JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 184-190

Long-term Clinical Evaluation of Coronally Advanced Flap with Chorion Membrane for the Treatment of Multiple Adjacent Gingival Recession Defects

1 Department of Periodontology, HP Government Dental College, Shimla, Himachal Pradesh, India
2 Department of Public Health Dentistry, HP Government Dental College, Shimla, Himachal Pradesh, India

Date of Submission18-Sep-2019
Date of Acceptance01-Nov-2019
Date of Web Publication14-Dec-2020

Correspondence Address:
Dr. Deepak Sharma
Department of Periodontology, HP Government Dental College, Shimla, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicdro.jicdro_40_19

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Multiple adjacent recessions are challenging defects since they present a number of critical anatomic features as large surgical field, frequently shallow vestibules and prominent roots as well as a variation in the size of defects and residual keratinized tissue. Different surgical techniques have been proposed for the treatment of multiple adjacent recessions, mainly derived from the coronally advanced flap with or without connective tissue graft or from tunnel approaches. Harvesting of connective tissue graft is time consuming, it is limited in quantity and exposes patient to another surgical wound. The overall objective of this study is to evaluate the effectiveness of Coronally advanced flap with Chorion membrane for the treatment of multiple adjacent gingival recession defects.

Keywords: Chorion membrane, coronally advanced flap, multiple gingival recessions

How to cite this article:
Sharma D, Jhingta PK, Bhardwaj VK, Thakur AS. Long-term Clinical Evaluation of Coronally Advanced Flap with Chorion Membrane for the Treatment of Multiple Adjacent Gingival Recession Defects. J Int Clin Dent Res Organ 2020;12:184-90

How to cite this URL:
Sharma D, Jhingta PK, Bhardwaj VK, Thakur AS. Long-term Clinical Evaluation of Coronally Advanced Flap with Chorion Membrane for the Treatment of Multiple Adjacent Gingival Recession Defects. J Int Clin Dent Res Organ [serial online] 2020 [cited 2021 Jun 19];12:184-90. Available from: https://www.jicdro.org/text.asp?2020/12/2/184/303404

   Introduction Top

The purpose of the study was to assess the long term clinical effectiveness of Coronally advanced flap (CAF) with Chorion membrane for the treatment of multiple adjacent gingival recession (GR) defects.

GR is defined as the exposure of the root surface due to the displacement of the gingival margin (GM) apical to the cementoenamel junction (CEJ).[1] The prevalence of GR has been shown to increase with age and can occur in patients with good standards of oral hygiene as well as those with poor oral hygiene and periodontal disease.[2] There are varied etiologic and predisposing factors related to GR, including trauma from tooth brushing, malposition of teeth, frenilia, and muscle attachments.[3] Indications for root coverage (RC) include esthetic demand, root hypersensitivity, prevention or management of root caries and cervical abrasion, enhancement of restorative outcomes, and prevention of disease progression in areas where hygiene cannot be adequately maintained.[3],[4]

During the past few years, the effectiveness of periodontal plastic surgery procedures in the treatment of localized or multiple recession-type defects (MRTDs) has been reported in several trials. Studies testing different techniques, such as CAF alone, subepithelial connective tissue graft (CTG) alone or in combination with rotated or advanced flaps, and guided tissue regeneration, have demonstrated that surgical treatment of exposed root surfaces improves clinical attachment levels (CALs) and reduces GR in most patients.[5] Other recent studies have suggested that the choice of treatment for MRTD involving two or more adjacent teeth may be based on a variety of factors, such as anatomic structure, anticipated level of discomfort during healing, cost, and need for more than one surgical procedure to treat the entire recession site.[6],[7]

Fetal membranes are comprised amniotic and chorion tissues. The chorion forms the outer limits of the sac that encloses the fetus and is composed of different types of collagen and cell adhesion bioactive factors. These are known to aid in the formation of granulation tissue by stimulating fibroblast growth and neovascularization.[8],[9] These properties suggest that a chorion membrane may have considerable potential for regeneration.

The aim of this study was to evaluate the clinical effectiveness of CAF in combination with chorion fetal membrane in multiple adjacent Miller’s Class I and II GRs.

   Materials and Methods Top

Five patients (three women and two men; age range: 36–53 years) with more than two Miller Class I or II[10] facial GRs who were systemically healthy, nonsmokers, and nontobacco chewers were selected for the study approved by the Ethics Committee of the Institute [Figure 1]. A total of 21 sites were treated. All patients were healthy, cooperative, and understood the study protocol. Written consent from all patients was obtained after the nature of the procedure and risks had been fully explained. A complete case history, including a periodontal evaluation, was recorded. Patients’ recruitment and surgical procedures were undertaken from January to May 2016.
Figure 1: multiple adjacent gingival recessions with respect to 24, 25, and 26

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All the measurements were recorded by a blinded, trained, and calibrated examiner at the baseline and at 6 months, 12 months, and 36 months after the surgery and quantified with a caliper of 0.01-mm resolution. The baseline measurements were recorded 1 month after the initial therapy which included full-mouth scaling and root planing and oral hygiene instructions. The following clinical values were recorded at the baseline, then at 6, 12, and 36 month postoperatively: plaque index (Löe 1967), gingival index (GI) (Löe and Silness 1963), Probing Depth (PD), CAL, GR height (GRH), recession width (RW), and width and thickness of keratinized gingiva.

GRH was measured from the CEJ to the GM at the mid-buccal point of the teeth involved, using a periodontal probe, UNC 15 (Hu Friedy, USA). Keratinized gingival width was measured from the mucogingival junction to the GM. RW was measured at the CEJ. The thickness of the keratinized gingiva was measured 3 mm below the GM in the attached gingiva or the alveolar mucosa, using a number 15 endodontic reamer with a silicone disk stop. The mucosal surface was pierced at a 90° angle with slight pressure until hard tissue was reached. The silicone stop on the reamer was then slid until it was in close contact with the gingiva. After removal of the reamer, the distance between the tip of the reamer and the inner border of the silicone stop was measured to the nearest 0.1 mm with caipers.

Patient satisfaction

A questionnaire was given to each patient at follow-up visit for suture removal to evaluate the postoperative pain, discomfort, and swelling. Another questionnaire was filled by the patients and recorded the results of the procedures relative to esthetics and root sensitivity at 6 month postoperative period. The questionnaires were administered by a research assistant, independent of the surgeon. In terms of the discomfort, pain, and swelling experienced in the postoperative period, patients selected one of the following choices: none, mild, moderate, or severe. In terms of esthetic outcome and improvement in dentin sensitivity, patients expressed their opinion by selecting one of the following choices: bad, sufficient, good, or excellent [Table 1].
Table 1: Results from the survey of patient-related outcomes

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Surgical procedure

CAF design used in the study is similar to that described by Langer and Langer involving the use of vertical releasing incisions.[11] The flap design consisted of a horizontal incision extended to the most distal teeth with GRs on each side. The flap was raised with a split-full-split approach in the coronal–apical direction; the surgical papilla was elevated split thickness. Gingival tissue apical to the root exposures was raised full thickness and it terminated once 3–4 mm of the bone was denuded apical to the bone dehiscence. The most apical portion of the flap was elevated split thickness to facilitate coronal displacement of the flap. The remaining soft tissue of the anatomic interdental papillae was de-epithelialized [Figure 2].
Figure 2: flap reflection and root planning

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During coronal advancement, flap mobilization was considered adequate when the marginal portion of the flap was able to passively reach a level coronal to the CEJ at every tooth in the surgical area and when the surgical papillae covered the corresponding anatomic papillae. Root planing of the exposed root surface was performed with Gracey curettes (Hu Friedy, USA). Chorion membranes were procured from Tissue bank, Tata Memorial Hospital, Mumbai, Maharashtra, India [Figure 3]. The membrane of the desired defect dimensions was trimmed and placed over the defect and sutured with interdental papilla with resorbable suture (Ethicon 5–0 Vicryl absorbable suture) [Figure 4]. CAF was sutured with a silk suture (Ethicon Mersilk Black Braided Suture). The periodontal surgical dressing was placed on the operated sites. [Figure 5],[Figure 6],[Figure 7] show postoperative views at 6, 12, and 36 months, respectively.
Figure 3: chorion membrane used in the study

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Figure 4: chorion membrane sutured

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Figure 5: 6 month postoperative

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Figure 6: 12 month postoperative

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Figure 7: 36 month postoperative

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Postsurgical care and follow-up

Postoperative instructions were given to each patient, and analgesics were prescribed ibuprofen 400 mg as and when required by the patient to relieve postoperative pain. Tooth brushing was discontinued at the site of the operation for 4 weeks. Patients were instructed to keep the surgical site clean by a moist cotton pellet. During this period, plaque control was provided by rinsing with a 0.12% chlorhexidine digluconate solution twice a day. Sutures were removed 2 weeks after the surgery. One month after the surgery, the patients were instructed to resume mechanical tooth cleaning of the treated area using a coronally directed roll technique that minimized apically directed trauma to the tissues of the treated teeth. Patients were enrolled in a periodontal maintenance program (professional plaque control) weekly for the first 4 weeks and then monthly until the end of the study period. All patients were evaluated at 6, 12, and 36 months for the recording of all study parameters. Photographs of the second patient are shown in [Figure 8],[Figure 9],[Figure 10],[Figure 11],[Figure 12],[Figure 13],[Figure 14],[Figure 15].
Figure 8: second patient with multiple adjacent gingival recession with respect to 13, 14, 15, 16 and 44, 45, and 46

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Figure 9: flap reflection and root planning

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Figure 10: chorion membrane sutured

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Figure 11: CAF sutured

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Figure 12: chorion membrane placement w.r.t. 44, 45, 46

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Figure 13: 6 month postoperative

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Figure 14: 12 month postoperative

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Figure 15: 36 month postoperative second patient

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   Results Top

The statistical analysis was performed using a statistical software program SPSS version 11.5 (IBM, USA). The results were averaged as mean ± standard deviation for all clinical parameters at the baseline and at 6, 12, and 36 months and are presented in [Table 2].
Table 2: Clinical measurements at the baseline and 6, 12, and 36 month postsurgery

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Statistically significant increase in the width of the keratinized gingiva (WKG) was observed at 6, 12, and 36 months as compared to the baseline. The thickness of the keratinized gingiva was significantly increased at 6 months of follow-up, however, nonsignificantly increased at 12 and 36 months as compared to the baseline. Clinical parameter of the probing depth (PD) was significantly decreased at 12-month and 36-month follow-up. Although the decrease in PD was seen at 6-month follow–up, it was not significant. Statistically significant reduction in recession height (RH), RW, and CAL was observed at 6, 12, and 36 months postoperatively. The mean recession (RH) coverage was 2.94 ± 0.32 at 6 months, 3.24 ± 0.37 at 12 months, and 3.44 ± 0.53 at 36 months. Complete recession coverage was observed in 71% (15/21) of the treated sites. Four patients showed thick tissue biotype posttreatment with chorion membrane as compared to 1 at the baseline as measured with the transparency of the periodontal probe.

Patient-reported outcome measures are also measured and presented in [Table 1]. Three out of five patients experience no pain and discomfort postsurgery. Two patients reported with mild pain and discomfort after the surgery. Four patients felt no postoperative swelling, whereas one experienced moderate swelling.

The esthetic outcome was as follows: all patients reported an excellent esthetic result. Four patients reported with an excellent improvement in dentin sensitivity. Regarding the postoperative period, all patients took analgesic pills on the 1st day only.

   Discussion Top

The treatment of MRTDs is still a challenge for the clinician, as in these cases, the management of soft tissues becomes more difficult and the wound healing may be compromised by various factors such as the width of the avascular surface, limited blood supply, and differences in recession depth and position of the teeth.[12]

Moreover, due to the longer surgical time and increase in patient morbidity, the treatment of MRTD is very demanding for both clinician and patient. Thus, when GRs occur in a continuum, affecting multiple adjacent teeth, minimizing the number of surgical appointments to optimize esthetics by treating the defects in a single sitting with minimum surgical intervention becomes a priority.[13] A coronally displaced flap is a reliable and predictable treatment modality in these situations.[14]

The CTG procedure is the “gold standard” as far as predictability and esthetic results are concerned in the treatment of GR. Although excellent esthetic results have been reported and RC has ranged from 69% to 97% in many studies, this technique requires a suitable donor site.[15] Superior clinical outcomes of the CAF + CTG approach were, however, associated with longer chair time and greater morbidity than CAF alone. CTG harvesting is often associated with the possibility of postoperative complications such as bleeding, numbness, and sensitivity changes in the donor area.[16] To overcome these inconveniences, attempts are made to develop new materials aiming to replace CTG to improve patient acceptance and minimize morbidity. To the best of authors’ knowledge, this is the first clinical evaluation of cases on the use of chorion membrane in the treatment of multiple adjacent recession defects with 3-year follow-up.

The chorion membrane used has numerous advantages because of its structure and composition. Structurally, it consists of the following layers: (1) reticular, (2) basement membrane, and (3) trophoblasts. The extracellular matrix comprises collagen Types I, III, IV, V, and VI and cell-adhesion bioactive factors, such as fibronectin and laminin. Collagen is well tolerated and bioabsorbable, has hemostatic properties, and encourages the migration of adjacent autogenous connective tissue. Fibronectin is involved in many cellular processes, including tissue repair, blood clotting, cell migration, and adhesion. Laminin has a high affinity for binding epithelial cells, and in contrast to traditionally available membranes, this membrane allows for rapid epithelial cell growth rather than epithelial exclusion. In addition, the matrix of the chorion contains abundant growth factors, such as keratinocyte growth factor, basic fibroblast growth factor, and transforming growth factor- beta that promote periodontal regeneration and provide a natural environment for accelerated healing. Furthermore, the ability of this allograft to self-adhere eliminates the need for suturing, thus making it easier to use in posterior defects.[17]

Pundir et al. did a split-mouth study and surgically treated 12 Miller’s Class I recession defects with a modified CAF along with Amniotic Membrane (Group A) and Chorion membrane (Group B). Clinical parameters measured at the baseline and at 3 and 6 months were WKG, PD, RH, CAL, and assessment of the gingival biotype. All these parameters showed marked improvement in both the groups. Nine out of 12 treated recession defects showed 100% RC.[18] Esteves et al. reported a case series of ten healthy adult patients presenting with 21 Miller Class I GR defects (isolated or adjacent multiple) and were surgically treated with a modified CAF and chorion membrane for RC. The results showed statistically significant improvements in all clinical parameters of PD, CAL, WKG, and gingival biotype at the 3- and 6-month follow-ups. The mean percentage of RC at the end of 6 months was 89.92%–15.59%.[19]

In the present study also, significant improvement in all clinical parameters was observed at 6, 12, and 36 months after surgical treatment with CAF and chorion membrane in multiple adjacent GR defects. Clinical parameter of the PD was significantly decreased at 12- and 36-month follow-ups. Statistically significant reduction in RH, RW, and CAL was observed at all follow-up intervals. There was increasing recession coverage at 12 and 36 months after treatment showing signs of creeping attachment with the maturation of flap margins. The thickness of the gingival biotype also improved in three patients. About 71% (15/21) of the treated sites showed complete RC.

   Conclusion Top

The results of this case series indicate a significant improvement in RH, RW, and CAL along with a gain in CAL, which could be attributed to the regenerative potential of the membrane at 6, 12, and 36 months after treatment with CAF and chorion membrane. Increase in WKG was also noted as early as 6 months, along with a resultant thicker gingival biotype. The significant gain in WKG and the improvement in the biotype may also be attributed to the presence of mitogenic factors and anti-inflammatory protein of the membrane. No donor site means less pain and discomfort, morbidity, and surgical chair-time with the chorion membrane. Natural texture and color match to the surrounding native tissue are improved patient-reported outcomes. However, further studies with more statistical power and splitmouth design are necessary to measure clinical parameters to facilitate a more accurate long-term evaluation of gingival changes. In conclusion, the present findings indicate that the use of the chorion membrane may represent an alternative to CTG by reducing surgical time and patient morbidity.


The authors would like to thank Mr Astrid Lobo Gajiwala, Incharge of Tata Memorial Hospital Tissue bank, Mumbai, India, for providing the chorion membrane.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Wennström JL. Mucogingival therapy. Ann Periodontol 1996;1:671-701.  Back to cited text no. 1
Baker P, Spedding C. The aetiology of gingival recession. Dent Update 2002;29:59-62.  Back to cited text no. 2
Trott JR, Love B. An analysis of localized gingival recession in 766 Winnipeg high school students. Dent Pract Dent Rec 1966;16:209-13.  Back to cited text no. 3
Albandar JM, Kingman A. Gingival recession, gingival bleeding, and dental calculus in adults 30 years of age and older in the United States, 1988-1994. J Periodontol 1999;70:30-43.  Back to cited text no. 4
Cairo F, Nieri M, Pagliaro U. Efficacy of periodontal plastic surgery procedures in the treatment of localized facial gingival recessions. A systematic review. J Clin Periodontol 2014;41 Suppl 15:S44-62.  Back to cited text no. 5
Carvalho PF, da Silva RC, Cury PR, Joly JC. Modified coronally advanced flap associated with a subepithelial connective tissue graft for the treatment of adjacent multiple gingival recessions. J Periodontol 2006;77:1901-6.  Back to cited text no. 6
Prato GP, Clauser C, Magnani C, Cortellini P. Resorbable membrane in the treatment of human buccal recession: A nine-case report. Int J Periodontics Restorative Dent 1995;15:258-67.  Back to cited text no. 7
Suresh DK, Gupta A. Gingival biotype enhancement and root coverage using human placental chorion membrane. Clin Adv Periodontics 2013;3:237-42.  Back to cited text no. 8
Koizumi NJ, Inatomi TJ, Sotozono CJ, Fullwood NJ, Quantock AJ, Kinoshita S. Growth factor mRNA and protein in preserved human amniotic membrane. Curr Eye Res 2000;20:173-7.  Back to cited text no. 9
Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13.  Back to cited text no. 10
Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20.  Back to cited text no. 11
Hofmänner P, Alessandri R, Laugisch O, Aroca S, Salvi GE, Stavropoulos A, et al. Predictability of surgical techniques used for coverage of multiple adjacent gingival recessions – A systematic review. Quintessence Int 2012;43:545-54.  Back to cited text no. 12
Hakim A, Sathyanarayana S. Treatment of multiple adjacent gingival recession defects with Zucchelli technique – Report of a successful case with 9 months follow up. Int J Curr Res 2017;9:53111-4.  Back to cited text no. 13
Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures: A systematic review. J Clin Periodontol 2008;35:136-62.  Back to cited text no. 14
Cortellini P, Tonetti M, Baldi C, Francetti L, Rasperini G, Rotundo R, et al. Does placement of a connective tissue graft improve the outcomes of coronally advanced flap for coverage of single gingival recessions in upper anterior teeth? A multi-centre, randomized, double-blind, clinical trial. J Clin Periodontol 2009;36:68-79.  Back to cited text no. 15
Buff LR, Bürklin T, Eickholz P, Mönting JS, Ratka-Krüger P. Does harvesting connective tissue grafts from the palate cause persistent sensory dysfunction? A pilot study. Quintessence Int 2009;40:479-89.  Back to cited text no. 16
Gupta A, Kedige SD, Jain K. Amnion and chorion membranes: Potential stem cell reservoir with wide applications in periodontics. Int J Biomater 2015;2015:1-9.  Back to cited text no. 17
Pundir AJ, Agrawal V, Pundir S, Diwan V, Bodhi S. Comparative evaluation of the efficacy of human chorion and amnion with coronally advanced flap for recession coverage: A Case series. Clin Adv Periodontics 2016;6:118-26.  Back to cited text no. 18
Esteves J, Bhat KM, Thomas B, Varghese JM, Jadhav T. Efficacy of human chorion membrane allograft for recession coverage: A case series. J Periodontol 2015;86:941-4.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]

  [Table 1], [Table 2]


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