CLINICAL GUIDELINES „9

Giovanpaolo Pini-Prato, Michele Nieri, Umberto Pagliaro, Teresa Schifter Giorgi,

Michele La Marca, Debora Franceschi, Jacopo Buti, Monica Giani, Julia Hanne Weiss,
Luigi Padeletti, Pierpaolo Cortellini, Leandro Chambrone, Luca Barzagli, Efisio Defraia,
Roberto Rotundo

Surgical treatment of single gingival recessions:

Clinical guidelines
Giovanpaolo
Pini-Prato, Professor
Department of Surgery and
Translational Medicine, Uni-
Key words aesthetics, gingival recession, guidelines, mucogingival surgery, systematic review versity of Florence, Italy

Michele Nieri, DMD

Purpose: The purpose of this clinical guidelines project was to determine the most appropriate surgi- Department of Surgery and
Translational Medicine, Uni-
cal techniques, in terms of efficacy, complications, and patient opinions, for the treatment of buccal versity of Florence, Italy
single gingival recessions without loss of interproximal soft and hard tissues. Umberto Pagliaro,
Methods: Literature searches were performed (electronically and manually) for entries up to 28 Feb- Med Dent
Private Practice, Florence,
ruary, 2013 concerning the surgical approaches for the treatment of gingival recessions. Systematic Italy
reviews (SRs) of randomised controlled trials (RCTs) and individual RCTs that reported at least 6
Teresa Schifter Giorgi,
months of follow-up of surgical treatment of single gingival recessions were included. The full texts DMD
of the selected SRs and RCTs were analysed using checklists for qualitative evaluation according to Private Practice, Florence,
Italy
the Scottish Intercollegiate Guidelines Network (SIGN) method. The following variables were evalu-
ated: Complete Root Coverage (CRC); Recession Reduction (RecRed); complications; functional and Michele La Marca,
DMD
aesthetic satisfaction of the patients; and costs of therapies. Private Practice, Florence,
Italy
Results: Out of 30 systematic reviews, 3 SRs and 16 out of 313 RCTs were judged to have a low
risk for bias (SIGN code: 1+). At a short-term evaluation, the coronally advanced flap plus connec- Debora Franceschi,
DMD
tive tissue graft method (CAF+CTG) resulted in the best treatment in terms of CRC and/or RecRed; Department of Surgery and
in case of cervical abrasion and presence of root sensitivity CAF + CTG + Restoration caused less Translational Medicine, Uni-
versity of Florence, Italy
sensitivity than CAF+CTG. CAF produced less postoperative discomfort for patients. Limited in-
formation is available regarding postoperative dental hypersensitivity and aesthetic satisfaction of Jacopo Buti, DMD,
PhD
the patients. School of Dentistry, The
Conclusion: In presence of aesthetic demands or tooth hypersensitivity, the best way to surgically University of Manchester,
UK
treat single gingival recessions without loss of interproximal tissues is achieved using the CAF pro-
cedure associated with CTG. Considering postoperative discomfort, the CAF procedure is the less Monica Giani, Dent
Hygienist
painful surgical approach, while the level of aesthetic satisfaction resulted higher after CAF either Dental Hygienist repre-
sentative, Private Practice,
alone or with CTG. It is unclear how much tooth hypersensitivity is reduced by surgically covering Florence, Italy
buccal recessions. It is important to note that the present recommendations are based on short-term
Julia Hanne Weiss,
data (less than 1 year). Patient Representa-
Source of funding: The guidelines project was made possible through self-financing by the authors. tive
Patient representative,
Florence, Italy
Conflict of interest: The authors certify that there are no conflicts of interest related to this review.
Luigi Padeletti,
Professor
Department of Experimen-
tal and Clinical Medicine,
University of Florence,
Italy (General Practitioner
Representative)

Eur J Oral Implantol 2014;7(1):9–43

10 „
Pierpaolo Cortellini,
Med Dent
European Research Group on
Periodontology (ERGOPER-
IO), Berne, Switzerland
Leandro Chambrone,
Professor
Department of Periodontol-
ogy, Dental Research Divi-
sion, Guarulhos University,
Guarulhos, SP, Brazil
Luca Barzagli,
Med Dent
National Association of Ital-
ian Dentists (ANDI) – Tuscan
Section
Efisio Defraia,
Professor
Department of Surgery and
Translational Medicine, Uni-
versity of Florence, Italy
Roberto Rotundo,
DMD
Department of Surgery and
Translational Medicine, Uni-
versity of Florence, Italy and
Periodontal Unit, Eastman
Dental Institute, University
College of London, UK
Correspondence to:
Roberto Rotundo,
via Vasco de’ Gama,
33/3 - 50127, Firenze, Italy
Email: roberto.rotundo@
gmail.com
Pini-Prato et al Guidelines for single gingival recessions
„ Introduction
In 2011, the US Institute of Medicine of the National
Academies (IOM)1 stated “Clinical practice guide-
lines are statements that include recommendations
intended to optimize patient care that are informed
by systematic reviews of evidence and an assessment
of the benefits and harms of alternative care options”.
According to the Evidence-Based Medicine phi-
losophy, guidelines must be performed on the basis
of the most reliable scientific evidence (systematic
reviews [SRs]). In fact, SRs have been defined as
“Literature reviews that summarize evidence by
identifying, selecting, assessing and synthesizing the
findings of similar but separate studies. They can
help to clarify what is known and not known about
the potential benefits and harms of drugs, devices
and other health care services”2.
The clinical practice guidelines must meet sev-
eral new revised criteria for their inclusion in the US
National Guidelines Clearinghouse (Effective June
2014)3. Among these criteria, three are of para-
mount importance:
1. “The clinical practice guideline contains system-
atically developed statements including recom-
mendations intended to optimise patient care
and assist physicians and/or other health care
practitioners and patients to make decisions
about appropriate health care for specific clinical
circumstances”;
2. “The clinical practice guideline was produced
under the auspices of a medical specialty as-
sociation; relevant professional society; public
or private organisation; government agency at
the Federal, State, or local level; or health care
organisation or plan. A clinical practice guide-
line developed and issued by an individual(s) not
officially sponsored or supported by one of the
above types of organisations does not meet the
inclusion criteria for NGC”;
3. “The clinical practice guideline is based on sys-
tematic review of evidence”.
Practically, clinical guidelines have been developed
in medicine to transfer the results of scientific rec-
ognised research in clinical practice and provide use-
ful information for institutions, universities, insurers,
clinical practitioners, and mostly for patients.
Eur J Oral Implantol 2014;7(1):9–43
In periodontology, one of the therapies requested
by patients is the treatment of gingival recessions
that may be associated with dental hypersensitiv-
ity and personal aesthetic concerns. Case reports,
case series, controlled clinical trials, randomised con-
trolled trials (RCTs) and SRs have been published on
this topic and different techniques were proposed to
treat these lesions. Data on outcomes of surgical pro-
cedures are widely available in the literature for the
clinicians. Even in the more recent and well-designed
articles (RCTs and SRs) that reported detailed and
statistically sound results, little information is avail-
able on patient-based outcomes (i.e. patient’s satis-
faction, complications, side effects and economical
costs). These factors, often underestimated in these
papers, could be able to influence and to facilitate
the choice of treatment, if properly evaluated by
clinicians together with patients. In fact, the patient
(‘the person’) is placed at the centre of the medical
process. The physicians must take his/her percep-
tion, information and sensations, along with a clear
decisive consensus to treatment into great consid-
eration.
Gingival recession is defined as “the location of
the gingival margin apical to the cementoenamel
junction (CEJ)”4 and may involve one or more tooth
surfaces. Recessions are frequent clinical features
in populations with both good5,6 and poor stand-
ards5,7,8 of oral hygiene, as reported in some large-
scale epidemiological studies. For instance, Kassab
and Cohen9 reported that 88% of 65-year old
patients show recessions, while 50% of the 18- to
64-year-old patient group had recessions. Other
studies reported similar trends of recession distribu-
tion in different populations10-13.
Furthermore, it has been shown that several con-
ditions may be associated with the presence of buc-
cal recessions:
• Anatomical factors. Gingival recessions may be
associated with sites showing a developmental
absence of bone, known as bone dehiscence.
This condition often occurs when the teeth are
positioned beyond the thickness of the alveolar
bone, in a buccolingual direction, with disconti-
nuity of the cortical plate14-16. Other anatomical
conditions may be associated with gingival reces-
sions, such as frenulum attachment positioned
close to the gingival margin17,18.
 Pini-Prato et al
• Traumatic toothbrushing. The type of technique,
frequency, strength and duration of tooth brush-
ing are often associated with gingival reces-
sions9,16. Many studies have shown that high
standards of oral hygiene increase the prob-
ability of developing gingival recessions19,20. For
instance, a previous RCT compared manual and
electric toothbrushing showing no differences
between the two approaches in terms of pro-
gression of recessions21. Nevertheless, a recent
SR concluded that data supporting or refuting
the association between traumatic toothbrush-
ing and gingival recession are still inconclusive22.
• Occlusion. Some authors23 found associations
between gingival clefts and occlusal traumatism,
reporting that occlusal adjustment seemed to
improve these lesions. However, other authors
reported that there does not appear to be any
relationship between occlusal discrepancies and
gingival recessions24.
• Tobacco use. An observational study on Swed-
ish adolescent patients25 compared a group of
non-user with a group of patients using smoke-
less tobacco (moist snuff). In that population,
the use of moist snuff was not associated with
the presence of periodontal disease, but a sig-
nificantly high prevalence of gingival recessions
was observed.
• Orthodontic treatment. Cases of gingival reces-
sions were observed during/after orthodontic
tooth movement, mostly in the mandibular inci-
sors9,16. In fact, if the orthodontic labial move-
ment of the tooth can result in the establishment
of an alveolar bone dehiscence, there is a high
risk of developing a gingival recession26.
• Piercing. Another factor associated with gin-
gival recessions is the presence of piercing in
young populations. Some case reports have been
recently published showing presence of marginal
gingival recessions in sites traumatised by labial
and lingual piercings27-31.
• Chemical agents. Local cocaine application has
been implicated as cause of gingival erosions and
ulcerations, and associated with rapid progres-
sion of gingival recession32,33.
Considering the classification systems, several meth-
ods have been proposed in the literature to facilitate
Guidelines for single gingival recessions „ 11
the diagnosis of gingival recessions34-38. An initial
classification of gingival recessions proposed by Sul-
livan and Atkins in 196834, classified recessions as
wide or narrow lesions with the involvement of the
gingiva and/or the alveolar mucosa. Later, on the
basis of clinical and prognostic criteria and to facili-
tate treatment decisions for clinicians, Miller37 pro-
posed a classification of recessions into four classes,
depending on the degree of destruction of the soft
and hard periodontal tissues.
Recently, Cairo et al39 published a new classi-
fication of recessions considering the interdental
attachment level as the reference measurement and
identified three classes of recessions. Considering
the exposed root surface following the apical shift
of the gingival margin, Pini Prato et al40 proposed
a classification based on two factors: presence or
absence of an identifiable CEJ and the presence or
absence of dental surface discrepancy (abrasion),
thus four classes are identified on the basis of these
factors. Following this information, Rotundo et al41
presented a classification taking into consideration
all of these factors, and in particular, the amount of
keratinised tissue around the gingival recession, the
presence/absence of non-carious cervical lesions,
and the presence/absence of interproximal attach-
ment loss.
The treatment of gingival recession is mainly
indicated to improve aesthetics and to reduce or
eliminate dental hypersensitivity due to root expo-
sure. Different surgical and non-surgical techniques
have been described for the treatment of single and
multiple recessions. Because of the patients’ ever-
increasing aesthetic demands, new and sophisticated
surgical techniques have been developed to obtain
complete root coverage associated with perfect inte-
gration of grafted tissue with the adjacent soft tis-
sues. The choice of treatment depends on the assess-
ment of the factors linked to the characteristics of
the single patient, of the tooth, and of the site. In
fact, the size of the recession, both horizontally and
vertically, the amount of residual keratinised gingiva
apical and adjacent to the lesion, the presence of
pulling frenum, as well as the presence or absence
of dental abrasion at the cementoenamel junction,
influence the choice of the most appropriate tech-
nique. Other factors, such as the patient’s personal
aesthetic expectations, subjective dental hypersen-
Eur J Oral Implantol 2014;7(1):9–43
12 „ Pini-Prato et al Guidelines for single gingival recessions
sitivity, smoking habit and the need to reduce the
number of interventions may further influence the
choice of the treatment.
Nowadays, on the basis of the published litera-
ture, two approaches can be identified as the most
effective: the coronally advanced flap and the com-
bined procedures based on a coronally advanced flap
with connective tissue; or allogenic materials inter-
posed between the flap and the root surface42,43.
Recently, Buti et al44 used a Bayesian Network
meta-analysis model to summarise evidence from
the published information on comparisons among
different root coverage procedures based on coro-
nally advanced flap or combined techniques with
the aim of drawing inferences even on comparisons
which have not been conducted yet. The coronally
advanced flap with connective tissue proved the
most effective procedure (first in the ranking of
treatments) among all the compared root coverage
techniques. This outcome confirmed the results of a
meta-analysis on individual patient data conducted
by Chambrone et al45.
The even more sophisticated surgical techniques
used for treating single recessions allow for a high
percentage of recession reduction ranging from 52
to 99%, with a percentage of complete root cover-
age from 9 to 95%46. In cases of multiple recessions,
the mean recession reduction ranges from 94 to
98%, with a mean complete root coverage ranging
from 68 to 90%47. This high variability of the results
is found not only when comparing different tech-
niques, but also within the same surgical technique.
This means that the treatment of root coverage is
affected by the operator’s skills and that other fac-
tors have not been adequately considered. Potential
prognostic factors are divided into three different
categories48: patient-related factors (gender, age,
smoking) tooth/site-related factors (tooth-vitality,
tooth position, vestibulum depth, cervical caries,
tooth malpositioning) and technique-related factors
(microsurgery, materials, operator skill). Neverthe-
less, there is a lack of scientific evidence on many
prognostic factors and data on these issues are often
not available in periodontal literature.
Among the tooth/site related factors, the residual
amount of keratinised tissue apical to the recessions
is of paramount importance for establishing the
most appropriate treatment approach. The absence
Eur J Oral Implantol 2014;7(1):9–43
or reduced amount of keratinised tissue represents a
critical situation for clinicians. Few data are available.
Pini Prato et al49 observed that recession reduction is
associated with the amount of baseline keratinised
tissue: every millimetre of additional KT at baseline
is associated with an increment of 0.23 mm of reces-
sion reduction after CAF procedure at the 8-year
follow-up visit. However, an important question is
still open: what is the appropriate amount of kerati-
nised tissue for choosing CAF or CAF+CTG?
Often, gingival recessions are associated with
non-carious cervical lesions such as abrasions, ero-
sions, and abfractions50. In these cases, even if the
width and depth of the recessions are minimal, the
final outcomes in terms of complete root coverage
are not predictable. Combined restorative-periodon-
tal approaches have been also suggested51-53.
Although a large number of well-done RCTs on
mucogingival root coverage procedures have been
published giving detailed information on the selected
population, sample size calculation, entry criteria,
type of recessions, periodontal measurements, and
several statistical analyses, only one recent study
provides information about the patient’s percep-
tion and the personal and spontaneous request for
undergoing surgical or non-surgical treatment54.
In this study, out of 120 enrolled patients, 96 pre-
sented 783 gingival recessions, of which 565 were
unperceived. Of 218 perceived recessions, 160
were asymptomatic, 36 showed dental hypersen-
sitivity, 13 aesthetic problems, and 9 aesthetic plus
hypersensitivity issues. Only 11 patients requested
treatment for their 57 recessions. Age (i.e. younger
individuals), deeper recessions, incisors and canines
and non-carious cervical lesions were significantly
associated with patient perception of recessions.
Younger subjects, deeper recessions and incisors
were significantly associated with patient requests
for treatment.
Moreover, there is little information on postop-
erative discomfort and on a possible impairment of
personal daily life55,56. Complications of the surgical
treatment are rarely reported in the articles; one
case report shows a severe root resorption after a
successful bilaminar procedure on a maxillary pre-
molar57. In addition, very few studies have consid-
ered patient satisfaction as the true outcome of the
procedure mainly addressing the goal of aesthetic
 Pini-Prato et al
improvement. On this issue, a study by Rotundo et
al58 investigated the perceived aesthetic outcomes
on simulated root coverage procedures in three dif-
ferent groups of evaluators: patients, dentists and
periodontists. The three groups considered complete
root coverage the most desirable outcome.
With regard to changes in dental hypersensitiv-
ity, this variable is seldom reported in the studies. An
RCT55 reported that coronally advanced flap alone
or associated with a connective tissue graft are effec-
tive in reducing dental hypersensitivity.
The financial cost of the procedure in terms of
materials, chair-time, and post-surgical controls is
often underestimated as well. The cost of the ther-
apy could influence the patient’s choice for a cheaper
approach, thereby affecting the outcomes of the
procedures48.
Therefore, the aim of these clinical guidelines
requested by the National Association of Italian
Dentists (ANDI) – Tuscany Region was to determine
which surgical techniques are most appropriate for
the treatment of patients showing single buccal gin-
gival recessions without loss of interproximal soft
and hard tissues.
Multiple gingival recessions have not been con-
sidered in these guidelines due to the reduced num-
ber of available studies and to their low level of evi-
dence. Nevertheless, this clinical condition will be
taken into consideration for specific guidelines in the
future. In addition, for statistical reasons, the RCTs
that dealt with multiple recessions in a single patient
were excluded if they did not take into account the
existence of non-independent sites (patient effect).
These clinical guidelines were complied with the
tools and instructions of the Appraisal of Guidelines
for Research and Evaluation (AGREE) Collabora-
tion59. The guidelines were drawn up by multidis-
ciplinary development groups and based on a sys-
tematic review of the evidence for best practice,
following a standard methodology designed to bal-
ance scientific rigour with an open and consultative
approach.
The key clinical issues included:
Efficacy
1. Which is the most effective surgical technique
for the treatment of single gingival recessions in
terms of complete root coverage and recession
reduction?
Guidelines for single gingival recessions „ 13
2. Which is the most effective surgical technique
for recessions associated with non-carious cervi-
cal lesions?
Complications
3. Which surgical technique for the treatment of
single gingival recessions has the least adverse
reactions (discomfort, postoperative pain, hae-
matoma, etc.)?
Patient opinions
4. Which is the most effective surgical technique
for the treatment of single gingival recessions,
in terms of:
–(a) absence of dental hypersensitivity
–(b) aesthetic satisfaction.
Available data on the following techniques were
evaluated:
• Coronally Advanced Flap (CAF)
• CAF plus Connective Tissue Graft (CAF+CTG)
• CAF plus resorbable and non-resorbable Barrier
Membrane (CAF+BM)
• CAF plus Enamel Matrix Derivative (CAF+EMD)
• CAF plus Acellular Dermal Matrix (CAF+ADM)
• CAF plus Platelet-Rich Plasma (CAF+PRP)
• CAF plus Human Fibroblast-Derived Dermal Sub-
stitute (CAF+HF-DDS)
• CAF plus Xenogenic Collagen Matrix (CAF+CM)
• Semilunar Technique (ST)
• Free Gingival Graft (FGG)
• Laterally Positioned Flap (LPF)
• Envelope Technique plus CTG (ET+CTG)
• CAF plus Anorganic Bovine Derived Hydroxyapa-
tite Matrix Cell Bridging Peptide (ADMP15)
• CAF plus CTG plus Resin Composite Restoration
(CAF+CTG+R)
• CAF plus Resin Composite Restoration (CAF+R).
„ Materials and methods
„ Criteria used for drafting the guidelines
These guidelines requested by the National Asso-
ciation of Italian Dentists (ANDI) – Tuscany Region
were organised using PICO60, a worksheet assess-
ment that uses four categories for breaking down
Eur J Oral Implantol 2014;7(1):9–43
14 „ Pini-Prato et al Guidelines for single gingival recessions
and converting the issues to investigate and the
information sought into specific, precise questions.
According to PICO, a well-structured research strat-
egy calls for at least four questions that define the
characteristics of the patient (patient or population
[P]), the treatments to investigate (intervention [I]),
the comparisons among the identified treatments
(comparison [C]), and the outcome variables con-
sidered important for the evaluation of the results
(outcomes [O])60.
„ Development of the guidelines
According to the Scottish Intercollegiate Guidelines
Network (SIGN) the present clinical practice guide-
lines have been developed by dentists/physicians
(GPP, MN, UP, RR) in collaboration with representa-
tives of those who will be affected by the specific
intervention(s) in question, including general practi-
tioners, dental hygienists, and patients.
These guidelines have been based on all the SRs
of RCTs and individual RCTs published up to 28 Feb-
ruary, 2013. At the same time, internal (MN, UP) and
external (LC, PC) reviewers were selected to validate
the outcomes of this study. When the first draft of
the manuscript was completed, the panel of authors
evaluated and discussed the text to reach an agree-
ment on the guidelines. Subsequently, the guidelines
were sent to the external reviewers (LC, PC) for the
definitive agreement.
„ Patient, dental hygienist, and general
practitioner involvement in guidelines
development
Following the SIGN recommendations, “the purpose
of patient involvement is to ensure that the guideline
addresses issues that matter to them and that their
perspectives are reflected in the guideline. Patients
can identify issues that may be overlooked by health
professionals, can highlight areas where the patient’s
perspective differs from the views of health profes-
sionals, and can ensure that the guideline addresses
key issues of concern to patients. A key role for patient
and career representatives is to ensure that patient
views and experiences inform the group’s work”.
Dental hygienists and general practitioners were
also involved in guideline development in order to
Eur J Oral Implantol 2014;7(1):9–43
provide their personal opinions and to comment on
draft documents. Although the areas of expertise
may vary, members of the guidelines development
group shared equal status in the group. Patients,
dental hygienists, and general practitioners were
invited to take part in the peer review stage of each
guideline and specific guidance for lay reviewers has
been produced.
„ Type of studies and participants –
inclusion and exclusion criteria
Only RCTs-based SRs (i.e. SRs of RCTs) and indi-
vidual RCTs were selected for these guidelines. RCTs
had to report the treatment of adult patients (at least
18 years old) presenting single recessions without
interproximal soft and hard tissue loss associated or
not with non-carious cervical lesions, and a follow-
up ≥ 6 months after the surgical procedure. For sta-
tistical analyses, the RCTs that dealt with multiple
recessions in a single patient were excluded if they
did not take into account the existence of non-inde-
pendent sites (patient effect).
„ Surgical techniques of interest
The results published in the literature concerning
the following surgical techniques were searched and
compared: CAF; CAF+CTG; CAF+BM; CAF+EMD;
CAF+ADM; CAF+PRP; CAF+HF-DDS; CAF+CM; ST;
FGG; LPF; ET+CTG; CAF+ADMP15; CAF+CTG+R;
CAF+R. Data concerning the techniques were
sought for the following 105 comparisons: CAF vs.
CAF+CTG; CAF vs. CAF+BM; CAF vs. CAF+EMD;
CAF vs. CAF+ADM; CAF vs. CAF+PRP; CAF vs.
CAF+HF-DDS; CAF vs. CAF+CM; CAF vs. ST; CAF
vs. FGG; CAF vs. LPF; CAF vs. ET+CTG; CAF vs.
CAF+ADMP15; CAF vs. CAF+CTG+R; CAF vs.
CAF+R; CAF+CTG vs. CAF+BM; CAF+CTG vs.
CAF+EMD; CAF+CTG vs. CAF+ADM; CAF+CTG vs.
CAF+PRP; CAF+CTG vs. CAF+HF-DDS; CAF+CTG
vs. CAF+CM; CAF+CTG vs. ST, CAF+CTG vs. FGG;
CAF+CTG vs. LPF; CAF+CTG vs. ET+CTG; CAF+CTG
vs. CAF+ADMP15; CAF+CTG vs. CAF+CTG+R;
CAF+CTG vs. CAF+R; CAF+BM vs. CAF+EMD;
CAF+BM vs. CAF+ADM; CAF+BM vs. CAF+PRP;
CAF+BM vs. CAF+HF-DDS; CAF+BM vs. CAF+CM;
CAF+BM vs. ST; CAF+BM vs. FGG; CAF+BM vs. LPF;
 Pini-Prato et al
CAF+BM vs. ET+CTG; CAF+BM vs. CAF+ADMP15;
CAF+BM vs. CAF+CTG+R; CAF+BM vs. CAF+R;
CAF+EMD vs. CAF+ADM; CAF+EMD vs.
CAF+PRP; CAF+EMD vs. CAF+HF-DDS; CAF+EMD
vs. CAF+CM; CAF+EMD vs. ST; CAF+EMD vs.
FGG; CAF+EMD vs. LPF; CAF+EMD vs. ET+CTG;
CAF+EMD vs. CAF+ADMP15; CAF+EMD vs.
CAF+CTG+R; CAF+EMD vs. CAF+R; CAF+ADM vs.
CAF+PRP; CAF+ADM vs. CAF+HF-DDS; CAF+ADM
vs. CAF+CM; CAF+ADM vs. ST; CAF+ADM vs.
FGG; CAF+ADM vs. LPF; CAF+ADM vs. ET+CTG;
CAF+ADM vs. CAF+ADMP15; CAF+ADM vs.
CAF+CTG+R; CAF+ADM vs. CAF+R; CAF+PRP vs.
CAF+HF-DDS; CAF+PRP vs. CAF+CM; CAF+PRP vs.
ST; CAF+PRP vs. FGG; CAF+PRP vs. LPF; CAF+PRP
vs. ET+CTG; CAF+PRP vs. CAF+ADMP15; CAF+PRP
vs. CAF+CTG+R; CAF+PRP vs. CAF+R; CAF+HF-
DDS vs. CAF+CM; CAF+HF-DDS vs. ST; CAF+HF-
DDS vs. FGG; CAF+HF-DDS vs. LPF; CAF+HF-DDS
vs. ET+CTG; CAF+HF-DDS vs. CAF+ADMP15;
CAF+HF-DDS vs. CAF+CTG+R; CAF+HF-DDS
vs. CAF+R; CAF+CM vs. ST; CAF+CM vs. FGG;
CAF+CM vs. LPF; CAF+CM vs. ET+CTG; CAF+CM
vs. CAF+ADMP15; CAF+CM vs. CAF+CTG+R;
CAF+CM vs. CAF+R; ST vs. FGG; ST vs. LPF; ST vs.
ET+CTG; ST vs. CAF+ADMP15; ST vs. CAF+CTG+R;
ST vs. CAF+R; FGG vs. LPF; FGG vs. ET+CTG; FGG
vs. CAF+ADMP15; FGG vs. CAF+CTG+R; FGG vs.
CAF+R; LPF vs. ET+CTG; LPF vs. CAF+ADMP15;
LPF vs. CAF+CTG+R; LPF vs. CAF+R; ET+CTG vs.
CAF+ADMP15; ET+CTG vs. CAF+CTG+R; ET+CTG
vs. CAF+R; CAF+ADMP15 vs. CAF+CTG+R;
CAF+ADMP15 vs. CAF+R; CAF+CTG+R vs. CAF+R.
With regard to the barrier (BM), both resorbable
and non-resorbable membranes were grouped
together. Acellular dermal matrix (ADM), xeno-
genic collagen matrix (CM) and anorganic bovine
derived hydroxyapatite matrix cell bridging peptide
(ADMP15) were considered separately. Results con-
cerning combinations of the above treatments were
not taken into consideration because the literature
available on these techniques is still scanty and very
heterogeneous, and it would be difficult to deter-
mine the contributions of the single techniques to
the overall results.
Guidelines for single gingival recessions „ 15
„ Procedure-based outcomes (for
professional reference use)
The following variables were taken into considera-
tion: percentage of Complete Root Coverage (CRC),
Recession Reduction (RecRed) in millimetres, com-
plications (swelling, haematoma, membrane expo-
sure), and adverse reactions.
„ Patient-based outcomes (for patient
reference use)
The following variables were considered: level of
functional satisfaction; level of aesthetic satisfaction;
dentinal hypersensitivity; pain; and cost.
„ Identification of scientific sources:
search strategy
Identification of studies considered eligible for inclu-
sion in these guidelines was performed independently
and in duplicate (UP and RR) according to compre-
hensive search strategies prepared for each database.
The electronic search of the literature was conducted,
up to 28 February, 2013, and included nine data-
bases: (1) Cochrane Database of Systematic Reviews;
(2) Cochrane Central Register of Controlled Trials
(CENTRAL); (3) Embase; (4) MEDLINE (PubMed); (5)
National Institute for Health and Clinical Excellence;
(6) National Guideline Clearinghouse; (7) National
Library of Guidelines; (8) NHS Economic Evaluation
Database; and (9) Centre for Reviews and Dissemina-
tion. Databases were searched to include all SRs and
RCTs ever published. The electronic search on the
Cochrane, Embase and PubMed databases was con-
ducted using the search strategies listed in Table 1.
The searches on the other electronic databases were
conducted asking questions with free text.
Moreover, four reviewers (DF, JB, ML, TS) con-
ducted a manual search of the SRs and RCTs pub-
lished from 1 January, 1985 to 28 February, 2013 in
the following journals: Journal of Clinical Periodon-
tology, Journal of Periodontology, Journal of Peri-
odontal Research, International Journal of Prosthetic
and Restorative Dentistry, Perio, and Periodontology
2000. Furthermore, SRs and RCTs were sought in
the bibliographies (i.e. reference lists) of the selected
studies.
Eur J Oral Implantol 2014;7(1):9–43
16 „ Pini-Prato et al Guidelines for single gingival recessions

Table 1 Electronic search strategies for each respective database.

Database Type of study Strategy

Cochrane SR – (‘Gingival Recession/surgery’ [Mesh] OR ‘Gingival Recession/therapy’ [Mesh]) AND

(Cochrane Reviews [ptyp])
– (‘Gingival Recession/surgery’ [Mesh] OR ‘Gingival Recession/therapy’ [Mesh]) AND
(Other Reviews [ptyp])
RCT (‘Gingival Recession/surgery’ [Mesh] OR ‘Gingival Recession/therapy’ [Mesh]) AND
(Clinical Trials [ptyp])
Embase SR ‘gingiva disease’/exp/mj AND ‘gingival recession’/mj AND ([Cochrane review]/lim OR
[meta analysis] /lim OR [systematic review]/lim) AND [humans]/lim
RCT ‘gingiva disease’/exp/mj AND ‘gingival recession’/mj AND [randomised controlled trial]/
lim AND [humans]/lim
PubMed SR (‘Gingival Recession/surgery’ [Mesh] OR ‘Gingival Recession/therapy’ [Mesh]) AND
‘humans’ [MeSH Terms] AND Meta-Analysis [ptyp])
RCT (‘Gingival Recession/surgery’ [Mesh] OR ‘Gingival Recession/therapy’ [Mesh]) AND
‘humans’ [MeSH Terms] AND Randomised Controlled Trial [ptyp])
SR: Systematic Review; RCT: Randomised Controlled Trial.

In addition, in cases where more than one SR
was published on the same subject by the same
authors, the most recent SR was selected. The
search also sought out any RCTs dated after the
publication of the selected SRs. In the event that
no SRs meeting the inclusion criteria were found,
the RCTs were evaluated directly. In the event of
more than one RCT conducted on the same test
population, the RCT with the longest follow-up was
considered. The RCTs that dealt with more than
one site in the same patient were excluded if the
statistical analysis did not take into account the
presence of non-independent sites. In case of sev-
eral selected SRs with the same comparisons, data
from the largest and most recent SR are reported.
Subsequently, three reviewers (JB, ML, and UP)
compared the results of the electronic and manual
searches to eliminate duplicated articles and arrive
at two separate lists for both SRs and RCTs. Finally,
by reading the abstracts of the found SRs and RCTs,
the same three reviewers selected the articles to
submit to full-text reading.
the use of checklists prepared specifically for the
qualitative evaluation of SRs with meta-analyses61.
Working independently, three researchers (JB, ML,
and MN) analysed the full texts of the selected
RCTs according to the SIGN method that calls for
the use of checklists for the qualitative evaluation
of RCTs61. At the conclusion of the independent
analyses, the researchers compared their evalua-
tions with the aim of reaching agreement. If reach-
ing unanimity was difficult, the final results were
obtained after a discussion involving all members
of the research team.
„ Data extraction from scientific sources
Four independent researchers (JB, ML, MN, and
UP) extracted and then compared the available
data from the selected SRs and RCTs. If reach-
ing unanimity was difficult, the final results were
obtained after a discussion involving all members
of the research team.

„ Methods for formulating the

„ Selection and evaluation of scientific recommendations
sources: full text analysis
The methods used to formulate the recommenda-
Four independent researchers (DF, JB, MN, and RR) tions were based on a group discussion followed by
analysed the complete texts of the selected reviews voting in accordance with the suggestions of SIGN.
according to the method of the Scottish Intercol-
legiate Guidelines Network (SIGN) that calls for

Eur J Oral Implantol 2014;7(1):9–43

 Pini-Prato et al Guidelines for single gingival recessions „ 17

„ Results Fig 1 Flow chart of manuscripts screened for the development of the guidelines.
SIGN: Scottish Intercollegiate Guidelines Network; SRs: Systematic Reviews; RCTs: Ran-
domised Controlled Trials.
„ SRs

Regarding the SRs, the outcomes of electronic and
hand searching are shown in Fig 1. Twenty-four
articles were identified during electronic searching,
whereas hand searching yielded 13 publications.
Crossing-checking the results of both searches identi-
fied a final list of 30 different reviews, but of them
10 were promptly excluded after their abstracts were
examined. The full texts of the 20 remaining SRs still
eligible for inclusion were screened, but only five met
Systematic reviews identified via elec-
tronic searching:
• Cochrane Database of Systematic
Reviews: 9
• Embase: 23
• MEDLINE (PubMed): 17
• National Institute for Health and
Clinical Excellence: 0
• National Guideline Clearinghouse: 0
Total number of different reviews
found by electronic searches: 24
Centre for Reviews and Dissemination: 11
Systematic reviews identified via hand
searching:
• Journal of Clinical Periodontology: 3
• Journal of Periodontology: 9
• Journal of Periodontal Research: 1
• International Journal of Periodontics
and Restorative Dentistry: 0
Total number of different reviews
found by hand searches: 13

the inclusion criteria for the present guidelines42,62-65.

Total number of different reviews
Of these five SRs submitted to judgment by the SIGN
following exclusion of duplicates
checklist method, the results of three SRs42,64,65 were (electronic + manual searches): 30
accepted for the drafting of these guidelines. Two
reviews were not used for the recommendations pre- Reviews selected by reading
sented in the guidelines, due to the date of publica- abstracts: 20
tion44 and the peculiarity of the statistical analysis (i.e.
individual patient data meta-analysis)45.
Reviews selected by full text
All the three analysed SRs were judged to have reading: 5
a low risk for bias, according to the SIGN check-
list method (SIGN code: 1+) (Table 2). At the end
of this process, of the remaining 17 reviews, four Studies selected after evaluation
by the SIGN checklist method:
reviews66-68,76 were excluded because they were 3 SRs and 16 RCTs
not systematic; eight42,47,69-74 because they were
not SRs of only RCTs, one43 because it analysed the
same SR by Chambrone et al42; one45, because it Articles selected by full text
reading: 16
analysed only RCTs that reported individual patient
data but excluded other well-performed RCTs that
did not publish the relative individual data, two62-63 Articles selected by reading
abstracts: 168
because they were considered to have a high risk for
bias, according to the SIGN checklist method (SIGN
code: 1-) and one75 because it considered just mul- Total number of different articles
following exclusionof duplicates
tiple gingival recessions. In addition, data from RCTs (electronic + manual searches): 321
included in the eligible SRs were also checked in the
original article.
Total number of different articles found Total number of different articles found
by electronic searches: 300 by hand searches: 132

„ RCTs
The electronic searches yielded 263 publications in
the Cochrane database, 176 in Embase and 287 in
PubMed, regarding a single list of 300 articles fol-
lowing elimination of duplicates (Fig 1). The manual
search yielded 132 articles. Crossing-checking the
results of both searches identified a final list of 321
different articles.
RCTs identified via electronic searching:
• Cochrane Database of Systematic
Reviews: 263
• Embase: 176
• MEDLINE (PubMed): 287
• National Institute for Health and
Clinical Excellence: 0
• National Guideline Clearinghouse: 0
RCTs identified via hand searching:
• Journal of Clinical Periodontology: 24
• Journal of Periodontology: 71
• Journal of Periodontal Research: 0
• International Journal of Prosthetic and
Restorative Dentistry: 20
• Perio: 2

Eur J Oral Implantol 2014;7(1):9–43

18 „ Pini-Prato et al Guidelines for single gingival recessions

Table 2 SIGN Grading System.

LEVELS OF EVIDENCE
1++ High-quality meta-analyses, SRs, or RCTs, or RCTs with a very low risk for bias
1+ Well-conducted meta-analyses, SRs, of RCTs, or RCTs with a low risk for bias
1- Meta-analyses, SRs of RCTs, or RCTs with a high risk for bias

2++ High-quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high
probability that the relationship is causal
2+ Well-conducted case-control or cohort studies with a low risk for confounding, bias, or chance and a moder-
ate probability that the relationship is causal
2- Case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the
relationship is not causal
3 Non-analytic studies, e.g. case report, case series
4 Expert opinion
GRADES OF RECOMMENDATIONS
A At least one meta-analysis, SR, or RCT rated as 1++ and directly applicable to the target population; or an SR
of RCTs or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target
population, and demonstrating overall consistency of results
B A body of evidence including studies rated as 2++, directly applicable to the target population, and demon-
strating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable to the target population, and demon-
strating overall consistency of results; or extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+
SIGN: Scottish Intercollegiate Guidelines Network; SR: Systematic Review; RCT: Randomised Controlled Trial.

Subsequent to the examination of 321 selected
abstracts, 168 articles had their full text considered
for inclusion. At the end of this process, 152 of
the 168 selected articles were excluded from the
guidelines and the reasons for exclusion are listed
in Table 3. At this point, by reading the full texts
of these selected articles, only 16 RCTs52-53,77-89,240
met the proposed criteria and were included in the
present guidelines. These 16 articles were com-
parisons of surgical techniques that were either not
discussed in the three selected SRs (i.e. RCTs that
reported comparisons of surgical techniques not
found through the SRs) or were published after the
reference period of the same SRs. The 16 selected
RCTs were analysed according to the SIGN checklist
method and were all judged to have a low risk for
bias, according to that method (SIGN code: 1+).
With regard to the type of study design, out of
the 16 included RCTs1152,77,79-80,82-83,85-87,89,240
had a split-mouth design, while 5 RCTs53,78,81,84,88
had a parallel design.
With respect to the duration of the follow-up, 11
RCTs53,77,79,81-84,86,88-89,240 had a short follow-up
(from 1 to 12 months duration), 4 RCTs52,78,80,85 had
a medium term duration (from 13 to 60 months),
and only 1 study87 showed a 120-month duration.
Data about the number of treated patients in each
included RCT are reported in the Appendix.
The final analysis of the 3 SRs and the 16 RCTs
included in this study enabled the assessment of 19
different comparisons (Table 4). In addition, detailed
descriptions of the study characteristics and out-
comes of included SRs and RCTs are depicted in the
Appendix.
„ Patient, dental hygienist and general
practitioner involvement in guidelines
development
Patients
In a recent study54, a questionnaire-based survey
investigated the perception of buccal gingival reces-
sions and the request for their treatment. Out of
these 120 patients, only 54 (45%) answered that
they had gingival recessions, while 96 (80%) actually
had at least one gingival recession in their mouth.
Only 11 (11%) of the 96 patients with recessions

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 Pini-Prato et al Guidelines for single gingival recessions „ 19

Table 3 Characteristics of the 152 excluded studies.

Reason for exclusion Studies

Miller Class not specified or Guinard et al90; Caffesse et al91; Caffesse et al92; Espinel et al93; Cueva et al 94; Henriques et al95; Cairo et al96
Miller Class III gingival reces-
sions defects treated
Not comparison between sur- Borghetti et al97
gical techniques
Not study on root coverage Wei et al98; Maurer et al99; Harris100; McGuire et al101; Bertoldi et al 102; McGuire et al103; Sanz et al104; Dilsiz
et al105; Dilsiz et al106; Nevins et al107; McGuire et al108; Nevins et al109

Comparison between
variations of the same surgical
technique
Not RCT
Follow-up <6 months
Ibbott et al110; Oles et al111; Caffesse et al112; Bouchard et al113; Trombelli et al114; Roccuzzo et al115; Trombelli
et al116; Bouchard et al117; Matarasso et al118; Pini Prato et al119; Caffesse et al120; Pini Prato et al121; Hender-
son et al122; Del Pizzo et al123; Zucchelli et al124; Barros et al125; Barros et al126, Burkhardt & Lang127; Francetti
et al128; Tozum et al29; Kassab et al130; Al-Zahrani et al131; Barros et al132; Bittencourt et al133; Felipe et al134;
Lucchesi et al135; Andrade et al136; Byun et al137; Zucchelli et al138; Zucchelli et al139; Andrade et al140; Barker et
al141; Zucchelli et al142; Mazzocco et al143; Ozturan et al144; Pini Prato et al145; Mahajan et al146; Bittencourt et
al147; Ayub et al148; Kuru & Yildirim149
Pini Prato et al150; Trombelli et al151; Pini Prato et al152; Wennströmm et al153; Harris154; Ozcan et al155; Har-
ris156; Muller et al157; Harris158; Cordioli et al159; Nemcovsky et al160; Berlucchi et al161; Harris et al162; Hirsch et
al163; Erley et al164; McGuire et al165; Moses et al166; Silva et al167; Keceli et al168; Pini Prato et al169; Santamaria
et al170; Schlee et al171
Laney et al172; Lafzi et al173; Han et al174; Papageorgakopoulos et al175; Barbosa et al176; de Toledo et al177;
Shepherd et al178; Lafzi et al179; Baghele et al180

Study already considered in
the selected SRs
Comparison with a combina-
tion of techniques
Inadequate statistics
Not surgical therapy
Jepsen et al181; Trombelli et al182; Zucchelli et al183; Borghetti et al184; Amarante et al185; Tatakis et al186; Mod-
ica et al187; Aichelmann-Reidy et al188; Romagna-Genon189; Wang et al190; Hagewald et al191; Paolantonio et
al192; Tal et al193; Lins et al194; McGuire et al195; Cortes et al196; da Silva et al197; Woodyard et al198; Del Pizzo
et al199; Huang et al200; Leknes et al201; Spahr et al202; Wilson et al203; Castellanos et al204; Cortes et al205; Pil-
loni et al206; Joly et al207; Cortellini et al55
Dodge et al208; Duval et al209; Rosetti et al210; Berlucchi et al161; Paolantonio et al211; Kimble et al212; Trabulsi et
al213; Cardaropoli et al214; McGuire et al103; Jankovic et al215; Jhaveri et al216; Alkan et al217; Rasperini et al218;
Alves et al219; Jankovic et al220
Ricci et al221; Novaes et al222; Cetiner et al223; Cheung et al224; Rahmani et al225; Abolfazli et al226; Banihashem-
rad et al227; Cardaropoli et al228
Aimetti et al229

Multiple gingival recessions Ito et al230; Dembowska et al231; Shin et al232; De Souza et al233; Aroca et al234; Pourabbas et al235; Nickles et
treated al236; Aroca et al237; Ozcelik et al 238; Cordaro et al239

RCT: Randomised Controlled Trial; SRs: Systematic Reviews.

requested treatment for their recessions. One patient General practitioners

(JW), representative of these 120 patients, partici-
pated in developing the guidelines and stated that
the reading of the full guidelines appears under-
standable and clear.
Dental hygienist
The dental hygienists involved in these clinical guide-
lines reported through their representative (MG) that
the reading of the full text is understandable. They
suggested the inclusion of non-surgical treatments
(such as single restorative approach or use of desen-
sitising gel) of gingival recessions in a future version
of the guidelines.
After an accurate reading of the document, a repre-
sentative of three general practitioners (LP) reported
that the knowledge of the ‘gingival recession’ issue
is scarce. The association of dental hypersensitivity
with the ‘longer tooth’ has been identified as a rele-
vant factor for undergoing treatment. In addition,
one physician focused his attention on the insurance
aspects related to this document, if it will be consid-
ered its use in countries where the private insurance
companies works also in this field.

Eur J Oral Implantol 2014;7(1):9–43

20 „ Pini-Prato et al Guidelines for single gingival recessions

Table 4 Final eligible trials selected for the guidelines. for Health Care Policy and Research3, approved and
introduced in 2000. The evidence levels are rated
COMPARISON STUDIES
by four (Arabic) numerals and ++, +, and - signs
CAF vs. CAF+CTG Cairo et al 64
(decreasing levels of evidence: 1++, 1+, 1-, 2++, 2+,
CAF vs. CAF+BM Cairo et al64
2-, 3,4). The strength of the recommendations is clas-
CAF vs. CAF+EMD Cairo et al64
sified in four levels indicated by letters (decreasing
CAF vs. CAF+ADM Chambrone et al42;
Mahajan et al81
strength levels) from A to D. The evidence level of a
CAF vs. CAF+PRP Cairo et al64
recommendation refers to the probability that specific
CAF vs. ST Santana et al83
knowledge is obtained from studies with low risk for
CAF vs. LPF Santana et al84
bias. The strength of the recommendations refers to
CAF vs. CAF+ADMP15 Nazareth & Cury86
the probability that transferring them to clinical prac-
CAF vs. CAF+R Santamaria et al, 200952
tice can promote improvement in the health of the
CAF vs. CAF+CM Jepsen et al89
population for which the recommendation was made.
CAF+CTG vs. CAF+BM Cairo et al64; Chambrone
et al65
CAF+CTG vs. CAF+EMD Cairo et al64; McGuire
et al87
„ Evidences
CAF+CTG vs. CAF+ADM Cairo et al64; Haghighati
et al82; Moslemi et al85 „ Efficacy
CAF+CTG vs. CAF+PRP Chambrone et al42
1. Which is the most appropriate surgical technique
CAF+CTG vs. CAF+HF-DDS Cairo et al64
for treating single gingival recessions in terms of
CAF+CTG vs. ST Bittencourt et al79,80
complete root coverage and recession reduction?
CAF+CTG vs. FGG Paolantonio et al78
CAF+CTG vs. CAF+CTG+R Santamaria et al53
ET+CTG vs. FGG Jahnke et al77 „ Complete Root Coverage (CRC)
CAF+CTG vs. CAF+CM Mc Guire et al240
CAF+CTG vs. LPF Zucchelli et al88 CAF vs. CAF+CTG
CAF: Coronally Advanced Flap; CTG: Connective Tissue Graft; BM:
resorbable and non-resorbable Barrier Membrane; EMD: Enamel A meta-analysis of two studies55,197 comparing CAF
Matrix Derivative; ADM: Acellular Dermal Matrix; PRP: Platelet- vs. CAF+CTG showed a statistically significant Odds
Rich Plasma; HF-DDS: Human Fibroblast-Derived Dermal Substi-
Ratio (OR) of 2.49 (CI 95%: 1.10 to 5.68; P = 0.03;
tute; CM: Xenogenic Collagen Matrix; ST: Semilunar Technique;
FGG: Free Gingival Graft; LPF: Laterally Positioned Flap; ET: Enve- I2 = 0%) in favour of CAF+CTG64. The total per-
lope Technique; ADMP15: Anorganic Bovine Derived Hydroxyapa- centage of CRC was 52% (27/52 recessions) for
tite Matrix Cell Bridging Peptide; R: Resin Composite Restoration.
CAF+CTG and 32% (17/53 recessions) for CAF.

„ Guide to evidence levels and strength of CAF vs. CAF+BM

the recommendations (Table 2)
In accordance with the suggestions of the
recommendations in these guidelines distinguish
between those supported by strong evidence and
those based on trials of lower scientific value. It is
important to bear in mind that the grading of a rec-
ommendation is not related to the importance of the
recommendation itself, but to the strength of the
supporting scientific trials.
The recommendations are classified by evidence
level and strength of the recommendations in accord-
ance with the guidelines of the United States Agency
Data from 12 months of a split-mouth study201
SIGN61, comparing CAF vs. CAF+BM showed a not statis-
tically significant OR of 0.58 (CI 95%: 0.16 to 2.08;
P = 0.41) in favour of CAF64. The percentage of CRC
was 30% (6/20 recessions) for CAF and 20% (4/20
recessions) for CAF+BM.
CAF vs. CAF+EMD
A meta-analysis of four studies187,199,202,206 compar-
ing CAF vs. CAF+EMD showed a statistically signifi-
cant OR of 3.89 (CI 95%: 1.59 to 9.50; P = 0.003;

Eur J Oral Implantol 2014;7(1):9–43

 Pini-Prato et al
I2 = 15.2%) in favour of CAF+EMD64. The total
percentage of CRC was 66% (46/70 recessions) for
CAF+EMD and 39% (27/70 recessions) for CAF.
CAF vs. CAF+ADM
A meta-analysis of two studies205,198 comparing CAF
vs. CAF+ADM showed a not statistically significant
Relative Risk (RR) of 1.95 (CI 95%: 0.76 to 5.04;
P = 0.17; I2 = 34%) in favour of CAF+ADM42. The
total percentage of CRC was 48% (12/25 recessions)
for CAF+ADM and 20% (5/25 recessions) for CAF.
CAF vs. CAF+PRP
One parallel 6-month study200 comparing CAF vs.
CAF+PRP showed a not statistically significant OR
of 1.25(CI 95%: 0.23 to 6.71; P = 0.79) in favour of
CAF+PRP64. The percentage of CRC was 64% (7/11
recessions) for CAF+PRP and 58% (7/12 recessions)
for CAF.
CAF vs. CAF+CM
In a split-mouth 6-month RCT89, CRC was achieved
in 16 out of 45 sites (36%) treated with CAF+CM
and in 14 out of 45 sites (31%) treated with CAF
alone. The difference was not statistically significant
(P = 0.3870).
CAF vs. ST
In a split-mouth 6-month RCT83, 2 out of 22 sites
(9%) belonging to the ST group showed CRC, while
14 out 22 sites (64%) treated with CAF obtained
CRC. P value was not reported. A calculation using
the intra-class correlation coefficient of a previous
study190 yielded an OR = 0.06 (CI 95%: 0.01 to
0.26; P = 0.0002) in favour of CAF.
CAF vs. LPF
In a parallel 6-month RCT84, 15 out of 18 sites (83%)
belonging to the LPF group showed CRC, while
16 out of 18 sites (89%) treated with CAF alone
obtained CRC. P value was not reported (P >0.05).
A calculation yielded an OR=0.63 (CI 95%: 0.09 to
4.28; P = 0.63) in favour of CAF.
Guidelines for single gingival recessions „ 21
CAF vs. CAF+ABM/P-15
In a split-mouth 6-month RCT86, 10 out 15 sites
(67%) in the CAF+ABM/P-15 showed CRC, while
11 out 15 sites (73%) treated with CAF alone
obtained CRC. P value was not reported. A calcu-
lation yielded an OR=0.73 (CI 95%: 0.18 to 2.86;
P = 0.65) in favour of CAF.
CAF+CTG vs. CAF+BM
Two meta-analyses showed very similar results on
this comparison in terms of odds ratio64,65.
A meta-analysis of 7 studies182-184,186,189,200,211
comparing CAF+CTG vs. CAF+BM (resorbable
membranes) showed a statistically significant OR of
0.47 (CI 95%: 0.24 to 0.90; P = 0.02; I2 = 0%) in
favour of CAF+CTG65.
A meta-analysis of 6 studies181-184,186,190 com-
paring CAF+CTG vs. CAF+BM showed a not statis-
tically significant OR of 0.45 (CI 95%: 0.20 to 1.04;
P = 0.06; I2 = 31.9%) in favour of CAF+CTG64. The
total percentage of CRC was 53% (46/87 reces-
sions) for CAF+CTG and 36% (38/105 recessions)
for CAF+BM.
CAF+CTG vs. CAF+EMD
Data from one study195 comparing CAF+CTG vs.
CAF+EMD showed a not statistically significant
OR of 2.31 (CI 95%: 0.45 to 11.74; P = 0.31) in
favour of CAF+EMD64. In the 10-year follow-up of
the same split-mouth study with 9 patients (out of
17), 5 out of 9 sites (56%) in the CAF+EMD group
showed CRC, while 7 out of 9 sites (78%) treated
with CAF+CTG achieved CRC (P = 0.157)87.
CAF+CTG vs. CAF+ADM
A meta-analysis of four studies188,192,193,207 com-
paring CAF+CTG vs. CAF+ADM showed a not stat-
istically significant OR of 0.49 (CI 95%: 0.23 to 1.03;
P = 0.06; I2 = 0%) in favour of CAF+CTG64.
In a successive split-mouth 5-year RCT, 3 out of
15 sites (20%) in the CAF+ADM group showed CRC,
while 2 out of 15 sites (13%) treated with CAF+CTG
achieved CRC85. The difference favouring CAF+ADM
was not significant (P = 1.0). The total percentage of
Eur J Oral Implantol 2014;7(1):9–43
22 „ Pini-Prato et al Guidelines for single gingival recessions
CRC was 39% (27/69 recessions) for CAF+CTG and
25% (17/69 recessions) for CAF+ADM.
CAF+CTG vs. CAF+HF+DDS
One split-mouth 6-month study203 comparing
CAF+CTG vs. CAF+HFDDS showed a not statistic-
ally significant OR of 1.00 (CI 95%: 0.02 to 50.40;
P = 1.00)64. The percentage of CRC was 10% (1/10
recessions) for CAF+CTG and 10% (1/10 recessions)
for CAF+HF+DDS.
CAF+CTG vs. CAF+CM
In a split-mouth RCT240, at the 12-month evalu-
ation, 17 out of 23 sites (74%) in the CAF+CM
group showed CRC, while 22 out of 23 sites (96%)
treated with CAF+CTG achieved CRC. P value was
not reported (P > 0.05).
CAF+CTG vs. ST
In a split-mouth 30-month RCT80, 8 out of 17 sites
(47%) in the ST group showed CRC, while 15 out
of 17 sites (88%) treated with CAF+CTG achieved
CRC. P value was not reported. A calculation yielded
an OR = 0.19 (CI 95%: 0.04 to 0.91; P = 0.04) in
favour of CAF+CTG.
CAF+CTG vs. FGG
In a parallel 5-year RCT78, 3 out of 35 sites (9%)
in the FGG group showed CRC, while 17 out of 35
sites (49%) treated with CAF+CTG achieved CRC.
The P value was not reported. A calculation yielded
an OR = 0.10 (CI 95%: 0.03 to 0.39; P = 0.0008) in
favour of CAF+CTG.
CAF+CTG vs. LPF
In a parallel 1-year RCT88, CRC was achieved in 12
out of 25 defects in the CAF+CTG group (48%),
and in 1 out of 25 in the LPF group (4%). The differ-
ence was statistically significant (P <0.05), favouring
CAF+CTG.
Eur J Oral Implantol 2014;7(1):9–43
ET+CTG vs. FGG
In a split-mouth 6-month RCT77, 5 out of 9 sites
(56%) in the ET+CTG group showed CRC, while
1 out of 9 sites (11%) treated with FGG achieved
CRC. P value was not reported. A calculation yielded
an OR = 0.10 (CI 95%: 0.01 to 0.88; P = 0.04) in
favour of ET+CTG.
„ Recession Reduction (RecRed)
CAF vs. CAF+CTG
A meta-analysis of two studies55,197 comparing CAF
vs. CAF+CTG showed a statistically significant dif-
ference in terms of RecRed of 0.49 mm (CI 95%:
0.14 to 0.83 mm; P = 0.005; I2 = 0%) in favour of
CAF+CTG64.
CAF vs. CAF+BM
A meta-analysis of two studies185,194 comparing
CAF vs. CAF+BM showed a not statistically signifi-
cant difference in terms of RecRed of -0.27 mm
(CI 95%: -0.60 to 0.06 mm; P = 0.11, I2 = 0%) in
favour of CAF64.
CAF vs. CAF+EMD
A meta-analysis of five studies187,199,202,204,206 com-
paring CAF vs. CAF+EMD showed a statistically sig-
nificant difference in terms of RecRed of 0.58 mm
(CI 95%: 0.21 to 0.95 mm; P = 0.002; I2 = 50.5%)
in favour of CAF+EMD64.
CAF vs. CAF+ADM
A meta-analysis of two studies196,198 comparing
CAF vs. CAF+ADM showed a not statistically sig-
nificant difference in terms of RecRed of 0.62 mm
(CI 95%: -0.51 to 1.74 mm; P = 0.28; I2 = 84%) in
favour of CAF+ADM42.
In one parallel 6-month RCT81, CAF+ADM pro-
cedure showed a reduction of 3.85 ± 0.89 mm;
while the CAF technique resulted in 2.85 ± 0.89 mm
reduction. The difference was statistically significant
(P = 0.05).
 Pini-Prato et al
CAF vs. CAF+PRP
Data from one parallel 6-month study200 comparing
CAF vs. CAF+PRP showed a not statistically signifi-
cant difference in terms of RecRed of -0.20 mm (CI
95%: -0.89 to 0.49 mm; P = 0.57) in favour of CAF64.
CAF vs. CAF+CM
In a split-mouth 6-month RCT89, the CAF+CM
procedure showed a reduction of 2.59 ± 1.11 mm,
while CAF technique resulted in 2.32 ± 0.99 mm of
recession reduction. The difference was statistically
significant (P = 0.0175) in favour of CAF+CM.
CAF vs. ST
In a split-mouth 6-month RCT83, ST procedure
showed a reduction of 1.2 ± 0.5 mm; while the CAF
technique resulted in a 2.6 ± 0.7 mm reduction.
The difference was statistically significant (P <0.05),
favouring CAF procedure.
CAF vs. LPF
In a parallel 6-month RCT84, LPF procedure showed
a reduction of 3.26 ± 0.4 mm; while the CAF tech-
nique resulted in a 3.09 ± 0.5 mm reduction. The
difference was not statistically significant (P = 0.26
t test).
CAF vs. CAF+ABM/P-15
In a split-mouth 6-month RCT86, CAF+ABM/P-15
procedure showed a reduction of 2.20 ± 0.54 mm;
while the CAF technique resulted in 2.40 ± 0.80 mm
reduction. The difference (-0.20 ± 0.14 mm, favour-
ing CAF group) was not statistically significant
(P = 0.33).
CAF+CTG vs. CAF+BM
A meta-analysis of 6 studies181-184,186,190 comparing
CAF+CTG vs. CAF+BM showed a statistically signifi-
cant difference in terms of RecRed of -0.38 mm (CI
95%: -0.65 to -0.10 mm; P = 0.008; I2 = 45.6%) in
favour of CAF+CTG64.
Guidelines for single gingival recessions „ 23
CAF+CTG vs. CAF+ADM
A meta-analysis of four studies188,192,193,207 com-
paring CAF+CTG vs. CAF+ADM showed a not
statistically significant difference in terms of Rec-
Red of -0.40 mm (CI 95%: -1.07 to 0.26; P = 0.24;
I2 = 79.4%) in favour of CAF+CTG64.
In a subsequent split-mouth 5-year RCT85,
CAF+ADM procedure showed a reduction of
1.60 ± 1.22; while the CAF+CTG technique resulted in
1.50 ± 1.42 mm reduction. The difference was not stat-
istically significant (P = 0.838) favouring CAF+ADM.
CAF+CTG vs. CAF+EMD
In a split-mouth 10-year RCT87, the CAF+EMD pro-
cedure showed a reduction of 3.33 ± 0.87 mm; while
the CAF+CTG technique resulted in 3.67 ± 1.12 mm
reduction. The difference was not statistically signifi-
cant (P = 0.625).
CAF+CTG vs. CAF+CM
In a split-mouth 1-year RCT240, CAF+CM procedure
showed a reduction of 2.78 mm; while the CAF+CTG
technique resulted in 3.17 mm reduction. The differ-
ence was statistically significant (P = 0.0172) favour-
ing CAF+CTG.
CAF+CTG vs. LPF
In a parallel 1-year RCT88, the CAF+CTG procedure
showed a reduction of 4.04 ± 0.64 mm, while LPF
technique resulted in 3.68 ± 0.75 mm of recession
reduction. The difference was not statistically signifi-
cant (P = 0.07 t test).
2. Which is the most effective surgical technique
for recessions associated with non-carious cervical
lesions?
CAF vs. CAF+R
In one split-mouth 2-year RCT52, CAF+R procedure
showed a reduction of 1.31 ± 0.37 mm; while the
CAF technique resulted in 1.39 ± 0.41 mm reduction
in 16 patients. The difference was not statistically
significant (P >0.05).
Eur J Oral Implantol 2014;7(1):9–43
24 „ Pini-Prato et al Guidelines for single gingival recessions
CAF+CTG vs. CAF+CTG+R
In one parallel 6-month RCT53, CAF+CTG+R pro-
cedure showed a reduction of 2.31 ± 0.74 mm in 20
patients; while the CAF+CTG technique resulted in
2.53 ± 0.78 mm reduction in 20 patients. The differ-
ence was not statistically significant (P = 0.41).
„ Complications
3. Which is the surgical technique for the treatment of
single gingival recessions with less adverse reactions
(discomfort, postoperative pain, haematoma etc.)?
CAF vs. CAF+CTG
da Silva et al197 reported no complications on com-
paring CAF vs. CAF+CTG. Cortellini et al55 reported
3 cases of haematoma in 43 patients treated with
CAF, while 5 cases of haematoma were reported in
42 patients treated with CAF+CTG. A higher number
of cases of swelling were reported for the CAF+CTG
group, and these differences were statistically signifi-
cant (CAF+CTG 32.2 ± 28.4 and CAF 17.8 ± 19.9
using visual analogue scale (VAS), P = 0.0068). No
statistically significant differences for pain were
reported between two groups (23.8 ± 19.4 for
CAF and 31.4 ± 24.6 for CAF+CTG, using VAS,
P = 0.0811).
CAF vs. CAF+BM
Lins et al194 reported the exposure of all membranes
in all treated sites (10/10).
CAF vs. CAF+PRP
No statistically significant differences for com-
plications were reported on comparing CAF vs.
CAF+PRP200 using a Wound Healing Index (1.3 ± 0.5
for CAF and 1.2 ± 0.4 for CAF+PRP, P >0.05).
CAF vs. CAF+ADM
Pain and discomfort during surgery: 2 out of 7
patients in the CAF+ADM group reported no pain or
discomfort, and 6 out of 7 patients in the CAF group
also reported no pain or discomfort. The difference
Eur J Oral Implantol 2014;7(1):9–43
was statistically significant (P = 0.03), favouring the
CAF group81.
Postoperative pain and swelling: 2 out of 7
patients in the CAF+ADM group were fully satisfied,
and 6 out of 7 patients in the CAF group were also
fully satisfied. The difference was statistically signifi-
cant (P = 0.03), favouring the CAF group81.
Cost effectiveness: 2 out of 7 patients in the
CAF+ADM group were fully satisfied, and 6 out of
7 patients in the CAF group were also fully satisfied.
The difference was statistically significant (P = 0.03),
favouring the CAF group81.
CAF vs. CAF+CM
In a RCT89, after 7 days, the pain VAS was 2.32 ± 2.08
for CAF+CM and 2.04 ± 1.82 for CAF. After 14 days,
the pain VAS was 0.68 ± 1.21 for CAF+CM and
0.59 ± 0.91 for CAF. The differences were not stat-
istically significant (P >0.05).
CAF+CTG vs. CAF+BM
In comparisons between CAF+CTG vs. CAF+BM,
membrane exposure was reported as a complication
(7/15181, 2/12182, 5/12186, 0/20189).
Jepsen et al181 reported pain and swelling on
comparing CAF+CTG vs. CAF+BM in 15 split-mouth
patients. Five patients reported more discomfort
after CAF+CTG, 5 patients following CAF+BM,
whereas the remaining 5 patients experienced no
difference. When asked which technique they would
have preferred for future root coverage, 7 patients
opted for the CAF+CTG, and 8 for the CAF+BM.
Tatakis and Trombelli186 reported 7 cases of swell-
ing in 12 patients treated with CAF+BM and none
for CAF+CTG. On the other hand, no complications
for CAF+BM were reported by Wang et al190: they
reported 1 of 16 cases of swelling and 1 ecchymosis
in the CAF+CTG arm. Romagna-Genon189 described
postoperative discomfort for the palatal donor site
for the CAF+CTG. None of the sites showed expo-
sure of the membrane.
CAF+CTG vs. CAF+EMD
McGuire and Nunn195 compared CAF+CTG vs.
CAF+EMD: at 1 month, 9 patients (45%) reported
 Pini-Prato et al
high discomfort levels associated with the CAF+CTG
treatment as opposed to 1 patient (5%) in the
CAF+EMD group. This difference was statistically sig-
nificant (P = 0.011). Ten patients (50%) reported no
differences in discomfort between the two treatments.
At 3 months, 5 patients (25%) reported discomfort
with CAF+CTG treatment as opposed to 3 patients
(15%) reporting discomfort with CAF+EMD. After 6
months, differences in discomfort levels between the
two groups were minimal. At 1 year, only 1 patient
exhibited any ongoing adverse reaction. In this sub-
ject, the CAF+CTG site was still mildly painful, and
the CAF+EMD site was still mildly sensitive. The only
reported adverse events were pain, swelling, bleed-
ing, bruising, and sensitivity. These events were simi-
larly distributed among both groups.
At the 10-year follow-up visit87, the patients
were asked to indicate their preference of the pro-
cedure: 6 out of 9 patients preferred the CAF+EMD
treatment, 1 favoured CAF+CTG, and 2 had no pref-
erence. The difference was not statistically significant
(P = 0.059).
CAF+CTG vs. CAF+PRP
Keceli et al168 compared CAF+CTG vs. CAF+PRP
finding postoperative healing was generally une-
ventful. Immediate postoperative bleeding at the
donor site occurred in one patient in the CAF+CTG
group and was easily managed with a sterile gauze
compress.
CAF+CTG vs. ST
A median pain VAS score of 30 mm (range 20 to
60 mm) was recorded in CAF+CTG group and 0 mm
(meaning no pain at all) in the ST group; P value was
not reported80. The pain intensity and the number of
pills taken were statistically different between groups
only on the first day (P = 0.02), favouring the ST
group79.
CAF+CTG vs. LPF
In a RCT88, after 7 days the VAS values related to
pain were 77.2 ± 16.4 for CAF+CTG and 93.2 ± 8.0
for LPF. The difference favouring LPF was statistically
significant (P <0.01).
Guidelines for single gingival recessions „ 25
After 7 days the VAS values related to chew-
ing ability were 72.8 ± 14.3 for CAF+CTG and
88.8 ± 8.3 for LPF. The difference favouring LPF was
statistically significant (P <0.01).
„ Patient opinions
4. Which is the most effective surgical technique for
the treatment of single gingival recessions in terms
of: (a) Absence of dental hypersensitivity.
CAF vs. CAF+CTG
In a parallel RCT, Cortellini et al55 compared CAF vs.
CAF+CTG, reporting no statistically significant dif-
ferences for dental sensitivity [5/42 patients (12%)
in the CAF+CTG group and 5/43 patients (12%) in
the CAF group] 6 months following therapy (P = 1.0
Fisher exact test).
CAF vs. CAF+ADM
In a parallel RCT, 6 out of 7 patients of the CAF+ADM
group were fully satisfied, and 5 out of 7 patients of
the CAF group were also fully satisfied 6 months fol-
lowing therapy. The difference was not statistically
significant (P = 0.58)81.
CAF+CTG vs. CAF+EMD
In a split-mouth study, at the 10-year follow-up, 3
out of 9 sites of the CAF+EMD procedure and 1 out
of 9 sites of CAF+CTG procedure showed dental
sensitivity. The difference was not statistically signifi-
cant (P = 0.157)87.
CAF+CTG vs. ST
In a split-mouth study, three out of 17 patients
in the ST group reported dental sensitivity, while
none of the patients belonging to the CAF+CTG
group reported dental sensitivity 30 months after
surgery80. The difference was not statistically signifi-
cant (P = 0.25, McNemar test).
Eur J Oral Implantol 2014;7(1):9–43
26 „ Pini-Prato et al Guidelines for single gingival recessions
CAF+CTG vs. LPF
In a parallel study with 25 patients per arm, sensi-
tivity VAS was 94.0 ± 6.5 for CAF+CTG group and
87.6 ± 8.3 for LPF group. The difference favour-
ing CAF+CTG was statistically significant (P <0.01)
1 year after surgery88.
CAF+CTG vs. CAF+CTG+R
In a parallel study, 1 out of 20 patients reported den-
tal sensitivity in the CAF+CTG+R, while 7 out of 20
patients showed dental sensitivity after 6 months in
CAF+CTG. The difference was statistically significant
(P = 0.04 Fisher exact test), favouring CAF+CTG+R
procedure53.
(b) Aesthetic satisfaction.
CAF vs. CAF+ADM
In a parallel 6-month RCT81, aesthetic satisfaction
was considered as: root coverage perception, col-
our of gums and shape of gum contour: root cover-
age perception: All the 7 patients in the CAF+ADM
group were fully satisfied, and 4 out of 7 patients in
the CAF group were satisfied. The difference was not
statistically significant (P = 0.15)81.
Colour of gums: All 7 patients in the CAF+ADM
group were fully satisfied, and 6 out of 7 patients in
the CAF group were satisfied. The difference was not
statistically significant (P = 0.30)81.
Shape of gum contour: 5 patients in the
CAF+ADM group were fully satisfied, and 5 out of
7 patients in the CAF group were also fully satis-
fied. The difference was not statistically significant
(P = 1)81.
CAF vs. ST
No data are available, even if the authors of a split-
mouth 6-month RCT reported that all sites (22/22)
treated with ST resulted in a noticeable semilunar
white scar83.
CAF+CTG vs. CAF+BM
Romagna-Genon189 reported aesthetic results
obtained comparing CAF+CTG vs. CAF+BM in a
Eur J Oral Implantol 2014;7(1):9–43
split-mouth 6-month study. Among the 20 patients
who were treated, 19 expressed their satisfaction
with the clinical results for both tested surgical pro-
cedures; only one patient, who had a pair of man-
dibular recessions, was disappointed because of the
small amount of coverage obtained following both
treatments.
Wang et al190 compared the aesthetic results of
CAF+CTG vs. CAF+BM procedures in a split-mouth
6-month study. Six out of 16 of CAF+BM sites
rated by patients had ‘excellent’ colour match and
9 CAF+CTG sites reported the same. In overall satis-
faction, 9 patients rated the CAF+BM procedure as
‘excellent’ vs. 7 in the CAF+CTG group. With regard
to the amount of root coverage, 7 patients in the
CAF+BM group rated it ‘excellent’ with CAF+BM
procedure, while 10 patients treated with CAF+CTG
did the same. The differences were not significant
(P >0.05).
CAF+CTG vs. CAF+ADM
Aichelmann-Reidy et al188 compared CAF+CTG vs.
CAF+ADM in a split-mouth 6-month study in 22
patients. Patients considered CAF+ADM to have
better aesthetics in 9 cases out of 22; in 12 cases,
they considered it similar to CAF+CTG; and only 1
patient preferred the site with CAF+CTG. A keloid
formation was reported in one case treated with
CAF+CTG. The difference favouring CAF+ADM was
statistically significant (P = 0.0215 – McNemar test).
CAF+CTG vs. CAF+EMD
With regard to aesthetic satisfaction, in a split-mouth
10-year study, 6 patients had no preference for a
particular type of treatment, 2 declared better aes-
thetic results following CAF+EMD procedure and 1
preferred the aesthetic outcomes of the CAF+CTG
procedure (P = 0.564)87.
CAF+CTG vs. ST
Fourteen out of 17 patients of the ST group of a
split-mouth 30-month study reported excellent or
good aesthetic results, and 3 reported bad results80.
All subjects in the CAF+CTG group reported excel-
lent or good results. Seven patients reported a bet-
 Pini-Prato et al
ter aesthetic in the sites treated with CAF+CTG
than the other treated site. No patients reported
any preference for the sites treated with ST, and 10
patients did not report any difference in terms of
preference between the two therapies80. The differ-
ence favouring CAF+CTG was statistically significant
(P = 0.0215, McNemar test).
CAF+CTG vs. LPF
In a parallel 1-year study, aesthetic patient evalu-
ation in a VAS was 91.2 ± 9.3 for CAF+CTG (25
patients) and 89.6 ± 7.9 for LPF (25 patients). The
difference was not statistically significant (P = 0.52,
t test)88.
„ Summary of recommendations
Recessions may not have to be treated. If it is
decided to treat them to improve aesthetics or
decrease tooth hypersensitivity, the best way to
surgically treat single gingival recessions without
loss of interproximal tissues is achieved using the
CAF procedure associated with CTG.
„ Efficacy
1. Which is the most effective surgical technique
for treating single gingival recessions in terms of
complete root coverage and recession reduction?
Answer: Coronally Advanced Flap plus Con-
nective Tissue Graft (CAF+CTG) and Coronally
Advanced Flap plus Enamel Matrix Derivative
(CAF+EMD) showed greater Complete Root
Coverage (CRC) than Coronally Advanced
Flap (CAF) alone (evidence level: 1+; grade of
the recommendation: A). Coronally Advanced
Flap (CAF) showed greater CRC than Semilu-
nar Technique (ST) (evidence level: 1+; grade
of the recommendation: A). In addition, Coro-
nally Advanced Flap plus Connective Tissue
Graft (CAF+CTG) showed greater CRC and/or
Recession Reduction (RecRed) than Coronally
Advanced Flap (CAF), Coronally Advanced Flap
plus resorbable and non-resorbable Barrier Mem-
brane (CAF+BM), Coronally Advanced Flap plus
Xenogenic Collagen Matrix (CAF+CM), Semilu-
Guidelines for single gingival recessions „ 27
nar Technique (ST), Free Gingival Graft (FGG),
Laterally Positioned Flap (LPF) (evidence level:
1+; grade of the recommendation: A).
2. Which is the most effective surgical technique
for recessions associated with non-carious cervi-
cal lesions?
Answer: Surgical procedures associated with res-
torations for treating sites affected by gingival
recession and non-carious cervical lesions did not
show greater recession reduction compared to
the surgical procedure alone (evidence level: 1+;
grade of the recommendation: A). In case of cervi-
cal abrasion and presence of root sensitivity after
6 months of follow-up Coronally Advanced Flap
plus Connective Tissue Graft plus Resin Composite
Restoration (CAF+CTG+R) showed less sensitiv-
ity than Coronally Advanced Flap plus Connec-
tive Tissue Graft (CAF+CTG) (evidence level: 1+;
grade of the recommendation: A). Further studies
on these aspects should be conducted.
„ Complications
1. Which is the surgical technique for the treatment
of single gingival recessions with less adverse
reactions (discomfort, postoperative pain, hae-
matoma etc.)?
2. Answer: The Coronally Advanced Flap (CAF) pro-
cedure produces less postoperative discomfort
than the Coronally Advanced Flap plus Connec-
tive Tissue Graft (CAF+CTG) method, Coronally
Advanced Flap plus resorbable and non-resorba-
ble Barrier Membrane (CAF+BM) and Coronally
Advanced Flap plus Acellular Dermal Matrix
(CAF+ADM) (evidence level: 1+; grade of the
recommendation: A). Coronally Advanced Flap
plus Connective Tissue Graft (CAF+CTG) caused
greater postoperative discomfort than Coronally
Advanced Flap plus Enamel Matrix Derivative
(CAF+EMD), Semilunar Technique (ST) and Lat-
erally Positioned Flap (LPF) (evidence level: 1+;
grade of the recommendation: A). Further stud-
ies on these aspects should be conducted.
„ Patient opinions
Which is the most effective surgical technique for the
treatment of single gingival recessions in terms of:
Eur J Oral Implantol 2014;7(1):9–43
28 „ Pini-Prato et al Guidelines for single gingival recessions
(a) Absence of dental hypersensitivity
• Answer: Coronally Advanced Flap plus Connec-
tive Tissue Graft (CAF+CTG) showed less sensitiv-
ity than Laterally Positioned Flap (LPF)(evidence
level: 1+; grade of the recommendation: A). In
cases of cervical abrasion and presence of dental
sensitivity Coronally Advanced Flap plus Connec-
tive Tissue Graft plus Resin Composite Restoration
(CAF+CTG+R) caused less sensitivity than Coro-
nally Advanced Flap plus Connective Tissue Graft
(CAF+CTG) after 6-month follow-up (evidence
level: 1+; grade of the recommendation: A). Fur-
ther studies on these aspects should be conducted.
(b) Aesthetic satisfaction
• Answer: There is little information about aesthetic
satisfaction. Recessions treated with Coronally
Advanced Flap (CAF) or Coronally Advanced
Flap plus Connective Tissue Graft (CAF+CTG)
may have led to more aesthetic satisfaction than
Semilunar Technique (ST) (evidence level: 1+;
grade of the recommendation: A). Further stud-
ies on these aspects should be conducted.
„ Conclusions
Since the present clinical guidelines have been
focused on the treatment of single gingival reces-
sions, it has been assumed that the main indications
for their treatment remain the ones reported in the
literature and represented by aesthetic demands and
dental hypersensitivity17.
Based on the outcomes of this comprehensive
project, it may be expected that general dentists,
dental hygienists, general medical practitioners,
dental specialists (i.e. specialists in periodontology,
prosthetics, orthodontics, and restorative dentistry),
patients, and members of the business community
will benefit from these guidelines. Commonly, root
coverage-based procedures are indicated to resolve/
reduce root hypersensitivity and to restore an attrac-
tive smile. These clinical guidelines may lead to
improvements in the level of patient care, as well as
the recognition on the part of insurance companies
of the importance of treating gingival recessions.
However, it is important to underline that the pre-
sent recommendations are mostly based on short-term
(less than 1 year) data and, therefore, they should be
Eur J Oral Implantol 2014;7(1):9–43
considered in light of this aspect when clinicians or
patients have to make the treatment decision.
In addition, it seems important to apply these
guidelines as a strategy targeting specific groups
of patients attended by dental professionals, in pri-
vate practices, public and university dental clinics
(e.g. universities, National Health Systems) to verify
user satisfaction (health professionals and patients),
as well as to permit monitoring of the success of
improvements associated with the implementation
of the guidelines. Consequently, these guide-
lines will be updated at least every 3 years or when
requested.
„ Implication for practice
Considering the main question for which the present
guidelines should give an answer (“Which is the best
way to treat a gingival recession?), the following
statements and answers have been produced.
The greater effectiveness in the treatment of
single gingival recessions without loss of interproxi-
mal tissues is achieved using the Coronally Advanced
Flap (CAF) procedure associated with Connective
Tissue Graft (CTG). In some cases, the use of amelo-
genines showed a significant positive result, but its
adjunctive financial cost should be considered when
planning treatment. Considering postoperative dis-
comfort, the Coronally Advanced Flap (CAF) pro-
cedure is the less painful surgical approach.
As to postoperative dental hypersensitivity,
most of the various suggested surgical approaches
do not show any significant difference. The quality
of post-surgical aesthetic appearance has not been
thoroughly investigated; the few available results
indicate a higher level of aesthetic satisfaction after
the Coronally Advanced Flap (CAF) technique,
either alone or with Connective Tissue Graft (CTG).
„ Acknowledgements
The authors wish to thank Massimiliano Mori, Gloria
Iachetti, Francesco Cairo, Luisa Guidi, Jana Mervelt,
Sandro Cincinelli, Elisabetta Capanni, Nada Mag-
nani, Leonardo Corcos, Giuseppe Giannecchini, and
Daniele Saletta for their support with preparing these
guidelines.
 Pini-Prato et al
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36 „ Pini-Prato et al Guidelines for single gingival recessions

„ Appendix – Characteristics and outcomes of included SRs and RCTs

Study Method
CRC
Cairo et al SR of RCTs of Miller class I Meta-analyses’ outcomes:
200864 and II single gingival reces-
sions with at least 6 months CAF vs. CAF+CTG (2 studies55,197): A statistically significant
of follow-up. OR of 2.49 (CI 95%: 1.10 to 5.68; P = 0.03; I2 = 0%) in
favour of CAF+CTG was reported. The total percentage of
CRC was 52% (27/52 recessions) for CAF+CTG and 32%
(17/53 recessions) for CAF.
CAF vs. CAF+BM (1 study201): A non-statistically significant
OR of 0.58 (CI 95%: 0.16 to 2.08; P = 0.41) in favour of
CAF was reported. The percentage of CRC was 30% (6/20
recessions) for CAF and 20% (4/20 recessions) for CAF+BM.
CAF vs. CAF+EMD (4 studies187,199,202,206): A statistically
significant OR of 3.89 (CI 95%: 1.59 to 9.50; P = 0.003;
I2 = 15.2%) in favour of CAF+EMD was reported. The
total percentage of CRC was 66% (46/70 recessions) for
CAF+EMD and 39% (27/70 recessions) for CAF.
CAF vs. CAF+ADM (2 studies196,198): A non-statistically
significant OR of 4.83 (CI 95%: 0.23 to 99.88; P = 0.31;
I2 = 67.4%) in favour of CAF+ADM was reported.
CAF vs. CAF+PRP (1 study200): A non- statistically significant
OR of 1.25(CI 95%: 0.23 to 6.71; P = 0.79) in favour of
CAF+PRP was reported. The percentage of CRC was 64%
(7/11 recessions) for CAF+PRP and 58% (7/12 recessions)
for CAF.
CAF+CTG vs. CAF+BM (6 studies181-184,186,190): A non-
statistically significant OR of 0.45 (CI 95%: 0.20 to1.04;
P = 0.06; I2 = 31.9%) in favour of CAF+CTG was reported.
The total percentage of CRC was 53% (46/87 recessions) for
CAF+CTG and 36% (38/105 recessions) for CAF+BM.
RecRed
Meta-analyses’ outcomes:
CAF vs. CAF+CTG (2 studies197,55): A statistically significant
difference of 0.49 mm (CI 95%: 0.14 to 0.83 mm; P = 0.005;
I2 = 0%) in favour of CAF+CTG was reported.
CAF vs. CAF+BM (2 studies185,194): A not statistically significant
difference of -0.27 mm (CI 95%: -0.60 to 0.06 mm; P = 0.11,
I2 = 0%) in favour of CAF was reported.
CAF vs. CAF+EMD (5 studies187,199,202,204,206): A statistically
significant difference of 0.58 mm (CI 95%: 0.21 to 0.95 mm;
P = 0.002; I2 = 50.5%) in favour of CAF+EMD was reported.
CAF vs. CAF+ADM (2 studies196,198): A non- statistically sig-
nificant difference of 0.60 mm (CI 95%: -0.52 to 1.73 mm;
P = 0.29; I2 = 87.1%) in favour of CAF+ADM was reported.
CAF vs. CAF+PRP (1 study200): A not statistically significant
difference of -0.20 mm (CI 95%: -0.89 to 0.49 mm; P = 0.57) in
favour of CAF was reported.
CAF+CTG vs. CAF+BM (6 studies181-184,186,190): A statistically
significant difference of -0.38 mm (CI 95%: -0.65 to -0.10 mm;
P = 0.008; I2 = 45.6%) in favour of CAF+CTG was reported.
CAF+CTG vs. CAF+ADM (4 studies188,192,193,207):
A non-statistically significant difference of -0.40 mm (CI 95%:
-1.07 to 0.26; P = 0.24; I2 = 79.4%) in favour of CAF+CTG was
reported.

CAF+CTG vs. CAF+EMD (1 study195): A non-statistically

significant OR of 2.31 (CI 95%: 0.45 to 11.74; P = 0.31) in
favour of CAF+EMD was reported. In the 10-years follow-up
of the same split-mouth study with 9 patients (out of 17),
5 out of 9 sites (56%) in the CAF+EMD group showed CRC,
while 7 out of 9 sites (78%) treated with CAF+CTG achieved
CRC (P = 0.157)87.

CAF+CTG vs. CAF+ADM

(4 studies188,192,193,207): A non-statistically significant OR of
0.49 (CI 95%: 0.23 to 1.03; P = 0.06; I2 = 0%) in favour of
CAF+CTG was reported. The total percentage of CRC was
39% (27/69 recessions) for CAF+CTG and 25% (17/69
recessions) for CAF+ADM.

CAF+CTG vs. CAF+HF+DDS

(1 study203): A not statistically significant OR of 1.00
(CI 95%: 0.02 to 50.40; P = 1.00) was reported.
The percentage of CRC was 10% (1/10 recessions) for
CAF+CTG and 10% (1/10 recessions) for CAF+HF+DDS.

Eur J Oral Implantol 2014;7(1):9–43

 Pini-Prato et al Guidelines for single gingival recessions „ 37

Results
LAS
No meta-analysis was performed for this vari-
able because data were few and heterogene-
ous.
Individual studies’ outcomes:
CAF+CTG vs. CAF+BM
Romagna-Genon189 reported the aesthetic
results obtained comparing CAF+CTG vs.
CAF+BM in a split-mouth study. Among the
20 patients who were treated, 19 expressed
their satisfaction with the clinical result for
both the tested surgical procedures; only one
patient, who had a pair of mandibular reces-
sions, was disappointed because of the small
amount of coverage obtained following the
two treatments.
Wang et al190 compared the aesthetic results
of CAF+CTG vs. CAF+BM procedures in a
split-mouth 6-month study. An independ-
ent periodontist was asked to rate the colour
match, contour, consistency, contiguity or
blending, and keloid formation 6 months
post-surgery. Patient satisfaction with the
aesthetic (colour match, overall satisfaction,
and amount of root coverage) was recorded.
When the periodontist rated the treatment
results at 6 months, 15 out of 16 of CAF+BM
sites had excellent colour match and only
11 CAF+CTG sites reported the same. Good
contour was noted in 15 CAF+BM sites versus
13 CAF+CTG sites. Tissues showed firm con-
sistency in all sites treated by either technique.
Sixteen CAF+BM-treated sites were rated as
having acceptable blend as compared to 14
CAF+CTG sites. Keloid formation was noted
in only one CAF+CTG site. Six out of 16 of
CAF+BM sites rated by patients had ‘excellent’
colour match and 9 CAF+CTG sites reported
the same. In overall satisfaction, 9 patients
rated as ‘excellent’ with CAF+BM procedure,
vs. 7 of the CAF+CTG group. With regard to
the amount of root coverage, 7 patients of the
CAF+BM group rated the CAF+BM procedure
as ‘excellent, while 10 patients of CAF+CTG
obtained the same. The differences were not
significant (P >0.05).
CAF+CTG vs. CAF+ADM
Aichelmann-Reidy et al188 compared
CAF+ADM vs. CAF+CTG in a split-mouth
study in 22 patients by performing a double
aesthetic evaluation (blinded clinician and
patient). Clinicians considered sites with
CAF+ADM to have better results in 11 cases,
while the other 11 were similar to CAF+CTG.
Patients considered CAF+ADM to have
better aesthetics in 9 cases out of 22; in 12
cases, they considered it similar to CAF+CTG;
and only 1 patient preferred the site with
CAF+CTG. A keloid formation was reported in
one case of CAF+CTG. The difference favour-
ing CAF+ADM was statistically significant
(P = 0.0215; McNemar test).
Hypersensitivity
No meta-analysis was performed for this variable No meta-analysis was performed for this variable
because data were few and heterogeneous.
Individual studies’ outcomes:
CAF vs. CAF+CTG
Cortellini et al55 compared CAF vs. CAF+CTG,
reporting no statistically significant differences da Silva et al197 reported no complication on
for root sensitivity (12% of patients in the test comparing CAF vs. CAF+CTG. Cortellini et al55
group and 12% in the control group) six months reported 3 cases of haematoma in 43 patients
following therapy (P = 1.0 Fisher exact test).
CAF+CTG vs. CAF+EMD
McGuire & Nunn195 reported root sensitivity in
only one case treated with CAF+EMD and none these differences were statistically significant
for CAF+CTG 1 year following therapy.
Postoperative pain/complications Cost effectiveness
NR
because data were few and heterogeneous.
Individual studies’ outcomes:
CAF vs. CAF+CTG
treated with CAF, while 5 cases of haema-
toma were reported in 42 patients treated with
CAF+CTG. A higher number of cases of swelling
were reported for the CAF+CTG group, and
(CAF+CTG 32.2 ± 28.4 and CAF 17.8 ± 19.9
using visual analogue scale (VAS), P = 0.0068).
No statistically significant differences for pain
were reported between two groups (23.8 ± 19.4
for CAF and 31.4 ± 24.6 for CAF+CTG, using
VAS, P = 0.0811).
CAF vs. CAF+BM
Amarante et al185 reported exposure of several
membranes in CAF+BM sites, while Lins et al194
reported the exposure of all membranes in all
treated sites (10/10).
CAF vs. CAF+PRP
No statistically significant differences for com-
plications were reported on comparing CAF vs.
CAF+PRP200 using a Wound Healing Index
(1.3 ± 0.5 for CAF and 1.2 ± 0.4 for CAF+PRP,
P > 0.05).
CAF+CTG vs. CAF+BM
In comparisons between CAF+CTG vs. CAF+BM,
membrane exposure was reported as a possible
complication (7/15 Jepsen et al181, 2/12
Trombelli at al.182, 5/12 Takatis & Trombelli186,
0/20 Romagna-Genon189).
Jepsen et al181 reported pain and swelling on
comparing CAF+CTG vs. CAF+BM in 15 split-
mouth patients. Five patients reported more
discomfort after CAF+CTG procedure, 5 patients
following CAF+BM, whereas the remaining 5
patients experienced no difference. When asked
which technique they would have preferred
for future root coverage, 7 patients opted for
the CAF+CTG method, and 8 for the CAF+BM
technique.
Tatakis & Trombelli186 reported 7 cases of swelling
in 12 patients treated with CAF+BM and none
for CAF+CTG. On the other hand, no complica-
tion for CAF+BM was reported by Wang et al190:
they reported 1 of 16 cases of swelling and 1
ecchymosis in the CAF+CTG arm.
Romagna-Genon189 described postoperative
discomfort for the palatal donor site for the
CAF+CTG. Sites treated with CAF+BM
were more frequently symptom-free compared
with CTG sites. None of the sites showed expo-
sure of the membrane.

Eur J Oral Implantol 2014;7(1):9–43

38 „ Pini-Prato et al
Study Method
Cham- SR of RCTs (minimum 10
brone et al patients per arm at final
200865 examination) of Miller class
I and II gingival recessions
2 mm or deeper, with at
least 6 months of follow-
up; the authors compared
CAF+CTG with other
procedures.
Cham- SR of RCTs (minimum 10
brone et patients per arm at final
al 200942 examination) of Miller
class I and II gingival reces-
sions ≥ 3 mm with at least
6 months of follow-up;
seventeen RCTs were not
included in the analysis due
to the presence of gingival
recessions <3 mm and
5 RCTs because they
included <10 patients per
arm at the last follow-up.
Jahnke et FGG vs. ET+CTG
al 199377
6-month follow-up; split-
mouth study; 10 patients;
single recessions.
Eur J Oral Implantol 2014;7(1):9–43
Guidelines for single gingival recessions
CRC
Meta-analyses’ outcomes:
CAF+CTG vs. CAF+BM (resorbable membranes)
(7 studies182-184,186,189,200,211): A statistically significant OR
of 0.47 (CI 95%: 0.24 to 0.90; P = 0.02; I2 = 0%) in favour
of CAF+CTG was reported.
Meta-analyses’ outcomes:
CAF vs. CAF+ADM (2 studies196,198): A non-statistically
significant RR of 1.95 (CI 95%: 0.76 to 5.04; P = 0.17;
I2 = 34%) in favour of CAF+ADM was reported. The
total percentage of CRC was 48% (12/25 recessions) for
CAF+ADM and 20% (5/25 recessions) for CAF.
5 out of 9 sites (56%) belonging to the ET+CTG group
showed CRC, while 1 out of 9 sites (11%) treated with
FGG obtained CRC. P value was not reported. A calculation
yielded an OR = 0.10 (CI 95%: 0.01 to 0.88; P = 0.04) in
favour of ET+CTG.
RecRed
Meta-analyses’ outcomes:
CAF+CTG vs. CAF+BM (resorbable membranes)
(7 studies182-184,186,189,200,211): A statistically significant differ-
ence of -0.41 mm (CI 95%: -0.62 to -0.20 mm; P = 0.0002;
I2 = 0%) in favour of CAF+CTG was reported.
CAF+CTG vs. CAF+BM (non-resorbable membranes)
(2 studies181,183): A not statistically significant difference of
-0.43 mm (CI 95%: -1.21 to 0.35 mm; P = 0.28; I2 = 72.5%) in
favour of CAF+CTG was reported.
CAF+CTG vs. CAF+ADM (3 studies188,192,207): A statistically
significant difference of -0.63 mm (CI 95%: -1.26 to 0.00;
P = 0.05, I2 = 52.5%)] in favour of CAF+CTG was reported.
Meta-analyses’ outcomes:
CAF vs. CAF+EMD (2 studies199,202): A not statistically sig-
nificant difference of 0.25 mm (CI 95%: -0.13 to 0.64 mm;
P = 0.19; I2 = 21%) in favour of CAF+EMD was reported.
CAF vs. CAF+ADM (2 studies196,198): A not statistically sig-
nificant difference of 0.62 mm (CI 95%: 0.51 to 1.74 mm;
P = 0.28; I2 = 84%) in favour of CAF+ADM was reported.
CAF+CTG vs. CAF+ADM (2 studies): A not statistically signifi-
cant difference of -0.76 mm (CI 95%: -1.93 to 0.42; P = 0.21,
I2 = 76%)] in favour of CAF+CTG was reported.
Estimates were not reported. The difference was statistically
significant (P = 0.03) favouring ET+CTG.
 Pini-Prato et al Guidelines for single gingival recessions „ 39

Results

LAS Hypersensitivity Postoperative pain/complications Cost effectiveness

No meta-analysis was performed for this vari- No meta-analysis was performed for this variable No meta-analysis was performed for this variable NR
able because data were few and heterogene- because data were few and heterogeneous. because data were few and heterogeneous.
ous.

Individual studies’ outcomes:

CAF+CTG vs. CAF+BM

In two different studies181,189 subjective
patient preference did not differ between the
two treatment procedures.

No meta-analysis was performed for this vari- No meta-analysis was performed for this vari- No meta-analysis was performed for this variable NR
able because data were few and heterogene- able because data were few and heterogeneous. because data were few and heterogeneous.
ous. Individual studies’ outcomes:

CAF+CTG vs. CAF+EMD

McGuire & Nunn195 compared CAF+CTG vs.
CAF+EMD reporting: at 1 month, 9 patients
(45%) reported high discomfort levels associated
with the CAF+CTG treatment as opposed to 1
patient (5%) within the CAF+EMD group. This
difference was statistically significant (P = 0.011).
Ten patients (50%) reported no differences in
discomfort between the two treatments. At 3
months, 5 patients (25%) reported discomfort
with the CAF+CTG treatment as opposed to
3 patients (15%) reporting discomfort with
CAF+EMD treatment. After 6 months, differenc-
es in discomfort levels between the two groups
were minimal. At 1 year, only 1 patient exhibited
any ongoing adverse reaction. In this subject, the
CAF+CTG site was still exhibiting mild pain, and
the CAF+EMD site was still exhibiting mild sensi-
tivity. The only reported adverse events included
pain, swelling, bleeding, bruising, and sensitivity
– these events were similarly distributed among
both groups.

CAF+CTG vs. CAF+PRP

Keceli et al168 compared CAF+CTG vs. CAF+PRP
finding postoperative healing was generally
uneventful. Minor complications were related to
usual postoperative swelling and occurred within
the first days after surgery. Immediate postopera-
tive bleeding at the donor site occurred in 1
patient from the CAF+CTG group and was easily
managed by a sterile gauze compression.
NR NR In one patient, the dressing from an ET+CTG NR
site was dislodged while eating in a manner
inconsistent with postoperative instructions. He
returned to the clinic the following day, where it
was found that the CTG was no longer beneath
the recipient flap. Although the tissue healed
uneventfully to its original position, the patient
was dropped from the study. This represents a
violation of the intention to treat procedure.

Eur J Oral Implantol 2014;7(1):9–43

40 „ Pini-Prato et al Guidelines for single gingival recessions

Study Method

CRC RecRed

Paolanto- CAF+CTG vs. FGG Three out of 35 sites (9%) belonging to the FGG group Even if no data about RecRed are available, the final calculated
nio et al showed CRC, while 17 out of 35 sites (49%) treated with recession was 1.50 ± 0.39 mm in the FGG group, and
199778 5-year follow-up; parallel CAF+CTG obtained CRC. The P value was not reported. A 0.58 ± 0.46 mm in the CAF+CTG group.
study; 70 patients; single calculation yielded an OR = 0.10 (CI 95%: 0.03 to 0.39; The difference was statistically significant (P < 0.001).
recessions. P = 0.0008) in favour of CAF+CTG.

Bitten- CAF+CTG (without vertical
court et incisions) vs. ST
al 200679,
200980 6-month follow-up79 and
30-months follow-up80;
split-mouth study; 17
patients; single recessions.
Eight out of 17 sites (47%) belonging to the ST group
showed CRC, while 15 out of 17 sites (88%) treated with
CAF+CTG obtained CRC. P value was not reported. A
calculation yielded an OR = 0.19 (CI 95%: 0.04 to 0.91;
P = 0.04) in favour of CAF+CTG.
Even if no data about RecRed are available, the final calculated
recession was 0.28 ± 0.56 mm in the ST group, and
0.07 ± 0.20 mm in the CAF+CTG group.
The difference was not statistically significant (P >0.05).

Mahajan CAF vs. CAF+ADM NR The CAF+ADM procedure showed a reduction of

et al 3.85 ± 0.89 mm; while the CAF technique resulted in
200781 6-month follow-up; parallel 2.85 ± 0.89 mm reduction. The difference was statistically
study; 14 patients (7 per significant (P = 0.05).
group); single recessions.

Santama- CAF vs. CAF+ restoration
ria et al
200952 24-month follow-up; split-
mouth study; 16 patients;
single recessions.
Santama- CAF+CTG vs. CAF+CTG+
ria et al restoration
200953
6-month follow-up; parallel
study; 40 patients; single
recessions.
Haghigh- CAF+CTG vs. CAF+ADM
ati et al
200982; 6 month82 and 5 year
Moslemi et follow-up85; split-mouth
al 201185 study; 16 patients at 6
months and 15 at 5 years;
single recessions; data are
presented at 5 years.
Santana et CAF vs. Semilunar coronal
al 201083 flap (ST) procedure
6-month follow-up; split-
mouth study; 22 patients;
single recessions.
NR
NR
3 out of 15 sites (20%) belonging to the CAF+ADM group
showed CRC, while 2 out of 15 sites (13%) treated with
CAF+CTG obtained CRC. The difference favouring CAF+
ADM was not significant (P = 1.0)
Two out 22 sites (9%) belonging to the ST group showed
CRC, while 14 out 22 sites (64%) treated with CAF only
obtained CRC. P value was not reported. A calculation using
the intra-class correlation coefficient of a previous study190
yielded an OR = 0.06 (CI 95%: 0.01 to 0.26; P = 0.0002) in
favour of CAF.
The CAF+R procedure showed a reduction of 1.31 ± 0.37 mm;
while the CAF technique resulted in 1.39 ± 0.41 mm reduction.
The difference was not statistically significant (P >0.05).
CAF+CTG+R procedure showed a reduction of 2.31 ± 0.74
mm; while the CAF+CTG technique resulted in a 2.53 ± 0.78
mm reduction. The difference was not statistically significant
(P = 0.41).
At 5-year follow-up, the CAF+ADM procedure showed a reduc-
tion of 1.60 ± 1.22; while the CAF+CTG technique resulted in
1.50 ± 1.42 mm reduction. The difference was not statistically
significant (P = 0.838) favouring CAF+ADM.
The ST procedure showed a reduction of 1.2 ± 0.5 mm; while
the CAF technique resulted in 2.6 ± 0.7 mm reduction. The dif-
ference was statistically significant (P <0.05), favouring the CAF
procedure.

Eur J Oral Implantol 2014;7(1):9–43

 Pini-Prato et al Guidelines for single gingival recessions „ 41

Results

LAS Hypersensitivity Postoperative pain/complications Cost effectiveness

NR NR NR NR

Fourteen out of 17 patients belonging to
the ST group reported an excellent or good
aesthetic result, and 3 reported a bad result.
All subjects of the CAF+CTG group reported
an excellent or good result. Seven patients
reported a better aesthetic in the sites treated
with CAF+CTG than the opposite treated site.
No patients reported any preference for the
sites treated with ST, and 10 patients did not
report any difference in terms of preference
between the 2 therapies80. The difference
favouring CAF+CTG was statistically signifi-
cant (P = 0.0215; McNemar test).
Root coverage perception:
All the 7 patients belonging to the CAF+ADM
group were fully satisfied, while 4 out of 7
patients of the CAF group were satisfied.
The difference was not statistically significant
(P = 0.15).
Colour of gums: All of the 7 patients belong-
ing to the CAF+ADM group were fully
satisfied, while 6 out of 7 patients of the CAF
group were satisfied. The difference was not
statistically significant (P = 0.30).
Shape of gum contours: 5 patients belonging
to the CAF+ADM group were fully satisfied,
while 5 out of 7 patients of the CAF group
were also fully satisfied. The difference was
not statistically significant (P = 1).
Three out of 17 patients of the SCF group
reported dental sensitivity, while none of the
patients belonging to the CAF+CTG group
reported dental sensitivity 30 months after
surgery. The difference was not statistically sig-
nificant (P = 0.25; McNemar test).
Six out of 7 patients of the CAF+ADM group
were fully satisfied, while 5 out of 7 patients
of the CAF group were also fully satisfied.
The difference was not statistically significant
(P = 0.58).
A median pain VAS score of 30 mm (range
20–60 mm) was recorded in the CAF+CTG
group and 0 mm (meaning no pain at all) in the
ST group; P value was not reported80. The pain
intensity and the number of pills taken were
statistically different between groups only on the
first day (P = 0.02), favouring the ST group79.
Pain and discomfort during surgery: 2 out of 2 out of 7 patients
7 patients of the CAF+ADM group were fully of the CAF+ADM
satisfied, while 6 out of 7 patients of the CAF group were fully
group were also fully satisfied. The difference satisfied, while 6
was statistically significant (P = 0.03), favouring out of 7 patients
the CAF group. of the CAF group
were also fully
Postoperative pain and swelling: 2 out of 7 satisfied. The dif-
patients of the CAF+ADM group were fully satis- ference was statis-
fied, while 6 out of 7 patients of the CAF group tically significant
were as well fully satisfied. The difference was (P = 0.03), favour-
statistically significant (P = 0.03), favouring the ing the CAF group.
CAF group.

NR NR NR NR

NR One out of 20 patients reported dental sensitivity NR NR

in the CAF+CTG+R, while 7 out of 20 patients
showed dental sensitivity after 6 months with
the CAF+CTG method. The difference was stat-
istically significant (P = 0.04 Fisher exact test),
favouring the CAF+ CTG +R procedure.
NR NR NR NR

No data are available, even if the authors NR No postoperative pain or complications were NR
reported that all sites treated with ST resulted observed in any patients.
in a notable semilunar white scar.

Eur J Oral Implantol 2014;7(1):9–43

42 „ Pini-Prato et al Guidelines for single gingival recessions

Study Method

CRC RecRed

Santana et CAF vs. Laterally positioned
al 201084 flap (LPF)
6-month follow-up; parallel
study; 36 patients (18 per
group); single recessions.
Fifteen out of 18 sites (83%) belonging to the LPF group
showed CRC, while 16 out of 18 sites (89%) treated with
CAF only obtained CRC. P value was not reported (P >0.05).
A calculation yielded an OR = 0.63 (CI 95%: 0.09 to 4.28;
P = 0.63) in favour of CAF.
The LPF procedure showed a reduction of 3.26 ± 0.4 mm; while
the CAF technique resulted in 3.09 ± 0.5 mm reduction. The dif-
ference was not statistically significant (P = 0.26 t test).

McGuire CAF+CTG vs. CAF+CM
& Scheyer
2010240 1-year follow-up; split-
mouth study; 25 patients at
6 months and 23 at 1 year;
single recessions.
Fifteen out of 25 sites belonging to the CAF+CM group
showed CRC, while 23 out of 25 sites treated with CAF+CTG
obtained CRC 6 months after treatment. At the 12-month
evaluation, 17 out 23 (CAF+CM) (74%) and 22 out 23 sites
(CAF+CTG) (96%) achieved CRC. P value was not reported
(P >0.05).
At 1-year follow-up, the CAF+CM procedure showed a reduc-
tion of 2.78 mm; while the CAF+CTG technique resulted in
3.17 mm reduction. The difference was statistically significant
(P = 0.0172) favouring CAF+CTG.

Nazareth CAF vs. CAF+Anorganic Ten out 15 sites (67%) belonging to the CAF+ABM/P-15 CAF+ABM/P-15 procedure showed a reduction of
& Cury Bovine-derived hydroxyapa- showed CRC, while 11 out 15 sites (73%) treated with CAF 2.20 ± 0.54 mm; while CAF technique resulted in
201086 tite Matrix/cell-binding only obtained CRC. P value was not reported. A calculation 2.40 ± 0.80 mm reduction. The difference (-0.20 ± 0.14 mm,
peptide (ABM/P-15) pro- yielded an OR = 0.73 (CI 95%: 0.18 to 2.86; P = 0.65) in favouring CAF group) was not statistically significant (P = 0.33).
cedure favour of CAF.

6-month follow-up; split-

mouth study; 15 patients;
single recessions.

McGuire et CAF+CTG vs. CAF+EMD 5 out of 9 sites (56%) belonging to the CAF+EMD group CAF+EMD procedure showed a reduction of 3.33 ± 0.87 mm;
al 2101287 showed CRC, while 7 out of 9 sites (78%) treated with while CAF+CTG technique resulted in 3.67 ± 1.12 mm reduc-
10-year follow-up (the CAF+CTG obtained CRC (P = 0.157). tion. The difference was not statistically significant (P = 0.625).
1-year follow-up was previ-
ously published, McGuire &
Nunn 2003195); split-mouth
study; 9 patients (out of
17); single recessions.

Zucchelli et CAF+CTG vs. Laterally CRC was achieved in 12 out of 25 defects of the CAF+CTG The CAF+CTG procedure showed a reduction of
al 201288 Moved Coronally Advanced group (48%), while in 1 out of 25 of the LPF group (4%). 4.04 ± 0.64 mm, while the LPF technique resulted in
Flap (LPF) The difference was statistically significant (P <0.05) favouring 3.68 ± 0.75 mm of recession reduction. The difference was not
CAF+CTG. statistically significant (P = 0.07 t test).
1-year follow-up; parallel
study; 50 patients; 50 single
recessions.

Jepsen et CAF vs. CAF+CM CRC was achieved in 16 out of 45 sites (36%) treated The CAF+CM procedure showed a reduction of
al 201389 with the CAF+CM group, while in 14 out of 45 sites 2.59 ± 1.11 mm, while the CAF technique resulted in
(31%) were treated with CAF. The difference was not 2.32 ± 0.99 mm of recession reduction. The difference was
6-month follow-up; multi-
statistically significant (P = 0.3870). statistically significant (P = 0.0175) in favour of CAF+CM.
centre split-mouth study;
45 patients; 90 single
recessions.

CRC: Complete Root Coverage; LAS: Level of Aesthetic Satisfaction; RecRed: Recession Reduction; SR: Systematic Review; RCTs: Randomised Controlled Trials; OR: Odds
Ratio; RR: Relative Risk; CAF: Coronally Advanced Flap; CTG: Connective Tissue Graft; BM: resorbable and non-resorbable Barrier Membrane; EMD: Enamel Matrix Deriva-
tive; ADM: Acellular Dermal Matrix; PRP: Platelet-Rich Plasma; HF-DDS: Human Fibroblast-Derived Dermal Substitute; CM: Xenogenic Collagen Matrix; ST: Semilunar Tech-
nique; FGG: Free Gingival Graft; LPF: Laterally Positioned Flap; ET: Envelope Technique; ADMP15: Anorganic Bovine Derived Hydroxyapatite Matrix Cell Bridging Peptide; R:
Resin Composite Restoration.

Eur J Oral Implantol 2014;7(1):9–43

 Pini-Prato et al Guidelines for single gingival recessions „ 43

Results

LAS Hypersensitivity Postoperative pain/complications Cost effectiveness

NR NR No postoperative pain or complications were NR

observed in any patients.

The estimates were not reported. No statistic- NR The estimates were not reported. No statistically NR
ally significant difference could be discerned. significant difference could be discerned in pain
or discomfort.

NR NR No postoperative pain and complications were NR

observed in any patients.

As regard to the aesthetic satisfaction, six Three out of 9 sites of the CAF+EMD proced- At the 10-year
patients had no preference for a particular type ure and 1 out of 9 sites of CAF+CTG procedure follow-up visit,
of treatment, two declared better aesthetic showed dental sensitivity. The difference was not patients were asked
results following CAF+EMD procedure and statistically significant (P = 0.157). to indicate the
one preferred the aesthetic outcomes with preference of the
CAF+CTG procedure (P = 0.564). CAF+EMD procedure: 6 out of
sites showed an equivalent texture to sur- 9 patients preferred
rounding tissues in 8 out of 9 sites versus 5 the CAF+EMD
out of 9 sites in CAF+CTG group. The differ- treatment, 1
ence was not statistical significant (P = 0.083). favoured CAF+CTG
When examining the colour equivalence of the procedure, and 2
surgical sites to the adjacent tissues, 8 out of had no preference.
9 CAF+EMD sites and 6 out of 9 CAF+CTG The difference was
sites were judged to have equivalent colour not statistically sig-
to surrounding tissues. The difference was not nificant
statistical significant (P = 0.157). (P = 0.059).
Eight out of 8 CAF+EMD sites and 1 of 8
CAF+CTG sites had equivalence of tissue con-
tour. The difference was statistically significant
(P = 0.008) favouring CAF+EMD sites.

Aesthetic patient evaluation in a VAS was
91.2 ± 9.3 for CAF+CTG (25 patients) and
89.6 ± 7.9 for LPF (25 patients).
The difference was not statistically significant
(P = 0.52 t test).
NR
Sensitivity VAS was 94.0 ± 6.5 for CAF+CTG
and 87.6 ± 8.3 for LPF. The difference favouring
CAF+CTG was statistically significant (P <0.01).
NR
After 7 days, the VAS values relating to pain were NR
77.2 ± 16.4 for CAF+CTG and 93.2 ± 8.0 for
LPF. The difference favouring LPF was statistically
significant (P <0.01).
After 7 days, the VAS values related to chewing
ability was 72.8 ± 14.3 for CAF+CTG and
88.8 ± 8.3 for LPF. The difference favouring LPF
was statistically significant (P <0.01).
After 7 days, pain VAS was 2.32 ± 2.08 for NR
CAF+CM and 0.04 ± 1.82 for CAF.
After 14 days, pain VAS was 0.68 ± 1.21 for
CAF+CM and 0.59 ± 0.91 for CAF. The dif-
ferences were not statistically significant (P
>0.05).

Eur J Oral Implantol 2014;7(1):9–43