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ORIGINAL ARTICLE
Year : 2022 | Volume
: 21
| Issue : 4 | Page : 415-420
Comparative efficacy of coronally advanced flap with and without guided tissue regeneration in the management of gingival recession defects: A split-mouth trial
Santhi Priya Potharaju1, Santha Kumari Prathypaty1, Ravi Kanth Chintala2, D Sunil Kumar3, Y Durga Bai1, Vijaya Lakshmi Bolla1, Pradeep Koppolu4, Ali Barakat5, Amara Swapna Lingam6
1 Periodontics, Government Dental College and Hospital, Hyderabad, Telangana, India
2 Endodontist Armed Forces Dental Clinic, New Delhi, India
3 Ministry of Health, Kingdom of Bahrain
4 Department of Preventive Dental Sciences, College of Dentistry, Dar Al Uloom University, Riyadh, Kingdom of Saudi Arabia
5 Department of Restorative and Prosthetic Dental Sciences, College of Dentistry, Dar Al Uloom University, Riyadh, Kingdom of Saudi Arabia
6 Department of Surgical and Diagnostic Sciences, College of Dentistry, Dar Al Uloom University, Riyadh, Kingdom of Saudi Arabia
Correspondence Address:
Santhi Priya Potharaju
Department of Periodontics, Government Dental College and Hospital, Hyderabad - 500 012, Telangana
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_142_21
Abstract
Background: The gingival recession causes tooth sensitivity, poor esthetics, and tooth mobility in severe cases. Scientific documentation revealed effective root coverage (RC) and increased keratinized tissue heights acquired with the coronally advanced flap (CAF) for multiple recession defects. Objectives: This research evaluates and compares the efficacy of CAF procedures with and without Type I collagen bio-absorbable membrane in guided tissue regeneration (GTR) in the treatment of Miller's Class I and II gingival recession. Materials and Methods: A total of 30 sites from 15 patients were selected for the study after fulfilling the presurgical phase of treatment. The chosen sites were randomly allocated into Group A CAF and Group B (CAF + Resorbable GTR membrane). The clinical variables such as plaque index, gingival index, recession depth (RD), recession width (RW), width of keratinized gingiva (WKG), clinical attachment level (CAL), and surface area of the defect were recorded at the baseline and 6 months postoperatively. Results: Both therapies resulted in a notable gain in RC with a mean of 73.13% and 71.60%, respectively, but it was not statistically significant when compared between the groups. Both the RD and RW were significantly reduced from baseline to 6 months postoperatively. Although there was a gain in WKG and CAL in both experimental sites, no significant difference was observed between both the groups. Conclusion: Although there are several RC procedures, CAF furnishes a foreseeable, straightforward, and appropriate perspective for treating Miller's Class I and II recessions. Integrating this approach with placing a bio-absorbable membrane does not seem to improve the results following surgical treatment of such defects. However, both groups showed the potential advantage of achieving RC.
Abstract in French Résumé
Contexte: La récession gingivale provoque une sensibilité dentaire, une mauvaise esthétique et une mobilité dentaire dans les cas graves. La documentation scientifique a révélé une couverture efficace de la racine (RC) et une augmentation de la hauteur du tissu kératinisé acquises avec le lambeau coronalement avancé (CAF) pour de multiples défauts de récession multiples. Objectifs: Cette recherche évalue et compare l'efficacité des procédures CAF avec et sans membrane bio-absorbable de collagène de type I dans la régénération tissulaire guidée (RTC). de collagène de type I dans la régénération tissulaire guidée (RTG) dans le traitement de la récession gingivale de classe I et II de Miller. Matériaux et Méthodes: Un total de 30 sites de 15 patients ont été sélectionnés pour l'étude après avoir rempli la phase pré-chirurgicale du traitement. Les sites choisis ont été répartis au hasard dans le groupe A (CAF) et le groupe B (CAF + membrane GTR résorbable). Les variables cliniques telles que l'indice de plaque, l'indice gingival, la profondeur de la récession (RD), la largeur de la récession (GTR) ont été évaluées. gingivale, la profondeur de la récession (RD), la largeur de la récession (RW), la largeur de la gencive kératinisée (WKG), le niveau d'attachement clinique (CAL) et la surface du défaut. ont été enregistrés au début de l'étude et 6 mois après l'opération. Résultats: Les deux thérapies ont entraîné un gain notable de RC avec une moyenne de 73,13 % et 71,60 % respectivement. 71,60 %, respectivement, mais la comparaison entre les groupes n'était pas statistiquement significative. La RD et la RW ont toutes deux été réduites de manière significative de la ligne de base à 6 mois après l'opération. Bien qu'il y ait eu un gain en WKG et CAL dans les deux sites expérimentaux, aucune différence significative n'a été observée entre les deux groupes. observée entre les deux groupes. Conclusion: Bien qu'il existe plusieurs procédures de RC, la CAF fournit une perspective prévisible, directe et appropriée pour traiter la classe de Miller perspective prévisible, simple et appropriée pour traiter les récessions de classe I et II de Miller. L'intégration de cette approche avec la mise en place d'une membrane bio-absorbable ne semble pas améliorer les résultats après le traitement chirurgical. semble pas améliorer les résultats après le traitement chirurgical de ces défauts. Cependant, les deux groupes ont montré l'avantage potentiel de réaliser une RC.
Mots-clés: Lambeau avancé coronaire, récession gingivale, régénération tissulaire guidée, chirurgie plastique parodontale, membrane résorbable
Keywords: Coronally advanced flap, gingival recession, guided tissue regeneration, periodontal plastic surgery, resorbable membrane
Introduction 
Gingival recession is the apical migration of the gingival margin to the cementoenamel junction (CEJ).[1] The gingival recession causes tooth sensitivity, poor esthetics, and tooth mobility in severe cases. The risk of this condition increases with age.[2] Adults are at more risk compared to children, i.e. 8% in children to 100% after the age of 50 years.[3] It was also observed that the male gender is at higher risk than females of the identical age.[2] Mucogingival surgery is performed to correct the gingival recession. Miller, in 1993 renamed this procedure periodontal plastic surgery. The principal focus of this surgery is to cover the root surface, which reduces the tooth sensitivity, but this may or may not reinstate the anatomy of the mucogingival complex. In certain defects, conventional mucogingival surgery may not yield favorable results. The long-established surgical approaches have primarily utilized soft tissue grafts for the care of gingival recession. Several surgical procedures such as coronally or laterally positioned pedicle grafts, rotational flaps, epithelialized free tissue grafts, connective tissue grafts, and guided tissue regeneration (GTR) are employed to enhance the width of keratinized tissue. Various surgical approaches enhance the width of keratinized tissue comprising coronally or laterally positioned pedicle grafts, rotational flaps, epithelialized free tissue grafts, connective tissue grafts, and GTR.
The edge of averting a donor site surgery and a subsidiary surgical course of action for the membrane removal in GTR treatment can be obtained through the employment of resorbable membranes.[4] GTR has also proven to indulge new attachment formation in the treatment of recession in animals[5] and humans.[6] The possibility of having an ideal healing approach to attain periodontal regeneration, preferably than connective tissue repair, is anticipated to gain by applying the principles of GTR in the root coverage (RC) procedures in the current research.[7]
Scientific documentation has revealed that adequate RC and the increase in keratinized tissue height acquired with the coronally advanced flap (CAF) for multiple recession defects.[8] Studies also stipulate that Miller's Class I and II gingival recessions are amenable to treatment using the GTR technique with the acceptable end result.[9] Therefore, the current study aimed to evaluate and compare the outcome of treatment of Miller's Class I and Class II gingival recession by CAF technique with or without using a bioabsorbable barrier membrane.
Materials and Methods The participants for this study were selected from the outpatient department of periodontics. We included those patients in the age group of 20–55 years who were systemically healthy and with Miller's Class I gingival recession defects measuring ≥3 mm either on cuspids or 1st and 2nd premolars one in each quadrant or on the contralateral sides of same arch and with a probing depth of <3 mm. We excluded patients who lacked manual dexterity to maintain oral hygiene, smokers, tobacco chewers, undergoing/underwent orthodontic corrections, and if the bone loss was detected at the recession site on the radiological examination.
Ethical approval from the Institutional Ethics Committee was obtained before the implementation of the study. Furthermore, we got voluntary informed consent from all participants after giving adequate information about the procedures, duration, benefits, and risks involved in the study. All participants underwent the presurgical phase of treatment and after which a total of 30 sites from 15 patients were selected. The selected sites were randomly assigned to two study groups according to the type of treatment rendered using a split-mouth design represented in [Figure 1]. The two study groups were Group A: Treated with CAF alone and Group B: Treated with (CAF + GTR) CAF followed by placement of a bioabsorbable, Type I collagen membrane [Figure 2] and [Figure 3].
Figure 2: Williams periodontal probe measuring the RD on labial surface of tooth #13 in Group A at baselineInitially, all participants were educated about basic oral hygiene measures and also underwent scaling and root planning of all the teeth. This process was repeated until patients reached a plaque score of 15% or less. After initial therapy, study models of the teeth with acrylic stents were prepared.
Clinical parameters plaque index (PI): (Silness and Loe, 1964)[10], gingival index (GI): (Loe and Silness, 1963),[11] clinical attachment level (CAL)[12], gingival recession depth (RD),[13] gingival recession width (RW), width of the keratinized gingiva (WKG), and surface area of the defect (SAD) were recorded at baseline and 6 months after the intervention. The CAL and Gingival RD were measured from a fixed reference point to the base of the pocket and most apical margin of the gingiva, respectively, with the help of William's probe using the acrylic stent. Gingival RW was measure between the ends of the gingival margin with the help of William's graduated periodontal probe. The SAD was measured by placing tin foil over the defect, conforming to defect shape, placing it foil over a graph paper, and counting the number of squares in the area of the foil. The surface area was calculated in mm2.
Percentage of root coverage %
It was calculated using the following formula
Pre-operative recession area – postoperative recession area × 100 Preoperative recession area.[14]
During the surgical procedure, first, the patient's extraoral surfaces got swabbed with 5% povidone-iodine solution. And then, the operative site got anaesthetized with 2% xylocaine Hydrochloric acid (HCL) with adrenaline (1:80,000). Horizontal incisions were given at the level of CEJ on the facial surface on either side of the tooth, followed by the crevicular incisions, and vertical releasing incisions were given using Bard Parker handle no: 3 with blades #15 and # 11. The interdental papillary tissue preserved as much as possible. Full-thickness mucoperiosteal flap got reflected up to the mucogingival junction. It was followed by a partial-thickness flap using periosteal elevators. After the reflection of the flap, the exposed root surfaces were planed thoroughly using the curettes. The surgical site was then thoroughly irrigated with normal saline. In Group A, the elevated mucoperiosteal flap got positioned coronally to cover the root surface. In Group B, the elevated mucoperiosteal flap held with tissue holding forceps. Type I collagen membrane was placed over the recession defect, and was covered by a CAF.
Preparation of type I collagen membrane
After extracting the exact size of the barrier or collagen membrane with the help of a trimmed sterile template, the membrane was placed directly over the recession defect in such a way that it completely covered the defect and extended a minimum of 2–3 mm beyond the recession defect apically, mesially, and distally and 1 mm short of CEJ in a coronal direction.
In both instances, the mucoperiosteal flaps were positioned coronally and secured in place using the black braided (5-0) Mersilk (Ethicon, Johnson and Johnson Co.,) nonresorbable sutures. The periodontal dressing was placed to protect the surgical site in all cases. Postoperative medication Amoxicillin 500 mg thrice daily for 5 days and Ibuprofen 400 mg thrice daily for 3 days was prescribed to relieve postoperative pain and infection. The patients were also instructed to rinse with 0.2% chlorhexidine mouthwash twice daily for 2 weeks and abstain from brushing at the surgical site for at least 4 weeks.
Postoperatively, the patients were recalled after 10 days for periodontal dressing and sutures removal. Patients were recalled weekly for the 1st month and then at 3 months and 6 months postoperatively.
All the clinical parameters measured at baseline and 6 months were analyzed using the SPSS 16.0; SPSS Inc., Chicago, IL, USA. The intragroup comparison between baseline and 6-month values was made using the Wilcoxon matched-pairs test, and intergroup comparison was made using the Mann–Whitney U-test. P < 0.05. Statistical significance was fixed at 5%.
Results In this study, a total of 30 sites were selected from 15 patients. Later, for each group, 15 sites were allocated. There were no dropouts in this study. At baseline, the parameters of the control and test groups did not show any statistically significant difference. There was a statistically significant difference when the parameters were compared within the group from baseline to 6 months, as shown in [Table 1]. There was no statistically significant difference in the PI, GI, RD, RW, CAL, WKG, SAD, and RC % between the two groups at baseline and 6 months [Table 2] and [Table 3]. The mean and P values for the test and control groups are mentioned in the [Table 1],[Table 2],[Table 3].
Table 1: Intragroup comparison of all parameters recorded at baseline and 6 months by Wilcoxon matched pairs test
Table 2: Intergroup comparison of all parameters recorded at baseline and 6 months, by Mann-Whitney U-test
Table 3: Comparison of Group A and Group B with respect to root coverage percentageComparing the mean surface area of defect between the two groups at baseline and 6 months was not statistically significant [Figure 4]. The mean RC area percentage achieved at 6 months in the control and test groups was 71.60% and 73.13%, respectively. Statistically, no significant difference could be observed in the rate of RC achieved when both the groups were compared.
Discussion The CAF corrects the defects of gingival recession by forming a long junctional epithelium with the meager volume of bone and cementum formation. Alternative to this method, a new process of GTR was preferred for the RC because the existing evidence suggests that histologically it forms new attachment formation.[6] The success of CAF for RC procedure depends on several factors such as anatomical factors (height and thickness of gingiva apical to the recession, width, and thickness of the keratinized gingiva,[15] adjacent bone height, adjacent papilla dimension, defect size, flap thickness, and location of the tooth), patient factors (such as oral hygiene, smoking, and systemic health), and surgical factors (such as surgeons clinical experience, flap tension, and root surface preparation techniques).[16]
The best clinical outcomes in RC treatment are achieved when the flap is passively adapted to the exposed root surface and the gingival margin is positioned at the CEJ. The other factors which may influence the outcomes of the CAF are root prominence, frenum position, kind of periodontium, RD, and the depth of vestibulum.[17]
The other technique that gained popularity over the conventional coronally flap technique is GTR because it can facilitate periodontal new attachment on exposed root surfaces.[18],[19] The placement of a membrane barrier closely adapted to the root surface facilitates the migration of cells necessary for constructing new attachment onto the root surface. Thus, the amount of regenerated tissue underneath the membrane in GTR procedures depends upon the volume of secluded space bounded by the barrier.
The rationale of implementing collagen membrane for RC comprises: Validated barrier role, bioabsorbable, chemotactic activity for periodontal ligament fibroblasts and gingival fibroblasts, hemostatic effects[20] frail immunogenicity, effortless handling, the capability to elevate tissue thickness by providing a collagenous scaffold, stimulating wound healing through the clot stabilization wound stability.[21] The membrane used is an Food and Drug Administration ratified resorbable and unyielding barrier product developed from decontaminated bovine Achilles tendon. It is 100% Type I collagen. The resorption rate is 4–8 weeks. The period in which a collagen membrane remains sound is ample for intercepting apical migration of epithelium throughout early periodontal wound healing since the critical time for epithelial proliferation occurs within the initial 14 days. To stay for a sufficient time underneath the flap, the membrane had a cross-linked structure to reduce the degradation rate.[22]
Bunyaratavej P., and Wang HL., proposed that collagen may be more acceptable than the PTFE barrier to attaining periodontal regeneration.[23] The comparative study describes the properties, functions, and placement of collagen-based GTR membrane to treat gingival recession by CAF procedure.
The comparative study describes the numerous properties, functions, and placement of the collagen-based GTR membrane to treat gingival recession by CAF procedure.[24] The added reason may be the interference of the ligature used to keep the membrane intact with healing at the recession site.
No statistically significant differences were observed in a mean gain in width of keratinized when compared between the groups at baseline and 6 months postoperatively. The increase in WKG can be pertained to the stimulus obtained from the underlying newly formed connective tissue and also by the genetically determined phenotype of epithelial cells.[24]
There was also no statistically significant difference in CAL and SAD values at baseline and 6 months compared to the two groups. Placement of a biodegradable membrane underneath the flap does not seem to improve either the short or the long-term results.[24] Postsurgical exposure of the membrane may also lead to improper healing in the membrane group. Other elements comprise affect the healing or outcome of the CAF for RC. Although test Group B clinically presented better results when compared to Group A, statistically, it was not significant. The mean RC area percentage achieved at 6 months in test and control groups was 73.13% and 71.60%, respectively, which is similar to other studies directed utilizing bio-absorbable collagen membranes Kimble (69%) but no significant difference statistically.[25] The finding of this has limited generalizability because of the small sample size. Hence, future studies should test this hypothesis with larger sample size.
Conclusion In the treatment of Miller's Class I and II gingival recessions, CAF was considered a foreseeable, accessible, and timely technique. Combining such technique with the placement of a bio-absorbable membrane does not appear to enhance the outcome following surgical treatment of such defects statistically. However, both the groups manifested the promising edge of achieving RC.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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