The Free Rotated Papilla Autograft: A

New Bilaminar Grafting Procedure for

the Coverage of Multiple Shallow
Gingival Recessions

THE AIM OF THIS CLINICALPILOT STUDY is to evaluate the possibility and, from a
statistical point of view, the predictability of a new mucogingival technique. The pur-
pose of this surgical procedure is to cover the exposed buccal root surface with less
than 5 mm clinical probing attachment loss either in corono-apical or mesio-distal
aspects. This surgical procedure is particularly indicated in either single or multiple.
gingival recessions with perfectly preserved mesial and distal interproximal osseous
crests, and with a papillary dimension not inferior to the defect which needs to be
treated. A sharp incision is performed at a 90° angle to the vestibule, following the
mucogingival line. A sharp dissection is accomplished to create a partial thickness
envelope flap on the underlying alveolar mucosa. The epithelium from the facial aspect
of the papilla is debrided with a full thickness approach, the facial papillary tissue is
removed from the underlying tissue bed. The papilla is then reversed in such a way
that the base of the papilla is at the cemento-enamel junction (CEl) and the apex is
at the base of the gingival recession area. The papilla is then sutured in place and
completely covered by a coronally displaced partial thickness flap. The results obtained
either as root coverage, or as an aesthetic result, may be considered positive. This
procedure has the decided advantage of a single surgical site, avoiding any palatal
patient discomfort, good color compatibility with adjacent tissue, and healing by pri-
mary intention. J Periodontal 1996;67: 1016-1024.

Key Words: Tooth root; grafts, gingival; surgical flaps; gingival recession/surgery;
transplantation/au tologous.

The periodontal literature describes several surgical pro-
cedures, the goal of which is to completely cover exposed
root surfaces with gingival tissue through attachment of
soft tissue to the previously exposed root surface. The
laterally positioned flap was one of the first procedures
described to attain gingival coverage of denuded roots. I
Variations of this procedure have been reported in several
papers.2-4 In 1963 Bjom5 reported the first free gingival
graft. Nabers6 subsequently reported on the use of a free
gingival graft to increase the band of keratinized tissue.
The past 20 years has seen an explosion of interest in
mucogingival surgery, with accompanying variations in
surgical techniques to treat recession defects. Clinical tri-
als related to root coverage with mucogingival procedures
*Private practice, FIero Brescia, Italy.
'Department of Periodontology, University of Ferrara, Dental School
Ferrara, Italy.
have reported varying results. The percentage of root cov-
erage varies from 43% to 97% although all these tech-
niques require integrity of interdental bony septa and
shallow interproximal probing depths.7-13 A possible ex-
planation for this wide variation may be related to case
selection surgical technique, root conditioning and eval-
uation methods.
In 1985 Miller's classification of gingival recession em-
phasized the indications and contraindications of various
procedures.14 In a series of papers several authorslS-21
demonstrated that successful root coverage for Class I
(shallow-narrow and shallow-wide) and Class II (deep-
narrow and deep-wide) gingival recessions can be accom-
plished by using free gingival grafts. Unfortunately, the
esthetical results are not always satisfactory due to color
and texture discrepancies between donor and receptor
sites. The keloid appearance may be avoided when ade-
quate donor tissue adjacent to the defect is present and
Volume 67
Number 10

Figure IA. Clinical photograph depicting WI eW/l1ple of 2 gingi"ol 3 Figure 2A. The initial horizontal right-angle incision is made following
mm recessions, first and second l/IondilJIIlor righl premololl, "eoled the lIluco!?ingival line, and extending in a mesio-distal direction to com-
with the fi-ee rotated papillo I/ll/ogmfl pletelv in elude the mesial and distal adjacent papillae to the gingival
recession thaI need to be treated,

laterally positioned, coronally repositioned flaps, other

various pedicle grafts, and, more recently, bilaminar pro-
cedures may be performed.22 24 In 1974, EdeF' presented
the first article on free connective tissue graft to increase
the width of keratinized tissue. The connective tissue graft
technique for root coverage was reported by Raetzke,26
describing an "envelope" technique at the recipient site.
The author reported complete root coverage in 5 out of
12 cases. This was followed by Langer and Langer's ar-
tic1e,27where the recipient flap was positioned coronally
to cover the connective tissue graft as much as possihle,
extending slightly coronally to the eEl. They treated 56
cases with different amounts of recession and found an
increase in root coverage of 2 to 6 mm. Tn I 9R7. Nelson2R
reported variations of the Langer and Langer technique,
Figure 3A. After raising the partial thickness flap well beyond the mu-
in which either double papilla grafts. laterally positioned cogingival junction the epithelium from the facial aspect of the papillae
pedicle grafts, or combined flaps are utilized to protect is debrided with a rotary diamond bur under copious sterile-saline ir-
the free connective tissue graft on its more critical points. rigation.
In the last decade several bilaminar procedures have heen
shown to predictably cover exposed root surfaces.)Ol? was low acceptance by the profession and/or patients. In
More recently Bruno" presented significant modifica- the same year, Allen and Miller24 proposed coronally po-
tions of the original Langer and Langer technique for root sitioned flaps in the treatment of shallow marginal tissue
coverage on areas of wide gingival recessions. recessions with a coronal positioning of existing gingiva.
The coronally positioned flap has never been greatly They reported a high degree of predictability and patient
accepted hy the periodontal community as an effective satisfaction. Recently, the biological principle of guided
means to cover exposed roots.1f' More encouraging results tissue regeneration (GTR) has been successfully applied
have been obtained when this procedure is comhined with for the treatment of buccal recession both in animal and
a free gingival graft.'4.,' The goal of the comhined free human models, in a 2-step mucogingival procedure.36-42
graft/coronally positioned flap is to create an adequate Several clinical studies have been reported in periodontal
band of keratinized tissue where inadequate attached gin- literature where deep and wide facial gingival recessions
giva is present and to coronally position it after a few have been treated with the GTR technique, utilizing ex-
months of healing with a second surgical procedure. In a panded polytetrafluoroethylene membrane with and with-
1989 literature review, HalF2 reported that the I step co- out metal support.36,,7,41,42This new technique is recom-
ronally positioned flap was not, as such, a viable entity mended in deep and wide recessions (2: 5 mm).37 Eval-
at that time, when compared with the 2-step procedure uating these clinical studies it can be concluded that for
(free graft/coronally positioned flap); nevertheless there facial gingival recessions > 5 mm GTR might be indi-

cated; conversely with gingival recessions < 5 mm a
"classical" mucogingival approach might be indicated.
Among these, the most widely performed is a bilaminar
approach utilizing a connective tissue graft harvested
from the palate. The purpose of this study was to describe
a new mucogingival bilaminar grafting procedure devel-
oped for treatment of Class I and II gingival recessions,
in well-selected cases, and to outline criteria for predict-
able results. - sial and distal papillae adjacent to the gingival recession
Patients
Fourteen non-smoker patients (9 females and 5 males,
aged between 22 and 46) who required root coverage ei-
ther for esthetics or for treatment of sensitivity partici-
pated in the study. Patients had a total of 29 multiple
gingival recessions and excellent general medical health,
with no detectable systemic contraindications to surgical
treatment. Selection of patients was made on the basis of
pure multiple recessions, no interproximal bone loss, and
a good level of oral hygiene and with clinical attachment
loss ::s 5 mm. The etiology of these multiple recessions
was due either to plaque-induced slight gingival inflam-
mation or to incorrect brushing technique. Patients mod-
ified their brushing techniques, adopting the "roll tech-
nique" in this area in order to completely remove dental
plaque without causing trauma to the exposed root surface
and thin soft tissue and to improve soft tissue health prior
to the surgical phase. They were informed that a new
modification of a well-known and predictable technique
was going to be applied during their surgical approach
and it would be possible to avoid a surgical palatal pro-
cedure as a donor tissue. All the patients agreed to par-
ticipate in this study and signed a surgical consent form.
Mucogingival recession sites were selected on the basis
of the following anatomic considerations: 1) the width
and depth of the gingival recession was ::s 5 mm; 2) in-
terproximal bone crests showed no periodontal lesion; 3)
it is necessary to have thick and wide interproximal pa-
pillae not smaller than the recession defect; 4) it is not
necessary to have residual keratinized tissue; and 5) deep
gingival grooves were not present on the donor papillae.
Oral hygiene instructions were given to every patient
in order to eliminate the etiological factors. Scaling and
root planing were performed where indicated, although in
many cases this was not necessary. All clinical measure-
ments were made for the selected teeth 4 weeks after
initial preparation, and repeated 6 and 12 months post-
operatively. Gingival recession and sulcus depth were re-
corded as the distance from the CEl to the gingival crest
and to the bottom of the sulcus, respectively. These di-
mensions were measured to the nearest 1 mm. The pres-
ence of supragingival plaque and bleeding on probing
J Periodont
October I
were recorded in every patient. Preoperative sensitivi
was recorded on a scale as described by Harris.3D
Surgical Technique
The following 10 steps are suggested:
1. A sharp incision is performed at a 90° angle to th
vestibule, following the mucogingivalline, and extendin
in a mesio-distal direction to completely include the me~
that needs to be treated (Figs. lA, IB, 2A).
2. Sharp dissection is accomplished to create a partial
thickness envelope flap on the underlying alveolar mu-
cosa. The muscle fibers are dissected with a corona-apical
direction of the blade well beyond the mucogingival junc-
tion for approximately 10 to 12 mm in order to reflect a
partial thickness flap on the facial aspect only. Although
in this flap design vertical releasing incisions are not uti-
lized, it is possible to position it slightly coronally.
3. The epithelium from the facial aspect of the papillae
is debrided with a rotary diamond bur under copious ster-
ile-saline irrigation (Fig. 3A).
4. The exposed root surface is root planed with curets
to remove bacterial contamination and rotary instruments
to reduce root convexity (Fig. 4A).
5. A third incision is made beginning at the first inci-
sion and extended coronally, maintaining the full thick-
ness of the facial papillary tissue (Fig. 5).
6. This band of tissue containing the papilla is re-
moved from the underlying tissue bed (Fig. 6).
7. The papilla is then reversed in such a manner that
the base of the papilla is at the CEl and the apex is at
the base of the area of recession (Figs. 2B and 7).
8. The papilla is then sutured in place utilizing a hor-
izontal mattress crossed suture (Figs. 8 and 1C).
9. In order to improve vascularization and also to fa-
cilitate the healing process, this previously raised partial-
thickness envelope flap is coronally positioned to a point
where it may completely cover the rotated papillae and is
then secured into this new position utilizing a continuous
sling suturing technique (Figs. 9 and 3B).
10. Digital pression is applied for 5 minutes. A peri-
odontal surgical dressing will protect the wound for ap-
proximately 8 days. An ice-pack is recommended in order
to avoid undesired swelling. Antibiotic therapy (amoxi-
cillin 1 g X 2) is prescribed for 6 days.
Chemical plaque control with topical application or
chlorhexidine-digluconate gel (2 X 1 min/day) is contin-
ued for 14 days. After the first week, the periodontal sur-
gical dressing is removed and the area gently debrided
with a cotton swab and hydrogen peroxide.
The sutures are left in place for another week and then
removed at the end of the 14-day healing period. Tooth-
brushing is discontinued for the first 2 weeks in the sur-
gical site. After the second week the patient is instructed
to use a soft tooth brush with a roll-technique followed
Volume 67
Number 10
by a 60-second rinse with chlorhexidine-digluconate. At
the end of the 6-week healing period, the patient can re-
turn to the usual oral hygiene technique.
After a 6-month healing period, it is possible to observe
the complete healing process and coverage of the gingival
recessions (Figs. 4B and 10).
Every patient was checked and the measurements re-
peated after 6- and 12-month healing periods.
After a 12-month healing period, a gingivoplasty with
a diamond rotary instrument may be performed in order-
to remove the oral mucosa covering the gingival reces-
sion, to expose the underlying connective tissue, and to
improve the soft tissue blending.
RESULTS
This bilaminar procedure was performed to cover either
single, or more often multiple, gingival recessions in 29
sites including 4 maxillary incisors, 3 maxillary cuspids,
4 maxillary premolars, 4 mandibular cuspids, 8 mandib-
ular premolars, and 6 mandibular incisors.
A detailed description of initial defect characteristics
and clinical results I-year postoperatively are reported re-
spectively in Tables 1 and 2. Gingival recession ranged
from 2 mm to 4 mm (average 3.32 mm) prior to treat-
ment. The residual gingival recession I-year post-treat-
ment revealed 0.27 mm (Table 3). Sulcus depth ranged
from 1 mm to 2 mm (average 1.1 mm). Total root cov-
erage was achieved in 10 of the 14 cases. In the other
cases the residual recession was from 0.5 mm to 1.3 mm.
The average result (all areas) was 91.87%. A significant
gain of keratinized tissue was noticed in every case, rang-
ing from 2 mm to 4 mm (average 3.25 mm) (Table 4).
Probing depth at these sites both at 6 and 12 months post-
operatively was 1 mm (Table 2). The mean gain of av-
erage root coverage at 12 months was 3.05 mm. The av-
erage attachment loss before treatment was 4.07 mm at 6
months and 1.2 mm at 12 months postoperatively (Tables
1,2, and 5). The gingival margin was either at the coronal
or the CEJ in 10 of the 14 cases at both the 6- and
12-month postoperative evaluations. Of the remaining
cases, 1 had < 1 mm recession and 3 1 mm recession
(Table 2). From Table 6, it is possible to extrapolate the
following data: 1) recession decrease was highly statisti-
cally and clinically significant (P < 0.00001); 2) changes
in probing depth were not significant (P = 0.19); 3) at-
tachment gain was statistically significant (P < 0.00001);
and 4) increase in keratinized tissue was statistically sig-
nificant (P < 0.00001).
Initially, 8 patients complained of root sensitivity. Both
at the 6- and 12-month evaluations no patients com-
plained of root sensitivity.
Histological information regarding the nature of the at-
tachment of the free rotated papilla autograft to the root
has not been published yet, however it is the authors'
assumption that it would be similar to that for other bi-
laminar autografts.
DISCUSSION
With the bilaminar approach, the retention of the vascular
periosteum on the recipient site and the overlying flap
may result in a more rapid re-establishment of circulation
within the free rotated papilla autograft and contribute to
more predictable and successful root coverage.
The free rotated papilla autograft combined with the
coronally positioned flap has been described as a muco-
gingival procedure for coverage of multiple and shallow
gingival recessions. This new root coverage technique has
not been performed in recessions > 5 mm since no cases
with such a depth met the criteria described.
The mean gain of 3.05 mm of root coverage repre-
sented 91.87% coverage of the exposed root surface at 12
months postoperatively. Caffesse and Guinard,7 and Ber-
nimoulin et al.,34 utilizing a coronal positioning of pre-
viously placed free gingival grafts, reported respectively
a 2.73 mm and 64% root coverage, and 1.82 mm and
75% root coverage. Allen and Miller,24 with coronal po-
sitioning of existing gingiva, found a mean gain of 3.18
mm of root coverage represented 97.8% coverage of the
exposed root at 6 months postoperatively, with a complete
root coverage in 84% of the treated sites.
Holbrook and Ochsenbein,19 utilizing thick free gingi-
val grafts without citric acid application on the exposed
root surface, reported that recessions of less than 3 mm
had 95.5% total root coverage, recessions of 3 to 5 mm
had 80.6% coverage. Miller,15 with a saturated citric acid
burnished into the root prior to positioning thick free gin-
gival grafts, found a root coverage of 100% on (13 out
of 13) of shallow-wide recession.
Nelson28 treated 6 teeth with slight recession (~ 3 mm),
and showed 100% coverage in this group. However, this
high percentage of root coverage decreased to 92% in the
moderate group (recession of 4 to 6 mm). In all the above
mentioned procedures, a clinically adequate attached gin-
giva and a healthy gingival unit was re-established.
The rotated papilla autograft combined to a coronally
positioned flap resulted in 91.87% of average coverage in
29 moderate recessions of 2 to 4 mm; a total of 14 pa-
tients were treated with moderate recessions. Harris30 de-
scribed a root coverage bilaminar technique utilizing the
palatal connective tissue and a partial thickness double
pedicle graft in 20 patients with 30 defects. A mean per-
cent root coverage of 97.4% was achieved and a total root
coverage in 24 out of 30 defects, or 80%. Initially, the
mean amount of exposed root surface was 3.6 mm and,
compared to the final one of 0.1 mm, the net root cov-
erage was of 3.5 mm or 97.2%.
Allen31.32described a reassessment of the "envelope"
technique in soft tissue grafting for root coverage. Com-
plete root coverage was attempted in 23 sites exhibiting
 J Periodontol
October 1996

Figure 4A. The exposed root surface is thoroughly root planed. An at-
tempt is made to flatten the root in areas of root prominence.

Figure 6A. Both facial papillae are removed from the underlying tissue Figure 7A. Both papillae are then reversed in such a manner that the
bed. bases of the papillae are at the CEJ and the apexS. at the areas of
recessions.

Figure 8A. The donor tissue is then sutured in place by utilizing a re- Figure 9A. The overlying flap is sutured in place with a non-resorbable
sorbable 5-0 dexon suture. suture with a standard sling suture. Note the amount of complete cov-
erage of the underlying connective tissue by the overlying flap.
Volume 67
Number 10

Figure lOA. The area 6 months postoperatively. Note the amount of root Figure 1B. Preoperative view of 2 shallow gingival recessions on man-
coverage obtained. dibular left cuspid and first premolar.

Figure 3B. A split thickness flap is coronally re-positioned, to completely

Figure 2B. Two free rotated papilla autografts are positioned over the
cover the papilla autografts and sutured.
2 gingival recessions.

Figure 1C. Drawing of the suture method, a horizontal mattress crossed

suture, for securing the papillae grafts.
 J Periodontal
1022 THE FREE ROTATED PAPILLA GRAFT October 1996

Table 1. Initial Defect Characteristics

Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Gender F F M M F F F F M F F F M M
Age 34 42 40 22 25 27 31 24 28 38 42 38 45 46
Treated recessions 2 3 2 2 3 1 2 2 2 2 2 2 3 1
Average recession depth 3.5 3.5 3 3.5 3 3 3.5 3 3 4 3 3.5 3 4
Average probing depth 1 1 1 1.5 1 1 1 1 I I 1 2 1 I
Average attachment loss 4.5 4.5 4 5 4.6 4 4.5 4 4 5 3 3 4 3
Average residual
keratizined tissue 1.5 1.5 1.3 1.5 0 0 0

Table 2. 12-Month Postoperative Results

Patient 2 3 4 5 6 7 8 9 10 11 12 13 14
Average residual
gingival recession 0 0 0 0 1.3 0 0.5 0 0 0 0 a
A verage residual
probing depth
Average residual
attachment loss 2.3 1.5 2 2
Quantity average
keratinized tissue 3 3 4 4 3.6 3 3 4 2 3 3 3 3 4.6

Table 3. Average Gingival Recession (29 Recessions in 14 Patients) Table 4. Average Keratinized Tissue (29 Recessions in 14 Patients)

o5jO~~1
Before 1 Year . !'.'mm
'
f
Treatment Post-treatment 01.'
Before 1 Year
Miller Class I and II recessions, and was achieved in 14 Treatment Post- Treatment
out of 23 sites (61 %). The average root coverage for all
sites was 84% with shallow defects averaging 95% cov-
erage, while moderate defects averaged 73%. The com- method to cover exposed root surfaces in shallow reces-
plete root coverage (61 %) reported in these two papers sion areas utilizing a coronally positioned pedicle graft
compared favorably with the total coverage percentage with inlaid margins in 20 isolated Class I defects. The
reported by Raetzke26 (42%), Nelson28 (62%), and Jahnke authors reported that a complete root coverage was ob-
et alY (56%). Conversely, differing results in total root tained 95% of the time, and the mean root coverage was
coverage have been reported by Miller]? and Harris,30 98.8%. In this report the free rotated papilla autograft has
which may be explained in part by the nature of the treat- demonstrated its ability to completely cover denuded root
ed lesions. surfaces in a high percentage of cases. This specific sur-
Recently, Harris and Harris43 reported a predictable gical technique can be adapted to satisfy the individual
Volume 67
Number 10

The authors consider this new surgical technique an

{~_._ .. _~- additional procedure to treat multiple shallow small gin-

/1 gival recessions.
The best indications are the treatment of multiple gin-
4.51 gival recessions in only one step and a single surgical
4"; site. With this surgical procedure the clinician may avoid
I the need for a second surgical site, most frequently rep-
3.5-1 resented by the palatal connective tissue. All the patients
reported relatively minimal discomfort. The technique
3~ may be used when adequate donor tissue for neither the

25
! 4.07 laterally positioned nor obliquely positioned nor the dou-
'l mm ble papilla pedicle graft is available. This procedure has

1
2 the decided advantage of a single surgical site, good color
compatibility with adjacent ti~sue, minimum discomfort
1.51 for the patient, and healing by primary intention. Fur-
1-:... thermore, the impossibility of recession at the donor site
may represent a strength versus all the above mentioned

O.sj' pedicle grafts. Despite its limited possibilities for utili-

zation, the free rotated papilla autograft has a unique, spe-
o ·'· __ c, __ cific place for use and should be included in the arma-
mentarium of every periodontal practitioner. The authors
Before 1 Year consider this new root coverage surgery an additional pro-
Treatment Post- Treatment cedure to treat multiple shallow small gingival recessions.

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Send reprint requests to: Dr. Carlo Tinti, Via Cavour 3, 25020 Flero
Brescia, Italy.
Accepted for publication March 4, 1996.