Single Stage Root Coverage for Gingival Recession With or Without Free Gingival Graft
Condition: Gingival Recession
MeSH terms: Gingival Recession
Study type: Interventional

Summary: 
      Background and Objective: Gingival recession accounts for apical migration of the gingival
      margin resulting in exposure of the cementoenamel junction (CEJ) and root surface. It is a
      matter of concern for both patients and dental professionals, especially when exposure of the
      root surface is linked to deterioration in esthetic appearance and increase in dentinal
      hypersensitivity which leads to improvements in various surgical techniques that have been
      used to correct labial gingival recession defects. The present study thus was aimed to
      evaluate and compare the results of Semilunar Coronally Positioned Flap alone and Semilunar
      Coronally Positioned Flap in Conjunction with Free Gingival Graft for treatment of Miller
      Class I and II gingival recession defects in maxillary anterior teeth.

      Materials and Method: A total of 20 bilateral Miller's class I and II gingival recession
      sites in systemically healthy subjects, 20-45 years of age were recruited for this study.
      Recession sites were divided and randomly allocated to either of the two groups SCPF+FGG
      (test group) and SCPF (control group) with 10 sites per group to be treated with semilunar
      coronally positioned flap with free gingival graft technique for SCPF+FGG group and semilunar
      coronally positioned flap technique alone for SCPF group. Longitudinal alterations during a
      follow-up period of 1, 3, 6 and 12 months in terms of Probing depth (PD), Recession width
      (RW), Recession height (RH), Width of keratinized tissue (WKT) and Clinical attachment level
      (CAL) were measured for both the groups and the values were statistically analysed.
    

Detailed description: 
      Gingival recession is a matter of concern for both patients and dental professionals,
      especially when exposure of the root surface is linked to deterioration in esthetic
      appearance and increase in dental hypersensitivity which provoked to propose various surgical
      techniques that have been used to correct labial/buccal gingival recession defects including
      periodontal plastic surgery. The goal of these surgical procedures is to correct the
      recession defects and remove or control the etiologic factors that result in mucogingival
      problems including free gingival autografts,laterally and coronally positioned flap,
      semilunar flap, guided tissue regeneration(GTR), subepithelial connective tissue graft (SCTG)
      and combination of procedures.

      The selection of surgical technique depends on several factors including the anatomy of the
      defect site, size of recession defect, presence or absence of keratinized tissue adjacent to
      the defect, width and height of the interdental soft tissue and depth of the vestibule or the
      presence of frenula. It also depends on the objective of the treatment outcome which varies
      in maxilla and in mandible. In maxilla the desired outcome is aesthetics where as in case of
      mandible it is the mucogingival problems with restoration of normal function. Because of the
      existing controversies about using different techniques of root coverage and their
      disadvantages, there are only few documented reports about an esthetic outcome which is
      important in maxilla that can be gained through increased width of keratinized tissue.

      The semilunar coronally positioned flap (SCPF) procedure introduced by Tarnow for treatment
      of gingival recessions is confined to the maxillary arch with esthetic outcome but no attempt
      is made to increase the width of keratinized tissueor thickness of gingival tissue. On the
      other hand, free gingival autograft (FGG) increases the width of keratinized tissue or
      thickness of gingiva predictably but may result in compromised color match due to lighter
      color of the graft. Thus simultaneous use of SCPF and FGG was performed to combine both
      desirable outcomes.

      As there are no documented reports about comparative clinical evaluation of SCPF and
      simultaneous use of SCPF and FGG for covering the exposed root surface in Miller's class I
      and II gingival recession, an attempt is made to evaluate the results of simultaneous use of
      SCPF and FGG for covering the exposed root surface and its comparison with SCPF alone in the
      present study. Thus the aim of the present study is to compare and evaluate the results of
      using semilunar coronally positioned flap alone for root coverage with a combination
      technique of semilunar coronally positioned flap along with free gingival graft for root
      coverage and to assess the results of a combination technique of semilunar coronally
      positioned flap along with free gingival graft for root coverage. The goal of treatment is to
      improve aesthetic outcomes with gain in the keratinised tissue levels and clinical attachment
      level in addition to possible root coverage in maxillary anteriors.

      Study Design:

      A total of 20 bilateral Miller's class I and II recession sites in maxillary anteriors
      (incisors or premolars) in systemically healthy subjects, 20-45 years of age, were
      consecutively recruited from the outpatient department of Periodontology, Kamineni Institiute
      of Dental sciences, Narketpally, Nalgonda (Dist) who desired treatment for gingival recession
      in maxillary incisor or premolar area for this study. The study design was approved by the
      Institutional Ethical Committee, Kamineni Institute of Dental Sciences. The nature and
      purpose of the study was explained to the patients in their native language and an informed
      consent was obtained.

      Bilateral recession defects in each patient were randomly divided into two groups, SCPF+FGG
      (test group) who were treated with combined technique of semilunar coronally positioned flap
      with free gingival graft and SCPF (control group) treated with semilunar coronally positioned
      flap alone, 10 defects in each group. The defects were randomly selected by coin toss to be
      treated either with the SCPF + FGG or SCPF alone. Changes in clinical parameters during a
      follow-up period of 1, 3, 6 and 12 months were recorded using UNC 15 probe along the long
      axis of the tooth over the mid-root surface expressed in millimetres. An acrylic occlusal
      stent was used as the fixed reference point to determine the amount of root coverage gained
      and changes in probing attachment level during the follow up where as WKT assessed using
      Lugol's iodine.

      Initial therapy:

      Prior to surgery, all subjects received oral prophylaxis, which included scaling and root
      planing with ultrasonic instruments (EMS) and Gracey curettes (Hu-Friedy, USA) and crown
      polishing along with oral hygiene instructions.Only when the patient demonstrated the ability
      to maintain a good level of oral hygiene was the surgical phase initiated.

      SURGICAL PROCEDURE:

      Bilateral defects were treated at the same appointment and all the defects were treated by
      the single person.

      Control Group: Semilunar Coronally Positioned Flap (SCPF) Group The operation area was
      anaesthetized using local anesthesia (2% lignocaine with 1:80000 adrenaline). The exposed
      root surface was planed to remove altered cementum and flatten it to permit a more intimate
      adaptation of the flap to the recipient bed. Semilunar incision following the curvature of
      the free gingival margin is made with No. 15 blade. The incision should curve apically far
      enough mid-facially to ensure that the apical part of the flap rests on bone after it is
      brought down to cover the exposed root. The incision should end into the papilla on each end
      of the tooth,but not all the way to the tip of the papilla. At least 2 mm must be left on
      either side of the flap (Fig.1-B), since this is the main source of blood supply. Later a
      sulcular split thickness incision is made.Using microsurgical blades (Lance tip blade 150 and
      Slit blade 2.8mm), a split thickness dissection is made from the initial incision line
      coronally. This is connected with an intra-sulcular incision, made mid-facially. The
      mid-facial tissue is then coronally positioned to the CEJ, or to the height of the adjacent
      papilla. The tissue is held in place with moist gauze against the tooth for 5 min then
      sutured with sling sutures using vicryl 5-0 (Fig.1-C). A thin layer of periodontal dressing
      (Coepack®) was applied over the site.

      SCPF+FGG (Test Group): Combined technique of Semilunar coronally positioned flap with Free
      gingival graft:

      After initial semilunar coronally positioned flap similar to SCPF group, the denuded area
      between the initial incision and the apical margin of the coronally positioned flap is the
      recipient site for the free gingival graft. A tin foil was placed on the recipient site and a
      template was prepared. The tin foil template was then placed over the palatal area and an
      incision was made all round the template to a depth of 2 mm and 1 mm larger than the outline
      of the tin foil to accommodate graft shrinkage. The harvested graft (Fig.1-D) was placed on
      to gauze soaked in normal saline solution. The underside of the graft was inspected
      overhanging tissues. The donor area was then closed with continuous sutures.The graft was
      adapted to the recipient site and immobilized by holding sutures using 5-0 vicryl suture
      (Fig.1-E). The graft was firmly held in place using digital pressure for 5 minutes to reduce
      the dead space, permit fibrin clot formation and prevent bleeding as it may result in a
      hematoma under the graft and cause subsequent necrosis. Periodontal dressing (Coepack®) was
      placed at the donor site and over the graft.

      Post operative care:

      The patients were advised not to brush the treated site for 2 weeks and instead 0.2%
      chlorhexidine rinse was prescribed for 4 weeks.Antibiotics and analgesics were administered
      as needed.Then they were examined after 2 weeks to assess healing and removal of sutures.
      Then after, the patients were instructed to gently brush around the surgical site with an
      ultra soft toothbrush using roll technique. Routine oral health care was used in other sites.
      Subjects were enrolled in a follow up program at 1, 3, 6 and 12 months after surgery for the
      rest of the study. Complete plaque elimination was performed every 3 months.

      Stastical Analysis:

      Statistical analysis was performed using a commercially available software program (SPSS
      version 16.0;SPSS, Chicago, IL, USA).Repeated Measure ANOVA was used to investigate whether
      data were normally distributed or not. The Wilcoxonsigned-ranks test was used for intragroup
      comparisons and Mann-Whitney U non-parametric test for intergroup comparisons of the clinical
      findings.
    

Intervention name(s): semilunar coronally positioned flap with free gingival graft; semilunar coronally positioned flap alone
Intervention type(s): Procedure; Procedure
Other intervention name(s): combination technique; pedicle flap
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: aesthetics; root coverage; semilunar coronally positioned flap; free gingival graft; width of keratinised tissue