Volume 81 • Number 4

Review
Root-Coverage Procedures for the Treatment of Localized
Recession-Type Defects: A Cochrane Systematic Review
Leandro Chambrone,* Flávia Sukekava,*† Maurı́cio G. Araújo,† Francisco E. Pustiglioni,*
Luiz Armando Chambrone,‡ and Luiz A. Lima*

Background: The purpose of this review is to evaluate the

effectiveness of different root-coverage procedures in the
treatment of recession-type defects.
Methods: The Cochrane Oral Health Group Trials Register,
Cochrane Central Register of Controlled Trials, MEDLINE,
and EMBASE were searched for entries up to October 2008.
There were no restrictions regarding publication status or the

G
language of publication. Only clinical randomized controlled ingival recession (GR) is a term
trials (RCTs) with a duration ‡6 months that evaluated reces- that designates the oral exposure
sion areas (Miller Class I or II ‡3 mm) that were treated by means of the root surface because of a
of periodontal plastic surgery procedures were included. displacement of the gingival margin
Results: Twenty-four RCTs provided data. Only one trial was apical to the cemento-enamel junc-
considered to be at low risk of bias. The remaining trials were tion.1-3 Reports from diverse epidemio-
considered to be at high risk of bias. The results indicated a sig- logic surveys revealed that GR may
nificantly greater reduction in gingival recession and gain in affect most of the adult population.4-6
keratinized tissue for subepithelial connective tissue grafts Gingival anatomic factors, chronic
(SCTGs) compared to guided tissue regeneration (GTR) with trauma, periodontitis, and tooth align-
bioabsorbable membranes (GTR bms). A significantly greater ment are the main conditions leading to
gain in keratinized tissue was found for enamel matrix protein the development of these defects.2,7-9
compared to a coronally advanced flap (0.40 mm) and for GR is also regularly linked to the de-
SCTGs compared to GTR bms plus bone substitutes. Limited terioration of dental esthetics and buccal
data exist on the changes of esthetic conditions as related to cervical dentine hypersensitivity.10 In
the opinions and preferences of patients for specific proce- such cases, the goal of periodontal therapy
dures. should be to address the needs and wishes
Conclusions: SCTGs, coronally advanced flaps alone or of each patient, and treatment options
associated with other biomaterial, and GTR may be used as should be made available to them.11
root-coverage procedures for the treatment of localized reces- Preferably, treatment options should
sion-type defects. In cases where root coverage and gain in be based on systematic, unbiased, and
keratinized tissue are expected, the use of SCTGs seems to objective evaluations of the literature.12
be more adequate. J Periodontol 2010;81:452-478. Moreover, the introduction of specific ob-
jectives, inclusion criteria, and search
KEY WORDS strategies based on evidence and scien-
Connective tissue; gingival recession; gingival recession/ tifically valid information may reduce
surgery; gingival recession/therapy; systematic review; the variation in clinical outcomes, estab-
tooth root/surgery. lish the application and predictability
of a specific procedure, and improve
the effectiveness of clinical practice.12
* Division of Periodontics, Department of Stomatology, School of Dentistry, University of Consequently, scientific evidence-based
São Paulo, São Paulo, SP, Brazil.
† Department of Dentistry, State University of Maringá, Maringá, PR, Brazil. information should be achieved by well-
‡ Private practice, São Paulo, SP, Brazil. delineated systematic reviews.13
Successful treatment of recession-
type defects is based on the use of
This paper is based on a Cochrane Review1 published in The Cochrane Library 2009, Issue 2
(see www.thecochranelibrary.com for information). Cochrane Reviews are regularly updated
as new evidence emerges and in response to feedback, and The Cochrane Library should be
consulted for the most recent version of the review. doi: 10.1902/jop.2010.090540

452
J Periodontol • April 2010
clinically predictable periodontal plastic surgery
(PPS) procedures. As first proposed by Miller in
1988,14 PPS comprises different surgical techniques
intended to correct and prevent anatomic, develop-
mental, traumatic, or plaque disease-induced defects
of the gingiva, alveolar mucosa, or bone. Historically,
these procedures originated at the beginning of the
20th century and were presented by Younger in
1902, Harlan in 1906, and Rosenthal in 1911; they de-
scribed the use of pedicle or free soft tissue grafts to
cover denuded root surfaces.15 However, these tech-
niques were abandoned for a long time. During recent
decades, different surgical procedures were pro-
posed. Coronally advanced flaps (CAFs), laterally re-
positioned flaps, free gingival grafts (FGGs), and
subepithelial connective tissue grafts (SCTGs) ap-
peared as novel approaches to achieve improve-
ments in recession depth, clinical attachment level,
and width of keratinized tissue.3,16-28
In more recent years, some systematic reviews29-31
were published focusing on the effect of PPS proce-
dures on the treatment of localized GRs, The authors
of these reviews reported that different surgical tech-
niques and flap designs were described and used in an
attempt to correct localized GRs producing statisti-
cally significant improvements in GR and clinical
attachment level. Also, it was recommended for clin-
ical practice that SCTGs, CAFs, or guided tissue re-
generation (GTR) may be used when root coverage
is indicated.29-31
Despite the remarkable work performed by these
authors,29-31 the following issues should be consid-
ered: Roccuzzo et al.31 included non-randomized
studies, only English-language trials, and did not in-
clude randomized controlled trials (RCTs) testing
acellular dermal matrix grafts (ADMGs) and the use
of PPS procedures in multiple recession-type defects.
Chambrone et al.29 did not include unpublished stud-
ies and non-English studies, and their review was spe-
cifically designed to evaluate the effectiveness of
a single procedure (i.e., SCTGs) in localized reces-
sion-type defects. The systematic review by Oates
et al.30 only included published studies, English-lan-
guage studies, studies with small populations (e.g.,
<10 patients), studies presenting defect-based analy-
sis (i.e., patients were not considered the unit of anal-
ysis), studies with patients with interproximal tissue
loss, and comparisons among trials reporting very dif-
ferent follow-up periods (i.e., 6 to 48 months). Addi-
tionally, the searches of two of these reviews30,31 were
conducted >7 years ago. Consequently, some of these
conditions may represent a source of bias in each of
these systematic reviews.
There are other questions and conditions that were
not previously evaluated: 1) because recession de-
fects do not improve spontaneously, what is an appro-
Chambrone, Sukekava, Araújo, Pustiglioni, Chambrone, Lima
priate control group for the treatment of recession-
type defects? 2) exclusion of non-randomized studies
allows bias protection, but there is also a potential loss
of the evidence base because only studies that com-
pare two (or more) active treatments can be studied;
and 3) assessing the mean difference (MD) between
groups is helpful but does not inform as to whether
the interventions are beneficial. For instance, where
there is no difference between treatments, are they
similarly good or bad? Normally, this would be as-
sessed 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 de-
fects. Given the common occurrence of recession
areas involving localized or adjacent teeth, evidence-
based information associating the results achieved
by different surgical techniques can be considered an
important tool in clinical decision making. Thus, the
aim of this systematic review is to evaluate the effec-
tiveness of different root-coverage procedures in the
treatment of recession-type defects.
This review is the main article of a research project
designed to explore the effects of the PPS procedures
in the treatment of recession-type defects via sys-
tematic reviews. The study protocol (i.e., electronic
searching and methodology) used in this review al-
lowed for the evaluation of further research questions
and meta-analyses that were reported in others pub-
lications.29,32,33
MATERIALS AND METHODS
Criteria for Considering Studies for This Review
Types of studies. Only RCTs with a duration ‡6
months were included.
Types of participants. Studies were included if the
participants met the following criteria: 1) had a clinical
diagnosis of localized or multiple recession-type de-
fects, 2) had recession areas selected for treatment
classified as Miller34 Class I or II ‡3 mm that were sur-
gically treated by PPS procedures (studies including
Miller Class III or IV were not included), and 3) there were
‡10 participants per group at the final examination.
Types of interventions. The interventions of inter-
est were FGGs, laterally positioned flaps (LPFs),
CAFs, SCTGs alone or in combination with LPFs or
CAFs, ADMGs, GTR, and the use of enamel matrix
protein (EMP).
Types of outcome measures. Primary. Primary
outcome measures included the change of esthetic con-
dition as it related to the patient’s opinion (satisfactory,
non-satisfactory, or not reported) and GR change.
Secondary. Secondary outcome measures were as
follows: clinical attachment change, keratinized tissue
change, percentage of sites with complete root
453
Treatment of Recession-Type Defects
coverage, mean root coverage, preference of a patient
for a specific PPS procedure (in split-mouth trials), oc-
currence of adverse effects (yes/no), and/or postop-
erative complications (yes/no).
In addition, outcome measures were separated into
short term (evaluated 6 to 12 months after interven-
tions) or long term (evaluated ‡13 months after inter-
ventions).
Search Methods for Identification of Studies
Electronic searching. For the identification of stud-
ies 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 Reg-
ister of Controlled Trials (CENTRAL). Databases were
searched to include articles and abstracts published in
all languages, and every effort was made to translate
non-English papers. The following databases were
searched: the Cochrane Oral Health Group Trials
Register, CENTRAL, MEDLINE (1950 to October
2008), and EMBASE (1986 to October 2008).
In addition, the Cochrane Highly Sensitive Search
Strategy for identifying randomized trials in MEDLINE
(sensitivity maximizing version [2008 revision] refer-
enced in Chapter 6.4.11.1 and detailed in box 6.4.c
of the Cochrane Handbook for Systematic Reviews of
Interventions5.0.135) wasaddedtothe MEDLINEsearch.
Hand searching. The following journals were iden-
tified as important to this review and were hand
searched: Journal of Periodontology, Journal of Peri-
odontal Research, Journal of Clinical Periodontology,
and International Journal of Periodontics and Restor-
ative Dentistry.
Unpublished data. Unpublished data were sought
by searching a database (System for Information on
Grey Literature in Europe) listing unpublished studies,
abstracts, and conference proceedings from the rele-
vant journals. In addition, reference lists of any poten-
tial clinical trials were examined in an attempt to
identify any other studies. Authors of included studies
were contacted to ask for details of additional pub-
lished and unpublished trials.
Data Collection and Analysis
Selection of studies. Initially, two review authors (LC
and FS) independently screened titles, abstracts, and
full texts of the search results. Agreement between the
review authors was assessed by calculating k scores.
The review authors remained unmasked regarding
the authors, their institutional affiliations, and the site
of publication of reports. Full reports were obtained for
all studies appearing to meet the inclusion criteria or
in instances 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. Disagreement be-
454
Volume 81 • Number 4
tween the review authors was resolved by discussion
with the inclusion of two other review authors (LAC
and LAL). In the case of missing data, authors were
contacted to resolve eventual doubts and provide fur-
ther details from the trials. Data were excluded until
further clarification was available if agreement could
not be reached. The studies meeting the inclusion cri-
teria underwent validity assessment and data extrac-
tion. 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) inde-
pendently and in duplicate using specially designed
data-extraction forms. Data were extracted and
loaded into softwarei of the Cochrane Collaboration
and checked. Data on the following issues were ex-
tracted and recorded: 1) citation, publication status,
and year of publication; 2) location of trial: country
and place where the patients were treated (e.g., pri-
vate practice or university dental hospitals); 3) study
design: RCT (i.e. if the study was an RCT or not); d)
characteristics of participants: sample size, gender,
age, locale, and systemic conditions; e) methodologic
quality of trials: patient and defect selection bias, se-
lection of a control group, adequate inclusion criteria,
statistical analysis, randomization selection, validity
of conclusions, and clinical variables analyzed; f)
characteristics of interventions: FGGs, LPFs, CAFs,
SCTGs alone or in combination with LPFs or CAFs,
ADMGs, GTR, or use of EMP; and g) source of funding
and conflicts of interest.
Assessment of risk of bias in included studies.
The methodologic quality of the studies was assessed
by focusing on the following points:
Method of randomization (e.g., method used to gen-
erate the randomization sequence): 1) adequate = when
random number tables, a tossed coin, or shuffled cards
were used; 2) inadequate = when other methods were
used such as an alternate assignment, hospital number,
or an odd/even date of birth; and 3) unclear = when
a method of randomization was not reported or explained.
Allocation concealment (e.g., how the randomiza-
tion sequence was concealed from the examiners): 1)
adequate = when examiners were kept unaware of
the randomization sequence (e.g., by means of cen-
tral randomization, pharmacy sequential numbers,
or opaque envelopes); 2) inadequate = when other
methods were used, such as an alternate assignment
or hospital number; and 3) unclear = when the method
was not reported or explained.
Masking of examiners with regard to the treatment
procedures used in the study period was assessed as
yes, no, or unclear.
i Review Manager (RevMan) (computer program), version 5.0, The Nordic
Cochrane Center, The Cochrane Collaboration, Copenhagen, Denmark.
J Periodontol • April 2010
The completeness of the follow-up was based on
the following question: Were the numbers 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 dropouts was
checked. Studies that did not report completeness
of the follow-up were not included.
The risk of bias in the included studies was catego-
rized as follows: 1) Low risk of bias (plausible bias
unlikely to seriously alter the results) = if all criteria
were met. 2) Moderate risk of bias (plausible bias
that raises some doubt about the results) = if one or
more criteria were partly met. 3) High risk of bias
(plausible bias that seriously weakens confidence in
the results) = if one or more criteria were not met.
The agreement between the review authors for
study inclusion was assessed using the k statistic.
Data Synthesis
Data were collated into evidence tables and grouped
according to the type of intervention. A descriptive
summary was performed to determine 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 the suitability of further synthesis methods, in-
cluding a possible meta-analysis.
Random effects meta-analyses were used through-
out the review. For continuous data, pooled outcomes
were expressed as weighted MDs with their associated
95% confidence intervals (CIs). For dichotomous
data, these were predominately pooled risk ratios
and associated 95% CIs. Statistical heterogeneity
was assessed by calculating the Q statistic. Analyses
were performed using software.¶ The analysis for con-
tinuous outcomes was conducted using the generic
inverse variance statistical method where the MDs
and SEs were entered for all studies to allow the com-
bination of parallel and split-mouth group studies.
Variance imputation methods were conducted to
estimate appropriate variance estimates in some
split-mouth studies where the appropriate SD of the
differences was not included in the trials.36
The significance of discrepancies in the estimates
of the treatment effects from the different trials was as-
sessed by means of the Cochrane test for heterogene-
ity and the I2 statistic.35
RESULTS
Description of Studies
Results of the search. The search strategy identified
649 potentially eligible articles (Appendix 2), of which
558 articles were excluded after the titles and/or ab-
stracts were reviewed (k score for interreviewer agree-
ment: 0.84; 95% CI: 0.77 to 0.91). Subsequently, the
Chambrone, Sukekava, Araújo, Pustiglioni, Chambrone, Lima
full texts of the remaining articles that were consid-
ered potentially relevant were screened. From the
91 articles, 64 of them did not meet the criteria of
eligibility (k score for interreviewer agreement: 0.75;
95% CI: 0.58 to 0.88), and the reasons for exclusion
were reported.
Included studies. Twenty-seven papers were in-
cluded in this review regarding 24 RCTs (Table 1).
Three RCTs had their data reported in two articles
each (i.e., according to the follow-up period). Con-
sequently, the articles with a shorter follow-up
period37-39 were included under one study name
(e.g., articles with the longer follow-up).40-42
Of the 24 included RCTs, 14 trials were conducted
according to a split-mouth design,40-53 and 10 trials
were conducted according to a parallel design.54-63
In total, 599 patients were treated, and all studies were
published in full. Five RCTs45,48,54,55,58 were private-
practice based, 17 studies40,41,43,46,47,49-53,56,57,59-63
were based in universities or dental hospitals, and
two studies42,44 were multicenter studies. Nine
trials44,49,51,53,57-60,63 were conducted in Italy, five
trials45,46,48,52,62 were conducted in the United States,
four trials40,43,47,50 were conducted in Brazil, two tri-
als54,55 were conducted in France, two trials56,61 were
conducted in Turkey, one trial42 was conducted in
Germany, and one trial41 was conducted in Norway.
Five trials50,51,56,59,60 were totally or partially sup-
ported by governmental agencies or university pro-
grams, and five trials41,42,46,48,52 were supported by
companies that provided products that were used as
interventions in the RCTs.
The majority of trials followed participants during
a short-term period (6 to 12 months). Only six publi-
cations40-42,44,50,58 with long-term follow-ups were
included.
Treatment modalities. Different interventions were
evaluated: ADMGs, CAFs, FGGs, use of EMP, GTR
with bioabsorbable membranes (GTR bms), GTR with
non-resorbable membranes (GTR nrms), and GTR
bms associated with bone substitutes and SCTGs.
Clinical RCTs evaluating LPFs or multiple recession-
type defects were not found.
Excluded studies. Sixty-four studies were ex-
cluded. Twenty-four of these studies were excluded
because they were not RCTs.64-86
Forty articles were classified as randomized trials;
however, they did not fulfill the inclusion criteria. Sev-
enteen RCTs87-104 included patients with recession
defects <3 mm. Two studies104,105 were classified as
randomized non-controlled trials. Six articles106-111
did not present a patient-based analysis. In addition,
studies including Miller Class III or IV recessions,112
¶ Review Manager (RevMan) (computer program), version 5.0, The Nordic
Cochrane Center, The Cochrane Collaboration.
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Treatment of Recession-Type Defects Volume 81 • Number 4

Table 1.
Characteristics of Included Studies

Allocation
Study Methods Participants Interventions Outcomes Notes Concealment

de Queiroz RCT, split-mouth 13 individuals 1. ADMG + CAF GRC University/hospital Unclear

Côrtes design, two (seven females based
et al.40 treatment and six males; 2. CAF CALC Data from an
groups, and mean age: KTC earlier article
24-month 32.8 years) (de Queiroz
duration with two SCRC Côrtes et al.38)
bilateral Miller PCR were reported
Class I as part of
buccal GRs MRC this trial
‡3 mm
(Manual probe)
Leknes RCT, split-mouth 20 individuals 1. GTR GRC University/hospital Unclear
et al.41 design, two (10 females (polylactic based and
treatment and 10 males; acid membranes
groups, and mean age: membrane) provided by
72-month 38.4 years) the membrane’s
duration with two Miller manufacturer
Class I or II 2. CAF CALC Unpublished data
buccal GRs were included
‡3 mm; 11 after contact
individuals with author
completed
the study KTC Data from
SCRC earlier article
(Amarante
PCR et al.37) were
MRC reported as
part of this trial
(Automated
controlled-
force probe
and manual
probe)

Spahr RCT, split-mouth 37 individuals 1. EMP + CAF GRC University/hospital Unclear

et al.42 design, two (17 females based
treatment and 20 males; (multicenter
groups, and aged 22 to study) and
24-month 62 years) with supported by
duration two Miller the EMP’s
Class I or II manufacturer
buccal GRs 2. Placebo CALC Data from an
‡3 mm; 30 (propylene KTC earlier article
individuals glycol (Hagewald
completed alginate) PCR et al.39) were
the study + CAF MRC reported as
part of this trial
(Automated
controlled-
force probe,
caliper, and
manual probe)

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Table 1. (continued)
Characteristics of Included Studies

Allocation
Study Methods Participants Interventions Outcomes Notes Concealment
da Silva RCT, split-mouth 11 individuals 1. SCTG + CAF GRC University/ Unclear
et al.43 design, two (five females hospital
treatment and six males; based
groups, and aged 18 to 2. CAF CALC Unpublished
6-month 43 years) KTC* (1) data were
duration with two included after
bilateral Miller SCRC contact
Class I or II PCR with author
buccal GRs
‡3 mm MRC
(Automated
controlled-
force probe)
Del Pizzo RCT, split-mouth 15 individuals 1. EMP + CAF GRC University/ Unclear
et al.44 design, two (11 females CALC hospital
treatment and four males; based
groups, and aged 18 to KTC* (1) (multicenter
24-month 56 years) with 2. CAF SCRC study)
duration two bilateral
Miller Class I or II PCR
buccal GRs
MRC
‡3 mm
(Manual probe)
Dodge RCT, split-mouth 12 individuals 1. GTR (polylactic GRC Practice based Unclear
et al.45 design, two (eight females acid membrane) +
treatment and four males; TTC-HCl
groups, and aged 23 to + DFDBA
12-month 51 years) 2. GTR (polylactic CALC* (1)
duration with two acid membrane)
Miller Class I or + TTC-HCl KTC* (1)
II buccal SCRC
GRs ‡3 mm
PCR
MRC
(Manual probe)

Henderson RCT, split-mouth 10 individuals 1. ADMG (connective GRC University/hospital Unclear

et al.46 design, two (five females tissue side based and
treatment and five males; against the tooth) supported by
groups, and aged 24 + CAF the ADMG’s
12-month to 68 years) 2. ADMG (basement CALC manufacturer
duration with two Miller membrane side
Class I or II against the KTC
buccal GRs tooth) + CAF MRC
‡3 mm
(Manual probe)

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Treatment of Recession-Type Defects Volume 81 • Number 4

Table 1. (continued)
Characteristics of Included Studies

Allocation
Study Methods Participants Interventions Outcomes Notes Concealment
Joly et al.47 RCT, split- 10 individuals 1. ADMG + CAF GRC* (2) University/ Unclear
mouth (four females (flap without hospital
design, two and six males; vertical incisions) based
treatment aged 24 to 2. SCTG + CAF CALC* (2)
groups, and 68 years) with (flap without
6-month two Miller vertical incisions) KTC
duration Class I or II MRC
maxillary buccal
GRs ‡3 mm (Manual probe)
McGuire RCT, split- 20 individuals 1. EMP + CAF GRC Practice based Adequate
and mouth (10 females and supported (sealed
Nunn48 design, two and 10 males; by EMP’s envelope)
treatment aged 23 to 62 manufacturer
groups, and years) with two 2. SCTG + CAF CALC Unpublished data
12-month Miller Class II KTC* (2) were included
duration maxillary buccal after contact
GRs ‡4 mm; 17 PCR with author
individuals MRC
completed the
study (Manual probe)
Roccuzzo RCT, split-mouth 12 individuals 1. GTR (polylactic GRC University/ Unclear
et al.49 design, two (three females acid membrane) hospital based
treatment and nine 2. GTR (ePTFE CALC
groups, and males; aged membrane)
6-month 21 to 31 years) KTC
duration with two Miller SCRC
Class I or II
buccal GRs PCR
‡4 mm
MRC
(Manual probe)
Rosetti RCT, split-mouth 12 individuals 1. GTR (collagen ECC University/hospital Unclear
et al.50 design, two (nine females membrane) + based and
treatment and 3 males; TTC-HCl + supported by
groups, and aged 25 to 60 DFDBA Brazilian National
18-month years) with two 2. SCTG + HCl GRC Council for
duration Miller Class I or Scientific and
II buccal GRs KTC Technologic
‡3 mm MRC Development,
Brasilia, DF, Brazil
(Manual probe)

Trombelli RCT, split-mouth 15 individuals 1. CAF (fibrin glue + GRC University/hospital Unclear
et al.51 design, two (three females TTC-HCl) based and
treatment and 12 males; 2. CAF (TTC-HCl) CALC supported by
groups, and aged 25 to the Italian
6-month 51 years) KTC Ministry of
duration with two Miller SCRC University and
Class I or II Scientific
maxillary buccal PCR Research,
GRs ‡3 mm Roma, Italy
MRC
(Manual probe)

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Table 1. (continued)
Characteristics of Included Studies

Allocation
Study Methods Participants Interventions Outcomes Notes Concealment
Wang et al.52 RCT, split-mouth 16 individuals 1. GTR (resorbable ECC University/hospital Unclear
design, two (10 females double-thickness based, and
treatment and six males; collagen membrane) supported by
groups, and aged 30 to 2. SCTG + CAF GRC the membrane’s
6-month 54 years) with manufacturer
duration two Miller CALC
Class I or II KTC
buccal
GRs ‡3 mm MRC
(Manual probe)
Zucchelli RCT, split-mouth 15 individuals 1. SCTG (graft size ECC University/hospital Unclear
et al.53 design, two (aged 18 to equal to the bone based
treatment 35 years) with dehiscence) + CAF
groups, and two Miller 2. SCTG (graft size GRC
12-month Class I or II 3 mm greater than
duration maxillary the bone CALC* (1)
buccal GRs dehiscence) + CAF KTC* (2)
‡3 mm
SCRC

PCR
MRC
(Manual pressure-
sensitive probe)

Bouchard RCT, parallel 30 individuals 1. SCTG + CAF + ECC Practice based Unclear
et al.54 design, two (24 females CA (graft
treatment and six males; without
groups, and aged 21 epithelial
6-month to 62 years) collar)
duration with one 2. SCTG (graft GRC
Miller Class I with epithelial
or II buccal collar) CALC
GR ‡3 mm KTC
SCRC

PCR
MRC
(Automated
controlled-
force probe:
0.50 N)

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Table 1. (continued)
Characteristics of Included Studies

Allocation
Study Methods Participants Interventions Outcomes Notes Concealment
Bouchard RCT, parallel 30 individuals 1. SCTG + CAF + GRC Practice based Unclear
et al.55 design, two (25 females TTC-HCl
treatment and five males; 2. SCTG + CALC
groups, and aged 21 to CAF + CA
6-month 70 years) with KTC
duration one Miller Class SCRC
I or II buccal
GR ‡3 mm PCR

MRC
(Automated
controlled-
force probe:
0.50 N)
Keceli et al.56 RCT, parallel 40 individuals 1. SCTG + GRC University/hospital Unclear
design, two (30 females platelet-rich based and
treatment and 10 males; plasma supported by
groups, and aged 16 to 2. SCTG CALC The Research
12-month 60 years) Foundation of
duration with one Miller KTC Hacettepe
Class I or II SCRC University,
buccal GR Beyetepe-Ankara,
‡3 mm; 36 PCR Turkey
individuals
MRC
completed
the study (Manual probe)
Matarasso RCT, parallel 20 individuals 1. GTR (polylactic GRC University/ Unclear
et al.57 design, two (eight females acid membrane) + hospital based
treatment and 12 males; double papilla flap
groups, and aged 18 to 2. GTR (polylactic CALC Unpublished data
12-month 42 years) with acid membrane) + KTC were included
duration one Miller CAF after contact
Class I or II MRC with author
buccal (Manual probe)
GR ‡3 mm
Paolantonio RCT, parallel 70 individuals 1. SCTG + double GRC* (1) Practice based Unclear
et al.58 design, two (38 females papilla flap
treatment and 32 males; 2. FGG KTC Unpublished data
groups, and aged 25 SCRC were included
60-month to 48 years) after contact
duration with one PCR with author
Miller Class I MRC
or II buccal
GR ‡3 mm (Manual probe)

460
J Periodontol • April 2010 Chambrone, Sukekava, Araújo, Pustiglioni, Chambrone, Lima

Table 1. (continued)
Characteristics of Included Studies

Allocation
Study Methods Participants Interventions Outcomes Notes Concealment
Paolantonio59 RCT, parallel 45 individuals 1. GTR (polylactic GRC University/hospital Unclear
design, three (31 females acid membrane) based and
treatment and 14 males; supported by
groups, and aged 27 Italian Ministry
12-month to 51 years) of University and
duration with one Scientific Research
Miller Class I 2. GTR (polylactic CALC Unpublished data
or II buccal acid membrane) + were included
GR ‡3 mm hydroxyapatite/ after contact
collagen/ with author
chondroitin sulfate
graft
3. SCTG + double KTC* (3)
papilla flap
SCRC
PCR
MRC

(Manual probe)
Paolantonio RCT, parallel 30 individuals 1. ADMG + CAF GRC University/hospital Unclear
et al.60 design, two (19 females and based and
treatment 11 males; supported by
groups, and aged 29 to Italian Ministry of
12-month 51 years) with University and
duration one Miller Class I Scientific Research
or II buccal 2. SCTG + CAF CALC Unpublished data
GR ‡3 mm KTC* (2) were included
after contact
SCRC with author
PCR
MRC
(Automated
controlled-
force probe: 20 g
and caliper)

Tozum et al.61 RCT, parallel 31 individuals 1. SCTG + modified GRC* (1) University/ Unclear
design, two (21 females tunnel procedure hospital based
treatment and 10 males; 2. SCTG + CAF CALC* (1) Unpublished
groups, and aged 16 to MRC data were
6-month 59 years) included after
duration with one Miller (Manual probe) contact
Class I or II with author
buccal GR
‡3 mm

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Treatment of Recession-Type Defects Volume 81 • Number 4

Table 1. (continued)
Characteristics of Included Studies

Allocation
Study Methods Participants Interventions Outcomes Notes Concealment
Woodyard RCT, parallel 24 individuals 1. ADMG + CAF GRC* (1) University/ Unclear
et al.62 design, two (14 females 2. CAF CALC* (1) hospital based
treatment and 10 males;
groups, and mean age: KTC
6-month 34.6 years) SCRC
duration with one Miller
Class I or II PCR
buccal GR
MRC
‡3 mm
(Manual probe)
Zucchelli RCT, parallel 54 individuals 1. GTR (polylactic GRC University/ Unclear
et al.63 design, three (29 females acid membrane) hospital based
treatment and 25 males; 2. GTR (ePTFE CALC
groups, and aged 23 to membrane)
12-month 33 years) with 3. SCTG + CAF KTC* (3)
duration one Miller
Class I or II SCRC
buccal PCR
GR ‡3 mm
MRC* (3)

(Manual probe)
GRC = GR change; CALC = clinical attachment level change; KTC = keratinized tissue change; SCRC = sites with complete root coverage; PCR = percentage
of complete root coverage; MRC = mean root coverage; TTC-HCl = tetracycline hydrochloride; DFDBA = demineralized freeze-dried bone allograft; ePTFE =
expanded polytetrafluoroethylene; ECC = esthetic condition change; CA = citric acid.
* Statistically significant results between/among groups (superior group). The number in parentheses indicates which group was statistically superior
(significant).

a follow-up period <6 months,113 an intervention not
of interest for this review,114 and those interventions
that counted <10 participants per group at the final
examination115-119 were also excluded.
The remaining articles were excluded due to the
combination of two or more factors including the
treatment of recession <3 mm and a follow-up period
<6 months120,121 and <10 patients per group at the
final examination, recessions <3 mm, and patient-
based analyses that were not presented.122,123 In
addition, three trials124-126 were excluded from the
review because of the lack of information regarding
the baseline depth of GRs.
Risk of bias in included studies. The quality of
assessment of the included studies was evaluated
using the data extracted from each trial. Moreover,
all authors were contacted to provide complementary
information by means of a questionnaire regarding
the methodologic quality of their trials.
Randomization. All trials were described as RCTs,
but not all of them reported randomization and alloca-
tion methods in detail. Sixteen trials40-45,47-49,52,53,58-62
presented an adequate method of randomization,
whereas one trial56 reported an inadequate method.
In seven trials,46,50,51,54,55,57,63 the method of ran-
domization was unclear.
Allocation. Only one trial presented an adequate
method of allocation concealment.48 All other trials
were classified as unclear because the method of allo-
cation was not described (Table 1).
Masking. Examiners were considered masked
in 15 studies,41,42,44-46,48-53,56,60,62,63 not masked
in eight studies,43,47,54,55,57-59,61 and unclear in one
study.40
Although authors from three trials58,59,61 re-
sponded to the review inquiry (i.e., a questionnaire re-
garding the methodologic quality of each trial) that
their study had masked examiners, in practical terms
this might have been impossible to achieve with very
different interventions (i.e., SCTGs versus FGGs, GTR
bms versus GTR bms with bone substitutes versus
SCTGs and modified tunnel procedures + SCTGs ver-
sus SCTGs + a CAF). Consequently, where the inter-
vention was very different and therefore the examiner
could guess the group allocation, the study was inter-
preted as unmasked.
Withdrawals, dropouts, and risk of bias. Only four
studies41,42,48,56 reported withdrawals and dropouts.

462
J Periodontol • April 2010
In the first study,41 11 of 20 subjects were available for
the final evaluation (six subjects refused to complete
the study, and three subjects moved to other parts of
Norway). In the second trial,42 six patients could not
be recalled after the follow-up period (they moved
and did not provide their addresses), and one patient
was excluded after enrollment in the study because of
injuries of gingival tissues in the course of dental treat-
ment by the referring dentist. In the third study,48
one participant dropped out because he moved out of
the country where the RCT was conducted, one partic-
ipant had a change in job and could not comply with the
study schedule, and one participant was not compliant
and was exited from the trial. In the last trial,56 four pa-
tients discontinued the study between the 6- and 12-
month evaluations because of moving to another city.
In addition, only one RCT48 was considered to be at
low risk of bias. The remaining trials were considered
to be at high risk of bias.
Publication bias. Publication bias would have been
investigated, especially because its presence was
detected in a previous review,32 by graphical methods
and via the Begg and Mazumdar127 adjusted rank-
correlation test and the Egger regression asymmetry
test.128 However, the limited number of studies pre-
vented such an evaluation.
Effects of Interventions
Change of esthetic condition. The changes of es-
thetic conditions as related to the opinions of patients
were reported in three RCTs.50,53,54 One trial50 com-
pared the GTR bms procedure associated with demin-
eralized freeze-dried bone allografts to SCTGs in
patients with bilateral GRs. Similarly, an esthetic eval-
uation was performed by five examiners who were not
participating in the study. In the study,50 the authors
only mentioned that the patient-satisfaction survey
indicated that all patients were satisfied with the
esthetic results achieved by both procedures at 18
months post-surgery.
The second study53 was designed to compare root-
coverage and esthetic 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., the graft dimension equal
to the depth of the bone dehiscence) and less satisfied
with poor color blending and the excessive thickness
of control-treated recessions (i.e., a graft dimension 3
mm greater than the depth of the bone dehiscence).
The last trial54 evaluated the clinical and esthetic
effects of SCTGs to cover GRs using grafts without
an epithelial collar plus citric acid conditioning and
coronally repositioned flaps or grafts with an epithelial
Chambrone, Sukekava, Araújo, Pustiglioni, Chambrone, Lima
collar and no root conditioning. An esthetic evaluation
was performed by two independent examiners who
were masked to the given treatment. Additionally,
the authors54 commented that no patient was dissat-
isfied with the esthetic results obtained.
Changes in GR, clinical attachment level, and
keratinized tissue. Of the 24 included trials, 12 trials
were included into the following meta-analyses: 1)
ADMG versus SCTG (short term),47,60 2) ADMG ver-
sus CAF (short term),40,62 3) EMP + CAF versus CAF
(long term),42,44 4) GTR bms versus SCTG (short
term),52,59,63 5) GTR bms versus GTR nrms (short
term);49,63 6) GTR bms associated with bone substi-
tutes versus SCTG,50,59 and 7) GTR bms associated
with bone substitutes versus GTR bms (short
term)45,59 (Table 2). Moreover, analyses were per-
formed 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 bms associated with bone substitutes versus
SCTG (comparison 6) where the data were derived
from 12-month59 and 18-month50 measurements.
Table 2 shows the results of meta-analyses. With re-
spect to GR change, there was a statistically signifi-
cantly greater reduction in GR for SCTG compared to
GTR bioabsorbable membrane sites (P = 0.0041). Re-
garding clinical attachment level changes, all com-
parisons failed to demonstrate significant differences
among procedures. For keratinized tissue changes,
there was a significantly greater gain in the width of
keratinized tissue for EMP + CAF and SCTG com-
pared to CAF alone and GTR bms associated or not
with bone substitutes, respectively (Table 2).
The results from the 12 trials that were not included
in meta-analyses are as follows:
Bouchard et al.:54 The mean GR decreased from
4.20 to 1.27 mm for SCTG without an epithelial col-
lar + CAF + citric acid and from 4.53 to 1.60 mm for
SCTG with an epithelial collar (Wilcoxon rank-sum
test; intragroup comparisons: P <0.05). Differences
between groups were not statistically significant
(P >0.05). The mean clinical attachment level de-
creased from 5.47 to 2.73 mm for SCTG without
an epithelial collar + CAF + citric acid and from 6.13
to 3.27 mm for SCTG with an epithelial collar (intra-
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 to 3.07 mm for SCTG without an epithelial col-
lar + CAF + citric acid and from 1.73 to 3.80 mm for
SCTG with an epithelial collar (intragroup compari-
sons: P <0.05; comparison between groups: P <0.005).
Bouchard et al.:55 The mean GR decreased from
3.86 to 0.80 mm for SCTG without an epithelial collar
+ CAF + tetracycline hydrochloride and from 4.13 to
0.66 mm for SCTG without an epithelial collar +
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Treatment of Recession-Type Defects Volume 81 • Number 4

Table 2.
Summary of Meta-Analyses

Comparison Studies Outcomes Statistical Method Effect Size P Value x2 P Value (Q) I2 (%)

ADMG versus Joly et al.,47 GRC MD (95% CI) -0.76 (-1.93 to 0.42) 0.21 4.13 0.04 76.0
SCTG Paolantonio et al.60 CALC MD (95% CI) -0.81 (-1.92 to 0.30) 0.15 3.26 0.07 69.0
KTC MD (95% CI) -0.83 (-2.09 to 0.44) 0.20 4.51 0.03 78.0
ADMG versus de Queiroz GRC MD (95% CI) 0.62 (-0.51 to 1.74) 0.28 6.25 0.01 84.0
CAF Côrtez et al.,40 CALC MD (95% CI) 0.56 (-0.21 to 1.33) 0.16 1.82 0.18 45.0
Woodyard et al.62 KTC MD (95% CI) 0.31 (-0.15 to 0.77) 0.18 0.25 0.62 0
EMP + CAF Del Pizzo et al.,44 GRC MD (95% CI) 0.25 (-0.13 to 0.64) 0.19 1.27 0.26 21.0
versus CAF Spahr et al.42 CALC MD (95% CI) 0.27 (-0.16 to 0.69) 0.22 0.36 0.55 0
KTC MD (95% CI) 0.40 (0.09 to 0.71) 0.01* 0.52 0.47 0
GTR bms versus Paolantonio,59 GRC MD (95% CI) -0.39 (-0.65 to -0.12) 0.00* 0.17 0.92 0
SCTG Wang et al.,52 CALC MD (95% CI) 0.31 (-0.01 to 0.62) 0.05 0.64 0.73 0
Zucchelli et al.63 KTC MD (95% CI) -1.95 (-2.66 to -1.24) 0.00* 8.56 0.01 77.0
SCRC RR (95% CI) 0.71 (0.47 to 1.08) 0.11 1.09 0.58 0

GTR bms versus Roccuzzo e al.,49 GRC MD (95% CI) 0.32 (-0.03 to 0.68) 0.07 0.94 0.33 0
GTR nrms Zucchelli et al.63 CALC MD (95% CI) 0.15 (-0.38 to 0.68) 0.57 0.15 0.69 0
KTC MD (95% CI) 0.11 (-0.29 to 0.51) 0.60 0.01 0.92 0
SCRC RR (95% CI) 1.18 (0.61 to 2.31) 0.62 0.24 0.62 0

GTR bms Rosetti et al.,50 GRC MD (95% CI) -0.75 (-1.92 to 0.43) 0.21 7.34 0.007 86.0
associated Paolantonio59 KTC MD (95% CI) -2.10 (-2.51 to -1.69) 0.00* 0.04 0.84 0
with bone
substitutes
versus SCTG
GTR bms Dodge et al.,45 GRC MD (95% CI) 0.46 (-0.02 to 0.94) 0.06 0.07 0.79 0
associated Paolantonio59 CALC MD (95% CI) 0.72 (-0.06 to 1.50) 0.07 2.21 0.14 55.0
with bone KTC MD (95% CI) 0.13 (-0.12 to 0.37) 0.30 0.88 0.35 0
substitutes SCRC RR (95% CI) 1.40 (0.76 to 2.57) 0.28 0.03 0.85 0
versus
GTR bms
CALC = clinical attachment level change; GRC = GR change; KTC = keratinized tissue change; RR = risk ratio; SCRC = sites with complete root coverage.
* Statistically significant (P <0.05).

CAF + citric acid (Wilcoxon rank-sum test; intragroup
comparisons: P <0.05). Differences between groups
were not statistically significant (P >0.05). The mean
clinical attachment level decreased from 5.26 to 2.60
mm for SCTG without an epithelial collar + CAF +
tetracycline hydrochloride and from 5.66 to 2.46
mm for SCTG without an epithelial collar + CAF + citric
acid (intragroup comparisons: P <0.05). Differ-
ences between groups were not statistically signifi-
cant (P >0.05).The mean width of keratinized tissue
increased from 1.73 to 2.73 mm for SCTG without
an epithelial collar + CAF + tetracycline hydrochloride
and from 2.13 to 3.06 mm for SCTG without an epi-
thelial collar + CAF + citric acid (intragroup compar-
isons: P <0.05). Differences between groups were not
statistically significant (P >0.05).
da Silva et al.:43 The mean GR decreased from 4.20
to 1.04 mm for SCTG + CAF and from 3.98 to 1.25
mm for CAF (Student t test; within-group compari-
son: P <0.05). Differences between groups were not
statistically significant (P >0.05).The mean clinical
attachment level decreased from 5.60 to 3.07 mm
for SCTG + CAF and from 5.45 to 3.15 mm for
CAF (within-group comparison: P <0.05). Differences
between groups were not statistically significant
(P >0.05).The mean width of keratinized tissue in-
creased from 2.79 to 3.35 mm for SCTG + CAF and
decreased from 3.38 to 3.17 mm for CAF (within-
group comparison: P <0.05). Differences between
groups were statistically significant (P <0.05).
Henderson et al.:46 The mean GR decreased from
4.20 to 0.25 mm for ADMG (basement membrane
side against the tooth) + CAF and from 3.70 to 0.15
mm for ADMG (connective tissue side against the
tooth) + CAF (Student t test; within-group compari-
son: P <0.05). Differences between groups were not

464
J Periodontol • April 2010
statistically significant (P >0.05). The mean clinical
attachment level decreased from 6.20 to 2.05 mm
for ADMG (basement membrane side against the
tooth) + CAF and from 5.60 to 1.95 mm for ADMG
(connective tissue side against the tooth) + CAF
(within-group comparison: P <0.05). Differences be-
tween groups were not statistically significant. The mean
width of keratinized tissue increased from 1.80 to 2.60
mm for ADMG (basement membrane side against the
tooth) + CAF and from 1.60 to 2.40 mm for ADMG (con-
nective tissue side against the tooth) + CAF (within-
group comparison: P <0.05). Differences between
groups were not statistically significant (P >0.05).
Keceli et al.:56 The results from this study were
reported as median values. The median value regard-
ing the amount of root coverage achieved was 3.0 mm
for both procedures, i.e., SCTG + platelet-rich plasma
and SCTG (Friedman test; within-group comparison:
P <0.05). Differences between groups were not statis-
tically significant (Mann-Whitney U test; P >0.05). The
median values regarding attachment gains were 2.5
mm for SCTG + platelet-rich plasma and 3.0 mm
for SCTG (Friedman test; within-group comparison:
P <0.05). Differences between groups were not sta-
tistically significant (Mann-Whitney U test; P >0.05).
The median values regarding keratinized tissue
gains were not reported. Only baseline and 12-
month median values were reported. Differences
within groups were considered statistically signifi-
cant (Friedman test; P <0.05). Conversely, differ-
ences between groups were not statistically
significant (Mann-Whitney U test; P >0.05).
Leknes et al.:41 The mean GR decreased from 4.00
to 2.5 mm for GTR bms and from 3.80 to 2.6 mm for
CAF. In this study, the gain of root coverage from
baseline to 12 months was statistically significant for
both groups (Student t test; within-group comparison:
P <0.01; between-group comparison: P <0.05). How-
ever, 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 to
11.60 mm for GTR bms and from 13.30 mm to
11.80 mm for CAF. In this study, the clinical attachment
level was measured by an automated periodontal probe
mid-buccally from the buccal cusp/incisal edge (within-
group comparison: P <0.01). Differences between
groups were not statistically significant (P >0.05).The
mean width of keratinized tissue at baseline was 2.60
mm for both procedures (i.e., GTR bms and CAF). In
this study, at the 6-year evaluation, both treatments
showed a non-significant rebound to baseline levels
(within- and between-group comparisons: P >0.05).
Matarasso et al.:57 The mean GR decreased from
4.60 to 1.20 mm for GTR bms + a double papilla flap
and from 4.00 to 1.50 mm for GTR bms + CAF
Chambrone, Sukekava, Araújo, Pustiglioni, Chambrone, Lima
(Student t test; within-group comparison: P <0.001).
Differences between groups were not statistically sig-
nificant (P >0.05).The mean clinical attachment level
decreased from 5.80 to 2.70 mm for GTR bms + a dou-
ble papilla flap and from 5.50 to 2.70 mm for GTR
bms + CAF (within-group comparison: P <0.001).
Differences between groups were not statistically
significant (P >0.05). The mean width of keratinized
tissue increased statistically from 1.70 to 3.70 mm
for GTR bms + a double papilla flap (P <0.001) and
non-statistically from 2.10 to 3.00 mm for GTR bms +
CAF (P >0.05). Differences between groups were not sta-
tistically significant (P >0.05).
McGuire and Nunn:48 The mean GR decreased
from 4.25 to 0.18 mm for EMP + CAF and from 4.25
to 0.24 mm for SCTG + CAF (Wilcoxon rank-sum test;
within-group comparison: P = 0.05). Differences be-
tween groups were not statistically significant (anal-
ysis of covariance [ANCOVA]; P = 0.281). The mean
clinical attachment level decreased from 6.10 to
1.59 mm for EMP + CAF and from 6.15 to 1.59 mm
for SCTG + CAF (Wilcoxon rank-sum test, within-
group comparison P <0.05). Differences between
groups were not statistically significant (ANCOVA;
P = 0.753). The mean width of keratinized tissue
increased from 2.40 to 2.76 mm for EMP + CAF
(Wilcoxon rank-sum test; P <0.0001) and from 2.50
to 3.71 mm for SCTG + CAF (P <0.0156). Differences
between groups were considered statistically signifi-
cant (ANCOVA; P = 0.0005).
Paolantonio et al.:58 The mean GR decreased from
3.43 to 0.58 mm for SCTG + a double papilla flap and
from 3.11 to 1.50 mm for FGG (Mann-Whitney U test;
within-group comparison: P = 0.000). Differences
between groups were considered statistically signifi-
cant (P = 0.000).The mean width of keratinized tissue
increased from 1.94 to 4.75 mm for SCTG + a double
papilla flap and from 1.57 to 5.23 mm for FGG
(within-group comparison: P <0.000). Differences be-
tween groups were not statistically significant (P =
0.091). The data regarding the mean increase in clin-
ical attachment level were not reported in the trial.
Tozum et al.:61 The mean GR decreased from
3.50 to 0.14 mm for SCTG + a modified tunnel ap-
proach and from 3.47 to 0.97 mm for SCTG + CAF
(Mann-Whitney U test; within-group comparison:
P <0.0001). Differences between groups were con-
sidered statistically significant (Student t test; P =
0.005).The mean clinical attachment level decreased
from 5.14 to 1.14 mm for SCTG + a modified tunnel
approach and from 4.71 to 2.26 mm for SCTG +
CAF (Mann-Whitney U test; within-group com-
parison: P <0.0001). Differences between groups
were considered statistically significant (Student t
test; P = 0.005).The data regarding the mean width
of keratinized tissue were not reported in the trial.
465
Treatment of Recession-Type Defects
Trombelli et al.:51 The mean GR decreased from
3.80 to 1.40 mm for CAF + fibrin glue + tetracycline
hydrochloride and from 3.40 to 1.70 mm for CAF +
tetracycline hydrochloride (Student t test; within-
group comparison: P <0.0001). Differences between
groups were not statistically significant (P >0.05).
The mean clinical attachment level decreased from
5.00 to 2.60 mm for CAF + fibrin glue + tetracycline
hydrochloride and from 4.40 to 2.50 mm for CAF +
tetracycline hydrochloride (within-group compari-
son: P <0.0001). Differences between groups were
not statistically significant (P >0.05).The mean width
of keratinized tissue decreased from 3.00 to 2.60 mm
for CAF + fibrin glue + tetracycline hydrochloride and
from 2.90 to 2.30 mm for CAF + tetracycline hydro-
chloride. Differences within and between groups were
not statistically significant (P >0.05).
Zucchelli et al.:53 The mean GR decreased from
4.00 to 0.10 mm for SCTG (graft size equal to the bone
dehiscence) + CAF and from 3.90 to 0.30 mm for
SCTG (graft size 3 mm greater than the bone dehis-
cence) + CAF (Student t test; within-group compar-
ison: P <0.01). Differences between groups were not
statistically significant (P >0.05). The mean clinical
attachment level decreased from 5.10 to 1.20 mm
for SCTG (graft size equal to the bone dehiscence) +
CAF and from 5.00 to 1.90 mm for SCTG (graft size
3 mm greater than the bone dehiscence) + CAF
(within-group comparison: P <0.01). Differences be-
tween groups were considered statistically significant
(P <0.01). The mean width of keratinized tissue in-
creased from 1.10 to 3.40 mm for SCTG (graft size
equal to the bone dehiscence) + CAF and from 1.20
to 4.50 mm for SCTG (graft size 3 mm greater than
the bone dehiscence) + CAF (within-group compari-
son: P <0.01). Differences between groups were con-
sidered 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 18 studies.40,41,43-46,49-56,58-60,62,63 Two
studies42,48 only reported the percentage of sites with
complete root coverage (Table 3).
Among the included RCTs, the percentage of com-
plete root coverage varied from 7.7%40 to 91.6%62
for ADMG, 18.1%43 to 86.7%53 for SCTG, 53.0%42
to 89.5%48 for EMP, 7.7%40 to 60.0%44 for CAF,
33.3%45 to 53.3%59 for GTR bms, and 28.0%63 to
41.6%49 for GTR nrms (Table 3).
In addition, risk-ratio analyses were available
for four comparisons: ADMG versus CAF (outcome
2.4), GTR bms versus SCTG (outcome 4.4), GTR
bms versus GTR nrms (outcome 5.4), and GTR bms
with bone substitutes versus GTR bms (outcome
7.4). Although no statistical differences were found
among procedures, a substantial number of patients
466
Volume 81 • Number 4
did not achieve complete root coverage: for ADMG
and CAF procedures, 14 of 25 (56%) and seven of
25 (28%) patients, respectively, did not achieve com-
plete root coverage; for the SCTG and GTR bioabsorb-
able membrane procedures, 20 of 49 (40.81%) and 28
of 49 (57.14%) patients, respectively, did not achieve
complete root coverage; for the GTR bioabsorbable
membrane and GTR non-resorbable membrane pro-
cedures, 12 of 30 (40%) and 10 of 30 (33.33%) pa-
tients, respectively, did not achieve complete root
coverage; and for the GTR bioabsorbable membrane
bone substitutes and GTR bioabsorbable membrane
procedures, 14 of 27 (51.85%) and 10 of 27 (37.03%)
patients, respectively, did not achieve complete root
coverage.
Mean root coverage. All included trials reported the
mean root coverage. This outcome varied from 50.0%47
to 96.0%62 for ADMG, 64.7%54 to 97.3%53 for SCTG,
84.0%42 to 95.1%48 for EMP, 55.9%40 to 86.7%44 for
CAF, 62.5%57 to 73.7%45 for GTR bms, 84.2%50 to
89.9%45 for GTR bms associated with bone substitutes
and 80.5%63 to 82.4%49 for GTR nrms (Table 3).
Preferences of patients for specific PPS pro-
cedures. Preferences of patients for specific PPS pro-
cedures (in split-mouth trials) were reported in three
trials.49,52,53
In the first study,49 all patients preferred the GTR treat-
ment because it was a single-step procedure. The sec-
ond trial,52 which compared patient satisfaction with
esthetics (i.e., amount of root coverage, color match,
and overall satisfaction) obtained by SCTG and GTR
bms showed that the participants reported greater
overall satisfaction with the GTR procedures, a prefer-
ence that is probably explained by the reduction in
treatment time and elimination of the need for a second
surgical intervention. In the third study,53 12 patients
(80%) preferred treatment with a reduced size SCTG
(i.e., graft dimension equal to the depth of the bone de-
hiscence) because of the better esthetics achieved.
Occurrence of adverse effects and/or postoper-
ative complications. The occurrence of adverse
effects and/or postoperative complications during
the post-surgical period was reported in seven tri-
als.42,45,48,49,52,53,56 In one trial48 with a split-mouth
design, patient-reported discomfort was only consid-
ered statistically significantly higher for SCTG com-
pared to EMP + CAF at 1 month postoperatively.
Similarly, there was a trial53 reporting greater de-
hiscence of the advanced flap, more painful wound
healing of the palate, and necrosis of the primary pal-
atal flap during the first period of healing in patients
treated with SCTG (i.e., graft dimension 3 mm greater
than the depth of the bone dehiscence).
Two trials45,49 reported membrane exposure be-
tween weeks 1 and 2 of healing. In one RCT,42 six
patients felt moderate discomfort postoperatively
J Periodontol • April 2010 Chambrone, Sukekava, Araújo, Pustiglioni, Chambrone, Lima

Table 3.
Root-Coverage Outcomes: Complete Root Coverage and Mean Root Coverage

Study Interventions SCRC PCRC MRC (%)

de Queiroz Côrtes et al.40 1. ADMG + CAF (6 months) 3/13 23.0 76.0

2. CAF (6 months) 3/13 23.0 71.0
1. ADMG + CAF (12 months) 2/13 15.3 71.0
2. CAF (12 months) 2/13 15.3 66.7
1. ADMG + CAF (24 months) 1/13 7.7 68.4
2. CAF (24 months) 1/13 7.7 55.9
Leknes et al.41 1. GTR (polylactic acid membrane) (6 months) 5/20 25.0 51.2
2. CAF (6 months) 10/20 50.0 63.8
1. GTR (polylactic acid membrane) (12 months) 4/20 20.0 51.2
2. CAF (12 months) 6/20 30.0 61.1
1. GTR (polylactic acid membrane) (72 months) 2/11 18.2 35.0
2. CAF (72 months) 1/11 9.1 34.2
Spahr et al.42 1. EMP + CAF (6 months) NR NR 80.0
2. Placebo (propylene glycol alginate) + CAF (6 months) NR NR 79.0
1. EMP + CAF (12 months) NR NR 80.0
2. Placebo (propylene glycol alginate) + CAF (12 months) NR NR 79.0
1. EMP + CAF (24 months) NR 53.0 84.0
2. Placebo (propylene glycol alginate) + CAF (24 months) NR 23.0 67.0
da Silva et al.43 1. SCTG + CAF 2/11 18.1 75.3
2. CAF 1/11 9.0 68.8

Del Pizzo et al.44 1. EMP + CAF 11/15 73.3 90.7

2. CAF 9/15 60.0 86.7
Dodge et al.45 1. GTR (polylactic acid membrane) + tetracycline 6/12 50.0 89.9
hydrochloride + DFDBA
2. GTR (polylactic acid membrane) + tetracycline 4/12 33.3 73.7
hydrochloride
Henderson et al.46 1. ADMG (connective tissue side against the tooth) + 7/10 70.0 94.9
CAF
2. ADMG (basement membrane side against the tooth) + 8/10 80.0 95.5
CAF
Joly et al.47 1. ADMG + CAF (flap without vertical incisions) NR NR 50.0
2. SCTG + CAF (flap without vertical incisions) NR NR 79.5
McGuire and Nunn48 1. EMP + CAF NR 89.5 95.1
2. SCTG + CAF NR 79.0 93.8
Roccuzzo et al.49 GTR (polylactic acid membrane) 5/12 41.6 82.4
GTR (ePTFE membrane) 5/12 41.6 82.4
Rosetti et al.50 1. GTR (collagen membrane) + tetracycline NR NR 84.2
hydrochloride + DFDBA
2. SCTG + tetracycline hydrochloride NR NR 95.6
Trombelli et al.51 1. CAF (fibrin glue + tetracycline hydrochloride) 1/11 9.1 63.1
2. CAF (tetracycline hydrochloride) 2/11 18.2 52.9
Wang et al.52 1. GTR (resorbable double-thickness collagen 7/16 43.8 73.0
membrane)
2. SCTG + CAF 7/16 43.8 84.0
53
Zucchelli et al. 1. SCTG (graft size equal to bone dehiscence) + 13/15 86.7 97.3
CAF

467
Treatment of Recession-Type Defects Volume 81 • Number 4

Table 3. (continued)
Root-Coverage Outcomes: Complete Root Coverage and Mean Root Coverage

Study Interventions SCRC PCRC MRC (%)

2. SCTG (graft size 3 mm greater than 12/15 80.0 94.7
the bone dehiscence) + CAF
Bouchard et al.54 1. SCTG + CAF + citric acid (graft 3/15 20.0 69.7
without epithelial collar)
2. SCTG (graft with epithelial collar) 5/15 33.3 64.7
55
Bouchard et al. 1. SCTG + CAF + tetracycline 6/15 40.0 79.3
hydrochloride
2. SCTG + CAF + citric acid 8/15 53.3 84.0
56
Keceli et al. 1. SCTG + platelet-rich plasma 6/17 35.3 86.4
2. SCTG 8/19 42.1 86.4

Matarasso et al.57 1. GTR (polylactic acid membrane) + NR NR 73.9

double papilla flap
2. GTR (polylactic acid membrane) + NR NR 62.5
CAF
Paolantonio et al.58 1. SCTG + double papilla flap 17/35 48.6 85.2
2. FGG 3/35 8.6 53.2
Paolantonio59 1. GTR (polylactic acid membrane) 6/15 40.0 81.0
2. GTR (polylactic acid membrane) + 8/15 53.3 87.1
hydroxyapatite/collagen/
chondroitin sulfate graft
3. SCTG + double papilla flap 9/15 60.0 90.0
Paolantonio et al.60 1. ADMG + CAF 4/15 26.6 83.3
2. SCTG + CAF 7/15 46.6 88.8
Tozum et al.61 1. SCTG + modified tunnel procedure NR NR 96.4
2. SCTG + CAF NR NR 77.1
Woodyard et al.62 ADMG + CAF 11/12 91.6 96.0
CAF 4/12 33.3 67.0

Zucchelli et al.63 1. GTR bms 7/18 39.0 85.7

2. GTR nrms 5/18 28.0 80.5
3. SCTG + CAF 12/18 66.0 93.5
SCRC = sites with complete root coverage; PCRC = percentage of complete root coverage; MRC = mean root coverage; NR = not reported; DFDBA =
demineralized freeze-dried bone allograft; ePTFE = expanded polytetrafluoroethylene.

without differences between treatment modalities
(CAF + EMP versus CAF). Authors from one study56
reported minor complications related to postopera-
tive swelling occurring within the first days after sur-
gery and immediate postoperative bleeding in one
donor site of SCTG.
In addition, the last trial52 showed that two patients
treated with SCTG experienced adverse effects: one
patient experienced post-surgical swelling, and the
other patient experienced post-surgical ecchymosis.
DISCUSSION
Summary of Main Results
The objectives of PPS procedures are to improve the
esthetic conditions and other clinical outcomes
(e.g., clinical attachment level and width of keratinized
tissue) of patients through the coverage of previously
denuded root surfaces. A summary of the main re-
sults are reported as primary and secondary out-
comes.
Primary Outcomes
Despite esthetics being considered the primary goal
of root-coverage procedures, few studies50,52-54 eval-
uated the changes of esthetic conditions as they
related to the opinions of patients. In these stud-
ies,50,52-54 the majority of patients were satisfied with
the final esthetic result. Also, procedures that made
a reduction in the operatory time, eliminated the need
for a second surgical site and its associated morbidity
(i.e., GTR bms),52 and used smaller palatal grafts53
were better accepted by patients.

468
J Periodontol • April 2010
Results from meta-analyses demonstrated that
SCTGs led to a statistically significant gain in GR com-
pared to GTR bioabsorbable membrane procedures.
Although statistical analyses (i.e., meta-analyses)
did not reveal significant differences between group
comparisons, the evaluated procedures were simi-
larly efficient in reducing baseline mean GR.
Secondary Outcomes
With respect to secondary outcomes, three compari-
sons showed significant improvements in the width of
keratinized tissue for SCTG and EMP compared to
GTR bms (associated or not with bone substitutes)
and a CAF, respectively (Table 1).
Only one trial58 reported results from FGGs com-
pared to SCTGs after a follow-up period of 5 years.
The results of this study58 showed 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 marked variation in the
amount of root coverage achieved, with a mean root
coverage of 80.9% (range: 50% to 97.3%) and
a complete root coverage of 46.6% (range: 7.7%
to 91.6%) (Table 3). Additionally, data from two
long-term trials40,41 showed that mean root cover-
age and complete root coverage decreased over
time. The preferences of patients for specific PPS
procedures followed the same pattern as changes of
esthetic conditions.49,53
The occurrence of early discomfort with or without
pain was related to donor sites of SCTGs.48,52,53 This
aspect may be related to the size of the graft obtained
from the palate and the surgical approach used.53
With respect to GTR techniques, membrane exposure
during healing was associated with primary postoper-
ative complications.45,49
Overall Findings and Conditions
Although 24 RCTs were included in this systematic
review, it was difficult to combine data from these
trials because of a great variability of comparisons
between the various PPS procedures and the non-
existence of a gold-standard control group. Con-
sequently, only 12 trials were incorporated into
meta-analyses40,42,44,45,47,49,50,52,59,60,62,63 in seven
different group comparisons (i.e., six analyses con-
sisted of two studies and one of three studies) (Table
2). These aspects prevent us from drawing definitive
conclusions.
Few studies reported a follow-up period >12
months.40,42,44,50,58 In three of these studies,40,42,44
a chronologic evaluation of the results showed a loss
in the amount of root coverage obtained (e.g., mean
root coverage and sites with complete root coverage)
mainly between the 6- to 12-month periods of evalu-
ation. Long-term evaluations are probably linked to
Chambrone, Sukekava, Araújo, Pustiglioni, Chambrone, Lima
individual conditions such as changes in periodontal
health status, toothbrushing, habits, and genetic and
systemic conditions.
Overall, the results of this systematic review dem-
onstrate that all included studies show a statistically
significant reduction in the extent of GR and a concom-
itant gain in the clinical attachment level with or with-
out improvements in keratinized tissue.
Quality of the Evidence
All authors who had articles included in this review
were contacted to supply additional details regard-
ing the methodologic quality of their trials by means
of a questionnaire (e.g., regarding the method of
randomization, allocation concealment, masking
of examiners, and completeness of the follow-up pe-
riod). On the basis of the replies provided by the au-
thors, only one RCT48 was assessed as low risk of
bias, whereas the remaining studies were assessed
as high risk of bias because one or more criteria
were not met. Therefore, the lack of allocation con-
cealment and/or masking and inadequate methods of
randomization, as well as the lack of similar inclusion
criteria between trials, can act as sources of biases
and can affect the accuracy of the results.13,129
Potential Biases in the Review Process
In this review, only defects >3 mm were included to
minimize heterogeneity between trials. However, this
inclusion criterion might have eliminated data from
studies that could have been incorporated into
meta-analyses. In addition, the limited number of
studies included into the meta-analyses prevented
the formal testing for publication bias.
Agreements and Disagreements With Other
Studies or Reviews
Data from the included studies in this review showed
that the percentage of success achieved by PPS pro-
cedures was regularly associated with improvements
in clinical parameters (i.e., outcomes measures),
which were mainly evaluated by gains in the clinical
attachment level, width of keratinized tissue, and
mean root coverage achieved. Nevertheless, different
authors32,130-132 pointed out that these currently
used parameters only reflect the final clinical results
expected and not the changes that occurred in
patient-centered outcomes, such as changes of
esthetic conditions, functional limitations (e.g., limi-
tations on the chewing and deglutition of food), dis-
comfort, pain, alterations in the level of sociability
after surgery (e.g., psychologic and behavioral
impacts), and patient preference for a specific PPS
procedure in trials with a split-mouth design. Conse-
quently, patients and professionals can present differ-
ent points of view regarding the procedures performed
and the final result achieved.
469
Treatment of Recession-Type Defects
More objective patient-centered evaluations can be
performed through the use of visual scales. The visual
analog scale (VAS) is a tool that has been used to eval-
uate the levels of discomfort and pain subsequent to
different modalities of periodontal treatment.133-136
This resource can be applied to evaluate various es-
thetic and functional individual outcomes. In a recent
study,137 the use of a VAS showed that the opinions of
the patients with respect to their own smiles were sta-
tistically significantly better than the opinions of two
different clinicians, highlighting that the patient’s indi-
vidual perception can influence the clinical decision-
making choice.
The great variability in the percentages of sites with
complete and mean root coverage is probably associ-
ated with a set of factors such as the type of defect,
amount and quality of adjacent gingival tissue, sample
size, and the applied inclusion criteria (e.g., selection of
patients, methodologic quality, type of technique, de-
vices used for measurements, and differences between
operators). It seems that the amount of root coverage
obtained was associated with the initial recession anat-
omy. Better results in terms of percentages of complete
and mean root coverage can be expected when base-
line recession defects are <4 mm;138 at the same time,
flaps with <1 mm thickness can harm the achievement
of complete root coverage.64,138,139 It should also be
noted that the inclusion of studies with recession de-
fects >4 mm tended to show greater differences be-
tween baseline and follow-up means (i.e., outcome
change), a factor that may influence the calculation
of meta-analyses. With respect to flap tension, it was
suggested that the higher the flap tension, the lower
the recession reduction.121
Consequently, all of these factors make compari-
sons and combinations of data from different trials
a critical issue. In this way, trials investigating the
treatment of GR with similar baseline characteristics
or that included baseline and final individual defect
measurements will allow for more effective evalua-
tions of each surgical technique as well as facilitating
future meta-analyses.
It was shown that smoking can affect the results ob-
tained by PPS procedures.33 Five trials42,48,54,55,63
included smokers. Bouchard et al.54,55 and Spahr
et al.42 included patients who smoked <10 cigarettes
per day. However, none of these authors performed
comparisons between smokers and non-smokers.
Zucchelli et al.63 only commented that patients who
smoked ‡10 cigarettes a day presented the worst per-
centage of root coverage. This is in line with data from
recent studies that compared the amount of root cov-
erage obtained by smokers and non-smokers through
the use of CAF140 and SCTG.67,141 Similarly, root-
modification agents (e.g., tetracycline solution and
citric acid) were evaluated in few studies. Nevertheless,
470
Volume 81 • Number 4
these RCTs suggested that there is no significant clin-
ical benefit of root conditioning in conjunction with
root-coverage procedures45,50,51,54,55.
In recent years, some extensive systematic reviews
(Appendix 3 shows data from a systematic review142
not included in the present review during the review
process performed by The Cochrane Collaboration
[Oral Health Group]) evaluated the effects of PPS pro-
cedures in the treatment of recession defects. The re-
view by Roccuzzo et al.31 used stringent inclusion
criteria, but it also included non-randomized trials
and GRs <3 mm and did not evaluate changes in the
width of keratinized tissue or the use of biomaterials
such as ADMGs. Oates et al.30 included only RCTs,
and their inclusion criteria were only based on the
terms ‘‘human study, English language, and thera-
peutic study including the use of a gingival surgical
procedure to treat GR.’’ Chambrone et al.32 mainly
focused on the treatment of recession defects with
SCTGs. These reviews did not include searches for
unpublished data (i.e., gray literature), articles pub-
lished in all languages,30-32 or evaluations of the risk
of bias.31,32 The protocol of the present review that
was applied for identifying studies during the review
process was prepared according to strict guidelines
proposed by The Cochrane Collaboration, where
specific search strategies were developed for each da-
tabase to allow a comprehensive evaluation of the
current literature. These guidelines aimed to reduce
heterogeneity among trials and to obtain the best ev-
idence available. All retrieved articles were checked in
duplicate (by LC and FS), and the data that were ex-
tracted from the included trials were sent to the Co-
chrane’s Oral Health Group Editorial Base (Trials
Search Coordinator) for a final check of the precision
of the review authors. Compared to the article written
by Oates et al.,30 our search strategy identified and in-
cluded the results from 11 RCTs published up to April
2002 (Oates et al.30 included 32 articles). Moreover,
we were able to include an additional 13 trials that
were published between 2002 and 2008 (54% of our
sample). Despite the amount of knowledge published
in the previous 7 years, the overall results of the pres-
ent review were similar to earlier publications.30-32 On
the other hand, this review evidenced further issues
that were not previously investigated, such as the ne-
cessity of studies exploring differences between differ-
ent operators, comparisons between long-term trials
(to evaluate the long-term stability of PPS), an evalu-
ation of the changes of esthetic conditions related to
the opinions and preferences of patients, the great
variability of results and biases found in the literature,
and the lack of a gold-standard procedure for the
treatment of recession-type defects.
Regarding this final issue, all included trials reported
different procedures as control groups. In this review,
J Periodontol • April 2010
the exclusion of non-randomized studies and the use of
stringent inclusion criteria may have led to the loss of
evidence-based information because only studies that
compared two (or more) active treatments were stud-
ied. Studies that evaluated recession defects <3 mm
were also excluded. Overall, data from the included
studies indicate that SCTG is the procedure that can
become the gold standard; however, further research
on this matter is needed. In addition, similar to another
Cochrane review,143 the majority of included RCTs
were often performed using patients who presented dif-
ferent clinical and systemic conditions from patients
currently found in a conventional private practice.
These conditions can cause more variability of the re-
sults when extrapolated for daily practice.
CONCLUSIONS
Implications for Practice
1. SCTGs, a CAF alone or associated with grafts or
biomaterials (e.g., ADMGs, EMP, and SCTGs), and
GTR may be used as root-coverage procedures for
the treatment of recession-type defects. In cases
where both root coverage and gain in the width of
keratinized tissue are expected, the use of SCTG
seems to be more adequate.
2. ADMGs may be an alternative treatment in
cases where SCTGs harvested from the palate are
not sufficient to cover a recession area.
3. Root modification agents may be used for root
conditioning; however, it is not evident that these
products improve root coverage.
Implications for Research
1. Further RCTs are required to evaluate primary
(i.e., especially esthetics) and secondary outcomes
between different procedures, as well as to establish
a gold-standard procedure for the treatment of reces-
sion-type defects.
2. Precise and objective esthetic evaluations should
be included in future studies. The use of a VAS will
allow more precise evaluations of patient-based out-
comes.
3. The inclusion of baseline and final individual
defect measurements will allow more precise evalua-
tions, subgroup evaluations (e.g., patients presenting
similar defects), and future comparisons via meta-
analyses. These outcome measures should include
GR depth and width, clinical attachment level, the
width and thickness of keratinized tissue, and root
surface conditions (i.e., the presence of caries, abra-
sions, or restorations).
4. Comparisons between different operators (i.e.,
with respect to the degree of an operator’s experi-
ence) are necessary to evaluate differences in the
expected outcome measures.
Chambrone, Sukekava, Araújo, Pustiglioni, Chambrone, Lima
5. Multicenter studies may favor the inclusion and
evaluation of larger samples of patients and, there-
fore, the achievement of statistical power.
6. Long-term RCTs are necessary to adequately
confirm and identify possible factors associated with
the prognosis and indications of each PPS procedure.
The Consolidated Standards of Reporting Trials State-
ment144 should be considered when designing and
reporting future studies.
Overall Conclusions
Primary outcomes. 1. Limited data exist on the
changes of esthetic conditions as related to the opin-
ions of patients.
2. All PPS procedures led to statistically significant
gains in GR.
3. SCTGs were statistically superior to GTR bms
for achieving root coverage.
4. The remaining meta-analyses comparisons
(e.g., ADMG versus SCTG, ADMG versus CAF, EMP
+ CAF versus CAF, GTR bms versus GTR nrms,
GTR bms associated with bone substitutes versus
GTR bms) did not show statistically significant differ-
ences in the amount of root coverage achieved. How-
ever, few RCTs were available for analysis.
Secondary outcomes. 1. The majority of proce-
dures produced significant gains in the clinical attach-
ment level and width of keratinized tissue. Also,
a great variability in the percentages of complete root
coverage and mean root coverage was observed.
2. SCTGs were statistically superior to GTR bms
(with or without bone substitutes), and EMP + CAF
was superior to CAF alone with respect to keratinized
tissue gain.
3. Few included studies49,52,53 reported the prefer-
ences of patients for a specific PPS procedure (in split-
mouth trials).
4. The incidence of adverse effects, such as dis-
comfort with or without pain, was directly related to
donor sites of SCTGs.
Also, the results of this review indicate that:
1. The potential impact of bias on these outcomes
(primary and secondary) is unclear.
2. In accordance with the proposed inclusion cri-
teria of the different PPS procedures analyzed in
clinical RCTs, no data exist regarding laterally posi-
tioned flaps, and there is limited data regarding
FGGs.
3. Outcome measures of the evaluated surgical tech-
niques were not improved by the use of root-modification
agents (e.g., citric acid or tetracycline solution).
ACKNOWLEDGMENTS
The authors acknowledge Sylvia Bickley and Anne
Littlewood, who served as trial search coordinators,
471
Treatment of Recession-Type Defects
information managers, and feedback editors, Co-
chrane Oral Health Group, Manchester, UK, for their
assistance and comments on the search strategy sec-
tion and Helen Worthington, Marco Esposito, Ian Nee-
dleman, and Luisa Fernandez Mauleffinch of the
Cochrane Oral Health Group for their help with the
preparation of the protocol and full text of the present
review.
The authors report no conflicts of interest related to
this review.
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Correspondence: Dr. Leandro Chambrone, Division of
Periodontics, Department of Stomatology, School of
Dentistry, University of São Paulo, Av. Prof. Lineu Prestes,
2227 Cidade Universitária, São Paulo, SP 05508-000,
Brazil. E-mail: chambrone@usp.br.
Submitted September 21, 2009; accepted for publication
November 24, 2009.
J Periodontol • April 2010
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 (exploded
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-posi-
tioned 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
APPENDIX 2. QUORUM STATEMENT: FLOW-
CHART OF ARTICLES SCREENED THROUGH
THE REVIEW PROCESS
Chambrone, Sukekava, Araújo, Pustiglioni, Chambrone, Lima
APPENDIX 3. DATA FROM THE REVIEW CON-
DUCTED BY CAIRO ET AL.142 THAT WERE NOT
INCLUDED AT THE TIME OF THE REVIEW
PROCESS PERFORMED BY THE COCHRANE
COLLABORATION (ORAL HEALTH GROUP)
This section describes data from a recent systematic
review conducted by Cairo et al.142 that were not
included in original text published in The Cochrane
Library.
OBJECTIVE
The objective of the review is to evaluate the clinical
advantages of associating grafts or biomaterials, such
as SCTGs, membranes (GTR), EMP, ADMGs, plate-
let-rich plasma, or living tissue-engineered human
fibroblast derived dermal substitute (HF-DDS) to the
CAF procedure in the treatment of Miller Class I and
II localized recession-type defects recessions.
METHODS
Types of Studies
Only randomized, controlled clinical trials (RCTs),
including a split-mouth model, with a duration ‡6
months were considered.
Types of Participants
The participants included patients presenting a clini-
cal diagnosis of Miller Class I or II localized GR.
Types of Interventions
CAF alone or associated to ADMG, EMP, HF-DDS,
GTR, platelet-rich plasma or SCTG.
Types of Outcome Measures
Primary outcome. The primary outcome was com-
plete root coverage.
Secondary outcomes. Secondary outcomes in-
cluded changes in GR, clinical attachment level, and
keratinized tissue, postoperative complications/pain,
esthetic condition change related to the opinions of pa-
tients, and perceptions of patients of root sensitivity.
Search Methods for Identification of Studies
Search methods for identification of studies included
using MEDLINE and Cochrane Oral Health Group Tri-
als Register (electronic databases) with no language
restriction. Hand searching included a complete
search of the Journal of Clinical Periodontology, Jour-
nal of Periodontology, Journal of Periodontal Re-
search, International Journal of Periodontics and
Restorative Dentistry, and PERIO from January
2000 to August 2007. The authors from the original
trials (trials included in Cairo’s et al. review) and ex-
perts in the field of PPS (researchers) were contacted
by Dr. Cairo and their colleagues to obtain missing
data. (unpublished data and studies not yet pub-
lished).
477
Treatment of Recession-Type Defects
Data Collection and Analysis
Data extraction and management were performed in
duplicate. Quality assessment included allocation con-
cealment, masking of examiners, and completeness of
follow-up. Odds ratios for dichotomous variables and
MDs for continuous variables were calculated.
Results and Discussion
Twenty-five RCTs were included, with a total of 794
GRs treated in 530 patients. A CAF was associated
with a mean reduction in recession and complete root
coverage. The addition of SCTG or EMP improved the
clinical outcomes for complete root coverage, and
the results achieved by ADMG were controversial.
Conclusions
The use of CAF was a safe and predictable approach
for root coverage. When this procedure was associ-
ated with SCTG or EMP, the probability of obtaining
CRC and GR reduction improved, whereas its associ-
ation with GTR did not improve the clinical benefits of
CAF alone. The results were contradictory concerning
the use of ADMG.
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Volume 81 • Number 4
Comments
Several topics found in the present review and the
review by Cairo et al.142 were very similar, such
as searching methods, type of recession, studies
reviewed, quality assessment, and outcome mea-
sures. Differences between the reviews mainly con-
cerned the type of interventions and some issues
related to inclusion criteria. Both reviews showed
similar outcomes. The results found by Cairo
et al.142 showed that SCTG or EMP enhanced clini-
cal outcomes of CAF alone (control group), whereas
the use of GTR or ADMG did not. In the present
Cochrane review, no specific control group was
proposed. SCTG and CAF alone or associated with
GTR, ADMG, or EMP were efficient in treating
localized recession-type defects. In cases where
root coverage and gain in the width of keratinized
tissue were expected, the use of SCTG seemed to
be more adequate (a possible control group for fu-
ture researches). Also, a more detailed set of conclu-
sions (i.e., implications for practice and research
and overall results) was reported.