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 409

Clinical Considerations on the

Root Coverage of Gingival Recessions in
Thin or Thick Biotype

Sergio Kahn, DDS, PhD1 Gingival recession is defined as the

Renato Alves da Rocha Almeida, DDS, MSD2
location of the marginal tissue api-
Alexandra Tavares Dias, DDS, MSD2
cal to the cementoenamel junction
Walmir Júnior de Pinho Reis Rodrigues, DDS3
(CEJ) and may be related to esthet-
Marcos Oliveira Barceleiro, DDS, MSD, PhD4
Mario Taba Jr, DDS, MSD, PhD5 ic problems, root hypersensitivity,
and caries lesions.1,2
Different classifications have
Gingival biotype is a clinical term used to describe the thickness of the gingiva. been proposed to classify gingival
It has been classified as being thick or thin and may be related to the clinical recession.3,4 Miller classification3 is
outcome of root coverage procedures. This study evaluated the impact of most frequently used and takes into
gingival biotype on the clinical outcome of root coverage procedures following
consideration the depth of reces-
subepithelial connective tissue graft plus coronally positioned flap. A total of
19 patients, 10 with thin and 9 with thick gingival biotype, were treated for sion and the loss of interproximal
localized Miller Class I or II gingival recessions. After 6 months, 14 patients tissue. Similarly, there are different
achieved complete root coverage, 7 from each group. The overall mean pooled classifications for soft tissue bio-
root coverage rate was 90.93%. The thin biotype cases yielded a reduced mean types such as thick-flat and thin- or
root coverage of 88.51% compared with 93.63% for patients who had the thick thick-scalloped.5–7
biotype classification. Although the thin gingival biotype may impair the clinical
The surgical technique for the
outcome of root coverage procedures, this limitation does not appear to have a
strong influence on the success of the root coverage therapy when subepithelial treatment of gingival recession was
connective tissue graft was associated with the coronal positioning of the flap. initially described by Grupe and
Int J Periodontics Restorative Dent 2016;36:409–415. doi: 10.11607/prd.2249 Warren in 1956.8 In 1985, Langer
and Langer proposed the use of
palatal subepithelial connective tis-
sue grafts with predictable results.9
Since then, various modifications
have been suggested that use dif-
Professor, Master of Science Program in Oral Rehabilitation, Veiga de Almeida University,
1 ferent flap approaches, such as the
Rio de Janeiro, Brazil. techniques reported by Nelson10
2Researcher, Master of Science Program in Oral Rehabilitation, Veiga de Almeida University,
(a subpedicle connective tissue
Rio de Janeiro, Brazil.
3Researcher, Master of Science Program in Periodontics, Rio de Janeiro State University,
graft), Bruno11 (a procedure with-
Rio de Janeiro, Brazil. out vertical incisions), and Harris12
4Professor, Department of Dentistry, School of Dentistry, Fluminense Federal University,
(a partial thickness double pedicle
Nova Friburgo, Rio de Janeiro, Brazil. graft).
5Associate Professor, Department of Oral Surgery and Periodontology, University of

São Paulo, São Paulo, Brazil.

Subepithelial connective tis-
sue grafting has shown high rates
Correspondence to: Dr Sergio Kahn, Rua Hugo Regis dos Reis 10, of root coverage and is associated
casa 1, Barra da Tijuca, Rio de Janeiro, Brazil, CEP 22793-328.
with predictable results.13–16 Sys-
Fax: 55(21) 22853846. Email: sergiokahn@terra.com.br
tematic reviews have compared this
 ©2016 by Quintessence Publishing Co Inc. approach with several others and

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410
Fig 1  Gingival recession on a maxillary first
premolar.
have demonstrated that it provides
higher root coverage rates.17–19
The influence of flap thickness
and gingival biotype on periodon-
tal surgical techniques and their
relation with the clinical outcome
of root coverage procedures have
been briefly discussed in the lit-
erature.17,20–24 Therefore, the aim of
the present study was to evaluate
the influence of gingival biotype on
the root coverage rates of localized
Miller Class I or II gingival recessions
using the subepithelial connective
tissue graft plus the coronally ad-
vanced flap technique.
Materials and methods
Study population
A total of 19 patients (12 women and
7 men), aged between 18 and 40
years (mean age: 27.36 ± 6.27 years)
were selected to participate in the
study. All patients were nonsmokers
who were periodontally and system-
ically healthy, with no contraindica-
tions for periodontal surgery, and
had not taken medications known
to interfere with periodontal tissue
health or healing within 6 months
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prior to the study. The following
inclusion criteria were used: pres-
ence of localized Miller Class I or II
gingival recession (< 3 mm) in maxil-
lary incisors, canines, or premolars;
probing depths (PD) ≤ 3 mm, no
bleeding on probing, presence of
tooth vitality, and absence of caries
and restorations in the areas to be
treated.
The participating subjects were
selected from patients referred for
dental treatment at the School of
Dentistry of Veiga de Almeida Uni-
versity (UVA) because they showed
concerns about esthetics and/or root
hypersensitivity (Fig 1). They signed
an informed consent form with re-
gard to participating in this study.
The University’s Ethical Committee
approved the consent form and ex-
perimental protocol (#103/08).
Initial therapy
All patients were enrolled in a plaque
control regimen that included oral
hygiene instructions, scaling and
root planing using an ultrasonic ap-
pliance (Cavitron Select, Dentsply),
and tooth crown polishing, 28 days
before surgery. The visible plaque
index (VPI)25 and sulcus bleeding in-
dex (SBI)26 were recorded and used
to monitor gingival health through-
out the study.
Clinical parameters
A single experienced examiner re-
corded the following clinical param-
eters on the day of surgery and 6
months after the surgical procedure:
• Recession height (RH): Distance
between the midbuccal
cementoenamel junction (CEJ)
and gingival margin (GM)
• Recession width (RW): distance
from one border of the
recession to another, measured
at the CEJ level
• Probing depth (PD): distance
between the GM and the
bottom of the gingival sulcus
• Clinical attachment level (CAL):
distance between the CEJ
and the bottom of the gingival
sulcus
• Width of keratinized tissue
(WKT): distance between the
most apical point of the GM and
the mucogingival junction (MGJ)
• Thickness of keratinized tissue
(TKT): measured at the midpoint
of the base of the papillae of the
tooth to be treated
The PD and CAL measure-
ments were taken using a 15-mm
periodontal probe (Hu-Friedy). The
RH, RW, WKT, and TKT parameters
were gauged with an endodon-
tic finger spreader coupled with a
rubber stopper (Maillefer, Dentsp-
ly), and the measurements were
recorded with the aid of a digital
caliper with a 0.01-mm resolution
(Mitutoyo, Suzano).
Gingival biotype was clinically
assessed by two calibrated exam-
iners (A.D., R.A.). In any case of di-
vergence between them, a third
experienced examiner (S.K.) was
asked to evaluate the case. Cali-
bration between the examiners
was evaluated using kappa, and
the index was > 0.8 between the
examiners. The tissue biotype was

Fig 2  Examples of thin (left) and thick (right) gingival biotype.
classified as thin or thick, according
to the clinical characteristics recom-
mended by Kao and Pasquinelli.6
The tissue biotype was considered
thin when a highly scalloped soft
tissue and bone architecture, a deli-
cate friable soft tissue, a minimal
amount of attached gingiva, and
a thin underlying bone were ob-
served. Inversely, a thick biotype
presented a flat soft tissue and bony
architecture, a dense fibrotic tissue,
a large amount of attached gingiva,
and a thick underlying osseous form
(Fig 2).6 The quality of soft tissue
and bone structure were carefully
examined while the patient was un-
der anesthesia during the surgical
procedure to confirm the biotype
classification and group separation.
Surgical procedure
All surgical procedures were per-
formed by one operator (S.K.).
One hour before surgery, each pa-
tient was given a single dose of 8
mg dexamethasone (Medley), as
preemptive analgesia. Extraoral
antisepsis was performed with an
antibacterial agent (LM Farma), and
intraoral antisepsis was performed
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with a 0.12% chlorhexidine rinse
(Lacer) for 2 minutes. Mepivacaine
(2.0%) with 1:100,000 epinephrine
(DFL) was used to achieve local an-
esthesia.
An initial intrasulcular incision
was made on the buccal aspect
of the involved tooth. Then, two
oblique incisions were made me-
sially and distally to the recession
from the level of the CEJ, crossing
the middle portion of the papillae
without reaching the neighboring
gingival margins. These releasing
incisions were carried out across the
MGJ, reaching the alveolar mucosa.
A partial thickness flap was raised,
and then the papillae adjacent to
the involved tooth were deepithe-
lialized using Castroviejo scissors
(G. Hartzell & Son) to create a con-
nective tissue bed to stabilize the
suturing of the graft and the coro-
nally advanced flap.
The exposed root surface was
planed with a McCall 13/14 curette
(Hu-Friedy) followed by finishing
burs (Komet), and citric acid gel
(pH 1, Nóbrega Farmácia de Manip-
ulação) was applied for 3 minutes.
The surface was then washed for 45
seconds with a physiologic solution
(Farmax).
411
Fig 3  Connective tissue graft after removal
of the epithelium.
The recipient site was measured
using a periodontal probe (Hu-
Friedy), and these measurements
were transferred to the donor site. A
connective tissue graft was harvest-
ed from an area distal to the canine
and anterior to the mesial aspect of
the first molar on the same side of
the surgery, using a Harris double-
blade scalpel (G. Hartzell & Son) with
a distance of 1 mm between the
blades. The epithelium present in
the graft was removed using a 15C
scalpel blade (Morton) (Fig 3). After
the graft was stabilized in the ap-
propriate position using a 6-0 vicryl
suture (Ethicon, Johnson & Johnson)
(Fig 4), the flap was coronally repo-
sitioned using a 5-0 vicryl suture
Volume 36, Number 3, 2016
412

Fig 4  Graft stabilized using a 6-0 vicryl Fig 5  Immediate postoperative view of the Fig 6  The same region, 6 months after
suture. region. surgery.

Table 1 Descriptive statistics of recession height Statistical analysis

measurements before and 6 months after surgery
Clinical data were grouped and de-
Initial recession Periodontal Recession after
Patient (mm) biotype 6 mo (mm) Coverage (%) scriptive statistics were expressed
 1 2.19 Thin 0 100 as mean ± standard deviation (SD).
 2 2.10 Thin 0 100 The differences between pre- and
 3 2.51 Thin 0 100 postoperative periods within each
 4 2.15 Thick 0.53 75.35 group were evaluated by Wilcoxon
 5 2.33 Thin 0.73 68.67 test. Mann-Whitney test was used to
 6 1.78 Thin 0 100 perform comparisons between the
 7 2.01 Thin 1.15 42.79
groups. Chi-square test was used to
 8 2.34 Thick 0 100
verify the association between peri-
 9 2.70 Thick 0 100
odontal biotype and the outcome
10 2.47 Thin 0 100
of the root coverage procedure. The
11 1.90 Thin 0 100
12 1.52 Thick 0 100 level of significance adopted was 5%.
13 1.95 Thin 0 100
14 2.29 Thick 0 100
15 2.66 Thick 0.87 67.29 Results
16 1.57 Thick 0 100
17 1.97 Thick 0 100 The tissue biotypes of 10 patients
18 2.88 Thin 0.76 73.61 were classified as thin, and 9 were
19 1.79 Thick 0 100 classified as thick. After 6 months, a
GR = gingival recession. mean root coverage of 90.93% was
observed (Fig 6). Complete root
(Ethicon) (Fig 5). The palate was then operative pain. Tooth brushing was coverage was achieved in 14 pa-
sutured with a continuous basting discontinued around the surgical tients (73.7%), 7 with thin biotypes
suture using 4-0 silk (Ethicon). sites for 3 weeks and the sutures were and 7 with thick. The mean cover-
removed after 7 days. During this pe- age achieved by the thin biotype
riod, plaque control was provided by was 88.51%, and the mean coverage
Postoperative care rinsing with a 0.12% chlorhexidine achieved by the thick biotype was
solution (Lacer) twice a day. After 93.63% (Table 1). Complete cover-
Patients were prescribed an analge- the 3-week period, patients were age was accomplished in 77.8% of
sic medication (750 mg paracetamol, instructed to use an end-tufted patients with a thick biotype, com-
Medley) to be used in case of post- toothbrush (Bitufo) to clean the site. pared with 70.0% of patients with the

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 413

thin biotype, which showed no statis-

Table 2 Patients submitted to surgery by periodontal biotype,
tical significance (P = .7) (Table 2).
according to recession height after 6 mo
The rates of recession height
Periodontal biotype
coverage at 6 months were simi-
Total Thin Thick
lar in the two groups, and all other
Recession height after 6 mo n (%) n (%) n (%)
evaluated clinical parameters pre-
Recession = 0 (complete coverage) 14 73.7 7 70.0 7 77.8
sented no significant differences
Recession > 0 (partial coverage) 5 26.3 3 30.0 2 22.2
between the groups (Table 3). Total 19 100.0 10 100.0 9 100.0
P = .701.

Discussion
Table 3 Clinical parameters (mean ± standard error) at
baseline and 6 mo after surgery, according to
Gingival recession is the oral expo-
periodontal biotype
sure of root surface due to a dis-
Periodontal biotype Difference
placement of the gingival margin
Parameter Thin Thick (Thin–thick)
apical to the CEJ. Reports from
Recession height
diverse epidemiologic surveys re-  Baseline 2.21 ± 0.11 2.16 ± 0.14 0.05 ± 0.17
vealed that gingival recession may   6 mo 0.26 ± 0.14 0.16 ± 0.11 0.10 ± 0.18
affect most of the adult population.  Difference 1.95 ± 0.15* 1.95 ± 0.14* 0.00 ± 0.20
Anatomy, chronic trauma, periodon- Recession width
 Baseline 3.84 ± 0.19 3.57 ± 0.14 0.27 ± 0.23
titis, and tooth alignment are the   6 mo 0.77 ± 0.40 0.54 ± 0.37 0.23 ± 0.55
main factors in the development  Difference 3.08 ± 0.48* 2.99 ± 0.33* 0.09 ± 0.60
of these defects. Recession is also Gingival strip width
 Baseline 1.93 ± 0.46 2.60 ± 0.30 −0.67 ± 0.55
regularly linked to deterioration of
  6 mo 2.53 ± 0.30 3.12 ± 0.29 −0.59 ± 0.41
dental esthetics and buccal cervical  Difference −0.60 ± 0.42 −0.66 ± 0.36 0.06 ± 0.56
dentin hypersensitivity.17 Gingival thickness (mesial)
The main goal of periodontal  Baseline 1.78 ± 0.23 1.68 ± 0.23 0.10 ± 0.34
  6 mo 1.63 ± 0.13 1.63 ± 0.22 0.00 ± 0.21
therapy is to improve periodontal  Difference 0.15 ± 0.30 −0.09 ±0.35 0.24 ± 0.46
health and thereby to maintain a pa- Gingival thickness (distal)
tient’s functional dentition through-  Baseline 1.76 ± 0.19 1.84 ± 0.26 −0.08 ± 0.29
out his/her life. However, esthetics   6 mo 1.78 ± 0.16 1.80 ± 0.25 −0.02 ± 0.26
 Difference −0.02 ± 0.31 −0.02 ± 0.43 0.00 ± 0.51
are an inseparable part of oral ther-
Probing depth
apy, and several procedures have  Baseline 1.30 ± 0.15 1.33 ± 0.24 −0.03 ± 0.27
been proposed to preserve or en-   6 mo 1.80 ± 0.13 1.22 ± 0.15 0.58 ± 0.20**
hance patient esthetics.19  Difference −0.50 ± 0.17* 0.11 ± 0.31 −0.61 ± 0.34
Clinical attachment level
Some authors have found no
 Baseline 3.20 ± 0.25 3.67 ± 0.17 −0.47 ± 0.29
relationship between hypersensitiv-   6 mo 2.20 ± 0.20 1.56 ± 0.24 0.64 ± 0.31
ity and recession depth27; this lack of  Difference 1.00 ± 0.33* 2.11 ± 0.26* −1.11 ± 0.43**
association is consistent with clinical   *Comparisons within groups (Wilcoxon test) with P < .05.
**Comparisons between groups (Mann-Whitney test) with P < .05.
observations that show that shallow
recessions are sometimes associ-
ated with marked hypersensitivity, of sensitive teeth (708 of 782) had similar to the average recession of
whereas deep recessions may not some associated buccal gingival 2.16 mm found in the present study.
be associated with any hypersensi- recession, the majority (87%) in the According to the Miller classifi-
tivity. Another study found that 91% range of 1 to 3 mm.28 This range is cation system, complete coverage is

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414
more predictable in sites where there
is no bone or soft tissue loss in the
interdental area (Classes I and II).3 In
the present study, only patients with
Miller Class I or II were selected. The
results of this study (mean root cov-
erage of 90.93% and percentage of
complete coverage of 73.70%) were
in agreement with those presented
by Chambrone and Chambrone,15
who found a mean root coverage of
96.00% and a percentage of com-
plete coverage of 71.00% 6 months
after surgery, and with Bittencourt et
al,16 who found a mean root coverage
of 96.10% and a percentage of com-
plete coverage of 76.47%.
Moriyama et al verified that a flap
thickness of ≥ 1 mm was associated
with 100% coverage when evaluating
the use of an enamel matrix deriva-
tive.20 Other studies have affirmed
that flap thicknesses < 1 mm had
a negative influence on obtaining
complete coverage in procedures
that involved coronally advanced
flaps.14,16,20 A systematic review on the
influence of flap thickness on obtain-
ing better root coverage using dif-
ferent techniques (connective tissue
graft, guided tissue regeneration,
and coronally advanced flaps) dem-
onstrated that flaps with a thickness
≥ 1.1 mm were positively correlated
to complete coverage of roots.21
On the other hand, Harris ob-
served that the success of root cov-
erage surgeries have no relationship
to flap thickness.24 In patients sub-
mitted to the double-papilla flap
technique, those who presented
thin gingiva (< 0.5 mm) obtained a
mean root coverage of 100%, and
patients with thick gingiva obtained
a mean root coverage of 95.9%. As
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an exception, when guided tissue re-
generation was used with the aid of
membranes, the flaps considered the
thinnest presented significantly low-
er root coverage rates in comparison
with patients with thick flaps.24 Baldi
et al observed that, 3 months after
surgery using a coronally advanced
flap, patients who had a flap thick-
ness ≥ 0.8 mm presented complete
coverage of their gingival recession.
Patients who had a flap thickness of
< 0.8 mm presented partial coverage
of their gingival recession.23 Howev-
er, the technique used by the authors
was not performed with subepithelial
connective tissue.23
Studies have demonstrated that
the use of subepithelial connective
tissue graft increased the gingival
thickness in the operated regions,
even 6 months after surgery.13,16 Ad-
ditionally, root coverage using sub-
epithelial connective tissue grafting
was shown to be superior and more
predictable than coronally posi-
tioned flaps alone.14,18,19 The present
results, grouped by gingival biotype
instead of flap thickness, are in ac-
cordance with the general rule that
complete root coverage is associ-
ated with flap thickness.21 These re-
sults suggest that a comprehensive
clinical evaluation of the quality of
the soft tissue and underlying bone
are helpful for decision making.
For clinicians, gingival biotype
determination will add parameters
to the visual assessment of soft tis-
sue and corroborate with alterna-
tive methods of tissue dimension
assessment such as transgingival
probing under anesthesia or evalu-
ation of the probe shining through
the buccal aspect of the gingiva.5
Bittencourt et al pointed out
that the main predictor of success
in root coverage is the position of
the gingival margin in relation to the
CEJ early after surgery, and indirect-
ly, to the recession height, as ob-
served in the present study.16 Nieri
et al asserted that complete root
coverage seems to be influenced by
the postsurgical position of the gin-
gival margin and, indirectly, by the
baseline recession depth.27
Complete root coverage is the
ultimate clinical outcome expected
after treatment of recession-type
defects by means of root cover-
age procedures. Commonly, the
achievement of such an outcome
will lead to not only an esthetic
correction but a functional treat-
ment (ie, resolution/decrease of
tactile and thermal hypersensitivity
and prevention of root abrasion) as
well.29 Several studies have shown
that better results in terms of per-
centages of complete and mean
root coverage can be expected
when baseline recession defects
are < 4 mm.17,27,29 It was found that
the greater the baseline recession,
the smaller the chance of achieving
complete root coverage.29
Considering that only shallow,
localized Miller Class I or II gingi-
val recessions were treated in this
study and the chosen surgical ap-
proach has shown clinical evidence
of predictable results,14,18,19 it is rea-
sonable that the observed root cov-
erage rates were similar between
groups independent of the gingival
biotype. To circumvent this posi-
tive bias, more studies should be
performed in a more challenging
clinical situation using recessions >

3 mm to evaluate the influence of
periodontal biotype. Nevertheless,
any attempt to treat more challeng-
ing recession lesions will need to
overcome not only gingival biotype
features but also periodontal tissue
loss at the interproximal area and a
limited prognosis.
Indeed, the present results have
shown that although there are clini-
cal concerns about the effect of thin
gingival biotype on root coverage
success rates, it seems to be less
critical when the root coverage sur-
gical procedure is associated with
connective tissue graft.
Conclusions
Gingival thickness does not appear
to exert a significant influence on
the root coverage of shallow, local-
ized Miller Class I or II gingival re-
cessions. The assessment of tissue
biotype might serve as an additional
parameter for decision making re-
garding which surgical approach is
best. Further studies must be con-
ducted to confirm this result, as only
sites that presented Class I and II re-
cessions of ≤ 3 mm were evaluated
in the present study.
Acknowledgments
This study was financially supported by
FAPERJ (Fundação de Amparo à Pesquisa
do Estado do Rio de Janeiro / Rio de Janeiro
Foundation for Research Support) Process
Number E-26/171.238/2006. The authors
state that there is no conflict of interest what-
soever with regard to this article.
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Volume 36, Number 3, 2016