Cairo 2008

J Clin Periodontol 2008; 35 (Suppl. 8): 136–162 doi: 10.1111/j.1600-051X.2008.01267.
Treatment of gingival recession Francesco Cairo, Umberto Pagliaro

and Michele Nieri
Department of Periodontology, University of
with coronally advanced flap Florence, Florence, Italy
procedures: a systematic review

Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally
advanced flap procedures: a systematic review. J Clin Periodontol 2008; 35
(Suppl. 8): 136–162. doi: 10.1111/j.1600-051X.2008.01267.x.
Abstract
Background: The treatment of buccal gingival recessions is a common requirement
due to aesthetic concern or root sensitivity. The aim of this manuscript was to
systematically review the literature on coronally advanced flap (CAF) alone or in
combination with tissue grafts, barrier membranes (BM), enamel matrix derivative
(EMD) or other material for treating gingival recession.
Material and Methods: Randomized clinical trials on treatment of Miller Class I and
II gingival recessions with at least 6 months of follow-up were identified. Data sources
included electronic databases and hand-searched journals. The primary outcome
variable was complete root coverage (CRC). The secondary outcome variables were
recession reduction, clinical attachment gain, keratinized tissue gain, aesthetic
satisfaction, root sensitivity, post-operative patient pain and complications.
Results: A total of 794 Miller Class I and II gingival recessions in 530 patients from
25 RCTs were evaluated in this systematic review. CAF was associated with mean
recession reduction and CRC. The addition of connective tissue graft (CTG) or EMD Key words: complete root coverage; coronally
advanced flap; gingival recession;
enhanced the clinical outcomes of CAF in terms of CRC, while BM did not. The muco-gingival surgery; root coverage;
results with respect to the adjunctive use of acellular dermal matrix were controversial. systematic review
Conclusions: CTG or EMD in conjunction with CAF enhances the probability of
obtaining CRC in Miller Class I and II single gingival recessions. Accepted for publication 20 May 2008
The treatment of buccal gingival reces- good appearance related to adjacent soft root conditioning was detected (Roccuz-
sion is a common requirement due to tissues and minimal probing depth (PD) zo et al. 2002, Cheng et al. 2007). An
aesthetic concern or root sensitivity in (Miller 1985, Roccuzzo et al. 2002, earlier European Federation of Perio-
patients with high standards of oral Clauser et al. 2003). Previous systematic dontology Systematic Review on root
hygiene (American Academy of Perio- reviews showed that several surgical coverage (Roccuzzo et al. 2002)
dontology 1996). The ultimate goal of a procedures such as pedicle flaps, free reported that complete root coverage
root coverage procedure is the complete soft tissue grafts, combinations of pedi- (CRC) and mean percentage of root
coverage of the recession defect with cle flaps and grafts or barrier mem- coverage varied considerably between
branes (BM) may be indicated to studies comparing the same techniques.
improve the coronal level of the gingival The coronally advanced flap (CAF)
Conflict of interest and source of margin on the root surface (Roccuzzo et procedure is a very common approach
funding statement al. 2002, Clauser et al. 2003, Oates et al. for root coverage. This procedure is
The Authors declare that they have no 2003), even if very limited data for based on the coronal shift of the soft
conflict of interests. epithelialized free gingival graft and tissues on the exposed root surface
This study has been self-funded by the laterally positioned flap are available (Allen & Miller 1989, Pini Prato et al.
authors and their institutions. (Roccuzzo et al. 2002). In addition, no 2000). This approach may be used alone
The 6th European Workshop on Perio- difference between resorbable and non- or in combination with soft tissue grafts
dontology was supported by an unrest- resorbable barriers in terms of mean root (Wennström & Zucchelli 1996), BM
ricted educational grant from Straumann coverage was reported (Roccuzzo et al. (Pini Prato et al. 1992), enamel matrix
AG.
2002) and no clinical benefit following derivative (EMD) (Rasperini et al.
136 r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
Systematic review of root coverage procedures 137
2000), acellular dermal matrix (ADM) References from AAP position paper CAF1CTG versus CAF1BM,
(Harris 1998), platelet-rich plasma (American Academy of Periodontology CAF1CTG versus CAF1EMD,
(PRP) (Marx et al. 1998) and living 1996), EFP review article (Wennström CAF1CTG versus CAF1ADM,
tissue-engineered human fibroblast- 1994) and previous systematic reviews CAF1CTG versus CAF1PRP,
derived dermal substitute (HF-DDS) dealing with root coverage procedures CAF1CTG versus CAF1HF-
(Wilson et al. 2005). (Greenwell et al. 2000, Roccuzzo et al. DDS,
The purpose of this systematic review 2002, Oates et al. 2003, Clauser et al. CAF1BM versus CAF1EMD,
was to answer the following question: 2003, Al-Hamdan et al. 2003, Gapski et CAF1BM versus CAF1ADM,
‘‘What is the clinical benefit of adding al. 2005, Hwang & Wang 2006, Cheng CAF1BM versus CAF1PRP,
to the CAF procedure: connective tissue et al. 2007) were checked for article CAF1BM versus CAF1HF-DDS,
graft (CTG) or BM or EMD or ADM or identification. CAF1EMD versus CAF1ADM,
PRP or living tissue-engineered HF- In addition, all authors of the identi- CAF1EMD versus CAF1PRP,
DDS in the treatment of Miller Class I fied studies, clinical experts or research- CAF1EMD versus CAF1HF-
and II localized gingival recessions?’’ ers in the field of mucogingival surgery DDS,
were contacted in an attempt to identify CAF1ADM versus CAF1PRP,
unpublished data or studies not yet CAF1ADM versus CAF1HF-
published. DDS,
Material and Methods CAF1PRP versus CAF1HF-DDS.
This systematic review was conducted
Selection (O) Type of outcome measures
according to the QUOROM statement
instruments for systematic reviews The criteria for considering studies for The following outcome measures
(Moher et al. 1999). this review were organized by the PICO were considered:
In this systematic review, only rando- method (Glossary of Evidence-Based
mized-controlled clinical trials (RCTs), Terms 2007) and were follows: Primary outcome
including a split-mouth model, of at least (P) Types of participants
6 months’ duration were considered. Patients with a clinical diagnosis of
Miller Class I or II localized gingival Recession defects that obtained
recession defect. CRC.
Searching
(I) Types of interventions
For the identification of the studies The following surgical procedures for
the treatment of single recessions were Secondary outcomes
investigated in this review and pub-
lished until December 1999, the register considered:
of clinical studies published in previous Change in gingival recession
systematic reviews (Pagliaro et al. 2003, CAF, expressed as recession reduction in
Clauser et al. 2003) was consulted. CAF plus CTG (CAF1CTG), mm at follow-up visit (RecRed),
For the identification of studies con- CAF plus Barrier Membrane Change in clinical attachment level
sidered for this review and published (CAF1BM), (CAL) expressed as CAL gain in
from January 2000 to August 2007, a CAF plus EMD (CAF1EMD), millimetres at follow-up visit
search was performed using two elec- CAF plus ADM (CAF1ADM), (CAL gain),
tronic evidence sources: CAF plus PRP (CAF1PRP), Change in width of keratinized tis-
CAF plus HF-DDS (CAF1HF- sue (KT) expressed as KT gain in
1. The National Library of Medicine DDS). millimetres at follow-up visit (KT
(MEDLINE by PubMed), on gain),
RCTs comparing CAF with multiple
07.09.2007, using the strategy: Biological complications during the
(‘‘Gingival Recession/surgery’’ combinations (i.e. CAF1CTG1EMD,
post-operative healing period (Com-
[Mesh] OR ‘‘Gingival Recession/ CAF1BM1CTG, CAF1 BM1EMD,
plications),
etc.) or RCTs comparing variations of
therapy’’ [Mesh]) AND ((Humans Patient discomfort during the post-
[Mesh]) AND (Randomized Con- the same technique (i.e. CAF with
operative healing period (Post-
trolled Trial[ptyp])); releasing incisions versus CAF without
operative pain),
releasing incisions) were excluded from
2. The Cochrane Oral Health Group Patient preference in terms of aes-
Trials Register, on 07.09.2007, using the systematic review.
thetic result at follow-up visit (Aes-
the following strategy: ‘‘Gingival (C) Comparison between interven-
thetic satisfaction),
tions
Recession’’ [Search All Text] AND Patient perception of root sensitivity
‘‘Root Coverage’’ [Search All Text]. The following comparisons between
at follow-up visit (Root sensitivity).
the selected techniques were investi-
There was no language restriction. gated:
Hand searching included a complete Validity assessment
search of Journal of Clinical Perio- CAF versus CAF1CTG,
dontology, Journal of Periodontology, CAF versus CAF1BM, The quality assessment of the included
Journal of Periodontal Research, Inter- CAF versus CAF1EMD, trials was independently performed and
national Journal of Periodontics and CAF versus CAF1ADM, in duplicate form by two review authors
Restorative Dentistry and PERIO from CAF versus CAF1PRP, (F. C. and U. P.). According to the
January 2000 up to August 2007. CAF versus CAF1HF-DDS, Cochrane Handbook Systematic Review
r 2008 The Authors
138 Cairo et al.
of Interventions 4.3.6. (section 6.3) electronic and manual searches were tion and Root sensitivity had to be
(Higgins & Green 2006), three main screened independently by two review described at least in a narrative form.
quality criteria were examined: alloca- authors (F. C. and U. P.). When studies
tion concealment, blinding treatment met the inclusion criteria or when insuf-
Quantitative data synthesis
outcomes to outcome assessors and ficient data from abstracts to evaluate
completeness of follow-up. inclusion criteria were gained, the full For dichotomous outcomes (CRC), the
article was obtained. The full text of all estimates of effect of an intervention
1) Allocation concealment was consid- studies of possible relevance was inde- were expressed as odds ratios (OR)
ered adequate, inadequate or pendently assessed by two review together with 95% confidence intervals
unclear. Ideally, the surgeon should authors (F. C and U. P.). All studies (CI). For continuous outcomes, mean
have known the allocation group just meeting the inclusion criteria then differences and standard deviations
before the treatment was delivered. underwent quality assessment and data were used to summarize the data from
AC was considered as adequate recording. When there was disagree- each group. In each patient only one site
when it was centralized (allocation ment between the two reviewers, con- for each technique was permitted. When
by a central office unaware of sub- sensus was achieved by discussion with individual patient data (IPD) were avail-
jects’ characteristics). AC was con- the third reviewer/statistical advisor (M. able, multiple sites treated with the same
sidered as adequate when pre- N.). Then data were independently technique in the same patient were
numbered or coded identical contain- extracted and entered into a computer eliminated.
ers were serially administered to by two review authors (F. C and U. P.) OR were combined for dichotomous
participants; when there was an on- using specifically designed data-collec- data and mean differences for continu-
site computer system combined with tion forms. Patient characteristics, treat- ous data using a random-effect model.
allocation kept in a locked unread- ments, clinical outcomes, complications Data from split-mouth studies were
able computer file that could be and study quality were systematically combined with data from parallel group
accessed only after the characteris- registered. When clinical data on CRC trials with the method outlined by
tics of an enrolled patient had been were lacking, authors of the trials were Elbourne et al. (2002), using the generic
entered; when numbers in closed contacted. inverse variance method in the RevMan.
envelopes opened before the surgical When several articles reporting dif- The techniques described by Follmann
procedure were used; when coin flip ferent follow-up durations were pub- et al. (1992) were used to calculate the
was used before surgical treatment. lished for the same study population, standard error of the difference for split-
AC was considered as inadequate the longest follow-up duration article mouth studies, where the appropriate
when any procedure was entirely was considered, but if the number of data were not presented.
transparent before the treatment was withdrawals and drop-outs were X 30% The significance of any discrepancies
delivered. When details of AC were of the original sample, the previous in the estimates of the treatment effects
not provided, it was coded as article with a shorter follow-up was from different trials was assessed by
unclear. considered. means of Cochran’s test for heterogene-
2) Treatment blind to outcomes asses- ity and the I2 statistic, which describes
sors (TB) was recorded as yes, no, Study characteristics the percentage total variation across
unclear and not possible. studies that is due to heterogeneity
3) Completeness of follow-up (CF): a Only RCTs, with or without a split- rather than change. It was planned to
clear explanation for drop-outs in mouth design, were included in the undertake sensitivity analyses to exam-
each treatment group was searched systematic review. ine the effect of the study quality for
in the manuscript. CF was evaluated Eligible RCTs, with a follow-up dura- CRC.
as no drop-outs/yes when authors tion X6 months, had to compare the
specified that no drop-outs were results of at least 2 of the investigated
detected or when authors specified surgical techniques in patients with Results
the numbers of drop-outs and related Miller Class I or II gingival recession Searching results
reasons. CF was evaluated as no defects.
when no information on complete- CRC had to be expressed as the The search results are presented in
ness of follow-up was provided. number or the percentage of treated Fig. 1.
teeth of each considered study arm that The register of clinical studies pub-
After quality assessment, studies achieved total root coverage at the fol- lished in previous systematic reviews
were grouped into 2 categories: low-up visit. RecRed had to be (Clauser et al. 2003, Pagliaro et al.
expressed as mean recession reduction 2003) provided 5 articles (Ricci et al.
A) Low risk of bias, if all 3 quality in millimetres of the treated teeth of 1996, Jepsen et al. 1998, Trombelli et al.
criteria were met. each study arm at the follow-up visit. 1998, Zucchelli et al. 1998, Borghetti
B) High risk of bias, if one or more of KT gain had to be expressed as mean et al. 1999) published until December
the 3 quality criteria were not met. KT width increase in millimetres of the 1999 and that met inclusion criteria.
treated teeth of each study arm at the The electronic search in MEDLINE
follow-up visit. CAL gain had to be (by PubMed) and in the Cochrane
Data abstraction
recorded as mean CAL in millimetres Collaboration databases provided, re-
of the treated teeth of each study arm at spectively, 120 and 57 articles published
The titles and abstracts (when available) the follow-up visit. Complications, from January 2000 until August 2007.
of all reports identified through the Post-operative pain, Aesthetic satisfac- Subsequently, after reading all the
r 2008 The Authors
Fig. 1. Literature search process and results.
abstracts, 56 articles (51 PubMed and 50 Table 1. Twenty-five included studies (27 articles)
Cochrane) were selected. Four (Ito et al.
Study Comparison
2000, Kassab et al. 2006, Rahmani &
Lades 2006, Barros et al. 2005) of these da Silva et al. (2004) CAF versus CAF1CTG
56 articles were not published in the Cortellini et al., unpublished data
journals selected for the hand searching Lins et al. (2003) CAF versus CAF1BM
of the present systematic review. Amarante et al. (2000), Leknes et al. (2005)
The hand searching found 47 articles Modica et al. (2000) CAF versus CAF1EMD
Spahr et al. (2005)
and 5 of these were not found by the
Del Pizzo et al. (2005)
electronic search. Castellanos et al. (2006)
The search of the ‘‘grey literature’’ Pilloni et al. (2006)
(unpublished data) by e-mail contact Woodyard et al. (2004) CAF versus CAF1ADM
with all the authors of the identified Côrtes et al. (2004, 2006)
studies and clinical experts or research- Huang et al. (2005) CAF versus CAF1PRP
ers in the field of mucogingival surgery Zucchelli et al. (1998) CAF1CTG versus CAF1BM
provided the complete data of 1 trial Jepsen et al. (1998)
Trombelli et al. (1998)
(Cortellini et al., unpublished data).
Borghetti et al. (1999)
Finally, by crossing the literature Tatakis & Trombelli (2000)
searches (electronic, manual and unpub- Romagna-Genon (2001)
lished data searches) we were able to Wang et al. (2001)
select 66 articles (5 articles published McGuire & Nunn (2003) CAF1 CTG versus CAF1EMD
until December 1999 and 61 articles Aichelmann-Reidy et al. (2001) CAF1CTG versus CAF1ADM
published from January 2000 to August Paolantonio et al. (2002)
2007) and 1 still unpublished study. Tal et al. (2002)
Joly et al. (2007)
The full text reading of the 67 articles Wilson et al. (2005) CAF1CTG versus CAF1HF-DDS
(5 by register 1 56 by electronic search
1 5 by hand-search 1 1 by ‘‘gray CAF, coronally advanced flap; CTG, connective tissue graft; BM, barrier membrane; EMD, enamel
literature’’ search) allowed the selection matrix derivative; ADM, acellular dermal matrix graft; PRP, platelet-rich plasma; HF-DDS, human
of 25 studies (27 reports) (Table 1) that fibroblast-derived dermal substitute.
met the inclusion criteria of this sys-
tematic review and the exclusion of 40 In 3 of the selected clinical studies, 2 and 72-month follow-up) publications
articles from the analysis. Rejected stu- articles with different follow-up dura- were considered to complete data
dies at this stage are listed in Table 2 tions were published. For the first study, recording; for the second study, Häge-
(characteristics of excluded studies) and both Amarante et al. (2000) (6-month wald et al. (2002) publication (12-month
the reason for exclusion was recorded. follow-up) and Leknes et al. (2005) (12- follow-up) was not utilized because the
r 2008 The Authors
140 Cairo et al.
Table 2. Characteristics of the 40 excluded articles 1998, Borghetti et al. 1999, Tatakis
& Trombelli 2000, Romagna-Genon
Study Reason for exclusion
2001, Wang et al. 2001) (Table 8);
Aimetti et al. (2005) Not surgical theraphy CAF1 CTG versus CAF1EMD: 1
Al-Zahrani et al. (2004) Comparison between variations of a same surgical technique study (McGuire & Nunn 2003)
Barros et al. (2004) Comparison between variations of a same surgical technique (Table 9);
Barros et al. (2005) Comparison between variations of a same surgical technique CAF1CTG versus CAF1ADM: 4
Barros et al. (2007) Comparison between variations of a same surgical technique studies (Aichelmann-Reidy et al.
Berlucchi et al. (2002) Comparison with a combination of techniques
2001, Paolantonio et al. 2002,
Bertoldi et al. (2007) Not study on root coverage
Bittencourt et al. (2006)Comparison with a surgical techniques not investigated Tal et al. 2002, Joly et al. 2007)
Bittencourt et al. (2007)Surgical techniques not investigated in the present systematic review (Table 10);
Burkhardt & Lang (2005) Surgical techniques not investigated in the present systematic review CAF1CTG versus CAF1HF-DDS: 1
Caffesse et al. (2000) Comparison between variations of a same surgical technique study (Wilson et al. 2005) (Table 11).
Çetiner et al. (2003) More than one treated site for each technique in the same patient
Cheung & Griffin (2004) More than one treated site for each technique in the same patient In the case of Leknes et al. (2005), the
Cueva et al. (2004) Miller Class III gingival recession defects treated article referred to the same pool of
Dodge et al. (2000) Comparison with a combination of techniques
patients as the previous publication
Duval et al. (2000) Comparison with a combination of techniques
Felipe et al. (2007) Comparison between variations of a same surgical technique (Amarante et al. 2000), but reported
Francetti et al. (2005) Comparison not investigated in the present systematic review data with a longer follow-up (12 and
Hägewald et al. (2002) Same pool of patients with a shorter follow-up of an included study 72 months). The 12-month follow-up
in this systematic review data were considered for the comparison
Harris (2000) Not RCT because in the 72-month follow-up data
Harris et al. (2005) Comparison with a surgical techniques not investigated there were 430% drop-outs among the
Henderson et al. (2001) Comparison between variations of a same surgical technique participants.
Ito et al. (2000) Comparison with a surgical techniques not investigated
Kassab et al. (2006) Comparison between variations of a same surgical technique
In the case of Modica et al. (2000), 2
Kimble et al. (2004) Comparison with a combination of techniques of the 12 participants were excluded
Lucchesi et al. (2007) Comparison between variations of a same surgical technique from meta-analyses because they parti-
McGuire & Nunn (2005) Not study on root coverage cipated in a split-mouth study with more
Moses et al. (2006) Not RCT than 1 pair of bilateral gingival reces-
Nemcovsky et al. (2004) Not RCT sions. Hence, IPD of the remaining 10
Novaes et al. (2001) More than one treated site for each technique in the same patient pair of recession defects were reana-
Paolantonio (2002) Comparison not investigated in the present systematic review lysed.
Pini Prato et al. (2000) Comparison between variations of a same surgical technique
Rahmani & Lades (2006) More than one treated site for each technique in the same patient
For all the other possible comparisons
Ricci et al. (1996) Comparison not investigated in the present systematic review investigated in the systematic review, no
Rosetti et al. (2000) Comparison with a combination of techniques eligible study was found.
Shin et al. (2007) Comparison with a combination of techniques Of the 25 included studies, 18 studies
Silva et al. (2006) Not RCT (Jepsen et al. 1998, Trombelli et al.
Tözüm et al. (2005) Comparison between variations of a same surgical technique 1998, Borghetti et al. 1999, Amarante
Trabulsi et al. (2004) Comparison with a combination of techniques et al. 2000, Modica et al. 2000, Tatakis
Zucchelli et al. (2003) Comparison between variations of a same surgical technique & Trombelli 2000, Aichelmann-Reidy
RCT, randomized clinical trial. et al. 2001, Romagna-Genon 2001,
Wang et al. 2001, Tal et al. 2002, Lins
et al. 2003, McGuire & Nunn 2003,
longer duration of the Spahr et al. (2005) CAF versus CAF1CTG: 2 studies Côrtes 2004, 2006, da Silva et al.
publication (24-month follow-up) was (da Silva et al. 2004, Cortellini et al., 2004, Del Pizzo et al. 2005, Leknes
used; for the third study, both Côrtes et unpublished data) (Table 3); et al. 2005, Spahr et al. 2005, Wilson
al. (2006) (24-months follow-up) and CAF versus CAF1BM: 2 studies et al. 2005, Joly et al. 2007) had an
Côrtes et al. (2004) (6-months follow- (3 articles) (Amarante et al. 2000, intra-individual (split-mouth) design,
up) publications were respectively uti- Lins et al. 2003, Leknes et al. 2005) while 7 studies (Zucchelli et al. 1998,
lized for CRC variable analysis and for (Table 4); Paolantonio et al. 2002, Woodyard et al.
all the other variable analyses. CAF versus CAF1EMD: 5 studies 2004, Huang et al. 2005, Castellanos
Only 1 (Joly et al. 2007) of all con- (Modica et al. 2000, Del Pizzo et al. et al. 2006, Pilloni et al. 2006, Cortellini
tacted research groups was able to pro- 2005, Spahr et al. 2005, Castellanos et al., unpublished data) had a parallel
vide additional unpublished data of CRC. et al. 2006, Pilloni et al. 2006) group design.
(Table 5); Two studies (Paolantonio et al. 2002,
Study characteristics CAF versus CAF1ADM: 2 studies Huang et al. 2005) were completely
(3 articles) (Côrtes et al. 2004, 2006, supported by public institutes for
Included studies
Woodyard et al. 2004) (Table 6); research, 1 study (Cortellini et al.
The list of included studies is presented CAF versus CAF1PRP: 1 study unpublished data) was supported by
in Table 1. (Huang et al. 2005) (Table 7); private institutes for reasearch, 9 studies
The 25 selected studies (27 articles) CAF1CTG versus CAF1BM: 7 (Trombelli et al. 1998, Amarante et al.
allowed the following comparisons studies (Jepsen et al. 1998, Trom- 2000, Tatakis & Trombelli 2000,
(Fig. 2): belli et al. 1998, Zucchelli et al. Aichelmann-Reidy et al. 2001, Wang
r 2008 The Authors
2006, Barros et al. 2007, Felipe

et al. 2007, Lucchesi et al. 2007).
7 studies reported comparisons with
a combination of techniques (Dodge
et al. 2000, Duval et al. 2000,
Rosetti et al. 2000, Berlucchi et al.
2002, Kimble et al. 2004, Trabulsi
et al. 2004, Shin et al. 2007).
7 studies reported comparisons with
or between surgical techniques not
investigated in the present systema-
tic review (Ricci et al. 1996, Ito et
al. 2000, Paolantonio 2002, Bur-
khardt & Lang 2005, Harris et al.
2005, Bittencourt et al. 2006, Bit-
tencourt et al. 2007).
1 study was on non-surgical therapy
(Aimetti et al. 2005).
1 study treated Miller Class III gin-
gival recession defects (Cueva et al.
2004).
1 study evaluated different surgical
procedures under an operative
microscope (Francetti et al. 2005).
4 studies were not RCTs (Harris
2000, Nemcovsky et al. 2004,
Moses et al. 2006, Silva et al. 2006).
2 studies were not on root coverage
(McGuire & Nunn 2005, Bertoldi
et al. 2007).
4 studies evaluated more than one
site for each technique in each
patient (Novaes et al. 2001, Çetiner
et al. 2003, Cheung & Griffin 2004,
Rahmani & Lades 2006).
1 study evaluated patients with a
shorter follow-up of a study
included in the systematic review
(Hagewold et al. 2002).
Methodological quality of the included

studies
Randomization was reported in all stu-

Fig. 2. Comparisons of techniques: 25 included studies (27 articles) in the systematic review. dies included in the present systematic
review.
Concealment of the randomization
et al. 2001, Tal et al. 2002, McGuire & Excluded Studies code during patient selection was judged
Nunn 2003, Leknes et al. 2005, Spahr et as adequate in 13 studies (Jepsen et al.
al. 2005, Wilson et al. 2005) were See Table 2 (Characteristics of the 40
1998, Aichelmann-Reidy et al. 2001,
supported, in part, by companies whose excluded studies).
Romagna-Genon 2001, Wang et al.
products were being used as interven- There were 40 excluded studies out of
2001, Lins et al. 2003, McGuire &
tions in the trials and 13 studies (Jepsen which:
Nunn 2003, da Silva et al. 2004, Del
et al. 1998, Zucchelli et al. 1998, Pizzo et al. 2005, Huang et al. 2005,
Borghetti et al. 1999, Modica et al. 12 studies reported comparisons Spahr et al. 2005, Wilson et al. 2005,
2000, Romagna-Genon 2001, Lins between variations of the same sur- Joly et al. 2007, Cortellini et al., unpub-
et al. 2003, Côrtes et al. 2004, 2006, gical technique (Caffesse et al. lished data) and inadequate in all the
da Silva et al. 2004, Woodyard et al. 2000, Pini Prato et al. 2000, Hen- other studies.
2004, Del Pizzo et al. 2005, Castellanos derson et al. 2001, Zucchelli et al. Examiner blinding was described in
et al. 2006, Pilloni et al. 2006, Joly et al. 2003, Al-Zahrani et al. 2004, Barros 14 of the studies (Zucchelli et al. 1998,
2007) did not report how the study was et al. 2004, Barros et al. 2005, Amarante et al. 2000, Modica et al.
supported. Tözüm et al. 2005, Kassab et al. 2000, Tatakis & Trombelli 2000,
r 2008 The Authors
142 Cairo et al.
Table 3. Characteristics of the 2 included studies comparing CAF versus CAF1CTG Aichelmann-Reidy et al. 2001, Wang
et al. 2001, McGuire & Nunn 2003,
Study da Silva et al. (2004)
Woodyard et al. 2004, Del Pizzo et al.
Methods RCT, split mouth design 2005, Huang et al. 2005, Leknes et al.
2 treatment groups, 6 months duration 2005, Spahr et al. 2005, Wilson et al.
Participants 11 individuals, 5 females, mean age 29.2 years (range 18–43) 2005, Pilloni et al. 2006, Cortellini et al.,
with bilateral Miller Class I gingival recessions Non-smokers unpublished data) and was ‘‘unclear’’ or
Intervention Control: CAF (11 treated sites) not described in all the other studies.
Test: CAF1CTG (11 treated sites)
Only 14 of the 25 included studies
Mean % of root coverage Control: 68.8%
Test: 75.3% reported about drop-outs (Modica et al.
Founding Not reported 2000, Tatakis & Trombelli 2000,
Allocation concealment Adeguate Aichelmann-Reidy et al. 2001, Romag-
Examiner blinding No na-Genon 2001, Wang et al. 2001,
Drop-outs No drop out McGuire & Nunn 2003, Côrtes et al.
Study Cortellini et al. (unpublished data) 2004, 2006, da Silva et al. 2004, Wood-
yard et al. 2004, Del Pizzo et al. 2005,
Methods RCT, parallel study design Huang et al. 2005, Spahr et al. 2005,
2 treatment groups, 6 months duration Wilson et al. 2005, Cortellini et al.,
Participants 83 individuals, 48 females, age range 20–59 years, with one unpublished data). The number of
Miller Class I or II gingival recession X2 mm drop-outs was 7 for Spahr et al.
21 smokers
(2005), 3 for McGuire & Nunn (2003),
Intervention Control: CAF
Test: CAF1CTG 2 for Wilson et al. (2005) and 1, respec-
Mean % of root coverage Control: 62% 44 tively, for Tatakis & Trombelli (2000),
Test: 76% 36 Romagna-Genon (2001) and Huang
Founding Supported by A.T.R.O. and ERGOPERIO et al. (2005).
Allocation concealment Adeguate After quality assessment, 8 RCTs
Examiner blinding Yes were classified as studies at a low risk
Drop-outs 2 drop outs of bias (Aichelmann-Reidy et al. 2001,
CAF, coronally advanced flap; CTG, connective tissue graft; RCT, randomized clinical trial. Wang et al. 2001, McGuire & Nunn
2003, Del Pizzo et al. 2005, Huang et
al. 2005, Spahr et al. 2005, Wilson et al.
Table 4. Characteristics of the 2 included studies (3 articles) comparing CAF versus CAF1BM. 2005, Cortellini et al., unpublished
data). All the other studies were classi-
Study Lins et al. (2003)
fied as studies at a high risk of bias.
Methods RCT, split mouth design
2 treatment groups, 6 months duration
Participants 10 individuals, 4 females, mean age 38.2 years (range 25–55) Results of the Analyses
with 2 contralateral Miller Class I or II gingival recessions
X2 mm A total of 794 Miller Class I and II
Non-smokers gingival recessions in 530 patients from
Intervention Control: CAF (10 treated sites) 25 RCTs were evaluated in this sys-
Test: titanium reinforced CAF1BM (10 treated sites) tematic review.
Test: 45.0%
Founding Not reported Complete Root Coverage (CRC)
Allocation concealment Adeguate
Examiner blinding No The primary outcome variable was
Drop-outs No CRC. When considering CAF as the
Study Leknes et al. (2005) control surgical procedure, 5 compari-
sons were possible.
2 treatment groups, 12 and 72 months duration Comparison between CAF1CTG
Same patients of the previous article (Amarante et al. 2000)
versus CAF (2 studies) showed bet-
Participants 20 individuals, 10 females, mean age 38.4 years (range 25–55)
with 2 bilateral Miller Class I or II gingival recessions X3 mm ter results for CAF1CTG, p 5 0.03
8 smokers (OR 5 2.49; 95% CI from 1.10 to
Intervention Control: CAF (20 treated sites) 5.68) (Fig. 3);
Test: CAF1BM (20 treated sites) Only one study compared
Mean % of root coverage Control: 34.0% CAF1BM versus CAF, reporting
Test: 35.0% no significant difference, p 5 0.41
Founding In part by Guidor (OR 5 0.58; 95% CI from 0.16 to
Allocation concealment Inadeguate
2.08) (Fig. 4);
Examiner blinding Yes
Drop-outs No Four studies compared CAF1EMD
versus CAF. Meta-analysis showed
CAF, coronally advanced flap; BM, barrier membrane; RCT, randomized clinical trial. better results for CAF1EMD,
r 2008 The Authors
Table 5. Characteristics of the 5 included studies comparing CAF versus CAF1EMD p 5 0.003 (OR 5 3.89; 95% CI from
1.59 to 9.50) (Fig. 5);
Study Modica et al. (2000)
Two studies compared CAF1ADM
Methods RCT, split mouth design versus CAF. Meta-analysis reported
2 treatment groups, 6 months duration no significant difference between
Participants 10 individuals, 5 females, mean age 33.8 years (range 20–50) therapies, p 5 0.31 (OR 5 4.83;
with 2 bilateral Miller Class I or II gingival recessions X3 mm (2 95% CI from 0.23 to 99.88) (Fig. 6).
patients excluded from meta-analyses because participated to Only one study compared
study with more than 1 pair of recessions)
CAF1PRP versus CAF reporting
Non-smokers
Intervention Control: CAF (10 treated sites) no significant difference, p 5 0.79
Test: CAF1EMD (10 treated sites) (OR 5 1.25; 95% CI from 0.23 to
Mean % of root coverage Control: 80.9% 21.3 6.71) (Fig. 7).
Test: 91.2% 1.55
Founding Not reported Therefore, only CAF1CTG and
Allocation concealment Inadeguate CAF1EMD provided better results in
Examiner blinding Yes terms of Complete Root Coverage
Drop-outs No drop outs (CRC) compared with CAF alone.
Study Del Pizzo et al. (2005)
When considering CAF1CTG as a
comparative surgical procedure, 4 com-
Methods RCT, split mouth design parisons were performed.
Same patients of the previous article (Hägewald et al. 2002) No significant difference in compar-
Participants 30 individuals, 12 females, mean age 36.5 years (range 23–62) ing CAF1BM versus CAF1CTG
with one pair of bilateral Miller Class I or II gingival recessions
X3 mm
was reported (6 RCTs included), al-
5 smokers though a trend favouring CAF1CTG
Intervention Control: CAF1Placebo (30 treated sites) was detected, p 5 0.06 (OR 5 0.45;
Test: CAF1EMD (30 treated sites) 95% CI from 0.20 to 1.04) (Fig. 8).
Mean % of root coverage Control: 67% Only one study compared CAF1
Test: 84% EMD versus CAF1CTG, reporting
Founding In part by Biora AB/Straumann Biologics no significant difference p 5 0.31
Allocation concealment Adeguate (OR 5 2.31; 95% CI from 0.45 to
Drop-outs 7 drop outs
11.74) (Fig. 9).
Four studies compared CAF1ADM
Study Spahr et al. (2005) versus CAF1CTG. Meta-analysis
reported no significant difference
for CRC, although a trend favouring
Participants 15 individuals, 11 females, mean age 39.46 years (range 18–56) CAF1CTG was detected, p 5 0.06
with bilateral Miller Class I (28 sites) or II (2 sites) gingival (OR 5 0.49; 95% CI from 0.23 to
recessions 1.03) (Fig. 10).
Non-smokers Only one study compared
Intervention Control: CAF (15 treated sites) CAF1HF-DDS versus CAF1CTG,
Test: CAF1EMD (15 treated sites) reporting no significant difference,
Mean % of root coverage Control: 86.67% 18.29 p 5 1.00 (OR 5 1.00; 95% CI from
Test: 90.67% 16.99
Founding Not reported
0.02 to 50.40) (Fig. 11).
Allocation concealment Adeguate Therefore, no combined therapy was
more effective than CAF1CTG for CRC.
Drop-outs No drop out
Study Castellanos et al. (2006) The secondary outcome variables in
this systematic review were Recession
Methods RCT, parallel study design
Reduction, Clinical Attachment gain,
Participants 22 individuals, 13 females, mean age 42.5 years (range 28–71) KT gain, Root Sensitivity, Aesthetic
with 1 Miller Class I or II gingival recession 42 mm Satisfaction, Post-operative Pain and
Non-smokers Complications including sites with PD
Intervention Control: CAF (11 treated sites) 43 mm at 6 months following therapy.
Test: CAF1EMD (11 treated sites)
Mean % of root coverage Control: 62.2% Recession Reduction
Test: 88.6%
Founding Not reported For Recession Reduction (RecRed), 5
Allocation concealment Inadeguate comparisons were possible considering
Examiner blinding No CAF as the control surgical procedure.
Drop-outs No
Two studies compared CAF1CTG
versus CAF. Meta-analysis reported
r 2008 The Authors
144 Cairo et al.
Table 5. (Cont.) comparison, the test for heterogene-

ity was statistically significant
Study Pilloni et al. (2006) (p 5 0.005) (Fig. 15).
Methods RCT, parallel design Only one study compared CAF1
2 treatment groups, 18 months duration PRP versus CAF, reporting no dif-
Participants 30 individuals, 13 females, with age ranged from 19 to 67 years, ference p 5 0.57 (mean differen-
with one Miller Class I or II gingival recession ce 5 0.20 mm; 95% CI from
Non-smokers 0.89 to 0.49) (Fig. 16).
Intervention Control: CAF (15 treated sites)
Test: CAF1EMD (15 treated sites) Therefore, 2 combinations,
Mean % of root coverage Control: 65.5% 26.03 CAF1CTG and CAF1EMD, provided
Test: 93.8% 12.90
better results than CAF in terms of
Allocation concealment Inadeguate RecRed.
Examiner blinding Yes When considering CAF1CTG as the
Drop-outs No control comparative surgical procedure,
2 comparisons were performed.
CAF, coronally advanced flap; EMD, enamel matrix derivative; RCT, randomized clinical trial.
Six studies compared CAF1BM

Table 6. Characteristics of the 2 included studies (3 articles) comparing CAF versus CAF1ADM
versus CAF1CTG. Meta-analyses
reported better results for
Study Woodyard et al. (2004) CAF1CTG, p 5 0.008 (mean differ-
ence 5 0.38 mm; 95% CI from
Methods RCT, parallel study design
0.65 to 0.10) (Fig. 17).
Participants 24 individuals, 14 females, mean age 34.6 years with one Miller No significant differences were
Class I (17 sites) or II (7 sites) gingival recessions X3 mm reported comparing CAF1ADM ver-
Non-smokers sus CAF1CTG (4 RCTs included),
Intervention Control: CAF (12 treated sites) p 5 0.24 (mean difference 5
Test: CAF1ADM (12 treated sites) 0.40 mm; 95% CI from 1.07
Mean % of root coverage Control: 67% 27 to 0.26); for this comparison, the test
Test: 99% 5 for heterogeneity was statistically
Allocation concealment Inadeguate
significant (p 5 0.002) (Fig. 18).
Drop-outs No drop outs Comparison in terms of RecRed
between CAF1EMD versus CAF1
Study Côrtes et al. 2006 CTG and CAF1HF-DDS versus
Methods RCT, split mouth design CAF1CTG was not possible due to
2 treatment groups, 24 months duration data presentation in the original arti-
Same patients of the previous article (Côrtes et al. 2004) cles (McGuire & Nunn 2003, Wilson
Participants 13 individuals, 7 females, mean age 32.8 years (range 25–55) et al. 2005), even though no statisti-
with 2 bilateral Miller Class I gingival recessions X3 mm cally significant difference was
Non-smokers reported by the authors.
Test: CAF1ADM (13 treated sites) Therefore, no combination was more
Mean % of root coverage Control: 55.98% 23.00 effective than CAF1CTG for RecRed.
Test: 68.04% 17.87
Allocation concealment Inadeguate CAL gain
Examiner blinding No
Drop-outs No drop out For CAL gain, 5 comparisons were
possible considering CAF as the control
CAF: coronally advanced flap; ADM, acellular dermal matrix; RCT, randomized clinical trial.
surgical procedure.
Two studies compared CAF1CTG

versus CAF. Meta-analysis reported
better results for CAF 1CTG, CAF1EMD provided better results better results for CAF1CTG, p 5
p 5 0.005 (mean differen- than CAF alone (5 RCTs included), 0.05 (mean difference 5 0.38 mm;
ce 5 0.49 mm; 95% CI from 0.14 p 5 0.002 (mean difference 95% CI from 0.01 to 0.75) (Fig. 19);
to 0.83) (Fig. 12); 5 0.58 mm; 95% CI from 0.21 to No statistically significant differ-
No significant difference was 0.95) (Fig. 14). ences were reported comparing
reported in comparing CAF1BM Two studies compared CAF1ADM CAF1BM versus CAF (2 studies
versus CAF (2 studies included), versus CAF. Meta-analysis reported included), although a trend favour-
p 5 0.11 (mean difference 5 0.27 no significant difference p 5 0.29 ing CAF was detected, p 5 0.06
mm; 95% CI from 0.60 to 0.06) (mean difference 5 0.60 mm; 95% (mean difference 5 0.33 mm; 95%
(Fig. 13). CI from 0.52 to 1.73); for this CI from 0.68 to 0.02) (Fig. 20);
r 2008 The Authors
Table 7. Characteristics of the included study comparing CAF1PRP versus CAF CAF1EMD provided better results
than CAF alone (5 RCTs included),
Study Huang et al. (2005)
p 5 0.0001 (mean difference
Methods RCT, parallel study design 5 0.53 mm; 95% CI from 0.26 to
2 treatment groups, 6 months duration 0.80) (Fig. 21).
Participants 23 individuals, 17 females, mean age 43.8 years (range 24–63) Comparison between CAF1ADM
with 1 Miller Class I gingival recession X2 mm versus CAF (2 studies included)
Non-smokers resulted in no significant differ-
ence p 5 0.22 (mean difference 5
Test: CAF1PCG (11 treated sites)
Mean % of root coverage Control: 83.5% 21.8 0.28 mm; 95% CI from 0.16 to
Test: 87.1% 21.4 0.72) (Fig. 22).
Founding Supported by the University of Michigan Periodontal Graduate Only one study compared
Student Research Fund and the 2003 Dental Master’s Thesis CAF1PRP versus CAF, reporting
Award Program from the Delta Dental Fund, Okemos, Michigan. no difference p 5 0.39 (mean differ-
Allocation concealment Adeguate ence 5 0.50 mm; 95% CI from
Examiner blinding Yes 1.64 to 0.64) (Fig. 23).
Drop-outs 1 drop out
CAF, coronally advanced flap; PRP, platelet-rich plasma; RCT, randomized clinical trial. Therefore, 2 combinations,
CAF1CTG and CAF1EMD, provided
better results than CAF in terms of CAL
Table 8. Characteristics of the 7 included studies comparing CAF1CTG versus CAF1BM gain.
Study Zucchelli et al. (1998) When considering CAF1CTG as the
Methods RCT, parallel study design comparative surgical procedure, 2 com-
3 treatment groups, 12 months duration parisons were performed.
with one Miller Class I or II gingival recessions X5 mm No significant differences were
16 smokers reported comparing CAF1BM ver-
Intervention Control: CTG1CAF (18 treated sites)
sus CAF1CTG (6 studies included),
Test: Bioabsorbable BM1CAF (18 treated sites)
Test: Unresorbable BM1CAF (18 treated sites) p 5 0.73 (mean difference 5
Mean % of root coverage Control (CAF1CTG): 93.5 % 8.6 0.05 mm; 95% CI from 0.32 to
Test (Bioabsorbable CAF1BM): 85.7 % 13.8 0.22) (Fig. 24).
Test (Unresorbable CAF1BM): 80.5% 14.9 Four studies compared CAF1ADM
Founding Not reported versus CAF1CTG. Meta-analysis
Allocation concealment Inadeguate reported no significant differ-
Examiner blinding Yes ence, p 5 0.20 (mean difference 5
Drop-outs No
0.39 mm; 95% CI from 1.00 to
Study Jepsen et al. (1998) 0.21); for this comparison, the test
for heterogeneity was statistically
Methods RCT, split mouth design significant (p 5 0.03) (Fig. 25).
Participants 15 individuals, 9 females, mean age 40 years (range 20–62) with Comparison in terms of CAL gain
two Miller Class I or II gingival recessions located in different
between CAF1EMD versus CAF1
quadrants
No data on smoking habits CTG and CAF1HF-DDS versus CAF
Intervention Control: CAF1CTG (15 treated sites) 1CTG was not possible due to data
Test: CAF1titanium reinforced ePTFE Membrane (15 treated presentation in the original articles
sites) (McGuire & Nunn 2003, Wilson et al.
Mean % of root coverage Control: 86.9% 15.4 2005), even though no statistically sig-
Test: 87.1% 13.8 nificant difference was reported by the
Founding Not reported authors.
Allocation concealment Adeguate
Drop-outs No KT gain
Study Trombelli et al. (1998) For KT gain, 5 comparisons were pos-
sible considering CAF as the compara-
2 treatment groups, 6 months duration tive surgical procedure.
Participants 12 individuals, 10 females, mean age 34 years (range 23–58) with
2 controlateral Miller Class I or II gingival recessions Comparison between CAF1CTG
No data on smoking habits versus CAF (2 studies included)
Intervention Control: CAF1CTG (12 treated sites) resulted in better outcomes
Test: CAF1BM (12 treated sites)
for CAF1CTG, p 5 0.0001 (mean
Mean % of root coverage Control: 81%
Test: 48% difference 5 0.73 mm; 95% CI from
0.35 to 1.10) (Fig. 26).
r 2008 The Authors
146 Cairo et al.
Table 8. (Cont.) Two studies compared CAF1

BM versus CAF: meta-analysis
Study Trombelli et al. (1998)
reported no significant difference,
Founding In part by GORE and Associates Inc. and by MURST (Italian p 5 0.30 (mean difference 5
Department of scientific Research and Technology) 0.15 mm; 95% CI from 0.13 to
Allocation concealment Inadequate 0.42) (Fig. 27).
Examiner blinding No CAF1EMD achieved better out-
Drop-outs No comes than CAF alone (5 RCTs
Study Borghetti et al. (1999) included), p 5 0.0007 (mean differ-
ence 5 0.42 mm; 95% CI from 0.18
Methods RCT, split mouth design to 0.66) (Fig. 28).
2 treatment groups, 6 months duration No difference was reported between
Participants 14 individuals, 11 females, mean age 37.5 years (range 20–55) CAF1ADM versus CAF (2 studies
with 14 pair of bilateral Miller Class I gingival recessions
X2 mm
included), p 5 0.19 (mean differ-
No data on smoking habits ence 5 0.31 mm; 95% CI from
Intervention Control: CAF1CTG (14 treated sites) 0.15 to 0.78) (Fig. 29).
Test: CAF1BM (14 treated sites) Only one study compared CAF1
Mean % of root coverage Control: 76% PRP versus CAF, reporting no sig-
Test: 70.2% nificant difference p 5 0.38 (mean
Founding Not reported difference 5 0.30 mm; 95% CI
Allocation concealment Inadequate from 0.97 to 0.37) (Fig. 30).
Drop-outs No
The additional effect of CTG or EMD
Study Tatakis & Trombelli (2000) in combination with CAF was asso-
ciated with better outcomes in terms of
Methods RCT, split mouth design KT gain than CAF alone.
Participants 12 individuals, 8 females, mean age 38 years (range 22–48) with
2 controlateral Miller Class I or II gingival recessions X2 mm, When considering CTG1CAF as the
with no more than 1 mm difference between the two defects control surgical procedure, 2 compari-
Non-smokers sons were possible for KT gain.
Intervention Control: CAF1CTG (12 treated sites)
Test: CAF1BM (12 treated sites) Comparison between CAF1BM
Mean % of root coverage Control: 96%
Test: 81%
versus CAF1CTG (6 studies
Founding In part by Guidor, USA and by Loma Linda University School of included) resulted in better out-
Dentistry comes for CTG1CAF, p 5 0.004
Allocation concealment Inadequate (mean difference 5 1.18 mm;
Examiner blinding Yes 95% CI from 1.98 to 0.39).
Drop-outs 1 drop out For this comparison, the test for
Study Romagna-Genon (2001) heterogeneity was found to be sta-
tistically significant (po0.00001)
Methods RCT, split mouth design (Fig. 31).
2 treatment groups, 6 months duration Comparison between CAF1ADM
Participants 20 individuals, 19 females, mean age 37 years (range 21–54) with versus CAF1CTG (4 studies
one pair of controlateral Miller Class I or II gingival recessions included) resulted in better outcomes
Non-smokers
for CAF1CTG, p 5 0.004 (mean
Test: CAF1BM (20 treated sites) difference 5 0.90 mm; 95%
Mean % of root coverage Control: 84.84% CI from 1.51 to 0.28) (Fig. 32).
Test: 74.59 %
Founding Not reported Comparison in terms of KT gain
Allocation concealment Adequate between CAF1EMD versus
Examiner blinding No CAF1CTG and CAF1HFDDS versus
Drop-outs 1 drop out CAF 1CTG was not possible due to
Study Wang et al. (2001) data presentation in original articles
(McGuire & Nunn 2003, Wilson et al.
Methods RCT, split mouth design 2005). However, McGuire & Nunn
2 treatment groups, 6 months duration (2003) reported higher KT gain for
Participants 16 individuals, 10 females, mean age 40.6 years (range 30–54) CAF1CTG than EMD1CAF
with 2 bilateral Miller Class I or II gingival recessions X3 mm
Non-smoking
(po0.001) one year following therapy,
Intervention Control: CAF1CTG (16 treated sites) while Wilson et al. (2005) reported no
Test: CAF1BM (16 treated sites) difference.
Mean % of root coverage Control: 84% 25 Therefore, no therapy was found to be
Test: 73% 26 more effective than CAF1CTG in KT
Founding In part by Sulzer Calcitek Inc., Carlsbad, California gain.
r 2008 The Authors
Table 8. (Cont.) Root sensitivity

Study Wang et al. (2001) Very few studies evaluated Root sensi-
tivity following root coverage proce-
Allocation concealment Adequate
dures. No meta-analysis was performed
Drop-outs No drop outs
for this variable due to the fact that data
were few and heterogeneous. Cortellini
CAF, coronally advanced flap; CTG, connective tissue graft; BM, barrier membrane; RCT, et al. (unpublished data) compared
randomized clinical trial. CAF1CTG versus CAF, reporting no
statistically significant differences for
Table 9. Characteristics of the included study comparing CAF1CTG versus CAF1EMD root sensitivity (12% in the test group
Study McGuire & Nunn (2003) and 12% in the control group) six
months following therapy. McGuire &
Methods RCT, split mouth design Nunn (2003) reported root sensitivity in
2 treatment groups, 12 months duration only one case treated with CAF1EMD
and none for CAF1CTG one year fol-
with 2 contralateral Miller Class II gingival recessions X3 mm
Non-smokers lowing therapy.
Test: CAF1EMD (17 treated sites) Aesthetic satisfaction
Test: 95.1% Few studies evaluated aesthetic satisfac-
Founding In part by Biora AB, Malmo, Sweden tion following therapy. No meta-analy-
Allocation concealment Adequate sis was performed for this variable
Drop-outs 3 drop outs
because data were few and heteroge-
neous. Romagna-Genon (2001) com-
CAF, coronally advanced flap; CTG, connective tissue graft; EMD, enamel matrix derivative; RCT, pared CAF1BM versus CAF1CTG
randomized clinical trial. in a split-mouth study, reporting that
one patient was not satisfied by either
Table 10. Characteristics of the 4 included studies comparing CAF1CTG versus CAF1ADM treatment. In the study by Wang et al.
(2001), a double aesthetic evaluation
Study Aichelmann-Reidy et al. (2001)
was performed by a periodontist blinded
Methods RCT, split mouth design to the treatment and by the patient. The
2 treatment groups, 6 months duration periodontist evaluated treatment out-
Participants 22 individuals, 15 females, mean age 47.2 years (range 24–67) comes at 6 months, rating 15 out of 16
with 22 pair of bilateral Miller Class I or II gingival recessions BM sites as an excellent colour match,
X2 mm while 11 CTG sites reported a similar
Non-smokers score. Patient satisfaction with aes-
thetics (colour match, overall satisfac-
Test: CAF1ADM (22 treated sites)
Mean % of root coverage Control: 74.1% 38.3 tion and amount of root coverage) was
Test: 65.9% 46.7 the same for both treatments, although
Founding In part by LifeCell Corp., and by the Louisiana Periodontics greater overall satisfaction was
Support Fund expressed for BM sites compared with
Allocation concealment Adequate CTG sites. Aichelmann-Reidy et al.
Examiner blinding Yes (2001) compared CAF1ADM versus
Drop-outs No drop outs CAF1CTG in a split-mouth study in
Study Paolantonio et al. (2002) 22 patients by performing a double
aesthetic evaluation (blinded clinician
Methods RCT, parallel design and patient). Clinicians considered sites
2 treatment groups, 12 months duration with CAF 1ADM to have better results
in 11 cases, while the other 11 were
with one Miller Class I or II gingival recession X3 mm
Non-smokers similar to CAF1CTG. Patients consid-
Intervention Control: CAF1CTG (15 treated sites) ered CAF1ADM to have better aes-
Test: CAF1ADM (15 treated sites) thetics in 9 cases out of 22; in 12
Mean % of root coverage Control: 88.80% 11.65 cases, they considered it similar to
Test: 83.33% 11.40 CAF1CTG; and only 1 patient pre-
Founding Supported by Italian Ministry of University and Scientific ferred the site with CAF1CTG. A
Research (ex MURST 60%) keloid formation was reported in one
Allocation concealment Inadequate
case of CTG1CAF.
Drop-outs No
Study Tal et al. (2002)
Post-operative pain and complications
Methods RCT, split mouth design Pain and complications (including sites
2 treatment groups, 12 months duration with PD 43 mm) were unusual follow-
r 2008 The Authors
148 Cairo et al.
Table 10. (Cont.) ing root coverage procedures. No meta-

analysis was performed for this variable
Study Tal et al. (2002)
due to the fact that data were few and
Participants 7 individuals, 5 females, mean age 47.3 years (range 23–54) with heterogeneous. Da Silva et al. (2004)
one pair of bilateral Miller Class I or II gingival recessions reported no complication on comparing
X4 mm CAF1CTG versus CAF. Cortellini et al.
Non-smokers (unpublished data) reported 3 cases of
Intervention Control: CAF1CTG (7 treated sites) haematoma in 43 patients treated with
Test: CAF1ADM (7 treated sites)
CAF, while 5 cases of haematoma were
Test: 89.1 %
reported in 42 patients treated with
Founding Supported by the Gerald A. Niznick Chair of Implant Dentistry at CAF1CTG. A higher number of cases
Tel Aviv University, School of Dental Medicine and by Perimed, of swelling were reported for the
Ra’anana, Israel CAF1CTG group, and these differences
Allocation concealment Inadequate were statistically significant
Examiner blinding Unclear (CAF1CTG 32.2 28.4 and CAF
Drop-outs No 17.8 19.9 using visual analogue
Study Joly et al. (2007) scale-(VAS), p 5 0.0068). No statisti-
cally significant differences for pain
Methods RCT, split mouth design were reported between two groups
2 treatment groups, 6 months duration (23.8 19.4 for CAF and 31.4 24.6
Participants 10 individuals, 4 females, age range 27–51 years, with one pair of for CAF1CTG, using VAS,
bilateral Miller Class I or II gingival recessions X3 mm
Non-smokers
p 5 0.0811). No treated sites reported
Intervention Control: CAF1CTG (10 treated sites) PD43 mm 6 months following therapy.
Test: CAF1ADM (10 treated sites) Studies using BM reported membrane
Mean % of root coverage Control: 79.5% exposure as a frequent complication.
Test: 50.0% Amarante et al. (2000) reported expo-
Founding Not reported sure of several membranes in CAF1BM
Allocation concealment Adequate sites, while Lins et al. (2003) reported
the exposure of all membranes in all
Drop-outs No
treated sites (10/10). PD 42 mm
CAF: coronally advanced flap; CTG: connective tissue graft; ADM: acellular dermal matrix graft; resulted following therapy. In compar-
RCT: randomized clinical trial. isons between CAF1BM versus
CAF1CTG, membrane exposure was
Table 11. Characteristics of the included study comparing CAF1CTG versus CAF1HF-DDS reported as a possible complication (7/
Study Wilson et al. (2005)
15 Jepsen et al. 1998, 2/12 Trombelli
et al. 1998, 5/12 Tatakis & Trombelli
Methods RCT, split mouth design 2000). Jepsen et al. (1998) reported a
2 treatment groups, 6 months duration similar incidence of post-operative pain
Participants 10 individuals, 11 females, mean age 47.7 years (range 38–60) with
2 bilateral Miller Class I or II gingival recessions X3 mm for both treatments (5/15 patients) with
Non-smoking final PD 42.8 mm. Tatakis & Trombelli
Intervention Control: CAF1CTG (10 treated sites) (2000) reported 7 cases of swelling in 12
Test: CAF1HF-DDS (13 treated sites) patients treated with CAF1BM and
Mean % of root coverage Control: 64.4% 31.9 none for CAF1CTG; the final PD was
Test: 56.7% 27.8
Founding In part by Advanced Tissue Science, Inc., La Jolla, Ca, 42 mm. On the other hand, no compli-
Allocation concealment Adequate cation for CAF1BM was reported by
Examiner blinding Yes Wang et al. (2001): they reported one
Drop-outs 2 drop outs swelling and one ecchymosis in the
CAF, coronally advanced flap; CTG, connective tissue graft; HF-DDS, human fibroblast-derived CAF1CTG arm. Romagna-Genon
dermal substitute; RCT, randomized clinical trial.
Fig. 3. Comparison CAF1CTG versus CAF for CRC. CAF, coronally advanced flap; CTG, connective tissue graft; CRC, complete root coverage.
r 2008 The Authors
Fig. 4. Comparison CAF1BM versus CAF for CRC. CAF, coronally advanced flap; CRC, complete root coverage; BM, barrier membranes.
Fig. 5. Comparison CAF1EMD versus CAF for CRC. CAF, coronally advanced flap; CRC, complete root coverage; EMD, enamel matrix
derivative.
Fig. 6. Comparison CAF1ADM versus CAF for CRC. CAF, coronally advanced flap; CRC, complete root coverage; ADM, acellular dermal
matrix.
Fig. 7. Comparison CAF1PRP versus CAF for CRC. CAF, coronally advanced flap; CRC, complete root coverage; PRP, platelet-rich
plasma.
(2001) described postoperative discom- CTG sites. None of the sites showed CAF (Modica et al. 2000), CAF1ADM
fort for the palatal donor site for the exposure of the membrane. versus CAF (Côrtes et al. 2004, Wood-
CTG. Sites treated with BM were more No complication was reported in yard et al. 2004) and CAF1ADM ver-
frequently symptom-free compared with comparisons among CAF1EMD versus sus CAF1CTG (Joly et al. 2007) with
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150 Cairo et al.
Fig. 8. Comparison CAF1BM versus CAF1CTG for CRC. CAF, coronally advanced flap; CTG, connective tissue graft; CRC, complete root
coverage; BM, BM, barrier membranes.
Fig. 9. Comparison CAF1EMD versus CAF1CTG for CRC. CAF, coronally advanced flap; CTG, connective tissue graft; CRC, complete
root coverage; EMD, enamel matrix derivative.
Fig. 10. Comparison CAF1ADM versus CAF1CTG for CRC. CAF, coronally advanced flap; CTG, connective tissue graft; CRC, complete
root coverage; ADM, acellular dermal matrix.
Fig. 11. Comparison CAF1HF-DDS versus CAF1CTG for CRC. CAF, coronally advanced flap; CTG, connective tissue graft; CRC,
complete root coverage; HF-DDS, human fibroblast-derived dermal substitute.
r 2008 The Authors
Fig. 12. Comparison CAF1CTG versus CAF for RecRed. CAF, coronally advanced flap; CTG, connective tissue graft.
Fig. 13. Comparison CAF1BM versus CAF for RecRed. CAF, coronally advanced flap; BM, BM, barrier membranes.
Fig. 14. Comparison CAF1EMD versus CAF for RecRed. CAF, coronally advanced flap; EMD, enamel matrix derivative.
Fig. 15. Comparison CAF1ADM versus CAF for RecRed. CAF, coronally advanced flap; ADM, acellular dermal matrix.
r 2008 The Authors
152 Cairo et al.
Fig. 16. Comparison CAF1PRP versus CAF for RecRed. CAF, coronally advanced flap; PRP, platelet-rich plasma.
Fig. 17. Comparison CAF1BM versus CAF1CTG for RecRed. CAF, coronally advanced flap; CTG, connective tissue graft; BM, barrier
membranes.
Fig. 18. Comparison CAF1ADM versus CAF1CTG for RecRed. CAF, coronally advanced flap; CTG, connective tissue graft; ADM,
acellular dermal matrix.
Fig. 19. Comparison CAF1CTG versus CAF for CAL gain. CAF, coronally advanced flap; CTG, connective tissue graft; CAL, clinical
attachment level.
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Fig. 20. Comparison CAF1BM versus CAF for CAL gain. CAF, coronally advanced flap; BM, barrier membranes; CAL, clinical attachment
level.
Fig. 21. Comparison CAF1EMD versus CAF for CAL gain. CAF, coronally advanced flap; EMD, enamel matrix derivative.
Fig. 22. Comparison CAF1ADM versus CAF for CAL gain. CAF, coronally advanced flap; CAL, clinical attachment level; ADM, acellular
dermal matrix.
Fig. 23. Comparison CAF1PRP versus CAF for CAL gain. CAF, coronally advanced flap; PRP, platelet-rich plasma; CAL, clinical
attachment level.
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154 Cairo et al.
Fig. 24. Comparison CAF1BM versus CAF1CTG for CAL gain. CAF, coronally advanced flap; CTG, connective tissue graft; CAL, clinical
attachment level; BM, barrier membranes.
Fig. 25. Comparison CAF1ADM versus CAF1CTG for CAL gain. CAF, coronally advanced flap; CTG, connective tissue graft; CAL,
clinical attachment level; ADM, acellular dermal matrix.
Fig. 26. Comparison CAF1CTG versus CAF for KT gain. CAF, coronally advanced flap; CTG, connective tissue graft; KT, keratinized
tissue.
Fig. 27. Comparison CAF1BM versus CAF for KT gain. CAF, coronally advanced flap; KT, keratinized tissue.
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Fig. 28. Comparison CAF1EMD versus CAF for KT gain. CAF, coronally advanced flap; KT, keratinized tissue; EMD, enamel matrix
derivative.
Fig. 29. Comparison CAF1ADM versus CAF for KT gain. CAF, coronally advanced flap; KT, keratinized tissue; ADM, acellular dermal
matrix.
Fig. 30. Comparison CAF1PRP versus CAF for KT gain. CAF, coronally advanced flap; KT, keratinized tissue; PRP, platelet-rich plasma.
PD 41 mm (Joly et al. 2007) or Sensitivity analysis on CRC CAF1CTG versus CAF (Fig. 33)
42.5 mm (Tal et al. 2002). In a com- CAF1BM versus CAF1CTG
parison between CAF1EMD versus Following methodological analysis, some (Fig. 34)
CAF1CTG, McGuire & Nunn (2003) studies showed a low risk of bias (Aichel- CAF1EMD versus CAF (Fig. 35)
reported higher discomfort for CTG mann-Reidy et al. 2001, Wang et al. CAF1ADM versus CAF1CTG
procedure (p 5 0.011) 1 month follow- 2001, McGuire & Nunn 2003, Del Pizzo (Fig. 36)
ing therapy, while no difference et al. 2005, Spahr et al. 2005, Wilson et
between the two approaches was al. 2005, Hwang & Wang 2006, Cortelli- The results of sensitivity analysis
reported at the 1-year follow-up. ni et al. unpublished data). A sensitivity showed no marked difference between
No statistically significant differences analysis to assess possible differences studies at a low risk and at a high risk of
for complications were reported on was performed considering only the pri- bias in terms of CRC.
comparing CAF1PRP versus CAF mary outcome variable (CRC) comparing
(Huang et al. 2005) using a Wound studies at a low risk versus at a high risk Discussion
Healing Index (1.3 0.5 for CAF and of bias. For sensitivity analysis, only 4 In the era of evidence-based medicine,
1.2 0.4 for CAF1PRP). comparisons were possible: systematic reviews provide concise
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156 Cairo et al.
Fig. 31. Comparison CAF1BM versus CAF1CTG for KT gain. CAF, coronally advanced flap; KT, keratinized tissue; BM, barrier
membranes; CTG, connective tissue graft.
Fig. 32. Comparison CAF1ADM versus CAF1CTG for KT gain. CAF, coronally advanced flap; CTG, connective tissue graft; KT,
keratinized tissue; ADM, acellular dermal matrix.
Fig. 33. Sensitivity analysis comparing CAF1CTG versus CAF considering CRC. CAF, coronally advanced flap; CTG, connective tissue
graft.
information from the available literature clinical benefit of adding to the CAF selected as a reference treatment and
using a clearly formulated question procedure, CTG or BM or EMD or then possible combinations (CAF1
(Needleman 2002). The focused ques- ADM or PRP or living tissue-engi- CTG; CAF1EMD; CAF1BM, etc)
tion of this systematic review evaluating neered HF-DDS in the treatment of were compared with it, although no
only RCTs in Miller Class I and II Miller Class I and II localized gingival multiple combinations were evaluated,
gingival recessions was: ‘‘What is the recessions?’’ Therefore, CAF was due to difficulties in detecting the
r 2008 The Authors
Fig. 34. Sensitivity analysis comparing CAF1BM versus CAF1CTG considering CRC. CAF, coronally advanced flap; CTG, connective
tissue graft; CRC, complete root coverage; BM, barrier membranes.
Fig. 35. Sensitivity analysis comparing CAF1EMD versus CAF considering CRC. CAF, coronally advanced flap; CRC, complete root
coverage; EMD, enamel matrix derivative.
weight of a single therapy in the overall vided better results than CAF1CTG. A single study on a sample of 17
clinical outcome. CRC was considered Possible biological reasons to explain patients with 2 bilateral recessions com-
to be the treatment goal and, conse- the clinical outcomes of CAF 1CTG pared CAF 1EMD versus CAF1CTG
quently, the primary outcome variable. may be related to (i) the ability of the (McGuire & Nunn 2003). This study
This systematic review confirms that bilaminar blood supply from both the was at a low risk of bias and reported
the CAF procedure is a safe and reliable periosteal surface and the overlaying no significant difference in terms of
approach in periodontal plastic surgery flap in promoting survival of CTG on CRC between the two approaches.
and is associated with consistent the root surface (Langer & Langer 1985) Unfortunately, no meta-analysis was
recession reduction and frequently with and (ii) the capacity of CTG to reduce possible for RecRed due to the data
CRC. The results of meta-analyses the apical relapse of the coronally posi- presentation, although the authors
showed that only two combinations tioned gingival margin during the heal- (McGuire & Nunn 2003) reported no
(CAF1CTG and CAF1EMD) provided ing phase of the CAF procedure (Pini difference in terms of the mean amount
better results than CAF alone. Prato et al. 2005). of root coverage. Further RCTs with a
CAF1CTG resulted in better clinical The combination of CAF1EMD was high power comparing CAF1EMD
outcomes for both CRC (OR 5 2.49) associated with a higher probability to versus CAF1CTG are needed.
and RecRed (10.49 mm) compared obtain CRC (OR 5 3.89) and a higher A possible benefit following root
with CAF, and no other therapy pro- amount of RecRed (0.58 mm) than CAF. coverage procedures may be the aug-
r 2008 The Authors
158 Cairo et al.
Fig. 36. Sensitivity analysis comparing CAF1ADM versus CAF1CTG considering CRC. CAF, coronally advanced flap; CTG, connective
tissue graft; CRC, complete root coverage; ADM, acellular dermal matrix.
mentation of KT. This systematic nificant differences for CRC (p 5 0.06, considering the high incidence of com-
review showed that CAF1CTG was OR 5 0.49) and RecRed (p 5 0.24, mean plications (i.e. membrane exposure)
associated with better clinical outcomes difference 5 0.40 mm), even if a ten- related to the use of BM for root cover-
in terms of KT gain following therapy. dency favouring CTG was observed for age (Jepsen et al. 1998, Trombelli et al.
The decision on whether to select both variables. Moreover, statistically 1998, Tatakis & Trombelli 2000).
CTG or EMD in conjunction with CAF significant differences for KT gain Only one RCT (Huang et al. 2005)
may be only partially explained by the favouring CTG (p 5 0.004, mean differ- comparing CAF1PRP versus CAF was
systematic review. Further studies with ence 5 0.90 mm) were detected. identified, with no statistically signifi-
higher power for assessing possible Meta-analyses of the selected studies cant differences reported in terms of
interactions between prognostic factors (Côrtes et al. 2004, Woodyard et al. CRC, RecRed and KT gain. Similarly,
(baseline recession, baseline KT, etc.) 2004) showed a large heterogeneity in only one RCT (Wilson et al. 2005)
and the surgical techniques are needed. RecRed for both comparisons (CAF1 analysed the addition of HF-DDS in
However, the ability of the CAF1CTG ADM versus CAF and CAF1CTG ver- conjunction with CAF compared with
procedure to increase KT may suggest sus CAF), thus indicating the possible CAF1CTG, reporting no difference for
this approach when KT augmentation influences of patient’s related factors, CRC, RecRed and KT gain. Even if
with recession reduction is the treatment operator skill and recession severity on further studies are needed to better
goal. In fact, this systematic review the clinical outcomes. On the other understand the potential benefits of
showed that CAF1CTG was associated hand, CAF1ADM resulted in better these innovative approaches, current
with better clinical outcomes in terms of overall aesthetic outcomes for both evidence does not support the introduc-
KT gain. On the contrary, CAF1EMD blinded clinicians and patients com- tion of PRP or HF-DDS under CAF as a
appears to be an easier procedure than pared with CAF1CTG, even if it routine root coverage procedure due to
CAF1CTG and does not require a showed less CRC than CAF1CTG both cost/benefit ratio and practicality.
donor area for CTG harvest, which (Aichelmann-Reidy et al. 2001). This Aesthetics and root sensitivity are the
generally implies greater post-operative finding may be related to different col- sole indications for the root coverage
discomfort in the first month following our matches with adjacent tissues for procedure (American Academy of
therapy (McGuire & Nunn 2003). On ADM and CTG or poorer healing for Periodontology 1996) but are generally
the other hand, the cost/benefit ratio of CTG where size exceeds the bone dehis- poorly investigated. Nonetheless, it is
CAF1EMD should be carefully evalu- cence (Zucchelli et al. 2003). reasonable to hypothesize that complete
ated. This systematic review showed that root coverage is associated with a higher
ADM was introduced in mucogingi- the use of BM in conjunction with CAF reduction of root sensitivity than partial
val surgery as an alternative to CTG in (CAF1BM) did not improve the result root coverage, thus supporting CRC as
order to reduce the patient discomfort of CAF in terms of CRC and RecRed. the treatment goal. In addition, CRC
(Harris 1998). Meta-analyses showed When comparing CAF 1BM versus may be associated with greater patient
that no statistically significant differ- CAF1CTG, statistically significant dif- satisfaction, especially when the root
ence between CAF1ADM versus CAF ferences favouring CAF1CTG were surface shows a colour contrast with
in terms of CRC, RecRed and KT gain detected for both RecRed (p 5 0.008, the enamel surface was completely cov-
was detected, suggesting that no addi- mean difference 5 0.38 mm) and KT ered, but it does not completely assess
tional benefit over CAF alone may be gain (p 5 0.004, mean differen- overall aesthetic satisfaction. In fact, in
provided by ADM. Similarly, the com- ce 5 1.18 mm). Therefore, the use of an RCT comparing two CAF1CTG
parison between CAF 1ADM versus BM for the root coverage procedure techniques, a CTG with size exceeding
CAF1CTG showed no statistically sig- appears to be unadvisable, especially the distance between the most apical
r 2008 The Authors
extension of buccal bone crest and procedure minimizing the risk of bias Borghetti, A., Glise, J-M., Monnet-Corti, V. &
cemento-enamel junction (bone dehis- (i.e. based on CONSORT guidelines) Dejou, J. (1999) Comparative clinical study
cence) was associated with poorer aes- are advisable. of a bioabsorbable membrane and subepithe-
thetic outcomes compared with CRC in Few RCTs included in this systematic lial connective tissue graft in the treatment of
sites where the CTG was equal to the review evaluated clinical outcomes over human gingival recession. Journal of Perio-
dontology 70, 123–130.
bone dehiscence (Zucchelli et al. 2003). a 1-year follow-up (Del Pizzo et al.
Castellanos, A. T., de la Rosa, M. R., de la
The authors suggested that possible rea- 2005, Leknes et al. 2005, Spahr et al. Garza, M. & Caffesse, R. G. (2006) Enamel
sons may be related to difficulties in 2005, Côrtes et al. 2006, Pilloni et al. matrix derivative and coronal flaps to cover
vascular exchanges between the cover- 2006). Interestingly, a study by Leknes marginal tissue recessions. Journal of Perio-
ing flap and CTG with excessive size/ et al. (2005) reported 1- and 6-year dontology 77, 7–14.
thickness, favouring statistically signifi- follow-ups of the CAF procedure with Cortellini, P., Baldi, C., Francetti, L., Raperini,
cant flap dehiscence and graft exposure and without resorbable BM. In the meta- G., Rotundo, R., Nieri, M., Franceschi, D.,
with poorer aesthetic outcomes (Zuc- analysis, only data of the 1-year follow- Labriola, A., Tonetti, M. & Pini Prato, G.
chelli et al. 2003). Therefore, the up were considered due to the high Comparative study of coronally advanced
achievement of CRC associated with drop-out rate at the 6-year follow-up. flap and bilaminar technique in the treatment
of gingival recessions. A multi-centre, rando-
poor colour match, inadequate integra- Leknes et al. (2005) reported a signifi-
mized, double blind, clinical study. Unpub-
tion with adjacent tissues or a flat gingi- cant reduction in the number of sites lished Data.
val contour may affect the aesthetic with CRC and a decrease in mean Côrtes, A. Q., Martins, A. G., Nociti, F. H. Jr.,
perception of treatment (Aichelmann- RecRed for both treatments at the Salllum, A. W., Casati, M. Z. & Sallum, E. A.
Reidy et al. 2001, Zucchelli et al. 6-year follow-up compared with the (2004) Coronally positioned flap with or
2003). Moreover, the possible associa- 1-year and 6-month follow-ups (Amar- without acellular dermal matrix graft in the
tion between KT gain and aesthetic ante et al. 2000). These detrimental treatment of class I gingival recessions: a
satisfaction has to be tested. Future effects were thought to be associated randomized controlled clinical study. Journal
RCTs in the field of root coverage with traumatic tooth brushing: in fact, of Periodontology 75, 1137–1144.
procedures must consider patient satis- new gingival recessions in non-treated Côrtes, A. Q., Sallum, A. W., Casati, M. Z.,
Nociti, F. H. Jr. & Sallum, E. A. (2006) A
faction as one of the treatment outcomes sites were identified at the last follow-
two-year prospective study of coronally posi-
towards a better understanding of the up. These observations suggest that
tioned flap with or without acellular dermal
potential benefit of the tested techniques. careful maintenance may be the key matrix graft. Journal of Clinical Perio-
Post-operative pain and complica- for long-term stability of the gingival dontology 33, 683–689.
tions following therapy were difficult margin. da Silva, R. C., Joly, J. C., de Lima, A. F. &
to investigate in this systematic review Tatakis, D. N. (2004) Root coverage using
due to data heterogeneity. CAF1BM Conclusions
the coronally positioned flap with or without
was frequently associated with mem- a subepithelial connective tissue graft. Jour-
brane exposure (Jepsen et al. 1998, nal of Periodontology 75, 413–419.
Amarante et al. 2000, Tatakis & Trom- 1. CAF is a safe and predictable Del Pizzo, M., Zucchelli, G., Modica, F., Villa,
belli 2000, Lins et al. 2003) even if R. & Debernardi, C. (2005) Coronally
approach for root coverage.
advanced flap with or without enamel matrix
others did not report exposure (Romag- 2. CTG or EMD in conjunction with derivative for root coverage: a 2-year study.
na-Genon 2001). CTG1CAF was fre- CAF procedure enhances the prob- Journal of Clinical Periodontology 32,
quently associated with swelling ability to obtain CRC and to improve 1181–1187.
(Cortellini et al. unpublished data) and recession reduction in Miller Class I Huang, L-H., Neiva, R. E. F., Soehren, S. E.,
pain at the donor site (Romagna-Genon and II single gingival recession. Giannobile, W. V. & Wang, H-L. (2005) The
2001), even if these side effects were not 3. BM do not improve the clinical ben- effect of platelet-rich plasma on the coronally
confirmed by others (Jepsen et al. 1998, efits of CAF alone. advanced flap root coverage procedure: a
Tatakis & Trombelli 2000). Possible 4. Contradictory results were associated pilot human trial. Journal of Periodontology
reasons may be related to different with use of ADM in conjunction with 76, 1768–1777.
approaches in the harvesting technique Jepsen, K., Heinz, B., Halben, J. H. & Jepsen, S.
CAF.
(1998) Treatment of gingival recession with
or suturing modalities in different stu-
titanium reinforced barrier membranes versus
dies. On the other hand, CAF1EMD connective tissue grafts. Journal of Perio-
seemed to have limited post-operative dontology 69, 383–391.
discomfort. No RCT included in this References
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systematic review describes PD Ciotti, D. L. & Cury, P. R. (2007) Root
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The methodological assessment per- G. H., Nasr, H. F. & Mayer, E. T. (2001) nal of Periodontology 78, 1017–1022.
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Saletta, D., Cairo, F. & Cortellini, P. (2000) Sanz, M. (2002) Periodontal plastic surgery E-mail: cairofrancesco@virgilio.it
Clinical Relevance Principal findings: The additional Practical implications: CTG or

Scientific rationale for the study: To use of CTG and EMD enhanced the EMD should be considered in con-
investigate the potential benefit of clinical outcomes of CAF, while BM junction with CAF to improve the
adding tissue grafts, BM, EMD or did not. Controversial results were probability of obtaining CRC.
other material under CAF. found with the adjunctive use of
ADM.
r 2008 The Authors


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J Clin Periodontol 2008; 35 (Suppl. 8): 136–162 doi: 10.1111/j.1600-051X.2008.01267.

Treatment of gingival recession Francesco Cairo, Umberto Pagliaro

with coronally advanced flap Florence, Florence, Italy

procedures: a systematic review

Fig. 1. Literature search process and results.

2006, Barros et al. 2007, Felipe

Methodological quality of the included

Randomization was reported in all stu-

Table 5. (Cont.) comparison, the test for heterogene-

Six studies compared CAF1BM

Two studies compared CAF1CTG

Table 8. (Cont.) Two studies compared CAF1

Table 8. (Cont.) Root sensitivity

Table 10. (Cont.) ing root coverage procedures. No meta-

Clinical Relevance Principal findings: The additional Practical implications: CTG or

r 2008 The Authors

You might also like

Cairo 2008

Uploaded by

Document Information

Copyright

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Share this document

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Copyright:

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Cairo 2008

Uploaded by

Copyright:

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J Clin Periodontol 2008; 35 (Suppl. 8): 136–162 doi: 10.1111/j.1600-051X.2008.01267.

Treatment of gingival recession Francesco Cairo, Umberto Pagliaro

with coronally advanced flap Florence, Florence, Italy

procedures: a systematic review

Fig. 1. Literature search process and results.

2006, Barros et al. 2007, Felipe

Methodological quality of the included

Randomization was reported in all stu-

Table 5. (Cont.) comparison, the test for heterogene-

 Six studies compared CAF1BM

 Two studies compared CAF1CTG

Table 8. (Cont.)  Two studies compared CAF1

Table 8. (Cont.) Root sensitivity

Table 10. (Cont.) ing root coverage procedures. No meta-

Clinical Relevance Principal findings: The additional Practical implications: CTG or

r 2008 The Authors

You might also like

Six studies compared CAF1BM

Two studies compared CAF1CTG

Table 8. (Cont.) Two studies compared CAF1