8012.

qxd 12/30/03 3:34 PM Page 303

Ann Periodontol

Surgical Therapies for the Treatment of Gingival Recession.

A Systematic Review
Thomas W. Oates,* Melanie Robinson,* and John C. Gunsolley

* Department of Periodontics, University of Texas Health Science Center at San Antonio, San Antonio, Texas.
Department of Periodontics, Baltimore College of Dental Surgery, University of Maryland, Baltimore, Maryland.

Background: A variety of soft tissue augmentation procedures directed at root coverage have been docu-
mented in the literature utilizing autogenous or allogenic soft tissue grafting or guided tissue regeneration
(GTR).
Rationale: The purpose of this systematic review was to assess the literature regarding the efficacies of
various surgical gingival augmentation procedures relative to clinical and patient-oriented outcomes.
Focused Question: What is the effect of surgical therapy for root coverage in patients with gingival reces-
sion compared with other treatment modalities or baseline values?
Search Protocol: PubMed and the Cochrane Oral Health Group Trials Register were searched to identify
human studies in English investigating the therapeutic use of a soft tissue surgical procedure to treat gin-
gival recession. Searches were performed for articles published by April 2002.
Selection Criteria: Initial screening of identified abstracts accepted all studies evaluating surgical inter-
vention of gingival recession. Independent review by 2 reviewers evaluated full-text reports regarding study
characteristics. Only those studies determined to be randomized clinical trials (RCTs) were included in the
final analysis.
Data Analysis and Collection: Outcome measures included changes in root coverage, clinical attachment
levels (CAL), probing depth (PD), and width of keratinized tissue (KT). The only data suitable for meta-
analysis were comparisons of the efficacy of connective tissue grafts with GTR.
Main Results
1. Thirty-two articles (total study population: 687) met the criteria for RCTs: 11 (population: 286) related to
various autogenous soft tissue augmentation procedures; 18 (population: 360) to GTR; and 3 (population: 41)
to allogenic soft tissue augmentation.
2. Meta-analysis identified greater gains in both root coverage and keratinized tissue width for connective
tissue graft procedures compared to GTR.
3. No other data were compatible with meta-analysis.
Reviewers Conclusions
1. Soft tissue augmentation procedures are effective means of obtaining root coverage.
2. Connective grafting techniques appear to have an advantage over GTR.
3. There is a need for further efficacy studies and for investigation of these procedures relative to patient-
oriented outcomes such as esthetics, root sensitivity, and postoperative morbidities.
Ann Periodontol 2003;8:303-320.
KEY WORDS
Grafts, soft tissue; guided tissue regeneration; tooth root/surgery; periodontal diseases/surgery;
review literature; meta-analysis.

303
8012.qxd 12/30/03 3:34 PM Page 304
Surgical Treatment of Gingival Recession
BACKGROUND
Periodontal therapy has historically been directed pri-
marily at the elimination of disease and the maintenance
of a functional, healthy dentition and supporting tissues.
However, more recently periodontal therapy, consistent
with dental therapy in general, is increasingly directed
at esthetic outcomes for patients, which extend beyond
tooth replacement and tooth color to include the soft
tissue component framing the dentition.
Probably one of the most common esthetic con-
cerns associated with the periodontal tissues is gingival
recession. Gingival recession may be associated with
anatomic factors, inflammatory conditions, or trauma.
The progression of recession defects warrants both the
investigation of etiologic factors and the consideration
of therapeutic actions directed at minimizing the pro-
gression of the apical movement of the gingival margin.
In many cases, these therapies directed at stopping
the progression also enhance the esthetic appearance
of the tissues. Root surface exposure resulting from
gingival recession may also produce hypersensitivity;
that is, a region of heightened temperature or tactile
sensitivity along the exposed root surface. Covering
the exposed root surface may decrease these symp-
toms. Additionally, there may be circumstances where
recession defects create anatomic contours or a lack
of keratinized tissue limiting proper plaque removal.
Any of these indications, including esthetics, progres-
sion of the defect, hypersensitivity, or difficulties with
oral hygiene may support the use of periodontal plastic
surgical procedures.
Periodontal plastic surgery includes periodontal
surgical procedures performed to prevent, correct, or eli-
minate anatomical, developmental, traumatic, or plaque-
induced disease-related defects in the gingiva or alveolar
mucosa.1 The adoption of the plastic surgery termi-
nology in itself suggests the increasing importance of
the supporting tissues in the esthetics of the dentition.
There are multiple periodontal plastic surgery app-
roaches documented in the literature for the treatment
of gingival recession defects. These treatment approa-
ches generally include the manipulation of the patients
tissues to augment the soft tissues and cover the
exposed root surface. Flap positioning allows for the
maintenance of a vascular blood supply to the tissue,
whereas a complete removal of autogenous graft tissue
from intact vascular support to a distinct location
requires the reformation of vascular supply to the grafted
tissue. These grafting procedures may also take advan-
tage of tissues procured in an allogeneic manner. More
recently, the use of guided tissue regeneration (GTR)
techniques have been utilized in re-establishing soft
tissue dimensions over areas of recession. Each of these
treatment approaches has been documented in the
literature as having therapeutic benefit. There are mul-
tiple surgical techniques, materials, and root surface
304
Volume 8 Number 1 December 2003
modification variables that may be considered, which
complicate investigations relating to the effectiveness of
these various approaches.
RATIONALE
The treatment options for soft tissue augmentation of
gingival recession defects have been documented in
numerous case reports and clinical investigations. A
recent comprehensive review of this literature initially
considered 590 articles related to this topic, selecting
216 for review.1 This review failed to identify any sig-
nificant treatment advantages of one surgical approach
over the others. With the current trend toward evidence-
based assessments of treatment, it becomes increas-
ingly important for us to consider therapeutic outcomes
relative to currently accepted treatment approaches.
With the extensive literature available, it is difficult to
assimilate these various studies into a meaningful pol-
icy. One approach toward achieving this assimilation
of a large number of investigations is to perform a
prospective, systematic review of the literature using
well-defined criteria for inclusion of reports in the final
considerations.
FOCUSED QUESTION
The purpose of this prospective systematic review was
to assess the effectiveness of periodontal plastic
surgery procedures in treating patients with gingival
recession. Specifically, this assessment was to answer
the following question: What is the effect of surgical
therapy for root coverage in patients with gingival
recession compared with other treatment modalities
or baseline values?
SEARCH PROTOCOL
Data Sources and Search Strategies
Initially, all identified references collected from 2 data-
bases (PubMed, NCBI, National Library of Medicine
and the Cochrane Oral Health Group) were screened
to include only those human studies written in the Eng-
lish language investigating the therapeutic use of a
soft tissue surgical procedure in the treatment of gin-
gival recession.
Search Strategy
Database searches were conducted to identify studies
with or as the connector between the following terms:
gingival recession, gingival augmentation, mucogin-
gival defect, mucogingival surgery, gingival graft, root
coverage, and connective tissue graft. Publication cut-
off date was April 2002.
Inclusion criteria: Inclusion of articles was based on
a careful review of the study title and abstract as to meet-
ing the following eligibility criteria: human study, English
language, and therapeutic study including the use of a
gingival surgical procedure to treat gingival recession.
8012.qxd 12/30/03 3:34 PM Page 305

Ann Periodontol Oates, Robinson, Gunsolley

Exclusion criteria: Reports clearly not meeting inclu- Study participants: Studies included subjects hav-
sion criteria were excluded, otherwise articles were ing identified gingival recession defects of the soft tis-
considered in a secondary review. sue margin exposing the root surface of a tooth.
Interventions. Surgical therapy interventions included
Screening Procedures all surgical therapies aimed at treating gingival reces-
Preliminary screening of identified studies included an sion defects and specifically included the use of auto-
independent assessment by the primary reviewer (TWO). genous and allogeneic soft tissue grafts and guided
Review of these references was based on title and abs- tissue regeneration procedures.
tract information. Outcomes: Primary outcome measures included
Secondary review of all identified references, con- patient attitude toward defect, procedures, and results,
ducted in an independent manner by the primary including changes in esthetics, root surface sensitivity,
(TWO) and secondary (MR) reviewers, involved the and therapeutic morbidity. Additionally, surrogate meas-
review of full text versions of the studies identified in ures included percentage of sites with complete root
the initial screening. Each reviewer independently coverage, changes in gingival recession, probing depth
assessed studies for qualitative characteristics using (PD), clinical attachment levels (CAL), and amount of
a standardized assessment form (Fig. 1). All studies keratinized tissue.
excluded by both reviewers were excluded from further
consideration. Disagreements between examiners were Data Collection and Analysis
resolved following joint review and discussion by the Quality appraisal. Studies were evaluated for randomi-
examiners. Only studies determined to be randomized zation, masking, inclusion of control comparisons, and
controlled clinical trials (RCTs) were considered in the follow-up of subjects.
final analysis. Analysis. Study summary statistics included thera-
peutic modality, follow-up
I. Study Design: period, number of patients/
teeth, pretreatment defect
________ Randomized controlled clinical trial (RCT) dimensions, changes in defect
________ Case-control (observational with control group)
dimensions and/or root cover-
________ Case series (observational-no control group)
age, residual PD, changes in
II. Study Criteria: (need both of these: check if yes or not sure) CAL and gingival margin posi-
tions, and subject assessments
________ Human
of changes in esthetics or tooth
________ Therapeutic for gingival recession/root coverage
sensitivity.
III. If steps I and II above are met, proceed below: Study groupings were based
on therapeutic modalities inves-
1. What was test treatment? ____________________
2. What was control treatment? ____________________ tigated, outcomes measured,
3. Was it randomized? ________ Yes ________ no ________ unsure and quality of studies. Identifi-
4. Method of randomization listed? ________ Yes ________ no ________ unsure cation of 3 or more randomized
5. Patients masked? ________ Yes ________ no ________ unsure controlled clinical studies com-
6. Therapists masked? ________ Yes ________ no ________ unsure paring the same therapeutic
7. Examiners masked? ________ Yes ________ no ________ unsure modalities were considered for
8. Method of masking adequate? ________ Yes ________ no ________ unsure meta-analysis based on com-
9. Prospective assessment? ________ Yes ________ no ________ unsure mon outcome measures and
10. Retrospective assessment? ________ Yes ________ no ________ unsure levels of study quality.
11. Sequential cases? ________ Yes ________ no ________ unsure
The only study information
12. All cases accounted for? ________ Yes ________ no ________ unsure
that was appropriate for meta-
13. Outcome Measures Included:
Defect types: _________________ ________ Change in keratinized tissue analysis was a comparison of
______ Number of subjects ________ Number of sites the efficacy of connective
______ Follow-up period ________ Number of teeth/patient tissue (CT) grafts with guided
______ Pretreatment defect dimensions ________ Change in defect dimension tissue regeneration procedures
______ Changes in root coverage ________ Residual CAL/PD (GTR). The outcome variables
______ Changes in CAL/PD: ________ Changes in gingival margin assessed were amount of root
coverage gained and kera-
Subject assessments of: ________ esthetics ________ sensitivity ________ other
tinized tissue. Heterogeneity of
results between studies was
Figure 1. also assessed. The data were
Form used for full article screening.
analyzed using a standardized

305
8012.qxd 12/30/03 3:34 PM Page 306

Surgical Treatment of Gingival Recession Volume 8 Number 1 December 2003

difference as described by Fleiss.2 The results were teen12,13,20,21,24,25,28,32,34,44,46,49,52,53,68,72,74,87 of the 32

checked with both a fixed effects model and a ran-
dom effects model and the results were consistent. To
test for heterogeneity both Cohens d (unadjusted) and
Hedgess g (adjusted) were used.3,4 Both tests had to
be nonsignificant to support the lack of heterogeneity.
RESULTS
Initial application of described search strategies resulted
in the identification of 1,434 reports that were eligible for
screening. Initial screening by the primary reviewer iden-
tified 139 articles appropriate for full review by both
reviewers.5-143 Of these 139 articles, 32 were selected
based on the criteria above for inclusion in this system-
atic review, with all but 2 articles included without dis-
cussion between reviewers to reach agreement. Of the
32 articles under review, 1110,33,36,41,62,63,70,76,78,86,110
evaluated autogenous soft tissue grafting procedures,
including coronally advanced flap procedures with or
without free tissue augmentation, free gingival grafts,
and connective tissue grafts using several technical
approaches (Table 1). These studies were so
inconsistent on the basis of interventions for both the
experimental group and the control group that there
were virtually no 2 studies alike. For that reason there
was no quantitative analysis of the data. Eigh-
articles evaluated GTR procedures aimed at soft tissue
augmentation. These studies evaluated both bioab-
sorbable and non-resorbable materials (Table 2, page
308). The 3 remaining studies9,14,18 evaluated the use
of allogeneic soft tissue grafting materials (Table 3, page
310). The studies evaluated the effects of these various
therapies from 3 months postsurgically to as long as 6
years. As may be expected, those studies with the
longest follow-up period also had the greatest ranges in
evaluation periods. The most consistent comparison
among the studies was a control group of a connective
tissue graft compared to a therapeutic group of GTR (9
studies9,12,13,14,34,44,49,52,53 evaluated). A meta-analy-
sis of this comparison was done (Fig 2, page 312.)
Quality Assessment of Studies
Overall, evaluation of the quality of the studies was
very difficult due to the failure of many reports to
provide sufficient information allowing for accurate
assessment. Eleven of the 32 studies reported masked
examiners and 5 studies clearly utilized sequentially
enrolled subjects (see Tables 1, 2, and 3).
Only randomized studies were included for this analy-
sis. Methods of randomization for these studies varied
from no mention of methods of randomization (but were

Table 1.
Autogenous Grafting Procedures*

Intervention
N N Examiner Sequential
Reference Defect Type Subjects Defects Blinded? Cases Test Controls

Borghetti & Louise76 1994 Miller I-III 15 30 N N CTG/double papillae None

Bouchard et al.62 1997 Miller I-II 30 30 N N CTG/CPF + TET CTG/CPF + CA

Kennedy et al.110 1985 Mean rec = 1.1 32 64 N N FGG None

Mean rec = 1.0

Jahnke et al.86 1993 Miller I-II 10 20 N N CGT/envelope FGG (thick)

Trombelli et al.70 1996 11 22 N Y CPF-TET + fibrin glue CPF/TET; no

fibrin glue

Paolantonio et al.63 1997 Miller I-II 70 70 N N CTG/CPF FGG

Cordioli et al.10 2001 Miller I-II 31 62 N Y CTG-envelope CTG/CPF

Pini Prato et al.41 1970 Miller I-II >2 m 10 20 N N CPF + root polishing CPF + root planing

Caffesse et al.33 2000 Miller I-II 36 36 N N CTG/CPF + citric acid CTG/CPF; no CA

Pini Prato et al.36 2000 Miller I >2 m 11 22 Y N CPF + tension CPF; no tension

Bouchard et al.78 1994 Miller I-II 30 30 N N CTG/CPF No CA + EPI collar

CA; no EPI collar CTG/CPF
* Only RCTs are included in this review; therefore, in accordance with previously reported classifications, all studies are ranked 1 (highest).144
Yes (Y) or no or unsure (N).
Abbreviations: CA = citric acid; CPF = coronally positioned flap; CTG = connective tissue graft; EPI = epithelial; FGG = free gingival graft; TET = tetracycline.

306
8012.qxd 12/30/03 3:34 PM Page 307
Ann Periodontol
included as a randomized study as long as suggestion
of randomization was made in article) to complete ran-
domization methodology descriptions. Of the 32 studies
considered here, 17 failed to report some mechanism
of randomization, and only 9 presented appropriate ran-
domization mechanisms.12-14,24,33,41,49,72,86
Subjective Evaluation of Therapies
Seven of the 32 articles considered a subjective eval-
uation of the results regarding esthetics, root sensitiv-
ity, or patient preferences for individual procedures
(Table 4, page 313).12-14,28,72,78,87 There was no stan-
dardization in the format of the results or in the method-
ology of these assessments. The findings ranged from
general preference queries to the patients in split-mouth
studies, to masked examiner assessments of proce-
dures using a 4-point categorical assessment tool. The
variability of the methods of assessment for these
patient-oriented outcomes precluded our formal analy-
sis of the results. However, evaluating the reported
outcomes for each of these reports, there appeared to
be consistent improvement of symptoms and esthetic
concerns following root coverage procedures.
Objective Evaluation of Therapies
The only therapeutic comparisons providing informa-
tion appropriate for meta-analysis were efficacy stud-
ies comparing autogenous connective tissue grafting
with GTR or allogeneic graft procedures for the cov-
erage of recession defects (Fig. 2). This comparison
lent it self to meta-analysis since there were a sufficient
number of studies (9) and the studies had 2 consistent
outcome measures, change in keratinized tissue and
change in recession.
In evaluating the gain in root coverage between con-
nective tissue (CT) grafts with GTR or allogeneic grafts,
CT grafts had significantly (P = 0.012) greater gains in
root coverage than did these other procedures. CT grafts
had a mean (SD) gain of 2.90 mm (1.10) compared
with a mean (SD) gain of root coverage of 2.56 mm
(1.09) for the GTR with bioabsorbable membranes. A
comparison of 2 studies using non-resorbable mem-
branes found a similar relationship, with CT grafts pro-
viding a greater gain in root coverage than the GTR
procedures.52,53 In these studies, CT grafts produced
4.20 mm (0.90) gain in root coverage, compared with
a mean gain of 3.80 mm (0.75) for GTR. The meta-
analyses of these data are difficult to interpret. For the
combined group of studies with bioabsorbable mem-
branes and allogeneic grafts, there was a statistically
significant (P = 0.041) difference between the 2 treat-
ment groups. For the non-resorbable studies, the dif-
ference was not statistically significant (P = 0.309), but
since there were only 2 studies with small sample sizes,
there was not sufficient statistical power to find a dif-
ference. The test for heterogeneity was also significant,
Oates, Robinson, Gunsolley
thus the results of these studies were inconsistent and
it can be argued that they should not have been com-
bined. However, 5 of these studies do show a trend
favoring CT grafts, with 2 studies having a neutral effect,
and only one using allogeneic grafts9 favoring the alter-
native treatment.
In evaluating the gain in width of keratinized tissue
comparing connective tissue (CT) grafts with GTR or
allogeneic grafts, 7 of the previously mentioned stud-
ies had data which could be evaluated (Fig. 3, page
313).9,12,14,44,49,52,53 CT grafts had significantly greater
(P = 0.002) gains in keratinized tissue than did these
other procedures. This difference is evident in the meta-
analysis as all the studies considered favored CT grafts
regarding gains in KT. CT grafts had a mean gain of
1.33 mm (1.19) compared to a mean gain of kera-
tinized tissue of 0.48 mm (1.03) for the GTR using
bioabsorbable membranes. A similar comparison with
2 studies using non-resorbable membranes found a
similar relationship with CT grafts providing a greater
gain in keratinized tissue than the GTR procedures.52,53
In these studies, CT grafts produced 2.30 mm (0.90)
gain in KT, compared with a mean gain of 0.50 mm
(1.01) for GTR. However, this difference was not sta-
tistically significant (P = 0.158) due to the heterogeneity
and small number of studies under consideration. The
analysis of the data was similar to the previous analysis
with a significant (P <0.05) difference for the bioab-
sorbable membranes or allogeneic grafts providing less
keratinized tissue than the connective tissue groups.
The test for heterogeneity was again statistically signifi-
cant. However, in this case the reason for the inconsis-
tence was that the gains for the connective tissue grafts
varied in the degree by which the connective tissue
grafts outperformed the GTR approach. Since all of
the 7 studies favored the connective tissue grafts, the
studies were combined and the subsequent meta-
analysis supported the superiority of the connective
tissue graft.
GTR Procedures
Overall, this review identified 18 studies in which GTR
procedures were assessed for treatment of gingival
recession defects. The GTR procedures in these studies
utilized either bioabsorbable or non-resorbable mater-
ials. The comparative treatments in these studies in-
cluded either autogenous tissue grafting procedures
or alternative GTR membranes. In addition to meta-
analysis, observations were made regarding clinical
attachment levels and probing depths for all studies
presenting appropriate data. Evaluation of mean root
coverage for 17 of these 18 studies utilizing GTR pro-
cedures found 76.4 (11.3)% root coverage, with 100%
root coverage at 33.1 (20.4)% of the sites. These find-
ings compare with various autogenous grafting pro-
cedures which served as controls with mean root cov-
307
8012.qxd 12/30/03 3:34 PM Page 308

Surgical Treatment of Gingival Recession Volume 8 Number 1 December 2003

Table 2.
GTR Procedures*

Examiner
Reference Defect Type N Subjects N Defects Masked? Sequential Cases?

Tatakis & Trombelli34 2000 Miller I, II; 2 mm 12 24 Y Y

Amarante et al.32 2000 Miller I, II; 3 mm 20 40 Y N

Borghetti et al.44 1999 Miller I; 2 mm 14 28 N N

Romagna-Genon13 2001 Miller I, II 21 42 N Y

Dodge et al.21 2000 Miller I, II; 3 mm 12 24 Y N

Ito et al.20 2000 Miller I, II; 4 mm 6 8 N N

Pini Prato et al.87 1992 Miller I, II; 3 mm 50 50 N N

Jepsen et al.52 1998 MIller I, II 15 30 N N

Zucchelli et al.53 1998 Miller I, II; 5 mm 54 54 Y Y

Trombelli et al.49 1998 Miller I, II 12 24 N N

Trombelli et al.74 1995 Miller I, II; 4 mm 8 16 Y N

Rosetti et al.28 2000 Miller I, II; (3-5 mm) 12 24 Y N

Pini Prato et al.68 1996 3 mm 50 50 N N

Wang et al.12 2001 Miller I, II; 3 mm 16 32 Y N

Duval et al.25 2000 Miller I, II; 3 mm 14 17 N N

Modica et al.24 2000 Miller I, II 12 14 Y N

308
8012.qxd 12/30/03 3:34 PM Page 309

Ann Periodontol Oates, Robinson, Gunsolley

Table 2. (continued)
GTR Procedures*

Mean Results

Study Root Root

Interventions
Duration Coverage Coverage
Test Controls (months) mm % 100% CAL PD KT

GTR/Bioab (PLA) 6 2 81 58 2.1 0 0.7

CTG/CPF 2.4 96 83 2.2 0.3 0

GTR/Bioab (PLA) 6 2.7 56 25 1.3 0.7 0.5

CPF (no membrane) 2.6 69 50 1.5 0.2 0.4

GTR/Bioab (PLA) 6 2.89 70 29 2.88 0 0.43

CTG/CPF 2.89 76 29 2.73 0.22 2.03

GTR/Bioab (Por coll) 6 2.8 75 3.31 0.61

CTG/CPF 3.3 85 3.09 0.11

GTR/Bioab (PLA) + 12 3.38 90 50 3.29 0.08

PLA910 + DFDBA
GTR/Bioab (PLA) 2.85 74 33 2.19 0.67 2.25

GTR/Non-res (ePTFE) 12 2.5 74 3.75 1.25 0.12

FGG 3.13 86 3.38 0.25 5.75

GTR/Non-res (ePTFE) 18 4.12 73 5.12 1 0.56

FGG + CPF (2-step) 3.62 71 3.56 0.06 5.32

GTR/Non-res 12 3.1 87 47 3 0.1 1.5

(TR-ePTFE) + TET
CTG/envelope + TET 3.1 87 47 3.1 0.1 2.5

GTR/Bioab (Por coll) 12 4.9 86 39 4.9 0.02 0.7

GTR/Non-res (ePTFE) 4.5 81 28 4.7 0.11 0.6
CTG/CPF 5.3 94 66 4.7 0.47 3.1

GTR/Bioab (PLA/PGA) 6 1.6 48 8 1.7 0.1 .8

CTG/CPF 2.5 81 50 2.3 0.2 1.8

GTR/Non-res (ePTFE) + 6 3 67 13 3.6 0.6 1.1

TET/FN/FBN
GTR/Non-res (ePTFE) 2.6 60 13 2.6 0.1 0.9
GTR/Bioab (coll) + 18 2.63 84 1.41 1.5
DFDBA
CTG/CPF 3.96 96 0.84 3.5
GTR/non-res (ePTFE) 48 4.2 73 5 0.8 1.8
FGG + CPF (2-step) 3.8 72 3.9 0.05 5.2
GTR/Bioab (coll) 6 2.5 73 44 2.8 0.3 0.7
CTG/CPF 2.8 84 44 2.3 0.4 1.1
GTR/Bioab (PLA) + 6 2.75 82 0.88
DFDBA
GTR/Bioab (PLA) 3 90 0.88
CPF + EMD 6 3.36 91 64 3.57 0.21 0.22
CPF 2.7 81 44 2.79 0.07 0.07
(continued)

309
8012.qxd 12/30/03 3:34 PM Page 310

Surgical Treatment of Gingival Recession Volume 8 Number 1 December 2003

Table 2. (continued)
GTR Procedures*

Examiner
Reference Defect Type N Subjects N Defects Masked? Sequential Cases?

Roccuzzo et al.72 1996 Miller I, II; 4 mm 12 24 N N

Matarasso et al.46 1998 Miller I, II; >3 mm 20 20 N N

* Only RCTs are included in this review; therefore, in accordance with previously reported classifications, all studies are ranked 1 (highest).144
Yes (Y) or no or unsure (N).
Abbreviations: Biob = bioabsorbable membrane; Coll = collagen; CPF = coronally positioned flap; CTG = connective tissue graft; DFDBA = demineralized
freeze-dried bone allograft; DPF = double pedicle flap; EMD = enamel matrix derivative; ePTFE = expanded polytetrafluoroetheylene; FGG = free gingival graft;
FBN = fibronectin; FN = fibrin; Non-res = non-resorbable membrane; PLA = polylactic acid; PLA/PGA = polylactic/polygycolic acid- PLA 910 = polyglactin
910- Por coll = porcine collagen; TET = tetracycline; TR = titanium-reinforced.

Table 3.
Allogeneic Soft Tissue Grafts*

Interventions
Defect N N Examiner Sequential
Reference Type Subjects Defects Masked? Cases? Test Controls

Novaes et al.9 2001 Miller I, II 9 30 N N Allogeneic graft

CTG

Aichelmann-Reidy et al.14 Miller I, II 22 44 Y N Allogeneic graft

2001 2 mm
CTG against tooth

Henderson et al.18 2001 Miller I, II 10 20 Y N Allogeneic graft +

3 mm CPF/basement
membrane
against tooth Allogeneic graft + CPF/
CT side against tooth
* Only RCTs are included in this review; therefore, in accordance with previously reported classifications, all studies are ranked 1 (highest).144
Yes (Y) or no or unsure (N).
Abbreviations: CPF = coronally positioned flap; CT = connective tissue; CTG = connective tissue graft.

erage of 81.9 (9.8)%, with 42.2 (23.6)% of the sites
having 100% root coverage. Using GTR procedures,
mean (SD) gains in clinical attachment levels were
3.20 (1.14) mm based on 16 of the 18 studies.
Changes in probing depths were minimal for all 18
studies (mean: 0.53 0.41 mm) and may be reflective
of the shallow probing depth identified at baseline
(mean: 1.54 mm).
Autogenous Tissue Grafts
In comparing the studies meeting the criteria set forth
in this analysis, 11 studies were identified in which
autogenous tissue grafting procedures were assessed
(Table 1).10,33,35,41,62,63,70,76,78,86,110 These procedures
included connective tissue grafting using various tech-
niques (e.g., coronally positioned, double papillae, or
envelope flap) and adjunctive materials (e.g., fibrin
glue, citric acid, or tetracycline). They also assessed
the levels of tension on the flap and the need for root
planing versus root polishing. None of these studies
allowed for consideration using meta-analysis.
However, observations were made regarding reduction
in recession, clinical attachment levels, probing depths,
and gains in keratinized tissues. Reductions in recession

310
8012.qxd 12/30/03 3:34 PM Page 311

Ann Periodontol Oates, Robinson, Gunsolley

Table 2. (continued)
GTR Procedures*

Mean Results:

Study Root Root

Interventions
Duration Coverage Coverage
Test Controls (months) mm % 100% CAL PD KT

GTR/Bioab 6 3.9 82 42 4.3 0.4 0

ePTFE 4 83 42 4.4 0.4 0.2

GTR/Bioab (PLA) GRT/Bioab (PLA) + 12 3.4 74 3.1 74 0.3 2.0

DPF CPF
2.5 63 2.8 63 0.3 0.9

studies and 2.62 (0.68) mm when excluding the free

Table 3. (continued) gingival graft data. Changes in mean PD were minimal
Allogeneic Soft Tissue Grafts* for all studies, 0.11 (0.32) mm, and may be reflec-
tive of the shallow probing depth identified at base-
Results line, 1.33 (0.23) mm. Evaluating the mean gain in
Study keratinized tissue showed an increase of 1.85 (1.05)
Root Coverage mm, with the free gingival grafting study110 having the
Duration
(months) mm % 100% CAL PD KT greatest increase (4.9 mm). Excluding this study, the
mean gain in keratinized tissue was 1.52 (0.96) mm.
6 2.1 65 33 0.81 0.13 0.63
1.84 62 40 0.92 0.09 1.26 Allogeneic Tissue Grafts
6 1.7 66 1.5 0.2 1.2 In comparing the studies meeting the criteria set forth
in this systematic review, 3 studies9,14,18 were identified
2.2 74 1.6 0.6 1.6 in which allogeneic tissue grafting procedures were
assessed (see Table 3). The grafts utilized in each of
12 3.95 95 70 4.15 0.1 0.8
these studies were allogeneic dermal connective tissue
matrix grafts. These studies did not allow for consid-
4.2 95 80 3.65 0 0.8 eration using meta-analysis. However, certain
observations were made using the 2 studies in which
autogenous CT grafting was compared,9,14 including
reduction in recession, clinical attachment levels, and
probing depths, and gains in keratinized tissue. Reduc-
defects showed a mean gain of 2.46 (0.61) mm. tions in recession defects using allogeneic grafts
When excluding the one and only study110 using free showed a mean gain of 1.90 (0.28) mm and mean
gingival grafts as a test intervention, with a mean changes in clinical attachment levels of 1.15 (0.49)
reduction of 0.3 mm, the mean gain in root coverage mm. This change equaled 65.5 (0.71)% root cover-
for the remaining 10 studies was 2.68 (0.45) mm. age. This compared with autogenous connective tissue
The mean percentage of root coverage for these 10 grafting, in which reductions in recession defects showed
studies was 77.9 (10.0)% root coverage, with 100% a mean gain of 2.05 (0.18) mm, or 67.3 (6.11)% root
root coverage 37.4 (19.4)% for procedures utilizing coverage, and a mean change in clinical attachment
connective tissue grafting and/or coronally positioned level of 1.34 (0.36) mm.9,14 Changes in probing depths
flaps. These findings appear favorable compared with were minimal for all studies, mean increase of 0.19
free gingival grafts in 2 studies.63,86 The mean root (0.31) mm, and may be reflective of the shallow mean
coverage was 48.1 (7.2)%, with 9.3 (1.0)% of sites probing depth identified at baseline, 1.20 (0.13) mm.
having 100% root coverage. The mean gain in CAL Evaluating the mean gain in keratinized tissue showed
level was 2.33 (0.80) mm when considering all 11 an increase of 0.92 (0.40) mm with allogeneic tissue

311
8012.qxd 12/30/03 3:34 PM Page 312
Surgical Treatment of Gingival Recession
Figure 2.
Comprehensive meta-analysis of recession comparing autogenous connective tissue grafting with GTR procedures.
Abbreviations: Coll = collagen; ePTFE = expanded polytetrafluoroethylene; PLA = polylactic acid; PLA/PGA = polylactic/polyglycolic acid; Por coll = porcine
collagen.
grafting compared with 1.35 (0.22) mm in autogenous
connective tissue grafting.9,14
DISCUSSION
The results of the meta-analyses in this review identified
statistically greater reductions in gingival recession and
gains in keratinized tissue utilizing autogenous con-
nective tissue grafts compared with guided tissue regen-
eration procedures. This result is interesting in that the
identified differences found in this meta-analysis were
based on a series of individual studies in which a sig-
nificant difference was not detected. Unfortunately,
inconsistencies between studies did not permit similar
analyses of study comparisons between various aspects
of autogenous soft tissue grafting procedures nor
between procedures using allogeneic grafting pro-
cedures.
An additional shortcoming with the majority of the
reviewed studies was a general insufficiency in pre-
senting study parameters. In evaluating the studies
meeting our inclusion criteria, there was a minority of
reports that had identified methods of randomization
that were viewed as adequate, such as randomization
lists or coin toss. The majority of the reports did not
identify the method of randomization, but merely noted
that randomization was performed as part of the study
design. Three studies listed as randomized utilized alter-
nating patterns for randomization. These studies, and
those without any specific description of method of ran-
domization, were included in these analyses. Similarly,
312
Volume 8 Number 1 December 2003
only 11 studies12,14,18,21,24,28,32,34,36,53,74 reported that
the examiners were masked as to the treatment pro-
vided. None of the studies reported any masking of the
patient or the individual providing the therapies. These
deficiencies may be viewed as a limitation of this cur-
rent analysis of the literature.
The evaluated studies included 2 investigations com-
paring autogenous tissue grafting to no treatment.44,110
These 2 studies were consistent in demonstrating the
potential for either free gingival grafting or connective tis-
sue grafting to successfully augment keratinized tissue;
however the control conditions demonstrated little change
over extended evaluations as long as 12 to 72 months.
These findings do support the potential for stability with
recession defects having little keratinized tissues.
Soft tissue augmentation procedures have multiple
indications including esthetics, prevention of the pro-
gression of the recession defect, hypersensitivity, and
anatomic deficiencies that may affect tissue health.
Treatment based on these indications may be add-
ressed with the goals of obtaining an increased zone
of keratinized tissue and root coverage. It is clear that
these studies demonstrate a wide range of root cov-
erage success. The mean levels of root coverage
obtained were between 73 to 80% for the 3 general
treatment groupings, but the ranges reported from indi-
vidual studies varied from 48 to 91%, thus raising some
question as to the predictability of these procedures.
One of the most utilized methods in the reviewed stud-
ies to quantify this predictability was by measuring the
8012.qxd 12/30/03 3:35 PM Page 313

Ann Periodontol Oates, Robinson, Gunsolley

Table 4.
Patient Centered Outcomes

Intervention

Reference Test Control Results

Romagna-Genon13 GTR/Bioab CTG/CPF Width of recession defect was reduced more in control than
2001 (Por coll) test defects, all control patients complained of soreness at
donor site

Rosetti et al.28 2000 GTR/Bioab CTG/CPF Patients satisfied with result (good) for CT graft (80%) and
(coll) + DFDBA GTR (82%)

Wang et al.12 2001 GTR/Bioab (coll) CTG/CPF Examiner: 15/16 excellent color for GTR; 16/16 excellent or
good color for CT graft
Patient: 14/16 exellcent or good for both treatments

Roccuzzo et al.72 GTR/Bioab ePTFE Postoperative pain, swelling, esthetics similar between groups
1996 GTR/bioab preferred due to 1 sx-(No statistics shown)

Aichelmann- Allogeneic CTG Both patient and clinician evaluations: significantly greater fre-
Reidy et al.14 2001 quency of excellent appearance scores with allogeneic graft

Pini Prato et al.87 GTR/non-res FGG + CPF 4/25 patients in test group with baseline root hypersensitivity;
1992 (ePTFE) (2 step) 0/25 postoperatively
0/25 patients in control group with root hypersensitivity
at baseline and postoperatively

Bouchard et al.78 CTG/CPF No CA + EPI Examiner: 20/30 had good esthetic result and 10/30
1994 collar moderate esthetic result
CA; no EPI collar CTG/CPF 5/30 patients with baseline root hypersensitivity;
0/30 postoperatively
Abbreviations: Bioab = bioabsorbable membrane; Coll = collagen; CPF = coronally positioned flap; CTG = connective tissue graft; DFDBA = demineralized
freeze-dried bone allograft; EPI = epithelial; ePTFE = expanded polytetrafluoroetheylene; FGG = free gingival graft; Non-res = non-resorbable membrane.

Figure 3.
Comprehensive meta-analysis of gains in keratinized tissue comparing autogenous connective tissue grafting with GTR procedures.
Abbreviations: Coll = collagen; ePTFE = expanded polytetrafluoroethylene; PLA = polylactic acid; PLA/PGA = polylactic/polyglycolic acid; Por coll =
porcine collagen.

313
8012.qxd 12/30/03 3:35 PM Page 314
Surgical Treatment of Gingival Recession
incidence of achieving 100% root coverage following
the tested treatment. The results for percentage of sites
with 100% root coverage varied widely for the 3 treat-
ment groups, from 33 to 52%. The mean ranges
reported within the individual studies varied from 8 to
70%. These ranges suggest there are numerous fac-
tors that may influence treatment success using pro-
cedures directed at root coverage. Many of the techni-
cal and therapeutic factors have been evaluated through
the efforts of individual investigations. However, there is
no single factor or group of factors that have been iden-
tified to explain this variance.
Based on the limited assessments of the 7 reviewed
studies in which patient-oriented outcomes were
assessed,12-14,28,72,78,87 each of these surgical options
appears to have positive effects. Three studies
addressed esthetic results12,14,28 and showed definite
improvements with treatment. One study72 found that
there was difference in postoperative morbidities and
esthetics between bioabsorbable and non-resorbable
membranes. The findings of 2 additional studies sup-
port the use of these procedures to reduce root hyper-
sensitivity.78,87 Although postoperative discomfort was
demonstrable in study surveys, at least in association
with palatal connective tissue donor sites, the level of
discomfort appears minimal.13,14
The evaluation of these reports in the present
analysis was based on the assessment of soft tissue
augmentation procedures aimed at root coverage.
These procedures were classified as using autoge-
nous or allogeneic tissue graft materials with any of
several manipulative approaches or the use of GTR
procedures. The use of GTR represents an interest-
ing shift in the treatment paradigm for GTR proce-
dures typically associated with intrabony defects
rather than soft tissue defects. From our investiga-
tion it is clear that considerable research effort has
gone into investigating the efficacy of this treatment
approach. It is therefore significant that the present
study found the GTR approach did not provide the
same levels of root coverage and gains in keratinized
tissues that are associated with the more traditional
soft tissue augmentation approaches.
It is also of interest to note that this analysis included
a single study utilizing a non-barrier technique in the
GTR group.24 This classification was based on the pro-
posed effects of the enamel matrix protein extract to
stimulate specific patterns of cellular proliferation and
differentiation. This non-barrier GTR study compared
coronally positioned flap surgery with or without enamel
matrix extract treatment and failed to find a significant
difference in percentages of root coverage obtained,
although mean values for percentage of root coverage
were greater with the addition of the extract.24 This find-
ing is consistent with a recent report that compared the
use of the enamel protein extract application or con-
314
Volume 8 Number 1 December 2003
nective tissue grafts in conjunction with coronally posi-
tioned flap procedures.145 This study showed that there
was no difference in the amounts of root coverage
obtained between treatment approaches. In addition,
there was less keratinized tissue resulting from this non-
barrier GTR procedure, consistent with our meta-analysis
for GTR procedures using barrier techniques compared
with connective tissue grafting procedures.
In summary, the overall goal of this study to assess
both clinical and patient-oriented outcomes using a pros-
pectively designed systematic analysis was only par-
tially achieved. Wide variations in results obtained and
in techniques utilized impacted on our ability to accom-
plish this goal. However, this in itself may be a signifi-
cant finding regarding our current state of knowledge
and the high level of difficulty in effectively synthesizing
reports into clinical decisions. Hopefully, analyses of the
literature such as this will provide guidance for future
studies directed at the evidence-based assessment of
therapy.
REVIEWERS CONCLUSIONS
1. The systematic review of the data demonstrates
there are several surgical procedures that successfully
cover exposed root surfaces. There is evidence that
these surgical procedures result in improved patient-
oriented outcomes including decreased root sensitiv-
ity and enhanced soft tissue esthetics.
2. Meta-analysis identified statistically significant
advantages for autogenous connective tissue grafts
when compared with GTR using bioabsorbable barri-
ers in terms of root coverage and width of keratinized
tissue.
3. A limited number of recent randomized controlled
studies support the efficacy of coronally positioned
flaps with allogeneic soft tissue grafts for root coverage.
4. The studies identified in this systematic review
concerning patient-oriented outcomes lacked standard-
ization of measures, precluding quantitative analysis.
FUTURE DIRECTIONS FOR PRACTICE
AND RESEARCH
1. Future studies designed primarily to investigate
patient-oriented outcomes such as esthetics, hypersen-
sitivity, morbidities, and overall satisfaction are needed.
2. Most of the literature dealing with root coverage
procedures consists of case series and non-randomized
studies. Future well-designed investigations are needed
to further clarify the relative efficacy of different treat-
ment options.
3. Based on the number of studies using autogenous
connective tissue grafts in conjunction with coronally
positioned flap surgery, it is surprising there are no
comparative randomized controlled clinical trials for
this treatment and coronally positioned flap surgery
alone. Future studies are needed to assess the effi-
8012.qxd 12/30/03 3:35 PM Page 315
Ann Periodontol
cacy of coronally positioned flap procedures in the
presence or absence of connective tissue grafting.
ACKNOWLEDGMENTS
The authors extend their appreciation to Ms. Madgeline
Cluck for her untiring assistance throughout the devel-
opment of this report.
REFERENCES
1. Wennstrm JL. Mucogingival therapy. Ann Periodontol
1996;1:671-701.
2. Fleiss JL. The statistical basis of meta-analysis. Stat
Methods Med Res 1993;2(2):121-145.
3. Katerndahl DA, Cohen PA. Quantitatively reviewing the
literature: The application of meta-analysis. Fam Pract
Res J 1987;6(3):123-129.
4. Heges L, Olkin I. Statistical Methods of Meta-Analysis.
Orlando: Academic Press; 1985.
5. Hgewald S, Spahr A, Rompola E, Haller B, Heijl L,
Bernimoulin J-P. Comparative study of Emdogain and
coronally advanced flap technique in the treatment of
human gingival recessions. A prospective controlled
clinical study. J Clin Periodontol 2002;29:35-41.
6. Mller H-P, Stahl M, Eger T. Failure of root coverage of
shallow gingival recessions employing GTR and a biore-
sorbable membrane. Int J Periodontics Restorative Dent
2001;21:171-181.
7. Tinti C, Manfrini F, Parma-Benfenati S. A bioresorbable
barrier in the treatment of gingival recession: Descrip-
tion of a new resorbable dome device. Int J Periodontics
Restorative Dent 2001;21:31-39.
8. Hirsch A, Attal U, Chai E, Goultschin J, Boyan BD,
Schwartz Z. Root coverage and pocket reduction as
combined surgical procedures. J Periodontol 2001;72:
1572-1579.
9. Novaes AB Jr, Grisi DC, Molina GO, Souza SLS, Taba M
Jr, Grisi MFM. Comparative 6-month clinical study of a
subepithelial connective tissue graft and acellular der-
mal matrix graft for the treatment of gingival recession.
J Periodontol 2001;72:1477-1484.
10. Cordioli G, Mortarino C, Chierico A, Grusovin MG,
Majzoub Z. Comparison of 2 techniques of subepithelial
connective tissue graft in the treatment of gingival reces-
sions. J Periodontol 2001;72:1470-1476.
11. Nelson SW. Subperiosteal and intraosseous connective
tissue grafts for pocket reduction: A 9- to 13-year ret-
rospective case series report. J Periodontol 2001;72:
1424-1435.
12. Wang H-L, Bunyaratavej P, Labadie M, Shyr Y, MacNeil RL.
Comparison of 2 clinical techniques for treatment of
gingival recession. J Periodontol 2001;72:1301-1311.
13. Romagna-Genon C. Comparative clinical study of guided
tissue regeneration with a bioabsorbable bilayer colla-
gen membrane and subepithelial connective tissue graft.
J Periodontol 2001;72:1258-1264.
14. Aichelmann-Reidy ME, Yukna RA, Evans GH, Nasr HF,
Mayer ET. Clinical evaluation of acellular allograft der-
mis for the treatment of human gingival recession. J Peri-
odontol 2001;72:998-1005.
15. Harris RJ. Clinical evaluation of 3 techniques to augment
keratinized tissue without root coverage. J Periodontol
2001;72:932-938.
16. Harris RJ. Histologic evaluation of root coverage obtained
with GTR in humans: A case report. Int J Periodontics
Restorative Dent 2001;21:240-251.
17. Saletta D, Pini Prato G. Pagliaro U. Baldi C. Mauri M.
Oates, Robinson, Gunsolley
Nieri M. Coronally advanced flap procedure: Is the inter-
dental papilla a prognostic factor for root coverage?
J Periodontol 2001;72:760-766.
18. Henderson RD, Greenwell H, Drisko C, et al. Predictable
multiple site root coverage using an acellular dermal
matrix allograft. J Periodontol 2001;72:571-582.
19. Jorgic-Srdjak K, Bosnjak A, Plancak D, Maricevic T.
Ten-year evaluation of conservative and surgical treat-
ment of gingival recession. A case series study. Coll
Antropol 2000;24:495-500.
20. Ito K, Oshio K, Shiomi N, Murai S. A preliminary com-
parative study of the guided tissue regeneration and free
gingival graft procedures for adjacent facial root cover-
age. Quintessence Int 2000;31:319-326.
21. Dodge JR, Greenwell H, Drisko C, Wittwer JW, Yancey J,
Rebitski G. Improved bone regeneration and root cov-
erage using a resorbable membrane with physically
assisted cell migration and DFDBA. Int J Periodontics
Restorative Dent 2000;20:399-411.
22. Harris RJ. A comparative study of root coverage obtained
with an acellular dermal matrix versus a connective tissue
graft: Results of 107 recession defects in 50 consecutively
treated patients. Int J Periodontics Restorative Dent
2000;20:51-59.
23. Maurer S, Hayes C, Leone C. Width of keratinized tissue
after gingivoplasty of healed subepithelial connective
tissue grafts. J Periodontol 2000;71:1729-1736.
24. Modica F, Del Pizzo M, Roccuzzo M, Romagnoli R.
Coronally advanced flap for the treatment of buccal gin-
gival recessions with and without enamel matrix deri-
vative. A split-mouth study. J Periodontol 2000;71:
1693-1698.
25. Duval BT, Maynard JG, Gunsolley JC, Waldrop TC.
Treatment of human mucogingival defects utilizing a
bioabsorbable membrane with and without a deminer-
alized freeze-dried bone allograft. J Periodontol 2000;71:
1687-1692.
26. Boltchi FE. Allen EP. Hallmon WW. The use of a bioab-
sorbable barrier for regenerative management of mar-
ginal tissue recession. I. Report of 100 consecutively
treated teeth. J Periodontol 2000;71:1641-1653.
27. Zucchelli G, De Sanctis M. Treatment of multiple
recession-type defects in patients with esthetic demands.
J Periodontol 2000;71:1506-1514.
28. Rosetti EP, Marcantonio RAC, Rossa C Jr, Chaves ES,
Goissis G, Marcantonio E Jr. Treatment of gingival
recession: Comparative study between subepithelial
connective tissue graft and guided tissue regeneration.
J Periodontol 2000;71:1441-1447.
29. Jepsen S, Heinz B, Kermanie MA, Jepsen K. Evaluation
of a new bioabsorbable barrier for recession therapy:
A feasibility study. J Periodontol 2000;71:1433-1440.
30. Greenwell H, Bissada NF, Henderson RD, Dodge JR.
The deceptive nature of root coverage results. J Peri-
odontol 2000;71:1327-1337.
31. Wei P-C, Laurell L, Geivelis M, Lingen MW, Maddalozzo D.
Acellular dermal matrix allografts to achieve increased
attached gingiva. Part 1. A clinical study. J Periodontol
2000;71:1297-1305.
32. Amarante ES, Leknes KN, Skavland J, Lie T. Coronally
positioned flap procedures with or without a bioab-
sorbable membrane in the treatment of human gingival
recession. J Periodontol 2000;71:989-998.
33. Caffesse RG, De La Rosa M, Garza M, Munne-Travers A,
Mondragon JC, Weltman R. Citric acid demineralization
and subepithelial connective tissue grafts. J Periodontol
2000;71:568-572.
315
8012.qxd 12/30/03 3:35 PM Page 316
Surgical Treatment of Gingival Recession
34. Tatakis DN, Trombelli L. Gingival recession treatment:
Guided tissue regeneration with bioabsorbable mem-
brane versus connective tissue graft. J Periodontol 2000;
71:299-307.
35. Pini Prato G, Pagliaro U, Baldi C, et al. Coronally advan-
ced flap procedure for root coverage. Flap with tension
versus flap without tension: A randomized controlled
clinical study. J Periodontol 2000;71:188-201.
36. Pini Prato G, Baccetti T, Magnani C, Agudio G, Cortellini P.
Mucogingival interceptive surgery of buccally-erupted
premolars in patients scheduled for orthodontic treat-
ment. I. A 7-year longitudinal study. J Periodontol 2000;
71:172-181.
37. Mller H-P, Stahl M, Eger T. Dynamics of mucosal
dimensions after root coverage with a bioresorbable
membrane. J Clin Periodontol 2000;27:1-8.
38. Zabalegui I, Sicilia A, Cambra J, Gil J, Sanz M. Treat-
ment of multiple adjacent gingival recessions with the
tunnel subepithelial connective tissue graft: A clinical
report. Int J Periodontics Restorative Dent 1999;19:
199-206.
39. Carnio J, Miller PD Jr. Increasing the amount of attached
gingiva using a modified apically repositioned flap. J Peri-
odontol 1999;70:1110-1117.
40. Baldi C, Pini-Prato G, Pagliaro U, et al. Coronally
advanced flap procedure for root coverage. Is flap thick-
ness a relevant predictor to achieve root coverage?
A 19-case series. J Periodontol 1999;70:1077-1084.
41. Pini-Prato G, Baldi C, Pagliaro U, et al. Coronally
advanced flap procedure for root coverage. Treatment
of root surface: Root planing versus polishing. J Peri-
odontol 1999;70:1064-1076.
42. Mller H-P, Stahl M, Eger T. Root coverage employing an
envelope technique or guided tissue regeneration with a
bioabsorbable membrane. J Periodontol 1999;70:743-751.
43. Tatakis DN. Trombelli L. Adverse effects associated with
a bioabsorbable guided tissue regeneration device in the
treatment of human gingival recession defects. A clinico-
pathologic case report. J Periodontol 1999;70:542-547.
44. Borghetti A, Glise J-M, Monnet-Corti V, Dejou J. Com-
parative clinical study of a bioabsorbable membrane and
subepithelial connective tissue graft in the treatment of
human gingival recession. J Periodontol 1999;70:123-130.
45. Milano F. A combined flap for root coverage. Int J Peri-
odontics Restorative Dent 1998;18:545-551.
46. Matarasso S, Cafiero C, Coraggio F, Vaia E, de Paoli S.
Guided tissue regeneration versus coronally repositioned
flap in the treatment of recession with double papillae.
Int J Periodontics Restorative Dent 1998;18:445-453.
47. Harris RJ. A comparison of 2 root coverage techniques:
Guided tissue regeneration with a bioabsorbable matrix
style membrane versus a connective tissue graft com-
bined with a coronally positioned pedicle graft without
vertical incisions. Results of a series of consecutive
cases. J Periodontol 1998;69:1426-1434.
48. Scabbia A, Trombelli L. Long-term stability of the
mucogingival complex following guided tissue regener-
ation in gingival recession defects. J Clin Periodontol
1998;25:1041-1046.
49. Trombelli L, Scabbia A, Tatakis DN, Calura G. Sub-
pedicle connective tissue graft versus guided tissue
regeneration with bioabsorbable membrane in the treat-
ment of human gingival recession defects. J Periodon-
tol 1998;69:1271-1277.
50. Zahedi S, Bozon C, Brunel G. A 2-year clinical evaluation
of a diphenylphosphorylazide-cross-linked collagen
membrane for the treatment of buccal gingival recession.
316
Volume 8 Number 1 December 2003
J Periodontol 1998;69:975-981.
51. Mller H-P, Eger T, Schorb A. Gingival dimensions after
root coverage with free connective tissue grafts. J Clin
Periodontol 1998;25:424-430.
52. Jepsen K, Heinz B, Halben JH, Jepsen S. Treatment of
gingival recession with titanium reinforced barrier mem-
branes versus connective tissue grafts. J Periodontol
1998;69:383-391.
53. Zucchelli G, Clauser C, De Sanctis M, Calandriello M.
Mucogingival versus guided tissue regeneration proce-
dures in the treatment of deep recession type defects.
J Periodontol 1998;69:138-145.
54. Mendes DN, Novaes AB Jr, Novaes AB. Root coverage
of large localized gingival recession: A biometric study.
Braz Dent J 1997;8:113-120.
55. Ozcan G, Kurtis B, Balos K. Combined use of root con-
ditioning, fibrin-fibronectin system and a collagen mem-
brane to treat a localized gingival recession: A 10-case
report. J Marmara Univ Dent Fac 1997;2:588-598.
56. Trombelli L, Tatakis DN, Scabbia A, Zimmerman GJ.
Comparison of mucogingival changes following treat-
ment with coronally positioned flap and guided tissue
regeneration procedures. Int J Periodontics Restorative
Dent 1997;17:449-455.
57. Waterman CA. Guided tissue regeneration using a bioab-
sorbable membrane in the treatment of human buccal
recession. A re-entry study. J Periodontol 1997;68:
982-989.
58. Harris RJ. Creeping attachment associated with the con-
nective tissue with partial-thickness double pedicle graft.
J Periodontol 1997;68:890-899.
59. Harris RJ. A comparative study of root coverage ob-
tained with guided tissue regeneration utilizing a bioab-
sorbable membrane versus the connective tissue with
partial-thickness double pedicle graft. J Periodontol
1997;68:779-790.
60. Shieh A-T, Wang H-L, ONeal R, Glickman GN, MacNeil
RL. Development and clinical evaluation of a root cov-
erage procedure using a collagen barrier membrane.
J Periodontol 1997;68:770-778.
61. Trombelli L, Scabbia A. Healing response of gingival
recession defects following guided tissue regeneration
procedures in smokers and non-smokers. J Clin Peri-
odontol 1997;24:529-533.
62. Bouchard P, Nilvus R, Etienne D. Clinical evaluation of
tetracycline HCl conditioning in the treatment of gingi-
val recessions. A comparative study. J Periodontol
1997;68:262-269.
63. Paolantonio M, di Murro C, Cattabriga A, Cattabriga M.
Subpedicle connective tissue graft versus free gingival
graft in the coverage of exposed root surfaces. A 5-year
clinical study. J Clin Periodontol 1997;24:51-56.
64. Ricci G, Silvestri M, Rasperini G, Cattaneo V. Root
coverage: A clinical/statistical comparison between
subpedicle connective tissue graft and laterally posi-
tioned full thickness flaps. J Esthetic Dent 1996;8:
66-73.
65. Ricci G, Silvestri M, Tinti C, Rasperini G. A clinical/
statistical comparison between the subpedicle connective
tissue graft method and the guided tissue regeneration
technique in root coverage. Int J Periodontics Restora-
tive Dent 1996;16:539-545.
66. De Sanctis M, Zucchelli G. Guided tissue regeneration
with a resorbable barrier membrane (Vicryl) for the man-
agement of buccal recession: A case report. Int J Peri-
odontics Restorative Dent 1996;16:435-441.
67. Wang H-L, MacNeil RL, Shieh A-T, ONeal R. Utilization
8012.qxd 12/30/03 3:35 PM Page 317
Ann Periodontol
of a resorbable collagen membrane in repairing gingi-
val recession defects. Pract Periodont Aesthetic Dent
1996;8:441-448.
68. Pini Prato G, Clauser C, Cortellini P. Tinti C. Vincenzi G.
Pagliaro U. Guided tissue regeneration versus mucogin-
gival surgery in the treatment of human buccal reces-
sions. A 4-year follow-up study. J Periodontol 1996;67:
1216-1223.
69. Wennstrm JL, Zucchelli G. Increased gingival dimen-
sions. A significant factor for successful outcome of root
coverage procedures? A 2-year prospective clinical
study. J Clin Periodontol 1996;23:770-777.
70. Trombelli L, Scabbia A, Wikesj UME, Calura G. Fibrin
glue application in conjunction with tetracycline root
conditioning and coronally positioned flap procedure in
the treatment of human gingival recession defects. J Clin
Periodontol 1996;23:861-867.
71. Rachlin G, Koubi G, Dejou J, Franquin JC. The use of
a resorbable membrane in mucogingival surgery. Case
series. J Periodontol 1996;67:621-626.
72. Roccuzzo M, Lungo M, Corrente G, Gandolfo S. Com-
parative study of a bioresorbable and a non-resorbable
membrane in the treatment of human buccal gingival
recessions. J Periodontol 1996;67:7-14.
73. Pini Prato G, Clauser C, Magnani C, Cortellini P.
Resorbable membranes in the treatment of human buc-
cal recession: A nine-case report. Int J Periodontics
Restorative Dent 1995;15:258-267.
74. Trombelli L, Schincaglia GP, Zangari F, Griselli A,
Scabbia A, Calura G. Effects of tetracycline HCl con-
ditioning and fibrin-fibronectin system application in the
treatment of buccal gingival recession with guided tis-
sue regeneration. J Periodontol 1995;66:313-320.
75. Trombelli L, Schincaglia GP, Scapoli C, Calura G. Healing
response of human buccal gingival recessions treated
with expanded polytetrafluoroethylene membranes. A
retrospective report. J Periodontol 1995;66:14-22.
76. Borghetti A, Louise F. Controlled clinical evaluation of
the subpedicle connective tissue graft for the coverage
of gingival recession. J Periodontol 1994;65:1107-1112.
77. Tinti C, Vincenzi GP. Expanded polytetrafluoroethylene
titanium-reinforced membranes for regeneration of
mucogingival recession defects. A 12-case report. J Peri-
odontol 1994;65:1088-1094.
78. Bouchard P, Etienne D, Ouhayoun J-P, Nilvus R. Subep-
ithelial connective tissue grafts in the treatment of gin-
gival recessions. A comparative study of 2 procedures.
J Periodontol 1994;65:929-936.
79. Allen AL. Use of the supraperiosteal envelope in soft
tissue grafting for root coverage. II. Clinical results. Int
J Periodontics Restorative Dent 1994;14:302-315.
80. Harris RJ, Harris AW. The coronally positioned pedicle
graft with inlaid margins: A predictable method of obtain-
ing root coverage of shallow defects. Int J Periodontics
Restorative Dent 1994;14:229-241.
81. Trombelli L, Schincaglia G, Checchi L, Calura G. Com-
bined guided tissue regeneration, root conditioning, and
fibrin-fibronectin system application in the treatment of
gingival recession. A 15-case report. J Periodontol
1994;65:796-803.
82. Stakiw JE. Root coverage using a lateral pedicle gingival
flapa 22 year case study. J Can Dent Assoc 1994;60:
891-892.
83. Harris RJ. The connective tissue with partial thickness
double pedicle graft: The results of 100 consecutively-
treated defects. J Periodontol 1994;65:448-461.
84. Landsberg CJ, Smukler H, Tal H. The use of gingival
Oates, Robinson, Gunsolley
autografts that contain submucosa in the repair of
mucogingival defects in maxillary molars: Case reports.
Quintessence Int 1993;24:693-700.
85. Romanos GE, Bernimoulin J-P, Marggraf E. The dou-
ble lateral bridging flap for coverage of denuded root
surface: Longitudinal study and clinical evaluation after
5 to 8 years. J Periodontol 1993;64:683-688.
86. Jahnke PV, Sandifer JB, Gher ME, Gray JL, Richard-
son AC. Thick free gingival and connective tissue auto-
grafts for root coverage. J Periodontol 1993;64:315-
322.
87. Pini Prato G, Tinti C, Vincenzi G, Magnani C, Cortellini
P, Clauser C. Guided tissue regeneration versus
mucogingival surgery in the treatment of human buc-
cal gingival recession. J Periodontol 1992;63:919-928.
88. Harris RJ. The connective tissue and partial thickness
double pedicle graft: A predictable method of obtain-
ing root coverage. J Periodontol 1992;63:477-486.
89. Tinti C, Vincenzi G, Cortellini P, Pini Prato G, Clauser
C. Guided tissue regeneration in the treatment of
human facial recession. A 12-case report. J Periodon-
tol 1992;63: 554-560.
90. Laney JB, Saunders VG, Garnick JJ. A comparison of
two techniques for attaining root coverage. J
Periodontol 1992;63:19-23.
91. Tolmie PN, Rubins RP, Buck GS, Vagianos V, Lanz JC.
The predictability of root coverage by way of free
gingival autografts and citric acid application: An eval-
uation by multiple clinicians. Int J Periodontics Restora-
tive Dent 1991;11:261-271.
92. Levine RA. Covering denuded maxillary root surfaces
with the subepithelial connective tissue graft. Com-
pendium Continuing Educ Dent 1991;12:568, 570,
572, 574, 576, 578.
93. Daniel A, Cheru R. Treatment of localised gingival
recession with subpedicle connective tissue graft and
free gingival auto grafta comparative clinical eval-
uation. J Indian Dent Assoc 1990;61:294-297.
94. Borghetti A, Gardella JP. Thick gingival autograft for
the coverage of gingival recession: A clinical eval-
uation. Int J Periodontics Restorative Dent 1990;10:
216-229.
95. Pollack RP. Root coverage using submarginal free
mucosal grafts in conjunction with a retained gingival
collar. Compendium Continuing Educ Dent 1990;11:
160, 162-164.
96. Levine RA. Esthetics in periodontics: Covering denuded
root surfaces using free gingival grafts without citric
acid, Part II: A report on 14 teeth in 10 patients.
Compendium Continuing Educ Dent 1989;10:642,
644-646, 650.
97. Allen EP, Miller PD Jr. Coronal positioning of existing
gingiva: Short term results in the treatment of shallow
marginal tissue recession. J Periodontol 1989;60:
316-319.
98. Sbordone L, Ramaglia L, Spagnuolo G, De Luca M.
A comparative study of free gingival and subepithelial
connective tissue grafts. Periodontal Case Reports
1988;10:8-12.
99. Caffesse RG, Alspach SR, Morrison EC, Burgett FG.
Lateral sliding flaps with and without citric acid. Int
J Periodontics Restorative Dent 1987;7(6):43-57.
100. Salkin LM, Freedman AL, Stein MD, Bassiouny MA.
A longitudinal study of untreated mucogingival defects.
J Periodontol 1987;58:164-166.
101. Wennstrm JL. Lack of association between width of
attached gingiva and development of soft tissue reces-
317
8012.qxd 12/30/03 3:35 PM Page 318
Surgical Treatment of Gingival Recession
sion. A 5-year longitudinal study. J Clin Periodontol
1987;14:181-184.
102. Nelson SW. The subpedicle connective tissue graft. A
bilaminar reconstructive procedure for the coverage of
denuded root surfaces. J Periodontol 1987;58:95-102.
103. Kunjamma S, Varma BR, Nandakumar K. A compar-
ative evaluation of coverage of denuded root surface
by gingival autograft and lateral sliding flap operation.
J Indian Dent Assoc 1986;58:527-534.
104. Ross SE, Crosetti HW, Gargiulo A, Cohen DW. The
double papillae repositioned flapAn alternative. I.
Fourteen years in retrospect. Int J Periodontics Restora-
tive Dent 1986;6(6):47-59.
105. Hines RA, Walters PL. A comparison of gingival graft
techniques. Compendium Continuing Educ Dent 1986;
7:522, 524, 526, 528, 529.
106. Becker BE, Becker W. Use of connective tissue auto-
grafts for treatment of mucogingival problems. Int
J Periodontics Restorative Dent 1986;6(1):89-94.
107. Kisch J, Badersten A, Egelberg J. Longitudinal obser-
vation of unattached, mobile gingival areas. J Clin
Periodontol 1986;13:131-134.
108. Langer B, Langer L. Subepithelial connective tissue
graft technique for root coverage. J Periodontol 1985;
56:715-720.
109. Ibbott CG, Oles RD, Laverty WH. Effects of citric acid
treatment on autogenous free graft coverage of local-
ized recession. J Periodontol 1985;56:662-665.
110. Kennedy JE, Bird WC, Palcanis KG, Dorfman HS. A
longitudinal evaluation of varying widths of attached
gingiva. J Clin Periodontol 1985;12:667-675.
111. Zade RM, Hirani SH. A clinical study of localized gin-
gival recession treated by lateral sliding flap. J Indian
Dent Assoc 1985;57:19-26, 40.
112. Schoo WH, van der Velden U. Marginal soft tissue reces-
sions with and without attached gingiva. A five year
longitudinal study. J Periodont Res 1985;20:209-211.
113. Oles RD, Ibbott CG, Laverty WH. Effects of citric acid
treatment on pedicle flap coverage of localized reces-
sion. J Periodontol 1985;56:259-261.
114. Miller PD Jr. Root coverage using the free soft tissue
autograft following citric acid application. III. A suc-
cessful and predictable procedure in areas of deep-
wide recession. Int J Periodontics Restorative Dent
1985;5(2):15-37.
115. Lindeberg RW. Combined management of mucogingival
defects with citric acid root conditioning, lateral pedi-
cle grafts, and free gingival grafts. Compendium Con-
tinuing Educ Dent 1985;6:265-266, 268, 270-272.
116. Marggraf E. A direct technique with a double lateral
bridging flap for coverage of denuded root surface and
gingiva extension. Clinical evaluation after 2 years.
J Clin Periodontol 1985;12:69-76.
117. Waite IM. An assessment of the postsurgical results fol-
lowing the combined laterally positioned flap and gingi-
val graft procedure. Quintessence Int 1984;15:441-450.
118. Miller PD Jr. Root coverage using the free soft tissue
autograft following citric acid application. II. Treatment
of the carious root. Int J Periodontics Restorative Dent
1983;3(5):39-51.
119. Holbrook T, Ochsenbein C. Complete coverage of the
denuded root surface with a one-stage gingival graft. Int
J Periodontics Restorative Dent 1983;3(3):8-27.
120. Carvalho JCM, Pustiglioni FE, Kon S. Combination of
a connective tissue pedicle flap with a free gingival
graft to cover localized gingival recession. Int J Peri-
odontics Restorative Dent 1982;2(4):27-33.
318
Volume 8 Number 1 December 2003
121. Dorfman HS, Kennedy JE, Bird WC. Longitudinal eval-
uation of free autogenous gingival grafts. A four year
report. J Periodontol 1982;53:349-352.
122. Langer B, Calagna LJ. The subepithelial connective
tissue graft. A new approach to the enhancement of
anterior cosmetics. Int J Periodontics Restorative Dent
1982;2(2):22-33.
123. Espinel MC, Caffesse RG. Comparison of the results
obtained with the laterally positioned pedicle sliding
flap-revised technique and the lateral sliding flap with
a free gingival graft technique in the treatment of local-
ized gingival recessions. Int J Periodontics Restorative
Dent 1981;1(6):31-37.
124. Bartolucci EG. A clinical evaluation of freeze-dried
homologous dura mater as a periodontal free graft
material. Study in humans. J Periodontol 1981;52:
354-361.
125. Mrmann W, Schaer F, Firestone AR. The relationship
between success of free gingival grafts and transplant
thickness. Revascularization and shrinkageA one year
clinical study. J Periodontol 1981;52:74-80.
126. Tenenbaum H, Klewansky P, Roth JJ. Clinical evalua-
tion of gingival recession treated by coronally reposi-
tioned flap technique. J Periodontol 1980;51:686-690.
127. Matter J. Creeping attachment of free gingival grafts.
A five-year follow-up study. J Periodontol 1980;51:
681-685.
128. Dorfman HS, Kennedy JE, Bird WC. Longitudinal eval-
uation of free autogenous gingival grafts. J Clin Peri-
odontol 1980;7:316-324.
129. Liu WJ-L, Solt CW. A surgical procedure for the treat-
ment of localized gingival recession in conjunction with
root surface citric acid conditioning. J Periodontol 1980;
51:505-509.
130. Hangorsky U, Bissada NF. Clinical assessment of free
gingival graft effectiveness on the maintenance of peri-
odontal health. J Periodontol 1980;51:274-278.
131. Caffesse RG, Guinard EA. Treatment of localized gin-
gival recessions. Part IV. Results after three years. J Peri-
odontol 1980;51:167-170.
132. Matter J. Free gingival graft and coronally repositioned
flap. A 2-year follow-up report. J Clin Periodontol
1979;6:437-442.
133. Caffesse RG, Guinard EA. Treatment of localized
gingival recessions. Part II. Coronally repositioned flap
with a free gingival graft. J Periodontol 1978;49:
357-361.
134. Guinard EA, Caffesse RG. Treatment of localized gin-
gival recessions. Part I. Lateral sliding flap. J Periodontol
1978;49:351-356.
135. James WC, McFall WT Jr. Placement of free gingival
grafts on denuded alveolar bone. Part I: Clinical eval-
uations. J Periodontol 1978;49:283-290.
136. Maynard JG Jr. Coronal positioning of a previously
placed autogenous gingival graft. J Periodontol 1977;
48:151-155.
137. Irwin RK. Combined use of the gingival graft and
rotated pedicle procedures: Case reports. J Periodon-
tol 1977;48:38-40.
138. Matter J, Cimasoni G. Creeping attachment after free
gingival grafts. J Periodontol 1976;47:574-579.
139. Bernimoulin J-P, Lscher B, Mhlemann HR. Coronally
repositioned periodontal flap. Clinical evaluation after
one year. J Clin Periodontol 1975;2:1-13.
140. Vandersall DC. Management of gingival recession and
a surgical dehiscence with a soft tissue autograft: 4 year
observation. J Periodontol 1974;45:274-278.
8012.qxd 12/30/03 3:35 PM Page 319
Ann Periodontol
141. Ward VJ. A clinical assessment of the use of the free
gingival graft for correcting localized recession
associated with frenal pull. J Periodontol 1974;45:
78-83.
142. Fagan F, Freeman E. Clinical comparison of the free
gingival graft and partial thickness apically positioned
flap. J Periodontol 1974;45:3-8.
143. Sullivan HC, Atkins JH. Free autogenous gingival
grafts. III. Utilization of grafts in the treatment of gin-
gival recession. Periodontics 1968;6:152-160.
144. Newman MG, Hujoel PP. Statement of purpose and
methods. J Evid Based Dent 2001;1:3A-5A.
145. McGuire MK, Nunn M. Evaluation of human recession
defects treated with coronally advanced flaps and either
enamel matrix derivative or connective tissue. Part 1:
Comparison of clinical parameters. J Periodontol 2003;
74:1110-1125.
Correspondence: Dr. Thomas Oates, Department of Peri-
odontics, University of Texas Health Science Center at San
Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78229-3900.
E-mail: oates@uthscsa.edu.
Accepted for publication August 17, 2003.
APPENDIX A
CONSENSUS REPORT
Members of the Section read and studied the review
titled Surgical Therapies for the Treatment of Gingival
Recession. A Systematic Review, by Thomas Oates,
Melanie Robinson, and John C. Gunsolley. The focused
PICO question addressed by this evidence-based sys-
tematic review is: What is the effect of surgical therapy
for root coverage in patients with gingival recession
compared with other treatment modalities or baseline
values?
INTRODUCTION
The Section participants declared there were no con-
flicts of interest regarding the topics to be discussed. The
generated discussions were centered around the evi-
dence-based systematic review as well as 2 previously
published systematic reviews. The Sections extensive
personal clinical experience in the area of periodontal
plastic surgery brought insight, clarity, and clinical rel-
evance to the deliberations. This allowed the partici-
pants to integrate individual clinical experience with the
best available evidence.
The deliberations were focused on the PICO ques-
tion and the data provided by the systematic review.
Decisions were reached after consideration of the
strength of evidence for each of the 5 Consensus
Report questions.
It is important for readers to understand that treat-
ment decisions based on recommendations from this
Section must take into account the expertise of the
clinician, type of lesion presented, and patient treat-
ment needs and desires.
It was not within the scope of the systematic review
to assess elements important in case selection (e.g.,
Oates, Robinson, Gunsolley
patient factors, defect morphology, and site characteris-
tics) and the critical aspects of the execution of these
procedures (e.g., flap design and suturing techniques)
in accomplishing optimal root surface coverage. How-
ever, these factors may influence specific procedure
selection, outcomes, or decision to treat.
1. Does the Section agree that the evidence-based
systematic review is complete and accurate?
The data review was complete and accurate within the
context of the question posed.
2. Has any new information been generated
or discovered since the evidence-based search
cut-off date?
New information including 2 systematic reviews and
3 RCTs directly relevant to the PICO question was eval-
uated by the Section.1-5 Two studies compared coro-
nally positioned flaps with either soft tissue allografts
or autogenous connective tissue grafts.3,4 Another
study compared coronally positioned flaps with either
enamel matrix derivative or autogenous connective
tissue grafts.5 The results of these studies were con-
sistent with those included in the systematic review.
3. Does the Section agree with the interpretations
and conclusions of the reviewers?
After assessment of the original evidence, the Section
agrees with the following conclusions:
The systematic review of the data demonstrates
there are several surgical procedures that successfully
cover exposed root surfaces. There is evidence that
these surgical procedures result in improved patient-
oriented outcomes including decreased root sensitivity
and enhanced soft tissue esthetics.
The studies identified in this systematic review
concerning patient-oriented outcomes lacked standard-
ization of measures, precluding quantitative analysis.
Future studies designed primarily to investigate
patient-oriented outcomes such as esthetics, hypersen-
sitivity, morbidities, and overall satisfaction are needed.
Meta-analysis identified statistically significant
advantages for autogenous connective tissue grafts when
compared with GTR using bioabsorbable barriers in
terms of root coverage and width of keratinized tissue.
A limited number of recent randomized controlled
studies support the efficacy of coronally positioned
flaps with allogeneic soft tissue grafts for root coverage.
Based on the number of efficacy studies using
autogenous connective tissue grafts in conjunction with
coronally positioned flap surgery, it is surprising that
there are no comparative randomized controlled trials
for this treatment and coronally positioned flap surgery
alone. Future studies are needed to assess the effi-
cacy of coronally positioned flap procedures in the
presence or absence of connective tissue grafting.
319
8012.qxd 12/30/03 3:35 PM Page 320
Surgical Treatment of Gingival Recession
Most of the literature dealing with root coverage
procedures are case series and non-randomized studies.
Future well-designed investigations are needed to further
clarify the relative efficacy of different treatment options.
4. What further research needs to be done relative
to the focused questions of the evidence-based
review?
The Section members observed that the majority of
published research is focused on clinical measures of
single-tooth gingival recession involving intact root
surfaces. Such research was critical in providing the
evidence of efficacy. The Section identified several
areas of future research needs:
1. More data are needed with relation to the benefit
of root coverage in terms of root abrasion, root sensi-
tivity, root caries prevention, ease of maintenance,
patient comfort, tooth survival, improved function, and
esthetics.
2. More information is also needed to assist in selec-
tion of the appropriate treatment options for specific
site characteristics and clinical situations.
3. The Section felt that future research should include
application of cell transplantation, biological mediators,
and appropriate bioactive scaffolds to improve the extent
and predictability of root coverage. Such research should
proceed in parallel with efforts to further refine and eval-
uate existing techniques and understand the sources of
their variability. As part of these investigations the
histologic nature of the wound healing process should
be identified.
5. How can the information from the evidence-
based review be applied to patient management?
A. There is evidence to indicate that several surgical
procedures are effective in the coverage of an exposed
root.
Level of Evidence:6 Strong.
Rationale: Assignment of this level of evidence is
based on the current systematic review (31 independent
RCTs) and 2 independent systematic reviews reaching
similar conclusions.
B. There is evidence to indicate that coronally posi-
tioned flaps with autogenous connective tissue grafts
result in greater root coverage and increase keratinized
tissue compared to GTR procedures using bioresorbable
membranes.
Level of Evidence: Strong.
Rationale: Assignment of this level of evidence is
based on a meta-analysis of 6 RCTs in the current sys-
tematic review and was consistent with a second sys-
tematic review.
C. There is evidence to indicate that root coverage
procedures result in decreased root sensitivity and
improved esthetics.
320
Volume 8 Number 1 December 2003
Level of Evidence: Moderate.
Rationale: Assignment of this level of evidence is
based on the current systematic review (7 RCTs) and
a recent RCT.5
D. There is evidence to indicate that coronally posi-
tioned flaps with allogeneic soft tissue grafts result in
similar root coverage as coronally positioned flaps with
autogenous connective tissue.
Level of Evidence: Moderate.
Rationale: Assignment of this level of evidence is
based on the current systematic review (2 RCTs) and
2 recent RCTs.3,4
E. There is limited evidence that coronally posi-
tioned flaps plus enamel matrix derivative (EMD) pro-
vides similar root coverage as coronally positioned
flaps with autogenous connective tissue.
Level of Evidence: Limited.
Rationale: Assignment of this level of evidence is
based on a single-center recent RCT.5
REFERENCES
1. Roccuzzo M, Bunino M, Needleman I, Sanz M. Peri-
odontal plastic surgery for treatment of localized gingi-
val recessions: A systematic review. J Clin Periodontol
2002;29(Suppl. 3):178-194.
2. Clauser C, Nieri M, Franceschi D, Pagliaro U, Pini Prato
G. Evidence-based mucogingival therapy. Part 2: Ordinary
and individual patient data meta-analyses of surgical treat-
ment of recession using complete root coverage as the
outcome variable. J Periodontol 2003;74:741-756.
3. Tal H, Moses O, Zohar R, Meir H, Nemcovsky C. Root cov-
erage of advanced gingival recession: A comparative study
between acellular dermal matrix allograft and subepithelial
connective tissue grafts. J Periodontol 2002;73:1405-1411.
4. Paolantonio M. Treatment of gingival recessions by com-
bined periodontal regenerative technique, guided tissue
regeneration, and subpedicle connective tissue graft. A
comparative clinical study. J Periodontol 2002;73:53-62.
5. McGuire MK, Nunn ME. Evaluation of human recession
defects treated with coronally advanced flaps and either
enamel matrix derivative or connective tissue. Part I:
Comparison of clinical parameters. J Periodontol 2003;
74:1110-1125.
6. Newman MG, Caton J, Gunsolley JC. The use of the evi-
dence-based approach in a periodontal therapy contem-
porary science workshop. Ann Periodontol 2003;8:1-11.
SECTION MEMBERS
James T. Mellonig, Pierpaolo S. Cortellini
Group Leader J. Gary Maynard
Maurizio Tonetti, Chair Michael MacNeil
Donald S. Clem, III, Michael K. McGuire
Secretary Kevin G. Murphy
Thomas Oates, Reviewer Robert G. Schallhorn
Edward P. Allen Henry H. Takei
Kenneth W. Bueltmann Raymond A. Yukna