Chambro 2019

Root coverage procedures for treating single and multiple recession-type
defects: A Cochrane Systematic Review Updated
Leandro Chambrone,* Maria Aparecida Salinas Ortega,* Flávia Sukekava, † Roberto

Rotundo,‡ Zamira Kalemaj,§ Jacopo Buti‡ and Giovan Paolo Pini Prato¶
*MSc Dentistry Program, Ibirapuera University, São Paulo, Brazil
†
Private practice, Curitiba, Brazil
‡ Unit of Periodontology, UCL Eastman Dental Institute, London, UK
§
Private practice, Milan, Italy
¶
Tuscany Academy of Dental Research (ATRO), Florence, Italy
1
This paper is based on a Cochrane Review published in The Cochrane Library 2018, Issue 10 (see
www.thecochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence
emerges and in response to feedback, and The Cochrane Library should be consulted for the most recent
version of the review
Correspondence :
Dr. Leandro Chambrone, Rua da Moóca, 2518, cj13
03104-002, São Paulo, SP, Brazil.
E-mail:[email protected]
Words: 3,887 Number of tables: 3 Number of Figures: 2 References: 83
Number of online supplemental appendixes: 8
Short running title: Treatment of recession type-defects
Summary sentence: Subepithelial connective tissue grafts, coronally advanced flaps alone
or associated with other allogenous/xenogenous soft tissue substitutes can be used as root
coverage procedures for the treatment of recession-type defects
ABSTRACT
This article is protected by copyright. All rights reserved.

Background: This updated Cochrane systematic review (SR) evaluated the efficacy of
different root coverage (RC) procedures in the treatment of single and multiple gingival
recessions (GR).
Material and Methods: We included randomized controlled trials (RCTs) only of at least 6
months‟ duration evaluating Miller‟s Class I or II GR (≥ 3 mm) treated by means of RC
procedures. Five databases were searched up to January 16, 2018. Random effects meta-
analyses were conducted thoroughly.
Results: We included 48 RCTs in the SR. The results indicated a greater GR reduction for
subepithelial connective tissue grafts (SCTG) + coronally advanced flap (CAF) compared to
guided tissue regeneration with resorbable membranes (GTR rm) + CAF (mean difference
[MD]: -0.37 mm). There was insufficient evidence of a difference in GR reduction between
acellular dermal matrix grafts (ADMG) + CAF and SCTG + CAF or between enamel matrix
derivative (EMD) + CAF and SCTG + CAF. Greater gains in the keratinized tissue width
(KTW) were found for SCTG + CAF when compared to EMD + CAF (MD: -1.06 mm), and
SCTG + CAF when compared to GTR rm + CAF (MD: -1.77 mm). There was insufficient
evidence of a difference in KTW gain between ADMG + CAF and SCTG + CAF.
Conclusions: SCTG, CAF alone or associated with another biomaterial may be for treating
single or multiple GR. There is also some evidence suggesting that ADMG appear as the
soft tissue substitute that may provide the most similar outcomes to those achieved by
SCTG.
KEY WORDS (MESH verified): Gingival recession; therapy; surgery; tooth root; surgical
flaps.
INTRODUCTION

Different systematic reviews (SR) have been published focusing on the effect of root
coverage (RC) procedures on the treatment of single gingival recessions (GR).2-7 These
authors reported that different surgical techniques led to statistically significant
improvements in recession depth (RD), clinical attachment level (CAL) and in the keratinized
tissue width (KTW) (when indicated).2-7 Also, it was recommended for clinical practice that
when RC is indicated, subepithelial connective tissue grafts (SCTG), should be considered
as the „gold standard‟ procedure.2-7 Moreover, the use of other biomaterials of allogenous
(acellular dermal matrix graft [ADMG]8) or xenogenous (i.e. collagen membranes,9,10 enamel
matrix derivative [EMD]11 and collagen bilayer matrix graft [XCM]12) origin has been broadly
studied since the late 1990s to treat GR.
The previous version of this Cochrane Review13,14 endorsed these outcomes, and also
emphasized the importance of SCTG in improving the KTW. Since its original publication in
the Cochrane Database of Systemtatic Reviews in 200913 and in the Journal of
Periodontology in 2010,14 the knowledge on RC procedures and materials have evolved and
new randomized clinical trials (RCT) have been published so far. Thus, this updated version
of the original Cochrane SR13,14 evaluated the efficacy of different RC procedures in the
treatment of single and multiple GR.
MATERIALS & METHODS
Detailed descriptions of the SR protocol (i.e., criteria for considering studies for the review,
search methods for identification of studies, and data collection and analysis) used in this
paper have been published previously.13,14 The following sections provide a brief description
of the overall specific methodologic aspects of the 2018 version of the review.1
Criteria for considering studies for this review

Types of studies and participants: RCTs > 6 months‟ duration and reporting patient-
based analysis. Studies were included if they reported the treatment of single or multiple
Miller‟s15 Class I or II GR (RD > 3 mm), as well as at least 10 participants per group at final
examination (with a follow-up < 5 years).
Exclusion criteria: Studies including Miller's15 Class III and IV and restored root surfaces
were not included.
Types of interventions: The interventions of interest were: a) free gingival grafts (FGG); b)
laterally positioned flap (LPF); c) CAF; d) SCTG alone or in combination with LPF or CAF;
and e) CAF in association with allograft (e.g., ADMG, others), GTR (with resorbabable [rs] or
non-resorbable membranes [nrm]), EMD, XCM or other biomaterial. In addition, RCTs
comparing variations of the same procedure (e.g. CAF with vertical incisions versus CAF
without vertical incisions, etc) were also considered eligible for inclusion in the review.
Outcome measures: Primary outcome measures included aesthetic condition change
(ACC) related to patient's opinion, complete root coverage (CRC) and RD change.
Secondary outcome measures were as follows: CAL change, KTW change, mean root
coverage (MRC), patients' preference for a specific RC procedure (in split-mouth trials),
occurrence of adverse effects and/or postoperative complications. Outcome measures were
separated into short-term (as evaluated 6 months to 12 months following interventions),
medium-term (13 months to 59 months) or long-term (≥ 5 years).
Search methods for identification of studies (for details see supplementary Appendix
1 in online Journal of Periodontology).
Data collection and analysis
Details regarding data collection until October 2008 were reported previously.13,14
Identification of studies conducted from November 2008 to January 16, 2018 were
performed by two independent reviewers (LC and MASO). Agreement between review
authors was assessed calculating Kappa scores. Disagreement between the review authors

was resolved by discussion with the inclusion of another review author (RR). Risk of bias
(low, high, or unclear) of each included study was assessed using the Cochrane domain-
based, two-part tool as described in the Cochrane Handbook for Systematic Reviews of
Interventions.17
Data synthesis
Data were collated into evidence tables. Random-effects meta-analyses were used
throughout. For continuous data, pooled outcomes were expressed as weighted mean
differences (MD) with their associated 95% confidence intervals (CI). For dichotomous data,
these were predominately pooled odds ratios (OR) and associated 95% CI. The analyses
were conducted using the generic inverse variance statistical method where the MD or
log[OR] and standard error (SE) are entered for all studies. Becker-Balagtas method18 was
used to calculate MD and log ORs, as indicated by Curtin et al.19 to accommodate data
pooling from split-mouth and parallel-group studies in a single meta-analysis, and facilitate
data synthesis.18 For split-mouth trials it was assumed a intracluster correlation co-efficient
of 0.05, while for parallel trials a co-efficient of zero for the calculation of SE. Statistical
heterogeneity was assessed by calculation of the Q statistic. Analyses were performed using
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RevMan software.
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Review Manager software, version 5.3; The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark
Variance imputation methods were conducted to estimate appropriate variance estimates in
some split-mouth studies, where the appropriate standard deviation of the differences was
not included in the trials.20 The significance of discrepancies in the estimates of the

treatment effects from the different trials was assessed by means of Cochran's test for
heterogeneity and the I2 statistic.
Presentation of main results: 'Summary of findings' tables for the main comparisons
on single GR involving the "gold-standard" procedure (i.e., SCTG-based procedures
versus other root coverage procedures) and the currently used alternative
approaches (i.e., CAF, CAF + ADMG, CAF + EMD and CAF + XCM) 5,21,22 were produced
for the following outcomes: a) CRC; b) GR change; c) CAL change; and d) KTW
change. GRADE methods,23 and the GRADEpro online tool were used for developing
'Summary of findings' tables (www.guidelinedevelopment.org). The quality of the
body of evidence was assessed for each comparison and outcome by considering the
overall risk of bias of the included studies, the directness of the evidence, the
inconsistency of the results, the precision of the estimates, and the risk of publication
bias. The quality of each body of evidence was categorised as high, moderate, low, or
very low.
RESULTS
Results of the search and included studies
A total of 1714 records were retrieved from the searches (see supplementary Appendix 2 in
online Journal of Periodontology). After the removal of duplicates, 724 records were
screened for eligibility. 530 records were discarded, and the full-texts of 194 articles were
assessed. From the 194 papers, 137 did not meet the criteria of eligibility and the reasons
for exclusion were reported in the supplementary Appendix 3 in online Journal. Kappa
scores for the searches conducted from November 2008 to January 2018 for title and/or
abstract review, and full texts screening were 0.88 and 0.87, respectively.
Forty-eight studies (reported in 57 papers8-12,24-75) were included in the review, with 20
providing data for meta-analyses. Nine RCTs had their data reported in two articles each

(i.e. according to the follow-up period or type of data (i.e. clinical or patient-reported
outcomes).12,31,32,34,35,44,45,47-51,61-64,66,67 Consequently, the papers with a shorter follow-up
period were included under the one study name (e.g. papers with the longer follow-
up),32,35,45,48,50,51,61,67 while one article reporting patient-reported outcomes was included
under the name of the clinical outcomes paper.64 Data on the type of study design, location
and country of trial are described in Table 1. Five studies evaluated multiple GR,25,38,52,53,70
whereas the others single defects. Two studies32,59 evaluated exclusively outcomes of
smokers (i.e. 10 or more cigarettes per day for more than 5 years). In addition, the majority
of trials followed participants during a short-term period (6 months to 12 months). Only five
publications with medium-term follow-up11,24,35,61,67 and five with long-term follow-up45,48,50,51,54
were included. In total, 1227 patients were treated and details on the different treatment
modalities are depicted in Table 1.
Risk of bias in included studies
Only one study was considered to be at a low overall risk of bias (Figure 1).64 According to
GRADE methods23 all evidence was considered to be of low to very low quality, mainly for
imprecision and inconsistency (see supplementary Appendix 4 in online Journal of
Periodontology).
Effects of interventions
ACC, GR change, CAL change and KTW change: ACC related to patient‟s opinion was
reported in 10 RCTs25,29,48,50,51,53,61,72,74,75 (Table 2) Given the heterogeneity of
methods/criteria used to assess this outcome and types of procedures compared, formal
pooling of data via meta-analysis was precluded. Of the 48 included trials, 18 evaluating
single GR8-11,24,28,35,36,40,41,48,55,56,61,64,65,67,71 and two multiple GR52,70 were included into 11 sets

of meta-analyses (Table 3). In addition, data from studies not included in meta-analyses are
presented in supplementary Appendix 5 in online Journal.
Single GR: With respect to RD change, there was evidence of greater RD reduction for
EMD + CAF when compared to CAF alone (short/medium term; P = 0.005, MD: 0.32 mm),
for SCTG + CAF when compared to GTR rm + CAF (P = 0.002, MD: -0.37 mm), for GTR rm
+ CAF associated with bone substitutes compared to GTR rm + CAF (P = 0.02, MD: 0.48
mm) and for XCM + CAF compared to CAF alone (P = 0.006, MD: 0.40 mm). Regarding
CAL change, there was evidence of greater reduction of CAL for EMD + CAF when
compared to CAF alone (short/medium-term, P = 0.009, MD: 0.35 mm), and for GTR rm +
CAF compared to SCTG + CAF (P = 0.02, MD: of 0.35 mm). For KTW change, there was
evidence of greater gain in the KTW for EMD + CAF when compared to CAF alone (short-
term, P = 0.001, MD: 0.35 mm; short/medium term, P = 0.0005, MD: 0.40 mm), for SCTG +
CAF when compared to EMD + CAF (P < 0.00001, MD: -1.06 mm), for SCTG + CAF when
compared to GTR rm + CAF (P < 0.0001, mean difference -1.77 mm), for SCTG + CAF
when compared to GTR rm + CAF associated with bone substitutes (P < 0.00001, MD: -2.38
mm), and for XCM + CAF when compared to CAF alone (P = 0.03, MD: 0.44 mm). Multiple
GR: There was evidence of greater reduction of CAL for SCTG + CAF compared to PRF +
CAF (P = 0.02, MD: -0.37 mm).
CRC
CRC was reported in 34 studies (Table 2) Among the included RCTs designed to evaluate
single GR (excluding the data from Costa et al.31,32 and Reino et al.59 who included only
heavy smokers), CRC varied from 0%26 to 91.6%8 for ADMG; 18.1%33 to 95.6%12,51 for
SCTG; 25%24 to 89.5%47,48 for EMD; 7.7 %34,35 to 81.8%73 for CAF; 33.3%36 to 53.3%55 for
GTR rm; and 28%10 to 41.6%9 for GTR nrm. Also, OR analyses of six comparisons did not
find statistical differences between procedures (Table 3). For XCM + CAF versus CAF, the

combined therapy improved the achievement of sites displaying CRC compared to the use
of CAF alone (OR of 4.73, 95% CI 2.35 to 9.50).
MRC
All included trials reported the MRC. Within studies evaluating single GR (excluding the data
from two RCT31,32,59 who included heavy smokers), this outcome varied from 50%41 to 96%8
for ADMG, 64.7%29 to 99.3%12,51 for SCTG, 70.5%39 to 95.1%47,48 for EMD, 55.9%34,35 to
95.4%73 for CAF, 62.5%46 to 73.7%36 for GTR rm, 84.2 %61,62 to 89.9%36 for GTR rm
associated with bone substitutes, and 80.5%10 to 82.4%9 for GTR nrm (Table 2).
Patients’ preference for a specific RC procedure in split-mouth trials
This update did not identify additional data to those already publish by the previous version
of this SR.13,14 Details on this outcome are described in supplementary Appendix 6 in online
Journal of Periodontology.
Occurrence of adverse effects and/or postoperative complications
Occurrence of adverse effects and/or postoperative complications during the postsurgical
period was reported in 15 trials,12,28,36,39,40,42,45,47,49,52,66,71,72,74,75 but restricted to a limited
number of patients/cases (see supplementary Appendix 7 in online Journal). Overall, the
most common adverse outcomes were postsurgical pain/swelling within the first days after
surgery, ADMG graft or membrane exposure and postoperative pain in donor site of SCTG.
DISCUSSION

Summary of main results
The main changes since the last version13,14 are reported in Figure 2. In spite of aesthetics
being considered the primary goal of RC procedures, few studies had evaluated ACC related
to patients‟ opinion.12,24,29,47-51,53,61,62,72,74,75 In these studies, the majority of the patients were
satisfied with the final aesthetic result achieved (Table 2). Also, procedures that make a
reduction in the operatory time possible, that eliminate the need for a second surgical site
and that use smaller palatal grafts72,74 were better accepted by the patients. In terms of RD
reduction, results from meta-analyses demonstrated evidence that at short-term: SCTG +
CAF promoted additional gains to those achieved by GTR rm + CAF; XCM + CAF improved
the gains obtained by CAF alone; EMD + CAF led to better stability of the gingival margin
after treatment than CAF alone; and GTR rm + bone substitutes + CAF provided better
outcomes than GTR rm + CAF (Table 3).
There was a marked variation between procedures in terms of the achievement of CRC at
short-term (Table 2): 0% to 95.6%. OR analyses on CRC did not reveal evidence of
differences between procedures in none of the available comparisons, except for XCM +
CAF versus CAF (i.e. the combined therapy promoted better outcomes). Additionally, some
studies showed a decrease in the number of sites displaying CRC over time.12,33,34,47-51
With respect to secondary outcomes, four comparisons showed evidence that SCTG + CAF
promoted additional gains in the KTW compared to EMD + CAF, GTR rm + CAF, or GTR rm
+ bone substitutes + CAF. Similarly, the use of EMD + CAF or XCM + CAF promoted
additional gains in the KTW compared to the use of CAF alone (Table 3). Regarding CAL
changes, there was evidence that SCTG + CAF promoted additional gains to those achieved
by platelet-rich fibrin (PRF) + CAF, and that GTR rm + CAF promoted additional gains
compared to SCTG + CAF. Also, there was a markedly variation in the amount of RC

achieved. MRC varied from 44% to 99.3% (Table 2). Furthermore, data from some medium-
and long-term trials12,33,34,47-51 showed that MRC decreased over time.
Patients‟ preference for a specific RC procedure followed the same pattern as ACC.9,71,72
Occurrence of an early discomfort with or without pain was related to donor sites of
SCTG.47,48,52,71,72 This aspect may be related to the size of the graft obtained from the palate
and the surgical approach used.72 Moreover, „bigger grafts‟ were more associated to
shrinkage of the covering flap with graft exposure when compared to „small grafts‟.72,74 In
terms of flap preparation, the removal of the labial submucosal tissue, in the area of lower
incisors, led to a reduction in the number of sites experiencing covering flap shrinkage than
sites where the submucosal tissue was not removed.75
Although 48 RCTs were included in this Cochrane SR, it was difficult to combine data from
these trials due to a great variability of comparisons between the various RC procedures and
the inexistence of a unique gold standard control group in all studies. Consequently, only 20
trials were incorporated into meta-analyses8-12,24,28,34-36,40,41,47,48,52,55,56,61-67,70,71 in 11 different
group comparisons (Table 3). Few studies reported a follow-up period superior to 12
months.12,24,34,35,44,45,47-51,54,61,62,66,67 In six of these studies a chronological evaluation of the
results evidenced loss in the amount of RC obtained (e.g. MRC and CRC) between the 6
months to 12 months period of evaluation11,34,35,66,67 and between the first year and 5-and
10-year follow-ups.12,47-51 This assumption was evidenced by the findings of pooled
estimates on EMD + CAF versus CAF (Table 3). Two trials31,32,59 evidenced the detrimental
impact of smoking on root coverage outcomes (i.e. MRC and CRC decrease) within patients
who smoke ≥ 10 cigarettes per day for more than 5 years.
Overall, both the individual studies‟ outcomes (i.e. within-group comparisons reported by
each individual trial) and findings of pooled estimates clearly demonstrated that all RC
procedures included in this Cochrane Review promoted reduction in the extent of GR and

concomitant gain in the CAL for both single and multiple GR. Likewise, it was evidenced that
KTW augmentation of these sites was associated to the use of SCTG or allogenous
(ADMG)/xenogenous (XCM) soft tissue substitutes.
Quality of the evidence
Only one study was considered to be at a low overall risk of bias. GRADE methods23 were
used to assess the quality of the body of evidence of our main comparisons and our
assessment is presented in the supplementary Appendix 4 in online Journal of
Periodontology with all evidence considered to be of low to very low quality, mainly for
imprecision and inconsistency.
Potential biases in the review process
In this review, only defects ≥ 3 mm were included in order to minimize heterogeneity
between the trials. However, this inclusion criterion could have eliminated data from studies
that could be incorporated into meta-analyses.
Agreements and disagreements with other studies or reviews
Important aspects already described in both the previous13,14 and current versions of this
Cochrane SR are depicted in supplementary Appendix 8 in online Journal. The current
version of this SR evidenced that both patients and clinicians seem to agree that, in terms of
aesthetic perception, CRC is perceived as the primary ‟successful outcome‟ of a RC
procedure.76 However, it is important to highlight that patients‟ perception of buccal
recessions is not high (approximately half of the patients with one gingival recession do not
perceive them), as well as that the majority of those defects do not lead to functional or
aesthetic concerns.77

It has been demonstrated by an individual patient data meta-analysis of 602 Miller Class I
and II recession defects4 that the greater the baseline RD, the smaller the chance of CRC. It
should also be noted that the inclusion of studies with recession defects ≥ 4 mm tends to
show greater differences between baseline and follow-up means (i.e. outcome change), a
factor that may influence the calculation of meta-analyses.4,13,14 Another couple of studies78,79
demonstrated that sites in which the gingival margin was sutured at the level of the cemento-
enamel junction the achievement of CRC was inferior to those sites where a trapezoidal flap
was sutured coronal (approximately 1 mm to 2 mm) (i.e. the more apical the gingival margin
after surgery, the smaller the chance of CRC). Moreover, other anatomic aspects related to
the interproximal dental papillae were already described previously13,14 (see supplementary
Appendix 8 in online Journal of Periodontology). Consequently, all these factors make
comparisons and combination of data from different trials a critical issue.
It has been shown that smoking can affect the results obtained by RC procedures.5 Two
RCTs31,32,59 evaluated only patients who smoked ≥ 10 cigarettes per day for at least 5 years,
and their results showed that heavy smokers may be benefited by RC therapy, as well.
However, MRC and CRC were clearly inferior to the outcomes achieved by trials evaluating
non-smokers (Table 2). Eight trials29,30,40,12,51,73-75 reported the inclusion of smokers who
smoked less than 10 cigarettes per day. None of them performed comparisons between
smokers and non-smokers. Zucchelli et al.10 commented only that patients who smoke more
than 10 cigarettes a day presented the worst percentage of RC. This is in line with included
RCTs on smokers31,32,59 and the data from other studies that have assessed the amount of
RC obtained by smokers and non-smokers through CAF and SCTG.5,3,14
The present version of this Cochrane Review is completely in line with data from the recent
American Academy of Periodontology Regeneration Workshop SR5 that concluded that: 1)
“all RC procedures can provide significant reduction in RD and CAL gain without alteration of

probing depth for Miller Class I and II single GR, but multiple GR seems to be benefit as well
despite the reduced quantity of information available;” 2) “SCTG-based procedures provided
the best outcomes for clinical practice because of their superior percentages of MRC and
CRC and the significant increase of KTW when compared with most of the other procedures”
(as reported by the individual studies‟ outcomes, Table 2); 3) “the use of CAF with ADMG,
EMD, and XCM also provided gains, many of them similar to SCTG-based procedures, and
thus these may be considered as adequate substitute treatment approaches”; and 4)
“smoking may decrease the expected results”.5
It is also important to highlight that recent evidence from three long-term non-randomized
studies, that followed patients for at least 20 years, found that GR relapse appears to be
associated to sites lacking an attached KT band of at least 2mm.80-82 Similarly, a recent SR83
evaluating the long-term outcomes of untreated buccal GR (in terms of associated reported
aesthetic and functional alterations and factors influencing the progression/worsening of
dental and periodontal tissue conditions) found that: a) untreated GR in individuals with good
oral hygiene are highly likely to experience RD increase during long-term follow-up (78% of
the defects displayed clinical worsening); and b) the presence of KTW and/or greater KTW
decrease the chance of RD increase or the development of new recessions. Nonetheless,
individual data from some of the studies included in the present SR suggest that SCTG
promoted better stability of the gingival margin/some degree of creeping attachment over
time, compared to other surgical approaches.12,24,40,51,70
CONCLUSIONS
 All the analyzed RC procedures led to RD reduction and CAL gain and thus can be used
in clinical practice. However, there was a great variability in the percentages of CRC and
MRC.
 The available evidence base indicates that the most suitable options for RC of single GR,
in terms of clinical outcomes and cost-to-benefit ratio, are: (1) SCTG plus CAF; (2) ADMG

plus CAF; (3) EMD + CAF; (4) XCM + CAF; and (5) CAF alone. Despite of the restricted
number of studies on multiple GR included in this SR, this „hierarchy criterion‟ may be
applied for the treatment of such defects, as well.
 GTR could be used to treat single GR, but most the information on these procedures
were obtained from studies published up to the early 2000‟0.
 Individual studies‟ outcomes and the available pooled estimates suggest that SCTG plus
CAF may be considered as „gold standard‟ procedure for the treatment of single and
multiple GR. Moreover, evidence suggests that SCTG promoted better stability of the
gingival margin/some degree of creeping attachment over time, compared to other
surgical approaches.
 ADMG (primarily) and XCM (secondly) may be considered as alternative soft tissue
grafting materials.
 Outcome measures of the evaluated surgical techniques were not improved by the use of
root modification agents or the type of mechanical root scaling during surgery.
 The incidence of adverse effects, such as discomfort with or without pain, was mainly
related to donor sites of SCTG. However, these conditions occurred mainly within the first
week after surgery and did not influence on RC outcomes.
Implications for research
• Limited data exist on ACC related to patient‟s opinion, thus further RCTs are still required
to evaluate this primary outcome variable. The use of the VAS (or other „standardized
scales‟) will allow more precise evaluations of patient-based outcomes.
• Future split-mouth trials should focus on patients‟ preference for a specific RC procedure.
• The inclusion of baseline and final individual defect measurements will allow more precise
evaluations, as well as subgroup evaluations (e.g. patients presenting similar defects) and
future comparisons via meta-analyses. These outcome measures should include GR depth
and width, CAL, KTW and thickness, and root surface conditions (i.e. presence of caries,
abrasions or restorations). Also, in order to draw more robust conclusions about treatment of

sites lacking attached gingiva: a) the number of Miller Class I and II should be balanced and
equally distributed in the study groups (i.e., test and control); and b) the differences in
response to treatment between these sites should be considered.
• Comparisons between different operators (i.e. with respect to the degree of operator‟s
experience) remain necessary to evaluate differences in the expected outcome measures.
• Considering the proposed inclusion criteria, no data were available for LPF and there is
limited information for FGG and platelet-rich fibrin. These procedures might be evaluated by
future research.
ACKNOWLEDGEMENTS
The review authors would like to acknowledge Anne Littlewood for her assistance on the
search strategy section and Helen Worthington, Ian Needleman, Luisa Fernandez
Mauleffinch and Marco Esposito from Cochrane Oral Health for their help with the
preparation of the protocol and full text of the review. We would like to thank Professor Kevin
Seymour from Division of Dentistry, School of Medical Sciences, Faculty of Biology,
Medicine and Health, the University of Manchester for providing comments on this update.
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Figure legends.
Figure 1 - Risk of bias summary: review authors' judgements about each risk of bias item for
each included study.
Figure 2 - „What‟s new‟ table - changes since the last version.
Table 1 - Characteristics of included studies

Study Method Participant Interventions Outcomes Notes
s s
Abolfazli et RCT, 12 1. EMD + CAF GRC*(2), Practice-based
24
al. split- individuals, 2. SCTG + CAF CALC*(2), (Iran)
mouth 8 females, KTC*(2),
design, aged 28 to SCRC,
2 51 years, PCRC*(2),
treatme with 2 MRC*(2)
nt bilateral
groups, Miller Class (Manual
24 I buccal probe)
months' gingival
duration recessions
of at least 3
mm
RCT, 24 1. ADMG + CAF ACC, University/hospi

Ahmedbeyli parallel individuals, 2. CAF GRC*(1), tal-based
25
et al. design, 12 females, CALC*(1) (Turkey)
2 aged 22 to KTC*(1),
treatme 40 years, SCRC,
nt with Miller PCRC, MRC
groups, Class I
12 multiple (Manual
months' buccal probe)
duration gingival
recessions
of at least 3
mm
26
Ayub et al. RCT, 15 1. ADMG (positioned 1 mm apical to GRC*(1), University/hospi
split- individuals, the cemento-enamel junction) + CALC*(1), tal-based
mouth number of CAF (extended flap) KTC, SCRC, (Brazil) and
design, females not 2. ADMG + CAF (extended flap) PCRC, MRC supported by
2 reported, the State of São
treatme aged 20 to (Automated Paulo Research
nt 56 years, controlled Foundation
groups, with 2 force probe and
6 bilateral and manual BioHorizons Inc
months‟ Miller Class probe)
duration I or II buccal
gingival
recessions
of at least 3
mm
Babu et RCT, 10 1. GTR + CAF (collagen membrane GRC, CALC, University/hospi
27
al. split- individuals, - Bioproducts Lab) KTC, MRC tal-based (India)
mouth number of 2. SCTG + CAF
design, females not (Manual
2 reported, probe)
treatme age not
nt reported,
groups, with 2 Miller
6 Class I or II
months‟ buccal
duration gingival
recessions
of at least 3
mm
Barros et RCT, 15 1. ADMG + CAF (extended flap) GRC, CALC, University/hospi
28
al. split- individuals, 2. SCTG + CAF (extended flap) KTC, MRC tal-based
mouth 10 females, (Brazil)
design, aged 23 to (Automated
2 54 years, controlled
treatme with 2 force probe -
nt bilateral 0.50 N)
groups, Miller Class
12 I or II buccal
months‟ gingival
duration recessions
of at least 3
mm
Bouchard RCT, 30 1. SCTG + CAF + CA (graft without ACC, Practice-based
29
et al. parallel individuals, epithelial collar) GRC,CALC, (France)
design, 24 females, 2. SCTG (graft with epithelial collar) KTC, SCRC,
2 aged 21 to PCRC, MRC
treatme 62 years,
nt with 1 Miller (Automated
groups, Class I or II controlled
6 buccal force probe -
months‟ gingival 0.50 N)
duration recession of
at least 3
mm
Bouchard RCT, 30 1. SCTG + CAF + TTC-HCl GRC, CALC, Practice-based
30
et al. parallel individuals, 2. SCTG + CAF + CA KTC, SCRC, (France)
design, 25 females, PCRC, MRC
2 aged 21 to
treatme 70 years, (Automated
nt with 1 Miller controlled
groups, Class I or II force probe -
6 buccal 0.50 N)
months‟ gingival
at least 3
mm
Costa et RCT, 20 1. ADMG + EMD + CAF (extended GRC*(1), University/hospi
31,32
al. split- individuals flap) CALC, KTC, tal-based
mouth (heavy 2. ADMG + CAF (extended flap) SCRC, (Brazil)
design, smokers - > PCRC, MRC
2 10
treatme cigarettes/d (Automated
nt ay for over controlled
groups, 5 years), 12 force probe
6 females, and
months‟ aged 30 to compass)
duration 50 years,
with 2
bilateral
Miller Class
I or II buccal
gingival
recessions
of at least 3
mm
Da Silva et RCT, 11 1. SCTG + CAF GRC, CALC, University/hospi

33
al. split- individuals, 2. CAF KTC*(1), tal-based
mouth 5 females, SCRC, (Brazil)
design, aged 18 to PCRC, MRC Unpublished
2 43 years, data were
treatme with 2 (Automated included
nt bilateral controlled following
groups, Miller Class force probe) contact with
6 I or II buccal author
months‟ gingival
duration recessions
of at least 3
mm

De Queiroz RCT, 13 1. ADMG + CAF GRC, CALC, University/hospi
34,35
et al. split- individuals, 2. CAF KTC, SCRC, tal-based
mouth 7 females, PCRC, MRC (Brazil)
design, mean age (Manual
2 32.8 years, probe)
treatme with 2
nt bilateral
24 I buccal
months‟ gingival
duration recessions
of at least 3
mm
Del Pizzo et RCT, 15 1. EMD + CAF GRC, CALC, University/hospi
11
al. split- individuals, 2. CAF KTC*(1), tal-based (Italy)
mouth 11 females, SCRC,
design, aged 18 to PCRC, MRC
2 56 years,
treatme with 2 (Manual
nt bilateral probe)
24 I or II buccal
months‟ gingival
duration recessions
of at least 3
mm
Dodge et RCT, 12 1. GTR (polylactic acid membrane - GRC, Practice-based
36
al. split- individuals, Guidor) + TTC-HCl + DFDBA CALC*(1), (USA)
mouth 8 females, 2. GTR (polylactic acid membrane - KTC*(1),
design, aged 23 to Guidor) + TTC-HCl SCRC
2 51 years, PCRC, MRC
treatme with 2 Miller
nt Class I or II (Manual
groups, buccal probe)
12 gingival
months‟ recessions
duration of at least 3
mm
Henderson RCT, 10 1. ADMG (connective tissue side GRC, CALC, University/hospi
37
et al. split- individuals, against the tooth) + CAF KTC, MRC tal-based (USA)
mouth 5 females, 2. ADMG (basement membrane and supported
design, aged 24 to side against the tooth) + CAF (Manual by Lifecore
2 68 years, probe) Biomedical
nt Class I or II
groups, buccal
12 gingival
mm
Jaiswal et RCT, 20 1. EMD + CAF GRC*(1), University/hospi
38
al. parallel individuals, 2. CAF CALC*(1), tal-based (India)
design, 8 females, KTC, MRC
2 aged 25 to
nt with Miller controlled
groups, Class II force probe -
6 multiple 15g)
months‟ buccal
duration gingival
recessions
of at least 3
mm

Jankovic et RCT, 20 1. Platelet-rich fibrin + CAF GRC, University/hospi
39
al. split- individuals, 2. EMD + CAF KTC*(2), tal-based
mouth 12 females, SCRC, (Serbia)
design, aged 21 to PCRC, MRC
2 48 years,
treatme with (Manual
nt bilateral probe)
12 I and II
months‟ maxillary
duration buccal
gingival
recessions
of at least 3
mm
Jepsen et RCT, 35 1. XCM + CAF GRC*(1), University/hospi
40
al. split- individuals, 2. CAF CALC, tal-based
mouth age > 18 KTC*(1), (German, Italy,
design, years, with SCRC, Sweden and
2 2 Miller PCRC, MRC Spain) and
treatme Class I or II supported by
nt buccal (Manual Geistlich
groups, gingival probe) Pharma AG
6 recessions
months‟ of at least 3
duration mm
41
Joly et al. RCT, 10 1. ADMG + CAF (flap without GRC*(2), University/hospi
split- individuals, vertical incisions) CALC*(2), tal-based
mouth 4 females, 2. SCTG + CAF (flap without vertical KTC, MRC (Brazil)
design, aged 24 to incisions)
2 68 years, (Manual
treatme with 2Miller probe)
nt Class I or II
groups, maxillary
6 buccal
months‟ gingival
duration recessions
of at least 3
mm
Keceli et RCT, 40 1. SCTG + platelet-rich plasma + GRC, CALC, University/hospi
42
al. parallel individuals, CAF KTC, SCRC, tal-based
design, 30 females, 2. SCTG + CAF PCRC, MRC (Turkey) and
2 aged 18 to supported by
treatme 60 years, (Manual The Research
nt with 1Miller probe) Foundation of
groups, Class I or II Hacettepe
12 buccal University
months‟ gingival
at least 3
mm. 36
individuals
completed
the study
Keceli et RCT, 40 1. SCTG + platelet-rich fibrin + CAF GRC, CALC, University/hospi
43
al. parallel individuals, 2. SCTG + CAF KTC, SCRC, tal-based
design, 27 females, PCRC, (Turkey)
2 aged 22 to MRC*(1)
treatme 50 years,
nt with 1Miller (Manual
groups, Class I or II probe)
6 buccal
months‟ gingival
at least 3
mm

Leknes et RCT, 20 1. GTR (polylactic acid membrane - GRC, CALC, University/hospi
44,45
al. split- individuals, Guidor) KTC, SCRC, tal-based
mouth 10 females, 2. CAF PCRC, MRC (Norway) and
design, mean age membranes
2 38.4 years, (Automated provided by
treatme with controlled Guidor AB
nt 2MillerClass force probe Unpublished
groups, I or II buccal and manual data were
72 gingival probe) included
months‟ recessions following
duration of at least 3 contact with
mm. 11 author
individuals
completed
the study
Matarasso RCT, 20 1. GTR (polylactic acid membrane - GRC, CALC, University/hospi
46
et al. parallel individuals, Guidor) + double papilla flap KTC, MRC tal-based (Italy)
design, 8 females, 2. GTR (polylactic acid membrane - Unpublished
2 aged 18 to Guidor) + CAF (Manual data were
treatme 42 years, probe) included
nt with 1 Miller following
groups, Class I or II contact with
12 buccal author
months‟ gingival
at least 3
mm
McGuire et RCT, 20 1. EMD + CAF GRC, CALC, Practice-based
47,48
al. split- individuals, 2. SCTG + CAF KTC*(2), (USA) and
mouth 10 females, PCRC, MRC supported by
design, aged 23 to BIORA AB
2 62 years, (Manual (currently
treatme with 2 Miller probe) Straumann)
nt Class II Unpublished
groups, maxillary data were
5 years‟ buccal included
duration gingival following
recessions contact with
of at least 4 author
mm. 19
individuals
completed
the 6-month
follow-up,
17
completed
the 12-
month
follow-up,
and 9 the 5-
year follow-
up
McGuire et RCT, 30 1. Beta-tricalcium phosphate (b- ACC, Practice-based
49,50
al. split- individuals, TCP) + recombinant human platelet- GRC*(2), (USA) and
mouth 26 females, derived growth factor-B with a CALC, supported by
design, aged 18 to bioabsorbable collagen wound- KTC*(2), Osteohealth
2 70 years, healing dressing + CAF SCC, PCRC, Unpublished
treatme with 2 Miller 2. SCTG + CAF MRC data were
nt Class II included
groups, buccal (Manual following
5 years‟ gingival probe) contact with
duration recessions author
of at least 3
mm. 30
individuals
completed
the 6

months
follow-up,
whereas
20 the 5
years
follow-up
McGuire et RCT, 25 1. XCM + CAF ACC, Practice-based

12,51
al. split- individuals, 2. SCTG + CAF GRC*(2), (USA) and
mouth 17 females, CALC*(2), supported by
design, aged 18 to KTC, SCC, Giestlich
2 70 years, PCRC, MRC Pharma AG
treatme with 2 Miller Unpublished
nt Class II (Manual data were
groups, buccal probe) included
5 years‟ gingival following
duration recessions contact with
of at least 3 author
mm. 23 Data from
individuals earlier article
completed were reported
the 12 as part of this
months trial
follow-up,
whereas
17 the 5
years
follow-up
Öncü et RCT, 20 1. Platelet-rich fibrin + CAF without GRC, CALC, University/hospi
52
al. split- individuals, vertical incisions KTC*(2), tal-based
mouth 11 females, 2. SCTG + CAF without vertical SCRC, (Turkey)
design, age > 18 incisions PCRC, MRC
2 years, with
treatme maxillary (Manual
nt bilateral probe)
groups, multiple
6 Miller Class
months‟ I or II buccal
duration gingival
recession of
at least 3
mm
Ozenci et RCT, 20 1. ADMG + Tunnel (CAF) ACC*(2), University/hospi
53
al. parallel individuals, 2. ADMG + CAF GRC*(2), tal-based
design, 13 females, CALC*(2), (Turkey)
2 aged 22 to KTC*(2),
treatme 42 years, SCC, PCRC,
nt with Miller MRC
groups, Class I
12 multiple (Manual
months‟ buccal probe)
duration gingival
recessions
of at least 3
mm
Paolantoni RCT, 70 1. SCTG + double papilla flap GRC*(1), Practice-based
54
o et al. parallel individuals, 2. FGG KTC, SCRC, (Italy)
design, 38 females, PCRC, MRC Unpublished
2 aged 25 to data were
treatme 48 years, (Manual included
nt with 1 Miller probe) following
groups, Class I or II contact with
60 buccal author
months‟ gingival

at least 3
mm
Paolantoni RCT, 45 1. GTR (polylactic acid membrane - GRC, CALC, University/hospi

55
o parallel individuals, Guidor) KTC*(3), tal-based (Italy)
design, 31 females, 2. GTR (polylactic acid membrane - SCRC, and supported
3 aged 27 to Paroguide) + PCRC, MRC by
treatme 51 years, hydroxyapatite/collagen/chondroitin ItalianMinistry of
nt with 1Miller sulfate (Manual University and
groups, Class I or II graft probe) Scientific
12 buccal 3. SCTG + double papilla flap Research
months‟ gingival Unpublished
duration recession of data were
at least 3 included
mm following
contact with
author
Paolantoni RCT, 30 1. ADMG + CAF GRC, CALC, University/hospi
56
o et al. parallel individuals, 2. SCTG + CAF KTC*(2), tal-based (Italy)
design, 19 females, SCRC, and supported
2 aged 29 to PCRC, MRC by
treatme 51 years, ItalianMinistry of
nt with 1Miller (Automated University and
groups, Class I or II controlled Scientific
12 buccal force probe - Research
months‟ gingival 20 g and Unpublished
duration recession of calliper) data were
at least 3 included
mm following
contact with
author
Pendor et RCT, 20 1. SCTG + double pedicle flap GRC, CALC, University/hospi
57
al. parallel individuals, 2. SCTG + CAF KTC, SCRC, tal-based (India)
2 aged 25 to
nt with 1 Miller controlled
groups, Class I or II force probe -
6 buccal 15 g and
months‟ gingival calliper)
at least 3
mm
Rasperini RCT, 56 1. EMD + SCTG + CAF GRC, CALC, University/hospi
58
et al. parallel individuals, 2. SCTG + CAF KTC, SCRC, tal-based (Italy)
2 mean 35.5
treatme years, with (Manual
nt 1 Miller probe)
groups, Class I or II
12 buccal
months‟ gingival
at least 3
mm
Reino et RCT, 12 1. SCTG + CAF (extended flap) SCRC, University/hospi
59
al. split- individuals 2. SCTG + CAF PCRC, MRC tal-based
mouth (heavy (Brazil) and
design, smokers - > (Automated supported by
2 20 controlled the State of São
treatme cigarettes force probe Paulo Research
nt per day for and manual Foundation,
groups, more than 5 probe) São Paulo,
6 years), 10 Brazil
months‟ females,

duration aged 35 to
50 years,
with 2
bilateral
Miller Class
I or II buccal
gingival
recessions
of at least 3
mm
Reino et RCT, 20 1. XCM + CAF (extended flap) GRC*(1), University/hospi
60
al. split- individuals, 2. XCM + CAF CALC, KTC, tal-based
mouth 14 females, MRC (Brazil) and
design, aged 26 to supported by
2 46 years, (Automated the State of São
treatme with 2 controlled Paulo Research
nt bilateral force probe Foundation,
groups, Miller Class and calliper) São Paulo,
6 I or II buccal Brazil and
months‟ gingival Geistlich
duration recessions Pharma AG
of at least 3
mm
Roccuzzo RCT, 12 1. GTR (polylactic acid membrane - GRC, CALC, University/hospi
9
et al. split- individuals, Guidor) KTC, SCRC, tal-based (Italy)
mouth 3 females, 2. GTR (ePTFE membrane - Gore- PCRC, MRC
design, aged 21 to Tex)
2 31 years, (Manual
treatme with 2 Miller probe)
nt Class I or II
groups, buccal
6 gingival
mm
Rossetti et RCT, 12 1. GTR (collagen membrane) + ACC, GRC, University/hospi
61,62
al. split- individuals, TTC-HCl + DFDBA CALC, tal-based
mouth 9 females, 2. SCTG + HCl KTC*(2), (Brazil) and
design, aged 25 to MRC supported by
2 60 years, Brazilian
treatme with 2 Miller (Manual National Council
nt Class I or II probe) for Scientific
groups, buccal and
30 gingival Technologic
months‟ recessions Development
mm
Sangiorgio RCT, 68 1. XCM + CAF ACC, University/hospi
62,64
et al. parallel individuals, 2. EMD + CAF GRC*(Group tal-based and
design, aged 18 to 3. XCM + EMD + CAF s 1, 2 and 3 supported by
4 60 years, 4. CAF were the State of São
treatme with 1 superior to Paulo Research
nt maxillary 4), CALC, Foundation,
groups, Miller Class KTC São Paulo,
6 I or II buccal SCRC, Brazil
months‟ gingival PCRC*(Grou
duration recession of ps 2 and 3
at least 3 were
mm superior to
4), MRC*
(Groups 1, 2
and 3 were
superior to 4)
(Manual
probe and
digital

calliper)
Shori et RCT, 20 1. ADMG + CAF GRC, CALC, University/hospi

65
al. parallel individuals, 2. SCTG + CAF KTC*(2), tal-based (India)
design, aged 18 to SCR, PCRC,
2 50 years, MRC
nt Class I or II (Automated
groups, buccal controlled
6 gingival force probe)
mm
Spahr et RCT, 37 1. EMD + CAF GRC, CALC, University/hospi
66,67
al. split- individuals, 2. Placebo (propylene glycol KTC, PCRC, tal-based
mouth 17 females, alginate) + CA MRC (Germany)and
design, aged 22 to supported by
2 62 years, (Automated BIORA AB
treatme with 2 Miller controlled (currently
nt Class I or II force probe, Straumann)
groups, buccal calliper and
24 gingival manual
months‟ recessions probe)
mm. 30
individuals
completed
the study
Tözum et RCT, 31 1. SCTG + modified tunnel GRC*(1), University/hospi
68
al. parallel individuals, procedure CALC*(1), tal-based
design, 21 females, 2. SCTG + CAF MRC (Turkey)
2 aged 16 to Unpublished
treatme 59 years, (Manual data were
nt with 1 Miller probe) included
groups, Class I or II following
6 buccal contact with
months‟ gingival author
at least 3
mm
Trombelli RCT, 15 1. CAF (fibrin glue + TTC-HCl) GRC, CALC, University/hospi
69
et al. split- individuals, 2. CAF (TTC-HCl) KTC, SCRC, tal-based (Italy)
mouth 3 females, PCRC, MRC and supported
design, aged 25 to by Italian
2 51 years, (Manual Ministry of
treatme with 2 Miller probe) University and
nt Class I or II Scientific
groups, maxillary Research
6 buccal
months‟ gingival
duration recessions
of at least 3
mm

Tunali et RCT, 10 1. Leukocyte- and platelet-rich fibrin GRC, CALC, University/hospi
70
al. split- individuals, + CAF KTC, SCRC, tal-based (Italy)
mouth 6 female, 2. SCTG + CAF PCRC, MRC Unpublished
design, aged 25 to data were
2 52 years, (Manual included
treatme with 2 Miller probe) following
nt Class I or II contact with
groups, multiple author
12 buccal
months‟ gingival
duration recessions
of at least 3
mm
Wang et RCT, 16 1. GTR (reabsorbable double ACC, GRC, University/hospi
71
al. split- individuals, thickness collagen membrane - CALC, KTC, tal-based (USA)
mouth 10 females, Sulzer Dental Inc) MRC and supported
design, aged 30 to 2. SCTG + CAF by Sulzer
2 54 years, (Manual Calcitek Inc
treatme with 2 Miller probe)
nt Class I or II
groups, buccal
6 gingival
mm
Woodyard RCT, 24 1. ADMG + CAF GRC*(1), University/hospi
8
et al. parallel individuals, 2. CAF CALC*(1), tal-based (USA)
design, 14 KTC, SCRC,
2 females,me PCRC, MRC
treatme an age 34.6
nt years, with (Manual
groups, 1 Miller probe)
6 Class I or II
months‟ buccal
duration gingival
recession of
at least 3
mm
Zucchelli et RCT, 54 1. GTR (polylactic acid membrane - GRC, CALC, University/hospi
10
al. parallel individuals, Guidor) KTC*(3), tal-based (Italy)
design, 29 females, 2. GTR (ePTFE membrane - Gore- SCRC,
3 aged 23 to Tex) PCRC, MRC
treatme 33 years, 3. SCTG + CAF
nt with 1 Miller (Manual
groups, Class I or II probe)
12 buccal
months‟ gingival
at least 3
mm
Zucchelli et RCT, 15 1. SCTG (graft size equal to the ACC, GRC, University/hospi
72
al. split- individuals, bone dehiscence) + CAF CALC*(1), tal-based (Italy)
mouth aged 18 to 2. SCTG (graft size 3 mm greater KTC*(2),
design, 35 years, than the bone dehiscence) + CAF SCRC,
2 with 2 Miller PCRC, MRC
treatme Class I or II
nt maxillary (Manual
groups, buccal pressure
12 gingival sensitive
months‟ recessions probe)
mm
Zucchelli et RCT, 11 1. Ultrasonic instrumentation - CAF GRC, CALC, University/hospi
73
al. split- individuals, 2. Hand instrumentation – CAF KTC, SCRC, tal-based (Italy)
mouth aged 18 to PCRC, MRC
design, 40 years,
2 with 2 Miller (Manual

treatme Class I pressure
nt maxillary sensitive
groups, buccal probe)
6 gingival
mm
Zucchelli et RCT, 60 1. SCTG (de-epithelialized free ACC, GRC, University/hospi
74
al. parallel individuals, gingival graft: graft height equal to CALC, KTC, tal-based (Italy)
design, aged > 18 the depth of bone dehiscence and SCRC,
2 years, with thickness ≥ 2 mm) + CAF PCRC, MRC
treatme 1 Miller 2. SCTG (de-epithelialized free
nt Class I or II gingival graft: graft height of 4 mm (Manual
groups, maxillary thickness < 2 mm ) + CAF probe)
12 buccal
months‟ gingival
at least 3
mm
Zucchelli et RCT, 50 1. SCTG + CAF - with removal of ACC*(1), University/hospi
75
al. parallel individuals, the labial submucosal tissue GRC*(1), tal-based
design, 28 females, 2. SCTG + CAF - without removal of CALC,
2 age > 18 the labial submucosal tissue KTC*(2),
treatme years, with SCRC,
nt 1 Miller PCRC, MRC
groups, Class I or II
12 gingival (Manual
months‟ recession of probe and
duration at least 3 calliper)
mm at the
buccal
aspect of
lower
incisors
ACC: aesthetic condition change; ADMG: acellular dermal matrix graft; CA: citric acid; CAF: coronally advanced
flap; CALC: clinical attachment change; DFDBA: demineralized freeze-dried bone allograft; EMD: enamel matrix
derivative; ePTFE: expanded polytetrafluorethylene; FGG: free gingival graft; GRC: gingival recession change;
GTR: guided tissue regeneration; KTC: keratinized tissue change; MRC: mean root coverage; PCRC: percentage
of complete root coverage; RCT: randomized controlled trial; SCRC: sites with complete root coverage; SCTG:
subepithelial connective tissue graft; TTC-HCl: tetracycline hydrochloride; XCM - xenogeneic collagen matrix.
*statistically significant between-groups (superior group).

Table 2 - Root coverage outcomes (i.e., complete root coverage and mean root coverage)
and aesthetic condition change
Study Interventions SCRC PCRC MRC ACC
Abolfazli et EMD + CAF (12 months) NR NR 77.7 NR
24
al.
(single GR)
SCTG + CAF (12 months) NR NR 83.4
EMD + CAF (24 months) 3/12 25.0 76.9
SCTG + CAF (24 months) 8/12 66.6 93.1

Ahmedbeyli ADMG + CAF 11/12 83.3 94.8 The authors asked each
25
et al.
(multiple GR) patient about different
CAF 6/12 50.0 74.9
patient-reported outcomes
(i.e. root coverage attained,
color of gums, shape and
contour of gums), and both
procedures were rated
equally in all aspects
26
Ayub et al. ADMG (1 mm apical to the CEJ) + CAF 4/15 26.6 88.4 NR
(single GR)
(extended flap)
0/15 0 65.8
ADMG + CAF (extended flap)
27
Babu et al. GTR (collagen membrane) + CAF NR NR 84.0 NR
(single GR)
SCTG + CAF NR NR 84.8
Barros et ADMG + CAF (extended flap) NR NR 80.7 NR

28 (single GR)
al.
SCTG + CAF (extended flap) NR NR 78.7
Bouchard et SCTG + CAF + citric acid (graft without 3/15 20.0 69.7 Aesthetic evaluation was
29
al. epithelial collar)
(single GR) performed by 2 independent
5/15 33.3 64.7
SCTG (graft with epithelial collar) examiners who were blinded
to the given treatment.
Additionally, the authors
commented that no patient
was dissatisfied with the
aesthetical results obtained
Bouchard et SCTG + CAF + tetracycline 6/15 40.0 79.3 NR
30
al. hydrochloride
(single GR)
8/15 53.3 84.0
SCTG + CAF + citric acid
Costa et ADMG + EMD + CAF (6 months) 3/19 15.8 55.4 NR
31,32
al.
(single GR)
ADMG + CAF (6 months) 1/19 5.3 44.0
ADMG + EMD + CAF (12 months) 3/19 59.7
ADMG + CAF (12 months) 1/19 52.8

da Silva et SCTG + CAF 2/11 18.1 75.3 NR
33
al.
(single GR)
CAF 1/11 9.0 68.8
de Queiroz et ADMG + CAF (6 months) 3/13 23.0 76.0 NR

34,35
al.
(single GR)
CAF (6 months) 3/13 23.0 71.0
ADMG + CAF (12 months) 2/13 15.3 71.0
CAF (12 months) 2/13 15.3 66.7
ADMG + CAF (24 months) 1/13 7.7 68.4
CAF (24 months) 1/13 7.7 55.9
Del Pizzo et EMD + CAF 11/15 73.3 90.7 NR

11
al.
(single GR)
CAF 9/15 60.0 86.7
36
Dodge et al. GTR (polylactide membrane - Guidor) + 6/12 50.0 89.9 NR
(single GR)
tetracycline hydrochloride + DFDBA +
CAF 4/12 33.3 73.7
GTR (polylactide membrane - Guidor) +

tetracycline hydrochloride + CAF
Henderson et ADMG (basement membrane side 7/10 70.0 94.9 NR
37
al. against the tooth) + CAF
(single GR)
8/10 80.0 95.5
ADMG (connective tissue side against
the tooth) + CAF
Jaiswal et EMD + CAF NR NR 86.3 NR
38
al.
(multiple GR)
CAF NR NR 79.6
Jankovic et Platelet-rich fibrin + CAF 12/20 60.0 72.1 NR

39
al.
(single GR)
EMD + CAF 13/20 65.0 70.5
Jepsen et XCM + CAF 29/35 82.8 72.0 NR

40
al.
(single GR)
CAF 17/35 48.6 66.2
41
Joly et al. ADMG + CAF (without vertical incisions) NR NR 50.0 NR
(single GR)
SCTG + CAF (without vertical incisions) NR NR 79.5

42
Keceli et al. SCTG + platelet-rich plasma + CAF 6/17 35.3 86.4 NR
(single GR)
SCTG + CAF 8/19 42.1 86.4

43
Keceli et al. SCTG + platelet-rich fibrin + CAF 11/20 55.0% 89.6 NR
(single GR)
SCTG + CAF 7/20 35.0% 79.9

Leknes et GTR (polylactide membrane - Guidor) (6 5/20 25.0 51.2 NR
44,45
al. months) + CAF
(single GR)
10/20 50.0 63.8
CAF (6 months)
4/20 20.0 51.2
GTR (polylactide membrane - Guidor)
(12 months) + CAF 6/20 30.0 61.1
CAF (12 months) 2/11 18.2 35.0
GTR (polylactide membrane - Guidor) 1/11 9.1 34.2

(72 months) + CAF
CAF (72 months)

Matarasso et GTR (polylactide membrane - Guidor) + NR NR 73.9 NR
46
al. double papilla flap
(single GR)
NR NR 62.5
GTR (polylactide membrane - Guidor) +
CAF
McGuire et EMD + CAF (6 months) 17/19 89.5 95.1 Ten years after surgery
47,48
al.
(single GR) patients were asked to
SCTG + CAF (6 months) 15/19 79.0 93.8
respond to questions related
EMD + CAF (10 years) 5/9 55.6 83.3 to aesthetic satisfaction. Six
patients had no preference
SCTG + CAF (10 years) 7/9 77.8 89.8
for a particular type of
treatment, two favored
aesthetic results with the test
treatment (i.e. EMD + CAF),
and one favored results with
the control treatment (SCTG
+ CAF) (P = 0.564).
McGuire et B-TCP + CD with rhPDGF-BB + CAF (6 NR NR 90.8 At 6 months, patients
49,50
al. months)
(single GR) aesthetic rating by 10 cm
NR NR 98.6
SCTG + CAF (6 months) visual analogue scale did not
12/20 60.0 74.1 identify differences in the
B-TCP + CD with rhPDGF-BB + CAF (5 clinical rating of color/texture
years) 15/20 75.0 89.3
of the tissues observed
SCTG + CAF (5 years) between the treatments. At 5
years, of the 20 test and 20
control sites, "14 sites for
each were rated as 'very
satisfied.' In the test group, 4
sites were rated as 'satisfied,'
1 as 'unsatisfied,' and 1 as
'very unsatisfied.' In the
control group, the remaining
6 sites were rated as
'satisfied'

McGuire et XCM + CAF (6 months) 15/25 60.0 83.5 Patients rated equivalent
12,51
al.
(single GR) aesthetic changes from
SCTG + CAF (6 months) 23/25 92.0 97.0
baseline to 6 months for XCM
XCM + CAF (12 months) 17/23 73.9 88.5 + CAF versus SCTG + CAF
(overall, "for both test and
SCTG + CAF (12 months) 22/23 95.6 99.3
control treatments, > 90% of
XCM + CAF (5 years) 9/17 52.9 77.6 subjects recorded

improvement"). Similarly,
SCTG + CAF (5 years) 15/17 88.2 95.5 approximately 90% of
patients (15 XCM + CAF and
16 SCTG + CAF) remained
"satisfied or very satisfied" 5
year after root coverage
therapy and no statistical
difference in satisfaction was
reported
52
Öncü et al. Platelet-rich fibrin + CAF (6 months) 15/30(t) 50.0 77.1 NR
(mutiple GR)
SCTG + CAF (6 months) 18/30(t) 60.0 84.0

Ozenci et ADMG + CAF (tunnel) 12/31(t) 37.4(t) 75.7 A similar overall patient
53 (multiple GR)
al.
satisfaction was recorded for
ADMG + CAF (without vertical realising 23/27(t) 85.0(t) 93.8
incisions) patients with multiple
recession-type defects
treated by ADMG + coronally
advanced tunnel flap or
ADMG + CAF (without
vertical releasing incisions)
(P > 0.05)
Paolantonio SCTG + double papilla flap 17/35 48.6 85.2 NR

54
et al.
(single GR)
FGG 3/35 8.6 53.2
55
Paolantonio GTR (polylactide membrane - Guidor) + 6/15 40.0 81.0 NR
(single GR)
CAF
8/15 53.3 87.1
GTR (polylactic acid membrane -
Paroguide) + 9/15 60.0 90.0
hydroxyapatite/collagen/chondroitin-
sulphate graft + CAF
SCTG + double papilla flap
Paolantonio ADMG + CAF 4/15 26.6 83.3 NR

56
et al.
(single GR)
SCTG + CAF 7/15 46.6 88.8

Pendor et SCTG + double papilla flap 6/10 60.0 88.0 NR
57
al.
(single GR)
SCTG + CAF 6/10 60.0 84.7
Rasperini et SCTG + EMD + CAF 16/26 61.5 90.7 NR

58
al.
(single GR)
SCTG + CAF 14/30 46.6 76.6
59
Reino et al. SCTG + CAF (extended flap) 2/20 10.0 44.5 NR
(single GR)
SCTG + CAF 0/20 0 43.2
60
Reino et al. XCM + CAF (extended flap) NR NR 81.9 NR
(single GR)
XCM + CAF NR NR 62.8
Roccuzzo et GTR (polylactic acid membrane - 5/12 41.6 82.4 NR

9
al. Guidor) + CAF
(single GR)
5/12 41.6 82.4
GTR (ePTFE membrane - Gore-Tex) +
CAF
Rosetti et GTR (collagen membrane) + NR NR 84.2 Aesthetical evaluation was

61,62
al. tetracycline hydrochloride + DFDBA +
(single GR) performed by five examiners
CAF (18 months) NR NR 95.6
who were not participating in
SCTG + tetracycline hydrochloride (18 NR NR 87.0 the study. In this study, the
months)
authors have mentioned only
NR NR 95.5
GTR (collagen membrane) + that the patient satisfaction
tetracycline hydrochloride + DFDBA + survey indicated that all
CAF (30 months)
patients were satisfied with
SCTG + tetracycline hydrochloride (30 the aesthetic results achieved
months)
by both procedures at 18
months post-surgery. In
addition, no significant
differences were identified
between the 18 and 30
months assessments.
Sangiorgio et XCM + CAF 9/17 52.9 87.2 The reported the results of
63,64
al.
(single GR) root coverage aesthetics and
EMD + CAF 12/17 70.6 88.8
overall aesthetic results
XCM + EMD + CAF 10/17 58.8 91.6 evaluated by each patient
with the assistance of a VAS.
CAF 4/17 23.5 68.0
In terms of root coverage
aesthetics both treatment
approaches showed
evidence of similar
improvements between
baseline and 6-month

evaluation. Regarding overall
aesthetic results following
treatment, there was
evidence of equivalent
outcomes for all groups (i.e.
similar aesthetics).
65
Shori et al. ADMG + CAF NR NR 86.9 NR
(single GR)
Spahr et EMD + CAF (6 months) NR NR 80.0 NR

66,67
al.
(single GR)
Placebo (propylene glycol alginate) + NR NR 79.0
CAF (6 months)
NR NR 80.0
EMD + CAF (12 months)
NR NR 79.0
Placebo (propylene glycol alginate) +
CAF (12 months) NR 53.0 84.0
EMD + CAF (24 months) NR 23.0 67.0
Placebo (propylene glycol alginate) +

CAF (24 months)
Tozum et SCTG + modified tunnel procedure NR NR 96.4 NR

68 (single GR)
al.
Trombeli et CAF + fibrin glue + tetracycline 1/11 9.1 63.1 NR

69
al. hydrochloride
(single GR)
2/11 18.2 52.9
CAF + tetracycline hydrochloride
70
Tunali et al. Leukocyte- and platelet-rich fibrin + CAF 4/22(t) 18.2 74.6 NR
(multiple GR)
(6 months)
2/22(t) 9.1 74.1
SCTG + CAF (6 months)
3/22(t) 13.6 76.6
Leukocyte- and platelet-rich fibrin + CAF
(12 months) 4/22(t) 18.2 77.4
SCTG + CAF (12 months)

71
Wang et al. GTR (reabsorbable double thickness 7/16 43.8 73.0 NR
(single GR)
collagen membrane - Sulzer Dental Inc)
+ CAF 7/16 43.8 84.0
SCTG + CAF
Woodyard et ADMG + CAF 11/12 91.6 96.0 NR
8
al.
(single GR)
CAF 4/12 33.3 67.0

Zucchelli et GTR (polylactic acid membrane - 7/18 39.0 85.7 NR
10
al. Guidor) + CAF
(single GR)
5/18 28.0 80.5
GTR (ePTFE membrane - Gore-Tex) +
CAF 12/18 66.0 93.5
SCTG + CAF
Zucchelli et SCTG (graft size equal to the bone 13/15 86.7 97.3 The results obtained at the
72
al. dehiscence) + CAF
(single GR) 12-month follow-up visit
12/15 80.0 94.7
SCTG (graft size 3 mm greater than the showed that patients were
bone dehiscence) + CAF more satisfied with the
appearance of test-treated
recessions (i.e. graft
dimension equal to the depth
of the bone dehiscence), as
well as, less satisfied with
poor color blending and
excessive thickness of the
control-treated recessions
(i.e. graft dimension 3 mm
greater than the depth of the
bone dehiscence
Zucchelli et Ultrasonic scaling + CAF 6/11 54.5 84.2 NR
73
al.
(single GR)
Manual/hand scaling + CAF 9/11 81.8 95.4
Zucchelli et SCTG (de-epithelialized FGG (graft 25/30 83.3 96.3 Based on a visual analogue
74
al. height of 4 mm and thickness < 2 mm))
(single GR) scale, the authors did not
+ CAF 24/30 80.0 96.7
identify differences in terms
SCTG (de-epithelialized FGG (graft of patient root coverage
height > 4 mm and thickness > 2 mm) )
+ CAF aesthetic assessment 12
months after surgery
between sites treated with
SCTG (de-epithelialized FGG
(graft height of 4 mm and
thickness < 2 mm)) + CAF
versus SCTG (de-
epithelialized FGG (graft
height > 4 mm and thickness
> 2 mm)) + CAF. Overall,
both procedures led to high
aesthetic results, but color
match scores were higher for
patients receiving reduced
size grafts (P < 0.01)
Zucchelli et SCTG + CAF (removal of the labial 22/25 88.0 97.8 The outcomes achieved with
75
al. submucosal tissue)
(single GR) a visual analogue scale did
12/25 48.0 82.8

SCTG + CAF not show differences
between procedures in terms
of root coverage, but color
match was identified by
patients as better when the
labial submucosal tissue was
removed
ADMG: acellular dermal matrix graft; B-TCP: Beta-tricalcium phosphate; CAF: coronally advanced flap; CEJ: cemento-
enamel junction; DFDBA: demineralized freeze-dried bone allograft; EMD: enamel matrix derivative; ePTFE: expanded
polytetrafluorethylene; FGG: free gingival graft; GTR: guided tissue regeneration; MRC: mean root coverage; NR: not
reported; PCRC: percentage of complete root coverage; rhPDGF-BB: recombinant human platelet-derived growth
factor-BB; SCRC: sites with complete root coverage; SCTG: subepithelial connective tissue graft; t: teeth; XCM:
xenogeneic collagen matrix;

Table 3 – Summary of meta-analyses
Comparison Outcome Statistical method Effect size Chi2 P value (Q) I2 (%)
ADMG + CAF versus GR depth change MD 95% CI -0.36 (-1.03, 0.30) 15.06 0.002 80.0
SCTG + CAF28,41,56,65 CAL change MD 95% CI -0.53 (-1.14, 0.08) 9.73 0.02 69.0
(single GR) KT width change MD 95% CI -0.59 (-1.27, 0.10) 17.17 0.0007 83.0
SCRC OR 95% CI 0.43 (0.13, 1.37) 0.00 0.96 0
ADMG + CAF versus GR depth change MD 95% CI 0.61 (-0.52, 1.73) 7.45 0.006 87.0
CAF8,35 CAL change MD 95% CI 0.51 (-0.25, 1.27) 2.32 0.13 57.0
(single GR) KT width change MD 95% CI 0.28 (-0.08, 0.64) 0.30 0.59 0
SCRC OR 95% CI 3.97 (0.20, 80.50) 5.03 0.02 80.0
EMD + CAF versus GR depth change MD 95% CI 0.07 (-0.25, 0.40) 5.62 0.06 64.0
CAF11,64,67 (*) CAL change MD 95% CI 0.22 (-0.02, 0.45) 1.57 0.46 0
(single GR) KT width change MD 95% CI 0.35 (0.13, 0.56) 0.64 0.73 0
EMD + CAF versus CAF GR depth change MD 95% CI 0.32 (0.10, 0.55) 2.10 0.35 5.0
(2)11,64,67 (**) CAL change MD 95% CI 0.35 (0.09, 0.61) 1.25 0.53 0
(single GR) KT width change MD 95% CI 0.40 (0.17, 0.62) 1.63 0.44 0
EMD + CAF versus GR depth change MD 95% CI -0.39 (-1.27, 0.48) 25.79 <0.00001 96.0
SCTG + CAF24,48 CAL change MD 95% CI -0.25 (-0.69, 0.20) 2.95 0.09 66.0
(single GR) KT width change MD 95% CI -1.06 (-1.36, -0.76) 2.47 0.12 59.0
SCRC OR 95% CI 0.61 (0.05, 7.86) 7.86 0.005 87.0
GTR rm + CAF versus GR depth change MD 95% CI -0.37 (-0.60, -0.13) 0.25 0.88 0
SCTG + CAF10,55,71 CAL change MD 95% CI 0.35 (0.06, 0.63) 0.93 0.63 0
(single GR) KT width change MD 95% CI -1.77 (-2.66, -0.89) 15.84 0.0004 87.0
SCRC OR 95% CI 0.61 (0.30, 1.24) 2.01 0.37 0
GTR rm + CAF versus GR depth change MD 95% CI 0.23 (-0.22, 0.68) 1.59 0.21 37.0
GTR nrm + CAF9,10 CAL change MD 95% CI 0.12 (-0.37, 0.60) 0.28 0.60 0
(single GR) KT width change MD 95% CI 0.12 (-0.23, 0.48) 0.03 0.86 0
SCRC OR 95% CI 1.33 (0.46, 3.85) 0.21 0.65 0
GTR rm associated with GR depth change MD 95% CI -0.82 (-2.13, 0.49) 9.92 0.002 90.0
bone substitutes + CAF CAL change MD 95% CI -0.52 (-1.34, 0.30) 2.72 0.10 63.0
versus SCTG + CAF55,61 KT width change MD 95% CI -2.38 (-2.84, -1.92) 1.86 0.17 46.0
(single GR)
GTR rm associated with GR depth change MD 95% CI 0.48 (0.09, 0.88) 0.10 0.76 0
bone substitutes + CAF CAL change MD 95% CI 0.76 (-0.01, 1.54) 2.83 0.09 65.0
versus GTR rm + KT width change MD 95% CI 0.23 (-0.21, 0.68) 1.63 0.20 39.0
CAF36,55 SCRC OR 95% CI 1.87 (0.75, 4.64) 0.03 0.87 0
(single GR)
XCM + CAF versus GR depth change MD 95% CI 0.40 (0.11, 0.68) 0.86 0.35 0
CAF40,64 CAL change MD 95% CI 0.37 (-0.09, 0.83) 1.70 0.19 41.0
(single GR) KT width change MD 95% CI 0.44 (0.04, 0.85) 1.16 0.28 14.0
SCRC OR 95% CI 4.73 (2.35, 9.50) 0.16 0.69 0
PRF + CAF versus GR depth change MD 95% CI -0.01 (-0.89, 0.86) 14.71 0.0001 93.0
SCTG + CAF52,70 CAL change MD 95% CI -0.37 (-0.69, -0.06) 0.58 0.45 0
(multiple GR) KT width change MD 95% CI -0.26 (-0.98, 0.45) 13.41 0.0003 93.0
ADMG: acellular dermal matrix graft; CAF: coronally advanced flap; CAL: clinical attachment level; CI: confidence interval; EMD: enamel matrix
derivative; GR: gingival recession; GTR rm: guided tissue regeneration resorbable membrane; GTR nrm: guided tissue regeneration non-
resorbable membrane; KT: keratinized tissue; MD: mean difference; OR: odds ratio; PRF: platelet-rich fibrin; SCRC: sites with complete root
coverage; SCTG: subepithelial connective tissue graft; XCM: xenogeneic collagen matrix.
Authors‟ Note: Analyses were performed according to the follow-up evaluation (i.e. short term (6 months follow-up preferably) in the majority of
comparisons, except for two comparisons: EMP + CAF versus CAF where the data were derived from short-term (6 months64)* and medium-term
(24 months11,67)** measurements; and EMP + CAF versus SCTG + CAF where the data from mean changes from baseline (i.e. gingival
recession, clinical attachment level and keratinized tissue width) were derived from short-term measurements, whereas sites with complete root
coverage the data were derived from 6-month48 and 24-month24 measurements.

Figure 2: „What‟s new‟ table - changes since the last version.
Description
 Changes to the original protocol

 Title: Inclusion of 'multiple' defects
 Objectives: 'effectiveness' was changed to 'efficacy'
 Type of interventions: Assessment of CAF + different biomaterial
 Type of outcomes: 'number/percentage of sites achieving complete root
coverage' became a primary outcome
 Type of outcomes: studies with follow-up >12 months and <60 months were
considered as medium-term trials, whereas RCT with follow-up > 60 months of
long-term.
 Search methods for identification of studies: Searches were updated up to
January 16, 2018
 Assessment of risk of bias in included studies: Risk of bias assessment was
updated to follow the current version of the Cochrane Handbook
 GRADE methods were used to assess the quality of the body of evidence of
our main comparisons (i.e., SCTG-based procedures versus other root
coverage procedures and CAF versus other biomaterials)
 Inclusion of 24 new RCTs (50% of the total number of included studies)
 Outcomes on smokers were provided by two RCTs
 Data from 20 RCTs were included into the meta-analyses
 Inclusion of outcomes from multiple recession-type defects and data from
xenogeneic collagen matrix
 Three new comparisons added; EMD + CAF versus SCTG + CAF and XCM +
CAF versus CAF for the treatment of single gingival recessions and PRF + CAF
versus SCTG + CAF for the treatment of multiple recession-type defects

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Root coverage procedures for treating single and multiple recession-type

defects: A Cochrane Systematic Review Updated

Leandro Chambrone,* Maria Aparecida Salinas Ortega,* Flávia Sukekava, † Roberto

*MSc Dentistry Program, Ibirapuera University, São Paulo, Brazil

‡ Unit of Periodontology, UCL Eastman Dental Institute, London, UK

Dr. Leandro Chambrone, Rua da Moóca, 2518, cj13

03104-002, São Paulo, SP, Brazil.

Words: 3,887 Number of tables: 3 Number of Figures: 2 References: 83

Number of online supplemental appendixes: 8

Short running title: Treatment of recession type-defects

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months‟ duration evaluating Miller‟s Class I or II GR (≥ 3 mm) treated by means of RC

analyses were conducted thoroughly.

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authors reported that different surgical techniques led to statistically significant

when RC is indicated, subepithelial connective tissue grafts (SCTG), should be considered

studied since the late 1990s to treat GR.

the Cochrane Database of Systemtatic Reviews in 200913 and in the Journal of

treatment of single and multiple GR.

MATERIALS & METHODS

Criteria for considering studies for this review

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examination (with a follow-up < 5 years).

were not included.

non-resorbable membranes [nrm]), EMD, XCM or other biomaterial. In addition, RCTs

Outcome measures: Primary outcome measures included aesthetic condition change

occurrence of adverse effects and/or postoperative complications. Outcome measures were

separated into short-term (as evaluated 6 months to 12 months following interventions),

medium-term (13 months to 59 months) or long-term (≥ 5 years).

1 in online Journal of Periodontology).

Data collection and analysis

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Variance imputation methods were conducted to estimate appropriate variance estimates in

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heterogeneity and the I2 statistic.

on single GR involving the "gold-standard" procedure (i.e., SCTG-based procedures

'Summary of findings' tables (www.guidelinedevelopment.org). The quality of the

Results of the search and included studies

Forty-eight studies (reported in 57 papers8-12,24-75) were included in the review, with 20

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outcomes).12,31,32,34,35,44,45,47-51,61-64,66,67 Consequently, the papers with a shorter follow-up

up),32,35,45,48,50,51,61,67 while one article reporting patient-reported outcomes was included

publications with medium-term follow-up11,24,35,61,67 and five with long-term follow-up45,48,50,51,54

modalities are depicted in Table 1.

Risk of bias in included studies

imprecision and inconsistency (see supplementary Appendix 4 in online Journal of

reported in 10 RCTs25,29,48,50,51,53,61,72,74,75 (Table 2) Given the heterogeneity of

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presented in supplementary Appendix 5 in online Journal.

CAF (P = 0.02, MD: -0.37 mm).

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of CAF alone (OR of 4.73, 95% CI 2.35 to 9.50).

Patients’ preference for a specific RC procedure in split-mouth trials

Occurrence of adverse effects and/or postoperative complications

Occurrence of adverse effects and/or postoperative complications during the postsurgical

period was reported in 15 trials,12,28,36,39,40,42,45,47,49,52,66,71,72,74,75 but restricted to a limited

number of patients/cases (see supplementary Appendix 7 in online Journal). Overall, the

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to patients‟ opinion.12,24,29,47-51,53,61,62,72,74,75 In these studies, the majority of the patients were