Root coverage procedures for the treatment of …...Root coverage procedures for the treatment of localised recession-type defects Gingival recession is a term that designates the

Root coverage procedures for the treatment of localised

recession-type defects (Review)

Chambrone L, Sukekava F, Araújo MG, Pustiglioni FE, Chambrone LA, Lima LA

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2009, Issue 2

http://www.thecochranelibrary.com

Root coverage procedures for the treatment of localised recession-type defects (Review)

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

44DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 ADMG versus SCTG - Short term, Outcome 1 Gingival recession change. . . . . . 46

Analysis 1.2. Comparison 1 ADMG versus SCTG - Short term, Outcome 2 Clinical attachment level change. . . . 48

Analysis 1.3. Comparison 1 ADMG versus SCTG - Short term, Outcome 3 Keratinized tissue change. . . . . . 49

Analysis 2.1. Comparison 2 ADMG versus CAF - Short term, Outcome 1 Gingival recession change. . . . . . . 51

Analysis 2.2. Comparison 2 ADMG versus CAF - Short term, Outcome 2 Clinical attachment change. . . . . . 52

Analysis 2.3. Comparison 2 ADMG versus CAF - Short term, Outcome 3 Keratinized tissue change. . . . . . . 54

Analysis 2.4. Comparison 2 ADMG versus CAF - Short term, Outcome 4 Sites with complete root coverage. . . . 55

Analysis 3.1. Comparison 3 EMP + CAF versus CAF - Long term, Outcome 1 Gingival recession change. . . . . 56

Analysis 3.2. Comparison 3 EMP + CAF versus CAF - Long term, Outcome 2 Clinical attachment change. . . . 57

Analysis 3.3. Comparison 3 EMP + CAF versus CAF - Long term, Outcome 3 Keratinized tissue change. . . . . 58

Analysis 4.1. Comparison 4 GTR rm versus SCTG - Short term, Outcome 1 Gingival recession change. . . . . . 59

Analysis 4.2. Comparison 4 GTR rm versus SCTG - Short term, Outcome 2 Clinical attachment level change. . . 61

Analysis 4.3. Comparison 4 GTR rm versus SCTG - Short term, Outcome 3 Keratinized tissue change. . . . . . 62

Analysis 4.4. Comparison 4 GTR rm versus SCTG - Short term, Outcome 4 Sites with complete root coverage. . . 64

Analysis 5.1. Comparison 5 GTR rm versus GTR nrm - Short term, Outcome 1 Gingival recession change. . . . 65

Analysis 5.2. Comparison 5 GTR rm versus GTR nrm - Short term, Outcome 2 Clinical attachment level change. . 66

Analysis 5.3. Comparison 5 GTR rm versus GTR nrm - Short term, Outcome 3 Keratinized tissue change. . . . . 68

Analysis 5.4. Comparison 5 GTR rm versus GTR nrm - Short term, Outcome 4 Sites with complete root coverage. . 69

Analysis 6.1. Comparison 6 GTR rm + bone substitutes versus SCTG, Outcome 1 Gingival recession change. . . . 70

Analysis 6.2. Comparison 6 GTR rm + bone substitutes versus SCTG, Outcome 2 Keratinized tissue change. . . . 71

Analysis 7.1. Comparison 7 GTR rm + bone substitutes versus GTR rm - Short term, Outcome 1 Gingival recession

change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Analysis 7.2. Comparison 7 GTR rm + bone substitutes versus GTR rm - Short term, Outcome 2 Clinical attachment level

change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Analysis 7.3. Comparison 7 GTR rm + bone substitutes versus GTR rm - Short term, Outcome 3 Keratinized tissue

change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Analysis 7.4. Comparison 7 GTR rm + bone substitutes versus GTR rm - Short term, Outcome 4 Sites with complete root

coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

77APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

78HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

78CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

78DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

79SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iRoot coverage procedures for the treatment of localised recession-type defects (Review)


[Intervention Review]

Root coverage procedures for the treatment of localisedrecession-type defects

Leandro Chambrone1, Flávia Sukekava1, Maurício G Araújo2, Francisco E Pustiglioni1 , Luiz Armando Chambrone3, Luiz A Lima1

1Department of Periodontology, University of São Paulo, São Paulo, Brazil. 2 Department of Periodontology, State University of Maringá,

Maringá, Brazil. 3Department of Periodontology, Methodist University of São Paulo, São Paulo, Brazil

Contact address: Leandro Chambrone, Department of Periodontology, University of São Paulo, Av. Prof. Lineu Prestes, 2227 Cidade

Universitária, São Paulo, SP, 05508-000, Brazil. [email protected]. (Editorial group: Cochrane Oral Health Group.)

Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this issue: New)


DOI: 10.1002/14651858.CD007161.pub2

This version first published online: 15 April 2009 in Issue 2, 2009.

Last assessed as up-to-date: 25 January 2009. (Help document - Dates and Statuses explained)

This record should be cited as: Chambrone L, Sukekava F, Araújo MG, Pustiglioni FE, Chambrone LA, Lima LA. Root coverage

procedures for the treatment of localised recession-type defects. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.:

CD007161. DOI: 10.1002/14651858.CD007161.pub2.

A B S T R A C T

Background

Gingival recession is defined as the oral exposure of the root surface due to a displacement of the gingival margin apical to the cemento-

enamel junction and it is regularly linked to the deterioration of dental aesthetics. Successful treatment of recession-type defects is based

on the use of predictable periodontal plastic surgery (PPS) procedures.

Objectives

To evaluate the effectiveness of different root coverage procedures in the treatment of recession-type defects.

Search strategy

The Cochrane Oral Health Group’s Trials Register, CENTRAL, MEDLINE and EMBASE were searched up to October 2008. The

main international periodontal journals were handsearched. There were no restrictions with regard to publication status or language of

publication.

Selection criteria

Only randomised controlled clinical trials (RCTs) of at least 6 months’ duration evaluating recession areas (Miller’s Class I or II > 3

mm) and that were treated by means of PPS procedures were included.

Data collection and analysis

Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently

and in duplicate. Authors were contacted for any missing information. Results were expressed as random-effects models using mean

differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals.

Main results

Twenty-four RCTs provided data. Only one trial was considered to be at low risk of bias. The remaining trials were considered to be

at high risk of bias.

1Root coverage procedures for the treatment of localised recession-type defects (Review)


mailto:[email protected]

http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/DatesStatuses.pdf

The results indicated a significant greater reduction in gingival recession and gain in keratinized tissue for subepithelial connective

tissue grafts (SCTG) compared to guided tissue regeneration with resorbable membranes (GTR rm).

A significant greater gain in the keratinized tissue was found for enamel matrix protein when compared to coronally advanced flap

(0.40 mm) and for SCTG when compared to GTR rm plus bone substitutes.

Limited data exist on aesthetic condition change related to patients’ opinion and patients’ preference for a specific procedure.

Authors’ conclusions

Subepithelial connective tissue grafts, coronally advanced flap alone or associated with other biomaterial and guided tissue regeneration

may be used as root coverage procedures for the treatment of localised recession-type defects. In cases where both root coverage and

gain in the keratinized tissue are expected, the use of subepithelial connective tissue grafts seems to be more adequate.

Randomised controlled clinical trials are necessary to identify possible factors associated with the prognosis of each PPS procedure.

The potential impact of bias on these outcomes is unclear.

P L A I N L A N G U A G E S U M M A R Y

Root coverage procedures for the treatment of localised recession-type defects

Gingival recession is a term that designates the oral exposure of the root surface due to a displacement of the gingival margin apical to

the cemento-enamel junction and it is also regularly linked to the deterioration of dental aesthetics as well as buccal cervical dentine

hypersensitivity. The results of this review have shown that the majority of periodontal plastic surgery (PPS) procedures led to statistical

significant gains in gingival recession depth, clinical attachment level and in the width of keratinized tissue, 23/24 studies were however

judged to be at high risk of bias. Also, we observed a great variability in the percentages of complete root coverage and mean coverage.

Preferably, subepithelial connective tissue grafts, coronally advanced flaps alone or associated with other graft or biomaterial and guided

tissue regeneration can be used as root coverage procedures for the treatment of recession-type defects. We recommend further research

to adequately confirm and identify possible factors associated with the prognosis and indications of each PPS procedure.

B A C K G R O U N D

Gingival recession (GR) is a term that designates the oral exposure

of the root surface due to a displacement of the gingival margin api-

cal to the cemento-enamel junction (Camargo 2001; Wennström

1996). Reports from diverse epidemiological surveys revealed that

GR may affect most of the adult population (Richmond 2007;

Susin 2004; Thomson 2006). Gingival anatomical factors, chronic

trauma, periodontitis and tooth alignment are considered the main

conditions leading to the development of these defects (Camargo

2001; Chambrone 2003; Khocht 1993; Yoneyama 1988). GR is

also regularly linked to the deterioration of dental aesthetics as well

as buccal cervical dentine hypersensitivity (Chambrone 2006). In

such cases, the goals of periodontal therapy should be to address

the needs and wishes of each patient, and treatment options should

be made available to them (Caffesse 1995).

Preferably, treatment options should be based on systematic, un-

biased and objective evaluations of the literature (McGuire 1995).

Moreover, the introduction of specific objectives, inclusion criteria

and search strategies based on evidence and scientifically valid in-

formation may reduce the variation in clinical outcomes, establish

the application and predictability of a specific procedure and im-

prove the effectiveness of clinical practice (McGuire 1995). Conse-

quently, scientific evidence-based information should be achieved

by well delineated systematic reviews (Needleman 2002).

Currently, successful treatment of recession-type defects is based

on the use of clinically predictable periodontal plastic surgery

(PPS) procedures. As first proposed by Miller in 1988, the term

PPS comprises different surgical techniques intended to correct

and prevent anatomical, developmental, traumatic or plaque dis-

ease-induced defects of the gingiva, alveolar mucosa or bone (AAP

1996).

Historically, these procedures originated at the beginning of the

20th century, presented by Younger in 1902, Harlan in 1906 and

Rosenthal in 1911 (Baer 1981) who first described the use of pedi-

cle or free soft tissue grafts to cover denuded root surfaces. How-

ever, these techniques were abandoned for a long time. During re-

cent decades, different surgical procedures were proposed. Coro-



nally advanced flaps, laterally repositioned flaps, free gingival grafts

and subepithelial connective tissue grafts appeared as novel ap-

proaches to achieve improvements in recession depth, clinical at-

tachment level and width of keratinized tissue (Bernimoulin 1975;

Björn 1963; Cohen 1968; Grupe 1956; Grupe 1966; Harris 1992;

Harvey 1965; Harvey 1970; Langer 1985; Nabers 1966; Patur

1958; Sullivan 1968; Sumner 1969; Wennström 1996). Concomi-

tantly, in the mid1980s Miller’s classification of recession defects

(Miller 1985) appeared as an adequate and useful tool providing

surgical predictability, especially for the correction of Class I and

II recession (e.g. defects without loss of interproximal bone or soft

tissue).

In recent years, some systematic reviews were published focusing

on the effect of PPS procedures on the treatment of localised gin-

gival recessions (Chambrone 2008; Oates 2003; Roccuzzo 2002).

These authors reported that different surgical techniques and flap

designs had been described and used in an attempt to correct lo-

calised gingival recessions producing statistically significant im-

provements in gingival recession and clinical attachment level.

Also, it was recommended for clinical practice that when root

coverage is indicated, subepithelial connective tissue grafts, coro-

nally advanced flaps or guided tissue regeneration may be used

(Chambrone 2008; Oates 2003; Roccuzzo 2002). However, the

following issues should be considered: Roccuzzo 2002 included

non-randomised studies and only English language trials and did

not include randomised controlled trials (RCTs) testing acellu-

lar dermal matrix grafts as well as the use of PPS procedures in

multiple recession-type defects. Chambrone 2008 and Oates 2003

did not include unpublished studies or non-English studies. The

last review was specifically designed to evaluate the effectiveness

of a single procedure (i.e. subepithelial connective tissue grafts).

Consequently, the analysis of non-controlled groups, as well as the

possible exclusion of some well designed RCTs may represent a

source of bias in each of these systematic reviews.

Additionally, other questions and conditions that were not pre-

viously evaluated need to be discussed: a) since recession defects

do not improve spontaneously, the question becomes, what is an

appropriate control group for the treatment of recession-type de-

fects?; b) exclusion of non-randomised studies allows bias protec-

tion, but there is also a potential loss of the evidence base since

only studies which compare two (or more) active treatments can

be studied; and c) assessing the mean difference between groups is

helpful but does not inform on whether the interventions are ben-

eficial or not. For instance, where there is no difference between

treatments are they similarly good or bad? Normally this would

be assessed in relation to a reference control group, but it was not

present in previous reviews.

Consequently, these aspects demonstrate the need for an additional

complete evidence-based systematic review on the treatment of

recession defects.

Given the common occurrence of recession areas involving lo-

calised or adjacent teeth, evidence-based information associating

the results achieved by different surgical techniques can be con-

sidered as an important tool in clinical decision making.

O B J E C T I V E S

To evaluate the effectiveness of different root coverage procedures

in the treatment of recession-type defects.

M E T H O D S

Criteria for considering studies for this review

Types of studies

Only randomised controlled clinical trials (RCTs) of at least 6

months’ duration were included.

Types of participants

Studies were included if the participants met the following criteria.

- A clinical diagnosis of localised or multiple recession-type defects.

- Recession areas selected for treatment classified as Miller’s (Miller

1985) Class I (marginal tissue recession not extending to the

mucogingival junction and no loss of interproximal bone or soft

tissue) or Class II (marginal tissue recession extending to or be-

yond the mucogingival junction and no loss of interproximal bone

or soft tissue) of at least 3 mm, and that were surgically treated

by means of periodontal plastic surgery (PPS) procedures. Studies

including Miller’s Class III (marginal tissue recession extending

to or beyond the mucogingival junction with loss of bone or soft

tissue, apical to the cemento-enamel junction but coronal to the

level of the recession defect) or Class IV (marginal tissue recession

extending to or beyond the mucogingival junction with loss of

bone or soft tissue apical to the level of the recession defect) were

not included.

- At least 10 participants per group at final examination.

Types of interventions

The interventions of interest were free gingival grafts (FGG), later-

ally positioned flap (LPF), coronally advanced flap (CAF), subep-

ithelial connective tissue grafts (SCTG) alone or in combination

with LPF or CAF, acellular dermal matrix grafts (ADMG), guided

tissue regeneration (GTR) and enamel matrix protein (EMP).

Types of outcome measures

Primary and secondary outcome measures were reported.



Primary: Aesthetic condition change related to patient’s opinion

(satisfactory, non-satisfactory or not reported) and gingival reces-

sion change.

Secondary: Clinical attachment change, keratinized tissue change,

percentage of sites with complete root coverage, mean root cov-

erage, patients’ preference for a specific PPS procedure (in split-

mouth trials), occurrence of adverse effects (yes/no) and/or post-

operative complications (yes/no).

In addition, outcome measures were separated into short term (as

evaluated 6 to 12 months following interventions) or long term

(13 or more months).

Search methods for identification of studies

Electronic searching

For the identification of studies included or considered for this

review, detailed search strategies were developed for each database

searched based on the search strategy presented in Appendix 1

for searching the Cochrane Central Register of Controlled Tri-

als (CENTRAL). Databases were searched to include papers and

abstracts published in all languages and every effort was made to

translate non-English papers.

The following databases were searched:

Cochrane Oral Health Group’s Trials Register

CENTRAL (The Cochrane Library 2008, Issue 4)

MEDLINE (1950 to October 2008)

EMBASE (1986 to October 2008).

In addition, the Cochrane Highly Sensitive Search Strategy

(CHSSS) for identifying randomised trials in MEDLINE: sensi-

tivity maximising version (2008 revision) as referenced in Chap-

ter 6.4.11.1 and detailed in box 6.4.c of the Cochrane Handbookfor Systematic Reviews of Interventions 5.0.1 (updated September

2008) (Higgins 2008) was added to the MEDLINE search.

Handsearching

The following journals were identified as important to this review

and were handsearched: Journal of Periodontology, Journal of Pe-riodontal Research, Journal of Clinical Periodontology, and Interna-tional Journal of Periodontics and Restorative Dentistry.

Unpublished data

Unpublished data were sought by searching a database listing un-

published studies (System for Information on Grey Literature in

Europe (SIGLE)), abstracts and conference proceedings from the

relevant journals. In addition, reference lists of any potential clini-

cal trials were examined in an attempt to identify any other studies.

Authors of included studies were also contacted to ask for details

of additional published and unpublished trials.

Data collection and analysis

Selection of studies

Initially, two review authors (Leandro Chambrone (LC) and Flavia

Sukekava (FS)) independently screened titles, abstracts and full

texts of the search results. Agreement between review authors was

assessed calculating Kappa scores. The review authors remained

unblinded regarding the author(s), their institutional affiliations

and the site of publication of reports. The full report was obtained

for all studies appearing to meet the inclusion criteria or in in-

stances where there was insufficient information from the title,

keywords and abstract to make a clear decision. All studies were

assessed independently for eligibility by both review authors. Dis-

agreement between the review authors was resolved by discussion

with the inclusion of two other review authors (Luiz A Cham-

brone (LAC) and Luiz A Lima (LAL)). In case of missing data,

authors were contacted to resolve eventual doubts and provide fur-

ther details from the trial. Data were excluded until further clarifi-

cation was available if agreement could not be reached. The studies

meeting the inclusion criteria underwent validity assessment and

data extraction. Studies rejected at this or subsequent stages were

recorded in a table of excluded studies.

Data extraction and management

Data extraction was performed by two review authors (LC and

FS) independently and in duplicate using specially designed data

extraction forms.

Data were extracted and loaded onto Review Manager (RevMan)

software and checked. Data on the following issues were extracted

and recorded:

- citation, publication status and year of publication;

- location of trial: country and place where the patients were treated

(e.g. private practice or university dental hospitals);

- study design: randomised controlled trial (RCT);

- characteristics of participants: sample size, gender, age, local and

systemic conditions;

- methodological quality of trials: patient/defect selection bias, se-

lection of a control group, adequate inclusion criteria, statistical

analysis, randomisation selection, validity of conclusions and clin-

ical variables analysed;

- characteristics of interventions: free gingival grafts (FGG), later-

ally positioned flap (LPF), coronally advanced flap (CAF), subep-

ithelial connective tissue grafts (SCTG) alone or in combination

with LPF or CAF, acellular dermal matrix grafts (ADMG), guided

tissue regeneration (GTR) or enamel matrix protein (EMP);

- source of funding and conflict of interest.

Authors of the RCTs were contacted when necessary for clarifi-

cation of data or, where possible, to obtain missing data. Data

were excluded until further clarification was available if agreement

could not be reached.



Assessment of risk of bias in included studies

The methodological quality of the studies was assessed focusing

on the following points.

- Method of randomisation (e.g. method used to generate the ran-

domisation sequence): (a) adequate, when random number tables,

tossed coin or shuffled cards were used; (b) inadequate, when other

methods were used, such as alternate assignment, hospital num-

ber or odd/even date of birth; and (c) unclear, when method of

randomisation was not reported or explained.

- Allocation concealment (e.g. how the randomisation sequence

was concealed from the examiners): (a) adequate, when examiners

were kept unaware of randomisation sequence (e.g. by means of

central randomisation; pharmacy sequential numbers or opaque

envelopes); (b) inadequate, when other methods were used, such

as alternate assignment, hospital number; and (c) unclear, when

the method was not reported or explained.

- Blindness of examiners with regard to the treatment procedures

used in the study period was assessed as yes, no or unclear.

- Completeness of the follow up was based on the following ques-

tions: Was the number of subjects at baseline and at the completion

of the follow-up period interval reported? (yes/no). In addition,

the presence of explanations (reasons) for drop outs was checked.

Studies that did not report completeness of the follow up were not

included.

Risk of bias in the included studies was categorised according to

the following.

(A) Low risk of bias (plausible bias unlikely to seriously alter the

results) if all criteria were met.

(B) Moderate risk of bias (plausible bias that raises some doubt

about the results) if one or more criteria were partly met.

(C) High risk of bias (plausible bias that seriously weakens confi-

dence in the results) if one or more criteria were not met.

The agreement between the review authors for study inclusion was

assessed using the Kappa statistic.

Data synthesis

Data were collated into evidence tables and grouped according to

type of intervention. Descriptive summary was performed to de-

termine the quantity of data, checking further for study variations

in terms of study characteristics, study quality and results. This

assisted in confirming the similarity of studies and suitability of

further synthesis methods, including possible meta-analysis.

Random-effects meta-analyses were used throughout. For contin-

uous data, pooled outcomes were expressed as weighted mean dif-

ferences (MD) with their associated 95% confidence intervals. For

dichotomous data, these were predominately pooled risk ratios

and associated 95% confidence intervals. Statistical heterogeneity

was assessed by calculation of the Q statistic. Analyses were per-

formed using RevMan software. The analysis for the continuous

outcomes was conducted using the generic inverse variance statis-

tical method where the mean differences and standard error are en-

tered for all studies to allow the combination of parallel and split-

mouths group studies. Variance imputation methods were con-

ducted to estimate appropriate variance estimates in some split-

mouth studies, where the appropriate standard deviation of the

differences was not included in the trials (Follmann 1992).

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.

R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of excluded

studies.

Results of the search

Search strategy identified 649 potentially eligible articles, of which

558 were excluded after the title and/or abstract were reviewed

(Kappa score for interreviewer agreement: 0.84, 95% confidence

interval (CI): 0.77 to 0.91). Subsequently, the full texts of the

remaining articles considered potentially relevant were screened.

From the 91 papers, 64 did not meet the criteria of eligibility

(Kappa score for interreviewer agreement: 0.75, 95% CI: 0.58 to

0.88) and the reasons for exclusion were reported in a separate

table (see Characteristics of excluded studies) .

Included studies

Twenty-seven papers were included in this review regarding 24

randomised controlled trials (RCTs). Three RCTs had their data

reported in two articles each (i.e. according to the follow-up pe-

riod). Consequently, the papers with a shorter follow-up period

were included under the one study name (e.g. papers with the

longer follow up) (de Queiroz 2006; Leknes 2005; Spahr 2005).

Out of the 24 included RCTs, 14 trials were conducted accord-

ing to a split-mouth design (da Silva 2004; de Queiroz 2006; Del

Pizzo 2005; Dodge 2000; Henderson 2001; Joly 2007; Leknes

2005; McGuire 2003; Roccuzzo 1996; Rosetti 2000; Spahr 2005;

Trombelli 1996; Wang 2001; Zucchelli 2003) and 10 accord-

ing to a parallel design (Bouchard 1994; Bouchard 1997; Keceli

2008; Matarasso 1998; Paolantonio 1997; Paolantonio 2002;

Paolantonio 2002b; Tozum 2005; Woodyard 2004; Zucchelli

1998). In total, 599 patients were treated and all studies were pub-

lished in full.

Five RCTs were private practice based (Bouchard 1994; Bouchard

1997; Dodge 2000; McGuire 2003; Paolantonio 1997), 17 were

based in universities or dental hospitals (da Silva 2004; de Queiroz

2006; Henderson 2001; Joly 2007; Keceli 2008; Leknes 2005;

Matarasso 1998; Paolantonio 2002; Paolantonio 2002b; Roccuzzo

1996; Rosetti 2000; Tozum 2005; Trombelli 1996; Wang 2001;



Woodyard 2004; Zucchelli 1998; Zucchelli 2003) and two were

multicentre studies (Del Pizzo 2005; Spahr 2005).

Nine trials were conducted in Italy (Del Pizzo 2005; Matarasso

1998; Paolantonio 1997; Paolantonio 2002; Paolantonio 2002b;

Roccuzzo 1996; Trombelli 1996; Zucchelli 1998; Zucchelli 2003),

five in USA (Dodge 2000; Henderson 2001; McGuire 2003; Wang

2001; Woodyard 2004), four in Brazil (da Silva 2004; de Queiroz

2006; Joly 2007; Rosetti 2000), two in France (Bouchard 1994;

Bouchard 1997), two in Turkey (Tozum 2005; Keceli 2008), one

in Germany (Spahr 2005), and one in Norway (Leknes 2005).

Five trials were supported, totally or in part, by governmental

agencies or university programs (Keceli 2008; Paolantonio 2002;

Paolantonio 2002b; Rosetti 2000, Trombelli 1996) and five by

companies who provided products that were used as interventions

in the RCTs (Henderson 2001; Leknes 2005; McGuire 2003;

Spahr 2005; Wang 2001).

The majority of trials followed participants during a short-term

period (6 to 12 months). Only six publications with long-term

follow up were included (de Queiroz 2006; Del Pizzo 2005; Leknes

2005; Paolantonio 1997; Rosetti 2000; Spahr 2005).

Treatment modalities

Different interventions have been evaluated: acellular dermal ma-

trix grafts (ADMG), coronally advanced flap (CAF), free gingi-

val grafts (FGG), enamel matrix protein (EMP), guided tissue re-

generation with resorbable membranes (GTR rm), guided tissue

regeneration with non-resorbable membranes (GTR nrm), GTR

rm associated with bone substitutes and subepithelial connective

tissue grafts (SCTG). Randomised controlled clinical trials eval-

uating laterally positioned flap (LPF) or multiple recession-type

defects were not found.

Excluded studies

Sixty-four studies were excluded. Twenty-five were excluded on the

grounds that they were not randomised controlled trials (Berlucchi

2005; Daniel 1990; Dembowska 2007; Erley 2006; Gupta 2006;

Harris 1997; Harris 2000; Harris 2002; Harris 2005; Hirsch 2005;

Muller 1998; Muller 1999; Pini Prato 1992; Pini Prato 1996; Pini

Prato 1999; Pini Prato 2005; Ricci 1996; Ricci 1996b; Sallum

2003; Sbordone 1988; Scabbia 1998; Trombelli 1995; Trombelli

1997; Trombelli 2005; Wennström 1996).

Thirty-eight papers were classified as randomised trials; however

they did not fulfil the inclusion criteria. Seventeen RCTs included

patients with recession defects < 3 mm (Aichelmann Reidy 2001;

Berlucchi 2002; Bittencourt 2006; Borghetti 1999; Castellanos

2006; Cheung 2004; Felipe 2007; Huang 2005; Jahnke 1993;

Jepsen 1998; Kennedy 1985; Lins 2003; Modica 2000; Pilloni

2006; Tatakis 2000; Trabulsi 2004; Trombelli 1998).

Two studies were classified as randomised non-controlled trials (

Moses 2006; Nemcovsky 2004). Other five articles did not present

a patient-based analysis (Barros 2004; Barros 2005; Cetiner 2003;

Cordioli 2001; Rahmani 2006). Studies including Miller’s Class

III or Class IV recessions (Borghetti 1994), a follow-up period < 6

months (Lafzi 2007), interventions not of interest for this review

(Wilson 2005) and that had counted less than 10 participants

per group at final examination (Burkhardt 2005; Kimble 2004;

Mahajan 2007; Tal 2002; Trombelli 1995b) were excluded as well.

The remaining papers were excluded due to the combination of

two or more factors such as the treatment of recession < 3 mm and

a follow-up period < 6 months (Laney 1992; Pini Prato 2000) and

less than 10 patients per group at final examination, recessions <

3 mm and patient-based analysis not presented (Duval 2000; Ito

2000).

In addition, the authors from three studies were contacted to re-

solve doubts and provide further details from their trials (Caffesse

2000; Novaes 2001; Romagna-Genon 2001). However, these au-

thors did not provide the requested explanations, consequently,

their papers were excluded from the review.

Risk of bias in included studies

Quality assessment of the included studies was evaluated using

the data extracted from each trial. Moreover, all authors were con-

tacted to provide complementary information by means of a ques-

tionnaire regarding the methodological quality of their trials.

Randomisation

All the trials were described as RCTs, but not all reported randomi-

sation and allocation methods in detail. Sixteen trials (da Silva

2004; de Queiroz 2006; Del Pizzo 2005; Dodge 2000; Joly 2007;

Leknes 2005; McGuire 2003; Paolantonio 1997; Paolantonio

2002; Paolantonio 2002b; Roccuzzo 1996; Spahr 2005; Wang

2001; Woodyard 2004; Tozum 2005; Zucchelli 2003) presented

an adequate method of randomisation, while one reported an in-

adequate method (Keceli 2008). In seven, the method of randomi-

sation was considered unclear (Bouchard 1994; Bouchard 1997;

Henderson 2001; Matarasso 1998; Rosetti 2000; Trombelli 1996;

Zucchelli 1998).

Allocation

Only one trial presented an adequate method of allocation con-

cealment (McGuire 2003). All other trials were classified as un-

clear because the method of allocation was not described (seeCharacteristics of included studies).

Blinding

Examiners were considered blinded in 15 studies (Del Pizzo

2005; Dodge 2000; Henderson 2001; Keceli 2008; Leknes 2005;

McGuire 2003; Paolantonio 2002b; Roccuzzo 1996; Rosetti 2000;

Spahr 2005; Trombelli 1996; Wang 2001; Woodyard 2004;

Zucchelli 1998; Zucchelli 2003), not blinded in eight studies



(Bouchard 1994; Bouchard 1997; da Silva 2004; Joly 2007;

Matarasso 1998; Paolantonio 1997; Paolantonio 2002; Tozum

2005) and unclear in one study (de Queiroz 2006).

Whilst authors from three trials (Paolantonio 1997; Paolantonio

2002; Tozum 2005) have responded to the review enquiry (i.e.

questionnaire regarding the methodological quality of each trial)

that their study had blinded examiners, in practical terms this

might have been impossible to achieve with very different inter-

ventions (i.e. SCTG versus free gingival grafts, GTR rm versus

GTR rm with bone substitutes versus SCTG and modified tunnel

procedures + SCTG versus SCTG + CAF). Consequently, where

the intervention was very different and where the examiner could

therefore guess the group allocation, the study was interpreted to

be not blinded.

Withdrawals, drop outs and risk of bias

Only four studies (Keceli 2008; Leknes 2005; McGuire 2003;

Spahr 2005) reported withdrawals and drop outs. In the first trial

(Keceli 2008), four patients discontinued the study between 6- to

12-month evaluations due to moving to another city. In the second

study (Leknes 2005), 11 out of 20 subjects were available for the

final evaluation (six subjects rejected to complete the study and

three moved to other part of Norway). In the third study (McGuire

2003), one participant dropped out because he had moved out of

the country (where the RCT was conducted), one had a change

in job and could not comply with study schedule and one was not

compliant and was exited from the trial. In the last trial (Spahr

2005), six patients could not be recalled after the follow-up period

(they moved with address unknown) and one patient was excluded

after enrolment in the study due to injuries of gingival tissues in

the course of dental treatment by the referring dentist.

In addition, only one RCT was considered to be at low risk of bias

(McGuire 2003). The remaining trials were considered to be at

high risk of bias.

Publication bias

Publication bias would be investigated, especially as its presence

was detected in a previous review (Roccuzzo 2002), by graphical

methods and via the Begg and Mazumdar (Begg 1994) adjusted

rank correlation test and the Egger regression asymmetry test (

Egger 1997). However, the limited number of studies prevented

such evaluation.

Effects of interventions

Aesthetic condition change

Aesthetic condition change related to patient’s opinion was re-

ported in three RCTs (Bouchard 1994; Rosetti 2000; Zucchelli

2003).

One trial (Bouchard 1994) evaluated the clinical and aesthetical

effects of subepithelial connective tissue grafts (SCTG) to cover

gingival recessions using grafts without epithelial collar plus citric

acid conditioning and coronally repositioned flap or grafts with

epithelial collar and no root conditioning. Aesthetic evaluation

was performed by two independent examiners who were blinded

to the given treatment. Additionally, the authors commented that

no patient was dissatisfied with the aesthetical results obtained.

The second trial (Rosetti 2000) compared the GTR rm proce-

dure associated with demineralized freeze-dried bone allografts to

SCTG in patients with bilateral gingival recessions. Similarly, aes-

thetical evaluation was performed by five examiners who were not

participating in the study. In this study, the authors have men-

tioned only that the patient satisfaction survey indicated that all

patients were satisfied with the aesthetic results achieved by both

procedures at 18 months postsurgery.

The last study (Zucchelli 2003) was designed to compare root cov-

erage and aesthetic results of a modified surgical approach for the

bilaminar procedure with those achieved with a more traditional

bilaminar technique in patients with bilateral recession defects.

The results obtained at the 12-month follow-up visit showed that

patients were more satisfied with the appearance of test-treated

recessions (i.e. graft dimension equal to the depth of the bone de-

hiscence), as well as, less satisfied with poor colour blending and

excessive thickness of the control-treated recessions (i.e. graft di-

mension 3 mm greater than the depth of the bone dehiscence).

Gingival recession change, clinical attachment level

change and keratinized tissue change

Of the 24 included trials, 12 were included into the following

meta-analyses: (1) ADMG versus SCTG - Short term (Joly 2007;

Paolantonio 2002b); (2) ADMG versus CAF - Short term (de

Queiroz 2006; Woodyard 2004); (3) EMP + CAF versus CAF

- Long term (Del Pizzo 2005; Spahr 2005); (4) GTR rm versus

SCTG - Short term (Paolantonio 2002; Wang 2001; Zucchelli

1998); (5) GTR rm versus GTR nrm - Short term (Roccuzzo

1996; Zucchelli 1998); (6) GTR rm associated with bone sub-

stitutes versus SCTG (Paolantonio 2002; Rosetti 2000); and (7)

GTR rm associated with bone substitutes versus GTR rm - Short

term (Dodge 2000; Paolantonio 2002) (see Additional Table 1).

Moreover, analyses were performed according to the follow-up

evaluation (i.e. short term (6 and 12 months) or long term (more

than 12 months)) in the majority of comparisons, except for GTR

rm associated with bone substitutes versus SCTG (Comparison 6)

where the data were derived from 12-month (Paolantonio 2002)

and 18-month (Rosetti 2000) measurements. In addition, data

from studies not included in meta-analyses are presented in Addi-

tional Table 2.



Table 1. Summary of meta-analyses

Comparison Studies Outcome Statistical

method

Effect size Chi2 P value (Q) I2 (%)

ADMG versus

SCTG

Joly

2007, Paolan-

tonio 2002b

GR change MD 95% CI -0.76 [-1.93,

0.42]

4.13 0.04 76.0

CAL change MD 95% CI -0.81 [-1.92,

0.30]

3.26 0.07 69.0

KT change MD 95% CI -0.83 [-2.09,

0.44]

4.51 0.03 78.0

ADMG versus

CAF

de Queiroz

2006, Wood-

yard 2004

GR change MD 95% CI 0.62 [-0.51,

1.74]

6.25 0.01 84.0

CAL change MD 95% CI 0.56 [-0.21,

1.33]

1.82 0.18 45.0

KT change MD 95% CI 0.31 [-0.15,

0.77]

0.25 0.62 0

EMP + CAF

versus CAF

Del Pizzo

2005, Spahr

2005

GR change MD 95% CI 0.25 [-0.13,

0.64]

1.27 0.26 21.0

CAL change MD 95% CI 0.27 [-0.16,

0.69]

0.36 0.55 0

KT change MD 95% CI 0.40 [0.09,

0.71]

0.52 0.47 0

GTR rm ver-

sus SCTG

Paolantonio

2002, Wang

2001, Zuc-

chelli 1998

GR change MD 95% CI -0.39 [-0.65, -

0.12]

0.17 0.92 0

CAL change MD 95% CI 0.31 [-0.01,

0.62]

0.64 0.73 0

KT change MD 95% CI -1.95 [-2.66, -

1.24]

8.56 0.01 77.0



Table 1. Summary of meta-analyses (Continued)

SCRC RR 95% CI 0.71 [0.47,

1.08]

1.09 0.58 0

GTR rm ver-

sus GTR nrm

Roccuzzo

1996, Zuc-

chelli 1998

GR change MD 95% CI 0.32 [-0.03,

0.68]

0.94 0.33 0

CAL change MD 95% CI 0.15 [-0.38,

0.68]

0.15 0.69 0

KT change MD 95% CI 0.11 [-0.29,

0.51]

0.01 0.92 0

SCRC RR 95% CI 1.18 [0.61,

2.31]

0.24 0.62 0

GTR rm as-

sociated with

bone sub-

stitutes versus

SCTG

Rosetti

2000, Paolan-

tonio 2002

GR change MD 95% CI -0.75 [-1.92,

0.43]

7.34 0.007 86.0

KT change MD 95% CI -2.10 [-2.51, -

1.69]

0.04 0.84 0

GTR rm as-

sociated with

bone sub-

stitutes versus

GTR rm

Dodge

2000, Paolan-

tonio 2002

GR change MD 95% CI 0.46 [-0.02,

0.94]

0.07 0.79 0

CAL change MD 95% CI 0.72 [-0.06,

1.50]

2.21 0.14 55.0

KT change MD 95% CI 0.13 [-0.12,

0.37]

0.88 0.35 0

SCRC RR 95% CI 1.40 [0.76,

2.57]

0.03 0.85 0

ADMG - acellular dermal matrix graft; CAF - coronally advanced flap; CAL - clinical attachment level; CI - confidence interval; EMP- enamel matrix protein; GR - gingival recession; GTR rm - guided tissue regeneration resorbable membrane; GTR nrm - guided tissueregeneration non-resorbable membrane; KT - keratinized tissue; MD - weighted mean difference; RR - risk ratio; SCRC - sites with completeroot coverage; SCTG - subepithelial connective tissue graft



Table 2. Outcome changes of trials not incorporated into meta-analyses

Study Intervention Mean GR change Mean CAL change Mean KT change

Bouchard 1994 SCTG + CAF + citric

acid (graft without epithe-

lial collar)

2.93 2.74 0.94

SCTG (graft with epithe-

lial collar)

2.93 2.86 2.07*

Bouchard 1997 SCTG + CAF + tetracy-

cline hydrochloride

3.06 2.66 1.00

SCTG + CAF + citric acid 3.47 3.20 0.93

da Silva 2004 SCTG + CAF 3.16 (0.86) 2.53 (1.14) 0.55 (0.91)*CAF 2.73 (0.99) 2.30 (1.05) -0.21 (0.63)

Henderson 2001 ADMG (basement mem-

brane side against the

tooth) + CAF

3.95 (2.19) 4.15 (2.21) 0.80 (0.92)

ADMG (connective tissue

side against the tooth) +

CAF

3.55 (1.07) 3.65 (1.45) 0.80 (1.14)

Keceli 2008¶ SCTG (full thickness flap)

+ platelet-rich plasma

NR NR NR

SCTG NR NR NR

Leknes 2005 GTR (polylactide

membrane - Guidor) (72

months)

1.4 1.7 0

CAF (72 months) 1.3 1.5 0

Matarasso 1998 GTR (polylactide mem-

brane - Guidor) + double

papilla flap

3.4 (0.39) 3.1 (0.41) 2.0 (0.36)*

GTR (polylactide mem-

brane - Guidor) + CAF

2.5 (0.45) 2.8 (0.47) 0.9 (0.65)

McGuire 2003 EMP + CAF 4.07 4.51 0.71SCTG + CAF 4.01 4.56 1.56*

Paolantonio 1997 SCTG + double papilla

flap

2.85 NR 2.81

FGG 1.61 NR 3.66

Tozum 2005 SCTG + modified tunnel

approach

3.36 (0.17)* 3.93 (0.27)* NR

SCTG + CAF 2.56 (0.19) 2.44 (0.34) NR

Trombelli 1996 CAF + fibrin glue + tetra-

cycline hydrochloride

2.4 (0.5) 2.4 (0.8) -0.4 (0.6)

CAF + tetracycline hy-

drochloride

1.8 (1.0) 1.9 (0.8) -0.5 (1.2)



Table 2. Outcome changes of trials not incorporated into meta-analyses (Continued)

Zucchelli 2003 SCTG (graft size equal

to the bone dehiscence) +

CAF

3.9 (0.71) 3.9 (0.70)* 2.3 (0.59)

SCTG (graft size 3 mm

greater than the bone de-

hiscence) + CAF

3.6 (0.72) 3.1 (0.74) 3.3 (0.72)*

ADMG - acellular dermal matrix graft; CAF - coronally advanced flap; CAL - clinical attachment level; EMP - enamel matrix protein; FGG- free gingival graft; GR - gingival recession; GTR - guided tissue regeneration; KT - keratinized tissue; SCTG - subepithelial connectivetissue graft; *statistically significant between-groups (superior group); ¶ changes from baseline to final examination were reported as medianvalues

ADMG versus SCTG (Comparison 1)

• Gingival recession, clinical attachment level and ker-

atinized tissue changes (Outcomes 1.1 to 1.3) - there

were two trials (Joly 2007; Paolantonio 2002b) report-

ing these outcomes measured as changes from the base-

line values and no statistically significant differences be-

tween ADMG and SCTG treatment were found.

1. ADMG versus SCTG (Comparison 1, Outcome 1.1) -

P = 0.21, mean difference -0.76 mm (95% confidence

interval (CI) -1.93 to 0.42, Chi2 = 4.13, degrees of

freedom (df ) = 1, P = 0.04, I2 = 76.0%).


P = 0.15, mean difference -0.81 mm (95% CI -1.92 to

0.30, Chi2 = 3.26, df = 1, P = 0.07, I2 = 69.0%).


P = 0.20, mean difference -0.83 mm (95% CI -2.09 to

0.44, Chi2 = 4.51, df = 1, P = 0.03, I2 = 78.0%).

ADMG versus CAF (Comparison 2)



were two trials (de Queiroz 2006; Woodyard 2004) re-

porting these outcomes measured as changes from the

baseline values and no statistically significant differences

between ADMG and CAF treatment were found.

1. ADMG versus CAF (Comparison 2, Outcome 2.1) -

P = 0.28, mean difference 0.62 mm (95% CI -0.51 to

1.74, Chi2 = 6.25, df = 1, P = 0.01, I2 = 84.0%).



1.33, Chi2 = 1.82, df = 1, P = 0.18, I2 = 45.0%).



0.77, Chi2 = 0.25, df = 1, P = 0.62, I2 = 0%).

EMP + CAF versus CAF (Comparison 3)

• Gingival recession and clinical attachment level changes

(Outcomes 3.1 and 3.2) - there were no statistically

significant differences between the EMP + CAF and

the CAF in gingival recession and clinical attachment

changes (two trials - Del Pizzo 2005; Spahr 2005).

1. EMP + CAF versus CAF (Comparison 3, Outcome 3.1)

- P = 0.19, mean difference 0.25 mm (95% CI -0.13 to

0.64, Chi2 = 1.27, df = 1, P = 0.26, I2 = 21.0%).

2. EMP + CAF versus CAF (Comparison 3, Outcome 3.2)

- P = 0.22, mean difference 0.27 mm (95% CI -0.16 to

0.69, Chi2 = 0.36, df = 1, P = 0.55, I2 = 0%).

• Keratinized tissue change (Comparison 3, Outcome

3.3) - there was a significant greater gain in the width

of keratinized tissue for EMP + CAF when compared

to CAF alone of 0.40 mm (95% CI 0.09 to 0.71, Chi2

= 0.52, df = 1, P = 0.47, I2 = 0%).

GTR rm versus SCTG (Comparison 4)

• Gingival recession change (Comparison 4, Outcome

4.1) - there were three trials (Paolantonio 2002; Wang

2001; Zucchelli 1998) for this outcome measured as

change from the baseline values. There was a statisti-

cally significant greater reduction in gingival recession

for SCTG compared to GTR rm sites with weighted

mean difference of -0.39 mm (95% CI -0.65 to -0.12,

Chi2 = 0.17, df = 2, P = 0.92, I2 = 0%).



• Clinical atachment level change (Comparison 4, Out-

come 4.2) - no statistically significant difference be-

tween GTR rm versus SCTG was found (mean differ-

ence of 0.31 mm, P = 0.05 (95% CI -0.01 to 0.62, Chi2

= 0.64, df = 2, P = 0.73, I2 = 0%)).


4.3) - a statistically significant gain of -1.95 mm was

found for SCTG when compared to GTR rm (95%

CI -2.66 to -1.24, Chi2 = 8.56, df = 2, P = 0.01, I2 =

77.0%) .

GTR rm versus GTR nrm (Comparison 5)



were two trials (Roccuzzo 1996; Zucchelli 1998) report-

ing these outcomes measured as changes from the base-

line values and no statistically significant differences be-

tween GTR rm and GTR nrm treatment were found.

1. GTR rm versus GTR nrm (Comparison 5, Outcome

5.1) - P = 0.08, mean difference 0.32 mm (95% CI -

0.03 to 0.68, Chi2 = 0.94, df = 1, P = 0.33, I2 = 0%).



0.38 to 0.68, Chi2 = 0.15, df = 1, P = 0.69, I2 = 0%).



0.29 to 0.51, Chi2 = 0.01, df = 1, P = 0.92, I2 = 0%).

GTR rm associated with bone substitutes versus SCTG

(Comparison 6)

• Gingival recession change (Comparison 6, Outcome

6.1) - two trials (Paolantonio 2002; Rosetti 2000) were

evaluated and no significant differences were found (P

= 0.21, mean difference -0.75 mm (95% CI -1.92 to

0.43, Chi2 = 7.34, df = 1, P = 0.007, I2 = 86.0%)).


6.2) - there was a statistically significant greater gain in

keratinized tissue for SCTG when compared to GTR

rm associated with bone substitutes of -2.10 mm (95%

CI -2.51 to -1.69, Chi2 = 0.04, df = 1, P = 0.84, I2 =

0%) (Paolantonio 2002; Rosetti 2000).

Changes in the clinical attachment level were not evaluated due

to the lack of data from Rosetti 2000.

GTR rm associated with bone substitutes versus GTR rm

(Comparison 7)



were two trials (Dodge 2000; Paolantonio 2002) re-

porting these outcomes measured as changes from the

baseline values and no statistically significant differences

between GTR rm associated with bone substitutes and

GTR rm treatment were found.

1. GTR rm + bone substitutes versus GTR rm (Compar-

ison 7, Outcome 7.1) - P = 0.06, mean difference 0.46

mm (95% CI -0.02 to 0.94, Chi2 = 0.07, df = 1, P =

0.79, I2 = 0%).



mm (95% CI -0.06 to 1.50, Chi2 = 2.21, df = 1, P =

0.14, I2 = 55.0%).



mm (95% CI -0.12 to 0.37, Chi2 = 0.89, df = 1, P =

0.35, I2 = 0%).

Results from trials not included in meta-analyses

The results from the 12 trials that were not included into meta-

analyses are depicted below.

• Bouchard 1994 - The mean gingival recession decreased

from 4.20 mm to 1.27 mm for SCTG without epithe-

lial collar + CAF + citric acid and from 4.53 mm to

1.60 mm for SCTG with epithelial collar (Wilcoxon’s

Rank Sum Test, intra-group comparisons P < 0.05).

Differences between groups were not statistically sig-

nificant (P > 0.05). The mean clinical attachment level

decreased from 5.47 mm to 2.73 mm for SCTG with-

out epithelial collar + CAF + citric acid and from 6.13

mm to 3.27 mm for SCTG with epithelial collar (in-

tra-group comparisons P < 0.05). Differences between

groups were not statistically significant (P > 0.05). The

mean width of keratinized tissue increased from 2.13

mm to 3.07 mm for SCTG without epithelial collar +

CAF + citric acid and from 1.73 mm to 3.80 mm for

SCTG with epithelial collar (intra-group comparisons

P < 0.05; comparison between groups P < 0.005).

• Bouchard 1997 - The mean gingival recession decreased


lial collar + CAF + tetracycline hydrochloride and from

4.13 mm to 0.66 mm for SCTG without epithelial col-

lar + CAF + citric acid (Wilcoxon’s Rank Sum Test, in-

tra-group comparisons P < 0.05). Differences between

groups were not statistically significant (P > 0.05). The

mean clinical attachment level decreased from 5.26 mm

to 2.60 mm for SCTG without epithelial collar + CAF

+ tetracycline hydrochloride and from 5.66 mm to 2.46

mm for SCTG without epithelial collar + CAF + citric

acid (intra-group comparisons P < 0.05). Differences



between groups were not statistically significant (P >

0.05).The mean width of keratinized tissue increased


lial collar + CAF + tetracycline hydrochloride and from

2.13 mm to 3.06 mm for SCTG without epithelial col-

lar + CAF + citric acid (intra-group comparisons P <

0.05). Differences between groups were not statistically

significant (P > 0.05).

• da Silva 2004 - The mean gingival recession decreased

from 4.20 mm to 1.04 mm for SCTG + CAF and from

3.98 mm to 1.25 mm for CAF (Student t test, within-

groups comparison P < 0.05). Differences between

groups were not statistically significant (P > 0.05).The

mean clinical attachment level decreased from 5.60 mm

to 3.07 mm for SCTG + CAF and from 5.45 mm

to 3.15 mm for CAF (within-groups comparison P <


significant ( P > 0.05).The mean width of keratinized

tissue increased from 2.79 mm to 3.35 mm for SCTG

+ CAF and decreased from 3.38 mm to 3.17 mm for

CAF (within-groups comparison P < 0.05). Differences

between groups were statistically significant (P < 0.05).

• Henderson 2001 - The mean gingival recession de-

creased from 4.20 mm to 0.25 mm for ADMG (base-

ment membrane side against the tooth) + CAF and

from 3.70 mm to 0.15 mm for ADMG (connective

tissue side against the tooth) + CAF (Student t test,

within-groups comparison P < 0.05). Differences be-

tween groups were not statistically significant (P > 0.05).

The mean clinical attachment level decreased from 6.20

mm to 2.05 mm for ADMG (basement membrane side

against the tooth) + CAF and from 5.60 mm to 1.95 mm

for ADMG (connective tissue side against the tooth) +


between groups were not statistically significant. The


mm to 2.60 mm for ADMG (basement membrane side

against the tooth) + CAF and from 1.60 mm to 2.40 mm

for ADMG (connective tissue side against the tooth) +



0.05).

• Keceli 2008 - The results from this study were re-

ported as median values. The median value regarding

the amount of root coverage achieved was 3.0 mm for

both procedures, i.e. SCTG + platelet-rich plasma and

SCTG (Friedman test, within-groups comparison P <


significant (Mann-Whitney test - P > 0.05). The median

value regarding attachment gains values were 2.5 mm

for SCTG + platelet-rich plasma and 3.0 mm for SCTG

(Friedman test, within-groups comparison P < 0.05).

Differences between groups were not statistically signif-

icant (Mann-Whitney test - P > 0.05). The results from

this study were reported as median values. However, the

median values regarding keratinized tissue gains values

were not reported. Only baseline and 12-month me-

dians values were reported. Differences within-groups

were considered statistically significant (Friedman test,

P < 0.05). Conversely, differences between groups were

not statistically significant (Mann-Whitney test - P >

0.05).

• Leknes 2005 - The mean gingival recession decreased

from 4.00 mm to 2.5 mm for GTR rm and from 3.80

mm to 2.6 mm for CAF. In this study, the gain of

root coverage from baseline to 12 months was statisti-

cally significant for both groups (Student t test, within-

groups comparison P < 0.01, between-groups compar-

ison P < 0.05). However, at 6 years it turned out to be

non-significant for the membrane group (P = 0.09) and

significant for the non-membrane group (P < 0.05).The

mean clinical attachment level decreased from 13.30

mm to 11.60 mm for GTR rm and from 13.30 mm

to 11.80 mm for CAF. In this study, clinical attach-

ment level was measured by an automated periodon-

tal probe mid-buccally from the buccal cusp/incisal

edge (within-groups comparison P < 0.01). Differences


0.05).The mean width of keratinized tissue at base-

line was 2.60 mm for both procedures (i.e. GTR rm

and CAF). In this study, at 6-year evaluation, both

treatments showed a non-significant rebound to base-

line level (within- and between-groups comparisons P

> 0.05).

• Matarasso 1998 - The mean gingival recession decreased

from 4.60 mm to 1.20 mm for GTR rm + double papilla

flap and from 4.00 mm to 1.50 mm for GTR rm + CAF

(Student t test, within-groups comparison P < 0.001).

Differences between groups were not statistically sig-

nificant (P > 0.05).The mean clinical attachment level

decreased from 5.80 mm to 2.70 mm for GTR rm +

double papilla flap and from 5.50 mm to 2.70 mm for

GTR rm + CAF (within-groups comparison P < 0.001).


icant (P > 0.05). The mean width of keratinized tissue

increased statistically from 1.70 mm to 3.70 mm for

GTR rm + double papilla flap (P < 0.001) and non-

statistically from 2.10 mm to 3.00 mm for GTR rm +

CAF (P > 0.05). Differences between groups were not

statistically significant (P > 0.05).

• McGuire 2003 - The mean gingival recession decreased

from 4.25 mm to 0.18 mm for EMP + CAF and from



4.25 mm to 0.24 mm for SCTG + CAF (Wilcoxon’s

Rank Sum Test, within-groups comparison P = 0.05).


icant (ANCOVA, P = 0.281). The mean clinical attach-

ment level decreased from 6.10 mm to 1.59 mm for

EMP + CAF and from 6.15 mm to 1.59 mm for SCTG

+ CAF (Wilcoxon’s Rank Sum Test, within-groups com-

parison P < 0.05). Differences between groups were

not statistically significant (ANCOVA, P = 0.753). The


mm to 2.76 mm for EMP + CAF (Wilcoxon’s Rank Sum

Test, P < 0.0001) and from 2.50 mm to 3.71 mm for

SCTG + CAF (P < 0.0156). Differences between groups

were considered statistically significant (ANCOVA, P =

0.0005).

• Paolantonio 1997 -The mean gingival recession de-

creased from 3.43 mm to 0.58 mm for SCTG + double

papilla flap and from 3.11 mm to 1.50 mm for FGG

(Mann-Whitney U-test, within-groups comparison P

= 0.000). Differences between groups were considered

statistically significant (P = 0.000).The mean width of

keratinized tissue increased from from 1.94 mm to 4.75

mm for SCTG + double papilla flap and from 1.57 mm

to 5.23 mm for FGG (within-groups comparison P <

0.000). Differences between groups were not statisti-

cally significant (P = 0.091).The data from mean clin-

ical attachment level increase were not reported in the

trial.

• Tozum 2005 - The mean gingival recession decreased

from 3.50 mm to 0.14 mm for SCTG + modified tun-

nel approach and from 3.47 mm to 0.97 mm for SCTG

+ CAF (Mann-Whitney U-test, within-groups com-


considered statistically significant (Student t-test, P =

0.005).The mean clinical attachment level decreased

from 5.14 mm to 1.14 mm for SCTG + modified tun-

nel approach and from 4.71 mm to 2.26 mm for SCTG

+ CAF (Mann-Whitney U-test, within-groups com-


considered statistically significant (Student t-test, P =

0.005).The data from mean width of keratinized tissue

were not reported in the trial.

• Trombelli 1996 - The mean gingival recession decreased

from 3.80 mm to 1.40 mm for CAF + fibrin glue + tetra-

cycline hydrochloride and from 3.40 mm to 1.70 mm

for CAF + tetracycline hydrochloride (Student t test,

within-groups comparison P < 0.0001). Differences be-

tween groups were not statistically significant (P > 0.05).

The mean clinical attachment level decreased from 5.00

mm to 2.60 mm for CAF + fibrin glue + tetracycline hy-

drochloride and from 4.40 mm to 2.50 mm for CAF +

tetracycline hydrochloride (within-groups comparison

P < 0.0001). Differences between groups were not sta-

tistically significant (P > 0.05).The mean width of ker-

atinized tissue decreased from 3.00 mm to 2.60 mm for

CAF + fibrin glue + tetracycline hydrochloride and from

2.90 mm to 2.30 mm for CAF + tetracycline hydrochlo-

ride. Differences within and between groups were not

statistically significant (P > 0.05).

• Zucchelli 2003 - The mean gingival recession decreased

from 4.00 mm to 0.10 mm for SCTG (graft size equal

to the bone dehiscence) + CAF and from 3.90 mm to

0.30 mm for SCTG (graft size 3 mm greater than the

bone dehiscence) + CAF (Student t test, within-groups

comparison P < 0.01). Differences between groups were

not statistically significant (P > 0.05). The mean clinical

attachment level decreased from 5.10 mm to 1.20 mm

for SCTG (graft size equal to the bone dehiscence) +

CAF and from 5.00 mm to 1.90 mm for SCTG (graft

size 3 mm greater than the bone dehiscence) + CAF

(within-groups comparison P < 0.01). Differences be-

tween groups were considered statistically significant (P

< 0.01). The mean width of keratinized tissue increase

from 1.10 mm to 3.40 mm for SCTG (graft size equal

to the bone dehiscence) + CAF and from 1.20 mm to

4.50 mm for SCTG (graft size 3 mm greater than the

bone dehiscence) + CAF (within-groups comparison P

< 0.01). Differences between groups were considered

statistically significant (P < 0.01).

Sites with complete root coverage and percentage of

complete root coverage

Data from the number and percentage of sites with complete

root coverage were reported in 17 studies (Bouchard 1994;

Bouchard 1997; da Silva 2004; de Queiroz 2006; Del Pizzo 2005;

Dodge 2000; Henderson 2001; Leknes 2005; Paolantonio 1997;

Paolantonio 2002; Paolantonio 2002b; Roccuzzo 1996; Trombelli

1996; Wang 2001; Woodyard 2004; Zucchelli 1998; Zucchelli

2003). Two studies reported only the percentage of sites with

complete root coverage (McGuire 2003, Spahr 2005) (Additional

Table 3).

Table 3. Root coverage outcomes - complete root coverage and mean root coverage



Table 3. Root coverage outcomes - complete root coverage and mean root coverage

Study Interventions SCRC PCRC MRC

Bouchard 1994 SCTG + CAF + citric acid

(graft without epithelial

collar)

3/15 20.0 69.7

SCTG (graft with epithe-

lial collar)

5/15 33.3 64.7

Bouchard 1997 SCTG + CAF + tetracy-

cline hydrochloride

6/15 40.0 79.3

SCTG + CAF + citric acid 8/15 53.3 84.0

da Silva 2004 SCTG + CAF 2/11 18.1 75.3

CAF 1/11 9.0 68.8

de Queiroz 2006 ADMG + CAF (6

months)

3/13 23.0 76.0

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 2005 EMP + CAF 11/15 73.3 90.7

CAF 9/15 60.0 86.7

Dodge 2000 GTR (polylactide mem-

brane - Guidor) + tetra-

cycline hydrochloride +

DFDBA

6/12 50.0 89.9


brane - Guidor) + tetracy-

cline hydrochloride

4/12 33.3 73.7



Table 3. Root coverage outcomes - complete root coverage and mean root coverage (Continued)

Henderson 2001 ADMG (basement mem-

brane side against the

tooth) + CAF

7/10 70.0 94.9

ADMG (connective tis-

sue side against the tooth)

+ CAF

8/10 80.0 95.5

Joly 2007 ADMG + CAF (without

vertical incisions)

NR NR 50.0

SCTG + CAF (without

vertical incisions)

NR NR 79.5

Keceli 2008 SCTG + platelet-rich

plasma

6/17 35.3 86.4

SCTG 8/19 42.1 86.4

Leknes 2005 GTR (polylac-

tide membrane - Guidor)

(6 months)

5/20 25.0 51.2

CAF (6 months) 10/20 50.0 63.8

GTR (polylactide


months)

4/20 20.0 51.2

CAF (12 months) 6/20 30.0 61.1

GTR (polylactide


months)

2/11 18.2 35.0

CAF (72 months) 1/11 9.1 34.2

Matarasso 1998 GTR (polylactide mem-

brane - Guidor) + double

papilla flap

NR NR 73.9


brane - Guidor) + CAF

NR NR 62.5

McGuire 2003 EMP + CAF NR 89.5 95.1

SCTG + CAF NR 79.0 93.8




Paolantonio 1997 SCTG + double papilla

flap

17/35 48.6 85.2

FGG 3/35 8.6 53.2

Paolantonio 2002 GTR (polylactide mem-

brane - Guidor)

6/15 40.0 81.0

GTR (poly-

lactic acid membrane -

Paroguide) + hydroxyap-

atite/collagen/chondroitin-

sulphate graft

8/15 53.3 87.1

SCTG + double papilla

flap

9/15 60.0 90.0

Paolantonio 2002b ADMG + CAF 4/15 26.6 83.3

SCTG + CAF 7/15 46.6 88.8

Roccuzzo 1996 GTR (polylactic acid

membrane - Guidor)

5/12 41.6 82.4

GTR (ePTFE membrane

- Gore-Tex)

5/12 41.6 82.4

Rosetti 2000 GTR (collagen

membrane) + tetracycline

hydrochloride + DFDBA

NR NR 84.2

SCTG + tetracycline hy-

drochloride

NR NR 95.6

Spahr 2005 EMP + CAF (6 months) NR NR 80.0

Placebo (propylene gly-

col alginate) + CAF (6

months)

NR NR 79.0

EMP + CAF (12 months) NR NR 80.0






months)

NR NR 79.0

EMP + CAF (24 months) NR 53.0 84.0



months)

NR 23.0 67.0

Tozum 2005 SCTG + modified tunnel

procedure

NR NR 96.4

SCTG + CAF NR NR 77.1

Trombeli 1996 CAF + fibrin glue + tetra-

cycline hydrochloride

1/11 9.1 63.1

CAF + tetracycline hy-

drochloride

2/11 18.2 52.9

Wang 2001 GTR (reabsorbable

double thickness collagen

membrane - Sulzer Den-

tal Inc.)

7/16 43.8 73.0

SCTG + CAF 7/16 43.8 84.0

Woodyard 2004 ADMG + CAF 11/12 91.6 96.0

CAF 4/12 33.3 67.0

Zucchelli 1998 GTR (polylactic acid

membrane - Guidor)

7/18 39.0 85.7

GTR (ePTFE membrane

- Gore-Tex)

5/18 28.0 80.5

SCTG + CAF 12/18 66.0 93.5

Zucchelli 2003 SCTG (graft size equal

to the bone dehiscence) +

CAF

13/15 86.7 97.3

SCTG (graft size 3 mm

greater than the bone de-

hiscence) + CAF

12/15 80.0 94.7



ADMG - acellular dermal matrix graft; CAF - coronally advanced flap; DFDBA - demineralized freeze-dried bone allograft; EMP - enamelmatrix protein; ePTFE - expanded polytetrafluorethylene; FGG - free gingival graft; GTR - guided tissue regeneration; MRC - mean rootcoverage; PCR - percentage of complete root coverage; SCRC - sites with complete root coverage; SCTG - subepithelial connective tissue graft

Among the included RCTs the percentage of complete root cov-

erage varied from 7.7% (de Queiroz 2006) to 91.6% (Woodyard

2004) for ADMG, 18.1% (da Silva 2004) to 86.7% (Zucchelli

2003) for SCTG, 53.0% (Spahr 2005) to 89.5% (McGuire 2003)

for EMP, 7.7 % (de Queiroz 2006) to 60.0% (Del Pizzo 2005)

for CAF; 33.3% (Dodge 2000) to 53.3% (Paolantonio 2002) for

GTR rm and 28.0% (Zucchelli 1998) to 41.6% (Roccuzzo 1996)

for GTR nrm (Additional Table 3).

In addition, risk ratio analyses were available for four comparisons:

• ADMG versus CAF (Outcome 2.4), GTR rm versus

SCTG (Outcome 4.4), GTR rm versus GTR nrm (Out-

come 5.4), and GTR rm + bone substitutes versus GTR

rm (Outcome 7.4) - Although no statistical differences

were found between procedures, a substantial num-

ber of patients did not achieve complete root coverage:

ADMG 14/25 (56%) and CAF 7/25 (28%), SCTG

20/49 (40.81%) and GTR rm 28/49 (57.14%) pa-

tients; GTR rm 12/30 (40.00%) and GTR nrm 10/30

(33.33%) patients; and GTR rm + bone substitutes

14/27 (51.85%) and GTR rm 10/27 (37.03%), respec-

tively.

Mean root coverage

All included trials reported the mean root coverage. This outcome

varied from 50.0% (Joly 2007) to 96.0% (Woodyard 2004) for

ADMG, 64.7% (Bouchard 1994) to 97.3% for SCTG (Zucchelli

2003), 84.0% (Spahr 2005) to 95.1% (McGuire 2003) for EMP,

55.9 % (de Queiroz 2006) to 86.7% (Del Pizzo 2005) for CAF,

62.5% (Matarasso 1998) to 73.7% (Dodge 2000) for GTR rm,

84.2 % (Rosetti 2000) to 89.9% (Dodge 2000) GTR rm associated

with bone substitutes and 80.5% (Zucchelli 1998) to 82.4% (

Roccuzzo 1996) for GTR nrm (Additional Table 3).

Patients’ preference for a specific PPS procedure

Patients’ preference for a specific PPS procedure (in split-mouth

trials) was reported in three trials (Roccuzzo 1996; Wang 2001;

Zucchelli 2003).

In the first study (Roccuzzo 1996), all patients preferred the GTR

treatment only because it was a single-step procedure.

The second trial (Wang 2001) comparing patient satisfaction with

aesthetics (i.e. amount of root coverage, colour match and overall

satisfaction) obtained by SCTG and GTR rm showed that the

participants reported greater overall satisfaction with the GTR

procedures, probably explained by the reduction in treatment time

and elimination of the need for a second surgical intervention.

In the third (Zucchelli 2003), 12 patients (80.0%) preferred the

treatment with reduced size SCTG (i.e. graft dimension equal to

the depth of the bone dehiscence) due to the better aesthetics

achieved.

Occurrence of adverse effects and/or postoperative

complications

Occurrence of adverse effects and/or postoperative complications

during the postsurgical period was reported in seven trials (Dodge

2000; Keceli 2008; McGuire 2003; Roccuzzo 1996; Spahr 2005;

Wang 2001; Zucchelli 2003).

In one trial (McGuire 2003) with a split-mouth design, patient-re-

ported discomfort was considered statistically significantly higher

for SCTG when compared to EMP + CAF, only at 1 month post-

operatively. Similarly, there was a trial (Zucchelli 2003) report-

ing greater covering flap dehiscence, a more painful palate wound

healing and necrosis of the primary palatal flap during the first

period of healing in patients treated with SCTG (i.e. graft dimen-

sion 3 mm greater than the depth of the bone dehiscence).

Two trials (Dodge 2000; Roccuzzo 1996) reported membrane ex-

posure between the first and second weeks of healing.

In one RCT (Spahr 2005) six patients felt moderate discomfort

postoperatively, without differences between treatment modalities

(CAF + EMP versus CAF).

Authors from one study (Keceli 2008) reported minor complica-

tions related to postoperative swelling occurring within the first

days after surgery, and immediate postoperative bleeding in one

donor site of SCTG.

In addition, the last trial (Wang 2001) showed that two patients

treated with SCTG experienced adverse effects: one patient expe-

rienced postsurgical swelling and the other postsurgical ecchymo-

sis.

D I S C U S S I O N

Summary of main results

The objectives of the periodontal plastic surgery (PPS) procedures

are to improve patients’ aesthetic conditions and other clinical out-

comes (e.g. clinical attachment level and the width of keratinized

tissue) through the coverage of previously denuded root surfaces.

As reported as primary and secondary outcomes, a summary of

the main results is depicted below.

Primary outcomes



In spite of aesthetics being considered the primary goal of root

coverage procedures, few studies had evaluated aesthetic condition

change related to patients’ opinion (Bouchard 1994; Rosetti 2000;

Wang 2001; Zucchelli 2003). In these studies, the majority of

the patients were satisfied with the final aesthetic result achieved.

Also, procedures that make a reduction in the operatory time pos-

sible, that eliminate the need for a second surgical site and their

associated morbidity (guided tissue regeneration with resorbable

membranes (GTR rm)) (Wang 2001) and that use smaller palatal

grafts (Zucchelli 2003) were better accepted by the patients.

Results from meta-analyses demonstrated that subepithelial con-

nective tissue grafts (SCTG) led to a statistically significant gain in

gingival recession when compared to GTR rm procedures. Whilst

statistical analyses (i.e. meta-analyses) did not reveal significant

differences between group comparisons, it was possible to demon-

strate that the evaluated procedures were similarly efficient in re-

ducing baseline mean gingival recession.

Secondary outcomes

With respect to secondary outcomes, three comparisons showed

significant improvements in the width of keratinized tissue for

SCTG and enamel matrix protein (EMP) when compared to GTR

rm (associated or not with bone substitutes) and coronally ad-

vanced flap (CAF), respectively (Additional Table 1).

Only one trial reported results from free gingival grafts compared

to SCTG after a follow-up period of 5 years (Paolantonio 1997).

The results of this study evidenced the superiority of connective

grafts in terms of gains in root coverage and similarities in the

amount of keratinized tissue achieved.

Also, there was a markedly variation in the amount of root coverage

achieved. Mean root coverage was of 80.9% (50 % to 97.3%) and

complete root coverage of 46.6% (7.7% to 91.6%) (Additional

Table 3). Additionally, data from two long-term trials (de Queiroz

2006; Leknes 2005) showed that both mean root coverage and

complete root coverage decreased over time.

Patients’ preference for a specific PPS procedure followed the same

pattern as aesthetics condition change (Roccuzzo 1996; Zucchelli

2003).

Occurence of an early discomfort with or without pain was related

to donor sites of SCTG (McGuire 2003; Wang 2001; Zucchelli

2003). This aspect may be related to the size of the graft ob-

tained from the palate and the surgical approach used (Zucchelli

2003). With respect to GTR techniques, membrane exposure dur-

ing healing was associated with primary postoperative complica-

tions (Dodge 2000; Roccuzzo 1996).

Overall findings and conditions

Although 24 randomised controlled trials (RCTs) were included

in this systematic review, it was difficult to combine data from

these trials due to a great variability of comparisons between the

various PPS procedures and the inexistence of a gold standard con-

trol group. Consequently, only 12 trials were incorporated into

meta-analyses (de Queiroz 2006; Del Pizzo 2005; Dodge 2000;

Joly 2007; Paolantonio 2002; Paolantonio 2002b; Roccuzzo 1996;

Rosetti 2000; Spahr 2005; Wang 2001; Woodyard 2004; Zucchelli

1998) in seven different group comparisons (i.e. six analyses con-

sisted of two studies and one of three studies) (Additional Table

1). These aspects prevent us from drawing definitive conclusions.

Few studies reported a follow-up period superior to 12 months (de

Queiroz 2006; Del Pizzo 2005; Paolantonio 1997; Rosetti 2000;

Spahr 2005). In three of these studies a chronological evaluation

of the results evidenced loss in the amount of root coverage ob-

tained (e.g. mean root coverage and sites with complete root cov-

erage) mainly between the 6 to 12 months period of evaluation (

de Queiroz 2006; Del Pizzo 2005; Spahr 2005). Long-term pe-

riod evaluations are probably linked to individual conditions such

as changes in the periodontal health status, toothbrushing, habits

and genetic and systemic conditions.

Overall, the results of this systematic review demonstrated that all

included studies showed statistically significant reduction in the

extent of gingival recession and concomitant gain in the clinical

attachment level with or without improvements in keratinized

tissue.

Quality of the evidence

All the authors who had articles included in this review were con-

tacted to supply additional details regarding the methodological

quality of their trials by means of a questionnaire (e.g. regarding

the method of randomisation, allocation concealment, blindness

of examiners and completeness of the follow-up period). Consid-

ering the replies provided by the authors only one RCT was as-

sessed as at low risk of bias (McGuire 2003), while the remaining

studies were assessed as at high risk of bias because one or more

criteria were not met. Therefore, the lack of allocation conceal-

ment and/or blinding and inadequate methods of randomisation,

as well as the lack of similar inclusion criteria between trials, can

act as source of biases and can affect the accuracy of the results (

Needleman 2002; Needleman 2005).

Potential biases in the review process

In this review, only defects > 3 mm were included in order to mini-

mize heterogeneity between the trials. However, this inclusion cri-

terion could have eliminated data from studies that could be in-

corporated into meta-analyses (see Agreements and disagreements

with other studies or reviews). In addition, the limited number of

studies included into the meta-analyses prevented formal testing

for publication bias.

Agreements and disagreements with otherstudies or reviews



Data from the included studies in this review have shown that

the percentage of success achieved by PPS procedures was regu-

larly associated with improvements in the clinical parameters (i.e.

outcomes measures), mainly evaluated by gains in the clinical at-

tachment level and in the width of keratinized tissue and achieved

mean root coverage. Nevertheless, different authors have pointed

out that these currently used parameters only reflect the final clin-

ical results expected and not the changes that had occurred in pa-

tient-centred outcomes, such as changes in the aesthetic condition,

functional limitations (e.g. limitations in chew and deglutition of

food), discomfort, pain, alterations in the level of sociability after

surgery (e.g. psychological and behavioural impact), and patients’

preference for a specific PPS procedure in trials with a split-mouth

design (Needleman 2005b; Ng 2006; Ozcelik 2007; Roccuzzo

2002). Consequently, patients and professionals can present dif-

ferent points of view regarding the performed procedures and the

achieved final result.

More objective patient-centred evaluations can be performed

through the use of visual scales. The Visual Analogue Scale (VAS)

is a tool that has been used to evaluate the levels of discomfort

and pain subsequent to different modalities of periodontal treat-

ment (Checchi 1993; Fardal 2002; Karadottir 2002; Matthews

1993). This resource can be applied to evaluate various aesthetic

and functional individual outcomes. In a recent study (Jørnung

2007) the use of VAS showed that the opinion of the patients

with respect to their own smile was statistically significantly bet-

ter than the opinion of two different clinicians, highlighting that

the patient’s individual perception can influence clinical decision

making choice.

The great variability in the percentages of sites with complete and

mean root coverage is probably associated with a set of factors

such as the type of defect, amount and quality of adjacent gingi-

val tissue, sample size and the applied inclusion criteria (e.g. pa-

tients’ selection, methodological quality, type of technique, de-

vices used for measurements and differences between operators).

It seems that the amount of root coverage obtained is associated

with initial recession anatomy. Better results in terms of percent-

age of complete and mean root coverage can be expected when

baseline recession defects are < 4 mm (Berlucchi 2005), at the

same time flaps with < 1 mm thickness can harm the achievement

of complete root coverage (Baldi 1999; Berlucchi 2005).Thick

and wide interproximal dental papillae can positively influence

the percentage of complete root coverage (Berlucchi 2005; Saletta

2001), however, their baseline anatomy is directly associated with

the distance from the contact point to the bone crest. When the

measurement from the contact point to the bone crest is 5 mm

or less, the papilla is present almost 100% of the time, whereas,

when the distance is 6 mm, the papilla is present 56% of the time

(Tarnow 1992). When this distance is between 7 to 10 mm the

papilla is missing most of the time (Tarnow 1992). It should also

be noted that the inclusion of studies with recession defects > 4

mm tends to show greater differences between baseline and fol-

low-up means (i.e. outcome change), a factor that may influence

the calculation of meta-analyses. With respect to flap tension, it

has been suggested that the higher the flap tension, the lower the

recession reduction (Pini 2000). Consequently, all theses factors

make comparisons and combination of data from different trials a

critical issue. In this way, trials investigating the treatment of gin-

gival recession with similar baseline characteristics or which have

included baseline and final individual defects measurements will

allow more effective evaluations of each surgical technique, as well

as facilitating future meta-analyses.

It has been shown that smoking can affect the results obtained by

PPS procedures (Chambrone 2009). Five trials reported the inclu-

sion of smokers (Bouchard 1994; Bouchard 1997; McGuire 2003;

Spahr 2005; Zucchelli 1998). Bouchard 1994; Bouchard 1997;

Spahr 2005 included patients who smoked less than 10 cigarettes

per day. None of them performed comparisons between smokers

and non-smokers. Zucchelli 1998 commented only that patients

who smoke more than 10 cigarettes a day presented the worst

percentage of root coverage. This is in line with the data from

recent studies that have compared the amount of root coverage

obtained by smokers and non-smokers through CAF (Silva 2007)

and SCTG (Erley 2006; Martins 2004). Similarly, root modifica-

tion agents (e.g. tetracycline solution and citric acid) were evalu-

ated in few studies. Nevertheless, these RCTs have suggested that

there is no significant clinical benefit of root conditioning in con-

junction with root coverage procedures (Additional Table 2).

In recent years, some extensive systematic reviews have evaluated

the effects of PPS procedures in the treatment of recession defects.

Roccuzzo 2002 used stringent inclusion criteria, but it also in-

cluded non-randomised trials, gingival recessions < 3 mm and did

not evaluate changes in the width of keratinized tissue or the use

of biomaterials such as acellular dermal matrix grafts. Oates 2003

included only RCTs and its inclusion criteria were only based on

the terms ’human study, English language, and therapeutic study

including the use of a gingival surgical procedure to treat gingi-

val recession’. Chambrone 2008 focused mainly on the treatment

of recession defects with SCTG. These reviews did not include

searches for unpublished data (i.e. grey literature), papers pub-

lished in all languages (Chambrone 2008; Oates 2003; Roccuzzo

2002) or evaluation of the risk of bias (Oates 2003; Roccuzzo

2002). However, their results were similar to ours.

Several trials on PPS have been performed evaluating different

procedures as control groups. They have evidenced the lack of

a standard procedure that could be considered as gold standard

(i.e. control group) for the majority of trials. In this review, the

exclusion of non-randomised studies and the use of stringent in-

clusion criteria may have led to the loss of evidence-based infor-

mation since only studies which compared two (or more) active

treatments were studied (since a placebo or no control treatment

group were not possible). Studies that evaluated recession defects <

3 mm were also excluded. Overall, data from the included studies

indicate that the SCTG is the procedure that can become this gold



standard; however, further research on this matter is needed.

In addition, similar to another Cochrane review (Esposito 2005),

the majority of included RCTs were often performed on patients

presenting different clinical and systemic conditions from those

currently found in a conventional private practice. These condi-

tions can cause more variability of the results when extrapolated

to daily practice.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

1. Subepithelial connective tissue grafts (SCTG), coronally ad-

vanced flaps (CAF) alone or associated with grafts

or biomaterials (e.g. acellular dermal matrix grafts

(ADMG), enamel matrix protein (EMP) and SCTG)

and guided tissue regeneration (GTR) may be used as

root coverage procedures for the treatment of recession-

type defects. In case where both root coverage and gain

in the width of keratinized tissue are expected, the use

of SCTG seems to be more adequate.

2. Acellular dermal matrix grafts may be an alternative in

cases where SCTG harvested from the palate are not

sufficient to cover a recession area.

3. Root modification agents may be used for root condi-

tioning, however it is not evident that these products

will improve root coverage.

Implications for research

1. Further randomised controlled trials (RCTs) are required

to evaluate primary (i.e. especially aesthetics) and sec-

ondary outcomes between different procedures, as well

as to establish a gold standard procedure for the treat-

ment of recession-type defects.

2. Precise and objective aesthetic evaluations should be in-

cluded in future studies. The use of the Visual Analogue

Scale (VAS) will allow more precise evaluations of pa-

tient-based outcomes.

3. 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-anal-

yses. These outcome measures should include gingival

recession depth and width, clinical attachment level,

width and thickness of keratinized tissue, and root sur-

face conditions (i.e. presence of caries, abrasions or

restorations).

4. Comparisons between different operators (i.e. with re-

spect to the degree of operator’s experience) are nec-

essary to evaluate differences in the expected outcome

measures.

5. Multicentre studies may favour the inclusion and eval-

uation of larger samples of patients and therefore the

achievement of statistical power.

6. Long-term RCTs are necessary to adequately confirm

and identify possible factors associated with the prog-

nosis and indications of each periodontal plastic surgery

(PPS) procedure. The Consolidated Standards of Re-

porting Trials (CONSORT) Statement ( www.consort-

statement.org/) should be considered when designing

and reporting future studies.

Overall conclusions

Primary outcomes

1. Limited data exist on aesthetic condition change related

to patient’s opinion.

2. All PPS procedures led to statistically significant gains

in gingival recession.

3. Subepithelial connective tissue grafts were statistically

superior to GTR with resorbable membranes (GTR rm)

in achieving root coverage.

4. The remaining meta-analyses comparisons (e.g.

ADMG versus SCTG, ADMG versus CAF, EMP +

CAF versus CAF, GTR rm versus GTR nrm, GTR

rm associated with bone substitutes versus GTR rm)

did not show statistically significant differences in the

amount of root coverage achieved. However, few RCTs

were available for analysis.

Secondary outcomes

1. The majority of procedures produced significant gains

in clinical attachment level and in the width of kera-

tinized tissue. Also, a great variability in the percentages

of complete root coverage and mean root coverage was

observed.

2. Subepithelial connective tissue grafts were statistically

superior to GTR rm (with or without bone substitutes),

and EMP + CAF were superior to CAF alone with re-

spect to keratinized tissue gain.

3. Few included studies reported patients’ preference for a

specific PPS procedure (in split-mouth trials).

4. The incidence of adverse effects, such as discomfort with

or without pain, was directly related to donor sites of

SCTG.

Also it can be concluded that.



http://www.consort-statement.org/

http://www.consort-statement.org/

1. The potential impact of bias on these outcomes (pri-

mary and secondary) is unclear.

2. In accordance with the proposed inclusion criteria,

of the different periodontal plastic surgery procedures

analysed in randomised controlled clinical trials, no data

exist for lateral positioned flaps and there is limited data

for free gingival grafts.

3. Outcome measures of the evaluated surgical techniques

were not improved by the use of root modification

agents (e.g. citric acid or tetracycline solution).

A C K N O W L E D G E M E N T S

The review authors would like to acknowledge Sylvia Bickley and

Anne Littlewood for their assistance and comments on the search

strategy section and the Cochrane Oral Health Group (Helen Wor-

thington, Marco Esposito, Ian Needleman and Luisa Fernandez

Mauleffinch) for their help with the preparation of the protocol

and full text of the present review.

R E F E R E N C E S

References to studies included in this review

Bouchard 1994 {published data only}

Bouchard P, Etienne D, Ouhayoun JP, Nilveus R. Subepithelial con-

nective tissue grafts in the treatment of gingival recessions. A com-

parative study of 2 procedures. Journal of Periodontology 1994;65:

929–36.

Bouchard 1997 {published data only}

Bouchard P, Nilveus R, Etienne D. Clinical evaluation of tetracycline

HCl conditioning in the treatment of gingival recessions. A compar-

ative study. Journal of Periodontology 1997;68(3):262–9.

da Silva 2004 {published data only}

da Silva RC, Joly JC, de Lima AF, Tatakis DN. Root coverage using the

coronally positioned flap with or without a subepithelial connective

tissue graft. Journal of Periodontology 2004;75(3):413–9.

de Queiroz 2006 {published data only}

de Queiroz Cortes A, Martins AG, Nociti FH Jr, Sallum AW, Casati

MZ, Sallum EA. Coronally positioned flap with or without acellular

dermal matrix graft in the treatment of Class I gingival recessions: a

randomized controlled clinical study. Journal of Periodontology 2004;

75(8):1137–44.∗ de Queiroz Cortes A, Sallum AW, Casati MZ, Nociti FH Jr, Sallum

EA. A two-year prospective study of coronally positioned flap with

or without acellular dermal matrix graft. Journal of Clinical Periodon-

tology 2006;33(9):683–9.

Del Pizzo 2005 {published data only}

Del Pizzo M, Zucchelli G, Modica F, Villa R, Debernardi C. Coro-

nally advanced flap with or without enamel matrix derivative for root

coverage: a 2-year study. Journal of Clinical Periodontology 2005;32

(11):1181–7.

Dodge 2000 {published data only}

Dodge JR, Greenwell H, Drisko C, Wittwer JW, Yancey J, Rebitski

G. Improved bone regeneration and root coverage using a resorbable

membrane with physically assisted cell migration and DFDBA. The

International Journal of Periodontics & Restorative Dentistry 2000;20

(4):398–411.

Henderson 2001 {published data only}

Henderson RD, Greenwell H, Drisko C, Regennitter FJ, Lamb JW,

Mehlbauer MJ, et al.Predictable multiple site root coverage using an

acellular dermal matrix allograft. Journal of Periodontology 2001;72

(5):571–82.

Joly 2007 {published data only}

Joly JC, Carvalho AM, da Silva RC, Ciotti DL, Cury PR. Root cov-

erage in isolated gingival recessions using autograft versus allograft:

a pilot study. Journal of Periodontology 2007;78(6):1017–22.

Keceli 2008 {published data only}

Keceli HG, Sengun D, Berberoglu A, Karabulut E. Use of platelet

gel with connective tissue grafts for root coverage: a randomized-

controlled trial. Journal of Clinical Periodontology 2008;35(3):255–

62.

Leknes 2005 {published data only}

Amarante ES, Leknes KN, Skavland J, Lie T. Coronally positioned

flap procedures with or without a bioabsorbable membrane in the

treatment of human gingival recession. Journal of Periodontology

2000;71(6):989–98.∗ Leknes KN, Amarante ES, Price DE, Boe OE, Skavland RJ, Lie T.

Coronally positioned flap procedures with or without a biodegradable

membrane in the treatment of human gingival recession. A 6-year



follow-up study. Journal of Clinical Periodontology 2005;32(5):518–

29.

Matarasso 1998 {published data only}

Matarasso S, Cafiero C, Coraggio F, Vaia E, de Paoli S. Guided tissue

regeneration versus coronally repositioned flap in the treatment of

recession with double papillae. The International Journal of Periodon-

tics & Restorative Dentistry 1998;18(5):444–53.

McGuire 2003 {published data only}

McGuire MK, Nunn M. Evaluation of human recession defects

treated with coronally advanced flaps and either enamel matrix

derivative or connective tissue. Part 1: Comparison of clinical pa-

rameters. Journal of Periodontology 2003;74(8):1110–25.

Paolantonio 1997 {published data only}

Paolantonio M, di Murro C, Cattabriga A, Cattabriga M. Subpedicle

connective tissue graft versus free gingival graft in the coverage of

exposed root surfaces. A 5-year clinical study. Journal of Clinical

Periodontology 1997;24(1):51–6.

Paolantonio 2002 {published data only}

Paolantonio M. Treatment of gingival recessions by combined peri-

odontal regenerative technique, guided tissue regeneration, and sub-

pedicle connective tissue graft. A comparative clinical study. Journal

of Periodontology 2002;73(1):53–62.

Paolantonio 2002b {published data only}

Paolantonio M, Dolci M, Esposito P, D’Archivio D, Lisanti L, Di

Luccio A, et al.Subpedicle acellular dermal matrix graft and autoge-

nous connective tissue graft in the treatment of gingival recessions:

a comparative 1-year clinical study. Journal of Periodontology 2002;

73(11):1299–307.

Roccuzzo 1996 {published data only}

Roccuzzo M, Lungo M, Corrente G, Gandolfo S. Comparative study

of a bioresorbable and a non-resorbable membrane in the treatment

of human buccal gingival recessions. Journal of Periodontology 1996;

67(1):7–14.

Rosetti 2000 {published data only}

Rosetti EP, Marcantonio RA, Rossa C Jr, Chaves ES, Goissis G,

Marcantonio E Jr. Treatment of gingival recession: comparative

study between subepithelial connective tissue graft and guided tissue

regeneration. Journal of Periodontology 2000;71(9):1441–7.

Spahr 2005 {published data only}

Hagewald S, Spahr A, Rompola E, Haller B, Heijl L, Bernimoulin JP.

Comparative study of Emdogain and coronally advanced flap tech-

nique in the treatment of human gingival recessions. A prospective

controlled clinical study. Journal of Clinical Periodontology 2002;29

(1):35–41.∗ Spahr A, Haegewald S, Tsoulfidou F, Rompola E, Heijl L, Berni-

moulin JP, et al.Coverage of Miller class I and II recession defects us-

ing enamel matrix proteins versus coronally advanced flap technique:

a 2-year report. Journal of Periodontology 2005;76(11):1871–80.

Tozum 2005 {published data only}

Tozum TF, Keceli HG, Guncu GN, Hatipoglu H, Sengun D. Treat-

ment of gingival recession: comparison of two techniques of subep-

ithelial connective tissue graft. Journal of Periodontology 2005;76

(11):1842–8.

Trombelli 1996 {published data only}

Trombelli L, Scabbia A, Wikesjö UM, Calura G. Fibrin glue appli-

cation in conjunction with tetracycline root conditioning and coro-

nally positioned flap procedure in the treatment of human gingival

recession defects. Journal of Clinical Periodontology 1996;23(9):861–

7.

Wang 2001 {published data only}

Wang HL, Bunyaratavej P, Labadie M, Shyr Y, MacNeil RL. Com-

parison of 2 clinical techniques for treatment of gingival recession.

Journal of Periodontology 2001;72(10):1301–11.

Woodyard 2004 {published data only}

Woodyard JG, Greenwell H, Hill M, Drisko C, Iasella JM, Scheetz J.

The clinical effect of acellular dermal matrix on gingival thickness and

root coverage compared to coronally positioned flap alone. Journal


Zucchelli 1998 {published data only}

Zucchelli G, Clauser C, De Sanctis M, Calandriello M. Mucogingival

versus guided tissue regeneration procedures in the treatment of deep

recession type defects. Journal of Periodontology 1998;69(2):138–45.

Zucchelli 2003 {published data only}

Zucchelli G, Amore C, Sforzal NM, Montebugnoli L, De Sanctis M.

Bilaminar techniques for the treatment of recession-type defects. A

comparative clinical study. Journal of Clinical Periodontology 2003;

30(10):862–70.

References to studies excluded from this review

Aichelmann Reidy 2001 {published data only}

Aichelmann-Reidy ME, Yukna RA, Evans GH, Nasr HF, Mayer ET.

Clinical evaluation of acellular allograft dermis for the treatment of

human gingival recession. Journal of Periodontology 2001;72(8):998–

1005.

Barros 2004 {published data only}

Barros RR, Novaes AB, Grisi MF, Souza SL, Taba MJ, Palioto DB.

A 6-month comparative clinical study of a conventional and a new

surgical approach for root coverage with acellular dermal matrix.


Barros 2005 {published data only}

Barros RR, Novaes AB Jr, Grisi MF, Souza SL, Taba M Jr, Palioto DB.

New surgical approach for root coverage of localized gingival recession

with acellular dermal matrix: a 12-month comparative clinical study.

Journal of Esthetic and Restorative Dentistry 2005;17(3):156–64.

Berlucchi 2002 {published data only}

Berlucchi I, Francetti L, Del Fabbro M, Testori T, Weinstein RL.

Enamel matrix proteins (Emdogain) in combination with coronally

advanced flap or subepithelial connective tissue graft in the treatment

of shallow gingival recessions. The International Journal of Periodon-

tics & Restorative Dentistry 2002;22(6):583–93.

Berlucchi 2005 {published data only}

Berlucchi I, Francetti L, Del Fabbro M, Basso M, Weinstein RL. The

influence of anatomical features on the outcome of gingival recessions

treated with coronally advanced flap and enamel matrix derivative: a

1-year prospective study. Journal of Periodontology 2005;76(6):899–

907.

Bittencourt 2006 {published data only}

Bittencourt S, Del Peloso Ribeiro E, Sallum EA, Sallum AW, Nociti

FH Jr, Casati MZ. Comparative 6-month clinical study of a semilunar



coronary positioned flap and subepithelial connective tissue graft for

the treatment of gingival recession. Journal of Periodontology 2006;

77(2):174–81.

Borghetti 1994 {published data only}

Borghetti A, Louise F. Controlled clinical evaluation of the subpedicle

connective tissue graft for the coverage of gingival recession. Journal


Borghetti 1999 {published data only}

Borghetti A, Glise JM, Monnet-Corti V, Dejou J. Comparative clin-

ical study of a bioabsorbable membrane and subepithelial connective

tissue graft in the treatment of human gingival recession. Journal of


Burkhardt 2005 {published data only}

Burkhardt R, Lang NP. Coverage of localized gingival recessions:

comparison of micro- and macrosurgical techniques. Journal of Clin-

ical Periodontology 2005;32(3):287–93.

Caffesse 2000 {published data only}

Caffesse RG, De LaRosa M, Garza M, Munne-Travers A, Mondragon

JC, Weltman R. Citric acid demineralization and subepithelial con-

nective tissue grafts. Journal of Periodontology 2000;71(4):568–72.

Castellanos 2006 {published data only}

Castellanos A, de la Rosa M, de la Garza M, Caffesse RG. Enamel

matrix derivative and coronal flaps to cover marginal tissue recessions.


Cetiner 2003 {published data only}

Cetiner D, Parlar A, Balos K, Alpar R. Comparative clinical study of

connective tissue graft and two types of bioabsorbable barriers in the

treatment of localized gingival recessions. Journal of Periodontology

2003;74(8):1196–205.

Cheung 2004 {published data only}

Cheung WS, Griffin TJ. A comparative study of root coverage with

connective tissue and platelet concentrate grafts: 8-month results.


Cordioli 2001 {published data only}

Cordioli G, Mortarino C, Chierico A, Grusovin MG, Majzoub Z.

Comparison of 2 techniques of subepithelial connective tissue graft in

the treatment of gingival recessions. Journal of Periodontology 2001;

72(11):1470–6.

Daniel 1990 {published data only}

Daniel A, Cheru R. Treatment of localised gingival recession with

subpedicle connective tissue graft and free gingival auto graft--a com-

parative clinical evaluation. Journal of the Indian Dental Association

1990;61(12):294–7.

Dembowska 2007 {published data only}

Dembowska E, Drozdzik A. Subepithelial connective tissue graft

in the treatment of multiple gingival recession. Oral Surgery, Oral

Medicine, Oral Pathology, Oral Radiology, and Endodontics 2007;104

(3):1–7.

Duval 2000 {published data only}

Duval BT, Maynard JG, Gunsolley JC, Waldrop TC. Treatment of

human mucogingival defects utilizing a bioabsorbable membrane

with and without a demineralized freeze-dried bone allograft. Journal


Erley 2006 {published data only}

Erley KJ, Swiec GD, Herold R, Bisch FC, Peacock ME. Gingival

recession treatment with connective tissue grafts in smokers and non-

smokers. Journal of Periodontology 2006;77(7):1148–55.

Felipe 2007 {published data only}

Felipe ME, Andrade PF, Grisi MF, Souza SL, Taba M, Palioto DB,

et al.Comparison of two surgical procedures for use of the acellular

dermal matrix graft in the treatment of gingival recessions: a ran-

domized controlled clinical study. Journal of Periodontology 2007;78

(7):1209–17.

Gupta 2006 {published data only}

Gupta R, Pandit N, Sharma M. Clinical evaluation of a bioresorbable

membrane (polyglactin 910) in the treatment of Miller type II gingi-

val recession. The International Journal of Periodontics & Restorative

Dentistry 2006;26(3):271–7.

Harris 1997 {published data only}

Harris RJ. A comparative study of root coverage obtained with guided

tissue regeneration utilizing a bioabsorbable membrane versus the

connective tissue with partial-thickness double pedicle graft. Journal



Harris RJ. A comparative study of root coverage obtained with an

acellular dermal matrix versus a connective tissue graft: results of

107 recession defects in 50 consecutively treated patients. The Inter-

national Journal of Periodontics & Restorative Dentistry 2000;20(1):

51–9.


Harris RJ. Root coverage with connective tissue grafts: an evaluation

of short- and long-term results. Journal of Periodontology 2002;73

(9):1054–9.


Harris RJ, Miller LH, Harris CR, Miller RJ. A comparison of three

techniques to obtain root coverage on mandibular incisors. Journal


Hirsch 2005 {published data only}

Hirsch A, Goldstein M, Goultschin J, Boyan BD, Schwartz Z. A 2-

year follow-up of root coverage using sub-pedicle acellular dermal

matrix allografts and subepithelial connective tissue autografts. Jour-

nal of Periodontology 2005;76(8):1323–8.

Huang 2005 {published data only}

Huang LH, Neiva RE, Soehren SE, Giannobile WV, Wang HL. The

effect of platelet-rich plasma on the coronally advanced flap root

coverage procedure: a pilot human trial. Journal of Periodontology

2005;76(10):1768–77.

Ito 2000 {published data only}

Ito K, Oshio K, Shiomi N, Murai S. A preliminary comparative study

of the guided tissue regeneration and free gingival graft procedures

for adjacent facial root coverage. Quintessence International 2000;31

(5):319–26.

Jahnke 1993 {published data only}

Jahnke PV, Sandifer JB, Gher ME, Gray JL, Richardson AC. Thick

free gingival and connective tissue autografts for root coverage. Jour-




Jepsen 1998 {published data only}

Jepsen K, Heinz B, Halben JH, Jepsen S. Treatment of gingival reces-

sion with titanium reinforced barrier membranes versus connective

tissue grafts. Journal of Periodontology 1998;69(3):383–91.

Kennedy 1985 {published data only}

Kennedy JE, Bird WC, Palcanis KG, Dorfman HS. A longitudinal

evaluation of varying widths of attached gingiva. Journal of Clinical


Kimble 2004 {published data only}

Kimble KM, Eber RM, Soehren S, Shyr Y, Wang HL. Treatment of

gingival recession using a collagen membrane with or without the use

of demineralized freeze-dried bone allograft for space maintenance.


Lafzi 2007 {published data only}

Lafzi A, Mostofi Zadeh Farahani R, Abolfazli N, Amid R, Safaiyan

A. Effect of connective tissue graft orientation on the root coverage

outcomes of coronally advanced flap. Clinical Oral Investigations

2007;11(4):401–8.

Laney 1992 {published data only}

Laney JB, Saunders VG, Garnick JJ. A comparison of two techniques

for attaining root coverage. Journal of Periodontology 1992;63(1):

19–23.

Lins 2003 {published data only}

Lins LH, de Lima AF, Sallum AW. Root coverage: comparison of

coronally positioned flap with and without titanium-reinforced bar-

rier membrane. Journal of Periodontology 2003;74(2):168–74.

Mahajan 2007 {published data only}

Mahajan A, Dixit J, Verma UP. A patient-centered clinical evaluation

of acellular dermal matrix graft in the treatment of gingival recession

defects. Journal of Periodontology 2007;78(12):2348–55.

Modica 2000 {published data only}

Modica F, Del Pizzo M, Roccuzzo M, Romagnoli R. Coronally ad-

vanced flap for the treatment of buccal gingival recessions with and

without enamel matrix derivative. A split-mouth study. Journal of


Moses 2006 {published data only}

Moses O, Artzi Z, Sculean A, Tal H, Kozlovsky A, Romanos GE, et

al.Comparative study of two root coverage procedure: a 24-month

follow-up multicenter study. Journal of Periodontology 2006;77(2):

195–202.

Muller 1998 {published data only}

Muller HP, Eger T, Schorb A. Gingival dimensions after root coverage

with free connective tissue grafts. Journal of Clinical Periodontology

1998;25(5):424–30.

Muller 1999 {published data only}

Muller HP, Stahl M, Eger T. Root coverage employing an envelope

technique or guided tissue regeneration with a bioabsorbable mem-

brane. Journal of Periodontology 1999;70(7):743–51.

Nemcovsky 2004 {published data only}

Nemcovsky CE, Artzi Z, Tal H, Kozlovsky A, Moses O. A multicen-

ter comparative study of two root coverage procedures: coronally ad-

vanced flap with addition of enamel matrix proteins and subpedicle

connective tissue graft. Journal of Periodontology 2004;75(4):600–7.

Novaes 2001 {published data only}

Novaes AB Jr, Grisi DC, Molina GO, Souza SL, Taba M Jr, Grisi MF.

Comparative 6-month clinical study of a subepithelial connective

tissue graft and acellular dermal matrix graft for the treatment of

gingival recession. Journal of Periodontology 2001;72(11):1477–84.

Pilloni 2006 {published data only}

Pilloni A, Paolantonio M, Camargo PM. Root coverage with a coro-

nally positioned flap used in combination with enamel matrix deriva-

tive: 18-month clinical evaluation. Journal of Periodontology 2006;

77(12):2031–9.

Pini Prato 1992 {published data only}

Pini Prato G, Tinti C, Vincenzi G, Magnani C, Cortellini P, Clauser

C. Guided tissue regeneration versus mucogingival surgery in the

treatment of human buccal gingival recession. Journal of Periodon-

tology 1992;63(11):919–28.


Pini Prato G, Clauser C, Cortellini P, Tinti C, Vincenzi G, Pagliaro

U. Guided tissue regeneration versus mucogingival surgery in the

treatment of human buccal recessions. A 4-year follow-up study.



Pini-Prato G, Baldi C, Pagliaro U, Nieri M, Saletta D, Rotundo R, et

al.Coronally advanced flap procedure for root coverage. Treatment of

root surface: root planning versus polishing. Journal of Periodontology

1999;70(9):1064–76.


Pini Prato G, Pagliaro U, Baldi C, Nieri M, Saletta D, Cairo F, et

al.Coronally advanced flap procedure for root coverage. Flap with

tension versus flap without tension: a randomized controlled clinical

study. Journal of Periodontology 2000;71(2):188–201.


Pini Prato GP, Baldi C, Nieri M, Franseschi D, Cortellini P, Clauser

C, et al.Coronally advanced flap: the post-surgical position of the

gingival margin is an important factor for achieving complete root

coverage. Journal of Periodontology 2005;76(5):713–22.

Rahmani 2006 {published data only}

Rahmani ME, Lades MA. Comparative clinical evaluation of acellular

dermal matrix allograft and connective tissue graft for the treatment

of gingival recession. The Journal of Contemporary Dental Practice

2006;7(2):63–70.

Ricci 1996 {published data only}

Ricci G, Silvestri M, Rasperini G, Cattaneo V. Root coverage: a

clinical/statistical comparison between subpedicle connective tissue

graft and laterally positioned full thickness flaps. Journal of Esthetic

Dentistry 1996;8(2):66–73.

Ricci 1996b {published data only}

Ricci G, Silvestri M, Tinti C, Rasperini G. A clinical/statistical com-

parison between the subpedicle connective tissue graft method and

the guided tissue regeneration technique in root coverage. The Inter-

national Journal of Periodontics & Restorative Dentistry 1996;16(6):

538–45.

Romagna-Genon 2001 {published data only}

Romagna-Genon C. Comparative clinical study of guided tissue

regeneration with a bioabsorbable bilayer collagen membrane and



subepithelial connective tissue graft. Journal of Periodontology 2001;

72(9):1258–64.

Sallum 2003 {published data only}

Sallum EA, Casati MZ, Caffesse RG, Funis LP, Nociti Junior FH,

Sallum AW. Coronally positioned flap with or without enamel matrix

protein derivative for the treatment of gingival recessions. American

Journal of Dentistry 2003;16(5):287–91.

Sbordone 1988 {published data only}

Sbordone L, Ramaglia L, Spagnuolo G, De Luca M. A comparative

study of free gingival and subepithelial connective tissue grafts. Pe-

riodontal Case Reports 1988;10(1):8–12.

Scabbia 1998 {published data only}

Scabbia A, Trombelli L. Long-term stability of the mucogingival

complex following guided tissue regeneration in gingival recession

defects. Journal of Clinical Periodontology 1998;25(12):1041–6.

Tal 2002 {published data only}

Tal H, Moses O, Zohar R, Meir H, Nemcovsky C. Root coverage of

advanced gingival recession: a comparative study between acellular

dermal matrix allograft and subepithelial connective tissue grafts.


Tatakis 2000 {published data only}

Tatakis DN, Trombelli L. Gingival recession treatment: guided tissue

regeneration with bioabsorbable membrane versus connective tissue

graft. Journal of Periodontology 2000;71(2):299–307.

Trabulsi 2004 {published data only}

Trabulsi M, Oh TJ, Eber R, Weber D, Wang HL. Effect of enamel

matrix derivative on collagen guided tissue regeneration-based root

coverage procedure. Journal of Periodontology 2004;75(11):1446–

57.


Trombelli L, Schincaglia GP, Scapoli C, Calura G. Healing response

of human buccal gingival recessions treated with expanded polyte-

trafluoroethylene membranes. A retrospective report. Journal of Pe-

riodontology 1995;66(1):14–22.

Trombelli 1995b {published data only}

Trombelli L, Schincaglia GP, Zangari F, Griselli A, Scabbia A, Calura

G. Effects of tetracycline HCl conditioning and fibrin-fibronectin

system application in the treatment of buccal gingival recession with

guided tissue regeneration. Journal of Periodontology 1995;66(5):

313–20.


Trombelli L, Tatakis DN, Scabbia A, Zimmerman GJ. Comparison of

mucogingival changes following treatment with coronally positioned

flap and guided tissue regeneration procedures. The International

Journal of Periodontics & Restorative Dentistry 1997;17(5):448–55.


Trombelli L, Scabbia A, Tatakis DN, Calura G. Subpedicle connec-

tive tissue graft versus guided tissue regeneration with bioabsorbable

membrane in the treatment of human gingival recession defects. Jour-



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Wennström JL, Zucchelli G. Increased gingival dimensions. A sig-

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bility study. Journal of Periodontology 2005;76(6):881–9.

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C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Bouchard 1994

Methods RCT, parallel design, 2 treatment groups, 6 months’ duration

Participants 30 individuals, 24 females, aged 21-62, with 1 Miller Class I or II buccal gingival recession of at least 3 mm

Interventions 1) SCTG + CAF + CA (graft without epithelial collar)

2) SCTG (graft with epithelial collar)

Outcomes ACC

GRC

CALC

KTC

SCRC

PCR

MRC

(Automated controlled force probe - 0.50 N)

Notes Practice-based

Bouchard 1997



Interventions 1) SCTG + CAF + TTC-HCl

2) SCTG + CAF + CA

Outcomes GRC

CALC

KTC

SCRC

PCR

MRC

(Automated controlled force probe - 0.50 N)




da Silva 2004

Methods RCT, split-mouth design, 2 treatment groups, 6 months’ duration

Participants 11 individuals, 5 females, aged 18-43, with 2 bilateral Miller Class I or II buccal gingival recessions of at least 3 mm

Interventions 1) SCTG + CAF

2) CAF

Outcomes GRC

CALC

KTC*(1)

SCRC

PCR

MRC

(Automated controlled force probe)

Notes University/hospital-based

Unpublished data were included following contact with author

de Queiroz 2006


Participants 13 individuals, 7 females, mean age 32.8, with 2 bilateral Miller Class I buccal gingival recessions of at least 3 mm

Interventions 1) ADMG + CAF

2) CAF

Outcomes GRC

CALC

KTC

SCRC

PCR

MRC

(Manual probe)


Data from earlier article (’de Queiroz 2004’) were reported as part of this trial

Del Pizzo 2005


Participants 15 individuals, 11 females, aged 18-56, with 2 bilateral Miller Class I or II buccal gingival recessions of at least 3 mm



Del Pizzo 2005 (Continued)

Interventions 1) EMP + CAF

2) CAF

Outcomes GRC

CALC

KTC*(1)

SCRC

PCR

MRC

(Manual probe)


Dodge 2000


Participants 12 individuals, 8 females, aged 23-51, with 2 Miller Class I or II buccal gingival recessions of at least 3 mm

Interventions 1) GTR (polylactic acid membrane - Guidor) + TTC-HCl + DFDBA

2) GTR (polylactic acid membrane - Guidor) + TTC-HCl

Outcomes GRC

CALC*(1)

KTC*(1)

SCRC

PCR

MRC

(Manual probe)


Henderson 2001



Interventions 1) ADMG (connective tissue side against the tooth) + CAF

2) ADMG (basement membrane side against the tooth) + CAF



Henderson 2001 (Continued)

Outcomes GRC

CALC

KTC

MRC

(Manual probe)

Notes University/hospital-based and supported by Lifecore Biomedical

Joly 2007


Participants 10 individuals, 4 females, aged 24-68, with 2 Miller Class I or II maxillary buccal gingival recessions of at least 3 mm

Interventions 1) ADMG + CAF (flap without vertical incisions)

2) SCTG + CAF (flap without vertical incisions)

Outcomes GRC*(2)

CALC*(2)

KTC

MRC

(Manual probe)


Keceli 2008


Participants 40 individuals, 30 females, aged 16-60, with 1 Miller Class I or II buccal gingival recession of at least 3 mm. 36

individuals completed the study

Interventions 1) SCTG + platelet-rich plasma

2) SCTG

Outcomes GRC

CALC

KTC

SCRC

PCR

MRC

(Manual probe)



Keceli 2008 (Continued)

Notes University/hospital-based and supported by The Research Foundation of Hacettepe University

Leknes 2005


Participants 20 individuals, 10 females, mean age 38.4, with 2 Miller Class I or II buccal gingival recessions of at least 3 mm. 11


Interventions 1) GTR (polylactic acid membrane - Guidor)

2) CAF

Outcomes GRC

CALC

KTC

SCRC

PCR

MRC

(Automated controlled force probe and manual probe)

Notes University/hospital-based and membranes provided by Guidor AB


Data from earlier article (’Amarante 2000’) were reported as part of this trial

Matarasso 1998



Interventions 1) GTR (polylactic acid membrane - Guidor) + double papilla flap

2) GTR (polylactic acid membrane - Guidor) + CAF

Outcomes GRC

CALC

KTC

MRC

(Manual probe)





McGuire 2003


Participants 20 individuals, 10 females, aged 23-62, with 2 Miller Class II maxillary buccal gingival recessions of at

least 4 mm. 17 individuals completed the study


2) SCTG + CAF

Outcomes GRC

CALC

KTC*(2)

PCR

MRC

(Manual probe)

Notes Practice-based and supported by BIORA AB (currently Straumann)


Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes Adequate - Sealed envelope

Paolantonio 1997



Interventions 1) SCTG + double papilla flap

2) FGG

Outcomes GRC*(1)

KTC

SCRC

PCR

MRC

(Manual probe)





Paolantonio 2002




2) GTR (polylactic acid membrane - Paroguide) + hydroxyapatite/colagen/chondroitin-sulfate graft

3) SCTG + double papilla flap

Outcomes GRC

CALC

KTC*(3)

SCRC

PCR

MRC

(Manual probe)

Notes University/hospital-based and supported by Italian Ministry of University and Scientific Research


Paolantonio 2002b




2) SCTG + CAF

Outcomes GRC

CALC

KTC*(2)

SCRC

PCR

MRC

(Automated controlled force probe - 20 g and calliper)



Roccuzzo 1996





Roccuzzo 1996 (Continued)


2) GTR (ePTFE membrane - Gore-Tex)

Outcomes GRC

CALC

KTC

SCRC

PCR

MRC

(Manual probe)


Rosetti 2000



Interventions 1) GTR (collagen membrane) + TTC-HCl + DFDBA

2) SCTG + HCl

Outcomes ACC

GRC

KTC

MRC

(Manual probe)

Notes University/hospital-based and supported by Brazilian National Council for Scientific and Technologic Development

Spahr 2005


Participants 37 individuals, 17 females, aged 22-62, with 2 Miller Class I or II buccal gingival recessions of at least 3 mm. 30



2) Placebo (propylene glycol alginate) + CAF

Outcomes GRC

CALC

KTC



Spahr 2005 (Continued)

PCR

MRC

(Automated controlled force probe, calliper and manual probe)

Notes University/hospital-based and supported by BIORA AB (currently Straumann)

Data from earlier article (’Hagewald 2002’) were reported as part of this trial

Tozum 2005



Interventions 1) SCTG + modified tunnel procedure

2) SCTG + CAF

Outcomes GRC*(1)

CALC*(1)

MRC

(Manual probe)



Trombelli 1996


Participants 15 individuals, 3 female, aged 25-51, with 2 Miller Class I or II maxillary buccal gingival recessions of at least 3 mm

Interventions 1) CAF (fibrin glue + TTC-HCl)

2) CAF (TTC-HCl)

Outcomes GRC

CALC

KTC

SCRC

PCR

MRC

(Manual probe)




Wang 2001



Interventions 1) GTR (reabsorbable double thickness collagen membrane - Sulzer Dental Inc.)

2) SCTG + CAF

Outcomes ACC

GRC

CALC

KTC

MRC

(Manual probe)

Notes University/hospital-based and supported by Sulzer Calcitek Inc.

Woodyard 2004


Participants 24 individuals, 14 females, mean age 34.6, with 1 Miller Class I or II buccal gingival recession of at least 3 mm


2) CAF

Outcomes GRC*(1)

CALC*(1)

KTC

SCRC

PCR

MRC

(Manual probe)


Zucchelli 1998




2) GTR (ePTFE membrane - Gore-Tex)

3) SCTG + CAF



Zucchelli 1998 (Continued)

Outcomes GRC

CALC

KTC*(3)

SCRC

PCR

MRC*(3)

(Manual probe)


Zucchelli 2003


Participants 15 individuals, aged 18-35, with 2 Miller Class I or II maxillary buccal gingival recessions of at least 3 mm

Interventions 1) SCTG (graft size equal to the bone dehiscence) + CAF

2) SCTG (graft size 3 mm greater than the bone dehiscence) + CAF

Outcomes ACC

GRC

CALC*(1)

KTC*(2)

SCRC

PCR

MRC

(Manual pressure sensitive probe)


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; EMP - enamel matrix protein; ePTFE - expandedpolytetrafluorethylene; FGG - free gingival graft; GRC - gingival recession change; GTR - guided tissue regeneration; KTC - keratinizedtissue change; MRC - mean root coverage; PCR - percentage of complete root coverage; RCT - randomised controlled trial; SCRC - siteswith complete root coverage; SCTG - subepithelial connective tissue graft; TTC-HCl - tetracycline hydrochloride

*statistically significant between-groups (superior group)



Characteristics of excluded studies [ordered by study ID]

Aichelmann Reidy 2001 Inclusion of patients with recession depth < 3 mm

Barros 2004 Patient-based analysis not presented

Barros 2005 Patient-based analysis not presented

Berlucchi 2002 Inclusion of patients with recession depth < 3 mm

Berlucchi 2005 Inclusion of patients with recession depth < 3 mm

Bittencourt 2006 Inclusion of patients with recession depth < 3 mm

Borghetti 1994 Inclusion of patients with Miller’s Class III or IV recession defects

Borghetti 1999 Inclusion of patients with recession depth < 3 mm

Burkhardt 2005 Less than 10 patients per group at final examination

Caffesse 2000 Authors did not provide requested explanations

Castellanos 2006 Inclusion of patients with recession depth < 3 mm

Cetiner 2003 Patient-based analysis not presented

Cheung 2004 Inclusion of patients with recession depth < 3 mm

Cordioli 2001 Patient-based analysis not presented

Daniel 1990 Not a randomised controlled trial

Dembowska 2007 Not a randomised controlled trial

Duval 2000 Inclusion of patients with recession depth < 3 mm, less than 10 patients per group at final examination

and patient-based analysis not presented

Erley 2006 Not a randomised controlled trial

Felipe 2007 Inclusion of patients with recession depth < 3 mm

Gupta 2006 Not a randomised controlled trial

Harris 1997 Not a randomised controlled trial



(Continued)




Hirsch 2005 Not a randomised controlled trial

Huang 2005 Inclusion of patients with recession depth < 3 mm

Ito 2000 Inclusion of patients with recession depth < 3 mm, less than 10 patients per group at final examination

and patient-based analysis not presented

Jahnke 1993 Inclusion of patients with recession depth < 3 mm

Jepsen 1998 Inclusion of patients with recession depth < 3 mm

Kennedy 1985 Inclusion of patients with recession depth < 3 mm

Kimble 2004 Less than 10 patients per group at final examination

Lafzi 2007 Follow-up period < 6 months

Laney 1992 Inclusion of patients with recession depth < 3 mm and follow-up period < 6 months

Lins 2003 Inclusion of patients with recession depth < 3 mm

Mahajan 2007 Less than 10 patients per group at final examination

Modica 2000 Inclusion of patients with recession depth < 3 mm

Moses 2006 Randomised non-controlled trial

Muller 1998 Not a randomised controlled trial

Muller 1999 Not a randomised controlled trial

Nemcovsky 2004 Randomised non-controlled trial

Novaes 2001 Authors did not provide requested explanations

Pilloni 2006 Inclusion of patients with recession depth < 3 mm

Pini Prato 1992 Not a randomised controlled trial



(Continued)



Pini Prato 2000 Inclusion of patients with recession depth < 3 mm and follow-up period < 6 months


Rahmani 2006 Not a randomised controlled trial

Ricci 1996 Not a randomised controlled trial

Ricci 1996b Not a randomised controlled trial

Romagna-Genon 2001 Author did not provide requested explanations

Sallum 2003 Not a randomised controlled trial

Sbordone 1988 Not a randomised controlled trial

Scabbia 1998 Not a randomised controlled trial

Tal 2002 Authors did not provide requested explanations

Tatakis 2000 Inclusion of patients with recession depth < 3 mm

Trabulsi 2004 Inclusion of patients with recession depth < 3 mm

Trombelli 1995 Not a randomised controlled trial

Trombelli 1995b Less than 10 patients per group at final examination


Trombelli 1998 Inclusion of patients with recession depth < 3 mm


Wennström 1996 Not a randomised controlled trial

Wilson 2005 Intervention not of interest



D A T A A N D A N A L Y S E S

Comparison 1. ADMG versus SCTG - Short term

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Gingival recession change 2 50 Mean Difference (Random, 95% CI) -0.76 [-1.93, 0.42]

1.1 Parallel group 1 30 Mean Difference (Random, 95% CI) -0.2 [-0.89, 0.49]

1.2 Split-mouth studies 1 20 Mean Difference (Random, 95% CI) -1.4 [-2.33, -0.47]

2 Clinical attachment level change 2 50 Mean Difference (Random, 95% CI) -0.81 [-1.92, 0.30]



3 Keratinized tissue change 2 50 Mean Difference (Random, 95% CI) -0.83 [-2.09, 0.44]

3.1 Parallel group 1 30 Mean Difference (Random, 95% CI) -1.4 [-1.98, -0.82]

3.2 Split-mouth studies 1 20 Mean Difference (Random, 95% CI) -0.1 [-1.15, 0.95]

Comparison 2. ADMG versus CAF - Short term


studies

No. of


1 Gingival recession change 2 50 Mean Difference (Random, 95% CI) 0.62 [-0.51, 1.74]

1.1 Parallel group 1 24 Mean Difference (Random, 95% CI) 1.23 [0.48, 1.98]

1.2 Split-mouth studies 1 26 Mean Difference (Random, 95% CI) 0.08 [-0.42, 0.58]

2 Clinical attachment change 2 50 Mean Difference (Random, 95% CI) 0.56 [-0.21, 1.33]



3 Keratinized tissue change 2 50 Mean Difference (Random, 95% CI) 0.31 [-0.15, 0.77]

3.1 Parallel group 1 24 Mean Difference (Random, 95% CI) 0.48 [-0.32, 1.28]


4 Sites with complete root coverage 2 50 Risk Ratio (M-H, Random, 95% CI) 1.95 [0.76, 5.04]

Comparison 3. EMP + CAF versus CAF - Long term


studies

No. of



1.1 Parallel group 0 0 Mean Difference (Random, 95% CI) Not estimable


2 Clinical attachment change 2 90 Mean Difference (Random, 95% CI) 0.27 [-0.16, 0.69]



3 Keratinized tissue change 2 90 Mean Difference (Random, 95% CI) 0.40 [0.09, 0.71]




3.2 Split-mouth studies 2 90 Mean Difference (Random, 95% CI) 0.40 [0.09, 0.71]

Comparison 4. GTR rm versus SCTG - Short term


studies

No. of


1 Gingival recession change 3 98 Mean Difference (Random, 95% CI) -0.39 [-0.65, -0.12]



2 Clinical attachment level change 3 98 Mean Difference (Random, 95% CI) 0.31 [-0.01, 0.62]



3 Keratinized tissue change 3 98 Mean Difference (Random, 95% CI) -1.95 [-2.66, -1.24]




Comparison 5. GTR rm versus GTR nrm - Short term


studies

No. of




1.2 Split-mouth studies 1 24 Mean Difference (Random, 95% CI) -0.09 [1.00, 0.82]








Comparison 6. GTR rm + bone substitutes versus SCTG


studies

No. of


1 Gingival recession change 2 54 Mean Difference (Random, 95% CI) -0.75 [-1.92, 0.43]



2 Keratinized tissue change 2 54 Mean Difference (Random, 95% CI) -2.10 [-2.51, -1.69]





Comparison 7. GTR rm + bone substitutes versus GTR rm - Short term


studies

No. of







2.2 Split-mouth studies 1 24 Mean Difference (Random, 95% CI) 1.1 [0.40, 1.80]





Analysis 1.1. Comparison 1 ADMG versus SCTG - Short term, Outcome 1 Gingival recession change.

Review: Root coverage procedures for the treatment of localised recession-type defects

Comparison: 1 ADMG versus SCTG - Short term

Outcome: 1 Gingival recession change

Study or subgroup Favours SCTG Control Mean Difference (SE) Mean Difference Weight Mean Difference

N N IV,Random,95% CI IV,Random,95% CI

1 Parallel group

Paolantonio 2002b 15 15 -0.2 (0.352) 53.5 % -0.20 [ -0.89, 0.49 ]

Subtotal (95% CI) 53.5 % -0.20 [ -0.89, 0.49 ]

Heterogeneity: not applicable

Test for overall effect: Z = 0.57 (P = 0.57)

2 Split-mouth studies

Joly 2007 10 10 -1.4 (0.4744) 46.5 % -1.40 [ -2.33, -0.47 ]

Subtotal (95% CI) 46.5 % -1.40 [ -2.33, -0.47 ]



Total (95% CI) 100.0 % -0.76 [ -1.93, 0.42 ]

Heterogeneity: Tau2 = 0.55; Chi2 = 4.13, df = 1 (P = 0.04); I2 =76%


-10 -5 0 5 10

Favours SCTG Favours ADMG








1 Parallel group

Paolantonio 2002b 15 15 -0.2 (0.352) 53.5 % -0.20 [ -0.89, 0.49 ]

Subtotal (95% CI) 53.5 % -0.20 [ -0.89, 0.49 ]



-10 -5 0 5 10








Joly 2007 10 10 -1.4 (0.4744) 46.5 % -1.40 [ -2.33, -0.47 ]

Subtotal (95% CI) 46.5 % -1.40 [ -2.33, -0.47 ]



-10 -5 0 5 10




Analysis 1.2. Comparison 1 ADMG versus SCTG - Short term, Outcome 2 Clinical attachment level change.



Outcome: 2 Clinical attachment level change

Study or subgroup Experimental Control Mean Difference (SE) Mean Difference Weight Mean Difference


1 Parallel group

Paolantonio 2002b 15 15 -0.27 (0.4081) 52.3 % -0.27 [ -1.07, 0.53 ]

Subtotal (95% CI) 52.3 % -0.27 [ -1.07, 0.53 ]




Joly 2007 10 10 -1.4 (0.4744) 47.7 % -1.40 [ -2.33, -0.47 ]

Subtotal (95% CI) 47.7 % -1.40 [ -2.33, -0.47 ]



Total (95% CI) 100.0 % -0.81 [ -1.92, 0.30 ]



-10 -5 0 5 10







1 Parallel group

Paolantonio 2002b 15 15 -0.27 (0.4081) 52.3 % -0.27 [ -1.07, 0.53 ]

Subtotal (95% CI) 52.3 % -0.27 [ -1.07, 0.53 ]



-10 -5 0 5 10










Joly 2007 10 10 -1.4 (0.4744) 47.7 % -1.40 [ -2.33, -0.47 ]

Subtotal (95% CI) 47.7 % -1.40 [ -2.33, -0.47 ]



-10 -5 0 5 10


Analysis 1.3. Comparison 1 ADMG versus SCTG - Short term, Outcome 3 Keratinized tissue change.



Outcome: 3 Keratinized tissue change



1 Parallel group

Paolantonio 2002b 15 15 -1.4 (0.2959) 55.9 % -1.40 [ -1.98, -0.82 ]

Subtotal (95% CI) 55.9 % -1.40 [ -1.98, -0.82 ]


Test for overall effect: Z = 4.73 (P < 0.00001)


Joly 2007 10 10 -0.1 (0.5357) 44.1 % -0.10 [ -1.15, 0.95 ]

Subtotal (95% CI) 44.1 % -0.10 [ -1.15, 0.95 ]



Total (95% CI) 100.0 % -0.83 [ -2.09, 0.44 ]



-10 -5 0 5 10









1 Parallel group

Paolantonio 2002b 15 15 -1.4 (0.2959) 55.9 % -1.40 [ -1.98, -0.82 ]

Subtotal (95% CI) 55.9 % -1.40 [ -1.98, -0.82 ]



-10 -5 0 5 10








Joly 2007 10 10 -0.1 (0.5357) 44.1 % -0.10 [ -1.15, 0.95 ]

Subtotal (95% CI) 44.1 % -0.10 [ -1.15, 0.95 ]



-10 -5 0 5 10




Analysis 2.1. Comparison 2 ADMG versus CAF - Short term, Outcome 1 Gingival recession change.


Comparison: 2 ADMG versus CAF - Short term




1 Parallel group

Woodyard 2004 12 12 1.23 (0.3826) 46.9 % 1.23 [ 0.48, 1.98 ]

Subtotal (95% CI) 46.9 % 1.23 [ 0.48, 1.98 ]




de Queiroz 2006 13 13 0.08 (0.2551) 53.1 % 0.08 [ -0.42, 0.58 ]

Subtotal (95% CI) 53.1 % 0.08 [ -0.42, 0.58 ]



Total (95% CI) 100.0 % 0.62 [ -0.51, 1.74 ]



-10 -5 0 5 10

Favours CAF Favours ADMG






1 Parallel group

Woodyard 2004 12 12 1.23 (0.3826) 46.9 % 1.23 [ 0.48, 1.98 ]

Subtotal (95% CI) 46.9 % 1.23 [ 0.48, 1.98 ]



-10 -5 0 5 10










de Queiroz 2006 13 13 0.08 (0.2551) 53.1 % 0.08 [ -0.42, 0.58 ]

Subtotal (95% CI) 53.1 % 0.08 [ -0.42, 0.58 ]



-10 -5 0 5 10


Analysis 2.2. Comparison 2 ADMG versus CAF - Short term, Outcome 2 Clinical attachment change.



Outcome: 2 Clinical attachment change



1 Parallel group

Woodyard 2004 12 12 0.98 (0.4387) 46.6 % 0.98 [ 0.12, 1.84 ]

Subtotal (95% CI) 46.6 % 0.98 [ 0.12, 1.84 ]




de Queiroz 2006 13 13 0.19 (0.3877) 53.4 % 0.19 [ -0.57, 0.95 ]

Subtotal (95% CI) 53.4 % 0.19 [ -0.57, 0.95 ]



Total (95% CI) 100.0 % 0.56 [ -0.21, 1.33 ]



-10 -5 0 5 10

Favours experimental Favours control








1 Parallel group

Woodyard 2004 12 12 0.98 (0.4387) 46.6 % 0.98 [ 0.12, 1.84 ]

Subtotal (95% CI) 46.6 % 0.98 [ 0.12, 1.84 ]



-10 -5 0 5 10








de Queiroz 2006 13 13 0.19 (0.3877) 53.4 % 0.19 [ -0.57, 0.95 ]

Subtotal (95% CI) 53.4 % 0.19 [ -0.57, 0.95 ]



-10 -5 0 5 10




Analysis 2.3. Comparison 2 ADMG versus CAF - Short term, Outcome 3 Keratinized tissue change.






1 Parallel group

Woodyard 2004 12 12 0.48 (0.4081) 32.9 % 0.48 [ -0.32, 1.28 ]

Subtotal (95% CI) 32.9 % 0.48 [ -0.32, 1.28 ]




de Queiroz 2006 13 13 0.23 (0.2857) 67.1 % 0.23 [ -0.33, 0.79 ]

Subtotal (95% CI) 67.1 % 0.23 [ -0.33, 0.79 ]



Total (95% CI) 100.0 % 0.31 [ -0.15, 0.77 ]

Heterogeneity: Tau2 = 0.0; Chi2 = 0.25, df = 1 (P = 0.62); I2 =0.0%


-10 -5 0 5 10







1 Parallel group

Woodyard 2004 12 12 0.48 (0.4081) 32.9 % 0.48 [ -0.32, 1.28 ]

Subtotal (95% CI) 32.9 % 0.48 [ -0.32, 1.28 ]



-10 -5 0 5 10










de Queiroz 2006 13 13 0.23 (0.2857) 67.1 % 0.23 [ -0.33, 0.79 ]

Subtotal (95% CI) 67.1 % 0.23 [ -0.33, 0.79 ]



-10 -5 0 5 10


Analysis 2.4. Comparison 2 ADMG versus CAF - Short term, Outcome 4 Sites with complete root coverage.



Outcome: 4 Sites with complete root coverage

Study or subgroup ADMG CAF Risk Ratio Weight Risk Ratio

n/N n/N M-H,Random,95% CI M-H,Random,95% CI

de Queiroz 2006 3/13 3/13 33.8 % 1.00 [ 0.25, 4.07 ]

Woodyard 2004 11/12 4/12 66.2 % 2.75 [ 1.21, 6.23 ]

Total (95% CI) 25 25 100.0 % 1.95 [ 0.76, 5.04 ]

Total events: 14 (ADMG), 7 (CAF)



0.1 0.2 0.5 1.0 2.0 5.0 10.0




Analysis 3.1. Comparison 3 EMP + CAF versus CAF - Long term, Outcome 1 Gingival recession change.


Comparison: 3 EMP + CAF versus CAF - Long term




1 Parallel group

Subtotal (95% CI) 0.0 % 0.0 [ 0.0, 0.0 ]


Test for overall effect: not applicable


Del Pizzo 2005 15 15 -0.01 (0.301) 35.4 % -0.01 [ -0.60, 0.58 ]

Spahr 2005 30 30 0.4 (0.204) 64.6 % 0.40 [ 0.00, 0.80 ]

Subtotal (95% CI) 100.0 % 0.25 [ -0.13, 0.64 ]



Total (95% CI) 100.0 % 0.25 [ -0.13, 0.64 ]



-10 -5 0 5 10

Favours CAF Favours EMP + CAF







Del Pizzo 2005 15 15 -0.01 (0.301) 35.4 % -0.01 [ -0.60, 0.58 ]

Spahr 2005 30 30 0.4 (0.204) 64.6 % 0.40 [ 0.00, 0.80 ]

Subtotal (95% CI) 100.0 % 0.25 [ -0.13, 0.64 ]



-10 -5 0 5 10




Analysis 3.2. Comparison 3 EMP + CAF versus CAF - Long term, Outcome 2 Clinical attachment change.






1 Parallel group

Subtotal (95% CI) 0.0 % 0.0 [ 0.0, 0.0 ]




Del Pizzo 2005 15 15 0.14 (0.302) 51.5 % 0.14 [ -0.45, 0.73 ]

Spahr 2005 30 30 0.4 (0.3112) 48.5 % 0.40 [ -0.21, 1.01 ]

Subtotal (95% CI) 100.0 % 0.27 [ -0.16, 0.69 ]



Total (95% CI) 100.0 % 0.27 [ -0.16, 0.69 ]



-10 -5 0 5 10








Del Pizzo 2005 15 15 0.14 (0.302) 51.5 % 0.14 [ -0.45, 0.73 ]

Spahr 2005 30 30 0.4 (0.3112) 48.5 % 0.40 [ -0.21, 1.01 ]

Subtotal (95% CI) 100.0 % 0.27 [ -0.16, 0.69 ]



-10 -5 0 5 10




Analysis 3.3. Comparison 3 EMP + CAF versus CAF - Long term, Outcome 3 Keratinized tissue change.






1 Parallel group

Subtotal (95% CI) 0.0 % 0.0 [ 0.0, 0.0 ]




Del Pizzo 2005 15 15 0.53 (0.2397) 43.2 % 0.53 [ 0.06, 1.00 ]

Spahr 2005 30 30 0.3 (0.2091) 56.8 % 0.30 [ -0.11, 0.71 ]

Subtotal (95% CI) 100.0 % 0.40 [ 0.09, 0.71 ]



Total (95% CI) 100.0 % 0.40 [ 0.09, 0.71 ]



-10 -5 0 5 10








Del Pizzo 2005 15 15 0.53 (0.2397) 43.2 % 0.53 [ 0.06, 1.00 ]

Spahr 2005 30 30 0.3 (0.2091) 56.8 % 0.30 [ -0.11, 0.71 ]

Subtotal (95% CI) 100.0 % 0.40 [ 0.09, 0.71 ]



-10 -5 0 5 10




Analysis 4.1. Comparison 4 GTR rm versus SCTG - Short term, Outcome 1 Gingival recession change.


Comparison: 4 GTR rm versus SCTG - Short term




1 Parallel group

Paolantonio 2002 15 15 -0.46 (0.3163) 18.0 % -0.46 [ -1.08, 0.16 ]

Zucchelli 1998 18 18 -0.4 (0.1785) 56.5 % -0.40 [ -0.75, -0.05 ]

Subtotal (95% CI) 74.4 % -0.41 [ -0.72, -0.11 ]




Wang 2001 16 16 -0.3 (0.2653) 25.6 % -0.30 [ -0.82, 0.22 ]

Subtotal (95% CI) 25.6 % -0.30 [ -0.82, 0.22 ]



Total (95% CI) 100.0 % -0.39 [ -0.65, -0.12 ]



-10 -5 0 5 10

Favours SCTG Favours GTR rm






1 Parallel group

Paolantonio 2002 15 15 -0.46 (0.3163) 18.0 % -0.46 [ -1.08, 0.16 ]

Zucchelli 1998 18 18 -0.4 (0.1785) 56.5 % -0.40 [ -0.75, -0.05 ]

Subtotal (95% CI) 74.4 % -0.41 [ -0.72, -0.11 ]



-10 -5 0 5 10










Wang 2001 16 16 -0.3 (0.2653) 25.6 % -0.30 [ -0.82, 0.22 ]

Subtotal (95% CI) 25.6 % -0.30 [ -0.82, 0.22 ]



-10 -5 0 5 10




Analysis 4.2. Comparison 4 GTR rm versus SCTG - Short term, Outcome 2 Clinical attachment level

change.






1 Parallel group

Paolantonio 2002 15 15 0.33 (0.3622) 19.5 % 0.33 [ -0.38, 1.04 ]

Zucchelli 1998 18 18 0.2 (0.2193) 53.2 % 0.20 [ -0.23, 0.63 ]

Subtotal (95% CI) 72.7 % 0.23 [ -0.13, 0.60 ]




Wang 2001 16 16 0.5 (0.3061) 27.3 % 0.50 [ -0.10, 1.10 ]

Subtotal (95% CI) 27.3 % 0.50 [ -0.10, 1.10 ]



Total (95% CI) 100.0 % 0.31 [ -0.01, 0.62 ]



-10 -5 0 5 10







1 Parallel group

Paolantonio 2002 15 15 0.33 (0.3622) 19.5 % 0.33 [ -0.38, 1.04 ]

Zucchelli 1998 18 18 0.2 (0.2193) 53.2 % 0.20 [ -0.23, 0.63 ]

Subtotal (95% CI) 72.7 % 0.23 [ -0.13, 0.60 ]



-10 -5 0 5 10










Wang 2001 16 16 0.5 (0.3061) 27.3 % 0.50 [ -0.10, 1.10 ]

Subtotal (95% CI) 27.3 % 0.50 [ -0.10, 1.10 ]



-10 -5 0 5 10


Analysis 4.3. Comparison 4 GTR rm versus SCTG - Short term, Outcome 3 Keratinized tissue change.






1 Parallel group

Paolantonio 2002 15 15 -2.2 (0.25) 39.0 % -2.20 [ -2.69, -1.71 ]

Zucchelli 1998 18 18 -2.4 (0.1887) 42.4 % -2.40 [ -2.77, -2.03 ]

Subtotal (95% CI) 81.4 % -2.33 [ -2.62, -2.03 ]




Wang 2001 16 16 -0.4 (0.6581) 18.6 % -0.40 [ -1.69, 0.89 ]

Subtotal (95% CI) 18.6 % -0.40 [ -1.69, 0.89 ]

-10 -5 0 5 10


(Continued . . . )



(. . . Continued)Study or subgroup Experimental Control Mean Difference (SE) Mean Difference Weight Mean Difference




Total (95% CI) 100.0 % -1.95 [ -2.66, -1.24 ]



-10 -5 0 5 10







1 Parallel group

Paolantonio 2002 15 15 -2.2 (0.25) 39.0 % -2.20 [ -2.69, -1.71 ]

Zucchelli 1998 18 18 -2.4 (0.1887) 42.4 % -2.40 [ -2.77, -2.03 ]

Subtotal (95% CI) 81.4 % -2.33 [ -2.62, -2.03 ]



-10 -5 0 5 10










Wang 2001 16 16 -0.4 (0.6581) 18.6 % -0.40 [ -1.69, 0.89 ]

Subtotal (95% CI) 18.6 % -0.40 [ -1.69, 0.89 ]



-10 -5 0 5 10


Analysis 4.4. Comparison 4 GTR rm versus SCTG - Short term, Outcome 4 Sites with complete root

coverage.




Study or subgroup SCTG GTR rm Risk Ratio Weight Risk Ratio


Paolantonio 2002 6/15 9/15 31.7 % 0.67 [ 0.32, 1.40 ]

Wang 2001 7/16 7/16 28.5 % 1.00 [ 0.46, 2.19 ]

Zucchelli 1998 7/18 12/18 39.8 % 0.58 [ 0.30, 1.13 ]

Total (95% CI) 49 49 100.0 % 0.71 [ 0.47, 1.08 ]

Total events: 20 (SCTG), 28 (GTR rm)



0.1 0.2 0.5 1.0 2.0 5.0 10.0




Analysis 5.1. Comparison 5 GTR rm versus GTR nrm - Short term, Outcome 1 Gingival recession change.


Comparison: 5 GTR rm versus GTR nrm - Short term




1 Parallel group

Zucchelli 1998 18 18 0.4 (0.1989) 84.5 % 0.40 [ 0.01, 0.79 ]

Subtotal (95% CI) 84.5 % 0.40 [ 0.01, 0.79 ]




Roccuzzo 1996 12 12 -0.09 (0.4642) 15.5 % -0.09 [ -1.00, 0.82 ]

Subtotal (95% CI) 15.5 % -0.09 [ -1.00, 0.82 ]



Total (95% CI) 100.0 % 0.32 [ -0.03, 0.68 ]



-10 -5 0 5 10

Favours GTR rm Favours GTR nrm






1 Parallel group

Zucchelli 1998 18 18 0.4 (0.1989) 84.5 % 0.40 [ 0.01, 0.79 ]

Subtotal (95% CI) 84.5 % 0.40 [ 0.01, 0.79 ]



-10 -5 0 5 10










Roccuzzo 1996 12 12 -0.09 (0.4642) 15.5 % -0.09 [ -1.00, 0.82 ]

Subtotal (95% CI) 15.5 % -0.09 [ -1.00, 0.82 ]



-10 -5 0 5 10


Analysis 5.2. Comparison 5 GTR rm versus GTR nrm - Short term, Outcome 2 Clinical attachment level

change.






1 Parallel group

Zucchelli 1998 18 18 0.2 (0.2959) 82.7 % 0.20 [ -0.38, 0.78 ]

Subtotal (95% CI) 82.7 % 0.20 [ -0.38, 0.78 ]




Roccuzzo 1996 12 12 -0.08 (0.6479) 17.3 % -0.08 [ -1.35, 1.19 ]

Subtotal (95% CI) 17.3 % -0.08 [ -1.35, 1.19 ]



Total (95% CI) 100.0 % 0.15 [ -0.38, 0.68 ]



-10 -5 0 5 10









1 Parallel group

Zucchelli 1998 18 18 0.2 (0.2959) 82.7 % 0.20 [ -0.38, 0.78 ]

Subtotal (95% CI) 82.7 % 0.20 [ -0.38, 0.78 ]



-10 -5 0 5 10








Roccuzzo 1996 12 12 -0.08 (0.6479) 17.3 % -0.08 [ -1.35, 1.19 ]

Subtotal (95% CI) 17.3 % -0.08 [ -1.35, 1.19 ]



-10 -5 0 5 10




Analysis 5.3. Comparison 5 GTR rm versus GTR nrm - Short term, Outcome 3 Keratinized tissue change.






1 Parallel group

Zucchelli 1998 18 18 0.1 (0.2193) 87.2 % 0.10 [ -0.33, 0.53 ]

Subtotal (95% CI) 87.2 % 0.10 [ -0.33, 0.53 ]




Roccuzzo 1996 12 12 0.16 (0.5714) 12.8 % 0.16 [ -0.96, 1.28 ]

Subtotal (95% CI) 12.8 % 0.16 [ -0.96, 1.28 ]



Total (95% CI) 100.0 % 0.11 [ -0.29, 0.51 ]



-10 -5 0 5 10







1 Parallel group

Zucchelli 1998 18 18 0.1 (0.2193) 87.2 % 0.10 [ -0.33, 0.53 ]

Subtotal (95% CI) 87.2 % 0.10 [ -0.33, 0.53 ]



-10 -5 0 5 10










Roccuzzo 1996 12 12 0.16 (0.5714) 12.8 % 0.16 [ -0.96, 1.28 ]

Subtotal (95% CI) 12.8 % 0.16 [ -0.96, 1.28 ]



-10 -5 0 5 10


Analysis 5.4. Comparison 5 GTR rm versus GTR nrm - Short term, Outcome 4 Sites with complete root

coverage.




Study or subgroup GTR rm GTR nrm Risk Ratio Weight Risk Ratio


Roccuzzo 1996 5/12 5/12 49.8 % 1.00 [ 0.39, 2.58 ]

Zucchelli 1998 7/18 5/18 50.2 % 1.40 [ 0.54, 3.60 ]

Total (95% CI) 30 30 100.0 % 1.18 [ 0.61, 2.31 ]

Total events: 12 (GTR rm), 10 (GTR nrm)



0.1 0.2 0.5 1.0 2.0 5.0 10.0

Favours GTR nrm Favours GTR rm



Analysis 6.1. Comparison 6 GTR rm + bone substitutes versus SCTG, Outcome 1 Gingival recession change.


Comparison: 6 GTR rm + bone substitutes versus SCTG




1 Parallel group

Paolantonio 2002 15 15 -0.13 (0.3469) 48.5 % -0.13 [ -0.81, 0.55 ]

Subtotal (95% CI) 48.5 % -0.13 [ -0.81, 0.55 ]




Rosetti 2000 12 12 -1.33 (0.2755) 51.5 % -1.33 [ -1.87, -0.79 ]

Subtotal (95% CI) 51.5 % -1.33 [ -1.87, -0.79 ]



Total (95% CI) 100.0 % -0.75 [ -1.92, 0.43 ]



-10 -5 0 5 10

Favours SCTG Favours GTR rm + bone sub






1 Parallel group

Paolantonio 2002 15 15 -0.13 (0.3469) 48.5 % -0.13 [ -0.81, 0.55 ]

Subtotal (95% CI) 48.5 % -0.13 [ -0.81, 0.55 ]



-10 -5 0 5 10










Rosetti 2000 12 12 -1.33 (0.2755) 51.5 % -1.33 [ -1.87, -0.79 ]

Subtotal (95% CI) 51.5 % -1.33 [ -1.87, -0.79 ]



-10 -5 0 5 10


Analysis 6.2. Comparison 6 GTR rm + bone substitutes versus SCTG, Outcome 2 Keratinized tissue change.






1 Parallel group

Paolantonio 2002 15 15 -2.13 (0.2551) 66.8 % -2.13 [ -2.63, -1.63 ]

Subtotal (95% CI) 66.8 % -2.13 [ -2.63, -1.63 ]




Rosetti 2000 12 12 -2.04 (0.362) 33.2 % -2.04 [ -2.75, -1.33 ]

Subtotal (95% CI) 33.2 % -2.04 [ -2.75, -1.33 ]



Total (95% CI) 100.0 % -2.10 [ -2.51, -1.69 ]



-100 -50 0 50 100









1 Parallel group

Paolantonio 2002 15 15 -2.13 (0.2551) 66.8 % -2.13 [ -2.63, -1.63 ]

Subtotal (95% CI) 66.8 % -2.13 [ -2.63, -1.63 ]



-100 -50 0 50 100








Rosetti 2000 12 12 -2.04 (0.362) 33.2 % -2.04 [ -2.75, -1.33 ]

Subtotal (95% CI) 33.2 % -2.04 [ -2.75, -1.33 ]



-100 -50 0 50 100




Analysis 7.1. Comparison 7 GTR rm + bone substitutes versus GTR rm - Short term, Outcome 1 Gingival

recession change.


Comparison: 7 GTR rm + bone substitutes versus GTR rm - Short term




1 Parallel group

Paolantonio 2002 15 15 0.4 (0.3316) 53.7 % 0.40 [ -0.25, 1.05 ]

Subtotal (95% CI) 53.7 % 0.40 [ -0.25, 1.05 ]




Dodge 2000 12 12 0.53 (0.3571) 46.3 % 0.53 [ -0.17, 1.23 ]

Subtotal (95% CI) 46.3 % 0.53 [ -0.17, 1.23 ]



Total (95% CI) 100.0 % 0.46 [ -0.02, 0.94 ]



-10 -5 0 5 10

Favours GTR rm Favours GTR rm + bone sub






1 Parallel group

Paolantonio 2002 15 15 0.4 (0.3316) 53.7 % 0.40 [ -0.25, 1.05 ]

Subtotal (95% CI) 53.7 % 0.40 [ -0.25, 1.05 ]



-10 -5 0 5 10










Dodge 2000 12 12 0.53 (0.3571) 46.3 % 0.53 [ -0.17, 1.23 ]

Subtotal (95% CI) 46.3 % 0.53 [ -0.17, 1.23 ]



-10 -5 0 5 10


Analysis 7.2. Comparison 7 GTR rm + bone substitutes versus GTR rm - Short term, Outcome 2 Clinical

attachment level change.






1 Parallel group

Paolantonio 2002 15 15 0.3 (0.403) 47.3 % 0.30 [ -0.49, 1.09 ]

Subtotal (95% CI) 47.3 % 0.30 [ -0.49, 1.09 ]




Dodge 2000 12 12 1.1 (0.3571) 52.7 % 1.10 [ 0.40, 1.80 ]

Subtotal (95% CI) 52.7 % 1.10 [ 0.40, 1.80 ]



Total (95% CI) 100.0 % 0.72 [ -0.06, 1.50 ]



-10 -5 0 5 10









1 Parallel group

Paolantonio 2002 15 15 0.3 (0.403) 47.3 % 0.30 [ -0.49, 1.09 ]

Subtotal (95% CI) 47.3 % 0.30 [ -0.49, 1.09 ]



-10 -5 0 5 10








Dodge 2000 12 12 1.1 (0.3571) 52.7 % 1.10 [ 0.40, 1.80 ]

Subtotal (95% CI) 52.7 % 1.10 [ 0.40, 1.80 ]



-10 -5 0 5 10




Analysis 7.3. Comparison 7 GTR rm + bone substitutes versus GTR rm - Short term, Outcome 3

Keratinized tissue change.






1 Parallel group

Paolantonio 2002 15 15 0.1 (0.1275) 94.6 % 0.10 [ -0.15, 0.35 ]

Subtotal (95% CI) 94.6 % 0.10 [ -0.15, 0.35 ]




Dodge 2000 12 12 0.62 (0.5357) 5.4 % 0.62 [ -0.43, 1.67 ]

Subtotal (95% CI) 5.4 % 0.62 [ -0.43, 1.67 ]



Total (95% CI) 100.0 % 0.13 [ -0.12, 0.37 ]



-10 -5 0 5 10







1 Parallel group

Paolantonio 2002 15 15 0.1 (0.1275) 94.6 % 0.10 [ -0.15, 0.35 ]

Subtotal (95% CI) 94.6 % 0.10 [ -0.15, 0.35 ]



-10 -5 0 5 10










Dodge 2000 12 12 0.62 (0.5357) 5.4 % 0.62 [ -0.43, 1.67 ]

Subtotal (95% CI) 5.4 % 0.62 [ -0.43, 1.67 ]



-10 -5 0 5 10


Analysis 7.4. Comparison 7 GTR rm + bone substitutes versus GTR rm - Short term, Outcome 4 Sites with

complete root coverage.




Study or subgroup GTR rm + biomaterial GTR rm Risk Ratio Weight Risk Ratio


Dodge 2000 6/12 4/12 38.8 % 1.50 [ 0.56, 4.00 ]

Paolantonio 2002 8/15 6/15 61.2 % 1.33 [ 0.61, 2.91 ]

Total (95% CI) 27 27 100.0 % 1.40 [ 0.76, 2.57 ]

Total events: 14 (GTR rm + biomaterial), 10 (GTR rm)



0.1 0.2 0.5 1.0 2.0 5.0 10.0

Favours GTR rm Favours GTR rm + bio



A P P E N D I C E S

Appendix 1. CENTRAL search strategy

#1 GINGIVAL RECESSION [Single MeSH term]

#2 ((recession NEAR gingiva*) OR (recession NEAR defect*) or “recession-type defect*”)

#3 ((exposure NEAR root*) or (exposed NEAR root*))

#4 (gingiva* NEAR defect*)

#5 denude* NEAR “root surface*”

#6 #1 or #2 or #3 or #4 or #5

#7 GUIDED TISSUE REGENERATION [Explode MeSH term]

#8 “tissue NEAR regenerat*

#9 ((gingiva* NEAR esthetic*) or (gingiva* NEAR aesthetic*))

#10 periodont* AND ”plastic surgery“

#11 ”soft tissue graft*“ or ”coronally advanced flap*“

#12 ”laterally positioned flap*“ or ”laterally-positioned flap*“

#13 ”connective tissue graft*“ or ”connective-tissue graft*“

#14 gingiva* NEAR transplant*

#15 ”dermal matrix“ NEAR graft*

#16 ”enamel matrix protein“

#17 #7 or #8 or #9 or #10 or #11 or #12 or #14 or #15 or #16

#18 #6 AND #17

H I S T O R Y

Protocol first published: Issue 2, 2008

Review first published: Issue 2, 2009

C O N T R I B U T I O N S O F A U T H O R S

Leandro Chambrone: conceiving the review, designing the protocol, designing the review, undertaking searches, obtaining and screening

data on unpublished studies, data collection and extraction for the review, writing to authors of papers for additional information,

entering data into RevMan, analysis of data, interpretation of data and writing the review.

Flávia Sukekava: undertaking searches, data collection and extraction for the review, and analysis of data.

Francisco E Pustiglioni: interpretation of data and writing the review.

Mauricio G Araújo: interpretation of data.

Luiz A Lima: interpretation of data, co-ordinating and writing the review.

Luiz A Chambrone: designing the review, analysis of data and co-ordinating the review.



D E C L A R A T I O N S O F I N T E R E S T

None known.

S O U R C E S O F S U P P O R T

Internal sources

• University of São Paulo, Brazil.

External sources

• No sources of support supplied



Documents

Root coverage procedures for the treatment of …...Root coverage procedures for the treatment of localised recession-type defects Gingival recession is a term that designates the