The Efficacy of De-epithelialized Free Gingival Graft on Treatment of Multiple Gingival Recessions With Tunnel Technique
Condition: Gingival Recession
MeSH terms: Gingival Recession
Study type: Interventional

Summary: 
      The predictable treatment of multiple adjacent gingival recessions (MAGRs) represents a major
      challenge in periodontal plastic surgeries due to MAGRs' complicated predisposing anatomic
      features, such as thin gingival phenotype or limited keratinized tissue. The present study
      aimed to investigate the clinical efficacy and postoperative morbidity of de-epithelialized
      gingival graft (DGG) compared to subepithelial connective tissue graft (SCTG) on the
      treatment of multiple adjacent gingival recessions (MAGRs) with tunnel technique (TUN). A
      total of 38 patients, who have been referred to the Gazi University Faculty of Dentistry
      Department of Periodontology, were randomly assigned to receive TUN in combination with
      either DGG or SCTG. Clinical measurements were recorded at baseline and at 3, 6 and 12 months
      after surgeries. Immediately after surgery, a questionnaire was given to each patient
      evaluating postoperative pain, patients' discomfort, sensitivity and bleeding at 1, 2, 3, 7,
      14 and 28 days after surgery. Moreover, the characteristics of the grafts harvested by these
      two different techniques were evaluated histopathologically and histomorphometrically.
    

Detailed description: 
      The predictable treatment of multiple adjacent gingival recessions (MAGRs) represents a major
      challenge in periodontal plastic surgeries due to MAGRs' complicated predisposing anatomic
      features, such as thin gingival phenotype or limited keratinized tissue, variations in the
      depth and width of the adjacent recession defects, shallow vestibules and high frenum
      attachments. Furthermore, in these cases, wound healing is often more difficult due to
      factors such as larger avascular surface and poor blood supply.

      The coronally advanced flap (CAF) or the tunnel technique (TUN) with graft-based
      subepithelial connective tissue procedures have been reported to be the most predictable
      methods for the treatment of MAGRs. On account of the advantages of TUN, including superior
      blood supply and advanced wound healing owing to its conservative characteristics associated
      with the flap elevation without papillae dissection or vertical releasing incisions, this
      approach has recently achieved popularity compared to other methods.

      Although the use of connective tissue grafts (CTGs), together with various surgical
      techniques, has been accepted as "the gold standart" for the treatment of GRs, some
      disadvantages of CTG are underlined. Limited donor tissue in the cases where inadequate
      amount of palatal tissue thickness and/or a bigger dimension of CTG is needed, as in the
      treatment of MAGRs are claimed to be among those disadvantages (Zucchelli et al., 2010).
      Moreover, subepitelial CTG (SCTG), either harvested by 'trap-door' (TD) or 'single-incision'
      (SI) approaches, have been frequently associated with post-operative pain and discomfort, as
      well as palatal flap necrosis/dehiscence at the donor site.

      To overcome these limitations, and obtain a firmer and uniform CTG, de-epithelializing of the
      free gingival grafts (FGG) have been proposed, especially when palatal fibromucosal tissue
      thickness is inadequate (≤2.5 mm) and a large graft dimension in apico-coronal or
      mesio-distal directions is required. De-epithelialized gingival graft (DGG) have also been
      suggested to have less prone to post-operative shrinkage, because of obtaining larger amount
      of collagen-rich connective tissue from lamina propria, minimal amount of fatty/glandular
      tissue and less number of medium to large vessels. Previously it was reported that DGG
      applied with the TUN presented better manuplation in recipent area and reduced postoperative
      morbidity compared to a conventional CTG, and resulted in a successful root coverage outcome
      with increased both width and thickness of the keratinized tissue in the treatment of MAGRs.
      In a randomized clinical trial (RCT), Zuchelli et al. found no significant differences
      regarding post-operative pain and root coverage outcomes when compared SCTG and DGG in
      combination with CAF in the treatment of single or multiple GRs. However, a significant
      difference was observed in terms of keratinized tissue thickness (KTT) in favor of DGG, and
      this finding was attributed to the its characteristics of better stability, low shrinkage
      rates and to allow the incorporation of the portion of connective tissue closest to the
      epithelium. Despite all biologically advantages of DGG, there is scarce information in the
      literature on its clinical significance in combination with TUN compared to conventional CTG
      procedures in the treatment of MAGRs. Therefore, the present study aimed to investigate the
      clinical efficacy and postoperative morbidity of DGG compared to SCTG on treatment of MAGRs
      with TUN. The primary objective was to assess the root coverage outcomes of DGG versus SCTG
      with TUN at 1-year postoperatively. The secondary objectives were to evaluate postoperative
      patient morbidity of these procedures and the characteristics of the grafts harvested by
      these two different techniques histopathologically and histomorphometrically.
    

Intervention name(s): DGG + TUN; SCTG + TUN
Intervention type(s): Procedure; Procedure
Intervention description(s): In the DGG group, CTG was obtained at palatal mucosa by means of intra-oral de-epithelialization of the FGG using a 2.3 mm diameter diamond burr (801G/023, EMS, Aldrich Co., USA) with NaCL 0.9% saline irrigation; In SCTG group, graft was harvested through the single-incision approach at palatal mucosa
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Investigator)
Primary purpose: Treatment
Keywords: gingival recessions; connective tissue graft; de-epithelialized gingival graft; tunnel technique