Long‐term stability of periodontal plastic surgery featuring traditional autogenous graft and coronally advanced flap alone

BACKGROUND: Coronally advanced flap (CAF), either alone or in combination with a connective tissue graft (CTG), represents one of the most extensively investigated surgical approaches for the treatment of gingival recessions, demonstrating high rates of mean root coverage (MRC) and complete root coverage (CRC). However, evidence regarding their long-term performance remains limited. AIM: This review critically analyzes the long-term clinical performance of CAF alone and in combination with CTG, examining root coverage outcomes, stability of the gingival margin, keratinized tissue (KT), and gingival thickness (GT) gain, and esthetic integration over extended follow-up periods. The influence of baseline phenotype, surgical modifications, and specific clinical scenarios on long-term success is explored. MATERIAL AND METHODS: A comprehensive narrative review of randomized clinical trials (RCTs), controlled studies, case series, and retrospective cohorts with a minimum follow-up of 5 years was conducted. Outcomes were stratified by surgical technique (CAF vs. CAF + CTG), defect complexity, and follow-up duration (5 to >20 years). RESULTS: CAF alone demonstrates satisfactory short-term coverage but exhibits gradual apical relapse over time, particularly in inadequate phenotype. Long-term studies indicate progressive reduction of CRC, with stability strongly linked to early gingival margin position and phenotype maturity. In contrast, CTG adjunctive therapy consistently enhances long-term stability by increasing KT and GT, improving resistance to mechanical and biological relapse. According to the authors' experience, CTG is especially beneficial in anatomically or etiologically complex conditions. Extended follow-up (>20 years) confirms the enduring role of CTG-driven phenotype modification in preventing marginal relapse. CONCLUSIONS: Long-term success in root coverage procedures is predominantly phenotype-dependent. While CAF alone may be appropriate in selected sites with favorable anatomical and phenotypic features, CAF + CTG remains the gold standard for securing stable outcomes over time, particularly in challenging clinical scenarios. The drawbacks of applying CTG must be considered alongside the treatment benefits. CLINICAL RELEVANCE: Future therapeutic algorithms should incorporate a phenotype- and defect-driven approach to optimize the lifetime stability of periodontal plastic surgery outcomes.