CLINICAL RESEARCH

Tunneled coronally advanced flap

for the treatment of isolated gingival
recessions with deficient papilla

Shayan Barootchi, DMD

Department of Periodontics & Oral Medicine, University of Michigan School of Dentistry,
Ann Arbor, MI, USA
Center for clinical Research and evidence synthesis In oral TissuE RegeneratION
(CRITERION), Ann Arbor-Boston, USA

Lorenzo Tavelli, DDS, MS

Department of Periodontics & Oral Medicine, University of Michigan School of Dentistry,
Ann Arbor, MI, USA
Center for clinical Research and evidence synthesis In oral TissuE RegeneratION
(CRITERION), Ann Arbor-Boston, USA
Department of Oral Medicine, Infection, and Immunity, Division of Periodontology,
Harvard School of Dental Medicine, Boston, MA, USA

Correspondence to: Dr Shayan Barootchi

Department of Periodontics and Oral Medicine, University of Michigan, School of Dentistry, 1011 N University
Avenue, Ann Arbor, MI, USA; Email: shbaroot@umich.edu

14 | The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022


Abstract
Background and aim: The coronally advanced flap
(CAF) and the tunnel technique (TUN) are the most
performed surgical approaches for treating gingival
recessions (GRs). Nonetheless, these two approaches
have commonly been regarded as substitutes for one
another, and clinicians are often faced with the choice
of performing only one during root coverage proce-
dures. The aim of the present article is to describe a
surgical design in which the benefits of both the CAF
and the TUN are combined for the treatment of isolat-
ed type 2 (RT2) GRs with deficient papilla.
Materials and methods: Ten patients with isolated
RT2 GRs were treated using the tunneled coronally
advanced flap (TCAF) + connective tissue graft (CTG)
technique.
Results: The healing was uneventful, and patients
consistently reported minimal discomfort. After
6 months, the TCAF + CTG resulted in an average
The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022
BAROOTCHI/TAVELLI
mean root coverage of 86.5%, with six sites showing
complete root coverage (60%). The mean increases
in keratinized tissue width and gingival thickness were
1.40 and 0.92 mm, respectively. All the treated GRs
showed an increased soft tissue phenotype. No sig-
nificant changes were observed for midfacial probing
depth, while a mean midfacial clinical attachment
level gain of 3.05 mm was obtained after 6 months.
The professional esthetic evaluation, according to the
root coverage esthetic score, was 7.90 ± 1.66.
Conclusions: The present article suggests that the
TCAF + CTG is a suitable technique for treating iso-
lated RT2 GRs. The newly introduced technique may
have the potential to enhance flap blood supply and
graft vascularization and improve clinical-, esthetic-,
and patient-reported outcomes of RT2 GRs with
deficient papilla. Future studies with larger sample
sizes and comparative groups are needed to support
these preliminary results.
(Int J Esthet Dent 2022;17:14–26)
| 15
CLINICAL RESEARCH
Introduction
Gingival recession (GR) is a highly preva-
lent condition that affects a large part of the
population, irrespective of age, gender or
ethnicity.1-3 According to a recent epidemio-
logical study, the overall patient-level preva-
lence of GR in the midfacial region is 91.6%.4
Interestingly, despite most studies in the
literature focusing on the treatment of GR
without attachment loss (recession type 1
[RT1]),5,6 recession defects with an inter-
proximal attachment loss less than or equal
to the loss of buccal attachment (recession
type 2 [RT2]) are found to be the most com-
mon type of GR, with a patient-level preva-
lence of 88.8%.4
An interproximal attachment loss does
not solely have a diagnostic value but also
severely impairs the chance of achieving
a complete root coverage (CRC) of the
GR.7-10 Indeed, interproximal attachment
loss is considered a reliable tool for indirect-
ly evaluating the presence of bone loss,11,12
which has long been considered a negative
predictor for CRC.7,9,12,13
A randomized study by Henriques
and coworkers14 found that the coronally
advanced flap (CAF) in combination with a
subepithelial connective tissue graft (CTG)
had limited coverage of RT2 GRs, either
alone or with the addition of a biologic
agent. In line with this study, a recent trial by
Mercado et al15 found an incidence of CRC
of 18.5% and 22.2% when RT2 GRs were
treated with CAF + CTG and CAF + CTG +
enamel matrix derivative, respectively.
Aroca et al16 investigated the efficacy of
the tunnel technique (TUN) with a CTG from
the tuberosity for the treatment of multiple
RT2 GRs. The rationale behind using this ap-
proach relies on the fact that the TUN can
detach the buccal papillae from the inter-
proximal bone, allowing for a coronal re-
positioning of the midfacial and interproxi-
mal soft tissue.16,17 After 1 year, TUN + CTG
16 | The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022
resulted in a papilla gain of up to 59% of its
initial height.16 However, graft stabilization
and a limited predictability for deep GRs
have been indicated as the main drawbacks
of the TUN compared with the CAF.8,18,19
In this scenario, it is reasonable to
assume that the techniques of the CAF and
TUN should not be viewed as alternatives to
one another. Indeed, the surgical approach
should be tailored toward the particular
recession defect and each of its mesial/dis-
tal properties. In case of RT2 GRs, several
variables must be considered prior to the
execution of the flap, including REC, papilla
width, papilla height, tooth malpositioning,
and interproximal attachment loss.7,20 It
is reasonable to assume that the CAF and
TUN can both be performed at the same
time for combining the advantages of the
two techniques. In particular, in the pres-
ence of single moderate or deep RT2 GRs,
it is not uncommon to find one papilla with
no/minimal clinical attachment loss and the
other with a higher clinical attachment loss.
In these cases, the CAF and TUN may there-
fore be performed simultaneously in order
to take advantage of the improved access
and graft stabilization of the CAF at the
papilla without (or with the least amount
of) attachment loss, while preserving the
integrity and tunneling the papilla with the
greater attachment loss.
Therefore, the aim of this article is to de-
scribe a technique based on a combination
of the TUN and CAF, called the tunneled
coronally advanced flap (TCAF), for the
treatment of isolated RT2 GRs, underlining
its indications, possible advantages, and
expected outcomes through a preliminary
case series.
Materials and methods
Ten nonsmoker systemically and periodon-
tally healthy patients presenting with an
isolated GR with interproximal attachment

loss (RT2)12 and a single (mesial or distal)
deficient papilla (either shallower or narrow-
er than the other papilla) were recruited at
the Department of Periodontics and Oral
Medicine, School of Dentistry, University of
Michigan, USA. Patients gave their informed
consent and were all treated with the same
TCAF described in this article, and in combi-
nation with a CTG. The study protocol was
in full accordance with the Helsinki Declara-
tion of 1975, as revisited in 2004.
The clinical parameters of recession
depth (REC), probing depth (PD), keratinized
tissue width (KTW), and gingival thickness
(GT) were assessed at baseline (pretreat-
ment) and at the 6-month follow-up of
all procedures, as previously described.21
The soft tissue phenotype was also evalu-
ated with a color-coded probe (Colorvue,
Hu-Friedy) before the surgery and after
6 months.22 Patient morbidity during the first
10 postoperative days was also recorded us-
ing a 0 to 10 visual analog scale (VAS),21,23
and the root coverage esthetic score (RES)
was used to assess the esthetic outcomes
at the 6-month timepoint .21
All patients received personalized oral
hygiene instructions in order to correct
possible traumatic brushing habits at least
4 weeks prior to the surgical procedure.
These instructions were repeated again at
subsequent follow-up visits.
The tunneled coronally advanced flap
(TCAF)
The TCAF for isolated RT2 GRs involves the
elevation of one trapezoidal surgical papil-
la and the execution of only one vertical
incision, which are both performed at the
papilla that does not have (or has the least)
interdental clinical attachment loss (Figs 1
and 2). In cases where both the mesial and
distal papillae show a similar amount of
attachment loss, the elevation of the papil-
la and the vertical incision are performed
BAROOTCHI/TAVELLI
at the papilla that displays a higher height
and width. The rationale for this decision is
based on the higher probability of flap sur-
vival when the flap is coronally repositioned
and sutured to its recipient bed, while pre-
serving the integrity of the papilla with the
greater clinical attachment loss (and/or with
less height and width).
The level of the horizontal incision to
create the trapezoidal surgical papilla is
based on the recommendation for conven-
tional CAFs24 and is therefore performed
at a distance equal to the REC plus 1 mm
apical to the papilla tip. A slightly divergent
vertical incision was therefore performed. A
mini-crescent knife II was utilized to execute
the intrasulcular incision on the treated site
and on the tooth adjacent to the papilla that
was being preserved. Indeed, for achieving a
tension-free flap advancement, at least one
more tooth after the recession defect (not
on the site adjacent to the vertical incision)
also needs to be tunneled. The midfacial
aspect of the tooth was elevated with tunnel-
ing knives (Sharptome; Surgical Specialties,
and Tunneling knives nos. 1 and 2; American
Dental Systems), while the surgical papilla
was incised and elevated in a split-thickness
manner with a mini-blade (Mini Blade no.
67; Salvin Dental Specialties). The flap was
then released with a 15c blade from the area
in which the surgical papilla and the vertical
incision were performed, and was further
completed by introducing curved tunneling
knives from the sulcus of the tooth with the
intact papilla. The flap was considered ten-
sion free only when it was able to passively
reach a level approximately 2 mm coronal
to the cementoenamel junction. The ana-
tomical papilla that was incised was then
deepithelialized, either with a mini-blade or
microsurgical scissors (Hu-Friedy), while the
other papilla was gently detached from the
interproximal bone and mobilized with a
papilla elevator instrument. After mechani-
cal and chemical root conditioning with 24%
The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022 | 17
CLINICAL RESEARCH

a b c

d e f

g h i

Fig 1 AF) on a mandibular incisor characterized by isolated gingival recession (GR) with interproximal
attachment loss and deficient mesial papilla with loss of vertical dimension. (a) Baseline. (b) Incision design with a single vertical incision on
the distal aspect of the tooth. (c) Tunneling of the adjacent (mesial) tooth. (d and e) Connective tissue graft (CTG) harvested as a free gingival
graft and then extraorally deepithelialized. (f) The CTG is sutured to the deepithelialized distal papilla and to the periosteum. (g) The flap is
released and is able to passively reach a position approximately 2 mm coronal of the cementoenamel junction. (h) Flap suturing using sling
and simple sutures and a suspended suture around the splinted contact point at the level of the deficient papilla. (i) Clinical outcome at
6 months with complete coverage of the GR.

18 | The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022


ethylenediaminetetraacetic acid (EDTA T ) for
2 min,25 and rinsing with sterile saline, a CTG
(obtained from the palate as a free gingival
graft and extraorally deepithelialized) was
inserted underneath the flap and tunneled
below the nonincised papilla. The graft was
then sutured to the deepithelialized ana-
tomical papilla with a simple interrupted
suture (6/0 or 7/0 PGA; AD Surgical). Fur-
ther stabilization of the graft was obtained
with simple interrupted sutures engaging
the periosteum and/or sling sutures around
the tooth (6/0 or 7/0 PGA). The flap was
then coronally advanced and sutured with
sling sutures from the incised papilla to the
tunneled papilla and from the incised papilla
to the papilla of the adjacent tooth not in-
volved in the flap (6/0 or 7/0 Polypropylene;
AD Surgical). Further coronal advancement
of the tunneled papilla was obtained with
a suspended suture (6/0 or 7/0 Polypro-
pylene) around the contact point previ-
ously splinted with a composite stop, as
described by Aroca et al.16 The vertical inci-
sion was then approximated to the adjacent
soft tissue with simple interrupted sutures
(7/0 Polypropylene and 7/0 PGA). Figure 3
illustrates the execution of the TCAF.
Oral and written postoperative instruc-
tions were provided to patients and includ-
ed ibuprofen (600 mg) every 4 to 6 h as
needed, amoxicillin (500 mg) 3 times daily
for 7 days, and chlorhexidine mouth rinse
(0.12%) twice daily for 2 weeks, as well as the
recommendation of gentle warm saltwater
rinses. Suture removal occurred at 2 weeks,
at which point patients received further in-
structions regarding the type of toothbrush
and brushing technique.21
Data analysis
Means and standard deviations (SDs) were
obtained for the descriptive presentation of
continuous data gathered at baseline and at
6 months. CRC is reported as the percent-
age of sites that obtained a full coverage of
BAROOTCHI/TAVELLI
the GR at 6 months. The mean root cover-
age (mRC) was assessed, as has been uni-
formly described in the literature.5,21 Paired t
tests were used for statistical inferences re-
garding the changes in the continuous clin-
ical measures from baseline to 6 months.
Results
Ten patients (mean age 39.4 ± 12.1; seven
females) each contributing with a single GR
were treated with TCAF + CTG. Six GRs were
located in the maxilla, while the remaining
four were located in the mandible. Table 1
depicts the characteristics of the GRs at
baseline, and Table 2 presents the 6-month
follow-up outcomes.
The healing was uneventful at all sites,
and patients consistently reported minimal
discomfort (average VAS 2.35 ± 1.84). After
6 months, the TCAF + CTG resulted in an
average mRC of 86.5 ± 17.7%, with 6 out
of 10 sites (60%) showing CRC. The mean
KTW and GT gain were 1.40 and 0.92 mm,
respectively. All the treated GRs showed an
increased soft tissue phenotype. No signifi-
cant changes were observed for midfacial
PD, while a significant increase in mean mid-
facial clinical attachment level of 3.05 mm
was obtained after 6 months.
The overall esthetic outcome, according
to the RES, was 7.9 ± 1.7. The outcomes of
the individual five RES components are also
reported in Table 2.
Discussion
The present study combined the application
of CAF and TUN for the treatment of iso-
lated RT2 GRs. Traditionally in the literature,
the two approaches of CAF and TUN have
often been compared and contrasted as
different approaches.18,19,26,27 Nonetheless,
their combination (TCAF) may be benefi-
cial for several distinct scenarios, including
root coverage of teeth with adjacent dental
The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022 | 19
CLINICAL RESEARCH

a b

c d

e f

Fig 2 Illustration of the TCAF. (a) Baseline. (b) Incision design. (c) Tunneling of the adjacent tooth with a tunneling knife. (d) Detachment of
the preserved papilla with a papilla elevator for achieving further coronal advancement of the flap. (e) Graft stabilization. (f) Suturing of the flap
using sling sutures and suspended sutures around the splint contact point. The vertical incision is approximated with simple interrupted
sutures.

20 | The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022

 BAROOTCHI/TAVELLI

implants, treatment of RT2 GRs, and GRs Table 1 Clinical parameters at baseline (pretreatment)
with one narrow or shallow papilla, as was
Baseline value
performed in the present study. The preser- Parameter
(mean ± SD) (mm)
vation of the integrity of a papilla that shows REC – midfacial 3.45 ± 0.59
a significant attachment loss or has narrow/
REC – mesial 0.15 ± 0.12
shallow dimensions is intended for prevent-
REC – distal 0.37 ± 0.17
ing the sloughing of the flap in that region.
Indeed, a narrow/shallow papilla may not PD – midfacial 1.25 ± 0.42
provide a good recipient bed for the survival PD – mesial 2.65 ± 0.63
of a CAF.9 In addition, performing two ver- PD – distal 3.05 ± 0.64
tical incisions in a single site with shallow/ CAL – midfacial 4.70 ± 0.76
narrow papillae may also compromise the
CAL – mesial 2.82 ± 0.62
vascularization of the graft and flap.17 On
CAL – distal 3.34 ± 0.56
the other hand, it has been suggested that
the TUN is a less invasive technique that KTW 2.30 ± 0.94
can improve blood supply of the graft and GT 1.03 ± 0.25
flap as well as the esthetic outcomes, while CAL: clinical attachment level; GT: gingival thickness, measured at the
significantly reducing patient morbidity.17,27,28 midfacial aspect of the tooth; KTW: keratinized tissue width, measured at the
However, limitations of the TUN may also midfacial aspect of the tooth; PD: pocket depth; REC: recession depth; SD:
include reduced access and limited graft standard deviation
stabilization, compared with the CAF.
In order to improve access and facilitate
graft placement, Allen29 recently described Table 2 Clinical and esthetic outcomes at 6 months
a modification of the conventional TUN
for multiple GRs, involving the incision of Parameter 6-month outcome
two papillae. Although this approach may mRC (mean ± SD) (%) 86.5 ± 17.7
be beneficial in several scenarios, it was CRC (N) (%) 60
mainly intended for multiple RT1 GRs and PD change (mean ± SD) (mm) 0.05 ± 0.55
has different characteristics from the TCAF.
CAL gain (mean ± SD) (mm) 3.05 ± 0.89
The TCAF includes a single papilla incision
KTW gain (mean ± SD) (mm) 1.40 ± 0.69
and only one vertical incision (at the level of
the ‘healthiest’ papilla) and the suturing of GT gain (mean ± SD) (mm) 0.92 ± 0.23

the graft to the deepithelialized anatomical Final RES (mean ± SD) (points) 7.90 ± 1.66
papilla and to the periosteum, likely enhanc- GM (mean ± SD) (points) 4.80 ± 1.55
ing the chance of graft survival. The differ- MTC (mean ± SD) (points) 0.80 ± 0.42
ence in graft stabilization between the con- STT (mean ± SD) (points) 0.80 ± 0.42
ventional CAF and the TUN may explain the
MGJ (mean ± SD) (points) 0.70 ± 0.48
higher mRC and CRC that have been report-
GC (mean ± SD) (points) 0.80 ± 0.42
ed for the CAF in the treatment of GRs with-
out interproximal attachment loss.18,19,30 The CAL: clinical attachment level, measured at the midfacial aspect of the tooth;
TCAF takes advantage of the access provid- CRC: complete root coverage; GC: gingival color; GM: level of the gingival
margin; GT: gingival thickness, measured at the midfacial aspect of the tooth;
ed by the vertical incision and the creation
KTW: keratinized tissue width, measured at the midfacial aspect of the tooth;
of a single surgical papilla for suturing the
MGJ: mucogingival junction alignment; mRC: mean root coverage;
graft, which is then inserted below the tun- MTC: marginal tissue contour; PD: pocket depth, measured at the midfacial
neled part of the flap and sutured along with aspect of the tooth; RES: root coverage esthetic score; SD: standard deviation;
it. Compared with traditional approaches, STT: soft tissue texture

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CLINICAL RESEARCH

a b

c d

Fig 3 TCAF on a maxillary premolar with GR and interproximal attachment loss on the distal aspect due to an edentulous area. (a) Baseline.
(b) Incision design with a trapezoidal papilla and a vertical incision on the mesial aspect of the tooth. (c) Elevation of the flap. (d and e [on next
page]) CTG.

the TCAF may not only have the poten-
tial to enhance graft stabilization and root
coverage outcomes but also to provide fa-
vorable esthetic results, accelerate wound
healing, and reduce patient discomfort.18,31,32
In the present study, an average VAS score
of 2.35 (out of 10) was observed for post-
operative morbidity, which is slightly inferior
to the VAS found for CTG-based approach-
es in a recent network meta-analysis.33
Azaripour and coworkers30 showed that the
TUN and CAF, both in combination with a
CTG, resulted in a similar morbidity during
the first 2 weeks (2.8 ± 2.29 and 2.2 ± 2.9
VAS, respectively). Nevertheless, the mini-
mal invasiveness of the TCAF and its re-
ported patient morbidity and preference
compared with other techniques should be
assessed in future studies.
Another advantage of the TCAF involves
the preservation of the deficient papilla that
can also be detached from the bone and

22 | The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022

 BAROOTCHI/TAVELLI

e f

g h

Fig 3 cont (f) Stabilization of the CTG. (g) Flap advancement and closure. (h) Clinical outcome at 6 months showing a significant improve-
ment of the GR defect.

coronally repositioned with suspended su-
tures around the splinted contact point, as
previously shown by Aroca et al16 and Zuhr
et al.34 While this suture technique may not
be strictly necessarily for GRs without inter-
proximal attachment loss, it may play a key
role for RT2 GRs.
Previous studies investigating the
treatment of RT2 GRs with conventional
CAF + CTG reported an mRC ranging from
52% to 86%.14,15,35 Aroca and coworkers16
obtained an mRC of 82% using TUN + CTG
for RT2 multiple GRs. While different factors,
including study design, surgical site, and
amount of interproximal attachment loss,
may prevent a direct comparison of the
present findings with those in the literature,
it seems that the outcomes of the TCAF are
in line with (if not superior to) convention-
al approaches. The esthetic results of the
treatment, evaluated with the RES, showed
an average score of 7.9. Lower scores for

The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022 | 23

CLINICAL RESEARCH
soft tissue texture and for the final RES
values were reported following conven-
tional RT2 GRs treated with CAF + CTG,35
further suggesting that the TCAF may also
have the potential to improve esthetic out-
comes of RT2 GRs due to the preservation
of the integrity of the papilla with greater
attachment loss. Indeed, sloughing of the
surgical papilla/flap is often observed dur-
ing the healing. While this event does not
necessarily compromise the amount of
root coverage, it can result in keloid or scar
formation at the base of the papilla. Previ-
ous studies using conventional CAF + CTG
reported a mean soft tissue texture (STT)
value ranging between 0.29 and 0.6 points
out of 10,18,35,36-39 while the present authors
obtained a mean STT value of 0.80. Two
studies utilizing TUN + CTG showed similar
STT values (0.76 and 0.84), further suggest-
ing that the TCAF is able to combine the
advantages of both conventional CAF and
TUN.18,27
Nevertheless, this speculation, as well
as a comparison between the TCAF and
conventional approaches, can only be per-
formed in an adequately powered and de-
signed randomized study, which was not
the aim of the present study. Thus, future
studies are needed to support these prelimi-
nary findings. Other approaches that have
been suggested for the treatment of iso-
lated RT2 GRs include the laterally moved
CAF40 and the laterally closed tunnel,41 and
thus, based on their indications and case
selection, they should also be considered
for the treatment of isolated GRs with inter-
proximal attachment loss.
Lastly, it should be mentioned that a
substantial increase in soft tissue pheno-
type was observed in the treated sites, with
an average KTW and GT gain of 1.40 and
0.92 mm, respectively. It can be speculat-
ed that this modification of the soft tissue
phenotype induced by the CTG5 was also
enhanced by the TCAF, which involves graft
24 | The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022
stabilization but with a limited flap open-
ing, with the preservation of the integrity of
one (the most fragile) papilla and flap blood
supply. Also, the nature of the CTG that was
utilized in the present study, derived as it
was from the most superficial palate after
removal of the epithelium, could also have
contributed to these findings, as it has been
reported that a CTG obtained with a free
gingival graft harvesting technique is mainly
composed of lamina propria, with a limited
amount of fatty and glandular tissue,8 and
this may also explain the substantial increase
in the soft tissue phenotype observed in the
present study following TCAF + CTG. In
particular, as it relates to the concept of the
periodontal soft tissue phenotype, consid-
ering site-specific and individualized treat-
ments for a particular phenotype, future
studies should explore the enhancements
in clinical outcomes that can be obtained in
each case scenario.
Conclusions
The present article reports on the design
and application of the TCAF in combination
with a CTG for treating isolated RT2 GRs
with deficient papilla. The newly introduced
approach may have the potential to en-
hance flap blood supply and graft vascular-
ization and improve clinical-, esthetic-, and
patient-reported outcomes compared with
conventional surgical techniques. Never-
theless, future studies with an adequate
sample size and comparative groups are
needed to support these preliminary results.
Acknowledgment
The authors express their gratitude to
Dr Teresa Heck (Department of Periodon-
tics and Oral Medicine, University of Mich-
igan, School of Dentistry, Ann Arbor, USA)
for the illustrations presented in this article.

Disclaimer
This study was self-sponsored by the
authors, who declare no conflicts of in-
terest. The authors also declare that they
have no financial interests, either directly
or indirectly, in the products or information
included in this article.
References
1. Albandar JM, Kingman A. Gingival
recession, gingival bleeding, and dental
calculus in adults 30 years of age and
older in the United States, 1988-1994.
J Periodontol 1999;70:30–43.
2. Cortellini P, Bissada NF. Mucogingival
conditions in the natural dentition: Narrative
review, case definitions, and diagnostic
considerations. J Periodontol 2018;89
(suppl 1):S204–S213.
3. Barootchi S, Tavelli L, Gianfilippo RD,
et al. Acellular dermal matrix for root
coverage procedures: 9-year assessment of
treated isolated gingival recessions and
their adjacent untreated sites. J Periodontol
2021;92:254–262.
4. Romandini M, Soldini MC, Montero E,
Sanz M. Epidemiology of mid-buccal
gingival recessions in NHANES according
to the 2018 World Workshop Classification
System. J Clin Periodontol 2020;47:
1180–1190.
5. Barootchi S, Tavelli L, Zucchelli G,
Giannobile WV, Wang HL. Gingival
phenotype modification therapies on
natural teeth: a network meta-analysis.
J Periodontol 2020;91:1386–1399.
6. Tavelli L, Barootchi S, Cairo F, Rasperini G,
Shedden K, Wang HL. The effect of
time on root coverage outcomes: a
network meta-analysis. J Dent Res 2019;
98:1195–1203.
7. de Sanctis M, Clementini M. Flap
approaches in plastic periodontal and
implant surgery: critical elements in design
and execution. J Clin Periodontol
2014;41(suppl 15):S108–S122.
8. Zucchelli G, Tavelli L, McGuire MK, et al.
Autogenous soft tissue grafting for
periodontal and peri-implant plastic surgical
reconstruction. J Periodontol 2020;91:9–16.
9. Zucchelli G, Tavelli L, Barootchi S,
Stefanini M, Wang HL, Cortellini P. Clinical
remarks on the significance of tooth
malposition and papillae dimension on the
prediction of root coverage. Int J Periodon-
tics Restorative Dent 2020;40:795–803.
10. Rasperini G, Tavelli L, Barootchi S, et al.
Interproximal attachment gain: The
challenge of periodontal regeneration.
J Periodontol 2021;92:931–946.
11. Papapanou PN, Wennstrom JL.
Radiographic and clinical assessments of
destructive periodontal disease. J Clin
Periodontol 1989;16:609–612.
12. Cairo F, Nieri M, Cincinelli S, Mervelt J,
Pagliaro U. The interproximal clinical
attachment level to classify gingival
recessions and predict root coverage
outcomes: an explorative and reliability
study. J Clin Periodontol 2011;38:661–666.
13. Miller PD Jr. A classification of
marginal tissue recession. Int J Periodontics
Restorative Dent 1985;5:8–13.
14. Henriques PS, Pelegrine AA,
Nogueira AA, Borghi MM. Application of
subepithelial connective tissue graft with or
without enamel matrix derivative for root
coverage: a split-mouth randomized study.
J Oral Sci 2010;52:463–471.
15. Mercado F, Hamlet S, Ivanovski S.
Subepithelial connective tissue graft with or
without enamel matrix derivative for the
treatment of multiple Class III–IV recessions
in lower anterior teeth: a 3-year randomized
clinical trial. J Periodontol 2020;91:473–483.
16. Aroca S, Keglevich T, Nikolidakis D, et al.
Treatment of class III multiple gingival
The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022
BAROOTCHI/TAVELLI
recessions: a randomized-clinical trial. J Clin
Periodontol 2010;37:88–97.
17. Zuhr O, Rebele SF, Cheung SL,
Hürzeler MB; Research Group on Oral Soft
Tissue Biology and Wound Healing. Surgery
without papilla incision: tunneling flap
procedures in plastic periodontal and
implant surgery. Periodontol 2000 2018;
77:123–149.
18. Santamaria MP, Neves F, Silveira CA,
et al. Connective tissue graft and tunnel or
trapezoidal flap for the treatment of single
maxillary gingival recessions: a randomized
clinical trial. J Clin Periodontol 2017;44:
540–547.
19. Tavelli L, Barootchi S, Nguyen TVN,
Tattan M, Ravidà A, Wang HL. Efficacy of
tunnel technique in the treatment of
localized and multiple gingival recessions:
a systematic review and meta-analysis.
J Periodontol 2018;89:1075–1090.
20. Zucchelli G, De Sanctis M. The
coronally advanced flap for the treatment of
multiple recession defects: a modified
surgical approach for the upper anterior
teeth. J Int Acad Periodontol 2007;9:
96–103.
21. Stefanini M, Mounssif I, Barootchi S,
Tavelli L, Wang HL, Zucchelli G. An
exploratory clinical study evaluating safety
and performance of a volume-stable
collagen matrix with coronally advanced
flap for single gingival recession treatment.
Clin Oral Investig 2020;24:3181–3191.
22. Rasperini G, Codari M, Limiroli E,
Acunzo R, Tavelli L, Levickiene AZ. Graftless
tunnel technique for the treatment of
multiple gingival recessions in sites with
thick or very thick biotype: a prospective
| 25
CLINICAL RESEARCH
case series. Int J Periodontics Restorative
Dent 2019;39:e203–e210.
23. Tavelli L, Ravida A, Saleh MHA, et al. Pain
perception following epithelialized gingival
graft harvesting: a randomized clinical trial.
Clin Oral Investig 2019;23:459–468.
24. de Sanctis M, Zucchelli G. Coronally
advanced flap: a modified surgical approach
for isolated recession-type defects:
three-year results. J Clin Periodontol 2007;
34:262–268.
25. Barootchi S, Tavelli L, Ravida A,
Wang CW, Wang HL. Effect of EDTA T root
conditioning on the outcome of coronally
advanced flap with connective tissue graft:
a systematic review and meta-analysis.
Clin Oral Investig 2018;22:2727–2741.
26. Tavelli L, Barootchi S, Di Gianfilippo R,
et al. Acellular dermal matrix and coronally
advanced flap or tunnel technique in the
treatment of multiple adjacent gingival
recessions. A 12-year follow-up from a
randomized clinical trial. J Clin Periodontol
2019;46:937–948.
27. Zuhr O, Rebele SF, Schneider D,
Jung RE, Hürzeler MB. Tunnel technique
with connective tissue graft versus coronally
advanced flap with enamel matrix derivative
for root coverage: a RCT using 3D digital
measuring methods. Part I. Clinical and
patient-centred outcomes. J Clin Periodon-
tol 2014;41:582–592.
28. Aroca S, Molnar B, Windisch P, et al.
Treatment of multiple adjacent Miller class I
and II gingival recessions with a Modified
Coronally Advanced Tunnel (MCAT) A of inter-dental attachment. A randomized
technique and a collagen matrix or palatal
connective tissue graft: a randomized,
controlled clinical trial. J Clin Periodontol
2013;40:713–720.
26 | The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022
29. Allen EP. The papilla access tunnel
technique for the treatment of shallow
recession and thin tissue in the mandibular
anterior region. Int J Periodontics Restora-
tive Dent 2020;40:165–169.
30. Azaripour A, Kissinger M, Farina VS, et al.
Root coverage with connective tissue graft
associated with coronally advanced flap or
tunnel technique: a randomized, double-
blind, mono-centre clinical trial.
J Clin Periodontol 2016;43:1142–1150.
31. Zabalegui I, Sicilia A, Cambra J, Gil J,
Sanz M. Treatment of multiple adjacent
gingival recessions with the tunnel
subepithelial connective tissue graft: a
clinical report. Int J Periodontics Restorative
Dent 1999;19:199–206.
32. Allen AL. Use of the supraperiosteal en-
velope in soft tissue grafting for root cover-
age. I. Rationale and technique. Int J Peri-
odontics Restorative Dent 1994;14:216–227.
33. Cairo F, Barootchi S, Tavelli L, et al.
Aesthetic and patient-related outcomes
following root coverage procedures: a
systematic review and network meta-analy-
sis. J Clin Periodontol 2020;47:1403–1415.
34. Zuhr O, Rebele SF, Thalmair T, Fickl S,
Hurzeler MB. A modified suture technique
for plastic periodontal and implant
surgery – the double-crossed suture. Eur
J Esthet Dent 2009;4:338–347.
35. Cairo F, Cortellini P, Tonetti M, et al.
Coronally advanced flap with and without
connective tissue graft for the treatment of
single maxillary gingival recession with loss
controlled clinical trial. J Clin Periodontol
2012;39:760–768.
36. Barootchi S, Tavelli L, Di Gianfilippo R,
et al. Long term assessment of root
coverage stability using connective tissue
graft with or without an epithelial collar for
gingival recession treatment. A 12-year
follow-up from a randomized clinical trial.
J Clin Periodontol 2019;46:1124–1133.
37. Cairo F, Cortellini P, Nieri M, et al.
Coronally advanced flap and composite
restoration of the enamel with or without
connective tissue graft for the treatment of
single maxillary gingival recession with
non-carious cervical lesion. A randomized
controlled clinical trial. J Clin Periodontol
2020;47:362–371.
38. Jhaveri HM, Chavan MS, Tomar GB,
Deshmukh VL, Wani MR, Miller PD Jr.
Acellular dermal matrix seeded with
autologous gingival fibroblasts for the
treatment of gingival recession: a proof-
of-concept study. J Periodontol 2010;
81:616–625.
39. Pelekos G, Lu JZ, Ho DKL, et al.
Aesthetic assessment after root coverage
of multiple adjacent recessions with
coronally advanced flap with adjunctive
collagen matrix or connective tissue graft:
randomized clinical trial. J Clin Periodontol
2019;46:564–571.
40. Ucak O, Ozcan M, Seydaoglu G,
Haytac MC. Microsurgical instruments in
laterally moved, coronally advanced flap
for Miller Class III isolated recession defects:
a randomized controlled clinical trial. Int
J Periodontics Restorative Dent 2017;37:
109–115.
41. Sculean A, Allen EP. The laterally closed
tunnel for the treatment of deep isolated
mandibular recessions: surgical technique
and a report of 24 cases. Int J Periodontics
Restorative Dent 2018;38:479–487.
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