DOI: 10.1111/prd.
12248
REVIEW ARTICLE
The concepts of evidence‐based periodontal plastic surgery:
Application of the principles of evidence‐based dentistry for
the treatment of recession‐type defects
Leandro Chambrone1,2 | Rodrigo Carlos Nahas de Castro Pinto3 |
Luiz Armando Chambrone3
1
M.Sc. Dentistry Program, Ibirapuera University, Sao Paulo, SP, Brazil
2
Unit of Basic Oral Investigation (UIBO), School of Dentistry, El Bosque University, Bogota, Colombia
3
Private Practice, São Paulo, SP, Brazil
Correspondence
Leandro Chambrone, M.Sc. Dentistry Program, Ibirapuera University, São Paulo, SP, Brazil.
Email: leandro_chambrone@hotmail.com
1 | INTRODUCTION
Reestablishments of health, masticatory function, and/or esthetics
are undoubtedly the expected final outcomes of the whole periodon-
tal therapy. According to the Oxford Dictionary, health is character-
ized as “the state of being free from illness or injury”, function is
described as “an activity or purpose natural to or intended for a per-
son or thing”, and esthetics as “a set of principles concerned with
1
the nature and appreciation of beauty”.
With respect to the treatment of recession‐type defects, health,
function, and esthetics are very closely interrelated because such
defects may routinely be associated with pink (gingival) and white
(teeth) esthetics breakdown, buccal cervical dentin hypersensitivity,
root abrasion, accumulation of dental biofilm (as a result of the
anatomical characteristics of the gingival recession or lack of ade-
quate plaque control because of hypersensitivity), inflammation and
2–11
ulcerations at the free gingival margin, and root caries (Figure 1).
These factors may influence the ability to chew and digest food, and
they are also a matter of concern for both patients and profession-
als. Therefore, adequate diagnosis and evidence‐based treatment
options should be offered to fulfill patients’ expectations.
For decades, the treatment of recession‐type defects has been
evaluated using a large number of different root‐coverage proce-
dures.2–88 However, there is huge variation between and within the
vast number of studies carried out, and the surgical techniques used,
regarding the outcome measures reported, especially in terms of
reduction of gingival recession depth and/or complete root coverage,
clinical attachment level gain, and increase in width of the kera-
tinized tissue. This variation is presumably because of discrepancies
associated with anatomical conditions and the type of defects
Periodontology 2000. 2019;79:81–106. wileyonlinelibrary.com/journal/prd
requiring treatment, the characteristics of adjacent gingival tissues,
patients’ smoking status, and mainly the characteristics of root‐cov-
erage procedures.2,3,5–11,28,71
As a consequence, and to enlighten treatment decision‐making,
root‐coverage procedures have frequently been compared by com-
bining outcomes derived from controlled clinical trials, and particu-
larly randomized controlled trials reporting similar methodology,
using systematic appraisals of periodontal literature (ie, systematic
reviews). In such a way, implications for research and practice
identified in systematic reviews are aiming to turn treatment
options into usable and predictable tools to be applied in dental
practice.6–9,89,90
In the first part of this review, gingival recession‐related factors
are briefly discussed (from etiology to the main root coverage/peri-
odontal plastic surgery procedures reported in the literature). The
second part of this review provides, in detail, some definitions
related to evidence‐based dental approaches and appraises evidence‐
based periodontal plastic surgery through an overview of different
published systematic reviews designed to evaluate the results
achieved by root‐coverage procedures in the treatment of localized
and multiple recession‐type defects. The third part describes a sys-
tematic evaluation of the role and outcomes of Latin American ran-
domized controlled trials within the current evidence. The final part
reports the results of an individual patient data meta‐analysis of ran-
domized controlled trials evaluating the association of root coverage
and restorative procedures in achieving complete root coverage of
noncarious cervical lesions. The aims were to provide a thorough
assessment of the conclusions and implications for practice and
future research from systematic reviews, as well as a synthesis of
the evidence produced in Latin American research centers.
© 2019 John Wiley & Sons A/S. | 81
Published by John Wiley & Sons Ltd
82 | CHAMBRONE
F I G U R E 1 Clinical view of an area of multiple recession‐type
defects associated with traumatic toothbrushing and dentinal
hypersensitivity (the continued trauma led to an unsuccessful and
unesthetic restorative treatment)
2 | GINGIVAL RECESSION REVISITED: A
BRIEF REVIEW
2.1 | Etiology and classification
Gingival recession has been described as the oral exposure of the
root surface as a result of displacement of the gingival margin apical
to the cemento‐enamel junction, with or without interdental soft
and hard tissue loss.91 Data from epidemiologic studies conducted in
different regions of the world, comprising both adult and young sub-
jects, with or without adequate dental biofilm control, show that
buccal gingival recession is highly prevalent.92–94
Etiologically, the development of recession‐type defects can be
related to the following anatomic‐, pathologic‐, professional (iatro-
genic)‐, or traumatic‐related factors:
Class I Class II
Class I*
Class III Class IV
Class III
ET AL.
• Anatomic-related factor: lack of attached gingiva, muscular inserts
near the gingival margin,27,29 poor tooth alignment,96 or inadequate
thickness of the alveolar bone plate and root prominences.85
• Pathologic-related factors: periodontitis96 or viral infection.69
• Iatrogenic-related factors: improper restorations invading the bio-
logical space.97
• Traumatic-related factors: trauma associated with toothbrushing98
or other objects in close contact to the gingival margin (eg, lip-
piercing).4
With respect to the anatomic characteristics of these defects, dif-
ferent classification systems have been reported in which the amount
of tissue lost over the exposed root surface is described.59,79,99–102 Of
these systems, the Classification of Marginal Tissue Recession is the
one most commonly used and accepted by the scientific community: it
was proposed by Miller in 1985,101 who used it to separate recession‐
type defects into four classic morphological groups (Figure 2):
• Class I: “Marginal tissue recession which does not extend to the
mucogingival junction. There is no periodontal loss (bone or soft
tissue) in the interdental area, and 100% root coverage can be
anticipated.”
• Class II: “Marginal tissue recession which extends to or beyond
the mucogingival junction. There is no periodontal loss (bone or
soft tissue) in the interdental area, and 100% root coverage can
be anticipated.”
• Class III: “Marginal tissue recession which extends to or beyond
the mucogingival junction. Bone or soft tissue loss in the inter-
dental area is present or there is malpositioning of the teeth
which prevents the attempting of 100% root coverage. Partial
root coverage can be anticipated.”
• Class IV: “Marginal tissue recession which extends to or beyond
the mucogingival junction. The bone or soft tissue loss in the
interdental area and/or malpositioning of teeth is so severe that
root coverage cannot be anticipated.”
F I G U R E 2 Miller's classification of
gingival recessions; *Reprinted/adapted by
permission from Springer Nature Customer
Class II Service Centre GmbH: Springer Nature,
Rationale for the Surgical Treatment of
Single and Multiple Recession‐Type
Defects. In: Evidence‐Based Periodontal
and Peri‐Implant Plastic Surgery: A Clinical
Roadmap from Function to Aesthetics by
Class IV Leandro Chambrone, SPRINGER
INTERNATIONAL PUBLISHING
SWITZERLAND (2015)
CHAMBRONE ET AL.
2.2 | Root coverage procedures: evolution from
mucogingival surgery to periodontal plastic surgery
As previously reported, recession‐type defects are linked to
esthetic, functional, and health conditions. In their historical note
published in the early 1980s, Baer and Benjamin103 narrated that
the first reports describing the use of pedicle or free soft tissue
grafts for the treatment of recession‐type defects originated at the
beginning of the 20th century. However, “scientific interest” in
these procedures, originally described by Younger in 1902, Harlan
in 1906, and Rosenthal in 1911,103 apparently remained “forgotten”
until the mid‐1950s when techniques exploring laterally posi-
tioned40 and coronally advanced67 flaps were proposed specifically
to cover denuded root surfaces. Since then, modifications to pedi-
11,16,19,21,33,39,41,44–46,52,67,68,80,81,87,88
cle flaps, as well as the use of
26,56,57,61,79
free gingival grafts, subepithelial connective tissue
grafts,10,14,15,24,25,27,34,43,51,63,70,83,85 matrix grafts,13,20,35,36,45,55
positioned flaps*
F I G U R E 3 Examples of periodontal
plastic surgery procedures proposed for
root coverage; *Reprinted/adapted by
permission from Springer Nature Customer
Service Centre GmbH: Springer Nature,
Rationale for the Surgical Treatment of
Single and Multiple Recession‐Type
Defects. In: Evidence‐Based Periodontal
and Peri‐Implant Plastic Surgery: A Clinical
Roadmap from Function to Aesthetics by
Leandro Chambrone, SPRINGER
INTERNATIONAL PUBLISHING
SWITZERLAND (2015)
| 83
guided tissue regeneration,17,49,53,72,82,86 and other procedures
associated with several biomaterials30,34,41,48,60,62,104 have been
proposed and evaluated, formerly as part of mucogingival therapy/
surgery and currently as periodontal plastic surgery procedures
(Figure 3). As originally defined by Miller, periodontal plastic sur-
gery comprises different surgical techniques that aim to correct and
prevent anatomic, developmental, traumatic, or plaque disease‐
induced defects of the gingiva, alveolar mucosa, or bone,58 and it
represents an important aspect in modern periodontology.
On the other hand, despite the vast number of procedures
appraising the efficacy or effectiveness of root coverage in recent
decades, substantial disparity in outcomes can be found between
and within procedures as a result of methodological differences
between studies.2,3,6,7,9 Consequently, accurate and reliable tools
for assessing data obtained from clinical research have also been
introduced and used in the contemporary clinical decision‐making
process.
Laterally
Coronally
advanced flaps
Free gingival
grafts
Subepithelial
connective
tissue grafts*
84 | CHAMBRONE
3 | BASE OF EVIDENCE: DEFINITIONS
AND EXPECTED OUTCOMES
3.1 | Translation of research findings to practice:
evidence‐based dentistry and evidence‐based
periodontal plastic surgery
The initial point for constructing a framework to assess and enhance
the excellence of treatment of patients presenting gingival recession
is identification of the appropriate base of evidence for interventions.
Different sources of clinical evidence, such as case series, controlled
clinical trials, and randomized controlled trials, are available for assess-
ment; however, arbitrary comparisons of studies or treatment proce-
dures cannot be considered as appropriate for drawing reliable and
accurate conclusions (or a “scientific truth”). Inconsistent and over-
stated outcomes from inadequately planned and reported biased
research and analytical reviews may lead to misleading interpretations,
and can guide professionals into making inaccurate treatment
options.105 As previously noted, the surgical correction of recession‐
type defects has been widely studied over the last 50‐60 years; how-
ever, in the last decade, in particular, clinicians and researchers have
been focusing their treatment options and research designs, respec-
tively, on the quality of the available base of evidence (in other words,
are performing evidence‐based dentistry). Furthermore, other condi-
tions related to patient‐, procedure‐, and/or outcomes‐related factors
(ie, the anatomy of recessions, the follow‐up period of studies, sample
of patients treated, site selection, standardized treatment techniques,
Patient-related factors
Recession classification, depth
and width
Clinical attachment level
Width of keratinized tissue
Systemic and local conditions
(e.g. smoking, toothbrushing)
Patient’s expectation (i.e.
esthetics)
Success
Outcomes-related factors
Intervention-related factors
Type of technique
postoperative complications
Standardized procedures
Standardized examination
Operator`s experience and skills
Mean root coverage achieved
ET AL.
and measurements) can influence the amount of root coverage
achieved and thus the success of treatment2,3,5–9 (Figure 4).
It is currently expected that choice of the best treatment options
should be supported by the highest quality findings of the evidence
available, that is, evidence‐based dentistry, which “is an approach to
oral health care that requires the judicious integration of systematic
assessments of clinically relevant scientific evidence, relating to the
patient's oral and medical condition and history, with the dentist's
clinical expertise and the patient's treatment needs and prefer-
ences”.106 The main objectives of evidence‐based dentistry within
the base of knowledge are: (a) to ask about what is known and what
is missing, (b) to obtain/retrieve the best information available, (c) to
evaluate the quality and results of the extracted data, (d) to analyze
and to adjust such outcomes for clinical and research use, and (e) to
apply the best treatment options to patients’ needs (Figure 5). As a
consequence, translation of the outcomes reported by high‐quality
meta‐analyses and systematic reviews to daily practice has grown in
popularity because they can offer a homogeneous, accurate, reliable,
and quality combination of a huge amount of data (excluding inade-
quate outcome measures).105 Thus, systematic reviews of random-
ized controlled trials are considered the gold standard study design
with respect to the clinical decision‐making process. In the field of
periodontology, evidence‐based dentistry became a key instrument
to sustain decision‐making once it shared the finest evidence existing
with clinical practice.90
With respect to application of an evidence‐based approach to
periodontal plastic surgery, this involves combination of the
Patient satisfaction
Adverse effects and/or
Long-term monitoring
F I G U R E 4 Factors associated with
success of root coverage procedures
CHAMBRONE ET AL. | 85

Scientific community,
3.2 | An Overview of periodontal plastic surgery for
clinicians and patients
root coverage: outcomes from systematic reviews
To ask
3.2.1 | The first decade of evidence‐based
periodontal plastic surgery (2002‐2012)
Since the landmark systematic review conducted by Roccuzzo et al.,
in 2002,71 more than 10 systematic reviews and meta‐analyses
To
To apply Truth exploring the effects of periodontal plastic surgery for root coverage
Obtain/retrieve
have been published in different parts of the world in the following
decade.2,3,5–7,9,11,28,32,65,66,71 and their methodology and results are
described in detail in Table 1. In its great majority, this collection of
reviews addresses the effects, clinical advantages, and adverse
To analyse effects/complications of different flap and graft procedures, associ-
To evaluate
and to adjust
ated or not with biomaterials, for the treatment of Miller Class I and
II localized or multiple recession‐type defects. For such a purpose,
FIGURE 5 Impact of evidence‐based evaluations these systematic reviews developed and incorporated specific
focused questions, inclusion and exclusion criteria, comprehensive
search strategies, quality assessment tools, and statistical models (ie,
requirements advocated by evidence‐based dentistry and periodontal
research synthesis models).
plastic surgery with clinician and patient‐related factors. Therefore,
In the broadest sense, these systematic reviews were consistent
evidence‐based periodontal plastic surgery is defined as “the system-
in their agreement on a sufficient amount of evidence for root‐cov-
atic assessment of clinically relevant scientific evidence designed to
erage procedures leading to significant recession depth reduction
explore the esthetic and functional effects of treatment of defects
and clinical attachment level gain, and thus the assessment of the
of the gingiva, alveolar mucosa, and bone, based on clinician's knowl-
outcomes of these publications represents the uppermost level of
edge and patient‐centered outcomes, such as perception of esthetic
evidence available and should be considered as the basis for clinical
conditions, functional limitations, discomfort, root sensitivity, level of
8 decision making. Despite some differences between protocols in the
sociability after surgery, and preferences” (Figure 6). Evidence‐based
reviews, it should be considered that: (a) all reviews adopted similar
periodontal plastic surgery is an important part of contemporary evi-
focused questions; (b) all reviews reported significant reduction in
dence‐based periodontology; accordingly, periodontal plastic surgery
recession depth and clinical attachment level gain, with or without a
been constantly explored and improved for use in the treatment of
significant increase in the keratinized tissue width, independently of
recession‐type defects with root‐coverage procedures.
the periodontal plastic surgery procedure; (c) outcomes from pooled
data, as reported via meta‐analyses, showed that surgical techniques
describing the use of subepithelial connective tissue grafts and coro-
nally advanced flaps (associated or not with subepithelial connective
tissue grafts or some biomaterials) were the procedures with the
Evidence-based
dentistry best outcomes (Figures 7 and 8); (d) complete root coverage was
more prevalent within subepithelial connective tissue graft proce-
dures; (e) there are insufficient data on patient‐centered outcomes
(esthetics, preferences, pain, and root sensitivity); and (f) the base of
evidence available for assessment and the criteria for conducting
Evidence-based systematic reviews were significantly improved over the last decade
Clinicians' Patient-centered
knowledge Periodontal outcomes and thus differences between systematic reviews regarding method-
plastic surgery
ology and comparisons may be evident, but they are nonsignificant
and certainly cannot decrease the value of these older reviews.

3.2.2 | The “second generation” of systematic

Periodontal plastic
reviews on root coverage procedures (2013‐2018)
surgery
and the overall findings of the base of evidence”
Together with the “first generation” of systematic reviews published
up to 2012, other five “comissioned” high‐quality systematic
FIGURE 6 Concept of evidence‐based periodontal plastic surgery reviews107–111 published after 2013 (‘the second generation’ of
 86

T A B L E 1 Evidence‐based periodontal plastic surgery: summary of the the first decade/‘generation’ (2002–2012) of systematic reviews appraising root coverage procedures
|

Types of study Interventions of

and participants interest and literature Outcomes No. of Statistical P‐values
Reference included search included Comparisons studies method Effect size Z Chi2 I2 (%) Authors’ main conclusions
Roccuzzo RCTs CCTs, and CAF, FGG, GTRr, ΔGR GTR vs SCTC 6 F WMD 95%CI −0.43 [−0.62, −0.23] <0.05 0.17 N/A “Overall, periodontal plastic
et al.71 CSs of at least GTRn, LPFs, and ΔCAL ΔGR 5 F WMD 95%CI 0.21 [−0.005, 0.43] NS 0.58 N/A surgery was effective in
6 mo duration SCTC SCRC ΔCAL 2 F WMD 95%CI 0.18 [−0.45, 0.82] NS 0.29 N/A reducing gingival
Patients with Electronic (Medline PCR GTR vs CAF 2 F WMD 95%CI 0.75 [−0.97, 2.47] NS 0.03 N/A recessions with a
Miller Class I or II and Cochrane OHG) MRC ΔGR 2 F WMD 95%CI 0.27 [−0.07, 0.60] NS 0.21 N/A concomitant improvement
gingival and manual PBA ΔCAL 2 F WMD 95%CI 0.12 [−0.37, 0.60] NS 0.59 N/A in attachment levels. Even
recessions of at searching up to and Stab GTRr vs GTRn though no single
least 2 mm including April 2001 ΔGR treatment can be
limited to English ΔCAL considered superior to all
language journals, the others, SCTC was
agreement between statistically significantly
the review authors more effective than GTR
calculated by k in recession reduction.
scores, and contact Further research is needed
with original authors to identify the factors
when necessary most associated with
successful outcomes.”
Pagliaro et al66 RCTs, CCTs, and CAF, FGG, ΔGR SCTC vs GTR 5 R ORa 95%CI 1.41 [1.03, 1.94] 0.03 0.40 2 “A standard format with
Clauser et al32 CSs FGG + CAF, GTR, ΔCAL complete root minimal requirements for
Patients with LPFs, and SCTC PCR coverage data collection and
gingival Electronic (Medline) MRC presentation should be
recessions and manual PBA established and imposed
searching up to and by international journals in
including November order to provide readers
2, 2000 and researchers with more
useful information.(ref)”
“Few studies reported IPD;
they are a valuable
contribution to clinical
decision‐ making, but IPD
published in the literature
are still insufficient to
provide a reliable guide for
clinical decision‐making.
Therefore, decisive steps
should be taken to
facilitate the publication of
IPD, in electronic format,
whenever a clinical study
is published in a leading
journal.(ref)”
CHAMBRONE

(Continues)
ET AL.
TABLE 1 (Continued)
Types of study Interventions of
and participants interest and literature Outcomes No. of Statistical P‐values
CHAMBRONE

Reference included search included Comparisons studies method Effect size Z Chi2 I2 (%) Authors’ main conclusions
ET AL.

b
Oates RCTs All periodontal plastic ΔGR GTR/ADMG vs 9 F WMD 95%CI −0.29 [−0.52, −0.06] 0.01 < 0.05 N/A “Soft tissue augmentation
et al66 Patients with surgery procedures clinical SCTC 7 F WMD 95%CIb −0.86 [−1.13, −0.58] <0.01 < 0.05 N/A procedures are effective
gingival aimed at treating GR attachment ΔGR means of obtaining root
recessions Electronic (Medline level ΔKT coverage, SCTC
and Cochrane OHG) PD techniques appear to have
and manual KT an advantage over GTR,
searching up to April PCR and there is a need for
2002 MRC further efficacy studies
limited to English PBA and for investigation of
language journals these procedures relative
to patient‐oriented
outcomes such as
esthetics, root sensitivity,
and postoperative
morbidities.”
Gapski RCTs of at least ADG vs CAF or SCTC ΔGR SCTC vs ADMG 4 R WMD 95%CI −0.41 [−1.33, 0.52] 0.39 < 0.05 85.6 “Differences in study design
et al39 3 mo duration Electronic (Medline ΔPD ΔGR 4 R WMD 95%CI 0.02 [−0.28, 0.24] 0.89 0.29 20.6 and lack of data precluded
Patients with and Cochrane OHG) ΔCAL ΔPD 4 R WMD 95%CI 0.52 [−0.12, 1.16] 0.11 0.02 68.3 an adequate and complete
gingival and manual ΔKT ΔKT 2 R WMD 95%CI −0.62 [−0.74, 0.51] 0.28 0.01 83.6 pooling of data for a more
recessions searching up to CAF vs ADMG 2 R WMD 95%CI 0.00 [−0.36, 0.35] 0.99 0.34 0 comprehensive analysis.
October 2004 ΔGR 2 R WMD 95%CI −0.56 [−1.33, 0.21] 0.16 0.18 45.2 Therefore, considering the
limited to English ΔPD 2 R WMD 95%CI −0.31 [−0.78, 0.15] 0.19 0.62 0 trends presented in this
language journals, ΔCAL study, there is a need for
and agreement ΔKT further randomized clinical
between the review studies of ADMG
authors calculated procedures in comparison
by k scores to common mucogingival
surgical procedures to
confirm our findings. It is
difficult to draw anything
other than tentative
conclusions from this
meta‐analysis of ADMG
for mucogingival surgery,
primarily because of the
weakness in the design
and reporting of existing
trials.”

(Continues)
|
87
 88

TABLE 1 (Continued)
|

Types of study Interventions of

and participants interest and literature Outcomes No. of Statistical P‐values
Reference included search included Comparisons studies method Effect size Z Chi2 I2 (%) Authors’ main conclusions
Cheng RCTs, CCTs or CSs CAF, CAF + EMD, ΔGR N/A N/A N/A N/A N/A N/A N/A “The results suggest that
et al31 of 6‐12 mo CAF + RC ΔCAL root coverage by the CAF
duration Electronic (Medline) ΔPD and CAF + chemical root
Patients with and manual ΔKT surface conditioning
Miller Class I or II searching up to the MRC procedures were
gingival end of October unpredictable but became
recessions of at 2005 limited to more predictable when the
least 2 mm English language CAF procedure was
journals improved by the
modification of adding
EMD.”
Chambrone RCTs of at least SCTC vs any root ΔGR ADMG vs SCTC 3 R WMD 95%CI −0.63 [−1.26, 0.00] 0.05 0.12 52.5 “The results of this review
et al2 6 mo duration coverage procedure ΔCAL ΔGR 3 R WMD 95%CI −0.53 [−1.27, 0.21] 0.16 0.17 62.4 show that SCTC provided
Patients with Electronic (Medline, ΔKT ΔCAL 3 R WMD 95%CI −0.72 [−1.58, 0.14] 0.10 0.05 67.0 significant root coverage,
Miller Class I or II Embase, CENTRAL SCRC ΔKT 2 R WMD 95%CI −0.12 [−0.43, 0.19] 0.45 0.39 0 clinical attachment and
gingival and Cochrane OHG) PCR CAF vs SCTC 2 R WMD 95%CI 0.10 [0.28, 0.48] 0.61 0.44 0 keratinized tissue gain.
recessions of at and manual MRC ΔGR 2 R WMD 95%CI −0.28 [−0.69, 0.12] 0.17 0.83 0 Overall comparisons allow
least 2 mm searching up to PBA ΔCAL 7 R WMD 95%CI −0.41 [−0.62, −0.20] <0.01 0.88 0 us to consider it as “the
At least 10 December 2007 ΔKT 7 R WMD 95%CI 0.11 [−0.15, 0.36] 0.42 0.36 8.9 gold standard” procedure
patients per limited to English GTRr vs SCTC 6 R WMD 95%CI −1.46 [−2.12, −0.81] 0.01 < 0.01 84.9 in the treatment of
group at final language journals, ΔGR 6 R OR 95%CI 0.47 [0.24, 0.90] 0.02 0.49 0 recession‐type defects”
examination agreement between ΔCAL 2 R WMD 95%CI −0.43 [−1.21, 0.35] 0.28 0.06 72.5
the review authors ΔKT 2 R WMD 95%CI −0.04 [−0.52, 0.44] 0.88 0.84 0
calculated by k SCRC 2 R WMD 95%CI −1.82 [−3.28, −0.35] 0.02 < 0.01 88.7
scores, and contact GTRn vs SCTC 2 R WMD 95%CI −0.75 [−1.92, 0.43] 0.21 < 0.01 86.3
with original authors ΔGR 2 R WMD 95%CI −2.10 [−2.51, −1.69] 0.01 0.84 0
when necessary ΔCAL
ΔKT
GTRr bs vs SCTC
ΔGR
ΔKT
Cairo et al28 RCTs of at least CAF alone or ΔGR CAF + SCTC vs 2 R WMD 95%CI 0.49 [0.14, 0.83] <0.01 0.82 0 “SCTC or EMD in
6 mo duration associated to ΔCAL CAF 2 R WMD 95%CI 0.38 [0.01, 0.75] 0.05 0.86 0 conjunction with CAF
Patients with ADMG, EMD, HF‐ ΔKT ΔGR 2 R WMD 95%CI 0.73 [0.35, 1.10] <0.01 0.88 0 enhances the probability
Miller Class I or II DDS, GTR, platelet‐ SCRC ΔCAL 2 R OR 95% CI 2.49 [1.10, 5.68] 0.03 0.91 0 of obtaining complete root
localised gingival rich plasma or SCTC. PCR ΔKT 2 R WMD 95%CI −0.27 [−0.60, 0.06] 0.11 0.58 0 coverage in Miller Class I
recessions Electronic (Medline PBA SCRC 2 R WMD 95%CI −0.33 [−0.68, 0.02] 0.06 0.41 0 and II single gingival
and Cochrane OHG) CAF + GTRr vs 2 R WMD 95%CI 0.15 [−0.13, 0.42] 0.30 0.36 0 recessions.”
and manual CAF 5 R WMD 95%CI 0.58 [0.21, 0.95] < 0.01 0.09 50.5
searching up to ΔGR 5 R WMD 95%CI 0.53 [0.26, 0.80] < 0.01 0.36 7.6
August 2007 ΔCAL 5 R WMD 95%CI 0.42 [0.18, 0.66] < 0.01 0.08 52.7
CHAMBRONE

(Continues)
ET AL.
TABLE 1 (Continued)
Types of study Interventions of
and participants interest and literature Outcomes No. of Statistical P‐values
Reference included search included Comparisons studies method Effect size Z Chi2 I2 (%) Authors’ main conclusions
CHAMBRONE

without language ΔKT 4 R OR 95%CI 3.89 [1.59, 9.50] < 0.01 0.32 15.2
ET AL.

restriction, and CAF + EMD vs 2 R WMD 95%CI 0.60 [−0.52, 1.73] 0.29 < 0.01 87.1
contact with original CAF 2 R WMD 95%CI 0.28 [−0.16, 0.72] 0.22 0.55 0
authors when ΔGR 2 R WMD 95%CI 0.31 [−0.15, −0.78] 0.19 0.62 0
necessary ΔCAL 2 R OR 95%CI 4.83 [0.23, 99.88] 0.31 0.08 67.4
ΔKT 6 R WMD 95%CI −0.38 [−0.65, −0.10] < 0.01 0.10 45.6
SCRC 6 R WMD 95%CI −0.05 [−0.32, −0.22] 0.73 0.15 38.0
CAF + ADMG vs 6 R WMD 95%CI −1.18 [−1.98, −0.39] <0.01 < 0.01 91.9
CAF 6 R OR 95% CI 0.45 [0.20, 1.04] 0.06 0.20 31.9
ΔGR 4 R WMD 95%CI −0.40 [−1.07, 0.26] 0.24 < 0.01 79;4
ΔCAL 4 R WMD 95%CI −0.39 [−1.00, 0.21] 0.20 0.03 67.5
ΔKT 4 R WMD 95%CI −0.90 [−1.51, −0.28] <0.05 0.10 52.1
SCRC 4 R OR 95% CI 0.49 [0.23, 1.03] 0.06 0.61 0
CAF + GTRr vs
GAF+SCTC
ΔGR
ΔCAL
ΔKT
SCRC
CAF + ADMG vs
CAF + SCTC
ΔGR
ΔCAL
ΔKT
SCRC
Chambrone RCTs, CCTs, and ADMG, CAF, FGG, ΔGR CAF (smokers) vs. 2 R WMD 95%CI −0.09 [−0.81, 0.63] 0.81 0.04 75.0 “The results of this review
et al3 CSs of at least GTR and SCTC ΔCAL CAF 2 R WMD 95%CI 0.01 [−0.54, 0.56] 0.97 0.45 0 show that smoking may
6 mo duration Electronic (Medline, ΔKT (nonsmokers) 2 R WMD 95%CI −0.22 [−1.40, 0.97] 0.72 < 0.01 89.0 negatively influence GR
Patients with Embase, CENTRAL SCRC ΔGR 2 R RR 95%CI 0.30 [0.02, 5.78] 0.42 0.07 70.0 reduction and clinical
Miller Class I or II and Cochrane OHG) PCR ΔCAL 3 R WMD 95%CI −0.78 [−1.06, −0.51] < 0.01 0.48 0 attachment level gain,
gingival and manual MRC ΔKT 3 R WMD 95%CI −0.75 [−1.13, −0.38] <0.01 0.98 0 especially for SCTC.
recessions searching up to and Stab SCRC 2 R WMD 95%CI −0.02 [−1.05, 1.02] 0.97 0.10 63.0 Additionally, smokers may
At least 10 including June 2008 SCTC (smokers) 3 R RR 95%CI 0.24 [0.10, 0.58] <0.01 0.63 0 exhibit fewer sites with
patients per limited to English vs SCTC complete root coverage.”
group at final language journals, (nonsmokers)
examination agreement between ΔGR
Outcome measures the review authors ΔCAL
from smokers (≥ calculated by k ΔKT
10 cigarettes/day) scores, and contact SCRC
and nonsmokers, with original authors
recorded when necessary
separately
|

(Continues)
89
 90

TABLE 1 (Continued)
|

Types of study Interventions of

and participants interest and literature Outcomes No. of Statistical P‐values
Reference included search included Comparisons studies method Effect size Z Chi2 I2 (%) Authors’ main conclusions
Chambrone RCTs of at least ADMG, CAF, EMD, ΔGR ADMG vs SCTC 2 R WMD 95%CI −0.76 [−1.93, 0.42] 0.21 0.04 76.0 “SCTC, CAF alone or
et al6,7 6 mo duration FGG, GTR, LPFs, ΔCAL ΔGR 2 R WMD 95%CI −0.81 [−1.92, 0.30] 0.15 0.07 69.0 associated with other
Patients with SCTC alone or in ΔKT ΔCAL 2 R WMD 95%CI −0.83 [−2.09, 0.44] 0.20 0.03 78.0 biomaterial and GTR may
Miller Class I or II combination with SCRC ΔKT 2 R WMD 95%CI 0.62 [−0.51, 1.74] 0.28 0.01 84.0 be used as root coverage
gingival LPFs or CAF PCR ADMG vs CAF 2 R WMD 95%CI 0.56 [−0.21, 1.33] 0.16 0.18 45.0 procedures for the
recessions of at Electronic (Medline, MRC ΔGR 2 R WMD 95%CI 0.31 [−0.15, 0.77] 0.18 0.62 0 treatment of localized
least 3 mm Embase, CENTRAL PBA ΔCAL 2 R WMD 95%CI 0.25 [−0.13, 0.64] 0.19 0.26 21.0 recession‐type defects. In
At least 10 and Cochrane OHG) Stab ΔKT 2 R WMD 95%CI 0.27 [−0.16, 0.69] 0.22 0.55 0 cases where both root
patients per and manual EMD+CAF vs 2 R WMD 95%CI 0.40 [0.09, 0.71] 0.01 0.47 0 coverage and gain in the
group at final searching up to CAF 3 R WMD 95%CI 0.39 [−0.65, −0.12] <0.01 0.92 0 KT are expected, the use
examination October 2008, ΔGR 3 R WMD 95%CI 0.31 [−0.01, 0.62] 0.05 0.73 0 of SCTC seems to be
without language ΔCAL 3 R WMD 95%CI −1.95 [−2.66, −1.24] <0.01 0.01 77.0 more adequate. RCT are
restriction,agreement ΔKT 3 R RR 95%CIU 0.71 [0.47, 1.08] 0.11 0.58 0 necessary to identify
between the review GTRr vs SCTC 2 R WMD 95%CI 0.32 [−0.03, 0.68] 0.07 0.33 0 possible factors associated
authors calculated ΔGR 2 R WMD 95%CI 0.15 [−0.38, 0.68] 0.57 0.69 0 with the prognosis of each
by k scores, and ΔCAL 2 R WMD 95%CI 0.11 [−0.29, 0.51] 0.60 0.92 0 periodontal plastic surgery
contact with original ΔKT 2 R RR 95%CI 1.18 [0.61, 2.31] 0.62 0.62 0 procedure, and the
authors when SCRC 2 R WMD 95%CI −0.75 [−1.92, 0.43] 0.21 < 0.01 86.0 potential impact of bias on
necessary GTRr vs GTRnr 2 R WMD 95%CI −2.10 [−2.51, −1.69] <0.01 0.84 0 these outcomes is
ΔGR 2 R WMD 95%CI 0.46 [−0.02, 0.94] 0.06 0.79 0 unclear.”
ΔCAL 2 R WMD 95%CI 0.72 [−0.06, 1.50] 0.07 0.14 55.0
ΔKT 2 R WMD 95%CI 0.13 [−0.12, 0.37] 0.30 0.35 0
SCRC 2 R RR 95%CI 1.40 [0.76, 2.57] 0.28 0.85 0
GTRr bs vs SCTC
ΔGR
ΔKT
GTRr bs vs GTRr
ΔGR
ΔCAL
ΔKT
SCRC
Chambrone RCTs, CCTs, and CAF, FGG, GTRr, ΔGR N/A N/A N/A N/A N/A N/A N/A “Analysis of the limited
et al5 CSs of at least GTRn, LPFs, and ΔCAL information available in
6 mo duration SCTC ΔKT the dental literature
Patients with Electronic (Medline, SCRC showed improvements in
Miller Class I or II Embase and PCR clinical parameters with all
multiple gingival CENTRAL) and MRC of the periodontal plastic
recessions of at manual searching up surgery procedures. RCT
least 2 mm to and including are needed to identify the
June 2008, without indications for each
language restriction,
CHAMBRONE

(Continues)
ET AL.
 CHAMBRONE
ET AL.

TABLE 1 (Continued)
Types of study Interventions of
and participants interest and literature Outcomes No. of Statistical P‐values
Reference included search included Comparisons studies method Effect size Z Chi2 I2 (%) Authors’ main conclusions
and contact with surgical technique and any
original authors prognostic factors.”
when necessary
Chambrone RCTs of at least ADMG, CAF, EMD,
et al9 6 mo duration FGG, GTR, LPFs,
Patients with SCTC alone or in
Miller Class I or II combination with
gingival LPFs or CAF
recessions Electronic (Medline,
Embase, CENTRAL
and Cochrane OHG)
and manual
searching up to April
2011, without
language restriction,
agreement between
the review authors
calculated by k
scores, and contact
with original authors
when necessary

ADMG, acellular dermal matrix grafts; bs, associated with bone substitutes; CAF, coronally advanced flap; CCT, controlled clinical trial; CENTRAL, Cochrane Central Register of Controlled Trials; CI, confi-
dence interval; Cochrane OHG, Cochrane Oral Health Group specialist trials register; CS, case series; EMD, enamel matrix derivative protein; F, fixed‐effects meta‐analysis; FGG, free gingival graft; GR, gin-
gival recession; GTR, GTR (r, resorbable membrane; n, nonresorbable membrane); HF‐DDS, living tissue‐engineered human fibroblast‐derived dermal substitute; LPFs, laterally positioned flap; MRC, mean
root coverage; N/A, not available; OR, odd ratio; PBA, patient‐based outcomes; PCR, percentage of complete root coverage; PPS, periodontal plastic surgery; R, random‐effects meta‐analysis; RC, root condi-
tioning; RCT, randomized controlled trial; RR, risk ratio; SCRC, sites with complete root coverage; SCTG, subepithelial connective tissue graft; Stab, long‐term stability; WMD, weighted mean difference
(mm); ΔCAL, clinical attachment change; ΔGR, gingival recession change; ΔKT, keratinized tissue change; ΔPD, probing depth change.
a
Analysis performed using data extracted from the review.
b
Data extracted from the forest plots found in the review.
|
91
92 | CHAMBRONE
F I G U R E 7 Long‐term follow‐up (72 mo) of a single recession‐
type defect treated with subepithelial connective tissue
graft + coronally advanced flap51
reviews) also support the positive effects of treatment of recession‐
type defects by root coverage procedures. These ‘first and second
generation’ reviews highlighted some specific esthetical and func-
tional issues.
With respect to complete root coverage, it combines esthetics,
and also, if necessary, can put an end to dental hypersensitivity.9
However, great variability can be observed in the outcomes of
ET AL.
treated sites showing complete root coverage within the base of evi-
dence because of aspects linked to characteristics of defects (ie,
depth, width, and classification of the recession), the amount and qual-
ity of adjacent gingival tissue, smoking habits, traumatic toothbrushing,
and the surgical procedure chosen.2,3,5–7,9,11,28,32,65,66,71,107–110
In a previous Cochrane review it was stated that better outcomes
(in terms of percentage of complete root coverage) can be accom-
plished in recession‐type defects with a baseline recession depth of
<4 mm, and also that achieving complete root coverage may be influ-
enced by the baseline position of the gingival margin.6,7,108 This view
is supported, in part, by another review included in this overview (an
individual patient data network meta‐analysis with data from 22 ran-
domized controlled trials) that appraised whether baseline recession‐,
patient‐, and procedure‐related factors could influence achievement
of complete root coverage.9 The results of this review showed that:
(a) the deeper the baseline recession depth, the smaller the chance of
achieving complete root coverage; (b) subepithelial connective tissue
grafts, matrix grafts, and enamel matrix derivative (with or without
subepithelial connective tissue graft) were superior to coronally
advanced flaps in terms of complete root coverage; and (c) trials
reporting conflicts of interest and Class I recession defects presented
a trend of better outcomes when compared with trials not reporting
conflicts of interest and Class II defects, respectively.9
In the majority of the systematic reviews, statistical methods
employing conventional pairwise meta‐analyses (ie, based on aggre-
gate data at the study level and outcomes derived from randomized
controlled trials normally comparing a new treatment with a gold
standard one) were used to supply a general estimate of the differ-
ences in the outcome measures,2,3,5–7,9,11,29,33,67,68,73,107–110 but
the calculation of weighted mean differences for some continuous
outcomes (eg, recession depth and clinical attachment level) can be
impaired by the inclusion of studies investigating gingival recession
>4 mm in depth because such trials commonly report greater out-
comes changes (ie, differences in the mean values between baseline
and follow‐up results).6,7 Likewise, other methodological factors
should be considered when pairwise meta‐analyses are used: (a)
pairwise comparisons are usually pooled using statistical methods
to supply a general estimate of the differences in the outcome
measures and thus it is not always possible to conduct direct com-
parisons when some head‐to‐head trials have not yet been per-
formed (ie, laterally positioned flaps vs subepithelial connective
tissue grafts or coronally advanced flaps + matrix grafts)112–115; (b)
when there are more than two test treatments (eg, coronally
advanced flaps, guided tissue regeneration, and lateral pedicle
flaps), at least six pairwise meta‐analyses have to be undertaken to
compare the differences in efficacy between pairs of treatments
(eg, coronally advanced flaps vs coronally advanced flaps + guided
tissue regeneration; coronally advanced flaps vs lateral pedicle
flaps; and guided tissue regeneration vs lateral pedicle flaps) and
between each of them and the gold standard (for instance, for
subepithelial connective tissue grafts: coronally advanced flaps vs
subepithelial connective tissue grafts; guided tissue regeneration vs
subepithelial connective tissue grafts; and lateral pedicle flaps vs
CHAMBRONE ET AL.
F I G U R E 8 Short‐term follow‐up (6 mo)
of multiple recession‐type defects treated
with coronally advanced flap90; Reprinted/
adapted by permission from Springer
Nature Customer Service Centre GmbH:
Springer Nature, Rationale for the Surgical
Treatment of Single and Multiple
Recession‐Type Defects. In: Evidence‐
Based Periodontal and Peri‐Implant Plastic
Surgery: A Clinical Roadmap from Function
to Aesthetics by Leandro Chambrone,
SPRINGER INTERNATIONAL PUBLISHING
SWITZERLAND (2015)
subepithelial connective tissue grafts);113 and (c) they did not avoid
the dilemma of combining odds ratio and risk ratio of studies
reporting dichotomous data (eg, the number of treated sites show-
ing complete root coverage) that have or not have not corrected
for some confounders (ie, defects with different characteristics,
smoking, and follow‐up period).9 Therefore, the use of individual
patient data meta‐analyses may surmount such constraints and
incorporate the information of both patients (eg, anatomy of reces-
sion‐type defects and systemic conditions, both at baseline) and
procedures into a single statistical model measuring overall effi-
cacy,116 as well as decrease the risk of including potential sources
of heterogeneity and bias.105,117,118
On the one hand, evidence emerging from some of the
included systematic reviews also supports that periodontal plastic
surgery can effectively be applied to multiple recession
defects5,108,109 and to smokers.3,107,108 On the other hand, it
should be taken into consideration that for multiple defects, the
base of evidence available is still very fragile. When the systematic
review was performed, there were no randomized controlled trials
available, the data retrieved for analysis was exclusively derived
from case series, and from then until the time when this review
was prepared, few randomized controlled trials have been pub-
lished.12,89,107,108 Regarding the effect of treatment in smokers
compared with treatment in nonsmokers, data were retrieved from
controlled clinical trials (because it is impossible to randomize stud-
ies in which only one surgical procedure is tested), and the findings
showed that root‐coverage procedures promoted significant reduc-
tion in recession depth and in clinical attachment level gain for
both groups of subjects.3 However, pooled estimates evidenced
that subepithelial connective tissue grafts were less effective in
smokers than in nonsmokers concerning both recession and clinical
attachment level reduction, while no significant differences were
found for patients treated with coronally advanced flaps. In
| 93
addition, the authors concluded: (a) the hypothesis that smoking
decreases the expected success of root coverage is valid for
subepithelial connective tissue grafts; (b) at least three smokers
need to be treated so that one can achieve complete root cover-
age over nonsmokers when subepithelial connective tissue grafts
are the procedure of choice; and (c) the way in which individual
studies define a subject as a smoker, and how the investigators
ascertain the accuracy of this classification, should be improved
and better described.3
In addition, and common to all these reviews, was the finding
that they, in their majority, were considered to be of medium to high
quality (ie, they described an overall scientific quality with minor
flaws),8 which, in practical terms, indicates that the conclusions
about the effects of interventions may be considered as fairly cer-
tain. Nevertheless, in order to overcome eventual biases in their
review processes, the complexity in interpreting results reinforces
the premise that systematic evaluations of the literature must be
built on a logical and transparent methodology, with the reader of
the systematic review (patient, clinician, or researcher) being able to
distinguish what has been carried out.8,89,90,105
3.3 | Concluding remarks from systematic reviews
The results from the set of systematic reviews on root‐coverage pro-
cedures included in this chapter and published over the last 18 years
indicate that:
• Within the surgical procedures assessed, all can lead to statisti-
cally significant reduction of recession depth and gain in clinical
attachment level when the characteristics of postsurgical reces-
sion defects are compared with those at baseline.
• Between procedures, techniques advocating the use of subepithe-
lial connective tissue grafts (associated with coronally advanced
94 | CHAMBRONE
flaps alone or coronally advanced flaps + or enamel matrix deriva-
tive), coronally advanced flaps (alone or in combination with acellu-
lar dermal matrix graft or enamel matrix derivative) showed a
better evidence of statistically significant gains in recession depth
and clinical attachment level when compared with other root-cov-
erage procedures; however, significant improvements in the width
of keratinized tissue were directly associated with the use of
subepithelial connective tissue grafts (Figure 7).
• Apart from the findings related to increases of keratinized tissue
width, subepithelial connective tissue grafts also showed better
outcomes in terms of complete root coverage (the main and final
outcome anticipated).
• The use of root-modification agents did not increase or decrease
the rate of root coverage.
• Assessment of periodontal plastic surgery procedures for the treat-
ment of areas of multiple recession-type defects remains partially
explored. The findings of the narrow base of evidence available
suggest that both subepithelial connective tissue grafts and coro-
nally advanced flaps (Figures 8 and 9) can be safely used to
reestablish esthetics and decrease dental hypersensitivity.
• Comparisons between procedures exploring continuous data were
performed mainly on a pairwise basis (through obtaining weighted
mean differences of the outcomes, ie, calculating final baseline
means), and consequently such an approach precludes the direct
comparison of more than two distinct procedures.
• As reported in a previous study,113 because the base of evidence
is not always equal across all comparisons, some inconsistencies
associated with multiple pairwise meta-analyses should be taken
into consideration, such as the impossibility of making direct com-
parisons between two different procedures when head-to-head tri-
als are not available for analysis, as well as the lack of power to
detect any significant between-treatment differences for meta-ana-
lysis that include only a few studies. These aspects may lead to
ET AL.
imprecise conclusions for some groups of comparisons because of
the lack of information on individual patient data.
• The unique systematic review of randomized controlled trials, in
which individual patient data of 602 recessions were pooled in
two sets of network meta-analyses9, as well as the 2015 Ameri-
can Academy of Periodontology Regeneration Workshop and
2018 Cochrane Systematic Reviews gave support to the assump-
tion that achieving complete root coverage is directly associated
with initial depth (apico-cervical length) of the gingival recession,
and that surgical techniques employing subepithelial connective
tissue grafts are, currently the gold standard procedures.
4 | SYSTEMATIC EVALUATION OF THE
ROLE AND OUTCOMES OF LATIN
AMERICAN STUDIES FOR INCREASING THE
BASE OF EVIDENCE
The role of Latin American randomized controlled trials in increasing
the base of knowledge concerning our understanding of periodontal
disease patterns and therapy has been gaining worldwide impor-
tance. With respect to evaluation of periodontal plastic surgery for
treatment of recession‐type defects, some research groups have
been able to conduct and present their findings in the main interna-
tional and renowned periodontal journals. In addition to the profits
that their results have brought to regional and worldwide research
communities, they substantiate the development, growth, and con-
solidation of new high‐quality research centers. In order to assess
their contribution to the current base of evidence, a systematic eval-
uation was developed and conducted. Detailed descriptions of the
protocol (ie, electronic and manual searching and methodology) used
to search for Latin American randomized controlled trials in the den-
tal literature have been published elsewhere.2,3,5–7,9 The following
F I G U R E 9 Short‐term follow‐up
(24 mo) of multiple recession‐type defects
treated with coronally advanced flap90;
Reprinted/adapted by permission from
Springer Nature Customer Service Centre
GmbH: Springer Nature, Rationale for the
Surgical Treatment of Single and Multiple
Recession‐Type Defects. In: Evidence‐
Based Periodontal and Peri‐Implant Plastic
Surgery: A Clinical Roadmap from Function
to Aesthetics by Leandro Chambrone,
SPRINGER INTERNATIONAL PUBLISHING
SWITZERLAND (2015)
CHAMBRONE ET AL.
sections provide a brief description of the specific methodological
aspects of the present review.
4.1 | Criteria for considering studies for this review
4.1.1 | Inclusion criteria, type of participants, and
studies
Studies were considered for inclusion if they involved the following:
• Participants with a clinical diagnosis of localized or multiple reces-
sion-type defects.
• Recession areas selected for treatment classified as Miller Class I, II,
or III101 that were surgically treated by root-coverage procedures.
• Treatment of subjects ≥18 years of age.
• A randomized controlled trial design with a follow-up period of
≥6 months focusing the treatment of nonsmoking patients, and
published in one of the most traditional/important periodontal
journals (i.e., Journal of Periodontology, Journal of Clinical Periodon-
tology, Journal of Periodontal Research and International Journal of
Periodontics & Restorative Dentistry).
4.1.2 | Type of interventions
All periodontal plastic surgery procedures described to attain root
coverage of previously exposed root surfaces were included. Overall,
the main interventions of interest were:
• Coronally advanced flaps, alone or in combination with guided tis-
sue regeneration, acellular dermal matrix grafts, enamel matrix
derivative protein, xenogenic matrix grafts or other biomaterials.
• Free gingival grafts.
• Laterally positioned flaps.
• Subepithelial connective tissue grafts, alone or in combination
with coronally advanced flaps.
4.2 | Search methods for identification of studies
Identification of Latin American randomized controlled trials was
conducted via detailed search strategies developed for MEDLINE
(Medical Literature Analysis and Retrieval System Online),
EMBASE (Excerpta Medica Database), CENTRAL (Cochrane Cen-
tral Register of Controlled Trials), the Cochrane Oral Health
Group's Specialized Register database, and LILACS (Latin American
and Caribbean Health Sciences Literature) without language
restriction.2,3,5–7,9 Database searches were conducted up to and
including January 15, 2018.107 Medical Subject Headings terms,
key words, and other free terms were used for searching, and
Boolean operators (OR, AND) were used to combine searches.
The search strategy applied was: (gingival recession OR ((recession
NEAR gingiva*) OR (recession NEAR defect*) OR “recession‐type
defect*”) OR ((exposure NEAR root*) OR (exposed NEAR root*))
OR (gingiva* NEAR defect*), OR denude* NEAR “root surface*”
| 95
AND GTR OR “tissue NEAR regenerat* OR [(gingiva* NEAR
esthetic*) OR (gingiva* NEAR aesthetic*)] OR periodont*) AND
(“plastic surgery” OR “soft tissue graft*” OR “coronally advanced
flap*” OR “laterally positioned flap*” OR “laterally positioned
flap*” OR “connective tissue graft*” OR “connective tissue graft*”,
OR gingiva* NEAR transplant* OR “dermal matrix” NEAR graft*
OR “enamel matrix protein”).
Reference lists of any potential studies were examined (ie, by
manual searching) in an attempt to identify any other papers.
4.3 | Selection of Latin American randomized
controlled trials, assessment of validity, data
extraction, and management
Identification of randomized controlled trials conducted in Latin
American universities or private practices was performed by the lead
reviewer of this review (L.C.) who screened the titles, abstracts, and
full texts of the articles identified by searching. Data on the citation
(journal, publication status, and year of publication), location of trial
(place where the patients were treated: university or private practice
environment and country in which the trial was conducted), methods
reported (study design [parallel or split‐mouth], number of treatment
groups, and duration), characteristics of participants (sample size,
smoking status, gender, age, characteristics of defects), type of inter-
ventions, outcome measures evaluated, source of funding, and con-
flicts of interest were extracted and recorded using specially
designed data‐extraction forms.
4.4 | Assessment of risk of bias in included studies
and data synthesis
The methodological quality of the randomized controlled trials was
appraised by focusing on the points described in the Cochrane Collab-
oration tool for assessing risk of bias (as referenced in Chapter 8 the
Cochrane Handbook for Systematic Reviews of Interventions.105 Specifi-
cally, details of randomization/sequence generation (selection bias),
allocation concealment (selection bias), blinding of participants and
personnel (performance bias), blinding of outcome assessment (detec-
tion bias), incomplete outcome data (attrition bias), selective outcome
reporting (reporting bias), and other bias were assessed in the included
trials to classify the risk of bias, as follows: (a) low risk of bias if all cri-
teria were met; (b) unclear risk of bias if 1 or more criteria were partly
met; and (c) high risk of bias if 1 or more criteria were not met.
In addition, all data extracted were pooled into evidence tables
and a descriptive summary was performed to determine the quantity
of data, checking further for study variations in terms of the study
characteristics and results.
5 | MAIN FINDINGS
Of the 724 publications previously retrieved and identified from the
search strategy (for details, see Chambrone et al.107), 23 randomized
96 | CHAMBRONE
controlled trials conducted in Latin American universities or private
practices were screened and included in this review. The full text of
the included trials was obtained and their main characteristics are
presented in Table 2.
Twenty‐nine papers,18,20–22,30,34,36–38,50,53,54,62,64,73–78 on 23 ran-
domized controlled trials published in full, were included; therefore,
Trials reported in more than one publication were grouped under
23,37,76,119,120
one study name (ie, that of the most recent paper).
In total, 558 patients (771 defects) allocated in ten paral-
lel18,31,39,56,76,79,119–124 and 13 split‐mouth design trials were treated.
One study was private practice‐based64 and 22 were based in
universities. All randomized controlled trials were conducted in the
same country (Brazil), except for the trial by Castellanos et al,30
which was performed in Mexico. The majority of samples involved
localized recession‐type defects classified as Class I or II, but one
study tested the use of periodontal plastic surgery procedures for
Class III defects.18 Eleven studies were supported, in total or in part,
by government agencies,18,23,38,73,121–126 and one was supported by
a commercial company.64 Finally, most of the follow‐up evaluations
were after 6 months’ duration, but some lasted for up to
23
30 months.
The procedures evaluated were: coronally advanced flaps, either
alone or associated with barrier/membranes or different biomaterials
(ie, acellular dermal matrix grafts, xenogenic matrix grafts bone sub-
stitutes, or enamel matrix derivative); subepithelial connective tissue
grafts associated with coronally advanced flaps; and lateral pedicle
flaps (Table 2). Three randomized controlled trials assessed the com-
bination of restorative procedures plus coronally advanced
flap54,75,76 or subepithelial connective tissue graft74 procedures in
noncarious cervical lesions. Within and between studies, the peri-
odontal plastic surgery procedures tested showed statistically signifi-
cant reductions in recession depth and gain in attachment level.
Surgical techniques advocating the use of subepithelial connective
tissue grafts also reported better outcomes in terms of keratinized
tissue gain. For trials evaluating the restoration of noncarious cervi-
cal lesions and root‐coverage procedures, it was shown that such a
combined approach was as safe, predictable, and effective as the as
the treatment of noncarious cervical lesions with root‐coverage pro-
cedures only.54,74–76
The criteria used to assess the risk of bias (ie, methods of ran-
domization and allocation concealment, blinding, completeness of
the follow‐up period, selective outcome reporting, and other bias)
showed that three trials were considered to have low risk of bias. As
reported in Table 2, most of the trials failed to report data on one or
more topics and accordingly were classified to be at unclear risk of
bias. Moreover, it should be taken into consideration that in two tri-
als74–76 evaluating noncarious cervical lesions, blindness of the
examiner could not be achieved because it was not feasible to hide
the type of treatment performed (that is, the examiner was able to
identify whether the restoration was applied at the noncarious cervi-
cal lesions). On the other hand, none of the included trials showed
evidence of reporting bias (ie, selective outcome reporting) and other
sources bias, none of the trials (data not included in Table 2). In
ET AL.
addition, it should be noted that all Latin American randomized con-
trolled trials found in the literature were published within the last
18 years and their results are clearly in line with the world's base of
evidence. Their outcomes have been individually assessed and/or
combined into pooled estimates by most of the systematic reviews
available in order to assist clinicians and researchers during the clini-
cal decision‐making process. As a result, this group of studies clearly
contributes to improving knowledge in the treatment of recession‐
type defects as they now represent an important part of the global
and relevant set of information available for analysis.
5.1 | Concluding remarks from Latin American
randomized controlled trials
Data retrieved from the 23 Latin American randomized controlled
trials on the effect of root‐coverage procedures in treatment of
recession‐type defects included in this paper indicate that:
• Statistically significant recession reduction and clinical attachment
level gain may be expected following the use of different root-
coverage procedures.
• Keratinized tissue gain is directly associated with subepithelial
connective tissue graft procedures.
• There is substantial variation in terms of mean and complete root
coverage between studies. The results from the included studies
indicate better outcomes for subepithelial connective tissue
grafts.
• The use of restorative procedures associated with root-coverage
techniques in the treatment of recession-type defects associated
with noncarious cervical lesions seems to be an effective
approach.
• Despite the extensive number of publications conducted in Latin
America, almost all randomized controlled trials were performed
in only one country. However, it should be considered that this
probably did not reflect the enthusiasm and the search for
knowledge of other research centers. Clinicians from several
Latin American countries have been working hard to disseminate
and clinically appraise the outcomes of their network; accord-
ingly, further information will doubtless be available in the
future.
6 | EFFECTS OF PERIODONTAL PLASTIC
SURGERY ON NONCARIOUS CERVICAL
LESIONS: RESULTS OF AN INDIVIDUAL
PATIENT DATA META‐ANALYSIS
EVALUATING COMPLETE ROOT COVERAGE
Complete root coverage represents the final clinical outcome
expected after treatment of recession‐type defects.2–11 As
reported in previous sections of this review, complete root cover-
age of exposed root surfaces may be influenced by the type of
periodontal plastic surgery procedure and by the baseline recession
T A B L E 2 Characteristics of Latin American randomized controlled trials evaluating different root coverage procedures
Method of
Main outcomes random Allocation Blindness of Risk of Site (location), funding and
Study Methods Participants Interventions evaluated ization concealment examiners bias notes
CHAMBRONE

Andrade et al18 RCT, parallel design, 30 nonsmoking individuals, 16 1) EMD + CAF CAL, GRD, KTT, KTW, Adequate Unclear Unclear Unclear University‐based (Brazil) and
2 treatment groups, females, aged 22‐44, with one Miller (macrosurgery) MRC, POPain, PPD, supported by the State of São
ET AL.

06 mo duration Class I or III buccal gingival recession 2) EMD + CAF SCRC/PCR Paulo Research Foundation
of at least 2 mm (microsurgery) (Automated controlled (FAPESP)
A total of 30 defects were treated (15 force periodontal probe)
per group)
Only two patients with Class III
recessions defects were included

Barros et al20 RCT, split‐mouth 14 nonsmoking individuals, 09 1) ADMG + CAF CAL, GRD, KTW, MRC, Adequate Unclear Unclear Unclear University‐based (Brazil) and
design, 2 treatment females, aged 21‐46, with at least 2 extended PPD, SCRC/PCR author contacted to provide
groups, 6 mo bilateral Miller Class I or II buccal 2) ADMG + CAF (Automated controlled further details from the trial
duration gingival recessions of at least 3 mm force periodontal probe)
A total of 32 defects were treated (16
per group)

Bittencourt RCT, split‐mouth 17 nonsmoking individuals, 11 1) Semilunar CAF ACC, CAL, GRD, GRW, Adequate Unclear Yes Unclear University‐based (Brazil),
et al22,23 design, 2 treatment females, aged 21‐52, with two 2) SCTG KTT, KTW, MRC, PPD, supported by the State of São
groups, 30 mo bilateral Miller Class I maxillary RH, SCRC/PCR Paulo Research Foundation
duration buccal gingival recessions of at least (Manual periodontal (FAPESP) and author contacted
2 mm and ≤ 4 mm probe) to provide further details from
A total of 34 defects were treated (17 the trial
per group)

Castellanos et al30 RCT, parallel design, 22 nonsmoking individuals, 13 1) EMD + CAF GRD, GRW, clinical Inadequate Unclear Unclear High University‐based (Mexico)
2 treatment groups, females, aged 28‐71, with one Miller 2) CAF attachment level,
12 mo duration Class I or II buccal gingival recessions KTW, PI, PPD, MRC
of at least 2 mm (Manual periodontal
A total of 22 defects were treated (11 probe)
per group)

da Silva et al34 RCT, split‐mouth 11 nonsmoking individuals, 5 females, 1) SCTG + CAF CAL, GRD, KTT, KTW, Adequate Unclear No High University‐based (Brazil) and
design, 2 treatment aged 18‐43, with two bilateral Miller 2) CAF MRC, SCRC/PCR author contacted to provide
groups, 6 mo Class I or II maxillary buccal gingival (Automated controlled further details from the trial
duration recessions of at least 3 mm force periodontal probe)
A total of 22 defects were treated (11
per group)

de Queiroz Cortes RCT, split‐mouth 13 nonsmoking individuals, 7 females, 1) ADMG + CAF CAL, GRD, GRW KTT, Adequate Unclear Unclear Unclear University‐based (Brazil)
et al36,37 design, 2 treatment mean age 32.8, with two bilateral 2) CAF KTW, MRC, PPD,
groups, 24 mo Miller Class I maxillary buccal gingival SCRC/PCR (Manual
duration recessions of at least 3 mm periodontal probe)
A total of 26 defects were treated (13
per group)

Felipe et al38 RCT, parallel design, 15 nonsmoking individuals, 6 females, 1) ADMG + CAF ACC, CAL, GRD, KTT, Adequate Unclear Uncleara Unclear University‐based (Brazil) and
2 treatment groups, aged 22‐54, with two bilateral Miller extended KTW, MRC,PPD, SCRC/ supported by the State of São
06 mo duration Class I or II buccal gingival recession 2) ADMG + CAF PCR (Automated Paulo Research Foundation
of at least 2 mm extended modified controlled force (FAPESP)
A total of 30 defects were treated (15 periodontal probe)
per group)
|

(Continues)
97
 98

TABLE 2 (Continued)
|

Method of
Main outcomes random Allocation Blindness of Risk of Site (location), funding and
Study Methods Participants Interventions evaluated ization concealment examiners bias notes

Joly et al50 RCT, split‐mouth 10 nonsmoking individuals, 4 females, 1) ADMG + CAF (flap CAL, GRD, KTT, KTW, Adequate Unclear No High University‐based (Brazil) and
design, 2 treatment aged 24‐68, with two bilateral Miller without vertical MRC, PPD (Manual author contacted to provide
groups, 6 mo Class I or II maxillary buccal gingival incisions) probe) further details from the trial
duration recessions of at least 3 mm 2) SCTG + CAF (flap
A total of 20 defects were treated (10 without vertical
per group) incisions)

Lins et al53 RCT, parallel design, 10 nonsmoking individuals, 4 females, 1) GTR (ePTFE) + CAF CAL, GRD, KTT, KTW, Unclear Unclear Unclear Unclear University‐based (Brazil)
2 treatment groups, aged 22‐55, with 2 bilateral Miller 2) CAF MRC, PPD, SCRC/PCR,
6 mo duration Class I or II maxillary buccal gingival (Manual probe)
recessions of at least 2 mm
A total of 20 defects were treated (10
per group)

Lucchesi et al54 RCT, split‐mouth 59 nonsmoking individuals, 44 1) CAF (20 defects CAL, GRD, KTT, KTW, Adequate Unclear Yes (regarding Unclear University‐based (Brazil) and
design, 3 treatment females, aged 23‐65, with one Miller without NCCL) MRC, PPD, SCRC/PCR, restorative author contacted to provide
groups, 6 mo Class I maxillary buccal gingival 2) CAF + RMGI (20 (Manual probe) materials) further details from the trial
duration recession of at least ≥ 2 mm and defects with NCCL)
≤ 5 mm 3) CAF + RCR (19
A total of 59 defects were treated (2 defects with NCCL)
groups of 20 and one of 19 defects)

Nazareth & Cury62 RCT, split‐mouth 15 nonsmoking individuals, 6 females, 1) ABN/P‐15 + CAF CAL, GRD,KTT, KTW, Adequate Unclear Yes Unclear Practice‐based (Brazil) and
design, 2 treatment aged 22‐47, with two bilateral Miller 2) CAF MRC, PPD, SCRC/PCR, author contacted to provide
groups, 6 mo Class I maxillary buccal gingival (Manual probe) further details from the trial
duration recessions of at least 2 mm
A total of 30 defects were treated (15
per group)

Novaes et al64 RCT, split‐mouth 9 nonsmoking individuals, 7 females, 1) ADMG + CAF CAL, GRD, KTW, MRC, Unclear Unclear Unclear Unclear University‐based (Brazil) and
design, 2 treatment aged 23‐53, with at least two Miller 2) SCTG + CAF PPD, SCRC/PCR supported by Promodent Ltd.,
groups, 6 mo Class I or III buccal gingival (Automated controlled São Paulo, BR
duration recessions force periodontal probe)
A total of 30 defects were treated (15
per group)

Rossetti et al73 RCT, split‐mouth 1 1) GTR (collagen ACC, CAL, GRD, KTW, Unclear Unclear Yes Unclear University/hospital‐based (Brazil),
design, 2 treatment 2 individuals, 9 females, aged 25‐60, membrane) + TTC‐ MRC, PPD, SCRC/PCR supported by the Brazilian
groups, 18 mo with tw bilateral Miller Class I or II HCl + DFDBA (Manual probe) National Council for Scientific
duration maxillary buccal gingival recessions 2) SCTG + HCl and Technologic Development
of at least 3 mm (CNPQ) and author contacted
A total of 24 defects were treated (12 to provide further details from
per group) the trial

Santamaria RCT, split‐mouth 19 nonsmoking individuals, 10 1) CAF CAL, GRD, KTT, KTW, Adequate Unclear No High University‐based (Brazil) and
et al75,76 design, 2 treatment females, aged 24‐58, with bilateral 2) CAF + RMGI MRC, PPD, SCRC/PCR, supported by the State of São
groups, 24 mo Miller Class I maxillary buccal gingival (Manual probe) Paulo Research Foundation
duration recessions (FAPESP)
A total of 38 defects associated to
NCCL were treated (19 per group)
CHAMBRONE

(Continues)
ET AL.
TABLE 2 (Continued)
Method of
Main outcomes random Allocation Blindness of Risk of Site (location), funding and
Study Methods Participants Interventions evaluated ization concealment examiners bias notes
CHAMBRONE

Santamaria et al74 RCT, parallel design, 40 nonsmoking individuals, 19 1) SCTG CAL, GRD, KTT, KTW, Adequate Unclear No High University‐based (Brazil)
ET AL.

2 treatment groups, females, aged 19‐71, with one Miller 2) SCTG + RMGI MRC, PPD, SCRC/PCR,
06 mo duration Class I maxillary buccal gingival (Manual probe)
recession
A total of 40 defects associated to
NCCLs were treated (20 per group)

Santana et al77 RCT, parallel 36 nonsmoking individuals, 26 1) LPF CAL, GRD, KTW, MRC, Adequate Unclear Yes Unclear University‐based (Brazil)
design, 2 treatment females, mean age 34 years, with 2) CAF PPD, SCRC/PCR,
groups, 6 mo one Miller Class I maxillary buccal (Manual probe)
duration gingival recession

Santana et al78 RCT, split‐mouth 22 nonsmoking individuals, 13 1) Semilunar CAF CAL, GRD, KTW, MRC, Adequate Unclear Yes Unclear University‐based (Brazil)
design, two females, aged 18 to 47 years, with 2 2) CAF PPD, SCRC/PCR
treatment groups, bilateral maxillary Miller Class I (Manual probe)
06 mo duration buccal gingival recessions (≤5 mm)
125
Andrade et al. RCT, split‐mouth 15 nonsmoking individuals, six 1) ADMG + CAF without CAL, GRD, KTT, KTW, Adequate Unclear Yes Unclear University‐based (Brazil) and
design, 2 treatment females, aged 20 to 56 years, with vertical incisions MRC, PPD, SCRC/PCR supported by the State of São
groups, 12 mo two bilateral Miller Class I or II 2) ADMG + CAF (Automated controlled Paulo Research Foundation
duration buccal gingival recessions of at least (extended flap) force probe and (FAPESP) and Coordination for
2 mm compass) the Development of Personnel
A total of 30 defects were treated (15 in Higher Education (CAPES)
per group)
126
Ayub et al. RCT, split‐mouth 15 nonsmoking individuals, number of 1) ADMG (positioned 1 CAL, GRD, KTT, KTW, Adequate Adequate No High University‐based (Brazil) and
design, 2 treatment females not reported, aged 20 to 56 mm apical to the MRC, PPD, SCRC/PCR supported by the State of São
groups, 6 mo years, with two bilateral Miller Class cemento‐enamel (Automated controlled Paulo Research Foundation
duration I or II buccal gingival recessions of at junction) + CAF force probe and digital (FAPESP) and BioHorizons Inc
least 3 mm (extended flap) 2) caliper)
A total of 30 defects were treated (15 ADMG + CAF
per group) (extended flap)

Bittencourt et al. RCT, parallel design, 24 nonsmoking individuals, 11 1) EMD + CAF CAL, GRD, GRW, KTT, Adequate Unclear Yes Unclear University‐based (Brazil) and
121
2 treatment groups, females, aged 18‐55‐44, with two (macrosurgery) KTW, MRC, PPD, supported by the Research
06 mo duration bilaterl Miller Class I or II buccal 2) EMD + CAF SCRC/PCR (Manual Funding Agency of Bahia State
gingival recession of at least 2 mm (microsurgery) probe and digital
A total of 24 defects were treated (12 caliper)
per group)

Fernades‐Dias RCT, parallel design, 40 nonsmoking individuals, 20 1) Low‐level laser ACC, CAL, GRD, KTW, Adequate Adequte Yes Low University based (Brazil) and
et al.122/ 2 treatment groups, females, mean age 40.5 years, with therapy + SCTG + CAF KTT, MRC, PPD, RH, supported by the State of São
Santamaria 24 mo duration one maxillary Miller Class I or II 2) SCTG + CAF SCRC/PCR (Manual Paulo Research Foundation
et al.120 buccal gingival recession of at least probe and digital (FAPESP)
2 mm caliper)
A total of 40 defects were treated (20
per group) All patients completed the
6 mo evaluation, whereas 36 the
24 mo follow‐up

(Continues)
|
99
100 | CHAMBRONE ET AL.

depth.2,3,5–9 However, some patients may present, together with

ABN/P‐15, anorganic bone mineral/cell binding peptide; ACC, aesthetic condition change; ADMG, acellular dermal matrix graft; CAF, coronally advanced flap; CAL, clinical attachment level; DFDBA, deminer-

KTT, keratinized tissue thickness; KTW, keratinized tissue width; LPF, laterally positioned flap; MRC, mean root coverage; NCCL, noncarious cervical lesion; POPain, level of pain recorded 1 wk after sur-
gery; RCR, resin composite restoration; RCT, randomized controlled trial; RH, root hypersensitivity; RMGI, resin‐modified glass ionommer; SCRC/PCR, sites with complete root coverage/percentage of com-
alized freeze‐dried bone allograft; EMD, enamel matrix derivative; ePTFE, expanded polytetrafluorethylene; GRD, gingival recession depth; GRW, gingival recession width; GTR, guided tissue regeneration;
supported by the State of São

supported by the State of São

gingival recession, noncarious cervical lesions.54,74–76 Noncarious

Paulo Research Foundation

Paulo Research Foundation

University based (Brazil) and

University based (Brazil) and

Site (location), funding and
cervical lesions are characterized by the loss of mineral structures
(root cementum and dentin) and the formation of lesion‐shaped
concavities.56,76–78 The different conditions associated with trau-
matic toothbrushing (ie, abrasion), occlusion (ie, abfraction), and
(FAPESP)

(FAPESP)
dietary habits (ie, erosion) can cause noncarious cervical
notes

54,74–76,127
lesions.
Despite the possibility of restoring these defects with resin‐
Risk of

Low

Low
bias

modified glass ionomer cements or resin composites, the length

Despite ACC being conducted by two dentists unaware of the surgical procedures performed, blinding of examiners regarding the clinical outcomes was not reported.
of the exposed root surface can prevent adequate improvement
of the esthetic condition.54 Also, because the original position of
Blindness of
examiners

the gingival margin will not be reestablished when restorative pro-

cedures are used alone, a possible disequilibrium of the entire
Yes

Yes

gingival complex may occur (owing to the lack of symmetry with

concealment

adjacent teeth). In previous studies, the outcomes of the combina-

Allocation

Adequate

Adequate

tion of restorative procedures and periodontal plastic surgery

used to treat recession‐type defects associated with noncarious
cervical lesions were assessed.54,74–76,127 Literature searching for
Method of

Adequate

Adequate
random

the series of systematic reviews conducted by our group (includ-

ization

ing for the preparation of the current review), found only three
randomized controlled trials (two randomized controlled trials con-
ACC, CAL, GRD, KTW,

ACC, CAL, GRD, KTW,

ducted by Santamaria et al74–76,127 was reported in two papers)

KTT, MRC, PPD, RH,

KTT, MRC, PPD, RH,

SCRC/PCR (Manual

SCRC/PCR (Manual
probe and digital

probe and digital

comparing the treatment of such lesions with root coverage pro-

Main outcomes

cedures alone or associated to restorative procedure, all of which

evaluated

were conducted in Latin American research centers.54,74–76,127

caliper)

caliper)

Therefore, it was decided to carry out individual patient data

meta‐analyses to establish the influence of conventional restora-
2) SCTG + CAF (Tunnel)
3) XCM + EMD + CAF

tive procedures, type of restorative material, and periodontal plas-

tic surgery procedure on achievement of complete root coverage.
1) SCTG + CAF
1) XCM + CAF
2) EMD + CAF
Interventions

Individual patient data meta‐analyses were undertaken using

mixed‐effects logistic regression using the command for logistic
4) CAF

regression in the statistical software package (NCSS 2007; Num-

ber Cruncher Statistical System, Kaysville, UT, USA). The statistical
68 nonsmoking individuals, aged 18 to

A total of 68 defects were treated (17

with one maxillary Miller Class I or II

Class I or II buccal gingival recession

program used individual data reported by each included trial to

buccal gingival recession of at least
60 years, with one maxillary Miller

A total of 42 defects were treated

27 females, aged 24 to 59 years,

evaluate the association between the periodontal plastic surgery

procedure used to treat gingival recession, the type of restorative
plete root coverage; SCTG, subepithelial connective tissue graft.
42 nonsmoking individuals,

material (if used), and complete root coverage. The binary depen-
dent variable was complete root coverage (yes was coded as 1
of at least 3 mm

(21 per group)

and no was coded as 0), and the independent variables were use
Participants

per group)

of restorative procedures (as part of surgical therapy), the type of

2 mm

restorative material (resin‐modified glass ionomer cement or resin

composite), and periodontal plastic surgery procedure (subepithe-
4 treatment groups,

2 treatment groups,
RCT, parallel design,

RCT, parallel design,

lial connective tissue grafts or coronally advanced flaps). Analyses

6 mo duration

6 mo duration

were conducted taking into consideration the outcomes after a 6‐

month follow‐up period, and values of P < 0.05 were considered
Methods
(Continued)

statistically significant.
Table 3 shows the findings of the meta‐analysis performed. It
Sangiorgio et al.119/

was found that restored noncarious cervical lesions showed similar

Santamaria et al.124
Rocha dos Santos

outcomes in terms of complete root coverage when compared with

TABLE 2

nonrestored noncarious cervical lesions. The use of periodontal

et al.123
Study

plastic surgery procedures (either alone or combined with resin‐

modified glass ionomer cement or resin composite restorations)
a
CHAMBRONE ET AL. | 101

T A B L E 3 Mixed‐effects logistic regression analysis estimating the
association between complete root coverage and receipt site
characteristics
OR SE z P > |z| 95% CI
Type of PPS 0.21 0.81 −1.91 0.05 −3.15 to 0.03
procedure (SCTG)
PPS associated with 1.41 0.83 0.41 0.67 −1.29 to 1.99
restoration (no.)
Restorative 0.28 0.86 −1.47 0.14 −2.96 to 0.42
material (RCR)
95% CI, 95% confidence interval; OR, odds ratio; PPS, periodontal plastic
surgery; RCR, resin composite restoration; SCTG, subepithelial connective
tissue graft; SE, standard error; z, Wald z‐value.
achieved comparable results 6 months following surgical proce-
dures. However, there was a trend for better outcomes (ie, com-
plete root coverage) when subepithelial connective tissue grafts
were the periodontal plastic surgery procedure of choice (odds
ratio = 0.21, P = 0.05).
7 | DISCUSSION
Serious appraisal of the base of evidence for health promotion
requires use of a structured sequence of criteria to retrieve and
extract the best pool of information. The overall outcomes reported
by the available systematic reviews on periodontal plastic surgery
clearly, adequately, and positively were able to translate the signifi-
cance of these procedures for daily practice, and able to enlighten
the limitations to be considered in future research.
It is important to consider that systematic reviews are planned
to recognize, appraise, and combine information from clinical trials to
provide evidence‐based responses and alternatives to clinical
8,89,90,105
research problems. Queries linked to development of the
clinical decision‐making process, estimation of the value of treatment
modalities, and assessment of disparities in daily practice, as well as
aspects evidencing the need for further research, may encourage
105
researchers to write a systematic review. As a result, these issues
can provide important scientific bases of information for clinicians
because they identify current knowledge (ie, what is known and
what should be studied in future randomized controlled trials).105
In order to increase such a base of evidence, well‐designed ran-
domized controlled trials aid in assembling suitable health care deci-
sions, provided that such trials clearly and entirely describe their
aims, methodology (ie, inclusion criteria, study population, interven-
tions, and statistical analysis), results, agreements and disagreements
8,89,90,105
with previous studies, and conclusions. Regarding the Latin
American randomized controlled trials included in this review, most
adequately fulfilled these criteria. However, and inherent to such a
study design, some limitations may be found, independently of the
location/country in which a randomized controlled trial is performed.
Consequently, the aim of systematic overview studies (like the pre-
sent) is not just to mention the Latin American studies (or arbitrarily
attribute risk of bias to them), but to identify the central points that
could not have been adequately reported in the papers. Moreover, it
should be taken into consideration that differences between the
included randomized controlled trials may occur because such trials
cannot always illustrate how the study was actually conducted,
rather only what has been published in the final paper(s).8 As a
result, an evident complexity in interpreting their outcomes strength-
ens the condition that a randomized controlled trial has to report as
completely as possible (and in a transparent manner) the main crite-
ria employed in the preparation of its research protocol. As such, it
will provide the clinicians and experts who read it the opportunity to
understand and distinguish what has been achieved.8
Accordingly, it is desirable that future randomized controlled tri-
als should present their individual patient data. It has been shown by
one of the included systematic reviews that meta‐analyses of indi-
vidual patient data can fully investigate, adjust, and assess the signif-
icance of individual, baseline, and patient/site‐level characteristics,9
as well as avoid some forms of publication bias (they permit pooling
of estimates using data from trials that could not be included in pair-
wise meta‐analysis), and some of the problems caused by the use of
meta‐analyses containing aggregated patient data (eg, issues that are
not always able to prevent bias related to randomized controlled tri-
als design). Conversely, it may also be deemed that systematic
reviews on individual patient data alike conventional systematic
reviews, are also liable to bias because they depend on the amount
of data retrieved for analysis, the researchers who conducted the
individual randomized controlled trials (free access to their study
data), human resources (trained review teams), costs, and time.9
It is also desirable that the research protocols for both random-
ized controlled trials and systematic reviews are registered at inter-
national databases of prospectively registered protocols (eg,
Clinicaltrials.gov, CENTRAL, or PROSPERO). Protocol registers can
control for bias, offer transparency in the clinical and review pro-
cesses, increase quality, and improve confidence that the outcomes
of these types of study are indeed derived from the best quality
methodology available. Furthermore, PROSPERO assists in counter-
ing publication bias by providing a permanent record of prospec-
tively registered protocols, it protects against reporting biases by
revealing any divergences between the procedures or outcome mea-
sures reported in the final publications and those planned in the reg-
istered protocols, and it allows those commissioning or planning
future studies to identify whether there are any studies already
ongoing that address their subject of interest.9
In the present overview, it could be seen that within randomized
controlled trials and systematic reviews, patient selection was based
on esthetic and/or functional conditions, and treatment was intended
to prevent continuing development of soft (gingival recession) or hard
(root abrasion or caries) tissue defects. Consequently, patients’ con-
cerns must be carefully assessed before any periodontal plastic sur-
gery technique is planned, with meticulous attention to whether it is
possible to accomplish the patient's desires using the proposed treat-
ment modality.3,4,6–9 Moreover, recent evidence indicates that over
the last two decades improvements on surgical instruments, flap
preparation and suture refelected positvely on root coverage achieved
102 | CHAMBRONE ET AL.

by most of periodontal plastic surgical procedures at short‐term (ie. 6

to 12 months after treatment).128 Conversely, at long‐term (>5 years
follow‐up) other recent long‐term studies showed that the width of Keratinized tissue
width gain
attached keratinized tissue (at least 2 mm) promotes better stability of subepithelial connective
the gingival margin and may prevent gingival recession relapse.129–131 tissue grafts
In general terms “subepitheial connective tissue graft‐based proce-
dures might be selected to treat any kind of recession, but their cur- Keratinized tissue
thickness gain
rent/recent indications also suggest that selective approaches could be
(matrix grafts and
preferable to prevent some sort of overtreatment”.128 Thus, selection SCTG)
of the most appropriate procedure for each recession defect will guar-
antee that patients’ individual needs and complaints will certainly be
addressed (leading to the best esthetic and functional outcomes).
In addition, and as reported throughout the text, the primary Root coverage
objectives of the periodontal plastic surgery procedures are to Clinical attachment
level gain and
improve patients’ esthetic/sensitivity conditions and other clinical out-
decrease of root
comes (eg, clinical attachment level and width of keratinized tissue) hypersensitivity
through the coverage of previously denuded root surfaces. It must be all root coverage
taken into consideration that the selection of one periodontal plastic procedures

surgery procedure over any other for the treatment of recession‐type

defects is also based on an assortment of conditions (ie, anatomy and
F I G U R E 1 0 Implications for clinical practice based on the
location of the defect, availability of keratinized tissue adjacent to the
outcomes and concepts of evidence‐based periodontal plastic surgery
defect, the number of adjacent teeth to be treated, donor site, profes-
alone or associated with guided tissue regeneration, may be used
sional's skills and experience, patients’ preference for a specific peri-
(preferably in that order) (Figure 10). For noncarious cervical lesions,
odontal plastic surgery procedure, and the occurrence of early
the association of restorative procedures and either subepithelial
discomfort, with or without pain related to donor sites of subepithelial
connective tissue grafts or coronally advanced flaps can also achieve
connective tissue grafts because of the size of the donor area, and
similar statistically significant outcomes, but subepithelial connective
the surgical approach used to obtain the graft from the palate). As a
tissue grafts showed a trend of better outcomes.
result, all these factors, together with the best evidence available,
On the other hand, professionals and patients can present differ-
should be evaluated as part of the decision‐making process. These
ent views regarding the procedures performed and the results
conditions will guide and assist clinicians and researchers in exploring
achieved. Therefore, and given the common occurrence and esthetic/
and translating the treatment options with the greatest efficacy to the
functional conditions associated with recession‐type defects, the
clinical decisions that are most effective.
triad that orients the concepts of evidence‐based dentistry (ie, best
evidence available, clinician's knowledge, and patient's preferences),
site‐related factors (ie, recession depth and width, clinical attachment
8 | CONCLUDING REMARKS
level, and amount of keratinized tissue), patient‐centered variables
(ie, postoperative complications, adverse effects, tactile/thermal
The translation of research findings to clinical practice is based on
hypersensitivity of the tooth, and changes in the level of sociability
critical assessments of the evidence available and it represents the
after esthetic surgery), and professional‐based conditions (ie, scien-
main tool in the decision‐making process. The results from the set of
tific knowledge, clinical skills, and experience), also need to be con-
systematic reviews included in this review reported that, regardless
sidered for the selection of a periodontal plastic surgery procedure.
of the periodontal plastic surgery procedure used to achieve root
coverage, all can lead to statistically significant improvements in ini-
tial clinical parameters, regardless of the technique. However, the ACKNOWLEDGEMENT
base of evidence also showed that subepithelial connective tissue
We are grateful to Dr Francisco Salvador Garcia Valenzuela for his
graft procedures should be considered as the gold standard (that is,
significant assistance in updating the information in this paper.
the procedure of first choice) when planning a treatment involving
the coverage of exposed roots, because of their better predictability
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How to cite this article: Chambrone L, de Castro Pinto RCN,
Chambrone LA. The concepts of evidence‐based periodontal
plastic surgery: Application of the principles of evidence‐
based dentistry for the treatment of recession‐type defects.
Periodontol 2000. 2019;79:81–106. https://doi.org/10.1111/
prd.12248