Skip to content
OsteoPerio

OsteoPerio Academy / Illustrated chapter 01

Mucogingival grafting.
Understand the design.

CAF, tunnel and VISTA: follow the anatomy, the graft and the forces that hold the tissues in position.

A literature-based chapter for qualified dentists and postgraduate learners. Access design, graft choice and suturing are three connected decisions—not one interchangeable technique.

Explore the chapter
Read the recession anatomyUpper anterior teeth in labial view. The central teeth have exposed roots between their gingival margins and the cemento-enamel junction. The papilla between them remains continuous. A dashed line higher in the vestibule marks the mucogingival junction schematically. These landmarks do not measure attachment loss or establish a recession class.LABIAL VIEW · MAXILLARY TEETH1234coronalANATOMICAL RELATIONSHIPS · NOT A DIAGNOSTIC MEASUREMENT
Start with the tissues, not the technique name.
  1. Cemento-enamel junction (CEJ): the anatomical reference.
  2. Exposed root: assess depth, width and surface condition.
  3. Papilla: assess interdental attachment clinically.
  4. Mucogingival junction: evaluate the available tissue.

01 / Assessment

Read the defect before choosing the access.

Establish the patient’s concern, plaque control and periodontal stability. Record recession dimensions, CEJ detectability, cervical lesions, phenotype, keratinized tissue, vestibular anatomy and tooth position. Recession alone does not automatically require surgery.[1][2]

RT1

No interproximal attachment loss.

RT2

Interproximal attachment loss is less than or equal to buccal attachment loss.

RT3

Interproximal attachment loss is greater than buccal attachment loss.

Cairo classification uses attachment measurements, not the apparent papilla height in a photograph. It helps frame coverage potential; it does not promise complete coverage or prescribe CAF, tunnel or VISTA.[1]

Define the endpoint together.

Root coverage, increased tissue thickness and an improved keratinized-tissue band are different objectives. Sensitivity, appearance, cleaning comfort and donor-site burden matter alongside millimetres of coverage.[2][3]

02 / Graft and recipient design

Separate access design from graft choice.

CAF, tunnel and VISTA describe access and tissue positioning. A connective-tissue graft describes an added tissue layer. Choose the biological objective and the recipient design separately, then make them work together.[3][5][7]

Connective tissue graft beneath a flapThe gold connective tissue graft is shown between a pink covering flap and a vascular recipient bed. The separated layers explain the arrangement and are brought into intimate contact in surgery; they are not left as open spaces.ENLARGED TISSUE SECTION · LAYERS SEPARATED FOR TEACHING123EXPLODED VIEW · NO SURGICAL GAP OR HEALING IS IMPLIED

CTG: connective-tissue graft

Commonly placed under a covering flap or tunnel for root coverage and / or phenotype modification. The gold layer represents connective tissue, not a membrane or bone graft.

  1. Covering soft tissue.
  2. Connective-tissue graft.
  3. Vascular recipient bed; its preparation depends on the site.
Epithelialized free gingival graft on a recipient bedAn epithelialized free gingival graft is shown on its vascular recipient bed. Its surface epithelium remains exposed rather than being buried beneath a flap. This represents an augmentation concept, not guaranteed root coverage.ENLARGED TISSUE SECTION · LAYERS SEPARATED FOR TEACHING12EXPLODED VIEW · NO SURGICAL GAP OR HEALING IS IMPLIED

FGG: free gingival graft

An epithelialized graft often used to augment keratinized tissue. Its exposed surface, appearance and treatment objective differ from a buried CTG; it is not simply another name for CTG.

  1. Exposed epithelial surface over the graft.
  2. Prepared vascular recipient bed.

Autogenous grafting adds a donor-site wound. Substitutes may avoid harvesting, but their performance depends on the material and indication; they are not automatically equivalent to CTG. These figures explain layer relationships, not harvesting dimensions or a universal graft prescription.[3][5]

Compare the access concepts. This table does not rank success rates.
Access familyEntryPapillary continuityPreparation plane
CAFMarginal / papillary design; releasing incisions in some variants.Papillary preparation follows the selected flap design.Thickness and release vary with the design and site.
TunnelSulcular access into connected recipient spaces.Papillary bridge retained.Partial, full or mixed planes, depending on the described variant.
Original VISTARemote vestibular incision.Marginal tissues and papillae kept continuous.Subperiosteal access in the original description.

Confirm the exact operative variant in its source before applying these distinctions.[4][7][12][13]

03 / Coronally advanced flap

Move the flap. Support the graft.

CAF mobilizes the local soft tissue and advances its margin coronally. A CTG can be added underneath. The illustration uses an envelope concept for adjacent recessions; CAF also includes designs with releasing incisions.[4][5]

  1. CAF — accessAn envelope CAF concept viewed from the front of upper teeth. Red incision lines follow the marginal and papillary access. This is one CAF design; vertical releasing incisions are not shown. The two central roots are exposed by recession.LABIAL VIEW · MAXILLARY TEETH12RED: SURFACE ACCESS · DASHED: CONCEALED CORRIDOR

    Concept 1

    Define the access

    Plan the marginal and papillary design around the defect and the available tissue. Preserve an appropriate vascular supply.

    1. Marginal / papillary access in an envelope design.
    2. Interdental tissue: its dimensions and preparation matter.
  2. CAF — graftA connective tissue graft lies over the central root exposure and adjacent recipient bed. The mobilized overlying flap is made transparent to show its relationship to the graft. No healing or new attachment is depicted.LABIAL VIEW · MAXILLARY TEETH12TRANSPARENT TEACHING VIEW · CTG SHOWN IN GOLD

    Concept 2

    Create passive mobility

    Release the flap sufficiently for passive coronal positioning. If indicated, adapt a CTG to the recipient bed before covering it.

    1. CTG positioned over the target roots and recipient bed.
    2. Covering flap shown transparent for teaching.
  3. CAF — stabilizeThe mobilized flap is positioned coronally over the graft, with tooth-supported sling sutures. The central margins cover the previous root exposure in this planned surgical position. This is not a predicted healed result.LABIAL VIEW · MAXILLARY TEETH12coronalPLANNED POSITION · NOT A HEALED OUTCOME

    Concept 3

    Cover and stabilize

    Adapt the flap over the graft and secure its planned position. Sutures hold a mobile flap; they should not force an inadequately released flap into place.

    1. Tooth-supported stabilization, shown schematically.
    2. Planned margin position; not a healed result.
When to consider it
A flap can be mobilized predictably and the papillary / marginal anatomy supports the chosen design.
What to question
Flap thickness, available keratinized tissue, interdental support and tension influence planning. A releasing incision is not compulsory in every CAF.
How to read the evidence
A systematic review supports adding CTG to CAF for selected single recessions without interdental attachment loss. That evidence should not be extended to every defect or every flap variant.

Conceptual sequence, not a complete operative protocol. Planes, grafts and stabilization differ across published variants.[4][5]

OsteoPerio Academy / Illustrated procedure

One graft. Two sites. A coordinated sequence.

Watch a three-dimensional teaching film (3 min 4 sec) of an isolated-recession CAF with a de-epithelialized gingival graft (DGG). Follow recipient preparation, palatal incisions and harvesting, extraoral de-epithelialization, graft fixation and suspensory suturing.

English teaching draft · Clinical review pending · Silent, with written explanations · No autoplay

Use the video controls to pause, change speed or enter fullscreen. Selecting a chapter pauses the film at that step.

Step 1 of 12 / 0:00

Plan two connected sites

This film uses one isolated upper-tooth recession and a trapezoidal CAF with a de-epithelialized palatal graft. It differs from the multiple-recession envelope illustration above. Diagnosis, inflammation control, consent and anaesthesia precede the operative scenes.

Clinical check: The CEJ is the enamel–root landmark. The target position depends on the defect and cervical anatomy.

Read the complete sequence and scientific sources

An original educational synthesis of the isolated CAF design and DGG literature, rather than a reproduction of one paper’s complete protocol. Donor and recipient views alternate; layer spacing and instrument movements are simplified. Assessment, medical preparation, anatomical precautions and postoperative prescriptions require supervised clinical teaching.

  1. 1. Plan two connected sites (0:00)

    This film uses one isolated upper-tooth recession and a trapezoidal CAF with a de-epithelialized palatal graft. It differs from the multiple-recession envelope illustration above. Diagnosis, inflammation control, consent and anaesthesia precede the operative scenes.

    The CEJ is the enamel–root landmark. The target position depends on the defect and cervical anatomy.

    Scientific sources: [2][3][16]

  2. 2. Design the recipient access (0:10)

    Marginal and papillary access is extended by two divergent releases into the mobile mucosa. This is one CAF variant; it does not mean that releasing incisions are needed for every recession.

    Maintain a viable flap and appropriate papillary dimensions; the illustration gives no incision measurements.

    Scientific sources: [16][17]

  3. 3. Elevate and mobilize the flap (0:20)

    The split–full–split concept preserves tissue for adaptation while allowing coronal movement. The three-dimensional view shows mobility; it does not reveal every dissection plane. Apical release is tailored to the anatomy.

    The flap must reach the planned position passively. Sutures cannot substitute for adequate mobility.

    Scientific sources: [16][17]

  4. 4. Prepare the receiving surfaces (0:30)

    The recipient is prepared and measured before graft harvesting in this example. Connective-tissue papillary beds accept the surgical papillae. Root-surface preparation is conservative and related to the actual surface findings.

    No mandatory chemical conditioner or aggressive removal of root structure is implied.

    Scientific sources: [3][16][17]

  5. 5. Harvest the palatal graft (0:40)

    Follow the coronal and apical horizontal incisions, the two connecting vertical incisions, then the split-thickness separation toward the palatal vault. A 2 mm collar is measured along the modeled surface in this example, following a later published protocol. The original 2010 study described 1–1.5 mm instead. The illustrated No.15 instrument is not a replica of a particular author’s instrument or a patient-specific cutting depth.

    The blade changes from an upright outline cut to a near-parallel undercut. Preserve residual donor tissue; depth and vascular precautions are individual.

    Scientific sources: [15][18]

  6. 6. Remove the epithelium extraorally (1:12)

    The graft is supported on moist sterile gauze while the connected scalpel blade follows a near-parallel plane to its surface. The animation shows superficial epithelial removal and the remaining connective tissue. A No.15 blade is illustrated; the cited extraoral protocols used a 15C. Dimensions and movements remain an educational model.

    The resulting DGG is used as connective tissue beneath the CAF, rather than left as an epithelialized onlay.

    Scientific sources: [15][18]

  7. 7. Protect the palatal donor bed (1:32)

    Unlike a single-incision subepithelial harvest, this surface wound is not shown primarily closed. A protective haemostatic dressing and its retention are illustrated as one approach; subsequent healing and review need individual care.

    Blue lines retain the dressing. They do not pull the epithelial wound edges together over the harvested area.

    Scientific sources: [3][15][17]

  8. 8. Adapt the connective tissue (1:42)

    The graft is brought to the prepared site, oriented and adapted without folds. Its relationship to the root, the adjacent connective tissue and the planned covering flap matters more than a fixed graft dimension.

    A root surface itself is avascular; contact with the surrounding vascular tissues supports graft survival.

    Scientific sources: [3][5][17]

  9. 9. Stabilize the graft (1:52)

    Peripheral graft fixation is shown schematically. The choice of anchorage and material follows the actual bed and flap design. The stitch drawing explains fixation, not every needle pass of a named suture.

    Avoid displacement, folding or excessive compression. Blue denotes suture, not an incision.

    Scientific sources: [3][9][17]

  10. 10. Advance the flap coronally (2:02)

    The released flap moves toward the tooth crown and covers the graft as it settles onto the recipient. The simplified motion illustrates the relationship between the graft and covering flap. This is an immediate surgical position.

    This example uses full graft coverage; exposure and final margin position are not interchangeable across techniques.

    Scientific sources: [5][16][17]

  11. 11. Support and close (2:20)

    The modified sling passes buccal to palatal through the mesial surgical and anatomical papillae, around the palatal cingulum, back beneath the distal contact, then through the distal papillae and beneath the mesial contact to a buccal knot. The return beneath a contact is distinct from the tissue bite. An incisal inset reveals the concealed palatal route. Separate interrupted stitches adapt the releases. This is a teaching synthesis of the cited descriptions, with simplified instrument handling.

    Stabilize a passively positioned flap; do not use tight sutures to overcome residual tension.

    Scientific sources: [9][16][19]

  12. 12. Review both sites over time (2:54)

    Give individual postoperative instructions, wound-protection advice and review arrangements. Healing, suture removal and later root-coverage assessment occur after this sequence. No long-term outcome is predicted by the final illustration.

    Published technique studies do not make this film a complete operative manual or replace supervised training.

    Scientific sources: [2][3][5][15]

Anatomical model credits

Tooth models: University of Dundee, School of Dentistry, licensed under Creative Commons Attribution 4.0. Adapted for this teaching animation: scaled, mirrored, arranged and retextured. Surrounding tissues, grafts and procedural animation are original teaching models. These adaptations do not imply Dundee endorsement or clinical validation.

Original models: Central incisorLateral incisorCanineFirst premolarSecond premolarFirst molarSecond molar

Read the full model and scientific credits

04 / Tunnel-based access

Preserve the bridge of tissue.

A tunnel connects recipient spaces beneath the marginal tissues while preserving papillary continuity. The graft is introduced beneath this envelope. Tunnel is a family of techniques: preparation depth, papillary mobilization and coronal advancement differ between protocols.[6][10][13][14]

  1. TUNNEL — accessA connected access corridor extends beneath the marginal tissues and intact papillae. Short red lines indicate sulcular access at the teeth; the dashed outline identifies the underlying tunnel, not a surface incision. No vertical releasing incision is shown.LABIAL VIEW · MAXILLARY TEETH12RED: SURFACE ACCESS · DASHED: CONCEALED CORRIDOR

    Concept 1

    Connect the recipient space

    Sulcular access leads to an underlying corridor. Maintain papillary continuity and avoid perforating a thin envelope.

    1. Sulcular access: distinct from a vertical release.
    2. Connected concealed corridor beneath the tissues.
  2. TUNNEL — graftA connective tissue graft extends beneath the preserved papillary bridge. The overlying tunnel envelope is transparent to show the buried graft. The preparation plane varies between described tunnel techniques.LABIAL VIEW · MAXILLARY TEETH12TRANSPARENT TEACHING VIEW · CTG SHOWN IN GOLD

    Concept 2

    Adapt the graft

    Introduce and adapt the CTG beneath the envelope. The graft should contact its recipient bed without folds or displacement.

    1. Buried CTG; transparency reveals its position.
    2. Papillary bridge retained above the corridor.
  3. TUNNEL — stabilizeThe graft and gingivopapillary envelope are held in their coronal position by suspensory support around the tooth contacts. This simplified force concept does not reproduce every needle pass of a named tunnel suture.LABIAL VIEW · MAXILLARY TEETH12coronalPLANNED POSITION · NOT A HEALED OUTCOME

    Concept 3

    Support the envelope

    Select a fixation and suspension approach suited to the graft and tissue. Coronal advancement is part of some, rather than all, tunnel protocols.

    1. Contact-supported suspension: force concept only.
    2. Coronal tissue support without excessive tension.
When to consider it
Preserved papillary continuity and a connected recipient envelope fit the defect, the tissue thickness and the operator’s training.
What to question
Restricted visibility, thin-tissue perforation and graft handling can make this demanding. “Minimally invasive” does not guarantee less postoperative pain.
How to read the evidence
A CAF-versus-tunnel RCT using CTG in both groups found similar root coverage, with more early morbidity in its tunnel group. The finding concerns those tested protocols, not every tunnel variation.

Conceptual sequence, not a complete operative protocol. Planes, grafts and stabilization differ across published variants.[6][10][13][14]

05 / Vestibular incision subperiosteal tunnel access

Reach the site from a remote incision.

The original VISTA concept uses a remote vestibular incision and subperiosteal access, keeping marginal incisions away from the recession sites. Coronal anchorage helps maintain the intended margin position. Later CTG-based and modified VISTA protocols are not identical to the original report.[7][8]

  1. VISTA — accessA short remote midline vestibular incision, above the upper central incisors in this view, provides access to a subperiosteal tunnel. The marginal gingiva and papillae are not cut in this original VISTA access concept. The dashed tunnel outline is concealed beneath the tissue.LABIAL VIEW · MAXILLARY TEETH12RED: SURFACE ACCESS · DASHED: CONCEALED CORRIDOR

    Concept 1

    Enter remotely

    The original maxillary-anterior description accesses the tissues through a midline vestibular incision. The concealed preparation extends toward the affected margins.

    1. Remote vestibular access in the midline.
    2. Subperiosteal corridor; its boundary is not a surface cut.
  2. VISTA — graftA connective tissue graft is introduced through the remote vestibular opening into the recipient compartment. This illustrates a CTG-based modification. Zadeh’s original 2011 report used a growth factor and scaffold instead of this graft.LABIAL VIEW · MAXILLARY TEETH12TRANSPARENT TEACHING VIEW · CTG SHOWN IN GOLD

    Concept 2

    Place the selected material

    A CTG is shown here to explain a graft-based modification. The original 2011 report instead used rhPDGF-BB with a β-TCP scaffold.

    1. CTG in a modified graft-based concept.
    2. The overlying tissue is transparent, not absent.
  3. VISTA — stabilizeCoronally anchored sutures are supported at composite fixation points on the facial crown surfaces. The remote access is closed separately. The planned surgical position does not guarantee a healed root-coverage result.LABIAL VIEW · MAXILLARY TEETH12coronalPLANNED POSITION · NOT A HEALED OUTCOME

    Concept 3

    Anchor and close

    Coronally anchored sutures support the margins from fixation points on the facial crowns. Close the remote access separately.

    1. Facial crown anchor points, shown in pale green.
    2. Sutures maintain the planned tissue position.
When to consider it
Remote access and a subperiosteal preparation are appropriate to the site and the particular protocol being taught.
What to question
Avoid treating VISTA as a synonym for every tunnel. Vestibular anatomy, access, tissue mobility and reliable anchorage still require assessment.
How to read the evidence
The original publication is a technique report with two cases. A later m-VISTA-versus-CAF RCT in multiple RT2 defects found no significant difference in mean coverage at 6 or 12 months.

Conceptual sequence, not a complete operative protocol. Planes, grafts and stabilization differ across published variants.[7][8]

Partial-thickness and subperiosteal preparation conceptsTwo enlarged recipient-site sections illustrate different preparation planes away from a root. In the upper example, the access lies within the connective tissue, leaving tissue and periosteum over the bone. In the lower example, the access lies between periosteum and bone, so periosteum remains with the elevated tissues. Actual tunnel protocols may combine planes. Lines identify planes, not open spaces left at closure.RECIPIENT-SITE SECTION AWAY FROM A ROOT · NOT TO SCALEA / PARTIAL-THICKNESS EXAMPLE1B / SUBPERIOSTEAL CONCEPT2PINK: SOFT TISSUE · PURPLE LINE: PERIOSTEUM · STONE: BONE

Know which layer you are mobilizing.

Subperiosteal means beneath the periosteum. A partial-thickness preparation leaves tissue over the underlying surface. These sections are away from a root, where bone is present.

  1. One partial-thickness example: access within the connective tissue.
  2. Subperiosteal concept: periosteum stays with the elevated tissues.

Tunnel modifications can combine planes. The original VISTA preparation and the partial-thickness tunnel example described by Ronco are not the same dissection. The dashed lines mark a plane, not a gap left open at closure.[7][12]

06 / Suture atlas

Choose the stitch for the job.

Separate three jobs: adapting wound edges, immobilizing a graft and supporting coronal tissue position. A combination may be needed. More traction is not a substitute for adequate tissue mobilization.[9][10][12]

External threadConcealed thread routeComposite anchor
Simple interrupted suture — mechanical conceptEnlarged wound cross-section. One loop connects opposing wound edges. The knot is outside the wound. The superficial external strand is solid blue and its buried return is dashed blue. This is a closure concept, not a knot-tying tutorial.ENLARGED WOUND · CROSS-SECTION12BLUE: EXTERNAL THREAD · DASHED BLUE: CONCEALED ROUTE

Simple interrupted

Independent adaptation of a local wound edge or a separate access incision.

  1. External loop; knot offset from the wound.
  2. Concealed return through tissue.

Clinical attention: A closure stitch alone does not create passive coronal advancement. Keep the knot away from the incision line.[9]

Horizontal mattress suture — mechanical conceptEnlarged wound surface view. Two side-by-side cross-wound passes form a horizontal mattress loop with external turns along the tissue on either side. Dashes identify concealed passes. This distributes support across a broader area; excessive tension can compromise perfusion.ENLARGED WOUND · SURFACE VIEW12BLUE: EXTERNAL THREAD · DASHED BLUE: CONCEALED ROUTE

Horizontal mattress

Spreads support over a wider surface through two adjacent passes; may help graft adaptation.

  1. Two adjacent concealed cross-wound passes.
  2. External turns on either side.

Clinical attention: Excessive compression can compromise perfusion. This is a surface view, not the vertical mattress cross-section beside it.[9][12]

Vertical mattress suture — mechanical conceptEnlarged wound cross-section. A deeper far-far bite and a more superficial near-near bite form a vertical mattress loop. Four tissue entry points are shown. Depths and distances are schematic rather than prescribed clinical measurements.ENLARGED WOUND · CROSS-SECTION12BLUE: EXTERNAL THREAD · DASHED BLUE: CONCEALED ROUTE

Vertical mattress

A deeper far–far and a shallower near–near component control tissue adaptation.

  1. Far–far component shown deeper.
  2. Near–near component shown superficially.

Clinical attention: Bite depth and position depend on the tissue and objective. The diagram prescribes no fixed clinical distances.[9][12]

Tooth-supported sling — mechanical conceptUpper anterior teeth viewed from the front. A tooth-supported sling supports the marginal tissues. The concealed lingual portion is dashed. The tooth supplies anchorage; tissue mobilization must already permit passive positioning.LABIAL VIEW · ANCHORAGE CONCEPT12coronalBLUE: EXTERNAL THREAD · DASHED BLUE: CONCEALED ROUTE

Tooth-supported sling

Uses a tooth as an anchor to support the marginal tissues; continuous designs can also secure a tunnel graft.

  1. External tooth-supported loop.
  2. Concealed lingual segment shown dashed.

Clinical attention: An independent sling and Allen’s subpapillary continuous sling are related concepts, not interchangeable step-by-step protocols.[9][10]

Double-crossed suspension — mechanical conceptUpper anterior papilla with two crossing suspension lines anchored around a supported contact point. This illustrates the coronal support and adaptation objective of the double-crossed family, not every needle passage in Zuhr and colleagues’ named technique.LABIAL VIEW · ANCHORAGE CONCEPT12coronalBLUE: EXTERNAL THREAD · DASHED BLUE: CONCEALED ROUTE

Double-crossed suspension

Illustrates coronal support and close adaptation of the gingivopapillary complex in the double-crossed family.

  1. Supported contact-point anchorage.
  2. Two crossing support lines: force concept.

Clinical attention: The drawing shows the mechanical objective, not every needle pass of Zuhr’s named technique. Thin papillae require particular care.[11][12]

Coronally anchored suture — mechanical conceptUpper anterior teeth viewed from the front. Sutures support coronal tissue positioning at facial composite anchor points on the crowns, as in the VISTA coronally anchored concept. Anchors are not implants and the lines do not represent regenerative membranes.LABIAL VIEW · ANCHORAGE CONCEPT12coronalBLUE: EXTERNAL THREAD · DASHED BLUE: CONCEALED ROUTE

Coronally anchored suture

Supports coronal positioning from facial crown fixation points, as described in VISTA.

  1. Facial composite fixation points.
  2. Coronal support of the marginal tissues.

Clinical attention: The anchor must be reliable, while the tissue remains passively positionable. This is different from contact-point suspension.[7]

Stability with perfusion.

Check passive adaptation, graft contact and absence of folding or movement. Match the needle, material, diameter and support pattern to tissue thickness and the task. Avoid strangulation and unnecessary tissue trauma. Timing of removal and postoperative care belong to the individual protocol.[9][12]

The atlas explains mechanics. In particular, the double-crossed and anchored drawings are conceptual: use the original articles and supervised practical teaching to learn the complete needle route and knot sequence.

07 / Apply the chapter

Explain the choice before naming the technique.

Teaching scenario: two adjacent RT1 recessions, a thin phenotype and preserved papillae. The patient is concerned about appearance. This description is incomplete by design: the operation cannot be selected from these facts alone.

What else would you record?

Plaque control and periodontal stability, recession depth and width, root-surface condition, CEJ, keratinized tissue, vestibular / frenum anatomy, tooth position and patient preferences. Confirm the attachment measurements.

What would justify a graft?

Explain the intended gain: coverage, thickness or keratinized tissue. Discuss recipient biology, donor-site morbidity and alternatives. A thin phenotype contributes to the decision; a technique name does not determine the material.

How would you test your closure plan?

Ask whether the tissue reaches the planned position passively, what fixes the graft, what supplies anchorage, and whether the support preserves perfusion. Then identify the exact published variant and its limits.

Read comparisons fairly.

A comparison of CAF + CTG with tunnel + CTG differs from a comparison that also changes the biomaterial. Check defect type, graft, operator experience, follow-up, complete versus mean coverage and patient-reported outcomes. A technical report demonstrates an approach; it does not establish superiority.[5][6][8]

08 / Scientific reading

Start with the original descriptions.

Selected foundational publications, comparative research and scholarly reviews. Short descriptive titles below identify each paper’s role. This is a focused teaching bibliography, not an exhaustive systematic review. Figures are original OsteoPerio schematics; no article figures have been reproduced.

Read the original descriptions alongside Tavelli and colleagues’ 2026 review of how CAF and tunnel approaches evolved. A current synthesis helps distinguish established concepts from later modifications.[13]

  1. [1] Classification study / 2011

    Interproximal attachment, recession classification and root-coverage prediction

    Cairo F, Nieri M, Cincinelli S, et al. Journal of Clinical Periodontology. 38:661–666.

    Defines RT1, RT2 and RT3 using interproximal versus buccal attachment loss.

  2. [2] World Workshop narrative review / 2018

    Mucogingival conditions in the natural dentition

    Cortellini P, Bissada NF. Journal of Periodontology. 89(Suppl 1):S204–S213.

    Assessment includes phenotype, root-surface condition, symptoms, patient concerns and monitoring.

  3. [3] Critical review / 2014

    Soft-tissue replacement grafts: critical elements in design and execution

    Zuhr O, Bäumer D, Hürzeler M. Journal of Clinical Periodontology. 41(Suppl 15):S123–S142.

    Donor tissues, substitutes, harvesting considerations and recipient-site biology.

  4. [4] Clinical case series / 2000

    Treatment of multiple recession-type defects in patients with esthetic demands

    Zucchelli G, De Sanctis M. Journal of Periodontology. 71:1506–1514.

    A multiple-recession CAF design; not a guarantee for every defect or every CAF variant.

  5. [5] Systematic review / 2014

    Efficacy of periodontal plastic surgery for localized gingival recessions

    Cairo F, Nieri M, Pagliaro U. Journal of Clinical Periodontology. 41(Suppl 15):S44–S62.

    Supports CAF with CTG for selected single recessions; findings depend on the comparator and defect.

  6. [6] Randomized clinical trial / 2016

    CAF + CTG versus tunnel + CTG: morbidity and root-coverage outcomes

    Gobbato L, Nart J, Bressan E, et al. Clinical Oral Investigations. 20:2191–2202.

    Similar coverage in this trial; the tunnel group reported more early morbidity. Less invasive terminology does not ensure less pain.

  7. [7] Technique report / two clinical cases / 2011

    VISTA access and coronally anchored suturing: the original report

    Zadeh HH. International Journal of Periodontics & Restorative Dentistry. 31:653–660.

    Remote vestibular incision, subperiosteal tunnel and coronal anchorage. The original report used rhPDGF-BB with a β-TCP scaffold.

  8. [8] Randomized clinical trial / 2023

    Modified VISTA versus CAF with CTG for multiple RT2 recessions

    Fernández-Jiménez A, Estefanía-Fresco R, García-De-La-Fuente AM, et al. Clinical Oral Investigations. 27:505–517.

    No statistically significant between-group difference in mean coverage at 6 or 12 months; modified VISTA is not identical to the original protocol.

  9. [9] Technical review / 1996

    Suturing techniques for periodontal plastic surgery

    Moore RL, Hill M. Periodontology 2000. 11:103–111.

    Conventional suture patterns, wound adaptation and tissue stabilization.

  10. [10] Technical report / 2010

    Subpapillary continuous sling suturing for soft-tissue grafting with tunneling

    Allen EP. International Journal of Periodontics & Restorative Dentistry. 30:479–485.

    Combines graft fixation and advancement of the pouch margins in a continuous sling design.

  11. [11] Technical report / 2009

    The double-crossed suture for periodontal and implant plastic surgery

    Zuhr O, Rebele SF, Thalmair T, et al. European Journal of Esthetic Dentistry. 4:338–347.

    A named suspensory suture design. Consult the original description for the complete needle route.

  12. [12] Technical case report / 2016

    A suturing approach for tissue displacement in minimally invasive periodontal plastic surgery

    Ronco V, Dard M. Clinical Case Reports. 4:831–837.

    Anchored horizontal and vertical mattress concepts; stabilization and compression with attention to tissue trauma.

  13. [13] Contemporary narrative review / 2026

    Root-coverage surgery: the evolution of CAF and tunnel approaches

    Tavelli L, Yilmaz B, Steiner Back L, et al. Journal of Periodontology. 97:983–1009.

    Places access designs and their modifications in context, including different preparation planes and coronal positioning concepts.

  14. [14] Microsurgical tunnel case report / 2007

    Gingival recession coverage with a modified microsurgical tunnel

    Zuhr O, Fickl S, Wachtel H, et al. International Journal of Periodontics & Restorative Dentistry. 27:457–463.

    Describes a split-flap modification with microsurgical instruments. A technical report does not establish universal superiority.

  15. [15] Randomized controlled trial / 2010

    Patient morbidity and root coverage after subepithelial and de-epithelialized grafts

    Zucchelli G, Mele M, Stefanini M, et al. Journal of Clinical Periodontology. 37:728–738.

    Compares CAF with grafts obtained through trap-door harvesting or extraoral de-epithelialization of an epithelialized graft. Donor techniques and wound management differ.

  16. [16] Clinical follow-up study / 2007

    Modified CAF for isolated recession-type defects: three-year results

    de Sanctis M, Zucchelli G. Journal of Clinical Periodontology. 34:262–268.

    Isolated-recession flap design with differentiated preparation thickness. Distinct from the multiple-recession envelope example.

  17. [17] Randomized controlled clinical trial / 2022

    De-epithelialized graft versus single-incision subepithelial graft with CAF

    Mashaly M, Ghallab NA, Elbattawy W, Ezz Elarab A. Contemporary Clinical Dentistry. 13:227–235.

    Describes isolated CAF preparation, extraoral epithelial removal, donor-wound protection, graft fixation and covering-flap stabilization. Study dimensions are not universal prescriptions.

  18. [18] Experimental human-cadaver study / 2024

    Histological assessment of a novel de-epithelialization method for connective tissue grafts harvested from the palate

    Bara-Gaseni N, Jorba-Garcia A, Alberdi-Navarro J, et al. Clinical Oral Investigations. 28:343.

    Documents a 2 mm marginal collar, horizontal and connecting incisions, split-thickness harvesting and extraoral scalpel de-epithelialization. These are study-specific methods, not universal safe dimensions.

  19. [19] Narrative review / 2026

    Mucogingival surgery techniques: Coronally advanced flap versus tunnel approach

    Aroca S, Di Domenico GL, de Sanctis M. Journal of Periodontology. 97:1714–1732.

    Details mesial and distal papillary passes, palatal cingulum anchorage and returns beneath the contacts for a modified sling. Its clinical figure illustrates multiple CAF; it is not an isolated-recession DGG trial.

Back to the AcademyPatient guide to recession treatmentBack to the chapter map