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303

Use of the Supraperiosteal Envelope

in Soft Tissue Grafting for Root
Coverage, ii. Clinicai Resuits

Andrew L. Alien. Selection of the most oppropri-

ate soft tissue grafting proce-
dure for root coverage requires
careful consideration of avaii-
obie techniques. The clinioai
goal is to produce minimal
trauma to periodontai tissues
while creating a predictabie
Results using the supraperiasteai envelope in soff tissue grafting for root result that is functional, oom-
coverage are reported, along with three iliustrative case reports. fortable, and esthetioally
Treatment af 23 sites In 12 patients resulted in average root coverage of acceptable to the patient,
84%. Total coverage was achieved in 61% of sites treated. The percentage
of root coverage tended to decrease with increasing depth and width of
When gingiva adjacent to
recession. The supraperiosteoi ehvetope reduces surgicai trauma to the the orea of recession is not suit-
récipient site, maintains intact papillae, and produces consistent color obie as donor tissue, soft tissue
biending of invoived tissues in singie and multiple adjacent areas of reces- grafting trom a noncontiguous
sion. (Int J Periodont Rest Dent 1994,14:303-315.) intraoral source may be con-
sidered. Miller,' v/ho described
the gingival graft as a success-
fui and predictobie procedure
for root coverage, reported
complete success in 71 of 79
coses (90%) ot Class I and il
recession.
Langer and Langer^ noted
that most of Milier's cases
involved treatment of recession
in fhe mondibie and stafed
that the survival of the gingival
•Private Proctice in Periodantics, Brunswick, Maine graft over wide, denuded root
surtaoes frequently tound in the
Coriespondenoe to: Andrew L Aiien, 117 Pleasont Street, maxiiia has not been pre-
Brunswick, Maine 04011.

Voiume 14. Number 4, 1994

 304

dictable. The authors de- author did not disouss the and were ossessed preopera-
scribed the subepltheliai con- effect ot depth ond width of tiveiy and 3 and ó months post-
nective tissue graft technique recession on the results operotiveiy. Root coverage
and reported satisfoctory achieved. overoged 43% for free gingival
results in maxiiiory areas of Neison" presented results grofts and 80% for connective
deep-wide recession, with for 29 sites on 14 patients using tissue grafts. Complete root
postoperative stobiiity of the the subpedicie cannective tis- coveroge was ochieved in five
marginoi gingivo over o 4-year sue graft. The author classified of nine connective tissue grafts
period of observotion in 56 defects as mild, moderote, or (56%) and one of nine free gin-
coses. A comporison of the advanced, bosed upon depth gival grafts (11%). Resuits af
predictobility of this technique ot recession. Twenty of the sites grafting did not appear to be
with other mucagingivai ap- were advanced iesions (7 to 10 affected by adjacent papillary
proaches was hindered by the mm), which averaged 88% root width, or the width ond depth
sparse reporting of data. The coverage with treatment. of recession.
principies described, however, Results were mare favorable Results from these reports
oppear to have significant for mild and maderate reces- suggest that biiaminor connec-
oppiication to periodontai sien. Total root coverage tive tissue grofting offers great
proctioe and have generoted was achieved in ó2% of sites potentioi for achieving pre-
keen interest among clinicians. treated. dictabie root coveroge. With
The outhors^ conciuded that Harris^ described the sub- the exception of Jahnke et al,*
biiominor connective tissue pedicie approoch to connec- most outhors'"^-^'^-' have indi-
grafting offered severai advan- tive tissue grafting as a predi- cated width of recession as a
tages over current gingival cabie mefhod for obtaining foctor in the prognosis for suc-
groffing techniques for rcot roof coverage. He reported cessful soft tissue grafting.
coveroge. These advantages 97.4% root coverage in his first Raetzke,^ Harris,^ and Tolmie et
inciuded more complete cio- 20 cases. Totol root coverage af recorded defect width pre-
sure of fhe palatal donor site, was obtained in 24 of 30 sites operatively, but did not indi-
more consistent color blending (80%), Four sites in three cate its effecf on the results of
In the recipient site, and potients occurred in the moxii- theropy. It seemed oppropri-
Increased predictability for suc- lo, Harris reported full coverage ote. therefore, to include in this
cess In wide areas cf recession. in 2 of 4 maxiiiory feeth (50%). report a reproducible meosure-
Raetzke^ repcrted success- and 22 of 26 mandibuiar teeth ment ot width ond its relation
ful results in deep-wide areas ot (85%). Aithough oniy four maxil- to clinicol resuits.
recession using the "envelope" lary teeth were included, resuits in Part I of this report, the
technique. Results in 10 support the concept that mox- rationaie and technique for
potients with 12 iocolized oreos iiiary recession moy be more use of the suproperiosteol
of recession ranging from 2 to 5 difficult to treat successfully, envelope in soff tissue grofting
mm in depth and 1,5 to 6 mm Jahnke et oi* compared for root coveroge were pre-
in width inciuded complete fhe results of thick free gingivai sented in detail. The purpose of
coverage in 5 areas (42%) and and connective tissue grofts for Part II of this report is to present
from 00% fo 80% coverage in root coveroge in nine patients. the clinicai resuits aiong with
the remaining 7 areos. The Poired defects were identified several iiiustrative case reports.

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Table 1 Preoperotive and postoperative clinical measures

Preoperattve Postope rôti ve

Tootti Probing tîe cession Kèrat Pfobing Re cession Kerot Coveroge
Patißnt Age Sex # depth widtti depth ttssue deptti widtti deptti tissue
27 F 13 2 4 8 3 1 3 2 75
C3)
23 1 3 4 4 1 0 0 7 100
2 47 F 13 1 4 4 2 1 0 1 5 75
3 32 F 14 1 4 2

to

CM CN
0 0 5 100
13 2 3

CN
4 0 0 6 100
4 29 F 14 2 3 2 2 1 0 0 4 100
13 2 4 5 2 2 4 4 3 20
12 2 2 2 3 2 0 0 5 100
23 1 4 3 2 1 0 0 5 100
24 1 3 2 2 1 0 0 4 100
5 25 F 21 1 2 2 3 2 0 0 5 100

6 46 F 21
CNCM

3 2 4 1 0 7 100

coo
22 4 5 3 1 4 5 40
7 42 F 35
ro to

3 2 3 2 0 0 5 100
34 3 3 2 1 0 1 4 75

8 27 F 14 2 2 3 4 2 0 0 7 100
13 1 4 4 3 3 0 0 6 100
12 1 2 1 4 2 0 0 7 100
CO CO

9 19 F 14 2 3 3 1 2 1 4 67
24 2 d 1 1 0 1 4 75
10 17 M 41 2 2 4 0 2 2 1 4 75
11 15 F 23 1 4 4 2 1 0 0 6 100
12 36 F 31 2 3 6 3 1 3 3 6 50

Method and materials the indicotions and controindi- Detaiied information is avail-
cations iisted in Part I of this Gbie in Tabie 1. Measurements
Twelve cases exhibiting Miiier report, were determined with a peri-
Closs I and II recession were Twenty-three sites were odontai probe CP26G, Hu-
selected from a series of 15 treated in a predominontly Friedy) and rounded to the
patients treated over the past femaie popuiction from 15 to nearest mm. Surgicai sites were
4 years with the supraperiosteal 4Ó years of oge. Nineteen sites evaiuated from ó months to 4
envelope teohnique. Criteria were located in the maxilia yeors postoperativeiy,
tor selection were based upon and four in the mondibie.

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 30Ó

Results was achieved in 10 of the 12 Cose I

shallow defects (83%) and 4 of
Early postoperative events par- 10 moderate defects (40%). A 27-year-oid white woman
alleled previous reports of bi- Shallow defects averoged 95% presented for periodontal evai-
laminor grafting tor root cover- coverage, while moderate uation at the request of her
age using polatal donor defects averaged 73% cover- orthodontist. The patient's den-
tissue.^"'' The palatal donor age. One area of advanced tal history reveaied that orthog-
area appeared to heol faster, depth resulted in 75% cover- nathic surgery to reposition the
with slightiy more swelling, but age, maxiila wos performed lo
less overall discomfort and Width of recession was months previously. She was cur-
postoperative bleeding than determined by measuring the rently in orthodontic therapy,
previously noted in patients mesiodistai dimension of the and had recently experienced
treated with full-thickness auto- exposed root surface at the sudden-pnset recession invciv-
genous gingival grafting. The level of the cemehtoenamel ing the facial aspects of teeth
recipient envelope produced junction. The width ot each 13 and 23, Probing depths were
minimal apparent patient dis- defect wos classified as narrow within normal limits, but teeth 12
comtort. One week postopera- (2 mm), moderate (3 mm), or and 13 were found to be in
tively, the graft often appeared wide (4 mm). Coverage of root severe occlusal trauma and
bulky ond edematous. In 4 to 6 surfoces in each of the three were equilibrated to permit
weeks, however, the graft and categories averaged 95%, 87%, group function in right iaterai
surrounding gingival tissues usu- ond 76%, respectiveiy. Ciinicai excursion.
ally achieved acceptable color findings inciuding unusuoi After compietion of active
blending and contour. Two of resuits will be presented in the orthodohtic therapy, muoogin-
the patients required postoper- case reports to follow. gival surgery was accom-
otive gingivoplasty to obtain piished in an attempt to correct
the desired result. the wide-deep (4 mm x 8 mm)
Complete root coverage Case reports area ot facial recession at
was ochieved in 14 of 23 sites tooth 13 (Fig la). Severe scar-
(61%). Of the nine remaining The follawing cases have been ring related to the orthognathic
sites, five resulted in 75% cover- selected from those reported in surgery was ehcountered in the
age, and four resulted in cover- Toble i to iliustrate fhe indica- subjacent vestibule, impeding
age from 20% to ó7%. The aver- tions and use for the supraperi- effective infiitraticn ot local
age root coverage for all sites osteai enveiope in ciinicai anesthetic solution and discour-
was 84%, practice. Seme tigures depict aging the use of pedicle or
The depth of recession was less than optimai results repre- other tiap procedures.
measured preoperatively from senting informative coordinates Portly for lack of a viable
the cementoenamel juhctioh on the author's learning curve. alternative at the time of
to the existing gingival margin. Hopefuily, subsequent discus- surgery, a supraperiosteol
Results ot classification accord- sioh wili heip ciarify principles of enveiope was created, A con-
ing to depth are summarized in graft procurement ond place- nective tissue graft more than 2
Table 1. Oomplete coverage ment necessary for optimai mm thick was procured from
resuits. the underside ot a palatai

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f i g l a ( l e t t ) Preoperofive view of
deep-wide facial recession on tooth
13.

Fig ;b(rigtit) Graft sutured in pasition.

Submucosal elements predominated
in this eorty graft attempt.

FigJc(len) Heoling of grafted area 2

weeks postoperotiveiy. Nofe evidence
of vascular prolifefotion within groft.

Fig rci(right) Four-year postoperative

heoling. Note voscuior oppeorance of
groft oreo suggesting noni<erafinizing
alveolar mucosa

"frap door" flap. The groft con- depths ond opproximately 1

toined on abundonce of loose mm ot reoession when com-
submucosa, which resulted in o pared to the original position ot
rather tluctuont elastic speci- the gratt in relotion to the
men thot oompletely filled the cementoenamel junction (Fig
envelope when sufured into Id). Glinicolly, the grotted oreo
position (Fig 1b), a p p e a r e d tunctionol but
The g rotted tissue ap- revealed subsurtace vessels
peared bulbous, but wel[ per- morginolly and further apicolly
fused ond vio ble 2 weeks post- suggestive ot nonkeratinizing
operatively (Fig Ic), Gontaurs alveolar mucosa, Results
improved ropidly in fhe next 4 emphasize the need to include
weeks, No gingivopfosty was a d e q u o t e amounts of grott
pertormed. A 4-year evaluation lomina propria Vi/here kera-
revealed minimal probing tinized gingival tissue is desired.

Volume 14, Number 4, 1994

 308

Cose 2 stressful experience for her. At Cannecfive tissue grafts for

one point she became "very both sites were procured from
This 27-year-old woman, a for- thin and depressed." Although the palate, which was then
mer patient, returned for evalu- she denied anarexia nervosa, sutured primariiy (Fig 2b), Grafts
ation ot recurrent recession in she stated that she rautineiy were adjusfed to size and oon-
severoi sites. The patient oom- brushed her teeth 10 to 12 tour, and sutured into position
plained of thermai sensitivity in times daily, "I tound that old (Fig 2c). Fifteen months pcstop-
the maxillary right first premolar habits were hard to break, " she eratively, marginal tissues ap-
and canine area. She stated said, "I wanted to be sure my pear restored to function, with
that the recession seemed to teeth were olean and fresh esthetics acceptabie to the
be getting worse and showed whenever i ieff the dorm. " patient (Fig 2d). When com-
when she smiied. Excessive toothbrushing pared to preoperative mea-
Past clinicai records and was presented to the patient surements (see Tabie 1 and Fig
progress notes indicated that as the primary etioiogic factor 2a), fhe width of gingiva over
the maxiiiary and mandibuiar in the recurrence and worsen- tooth 12 appeared to have
canine and premciar areas ing of her recession. She increased more than anticipat-
bilaterally had exhibited muoo- seemed most willing to de- ed, suggesting that the original
gingivai detects, which had crease both toothbrushing fre- mucogingival junction had
received outogenous gingivai quency and dentifrice use been dispiaced apicaiiy as o
grafts 8 years prior to the cur- after being shown compara- resuit of the grafting proce-
rent referrai. The patient had tive measurements and dam- dure.
ieft the area ó weeks after this oged areas of gingiva. Under similar circumstances
surgery to begin 4 years of col- The supraperiosteai enve- about a year earlier an another
lege, iope vi/as chosen to correct patient (Patient 3 in Tabie 1),
Periodonfoi examination on areas of recession associated the mesiai margin of fhe enve-
her return visit reveaied gener- with teeth 12 fo 14, bosed on lope was inadvertently folded
aiized recession ranging from 0 post periodontal history, ther- under itseif, submerging a por-
to 4 mm. Recurrence and mol and esthetic sensitivity, tion ot the keratinized epitheli-
deepening of recession within and the presence of morginai um (Fig 3a), Resuitant healing 1
the graff was apparent in the contours potentiaily detrimen- year postoperatively praduoed
area cf teeth 13 and 14, tal to etfective daiiy hygiene. a smail cleftiike thinning oi fhe
Defects were classified as Miller Dual recipient sites were pre- marginal gingiva in the area
Class I with siightly erythema- pared in the area of teeth 13 (Fig 3b). Consequently, every
fous gingival margins, Reces- and 14 and over tooth 12, Full- attempt is made to eiiminate
sian was noted for the first time thickness elevation was used to epithelium between the graft
on the facial aspect of tooth form the envelope aver fhe and the overlying gingivai tis-
12, as well (Fig 2a), root prominence of tooth 12 to sue.
The pofient reveaied that prevent possible necrosis of the
coiiege had been an unusuaiiy thin gingiva in this area.

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Fig 2a Preoperauve vie A- o: iacial recession on teefti 12 to 14 Note retotively thii Fig 2b Palatal view of öonor sites. Note
narrow zone of gingiva over tooth 12. primory closure.

Fig 2c deft) Seporote grofts for teeth

!3and läondtooth 12 sutured into
position.

fig 2a (righit) Fifteen-month postopero-

tive tieoling of teeth 12 to M. Notesig-
niticont increose in zone of gingivo ot
tooth 12, suggesting apicol displace-
ment of mucogingivol Junction in oreo

Groft sutured In position

over teeth 13 ond la. Note gingival mor-
gin ot envelope inodvertentiy folded
under itseif (ariow).

figi 3b (rigtit) One-year postoperotive

result revealing residual ctetttike thin-
ning ofgingivoi margin (orraw).

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 310

Case 3 The suprapericsteai enve-

iope procedure was chosen to
A 15-year-old vi/hite girl was correct the facial defect. After
referred for periodontal evalu- enucleation of the sulcular
atian by her orthodontist. The epithelium, partiói-thickness dis-
potient was concerned about section wos used to form a
the inoreasing length of her supraperiosteoi enveiope on
maxiilary ieft canine, whose the faciai aspect of tooth 23.
prominence and recession Semilunor palotai incisions pro-
were accentuated when she duced a connective tissue
smiied (Fig 4a). The patient's graft, which was contoured
dental history reveaied that and beveled prior to insertion
both maxiilory conines experi- into the enveiope (Fig 4c). The
enced deiayed eruption asso- graft was composed of dense
ciated with anterior crowding. iamina propria and Included
After removai of teeth 14 and submucosal elements apical
24, the conines were surgically and deep to the gingivol zone.
exposed ond brought into Submucosai eiements were
occiusicn orthodonticaiiy. placed predominately within
Clinical evaiuation re- the envelope when the graft
veaied probing depths within was sutured in position (Fig 4d).
normal limits and ampie evi- Healing in the area ó months
dence of effective daily crai postoperativeiy reveols ac-
hygiene. Minimai, but healthy, ceptable blending of involved
zones of gingiva were noted tissues (Fig 4e) and improved
biiateraiiy in the oanine ond esthetics for the patient (Fig 40.
premoior oreas. The maxiilory
ieft oonine exhibifed root
prominence, which was associ-
ated with wide recession ot
moderate depth (Fig 4b).

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 311

Fig 4a (left) Preoperotive view of

patient smiting. Note accentuated
pfominence ond recession ot toatti 23
odvBrsBly affecting esthetics.

fig 4tJ (below) Preoperative view of

wide moderatety deep areo of reces-
sion at tooth 23

Fig4cQeñ) View at polatat graft con-

toured and bevelled tor insertion into
undeiiying envelope Note dense tam-
ina propria in gingival zone witti sub-
mucosd present in the apicot one hotf
of groft.

Fig dd (right) Graff sutured iri position

witti submucosa pioosd predaminently
within the enveiope.

f'g4e (above) Siy-mantn postopera-

tive view af tootti 23 stiowing compiete
coveroge of root. Note esthetic Piend-
ing and contaur of invotved tissues.

Fig 4Í (light) Postoperative view.

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 312

Table 2 Classification of recession according fo depth Table 3 Classification of recession according fo width

% tatal caveroge % average % total coverage % average

Deptti Total sites (fl ot sites) coverage Widtin Total sites (# ot sites) coverage

Shollow Norrow
(1 to 3 mm) 12 83% (10) 95% (2 mm) 5 80% (4) 95%

Moderate Moderate
(4 to à mm) 10 40% (4) 73% (3 mm) 10 60% (6) 87%

Advanced Wide
(7 to 1Q mm) 1 0% (0) 75% (4 mm) 8 50% (4) 76%

Discussion Esthetic postoperative faces tor immediate use by the

blending ot involved tissues graft. Gustomary incisions are
Twelve patients were selected was a satistying, consistent eliminated. Reduced interfer-
frcm a series of 15 cases treoted observation with the exception ence wifh vascular profusion
Vk/ith the suproperiosteol enve- of the patient in Gase 1, who from overlying gingival tissues
lope. Among the three potients will be discussed below, Golor moy foster less graft necrosis
excluded, one sustained trau- matching seemed to depend and scarring and more capil-
ma to the graft site, displacing upon achieving sufficient lary ingrowth, resulting in opti-
the graft 5 days after place- revasculorizotion ot graft lomi- mal tissue blending.
ment; a second resumed cigo- na proprio. A balanced ccmbi- Most sites Vk/ere located in
rette smoking within 10 days notion of lamina propria and the maxilla (83%) and exhibited
after surgery: and a third was a loosely organized submucosa a mean detect width ot 3.2
chrohic snutf user, who hod a p p e a r e d to promote the mm. Totol root coverage was
beeh treated uhsuccessfully desired result. In addition, achieved in 61% of the sites
with a gingival groft 2 years design ot fhe recipient enve- treated. These results compared
prior to envelope surgery. lope may have contributed to favorably with the percent of
Although the latter two oases groff revascularizatJon and total coverage reported by
resulted in over 50% root cover- esthetics. Unlike the single Nelson (02%)," Roetzke (42%),^
age, both possessed factors petiosteol surface underlying Tolmie et ai (73%).^ ond Jahnke
deemed detrimental to suc- fhe traditional gingival graft, et al (50%),"^ but unfavorably
cessful healing and were thus the supraperiosteal envelope with the reports of Miller (90%)'
excluded from the study. creates multiple vascular sur- and Harris (80%),^ The more

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 313

favorable results achieved by techniques. Whiie the thick subjacent vestibuie hove proiif-
fhe latter twa authors may be palatoi graft survived under erated coronaliy into the graft-
explained in part by the nature challenging ciinical oiroum- ed area.
of the defects treated. Unlike in stances. postoperative biend- Case 2 involved a former
the present study, few surgical ing of the invoived tissues was patient who had received a
sites were iocated in the maxil- less than optimoi (see Fig Id). gingival graft 8 years prior to
la, which has been associated Previous reports'^'" have treatment with the supraperi-
with wider recession.^ Stan- indicated thot gingivai lamina osteal envelope. Although the
dardization of data coliection propria contains the genetic past history of surgery was con-
ond reporting would be useful determinants necessary to sidered a negative influence
in future comparison ot resuits. restore keratinized surface on potential vascular supplies
Further research is indicated to epitheiium. Retrospective anal- avGiiabie to the graft, the exist-
clarify the reasons for differing ysis suggested that the pre- ing gingivai tissue appeared
results in total root coverage dominantly submucosai char- normai in color and well vascu-
among the surgicai approach- aoter of the graft in Cose 1 iarized. Residual areas of reces-
es. facilitated prompt revasouiar- sion aii too frequentiy remain
As anticipated, the severity ization ond survival, but lacked öfter root coverage attempts,
of recession appeared to hove the determinants neoessary for inviting additional surgicai pro-
an inverse relationship to the mature orthokeratinization and cedures for correction. The
tissue blending. The resuitant supraperiosteoi envelope
degree of success, as shown in
muoosal appearance empha- seems weli suited as a second-
Tables 2 and 3. The relative
sized the need to prooure and stage surgical procedure, as
effects of increasing depth ond
accurately place a graft with the recipient site design mini-
width remain uncertain be-
sufficient amounts of dense mizes trauma to the avaiiable
cause of the iimited number of vascuiar resources.
connective tissue iamino to fos-
sites e v a i u a t e d . However,
ter keratinized gingival tissue
results suggested that the aver- formation where required for Duai recipient enveiopes
age amaunt ot root coverage esthetics and function. were prepared for grafting in
decreased as the depth and the area of teeth 13 and 14,
width of recession increased, Seibert'2 has suggested and over tooth 12. if teeth 13
supporting the need for repro- that the ioosely organized sub- and 14 had not required groft-
ducible measurements of both muoosa may readiiy accept ing, the recession present on
depth and width in future stud- capiliary ingrowth fostering the facial aspeot ot tooth 12
ies. More research is indicated prompt revascularization. The would have been considered
to clarify the effect of these resuits in Case 1 appear to sup- clinicaiiy acceptable. Tooth 12
factors on the outcome of port this view. Figure lc dem- was inciuded in the grafting
surgery. onstrates abundant evidence procedure to restore esfhetic
of restored vascularity 2 weeks continuity to the orea. A sepa-
Clinical results in Cose 1
postoperativeiy. while Fig Id rate connective tissue graft
were informative and influentiai was prepared for two reasons:
suggests that vesseis originating
in shaping subsequent graft the area of recession associ-
in the alveolar mucosa of the
procurement and piacement

Vaiume 14. Numbei4, 1994

 314

ated with tooth 12 wos ouf of procedure on the faciai aspect

aiignmenf wifh recession over of tooth 23 thot resulted in
teeth 13 ond 14, making a sin- compiete root coverage ond
gle connective tissue graft diffi- compatibie tissue biending in
cult to contour and ploce in on areo of extreme esthetic
acceptabie position; aiso, sep- sensitivity (see Figs 4e and 4f). In
arate grofts heiped controi contrast to the predominately
contours ond prevent exces- submucosal graft used in Oase
sive thickness in the papiiiory 1, this palatoi groff was com-
orea between teeth 12 ond 13, posed of dense lamina propria
The finoi confour sfiil oppeored coronally with submucosal ele-
slightiy excessive, but results ments visibie opicaiiy before
were acceptabie to fhe pa- insertion into the envelope (see
tient (see Fig 2d). Fig 4c). The rotio of these two
The substontial increase in connective tissues in this cose
the zone of gingiva over tooth was feit to be optimal for graft
12 wos suggestive of apical dis- success.
piacemenf of the mucogingi- Previous reports suggest
vai junction in the area (see thot bilaminar connective tis-
Figs 2a ond 2d). it is tempting sue grafting offers great poten-
to speculote that the underly- tiai for ochieving predictobie
ing graft lamina propria initiat- root ooveroge. Thus for. results
ed a change in the fhin overiy- using the supraperiosteal enve-
ing aiveolar mucoso that iope fully support this view.
resulted in the formation of ker- Recipient site design minimizes
atinized gingivai tissue and api- trauma to voscuiar suppiies
cal displooement of fhe muco- avaiiabie to the graft, pre-
gingival junction. This finding serves intact papiiiae. and pro-
was not apporenf in other sites. motes esthetic blending of
More research is indicoted to involved fissues. More research
determine the effect of sub- is necessary to further deiin-
merged graft lomina prcprio eate indicotions for use of the
on overiying alveolar mucosa. various biiaminor techniques in
The potient in Case 3 soft fissue gratfing for root cov-
(Potient 11 in Tobie 1) received eroge.
o suproperiosteol envelope

Ttie International Journal of Periodontics & Restorotive Dentistry

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Acknowledgments 7.tHotbroot< T. Osotienbein C. Com-

ptete oove'oge of the denuded
I wisli to express heartfelt appreciation root surfooe with a one-stage gingi-
to Dr William C Hurt, who introducect vot gtaft. int J Petiodont fîest Dent
me to manuscript preparation. 1933:3:9-27
6. Sullivan HC. Atkins JH. Free outoge-
nous gingivol gratts. til. Utitizotion of
grofls in the treotment of gingivot
References recession. Periodont 1968:6.152-100.
9.Tolmie PN, Rubins RP. Buch GS.
1. tuiilter PD Jr. Root coveroge using the Vagianos V. Lonz JC. The pre-
free sott tissue outogiaft following dictability ot root ooverage by wav
citric acid application, til A suocess- of free gingival autogtafts and citric
tut and predictable procedure in acid applicotion. An evaluation by
oreas of cteep-wiäe recession, tnt J multiple clinicians. Int J Periodont
Periodont Rest Dent 1985:5; 14-37. 1991:11:261-271.
2. Langer B, Langer L. Subepittietiat 10. Karring T, Lang NP, Loe H. Ttie role
connective tissue graft technique of gingivat connective tissue in
for root coverage. J Periodontoi determining epitheliol differentia-
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Volume Id, Number 4, 1994