Case Series

Coronally Advanced Flap Procedure for Root Coverage.

Treatment of Root Surface: Root Planing Versus Polishing
Giovanpaolo Pini-Prato,* Carlo Baldi,† Umberto Pagliaro,‡ Michele Nieri,§ Daniele Saletta,§
Roberto Rotundo,! and Pierpaolo Cortellini¶

This clinical study was designed to determine if is not necessary when shallow recessions caused by
mechanical instrumentation (root planing) of the traumatic toothbrushing are treated using a coronally
exposed root is useful in treating gingival recession advanced flap (CAF) in patients with high levels of
caused by traumatic toothbrushing following a coro- oral hygiene. J Periodontol 1999;70:1064-1076.
nally advanced flap (CAF). Ten patients with high
KEY WORDS
levels of oral hygiene (full-mouth plaque score
<20%), from 25 to 57 years of age, were selected for Gingival recession/surgery; planing; surgical flaps;
the study. Each patient showed 2 bilateral Class I or tooth root/surgery; toothbrushing/adverse effects.
II maxillary recessions. A total of 20 recessions were
treated. The difference in the recessions was ≤1 mm.
In each patient, one recession was randomly
assigned to the test group and the contralateral one
to the control group. In the test group, the exposed
root surface was polished at slow speed with a rub-
ber cup and prophylaxis paste for 60 seconds. In the
control group, the exposed root surface was planed
with a sharp curet. In both test and control groups, a
trapezoidal full- and partial-thickness flap was ele-
vated, coronally displaced, and sutured to cover the
treated root surface. Before treatment, the mean
recession depth in the test group (polishing) was 3.1 ±
1.1 mm; and in the control group (root planing),
2.9 ± 1.0 mm. Three months after the described pro-
cedures, the test group (polishing) showed a mean
recession reduction of 2.6 ± 0.6 mm; mean percent
root coverage was 89 ± 14%. In the control group
(root planing), the mean recession reduction was
2.3 ± 0.7 mm and mean percent root coverage was
83 ± 16%. The difference of recession reduction
between the test and control group was not statisti-
cally significant ( P = 0.1405), even though the test
group showed slightly better clinical results in terms
of root coverage. This prospective clinical, controlled,
randomized study shows that mechanical instru-
mentation (root planing) of the exposed root surfaces

* Dental School, University of Florence, Florence, Italy.

† Private practice, Prato, Italy.
‡ Private practice, Campi Bisenzio, Italy.
§ Private practice, Florence, Italy.
! Department of Periodontology, University of Siena, Siena, Italy.
¶ School of Dental Medicine, University of Bern, Bern, Switzerland.

1064 Volume 70 • Number 9


Treatment of gingival recession for esthetics and/or
root hypersensitivity is a very common approach in
clinical practice. One of the most widely used
mucogingival procedures to achieve root coverage is
the coronally advanced flap (CAF). Several authors
have utilized this approach, applying the following
techniques: shifting the residual gingiva (CAF) in a
coronal direction 1-5 or using a previously placed
epithelialized free gingival graft (2-stage procedure:
EFGG + CAF)6-12 to cover a connective tissue graft
(CTG)3,13-17 or a bioabsorbable or non-resorbable
membrane, according to the principles of guided
tissue regeneration (GTR).5,12,18-31
The reported average percent root coverage in
Miller Class I and II recession defects32 ranges from
60%4 to 99%2 for CAF; from 36%11 to 74%8 for EFGG
+ CAF; from 70%16 to 98%3 for CAF associated with
CTG; and from 52%29 to 90%26 for CAF in combina-
tion with GTR techniques.
One of the fundamental steps of root coverage
procedures is the preliminary mechanical root sur-
face modification (root planing), suggested by most
authors for different purposes, such as smoothing
irregularities and grooves of the root surface, 33
removing root caries lesions,34-35 reducing the con-
vexity of the root and the mesio-distal distance
between periodontal spaces, 36-37 and minimizing
cementum toxicity.38
In combination with scaling and root planing, sev-
eral authors suggest the use of different chemical
agents, such as citric acid,1,9,11,16,37-44 tetracycline
HCl,2,15,30,45 fibrin glue associated with tetracycline
HCl,4-5,20 and sodium hypochlorite.46 These agents
have been used to remove the smear layer produced
by root instrumentation; expose the collagen fibrils
of the dentin matrix, facilitating the formation of
new connective tissue attachment;47,48 and remove
cytopathic substances that inhibit human gingival
fibroblast growth from infected cementum.49
Results from controlled clinical trials in
humans,11,16,38-41,44,46 however, did not show signi-
ficant differences in terms of root coverage between
sites treated with root planing alone or with a com-
bined treatment. Chemical root surface conditioning,
therefore, cannot be considered beneficial for root
coverage.33
With regards to the mechanical removal of the
exposed cementum, many published studies stress
the importance of root planing before or during
surgery, but they do not prove the true influence of
this practice on the clinical results of root coverage
procedures.
J Periodontol • September 1999
Case Series
Only one controlled clinical study 46 compared 3
different treatment modalities of exposed root sur-
faces in combination with a laterally positioned flap
(LPF): root planing, scaling and polishing, and root
conditioning with sodium hypochlorite. Three months
after treatment, the authors did not find any statistical
difference in the clinical outcomes among the 3
groups.
It should be emphasized that most of the reces-
sions, categorized as Miller Class I or II, are caused by
toothbrushing trauma in patients with high levels of
oral hygiene. These patients show recessions associ-
ated with low levels of plaque, presence of clinically
healthy gingiva, and clean, smooth exposed root sur-
faces. In these cases, the importance of mechanical
instrumentation (root planing) of the exposed root
surface seems doubtful.33
The aim of this short-term prospective, con-
trolled, randomized clinical trial is to compare in
terms of root coverage 2 different modalities of root
surface treatment – root planing versus root surface
polishing – used in combination with a coronally
advanced flap procedure for the treatment of gingi-
val recessions.
MATERIALS AND METHODS
Study Population
Ten patients, 2 males and 8 females, aged between
25 and 57 years (mean age 33.6 ± 9.9), 2 of whom
were smokers, presented with bilateral maxillary gin-
gival recessions and were treated with the CAF pro-
cedure between Januar y and June 1996. Nine
patients presented with similar bilateral recessions
situated on homologous teeth, while 1 patient (case
4) presented with recessions associated with 1
canine and 1 lateral incisor. The patients were
selected among individuals referred to the
Department of Periodontology of the University of
Siena Dental School. The patients agreed to partici-
pate in the study and signed an appropriate consent
form in agreement with the Helsinki Declaration on
human experimentation.
The following entry criteria for participation were
used: 1) non-compromised systemic health and no
contraindications for periodontal surgery; 2) presence
of maxillary bilateral buccal recessions (≥2 mm) clas-
sified as Miller Class I or II;32 3) difference in exten-
sion of the gingival recession between right and left
site ≤1 mm and difference in clinical attachment level
≤2 mm; 4) presence of identifiable cemento-enamel
junction (CEJ); 5) tooth vitality and absence of
grooves, irregularities, caries, or restorations in the
Pini-Prato, Baldi, Pagliaro, et al. 1065
 Case Series
area to be treated; 6) no periodontal surgical treat-
ment during the previous 24 months on the involved
sites; 7) full-mouth plaque score (FMPS)50 <20% and
full-mouth bleeding score (FMBS) 51 <20%; and
8) absence of plaque and bleeding on probing at the
selected sites.
All patients received oral hygiene instructions
to eliminate habits related to the etiology of the
recession.
A split-mouth design was utilized. The sites were
assigned to 2 treatment groups (test and control) at
random by tossing a coin immediately prior to
surgery. In the test group, the exposed root surfaces
were treated by means of polishing, while in the con-
trol group, they were treated by means of root plan-
ing. Both groups underwent the CAF procedure. In
8 cases, both test and control sites were treated in the
same surgical session.
The test group consisted of 4 first premolars,
4 canines, and 2 central incisors. Recessions ranged
from 2 to 5 mm. The control group consisted of 4 first
premolars, 3 canines, and 2 central and 1 lateral
incisor. Recessions ranged from 2 to 5.5 mm. All sur-
gical procedures were performed by a single operator
with more than 10 years of clinical experience.
Root Surface Treatment
Test group (polishing). The exposed root surfaces
were polished at slow speed with a rubber cup and
prophylaxis paste for 60 seconds under local anes-
thesia (lidocaine with adrenaline and noradrenaline
1:50,000), before flap elevation. Polishing was also
performed in the intrasulcular area. Immediately after
polishing, the root surface was washed for 60 sec-
onds with water spray.
Control group (root planing). The exposed root
surfaces were gently planed with curets# under local
anesthesia, before flap elevation to reduce root con-
vexity. Root planing was also performed in the intra-
sulcular area. Immediately after instrumentation, the
root surface was washed for 60 seconds with water
spray.
Surgical Procedure
Both test and control sites underwent an identical
CAF procedure. An intrasulcular incision was made
with a surgical blade# on the buccal aspect of the
involved tooth. This incision was horizontally
extended mesio-distally to dissect the buccal aspect
of the adjacent papillae, avoiding the gingival margin
of the adjacent teeth. Two oblique releasing incisions
were carried out from the mesial and distal extremi-
ties of the horizontal incisions beyond the mucogingi-
val junction. A trapezoidal full-thickness flap was
1066 Root Planing Versus Polishing in Root Coverage Treatment
raised with a periosteal elevator # towards the
mucogingival junction. Then a partial-thickness dis-
section was carried out apically towards the marginal
bone crest, leaving the underlying periosteum in
place. A mesio-distal and apical dissection parallel
to the vestibular lining mucosa was performed to
release residual muscle tension and facilitate the pas-
sive coronal displacement of the flap. The papillae
adjacent to the involved tooth were de-epithelialized.
The flap was then coronally displaced.
Suturing of oblique releasing incisions was per-
formed with 5-0 silk sutures as described by Allen and
Miller,1 while the coronal mesial and distal extremities
of the flap were secured with 2 single sutures placed
in the interdental areas. Additional interrupted sutures
were applied, when necessary, to close the oblique
releasing incisions in the alveolar mucosa. In 4 cases
(2 in the test group and 2 in the control group), the
coronal margin of the flap was positioned at the CEJ,
while in 16 cases (8 in the test group and 8 in the
control group), it was fixed coronally to the CEJ. No
periodontal dressing was applied.
Postsurgical Care
Immediately following surgery, use of ice packs was
recommended for 3 hours. All patients were
instructed to discontinue toothbrushing, avoid trauma
around the surgical site, and reduce smoking. A
0.12% chlorhexidine digluconate rinse was prescribed
4 times (60 seconds) daily for the first 10 days, and
the use of nimesulide (100 mg twice daily) was rec-
ommended for pain.
The sutures were removed after 10 days. All
patients were instructed to clean the surgical sites
with a cotton pellet soaked in a 0.12% chlorhexidine
digluconate solution, 4 times daily for 10 days. Three
weeks after surgery, the patients were instructed to
resume mechanical tooth cleaning of the treated
areas using a soft toothbrush and a careful roll tech-
nique. All patients were recalled for prophylaxis after
1, 2, 3, and 4 weeks and, subsequently, once a
month, until the final examination (3 months).
Data Collection
All measures were recorded by the same investiga-
tor, with more than 10 years of clinical experience,
using a UNC 15 periodontal probe# and 3× magnifi-
cation lens. All measurements were rounded to the
nearest 0.5 millimeters.
The following data were collected at the mid-
buccal point of the involved tooth before surgery
(baseline): 1) recession depth (Rec): the distance
# Hu-Friedy, Chicago, IL.
Volume 70 • Number 9

between the CEJ and gingival margin (GM); 2) prob-
ing depth (PD): the distance between the GM and the
bottom of the pocket; 3) clinical attachment level
(CAL): the distance from the CEJ and the bottom of
the pocket; and 4) width of keratinized tissue (KT):
the distance between the GM and mucogingival junc-
tion (MGJ).
These standard periodontal measurements were
considered insufficient to ascertain the position and
movement of the involved soft tissues (keratinized
tissue and alveolar mucosa) after surgery and during
the follow-up period (3 months). Therefore, addi-
tional measurements were taken at the mid-buccal
point of the involved tooth using the incisal margin
(IM) as a reference point because of its stability and
its simple identification after surgery and during the
follow-up (Fig. 1): 1) anatomical crown length (IM-
CEJ): the distance between the incisal margin (IM)
and CEJ, representing the apico-coronal dimension
of the anatomic crown; 2) distance between IM and
GM (IM-GM): to evaluate the position of the gingival
margin when the CEJ was masked by the flap after
surgery and its displacement, if any, during the fol-
low-up period; and 3) distance between IM and
mucogingival junction (IM-MGJ): to evaluate the
position of the MGJ before and after surgery and to
detect its possible shift during the follow-up period in
the treated area.
Immediately after surgery, IM-GM and IM-MGJ
were recorded at the mid-buccal point of the surgical
site. The position of the GM in relation to CEJ (GM1)
was calculated subtracting IM-CEJ from IM-GM.
Figure 1.
Clinical measurements on the mid-buccal point of the recession-
involved tooth.
J Periodontol • September 1999
Case Series
At 1, 2, 3, and 4 weeks, and 2 and 3 months post-
surgery, the following data were collected at the same
mid-buccal point of the involved tooth: Rec, IM-GM,
IM-MGJ, KT. At 3 months, PD and CAL were
recorded. Dentin hypersensitivity was recorded as pre-
sent or absent at baseline and 3 months postsurgery.
Statistical Analysis
Quantitative data were summarized as means ±
standard deviation. The possible presence of ran-
domization imbalance was checked for GM1, IM-GM,
and IM-MGJ immediately postsurgery by means of
Student t tests for paired observations.
Differences in the reduction of recession between
treatment groups were analyzed with the Student
t test for paired observations. The power of the test
was calculated for recession reduction as an outcome
variable, with a mean difference of 0.5 mm between
groups clinically significant.
Differences in reduction of recession and loss of
KT between treatment groups were also analyzed,
considering Rec at baseline as a covariate for reces-
sion reduction and KT as a covariate for loss of KT.
Model diagnostics always included analysis of stan-
dardized residual and partial regression leverage plot.
The significance of the contribution of each factor to
the models was assessed using computer software.**
RESULTS
The average initial recession depth at baseline for all
20 sites was 3.0 ± 1.0 mm (range 2 to 5.5 mm).
Recession reduction in all the sites was 2.5 ± 0.6 mm
3 months after surgery. The average root coverage
was 86 ± 15%. Nine teeth (45%) showed complete
root coverage.
Six patients showed dentin hypersensitivity on 9
of the 20 teeth at baseline. Two patients showed
dentin hypersensitivity on 1 tooth each in the con-
trol group 3 months after surgery. All patients were
satisfied with the final esthetic appearance.
Figure 2 shows the mean values of the distance
between CEJ and both GM and MGJ at different time
points on pooled data from both test and control
sites. The figure shows that GM immediately after
suturing was positioned 1.0 ± 0.8 mm coronally to
the CEJ. During the first week, the position of GM
remained stable. From the second to the fourth
week, GM shifted apically, uncovering the CEJ. From
the first to the third month, GM remained stable.
Keratinized tissue width (KT) underwent a slight
reduction from baseline (2.9 ± 1.2 mm) to 3 months
postsurgery (2.5 ± 1.2 mm).
** JMP Software, Version 3.1, SAS Institute, Inc., Cary, NC.
Pini-Prato, Baldi, Pagliaro, et al. 1067
 Case Series
Figure 2.
Mucogingival junction (MGJ), keratinized tissue (KT), gingival margin (GM), and recession at baseline, immediately after surgery and during the follow-up
period for all the 20 surgical sites. X axis: time at baseline, immediately after surgery, and follow-up periods (W = week; M = month).Y axis: distance (mm)
of MGJ and GM with respect to CEJ. Recession area represents the exposed root surface; numbers indicate the mean recession depth (mm). KT area
represents width; numbers indicate the mean width (mm).
Test Group (Polishing)
Baseline, surgery, and 3-month data are presented
in Table 1.
The initial mean recession depth was 3.1 ± 1.1 mm
(range 2 to 5 mm). Three months after surgery, the
mean recession reduction was 2.6 ± 0.6 mm and
mean root coverage was 89 ± 14%. Five teeth (50%)
achieved complete root coverage. Mean probing
depth was 1.3 ± 0.5 mm at baseline, while 3 months
after surgery it was 0.7 ± 0.4 mm. The initial clinical
attachment level was 4.4 ± 1.3 mm on average, while
three months later it was 1.2 ± 0.8 mm. The initial
keratinized tissue width (KT) was 3.1 ± 1.3 mm on
average, while 3 months after surgery it was 2.4 ±
1.4 mm. The mean loss of KT was 0.7 ± 0.8 mm.
Five sites showed dentin hypersensitivity at baseline.
None showed dentin hypersensitivity at the 3-month
follow-up.
Control Group (Root Planing)
Baseline, surgery, and 3-month data are presented in
Table 2. The initial recession depth was 2.9 ± 1.0 mm
on average (range 2 to 5.5 mm). Three months after
surgery, average recession reduction was 2.3 ±
1068 Root Planing Versus Polishing in Root Coverage Treatment
0.7 mm and mean root coverage was 83 ± 16%. Four
teeth (40%) achieved complete root coverage. Mean
probing depth was 1.3 ± 0.5 mm at baseline, while
3 months after surgery it was 0.7 ± 0.4 mm. The
initial clinical attachment level was 4.2 ± 1.3 mm on
average, while 3 months later it was 1.3 ± 0.5 mm.
The initial keratinized tissue width (KT) was on
average 2.7 ± 1.2 mm, while three months after
surgery it was 2.5 ± 1.0 mm. The mean loss of KT
was 0.2 ± 1.1 mm.
Four sites showed dentin hypersensitivity at base-
line. One of these sites presented with hypersensitiv-
ity at the 3-month follow-up visit, while in another
patient, a site without hypersensitivity at baseline
developed after surgery.
Comparison Between Groups
No statistically significant differences were detected
between test and control groups for GM1 (P =
0.8534), IM-GM (P = 0.5450), or IM-MGJ (P =
0.6637) immediately after suturing.
Figure 3 shows the average recession reduction
after surgery and during the follow-up period in both
groups.
Volume 70 • Number 9

The healing patterns for the 2 procedures were
quite similar. No statistically significant differences in
recession reduction were detected between test and
control groups during the follow-up period, from the
first week after surgery (0.1 mm; P = 0.6849) to
3 months postsurgery (0.3 mm; P = 0.1405). The 95%
confidence limits for the mean recession reduction
difference at 3 months postsurgery were −0.1 mm
and +0.7 mm.
Power calculation, considering recession reduc-
tion as an outcome variable, showed that this study
had 67% power to detect a difference in change of
0.5 mm at a significance level of α = 0.05.
If the initial recession depth is used as a covari-
ate, there was no statistically significant difference
between the two groups (P = 0.2815).
In regards to the changes of the keratinized tissue
width (KT), both groups showed a reduction of KT
width at the 3-month follow-up. The difference
between test and control groups was not statistically
significant (P = 0.1066), even if the width of initial
KT was used as a covariate (P = 0.3409).
Figures 4, 5, and 6 show patient 8 before, during,
and after treatment.
DISCUSSION
Results from this study indicate that in the test group
(polishing), mean recession reduction was 2.6 ± 0.6
mm and mean root coverage was 89% 3 months
after CAF surgery. Similarly, in the control group
(root planing), recession reduction and mean root
coverage were 2.3 ± 0.7 mm and 83%, respectively.
No statistically significant differences were observed
between the test group (polishing) and the control
group (root planing) in terms of recession reduction
and percentage of root coverage at 3 months.
These results indicate that when surgical root
coverage of gingival recessions secondary to tooth-
brushing trauma was performed in patients with high
levels of oral hygiene, with no surface irregularities,
no grooves, and no superficial root caries, the
mechanical treatment of exposed root surfaces can
be achieved by polishing alone without the need for
root planing.
Results from the present study are in agreement
with the conclusions of Oles et al.46 In that study, 3
different treatments of the exposed root surfaces (root
planing, scaling and polishing, and root conditioning
with sodium hypochlorite) were tested in combination
with a laterally positioned flap (LPF). The authors did
not find differences in terms of root coverage.
Under these conditions, both of these studies fail
to support the need for root planing before or during
J Periodontol • September 1999
Case Series
mucogingival surgery suggested in most of the
published evidence.
It should be noted that the issue of scaling and root
planing of exposed roots is also controversial in the
treatment of periodontitis, where the root surface is
exposed to the oral environment and contaminated by
bacteria. Evidence from early studies52-54 suggests
that the removal of calculus and superficial layers of
cementum may eliminate adsorbed microbial toxins.
Successive experimental55,56 and clinical57 stud-
ies have demonstrated no differences in the out-
comes following the treatment of diseased root
sur faces with or without root planing. Several
studies58-63 demonstrated that endotoxins are super-
ficially bound to the exposed root surfaces. Mild
instrumental procedures are able to detoxify the
exposed roots.59-60 In addition, Moore et al.58 ana-
lyzed the surface distribution of lipopolysaccharides
on extracted periodontally involved teeth and
reported that 39% of lipopolysaccharides were
removed by washing teeth and 99% of lipopolysac-
charides were removed by mechanical brushing at
slow speed for 60 seconds.
Based on this evidence, Cobb64 stated that “. . .
investigations have begun to seriously challenge the
validity of extensive cementum removal and deliber-
ate smoothing of the root surface for the purpose of
adsorbed endotoxin removal.”
Analysis performed on the data from this study
demonstrates that if the initial recession depth was
used as a covariate, there was no statistically sig-
nificant difference in recession reduction between
the 2 groups (P = 0.2815). A relationship between
initial recession depth and final recession reduction
is evident at 3 months (P = 0.0193). In other words,
the sites that showed a greater recession at base-
line resulted in a greater recession reduction after
3 months.
Since clinical results from the test and control
group were similar, data from the two groups were
pooled together and further analyzed.
The overall average root coverage, considering all
the treated sites (test and control), was 86%. These
results confirm previous data1-5 showing the percent
root coverage ranging from 60%4 to 99%.2 Shallow
probing depths were consistently observed in all the
treated sites at the 3-month observation, indicating
that coronal displacement of the gingival margin
was associated with clinical attachment level gains.
A statistically significant reduction (0.4 mm, P =
0.0464) of the keratinized tissue width was observed
after 3 months when compared to baseline measure-
ments (Fig. 2). This event has been explored by
Pini-Prato, Baldi, Pagliaro, et al. 1069
 Case Series
Table 1.
Test Group (Polishing)

Baseline

Rec IM- IM- IM-

Patient Gender Age Smoke Tooth Cl HS CEJ Rec GM KT MGJ PD CAL

1 F 25 N 14 1 Y 8 2 10 4 14 1 3
2 M 57 N 21 1 N 11 5 16 2 18 2 7
3 F 42 N 23 1 N 10 2 12 2.5 14.5 1.5 3.5
4 F 27 N 13 1 Y 10 2 12 4 16 2 4
5 F 28 N 21 1 N 11.5 3 14.5 3.5 18 1 4
6 F 26 N 24 2 N 7 4 11 1 12 1 5

7 F 32 N 14 1 Y 8 4 12 5 17 2 6
8 M 30 Y 23 1 Y 10 4 14 2 16 1 5
9 F 30 Y 23 1 N 11 2.5 13.5 2.5 16 1 3.5
10 F 39 N 24 1 Y 7.5 2.5 10 4.5 14.5 1 3.5

Mean 33.6 9.4 3.1 12.5 3.1 15.6 1.3 4.4

Key: Rec Cl: Miller’s recession class; HS: dental hypersensitivity; IM-CEJ: incisal margin—cemento-enamel junction; Rec: recession; IM-GM: incisal margin—
gingival margin; KT: keratinized tissue width; IM-MGJ: incisal margin—mucogingival junction; PD: probing depth; CAL: clinical attachment level; Rec Red:
recession reduction; % RC: percentage of root coverage.

Table 2.
Control Group (Root Planing)

Baseline

Rec IM- IM- IM-

Patient Gender Age Smoke Tooth Cl HS CEJ Rec GM KT MGJ PD CAL

1 F 25 N 24 1 N 9 3 12 2 14 2 5

2 M 57 N 11 1 N 10.5 5.5 16 2 18 2 7.5

3 F 42 N 13 1 N 10 2 12 2 14 1 3

4 F 27 N 22 1 Y 10 2 12 5 17 2 4
5 F 28 N 11 1 Y 11 2.5 13.5 3 16.5 1 3.5
6 F 26 N 14 1 N 7 3.5 10.5 1.5 12 1 4.5
7 F 32 N 24 1 Y 8 3 11 4 15 1 4
8 M 30 Y 13 1 Y 11 3 14 2 16 1 4

9 F 30 Y 13 1 N 11 2 13 2 15 1 3
10 F 39 N 14 1 N 8 2.5 10.5 4 14.5 1 3.5
Mean 33.6 9.5 2.9 12.4 2.7 15.2 1.3 4.2
Key: Rec Cl: Miller’s recession class; HS: dental hypersensitivity; IM-CEJ: incisal margin—cemento-enamel junction; Rec: recession; IM-GM: incisal margin—
gingival margin; KT: keratinized tissue width; IM-MGJ: incisal margin—mucogingival junction; PD: probing depth; CAL: clinical attachment level; Rec Red:
recession reduction; % RC: percentage of root coverage.

1070 Root Planing Versus Polishing in Root Coverage Treatment Volume 70 • Number 9
 Case Series
Table 1. (continued)
Test Group (Polishing)

At Surgery 3-Month Evaluation

IM- IM- IM- IM- Rec

GM MGJ HS Rec GM KT MGJ PD CAL Red % RC

5.5 9.5 N 0 8 3 11 0.5 0.5 2 100

10.5 12.5 N 2 13 1 13 0.5 2.5 3 60

9 11.5 N 0 10 2 12 0.5 0.5 2 100

9 13 N 0 10 3 13 0.5 0.5 2 100
11.5 15 N 0.5 12 3 15 1 1.5 2.5 83.3
7 8 N 1 8.5 1 9.5 1 2 3 75
7 12 N 0.5 8.5 5 13.5 1.5 2 3.5 87.5

9 11 N 0.5 10.5 2.5 13 0.5 1 3.5 87.5

9 11.5 N 0 11 1 12 0.5 0.5 2.5 100
6 10.5 N 0 7.5 3.5 11 1 1 2.5 100
8.3 11.4 0.4 9.9 2.4 12.3 0.7 1.2 2.6 89.3

Table 2. (continued)
Control Group (Root Planing)

At Surgery 3-Month Evaluation

IM- IM- IM- IM- Rec

GM MGJ HS Rec GM KT MGJ PD CAL Red % RC

7.5 9.5 N 1 10 2.5 12.5 0.5 1.5 2 66.7

10.5 12.5 Y 1.5 12 1 13 0.5 2 4 72.7

7.5 9.5 N 0 10 3 13 0.5 0.5 2 100

9.5 14.5 N 0.5 10.5 2.5 13 1 1.5 1.5 75

10.5 13.5 N 0.5 11.5 3 14.5 0.5 1 2 80

7 8.5 N 1.5 8.5 1.5 10 0.5 2 2 57.1
7 11 Y 0.5 8.5 4.5 13 1 1.5 2.5 83.3
9 11 N 0 11 3 14 1.5 1.5 3 87.5
10 12 N 0 11 1.5 12.5 0.5 0.5 2 100
7 11 N 0 8 3 11 1 1 2.5 100
8.5 11.3 0.5 10.1 2.5 12.6 0.7 1.3 2.3 83.5

J Periodontol • September 1999 Pini-Prato, Baldi, Pagliaro, et al. 1071

 Case Series

Figure 3.
Mean recession reduction (mm) after surgery and during the follow-up period (1, 2, and 3 weeks, and 1, 2, and 3 months) in test and control groups.

analyzing the healing dynamics of the flap in the of explorative statistical analysis. The dependent
considered time frame. At week 1, the GM remained variable was AD. A linear regression model was
at the same postsurgical position; this may be due applied: AD = β 0 + β 1 Patient + β 2 GM1. Patients
to the edema the flap developed during the first and GM1 were the independent variables. The
post-operative week. From week 1 to month 1, GM model itself is highly significant (P = 0.0036, R2 =
moved apically, uncovering the CEJ; KT width was 0.89). The coefficients of the independent vari-
reduced; and MGJ tended to move apically. From ables are significantly different from 0 (P = 0.0236
the first to the third month, GM, KT, and MGJ
remained stable.
The gingival margin shifted, on average, 1.5 ± 0.6
mm apically from its postsurgical position during the
3 months. The shift could not be fully explained with
a correspondent reduction of KT because it
decreased only 0.4 ± 0.9 mm (from 2.9 ± 1.2 mm to
2.5 ± 1.2 mm). The entity of the residual shift of GM
could be explained at least in part by the shift of 1.1
± 1.2 mm of the MGJ during the same time interval.
Although this study was designed to compare the
ef fect of root planing versus polishing of the
exposed root surfaces, since the clinical results of
the test and control groups were similar, further sta-
tistical analysis considering the two groups as one
was considered.
The postsurgical apical shift (AD) of the gingi- Figure 4.
Patient 8. Bilateral recessions (arrows) on maxillary canines.
val margin (GM1) has been investigated by means

1072 Root Planing Versus Polishing in Root Coverage Treatment Volume 70 • Number 9

Figure 5.
Left side (test).The exposed root was treated by a rubber cup and prophy paste (upper left); the design of the flap (upper
right); the flap was sutured coronally to the CEJ (lower left); healing after 3 months (lower right).
and P = 0.0016, respectively). The significance of
the variable “Patient” suggests that different AD
can be expected in different patients, even with the
same GM1. Since the AD is proportional to GM1,
with an estimated coef ficient β 2 = −0.76, an
increase in AD is expected whenever GM1
decreases: the expected increment in AD is 76% of
the decrement in GM1, when this increase is in the
observed range (0 to −2.5 mm), that is, from CEJ
level to 2.5 mm coronal to the CEJ. In our study,
100% root coverage was observed in 4 sites where
the GM was sutured extremely coronally to the
CEJ (≥2 mm). However, the 95% confidence inter-
val of the estimate of the β2 coefficient is −0.37 to
−1.15 and includes the −1 value, which is the
threshold for the clinical advantage.
Therefore, this model is inadequate to establish
whether a marked coronal displacement of the flap is
advantageous in reducing the recession. This possi-
bility could be investigated by a prospective study
aimed at testing the hypothesis that GM1 affects the
reduction of a recession or the residual amount of
recession rather than AD. Other known potential pre-
dictors should be considered.
J Periodontol • September 1999
Case Series
In regards to dentin hypersensitivity, in the test
group, sites treated by polishing techniques did not
show dentin hypersensitivity 3 months after surgery.
On the contrary, in the control group, 2 sites treated
by root planing presented hypersensitivity at the
3-month follow-up. One of the 2 sites developed
hypersensitivity ex novo. Root surfaces of both sites
were not completely covered. These results suggest
that root planing could be associated with hypersensi-
tivity if root coverage is incomplete. A possible expla-
nation is an extensive opening of dentin tubules as
suggested by Oles et al.46
A shor t-term follow-up was purposely set at
3 months in order to: 1) verify the true effectiveness
of CAF in terms of “primary root coverage; 2) mini-
mize the risk of confounding the interpretation of the
results with “secondary root coverage”11,65 due to the
creeping attachment;66 and 3) avoid influences due
to possible damages of the gingival margin caused by
traumatic toothbrushing.
In conclusion, the present study indicates that:
1) CAF is a useful and predictable surgical technique
for the treatment of shallow gingival recessions;
2) two different treatments of the exposed root sur-
Pini-Prato, Baldi, Pagliaro, et al. 1073
 Case Series
Figure 6.
Right side (control). Root planing (upper left); the design of the flap (upper right); the flap was sutured coronally to the CEJ
(lower left); healing after 3 months (lower right).
faces (root planing and polishing) resulted in similar
clinical outcomes in terms of root coverage, probing
depth, and clinical attachment level when gingival
recessions were treated with CAF in patients with a
high level of oral hygiene; mechanical instrumenta-
tion (root planing) of the exposed root surface does
not seem necessary in these cases; and 3) healing
of CAF occurs with a minimal recession and a slight
reduction of keratinized tissue width associated with
an apical shift of GM and MGJ after 3 months.
ACKNOWLEDGMENTS
The authors would like to acknowledge Dr. Lisa
Wiechmann for her help in the preparation of this
manuscript.
REFERENCES
1. Allen EP, Miller PD. Coronal positioning of existing
gingiva: Shor t-term results in the treatment of
shallow marginal tissue recession. J Periodontol
1989;60:316-319.
2. Harris RJ, Harris AW. The coronally positioned pedicle
graft with inlaid margins: A predictable method to
obtaining root coverage of shallow defects. Int
1074 Root Planing Versus Polishing in Root Coverage Treatment
J Periodontics Restorative Dent 1994;14:229-241.
3. Wennström JL, Zucchelli G. Increased gingival
dimensions. A significant factor for successful outcome
of root coverage procedures? A 2-year prospective
clinical study. J Clin Periodontol 1996;23:770-777.
4. Trombelli L, Scabbia A, Wikesjö UME, Calura G. Fibrin
glue application in conjunction with tetracycline root
conditioning and coronally positioned flap procedure in
the treatment of human gingival recession defects.
J Clin Periodontol 1996;23:861-867.
5. Trombelli L, Tatakis DN, Scabbia A, Zimmerman GJ.
Comparison of mucogingival changes following
treatment with coronally positioned flap and guided
tissue regeneration procedures. Int J Periodontics
Restorative Dent 1997;17:449-455.
6. Bernimoulin JP, Lüsher B, Mühlemann HR. Coronally
repositioned periodontal flap. Clinical evaluation after
one year. J Clin Periodontol 1975;2:1-13.
7. Matter J. Free gingival graft and coronally repositioned
flap. A 2-year follow-up report. J Clin Periodontol
1979;6:437-442.
8. Caffesse RG, Guinard EA. Treatment of localized
gingival recessions. Part IV. Results after three years.
J Periodontol 1980;51:167-170.
9. Liu WJL, Solt CW. A surgical procedure for the treat-
ment of localized gingival recession in conjunction with
root surface citric acid conditioning. J Periodontol
1980;51:505-509.
Volume 70 • Number 9

10. Tenenbaum H, Klewansky P, Roth JJ. Clinical
evaluation of gingival recession treated by coronally
repositioned flap technique. J Periodontol 1980;51:
686-690.
11. Laney JB, Saunders VG, Garnick JJ. A comparison of
two techniques for attaining root coverage. J Perio-
dontol 1992;63:19-23.
12. Pini-Prato GP, Clauser C, Cortellini P, Tinti C, Vincenzi
G, Pagliaro U. Guided tissue regeneration versus
mucogingival surgery in the treatment of human
buccal recessions. A 4-year follow-up study. J Perio-
dontol 1996;67:1216-1223.
13. Daniel A, Cheru R. Treatment of localized gingival
recession with subpedicle connective tissue graft and
free gingival autograft–A comparative clinical eva-
luation. J Indian Dent Assoc 1990;61:294-297.
14. Levine RA. Covering denuded maxillary root surfaces
with the subepithelial connective tissue graft. Com-
pendium Continuing Educ Dent 1991;12:568-577.
15. Harris RJ. The connective tissue and partial thickness
double pedicle graft: A predictable method of obtaining
root coverage. J Periodontol 1992;63:477-486.
16. Bouchard P, Etienne D, Ouhayoun J-P, Nilvéus R.
Subepithelial connective tissue grafts in the treatment
of gingival recessions. A comparative study of
2 procedures. J Periodontol 1994;65:929-936.
17. Paolantonio M, di Murro C, Cattabriga A, Cattabriga M.
Subpedicle connective tissue graft versus free gingival
graft in the coverage of exposed root surfaces. A 5-
year clinical study. J Clin Periodontol 1997;24:51-56.
18. Tinti C, Vincenzi GP, Cortellini P, Pini-Prato G, Clauser
C. Guided tissue regeneration in the treatment of
human facial recession. A 12-case report. J Periodontol
1992;63:554-560.
19. Tinti C, Vincenzi GP, Cocchetto R. Guided tissue
regeneration in mucogingival surgery. J Periodontol
1993;64:1184-1191.
20. Trombelli L, Schincaglia G, Checchi L, Calura G.
Combined guided tissue regeneration, root con-
ditioning, and fibrin-fibronectin system application in
the treatment of gingival recession. A 15-case report.
J Periodontol 1994;65:796-803.
21. Tinti C, Vincenzi GP. Expanded polytetrafluo-
roethylene titanium-reinforced membranes for
regeneration of mucogingival recession defects. A 12-
case report. J Periodontol 1994;65:1088-1094.
22. Pini-Prato G, Clauser C, Magnani C, Cortellini P.
Resorbable membranes in the treatment of human
buccal recession: A nine-case report. Int J Periodontics
Restorative Dent 1995;15:258-267.
23. Trombelli L, Schincaglia G, Scapoli C, Calura G.
Healing response of human buccal gingival recessions
treated with expanded polytetrafluoroethylene mem-
branes. A retrospective report. J Periodontol 1995;
66:14-22.
24. Roccuzzo M, Lungo M, Corrente G, Gandolfo S.
Comparative study of a bioresorbable and a non-
resorbable membrane in the treatment of human
buccal gingival recessions. J Periodontol 1996;67:7-14.
25. Roccuzzo M, Buser D. Treatment of buccal gingival
recessions with e-PTFE membranes and miniscrews:
Surgical procedure and results of 12 cases. Int J
Periodontics Restorative Dent 1996;16:357-365.
J Periodontol • September 1999
Case Series
26. De Sanctis M, Zucchelli G. Guided tissue regeneration
with a resorbable barrier membrane (Vicryl) for the
management of buccal recession: A case report. Int
J Periodontics Restorative Dent 1996;16:435-441.
27. Ricci G, Silvestri M, Tinti C, Rasperini G. A clinical/
statistical comparison between the subpedicle con-
nective tissue graft method and the guided tissue
regeneration technique in root coverage. Int J
Periodontics Restorative Dent 1996;16:539-545.
28. Rachlin G, Koubi G, Dejou J, Franquin JC. The use of
a resorbable membrane in mucogingival surgery. Case
series. J Periodontol 1996;67:621-626.
29. Shieh A-T, Wang H-L, O’Neal R, Glickman GN,
MacNeil RL. Development and clinical evaluation of a
root coverage procedure using a collagen barrier
membrane. J Periodontol 1997;68:770-778.
30. Harris RJ. A comparative study of root coverage
obtained with guided tissue regeneration utilizing a
bioabsorbable membrane versus the connective tissue
with partial-thickness double pedicle graft. J Peri-
odontol 1997;68:779-790.
31. Waterman CA. Guided tissue regeneration using a
bioabsorbable membrane in the treatment of human
buccal recession. A re-entry study. J Periodontol 1997;
68:982-989.
32. Miller PD. A classification of marginal tissue recession.
Int J Periodontics Restorative Dent 1985;5(2):9-13.
33. Wennström JL. Mucogingival therapy. Ann Periodontol
1996;1:671-701.
34. Fourel J. Gingival reattachment on carious tooth sur-
faces. A 4-year follow-up. J Clin Periodontol 1982;9:
285-289.
35. Miller PD. Root coverage using the free soft tissue
autograft following citric acid application. II. Treatment
of carious root. Int J Periodontics Restorative Dent
1983;3(5):39-51.
36. Holbrook T, Ochsenbein C. Complete coverage of the
denuded root surface with a one-stage gingival graft.
Int J Periodontics Restorative Dent 1983;3(3):9-27.
37. Miller PD. Root coverage using a free soft tissue
autograft following citric acid application. III. A
successful and predictable procedure in areas of deep-
wide recession. Int J Periodontics Restorative Dent
1985;5(2):15-37.
38. Bertrand PM, Dunlap RM. Coverage of deep, wide
gingival clefts with free gingival autografts: Root
planing with and without citric acid demineralization.
Int J Periodontics Restorative Dent 1988;8(1):65-77.
39. Oles RD, Ibbott CG, Laverty WH. Effects of citric acid
treatment on pedicle flap coverage of localized
recession. J Periodontol 1985;56:259-261.
40. Ibbott CG, Oles RD, Laverty WH. Effects of citric acid
treatment on autogenous free graft coverage of
localized recession. J Periodontol 1985;56:662-665.
41. Caffesse RG, Alspach SR, Morrison EC, Burgett FG.
Lateral sliding flaps with and without citric acid. Int J
Periodontics Restorative Dent 1987;7(6):43-57.
42. Borghetti A, Gardella J-P. Thick gingival autograft for
the coverage of gingival recession: A clinical eval-
uation. Int J Periodontics Restorative Dent 1990;10:
217-229.
43. Tolmie PN, Rubins RP, Buck GS, Vagianos V, Lanz JC.
The predictability of root coverage by way of free
Pini-Prato, Baldi, Pagliaro, et al. 1075
 Case Series
gingival autografts and citric acid application: An
evaluation by multiple clinicians. Int J Periodontics
Restorative Dent 1991;11:261-271.
44. Jahnke PV, Sandifer JB, Gher ME, Gray JL, Richardson
AC. Thick free gingival and connective tissue autografts
for root coverage. J Periodontol 1993;64:315-322.
45. Harris RJ. The connective tissue with partial thickness
double pedicle graft: The results of 100 consecutively-
treated defects. J Periodontol 1994;65:448-461.
46. Oles RD, Ibbott CG, Laver ty WH. Effect of root
curettage and sodium hypochlorite treatment on
pedicle flap coverage of localized recession. J Can
Dent Assoc 1988;54:515-517.
47. Selvig KA, Ririe CM, Nilveus R, Egelberg J. Fine
structure of new connective tissue attachment following
acid treatment of experimental furcation pockets in
dogs. J Periodont Res 1981;16:123-129.
48. Polson AM, Proye MP. Effects of root sur face
alterations on periodontal healing. II. Citric acid
treatment of the denuded root. J Clin Periodontol 1982;
9:441-454.
49. Olson RH, Adams DF, Layman DL. Inhibitory effect of
periodontally diseased root extracts on the growth of
human gingival fibroblasts. J Periodontol 1985;56:
592-596.
50. O’Leary TJ, Drake RB, Naylor JE. The plaque control
record. J Periodontol 1972;43:38-42.
51. Ainamo J, Bay I. Problems and proposals for record-
ing gingivitis and plaque. Int Dent J 1975;25:229-235.
52. Aleo JJ, De Renzis FA, Farber PA. In vitro attachment
of human gingival fibroblasts to root surfaces. J Peri-
odontol 1975;46:639-645.
53. Adelson LJ, Hanks CT, Ramfjord SJ, Caffesse RG.
Cytotoxicity of periodontally diseased root surfaces.
J Periodontol 1980;51:700-704.
54. Karring T, Nyman S, Lindhe J. Healing following
implantation of periodontitis affected roots into bone
tissue. J Clin Periodontol 1980;7:96-105.
55. Blomlöf L, Linskog S, Appelgren R, Jonsson B,
Weintraub A, Hammarström L. New attachment in
monkeys with experimental periodontitis with and
without removal of the cementum. J Clin Periodontol
1987;14:136-143.
56. Nyman S, Sarhed G, Ericsson I, Gottlow J, Karring T.
Role of “diseased” root cementum in healing following
treatment of periodontal disease. An experimental
study in the dog. J Periodont Res 1986;21:496-503.
1076 Root Planing Versus Polishing in Root Coverage Treatment
57. Nyman S, Westfelt E, Sarhed G, Karring T. Role of
“diseased” root cementum in healing following
treatment of periodontal disease. A clinical study.
J Clin Periodontol 1988;15:464-468.
58. Moore J, Wilson M, Kieser JB. The distribution of
bacterial lipopolysaccharide (endotoxin) in relation to
periodontally involved root surfaces. J Clin Periodontol
1986;13:748-751.
59. Cheetham WA, Wilson M, Kieser JB. Root surface
debridement—an in vitro assessment. J Clin Peri-
odontol 1988;15:288-292.
60. Smart GJ, Wilson M, Davies EH, Kieser JB. The
assessment of ultrasonic root surface debridement by
determination of residual endotoxin levels. J Clin Peri-
odontol 1990;17:174-178.
61. Chiew SY, Wilson M, Davies EH, Kieser JB.
Assessment of ultrasonic debridement of calculus-
associated periodontally-involved root surfaces by the
limulus amoebocyte lysate assay. An in vitro study.
J Clin Periodontol 1991;18:240-244.
62. Nakib NM, Bissada NF, Simmelink JW, Goldstine SN.
Endotoxin penetration into root cementum of
periodontally healthy and diseased human teeth. J Peri-
odontol 1982;53:368-378.
63. Ito K, Hindman RE, O’Lear y TJ, Kafrawy AH.
Determination of the presence of root-bound endotoxin
using the Local Shwartzman Phenomenon (LSP).
J Periodontol 1985;56:8-17.
64. Cobb CM. Non-surgical pocket therapy: Mechanical.
Ann Periodontol 1996:1:443-490.
65. Matter J. Creeping attachment of free gingival grafts:
A five-year follow-up study. J Periodontol 1980;51:
681-685.
66. Goldman H, Schluger S, Fox L, Cohen DW. Periodontal
Therapy, 3rd ed. St. Louis: The CV Mosby Company;
1964:560.
Send reprint requests to: Dr. Giovanpaolo Pini-Prato, Viale
Matteotti, 11, 50121 Florence, Italy. Fax: 39 55 572881;
e-mail: gpinipr@tin.it
Accepted for publication January 23, 1999.
Volume 70 • Number 9