De-epithelialized Free Gingival Graft Versus Subepithelial Connective Tissue Graft in the treatment of multiple adjacent gingival recessions using Modified Coronally Advanced Tunnel Technique: A Randomized Controlled Trial.

Gingival recession is the exposure of the root surface resulting from migration of the gingival margin apical to the cementoenamel junction (CEJ).Multiple adjacent gingival recession(MAGR) is common and various techniques have been described for the its treatment [e.g., coronally advanced flap (CAF), tunnel technique (TUN), flap designs (e.g., CAF with/without vertical releasing incisions, TUN with/without split-flap, etc.), adjuncts [e.g., free gingival graft (FGG), connective tissue graft (CTG), enamel matrix derivatives (EMD), soft tissue substitutes (STS) membranes for guided tissue regeneration (GTR), etc.], and combinations thereof have been tried. Most systematic reviews conclude that CAF + CTG should be considered as the ‘gold standard’ for single Miller class I and II GR, also coined as recession type (RT1). Recent literature indicate that tunnel technique (TUN) is a highly effective and predictable procedure in the treatment of multiple Gingival Recession (GR) defects. Positive outcomes of root coverage with TUN might be attributed to inherent advantage of this approach being a minimally invasive procedure with limited flap opening and lack of vertical releasing incisions, all of which contribute to decreased tissue trauma, enhanced wound healing, and greater blood supply to the graft. (Azzi & Etienne 1998, Zuhr et al. 2007, Aroca et al. 2010). Tunnel technique was first introduced by Allen in 1994, and its modifications by Zabalegui in 1999, Modified Coronally Advanced Tunnel (MCAT) by Azzi et al 2002 and Microsurgical CAT by Zuhr 2007. Over the following years, additional modifications of MCAT technique were proposed, such as introduction of the microsurgical approach, full-thickness flap preparation, papillae detachment and elevation, modified suturing technique, application of collagen porcine dermal matrix in lieu of SCTG , inclusion of biological factors such as enamel matrix derivative (EMD) or concentrated growth factor (CGF) , and site-specific application of Sub-epithelial connective tissue graft (SCTG). Various techniques have been proposed to obtain SCTG. Recently, de-epithelialized free gingival graft (FGG) has been used as another method to obtain SCTG. Therefore, the aim of this split mouth randomized controlled study is to evaluate and compare de-epithelialized FGG or SCTG in the treatment of multiple adjacent gingival recessions using MCAT.