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Year : 2019  |  Volume : 23  |  Issue : 2  |  Page : 137-144  

Comparative evaluation of clinical efficacy of coronally advanced flap alone and in combination with placental membrane and demineralized freeze-dried bone allograft in the treatment of gingival recession

Department of Periodontics, Faculty of Dental Sciences, SGT University, Gurugram, Haryana, India

Date of Submission04-May-2018
Date of Acceptance16-Sep-2018
Date of Web Publication1-Mar-2019

Correspondence Address:
Dr. Priyanka Chopra
Professor and Head, Department of Periodontics, Faculty of Dental Sciences, SGT University, Gurugram, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisp.jisp_308_18

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Background: Guided tissue regeneration is a very commonly employed technique for treating recession defects. However, achieving the required space beneath the membrane is often difficult. Aim and Objectives: The purpose of the present study was to compare and evaluate the clinical efficacy of coronally advanced flap (CAF) alone or in combination with amnion membrane (AM) or chorion membrane (CM) and demineralized freeze-dried bone allografts (DFDBAs) in the management of gingival recession (GR) defects. Materials and Methods: The sample size (Miller's Class I and Class II GR-type defects) consisted of thirty patients which were stratified into three groups randomly (ten for each group). Group A patients were treated with only CAF and Group B patients were treated by CAF in combination with CM and DFDBA. Similarly, Group C patients were treated by CAF in combination with AM and DFDBA. Clinical parameters such as gingival index, GR depth, GR width, relative attachment level, and width of keratinized tissue were assessed at baseline and 3 months postoperatively. Results: Inter- and intragroup data were analyzed by paired t-test. The percentage of root coverage obtained in the study groups was 60%, 78%, and 63%, respectively, for Groups A, B, and C. Statistically significant difference was obtained in the clinical parameters of Group B which was treated with CM and DFDBA. Conclusions: Combination of DFDBA and placental membrane (chorion/amnion) in CAF procedure provided an additional benefit over CAF alone in the treatment of Class I and II GR defects.

Keywords: Amnion membrane, chorion membrane, demineralized freeze-dried bone allograft, gingival recession

How to cite this article:
Chopra P, Kassal J, Masamatti SS, Grover HS. Comparative evaluation of clinical efficacy of coronally advanced flap alone and in combination with placental membrane and demineralized freeze-dried bone allograft in the treatment of gingival recession. J Indian Soc Periodontol 2019;23:137-44

How to cite this URL:
Chopra P, Kassal J, Masamatti SS, Grover HS. Comparative evaluation of clinical efficacy of coronally advanced flap alone and in combination with placental membrane and demineralized freeze-dried bone allograft in the treatment of gingival recession. J Indian Soc Periodontol [serial online] 2019 [cited 2022 Aug 18];23:137-44. Available from:

   Introduction Top

Reconstruction of gingiva is an essential part of periodontal practice.[1] Gingival recession (GR) is a state in which the apical migration of gingiva occurs leading to dentinal hypersensitivity, root caries, and esthetic concerns. According to the cross-sectional and longitudinal analyses, Serino et al. stated that in individuals with a high standard of oral hygiene: (i) buccal GR was frequent, (ii) the proportion of participants with recession increased with age, and (iii) the prevalence as well as the incidence of recessions within the dentition showed different patterns depending on age.[2]

Expected coverage of recession defects is a challenge for any periodontist.[3] Several treatment modalities have been used such as pedicle flaps, coronally advanced flaps (CAFs), and combination techniques such as subepithelial connective tissue grafts.[4] These procedures hold some drawbacks as there is a requirement for the second surgical site, morbidity associated with procuring donor grafts, discomfort, and poor color match.[3],[4]

To overcome these limitations, additive treatment modalities such as guided tissue regeneration (GTR) was introduced. Pini-Prato et al. stated that occlusive membranes can be successfully used in the management of GR defects.[5]

Lately, the use of placental-derived tissue which serves mesenchymal stem cell reserve has gained popularity. For successful tissue engineering, the role of scaffold is very crucial. Cells and tissues grow on the scaffold. Niknejad et al. stated that the amniotic membrane (AM) may be regarded as a possible source for scaffolding material.[6]

In dentistry, AMs and chorion membranes (CMs) which are derived from fetal tissue are being used for GTR. These membranes are able to maintain morphology of regenerated tissues and induce pronounced healing as well along with reduced scarring.[6],[7] To be successful in GTR procedures, it is required to create and retain the potential space formed involving the overlying GTR barrier and the underlying root. This space facilitates relocation of progenitor cells which further differentiate into cementoblasts and periodontal ligament-forming cells.[5],[8] According to Duval et al., it is not easy to attain space maintenance when performing root coverage procedures. GTR membranes have a tendency to collapse against the root; hence, techniques to allow space for regeneration of tissue have been developed such as tenting sutures, root modification, titanium-reinforced membranes, and bone grafts such as demineralized freeze-dried bone allograft (DFDBA).[9]

Thus, the aim of the present study was to compare the clinical efficacy of CAF alone or in combination with AM or CM and DFDBA in the management of GR of Miller's Class I or II defects.

   Materials and Methods Top

Thirty patients in the age range of 20–50 years, attending the outpatient department of periodontics, were enrolled for the study [Figure 1].
Figure 1: Consort flowchart of the study. n – sample size

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The sample size was analyzed using the following formula:[10]

n = [Zα/2 + Zβ]2* 2*α2/d2

Where Zα/2 is the critical value of the normal distribution at α/2.

Once the ethical committee of the university approved the study, the study design was communicated to the patients and their informed consent was obtained.

Miller's[11] Class I and II recession defects present in the maxillary anteriors and premolars were included in the study. Patients had to be more than 18 years old who were able to maintain adequate oral hygiene measures (full-mouth plaque index score of ≤20%).

Patients fulfilling any of the following criteria were excluded from the study:

  1. Systemic diseases or condition/s known to affect the outcome of periodontal therapy
  2. Allergic to any medications
  3. Pregnant and lactating women
  4. Use of tobacco in any form
  5. Patients under anticoagulant treatment or having any bleeding disorder
  6. Patients with caries or restorations in the area of concern
  7. Patients undergoing orthodontic treatment
  8. Patients with recent account of dental/periodontal surgery in a span of 6 months.

Randomization was done by drawing envelopes and patients were assigned to three treatment groups:

  • Group A – Patients treated by CAF only (n = 10)
  • Group B – Patients treated by CAF in combination with DFDBA and CM (n = 10)
  • Group C – Patients treated by CAF in combination with DFDBA and AM (n = 10).

Just before the surgical procedure, the sealed envelope containing the treatment assigned was opened.

Clinical measurements

The study models and working cast models were prepared, and photographs were taken. Acrylic stents were used for all pre- and postoperative clinical measurements. An orientation point was marked on the stent at the mid-facial area of the intended tooth [Figure 2].
Figure 2: Preoperative recession defect measurement at baseline

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Clinical parameters were evaluated at baseline (BL) and 3 months postoperatively. The following clinical measurements were taken:

  1. Gingival index (GI)[12]
  2. GR depth (GRD) calculated from the cementoenamel junction (CEJ) to the free gingival margin at the center of facial surface[9],[13]
  3. GR width (GRW) calculated across the labial surface and at CEJ[9],[13]
  4. Relative attachment level (RAL) measured midlabially with the reference point situated at the buccal cusp/incisal edge[9],[13],[14]
  5. Complete or partial root coverage[9],[13],[14] estimated using the following formula:

  6. Width of keratinized tissue (KTW) measured from the gingival margin to the mucogingival junction (MGJ), at the mid-buccal point. The MGJ was noted by means of Schiller's iodine.[13],[14]

The gingival biotype and its thickness were assessed according to the transparency of the periodontal probe.[15] Complete hematological and biochemical investigations were carried out. The enrolled patients underwent nonsurgical therapy comprising thorough scaling and root planing and occlusal adjustments as required. After 3 weeks, a periodontal re-assessment was performed. All the clinical parameters were measured by a sole examiner at BL and at 3 months.

Evaluation of patient perception and intraoperative morbidity

Patient awareness of intra- and postoperative morbidity[16] was assessed with a questionnaire provided directly after surgery and at the time of suture removal. The questionnaire incorporated dichotomous questions and the assessment of the given episode on a visual analog scale (VAS) of 10 cm.

Surgical procedure

All the surgical procedures were carried out by a sole operator. CAF was advocated utilizing the method depicted by Pini-Prato et al.[17],[18] After preoperative oral antisepsis, the surgical area was anesthetized. Mesial and distal to the incorporated tooth, vertical releasing incisions on the facial side were executed going beyond the MGJ and into the mucobuccal fold [Figure 3] so that the flap could be easily repositioned coronally without any tension. Intrasulcular incision was then executed in the same tooth, and a mucoperiosteal flap, trapezoidal in shape, was elevated up to the defect. Partial-thickness flap was then raised in the area apical to the recession defect [Figure 4]. In the adjoining interdental papillae, de-epithelialization was made to provide a bleeding connective tissue bed.[17] Root planing was done using a sharp curette up to 1 mm from the osseous crest. Any remaining muscle tension was relieved by extension of the partial-thickness flap and coronally repositioned to cover the CEJ entirely in the Group A. Direct loop sutures were given. Similarly, in the Group B [Figure 5] and Group C [Figure 2], the incision and reflection of the flap remained the same [Figure 6]. DFDBA bone graft was coated uniformly to a thickness of approximately 1 mm to cover the root to the CEJ and 2 mm of the adjacent bone [Figure 7] and [Figure 8]. A placental-derived membrane (human chorion [Tissue Bank, Tata Memorial Hospital, Mumbai, Maharashtra, India] in Group B and amnion # in Group C) was trimmed to cover 2–3 mm of the bone surrounding the exposed root surface. Cervical portion of the membrane was trimmed in a semilunar shape to allow adaptation to the root. At the level of the CEJ, the membrane was grasped to the tooth with 5-0 polyglycolide-polylactide absorbable sling-tag suture, engaging both membrane and the papillae. The membrane was repositioned to cover the DFDBA [Figure 8]. The pedicle flap was coronally advanced to envelop the membrane and secured to the adjacent papillae with 4-0 silk sutures.
Figure 3: Group A – Two divergent vertical releasing incisions made beyond mucogingival junction. An intrasulcular incision is made to connect the two vertical releasing incisions

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Figure 4: Group A – Partial-thickness flap elevated

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Figure 5: Group B – Demineralized freeze-dried bone allografts followed by human chorion membrane placed

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Figure 6: Group C – Partial-thickness flap elevated

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Figure 7: Group C – Demineralized freeze-dried bone allografts placed evenly over the root surface

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Figure 8: Group C – Human amniotic membrane is positioned over the graft, and flap is relieved of any tension

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Postoperative instructions were provided. For plaque control, 0.2% chlorhexidine gluconate solution was prescribed to apply at the surgical site with a cotton swab daily. Amoxicillin 500 mg TDS and ibuprofen 400 mg TDS for 7 days were prescribed. Two weeks later, patients were recalled for suture removal and follow-up. Clinical parameters were assessed after 3 months [Figure 9], [Figure 10], [Figure 11].
Figure 9: Group A – Healing at 3 months

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Figure 10: Group B – Root coverage at 3 months healing

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Figure 11: Group C – Root coverage at 3 months healing

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Statistical analysis

Mean ± standard deviation was used to execute descriptive statistics. Student's paired t-test was utilized to statistically analyze pre- and postsurgical outcomes. At 95% confidence level, significance was stated. P ≤ 0.05 was regarded as statistically significant.

   Results Top

Thirty patients presenting with Miller's Class I and II GR defects were enrolled in the study. [Table 1] represents the demographic details of the study population. There was no significant difference among the study population. They were equally divided into three groups. [Table 2] presents the clinical parameters at BL and 3 months.
Table 1: Demographic details

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Table 2: Clinical parameters in the study groups at baseline and 3 months

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Throughout the study period, no untoward events such as exposure of the membrane or any postoperative complications occurred. Patient perception of the hardship of the three procedures based on VAS was mild, and there was no statistically significant difference between study groups. Patients were assessed at 3 months for gingival biotype transformation, and 27 of 30 GR defects had a thick biotype [Table 3].
Table 3: Pre- and postoperative number of gingival recession with thick and thin biotype

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Comparison of the study groups with respect to GI score at BL and 3 months depicted that score of GI reduced significantly in all the study groups [Table 2], P ≤ 0.05]. GRW also reduced significantly in all the study groups. A highly significant reduction was seen in the Group B treated with CM and DFDBA (P < 0.01) when compared to Group A and Group C. Similarly, the GRD and RAL significantly reduced in all the study groups over the 3-month period. However, KTW increased (statistically significant, P ≤ 0.01) in all the study groups.

A highly significant reduction in the GRD as calculated by the percentage of root coverage was seen in Group B (78%) which was treated with CM and DFDBA [Graph 1].

   Discussion Top

GR is one of the major esthetic concerns in periodontology, leading to hypersensitivity because of root exposure and subsequent exposure of dentinal tubules. Maintenance of overall health of the gingiva is crucial in the outcomes of root coverage procedures. Zucchelli and De Sanctis[19] stated that individuals who fail to comply with the regular maintenance care plan are related with the recurrence in GR. In the present study, the score of GI decreased over the study period, indicating good maintenance of oral hygiene by the study participants. A significant decrease in GI also suggests an uneventful healing and enhanced gingival health during the study time.

CAF is a commonly employed root coverage procedure. Various studies with CAF have shown mean root coverage ranging from 45% to 95% in Miller's Class I and II GR.[19] A meta-analysis reported that CAF and/or combined procedures had the highest probability for recession reduction and maximum root coverage.[20] We have incorporated CAF, which resulted in 60% root coverage in Group A. However, CAF when used alone is unstable, especially for long duration. GTR procedures have been established to provide good results.[21] Leong and Wang stated that if the purpose is to obtain a new attachment, then additive procedures such as GTR can be considered.[22] These kind of techniques offer numerous advantages compared to the autogenous grafts.[23],[24] AM–CM is a placental-derived tissue that has been introduced lately as GTR membrane.[25] Amnion is a thin, tough, transparent membrane. Chorion side of the membrane is coarse and porous. Both membranes are easily separable from each other. Following separation, the amnion seems smooth, shiny, and also easily manageable than the chorion.[26]

Numerous growth factors, proteins, and stem cell reserves in amnion aid wound healing and regeneration process. Amnion is composed of several types of laminins, with laminin-5 being the most prevalent which plays a role in the cellular adhesion of gingival cells. Chorion is a rich source of collagen and noncollagen proteins.[27]

DFDBA used in the study may create and maintain extra space that is needed for new attachment formation.[9] Furthermore, it has been shown to possess osteoinductive and/or osteogenic properties that may promote new attachment and bone formation.[14],[28]

The GRW reduction observed is according to the results by Chakraborthy et al.[29] and Irfan et al.[10] In the study,[29] on comparison of chorion and amnion groups with respect to the width of recession, statistically significant difference was observed in both the groups at 3 months (P = 0.001) and at 6 months. In the present study, relative reduction of GRW at 3 months in the Group C (treated with AM and DFDBA) is less as compared to Group A and Group B. This finding can be attributed to the fact that AM is thin and it is difficult to handle as compared to the CM.[10],[29]

Mean gain of attachment level at 3 months was highest (2.6 mm) for the Group B treated with chorion and DFDBA. Our results are in accordance to Esteves et al.[13] where they reported a gain of 3.71 mm at 3 months with CM only. Brain[30] accounted a clinical attachment gain in the range of 1.2 ± 1.51 mm with AM, which is in accordance to the results of the present study. Similar results were also obtained by authors who used amnion as GTR membrane.[10],[30],[31]

At BL, there were no significant differences in KTW. However, a significant increase in the width of keratinized gingiva was observed in all the groups at 3 months. According to a study done by Lafzi et al.[32] there were no significant differences in KTW assessment in visual and histochemical methods.

In the present study, Miller's Class I and II recessions with not more than 4 mm were involved. This is because sites with deeper recession defects tend to respond less favorably than shallower sites.[17],[18] GRD was reduced significantly from BL to 3 months in all the groups, with maximum reduction taking place in Group B. This was evident in the percentage of root coverage calculation, where 60%, 78%, and 63% of root coverage was observed in the Groups A, B, and C, respectively [Graph 1]. Esteves et al. in a similar study reported promising results when the recessions were treated with CM.[13] However, Chakraborthy et al. reported that the root coverage was 24% and 28% for amnion and chorion groups, respectively.[29] The better results achieved in our study can be attributed to the addition of DFDBA, which provided adequate space beneath the membrane for new attachment. Few studies have reported regarding additive effect of bone grafts in the treatment of GR.[14] To our knowledge, no single report exists regarding the use of DFDBA and placental membranes. Both the Groups A and B demonstrated enhancement in the numerous clinical parameters, and CM exhibited superior handling properties in contrast to the AM owing to its thickness and hence showed improved results at the end of 3 months.[10],[13],[29] Placental membrane completely resorbs into the wound in about 2–4 weeks. AM may induce rapid epithelialization and acceptable collagen formation in as early as 10 days, suggesting that AM transplantation may promote rapid gingival wound healing.[33]


Randomized controlled trials with long-term follow-up period need to be carried out to assess the benefits of both the placental allografts in combination with bone grafts.

   Conclusions Top

In the light of the above findings, it can be safely concluded that CAF when combined with placental membrane and DFDBA can yield better results compared to CAF alone in Miller's Class I and II GRs. More studies with bigger sample size and extended duration are necessary to validate the above results.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

# Tissue bank, Tata Memorial Hospital, Mumbai, Maharashtra, India.

   References Top

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Serino G, Wennström JL, Lindhe J, Eneroth L. The prevalence and distribution of gingival recession in subjects with a high standard of oral hygiene. J Clin Periodontol 1994;21:57-63.  Back to cited text no. 2
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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. 4
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]

  [Table 1], [Table 2], [Table 3]

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