J Clin Periodontol 2014; 41: 387–395 doi: 10.1111/jcpe.

12207

Coronally advanced flap versus Leila Salhi1, Geoffrey Lecloux1,

Laurence Seidel2, Eric Rompen3 and
France Lambert1

the pouch technique combined 1

Faculty of Medicine, Department of
Periodontology and Oral Surgery, University
of Liege, Liege, Belgium; 2Faculty of

with a connective tissuegraft to Medicine, Department of Biostatistics,

University of Liege, Liege, Belgium; 3Faculty
of Medicine, Head of the Department of

treat Miller's class I gingival Periodontology and Oral Surgery, University

of Liege, Liege, Belgium

recession: a randomized
controlled trial
Salhi L, Lecloux G, Seidel L, Rompen E, Lambert F. Coronally advanced flap
versus the pouch technique combined with a connective tissuegraft to treat Miller’s
class I gingival recession: a randomized controlled trial. J Clin Periodontol 2014;
41: 387–395. doi: 10.1111/jcpe.12207.

Abstract
Aim: The objective of this study was to compare two different periodontal plastic
surgery procedures to treat Miller’s class I recession: a coronally advanced flap
(control group) versus the pouch technique (test group), both of which were asso-
ciated with connective tissue graft.
Methods: Forty consecutive patients were included, with 20 patients being allo-
cated for each group. The level of recession coverage, the keratinized tissue (KT)
quantity, gingival aesthetics (PES) and post-operative outcomes were assessed for
a follow-up period of 6 months.
Results: After 6 months, both techniques allowed for the excellent mean root cover-
age of 96.3  12.1% in the control group and of 91.3  17.6% in the test group.
Complete root coverage was achieved in 89.5% (17/19) and 79% (15/19) of the reces-
sion cases in the control and the test groups respectively. A significant increase in
KT height (p = 0.0011) was observed in the test group. A significant improvement in
the pink aesthetic score was found in the two groups, but gingival texture displayed
significantly better results in the test group (p < 0.0001). No significant difference
between the two groups was found in terms of the morbidity outcomes. Pain killer Key words: Connective tissue graft; dental
consumption was similar in the two groups and significantly decreased over time. root coverage; mucogingival surgery;
Conclusions: Both surgical techniques are relevant in treating Miller’s class I periodontal plastic surgery
recession. The pouch technique seems to increase the height of KT better and
Accepted for publication 24 November 2013
provides good gingival-related aesthetic outcomes.

Conflict of interest and source of According to several authors (Alban-
funding statement dar & Kingman 1999, Al-Wahadni
The authors declare that they have no & Linden 2002, Kassab & Cohen
conflict of interests. This study has 2002), gingival recession occurs in
been self-funded by the authors and more than 50% of individuals. The
their institutions. consequences of this recession might
involve aesthetic dissatisfaction
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
(Al-Wahadni & Linden 2002), dental
hyperesthesia (Andrade et al. 2010)
and difficulty in plaque control
(Kassab & Cohen 2002). To cover
the exposed root surface, several
periodontal plastic surgery proce-
dures have been described over
387
388 Salhi et al.
recent decades. The primary goal of
these surgical therapies is to obtain
complete root coverage (CRC).
The first techniques described for
root coverage of gingival recession
were the lateral displacement of a
full or split thickness flap (LPL)
(Grupe HE 1956, Staffileno 1964)
and free gingival grafts (Sullivan &
Atkins 1968) to cover mandibular
gingival recession. Coronally
advanced flaps (CAF) were intro-
duced in the mid-1980s by several
authors (Allen 1988, Miller 1988,
Tarnow 1986). According to the
available literature, the mean root
coverage (MRC) of CAF procedures
remains highly heterogeneous, vary-
ing from 55.9% to 86.7% (Del Pizzo
et al. 2005, de Queiroz Cortes et al.
2006). To increase the root coverage,
associated procedures have been
suggested, such as CAF combined
with connective tissue grafts (CTG)
(Langer & Langer 1985).
To avoid soft tissue harvesting,
other surgical procedures using bi-
omaterials or biological factors were
developed, including guided tissue
regeneration (Pini Prato et al. 1992,
Roccuzzo & Buser 1996, Trombelli &
Scabbia 1997), enamel matrix-derived
proteins (EMD) (Modica et al. 2000,
Spahr et al. 2005, McGuire & Coch-
ran 2003, McGuire & Nunn 2003),
platelet-rich plasma and fibrin (Hu-
ang et al. 2005, Keceli et al. 2008),
acellular dermal matrices (Woodyard
et al. 2004, Joly et al. 2007) and
human fibroblast dermal derivative
cells (HF-DDS) (Wilson et al. 2005).
According to several systematic
reviews (Roccuzzo et al. 2002, Cheng
et al. 2007, Cairo et al. 2008,
Chambrone et al. 2010), most of
these periodontal plastic surgery pro-
cedures were efficient in reducing the
depth of Miller’s class I or II reces-
sion. Nevertheless, CAF in combina-
tion with CTG or EMD seems to
display the most predictable results
in terms of CRC and currently is
considered to be the gold standard
technique for root coverage.
However, the success of peri-
odontal plastic surgery procedures is
not only related to the root cover-
age. Other parameters, such as the
gain of keratinized gingiva, aesthetic
outcomes, and patient-centred out-
comes related to the morbidity of
the procedures, should be taken into
account when recommending a spe-
cific technique over the other
options.
Only a small number of studies
have investigated such parameters. In
their case series describing the pouch
technique, (Raetzke 1985) disclosed
an increase of keratinized tissue (KT)
height in each patient, and in a sys-
tematic review, (Chambrone et al.
2010) found that the expected gain of
KT tissue is higher with CAF + CTG
than CAF alone. However, none of
these studies investigated the aes-
thetic or morbidity outcomes of such
procedures. There is a lack of ran-
domized controlled trials that com-
pare several surgical techniques
based on these parameters.
Moreover, one of the conclusions
of the systematic review by Cairo
et al. (2008) is that there is a need
for RCTs that evaluate KT gain
between different surgical proce-
dures. These authors also showed
that the association with CTG seems
to produce higher results. However,
these researchers also recommended
more studies to evaluate the possible
association between KT gain and
aesthetic satisfaction.
The objective of the present ran-
domized controlled clinical trial was
to compare the CAF (Langer &
Langer 1985) versus the pouch tech-
nique (Raetzke 1985), both associ-
ated with connective tissue graft, in
treating Miller’s class I recession
(Miller 1985) in the anterior upper
maxilla. The primary objective was
to assess the mean and CRC of both
techniques. The secondary objectives
were to evaluate the gain of kerati-
nized gingiva, the aesthetic outcomes
using the pink aesthetic score (PES),
and the morbidity for each tech-
nique.
Materials and Methods
Experimental design
This study was designed as a ran-
domized controlled trial comparing
two surgical protocols for the treat-
ment of gingival recession:
CAF + CTG versus pouch + CTG.
Forty consecutive patients from
the Department of Periodontology
and Oral Surgery at the University
of Liege, Belgium were enrolled from
May 2011 to February 2012. Each
patient (experimental unit) contrib-
uted a single recession. In cases of
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
multiple recessions, the deepest one
was included. Four distinct investi-
gators (specialists in periodontology)
were involved in the surgical proce-
dures. A single examiner collected
the clinical and outcome measure-
ments. All clinical parameters and
outcomes were performed at base-
line, after 3 months and after
6 months. The morbidity outcomes
were evaluated 10 days after surgery.
Sample size
The study was powered to detect a
minimum clinically significant differ-
ence in root coverage of 1 mm using
a = 0.05. The recession depth (RD)
at baseline was considered covariate.
Investigator training
The four investigators were invited
to attend two calibration meetings,
where the objectives of the study,
the surgical protocol, and the assess-
ment method were reviewed.
Study population
The inclusion criteria were: (i) Mill-
er’s class I recession; (ii) recession of
2 mm to 5 mm; (iii) maxillary inci-
sors, canine or premolars; (iv) identi-
fiable cemento-enamel junction
(CEJ); (v) minimum of 18 years old;
(vi) controlled periodontal disease;
(vii) ASA1 or ASA2 (American
Society of Anesthesiologists) general
health status; and (viii) providing a
signed informed consent form.
Exclusion criteria were: (i) smokers;
(ii) presence of cervical carious
lesion; (iii) pocket depth greater than
4 mm; (iv) sites where previous
muco-gingival therapy was per-
formed; and (v) pregnancy. In pres-
ence of non-carious cervical lesions,
the anatomical CEJ was recon-
structed by the use of a composite
before the procedure.
Patient inclusion (informed consent,
patient registration and randomization)
After explaining the purpose, risks,
benefits and monitoring of the study,
patients were invited to sign an
informed consent form. The ethics
committee of the University Hospital
of Liege approved this randomized
controlled trial as a whole. Patients
were subjected to a full periodontal

examination. A pre-surgical full-
mouth professional prophylaxis
appointment was scheduled 1 week
prior to the surgical procedure. An
alginate impression was taken to fab-
ricate an individual resin stent that
was used as a reference point for all
measurements (Byun et al. 2009).
The distribution of patients
within the groups was performed
randomly; the allocation of the sur-
gical techniques was performed by
lottery through a sealed envelope.
The sealed envelope was opened
after the connective tissue graft was
harvested.
Surgical procedure
The patient received 600 mg of ibu-
profen (paracetamol 1 g in case of
allergy) prior to surgery, and chlorh-
exidine mouthwash for 0.2% was
provided for 2 min. Patients received
local anaesthesia at the donor and
recession site (articaine hydrochlo-
ride 7200 mg/1.8 ml, adrenalin
1800 mcg/1.8 ml). The harvest of the
connective tissue graft was per-
formed prior to the preparation of
the reception site to avoid any bias.
The graft dimension was calculated
according to the recession dimen-
sions; a minimum of 3 mm of the
graft was submerged mesially, dis-
tally and apically (Fig. 1). The con-
nective tissue graft was harvested
from the palate with the single edge
incision and sutured with 4.0 silk.
The patient was subsequently
assigned randomly to the control
(CAF) or the test group (pouch).
The surgical protocol in the con-
trol group was performed as
described by Langer & Langer
(1985). A horizontal incision at the
level of the CEJ and a two vertical
incisions were designed to raise a
split thickness flap beyond the muco-
gingival line (MGL). The papillae
were disepithelialized. The root was
planed using a curette, and a chemi-
cal treatment was administered using
a doxycycline solution (1 mg/ml)
considering its non-antibiotic effects
(Rompen et al. 1993, Vanheusden
et al. 1998, Vanheusden et al. 1999).
The connective tissue graft was
sutured to the recipient bed by
means of a resorbable suture (Vicryl
5.0: Saint Stevens- Woluwe, Bel-
gium), and the flap was coronally
advanced and sutured by simple
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Two procedures for root coverage
interrupted sutures (Silk 5.0; ethicon,
Johnson & Johnson Company). The
connective tissue graft was com-
pletely covered by the flap (Fig. 2d).
In the test group, the surgical pro-
tocol was performed as described by
Raetzke (1985) and Allen (1994). The
sulcular epithelium was removed with
a blade and a partial thickness pouch
was created, preserving the papillae.
The roots were treated similarly to
those of the control group. The con-
nective tissue graft was inserted inside
the pouch and stabilized mesially and
distally with simple interrupted
sutures (silk 5.0), leaving the connec-
tive tissue that covered the recession
exposed (Fig. 2h).
The post-operative instructions and
follow-up
The patients were asked to take pain
killers only if necessary and to count
the amount of pain killer intake
every day for 1 week. Patients were
informed to avoid brushing at the
surgical site for 2 weeks, to use
mouthwash [chlorhexidine 0.2%
(Perio-aid, Dentaid Benelux, Hou-
ten, Netherlands)] until suture
removal, and to consume a soft food
diet for 1 week. Sutures were
removed after 10 days, and patients
were seen after 3 months and
6 months.
Data collection
All measurements were performed
by a single examiner. Local plaque
score (LPS), local bleeding score,
RD, recession width (RW), gingival
thickness (GT) and KT height were
recorded at baseline, 3 months and
6 months. CT was measured using
an endo-lime 15 and a stop buccally,
1 mm below the cervical limit.
The gain in KT height, the
MRC, and the percentage of CRC
were calculated at 3 months and
6 months.
The PES was assessed at baseline
and 6 months according to the seven
parameters described by Furhauser
et al. (2005). All of these measure-
ments were performed intra-orally
using the individual resin stent.
Patient-related aesthetic outcomes
were also recorded in a questionnaire
using a 0–10 graduated scale.
The following parameters were
recorded in the patient’s morbidity
389
questionnaire (graduated scale from
0 to 10): discomfort during and after
the surgical procedure, pain at the
donor site, pain at the recipient site,
and the number of pain killers con-
sumed per day.
Statistical analyses
The comparisons between groups
were performed with Student’s t-test
or the Kruskal–Wallis non-paramet-
ric test. A generalized linear mixed
model was used to study the param-
eters’ evolution over time and
between groups. The respective dif-
ferences between 0 and 3 months, 0
and 6 months, and 3 and 6 months
were tested by paired Student’s t-
test. Results were considered signifi-
cant at the 5% critical level
(p < 0.05). Calculations were per-
formed using SAS software version
9.2 (SAS Institute, Cary, NC, USA).
Results
Patients’ characteristics
Forty patients (14 males and 26
females) aged from 22 to 63
(43.5  13.1) years were included in
the study. Thirty-one (77.5%)
patients presented a single recession
site, and 9 (22.5%) patients had mul-
tiple recession sites. The patients
were equally distributed within the
control and the test groups. Two
patients dropped out after 3 months
of follow-up (one in each group).
Clinical parameters
Defect-related clinical characteristics
at baseline and at 6-month follow-up
are described in Table 1.
At baseline and after 6 months,
the test and control groups were com-
parable for all clinical parameters
(RD, RW, KT, GT, LPS and local
bleeding percentage) and for aesthetic
scores (PES). From baseline to
6 months, significant improvements
of RD (p < 0.0001 in both test and
control groups), RW (p < 0.0001 in
both test and control groups), clinical
attachment level (p < 0.0001 in both
test and control groups), GT
(p = 0.035 in control group and
p = 0.0075 in test group) and PES
(p < 0.0001 in both test and control
groups) were found in the two
groups.
390 Salhi et al.

Recession coverage two groups. Moreover, at 6 months,

p value

0.35
0.99
0.59
The baseline mean RD was the “texture” assessment was signifi-
3.03  0.90 mm for the control cantly better in the test group
group and 2.78  0.94 mm for the (p = 0.0007) (Fig. 3). The other

1.32  5.74
1.32  5.74
6 months
parameters remained unchanged.
LBS (%)

0.99
test group. From baseline to
3 months, the mean RD decreased Details are reported in Table 3.
significantly in the two groups
(p < 0.0001) and later was stable Patient-centred aesthetic outcomes
0.05  0.22
1.25  5.59
Baseline

from 3 months to 6 months

0.34

GT, gingival thickness; LBS, local bleeding score; LPS, local plaque score; RD, recession depth; RW, recession width. Values in italics indicate p-value differences. (p = 0.64). At 6 months, the MRC
reached 96% in the control group
and 91% in the test group. CRC
p value
Patients from the two groups recog-
nized a significant aesthetic improve-
ment from baseline to 6 months
based on the four following parame-

was found in 89.5% of the cases (17/

ters: aspect, colour, contour of the
0.99
0.99
0.99

19) in the control group and in 79%

of the cases (15/19) in the test group. gum and scars. No significant differ-
There was no significant difference ences were observed between the test
6 months
LPS (%)

in MRC or CRC between the two and control groups (p < 0.0001).
00
00
0.99

groups. Details are reported in

Table 2. No statistical difference was Morbidity outcomes
Baseline

found among the surgeons in terms

00
00

No significant differences in terms of

0.99

of recession coverage.
pain were found at the donor and
recipient sites between the control
p value

and test groups. On a scale from 0

0.0075
0.0035

Gain of keratinized tissue

0.79

At baseline, the two groups had a to 10, the pain level was, on average,
comparable mean height of KT. 3.3  2.7 (range: 0–10) in the donor
site and 3.0  2.2 (range: 0–8) in the
1.37  0.37
1.25  0.35
6 months

From baseline to 3 months, there

Table 1. Clinical parameters at baseline and at 6-month post-surgery. Data are expressed as the mean  SD
GT (mm)

was a significant increase in KT in recipient site. Pain killer consump-

tion decreased significantly from
0.32

both groups. Although there was a

greater increase of KT in the test baseline (1.25  1.3 per day) to
group, the increase up to 3 months 10 days (0.25  0.74 per day) in
1.08  0.34
1.03  0.26

both groups (p < 0.0001), and no

Baseline

did not differ between the two

groups (p = 0.34). At 6 months, the significant difference was observed
0.60

amount of KT was significantly between the two groups.

higher in the test group (p = 0.0004). No significant difference was
<0.0001
<0.0001

observed for any of the studied

p value

Details are reported in Table 2.

0.85

Between 3 to 6 month, the height parameter between male and female

of KT decrease in the control group or single and multiple recessions.
( 0.68  0.67, p = 0.0003),
0.32  0.95

but
6 months
RW (mm)

0.00  0

remain stable in the test group Discussion

(p = 0.99).
0.15

The objective of the present random-

ized controlled clinical trial was to
4.45  1.15
4.1  0.85

Gingival thickness compare the effectiveness of two dif-

Baseline

A significant increase in the GT ferent surgical protocols to treat

0.28

(20%) was observed from baseline to Miller’s class I recession in the ante-
3 months in both groups, and there rior upper maxilla. The Langer &
Langer technique (1985), which are
<0.0001
<0.0001

was no significant difference between

p value

0.08

the two groups (p = 0.64). Gingival still regarded as the gold standard
thickening remained stable from 3 to for root coverage, was used in the
6 months. control group, the pouch technique
0.29  0.61
0.16  0.50
6 months

as described by Raetzke (1985) and

RD (mm)

0.47

Allen (1994), was implemented in the

Pink aesthetic score
test group. The two tested surgical
From baseline to 6 months, the PES techniques were assessed for root
2.78  0.94

increased significantly in the two coverage, KT gain, aesthetic and

3.03  0.9
Baseline

groups, and no significant difference

0.39

morbidity outcomes.
was determined between the groups
(p = 0.44). Within the seven parame-
Root Coverage
ters considered in calculating the
Significance

PES, the “level of the soft tissue The MRC found in this study was
Control

margin” and the “soft tissue con- fairly high compared to the existing
Test

tours” improved significantly in the data in the literature on this particu-

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Table 2. Root coverage and keratinized tissue (KT) height at 3 and 6 months post-surgery. Data are expressed in % and number of
patients or in mean  SD
MRC (%)
3 months
Test 91.55  22.4% 91.3  17.6%
Control 99.0  4.47% 96.3  12.1%
Significance 0.15
CRC, complete root coverage – patients, Gain of KT height; MRC, mean root coverage.
lar topic (96% in the control group
and 91% in the test group), and no
significant differences were observed
between the two groups (Table 2).
According to the published clinical
trials and systematic reviews, the
MRC found with the “CAF associ-
ated with CTG” and with the
“pouch technique” were notably het-
erogeneous and varied from 75.5%
to 97% (Paolantonio et al. 1997,
Zucchelli et al. 1998, Trombelli
1999, Zucchelli & De Sanctis 2000,
Cordioli et al. 2001, Cetiner et al.
2004, Carvalho et al. 2006, Chamb-
rone & Chambrone 2006, Tozum
2006, Han et al. 2008) and from
69.2% to 96.4% respectively (Rae-
tzke 1985, Jahnke et al. 1993, Allen
1994, Bouchard et al. 1994, Muller
et al. 1999, Zabalegui et al. 1999,
Cordioli et al. 2001, Tozum & Dini
2003, Tozum 2006, Han et al. 2008).
This high variability found in the lit-
erature for the present surgical tech-
niques might be attributed to the
unclear selection of inclusion and
exclusion criteria, such as the selec-
tion of smokers and non-smokers or
of cases of Miller’s class I and II
recession. The present data indicate
that the two surgical approaches
used in this study were highly effec-
tive and predictable for root cover-
age. The experience level of the
practitioner could also have influ-
enced the results. In the present
study, a strict selection of the inclu-
sion criteria (materials and methods)
was conducted, and only experienced
and calibrated periodontists per-
formed the surgical procedures.
There was no significant differ-
ence between the two groups in
MRC and CRC and the results of
this study show that if the outcomes
were predictable with both tech-
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Two procedures for root coverage
CRC (%)
6 months 3 months 6 months
89.5% (17/19) 79% (15/19)
95% (19/20) 89.5 (17/20)
0.31 0.48 0.38
niques. However, it has to be
emphasized that the vascular bed of
the connective tissue graft was opti-
mal (minimum of 3 mm in the apical
direction and 3 min in the mesio-dis-
tal direction) in order to avoid any
risk of necrosis and consequent lack
of coverage. Nevertheless, one can
notice that the test group tended to
display slightly inferior results. This
finding might be attributed to two
specific cases of the test group: one
patient displayed a higher baseline
RD (4 mm) and RW (5 mm), and a
second patient brushed on the surgi-
cal site and ripped off the graft,
despite receiving the post-operative
instructions.
Keratinized Tissue Gain
An increase in the KT height is a
desired effect in that it decreases the
possibility of recurrence of gingival
recession due to chronic trauma or
inflammatory reactions (Paolantonio
et al. 2002, Bittencourt et al. 2009).
Nevertheless, the KT height is rarely
considered in the existing literature.
Within the limitation of this study,
the present results demonstrated that
the KT height increased in the two
groups; however, the augmentation
was significantly higher in the test
group (pouch technique) (Table 3).
In the test group, the MGL
remained in place, and the KT gain
seemed to come from the coloniza-
tion of the CTG by the neighbouring
epithelial cells, which easily explains
the optimal regeneration of KT
using this technique. In the control
group, the MGL was coronally dis-
placed; thus, the gain of KT could
result in the apicalization of the
MGL. Indeed, this phenomenon was
already described by several authors,
391
Gain of KT (mm/%)
3 months 6 months
1.2  1.0 mm 1.11  1.1 mm
(p < 0.0001) (p = 0.0004)
39.8  39.0% 37.9  42.4%
0.83  1.14 mm 0.18  1.22 mm
(p = 0.0043) (p = 0.52)
31.1  49.0%
0.34 0.019
who stated that the MGL would
have the tendency to regain its
genetically determined position (Ai-
namo et al. 1992, Zucchelli & De
Sanctis 2005, Abolfazli et al. 2009).
Nevertheless, according to the pres-
ent data, the apicalization of the
MGL and the regeneration of KT
seem to be partial and limited. Thus,
these 6-month results have to be
interpreted cautiously because fur-
ther maturation of the regenerated
soft tissues might occur over time.
However, the decrease of KT
height from 3 to 6 months in the
control group without any change in
RD might be explained by the ten-
dency for over correction of the
recession with the coronally
advanced flap (Fig. 4). Since the
CEJ is the reference point to mea-
sure the RD, in case of over cover-
age, a decrease of KT might happen
during the maturation of the tissues
and if the tissue remodelling remains
over the CEJ, no RD is recorded.
Aesthetic Outcomes
One of the reasons to treat surgically
gingival recession, besides improve-
ments in sensitivity or plaque con-
trol, is to achieve a better aesthetics.
However, aesthetic outcomes after
surgical root coverage procedures
are rarely evaluated in the literature.
The appreciation of the aesthetic
outcomes by clinicians and patients
is of interest. Because the soft tissue
maturity is considered stable after a
period of 6 months post-surgery
(Roccuzzo et al. 2002, Rotundo
et al. 2008, Cairo et al. 2009), the
aesthetic outcomes of the present
study were evaluated after 6 months
by both the dentist and the patient
himself. According to the patients
392 Salhi et al.

11.6* (0.61)
11.0* (1.03)
6 months
PES (max 14)

0.027
8.75 (1.48)
8.65 (1.23)
Baseline

0.82
1.95* (0.23)
1.32* (0.48)
p < 0.0001
6 months
Texture

1.15 (0.37)
1.05 (0.22)
Baseline

0.30
6 months

2.00 (0.0)
2.00 (0.0)

Fig. 1. Connective tissue graft placement.

0.99
Colour

and the dentists, both surgical tech- further follow-up are needed to con-
1.85 (0.37)
1.85 (0.37)
Baseline

niques promoted significant improve- firm the absence of keloid/patch

0.99

ment and optimal aesthetic results effect on the long term with the
(Table 3). Nevertheless, in consider- pouch technique.
6 months

ing the details of the PES rated by

Alveolar process

0 (0.0)
0 (0.0)

the dentist, the texture was signifi-

0.99

Morbidity Outcomes
cantly better with the pouch tech-
nique. The inferior score regarding The morbidity outcomes were similar
Baseline

0 (0.0)
0 (0.0)

the texture found in the control in the two groups and decreased
0.99

group seems to be related to the over time. The level of pain was
scars left by the vertical releasing never higher than x on a 1–10 scale.
1.95* (0.22)
1.89* (0.22)
6 months

incisions of the CAF. Vertical releas- However, the feeling of pain was
Soft tissue contour

ing incisions impair the vasculariza- highly variable in the population.

0.99

tion, and soft tissue healing can There was great intrinsic variability,
result in fibrotic scars, jeopardizing dependent on the patient, and also
1.30 (0.47)
1.20 (0.41)
Table 3. Pink aesthetic score (PES) (mean  SD) at baseline and 6-month post-surgery

Baseline

aesthetic outcomes (Allen 1994, high extrinsic variability between

Bruno 1994, Zabalegui et al. 1999, patients; thus, the interpretation of
0.48

Zucchelli & De Sanctis 2000, Carv- pain perception was difficult (Shav-
alho et al. 2006). Conversely, the ers et al. 2010, Young et al. 2012).
2.00* (0.0)
2.00* (0.0)
6 months
Level of soft tissue

optimal texture obtained in the test Moreover, the pain killer intake sig-
0.99

group was most likely related to (i) nificantly decreased over time in
margin

the removal of the intra-sucular epi- both groups.

*Significant improvement (p < 0.05) between baseline and 6 months.
0.95 (0.39)
0.90 (0.45)

thelium, avoiding epithelial invagina-

Baseline

tion and consequent visible junction

0.31

Conclusions
In bold: Significant difference between groups’ improvement.

between the former and the new cer-

vical level; and (ii) the absence of The findings of this study indicate
1.84 (0.38)
1.89 (0.32)
6 months

releasing incisions, better preserving that the pouch technique and the
Distal papilla

the architecture of the soft tissues. coronally advanced flap technique in

0.64

These 6-month results also combination with a connective tissue

emphasize that the epithelialization graft can be successfully used to
1.75 (0.44)
1.85 (0.49)
Baseline

of the exposed connective tissue does treat Miller’s class I recession in aes-
not impair the aspect of the gingival thetic areas. Both surgical techniques
0.50

tissues described as the “patch were effective and predictable for

1.84 (0.38)
1.84 (0.38)

effect” by some authors. Even root coverage. Moreover, post-oper-

6 months

though prior studies have suggested ative outcomes and painkiller con-
Mesial papilla

0.99

that the genetic information in the sumption were moderate and similar
connective tissue ultimately deter- for both surgical procedures. Never-
1.70 (0.47)
1.80 (0.41)

mines the character of the surface theless, the pouch technique dis-
Baseline

epithelium (Bittencourt et al. 2006), played greater increases in KT and

0.48

the present aesthetic outcomes do seemed to offer lower levels of scar-

not show, after period follow-up of ring. Nevertheless, these results have
Significance

6 months, any difference between to be interpreted cautiously and

Control

the grafted and neighbouring gingiva long-term follow-up up would be

Test

(Tozum & Dini 2003). Nevertheless, necessary to confirm the hypothesis

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Two procedures for root coverage 393

(a) (b) (c) (d)

(e) (f) (g) (h)

Fig. 2. Surgical procedures. (a) Control-Baseline. (b) Control-flap elevation and placement of the connective tissue graft. (c) Con-
trol-suture. (d) Control- 6-month follow-up. (e) Test-Baseline. (f) Test-incisions and sulcular epithelium removal. (g) Test-connective
tissue placement according to Fig. 1 and suture placement. (h) Test- 6-month follow-up.

Texture
2.0
1.8
1.6
1.4
1.2
1.0

0 1 2 3 4 5 6
Time (months)

Fig. 3. Aesthetics – Inferior texture evaluation after 6 months in the control group.

Fig. 4. Mean root coverage and keratinized tissue gain (%).

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
394 Salhi et al.
of increase of KTs and better gingi-
val texture using the pouch tech-
nique.
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Clinical Relevance
Scientific rationale for the study:
There is a lack of randomized
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© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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combination with a connective tissue
graft.
Principle findings: The most impor-
tant outcome of this study is that,
within its limits, similar outcomes
were observed between the two tech-
niques in terms of clinical root cov-
erage, overall pink aesthetic and
patient morbidity. Nevertheless, a
395
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outcome following treatment of multiple Miller
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Address:
Leila Salhi
Service de Medecine Dentaire
Domaine du Sart Tilman Bat B-35
B-4000 Liege
Belgium
E-mail: lei.salhi@gmail.com
higher gain of keratinized tissue
and lower level of scaring were
found with the pouch technique.
Practical implications: In cases of
Miller’s class I recession with aes-
thetic concerns, the pouch tech-
nique combined with a connective
tissue graft is indicated.