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Volume 71 • Number 2

Coronally Advanced Flap Procedure for

Root Coverage. Flap With Tension Versus
Flap Without Tension: A Randomized
Controlled Clinical Study
Giovanpaolo Pini Prato,* Umberto Pagliaro,† Carlo Baldi,‡ Michele Nieri,§ Daniele Saletta,§
Francesco Cairo, and Pierpaolo Cortellini§

Background: This clinical controlled study was designed to measure the tension of coronally advanced
flaps (CAF) performed to treat shallow gingival recessions and to compare the recession reduction (Rec
Red) achieved in a test group (flaps with tension) and in a control group (flaps without tension) 3 months
after surgery.
Methods: Eleven patients, aged 22 to 41 years, with high levels of oral hygiene (full mouth plaque score
<20%) were selected for the study. Each patient showed 2 bilateral Miller Class I maxillary or mandibular
gingival recessions located on homologous teeth. A total of 22 recessions were treated. The recession depth
at the right site was similar to that at the left site (difference ≤1 mm). For each patient, the 2 recessions
underwent CAF procedure in the same surgical session. Before suturing, the residual tension (FTens) of both
right and left flaps was measured with a dynamometer. Then, one site was randomly assigned to the test
group and the contralateral site to the control group. In the test site the flap was sutured. In the control site
the flap was further relaxed, the tension was measured again, and the flap was sutured.
Results: In the test group (with tension) the initial mean recession depth was 2.82 ± 0.64 mm and mean
FTens was 6.5 g, while in the control group (without tension) the initial mean recession depth was 2.68 ±
0.81 mm and mean FTens was 0.4 g. Three months later, the test group showed a mean recession reduc-
tion of 2.18 ± 0.60 mm, a mean percent root coverage of 78 ± 15%, and complete root coverage was
achieved on 2 teeth (18%). In the control group the mean recession reduction was 2.32 ± 0.81 mm and
mean percent root coverage was 87 ± 13%. Complete root coverage was obtained on 5 teeth (45%). The
difference of recession reduction between the test and control group was not statistically significant (P =
0.3911). In the test group, linear regression analysis showed a statistically significant association between
recession reduction and both recession depth at baseline (P = 0.0001) and mean of the 3 tensions recorded
on the test side (MFTens) (P = 0.0009).
Conclusions: This study shows that minimal flap tension does not influence recession reduction after 3
months when shallow recessions are treated by means of CAF. In the test group (with tension), the statis-
tical analysis suggests that the higher the flap tension, the lower the recession reduction. J Periodontol
2000;71:188-201.
KEY WORDS
Clinical trials, controlled; gingival recession/surgery; surgical flaps; follow-up studies.

* Dental School, University of Florence, Italy.

† Private practice, Campi Bisenzio, Italy.
‡ Private practice, Prato, Italy.
§ Private practice, Florence, Italy.
 Department of Periodontology, University of Siena, Italy.

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J Periodontol • February 2000
oronally advanced flap (CAF)1-7 is a predictable
C mucogingival surgical procedure used to achieve
root coverage in the treatment of Miller Class I
and II gingival recessions.8
Best clinical outcomes in terms of root coverage are
reported when the flap is passively adapted to the
exposed root surface and the gingival margin (GM) is
positioned at the cemento-enamel junction (CEJ).1-7,9
Root prominence, presence of frena, type of peri-
odontium, recession depth, and depth of vestibulum
may influence the shift of the coronally advanced flap
towards the CEJ: passively and completely relaxed
or slightly pulled because of residual tension within
the flap. In the first case, sutures stabilize the flap in
the correct position without tension. In the second
case sutures overcome tension and stabilize the flap
at the CEJ.
No study has ever measured the tension of the coro-
nally advanced flap nor whether this tension can influ-
ence the final root coverage. The aims of this con-
trolled randomized clinical study are to measure the
tension of CAF before suturing and to compare the
recession reduction following CAF with or without ten-
sion.
MATERIALS AND METHODS
Study Population
This randomized intra-individual double-blind prospec-
tive clinical trial was performed on a sample of 11
patients, 4 males and 7 females, aged between 22 and
41 years (mean 32.3 ± 6.3), 3 of whom were smok-
ers, with maxillary or mandibular bilateral gingival
recessions, which were treated with CAF procedure
between January and May 1997. All patients showed
2 similar bilateral recessions situated on homologous
teeth. The patients were selected among individuals
referred to private practices. The patients agreed to
participate in the study and signed an appropriate con-
sent form in agreement with the Helsinki Declaration
on human experimentation.
Inclusion Criteria
The following inclusion criteria for participation to the
study were used: 1) non-compromised systemic health
and no contraindications for periodontal surgery; 2)
presence of Miller Class I8 maxillary or mandibular
bilateral buccal recessions (≥2 mm); 3) difference in
extension of the gingival recession between right and
left site ≤1 mm and difference in clinical attachment
level ≤1 mm; 4) presence of identifiable cemento-
enamel junction (CEJ); 5) tooth vitality and absence
of grooves, irregularities, caries, or restorations in the
area to be treated; 6) no periodontal surgical treat-
ments in the previous 24 months on the involved
sites; 7) full-mouth plaque score (FMPS)10 <20% and
Pini Prato, Pagliaro, Baldi, et al.
full-mouth bleeding score (FMBS)11 <20%; and 8)
absence of plaque and bleeding on probing at the
selected sites.
Before surgery, all patients received oral hygiene
instructions to eliminate habits related to the etiol-
ogy of the recession. All 22 recessions underwent a
CAF procedure. The study design is illustrated in
Table 1.
Surgical Procedure
All surgical procedures were performed by one oper-
ator with more than 10 years of clinical experience.
Each pair of recessions was treated in the same sur-
gical session.
After scaling and root planing with sharp curets
under local anesthesia (lidocaine with adrenaline and
noradrenaline 150.000), an intrasulcular incision was
performed with a surgical blade on the buccal aspect
of the involved tooth. This incision was horizontally
extended mesiodistally to dissect the buccal aspect of
the adjacent papillae avoiding the gingival margin of
the adjacent teeth. Two oblique releasing incisions were
carried out from the mesial and distal extremities of the
horizontal incisions across the mucogingival junction
reaching the alveolar mucosa. A trapezoidal full thick-
ness flap was raised with a periosteal elevator towards
the mucogingival junction. A partial thickness dissec-
tion was carried out apically toward the marginal bone
crest leaving the underlying periosteum in place. The
dissection was extended in the mesiodistal and api-
cal directions to release residual muscle tension and
facilitate the passive coronal displacement of the flap.
Table 1.
Study Design
Recession
Coronally Advanced Flap
Measurement of residual flap tension
Randomization
Test Group Control group
Further releasing incisions
Measurement of flap tension
Suture to CEJ Suture to CEJ
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Measurement of Flap Tension in Root Coverage Treatment Volume 71 • Number 2

The papillae adjacent to the involved tooth were de- At the test site, the 3 previous measurements of the
epithelialized. The flap was then coronally displaced. tension were recorded and the flap was sutured to
cover the CEJ (Fig. 2).
At the control site, the flap was further relaxed
Measurements of Tension improving the dissection with the underlying perios-
When the surgeon considered the flap elevation com- teum and/or extending the lateral releasing incisions
pleted and the flaps were sufficiently mobile to reach in the alveolar mucosa (Fig. 2).
the CEJ when shifted with pliers, the residual tension When the flap reached the CEJ passively and could
of both flaps was measured. All measurements were not be displaced when moving the lips (traction on
collected with a dynamometer by a second clinician vestibulum), 3 further measurements were obtained
blind to the procedure (Fig. 1). and recorded. The flap was considered without ten-
To obtain these measurements the patient was sion when 2 measurements were almost equal to 0
seated so that the direction of the traction exerted on grams and the third one ranged from 0 to 2 grams. The
the dynamometer was on the vertical plane on both flap was then sutured to cover the CEJ (Fig. 2). In all
dental arches. treated cases (test and control sites) the gingival mar-
A 5-0 silk suture connected the coronal portion of gin was positioned to cover the CEJ completely. No
the flap to the hook of the dynamometer (Fig. 1). When periodontal dressing was applied.
the coronal margin of the flap reached the CEJ, the
tension was recorded. The measurement was repeated Postsurgical Care
3 times at short intervals (approximately 10 seconds). Immediately following surgery, use of ice packs was
The 2 surgical sites in each patient were measured recommended for 3 hours. All patients were instructed
with the same procedure. to discontinue toothbrushing, avoid trauma around the
surgical site, and reduce smoking. A 0.12% chlorhex-
idine digluconate solution rinse was prescribed 4 times
Split-Mouth Design (60 seconds)/day for the first 10 days and the use of
The sites were assigned to 2 treatment groups (test and nimesulide (100 mg twice daily) was recommended for
control) by tossing a coin. pain.
The sutures were removed
after 10 days. All patients
were instructed to clean the
surgical sites with a cotton
pellet soaked in a 0.12%
chlorhexidine digluconate
solution, 4 times daily for the
next 10 days. Three weeks
after surgery, the patients
were instructed to resume
mechanical tooth cleaning of
the treated areas using a soft
toothbrush and a careful roll-
technique. All patients were
recalled for control and pro-
phylaxis after 1, 2, 3, and 4
weeks and, subsequently,
once a month, until the final
examination (3 months).
Data Collection
All measurements were
recorded by one investigator
blind to the surgical proce-
dure, with more than 10
years of clinical experience,
using a periodontal probe and
Figure 1. 3× magnification lens. All
Measurement technique with the dynamometer. Left: Dynamometer; Right: A silk suture connects the
flap and the dynamometer. measurements were rounded
to the nearest 0.5 mm.

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J Periodontol • February 2000 Pini Prato, Pagliaro, Baldi, et al.

5. Anatomical crown length (IM-CEJ): dis-

tance between incisal margin (IM) and CEJ. It
represents the apico-coronal dimension of the
anatomic crown.
6. Distance between IM and GM (IM-GM):
measured to evaluate the position of the gingival
margin when the CEJ was masked by the flap
after surgery and to measure gingival margin dis-
placement, if any, during the follow-up period.
7. Distance between IM and mucogingival
junction (IM-MGJ): measured to evaluate the
position of the MGJ before and after surgery and
to detect its possible shift during the follow-up
period in the treated area.
During surgery, after the elevation of the flap,
flap tension (FTens) was measured 3 times on each
site with the dynamometer. The mean of the 3
measurements was calculated and named MFTens.
Immediately after surgery, IM-GM was recorded
at the mid-buccal point of the surgical site. The
position of the GM in relation to CEJ (GM1) was
calculated subtracting IM-CEJ from IM-GM.
At 1, 2, 3, and 4 weeks, and 2 and 3 months
postsurgery, the following measurements were
collected at the same mid-buccal point of the
involved tooth: Rec, IM-GM, IM-MGJ, KT.
At 3 months, PD and CAL were also recorded.
Dentin hypersensitivity was recorded as present
or absent at baseline and 3 months postsurgery.

Figure 2.
Case 1. Upper left frame (test site).The dynamometer is applied to the flap.
The tension is demonstrated by the presence of the indicator. Upper right
frame (control site).The dynamometer is applied.The indicator, which remains
inside of the dynamometer, demonstrates the lack of tension. Lower frame:
Test and control sites after suturing.
Before surgery (baseline) the following measure-
ments were collected at the mid-buccal point of the
involved tooth:
1. Recession depth (Rec): distance between CEJ
and the gingival margin (GM).
2. Probing depth (PD): distance between GM and the
bottom of the pocket.
3. Clinical attachment level (CAL): calculated as
Rec + PD.
4. Width of keratinized tissue (KT): distance between
GM and mucogingival junction (MGJ).
Statistical Analysis
Quantitative data were summarized as means ±
standard deviation.The possible presence of ran-
domization imbalance was checked for GM1
immediately postsurgery by means of ANOVA
test matched for patient. Differences in reduc-
tion of recession between treatment groups were
analyzed with the ANOVA test matched for
patient. The 95% confidence intervals for the
difference in recession reduction were also cal-
culated. The power of the test was calculated for
recession reduction as an outcome variable con-
sidering a mean difference between treatment
groups of 0.5 mm clinically significant. Differ-
ences in reduction of recession and loss of KT
between treatment groups were also analyzed con-
sidering recession at baseline as a covariate for reces-
sion reduction and KT as a covariate for loss of KT.
In the test group an explorative analysis was also per-
formed. A linear regression analysis using recession
reduction (Rec Red) as an outcome variable and both
recession at baseline (Rec) and the mean of the 3
tensions recorded on the test side (MFTens) as regres-
sors was utilized. Model diagnostics always included
analysis of studentized residual and partial regres-
sion leverage plot. The significance of the contribu-

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Measurement of Flap Tension in Root Coverage Treatment Volume 71 • Number 2

tion of each factor to the models was assessed using
a statistical software program.
RESULTS
Eleven patients contributed with similar bilateral reces-
sions situated on homologous teeth (2 maxillary lateral
incisors, 2 mandibular lateral incisors, 12 maxillary
canines, 2 mandibular canines, and 4 maxillary pre-
molars).
The average initial recession depth at baseline for
all 22 sites was 2.75 ± 0.72 mm, (range 2 to 4 mm).
Recession reduction in all the sites was 2.25 ± 0.70 mm

Table 2.
Test Group (with tension; all Miller Class I recessions)

Baseline

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

1 F 33 No 13 No 11 3 14 3 17 1 4

2 M 27 No 24 Yes 8 3 11 4 15 1 4

3 F 26 No 42 Yes 10.5 3 14 3 17 1 4

4 F 35 No 23 Yes 11 2 13 3 16 1 3

5 F 22 Yes 25 No 10 3 13 2 15 1 4

6 F 26 No 23 No 12 3 15 2 17 0.5 3.5

7 M 41 Yes 22 No 9 3.5 12.5 2.5 15 1.5 5

8 M 39 No 23 Yes 8 2 10 4 14 1 3

9 F 38 Yes 43 Yes 12 2 14 2.5 16.5 1 3

10 F 37 No 23 Yes 10 4 14 4 18 0.5 4.5

11 M 31 No 23 No 10 2.5 12.5 4 17 1 3.5

Mean 32.27 10.14 2.82 13.00 3.09 16.14 0.95 3.77

Periodontal measurements are expressed in millimeters (mm) and flap tension in grams (g).
Key: HS: dental hypersensitivity; IM-CEJ: incisal margin - cemento-enamel junction; Rec: recession; IM-GM: incisal margin - gingival margin; KT: keratinized tissue
width; IM-MGJ: incisal margin - mucogingival junction; PD: probing depth; CAL: clinical attachment level; FTens: flap tension; Rec Red: recession reduction; % RC:
percent of root coverage.

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J Periodontol • February 2000 Pini Prato, Pagliaro, Baldi, et al.

3 months after surgery. The average percentage of
root coverage was 82 ± 14%. Seven teeth (32%)
showed complete root coverage.
Ten patients reported dentin hypersensitivity on a
total of 12 teeth at baseline. Five sites in 4 patients
showed dentin hypersensitivity 3 months after surgery.
All patients were satisfied with the final esthetic appear-
ance.
Test Group (with tension)
Baseline, surgery, and 3-month data are presented in
Table 2. Mean flap tension (mean MFTens) recorded

Table 2. (continued)
Test Group (with tension; all Miller Class I recessions)

Surgery 3-Month Follow-up

FTens IM-GM HS Rec IM-GM KT IM-MGJ PD CAL Rec Red % RC

7
4 9.5 No 0.5 11.5 2.5 14 0.5 1 2.5 83
8

6
6 7 Yes 0.5 8.5 4 12.5 1 1.5 2.5 83
4

12
9 9 Yes 1.5 11.5 3 14.5 0.5 2 1.5 50
10

4
5 9.5 Yes 0.5 11.5 2.5 14 0.5 1 1.5 75
4

10
8 9 No 1 11 2.5 13.5 0.5 1.5 2 66.7
7

11
9 10.5 No 1 13 2 15 0.5 1.5 2 66.7
12

7
8 8.5 No 1 10 2 12 1 2 2.5 71
6

4
5 7 No 0 8 3.5 11.5 0.5 0.5 2 100
3

6
5 11 No 0.5 12.5 2 14.5 0.5 1 1.5 75
6

5
5 9 No 0.5 10.5 3.5 14 1 1.5 3.5 87.5
6

3
5 8 No 0 10 3.5 13.5 1 1 2.5 100
4

6.48 8.91 0.64 10.73 2.82 13.55 0.68 1.32 2.18 78

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Measurement of Flap Tension in Root Coverage Treatment
Figure 3.
Test group: percent root coverage and flap tension in each patient.The number at the base of each bar indicates patient in Table 2.Tension (g) is
shown in each bar.
at surgery was 6.5 g. The initial mean recession depth
was 2.82 ± 0.64 mm (range 2 to 4 mm). Three months
after surgery the mean recession was 0.64 ± 0.45,
mean recession reduction was 2.18 ± 0.60 mm and
mean root coverage was 78 ± 15%. Two teeth (18%)
achieved complete root coverage.
Mean probing depth (PD) was 0.95 ± 0.27 mm at
baseline, and 3 months after surgery it was 0.68 ± 0.25
mm. The initial clinical attachment level (CAL) was
3.77 ± 0.65 mm; 3 months later it was 1.32 ± 0.46 mm.
The initial keratinized tissue (KT) width was 3.09 ±
0.80 mm on average; 3 months after surgery it was
2.82 ± 0.72 mm.
Six sites showed dentin hypersensitivity at baseline
and 3 at the 3-month follow-up visit.
Figure 3 shows the flap tension and the percentage
of root coverage in each patient. Patients 8 and 11, who
obtained 100% of root coverage, were those that pre-
sented lower residual tension.
Multiple linear regression executed on the test sites
for recession reduction as an outcome variable showed
a significant association between recession reduction
and both recession depth at baseline (P = 0.0001) and
MFTens (P = 0.0009) (Fig. 4 and Table 3).
Case 10 is illustrated in Figures 5 and 6 (page 198).
194
Volume 71 • Number 2
Control Group (without tension)
Baseline, surgery, and 3-month data are presented in
Table 4.
Mean flap tension (Mean MFTens) recorded during
surgery was 0.4 g. The initial recession depth was 2.68
± 0.81 mm (range 2 to 4 mm). Three months after
surgery the mean recession was 0.36 ± 0.39, mean
recession reduction was 2.32 ± 0.81 mm, and mean
root coverage was 87 ± 13%. Five teeth (45%) achieved
complete root coverage.
Mean probing depth (PD) was 1.09 ± 0.38 mm at
baseline and 3 months after surgery it was 0.64 ±
0.23 mm. The initial clinical attachment level (CAL)
was 3.77 ± 0.96 mm; 3 months later it was 1.00 ±
0.50 mm.
The initial keratinized tissue (KT) width was on aver-
age 2.82 ± 0.87 mm; 3 months after surgery it was
2.55 ± 0.93 mm.
Six sites showed dentin hypersensitivity at baseline
and 2 of these sites presented with hypersensitivity at
the 3 month follow-up visit.
Case 10 is illustrated in Figures 7 and 8.
Comparison Between Test and Control Groups
No statistically significant differences were detected
between test and control groups for the position of gin-
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Table 3. as an outcome vari-

Multiple Linear Regression Analysis for Recession Reduction (test
group)
Parameter Estimates Table
Parameter Estimates Estimate Lower 95% Upper 95%
b0 (Intercept) 0.64 –0.10
b1 (Rec) 0.92 0.65
b2 (MFTens) –0.16 –0.24
The outcome variable is Rec Red and the predictor variables are recession at baseline (Rec) and mean flap tension (MFTens). cally significant differ-
The Parameter Estimates Table lists the estimates and standard errors for b0, b1 and b2. Lower 95% and Upper 95% represent ence between the two
the confidential limits for the estimate.
Model: Rec Red = β0 + β1 Rec + β2 MFTens + ε
R2 = 0.89
gival margin after suturing (GM1) (P = 0.6595). No
statistically significant differences in recession reduc-
tion were detected between test (2.18 ± 0.60 mm) and
control groups (2.32 ± 0.81 mm) 3 months after
surgery (mean difference: 0.14 mm; P = 0.3911) (Table
5). The 95% confidence limits for the mean recession
reduction difference at 3 months post-surgery, esti-
mated 0.14 mm, were −0.20 mm and +0.48 mm.
Power calculation concerning recession reduction
Figure 4.
Partial regression leverage plot for recession reduction (FTens) in
test group.The linear relationship between recession reduction
(RecRed) and MFTens is shown when the other regressor
(recession at baseline) is used.The dotted lines represent 95%
confidence interval of the regression line.
able shows that this
study could have
detected a difference
between the 2 treat-
ments of 0.5 mm
Standard Error t Ratio P value with a 84% power at
a significance level of
1.38 0.32 2.00 0.0804 α = 0.05. If the initial
1.19 0.12 7.90 <0.0001 recession depth was
used as a covariate,
–0.09 0.03 –5.14 0.0009 there was no statisti-
groups (P = 0.1053).
Regarding changes
in keratinized tissue
(KT) width, both
groups show a slight reduction at the 3-month follow-
up. The difference between test and control group was
not statistically significant (P = 1.000), even if the width
of initial KT was used as a covariate (P = 0.6538).
Figure 9 shows the comparison in terms of mean
recession (Rec), mean keratinized tissue (KT) width
and mean flap tension (FTens) between test and con-
trol group at baseline, at surgery, and 3 months later.
DISCUSSION
Flap tension has been reported as an important fac-
tor in the surgical treatment of gingival recessions.1-7
No paper has ever measured the quantity of such ten-
sion nor compared root coverage by comparing flaps
sutured under different tensions. In the present study
the tension of a coronally advanced flap (CAF) was
measured by a dynamometer.
The tension was measured in the test group (with
tension) once the surgeon had judged the flap suffi-
ciently released for ethical reasons, and therefore con-
sidered the procedure complete. In this group the aver-
age residual tension of the flap was 6.5 grams (ranging
from 4 g to 10.7 g). This measurement demonstrates
that after CAF procedure, a certain amount of resid-
ual tension can remain in the flap that has already
been clinically judged as completely released. In the
test group, the average root coverage was 78 ± 15%
and 2 cases (18%) showed a complete root coverage.
The results of this group are in line with the data pre-
sented in the literature.1-7 Therefore, some reduced
residual tension is compatible with good root coverage.
Once the procedure was deemed complete by the
surgeon, the residual tension was reduced in the con-
trol group (without tension) with further incisions
obtaining an average of 0.4 grams (ranging from 0.0
g to 0.7 g). In this group, the average root coverage
was 87 ± 13% with 5 cases (45%) showing complete
root coverage.

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Measurement of Flap Tension in Root Coverage Treatment Volume 71 • Number 2

Table 4.
Control Group (without tension; all Miller Class I recessions)

Baseline

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

1 F 33 No 23 Yes 10 3.5 14 2 16 1 4.5

2 M 27 No 14 Yes 8 2.5 11 4 15 1.5 4

3 F 26 No 32 No 10.5 3 13.5 3 17 1 4

4 F 35 No 13 No 11 2 13 2 15 1 3

5 F 22 Yes 15 Yes 9 2 11 3 14 1 3

6 F 26 No 13 Yes 12 2.5 15 4 19 1 3.5

7 M 41 Yes 12 No 9 4 13 2 15 2 6

8 M 39 No 13 No 9 2 11 2 13 1 3

9 F 38 Yes 33 No 11 2 13 2 15 1 3

10 F 37 No 13 Yes 10 4 13 3 16 0.5 4.5

11 M 31 No 13 Yes 11 2 13 4 17 1 3

Mean 32.27 10.05 2.68 12.77 2.82 15.64 1.09 3.77

Periodontal measurements are expressed in millimeters (mm) and flap tension in grams (g).
Key: HS: dental hypersensitivity; IM-CEJ: incisal margin - cemento-enamel junction; Rec: recession; IM-GM: incisal margin - gingival margin; KT: keratinized tissue
width; IM-MGJ: incisal margin - mucogingival junction; PD: probing depth; CAL: clinical attachment level; FTens: flap tension; Rec Red: recession reduction; % RC:
percent of root coverage.

Although there were distinct clinical differences,
statistical analysis did not show significant differ-
ences in recession reduction between test and con-
trol groups 3 months after surgery. These statistical
results were surprising. Contrary to our clinical expec-
tations and the conclusions in current literature, the
elimination of the residual tension of the flap with
further releasing incisions did not produce a signifi-
cant statistical improvement in terms of root cover-
age.
This fact may be explained by the presence of other
factors. Some of these factors may not be linked to flap
tension (i.e., root prominence) and may condition the
outcome of the CAF.

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Table 4. (continued)
Control Group (without tension; all Miller Class I recessions)

Surgery 3-Month Follow-up

FTens IM-GM HS Rec IM-GM KT IM-MGJ PD CAL Rec Red % RC

0
0 9 No 0 10 2 12 0.5 0.5 3.5 100
1

0
0 7 Yes 0.5 8.5 3.5 12 1 1.5 2 80
1

2
0 8.5 No 1 11.5 2.5 14 0.5 1.5 2 66.7
0

0
0 10.5 No 0 11 1.5 12.5 0.5 0.5 2 100
2

1
0 7 No 0 9 3 12 1 1 2 100
0

1
0 11 Yes 0.5 12.5 4 16.5 0.5 1 2 80
0

1
0 8 No 1 10 1 11 1 2 3 75
0

0
2 7.5 No 0.5 9.5 2 11.5 0.5 1 1.5 75
0

0
0 11 No 0.5 11.5 2 13.5 0.5 1 1.5 75
0

0
0 9 No 0 10 3 13 0.5 0.5 4 100
0

0
1 9.5 No 0 11 3.5 14.5 0.5 0.5 2 100
0

0.36 8.91 0.36 10.41 2.55 12.95 0.64 1.00 2.32 87

In addition, flap thickness should be also taken into
consideration. The further releasing incisions that are
necessary in the elimination of residual tension pro-
duce a reduction in the flap thickness. The major
thickness of the CAF is directly related to an improve-
ment in root coverage as demonstrated by a previ-
ous study.7
Even though this study was designed to compare the
clinical outcome of CAF with or without tension, for
exploratory reasons, a further analysis was conducted
solely on the test group results (with tension) which
provided some interesting results.
Descriptive statistics show that 2 sites out of 11 that
obtained complete root coverage were those who pre-

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Measurement of Flap Tension in Root Coverage Treatment Volume 71 • Number 2

Figure 5.
Test site of case 10. Upper left frame: 4 mm gingival recession. Upper right frame: the flap is
coronally displaced. Lower left frame: the dynamometer in position. Lower right frame: 5 g tension.

Figure 6.
Test site of case 10. Upper left frame: the CAF after suturing. Gingival margin (GM1) is displaced 1 mm
coronally to CEJ. Upper right frame: 10 days later, before suture removal. Gingival margin is slightly
shifted in apical direction. Lower left frame: healing after 3 months. Lower right frame: 0.5 mm
residual recession at 3 months.

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J Periodontol • February 2000 Pini Prato, Pagliaro, Baldi, et al.

Figure 7.
Control site of case 10. Upper left frame: 4 mm gingival recession. Upper right frame: the flap is
coronally displaced. Lower left frame: the dynamometer in position. Lower right frame: 0 g tension.

Figure 8.
Control site of case 10. Upper left frame: the CAF after suturing. Gingival margin (GM1) is displaced 1
mm coronally to CEJ. Upper right frame: 10 days later, before suture removal. Gingival margin is slightly
inflamed. Lower left frame: healing after 3 months.The gingival margin is in correspondence of CEJ.
Lower right frame: 100% complete coverage at 3 months.

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Measurement of Flap Tension in Root Coverage Treatment Volume 71 • Number 2

Figure 9.
Means of recession depth (Rec), width of gingiva (KT), and flap tension (FTens) at baseline, surgery, and 3-month follow-up both in test and control
groups. CEJ: cemento-enamel junction; GM: gingival margin; MGJ: mucogingival junction.The white areas represent the exposed root surface; the
numbers in the white areas indicate the mean recession depth values (mm).The gray areas represent the keratinized tissue width (KT); the numbers
in gray areas indicate the mean width values of KT (mm). The striped areas represent the alveolar mucosa. Mean flap tension (FTens) at surgery is
reported below CEJ.

Table 5. pendent variables. The results

of this analysis demonstrated
ANOVA Table
a significant statistical rela-
tion between the increase of
Sum of Squares DF Means Square F-Ratio P value
the tension and the reduction
Treatment (Test vs. Control) 0.103 1 0.103 0.804 0.3911 of the recession (P =
0.0009). Although the lim-
Patient 9.000 10 0.900 7.071 0.0024
ited number of the sites give
Error 1.273 10 0.127 an explorative value to this
Recession reduction is the outcome variable.
analysis, the R2 = 0.89, the
partial regression leverage
plot, and analysis of student-
sented the lowest residual tension (4 g). In the other ized residual prove the statistical validity of the model.
9 sites in this group as the flap tension increases, the Based on this analysis, it can be assumed that on
root coverage decreases (Fig. 3). the test sites (with tension) of this study a greater flap
In addition, an inferential statistical investigation of tension is related to a lower recession reduction; fur-
an explorative nature was performed in this group in ther studies are necessary to confirm these data.
order to highlight the influence of an increase in the The technique used to measure the tension of the
tension on root coverage. A multiple linear regression flap should be improved because the dynamometer
analysis was conducted in which the reduction of the utilized was not built for this purpose. A more accu-
recession was the dependent variable, while the initial rate device to measure flap tension is preferable.
recession depth and the flap tension were the inde- Regarding the width of keratinized tissue (KT), the

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J Periodontol • February 2000 Pini Prato, Pagliaro, Baldi, et al.

reduction of KT width at 3 months was similar in the 7. Baldi C, Pini-Prato GP, Pagliaro U, et al. Coronally
test and control groups. The smaller recession reduc- advanced flap procedure for root coverage. Is flap thick-
ness a relevant predictor to achieve root coverage? A 19-
tion at 3 months was obtained in the test group; this
case series. J Periodontol 1999;70:1077-1084.
may be due to a shift of the flap in the apical direc- 8. Miller PD. A classification of marginal tissue recession.
tion that was greater in the test group in respect to Int J Periodontics Restorative Dent 1985;5(2):9-13.
the control group (Fig. 9). These results agree with 9. Mörmann W, Ciancio SG. Blood supply of human gin-
those of a previous study.6 giva following periodontal surgery. A fluorescein angio-
graphic study. J Periodontol 1977;48:681-692.
Finally, a short-term follow-up was purposely set at
10. O’Leary TJ, Drake RB, Naylor JE. The plaque control
3 months in order 1) to verify the true effectiveness of record. J Periodontol 1972;43:38-42.
CAF in terms of “primary root coverage;” 2) to mini- 11. Ainamo J, Bay I. Problems and proposals for recording
mize the risk of confounding the interpretation of the gingivitis and plaque. Int Dent J 1975;25:229-235.
results with “secondary root coverage”12-13 due to the 12. Laney JB, Saunders VG, Garnick JJ. A comparison of
two techniques for attaining root coverage. J Periodon-
creeping attachment;14 and 3) to avoid influences due
tol 1992;63:19-23.
to possible damage of the gingival margin caused by 13. Matter J. Creeping attachment of free gingival grafts: A
traumatic tooth brushing. five-year follow-up study. J Periodontol 1980;51:681-
In conclusion, the present study indicates that: 1) 685.
CAF is a useful and predictable surgical technique for 14. Goldman H, Schluger S, Fox L, Cohen DW. Periodontal
Therapy, 3rd ed. St. Louis: The CV Mosby Company;
the treatment of shallow gingival recessions; 2) the
1964:560.
residual average tension of the CAF test group is
6.5 g once the procedure is considered complete; 3) Send reprint requests to: Dr. Giovanpaolo Pini Prato, Viale
minimal tension does not influence recession reduction Matteotti, 11, 50121 Florence, Italy. Fax: 39 055 572881;
following CAF procedure after 3 months; and 4) in the e-mail: gpinipr@tin.it
test group (with tension), the statistical analysis sug-
Accepted for publication June 14, 1999.
gests that the higher the flap tension, the lower the
recession reduction.
ACKNOWLEDGMENTS
The authors would like to acknowledge Dr. Lisa Wiech-
mann and Mr. James McMenamin for their help in the
preparation of this manuscript.
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giva: short-term results in the treatment of shallow mar-
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graft with inlaid margins: a predictable method to obtain-
ing root coverage of shallow defects. Int J Periodontics
Restorative Dent 1994;14:229-241.
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