For root coverage, the subepithelial connective tissue graft (SCTG) has long been regarded as the gold standard for Miller Class I–II recession, with significant root coverage and keratinized tissue gain.1 However, newer evidence supports the Chao Pinhole® Surgical Technique (PST®) as a minimally invasive alternative that can be integrated before or in close coordination with orthodontic care.
Key Evidence
- Long-term outcomes (14.5 years). A retrospective follow-up of the original PST® cohort (28 patients; 68 Class I–II sites) reported complete root coverage of 77.9% and mean root coverage of 86.6%, concluding PST® shows “long-term predictability and effectiveness.”2
- Randomized clinical trial (12 months). In a split-mouth RCT (36 subjects), PST® + collagen membrane and CAF + CTG achieved statistically similar outcomes at 1 year: mean recession reduction 1.97–1.98 mm (P=0.53) and mean percent root coverage 63.6–65.4% (P=0.72). Authors concluded both methods can successfully treat recession with no significant difference in efficacy.3
When Orthodontics Is Also Planned
In patients at risk (e.g., thin phenotype) or already presenting recession, literature on timing indicates that soft-tissue augmentation/management before or alongside orthodontics may help reduce recession progression, though high-level evidence on exact timing remains limited.4–5 A periodontal-orthodontic RCT in periodontitis-susceptible patients also supports simultaneous ortho during periodontal therapy without compromising clinical outcomes.6
Our Coordinated Protocol (Concise)
Step 1: Place a passive retainer/inactive aligner to hold occlusion and minimize traumatic forces.
Step 2: Perform PST® for recession/soft-tissue stabilization (no graft harvest, no sutures).
Step 3: After a brief healing window (~3–4 months), reactivate orthodontic movement.
Why Consider PST® with Ortho?
- No palatal donor site or sutures; rapid recovery and aesthetics.
- Designed to stabilize soft tissues prior to re-applying orthodontic forces.
- Clinical outcomes comparable to SCTG at 12 months (in RCT), with long-term case-series support.
References
- Chambrone L, Chambrone D, Pustiglioni FE, Chambrone LA, Lima LA. Can subepithelial connective tissue grafts be considered the gold standard procedure in the treatment of Miller Class I and II recession-type defects? J Dent. 2008;36(9):659-671. Conclusion: SCTG provided significant root coverage, attachment and KT gain; “consider it as the ‘gold standard’.” PubMed, DOI.
- Chao J, Reyes Rosales E, El Chaar E, Shibly O, Al-Sabbagh M, Ma LW. Long-term Retrospective Case Series of the Pinhole® Surgical Technique. Int J Periodontics Restorative Dent. 2025 Jan 14:1-16. Online ahead of print. Abstract: CRC 77.9%; mean root coverage 86.6%; PST® shows long-term predictability over 14.5 years. PubMed, DOI.
- Shibly O, Chao JC, Albandar JM, Almehmadi N, Al-Sabbagh M. Treatment of Gingival Recession Using the Pinhole® Surgical Technique with Collagen Membrane vs Coronally Advanced Flap with Connective Tissue Graft: A Split-Mouth Randomized Clinical Trial. Compend Contin Educ Dent. 2025;46(1):35-41. Abstract: No significant differences at 12 months for recession reduction (1.98 vs 1.97 mm; P=0.53) or % root coverage (65.4% vs 63.6%; P=0.72). PubMed.
- Kloukos D, Gkantidis N, Katsaros C, Eliades T. Indication and timing of soft tissue augmentation at maxillary and mandibular incisors in orthodontic patients: a systematic review. Eur J Orthod. 2014;36(4):442-449. Abstract: Limited evidence; studies implementing soft-tissue intervention before orthodontics “may yield satisfactory results,” but RCTs are needed. PubMed, DOI.
- Chen J, et al. Efficacy of periodontal soft tissue augmentation prior to orthodontic treatment on preventing gingival recession: study protocol for a randomized controlled trial. BMJ Open. 2022;12:e058942. Intro cites prior review suggesting prophylactic augmentation may limit recession progression; high-quality trials are underway. BMJ Open.
- Zasčiurinskienė E, Basevičienė N, Lindsten R, Slotte C, Jansson H, Bjerklin K. Orthodontic treatment simultaneous to or after periodontal cause-related treatment in periodontitis-susceptible patients. Part I: Clinical outcome. A randomized clinical trial. J Clin Periodontol. 2018;45(2):213-224. Conclusion: Simultaneous orthodontic treatment during periodontal therapy can be used in routine care of plaque-induced periodontitis patients. PubMed, DOI.
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This article raises an important question about whether the gold standard of SCTG should automatically be the default when patients are also planning orthodontic treatment. The 14.5-year follow-up data showing 77.9% complete root coverage with PST is impressive, especially since minimally invasive approaches can be performed alongside orthodontics without the donor-site morbidity of connective tissue grafts. In my own experience observing periodontal-orthodontic cases, thin phenotype patients are often the ones where timing decisions get the most complicated, and the point about placing a passive retainer to manage occlusal trauma before soft tissue work makes a lot of clinical sense. The 12-month RCT data showing statistical equivalence between PST + collagen membrane and CAF + CTG is also compelling, though I’d be curious whether longer-term randomized data will hold up the same way. Overall, this makes a strong case that patient-specific factors rather than dogma should drive the decision between the two approaches.
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