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, 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
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 per- with a follow-up duration
the considered surgical procedures
formed in a duplicate form by two ≥6 months, had to compare the
were investigated.
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: alloca- CRC had to be expressed as the
number or the percentage of treated
• Recession defects that obtained tion concealment, blinding treatment
teeth of each considered study arm
complete root coverage (CRC). 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 section, be expressed as mean recession
reduction in millimetres of the trea-
• Change in gingival recession Data S2: Validity assessment). After
quality assessment, studies were ted teeth of each study arm at fol-
expressed as recession reduction
grouped into two categories: low-up visit. KT Gain had to be
in millimetres at follow-up visit
expressed as mean keratinized tissue
(RecRed), ● Low risk of bias, if all three qual- width increase in millimetres of the
• Change in width of keratinized ity criteria were met. treated teeth of each study arm at
tissue (KT) expressed as KT gain ● High risk of bias, if one or more of follow-up visit. Complications, Post-
in millimetres at follow-up visit the three quality criteria was 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. Figures 4–9 showed some meta-
Included studies 2006, da Silva et al. 2004, Wood- analyses for CRC, corresponding to
yard et al. 2004, Del Pizzo et al. comparisons CAF+CTG versus
The list of included studies is pre- 2005, Castellanos et al. 2006, CAF, CAF+GTR versus CAF, CAF+
sented in Table 1. The 51 selected Pilloni et al. 2006, Joly et al. GTR versus CAF+CTG, CAF+EMD
studies (53 articles) allowed the com- 2007, Abolfazli et al. 2009, versus CAF+CTG, CAF+CM versus
parisons showed in Fig. 2. For all Jankovic et al. 2010, Rasperini CAF and CAF+CM versus CAF+
the other possible comparisons et al. 2011, Jankovic et al. 2012, CTG.
investigated in the systematic review, Barros et al. 2013) did not report All performed meta-analyses were
no eligible study was found. how the study was supported. presented in the online material as sup-
In the case of Modica et al. plementary information (Data S1).
(2000), two of the 12 participants
were excluded from meta-analyses Excluded studies
Evaluation of the strength of evidence
because they participated in a split- There were 123 excluded studies.
mouth study with more than one The reasons for exclusion are The evaluation of the strength of
pair of bilateral gingival recessions. reported in Table 2 (Characteristics evidence using the modified GRADE
Hence, IPD of the remaining 10 pair of the 123 excluded studies). system showed for CRC that three
of recession defects were re-analysed. groups of comparisons were at
Among included studies, 2 RTCs moderate strength of evidence
were multicentre (Cortellini et al. Results of the analyses
(CTG+CAF > CAF; CAF+EMD
2009, Jepsen et al. 2013) while all Clinical outcomes from 51 RCTs > CAF; CAF+CTG > CAF+
others were single centre study. (corresponding to 53 articles) with GTR), while other comparisons were
Among the enclosed RCTs 1574 patients and 1744 treated considered at low strength of evi-
• Ten studies (Jahnke et al. 1993, recessions were included in this SR.
A total of 80 meta-analyses were
dence. No comparison for CRC was
rated at high strength of evidence.
Paolantonio (2002a), Paolantonio
et al. 2002b, Kimble et al. 2004, performed. Table 3 reported the For RecRed, two groups of com-
Huang et al. 2005, Bittencourt results of meta-analyses for CRC parisons were at moderate strength
et al. 2009, Jhaveri et al. 2010, (primary outcome), RecRed (sec- of evidence (CTG + CAF > CAF;
Alkan & Parlar 2011, Moslemi ondary outcome) and KT Gain CAF+CTG>CAF+GTR), while
et al. 2011, Nazareth & Cury (secondary outcome) for each possi- other comparisons were considered
2010) were completely supported ble comparison between surgical at low strength of evidence. No com-
by public institutes for research, procedures. parison for RecRed was rated at
• One study (Cortellini et al. 2009) Among different RTCs, only a
single study evaluating root coverage
high strength of evidence.
was supported by private insti- Aesthetic satisfaction
tutes for research, at Rec with iCAL (Cairo et al. 2012)
• Thirteen studies (Trombelli et al. was enclosed in the SR.
Main results can be summarized
Few studies evaluated aesthetic satis-
faction following therapy, mainly
1998, Tatakis & Trombelli 2000,
Aichelmann-Reidy et al. 2001, in: collecting patient opinion with no
standardized approaches. No meta-
Wang et al. 2001, Tal et al. 2002, • CAF+CTG was more effective
analysis throughout conventional
McGuire et al. 2012, Trabulsi than CAF in term of CRC
et al. 2004, Leknes et al. 2005, system was possible. Possible aes-
(p = 0.03), RecRed (p = 0.005)
Spahr et al. 2005, Wilson et al. thetic evaluation of the clinical out-
and KT gain (p = 0.0001) for
2005, McGuire et al. 2009, comes included a double assessment
Rec with no iCAL.
by patient and periodontist (Wang
McGuire & Scheyer 2010, Jepsen • CAF+CTG was more effective
et al. 2001, Aichelmann-Reidy et al.
et al. 2013) were supported, in than CAF in term of RecRed
part, by companies whose prod- 2001). Lately, the Root coverage
(p = 0.03) and KT gain (p <
ucts were being used as interven- Esthetic Score (RES), a standardized
0.00001) for Rec with iCAL.
system to aesthetic evaluation after
tions in the trials, • The adjunctive use of GTR was
• Three studies (Mahajan et al. not able to improve CAF with
root coverage, was introduced (Cairo
et al. 2009, 2010) and applied in
2007, Santana et al. 2010a,b) no significant difference with the
specified that the authors not recent RCTs (Jhaveri et al. 2010,
control procedure (CRC p =
received founding, Cairo et al. 2012, Roman et al.
0.41; RecRed p = 0.11)
• Three studies (Alves et al. 2012, • The adjunctive use of EMD
2013).
Cairo et al. 2012, Zucchelli et al. yielded to significant improvement Root sensitivity
2012) specified that the authors of CAF alone in term of CRC
self-supported the research, Very few studies evaluated Root
(p = 0.003), RecRed (p = 0.002)
• Twenty-one studies (Ricci et al. and KT gain (p = 0.0007).
sensitivity following root coverage
procedures. No meta-analysis was
1996, Paolantonio et al. 1997, • Multiple combinations, using
performed for this variable due to
Jepsen et al. 1998, Zucchelli et al. more than a single graft/biomate-
1998, Borghetti et al. 1999, the fact that data were few and het-
rial under the flap, usually pro-
Dodge et al. 2000, Modica et al. erogeneous. Cortellini et al. (2009)
vide similar or less benefits than
2000, Romagna-Genon 2001, compared CAF+CTG versus CAF,
simpler, control procedures.
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: 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
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
Comparations of techniques for gingival recession 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.
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-
in a 10-year follow-up study compar- sis. Complications were frequently sure was reported as a possible com-
ing CAF+EMD (test) versus not investigated or reported in anec- plication (7/15 in Jepsen et al. 1998,
CAF+CTG (control) reported one of dotal forms. 2/12 in Trombelli et al. 1998, 5, /12
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.
in Tatakis & Trombelli 2000). Jepsen compared with CTG sites. None of et al. 2007). In a comparison
et al. (1998) reported a similar inci- the patients reported exposure of the between CAF+EMD versus
dence of post-operative pain for membrane. CAF+CTG, McGuire & Nunn
both treatments (5/15 patients). On No complication was reported in (2003) reported higher discomfort
the other hand, Romagna-Genon comparisons between CAF+EMD for CTG procedure (p = 0.011)
(2001) described postoperative dis- versus CAF (Modica et al. 2000), 1 month following therapy, whereas
comfort for the palatal donor site CAF+ADM versus CAF (Woodyard no difference between the two
for the CTG. Sites treated with BM et al. 2000, Côrtes et al. 2004) and approaches was reported at the
were more frequently symptom-free CAF+ADM versus CAF+CTG (Joly 1-year follow-up.
More recently, the use of CON- CAF+CTG (McGuire & Nunn was the Coronally Advanced Flap
SORT guidelines in reporting RTCs 2003) considering 9 of 17 original (Allen & Miller 1989). This tech-
improved also information on patients. The authors described nique became very popular in the
patient-related outcomes by using stability of achieved outcomes in 1990s and several combinations by
Visual Analogue Scale (VAS). That the long-term with no significant adding grafts, barriers or biomateri-
is, Cortellini et al. (2009) reported difference between the two als over the root were suggested
higher number of cases of swelling in procedures. (Cairo et al. 2008). On the other
CAF+CTG group compared with hand, flap designs different from
CAF group, and these differences CAF as LPS or SCPF showed a very
were statistically significant (for Discussion limited number of RCTs and should
CAF+CTG, VAS = 32.2 28.4 be considered with caution in mod-
whereas for CAF, VAS = 17.8 The focused question of this system- ern treatment. When considering the
19.9). Furthermore, CAF+CTG was atic review was “what is the clinical pure flap design, RTCs comparing
associated with longer surgical time efficacy of periodontal plastic surgery the CAF technique to LPF (Santana
(p < 0.0001), higher number of days procedures in the treatment of local- et al. 2010a) or SCPF (Santana et al.
with post-operative morbidity ized gingival recessions with or with- 2010b) are available. The results of
(p = 0.0222) and greater number of out inter-dental clinical attachment the present meta-analysis showed
post-operative analgesics (p = 0.0178) loss?” The current article covered that CAF is superior to different flap
than CAF alone in a RCT on single 35 years of clinical research in muco- designs in term of probability to
recession with iCAL (Cairo et al. gingival surgery, starting from the obtain CRC. Interestingly, the use of
2012). Finally, add of CM under- late 1970s when Raul Caffesse’s LPF is associated with higher
neath CAF was not associated with group published the early RTCs on amount of KT gain than CAF after
increased post-operative morbidity the treatment of single gingival healing (Santana et al. 2010b); how-
than CAF (Jepsen et al. 2013). recession (Guinard & Caffesse 1978, ever, it should be taken into account
Caffesse & Guinard 1978, 1980, that the presence of a well-repre-
Long-term stability of the outcome Espinel & Caffesse 1981). From this sented amount of KT from the adja-
variables historical perspective, it has been cent site is pre-requisite to perform
A very limited number (8%) of RTCs observed that several paradigms LPF.
showed long-term outcomes of treat- changed during the last decades. The efficacy of CAF alone as reli-
ment with a follow-up of at least Between 1970s and 1980s gold stan- able method to obtain root coverage
5 years (Paolantonio et al. 1997, Lek- dard procedures were considered the is associated with the flap design
nes et al. 2005, Moslemi et al. 2011, free gingival graft (FGG) and later- that is able to maintain an adequate
McGuire et al. 2012); three of four ally positioned flap (LPF) even if the blood supply for the gingival mar-
studies were long-term update of pre- scientific background was mostly gin, as demonstrated by the classical
viously published short-term out- represented by case-series studies. In paper from M€ ormann & Ciancio
comes (Leknes et al. 2005, Moslemi the late 1980s a complete description (1977). In this angiographic study,
et al. 2011, McGuire et al. 2012). of the CAF procedure was presented some aspects of flap design were
(Allen & Miller 1989) opening a new
• Leknes et al. (2005) reported a era of treatment, not only focused
stressed, including a broad enough
flap base to incorporate major gingi-
significant reduction in CRC and on the reconstruction of an “ade-
mean RecRed for both val vessels, a proper flap’s length to
quate” amount of attached gingiva width ratio, a minimal residual
CAF+GTR and CAF-treated but also effective in enhancing soft
sites when comparing 6-year fol- tension and the careful preparation
tissue aesthetics. The definition of of the partial thickness flap
low-up with the 1-year and 6- Periodontal Plastic Surgery was then
month follow-ups (Amarante (M€ ormann & Ciancio 1977). These
introduced (Miller 1993, American findings represent a milestone in the
et al. 2000). Academy of Periodontology 1996),
• Moslemi et al. (2011) reported thus capturing the target of contem-
development of modern in periodon-
tal plastic surgery and provide a nice
the 5-year follow-up of a short- porary treatment. In modern evi-
term study (Haghighati et al. interpretation of soft tissue healing
dence-based era, the interest was process over the exposed root sur-
2009) comparing CAF+ADM mostly focused on the predictability
versus CAF+CTG. At last fol- face after mucogingival surgery.
of soft tissue reconstruction over the
low-up, significant relapses were exposed root thus obtaining CRC
detected in CRC and reduction The clinical efficacy of Coronally
along with pleasant aesthetics (Cairo Advanced Flap plus Connective Tissue
in RD and RW in both groups et al. 2009, Kerner et al. 2009, Cairo Graft
with no statistically significant et al. 2010).
difference. Patients reporting hor- Data from this SR showed that
izontal tooth-brushing habits CAF+CTG could be considered the
were more prone to develop Rec The flap design for root coverage gold standard for treatment of the
procedure: coronally advanced flap
relapse (p = 0.01). single gingival recession. In fact, two
versus different flap designs
• McGuire & Nunn (2012) RCTs for Rec with no iCAL (da
reported the long-term follow-up Among the different types of flap Silva et al. 2004, Cortellini et al.
(10 years) of short-term study designs used in periodontal plastic 2009) and one for Rec with iCAL
comparing CAF+EMD versus surgery, the most frequent approach (Cairo et al. 2012) showed that this
S58 Cairo et al.
combination was associated with Alternatives to connective tissue graft 2009) showed also that CAF+EMD
higher probability to obtain CRC underneath the flap: enamel matrix was inferior to CAF+CTG in term of
than CAF alone. Interestingly, when derivative, acellular dermal matrix, CRC, although this result was not
barriers membranes and collagen matrix
considering Rec with iCAL, the use significant.
of CTG was associated with 57% of The use of CTG implies an obvious Initial data support also benefit
CRC (Cairo et al. 2012), thus con- increase in patient discomfort com- in using CM, 3D-matrix made of
futing the paradigm suggesting a pared with procedures requiring a porcine collagen able to promote
limit for root coverage due to the single surgical site in the mouth soft tissue regeneration. One RCT
baseline inter-dental bone loss (Cairo et al. 2012). To reduce (Jepsen et al. 2013) showed that CM
(Miller 1985). Furthermore, CTG patient morbidity, several biomateri- was able to improve the probability
procedure is more effective than the als/barriers/replacement grafts were of obtaining RecRed than CAF
CAF procedure to augment kerati- tested. Considering data from these alone, whereas one RCT (McGuire
nized tissue, leading to a final meta-analyses, biomaterials able or & Scheyer 2010) showed less RecRed
increase in approximately 1 mm of not able to improve CAF can be dis- and similar KT gain compared with
KT. tinguished. CAF+CTG. Therefore, data from
When considering potential mate- In the last 15 years, barrier mem- the present SR suggest that EMD
rials underneath CAF compared branes for regeneration and ADM and CM are useful biomaterials in
with CTG, add of ADM or GTR were extensively used for root cover- current periodontal plastic surgery,
was less effective than CAF+CTG in age. A large evidence showed limited but further studies are necessary to
term of root coverage outcomes. clinical benefits in using these mate- definitively evaluate indications for
Furthermore, CAF+CTG was simi- rials. GTR was extensively tested in treatment and associated clinical
larly effective than CAF+ EMD for comparison to CAF+CTG or CAF benefits.
CRC and more effective than alone: the current meta-analysis
CAF+CM for RecRed. In addition, showed that bilaminar procedure or Multiple combinations for root coverage
the use of CTG with different over- CAF alone was associated with sig-
laying flap design as Double Papilla nificant higher probability to obtain Among 51 enclosed RCTs, nine
Coronally Advanced Flap was also CRC and RedRed than CAF+GTR. studies tested multiple combinations
associated with better root coverage In addition, a high incidence of com- (application of more than a single
outcomes than FGG (Jahnke et al. plications as membrane exposure graft/biomaterial under the flap) for
1993, Paolantonio et al. 1997). was frequently reported (Jepsen treating the single gingival recession
A possible hypothesis to explain et al. 1998, Trombelli et al. 1998, compared with a simpler technique.
the clinical efficacy of CTG may be Tatakis & Trombelli 2000). Based on These approaches included the addi-
related with the specific healing these data, the use of GTR for root tion of EMD to CAF+CTG (Raspe-
model of the procedure. In fact, the coverage seems to be poorly indi- rini et al. 2011, Alkan & Parlar
high stability of the wound over cated in modern periodontal plastic 2011), the use of ADM and cultured
CTG is associated with graft vascu- surgery. fibroblasts under CAF (Jhaveri et al.
larization originated from both the ADM, an allograft of cadaveric 2010), the use recombinant human
periodontal plexus and the overlying origin, was compared in six RTCs platelet-derived growth factor under
flap leading to a complete blood with CAF+CTG (Aichelmann-Reidy GTR and CAF (McGuire et al.
supply for the graft after 2 weeks et al. 2001, Paolantonio 2002a, 2009), the addition of bone graft
(Guiha et al. 2001). Furthermore, Paolantonio et al. 2002b, , Tal et al. under GTR (Paolantonio 2002a,
CTG could be considered biological 2002, Joly et al. 2007, Haghighati Dodge et al. 2000, Kimble et al.
filler able to adapt the inner of the et al. 2011, Barros et al. 2013) and in 2004) and the use of EMD under
flap to the root surface thus limiting two RTCs with CAF alone (Wood- GTR (Trabulsi et al. 2004) or in
the post-operative shrinkage of yard et al. 2004, C^ ortes et al. 2006), combination with ADM (Alves et al.
CAF in apical direction (Cairo showing inferior outcomes than CTG 2012). Among these studies, only a
et al. 2008, Cortellini et al. 2009). and no additional benefit when added single RCT (Dodge et al. 2000)
This hypothesis is supported by to CAF, although not significant and showed that CAF+ GTR+ BG was
data from a recent RCT for the with high heterogenic I2 index. These associated with better significant
treatment of RT2 single Rec (Cairo data seem to suggest caution in apply- RecRed than CAF+GTR.
et al. 2012): the CAF-treated sites ing ADM for root coverage. The results of the present meta-
showed an increasing apical shift of On the other hand, EMD and CM analyses showed that multiple com-
the gingival margin between 3 and show promising results to improve binations usually provide similar or
6 months, whereas the CAF+CTG- the clinical efficacy of CAF. EMD less benefits than the simpler, control
treated sites showed a consistent was extensively tested in comparison procedures in term of root coverage
stability in the same time frame. with CAF alone (Modica et al. 2000, outcomes. Clinicians and researchers
This resulted into a significant Del Pizzo et al. 2005, Spahr et al. should consider this finding in plan-
reduction in sites completely cov- 2005, Castellanos et al. 2006 Pilloni ning further studies on the treatment
ered in CAF-treated sites, while in et al. 2006), showing higher signifi- of single gingival recessions. Further-
the CAF+CTG group the number cant probability to improve root more, the reader should consider
of sites with CRC was the same at coverage outcomes. Two RTCs that cost-benefit ratio and practical-
3- and 6-month follow-ups. (McGuire et al. 2003, Abolfazli et al. ity are key factors in selecting a
proper treatment. In the light of

present outcomes, multiple combina-
traumatic tooth brushing is strongly
associated with Rec recurrence at
• Barrier Membranes are not effec-
tive to improve Coronally
tions appeared not indicated for root CAF+ADM and CAF+CTG-treated Advanced Flap (1 RCT, low
coverage. sites after 5 years (Moslemi et al. strength of evidence).
2011) or at CAF+GTR and CAF-
treated sites after 6-years (Leknes
• Initial data suggest that add of
Patient-related outcomes including CM may improve the efficacy
discomfort/pain and aesthetic satisfaction et al. 2005). Similar observations of CAF (1 RCT, low strength of
after periodontal plastic surgery were recently reported in a RCT evidence).
Data on pain and complications
with long-term evaluation (14 years)
of CAF procedure (Pini Prato et al.
• Multiple combinations, using
including residual root sensitivity more than a single graft/biomate-
2011). A recurrence of gingival rial under the flap, usually pro-
after root coverage procedures are recession was described in 39% of
heterogeneous and usually reported vide similar or less benefits than
the treated sites (Pini Prato et al. simpler, control procedures in
in anecdotal form. The use of GTR 2011). On the other hand, stability
was frequently described as associ- term of root coverage outcomes
of gingival margin 10 years after (a total of 10 RCTs with low
ated with exposure of the barrier. CAF+EMD or CAF+CTG was
This information may explain the lim- strength of evidence).
reported in nine of 17 original
ited efficacy of this procedure com- patients treated in a private peri-
pared with CAF alone or CAF+CTG odontal office (McGuire & Nunn
in terms of root coverage outcomes 2012). Nevertheless, when interpret- Indications for future research
thus limiting the indications for this ing these data, heterogeneity among
type of procedure. More recently, the studies in terms of setting (university • Increased number of RTCs
use of CONSORT guidelines in versus private office), applied tech- assessing the efficacy of EMD
reporting RTCs improved also infor- niques (grafted versus not grafted and CM compared with
mation on patient-related outcomes procedure) and residual number of CAF+CTG are suggested.
in a standardized form. RTCs investi- patients/dropouts should be carefully • Trials assessing the efficacy of
gating the clinical efficacy of considered. the addiction of CM underneath
CAF+CTG (Cortellini et al. 2009, CAF are indicated.
Cairo et al. 2012) showed that this • Further trials assessing the effi-
procedure is usually associated with Conclusions cacy of root coverage at gingival
higher post-operative morbidity than recessions with iCAL are encour-
CAF alone, thus capturing an impor- • Coronally Advanced Flap plus aged.
tant 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 et al. and II or RT1) (2 RTCs, moder- site with restored CEJ are advo-
2009, Kerner et al. 2009). In fact, the ate strength of evidence). cated.
evaluation of the level of gingival • Coronally Advanced Flap plus • RTCs assessing the long-term
margin following surgery might be Connective Tissue Graft is more outcomes of root coverage out-
restrictive and not adequate to assess effective than CAF plus GTR comes are encouraged.
the final aesthetic results. Therefore, (6 RTCs, moderate strength of • The collection of patient-related
the collection of patient-related out- evidence). outcomes including pain/discom-
comes using a standardized approach • Enamel Matrix Derivative impro- fort and satisfaction using stan-
along with information on clinical ves the efficacy of Coronally dardized approach is suggested.
outcomes is strongly recommended Advanced Flap alone (4 RTCs, • The use of CONSORT guidelines
in future researches. moderate strength of evidence). to minimize the risk of bias is
• Initial data suggest that CRC is strongly encouraged.
feasible in case of single Rec with
Long-term stability of the outcome
loss of interdental attachment
variables
equal or less than the buccal site
Only 8% of RTCs showed long-term (Miller III or RT2) and the use Acknowledgement
outcomes of treatment with at least of CAF+CTG is more effective We thank Prof. Arthur Novaes jr.
5 years of follow-up of (Paolantonio than CAF alone (1 RCT, low for courtesy in providing unpub-
et al. 1997, Leknes et al. 2005, strength of evidence). lished data.
Moslemi et al. 2011, McGuire et al. • Studies adding Acellular Dermal
2012); three of them were long-term Matrix (ADM) under CAF
update of previously published short- showed a large heterogeneity and References
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Dentistry 5 (5), 15–20. treatment of localized gingival recessions: a sys-
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, Michele Nieri1 and

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

treatment of localized facial gingival

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

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

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

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

proper treatment. In the light of

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