylene) for
primary closure, without engaging
the fixed CTG. In case of deep GRs
(≥ 4 mm), the margins of the pouch
were sutured with single sutures
over the CTG in a mesiodistal direc-
tion to accomplish complete or par-
tial coverage of the graft.16
Postsurgical Care
After the surgery, all the patients
were prescribed ibuprofen (600 mg
twice daily) for 3 days and systemic
amoxicillin combined with clavu-
lanic acid (1,000 mg, bid) for 7 days,
and they abstained from mechani-
cal measures of oral hygiene for 4
weeks.16,22 During this period, 0.12%
chlorhexidine digluconate mouth
rinsing was prescribed for a duration
of 1 minute, twice daily. Sutures at
the donor and recipient sites were
removed at 7 and 14 days postsur-
gery, respectively. At 1 month post-
surgery, patients were instructed
to resume mechanical tooth clean-
ing with a soft-bristle toothbrush,
and they received professional me-
chanical plaque control (performed
by S.A.). Recall appointments were
scheduled at 3, 6, and 12 months
postsurgery.
Statistical Analysis
All statistical analyses were per-
formed using SPSS Statistics soft-
ware (version 25.0, IBM). Normal-
ity of parameters was assessed by
Shapiro-Wilk test. Descriptive sta-
tistics included mean values, SDs,
and 95% confidence intervals. For
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paired observations, intragroup
comparisons for normally distrib-
uted parameters were performed
using Student t test, and Wilcoxon
signed-rank test was used for pa-
rameters that were not normally dis-
tributed. For statistical analyses, the
level of significance was set at 5%
(α ≤ .05). Before patient recruitment,
a sample size was calculated based
on mean RC percentage (mRC). Pre-
vious studies using TUN + CTG25
reported 87% mRC with an SD of
17%. Using this data and accepting
an alpha risk of 5% and a beta risk of
20% (power: 0.8) in a two-sided test,
a minimum of 14 patients was nec-
essary. A drop-out rate of 10% was
anticipated.
The following formula was used
for mRC calculation: [(baseline RD)
– (1-year RD) / (baseline RD)] x 100.
The investigated teeth were divided
into two subgroups according to
the final mRC: subgroup 1 patients
reached 100% RC (CRC), and sub-
group 2 patients achieved partial
RC (PRC). Multilevel analysis consid-
ering tooth level was performed to
investigate factors related to reces-
sion anatomy influencing the mRC.
Baseline variables (RD, RW, and
ARR) were analyzed in the models
as explicative variables.
Results
The study population consisted of
16 patients presenting with 33 GRs.
There were no drop-outs and no
missing data throughout the study
period. Nine patients (56%) pre-
sented with a single recession, and
7 patients (44%) had multiple GRs.
e107
Twelve recessions (36%) were classi-
fied as RT1, and 21 (64%) were RT2.
Descriptive statistics of the clinical
parameters at baseline are present-
ed in Table 1.
At 12 months, highly statisti-
cally significant decreases in RD
(P < .0001) and RW (P < .0001) were
observed (Table 2). There was a
negligible increase in PD, without
any statistically significant difference
(P = .711). The mRC was 88.85% ±
2.73%, and CRC was achieved in 19
sites (58%). The esthetic evaluation
performed at 12 months using RES
was 8.52 ± 1.75 (Table 3).
Subgroup analyses were per-
formed between sites showing CRC
and PRC. All clinical parameters (RD,
CAL, iCAL, KTW, GT, mP, dP, and
ARR) measured at baseline exhib-
ited significant differences between
the two subgroups, with the excep-
tion of RW (Table 4). Sites exhibiting
CRC had a mean ARR of 0.84 ± 0.06,
while those with PRC had a mean
ARR of 0.60 ± 0.11 (P < .001). At 12
months, RES values were 9.95 ± 0.23
in the CRC subgroup and 6.57 ±
0.65 in the PRC subgroup (P < .001).
Regression analyses at 12
months revealed a positive corre-
lation between ARR and the mRC
(Figs 5 and 6); both regression coef-
ficients were highly significant (P <
.0001).
The multilevel analyses were
performed to explore anatomical
factors associated with mRC. The
generated model was highly signifi-
cant (P < .0001) and explained 77%
of the observed variability in mRC
(Table 5). Only ARR was found to be
associated with mRC (P = .0005). RD
(P = .527) and RW (P = .191) did not
Volume 42, Number 4, 2022
e108

Table 1 Demographic Characteristics of Patients and Baseline Clinical Parameters

Parameter Parameter
Gender, n CAL, mm
Female 10 Mean ± SD 3.96 ± 0.24
Male 6 95% CI 3.46, 4.45
Age, y iCAL, mm
Mean ± SD 33.75 ± 11.47 Mean ± SD 1.97 ± 0.31
Range 18–53 95% CI 1.33, 2.61
Tooth type, n KTW, mm
Maxillary incisor 9 Mean ± SD 2.39 ± 0.25
Maxillary canine 4 95% CI 1.87, 2.9
Mandibular incisor 15 GT, mm
Mandibular canine 5 Mean ± SD 0.89 ± 0.05
Recession type (RT), n 95% CI 0.78, 1
RT1 12 mP, mm
RT2 21 Mean ± SD 4.42 ± 0.33
RD, mm 95% CI 3.75, 5.09
Mean ± SD 2.74 ± 0.22 dP, mm
95% CI 2.31, 3.19 Mean ± SD 4.17 ± 0.29
RW, mm 95% CI 3.57, 4.77
Mean ± SD 3.66 ± 0.21 ARR
95% CI 3.22, 4.09 Mean ± SD 0.74 ± 0.3
PD, mm 95% CI 0.69, 0.79
Mean ± SD 1.18 ± 0.39
95% CI 1.04, 1.32
RD = gingival recession depth; RW = gingival recession width; PD = probing depth; CAL = clinical attachment level; iCAL = interdental CAL;
KTW = keratinized tissue width; GT = gingival thickness; mP and dP = distance from tip of the mesial and distal papilla, respectively, to the
point where the recession contacts the cementoenamel junction; ARR = anatomic recession ratio.

Table 2  Clinical Measurements at Baseline and 12 Months After Treatment

Baseline 12 mo
Variables Mean ± SD 95% CI Mean ± SD 95% CI P
RD, mm 2.74 ± 0.22 2.31, 3.19 0.46 ± 0.13 0.19, 0.73 < .0001
RW, mm 3.66 ± 0.21 3.22, 4.09 1.16 ± 0.29 0.56, 1.75 < .0001
PD, mm 1.18 ± 0.39 1.04, 1.32 1.21 ± 0.42 1.51, 3.21 .711
CAL, mm 3.96 ± 0.24 3.46, 4.45 1.66 ± 0.16 1.34, 1.98 < .0001
iCAL, mm 1.97 ± 0.31 1.33, 2.61 2.00 ± 0.32 1.35, 2.65 .655
KTW, mm 2.39 ± 0.25 1.87, 2.9 2.90 ± 0.25 2.39, 3.41 < .001
GT, mm 0.89 ± 0.05 0.78, 1 1.19 ± 0.06 1.08, 1.31 < .001
RD = gingival recession depth; RW = gingival recession width; PD = probing depth; CAL = clinical attachment level; iCAL = interdental CAL;
KTW = keratinized tissue width; GT = gingival thickness.

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 e109

Table 3  Treatment Outcomes at 12 Months

TUN + CTG
All sites RT1 sites RT2 sites
Variables (n = 33) (n = 12) (n = 21)
mRC, % 88.85 ± 2.73 96.33 ± 8.61 84.57 ± 17.34
Sites with CRC, n (%) 19 (58%) 10 (83%) 9 (43%)
RES 8.52 ± 1.75 9.5 ± 1.17 7.95 ± 1.8
mRC = mean percentage of root coverage; CRC = complete root coverage; RES = root coverage esthetic score; RT1 = recession type 1;
RT2 = recession type 2.
mRC and RES values are presented as mean ± SD.

Table 4  Descriptive Subgroup Analyses of the Clinical Parameters According to Root Coverage Rate
CRC sites PRC sites
Variables (n = 19) (n = 14) P
RD, mm 1.93 ± 0.57 3.86 ± 1.03 < .001
RW, mm 3.41 ± 1.21 4.01 ± 1.19 .132
CAL, mm 3.08 ± 0.78 5.14 ± 1.18 < .001
iCAL, mm 1.11 ± 1.24 3.14 ± 1.83 < .01
KTW, mm 2.80 ± 1.62 1.81 ± 0.98 < .05
GT, mm 0.99 ± 0.34 0.75 ± 0.19 < .05
mP, mm 5.54 ± 1.52 2.89 ± 1.10 < .001
dP, mm 4.86 ± 1.39 3.23 ± 1.66 < .01
ARR 0.84 ± 0.06 0.60 ± 0.11 < .001
RES 9.95 ± 0.23 6.57 ± 0.65 < .001
mRC, % 100 ± 0 73.71 ± 13.35 < .001
CRC = complete root coverage; PRC = partial root coverage; RD = gingival recession depth; RW = gingival recession width; CAL = clinical
attachment level; iCAL = interdental CAL; KTW = keratinized tissue width; GT = gingival thickness; mP and dP = distance from tip of the me-
sial and distal papilla, respectively, to the point where the recession contacts the cementoenamel junction; ARR = anatomic recession ratio;
RES = root coverage esthetic score; mRC = mean percentage of root coverage.
Values are presented as mean ± SD.

reach the level of statistical signifi-
cance individually.
Discussion
The major purpose of this study was
to explore a possible correlation be-
tween RC and ARR; a novel ratio in-
cluding multiple baseline anatomical
characteristics of the recession site.
The clinical results demonstrated a
significant positive correlation be-
tween ARR and mRC: a higher mRC
was associated with higher ARR val-
ues, suggesting that ARR may be
used as an analytical baseline param-
eter for CRC in TUN + CTG treatment
and may help clinicians to decide on
the surgical technique.
TUN preparation, especially in
deep GR cases, does not predict-
ably allow such a coronal postsur-
gical gingival margin position.16 In
a case series investigating the out-
comes of TUN + CTG in the anterior
mandible, 3 mm of RD was found
to be the critical value affecting the
clinical outcomes.17 In other words,
as the baseline RD increased from

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e110

100 100
mRC

mRC
50 50

0 0
0.0 0.2 0.4 0.6 0.8 1.0 0.0 0.2 0.4 0.6 0.8 1.0
ARR ARR

Fig 5  Correlation between ARR and mean percentage of root Fig 6  Correlation between ARR and mean percentage of root
coverage (mRC) at 12 months in all gingival recessions (r2: 0.73, coverage (mRC) at 12 months in RT2 gingival recessions (r2: 0.69,
y = 92.10x + 20.73, P < .0001). y = 93.97x + 19.24, P < .0001).

Table 5 Multilevel Analysis on Tooth Level Evaluating Factors Associated with Mean Percentage of
Root Coverage
Estimate SE P
Intercept 40.73 19.44 .045
RD –1.58 2.48 .527
RW –1.79 1.34 .191
ARR 79.78 20.22 .0005
RD = gingival recession depth; RW = gingival recession width; ARR = anatomic recession ratio; SE = standard error.
The model was highly significant: P < .0001; r2 = 0.768.

3 to 4 mm, the CRC rate decreased
from 88% to 41.67%. From a clinical
perspective, factors related with the
finding of 41.67% CRC rate still re-
main unknown. In the present study,
using ARR as an additional clinical
baseline parameter provided a ra-
tio that helped determine a cut-off
value for CRC in TUN + CTG. An
optimal cut-off point of 0.77 for ARR
was found, meaning that an ARR of
0.77 was the critical threshold for
obtaining CRC in the present study.
Thus, it can be speculated that clini-
cal scenarios with an ARR < 0.77
may benefit more from CAF-based
procedures. Nevertheless, further
clinical trials are necessary to con-
firm this finding.
Several factors specific to patient,
site, and technique that affect the
clinical outcomes have been evalu-
ated in previous studies, mainly when
applying CAF-based procedures.
Among the site-specific factors, GT,
KTW, papilla height, tooth location
and position, RD, and RW seem to
play a major role in obtaining good
clinical outcomes.26–28 Ozcelik et al29
suggested that the avascular exposed
root surface area (AERSA) and inter-
dental papilla height may predict CRC
with CAF + CTG procedures. They
also pointed out that the interdental
papilla height was more prominent
than AERSA in RT2 defects. There
is a great variation in RT2 defects in
terms of anatomic reference points,
and thus, ARR is suggested to be cal-
culated in the presence of both GCs
along the CEJ.
ARR consists of novel reference
points and distances, such as the
distance between the tip of the in-
terdental papilla and GC. To the best

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of the present authors’ knowledge,
this is the first study calculating the
curvilinear distance of the papilla
reaching the CEJ-GR contact. In the
subgroup analysis, it is interesting to
see the difference between the CRC
and PRC groups in terms of mP and
dP length. A longer curvilinear dis-
tance between the papilla tip and
GC revealed a higher CRC rate. In
the ARR equation, longer curvilinear
papilla distances increased the ratio
rate more than shorter distances.
For example, a 12-mm curvilinear
papilla distance is calculated with
10% more ARR value than a 6-mm
curvilinear papilla distance using the
same anatomic and GR lines.
Significant differences were
found in the baseline values of RD,
CAL, iCAL, KTW, GT, mP, dP, and
ARR between the CRC and PRC
subgroups, but not in RW. Sites with
deeper baseline RD showed less
RC. The difference in ARR between
the subgroups provides strong sup-
port for the hypothesis that a higher
ARR increases the probability of
achieving CRC. Moreover, the pres-
ent finding of higher RES values be-
ing associated with the tendency to
obtain CRC is in line with previous
studies reporting the highest per-
centage of RC in deep but narrow
recessions.21,30 Further studies using
different surgical techniques with
and without CTG are warranted to
support the present findings.
There are some limitations of
the present study, such as the use
of only one surgical technique and
the lack of a control group. The ad-
ditional digital image analysis re-
quired to calculate ARR may also
be regarded as a limitation. Fur-
© 2022 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
ther controlled studies comparing
the efficacy of a surgical technique
with and without CTG/soft tissue
substitutes using ARR would bet-
ter clarify the general applicability
of this novel clinical parameter. The
comparison of two different surgical
techniques with the same setting
is likely to provide new insights for
the preference of one surgical tech-
nique to the other(s).
Conclusions
Within the limitations of the pres-
ent study, it can be suggested that
higher ARR values are positively
associated with mRC outcomes in
the treatment of RT1 and RT2 GRs
treated with TUN + CTG. Long-term
controlled trials with a larger sample
size are needed to support the find-
ings of the present study and bet-
ter clarify the potential of ARR to
predict RC.
Acknowledgments
The study was funded solely by the institu-
tions of the authors. The authors declare no
conflicts of interest.
10. Zucchelli G, Mounssif I, Mazzotti C, et al.
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