|Year : 2014 | Volume
| Issue : 3 | Page : 326-330
A comparison between connective tissue grafts combined with either double pedicle grafts or coronally positioned pedicle grafts: A clinical study
Sunil Pendor1, Vidya Baliga1, Manohar L. Bhongade1, Viral Turakia2, Tony Shori3
1 Department of Periodontics, Sharad Pawar Dental College and Hospital, Sawangi (M), Wardha, Maharashtra, India
2 Department of Periodontics, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
3 Department of Periodontics, Vidya Shikshan Prasarak Mandal Dental College and Hospital, Nagpur, Maharashtra, India
|Date of Submission||22-Jun-2013|
|Date of Acceptance||09-Nov-2013|
|Date of Web Publication||17-Jun-2014|
Department of Periodontics, Sharad Pawar Dental College and Hospital, Sawangi (M), Wardha 442 004, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Various surgical techniques have been proposed for treating gingival recession. This randomized clinical study compared the effectiveness of using a sub-epithelial connective tissue graft (SCTG) combined with an overlying double pedical graft (DPG) or a coronally positioned flap (CPF) in the treatment of isolated gingival recession. Materials and Methods: A total of 20, healthy, non-smoking subjects with single Miller's Class I or Class II recession defects were selected. The defects, at least 3.0 mm deep, were randomly assigned to the test (DPG + SCTG) or control group (CPF + SCTG). Gingival recession (REC), probing pocket depth (PPD), clinical attachment level (CAL), width of keratinized gingival tissue (WKG), plaque index and papillary bleeding index were assessed at baseline and 6 months post-operatively. Results: Recession depth was significantly reduced 6 months post-operatively (P < 0.05) for both groups. Mean root coverage was 88% and 84% in the test and control groups, respectively. There were no significant differences between the two groups in REC, PPD, CAL, or WKG at baseline. However, at 6 months post-operatively, there were statistically significant changes in REC, CAL and WKG in favor of the test group (P < 0.05) from the baseline, but the comparison between the two was not statistically significant. The percentage of teeth with complete root coverage was greater in the test group when compared to the control group, but the results were not statistically significant. Conclusions: The results indicate that both surgical approaches are effective in addressing root coverage. Furthermore, when an increase in keratinized tissue width is a desired outcome, both the treatment modalities have shown comparable outcomes.
Keywords: Connective tissue graft, coronally positioned flap, double pedicle, recession, root coverage
|How to cite this article:|
Pendor S, Baliga V, Bhongade ML, Turakia V, Shori T. A comparison between connective tissue grafts combined with either double pedicle grafts or coronally positioned pedicle grafts: A clinical study. J Indian Soc Periodontol 2014;18:326-30
|How to cite this URL:|
Pendor S, Baliga V, Bhongade ML, Turakia V, Shori T. A comparison between connective tissue grafts combined with either double pedicle grafts or coronally positioned pedicle grafts: A clinical study. J Indian Soc Periodontol [serial online] 2014 [cited 2019 Jul 21];18:326-30. Available from: http://www.jisponline.com/text.asp?2014/18/3/326/134570
| Introduction|| |
Gingival recession is a clinical condition frequently seen in the general population ,, and may result in esthetically unfavorable effects,  compromised plaque control, increased susceptibility to root caries,  and dentin hypersensitivity.  At the present time, five groups of procedures have been shown in clinical studies to achieve predictable root coverage with a single surgical procedure: Pedicle grafts, free gingival grafts, guided tissue regeneration, acellular dermal matrix grafts, and connective tissue (CT) grafts combined with pedicle grafts (sub-epithelial grafts). ,
Studies have stated that the sub-epithelial connective tissue graft (SCTG) has not only the highest percentage of mean root coverage but also the least variability. , In addition, the World Workshop review of the various studies that used a sub-epithelial graft, the mean root coverage in all studies was 89.3%. 
Among various factors affecting root coverage, it has been suggested that the type of pedicle used to cover the CT graft could have an effect on the results. In a study comparing two pedicle grafts used to cover the CT, successful root coverage was obtained with both coronally positioned flap (CPF) as well as double pedicle graft (DPG). In addition, a larger increase in the amount of keratinized tissue was seen when the overlying pedicle was a double pedicle. 
Though several studies have reported the effectiveness of DPG ,,,, and CPF , in combination with CT, only one study so far has compared the two techniques.  Therefore, the present randomized, controlled, clinical study was undertaken to compare the effectiveness of double pedicle flap and CPF over the SCTG in the treatment of isolated gingival recession defect.
| Materials and methods|| |
A total of 20 systemically healthy patients (14 males and 6 females) with labial or buccal recession defects >3 mm, with the loss of clinical attachment level (CAL) >4 mm and having equal amount of keratinized gingiva apical to the recession on more than one adjacent teeth were selected among those seeking care at the Periodontal Department of Sharad Pawar Dental College and Hospital, Wardha. Recession classified as either Miller's Class I or Class II with radiographic evidence of sufficient interdental bone (distance between the crestal bone and cementoenamel junction (CEJ) as <2 mm) were selected. The patient population ranged in age from 25 to 46 years (mean 30.4 years). Patients agreed to participate in the study and gave their written informed consent.
Patients using tobacco in any form, uncooperative patients, with unacceptable oral hygiene after Phase I therapy and with a history of periodontal surgery were excluded from the study. Information concerning dietary status, systemic background and mouth cleaning habits, gingival and periodontal status along with other routine clinical data were recorded in a specially designed chart.
Full mouth plaque score was obtained by using Turesky et al. modification of Quigley-Hein (1970) plaque index (PI),  which revealed the presence of plaque. Full mouth bleeding score was obtained by using papillary bleeding index (PBI),  and the two indices were recorded at baseline, 3 months and 6 months after surgery. Plaque score for the tooth was obtained by dividing the sum of the scores per tooth by two; a plaque score per person was obtained by dividing the total plaque score by the number of teeth examined. PBI was obtained by dividing the total papilla bleeding scores by the number of teeth examined.
The study was a randomized, controlled, clinical study performed over a period of 6 months. A total of 20 Millers Class I recession defects in 20 patients (one in each) were included in this study. The selected recession defects were randomly divided by a coin flip to test (n = 10) and control (n = 10) group. Power analysis indicated a statistical power of 85% for a sample of 20. The test group (Male:Female, 5:5) was treated with CT graft in combination with double pedicle graft while the control group (Male:Female, 9:1) was treated with CT graft in combination with CPF.
Following selection, all patients were monitored in oral hygiene and instructed in proper tooth brushing, with roll-stroke technique being prescribed for teeth with recession-type defects. In order to achieve a regular and smooth surface, scaling and selective root planing followed by professional polishing with the use of rubber cup and a low abrasive polishing paste were performed if necessary. Coronoplasty was performed if necessary. At the end of therapy, before the surgical procedure, all patients had a plaque Score of <1 and bleeding Score of <1.
One calibrated examiner collected the following data at baseline, 3 months and 6 months post-operatively: Gingival recession (REC), probing pocket depth (PPD), CAL and width of keratinized gingiva (WKG) were measured using a computerized constant pressure probe i.e., Florida Probe (Florida Probe Corporation, Gaineswille, FL, USA) with a constant force of 15 g (pressure-154 N/cm 2 ), tip diameter of 0.40 mm, precision of 0.2 mm and a probe length of 11 mm. The CEJ was used as a fixed reference point and where CEJ was not visible the lower border of the groove on the acrylic stent, which covered the experimental tooth was used as a reference point. One examiner performed all the surgeries Vidya Baliga (Vidya Baliga) and the clinical measurements were carried out by another examiner Manohar L Bhongade (Manohar L Bhongade). The patient was unaware of the type of treatment he would receive. The mean intra-examiner standard deviation of differences in repeated PD measurements and CAL measurements were obtained using single passes of measurements with a UNC- 15 probe (Hu-Friedy, Chicago, IL, USA) (correlation coefficients between duplicate measurements; r = 0.95).
After local anesthesia (2% Lidocaine HCl with 1:100,000 epinephrine) the exposed root surfaces were thoroughly planed with curettes and ultrasonic instruments. An intrasulcular incision was made with a #15C (Ribbel, New Delhi, India) blade on the buccal aspect of the involved teeth and extended horizontally to adjacent interdental areas. Two oblique releasing incisions were made from the mesial and distal extremities of the horizontal incision beyond the mucogingival junction. An incision was made so that a "V" shaped wedged of marginal tissue could be removed. This would provide a fresh wound surface for approximation after removal of surrounding ulcerated crevicular epithelium. Once the incisions were given, the flap reflection was done by sharp dissection extending beyond the mucogingival junction. The exposed root surface was then planed with curettes to remove the deposits and smoothen the root surface. A CT graft in the proper dimensions was harvested from the palate (canine to first molar area) using the trap door approach  and trimmed as necessary after removal of excess fatty and glandular tissue. The flap was then repositioned to completely cover the donor site and sutured. The CT graft was placed immediately over the exposed root(s) covering the entire defect and the adjacent recipient bed at the level of CEJ and sutured to the interproximal papilla with 5-0 resorbable sutures (Vicryl 5-0, ETHICON, Johnson and Johnson, Waluj, Aurangabad, India).
The reflected flap was positioned as a double pedicle graft over the CT graft in the area of recession with a sling suture and the pedicles were sutured together in this position with 5-0 resorbable interrupted sutures [Figure 1]. In the control group, the reflected flap was coronally advanced to completely cover the CT graft, placing it slightly coronal to the CEJ and stabilized with simple interrupted 5-0 Vicryl sutures laterally and with continuous sling sutures coronally [Figure 2].
|Figure 1: Intraoral photograph, showing pre-operative and 6 months post-operative photo of single recession defect treated with sub-epithelial connective tissue graft combined with a double pedicle graft|
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|Figure 2: Intraoral photograph, showing pre-operative and 6 months post-operative photo of single recession defect treated with sub-epithelial connective tissue graft combined with a coronally positioned flap|
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Post-surgery periodontal dressings (COE-PAK TM , GC America Inc., ALSIP, IL, USA) were placed at the recipient sites of both the test and control groups. All patients were advised to discontinue all mechanical oral hygiene measures for 4 weeks and avoid any trauma to the surgical sites. Analgesics (Ibugesic- Ibuprofen and Paracetamol) were prescribed as required. A 0.2% chlorhexidine gluconate mouthwash was prescribed twice a daily for 4 weeks. 1 week post-surgery, periodontal pack was removed. The areas were professionally cleaned as a supragingival prophylaxis with a rubber cup at low speed and by using a prophylaxis paste was performed. At 3 weeks, brushing was reinstituted with a soft toothbrush utilizing charter's method of brushing. Professional plaque control was performed at 1 month; 3 month and 6 month recall visits.
The means and standard deviations of REC, PPD, CAL, and WKG at baseline and 6 months post-surgery were calculated for both the test and control groups. The Student's paired t-test was used to compare the data from baseline to those at 6 months for each treatment group. Comparisons between treatment groups at baseline and 6 months post-surgery were accomplished with the Student's unpaired t-test. Comparisons of the PI and PBI at baseline, 3 months and 6 months were made by Student's paired t-test. If the P > 0.05, the difference observed was considered as non-significant and if <0.05 was considered as statistically significant for all analyses.
| Results|| |
During the course of the study, wound healing was uneventful. The periodontal dressing remained in place until the first post-operative appointment. There were no post-operative complications in any of the treated patients. None of the selected patients dropped out before termination of the study.
The baseline PI and PBI scores are given in [Table 1]. At 6 months follow-up, PI was increased to 1.54 ± 0.35 mm in test and 0.94 ± 0.14 mm in control when mean PI scores after 6 month in both the groups were analyzed by the Student's unpaired t-test, the difference was statistically highly significant. At baseline mean PBI scores in test group was 1.03 ± 0.12 mm and 1.07 ± 0.28 mm in control group. After 6 months follow-up, it was increased to 1.41 ± 0.45 mm, in test and 1.53 ± 0.27 mm in control. When mean PI scores after 6 month in both groups were analyzed by the Student's unpaired t-test, the difference was statistically highly significant. During 3-6 months study period both PI and PBI scores were significantly increased in spite of repeated oral hygiene instructions at regular intervals.
|Table 1: Comparison of clinical parameters at baseline, 3 months and 6 months follow-up among the test (CTDPG) and control (CTCPF) groups |
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At baseline no statistically significant differences in any of the investigated parameters [Table 1] except WKG were observed between the test and the control group (P > 0.05), indicating that randomization process was effective. At 6 months, when mean gingival recession reductions between the two groups were compared a greater reduction of 0.58 ± 0.21 mm was demonstrated in the test group, but the difference was not statistically significant [Table 2]. The mean root coverage attained was greater in the test group than the control, with 88% and 84.56% respectively [Table 2], but the results did not reach a level of significance. Furthermore, a greater percentage of individual root coverage and predictability of 100% root coverage was found in the connective tissue double pedical graft (CTDPG) when compared to the connective tissue coronally positioned flap (CTCPF) group [Table 3] and [Table 4], however, the difference was not statistically significant.
|Table 2: Comparison of clinical parameters between the test (CTDPG) and control groups at 6 months follow-up (mm) |
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|Table 3: Recession data and individual 6 months root coverage results in CTDPG group |
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|Table 4: Recession data and individual 6 months root coverage results in CTCPF group |
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The PPD reduction and CAL gain when compared to the baseline values were seen in both groups [Table 1]. The mean reduction in PPD and CAL gain at 6 months was greater in the test group when compared to the control, the difference between the two groups, however, did not reach a level of significance [Table 2]. In addition, both groups showed statistically significant increases in the amount of keratinized tissue from baseline [Table 1], the increase being greater in the test group when compared to the control, but difference between the groups at 6 months was not statistically significant [Table 2].
| Discussion|| |
The purpose of the present investigation was to obtain a valid comparison between the two techniques employing CT graft: CTDPG (test) and CTCPF (control). The clinical outcomes of various forms of surgical interventions are influenced by general level of oral hygiene. In the present study, means of both PI and PBI scores were low at the baseline and remained significantly low (<1) throughout the study.
In the present study, both groups showed significant increase in the studied clinical parameters with respect to baseline. At 6 months, statistical significant improvement was found in recession depth in both CTDPG (3.80 mm) and CTCPF (3.34 mm) groups. The mean root coverage obtained in the present study was 88% for CTDPG and 84.72% for CTCPF. The results obtained are similar to that reported by Harris,  utilizing a larger sample size, however, the study was not a controlled one. In addition, the study did not exclude smokers, whereas the present study excluded smokers or subjects using tobacco in any form, since it has been shown that smoking negatively affects the clinical outcome, specifically the residual recession, percent root coverage and frequency of complete root coverage.  In addition, the clinical measurements had been made using a manual probe and hence are subjected to error, whereas, in our study all the measurements were made utilizing a computerized constant pressure and force probe, the Florida Probe. More importantly, the study was evaluated only for a period of 3 months, whereas, the evaluation period used in this study was 6 months from the last surgical treatment because this period is considered adequate to provide soft-tissue maturity and stability.  In addition, a 36 month follow-up study reported that no significant clinical changes were seen from the period of surgical reentry at 6 months upto 3 years of follow-up.
A clinical attachment gain was observed at 6 months in both CTDPG (3.80 mm) and CTCPF (3.34 mm) groups, which was statistically significant from baseline and the differences between the groups was statistically significant. The results of the present study show that a statistically significant increase in WKG was observed at 6 months surgery in both CTDPG (3.80 mm) and CTCPF (3.30 mm) groups.
| Conclusion|| |
Based on the above study it can be concluded that the CT grafts and its variations are extremely effective techniques in obtaining coverage. In this study, very high percentage of root coverage (88% and 84%) was obtained with CT grafts and both types of pedicles to cover the graft were effective in obtaining comparable coverage. Based on this study, it can be said that whenever an increase in keratinised tissue is required the CT graft can be obtained with either a double pedicle graft or an overlying CPF.
| References|| |
|1.||Albandar JM, Kingman A. Gingival recession, gingival bleeding, and dental calculus in adults 30 years of age and older in the United States, 1988-1994. J Periodontol 1999;70:30-43. |
|2.||Susin C, Haas AN, Oppermann RV, Haugejorden O, Albandar JM. Gingival recession: Epidemiology and risk indicators in a representative urban Brazilian population. J Periodontol 2004;75:1377-86. |
|3.||van Palenstein Helderman WH, Lembariti BS, van der Weijden GA, van 't Hof MA. Gingival recession and its association with calculus in subjects deprived of prophylactic dental care. J Clin Periodontol 1998;25:106-11. |
|4.||Lawrence HP, Hunt RJ, Beck JD. Three-year root caries incidence and risk modeling in older adults in North Carolina. J Public Health Dent 1995;55:69-78. |
|5.||Al-Wahadni A, Linden GJ. Dentine hypersensitivity in Jordanian dental attenders. A case control study. J Clin Periodontol 2002;29:688-93. |
|6.||Wennström JL. Mucogingival therapy. Ann Periodontol 1996;1:671-701. |
|7.||Harris RJ. A comparative study of root coverage obtained with an acellular dermal matrix versus a connective tissue graft: Results of 107 recession defects in 50 consecutively treated patients. Int J Periodontics Restorative Dent 2000;20:51-9. |
|8.||Nelson SW. The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1987;58:95-102. |
|9.||Raetzke PB. Covering localized areas of root exposure employing the "envelope" technique. J Periodontol 1985;56:397-402. |
|10.||Harris RJ. Connective tissue grafts combined with either double pedicle grafts or coronally positioned pedicle grafts: Results of 266 consecutively treated defects in 200 patients. Int J Periodontics Restorative Dent 2002;22:463-71. |
|11.||Borghetti A, Louise F. Controlled clinical evaluation of the subpedicle connective tissue graft for the coverage of gingival recession. J Periodontol 1994;65:1107-12. |
|12.||Harris RJ. The connective tissue and partial thickness double pedicle graft: A predictable method of obtaining root coverage. J Periodontol 1992;63:477-86. |
|13.||Harris RJ. The connective tissue with partial thickness double pedicle graft: The results of 100 consecutively-treated defects. J Periodontol 1994;65:448-61. |
|14.||Harris RJ. A comparison of two techniques for obtaining a connective tissue graft from the palate. Int J Periodontics Restorative Dent 1997;17:260-71. |
|15.||Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20. |
|16.||Allen EP. Pedicle flaps, gingival grafts, and connective tissue grafts in aesthetic treatment of gingival recession. Pract Periodontics Aesthet Dent 1993;5:29-38, 40;40. |
|17.||Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of victamine C. J Periodontol 1970;41:41-3. |
|18.||Mühlemann HR. Psychological and chemical mediators of gingival health. J Prev Dent 1977;4:6-17. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]