J Clin Periodontol 2014; 41 (Suppl. 15): S44–S62 doi: 10.1111/jcpe.

12182

Efficacy of periodontal plastic Francesco Cairo1, Michele Nieri1 and

Umberto Pagliaro2
1
Department of Periodontology, University of

surgery procedures in the Firenze, Firenze, Italy; 2Private Practice,

Campi Bisenzio-Firenze, Florence, Italy

treatment of localized facial gingival

recessions. A systematic review
Cairo F, Nieri M, Pagliaro U. Efficacy of periodontal plastic surgery procedures in
the treatment of localized gingival recessions. A systematic review. J Clin
Periodontol 2014; 41 (Suppl. 15): S44–S62. doi: 10.1111/jcpe.12182.

Abstract
Background: The aim of this Systematic Review (SR) was to assess the clinical
efficacy of periodontal plastic surgery procedures in the treatment of localized gin-
gival recessions (Rec) with or without inter-dental clinical attachment loss (iCAL).
Material and Methods: Electronic and hand searches were performed to identify
randomized clinical trials (RCTs) on treatment of single gingival recessions with
at least 6 months of follow-up. Primary outcome variable was complete root cov-
erage (CRC). Secondary outcome variables were recession reduction (RecRed)
and keratinized tissue (KT) gain. To evaluate treatment effect, Odds Ratios were
combined for dichotomous data and mean differences in continuous data using a
random-effect model.
Results: Fifty-one RCTs (53 articles) with a total of 1574 treated patients (1744
recessions) were included in this SR. Finally, 30 groups of comparisons were
identified and a total of 80 meta-analyses were performed. Coronally Advanced
Flap (CAF) was associated with higher probability of CRC and higher amount
of RecRed than Semilunar Coronal Positioned Flap (SCPF). The combination
CAF plus Connective Tissue Graft (CAF+CTG) or CAF plus Enamel Matrix
Derivative (CAF+EMD) was more effective than CAF alone in terms of CRC
and RecRed. The combination CAF plus Collagen Matrix (CAF+CM) achieved
higher RecRed than CAF alone. In addition, CAF+CTG achieved CRC more
frequently than CAF+EMD, SCPF, Free Gingival Graft (FGG) and Laterally
Positioned Flap (LPS). CAF+CTG was also associated with higher RecRed than
Barrier Membranes (CAF+GTR), CAF+EMD and CAF+CM. GTR was not
able to improve the clinical efficacy of CAF. Studies adding Acellular Dermal
Matrix (ADM) under CAF showed a large heterogeneity and not significant ben-
efits compared with CAF alone. Multiple combinations, using more than a single
graft/biomaterial under the flap, usually provide similar or less benefits than sim- Key words: connective tissue graft; coronally
pler, control procedures in term of root coverage outcomes. advanced flap; gingival recession; periodontal
plastic surgery; root coverage; systematic
Conclusions: CAF procedures alone or with CTG, EMD are supported by large
review
evidence in modern periodontal plastic surgery. CAF+CTG achieved the best clin-
ical outcomes in single gingival recessions with or without iCAL. Accepted for publication 13 October 2013

Conflict of interest and source of funding statement

This study has been self-funded by the authors. Authors declare that they have no conflict of interest.

S44 © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

The treatment of gingival recessions
with periodontal plastic surgery pro-
cedures is possible request in modern
dentistry (Nieri et al. 2013). The ulti-
mate goal of these procedures is the
complete root coverage (CRC) and
pleasant aesthetic outcomes (Cairo
et al. 2009, 2010).
A previous systematic review
(SR) committed by European Work-
shop in Periodontology for the treat-
ment of single recession was focused
on the clinical efficacy of Coronally
Advanced Flap (CAF) and its
related procedures. This SR showed
that CAF alone was a safe and pre-
dictable procedure and the adjunc-
tive use of Connective Tissue Graft
(CTG) or Enamel Matrix Derivative
(EMD) under CAF enhanced the
probability of obtaining CRC (Cairo
et al. 2008).
The purpose of this SR was to
answer at the following focused
question: “what is the clinical efficacy
of periodontal plastic surgery proce-
dures in the treatment of localized
gingival recession with or without
inter-dental clinical attachment loss?”
Material and Methods
A detailed protocol was designed
according to the PRISMA (Preferred
Reporting Items Systematic review
and Meta-Analyses) statement (Lib-
erati et al. 2009, Moher et al. 2009).
The present manuscript was written
according to PRISMA checklist.
Information sources and Search
An expert operator (UP) conducted
a search on electronic databases
until April 2013 to identify studies
included or investigated for this
review. Three online evidence
sources were used:
● The National Library of Medi-
cine (MEDLINE by PubMed),
on April.30.2013, using the strat-
egy: (“Gingival Recession/sur-
gery”[Mesh] OR “Gingival
Recession/therapy” [Mesh]) AND
((Humans[Mesh]) AND (Ran-
domized Controlled Trial[ptyp]));
● The Cochrane Database Trials
Register, on April.30.2013, using
the following strategy: “Gingival
Recession” [Search All Text]
AND “Root Coverage” [Search
All Text].
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Systematic review on periodontal plastic surgery
● Embase, on April 30, 2013, using
the following strategy: ‘gingiva
disease’/exp/mj AND ‘gingival
recession’/mj AND (randomized
controlled trial)/lim AND
(humans)/lim.
There was no language restric-
tion.
Hand searching included a com-
plete search of Journal of Clinical
Periodontology, Journal of Periodon-
tology, Journal of Periodontal
Research, International Journal of
Periodontics and Restorative Den-
tistry and PERIO up to April
2013.
References from American Acad-
emy of Periodontology position
paper (American Academy of Peri-
odontology 1996), EFP review article
(Wennstr€ om 1994) and previous sys-
tematic reviews dealing with root
coverage procedures for single reces-
sion (Roccuzzo et al. 2002, Oates
et al. 2003, Pagliaro et al. 2003, Cla-
user et al. 2003, Al-Hamdan et al.
2003, Gapski et al. 2005, Hwang &
Wang 2006, Cheng et al. 2007,
Chambrone et al. 2008, Cairo et al.
2008, Chambrone et al. 2009a,b,
2010, Ko & Lu 2010, Chambrone
et al. 2012, Fu et al. 2012, Buti et al.
2013;) were checked for article iden-
tification.
In addition, all authors of the
identified studies, clinical experts or
researchers in the field of periodontal
plastic surgery were contacted in an
attempt to identify unpublished data
or studies not yet published.
Selection
Criteria used in this SR for studies
selection were based on the PICOS
method (Glossary of Evidence-Based
Terms 2007) and were the following:
Types of participants
Patients with a clearly specified diag-
nosis of single gingival recession
defect were included. Miller classifi-
cation (Miller 1985) and Recession
Type (RT) classification using the
inter-dental clinical attachment level
(Cairo et al. 2011) were considered.
Single recessions with no loss (Miller
I and II or RT1) or with minimal
loss of inter-dental bone/clinical
attachment (Miller III or RT2) were
included.
S45
Types of interventions
The following surgical procedures
for the treatment of single recessions
were considered:
• Coronally Advanced Flap (CAF);
• CAF plus Connective Tissue
Graft (CAF+CTG);
• CAF plus Guided Tissue Regen-
eration (GTR) procedures for
root coverage (CAF+GTR);
• CAF plus Enamel Matrix Deriv-
ative (CAF+EMD);
• CAF plus Acellular Dermal
Matrix (CAF+ADM);
• CAF plus porcine Collagen
Matrix (CAF+CM);
• CAF plus Platelet Concentrate
Graft (CAF+PCG);
• CAF plus Human Fibroblast-
Derived Dermal Substitute
(CAF+HF-DDS);
• CAF plus Bone Graft Substitute
(CAF+BGS);
• CAF plus Platelet-Rich Fibrin
Membrane (CAF+P-RFM);
• CAF plus Semilunar Coronally
Positioned Flap (CAF+SCPF);
• Double Papilla Flap (DPF) plus
CTG (DPF+CTG);
• Semilunar Coronally Positioned
Flap (SCPF);
• Laterally Positioned Flap (LPF);
• Free Gingival Graft (FGG).
In addition, the following combi-
nations of surgical techniques
(applying more than a single graft/
biomaterial under the flap) for the
treatment of single recessions were
considered:
• CAF plus Bone Graft (BG) plus
GTR (CAF+BG+GTR);
• CAF plus CTG plus EMD
(CAF+CTG+EMD);
• CAF plus Beta-Tricalciun Phos-
phate (b-TCP) plus Recombi-
nant Human Platelet-Derived
Growth Factor-BB (rhPDGF-
BB) (CAF+ b-TCP+ rhPDGF-
BB);
• CAF plus GTR plus EMD
(CAF+GTR+EMD);
• CAF plus CTG plus EMD
(CAF+CTG+EMD);
• CAF plus ADM plus autologous
gingival Fibroblasts (Fibr)
(CAF+ADM+Fib);
• CAF plus GTR plus Hydroxyap-
atite (HP) (CAF+GTR+HP).
S46 Cairo et al.
Comparison between interventions
All possible comparisons between
the considered surgical procedures
were investigated.
Type of outcome measures
The following outcome measures
were considered:
Primary outcome.
• Recession defects that obtained
complete root coverage (CRC).
Secondary outcomes.
• Change in gingival recession
expressed as recession reduction
in millimetres at follow-up visit
(RecRed),
• Change in width of keratinized
tissue (KT) expressed as KT gain
in millimetres at follow-up visit
(KT gain),
• Biological complications during
the post-operative healing period
(Complications),
• Patient discomfort during the
post-operative healing period
(Post-operative pain),
• Patient preference in term of aes-
thetic result at follow-up visit
(Aesthetic satisfaction),
• Patient perception of root sensi-
tivity at follow-up visit (Root sen-
sitivity).
Types of studies
In this systematic review, only ran-
domized controlled clinical trials
(RCTs), including split-mouth
model, for the treatment of single
gingival recession of at least
6 months duration were considered.
In this SR, the following items
were considered as exclusion crite-
ria:
• RCTs comparing variations of a
same technique (i.e. CAF with
releasing incisions versus CAF
without releasing incisions),
• RCTs with unclear/not specified
type of treated recessions,
• RTCs treating multiple gingival
recessions or treating both single
and multiple recessions,
• RTCs with multiple treated sites
into a single patient without
appropriate statistical analysis
and unavailable individual
patient data (IPD),
Validity assessment
The quality assessment of the
included trials was independently per-
formed in a duplicate form by two
review authors (F.C. and U.P.).
According to Cochrane Handbook for
Systematic Reviews of Interventions
Version 5.1.0 [updated March 2011]
(Higgins & Green 2011), three main
quality criteria were examined: alloca-
tion concealment, blinding treatment
outcomes to outcome assessors and
completeness of follow-up (for
detailed explanation see Cairo et al.
2008 and additional material section,
Data S2: Validity assessment). After
quality assessment, studies were
grouped into two categories:
● Low risk of bias, if all three qual-
ity criteria were met.
● High risk of bias, if one or more of
the three quality criteria was not met.
Data abstraction
The titles and abstracts (when avail-
able) of all reports identified through
the electronic and manual searches
were independently screened by two
review authors (F.C. and U.P.).
When studies met the inclusion crite-
ria or when insufficient data from
abstracts for evaluating inclusion cri-
teria were gained, the full article was
obtained. The full text of all studies
of possible relevance was indepen-
dently assessed by two review
authors (F.C. and U.P.). All studies
meeting the inclusion criteria then
underwent to quality assessment and
data recording. When disagreement
between the two reviewers was
revealed, consensus was achieved by
discussion with the third reviewer/
statistical advisor (M.N.). Then, data
were independently extracted and
inserted into a computer by two
review authors (F.C. and U.P.) using
specifically designed data-collection
forms. Patient characteristics, treat-
ments, clinical outcomes, complica-
tions and study quality were
systematically registered. When clini-
cal data on CRC were lacking,
authors of the trials were contacted.
Study characteristics
Only randomized clinical trials
(RCTs), with or without a split-
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
mouth design, were included in the
systematic review. Eligible RCTs,
with a follow-up duration
≥6 months, had to compare the
results of at least 2 of the investi-
gated surgical techniques in patients
with Miller Class I, II or III (Miller
1985) or Recession Types 1 or 2
(Cairo et al. 2011) defects.
CRC had to be expressed as the
number or the percentage of treated
teeth of each considered study arm
that achieved total root coverage at
the follow-up visit. RecRed had to
be expressed as mean recession
reduction in millimetres of the trea-
ted teeth of each study arm at fol-
low-up visit. KT Gain had to be
expressed as mean keratinized tissue
width increase in millimetres of the
treated teeth of each study arm at
follow-up visit. Complications, Post-
operative pain, Aesthetic satisfaction
and Root sensitivity had to be
described at least in a narrative
form.
Quantitative data synthesis
For dichotomous outcomes (CRC),
the estimates of effect of an interven-
tion were expressed as odds ratio
(OR) together with 95% confidence
intervals (CI). For continuous out-
comes, mean differences and stan-
dard deviations were used to
summarize the data from each
group. In each patient, only one site
for each technique was considered.
In fact, multiple sites in same patient
are not independent as are exposed
to similar patient-related risk factors.
When studies with multiple sites
were identified, the presence of Indi-
vidual Patient Data (IPD) was
checked and multiple sites were elim-
inated. This allowed the selection of
a single recession for technique in
the single patient.
OR were combined for dichoto-
mous data and mean differences in
continuous data using a random-
effect model. Data from split-mouth
studies were combined with data
from parallel group trials with the
method outlined by Elbourne et al.
(2002), using the generic inverse var-
iance method in the RevMan. The
techniques described by Follmann
et al. (1992) were used to calculate
the standard error of the difference
in split-mouth studies, where the

appropriate data were not pre-
sented.
The significance of any discrepan-
cies in the estimates of the treatment
effects from different trials was
assessed by means of Cochran’s test
for heterogeneity and the I2 statistic,
which describes the percentage total
variation across studies that is due
to heterogeneity rather than change.
It was planned to undertake sensitiv-
ity analyses to examine the effect of
the study quality for CRC.
Evaluation of the strength of
evidence
Evidence regarding CRC and
RecRed provided by RTCs was rated
using different levels of methodologi-
cal strength modified from GRADE
(grading of recommendations assess-
ments development and evaluation)
(Guyatt et al. 2008). Three different
strength of evidence were considered:
● High: at least 3 RCTs of low risk
of bias and low heterogeneity
● Moderate: > 1 RCT and at least
1 RCTs of low risk of bias, low I2
● Low: lack of RCT or RCT at high
risk of bias or high heterogeneity
Results
Study selection
The search results are presented in
Fig. 1. The electronic search in
Fig. 1. Literature search process and results.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Systematic review on periodontal plastic surgery
MEDLINE (by PubMed), in the
Cochrane Collaboration databases,
and in EMBASE provided, respec-
tively, 294, 141 and 159 articles
published until April 2013. Subse-
quently, after reading all the
abstracts and discarding duplicates,
161 articles were selected. Twenty-
two of these 161 articles were not
published in the journals selected for
the hand searching of the present
systematic review.
The hand searching found 103
articles and 14 of these were not
found by the electronic search.
The search of the “grey literature”
(unpublished data) by e-mail contact
with all the authors of the identified
studies and clinical experts or
researchers in the field of mucogingi-
val surgery provided the complete
data of one trial (Barros et al. 2013).
Finally, by crossing the literature
searches (electronic, manual and
unpublished data searches) to elimi-
nate duplicates, 176 articles (161 by
electronic, 14 by hand-search and 1
still unpublished study by “grey liter-
ature” search) were selected.
The full text reading of the 176
articles allowed the selection of 51
studies (53 reports) (Table 1) that
met the inclusion criteria of this sys-
tematic review and the exclusion of
123 articles from the analysis.
Rejected studies at this stage are
listed in Table 2 (characteristics of
excluded studies) and the reason for
exclusion was recorded.
S47
Forty-three of the 52 selected
studies allowed 20 comparisons
between single surgical techniques
(Fig. 2), whereas nine studies led to
nine adjunctive comparisons between
single techniques and combinations
of surgical procedures (Fig. 3). Fur-
thermore, only one contacted
research group (Joly et al. 2007) was
able to provide additional unpub-
lished data on CRC.
For six selected RCTs, two arti-
cles with different follow-up dura-
tions were published. In this case,
studies with follow-up ≥ 5 years
were considered as long-term obser-
vation of short-term studies. When
multiple studies were restricted to
follow-ups < 5 years, the manu-
script with longest follow-up was
considered, although both papers
were checked to retrieve all data
when necessary. When multiple
studies showed also follow-up
≥ 5 years, the shorter observation
was considered, to limit the possi-
ble influence of self-performed and
professional maintenance on the
clinical efficacy of tested technique.
In details, the six multiple publica-
tions were managed for meta-analy-
sis as follow:
• Amarante et al. (2000) showed a
6-month follow-up whereas Lek-
nes et al. (2005) corresponded to
the (1- and 6-year follow-ups).
One-year data from Leknes et al.
(2005) were considered.
• H€agewald et al. (2002) showed a
1-year follow-up whereas Spahr
et al. (2005) presented the 2-year
follow-up in the same sample of
patients. Data from Spahr et al.
(2005) were considered for meta-
analysis.
• C^ortes et al. (2004) reported 6-
months follow-up whereas C^ ortes
et al. (2006) described 2-years
follow-up. Both publications
were utilized to retrieve data.
• McGuire & Nunn (2003) showed
6-month follow-up whereas
McGuire et al. (2012) presented
the 10-year follow-up. Data from
McGuire & Nunn (2003) were
considered for meta-analysis.
• Haghighati et al. (2009) reported
1-year follow-up whereas Mos-
lemi et al. (2012) described a
5-year follow-up. Data from
Haghighati et al. (2009) were
considered.
S48 Cairo et al.

Table 1. Fifty-one included studies (53 articles)

Comparations between single and/or combinations of techniques

Study MRC MRC CRC CRC

Comparison Design Test Control Test Control (%)
Study (Test versus Control) (%) (%) (%)

da Silva et al. (2004) 1. CAF+CTG versus CAF SM 75.3 68.8 18.2 9.1
Cortellini et al. (2009) P 74.1 62.5 60.0 37
Amarante et al. (2000) 2. CAF+GTR versus CAF SM 56.1 69.4 25.0 50
Lins et al. (2003) SM 45.0 60.0 NR NR
Leknes et al. (2005) SM 35.0 34.2 18.2 9.1
Modica et al. (2000) 3. CAF+EMD versus CAF SM 91.2  1.5 80.9  21.3 64.3 50
Del Pizzo et al. (2005) SM 90.7  17 86.7  18.3 73.3 60.0
Spahr et al. (2005) SM 84.0 67.0 53 23
Castellanos et al. (2006) P 88.6 62.2 NR NR
Pilloni et al. (2006) P 93.8  12.9 65.5  26.0 86.7 33.3
Woodyard et al. (2004) 4. CAF+ADM versus CAF P 99  5 67  27 91.7 33.3
C^ortes et al. (2004, 2006) SM 68.0  17.9 56  23.0 7.7 7.7
Mahajan et al. (2007) P 97.1 77.4 NR NR
Huang et al. (2005) 5. CAF+PCG versus CAF P 87.1  21.4 83.5  21.8 63.6 58.3
Nazareth & Cury (2010) 6. CAF+BGS versus CAF SM 85.6  21.7 90.0  18.4 66.7 73.3
Jepsen et al. (2013) 7. CAF+CM versus CAF SM 75.29 72.66 36.0 31.0
Santana et al. (2010a) 8. SCPF versus CAF SM 41.8 83.9 9.0 63.6
Santana et al. (2010b) 9. LPF versus CAF P 95.5 96.6 83.3 88.8
Jepsen et al. (1998) 10. CAF+GTR versus CAF+CTG SM 87.1  13.8 86.9  15.4 46.7 46.7
Trombelli et al. (1998) SM 48.0 81.0 8.3 50.0
Zucchelli et al. (1998) P B 5.7  13.8 93.5  8.6 B 38.9 66.7
Borghetti et al. (1999) U 80.5  14.9 U 27.8 28.6
Tatakis & Trombelli (2000) SM 70.2 76.0 28.6 83.3
Romagna-Genon (2001) SM 81.0 96.0 58.3 NR
Wang et al. (2001) SM 74.59 84.84 NR 43.7
SM 73  26 84  25 43.7
Abolfazli et al. (2009) 11. CAF+EMD versus CAF+CTG SM 76.9 93.1 25.0 66.6
McGuire et al. (2003) SM 95.1 93.8 89.5 79.0
Aichelmann-Reidy et al. (2001) 12. CAF+ADM versus CAF+CTG SM 65.9  46.7 74.1  38.3 31.8 50.0
Paolantonio et al. (2002b) P 83.3  11.40 88.8  11.6 26.7 46.7
Tal et al. (2002) SM 89.1 88.7 42.9 42.9
Joly et al. (2007) SM 50.0 79.5 75.0 40.0
Haghighati et al. (2009) SM 85.4  22.7 69.1  24.2 NR 31.3
Barros et al. (2013) SM 72.9 78.73 NR
McGuire & Scheyer (2010) 13. CAF+CM versus CAF+CTG SM 88.5  21.2 99.3  3.5 NR NR
Wilson et al. (2005), 14. CAF+HF-DDS versus SM 56.7  27.8 64.4  31.9 10.0 10.0
CAF+CTG
Bittencourt et al. (2009) 15. SCPF versus CAF+CTG SM 89.2 96.8 58.8 88.2
Jankovic et al. (2012) 16. CAF+P-RFM versus SM 88.6  10.6 92.0  15.5 75.8 79.6
CAF+CTG
Jahnke et al. (1993) 17. FGG versus CAF+CTG SM 43.0 80.0 11.1 55.5
Paolantonio et al. (1997) P 53.2  21.5 85.2  17.9 8.6 48.6
Ricci et al. (1996) 18. DPF+CTG versus CAF+GTR P 77.1 80.9 NR NR
Paolantonio (2002a) P 90.0 81.0 60.0 40.0
Jankovic et al. (2010) 19. CAF+P-RFM versus CAF+EMD SM 72.1  9.5 70.5  11.8 65.0 60.0
Zucchelli et al. (2012) 20. LPF versus CAF+CTG P 74.2  8.2 88.8  11.2 4.0 48.0

Comparations between single or combinations of techniques and multiple combinations of techniques

Rasperini et al. (2011) 21. CAF+CTG+EMD versus P 90.0  10.0 80.0  30.0 61.5 46.7
CAF+CTG
McGuire et al. (2009) 22. CAF+b-TCP+rhPDGF-BB versus SM 90.8 98.6 NR NR
CAF+CTG
Jhaveri et al. (2010) 23. CAF+ADM+Fib versus CAF+CTG SM 83.3 83.3 70.0 60.0
Paolantonio (2002a) 24. CAF+GTR+HP versus DPF+CTG P 87.1 90.0 53.3 60.0
Paolantonio (2002a) 25. CAF+GTR+HP versus CAF+GTR P 87.1 81.0 53.3 40.0
Dodge et al. (2000) 26. CAF+BG+GTR versus CAF+GTR SM 89.9  26.5 73.7  24.6 50.0 33.0
Kimble et al. (2002) P 74.3  11.7 68.4  15.2 NR NR
Trabulsi et al. (2004) 27. CAF+GTR+EMD versus P 63  16.5 75  25.6 7.7 38.5
CAF+GTR

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Systematic review on periodontal plastic surgery S49

Table 1. (continued)
Comparations between single and/or combinations of techniques

Study MRC MRC CRC CRC

Comparison Design Test Control Test Control (%)
Study (Test versus Control) (%) (%) (%)

Alkan & Parlar (2011) 28. CAF+CTG+EMD versus SM 89  14 92  14 58.3 75.0

CAF+EMD
Alves et al. (2012) 29. CAF+ADM+EMD versus SM 55.4 44 15.8 5.3
CAF+ADM
Cairo et al. (2012) 30. CAF+CTG versus CAF P 85.0 69.0 57.0 29.0

SM, Split-Mouth design; P, Parallel design; MRC, Mean% of Root Coverage; CRC, Complete Root Coverage; NR, Not Reported; CAF,
Coronally Advanced Flap; CTG, subepithelial Connective Tissue Graft; GTR, Guided Tissue Regeneration procedures for root coverage; B,
Bioabsorbable barrier membrane; U, Unsorbable barrier membrane; EMD, Enamel Matrix Derivative; ADM, Acellular Dermal Matrix;
CM, porcine Collagen Matrix; PCG, Platelet Concentrate Graft; HF-DDS, Human Fibroblast-Derived Dermal Substitute; BGS, Bone Graft
Substitute; P-RFM, Platelet-Rich Fibrin Membrane; SCPF, Semilunar Coronally Positioned Flap; DPF, Double Papilla Flap; LPF, Later-
ally Positioned Flap; FGG, Free Gingival Graft. BG, Bone Graft; b-TCP, Beta-Tricalciun Phosphate; rhPDGF-BB, Recombinant Human
Platelet-Derived Growth Factor-BB; Fib, autologous gingival Fibroblasts; HP, Hydroxyapatite.

Table 2. Characteristics of the 123 excluded articles

Reason for exclusion Study

Unspecified classification of recession
Not surgical therapy
Comparison between variations of a same surgical
technique
Study not dealing root coverage
Also Miller Class III gingival recession defects treated
Same pool of patients with a shorter follow-up of an
included study in this systematic review
Not RCT
Shorter follow-up duration
Comparison with untreated recessions
Data not useful for meta-analysis
Only abstract available
Histological study
Multiple or not only single gingival recessions treated
Un-appropriate statistical analysis
Guinard & Caffesse (1978), Caffesse & Guinard (1978, 1980),Espinel & Caffesse
(1981).
Aimetti et al. (2005).
Ibbott et al. (1985), Oles et al. (1985), Caffesse et al. (1987, 2000), Bouchard et al.
(1994, 1997), Trombelli et al. (1995b (313), 1996), Roccuzzo et al. (1996),
Matarasso et al. (1998), Pini Prato et al. (1999, 2000, Pini Prato et al. 2011),
Henderson et al. (2001), Del Pizzo et al. (2002), Zucchelli et al. (2003, 2009a (577),
2009b (1083), 2010), Al-Zahrani et al. (2004), Barros et al. (2004, 2005, 2007),
Burkhardt & Lang (2005), Francetti et al. (2005), Tozum et al. (2005), Rahmani &
Lades (2006), Kassab et al. (2006), Bittencourt et al. (2007, 2012), Lucchesi et al.
(2007), Felipe et al. (2007), Andrade et al. (2008, 2010), Santamaria et al. (2008,
2009a (434), 2009b (791)), Byun et al. (2009), Barker et al. (2010), Mazzocco et al.
(2011), Ozturan et al. (2011), Ayub et al. (2012), Kuru & Selin (2012), Mahajan
et al. (2012)
Wei et al. (2000), Harris et al. (2001), McGuire & Nunn (2005), Bertoldi et al.
(2007), Sanz et al. (2009), Dilsiz et al. (2010a (337), 2010b (511)), Nevins et al.
(2010, 2011), McGuire et al. (2011)
Cueva et al. (2004)
Hagewald et al. (2002), McGuire & Nunn (2003), Bittencourt et al. (2006),
Haghighati et al. (2009)
Pini Prato et al. (1992, 1996, 2010), Trombelli et al. (1995a (14)), Wennstr€ om &
Zucchelli (1996), Harris (1997, 1998, 2000), Ozcan et al. (1997), Muller et al.
(1999), Duval et al. (2000), Cordioli et al. (2001), Nemcovsky et al. (2004), Harris
et al. (2005), Hirsch et al. (2005), Berlucchi et al. (2005), McGuire & Scheyer
(2006), Silva et al. (2006), Moses et al. (2006), Erley et al. (2006), Keceli et al.
(2008), Santamaria et al. (2010), Schlee & Esposito (2011)
Laney et al. (1992), Maurer et al. (2000), Lafzi et al. (2007, 2011),
Papageorgakopoulos et al. (2008), Han et al. (2008), Barbosa et al. (2009),
Shepherd et al. (2009), de Toledo et al. (2009), Baghele & Pol (2012)
Borghetti & Louise (1994)
Rosetti et al. (2000)
Barros et al. (2003)
McGuire et al. (2009)
Ito et al. (2000), Dembowska & Drozdzik (2007), Shin et al. (2007), De Souza
et al. (2008), Aroca et al. (2009, 2010), Pourabbas et al. (2009), Henriques et al.
(2010), Nickles et al. (2010), Aleksić et al. (2010), Ozcelik et al. (2011), Carney
et al. (2012), Cordaro et al. (2012), Roman et al. (2013).
Novaes et al. (2001), Berlucchi et al. (2002), Cetiner et al. (2003), Cheung &
Griffin (2004), Bahashemrad et al. (2009), Cardaropoli & Cardaropoli (2009),
Cardaropoli et al. (2012), Kuis et al. (2013)

RCT, Randomized Clinical Trial.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
S50 Cairo et al.

Fig. 2. Schematic drawing of comparisons of surgical techniques for single gingival recessions covering 43 studies (45 articles)
enclosed in the systematic review.

• Bittencourt et al. (2006) showed

6-month follow-up whereas Bit-
tencourt et al. (2009) reported
30-month follow-up. The longest
follow-up was considered for
meta-analysis.

The quality assessment of

enclosed studies showed that only 13
of 51 RTCs (25%) were rated at low
risk of bias (Aichelmann-Reidy et al.
2001, Wang et al. 2001, Kimble
et al. 2002, Huang et al. 2005, Del
Pizzo et al. 2005, Spahr et al. 2005,
Wilson et al. 2005, Cortellini et al.
2009, McGuire & Scheyer 2010,
McGuire et al. 2012, Zucchelli et al.
2012, Cairo et al. 2012, Jepsen et al.
2013)
Among a total of 51 RTCs only
a very limited number (8%) showed
long-term outcomes of treatment
with a follow-up of at least 5 years
Fig. 3. Schematic drawing of comparisons for multiple combinations techniques (Paolantonio et al. 1997, Leknes
(applying more than a single graft/biomaterial under the flap) covering nine studies et al. 2005, Moslemi et al. 2011,
(nine articles) enclosed in the systematic review. McGuire et al. 2012).

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Study characteristics
Included studies
The list of included studies is pre-
sented in Table 1. The 51 selected
studies (53 articles) allowed the com-
parisons showed in Fig. 2. For all
the other possible comparisons
investigated in the systematic review,
no eligible study was found.
In the case of Modica et al.
(2000), two of the 12 participants
were excluded from meta-analyses
because they participated in a split-
mouth study with more than one
pair of bilateral gingival recessions.
Hence, IPD of the remaining 10 pair
of recession defects were re-analysed.
Among included studies, 2 RTCs
were multicentre (Cortellini et al.
2009, Jepsen et al. 2013) while all
others were single centre study.
Among the enclosed RCTs
• Ten studies (Jahnke et al. 1993,
Paolantonio (2002a), Paolantonio
et al. 2002b, Kimble et al. 2004,
Huang et al. 2005, Bittencourt
et al. 2009, Jhaveri et al. 2010,
Alkan & Parlar 2011, Moslemi
et al. 2011, Nazareth & Cury
2010) were completely supported
by public institutes for research,
• One study (Cortellini et al. 2009)
was supported by private insti-
tutes for research,
• Thirteen studies (Trombelli et al.
1998, Tatakis & Trombelli 2000,
Aichelmann-Reidy et al. 2001,
Wang et al. 2001, Tal et al. 2002,
McGuire et al. 2012, Trabulsi
et al. 2004, Leknes et al. 2005,
Spahr et al. 2005, Wilson et al.
2005, McGuire et al. 2009,
McGuire & Scheyer 2010, Jepsen
et al. 2013) were supported, in
part, by companies whose prod-
ucts were being used as interven-
tions in the trials,
• Three studies (Mahajan et al.
2007, Santana et al. 2010a,b)
specified that the authors not
received founding,
• Three studies (Alves et al. 2012,
Cairo et al. 2012, Zucchelli et al.
2012) specified that the authors
self-supported the research,
• Twenty-one studies (Ricci et al.
1996, Paolantonio et al. 1997,
Jepsen et al. 1998, Zucchelli et al.
1998, Borghetti et al. 1999,
Dodge et al. 2000, Modica et al.
2000, Romagna-Genon 2001,
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Systematic review on periodontal plastic surgery
Lins et al. 2003, C^ ortes et al.
2006, da Silva et al. 2004, Wood-
yard et al. 2004, Del Pizzo et al.
2005, Castellanos et al. 2006,
Pilloni et al. 2006, Joly et al.
2007, Abolfazli et al. 2009,
Jankovic et al. 2010, Rasperini
et al. 2011, Jankovic et al. 2012,
Barros et al. 2013) did not report
how the study was supported.
Excluded studies
There were 123 excluded studies.
The reasons for exclusion are
reported in Table 2 (Characteristics
of the 123 excluded studies).
Results of the analyses
Clinical outcomes from 51 RCTs
(corresponding to 53 articles) with
1574 patients and 1744 treated
recessions were included in this SR.
A total of 80 meta-analyses were
performed. Table 3 reported the
results of meta-analyses for CRC
(primary outcome), RecRed (sec-
ondary outcome) and KT Gain
(secondary outcome) for each possi-
ble comparison between surgical
procedures.
Among different RTCs, only a
single study evaluating root coverage
at Rec with iCAL (Cairo et al. 2012)
was enclosed in the SR.
Main results can be summarized
in:
• CAF+CTG was more effective
than CAF in term of CRC
(p = 0.03), RecRed (p = 0.005)
and KT gain (p = 0.0001) for
Rec with no iCAL.
• CAF+CTG was more effective
than CAF in term of RecRed
(p = 0.03) and KT gain (p <
0.00001) for Rec with iCAL.
• The adjunctive use of GTR was
not able to improve CAF with
no significant difference with the
control procedure (CRC p =
0.41; RecRed p = 0.11)
• The adjunctive use of EMD
yielded to significant improvement
of CAF alone in term of CRC
(p = 0.003), RecRed (p = 0.002)
and KT gain (p = 0.0007).
• Multiple combinations, using
more than a single graft/biomate-
rial under the flap, usually pro-
vide similar or less benefits than
simpler, control procedures.
S51
Figures 4–9 showed some meta-
analyses for CRC, corresponding to
comparisons CAF+CTG versus
CAF, CAF+GTR versus CAF, CAF+
GTR versus CAF+CTG, CAF+EMD
versus CAF+CTG, CAF+CM versus
CAF and CAF+CM versus CAF+
CTG.
All performed meta-analyses were
presented in the online material as sup-
plementary information (Data S1).
Evaluation of the strength of evidence
The evaluation of the strength of
evidence using the modified GRADE
system showed for CRC that three
groups of comparisons were at
moderate strength of evidence
(CTG+CAF > CAF; CAF+EMD
> CAF; CAF+CTG > CAF+
GTR), while other comparisons were
considered at low strength of evi-
dence. No comparison for CRC was
rated at high strength of evidence.
For RecRed, two groups of com-
parisons were at moderate strength
of evidence (CTG + CAF > CAF;
CAF+CTG>CAF+GTR), while
other comparisons were considered
at low strength of evidence. No com-
parison for RecRed was rated at
high strength of evidence.
Aesthetic satisfaction
Few studies evaluated aesthetic satis-
faction following therapy, mainly
collecting patient opinion with no
standardized approaches. No meta-
analysis throughout conventional
system was possible. Possible aes-
thetic evaluation of the clinical out-
comes included a double assessment
by patient and periodontist (Wang
et al. 2001, Aichelmann-Reidy et al.
2001). Lately, the Root coverage
Esthetic Score (RES), a standardized
system to aesthetic evaluation after
root coverage, was introduced (Cairo
et al. 2009, 2010) and applied in
recent RCTs (Jhaveri et al. 2010,
Cairo et al. 2012, Roman et al.
2013).
Root sensitivity
Very few studies evaluated Root
sensitivity following root coverage
procedures. No meta-analysis was
performed for this variable due to
the fact that data were few and het-
erogeneous. Cortellini et al. (2009)
compared CAF+CTG versus CAF,
S52 Cairo et al.

Table 3. Results of the meta-analyses: 51 RCTs (53 articles) with a total of 1574 treated patients (1744 recessions) were considered
Comparations between single and/or combinations of techniques
Comparison CRC RecRed KT Gain

1. CAF+CTG versus CAF Better CAF+CTG Better CAF+CTG Better CAF+CTG

(2 studies, 1 at low risk of bias, moderate p = 0.03 p = 0.005 p = 0.0001
strength of evidence) OR = 2.49 MD = 0.49 mm MD = 0.73
95% CI: 1.10–5.68 95% CI: 0.14–0.83 95% CI: 0.35–1.10
I2 = 0% I2 = 0% I2 = 0%
2. CAF+GTR versus CAF No SSD No SSD No SSD
(2 studies at high risk of bias, low p = 0.41 p = 0.11 p = 0.30
strength of evidence) OR = 0.58 (favouring CAF) MD = 0.27 MD = 0.15
95% CI: 0.16–2.08 95% CI: 0.60–0.06 95% CI: 0.13–0.42
I2 = 0% I2 = 0%
3. CAF+EMD versus CAF Better CAF+EMD Better CAF+EMD Better CAF+EMD
(5 studies, 2 at low risk of bias, moderate p = 0.003 p = 0.002 p = 0.0007
strength of evidence for CRC and low OR = 3.89 MD = 0.5 MD = 0.42
for RecRed) 95% CI: 1.59–9.50 95% CI: 0.21–0.95 95% CI: 0.18–0.66
I2 = 15% I2 = 51% I2 = 53%
4. CAF+ADM versus CAF No SSD No SSD Better CAF+ADM
(3 studies at high risk of bias, low p = 0.31 p = 0.10 p = 0.02
strength of evidence) OR = 4.83 (favouring MD = 0.70 mm MD = 0.37
CAF+ADM) 95% CI: 0.14–1.54 95% CI: 0.05–0.70
95% CI: 0.23–99.88 I2 = 80% I2 = 0%
I2 = 67%
5. CAF+PCG versus CAF No SSD No SSD No SSD
(1 study at low risk of bias, low strength p = 0.79 (favouring CAF+PCG) p = 0.57 p = 0.38
of evidence) OR = 1.25 MD = 0.20 MD = 0.30
95% CI: 0.23–6.71 95% CI: 0.89–0.49 95% CI: 0.97–0.37
6. CAF+BGS versus CAF No SSD No SSD No SSD
(1 study at high risk of bias, low strength p = 0.65 p = 0.34 p = 1.00
of evidence) OR = 0.73 (favouring CAF) MD = 0.20 MD = 0.00
95% CI: 0.18–2.86 95% CI: 0.61–0.21 95% CI: 0.24–0.24
7. CAF+CM versus CAF No SSD Better CAF+CM Better CAF+CM
(1 study at low risk of bias, low strength p = 0.61 (favouring CAF+CM) p = 0.05 p = 0.04
of evidence) OR = 1.22 MD = 0.27 MD = 0.37
95% CI: 0.57–2.63 95% CI: 0.00–0.54 95% CI: 0.02–0.72
8. SCPF versus CAF Better CAF Better CAF Better SCPF
(1 study at high risk of bias, low strength p = 0.0002 p < 0.00001 p < 0.00001
of evidence) OR = 0.06 MD = 1.40 MD = 1.10
95% CI: 0.01–0.26 95% CI: 1.69 to 1.11 95% CI: 0.75–1.45
9. LPF versus CAF No SSD No SSD Better LPF
(1 study at high risk of bias, low strength p = 0.63 p = 0.26 p < 0.00001
of evidence) OR = 0.63 (favouring CAF) MD = 0.17 MD = 2.70
95% CI: 0.09–4.28 95% CI: 0.12–0.46 95% CI: 1.58–3.82
10. CAF+GTR versus CAF+CTG No SSD Better CAF+CTG Better CAF+CTG
(6 studies, 1 at low risk of bias, moderate p = 0.06 p = 0.008 p = 0.004
strength of evidence) OR = 0.45 (favouring CAF+CTG) MD = 0.38 MD = 1.18
95% CI: 0.20–1.04 95% CI: 0.65 to 0.10 95% CI: 1.98 to 0.39
I2 = 32% I2 = 46% I2 = 92%
11. CAF+EMD versus CAF+CTG No SSD Better CAF+CTG Better CAF+CTG
(2 studies, 1 at low risk of bias, low p = 0.71 p = 0.03 p < 0.00001
strength of evidence) OR = 0.61 (favouring CAF+CTG) MD = 1.17 MD = 1.25
95% CI: 0.05–8.05 95% CI: 1.93–0.41 95% CI: 1.78 to 0.72
I2 = 0%
12. CAF+ADM versus CAF+CTG No SSD No SSD No SSD
(6 studies, 1 at low risk of bias, low p = 0.68 p = 0.36 p = 0.07
strength of evidence) OR = 0.79 (favouring CAF+CTG) MD = 0.19 MD = 0.64
95% CI: 0.25–2.43 95% CI: 0.61–0.22 95% CI: 1.33–0.05
I2 = 63% I2 = 70% I2 = 73%
13. CAF+CM versus CAF+CTG No data Better CAF+CTG No SSD
(1 study at low risk of bias, low strength p = 0.03 p = 0.95
of evidence) MD = 0.39 MD = 0.02
95% CI: 0.64 to 0.14 95% CI: 0.61–0.65
14. CAF+HF-DDS versus CAF+CTG No SSD No data No data
(1 study at low risk of bias, low strength p = 1.00
of evidence) OR = 1.00
95% CI: 0.02–50.40

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Systematic review on periodontal plastic surgery S53

Table 3. (continued)
Comparations between single and/or combinations of techniques
Comparison CRC RecRed KT Gain

15. SCPF versus CAF+CTG Better CAF+CTG No data No data

(1 study at high risk of bias, low strength p = 0.04
of evidence) OR = 0.19
95% CI: 0.04–0.91
16. CAF+P-RFM versus CAF+CTG No SSD No SSD Better CAF+CTG
(1 study at high risk of bias, low strength p = 0.62 p = 0.25 p = 0.005
of evidence) OR = 0.69 (favouring CAF+CTG) MD = 0.24 MD = 0.56
95% CI: 0.15–3.05 95% CI: 0.65–0.17 95% CI: 0.95 to 0.17
17. FGG versus CAF+CTG Better CAF+CTG No data No data
(2 studies at high risk of bias, low p < 0.0001
strength of evidence) OR = 0.10
95% CI: 0.03–0.31
I2 = 0%
18. DPF+CTG versus CAF+GTR No SSD No SSD No SSD
(2 studies at high risk of bias, low p = 0.28 p = 0.90 p = 0.38
strength of evidence) OR = 0.44 (favouring DPF+CTG) MD = 0.08 MD = 1.03
95% CI: 0.10–1.92 95% CI: 0.13–1.28 95% CI: 3.34–1.28
I2 = 74% I2 = 97%
19. CAF+P-RFM versus CAF+EMD No SSD No SSD Better CAF+EMD
(1 study at high risk of bias, low strength p = 0.71 p = 0.10 p = 0.0001
of evidence) OR = 1.24(favouring CAF+ P- MD = 0.30 MD = 0.43
RFM) 95% CI: 0.05–0.65 95% CI: 0.63 to 0.23
95% CI: 0.40–3.79
20. LPF versus CAF+CTG Better CAF+CTG No SSD Better LPF
(1 study at high risk of bias, low strength p = 0.05 p = 0.07 p = 0.00001
of evidence) OR = 22.15 MD = 0.36 MD = 1.12
95% CI: 2.58–189.94 95% CI: 0.03–0.75 95% CI: 1.57 to 0.67

Comparations between single or combinations of techniques and multiple combinations of techniques

Comparison CRC RecRed KT Gain

21. CAF+CTG+EMD versus CAF+CTG No SSD No SSD No SSD

(1 study at high risk of bias, low strength p = 0.27 p = 0.27 p = 1.00
of evidence) OR = 1.83 (favouring MD = 0.30 MD = 0.00
CAF+CTG+EMD) CI95% CI: 0.33–0.93 95% CI: 0.67–0.67
95% CI: 0.63–5.32
22. CAF+b-TCP+rhPDGF-BB versus No data Better CAF+CTG Better CAF+CTG
CAF+CTG p = 0.0009 p = 0.01
(1 study at high risk of bias, low strength MD = 0.40 MD = 0.30
of evidence) 95% CI: 0.64 to 0.16 95% CI: 0.54 to 0.06
23. CAF+ADM+Fib versus CAF+CTG No SSD No data No data
(1 study at high risk of bias, low strength p = 0.59
of evidence) OR = 1.56 (favouring
CAF+ADM+Fib)
95% CI: 0.31–7.84
24. CAF+GTR+HP versus DPF+CTG No SSD No SSD Better DPF+CTG
(1 study at high risk of bias, low strength p = 0.71 p = 0.84 p = 0.00001
of evidence) OR = 0.76 (favouring DPF+CTG) MD = 0.07 MD = 2.13
95% CI: 0.18–3.24 95% CI: 0.76–0.62 95% CI: 2.64 to 1.62
25. CAF+GTR+HP versus CAF+GTR No SSD No SSD No SSD
(1 study at high risk of bias, low strength p = 0.43 p = 0.25 p = 0.62
of evidence) OR = 1.71 (favouring MD = 0.39 MD = 0.07
CAF+GTR+HP) 95% CI: 0.28–1.06 95% CI: 0.20–0.34
95% CI: 0.40–7.29
26. CAF+BG+GTR versus CAF+GTR No SSD Better CAF+BG+GTR No SSD
(1 study at high risk of bias, low strength p = 0.35 p = 0.04 p = 0.09
of evidence) OR = 2.00 (favouring MD = 0.47 MD = 0.53
CAF+BG+GTR) 95% CI: 0.03–0.92 95% CI: 0.08–1.14
95% CI: 0.47–8.44 I2 = 0% I2 = 0%
27. CAF+GTR+EMD versus CAF+GTR No SSD No SSD No SSD
(1 study at high risk of bias, low strength p = 0.09 p = 0.62 p = 0.55
of evidence) OR = 0.13(favouring CAF+ MD = 0.15 MD = 0.30
GTR) 95% CI: 0.74–0.44 95% CI: 1.28–0.68
95% CI: 0.01–1.36

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
S54 Cairo et al.

Table 3. (continued)
Comparations between single and/or combinations of techniques
Comparison CRC RecRed KT Gain

28. CAF+CTG+EMD versus CAF+EMD No SSD No SSD No SSD

(1 study at high risk of bias, low strength p = 0.33 p = 1.00 p = 0.61
of evidence) OR = 0.47 (favouring CAF+ MD = 0.00 MD = 0.25
EMD) 95% CI: 0.51–0.51 95% CI: 1.21–0.71
95% CI: 0.10–2.13
29. CAF+ADM+EMD versus No SSD No SSD No SSD
CAF+ADM p = 0.23 p = 0.11 p = 0.85
(1 study at high risk of bias, low strength OR = 3.56 (favouring CAF+ MD = 0.42 MD = 0.06
of evidence) ADM+EMD) 95% CI: 0.09–0.93 95% CI: 0.57–0.69
95% CI: 0.44–28.91

Comparations of techniques for gingival recession with loss of interdental clinical attachment (Miller CLASS III OR CLASS RT2)
Comparison CRC RecRed KT Gain

30. CAF+CTG versus CAF No SSD Better CAF+CTG Better CAF+CTG

1 study at low risk of bias, low strength p = 0.13 p = 0.03 p < 0.00001 MD = 1.29
of evidence) OR = 3.33 (favouring CAF+CTG) MD = 0.60 95% CI: 0.80–1.78
95% CI: 0.69–16.02 95% CI: 0.07–1.13

CRC: Complete Root Coverage; RecRed: Recession Reduction; KT Gain: Keratinized Tissue Gain; No SSD: No Statistical Significant Dif-
ference; OR: Odds Ratio; 95% CI: 95% Confidence Intervals (in millimeters); I2: Percentage total variation across studies (Heterogeneity);
MD: Mean Difference in millimeters; CAF: Coronally Advanced Flap; CTG: subepithelial Connective Tissue Graft; GTR: Guided Tissue
Regeneration procedures for root coverage; EMD: Enamel Matrix Derivative; ADM: Acellular Dermal Matrix; CM: porcine Collagen
Matrix; PCG: Platelet Concentrate Graft; HF-DDS: Human Fibroblast-Derived Dermal Substitute; BGS: Bone Graft Substitute; P-RFM:
Platelet-Rich Fibrin Membrane; SCPF: Semilunar Coronally Positioned Flap; DPF: Double Papilla Flap; LPF: Laterally Positioned Flap;
FGG: Free Gingival Graft. BG: Bone Graft; b-TCP: Beta-Tricalciun Phosphate; rhPDGF-BB: Recombinant Human Platelet-Derived
Growth Factor-BB; Fib: autologous gingival Fibroblasts; HP: Hydroxyapatite.

Fig. 4. Comparison between CAF+CTG versus CAF for CRC. CAF: Coronally Advanced Flap; CTG: Connective Tissue Graft;
CRC: Complete Root Coverage.

reporting no statistically significant
differences in root sensitivity (12%
in the test group and 12% in the
control group) 6 months following
therapy. Similarly, Cairo et al.
(2012) reported 15% of sites with
residual sensitivity for CAF-treated
sites and no residual sensitivity for
CAF+CTG-treated sites 6 months
after therapy. McGuire et al. (2012)
in a 10-year follow-up study compar-
ing CAF+EMD (test) versus
CAF+CTG (control) reported one of
nine control sites with root hyper-
sensitivity versus three of nine test
sites with root hypersensitivity.
Post-operative pain and complications
The reporting of information on
pain ad complications in RCTs on
root coverage procedures is infre-
quent and data were heterogeneous
not allowing a possible meta-analy-
sis. Complications were frequently
not investigated or reported in anec-
dotal forms.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
In studies on GTR, the mem-
brane exposure was reported as a
frequent complication. Amarante
et al. (2000) reported exposure of
several membranes in CAF+GTR
sites, whereas Lins et al. (2003)
reported the exposure of all mem-
branes in all treated sites (10/10). In
comparisons between CAF+BM+
versus CAF+CTG, membrane expo-
sure was reported as a possible com-
plication (7/15 in Jepsen et al. 1998,
2/12 in Trombelli et al. 1998, 5, /12
 Systematic review on periodontal plastic surgery S55

Fig. 5. Comparison between CAF+GTR versus CAF for CRC. CAF: Coronally Advanced Flap; GTR: Guided Tissue Regenera-
tion; CRC: Complete Root Coverage.

Fig. 6. Comparison between CAF+EMD versus CAF for CRC. CAF: Coronally Advanced Flap; EMD: Enamel Matrix Derivative;
CRC: Complete Root Coverage.

Fig. 7. Comparison between CAF+GTR versus CAF+CTG for CRC. CAF: Coronally Advanced Flap; GTR: Guided Tissue Regen-
eration; CTG: Connective Tissue Graft; CRC: Complete Root Coverage.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
S56 Cairo et al.

Fig. 8. Comparison between CAF+EMD versus CAF+CTG for CRC. CAF: Coronally Advanced Flap; EMD: Enamel Matrix
Derivative; CTG: Connective Tissue Graft; CRC: Complete Root Coverage.

Fig. 9. (a)Comparison between CAF+CM versus CAF for CRC. CAF: Coronally Advanced Flap; CM: Collagen Matrix; CRC:
Complete Root Coverage. (b) Comparison between CAF+CM versus CAF+CTG for CRC. CAF: Coronally Advanced Flap; CM:
Collagen Matrix; CTG: Connective Tissue Graft; CRC: Complete Root Coverage.

in Tatakis & Trombelli 2000). Jepsen
et al. (1998) reported a similar inci-
dence of post-operative pain for
both treatments (5/15 patients). On
the other hand, Romagna-Genon
(2001) described postoperative dis-
comfort for the palatal donor site
for the CTG. Sites treated with BM
were more frequently symptom-free
compared with CTG sites. None of
the patients reported exposure of the
membrane.
No complication was reported in
comparisons between CAF+EMD
versus CAF (Modica et al. 2000),
CAF+ADM versus CAF (Woodyard
et al. 2000, C^ortes et al. 2004) and
CAF+ADM versus CAF+CTG (Joly
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
et al. 2007). In a comparison
between CAF+EMD versus
CAF+CTG, McGuire & Nunn
(2003) reported higher discomfort
for CTG procedure (p = 0.011)
1 month following therapy, whereas
no difference between the two
approaches was reported at the
1-year follow-up.

More recently, the use of CON-
SORT guidelines in reporting RTCs
improved also information on
patient-related outcomes by using
Visual Analogue Scale (VAS). That
is, Cortellini et al. (2009) reported
higher number of cases of swelling in
CAF+CTG group compared with
CAF group, and these differences
were statistically significant (for
CAF+CTG, VAS = 32.2  28.4
whereas for CAF, VAS = 17.8 
19.9). Furthermore, CAF+CTG was
associated with longer surgical time
(p < 0.0001), higher number of days
with post-operative morbidity
(p = 0.0222) and greater number of
post-operative analgesics (p = 0.0178)
than CAF alone in a RCT on single
recession with iCAL (Cairo et al.
2012). Finally, add of CM under-
neath CAF was not associated with
increased post-operative morbidity
than CAF (Jepsen et al. 2013).
Long-term stability of the outcome
variables
A very limited number (8%) of RTCs
showed long-term outcomes of treat-
ment with a follow-up of at least
5 years (Paolantonio et al. 1997, Lek-
nes et al. 2005, Moslemi et al. 2011,
McGuire et al. 2012); three of four
studies were long-term update of pre-
viously published short-term out-
comes (Leknes et al. 2005, Moslemi
et al. 2011, McGuire et al. 2012).
• Leknes et al. (2005) reported a
significant reduction in CRC and
mean RecRed for both
CAF+GTR and CAF-treated
sites when comparing 6-year fol-
low-up with the 1-year and 6-
month follow-ups (Amarante
et al. 2000).
• Moslemi et al. (2011) reported
the 5-year follow-up of a short-
term study (Haghighati et al.
2009) comparing CAF+ADM
versus CAF+CTG. At last fol-
low-up, significant relapses were
detected in CRC and reduction
in RD and RW in both groups
with no statistically significant
difference. Patients reporting hor-
izontal tooth-brushing habits
were more prone to develop Rec
relapse (p = 0.01).
• McGuire & Nunn (2012)
reported the long-term follow-up
(10 years) of short-term study
comparing CAF+EMD versus
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Systematic review on periodontal plastic surgery
CAF+CTG (McGuire & Nunn
2003) considering 9 of 17 original
patients. The authors described
stability of achieved outcomes in
the long-term with no significant
difference between the two
procedures.
Discussion
The focused question of this system-
atic review was “what is the clinical
efficacy of periodontal plastic surgery
procedures in the treatment of local-
ized gingival recessions with or with-
out inter-dental clinical attachment
loss?” The current article covered
35 years of clinical research in muco-
gingival surgery, starting from the
late 1970s when Raul Caffesse’s
group published the early RTCs on
the treatment of single gingival
recession (Guinard & Caffesse 1978,
Caffesse & Guinard 1978, 1980,
Espinel & Caffesse 1981). From this
historical perspective, it has been
observed that several paradigms
changed during the last decades.
Between 1970s and 1980s gold stan-
dard procedures were considered the
free gingival graft (FGG) and later-
ally positioned flap (LPF) even if the
scientific background was mostly
represented by case-series studies. In
the late 1980s a complete description
of the CAF procedure was presented
(Allen & Miller 1989) opening a new
era of treatment, not only focused
on the reconstruction of an “ade-
quate” amount of attached gingiva
but also effective in enhancing soft
tissue aesthetics. The definition of
Periodontal Plastic Surgery was then
introduced (Miller 1993, American
Academy of Periodontology 1996),
thus capturing the target of contem-
porary treatment. In modern evi-
dence-based era, the interest was
mostly focused on the predictability
of soft tissue reconstruction over the
exposed root thus obtaining CRC
along with pleasant aesthetics (Cairo
et al. 2009, Kerner et al. 2009, Cairo
et al. 2010).
The flap design for root coverage
procedure: coronally advanced flap
versus different flap designs
Among the different types of flap
designs used in periodontal plastic
surgery, the most frequent approach
S57
was the Coronally Advanced Flap
(Allen & Miller 1989). This tech-
nique became very popular in the
1990s and several combinations by
adding grafts, barriers or biomateri-
als over the root were suggested
(Cairo et al. 2008). On the other
hand, flap designs different from
CAF as LPS or SCPF showed a very
limited number of RCTs and should
be considered with caution in mod-
ern treatment. When considering the
pure flap design, RTCs comparing
the CAF technique to LPF (Santana
et al. 2010a) or SCPF (Santana et al.
2010b) are available. The results of
the present meta-analysis showed
that CAF is superior to different flap
designs in term of probability to
obtain CRC. Interestingly, the use of
LPF is associated with higher
amount of KT gain than CAF after
healing (Santana et al. 2010b); how-
ever, it should be taken into account
that the presence of a well-repre-
sented amount of KT from the adja-
cent site is pre-requisite to perform
LPF.
The efficacy of CAF alone as reli-
able method to obtain root coverage
is associated with the flap design
that is able to maintain an adequate
blood supply for the gingival mar-
gin, as demonstrated by the classical
paper from M€ ormann & Ciancio
(1977). In this angiographic study,
some aspects of flap design were
stressed, including a broad enough
flap base to incorporate major gingi-
val vessels, a proper flap’s length to
width ratio, a minimal residual
tension and the careful preparation
of the partial thickness flap
(M€ ormann & Ciancio 1977). These
findings represent a milestone in the
development of modern in periodon-
tal plastic surgery and provide a nice
interpretation of soft tissue healing
process over the exposed root sur-
face after mucogingival surgery.
The clinical efficacy of Coronally
Advanced Flap plus Connective Tissue
Graft
Data from this SR showed that
CAF+CTG could be considered the
gold standard for treatment of the
single gingival recession. In fact, two
RCTs for Rec with no iCAL (da
Silva et al. 2004, Cortellini et al.
2009) and one for Rec with iCAL
(Cairo et al. 2012) showed that this
S58 Cairo et al.
combination was associated with
higher probability to obtain CRC
than CAF alone. Interestingly, when
considering Rec with iCAL, the use
of CTG was associated with 57% of
CRC (Cairo et al. 2012), thus con-
futing the paradigm suggesting a
limit for root coverage due to the
baseline inter-dental bone loss
(Miller 1985). Furthermore, CTG
procedure is more effective than the
CAF procedure to augment kerati-
nized tissue, leading to a final
increase in approximately 1 mm of
KT.
When considering potential mate-
rials underneath CAF compared
with CTG, add of ADM or GTR
was less effective than CAF+CTG in
term of root coverage outcomes.
Furthermore, CAF+CTG was simi-
larly effective than CAF+ EMD for
CRC and more effective than
CAF+CM for RecRed. In addition,
the use of CTG with different over-
laying flap design as Double Papilla
Coronally Advanced Flap was also
associated with better root coverage
outcomes than FGG (Jahnke et al.
1993, Paolantonio et al. 1997).
A possible hypothesis to explain
the clinical efficacy of CTG may be
related with the specific healing
model of the procedure. In fact, the
high stability of the wound over
CTG is associated with graft vascu-
larization originated from both the
periodontal plexus and the overlying
flap leading to a complete blood
supply for the graft after 2 weeks
(Guiha et al. 2001). Furthermore,
CTG could be considered biological
filler able to adapt the inner of the
flap to the root surface thus limiting
the post-operative shrinkage of
CAF in apical direction (Cairo
et al. 2008, Cortellini et al. 2009).
This hypothesis is supported by
data from a recent RCT for the
treatment of RT2 single Rec (Cairo
et al. 2012): the CAF-treated sites
showed an increasing apical shift of
the gingival margin between 3 and
6 months, whereas the CAF+CTG-
treated sites showed a consistent
stability in the same time frame.
This resulted into a significant
reduction in sites completely cov-
ered in CAF-treated sites, while in
the CAF+CTG group the number
of sites with CRC was the same at
3- and 6-month follow-ups.
Alternatives to connective tissue graft
underneath the flap: enamel matrix
derivative, acellular dermal matrix,
barriers membranes and collagen matrix
The use of CTG implies an obvious
increase in patient discomfort com-
pared with procedures requiring a
single surgical site in the mouth
(Cairo et al. 2012). To reduce
patient morbidity, several biomateri-
als/barriers/replacement grafts were
tested. Considering data from these
meta-analyses, biomaterials able or
not able to improve CAF can be dis-
tinguished.
In the last 15 years, barrier mem-
branes for regeneration and ADM
were extensively used for root cover-
age. A large evidence showed limited
clinical benefits in using these mate-
rials. GTR was extensively tested in
comparison to CAF+CTG or CAF
alone: the current meta-analysis
showed that bilaminar procedure or
CAF alone was associated with sig-
nificant higher probability to obtain
CRC and RedRed than CAF+GTR.
In addition, a high incidence of com-
plications as membrane exposure
was frequently reported (Jepsen
et al. 1998, Trombelli et al. 1998,
Tatakis & Trombelli 2000). Based on
these data, the use of GTR for root
coverage seems to be poorly indi-
cated in modern periodontal plastic
surgery.
ADM, an allograft of cadaveric
origin, was compared in six RTCs
with CAF+CTG (Aichelmann-Reidy
et al. 2001, Paolantonio 2002a,
Paolantonio et al. 2002b, , Tal et al.
2002, Joly et al. 2007, Haghighati
et al. 2011, Barros et al. 2013) and in
two RTCs with CAF alone (Wood-
yard et al. 2004, C^ ortes et al. 2006),
showing inferior outcomes than CTG
and no additional benefit when added
to CAF, although not significant and
with high heterogenic I2 index. These
data seem to suggest caution in apply-
ing ADM for root coverage.
On the other hand, EMD and CM
show promising results to improve
the clinical efficacy of CAF. EMD
was extensively tested in comparison
with CAF alone (Modica et al. 2000,
Del Pizzo et al. 2005, Spahr et al.
2005, Castellanos et al. 2006 Pilloni
et al. 2006), showing higher signifi-
cant probability to improve root
coverage outcomes. Two RTCs
(McGuire et al. 2003, Abolfazli et al.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
2009) showed also that CAF+EMD
was inferior to CAF+CTG in term of
CRC, although this result was not
significant.
Initial data support also benefit
in using CM, 3D-matrix made of
porcine collagen able to promote
soft tissue regeneration. One RCT
(Jepsen et al. 2013) showed that CM
was able to improve the probability
of obtaining RecRed than CAF
alone, whereas one RCT (McGuire
& Scheyer 2010) showed less RecRed
and similar KT gain compared with
CAF+CTG. Therefore, data from
the present SR suggest that EMD
and CM are useful biomaterials in
current periodontal plastic surgery,
but further studies are necessary to
definitively evaluate indications for
treatment and associated clinical
benefits.
Multiple combinations for root coverage
Among 51 enclosed RCTs, nine
studies tested multiple combinations
(application of more than a single
graft/biomaterial under the flap) for
treating the single gingival recession
compared with a simpler technique.
These approaches included the addi-
tion of EMD to CAF+CTG (Raspe-
rini et al. 2011, Alkan & Parlar
2011), the use of ADM and cultured
fibroblasts under CAF (Jhaveri et al.
2010), the use recombinant human
platelet-derived growth factor under
GTR and CAF (McGuire et al.
2009), the addition of bone graft
under GTR (Paolantonio 2002a,
Dodge et al. 2000, Kimble et al.
2004) and the use of EMD under
GTR (Trabulsi et al. 2004) or in
combination with ADM (Alves et al.
2012). Among these studies, only a
single RCT (Dodge et al. 2000)
showed that CAF+ GTR+ BG was
associated with better significant
RecRed than CAF+GTR.
The results of the present meta-
analyses showed that multiple com-
binations usually provide similar or
less benefits than the simpler, control
procedures in term of root coverage
outcomes. Clinicians and researchers
should consider this finding in plan-
ning further studies on the treatment
of single gingival recessions. Further-
more, the reader should consider
that cost-benefit ratio and practical-
ity are key factors in selecting a

proper treatment. In the light of
present outcomes, multiple combina-
tions appeared not indicated for root
coverage.
Patient-related outcomes including
discomfort/pain and aesthetic satisfaction
after periodontal plastic surgery
Data on pain and complications
including residual root sensitivity
after root coverage procedures are
heterogeneous and usually reported
in anecdotal form. The use of GTR
was frequently described as associ-
ated with exposure of the barrier.
This information may explain the lim-
ited efficacy of this procedure com-
pared with CAF alone or CAF+CTG
in terms of root coverage outcomes
thus limiting the indications for this
type of procedure. More recently, the
use of CONSORT guidelines in
reporting RTCs improved also infor-
mation on patient-related outcomes
in a standardized form. RTCs investi-
gating the clinical efficacy of
CAF+CTG (Cortellini et al. 2009,
Cairo et al. 2012) showed that this
procedure is usually associated with
higher post-operative morbidity than
CAF alone, thus capturing an impor-
tant limit of this technique.
Similarly, few studies evaluated
aesthetic satisfaction following ther-
apy, although some attempts to
introduce a standardized evaluation
are reported in literature (Cairo et al.
2009, Kerner et al. 2009). In fact, the
evaluation of the level of gingival
margin following surgery might be
restrictive and not adequate to assess
the final aesthetic results. Therefore,
the collection of patient-related out-
comes using a standardized approach
along with information on clinical
outcomes is strongly recommended
in future researches.
Long-term stability of the outcome
variables
Only 8% of RTCs showed long-term
outcomes of treatment with at least
5 years of follow-up of (Paolantonio
et al. 1997, Leknes et al. 2005,
Moslemi et al. 2011, McGuire et al.
2012); three of them were long-term
update of previously published short-
term outcomes (Leknes et al. 2005,
Moslemi et al. 2011, McGuire et al.
2012). When comparing short to
long-term outcomes, it appears that
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Systematic review on periodontal plastic surgery
traumatic tooth brushing is strongly
associated with Rec recurrence at
CAF+ADM and CAF+CTG-treated
sites after 5 years (Moslemi et al.
2011) or at CAF+GTR and CAF-
treated sites after 6-years (Leknes
et al. 2005). Similar observations
were recently reported in a RCT
with long-term evaluation (14 years)
of CAF procedure (Pini Prato et al.
2011). A recurrence of gingival
recession was described in 39% of
the treated sites (Pini Prato et al.
2011). On the other hand, stability
of gingival margin 10 years after
CAF+EMD or CAF+CTG was
reported in nine of 17 original
patients treated in a private peri-
odontal office (McGuire & Nunn
2012). Nevertheless, when interpret-
ing these data, heterogeneity among
studies in terms of setting (university
versus private office), applied tech-
niques (grafted versus not grafted
procedure) and residual number of
patients/dropouts should be carefully
considered.
Conclusions
• Coronally Advanced Flap plus
Connective Tissue Graft is more
effective than CAF to obtain
root coverage at single gingival
recession with no loss of inter-
dental attachment (Miller class I
and II or RT1) (2 RTCs, moder-
ate strength of evidence).
• Coronally Advanced Flap plus
Connective Tissue Graft is more
effective than CAF plus GTR
(6 RTCs, moderate strength of
evidence).
• Enamel Matrix Derivative impro-
ves the efficacy of Coronally
Advanced Flap alone (4 RTCs,
moderate strength of evidence).
• Initial data suggest that CRC is
feasible in case of single Rec with
loss of interdental attachment
equal or less than the buccal site
(Miller III or RT2) and the use
of CAF+CTG is more effective
than CAF alone (1 RCT, low
strength of evidence).
• Studies adding Acellular Dermal
Matrix (ADM) under CAF
showed a large heterogeneity and
reported benefits are not signifi-
cant compared with CAF alone
(2 trials, low strength of evi-
dence).
S59
• Barrier Membranes are not effec-
tive to improve Coronally
Advanced Flap (1 RCT, low
strength of evidence).
• Initial data suggest that add of
CM may improve the efficacy
of CAF (1 RCT, low strength of
evidence).
• Multiple combinations, using
more than a single graft/biomate-
rial under the flap, usually pro-
vide similar or less benefits than
simpler, control procedures in
term of root coverage outcomes
(a total of 10 RCTs with low
strength of evidence).
Indications for future research
• Increased number of RTCs
assessing the efficacy of EMD
and CM compared with
CAF+CTG are suggested.
• Trials assessing the efficacy of
the addiction of CM underneath
CAF are indicated.
• Further trials assessing the effi-
cacy of root coverage at gingival
recessions with iCAL are encour-
aged.
• Trials to explore aesthetic out-
comes of periodontal plastic sur-
gery are indicated.
• Future researches on the efficacy
of root coverage procedures at
site with restored CEJ are advo-
cated.
• RTCs assessing the long-term
outcomes of root coverage out-
comes are encouraged.
• The collection of patient-related
outcomes including pain/discom-
fort and satisfaction using stan-
dardized approach is suggested.
• The use of CONSORT guidelines
to minimize the risk of bias is
strongly encouraged.
Acknowledgement
We thank Prof. Arthur Novaes jr.
for courtesy in providing unpub-
lished data.
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Clinical Relevance
Scientific rationale for the study:
The aim of this systematic review
was to assess the clinical efficacy of
periodontal plastic surgery proce-
dures in the treatment of localized
gingival recessions (Rec).
Principal findings: The use of
CAF+CTG could be considered as
the gold standard procedure for
treating single REC with or with-
out iCAL. Enamel Matrix Deriva-
tive (EMD) or Collagen Matrix
(CM) enhanced the outcomes of
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Morovati, S. P. & Jamali, R. (2011) Acellular
dermal matrix allograft versus subepithelial con-
nective tissue graft in treatment of gingival reces-
sions: a 5-year randomized clinical study. Journal
of Clinical Periodontology 38, 1122–1129.
Nieri, M., Pini Prato, G. P., Giani, M., Magnani,
N., Pagliaro, U. & Roberto, R. (2013) Patient
perceptions of buccal gingival recessions and
requests for treatment. Journal of Clinical Peri-
odontology 40 (7), 707–712.
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(2003) Surgical therapies for the treatment of
gingival recession. A systematic review. Annals
of Periodontology 8, 303–320.
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C. & Pini-Prato, G. (2003) Evidence-based mu-
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the literature on root coverage procedures.
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Cairo, F., Cortellini, P. & Nieri, M. (2011)
Fourteen-year outcomes of coronally advanced
flap for root coverage: follow-up from a ran-
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Sanz, M. (2002) Periodontal plastic surgery for
treatment of localized gingival recessions: a sys-
CAF, whereas Barrier Membranes
(GTR) did not. Controversial out-
comes were observed by adding
Acellular Dermal Matrix. Surgical
techniques different from CAF as
Laterally Positioned Flap (LPS),
Semilunar Coronal Positioned Flap
(SCPF) and Free Gingival Graft
(FGG) are supported by limited evi-
dence.
Practical implications: Large evi-
dence supports the use of CAF pro-
cedures for treating single Rec. CAF
alone or plus CTG, EMD are effec-
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
tematic review. Journal of Clinical Periodontol-
ogy 29, 178–194.
Roman, A., Soanc a, A., Kasaj, A. & Stratul, S. I.
(2013) Subepithelial connective tissue graft with
or without enamel matrix derivative for the
treatment of Miller class I and II gingival
recessions: a controlled randomized clinical
trial. Journal of Periodontal Research. 48, 563–
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Supporting Information
Data S1. Meta-analyses Systematic
Review Cairo et al. 2014.
Data S2. Validity assessment.
Data S3. Reference for excluded
study.
Address:
Francesco Cairo
Via Fra’ Giovanni Angelico 51
50121 – Florence
Italy
E-mail: cairofrancesco@virgilio.it
tive combinations to obtain com-
plete root coverage. Factors as
potential morbidity, quantity and
quality of residual soft tissue, cost-
benefit ratio and operator experi-
ence are critical factors in decision-
making. Other biomaterials or flap
designs or multiple combinations
(applying more than a single graft/
biomaterial under flap) should be
considered with caution in clinical
practice.