CORONALLY ADVANCED FLAP vs THE POUCH TECHNIQUE COMBINED WITH A CONNECTIVE TISSUE GRAFT TO TREAT MILLER'S CLASS I GINGIVAL RECESSION, JCP 2014;41(4):387-395.

2. CORONALLY ADVANCED FLAP vs THE POUCH
TECHNIQUE COMBINED WITH A
CONNECTIVE TISSUE GRAFT TO TREAT
MILLER'S CLASS I GINGIVAL RECESSION: A
RANDOMIZED CONTROLLED TRIAL
Salhi L, Lecloux G, Seidel L, Rompen
E, Lambert F.
JCP 2014;41(4):387-395.
Shilpa Shivanand
II MDS

3. Introduction
• The primary goal of periodontal plastic surgery procedures 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 (Grupe HE 1956, Staffileno 1964) and free
gingival grafts (Sullivan & Atkins 1968) to cover mandibular
gingival recession.

4. • Coronally advanced flaps (CAF) were introduced 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,
varying 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

5. • 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 procedures were
efficient in reducing the depth of Miller’s class I or II
recession.
• Nevertheless, CAF in combination 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.

6. • However, the success of periodontal plastic surgery
procedures is not only related to the root coverage.
• Other parameters, such as the gain of keratinized gingiva,
aesthetic outcomes, and patient-centred outcomes related to
the morbidity of the procedures, should be taken into account
when recommending a specific technique over the other
options.
• Only a small number of studies have investigated such
parameters.

7. • In their case series describing the pouch technique, Raetzke
1985, disclosed an increase of keratinized tissue (KT) height in
each patient, and in a systematic 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 aesthetic or
morbidity outcomes of such procedures.
• There is a lack of randomized controlled trials that compare
several surgical techniques based on these parameters.

8. Aim
• The objective of the present randomized controlled clinical
trial was to compare the CAF (Langer & Langer 1985) versus
the pouch technique (Raetzke 1985), both associated 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
keratinized gingiva, the aesthetic outcomes using the pink
aesthetic score (PES), and the morbidity for each technique.

9. Materials and Methods
• 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) contributed a single
recession.
• In cases of multiple recessions, the deepest one was included.
• All clinical parameters and outcomes were performed at
baseline, after 3 months and after 6 months.
• The morbidity outcomes were evaluated 10 days after
surgery.

10. Inclusion criteria
• Miller’s class I recession
• Recession of 2 mm to 5 mm
• Maxillary incisors, canine or premolars
• Identifiable cemento-enamel junction
• Minimum of 18 years old
• Controlled periodontal disease
• Providing a signed informed consent form.

11. Exclusion criteria
• Smokers
• Presence of cervical carious lesion
• Pocket depth greater than 4 mm
• Sites where previous muco-gingival therapy was performed
• Pregnancy.
• In presence of non-carious cervical lesions, the anatomical CEJ
was reconstructed by the use of a composite before the
procedure.

12. • 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 fabricate an individual
resin stent that was used as a reference point for all
measurements (Byun et al. 2009).

13. Surgical procedure
• The patient received 600 mg of ibuprofen prior to surgery, and
chlorhexidine mouthwash for 0.2% was provided for 2 min.
• Patients received LA at the donor and recession site.
• The harvest of the connective tissue graft was performed
prior to the preparation of the reception site to avoid any
bias.
• The graft dimension was calculated according to the recession
dimensions; a minimum of 3 mm of the graft was submerged
mesially, distally and apically.

14. • The connective 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).

15. Control group
• The surgical protocol in the control 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 mucogingival line (MGL).
• The papillae were disepithelialized.
• The root was planed using a curette, and a chemical
treatment was administered using a doxycycline solution (1
mg/ml)
Rompen et al. 1993, Vanheusden et al. 1998, 1999.

16. • The connective tissue graft was sutured to the recipient bed
by means of a resorbable suture (Vicryl 5.0), and the flap was
coronally advanced and sutured by simple interrupted sutures
(Silk 5.0; ethicon).
• The connective tissue graft was completely covered by the
flap.

17. Test group
• In the test group, the surgical protocol 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 connective tissue graft was inserted inside the pouch and
stabilized mesially and distally with simple interrupted sutures
(silk 5.0), leaving the connective tissue that covered the
recession exposed.

18. The post-op 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]
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.

19. Data collection
• 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.
• 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 measurements were performed intra-orally using
the individual resin stent.

20. • 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 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 consumed per day.

21. Statistical analyses
• The comparisons between groups were performed with
Student’s t-test.
• The respective differences 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 significant if p < 0.05

22. Results – clinical parameters
• At baseline and after 6 months, the test and control groups
were comparable for all clinical parameters (RD, RW, KT, GT,
LPS and local bleeding percentage) and for aesthetic scores
(PES).
RD RW
Baseline 6 months P value Baseline 6 months P value
Test 2.78±0.94 0.29± 0.61 <0.0001 4.45 ± 1.15 0.32±
0.95
<0.0001
Control 3.03± 0.9 0.16±
0.50
<0.0001 4.1 ± 0.85 0.00 ± 0 <0.0001
Significanc
e
0.39 0.47 0.08 0.28 0.15 0.85

23. GT LPS % LBS %
Basel
ine
6
month
P value Baselin
e
6
month
P value Baselin
e
6
month
P value
Test 1.08
±
0.34
1.37
±0.37
0.0075 0± 0 0± 0 0.99 0.05 ±
0.22
1.32 ±
5.74
0.35
Control 1.03
±
0.26
1.25 ±
0.35
0.0035 0 ± 0 0± 0 0.99 1.25 ±
5.59
1.32 ±
5.74
0.99
Significa
nce
0.60 0.32 0.79 0.99 0.99 0.99 0.34 0.99 0.59

25. Pink aesthetic score (PES) (mean±SD) at baseline and 6-month post-surgery
Colour Texture PES
Baseline 6 months Baseline 6 months Baseline 6 months
Test 1.85
(0.37)
2.00 (0.0) 1.15
(0.37)
1.95*
(0.23)
8.75
(1.48)
11.6*
(0.61)
Control 1.85
(0.37)
2.00 (0.0) 1.05
(0.22)
1.32*
(0.48)
8.65
(1.23)
11.0*
(1.03)
Significanc
e
0.99 0.99 0.30 p < 0.0001 0.82 0.027

26. Control group – CAF
with SCTG
Test group – pouch
and tunnel with SCTG

27. Discussion
• The objective of the present study was to compare the
effectiveness of two different surgical protocols to treat
Miller’s class I recession in the anterior upper maxilla.
• The Langer & Langer technique (1985), which are still
regarded as the gold standard for root coverage, was used in
the control group, the pouch technique as described by
Raetzke (1985) and Allen (1994), was implemented in the test
group.
• The two tested surgical techniques were assessed for root
coverage, KT gain and aesthetic outcomes.

28. Root coverage
• The MRC found in this study was fairly high compared to the
existing data in the literature on this particular topic (96% in
the control group and 91% in the test group), and no
significant differences were observed between the two
groups.
• According to the published clinical trials and systematic
reviews, the MRC found with the “CAF associated with CTG”
and with the “pouch technique” were notably heterogeneous
and varied from 75.5% to 97% (Paolantonio et al. 1997,
Chambrone & Chambrone 2006) and from 69.2% to 96.4%
respectively (Raetzke 1985, Allen 1994, Han et al. 2008).

29. 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
• 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)

30. Aesthetic Outcomes
• 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 and the dentists, both surgical
techniques promoted significant improvement and optimal
aesthetic results.

31. • In considering the details of the PES rated by the dentist, the
texture was significantly better with the pouch technique.
• The inferior score regarding the texture found in the control
group seems to be related to the scars left by the vertical
releasing incisions of the CAF.
• Vertical releasing incisions impair the vascularization, and soft
tissue healing can result in fibrotic scars, jeopardizing
aesthetic outcomes.
Allen 1994, Bruno 1994, Zabalegui et al. 1999,
Zucchelli & De Sanctis 2000, Carvalho et al. 2006

32. Conclusion
• The findings of this study indicate that the pouch technique
and the coronally advanced flap technique in combination
with a connective tissue graft can be successfully used to treat
Miller’s class I recession in aesthetic areas.
• Both surgical techniques were effective and predictable for
root coverage.
• Moreover, post-operative outcomes and painkiller
consumption were moderate and similar for both surgical
procedures.
• Nevertheless, the pouch technique displayed greater
increases in KT and seemed to offer lower levels of scarring.

33. Critical evaluation
• Not mentioned method of measuring GT
• Not specified which index has been taken in
assessing plaque and bleeding score
• No clinical photographs of donor site graft
procurement

34. CROSS REFERENCE

35. I. Treatment of gingival recession with coronally
advanced flap procedures: a systematic review.
Cairo F et al, JCP 2008;35(8):136-62.
• The aim of this manuscript was to systematically review the
literature on coronally advanced flap (CAF) alone or in
combination with tissue grafts, barrier membranes (BM),
enamel matrix derivative (EMD) or other material for treating
gingival recession.
• Randomized clinical trials on treatment of Miller Class I and II
gingival recessions with at least 6 months of followup were
identified. Data sources included electronic databases and
handsearched journals. The primary outcome variable was
complete root coverage (CRC). The secondary outcome
variables were recession reduction, clinical attachment gain,
keratinized tissue gain, aesthetic satisfaction, root sensitivity,
postoperative patient pain and complications.

36. • RESULTS: A total of 794 Miller Class I and II gingival recessions
in 530 patients from 25 RCTs were evaluated in this systematic
review. CAF was associated with mean recession reduction
and CRC. The addition of connective tissue graft (CTG) or EMD
enhanced the clinical outcomes of CAF in terms of CRC, while
BM did not. The results with respect to the adjunctive use of
acellular dermal matrix were controversial.
• CONCLUSION: CTG or EMD in conjunction with CAF enhances
the probability of obtaining CRC in Miller Class I and II single
gingival recessions.

37. II. Root coverage with subepithelial connective tissue
grafts and modified tunnel technique. An evaluation
of long term results. Tözüm TF et al, N Y State Dent J
2006;72(4):38-41.
• AIM: The goal of the present study was to evaluate and
compare the shortterm and longterm (36 months) root
coverage results of SCTG and the modified tunnel procedure.
• METHOD: Patients, each contributing at least two adjacent
buccal gingival recessions, were treated with SCTG and
modified tunnel technique. The changes in the clinical
measurements were compared at baseline, shortterm and
longterm.

38. • RESULTS: The mean root coverage was 95% and 92.2% at
eight months and 36 months postsurgery, respectively. These
differences were statistically significant compared to the
baseline. The mean gain in attachment was 3.79 mm, and the
mean root coverage was 3.14 mm after 36 months.
• CONCLUSION: The results of the present clinical study
demonstrated that the SCTG with modified tunnel approach
was an effective periodontal plastic surgery method to cover
the exposed roots.