{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T05:30:03Z","timestamp":1780551003754,"version":"3.54.1"},"reference-count":50,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2020,8,14]],"date-time":"2020-08-14T00:00:00Z","timestamp":1597363200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: The long-term stability after soft tissue graft for covering gingival recession remains a pivotal goal for both patient and periodontist. Therefore, the aim of this study was to compare the four-year outcomes of the coronally advanced flap (CAF) versus the pouch\/tunnel (POT) technique, both combined with connective tissue graft (CTG), for gingival recession treatment. Methods: Forty patients were initially randomly assigned to the control group (CAF + CTG; N = 20) and the test group (POT + CTG; N = 20). Clinical outcomes included mean root coverage (MRC) and complete root coverage (CRC), gingival thickness (GT), and keratinized tissue (KT) gain. Esthetic outcomes were also analyzed using the pink esthetic score (PES) and patient-reported outcome measures (PROMs). All outcomes initially assessed at six months were extended to four years post-surgery. Results: No significant differences were observed between the two patient groups in terms of MRC and CRC. At four years, significantly greater GT and KT gain were noted in the POT + CTG group, and tissue texture enhancement was also more prominent in the test group. Conclusions: The POT + CTG technique allows for long-term clinical coverage of gingival recessions comparable to that of the CAF + CTG technique, but it potentially improves gingival thickness, keratinized tissue and esthetic results.<\/jats:p>","DOI":"10.3390\/jcm9082641","type":"journal-article","created":{"date-parts":[[2020,8,14]],"date-time":"2020-08-14T08:28:35Z","timestamp":1597393715000},"page":"2641","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":16,"title":["Tunnel\/Pouch versus Coronally Advanced Flap Combined with a Connective Tissue Graft for the Treatment of Maxillary Gingival Recessions: Four-Year Follow-Up of a Randomized Controlled Trial"],"prefix":"10.3390","volume":"9","author":[{"given":"Souheil","family":"Salem","sequence":"first","affiliation":[{"name":"Department of Periodontology and Oral Surgery, Faculty of Medicine, University of Li\u00e8ge, 4000 Liege, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3529-8452","authenticated-orcid":false,"given":"Leila","family":"Salhi","sequence":"additional","affiliation":[{"name":"Department of Periodontology and Oral Surgery, Faculty of Medicine, University of Li\u00e8ge, 4000 Liege, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laurence","family":"Seidel","sequence":"additional","affiliation":[{"name":"Biostatistics and Medico-Economic Information, University Hospital of Li\u00e8ge, 4000 Li\u00e8ge, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Geoffrey","family":"Lecloux","sequence":"additional","affiliation":[{"name":"Department of Periodontology and Oral Surgery, Faculty of Medicine, University of Li\u00e8ge, 4000 Liege, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric","family":"Rompen","sequence":"additional","affiliation":[{"name":"Department of Periodontology and Oral Surgery, Faculty of Medicine, University of Li\u00e8ge, 4000 Liege, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"France","family":"Lambert","sequence":"additional","affiliation":[{"name":"Department of Periodontology and Oral Surgery, Faculty of Medicine, University of Li\u00e8ge, 4000 Liege, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,8,14]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1016\/S0011-8532(22)01008-4","article-title":"Gingival recession. The condition, process, and treatment","volume":"20","author":"Gartrell","year":"1976","journal-title":"Dent. Clin. N. Am."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"316","DOI":"10.1902\/jop.1967.38.4.316","article-title":"Prevalence and etiology of gingival recession","volume":"38","author":"Gorman","year":"1967","journal-title":"J Periodontol."},{"key":"ref_3","first-page":"339","article-title":"Gingival recession of mandibular incisors related to malocclusions of the teeth","volume":"47","author":"Winders","year":"1971","journal-title":"J. Wis. State Dent. Soc."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"688","DOI":"10.1034\/j.1600-051X.2002.290804.x","article-title":"Dentine hypersensitivity in Jordanian dental attenders: A case control study","volume":"29","author":"Linden","year":"2002","journal-title":"J. Clin. Periodontol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"864","DOI":"10.1902\/jop.1994.65.9.864","article-title":"Gingival recession: Intra-oral distribution and associated factors","volume":"65","author":"Joshipura","year":"1994","journal-title":"J. Periodontol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1499","DOI":"10.14219\/jada.archive.2002.0080","article-title":"Treatment of gingival recession","volume":"133","author":"Kassab","year":"2002","journal-title":"J. Am. Dent. Assoc."},{"key":"ref_7","first-page":"152","article-title":"Free autogenous gingival grafts. 3. Utilization of grafts in the treatment of gingival recession","volume":"6","author":"Sullivan","year":"1968","journal-title":"Periodontics"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"316","DOI":"10.1902\/jop.1989.60.6.316","article-title":"Coronal positioning of existing gingiva: Short term results in the treatment of shallow marginal tissue recession","volume":"60","author":"Allen","year":"1989","journal-title":"J. Periodontol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1111\/j.1600-051X.1975.tb01721.x","article-title":"Coronally repositioned periodontal flap. Clinical evaluation after one year","volume":"2","author":"Bernimoulin","year":"1975","journal-title":"J. Clin. Periodontol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"S44","DOI":"10.1111\/jcpe.12182","article-title":"Efficacy of periodontal plastic surgery procedures in the treatment of localized facial gingival recessions. A systematic review","volume":"41","author":"Cairo","year":"2014","journal-title":"J. Clin. Periodontol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"S8","DOI":"10.1902\/jop.2015.130674","article-title":"Periodontal soft tissue root coverage procedures: A systematic review from the AAP Regeneration Workshop","volume":"86","author":"Chambrone","year":"2015","journal-title":"J. Periodontol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1902\/jop.1985.56.12.715","article-title":"Subepithelial connective tissue graft technique for root coverage","volume":"56","author":"Langer","year":"1985","journal-title":"J. Periodontol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"505","DOI":"10.1902\/jop.1980.51.9.505","article-title":"A surgical procedure for the treatment of localized gingival recession in conjunction with root surface citric acid conditioning","volume":"51","author":"Liu","year":"1980","journal-title":"J. Periodontol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"136","DOI":"10.1111\/j.1600-051X.2008.01267.x","article-title":"Treatment of gingival recession with coronally advanced flap procedures: A systematic review","volume":"35","author":"Cairo","year":"2008","journal-title":"J. Clin. Periodontol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1111\/eos.12401","article-title":"The effect of partially exposed connective tissue graft on root-coverage outcomes: A systematic review and meta-analysis","volume":"126","author":"Dodge","year":"2018","journal-title":"Eur. J. Oral. Sci."},{"key":"ref_16","first-page":"Cd007161","article-title":"Root coverage procedures for treating localised and multiple recession-type defects","volume":"10","author":"Chambrone","year":"2018","journal-title":"Cochrane Database Syst Rev."},{"key":"ref_17","first-page":"82","article-title":"Comparison between Subepithelial Connective Tissue Graft and De-epithelialized Gingival Graft: A systematic review and a meta-analysis","volume":"21","author":"Tavelli","year":"2019","journal-title":"J. Int. Acad. Periodontol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"572","DOI":"10.1111\/jcpe.13106","article-title":"Long-term stability of root coverage procedures for single gingival recessions: A systematic review and meta-analysis","volume":"46","author":"Dai","year":"2019","journal-title":"J. Clin. Periodontol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"296","DOI":"10.1111\/prd.12186","article-title":"Periodontal plastic surgery of gingival recessions at single and multiple teeth","volume":"75","author":"Cairo","year":"2017","journal-title":"Periodontology 2000"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1290","DOI":"10.1002\/JPER.17-0619","article-title":"Long-term evaluation (20 years) of the outcomes of subepithelial connective tissue graft plus coronally advanced flap in the treatment of maxillary single recession-type defects","volume":"89","author":"Prato","year":"2018","journal-title":"J. Periodontol."},{"key":"ref_21","first-page":"302","article-title":"Use of the supraperiosteal envelope in soft tissue grafting for root coverage. I. Rationale and technique","volume":"14","author":"Allen","year":"1994","journal-title":"Int. J. Periodontics restor. Dent."},{"key":"ref_22","first-page":"199","article-title":"Treatment of multiple adjacent gingival recessions with the tunnel subepithelial connective tissue graft: A clinical report","volume":"19","author":"Zabalegui","year":"1999","journal-title":"Int. J. Periodontics restor. Dent."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"397","DOI":"10.1902\/jop.1985.56.7.397","article-title":"Covering localized areas of root exposure employing the \u201cenvelope\u201d technique","volume":"56","author":"Raetzke","year":"1985","journal-title":"J. Periodontol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1111\/j.1600-051X.2009.01492.x","article-title":"Treatment of class III multiple gingival recessions: A randomized-clinical trial","volume":"37","author":"Aroca","year":"2010","journal-title":"J. Clin. Periodontol."},{"key":"ref_25","first-page":"141","article-title":"Root coverage and papilla reconstruction using autogenous osseous and connective tissue grafts","volume":"21","author":"Azzi","year":"2001","journal-title":"Int. J. Periodontics Restor. Dent."},{"key":"ref_26","first-page":"457","article-title":"Covering of gingival recessions with a modified microsurgical tunnel technique: Case report","volume":"27","author":"Zuhr","year":"2007","journal-title":"Int. J. Periodontics Restor. Dent."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1075","DOI":"10.1002\/JPER.18-0066","article-title":"Efficacy of tunnel technique in the treatment of localized and multiple gingival recessions: A systematic review and a meta-analysis","volume":"89","author":"Tavelli","year":"2018","journal-title":"J. Periodontol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1142","DOI":"10.1111\/jcpe.12627","article-title":"Root coverage with connective tissue graft associated with coronally advanced flap or tunnel technique: A randomized, double-blind, mono-centre clinical trial","volume":"43","author":"Azaripour","year":"2016","journal-title":"J. Clin. Periodontol."},{"key":"ref_29","first-page":"34","article-title":"Zucchelli\u2019s technique or tunnel technique with subepithelial connective tissue graft for treatment of multiple gingival recessions","volume":"16","author":"Bherwani","year":"2014","journal-title":"J. Int. Acad. Periodontol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"387","DOI":"10.1111\/jcpe.12207","article-title":"Coronally advanced flap versus the pouch technique combined with a connective tissue graft to treat Miller\u2019s class I gingival recession: A randomized controlled trial","volume":"41","author":"Salhi","year":"2014","journal-title":"J. Clin. Periodontol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"540","DOI":"10.1111\/jcpe.12714","article-title":"Connective tissue graft and tunnel or trapezoidal flap for the treatment of single maxillary gingival recessions: A randomized clinical trial","volume":"44","author":"Santamaria","year":"2017","journal-title":"J. Clin. Periodontol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1842","DOI":"10.1902\/jop.2005.76.11.1842","article-title":"Treatment of gingival recession: Comparison of two techniques of subepithelial connective tissue graft","volume":"76","year":"2005","journal-title":"J. Periodontol."},{"key":"ref_33","first-page":"19","article-title":"Long-term results of root coverage with connective tissue in the envelope technique: A report of 20 cases","volume":"28","author":"Rossberg","year":"2008","journal-title":"Int. J. Periodontics Restor. Dent."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"607","DOI":"10.1177\/00220345930720030901","article-title":"Kinetic aspects of gingival and periodontal ligament fibroblast attachment to surface-conditioned dentin","volume":"72","author":"Rompen","year":"1993","journal-title":"J. Dent. Res."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"594","DOI":"10.1902\/jop.1999.70.6.594","article-title":"In vitro stimulation of human gingival epithelial cell attachment to dentin by surface conditioning","volume":"70","author":"Vanheusden","year":"1999","journal-title":"J. Periodontol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1111\/j.1600-0765.1998.tb02333.x","article-title":"In vitro modulation of human gingival epithelial cell attachment and migration by minocycline-HCL","volume":"33","author":"Vanheusden","year":"1998","journal-title":"J. Periodontal Res."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"639","DOI":"10.1111\/j.1600-0501.2005.01193.x","article-title":"Evaluation of soft tissue around single-tooth implant crowns: The pink esthetic score","volume":"16","author":"Florescu","year":"2005","journal-title":"Clin. Oral Implant. Res."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1111\/j.1600-051X.2008.01262.x","article-title":"Periodontal tissue engineering and regeneration: Consensus Report of the Sixth European Workshop on Periodontology","volume":"35","author":"Palmer","year":"2008","journal-title":"J. Clin. Periodontol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"518","DOI":"10.1111\/j.1600-051X.2005.00706.x","article-title":"Coronally positioned flap procedures with or without a biodegradable membrane in the treatment of human gingival recession. A 6-year follow-up study","volume":"32","author":"Leknes","year":"2005","journal-title":"J. Clin. Periodontol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"590","DOI":"10.1902\/jop.2011.110410","article-title":"Long-Term 8-Year Outcomes of Coronally Advanced Flap for Root Coverage","volume":"83","author":"Prato","year":"2012","journal-title":"J. Periodontol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1111\/j.1600-051X.2011.01744.x","article-title":"Fourteen-year outcomes of coronally advanced flap for root coverage: Follow-up from a randomized trial","volume":"38","author":"Prato","year":"2011","journal-title":"J. Clin. Periodontol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1353","DOI":"10.1902\/jop.2012.110373","article-title":"Evaluation of Human Recession Defects Treated With Coronally Advanced Flaps and Either Enamel Matrix Derivative or Connective Tissue: Comparison of Clinical Parameters at 10 Years","volume":"83","author":"McGuire","year":"2012","journal-title":"J. Periodontol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"644","DOI":"10.1111\/j.1600-051X.2010.01559.x","article-title":"Coronally advanced flap versus connective tissue graft in the treatment of multiple gingival recessions: A split-mouth study with a 5-year follow-up","volume":"37","author":"Prato","year":"2010","journal-title":"J. Clin. Periodontol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1107","DOI":"10.1111\/jcpe.12932","article-title":"Predictor factors for long-term outcomes stability of coronally advanced flap with or without connective tissue graft in the treatment of single maxillary gingival recessions: 9 years results of a randomized controlled clinical trial","volume":"45","author":"Rasperini","year":"2018","journal-title":"J. Clin. Periodontol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1054","DOI":"10.1902\/jop.2002.73.9.1054","article-title":"Root coverage with connective tissue grafts: An evaluation of short- and long-term results","volume":"73","author":"Harris","year":"2002","journal-title":"J. Periodontol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"2286","DOI":"10.1902\/jop.2005.76.12.2286","article-title":"Long-Term Outcome Following Treatment of Multiple Miller Class I and II Recession Defects in Esthetic Areas of the Mouth","volume":"76","author":"Zucchelli","year":"2005","journal-title":"J. Periodontol."},{"key":"ref_47","first-page":"217","article-title":"Is periodontal guided tissue regeneration a reproducible technic? A review of the literature","volume":"53","author":"Zahedi","year":"1998","journal-title":"Rev. Belge. Med. Dent."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"593","DOI":"10.1111\/jcpe.12254","article-title":"Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivative for root coverage: A RCT using 3D digital measuring methods. Part II. Volumetric studies on healing dynamics and gingival dimensions","volume":"41","author":"Rebele","year":"2014","journal-title":"J. Clin. Periodontol."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"673","DOI":"10.11607\/prd.1808","article-title":"Quantitative three-dimensional methodology to assess volumetric and profilometric outcome of subepithelial connective tissue grafting at pontic sites: A prospective pilot study","volume":"34","author":"Veltri","year":"2014","journal-title":"Int. J. Periodontics Restor. Dent."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"705","DOI":"10.1902\/jop.2009.080565","article-title":"Root Coverage Esthetic Score: A System to Evaluate the Esthetic Outcome of the Treatment of Gingival Recession Through Evaluation of Clinical Cases","volume":"80","author":"Cairo","year":"2009","journal-title":"J. Periodontol."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/9\/8\/2641\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T10:00:39Z","timestamp":1760176839000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/9\/8\/2641"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,8,14]]},"references-count":50,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2020,8]]}},"alternative-id":["jcm9082641"],"URL":"https:\/\/doi.org\/10.3390\/jcm9082641","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,8,14]]}}}