315

Thick Free Gingival and Connective

Tissue Autografts for Root Coverage
Peter V. Jahnke, * Johnny B. Sandifer,* Marlin E. Gher,* Jonathan L. Gray, *
and A. Charles Richardson*

Studies have shown partial to complete root coverage of denuded root surfaces with
the use of thick free gingival autografts (FGGs) or subepithelial connective tissue autografts
(CTGs). The purpose of this study was to determine which technique would result in more
predictable root coverage of Miller Class I and II marginal tissue recession defects. Paired
defects in 10 patients were randomly selected for treatment with either the FGG or the CTG.
With Stents as reference points, soft tissue recession was measured with a calibrated probe
presurgically and 3 and 6 months postsurgically. No significant differences between paired
sites in presurgical defect dimensions were found. One patient was dropped from the study
for noncompliance with postoperative instructions. The mean percentage of root coverage
for the CTG 3 and 6 months postsurgery for the remaining 9 patients was 78% and 80%,
respectively. The mean percentage of root coverage for the FGG was 43% at both periods.
The difference in root coverage between the 2 techniques was significant (P< 0.03). Com-
plete root coverage was gained in 5 of 9 CTGs but only in one of 9 FGGs. Both techniques
resulted in a significant improvement in keratinized tissue and probing attachment level,
with most of the changes having occurred during the first three months postoperatively.
Results suggest that the CTG may provide a greater percentage of root coverage than the
FGG and that both techniques will effectively increase the width of keratinized tissue. J
Periodontol 1993; 64:315-322.

Key Words: Connective tissue; gingival recession/surgery; grafts/surgery; tooth root/

surgery.

Gingival defects caused by recession can result in root sen- Although the surgical technique for the FGG has become
sitivity, esthetic concern to the patient, predilection to root relatively standardized, several techniques for the CTG have
caries, cervical abrasion, and difficulty creating an aesthetic been described. Raetzke5 used palatal connective tissue and
restoration.1 Recent reports2 8 involving the treatment of an "envelope" technique at the recipient site to demon-
recession demonstrate techniques for root coverage that are strate complete root coverage in 5 of 12 cases (41.7%).
more procedures.9-10 Both the thick
successful than earlier Langer and Langer6 described a variation of this technique
free gingival autografi (FGG) and the subepithelial connec- in which the recipient flap was positioned coronally to cover
tive tissue autografi (CTG) have been shown to cover de- as much of the graft as possible. They reported an increase
nuded roots, but varying degrees of success with these in root coverage of 2 to 6 mm in 56 cases. Nelson7 used a
techniques have been reported. Using the FGG, Holbrook technically demanding subpedicle CTG procedure to gain
and Ochsenbein2 reported complete root coverage in 22 of root coverage and demonstrated an average root coverage
50 cases (44.0%), whereas Miller4 reported complete root of 91% in a study of 29 cases.
coverage in 71 of 79 cases (89.9%). Borghetti and Gardella8 Variations in case selection, surgical technique, and
treated 24 teeth with different amounts of recession and methodology in these reports make it difficult to compare
found that the FGG resulted in a mean root coverage of the success of the FGG with that of the CTG. In addition,
85.2%. other factors may be important when choosing the appro-
priate producers to cover denuded roots. Miller11 has re-
*Periodontics Department, Naval Dental Clinic, Great Lakes, IL. viewed factors that may predispose to incomplete root
Periodontics Department, Naval Dental School, National Naval Dental
coverage with the FGG. Root prominence, especially when
Center, Bethesda, MD. the tooth is facially positioned in the arch, may affect re-
Branch Dental Clinic, Rota, Spain.
those of the authors and vascularization of the graft and reduce overall success. Root
The opinions or assertions contained herein are
are not to be construed as official or as reflecting the views of the De- planing to flatten or reduce the convexity of the root has
partment of the Navy. been suggested as a necessary step to enhance root cover-

316 GINGIVAL AND CONNECTIVE TISSUE AUTOGRAPHS FOR ROOT COVERAGE
age. This, however, can result in severe root sensitivity if
the graft fails to completely cover the root. In addition,
increased postoperative morbidity may result from the sub-
stantial wound created when harvesting a thick graft from
the palate. Clinicians may hesitate to attempt root coverage
with the FGG due to the "unforgiving" nature of this pro-
cedure, along with potentially undesirable postoperative
sequelae.
CTGs for root coverage combine the features of the FGG
and the pedicle graft.6 Advantages of this combination in-
clude the retention of the blood supply both from the per-
iosteum and the underside of the covering flap; a closer
color blend of the graft with adjacent tissue, avoiding the
patchy healing seen with the FGG;6 healing of the donor
site by primary intention, which involves less postoperative
pain than the donor site of a FGG. The CTG technique may
provide the best root coverage in areas of thin gingiva and
alveolar bone.7 The possibility of improved esthetics, pre-
dictable root coverage, and a less demanding surgical tech-
nique make this technique attractive.
In spite of reported successes with each procedure, stud-
ies comparing the predictability of these two techniques in
covering denuded roots are limited. Sbordone et. al.12 com-
pared root coverage obtained with the subepithelial con-
nective tissue graft, as described by Langer and Langer,6
in isolated wide and deep gingival recessions to that ob-
tained with the free gingival graft as described by Sullivan
and Atkins.13 The results12 support the greater success in
obtaining root coverage with the connective tissue graft
versus the free gingival graft, however, neither the Miller14
classification system nor the thick free gingival graft tech-
nique was used.
The purpose of this study was to compare root coverage,
keratinized tissue width, and probing attachment level in
paired marginal tissue recession defects after treatment with
either CTGs or thick FGGs.
MATERIALS AND METHODS
Paired marginal gingival defects (Miller Class I or II) sep-
arated by at least four teeth were randomly selected for
treatment with either a thick FGG or a CTG. Five male and
five female subjects, ages 16 to 51 years, participated in
this study. Procedures used were thoroughly explained to
each patient, and all participants or their legal guardians
signed an informed consent statement. All patients were in
excellent health and free of contraindications for periodon-
tal therapy. Presurgical therapy included scaling, polishing,
and plaque control instructions using a modified Bass tech-
nique with a soft-bristle brush and fluoride toothpaste.
Measurements
All clinical measurements were made for the selected teeth
2 weeks after initial therapy (baseline) and again 3 and 6
months after surgery. Gingival index,15 plaque index,16 and
bleeding on probing (BOP) were recorded at all periods.
All test teeth were vital, and interproximal papilla were
J Periodontol
April 1993
Figure 1. Schematic drawing of clinical measurements. PW width of
interdental papilla at level of CEJ. HR
=
=
defect width at level of CEJ
(horizontal recession). VR defect height (vertical recession). PAL
= =
probing attachment level. KT width of keratinized tissue.
=
even with, or coronal to, the cemento-enamel junction (CEJ).
Interproximal sulcus depths were <3 mm. The dimensions
shown in Figure 1 were measured to the nearest 0.5 mm
with a periodontal probe. Vertical recession (VR) was de-
fined the distance from the CEJ to the FGM, and the
as
gingival defect width (HR) at the CEJ was the horizontal
dimension of the gingival defect. An acrylic occlusal stent
was used as the fixed reference point to determine the amount
of root coverage gained and changes in probing attachment
level. Complete root coverage was defined according to
Miller's criteria:11 the soft tissue margin must be at the CEJ,
there is clinical attachment to the root, the sulcus depth is
2 mm or less, and BOP is absent. When toothbrush abrasion
obliterated the CEJ, Stents were used to demarcate the ap-
proximate location of the original CEJ by comparison with
adjacent or contralateral teeth.
One defect from each pair was selected by coin toss to
be treated with the FGG or the CTG. When two adjacent
teeth required root coverage, a second coin toss determined
which tooth would be measured for the comparison of paired
defects. Two patients were treated with the FGG and CTG
during the same surgical appointment, and the remaining
eight patients had each procedure performed on separate
occasions 3 weeks apart. All measurements and surgeries
were performed by one author (PVJ).
Lidocaine (2%) with 1/100,000 epinephrine was used for
local anesthesia during all procedures. Ibuprofen (800 mg)
was prescribed 1 hour before all surgeries.
Thick free gingival graft. The procedure for the FGG
has been described in detail.3 The exposed root surface was
planed to remove altered cementum and flatten it to permit
a more intimate adaptation of the graft to the recipient bed.
Citric acid (pH =
1) was then burnished into the root sur-
face with a cotton pledget for 3 minutes. The pledget was
changed every minute or when contaminated by blood. The
Volume 64
Number 4
2B
area was then thoroughly flushed with sterile saline solu-
tion. The recipient site was prepared as follows. Butt joint
incisions were used at the recipient and donor sites. At the
recipient site, a horizontal incision was made at right angles
to the interdental papilla at the level of the CEJ to create a
margin for close graft adaptation. Vertical incisions were
made at the proximal line angles of adjacent teeth, and a
partial thickness flap was elevated and excised. No attempt
was made to accomplish a periosteal separation with fen-
estration in the apical area of the recipient site. A dry foil
template was trimmed to fit the recipient site exactly and
was then used to harvest the palatal donor tissue.
The donor tissue was removed from the palate and trimmed
with a #15 blade to a thickness of 2 to 3 mm. Within 1
minute of reriioval, the donor tissue was placed at the re-
cipient site, interdental positioning, apical stretching, and
vertical stabilizing sutures (4-0 silk or Vicryl11) were used
to secure the graft at or 1 mm coronal to the CEJ (Fig. 2),
JAHNKE, SANDIFER, GHER, GRAY, RICHARDSON 317
2C
Figure 2. Clinical photographs depicting an example of a site treated with
the thick free gingival graft. A. Preoperative recession defect #22; B.
Thick free gingival graft sutured in place; C. Healing 6 months after
surgery.
and a noneugenol periodontal dressing was placed over the
recipient area for 7 to 10 days postoperatively. An acrylic
palatal Stent was inserted immediately after surgery to pro-
tect the donor site, and patients were instructed to keep the
Stent in place for 24 hours and then as needed to eat and
to minimize discomfort. Chlorhexidine rinse1 bid was pre-
scribed for 3 weeks following surgery.
Seven to 10 days after surgery, the dressing and sutures
were removed and the teeth were polished. Home care in-
structions were given specifying the use of cotton swabs
with fluoride toothpaste until healing had progressed suf-
ficiently to permit gentle brushing and flossing. Teeth were
polished weekly for the first month after surgery and then
at 3 and 6 months. Plaque control instructions were rein-
forced at each appointment.
Subepithelial connective tissue graft. The exposed root
surface was planed (not intentionally flattened) and treated
with citric acid as described above. The recipient site was
prepared by elevating a partial thickness envelope flap around
the denuded root. No vertical releasing incisions were used.
Donor connective tissue, without an epithelial collar, was
harvested from the palate using a trap-door approach as
shown in Figure 3. The connective tissue was placed be-
neath the partial thickness flap, over the previously exposed
root surface, and positioned at or 1 mm coronal to the CEJ
(Fig. 4). Without coronal repositioning, the replaced flap
at the recipient site covered at least 50% of the donor con-
nective tissue. Sling or interproximal interrupted 4-0 silk
sutures were used to hold the recipient flap and the graft in
position, and the site was dressed as noted above. Finger
pressure was applied to the donor area for 5 minutes, and
a palatal Stent was inserted. No sutures were placed in the
 J Periodontol
318 GINGIVAL AND CONNECTIVE TISSUE AUTOGRAPHS FOR ROOT COVERAGE April 1993

3B 3D
Figure 3. Clinical photographs depicting the technique for harvesting the donor connective tissue from the palate. A. Three incisions to a depth of 3 to
4 mm are made in the palate adjacent to the first or second premolar. . Approximately I mm of epithelium is dissected from the underlying connective
tissue. C. With the epithelial trap-door reflected, the connective tissue can now be easily visualized. A fourth incision is made through the connective
tissue at the base of the trap-door to free the donor connective tissue. Donor connective tissue approximately 2-mm thick is sharply dissected from the
periosteum. If the connective tissue is too thin, a periosteal elevator may be used to remove the full thickness of connective tissue from the underlying
bone. D. The trap-door is replaced and finger pressure applied for 5 to 10 minutes. Suturing is optional if a postsurgical palatal Stent is inserted.

donor site. The same postsurgical medications and treat- RESULTS

ment regimens were used as with the FGG.
Statistical Evaluation
Presurgical defect dimensions were compared using the paired
Student r-test. Pre- and postsurgical measurements at 3 and
6 months were analyzed with a repeated measures analysis
of variance (ANOVA) model to determine differences in
healing for the two surgeries. Pearson correlation coeffi-
cients were used to determine possible correlations between
root coverage and presurgical vertical and horizontal reces-
sion, and root coverage and interdental papilla width.
Nine of 10 patients completed the study. The dressing was
dislodged from one patient while eating in a manner incon-
sistent with postoperative instructions. He returned to the
clinic the following day where it was found that the CTG
was no longer beneath the recipient flap. Although the tis-
sue healed uneventfully to its original position, the patient
was dropped from the study.
There were no significant presurgical differences in ver-
tical recession or width of defect between the paired sites
(Table 1). Four canines, three premolare, and two molars
were treated with FGGs, and three canines, four premolare,
Volume 64
Number 4 JAHNKE, SANDIFER, GHER, GRAY, RICHARDSON 319

4C

4B
Figure 4. Clinical photographs depicting an example of two adjacent sites
treated with the connective tissue graft. A. Preoperative recession defects
#10 and 11; B. Connective tissue graft sutured in place; C. Healing 6
months after surgery.
and two molars were treated with CTGs. Four paired de-
fects were located in the mandible and five in the maxilla.
A total of 14 Miller Class I and four Class II marginal tissue
recession defects were treated.
Repeated measures ANOVA of the vertical recession
measurements over the three time points (Fig. 5) indicated
a significantly greater reduction in recession was obtained
with the CTG technique (P < .03). The mean percentage
of root coverage for the two techniques were 80% for the
CTG and 43% for the FGG (Table 2). In seven of nine
cases, the percentage of root coverage was greater for the
CTG than the FGG; the remaining two cases were approx-
imately equivalent. Complete root coverage was gained in
five CTGs but in only one FGG.
Both techniques produced an increase in keratinized tis-
sue width and an improvement in probing attachment level
over baseline values (P < .001). There were, however, no
significant differences between the surgical techniques for
these changes (Figs. 6 and 7). No bleeding upon probing
was noted during the postoperative measurement phases of
this study.
There was no significant correlation between the width

Table 1: Pre- and Post-Surgical Measurements For Paired Sites (mean with range in mm; =
9)
FGG CTG(n 9) =

Time VR* KT PAL VR* KT PAL

Presurgical 2.9 1.0 4.7 2.8 0.6 4.1
(2.0-5.5) (0-2.0) (3.0-8.0) (2.0-3.5) (0-2.0) (2.5-5.5)
3 months 1.9 3.8 3.1 0.6 3.4 2.1
postsurgical (0-4.5) (2.0-6.0) (1.0-7.0) (0-1.5) (2.0-5.0) (0.5-3.5)
6 months 1.8 4.0 3.1 0.6 3.6 1.9
postsurgical (0-4.0) (2.0-7.0) (1.5-6.5) (0-1.5) (2.0-6.0) (1.0-3.5)
VR vertical recession.
=

KT width of kératinized tissue.

=

PAL probing attachment level.

=

"Change in VR statistically different between the 2 techniques (P<0.03).

 J Periodontol
320 GINGIVAL AND CONNECTIVE TISSUE AUTOGRAPHS FOR ROOT COVERAGE April 1993

LU
>
CO LU
to
UJ
O I-

<

0 3 6
0 3 6 0 3 6
FGG (MONTHS) CTG (MONTHS)
FGG (MONTHS) CTG (MONTHS)

Figure 6. Repeated attachment level measures forfree gingival graft (FGG,

Figure 5. Repeated vertical recession measures for free gingival graft 9) and connective tissue graft (CTG,
= =
9).
(FGG, =
9) and connective tissue graft (CTG, =
9).

Table 2: Percent Root Coverage 6 Months Postsurgically (n 9) =

FGG CTG
Patient Tooth Class %RC Tooth Class 'oRC
1 5 I 50 11 100
2 12 I 0 5 100
3 22 I 100 29 100
4 27 I 50 21 100 2
5 28 I 17 21 50
6 3 I 50 14 71 -
7 22 II 75 27 100
8 14 I 14 3 71
LU
9 11 I 27 5 25
Mean 43% 80%
RC =
root coverage.

of the interdental papilla at the level of the CEJ (FGG mean
8.8 mm, range 7.0 to 11.5; CTG mean 8.1 mm, range 6.5
to 10.5) and the amount of root coverage for either tech-
nique. In addition, the mesiodistal width of the defect at
the level of the CEJ (FGG mean 3.9 mm, range 2.5 to 6.0;
CTG mean 3.8 mm, range 2.0 to 6.0) did not correlate with
the amount of root coverage achieved for either technique.
DISCUSSION
Since the primary purpose of this study was to determine
which of these two procedures is the better choice to cover
denuded roots, the most important finding was that the CTG
resulted in more root coverage than the FGG in seven of
nine cases 6 months postoperatively. Over all, the amount
of root coverage obtained with the CTG was similar to that
found in previous studies.5-7,12 However, the amount of
root coverage for the FGG was less than that reported by
others.4-8
With the CTG, the blood supply from the periosteum and
the overlying flap may result in a more rapid reestablish-
ment of circulation within the graft and contribute to more
predictable and successful root coverage. The FGG (Fig.
0 3 6 0 3 6
FGG (MONTHS) CTG (MONTHS)
Figure 7. Repeated keratinized tissue measures for free gingival graft
(FGG, =
9) and connective tissue graft (CTG, =
9).
2) must rely on "plasmatic circulation" through a fibrin
clot for nourishment the first 2 days following healing.13
Capillary proliferation and extension into the CTG's vas-
culature may be enhanced due to more intact capillary sys-
tems within the graft itself. These capillaries may anastomose
with the recipient bed's vasculature. In our study, about
50% of the CTG was covered by the envelope flap at the
recipient site (Fig. 4B). This suggests that the combination
of the highly vascular donor connective tissue and the en-
velope flap without vertical releasing incisions is important
in achieving root coverage. Theoretically, if the envelope
flap covers and adequate amount of donor connective tis-
sue, it should provide more blood supply to the graft than
a coronally positioned flap with vertical releasing inci-
sions.17 Histologie study of the revascularization in healing
of CTGs for root coverage is required, however. Serfaty et
al.18 found inclusions of epithelial islands or epithelial pro-
Volume 64
Number 4
jections deep in the connective tissue of a subepithelial
connective tissue graft biopsy specimen. This suggests that
donor connective tissue may contain epithelium that sur-
vives transplantation to the recipient site. The effects of the
epithelium and possible transplantation of minor salivary
gland tissue remain to be studied, although clinical expe-
rience using connective tissue for ridge augmentation pro-
cedures suggests no detrimental effect.
Miller11 suggests that the width and thickness of inter-
dental papillae are related to the blood supply to the coronal
aspect of the free gingival graft (Fig. 2A). In the present
study, all adjacent interdental papillae were > 3 mm wide
(range 3 to 7 mm), and the width did not correlate with
root coverage for either technique. Perhaps papilla wider
than 3 mm provide no added beneficial blood supply to the
coronal aspect of the graft. However, sites in which two
adjacent teeth were grafted tended to result in more root
coverage than individual sites. This may have been due to
the increased surface area of the recipient bed.
Another factor that may explain the difference in root
coverage between the two techniques is the length of time
the grafts were dressed. A noneugenol dressing was used
to stabilize the grafts for 7 to 10 days, and patients were
placed on soft diets. Miller11 has advocated dressing the
graft for 2 weeks to reduce trauma. This longer dressing
period reportedly allows for greater tissue maturity before
dressing removal. A 2-week dressing period may be more
crucial for the FGG than the CTG.
One can only speculate on the nature of attachment of
these grafts to the root surface. It has been suggested that
the nature of the attachment may have more academic in-
terest than true clinical importance; however, it is likely
that a long junctional epithelial attachment exists. For this
reason, weekly maintenance with plaque control reinforce-
ment is highly recommended for the first month. Citric acid
was used in this study, but its benefits are inconclusive in
humans and remain controversial. Reported benefits include
removal of the smear layer,19 formation of cementum
pins,20-21 antibacterial effects,22 and fibrin linkage,23 all of
which are intended to enhance new connective tissue
attachment.
In general, the patients felt that the CTGs resulted in a
better color match with the adjacent gingiva (Fig. 4C), al-
though two patients thought the grafts looked "bulky."
Remodeling of CTGs was continuing 6 months after sur-
gery, and no patients had enough concern with the appear-
ance of the grafts to warrant gingivoplasty.
The width and depth of marginal tissue recession did not
correlate with the amount of root coverage for either tech-
nique. This agrees with Miller's14 findings that the width
and depth of marginal tissue recession are not overriding
considerations in obtaining root coverage. Thus, Miller's
system of classifying recession may also be applicable to
connective tissue grafting for gingival defects.
The trap-door technique used was designed following
preliminary grafting procedures, which showed that the
JAHNKE, SANDIFER, GHER, GRAY, RICHARDSON 321
technique provided better visualization and a more predict-
able amount of donor connective tissue. It has been sug-
gested that the epithelial collar aids in suturing.6 Such a
collar was not used, because it tended to slough early in
the healing process and did not seem to help in suturing the
connective tissue beneath the envelope flap. The possibility
of burying epithelium beneath the envelope flap was also a
factor in deciding against retaining an epithelial collar. Cau-
tion should also be exercised when obtaining the connective
tissue graft due to the possible proximity of the greater
palatine artery in the area of surgery.
In general, patients wore their postsurgical Stents longer
after the FGG than the CTG. Palatal discomfort diminished
14 to 21 days after the free gingival graft and 7 to 18 days
after the CTG. This agrees with previous reports on healing
following CTGs.5-7 The palatal flap raised for the CTG
healed with no necrosis in four patients, partial necrosis in
four patients, and total necrosis in two patients 7 to 10 days
after surgery. Edel24 found similar results with palatal flaps
following the harvesting of connective tissue to be used to
increase the width of keratinized tissue. Langer and Langer6
reported palatal flap necrosis and discomfort with excessive
undermining of the primary donor flap. In our study, palatal
discomfort was minimized by using a plastic stent. Perhaps
suturing the "trap-door" to its original position would have
lessened the amount of necrosis; however, palatal healing
seemed to depend more on the thickness of the lamina pro-
pria and the amount of connective tissue harvested than on
stabilization of the tissues.
Root sensitivity was assessed by stroking the root surface
with a periodontal probe at each postsurgical visit. All teeth
treated with FGGs that resulted in less than 100% root
coverage exhibited root sensitivity. This sensitivity lasted
from 7 to 180 days after dressing removal. Two patients
continued to have sensitive root surfaces despite daily ap-
plication of stannous fluoride with a cotton swab. Coronally
positioned grafts were successfully performed in these areas
after 6 months of healing. Root planing to flatten or reduce
the convexity of the root may have prolonged root sensi-
tivity. Teeth treated with CTGs that did not provide 100%
root coverage were sensitive for 7 to 28 days after dressing
removal.
Conclusions
As measured in this study: 1) the connective tissue graft
provided significantly greater root coverage than the free
gingival graft in Miller Class I and II marginal tissue reces-
sion defects and 2) both techniques were effective in in-
creasing the width of keratinized tissue and improving clinical
probing attachment level.
Acknowledgments
This project (NNMC Bethesda Study #90-06-1045-00) was
reviewed by the Committee for the Protection of Human
Subjects and the Scientific Review Committee. It was funded

322 GINGIVAL AND CONNECTIVE TISSUE AUTOGRAPHS FOR ROOT COVERAGE
by the Naval Health Sciences Education and Training Com-
mand (Code 0402), Bethesda, MD.
REFERENCES
1. Allen EP, Miller PD Jr. Coronal positioning of existing gingiva: Short-
term results in the treatment of shallow marginal tissue recession. /
Periodontal 1989; 60:316-319.
2. Holbrook , Ochsenbein C. Complete coverage of denuded root sur-
face with a one-stage gingival graft. Int J Periodontics Restorative
Dent 1983; 3(3):8-27.
3. Miller PD Jr. Root coverage using a free soft tissue autografi follow-
ing citric acid application. Part I: Technique. Int J Periodontics Re-
storative Dent 1982; 2(l):65-70.
4. Miller PD Jr. Root coverage using the free soft tissue autografi fol-
lowing citric acid application. Part III. A successful and predictable
procedure in areas of deep-wide recession. Int J Periodontics Restor-
ative Dent 1985; 5(2): 15-37.
5. Raetzke PB. Covering localized areas of root exposure employing the
"envelope" technique. J Periodontol 1985; 56:397^402.
6. Langer B, Langer L. Subepithelial connective tissue graft technique
for root coverage. / Periodontol 1985; 60:715-720.
7. Nelson SW. The subpedicle connective tissue graft. A bilaminar re-
constructive procedure for the coverage of denuded root surfaces. J
Periodontol 1987; 58:95-102.
8. Borghetti A, Gardella J-P. Thick gingival autografi for the coverage
of gingival recession: a clinical evaluation. Int J Periodontics Re-
storative Dent 1990; 10:216-229.
9. Caffesse R, Guinard E. Treatment of localized gingival recession.
Part II. Coronally repositioned flap with a free gingival graft. J Per-
iodontol 1978; 49:357-361.
10. Smukler H. Laterally positioned mucoperiosteal pedicle flaps in the
treatment of denuded roots—a clinical and statistical study. / Perio-
dontol 1976; 47:590-595.
11. Miller PD Jr. Root coverage with the free gingival graft. Factors asso-
ciated with incomplete coverage. / Periodontol 1987; 58:674-681.
J Periodontol
April 1993
12. Sbordone L, Ramaglia L, Spagnuolo G, DeLuca M. A comparative
study of free gingival and subepithelial connective tissue grafts. Peri-
odontal Case Reports 1988; 10(1):8-12.
13. Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Principles
of successful grafting. Periodontics 1968; 6:121-129.
14. Miller PD Jr. A classification of marginal tissue recession. Int J Per-
iodontics Restorative Dent 1985; 5(2):9-13.
15. Löe H. The gingival index, the plaque index, and the retention index
systems. J Periodontol 1967; 38:610-617.
16. O'Leary J, Drake RB, Naylor JE. The plaque control record. / Per-
iodontol 1972; 43:38.
17. Mörman W, Meier C, Firestone A. Gingival blood circulation after
experimental wounds in man. / Clin Periodontol 1979; 6:417-424.
18. Serfaty R, Itic J, Sawaf A. Subepithelial connective tissue grafts in
periodontal surgery and implantology. J Dent Res 1991; 70:509.
19. Poison AM, Frederick CT, Ladenheim S, Hanes PJ. The production
of a root surface smear layer by instrumentation and its removal by
citric acid. / Periodontol 1984; 55:443^146.
20. Register AA, Burdick FA. Accelerated reattachment with cemento-
genesis to dentin, demineralized in situ. I. Optimum range. / Per-
iodontol 1975; 46:646-655.
21. Register AA, Burdick FA. Accelerated reattachment with cemento-
genesis to dentin, demineralized in situ. II. Defect repair. / Perio-
dontol 1976; 47:497-505.
22. Daly CG. Anti-bacterial effect of citric acid treatment of periodontally
diseased root surfaces in vitro. J Clin Periodontol 1982; 9:386-392.
23. Poison AM, Proye M. Fibrin linkage: a precursor for new attachment.
J Periodontol 1983; 54:141-147.
24. Edel A. Clinical evaluation of free connective tissue grafts used to
increase the width of keratinized gingiva. J Clin Periodontol 1974;
1:185-196.
Send reprint requests to: Librarian, Naval Dental School, National Na-
val Dental Center, Bethesda, MD 20889-5602.
Accepted for publication October 26, 1992.