Complications and Treatment Errors in Root Coverag

Received: 30 April 2022 | Revised: 8 July 2022 | Accepted: 26 July 2022
DOI: 10.1111/prd.12468
REVIEW ARTICLE
Complications and treatment errors in root coverage

procedures
Claudio Mazzotti1 | Ilham Mounssif1 | Alexandra Rendón1 | Monica Mele1 |

Matteo Sangiorgi1 | Martina Stefanini1 | Giovanni Zucchelli1,2
1
Periodontology Unit, Department of Biomedical and Neuromotor Sciences, Bologna University, Bologna, Italy
2
Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, Michigan, USA
Correspondence
Ilham Mounssif, Department of Biomedical and Neuromotor Sciences, Bologna University, Via San Vitale 59, 40125 Bologna, Italy.
Email: ilham.mounssif2@unibo.it
1 | I NTRO D U C TI O N phases (presurgical, intrasurgical, and postsurgical) of root coverage

procedures and how to prevent and manage these issues.
Periodontal plastic surgery is a scientific term introduced to describe
a set of surgical procedures, including root coverage techniques.1
The latest consensus in periodontics2 pointed out the main indica- 2 | PR E S U RG I C A L PH A S E
tions for the treatment of gingival recession defects and the need
to bear in mind patient-centered outcomes when selecting a specific A comprehensive assessment of a patient's current health status,
surgical procedure. Esthetics, root hypersensitivity, oral hygiene im- history of the disease, and risk characteristics are essential for de-
provement, and carious/noncarious cervical lesions associated with termining the periodontal diagnosis and prognosis of the dentition
gingival recessions are considered the principal indications for the and crucial for the development of a logical treatment plan in order
treatment. 2 Over the years, several techniques have been proposed to achieve the desired results.10 The term treatment planning implies
to reach complete root coverage, meaning the gingival margin's complete knowledge of: the patient's requests, the precise diagno-
location is slightly coronal to the cemento–enamel junction with no sis, the etiology of the problems, the prognoses, and the possible
residual probing depth, together with no detectable inflammation management options to avoid/reduce treatment errors. Establishing
and a harmonic soft tissue and color integration.3 The coronally a comprehensive view of the problem(s) and patient compliance is
advanced flap (alone or combined with a connective tissue graft, mandatory before starting any treatment. In fact, even under the
enamel matrix derivative, and collagen matrix) and tunnel techniques best set of circumstances, the predetermined endpoints may not be
4–8
effectively pursue gingival recession resolution. By their nature, reached due to underestimation of risk factors or medical diseases
surgical procedures could be correlated to a risk of developing intra‑ that could interfere with the surgical treatment (Figure 1).
and postoperative complications, including pain, bleeding, swelling,
and infection, which are a matter of concern to the practitioner and
the patient.9 Furthermore, professional errors in treatment planning 2.1 | Dietary and herbal supplements consumption
and execution may contribute to the occurrence of complications
and side/adverse events, leading to a detrimental effect on the fore- Root coverage procedures, like any periodontal surgery, may be af-
seen treatment results. fected by systemic diseases, medication intake, and bad habits, po-
This review will focus on treatment errors, complications, or side/ tentially resulting in impaired wound healing and complications.11
adverse effects that may arise during the different therapeutical Treatment errors and complications in periodontal therapy in a
Claudio Mazzotti and Ilham Mounssif contributed equally.
[Correction added on August 10, 2023, after first online publication: The affiliation for the author Giovanni Zucchelli has been updated.]
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.
© 2023 The Authors. Periodontology 2000 published by John Wiley & Sons Ltd.
62 |
wileyonlinelibrary.com/journal/prd Periodontology 2000. 2023;92:62–89.
MAZZOTTI et al. | 63
F I G U R E 1 Presurgical phase
TA B L E 1 Bleeding effects of herbal

Interfering with
and dietary supplements
Antiplatelet Anticoagulant Antiplatelet and blood clotting by
properties properties anticoagulant properties other mechanisms
Aloe Chamomile Dong quai Coenzyme Q10

Cranberry Fenugreek Evening primrose Flaxseed
Feverfew Red clover Ginseng Grapefruit
Garlic Vitamin E Green tea
Ginger Oregano
Ginkgo Saw palmetto
Glucosamine
Lycopene
Magnesium
Meadowsweet
Omega-3 fish oil
Selenium
Turmeric
Vitamin A complex
White willow
medically compromised patient will be discussed in Cho et al's12 re- effects mainly correlated with the level of sedation and bleeding
view in this volume. tendencies. It has been reported that some herbal medicines22 and
Regarding systemically healthy patients, we would like to draw at- nutrients23 included in the dietary supplements have been shown to
tention to a topic that has been taken into account in general surgery possess the potential to interfere with blood clotting, leading to risk
but scarcely investigated in dentistry: dietary and herbal supplement of excessive intra‑ and postoperative bleeding (Table 1).
consumption. The US Food and Drug Administration13 defined dietary In light of these issues correlated with dietary and herbal supple-
and herbal supplement as a product taken orally that contains a “di- ments, the American Society of Anesthesiologists and the American
etary ingredient” intended to supplement the diet. Dietary and herbal Academy of Orthopedic Surgeons has introduced recommenda-
supplements do not need a medical prescription and are poorly reg- tions to discontinue the intake of specific herbal products for up to
ulated; these factors have created a positive environment for growth 2 weeks before surgery for all patients requiring surgery. 24 Although
14
in the market, and their consumption is increasing globally. Because this approach could be considered excessive, the lack of knowledge
these popular products contain “natural” ingredients, most con- regarding the identity, concentration, and pharmacokinetics of the
sumers perceive them to be safe. However, there is rising evidence active principles in most dietary and herbal supplements justifies
of health risks associated with these remedies in the perioperative a restrictive policy because of the risks and benefits that may be
population.15–17 Several papers16,18–21 have documented interaction involved. 25
64 | MAZZOTTI et al.
Like in other medical-surgical branches, more awareness should In the literature, two main classification systems of gingival
be promoted in surgical dentistry in order to predict the potential recessions are available28,29 for prognostic evaluation of root cov-
risk of bleeding in dental patients consuming dietary and herbal erage. According to said classifications, Miller class I/II and RT1 re-
supplements. This is especially true whenever there is concomitant cessions are expected to achieve complete root coverage outcomes,
administration of blood-thinning or analgesic drugs, such as certain whereas in Miller class III/RT2 and Miller class IV/RT3 only partial
nonsteroidal anti-inflammatory drugs (eg, ibuprofen) prescribed for and no root coverage can be accomplished, respectively. Still, it may
pain relief. 22 Therefore, clinicians' and patients' acquisition of im- be possible to improve the limited root coverage outcomes if the
proved knowledge about dietary and herbal supplements, recording factors affecting maximum root coverage are appropriately evalu-
their use in the patient medical history, and evaluating discontinuing ated and modified; that is, loss of interdental papilla height, presence
the consumption during the perioperative period may predict and of tooth rotation, buccal malposition, tooth extrusion (with or with-
prevent bleeding complications. out occlusal abrasion), and a cervical abrasion defects.30,31 Taking
this into account, a method has been proposed to predetermine the
maximum level of root coverage: by calculating the ideal vertical di-
2.2 | Diagnostic and prognostic errors mension of the interdental papillae of the tooth with the recession
defect, it is possible to predetermine the position of soft tissue mar-
The principal elements that lead to treatment errors are associated gin after root coverage surgery,30,32 allowing the identification and
with an incorrect diagnosis, nonidentification of the etiology, and reshaping (with composite restoration) of a new “clinical” cemento–
lack of knowledge in terms of prognosis of gingival recession treat- enamel junction whenever the anatomic cemento–enamel junction
ment. Gingival recession is defined as displacement of the soft-tissue is no longer clinically visible or when the ideal conditions to obtain
margin apical to the cemento–enamel junction. 26 The first mistake complete root coverage are not present (Figure 3). Furthermore, it
is strictly correlated to the definition itself: in order to diagnose a is crucial to identify the need to modify the soft tissue phenotype
gingival recession, the cemento–enamel junction must be identified on a case-by-case basis and for each individual tooth being treated
and the root surface exposed to the oral cavity. Clinically, gingival in cases of multiple adjacent recessions in order to achieve the ex-
recession determines an elongated appearance of the affected tooth pected root coverage and to ensure the stability of the results over
when compared with the adjacent teeth. A similar condition that time.33,34
may mislead an inexperienced practitioner into diagnosing a gingival In addition to the soft tissue assessment, it is mandatory to also
recession is when the teeth adjacent to the “elongated tooth” are af- take into consideration hard tissue discrepancies (ie, noncarious cer-
fected by the altered passive eruption (Figure 2). The latter is a clini- vical lesions) associated with gingival recession defects.35 Pini-Prato
cal situation in which the relationship between teeth, alveolar bone, et al36 introduced a classification system of dental surface defects
and soft tissues produces an excessive gingival display, resulting in in areas of gingival recession, based on the presence (A) or absence
apparently short clinical crowns. 27 Therefore, in the said scenario, (B) of identifiable cemento–enamel junction and presence (+) or ab-
the “elongated tooth” is actually a healthy tooth with a physiologic sence (−) of dental surface discrepancy caused by abrasion (step),
relationship between soft tissue margin location and cemento– thus resulting in four classes: A+, A−, B+, and B−. After having evalu-
enamel junction. For this reason, clinicians must have full knowl- ated 1010 exposed root surfaces associated with gingival recessions,
edge of altered passive eruption and its clinical and radiographical they found that 14% belonged in Class A+, 46% in Class A−, 24% in
diagnosis. 27 Class B+, and 15% in Class B−.
A B
F I G U R E 2 A, Misdiagnosis of gingival
recession in the presence of an “elongated
tooth” (left maxillary central incisor)
adjacent to a “short” tooth affected by the
altered passive eruption (right maxillary
central incisor). B, Tooth profile shows
a physiological crown length without
evidence of cemento–enamel junction or
root exposure, which are prerequisites for
diagnosing gingival recessions.
According to the mentioned study, approximately 50% of gingival factor contributing to the development of gingival recessions.40–4 4
recession defects presented in association with root surface lesions, Recent systematic reviews44,45 pointed to an association between
37
typically in the form of noncarious cervical lesions, therefore cre- toothbrushing and recession, although definitive evidence is lacking.
ating combined defects. This implies the need for specific treatment Among the most frequent factors associated with gingival recession,
protocols38,39 that include a mixed restorative-surgical approach in duration and frequency of toothbrushing, brushing force, frequency
order to achieve the desired outcomes in terms of root coverage of toothbrush renewal, bristle hardness, and toothbrushing tech-
and esthetics. In this respect, Zucchelli et al39 presented a decision- nique (horizontal or scrub method) were identified. Hence, during
making process for treating noncarious cervical lesions associated the examination phase, efforts should be concentrated on detecting
with gingival recessions based on the topographic relationship be- bad toothbrushing habits and on their modification through motiva-
tween the level of maximum root coverage and the extent of the non- tion and proper oral hygiene instructions. It has also been suggested
carious cervical lesions (Figure 4). The comprehensive assessment of that soft tissue inflammation plays a role in gingival recession devel-
the maximum root coverage achievable for every single case and the opment, especially at sites with a thin periodontal phenotype and
restoration of associated noncarious cervical lesions can prevent the difficulty in home oral hygiene.43,46,47 Moreover, as happens with
occurrence of incomplete root coverage, unaesthetic appearance other periodontal surgical procedures, poor oral hygiene is a factor
(for patients and clinicians), and inadequate emergence profiles that that negatively affects the success of root coverage techniques.48
39
would inevitably hinder proper oral hygiene practices (Figure 5). Smoking is a patient-related factor that can influence the wound
healing process due to the alteration of gingival tissue vasculariza-
tion, immune and inflammatory responses, and healing potential of
2.3 | Bad habits evaluation the periodontal connective tissues.49,50 Scientific evidence showed
that smokers might benefit from root coverage procedures since no
Bad patient habits that could affect the outcome of root cover- difference in root coverage outcomes has been reported between
age procedures should also be identified during the presurgical smokers and nonsmokers when coronally advanced flap alone was
evaluation. Particular attention should be paid when evaluating adopted for recession treatment.6 However, a recent meta-analysis6
toothbrushing habits and identifying smokers. An “improper” tooth- found that subepithelial connective tissue graft–based techniques
brushing method has been proposed as the most critical mechanical do not provide the same treatment effect as that achieved in
A B
F I G U R E 3 A, Gingival recessions and noncarious cervical lesions affecting the mandibular incisors. The presence of reduced height
of interdental papillae decreases the chance to achieve a complete root coverage, and for this reason the “new clinical cemento–enamel
junction” should compensate the interdental soft tissue loss. B, Clinical situation after 3 mo revealing the perfect root coverage and soft
tissue integration thanks to a combination of restorative approach (treatment of noncarious cervical lesions reshaping the clinical cemento–
enamel junction) and coronally advanced flap plus connective tissue graft
F I G U R E 4 Decision-making process for treating noncarious cervical lesions associated with gingival recessions. The depth and location of
the noncarious cervical lesions together with the maximum root coverage achievable determine the proper approach (surgical, restorative-
surgical, or restorative approach). The chart has already been described by Zucchelli et al.39 Reproduced with permission from John Wiley
and Sons
A B C
D E F
G H I
F I G U R E 5 A, Multiple gingival recessions associated with noncarious cervical abrasions affecting maxillary teeth. B, Noncarious cervical
lesions have been restored using composite according to the evaluation of the maximum root coverage. C, D, Envelope coronally advanced
flap plus connective tissue graft for the treatment of multiple gingival recessions. E, Clinical photograph showing the postoperative situation
immediately after surgery. F, Clinical situation after 3 mo revealing a successful outcome in terms of root coverage and soft tissue integration.
G-I, Comparison between baseline situation (G), after the restoration of noncarious lesions (H) and the final outcome at 3 months (I)
F I G U R E 6 Intrasurgical phase. CTG,

connective tissue graft
nonsmokers, reporting an additional 17.5% of mean root coverage All of these considerations stress the importance of an accurate
and a superior number of sites achieving complete root coverage in medical examination and a diagnostic process that takes into ac-
nonsmokers (risk ratio 0.36) compared with smokers. count possible etiologic factors and evaluates the presence of bad
F I G U R E 7 A, Deep split-thickness
A B
incisions adequately made using the blade
parallel to the periosteum, sufficient
to separate muscle insertions from the
underlying bone. B, Performing the
“superficial” incision by positioning the
blade parallel to the external mucosal
surface and detaching muscle insertions
from the inner aspect of the flap. The
correct accomplishment of the previous
incisions avoids damaging greater
vessels located in the submucosal layer
and muscular structure, reducing the
occurrence of “excessive bleeding”
habits and to avoid treatment errors that may contribute to the oc- Regarding root coverage surgeries, uncontrolled excessive bleed-
currence of complications and side events with detrimental effects ing is unlikely and limited to cases of inappropriately performed har-
on the expected treatment outcome. vesting procedures (ie, greater palatine artery injury; see the chapter
about complications of palatal soft tissue harvesting by Tavelli et al55
in this volume). In spite of this, it is important to know how to reduce
3 | I NTR A S U RG I C A L PH A S E and handle intrasurgical bleeding.
The control of bleeding starts before the incision is made, with
The performance of root coverage procedures requires varying the injection of topical anesthetic agents for intraoperative pain
levels of proficiency regarding technical knowledge, practical skill, management combined with a vasoconstrictor in the surgical site.
and abilities in addition to professional experience. A clinician's lack Epinephrine is the one most commonly used;56 in healthy patients,
of theoretical knowledge and/or practical experience might repre- its maximum dose is 0.2 mg (11 carpules at a 1:100 000 concentra-
sent the most frequent source of accidental errors during the treat- tion).57 A decrease in gingival blood flow should be apparent within
ment; consequently, a less experienced operator is responsible for 5 minutes after epinephrine injection.58 For patients undergoing
a greater number of errors and complications during the surgical periodontal surgery, it has been shown that anesthetic formula-
procedure—which could alter the course of wound healing to some tions containing 4% articaine and epinephrine (either 1:100 000
extent (Figure 6). or 1:200 000) provided excellent intrasurgical pain control; the 4%
articaine and 1:100 000 epinephrine formulation had the additional
therapeutic advantage of providing better visualization of the surgi-
3.1 | Intraoperative hemorrhage cal field and less bleeding.53
An adequate presurgical examination of medical history (assump-
As happens with other periodontal techniques, intraoperative tion of anticoagulant medications, nonsteroidal anti-inflammatory
bleeding is commonly associated with root coverage procedures drugs, and dietary and herbal supplements) might help to reduce
and requires proper management, especially when it appears ex- unexpected intraoperative bleeding. However, despite a favorable
cessive and uncontrolled (primary hemorrhage). The question is, medical history, increased bleeding can also result from errors made
what does “excessive bleeding” mean? To the best of our knowl- when carrying out flap incisions. For this reason, it is essential to
edge, no studies have reported on the incidence of “excessive” perform the split-thickness incisions adequately: A limited “deep”
intraoperative bleeding or given threshold values to describe incision is made, using the blade parallel to the periosteum, to sep-
it. Few studies have investigated the amount of blood loss dur- arate muscle insertions from the underlying bone just enough to
ing periodontal surgery (open flap debridement and regenerative allow performing the “superficial” incision by positioning the blade
techniques); those that did have reported a range from 0.5 mL up parallel to the external mucosal surface and thus detaching mus-
to 145.1 mL of blood loss, influenced by the preoperative intake cle insertions from the inner aspect of the flap. The latter incision
of nonsteroidal inflammatory drugs and the epinephrine concen- terminates when the flap's coronal mobilization is considered “ad-
51–5 4
tration in the local anesthetic. The reported volumes would equate,” meaning the flap's marginal portion can passively reach
point out that blood loss during periodontal surgical procedures a level coronal to the cemento–enamel junction59 (Figure 7). The
is relatively minimal compared with other procedures in general correct execution of the previous incisions avoids damaging larger
surgery. 54 vessels located in the submucosal layer and the muscular structure.
It is crucial to perform the split-thickness incisions at the beginning needle (ie, 7.0 suture, 8 mm cutting needle, 3/8 circle) to avoid fur-
of the surgery (immediately after full-thickness flap elevation), and ther damage to the soft tissues. Also, if the placement of a connec-
afterwards bleeding is controlled (even if particularly intense) by tive tissue graft was not initially considered, it is essential to include
keeping a gauze in place to protect the flap until the time of the it whenever the perforation is located on the root surface in order
suture. If, on the contrary, this surgical step is performed towards to avoid undesirable results. Moreover, even though it has been
the end of the procedure, delayed bleeding may appear after flap shown that small (4 mm height) and thin (<1 mm) connective tissue
closure or even after patient discharge (reactionary hemorrhage grafts are effective for achieving complete root coverage,62 in case
that occurs within 24 hours). Intraoperative hemostasis is achieved of perforation the use of a connective tissue graft of larger size and
by applying pressure to the surgical site for 3-5 minutes with a gauze greater thickness (at least 1 mm but <2 mm) is highly recommended
60
dressing, either dry or soaked in hemostatic agents. Among these, (Figure 11). A closure of flap perforation should be accomplished at
tranexamic acid is one of the most frequently used and it works by the end of the surgery in order to reduce tension at the level of the
inhibiting plasminogen action and reduces the fibrinolytic activity of flap margin and the consequent risk of perforation opening.
the early formed hemostatic clot. Despite being widely used, topical
application of tranexamic acid (irrigation, soaked gauze), still lacks
evidence for efficacy in the control of intra‑ and postoperative hem- 3.3 | Nerve injuries
orrhage.60 Alternatively, tranexamic acid injection can be used as a
hemostatic measure both intra‑ and postoperatively. When given Owing to their anatomical location, there are two nerve structures
preoperatively, a vial of tranexamic acid has been shown to signifi- of interest when treating gingival recessions: the infraorbital nerve
cantly reduce the total blood loss during maxillary surgery.61 and the mental nerve. The emergence of the infraorbital nerve is
well beyond the area of deep dissection if the coronally advanced
flap is performed adequately. Therefore, setting aside individual an-
3.2 | Flap perforation atomical variations, injuries to the former are fairly rare in the con-
text of mucogingival surgery.
Adequate management of the primary flap in root coverage pro- However, during the treatment of the canine-premolar area in
cedures is fundamental in order to achieve the expected results. the mandibular arch, there is a latent risk of injuring the mental nerve.
Among the technical errors that can be committed during soft tis- When dealing with deep gingival recessions in the aforementioned
sue manipulation, the most relevant mistake is flap perforation; that area, the operator should try to assess the location or proximity of
is, direct injury to the integrity and vascularization of the soft tis- the mental foramen with a periapical radiograph preoperatively.
sues resulting clinically in an “opening” within the flap extension. It During the surgery, deep periosteal releasing incisions should be
is more likely to appear when performing the split-thickness inci- avoided; instead, the initial flap release can be performed by com-
sions: during the “deep” split-thickness, if the blade is not maintained pressing the flap with a gauze in an apical direction (Figure 12A).
parallel and in contact with the bone while detaching muscular in- With this technique, muscle fibers are released, allowing an easier
sertions from the periosteum; and also, at the time of “superficial” distinction and separation between the deep plane (in which the
split-thickness, if the blade is not kept sufficiently parallel to the fibers are inserted into the periosteum) and the superficial plane
external flap surface while separating the muscle fibers from the (characterized by the insertion of the fibers into the inner aspect of
inner aspect of the flap. In the latter surgical step, the presence of the flap) (Figure 12B,C). Afterward, superficial split-thickness dissec-
scars as a result of previous surgeries can cause mucosal adhesions tion of the flap will ensure that the clinician does not encounter or
that might further increase the risk of perforation. Flap perforation sever main or accessory nerve fibers.
compromises its blood supply, leading to necrosis and affecting root
coverage outcomes as well as the integration and survival of the un-
derlying connective tissue graft, when applied (Figure 8). Therefore, 4 | P OS T S U RG I C A L PH A S E
this complication should be properly managed during the surgical
phase. First, it is essential to overcome the perforation with a full- Root coverage procedures are associated with patient morbidity,
thickness approach using an elevator carefully and gently; then, it is defined as a condition of being diseased26 due to the risk of postop-
possible to proceed with flap mobilization apical to the perforation erative complications in the first 2 weeks after surgery, which rep-
in a split-thickness manner without increasing its dimensions. This resents a matter of concern for both clinicians and patients.9 The
reduces tension at the level of the perforation when the opening is most common early complications reported in the literature are pain,
small (ie, 1-2 mm) and located on top of a vascular bed (connective infection, swelling, bleeding, and hematoma formation.
tissue or periosteum); no sutures are needed (Figure 9) unless con- Curtis et al,63 in 1985, assessed pain and complications after dif-
tinuous bleeding is still present at the end of the surgery, jeopard- ferent periodontal surgeries, including free gingival grafts and pedicle
izing blood clot stability. If the perforation is greater than 2 mm or grafts. They showed that approximately 50% of the patients reported
lies on an avascular area (root surfaces) (Figure 10), it is mandatory to minimal or no postoperative pain, whereas 4.6% reported severe pain.
close it using simple interrupted sutures with a thin thread and small Notably, 94.5% of the patients had no (46.1%) or minimal (48.4%)
A B C
D E F
F I G U R E 8 A, Multiple gingival recessions affecting mandibular teeth. B, Modified envelope flap for multiple gingival recessions was
performed with the addition of connective tissue grafts. C, Clinical photograph showing the postoperative situation immediately after
suturing. Notice the presence of a perforation located apically to the cuspid. D, The perforation was closed with sutures using a small
needle and thread. E, Situation 2 wk after the intervention showing flap fenestration and necrosis of the underlying graft, even though the
perforation had been sutured. F, Close-up of the fenestration showing root exposure. G, Clinical situation after 3 mo revealing perfect root
coverage and soft tissue integration except for the cuspid, in which the flap perforation led to failure of root coverage, determining a worse
situation compared with the baseline
A B
F I G U R E 9 A, Envelope-t ype flap for multiple gingival recessions. The technique involves the tunnelization of the peripherical area
through split-thickness incisions, which reduces the risk of perforation. Notice in the circled area the small perforation done with the tip
of the blade. B, Clinical situation after 30 d showing excellent healing of tissues without any impact of the complication on the expected
outcome.
postoperative complications, such as bleeding, infection, swelling, or grafting procedures at 1 week. They found that pain and swelling
adverse tissue changes. Moreover, mucogingival surgery was consid- were the most significant complications, with 27%-4 0% of subjects
ered 3.5 times more painful than bone surgery. A positive correlation reporting moderate or severe pain and 19%-60% of them reporting
was found between duration and mucogingival surgery: the longer moderate to severe swelling.
the surgery, the greater the reported pain. For the said study, it can be A recent retrospective study65 evaluated the incidence and
speculated that the increased pain after mucogingival surgery might severity of complications following oral, periodontal, and implant
be due to the harvesting procedures commonly adopted in the 1980s. surgeries. A postoperative incidence ranging between 10% in the
Later on, Griffin et al64 evaluated the incidence of complications connective tissue graft procedures (usually only one complica-
after free soft tissue grafting or subepithelial connective tissue tion in 9.7% of patients) and 19.7% using the free gingival graft
A B C D E
F G
F I G U R E 1 0 A, Deep gingival recession affecting left maxillary cuspid with an adequate amount of residual keratinized tissue and gingival
thickness. The surgical plan included a triangular-shaped coronally advanced flap. B, A perforation was done in the middle part of the flap
in correspondence to the root surface, forcing a change in the surgical plan. C, A connective tissue graft was added in conjunction with the
coronally advanced flap in order to compensate for the occurrence of perforation. D, After the flap has been sutured, (E) the perforation
borders should be closed as much as possible with a small needle and fine thread to reduce the opening of this area during the postoperative
healing. F, After 2 wk, the clinical situation shows the loss of the sutures at the perforation with consequent exposure of the underlying
connective tissue graft. G, After 3 mo, the clinical situation reveals a circular area of healing with a different appearance in terms of color and
texture, which may represent an esthetic concern for the patient.
technique (usually only one complication in 19% of patients) was 4.1 | Early bleeding of primary site
reported. Moreover, 2.3% of patients who underwent connective
tissue graft procedures and 3.7% of those who underwent free A meager amount of bleeding might occur after root coverage
gingival graft techniques experienced adverse effects on the sur- procedures, especially if there are associated palatal harvesting
gery's success. Conversely, because of scarce evidence in terms techniques. 55 However, postoperative bleeding at the primary flap
66
of reported morbidity data, the recent Cochrane review by is an uncommon complication that may present merely as blood-
Chambrone et al 8 did not provide values regarding the incidence tinged saliva, or it may become a hemorrhage that continuously
of complications after root coverage procedures. They pointed out fills the oral cavity with blood or even cause the formation of a
that discomfort was mainly related to donor sites of subepithelial “liver” clot, which can alarm the patient. Typically, the process of
connective tissue grafts and most of the times it was experienced blood coagulation and fibrinolysis takes place after periodontal
within the first week after surgery with no influence on root cov- flap surgery. Immediately after vessel injury, platelets adhere to
erage outcomes. Similar findings have been published recently in the subendothelial tissues at the injury site, aggregating to form
a network meta-analysis:67 Connective tissue graft–b ased tech- the primary hemostatic plug. These platelets cause the activation
niques have proven to increase patient morbidity compared with of clotting factors, with the consequent formation of a fibrin clot
flap alone or the use of graft substitutes. Several complications, that reinforces platelet aggregation. 68 Hence, platelets are key
deriving from or unrelated to treatment errors, may be identified players in hemostasis. An insufficient number of platelets results
during the early and delayed postoperative stages after root cov- in blood clotting disorders, leading to bloody discharge from peri-
erage procedures (Figure 13) odontal wounds.
A B C D
E F
F I G U R E 1 1 A, Deep gingival recession affecting the mesial root of this left maxillary first molar. This tooth represents a challenging area
to be treated with root coverage procedures due to the presence of reduced visibility and strong muscular insertions from the cheek. B, A
perforation occurred during the split-thickness performance, creating (C) a large opening in the covering flap. D, In this case, the use of a
connective tissue graft had already been planned; however, the applied graft was larger and thicker than the standard dimensions adopted in
the literature. E, Clinical situation immediately after the intervention: the coronal advancement of the flap was achieved, and the perforation
was perfectly closed. F, After 6 mo of healing, the clinical situation shows satisfying results in terms of root coverage and soft-tissue
appearance.
A B C
F I G U R E 1 2 A-C , After full thickness flap elevation (A), the “gauze” technique (B) allows the release of muscle fibers, providing an easier
distinction and separation between the deep plane (yellow arrow), in which the fibers are inserted into periosteum, and the superficial plane
(green arrow) (C), characterized by the insertion of the fibers into the inner aspect of the flap
There are many causes for abnormal blood coagulation, such as teeth (Figure 14). Secondary hemorrhage (occurring 24 hours after
liver disease, renal insufficiency, fibrinolysis, disseminated intravas- surgery) might be attributed to several factors: intrinsic trauma (ie,
cular coagulopathy, leukemia, pharmaceutical agents, and genetic tongue, chewing, and intentionally pulling surrounding muscles),
disorders that involve deficiencies of various clotting factors.69,70 presence of foreign bodies, premature suture loss, or inadequate
If the patient presents with significant postsurgical hemorrhagic marginal stability of the flap (ie, due to errors during suturing tech-
sequelae, laboratory blood studies must be done to look into the nique and flap management) that may cause repeated, delayed or-
possible causes. ganization of blood coagulum. Furthermore, it has been reported
“Liver clot” or “currant jelly clot” describes a red, jelly-like clot that vasoconstrictors included in the local anesthetic (ie, epineph-
that is rich in hemoglobin from the erythrocytes within the clot; rine) may produce rebound vasodilatation after the vasoconstric-
it usually results from venous hemorrhage, characterized by slow, tion effect has worn off, leading to increased risk for bleeding in
71,72
oozing, dark blood hemorrhage. According to the literature, the immediate postoperative period. There is a greater potential
the “liver clot” formation generally occurs 24-4 8 hours after sur- for such undesirable delayed hemorrhage following the use of
gical procedures73–78 and it is usually located at the margin of the 1:80 000 epinephrine than after the use of 1:100 000 epineph-
flap, extending up to the crowns of the involved and neighboring rine.79 Following gentle removal of the “liver clot” with a sterile
F I G U R E 1 3 A, B Postsurgical phase
A B
F I G U R E 1 4 A, Clinical appearance of early bleeding at the level of the primary site called “currant jelly” or “liver” clot. B, Close-up A. The
clot is rich in hemoglobin from erythrocytes and is usually located along the margins of the flap extending up to the crowns of interest and
the neighboring teeth
gauze and saline irrigation, soft pressure is applied to the area of in place. In the case of premature suture loss, new sutures should
interest by interposing a gauze between the flap and lip/cheek, ei- be placed to achieve flap stability in the marginal area, thus pro-
ther dry or soaked with a hemostatic agent (ie, tranexamic acid), moting blood clot stabilization. The patient should be discharged
for about 5-10 minutes. The cause of bleeding should be estab- only once complete control of bleeding is achieved, and the im-
lished by interviewing the patient regarding traumatic episodes portance of compliance regarding postoperative behaviors should
and evaluating the periodontal wound to assess if the sutures are again be stressed.
4.2 | Pain according to patient-reported outcomes evaluated through visual

analog scale and oral health impact profile questionnaire (measuring
Pain is defined as “an unpleasant sensory and emotional experi- the influence of the surgical intervention on a patient's life).103 Trials
ence associated with actual or potential tissue damage or described focusing on the healing of palatal donor sites have concluded that
in terms of such damage,” which results in a highly subjective the mesiodistal size of the graft does not seem to be associated with
80
experience. postoperative pain, but that characteristics like the apicocoronal
Pain is a conscious experience: It is the interpretation of the dimensions and thickness of the graft may have more influence on
nociceptive input influenced by memories, emotional, pathologic, perceived pain.62,104 The proper understanding of pain intensity and
genetic, and cognitive factors. Resultant pain is not necessarily re- variables that affect soreness is essential because pain may produce
lated linearly to the nociceptive drive or input, and the behavioral emotional responses that could affect compliance.87 By providing
response by a subject to a painful event is modified according to adequate information about the level of pain after various surger-
what is appropriate or possible in any particular situation.81 Pain, ies and the associated factors influencing pain, clinicians will help
by its various nature, is difficult to assess, investigate, manage, and patients have realistic expectations of their surgical procedures, en-
treat. Some studies showed how a painful experience could occur hancing the dentist-patient rapport.105
82–85
without a primary nociceptive input, further complicating the Pain management after root coverage procedures is reason-
pain assessment, but perhaps providing an alternative explanation ably straightforward: It is usually achieved with nonsteroidal anti-
for how pain might arise in difficult clinical cases where the organic inflammatory drugs (ie, ibuprofen) immediately after the surgery and
cause is not obvious. recommended in the following days according to the patient's needs.
Concerning surgical periodontal therapy, it has been suggested
that pain perception by the patient is influenced by several factors
associated with his or her emotions, such as anxiety, previous experi- 4.3 | Swelling
86–92
ences, the anticipation of stress, and control of the environment.
Periodontal soft and hard tissue damage during surgical treatment Swelling is part of the body's repair process and is considered a nor-
and manipulation directly stimulates the nociceptor terminals in the mal reaction to surgery. Intra-oral surgical trauma always determines
peripheral tissue. It releases inflammatory cytokines and chemok- injury characterized by hyperemia, vasodilatation, and increased
ines, which are the major causes of early discomfort and delayed capillary permeability with liquid accumulation in the interstitial
wound healing after periodontal surgery.93,94 Pain perception might space. Edema is the expression of exudates or transudation, and it
be associated with surgical and surgeon-related factors, such as the is likely that both events occur in surgery. Swelling becomes appar-
complexity of the surgery, the experience of the surgeon, the dura- ent after the day following surgery and will reach its peak within
tion of the surgery, the extension of the surgical site, the amount of 2-3 days postoperatively, typically subsiding within 4-5 days106,107
anesthesia used, periosteal fenestration/ dissection, and the type of (Figure 15). In a practice-based evaluation of 500 patients consecu-
pain medication used following surgery.63,64,93,95 Patients reported tively treated with subepithelial connective tissue grafts, swelling
experiencing more pain, swelling, and bruising when the duration of incidence was very low (5.4%). None of the potential predictive fac-
96
the periodontal surgery was 60 minutes or longer. tors included in the analysis (ie, age, sex, smoking, the purpose of the
Pain perception is most commonly assessed using the visual ana-
log scale, which has long been considered a valid, reproducible, and
easy to use tool,95 was introduced for mucogingival surgery in the
2000s.97,98
The visual analog scale consists of a 10 cm line delimited by two
extremes of pain: “no pain” and “maximum pain.” Patients are asked
to mark along the line their perceived level of pain intensity, and the
scale is scored by measuring the distance from the “no pain” end to
the patient's mark. An additional indirect method proposed in the
literature to evaluate postoperative pain is the number of analgesic
pills taken by patients after root coverage surgery.99–101 Despite the
vast number of trials available in the literature dealing with gingival
recession treatment, data regarding pain is heterogeneous, and sev-
eral systematic reviews5,6,8,67,102 failed to produce a meta-analysis.
In root coverage procedures, a substantial amount of patient mor-
bidity is attributed to postoperative pain related to soft tissue har-
vesting from the palate.5,6,8,67,102 However, multicenter randomized F I G U R E 1 5 Swelling appearance 2 d after surgery for treatment
clinical trials have recently shown that the recipient site might also of multiple gingival recessions localized at the left side of the
be a significant contributor for pain assessment during early healing, maxillary arch.
graft, recipient site size, or defect location) were directly associated (Figure 16A) or even involve facial skin, in which case it represents
108
with this complication. On the other hand, the prospective study an esthetic concern for the patient (Figure 16B). However, to the
by Griffin et al64 reported a higher incidence of moderate and severe best of our knowledge, no evidence has been reported correlating
swelling when bilaminar procedures are performed in comparison the influence of bruise formation on wound healing. Therefore, no
with free soft tissue grafting techniques (31.6% vs 21.3%). They medical therapy is generally required, as a complete and spontane-
found that swelling occurrence was more likely in smokers (three ous resolution occurs in a few weeks.
times) than in nonsmokers, especially when bilaminar procedures
with autogenous grafts were adopted. Furthermore, lengthy proce-
dures were more likely to result in moderate or severe swelling when 4.5 | Flap dehiscence
64
autogenous tissue was used.
Cryotherapy (ie, ice packing) is largely applied empirically to The first 14 days after root coverage procedures are considered
manage postoperative swelling and discomfort. However, to our of paramount importance in terms of flap stability for success-
knowledge, no specific data for root coverage procedures have been ful wound healing.112 In this period, traumatic or inflammatory/
reported in the literature. In a literature review by Greenstein,109 infective injuries may represent a cause for its dislodgement.113,114
where seven studies were analyzed, only two trials showed that lo- Early flap dehiscence—defined as a condition in which two layers,
cally applied cold therapy after third-molar extractions might reduce previously stitched together, separate or rupture71—may appear as
postoperative swelling and pain, confirming the inconclusive data a complication during this time frame. This event usually leads to
and advocating more clinical trials to assess the additional benefit flap shrinkage, with severe consequences for the expected results in
of cold therapy. The time interval for cold applications varied in dif- terms of root coverage. In order to understand how to deal with such
ferent studies, but there seemed to be a consensus among clinicians undesirable outcomes, it is mandatory to know the potential factors
that cryotherapy should be applied for 10-20 minutes followed by a correlated with flap dehiscence.
rest period. The total duration of therapy ranged from 2 to 48 hours. The first key factor to take into consideration for avoiding or re-
In a recent meta-analysis, Marques do Nascimento-Júnior et al110 ducing the risk of flap dehiscence is the adequate management of
highlighted the lack of standardization of cold application or effec- flap tension. One of the main features of performing the coronally
tive evidence-based treatment protocols for cryotherapy after third- advanced flap is eliminating muscle tension on the flap and its pas-
molar surgery, concluding that cryotherapy may have a small benefit sive displacement in the coronal position.59 The final passive posi-
in reducing pain after third-molar surgery, but it is not effective on tion of the flap can be achieved through adequate split-thickness
facial swelling and trismus. (deep and superficial) flap management as previously reported and
In light of the foregoing, the intake of pain killers with an anti- described by de Sanctis and Zucchelli.59,115,116
inflammatory effect combined with cryotherapy in the immediate A split-m outh randomized trial for the treatment of single
postsurgical phase might help to control swelling and pain. gingival recessions117 reported that minimal residual flap tension
(0.4 g) does not affect the final outcome of coronally advanced
flap procedures; however, increasing flap tension (6.5 g) was as-
4.4 | Bruising sociated with reduced root coverage percentages. Similar findings
have been reported by Burkhardt and Lang,118 who revealed that
A bruise is defined as “an injury involving rupture of small blood ves- primary wound closure after 1 week of healing was achieved in
sels and discoloration without a break in the overlying skin.”111 It is 100% of the implant sites when flap tension was minimal (0.05 N);
not an uncommon postoperative sequela after root coverage proce- if more tension was applied to the wound margins, but still in a
dures, and it might appear at the level of the flap's external mucosa low range of 0.05-0 .10 N, a small proportion (10%) exhibited
A B
F I G U R E 1 6 A, Bruising appearance
localized at the level of the flap's external
mucosa after a root coverage procedure.
B, This can involve the facial skin,
representing an esthetic concern for the
patient.
wound dehiscence. When exceeding the 0.10 N tension limit, the In the vertical releasing incisions, single interrupted sutures are per-
118
incidence of dehiscences increased dramatically to 40%-100%. formed to achieve primary intention wound healing.59
Flap passivity is pivotal for coronally advanced flap procedures, Together with suturing techniques, the selection of microsurgi-
because placing tight sutures in order to overcome residual flap cal sutures has been shown to reduce the risk of tissue trauma. In
tension may cause strain on the vascular system, reducing ves- fact, choosing finer suture diameters (6‑0, 7‑0 sutures) leads, in case
119
sel patency and impairing neovascularization. An angiographic of excessive tension, to thread breakage rather than tissue dam-
study on humans supports the hypothesis that the best clinical age.125,126 Furthermore, it has been established in an angiographic
outcomes, in terms of root coverage, are achievable when the flap study127 that minimally invasive (microsurgical) techniques can
is passively adapted and sutured without tension over the exposed lead to less tissue trauma, since sharper and finer surgical blades,
120
root surface. If the flap is not completely released, residual ten- together with smaller suture material and magnification, might be
sion could favor a postoperative apical shift of the gingival margin responsible for reduced tissue impairment, decreasing vessel injury
during the early phase of healing.119 in the first 7 days; the less the trauma, the lower the chances of end-
The second crucial aspect for reducing/avoiding the risk of flap ing up with flap dehiscence. This microsurgical approach seemed to
dehiscence when performing a coronally advanced flap is the ap- affect root coverage outcomes as well; in fact, gingival recessions
propriate de-epithelialization of the anatomical papillae, removing treated with minimally invasive procedures reported better root
all the epithelium and leaving as much connective tissue as possible. coverage percentages at short‑ and long-term follow-ups.127
This is one of the most important surgical steps, given that the de- Occasionally, even if the flap has been adequately prepared (free
epithelialized anatomical papillae represent the most coronal con- from tension and competently sutured), flap dehiscence due to pre-
nective tissue bed for the anchorage of the surgical papillae, thus mature suture loss can still occur if there is excessive swelling or if
ensuring vascular exchange, the survival of the marginal aspect of the area is accidentally traumatized in the days immediately follow-
the flap, and improving blending (in terms of color and thickness) of ing the surgery.
59
the surgically treated area with respect to adjacent soft tissues. Particular care should be taken in the mandibular anterior area.
In order to reduce the risk of losing anatomical papilla height, As a matter of fact, gingival recessions affecting the anterior man-
de-epithelialization is undertaken in two steps using two different dibular zone are very challenging due to the peculiar anatomical
instruments. The first step is done with the insertion of the blade tip conditions, such as shallow vestibule, thin gingival tissues, frenum
into the connective tissue layer exposed by the incision/elevation pull, and minimal keratinized tissue, all of which contribute to the
of the split-thickness surgical papillae, keeping it parallel to the ex- lower percentages of root coverage reported in the literature for
ternal gingival surface. The process is continued with microsurgical said area.128,129 A randomized clinical trial has recently introduced
scissors, because they are the only ones capable of handling the tip a surgical modification of the coronally advanced flap that includes
of the papillae effectively. Microsurgical scissors can de-epithelialize removal of the submucosal tissue130 to reduce/delay early muscle
even particularly narrow papillae, providing greater accuracy in the reinsertion on the flap. In that study, better root coverage outcomes
removal of the whole epithelial layer.121 If some epithelium were to and lower flap shrinkage were reported for sites treated with this
be left at the level of the anatomical papillae, it might interfere with novel procedure.
the vascular exchange and determine premature flap dehiscence In case of early flap dehiscence, no intervention is recommended;
with a detrimental effect on the expected outcome. clinicians should wait for soft tissue healing and stabilization (at least
The last, but not the least, crucial aspect for reducing/avoid- 3-6 months) and then reevaluate the clinical results. Sometimes, the
ing the risk of flap dehiscence is optimal surgical stability, meaning occurrence of flap dehiscence does not necessarily turn into a com-
wound stability through an effective suturing technique. Regarding plete failure, especially when the procedure involves the adjunction
the coronally advanced flap, the main stabilizing sutures are the final of a connective tissue graft. In fact, in such cases, soft tissue heal-
sling sutures suspended around palatal/lingual cingula that fix the ing and maturation may determine the achievement of the expected
surgical papillae on top of the interdental connective tissue beds and outcomes (Figure 17). However, whenever the anticipated results
provide for a precise adaptation of the flap margins over the under- have not been achieved or do not satisfy patient expectations, a sec-
lying convexity of the crowns.59 Sling sutures, also called suspended ond surgical step might be necessary to solve the recurrence of the
sutures, are the most precise way to position a flap coronally be- gingival recession (Figure 18).
cause the flap is attached to a fixed anchor point (teeth) rather than
another movable flap.122,123 A recent cadaver study124 tried to com-
pare the influence of different suturing techniques (interrupted su- 4.6 | Graft/biomaterial exposure
tures, sling sutures, and sling and tag sutures) on the performance of
coronally advanced flaps, finding greater marginal flap stability using Root coverage procedures are performed mainly for esthetic rea-
sling and tag and sling sutures rather than interrupted sutures alone. sons, 2 with the ultimate goal of obtaining perfect soft tissue inte-
This tight marginal adaptation is essential for promoting wound heal- gration among the treated area and the adjacent teeth. With this in
ing and blood clot stabilization,112,114 underlining the importance of mind, the root coverage esthetic score3,131 was proposed in 2009
not having any blood seeping from the sulcus at the end of surgery. in order to record (from 0 to 10 points) the final esthetic outcome
A B F I G U R E 1 7 A, Clinical photograph
showing the postoperative situation
immediately after a root coverage
procedure with a coronally advanced flap
plus connective tissue graft. B, Situation
2 weeks after the intervention showing
flap dehiscence. C, Clinical view at 1 mo
revealing soft tissue improvement. In this
situation, clinicians should wait at least
C 3 mo before planning further surgeries in
the case of an unsatisfied patient
F I G U R E 1 8 A, Preoperative facial view

A B
of mandibular incisors affected by gingival
recessions treated with a coronally
advanced flap plus connective tissue
graft. B, Immediate postoperative view.
C, Clinical situation at the time of suture
removal (2 wk) showing flap dehiscence
with the consequent exposure of the
root surface of the two central incisors.
D, Although flap dehiscence occurred,
soft tissue integration and complete root
coverage were achieved after 3 mo.
C D
of root coverage procedures from a professional standpoint. This for this event include an unpleasant appearance due to lighter tissue
score considers the amount of root coverage achieved (6 out of the color and/or a different texture in comparison to neighboring soft
10 points) and other aspects correlated with soft-tissue appearance. tissues (Figure 19).
However, Kim et al132 have shown that the patient's perception of In order to avoid or minimize premature graft exposure, some
esthetics was not always consistent with professional scoring, since fundamental surgical steps have to be respected. Regarding the po-
patients are more attentive to soft tissue appearance (color and tex- sition of the graft, it should be secured at the level of the cemento–
ture) than the amount of root coverage. enamel junction or slightly apical to it,133 but never coronally. In terms
In light of the foregoing, in order to achieve “overall success” in of thickness and size, it has been shown that using “small” grafts al-
these kinds of surgical procedures, it is safe to say that the same lows for better esthetic outcomes and minimizes impingement on
level of importance should be given to both root coverage percent- the flow of blood supply from the underlying connective tissue bed
age and soft tissue integration.66 The combination of a coronally to the coronally advanced covering flap.62,133 Consequently, less
advanced flap and a connective tissue graft is considered the gold early flap shrinkage has been reported by reducing the graft dimen-
standard for achieving the best root coverage. However, one of the sions. Another aspect is flap suture: Flap margins should be posi-
main complications with this technique is graft exposure during the tioned 1-2 mm coronal to the cemento–enamel junction134 to obtain
postoperative period. This might occur prematurely (within the first greater root coverage percentages and to avoid graft exposure by
1-2 months after the surgery) or be delayed. Undesirable sequelae compensating for the physiologic postoperative flap shrinkage. It
should also be noted that graft exposure and early flap dehiscence demands due to the altered appearance of the treated soft tissues
are strictly correlated, and all the recommendations expressed in the (ie, different color and/or texture).
corresponding section should be kept in mind. In the aforementioned scenarios, surgical reinterventions (such
Concerning delayed graft exposure, it might be possible to ob- as gingivoplasty, removal of the exposed part, and performance of
serve it after 9-12 months from the surgery. It is possible to spec- a second root coverage surgery) are the only viable options to solve
ulate that, despite a well-performed surgery and excellent healing, the patient's esthetic concerns (Figure 21). The gingivoplasty, which
the quality of the connective tissue harvested from the palate reduces the volume and may improve tissue texture, does not repre-
may determine a continued maturation of the graft under the flap, sent a definitive solution because the soft tissue white appearance
eventually leading to its exposure (Figure 20). The occurrence of would remain. In the end, if the patient does not accept the final
this complication is a relevant event for patients with high esthetic esthetic outcome, a second root coverage procedure should be per-
formed, including complete removal of the connective tissue graft
exposure.
Recently, porcine-derived matrices have been introduced as
connective tissue substitutes in root coverage procedures, with
the ultimate goal to reduce postoperative morbidity by avoiding a
second surgical site. They are becoming quite popular among clini-
cians and patients, with encouraging results so far.135–138 Most of
these new biomaterials have been designed to be entirely covered
by a tension-free primary flap (submerged healing)138 and, because
of their expected resorption, they are usually used in bigger sizes
compared to those of the connective tissue graft. However, in the
case of matrix exposure during the postoperative period, contrary
to the connective tissue graft, it tends to resorb. Generally, there
are no consequences when the exposure involves the vertical re-
leasing incisions (Figure 22) but it can lead to partial root cover-
age in case of coronal exposure of the matrix. Therefore, patient
complaints regarding color or texture will not be an issue, but the
F I G U R E 1 9 Connective tissue graft exposure 3 months after recurrence of gingival recession can result in an unsatisfied patient,
surgery, resulting in an unesthetic and unpleasant appearance from in which case a second surgery should be performed to improve
both the patient's and clinician's standpoint the outcome.
A B C
D E F
F I G U R E 2 0 A, Multiple gingival recessions affecting left maxillary quadrant. B, C, Treatment with an envelope-t ype coronally advanced
flap in combination with site-specific adjunction of connective tissue grafts. D, Follow-up at 6 months reveals a successful root coverage
and optimal soft tissue blending. E, At the 12-month visit, however, the graft at the level of the first premolar became exposed, resulting in a
double marginal contour. F, Close-up of the exposed grafted tissue
A B C D
F I G U R E 2 1 A, Clinical presentation of a gingival recession defect on the maxillary right lateral incisor associated with radicular caries.
B, Clinical appearance 3 mo after the performance of coronally advanced flap plus connective tissue graft and provisional veneer delivery.
Notice the connective tissue graft exposure responsible for inadequate soft tissue integration with the adjacent tissues. C, Gingivoplasty
was performed using a bur to improve soft tissue texture and volume. D, Final situation after delivery of final veneer, showing an area of
lighter color than the adjacent tissues
A B C
D E F G
F I G U R E 2 2 A-C , Treatment of a mandibular gingival recession with the coronally advanced flap for single defects combined with the
use of collagen matrix. D, At 1 wk after the surgery, wound dehiscence along the vertical releasing incisions occurred with the consequent
exposure of the underlying collagen matrix. E, At 2 wk after the surgery, the clinical situation shows wound dehiscence improvement;
F, its complete resolution at 30 days. G, The follow-up at 6 months reveals a successful outcome regarding root coverage and soft tissue
integration. Reproduced with permission from Springer Nature Clin Oral Investig 2020:24: 3181-3191
4.7 | Scars/keloid-like formations Scar tissue is characterized by excessive accumulation of disor-

derly arranged collagen (mostly type I and III), proteoglycans, and
Scars and keloid-like formations resulting from root coverage pro- persistent myofibroblasts, which leads to aberrant function of the
cedures may become esthetic concerns. They can happen along tissues.139 Compared with the healing of skin wounds, the oral mu-
the flap incisions or around suture sites, determining a localized cosa is less prone to scar formation owing to its different inflamma-
formation with a texture and color that differs from the adjacent tory cell infiltrate with lower levels of macrophages, neutrophils,
soft tissues. Depending on the treated area, these alterations could and T-cell infiltration and a lower level of the pro-f ibrotic cytokine
become visible during smiling, affecting the treatment outcome and transforming growth factor beta 1.140–142 Clinical observations
compromising esthetics (Figure 23). suggest that surgical wounds, especially in the oral keratinized
attached gingiva and palatal mucosa, heal with minimal scar for- plasma and subsequent revascularization from those parts of
143
mation. According to our clinical experience, incisions or sutures the graft resting on the connective tissue bed surrounding the
performed in alveolar mucosa can lead to scar formation. Sutures dehiscence.147,148 The establishment of collateral circulation
anchored to the underlying periosteum, if performed at the level from adjacent vascular borders of the bed allows the healing
of the alveolar mucosa, may lead to the formation of white and flat phenomenon of “bridging.”149 Hence, the amount of tissue that
scars. It has also been reported that increasing closing tension may can be maintained over the root surface is limited by the size of
lead to higher tensile strength on the tissues and, consequently, the avascular area,147,149 and the survival of the graft is strictly
104
to a stronger scar with increased collagen deposition. In root correlated to its thickness.150
coverage procedures including vertical releasing incisions, these • Second, the pedicle flap, when used by itself for root coverage
should be done as short as possible, avoiding placing them on buc- purposes, has to ensure its survival above the avascular root
cal root prominences and beveled so that the bone and periosteal surface, and it can also represent the second source of vascular-
tissues are not included in the superficial cut and thus do not par- ization for the underlying connective tissue graft when bilami-
ticipate in the healing process. By doing so, techniques requiring nar techniques are adopted. The healing in the area where the
vertical releasing incisions are less prone to result in unesthetic pedicle flap is in contact with the denuded root surface follows
scar formation144 (Figure 23). the four-s tage healing process introduced by Wilderman and
Whereas small, shallow wounds may result in flat scars, as pre- Wentz.151
viously mentioned, more extensive, deep wounds can lead to atro-
phic, hypertrophic, or keloid scars.143 The latter are defined as a When a small amount of blood flows to the tissue, necrosis may
growth of extra scar tissue that usually occurs where the skin has occur. This is defined as the death of body tissue that can derive
healed after an injury.145 Whereas keloid denotes skin lesions, the from injury, radiation, or chemicals, and it cannot be reversed.152 In
146
hyperplastic response is the designation for oral mucosa. In root root coverage procedures, tissue necrosis may involve the pedicle
coverage procedures, it may be possible to observe keloid-like flap, the connective tissue graft in bilaminar techniques, and the free
formation due to soft tissue hyperplastic response along vertical gingival graft. An inadequate flap design (reduced base of the pedicle
releasing incisions or periosteal incisions at the level of alveolar mu- flap) and/or thickness (too thin) may determine vascular distress and
cosa (ie, recipient bed for free gingival graft). Their characteristics a consequent tissue necrosis.
include a difference in volume, color, and texture compared with In the case of the bilaminar technique, early flap dehiscence,
the adjacent areas that may have a negative impact on the patient's by partial or complete necrosis of the flap, may affect the prema-
esthetic satisfaction. ture connective tissue graft exposure and its necrosis might occur
Overall, scars in the alveolar mucosa are seldom noticed by pa- (Figure 24).
tients or are considered acceptable, as they are located apically to When the free gingival graft is used for the purpose of root
the “pink” area exposed during a smile. However, the occurrence of coverage, the necrosis usually regards the central part above the
keloid-like formations deserves separate mention because it rep- avascular root surface, especially if the recipient bed, graft size
resents a challenging clinical situation to deal with from a surgical (dimension and thickness), and graft stabilization are inadequate
and psychologic standpoint. (Figure 25).
In order to avoid the occurrence of soft tissue necrosis, it is cru-
cial to respect the previously mentioned rules regarding flap/graft
4.8 | Flap/graft necrosis management. It is of paramount importance that adequate pedi-
cle flap design considers specific characteristics—such as surgical
One of the most important aspects of the success of root coverage papillae with appropriate dimension and thickness, vertical releas-
procedures is that, from a biological point of view, healing depends ing incisions parallel or slightly divergent, and proper flap thick-
on the interface between a flap or connective tissue/free gingival ness—to reach an overall suitable flap vascularization. Moreover, it
graft and a denuded avascular root surface. The survival of the soft seems that adrenergic vasoconstrictors included in the anesthetics
tissues positioned above the root, regardless of the technique em- may result in ischemic necrosis of surgical flaps (mainly if norepi-
ployed, is strictly correlated to two factors: nephrine is used instead of epinephrine) due to local ischemia with
subsequent tissue acidosis and accumulation of inflammatory me-
• First, the recipient bed (consisting of bone covered by connec- diators. Consequently, in root coverage procedures, the technique
tive tissue/periosteum) should, in the areas surrounding the re- of local anesthetics injections is also a matter of concern. It is ad-
cession defect, be wide enough to allow the invasion by cells visable to start the injection from the periphery of the flap at the
and blood vessels of the recipient bed as well as of the tissue mucogingival fold level to avoid soft tissue trauma due to needle
graft of the fibrin layer from which it is gradually replaced by penetration and to reduce the local ischemia due to the presence
connective tissue. In the case of a free soft tissue graft placed of a vasoconstrictor. In this manner, the anesthetic solution can
over a denuded root surface, healing depends on diffusion of reach the surgical area thanks to the diffusion mechanism.
A B F I G U R E 2 3 Facial view of, A, a right

maxillary cuspid and, B, central incisor
treated with a coronally advanced
flap with vertical releasing incisions at
which scars/keloid-like formations are
noticeable.
A B C D
F I G U R E 2 4 A, Clinical appearance of gingival recessions at central mandibular incisors; B, treatment with coronally advanced flap in
conjunction with a connective tissue graft. C, At 1 wk after the surgery, the patient presented with flap necrosis. D, This ended up at 2 weeks
with deeper gingival recessions compared with baseline
A B C
D E F G
F I G U R E 2 5 A, Gingival recession affecting a central mandibular incisor. B, Free gingival graft procedure was adopted to solve the root
exposure and also to increase keratinized tissue at the level of the adjacent tooth. C, Clinical appearance after 14 days revealing the failure
of the treatment determining even worse gingival conditions. D-F, After 3 months of healing (D), a new surgery (E, F) was performed to fix
the previous situation using a coronally advanced flap plus connective tissue graft. G, The second surgery was uneventful, with a successful
outcome in terms of root coverage
Whenever soft tissue necrosis occurs, we suggest checking this 4.9 | Infection
complication by following up the healing for at least 3-6 months and
reevaluating the clinical situation for a second corrective surgery. Like any other periodontal procedure, the root coverage procedure
If necrosis is associated with swelling, pain, local lymphadenopathy, is performed in a contaminated setting: the oral cavity. Therefore, it
and pus emergence from the sulcus at the time of the occurrence, follows that wound infection could occur due to the oral environment
antibiotic prescription is recommended. per se or in conjunction with flap fixation and suturing techniques.142
Using a strict aseptic technique, syringe irrigation to remove bac- importance to also put patients who have undergone root coverage
teria during wound cleansing, removing possible foreign bodies, and procedures under periodic maintenance care in order to detect any
careful debridement of all teeth are prerequisites for proper surgical modifications at the subgingival level in a timely manner (Figure 26).
interventions.142,152 Performing rinses with 0.2% chlorhexidine diglu- We suggest a restorative-mucogingival approach165 to treat this
conate solution for 1 minute immediately prior to periodontal surgery complication. First, a clinical evaluation and intraoral X-ray must
has been recommended to reduce bacterial load in the oral cavi- be done to understand the extension of the lesion and to decide
ty.153–155 It has also been reported that the use of chlorhexidine follow- whether or not to intervene. It is also crucial to check tooth vital-
ing periodontal surgery can significantly contribute to the reduction of ity to exclude endodontic involvement. Usually, invasive cervical
the infective burden in the oral cavity, and hence the promotion of oral resorption appears as an irregularly shaped lesion localized in the
142,156–159
health postsurgically. As there is a delicate balance between midfacial portion of the root. Flap elevation is recommended for ad-
the host's resistance to infection and factors initiating or promoting equate visualization of the entire lesion so that it can be properly
infection, on rare occasions infections might still appear after gingival cleaned from granulation tissue and bone ingrowths. Afterwards,
recession treatment, despite all the efforts mentioned herein. Given the field should be isolated using the rubber dam, and then the cav-
that soft tissues are highly capable of resisting and fighting infections, ity is recontoured using burs and filled with a flowable composite.
only antibiotic therapy is recommended to deal with the acute phase. In the literature, other restorative materials have been suggested to
fill the lesions, like glass-ionomer cement, composite resin, calcium
silicate–based cement, and calcium-enriched mixture cement.165
4.10 | External root resorption There is not enough evidence regarding the superiority of one ma-
terial over another; in any case, the restoration must be as smooth
External root resorption is a progressive and destructive loss of tooth as possible to allow the reattachment of connective fibers of the
structure that manifests itself in a mineralized or denuded area of flap's inner aspect above the root surface. Once the cavity has been
160 161
the root surface. According to Heithersay, periodontal surgeries restored, the mucoperiosteal flap is replaced and secured in posi-
that might potentially damage root cementum can result in resorp- tion166 (Figure 27). Even though further investigations are needed,
tion in 1.6% of cases. This is a rare occurrence following mucogin- this restorative-mucogingival approach has been shown to be pre-
gival surgery, with just a few studies (only case reports) available in dictable, assuring long-term outcomes (up to 5 years) (Figure 28).
162–164
the literature documenting this complication. External root
resorption, also called invasive cervical resorption when located in
the cervical area of the tooth,161 is one of the least known and under- 4.11 | Exostosis
stood forms of external root resorption; it is uncommon, insidious,
and often aggressive, and it has been reported after the treatment Exostosis is reported as a peripheral localized benign bone over-
of gingival recessions with connective tissue grafts. According to the growth of unknown etiology, with a base continuous to the origi-
extension and amount of tooth impairment, different treatment ap- nal bone and which seems to have a nodular, flat, or pedunculate
proaches have been adopted in the previously mentioned studies: protuberance located on the alveolar surface of the jaw bone.167 A
from extraction up to restorative-surgical approaches to save the small number of cases of buccal exostosis developing secondary to
tooth. Undoubtedly, the treatment of invasive cervical lesions is more soft tissue graft procedures (free gingival graft) have been reported
predictable when an early diagnosis is made. Hence, it is of utmost in periodontal literature.168–173 The etiologic factors of buccal
A B C D
F I G U R E 2 6 A-C , Performance of periodontal plastic surgery (coronally advance flap plus connective tissue graft) in this mandibular right
canine affected by gingival recession. D, Several years later, an external root resorption occurred at the cervical area of the tooth.
exostosis are unclear, but all previous reports have been unanimous these lesions to epithelial remnants embedded under the overlying
in suggesting that periosteal trauma seems to be associated with flap. On the other hand, two case reports175–180 placed the fault on
168–173
their development. Histologic examination revealed osseous deep epithelial projections in the connective tissue graft, which can
enlargements compatible with the diagnosis of exostoses at two create a cyst-like space when the graft is used in association with a
reentry procedures. Usually, these manifestations do not represent covering flap.
a real issue for patients unless the exostosis grows so much that it When the harvesting techniques adopted entail a graft with an
becomes a source of discomfort; in said case, a surgical procedure to epithelial layer, it is crucial to thoroughly remove the superficial ep-
remove the exostosis would be necessary. ithelium extraorally using a new blade, adequate light, and magnifi-
Despite being an infrequent finding, the clinical implication of cation. As a matter of fact, a recent histologic study181 revealed that,
exostosis following a gingival graft procedure is that it is a benign despite the efforts to carefully remove the epithelial tissue using a
condition that must be identified and differentiated from a malig- microscope (10×), small remnants were still present in all samples in
nant tumor, such as osteosarcoma.174 Corroboration of treatment different proportions.
along with palpation, horizontal sounding, and an occlusal radio- In our clinical experience, the cyst-like formations are more fre-
graphic view will help the practitioner establish a correct diagnosis quent when the graft has been harvested from the anterior palate,
and give the patient reassurance.171 due to the presence of rugae and epithelial invaginations extend-
ing into the lamina propria. However, they are usually self-limiting
and not painful or uncomfortable for patients. A localized lesion
4.12 | Cyst-like formation can be drained with soft digital pressure, and it is unlikely to recur.
Persistence of exudate might require some form of gingivoplasty
The use of connective tissue grafts has been correlated with the oc- based on the extension of the lesion, keeping in mind that this can
currence of cyst-like formations a few months or years after the sur- cause graft exposure and diminishing the esthetic outcome.
gery. This complication usually appears as a small fistula from which,
following the application of pressure on the facial aspect of the gin-
giva, a thick and white exudate may emerge (Figure 29). 4.13 | Residual hypersensitivity
A few cases have been described in the literature175–180 in which
the cyst-like formations have been biopsied and analyzed histologi- One of the primary goals of root coverage procedures is the resolu-
cally. The majority of the studies176–179 have attributed the origin of tion of dentin hypersensitivity due to root exposure. 2 Despite the
A B C D E F G H I J
F I G U R E 2 7 Surgical-restorative approach for the treatment of invasive cervical root resorption. A, Radiographic evaluation of the
lesion showing an irregularly shaped radiolucent area at the cervical level. B-I, The treatment involved the elevation of a trapezoidal
mucoperiosteal flap (B), granulation tissue removal (C), and the exposure of the resorbed area (D); field isolation with a rubber dam (E),
recontouring of the lesion borders using burs (F), application of a thin layer of a liner to protect the pulp (G), restoration of the cavity with
flowable composite (H), and polishing of the restoration (key aspect of this treatment) (I). J, The flap was repositioned using interrupted
sutures.
A B C D E F
F I G U R E 2 8 Clinical and radiographic appearance after the surgical-restorative approach showing tremendous soft tissue stability
together with tooth vitality. A, B, After 1 year. C, D, After 3 years. E, F, After 5 years
F I G U R E 2 9 A, Clinical manifestation A B
of a cyst-like formation characterized
by the emergence of a thick and white
exudate at the level of the grafted site. B,
Close-up view
A B
F I G U R E 3 0 A, Multiple gingival recessions affecting the first sextant in a patient with esthetic and hypersensivity complaints. B, Six
months after surgery (coronally advanced flap and site-specific adjunction of connective tissue graft), despite the improvement of the
gingival recession's appearance, root exposure is still visible in all the treated teeth.
enormous quantity of randomized clinical trials available in the lit- consequent exposure of dentinal tubuli to the oral cavity. In the case
erature regarding the treatment of gingival recessions, according to of minimal remaining recession, clinicians might opt for the use of
a systematic review published by Douglas de Oliveira et al,182 only desensitizers or placement of composite restorations to address the
nine trials evaluated the influence of root coverage procedures on issue. More extreme cases of incomplete coverage or recession re-
cervical dentinal hypersensitivity. In that review, a reduction in cer- currence normally require surgical reintervention, after 4-6 months,
vical dentinal hypersensitivity was reported with a mean percent- to settle the patient's complaint.
age of 77.83%; however, it was concluded that these results must
be viewed with caution because most of the studies had a high risk
of bias, and cervical dentinal hypersensitivity was assessed as a sec- 4.14 | Incomplete root coverage
ondary outcome.
The scarcity of evidence regarding residual hypersensitivity is All of the complications, side effects, and treatment errors reported
likely attributable to the lack of a standardized protocol for evaluat- above might result in either partial or no coverage of the gingival
ing this clinical condition, since it is not yet possible to state whether recession (Figure 30).
182
some methods are more valid than others. Complete root coverage is expected to solve the recession with
In the recent World Workshop AAP-EFF, it has been underlined the gingival margin located at or 1 mm coronally to the cemento–
that there is not enough evidence to conclude that surgical root enamel junction.
coverage procedures predictably reduce cervical dentinal hyper- Several systematic reviews5,6,8 have confirmed the superior-
sensitivity.35 None of the nine clinical trials included in the Douglas ity of coronally advanced flap plus connective tissue graft com-
de Oliveira et al182 review performed a correlation test between hy- pared with other procedures in terms of root coverage percentage.
persensitivity and percentage of root coverage or degree of gingival Furthermore, a recent systematic review showed that connective
recession. Thus, one should not exclude that the reduction in hyper- tissue graft–based techniques result in higher patient satisfaction
sensitivity could also be explained by other factors, such as brushing scores than flaps alone. This finding is most likely related to the
or the placebo effect.35 superior recession reduction and complete root coverage that con-
Generally, residual dentinal hypersensitivity after gingival re- nective tissue graft and connective tissue graft plus enamel matrix
cession treatments might be due to incomplete root coverage with derivative can achieve over treatment with flap alone.64
According to Kim et al,132 partial root coverage might not repre- University) and Dr Emanuele Ricci (Oral surgery Unit, Department
sent an esthetic issue from the patient's perspective. In that study, of Biomedical and Neuromotor Sciences, Bologna University) for
subjects considered the result to be “very good to excellent” when their contributions in providing pictures of clinical cases. Open
the mean percentage of root coverage was 80.2%.129 This tells us Access Funding provided by Universita degli Studi di Bologna
that patients are not always significantly influenced by the percent- within the CRUI-CARE Agreement.
age of root coverage but rather more by soft tissue integration vari-
ables (color and texture). C O N FL I C T O F I N T E R E S T
On the other hand, according to Zucchelli et al,39 residual root The authors have no conflicts of interest to declare. All co-authors
exposure, being of a different color (yellow dentin) than the white of have seen and agree with the contents of the manuscript.
the enamel, might be critical in terms of a successful esthetic evalu-
ation of root coverage as it represents the most visible area during DATA AVA I L A B I L I T Y S TAT E M E N T
smiling. In this study as well, the difference in color was more critical Data sharing not applicable to this article as no datasets were gener-
than the apicocoronal level of the soft tissue margin for a successful ated or analysed during the current study.
esthetic evaluation of root coverage from both professional and pa-
tient points of view. ORCID
Partial and incomplete root coverage should be handled accord- Ilham Mounssif https://orcid.org/0000-0001-7663-0402
ing to the patient's request and complaints. In the case of partial Martina Stefanini https://orcid.org/0000-0002-9154-637X
root coverage due to an incorrect evaluation of maximum root cov-
erage30,32 a composite restoration is needed to compensate for the REFERENCES
uncovered root; when treatment errors or complications (intra‑ and 1. Wennström JL. Mucogingival therapy. Ann Periodontol.
postoperative) determine partial or incomplete root coverage, a sec- 1996;1:671-701.
2. Tonetti MS, Jepsen S, Working Group 2 of the European Workshop
ond surgery is recommended to reach the ideal results.
on Periodontology. Clinical efficacy of periodontal plastic surgery
procedures: consensus report of group 2 of the 10th European
workshop on periodontology. J Clin Periodontol. 2014;41(Suppl
5 | CO N C LU S I O N S 15):S36-S 43.
3. Cairo F, Rotundo R, Miller PD, Pini Prato GP. Root coverage es-
thetic score: a system to evaluate the esthetic outcome of the
In recent decades, root coverage procedures have become very com- treatment of gingival recession through evaluation of clinical
mon in daily practice. As with any surgical procedure, patient morbid- cases. J Periodontol. 2009;80:705-710.
ity can be highly influenced by a number of factors, such as local and 4. Graziani F, Gennai S, Roldán S, et al. Efficacy of periodontal plastic
procedures in the treatment of multiple gingival recessions. J Clin
systemic conditions, as well as by the skill and knowledge of the clini-
Periodontol. 2014;41(Suppl 15):S63-S76.
cian performing the surgery. Proper patient evaluation and site diagno- 5. Cairo F, Nieri M, Pagliaro U. Efficacy of periodontal plastic surgery
sis can help avoid many undesirable outcomes. When performing the procedures in the treatment of localized facial gingival recessions.
surgery, the use of anesthetic with vasoconstrictor is advised in order A systematic review. J Clin Periodontol. 2014;41:S44-S62.
to reduce intraoperative bleeding and have a clear visual field. Specific 6. Chambrone L, Tatakis DN. Periodontal soft tissue root coverage
procedures: a systematic review from the AAP Regeneration
training is required for the execution of these plastic procedures, but
Workshop. J Periodontol. 2015;86:S8-S51.
the main technical errors to avoid during flap management are corre- 7. Tavelli L, Barootchi S, Nguyen TVN, Tattan M, Ravidà A, Wang
lated with its thickness, extension, and passivity; positioning the graft H-L . Efficacy of tunnel technique in the treatment of localized
at the level of the cemento–enamel junction is required for an esthetic and multiple gingival recessions: a systematic review and meta-
analysis. J Periodontol. 2018;89:1075-1090.
outcome (and will also prevent its exposure); when suturing, tight flap
8. Chambrone L, Salinas Ortega MA, Sukekava F, et al. Root coverage
adaptation and first intention wound closure without any residual ten- procedures for treating localised and multiple recession-t ype de-
sion will prevent flap dehiscence and early flap shrinkage. Regarding fects. Cochrane Database Syst Rev. 2018;10(10):CD007161.
the postoperative phase, locally applied cold therapy together with 9. López A, Nart J, Santos A, Alcázar J, Freixa O. Assessment of
morbidity after periodontal resective surgery. J Periodontol.
the prescription of anti-inflammatory drugs and analgesics are en-
2011;82:1563-1569.
couraged to reduce swelling and pain; patients should be motivated 10. American Academy of Periodontology. Comprehensive peri-
to carefully follow home-care instructions, since these play a crucial odontal therapy: a statement by the American Academy of
role during the early stages of healing and for the maintenance of the Periodontology. J Periodontol. 2011;82:943-949.
11. Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res.
outcome. Even if additional findings such as cyst-like formations, ex-
2010;89:219-229.
ostosis, or external root resorption are fairly rare, the clinician should 12. Cho H, Leira Y, Marletta D, Orlandi M, Kumar N, D’Aiuto F.
keep them in mind as possible complications over time. Complications and treatment errors in periodontal ther-
apy in medically compromised patients. Periodontol 2000.
2023;92(1):197-219.
AC K N OW L E D G M E N T S
13. Dietary Supplement Health and Education Act of 1994, Public Law
We would like to thank Dr Francesco Maiani (Periodontal Unit, 103–417, 103rd Congress.
Department of Biomedical and Neuromotor Sciences, Bologna
14. Binns CW, Lee MK, Lee AH. Problems and prospects: public 35. Cortellini P, Bissada NF. Mucogingival conditions in the natural
health regulation of dietary supplements. Annu Rev Public Health. dentition: narrative review, case definitions, and diagnostic con-
2018;39:403-420. siderations. J Periodontol. 2018;89(Suppl 1):S204-S213.
15. Heller J, Gabbay JS, Ghadjar K, et al. Top-10 list of herbal and sup- 36. Pini-Prato G, Franceschi D, Cairo F, Nieri M, Rotundo R.
plemental medicines used by cosmetic patients: what the plastic Classification of dental surface defects in areas of gingival reces-
surgeon needs to know. Plast Reconstr Surg. 2006;117:436-4 45; sion. J Periodontol. 2010;81:885-890.
discussion 446-4 47. 37. Sangnes G, Gjermo P. Prevalence of oral soft and hard tissue le-
16. Rowe DJ, Baker AC. Perioperative risks and benefits of herbal sup- sions related to mechanical toothcleansing procedures. Community
plements in aesthetic surgery. Aesthet Surg J. 2009;29:150-157. Dent Oral Epidemiol. 1976;4:77-83.
17. Chin SH, Cristofaro J, Aston SJ. Perioperative management of an- 38. Santamaria MP, Suaid FF, Nociti FH, Casati MZ, Sallum AW, Sallum
tidepressants and herbal medications in elective plastic surgery. EA. Periodontal surgery and glass ionomer restoration in the treat-
Plast Reconstr Surg. 2009;123:377-386. ment of gingival recession associated with a non-c arious cervical
18. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and periopera- lesion: report of three cases. J Periodontol. 2007;78:1146-1153.
tive care. JAMA. 2001;286:208-216. 39. Zucchelli G, Gori G, Mele M, et al. Non-c arious cervical lesions
19. Kaye AD, Kucera I, Sabar R. Perioperative anesthesia clinical con- associated with gingival recessions: a decision-making process. J
siderations of alternative medicines. Anesthesiol Clin North Am. Periodontol. 2011;82:1713-1724.
2004;22:125-139. 40. Kassab MM, Cohen RE. The etiology and prevalence of gingival
20. Wong WW, Gabriel A, Maxwell GP, Gupta SC. Bleeding risks of recession. JAm Dent Assoc. 2003;134:220-225.
herbal, homeopathic, and dietary supplements: a hidden night- 41. Khocht A, Simon G, Person P, Denepitiya JL. Gingival reces-
mare for plastic surgeons? Aesthet Surg J. 2012;32:332-3 46. sion in relation to history of hard toothbrush use. J Periodontol.
21. Abe A, Kaye AD, Gritsenko K, Urman RD, Kaye AM. Perioperative 1993;64:900-905.
analgesia and the effects of dietary supplements. Best Pract Res 42. Kapferer I, Benesch T, Gregoric N, Ulm C, Hienz SA. Lip piercing:
Clin Anaesthesiol. 2014;28:183-189. prevalence of associated gingival recession and contributing fac-
22. Abebe W. Review of herbal medications with the potential to tors. A cross-sectional study. J Periodontal Res. 2007;42:177-183.
cause bleeding: dental implications, and risk prediction and pre- 43. Sarfati A, Bourgeois D, Katsahian S, Mora F, Bouchard P. Risk as-
vention avenues. EPMA J. 2019;10:51-6 4. sessment for buccal gingival recession defects in an adult popula-
23. Grisa A, Florio S, Bellia E, Cho S-C , Froum SJ. The role of dietary tion. J Periodontol. 2010;81:1419-1425.
supplements in postsurgical bleeding: an update for the practi- 44. Heasman PA, Holliday R, Bryant A, Preshaw PM. Evidence for the
tioner. Compend Contin Educ Dent. 2016;37(10):690-695; quiz 696. occurrence of gingival recession and non-c arious cervical lesions
24. Tsen LC, Segal S, Pothier M, Bader AM. Alternative medicine use in as a consequence of traumatic toothbrushing. J Clin Periodontol.
presurgical patients. Anesthesiology. 2000;93:148-151. 2015;42(Suppl 16):S237-S255.
25. Jacobson PL, Cohan RP, Blumenthal M, Bruce G. Alternative 45. Rajapakse PS, McCracken GI, Gwynnett E, Steen ND, Guentsch A,
medicine in dentistry. In: Yagiela JA, Dowd FJ, Neidle EA, eds. Heasman PA. Does tooth brushing influence the development and
Pharmacology and Therapeutics in Dentistry. 5th ed. Mosby; progression of non-inflammatory gingival recession? A systematic
2004:880-886. review. J Clin Periodontol. 2007;34:1046-1061.
26. American Academy of Periodontology. Glossary of Periodontal 46. Baker DL, Seymour GJ. The possible pathogenesis of gingival re-
Terms. 4th ed. American Academy of Periodontology; 2001. cession. A histological study of induced recession in the rat. J Clin
27. Mele M, Felice P, Sharma P, Mazzotti C, Bellone P, Zucchelli G. Periodontol. 1976;3:208-219.
Esthetic treatment of altered passive eruption. Periodontol 2000. 47. Goldman HM, Cohen DW. Periodontal Therapy. 6th ed. Mosby;
2018;77:65-83. 1980.
28. Miller PD. A classification of marginal tissue recession. Int J 48. Caffesse RG, Alspach SR, Morrison EC, Burgett FG. Lateral slid-
Periodontics Restorative Dent. 1985;5:8-13. ing flaps with and without citric acid. Int J Periodontics Restorative
29. Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U. The interprox- Dent. 1987;7:42-57.
imal clinical attachment level to classify gingival recessions and 49. Chambrone L, Chambrone D, Pustiglioni FE, Chambrone LA, Lima
predict root coverage outcomes: an explorative and reliability LA. The influence of tobacco smoking on the outcomes achieved
study. J Clin Periodontol. 2011;38:661-666. by root-coverage procedures: a systematic review. J Am Dent
30. Zucchelli G, Testori T, De Sanctis M. Clinical and anatomical fac- Assoc. 2009;140:294-3 06.
tors limiting treatment outcomes of gingival recession: a new 50. Palmer RM, Wilson RF, Hasan AS, Scott DA. Mechanisms of ac-
method to predetermine the line of root coverage. J Periodontol. tion of environmental factors—tobacco smoking. J Clin Periodontol.
2006;77:714-721. 2005;32(Suppl 6):180-195.
31. Zucchelli G, Tavelli L, Barootchi S, Stefanini M, Wang H-L , 51. McIvor J. A method of assessing operative and post-operative
Cortellini P. Clinical remarks on the significance of tooth malposi- blood loss. Br J Oral Surg. 1967;5:1-10.
tion and papillae dimension on the prediction of root coverage. Int 52. Braganza A, Bissada N, Hatch C, Ficara A. The effect of non-
J Periodontics Restorative Dent. 2020;40:795-8 03. steroidal anti-inflammatory drugs on bleeding during periodontal
32. Zucchelli G, Mele M, Stefanini M, et al. Predetermination of root surgery. J Periodontol. 2005;76:1154-1160.
coverage. J Periodontol. 2010;81:1019-1026. 53. Moore PA, Doll B, Delie RA, et al. Hemostatic and anesthetic ef-
33. Stefanini M, Zucchelli G, Marzadori M, de Sanctis M. Coronally ficacy of 4% articaine HCl with 1:200,000 epinephrine and 4%
advanced flap with site-specific application of connective tissue articaine HCl with 1:100,000 epinephrine when administered in-
graft for the treatment of multiple adjacent gingival recessions: traorally for periodontal surgery. J Periodontol. 2007;78:247-253.
a 3-year follow-up case series. Int J Periodontics Restorative Dent. 54. Zigdon H, Levin L, Filatov M, Oettinger-Barak O, Machtei EE.
2018;38:25-33. Intraoperative bleeding during open flap debridement and regen-
34. Barootchi S, Tavelli L, Di Gianfilippo R, et al. Soft tissue pheno- erative periodontal surgery. J Periodontol. 2012;83:55-60.
type modification predicts gingival margin long-term (10-year) sta- 55. Tavelli L, Barootchi S, Stefanini M, Zucchelli G, Giannobile W, Wang
bility: longitudinal analysis of six randomized clinical trials. J Clin H. Wound healing dynamics, morbidity, and complications of pala-
Periodontol. 2022;49:672-683. tal soft tissue harvesting. Periodontol 2000. 2023;92(1):90-119.
56. Wahl MJ. Dental surgery in anticoagulated patients. Arch Intern 80. International Association for the Study of Pain, Subcommittee on
Med. 1998;158:1610-1616. Taxonomy. Classification of Chronic Pain: Descriptions of Chronic
57. Dym H, Ogle OE. Atlas of Minor Oral Surgery. Saunders; 2001. Pain Syndromes and Definitions of Pain Terms. Subcommittee on
58. Dodson TB, Bays RA, Paul RE, Neuenschwander MC. The effect of Taxonomy. Pain Suppl. 1986;3:S1-S226
local anesthesia with vasoconstrictor on gingival blood flow during 81. Tracey I, Mantyh PW. The cerebral signature for pain perception
Le Fort I osteotomy. J Oral Maxillofac Surg. 1996;54:810-814. and its modulation. Neuron. 2007;55:377-391.
59. de Sanctis M, Zucchelli G. Coronally advanced flap: a modified 82. Derbyshire SWG, Whalley MG, Stenger VA, Oakley DA. Cerebral
surgical approach for isolated recession-t ype defects: three-year activation during hypnotically induced and imagined pain.
results. J Clin Periodontol. 2007;34:262-268. Neuroimage. 2004;23:392-4 01.
60. Kamoh A, Swantek J. Hemostasis in oral surgery. Dent Clin N Am. 83. Eisenberger NI, Lieberman MD, Williams KD. Does rejection hurt?
2012;56:17-23. An fMRI study of social exclusion. Science. 2003;302:290-292.
61. Choi WS, Irwin MG, Samman N. The effect of tranexamic acid on 84. Raij TT, Numminen J, Närvänen S, Hiltunen J, Hari R. Brain cor-
blood loss during orthognathic surgery: a randomized controlled relates of subjective reality of physically and psychologically in-
trial. J Oral Maxillofac Surg. 2009;67:125-133. duced pain. Proc Natl Acad Sci USA. 2005;102:2147-2151.
62. Zucchelli G, Mounssif I, Mazzotti C, et al. Does the dimension 85. Singer T, Seymour B, O’Doherty J, Kaube H, Dolan RJ, Frith CD.
of the graft influence patient morbidity and root coverage out- Empathy for pain involves the affective but not sensory compo-
comes? A randomized controlled clinical trial. J Clin Periodontol. nents of pain. Science. 2004;303:1157-1162.
2014;41:708-716. 86. Croog SH, Baume RM, Nalbandian J. Pre-surgery psychological
63. Curtis JW, McLain JB, Hutchinson RA. The incidence and sever- characteristics, pain response, and activities impairment in fe-
ity of complications and pain following periodontal surgery. J male patients with repeated periodontal surgery. J Psychosom Res.
Periodontol. 1985;56:597-601. 1995;39:39-51.
64. Griffin TJ, Cheung WS, Zavras AI, Damoulis PD. Postoperative 87. Eli I, Schwartz-Arad D, Baht R, Ben-Tuvim H. Effect of anxiety on
complications following gingival augmentation procedures. J the experience of pain in implant insertion. Clin Oral Implants res.
Periodontol. 2006;77:2070-2079. 2003;14:115-118.
65. Askar H, Di Gianfilippo R, Ravida A, Tattan M, Majzoub J, Wang 88. Eli I, Uziel N, Blumensohn R, Baht R. Modulation of dental anxiety—
HL. Incidence and severity of postoperative complications follow- the role of past experiences, psychopathologic traits and individual
ing oral, periodontal, and implant surgeries: a retrospective study. attachment patterns. Br Dent J. 2004;196:689-694; discussion 3.
J Periodontol. 2019;90:1270-1278. 89. Hashem AA, Claffey NM, O’Connell B. Pain and anxiety follow-
66. Mounssif I, Stefanini M, Mazzotti C, Marzadori M, Sangiorgi M, ing the placement of dental implants. Int J Oral Maxillofac Implants.
Zucchelli G. Esthetic evaluation and patient-centered outcomes in 2006;21:943-950.
root-coverage procedures. Periodontol 2000. 2018;77(1):19-53. 90. Schwartz-Arad D, Bar-Tal Y, Eli I. Effect of stress on information
67. Cairo F, Barootchi S, Tavelli L, et al. Aesthetic‑ and patient- processing in the dental implant surgery setting. Clin Oral Implants
related outcomes following root coverage procedures: a sys- Res. 2007;18:9-12.
tematic review and network meta-analysis. J Clin Periodontol. 91. Fardal Ø, McCulloch CA. Impact of anxiety on pain perception as-
2020;47:1403-1415. sociated with periodontal and implant surgery in a private prac-
68. Fowler EB, Breault LG, Druckman RF. Post-surgical hemorrhage: tice. J Periodontol. 2012;83:1079-1085.
formation of a “liver clot” secondary to periodontal plastic surgery. 92. Kim S, Lee Y-J, Lee S, Moon H-S, Chung M-K . Assessment of pain
J Contemp Dent Pract. 2001;2:42-47. and anxiety following surgical placement of dental implants. Int J
69. Alling CC III, Alling RD. Hemorrhage and shock. In: Kruger GO, ed. Oral Maxillofac Implants. 2013;28:531-535.
Textbook of Oral and Maxillofacial Surgery. 6th ed. Mosby; 1984:229, 93. Mei C-C , Lee F-Y, Yeh H-C . Assessment of pain perception fol-
36-92. lowing periodontal and implant surgeries. J Clin Periodontol.
70. Little JW, Miller CS, Rhodus NL. Little and Falace's Dental 2016;43:1151-1159.
Management of the Medically Compromised Patient. 9th ed. Elsevier; 94. Oswal S, Ravindra S, Sinha A, Manjunath S. Antibiotics in peri-
2018. odontal surgeries: a prospective randomised cross over clinical
71. Mosby's Medical, Nursing, & Allied Health Dictionary. 5th ed. Mosby; trial. J Indian Soc Periodontol. 2014;18:570-574.
1998. 95. Seymour RA, Blair GS, Wyatt FA. Post-operative dental pain and
72. Weinberg S. Oral surgery complications in general practice. Dent J. analgesic efficacy. Part I. Br J Oral Surg. 1983;21:290-297.
1975;41:288-94, 99. 96. Tan WC, Krishnaswamy G, Ong MMA, Lang NP. Patient-reported
73. Pandya D, Manohar B, Mathur LK, Shankarapillai R. "Liver clot"—a outcome measures after routine periodontal and implant surgical
rare periodontal postsurgical complication. Indian J Dent Res. procedures. J Clin Periodontol. 2014;41:618-624.
2012;23:419-422. 97. Cheung WS, Griffin TJ. A comparative study of root coverage with
74. Bakutra G, Vishnoi S, Chandran S, Barot V. "Liver clot": a re- connective tissue and platelet concentrate grafts: 8-month re-
actionary haemorrhage-c ase report. Natl J Integr Res Med. sults. J Periodontol. 2004;75:1678-1687.
2018;6:115-117. 98. Cortellini P, Tonetti M, Baldi C, et al. Does placement of a con-
75. Druckman RF, Fowler EB, Breault LG. Post-surgical hemorrhage: nective tissue graft improve the outcomes of coronally advanced
formation of a "liver clot" secondary to periodontal plastic surgery. flap for coverage of single gingival recessions in upper anterior
J Contemp Dent Pract. 2001;2:62-71. teeth? A multi-centre, randomized, double-blind, clinical trial. J Clin
76. Elson N. Comprehensive approach in liver clot management case Periodontol. 2009;36:68-79.
report. Biomed J Sci Tech Res. 2018;3(5):3613-3616. 99. Bittencourt S, Del Peloso Ribeiro E, Sallum EA, Sallum AW, Nociti
77. Jayakrishnan R, Aneesh A, Basim Burhan KB. Liver clot after flap FH, Zaffalon Casati M. Comparative 6-month clinical study of a
surgery: a case report. Int Dent J Stud Res. 2020;6:35-37. semilunar coronally positioned flap and subepithelial connective
78. Mangukia H, Ravikiran G, Baldua K. "Liver clot": a reactionary tissue graft for the treatment of gingival recession. J Periodontol.
hemorrhage. Guident. 2017;34-36. 2006;77:174-181.
79. Wennström JL, Lindhe J. Periodontal surgery: access therapy. In: 100. Wessel JR, Tatakis DN. Patient outcomes following subepithe-
Lindhe J, Lang NP, eds. Clinical Periodontology and Implant Dentistry. lial connective tissue graft and free gingival graft procedures. J
6th ed. John Wiley & Sons, Ltd; 2015:767-796. Periodontol. 2008;79:425-430.
101. Zucchelli G, Mele M, Mazzotti C, Marzadori M, Montebugnoli L, De 119. Cortellini P, Pini Prato G. Coronally advanced flap and combi-
Sanctis M. Coronally advanced flap with and without vertical re- nation therapy for root coverage. Clinical strategies based on
leasing incisions for the treatment of multiple gingival recessions: scientific evidence and clinical experience. Periodontol 2000.
a comparative controlled randomized clinical trial. J Periodontol. 2012;59:158-184.
2009;80:1083-1094. 120. Mörmann W, Ciancio SG. Blood supply of human gingiva fol-
102. Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with lowing periodontal surgery. A fluorescein angiographic study. J
coronally advanced flap procedures: a systematic review. J Clin Periodontol. 1977;48:681-692.
Periodontol. 2008;35:136-162. 121. Zucchelli G. Mucogingival Esthetic Surgery. Quintessence
103. Tonetti MS, Cortellini P, Pellegrini G, et al. Xenogenic collagen Publishing; 2019.
matrix or autologous connective tissue graft as adjunct to cor- 122. Moore RL, Hill M. Suturing techniques for periodontal plastic sur-
onally advanced flaps for coverage of multiple adjacent gingival gery. Periodontol 2000. 1996;11:103-111.
recession: randomized trial assessing non-inferiority in root cov- 123. Morris ML. Suturing techniques in periodontal surgery.
erage and superiority in oral health-related quality of life. J Clin Periodontics. 1965;3:84-89.
Periodontol. 2018;45:78-88. 124. Tavelli L, Barootchi S, Ravidà A, Suárez-López del Amo F, Rasperini
104. Burkhardt R, Hämmerle CHF, Lang NP, Research Group on Oral G, Wang H-l. Influence of suturing technique on marginal flap sta-
Soft Tissue Biology & Wound Healing. Self-reported pain percep- bility following coronally advanced flap: a cadaver study. Clin Oral
tion of patients after mucosal graft harvesting in the palatal area. J Investig. 2019;23:1641-1651.
Clin Periodontol. 2015;42:281-287. 125. Burkhardt R, Preiss A, Joss A, Lang NP. Influence of suture tension
105. Chou R, Gordon DB, de Leon-C asasola OA, et al. Management of to the tearing characteristics of the soft tissues: an in vitro experi-
postoperative pain: a clinical practice guideline from the American ment. Clin Oral Implants Res. 2008;19:314-319.
Pain Society, the American Society of Regional Anesthesia and 126. Zuhr O, Akakpo DL, Hürzeler M. Wound closure and wound heal-
Pain Medicine, and the American Society of Anesthesiologists' ing. Suture techniques in contemporary periodontal and implant
Committee on Regional Anesthesia, Executive Committee, and surgery: interactions, requirements, and practical considerations.
Administrative Council. J Pain. 2016;17:131-157. Quintessence Int. 2017;48:647-660.
106. Sortino F, Cicciù M. Strategies used to inhibit postoperative swell- 127. Burkhardt R, Lang NP. Coverage of localized gingival reces-
ing following removal of impacted lower third molar. Dent Res J sions: comparison of micro- and macrosurgical techniques. J Clin
(Isfahan). 2011;8:162-171. Periodontol. 2005;32:287-293.
107. Suchetha A, Esha T, Darshan BM, Apporva SM, Dyvia B. Post- 128. Zucchelli G, Tavelli L, Barootchi S, et al. The influence of tooth lo-
operative complications after periodontal surgery. Int J Appl Dent cation on the outcomes of multiple adjacent gingival recessions
Sci. 2018;4(4):152-156. treated with coronally advanced flap: a multicenter re-analysis
108. Harris RJ, Miller R, Miller LH, Harris C. Complications with surgical study. J Periodontol. 2019;90:1244-1251.
procedures utilizing connective tissue grafts: a follow-up of 500 129. Zucchelli G, Tavelli L, Ravidà A, Stefanini M, Suárez-López
consecutively treated cases. Int J Periodontics Restorative Dent. Del Amo F, Wang H-L . Influence of tooth location on coro-
2005;25:449-459. nally advanced flap procedures for root coverage. J Periodontol.
109. Greenstein G. Therapeutic efficacy of cold therapy after in- 2018;89:1428-1441.
traoral surgical procedures: a literature review. J Periodontol. 130. Zucchelli G, Marzadori M, Mounssif I, Mazzotti C, Stefanini M.
2007;78:790-8 00. Coronally advanced flap + connective tissue graft techniques
110. Marques do Nascimento-Júnior E, Marques Sobral Dos Santos G, for the treatment of deep gingival recession in the lower inci-
Tavares Mendes ML, et al. Cryotherapy in reducing pain, trismus, sors. A controlled randomized clinical trial. J Clin Periodontol.
and facial swelling after third-molar surgery: systematic review 2014;41:806-813.
and meta-analysis of randomized clinical trials. J Am Dent Assoc. 131. Cairo F, Nieri M, Cattabriga M, et al. Root coverage esthetic score
2019;152:269-277.e1. after treatment of gingival recession: an interrater agreement mul-
111. Mish FC, ed. The Merriam-Webster Dictionary. 11th ed. Merriam- ticenter study. J Periodontol. 2010;81:1752-1758.
Webster Inc; 2005. 132. Kim SM, Choi YH, Kim YG, Park JW, Lee JM, Suh JY. Analysis
112. Wikesj UME, Nilvéus R. Periodontal repair in dogs: effect of of the esthetic outcome after root coverage procedures using
wound stabilization on healing. J Periodontol. 1990;61:719-724. a comprehensive approach. J Esthet Restor Dent. 2014;26:
113. Hiatt WH, Stallard RE, Butler ED, Badgett B. Repair following mu- 107-118.
coperiosteal flap surgery with full gingival retention. J Periodontol. 133. Zucchelli G, Amore C, Sforza NM, Montebugnoli L, De Sanctis
1968;39:11-16. M. Bilaminar techniques for the treatment of recession-
114. Wikesjö UM, Claffey N, Egelberg J. Periodontal repair in dogs. type defects. A comparative clinical study. J Clin Periodontol.
Effect of heparin treatment of the root surface. J Clin Periodontol. 2003;30:862-870.
1991;18:60-6 4. 134. Pini Prato GP, Baldi C, Nieri M, et al. Coronally advanced flap:
115. Zucchelli G, De Sanctis M. Treatment of multiple recession- the post-surgical position of the gingival margin is an import-
type defects in patients with esthetic demands. J Periodontol. ant factor for achieving complete root coverage. J Periodontol.
2000;71:1506-1514. 2005;76:713-722.
116. Zucchelli G, De Sanctis M. Long-term outcome following treat- 135. Jepsen K, Jepsen S, Zucchelli G, et al. Treatment of gingival re-
ment of multiple Miller class I and II recession defects in esthetic cession defects with a coronally advanced flap and a xenogeneic
areas of the mouth. J Periodontol. 2005;76:2286-2292. collagen matrix: a multicenter randomized clinical trial. J Clin
117. Pini Prato G, Pagliaro U, Baldi C, et al. Coronally advanced flap Periodontol. 2013;40:82-89.
procedure for root coverage. Flap with tension versus flap with- 136. Jepsen K, Stefanini M, Sanz M, Zucchelli G, Jepsen S. Long-term
out tension: a randomized controlled clinical study. J Periodontol. stability of root coverage by coronally advanced flap procedures. J
2000;71:188-201. Periodontol. 2017;88:626-633.
118. Burkhardt R, Lang NP. Role of flap tension in primary wound clo- 137. Stefanini M, Jepsen K, de Sanctis M, et al. Patient-reported out-
sure of mucoperiosteal flaps: a prospective cohort study: role comes and aesthetic evaluation of root coverage procedures: a
of flap tension in primary wound closure. Clin Oral Implants Res. 12-month follow-up of a randomized controlled clinical trial. J Clin
2010;21:50-54. Periodontol. 2016;43:1132-1141.
138. Stefanini M, Mounssif I, Barootchi S, Tavelli L, Wang H-L , Zucchelli 159. Solderer A, Kaufmann M, Hofer D, Wiedemeier D, Attin T,
G. An exploratory clinical study evaluating safety and perfor- Schmidlin PR. Efficacy of chlorhexidine rinses after periodon-
mance of a volume-stable collagen matrix with coronally advanced tal or implant surgery: a systematic review. Clin Oral Investig.
flap for single gingival recession treatment. Clin Oral Investig. 2019;23:21-32.
2020;24:3181-3191. 160. Hurt WC, Dahlberg WH, McFall WT, O’Leary TJ, Prichard JK.
139. Häkkinen L, Uitto VJ, Larjava H. Cell biology of gingival wound Glossary per periodontics terms. J Periodontol. 2001;57(Suppl):45.
healing. Periodontol 2000. 2000;24:127-152. 161. Heithersay GS. Treatment of invasive cervical resorption: an anal-
140. Coleman C, Tuan TL, Buckley S, Anderson KD, Warburton D. ysis of results using topical application of trichloracetic acid, curet-
Contractility, transforming growth factor-beta, and plasmin in tage, and restoration. Quintessence Int. 1999;30:96-110.
fetal skin fibroblasts: role in scarless wound healing. Pediatr Res. 162. White C. Repair of a root resorption lesion. A case report. J
1998;43:403-4 09. Periodontol. 1998;69:596-600.
141. Szpaderska AM, Zuckerman JD, DiPietro LA. Differential injury 163. Hokett SD, Peacock ME, Burns WT, Swiec GD, Cuenin MF. External
responses in oral mucosal and cutaneous wounds. J Dent Res. root resorption following partial-thickness connective tissue graft
2003;82:621-626. placement: a case report. J Periodontol. 2002;73:334-339.
142. Burkhardt R, Lang NP. Fundamental principles in periodontal plas- 164. Carnio J, Camargo PM, Kenney EB. Root resorption associated
tic surgery and mucosal augmentation--a narrative review. J Clin with a subepithelial connective tissue graft for root coverage: clin-
Periodontol. 2014;41(Suppl 15):S98-S107. ical and histologic report of a case. Int J Periodontics Restorative
143. Wong JW, Gallant-Behm C, Wiebe C, et al. Wound healing in oral Dent. 2003;23:391-398.
mucosa results in reduced scar formation as compared with skin: 165. Eftekhar L, Ashraf H, Jabbari S. Management of invasive cervical
evidence from the red Duroc pig model and humans. Wound Repair root resorption in a mandibular canine using biodentine as a re-
Regen. 2009;17:717-729. storative material: a case report. Iran Endod J. 2017;12:386-389.
144. Zucchelli G, Mounssif I. Periodontal plastic surgery. Periodontol 166. Mounssif I, Bentivogli V, Mazzotti C, Mele M, Marzadori M,
2000. 2015;68:333-368. Zucchelli G. PD188: Surgical-restorative management of invasive
145. Other (online med encyclopaedia). A.D.A.M. Medical Encyclopedia cervical resorption after mucogingival surgery. J Clin Periodontol.
2021. Keloid scar. https://medlineplus.gov/ency/imagepages/ 2018;45:110.
9865.htm. Accessed June 21, 2021. 167. Stafne EC, Gibilisco JA. Oral Roentgenographic Diagnosis. 4th ed.
146. Gluckman H, Du Toit J, Pontes CC, Hille J. Hyperplastic response Saunders; 1975.
following soft tissue augmentation in the esthetic zone. Clin Adv 168. Pack AR, Gaudie WM, Jennings AM. Bony exostosis as a sequela to
Periodontics. 2019;9:50-54. free gingival grafting: two case reports. J Periodontol. 1991;62(S19)
147. Oliver RC, Löe H, Karring T. Microscopic evaluation of the heal- :269-271.
ing and revascularization of free gingival grafts. J Periodontal Res. 169. Efeoglu A, Demirel K. A further report of bony exostosis occur-
1968;3:84-95. ring as a sequela to free gingival grafts. Periodontal Clin Investig.
148. Nobuto T, Imai H, Yamaoka A. Microvascularization of the free gin- 1994;16:20-22.
gival autograft. J Periodontol. 1988;59:639-6 46. 170. Czuszak CA, Tolson GE, Kudryk VL, Hanson BS, Billman MA.
149. Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Development of an exostosis following a free gingival graft: case
Principles of successful grafting. Periodontics. 1968;6:121-129. report. J Periodontol. 1996;67:250-253.
150. Miller PD. Root coverage using the free soft tissue autograft fol- 171. Otero-C agide FJ, Singer DL, Hoover JN. Exostosis associated
lowing citric acid application. III. A successful and predictable with autogenous gingival grafts: a report of 9 cases. J Periodontol.
procedure in areas of deep-wide recession. Int J Periodontics 1996;67:611-616.
Restorative Dent. 1985;5:14-37. 172. Echeverria JJ, Montero M, Abad D, Gay C. Exostosis following a
151. Wilderman MN, Wentz FM. Repair of a dentogingival defect with free gingival graft. J Clin Periodontol. 2002;29:474-477.
a pedicle flap. J Periodontol. 1965;36:218-231. 173. Chambrone LA, Chambrone L. Bony exostoses developed
152. Edlich RF, Rodeheaver GT, Thacker JG, Winn HR, Edgerton MT. subsequent to free gingival grafts: case series. Br Dent J.
Management of soft tissue injury. Clin Plast Surg. 1977;4:191-198. 2005;199:146-149.
153. Bonesvoll P, Lökken P, Rölla G. Influence of concentration, time, 174. Frost HM. The biology of fracture healing. An overview for clini-
temperature and pH on the retention of chlorhexidine in the cians. Part I. Clin Orthop Relat Res. 1989;(248):283-293.
human oral cavity after mouth rinses. Arch Oral Biol. 1974;19: 175. Ouhayoun JP, Khattab R, Serfaty R, Feghaly-A ssaly M, Sawaf MH.
1025-1029. Chemically separated connective tissue grafts: clinical application
154. Gjermo P, Bonesvoll P, Rölla G. Relationship between plaque- and histological evaluation. J Periodontol. 1993;64:734-738.
inhibiting effect and retention of chlorhexidine in the human oral 176. Harris RJ. Formation of a cyst-like area after a connective tissue
cavity. Arch Oral Biol. 1974;19:1031-1034. graft for root coverage. J Periodontol. 2002;73:340-3 45.
155. Johnson NR, Kazoullis A, Bobinskas AM, Jones L, Hutmacher DW, 177. Breault LG, Billman MA, Lewis DM. Report of a gingival "surgical
Lynham A. Bacterial comparison of preoperative rinsing and swab- cyst" developing secondarily to a subepithelial connective tissue
bing for oral surgery using 0.2% chlorhexidine. J Investig Clin Dent. graft. J Periodontol. 1997;68:392-395.
2015;6:193-196. 178. de Castro LA, Vêncio EF, Mendonça EF. Epithelial inclusion cyst
156. Hamp SE, Rosling B, Lindhe J. Effect of chlorhexidine on gingival after free gingival graft: a case report. Int J Periodontics Restorative
wound healing in the dog. A histometric study. J Clin Periodontol. Dent. 2007;27:465-469.
1975;2:143-152. 179. Wei P-C , Geivelis M. A gingival cul-de-sac following a root cover-
157. Langebaek J, Bay L. The effect of chlorhexidine mouthrinse on age procedure with a subepithelial connective tissue submerged
healing after gingivectomy. Scand J Dent Res. 1976;84:224-228. graft. J Periodontol. 2003;74:1376-1380.
158. Westfelt E, Nyman S, Lindhe J, Socransky S. Use of chlorhexidine 180. Parashis AO, Tatakis DN. Subepithelial connective tissue graft for
as a plaque control measure following surgical treatment of peri- root coverage: a case report of an unusual late complication of ep-
odontal disease. J Clin Periodontol. 1983;10:22-36. ithelial origin. J Periodontol. 2007;78:2051-2056.
181. Azar EL, Rojas MA, Patricia M, Carranza N. Histologic and histo-
morphometric analyses of de-epithelialized free gingival graft in How to cite this article: Mazzotti C, Mounssif I, Rendón A,
humans. Int J Periodontics Restorative Dent. 2019;39:221-226.
et al. Complications and treatment errors in root coverage
182. Douglas de Oliveira DW, Oliveira-Ferreira F, Dumont Flecha O,
Furtado Gonçalves P. Is surgical root coverage effective for the procedures. Periodontol 2000. 2023;92:62-89. doi: 10.1111/
treatment of cervical dentin hypersensitivity? A systematic re- prd.12468
view. J Periodontol. 2013;84:295-3 06.

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Received: 30 April 2022 | Revised: 8 July 2022 | Accepted: 26 July 2022