Long-Term 8-Year Outcomes of Coronally Advanced Flap for Root Coverageby Giovanpaolo Pini-Prato, Debora Franceschi, Roberto Rotundo, Francesco Cairo, Pierpaolo Cortellini, Michele Nieri

Journal of Periodontology




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Long-Term 8-Year Outcomes of Coronally Advanced Flap for Root Coverage

Giovanpaolo Pini-Prato,* Debora Franceschi,* Roberto Rotundo,* Francesco Cairo,*

Pierpaolo Cortellini,† and Michele Nieri*

Background: This long-term 8-year case series study aims at evaluating the results of the outcomes of coronally advanced flap (CAF) procedures performed for the treatment of single gingival recessions (GRs).

Methods: Sixty patients with single maxillary GRs ‡2 mm, without loss of interproximal soft and hard tissue, treated with the CAF procedure and evaluated at 6 months in a previously published article, were followed for 8 years. Complete root coverage, recession reduction, and amount of keratinized tissue (KT) were analyzed using descriptive statistics, the paired t test, McNemar test, and a general linear model.

Results: Three patients dropped out during the course of 8 years. Recession reduction from baseline to 8 years was 2.3 – 1.1 mm; P <0.0001, whereas GRs increased in 53% of the sites from 6 months to 8 years (0.5 – 0.7 mm;

P <0.0001). The percentage of sites with complete root coverage decreased from 55% at 6 months to 35% at 8 years (P = 0.0047). The amount of KT tended to decrease from baseline to 8 years (0.6 – 0.8 mm; P <0.0001). The general linear model shows that recession reduction is associated with both baseline recession depth and with the amount of initial KT. Sex, age, and smoking are not associated with recession reduction at 8 years.

Conclusions:The CAF procedure is effective in the treatment of GRs However, recession relapse and reduction of KT occurred during the follow-up period. The baseline width of KT is a predictive factor for recession reduction when using the

CAF technique. J Periodontol 2012;83:590-594.


Gingival recession; long-term care; surgical flap.

A large number of sound clinical trials demonstrate the efficacy of coronally advanced flap (CAF)based procedures for the treatment of single and multiple gingival recessions (GRs).1,2 However, little information is available on the long-term results of this approach.

A case series study on a modified CAF procedure on single-recession defects3 reported substantial stability of outcomes associated with a significant increase in keratinized tissue (KT) at 3 years (96.7% average root coverage) with respect to 1 year (98.6%). Leknes et al.4 reported recurrences of GR in a 6-year long-term study in sites treated with either CAF or barrier membranes. Seven of 11 CAFtreated sites showed an apical displacement of the gingival margin (GM).

A recent 14-year long-term randomized study5 on single recessions reported an apical shift of the GM (recession relapse) in 39% of the sites treated with

CAF. This evidence on single recessions treated with CAF seems to indicate a tendency to recurrences that becomes more evident with time. The same trend has also been noted after CAF procedures performed for multiple recessions. In fact, a5-year long-termevaluation ofacase series treatedwith theenvelope-typeCAFon multiple recessions reported a slight apical shift of the GM compared to 1 year.6

The 88% complete root coverage (CRC) observed at 1 year decreased to 85% at * Department of Periodontology, University of Florence, Florence, Italy. † European Research Group on Periodontology, Bern, Switzerland. doi: 10.1902/jop.2011.110410

Volume 83 • Number 5 590 5 years. This tendency was confirmed by a recent longterm comparative study7 on multiple recessions treated with CAF alone or with connective tissue graft (CTG).

The authors reported a significant apical shift of the

GM at 5 years in the CAF-treated sites, whereas the

CAF/CTG-treatedsites showeda tendency toacoronal shift of the GM. In other words, the use of a graft under a flap prevented the recurrence of the recessions.

A large case cohort study8 of 60 patients with single

GRs treated with CAF reported CRC in 33 sites (55%) with a mean recession reduction of 2.86 – 0.99 mm, associated with a 0.37-mm reduction of the amount

KT from baseline and an 0.82-mm apical shift of the mucogingival junction (MGJ) with respect to the postoperative position. This study demonstrated that the postoperative location of the GM, relative to the cemento-enamel junction (CEJ), influenced the probability of CRC: the more coronal the GM after suturing, the greater the probability of achieving CRC, at 6 months.

The described patient population was followed up for 8 years.

The aim of the present study is to evaluate the longterm outcomes of CAF performed for the treatment of single GRs in a population of 60 patients.


Study Population

The study population consisted of a group of 60 patients included in a previous short-term clinical trial, in which single recessions were treated with CAF.8

The main goal of the original study is to investigate the role of the post-surgical position of the GM on root coverage.8 The study protocol was approved by the internal ethics committee, Department of Odontostomatology, University of Florence, Florence, Italy. The patients agreed to participate in this study and gave written informed consent.

The baseline entry criteria included the following: 1) non-compromised systemic health and no contraindications for periodontal surgery; 2) presence of one maxillary buccal recession ‡2 mm (classified as

Miller’s Class I or II9); 3) recession-associated dental hypersensitivity (DH) or impaired esthetics; 4) the presence of identifiable CEJ; 5) tooth vitality and absence of grooves, irregularities, caries, or restorations in the area to be treated; 6) no periodontal surgical treatment during the previous 24 months on the involved sites; 7) full-mouth plaque score (FMPS) <20% and full-mouth bleeding score <20%; and 8) absence of plaque and bleeding on probing at the selected sites.

At baseline, one investigator (PC) took the following measurements using a periodontal probe‡: recession depth (REC) and probing depth (PD) at the mid-buccal site; KT width as the distance between the GM and the