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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.

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References

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.

Introduction

Gingival recession is a common oral health issue that can lead to root exposure, increased sensitivity, and aesthetic concerns. Traditional treatment methods, such as free connective tissue grafting, have been effective but often come with higher morbidity, longer recovery times, and secondary surgical sites.

The Pinhole Surgical Technique (PST), developed by Dr. John Chao, has emerged as a minimally invasive alternative to traditional grafting. This blog explores the long-term efficacy of PST through an in-depth look at a 33-month case study and an extended 14.5-year follow-up.

The 33-Month Case Study: Evaluating PST’s Predictability and Effectiveness

Study Overview

A retrospective study was conducted on 43 patients with 121 gingival recession sites to assess the feasibility and success of PST. Of these, 85 were Class I or II defects, and 36 were Class III defects.

Key Findings

• Complete Root Coverage (CRC) for Class I and II sites: 81.2%.
• Mean defect reduction for Class I and II sites: 94.0% ± 14.8%.
• Mean defect reduction across all sites (Class I, II, and III): 88.4% ± 19.8%.
• No secondary graft site was needed, as the procedure relied on bioresorbable membranes or acellular dermal matrix.
• Minimal post-operative complications with rapid healing.
• Mean procedure duration: 22.3 ± 10.1 minutes.
• Patient aesthetic satisfaction: 95.1% realized within 7.34 ± 13.5 days.

These results demonstrated that PST is an effective, predictable, and minimally invasive alternative to traditional grafting techniques for root coverage and gingival recession treatment.

The 14.5-Year Follow-Up: Assessing PST’s Long-Term Stability

Study Overview

Following the original case series, a long-term retrospective assessment was conducted on 28 patients with 68 Miller Class I-II sites from the original study. The goal was to evaluate the stability and effectiveness of PST over 14.5 years.

Key Findings

• Complete Root Coverage (CRC) for Class I-II sites: 77.9% (compared to 81.2% in the initial study).
• Mean root defect coverage: 86.6% ± 27.4% (compared to 94.0% ± 14.8% in the original study).
• Long-term stability of PST with minimal recession relapse.
• Patients retained functional and aesthetic improvements over the study period.

These findings confirm that PST remains an effective and long-lasting solution for gingival recession treatment. Although there was a slight decrease in CRC and defect coverage over time, the results remained highly favorable, with stable gum positioning and sustained root coverage for most patients.

Why PST Is a Game-Changer in Gum Recession Treatment

Advantages of PST Over Traditional Grafting

• Minimally invasive: No need for scalpel incisions or sutures.
• Faster healing times: Patients recover within 24 to 48 hours.
• No secondary grafting site required: Reduces discomfort and risk of complications.
• High predictability and success rates: Over 77% CRC after 14.5 years.
• Aesthetic and functional improvements: Enhances smile appearance and protects tooth roots from further exposure.

What This Means for Patients

Patients suffering from gingival recession can trust PST as a proven long-term solution. The high success rate, minimal invasiveness, and rapid recovery time make it a preferred alternative to traditional gum grafting.

What This Means for Dental Professionals

Dentists looking to enhance their periodontal practice should consider incorporating PST as a predictable and effective technique for treating gingival recession. The long-term stability of PST ensures that patients receive lasting benefits with fewer complications.

Conclusion

The 14.5-year follow-up case study of the Pinhole Surgical Technique (PST) confirms that it is a viable, long-term solution for treating gingival recession. With sustained root coverage, high patient satisfaction, and minimal post-operative complications, PST has redefined modern periodontal therapy.

For patients seeking an innovative, minimally invasive treatment for receding gums, PST remains a cutting-edge option backed by over a decade of clinical success. For dental professionals, offering PST can elevate patient outcomes and practice growth.

Interested in learning more? Contact a certified Pinhole provider today to explore how PST can transform gum recession treatment for you or your patients.