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 601

The Connective Tissue Graft Wall Technique and

Enamel Matrix Derivative to Improve Root Coverage and
Clinical Attachment Levels in Miller Class IV Gingival Recession

Giovanni Zucchelli, DDS, PhD1

Claudio Mazzotti, DDS, MSc2
Federico Tirone, DDS2/Monica Mele, DDS, MSc2
Pietro Bellone, DDS2/Ilham Mounssif, DDS2

The case reports in this article describe a surgical approach for improving root Gingival recession is defined as the
coverage and clinical attachment levels in Miller Class IV gingival recessions. Two displacement of the marginal gin­
gingival recessions affecting maxillary and mandibular lateral incisors associated gival tissue apical to the cemento­
with severe interdental hard and soft tissue loss were treated. The surgical technique
enamel junction1 (CEJ) with exposure
consisted of a connective tissue graft (CTG) that was placed below a coronally
advanced envelope flap and acted as a buccal soft tissue wall of the bony defect of the root surface to the oral envi­
treated with enamel matrix derivative (EMD). No palatal/lingual flap was elevated. ronment. Although in the literature
In the first clinical case, 6 months after surgery a ceramic veneer was placed to different surgical procedures have
correct tooth extrusion and improve the overall esthetic appearance. One year been proposed for the treatment
after the surgery in both cases, clinically significant root coverage, increase in of gingival recession, systematic
buccal keratinized tissue height and thickness, improvement in the position of
reviews define the bilaminar tech­
the interdental papilla, and clinical attachment level gain were achieved. The
radiographs demonstrate bone fill of the intrabony components of the defects. nique as the gold standard for ob­
This report encourages a novel application of CTG plus EMD to improve both taining complete root coverage.2–4
root coverage and regenerative parameters in Miller Class IV gingival recessions. There are many factors that appear
(Int J Periodontics Restorative Dent 2014;34:601–609. doi: 10.11607/prd.1978) to influence the extent of root cov­
erage, such as patient systemic and
local factors, but the most important
factor seems to be interdental peri­
odontal support.5,6
Gingival recession has been
classified into four categories ac­
cording to the prognosis of root cov­
erage.5 In Miller Class I and II, there is
no loss of interproximal periodontal
attachment, and complete root cov­
erage can be predictably achieved.
Professor, Department of Biomedical and Neuroscience, Bologna University, Bologna, Italy.
1
The predictability of treatments has
Research Assistant, Department of Biomedical and Neuroscience, Bologna University,
2

Bologna, Italy.
been reviewed extensively in sys­
tematic reviews.2–4 In Miller Class III,
Correspondence to: Prof Giovanni Zucchelli, Department of Biomedical and Neuroscience, the interdental periodontal support
Bologna University, Via S. Vitale 59, 40125 Bologna, Italy; fax: +39 051 225208;
loss is mild or moderate, and partial
email: giovanni.zucchelli@unibo.it.
root coverage can be accomplished.
©2014 by Quintessence Publishing Co Inc. A recent randomized controlled trial

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602

The following case reports de­

scribe the treatment of Miller Class
IV recessions associated with severe
interdental hard and soft tissue loss
with a combined approach, placing
a CTG below the CAF to act as the
buccal “soft tissue wall” of the in­
trabony defect treated with enamel
matrix derivative (EMD) to improve
a b
root coverage and clinical attach­
ment levels.
Fig 1    Baseline situation in case 1. (a) The lateral incisor shows Miller Class IV
gingival recession with loss of the interdental papilla, poor oral hygiene, and gingival
inflammation. (b) The radiograph shows horizontal bone loss between the lateral
incisor and canine with a small intrabony component affecting the lateral incisor.
Case 1

has demonstrated the possibility of
obtaining complete root coverage
(57% at 6 months) in recession as­
sociated with interdental clinical at­
tachment level (CAL) loss equal or
lower to vestibular CAL loss.7
In Miller Class IV, the interproxi­
mal periodontal attachment loss is
so severe that root coverage can­
not be anticipated. More recently,
factors other than the level of inter­
proximal attachment and bone have
been shown to limit the amount of
root coverage, such as the reduction
of papilla height, tooth rotation, and
tooth extrusion with or without oc­
clusal abrasion.8 A new method to
predetermine the level of root cover­
age, based on the calculation of the
ideal height of the anatomical inter­
dental papilla, was demonstrated to
be reliable in predicting the position
of the soft tissue margin in a study9
that showed the importance of the
interproximal soft tissue height in
achieving root coverage.
The Miller Class IV recession
associated with severe interdental
hard and soft tissue loss is always a
challenge for the periodontist be­
cause of poor prognosis with cur­
rent techniques. In the literature,
there are limited case reports dem­
onstrating the correction of Miller
Class IV recession and papilla re­
construction. Miller and Binkley in
198610 first described the use of a
coronally positioned free gingival
graft to achieve ridge augmenta­
tion and root coverage of Miller
Class IV recessions. Azzi et al11 pro­
posed a subepithelial connective
tissue graft (CTG) positioned below
an envelope flap performed at the
level of the mucogingival junction
and moved coronally. A modifica­
tion12 of this technique includes
the use of autogenous bone graft
harvested from the tuberosity area
and a palatal free connective tissue
graft inserted in an envelope flap.
De Castro Pinto et al13 described
the use of a coronally advanced flap
(CAF) with a subepithelial connec­
tive tissue pedicle flap to restore
the missing papilla and treat Class
IV recession defects. Recently, the
use of a CAF as a soft tissue wall
has been reported for periodontal
regeneration of intrabony defects.14
A 42-year-old man was referred to
the Department of Biomedical and
Neuroscience of Bologna Univer­
sity, Bologna, Italy, for evaluation of
a tissue defect involving the maxil­
lary right canine and lateral incisor
(Fig 1a). His chief complaint was the
unesthetic appearance during the
smile. The patient’s medical history
revealed no systemic contraindica­
tion for dental treatment. Clinical
examination revealed buccal gingi­
val recessions affecting the maxil­
lary right canine and lateral incisor of
2 and 5 mm, respectively, with buc­
cal probing depths (PD) of 2 mm
and, more importantly, loss of inter­
dental attachment with the reces­
sion of the papilla. The keratinized
tissue height at the buccal aspect of
the canine and lateral incisor was 1
and 1.5 mm, respectively. The lateral
incisor was buccally malpositioned
and extruded approximately 2 mm.
The distance from the contact point
to the tip of the interproximal soft
tissue was 4 mm. The distobuccal as­
pect of the lateral incisor revealed a
CAL of 7 mm with a 2-mm recession
defect (RD) and 5 mm of PD, while the

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CAL on the mesiobuccal aspect of
the right canine was 4 mm, with a
3-mm PD and 1-mm RD. A provi­
sional splint was already present
from central incisor to canine, having
been placed 1 year prior to decrease
mobility15 and discomfort with func­
tion. Radiographic examination
revealed early bone loss at the ca­
nine and advanced bone loss at the
lateral incisor with a limited (2-mm)
intrabony component (Fig 1b).
The defect was classified as
Class IV recession according to Mill­
er’s classification5 associated with a
Class II interdental papilla defect as
classified by Nordland and Tarnow.16
The objectives of the surgical
treatment were to improve root
coverage and the position of the
interdental papilla and achieve
clinical attachment gain at the inter­
dental site. The treatment plan con­
sisted of initial therapy, periodontal
plastic and regenerative surgery,
and restorative therapy to improve
the esthetic appearance of the ex­
truded and malpositioned tooth.
Case 2
A 37-year-old man was referred to
the Department of Biomedical and
Neuroscience of Bologna University
for evaluation of a recession defect
involving the mandibular left canine
and lateral incisor (Fig 2a). The pa­
tient’s medical history revealed no
systemic contraindication for den­
tal treatment. Clinical examination
showed buccal gingival recessions
affecting the canine and lateral inci­
sor of 2 and 5 mm, respectively, with
buccal PD of 2 mm at the canine
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603
a b
Fig 2    Baseline situation in case 2. (a) The lateral incisor shows Miller Class
IV gingival recession with loss of the interdental papilla. The canine shows
shallow buccal and interdental root exposure. (b) The radiograph shows
shallow horizontal bone loss between the lateral incisor and canine with a
deep (6-mm) intrabony component affecting the lateral incisor.
and 3 mm at the lateral as well as ning consisted of initial therapy fol­
recession of the papilla, with a dis­ lowed by periodontal plastic and
tance from the contact point to the regenerative surgery.
tip of the interproximal soft tissue of
4 mm. The keratinized tissue height
at the buccal aspect of the canine and Cause-related therapy
lateral incisor was less than 1 mm.
The distobuccal aspect of the later­ The patients received cause-related
al incisor revealed a CAL of 10 mm therapy to remove microbial de­
with a 1-mm RD and 9-mm PD, posits with ultrasonic instruments,
while the CAL on the mesiobuccal a rubber cup, and polishing paste
aspect of the canine was 4 mm, with and were instructed to use a coro­
a 3-mm PD and 1-mm RD. First- nally directed roll technique to mini­
degree tooth mobility15 of the lateral mize toothbrushing trauma to the
incisor was recorded. Radiographic soft tissue. The objective of sub­
examination revealed shallow hori­ gingival cause-related therapy with
zontal bone loss at the canine and narrow ultrasonic points was to
severe bone loss for the lateral in­ eliminate bleeding on probing in
cisor with a deep (6-mm) intrabony the soft tissue extending from the
component (Fig 2b). The defect tip of the interdental papilla to the
was classified as Class IV according bone crest with minimal trauma to
to Miller classification5 associated the interdental papilla.17 After this
with a Class II interdental papilla de­ initial phase, the patients showed
fect as classified by Nordland and no pathological probing depths in
Tarnow.16 The objectives of the sur­ areas other than the treatment de­
gical treatment were improvement fects and a low full-mouth plaque
in root coverage and the position of score (10% in case 1 and 12% in
the interdental papilla with clinical case 2) and bleeding score (9% in
attachment gain. Treatment plan­ case 1 and 12% in case 2).
Volume 34, Number 5, 2014
604

a b c

d e f

Fig 3    Surgical procedure in case 1. (a) Clinical view after cause-related therapy. (b) The
bony defect, after envelope buccal flap elevation, with severe horizontal and shallow
intrabony components. (c) Close-up of the supracrestal soft tissue after degranulation of
the bony defect. Note its tendency to collapse inside the intrabony component of the
defect despite the absence of palatal flap elevation. (d) The entirety of the supracrestal soft
tissue is pushed in the palatal direction until the tip of the interdental papilla is shifted into
the most coronal position possible. (e) Connective tissue graft acting as a buccal soft tissue
wall of the bony defect. (f) The envelope buccal flap is coronally advanced, and primary
interdental soft tissue closure is achieved in a more coronal position with respect to the
g baseline position of the interdental papilla. (g) Clinical healing after 3 months.

Surgical procedures
The CTG wall technique was ad­
opted for both clinical cases (Figs 3
and 4). The periodontal plastic and
regenerative surgery consisted of
the use of a CTG placed below a
CAF and used as a buccal soft tis­
sue wall for the bony defect treated
with EMD (see Figs 3e and 4c). Fol­
lowing local anesthesia, the CAF
designed for the treatment of mul­
tiple gingival recessions in soft tis­
sue plastic surgery18 was performed
from the central incisor to the sec­
ond premolar, while the simplified
papilla technique19 was adopted for
interdental soft tissue preservation
between the canine and lateral inci­
sor. At this level a triangular-shaped
surgical papilla was dissected split
thickness, up to the level of the
bone crest of the canine, in order
to expose the supracrestal con­
nective tissue above the intrabony
component of the defect. At the
other interdental areas included in
the envelope-flap design, submar­
ginal incisions directed toward the
midline and passing through the
canine18 were performed. The buc­
cal flap was raised with a split-full-
split approach in the corono-apical
direction: The surgical papilla was
dissected split-thickness up to the
level of the buccal bone crest, the
marginal keratinized tissue of the
flap was elevated full-thickness in
order to expose 2 to 3 mm of buc­
cal bone, and finally the most api­
cal portion of the flap was elevated
split-thickness in order to permit
coronal displacement of the buccal
flap. Intrasulcular incisions were per­
formed to dissect the supracrestal

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 605

a b c

d e f
Fig 4    Surgical procedure in case 2. (a) The bony defect, after envelope buccal flap elevation. The supracrestal soft tissue, after degranula-
tion of the bony defect, has the tendency to collapse inside the intrabony component of the defect although no lingual flap was elevated.
(b) The entirety of the supracrestal soft tissue is pushed in a lingual direction so that the tip of the interdental papilla is shifted in a more
coronal position, reaching the same level of the adjacent healthy papillae. (c) Connective tissue graft acting as the buccal soft tissue wall
of the bony defect. (d) The envelope buccal flap is coronally advanced, and primary interdental soft tissue closure is achieved in a more
coronal position with respect to the baseline position of the interdental papilla. (e) Six-month follow-up. (f) One-year follow-up.

soft tissues from the root surfaces of
the canine and lateral incisor, and a
horizontal buccolingual incision was
carried out at the level of the bone
crest of the canine in order to sepa­
rate the supracrestal soft tissue from
the granulation tissue filling the in­
trabony component of the defect.
The entirety of the supracrestal soft
tissue was pushed in a palatal direc­
tion until the tip of the interdental
papilla was shifted in the most coro­
nal position and it was possible to
gain access to the bony defect (see
Figs 3c, 3d, 4a, and 4b).
A single-flap20 approach was ad­
opted, and since no palatal/lingual
flap was raised, the palatal soft tis­
sue was used as a palatal wall for
the suprabony and intrabony com­
ponents of the defect. The remain­
ing facial portion of the adjacent
anatomical papillae was de-epithe­
lialized to create connective tissue
beds to which the surgical papillae
of the coronally advanced buccal
flap were secured at the time of su­
turing. The granulation tissue filling
the intrabony defect was removed,
and root planing of the exposed
roots was performed. The root sur­
faces were conditioned with a 24%
ethylenediaminetetraacetic acid gel
for 2 minutes in order to remove the
smear layer. After rinsing the surgi­
cal area with saline, an EMD gel was
gently applied and left in place on
the root surfaces and bony walls for
1 minute. A CTG, derived from the
de-epithelialization of a free gingival
graft harvested from the palate,21,22
was prepared. The mesiodistal
length of the CTG was approximate­
ly 20 mm, the api­cocoronal dimen­
sion was 5 mm, and the thickness

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606

a b c
Fig 5    Six-month follow-up of case 1. (a) Splinting removal. (b) Cementation of ceramic veneer under rubber dam isolation. (c) Six-month
follow-up with good esthetic outcome.

was 1 mm. Coronally the CTG was
sutured at the base of the ana­
tomical papillae of the two teeth
neighboring the bony defect, while
apically it was secured at the perios­
teum left in place apical to the bone
exposure with single interrupted 7-0
polyglycolic acid (PGA) sutures.
Once sutured, the main portion
of the CTG resided over the bony
defect and could act as a buccal soft
tissue wall of the suprabony and in­
trabony components of the defect,
while the peripheral portions, cov­
ering the exposed buccal root sur­
faces, might improve root coverage
by adding CTG to the CAF2–4 (see
Figs 3e and 4c).
Coronal advancement of the
buccal flap was obtained by means
of two split-thickness incisions: one
deep, ie, cutting the muscle inser­
tions on the periosteum, and one
superficial, ie, detaching muscle
inserting in the inner aspect of the
lining mucosa of the flap. It was
this second incision that allowed
for coronal advancement of the
flap. Flap mobilization was consid­
ered adequate when the marginal
portion of the flap was able to pas­
sively reach a level coronal to the
CEJ at every tooth included in the
flap design and when the buccal
simplified papilla was able to near­
ly contact the coronally shifted su­
pracrestal soft tissue. Sling sutures,
suspended around the palatal
cingula of the treated teeth, were
used to anchor all surgical papillae
comprised in the flap design to the
corresponding de-epithelialized
anatomical papillae. These sutures
were able to accomplish tight ad­
aptation of the buccal flap to the
dental crowns and to coronally
shift the simplified buccal papilla.
Complete soft tissue closure at the
interdental space was achieved
by means of a horizontal mattress
suture at the base of the simpli­
fied papilla and a vertical mattress
suture in a more coronal position
(see Figs 3f and 4d). All the sutures
were 6-0 PGA.
Results
Case 1
Six months after surgery, the splint
was removed (Fig 5a). Tooth hyper­
mobility at the lateral incisor was
solved. The tip of the papilla was
1.5 mm more coronal compared
with the baseline. Complete root
coverage was obtained on the ca­
nine, and 3.5 mm of root coverage
with a residual gingival recession of
1.5 mm was measured at the lateral
incisor; the depth of the residual
gingival recession was very similar
to the amount of dental extrusion.
At this time, the lateral incisor was
restored with a ceramic veneer (Fig
5b) that allowed alteration of its
color and the shape, making it simi­
lar to the contralateral homologous
tooth. The placement of the ce­
ramic veneer changed the contact
point, allowing soft tissue to fill the
interdental space and improve the
overall esthetic appearance. The
patient was very satisfied with the
final esthetic outcome (Fig 5c).
One year after surgery the es­
thetic result was stable (Fig 6), no
increase in gingival recession was
recorded at the buccal surface of
the lateral incisor and canine, and
the overall camouflaging of the
treated area with respect to the
adjacent soft tissue was even bet­
ter than at the 6-month evaluation
visit. The keratinized tissue height
at the buccal aspect of the canine
and lateral incisor were 2 mm and
3 mm, respectively. A PD of 3 mm
with no recession (CAL = 3 mm),
was measured both at the disto­
buccal aspect of the lateral incisor

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 607

and at the mesiobuccal aspect of

the right canine. Overall interdental
clinical attachment gain was 4 and
2 mm at the level of the lateral in­
cisor and canine, respectively. The
radiographic examination (Fig 7)
showed a reduction of the intrabo­
ny component of the defect and
increased radiopacity of the bone
a b
crest. The patient was highly satis­
fied about the esthetic appearance Fig 6    Comparison between case 1 (a) baseline and (b) 1-year clinical situations. Note the
esthetic improvement and the increase in keratinized tissue height and thickness, together
of the treated area during smiling. with the improvement in the position of the buccal and interdental soft tissues.

Case 2

Six months after surgery (see Fig

4e), no tooth mobility was recorded
at the lateral incisor. The tip of the
papilla was 1.5 mm more coronal
compared with baseline. Complete
root coverage was obtained on the
a b c
canine, and 4 mm of root coverage
Fig 7    Comparison between case 1 (a) baseline, (b) 6-month, and (c) 1-year radiographs.
with a residual gingival recession
Note the improvement in bone fill of the intrabony component at 1 year.
of 1 mm was measured at the lat­
eral incisor. Some exposure of the
graft was visible at the buccal as­
pect of the treated site. One year
after surgery (Fig 8) the root cover­
age results were stable; no increase
in gingival recession was recorded
at the buccal surface of the lateral
incisor and canine. The keratinized
tissue height at the buccal aspect
of the canine and lateral incisor was a b
3 mm. A PD of 2 mm with 1-mm Fig 8    Comparison between case 2 (a) baseline and (b) 1-year clinical situations. Note the
recession (CAL = 3 mm) at the increase in keratinized tissue height and thickness together with the improvement in the
position of the buccal and interdental soft tissues.
distobuccal aspect of the lateral
incisor and a PD of 2 mm with no
gingival recession at the mesiobuc­ graphic examination (Fig 9) showed coverage surgery of adjacent gin­
cal aspect of the canine were mea­ almost complete fill of the intrabo­ gival recessions at the mandibular
sured. Overall interdental clinical ny component of the defect and an premolars confirmed the complete
attachment gain was 7 and 2 mm increased radiopacity of the bone bone fill of the intrabony compo­
at the level of the lateral incisor and crest. The re-entry (18 months after nent of the defect (Fig 10).
canine, respectively. The radio­ surgery) performed during root

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608

Fig 9   Comparison use of CTG to replace a missing

a b
a b
Fig 10    (a and b) Reentry 18 months after the surgery in case 2 showing complete bone fill
of the deep intrabony component with healthy supracrestal soft tissue filling the interdental
space.
Discussion
The present case reports describe a
surgical technique that was able to
combine root coverage and regen­
erative outcomes in the treatment
of Miller Class IV gingival recession.
In fact, 1 year after surgical treat­
ment, significant root coverage with
clinical improvement of the inter­
dental papilla and significant inter­
dental CAL gain and PD reduction
were achieved in both cases (see
Figs 6 and 8). The CTG that was
covering the exposed buccal root
surfaces under a CAF was also re­
placing the bone plate lacking from
the bony defect treated with EMD.
In the first case the CTG was used
in a bilaminar root coverage tech­
between case 2 (a) baseline
and (b) 1-year radiographs.
Note the almost complete
bone fill of the intrabony
component.
nique, while in the second case the
CTG acted as a soft tissue barrier
for the suprabony and intrabony
components of the defects.
The capability of the CTG un­
der a CAF to improve complete
root coverage outcomes has been
extensively reported in the litera­
ture.2–4 This was ascribed to the role
of the CTG in limiting postsurgical
soft tissue shrinkage of the CAF and
increasing soft tissue thickness, thus
reducing the risk of gingival reces­
sion recurrence.23,24 The increase in
soft tissue thickness was also report­
ed to be responsible for the better
long-term complete root coverage
outcome associated with the use of
the bilaminar technique compared
with the use of CAF alone.24 The
bone plate has not been previously
suggested. However, the dense
subepithelial palatal connective
tissue (CTG), when firmly attached
to the papillae neighboring the
defect area and to the periosteum
apical to the bottom of the bony
defect, could represent a barrier
rigid enough to limit buccal soft tis­
sue collapse inside the bony defect
and to help blood clot stabilization
inside the intrabony component of
the defects. Furthermore, the coro­
nal advancement of the buccal flap
and the single-flap approach with
no palatal/lingual flap elevation
used in the present case reports fur­
ther contributed to minimizing soft
tissue collapse and to stabilizing
the coagulum forming inside the in­
trabony component of the defects.
An important aspect of the pre­
sented technique is that the supra­
crestal soft tissue was pushed in a
palatal direction until the tip of the
interdental papilla reached its most
coronal position. In this way the tip
of the papilla covering the bony de­
fect was almost at the same level
as the adjacent de-epithelialized
healthy anatomical papillae, de­
spite the presence of papillary
recession before surgery. The ad­
vancement of the buccal flap al­
lowed the split-thickness simplified
papilla to adjoin to the coronally
shifted supracrestal soft tissue in
the palatal aspect of the interden­
tal space. It can be speculated that
this modification with respect to the
original use of the simplified pa­
pilla preservation technique19 or the
single-flap approach20 permitted
some improvement in the position

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of the interdental papilla covering
the bony defect. Furthermore, it
can be speculated that the increase
in soft tissue thickness, thanks to
the interdental portion of the con­
nective tissue graft, might have
improved the squeezing effect on
the interdental papilla made by the
prosthetic restoration used in case
1.25 The improvement in interproxi­
mal periodontal parameters, with
reduction in PD and gain in CAL,
together with the improvement of
the interdental papilla covering the
bony defect achieved in the pres­
ent case report, encourages future
research in such use of the CTG in
association with EMD in the field of
periodontal regeneration.
Conclusions
Within the limit of the present case
reports, the use of a de-epithelialized
free gingival graft under a CAF cov­
ering the exposed buccal root sur­
faces and replacing the buccal bone
wall of the bony defect treated with
EMD can be suggested to improve
root coverage and interproximal peri­
odontal parameters in the treatment
of Miller Class IV gingival recession.
Acknowledgments
The authors reported no conflicts of interest
related to this study.
References
 1. American Academy of Periodontology.
Consensus report. Mucogingival therapy.
Ann Periodontol 1996;1:702–706.
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Volume 34, Number 5, 2014