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ORIGINAL ARTICLE
Year : 2011  |  Volume : 15  |  Issue : 4  |  Page : 376-382  

Evaluation of gingival fiber retention technique on the treatment of patients with chronic periodontitis: A comparative study


1 Department of Periodontics, Manav Rachna Dental College, Faridabad, India
2 Department of Periodontics, National Dental College, Derabassi, India
3 Department of Paedodontics, Manav Rachna Dental College, Faridabad, India

Date of Submission10-Jan-2011
Date of Acceptance30-Nov-2011
Date of Web Publication2-Feb-2012

Correspondence Address:
Pooja Palwankar
Department of Periodontics, Manav Rachna Dental College, Faridabad, Haryana 122 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-124X.92574

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   Abstract 

The destructive action of the chronic periodontitis on the periodontal tissues has provided a continuous challenge to the dental profession to develop better methods to achieve repair of the recession regions and even regeneration of post periodontal tissues. Aims: To assess the effect of periodontal muco-periostal flap surgery with gingival fiber retention technique on minimizing the post surgical recession. Materials and Methods: The sample for the study comprised of 20 patients. The criteria for selection included patients with moderate periodontitis, with minimum recession in the anterior teeth, with adequate width of the attached gingiva, and with no traumatic occlusion. Periodontal muco-periosteal flap surgery with gingival fiber retention technique was done in the experimental site with internal bevel incision, and in control site, muco periosteal flap surgery with crevicular incision was done. Thereafter, observation period was of one week, four weeks, and eight weeks were done for both the sites. Statistical Analysis Used: The results were subjected to statistical analysis using student's t`-test. Results: The result of this study suggests that the periodontal flap surgery with gingival fiber retention technique has a beneficial effect on the anterior teeth, as it maintains the esthetics, recontours the gingiva with minimal recession. The area of recession was more on the control site as compared to experimental site at 4 weeks, 8 weeks and 12 weeks. Conclusions: Gingival fiber retention technique showed less post-surgical recession and also there was fall in values of plaque index, gingival index, and periodontal index scores, throughout the study.

Keywords: Connective tissues, gingival fibers, the attachment apparatus


How to cite this article:
Palwankar P, Dhaliwal J, Mehta V. Evaluation of gingival fiber retention technique on the treatment of patients with chronic periodontitis: A comparative study. J Indian Soc Periodontol 2011;15:376-82

How to cite this URL:
Palwankar P, Dhaliwal J, Mehta V. Evaluation of gingival fiber retention technique on the treatment of patients with chronic periodontitis: A comparative study. J Indian Soc Periodontol [serial online] 2011 [cited 2019 Dec 7];15:376-82. Available from: http://www.jisponline.com/text.asp?2011/15/4/376/92574


   Introduction Top


Inter proximal areas up to the cemento-enamel junction and contact areas of the teeth. Many authors have demonstrated that by retaining the gingival fiber apparatus and its cemental insertion on the root surface, the collagen fibers from the healing margin of the flap will unite or fuse with the retained gingival fiber unit; thus giving rise to minimal post-surgical recession. [1],[2],[3],[4],[5] Periodontitis is the most common type of periodontal disease and it usually results from the extension of inflammatory process initiated in the gingival spreading to deeper supporting periodontal structures. [6] The goals of periodontal therapy are to eliminate the pathology, and to change the environment, so that the healing restores the tissues to a state of health identical to that present prior to the disease. [7]

These objectives of periodontal therapy can be attained by preserving further destruction of attachment apparatus, and if possible, promoting the reconstruction of the lost attachment. [8],[5]

To treat periodontal disease, one must know its mechanism part by part; one must provide insights into the etiological factors, subsequent tissue damage, and the potential for tissue repair. [9]

Dentistry traditionally has been concerned with the physical health of the oral cavity, but contemporary thinking on oral health means not only freedom from pathological conditions but a concern for the esthetic appearance of the dentition as well. [10]

Conflicting points of view concerning the etiology of gingival recession are evident in the literature, when the gingival recession violates, the cosmetic consciousness of individual, it is no less of a problem than sensitivity. [11] The detection and correct causative agent is important, so as to minimize the gingival recession. [11]

As all types of surgical periodontal therapy gave rise to the post-surgical recession, there was, therefore, a need for a surgical procedure which will produce minimum or no post surgical gingival recession. Hiatt [12] introduced muco-periosteal flap surgery with full gingival fiber retention technique. He stated that when flap is re-adapted on root surfaces with full gingival fiber retention, the proliferation and down growth of the epithelial attachment does not occur, thus giving rise to minimal post-surgical recession.

The gingival fiber retention technique is used to establish the healthy gingival unit in the most coronal position possible on the root of the teeth. [12]

In the present clinical study, therefore keeping all the pertinent points in mind, an attempt has been planned with the aim to evaluate clinically the efficacy of this new technique introduced by Leslie Levine (1972) as periodontal flap surgery with gingival fiber retention technique in treating suprabony periodontal pockets and minimizing postsurgical recession in anterior teeth. [2]

Therefore, the present clinical study is aimed at evaluating clinically the efficacy of periodontal flap surgery with gingival fiber retention technique with respect to:

  1. its efficacy in elimination of periodontal pocket
  2. its efficacy in reducing post-surgical gingival recession
  3. its effect on the maintenance of oral hygiene of the affected areas

   Materials and Methods Top


Sample for the present study comprised of 20 patients from both sexes, 16 male and 4 female in the age-group of 20-40 years, were selected from outpatient department of periodontics. All the selected patients were physically healthy and presented no detectable clinical signs and symptoms of any systemic diseases.

Following are the criteria used for the selection of the patients:

  1. Patients with moderate periodontitis without observable radiographic evidence of vertical or angular bone loss
  2. Each segment selected for treatment had minimum recession and had adequate width of attached gingiva
  3. Patients showing severe malocclusion leading to traumatic bite, but that could not be corrected by occlusal adjustment procedures were rejected
  4. In each patient, at least six teeth were included in the surgery
  5. Enthusiastic, well motivated, and co-operative patients, who could visit the hospital for frequent check-ups for evaluation of study for a period of at least three months, were selected.
Each of 20 patients selected according to the above criteria were explained about the entire procedure to be carried out as well as the purpose of the study. All the pertaining questions raised by the patients were answered to their satisfaction and a written consent was obtained from them. Patients visits were divided into four phases and following indices were repeated at every phase of treatment.

Phase - I

Pre-operative preparation of patient to get the tissues to a surgically manageable condition and following observations were repeated at every phase of treatment:

  1. Plaque index (Turesky's Modification of Quigley and Hein, plaque index), [6]
  2. Gingival index (Loe and silness) [6]
  3. Periodontal disease index (Ramfjord) [6]
  4. Clinical probing attachment level (in mm)
  5. Length of recession (in mm)
  6. Width of recession (in mm)
  7. Area of recession (in mm)

    (Evaluated at pre-operative, 1-week, 4-weeks, 8-weeks, and 12-weeks).
Above mentioned subjective and objective criteria were evaluated at 24- hrs and 1-week post surgically. The patients were called after a week for the surgical phase and were prescribed antibiotics and anti-inflammatory drugs to be taken one day prior to surgery.

Phase - II

After about a week of completion of phase-I therapy [Figure 1], phase-II was carried out. The surgical site was divided into two halves.

  1. Distal of right canine to the mesial of right central incisor
  2. Distal of left canine to the mesial of left central incisor.
Figure 1: Preoperative photograph of the upper anterior region

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Either in maxilla or mandible of permanent dentition. Both the surgical procedures were carried out in the same patient and at the same sitting to avoid biological variability. They were done under local anesthesia of 2% lignocaine hydrochloride with 1:80,000 adrenaline.

On the experimental site

An internally bevelled labial incision was made approximately 2 mm apical to the free gingival margin. If required, vertical or oblique releasing incisions were made. A muco-periosteal flap is then reflected with blunt periosteal elevator [Figure 2]. Excision of detached gingiva coronal to attached epithelial cuff was done with delicacy and precision. With the surgical blade No.11, held parallel to gingival surface, the free gingival epithelium was gently dissected out. If osseous surgical recontouring procedure was necessary, it was done by conventional method using burs without causing damage to the collagen fibers present in the connective tissue left on the tooth surface [Figure 3]. The unhealthy granulation tissue from the inner mucosal surface of the flap and interproximal surface was curetted out gently. The specks of calculus present on the root surface were also removed. Then the area was irrigated with normal saline. The flap was co-opted as close as possible to the retained connective tissue on the teeth, without creating any tension on the flap by means of interrupted sutures [Figure 4].
Figure 2: Photograph of experimental and control site taken after reflection of mucoperiosteal flap

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Figure 3: Photograph of the experimental site after retaining gingival fibers

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Figure 4: Photograph of the experimental and control site after suturing the flap with interrupted sutures

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A periodontal dressing was placed over the operated area and was left in place for seven days. Patients were given necessary instructions and were advised to continue with the medication.

On the control site

A full thickness micro-periosted flap was reflected with the crevicular incision [Figure 2]. The muco-periosteal flap was reflected with blunt periosteal elevator. The root surface was then thoroughly scaled and planed. The unhealthy granulation tissue from the interproximal as well as from the inner mucosal surface of the flap was curetted [Figure 3]. Bone recontouring, if required, was carried out by conventional method using burs. Then, the surgical site was irrigated with normal saline. The flap was then sutured to its original position by means of interrupted sutures [Figure 4].

A periodontal dressing was placed over the operated area and was left in place for seven days. Patients were given necessary instructions and were advised to continue with the medication.

Phase - III

Patients were asked to report the next day after 24-hours and subjective and objective observations were recorded.

Phase - IV

The patients were recalled after one week, after performing the surgical procedure. Periodontal dressing and sutures were removed and also the evaluation of subjective and objection symptoms were carried out once again [Figure 5]. Patients were called for follow-up visits at the intervals of the 1, 4, 8, and 12 weeks [Figure 6], [Figure 7], [Figure 8], [Figure 9] and [Figure 10]. Subsequently, all the values of the data were subject to statistical analysis for comparative evaluation.
Figure 5: Postoperative photograph of the experimental and control site taken after removal of periodontal dressing and interrupted sutures i.e., one week after surgery

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Figure 6: Postoperative photograph of the experimental and control site taken four weeks after surgery

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Figure 7: Postoperative photograph of the experimental and control site taken eight weeks after surgery

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Figure 8: Postoperative photograph of the experimental and control site taken eight weeks after surgery, periodontal probe comparing the amount of recession on boththe sites

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Figure 9: Postoperative photograph of the experimental and control site taken twelve weeks after surgery, periodontal probe comparing the amount of recession on both the sites

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Figure 10: Postoperative photograph of the experimental and control site taken twelve weeks after surgery, William's graduated probe measuring the length of recession on the control site

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Statistical analysis

Means and standard deviation were estimated from the samples for each study group. Mean values were compared by the student's t-test for both experimental and control sites for all the factors. In the present study, P=0.05 was considered as the level of significance.


   Results Top


All the result of this study was obtained on a statistical note by comparing and contrasting certain parameters at various designated phases for experimental over control groups.

[Table 1] shows continuous decline in plaque index, gingival index, and periodontal disease index score for the entire duration of the study. The difference in the fall of plaque levels, gingival index scores, and periodontal disease index scores for the both groups is not statistically significant [Figure 11], [Figure 12] and [Figure 13]. There was significant gain in the clinical probing attachment level on the experimental as well as control sites during entire duration of the clinical study [Figure 14].
Figure 11: Plaque index (Tureskey's modification of Quigley and Hein) average value at different time intervals. Series1- Experimental values. Series2- Control values

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Figure 12: Gingival index (Loe and Silness) average value at different time intervals. Series 1 - Experimental values. Series 2 - Control values

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Figure 13: Periodontitis index (Ramfjord) average value at different time intervals. Series 1 - Experimental values. Series 2 - Control values

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Figure 14: Clinical probing attachment level (in mm) average value at different time intervals. Series 1 - Experimental values. Series 2 - Control values

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Table 1: Average plaque, gingival, periodontal index and clinical probing attachment level (mm)

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[Table 2] shows that there was increase in average width, length, and area of recession in experimental as well as control sites. There is significant increase in width, length, and the area of recession at four weeks post-surgically on the experimental and control sites as compared to their to their pre-operative level. There is also an increase in the average area of recession on experimental and control site at 4-weeks, but at 8 and 12-weeks, it remained steady [Figure 15], [Figure 16] and [Figure 17]. There is statically significant increase in area of recession on the control site as compared to their pre-operative levels. There is also an increase in the average area of recession on the experimental site, but it is not statistically significant to their pre-operative levels.
Figure 15: Width of recession (in mm) average value at different time intervals. Series 1 - Experimental values. Series 2 - Control values

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Figure 16: Length of recession (in mm) average value at different time intervals. Series 1 - Experimental values. Series 2 - Control values

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Figure 17: Area of recession (in mm) average value at different time intervals. Series 1 - Experimental values. Series 2- Control values

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Table 2: Average width, length, and area of recession (in mm)


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   Discussion Top


The goals of any therapy is to eliminate the pathology and to change the environment, so that healing response restores the tissues to a state of health, identical to that present prior to the disease. [7] This objective is obtained by preventing further destruction of the attachment apparatus, and if possible, promoting the reconstruction of the lost attachment. [5]

With the development of various techniques of periodontal therapy, it has naturally become important to look after proper healing and regeneration of the tissues. [13] This post-operative phase is as important as the surgical phase planned after suitable diagnostic and pre-operative considerations. [14]

The periodontists used to frequently avoid periodontal surgery in the anterior region for fear of post-surgical gingival recession, even if periodontal surgery was undertaken, the plastic masks colored like gingival tissue was fabricated and were inserted over the labial aspect of the remaining gingiva, filling in the wide contact areas of the teeth. [14]

Gingival fiber retention technique in the treatment of chronic periodontitis was introduced as early as in 1960 by Kohler and Ramfjord. [15] Ever since, there have been regular reports on the successful role of this technique in minimizing the post-surgical recession. [16],[17]

However, inspite of the scientific contributions in this regard, a critical appraisal is required by standardizing certain factors and projecting a predictable and an efficient technique in periodontal therapy.

In the present study, the clinical evaluation was carried out during the designed phases spread over a period of three months, and the results obtained were then evaluated statistically.

Healing was uneventful and the period of healing was identical for all surgical sites and the gingiva looked pink throughout with a normal appearance three to four weeks, post-surgery.

The soft tissue changes were same in both experimental and control sites. It was observed from the results that there was decline in plaque index, gingival index, and periodontal disease index scores, which could be attributed to the preparatory phase carried out before surgery and motivation of patient at every recall visit.

There was significant gain in the clinical probing attachment level on the experimental as well as control sites during entire duration of study. But, at four weeks, there was slightly more gain in attachment level on the experimental site as compared to control site. At 8 and 12 weeks, there was no statistical significant difference in the attachment level between experimental and control sites. The findings were similar to Kohler and Ramfjord [15] reported that the surgical mucoperiosteal flaps separating the gingiva from the teeth with retention of gingival fibers healed without any significant loss of periodontal attachment in all of the 20 cases examined.

From the results, it was observed that there was an increase in the area of recession on experimental as well as on the control sites. The increase in the area of recession on the experimental site was not statistically significant to their preoperative levels, whereas on the control site, the area of recession was statistically significant to their pre-operative level.

There was an increase in the average width, length, and area of recession at 4 weeks, on both the control and experimental sites, but at 8 weeks and 12 weeks, the average width, length and area of recession remained steady. These findings were similar to those reported by Levine and Stahl [1],[18],[19],[20] reported minimum post-surgical recession after three months at the site, where muco-periosteal flap surgery was done with retention of gingival fibers.

Another study conducted by Russo [21] showed that the same results, in addition, he reported the gingival contour to be esthetically pleasing after 12 weeks post surgically.

Hiatt and his associates, [12],[22],[23] reported 1-3 mm post surgical recession in the region where gingival fibers were not retained.

Extrapolating the results of previous workers and combining the findings of the present study, it may be hypothesized that gingival fiber retention technique is successful in treating anterior teeth with chronic periodontitis with minimum recession.


   Conclusion Top


From the analysis of the data, it was concluded that there was fall in values of plaque index, gingival index, and periodontal index scores throughout the study, thus indicating improvement in the oral hygiene status of the patients. The experimental site showed less post-surgical recession indicating clinical superiority of treatment over control site as far as recession is concerned.

Gingival fiber retention technique does not involve any additional surgical trauma to the patient and also does not require any special additional post-operative care. The esthetic results the gingival fiber retention technique offered was excellent as compared to control site.

The gingival fiber retention technique is simple, requires less working time if performed skilfully, thus offering excellent results.

 
   References Top

1.Levine HL, Stahl SS. Repair following periodontal flap surgery with the retention of gingival fibers. J Periodontol 1972;43:99-103.  Back to cited text no. 1
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2.Levine L, Stahl S. Periodontal flapsurgery with gingival fibre retention. J Periodontol 1972;43:91.  Back to cited text no. 2
    
3.Stahl SS, Slavkin HC, Yamada L, Levine S. Speculation about gingival repair. J Periodontol 1972;43:395-402.  Back to cited text no. 3
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4.Stahl SS. Gingival repair potential. J Oral Med 1976;31:104.  Back to cited text no. 4
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5.Stahl SS. Repair or regeneration following periodontal therapy. J Clin Periodontol 1979;6:389.  Back to cited text no. 5
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6.Carranza F. Glickman's Clinical Periodontology, 7th ed. Philadelphia: WB Saunders Company; 1990. p. 27,212.  Back to cited text no. 6
    
7.Card S, Caffesse R, Smith B. A historical perspective of current new attachment Procedures - a review of literature. J West Soc Periodontal Periodontal Abstr 1987;35:93.  Back to cited text no. 7
    
8.Abdullah F, Kon S, Ruben M. Biochemical approach to periodontal regeneration A review of literature. J West Soc Periodontal Periodontal Abstr 1988;36:53-61.  Back to cited text no. 8
    
9.Aleo JJ, Vandersall DC. Cementum - recent concepts related to periodontal disease therapy. J Dent Clin North Am 1980;10:627-50.  Back to cited text no. 9
    
10.Nash D. Professional ethics and esthetic dentistry. J Am Dent Assoc 1988;9:10.  Back to cited text no. 10
    
11.Gartell JR, Mathews DP. Gingival recession - The condition process and treatment Gingival recession - The condition process and treatment. J Dent Clin North Am 1976;20:199-213.  Back to cited text no. 11
    
12.Hiatt W, Stallard R, Butler Repair following mucoperiosteal flap surgery with full Gingival retention. J Periodontol 1968;38:11.  Back to cited text no. 12
    
13.Zander H. Goals of periodontal therapy. J Periodontol 1976;47:261.  Back to cited text no. 13
    
14.Beube F. Surgery in periodontal therapy, Disadvantages of surgical techniques. J Dent Clin North Am 1960;11:677.  Back to cited text no. 14
    
15.Kohler C, Ramfjord S. Healing of mucoperiosteal flaps. J Oral Surgery 1960;13:89.  Back to cited text no. 15
    
16.Nyman S, Karring T. The healing following implantation of periodontitis affected roots into gingival connective tissue. J Clin Periodontol 1980;7:394.  Back to cited text no. 16
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17.Sharpio M. A reattachment operation. J Dent Clin North Am 1960;3:15.  Back to cited text no. 17
    
18.Stahl S. Healing following simulated fiber retention procedures in Rats. J Periodontal 1977;48:67.  Back to cited text no. 18
    
19.Stahl SS. The nature of healthy and diseased root surfaces. J Periodontol 1981;52:156.  Back to cited text no. 19
    
20.Stahl SS. Speculations on periodontal attachment loss. J Clin Periodontol 1962;13:56.  Back to cited text no. 20
    
21.Russo N. Use of fibre retention procedure in treating the maxillary anterior region. J Periodontol 1981;52:208.  Back to cited text no. 21
    
22.Linghorne W, O`Connel D. Studies in regeneration and reattachment of supporting structures of the teeth. II- Regeneration of alveolar process. J Dent Res 1951;30:604.  Back to cited text no. 22
    
23.Melcher A. On the repair potential of periodontal tissues. J Periodontol 1976;47:256-60.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]
 
 
    Tables

  [Table 1], [Table 2]



 

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