Coronal advanced flap in combination with a connective tissue graft. Is the thickness of the flap a predictor for root coverage? - A prospective clinical study. Department of Periodontology and Oral Implantology. "A Journal Club Presentation"

2. Coronal advanced flap in combination with
a connective tissue
graft. Is the thickness of the flap a predictor
for root coverage?
A prospective clinical study
Journal of Clinical Periodontology
- Teresa Garces-McIntyre1 | Josep Maria Carbonell2 | Lluís Vallcorba1
| Antonio Santos1 |
Cristina Valles1 | José Nart1
PRESENTATION BY – DR. MD ABDUL HALEEM

3. CONTENTS:
• INTRODUCTION
• MATERIALS AND METHODS
• Study design
• Patient selection
• Presurgical treatment
• Clinical measurements
• Surgical treatment (CAF+CTG)
• Post operative care
• Statistical analysis
• RESULTS
• DISCUSSION
• CONCLUSION

4. INTRODUCTION
• Complete root coverage (CRC)
with good appearance of the
adjacent soft tissues and
minimal probing depth (PD) is
the aim of periodontal plastic
surgery
• Aesthetics and/or root
sensitivity are the usual
reasons for demanding root
coverage (RC) procedures.

5. • Several surgical techniques have been proposed to treat gingival
recession:
• The free gingival graft
• The coronally advanced flap (CAF)
• The CAF with a subepithelial connective tissue graft (CAF + CTG) - Langer &
Langer, 1985

6. And various regenerative procedures such as:
• Use of resorbable and non-resorbable barriers
• Enamel Matrix Derivative
• The application of a platelet-rich gel in combination with CAF.
• Acellular dermal matrix has also been used as a replacement for CTG in
bilaminar techniques (Harris, 2000; Harris, 2004).
• Recently, the use of CAF with a xenogeneic porcine collagen matrix was
reported (McGuire & Scheyer, 2010).

7.  (Baldi et al., 1999; Hwang & Wang, 2006), (Pini Prato et al., 2005; Pini Prato et al., 2000) and (Saletta et al.,
2001)
Cairo, Nieri, & Pagliaro, 2014; Chambrone, Pannuti, et al., 2010 Chambrone, Sukekava et al., 2010; Sanz &
Simion, 2014
• During many years, the CAF has been widely used with studies
showing 24–95 % of CRC – (Wennström, 1996)
• Success rates depend directly on specific factors such as: *
• Gingival thickness
• The tension and position of the gingival margin in the moment of suturing
• The dimension of adjacent papillae.
• Recent systematic reviews confirm that “The gold standard in RC is
the CAF combined with a CTG” *

8. • The use of a graft underneath the CAF resulted in a significant
frequency of CRC and provided a slight increase in keratinized tissue
(KT).
• Furthermore, it is also reported that the presence of a graft might
provide stability to the coronally advanced soft tissue margin and
reduce soft tissue shrinkage.

9. • Baldi et al. (1999) in his study concluded that flap thickness (FT) (>0.8
mm) is a significant predictor of CRC when recessions were treated by
CAF procedures.
• Also, Huang et al. considered that FT >1.2 ± 3 mm was a decisive
factor for CRC in CAF
• However, it is unknown if the predictive factors related to CAF also
affect the rates of CRC of CAF + CTG.
• Therefore the purpose of this study was to evaluate the influence of
FT on CRC when using a CAF and a CTG at 6 months.

10. MATERIALS AND METHODS
Study design
• A prospective clinical study was designed to evaluate the
influence of FT on RC outcomes when a CTG is positioned
underneath a CAF
• In this study, multiple Miller Class I and II maxillary or
mandibular recessions were treated with a CAF + CTG.
• The main goal was to analyze if CRC is related to the thickness of
the overlying flap.
• A secondary goal was to evaluate the amount of RC, gingival
thickness and width of KT achieved at 6 months post-surgically.

11. Patient Selection
• A total amount of 20 patients with 45 recessions were recruited
• All defects were multiple Miller Class I and II recessions, affecting two
to three adjacent teeth, located in canines and premolars of both
maxilla and mandible.
• Maxillary incisors were also included.
Inclusion criteria:
• Age of at least 18 years
• Non-compromised systemic health and no contraindication for
periodontal surgery
• No active periodontitis
• Good oral hygiene - (O’Leary plaque index <20%) (O’Leary 1972).

12. Exclusion criteria:
• Any debilitating systemic diseases
• Smoking ≥10 cigarettes a day
• Wearing orthodontic appliances
• Having pulpal pathology
• Non-identifiable cementoenamel junction (CEJ) at the defect site.

13. Pre-surgical treatment:
• Initial periodontal therapy was performed 1 month prior to surgery.
• Patients received;
• Pre-surgical prophylaxis
• Oral hygiene instructions
• Toothbrushing technique
• They were taught to use a toothbrush of medium hardness applying
Roll brushing technique.

14. Clinical measurements:
• All patients taking part in the study signed a consent
form.
• Received a diagnostic workup including:
• Clinical examination
• Photographs
• Standardized periapical radiographs to evaluate the proposed
surgical sites.
• In addition, acrylic stents were fabricated to serve as a
fixed reference for standardizing the measurements of
the parameters evaluated.

15. • The following clinical parameters were assessed at baseline:
• Plaque Index (PI)
• Bleeding Index (BI)
• Probing Depth (PD)
• Clinical Attachment Level (CAL)
• Width of Keratinized Tissue (KT)
• Relative measurements were also recorded:
• Gingival Margin Level (GML) - vertical distance from an horizontal reference in the
grooved stent to the mesiodistal mid-point of the gingival margin.
• CRC - vertical distance from an horizontal reference in the grooved stent to the CEJ.
• Recession depth (RD) was calculated by subtracting CRC from GML.
• A recession was considered completely covered when the postsurgical gingival
margin was located coronally or at the same level of CEJ at the clinical examination.

16. Acrylic stent for measuring gingival
margin level (GML)
Acrylic stent for measuring
complete root coverage (CRC)

17. At the day of the surgery:
• Soft Tissue Thickness (STT) - measured
at 2 and 5 mm from the gingival margin
with a 25 endodontic K-file with a
rubber stop.
• Thickness of the flap (FT) - measured at
2 and 5 mm from the gingival margin
with a modified caliper (modified
Iwansson gauge 1,594/10 cm) were
collected under local anesthesia
(Articaine 4%-1:100 epinephrine) at the
mesiodistal mid-point of the gingiva.
Modified Iwansson gauge measuring
flap thickness (FT) at 2 mm from the
gingival margin.

18. During the 6 months follow-up:
• PI, GML, RD and KT were measured at 30, 60, 90 and 180 days.
• BI, PD and CAL were measured at 90 and 180 days.
• STT at 180 days.
• All clinical measurements were taken by one of the two calibrated
examiners (TGM, CV) on the midbuccal aspect of each tooth using a
periodontal probe (PCP-UNC 15, Hu-Friedy).
• Both intra-and inter-examiner reproducibility were conducted by
evaluating CRC in ten non-study patients.
• Quantitative measurements taken with the probe were recorded in
mm and rounded to the nearest half millimeter.

19. Surgical treatment (CAF + CTG):
• Local anesthesia (articaine 4%, 1:100 epinephrine)
administrated.
• Exposed roots were polished at slow speed with a
rubber cup and prophylaxis paste for 60 seconds and
root planned, if needed.
• Before raising the flap, STT was measured by an
endodontic file at two different levels.
• These measurements would later be compared with
FT measurement obtained directly using a modified
caliper.

20. Surgical treatment (CAF + CTG):
• The surgical approach consisted in preparing an envelope flap for multiple
recessions according to Zucchelli and De Sanctis technique.
• A full-thickness gingival flap was raised beyond the mucogingival junction
using periostotomes.
• A partial-thickness flap was performed at the papilla area.
• The flap design consisted of oblique sub-marginal incisions in the inter-dental
areas, which were continuous with the intrasulcular incision at the recession
defects.
• Then, the epithelium of the papillae was removed and the flap was mobilized
with a sharp dissection into the vestibular lining mucosa.

21. Coronally advanced flap technique:
(A) canine and first and second premolars in the upper jaw with gingival
recessions. Oblique submarginal incisions were made in the inter-dental areas.
(B) The epithelium of the papillae was removed, and the flap was mobilized
with a sharp dissection into the vestibular lining mucosa.
A B

22. • A 1-mm thick CTG was harvested from the palate –between the canine
and the mesial line angle of the maxillary first molar—using a double-
blade scalpel (Double-Bladed Scalpel No 5 Handle 1 mm. SKU:1013005D1
Hu-Friedy, USA.)
This special scalpel permitted the
standardization of the thickness of the
CTG in 1 mm.

23. • The palatal flap was sutured immediately after taking the donor tissue.
• CTG was then introduced underneath the flap, in the recipient area, and
flaps were coronally advanced 1 mm coronal to the CEJ with periosteal
incisions and sutured with 5/0 sutures using a continuous sling suture.

24. Postoperative care:
• Amoxicillin 500 mg every 8 hr for 6 days
• Ibuprofen 600 mg every 8 hr for 2–3 days
• Acetaminophen 650 mg, as needed.
• All patients were instructed to discontinue toothbrushing
and avoiding trauma around the surgical site for 7 days.
• A 0.12% chlorhexidine solution (Perio-Aid, Dentaid) was
prescribed as mouthwash two times daily for the first 10
days.
• Patients were also instructed to clean the surgical sites with
a soft toothbrush 2 times/day from day 8th to 16th after
surgery.

25. Statistical analysis
The level of statistical significance was set at p < .05. Analysis was
performed by the use of SPSS 22.0 software package (IBM SPSS, SPSS
Inc., Chicago, IL, USA).

26. • The study population consisted of 20 patients (30% males and 70%
females) and 45 recessions.
• Eleven subjects (55%) had Miller Class I recessions and nine subjects (45%)
had Class II defects.
• 6.7% were located in incisors, 28.9% in canines and 64.4% in premolars.
• Seven subjects (35%) had recessions in upper maxilla and 13 (65%) in
mandible.

27. • The postoperative healing was uneventful.
Healing 6-month after surgery:
complete root coverage was achieved

28. • All subjects showed a good level of plaque control during the study
period (Table 1).

29. • Descriptive statistics of the clinical parameters at baseline and at
different follow-up visits are depicted in Table 2.

30. • A statistically significant decrease
in RD was observed at the end of
the evaluation period
(p < .05; Figure 5).

31. • The mean RD at baseline was 2.4 ± 0.75 mm (range, 1–3.75 mm), and
at the final examination was 0.17 ± 0.28 mm (range, 0–1 mm).
• The mean percentage of RC was 93.44% for all treated recessions.
• CRC was achieved in 65% of cases (13 patients).

32. • The mean FT was 1.01 ± 0.64 mm at 2 mm and 1.01 ± 0.61 mm at 5
mm from the gingival margin.
• When analyzing the influence of FT at both 2 and 5 mm from the
margin on CRC at 6 months, no association was observed (0.770 and
0.855, respectively, p > .05).
• Furthermore, no correlation was observed between the percentage of
RC and FT at both 2 and 5 mm from the margin (rho: .15 and .79,
respectively, p > .05).

33. • All clinical parameters (PD, CAL, RD, KT, STT) changed significantly
between baseline and the final examination, with the exception of PI
and BI (Tables 1 and 2).
• The treatment resulted in a significant PD reduction (0.32 ± 0.66 mm;
from 1.62 ± 0.68 to 1.3 ± 0.37, p .039) and CAL gain (2.40 ± 1.1 mm;
from 4.01 ± 1.12 mm to 1.61 ± 0.62 mm, p < .001).
• Also, a significant gain in KT was achieved at the end of the clinical
evaluation period (1.06 ± 0.71 mm; from 2.15 ± 1.43 mm to 3.21 ±
1.50 mm, p < .001).

34. • Changes in KT were significant from
baseline to the final examination
(Figure 6).
• The mean gingival thickness at 2 mm
and 5 mm was: 1.12 ± 0.56 mm and
1.28 ± 0.74 mm at baseline and 1.88 ±
0.39 mm and 2.01 ± 0.62 at the end of
the clinical evaluation, respectively.
• The surgical procedure resulted in a
significant increase in STT both at 2
and at 5 mm (0.75 ± 0.34 and 0.73 ±
0.58 mm, respectively, p .001).

35. DISCUSSION:
• In the present study, conducted in 20 patients presenting 45
recession defects Miller Class I and II treated with a CAF + CTG, 65% of
sites showed CRC
• The mean percentage of RC was 93.44% at 6 months.
• The mean FT was 1.01 ± 0.64 mm at 2 mm, and 1.01 ± 0.61 mm at 5
mm from the gingival margin.

36. • The primary outcome of the study was to evaluate if FT was related to
the CRC.
• The results obtained from this research failed to show any
relationship between these two parameters.
• There was also no correlation between FT and the percentage of RC
achieved at the end of the study.
• Thus, FT seems not to affect the percentages of RC and CRC when
recessions are treated with CAF + CTG.

37. • Classically, several factors related to the patient, site and to the
surgical technique have been described to affect the outcome of RC
when performing a CAF*
• According to Huang et al, gingival thickness is the most significant
prognostic factor associated with CRC, although other factors such as
adjacent bone level, papilla dimension and flap tension have also a
direct impact on the outcomes.
• For a CAF procedure, an average thickness of 0.8–1.2 mm has been
suggested as the minimal tissue thickness to achieve CRC*.
 Huang et al., 2005; Pini Prato et al., 2005.
 Baldi et al., 1999; Huang et al., 2005; Hwang & Wang, 2006; Leong & Wang, 2011

38. • According to Baldi et al. CAF is a predictable surgical technique in the
treatment of gingival recessions if flaps are >0.8 mm, as only those
were associated with a CRC
• Following these results, Leong and Wang reported that in thin gingival
biotypes (<1 mm) the treatment of choice would be a CTG while in
thick gingival biotypes (≥1 mm), any soft tissue grafting procedure
could be selected.

39. • Nowadays, the gold standard in RC is CAF + CTG*
• According to the results of this study, FT is not related with the
amount of RC and CRC.
• Thus, favorable outcomes in these parameters can be expected when
treating thin biotypes if a CTG is placed underneath the flap,
suggesting that the presence of the graft and its features are more
determinant in the final outcome than FT.
• These results could be explained by the fact that CTG increases the FT
by 0.75 ± 0.34 mm at 2 mm from the gingival margin after healing.
 Cairo, Pagliaro & Nieri, 2008; Cairo et al., 2014; Chambrone, Chambrone, Pustiglioni, Chambrone, & Lima, 2008;
Chambrone, Pannuti et al., 2010; Chambrone, Sukekava et al.,2010

40. • It has also been suggested that the presence of a graft might provide
stability to the coronally advanced soft tissue margin*
• A recent study, including a control group (only CAF), has shown that
CTG under CAF results in increased probability of CRC only at sites
with thin (≤0.8 mm) baseline gingiva*
• As expected, recessions reduced significantly after the surgery. most
of the changes occurring in the first 3 months.
• Similar observations have been described before when using CTG in
combination with CAF.*
 Harris, 2004; Zucchelli et al., 2010.
 Cairo et al., 2016
 Agudio et al., 2009; Pini Prato et al., 2010

41. • A modified Iwansson gauge was used to
measure FT.
• The modification consisted on eliminating the
spring, therefore, avoiding an excessive
pressure on the soft tissue (Kan et al., 2010).
• In our study, FT measurements were
compared to those performed with an
endodontic file (STT) showing a high reliability.

42. • As secondary outcomes, this study wanted to assess changes in
clinical parameters at 6 months compared to the baseline.
• Statistically significant changes were observed in terms of PD
reduction, CAL gain, gain in KT and STT.
• These changes reflect the improvement of the soft tissue quality
achieved after the surgery.
• However, no relationship could be seen between those improvements
and the quality of patient cleansing as no significant changes were
found for BI and PI.

43. • Latest data from the systematic review of Cairo et al. reported a mean
KT gain of 1 mm after CAF + CTG.
• The results obtained in this study are in concordance with previous
ones. The mean gain of KT obtained was 1.06 ± 0.71 mm. Therefore,
CAF + CTG seems to give better outcomes in terms of KT gain
compared to CAF alone.
• At the end of this study, gingival thickness increased 0.75 ± 0.34 mm
and 0.73 ± 0.58 mm when measurements were performed at 2 and 5
mm from the gingival margin, respectively.
• In our study, flap design described by Zucchelli and de Sanctis without
vertical releasing incisions was used.

44. • Non-vertical releasing incisions with an increased blood supply may
be the responsible for the better results achieved in the present study
on the measurements performed at 2 mm from the margin.

45. • The methods for measuring the gingival thickness are not
100% precise with some possible slight deviations in the
measurements.
• Moreover, this is a prospective clinical study with no control
group.
• Longer follow-up should also be considered, to compare the
long-term effects of both techniques and their outcomes.

46. • The results obtained in this study seem to indicate that the degree of
CRC and the amount of RC achieved with CAF + CTG are not
influenced by the gingival thickness.
• CAF + CTG may be the treatment of choice for thin biotypes.