|Year : 2018 | Volume
| Issue : 1 | Page : 45-49
Treatment of gingival recession by coronally advanced flap in conjunction with platelet-rich fibrin or resin-modified glass-ionomer restoration: A clinical study
Sudheer Ramireddy, Jaideep Mahendra, Vijayalakshmi Rajaram, Geetha Ari, Anil Kumar Kanakamedala, Dhanadivya Krishnakumar
Department of Periodontology, Meenakshi Ammal Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Submission||01-Nov-2017|
|Date of Acceptance||11-Feb-2018|
|Date of Web Publication||28-Feb-2018|
Dr. Jaideep Mahendra
Department of Periodontology, Meenakshi Ammal Dental College and Hospital, No. 1, Alappakkam Main Road, Chennai - 600 095, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aims: The aim of this study is to compare the outcome of coronally advanced flap (CAF) along with the use of platelet-rich fibrin (PRF) versus CAF in conjunction with a resin-modified glass-ionomer cement (RmGIC) for the management of Millers Class I and Class II gingival recession coupled with noncarious cervical lesions (NCCLs). Materials and Methods: Single and multiple Miller's Class I and Class II gingival recessions were chosen for the study. Twenty participants with total of 78 sites associated with NCCL bilaterally in the anterior and premolar region of maxilla were selected. Thirty-nine sites were treated with CAF and PRF and the remaining 39 sites were treated with CAF and RmGIC. Clinical parameters such as probing pocket depth, relative gingival recession, relative clinical attachment level, NCCL height, NCCL width, width of keratinized tissue, and keratinized tissue thickness were measured at baseline, 90th, and 180th day in both the groups. The presence or absence of dentin sensitivity (DS) was determined at baseline and 180th day. Results: Both the groups showed optimal root coverage, with statistical significant difference in thickness of keratinized gingiva in Group I when compared to Group II from baseline to 90th day and from baseline to 180th day and also from 90th to 180th day. On comparing the DS between Group I and Group II from baseline to 180th day, Group II showed greater reduction in dentinal hypersensitivity as compared to Group I. Conclusion: The use of PRF along with CAF showed increased thickness of the keratinized tissue and the utilization of RmGIC resulted in decreased DS. Hence, the combination of CAF and PRF or CAF and RmGIC could provide a better treatment option in the management of gingival recession that is of esthetic concern.
Keywords: Cervical abrasions, mucogingival surgery, platelet-rich fibrin, resin-modified glass-ionomer cement
|How to cite this article:|
Ramireddy S, Mahendra J, Rajaram V, Ari G, Kanakamedala AK, Krishnakumar D. Treatment of gingival recession by coronally advanced flap in conjunction with platelet-rich fibrin or resin-modified glass-ionomer restoration: A clinical study. J Indian Soc Periodontol 2018;22:45-9
|How to cite this URL:|
Ramireddy S, Mahendra J, Rajaram V, Ari G, Kanakamedala AK, Krishnakumar D. Treatment of gingival recession by coronally advanced flap in conjunction with platelet-rich fibrin or resin-modified glass-ionomer restoration: A clinical study. J Indian Soc Periodontol [serial online] 2018 [cited 2019 Nov 17];22:45-9. Available from: http://www.jisponline.com/text.asp?2018/22/1/45/226363
| Introduction|| |
Gingival recession has been a prevalent problem in adults and if left untreated may lead to complications such as hypersensitivity, unesthetic appearance, root caries, resorption, or cervical lesions that are noncarious. The extent of these noncarious cervical lesions (NCCLs) such as abrasions, erosions, or abfraction, can go apically beyond the free gingival margin. Various treatment modalities have been advocated for NCCL of which conventional glass-ionomer materials were proposed as restorative materials for NCCL lesions. Recently, resin-modified glass-ionomer cement (RmGIC) came into existence owing to its superior physical properties than conventional glass-ionomers.
Platelets have a vital role in periodontal regeneration due to the presence of growth factors and cytokines which are essential for maturation of soft tissue and regeneration of bone. The slow polymerization during centrifugation and fibrin meshwork provides platelet-rich fibrin (PRF) with better healing properties compared to other platelet concentrates.
Among a variety of surgical techniques, coronally advanced flap (CAF) is the ideal surgical procedure in the presence of sufficient keratinized gingiva apical to the recession defect. Adequate root coverage, appropriate color match, and healing with the original alignment of the soft-tissue margin can also be achieved with CAF., Therefore, the CAF is very convincing in treating adjacent multiple gingival recession terms of esthetics. It is further suggested that combination of CAF with PRF and CAF with RmGIC for NCCLs may show better success compared to other techniques owing to the properties of PRF and RmGIC. Hence, we aim to assess the outcome of CAF with PRF to CAF in conjunction with a RmGIC for the management of Miller's Class I and Class II gingival recession coupled with cervical lesions that are noncarious.
| Materials and Methods|| |
Single and multiple Miller's Class I and Class II gingival recessions bilaterally in the canine and premolar region of maxilla were selected from the outpatient department were chosen for the study. Twenty participants with total of 78 sites associated with NCCL in the age group 24–58 years were selected. Inclusion criteria included patients with probing depth ≥3 mm and keratinized tissue width (KTW) ≥2 mm and clinical attachment level ≥5 mm. Patients under medication known to hinder periodontal tissue health and healing, recession along with demineralization/caries, teeth with any deep cervical abrasion or with any pulpal pathology, pregnant woman, smokers, patients with the history of infectious diseases, and patients who underwent periodontal surgery in the past 6 months were excluded from the present study.
The selected sites were assigned randomly as Group I or Group II by a coin-toss method. The sample size was calculated which was estimated to be 70 (sites) based on the methodology, assessment, and the findings of previous studies conducted by Santamaria et al. 2008 (a error: 0.05, Power [1-b]: 85%). Hence, 78 sites were selected for the study and divided into two groups. Group I consisted of 39 recession sites proposed to be treated with CAF and PRF and Group II also consisted of 39 recession sites proposed to be filled with RmGIC and treated with CAF. The study was validated by the review board (MADC/IRB/2014/014) according to the Declaration of Helsinki 1975 as revised in the year 2000. Consent was obtained from all the participants.
A standard Williams periodontal probe was used to record all the clinical parameters at baseline and postoperatively and at 90th and 180th day using an acrylic stent [Figure 1] and [Figure 2]. Clinical periodontal examination was performed by two trained and calibrated investigators (JM and SR) masked to study groups. The calibration was completed before the start of the study in the Periodontology Department, Meenakshi Ammal Dental College, Chennai, using 5 nonstudy patients diagnosed with gingival recession. Intra-examiner reliability and inter-examiner reliability were assessed using the intraclass correlation coefficient. The overall k value for intraexaminer reliability was 0.87. Thus, the degree of reliability was satisfactory in the measurements. The distance between the gingival margin to the base of the pocket was measured as probing pocket depth (PPD). Relative gingival recession (RGR) was assessed with the help of the Williams periodontal probe and placing it parallel to the long axis of tooth. The measurement of RGR was done from the gingival margin to the lower end of the occlusal stent as a reference point. The distance from the lower end of the occlusal stent was the reference point to the base of the pocket (PD + RGR) was measured as the relative clinical attachment level (RCAL). KTW was measured as the distance from the gingival margin to the mucogingival junction. keratinized tissue thickness (KTT) was measured under local anesthesia by piercing the endodontic spreader, through the soft tissue with gentle pressure till a hard surface was felt. The spreader was placed perpendicular to a midpoint located between the mucogingival junction and gingival margin. The NCCLH was measured as the distance between the coronal and apical margins of the NCCL and NCCLW was measured as the distance between mesial interdental papilla to the distal interdental papilla. Dentin sensitivity (DS) was determined from participant's answers regarding the presence or absence of sensitivity in the cervical sites included in the study.
|Figure 2: Root coverage using resin-modified glass-ionomer cement preoperative|
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All patients underwent an initial phase of periodontal therapy, which comprised of scaling and root planning. Oral hygiene instructions were given to the patients and occlusal adjustments were done if needed.
Platelet concentrate preparation
After initial prophylaxis, the patients were reassessed after 7 days and were reviewed after 4th week for their oral hygiene compliance and were scheduled for the surgical procedure. Platelet concentrate was prepared according to Choukroun et al. technique. About 10 ml of venous blood was drawn from the median cubital vein of the patient using a 20-gauge needle with the help of 10 ml syringe. Immediately after the blood was drawn, the dried Monovettes were centrifuged at 2700 rpm for 12 min. The eventual product consisted of three layers which comprised of upper layer of acellular platelet-poor plasma, middle portion comprised of PRF clot, and RBC's were formed at the base. Platelet concentrate was procured in the form of a membrane by compressing out the fluids from the PRF clot.,
Preparation of the recipient site
The surgical area in both the groups was anesthetized using 2% lignocaine HCl containing 1:80,000 epinephrine. The coronally repositioned flap procedure was performed as follows. On the buccal aspect of the tooth involved, intrasulcular incision was given followed by horizontal incisions perpendicular to the interdental papillae which is adjacent to the affected site. Care was taken that the incision was about 1-mm apical to the coronal border of the NCCL and it did not interfere with the gingival margin of the adjacent teeth. Vertical incisions (oblique) were extended apical to the mucogingival junction, after which a mucoperiosteal flap was elevated till the mucogingival junction. A split-thickness flap was raised to release the tension and favor coronal advancement of the flap. At the same time, the papilla over which the CAF was to be placed was de-epithelized.
In Group I, the smoothness of the root and NCCLs were obtained using a finishing bur, and the area was curetted until the tooth surface was smooth, over which PRF membrane was placed. In the Group II, NCCLs were restored with RmGIC, and the flap was placed coronally. Sutures were given to cover the NCCL completely. The surgical area was then covered with noneugenol dressing (Coe pack, GC America Inc., USA) and postoperative instructions were given.
On the 10th postoperative day, the sutures were removed and the patients were re-evaluated on 90th and 180th day.
The collected data were analyzed with SPSS Inc. Release2007. SPSS for windows, Version 16.0 (Chicago, SPSS Inc). The periodontal parameters such as PPD, RGR, RCAL, NCCLH, NCCLW, KTW, and KTT were analyzed for both groups at baseline, 90th, and 180th day using mean and standard deviation. The comparison of mean changes of the clinical parameters was done with the groups using Mann–Whitney test. To test the significance of mean differences between baseline to 90th day, baseline to 180th day and 90th to 180th day Wilcoxon test was employed. Fisher exact test was used compare the reduction in DS between Group I and Group II on 180th day.
| Results|| |
An optimal root coverage was achieved in both the groups [Figure 3] and [Figure 4]. On intergroup comparison, difference was not significant statistically in mean PPD (P = 0.78), mean RGR (P = 1), mean RCAL (P = 0.72), mean KTW (P = 1), mean NCCHL (P = 0.11), and mean NCCLW (P = 0.45) from baseline to 90th, baseline to 180th day, and 90th to 180th day between the groups. When the mean KTT was compared between the groups, a significant difference was noted on the 90th (P = 0.0001) day as well as 180th day (P = 0.0001) [Table 1]. The reduction in DS percentage on 180th day in Group II was more than that of Group I, which was found to be statistically significant (P = 0.02) [Table 2].
|Table 1: Intergroup comparison of clinical parameters at baseline day, 90th day, and 180th day|
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|Table 2: Percentage of reduction in dentin sensitivity between Group I and Group II|
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| Discussion|| |
The main objective of periodontal surgery is to create an easily maintainable periodontal environment to prevent recurrence of disease. In addition, there are procedures to improve esthetics that come under the category of periodontal plastic surgery (Miller 1982). Gingival regeneration has become an indispensable part of periodontal practice. The surgical techniques that involve exposed and sensitive root coverage to improvise esthetics have undergone a rapid expansion. Localized gingival recession that occurs at the smile line may be a great esthetic concern for the patient. In some situations, the exposed root surface can exhibit irregularities and grooves, caries, resorption, or NCCLs. These anatomical root surface presentations can impair the mechanical planing that is done before the surgical procedure for root coverage; however, to smoothen irregularities and grooves and to reduce the convexity root planing is one of the fundamental procedures in root coverage. The CAF has shown good results in the treatment of Miller's Class I gingival recessions. However, the predictability of the CAF, when used in conjunction with PRF for the management of teeth affected by gingival recession and NCCL simultaneously has not been assessed previously. Hence, we aim to analyze the outcome of CAF with PRF versus CAF in combination with an RmGIC in the management of gingival recession coupled with NCCLs.
In our study, both the groups showed optimal root coverage; however, PPD did not show any significant difference between the groups. These findings correlated with the results obtained from the study done by Santamaria et al. 2013. When Group I and Group II were compared, Group II showed greater reduction in RGR than Group I, on 180th day. However, it was not statistically significant. The gingival margin and the smooth surface of the tooth restored with RmGIC showed a positive correlation postoperatively. This finding was consistent with the study done by Santamaria et al. 2008.
When Group I and Group II were compared for RCAL, Group I showed greater reduction on 180th day; however, it was statistically insignificant. These findings correlate with the results reported by Lucchesi et al. 2007. Similarly, in our study, the amount of soft-tissue coverage achieved by CAF did not interfere with the presence of cervical restorations.
When Group I and Group II were compared for KTT, Group I showed a high increase in KTT as compared to Group II on 180th day, which was statistically significant. Thus, the gain in KTT in this study correlates with the results obtained from the study done by Aroca et al. 2009. The increase in KTT in Group I may be because the PRF membrane acts as a scaffold that maintains enough space to facilitate the various cell events that favor periodontal regeneration.
When Group I and Group II were compared, Group II showed more increase in KTW compared to Group I on 180th day; however, not statistically significant. This may be due to the affinity of the coronally displaced mucogingival line, which regained its original position, after the margin of the soft-tissue gained stability at the cementoenamel junction level. This increase in KTW in this group was in correlation with the study done by Pini-Prato et al. 1999.
There was statistically significant reduction seen in NCCLH and NCCLW from 0 to 180th day in Group I, which may be due to the properties of PRF which acts as a fibrin glue to stabilize the flap at stable position. It also has enhanced neo-angiogenesis, reduced necrosis and shrinkage of the flap, and contains thrombin which polymerizes fibrinogen into fibrin that favors wound healing. Similarly, Group II also showed, significant reduction in NCCLH and NCCLW from baseline to 180th day, which may be due to the presence of resin-ionomer restorative material which acts as a seal to minimize any internal or external bacterial contamination between the restorative margin on the tooth and surrounding tissues, thereby facilitating the health of the gingival complex.
When mean DS was compared between Group I and Group II, the percentage of reduction in DS from baseline to 180th day in Group II showed 83% reduction as compared to Group I which showed 46% from baseline to 180th day, and this was statistically significant. The results obtained from the study were in accordance with Santamaria et al. 2008. According to him, this may be due to the restoration of cervical lesions with RmGIC which can seal the dentinal tubules exposed to the environment, thereby reducing the chances of sensitivity.
From the above results, it can be concluded that CAF provides a reliable technique for covering exposed root surfaces associated with NCCLs. The use of PRF along with CAF results in increased KTT and promoted better wound healing. Studies have shown that PRF, when used with CAF for recession coverage, has shown to decrease matrix metalloproteinase-8 (MMP-8) and interleukin beta levels but increase in tissue inhibitor of MMP-1 levels at 10 days, thereby promoting periodontal wound healing., The coalition of CAF with RmGIC resulted in decreased DS.
| Conclusion|| |
The use of PRF along with CAF results in increased KTT and the use of RmGIC results in decreased DS. Hence, it can be concluded that CAF with PRF and RmGIC provides a reliable technique for covering exposed root surfaces associated with NCCLs. However, long-term follow-up is needed to assess the equanimity of the results to establish the long-term effectiveness of this combined technique. In the future, other surgical techniques along with the newer restorative materials should also be experimented to obtain the best results for the management of these NCCLs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Alkan A, Keskiner I, Yuzbasioglu E. Connective tissue grafting on resin ionomer in localized gingival recession. J Periodontol 2006;77:1446-51.
Pecie R, Krejci I, Godoy FG. Non-carious cervical lesions (NCCL) – A clinical concept based on the literature review. Part 2: Restoration. Am J Dent 2011;24:183-91.
Chandran P, Sivadas A. Platelet-rich fibrin: Its role in periodontal regeneration. Saudi J Dent Res 2014;5:117-22.
de Sanctis M, Zucchelli G. Coronally advanced flap: A modified surgical approach for isolated recession-type defects: Three-year results. J Clin Periodontol 2007;34:262-8.
Zucchelli G, De Sanctis M. Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol 2000;71:1506-14.
Santamaria MP, da Silva Feitosa D, Casati MZ, Nociti FH Jr., Sallum AW, Sallum EA, et al.
Randomized controlled clinical trial evaluating connective tissue graft plus resin-modified glass ionomer restoration for the treatment of gingival recession associated with non-carious cervical lesion: 2-year follow-up. J Periodontol 2013;84:e1-8.
Choukroun J, Diss A, Simonpieri A, Girard MO. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part V: Histologic evaluations of PRF effects on bone allograft maturation in sinus lift. Oral Surg Oral Med Oral Pathol Oral Radiol 2006;103:299-303.
Griffin TJ, Cheung WS. Treatment of gingival recession with a platelet concentrate graft: A report of two cases. Int J Periodontics Restorative Dent 2004;24:589-95.
Miller PD Jr. Root coverage using a free soft tissue autograft following citric acid application. Part 1: Technique. Int J Periodontics Restorative Dent 1982;2:65-70.
Santamaria MP, Suaid FF, Casati MZ, Nociti FH, Sallum AW, Sallum EA, et al.
Coronally positioned flap plus resin-modified glass ionomer restoration for the treatment of gingival recession associated with non-carious cervical lesions: A randomized controlled clinical trial. J Periodontol 2008;79:621-8.
Lucchesi JA, Santos VR, Amaral CM, Peruzzo DC, Duarte PM. Coronally positioned flap for treatment of restored root surfaces: A 6-month clinical evaluation. J Periodontol 2007;78:615-23.
Aroca S, Keglevich T, Barbieri B, Gera I, Etienne D. Clinical evaluation of a modified coronally advanced flap alone or in combination with a platelet-rich fibrin membrane for the treatment of adjacent multiple gingival recessions: A 6-month study. J Periodontol 2009;80:244-52.
Zucchelli G, Testori T, De Sanctis M. Clinical and anatomical factors limiting treatment outcomes of gingival recession: A new method to predetermine the line of root coverage. J Periodontol 2006;77:714-21.
Pini-Prato GP, Baldi C, Pagliaro U. Coronally advanced flap procedure for root coverage. Treatment of root surface: Root planing versus polishing. J Periodontol 1999;70:1064-76.
Marco DC. Choukroun's platelet-rich fibrin membranes in periodontal surgery: Understanding the biomaterial or believing in the magic of growth factors? J Periodontol 2009;80:1694-7.
Dragoo MR. Resin-ionomer and hybrid-ionomer cements: Part II, human clinical and histologic wound healing responses in specific periodontal lesions. Int J Periodontics Restorative Dent 1997;17:75-87.
Verma UP, Yadav RK, Dixit M, Gupta A. Platelet-rich fibrin: A Paradigm in periodontal therapy – A systematic review. J Int Soc Prev Community Dent 2017;7:227-33.
Femminella B, Iaconi MC, Di Tullio M, Romano L, Sinjari B, D'Arcangelo C, et al.
Clinical comparison of platelet-rich fibrin and a gelatin sponge in the management of palatal wounds after epithelialized free gingival graft harvest: A Randomized Clinical Trial. J Periodontol 2016;87:103-13.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]