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Title In a Patient with Gingival Recession, a Connective Tissue Graft Should be Combined with a Coronally Positioned Flap to Provide Best Long-Term Clinical Results
Clinical Question In a patient with gingival recession, does a coronally advanced flap combined with a connective tissue graft procedure offer better long-term esthetic results and periodontal health than a coronally advanced flap by itself?
Clinical Bottom Line Combining a connective tissue graft with the coronally positioned flap will provide better long-term esthetics and periodontal health when treating gingival recession than would a coronally advanced flap by itself.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 25039691Cheng/2014321 Adult patients from 13 RCT’sMeta-Analysis of Randomized Controlled Trials
Key resultsThis was a meta-analysis done on a literature search that encompassed a series of randomized controlled trials which compared the clinical performance of coronally advanced flaps (CAF) alone versus combining the flap with either a connective tissue graft (CTG), enamel matrix derivative, or both. A reduction of recession depth was greater for the CAF + CTG than with the CAF alone (95% CI: -0.32(-0.56, -0.08)). Further, increase in keratinized tissue width was greater for CAF + CTG than with CAF alone (95% CI: 0.61(0.32,0.89)). There was no significant difference between the groups for gain of clinical attachment level, however the control CAF alone outperformed CAF + CTG by a narrow margin.
#2) 24382170Zucchelli/201450 patients with multiple gingival recessionsRandomized Controlled Trial
Key resultsThis study was a randomized controlled trial consisting of 50 participants randomly assigned to receive either a coronally advanced flap (CAF) or coronally advanced flap plus connective tissue graft (CAF+CTG) to treat gingival recession. There was no statistically significant difference in recession depth reduction or probability for complete root coverage between the groups at either 6 months or 1-year follow-up. At 5-year follow-up, recession depth reduction was greater with the CAF+CTG group (p<0.01). Also at 5-years, the probability for complete root coverage was greater with the CAF+CTG group (odds ratio = 3.22). The keratinized tissue height was higher at 6 months, 1 year, and 5 year follow-ups for CAF +CTG (p<0.01). Regarding esthetics, statistically better contour was observed at 5 years for the CAF+CTG group.
#3) 23432657Kuis/201337 patients, ages 20-52, with bilaterally paired gingival recession lesionsRandomized Split-mouth Study
Key resultsIn this bilateral randomized controlled study, participants received the coronally advanced flap (CAF) procedure on one side of the dental arch and the coronally advanced flap combined with a connective tissue graft (CAF+CTG) on the opposite side of the arch. Overall, better reduction in recession was seen at 12, 24, and 60 months with CAF+CTG side, however this was not the case for Miller class II lesions when looked at separate from the miller class I lesions. There was an overall greater increase in keratinized tissue width for the CAF+CTG side at 6 months on through 60 months, however this increase was not significant in the Miller class I lesions when taken separate from the Miller class II lesions.
Evidence Search (coronally[All Fields] AND advanced[All Fields] AND ("surgical flaps"[MeSH Terms] OR ("surgical"[All Fields] AND "flaps"[All Fields]) OR "surgical flaps"[All Fields] OR "flap"[All Fields]) AND ("connective tissue"[MeSH Terms] OR ("connective"[All Fields] AND "tissue"[All Fields]) OR "connective tissue"[All Fields]) AND ("transplants"[MeSH Terms] OR "transplants"[All Fields] OR "graft"[All Fields])) AND (Randomized Controlled Trial[ptyp] OR Meta-Analysis[ptyp])
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The Evidence
Cheng conducted a systematic literature search of randomized controlled trials which compared four different restorative options for gingival recession, including comparison between coronally advanced flap (CAF) alone and a cornonally advanced flap in combination with a connective tissue graft (CAF+CTG). There were 16 studies ultimately included, and a meta-analysis was performed. All of the included articles had been chosen based on strict inclusion criterion and each was assessed for validity. Zucchelli conducted a randomized controlled trial which included 50 patients, each with multiple gingival recessions. Half of the patients were randomly assigned to each treatment group by computer, and the assignment was revealed to the surgeon right before surgery to ensure equal treatment and pre-op procedures for each group. Esthetic evaluations were made by an independent periodontist thus ensuring a double-blind study approach. There was 100% completion through the 5 years of study. Kuis conducted a randomized controlled trial which included 37 patients with ages ranging from 20 to 52 years, each with bilaterally paired lesions on the same tooth on opposite sides of the dental arch. In this bilateral design, each patient served as their own control, with one treatment option being randomly assigned to one side of the mouth, and the other treatment option subsequently being assigned to the opposite side. There was 100% completion rate through the 5 years of study.
Applicability These articles all encompassed adult patients with mild to moderate gingival recession. All of the patients were in good general health and had no contraindications for periodontal surgery. These patients represent typical general dental practice patients as well as patients likely to be found in periodontal specialty clinics. Overall, this evidence has wide applicability to patients in dental practices.
Specialty/Discipline (Periodontics)
Keywords Periodontics, Gingival Recession, Gingival Graft, Connective Tissue Graft
ID# 2846
Date of submission: 04/02/2015spacer
E-mail walkerk4@livemail.uthscsa.edu
Author Kyle Walker
Co-author(s) e-mail
Faculty mentor/Co-author David Lasho, DDS, MSD
Faculty mentor/Co-author e-mail lasho@uthscsa.edu
Basic Science Rationale
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