BACKGROUND:Mucogingival surgery techniques for treating gingival recessions (GRs) have evolved significantly over decades, reflecting advances in surgical understanding and patient demands. This narrative review tracesexamines the historical development of the coronally advanced flap-multiple coronally advanced flap (CAF/MCAF) and tunnel techniques, highlighting how these procedures have been refined to improve clinical outcomes and esthetic results. Emphasis is placed on the biological principles underlying these approaches and their adaptation based on growing scientific evidence. METHODS:A comprehensive review of the literature was conducted, synthesizing historical milestones and recent clinical studies including randomized controlled trials and systematic reviews. The focus was on comparing the CAF and tunnel approaches in terms of surgical principles, technical variations, and effectiveness in root coverage treatment, considering adjunctive use of grafting materials. RESULTS:Both the CAF/MCAF and tunnel techniques demonstrate high predictability and effectiveness in GR coverage. Their evolution reflects a trend toward minimally invasive surgery, improved vascularization, and tissue stability. Current evidence supports the choice of technique based on defect characteristics, tissue phenotype, and esthetic requirements, with connective tissue grafts (CTGs) and biomaterials enhancing outcomes in many cases. CONCLUSIONS:Both CAF and tunnel techniques provide predictable root coverage, enhanced by CTGs (gold standard) or substitutes (reducing morbidity but with limited evidence). The choice between the two techniques should be guided by recession and tissue phenotype characteristics to optimize functional and esthetic outcomes. PLAIN LANGUAGE SUMMARY:This study highlights the history and development of two key mucogingival surgical techniques, the coronally advanced flap and the tunnel technique, demonstrating that both provide reliable and effective options for treating gingival recessions, enabling successful root coverage outcomes.

BACKGROUND:Wire syndrome (WS) is increasingly reported and associated with significant dento-periodontal consequences. However, no standardized diagnostic criteria or consensual classification exist, complicating early detection and potentially leading to confusion with orthodontic relapse, or periodontal pathology. This study aimed to develop for the first time a diagnostic approach for WS, define clinical diagnostic criteria, and propose a severity-based classification applicable in routine practice. MATERIALS AND METHODS:A four-phase methodology was implemented using two retrospective case series (n=53). Phase 1 combined a literature review and expert clinical analysis to identify candidate diagnostic criteria and a preliminary severity grading. Phase 2 involved interdisciplinary expert consensus to refine decisive and non-decisive criteria. Phase 3 assessed inter-rater reliability using Gwet's AC1 coefficient on confirmed WS cases. Phase 4 evaluated discriminant validity in an independent cohort including both WS and non-WS cases. RESULTS:Three decisive criteria were retained, all required to confirm the diagnosis of WS (AC1=0.86): two dental criteria (differences in dental surface visibility or inclination/torque; misalignment of incisal edges or canine cusps) and one periodontal criterion (misalignment of gingival margins with or without gingival recession). Additional dental and periodontal non-decisive criteria were identified as optional complexity factors. Three severity grades were defined - early (grade 1), moderate (grade 2), and severe (grade 3) - based on gingival recession depth. CONCLUSIONS:This Severity-Based Classification of Wire Syndrome provides a reliable and reproducible tool applicable across dental specialties and easily integrated into routine retention follow-up using three photographs, facilitating systematic early detection of WS. REGISTRATION NUMBER:2025-EI-727; ClinicalTrials.gov: NCT07030023.

The multiple coronally advanced flap (MCAF) and the modified coronally advanced tunnel technique (MCAT) are the most commonly used methods for treating multiple gingival recessions. However, treating multiple defects is very complex due to various biologic and anatomical factors, and there is no clear guideline on the major or minor determinants that influence surgical decisions. The aim of the present article is to discuss a decision tree to suggest to clinicians the most relevant anatomical factors to consider when evaluating the choice between an MCAT and an MCAF. In the proposed decision-making process, the first crucial step involves the evaluation of the interdental clinical attachment loss according to the new EFP/AAP classification. The next step is to assess the dimensions of the lateral keratinized tissue (LKT)—that is, the keratinized tissue located laterally to the recession defect. When the amount of LKT is insufficient, the interdental papillae size, including base, height, and coronal width, must also be evaluated.

AIMS:The primary objective was to evaluate the 3-year outcomes of a coronally advanced flap with connective tissue graft (CAF + CTG) for treating gingival recession defects affecting lower incisors. Additionally, the study aimed to investigate whether anatomical factors related to mandibular incisors influence gingival margin stability 3 years post-surgery. METHODS:A prospective study was conducted on 30 patients with single gingival recession affecting mandibular incisors, treated with a trapezoidal CAF + CTG at San Raffaele Hospital (Milan, Italy) between January and May 2021. Clinical parameters, including recession depth (REC), keratinized tissue width (KTW), and marginal tissue thickness (MTT), were recorded at baseline and at the 1-year and 3-year follow-ups. Cone Beam Computed Tomography (CBCT) scans were also utilized to assess bucco-lingual inclination, apical root position, vestibular bone dehiscence, and root prominence. RESULTS:At the 3-year follow-up, complete root coverage (CRC) was achieved in 52% of treated sites. A statistically significant reduction in REC was observed over the evaluation period. However, no significant differences were found in clinical parameters (REC, KTW, and MTT) between the 1-year and 3-year follow-ups. REC at 3 years was significantly and positively correlated with baseline REC, whereas it was inversely correlated with apical root position. Factors associated with mRC at 3 years were KTW baseline, root prominence, and apical root position. CONCLUSION:The findings of this study highlight key site-specific anatomical factors that may negatively influence root coverage outcomes in mandibular incisors, providing valuable insights for predicting treatment success.

BACKGROUND:Aesthetics and patient-reported experiences (PREs) and outcomes (PROs) influence treatment choices, but have been largely overlooked in periodontology and implant dentistry. This consensus conference evaluated these factors by focusing on gingival recession defects (GRDs), immediate or early/delayed implant placement and peri-implant buccal soft-tissue dehiscences. METHODS:The workshop discussions were informed by five specifically commissioned systematic reviews covering PREs, PROs and clinician-reported outcomes (CROs), including effectiveness, aesthetics and other concerns. RESULTS:Following treatments such as coronally advanced flaps (CAFs) with a connective tissue graft (CTG) for root coverage (RC), a positive correlation was noted between clinician-reported aesthetic scores and RC measures for GRDs. However, a corresponding correlation for patient-reported aesthetic perceptions was not evident. In dental implant procedures, the addition of a CTG immediately after implant placement significantly mitigated the apical shift in the mid-facial mucosal level. However, clinician- and patient-reported aesthetic scores were not reflective of these changes. Neither set of scores captured the impact of grafting on improving peri-implant soft-tissue volume. In the treatment of peri-implant dehiscences, soft-tissue augmentation (STA), using CTG beneath CAF, resulted in favourable outcomes in clinician- and patient-perceived aesthetics. CONCLUSIONS:Clinician and patient views provide complementary perspectives for evidence-based clinical decision making. They need to be integrated into select interventions. Specific trials are needed encompassing PREs, PROs and CROs and reporting benefits and harms.

The introduction of a new collagen substitute, which will potentially reduce the invasiveness of techniques by avoiding the need for a second surgical site (ie, the donor site), needs to be evaluated in relation to the surgical procedure that could benefit the most by utilizing such a matrix. This study compared the clinical outcomes following treatment of RT1 multiple adjacent gingival recessions (MAGRs) using the modified coronally advanced tunnel (MCAT) technique or the multiple coro-nally advanced flap (MCAF) in conjunction with a new volume-stable xenogeneic collagen matrix (VXCM). Secondarily, the study evaluated whether patients report a preference between the two surgical techniques in terms of discomfort. A total of 20 patients requiring treatment of MAGRs were randomly assigned to one of the two treatment groups: MCAF+VCMX (Group A) or MCAT+VCMX (Group B). The following measurements were recorded at baseline (before surgery) and at 6 and 12 months: gingival recession depth (REC), probing pocket depth (PD), keratinized tissue width (KTW), and gingival thickness (GT). Postoperative pain and discomfort were recorded using a visual analog scale (VAS) at 1 week. The primary outcome variable was mean root coverage (mRC), and second-ary outcomes were complete root coverage (CRC), changes in KTW and GT, patient discomfort and satisfaction, and duration of surgery. Healing was uneventful in both groups. At 12 months, both treatments resulted in statistically significant improvements in REC and GT compared to baseline (P < .05). The mRC was 79.95% +/- 29.92% in the MCAF group and 64.74% +/- 40.5% in the MCAT group (P = .124). CRC was seen in 65.6% of MCAF-treated sites and 52% of MCAT-treated sites (P = .181). Similar clinical results should be expected when MAGRs are treated with MCAF or MCAT, with the adjunct of VCMX. Int J Periodontics Restorative Dent 2024;44:499-509. doi: 10.11607/prd.6796

This study aimed to histologically evaluate the healing at 8 weeks after coronally advanced flap (CAF) with either a superficial (SCTG) or deep palatal connective tissue graft (DCTG), or a collagen matrix (CM) to cover recession defects at teeth and implants. One mandibular side of 6 miniature pigs received each 3 titanium implants 12 weeks after extraction. Eight weeks later, recession defects were created around implants and contralateral premolars and 4 weeks later randomly subjected to CAF + SCTG, CAF + DCTG, or CAF + CM. After 8 weeks, block biopsies were histologically analyzed. For the primary outcome, i.e., keratinization of the epithelium, all teeth and implants exhibited a keratinized epithelium with no histological differences among them also not in terms of statistically significant differences in length (SCTG 0.86 ± 0.92 mm, DCTG 1.13 ± 0.62 mm, and Cm, 1.44 ± 0.76 mm). Pocket formation was histologically seen at all teeth, around most implants with SCTG and DCTG, however not in the CM implant group. The connective tissue grafts showed hardly signs of degradation, whereas the CM was partly degraded and integrated in connective tissue. The mean gain in gingival height was similar in all experimental groups (SCTG 3.89 ± 0.80 mm, DCTG 4.01 ± 1.40 mm, CM 4.21 ± 0.64 mm). Statistically significant differences were found in the height of the junctional epithelium between the control teeth and the connective tissue groups (p = 0.009 and 0.044). In this animal model, the use of either a superficial or deep connective tissue graft or a collagen membrane did not seem to have any impact on the epithelial keratinization around both teeth and implants. All procedures (CAF + SCTG/DCTG/CM) resulted in a long JE that was even longer at implants. Deep/superficial palatal connective tissue graft yielded similar keratinization around teeth/implants. Given the absence of pocket formation and inflammatory processes at implants when using a CM, CAF + CM might bear potential clinical benefits.

BackgroundThe purpose of the present study was to prospectively evaluate the 3-year changes in the gingival dimensions following multiple coronally advanced flap (MCAF) with selective use of connective tissue graft (CTG). In addition, the secondary aim was to histologically identify the factors related to phenotype changes. MethodsTwenty patients treated with MCAF and site-specific application of a CTG were available for the 3-year follow-up. Outcome measures included complete root coverage (CRC), recession reduction, keratinized tissue width (KTW), marginal tissue thickness changes, and primary flap position. Biopsies were harvested at one of the sites treated with the adjunct of CTG. All sections were stained with hematoxylin and eosin, Masson trichrome, Verhoeff-van Gieson, tenascin, and alcian blue stain for semiquantitative evaluation. ResultsAt 3 years, CRC was detected in 86% of sites treated with MCAF alone and 81% of sites treated with MCAF + CTG. The 47% of sites treated with MCAF + CTG presented an apical shift of primary flap from its original position. Linear regression showed a significant association between KTW change and the initial KTW in MCAF-treated sites, while both initial KTW and position of primary flap were statistically significantly associated factors with KTW changes in the MCAF + CTG group. In all the biopsies examined, there is always a marked and clear separation between the connective tissue of the gingival flap and the palatal connective tissue of the graft. ConclusionsThe selective use of CTG is an effective treatment for multiple gingival recessions. Only a limited increase in KTW can be expected in a bilaminar technique if, during the healing phases, the connective tissue is maintained completely covered.

(1) Background and objective: Tooth movements described as unexplained, aberrant, unexpected, unwanted, or undesirable can occur in the presence of an intact orthodontic retention wire, without detachment or fracture. This iatrogenic phenomenon, known little or not by many practitioners, responsible for significant dental and periodontal complications, both functional and aesthetic, is called “Wire Syndrome” (WS). It is therefore considered an undesirable event of bonded orthodontic retainers, which must be differentiated from an orthodontic relapse. The objective was to perform, for the first time, a systematic review of the literature in order to define the prevalence of WS and to study its associated clinical characteristics. (2) Methods: A systematic review of the literature was performed following the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and recommendations using an electronic search strategy on four databases complemented by a manual search. All the prospective and retrospective clinical studies, including case reports and series, written in English or French, clearly mentioning the description, detection, or management of WS were included. Three independent blinding review authors were involved in study selection, data extraction, and bias assessment using the Mixed Methods Appraisal Tool (MMAT). (3) Results: Of 1891 results, 20 articles published between 2007 and 2021 fulfilled the inclusion criteria, with a globally high risk of bias since 16 articles were case report/series. The analysis of each article allowed the highlighting of WS through 13 categories, as follows: prevalence, apparition delay, patient characteristics, arch and tooth involved, families of movements, dental and periodontal consequences, type of wire, risk factors, etiologies, treatment, and preventive approach. (4) Conclusion: This systematic review of the literature elaborated a synthesis on WS, allowing general practitioners, periodontists, and orthodontists to understand this adverse event, to facilitate the diagnostic approach, and to underline preventive measures against WS. This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO; number CRD42021269297).

BACKGROUND:The aim of this study was to investigate the inter- and intra-examiner agreement among international experts on the diagnosis of gingival recession defects using the 2018 Classification of Gingival Recession Defects and Gingival Phenotype as proposed in the 2017 World Workshop. METHODS:Standardized intraoral photographs from 28 gingival recession defects were evaluated twice by 16 expert periodontists. Recession type (RT), recession depth (RD), keratinized tissue width (KTW), gingival thickness (GT), detectability of the cemento-enamel junction (CEJ), and presence of root steps (RS) were recorded and used for the analysis. Intra- and inter-examiner agreements were calculated for individual variables and for the overall classification. Intraclass correlation coefficient with 95% CI was used for RD and KTW; Kappa with 95% CI was used for GT, CEJ, and RS; quadratic weighted Kappa with 95% CI was used for RT. RESULTS:Overall intra- and inter-examiner agreements were highest for KTW (0.95 and 0.90), lowest for GT (0.75 and 0.41), with the other variables in between (RD: 0.93 and 0.68, RS: 0.87 and 0.65, RT: 0.79 and 0.64, CEJ: 0.75 and 0.57). Overall intra- and inter-examiner agreements for the matrix were 62% and 28%, respectively. Significant effects existed between one variable's measurement and other variables' agreements. CONCLUSIONS:The 2018 Classification of Gingival Recession Defects and Gingival Phenotype is clinically reproducible within the examiners, and when the variables forming the matrix are analyzed individually. The between-examiner agreement for the complete matrix showed lower reproducibility. The agreement was highest for KTW and RD, and least for GT.

AIM:The present pilot RCT aimed to investigate the influence of a connective tissue graft (CTG) in combination with the immediate implant placement (IIP) on hard and soft tissue healing, without a bone replacement graft in the gap between the implant and the socket walls.MATERIALS AND METHODS:Thirty patients requiring extraction of one anterior tooth (from premolar to premolar) were randomly assigned to one of the two treatment groups (test: IIP + CTG; control: IIP). Cone-beam computed tomography and optically scans were performed before tooth extraction and at 6-month follow-up. Then, DICOM files were superimposed in order to allow the evaluation of osseous ridge and buccal bone changes, while the superimposition of DICOM and Standard Tessellation Language files allowed for evaluating of soft tissue contour. For testing the differences between the two groups, the non-parametric test as Wilcoxon rank-sum test, was used.RESULTS:Twenty-six of the 30 enrolled patients attended the 6-month follow-up visit. The four patients of the control group that were lost to follow-up were analysed under the intention-to-treat principle. No statistically significant differences between the groups were observed for the vertical buccal bone resorption (p = .90), as well as for the horizontal buccal bone resorption at all measured levels. Significant differences were found between the test and control groups in the horizontal dimensional changes of osseous ridge at the most coronal aspect (p = .0003 and p = .02). Changes in tissue contour were between -0.32 and -0.04 mm in the test group and between -1.94 and -1.08 mm in the control group, while changes in soft tissue thickness varied between 1.33 and 2.42 mm in the test group and between -0.16 and 0.88 mm in the control group, with statistically significant differences for both variables at all measured levels. At 6 months, the mean volume increase was 6.76 ± 8.94 mm3 and 0.16 ± 0.42 mm3 in the test and control groups, respectively, with a statistically significant difference.CONCLUSIONS:The findings of the present study indicate that the adjunct of a CTG at the time of IIP, without bone grafting, does not influence vertical bone resorption. Within the limits of this study, it can be suggested that the adjunct of a CTG at the time of IIP, without bone grafting, reduces the horizontal changes of the alveolar ridge. Moreover, it allows maintenance of the tissue contour due to an increase in soft tissue thickness.

The aim of the present case series was to evaluate the outcomes of the modified coronally advanced tunnel technique (MCAT) using the width of keratinized tissue (KTW) as an indicator to apply the connective tissue graft (CTG) specifically. Seven patients requiring treatment for the presence of multiple gingival RT1 recession defects in the maxilla were enrolled in the study. A total of 36 recessions were treated with MCAT, and the CTG was applied in 16 sites presenting < 2 mm of KTW at baseline. The mean root coverage from baseline to 1 year postsurgery was 90% for the sites treated with MCAT alone and 93.7% for those treated with MCAT+CTG. The increase of KTW was higher in the sites treated with CTG than in the sites treated without it. Within the limitations of the present case series, it can be concluded that the proposed surgical technique is extremely effective in gaining root coverage and reducing the amount of connective tissue harvested from the donor site.

L’anneau de tissu mou formé autour du col de l’implant est appelé muqueuse péri-implantaire. Un des rôles de cette attache tissulaire est de créer un joint biologique protecteur autour de l’implant afin de prévenir des maladies inflammatoires (mucosite, peri-implantite) qui pourraient compromettre lostéointegration. Ce rôle protecteur est une évidence clinique malgré les controverses existantes dans la littérature en relation avec la nécessité de la présence ou absence des tissus kératinisés autour des implants. Mais quelle épaisseur tissulaire est capable d’assurer une stabilité du joint biologique péri-implantaire ? Le tissu conjonctif joue-t-il un rôle prépondérant ? La stabilité du joint biologique, est-elle liée à l’épaisseur des tissus, à la stabilité des tissus osseux ou bien aux deux ? Par ailleurs, labsence de muqueuse kératinisée, un phenotype fin, aussi une insuffisance de volume, tant des situations cliniques qui risquent de favoriser linstabilité des tissus péri-implantaires. Les conséquences cliniques (outre le risque de maladie inflammatoire) sont multiples : 1 Mobilité et ou décollement de la muqueuse péri-implantaire 2 Récession de la muqueuse péri-implantaire 3Restauration implanto-portée inesthétique par rapport aux dents adjacentes Cet exposé a pour but de répondre à toutes ces questions et aussi de détailler les solutions qui sont nécessaires pour assurer ou rétablir une stabilité de la muqueuse péri-implantaire.

doi: 10.11607/prd.2020.5.e Brilliant ideas inspire the creation of scientific evidence. In our field, an idea is a clinical/surgical intuition that comes from the experience of one or more professionals. At first, this idea should be published and diffused as a pilot study, proof of principle, or case series, and subsequently, it must be scientifically validated through randomized controlled studies. This is exactly what happened to the envelope coronally advanced flap (CAF) technique (Fig 1). First described by Zucchelli and De Sanctis in 2000 in a case series,1 it has been tested in more than 100 studies and cited in 403 papers to date, proving its efficacy and repeatability. But what makes this transition from an innovative idea to a gold-standard procedure possible? Why are there so many surgical procedures that last only a few years, the so-called “meteors,” while others become scientific milestones? This mainly depends on the biologic principles upon which the technique is based. The envelope CAF technique was constructed to focus on achieving the best possible blood supply as well as the highest wound stability, both key elements in wound healing. The envelope CAF design consists of a number of oblique submarginal incisions in the papillae area. The peculiar displacement of the papilla tips was born to overcome an issue observed with previous techniques, in which the surgical papillae would cover the enamel instead of the interproximal vascular beds at the end of the surgery. The absence of vertical releasing incisions improves the tropism of the entire flap, avoiding damage to the lateral distribution of the vascular supply while eliminating the risk of scar formation. The concept of flap-thickness modulation, the split-full-split idea, was introduced to exploit the different characteristics of each thickness2 anastomosis with the deepithelialized anatomical papillae. The full-thickness elevation of the mid-portion maintains the entire soft tissue thickness as well as the highly vascularized periosteum in the flap area, which will be positioned above the avascular exposed root surface. And finally, the minimal, deep, split-thickness incision in an apical direction detaches the alveolar mucosa from the periosteum, and the superficial incision removes muscle insertions from the inner aspect of the alveolar mucosa; both are crucial steps to eliminate flap tension and obtain coronal displacement. Passivity of the flap is an issue of paramount importance, as using pulling and compressive sutures to overcome residual flap tension may damage the vascular supply by reducing vessel patency and impairing neovascularization. The absence of flap tension also contributes to its stability in the desired final position and reduces the risk of early flap shrinkage.3 Flap closure is accomplished with a limited number of sling sutures, only one for each papilla, providing a tight buccal adaptation of the flap above the convexity of the crowns without the risk of blood seeping from the gingival margin, thus improving clot stability. The solid biologic background behind every single step of the technique explains why there has been no need to make substantial changes over the years. Increased awareness of the necessity4 to aid flap stability by the site-specific addition of connective tissue graft has been the main innovation in the last years.5 Obviously, surgical instruments and suture materials have become more refined and magnification systems have improved; this has allowed the technique to become ever more precise. However, the legacy of the envelope CAF is its evolution from being a treatment for gingival recession to becoming a treatment philosophy. Coronal advancement is an ascertained concept to counteract the flap’s tendency to shrink during the early phases of wound healing. Thus, the envelope CAF concept is now applied in

Objectives The aim of this systematic review and meta-analysis was to compare the use of platelet-rich fibrin (PRF) with other commonly utilized treatment modalities for root coverage procedures. Materials and methods The eligibility criteria comprised randomized controlled trials (RCTs) comparing the performance of PRF with that of other modalities in the treatment of Miller class I or II (Cairo RT I) gingival recessions. Studies were classified into 5 categories as follows: (1) coronally advanced flap (CAF) alone vs CAF/PRF, (2) CAF/connective tissue graft (CAF/CTG) vs CAF/PRF, (3) CAF/enamel matrix derivative (CAF/EMD) vs CAF/PRF, (4) CAF/amnion membrane (CAF/AM) vs CAF/PRF, and (5) CAF/CTG vs CAF/CTG/PRF. Studies were evaluated for percentage of relative root coverage (rRC; primary outcome), clinical attachment level (CAL), keratinized mucosa width (KMW), and probing depth (PD) (secondary outcomes). Results From 976 articles identified, 17 RCTs were included. The use of PRF statistically significantly increased rRC and CAL compared with CAF alone. No change in KMW or reduction in PD was reported. Compared with PRF, CTG resulted in statistically significantly better KMW and RC. No statistically significant differences were reported between the CAF/PRF and CAF/EMD groups or between the CAF/PRF and CAF/AM groups for any of the investigated parameters. Conclusions The use of CAF/PRF improved rRC and CAL compared with the use of CAF alone. While similar outcomes were observed between CAF/PRF and CAF/CTG for CAL and PD change, the latter group led to statistically significantly better outcomes in terms of rRC and KTW. In summary, the use of PRF in conjunction with CAF may represent a valid treatment modality for gingival recessions exhibiting adequate baseline KMW. Clinical relevance The data indicate that the use of PRF in conjunction with CAF statistically significantly improves rRC when compared with CAF alone but did not improve KMW. Therefore, in cases with limited baseline KMW, the use of CTG may be preferred over PRF.

BACKGROUND:This report is intended to present a supplemental analysis of data from a prior report (Aroca et al., ) to investigate factors associated with a complete root coverage at 1 year. The purpose of the prior report was to investigate at 1 year the adjunction effect of EMD for the treatment of Miller's class III recession defects using a coronally advanced modified tunnel/CTG technique with (test group) or without (control group). The purpose of this report was to investigate additional factors associated with root coverage in the same data set.MATERIALS AND METHODS:On the 138 observations collected from 20 patients, a regression model was used to highlight the relationship between the percentages of root coverage (RC) and three following covariates: the distance from the tip of the papilla and the contact point (DCP) at baseline, the group membership (control vs. test) and tooth position in the mouth (maxillary vs. mandibular).RESULTS:The statistical analysis showed that there was a significant effect of the DCP at baseline (p = 0.01) and of the tooth type (p < .001) on the percentage of RC at 1 year, whereas no significant difference between the two techniques (group membership effect) was shown (p = 0.69).CONCLUSION:The probability to obtain a complete root coverage decreases when the DCP at baseline increases. Moreover, maxillary teeth are more likely to give better RC than mandibular teeth. However, in this analysis similar to the last, there was no group effect.

The primary indication for treatment of gingival recessions is esthetics. In the last decades, patients have become increasingly more demanding in the esthetic outcome expected. In order to obtain a successful final result, periodontal plastic surgery should provide not only complete root coverage but also perfect blending in terms of color and texture. In the literature, many techniques have been demonstrated to be effective in obtaining complete root coverage, and the selection of one surgical technique over another depends on several factors related to the anatomic characteristics of the defect. The purpose of this paper was to suggest a decision-making process which starts from the clinical observation of the defects and is structured in progressive nodes that will guide the clinician through the most suitable surgical technique to achieve the ideal esthetic outcome.

BACKGROUND A newly developed collagen matrix (CM) of porcine origin has been shown to represent a potential alternative to palatal connective tissue grafts (CTG) for the treatment of single Miller Class I and II gingival recessions when used in conjunction with a coronally advanced flap (CAF). However, at present it remains unknown to what extent CM may represent a valuable alternative to CTG in the treatment of Miller Class I and II multiple adjacent gingival recessions (MAGR). The aim of this study was to compare the clinical outcomes following treatment of Miller Class I and II MAGR using the modified coronally advanced tunnel technique (MCAT) in conjunction with either CM or CTG. METHODS Twenty-two patients with a total of 156 Miller Class I and II gingival recessions were included in this study. Recessions were randomly treated according to a split-mouth design by means of MCAT + CM (test) or MCAT + CTG (control). The following measurements were recorded at baseline (i.e. prior to surgery) and at 12 months: Gingival Recession Depth (GRD), Probing Pocket Depth (PD), Clinical Attachment Level (CAL), Keratinized Tissue Width (KTW), Gingival Recession Width (GRW) and Gingival Thickness (GT). GT was measured 3-mm apical to the gingival margin. Patient acceptance was recorded using a Visual Analogue Scale (VAS). The primary outcome variable was Complete Root Coverage (CRC), secondary outcomes were Mean Root Coverage (MRC), change in KTW, GT, patient acceptance and duration of surgery. RESULTS Healing was uneventful in both groups. No adverse reactions at any of the sites were observed. At 12 months, both treatments resulted in statistically significant improvements of CRC, MRC, KTW and GT compared with baseline (p < 0.05). CRC was found at 42% of test sites and at 85% of control sites respectively (p < 0.05). MRC measured 71 ± 21% mm at test sites versus 90 ± 18% mm at control sites (p < 0.05). Mean KTW measured 2.4 ± 0.7 mm at test sites versus 2.7 ± 0.8 mm at control sites (p > 0.05). At test sites, GT values changed from 0.8 ± 0.2 to 1.0 ± 0.3 mm, and at control sites from 0.8 ± 0.3 to 1.3 ± 0.4 mm (p < 0.05). Duration of surgery and patient morbidity was statistically significantly lower in the test compared with the control group respectively (p < 0.05). CONCLUSIONS The present findings indicate that the use of CM may represent an alternative to CTG by reducing surgical time and patient morbidity, but yielded lower CRC than CTG in the treatment of Miller Class I and II MAGR when used in conjunction with MCAT.