Cochrane · intervention · CD007161
Root coverage procedures for treating localised and multiple recession‐type defects
Chambrone, L, Salinas Ortega, MA, Sukekava, F, et al. · Cochrane Database of Systematic Reviews · 2018 · Cochrane Library
Full textEvery question was extracted from the full review (methods and results), not only its Summary of Findings table.
Questions
60
current version
GRADE rated
25
No studies
7
Included studies
48
as reported
No studies 7 · 11.7%Ungraded 28 · 46.7%Very low 7 · 11.7%Low 18 · 30%Moderate 0 · 0%High 0 · 0%
Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Clinical diagnosis of localised or multiple recession-type defects; Miller's Class I or Class II of at least 3 mm; at least 10 participants per group at final examination | 1227 patients treated; 48 RCTs (28 split-mouth, 20 parallel); 8 private practice based, 35 university or dental hospital based, 5 multicentre; 5 studies evaluated multiple recession-type defects and the rest single defects |
| Intervention | Free gingival grafts (FGG); laterally positioned flap (LPF); coronally advanced flap (CAF); subepithelial connective tissue grafts (SCTG) alone or with LPF or CAF; CAF in association with allograft (e.g. acellular dermal matrix grafts (ADMG)), guided tissue regeneration (GTR), enamel matrix protein (EMP), xenogeneic matrix grafts (XMG) or other biomaterial; RCTs comparing variations of the same procedure | ADMG + CAF (increased); CAF (increased); enamel matrix protein or derivative (EMP/EMD) + CAF (increased); GTR rm + CAF (increased); GTR nrm + CAF (increased); GTR rm associated with bone substitutes + CAF (increased); SCTG + CAF (increased); free gingival grafts (FGG); xenogeneic collagen matrix (XCM) + CAF (new); platelet-rich fibrin or plasma (PRF/PRP) + CAF (new); recombinant human platelet-derived growth factor (rhPDGF-BB) with beta-tricalcium phosphate (b-TCP) + CAF (new) |
| Comparison | Not specified (head-to-head comparisons of root coverage periodontal plastic surgery procedures) | Not reported |
| Outcomes | Primary: aesthetic condition change related to patient's opinion (including standardised methods, e.g. VAS); number and percentage of sites with complete root coverage; gingival recession depth change (mm). Secondary: clinical attachment level change (mm); keratinized tissue width change (mm); mean root coverage (%); patients' preference; adverse effects or postoperative complications | Aesthetic condition change related to patient's opinion (n=10); gingival recession depth change (n=48); clinical attachment level change (n=48); keratinized tissue width change (n=48); number and percentage of sites with complete root coverage (n=34); mean root coverage (n=48); patients' preference for a specific PPS procedure (n=3); occurrence of adverse effects and/or postoperative complications (n=15) |
| Study designs | Randomised controlled trials (RCTs) of at least 6 months' duration reporting patient-based analysis | Randomised controlled trials (n=48) |
| Timing | Short term (6 to 12 months); medium term (13 to 59 months); long term (60 or more months, at least 5 years) | Short term (6 to 12 months) (n=38); medium term (13 to 59 months) (n=5); long term (60 or more months) (n=5) |
Search date: 15 January 2018. Databases: Cochrane Oral Health's Trials Register; CENTRAL (2017, Issue 12) in the Cochrane Library; MEDLINE Ovid (1946 to 15 January 2018); Embase Ovid (1980 to 15 January 2018)
Questions and results
Current version onlyADMG + CAF vs SCTG + CAF
Population: Adult patients with single (localised) recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Gingival recession change Short term (6 to 12 months) | MD -0.36 [-1.03, 0.30] | 4 studies · 100 participants | Low Downgraded: imprecision, inconsistency |
Keratinized tissue change Short term (6 to 12 months) | MD -0.59 [-1.27, 0.10] | 4 studies · 100 participants | Very low Downgraded: imprecision, inconsistency |
Aesthetic condition change related to patient's opinion Short term (6 to 12 months) | Aesthetic condition change related to patient's opinion: Not reported (SoF main comparison) | 0 studies | No studies |
Clinical attachment level change Short term (6 to 12 months) | MD -0.53 [-1.14, 0.08] | 4 studies · 100 participants | Low Downgraded: imprecision, inconsistency |
Sites with complete root coverage Short term (6 to 12 months) | OR 0.43 [0.13, 1.37] -275 fewer per 1000 | 2 studies · 50 participants | Low Downgraded: imprecision |
ADMG + CAF vs CAF
Population: Adult patients with single (localised) recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Occurrence of adverse effects or postoperative complications Short term (6 to 12 months) | Ahmedbeyli 2014: patients rated ADMG + CAF and CAF equally for pain during surgery, discomfort, postsurgical pain/swelling and complications | 1 study | Ungraded |
Clinical attachment level change Short term (6 to 12 months) | MD 0.51 [-0.25, 1.27] | 2 studies · 50 participants | Low Downgraded: imprecision, inconsistency |
Sites with complete root coverage Short term (6 to 12 months) | OR 3.97 [0.20, 80.50] 327 more per 1000 | 2 studies · 50 participants | Very low Downgraded: imprecision, inconsistency |
Keratinized tissue width change Short term (6 to 12 months) | MD 0.28 [-0.08, 0.64] | 2 studies · 50 participants | Low Downgraded: imprecision, inconsistency |
Gingival recession depth change Short term (6 to 12 months) | MD 0.61 [-0.52, 1.73] | 2 studies · 50 participants | Low Downgraded: imprecision, inconsistency |
Aesthetic condition change related to patient's opinion Short term (6 to 12 months) | Aesthetic condition change related to patient's opinion: Not reported (SoF 2) | 0 studies | No studies |
EMP + CAF vs CAF
Population: Adult patients with single (localised) recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Aesthetic condition change related to patient's opinion | Sangiorgio 2017 (VAS): root coverage aesthetics and overall aesthetic results showed similar/equivalent outcomes for EMP + CAF and CAF | 1 study | Ungraded |
Keratinized tissue width change (short and medium term) Short and medium term (6 to 24 months) | MD 0.40 [0.17, 0.62] | 3 studies | Ungraded |
Gingival recession depth change (short and medium term) Short and medium term (6 to 24 months) | MD 0.32 [0.10, 0.55] | 3 studies | Ungraded |
Clinical attachment level change Short term (6 to 12 months) | MD 0.22 [-0.02, 0.45] | 3 studies · 136 participants | Low Downgraded: imprecision, inconsistency |
Gingival recession depth change Short term (6 to 12 months) | MD 0.07 [-0.25, 0.40] | 3 studies · 136 participants | Low Downgraded: imprecision, inconsistency |
Keratinized tissue width change Short term (6 to 12 months) | MD 0.35 [0.13, 0.56] | 3 studies · 136 participants | Low Downgraded: imprecision, inconsistency |
Clinical attachment level change (short and medium term) Short and medium term (6 to 24 months) | MD 0.35 [0.09, 0.61] | 3 studies | Ungraded |
GTR rm + CAF vs SCTG + CAF
Population: Adult patients with single (localised) recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Occurrence of adverse effects or postoperative complications Short term (6 to 12 months) | Wang 2001: two patients treated with SCTG experienced adverse effects (one postsurgical swelling, one postsurgical ecchymosis) | 1 study | Ungraded |
Gingival recession change Short term (6 to 12 months) | MD -0.37 [-0.60, -0.13] | 3 studies · 98 participants | Low Downgraded: imprecision |
Aesthetic condition change related to patient's opinion Short term (6 to 12 months) | Aesthetic condition change related to patient's opinion: Not reported (SoF 5) | 0 studies | No studies |
Clinical attachment level change Short term (6 to 12 months) | MD 0.35 [0.06, 0.63] | 3 studies · 98 participants | Low Downgraded: imprecision |
Patients' preference for a specific procedure Short term (6 to 12 months) | Wang 2001: participants reported greater overall satisfaction with GTR rm than SCTG (reduced treatment time, no need for a second surgical site) | 1 study | Ungraded |
Sites with complete root coverage Short term (6 to 12 months) | OR 0.61 [0.30, 1.24] -122 fewer per 1000 | 3 studies · 98 participants | Low Downgraded: imprecision |
Keratinized tissue change Short term (6 to 12 months) | MD -1.77 [-2.66, -0.89] | 3 studies · 98 participants | Very low Downgraded: imprecision, inconsistency |
GTR rm + CAF vs GTR nrm + CAF
Population: Adult patients with single (localised) recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical attachment level change Short term (6 to 12 months) | MD 0.12 [-0.37, 0.60] | 2 studies | Ungraded |
Keratinized tissue width change Short term (6 to 12 months) | MD 0.12 [-0.23, 0.48] | 2 studies | Ungraded |
Sites with complete root coverage Short term (6 to 12 months) | OR 1.33 [0.46, 3.85] | 2 studies | Ungraded |
Gingival recession depth change Short term (6 to 12 months) | MD 0.23 [-0.22, 0.68] | 2 studies | Ungraded |
Patients' preference for a specific procedure Short term (6 to 12 months) | Roccuzzo 1996: all patients preferred the GTR treatment because it was a single-step procedure | 1 study | Ungraded |
Aesthetic condition change related to patient's opinion Short term (6 to 12 months) | Aesthetic condition change was not reported for this comparison | 0 studies | No studies |
Occurrence of adverse effects or postoperative complications Short term (6 to 12 months) | Roccuzzo 1996: membrane exposure reported between the first and second weeks of healing | 1 study | Ungraded |
GTR rm associated with bone substitutes + CAF vs SCTG + CAF
Population: Adult patients with single (localised) recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Gingival recession depth change Short term (6 to 12 months) | MD -0.82 [-2.13, 0.49] | 2 studies | Ungraded |
Clinical attachment level change Short term (6 to 12 months) | MD -0.52 [-1.34, 0.30] | 2 studies | Ungraded |
Keratinized tissue width change Short term (6 to 12 months) | MD -2.38 [-2.84, -1.92] | 2 studies | Ungraded |
Aesthetic condition change related to patient's opinion Short term (6 to 12 months) | Rosetti 2013: patient satisfaction survey indicated all patients satisfied with aesthetic results of both procedures at 18 months; no significant differences between 18- and 30-month assessments | 1 study | Ungraded |
GTR rm associated with bone substitutes + CAF vs GTR rm + CAF
Population: Adult patients with single (localised) recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Keratinized tissue width change Short term (6 to 12 months) | MD 0.23 [-0.21, 0.68] | 2 studies | Ungraded |
Occurrence of adverse effects or postoperative complications Short term (6 to 12 months) | Dodge 2000: membrane exposure reported between the first and second weeks of healing | 1 study | Ungraded |
Clinical attachment level change Short term (6 to 12 months) | MD 0.76 [-0.01, 1.54] | 2 studies | Ungraded |
Sites with complete root coverage Short term (6 to 12 months) | OR 1.87 [0.75, 4.64] | 2 studies | Ungraded |
Gingival recession depth change Short term (6 to 12 months) | MD 0.48 [0.09, 0.88] | 2 studies | Ungraded |
Aesthetic condition change related to patient's opinion Short term (6 to 12 months) | Aesthetic condition change was not reported for this comparison | 0 studies | No studies |
Laterally positioned flap (LPF) vs Any other root coverage procedure
Population: Adult patients with single (localised) recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Outcome NR | We did not find any RCTs evaluating laterally positioned flaps (LPF) | 0 studies | No studies |
EMP + CAF vs SCTG + CAF
Population: Adult patients with single (localised) recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Sites with complete root coverage Short and medium term (6 to 24 months) | OR 0.61 [0.05, 7.86] -215 fewer per 1000 | 2 studies · 62 participants | Very low Downgraded: imprecision, inconsistency |
Aesthetic condition change related to patient's opinion 10 years | McGuire 2012 (10 years after surgery): 6 patients had no preference for a particular treatment, 2 favoured EMD + CAF, 1 favoured SCTG + CAF (P=0.564) | 1 study | Very low Downgraded: risk of bias, imprecision, inconsistency |
Clinical attachment change Short term (6 to 12 months) | MD -0.25 [-0.69, 0.20] | 2 studies · 62 participants | Low Downgraded: imprecision |
Occurrence of adverse effects or postoperative complications | McGuire 2012: patient-reported discomfort statistically significantly higher for SCTG than EMP + CAF, only at 1 month postoperatively | 1 study | Ungraded |
Keratinized tissue change Short term (6 to 12 months) | MD -1.06 [-1.36, -0.76] | 2 studies · 62 participants | Very low Downgraded: imprecision, inconsistency |
Gingival recession change Short term (6 to 12 months) | MD -0.39 [-1.27, 0.48] | 2 studies · 62 participants | Very low Downgraded: imprecision, inconsistency |
XCM + CAF vs CAF
Population: Adult patients with single (localised) recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Aesthetic condition change related to patient's opinion | Sangiorgio 2017 (VAS): root coverage aesthetics and overall aesthetic results were similar for XCM + CAF and CAF, irrespective of the treatment applied | 1 study | Low Downgraded: imprecision, inconsistency |
Sites with complete root coverage Short term (6 to 12 months) | OR 4.73 [2.35, 9.50] 358 more per 1000 | 2 studies · 104 participants | Low Downgraded: imprecision, inconsistency |
Gingival recession depth change Short term (6 to 12 months) | MD 0.40 [0.11, 0.68] | 2 studies · 104 participants | Low Downgraded: imprecision, inconsistency |
Keratinized tissue width change Short term (6 to 12 months) | MD 0.44 [0.04, 0.85] | 2 studies · 104 participants | Low Downgraded: imprecision, inconsistency |
Clinical attachment level change Short term (6 to 12 months) | MD 0.37 [-0.09, 0.83] | 2 studies · 104 participants | Low Downgraded: imprecision, inconsistency |
Occurrence of adverse effects or postoperative complications | Jepsen 2013: no differences regarding pain and discomfort between XCM + CAF and CAF (for all defects) | 1 study | Ungraded |
PRF + CAF vs SCTG + CAF
Population: Adult patients with multiple recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Occurrence of adverse effects or postoperative complications Short term (6 to 12 months) | Oncu 2017: VAS showed less discomfort during the first postoperative week for PRF + CAF compared to SCTG + CAF | 1 study | Ungraded |
Aesthetic condition change related to patient's opinion Short term (6 to 12 months) | Aesthetic condition change was not reported for this comparison | 0 studies | No studies |
Keratinized tissue width change Short term (6 to 12 months) | MD -0.26 [-0.98, 0.45] | 2 studies | Ungraded |
Clinical attachment level change Short term (6 to 12 months) | MD -0.37 [-0.69, -0.06] | 2 studies | Ungraded |
Gingival recession depth change Short term (6 to 12 months) | MD -0.01 [-0.89, 0.86] | 2 studies | Ungraded |
Acellular dermal matrix grafts (ADMG) vs Subepithelial connective tissue grafts (SCTG)
Population: Adults with localised or multiple recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical attachment level change Short term (6 to 12 months) | MD -0.81 [-1.92, 0.30] | 2 studies | Ungraded |
Keratinized tissue change Short term (6 to 12 months) | MD -0.83 [-2.09, 0.44] | 2 studies | Ungraded |
Gingival recession change Short term (6 to 12 months) | MD -0.76 [-1.93, 0.42] | 2 studies | Ungraded |
Acellular dermal matrix grafts (ADMG) vs Coronally advanced flap (CAF)
Population: Adults with localised or multiple recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Keratinized tissue change Short term (6 to 12 months) | MD 0.31 [-0.15, 0.77] | 2 studies | Ungraded |
Clinical attachment level change Short term (6 to 12 months) | MD 0.56 [-0.21, 1.33] | 2 studies | Ungraded |
Sites with complete root coverage Short term (6 to 12 months) | Sites with complete root coverage (Analysis 2.4): no statistically significant difference between ADMG and CAF; a substantial number did not achieve complete coverage (ADMG 14/25 and CAF 7/25 did not) | NR | Ungraded |
Gingival recession change Short term (6 to 12 months) | MD 0.62 [-0.51, 1.74] | 2 studies | Ungraded |
Enamel matrix protein (EMP) + CAF vs Coronally advanced flap (CAF)
Population: Adults with localised or multiple recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical attachment level change Long term (13 or more months) | MD 0.27 [-0.16, 0.69] | 2 studies | Ungraded |
Keratinized tissue change Long term (13 or more months) | MD 0.40 [0.09, 0.71] | 2 studies | Ungraded |
Gingival recession change Long term (13 or more months) | MD 0.25 [-0.13, 0.64] | 2 studies | Ungraded |
Guided tissue regeneration, resorbable membrane (GTR rm) vs Subepithelial connective tissue grafts (SCTG)
Population: Adults with localised or multiple recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Keratinized tissue change Short term (6 to 12 months) | MD -1.95 [-2.66, -1.24] | 3 studies | Ungraded |
Gingival recession change Short term (6 to 12 months) | MD -0.39 [-0.65, -0.12] | 3 studies | Ungraded |
Clinical attachment level change Short term (6 to 12 months) | MD 0.31 [-0.01, 0.62] | 3 studies | Ungraded |
Sites with complete root coverage Short term (6 to 12 months) | RR 0.71 [0.47, 1.08] | NR | Ungraded |
Guided tissue regeneration, resorbable membrane (GTR rm) vs Guided tissue regeneration, non-resorbable membrane (GTR nrm)
Population: Adults with localised or multiple recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Gingival recession change Short term (6 to 12 months) | MD 0.32 [-0.03, 0.68] | 2 studies | Ungraded |
Sites with complete root coverage Short term (6 to 12 months) | RR 1.18 [0.61, 2.31] | NR | Ungraded |
Keratinized tissue change Short term (6 to 12 months) | MD 0.11 [-0.29, 0.51] | 2 studies | Ungraded |
Clinical attachment level change Short term (6 to 12 months) | MD 0.15 [-0.38, 0.68] | 2 studies | Ungraded |
GTR rm associated with bone substitutes vs Subepithelial connective tissue grafts (SCTG)
Population: Adults with localised or multiple recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical attachment level change Short to medium term (12 to 18 months) | Clinical attachment level change not evaluated (not pooled) due to lack of data from Rosetti 2000 | NR | Ungraded |
Keratinized tissue change Short to medium term (12 to 18 months) | MD -2.10 [-2.51, -1.69] | 2 studies | Ungraded |
Gingival recession change Short to medium term (12 to 18 months) | MD -0.75 [-1.92, 0.43] | 2 studies | Ungraded |
Aesthetic condition change related to patient's opinion Short to medium term (12 to 18 months) | Rosetti 2000: patient satisfaction survey indicated all patients were satisfied with the aesthetic results achieved by both procedures at 18 months | 1 study | Ungraded |
GTR rm associated with bone substitutes vs Guided tissue regeneration, resorbable membrane (GTR rm)
Population: Adults with localised or multiple recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Gingival recession change Short term (6 to 12 months) | MD 0.46 [-0.02, 0.94] | 2 studies | Ungraded |
Sites with complete root coverage Short term (6 to 12 months) | RR 1.40 [0.76, 2.57] | NR | Ungraded |
Keratinized tissue change Short term (6 to 12 months) | MD 0.13 [-0.12, 0.37] | 2 studies | Ungraded |
Clinical attachment level change Short term (6 to 12 months) | MD 0.72 [-0.06, 1.50] | 2 studies | Ungraded |
Laterally positioned flap (LPF) vs Any other root coverage procedure
Population: Adults with localised or multiple recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Outcome NR | No data exist for laterally positioned flaps (LPF); a planned intervention for which no eligible RCT was identified | 0 studies | No studies |
Root coverage periodontal plastic surgery (PPS) procedures (FGG; LPF; CAF; SCTG alone or with LPF/CAF; ADMG; GTR; EMP) vs Head-to-head comparison with another root coverage procedure (not specified)
Population: Adults with localised or multiple recession-type defects (Miller Class I/II, at least 3 mm)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Mean root coverage | Protocol (2008): pre-specified planned secondary outcome; no studies included at protocol stage (protocol had no Results or Summary of findings). | 0 studies | No studies |
Gingival recession change | Protocol (2008): pre-specified planned primary outcome; no studies included at protocol stage (protocol had no Results or Summary of findings). | 0 studies | No studies |
Aesthetic condition change related to patient's opinion | Protocol (2008): pre-specified planned primary outcome; no studies included at protocol stage (protocol had no Results or Summary of findings). | 0 studies | No studies |
Keratinized tissue change | Protocol (2008): pre-specified planned secondary outcome; no studies included at protocol stage (protocol had no Results or Summary of findings). | 0 studies | No studies |
Occurrence of adverse effects and/or postoperative complications | Protocol (2008): pre-specified planned secondary outcome; no studies included at protocol stage (protocol had no Results or Summary of findings). | 0 studies | No studies |
Patients' preference for a specific PPS procedure | Protocol (2008): pre-specified planned secondary outcome; no studies included at protocol stage (protocol had no Results or Summary of findings). | 0 studies | No studies |
Clinical attachment change | Protocol (2008): pre-specified planned secondary outcome; no studies included at protocol stage (protocol had no Results or Summary of findings). | 0 studies | No studies |
Percentage of sites with complete root coverage | Protocol (2008): pre-specified planned secondary outcome; no studies included at protocol stage (protocol had no Results or Summary of findings). | 0 studies | No studies |