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ORIGINAL ARTICLE
Year : 2018  |  Volume : 22  |  Issue : 2  |  Page : 140-149  

Evaluation of periosteum eversion and coronally advanced flap techniques in the treatment of isolated Miller's Class I/II gingival recession: A comparative clinical study


Department of Periodontology, The Oxford Dental College, Bengaluru, Karnataka, India

Date of Submission02-Jan-2018
Date of Acceptance07-Mar-2018
Date of Web Publication23-Apr-2018

Correspondence Address:
Dr. Koel Debnath
#106, Block-B, GK Jewel City Apartment, Kudlu Harlur Main Road, Kudlu, Bengaluru - 560 068, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_5_18

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   Abstract 


Aim: The present investigation aimed to evaluate root coverage (RC) with periosteum eversion technique (PET) using periosteum as a graft and coronally advanced flap (CAF) with platelet-rich fibrin (PRF) membrane as a graft in the treatment of isolated Miller's class I and II gingival recession defects. Materials and Methods: Thirty sites in 15 participants with Miller's Class I or II gingival recession were randomly treated either with PET using periosteum as graft and CAF + PRF as graft. In a split mouth design, the parameters such as recession depth, recession width at cementoenamel junction, probing depth, periodontal attachment level (PAL), and keratinized gingival width were assessed at baseline, 3 months, and 6 months postoperative follow-up with William's graduated probe and Vernier caliper. Results: Both the treatment modalities yielded statistically nonsignificant desirable treatment outcomes at both postoperative levels in terms of all the parameters The mean RC with probe method and Vernier method in CAF + PRF was 75.01% and 86.86%, respectively, and PET showed a mean RC of 61.112% and 83.971%, respectively, at 6-month interval period which showed a nonstatistically significant difference. Conclusion: Both the treatment modalities, i.e., CAF + PRF and PET are essentially and equally effective in the treatment of Miller's Class I or II gingival recession defects.

Keywords: Coronally advanced flap, periosteum eversion technique, platelet-rich fibrin, root coverage


How to cite this article:
Debnath K, Chatterjee A. Evaluation of periosteum eversion and coronally advanced flap techniques in the treatment of isolated Miller's Class I/II gingival recession: A comparative clinical study. J Indian Soc Periodontol 2018;22:140-9

How to cite this URL:
Debnath K, Chatterjee A. Evaluation of periosteum eversion and coronally advanced flap techniques in the treatment of isolated Miller's Class I/II gingival recession: A comparative clinical study. J Indian Soc Periodontol [serial online] 2018 [cited 2020 Feb 23];22:140-9. Available from: http://www.jisponline.com/text.asp?2018/22/2/140/230843




   Introduction Top


The goal of periodontal therapy has been always directed toward elimination of the existing disease and maintenance of a functional and healthy dentition. From a periodontist perspective, one of the spiraling concerns of an esthetic issue of the periodontal tissues is gingival recession. Gingival recession is known to be as “displacement of the marginal tissue apical to the cementoenamel junction (CEJ).”[1] The ultimate goal of a root coverage (RC) procedure was to prevent, correct, or eliminate the recession defect with a good appearance related to the adjacent soft tissues and minimal probing depth (PD) following healing.[2] Various surgical procedures used in the treatment of recession defects may basically be of pedicle soft-tissue graft procedures with the use of additive treatment such as root surface biomodification, enamel matrix proteins, and last but not the least with guided tissue regeneration (GTR).[3] The selection of one surgical technique over another depends on several factors, some of which are related to the defect, whereas others are related to the patient.[4] GTR membrane enhances the possibility of obtaining new connective tissue attachment instead of a long junctional epithelium and the possibility of reconstruction of lost periodontal tissues through the model of compartmentalization.[5],[6]

Platelet-rich fibrin (PRF), a second-generation platelet concentrate, was introduced by Choukron et al. in 2001.[7] The use of PRF in the treatment of gingival recession has been evaluated in the literature which has shown to provide appreciable amount of success. Due to its prodigious nature, its use as a barrier membrane to promote periodontal regeneration in buccal gingival recession defects has gained popularity.[8]

In the medical field, the use of autogenous periosteum has been extensive and has shown promising results.[9] It is a highly vascular connective tissue sheath covering the external surface of all the bones with the inner cellular layer containing numerous osteoblasts and osteoprogenitor cells, and the outer layer is composed of dense collagen fiber, fibroblasts, and their progenitor cells.[10] It releases vascular endothelial growth factor (VEGF) which promotes revascularization during wound healing. The use of periosteum as GTR has been suggested to be used as the most effective use of periosteal grafts as barrier membranes.[11]

Hence, the present study aimed to evaluate RC with PET using periosteum as a graft and coronally advanced flap (CAF) with PRF membrane as a graft in the treatment of isolated Miller's Class I and II gingival recession defects.


   Materials and Methods Top


Study design

This split-mouth randomized controlled clinical trial was conducted in Bengaluru, India. The study protocol was approved by the local ethical committee of the institution. A total of twenty individuals with bilateral Miller's Class I or II gingival recession defects were recruited from the outpatient department of periodontics and were randomly divided to be treated either with CAF and PRF membrane (CAF + PRF) or PET. The inclusion criteria included systemically healthy individuals with an age range of 20–50 years, bilateral Miller's Class I or Class II isolated gingival recession, individuals with ≥1 mm of width of keratinized gingiva, and presence of good oral hygiene maintenance.

The exclusion criteria included a history of previous periodontal surgery last year or had underwent previous surgical correction for gingival recession, presence of dehiscence or fenestration, malposed/rotated teeth/root caries, endodontic treated teeth, use of fixed orthodontic or removable appliances, smokers and chewers of tobacco, and pregnant or lactating mothers.

Individuals participating in the clinical trial were explained about the nature of the study, need of the surgical procedure, and the benefit of it, following which a verbal and written informed consent was obtained. Consequentially, all the participants underwent scaling and root planing.

At baseline, the parameters evaluated at the periodic interval were plaque index (PI),[12] gingival index (GI),[13] recession depth (RD), recession width (RW) at CEJ, PD, probing attachment level (PAL),[14] and keratinized width of gingiva. All the parameters were evaluated at baseline and 3 months' and 6 months' interval after the surgery. The percentage of mean RC was calculated at 6-month interval. The parameters such as RD, RW, and WKT were evaluated with William's graduated probe and electronic Vernier caliper and PAL was measured with an acrylic stent maintaining CEJ as fixed reference point with William's graduated probe as observed in [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: Presurgical measurements of gingival recession defect in relation to 13 in Group A with coronally advanced flap + platelet-rich fibrin membrane by probe method. (a) Preoperative view; (b) recession depth; (c) recession width; (d) width of keratinized tissue; (e) periodontal attachment level with acrylic stent (PAL)

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Figure 2: Presurgical measurements of gingival recession defect in relation to 13 in Group A with coronally advanced flap + platelet-rich fibrin membrane by Vernier method. (a) Recession depth; (b) recession width; (c) width of keratinized tissue

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Figure 3: Presurgical measurements of gingival recession defect in relation to 23 in Group B with periosteum eversion technique by probe method. (a) Preoperative view; (b) recession depth; (c) recession width; (d) width of keratinized tissue; (e) periodontal attachment level with acrylic stent (PAL)

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Figure 4: Presurgical measurements of gingival recession defect in relation to 23 in Group B with periosteum eversion technique by Vernier method: (a) Recession depth; (b) recession width; (c) width of keratinized tissue

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The twenty participants were randomly divided using randomization software and were divided into two groups: Group A participants received CAF + PRF on the denuded root surface and Group B participants received PET for the RC procedure.

Surgical procedure

In Group A, CAF was reflected to prepare the recipient site. Horizontal incisions were made in the mesial and distal interdental papilla of the involved tooth at the level of CEJ. Apically divergent vertical incisions were made extending into the alveolar mucosa. An intrasulcular incision was given that would connect horizontal and vertical incisions. A full-thickness flap was raised 3–4 mm apical to the crest of the defect, beyond which, a partial-thickness flap was raised as shown in [Figure 5].[15] Required amount of PRF membrane was then placed on denuded root surface.
Figure 5: Surgical procedure of coronally advanced flap with platelet rich fibrin membrane (a) Placement of horizontal incision joined with vertical incision and sulcular incision was placed; (b)following a full- split- full thickness flap was raised; (c) Platelet rich fibrin (PRF) membrane was placed on the gingival recession defect; (d) direct interrupted suture was placed; (e) tin foil placed and (f) periodontal pack was placed on the surgical site

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Platelet-rich fibrin membrane preparation

Ten milliliters of blood was taken by venepuncture from the antecubital vein and immediately centrifuged at 2800 rpm for 12 min in REMI 4C centrifugation machine to obtain PRF layer between a base of red blood cells (RBCs) at the bottom and acellular plasma on the surface. Surface acellular plasma was separated by pipetting 2–3 ml of the top layer and the RBC layer was removed/cut and the PRF portion was then placed in a sterile Dappen dish. The PRF clot was then squeezed between sterile gauze to obtain the PRF membrane as depicted in [Figure 6].[16]
Figure 6: Preparation of platelet rich fibrin membrane (a) Blood withdrawn from antecubital vein (b) centrifugation in REMI 4c centrifugation machine; (c) centrifuged at 2700 rpm for 12 minutes; (d) the Platelet rich fibrin (PRF) obtained; (e) Platelet rich fibrin PRF gel was squeezed between sterile gauze to form Platelet rich fibrin (PRF) membrane

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In Group B, an horizontal incision was made in the mesial and distal interdental papilla of the involved tooth at the level of CEJ, and an intrasulcular incision in the soft-tissue margin of recession defect along with two lateral vertical incisions in the line angle of proximal side of recession was given and a full-thickness mucoperiosteal flap was reflected. A basal incision was given at baseline to incise the periosteum using No. 15 scalpel blade and then it was separated from the submucous connective tissue up to the border line of attached gingiva. The crestally pedicled periosteum was everted and transposed coronally as observed in [Figure 7].[17]
Figure 7: Surgical procedure of periosteum eversion technique (a) Placement of horizontal incision joined with vertical incision and sulcular incision; (b) a full- split- full thickness flap was raised; (c and d) from the inner surface of flap periosteum was separated and was placed on the gingival recession defect (arrow mark); (e) direct interrupted suture was placed; (f) tin foil placed; (g) periodontal pack was placed

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The flaps in both the Groups (A and B) were advanced coronally, 2–3 mm coronal to the CEJ and sutured with nonresorbable 4-0 silk suture. Releasing incisions were closed with interrupted suture and the sites were covered with foil followed by periodontal dressing (Coe Pack).[17] Postoperative instructions were given to the participants.

Statistical analysis

The results were statistically evaluated using SPSS (Released 2009, PASW Statistics for Windows, Version 18.0, Chicago, IL, USA). The power of the study was 95% and P < 0.05 was considered statistically significant. The parameters PI and GI were evaluated with Kruskal–Wallis test for Group A and Group B at different time intervals. The mean difference with respect to RD, RW, WKT, PD, and PAL and percentage of RC at 6-month period between the test and control groups was compared using Student's t-test.


   Results Top


Only 15 participants out of 20 returned for 3-month and 6-month follow-up period. Hence, the statistical evaluation was performed for 15 participants. The participants were evaluated for the parameters with probe and Vernier caliper as shown in [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12].
Figure 8: Postsurgical measurements of gingival recession defect in relation to 13 in Group A with coronally advanced flap with platelet-rich fibrin membrane by probe method (a) recession depth; (b) recession width; (c) width of keratinized tissue; (d) periodontal attachment level

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Figure 9: Post surgical measurements of gingival recession defects in relation to 13 in group A with coronally advanced flp with platelet rich fibrin membrane by Vernier method (a) recession depth; (b) recession with; (c) width of keratinized tissue

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Figure 10: Post surgical measurements of gingival recession defect in relation to 23 in relation to group B with periosteum eversion technique by probe method (a) width of keratinized tissue; (b) recession width; (c) recession depth and (d) periodontal attachment level

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Figure 11: Post-surgical measurements of gingival recession defect in relation to 23 in group B with periosteum eversion technique by Vernier method: (a) recession depth (RD); (b) Recession width (RW); (c) Width of keratinized tissue (WKT)

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Figure 12: Pre- and postoperative view of Group A with coronally advanced flap with platelet-rich fibrin membrane and Group B with periosteum eversion technique

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Plaque index

The PI at different intervals in Group A and Group B at baseline showed no statistically significant difference.

At the 3rd month, the mean values in both Groups A and B were 0.517 and 0.5 and at the 6th month the mean obtained were 0.383 and 0.4, respectively. The follow-up interval in Groups A and B had shown an equal amount of improvement and was not statistically significant as tabulated in [Table 1] and illustrated in [Figure 13].
Table 1: Measurement of mean plaque index at baseline, 3 months, and 6 months in both Group A (coronally advanced flap with platelet-rich fibrin membrane) and Group B (periosteum eversion technique)

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Figure 13: Comparison of mean values of plaque index in Group A with coronally advanced flap with platelet-rich fibrin membrane and Group B with periosteum eversion technique at baseline, 3rd month, and 6th month

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Gingival index

Group A at baseline, 3rd month, and 6th month had shown a mean of 0.683, 0.517, and 0.383, respectively. The mean obtained in Group B for the follow-up periods were 0.667, 0.5, and 0.4, respectively. Both the groups had maintained the gingival health for the follow-up period and were statistically nonsignificant as tabulated in [Table 2] and illustrated in [Figure 14].
Table 2: Measurement of mean gingival index at baseline, 3 months, and 6 months in both Group A (coronally advanced flap with platelet-rich fibrin membrane) and Group B (periosteum eversion technique)

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Figure 14: Comparison of mean values of gingival index in Group A with coronally advanced flap with platelet-rich fibrin membrane and Group B with periosteum eversion technique at baseline, 3rd month, and 6th month

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Recession depth

The mean of RD in Group A at baseline with probe and Vernier was 2.333 and 2.129 and in Group B was 2.267 and 2.026, respectively. The 3rd month period in Group A by probe and Vernier method had shown a mean of 0.867 and 0.604 and mean obtained by both methods in Group B was 1.113 and 0.745, respectively. In the 6th month follow-up period, Groups A and B had shown a mean of 0.6 and 0.867 by probe method. The Vernier method had shown a mean of 0.247 and 0.314 in Groups A and B, respectively. When Groups A and B were evaluated for both methods of measurements from baseline to 6-month follow-up period, they were not statistically significant as observed in [Figure 15] and tabulated in [Table 3].
Figure 15: Comparison of mean values of recession depth in Group A with coronally advanced flap with platelet rich fibrin membrane and Group B with periosteum eversion technique at baseline, 3rd month, and 6th month

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Table 3: Measurement of mean recession depth at baseline, 3 months, and 6 months in both Group A (coronally advanced flap with platelet-rich fibrin membrane) and Group B (periosteum eversion technique)

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Recession width

At baseline, the mean of RW obtained by probe and Vernier methods was 3.533 and 3.143 in Group A and Group B had shown a mean of 3.2 and 2.967, respectively [Table 4]. On evaluation at the 3rd and 6th months by probe method, Group A had shown a mean of 1.2 and 0.733 and the mean obtained by Vernier method was 0.86 and 0.399, respectively. The mean values of 1.4 and 0.933 were obtained by probe method in Group A and mean values of 1.079 and 0.529 were obtained from Group B by Vernier methods. The probe and Vernier methods of measurements in both groups were statistically nonsignificant and had shown an equal amount of improvement as observed in [Figure 16].
Table 4: Measurement of mean recession width at baseline, 3 months, and 6 months in both Group A (coronally advanced flap with platelet-rich fibrin membrane) and Group B (periosteum eversion technique)

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Figure 16: Comparison of mean values of recession width in Group A with coronally advanced flap with platelet-rich fibrin membrane and Group B with periosteum eversion technique at baseline, 3rd month, and 6th month

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Width of keratinized tissue

The mean obtained at baseline, 3rd month, and 6th month in Group A with probe method was 4.533, 4.2, and 4.133 and the mean obtained in Group B at each follow-up interval by probe methods was 4.467, 4.333, and 4.067, respectively. The mean obtained by Vernier methods in Group A from baseline to follow-up intervals was 4.198, 4.035, and 3.913 and in Group B it showed a mean of 4.201, 4.082, and 3.842, respectively. Both the groups from baseline to 3rd month and 6th month were statistically nonsignificant when measured by probe and Vernier methods as interpreted in [Table 5] and [Figure 17].
Table 5: Measurement of mean width of keratinized tissue at baseline, 3 months, and 6 months in both Group A (coronally advanced flap with platelet-rich fibrin membrane) and Group B (periosteum eversion technique)

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Figure 17: Comparison of mean values of width of keratinized tissue in Group A with coronally advanced flap with platelet-rich fibrin membrane and Group B with periosteum eversion technique at baseline, 3rd month, and 6th month

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Probing depth

At different interval period, Group A had shown a mean of 1.2 and 1.067. Group B at baseline had shown a mean of 1.267 which was reduced to 1 by 6th month. When evaluated, both groups had shown a statistically nonsignificant association and had an equal amount of improvement as visualized in [Table 6] and [Figure 18].
Table 6: Measurement of mean probing depth at baseline, 3 months, and 6 months in both Group A (coronally advanced flap with platelet-rich fibrin membrane) and Group B (periosteum eversion technique)

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Figure 18: Comparison of mean values of probing depth in Group A with coronally advanced flap with platelet-rich fibrin membrane and Group B with periosteum eversion technique at baseline, 3rd month, and 6th month

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Periodontal attachment level (PAL)

The PAL parameters from [Table 7] and [Figure 19] concluded that at baseline, 3rd month, and 6th month in between, Group A had shown a mean of 3.533, 1.933, and 1.667, respectively. In Group B, the mean obtained from baseline to 6th month was 3.533, 2.2, and 1.867, respectively. Both the groups when statistically evaluated had shown an equal amount of improvement from baseline and had no statistical significance.
Table 7: Measurement of mean periodontal attachment level (PAL) at baseline, 3 months, and 6 months in both Group A (coronally advanced flap with platelet-rich fibrin membrane) and Group B (periosteum eversion technique)

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Figure 19: Comparison of mean values of periodontal attachment level (PAL) in Group A with coronally advanced flap with platelet-rich fibrin membrane and Group B with periosteum eversion technique at baseline, 3rd month, and 6th month

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Percentage of root coverage

The mean obtained for %RC in Group A and in Group B by probe methods was 75.01 and 61.112 at 6th month interval with a minimum RC of 50% to maximum at 100%. With Vernier method of measurement, the minimum %RC obtained was 48.2 and maximum at 100, respectively. The mean %RC scores at 6th month interval for Groups A and B were 86.869 and 83.971, respectively. Both the groups when statistically evaluated for probe and Vernier methods of measurements had shown an equivalent amount of RC with no statistically significant association as shown in [Figure 20] and [Table 8].
Figure 20: Comparison of mean values of percentage of root coverage in Group A with coronally advanced flap with platelet-rich fibrin membrane and Group B with periosteum eversion technique at 6th month interval period with probe and vernier method of measurement

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Table 8: Measurement of mean percentage of root coverage at baseline, 3 months, and 6 months in both Group A (coronally advanced flap with platelet-rich fibrin membrane) and Group B (periosteum eversion technique)

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   Discussion Top


In the modern era, esthetic has behold an important demeanor in an individual's life. Various procedures performed in the treatment of gingival recession have shown healing with long junctional epithelium which might give a satisfactory success and predictability but fails to fulfill the ideal goal of periodontal regeneration.[18] Subepithelial connective tissue graft (CTG) is considered the gold standard due to its tremendous success and predictability in the treatment of gingival recession.[19] In order to reduce the risk of recession on donor site, Grupe in 1966 introduced the pedicle soft-tissue grafting procedure.[20] CAF has gained an exceptional success in the treatment of gingival recession as the lining mucosa is elastic and the mucosal flap raised beyond the mucogingival junction can be stretched in the coronal direction to cover the exposed root surface.[21] To achieve an ideal goal of periodontal therapy, GTR was introduced for the treatment of gingival recession because of its ability to promote new attachment.[22] The “wonderfabulous material” platelet concentrates were most effective in their regenerative potential and play a significant role in inflammatory regulation with the help of cytokines trapped in the fibrin network that are released during the remodeling of this initial matrix.[23] Aroca et al. in 2009[24] pioneered the use of autologous PRF membrane with modified CAF technique in multiple gingival recession defect which has shown 81% of RC. Various researches conducted with the use of PRF membrane in recession defect by Jankovic et al. in 2010[25] and 2012[26] have shown 72.1% of RC with an increase in thickness of keratinized tissue. Aleksic et al. in 2010[27] evaluated the healing index with the usage of PRF membrane and CTG which has shown a lesser patient discomfort and better acceptance with faster healing in the PRF group as compared to CTG. Recent studies performed by Padma et al.[28] in 2013, Shetty et al. in 2014,[29] and Thamaraiselvan et al., in 2015[15] have shown an improved gingival tissue thickness with appreciable amount of RC.

The cambium layer of the periosteum releases various growth factors mainly VEGF which promote revascularization during wound healing. In addition, the presence of periosteum adjacent to the gingival recession defects in sufficient amounts also makes it a suitable viable graft.[30],[31] Gaggl et al. in 2005[17] performed RC with periosteum as the membrane and obtained 100% RC at 12-month period.

The present study was the first of its own kind where measurements of the parameters RD, RW, and WKT were performed both by probe and Vernier methods, as the latter method allows to measure at an accurate precision of 0.1 mm. The individuals recruited were systemically healthy to avoid the influence of altered host response caused by various systemic illness.[32] Smokers too were excluded from the study as they interfere with the initial healing as observed by Silva et al., in 2006.[33]

Intergroup analysis of the plaque score in between Group A (CAF + PRF) and Group B (PET) from baseline to 3 months followed by 6 months has shown a decrease of 0.3 and 0.4, respectively, which when statistically evaluated showed no statistically significant difference. Both the treatments had shown an equal improvement due to its split-mouth design and maintenance of good oral hygiene by the participants during the follow-up period. The result of the present study is in agreement with the previous study conducted by Thamaraiselvan et al. in 2015[15] where PI score reduced from 0.87 at baseline to 0.49 at 6 months. The treatment of recession defect with PRF membrane has shown a considerable decrease in PI score from baseline to 6 months as per Aroca et al., 2009[27] and Jankovic et al., 2012,[25] and Gaggl et al. in 2005[17] also have shown a score of 0 in respect of PI at 6-month period.

The intergroup comparison of GI between the control (CAF + PRF) and test sites (PET) at different interval period has not shown a statistically significant difference with a fractional amount of change at 6 months with a mean of 0.38 and 0.4, respectively, in both the groups. The results could be due to the use of PRF membrane which was also known to release various pro-inflammatory cytokines such as interferon-gamma, tumor necrosis factor-alpha, interleukine (IL)-1β, and IL-6 which helps in T-cell differentiation and growth factors such as VEGF, PDGF, fibroblast growth factor, transforming growth factor, and insulin-like growth factor which acts as an anti-inflammatory agent and promotes faster healing.[13] The test group (PET) had shown the same amount of improvement which could be explained by the immense regenerative potential of periosteum.[30],[31] This finding in the present study was as per the study performed by Thamaraiselvan et al. in 2015[15] where a reduction from 0.87 to 0.4 was observed.

RD in both Groups A and B had not shown statistically significant difference by both probe and Vernier methods. RD in Group A from mean baseline reduced from 2.33 to 0.6 at 6th month interval by probe method and by Vernier method it reduced from 2.12 to 0.2. Group B too had similar amount of reduction by probe and Vernier methods at a mean reduction of 0.86 and 0.31, respectively. Thamaraiselvan et al. in 2015[15] had shown a mean decrease of 2.30–0.7 mm at 6-month period. The observation by Bayesian network by Nieri et al. in 2009[34] where they stated that a deeper baseline recession could make the difficulty in moving the gingival margin of the flap coronally and also the need for passive adaptation of the flap, virtually without tension, was an important aspect for obtaining a complete coverage of recession depth.

The reduction of mean RW from baseline to 6th month in Group A by probe and Vernier methods was 0.73 and 0.39, respectively, which was not statistically significant from Group B which had a mean reduction of 0.93 and 0.52 by probe and Vernier methods of measurement, respectively. These results were in agreement with that of Thamaraiselvan et al. in 2015[15] and Padma et al. in 2013[28] where an average mean reduction from 3.4 to 1.5 mm measured with periodontal probe was obtained. RW coverage at 6th month interval by Gaggl et al.[17] had too shown a mean reduction to 0.4 which was similar to the results seen in Group B.

WKT in Groups A and B did not show statistically significant difference from baseline to 6th month by probe and Vernier methods. The results obtained by probe method in Group A maintained at a mean of 4 which was in accordance to Thamaraiselvan et al. in 2015[15] where an WKT was maintained at a mean of 2.7. The maintenance of WKT from baseline to follow-up period might be due to the influence of growth factors from PRF membrane on the proliferation of gingival and PDL fibroblasts or to a spacing effect of PRF membrane. In Group B by probe method, a slight decrease in WKT was observed from 4.4 to 3.8 mm which was not in accordance to Gaggl et al.[17] and Mahajan et al.[31] where an increase in WKT was seen from 2.2 to 5.8 mm at 12-month interval. The increase in keratinized tissue is a slow, long-lasting phenomenon that may be attributed to the tendency of mucogingival junction line to regain its genetically determined position, and another possible reason as stated by Matter et al.[35] was that the time frame of 6 months considered in the study may not be appropriate to observe a significant creeping attachment.

The PD and PAL in Group A did not show statistically significant difference from 1.2 to 1 mm and 3.5 to 1.6 mm. Group B had shown a mean decrease from 1.2 to 1 mm and 3.5 to 1.8 mm. It was in accordance with Thamaraiselvan et al. in 2015[15] where a reduction from 1.3 to 1 mm was obtained and Gaggle et al.[30] from 5.8 to 1.8 mm at 6th month period. The observation could be attributed to the shrinkage of gingival tissue following scaling and root planing which was included in the treatment protocol and this can further be explained as the reason for increase in periodontal attachment level. The periosteal cells favor osteoblast attachment and spreading.

The mean root coverage percentage (MRC%) in control group by probe and Vernier methods was 75.01 and 86.86 in Group A and Group B showed 61.12% by probe method and 83.97% by Vernier methods. The Vernier method had shown a better MRC% as compared to probe method in both groups as measurement could be obtained by 0.1 mm precision, whereas in probe method, calibration was at 1 mm. The results were in accordance with Aroca et al. (80.07%),[24] Padma et al. (100%),[28] and Thamaraiselvan et al. in 2015[15] (74.1%). Group B when compared to that of Gaggl et al. in 2005[17] had shown an improvement in RC parameters from 6 months to 12 months as 100% MRC which was due to the creeping substitution phenomenon as stated by Goldman and Cohen in 1964.

Thus, concluding from the present investigation with the parameters and comparing with various clinical studies, CAF + PRF and PET showed promising results in terms of treatment outcomes. In addition to reduced patient morbidity and the absence of second surgical site, it procures the benefits of the advantageous properties of PRF and periosteum in the treatment of gingival recession defect.


   Conclusion Top


PRF has gained popularity due to its ease of preparation and regeneration capacity and the viable cells present in the periosteum within the surgical site, which makes both the groups equally beneficial and advantageous irrespective of the technique used. CAF has in store the best of evidence in the literature in respect to success and predictability. In addition, the method of measurement by both Williams' graduated periodontal probe and electronic Vernier caliper holds equally good future prospects as a measurement tool in evaluating the various parameters to be considered for the treatment of gingival recession defect.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given his their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
The American Academy of Periodontology. Glossary of Periodontal Terms. 4th ed. Chicago: American Academy of Periodontology; 2001. p. 44.  Back to cited text no. 1
    
2.
Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for treatment of localized gingival recessions: A systematic review. J Clin Periodontol 2002;29 Suppl 3:178-94.  Back to cited text no. 2
    
3.
Lindhe J, Lang N, Karring T. Mucogingival therapy. Periodontal plastic surgery. In: Ermes E, editor. Clinical Periodontology and Implant Dentistry. 6th ed. Oxford: Blackwell Munksgaard; 2008. p. 995-1043.  Back to cited text no. 3
    
4.
Zucchelli G, De Sanctis M. Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol 2000;71:1506-14.  Back to cited text no. 4
    
5.
Melcher AH. On the repair potential of periodontal tissues. J Periodontol 1976;47:256-60.  Back to cited text no. 5
    
6.
Nyman S, Lindhe J, Karring T, Rylander H. New attachment following surgical treatment of human periodontal disease. J Clin Periodontol 1982;9:290-6.  Back to cited text no. 6
    
7.
Choukron J, Adda F, Schoeffler C, Vervella A. An opportunity in perio implantology: The PRF. Implantodontie 2001;42:55-62.  Back to cited text no. 7
    
8.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part II: Platelet-related biologic features. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e45-50.  Back to cited text no. 8
    
9.
Finley JM, Acland RD, Wood MB. Revascularized periosteal grafts. A new method to produce functional new bone without bone grafting. Facial Plast Surg 1978;61:1-6.  Back to cited text no. 9
    
10.
Provenza DV, Seibel W. Basic Tissues, Oral Histology Inheritance and Development. 2nd ed. Michigan: Lea and Feibger, Rappaport; 1986. p. 465-85.  Back to cited text no. 10
    
11.
Gamal AY, Mailhot JM. A novel marginal periosteal pedicle graft as an autogenous guided tissue membrane for the treatment of intrabony periodontal defects. J Int Acad Periodontol 2008;10:106-17.  Back to cited text no. 11
    
12.
Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964;22:121-35.  Back to cited text no. 12
    
13.
Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51.  Back to cited text no. 13
    
14.
Lindhe J, Lang N, Karring T. Mucogingival therapy. Periodontal plastic surgery. In: Ermes E, editor. Clinical Periodontology and Implant Dentistry. 6th ed. Oxford: Blackwell Munksgaard; 2008. p. 137, 577.  Back to cited text no. 14
    
15.
Thamaraiselvan M, Elavarasu S, Thangakumaran S, Gadagi JS, Arthie T. Comparative clinical evaluation of coronally advanced flap with or without platelet rich fibrin membrane in the treatment of isolated gingival recession. J Indian Soc Periodontol 2015;19:66-71.  Back to cited text no. 15
[PUBMED]  [Full text]  
16.
Gassling V, Douglas T, Warnke PH, Açil Y, Wiltfang J, Becker ST, et al. Platelet-rich fibrin membranes as scaffolds for periosteal tissue engineering. Clin Oral Implants Res 2010;21:543-9.  Back to cited text no. 16
    
17.
Gaggl A, Jamning D, Trica A. A new technique for periosteoplasty for covering recession: Preliminary reports and first clinical results. PERIO Periodontal Pract Today 2005;2:55-62.  Back to cited text no. 17
    
18.
Wang HL, MacNeil RL. Guided tissue regeneration. Absorbable barriers. Dent Clin North Am 1998;42:505-22.  Back to cited text no. 18
    
19.
Chambrone L, Chambrone D, Pustiglioni FE, Chambrone LA, Lima LA. Can subepithelial connective tissue grafts be considered the gold standard procedure in the treatment of miller class I and II recession-type defects? J Dent 2008;36:659-71.  Back to cited text no. 19
    
20.
Grupe HE. Modified technique for the sliding flap operation. J Periodontol 1966;37:491-5.  Back to cited text no. 20
    
21.
Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures: A systematic review. J Clin Periodontol 2008;35:136-62.  Back to cited text no. 21
    
22.
Cortellini P, Pini Prato G, Tonetti MS. Periodontal regeneration of human infrabony defects. II. Re-entry procedures and bone measures. J Periodontol 1993;64:261-8.  Back to cited text no. 22
    
23.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part III: Leucocyte activation: A new feature for platelet concentrates? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e51-5.  Back to cited text no. 23
    
24.
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.  Back to cited text no. 24
    
25.
Jankovic S, Aleksic Z, Milinkovic I, Dimitrijevic B. The coronally advanced flap in combination with platelet-rich fibrin (PRF) and enamel matrix derivative in the treatment of gingival recession: A comparative study. Eur J Esthet Dent 2010;5:260-73.  Back to cited text no. 25
    
26.
Jankovic S, Aleksic Z, Klokkevold P, Lekovic V, Dimitrijevic B, Kenney EB, et al. Use of platelet-rich fibrin membrane following treatment of gingival recession: A randomized clinical trial. Int J Periodontics Restorative Dent 2012;32:e41-50.  Back to cited text no. 26
    
27.
Aleksic Z, Jankovic S, Dimitrijevic B, Divnic Resnik T, Milinkovic I, Lekovic V. The use of platelet-rich fibrin membrane in gingival recession treatment. Srp Arh Celok Lek 2010;138:11-8.  Back to cited text no. 27
    
28.
Padma R, Shilpa A, Kumar PA, Nagasri M, Kumar C, Sreedhar A, et al. Asplit mouth randomized controlled study to evaluate the adjunctive effect of platelet-rich fibrin to coronally advanced flap in miller's class-I and II recession defects. J Indian Soc Periodontol 2013;17:631-6.  Back to cited text no. 28
[PUBMED]  [Full text]  
29.
Shetty SS, Chatterjee A, Bose S. Bilateral multiple recession coverage with platelet-rich fibrin in comparison with amniotic membrane. J Indian Soc Periodontol 2014;18:102-6.  Back to cited text no. 29
[PUBMED]  [Full text]  
30.
Mahajan A. Periosteal pedicle graft for the treatment of gingival recession defects: A novel technique. Aust Dent J 2009;54:250-4.  Back to cited text no. 30
    
31.
Mahajan A. Treatment of multiple gingival recession defects using periosteal pedicle graft: A case series. J Periodontol 2010;81:1426-31.  Back to cited text no. 31
    
32.
Huang LH, Neiva RE, Wang HL. Factors affecting the outcomes of coronally advanced flap root coverage procedure. J Periodontol 2005;76:1729-34.  Back to cited text no. 32
    
33.
Silva CO, De Lima AF, Sallum AW, Tatakis DN. Coronally positioned flap for root coverage in smokers and non-smokers: stability of outcomes between 6 months and 2 years. J Periodontol 2007;78:1702-7.  Back to cited text no. 33
    
34.
Nieri M, Rotundo R, Franceschi D, Cairo F, Cortellini P, Pini Prato G, et al. Factors affecting the outcome of the coronally advanced flap procedure: A Bayesian network analysis. J Periodontol 2009;80:405-10.  Back to cited text no. 34
    
35.
Matter J. Creeping attachment of free gingival grafts. A five-year follow-up study. J Periodontol 1980;51:681-5.  Back to cited text no. 35
    


    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], [Figure 18], [Figure 19], [Figure 20]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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