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ORIGINAL ARTICLE
Year : 2018  |  Volume : 22  |  Issue : 6  |  Page : 492-497  

Regenerative potential of subepithelial connective tissue graft in the treatment of periodontal infrabony defects


1 Department of Periodontics, Aditya Dental College, Beed, Maharashtra, India
2 Department of Periodontology, Rungta College of Dental Sciences and Research, Bhilai, Chhattisgarh, India
3 Consultant Periodontist, Balaji Wards, Jagadalpur, Bastar, India
4 Consultant Periodontist, Ralas Enclave Society, Dagania, Raipur, Chhattisgarh, India

Date of Submission06-May-2018
Date of Acceptance02-Jul-2018
Date of Web Publication1-Nov-2018

Correspondence Address:
Dr. Shruti Bhatnagar
Department of Periodontology, Rungta College of Dental Sciences and Research, Bhilai - 490 024, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_312_18

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   Abstract 


Background: Due to high prevalence and progression of infrabony defects lead to increase in the possibility of tooth loss. Various regenerative techniques such as guided tissue regeneration, bone grafts, and biomimetic agents have been proposed. Subepithelial connective tissue graft (SCTG) is an autogenous membrane, which contains mesenchymal cells and has osteogenic, chondrogenic, and osteoblastic activities. The present study investigates the effective application of SCTG as an autogenous barrier membrane in the treatment of periodontal infrabony defect. Materials and Methods: Ten patients in the age group of 30–45 years suffering from chronic periodontitis with clinical and radiographic evidence of vertical defects were selected for the study. Clinical parameters evaluated were gingival index, plaque index, probing pocket depth, clinical attachment level, and gingival recession. These parameters were assessed at baseline, 6 and 9 months. Radiographic parameter (defect fill) was evaluated at baseline, 6, and 9 months postoperatively. Sites were treated with PERIOGLAS® and connective tissue graft. Statistical analysis was done using paired t-test. Results: All the patients finished the study. A significant improvement was observed regarding clinical parameters from baseline to 9 months. The radiographic defect fill was seen in all the cases at the end of 9 months, which was statistically significant in comparison with baseline scores. Conclusion: SCTG could be effectively used as a barrier membrane for the treatment of periodontal infrabony defects.

Keywords: Barrier membrane, infrabony defects, periodontal regeneration, PERIOGLAS®, subepithelial connective tissue graft


How to cite this article:
Siddeshappa ST, Bhatnagar S, Diwan V, Parvez H. Regenerative potential of subepithelial connective tissue graft in the treatment of periodontal infrabony defects. J Indian Soc Periodontol 2018;22:492-7

How to cite this URL:
Siddeshappa ST, Bhatnagar S, Diwan V, Parvez H. Regenerative potential of subepithelial connective tissue graft in the treatment of periodontal infrabony defects. J Indian Soc Periodontol [serial online] 2018 [cited 2018 Dec 19];22:492-7. Available from: http://www.jisponline.com/text.asp?2018/22/6/492/244564




   Introduction Top


The ultimate goal of periodontal therapy is to regenerate the lost periodontal structures, to regain its original form and function, and to prevent the niche for microorganism to cause the destruction of tissues. Successful regeneration of periodontium includes the regeneration of cementum, alveolar bone, periodontal ligament, and connective tissue fibers which attaches to the root surface.[1]

To promote this regeneration, the befitting guidance of cells capable of synthesizing collagen, cementum, and bone to damaged site is required.[2] Infrabony periodontal defects can be complex and difficult to treat. Surgical techniques, including guided tissue regeneration (GTR), have been used for the regeneration of tissues in this areas.[3]

The biologic basis of GTR is the hypothesis of preventing the migration of epithelial and connective tissue cells of the flap into the defect by placing a physical barrier. This way, periodontal ligament cells and mesenchymal cells will get the chance to migrate to the root surface.[4] Numerous absorbable and nonabsorbable membranes have been used for GTR. Because of the higher cost, need for a second surgery for membrane removal, complexity, and bacterial accumulation of nonresorbable and absorbable membranes are preferable.[5],[6]

The palatal connective tissue is an autogenous membrane. Available literature regarding the application of connective tissue as a membrane is scarce; however, most of them have shown that connective tissue can be used as a membrane.[7] A subepithelial connective tissue graft (SCTG) also could be used as a barrier for furcation defects and infrabony defects. Palatal connective tissue graft is autogenous membranes which have shown successful results in the previous studies.[8],[9] Mesenchymal cells are seen in the palatal connective tissue, and these cells are osteogenic.[10]

Using connective tissue graft as a barrier during GTR makes it possible to restore the hard tissue while enhancing the soft-tissue profile in the same procedure.[11] Hence, the present study was undertaken to estimate the potential of SCTG as a GTR membrane in the regeneration of infrabony defect.


   Materials and Methods Top


A total of 10 patients with complaints of loosening of teeth, food lodgment, bleeding on probing, and increased spacing were selected from the Outpatient Department of Periodontology. The sample size was determined using standard normal variate to be 1.96 (95% confidence interval), and the prevalence from the previous study keeping the allowable error in consideration. The patients were informed about the nature of the study, and written informed consent was obtained from them in accordance to the Helsinki Declaration of 1975, as revised in 2000. Ethical approval was attained from the Ethical Committee of the Institution. This study was a prospective analysis which started between February 2016 and completed in March 2017.

Selection criteria

Inclusion criteria

The patients included in the study were those having as follows: (1) patients with good general health, (2) patients who were nonsmoker, (3) patients having preoperative probing pocket depth (PPD) ≥5 mm, (4) infrabony defect with vertical bone loss of 3 mm or more as visible on radiograph, (5) patients having no history of periodontal therapy for the past 6 months, and (6) patients having no history of any medication affecting periodontal healing. The deepest defect either in the premolar or molar region was selected. One defect from each patient was selected.

Exclusion criteria

The patients having the one or more of the following were excluded from the study: (1) any history of systemic diseases, (2) pregnant or lactating patients, (3) inadequate oral hygiene after Phase I therapy, (4) allergic to any medication, and (5) patients with thin palatal connective tissue.

Clinical parameters

The following parameters were recorded at baseline, 3, 6, and 9 months: Plaque index (PI) (Silness and Loe, 1964),[12] gingival index (GI) (Loe and Silness, 1963),[12] (PPD, deliberated as distance between gingival margin to base of pocket), clinical attachment level (CAL, deliberated as distance between cement-enamel junction to base of pocket), and gingival recession (GR, deliberated as distance between cement-enamel junction to gingival margin) using a UNC-15 probe (Hu Friedy, USA). Phase 1 therapy was done for the patients. Oral hygiene instructions were given to the patients. Radiographic parameters as follows: standardize and reproducible intraoral periapical radiographs were taken using the long-cone paralleling technique at baseline, 6 and 9 months. The area of defect on the radiograph was calculated according to the landmarks described by Eickholz et al.[13] The area has been calculated as the following: cementoenamel junction-base of defect (CEJ-BD): distance from CEJ to base of defect, CEJ-AC: distance from CEJ to alveolar crest, H: length of the perpendicular from the vertex opposite the base of the triangle, and area of the defect A = ½ × CEJ − BD × H. This was repeated at each follow-up. The site with the deepest probing depth was selected to be the study site. Since only one site was involved, no randomization was done as there was only one group. The parameters were judged by the same clinician at every follow-up. All surgical procedures were carried out by a different operator who did not record the parameters to avoid bias.

Surgical procedure

Local anesthesia was obtained (2% lidocaine, epinephrine 1: 100,000) at the site of the surgery. The crevicular incision was given at facial and palatal/lingual within extent to the defect site, so that unnecessary trauma was avoided [Figure 1] and [Figure 2]. Mucoperiosteal flaps were elevated so that adequate exposure of the defect site was obtained. Debridement and root planing were done using hand and ultrasonic instruments. Degranulation was done on the inner side of the flap as required. Thorough irrigation of the surgical site was done. Probing depth was measured [Figure 3]. The size of connective tissue required to cover the defect was measured using a template, and marking was done on the palate.
Figure 1: Preoperative probing depth inpatient residential treatment 46

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Figure 2: Incision being placed

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Figure 3: Intraoperative probing inpatient residential treatment 46

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The SCTG of adequate thickness was obtained using trap-door approach [Figure 4]. After procuring the graft, palate wound was sutured back, and hemostasis was obtained. The graft was examined carefully, and any tissue tags were removed to obtain uniform thickness. The defect site was then isolated, presutured, and PERIOGLAS® bone graft was placed into the defect [Figure 5]. The SCTG was then deposed over the defect, and suturing was done using 3-0 silk suture [Figure 6] and [Figure 7]. The periodontal dressing was placed.
Figure 4: Procurement of subepithelial connective tissue graft

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Figure 5: Bone graft (PERIOGLAS®) being placed into the defect

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Figure 6: Subepithelial connective tissue graft being placed into the defect

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Figure 7: Suture placed at defect site

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Postoperative instructions and care

The patients were asked to rinse two times daily with 10 ml of 0.2% chlorhexidine mouthwash for 15 days. They were refrained from brushing on the surgical site for 10 days. Postoperative pain control was using ibuprofen, 400 mg, and every 8 h. Amoxicillin 500 mg was prescribed for postoperative infection control. The patients were recalled after 10 days for suture removal. The patients were not subjected to any oral hygiene measure until the end of the follow-up period.

Statistical analysis

The patients were recalled after 3, 6, and 9 months. All the parameters recorded at the baseline were reevaluated at the follow-up appointments. Paired t-test was used Statistical Package for Social Sciences Version 17.0 (Chicago: SPSS Inc.)statistical analysis software. The values were represented as the mean ± standard deviation (SD).


   Results Top


All ten patients (four females and six males) returned for follow-up. Healing was uneventful, no postoperative complications were reported. There was a statistically significant reduction in all parameters [Table 1] and [Table 2].
Table 1: Changes in clinical parameters at each follow-up period

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Table 2: Comparison of change in clinical parameters after treatment

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The mean PI at baseline was 1.93 ± 0.61 (mean ± SD) which declined to 0.88 ± 0.36 after 6 months. The mean GI at baseline was 1.39 ± 0.16 (mean ± SD) which reduced to 0.94 ± 0.07 at 6-month interval. Both gingival and PI showed regress at 9-month interval which was 1.10 ± 0. 13 and 1.38 ± 0.30, respectively; this may be due to no professional oral hygiene measure taken until the end of the study. However, the improvement was statistically significant when compared to baseline scores. There was a statistically significant reduction in PPD from baseline (6.30 ± 0.67) to 9 months (2.80 ± 0. 78). This trend was followed by CAL score too; a baseline score of 6.30 ± 0.67 was ameliorated to 2.90 ± 0.56 after 9 months. This difference was statistically significant, indicating defect resolution. GR is seen after the surgery which was statistically nonsignificant at the end of 9 months. The defect fill was calculated regarding defect resolution was measured by using the aforementioned method. The baseline score was 94.90 ± 32.24 [Figure 8], which came down to 73.42 ± 27.00 and to 57.39 ± 22.33 after 9 months. This reduction was statistically significant [Figure 9], [Figure 10] and [Table 3], [Table 4].
Figure 8: Preoperative intraoral periapical

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Figure 9: Postoperative probing inpatient residential treatment 46 after 9 months

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Figure 10: Postoperative intraoral periapical

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Table 3: Changes in radiographic parameters at each follow-up period

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Table 4: Comparison of change in radiographic parameters after treatment

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   Discussion Top


Regeneration of lost structures has become the primary therapeutic goal in periodontics over the past several decades.[14] Till date, numerous materials have been used from nonresorbable membrane such as polytetrafluoroethylene to resorbable membrane such as collagen and polylactide membrane/polyglycolic membrane. However, nonresorbable membrane requires second surgery, and resorbable membrane has an unpredictable rate of dissolution. The search for optimum and better material is perpetual.

Langer and Langer (1985) introduced and outlined the indications and procedures necessary for achieving success with the SCTG.[15] It is considered to be the gold standard for recession coverage. The concept of using SCTG as a barrier membrane is relatively new. It was proposed that the gingival connective tissue contains mesenchymal cells. These cells are osteogenic, chondrogenic, osteoblastic, and have immunomodulatory capacity.[16] In addition to this, the easy availability, cost-effectiveness, and versatility of the SCTG membrane were also appealing. Hence, the quest of evaluating the potential of SCTG as a barriers membrane was undertaken.

It has been stated that proliferation of the membrane harvested from the palatal connective tissue into the defect is unlikely. Therefore, it can very well play the role of a biologic membrane than can be well tolerated in the body. There is no risk of disease transmission, it is well tolerated by the body and if exposed into the oral cavity does not compromise the treatment outcome.[7] There is no proliferation of tissue graft into the defect is observed.[16]

In the present study, oral hygiene of the patients was evaluated using full-mouth PI, and gingival inflammation was estimated using full-mouth GI. There was a significant reduction in both indices from baseline to 9 months. However, the reduction was seen maximum at 6 months, and after which there was a slight increase in scores from 6 to 9 months [Table 1]. The results were similar to that of Stein et al.[17] There was a significant improvement regarding PPD and CAL gain which was 3.5 and 3.4 mm, respectively. The results were similar to that of Kwan et al.[9] and Moghaddas et al.[18] There was a slight increase in GR which was statistically insignificant. Moghaddas et al.,[18] in their study, comparing palatal connective tissue with collagen has shown a significant difference regarding GR in both the groups.

The radiographic parameter which was calculated as defect fill has shown statistically significant improvement from baseline to 9 months. The mean defect fill was measured as 37.54 mm2 from baseline to 9 months. These results coincide with that of studies conducted by Paolantonio et al.[19] and Esfahanian et al.[20] A bone graft was used as filling material beneath the membrane. It has been proved in many studies that a combination of bone grafts and GTR membrane effectuates more attachment gain than with the use of membrane alone.[21] The potency of SCTG to cripple the epithelial migration into the defect is similar to that of a bioabsorbable membrane and filling material used can transcend the results obtained.[22] Hence, it is assumed that the use of a bioactive glass for defect fill can also contribute to the amount of defect fill in addition to the benefits of SCTG barrier membrane.

Although the study has demonstrated the effectiveness of SCTG as a barrier membrane, the use of an autologous material, such as palatal connective tissue graft, demands a second surgical site, causes additional morbidity and discomfort for the patient, and not to mention the extrasurgical time.[23] The lack of comparison with negative and positive control is also one of the limitations of the study. No reentry or histological examination has been done.


   Conclusion Top


Within the bounds of the present study, it can be concluded that the efficacious application of SCTG as a barrier membrane can be done for the treatment of periodontal infrabony defects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Caton JG, Greenstein G. Factors related to periodontal regeneration. Periodontol 2000 1993;1:9-15.  Back to cited text no. 1
    
2.
Kasaj A, Reichert C, Götz H, Röhrig B, Smeets R, Willershausen B, et al. In vitro evaluation of various bioabsorbable and nonresorbable barrier membranes for guided tissue regeneration. Head Face Med 2008;4:22.  Back to cited text no. 2
    
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Needleman IG, Worthington HV, Giedrys-Leeper E, Tucker RJ. Guided tissue regeneration for periodontal infra-bony defects. Cochrane Database Syst Rev 2006:CD001724.  Back to cited text no. 3
    
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Gottlow J, Nyman S, Karring T, Lindhe J. New attachment formation as the result of controlled tissue regeneration. J Clin Periodontol 1984;11:494-503.  Back to cited text no. 4
    
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Cortellini P, Pini Prato G, Tonetti MS. Periodontal regeneration of human intrabony defects with bioresorbable membranes. A controlled clinical trial. J Periodontol 1996;67:217-23.  Back to cited text no. 5
    
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Wang HL, Yuan K, Burgett F, Shyr Y, Syed S. Adherence of oral microorganisms to guided tissue membranes: An in vitro study. J Periodontol 1994;65:211-8.  Back to cited text no. 6
    
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Moghaddas H, Kadkhodazadeh M, Pezeshkfar A. Comparison of the palatal connective tissue graft as a membrane with collagen membrane in combination with Bio-Oss and PRGF for treatment of intrabony defects: A randomized clinical trial. J Dent Sch 2012;1:30-40.  Back to cited text no. 7
    
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Moghaddas H, Ghasemi N. Comparison of the palatal connective tissue graft as a membrane with and without hydroxyapa-tite in the treatment of infrabony defects. Shahid Beheshti Dent J 1999;17:60-8.  Back to cited text no. 8
    
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Kwan SK, Lekovic V, Camargo PM, Klokkevold PR, Kenney EB, Nedic M, et al. The use of autogenous periosteal grafts as barriers for the treatment of intrabony defects in humans. J Periodontol 1998;69:1203-9.  Back to cited text no. 9
    
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Mitrano TI, Grob MS, Carrión F, Nova-Lamperti E, Luz PA, Fierro FS, et al. Culture and characterization of mesenchymal stem cells from human gingival tissue. J Periodontol 2010;81:917-25.  Back to cited text no. 10
    
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Deliberador TM, Trotta DR, Klug LG, Zielak JC, Giovanini AF. Bioactive glass and connective tissue graft used to treat intrabony periodontal defects. Gen Dent 2013;61:72-4.  Back to cited text no. 11
    
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Löe H. The gingival index, the plaque index and the retention index systems. J Periodontol 1967;38 Suppl:610-6.  Back to cited text no. 12
    
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Eickholz P, Hörr T, Klein F, Hassfeld S, Kim TS. Radiographic parameters for prognosis of periodontal healing of infrabony defects: Two different definitions of defect depth. J Periodontol 2004;75:399-407.  Back to cited text no. 13
    
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Srivastava S, Tandon P, Gupta KK, Srivastava A, Kumar V, Shrivastava T, et al. Acomparative clinico-radiographic study of guided tissue regeneration with bioresorbable membrane and a composite synthetic bone graft for the treatment of periodontal osseous defects. J Indian Soc Periodontol 2015;19:416-23.  Back to cited text no. 14
[PUBMED]  [Full text]  
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Kolliyavar B. Subepithelial connective tissue graft. Int J Inform Res Rev 2016;3:1647-51.  Back to cited text no. 15
    
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Esfahanian V, Golestaneh H, Moghaddas O, Ghafari MR. Efficacy of connective tissue with and without periosteum in regeneration of intrabony defects. J Dent Res Dent Clin Dent Prospects 2014;8:189-96.  Back to cited text no. 16
    
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Stein JM, Fickl S, Yekta SS, Hoischen U, Ocklenburg C, Smeets R, et al. Clinical evaluation of a biphasic calcium composite grafting material in the treatment of human periodontal intrabony defects: A 12-month randomized controlled clinical trial. J Periodontol 2009;80:1774-82.  Back to cited text no. 17
    
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Moghaddas H, Soltani L, Moghaddas O. Efficacy of palatal connective tissue graft as a membrane in the treatment of infrabony defects. J Periodontol Implant Dent 2010;2:70-6.  Back to cited text no. 18
    
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Paolantonio M, Femminella B, Coppolino E, Sammartino G, D'Arcangelo C, Perfetti G, et al. Autogenous periosteal barrier membranes and bone grafts in the treatment of periodontal intrabony defects of single-rooted teeth: A 12-month reentry randomized controlled clinical trial. J Periodontol 2010;81:1587-95.  Back to cited text no. 19
    
20.
Esfahanian V, Moghaddas H, Moghaddas O. Efficacy of connective tissue as a membrane with an organic bone using platelet-rich plasma in the treatment of infrabony vertical defects. J Isfahan Dent Sch 2012;8:1-17.  Back to cited text no. 20
    
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Sculean A, Nikolidakis D, Schwarz F. Regeneration of periodontal tissues: Combinations of barrier membranes and grafting materials – Biological foundation and preclinical evidence: A systematic review. J Clin Periodontol 2008;35:106-16.  Back to cited text no. 21
    
22.
Riberio FS, Pontes AE, Zuza EP, da Silva VC, Lia RC, Marcantonio E Jr. Connective tissue graft as a biological barrier for guided tissue regeneration in infrabony defects: A histological study in dogs. Clin Oral Invest 2015;19:997-1004.  Back to cited text no. 22
    
23.
Wiltfang J, Merten HA, Peters JH. Comparative study of guided bone regeneration using absorbable and permanent barrier membranes: A histological report. Int J Oral Maxillofac Implants 1998;13:416-21.  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]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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