C L I N I C A L P R A C T I C E
Background. Gingival recession is an
Treatment of gingival
recession
MOAWIA M. KASSAB, D.D.S., M.S.; ROBERT E.
COHEN, D.D.S., Ph.D.
ingival recession associated with root surface
G exposure is a complex phenomenon that may
present numerous therapeutic challenges to
the clinician. Recession may be accompanied
by root caries or abraded surfaces, and
patients may complain of esthetic defects or root hyper-
sensitivity. One goal of periodontal therapy is to regen-
erate the lost attachment apparatus of
the teeth. Accordingly, it has become
A variety of evident during the past decade that a
regenerative variety of regenerative procedures have
procedures the potential to correct gingival reces-
have the sion defects via augmentation of the
potential to width and height of keratinized or
attached gingiva, as well as to obtain
correct gingival partial or complete root coverage. The
recession majority of these procedures consist of
defects via periodontal plastic surgical (mucogin-
augmentation gival) graft techniques, either alone or
of the width in combination with guided tissue
and height of regenerative procedures. In this article,
we briefly review some of the methods
keratinized or commonly used to treat gingival reces-
attached sion and discuss which of those tech-
gingiva. niques (or combinations of procedures)
appear to be more clinically successful.
SOFT-TISSUE GRAFTING
One goal of soft-tissue grafting is root coverage. Many
techniques and flap designs have been used to meet that
goal; some do not require a donor site (pedicle grafts),
while others do (free autogenous grafts). It often is diffi-
cult to anticipate the success rate of root coverage pro-
cedures (table), since coverage depends on several fac-
tors, including the classification and location of the
recession and the technique used. The gingival dimen-
sion most commonly assessed is the height—the dis-
tance between the soft-tissue margin and the mucogin-
ABSTRACT
intriguing and complex phe-
nomenon. Patients fre- A D A
J
quently are disturbed by
✷
✷
recession owing to sensi- 
N
CON
tivity and esthetics.
IO
Many techniques have
T
T
A
N
I
C
been introduced to treat U
A ING EDU 2
gingival recession, R TICLE
including connective tissue
grafting, or CTG; various flap designs;
orthodontics; and guided tissue regenera-
tion, or GTR. The authors reviewed human
clinical studies to assess which techniques
provided optimal results.
Types of Studies Reviewed. The
authors reviewed controlled clinical trials to
assess the outcome of gingival grafting.
They also included histological studies in
this article to elucidate the type of healing
after those procedures were performed.
Results. The studies showed that the
combination of CTG and coronally posi-
tioned flaps yielded a higher percentage of
root coverage compared with other tech-
niques. When GTR using bioabsorbable or
nonbioabsorbable membranes was com-
pared with CTG, the studies were inconclu-
sive. Some studies found that GTR was as
effective as CTG, while the others found
that CTG was superior.
Clinical Implications. Gingival
grafting to treat recession is a predictable
and reliable periodontal procedure.
gival line measured in millimeters. An
increase in gingival height, independent of
the number of millimeters, is considered to
be a successful outcome of gingival augmen-
tation procedures.1
Pedicle grafts differ from free autogenous
soft-tissue grafts in that the base of the
pedicle flap contains its own blood supply,
which nourishes the graft and facilitates the
re-establishment of vascular union with the
recipient site. Pedicle grafts may be partial
or full thickness.2,3
Wood and colleagues4 used re-entry pro-
cedures to compare crestal radicular bone
responses with full- and partial-thickness
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C L I N I C A L P R A C T I C E

TABLE Lateral sliding flaps.

Although the term “lat-
THE PERCENTAGE OF ROOT COVERAGE, BY eral sliding flap” was
PERIODONTAL PROCEDURE. introduced first by Grupe
and Warren,7 Miller and
PERIODONTAL ROOT DURATION OF STUDY AND SOURCE
PROCEDURE COVERAGE STUDIES REVIEWED Allen8 have noted that
(%) (YEARS) that term now generally
Laterally Positioned 36-67 1-3 Guinard and Caffesse 16 refers to the laterally posi-
Pedicle Grafts and Caffesse and tioned pedicle graft, or
Guinard17
LPPG. An LPPG cannot
Coronally Positioned 67-98 1-3 Caffesse and Guinard,17 be performed unless there
Flaps Allen and Miller18 and
Harris 19 is significant gingiva lat-
eral to the recession site.
Free Gingival Grafts 43-84 1-3 Langer and Langer26,28
and Bouchard and A shallow vestibule also
colleagues31,33 may jeopardize outcomes.
Connective Tissue 65-85 1-5 35
Harris and Nelson 12 Although the use of the
Grafts LPPG provides an ideal
Guided Tissue 48-87 1-2 Genon and colleagues 44 color match, it often is
Regeneration and Harris55 inadequate for the
Combination of 88-98 1-4 Wennström and Zucchelli 1 treatment of multiple
Connective Tissue and The American recessions.
Grafts and Coronally Academy of
Positioned Flaps Periodontology 36 The use of pedicle
grafts to correct mucogin-
gival defects also has been
flaps. They concluded that, regardless of the flap proposed, using an edentulous area as a donor
procedure used, loss of crestal bone depended on site.9 The procedure is particularly useful in cases
thickness, with the thinnest radicular bone asso- in which the attached gingiva on facial surfaces of
ciated with greater postoperative bone loss. The two or three consecutive teeth is inadequate. That
mean bone loss for full- and partial-thickness technique involves developing partial-thickness
flaps was 0.62 mm and 0.98 mm, respectively. flaps around the involved teeth and sliding the
In animal studies,5,6 wound healing after entire flap one-half tooth width, while placing the
pedicle flap surgery was found to occur in four interdental papillary tissues over the buccal sur-
stages: faces of the affected teeth.10
dadaptation stage (zero to four days) character- Cohen and Ross11 proposed a double-papilla
ized by a fibrin clot with polymorphonuclear repositioned flap to cover defects in which an
leukocytes between the flap and the crestal bone; insufficient amount of gingiva is present or in
dproliferation stage (four to 21 days) with gran- which there is an inadequate amount of gingiva
ulation tissue invading the fibrin clot, fibroblasts in an adjacent area for a lateral sliding flap. The
appearing on the root surface (six to 10 days), papillae from each side of the tooth are reflected
apical epithelial migration (10 to 14 days) and and rotated over the midfacial aspect of the recip-
osteoclastic activity (four to 14 days) with an ient tooth and sutured. The only advantage of
average of 1 mm of crestal bone resorption; this technique is the dual blood supply and
dattachment stage (21 to 28 days) characterized denudation only of interdental bone. The disad-
by collagen and cementum formation, as well as vantages may include pulling of the sutures and
peak osteoblastic activity; tearing of the gingival papilla.11-13
dmaturation stage (28 to 180 days) with new Coronally positioned grafts. Bernimoulin and
periodontal ligament fibers orienting perpendicu- colleagues14 first reported the use of a coronally
larly to root surfaces. positioned graft, or CPG, subsequent to grafting
In general, repair consisted of a combination of with a free graft; it is a two-stage procedure. In
connective tissue attachment (2.1 mm) and long the first stage, a free autogenous soft-tissue graft
junctional epithelium (2.0 mm). Histologic analy- is placed apical to an area of denuded root. After
ses revealed minimal tissue destruction and rapid healing, the flap is coronally repositioned. The
repair. requirements for the success of CPGs include

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dthe presence of shallow crevicular depths on the papillae, staying at least 2 mm from the
proximal surfaces; papilla tip on either side. The incision is made far
dapproximately normal interproximal bone enough apically to ensure that the apical portion
heights; of the flap rests on bone after repositioning. A
dtissue height within 1 mm of the cemento- split-thickness dissection of the flap is made, and
enamel junction, or CEJ, on adjacent teeth; the flap is repositioned and held in place with
dadequate healing of the free graft (if per- light pressure and a periodontal dressing. The
formed) before coronal positioning; advantages of this technique include no tension
dreduction of any root prominence within the on the flap after repositioning, no shortening of
plane of the adjacent alveolar bone; the vestibule, no reflection of the papillae
dadequate release of the flap to prevent retrac- (thereby avoiding esthetic compromise) and no
tion during healing. suturing.
The second stage of the procedure uses a split- Free autogenous soft-tissue grafts. Both
thickness dissection with mesial and distal ver- the epithelialized palatal graft and the subepithe-
tical releasing incisions until adequate flap lial connective tissue graft, or CTG, offer a more
mobility is obtained. The flap is sutured 0.5 to versatile solution for root coverage than do the
1 mm coronal to the CEJ and covered with a peri- laterally positioned or coronally positioned pedicle
odontal dressing.15 flaps. There is an adequate amount
Coronally positioned flaps, or of donor tissue, a shallow vestibule
CPFs, were compared with lateral Two kinds of does not compromise the procedure,
sliding flaps in the treatment of autogenous grafts can and multiple recessions can be
localized gingival recessions.16,17 In be used for root treated. Two kinds of autogenous
a six-month report, both techniques grafts can be used for root coverage;
coverage; one has an
rendered satisfactory results, and one has an epithelialized layer,
no differences in tissue coverage, epithelialized layer, while the other does not or has only
sulcus depth or gain of attached while the other does a small epithelialized collar.
gingiva were reported. An average not or has only a Free epithelialized autogenous
of 2.7 mm of soft-tissue coverage small epithelialized gingival grafts. Sullivan and
21
was obtained, with average reces- collar. Atkins were the first to explore the
sion coverage of 67 percent. The feasibility and healing of free gin-
only difference between the two gival grafts, or FGGs. This proce-
techniques was an increase in root dure involves preparing a recipient
exposure of approximately 1 mm at the lateral site by using supraperiosteal dissection to remove
sliding flap donor site, while no additional reces- epithelium and connective tissue to the perios-
sion was observed with the CPF. Results were teum.
stable for three years. Some of the common areas for donor material
Allen and Miller18 used single-stage CPFs in include edentulous ridges, attached gingiva and
the treatment of shallow marginal recession. The palatal gingiva. Donor tissue should be approxi-
Miller Class I defects had a minimum keratinized mately 33 percent larger than the anticipated
tissue width of 3 mm, with recession between 2.5 healed graft due to shrinkage during healing.22
mm and 4 mm. The technique consisted of citric The grafts used should be approximately 0.8 to
acid root treatment, a split-thickness flap 1.3 mm thick to ensure that there is an adequate
extending into the vestibule and surface gingivo- connective tissue component.23
plasty of the papillae to produce a bleeding bed. In a two-year study comparing grafted sites
Flaps were sutured into position and dressed. with nongrafted sites, Dorfman and colleagues24
Complete root coverage was attained in 84 per- found that plaque control was more important
cent of the sites, with a mean root coverage gain than the width of the attached gingiva in deter-
of 3.2 mm. Similarly, Harris19 reported a 98 per- mining eventual breakdown and recession. They
cent success rate of root coverage in Class I also found that the using FGG was a predictable
defects using the CPG technique. way to increase the width of the attached gingiva.
Tarnow20 described the semilunar CPF tech- In a follow-up study two years later, they
nique. An incision is made that follows the curva- reported similar results, with the exception that
ture of the free marginal gingiva and extends into 10 percent of the nongrafted sites showed addi-

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tional soft-tissue recession compared with grafted Langer and Langer reported an increase of 2 to 6
sites with equivalent plaque scores.25 mm of root coverage in 56 cases over four years.
Holbrook and Ochsenbein26 have used FGG as Raetzke29 described an envelope technique for
a single-step procedure to cover denuded root sur- obtaining root coverage using CTGs. In that tech-
faces. The recipient bed is extended one tooth nique, the collar of marginal tissue around a
width lateral to the denuded roots and 5 mm localized area of recession was excised, the root
apical to the gingival margin of the denuded root. was débrided and planed, and a split-thickness
They suggested that donor tissue cover the gin- envelope was created around the denuded root
gival bed and extend at least 3 mm apical to the surface. The graft was collected from the palate
margin of the denuded root, using a graft of by means of the double parallel incision tech-
approximately 1.5-mm uniform thickness. In 50 nique. The CTG was placed in the previously cre-
randomly selected cases, recessions less than 3 ated envelope, covering the exposed root surface.
mm had 95.5 percent root coverage, recessions of Overall, 80 percent of the exposed root surfaces
3 to 5 mm had 80.6 percent coverage, and reces- were covered. Similarly, Allen30 reported an 84
sions more than 5 mm had 76.6 percent coverage. percent success rate for root coverage using that
Miller27 described a technique for same technique.
root coverage using a free soft- Jahnke and colleagues31 com-
tissue autograft with citric acid pared the results of FGGs and
In an attempt to
treatment. Predictable root cov- CTGs for root coverage in nine
erage depended on the severity and increase the success patients. They selected paired
classification of the gingival reces- rate of root coverage, defects and assessed them preoper-
sion. After root planing, citric acid many clinicians have atively and at three and six months
was applied and then was followed attempted to combine postoperatively. Root coverage
by horizontal incisions at the CEJ different procedures. averaged 43 percent for the FGG
level to preserve the interdental group and 80 percent for the CTG
papillae. Vertical incisions were group. Borghetti and Louise,32 in
made at proximal line angles of their split-mouth controlled clinical
adjacent teeth to facilitate the completion of the study, reported a 70 percent success rate for root
bed preparation. A thick palatal graft with a thin coverage at one year postoperatively.
layer of submucosa was placed on a moderately Most of the studies that used the CTGs for root
bleeding bed and stabilized with sutures at the coverage did not attempt to remove the epithelial
papillary and apical ends of the graft extending collar from the graft, but when Bouchard and col-
into periosteum. Results of 100 consecutively leagues33 did, no additional statistically signifi-
placed grafts showed 100 percent root coverage in cant benefits were observed (65 percent root cov-
Class I defects and 88 percent coverage in Class erage with the epithelial collar and 70 percent
II defects. The average root coverage for all sites root coverage without).
was 3.8 mm with a mean clinical attachment gain When Paolantonio and colleagues34 compared
of 4.5 mm. the root coverage from CTG with that from FGG,
Although Miller27 reported a combined 90 per- they found in a five-year postoperative study that
cent success rate in achieving 100 percent root CTG had an 85 percent success rate, while the
coverage, his 100 cases comprised 94 in the FGG had only a 53 percent success rate. They
mandible and only six in the maxilla. Other concluded that CTG is a long-term predictable
authors reported a root coverage success rate of procedure for root coverage.
only 36 percent16 and 44 percent.14 A variety of techniques have been used to
Connective tissue autogenous grafts. The use of obtain CTG, including parallel incisions and free
CTGs for root coverage first was reported by gingival knife methods, with no significant differ-
Langer and Langer28 A partial-thickness flap with ence in the percentage of root coverage.35
two vertical incisions was elevated on the recip- Combination of one or more techniques.
ient site, followed by placement of the graft, In an attempt to increase the success rate of root
which was collected from the palate by a double coverage, many clinicians have attempted to com-
parallel incision technique. The flap was posi- bine different procedures. Nelson12 used CTG
tioned coronally to attempt to cover the graft and with a double pedicle graft. A free CTG first was
so it could benefit from a double blood supply. placed over the denuded root surface, followed by

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A B

C D
Figure. Subepithelial connective tissue graft procedure. A. Preoperative buccal gingival recession (tooth no. 6).
B. Partial-thickness flap elevated and graft sutured in place. C. Flap coronally advanced and sutured.
D. At eight weeks postoperative.

a double pedicle graft to partially cover the CTG.
Twenty-nine defects were treated with that tech-
nique and monitored for four years, at which time
the mean root coverage was 88 percent (7-10 mm
of recession), 92 percent (4-6 mm of recession) and
100 percent (≤ 3 mm recession). Harris13 modified
Nelson’s technique with a split-thickness pedicle
graft to cover the CTG. Thirty Miller Class I and
Class II defects were selected, and the mean root
coverage was 97 percent.
Wennström and Zucchelli1 compared a CPF
procedure to a combination of a CPF procedure
and a CTG procedure. A total of 103 Miller Class
I and Class II defects were treated. At a two-year
postoperative evaluation, the success rate for the
combination group was 98.9 percent, while the
success rate for the control group was 97.0 per-
cent. The authors concluded that the CPF/CTG
combination procedure (as shown in the figure)
was the treatment of choice for achieving root
coverage.
GUIDED TISSUE REGENERATION
The American Academy of Periodontology defines
regeneration as “a reproduction or reconstitution
of a lost or injured part. It is, therefore, the bio-
logic process by which the architecture and func-
tion of lost tissues are completely restored.”36 This
implies regeneration of the tooth’s supporting tis-
sues, including alveolar bone, periodontal liga-
ment and cementum. Many studies have
attempted to achieve regeneration, but the out-
comes have varied from minimal or partial regen-
eration to almost complete regeneration.
More recently, the use of guided tissue regener-
ation, or GTR, has been suggested for the treat-
ment of recession. Tinti and Vincenzi37 first
reported a case in which GTR using an expanded

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polytetrafluoroethylene, or ePTFE, membrane either technique (PLACA, 82 percent; ePTFE, 83

was used to treat recession defects. Cortellini and percent). Zucchelli and colleagues46 had similar
38
colleagues conducted a histological study that results when they compared bioabsorbable with
also demonstrated that the root coverage obtained nonabsorbable membranes.
with an ePTFE membrane included new connec- The comparison between the use of GTR and
tive tissue attachment and new bone formation. gingival grafting to obtain root coverage has been
Different space-making solutions also have a controversial subject; Pini Prato and col-
been used in combination with nonresorbable leagues47 compared the results obtained with
membranes (such as titanium-reinforced mem- ePTFE membrane and mucogingival surgical pro-
branes, gold-bar–reinforced membranes and gold- cedure (a two-step procedure involving an FGG
frame–reinforced membranes) to increase the and a CPF). They reported mean root coverage of
percentage of root coverage with GTR. In a histo- 72 percent for the GTR procedure vs. mean root
logical study using titanium-reinforced mem- coverage of 70 percent for the two-step procedure;
branes, there was evidence of new connective the differences were not statistically significant.
tissue attachment and new bone growth after nine Harris48 also compared GTR with a bioabsorbable
39
months. Previous membrane designs resulted in membrane with connective tissue with double
77 percent root coverage.40 pedicle graft; the difference was not
Roccuzzo and colleagues41 used statistically significant.
ePTFE membranes in combination Different space- The combination of CPF pro-
with miniscrews to add space and cedures and GTR was assessed in a
making solutions also
create stability; they reported mean clinical investigation.49 In a six-
root coverage of 84 percent in 12 have been used in month split-mouth randomized
cases. Jepsen and colleagues42 com- combination with design, the authors found that there
pared titanium-reinforced mem- nonresorbable was no statistically significant dif-
branes and CTGs using the enve- membranes to ference between GTR and CPFs vs.
lope technique. They found no increase the CPFs alone. The mean root coverage
statistically significant difference was 56 percent and 69 percent,
percentage of root
in the two treatment modalities respectively. Another study reported
(the mean root coverage was 87 coverage with guided similar results, with no statistically
percent for the GTR group and 86 tissue regeneration. significant differences observed
percent for the CTG group). Wang between the two treatment groups.50
43
and colleagues also compared The latter study, however, reported
GTR with subepithelial CTG in 16 patients who a slight increase in the width of keratinized gin-
had bilateral Miller Class I and Class II reces- giva in the connective tissue group. Ricci and col-
sion. They concluded that both treatments leagues51 showed similar results after a one-year
showed statistically significant improvement from postoperative evaluation, with no statistically sig-
preoperative to postoperative measurements. The nificant differences between treatments (77 per-
mean root coverage was 73 percent for the GTR cent mean root coverage for the GTR group and 80
group and 84 percent for the subepithelial CTG percent for the connective tissue group). Harris52
group. combined a CTG with a CPG and compared it with
To eliminate the need for a second surgical pro- GTR with a bioabsorbable membrane. No differ-
cedure to remove a nonresorbable membrane, the ences were observed between groups (92 percent
use of various bioabsorbable materials have been for the GTR group and 95 percent for the connec-
proposed. In one study, 48 percent root coverage tive tissue with CPG group). He also noticed a
was obtained using a bioabsorbable polylactic greater increase in the amount of keratinized gin-
acid softened with citric acid ester, or PLACA gival tissue for the CTG group.
membrane.44 In another study, the PLACA mem- Trombelli and colleagues53 showed a significant
brane resulted in a mean root coverage of 64 per- difference in mean root coverage when they com-
cent.45 In a study comparing the use of a PLACA pared GTR with a bioabsorbable membrane to a
membrane with the use of a nonresorbable CTG procedure (48 percent root coverage for the
ePTFE membrane, Roccuzzo and colleagues41 GTR group and 81 percent root coverage for the
found there were no statistically significant dif- CTG group). They reported a significant increase
ferences in the mean root coverage obtained by in the amount of keratinized gingival tissue for

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the CTG group 13. Harris RJ. The connective tissue and partial thickness double
pedicle graft: a predictable method of obtaining root coverage. J Peri-
compared with odontol 1992;63:477-86.
the GTR group. 14. Bernimoulin JP, Luscher B, Muhlemann H. Coronally reposi-
tioned periodontal flap. J Clin Periodontol 1975;2:1-13.
In a more 15. Maynard JG. Coronal positioning of a previously placed autoge-
recent study,54 nous gingival graft. J Periodontol 1977;48:151-5.
16. Guinard EA, Caffesse RG. Treatment of localized gingival reces-
however, when sions, part III: comparison of results obtained with lateral sliding and
When this article was Dr. Cohen is a pro-
GTR was com- coronally repositioned flaps. J Periodontol 1978;49:457-61.
written, Dr. Kassab was fessor, Department of
17. Caffesse RG, Guinard EA. Treatment of localized gingival reces-
a clinical assistant pro- Periodontics and pared with CTG sions, part IV: results after three years. J Periodontol 1980;51:167-70.
fessor, Department of Endodontics, and the
with CPFs, the 18. Allen EP, Miller PD Jr. Coronal positioning of existing gingiva:
Periodontics and director, Postgraduate
short term results in the treatment of shallow marginal tissue reces-
Endodontics, School of Periodontics, School of authors con- sion. J Periodontol 1989;60:316-9.
Dental Medicine, State Dental Medicine, State
cluded that in 19. Harris RJ. The connective tissue with partial thickness double
University of New York University of New York
pedicle graft: the result of 100 consecutively treated defects. J Peri-
at Buffalo. He now is a at Buffalo. shallow reces- odontol 1994;65:448-61.
periodontist, The
sions (1.5-3.5 20. Tarnow DP. Semilunar coronally repositioned flap. J Clin Peri-
Forsythe Institute, 140
odontol 1986;13:182-5.
The Fenway, Boston, mm) GTR techniques only had a 21. Sullivan HC, Atkins JH. Free autogenous gingival grafts, part III:
Mass. 02115, e-mail
50 percent root coverage at 12 utilization of grafts in the treatment of gingival recession. Periodontics
“mmkassab@hotmail.
1968;6(4):152-61.
com”. Address reprint months postoperatively, while 22. Egli U, Vollmer W, Rateitschak KH. Follow-up studies of free gin-
requests to Dr. Kassab.
the CTG techniques yielded 82 gival grafts. J Clin Periodontol 1975;2:98-104.
23. Soehren SE, Allen AL, Cutright DE, Seibert JS. Clinical and his-
percent root coverage. Harris55 tologic studies of donor tissue utilized for free grafts of masticatory
supported the previous conclusion by reporting mucosa. J Periodontol 1973;44:727-41.
24. Dorfman HS, Kennedy JE, Bird WC. Longitudinal evaluation of
that 92 percent mean root coverage obtained six free gingival grafts. J Clin Periodontol 1980;7:316-24.
months postoperatively had been reduced to 58 25. Dorfman HS, Kennedy JE, Bird WC. Longitudinal evaluation of
free autogenous gingival grafts: a 4-year report. J Periodontol
percent after evaluations at a mean of 25 months 1982;53:349-52.
postoperative. 26. 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)8-27.
CONCLUSION 27. Miller PD. Root coverage using the free soft tissue autograft fol-
lowing citric acid application, part III: a successful and predictable pro-
The treatment of gingival recession can be accom- cedure in areas of deep-wide recession. Int J Periodontics Restorative
plished with a variety of different procedures. The Dent 1985;5(2):15-37.
28. Langer B, Langer L. Subepithelial connective tissue graft tech-
combination of CTG with a CPF, however, has nique for root coverage. J Periodontol 1985;56:715-20.
been shown to demonstrate the highest success. 29. Raetzke P. Covering localized areas of root exposure employing
the ‘envelope” technique. J Periodontol 1985;56:397-402.
GTR also can be used to treat recessions, particu- 30. Allen AL. Use of the supraperiosteal envelope in soft tissue
larly when patients are reluctant to consent to grafting for root coverage, part II: clinical results. Int J Periodontal
Restorative Dent 1994;14:302-15.
providing palatal gingiva donor sites. ■ 31. Jahnke PV, Sandifer JB, Gher ME, Gray JL, Richardson AC. Tick
free gingival and connective tissue autografts for root coverage. J Peri-
1. Wennström JL, Zucchelli J. Increased gingival dimensions: a sig- odontol 1993;64:315-22.
nificant factor for successful outcome of root coverage procedures? A 2- 32. Borghetti A, Louise F. Controlled clinical evaluation of the sub-
year prospective clinical study. J Clin Periodontol 1996;23:770-7. pedicle connective tissue graft for the coverage of gingival recession. J
2. Pfeifer J, Heller R. Histologic evaluation of full and partial thick- Periodontol 1994;65:1107-12.
ness lateral repositioned flaps: a pilot study. J Periodontol 1971;42: 33. Bouchard P, Etienne D, Ouhayoun J, Nilveus R. Subepithelial
331-3. connective tissue grafts in the treatment of gingival recessions: a com-
3. Sugarman EF. A clinical and histological study of the attachment parative study of 2 procedures. J Periodontol 1994;65:929-36.
of grafted tissue to bone and teeth. J Periodontol 1969;40:381-7. 34. Paolantonio M, di Murro C, Cattabriga A, Cattabriga M. Sub-
4. Wood DL, Hoag FM, Donnenfeld OW, Rosenfeld ID. Alveolar crest pedicle connective tissue graft versus free gingival graft in the coverage
reduction following full and partial thickness flaps. J Periodontol of exposed root surfaces: a 5 year clinical study. J Clin Periodontol
1972;43:141-4. 1997;24:51-6.
5. Wilderman MN, Wentz M. Repair of a dentogingival defect with a 35. Harris RJ. A comparison of two techniques for obtaining a connec-
pedicle flap. J Periodontol 1965;36:218-31. tive tissue graft from the palate. Int J Periodontics Restorative Dent
6. Staffileno H, Levy S, Gargiulo A. Histologic study of cellular mobi- 1997;17:260-71.
lization and repair following a periosteal retention operation via split 36. The American Academy of Periodontology. Annals of Periodon-
thickness mucogingival flap surgery. J Periodontol 1966;37(2):117-31. tology World Workshop in periodontics. Chicago: American Academy of
7. Grupe HE, Warren RF. Repair of gingival defects by a sliding flap Periodontics; 1996:621.
operation. J Periodontol 1956;27:92-5. 37. Tinti C, Vincenzi GP. Expanded polytetrafluoroethylene titanium-
8. Miller PD, Allen EP. The development of periodontal plastic reinforced membranes for regeneration of mucogingival recession
surgery. Periodontol 2000 1996;11:7-17. defects: a 12-case report. J Periodontol 1994;65;1088-94.
9. Corn H. Edentulous area pedicle grafts in mucogingival surgery. 38. Cortellini P, Clauser C, Pini Prato G. Histologic assessment of
Periodontics 1964;2:229-42. new attachment following the treatment of a human buccal recession
10. Hattler AB. Mucogingival surgery: utilization of interdental gin- by means of a guided tissue regeneration procedure. J Periodontol
giva as attached gingiva by surgical displacement. Periodontics 1993;64:387-91.
1967;5:126-31. 39. Parma-Benfenati S, Tinti C. Histologic evaluation of new attach-
11. Cohen DW, Ross SE. The double papillae repositioned flap in ment utilizing a titanium-reinforced barrier membrane in a mucogin-
periodontal therapy. J Periodontol 1968;39:65-70. gival recession defect: a case report. J Periodontol 1998;69:834-9.
12. Nelson S. The subpedicle connective tissue graft: a bilaminar 40. Tinti C, Vincenzi G, Cocchetto R. Guided tissue regeneration in
reconstructive procedure for the coverage of denuded root surfaces. J mucogingival surgery. J Periodontol 1993;64(supplement 11):1184-91.
Periodontol 1986;58:95-102. 41. Roccuzzo M, Lungo M, Corrente G, Gandolfo S. Comparative

JADA, Vol. 133, November 2002 1505

C L I N I C A L P R A C T I C E
study of a bioresorbable and a non-resorbable membrane in the treat-
ment of human recessions. J Periodontol 1996;67:7-14.
42. Jepsen K, Heinz B, Halben H, Jepsen S. Treatment of gingival
recession with titanium reinforced barrier membranes versus connec-
tive tissue grafts. J Periodontol 1998;69:383-91.
43. Wang HL, Bunyaratavej P, Labadie M, Shyr Y, MacNeil RL.
Comparison of 2 clinical techniques for treatment of gingival recession.
J Periodontol 2001;72(10):1301-11.
44. Genon P, Genon-Romagna C, Gottlow J. Treatment of gingival
recessions with guided tissue regeneration: a bioresorbable barrier. J
Periodontol Implantol Orale 1994;13:289-96.
45. Pini Prato G, Clauser C, Magnani C, Cortellini P. Resorbable
membrane in the treatment of human buccal recession: a nine-case
report. Int J Periodontics Restorative Dent 1995;15:258-67.
46. Zucchelli G, Clauser C, De Sanctis M, Calandriello M. Mucogin-
gival versus guided tissue regeneration procedures in the treatment of
deep recession type defects. J Periodontol 1998;69:138-45.
47. Pini Prato G, Tinti C, Vincenzi G, Magnani C, Cortellini P,
Clauser C. Guided tissue regeneration versus mucogingival surgery in
the treatment of human buccal recession. J Periodontol 1992;63:919-28.
48. 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
Periodontol 1997;68:779-90.
49. Amarante ES, Leknes KN, Skavland J, Lie T. Coronally posi-
1506 JADA, Vol. 133, November 2002
tioned flap procedures with or without a bioabsorbable membrane in
the treatment of human gingival recession. J Periodontol 2000;71:
989-98.
50. Borghetti A, Glise J, Monnet-Corti V, Dejou J. Comparative clin-
ical study of a bioabsorbable membrane and subepithelial connective
tissue graft in the treatment of human gingival recession. J Periodontol
1999;70:123-30.
51. Ricci G, Silvestri M, Tinti C, Rasperini G. A clinical/statistical
comparison between the subpedicle connective tissue graft method and
the guided tissue regeneration technique in root coverage. J Periodon-
tics Restorative Dent 1996;16:538-45.
52. Harris RJ. A comparison of 2 root coverage techniques: guided
tissue regeneration with a bioabsorbable matrix style membrane
versus a connective tissue graft combined with a coronally positioned
pedicle graft without vertical incisions: results of a series of consecutive
cases. J Periodontol 1998;69:1426-34.
53. Trombelli L, Scabbia A, Tatakis DN, Calura G. Subpedicle con-
nective tissue graft versus guided tissue regeneration with bioab-
sorbable membrane in the treatment of human gingival recession
defects. J Periodontol 1998;69:1271-7.
54. Muller HP, Stahl M, Eger T. Failure of root coverage of shallow
gingival recessions employing GTR and bioresorbable membrane. Int J
Periodontics Restorative Dent 2001;21:171-81.
55. Harris RJ. GTR for root coverage: a long-term follow-up. Int J
Periodontics Restorative Dent 2002;22:55-61.