Received: 5 May 2018 Revised: 13 June 2018 Accepted: 27 June 2018
DOI: 10.1002/JPER.18-0281
C O M M E N TA RY
Clinical insights about the evolution of root coverage procedures:
The flap, the graft, and the surgery
Leandro Chambrone1,2,3 Giovan Paolo Pini Prato4
1 School of Dentistry, Ibirapuera University (Unib), São Paulo, Brazil
2 Unit of Basic Oral Investigation (UIBO), School of Dentistry, El Bosque University, Bogota, Colombia
3 Department of Periodontics, College of Dentistry and Dental Clinics, The University of Iowa, Iowa City, IA
4 Tuscany Academy of Dental Research (ATRO), Florence, Italy
Correspondence
Dr. Leandro Chambrone, Rua da Moóca, 2518, cj13, 03104-002, São Paulo, SP, Brazil.
Email: leandro_chambrone@hotmail.com
The demand for cosmetic medical treatments has increased
markedly over the past few years. In periodontology, the treat-
ment of gingival recessions (GR), especially on anterior teeth,
is being requested more and more frequently, and patient
expectations are very high.
For >5 decades, several surgical techniques have been pro-
posed to treat single and multiple GR.1–6 Between the 1960s
and early 1980s, pedicle flaps7–10 (i.e., laterally or coronally
positioned) and free gingival grafts11 were used to achieve
two main treatment goals: recession reduction and keratinized
tissue increase (Figures 1A through 1C). During the mid-
dle 1980s and early 2000s, new approaches, such as bilam-
inar techniques or regenerative procedures were proposed
to accomplish the goal of complete root coverage, as well.
These combined procedures were mainly based on a coronally
advanced flap (CAF) associated with subepithelial connective
tissue grafts (SCTG)12–15 (Figures 1D through 1F) or with a
non-resorbable barrier,16,17 a bioresorbable-barrier,17 enamel
matrix derivative (EMD),18 or acellular dermal matrix graft
(ADMG).19
In the last decade, (2000 to 2010) because of the ever-
increasing esthetic demands from patients, surgical tech-
niques have been further developed and improved using
microsurgical materials20 and microscope to obtain com-
plete root coverage associated with a perfect integration of
the grafted tissue with the adjacent soft tissues (Figures 1G
through 1I).21 These technical advances, as well as other sur-
gical aspects, reflected on the clinical improvements for the
majority of root coverage procedures.
J Periodontol. 2019;90:9–15. wileyonlinelibrary.com/journal/jper
1 W H AT I S HAP P ENING TO M E AN
ROOT COVERAG E ( M RC )
O UTCO M ES S INC E 1 9 8 5 ?
It could be argued that the introduction of subepithelial con-
nective tissue graft-based procedures in the middle 1980s12–14
promoted superior clinical improvements to those achieved
solely by CAF and laterally positioned flap alone. Histori-
cally, Langer and Langer's paper12 is considered the landmark
publication of root coverage with SCTG associated to CAF.
Since then, different systematic reviews could also display that
the majority of root coverage outcomes improved over time,
including those achieved by SCTG-based procedures.1–6
Thus, this assumption may permit the formulation of the fol-
lowing query: What is happening to mean root coverage out-
comes since 1985?
To answer this question, a comprehensive literature search
for short-term (i.e., 6 to 12 months follow-up) RCT assessing
the treatment of non-smoking patients with single Class I
and II GR22 not associated with non-carious cervical lesions,
published in the most traditional/important periodontal
journals (i.e., Journal of Periodontology, Journal of Clinical
Periodontology, Journal of Periodontal Research and Inter-
national Journal of Periodontics & Restorative Dentistry),
was performed (see the list of included RCTs in supplemen-
tary Appendix 1). Based on the ‘decision tree’ developed by
the 2015 AAP Regeneration Workshop,5,23 four of the most
currently indicated treatment approaches for the treatment
of GR and that have been studied/used since the 1990s were
© 2018 American Academy of Periodontology 9
10 CHAMBRONE AND PRATO

FIGURE 1 A) Years 1980 to 1990 (A through C). Recession on maxillary canine. B) A free gingival graft was performed. C) Recession
reduction and increased amount of keratinized gingiva associated with poor esthetics were achieved. D) Years 1990 to 2000 (D through F). Recession
on maxillary premolar. E) SCTG + CAF was carried out. F) Complete root coverage was obtained but the integration of the grafted tissue with the
adjacent soft tissue was not perfect. G) Years 2000–2015 (G through I). Recession on maxillary canine. H) CAF was performed using the
microscope and the microsurgical instruments. I) Complete root coverage and perfect integration of the flap-tissue with the adjacent soft tissues was
achieved providing an optimal esthetic result

FIGURE 2 Graphic estimates (i.e., trendlines) demonstrating the upward trend of MRC improvement over time (see the list of included RCTs
in supplementary Appendix 1 in online Journal of Periodontology). A) Pooled estimates. B) Individual estimates from each root coverage procedure
CHAMBRONE AND PRATO 11

FIGURE 3 Individual graphic estimates (see the list of included/quoted RCTs in supplementary Appendix 1 in online Journal of
Periodontology). A) SCTG-based procedures. B) CAF

FIGURE 4 Individual graphic estimates (see the list of included/quoted RCTs in supplementary Appendix 1 in online Journal of
Periodontology). A) ADMG + CAF. B) EMD + CAF
12
appraised: SCTG-based procedures, CAF, ADMG + CAF and
EMD + CAF. The findings of 75 RCT (115 treatment groups)
published in these journals between 1993 and 2017 showed
an overall mean root coverage (MRC) of 83.34% ± 12.46%,
with a range of 41.80% to 99.30% (Figure 2). Regarding MRC
of each individual surgical procedure (Figures 3 and 4), these
are depicted below: 1) SCTG-based procedures, 49 RCTs (63
groups), MRC of 86.97% ± 9.68% (range: 64.5% to 99.3%); 2)
CAF, 24 RCTs (28 groups), MRC of 75.20% ± 14.37% (range:
41.80% to 96.60%); 3) ADMG + CAF, 13 RCTs (16 groups),
MRC of 79.36% ± 14.02% (range: 50.00% to 97.10%); and 4)
EMD + CAF, 8 RCTs (8 groups), MRC of 90.25% ± 4.78%
(range: 80.0% to 95.10%). Overall, both pooled and individual
graphic estimates (i.e., trendlines) demonstrated the upward
trend of MRC improvement over time (Figures 2 through 4).
Based on these findings, it seems inspiring the formulation
of clinical understandings/questionings on the reasons associ-
ated with this optimistic ‘path’: which are the factors involved
with MRC improvements over time? Are they related to the
flap, the graft or the surgery?
2 CLINICA L I NSIGHTS ON T HE
ROLE OF THE FLAP, THE GRAFT,
AND THE SU RG E RY
Although the efficacy of root coverage procedures is diverse
and well documented,1–6 the analysis about which factors led
to those enhancements, regardless of the periodontal surgical
technique, deserves some clinical reflection. It has been
demonstrated by different systematic reviews1–6 that there
are dissimilarities in some ‘surgical features’ between studies
designed and/or conducted between the early 1990s and the
early-middle 2000s, such as 1) different flap thicknesses (i.e.,
split-, full- or mixed-) and designs (i.e., flaps without coronal
advancement, CAF covering the graft as much as possible,
CAF positioned at the CEJ level or 1- to 2-mm coronal to it,
envelope flap, double papilla flap, and tunnel flap); 2) use of
microinstruments and magnification; and 3) different types
of suture materials (i.e., silk, catgut, polytetrafluoroethylene,
monofilament), moments of suture removal (i.e., 7, 10, and
14 days), and suture sizes (i.e. 4-0 or 5-0).
2.1 The flap
It has been recognized by many preclinical and/or clinical
data that the surgical outcomes might be influenced by the
different conditions involving a suturing protocol (i.e., the
needle's characteristics, bite size, suture position, and loca-
tion of knots tied) and its specific materials (i.e., mechanical
properties and inflammatory tissue reaction induction).24
Tatakis and Chambrone24 after investigating the possible
effect of suturing protocols on root coverage outcomes stated
CHAMBRONE AND PRATO
“that early suture removal (<10 days postoperatively) can
negatively affect the attainable complete root coverage in
single-tooth recession-type defects treated by CAF alone".
Moreover, other key ‘flap improvements’ were evaluated
during the same period, for instance, the importance of
flap thickness (>0.8 mm);25 and tension (≤0.4 g)26 as well
as its post-surgical position of the gingival margin (1.5 to
2.0 mm)27 on the achievement of complete root coverage.
Additionally, evidence from subsequent trials suggests that
CAF without vertical releasing incisions, like the coronally
advanced tunnel flap28 and the envelope type of flap,29
might perform better than CAF with vertical incisions in
terms of reducing trauma,28,29 promoting lower postoper-
ative discomforts,28,29 improving complete root coverage
(CRC)29 and esthetics (i.e., reduce scar-tissue formation).29
Consequently, the issue of the increasing improvement of
root coverage outcomes displayed by the different types
of root coverage procedures perceptibly suggests that flap
preparation and management appear as the ‘key issue’
impacting overall root coverage outcomes over time.
2.2 The graft
Undeniably, it is well documented that the ‘gold standard’
for treatment of GR is the association of a CAF (i.e., with or
without releasing, tunnel) to SCTG.,1–6 as well as all types
of defects might be treated with this combined approach.5
On the other hand, the knowledge on the rational use of the
SCTG has improved over the last 30 years. With respect
to graft characteristics, it has been demonstrated that the
anatomy of the palatal vault plays an important role during
the decision-making process. Thus, the selection of a palatal
donor site (e.g., between the distal aspect of the canine and
the mid-palatal region of the second molar or tuberosity),
the method used to harvest the graft (e.g., trap door, parallel
incision method, or deepithelialized free gingival graft) and
the cellular composition of these grafts may vary.5 There is
clear evidence that the use of CAF with SCTG and ADMG
leads to periodontal biotype changes, that is these grafting
procedures may unequivocally change thin periodontal
biotypes of recession sites to thick periodontal biotypes.5
Moreover, tissue thickening achieved by these types of
grafts as suggested by Ahmedbeyli et al.’s30 trial on ADMG
use as an alternative approach to autogenous grafts, suggests
that the thicker recipient site's gingival thickness after treat-
ment, the higher the chance of CRC achievement.30
On the other hand, it has been suggested that big grafts
might not be required, especially at anterior/esthetic sites. For
instance, trials by Zucchelli et al.31,32 demonstrated the lack
of differences in root coverage clinical outcomes between big
and small grafts, as well as identified improved positive results
for reduced size grafts in terms of patient-reported outcomes.
In the first study, the use of SCTG with reduced dimensions
CHAMBRONE AND PRATO
(i.e., equal to the depth of the bone dehiscence and with a
graft thickness [GT] <1 mm) and positioned apical to the
cemento-enamel junction (CEJ) allowed better coverage by
the CAF, improved esthetics and provided similar root cov-
erage than conventional size/big size grafts (i.e.,apicocoronal
dimension 3 mm greater than the depth of the bone dehis-
cence and GT > 1 mm) positioned at the level of CEJ.30 The
second trial recognized that even smaller grafts (i.e., deepithe-
lialized FFG 4 mm-high with GT <2 mm) inflicted less donor
site morbidity/pain and promoted better color match than big-
ger grafts (i.e., bone height equal to the bone dehiscence and
GT ≥ 2 mm).32
In addition, there is some recent evidence suggesting the
selective use of grafting procedures to treat GR. Cairo et al.33
recommended that the use of SCTG for the treatment of mul-
tiple recession-type defects in esthetic sites (i.e., the anterior
area of the maxilla) could be avoided at sites with a keratinized
thickness > 0.8 mm, where the use of CAF alone is associated
with similar clinical outcomes and better esthetics. Similarly,
Stefanini et al.34 found high, comparable and stable MRC and
complete root coverage (i.e., 93% for CAF alone and 100%
for SCTG + CAF) rates for teeth treated with or without the
adjunct use of SCTG at 1- and 3-year follow-ups, when: 1)
sites with a KT band >2 mm were treated only with CAF;
and 2) sites with a KT band <1 mm or between 1 and 2 mm
and gingival thickness <1 mm were treated with SCTG with
reduced dimensions (i.e., thin and small grafts). In addition,
it should be accounted that the base of evidence clearly indi-
cates that defects submitted to biotype modification of the GR
site (i.e., KT gain and soft tissue thickening) benefited from
better long-term stability and less GR recurrence,5,35,36 but
this assumption still need to be confirmed for such SCTG site-
specific applications.
2.3 The surgery
In addition, and as mentioned above, flap preparation and
suture have evolved over the last 3 decades, and much of these
advances are related to the development of new microsurgical
instruments and the use magnification.5,37 The use of these
devices seems to allow for less traumatic procedures, the
accomplishment of better flap refinement and stability, and
improved wound healing35 (from the early formation and
maintenance of a blood clot to the establishment of a long
junctional epithelium and a connective tissue attachment
to the previously denuded root dentin).5,24 Conversely, this
condition per se may not certify that the results of therapy are
going to be much better than those achieved by macro proce-
dures. In this clinical context, it is also important to highlight
the learning curve, the operator skill levels and patients’
compliance to treatment, and the aforementioned flap changes
mirror the expected development of clinical practice and
thus allowed improvements on the short-term outcomes of
13
the different root coverage procedures.34,35 Nonetheless,
the graphic estimates reported in this work are presumably
potential indicatives of the ongoing improvements achieved
by efficacy research that shall guide the decision-making
process (i.e., to give support to the use of new surgical
approaches in private practice)38 during the next years.
3 CONC LU SI ON S
There is clear evidence indicating that the methods/ways
used to prepare and manage the flap will reflect on the final
root coverage outcomes, regardless of the use of SCTG or
other soft tissue substitutes/biomaterials. Less traumatic flap
dissection and stabilization appear as chief elements for the
achievement of early and positive results. These flap condi-
tions are certainly well-known and are not new, but it's still of
paramount importance to always remember one of Mörmann
and Ciancio's postulates:39 ‘minimal tension should be
produced by suturing techniques and the tissue should be
managed gently during the surgical procedure’. It seems
important to consider that at short-term (up to 12 months
follow-up) the overall treatment results seems to be ‘clini-
cally equivalent’ (i.e., achievement of similar recession depth
reduction and attachment level gain). Furthermore, from a
clinical point of view, SCTG-based procedures might be
selected to treat any kind of recession, but their current/recent
indications also suggest that selective approaches could
be preferable to prevent some sort of ‘overtreatment’ (i.e.,
thickening of gingiva at sites already presenting GT >0.8 to
1.00 mm). Conversely, this clinical equivalency of procedures
at short-term does not seem to reflect treatment stability at
medium- and long-term (>5 years) follow-up. Therefore,
long-term studies are needed to explore the stability of gin-
gival margin following root coverage procedures over time.
ACKNOW LEDGMENTS
We would like to thank Dr. Francesco Cairo (Research Unit
in Periodontology and Periodontal Medicine, Department
of Surgery and Translational Medicine, University of Flo-
rence, Florence, Italy) for providing Figures 1G through 1I.
The authors report no conflicts of interest related to this
commentary.
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CHAMBRONE AND PRATO 15

36. Pini Prato GP, Franceschi D, Cortellini P, Chambrone L. Long- S U P P O RT I NG IN FO R M AT I O N

term evaluation (20 years) of the outcomes of subepithelial
Additional supporting information may be found online in the
connective tissue graft plus coronally advanced flap in the treat-
Supporting Information section at the end of the article.
ment of maxillary single recession-type defects. J Periodontol.
2018;89:1290–1299. https://doi.org/10.1002/JPER.17-0619
37. Burkhardt R, Lang NP. Fundamental principles in periodontal plas- How to cite this article: Chambrone L, Pini Prato GP.
tic surgery and mucosal augmentation – a narrative review. J Clin Clinical insights about the evolution of root coverage
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