|Year : 2017 | Volume
| Issue : 2 | Page : 88-97
Coverage of localized gingival recession using coronally advanced flap: A comparison between microsurgical and macrosurgical techniques
Sweta Kumari Singh1, Nikhil Sharma1, Sumit Malhotra2, Vidya Dodwad1, Shubhra Vaish1, Deepak Kumar Singh3
1 Department of Periodontics, I.T.S Dental College, Muradnagar, Uttar Pradesh, India
2 Department of Periodontics, Kalka Dental College, Meerut, Uttar Pradesh, India
3 Department of Oral Medicine and Radiology, SJM Dental College, Chitradurga, Karnataka, India
|Date of Web Publication||26-May-2017|
Sweta Kumari Singh
Sparkle Dental Clinic Chamber - 7, Vindhyachal Tower, Kaushambi, Ghaziabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: The aim of the present study was to compare the root coverage of localized gingival recession (GR) using modified coronally advanced flap (CAF) (Sanctis and Zucchelli's technique) and root conditioning 24% ethylenediaminetetraacetic acid (EDTA) when done under magnification and without magnification. Materials and Methods: A total of 20 sites were taken with Miller's Class I GR (10 in test and 10 in control). All clinical parameters were recorded at baseline, 1 month, and 3 months. CAF and root conditioning were done with 24% EDTA. Surgical procedure at test site was carried under magnification ×3.5 and at control site was done without magnification. Results: Plaque index, gingival index, clinical attachment level, probing depth, width of keratinized tissue (WKT), recession depth (RD), and recession width (RW) at baseline and 3 months were compared using Student's t- test. Mean WKT at baseline in control and test group was 4.22 ± 2.05 and 3.22 ± 1.09 which increased to 4.56 ± 1.59 and 4.50 ± 0.94, respectively, at 3 months. RD at baseline in control and test groups was 2.56 ± 0.53 and 2.67 ± 0.87 which reduced to 1.83 ± 0.71 and 1.22 ± 1.20, respectively. RW at baseline in control and test group was 3.56 ± 1.13 and 3.67 ± 0.50 which decreased to 3.06 ± 1.01 and 1.72 ± 1.39, respectively. All the clinical parameters were statistically not significant between control and test groups. Mean visual analog scale (VAS) at 7 days postoperatively in control and test groups was 1.78 ± 0.97 and 0.22 ± 0.44, respectively. The VAS scores were found to be significantly lower in the test group at both 3rd and 7th day postoperatively showing less pain in test group. Conclusion: Microsurgery offers less pain and enhanced outcomes when compared to traditional macrosurgery.
Keywords: 24% ethylenediaminetetraacetic acid, coronally advanced flap, microsurgery, visual analog scale
|How to cite this article:|
Singh SK, Sharma N, Malhotra S, Dodwad V, Vaish S, Singh DK. Coverage of localized gingival recession using coronally advanced flap: A comparison between microsurgical and macrosurgical techniques. Indian J Dent Sci 2017;9:88-97
|How to cite this URL:|
Singh SK, Sharma N, Malhotra S, Dodwad V, Vaish S, Singh DK. Coverage of localized gingival recession using coronally advanced flap: A comparison between microsurgical and macrosurgical techniques. Indian J Dent Sci [serial online] 2017 [cited 2018 Mar 19];9:88-97. Available from: http://www.ijds.in/text.asp?2017/9/2/88/207108
| Introduction|| |
The main goal of periodontal therapy is to improve periodontal health and thereby maintain a patient's functional dentition throughout his/her life. However, esthetics represents an inseparable part of today's oral therapy, and several procedures have been proposed to preserve or enhance patient esthetics.
Gingival recession (GR) is a term that designates the oral exposure of the root surface because of a displacement of the gingival margin apical to the cementoenamel junction (CEJ). Gingival anatomic factors, chronic trauma, periodontitis, and tooth alignment are the main conditions leading to these defects. GR may be of concern to the patient for a variety of reasons. In addition to root hypersensitivity, erosion, root caries, and aesthetic considerations may also come into play. The progression of recession defects warrants both the investigation of the etiologic factors and the consideration of therapeutic actions directed at minimizing the apical movement of the gingival margins.
Miller in 1983 proposed four classes of marginal GR based on the involvement of the periodontal tissues. Coronally positioned flap is one of the surgical options in the treatment of Miller's Class I and Class II GRs. During recent decades, different surgical procedures were proposed, and new techniques have been incorporated for single and multiple recession defects. Patient esthetic demands have become more stringent; thus, root coverage procedures should provide soft tissue anatomy comparable to and indistinguishable from adjacent tissue. To achieve this goal, mucogingival techniques used to treat GR defects have improved. Free gingival grafts, although effective in gaining root coverage, lack the esthetic aspect of the treatment.
To regenerate periodontal tissue, new connective tissue attachments to the root surfaces must first be achieved. This process is controlled by fibroblast migration and attachment to root surface collagen fibrils. Therefore, chemical conditioning agents are often used to help remove root surface impurities including minerals and cytotoxic materials derived from bacterial products., The demineralized root surface may also serve as a reservoir and retention site for biologically active extracellular matrix proteins and growth factors that could positively affect the wound healing environment. Despite differences in clinical applications, ethylenediaminetetraacetic acid (EDTA), tetracycline, and citric acid have all been used as conditioning agents., EDTA works at neutral pH. It is a chelating agent that could enhance the attachment of connective tissue to the root surface by exposing collagen and enhance root covering by causing lesser damage to the tissue.
Dentistry has borrowed microscopic surgery from medicine, which dates back to 1922. Periodontal microsurgery shares the attributes with medical microsurgery that will positively influence its professional acceptance. These include improved cosmetic results, increased predictability, less pain, and higher patient acceptance. Periodontal microsurgery does not compete with conventional periodontal surgery. It is an evolution of surgical techniques to permit reduced trauma. Its methodology improves existing surgical practice and introduces the possibility for better patient care to periodontics. It can be considered as a refinement of basic surgical techniques made possible by the improvement in visual acuity gained with the use of the surgical microscope or loupes.
Thus, the present study was undertaken to compare the root coverage of localized GR using modified coronally advanced flap (CAF) (de Sanctis and Zucchelli's technique in 2007) and root conditioning with 24% EDTA, when done under magnification and without magnification.
| Materials and Methods|| |
The study conducted was a randomized controlled clinical trial of 3-month duration. A total of twenty sites were taken with Miller's Class I and II GR.
Systemically healthy subjects, nonsmokers, participants who were ≥18-year-old, participants who were willing to comply with all the study-related procedures, and signed the informed consent form Miller's Class I or II recession defects, on maxillary or mandibular incisors, canines, or premolars were included in the study.
Participants who had undergone previous surgical attempt to correct GR in the past 6 months.
Participants with supraerupted tooth who had taken antibiotics in the past 3 months Patients on immunosuppressant drugs and/or patients on any medication known to cause gingival enlargement, and patients with active infectious diseases (e.g., hepatitis, tuberculosis, and HIV infection).
Participants with active caries or restoration on the root surface of the concerned tooth and pregnant and lactating mothers were excluded from the study.
Following procedures were performed before the surgery:
Oral hygiene instructions, full mouth scaling and root planing, and measurement of clinical parameters.
The following clinical parameters were recorded for each site at baseline as well as at 1and 3 months for the test and control group: plaque index (PI), gingival index  (GI), pocket probing depth (PD), and clinical attachment level (CAL). The measurement was made from the CEJ to the most apical part of the sulcus; width of keratinized tissue (WKT) was measured at the mid-buccal point from the mucogingival junction (MGJ) to the free gingival margin. The MGJ was determined by the rollover technique, recession height (RH) was measured at the mid-buccal aspect of the tooth to CEJ, and recession width (RW) was measured from one border of the recession to another at the CEJ.
Visual analog scale (VAS) was used to evaluate patient comfort in the two groups postsurgically. The participants were asked to place a mark on a 10 mm – long line on the VAS labeled from “no pain” (0) to “intolerable pain” (10) postoperatively on 3rd and 7th day of the surgery.
All the measurements were recorded using a University of North Carolina probe at baseline, 1st and 3rd month of the study.
All the results were statistically analyzed by Student's t-test, one-way ANOVA, and post hoc test (Bonferroni multiple comparison test).
The surgical technique employed was as illustrated by de Sanctis and Zucchelli. Surgical procedure at test site was carried under magnification ×3.5 [Figure 1] and at control site was done without magnification.
Local anesthesia of 2% lidocaine with 1:200000 epinephrine was given before the procedure. Two horizontal beveled incisions (3 mm in length), mesial and distal to the recession defect located at a distance from the tip of the anatomical papillae equal to the depth of the recession. Two beveled oblique incisions coming from the two horizontal incisions and extending to the alveolar mucosa [Figure 2].
The resulting trapezoidal flap was elevated with a split-full-split approach in the coronal–apical direction. The surgical papillae comprised between the horizontal incisions and sulcular area apical to the root exposure was elevated split thickness keeping the blade parallel to the root, and the soft tissue apical to the root exposure was elevated full thickness proceeding in the apical direction up to exposing 3–4 mm of bone apical to the bone dehiscence. Apical to bone exposure, flap elevation was continued to split thickness and was finished when possible to move the flap passively in the coronal direction. The root surface was mechanically treated with the use of curettes.
The facial soft tissue of the anatomic interdental papillae coronal to the horizontal incisions was de-epithelialized. The area was conditioned with 24% EDTA gel for 2 min to remove the smear layer and then copiously rinsed with sterile saline to obtain a surface devoid of organic debris and gently air dried [Figure 3]. Flaps were then coronally repositioned, with margins located on enamel and secured in position using interrupted sutures, and a periodontal pack was applied [Figure 4] and [Figure 5].
|Figure 3: Flap reflected and root conditioning done with 24% ethylenediaminetetraacetic acid gel.|
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Formulation of 24% ethylenediaminetetraacetic acid gel
To prepare 100 ml of EDTA solution, weigh 2.4 g EDTA (M. Wt. 372.24), dissolve it in 80 ml double distilled water, stir vigorously on a magnetic stirrer, and add NaOH pellet or solution (2N) simultaneously (~2 g NaOH pellet is required to adjust the pH 8.0). Note: To dissolve the EDTA completely, solution pH 8.0 is required.
To prepare gel, a weighed amount of sodium carboxymethylcellulose is added and heated up for 30 s to make it dissolved.
Patient was given routine postsurgical instructions:
Medication included antibiotics for infection control, analgesic for pain relief, and10 ml of 0.2% chlorhexidine mouthwash BD for 6 weeks.
Patients were called at the end of 1 week for suture removal. Participants were instructed to initiate mechanical oral hygiene at the end of 3rd week. Clinical measurements were repeated at 1- and 3-month intervals [Figure 6],[Figure 7],[Figure 8],[Figure 9].
The statistical analysis was done using SPSS (Statistical Package for the Social Sciences) Version 15.0 (SPSS Inc., Chicago, IL) statistical Analysis Software.
The values are given mean ± standard deviation (SD).
An unpaired t-test was used to evaluate statistical differences between the test and control groups (intergroup comparison).
A one-way ANOVA, post hoc-Bonferroni multiple test, and paired t-test were used to evaluate the statistical significance of the differences between baseline, 1 month, and 3 months in test and control groups (intragroup comparison).
| Results|| |
Independent t-test was used to compare the clinical parameters between the groups. It was found that none of the clinical parameters were statistically different between the control and test groups at the baseline, 1 month, and 3 months duration except the VAS scores [Table 1],[Table 2],[Table 3] and [Graph 1],[Graph 2],[Graph 3],[Graph 4],[Graph 5],[Graph 6],[Graph 7].
|Table 1: Comparison of clinical parameters (unpaired t-test) between groups at the baseline|
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|Table 2: Comparison of clinical parameters (unpaired t-test) between the groups at 1 month|
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|Table 3: Comparison of clinical parameters (unpaired t-test) between the groups at 3 months|
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The mean VAS at 3 days postoperatively in control and test group was 4.67 ± 1.00 and 0.78 ± 0.83, respectively. The mean VAS at 7 days postoperatively in control and test group was 1.78 ± 0.97 and 0.22 ± 0.44, respectively [Graph 8].
The mean VAS scores were found to be significantly lower in the test group at both 3rd and 7th day postoperatively [Table 4].
|Table 4: Comparison of visual analog scale (unpaired t-test) between both the groups|
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The mean differences for RW, RH, PD, CAL, WKT, PI, and GI were compared within groups at baseline, 1 month, and 3 months using the ANOVA test [Table 5],[Table 6],[Table 7],[Table 8],[Table 9],[Table 10],[Table 11].
The mean differences for VAS of pain at 3 days and 7 days postoperatively within the groups were compared by paired t-test [Table 12].
|Table 12: Comparison of visual analog scale (paired t-test) within the groups at various time intervals|
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Mean GI reduced significantly (P < 0.05) at 1 month and 3 months only in test group [Table 5].
Mean PI was found to be lower test group as well as in the control group but statistically not different at 1 month and 3 months [Table 6].
Mean CAL and recession depth (RD) reduced significantly within both control and test groups after 1 month and 3 months [Table 7],[Table 8],[Table 9],[Table 10],[Table 11].
Mean PD reduced significantly in the control group at 3 months although, in test group, PD remained stable at 3 months but were statistically indifferent [Table 8].
Whereas significant difference was found only within test group with regard to mean WKT, RW, and mean WKT increased significantly in test group at 3 months and mean reduction in RW was seen at 3 months [Table 9],[Table 10],[Table 11].
Bonferroni test was also applied to compare clinical parameters at different time intervals within the groups [Table 13].
|Table 13: Comparison of clinical parameters (post hoc test - Bonferroni multiple comparison test) within the groups at various time intervals|
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Mean GI reduced significantly at 3 months in the test after comparison with mean scores at 1 month.
None of the other values of PI and GI were significantly different in the groups between various time intervals.
Mean CAL reduced significantly (P < 0.05) in both the groups from baseline to 1 month. Mean CAL was also reduced significantly in test group from baseline to 3 months.
Mean PD reduced significantly in control group from 1 month to 3 months, but it got reduced and remained stable in test than in control group after 3 months.
Mean WKT increased in test group in all the intervals but were statistically indifferent (P > 0.05).
Mean RD and RW reduced significantly in test group from baseline to 1 month and baseline to 3 months, whereas in the control group, none of the values of RD and RW were significantly different between various time intervals.
Mean VAS reduced significantly from 3 days to 7 days postoperatively in control group, whereas VAS was not statistically significant in test group but was lower at 7 days postoperatively, thus showing that the pain was less in test group when compared to control group [Table 12].
| Discussion|| |
In the current practice of periodontics, clinicians are faced with the challenge of not only addressing biological and functional problems present in the periodontium but also providing therapy that results in acceptable esthetics. One of the surgical procedures employed for the root coverage is CAF given by Allen and Miller in 1989. The CAF is a root coverage surgery that does not involve a palatal donor site, and it was demonstrated to be a safe and predictable approach. In patients with high esthetic expectations, the CAF is the first choice when there is adequate keratinized tissue apical to the root exposure. With this approach, the soft tissue used to cover the root exposure is similar in color, texture, and thickness to that originally present at the buccal aspect of the tooth with the recession defect; thus, the esthetic result is more satisfactory.
In this present study, the surgical technique employed was as illustrated by de Sanctis and Zucchelli  with a modification of the surgical procedure at test site was carried under magnification ×3.5 and at control site was done without magnification. Two horizontal beveled incisions (3 mm in length), mesial and distal to the recession defect located at a distance from the tip of the anatomical papillae equal to the depth of the recession. Two beveled oblique incisions coming from the two horizontal incisions and extending to the alveolar mucosa. The resulting trapezoidal flap was elevated with a split-full-split approach in the coronal–apical direction. de Sanctis and Zucchelli  suggested that the split-thickness elevation at the level of the surgical papilla guarantees anchorage and blood supply in the interproximal areas mesial and distal to the root exposure; the full-thickness portion, by including the periosteum, confers more thickness and thus better opportunity to achieve root coverage.
Periodontitis-affected root surfaces are demineralized following mechanical instrumentation, and the resulting surface favors both the attachment of fibroblasts  and new connective tissue attachment. Register and Burdick  evaluated various acids such as hydrochloric, lactic, citric, phosphoric, trichloroacetic, and formic acid for their potential to promote new connective tissue attachment. Citric acid was found to have a negative effect on wound healing. EDTA buffered at neutral pH has recently been suggested for the use in periodontal regeneration. EDTA also showed enhanced wound healing as compared to citric acid. Kassab et al. hypothesized that root conditioning with neutral pH 24% EDTA would improve vertical RD, root surface coverage, pocket depth, and CALs. Modica et al. reported that EMD +24% EDTA did not show significant improvement in clinical outcomes of recession defects treated with CAF.
Roccuzzo et al. reviewed several systemic reviews and stated that the use of a barrier membrane or connective tissue, together with a CAF, do not give better results than CAF alone when root coverage is considered.
The introduction of microsurgery has helped the periodontist in treating the patient in a conservative manner using enhanced visibility of surgical field and minimizing surgical wounds to achieve a favorable treatment outcome. In broader sense, microsurgery implies an extension of surgical principles by which gentle handling of tissue and exceedingly accurate approximation of the wound edges is of paramount importance. Previous studies have shown the utility of surgical microscope to support regenerative procedures for deep infrabony with EMPs or access flap surgery for shallow-moderate infrabony defects.
The purpose of the present study was to evaluate the benefits of using surgical loupes for treatment of Miller's Class I and II recessions with CAF along with root conditioning with 24% EDTA. The results found with macrosurgical and microsurgical approach were satisfactory. Clinically, better outcome was seen in test group, but the results were not statistically significant between the groups. The results of the test group were also similar to those reported by Burkhardt and Lang  who used microscope to treat GR and found mean root coverage of range from 86% to 98%.
In the present study, there was no significant change in PI and GI between test and control groups. However, within test group, both PI and GI improved significantly from baseline to 3 months [Graph 1] and [Graph 2]. This is in agreement with the study by Adibrad et al., greater increase in WKT in the group which would enhance plaque removal around the gingival margin and aid subjects to maintain good oral hygiene in a proficient manner. This was not in accordance with the study by Miyasato et al. who failed to support the concept of a required minimum dimension of gingiva.
In the present study, the mean CAL at baseline in control and test group was 3.00 ± 0.33 mm (mean + SD) and 3.33 ± 1.23 mm, respectively. The mean CAL at 3 months in control group was 2.22 ± 0.83 mm and in test group was 1.39 ± 1.22 mm. The mean WKT at baseline for control and test group was 4.22 ± 2.05 mm and 3.22 ± 1.09 mm, respectively. The mean WKT at 3 months in control group was 4.56 ± 1.59 mm and in test group was 4.50 ± 0.94 mm [Graph 3] and [Graph 5]Andrade et al. compared the macrosurgical and microsurgical techniques and observed statistically significant gain in WKT. After 6 months, they found that there was no statistically significant difference between the techniques regarding root coverage. These results were contradictory to the findings of the present study. The increase in WKT after coronally positioned flap in their study ascribed to granulation tissue originating from the periodontal ligament and to a tendency of the mucogingival line to regain its original position.
The successful results in terms of root coverage achieved in the present study were associated with a clinically significant average increase in keratinized tissue height; thus, the gain in clinical attachment was well maintained during the observation period. Similarly, a study by Latha et al. who evaluated the success and predictability of a rotated papillary pedicle graft in combination with the CAF using surgical loupe (×2.5 magnification) for the treatment of Miller's Class I GR. There was no postoperative morbidity from where the graft was harvested at the end of the study period.
In the present study, the mean PD at baseline in control and test group was 0.78 ± 0.44 mm and 0.78 ± 0.44 mm, respectively. At 3 months, the mean PD in control group was 0.67 ± 0.50 mm and in test group was 0.44 ± 0.53 mm which had reduced in both the groups, respectively, but the difference was not statistically significant [Graph 4]. These findings were also observed by Bittencourt et al. who showed that PD remained stable at 3 years. Our present study was not in accordance with the study by Andrade et al. where PD was stable in both the groups at 6 months.
In the present study, the mean RDs at baseline in control and test groups were 2.56 ± 0.53 mm and 2.67 ± 0.87 mm, respectively. At 3 months, the mean RD reduction was 1.83 ± 0.71 mm in control group and was 1.22 ± 1.20 mm in test group [Graph 6]. Reduction in RD was statistically significant within both the groups, which goes in accordance with studies done by Francetti et al. who used magnification and showed better results in terms of success and predictability compared to conventional technique. They had reported a reduction of RD at 12 months from 3.17 ± 1.01 mm to 0.55 ± 0.69 mm when compared to control group which showed a reduction from 3.38 ± 1.11 mm to 0.73 ± 0.75 mm. The mean root coverage was 86% in test group and 78% in control group. However, our study was not in accordance with the study by Bittencourt et al. who showed average percentages of root coverage for test and control treatments, after 12 months, were 98.0% and 88.3%, respectively. For all parameters except RH, there was an improvement in the final examination but without difference between treatments.
Within the limits of this study, macrosurgical and microsurgical techniques provided a statistically significant reduction in RD and RW, as also observed in a study by Latha et al. and Francetti et al. [Graph 6] and [Graph 7].
In the present study, mean VAS scores at 3 days postoperatively in control and test group were 4.67 ± 1.00 and 0.78 ± 0.83, respectively. At 7th day postoperative, the mean VAS scores in control and test groups were 1.78 ± 0.97 and 0.22 ± 0.44, respectively. The mean VAS scores were significantly higher in control group at both the intervals showing that the pain perceived was more in the control group than the test group. These findings are also in accordance with the study by Francetti et al. Tibbetts found that microsurgery offers less postoperative pain, discomfort, and better healing because of finer sutures and instruments used in it  [Graph 8].
Microsurgery represents an amplification of universally recognized surgical principles, in which gentle handling of soft and hard tissues and extremely accurate wound closure are made possible through magnification, allowing for well-planned and precisely executed surgical procedures. Loupes are less expensive and easy to use. They are also less cumbersome in the operating field and less likely to breech a clean operating field, but it cannot be compared with the efficiency given by microscope in terms of comfort, versatility, and increased visual acuity. As a treatment philosophy, the use of microsurgery encourages improvement of motor skills, thereby enhancing surgical ability, passive wound closure with exact primary apposition of the wound edges, and reduced trauma at the surgical site. The choice of approaches must be based on the treatment outcomes, logistics, cost, and patient- centered parameters.
Regarding the advantage of periodontal microsurgery, more number of studies with long-term follow-up is required to be carried out. The smaller sample size and short follow-up period are the major limitations of the present study. Therefore, it would be desirable to carry out a study with a larger sample size and a longer follow-up. Histological studies should also be carried out to find the type of attachment on the root surface.
| Conclusion|| |
Both approaches are capable of producing root coverage. However, microsurgery offered less postoperative pain and discomfort when compared to macrosurgical approach. The variable of the study was the use of surgical loupes, microsurgical instruments, and microsurgical suture material in the test group, which resulted better wound stabilization and adaptation of the flaps. The choice of microsugical or macrosurgical procedures must be based on both the treatment outcomes, logistics, cost, and patient-centered parameters. Future longitudinal studies are indicated with different microsurgical techniques to evaluate the long-term stability of the root coverage procedures.
Financial support and sponsorship
3.5X loupes from Amdent (Ambala) and 24% EDTA gel from Department of Pharmacy, I.T.S Dental College, Muradnagar, Uttar Pradesh, India.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13]