Ralph DeLong D.D.S, M.S., PhD; Ralph Rosenblum Jr. DDS, MHA
All root coverage procedures studied produced gains in gingival root coverage, subepithelial connective tissue grafts yielded better gains in keratinized tissue.
Because only one RCT was considered to be at low risk of bias, and because of the substantial variability in results within studies of a given root coverage procedure, no procedure is clearly superior to the others.
In a patient population with localized gingival recession greater than three millimeters what is the effectiveness of periodontal plastic surgery (PPS) procedures for root coverage
The authors searched 4 databases up to October 2008 with no restrictions regarding publication status or language. The authors identified 649 potentially eligible articles of which 558 were excluded after they reviewed the title and/or abstract. Out of the 91 papers, 64 did not meet eligibility criteria. Grey literature was sought and authors were contacted about additional published and unpublished trials. Inclusion criteria were limited to RCTs of at least 6 months’ duration that evaluated and treated recession areas [Miller’s Class I or II > or = 3 mm] using PPS procedures.
Twenty-four RCTs provided data from 599 patients. Only 1 trial was considered to be at low risk of bias, with the remainder considered to be at high risk of bias. The results indicated a significantly greater reduction in gingival recession [0.39 mm; 95% confidence interval: 0.12 to 0.65 mm] and gain in keratinized tissue [1.95 mm; 95% confidence interval: 1.24 to 2.66 mm] for subepithelial connective tissue grafts compared to guided tissue regeneration with resorbable membranes. For all other PPS procedures [acellular dermal matrix grafts, coronally advanced flap, free gingival grafts, enamel matrix protein, guided tissue regeneration with nonresorbable membranes, and guided tissue regeneration with resorbable membranes associated with bone substitutes], no differences were found between procedures, although for some, few comparisons were available. Limited data exist on patients’ opinion and patients’ preference for a specific procedure.
All PPS procedures were associated with statistically significant gains in gingival recession for localized defects. Randomised controlled clinical trials are necessary to identify possible factors associated with the prognosis of each periodontal plastic surgery procedure and future trials should evaluate patient-oriented outcomes.
Source of Funding:
University of Sao Paulo, Brazil
Importance and Context:
Because many patients have exposure of the root surface and concomitant deterioration of dental aesthetics and buccal cervical hypersensitivity, practitioners should be aware of alternative approaches and their clinical outcomes when treating recession-type defects. Several periodontal plastic surgery procedures provide effective root coverage but data are lacking on patient-centered outcomes.
Strengths and Weaknesses of the Systematic Review:
The strength was, as with all Cochrane reviews, that it followed all standard protocols for reviews and was completely reported. An insufficient number of studies precluded assessment of publication bias.
Strengths and Weaknesses of the Evidence:
Although 24 RCTs were included, only 1 trial was considered to be at low risk of bias. Also, the number of comparisons between any 2 PPS procedures was small, and only 12 of the studies were suitable for inclusion in the 7 meta-analyses. Although consistency existed among the trial conclusions, the percentages of complete root coverage and mean coverage varied considerably across studies of any given procedure. Remarkably, for an aesthetic procedure only 3 trials formally evaluated patient-oriented outcomes.
Implications for Dental Practice:
Periodontal plastic surgery procedures will result in attachment gain. However, individual patient factors that may influence outcomes could not be determined from the available evidence.