Received: 10 October 2020 | Revised: 4 March 2021 | Accepted: 31 March 2021

DOI: 10.1111/jcpe.13470

ORIGINAL ARTICLE CLINICAL PERIODONTOLOGY

Tunnel technique with connective tissue graft versus coronally

advanced flap with enamel matrix derivate for root coverage:
5-­year results of an RCT using 3D digital measurement
technology for volumetric comparison of soft tissue changes

Otto Zuhr1,2 | Dodji Akakpo3 | Peter Eickholz2 | Kirstin Vach4 |

Markus B. Hürzeler1,5 | Hari Petsos2,6 | the Research Group for
Oral Soft Tissue Biology & Wound Healing

1
Private Practice Hürzeler/Zuhr, Munich,
Germany Abstract
Aim: Comparison of the clinical efficacy (digitally volumetric, aesthetic, patient-­
2
Department of Periodontology, Center of
Dentistry and Oral Medicine (Carolinum),
Johann Wolfgang Goethe-­University,
centred outcomes) of tunnel technique (TUN) with subepithelial connective tissue
Frankfurt/Main, Germany graft (CTG) versus coronally advanced flap (CAF) with enamel matrix derivate (EMD)
3
Private Practice DIE PRAXIS, Berlin, 5 years after gingival recession therapy.
Germany
4 Materials and methods: In 18 patients contributing 36 RT1 recessions, study mod-
Center for Medical Biometry and Medical
Informatics, Institute for Medical Biometry els were collected at baseline and follow-­ups. Optical scans assessed recessions
and Statistics, University Medical Center
computer-­assisted [recession depth, recession reduction (RECred), complete root
Freiburg, Freiburg, Germany
5
Department of Operative Dentistry coverage (CRC), percentage of root coverage (RC), pointwise (pTHK) and mean areal
and Periodontology, University School (aTHK) marginal soft tissue thickness]. Root coverage aesthetic Score (RES) was used
of Dentistry, Albert-­Ludwigs-­University,
Freiburg, Germany for aesthetic evaluation and visual analogue scales for patient-­centred data collection
6
Private Practice Dr. Korte, Soest, applied.
Germany
Results: Sixty months after surgery, 50.0% (TUN+CTG) and 0.0% (CAF+EMD) of
Correspondence sites showed CRC (p = 0.0118), 82.2% (TUN+CTG) and 32.0% (CAF+EMD) achieved
Otto Zuhr, Private Practice Huerzeler/
RC, respectively (p = 0.0023). CTG achieved significantly better RECred (TUN+CTG:
Zuhr, Rosenkavalierplatz 18, 81925
Munich, Germany. 1.75±0.74 mm; CAF+EMD: 0.50 ± 0.39 mm; p = 0.0009) and aTHK (TUN+CTG:
Email: [email protected]
0.95 ± 0.41 mm; CAF+EMD: 0.26 ± 0.28 mm; p = 0.0013). RES showed superior out-
Funding information comes (p = 0.0533) for TUN+CTG (6.86 ± 2.31) compared to CAF+EMD (4.63 ± 1.99).
The authors declare that they have no
The study failed to find significant differences related to patient-­centred outcomes
conflict of interest
(TUN+CTG: 8.30 ± 2.21; CAF+EMD: 7.50 ± 1.51; p = 0.1136).
Conclusions: Five years after treatment, CTG resulted in better clinical and aesthetic
outcomes than CAF+EMD. Increased THK was associated with improved outcomes
for RECred and RC.

KEYWORDS
coronally advanced flap, gingival recession therapy, randomized controlled trial, tunnel
technique, volumetric measurement technology

This is an open access article under the terms of the Creative Commons Attribution-­NonCommercial-­NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-­commercial and no modifications or adaptations are made.
© 2021 The Authors. Journal of Clinical Periodontology published by John Wiley & Sons Ltd.

J Clin Periodontol. 2021;48:949–961.  wileyonlinelibrary.com/journal/jcpe | 949

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950 ZUHR et al.

Clinical relevance
Scientific rationale for the study: Long-­term data on volumetric soft tissue alterations after root
coverage procedures do hardly exist. Thus, this study compared clinical efficacy and aesthetic
as well as patient-­centred outcomes of TUN+CTG versus CAF+EMD over a 5-­year period for the
first time using 3D digital data.
Principal findings: Application of CTG improved clinical (HKT), digitally assessed volumetric and
aesthetic results. Higher THK values were associated with better outcomes regarding RECred
and RC.
Practical implication: Achieving sufficient soft tissue thickness seems to be a relevant prognostic
factor for long-­term stability and aesthetic success after gingival recession treatment.

1 | I NTRO D U C TI O N was (a) to compare the efficacy of root coverage with TUN+CTG
and CAF+EMD by means of clinical, digital, aesthetic and patient-­
Besides aesthetics and patient-­centred criteria regarding root cover- centred outcomes, (b) to record three-­dimensional soft tissue al-
age procedures, complete root coverage (CRC), recession reduction terations with and without the use of CTG over time and evaluate
(RECred) and increased keratinized tissue height (HKT) are broadly possible clinical consequences, and (c) to relate volumetric findings
recognized endpoints (Tonetti & Jepsen, 2014). With this respect, to stability of root coverage in general.
the coronally advanced flap (CAF) and its modifications combined
with autologous connective tissue graft (CTG) offer the best prog-
nosis to treat single (Cairo et al., 2014; Cairo, 2017; Chambrone et al., 2 | M ATE R I A L S A N D M E TH O DS
2018) and multiple gingival recessions (Graziani et al., 2014; Cairo,
2017; Chambrone et al., 2018). True nature of the CTG effect is not The present article complies with the CONSORT 2010 statement
fully understood (Zuhr et al., 2014). However, recent publications (Moher et al., 2010; Schulz et al., 2010).
indicate a positive impact of the post-­operative soft tissue thickness The study reports the 5-­year follow-­up data of an RCT on the
on the previously exposed root surface for mid-­ and long-­term sta- treatment of single and multiple gingival recessions. Corresponding
bility of the gingival margin (Tavelli, Barootchi, Cairo, et al., 2019; papers describe the study protocol in detail (Rebele et al., 2014;
Tavelli, Barootchi, Di Gianfilippo, et al., 2019; Zuhr et al., 2020). Zuhr, Rebele, et al., 2014; Zuhr et al., 2020). The study protocol
Connective tissue graft harvesting adds additional morbidity and was approved by the University of Freiburg Ethics Committee (ap-
pain to any root coverage procedure (Tonetti et al., 2018; Zucchelli proval number: 148/09) and registered in the German Clinical Trials
et al., 2020). Thus, it is essential to clarify the clinical relevance Register (ID: DRKS00003285).
and true long-­term benefit of the combined procedure. Better un-
derstanding in this context will influence future research and clin-
ical developments (e.g. biomaterials for substitution of autologous 2.1 | Participants
soft tissue grafts) (Zuhr, Baumer, et al., 2014). Some fundamental
issues require clarification: How long takes healing regarding soft Patients were enrolled, treated and examined at the Private Dental
tissue volume? Is there any correlation between marginal soft tissue Office Huerzeler/Zuhr (Munich, Germany) between July 2009 and
thickness and the long-­term stability? Is there any critical soft tissue June 2011 according to the following inclusion criteria (Rebele et al.,
thickness required for stability? 2014; Zuhr, Rebele, et al., 2014):
Long-­term evaluations performed in university (Jepsen et al., 2017;
Pini Prato et al., 2018; Pini Prato et al., 2018; Barootchi et al., 2019; • Age ≥21 years
Bhatavadekar et al., 2019; Petsos et al., 2020) and in private office set- • Non-­smokers
tings (Wessels et al., 2019; Petsos, Eickholz, Raetzke, et al., 2020) have • No systemic diseases or pregnancy
contributed to better understanding of the wound healing dynamics • No active periodontal disease, full-­mouth plaque and bleeding
after root coverage procedures. However, published research combin- scores ≤25%
ing long-­term outcomes after gingival recession therapy and precise • No medication interfering with periodontal tissue health or
measurement technologies is currently unknown to the authors. healing
To the best of the authors’ knowledge, this is the first long-­ • No contraindication for periodontal surgery
term investigation evaluating clinical and three-­dimensional volu- • Presence of at least one RT1 recession defect (Cairo et al., 2011;
metric data. The aim of this 5-­year follow-­up (Rebele et al., 2014; Cortellini & Bissada, 2018) not exceeding 5 mm in depth with a
Zuhr et al., 2014; Zuhr et al., 2020) randomized clinical trial (RCT) clearly identifiable natural cemento-­enamel-­junction (CEJ).
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ZUHR et al. 951

(a) (b)

(c) (d)

(e) (f)

(g) (h)

F I G U R E 1 (a) Single gingival recession defect on a right lateral incisor at baseline, which was randomly assigned to the TUN+CTG group.
(b) 12-­month follow-­up, (c) 24-­month follow-­up, (d) and 60-­month follow-­up of the corresponding case. (e) Multiple gingival recession defect
on both upper right premolars at baseline, which were randomly assigned to the CAF+EMD group. (f) 12-­month follow-­up, (g) 24-­month
follow-­up, (h) and 60-­month follow-­up of the corresponding case

In patients exhibiting multiple adjacent gingival recessions, all investigators performed clinical (D.A., Stephan Rebele, Kilian
defects contributed to data collection. Patients with appropriate Hansen) and one of them (D.A.) digital assessments. D.A. was
defects in anatomically separated locations were allocated to both blinded with respect to surgery. All examiners were trained to op-
treatment approaches, resulting in independently treated sites. timize clinical recordings measured to the nearest 0.5 mm using a
periodontal probe (PCP-­UNC 15, Hu-­Friedy; Zuhr, Rebele, et al.,
2014).
2.2 | Study settings Digital measurements of dimensional soft tissue alterations at
baseline and follow-­up examinations after 12, 24 and 60 months in-
Surgery was performed by the same operator (O.Z.) with long-­ clude measurements of recession depth as well as mean marginal
standing experience in periodontal plastic surgery. Three soft tissue thickness (THK).
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952 ZUHR et al.

2.3 | Surgical procedure During the first year, patients were scheduled at 1, 3, 6 and
12 months for professional dental hygiene and afterwards dis-
Randomization and allocation concealment, surgery and post-­ charged from study-­related recalls (Rebele et al., 2014; Zuhr,
operative care were comprehensively depicted before (Zuhr et al., Rebele, et al., 2014; Zuhr et al., 2020). For this reason, tooth-­ and
2020). site-­specific plaque and bleeding scores were not recorded any
longer.

2.4 | TUN+CTG
2.6 | Clinical measurements
TUN was basically performed according to the modified tunnel tech-
nique (Zuhr et al., 2007). A continuous split-­thickness tunnel was Clinical parameters were assessed to the nearest 0.5 mm using a
created by undermining the buccal mucosa of the involved teeth fol- PCP-­UNC 15 periodontal probe (Hu-­Friedy):
lowed by detachment of the adjacent papillary tissues allowing for
coronal displacement of the soft tissue complex. CTG was harvested • Periodontal probing depth (PPD) at the central buccal site.
according to the single-­incision technique (Hürzeler & Weng, 1999). • Height of keratinized tissue (HKT) mid-­buccally from the most api-
The graft was trimmed to a thickness of 1–­1.5 mm and inserted into cal extension of the gingival margin to the mucogingival junction.
the tunnel. The soft tissue complex was stabilized 1–­2 mm coro-
nally to the CEJ with double-­crossed sutures (Seralene® 6.0; Serag-­
Wiessner KG) (Zuhr et al., 2009; Figure 1a–­d).

2.7 | Digital measurements

2.5 | CAF+EMD
The preparation and superimposing/matching of scans (Imetric
After split-­thickness flap preparation, remaining papillae were de-­ D103®, Imetric 3D GmbH; Swissmedia software/Smop, Swissmeda)
epithelialized. The root surfaces were pre-­conditioned with eth- for three-­dimensional measurement of soft tissue alterations over
®
ylenediaminetetraacetic acid (Straumann PrefGel) before EMD time (Figure 2a–­d) were described previously (Rebele et al., 2014).
(Straumann® Emdogain) was applied (Institute Straumann AG). All digital parameters were recorded to the nearest 0.01 mm. RECred
Tension-­free flap adaption was ensured coronally to the CEJ using was measured according to Zuhr, Rebele, et al. (2014). THK was as-
sling sutures (Seralene® 6.0; Serag-­Wiessner KG) and single inter- sessed in two different ways by defining an area of interest (AOI) ac-
®
rupted sutures to close vertical releasing incisions (Seralene 7.0; cording to the explanations given in the 2-­year follow-­up publication
Serag-­Wiessner KG) (Figure 1e–­h). (Zuhr et al., 2020) (Figure 2d).

F I G U R E 2 (a) Frontal view of the

digital model gained through virtual
superimposing of baseline and 60-­month
follow-­up scans. (b) Frontal view of a
digital model with the outlined AOI
derived from superimposement. (c)
Areal measurement of aTHK above the
(a) (b) formerly exposed root. (d) (i) Areal, three-­
dimensional measurement of aTHK as
mean thickness of the marginal soft tissue
on the formerly exposed root surface.
aTHK was exhibited as a polygonal shape
and was bordered by the pre-­and post-­
operative lining of the margo gingivae. (ii)
Point-­like, two-­dimensional measurement
of pTHK. Measurement was performed in
a rectangular cross section at the central
buccal site in the middle of the vertically
(c) (d) augmented soft tissue
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ZUHR et al. 953

2.8 | areal THK score [RES (Cairo et al., 2009)]. The evaluation was based on base-
line and 60-­month photographs paired in a file for presentation. RES
Area of interest was defined as the entire area of the newly formed includes five outcome variables leading to a final score ranging from
soft tissue on the previously denuded root surface (Zuhr et al., 0 to 10 points (Cairo et al., 2009).
2020). Thus, aTHK was defined as mean thickness of this marginal
soft tissue (aTHK [mm] = vol [mm3]/area [mm2]). In cases of recur-
rence of the gingival recession, reaching or even exceeding the 2.11 | Patient questionnaire
baseline value, aTHK was defined as “0.” Accordingly, data collection
included all models collected from baseline, 6-­month, 1-­year, 2-­year At the 60-­month follow-­up, questionnaires according to those from
and 5-­year follow-­up [Figure 2d (i)]. the 12-­month evaluation (Zuhr, Rebele, et al., 2014) were answered
by the patients. The questionnaires collected subjective data on will-
ingness to repeat surgery (yes or no) and aesthetic satisfaction using
2.9 | pointwise THK a Visual Analogue Scale from 0 to 10.

pTHK was defined as pointwise, two-­dimensional measurement

evaluating the distance from the formerly exposed root surface at 2.12 | Statistical analysis
baseline to the soft tissue surface at follow-­ups. It was performed in
a cross section rectangular at the central buccal site in the middle of Information on sample size calculation has been described before
the newly formed soft tissue [Figure 2d (ii)]. (Zuhr, Rebele, et al., 2014). Statistical analysis was conducted in
accordance with previous publications (Rebele et al., 2014; Zuhr,
Rebele, et al., 2014).
2.10 | Aesthetic evaluation Patient-­level analysis was performed regarding the experimen-
tal site as the statistical unit. Means for each patient and treatment
Three experts in plastic periodontal surgery (Ali Daouk, Ronny Jung, method were calculated for all measured parameters at different fol-
Giulio Rasperini), all blinded with respect to the surgical procedures, low-­up time points. Clinical attachment level (CAL) was calculated by
evaluated the aesthetic outcomes using root coverage aesthetic summing up PPD and RECred. Descriptive data have been analysed for

TA B L E 1 Patient-­/site-­specific
Tooth/teeth Surgical Age at surgery
characteristics
Patient ID Sites [FDI] approach Gender [years]

01 01 12 TUN+CTG Female 21
02 02 21 TUN+CTG Female 25
03 03 13 CAF+EMD Female 47
05 06 21, 22 CAF+EMD Female 41
07 08 22 TUN+CTG Female 43
08 09 11, 21 TUN+CTG Female 34
09 10 13 CAF+EMD Male 54
11 22, 23, 24 TUN+CTG
10 12 14 TUN+CTG Female 36
11 13 22, 23 TUN+CTG Female 40
12 14 14, 15 CAF+EMD Female 38
15 24, 25 TUN+CTG
13 16 12 TUN+CTG Female 55
14 17 22, 23 TUN+CTG Male 46
16 20 12, 11, 21, 22 CAF+EMD Female 43
17 21 12, 13 CAF+EMD Female 44
19 24 14 CAF+EMD Male 34
21 27 15 CAF+EMD Female 40
22 28 13 CAF+EMD Male 44
23 29 13, 14, 15 CAF+EMD Female 25

Abbreviations: CAF+EMD, coronal advanced flap with enamel matrix derivative; FDI, Fédération
Dentaire Internationale (French); TUN+CTG, tunnel with connective tissue graft.
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954 ZUHR et al.

TA B L E 2 Recession depth (REC, mm)

TUN+CTG CAF+EMD
and marginal soft tissue thickness (aTHK,
N Mean ± SD [mm] n Mean ± SD [mm] p-­value pTHK, mm) at baseline, 6, 12, 24 and
60 months
Recession depth
Baseline 15 1.93 ± 0.57 15 1.69 ± 0.63 0.41
A A
6 months 15 0.02 ± 0.05 13 0.53 ± 0.47 <0.0001
12 months 14 0.04 ± 0.07A 14 0.55 ± 0.49A <0.0001
A,B,C A
24 months 15 0.13 ± 0.20 14 0.72 ± 0.48 <0.0001
60 months 10 0.36 ± 0.56A,B,D 10 1.28 ± 0.67A,B,C <0.0001
aTHK
6 months 15 1.30 ± 0.32 A 13 0.66 ± 0.22 A <0.0001
12 months 14 1.32 ± 0.26 14 0.72 ± 0.19 <0.0001
24 months 15 1.11 ± 0.26 14 0.60 ± 0.26B <0.0001
60 months 10 0.95 ± 0.41 A 10 0.26 ± 0.28A,B <0.0001
pTHK
6 months 15 1.74 ± 0.38A 13 0.90 ± 0.19A <0.0001
12 months 14 1.62 ± 0.31 14 0.98 ± 0.22 <0.0001
B B
24 months 15 1.41 ± 0.35 14 0.78 ± 0.32 <0.0001
60 months 10 1.24 ± 0.52 A,B 10 0.50 ± 0.39A,B <0.0001

Note: Superscript letters indicate significant differences within the respective group (A: compared
to baseline, B: compared to 6 months, C: compared to 12 months, D: compared to 24 months).
Abbreviations: aTHK, areal marginal soft tissue thickness; CAF+EMD, coronal advanced flap with
enamel matrix derivate; n, number of patients; pTHK, point-­like marginal soft tissue thickness; SD,
standard deviation; TUN+CTG, tunnel technique with subepithelial connective tissue graft.

all sites examined per follow-­up examination. The differences described 2020). One patient in CAF+EMD received a new suprastructure at
in the text are based on the sites that were available at the respective the study site and was excluded from further analysis. Two more
time points. To comply with the split-­mouth design, linear mixed mod- patients moved out of reach, and additional three patients were not
els were used to analyse differences between and within the groups. able to keep the 60-­month follow-­up. Therefore, 18 patients were
For additional pairwise comparisons, a Bonferroni correction was used. available for the 5-­year follow-­up contributing 10 study sites to each
Pearson's correlation coefficient was calculated with the com- group (Figure S1). Further patient-­ and site-­specific characteristics
plete 5-­year data set to analyse the relationship between THK and are shown in Table 1.
RC/RECred within each group. Linear mixed models were used for
standardized variables to compute the corresponding correlation
coefficients for all data. Mixed linear regression analysis explored 3.2 | Defect characteristics at baseline, 6, 12,
the relationship between THK and RC/RECred, and a mixed logis- 24 and 60 months
tic model was calculated to analyse the influence of THK on CRC.
To compare VAS and RES for each timepoint between the groups, Table 2 shows descriptive data for mean RECred and mean THK at
Wilcoxon rank-­sum test was used, while answering the questions baseline, 6, 12, 24 and 60 months. Both, aTHK and pTHK show sig-
about repeating the surgical procedure Fisher's exact test was ap- nificantly higher values in TUN+CTG than in CAF+EMD at all fol-
plied. All tests were based on a significance level of 5%. low-­up timepoints (p < 0.005). Twice as many patients in CAF+EMD
Statistical analysis was performed by K.V. with STATA 15.1. showed an increase in REC (n = 10) in at least one site between 12
(StataCorp LT). and 60 months compared to TUN+CTG (n = 5; decrease: n = 1; un-
changed: n = 4). For CAF+EMD, REC increased ≥0.5 mm in 2 and
≥1.0 mm in 4 patients. In case of TUN+CTG, one patient showed an
3 | R E S U LT S increase of ≥0.5 mm and two patients of ≥1.0 mm. In all other cases,
only a slight increase in REC of <0.5 mm was detected.
3.1 | Experimental population Analysis regarding HKT, RECred, RC and CRC changes after 6,
12, and 60 months compared to baseline is shown in Table 3. Intra-­
Originally 24 patients with a mean age of 37.9 ± 9.8 years contrib- group changes of RC comparing the 60-­m onth results to the 12-­
uting 47 gingival recessions (30 study sites) were recruited for the and 24-­m onth data were decreasing in both groups (TUN+CTG:
study (Rebele et al., 2014; Zuhr, Rebele, et al., 2014; Zuhr et al., −16.79 ± 25.25%, p = 0.002; CAF+EMD: −43.86 ± 25.98%,
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ZUHR et al. 955

TA B L E 3 Comparison of TUN+CTG and CAF+EMD for variables of height of keratinized tissue (HKT, mm), recession depth reduction
(RECred, mm), percentage of root coverage (RC, %) and percentage of defects with complete root coverage (CRC, %) 6, 12, 24 and 60 months
after surgery

Height of keratinized tissue Recession depth reduction % Defects with complete

(HKT) (RECred) % Root coverage (RC) root coverage (CRC)

Mean ± SD Mean ± SD
N [mm] n Mean ± SD [mm] n Mean ± SD [%] n [%]

Baseline –­6 months

TUN+CTG 15 0.58 ± 0.82 15 1.91 ± 0.56 15 99.2 ± 1.6 15 80.0 ± 41.4
CAF+EMD 13 −0.36 ± 0.47 13 1.21 ± 0.46 13 72.2 ± 18.4 13 15.4 ± 37.5
p-­value <0.0001 <0.0001 0.0001 <0.0001
Baseline –­12 months
TUN+CTG 14 0.62 ± 0.83 14 1.94 ± 0.57 14 98.4 ± 3.6 14 78.6 ± 42.6
CAF+EMD 14 −0.34 ± 0.51 14 1.17 ± 0.42 14 71.8 ± 20.3 14 21.4 ± 42.6
p-­value <0.0001 <0.0001 <0.0001 <0.0001
Baseline –­24 months
TUN+CTG 15 0.54 ± 0.99 15 1.81 ± 0.56 15 94.0 ± 10.0 15 60.0 ± 50.7
A
CAF+EMD 14 −0.28 ± 0.61 14 0.90 ± 0.45 14 57.3 ± 25.5 14 0.0 B
p-­value 0.001 <0.0001 <0.0001 <0.0001
Baseline –­60 months
TUN+CTG 10 0.42 ± 2.04 10 1.75 ± 0.74A,B 10 82.2 ± 27.0A,B,C 10 50.0
A,B,C A,B,C
CAF+EMD 10 −0.32 ± 1.13 10 0.50 ± 0.39 10 32.0 ± 26.5 10 0.0
p-­value 0.825 <0.0001 <0.0001 0.002

Note: Superscript letters indicate significant differences within the respective group (A: compared to 6 months, B: compared to 12 months, C:
compared to 24 months).
Abbreviations: CAF+EMD, coronal advanced flap with enamel matrix derivate; n, number of patients; SD, standard deviation; TUN+CTG, Tunnel
technique with subepithelial connective tissue graft.

p < 0.001; TUN+CTG: −9.7 ± 17.84%, p=0.049; CAF+EMD: after 60 months above which no further benefit was seen with re-
−31.1 ± 30.81%, p < 0.0001). Intra-­group changes of RECred in- gard to RC (Figure 3b). A logistic model analysis assumed a mean
creased significantly from 12 to 60 months (p = 0.0001) in both aTHK of 1.26 mm and a mean pTHK of 1.68 mm being maintained
groups, and from 24 to 60 months (p = 0.001) in CAF+EMD as minimum thickness over 60 months to predict CRC with a confi-
(Table 3). Comparing RECred, RC and CRC at all follow-­ups with dence of 95%.
the baseline situation, significant improvements (p < 0.005) could
be determined favouring TUN+CTG. Descriptive values for HKT,
CAL and PPD are shown in Table 4. 3.4 | Patient questionnaires, RES

Patient-­centred outcomes and RES results are presented in Table 5.

3.3 | The relationship of marginal soft tissue Five years after root coverage, there was no significant difference
thickness to recession reduction and root coverage between TUN+CTG and CAF+EMD with regard to the patients’ aes-
thetic satisfaction (p = 0.1136). RES assessment revealed a trend to
Regarding complete data set, Pearson's correlation coefficient indi- superior outcomes (p = 0.0533) for TUN+CTG (6.86 ± 2.31) com-
cated a significant positive correlation between aTHK and RECred pared to CAF+EMD (4.63 ± 1.99). 90% of patients from both groups
after 60 months in the TUN+CTG group (r = 0.7444, p = 0.0135) as would undergo surgery again.
well as in the CAF+EMD group (r = 0.7286, p = 0.0169) (Figure 3a). Supplementary tables provide descriptive data limited to the pa-
The same correlation was found for pTHK and RECred (TUN+CTG: tients who were available for the 5-­year follow-­up (Tables S1–­S 4).
r = 0.600, p = 0.0666; CAF+EMD: r = 0.848, p = 0.0019).
RC and aTHK correlate significantly after 60 months in TUN+CTG
(r = 0.7901, p = 0.0065), but not for CAF+EMD (r = 0.5056, p = 0.1360). 4 | DISCUSSION
However, Pearson's correlation coefficient revealed a significantly
positive correlation between aTHK (r = 0.972, p < 0.0001) as well The results of this 5-­year follow-­up RCT reveal that both root cover-
as pTHK and RC (r = 0.910, p < 0.0001). Data indicate a mean aTHK age procedures with TUN+CTG and CAF+EMD exhibit deterioration
 |

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956 ZUHR et al.

TA B L E 4 Clinical parameters at
TUN+CTG CAF+EMD
baseline, 6, 12, 24 and 60 months after
n Mean ± SD [mm] n Mean ± SD [mm] p-­value surgery

Height of keratinized tissue (HKT)

Baseline 15 3.26 ± 1.25 15 2.95 ± 1.06 <0.0001
6 months 14 3.83 ± 1.58 13 2.52 ± 0.99 <0.0001
12 months 14 3.86 ± 1.67 14 2.61 ± 1.14 <0.0001
24 months 15 3.79 ± 1.68 14 2.71 ± 1.25 0.002
60 months 10 3.80 ± 2.11 10 2.91 ± 0.40 0.247
Clinical attachment level (CAL)
Baseline 14 3.28 ± 0.71 15 2.98 ± 0.62 0.720
A A
6 months 14 1.27 ± 0.54 13 1.89 ± 0.64 <0.0001
12 months 14 0.99 ± 0.59A 14 1.55 ± 0.70A 0.001
A,C A,C
24 months 15 1.54 ± 0.38 14 2.04 ± 0.66 0.001
60 months 10 2.53 ± 0.85B,C,D 10 3.07 ± 0.75A,B,C,D 0.194
Periodontal probing depths (PPD)
Baseline 14 1.34 ± 0.37 15 1.31 ± 0.42 0.847
A
6 months 14 1.76 ± 0.47 13 1.44 ± 0.46 0.049
12 months 14 1.45 ± 0.50 B 14 1.12 ± 0.19B 0.022
B
24 months 15 1.31 ± 0.26 14 1.22 ± 0.31 0.389
60 months 10 1.89 ± 0.44C 10 1.48 ± 0.69A,C,D 0.066

Note: Superscript letters indicate significant differences within the respective group (A: compared
to baseline, B: compared to 6 months, C: compared to 12 months, D: compared to 24 months).
Abbreviations: CAF+EMD, coronal advanced flap with enamel matrix derivate; n, number of
patients; SD, standard deviation; TUN+CTG, Tunnel technique with subepithelial connective tissue
graft.

of RC and CRC. TUN+CTG was found to be significantly superior results to the present findings. Salem and coworkers examined 24
(p < 0.005) to CAF+EMD in terms of RC, CRC and RECred. HKT as patients with single and multiple maxillary gingival recession defects
well as pTHK and aTHK changes failed to be significantly different. 4 years after root coverage with CAF+CTG or TUN+CTG. While
A significant correlation between RC as well as RECred and aTHK as there was a significant superiority in favour of TUN+CTG related to
well as pTHK was detected (p < 0.0001). After 5 years, minimal aTHK THK (TUN+CTG: 2.06 mm, CAF+CTG: 1.23 mm; p = 0.0012) and HKT
of 1.26 mm and pTHK of 1.68 mm correlated with CRC. Differences (TUN+CTG: 5.0 mm, CAF+CTG: 3.62 mm; p = 0.0014), no significant
related to patient-­centred and aesthetic outcomes failed to be sig- differences between both groups were noticed for RC (TUN+CTG:
nificant, but tended to do better for TUN+CTG. 90.1%, CAF+CTG: 95.9%, p = 0.32) and CRC (TUN+CTG: 81.3%,
Systematic reviews have analysed the predictability of both CAF+CTG: 100%, p = 0.52) (Salem et al., 2020). Comparable mid-­
investigated procedures (Cairo et al., 2014; Graziani et al., 2014; term root coverage outcomes for TUN+CTG could not be maintained
Chambrone & Tatakis, 2015; Chambrone et al., 2018; Tavelli et al., over a 5-­year period in the present investigation (RC 12–­60 months:
2018; Dai et al., 2019). However, there is only little data on soft tis- −16.79±25.25%, RECred 12–­60 months: −0.3 ± 0.55 mm). Due to the
sue stability after surgical root coverage procedures with and fol- lack of long-­term evidence for TUN+CTG, a comparison with other
low-­up of 5 years or longer. The relapse of the gingival margin in the studies is currently not possible.
test as well as in the control group with a decrease of RC and CRC Success rates of CAF-­based procedures for the treatment
between 12 and 60 months was one of the major findings in our of single (Cairo et al., 2014; Cairo, 2017; Chambrone et al., 2018)
investigation. and multiple gingival recessions (Graziani et al., 2014; Cairo, 2017;
Only one prospective clinical study considering long-­term effi- Chambrone et al., 2018) are primarily based on a combined split-­full-­
cacy of CAF+EMD has been published so far. Ten years after treat- split flap design mostly without additional vertical releasing incisions
ment, the authors reported in a split-­mouth comparison of 9 patients (Zucchelli et al., 2009; Cortellini & Prato, 2012). In the present study,
similar clinical results after surgical root coverage using CAF+EMD a consistent split-­thickness flap preparation including vertical releas-
or CAF+CTG. RC was 89.8 ± 22.7% for CAF+CTG and 83.3 ± 21.7% ing incisions (Zuhr, Rebele, et al., 2014) was applied. Based on the
for CAF+EMD. CRC could be detected in 77.8% of the teeth treated fact that McGuire et al. applied a combined split-­full-­split flap design
with CAF+CTG and in 55.6% of the teeth treated with CAF+EMD (McGuire et al., 2012), the divergent flap preparation may explain
(McGuire et al., 2012). Mid-­term data on TUN+CTG show comparable their superior results compared to our RCT.
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ZUHR et al. 957

TA B L E 5 Results for subjective (patients/VAS) and objective (professional examiners/RES) evaluation of the aesthetic outcomes and willingness for repetition of surgery according to patient

Abbreviations: CAF+EMD, coronal advanced flap with enamel matrix derivate; n, number of patients/cases; RES, Root coverage aesthetic score; SD, standard deviation; TUN+CTG, Tunnel technique with
60 months
(yes)

9
9
1.0
10
10
n
Questionnaire (patients)

12 months
(yes)

13
14
1.0
14
14
n

6.86 ± 2.31
4.63 ± 1.99
Mean ± SD
60 months

0.0533
Cases

10
10
Mean RES (examiners 1–­3)

6.92 ± 2.32
9.06 ± 0.83
Mean ± SD
12 months
F I G U R E 3 (a) Scatter plot of aTHK versus RECred at 60 months
with fitted linear regression line: There is a positive, linear

0.0034
Cases

relationship between aTHK achieved on the previously exposed 14

root surfaces and RECred. This leads to greater RECred in the 14
TUN+CTG group compared to the CAF+EMD group. (b) Scatter
plot of aTHK versus RC at 60 months with fitted logistic function
(curve): There is a positive correlation between aTHK achieved on
8.30 ± 2.21
7.50 ± 1.51
Mean ± SD
60 months

the on the previously exposed root surfaces and RC. This leads
to greater relative RC in the TUN+CTG group compared to the
CAF+EMD group
subepithelial connective tissue graft; VAS, Visual analogue scale.
0.1136

The use of three-­dimensional measuring methods makes a com-

10
10
n

parison with other studies using rigid millimetre-­scaled periodontal

probes difficult (Leknes et al., 2005; Cordaro et al., 2012; McGuire
9.07 ± 1.07
Mean ± SD

9.21 ± 1.41
12 months

et al., 2012; Garces-­McIntyre et al., 2017; Barootchi et al., 2019;

Neves et al., 2019; Petsos, Eickholz, Raetzke, et al., 2020; Salem
et al., 2020). The applied measuring technique has demonstrated
VAS (patients)

accuracy and high reproducibility to record in vitro imitated gingi-

val recessions to the nearest 0.01 mm (Lehmann et al., 2012). This
0.4568

method proved to improve measurement reproducibility, lowered

14
14

intra-­and inter-­individual variance of measurement (Schneider et al.,

n

2014; Fons-­Badal et al., 2020; Lee et al., 2020), and set the thresh-
questionnaires

old for CRC to 0.01 mm of remaining gingival recession. Therefore,

CAF+EMD
TUN+CTG

no rounding errors must be accepted, and CRC is only recorded,

p-­value

when the gingival margin actually reaches or exceeds the CEJ. The
same applies to THK recordings. Up to now, studies applied diverse
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958 ZUHR et al.

TA B L E 6 Complete root coverage (CRC, %) and percentage of root coverage (RC, %) 60 months after surgery digitally measured and
rounded to the nearest 0.01 mm as well as manually assessed using a periodontal probe and rounded to the nearest 0.5 and 1.0 mm

% Defects with complete root coverage (CRC) % Root coverage (RC)

TUN+CTG CAF+EMD TUN+CTG CAF+EMD

Mean ± SD Mean ± SD Mean ± SD Mean ± SD

n [%] n [%] p-­value n [%] n [%] p-­value

Digital measurements to 10 50.0 ± 52.70 10 0.0 0.0118 10 82.2 ± 27.04 10 32.0 ± 26.51 0.0023
the nearest 0.01 mm
Manual measurements 10 60.0 ± 51.64 10 0.0 0.0062 10 80.2 ± 27.69 10 38.2 ± 29.71 0.0107
rounded to the nearest
0.5 mm
Manual measurements 10 60.0 ± 51.64 10 10.0 ± 31.62 0.0223 10 75.0 ± 36.22 10 28.3 ± 34.29 0.0132
rounded to the nearest
1.0 mm

Abbreviations: CAF+EMD, coronal advanced flap with enamel matrix derivate; n, number of patients; SD, standard deviation; TUN+CTG, Tunnel
technique with subepithelial connective tissue graft.

endodontic instruments, anaesthetic needles or calliper to measure examination on coverage of mucosal recessions at dental implants
THK (Paolantonio, 2002; da Silva et al., 2004; Zucchelli et al., 2010; using epithelialized grafts after extraoral deepithelialization point to
Cardaropoli et al., 2012; Jepsen et al., 2013; Zucchelli et al., 2018; an influence of the harvesting technique (Zucchelli et al., 2018). In
Pietruska et al., 2019; Tavelli, Barootchi, Di Gianfilippo, et al., 2019; contrast to our findings, THK increased by 0.3 mm from 12 months
Cairo et al., 2020; Salem et al., 2020). Other investigations used ul- to 5 years post-­operatively. The results of Gil et al. also point to the
trasonic devices (Muller et al., 1998; Muller et al., 1999; Leknes et al., graft composition as predictive factor for THK gain. The authors
2005). In the present study, a non-­invasive three-­dimensional digi- used different graft materials and revealed different THK values
tal measuring method has been used to measure soft tissue volume after 14.6 months using a similar digital measurement method. The
changes and to quantify the two-­dimensional thickness of the mar- greatest THK gain was achieved with the tuberosity graft (Gil et al.,
ginal soft tissues that has been surgically established on the root sur- 2019). However, recent data point out that the obvious advantages
faces. Table 6 shows CRC and RC values of the present investigation of superficially harvested CTGs with respect to post-­operative vol-
after fictitious rounding to the nearest 0.5 and 1.0 mm. Recalculation ume stability might to some extent be offset by aesthetic disadvan-
based on rounding values leads in both study groups to higher values tages (Zucchelli et al., 2014; Pietruska et al., 2019).
concerning CRC and divergent results regarding RC. The latter find- Is there a critical soft tissue thickness above which additional
ing clarifies that rounding values differ from the real situation and thickening does not improve prognosis of root coverage? This ques-
illustrates the impact of rounding errors on the final results. The ap- tion can only be addressed indirectly, as no baseline THK values
plication of a three-­dimensional digital measurement technology pro- were recorded. Analysis of our 24-­month data indicates that sites
vides precision in the evaluation of surgical root coverage outcomes. with aTHK of at least 1.6 mm and pTHK of 1.8 mm reached CRC with
The present investigation identified post-­operative THK to be a confidence of 95%. The corresponding 60-­month data are reduced
a significant long-­term prognostic factor. Analysis of our 60-­month to 1.3 mm and 1.7 mm, respectively. It can be derived from our re-
data indicated that the overall relapse of the gingival margin in the sults that especially sites of thinner gingival phenotypes do benefit
test and the control group comes with a decrease of THK over time. even from minor gingival thickening during surgical root coverage,
Therefore, it is conclusive that RECred and RC were significantly aiming 1 year post-­operatively for THK values of about 2 mm at the
better at CT-­grafted sites (TUN+CTG: 1.75 mm and 82.2%) com- central areas and 1.5 mm.
pared to non-­augmented sites (CAF+EMD: 0.50 mm and 32.0%) con- As limitations of this study, the evaluation of singular and multi-
firming other long-­term evaluations (Barootchi et al., 2019; Tavelli, ple gingival recession defects, the incorporation of different investi-
Barootchi, Di Gianfilippo, et al., 2019). In contradiction to our find- gators, the lack of a reliability assessment among the examiners and
ings, a recently published 2-­year follow-­up RCT on gingival recession the fact that the majority of enrolled patients discontinued regular
treatment revealed stable THK with a tendency for increased HKT maintenance care in our office after the 12-­month follow-­up should
and RECred values from 1 to 2 years (Neves et al., 2019). A possible be considered critically. Within these limitations, the following con-
explanation might consist of the fact that the composition of the clusions can be drawn:
applied CTGs differs substantially from the ones used in our study.
Hence, different to the CTGs in our study being composed of deeper • TUN+CTG revealed significantly superior long-­term results com-
portions of the lamina propria and submucosa, the CTGs used in pared to CAF+EMD in terms of RECred, CRC and RC.
the trial by Neves et al. mainly consisted of superficial layers of the • A notable retraction of the gingival margin over 5 years occurred
lamina propria (Bertl et al., 2015). The results of a 5-­year follow-­up in both groups.
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ZUHR et al. 959

fatty/glandular tissue in connective tissue grafts depends on the

• Increased THK correlated significantly with better results in terms harvesting technique but not the donor site of the hard palate.
of RECred and RC. Journal of Periodontology, 86, 1331–­1339. https://doi.org/10.1902/
• A minimal remaining tissue thickness (aTHK pTHK) after jop.2015.150346
Bhatavadekar, N. B., Gharpure, A. S., & Chambrone, L. (2019). Long-­
60 months correlated with CRC with high confidence. Thus, sub-
term outcomes of coronally advanced tunnel flap (CATF) and the
stantial augmentation of thickness seems to be a prerequisite of
envelope flap (mCAF) plus subepithelial connective tissue graft
long-­term CRC. (SCTG) in the treatment of multiple recession-­t ype defects: A 6-­
• For the best possible long-­term stability after gingival recession year retrospective analysis. International Journal of Periodontics
therapy with CTG originating from deeper layers of palatal masti- and Restorative Dentistry, 39, 623–­630. https://doi.org/10.11607/​
prd.4026
catory mucosa, clinicians should aim for 12-­month THK values of
Cairo, F. (2017). Periodontal plastic surgery of gingival recessions at sin-
around 2 mm at the centre and 1.5 mm at the peripheral areas of gle and multiple teeth. Periodontology 2000, 75, 296–­316. https://
the formerly exposed root surfaces. doi.org/10.1111/prd.12186
Cairo, F., Cortellini, P., Nieri, M., Pilloni, A., Barbato, L., Pagavino, G., &
Tonetti, M. (2020). Coronally advanced flap and composite resto-
ration of the enamel with or without connective tissue graft for the
E T H I C S S TAT E M E N T treatment of single maxillary gingival recession with non-­c arious
University of Freiburg Ethics Committee (approval number: 148/09) cervical lesion. A randomized controlled clinical trial. Journal of
approved the protocol and consent form. It was conducted follow- Clinical Periodontology, 47, 362–­371. https://doi.org/10.1111/
jcpe.13229
ing the principles of the Declaration of Helsinki. All patients signed
Cairo, F., Nieri, M., Cincinelli, S., Mervelt, J., & Pagliaro, U. (2011). The in-
informed consent after receiving explanations on study objectives, terproximal clinical attachment level to classify gingival recessions
design, risks and potential benefits. and predict root coverage outcomes: An explorative and reliability
study. Journal of Clinical Periodontology, 38, 661–­666. https://doi.
org/10.1111/j.1600-­051X.2011.01732.x
AC K N OW L E D G E M E N T S
Cairo, F., Nieri, M., & Pagliaro, U. (2014). Efficacy of periodontal plas-
The authors gratefully acknowledge Dr. Ali Daouk (Private Practice, tic surgery procedures in the treatment of localized facial gingival
Obertshausen, Germany), Prof. Giulio Rasperini (Private Practice, recessions. A systematic review. Journal of Clinical Periodontology,
Piacenza, Italy) and Prof. Rony Jung (Clinic of Fixed and Removable 41(Suppl 15), S44–­S62. https://doi.org/10.1111/jcpe.12182
Cairo, F., Rotundo, R., Miller, P. D., & Pini Prato, G. P. (2009). Root cov-
Prosthodontics and Dental Material Science, Center of Dental
erage esthetic score: A system to evaluate the esthetic outcome
Medicine, University of Zurich, Zurich, Switzerland) for their profes-
of the treatment of gingival recession through evaluation of clin-
sional evaluation of the aesthetic outcomes. Moreover, the authors ical cases. Journal of Periodontology, 80, 705–­710. https://doi.
thank Dr. Ali Daouk (Private Practice, Obertshausen, Germany) and Dr. org/10.1902/jop.2009.080565
Sabine Hof (Private Practice, Niederselters, Germany) for their logistic Cardaropoli, D., Tamagnone, L., Roffredo, A., & Gaveglio, L. (2012).
Treatment of gingival recession defects using coronally advanced
support at completing the data collection. They also thank Dr. Stephan
flap with a porcine collagen matrix compared to coronally ad-
Rebele and Dr. Kilian Hansen for collecting clinical and digital data. vanced flap with connective tissue graft: A randomized controlled
clinical trial. Journal of Periodontology, 83, 321–­328. https://doi.
C O N FL I C T O F I N T E R E S T org/10.1902/jop.2011.110215
Chambrone, L., Salinas Ortega, M. A., Sukekava, F., Rotundo, R., Kalemaj,
The study was self-­funded by the authors and their institutions.
Z., Buti, J., & Pini Prato, G. P. (2018). Root coverage procedures for
treating localised and multiple recession-­t ype defects. Cochrane
DATA AVA I L A B I L I T Y S TAT E M E N T Database of Systematic Reviews, 10, CD007161. https://doi.
All data generated and analysed during this study are included in this org/10.1002/14651​858.CD007​161.pub3
Chambrone, L., & Tatakis, D. N. (2015). Periodontal soft tissue root cov-
published article. All data and materials are available upon request.
erage procedures: A systematic review from the AAP Regeneration
Workshop. Journal of Periodontology, 86, S8–­S51. https://doi.
ORCID org/10.1902/jop.2015.130674
Otto Zuhr https://orcid.org/0000-0001-8315-2015 Cordaro, L., di Torresanto, V. M., & Torsello, F. (2012). Split-­mouth com-
parison of a coronally advanced flap with or without enamel ma-
Peter Eickholz https://orcid.org/0000-0002-1655-8055
trix derivative for coverage of multiple gingival recession defects:
Hari Petsos https://orcid.org/0000-0002-8901-8017 6-­and 24-­month follow-­up. International Journal of Periodontics and
Restorative Dentistry, 32, e10–­e20.
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