The Laterally Closed Tunnel Versus Modified Coronally Advanced Tunnel for Mandibular Anterior Gingival Recession Defects
Condition: Gingival Recession, Localized
MeSH terms: Gingival Recession
Study type: Interventional

Summary: 
      The aim of this study is to comparatively evaluate the advantages of LCT with SCTG over MCAT
      with SCTG for coverage of deep isolated mandibular anterior recession.
    

Detailed description: 
      Gingival recession is defined as the displacement of the soft tissue margin apical to the
      cementoenamel junction.Different predisposing anatomic features can result in recession such
      as position and anatomy of teeth in the dental arch, bony dehiscence, thickness of the
      alveolar mucosa, muscle pull, orthodontic treatment, thin gingival biotype, buccal prominence
      of teeth, lack of keratinized tissue, high frenum attachment, or patient related factors such
      as vigorous brushing or chronic gingival inflammation.

      It is a common finding in patient with a high standard of oral hygiene as well as in
      periodontally untreated populations with poor oral hygiene.The migration of the marginal
      tissue to an apical position may lead to esthetic concern, dentin hypersensitivity, root
      caries, and cervical wear.

      Mandibular gingival recession defects present significant therapeutic challenges such as
      shallow vestibular depth, high frenal attachment, thin soft tissue biotypes leading to thin
      coronally advanced flaps, and thin often dehisced labial bone.Due to these factors the
      mandibular sites suffers strong and constant tension in comparison to the maxilla, hence
      there is lack of predictability in the mandibular sites.

      Various surgical techniques have been proposed for the treatment of isolated mandibular
      recessions including the use of fully or partially epithelized free gingival grafts (FGG) or
      sub epithelial connective tissue graft in conjunction with various types of flaps eg:
      (envelope, coronally or laterally positioned flap, double pedicle flap (DPF) or tunnelling
      (TUN) alone or combined with laterally positioned pedicle flaps (LPPF).

      Coronally advanced flap (CAF) +connective tissue graft (CTG) is considered as the gold
      standard treatment in reducing or eliminating gingival recession. Tunnel technique was first
      introduced by Allen in 19949, and its modifications by Zabalegui in 199910, Modified
      Coronally Advanced Tunnel (MCAT) by Azzi et al 2002 and Microsurgical CAT by Zuhr 2007.

      However, in deep isolated mandibular recessions located in the anterior area, tension free
      coronal displacement of the flap can be extremely difficult and may result in decreased
      vestibular depth and flap dehiscence due to increased flap tension.

      Therefore a new clinical approach of The Laterally Closed Tunnel (LCT), specifically designed
      for deep isolated anterior Mandibular Millers class I, II and III recession has been
      introduced to predictably cover recession and minimize the risk for post operative
      complications caused by unfavourable anatomical situations.

      The important aspect of LCT is the wide mesiodistal and apical mobilisation of the tunnel
      which enables tension free lateral movement of the flap margins to cover the graft and the
      recession. The tension free lateral movement and the passive lateral closure of the tunnel
      margins maybe advantageous in the treatment of isolated deep recessions located in areas with
      inserting frenula or shallow vestibule, which makes a coronal tension free advancement of the
      flap extremely difficult.

      Beside the tension free flap preparation, the use of SCTG plays a key role in increasing flap
      thickness and blood clot stability and in providing the cells needed for soft tissue
      regeneration and keratinization.
    

Intervention name(s): Group A The Laterally Closed Tunnel Technique with SCTG; Group B Modified Coronally Advanced Tunnel Technique with SCTG.
Intervention type(s): Procedure; Procedure
Intervention description(s): Following the administration of local anaesthesia 2% lignocaine hydrochloride.In the LCT technique a bevelled intrasulcular incisions will be made around the necks of the affected teeth with Orban Knife.The tunnelling will be accomplished with tunneling instrument (TKN2).A mucoperiosteal tunnel will be prepared using a specially designed tunneling instrument.The muscle and collagen fibres will be released using surgical blades and gracey curettes.Subepithelial CTG will be harvested from palate using single incision technique.The graft will be removed and will be placed on saline soaked gauze and kept wet until its transfer to the recipient bed.An immediate closure of the donor site is performed using modified mattress sutures.The graft will be adapted to the CEJ by means of sling suture.Finally the margins of the pouch will be pulled together over the graft and sutured with interrupted sutures.The surgical sites will be protected with a non eugenol periodontal dressing.; In MCAT technique all the buccal tissues will be undermined and connected only the papillary region will be left attached.A full thickness preparation of the papillary region will be created this will be done with a small elevator.A second surgical site to obtain the subepithelial CTG using single incision technique.A support suture will be performed to guide the CTG into the recipient site.The graft will be gently pushed into the pouch with a packing instrument and by pulling the support suture.The entire gingivopapillary complex will be moved coronally using a vertical mattress suture anchored in the lingual gingiva.The anchorage in the lingual gingiva will be placed far apically.The suture must capture the buccal flap and graft to avail optimal stabilization.The surgical sites will be protected with a non eugenol periodontal dressing.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: The patients will be assigned into two treatment groups Group A (Test Group) comprises of patient undergoing The Laterally Closed Tunnel Technique with SCTG and Group B(Control Group) comprises of patients undergoing Modified Coronally Advanced Tunnel Technique with SCTG
Masking: None (Open Label)
Primary purpose: Treatment