Efficacy of Periodontal Plastic Surgery Procedures in The Treatment of Localized Facial Gingival Recessions. A Systematic Review

J Clin Periodontol 2014; 41 (Suppl. 15): S44–S62 doi: 10.1111/jcpe.
12182
Efficacy of periodontal plastic Francesco Cairo1,2, Michele Nieri1,2

and Umberto Pagliaro3
1
Department of Periodontology and Implant
surgery procedures in the Dentistry, Tuscan School of Dental Medicine,

University of Florence, Florence, Italy;
2
Department of Periodontology and Implant
treatment of localized facial gingival Dentistry, Tuscan School of Dental Medicine,

University of Siena, Siena, Italy; 3Private
Practice, Campi Bisenzio-Florence, Florence,
recessions. A systematic review

Italy
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
Systematic review on periodontal plastic surgery S45
The treatment of gingival recessions ● Embase, on April 30, 2013, using Types of interventions
with periodontal plastic surgery pro- the following strategy: ‘gingiva
The following surgical procedures
cedures is possible request in modern disease’/exp/mj AND ‘gingival
for the treatment of single recessions
dentistry (Nieri et al. 2013). The ulti- recession’/mj AND (randomized
were considered:
mate goal of these procedures is the controlled trial)/lim AND
(humans)/lim.
complete root coverage (CRC) and
• Coronally Advanced Flap (CAF);
pleasant aesthetic outcomes (Cairo
et al. 2009, 2010). There was no language restric- • CAF plus Connective Tissue
Graft (CAF+CTG);
tion.
A previous systematic review
(SR) committed by European Work- Hand searching included a com- • CAF plus Guided Tissue Regen-
eration (GTR) procedures for
shop in Periodontology for the treat- plete search of Journal of Clinical
root coverage (CAF+GTR);
Periodontology, Journal of Periodon-
ment of single recession was focused
on the clinical efficacy of Coronally tology, Journal of Periodontal • CAF plus Enamel Matrix Deriv-
ative (CAF+EMD);
Research, International Journal of
Advanced Flap (CAF) and its
related procedures. This SR showed Periodontics and Restorative Den- • CAF plus Acellular Dermal
Matrix (CAF+ADM);
tistry and PERIO up to April
that CAF alone was a safe and pre-
dictable procedure and the adjunc- 2013. • CAF plus porcine Collagen
Matrix (CAF+CM);
References from American Acad-
tive use of Connective Tissue Graft
(CTG) or Enamel Matrix Derivative emy of Periodontology position • CAF plus Platelet Concentrate
Graft (CAF+PCG);
paper (American Academy of Peri-
(EMD) under CAF enhanced the
probability of obtaining CRC (Cairo odontology 1996), EFP review article • CAF plus Human Fibroblast-
Derived Dermal Substitute
et al. 2008). (Wennstr€ om 1994) and previous sys-
(CAF+HF-DDS);
tematic reviews dealing with root
The purpose of this SR was to
answer at the following focused coverage procedures for single reces- • CAF plus Bone Graft Substitute
(CAF+BGS);
sion (Roccuzzo et al. 2002, Oates
question: “what is the clinical efficacy
of periodontal plastic surgery proce- et al. 2003, Pagliaro et al. 2003, Cla- • CAF plus Platelet-Rich Fibrin
Membrane (CAF+P-RFM);
user et al. 2003, Al-Hamdan et al.
dures in the treatment of localized
gingival recession with or without 2003, Gapski et al. 2005, Hwang & • CAF plus Semilunar Coronally
Positioned Flap (CAF+SCPF);
Wang 2006, Cheng et al. 2007,
inter-dental clinical attachment loss?”
Chambrone et al. 2008, Cairo et al. • Double Papilla Flap (DPF) plus
CTG (DPF+CTG);
2008, Chambrone et al. 2009a,b,
Material and Methods
2010, Ko & Lu 2010, Chambrone • Semilunar Coronally Positioned
A detailed protocol was designed Flap (SCPF);
et al. 2012, Fu et al. 2012, Buti et al.
according to the PRISMA (Preferred 2013;) were checked for article iden- • Laterally Positioned Flap (LPF);
Reporting Items Systematic review tification. • Free Gingival Graft (FGG).
and Meta-Analyses) statement (Lib- In addition, all authors of the
erati et al. 2009, Moher et al. 2009). In addition, the following combi-
identified studies, clinical experts or
The present manuscript was written nations of surgical techniques
researchers in the field of periodontal
according to PRISMA checklist. (applying more than a single graft/
plastic surgery were contacted in an
biomaterial under the flap) for the
attempt to identify unpublished data
treatment of single recessions were
Information sources and Search or studies not yet published.
considered:
An expert operator (UP) conducted
a search on electronic databases Selection • CAF plus Bone Graft (BG) plus
until April 2013 to identify studies Criteria used in this SR for studies GTR (CAF+BG+GTR);
included or investigated for this selection were based on the PICOS • CAF plus CTG plus EMD
review. Three online evidence method (Glossary of Evidence-Based (CAF+CTG+EMD);
sources were used: Terms 2007) and were the following: • CAF plus Beta-Tricalciun Phos-
phate (b-TCP) plus Recombi-
● The National Library of Medi- Types of participants nant Human Platelet-Derived
cine (MEDLINE by PubMed),
Patients with a clearly specified diag- Growth Factor-BB (rhPDGF-
on April.30.2013, using the strat-
nosis of single gingival recession BB) (CAF+ b-TCP+ rhPDGF-
egy: (“Gingival Recession/sur-
defect were included. Miller classifi- BB);
gery”[Mesh] OR “Gingival
Recession/therapy” [Mesh]) AND cation (Miller 1985) and Recession • CAF plus GTR plus EMD
Type (RT) classification using the (CAF+GTR+EMD);
((Humans[Mesh]) AND (Ran-
domized Controlled Trial[ptyp])); inter-dental clinical attachment level • CAF plus CTG plus EMD
(CAF+CTG+EMD);
● The Cochrane Database Trials (Cairo et al. 2011) were considered.
Register, on April.30.2013, using Single recessions with no loss (Miller • CAF plus ADM plus autologous
I and II or RT1) or with minimal gingival Fibroblasts (Fibr)
the following strategy: “Gingival
loss of inter-dental bone/clinical (CAF+ADM+Fib);
Recession” [Search All Text]
AND “Root Coverage” [Search attachment (Miller III or RT2) were • CAF plus GTR plus Hydroxyap-
included. atite (HP) (CAF+GTR+HP).
All Text].
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
S46 Cairo et al.
Comparison between interventions Validity assessment mouth design, were included in the
The quality assessment of the systematic review. Eligible RCTs,
All possible comparisons between
included trials was independently with a follow-up duration
the considered surgical procedures
performed in a duplicate form by ≥6 months, had to compare the
were investigated.
two review authors (F.C. and U.P.). results of at least 2 of the investi-
Type of outcome measures According to Cochrane Handbook for gated surgical techniques in patients
Systematic Reviews of Interventions with Miller Class I, II or III (Miller
The following outcome measures
Version 5.1.0 [updated March 2011] 1985) or Recession Types 1 or 2
were considered:
(Higgins & Green 2011), three main (Cairo et al. 2011) defects.
Primary outcome. quality criteria were examined: allo- CRC had to be expressed as the
number or the percentage of treated
• Recession defects that obtained cation concealment, blinding treat-
teeth of each considered study arm
complete root coverage (CRC). ment outcomes to outcome assessors
and completeness of follow-up (for that achieved total root coverage at
detailed explanation see Cairo et al. the follow-up visit. RecRed had to
Secondary outcomes. 2008 and additional material sec- be expressed as mean recession
reduction in millimetres of the trea-
• Change in gingival recession tion). After quality assessment, stud-
ies were grouped into two categories: ted teeth of each study arm at fol-
expressed as recession reduction
low-up visit. KT Gain had to be
in millimetres at follow-up visit ● Low risk of bias, if all three qual- expressed as mean keratinized tissue
(RecRed), ity criteria were met. width increase in millimetres of the
• Change in width of keratinized ● High risk of bias, if one or more treated teeth of each study arm at
tissue (KT) expressed as KT gain of the three quality criteria was follow-up visit. Complications, Post-
in millimetres at follow-up visit not met. operative pain, Aesthetic satisfaction
(KT gain),
and Root sensitivity had to be
• Biological complications during
described at least in a narrative
the post-operative healing period
Data abstraction form.
(Complications),
• Patient discomfort during the The titles and abstracts (when avail- Quantitative data synthesis
post-operative healing period able) of all reports identified through
(Post-operative pain), the electronic and manual searches For dichotomous outcomes (CRC),
• Patient preference in term of aes- were independently screened by two the estimates of effect of an interven-
thetic result at follow-up visit review authors (F.C. and U.P.). tion were expressed as odds ratio
(Aesthetic satisfaction), When studies met the inclusion crite- (OR) together with 95% confidence
• Patient perception of root sensi- ria or when insufficient data from intervals (CI). For continuous out-
tivity at follow-up visit (Root sen- abstracts for evaluating inclusion cri- comes, mean differences and stan-
sitivity). teria were gained, the full article was dard deviations were used to
obtained. The full text of all studies summarize the data from each
Types of studies of possible relevance was indepen- group. In each patient, only one site
dently assessed by two review for each technique was considered.
In this systematic review, only ran- authors (F.C. and U.P.). All studies In fact, multiple sites in same patient
domized controlled clinical trials meeting the inclusion criteria then are not independent as are exposed
(RCTs), including split-mouth underwent to quality assessment and to similar patient-related risk factors.
model, for the treatment of single data recording. When disagreement When studies with multiple sites
gingival recession of at least between the two reviewers was were identified, the presence of Indi-
6 months duration were considered. revealed, consensus was achieved by vidual Patient Data (IPD) was
In this SR, the following items discussion with the third reviewer/ checked and multiple sites were elim-
were considered as exclusion crite- statistical advisor (M.N.). Then, data inated. This allowed the selection of
ria: were independently extracted and a single recession for technique in
• RCTs comparing variations of a inserted into a computer by two
review authors (F.C. and U.P.) using
the single patient.
OR were combined for dichoto-
same technique (i.e. CAF with
releasing incisions versus CAF specifically designed data-collection mous data and mean differences in
without releasing incisions), forms. Patient characteristics, treat- continuous data using a random-
• RCTs with unclear/not specified ments, clinical outcomes, complica-
tions and study quality were
effect model. Data from split-mouth
studies were combined with data
type of treated recessions,
• RTCs treating multiple gingival systematically registered. When clini-
cal data on CRC were lacking,
from parallel group trials with the
method outlined by Elbourne et al.
recessions or treating both single
and multiple recessions, authors of the trials were contacted. (2002), using the generic inverse var-
• RTCs with multiple treated sites iance method in the RevMan. The
techniques described by Follmann
into a single patient without Study characteristics
appropriate statistical analysis et al. (1992) were used to calculate
and unavailable individual Only randomized clinical trials the standard error of the difference
patient data (IPD), (RCTs), with or without a split- in split-mouth studies, where the
appropriate data were not pre- MEDLINE (by PubMed), in the Forty-three of the 52 selected
sented. Cochrane Collaboration databases, studies allowed 20 comparisons
The significance of any discrepan- and in EMBASE provided, respec- between single surgical techniques
cies in the estimates of the treatment tively, 294, 141 and 159 articles (Fig. 2), whereas nine studies led to
effects from different trials was published until April 2013. Subse- nine adjunctive comparisons between
assessed by means of Cochran’s test quently, after reading all the single techniques and combinations
for heterogeneity and the I2 statistic, abstracts and discarding duplicates, of surgical procedures (Fig. 3). Fur-
which describes the percentage total 161 articles were selected. Twenty- thermore, only one contacted
variation across studies that is due two of these 161 articles were not research group (Joly et al. 2007) was
to heterogeneity rather than change. published in the journals selected for able to provide additional unpub-
It was planned to undertake sensitiv- the hand searching of the present lished data on CRC.
ity analyses to examine the effect of systematic review. For six selected RCTs, two arti-
the study quality for CRC. The hand searching found 103 cles with different follow-up dura-
articles and 14 of these were not tions were published. In this case,
found by the electronic search. studies with follow-up ≥ 5 years
Evaluation of the strength of
The search of the “grey literature” were considered as long-term obser-
evidence
(unpublished data) by e-mail contact vation of short-term studies. When
Evidence regarding CRC and with all the authors of the identified multiple studies were restricted to
RecRed provided by RTCs was rated studies and clinical experts or follow-ups < 5 years, the manu-
using different levels of methodologi- researchers in the field of mucogingi- script with longest follow-up was
cal strength modified from GRADE val surgery provided the complete considered, although both papers
(grading of recommendations assess- data of one trial (Barros et al. 2013). were checked to retrieve all data
ments development and evaluation) Finally, by crossing the literature when necessary. When multiple
(Guyatt et al. 2008). Three different searches (electronic, manual and studies showed also follow-up
strength of evidence were considered: unpublished data searches) to elimi- ≥ 5 years, the shorter observation
● High: at least 3 RCTs of low risk nate duplicates, 176 articles (161 by was considered, to limit the possi-
of bias and low heterogeneity electronic, 14 by hand-search and 1 ble influence of self-performed and
● Moderate: > 1 RCT and at least still unpublished study by “grey liter- professional maintenance on the
1 RCTs of low risk of bias, low I2 ature” search) were selected. clinical efficacy of tested technique.
● Low: lack of RCT or RCT at high The full text reading of the 176 In details, the six multiple publica-
risk of bias or high heterogeneity articles allowed the selection of 51 tions were managed for meta-analy-
studies (53 reports) (Table 1) that sis as follow:
met the inclusion criteria of this sys-
tematic review and the exclusion of • Amarante et al. (2000) showed a
6-month follow-up whereas Lek-
Results 123 articles from the analysis. nes et al. (2005) corresponded to
Rejected studies at this stage are the (1- and 6-year follow-ups).
Study selection listed in Table 2 (characteristics of One-year data from Leknes et al.
The search results are presented in excluded studies) and the reason for (2005) were considered.
Fig. 1. The electronic search in exclusion was recorded.
• 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.
• Côrtes 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
Fig. 1. Literature search process and results. 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
Côrtes 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
Table 1. (continued)
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 Guinard & Caffesse (1978), Caffesse & Guinard (1978, 1980),Espinel & Caffesse
(1981).
Not surgical therapy Aimetti et al. (2005).
Comparison between variations of a same surgical Ibbott et al. (1985), Oles et al. (1985), Caffesse et al. (1987, 2000), Bouchard et al.
technique (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)
Study not dealing root coverage 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)
Also Miller Class III gingival recession defects treated Cueva et al. (2004)
Same pool of patients with a shorter follow-up of an Hagewald et al. (2002), McGuire & Nunn (2003), Bittencourt et al. (2006),
included study in this systematic review Haghighati et al. (2009)
Not RCT 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)
Shorter follow-up duration 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)
Comparison with untreated recessions Borghetti & Louise (1994)
Data not useful for meta-analysis Rosetti et al. (2000)
Only abstract available Barros et al. (2003)
Histological study McGuire et al. (2009)
Multiple or not only single gingival recessions treated 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).
Un-appropriate statistical analysis 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.
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).
Study characteristics Lins et al. 2003, C^ ortes et al. vide similar or less benefits than
Included studies 2006, da Silva et al. 2004, Wood- simpler, control procedures.
yard et al. 2004, Del Pizzo et al.
The list of included studies is pre- 2005, Castellanos et al. 2006, Pil- Figures 4–9 showed some meta-
sented in Table 1. The 51 selected loni et al. 2006, Joly et al. 2007, analyses for CRC, corresponding to
studies (53 articles) allowed the com- Abolfazli et al. 2009, Jankovic comparisons CAF+CTG versus
parisons showed in Fig. 2. For all et al. 2010, Rasperini et al. 2011, CAF, CAF+GTR versus CAF, CAF+
the other possible comparisons Jankovic et al. 2012, Barros et al. GTR versus CAF+CTG, CAF+EMD
investigated in the systematic review, 2013) did not report how the versus CAF+CTG, CAF+CM versus
no eligible study was found. study was supported. CAF and CAF+CM versus CAF+
In the case of Modica et al. CTG.
(2000), two of the 12 participants All performed meta-analyses were
were excluded from meta-analyses Excluded studies
presented in the online material as sup-
because they participated in a split- There were 123 excluded studies. plementary information (Data S1).
mouth study with more than one The reasons for exclusion are
pair of bilateral gingival recessions. reported in Table 2 (Characteristics Evaluation of the strength of evidence
Hence, IPD of the remaining 10 pair of the 123 excluded studies).
of recession defects were re-analysed. The evaluation of the strength of
Among included studies, 2 RTCs evidence using the modified GRADE
were multicentre (Cortellini et al. Results of the analyses
system showed for CRC that three
2009, Jepsen et al. 2013) while all Clinical outcomes from 51 RCTs groups of comparisons were at
others were single centre study. (corresponding to 53 articles) with moderate strength of evidence
Among the enclosed RCTs 1574 patients and 1744 treated (CTG+CAF > CAF; CAF+EMD
• Ten studies (Jahnke et al. 1993, recessions were included in this SR.
A total of 80 meta-analyses were
> CAF; CAF+CTG > CAF+
GTR), while other comparisons were
Paolantonio (2002a), Paolantonio
et al. 2002b, Kimble et al. 2004, performed. Table 3 reported the considered at low strength of evi-
Huang et al. 2005, Bittencourt results of meta-analyses for CRC dence. No comparison for CRC was
et al. 2009, Jhaveri et al. 2010, (primary outcome), RecRed (sec- rated at high strength of evidence.
Alkan & Parlar 2011, Moslemi ondary outcome) and KT Gain For RecRed, two groups of com-
et al. 2011, Nazareth & Cury (secondary outcome) for each possi- parisons were at moderate strength
2010) were completely supported ble comparison between surgical of evidence (CTG + CAF > CAF;
by public institutes for research, procedures. CAF+CTG>CAF+GTR), while
• One study (Cortellini et al. 2009) Among different RTCs, only a
single study evaluating root coverage
other comparisons were considered
at low strength of evidence. No com-
was supported by private insti-
tutes for research, at Rec with iCAL (Cairo et al. 2012) parison for RecRed was rated at
• Thirteen studies (Trombelli et al. was enclosed in the SR.
Main results can be summarized
high strength of evidence.
1998, Tatakis & Trombelli 2000, Aesthetic satisfaction
Aichelmann-Reidy et al. 2001, in:
Few studies evaluated aesthetic satis-
Wang et al. 2001, Tal et al. 2002, • CAF+CTG was more effective
faction following therapy, mainly
McGuire et al. 2012, Trabulsi than CAF in term of CRC
et al. 2004, Leknes et al. 2005, collecting patient opinion with no
(p = 0.03), RecRed (p = 0.005)
Spahr et al. 2005, Wilson et al. standardized approaches. No meta-
and KT gain (p = 0.0001) for
2005, McGuire et al. 2009, analysis throughout conventional
Rec with no iCAL.
system was possible. Possible aes-
McGuire & Scheyer 2010, Jepsen • CAF+CTG was more effective
thetic evaluation of the clinical out-
et al. 2013) were supported, in than CAF in term of RecRed
part, by companies whose prod- comes included a double assessment
(p = 0.03) and KT gain (p <
ucts were being used as interven- by patient and periodontist (Wang
0.00001) for Rec with iCAL.
et al. 2001, Aichelmann-Reidy et al.
tions in the trials, • The adjunctive use of GTR was
• Three studies (Mahajan et al. not able to improve CAF with
2001). Lately, the Root coverage
Esthetic Score (RES), a standardized
2007, Santana et al. 2010a,b) no significant difference with the
specified that the authors not system to aesthetic evaluation after
control procedure (CRC p =
received founding, root coverage, was introduced (Cairo
0.41; RecRed p = 0.11)
• Three studies (Alves et al. 2012, • The adjunctive use of EMD
et al. 2009, 2010) and applied in
recent RCTs (Jhaveri et al. 2010,
Cairo et al. 2012, Zucchelli et al. yielded to significant improve-
2012) specified that the authors Cairo et al. 2012, Roman et al.
ment of CAF alone in term of
self-supported the research, 2013).
CRC (p = 0.003), RecRed (p =
• Twenty-one studies (Ricci et al. 0.002) and KT gain (p = Root sensitivity
1996, Paolantonio et al. 1997, 0.0007).
Very few studies evaluated Root sen-
Jepsen et al. 1998, Zucchelli et al. • Multiple combinations, using
sitivity following root coverage pro-
1998, Borghetti et al. 1999, more than a single graft/biomate-
Dodge et al. 2000, Modica et al. cedures. No meta-analysis was
rial under the flap, usually pro-
2000, Romagna-Genon 2001, performed for this variable due to
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
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
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
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
95% CI: 0.57–2.63 95% CI: 1.00–1.72 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
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
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
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
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
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
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
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
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
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
21. CAF+CTG+EMD versus CAF+CTG No SSD No SSD No SSD
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
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
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
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
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
S54 Cairo et al.
28. CAF+CTG+EMD versus CAF+EMD No SSD No SSD No SSD

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
Comparation of techniques for gingival recessions with loss of interdental clinical attachment (Miller CLASS III OR CLASS RT2)
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.
the fact that data were few and het- in a 10-year follow-up study compar- sis. Complications were frequently
erogeneous. Cortellini et al. (2009) ing CAF+EMD (test) versus not investigated or reported in anec-
compared CAF+CTG versus CAF, CAF+CTG (control) reported one of dotal forms.
reporting no statistically significant nine control sites with root hyper- In studies on GTR, the mem-
differences in root sensitivity (12% sensitivity versus three of nine test brane exposure was reported as a
in the test group and 12% in the sites with root hypersensitivity. frequent complication. Amarante
control group) 6 months following et al. (2000) reported exposure of
Post-operative pain and complications
therapy. Similarly, Cairo et al. several membranes in CAF+GTR
(2012) reported 15% of sites with The reporting of information on sites, whereas Lins et al. (2003)
residual sensitivity for CAF-treated pain ad complications in RCTs on reported the exposure of all mem-
sites and no residual sensitivity for root coverage procedures is infre- branes in all treated sites (10/10). In
CAF+CTG-treated sites 6 months quent and data were heterogeneous comparisons between CAF+BM+
after therapy. McGuire et al. (2012) not allowing a possible meta-analy- versus CAF+CTG, membrane expo-
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.
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.
sure was reported as a possible com- (2001) described postoperative dis- No complication was reported in
plication (7/15 in Jepsen et al. 1998, comfort for the palatal donor site comparisons between CAF+EMD
2/12 in Trombelli et al. 1998, 5, /12 for the CTG. Sites treated with BM versus CAF (Modica et al. 2000),
in Tatakis & Trombelli 2000). Jepsen were more frequently symptom-free CAF+ADM versus CAF (Woodyard
et al. (1998) reported a similar inci- compared with CTG sites. None of et al. 2000, C^
ortes et al. 2004) and
dence of post-operative pain for the patients reported exposure of the CAF+ADM versus CAF+CTG (Joly
both treatments (5/15 patients). On membrane. et al. 2007). In a comparison
the other hand, Romagna-Genon between CAF+EMD versus
CAF+CTG, McGuire & Nunn difference. Patients reporting hor- The flap design for root coverage
(2003) reported higher discomfort izontal tooth-brushing habits procedure: coronally advanced flap
for CTG procedure (p = 0.011) were more prone to develop Rec versus different flap designs
1 month following therapy, whereas relapse (p = 0.01). Among the different types of flap
no difference between the two • McGuire & Nunn (2012) designs used in periodontal plastic
approaches was reported at the 1- reported the long-term follow-up surgery, the most frequent approach
year follow-up. (10 years) of short-term study was the Coronally Advanced Flap
More recently, the use of CON- comparing CAF+EMD versus (Allen & Miller 1989). This tech-
SORT guidelines in reporting RTCs CAF+CTG (McGuire & Nunn nique became very popular in the
improved also information on 2003) considering 9 of 17 original 1990s and several combinations by
patient-related outcomes by using patients. The authors described adding grafts, barriers or biomateri-
Visual Analogue Scale (VAS). That stability of achieved outcomes in als over the root were suggested
is, Cortellini et al. (2009) reported the long-term with no significant (Cairo et al. 2008). On the other
higher number of cases of swelling in difference between the two proce- hand, flap designs different from
CAF+CTG group compared with dures. CAF as LPS or SCPF showed a very
CAF group, and these differences limited number of RCTs and should
were statistically significant (for be considered with caution in mod-
CAF+CTG, VAS = 32.2 28.4 Discussion ern treatment. When considering the
whereas for CAF, VAS = 17.8 The focused question of this system- pure flap design, RTCs comparing
19.9). Furthermore, CAF+CTG was atic review was “what is the clinical the CAF technique to LPF (Santana
associated with longer surgical time efficacy of periodontal plastic surgery et al. 2010a) or SCPF (Santana et al.
(p < 0.0001), higher number of days procedures in the treatment of local- 2010b) are available. The results of
with post-operative morbidity ized gingival recessions with or with- the present meta-analysis showed
(p = 0.0222) and greater number of out inter-dental clinical attachment that CAF is superior to different flap
post-operative analgesics (p = 0.0178) loss?” The current article covered designs in term of probability to
than CAF alone in a RCT on single 35 years of clinical research in muco- obtain CRC. Interestingly, the use of
recession with iCAL (Cairo et al. gingival surgery, starting from the LPF is associated with higher
2012). Finally, add of CM under- late 1970s when Raul Caffesse’s amount of KT gain than CAF after
neath CAF was not associated with group published the early RTCs on healing (Santana et al. 2010b); how-
increased post-operative morbidity the treatment of single gingival ever, it should be taken into account
than CAF (Jepsen et al. 2013). recession (Guinard & Caffesse 1978, that the presence of a well-repre-
Long-term stability of the outcome Caffesse & Guinard 1978, 1980, Es- sented amount of KT from the adja-
variables pinel & Caffesse 1981). From this cent site is pre-requisite to perform
historical perspective, it has been LPF.
A very limited number (8%) of observed that several paradigms The efficacy of CAF alone as reli-
RTCs showed long-term outcomes changed during the last decades. able method to obtain root coverage
of treatment with a follow-up of at Between 1970s and 1980s gold stan- is associated with the flap design
least 5 years (Paolantonio et al. dard procedures were considered the that is able to maintain an adequate
1997, Leknes et al. 2005, Moslemi free gingival graft (FGG) and later- blood supply for the gingival mar-
et al. 2011, McGuire et al. 2012); ally positioned flap (LPF) even if the gin, as demonstrated by the classical
three of four studies were long-term scientific background was mostly paper from M€ ormann & Ciancio
update of previously published represented by case-series studies. In (1977). In this angiographic study,
short-term outcomes (Leknes et al. the late 1980s a complete description some aspects of flap design were
2005, Moslemi et al. 2011, McGuire of the CAF procedure was presented stressed, including a broad enough
et al. 2012). (Allen & Miller 1989) opening a new flap base to incorporate major gingi-
• Leknes et al. (2005) reported a era of treatment, not only focused val vessels, a proper flap’s length to
width ratio, a minimal residual
significant reduction in CRC and on the reconstruction of an “ade-
mean RecRed for both quate” amount of attached gingiva tension and the careful preparation
CAF+GTR and CAF-treated but also effective in enhancing soft of the partial thickness flap
sites when comparing 6-year fol- tissue aesthetics. The definition of (M€ ormann & Ciancio 1977). These
low-up with the 1-year and 6- Periodontal Plastic Surgery was then findings represent a milestone in the
month follow-ups (Amarante introduced (Miller 1993, American development of modern in periodon-
et al. 2000). Academy of Periodontology 1996), tal plastic surgery and provide a nice
• Moslemi et al. (2011) reported thus capturing the target of contem- interpretation of soft tissue healing
process over the exposed root sur-
the 5-year follow-up of a short- porary treatment. In modern evi-
term study (Haghighati et al. dence-based era, the interest was face after mucogingival surgery.
2009) comparing CAF+ADM mostly focused on the predictability
versus CAF+CTG. At last fol- of soft tissue reconstruction over the The clinical efficacy of Coronally
low-up, significant relapses were exposed root thus obtaining CRC Advanced Flap plus Connective Tissue
detected in CRC and reduction along with pleasant aesthetics (Cairo Graft
in RD and RW in both groups et al. 2009, Kerner et al. 2009, Cairo
Data from this SR showed that
with no statistically significant et al. 2010).
CAF+CTG could be considered the
S58 Cairo et al.
gold standard for treatment of the pletely covered in CAF-treated sites, et al. 2000, Del Pizzo et al. 2005,
single gingival recession. In fact, two while in the CAF+CTG group the Spahr et al. 2005, Castellanos et al.
RCTs for Rec with no iCAL (da number of sites with CRC was the 2006 Pilloni et al. 2006), showing
Silva et al. 2004, Cortellini et al. same at 3- and 6-month follow-ups. higher significant probability to
2009) and one for Rec with iCAL improve root coverage outcomes.
(Cairo et al. 2012) showed that this Alternatives to connective tissue graft
Two RTCs (McGuire et al. 2003,
combination was associated with underneath the flap: enamel matrix Abolfazli et al. 2009) showed also
higher probability to obtain CRC derivative, acellular dermal matrix, that CAF+EMD was inferior to
than CAF alone. Interestingly, when barriers membranes and collagen matrix CAF+CTG in term of CRC,
considering Rec with iCAL, the use although this result was not signifi-
of CTG was associated with 57% of The use of CTG implies an obvious cant.
CRC (Cairo et al. 2012), thus con- increase in patient discomfort com- Initial data support also benefit
futing the paradigm suggesting a pared with procedures requiring a in using CM, 3D-matrix made of
limit for root coverage due to the single surgical site in the mouth porcine collagen able to promote
baseline inter-dental bone loss (Cairo et al. 2012). To reduce soft tissue regeneration. One RCT
(Miller 1985). Furthermore, CTG patient morbidity, several biomateri- (Jepsen et al. 2013) showed that CM
procedure is more effective than the als/barriers/replacement grafts were was able to improve the probability
CAF procedure to augment kerati- tested. Considering data from these of obtaining RecRed than CAF
nized tissue, leading to a final meta-analyses, biomaterials able or alone, whereas one RCT (McGuire
increase in approximately 1 mm of not able to improve CAF can be dis- & Scheyer 2010) showed less RecRed
KT. tinguished. and similar KT gain compared with
When considering potential mate- In the last 15 years, barrier mem- CAF+CTG. Therefore, data from
rials underneath CAF compared branes for regeneration and ADM the present SR suggest that EMD
with CTG, add of ADM or GTR were extensively used for root cover- and CM are useful biomaterials in
was less effective than CAF+CTG in age. A large evidence showed limited current periodontal plastic surgery,
term of root coverage outcomes. clinical benefits in using these mate- but further studies are necessary to
Furthermore, CAF+CTG was simi- rials. GTR was extensively tested in definitively evaluate indications for
larly effective than CAF+ EMD for comparison to CAF+CTG or CAF treatment and associated clinical
CRC and more effective than alone: the current meta-analysis benefits.
CAF+CM for RecRed. In addition, showed that bilaminar procedure or
the use of CTG with different over- CAF alone was associated with sig-
Multiple combinations for root coverage
laying flap design as Double Papilla nificant higher probability to obtain
Coronally Advanced Flap was also CRC and RedRed than CAF+GTR. Among 51 enclosed RCTs, nine
associated with better root coverage In addition, a high incidence of com- studies tested multiple combinations
outcomes than FGG (Jahnke et al. plications as membrane exposure (application of more than a single
1993, Paolantonio et al. 1997). was frequently reported (Jepsen graft/biomaterial under the flap) for
A possible hypothesis to explain et al. 1998, Trombelli et al. 1998, treating the single gingival recession
the clinical efficacy of CTG may be Tatakis & Trombelli 2000). Based on compared with a simpler technique.
related with the specific healing these data, the use of GTR for root These approaches included the addi-
model of the procedure. In fact, the coverage seems to be poorly indi- tion of EMD to CAF+CTG (Raspe-
high stability of the wound over cated in modern periodontal plastic rini et al. 2011, Alkan & Parlar
CTG is associated with graft vascu- surgery. 2011), the use of ADM and cultured
larization originated from both the ADM, an allograft of cadaveric fibroblasts under CAF (Jhaveri et al.
periodontal plexus and the overlying origin, was compared in six RTCs 2010), the use recombinant human
flap leading to a complete blood with CAF+CTG (Aichelmann-Reidy platelet-derived growth factor under
supply for the graft after 2 weeks et al. 2001, Paolantonio 2002a, Pao- GTR and CAF (McGuire et al.
(Guiha et al. 2001). Furthermore, lantonio et al. 2002b, , Tal et al. 2009), the addition of bone graft
CTG could be considered biological 2002, Joly et al. 2007, Haghighati under GTR (Paolantonio 2002a,
filler able to adapt the inner of the et al. 2011, Barros et al. 2013) and Dodge et al. 2000, Kimble et al.
flap to the root surface thus limiting in two RTCs with CAF alone 2004) and the use of EMD under
the post-operative shrinkage of CAF (Woodyard et al. 2004, C^ ortes et al. GTR (Trabulsi et al. 2004) or in
in apical direction (Cairo et al. 2008, 2006), showing inferior outcomes combination with ADM (Alves et al.
Cortellini et al. 2009). This hypothe- than CTG and no additional benefit 2012). Among these studies, only a
sis is supported by data from a when added to CAF, although not single RCT (Dodge et al. 2000)
recent RCT for the treatment of significant and with high heterogenic showed that CAF+ GTR+ BG was
RT2 single Rec (Cairo et al. 2012): I2 index. These data seem to suggest associated with better significant Re-
the CAF-treated sites showed an caution in applying ADM for root cRed than CAF+GTR.
increasing apical shift of the gingival coverage. The results of the present meta-
margin between 3 and 6 months, On the other hand, EMD and analyses showed that multiple com-
whereas the CAF+CTG-treated sites CM show promising results to binations usually provide similar or
showed a consistent stability in the improve the clinical efficacy of CAF. less benefits than the simpler, control
same time frame. This resulted into EMD was extensively tested in com- procedures in term of root coverage
a significant reduction in sites comparison with CAF alone (Modica outcomes. Clinicians and researchers
should consider this finding in plan-

ning further studies on the treatment
et al. 1997, Leknes et al. 2005, Mos-
lemi et al. 2011, McGuire et al.
• Studies adding Acellular Dermal
Matrix (ADM) under CAF
of single gingival recessions. Further- 2012); three of them were long-term showed a large heterogeneity and
more, the reader should consider update of previously published short- reported benefits are not signifi-
that cost-benefit ratio and practical- term outcomes (Leknes et al. 2005, cant compared with CAF alone
ity are key factors in selecting a Moslemi et al. 2011, McGuire et al. (2 trials, low strength of evi-
proper treatment. In the light of 2012). When comparing short to dence).
present outcomes, multiple combina-
tions appeared not indicated for root
long-term outcomes, it appears that
traumatic tooth brushing is strongly
• Barrier Membranes are not effec-
tive to improve Coronally
coverage. associated with Rec recurrence at Advanced Flap (1 RCT, low
CAF+ADM and CAF+CTG-treated strength of evidence).
Patient-related outcomes including
sites after 5 years (Moslemi et al.
2011) or at CAF+GTR and CAF-
• Initial data suggest that add of
discomfort/pain and aesthetic satisfaction CM may improve the efficacy
after periodontal plastic surgery treated sites after 6-years (Leknes of CAF (1 RCT, low strength of
et al. 2005). Similar observations evidence).
Data on pain and complications
including residual root sensitivity
were recently reported in a RCT
with long-term evaluation (14 years)
• Multiple combinations, using
after root coverage procedures are more than a single graft/biomate-
of CAF procedure (Pini Prato et al. rial under the flap, usually pro-
heterogeneous and usually reported 2011). A recurrence of gingival
in anecdotal form. The use of GTR vide similar or less benefits than
recession was described in 39% of simpler, control procedures in
was frequently described as associ- the treated sites (Pini Prato et al.
ated with exposure of the barrier. term of root coverage outcomes
2011). On the other hand, stability (a total of 10 RCTs with low
This information may explain the of gingival margin 10 years after
limited efficacy of this procedure strength of evidence).
CAF+EMD or CAF+CTG was
compared with CAF alone or reported in nine of 17 original
CAF+CTG in terms of root cover- patients treated in a private peri-
age outcomes thus limiting the indi- odontal office (McGuire & Nunn Indications for future research
cations for this type of procedure. 2012). Data, heterogeneity among
More recently, the use of CON- studies in terms of setting (university • Increased number of RTCs
SORT guidelines in reporting RTCs versus private office), applied tech- assessing the efficacy of EMD
improved also information on niques (grafted versus not grafted and CM compared with
patient-related outcomes in a stan- procedure) and residual number of CAF+CTG are suggested.
dardized form. RTCs investigating patients/dropouts should be carefully • Trials assessing the efficacy of
the clinical efficacy of CAF+CTG considered. the addiction of CM underneath
(Cortellini et al. 2009, Cairo et al. CAF are indicated.
2012) showed that this procedure is • Further trials assessing the effi-
usually associated with higher post- Conclusions cacy of root coverage at gingival
operative morbidity than CAF recessions with iCAL are encour-
alone, thus capturing an important • Coronally Advanced Flap plus aged.
limit of this technique. Connective Tissue Graft is more • Trials to explore aesthetic out-
Similarly, few studies evaluated effective than CAF to obtain comes of periodontal plastic sur-
aesthetic satisfaction following ther- root coverage at single gingival gery are indicated.
apy, although some attempts to recession with no loss of inter- • Future researches on the efficacy
introduce a standardized evaluation dental attachment (Miller class I of root coverage procedures at
are reported in literature (Cairo and II or RT1) (2 RTCs, moder- site with restored CEJ are advo-
et al. 2009, Kerner et al. 2009). In ate strength of evidence). cated.
fact, the evaluation of the level of • Coronally Advanced Flap plus • RTCs assessing the long-term
gingival margin following surgery Connective Tissue Graft is more outcomes of root coverage out-
might be restrictive and not ade- effective than CAF plus GTR comes are encouraged.
quate to assess the final aesthetic (6 RTCs, moderate strength of • The collection of patient-related
results. Therefore, the collection of evidence). outcomes including pain/discom-
patient-related outcomes using a • Enamel Matrix Derivative impro- fort and satisfaction using stan-
standardized approach along with ves the efficacy of Coronally dardized approach is suggested.
information on clinical outcomes is Advanced Flap alone (4 RTCs, • The use of CONSORT guidelines
strongly recommended in future moderate strength of evidence). to minimize the risk of bias is
researches. • Initial data suggest that CRC is strongly encouraged.
feasible in case of single Rec with
loss of interdental attachment
Long-term stability of the outcome
equal or less than the buccal site
variables Acknowledgement
(Miller III or RT2) and the use
Only 8% of RTCs showed long-term of CAF+CTG is more effective We thank Prof. Arthur Novaes jr.
outcomes of treatment with at least than CAF alone (1 RCT, low for courtesy in providing unpub-
5 years of follow-up of (Paolantonio strength of evidence). lished data.
S60 Cairo et al.
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Francesco Cairo
(2012) Evaluation of Human Recession Defects the literature on root coverage procedures.
Treated With Coronally Advanced Flaps and Journal of Periodontology 74, 709–740.
Via Fra’ Giovanni Angelico 51
Either Enamel Matrix Derivative or Connective Pini Prato, G., Rotundo, R., Franceschi, D., 50121 – Florence
Tissue: Comparison of Clinical Parameters at Cairo, F., Cortellini, P. & Nieri, M. (2011) Italy
Ten Years. Journal of Periodontology 83, 1353– Fourteen-year outcomes of coronally advanced E-mail: cairofrancesco@virgilio.it
1362. flap for root coverage: follow-up from a ran-
Clinical Relevance CAF, whereas Barrier Membranes tive combinations to obtain com-
Scientific rationale for the study: (GTR) did not. Controversial out- plete root coverage. Factors as
The aim of this systematic review comes were observed by adding potential morbidity, quantity and
was to assess the clinical efficacy of Acellular Dermal Matrix. Surgical quality of residual soft tissue, cost-
periodontal plastic surgery proce- techniques different from CAF as benefit ratio and operator experi-
dures in the treatment of localized Laterally Positioned Flap (LPS), ence are critical factors in decision-
gingival recessions (Rec). Semilunar Coronal Positioned Flap making. Other biomaterials or flap
Principal findings: The use of (SCPF) and Free Gingival Graft designs or multiple combinations
CAF+CTG could be considered as (FGG) are supported by limited evi- (applying more than a single graft/
the gold standard procedure for dence. biomaterial under flap) should be
treating single REC with or with- Practical implications: Large evi- considered with caution in clinical
out iCAL. Enamel Matrix Deriva- dence supports the use of CAF pro- practice.
tive (EMD) or Collagen Matrix cedures for treating single Rec. CAF
(CM) enhanced the outcomes of alone or plus CTG, EMD are effec-

Efficacy of Periodontal Plastic Surgery Procedures in The Treatment of Localized Facial Gingival Recessions. A Systematic Review

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

Efficacy of periodontal plastic Francesco Cairo1,2, Michele Nieri1,2

surgery procedures in the Dentistry, Tuscan School of Dental Medicine,

treatment of localized facial gingival Dentistry, Tuscan School of Dental Medicine,

recessions. A systematic review

Cairo F, Nieri M, Pagliaro U. Efficacy of periodontal plastic surgery procedures in

Conflict of interest and source of funding statement

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

Study MRC MRC CRC CRC

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

Study MRC MRC CRC CRC

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

Table 2. Characteristics of the 123 excluded articles

RCT, Randomized Clinical Trial.

• Bittencourt et al. (2006) showed

The quality assessment of

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

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

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

should consider this finding in plan-

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Efficacy of Periodontal Plastic Surgery Procedures in The Treatment of Localized Facial Gingival Recessions. A Systematic Review

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Efficacy of Periodontal Plastic Surgery Procedures in The Treatment of Localized Facial Gingival Recessions. A Systematic Review

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Авторское право:

Доступные форматы

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

Efficacy of periodontal plastic Francesco Cairo1,2, Michele Nieri1,2

surgery procedures in the Dentistry, Tuscan School of Dental Medicine,

treatment of localized facial gingival Dentistry, Tuscan School of Dental Medicine,

recessions. A systematic review

Cairo F, Nieri M, Pagliaro U. Efficacy of periodontal plastic surgery procedures in

Conflict of interest and source of funding statement

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

Study MRC MRC CRC CRC

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

Study MRC MRC CRC CRC

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

Table 2. Characteristics of the 123 excluded articles

RCT, Randomized Clinical Trial.

• Bittencourt et al. (2006) showed

The quality assessment of

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

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

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

should consider this finding in plan-

Вам также может понравиться

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