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Received: 17 October 2018    Revised: 13 March 2019    Accepted: 26 March 2019

DOI: 10.1111/jcpe.13106

S Y S T E M AT I C R E V I E W

Long‐term stability of root coverage procedures for single

gingival recessions: A systematic review and meta‐analysis

Anna Dai | Jia‐Ping Huang | Pei‐Hui Ding  | Li‐Li Chen

Department of Periodontology, The Second

Affiliated Hospital of Zhejiang University
School of Medicine, Hangzhou, China
Correspondence
Li‐Li Chen and Pei‐Hui Ding, Department
of Periodontology, The Second Affiliated
Hospital of Zhejiang University School of
Medicine, Hangzhou 310009, China.
Emails: chenlili_1030@zju.edu.cn (LLC) and
phding@zju.edu.cn (PHD)
Funding information
This research was supported by National
Natural Science Foundation of China
(81771072, 81870765), Zhejiang Provincial
Natural Science Foundation of China under
Grant No. LY18H140002 and LY17H140002.
Abstract
Aim: To evaluate the long‐term (≥2 years) stability of root coverage procedures for
single gingival recessions.
Materials and Methods: A complete literature search was performed up to July 2018.
Randomized controlled trials (RCTs) following ≥2 years were selected. Primary out‐
comes were complete root coverage (CRC) and mean root coverage (MRC). Secondary
outcomes were width of keratinized tissue (KTW) and patient‐centred parameters.
Meta‐analysis was conducted when possible.
Results: A total of fifteen RCTs were included. The results demonstrated significantly
higher MRC in short‐term than long‐term after coronally advanced flap (CAF; 7.29%,
p = 0.006). When CAF combined with connective tissue graft (CTG), no significant
difference was observed in CRC or MRC for short‐term versus long‐term (1.00,
p = 0.97; 2.35%, p = 0.09), and it resulted in better long‐term efficacy than CAF alone
in terms of CRC (0.69, p = 0.0006) and KTW (−0.63 mm, p = 0.04). For CAF plus
enamel matrix derivative, the meta‐analysis showed no significant difference be‐
tween the short‐term and long‐term results of CRC (1.26, p = 0.21).
Conclusions: CAF alone could result in decreased postoperative percentage of root
coverage with time. CAF + CTG could maintain long‐term stability and result in bet‐
ter root coverage outcomes than CAF.

KEYWORDS
gingival recession, meta‐analysis, periodontal surgery, review, root coverage

1 | I NTRO D U C TI O N
Numerous root coverage procedures were proposed to treat gingival
recession, among which coronally advanced flap (CAF) has been a
common approach since it was first described in 1926 by Norberg
(1926). It is relatively low in technique demanding and could bring
favourable root coverage results, while still requires certain condi‐
tions including enough amount of residual keratinized tissue, both in
height and thickness (Zucchelli & Mounssif, 2015).
In recent decades, the additional use of connective tissue graft
(CTG) with CAF has been recommended as the optimal therapy to
achieve complete root coverage (CRC; Buti, Baccini, Nieri, La Marca,
& Pini‐Prato, 2013; Cairo, 2017). However, a second surgery to
harvest CTG increases patient morbidity, encouraging possible al‐
ternatives of CTG to be tested, including acellular dermal matrix
(ADM) and xenogeneic collagen matrix (XCM). A systematic review
compared CAF + ADM with CAF + CTG for Miller Class I and II re‐
cessions, and the results of meta‐analysis showed no differences
for mean root coverage (MRC) and clinical attachment level (CAL)
gain (Gallagher & Matthews, 2017). Other two systematic reviews
concluded that no sufficient evidence demonstrated the efficacy
of XCM in achieving greater MRC, recession reduction (RecRed) or
gain in keratinized tissue compared to CAF + CTG (Atieh, Alsabeeha,
Tawse‐Smith, & Payne, 2016; Huang, Liu, Wu, Chen, & Ding, 2019).

572  |  wileyonlinelibrary.com/journal/jcpe

© 2019 John Wiley & Sons A/S. J Clin Periodontol. 2019;46:572–585.
Published by John Wiley & Sons Ltd
DAI et al.
Different root surface modifiers were tested to increase the
predictability of root coverage, including enamel matrix deriv‐
ative (EMD), lasers, platelet‐rich fibrin (PRF) and other meth‐
ods. Histological studies (McGuire & Cochran, 2003; Yukna &
Mellonig, 2000) have found EMD promoted the formation of new
attachment and regeneration of soft tissue, while a systematic re‐
view revealed that it lacked strong clinical evidence to verify its
efficacy through root coverage and other periodontal parameters
(Karam et al., 2016). The combination use of PRF showed no evi‐
dent benefits in terms of MRC or CAL, but significantly increased
width of keratinized tissue (KTW) compared with CAF + CTG
(Moraschini & Barboza Edos, 2016). The meta‐analysis of four
randomized controlled trials (RCT) showed the adjunct use of low‐
level laser therapy (LLLT) to CAF + CTG depicted an improvement
of clinical and patient‐centred outcomes (Akram, Vohra, & Javed,
2018).
However, previous systematic reviews mainly selected and
synthesized short‐term results of clinical outcomes measured at 6
or 12 months, so the long‐term (≥2 years) efficacy remains uncer‐
tain. The report from American Academy of Periodontology (AAP)
Regeneration Workshop included trials with follow‐up ≥ 2 years to
assess the long‐term efficacy of various root coverage procedures
(Chambrone & Tatakis, 2015). However, the results were based on
the literatures published before 2013, and only two RCTs were
included in the meta‐analysis for long‐term efficacy. Afterwards,
several individually reported clinical trials have revealed different
comparative results between long‐term and short‐term, indicat‐
ing that the gingival margin might have a tendency to relapse api‐
cally in some cases after a period of more than 2 years or 5 years
(Jepsen, Stefanini, Sanz, Zucchelli, & Jepsen, 2017; McGuire &
Scheyer, 2016; Santamaria et al., 2017; Zucchelli et al., 2014). For
patients, the recurrence of gingival recessions is unacceptable
considering the postoperative discomfort, the financial cost and
the recurrence of aesthetic problems or dentin hypersensitivity.
Hence, clinicians have been seeking for the optimal therapy and
the appropriate postoperative instructions to maintain stability as
long as possible.
Therefore, this systematic review aimed to (a) evaluate the
long‐term stability of procedures used for single gingival reces‐
sions by comparing the short‐term versus long‐term outcomes;
and (b) compare the long‐term results of CRC, MRC, KTW and
patient‐centred parameters among different root coverage
procedures.
2 | M ATE R I A L S A N D M E TH O DS
This systematic review was performed in accordance with pre‐
ferred reporting items for systematic reviews and meta‐analyses
(PRISMA; Liberati et al., 2009; Moher, Liberati, Tetzlaff, Altman, &
Group, 2009), the Cochrane Handbook (Higgins & Green, 2011) and
Assessment of Multiple Systematic Reviews (AMSTAR) guideline
checklists (Shea et al., 2017; see in Table S3).
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Clinical Relevance
Scientific rationale for study: This systematic review aimed
to analyse the long‐term (≥2 years) stability of root cover‐
age procedures for single gingival recessions.
Principal findings: The gingival margin seemed unstable in
long‐term after coronally advanced flap therapy for single
gingival recessions. However, when combined with con‐
nective tissue graft, it could maintain stability during the
long‐term period and result in better complete and mean
root coverage outcomes and higher width of keratinized
tissue than coronally advanced flap alone.
Practical implications: Coronally advanced flap plus connec‐
tive tissue graft is the optimal procedure to maintain long‐
term stability.
2.1 | Selection criteria
2.1.1 | Types of studies
Only randomized controlled trials (RCTs) for the treatment of gingival
recession with a follow‐up duration of at least 2 years were included.
2.1.2 | Types of participants
Patients with a clear clinical diagnosis of non‐restored, localized
(single‐tooth) gingival recession without loss of inter‐dental attach‐
ment were considered.
2.1.3 | Types of interventions
Any form of root coverage procedures to treat localized gingival
recessions was considered.
2.1.4 | Types of outcomes
The primary outcomes were complete root coverage (CRC) and
mean root coverage (MRC). The secondary outcomes were width of
keratinized tissue (KTW) and patient‐centred parameters. Studies
with insufficient data were excluded.
2.2 | Search methods
Three online clinical evidence‐based databases and one grey data‐
base for unpublished data were used to search for papers published
before July 31, 2018 without language restriction. The search strat‐
egies were as follows:
• MEDLINE: using the following search strategy: ((gingival reces‐
sion[MESH]) OR (gingiva* AND (recession* OR defect*)) OR (root
coverage)) AND (randomized controlled trial[ptyp]);
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574       DAI et al.
• The Cochrane Central Register of Controlled Trials (CENTRAL):
using the following search strategy: ((“gingival recession”) OR
(“gingival defect”) OR (“root coverage”)) AND (“randomized con‐
trolled trial”);
• Embase: using the following search strategy: (‘gingival recession’/
mj OR (gingiva AND (recession OR defect)) OR ‘root coverage’)
AND [randomized controlled trial]/lim;
• OpenGrey: using the following search strategy: (gingiva* AND (re‐
cession* OR defect*)) OR (root coverage)
Hand searching included a complete search of Journal of Clinical
Periodontology, Journal of Periodontology, Journal of Periodontal Research
and International Journal of Periodontics and Restorative Dentistry.
References from previous systematic reviews (Atieh et al., 2016;
Buti et al., 2013; Cairo, Nieri, & Pagliaro, 2014; Cairo et al., 2016;
Chambrone & Tatakis, 2015; Chambrone et al., 2018; Huang et al.,
2019; Karam et al., 2016; Koop, Merheb, & Quirynen, 2012; Oliveira
& Muncinelli, 2012; Tavelli et al., 2018) concerning root coverage
procedures were checked for article screening. Authors of relevant
grey literatures who could be reached by email have been contacted.
2.3 | Study selection and data extraction
Two independent authors (Dai and Huang) read the titles, abstracts
and full texts to identify the validity of papers. Disagreement be‐
tween the reviewers was resolved by discussion. When consensus
could not be reached, the senior author (Ding) was consulted.
After selection process, the following information of included
studies was extracted independently by the two reviewers (Dai and
Huang): (a) authors, year of publication, study design, types of inter‐
vention, follow‐up duration, setting and funding; (b) characteristics
of the participants and recessions; (c) primary and secondary out‐
comes. Both primary and secondary outcomes were extracted from
6‐month results for short‐term evaluation and the results of the last
follow‐up for long‐term evaluation. When the data of 6 months were
not provided, the outcomes of 12 months were selected instead.
Authors of the studies were contacted by email if clinical parameters
were lacking.
2.4 | Assessment of risk of bias
The risk of bias of included studies was assessed independently by
two authors (Dai and Huang). The following points were focused:
random sequence generation, allocation concealment, blinding of
participants and personnel, blinding of outcome assessment, incom‐
plete outcome data, selective reporting and other bias. Judgement
of each entry to “low,” “unclear” or “high” was accomplished by
agreement between the two authors. When assessing the overall
risk of bias, low risk of bias was indicated if all parameters were “low,”
moderate risk of bias if one or more key parameters were “unclear”
and high risk of bias if one or more key parameters were “high.”
2.5 | Data synthesis
Risk ratio (RR) and mean difference (MD) with 95% confidence in‐
tervals (CIs) were used for the analysis of dichotomous data and
continuous data. The heterogeneity of the included studies for each
outcome was assessed through the Q test and I2 statistic, thus cal‐
culating the percentage of variation attributed to heterogeneity
(I2 < 40%: low heterogeneity; I2 ≥ 40%: high heterogeneity). If the
analysis of heterogeneity presented low, the fixed effects model
was applied. When the heterogeneity of data was assessed high, the
F I G U R E 1   PRISMA flow chart of
selection process
DAI et al.
random effects model was used. Afterwards, the Mantel–Haenszel
method was performed to combine the dichotomous outcomes, and
the generic inverse‐variance method was performed to combine
the continuous outcomes. A forest plot of meta‐analysis was gen‐
erated by the computer program (RevMan version 5.3, The Nordic
Cochrane Centre, The Cochrane Collaboration, Copenhagen, 2014).
The synthesized effect was defined as statistical significance if p
value < 0.05.
3 |  R E S U LT S
3.1 | Selection of studies
The PRISMA flow chart (Figure 1) presented the process of search
and selection of articles. A total of 908 studies were selected from
electronic and manual searches after removal of the duplicates.
Two viewers (Dai and Huang) identified these studies by titles and
abstracts independently. Studies with a follow‐up <2 years and
inclusion of multiple recessions were common reasons for exclu‐
sion. Then, a total of 38 articles were selected for full‐text screen‐
ing. Finally, 15 RCTs (Abolfazli, Saleh‐Saber, Eskandari, & Lafzi,
2009; Amarante, Leknes, Skavland, & Lie, 2000; Bittencourt et al.,
2009; Cortellini et al., 2009; Del Pizzo, Zucchelli, Modica, Villa, &
Debernardi, 2005; Fernandes‐Dias et al., 2015; Jepsen et al., 2013,
2017; Kuis et al., 2013; Leknes et al., 2005; McGuire & Nunn, 2003;
McGuire & Scheyer, 2010, 2016; McGuire, Scheyer, & Nunn, 2012;
McGuire, Scheyer, & Schupbach, 2009; McGuire, Scheyer, & Snyder,
2014; Nizam, Bengisu, & Sonmez, 2015; Pini Prato et al., 2011;
Pini‐Prato et al., 1999; de Queiroz Cortes, Sallum, Casati, Nociti, &
Sallum, 2006; Rasperini et al., 2018; Rosetti, Marcantonio, Zuza, &
Marcantonio, 2013; Santamaria et al., 2017) fulfilled the inclusion
criteria. The rest 23 studies were excluded for different reasons
(Table S1). The RCT by Spahr et al. (2005) was excluded due to insuf‐
ficient data of CRC, MRC and KTW.
3.2 | General characteristics of included studies
As shown in Table 1, among the 15 RCTs, 12 studies employed a
split‐mouth design, whereas the other three studies used paral‐
lel groups. Two trials were performed in multicentre, while the
remaining 13 studies had a single centre design. A total of 318
participants with 604 isolated gingival recessions were initially
enrolled, and 48 patients dropped out during the follow‐up. The
observation period ranged from 2 to 14 years. Eight studies evalu‐
ated the outcomes between 2 and 5 years, while the rest seven
studies had a follow‐up of at least 5 years. All studies included
Miller Class I or/and II or dehiscence‐type gingival recessions,
while the inclusion criteria of gingival recession depth varied. Four
trials were conducted in private practice, while the other 11 stud‐
ies were performed at universities. Five studies accepted support
from companies, seven studies were self‐supported or supported
by research funding, and the other three studies did not clarify
financial conflicts.
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As for types of interventions, CAF 
+ EMD versus CAF,
CAF 
+ biodegradable membrane versus CAF, CAF 
+ ADM ver‐
sus CAF, CAF + CTG versus CAF + EMD, CAF + CTG versus CAF,
CAF + polishing versus CAF + root planing, CAF + CTG versus
guided tissue regeneration 
+ demineralized freeze‐dried bone
allograft (GTR + DFDBA), CAF + CTG versus CAF+ platelet‐de‐
rived growth factor‐BB 
+ β‐tricalcium phosphate (CAF + PDGF‐
BB + β‐TCP), microsurgery of CAF + CTG versus macrosurgery of
CAF + CTG, CAF + CTG versus CAF + XCM, CAF + XCM versus CAF
and CAF + CTG + LLLT versus CAF + CTG were used. Extracted data
of all included studies are summarized in Table 2.
3.3 | Risk of bias assessment
The risk of bias of all the included studies is presented in Table S2.
Allocation concealment was the major source of bias. After all cri‐
teria were analysed, only two studies were assessed to be at low
risk of bias, 12 studies had moderate risk of bias, and one study was
considered to have a high risk of bias.
3.4 | Results for data
3.4.1 | Results of primary outcomes (CRC and MRC)
Nine groups in eight studies were included in the meta‐analy‐
sis to compare the short‐term and long‐term outcomes after CAF
procedure for single gingival recessions. No significant difference
was found in terms of CRC (p = 0.06, RR: 1.21, 95% CI: 0.99–1.48,
I2 = 0%; Figure 2a). Nevertheless, meta‐analysis revealed a statisti‐
cally higher percentage of MRC in short‐term than that in long‐term
(p = 0.006, MD: 7.29%, 95% CI: 2.14%–12.44%, I2 = 0%; Figure 2b).
Data on changes in CRC of CAF + CTG procedure were reported
in nine studies including 11 groups. No significant difference was
observed in the change of CRC for short‐term versus long‐term
(p = 0.97, RR: 1.00, 95% CI: 0.90–1.10, I2 = 26%; Figure 3a). For MRC,
the results also demonstrated that the efficacy between short‐term
and long‐term did not differ significantly (p = 0.09, MD: 2.35%, 95%
CI: −0.36% to 5.06%, I2 = 0%; Figure 3b).
For the comparison of CAF + CTG and CAF alone, three studies
were included to evaluate the short‐term and long‐term outcomes in
the change of CRC. Statistically significant difference was observed
in favour of CAF + CTG both in short‐term (p = 0.007, RR: 0.80, 95%
CI: 0.68–0.94, I2 = 0%; Figure 4a) and long‐term (p = 0.0006, RR:
0.69, 95% CI: 0.56–0.85, I2 = 0%; Figure 4b). Only one split‐mouth
study (Kuis et al., 2013) which included 114 sites reported the results
of MRC. Initial data after 6 months showed MRC was 91.9 ± 16.4%
in the CAF group, compared to 97.2 ± 10.6% in the CAF + CTG
group. Five years after surgery, the results of MRC in CAF alone and
CAF + CTG were 82.7 ± 23.8% and 92.3 ± 19.2%, respectively.
A few studies used alternative biomaterials of CTG, but no meta‐
analysis was possible to be conducted. For CAF + ADM, original
data showed that CRC was 3/13 at 6 months and reduced to 1/13
at 2 years, and MRC was 76.18 ± 20.81% at 6 months and decreased
TA B L E 1   Characteristics of the included studies
|

Initial partici‐ Interventions

576      

pants (female/ Initial Final Follow‐up

Study Study design male) sites drop‐outs Group 1 Group 2 (month) Type of recession Setting and funding

Del Pizzo (2005) Multicentre RCT; 11/4 30 0 CAF + EMD CAF 24 Miller Class I and II; University, NA
split‐mouth GR ≥ 3 mm
Leknes (2005)/ Single centre RCT; 10/10 40 9 CAF + biodegradable CAF 72 Miller Class I and II; University, supported by
Amarante (2000) split‐mouth membrane GR ≥ 3 mm company
de Queiroz Cortes Single centre RCT; 7/6 26 0 CAF + ADM CAF 24 Miller Class I; University, NA
(2006) split‐mouth GR ≥ 3 mm
Abolfazli (2009) Single centre RCT; 8/4 24 0 CAF + CTG CAF + EMD 24 Miller Class I; Private practice, NA
split‐mouth GR ≥ 3 mm
Bittencourt (2009) Single centre RCT; 11/6 34 0 CAF + CTG CAF (Semilunar) 30 Miller Class I; University, supported by
split‐mouth GR ≤ 4 mm research funding
Pini Prato et al. Single centre RCT; 8/2 20 1 CAF + polishing CAF + root scaling 168 Miller Class I and II; University, no external
(2011)/Pini‐Prato split‐mouth GR ≥ 2 mm funding
(1999)
McGuire (2012)/ Single centre RCT; 10/10 40 11 CAF + CTG CAF + EMD 120 Miller Class II; Private practice, supported
McGuire and split‐mouth GR ≥ 4 mm by company
Nunn (2003)
Kuis (2013) Single centre RCT; 25/12 114 0 CAF + CTG CAF 60 Miller Class I and II; University, supported by
split‐mouth 1 mm ≤ GR ≤ 4 mm research funding
Rosetti (2013). Single centre RCT; 9/3 24 0 CAF + CTG GTR + DFDBA 30 Miller Class I and II; University, no financial
split‐mouth GR ≥ 3 mm interest
McGuire (2014)/ Single centre RCT; 26/4 60 10 CAF + CTG CAF + PDGF‐ 60 Miller Class II; Private practice, supported
McGuire (2009) split‐mouth BB + β‐TCP GR ≥ 3 mm by company
Nizam (2015) Single centre RCT; 13/11 41 5 Microsurgery of Macrosurgery of 24 Miller Class I and II; University, no financial
parallel CAF + CTG CAF + CTG GR > 2 mm interest
McGuire and Single centre RCT; 17/8 50 8 CAF + CTG CAF + XCM 60 dehiscence‐type Private practice, supported
Scheyer (2016)/ split‐mouth recession; by company
McGuire and GR ≥ 3 mm
Scheyer (2010)
Jepsen (2017)/ Multicentre RCT; 10/8 36 0 CAF + XCM CAF 36 Miller Class I and II; University, supported by
Jepsen (2013) split‐mouth GR > 2 mm company
Santamaria (2017)/ Single centre RCT; 20/20 40 4 CAF + CTG + LLLT CAF + CTG 24 Miller Class I and II; University, supported by
Fernandes‐Dias parallel NA research funding
(2015)
Rasperini (2018)/ Single centre RCT; 15/10 25 0 CAF + CTG CAF 108 Miller Class I and II; University, self‐supported
Cortellini (2009) parallel GR ≥ 2 mm

Abbreviations: ADM, acellular dermal matrix; CAF, coronally advanced flap; CTG, connective tissue graft; DFDBA, demineralized freeze‐dried bone allograft; EMD, enamel matrix derivative; GR, gingival
recession; GTR, guided tissue regeneration; LLLT, low‐level laser therapy; NA, not available; PDGF‐BB, platelet‐derived growth factor‐BB; RCT, randomized controlled trial; XCM, xenogeneic collagen
DAI et al.

matrix; β‐TCP, β‐tricalcium phosphate.

TA B L E 2   Original data extracted from the included studies (primary and secondary outcomes)

Patient‐centred parameters
DAI et al.

Follow‐up N of
Study Interventions (month) sites CRC (n/N) MRC (%) KTW (mm) Hypersensitivity Aesthetics

Del Pizzo (2005) CAF + EMD 6 15 11/15 94.00 ± 10.39 2.20 ± 0.56 NA NA

24 15 11/15 90.67 ± 16.99 2.47 ± 0.52
CAF 6 15 11/15 93.00 ± 12.79 2.07 ± 0.59
24 15 9/15 86.67 ± 18.29 2.13 ± 0.52
Leknes (2005)/ CAF + biodegrad‐ 12 11 4/20 51.2 3.1 ± 0.6 NA NA
Amarante able membrane 72 11 2/11 35.0 2.6 ± 0.9
(2000)
CAF 12 11 6/20 61.1 3.0 ± 0.6
72 11 1/11 34.0 2.6 ± 0.7
de Queiroz CAF + ADM 6 13 3/13 76.18 ± 20.81 3.85 ± 0.75 NA NA
Cortes (2006) 24 13 1/13 68.04 ± 17.87 3.77 ± 0.60
CAF 6 13 3/13 71.19 ± 20.58 3.19 ± 0.75
24 13 1/13 55.98 ± 23.00 3.04 ± 0.85
Abolfazli (2009) CAF + CTG 12 12 7/12 83.4 4.49 ± 0.87 NA NA
24 12 8/12 93.1 4.74 ± 0.59
CAF + EMD 12 12 6/12 77.7 3.49 ± 0.87
24 12 3/12 76.9 3.66 ± 1.04
Bittencourt CAF + CTG 6 17 13/17 96.30 4.45 ± 1.11 7/17 (CAF + CTG) vs. Using a questionnaire, 14/17 (CAF) reported an
(2009) 30 17 15/17 96.83 4.44 ± 1.22 7/17 (CAF) at baseline, excellent or good aesthetic result, and 3/17 (CAF)
and 0/17 (CAF + CTG) reported a bad result. 17/17 (CAF + CTG) reported
CAF (Semilunar) 6 17 9/17 90.95 4.42 ± 1.34 vs. 3/17 (CAF) after an excellent or good result. Based on aesthetics
30 17 10/17 89.25 4.38 ± 1.66 30 months achieved, 7/17 preferred CAF + CTG and 10/17
showed no preference
Pini Prato (2011)/ CAF (polishing) 12 10 4/10 NA 2.4 ± 1.3 5/10 (polishing) vs. 4/10 NA
Pini‐Prato 168 9 5/9 NA 2.4 ± 1.8 (root scaling) at baseline,
(1999) 0/10 (polishing) vs. 0/10
CAF (root scaling) 12 10 4/10 NA 2.6 ± 0.8 (scaling) after 1 year,
168 9 3/9 NA 2.3 ± 1.3 and 3/9 (polishing) vs.
3/9 (root scaling) after
9 years
McGuire (2012)/ CAF + CTG 12 9 8/9 96.3 ± 11.1 NA 1/9 (CAF + EMD) vs. 3/9 6/9 had no preference for a particular type of
McGuire and 120 9 7/9 89.8 ± 22.7 NA (CAF + CTG) after treatment, 2/9 favoured CAF + EMD and 1/9
Nunn (2003) 10 years favoured CAF + CTG after 10 years
CAF + EMD 12 9 7/9 94.4 ± 11.0 NA
120 9 5/9 83.3 ± 21.7 NA
|
      577

(Continues)
TA B L E 2   (Continued)
|

Patient‐centred parameters
Follow‐up N of
578      

Study Interventions (month) sites CRC (n/N) MRC (%) KTW (mm) Hypersensitivity Aesthetics

Kuis (2013) CAF + CTG 6 57 53/57 97.2 ± 10.6 2.46 ± 0.60 NA NA

60 57 47/57 92.3 ± 19.2 2.70 ± 0.60
CAF 6 57 45/57 91.9 ± 16.4 2.09 ± 0.71
60 57 34/57 82.7 ± 23.8 2.25 ± 0.76
Rosetti (2013) CAF + CTG 6 12 NA 95.0 ± 8.0 4.7 ± 1.1 NA No differences between the groups of aesthetic
30 12 NA 95.5 ± 10.1 4.5 ± 1.2 evaluation conducted by professional dentists after
30 months
GTR + DFDBA 6 12 NA 76.4 ± 19.0 2.1 ± 1.0
30 12 NA 87.0 ± 17.2 3.4 ± 0.6
McGuire (2014)/ CAF + CTG 6 20 18/20 97.90 ± 6.59 NA No significant differences Using a questionnaire for patients, 18/20 were rated
McGuire (2009) 60 20 15/20 89.35 ± 21.63 NA between groups were as “very satisfied” or “satisfied,” and 2/20 as
seen by qualitative “unsatisfied” or “very unsatisfied” in the
CAF + PDGF‐ 6 20 14/20 89.85 ± 15.95 NA measures after 5 years CAF + PDGF‐BB + β‐TCP group. In the CAF + CTG
BB + β‐TCP 60 20 12/20 74.10 ± 32.27 NA group, 20/20 were rated as “very satisfied” or
“satisfied”
Nizam (2015) Microsurgery of 6 20 16/20 95.35 ± 9.68 NA NA The aesthetic scores of both groups were signifi‐
CAF + CTG 24 19 15/19 95.82 ± 8.41 2.70 ± 0.97 cantly and similarly improved compared with
baseline after 24 months assessed by patients
Macrosurgery of 6 20 13/20 90.73 ± 13.44 NA using a visual analog scale
CAF + CTG 24 18 9/18 83.46 ± 16.21 2.69 ± 0.91
McGuire and CAF + CTG 6 17 16/17 97.5 ± 10.4 4.18 ± 1.22 NA Assessed by professional dentists, CAF + XCM
Scheyer (2016)/ 60 17 15/17 95.5 ± 12.8 4.12 ± 0.88 provided significantly better aesthetic results
McGuire and compared with CTG + CAF after 5 years. Using a
Scheyer (2010) CAF + XCM 6 17 12/17 89.5 ± 19.2 4.12 ± 1.17 five‐point scale for patients, 15/17 were rated as
60 17 9/17 77.6 ± 29.2 3.41 ± 1.06 “very satisfied” or “satisfied” and 2/17 as
“unsatisfied” in the CAF + XCM group. 16/17 were
rated as “very satisfied” or “satisfied” and 1/17 as
“unsatisfied” in the CAF + CTG group after 5 years
Jepsen (2017)/ CAF + XCM 6 18 11/18 89.94 ± 14.46 3.56 ± 1.46 NA NA
Jepsen (2013) 36 18 11/18 91.70 ± 12.05 4.06 ± 1.55
CAF 6 18 7/18 83.70 ± 15.99 2.83 ± 0.94
36 18 7/18 82.77 ± 17.03 3.25 ± 0.81
Santamaria CAF + CTG + LLLT 6 20 13/20 91.84 ± 22.5 4.16 ± 1.20 NA 9.63 ± 0.76 (CAF + CTG + LLLT) vs. 9.70 ± 0.46
(2017)/ 24 19 15/19 93.43 ± 14.3 3.76 ± 0.78 (CAF + CTG) for patient‐centred aesthetic
Fernandes‐Dias evaluation by Visual Analog Scale. 8.52 ± 1.21
(2015) CAF + CTG 6 20 7/20 89.38 ± 22.3 4.00 ± 0.86 (CAF + CTG + LLLT) vs. 8.68 ± 0.97 (CAF + CTG)
24 17 13/17 92.32 ± 15 4.05 ± 0.89 for professional aesthetic evaluation using Red
Esthetic Score
DAI et al.

(Continues)
 DAI et al. |
      579

to 68.04 ± 17.87% at 2 years (de Queiroz Cortes et al., 2006). In the

Abbreviations: ADM, acellular dermal matrix; CAF, coronally advanced flap; CRC, complete root coverage; CTG, connective tissue graft; DFDBA, demineralized freeze‐dried bone allograft; EMD, enamel
sites treated by CAF + XCM, CRC was reported 11/18 (6 months)
versus 11/18 (3 years; Jepsen et al., 2017) and 12/17 (6 months)

matrix derivative; GTR, guided tissue regeneration; KTW, width of keratinized tissue; LLLT, low‐level laser therapy; MRC, mean root coverage; NA, not available; PDGF‐BB, platelet‐derived growth
versus 9/17 (5 years; McGuire & Scheyer, 2016). And MRC was re‐
ported 89.94 ± 14.46% (6 months) versus 91.70 ± 12.05% (3 years;
Jepsen et al., 2017) and 89.5 ± 19.2% (6 months) versus 77.6 ± 29.2%
(5 years; McGuire & Scheyer, 2016), respectively.
Some trials tested different root surface modifications for sin‐
gle gingival recessions. Three studies were included to evaluate the
long‐term stability of CAF + EMD. The meta‐analysis revealed no sig‐
nificant difference between the short‐term and long‐term results of
CRC (p = 0.21, RR: 1.26, 95% CI: 0.87–1.83, I2 = 0%; Figure S1). MRC
Aesthetics

was reported 94.00 ± 10.39% (6 months) versus 90.67 ± 16.99%

(2 years; Del Pizzo et al., 2005) and 94.4 ± 11.0% (6 months) versus
NA

83.3 ± 21.7% (10 years; McGuire et al., 2012). Only one study eval‐

Patient‐centred parameters

uated the long‐term results of the additional use of laser. During the
(CAF + CTG) vs. 0/13

2‐year follow‐up after CAF + CTG + LLLT, CRC changed from 13/20

1/12 (CAF + CTG) vs.

6 months, and 0/12

(CAF) after 9 years

to 15/19 and MRC changed from 91.84 ± 22.5% to 93.43 ± 14.3%

1/13 (CAF) after
Hypersensitivity

(Santamaria et al., 2017). One trial extending up to 5 years reported

the results of CAF combined with growth factors. For CAF + PDGF‐
BB + β‐TCP group, CRC changed from 14/20 to 12/20 and MRC sig‐
nificantly reduced from 89.85 ± 15.95% to 74.10 ± 32.27% (McGuire
et al., 2014).
KTW (mm)

2.8 ± 0.5

3.6 ± 0.7
4.8 ± 0.7
3.1 ± 0.4

3.4.2 | Results of secondary outcomes (KTW and

patient‐centred parameters)
Nine groups in eight studies were included to evaluate the change
in KTW from short‐term to long‐term after CAF. The analysis did
MRC (%)

not show significant difference in KTW (p = 0.16, MD: −0.12 mm,

95% CI: −0.28 to 0.05 mm, I2 = 13%; Figure 2c). As for the change
NA
NA
NA
NA

of KTW after CAF + CTG, random effects model was used because

of the high heterogeneity. The overall KTW change for CAF + CTG
CRC (n/N)

between short‐term and long‐term groups was not significant

factor‐BB; XCM, xenogeneic collagen matrix; β‐TCP, β‐tricalcium phosphate.
8/12
5/13
5/13
7/12

(p = 0.33, MD: −0.26 mm, 95% CI: −0.80 to 0.27 mm, I2 = 87%;

Figure 3c). Short‐term outcomes in CAF + CTG and CAF alone in
terms of KTW did not favour either group (p = 0.85, MD: −0.05 mm,
sites
N of

95% CI: −0.56 to 0.46 mm, I2 = 79%; Figure 4c). However, when

12
12
13
13

long‐term outcomes were compared, CAF + CTG resulted in greater

MRC: mean ± SD (standard deviation); KTW: mean ± SD.
Follow‐up

KTW than CAF alone (p = 0.04, MD: −0.63 mm, 95% CI: −1.21 mm to
(month)

−0.04 mm, I2 = 71%; Figure 4d).

108
108
6

Initial data showed significant increase of KTW in short‐time

compared to baseline in the groups including CAF + EMD (Abolfazli
et al., 2009; Del Pizzo et al., 2005), CAF + ADM (de Queiroz
Interventions

CAF + CTG

Cortes et al., 2006), CAF + XCM (Jepsen et al., 2013; McGuire &

Scheyer, 2010), CAF + PDGF‐BB + β‐TCP (McGuire et al., 2014) and
CAF
TA B L E 2   (Continued)

GTR + DFDBA (Rosetti et al., 2013). Furthermore, significant differ‐

ence was reported between the long‐term and short‐term results of
Cortellini (2009)
Rasperini (2018)/

KTW after CAF + EMD (Del Pizzo et al., 2005) and GTR + DFDBA

(Rosetti et al., 2013), both favouring the long‐term results.
The major two complaints about gingival recession from pa‐
Study

tients are dentin hypersensitivity and aesthetic requests (Cortellini

& Pini Prato, 2012). Among the included 15 RCTs, only five studies
 |
580       DAI et al.

F I G U R E 2   Forest plot comparing short‐term versus long‐term outcomes of coronally advanced flap (CRC) in the treatment of single
gingival recessions in terms of the following: (a) complete root coverage (CRC); (b) mean root coverage (MRC); (c) width of keratinized tissue
(KTW)

detected the dentin hypersensitivity in participants. Relief from hy‐
persensitivity in short‐term was observed in the studies all above,
while a small apical relapse of gingival margin may cause the recur‐
rence of hypersensitivity (Pini Prato et al., 2011). Aesthetic evalua‐
tion from clinicians or/and patients was reported in seven studies,
which applied different evaluation approaches. No meta‐analysis
was possible for the patient‐centred parameters for most of them
are qualitative assessment.
4 |  D I S CU S S I O N
The stability of various root coverage procedures has already
been qualitatively discussed by some authors (Cairo, 2017;
Chambrone & Tatakis, 2015; Chambrone et al., 2018; Cortellini &
Pini Prato, 2012; Silva, de Lima, Sallum, & Tatakis, 2007; Zucchelli
& De Sanctis, 2005; Zucchelli & Mounssif, 2015). To our limited
knowledge, this review is the first one to systematically compare
the short‐term with long‐term outcomes of a therapy for single
gingival recessions as well as the long‐term results among dif‐
ferent root coverage procedures. The results of meta‐analysis
demonstrated that CAF procedure could result in decreased post‐
operative percentage of root coverage with time. Comparing the
short‐term and long‐term outcomes of CAF + CTG, no significant
differences could be found in terms of CRC or MRC. CAF + CTG
resulted in better long‐term efficacy of root coverage than CAF
alone in terms of CRC and KTW. In addition, the meta‐analysis
showed no significant difference between the short‐term and
long‐term results of CRC after CAF + EMD. Because of a lack of
studies with long‐term follow‐up, we failed to conduct meta‐anal‐
ysis on short‐term and long‐term efficacy of other root coverage
procedures.
DAI et al. |
      581

F I G U R E 3   Forest plot comparing short‐term versus long‐term outcomes of CAF + CTG in the treatment of single gingival recessions in
terms of the following: (a)complete root coverage (CRC); (b) mean root coverage (MRC); (c) width of keratinized tissue (KTW)

Coronally advanced flap is regarded as one of reliable technique
for root coverage of localized recession‐type defects. It could be an‐
ticipated for CRC and MRC ranging from 7.7% to 60.0% and 55.9% to
86.7%, respectively, at short‐term (6–12 months; Chambrone et al.,
2010). Our meta‐analysis showed that gingival margin seemed un‐
stable in long‐term after CAF therapy for single gingival recessions.
This is similar with a retrospective study which evaluated the long‐
term (20 years) outcomes of CAF for single gingival recessions (Pini
Prato, Magnani, & Chambrone, 2018). In the study over the long pe‐
riod, the percentage of CRC for Miller Class I recessions decreased
from 41.66% (30/72) to 32.72% (18/55), and MRC decreased from
71.43% (12 months) to 59.70% (20 years), respectively. Another trial
by Pini‐Prato et al. (2012) reported 53% recurrence of gingival reces‐
sion 8 years after CAF.
The combined use of CTG could benefit the stability of gingival
margin, and four (Abolfazli et al., 2009; Bittencourt et al., 2009;
Rosetti et al., 2013; Santamaria et al., 2017) out of nine studies
even reported higher possibility of CRC in long‐term, which was
also described as “creeping attachment” (Harris, 1997). Decreased
KTW around recessions was not observed over time. These re‐
sults are partially in line with the long‐term (20 years) results of
CAF + CTG by Pini‐Prato, Franceschi, Cortellini, and Chambrone
(2018). Within localized Miller Class I defects, CRC was 57.14%
(12/21) at 1‐year follow‐up and 47.62% (10/21) after 20 years,
while MRC slightly decreased from 82.37% to 77.62%. In addition,
no significant change of KTW was detected between the 1‐year
and the following 5‐, 10‐, 15‐ and 20‐year measurement. It was
concluded that root coverage efficacy after CAF + CTG could be
 |
582       DAI et al.

F I G U R E 4   Forest plot comparing short‐term and long‐term outcomes of CAF + CTG versus CAF in the treatment of single gingival
recessions in terms of the following: (a) complete root coverage (CRC) in short‐term; (b) complete root coverage (CRC) in long‐term; (c) width
of keratinized tissue (KTW) in short‐term; (d) width of keratinized tissue (KTW) in long‐term

maintained for 20 years, with about 70% sites found no apical shift
of the gingival margin.
Three RCTs (Bittencourt et al., 2009; Kuis et al., 2013; Rasperini
et al., 2018) directly compared CAF + CTG and CAF alone. Both the
short‐term and long‐term results of CRC were significantly in favour
of CAF + CTG. Interestingly, with respect to KTW, the meta‐anal‐
ysis showed different results between short‐term and long‐term
(Figure 4c,d). Although characterized by limited clinical evidence and
unignorable heterogeneity, the results seemed to indicate a trend
that the postoperative change of KTW between the two groups
became more evident over time. The same tendency was also no‐
ticed in the treatment of multiple gingival recessions by CAF with or
without CTG. A 5‐year RCT reported statistically greater increase in
buccal KTW in the sites treated by CAF + CTG, which may facilitate
long‐term patient maintenance (Zucchelli et al., 2014).
Due to limited evidence on long‐term results of alternative
biomaterials, quantitative comparison was failed to be conducted
between the short‐term and long‐term outcomes of CAF + ADM
or CAF + XCM. According to initial data mentioned above (see in
Section 3.4.1), the outcomes of CAF in combination with XCM or
ADM seemed stable in long‐term. However, this result should be in‐
terpreted with caution. Because one study indicated better 5‐year
stability of CAF + CTG compared to CAF + XCM for single gingival
recessions (McGuire & Scheyer, 2016), whereas the other two stud‐
ies set the control group as CAF rather than CAF + CTG (Jepsen
et al., 2017; de Queiroz Cortes et al., 2006). Hence, more attention
should be paid to compare the long‐term validity of the alternative
bio‐products with that of CTG.
Different root surface modifiers are considered as attempts
to improve the predictability of clinical outcomes. Our results
DAI et al.
indicated that the additional use of EMD might benefit the long‐
term stability of CAF for single gingival recessions. This has also
been recommended in AAP's report for its superior outcomes
than CAF alone and more stable results (Chambrone & Tatakis,
2015). Nevertheless, the use of other surface biomodification to
enhance therapeutic stability of root coverage surgeries remains
inconclusive.
To maintain stability after surgery, several prognostic factors have
been explored. Technique‐related factors including operation pro‐
cess and operator skills could have an immediate and essential impact
on the predictability and the overall efficacy of the surgery (Zuhr,
Rebele, Cheung, Hurzeler, & Wound, 2018). Site‐related factors may
also have an influence on the stability, such as width of keratinized
tissue band (Jepsen et al., 2017; Kuis et al., 2013; Rasperini et al.,
2018), thickness of keratinized tissue (Bittencourt et al., 2009; de
Queiroz Cortes et al., 2006) and non‐caries cervical lesion (Rasperini
et al., 2018). At the patient level, smoking (Leknes et al., 2005), age‐
ing (Pini Prato et al., 2018) and oral hygiene habits (Rasperini et al.,
2018) appear to be relevant in the maintenance of root coverage. It is
worth noting that the role of traumatic toothbrushing was highlighted
as a challenge to gingival margin stability during follow‐up period
(Abolfazli et al., 2009; Leknes et al., 2005; de Queiroz Cortes et al.,
2006; Rasperini et al., 2018). Hence, to prevent the recurrence of gin‐
gival recession, regular recalls for proper oral hygiene maintenance
and reinforced instructions in non‐traumatic toothbrushing should be
strongly recommended for periodontal clinicians.
Some limitations should be taken into consideration in the
present review. Despite study types limited to RCTs, most of the
included studies had a moderate risk of bias and one was even
assessed as high risk. During the long period of follow‐up, a total
of 48 out of 318 participants dropped out, which presents a po‐
tential of bias and may decrease the strength of evidence. More
than half (11/20) patients lost follow‐up during 10‐year period
(McGuire et al., 2012), though enough power suggested by post
hoc power analysis allowed authors to conduct statistical and
clinical interpretation of the long‐term data (McGuire et al., 2012;
Pini Prato et al., 2011). Therefore, more well‐designed RCTs with
constant postoperative follow‐up are encouraged to provide evi‐
dence for the evaluation of long‐term stability. The 10 th European
Workshop on Periodontology even pointed out that results of at
least 5 years were needed to assess the stability of clinical out‐
comes (Tonetti & Jepsen, 2014). It should also be noted that dif‐
ferent follow‐up durations of the included studies may add to the
bias of the meta‐analysis results. Hence, to distinguish studies
with follow‐up ≥ 10 years, follow‐up ≥ 5 years from those with
follow‐up 2–5 years may be a good solution in future researches.
Furthermore, it is being emphasized to pay more attention to pa‐
tient‐centred parameters (Zucchelli, Sharma, & Mounssif, 2018).
Unfortunately, the lack of standardized questionnaire existing
made it difficult to quantitatively compare the patients’ aesthetic
satisfaction after different therapies. Hence, valid criteria to as‐
sess patient‐centred outcomes should be taken into consideration
in the following studies.
|
      583
In conclusion, within the limitations of the available results, this
systematic review and meta‐analysis revealed that CAF alone may
lose stability with time as the gingival margin had a tendency to shift
apically. CAF + CTG could maintain long‐term stability and result
in better long‐term efficacy of root coverage than CAF alone. The
additional use of EMD may enhance the stability of CAF. However,
insufficient evidence was available to evaluate the effectiveness of
alternative biomaterials and the benefit of other root surface modi‐
fiers for long‐term stability. It should be encouraged to follow up pa‐
tients continuously and report the long‐term results of both clinical
and patient‐centred outcomes.
C O N FL I C T O F I N T E R E S T
The authors have stated explicitly that there are no conflicts of inter‐
est in connection with this article.
ORCID
Pei‐Hui Ding  https://orcid.org/0000-0001-6147-1787
Li‐Li Chen  https://orcid.org/0000-0002-0620-8844
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S U P P O R T I N G I N FO R M AT I O N
Additional supporting information may be found online in the
Supporting Information section at the end of the article.    
How to cite this article: Dai A, Huang J‐P, Ding P‐H, Chen L‐L.
Long‐term stability of root coverage procedures for single
gingival recessions: A systematic review and meta‐analysis. J
Clin Periodontol. 2019;46:572–585. https​://doi.org/10.1111/
jcpe.13106​