World Journal of Dentistry
Volume 11 | Issue 1 | Year 2020

Comparison of a Semilunar Coronally Positioned Flap and Conventional Coronally Advanced Flap for the Treatment of Gingival Recession: A Split-mouth, Randomized Prospective Comparative Controlled Clinical Trial

Hala Albonni1, Omar Hamadah2, Suleiman Dayoub3

1,3Periodontology Department, Faculty of Dental Medicine, Damascus University, Damascus, Syria
2Oral Medicine Department, Faculty of Dental Medicine, Damascus University, Damascus, Syria

Corresponding Author: Hala Albonni, Periodontology Department, Faculty of Dental Medicine, Damascus University, Damascus, Syria, Phone: +963 932097644, e-mail: halaalbonni20@gmail.com

How to cite this article Albonni H, Hamadah O, Dayoub S. Comparison of a Semilunar Coronally Positioned Flap and Conventional Coronally Advanced Flap for the Treatment of Gingival Recession: A Split-mouth, Randomized Prospective Comparative Controlled Clinical Trial. World J Dent 2020;11(1):3–11.

Source of support: Nil

Conflict of interest: None


Aim: The aim of this trial was to compare the semilunar coronally positioned flap (SCPF) and the conventional coronally advanced flap (CAF) regarding the applied modifications in treating gingival recession.

Materials and methods: Sample consisted of 16 patients with bilateral class I gingival recessions, they were treated with SCPF or CAF. Two modifications were applied: a root surface biomodification with tetracycline (TTC) and suture anchors on the contact points of the tooth. Clinical parameters and a questionnaire were used as measures to evaluate the trial. Wilcoxon test was used for statistical analysis.

Results: The mean percentage of root coverage (RC) and complete RC (CRC) was 82.3 ± 15.6% (31.3%, n = 5/16) and 79.8 ± 27.7% (43.8%, n = 7/16), respectively, using SCPF and CAF. Statistically significant differences were observed in the intergroup width of keratinized tissue (WKT), thickness of keratinized tissue (TKT), vestibular depth (VD), and position of the mucogingival junction (MGJ). A significant difference was observed in wound healing index (WHI) 1 week postoperative. Full root coverage esthetic score (RES) was achieved in four teeth using SCPF and in two teeth using CAF. No statistically significant differences were observed in the intergroup in the postoperative pain and root sensitivity during the follow-up.

Conclusion: Both SCPF and CAF with the mentioned modifications were effective in managing shallow gingival recessions. However, SCPF’s results showed a significant gain in WKT, TKT, and VD.

Clinical significance: Our findings confirm that both procedures with the mentioned modifications can be used to treat gingival recession with effectively and satisfied results for periodontist and patient. Our results suggest it is preferable to use the SCPF in case of a shallow oral vestibulum and high demand for esthetic.

Keywords: Coronally advanced flap, Gingival recession, Mini-crescent knife, Root coverage, Semilunar coronal flap.


Gingival recession has become one of the most common reasons that urge patients to visit dental clinics, mainly because of its consequences such as root sensitivity and esthetic impairment.1 Gingival recession is defined by the exposure of root surface resulting from the displacement of the free gingival margin in the apical direction away from cementoenamel junction (CEJ) toward the MGJ. The most common cause of gingival recession is either frequent mechanical trauma caused by incorrect dental brushing or inflammatory periodontal diseases.1,2 Different surgical RC techniques have been proposed as successful treatment techniques for gingival recession, including using pedicle flaps which is a minimally invasive periodontal surgery.1 A systematic review has shown that using coronally advanced flap (CAF) leads to successful treatment of class I and II recession (according to Miller).2 Despite the success rate with this technique, it has a negative impact on flap tension on blood supply and consequently on clinical outcomes. Furthermore, the vertical releasing incisions may result in shallowing the oral vestibulum and a white scarred incisions, which could compromise the esthetic result.3 In order to overcome these difficulties, Tarnow had suggested using semilunar coronally position flap (SCPF), which is ideal for the upper anterior teeth and premolars that have 2–3 mm recession of the Miller’s class I.3,4 This technique has shown many advantages: it is simple, fast, and atraumatic; it increases the width of the keratinized gingiva; it did not involve narrowing of the oral vestibule; it required less time to operate; it preserves the blood supply with the absence of the flap tension; and it costs less and does not need sutures.3,5 However, not needing sutures has affected the results of the clinical parameters and its stability compared to other surgical techniques.5 Therefore, many attempts were made to adjust this technique in order to obtain better clinical performance; some of these modifications are suturing the flap,6 biological modification of the root surface,4 and the use of microscopic surgery.4


It was necessary to improve these two techniques to be affordable and efficient. Thus, the objective of this short-term randomized clinical trial was to compare the efficacy of the SCPF and the CAF by modifying them using a TTC biomodification of the root surface and stabilizing the coronal margin of the flap with anchored sutures on the composite stops on the contact points of the affected tooth for the treatment of localized maxillary Miller’s class I gingival recession.


Study Design

This is a split-mouth, randomized, prospective, comparative controlled clinical trial. The study protocol was registered on ClinicalTrials.gov, with the registration number: NCT03391947.

Eligibility Criteria

Inclusion Criteria

Recruited patients were (1) medically fit; (2) aged between 18 years and 60 years (for both genders); (3) nonsmokers (less than 10 cigarettes per day) and nonalcoholics; (4) nonpregnant females participants who (5) weren’t on menstruation days during the surgery phase; (6) committed to oral care and had a healthy periodontium; (7) not having severe oral habits; and (8) having bilateral buccal Miller class I gingival recessions (≤5 mm) in the maxillary incisors, canines, or premolars; (9) in addition to that, the WKT was conditioned to be ≥2 mm, (10) the tooth was vital and no presence of caries or restorations in the areas that would be treated, (11) pocket depth (PD) ≤3 mm with no bleeding on probing (BOP), (12) and the patients who agreed to sign a consent form.

Exclusion Criteria

We excluded patients who (1) had untreated periodontal disease; (2) had immunosuppressive systemic diseases (i.e., cancer, AIDS, diabetes…); (3) had gingival recession defects Miller class II, III, or IV; (4) were taking medications known to influence the health of the gingival tissue (such as calcium channel blockers, …) or long-term steroid usage.

Twenty patients met the criteria, each one had two contralateral class I gingival recession; and before the surgical operation, each recession was directly randomly distributed, by tossing a coin, to one of the following treatment groups:

  1. Group I (SCPF): treatment using the SCPF (n = 20).
  2. Group II (CAF): Treatment using the CAF (n = 20).

Treatment Protocol

Presurgical Phase

Initial dental treatment was provided to eliminate bad habits, which were related to the etiology of the recession. Plus, in order to improve oral hygiene, we demonstrated one of the proper brushing techniques, namely, the coronally directed roll technique or using a soft toothbrush. In addition, it might also require gentle scaling, root planning, and polishing.

A vacuum plate was designed, which covers the coronary third of the dental crowns to set the direction of entry for the periodontal probe and the spreader while taking the measurements during the follow-up sessions.

Clinical Parameters

(1) Full-mouth visible plaque index (VPI),7 (2) sulcus bleeding index (SBI),8 and (3) probing depth (measured using the University of North Carolina periodontal probe (UNC 15) [UNC 15 periodontal probe, Hu-Friedy, Chicago, IL, USA) with a rubber stopper and it was recorded to the nearest higher millimeters. (4) gingival recession height (GRH) (from the CEJ to the gingival margin (GM)), (5) clinical attachment level (CAL = GRH + PD), (6) gingival recession width (GRW)]; the distance from one border of the recession to another at the CEJ, (7) the amount of RC and the change in GRH, (8) WKT and the distance between the most apical point of the GM and the MGJ, (9) TKT which was assessed during anesthesia, 2 mm apical to the GM, in which the spreader penetrates through the soft tissue with light pressure until the beginning of the hard surface. The silicone stop was placed in tight contact with the external soft tissue surface, (10) VD; from the GM to the bottom of the vestibule, and (11) change in the position of the MGJ from the incisal edge. These parameters were measured using an endodontic finger spreader (Mani Finger Spreaders; JPY, Tochigi, Japan) attached to a rubber stopper and an electronic caliper of 0.01 mm resolution (Inside-precision measurement electronic caliper series-1112, USA). After removing the spreader, the penetration depth was measured using the caliper. (12) The WHI9 was recorded after 1–2 weeks and 4 weeks after surgery. (13) The percentage of RC (RC%) was calculated using the formula [(GRH preoperative − GRH postoperative)/GRH preoperative] × 100%. (14) The RES system10 which was evaluated after a 3-month follow-up.

After surgery, each patient was asked to fill a questionnaire that included postoperative pain level and root sensitivity using a 10-cm visual analog scale (VAS), where 0 indicated no pain, 5 is moderate pain, and 10 is the worst possible pain. Her/his satisfaction with esthetic (after 3 months of follow-up) was measured using the scale of bad, sufficient, good, or excellent rating. It was explained to patients the difference between the pain from cervical dentin hypersensitivity, which is acute, transient, and rapid pain, for example, the pain caused by cold and hot water and it disappears once the stimulus is removed, and between the pain as a result of the surgery, which involves continuous pain. In addition, the postoperative pain was estimated on the first 3 days after surgery, whereas the dentin hypersensitivity was first assessed 1 week after surgery.

Surgical Procedure

Disinfection of the area around the mouth was performed using povidone–iodine (Allied Povidone-Povidone Iodine-Allied®-Damascus-Syria) at a concentration of 10%. The patient was rinsed with 0.12% chlorhexidine digluconate solution (Zac, chlorhexidine 0.12%. Reg. Number s/94 Minis of Health, Damascus, Syria) for 1 minute before the surgery to reduce the bacterial load. The surgery area was anesthetized with a 2% lidocaine with 1:100,000 adrenaline (Lidocaine 2%, alphacaine and adrenaline 1:100,000; DFL Industria e Comercio, Rio de Janeiro, RJ, Brazil). The exposed root surface was planed and softened by Gracy curettes (Hu-Friedy, Chicago, IL, USA) and fine burs (Komet, Besigheim, Germany) to remove any edges or plaque and to reduce the coronal convex part of the root.

For the SCPF group,3 a semilunar incision (Fig. 1C) was made following the curvature of the gingival margin and ending about 2–3 mm below the tip of the papillae by blade 15 (Swann Morton, made in Sheffield, England). The most apical distance of this incision to the GM was obtained by adding the bone sounding measurement to the recession height. A split-thickness dissection was performed coronally from the incision and connected it to a split-thickness intrasulcular incision by using the mini-crescent knife (Tunnel Blade of 2.1 mm-SF No. 144/1, Villupuram (Dist), Tamil Nadu, India). The tissue easily collapsed toward the coronally and covered the denuded root.

Figs 1A to E: (A) Preoperative view of a buccal Miller class I gingival recession on the maxillary right premolar; (B) The exposed root surfaces were bioconditioned with the tetracycline (TTC) solution using a cotton pellet; (C) The semilunar incision was made and the most apical distance of this incision was in the mucosa; (D) The semilunar coronally positioned flap was stabilized by a coronally anchored suture with composite stops on the contact points of the tooth; (E) The healing of semilunar coronally positioned flap (3 months’ postoperatively)

For the CAF group,11 it was initiated with two vertical incisions, extending from a mesial and distal linear angle at the CEJ and going beyond the MGJ using blade 15. A split–thickness-releasing incisions was prepared by sharp dissection using a mini-crescent knife and connected with an intracrevicular incision (Fig. 2B). On the facial aspect of the tooth, a full-thickness flap was performed for approximately 3–4 mm apical to the crest of alveolar bone, whereas the remaining buccal bone that was still covered by the periosteum and gingival connective tissue as a split-thickness was performed using a blunt dissection into the vestibular lining mucosa to release the muscle tension. Afterward, the papillae were de-epithelized.

For the modifications that were used in this study in both SPCF and CAF, the exposed root surfaces were conditioned with TTC (Tetracycline HCL 250 mg, Damascus, Syria). The TTC solution was prepared by mixing 250 mg of TTC capsule in 2.5 mL distilled water until it fully dissolved. The root surfaces were adjusted for 5 minutes using a cotton pellet soaked with the solution while maintaining an active movement. The pellet was changed every 30 seconds to maintain a fresh TTC solution in contact with the root surface and followed with 60-second of saline for irrigation (Figs 1B and 2C).

Then the coronally repositioned gingival margin was stabilized by a coronally anchored suture (nylon 0/5—Blue-VERTMED GmbH-Hannover-str 38-D-28857-syke-Germany) with composite stops on the contact points of the tooth using flowable composite (Ivoclar Vivadent AG, Bendererstrasse 2, 9494 Schaan, Liechtenstein, Germany) (Fig. 1D). The additional suture was made to close the releasing incisions for CAF (Fig. 2D). Finally, the area was covered with a periodontal dressing (COE-PAK, GC AMERICA INC. ALSIP, IL 60803 U.S.A) on both sides. Both procedures were performed by the same periodontist and completed with the same appointment to prevent clinical change at the clinician’s side.

Postsurgical Care

The patients were instructed to take a tablet of Brufen 600 mg (BRUFEN 600 mg tablets; Unipharma, Damascus, Syria) immediately after the surgery and apply an ice pack on the surgery area for the first 24 hours. We also recommended repeating the dose of medication when experiencing pain. All patients were instructed to continue full oral care with the exception of the surgical area where it was kept isolated for 30 days. The plaque control on the surgical sites was made by a cotton pellet soaked in a 0.12% chlorhexidine digluconate solution and rinsed with the same solution four times (60 seconds) daily for 10 days.

The dressing was removed after 7 days and the surgical sutures were removed 2 weeks after the surgery.

Follow-up phase

A questionnaire was given to the patients to assess pain and root sensitivity during the initial healing phase and to record the need for medications. After 3 months, all patients had assessed their satisfaction with esthetic.

The patients were instructed to resume mechanical tooth cleaning of the treated area using a soft toothbrush and a careful roll technique 4 weeks after the surgery.

Data Collection and Statistical Analysis

All measures were recorded by the same blinded, trained, and calibrated investigator during the study. The statistical study was divided into two main sections. The first section included the sample characteristics and the descriptive data analysis (mean ± standard deviation). Cronbach α was calculated to check the questionnaire’s reliability. The second section included the inferential statistical analysis, and the Wilcoxon test was used to check the significant differences between the two therapeutic techniques (SCPF and CAF) before and after the surgery phase.

Figs 2A to E: (A) Preoperative view of a buccal Miller class I gingival recession on the maxillary left premolar; (B) The incisions of the coronally advanced flap (two vertical incisions and intracrevicular incision); (C) After the flap performed, the exposed root surfaces were bioconditioned with the tetracycline (TTC) solution with a cotton pellet; (D) The coronally advanced flap was stabilized by a coronally anchored suture with composite stops on the contact points of the tooth and the releasing incisions were closed with additional sutures; (E) The healing of coronally advanced flap (3 months’ postoperatively)

Statistical significance was set at p < 0.05 and a confidence interval of 95%. Statistical analysis was performed using the statistical package SPSS v. 22.0 (SPSS Inc., Chicago, IL, USA).


The study sample consisted of 20 patients, 4 of them were excluded due to either dropping out during the follow-up period or no adherence to the oral instruction given after surgery. A flow diagram of the study participants is provided (Flowchart 1).

A total of 32 bilateral maxillary buccal gingival recession sites (Miller class I) (1–4.2 mm) were treated in 16 patients (8 males and 8 females) whose age ranged between 19 years and 52 years with a mean of 33 years. The one site was treated with CAF technique (16 defects) and the opposite site was treated with semilunar coronally technique (16 defects). The treated teeth consisted of 1 central, 9 laterals, 5 canines, 15 first premolars, and 2 second premolars.

All patients tolerated the surgical procedures well, and no postoperative complications were reported. Full-mouth VPI and SBI were kept at 20% and below.

For the questionnaire used, Cronbach’s α was 0.8, a value higher than 7, which indicated that it is reliable to use.

The SCPF (Group I)

The initial mean probing depth and clinical attachment level were 1.4 ± 0.8 mm and 3.2 ± 1.1 mm, respectively. After the 3-month follow-up, they were 1.06 ± 0.2 mm and 1.3 ± 0.3 mm with statistical significance for CAL (p = 0) (Table 1).

At baseline, the mean recession height was 1.8 ± 0.5 mm (range 1–3 mm) and the average recession width was 3.4 ± 0.8 mm. Three months after the surgery, the recurrent GRH was 0.2 ± 0.2 mm and the GRW was 0.4 ± 0.3 mm. However, a statistically significant difference was observed for GRH and GRW (p = 0) (Table 1).

The WKT and TKT were 4.6 ± 1.4 mm and 0.9 ± 0.1 mm, respectively, at baseline, while they were 6.3 ± 1.4 mm and 1.2 ± 0.2 mm after the 3-month follow-up with statistically significant difference (p = 0) for both (Table 1).

The VD increased from 12.1 ± 2.1 mm at baseline to 13.5 ± 2.2 mm at the end point of the study with statistical significance (p = 0), while the position of the MGJ from the incisal edge was 15.4 ± 2.3 mm and increased to 15.5 ± 2.1 mm 3 months later (Table 1).

The mean amount of RC was 1.4 ± 0.6 mm (RC% was 82.3 ± 15.6%), and 5 teeth (31.3%) showed CRC. However, the RES was 7.50 ± 1.7, and 4 teeth achieved a total score (25%) (Table 1).

Thirteen patients were satisfied with the final esthetic appearance with an “excellent” rating by 81.3%. Seven patients selected this technique when asked about the technique they preferred (43.8%) (Table 2).

Flowchart 1: Flow diagram of the study

The average WHI was 1.8 ± 0.3, 1.13 ± 0.3, and 1 ± 0, at 1, 2, and 4 weeks after surgery, respectively (Table 3).

Root sensitivity at baseline was 87.6%. One week and two weeks after surgery, there was no sensitivity to any of the treated teeth. However, it was present in 87.5% (14 sites) and 81.3% (13 sites) after 1 and 3 months, respectively (Table 4).

No pain was observed in 75% of the sample 24 hours postoperative, while after 48 and 72 hours, the percentage increased to 81.3% and 93.8%, respectively. Of the 16 patients, 9 (56.3%) did not take any analgesics (Table 4).

The CAF (Group II)

The mean probing depth was 1.4 ± 0.8 mm at baseline; while 3 months after surgery, it decreased to 1 ± 0 mm. The initial clinical attachment level was 3.6 ± 1.1 mm. Three months later, it was 1.3 ± 0.3 mm with statistical significance for both values (p = 0.03, p = 0), respectively (Table 1).

The initial mean recession depth was 2.2 ± 0.6 mm (range 1.5–4.2 mm), and the average recession recurrent was 0.3 ± 0.3 mm 3 months after surgery. The recession width was 3.7 ± 0.8 mm initially, and 0.5 ± 0.6 mm after follow-up with statistical significance for both values (p = 0) (Table 1).

The initial WKT reduced from 4.1 ± 1.3 mm at baseline to 3.8 ± 1.1 mm 3 months after surgery. However, the average TKT had a similar value (0.9 ± 0.1 mm) at baseline and after the follow-up. Statistical significance was observed only for WKT (p = 0.04) (Table 1).

The VD was 11.9 ± 2.4 mm at baseline and decreased to 9.2 ± 2.6 mm at the end of the study, while the distance from the MGJ to the incisal edge was 15.7 ± 2.6 mm at baseline and 13.5 ± 2.02 mm after 3 months, with statistical significance for both values (p = 0) (Table 1).

The mean RC was 1.9 ± 0.8 mm (RC% was 79.8 ± 27.7%), seven teeth (43.8%) accomplished CRC. However, the RES was 7.25 ± 1.7. Two teeth (12.5%) achieved a total score (Table 1). In all, 56.3% of the patients were satisfied with the esthetic after 3 months and gave an “excellent” rate for the results they got (Table 2).

One week, 2, and 4 weeks after surgery, the average of WHI was 1.5 ± 0.5, 1.19 ± 0.4, and 1 ± 0, respectively (Table 3).

Root sensitivity at baseline was 87.6%. No sensitivity was observed at 93.8% (15 sites) 1 to 2 weeks after the surgery. While it decreased to 81.3% (13 sites) 1 month after surgery and the same percentage remained after 3 months (Table 4).

No postoperative pain was observed 24–48 hours after the procedure, in 62.5% and 68.8% of the sample, respectively. After 72 hours, 75% had no postoperative pain. Of the 16 patients, 9 (56.3%) needed analgesics to manage pain (Table 4).

Comparison between Groups

At baseline, no statistically significant intergroup differences were found for clinical parameters, except for GRH and GRW (p = 0.005 and p = 0.01) respectively. No statistical difference was observed between groups for PD, CAL, GRH, and GRW 3 months after the surgery.

Statistically significant differences were observed between groups I and II in the WKT (p = 0), TKT (p = 0), and VD (p = 0), in addition to the changes in the MGJ (p = 0) and RC (0.050) measurements at the end point of follow-up (Table 1).

A statistical significance was observed between the group for WHI only 1 week after the surgery (p = 0.03) (Table 3).

No statistically significant intergroup differences were found for root sensitivity during the follow-up period (Table 4).


The purpose of this randomized, controlled split-mouth design study was to compare the clinical efficacy of two types of coronally pedicle flap, namely, semilunar and conventional coronally flaps while using TTC as the biomodified agent for the root surface and modifying in suturing technique. Bilateral recession defects for the same patient allow each patient to have his/her own control. The results of the present trial demonstrated that both techniques with modifications were effective for the treatment of shallow localized gingival recessions.

The TTC root conditioning may remove the smear layer, regulate the adsorption of plasma proteins, enhance adhesion of blood clot, and stimulate the deposition of collagen against the root surface.12,13 Woodyard et al. used TTC with CAF and reported RC by 67%.12 George et al. conducted a study in which they used TTC and fibrin glue adhesive fibrin adhesive system (FAS) application with SCPF and reported coverage by 50% in the FAS with TTC group, while the FAS-only group received almost no coverage.13

Table 1: Baseline and the 3-month clinical measurement (mean ± SD) for the semilunar coronally positioned flap and coronally advanced flap groups
Probing depthBaseline1.4 ± 0.81.4 ± 0.81
3 Months1.06 ± 0.21 ± 00.3
CALBaseline3.2 ± 1.13.6 ± 1.10.06
3 Months1.3 ± 0.31.3 ± 0.30.8
GRHBaseline1.8 ± 0.52.2 ± 0.60.005
3 Months0.2 ± 0.20.3 ± 0.30.6
GRWBaseline3.4 ± 0.83.7 ± 0.80.01
3 Months0.4 ± 0.30.5 ± 0.60.7
WKTBaseline4.6 ± 1.44.1 ± 1.30.07
3 Months6.3 ± 1.43.8 ± 1.10
TKTBaseline0.9 ± 0.10.9 ± 0.11
3 Months1.2 ± 0.20.9 ± 0.10
VDBaseline12.1 ± 2.111.9 ± 2.40.7
3 Months13.5 ± 2.29.2 ± 2.60
Position of MGJBaseline15.4 ± 2.315.7 ± 2.60.2
3 Months15.5 ± 2.113.5 ± 2.020
RC3 Months1.4 ± 0.61.9 ± 0.80.05
% RC3 Months82.3 ± 15.679.8 ± 27.70.8
CRC3 Months5 (31.3%)7 (43.8%)
RCS (full total score)3 Months7.50 ± 1.7 (25%/4)7.25 ± 1.7 (12.5%/2)0.6

SCPF, semilunar coronally positioned flap; CAF, coronally advanced flap;

CAL, clinical attachment level; GRH, gingival recession height; GRW, gingival recession width; WKT, width of keratinized tissue; TKT, thickness of keratinized tissue; VD, vestibular depth; change in the position of the mucogingival junction, RC, root coverage; % RC, percentage of root coverage RC; CRC, complete root coverage; RCS, root coverage esthetic score system; MGJ, mucogingival junction

* Wilcoxon test

The use of anchorage sutures was to fix and stabilize the flap as coronally as possible for attaining better results. In a previous study, an orthodontic button was used as a passive component for holding sutures, and it attained better stability to the flap in a coronally displaced position.14

As far as we know, no previous study was conducted using these modifications to these two techniques to study the differences between them in terms of all the clinical parameters and questionnaires adopted by our study.

In the SCPF group, the RC% was 82.3 ± 15.6% and CRC was achieved in five teeth (31.3%) whose defect was treated. Our result of RC% is higher than those presented by Moka et al.15 and Rana et al.6 (66.75% and 42.5%, respectively). However, Bittencourt et al.4 and Santana et al.5 reported 91.1% and 90.95% (CRC was 9.3%), respectively. More recently, França-Grohmann et al.16 found the RC% 79.76 ± 17.44 after 1 year and CRC was 33.33% (5 out of 15). Another case series, Santamaria et al.17 modified the design of the SCPF and achieved a mean RC of 85.4 ± 24.7% and the CRC was 41.6%.

For the CAF, the RC% was 79.8 ± 27.7 and the CRC was accomplished in seven teeth (43.8%) with defects. These results are in accordance with the previous studies.5,9,1820 Some studies conducted by Santana et al.21 and Moka et al.15 showed higher RC percentage than our results (96.6% and 93.48%, respectively). However, Jepsen et al.22 and Rana et al.6 reported a lower percentage (76.44 ± 26.83% and 42.5%, respectively) than that reported in our present trial.

The absence of full RC in the semilunar CAF for all cases may be due to the scar formation in the place of the semilunar incision (where the scar is vertical to the direction of the displacement of the gingival tissue), and this may cause contract of the gingival margin in the apical direction.23 The vertical releasing incisions in the conventional CAF are parallel to the displacement side, possibly helping to obtain more CRC.24 However, the anchorage sutures may reverse these forces or decrease it.

Statistically significant differences were detected between groups for the amount of RC, which agrees with other studies.5,25 However, both techniques were effective for attaining satisfaction and esthetic RC.

The healing process in the area where the pedicle graft is in contact with the denuded root surface consisted of adaptation stage (from 0 days to 4 days), proliferation stage (from 4 days to 21 days), attachment stage (from 27 days to 28 days), and the last stage of healing is maturation stage. It is characterized by the continuous formation of collagen fibers. After 2–3 months, bundles of collagen fibers insert into the cementum layer on the curetted root surface in the apical portion of the recession.26 Therefore, we can take clinical measurements 3 months after surgery and these are in accordance with previous studies.6,13,18,20,22,25,2729

Table 2: The frequency and proportions (n%) of the patient’s opinion, esthetic, and preference for semilunar coronally positioned flap or coronally advanced flap with the reason
Good  318.80743.80
Preference method of treatment  743.8085016.30
Reason (the most beautiful)  531.30743.80
Reason (less pain)  212.501  6.30
Table 3: 1, 2, and 4 weeks for wound healing index (WHI) (minimum and maximum and mean ± SD)
MinMaxMean ± SDMinMaxMean ± SDTest valueSig
1 Week12  1.8 ± 0.312  1.5 ± 0.50.03*
2 Weeks121.13 ± 0.3121.19 ± 0.40.3No
Month11     1 ± 011     1 ± 01No

* Wilcoxon test

Table 4: The frequency and proportions (n%) of baseline and 3 months for root sensitivity, pain intensity in the first 3 days after surgery, and the number of patients who needed to take analgesic pills
TimeThe levelSCPF
Root sensitivityBefore the surgeryPresence1486.701486.701
3 months postsurgeryNone1381.301381.300.7
Pain intensityDuring 24 hours after surgeryNone12751062.50
Mild  425  531.30
Moderate  0  0  1  6.30
48 hours after surgeryNone1381.301168.80
Mild  318.80  531.30
72 hours after surgeryNone1593.801275
Mild  1  6.30  425
Did you need to take an analgesic pillYes  743.80  956.30Yes
No  956.30  743.80No

Both treatment groups showed significant postsurgical improvement for parameters (PD, CAL, GRH, and GRW) when compared with baseline. In the SCPF group, these results are consistent with the previous studies.5,6,1416,30,31 However, no statistically significant difference was observed for the position of the MGJ. The gain in KT and VD may be explained by the healing pattern of the connective tissue that remains exposed. In this case, granular tissue will fill this area (semilunar incision area) and turn to the same tissue that existed before the flap had advanced. The increase in the WKT and TKT is desirable to prevent the recurrence of the condition in the future.32

Results from the present coronally advanced technique are in agreement with other studies.5,6,15,18,20,21,27,28,33 However, the WKT had decreased with statistical significance (p = 0.04), which was consistent with the finding of the previous study conducted by Santana et al.21 In previous studies,18,19,27,29 they showed a slight reduction at the 3-month follow-up. There was a decrease in the VD and position of the MGJ, with a statistically significant difference (p = 0). This can be explained by the results of the coronally displaced tissue by using the extended releasing incisions within the mucosa. This can affect oral hygiene procedures that are difficult in the case of shallow oral vestibulum and may cause a relapse of the treatment.32

Statistically significant differences were observed between two groups in the WKT (p = 0) (this agrees with another study5), TKT (p = 0), VD (p = 0), change the position of MGJ (p = 0), and RC (0.050) measurements at the end of follow-up.

Differences in treatment results with the previous studies might be associated with differences in case selection, inclusion criteria including baseline recession depth, the amount of keratinized tissue, flap thickness, single-tooth or multiple teeth, technique design,6,17 using no suture for SCPF,5,15 using microsurgery,4 adhesive application,4,16,31 EDTA used for root surface biomodification,4 and differences in the follow-up period. In addition to that, there was a difference in the way of measuring the parameters, i.e., we used the digital caliper with 0.01 mm precision with spreader and rubber stop to attain the most possible precise measurements.

When looking into the healing pattern for CAF, in the first week, the wound exhibited minimal color alteration with edema and erythema. The vertical incisions were clearly distinguishable. In the second week, edema and erythematous aspect progressively diminished, and these findings are similar to those presented by Huang et al.9 At the 3-month evaluation point (Fig. 2E), the color, texture, and contour became similar to the adjacent soft tissues and minimal scarring was noticeable in releasing incisions. However, the healing in the SCPF followed different stages, because the connective tissue remained exposed after displacing the tissue toward the coronal direction. We also noticed reddish granulation tissue formation and edema at the 1-week evaluation point. The intensity of these signs decreased gradually in the second week. After 3 months (Fig. 1E), the tissue was normal. However, a distinguished semilunar white scar was noticed in the incision site in some cases and these results resemble those of previous studies.5,31

In the SCPF group, an improvement was observed in wound healing throughout the first, second, and fourth week after surgery. A notable statistically significant difference between the two procedures was seen in the WHI for only the first week after surgery (p = 0.03).

For esthetic evaluation was achieved using both subjective and objective measurements. The objective measurement estimated that the RES was 7.50 ± 1.7 in the SCPF group. Four teeth achieved a total score (25%), and when compared with a study that used a new modification, the RCS was lower than that reported in our study (6.8 ± 1.3). The subjective evaluation revealed that 13 patients were satisfied with the final esthetic appearance with “excellent” rating by 81.3%; however, Bittencourt et al.31 reported “excellent” rating by 9 of the 17 patients, “good” by 7 patients, and “sufficient” by 1 patient. When asked about the preferred procedure, seven patients selected this technique (43.8%) and the most frequent reason for preferring this technique was “more beautiful” (31.3%). These results agree with those reported by previous studies.16,31

Although the RES score was 7.25 ± 1.7 for the CAF group and only two teeth achieved a total score (12.5%). The patients were satisfied with the esthetic result after 3 months and 56.3% gave it an “excellent” rating. Eight patients (50%) preferred this treatment and the most frequent reason for preferring this technique was “more beautiful” (7 patients 43.8%). Cairo et al.10 estimated the RES for CAF and found the RC ranged between 50% and 100% and the RES score ranged between 6 and 10. However, it was 6.7 ± 1.5 in a previous study.29

The lesser value of RCS for CAF in comparison to SCPF may be explained by the fact that the SCPF does not interfere with papillae in its design,3 while CAF11 relies on incisions at linear angles of the tooth by de-epithelizing the papillae. In addition to the keloid formation along the vertical releasing incisions in some cases was responsible for decreasing the esthetic evaluation made by the periodontist and the patient.

Regarding root sensitivity, it reduced from 87.6% at baseline to 18.7% (patients reported without root sensitivity by 81.3%) after 3 months for both groups. On the contrary to the present study, Bittencourt et al.31 reported no sensitivity at the end of follow-up that may be explained by higher RC%. However, the sensitivity improved between baseline and at the end point of the study, which was consistent with previous studies.16,29

No postoperative pain was reported among 75%, 81.3%, and 93.8% of the patients after 24, 48, and 72 hours, respectively. Of the 16, 9 (56.3%) patients did not take analgesic pills in the SCPF group. This differs with another study31 that reported no pain during the healing period, which may be due to the gentle manipulation of tissues by using microsurgery.

For the CAF group, patients reported no postoperative pain by 62.5% and 68.8% after 24 and 48 hours, respectively. After 72 hours, the percentage was 75%. Of the 16, 9 (56.3%) patients needed analgesics. The stronger postoperative pain in the CAF group compared with the SCPF group can be explained by extending the releasing incisions within the mucosa and edema during the healing process.

Although significant improvements were achieved using TTC biomodification and anchorage sutures, this study has a series of methodological limitations. First, a small sample size of the study and the short follow-up period may affect the reproducibility of the results. Alas, further studies with a larger sample size are needed in order to evaluate the long-term stability of the positive results.


Based on the results of the present study, we found that both procedures with the TTC biomodification of the root surface and anchorage sutures were effective, predicted surgical techniques, and provided satisfactory results in the treatment of gingival recession Miller’s class I for the patient and the periodontist.

In the semilunar CAF, a slightly higher proportion of the RC is achieved compared to the procedure of conventional CAF. Also, the RES and proportions of the patient’s opinion, esthetic, and preference are higher for SCPF than for CAF.

A greater WKT and TKT can be expected with the SCPF in comparison with the CAF. The SCPF produced an increase in the depth of the vestibule. So in cases of a shallow oral vestibulum and a gingival recession, it may be contraindicated to use CAF and preferable to use SCPF.


The study protocol was registered on ClinicalTrials.gov, with Registration number: NCT03391947 https://clinicaltrials.gov/ct2/show/NCT03391947?cond=semilunarandrank=1.


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