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19

Long-Term Results of Root Coverage

with Connective Tissue in the Envelope
Technique: A Report of 20 Cases

Matthias Rossberg, Dr Med Dent* Whereas circularly denuded root sur-

Peter Eickholz, Prof Dr Med Dent** faces (facial/oral and interproximal
Peter Raetzke, Prof Dr Med Dent, MSD*** recessions) caused by periodontitis
Petra Ratka-Krüger, Prof Dr Med Dent**** respond neither completely nor pre-
dictably to surgical attempts at cover-
age,1 there are several techniques that
Connective tissue grafts (CTGs) are generally viewed as the most successful tech- are successfully used to treat facial
nique for root coverage. The aim of this retrospective study was to assess the long- recessions2: coronally advanced and
term clinical and patient-centered esthetic results of the envelope technique for laterally positioned flaps, free gingival
CTG. Thirty-nine defects in 20 patients (22 to 57 years of age; mean 37.8 ± 11.5 grafts, connective tissue grafts (CTGs),
years) had received CTG that had been harvested from the palate and grafted and guided tissue regeneration.3
according to the envelope technique of Raetzke. Factors influencing root coverage Further, there exists a wide variety of
were identified by multilevel analysis. The patients were also asked to judge the
modifications of these techniques, eg,
results of treatment. Follow-up examinations were performed 6 to 22 years (mean,
the envelope technique for CTGs.4
11.4 ± 5.4 years) after surgery. Mean baseline recession was 3.1 ± 1.3 mm (range, 1
A recent structured review failed
to 6 mm). Clinical re-examination revealed mean root coverage of 89.7% ± 25.1%.
In 32 of 39 defects (82%), complete root coverage was achieved. Recessions were
to identify a technique that was supe-
statistically significantly reduced by a mean of 2.7 ± 1.2 mm (P < .001), to a post- rior to others with regard to root cov-
surgical mean of 0.4 ± 0.94 mm. Higher baseline Miller classes resulted in less favor- erage. However, the observation
able prognoses for complete and relative root coverage. Baseline recession height periods of most studies range from 6
had a negative influence and location at a canine had a positive influence on the to 12 months, with a few reporting
percentage of relative root coverage. All patients judged the situation at the respec- results 24,5 48,6 or 60 months7 after
tive teeth as improved. (Int J Periodontics Restorative Dent 2008;28:19–27.) surgery. Thus, the questions of how
long root coverage lasts and on what
*Research Fellow and Clinical Instructor, Department of Periodontology, Center for Dental,
Oral, and Maxillofacial Medicine, University Hospital of Frankfurt/Main, Germany.
factors it depends over the long term
**Professor and Chair, Department of Periodontology, Center for Dental, Oral, and remain unanswered. Furthermore, a
Maxillofacial Medicine, University Hospital of Frankfurt/Main, Germany. recent structured review recom-
***Professor Emeritus, Department of Periodontology, Center for Dental, Oral, and
mended the use of patient-centered
Maxillofacial Medicine, University Hospital of Frankfurt/Main, Germany.
****Associate Professor, Department of Periodontology, Center for Dental, Oral, and outcomes based on esthetics. 3
Maxillofacial Medicine, University Hospital of Frankfurt/Main, Germany; Section of Hence, the objectives of this retro-
Periodontology, Department of Operative Dentistry and Periodontology, Dental School spective follow-up study were to
and Hospital, Albert-Ludwigs-University, Freiburg, Germany.
assess the long-term clinical and
Correspondence to: Prof Dr Peter Eickholz, Poliklinik für Parodontologie, Theodor-Stern- patient-centered esthetic results of
Kai 7, D-60590 Frankfurt/Main, Germany; e-mail: eickholz@med.uni-frankfurt.de. the envelope technique for CTG.

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Rossberg.qxd 1/11/08 12:34 PM Page 20

20

Figs 1a and 1b Mandibular right first pre-

molar (a, left) before CTG and (b, right) 21
years after CTG. The region of interest
(incisal margin to mucogingival line of the
test tooth and both adjacent teeth) was
37.5 mm rotated and enlarged until the hard tissue 37.5 mm
structures had the same length on both
images. This was controlled for by measur-
24 mm ing the mesiodistal distance of the inter- 45 mm
proximal contacts of the respective teeth
(black lines). The image size used for the
investigation was at 5⫻ magnification (9
mm at the periodontal probe = 45 mm on 25 mm
the image; red lines), with each side of the
grid squares measuring 25 mm. Recession
height (blue lines) was measured between
the cementoenamel juction (yellow lines)
and the gingival margin in the presurgical
and postsurgical images. At this particular
site, the denuded root surface with a base-
line recession height of 4.8 mm (24 mm/5)
was completely covered 21 years later.

Method and materials
Patients
The archives of the Center for Dental,
Oral, and Maxillofacial Medicine of the
University Hospital of Frankfurt/Main
and the archives of one author (P.R.)
were searched for the records of all
patients who had received a root-
coverage procedure according to the
envelope technique from one of two
authors (P.R. and P.R.K.).4 The following
criteria had to be fulfilled for patients
to be included in this analysis: (1) oral
hygiene instructions and professional
tooth cleaning had been provided
before and after surgery, ( 2 )
Approximal Plaque Index (API)8 was
under 25%, (3) surgical root coverage
had been performed at least 5 years
prior to re-examination, and (4) base-
line photograhs of the recession were
available. Exclusion criteria were: (1)
presence of supragingival plaque or
gingival bleeding at the recession site
to be treated; (2) probing depths (PD)
greater than 3 mm; (3) axial mobility; (4)
presence of systemic diseases (eg, dia-
betes mellitus, blood dycrasias, AIDS);
and (5) medication usage (eg,
cyclosporin A) that might affect the
gingival tissues.
Clinical examinations
PDs were measured at four sites on
each tooth (mesial, buccal, distal, and
lingual), whereas mucogingival para-
meters were assessed only at the buc-
cal aspect; these measurements were
determined to the nearest millimeter
using a manual periodontal probe
(PCP12, Hu-Friedy). Then, the follow-
ing parameters were evaluated: (1)
height of recession, (2) width of kera-
tinized gingiva without staining, and (3)
classification of the recession accord-
ing to Miller.1
For five patients who had received
CTGs 20 to 22 years previously, the
clinical records with the presurgical
data were no longer available. To
include these patients, whose data
were particularly valuable because of
the long observation periods, presur-
gical photographs were used to obtain
presurgical mucogingival parameters
(Fig 1a). At the re-examination, pho-
tographs of the respective test teeth
were also obtained (Fig 1b). The
authors attempted to use a similar pro-
jection as had been used for the
presurgical images, and a periodontal
probe was held next to the test tooth
as a reference. The presurgical and
postsurgical images were digitized
(Microtek ScanWizard Pro V3.09,
UMAX Systems) and processed using
computer software (Photoshop 7.0,
Adobe Systems). A grid with 5-mm
squares was placed over both images.
The region of interest (incisal margin to
mucogingival line of the test tooth and

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Rossberg.qxd 1/11/08 12:34 PM Page 21
both adjacent teeth) was rotated and
enlarged until the hard tissue struc-
tures had the same length on both
images (Fig 1, black markings). To
reduce measurement error, both
images were enlarged fivefold, with
the periodontal probe used as a refer-
ence (Fig 1b, red marking). Thus, each
square of the grid measured 25 ⫻ 25
mm (Fig 1b, white marking). Now the
recession height and width of the ker-
atinized gingiva were measured in the
presurgical and postsurgical images.
All presurgical examinations and pho-
tographs were performed by the ther-
apists (P.R., P.R.K.), whereas all post-
surgical examinations were performed
by an independent examiner (M.R.).
Periodontal surgery
The surgical technique that was re-
examined in this study is described in
detail elsewhere.4 Briefly, the tech-
nique proceeded as follows. The sul-
cular epithelium at the recession was
excised. The denuded root surface was
scaled and planed thoroughly. Then a
pouch (envelope) was prepared using
a no. 15 blade. The gingiva and
mucosa were separated from the
periosteum to provide nutrition for the
CTG from the underlying periosteum
and covering soft tissue. After the
pouch was prepared, the CTG was
harvested from the premolar-molar
region of the palate. Two parallel inci-
sions 1 to 2 mm apart were made 2
mm paramarginally. Their mesiodistal
length measured twice the recession
width. Next, the epithelium was
removed, and the CTG was placed
within the pouch to cover the denuded
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root surface totally while being at least
50% submerged within the pouch at
the same time. The CTG was fixed with
tissue adhesive (Histoacryl, B. Braun
Melsungen), and the surgical site was
covered by periodontal dressing (Coe-
Pak, GC America). The donor site was
sutured and occasionally dressed.
Patients were instructed to refrain
from mechanical plaque control at the
surgical sites for 1 week after surgery.
To prevent postsurgical infection,
patients rinsed with a 0.2% chlorhexi-
dine gluconate solution (Corsodyl,
Fink) for 2 minutes, two times daily, for
1 week. Thereafter, patients were
placed on a maintenance program
once every 3 months for approximately
a year. After this period, most patients
were seen for supportive maintenance
about every 6 months.
Patient-centered outcomes
At the time of clinical re-examination,
all patients were asked for their opin-
ion about CTG. The following patient-
centered outcomes were analyzed per
patient: (1) reason for CTG (esthet-
ics/hypersensitivity), (2) whether post-
surgical discomfort was experienced
(yes/no), (3) duration of postsurgical
discomfort (days/weeks/months/years)
at donor and recession sites, ( 4 )
whether the problem for undergoing
CTG had been resolved (yes/no), and
(5) whether the patient would undergo
this kind of surgery again (yes/no).
Some patient-centered outcomes
were analyzed per defect: (1) satisfac-
tion with the result (grade 1 [very good]
to 6 [insufficient]), and (2) satisfaction
with esthetics, ie, thickness of tissue
21
(appropriate/too thick/too thin), color
(appropriate/too pale/too dark), and
contour (appropriate/too wide/too
high).
Statistical analysis
The primary endpoint in this study was
the long-term change in root cover-
age. Three variables were used to
describe root coverage: (1) absolute
reduction of recession height in mil-
limeters (difference between presur-
gical and postsurgical recession
height), (2) relative root coverage (as a
percentage), and (3) amount of reces-
sion defects showing 100% root cov-
erage postsurgically. The patient was
defined as the statistical unit.
For analysis, baseline PD was set
to 1 mm for those patients for whom
baseline documentation of measure-
ments was not available, to provide a
conservative estimate of clinical attach-
ment (CAL) gains between baseline
and the re-examination. Baseline and
postsurgical CAL gains were calculated
by adding PD and recession height.
Means and standard deviations of
baseline and postsurgical recession
heights and CAL as well as their dif-
ference were calculated and compared
using a paired t test with P < .05 set as
the level of statistical significance.
Relative root coverage (as a percent-
age) was calculated for each recession
defect and as a mean ± standard devi-
ation for the total sample. Using mul-
tilevel regression analyses, an attempt
was made to identify factors influenc-
ing long-term root coverage. Models
were fitted for the dependent variables
(1) relative root coverage (%) and (2)
Volume 28, Number 1, 2008
Rossberg.qxd 1/11/08 12:34 PM Page 22
22
complete root coverage (yes/no). The
following independent variables were
also used in the calculations: sex, age,
tooth type (incisor/canine/premolar),
jaw type (maxilla/mandible), Miller
class, baseline width of keratinized gin-
giva, baseline recession height, and
observation time. For all analyses, the
basic level “defect” was nested in the
upper level “patient” (defect level: n =
39; patient level: 20).9 Statistical analy-
sis was performed using a computer
program (Systat for Windows version
10, Systat).
Results
Patients
Medical records or presurgical pho-
tographs were collected for 38 patients
who had undergone the envelope
technique in 59 recession defects and
fulfilled the inclusion criteria. All of
these patients were invited for a re-
examination. However, 18 patients (20
defects) did not respond; of these, 16
patients (17 defects) could not be con-
tacted because their address was
unknown, one (two defects) was not
interested in participating, and one
(one defect) had died. The 20 patients
(10 women) available for re-examina-
tion had been 37.8 ± 11.5 years (range,
22 to 57 years) of age at the time of first
CTG. They contributed 39 treated
recession defects (19 in women): one
patient contributed 7 defects, one had
6 recessions, and one had 3 recessions;
six patients contributed 2 defects each;
and 11 patients had 1 defect each.
Table 1 gives the distribution of reces-
sions according to jaw and tooth type.
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Clinical parameters
Re-examinations were performed 6 to
22 years (mean, 11.4 ± 5.4 years) after
surgery. The mean presurgical reces-
sion height of 3.1 ± 1.3 mm (range, 1
to 6 mm) was statistically significantly
reduced by 2.7 ± 1.2 mm (P < .001) to
a postsurgical mean of 0.4 ± 0.9 mm.
The mean baseline width of the kera-
tinized gingiva was 1.4 ± 1.5 mm
(range, 0 to 5 mm), which was statisti-
cally significantly increased by 4.7 ± 2.3
mm (P < .001) to a postsurgical mean
of 6.1 ± 1.8 mm. Clinical re-examina-
tion revealed mean root coverage of
89.7% ± 25.1%. In 32 of 39 defects
(82%), complete root coverage had
been achieved. Higher baseline Miller
classes resulted in less favorable prog-
noses for complete and relative root
coverage (Tables 2 and 3). The mean
reduction in height of recessions that
were Miller Class I or II (n = 36) at base-
line was 2.8 ± 1.2 mm; for recessions
that were Miller Class III or IV, the mean
reduction was 1.3 ± 0.6 mm (P < .05).
Baseline recession height had a nega-
tive influence, and location at a canine
had a positive influence on the relative
percentage of root coverage (see
Table 2).
Patient-centered outcomes
Sixteen of 20 patients had requested
periodontal plastic surgery to improve
esthetics, and four patients requested
it because of hypersensitivity. All
patients judged the situation at the
respective teeth as improved. None of
them remembered discomfort at the
CTG recipient site after surgery. Four
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23

Table 1 Distribution of recession defects according to jaw

and tooth type
Central Lateral First Second
Jaw incisor incisor Canine premolar premolar Total
Maxilla 6 5 17 3 1 32
Mandible 2 1 2 2 0 7
Total 8 6 19 5 1 39

Table 2 Multilevel regression analysis with complete root

coverage (yes/no) as the dependent variable*
Estimate SE Z P
Intercept 1.375 0.155 8.876 .000
Baseline Miller class –0.214 0.068 –3.157 .002
Baseline recession height –0.105 0.045 –2.340 .019
Canine 0.200 0.108 1.849 .064
*N = 20 patients/39 defects.

Table 3 Multilevel regression analysis with relative root

coverage (%) as the dependent variable*
Estimate SE Z P
Intercept 116.245 7.629 15.238 .000
Baseline Miller class 16.959 4.359 –3.891 .000
*N = 20 patients/39 defects.

patients complained about discomfort recessions were characterized as good

at the palatal donor site that lasted for
more than 1 day. One patient experi-
enced paraesthesia that lasted for
years. Nineteen of 20 patients indicated
they would undergo CTG surgery for
similar reasons again. For 25 treated
recessions, the patients judged the
result as very good (a rating of 1), 11
(a rating of 2), and 3 sites were judged
satisfactory (a rating of 3). The esthetic
result at 18 CTG sites was deemed suf-
ficient, and at 21 it was felt to be too
thick. At 28 sites, the color was consid-
ered appropriate, and at 11 sites it was
felt to be too pale. Clinical examples of
treated sites are provided in Figs 2 to 6.

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Rossberg.qxd 1/11/08 12:34 PM Page 24

24

Figs 2a and 2b Maxillary right canine and

incisors (a, left) before and (b, right) 20
years (central incisor), 16 years (lateral
incisor), and 13 years (canine) after CTG.
The keratinized gingiva at the central incisor
and particularly the canine is a bit too thick,
and the color does not blend in perfectly.
However, total root coverage was main-
tained.

Figs 3a and 3b Mandibular left canine

(a, left) before and (b, right) 20 years after
CTG.

Figs 4a and 4b Maxillary left canine (a, left)

before and (b, right) 9 years after CTG.
Complete root coverage and perfect color
match are apparent.

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Rossberg.qxd 1/11/08 12:34 PM Page 25
Discussion
Of a total of 38 patients contributing
59 recession defects who were invited
to participate in this re-examination,
only 20 patients accepted the invita-
tion. This represents a responder rate
of only 53%. An unknown address was
the most frequent reason for nonre-
sponse (16 patients). Up to 22 years
after surgery it is very likely that
patients have moved away and that
some have changed their family name,
eg, because of marriage, and thus can-
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25
Figs 5a and 5b Maxillary left canine (a,
left) before and (b, right) 11 years after
CTG. The keratinized gingiva is a bit too
thick, and the color does not blend in per-
fectly. However, total root coverage was
achieved.
Figs 6a and 6b Maxillary left canine (a,
left) before and (b, right) 20 years after
CTG.
not be contacted. However, it seems
unlikely that the results are distorted
toward more favorable outcomes
because of nonresponders; only one
patient expressed a lack of interest in
participating.
The present case series presents
results at 6 to 22 years (mean, 11.4 ±
5.4 years) after root coverage with CTG
according to the envelope technique.
Thus, the shortest observation period
included in this retrospective analysis
is longer than the observation periods
of any other study of root coverage
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26
using CTG.5–7 The mean relative root
coverage observed at 6 to 22 years
after surgery was 89.7% ± 25.1%.
Because there are no similar studies
reporting long-term results for CTG, it
is difficult to compare the present
results with other results. Mean cover-
age after CTG of 64.7% to 95.6% was
reported at 6 to 12 months after
surgery.3 One study observed 85.23%
coverage at 60 months after surgery.7
The present study reports complete
root coverage in 32 of 39 defects
(82%). Complete coverage was
achieved in 20% to 83.3% of patients
6 to 12 months after surgery3 and in
48.57% of patients 60 months after
CTG.7 Taking into consideration the
long observation period and the
results of other studies, it may be con-
cluded that CTG according to the
envelope technique provides satisfac-
tory long-term root coverage.
The data for the short-term results
(6 or 12 months after surgery) of the
reported sample are no longer avail-
able. Thus, the present case series can-
not report actual stability. Root cover-
age at 6 to 22 years after surgery could
be caused, at least partially, by creep-
ing attachment. Harris10 had reported
a mean creeping attachment of 0.8
mm from 4 weeks after surgery to the
final postoperative visit. The mean time
between surgery and the final post-
operative visit was not given, but the
figures give intervals between 37 and
47 weeks. Creeping attachment
occurred in 21 of 22 defects and
resulted in complete root coverage in
17 of 22 defects.10 However, it is not
quite clear whether this creeping
attachment occured in the first 6 to 12
months after surgery or later. It is pos-
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sible that the effect of creeping attach-
ment is included in the results of those
studies that report root coverage at 6
or 12 months after CTG.
In the present study several
patients contributed more than one
recession defect to the sample.
Considering the patient as a statistical
unit, multilevel regression analyses
were applied to identify prognostic
factors for long-term root coverage.
These analyses revealed that sites with
higher Miller classes at baseline
resulted in less favorable prognoses
for complete as well as relative root
coverage (P < .005). Baseline recession
height had a negative influence (P =
.019), and location at a canine had a
positive influence (P = .064) on relative
percentage of root coverage. Baseline
recession height is already known to be
a negative prognostic factor of relative
root coverage after CTG.11 Location in
the maxilla had been associated with
better root coverage. Smoking, as
assessed by pack-years, had no influ-
ence on root coverage but did affect
attachment gain. Although the enve-
lope technique for CTG was used,
at 12 months after surgery, a relative
root coverage of 74% and complete
coverage in only 11 of 28 (39.3%)
recession defects were achieved.
Unfortunately, multiple linear regres-
sion analysis was applied inappropri-
ately; several patients who contributed
more than one defect were not taken
into consideration.11 However, the fact
that the present study failed to identify
type of jaw as a prognostic factor may
be a result of the location of only seven
of the 39 recession defects in the
mandible.
Rossberg.qxd 1/11/08 12:34 PM Page 27
Under the limitations of the pres-
ent study we draw the following con-
clusions.
1. The use of CTG according to the
envelope technique provides sta-
ble, long-term root coverage.
2. Good prognoses for long-term
root coverage are associated with
recession location at canines, and
less favorable prognoses are asso-
ciated with defects that show
increasing Miller class and reces-
sion height at baseline.
3. Overall, patients are quite satis-
fied with the surgical technique
and its results.
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27
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