Clinical Oral Investigations (2022) 26:7135–7142

https://doi.org/10.1007/s00784-022-04674-9

ORIGINAL ARTICLE

Treatment of multiple adjacent RT 1 gingival recessions

with the modified coronally advanced tunnel (MCAT) technique
and a collagen matrix or palatal connective tissue graft: 9‑year results
of a split‑mouth randomized clinical trial
B. Molnár1 · S. Aroca2 · A. Dobos1 · K. Orbán1 · J. Szabó1 · P. Windisch1 · A. Stähli2 · A. Sculean2

Received: 21 April 2022 / Accepted: 10 August 2022 / Published online: 22 August 2022
© The Author(s) 2022

Abstract
Objectives To evaluate the long-term outcomes following treatment of RT 1 multiple adjacent gingival recessions (MAGR)
using the modified coronally advanced tunnel (MCAT) with either a collagen matrix CM or a connective tissue graft (CTG).
Material and methods Sixteen of the original 22 subjects included in a randomized, controlled split-mouth clinical trial were
available for the 9-year follow-up (114 sites). Recessions were randomly treated by means of MCAT + CM (test) or MCAT + CTG
(control). Complete root coverage (CRC), mean root coverage (MRC), gingival recession depth (GRD), probing pocket depth
(PD), keratinized tissue width (KTW), and thickness (KGT) were compared with baseline values and with the 12-month results.
Results After 9 years, CRC was observed in 2 patients, one in each group. At 9 years, MRC was 23.0 ± 44.5% in the
test and 39.7 ± 35.1% in the control group (p = 0.179). The MRC reduction compared to 12 months was − 50.1 ± 47.0%
and − 48.3 ± 37.7%, respectively. The upper jaw obtained 31.92 ± 43.0% of MRC for the test and 51.1 ± 27.8% for the
control group (p = 0.111) compared to the lower jaw with 8.3 ± 46.9% and 20.7 ± 40.3%. KTW and KGT increased for both
CM and CTG together from 2.0 ± 0.7 to 3.1 ± 1.0 mm (< 0.0001). There were no statistically significant changes in PD.
Conclusion The present results indicate that (a) treatment of MAGR using MCAT in conjunction with either CM or CTG
is likely to show a relapse over a period of 9 years, and (b) the outcomes obtained in maxillary areas seem to be more stable
compared to the mandibular ones.
Clinical relevance The mean root coverage at 12 months could not be fully maintained over 9 years. On a long-term
basis, the results seem to be less stable in the mandible as compared to maxillary areas.

Keywords Modified coronally advanced tunnel · Multiple adjacent gingival recessions · Subepithelial connective tissue
graft · Collagen matrix

Introduction exposure of the root surface to the oral environment [1, 2].
GR is commonly observed, especially among young and
Gingival recession (GR) is defined as the apical shift of middle-aged adults [3]. Besides aesthetic complaints, GR
the gingival margin with respect to the cemento-enamel may also cause root hypersensitivity, risk for development
junction (CEJ), associated with attachment loss and of caries or non-carious cervical lesions, and difficulties
to achieve optimal plaque control [4].
While most of the existing literature reports on the
treatment of single gingival recessions [5, 6], frequently,
* A. Sculean root exposures affect multiple adjacent teeth and are con-
anton.sculean@unibe.ch
sidered a generalized condition [7, 8]. The treatment of
1
Department of Periodontology, Semmelweis University, multiple adjacent gingival recessions (MAGR) poses a
Budapest, Hungary challenge for the clinician while data is still scarce on
2
Department of Periodontology, School of Dental Medicine, these procedures [9]. In the last two decades, the modified
University of Bern, Bern, Switzerland coronally advanced flap (MCAF) has become one of the

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most popular techniques for the treatment of MAGR [10]. Materials and methods
Another surgical approach which has provided successful
outcomes in the treatment of MAGR is the modified coro- The CONSORT statement for improving the quality of
nally advanced tunnel (MCAT) consisting of a preparation reports of parallel RCT (http://​www.​conso​rt-​state​ment.o​ rg/)
without raising a mucosal or mucoperiosteal flap and keep- was followed in the preparation of this study.
ing the papillae intact. Several studies have recently evalu-
ated the treatment of single and multiple recessions with Study design and patient demographics
MCAT demonstrating comparable improvements to those
following the use of MCAF [11–14]. This is a 9-year follow-up of a previously published ran-
MCAT with the absence of releasing incisions deliv- domized split-mouth study [15], involving twenty-two
ers aesthetic outcomes; other benefits are favorable wound patients with a total of 156 sites of class 1 (previously
healing, minimal postoperative morbidity, and optimal blood Miller I and II) MAGR [22, 23]. The original study was
supply and graft nutrition [15]. conducted between July 2010 and November 2011 at the
Palatal connective tissue graft (CTG) is still the gold Department of Periodontology of the Semmelweis Univer-
standard among the soft tissue grafts used for various soft sity, Budapest, Hungary, in accordance with the Helsinki
tissue augmentation procedures, although limitations in Declaration of 1975, as revised in 2013. The study protocol
the size, shape, and thickness homogeneity may be present was approved by the ethical committee of the Semmelweis
[7]. However, CTG harvesting may be associated with pro- University (protocol: 5242–0/2010-101SEKU; 365/PI/10).
longed surgical time, increased patient morbidity, and the The detailed protocol of the study along with the outcomes
possibility of postoperative complications. To overcome obtained at 1 year has been published before [15]. Thus,
these inconveniences, there has been a strong demand to in the following, only a summary of the study design and
find an alternative soft tissue grafting material [16]. The use patient demographics is presented.
of a porcine xenogeneic collagen matrix (CM; Mucograft, To detect a true difference for the primary outcome of
Geistlich, Wolhusen, Switzerland) in recession coverage was 20% assuming a power of 80%, the sample size calculation
first evaluated in a histological study in minipigs. CM can requested a minimal sample size of 18 patients. A total of
serve as a scaffold for cells to enhance blood clot stability 22 patients were finally included.
and conduce the ingrowth of blood vessels. Allergic reac-
tions and material exfoliations were not reported during the Inclusion criteria
application of this CM for recession coverage [17]. Clini-
cally, a case report [18] as well as randomized controlled The inclusion criteria are the following: 18 years old or
clinical studies compared the treatment of Miller class I older, systemically healthy subjects with at least 3 adjacent
and II single [19] and later multiple recessions [15, 20]. Miller I and II recessions on both sides. Full-Mouth Plaque
Several articles have compared sites treated by gingival Score (FMPS) had to be under 25%.
augmentation to untreated sites in long-term studies with
18–35-year follow-up. The long-term observations support Exclusion criteria
the importance of attached gingiva in preventing recession
development due to prolonged mechanical trauma, bacterial The exclusion criteria are the following: pregnancy or lacta-
inflammation, and iatrogenic factors during aging [1, 21]. A tion, tobacco smoking, uncontrolled medical conditions, medi-
study with a long-term follow-up showed that sites treated cations that can affect gingival conditions, infectious diseases,
with autologous soft tissue graft transplantation showed non-cooperative patients, failure to sign informed consent.
coronal displacement of the gingival margin with recession
reduction, whereas recessions at contralateral untreated sites Surgical approach
increased, or new recessions were developed during an 18-
to 35-year follow-up [21]. All the 22 patients underwent full-mouth supragingival
Despite the fact that CM was proven to be a realistic scaling and polishing; then, individualized oral hygiene
alternative to CTG on the short term (i.e., after a period instructions were given preoperatively. The modified cor-
of 12 months), long-term results are still missing in the onally advanced tunnel technique (MCAT) was applied
literature. in all cases in conjunction with either CM or CTG in a
Therefore, the aim of the present study was to evaluate the randomized split-mouth design. The random allocation of
long-term outcomes (i.e., after a period of 9 years) following groups was generated using a computer program. Thus,
treatment of class 1 (previously Miller class I and II) MAGR every patient had one side of the jaw treated by means of
by means of the MCAT and either CM or CTG. MCAT technique with a bioresorbable collagen matrix

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(Mucograft®, Geistlich, Wolhusen, Switzerland) as a test. were as follows: recession depth (RD), recession width
The other side of the jaw was treated with CTG, which [11], keratinized gingiva width (KGW) in the mid-buccal
was harvested from the palate and this site was considered aspect, papilla-contact point distance (PCD), papilla width
control. Both surgeries were performed by the same experi- (PW), probing depth on 3 surfaces (PD). Keratinized tissue
enced surgeon (SA) in one session. The surgical technique thickness (KT) was only measured at baseline, 6 months,
was described in detail in a previous article [18]. In brief, 12 months, and 9 years via sterile K-files following local
resin bonding at the contact points of the adjacent teeth anesthesia at 3-mm apical distance from the gingival margin.
was performed immediately before the surgery for sus- A UNC 15 type periodontal probe was used for measure-
pended suturing. Under local anesthesia, the exposed root ments (Hu-Friedy, Chicago, IL, USA) The examiner was
surfaces were gently planed by hand instruments (Gracey calibrated as discussed in original article. During surgery,
Curettes, Hu-Friedy). The preparation of MCAT started the length of the procedure was measured in minutes.
with an intrasulcular incision around involved teeth using Statistical analysis was performed using commercially
microsurgical tunneling knives (Stoma). Mucoperiosteal available software (Instats 2000, version 3.05, GraphPad
flaps were elevated first as an envelope flap subsequently Prism 9.0.0. Software Inc., San Diego, CA, USA). A patient-
interconnected in a tunnel preparation. Flap preparation was level analysis was performed for each parameter. Therefore,
extended beyond the mucogingival junction in split thick- mean values and standard deviations [26] for the clinical
ness and lastly, interdental papillae were gently undermined variables were calculated for each patient per treatment.
to allow tension-free, passive mobilization to the coronal The primary outcome variable was complete root coverage
aspect. After tunnel preparation, the grafting procedure was (CRC); secondary outcomes were MRC, amount of KTT,
carried out according to the randomization code. The colla- KTW, GRD, PW, and PD, respectively.
gen matrix was trimmed and adapted to the required length
and size. A CTG was harvested from the palate by the sin- Statistical analysis
gle incision technique [24] or a modified distal wedge pro-
cedure [25]. To close the donor site, either cross-mattress For each clinical parameter, a patient-level analysis was
sutures or modified mattress sutures were placed. The inser- performed; i.e., mean values and standard deviations were
tion of both grafts to the subperiosteal tunnel was started calculated for each outcome and patient, respectively. Due
in the widest recession using horizontal mattress sutures at to the non-parametric distribution of the data, between-
mesial and distal aspect of the grafts. Finally, suspended group comparisons including Bonferroni corrections were
sutures were placed above the approximal composite stops, conducted using the Mann–Whitney U test for independent
and the tunneled flap was positioned 1 mm coronally to the unpaired variables, the Wilcoxon signed rank test for paired,
cemento-enamel junction (CEJ). and the Friedman test for dependent variables. Significance
was set at p < 0.05.
Post‑surgical treatment

Patients were prescribed analgesics for 3 days (3 × 50 mg Results

diclofenac, Cataflam, Novartis) and antibiotics (3 × 625 mg
amoxicillin and clavulanic acid, Augmentin, GlaxoSmith- Original study with 12‑month results
Kline) for 7 days for infection prophylaxis. In addition,
patients were advised to rinse with a 0.2% chlorhexidine Detailed demographics and description of the original study
solution (2 × per day for 3 weeks) and to discontinue tooth sample were reported in the original publication [15].
brushing at the surgical sites until the suture removal Data in the original article represented split mouth data of
(2 weeks). The composite stops at the contact points were 22 patients with 156 recessions (78 treated with CTG and 78
removed after 3 weeks. Recall appointments were sched- with CM). Mean root coverage (MRC) was 71% on test and
uled every 3 months in the first 1 year and every 6 months 90% on control sites at 12 months. Complete root coverage
thereafter. (CRC) of all treated teeth was achieved in 5 sides out of 22 in
the test and in 13 sides out of 22 in the control, respectively.
Measurements Three patients presented with CRC for all treated recessions.
Mean KGW had increased from 2.1 ± 0.9 to 2.4 ± 0.7 mm on
Clinical assessments were performed at baseline, at 1 month, test sites and from 2.0 ± 0.7 to 2.7 ± 0.8 mm on the control sites.
3 months, 6 months, 12 months and 9 years after the surgery KGT had increased from 0.8 ± 0.3 to 0.95 ± 0.4 mm (test) and
by the same masked investigator (BM). Assessed parameters from 0.8 ± 0.4 to 1.3 ± 0.5 mm (control). PD had not changed.

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Table 1  Patient demographics Patients’ characteristics at 9‑year follow‑up

Baseline–9 years
Sixteen out of 22 (72%) individuals were available for a
Baseline 9 years
9-year recall with a total of 114 treated recessions (72 in the
Number of patients 22 16 maxilla and 42 in the mandible). None of the patients had
Number of total recessions 156 114 received restorations or lost any of the investigated teeth
Number of maxillary recessions 94 72 during the 9 years of follow-up (Table 1).
Number of mandibular recessions 62 42

Table 2  Mean and complete root coverage

Baseline–12 months Baseline–9 years
Test group Control group p value Test group Control group p value
(MCAT + CM) (MCAT + CTG) (MCAT + CM) (MCAT + CTG)

Mean root coverage (MRC) % 73.25 ± 21.05 88.07 ± 20.90 0.021 23.07 ± 44.56 39.73 ± 35.17 0.179
MRC maxilla % 69.38 ± 22.23 83.44 ± 25.31 0.109 31.92 ± 43.06 51.11 ± 27.80 0.111
MRC mandible % 79.71 ± 18.98 95.77 ± 6.05 0.187 8.83 ± 46.92 20.75 ± 40.36 > 0.99
Teeth with complete root coverage (CRC) 31 45 14 18
Patients with CRC for all teeth on one side 4 9 1 1

Table 3  Mucogingival Test group (MCAT + CM) Control group p value t vs c

parameters (MCAT + CTG)

Recession depth (RD)

Baseline (t1) 1.81 ± 0.63 1.78 ± 0.54 0.900
12 months (t2) 0.50 ± 0.40 0.21 ± 0.30 0.035
9 years (t3) 1.28 ± 0.68 1.06 ± 0.65 0.635
p value t1 vs t2 < 0.0001 < 0.0001
p value t2 vs t3 < 0.0001 < 0.0001
p value t1 vs t3 ns ns
Keratinized tissue thickness (KTT)
Baseline (t1) 0.833 ± 0.26 0.86 ± 0.29 0.515
12 months (t2) 0.97 ± 0.31 1.32 ± 0.40 0.0002
9 years (t3) 1.49 ± 0.32 1.57 ± 0.35 0.710
p value t1 vs t2 ns < 0.0001
p value t2 vs t3 < 0.0001 ns
p value t1 vs t3 < 0.0001 < 0.0001
Keratinized tissue width (KTW)
Baseline (t1) 2.00 ± 0.90 2.03 ± 0.65 0.845
12 months (t2) 2.32 ± 0.72 2.78 ± 0.82 0.074
9 years (t3) 2.97 ± 0.95 3.28 ± 1.14 0.336
p value t1 vs t2 ns ns
p value t2 vs t3 ns ns
p value t1 vs t3 0.002 0.0006
Papilla width (PW)
Baseline (t1) 3.54 ± 0.80 3.62 ± 0.86 0.968
12 months (t2) 4.65 ± 1.06 4.92 ± 1.16 0.189
9 years (t3) 4.67 ± 0.66 4.54 ± 0.53 0.425
p value t1 vs t2 0.0003 0.0002
p value t2 vs t3 Ns Ns
p value t1 vs t3 0.0003 0.0002

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Fig. 1  Case Nr. 19. Test side

treatment and follow-up — a
baseline, b CM adaptation,
c CM in tunnel, d suspended
suturing, e 1 year, f 9 years/CM,
mucograft collagen matrix

Clinical outcome after 9 years for the control group (p = 0.7197) whereas KTT gained
by 0.6 ± 0.3 mm in the test and 0.7 ± 0.3 mm in the con-
MRC trol group (p = 0.8403). When splitting up the results for
mandible and maxilla, in the mandible, the increase was
Results are compiled in Table 2. Compared to 12 months, MRC 1.7 ± 0.26 mm for the test group and 1.3 ± 1.3 mm for the
decreased from 73.2 ± 21.0 to 23.0 ± 44.5% in the test and from control group (p = 0.625) and in the maxilla 0.9 ± 1.3 mm
88.0 ± 20.9 to 39.7 ± 35.1% in the control among the 16 sub- and 0.47 ± 0.6 mm (p = 0.3047), respectively. Regard-
jects who attended the 9-year follow-up. Differences in MRC ing KTT, in the mandible, the increase was 0.7 ± 0.3 mm
between the groups were significant after 12 months (p = 0.021) and 0.7 ± 0.3 mm (p = 0.6562) for test and control. In the
but diminished after 9 years (p = 0.179). In the mandible, MRC maxilla, KTT increased by 0.58 ± 0.4 mm for the test and
decreased from 79.7 ± 18.9% at 12 months to 8.3 ± 46.9% at 0.6 ± 0.28 mm for the control group (p > 0.9).
9 years in the test group, and from 95.8 ± 6.6 to 20.7 ± 40.3% in
the control group, respectively. In the maxilla, MRC decreased Keratinized tissue gain compared to 12 months
from 69.3 ± 22.2 to 31.9 ± 43.0% (test) and 83.4 ± 25.3 to
51.1 ± 27.8% (control). After 9 years, CRC was maintained on The average gain in KTW at 9 years was 0.6 ± 0.9 mm and
32 teeth out of 114 treated recessions. There was one side in 0.4 ± 0.6 mm for CM and CTG (p = 0.7168). KTT revealed
each group that reached CRC for all treated teeth of the quadrant. an increase following both procedures of 0.5 ± 0.4 mm in
the test and 0.2 ± 0.3 mm in the control with a significant
Keratinized tissue gain compared to baseline difference between the groups (p = 0.0259).
In the mandible, KTW increased by 0.3 ± 0.7 mm in the
In terms of keratinized tissue volume gain (Table 3), KTW test and 0.5 ± 0.6 mm in the control (p = 0.375). The cor-
increased by 0.9 ± 1.1 mm for test and by 0.8 ± 1.0 mm responding values for the maxilla were 0.8 ± 1.0 mm for the

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Fig. 2  Case Nr. 19. Control side

treatment and follow-up — a
baseline, b CTG adaptation,
c CTG in tunnel, d suspended
suturing, e 1 year, f 9 years/
CTG, connective tissue graft

test and 0.4 ± 0.6 mm for the control (p = 0.2969). In the Discussion
mandible, KTT increased by 0.5 ± 0.3 mm in the test and
0.28 ± 0.3 mm in the control group (p = 0.0625). In the max- The present study has evaluated the long-term outcomes
illa, for KTT, the increase from 12 months to 9 years were following treatment of class 1 MAGR using the MCAT in
as follows: 0.47 ± 0.4 mm in the test, 0.17 ± 0.37 mm in the conjunction with either CM or CTG. The results revealed
control group (p = 0.1992). that both graft materials may lead to positive aesthetic out-
comes, which can be maintained over a period of 9 years.
Measurements of papilla‑contact point distance (PCD) One important observation, however, is the statistically sig-
and papilla width (PW) nificantly lower MRC measured in the lower jaw, compared
to the upper jaw in the group treated with CM. Interestingly,
PCD presented no differences between test and control the increase of the KTT was similar in both groups; KTW
for any timepoint whereas PW demonstrated a signifi- showed only a slight difference favoring the CTG.
cant increase at 12 months compared to baseline for both Most of the available literature compares different sur-
groups. This difference was maintained over the 9 years gical techniques or reports on a single surgical technique
(Table 3). alone and with one type of grafting material. There are only
a few randomized, controlled clinical studies comparing the
Pocket depth (PD) same surgical approach for the coverage of multiple gingival
recessions using different grafting materials [15, 26–28].
No differences of pocket depths were found between the The present study included multiple bilateral recessions
groups and timepoints. both in the maxilla and mandible, also involving recession
Clinical procedures and outcomes are represented in coverage at molars, which in turn may increase the risk of
Fig. 1 and Fig. 2. surgical difficulties and failures. Treatment of molars likely

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Clinical Oral Investigations (2022) 26:7135–7142 7141

influenced the overall results because of the anatomical con- in agreement with recent findings indicating that in cases
siderations: wide mesio-distal cervical contour, difficulties of multiple mandibular adjacent gingival recessions, the
to access. Although recessions in the lateral zone may be of treatment is frequently even more challenging due to dif-
concern for patients with high lip lines or root hypersensi- ficulties related to the preparation of a tension-free flap or
tivity, they are still considered to be a major challenge for tunnel, stabilization of the graft and complete, and tension-
clinicians. free coverage of the graft and of the exposed root surfaces
A recent systematic review has attempted to answer the [32]. However, further research is needed in order to shed
question whether any 3D matrix biomaterial used for root more light on the factors responsible for the differences in
coverage of localized class 1 defects may provide equivalent the outcomes between maxillary and mandibular recessions.
outcomes with CTG [29]. The results have shown that in
terms of relative root coverage, no statistically significant
differences were found among autogenous grafts, allografts, Conclusion
and xenogeneic materials. In terms of keratinized tissue
width, on 2 mm recessions, CTG showed superiority above Within their limits, the present results indicate that (a) the
other biomaterials, but on 3 mm recessions, the results were results obtained in MAGR using MCAT in conjunction with
the same. Interestingly, the percentage of recessions with either CM or CTG are likely to deteriorate over the course
CRC showed comparable results for all biomaterials. of 9 years, and (b) the outcomes obtained in maxillary areas
McGuire et al. investigated the short- (up to 6 months) seem to be more stable compared to the mandibular ones.
and the long-term outcomes (after 5 years) obtained with
CM or CTG in conjunction with coronally advanced flap
[30, 31] in single recessions. At 6 months, there were no Funding Open access funding provided by University of Bern
statistically significant differences in terms of MRC (i.e.,
Open Access This article is licensed under a Creative Commons Attri-
97.5% for CTG and 89.5% for CM, respectively), while at bution 4.0 International License, which permits use, sharing, adapta-
5 years the same values measured 95.5% for CTG and 77.6% tion, distribution and reproduction in any medium or format, as long
for CM, respectively. as you give appropriate credit to the original author(s) and the source,
The results of the present long-term study are also in line provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
with recent findings by Tonetti et al. [28], who have reported included in the article's Creative Commons licence, unless indicated
the 36-month follow-up of a trial comparing the adjunc- otherwise in a credit line to the material. If material is not included in
tive use of CM or CTG to CAF for the coverage of MAGR. the article's Creative Commons licence and your intended use is not
At 3 years, the root coverage measured 1.5 ± 1.5 mm for permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
CMX and 2.0 ± 1.0 mm for CTG (difference of 0.32 mm, copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/.
95% CI from − 0.02 to 0.65 mm) while the upper limit of
the confidence interval was over the non-inferiority margin
of 0.25 mm. Furthermore, no differences in the stability of References
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