Comparative Evaluation of The Effectiveness of Different Surgical Techniques of Coronally Advanced Flap In Gingival Recession Management- A Systematic Review

Background and objective : Although coronally advanced flap has been a gold standard technique for recession management, no systematic review has exclusively addressed the effectiveness of various surgical modifications of coronally advanced flap. A single technique addressing almost all the recession defects within a single visit, that is operator-friendly, time-efficient, no requirement for a second surgical site, and, most importantly, meeting the patient's esthetic demands is always a preferable option. Coronally advanced flap (CAF) technique is the gold standard technique indicated for the management of Miller's class I and class II gingival recession defects. Aim: The aim of this systematic review was to appraise the effectiveness of different surgical modifications in coronally advanced flap techniques in the management of Gingival recessions. Material and Methods : Randomized clinical trials with at least 3 months of follow-up comparing at least two techniques of coronally advanced flap for treatment of Miller Class I and II gingival recessions were identified. The primary outcome variable being the percentage of root coverage (%RC). The secondary outcomes were recession depth, recession width, clinical attachment gain, keratinized tissue gain, mean root coverage, complete root coverage, aesthetic satisfaction, tooth sensitivity, post-operative patient discomfort Results: A total of 503 Millers class I and II gingival recessions in 264 subjects from 10 RCT's included in this systematic review, which compared different techniques show that irrespective of the technique, there was a significant improvement in clinical outcome as compared to baseline. Comparison of the CAF with vertical releasing incisions and Tunnel technique, Coronally advanced flap showed better results. Whereas, CAF with and without vertical incisions had not shown significant difference except for the patient-related parameters favouring flap without vertical incision. Comparison of triangular CAF with trapezoidal CAF showed that triangular CAF had better results. Between CAF with tension and without tension, CAF without tension had favorable results. Long-term maintenance of the obtained recession coverage was not observed irrespective of the technique used except for one study.Conclusion: CAF with vertical releasing incisions is better compared to CAF without vertical incisions when root coverage is the major outcome. Aesthetics and patient-related outcome parameters were significantly better for CAF without vertical releasing incisions. More clinical trials are needed to confirm these results as there was heterogeneity in the included studies and the number of studies comparing each technique were very few.