Single-stage advanced versus rotated flaps in the treatment of gingival recessions – 5 year

longitudinal randomized clinical trial

*
Ronaldo B SANTANA, DDS, MScD, DSc
*
Edgard de Mello FONSECA, DDS, MScD, DSc
*
Maira B FURTADO, DDS, MScD
*
Carolina M.L.M SANTANA, DDS, MScD, DSc

Serge DIBART, DDS, MScD †

* Graduate Program in Dentistry, Department of Periodontology, Federal Fluminense University,

Dental School, Niteroi, Rio de Janeiro, Brazil.

† Department of Periodontology, Boston University, School of Dental Medicine, Boston, MA, USA.

Corresponding Address:

Ronaldo B Santana, DDS, MScD, DSc.

Department of Periodontology

Dental School – Universidade Federal Fluminense

Rua Sao Paulo 28 – Niteroi – Rio de Janeiro 24040 115 – Brazil

E-mail: rbarsantana@ig.com.br

Short running title:

Laterally positioned versus coronally advanced flap in recession defects

This is the author manuscript accepted for publication and has undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as
doi:10.1002/JPER.18-0284.

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Summary:

The laterally-positioned flap and the coronally advanced flap are effective for the treatment of Miller
class I maxillary recession defects in humans with the laterally-positioned flap resulting in more gain
in keratinized tissue and greater stability after 5 years of follow-up.

Figures—2; Tables—2; References—37; Words—3,025

ABSTRACT

BACKGROUND: The objective of the present study was to compare the efficacy of single-stage

laterally-positioned (LPF) and coronally-advanced (CAF) techniques in the treatment of localized

maxillary GR defects, 1 and 5-years after surgical procedures.

METHODS: Thirty-six patients, with Miller class I GR defects were randomly assigned to be treated by

either a CAF (n=18) or LPF (n=18). Recession height (RECH), width of keratinized tissue (WKT),

probing depth (PD), vertical clinical attachment level (VAL), visual plaque score (VPS) and bleeding

on probing (BOP) were assessed and compared. Clinical recordings were performed at baseline, 1

and 5 years later. The differences between initial clinical recordings and after 1 and 5 years were

subjected to statistical analysis.

RESULTS: Both flap designs effectively improved RECH and VAL on GR defects. The LPF resulted in

significantly more gains in KTW and RC after 5 years.

CONCLUSIONS: LPF and CPF procedures may be employed for the treatment of GR, however, LPF

results in greater longitudinal stability of RC and increased WKT in the treated areas.

KEY WORDS: gingival recession, surgical flaps.

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INTRODUCTION

Gingival recession (GR) may be considered a gingival and/or alveolar mucosa defect with

functional repercussion since progressive GR is caused by loss of attachment1 and may clinically

occur associated with absence of keratinized gingiva2. Exposure of the root surfaces due to recession

of the marginal gingival tissues present a major esthetic problem when localized in the anterior

dentition, due to the resultant disharmony in physiologic gingival countour3,4, increase in cervico-

incisal dimension of the affected tooth5,6, and may also result in tooth sensitivity1.

Periodontal therapy embraces a group of modalities whose objectives are intended to eliminate

and/or control of the etiologic factors; arrest of disease progression; obtain therapeutic results

compatible with biological and functional requisites, and to satisfy, if possible, to the patient’s

demands for esthetics, health and function7. Several procedures have been reported for the surgical

correction of GR, and the pedicle flaps were considered to be an adequate choice due to the

maintenance of vascular connections with the adjacent soft tissues, thus increasing the chances of

survival of the flap on the avascular root surface8,9. Among the pedicle flaps, the laterally positioned

flap (LPF) and the coronally advanced flap (CAF) present the possibility to cover the recession with

gingival tissues more harmonic with the adjacent teeth by the use of a single surgical procedure7.

The laterally sliding flap or laterally positioned flap (LPF), despite being poorly supported by

randomized controlled trials10, was long considered the gold-standard technique for treatment of a

single gingival recession when an adequate amount of keratinized tissue was available lateral to the

recession site10,11, while the coronally advanced flap (CAF) is one of the most reliable techniques for

the treatment of single gingival recessions with the possibility of achieving complete root

coverage12,13.

A systematic review evaluating both short- and long-term stability of root-coverage outcomes14

revealed that only 8% of the selected randomized controlled trials reported 5 years or more of

follow up15-18. Unfortunately, however, none of these studies evaluated or compared single-stage

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CAF or LPF techniques since either a connective tissue15,17,18 or free gingival graft15, acellular dermal

matrix17, barrier membrane16, or enamel matrix derivative18 were also employed. One study

evaluated the long-term outcomes of CAF procedures after fourteen years19. To the best of our

knowledge, only one short-term randomized clinical trial has previously evaluated the single-stage

LPF and CAF procedures for the treatment of GR defects7. Therefore, the objective of the present

report was to evaluate the results after 1 and 5-years, comparing the long-term efficacy of single-

stage LPF and CAF techniques in the treatment of localized maxillary GR defects.

MATERIALS AND METHODS

Study Population and Experimental Design

The study was designed as a randomized, prospective, parallel-arm, controlled clinical trial. It

was approved by the institutional review board from Universidade Federal Fluminense (CEP-

HUAP0129.0.258.000-08) and conducted in accordance with the guidelines of the Helsinki

Declaration of 1975, as revised in 2000. The study was registered in ClinTrials.gov under ID

NCT02433912. Written informed consent was obtained from all patients after thorough explanation

of the nature, risks, and benefits of the clinical investigation and associated procedures. The study

population consisted of patients referred for periodontal treatment at the School of Dentistry,

Federal Fluminense University, Brazil. The following inclusion criteria were used: adult patients with

no contraindications for periodontal surgery, and who had not taken medications known to interfere

with periodontal tissue health or healing in the preceding 6 months, exhibiting the presence of

Miller class I gingival recessions2 in maxillary incisors, canines or premolars, probing depth (PD)

<3mm without bleeding on probing, presenting tooth vitality and absence of caries or restorations in

the areas to be treated. Patients with untreated periodontal disease, smokers, subjects with

immunosuppressive systemic diseases (i.e., cancer, AIDS, diabetes) were not included in the study.

Miller class II, III or class IV recession defects2, presence of apical radiolucency or caries or

restorations in the areas to be treated, and previous lack of cooperation with the maintenance

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program were also exclusion criteria. Thirty-six patients (10 men and 26 women), with average age

of 34 ± 7 years, were included in the present prospective study from June 2002 to December

2006. Sample size was determined by p -tailed z value of 1.96

and a standard deviation of 0.72. This calculation indicated that with a sample of 16 subjects, the

study would have >90% power to detect a 1-mm difference in recession depth between the two

groups.

All individuals were subjected to initial periodontal therapy and were adherent to

maintenance care for at least six months before the beginning of the study. Treatment included oral

hygiene instructions, scaling and root planing where needed, tooth polishing, plaque control

measures and correction of traumatic tooth brushing technique or other negative habits. All

individuals were instructed and trained to use a soft toothbrush and to eliminate habits related to

the etiology of the recession. Baseline full mouth plaque and bleeding scores were low. Each defect

(one defect per individual) was randomly assigned, immediately before each surgical

appointment, to one of the two treatment modalities employed: coronally advanced flap (CAF)

(n=18) or laterally-positioned flap (LPF) (n=18) by the toss of a coin.

Clinical data collection

Clinical parameters were assessed as previously described4,7 (Mattos & Santana 2008,

Santana et al. 2010) at the mid-buccal site from the teeth using the cemento-enamel junction (CEJ)

or, when applicable, another defined landmark, as a fixed reference point from which REC was

recorded. All measurements were recorded using an UNC #15 periodontal probe ‡ by a blinded,

trained and calibrated examiner (CMMS), unaware of the treatment provided, at baseline and 6

months after surgery. Measurements were recorded to nearest higher mm. The point of maximum

convexity of the marginal gingival contour – the gingival zenith (GZ) – was employed as the reference

for measurements of the gingival margin (GM). Visual plaque score (VPS) and bleeding on probing

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(BOP) were assessed dichotomously at the mid-buccal location. Recession height (RECH) was

measured as the distance from the CEJ to GM. The width of keratinized tissue (WKT) was measured

as the distance between the GM and the MGJ. PD was measured as the distance from the GM to the

bottom of the gingival sulcus. Probing depth and gingival recession were used to calculate the

vertical clinical attachment level (VAL). In order to ensure the reproducibility and consistency of pre-

and post-intervention measurements, examiner calibration was performed before the beginning of

the study. Eighteen recession sites, in nine patients, were evaluated by the examiner on two

separate occasions, 48 h apart. Then, examiner reproducibility was assessed by calculating the kappa

coefficient (0.889) for the duplicate measurements. These procedures were repeated at the re-

evaluations, one and five-years after the surgical procedures, and the kappa coefficients were 0.778.

Surgical Procedures

All surgical procedures and associated pre- and post-surgical care was provided as previously

reported7. Briefly, the CAF was designed performing two vertical releasing incisions at both the

mesial and distal aspects of the recession to be treated, in such a way that both the proximal

papillae were not included as part of the flap. Beveled vertical incisions were performed in the

attached gingiva, avoiding the formation of butt-joints between the flap and adjacent tissues, and

were continued several millimeters apically into the alveolar mucosa. The vertical incisions were

joined by an intrasulcular incision. In the interproximal area, the papillae were split in a mesio-distal

dimension, resulting in a flat surface of connective tissue for contact between the flap tissues and

the retained portion of the papillae after repositioning and suturing of the flap. A combined

mucoperiosteal-mucosal flap was elevated such that only the first 3-4mm coronal aspect of the

alveolar bone was exposed. The root was instrumented and then washed with saline solution. The

flap was coronally advanced and passively maintained in place by means of individual silk sutures,

which were removed two weeks after the procedure.

The surgical procedures for the LPF were performed according standard techniques7. The

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receptor site was prepared using a surgical blade. Incisions were made in both - mesial and distal -

aspects of the recession, in order to remove the epithelial attachment and obtain connective tissue

surfaces, which extended several millimeters apically toward the alveolar mucosa. These incisions

were carried out to obtain an external bevel on the recipient site of the tooth to be treated, and an

internal bevel on the adjacent aspect of the flap. The excised gingival tissues were removed, and the

root surface was then instrumented. The flap design was outlined by two vertical incisions and a

horizontal incision, following the marginal gingival contour. The flap was elevated as full-thickness in

the portion adjacent to the recession and as partial thickness in the portion distal to the recession.

The flap was rotated laterally and suturing was performed in order to passively position and secure

the soft tissues over the root surface by means of sling and simple silk sutures, which were also

removed two weeks after the procedure.

Post surgical involved systemic analgesics for four days, placement of surgical dressing for

fourteen days and individualized oral home hygiene care7.

Maintenance Schedule

Following surgery, all patients were seen weekly during the first three months and bi-weekly

for the next three months. Then, the patients were seen after every six months up to five years.

Maintenance visits consisted of reinforcement of oral hygiene procedures and professional supra-

gingival coronal polishing. Additional oral chemical plaque control was performed once every three

months by means of mouth rinses with a solution of chlorhexidine gluconate 0.12% BID, for one

week.

Statistical Analysis

All descriptive statistics were expressed as mean +/– standard deviation (SD). The

differences between initial clinical recordings and after 1 and 5 years were subjected to analysis of

variance (ANOVA) and, as post hoc tests, were performed the Chi-squared test for qualitative ordinal

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variables and Wilcoxon test for quantitative continuous variables, with significance set at α<0.05.

RESULTS

Thirty-six patients (10 men and 26 women), with average age of 34 ± 7 years, with Miller’s

class I GR in single-rooted teeth of the maxillary jaw were included in the present prospective study.

The LPF group (n= 18) had an average age of 33 ± 8 years and the CAF group (n=18) had an average

age of 35 ± 6 years. The GR defect distribution between the LPF and CAF groups, was, respectively:

lateral incisor (3 and 4 teeth), canines (9 and 10 teeth), first pre-molar (5 and 3 tooth), second pre-

molar (1 tooth each group). Two patients dropped out of the study after 1 year. Full-mouth BOP and

VPS were maintained below 20% indicating a good standard of supra-gingival plaque control during

the study period (table 1).

Baseline, 1 year and 5 years measurements for the CAF and LPF groups are shown in Table 1.

No statistically significant differences were observed between groups in any of the clinical

parameters at baseline. Intra-group comparisons between baseline and 1 year and between baseline

and 5 years measurements revealed that statistically significant changes from baseline were found

for RECH for both the CAF and LPF groups. Neither group exhibited significant changes for PD, BOP

and VPS. The LPF demonstrated statistically significant increases of WKT. Representative cases are

presented in Figures 1 and 2.

The magnitude of changes in measurements after 1-year and 5-years for the CAF and LPF

groups are shown in Table 2. Measurements of change of RECH demonstrated that LPF resulted in

96.1 and 91.6% mean RC and CAF resulted in 94.7 and 82.1% mean RC after, respectively, 1 and 5

years. Intra-group comparisons demonstrated statistically significant (p<0.01) RECH reduction

changes for LPF and CPF at both time points. Inter-group measurements, however, demonstrated

that mean RECH was significantly (p<0.01) smaller for LPF-treated sites. Complete root coverage

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(CRC) was accomplished in 88.88% (15 out of 18) of the treated cases in the CAF group after 1 year

and 56,25% (9 out 16) after 5 years. In the LPF group, CRC was observed in 77.78% (14 out of 18) of

cases after 1 year and 68,76% of cases (11 out 16) after 5 years. Changes in WKT favored the LPF

procedure (2.1 versus 0.4mm after 1 year; 2.4 versus 0.2mm after 5 years). Differences in

measurements for PD, SBI and VPI did not reveal significant differences between the groups. Post-

hoc power calculations of intergroup differences observed for changes in WKT, percentages of mean

RECH and percentages of CRC revealed 100% power of detecting significant differences between the

two groups.

DISCUSSION

A very limited number of randomized clinical trials (RCTs) showed long-term outcomes of

treatment of GR with a follow–up of at least 5 years14. The present RCT comparatively evaluated two

flap designs – CAF and LPF - for the surgical treatment of maxillary buccal gingival recessions. To the

best of our knowledge, no previous studies have reported on the comparative longitudinal long-term

results of these techniques. The results of the present study demonstrated that both flap designs

were effective in treating maxillary single GR defects, 1 and 5-year after surgery, however, significant

differences were observed between the two surgical techniques 5 years after treatment.

The success of any mucogingival surgical procedure depends on the elimination of etiologic

factors, evaluation of interdental bone, correction of brushing habits, and, most importantly, the

choice of the most appropriate surgical technique20. Among the different types of flap design used in

periodontal plastic surgery, the most frequent approach is the Coronally Advanced Flap14. On the

other hand, flap designs different from CAF, such as LPF, were evaluated in a limited number of RCTs

and, thus, should be considered with caution in modern treatment14. Therefore, additional studies

employing these flap designs are of paramount importance.

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 The results of present study demonstrated that the group treated with LPF presented

significantly increased WKT over the CAF procedure, after 1 and 5

years of healing m). CAF group had a higher percentage of complete RC

after 1 year and the lowest percentage of complete RC after 5 years. Both groups exhibited similarly

reduced BOP and VPS scores indicating a good standard of supragingival plaque control during the

study period. The results of the present study agree with those of prior studies reporting on the

clinical behavior of LPF and CPF12,21-24.

The CAF group exhibited 88.88% of complete RC after 1 year and 56,25% after 5 years. These

results were compatible with others in the literature25-29. The longitudinal maintenance of RC

following CAF is controversial16,19,26-32. Zuchelli & DeSanctis26,28 reported a mean 97% and 94% RC

after 12 and 60 months, respectively. Lower amounts of RC after at least 5 years of follow up were

also reported16,27,33. In a long-term study evaluating the CAF procedure, Gurgan et al27 reported mean

RC of 68.3% and 44.9% after 12 and 60 months, respectively. Leknes et al.16 compared the 6 years

follow-up results of CAF with and without biodegradable membrane. RC achieved at one year were

reduced after 6 years, by 0.5 and 1.0mm, respectively, in membrane-treated and non-membrane

treated sites, revealing a significant relapse in the later group. Kuis et al.34 reported that RC tended

to decrease with time in CAF group and observed 60% of complete RC after 5 years. Pini Prato et al19

reported CRC in only 45% and a progressive worsening in RC in 39% and of the treated sites, 14 years

after of treatment. Interestingly, these changes were in parallel to the decrease in WKT over time.

Thus, the current data is in agreement with the literature in documenting a progressive reduction in

RC obtained with the single-stage CAF procedure after 5 years of follow-up.

The fact that areas treated with CAF resulted in significantly less gains in the WKT when

compared with those treated with LPF, may be due to the fact that the CAF procedure was

performed in a single-stage procedure. Other studies35,36 demonstrated different, more positive,

results in WKT probably because a free gingival graft (FGG) procedure was performed prior the CAF

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procedure. The potential of FGG in increasing the WKT is well documented1,37 and seems to explain

the increased WKT following the two-stage CAF procedures. Unfortunately, however, such increase

in WKT was not universally documented in studies evaluating single-stage CAF procedures19,28,30-32.

The present data demonstrating significantly increased WKT following LPF over the CAF

procedure may be related to the different results in complete RC after 5 years. Unfortunately,

however, scientific data evaluating the influence of the WKT in the long-term RC of GR are very

scarce for CAF19 and absent for LPF. Pini Prato et al19 demonstrated that the impact of the WKT in RC

appears to be also dependent in type of root instrumentation provided since polishing resulted in a

greater recession reduction in the presence of a greater KT width, while root planning showed a

greater recession reduction in sites with a smaller amount of KT. The authors reported complete RC

in 44% and 33% of sites after 5 and 14 years of follow up, respectively. In the present study it was

employed root planning in areas with < 3mm of WKT, thus, emphasizing that the results obtained for

the CAF procedure should be expected to have being optimized. Even then, complete RC regressed

from 89% to 56% in CAF sites between 1 and 5 years after treatment. Interestingly, complete RC was

78% after 1 year and only reduced to 69% in LPF sites after 5 years, while the WKT significantly

increased from baseline to one year, and also exhibited a modest enhancement between 1 and 5

years after treatment (Tables 1 and 2). Increased gingival thickness or larger amount of keratinized

tissue, associated with adequate control of traumatic tooth-brushing may be the most important

factor in preventing recurrence of gingival recession after surgical treatment of single GR defects14.

Unfortunately, gingival thickness, esthetic analysis and patient-related outcome measures (PROMS)

were not measured on the current longitudinal study, thus, emphasizing the necessity of additional

evaluations in this field.

CONCLUSION

The outcomes of the present RCT demonstrated that LPF and CPF procedures are two surgical

techniques that may be employed for the treatment of GR, however, LPF results in significantly

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increased WKT in the treated areas and greater stability of RC after 5 years.

Conflict of interest statement - the present study received no funding. The authors do not possess

any financial relationships that may pose a conflict of interest or potential conflict of interest and

have no commercial relationship to any of the products and instruments employed.

FOOTNOTES

‡ PCPUNC 15 – Hu-Friedy, Chicago, USA

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FIGURE LEGENDS

Figure 1 – Clinical aspect of area treated with CAF procedure. (A) baseline before
treatment, (B) one year and (C) five years after procedure.

Figure 2 – Clinical aspect of area treated with LPF procedure. (A) baseline before
treatment, (B) one year and (C) five years after procedure.

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Table 1 – Baseline, 1 and 5 years clinical measurements in mm

Treatments Baseline

VPS BOP PD RECH WKT

CAF 17±4 16±3 1.2±0.4 3.2±0.5 1.5±1.6

LPF 19±5 17±5 1.2±0.4 3.4±0.6 1.3±1.8

Significance 0.44 0.2 0.4 0.11 0.5

Treatments 1Year

VPS BOP PD RECH WKT

CAF 12±2 12±2 1.8±0.7 0.2±0.4 1.9±0.7

LPF 12±2 13±3 1.5±0.5 0.2±0.4 4.4±1.5

Significance 0.33 0.1 0.08 0.50 <0.01*

Treatments 5 Years

VPS BOP PD RECH WKT

CAF 12±2 11±2 1.6±0.6 0.5±0.6 1.7±0.6

LPF 12±2 12±2 1.3±0.5 0.3±0.6 4.7±1.5

Significance 0.47 0.2 0.08 0.35 <0.01*

Data presented as mean +/– standard deviation. VPS and BOP as percentages. PD, RECH
and WKT in millimeters. n.s = non-significant, * = P value < 0.01 (statistically significant).

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Table 2 – Magnitude of changes of clinical measurements obtained 1 and 5-years after
surgery in comparison with baseline (in mm)

Treatments Variables (1-Year)

VPS BOP PD RECH WKT

CAF 3±3 1±3 0±0.5 -3.0±0.6 0.4±1

LPF 3±2 2±3 0±0.7 -3.3±0.5 3.1±1.5

Significance 0.4 0.4 0.01* 0.3 <0.01*

Treatments Variables (5-Years)

VPS BOP PD RECH WKT

CAF 0±2 1±2 0±0.5 0.3±0.5 0.1±0.2

LPF 0±2 0±3 0±0.7 0.2±0.4 3.4±1.4

Significance 0.5 0.2 0.06 0.2 <0.01*

Data presented as mean +/– standard deviation. VPS and BOP as percentages. PD, RECH
and WKT in millimeters. n.s = non-significant, * = P value < 0.01 (statistically significant).

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