Aesthetic-And patient-related outcomes following root coverage procedures: A systematic review and network meta-analysis

Background: Aim of this systematic review (SR) of randomized controlled trials (RCTs) was to evaluate effect of different flap designs and graft materials for root coverage, in terms of aesthetics, patient satisfaction and self-reported morbidity (post-operative pain/discomfort). Material and Methods: A comprehensive literature search was performed. A mixed-modelling approach to network meta-analysis was utilized to formulate direct and indirect comparisons among treatments for Root Coverage Esthetic Score (RES), with its individual components, and for subjective patient-reported satisfaction and post-operative pain/discomfort (visual analogue scale (VAS) of 100). Results: Twenty-six RCTs with a total of 867 treated patients (1708 recessions) were included. Coronally Advanced Flap (CAF) + Connective Tissue Graft (CTG) (0.74 (95% CI [0.24, 1.26], p =.005)), Tunnel (TUN) + CTG (0.84 (95% CI [0.15, 1.53]), p =.01) and CAF + Graft substitutes (GS) (0.55 (95% CI [0.006, 1.094], p =.04)) were significantly associated with higher RES than CAF. No significant difference between CAF + CTG and TUN + CTG was detected (0.09 (95% CI [−0.54, 0.72], p =.77)). Addition of CTG resulted in less natural tissue texture (−0.21 (95% CI [−0.34, −0.08]), p =.003) and gingival colour (−0.06 (95% CI [−0.12, −0.03], p =.03)) than CAF. CTG techniques were associated with increased morbidity. Conclusions: Connective tissue graft procedures showed highest overall aesthetic performance for root coverage, although graft integration might impair soft tissue colour and appearance. Additionally, CTG-based techniques were also correlated with a greater patient satisfaction and morbidity.