Periodontology 2000, Vol. 77, 2018, 19–53 © 2018 John Wiley & Sons A/S.
ey & Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
Esthetic evaluation and
patient-centered outcomes in
root-coverage procedures
ILHAM MOUNSSIF, MARTINA STEFANINI, CLAUDIO MAZZOTTI,
MATTEO MARZADORI, MATTEO SANGIORGI & GIOVANNI ZUCCHELLI
Treatment of buccal gingival recession is frequently
needed for esthetic concerns, root sensitivity, root
caries and cervical abrasion in patients applying
incorrect toothbrushing (4). Randomized controlled
trials, systematic reviews and meta-analyses have
evaluated the efficacy of surgical techniques for treat-
ment of gingival recessions. Various objective and
reproducible parameters (complete root coverage,
root coverage, recession reduction, keratinized tissue
increase) have been used to evaluate different surgi-
cal techniques, but frequently ignored are patient
concerns and hence the true indications for treat-
ment. True end points are outcomes that directly
measure how a patient feels, functions or survives
(43) and, as such, are tangible to the patient. Esthetics
and root sensitivity are examples of issues of concern
for patients. True end points may also include subjec-
tive oral health-related quality of life measurements
(70, 71, 93) or simple self-reported symptoms. Surro-
gate end points are outcomes intangible to patients
but are used by researchers as a substitute for true
end points (43). Complete root coverage or increase
in keratinized tissue are examples of intangible
changes that patients cannot identify or realize. The
surrogate end points are often objective measures
that can be obtained by the clinician (rather than
relying on self-report by patients) or by laboratory
assays (54).
Until a decade ago, studies assessed treatment out-
comes of gingival recession defects by relying on sur-
rogate end points. However, there has lately been an
emphasis on patient-centered outcomes for the eval-
uation of root-coverage procedures. Patient-reported
outcomes are defined as any report of the status of a
patient’s health condition that comes directly from
PERIODONTOLOGY 2000
the patient, without interpretation of the patient’s
response by a clinician or anyone else (111). Creating
valid patient-reported outcome instruments and met-
rics requires more than simply removing clinicians
and staff from the interpretation of patient opin-
ions. The US Food and Drug Administration and the
European Medicines Agency have provided position
papers and guidelines for the development, imple-
mentation and interpretation of patient-reported out-
comes in clinical trials. In essence, patient-reported
outcomes instruments should: (i) be free from error
(be reliable); (ii) measure what they are intended to
measure (be valid); (iii) be sensitive to changes in the
patient’s condition (be able to detect treatment dif-
ferences); and (iv) be interpretable (be clinically
meaningful) (49). Patient-reported outcomes are sub-
jective and involve the measurement of patient
opinions and experiential responses in relation to dif-
ficult-to-quantify end points, such as anxiety, pain
and satisfaction. It is important to record, in real
time, the patient experiences that occur sporadically
(for example, sudden pain when chewing). Patient-
reported outcomes should ideally be administered
and recorded using a computerized methodology, or
questions should be posed by staff members who are
not involved in the clinical trial or clinical care of the
patient because patients may be reluctant to provide
honest, unguarded answers to such caregivers (88).
Recent systematic reviews by the European Federa-
tion of Periodontology group evaluated studies in
which the primary and secondary outcomes were
professional measurements of the soft-tissue dimen-
sions following surgery as compared with baseline
(23, 47). To our knowledge, only one study (66) has
tried to compare true and surrogate end points. In
19
Mounssif et al.
this study, 58 buccal, Miller Class I–III recession
defects were treated using a variety of surgical tech-
niques, including subepithelial connective tissue graft
with a coronally advanced flap, subepithelial connec-
tive tissue graft without coronally advanced flap and
a free gingival graft. The percentage of root coverage
and the root-coverage esthetic score system were
used as objective measurements and a patient-cen-
tered questionnaire with a five-point ordinal scale
was used for subjective evaluation. When esthetic
assessment was analyzed according to the degree
of root coverage, the percentage of root coverage
was found to be proportional to the root-coverage
esthetic score and the professional rating but not with
patient satisfaction. From the patients’ perspective,
degree of root-coverage alone might not be sufficient
to determine satisfaction. On the other hand, when
the root-coverage esthetic score or professional rating
was examined as an independent variable, it satisfied
all of the other measurements. However, in the
patient-based analysis, the professional rating did not
increase with patient satisfaction, suggesting that the
esthetic judgment of the periodontists may not
always be in line with patient satisfaction. Patient sat-
isfaction was correlated more with the root-coverage
esthetic score, which includes soft-tissue integration
variables, indicating that patients are affected by the
percentage of root coverage as well as by the integra-
tion of soft tissue with adjacent tissue. Finally,
patients in the trial appeared to rate the cosmetic
results more favorably than the professionals. The
authors concluded that, within the confines of the
study, clinicians seem to consider the percentage of
root coverage to be a dominant contributor toward a
successful outcome, and the inconsistency in satisfac-
tion between professionals and patients may be a
result, in part, of the different perceptions regarding
the importance of percentage of root coverage.
Figure 1 shows an example of root-coverage out-
come with an excellent evaluation score made by the
patient. The expert periodontist scored the result as
A B
Fig. 1. Good and excellent evaluations by the professional
and the patient, respectively. (A) Deep multiple gingival
recessions affecting the maxillary incisors and canines at
baseline. (B) One year after surgical treatment. The expert
20
good because of incomplete root coverage and a dif-
ference in the soft-tissue color. An example of a root-
coverage procedure with a good satisfaction score
from the patient’s perception is presented in Fig. 2.
The expert periodontist assessed the result as moder-
ate because of the difference in color between the
treated area and the adjacent soft tissue. Never-
theless, there are several clinical situations in which
a good professional evaluation corresponds to a
poor patient evaluation, above all with an exces-
sive increase of gingival thickness. As illustrated in
Fig. 3, despite a root-coverage esthetic score of 8 (26)
(Fig. 4), the patient was not satisfied with the clini-
cal outcome and requested a reduction of gingival
thickness.
The most recent consensus of the European Feder-
ation of Periodontology (109) pointed out the need to
include patient perception and request in future
research to align better professional (surrogate) end
points with patient-centered outcomes (true end
points). The present narrative review focuses on pro-
fessional assessments for various clinical outcomes of
root-coverage procedures in terms of esthetics. The
paper also considers patient-centered outcome mea-
sures (esthetic evaluation, morbidity and hypersensi-
tivity) in the treatment of gingival recessions.
Professional esthetic evaluation
Recent systematic reviews show that gingival reces-
sions can be successfully treated using various surgi-
cal techniques (23, 29). Coronally advanced flap in
combination with a connective tissue graft achieved
the best clinical outcomes in terms of complete root
coverage and recession reduction. The success of
surgery was based on the quantitative measure of
reduction of the initial recession defect. However,
if the esthetic appearance of the recession defect
is the main concern of patients, periodontal sur-
geons should evaluate the clinical outcomes of root-
periodontist evaluated the result as ‘good’ because incom-
plete root coverage was obtained at the level of the central
incisors and there was a difference in the soft-tissue color;
the patient evaluated the result as ‘excellent’.
 Patient-centered outcomes

A B

Fig. 2. Moderate and good evaluations by the professional and the patient, respectively. (A) Frontal view of gingival reces-
sions affecting the maxillary lateral incisors. (B) The patient evaluated the result as ‘good’; the expert periodontist evalu-
ated the result as ‘moderate’ because of the difference in color of the soft tissue.

A B

Fig. 3. Root-coverage esthetic score value of 8 and poor expert periodontist using the root-coverage esthetic
evaluation by the professional and the patient, respec- score. However, the patient was not satisfied at all with
tively. (A) Deep gingival recession affecting the right the result because of the excessive increase in gingival
maxillary canine. (B) A score of 8 was assessed by the thickness.

have evaluated detailed esthetic outcome, and this

Fig. 4. Root-coverage esthetic score. The final root-coverage
esthetic score was 8 (gingival margin, complete root cover-
age = 6; marginal tissue contour, scalloped gingival
margin = 1; soft-tissue contour, presence of scar forma-
tion = 0; mucogingival junction disalignment = 0; gingival
color, normal color = 1).
coverage surgical procedures based on the patients’
perception of subjective outcomes, such as esthetic
outcomes, as well as on objective criteria.
In the first clinical trials that compared different
surgical techniques for treatment of gingival reces-
sion, esthetic evaluation either was not reported (15,
60, 97, 106, 110, 120) or was reported using empirical
sentences, such as ‘patients were satisfied with the
esthetic results’ (17) or ‘excellent and good esthetic
results’ (13). To our knowledge, only a few studies
was performed using photographic assessment or
a categorical scale. Table 1 lists the study design,
methods of assessment and the major findings of
important papers on professional esthetic evaluation.
The first comparative trial by Bouchard et al. (16)
used a three-point photographic scale and impres-
sion assessment (poor, moderate and good) by two
blinded independent observers. Rosetti et al. (99)
introduced an esthetic objective scoring system, tak-
ing into consideration the root coverage as well as the
gingival anatomy, contour and color after surgery.
The scoring system was as follows: (i) good if esthetics
after treatment were better than before; (ii) regular if
esthetics did not improve after treatment; and (iii)
poor if esthetics after treatment were worse than
before. Clinical photographs taken at baseline and
after 18 months were provided to five independent,
calibrated and expert examiners who used scorings of
good, regular or poor. The esthetic analysis demon-
strated improvement using both subepithelial con-
nective tissue graft and guided tissue regeneration
with a collagen membrane; no significant difference
between the methods was demonstrated. None of the
defects was evaluated as poor, and regular and good
rating scores, respectively, were given to 20% and
80% of subepithelial connective tissue graft-treated

21
22
Mounssif et al.

Table 1. Professional esthetic evaluation

Study Study design Length Test group Control group Assessment method Major findings
of study

Bouchard Comparative 6 months Coronally advanced Coronally advanced flap + Photographic and impression Good results in 66% of the cases and
et al. 1994 study flap + connective connective tissue graft (15 evaluations were made by moderate results in 33%. The trend
(16) tissue graft Miller Class I–II gingival two independent and is toward better results in the
(epithelial collar recessions) blinded examiners. The control group than in the test
exposed; 15 Miller evaluation was scored as group
Class I–II gingival good, moderate or poor
recessions)
Rosetti et al. Split-mouth 18 months Coronally advanced Coronally advanced flap + Photographic evaluation by 20% of the subepithelial connective
2000 (99) comparative flap + guided tissue subepithelial connective five calibrated, independent tissue graft and 18.3% of the
study regeneration + tissue graft (12 Miller Class I and expert examiners. The guided tissue regeneration sites
demineralized –II gingival recessions) evaluation was scored as were scored as regular. 80% and
freeze-dried bone good, regular or poor 81.7% of the subepithelial
allograft (12 Miller connective tissue graft and guided
Class I–II gingival tissue regeneration-treated sites,
recessions) respectively, were scored as good
Aichelmann- Comparative 6 months Coronally advanced Coronally advanced flap+ Direct evaluation by an Better results for the acellular
Reidy et al. study flap + acellular connective tissue (12 Miller independent blinded dermal matrix group in terms of
2001 (2) dermal matrix (12 Class I–II gingival examiner. Color, contour, color match and contiguity.
Miller Class I–II recessions) contiguity and keloid Essentially similar scores between
gingival recessions) presence were evaluated on the two treatments for consistency
a four-point scale and lack of keloid formation
 Table 1. (Continued)

Study Study design Length Test group Control group Assessment method Major findings
of study

Wang et al. Comparative 6 months Coronally advanced Coronally advanced flap + Independent examiner was The examiner rated 15 out of 16 sites
2001 (113) split-mouth flap + collagen (16 Miller Class I–II gingival asked to evaluate as treated with collagen membrane
study membrane for recessions) excellent, good, adequate or for guided tissue regeneration as
guided tissue unsatisfactory the following having excellent color match
regeneration (16 parameters: color, contour, compared with only 11 sites
Miller Class I–II contiguity and keloid treated with subepithelial
gingival recessions) presence connective tissue graft. Good
contour was noted in 15 sites
treated with collagen membrane
for guided tissue regeneration vs.
13 sites treated with subepithelial
connective tissue graft. Tissues
showed firm consistency in all sites
treated with either technique.
Sixteen sites treated with collagen
membrane for guided tissue
regeneration were rated as having
an acceptable blend compared
with 14 sites treated with
subepithelial connective tissue
graft. Keloid formation was noted
in only one site treated with
subepithelial connective tissue
graft
Cheung & Split-mouth 8 months Platelet concentrate Subepithelial connective Clinical slides were evaluated All the examiners agreed that the
Griffin 2004 randomized graft + coronally tissue graft + coronally by three expert masked platelet concentrate graft group
(31) study advanced flap (25 advanced flap (29 Miller examiners: color match, yielded a better texture and
Miller Class I–II Class I–II gingival tissue texture and contour of contour.
gingival recessions) recessions) the surgical area were No statistically significant difference
compared with the adjacent could be detected in color match
tissue. The scoring scale between the two groups
ranged from 1 (most
favorable) to 4 (least
favorable)
Patient-centered outcomes

23
24
Mounssif et al.

Table 1. (Continued)

Study Study design Length Test group Control group Assessment method Major findings
of study

Zucchelli et al. Comparative 1 year Coronally advanced Coronally advanced flap for The esthetic evaluation was No statistically significant difference
2009 (123) controlled flap for multiple multiple recessions performed by an expert between groups was found
randomized recessions (with (envelope type; 45 gingival periodontist. Color match regarding the color match. Better
clinical trial vertical incisions; Miller Class I–II gingival and contour were scored on statistically significant results for
47 gingival Miller recessions) a visual analog scale; contour, contiguity and keloid
Class I–II gingival contiguity was rated as yes parameters in the coronally
recessions) or no; keloid was scored as advanced flap envelope type
absent or present procedure were reported
Kerner et al. Retrospective 24 years 495 gingival recessions treated by pedicle soft-tissue Photographic assessment was Photographic assessment of
2009 (64) study grafts, nonsubmerged grafts, submerged grafts or performed by a panel of quantifiable outcome variables is a
envelope techniques seven observers (five useful method. The assessment
professionals and two should be performed on the direct
nonprofessionals). evaluation of the difference
Two different methods of between preoperative and
assessment were postoperative views and not on the
successively used: ‘before– evaluation of each photograph a
after panel scoring system’ posteriori compared with the
(five-point ordinal scores. A five-point ordinal scale is
improvement scale: poor, a valuable and recommended tool
fair, good, very good and for subjective assessment of root
excellent) and ‘random coverage therapy
panel scoring system’ (four-
point ordinal scale: poor,
fair, good and excellent)
 Table 1. (Continued)

Study Study design Length Test group Control group Assessment method Major findings
of study

Kerner et al. Retrospective 24 years 281 gingival recessions treated by 162 root-coverage Three observers (two Good-to-excellent overall esthetic
2009 (65) study surgeries (pedicle soft-tissue grafts, nonsubmerged periodontists and one results were found by the
grafts, submerged grafts and envelope techniques) control) used a before–after professionals and control in > 70%
were included panel scoring system to of the surgical procedures.
evaluate the esthetics. A five- Degree of root coverage was not a
point ordinal scale (poor, significant predictive factor,
fair, good, very good and whereas soft-tissue appearance
excellent) was used to variables and the follow-up were
evaluate the overall esthetic significantly associated with
improvement and seven cosmetic assessment.
variables were considered in Nonsubmerged grafts are not
the assessment (root recommended in cases of esthetic
coverage, color match, demand
texture match, volume
match, lack of scars,
keratinized tissue, gingival
contour)
Patient-centered outcomes

25
26
Table 1. (Continued)

Study Study design Length Test group Control group Assessment method
Mounssif et al.

Major findings
of study

Zucchelli et al. Randomized 1 year Laterally moved Coronally advanced flap + The esthetic evaluation was No statistically significant difference
2012 (121) controlled coronally advanced connective tissue graft (25 performed by an expert between the techniques in terms of
study flap (25 Miller I and Miller I and II gingival periodontist. Color match color match. However, a
II gingival recessions at first molar and contour were scored on statistically significantly higher
recessions at first teeth) a visual analog scale; visual analog scale root-coverage
molar teeth) contiguity was rated as yes score for the coronally advanced
or no; keloid was scored as flap+ connective tissue graft group
absent or present with respect to the laterally moved
coronally advanced flap group was
found
Cairo et al. Prospective 6 months Thirty-one patients with Miller Class I and II An expert examiner evaluated The root-coverage esthetic score
2009 (26) study recession defects treated with root-coverage gingival margin, marginal system may be a useful tool for
procedures were evaluated (coronally advanced tissue contour, soft-tissue assessing the esthetic outcome
flap, coronally advanced flap+ connective tissue texture, mucogingival following root-coverage
graft, free gingival graft, double papilla flap) junction alignment, and procedures
gingival color. The ideal
esthetic score was 10
Cairo et al. Multicenter 6 months The inter-rater agreement of root-coverage esthetic Eleven periodontists were The root-coverage esthetic score
2010 (22) study score among expert periodontists selected in selected in different clinical seems to be a reliable method for
different clinical centers was assessed centers to evaluate gingival assessing the esthetic outcomes of
margin, marginal tissue root-coverage procedures
contour, soft-tissue texture,
mucogingival junction
alignment and gingival color.
The ideal esthetic score was
10
 Table 1. (Continued)

Study Study design Length Test group Control group Assessment method Major findings
of study

Zucchelli et al. Randomized 1 year Coronally advanced Coronally advanced flap + The esthetic evaluation was Statistically significant greater color
2014 (126) controlled flap + connective connective tissue graft (‘big performed by an expert match scores were demonstrated
study tissue graft (‘small graft’; 30 gingival Miller blinded independent in the test (‘small graft’) group.
graft’; 30 gingival Class I–II gingival periodontist. Color match Statistically greater keloid
Miller Class I–II recessions) and contour were scored on formation was found in the control
gingival recessions) a visual analog scale; group
contiguity was rated as yes
or no; keloid was scored as
absent or present
Zucchelli et al. Randomized 1 and Coronally advanced Coronally advanced flap for The esthetic evaluation was Colour match was statistically
2014 (127) controlled 5 years flap+ connective multiple gingival recessions performed by an expert significantly better at 1- and 5-year
study tissue graft for (25 patients) blinded independent follow-up visits in the coronally
multiple gingival periodontist. Color match advanced flap-treated patients.
recessions (25 and contour were scored on Contour was statistically significant
patients) a visual analog scale; better at the 5-year follow-up for
contiguity was rated as yes the coronally advanced flap +
or no; keloid was scored as connective tissue graft group.
absent or present Statistically greater keloid
formation was found in the test
group both at 1 and at 5 years
Cairo et al. Systematic Not A total of 16 randomized controlled trials were The gingival margin, marginal Periodontal plastic surgery
2016 (24) review and applicable selected in the systematic review; three tissue contour, soft-tissue techniques applying grafts
Bayesian randomized controlled trials presenting texture, mucogingival underneath coronally advanced
network professional esthetic evaluation with the root- junction alignment and flap with or without the addition of
meta- coverage esthetic score gingival color. The ideal enamel matrix derivative are
analysis esthetic score was 10 associated with improved esthetics
assessed using the root-coverage
esthetic score
CAF, coronally advanced flap; CTG, connective tissue graft; SCTG, subepithelial connective tissue graft; GTR, guided tissue regeneration; DFDBA, demineralized freeze-dried bone allograft; AD, acellular allogeneic dermal connective
tissue matrix; CT, connective tissue; GTRC, collagen membrane for guide tissue regeneration; PCG, platelet concentrate graft; VAS, visual analog scale; PSTG, pedicle soft tissue graft; NSG, non-submerged graft; SG, submerged grafts;
ET, envelope techniques; LMCAF, laterally moved coronally advanced flap; RES, root coverage esthetic score; RCT, randomized controlled trial; NA, not applicable; DPF, double papilla flap.
Patient-centered outcomes

27
Mounssif et al.
recessions and to 18.3% and 81.7% of guided tissue
regeneration-treated recessions. Aichelmann-Reidy
et al. (2) used a four-point scale to score color
match, contour, consistency, continuity or blending,
and degree of keloid formation at 3 and 6 months
post-treatment. Wang et al. (113) scored esthetic out-
comes by photographs at 6 months follow-up visit
and evaluated color match, contour, consistency,
continuity or blending, and degree of keloid forma-
tion. Cheung & Griffin (31) scored color match, tissue
texture and contour of the surgical area on a 4-point
grading scale at 8 months post-treatment and found
that platelet concentrate grafts yielded better texture
and contour than subepithelial connective tissue
grafts in treatment of Miller Class I and Class II reces-
sions. Zucchelli et al. (123) studied root coverage and
esthetic outcome of two types of coronally advanced
flap surgery – an envelope-type flap (test group) and
a flap with vertical-releasing incisions (control group)
– for treatment of multiple gingival recessions, using
as variables color match (blending), contour (correct
outline of the gingival margin in adjacent teeth), con-
tinguity (evaluated based on the invisible confluence
between the treated area and the adjacent soft tis-
sues) and the degree of keloid formation at 1 year
post-treatment. The surgically treated area was indis-
tinguishable from the adjacent soft tissues in all sub-
jects treated with the envelope type of coronally
advanced flap (test group) compared with seven of 15
patients treated using the coronally advanced flap
with vertical-releasing incisions (control group), and
keloid formation did not occur in any of the patients
in the test group compared with six of the 16 patients
in the control group (123). The results validate the
negative esthetic effect of vertical-releasing incisions
caused by the formation of white-scar keloids which
can compromise the continuity of the surgically
treated area (123). Zucchelli et al. (121, 126–128) used
the same professional assessment method in other
comparative studies and found it to be very use-
ful to evaluate esthetic outcomes of root-coverage
procedures.
Kerner et al. (64) emphasized the lack of consen-
sus regarding the best method to assess cosmetic
results, which should rely on simple quantitative
measures and is a prerequisite for comparing out-
comes between studies. A study of esthetic out-
come of root-coverage techniques which compared
a before–after panel or random panel scorings by
professional and nonprofessional, trained and
untrained observers, showed that trained professionals
and preoperative vs. postoperative views achieved
the highest intrarater reliability (63). Interestingly,
28
substantial preoperative intrarater agreement (k = 0.67)
but a negative corresponding postoperative value (k
= –0.53) was found for a nurse, suggesting inability
to score the result of the surgical procedure cor-
rectly (63). The study also showed that neither the
percentage of root coverage nor the percentage of
gingival augmentation correlated with subjective
scores (63), implying that the observers did not
consider the amount of root coverage to be the
most critical variable in judging the overall esthetic
outcome. Another study by Kerner et al. (65) evalu-
ated the esthetic outcomes of four root-coverage
techniques according to overall esthetic appear-
ance, degree of root coverage, color match, texture
match, volume match, lack of hypertrophic scars,
existing keratinized tissues and gingival contour. A
before–after scoring panel system was used (64).
The study showed that photographic assessment by
a dental professional using the before–after scoring
panel system is a good method for overall esthetic
evaluation, and that intra-observer reliability
between two periodontists was almost perfect and a
substantial degree of agreement was found between
them (65). The intra- and interobserver agreement of
a nurse was moderate to fair. The overall esthetic
results were good to excellent and seemed to confirm
that nonsubmerged grafts are less esthetic than other
root-coverage procedures (65).
Cairo et al. (26) introduced, in 2009, a root-cover-
age esthetic score system that evaluates five clinical
variables (gingival margin, marginal tissue contour,
soft-tissue texture, mucogingival junction alignment
and gingival color) at 6 months following periodontal
plastic surgery (pedicle flaps, soft-tissue grafts or
combinations). Each variable received a numerical
score, and the aggregate score for maximal esthetics
was 10; zero points were assigned if the final position
of the gingival margin was at, or apical to, the previ-
ous recession depth (failure of root-coverage proce-
dure), irrespective of color, the presence of a scar,
marginal tissue contour or mucogingival alignment,
or with a partial or total loss of interproximal papilla
(black triangle). An example of a root-coverage
esthetic score is shown in Fig. 4. A multicenter study
with experienced periodontists showed that the root-
coverage esthetic score had an almost perfect agree-
ment intraclass correlation coefficient of 0.92 (22).
Based on the classification of Landis & Koch (68), the
root-coverage esthetic score may be considered to be
a good instrument for using to evaluate the esthetic
outcomes of root-coverage procedures. Recently,
Cairo et al. (24) published a systematic review of ran-
domized controlled trials to explore if root-coverage

procedures, when assessed using the root-coverage
esthetic score system, were effective in improving
esthetics. Bayesian network meta-analysis was used
to create a network of interventions including both
direct and indirect comparisons among different
trials and to summarize the quantitative outcome
data. Three combinations of the coronally advanced
flap techniques (coronally advanced flap + connective
tissue graft; coronally advanced flap + connective
tissue graft + enamel matrix derivative; and coro-
nally advanced flap + acellular dermal matrix with
autologous fibroblasts) yielded higher root-coverage
esthetic scores than coronally advanced flap alone,
although the differences were not statistically sig-
nificant. The best outcomes were obtained with
coronally advanced flap + acellular dermal matrix
with autologous fibroblasts and with coronally
advanced flap + connective tissue graft, thus confirm-
ing that grafts improve the effectiveness of coronally
advanced flap alone (23, 25). An evaluation of excel-
lence by both the professional and the patient is
presented in Fig. 5.
Patient esthetic evaluation
The main indication for root-coverage procedures is
the esthetic demand of the patient (115). However,
few studies have evaluated the patients’ satisfaction
following therapy, and in those that have, patient
opinion was mainly collected without a standardized
approach. Nieri et al. (85) investigated patient per-
ception of gingival recessions and their requests for
treatment in a cross-sectional study. The authors
showed that only 11 of 120 patients requested treat-
ment for a total of 57 recession defects. Considering
the results of this study, and the fact that complete
root coverage is not fully predictable following sur-
gical procedures, the authors recommend careful
evaluation of the need for treatment of buccal reces-
sion defects if these are asymptomatic and unper-
ceived. Chambrone & Tatakis (30), in a systematic
A B
Fig. 5. Excellent evaluations by both the professional and the patient. (A) Frontal view of multiple gingival recessions in
the maxillary incisors and canines at baseline. (B) One year after the mucogingival surgery. The result achieved was evalu-
ated as ‘excellent’ by the expert periodontist and the patient.
Patient-centered outcomes
review and meta-analysis, found limited, but consis-
tent, evidence that untreated buccal gingival reces-
sion defects, in subjects with good oral hygiene, were
highly likely to progress (78% of defects) over a period
of more than 5 years.
Table 2 describes the methods of assessment and
the clinical relevance of studies on patient esthetic
evaluation. Bouchard et al. (17) reported that 30
patients who were concerned with the appearance of
their gingival recession defects were satisfied with
the esthetic treatment outcome. Rosetti et al. (99)
employed subepithelial connective tissue graft and
guided tissue regeneration with a collagen mem-
brane (demineralized freeze-dried bone allograft)
for the treatment of gingival recession defects, and
found that all patients were pleased with the esthetic
results of both procedures at 18 months postsurgery.
Romagna-Genon (97) compared, in a split-mouth
study, coronally advanced flap plus collagen barrier
membrane with coronally advanced flap plus connec-
tive tissue graft, and reported that only one of 20
patients was not satisfied with either treatment. Wang
et al. (113) recorded patient satisfaction with esthet-
ics (color match, overall satisfaction, amount of root
coverage) in a comparative study (guided tissue
regeneration with a collagen membrane vs. subep-
ithelial connective tissue graft) for root-coverage pro-
cedures, and found a greater degree of satisfaction
with treatment using guided tissue regeneration.
Aichelmann-Reidy et al. (2) compared an acellular
allogenic dermal connective tissue graft with an auto-
genous connective tissue graft for treatment of gingi-
val recession defects, and obtained a better patient
score for acellular allogenic dermal graft for appear-
ance (color match, overall satisfaction) and similar
scores for both tissue grafts for amount of root cover-
age. Zucchelli et al. (119) evaluated esthetic patient
outcomes in a split-mouth study in which gingival
recession defects, referred for esthetic concerns, were
treated with a bilaminar surgical technique, and the
size, thickness and positioning of the connective tis-
sue graft comprised the difference between test and
29
 Table 2. Patient esthetic evaluation

30
Study Study design Length of Test group Control group Assessment method Major findings
study

Bouchard Controlled 6 months Modified subepithelial Modified subepithelial NA All patients were satisfied with the esthetic results
Mounssif et al.

et al. 1997 clinical study graft plus citric acid graft plus tetracycline
(17) conditioning (15 Miller HCl
Class I-II gingival Conditioning (15
recessions) Miller Class I-II
gingival recessions)
Rosetti et al. Split-mouth 18 months CAF + GTR + DFDBA CAF + SCTG Patients were asked if All patients were pleased with the esthetic results
(2000) (99) comparative (12 Miller Class I-II (12 Miller Class I-II they were satisfied and obtained by both procedures at 6 and 18 months
study gingival recessions) gingival recessions) pleased with the result post-surgery
of the treatment by a
yes or no response.
Comments or subjective
responses were not
evaluated
Romagna- Comparative 6 months CAF + GTR CAF + CTG NA 19 out of 20 patients were satisfied with the clinical
Genon randomized (bioresorbable bilayer (20 Miller Class I or II results, whatever the technique. Only one patient
(2001) (97) controlled collagen mem- brane) gingival recessions) was disappointed
trial (20 Miller Class I or II
gingival recessions)
Aichelmann- Comparative 6 months CAF + AD CAF + CT Patients were asked to Better scores for AD for appearance (13 patients
Reidy et al. study (12 Miller Class I-II (12 Miller Class I-II score the esthetic result versus 8 patients rated the result as excellent)
(2001) (2) gingival recessions) gingival recessions) as excellent, good, fair were reported
and poor
Wang et al. Comparative 6 months CAF + GTRC CAF + SCTG Patients were asked to Patient satisfaction with esthetics (color match,
(2001) (113) split-mouth (16 Miller Class I-II (16 Miller Class I-II score the color match overall satisfaction, and amount of root coverage)
study gingival recessions) gingival recessions) and the overall esthetic was the same for both treatments. However,
(as excellent, good, fair patients expressed greater satisfaction overall
and no response) with GTRC
Zucchelli et al. Split-mouth 1 year CAF + CTG CAF + CTG Patients were asked to Patients were more satisfied with the appearance
(2003) (119) randomized (16 Miller Class I-II (16 Miller Class I-II express their esthetic of the test-treated areas with respect to the
clinical study gingival recessions) gingival recessions) opinion by selecting control sites
(CTG thin and with (CTG thick and with one of the following
reduced height) “conventional” height) choices: bad, sufficient,
good, optimum
aesthetics
 Table 2. (Continued)

Study Study design Length of Test group Control group Assessment method Major findings
study

Bittencourt Split mouth 6 months SCPF CAF + SCTG Patients expressed their The esthetic condition after both treatments was
et al. (2006) randomized (17 Miller Class I (17 Miller Class I opinion of each treated considered satisfactory by the patients
(10) study gingival recessions) gingival recessions) tooth by selecting one
of the following choices
on a questionnaire
given by an
independent
researcher: bad,
sufficient, good, or
excellent
Mahajan et al. Randomized 6 months CPF CPF + ADM Patient satisfaction (root There was no difference be- tween the two groups
(2007) (76) controlled (14 Miller Class I-II (14 Miller Class I-II coverage, color of gums, when overall patient satisfaction scores were
trial gingival recessions) gingival recessions) shape and contour of compared
gums) was assessed
using a three- point
rating scale: fully
satisfied = 3;
satisfied = 2; and
unsatisfied = 1
Bittencourt Split mouth 30 months SCPF CAF + SCTG Patients expressed their Patients in SCPF and SCTG groups were generally
et al. (2009) randomized (17 Miller Class I (17 Miller Class I opinion of each treated satisfied with both procedures
(11) study gingival recessions) gingival recessions) tooth by selecting one
of the following choices
on a questionnaire
given by an
independent
researcher: bad,
sufficient, good, or
excellent
Zucchelli et al. Comparative 1 year CAF for multiple CAF for multiple Patients were asked to No statistically significant difference between
2009 (123) controlled recessions (with vertical recessions (envelope select among 100 scores groups was demonstrated in terms of overall
randomized incisions) type) (0 indicating very bad, satisfaction, color match, and root coverage VAS
clinical trial (47 gingival Miller Class (45 gingival Miller 50 average and 100 value
I-II gingival recessions) Class I-II gingival indicating excellent)
recessions) (VAS) in terms of overall
satisfaction, color
match and amount of
root coverage
Patient-centered outcomes

31
32
Table 2. (Continued)
Mounssif et al.

Study Study design Length of Test group Control group Assessment method Major findings
study

McGuire & Split-mouth 1 year CAF + CM CAF + CTG Patient were asked to Overall subject-reported esthetic satisfaction with
Scheyer randomized (25 Miller Class I-II (25 Miller Class I-II score their esthetic both test and control treatments was equivalent
(2010) (78) controlled gingival recessions) gingival recessions) satisfaction
clinical trial (“unsatisfied” to “very
satisfied”) on a five-
point scale
McGuire et al. Split-mouth 10 years CAF + EMD CAF + CTG Patients were asked if Both procedures appeared to yield equally
(2012) (81) randomized (9 Miller Class I-II (9 Miller Class I-II they are equally satisfying esthetic results to the majority of the
controlled gingival recessions) gingival recessions) satisfied with the patients.
clinical trial esthetic results of the
two sites treated or they
are more satisfied with
one treated site over the
other
Roman et al. Prospective 1 year 33 patients with single or multiple gingival Patients were asked to All patients judged the esthetic appearance as
(2012) (98) case series recessions were treated using a CAF + CTG evaluate their esthetic improved. 87.9% of the patients reported
study changes on a Vas important improvements in esthetics
questionnaire
Zucchelli et al. Randomized 1 year CAF + CTG CAF + CTG Patients were asked to Better aesthetics outcomes were observed in the
(2014) (122) controlled (25 Miller Class I and II (25 Miller Class I and select among 100 scores test group
study gingival recessions at II gingival recessions (0 indicating very bad,
first molar teeth) LST at first molar teeth) 50 average and 100
indicating excellent)
(VAS) in terms of overall
satisfaction, color
match and amount of
root coverage
 Table 2. (Continued)

Study Study design Length of Test group Control group Assessment method Major findings
study

Zucchelli et al. Randomized 1 year CAF + CTG CAF + CTG Patients were asked to Patient root coverage esthetic assessment was high
(2014) (126) controlled (“small graft”) (30 (“big graft”) (30 select among 100 scores in both groups with no statistically significant
study gingival Miller Class I-II gingival Miller Class I- (0 indicating very bad, differences between them. Statistically significant
gingival recessions) II gingival recessions) 50 average and 100 better colour match scores were demonstrated
indicating excellent) for the test-treated patients
(VAS) in terms of overall
satisfaction, color
match and amount of
root coverage
Zucchelli et al. Randomized 1 and CAF + CTG for multiple CAF for multiple Patients were asked to Patient esthetic assessment was high in both
(2014) (127) controlled 5 years gingival recessions (25 gingival recessions (25 select among 100 scores groups with no statistically significant differences
study patients) patients) (0 indicating very bad, between them as well as the 5-year evaluation
50 average and 100
indicating excellent)
(VAS) in terms of overall
satisfaction, color
match and amount of
root coverage
McGuire & Split-mouth 5 years CAF + CM CAF + CTG Patient were asked to Patients were almost completely and equally
Scheyer randomized (17 Miller Class I-II (17 Miller Class I-II score their esthetic satisfied with both therapies
(2016) (79) controlled gingival recessions) gingival recessions) satisfaction
clinical trial (“unsatisfied” to “very
satisfied”) on a five-
point scale
Cairo et al. Systematic NA A total of 16 RCTs were selected in the SR; 3 Patients were asked to Periodontal plastic surgery is associated with high
(2016) (24) review and studies showed final self-perception using the score their overall patient satisfaction rated by VAS values indicating
Bayesian Visual Analogue Scale (VAS) esthetic satisfaction on that CAF + CTG with or without the adding of
network a Visual analog scale EMD is associated with highest aesthetic
meta- satisfaction after healing
analysis
CAF, coronally advanced flap; CTG, connective tissue graft; SCTG, subepithelial connective tissue graft; GTR, guided tissue regeneration; DFDBA, demineralized freeze-dried bone allograft; SCPF, semilunar coronally positioned flap;
AD, acellular allogeneic dermal connective tissue matrix; CPF, coronally positioned flap; ADM, acellular dermal matrix; LST, labial submucosal tissue; CM, collagen matrix; VAS, visual analog scale; EMD, enamel matrix derivative.
Patient-centered outcomes

33
Mounssif et al.
control sites. Twelve of 15 patients were more satis-
fied with the appearance of the test-treated areas
(smaller, thinner graft positioned apical to the
cemento–enamel junction) than of the control sites;
nine patients indicated excessive thickness of the
control-treated areas as one of the reasons for the
worst result, and in four patients the excessive thick-
ness was the only negative factor; eight patients
pointed to poor color blending and only one patient
indicated excessive tooth length (together with exces-
sive thickness of the graft and poor color blending)
for the worse esthetic outcomes in the control sites
(119). Bittencourt et al. (10, 12), in a split-mouth ran-
domized comparative study, found (at 6 months
post-treatment) that nine of 17 patients treated with
a semilunar coronally positioned flap reported an
excellent esthetic outcome (seven indicated a good
result and one reported a sufficient result), while 12
patients receiving a subepithelial connective tissue
graft reported an excellent result and the remaining
five patients a good result. Patients expressed no pref-
erence for either treatment at 6 months post-treat-
ment (10). At the end of the experimental period
(30 months) (12), 14 of 17 patients in the semilunar
coronally positioned flap group reported an excellent
or good esthetic outcome and three patients reported
a poor result, whereas all subjects in the subepithelial
connective tissue graft group reported an excellent or
a good result. In contrast to the 6-month results,
more patients stated that the subepithelial connective
tissue graft group was the better treatment with
regard to overall esthetics. All patients in the semilu-
nar coronally positioned flap group showed scar tis-
sue at 30 months post-treatment but only seven
patients complained about it (12). Mahajan et al.
(76), in a randomized controlled trial comparing an
acellular dermal matrix graft with a coronally posi-
tioned flap alone, found that patients rated the acel-
lular matrix graft and the coronally positioned flap
equally, but some patients were unhappy about the
soft-tissue bulge after the graft placement and two
patients rated the coronally positioned flap unsatis-
factory in terms of root coverage. Zucchelli et al.
(123), in a randomized clinical trial evaluating coro-
nally advanced flap with or without vertical incisions
for the treatment of multiple recessions, showed
patient satisfaction to be very high for both treatment
groups in terms of overall satisfaction, color match
and root coverage, and no poor esthetic scores were
recorded in either patient group. The same research
group found patient esthetic evaluation to be an
important component of root-coverage procedures
also in other randomized controlled studies (121, 122,
34
126, 127). McGuire & Scheyer (78) found that more
than 90% of subjects express improvement in esthet-
ics at 6 months after treatment of recession defects
with either a coronally advanced flap with a xeno-
geneic collagen matrix or a coronally advanced flap
with a connective tissue graft. At the 5-year follow-up,
satisfaction remained high for both treatments, with
more than 90% of patients still being satisfied or very
satisfied with the outcome (79). In a 10-year study
comparing subepithelial connective tissue graft with
enamel matrix derivative in combination with a coro-
nally positioned flap, McGuire et al. (81) found that
both procedures appeared to yield equally satisfying
esthetic results in the majority of the patients. Roman
et al. (98), in a clinical trial of single and multiple gin-
gival recessions treated with coronally advanced flap
plus connective tissue graft, found that 88% of
patients reported important improvements in esthet-
ics and no patients were dissatisfied with the esthetic
outcome at any of the 3-, 6- or 12-month examination
time points, suggesting that the grafted tissue was
integrated well enough at 3 months to confer a good
esthetic appearance. Cairo et al. (24), in the Bayesian
network meta-analysis review of randomized con-
trolled trials on root-coverage procedures, found that
the surgical procedures with the highest probability
of yielding the best esthetic outcomes, as judged by
patients, were the coronally advanced flap used with
connective tissue graft and coronally advanced flap
used with connective tissue graft as well as enamel
matrix derivative. This finding suggests that tech-
niques using connective tissue graft, which are also
more effective in terms of root coverage (20, 21, 23,
25), provide higher patient satisfaction. However,
despite achieving complete root coverage, Fig. 6
shows a poor esthetic satisfaction outcome, as judged
by both the professional and the patient, because of
differences in soft-tissue color and texture.
Morbidity
Surgical procedures for the treatment of gingival
recession defects are commonly carried out by clini-
cians and are well accepted by patients, and such sur-
gical procedures are associated with patient morbidity
(defined as a condition of being diseased) (4) because
of a risk of postoperative complications, including
infection and pain. These are a matter of concern for
the practitioner and the patient (74) and some studies
have assessed the incidence of such postoperative
complications after periodontal surgery. Curtis et al.
(36) assessed pain and the complications of bleeding,

A B
Fig. 6. Poor evaluations by both the professional and the
patient despite complete root coverage. (A) Frontal view of
the preoperative clinical situation. (B) A poor evaluation
by both professional and patient was reported; the
infection, swelling and adverse tissue changes (flap
necrosis or graft rejection) after periodontal surgery,
31.2% of which were scheduled as mucogingival sur-
gery (free gingival graft and pedicle graft). Postopera-
tive pain was measured using a simple verbal rating
scale (similar to the Bond scale) (14), and the number
and type of analgesics taken were recorded to obtain
an objective measurement of pain. The authors empir-
ically correlated the subjective and objective data to
create a nominal pain variable (0 = none, 1 = mini-
mal, 2 = moderate, 3 = severe) that was used in the
statistical analysis. The criteria thus established were
used to determine whether the postoperative compli-
cations that were present included both patient-
reported and operator-visualized findings. Compli-
cations were graded as nonexistent, minimal, moder-
ate or severe. Moderate and severe complications
required operator visualization. The authors reported
that approximately 50% of the patients reported mini-
mal or no postoperative pain, 4.6% reported severe
pain and 20.1% took five or more doses of an analgesic.
Mucogingival surgery was reported as being 3.5 times
more painful than bone surgery and six times more
painful than soft-tissue surgery. Increased duration of
the surgical procedure was significantly associated
with increased postoperative pain. Additionally,
mucogingival procedures frequently leave areas of
connective tissue exposed, necessitating wound cov-
erage by epithelial migration from the margins, lead-
ing to donor-site morbidity. It is notable that 94.5% of
the patients had no (46.1%) or minimal (48.4%) post-
operative complications of bleeding, infection, swel-
ling or adverse tissue changes.
Coronally advanced flap alone, for the treatment
of a single gingival recession defect, was a safe and
predictable procedure, and the adjunctive use of
connective tissue graft or enamel matrix derivative
under the coronally advanced flap enhanced the
probability of obtaining complete root coverage (23,
25). The main concerns, from a patient point of
Patient-centered outcomes
difference in soft-tissue color and texture resulted in a neg-
ative judgement of the outcome of surgery, even though
complete root coverage was achieved.
view, regarding periodontal plastic surgery seem to
be related to the second surgical site (donor site).
The free gingival graft, for many years, represented
the principal surgical technique for increasing the
width of attached gingiva. The literature on free
gingival grafts is contradictory and reports percent-
ages of root coverage ranging from 11% to 100%
(125). Increased postoperative morbidity may result
from the substantial wound created when harvest-
ing a thick graft from the palate and clinicians may
hesitate in attempting root coverage using a free
gingival graft because of the unforgiving nature of
this procedure, along with potentially undesirable
postoperative sequelae (82). In the first studies
that evaluated the free gingival graft procedure, no
questionnaire or standardized assessment methods
were applied to determine the postoperative course
experienced by patient; only empirical sentences
were reported (58, 83). Thereafter, novel surgi-
cal techniques that provided higher predictability
regarding esthetic outcomes, and which minimized
patient morbidity, replaced free gingival grafts in
periodontal surgery with subepithelial connective
tissue grafts; the latter were preferred by patients
because a less invasive palatal wound was created
and an improved esthetic result was obtained, com-
pared with epithelialized grafts (115). Different con-
nective tissue graft-harvesting procedures, with the
purpose of achieving healing of the palatal wound
by primary intention, have been described in the lit-
erature. In 1974, Edel (40) advocated the trapdoor
technique, a method for harvesting subepithelial
connective tissue grafts that allowed the residual
palatal epithelium to be retained, thereby reducing
patient discomfort. A single horizontal incision, par-
allel to the gingival margin, and two vertical-releas-
ing incisions were used to achieve sufficient visual
access. Later, Langer & Langer (69) introduced a
similar method that employed a second, parallel
horizontal incision to obtain a graft with an
35
Mounssif et al.
epithelial margin. Raetzke (94) resected a wedge of
connective tissue with an epithelial collar through
two semilunar converging incisions, whilst Harris
(51) advocated the use of a double-bladed scalpel
for harvesting a 1.5-mm-thick graft with an epithe-
lial margin. These flaps need an adequate thickness
of the palatal fibromucosa to avoid desquamation
of the undermined superficial flap as a result of
compromised vascularization.
In a free gingival graft, the surgical wound heals by
secondary intention within 2–4 weeks (41) and has
been consistently associated with greater discomfort
for the patient as a result of postoperative pain and/or
bleeding (37, 41, 58). However, this technique is easy
to perform and can be utilized even in the presence of
a thin palatal fibromucosa. Most of the aforemen-
tioned techniques involve the loss of parts of the pala-
tal epithelium, thereby precluding primary wound
closure and facilitating secondary wound healing.
Based on this knowledge, Hü rzeler & Weng (55) and
Lorenzana & Allen (75) presented a single-incision
technique that was designed to allow primary wound
healing, thereby decreasing patient discomfort.
Table 3 summarizes methods of assessment and
the major findings of studies on morbidity after root-
coverage procedures. Empirical results were reported
by Romagna-Genon (97) in a prospective randomized
clinical study comparing subepithelial connective
tissue graft and guided tissue regeneration for the
treatment of single gingival recession. The authors
reported that all patients were affected by postopera-
tive consequences from the palatal donor site for the
connective tissue graft. They complained of significant
pain and care they had to take when eating; no infor-
mation about the patient’s postoperative assessment
was given. McGuire & Nunn (77) evaluated the healing
pattern in a randomized controlled split-mouth study
[subepithelial connective tissue graft vs. enamel
matrix derivative (Emdogain)]; they categorized the
healing as ‘worse than expected’, ‘as expected’ or as
‘much better than expected’ on a visual analog scale.
At 1 week the healing observed with the enamel
matrix derivative was superior to that observed with
the connective tissue graft; this result was not surpris-
ing as the need for a second surgical site to harvest the
connective tissue would more than likely lead to more
discomfort than that associated with the enamel
matrix derivative-treated sites. Cheung & Griffin (31)
(Table 3), in a randomized clinical trial performed to
assess the clinical efficacy of platelet concentrate
grafts in the treatment of Miller Class I or Class II buc-
cal gingival defects and to compare their soft-tissue
healing with those of subepithelial connective tissue
36
grafts, asked patients to rate their postsurgical dis-
comfort level, on each side of the arch, at 1 week and
at 1 month of follow-up, according to their subjective
feelings. To do this, a form containing a visual analog
scale (of 0–10, with 0 indicating negligible discomfort
and 10 indicating unbearable pain) was provided. The
platelet concentrate graft procedure resulted in less
postoperative discomfort. Harris et al. (52) (Table 3)
evaluated the incidence and severity of the complica-
tions that occur after connective tissue grafts are used.
Five-hundred consecutively treated patients, for
whom connective tissue grafts were used for root cov-
erage or gingival augmentation, were included in this
study. Complications did occur, but the rates and
intensities seemed clinically acceptable. The authors
empirically correlated the subjective and objective
data to create a nominal variable: 0 = none; 1 = mini-
mal; 2 = moderate; 3 = severe [as in the study by Cur-
tis et al. (36)]. There was no pain reported in 81.4% of
the patients, no bleeding in 97.0%, no infection in
99.2% and no swelling in 94.6%. None of the factors
evaluated in this study were associated with a statisti-
cally significant increase in the rate or intensity of
complications. There is minimal evidence in the litera-
ture of differences in patient outcomes and morbidity
being evaluated following use of the connective tissue
graft and free gingival graft for root-coverage proce-
dures. A few prospective comparative studies (37, 48,
116) reported poorer patient outcomes, specifically a
greater incidence of postoperative pain, for free gingi-
val grafts compared with connective tissue graft pro-
cedures. Del Pizzo et al. (37) (Table 3) used a 4-point
discrimination scale (coronal, apical, mesial, distal)
around the donor area, before the surgical procedure
and afterwards at the follow-up visits. The immedi-
ate bleeding parameter – delayed bleeding – and the
complete wound epithelialization parameter were
assessed. Re-epithelialization was scored clinically as
none, partial or complete. Objective sensory loss was
recorded using a rubbing movement and pin pressure
nociception. Patients were asked to give a rating of
their loss of sensibility based on a 3-point verbal
descriptor scale (none, mild or moderate, or severe).
Discomfort was assessed as the level of pain experi-
enced from the palatal wound by the patients during
the postoperative weeks. Regarding the sensory
parameter, the same 3-point verbal descriptor scale
(none, mild or moderate, or severe) was used to record
discomfort levels reported by the participants. Follow-
ing the same scale, variation of feeding habits was
monitored as a change in patient’s diet on the basis of
its content and quality (liquid, soft or hard) and tem-
perature of the food (cold, tepid or warm). The authors
 Table 3. Morbidity after root-coverage procedures

Authors, year Type of study Test group Control group Time of Method of assessment Major findings
(ref. no.) assessment

Romagna- Comparative Coronally advanced Coronally advanced 3 and Not applicable All patients were affected by the
Genon 2001 randomized flap+ guided tissue flap+ connective 6 months postoperative consequences from the
(97) controlled trial regeneration tissue graft (20 Miller palatal donor site for the connective
bioresorbable bilayer Class I or Class II tissue graft. They complained of
collagen membrane; gingival recessions) significant pain and care they had to
20 Miller Class I or take when eating. The site treated with
Class II gingival the membrane was more frequently
recessions) symptom-free
Del Pizzo Case series Three different surgical procedures for 1, 2, 3 and Patients were asked to score Discomfort rate recorded for both single-
et al. 2002 harvesting a connective tissue graft were 4 weeks for ‘discomfort’ and ‘sensibility incision and trapdoor groups was
(37) evaluated: single incision; free gingival graft; discomfort, loss’ on a three-point verbal significantly lower than for the free
and trapdoor feeding descriptor scale: ‘none’; ‘mild or gingival graft group. Discomfort was
habits and moderate’; or ‘severe’. Variation statistically significantly higher during
sensibility; 5, of feeding habits was monitored the first postoperative week in the free
6, 7 and as a change in patient’s diet on gingival graft group than in the other
8 weeks for the basis of its content and two groups. No differences were
sensibility quality (‘liquid’, ‘soft’ or ‘hard’) recorded between the trapdoor and
and temperature of the food single-incision groups.
(‘cold’, ‘tepid’ or ‘warm’) Variation of feeding habits was more
marked (but not statistically
significant) for the free gingival graft
group with respect to the two other
groups. Complete sensibility was
recovered in all patients 8 weeks after
surgery
McGuire & Split-mouth, Coronally advanced Coronally advanced 1 week Patient perception of pain, The enamel matrix derivative group was
Nunn 2003 randomized flap+ enamel matrix flap+ connective discomfort, bleeding and superior to the connective tissue graft
(77) controlled trial derivative (17 Miller tissue graft (17 Miller sensitivity was evaluated by a group regarding postoperative
Class I or Class II Class I or Class II questionnaire discomfort
gingival recessions) gingival recessions)
Cheung & Split-mouth, Coronally advanced Coronally advanced 1 and 4 weeks Discomfort was evaluated on a No statistically significant difference
Griffin 2004 randomized flap+ platelet flap+ connective visual analog scale between the two groups was found
(31) controlled trial concentrate graft (15 tissue graft (15 Miller questionnaire during the first postoperative week.
Miller Class I or Class Class I or Class II The platelet concentrate graft
II gingival recessions) gingival recessions) procedure resulted in less
postoperative discomfort at 4 weeks’
follow-up
Patient-centered outcomes

37
 Table 3. (Continued)

38
Authors, year Type of study Test group Control group Time of Method of assessment Major findings
(ref. no.) assessment

Harris et al. Case series 500 consecutive patients treated with connective Not applicable The authors empirically No pain reported in 81.4% of patients,
Mounssif et al.

2005 (52) tissue grafts for root coverage or gingival correlated the subjective and no bleeding in 97.0% of patients, no
augmentation objective data to create a infection in 99.2% of patients and no
nominal variable: 0, none; 1, swelling in 94.6% of patients
minimal; 2, moderate; 3, severe
Griffin et al. Prospective 75 free soft-tissue grafts and 256 subepithelial 1 week Every patient was given a Free soft-tissue grafts will most probably
2006 (48) case series connective tissue grafts were performed by a questionnaire to rate increase the probability of postsurgical
single operator postoperative pain, swelling pain and bleeding
and bleeding for the previous
week and overall discomfort on
day 7 on a visual analog scale of
‘0–10’
Wessel & Observational 12 connective tissue grafts and 11 free gingival 3 days and Patients were asked to fill out a Free gingival grafts were associated with
Tatakis 2008 parallel-group grafts were performed; in five free soft-tissue 3 weeks questionnaire (visual analog a greater incidence of donor-site pain
(116) study and 84 bilaminar graft procedures, an acellular scale) regarding postoperative compared with connective tissue grafts
dermal matrix was used instead of autogenous pain, swelling and bleeding during the early postoperative period
tissue
Zucchelli et al. Comparative Coronally advanced Coronally advanced 1 week Visual analog scale A statistically significantly better
2009 (123) controlled flap for multiple flap for multiple questionnaire: postoperative postoperative course was reported by
randomized recessions (with recessions (envelope course was evaluated 1 week the test (envelope coronally advanced
clinical trial vertical incisions; 47 type; 45 gingival; following surgery based on a flap) compared with the control
gingival Miller Class I– Miller Class I–II visual analog scale. Patients (coronally advanced flap with vertical-
II gingival recessions) gingival recessions) were asked to select among 100 releasing incisions) patients
scores (of 0 indicating a very
bad, 50 an average and 100 an
excellent postoperative course).
Patients also had to specify if
and which adverse events
(including pain, swelling,
bleeding and hypersensitivity)
occurred during the
postoperative course
 Table 3. (Continued)

Authors, year Type of study Test group Control group Time of Method of assessment Major findings
(ref. no.) assessment

Cortellini Multicenter, Coronally advanced Coronally advanced 1 week Visual analog scale Visual analog scale values were very low
et al. 2009 randomized flap+ connective flap (43 gingival Miller questionnaire: immediately in both groups and the differences were
(34) controlled trial tissue graft (42 gingival Class I–II gingival after surgery (hardship of the not statistically significant
Miller Class I–II recessions) procedure and intrasurgical
gingival recessions) pain perception) and at the
time of suture removal
(postoperative pain, discomfort,
use of anti-inflammatory
tablets, interference with daily
life, interference with job,
interference with relationships
and tooth hypersensitivity)
Zucchelli et al. Randomized Coronally advanced Coronally advanced 1 week Visual analog scale Painkiller consumption increased with
2010 (124) controlled trial flap+ de-epithelialized flap+ connective questionnaire: discomfort, increasing height of the withdrawal and
gingival graft; 25 tissue graft (25 gingival bleeding, stress and inability to by reducing the thickness of the soft
gingival Miller Class I– Miller Class I–II chew. Postoperative pain was tissue still covering the palatal bone
II gingival recessions) gingival recessions). indirectly evaluated on the
The trapdoor basis of the mean consumption
technique was used as (in mg) of analgesics
the harvesting (ibuprofen)
technique
Mcguire & Split-mouth, Coronally advanced Coronally advanced 1 week, Visual analog scale Subjects’ assessments of pain and
Scheyer 2010 randomized, flap+ collagen matrix flap+ connective 1 month and questionnaire: pain or discomfort were equivalent. Collagen
(78) controlled (25 Miller Class I–II tissue graft (25 Miller 6 months discomfort assessments (‘no matrix+ coronally advanced flap
clinical trial gingival recessions) Class I–II gingival pain’ to ‘extreme pain’) on 10- presents a viable alternative to
recessions) cm visual analog scales. At the connective tissue graft+ coronally
same time intervals, subjects advanced flap, without the morbidity of
also indicated whether test, soft-tissue graft harvest
control or donor sites
presenting the greatest sites of
discomfort were equivalent
Hansmeir & Prospective Sixteen patients received connective tissue graft 1 week Oral Health Impact Profile Pain was more pronounced at the donor
Eickholz longitudinal harvested and grafted using the envelope questionnaire; visual analog site than at the recipient site regarding
2010 (50) study technique scale for the intensity prevalence, intensity and duration.
Baseline Oral Health Impact Profile was
decreased by 3 months after surgery
Patient-centered outcomes

39
 Table 3. (Continued)

40
Authors, year Type of study Test group Control group Time of Method of assessment Major findings
(ref. no.) assessment

Jepsen et al. Split-mouth, Coronally advanced Coronally advanced 1 and 2 weeks A questionnaire as well as a The patient assessments of pain or
Mounssif et al.

2013 (61) multicenter, flap+ collagen matrix flap (45 Miller Class I– visual analog scale was given to discomfort were equivalent for test and
randomized (45 Miller Class I–II II gingival recessions) the patients to assess pain and control groups
controlled trial gingival recessions) discomfort during the initial
healing phase
Aroca et al. Split-mouth Modified coronal Modified coronal 2 weeks Visual analog scale questionnaire Duration of surgery and patient
2013 (5) randomized advanced tunnel advanced tunnel+ for discomfort, duration and morbidity were statistically significantly
controlled trial +collagen matrix (78 connective tissue graft difficulty lower in the collagen matrix group
Miller Class I–II (78 Miller Class I–II compared with the connective tissue
gingival recessions) gingival recessions) graft group
Zucchelli et al. Randomized Coronally advanced Coronally advanced 1 week Postoperative pain was indirectly Lower analgesic consumption and better
2014 (126) controlled flap+connective tissue flap+ connective evaluated on the basis of the postoperative course evaluations were
study graft (‘small graft’; 30 tissue graft (‘big graft’; mean consumption (in mg) of found for the ‘small graft’ group
Miller Class I–II 30 Miller Class I–II analgesics (ibuprofen).
gingival recessions) gingival recessions) A visual analog scale
questionnaire was used to
record postoperative
discomfort, bleeding and
inability to chew
Zucchelli et al. Randomized Coronally advanced Coronally advanced 1 week Visual analog scale questionnaire The postoperative course-related visual
2014 (127) controlled flap+ connective flap for multiple for discomfort, bleeding, stress analog scale scores were high for both
study tissue graft for gingival recessions (25 and inability to chew procedures, indicating limited
multiple gingival patients) postoperative pain/discomfort for both
recessions (25 patient groups. However, a statistically
patients) significantly better postoperative
course was reported by the coronally
advanced flap group
Zucchelli et al. Randomized Coronally advanced Coronally advanced 1 week Postoperative pain was indirectly Very limited postoperative morbidity
2014 (122) controlled flap+ connective flap+ connective evaluated on the basis of the was reported by both patient groups.
study tissue graft (25 Miller tissue graft (25 Miller mean consumption (in mg) of There was no statistically significant
Class I and II gingival Class I and II gingival analgesics (ibuprofen). A visual difference in terms of discomfort and
recessions at first recessions at first analog scale questionnaire was bleeding according to the visual analog
molar teeth) labial molar teeth) used to evaluate postoperative scale value
submucosal tissue discomfort, bleeding and
inability to chew
 Patient-centered outcomes

reported that statistically significant differences were

SI, single incision; FGG, free gingival graft; TD, trap door technique; PCG, platelet concentrate graft; SCTG, subepithelial connective tissue graft; FSTG, free soft tissue graft; ADM, acellular dermal matrix; VAS, visual analog scale;
Postoperative pain was indirectly Surgical chair time required to develop a

connective tissue graft group reported

found between the single-incision and free gingival

Visual analog scale questionnaire Graft thickness was directly correlated

coronally advanced flap+ connective

Increased palatal mucosal thickness,

significantly longer than that in the

with the amount of pain perceived.
graft techniques in terms of complete wound epithe-

before and after graft harvesting,

tissue graft group. The coronally

lialization, which occurred faster in the single-incision

tunnel has been shown to be

advanced flap+ subepithelial

group. The discomfort rate recorded for both single-
incision and trapdoor groups was significantly lower

less pain or discomfort

decreased pain levels
than for the free gingival graft group, with no marked
differences between single-incision and trapdoor pro-
cedures. The latter was confirmed by patient inter-
Major findings

views. The results of this preliminary study have little

statistical significance because of the limited number
of patients but they represent an important basis for a
comparative clinical study. Griffin et al. (48) (Table 3)
conducted a prospective study to compare the fre-
mean consumption (in mg) of
evaluated on the basis of the

quency of occurrence of pain, swelling and bleeding

questionnaire was used to

discomfort, bleeding and after free soft-tissue grafting or subepithelial connec-

analgesics (ibuprofen).

evaluate postoperative

tive tissue grafting procedures, to evaluate any effect

Method of assessment

A visual analog scale

that the application of an acellular dermal matrix as

for perceived pain

inability to chew

the donor-tissue alternative to a free soft-tissue graft

or a subepithelial connective tissue graft might have
on the frequency and/or severity of these complica-
tions and to identify possible predictors for these com-
plications. At the 1-week follow-up appointment,
every patient was given a questionnaire to rate post-
and 28 days
1, 3, 7, 14, 21

operative pain, swelling and bleeding for the previous

assessment

DGG, de-epithelialized gingival graft; SCTG, subepithelial connective tissue graft; TT, tunnel technique; NA, not available.

week, and overall discomfort on day 7. The levels of

Time of

3 days

complications were classified as none to minimal if

the score was 0–3, moderate for a score of 4–6 and sev-
connective tissue graft connective tissue graft

gingival Miller Class I– gingival Miller Class I–

ere for a score of 7–10. Griffin et al. (48) reported that

90 patients scheduled for different periodontal

pain and swelling were the most significant complica-

Coronally advanced
flap+ subepithelial
and peri-implant plastic surgeries requiring

single or multiple
(25 patients with

tions, with 27–40% of subjects reporting moderate or

Control group

II recessions)

severe pain and 19–60% reporting moderate-to-severe

swelling. In general, bilaminar procedures were asso-
palatal mucosal graft harvesting

ciated with a lower incidence of moderate or severe

pain compared with free soft-tissue grafting (27% vs.
38.7%, respectively) but with a higher incidence of
moderate or severe swelling (31.6% vs. 21.3%, respec-
Tunnel technique+

single or multiple

tively). Only a small percentage of subjects (< 6%)

(25 patients with

experienced moderate or severe bleeding and only in

II recessions)
controlled trial subepithelial

the groups in which autogenous tissue was used.

Test group

Moderate or severe discomfort after 1 week was

reported only after subepithelial connective tissue
graft procedures and by relatively few subjects (7.6%).
The authors concluded that long surgical procedures
Observational
Authors, year Type of study

Gobbato et al. Randomized

and smoking habits correlate closely with postopera-

case series

tive complications. Among the different periodontal

Table 3. (Continued)

plastic surgeries, the free soft-tissue grafting proce-

dure will probably increase the probability of postsur-
gical pain and bleeding, whereas the use of an
Burkhartdt &
Lang 2015

acellular dermal matrix as an alternative graft material

2016 (46)
(ref. no.)

eliminates the second surgical site and may reduce

(18)

the likelihood for postsurgical swelling and bleeding.

The same procedures (connective tissue graft vs. free

41
Mounssif et al.
gingival graft) were investigated by Wessel & Tatakis
(116) (Table 3) in an observational parallel-group
study. Postoperative questionnaires were given to the
patients to evaluate pain using visual analog scale
scores from 1 to 10, with 1 indicating minimal pain
and 10 indicating severe pain. The 3-day question-
naire assessed pain in the first 3 postoperative days,
and the 3-week questionnaire assessed pain from 3-
days postoperatively to 3 weeks postoperatively. Sub-
jects were also asked to indicate the location of pain:
donor site; recipient site; or elsewhere in the mouth.
The results indicated that free gingival grafts were
associated with a greater incidence of donor-site pain
compared with connective tissue grafts during the
early postoperative period. There were significant dif-
ferences between early (3-day) and late (3-week) pain
levels for free gingival grafts. The results also indicated
that longer term (3-week) pain levels after soft-tissue
grafting were associated with higher levels of analgesic
usage. Among subjects treated with connective tissue
graft, 33% reported pain in the donor site, 25%
reported pain in the recipient site and none reported
pain elsewhere. Among the subjects treated with free
gingival grafts, 36% reported pain in the donor site,
18% reported pain in the recipient site and 9%
reported pain elsewhere. Intragroup comparisons for
the free gingival graft group showed that the visual
analog scale pain score was reduced significantly at
3 weeks compared with 3 days, whereas the differ-
ence did not reach significance for the connective tis-
sue graft group. The authors suggested that, from a
patient comfort perspective, connective tissue graft
might be the procedure of choice when both free gin-
gival graft and connective tissue graft can meet the
patient’s surgical needs. The results of that study also
suggested that there is an opportunity to improve the
postoperative protocols of commonly used soft-tissue
grafting procedures; such improvements may include
more effective analgesic protocols and donor wound-
protection schemes. In a recent systematic review,
Cairo et al. (25) showed that postoperative pain and
complications following therapy were difficult to
investigate as a result of data heterogeneity. Coronally
advanced flap plus barrier membrane was frequently
associated with membrane exposure (3, 60, 72, 106)
even if others did not report exposure (97). Coronally
advanced flap+ connective tissue graft was associated
with more pain at the donor site, even if this side
effects was not confirmed by others (60, 100). Possible
reasons may be related to different approaches in
the harvesting technique or suturing modalities
in different studies. Coronally advanced flap plus
enamel matrix derivative seemed to have limited
42
postoperative discomfort (25). In a randomized con-
trolled clinical study, Zucchelli et al. (124) (Table 3)
compared postoperative morbidity and root-coverage
outcomes in patients undergoing trapdoor connective
tissue (control group) and epithelialized (test group)
graft-harvesting techniques for the treatment of gingi-
val recession defects with bilaminar procedures. Post-
operative pain was indirectly evaluated on the basis of
the mean consumption (in mg) of analgesics (ibupro-
fen). Patients’ postoperative discomfort, bleeding,
stress and inability to chew were evaluated using a
questionnaire given to patients 1 week following sur-
gery. The questionnaire included evaluation of the
intensity of the given event on a visual analog scale of
100 mm. Discomfort was defined as the level of sore-
ness/pain experienced by the patients during the first
postoperative week as a result of the palatal wound.
Bleeding was considered to be the prolonged hemor-
rhaging during the postsurgical week as reported by
the patients. Stress was evaluated based on the level of
apprehension and fear experienced by the patients of
jeopardizing the palatal wound. Inability to chew was
described as the level of variation of the patient’s eat-
ing habits as a result of the presence of the palatal
wound. Healing was uneventful for all test patients. In
seven (28%) control patients, dehiscence/necrosis of
the primary palatal flap occurred during the first heal-
ing period (7 days). The difference in painkiller con-
sumption between control and test groups was not
statistically significant. A separate analysis demon-
strated statistically higher consumption of analgesics
in the seven patients experiencing primary flap dehis-
cence/necrosis than in test patients with secondary
intention palatal healing and in control patients with
primary intention palatal wound healing. In contrast,
the difference in analgesic consumption between the
test patients and the control patients experiencing pri-
mary intention wound healing was not statistically sig-
nificant. Painkiller consumption increased with
increasing height of the withdrawal and by reducing
the thickness of the soft tissue still covering the palatal
bone. Very limited postoperative morbidity was
reported in either patient group and no statistically
significant difference was demonstrated between the
control and the test patients in terms of postoperative
discomfort and bleeding-related visual analog scale
values. Statistically significant better results, in terms
of postoperative inability to chew and stress-related
visual analog scale values, were demonstrated in the
control patients than in the test patients. A parallel-
group, multicenter, double-blind, randomized-con-
trolled clinical trial was conducted to compare the
clinical outcomes and patient morbidity of coronally

advanced flap, alone, or in combination with a con-
nective tissue graft, in single Miller Class I and II gingi-
val recessions (34) (Table 3). Patient perception of
intraoperative and postoperative morbidity were eval-
uated using a questionnaire given to patients immedi-
ately after surgery (recording hardship of the
procedure and intrasurgical pain perception) and at
the time of suture removal (recording postoperative
pain, discomfort, use of anti-inflammatory tablets,
interference with daily life, interference with job,
interference with relationships and tooth hypersensi-
tivity). Questionnaires included dichotomous ques-
tions, and the intensity of the given event was
evaluated on a visual analog scale. Patient perception
of the intraoperative morbidity of the two procedures
was mild and there was no statistically significant dif-
ference between the coronally advanced flap alone, or
in combination with a connective tissue graft. How-
ever, the latter resulted in higher average visual analog
scale values and there was a significant effect accord-
ing to center. Hansmeier & Eickholz (50) (Table 3)
adopted oral health-related quality of life question-
naires to address patient-centered outcomes. The Oral
Health Impact Profile questionnaire is one of several
instruments developed to measure oral health-related
quality of life and is widely used in clinical research.
The 49-item version is the most comprehensive ques-
tionnaire to assess oral health-related quality of life
and is able to measure patients’ problems and symp-
toms. The results showed that more patients reported
postsurgical pain at the donor site (50%) than at the
recipient site (38%). Furthermore, those who reported
postoperative pain described it as more intense and
longer lasting at the donor site than at the recipient
site. It seems that harvesting of the connective tissue
graft causes more morbidity than grafting itself. The
results of that study showed that root coverage with
connective tissue graft used according to the envelope
technique improved the oral health impact profile,
although the improvement was not statistically signifi-
cant. Zucchelli et al. (126) (Table 3) evaluated, in a
double-blind, randomized, controlled clinical trial
with a parallel design, whether patient morbidity was
improved by diminishing graft thickness and height,
comparing connective tissue grafts of different thick-
ness and height used in conjunction with the coro-
nally advanced flap for the treatment of single gingival
recession. Postoperative pain was indirectly evaluated
on the basis of the mean consumption (in mg) of anal-
gesics (ibuprofen) (124). Patient postoperative dis-
comfort, bleeding and inability to chew (124) were
evaluated using a questionnaire given to patients
1 week following surgery. The questionnaire included
Patient-centered outcomes
an evaluation of the intensity of the given event using
a visual analog scale. Lower analgesic consumption,
better postoperative course evaluations, better patient
color-match scores and better periodontist esthetic
assessments were reported in the small graft group.
No statistically significant differences were demon-
strated between the two groups in terms of recession
reduction, complete root coverage and increase in
keratinized tissue height; greater gingival thickness
increase was obtained in the control-treated sites.
Recently, Burkhardt et al. (18) (Table 3) investigated
the factors influencing patients’ perception of pain
and morbidity at the palatal donor site after mucosal
graft harvesting. The authors found that pain was
most pronounced on the first postoperative day and
decreased with time. Graft thickness was directly cor-
related with the amount of pain perceived, while
increased palatal mucosal thickness before and after
graft harvesting was associated with decreased pain
levels. The denuded wound surface area, however, did
not influence the perceived pain level. The data
obtained confirm the results of previous studies (124,
126), in which less patient morbidity was reported in
coronally advanced flaps and connective tissue grafts
of reduced thickness and height compared with the
large graft group (126), and free gingival grafts with a
thinner dimension and the extra-oral removal of
epithelium are often preferred over thick grafts har-
vested using a trapdoor technique (124). In a recent
study, Gobbato et al. (46) (Table 3) pointed out that in
most instances, the focus of pain assessment revolves
around the tissue donor site, which is normally the
palatal region proximal to the maxillary premolars,
and minimal attention is paid to the perception of
pain from the recipient area or the overall oral cavity.
More trivial postoperative symptoms, such as pain,
discomfort, swelling and mild bleeding, are experi-
enced routinely by patients undergoing mucogingival
surgery (48, 52). In general, such manifestations are
short lived and occur over the early postoperative per-
iod (3 days) (116). The authors compared the patient
morbidity and root-coverage outcomes of a subep-
ithelial connective tissue graft used in combination
with a coronally advanced flap or tunnel technique.
Postoperative pain was indirectly evaluated on the
basis of the mean consumption (in mg) of analgesics
(ibuprofen). All patients were asked to complete a
questionnaire designed to evaluate pain experience,
such as postoperative discomfort, bleeding and inabil-
ity to chew, at early (3 days) stages following the surgi-
cal procedure. The survey utilized a visual analog scale
scored from 1 to 10, with 1 indicating minimal pain
and 10 indicating severe pain. If a patient indicated
43
Mounssif et al.
that no pain was present, a score of 0 was given. Differ-
ent parameters were investigated regarding postoper-
ative bleeding, quantity and type of analgesic
medication taken, and the patient undergoing a simi-
lar procedure in the future, if recommended by their
dentist. Discomfort was defined as the level of sore-
ness/pain in the grafted area that was experienced by
the patients during the first 3 days. Bleeding was con-
sidered to be prolonged hemorrhaging during the first
3 days postsurgery, as reported by the patient. Inabil-
ity to chew was described as the level of variation of
the patient’s eating and drinking habits because of the
presence of the wound. The results showed that
patients treated with subepithelial connective tissue
graft plus coronally advanced flap reported less pain
or discomfort in all four sections of the questionnaire:
pain experienced within the mouth as a whole; pain
experienced throughout the day; pain experienced at
night; and edema experienced after the surgery.
The surgical chair time required to develop a tunnel
was shown to be significantly longer than that in
the subepithelial connective tissue graft plus coro-
nally advanced flap group. On average, the surgeon
required 33.6 min for the subepithelial connective tis-
sue graft plus tunnel technique and 23.6 min for the
subepithelial connective tissue graft plus coronally
advanced flap. A positive linear relationship was
observed between surgical time and use of analgesic
medication. In other words, the longer the surgery, the
higher the dosage of painkillers consumed. This may
be explained in that the preparation of an adequate
tunnel requires extreme care and attention, in particu-
lar in patients with thin gingival soft tissue. In addi-
tion, in order to prepare adequately a tunnel, the
surgical area has to be extended at least one tooth
mesial and one tooth distal to the defect area. This
could explain why the group treated with subepithelial
connective tissue graft plus coronally advanced flap
reported less pain or discomfort in all four aspects of
the questionnaire. The pain perception and oral func-
tion gradually improved during the first week, but
social and recreational activities and daily routines
were affected, especially during the first three postop-
erative days.
To our knowledge, patient morbidity after root cov-
erage is highly associated with the harvest of soft tis-
sue from the palate, and the palate provides limited
donor tissue, allowing only a few teeth to be treated at
one time. Within the dental community, there is a
strong desire to identify an alternative graft material
that could be used as a substitute for connective tissue
graft (129). A suitable substitute would reduce morbid-
ity and the number of surgical sites required and
44
increase the number of teeth that could be treated in
one surgical visit. In principle, three basic soft-tissue
substitute materials of different origin can be distin-
guished – allogeneic (of human origin), xenogeneic
(from another species, e.g. of porcine or bovine origin)
and alloplastic (of artificial origin) (129) – and only a
few of these have shown scientifically documented
success. Acellular dermal substitutes were the first
soft-tissue substitute materials to be introduced to the
dental market. The best-researched type is the acellu-
lar dermal matrix, an allogeneic substitute that con-
sists of a freeze-dried connective tissue matrix,
without epithelium and cellular components, which is
obtained from tissue banks by a standardized, con-
trolled manufacturing process. A systematic review by
Cairo et al. (25) revealed considerable heterogeneity
in clinical outcome measures after 6–12 months and
concluded that adding acellular dermal matrix to
coronally advanced pedicle flaps did not improve the
clinical results compared with the use of coronally
advanced flaps alone and was inferior to the combina-
tion of coronally advanced flap and subepithelial con-
nective tissue graft (25), even though no postoperative
pain and complications were reported in comparisons
between coronally advanced flaps used with an acellu-
lar dermal matrix vs. coronally advanced flaps alone
(35, 117) and coronally advanced flaps used with an
acellular dermal matrix vs. coronally advanced flaps
used with connective tissue graft (62). Moreover, care
needs to be taken if grafts of larger dimensions are
required because folded or layered acellular dermal
matrices might impede vascularization and lead to
extensive shrinkage (8, 114). Ethical concerns stem-
ming from allograft being derived from human cadav-
ers and the purported risk of disease transmission are
remarkable counterpoints of the material frequently
expressed by patients (129). A newly developed xeno-
geneic collagen matrix has been shown to promote
regeneration of keratinized gingiva around teeth and
implants in association with tissue-augmentation pro-
cedures (102) and to improve early mucosal wound
healing (108). McGuire & Scheyer (78) studied the
safety and efficacy of this collagen matrix when used
with a coronally advanced flap in the treatment of
recession defects in 25 patients with bilateral Miller
Class I and Class II recession defects in a monocenter,
randomized, single-blind, split-mouth trial. Although
values of root coverage for coronally advanced flaps
used with connective tissue graft (99.3%) were higher
than for coronally advanced flaps used with collagen
matrix (88.5%), the latter procedure was found to be
less invasive and time consuming because of an
unlimited off-the-shelf supply of grafting material,

and it was concluded that it presents a viable alterna-
tive to the connective tissue graft procedure. A multi-
center single-blinded, randomized, controlled, split-
mouth trial (61) evaluated the clinical outcomes of the
use of a xenogeneic collagen matrix in combination
with the coronally advanced flap in the treatment of
localized recession defects. The use of collagen matrix
resulted in significantly more gain in gingival thick-
ness and width of keratinized tissue. The patients of
this study were instructed to record daily the intensity
of pain and the dose of medication in a patient ques-
tionnaire. The patient assessments of pain or discom-
fort were equivalent for test and control groups. No
differences could be observed in visual analog pain
scores at 7 and 14 days postsurgery. Aroca et al. (5)
(Table 3), in a prospective, randomized, controlled,
split-mouth clinical study, clinically evaluated the
treatment of Miller Class I and Class II multiple gingi-
val recessions using modified coronal advanced tun-
nel with either collagen matrix or connective tissue
graft. Both procedures were evaluated by the patient
(on a visual analog scale) for discomfort, duration and
difficulty. Postoperative complaints, duration of sur-
gery and patient morbidity were lower for the collagen
matrix group compared with the control group. The
authors showed that the use of collagen matrix may
represent an alternative to use of connective tissue
graft by reducing surgical time and patient morbidity,
but yielded lower complete root coverage than con-
nective tissue graft, in the treatment of Miller Class I
and Class II multiple adjacent gingival recession
defects, when used in conjunction with a modified
coronal advanced tunnel procedure. In a recent meta-
analysis, Atieh et al. (6) evaluated 645 studies, of
which six trials were included with 487 mucogingival
defects in 170 participants. The xenogeneic collagen
matrix had a significantly higher mean root coverage,
recession reduction and gain in keratinized tissue
compared with the coronally advanced flap alone. No
significant differences in patient’s esthetic satisfaction
were found between xenogeneic collagen and connec-
tive tissue graft, except for postoperative morbidity in
favor of xenogeneic collagen. Operating time was sig-
nificantly reduced with the use of xenogeneic collagen
compared with connective tissue graft but not with
coronally advanced flap alone. There is no evidence to
demonstrate the effectiveness of xenogeneic collagen
in achieving greater root coverage, recession reduc-
tion and gain in keratinized tissue compared with con-
nective tissue graft plus coronally advanced flap.
Superior short-term results in treating root coverage
compared with coronally advanced flap alone are pos-
sible. The authors showed that there is limited
Patient-centered outcomes
evidence that collagen matrix may improve esthetic
satisfaction, reduce postoperative morbidity and
shorten the operating time. Further long-term ran-
domized controlled trials are required to endorse the
supposed advantages of collagen matrix (6). The visual
analog scale is the most widely used approach to
assess patient morbidity after periodontal plastic
treatment; more recently, the use of CONSORT guide-
lines in reporting randomized clinical trials also
improved the information on patient-related out-
comes by using a visual analog scale (23) which is easy
to administer and is reproducible. There is evidence
showing that a visual analog scale has superior metri-
cal characteristics than discrete scales and thus a
wider range of statistical methods can be applied to
the measurements obtained using a visual analog
scale (96). McGuire et al. (80), in a recent commen-
tary, suggested that independent recorders administer
patient-reported outcomes questionnaires, before
and immediately after surgery, to investigate anxiety,
pain/discomfort and treatment preference. The
authors were able to understand the nature of the
patients’ experience of test and control therapies
only by asking multiple, specific questions about the
severity of pain experienced at different sites in the
mouth. This revealed that any pain advantage
offered by a nonharvest therapy is because of the
absence of tissue harvest and not a result of reduced
pain at the treatment site. Additionally, pain and
satisfaction changed dramatically over time, suggest-
ing that single measures of either construct may
miss important treatment differences at other time
points.
Hypersensitivity
Dentine hypersensitivity may be defined as pain aris-
ing from exposed dentine, typically in response to
chemical, thermal or osmotic stimuli and that cannot
be explained as arising from any other form of dental
defect or pathology (1). The main symptoms are sharp,
well-localized pain of short duration (91). Dentine
hypersensitivity is a common problem found in many
adults with prevalence figures ranging from 4% to 74%
(27, 42, 44, 57, 59, 73, 84, 87, 95). This wide variation in
prevalence may result from a number of factors,
including different methods used to diagnose the con-
dition and variation in the consumption of erosive
foods and drinks (39).
Cervical dentin hypersensitivity is one of the most
painful, and least predictably treated, chronic condi-
tions in dentistry (67). The treatment and prevention of
45
Mounssif et al.
cervical dentin hypersensitivity uses tubular occlusion
and/or the blockage of nerve activity (92, 107), and laser
therapy (45, 103), oxalates (7, 112) and dentinal tubule-
occluding agents (53, 104) were also investigated to
evaluate their effectiveness. Surgical root coverage is
another form of treatment for cervical dentin hypersen-
sitivity. In fact, alleviation of root sensitivity in areas with
localized or generalized soft-tissue recessions is one of
the major therapeutic goals in mucogingival surgery
(115). Surgical treatment occludes the exposed dentinal
tubules and offers the benefit of esthetic improvement
in the sensitive areas associated with gingival recessions
(23, 25, 28, 56).
Very few studies have evaluated root sensitivity fol-
lowing root-coverage procedures and no meta-ana-
lyses have been carried out as the data were few and
heterogeneous (23, 25). Recently, a systematic review
(39) surveyed the literature on the efficacy of surgical
root-coverage techniques at reducing cervical dentin
hypersensitivity in cases of gingival recession. They
evaluated nine randomized clinical trials that met the
inclusion criteria. In the studies analyzed, cervical
dentin hypersensitivity was assessed using patient
opinions in six and evaporative stimuli in two. One
randomized controlled study did not mention the
method used to assess dentin sensitivity (90). Cervical
dentin hypersensitivity was measured as present or
absent in six studies (9, 11, 34, 89, 100, 101) and on a
qualitative scale in the other randomized clinical tri-
als (10, 12, 77). The data extracted from the studies
evaluated in this review revealed heterogeneity in
relation to the type of intervention, follow-up period,
clinical parameters assessed, type of gingival reces-
sion, evaluation of cervical dentin hypersensitivity
and study design. Thus, it was not possible to estab-
lish a quantitative synthesis of the data, thereby
rendering meta-analysis impossible. A decrease in
cervical dentin hypersensitivity was observed after
periodontal surgery for root coverage, but the results
of this systematic review should be viewed with cau-
tion because most of the studies reviewed had a high
risk of bias and cervical dentin hypersensitivity was
assessed as a secondary outcome. Hence, there is not
enough evidence to conclude that surgical root-cov-
erage procedures predictably reduce cervical dentin
hypersensitivity. Adequately powered randomized
clinical trials with robust measurements of dentin
hypersensitivity are needed to allow periodontists to
indicate root coverage as a safe, lasting treatment for
cervical dentin hypersensitivity (39). The same group
conducted a case series (38) on 25 consecutive gingi-
val recession defects treated for cervical dentin hyper-
sensitivity. Dentin hypersensitivity was diagnosed by
46
cold stimulation spray and air blast from a triple syr-
inge (118). Cold was applied to the tooth using a cot-
ton swab for 5 s and the air blast was applied to the
exposed buccal cervical area at a distance of 1 cm for
5 s. Adjacent teeth were protected using utility wax. A
numeric rating scale was used to record the cervical
dentin hypersensitivity related to the stimuli, with a
pain score from 0 (no pain) to 10 (extreme pain). The
Oral Health Impact Profile-14 questionnaire was
used to assess oral health-related quality of life (86).
The Oral Health Impact Profile-14 evaluates seven
dimensions (functional limitations, physical pain,
psychological discomfort, physical disability, psycho-
logical disability, social disability, handicap) on a
scale ranging from 0 to 28 points, with higher scores
indicating more impact of oral conditions on quality
of life. The same instrument was used at baseline and
3 months after treatment and was completed by the
patient before the evaluation of clinical measures and
cervical dentin hypersensitivity. The participants
responded on a 5-point Likert scale. One operator
performed all surgeries using a coronally advanced
flap and connective tissue graft. The authors showed
a statistically significant reduction in cervical dentin
hypersensitivity evaluated by thermal and evapora-
tive stimuli. The difference found in cervical dentin
hypersensitivity before and after the surgery may
be explained by the increase of keratinized gingiva,
which was able to occlude the dentinal tubules.
However, some patients still complained of cervical
dentin hypersensitivity after the surgery, despite pain
levels being lower in comparison with baseline.
According to Clauser et al. (32), only complete defect
coverage ensures total recovery from cervical dentin
hypersensitivity. The statistically significant decrease
in cervical dentin hypersensitivity after defect cover-
age corroborates the findings of previous studies
(100, 101); however, those studies used no stimuli to
assess cervical dentin hypersensitivity – only patients’
reports were used, and cervical dentin hypersensitiv-
ity was measured as absent or present. Other ran-
domized clinical trials also found a reduction in
cervical dentin hypersensitivity after surgery (10, 34,
89) but cervical dentin hypersensitivity was reported
as absolute frequency and no statistical analyses were
performed regarding cervical dentin hypersensitivity
and defect coverage.
Conclusions
According to the literature, two main indications exist
for the treatment of gingival recession: esthetics and

hypersensitivity. The ultimate goal of treatment is to
achieve a satisfactory esthetic outcome in the eyes of
the patient and to resolve any hypersensitivity present
with minimal patient morbidity. Despite one of the
major goals of root-coverage surgery being the resolu-
tion of root sensitivity in areas with soft-tissue reces-
sions (115), very few data on this issue are available
in the literature. Numerous studies have reported
dentin hypersensitivity as an indication for the treat-
ment of gingival recessions; however, very few stud-
ies have carried out an appropriate assessment. In
fact, often the presence or absence of hypersensitiv-
ity, as well as its possible resolution after surgical
treatment, are reported with empirical sentences. A
standardized and reproducible method for the evalua-
tion of dentin sensitivity, which allows for compar-
ison between pre- and postoperative sensitivity, is
advocated.
Root-coverage surgical procedures are associated
with varying degrees of patient morbidity. Patients
report a greater degree of morbidity from the donor
site, where one is used, compared with the recipient
site during periodontal plastic surgery. Of the differ-
ent connective tissue graft-harvesting procedures
described in the literature, the trapdoor (40), single-
or double-incision technique (55, 75) and a thin free
gingival graft de-epithelialized extraorally (124, 126)
seem to be associated with a better postoperative
course. The wound depth at the donor site (graft
thickness) is positively correlated with the patient’s
perception of pain (18, 126). To date, the clinical deci-
sion of whether to harvest subepithelial connective
tissue grafts from the anterior or the posterior palate
is not based on scientific evidence but rather on the
amount of tissue available at the different donor sites,
the indication for transplantation and, in particular,
the personal preference of the treating surgeon (129).
As the palate provides limited donor tissue, allowing
only a few teeth to be treated at a time, efforts have
been made to identify an alternative graft material
that could be used as a substitute for connective tis-
sue graft. The use of allografts or xenogenic grafts
compared with connective tissue graft in the treat-
ment of gingival recessions were consistently associ-
ated with a better postoperative course (6, 78). The
method most commonly adopted to assess patient
morbidity is the visual analog scale, which seems
easy to administer and reproducible. It has been
suggested that this should be administered before and
after treatment by an independent assessor. Future
research should focus on standardized methods for
the evaluation of patient morbidity. These methods
should include postoperative discomfort (pain, bleeding,
Patient-centered outcomes
inability to chew) and the impact of the surgical pro-
cedure on patients’ life habits as well as anxiety and
treatment preference (80). The evaluation of esthetic
appearance by professionals after root-coverage pro-
cedures have been investigated in a few clinical trials.
The methods used are highly variable but all use pho-
tographic assessment (16, 26, 31, 64, 65, 99, 113) and
a scale (34, 122, 123, 126, 127). Color match, tissue
texture, contour, contiguity and keloid formation
were the parameters most commonly investigated by
expert periodontists. Root-coverage esthetic score
(22) seems to be a reliable method for professionals
to assess the esthetic outcomes of root-coverage pro-
cedures. Despite the numerous studies presents in
the literature on the treatment of gingival recessions,
only limited papers reported data about esthetic eval-
uation from a patient’s view. A visual analog scale or
a 5-point scale was the tool most commonly used to
determine patients’ satisfaction with the esthetic out-
come. The perception of recession defects by the
patients and the real need for treatment are often
underestimated in professional practice and are, as
yet, not discussed in the periodontal literature (85).
At present, no information on patient perceptions
and spontaneous patient requests for surgical or non-
surgical treatment are available in the literature.
Commonly, after the diagnostic phase, the treatment
used is decided exclusively by the periodontist and is
based on his/her own knowledge, clinical experience
and financial benefit (33, 125). Recently, it has been
shown (30) that untreated gingival recession defects
tend to progress over time. These findings may increase
the indications for treatment of gingival recession
defects. Therefore, the presence of gingival recessions,
per se, may become an indication for their treatment.
Untreated gingival recessions in teeth with no esthetic
relevance but localized in areas with unfavorable ana-
tomic conditions (i.e. mandibular incisors and molars)
(121, 122) should be treated by mucogingival surgery in
order to prevent further progression and worsening of
prognosis. In the mandibular incisors, the lack of early
diagnosis may render orthodontic repositioning of the
tooth/root with gingival recession mandatory before
the surgical treatment (128) (Figs 7–10).
The recent systematic reviews (23, 29) and consen-
sus (105, 109) point out the lack of patient esthetic
evaluation in the scientific studies and the authors of
the present review stress the need to focus research
on personal/individual requests. The patient per-
ception outcomes should be the center of the investi-
gation, and a standardized approach (taking into
account subjective evaluations) would be desirable.
The esthetic judgment of the periodontists (66) may
47
Mounssif et al.
not always be consistent with patient satisfaction and
it remains to be evaluated if what is more important
for the professional is really more critical for the
patient. For example, complete coverage provides a
greater contribution to root-coverage esthetic score
(26) but it has not been demonstrated that this is
really what the patient looks for in the final outcome.
Often, patients are more concerned by the difference
in color or, less frequently, by differences in tissue
thickness than incomplete root coverage. However,
overall, patients appear to rate the cosmetic results
more favorably than the professionals (66). The rea-
son for the discrepancy between the subjects’ and
professionals’ perceptions of esthetic outcome is
not well understood. Certainly, the subjectivity of
esthetic perception is crucial and it is different not
only between patient and clinician but also between
patients. The preoperative clinical situation probably
influences patients’ evaluation of the final outcome.
For example, when the preoperative situation is
highly compromised, patients’ expectations are real-
istic and accordingly patients might be more satisfied
than a professional evaluator, even when the esthetic
outcome, according to an objective index, is rated
acceptable or even poor. Furthermore, esthetic evalu-
ation made using photographs does not represent a
reliable method because in most of the photographs
used for esthetic assessment a lip retractor has been
A B
Fig. 7. Baseline clinical situation. (A) Deep gingival reces-
sion in the lower incisor. Tooth malposition, the depth of
root exposure, the absence of keratinized tissue and the
presence of a buccal probing pocket depth of 3 mm
A B
Fig. 8. Postorthodontic clinical situation. (A) Orthodon-
tic repositioning of the tooth/root allowed for reduction
of the root exposure in depth and width, new formation
of keratinized tissue and reduction of buccal probing
48
used, which removes the lip from the image and
influences the color and adds tension or muscles
and frenulum pull. Coupled with this, the reflection
of the flash light and different projection sometimes
make the outcome appear worse and sometimes bet-
ter than the true situation. Certainly, short videos
before and after therapy, during which the patient’s
speech, smile and usual gingival tissue show is appar-
ent, may represent a situation more similar to the
reality and may be used by the expert professional
periodontist for the esthetic evaluation of the out-
come of root-coverage surgical procedure. Finally,
comparison of photographs taken of the baseline,
presurgical clinical situation with photographs show-
ing the final result before undertaking the profes-
sional esthetic evaluation is a matter of debate. On
the one hand, it is true that the patient is influenced
in his/her evaluation of the final result by the mem-
ory of the pretreatment situation. On the other hand,
for an esthetic evaluation to be fair and objective, the
evaluation of the final result should be carried out
blinded to the preoperative situation. It is the opinion
of the authors that preoperative photographs (or,
better still, movies) should be used only to evaluate
certain outcomes of a surgical procedure, such as
the amount of root coverage, while post-treatment
photographs/movies should be utilized on their own,
by different, blinded operators (professional and
complicate surgical treatment. (B) The occlusal view shows
the disalignment, with buccal displacement of the tooth/
root with gingival recession. Orthodontic tooth/root repo-
sitioning is advocated before surgical treatment.
depth to (1 mm). (B) The occlusal view shows the
realignment of the tooth/root with gingival recession
and the newly formed keratinized tissue apical to the
root exposures.

A B
Fig. 9. Surgical technique. (A) A trapezoidal buccal flap
was elevated and the root exposure was planned. (B) A
connective tissue graft, deriving from the extra-oral disep-
ithelization of a free gingival graft, was sutured (7-0 PGA)
A B
Fig. 10. One-year clinical outcomes. (A) The buccal aspect
shows complete root coverage and good camouflaging of
the treated area with respect to the adjacent soft tissue.
The patient was extremely satisfied with the esthetic out-
come although she had not expressed any esthetic request
nonprofessional) to perform a more truthful esthetic
evaluation.
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