Treatment of localized gingival recession using the free rotated papilla autograft combined with coronally advanced flap by conventional (macrosurgery) and surgery under magnification (microsurgical) technique: A comparative clinical study.

BACKGROUND: The aim of the present study was to evaluate and compare the conventional (macro-surgical) and microsurgical approach in performing the free rotated papilla autograft combined with coronally advanced flap surgery in treatment of localized gingival recession.
MATERIALS AND METHODS: A total of 20 sites from 10 systemically healthy patients were selected for the study. The selected sites were randomly divided into experimental site A and experimental site B by using the spilt mouth design. Conventional (macro-surgical) approach for site A and micro-surgery for site B was applied in performing the free rotated papilla autograft combined with coronally advanced flap. Recession depth (RD), recession width (RW) clinical attachment level (CAL.) and width of keratinized tissue (WKT.) were recorded at baseline, 3 months and 6 months post-operatively.
RESULTS: Both (macro- and microsurgery) groups showed significant clinical improvement in all the parameters (RD, RW, CAL and WKT). However, on comparing both the groups, these parameters did not reach statistical significance.
CONCLUSION: Both the surgical procedures were equally effective in treatment of localized gingival recession by the free rotated papilla autograft technique combined with coronally advanced flap. However, surgery under magnification (microsurgery) may be clinically better than conventional surgery in terms of less post-operative pain and discomfort experienced by patients at the microsurgical site.

RCT Entities:   Population Interventions Outcomes

INTRODUCTION

The main goal of periodontal therapy is to improve periodontal health and thereby to maintain a patient's functional dentition throughout his/her life. However, esthetics represents an inseparable part of today's periodontal therapy and several procedures have been proposed to preserve or enhance patient esthetics. New technologies, materials, instruments and surgical techniques are therefore necessary to help the clinician ensure the best results and satisfy patient's expectations.[1] One of the most frequent indications of “periodontal plastic surgery,” first suggested by Miller in 1988, is the treatment of gingival recession in the esthetic zone.[2]

Gingival recession can be defined as a shift of the gingival margin to a position apical to the cemento-enamel junction (CEJ) with the exposure of root surface.[3] Plaque induced periodontal inflammation, tooth brushing trauma,[1] tooth malposition, alveolar bone dehiscence, high frenum attachment, iatrogenic factors related to restorative and periodontal procedures, as well as orthodontic tooth movement have been associated with the development of gingival recession.[4] Esthetics, dentin hypersensitivity, root caries and cervical abrasions are the indications for root coverage.[1]

Treatment modalities to obtain root coverage can be classified as pedicle grafts, free soft-tissue grafts or a combination of the two. Among the soft-tissue grafts, the subepithelial connective tissue graft combined with or without a coronally advanced flap, is the most widely used and predictable technique in the esthetic treatment of gingival recession. The main disadvantage of these procedures is the requirement of a second surgical site for procuring the connective tissue, thereby increasing post-operative patient discomfort and morbidity.[4]

To overcome the disadvantage of these procedures and improving patient's compliance, the free rotated papilla autograft procedure was described by Tinti and Parma-Benfenati.[5] The main indication of this procedure is the coverage of localized or multiple gingival recessions with perfectly preserved mesial and distal inter-proximal osseous crests and with a papillary dimension not inferior to the defect, which needs to be treated. This procedure has the added advantage of (i) a single surgical site thereby avoiding patient discomfort in the palatal region (ii) good color harmony with adjacent tissues and (iii) healing by primary intention.

Microsurgery refers to a surgical procedure performed under a microscope.[6] The surgical operating microscope is an invaluable tool in periodontal microsurgery.[4] The surgical operating microscope provides a microsurgical triad of illumination, magnification and an environment in which surgical skills can be refined.[7] Since only a few studies are available in the literature comparing the macro-surgical and microsurgical techniques in periodontal plastic surgery, the present study was undertaken (1) to evaluate the clinical effectiveness of free rotated papilla autograft procedure combined with coronally advanced flap using the microsurgical technique in root coverage procedures and (2) compare the efficacy of conventional macro-surgery and microsurgical techniques using free rotated papilla autograft combined with coronally advanced flap in treatment of localized gingival recession.

MATERIALS AND METHODS

Patient selection

Ten systemically healthy patients were selected from the Out-patient Department of Periodontics, Bapuji Dental College and Hospital, Davangere, Karnataka. Inclusion criteria were: Patients in the age range of 20-45 years, having at least two sites of Miller's class I or class II gingival recession labially in different quadrants with thick and wide interproximal papilla not smaller than the recession defect. Severe cervical abrasion/root caries that would require restoration, abnormal frenal attachments, interdental bone loss with tooth mobility and patients with contraindications for periodontal surgery were the exclusion criteria.

Study design

After the completion of the pre-surgical phase of treatment. A total of 20 bilateral sites from 10 patients were selected for the study. The selected sites were randomly divided into experimental site A and experimental site B by using the spilt mouth design. The following clinical parameters were recorded at baseline, 3 months and 6 months post-operatively:

Plaque index[8]

Gingival index[9]

Recession depth (RD): From CEJ to the free gingival margin

Recession width (RW): Horizontal dimension of gingival defect at the level of the CEJ

Clinical attachment level (CAL): From a fixed reference point (occlusal stent with guiding grooves) to the base of the pocket

Width of keratinized tissue (WKT): From the crest of gingival margin to mucogingival junction.

The clinical measurements were made with UNC 15 periodontal probe and occlusal stent with guiding grooves. Prior to commencement, the study design was approved by the Institutional Review Board and ethical clearance was taken from Institutional Ethical Committee. The nature, type and duration of treatment were discussed with all the participating patients and informed consent was obtained from each of them. All the selected patients underwent routine blood investigations and intra-oral periapical radiographs of the area of interest. On completion of the above procedures, the selected gingival recession sites were randomly assigned as either experimental site A or experimental-site B for surgical treatment.

After an extra-oral scrubbing with betadine antiseptic solution and a pre-procedural rinse of 0.2% chlorhexidine digluconate, the operative site was anaesthetized with 2% lignocaine HCl with adrenaline (1:80,000), using block and infiltration techniques.

Surgical procedure (experimental site A)

After obtaining adequate anesthesia, a vertical beveled sharp incision was made in the vestibule distal to the recession defect with Bard-Parker blade 15, continuing horizontally at the CEJ and in the gingival sulcus and finally ending in another vertical beveled releasing incision mesial to the recession defect. Initially, a full thickness trapezoidal flap continuing into a partial-thickness flap was raised, taking care to preserve the adjacent papillae. Then the buccal side of the larger papilla (donor site) and the recipient area was de-epithelized. The buccal papillary tissue of the de-epithelialized papilla was excised, rotated 180° to place its base at the CEJ and stabilized at the recipient site by a horizontal absorbable suture (Vicryl 5-0). The partial thickness flap was now coronally positioned, taking care to avoid any tension of the gingival tissue. Vertical mattress sutures for the papillae and interrupted through-and-through sutures for the vertical releasing incisions (prolene 5-0) were used to obtain stable and complete coverage of the grafted tissue. Digital pressure was then applied for 5 min.

Surgical procedure (experimental site B)

All of the above mentioned steps were performed with a surgical operating microscope (Serwell Company, Chennai) under ×10 magnification. The crevicular incisions were given using the crescent ophthalmic microsurgical knife (Sharpedge Company, Ahmedabad). The vertical incisions were given using the lancet ophthalmic microsurgical knife (Sharpedge Company, Ahmedabad) [Figures 1–6]. The operated site was covered with Coe-Pak (GC India) and routine post-surgical instructions were given. Patients were prescribed systemic amoxicillin 500 mg thrice daily for 5 days, ibuprofen 400 mg thrice daily for 3 days and chlorhexidine gluconate (0.2%) mouthwash twice daily for 2 weeks.

Figure 1

Placement of vertical incision by micro-scalpel

Figure 6

(a) Pre-operative view (site B); (b) Post-operative view at 6 months (site B)

Microsurgical view of flap reflection

Harvested papilla autograft

Flap coronally advanced and sutured

(a) Pre-operative view (site A); (b) Post-operative view at 6 months (site A)

The periodontal dressing and sutures were removed after 1 week and all patients were kept under a recall program for clinical examination at 3 months and 6 months.

Statistical analysis

Data were summarized as mean ± standard deviation Groups were compared by repeated measures two factor analysis of variance and the significance of mean difference within and between the groups was performed by Bon ferroni post-hoc test after adjusting for multiple contrasts. Categorical groups were compared by Chi-square test. A two sided (α =2) P < 0.05 was considered statistically significant.

RESULTS

On post-operative examinations, the following clinical observations were made:

RD

Site A

The mean RD at baseline was 2.97 ± 1.58 mm, which was reduced to 0.97 ± 0.50 mm at 3 months and 0.83 ± 0.43 mm at 6 months showing a mean reduction of 2.0 mm and 2.13 mm at 3 and 6 months respectively, which were statistically significant (P < 0.05).

Site B

The mean RD at baseline was 2.98 ± 1.45 mm which was reduced to 0.97 ± 0.45 mm at 3 months and 0.93 ± 0.42 mm at 6 months showing a mean reduction of 2.02 mm and 2.05 mm at 3 and 6 months respectively, which were statistically significant (P < 0.05).

Comparison of the mean reduction in RD between the two groups at baseline to 3 and 6 months revealed a difference of 0.01667 mm and 0.05 mm respectively, which was statistically not significant (P > 0.05) [Tables 1–3 and [Graph 1].

Table 1

Intra-group comparison of clinical parameters at site A

Table 3

Inter group comparison of clinical parameters

Graph 1

Comparison of mean changes in recession depth (inter-group)

RW

The mean RW at baseline was 3.50 ± 1.25 mm which was reduced to 1.90 ± 1.26 mm at 3 months and 1.70 ± 1.32 mm at 6 months showing a mean reduction of 1.60 mm and 1.80 mm at 3 and 6 months respectively, which were statistically significant (P < 0.05).

The mean RW at baseline was 3.85 ± 1.60 mm which was reduced to 2.20 ± 1.86 mm at 3 months and 2.05 ± 1.55 mm at 6 months showing a mean reduction of 1.65 mm and 1.80 mm at 3 and 6 months respectively, which were statistically significant (P < 0.05).

Comparison of the mean reduction in RW between the two groups at baseline to 3 and 6 months revealed a difference of 0.05 mm and 0.00 mm respectively, which was statistically not significant (P > 0.05) [Tables 1–3].

CAL

The mean CAL at baseline was 5.93 ± 1.00 mm which was reduced to 5.67 ± 1.11 mm at 3 months and 5.43 ± 1.12 mm at 6 months showing a mean reduction of 0.27 mm and 0.50 mm at 3 and 6 months respectively, which were statistically not significant (P > 0.05).

The mean CAL at baseline was 6.50 ± 1.50 mm which was reduced to 5.97 ± 1.19 mm at 3 months and 5.80 ± 1.16 mm at 6 months showing a mean reduction of 0.53 mm and 0.70 mm at 3 and 6 months respectively, which were statistically not significant (P > 0.05).

Comparison of the mean reduction in CAL between the two groups at baseline to 3 and 6 months revealed a difference of 0.266 mm and 0.020 mm respectively, which was statistically not significant (P > 0.05) [Tables 1–3].

WKT

The mean WKT at baseline was 2.95 ± 0.37 mm which was increased to 3.25 ± 0.26 mm at 3 months and 3.40 ± 0.21 mm at 6 months showing a mean gain of 0.30 mm and 0.45 mm at 3 and 6 months respectively. The mean gain of 0.30 mm from baseline to 3 months was statistically insignificant (P > 0.05). However, the mean gain of 0.45 mm from baseline to 6 months was found to be statistically significant (P < 0.05).

The mean WKT at baseline was 2.80 ± 0.42 mm which was increased to 3.15 ± 0.47 mm at 3 months and 3.25 ± 0.35 mm at 6 months showing a mean gain of 0.35 mm and 0.45 mm at 3 and 6 months respectively, which were statistically significant (P < 0.05).

Comparison of the mean gain in WKT between the two groups at baseline to 3 and 6 months revealed a difference of 0.05 mm and 0.00 mm respectively which was statistically not significant (P > 0.05) [Tables 1 and 3 and [Graph 2].

Graph 2

Comparison of mean changes in width of keratinized gingiva (intra-group)

The secondary outcome measures of the study were pain and discomfort at the operative sites. At the recall appointments, 60% of patients reported pain at site A while only 20% reported pain at site B [Graph 3]. Furthermore, when comparing between both the sites, 60% of patients reported less discomfort at site B in contrast to 30% at site A [Graph 4]. However, the difference between these measures was found to be statistically not significant (P > 0.05).

Graph 3

Pain response

Graph 4

Comfort level

DISCUSSION

In the current practice of periodontics, clinicians are faced with the challenge of not only addressing biological and functional problems present in the periodontium, but also providing therapy that result in acceptable esthetics. The presence of mucogingival problems and gingival recession around the teeth in the esthetic zone exemplifies a situation in which a treatment modality that addresses both biological and esthetic demands is required from the periodontist.[10] A variety of surgical techniques, classified as pedicle soft-tissue grafts, free soft-tissue grafts or combination of the two have been suggested to obtain root coverage in areas of soft-tissue recession. A newer technique introduced by Francetti et al.[4] describes the combined use of the free rotated papilla autograft, originally described by Tinti and Parma-Benfenati[5] for the coverage of multiple shallow gingival recessions and a coronally advanced flap. The main objective of this approach was to minimize the post-surgical course and patient discomfort in the treatment of localized recession with the main advantage being the involvement of a single surgical site unlike in the connective tissue grafting.

The application of magnification in periodontics promises to further enhance its clinical significance in providing specialist periodontal surgical care. Microsurgery implies an extension of surgical principles by which gentle handling of tissue and exceedingly accurate approximation of the wound edges is of paramount importance.[11] Therefore the present study was undertaken to compare the conventional macro-surgical and microsurgical approach and evaluate the effectiveness of the surgical procedure described by Francetti et al.[4] In the present study, the split mouth design was selected because it excludes the influence of patient's specific characteristics and facilitates the interpretation of trials by minimizing the effects of inter-patient variability.[12] The occlusal stent with guiding grooves was used as it maintains the constant position, direction and angulation of periodontal probe while recording clinical parameters.[13]

In the present study, there was significant reduction in RD in both the treatment groups when baseline reading was compared with 3 and 6 month data. This finding is consistent with the observations made by other group of researchers.[3514] This finding can be attributed to the cumulative effectiveness of the surgical procedure and the maintenance of good oral hygiene by patient during the post-operative follow-up period. Comparison of mean reduction in RD between the two groups at baseline to 3 and 6 months showed clinical improvement similar to those by Francetti et al.[115] though it was contradictory to the finding of other studies.[16] This observation in our study may be attributed to the comparable effectiveness of both the procedures in treating such problems. Similarly, the post-operative mean reduction in RW in both groups was clinically significant. This finding also supports the comparable effectiveness of both macro- and microsurgeries in treating such recession defects.[151617]

The mean CAL values at site A at 3 and 6 were not in accordance with the findings of many authors.[3514] At site B, the mean CAL values at 3 and 6 months were also not in accordance with the findings of many authors.[14] The reason for the contradictory findings at both the sites may be that in the present study, the use of pressure sensitive probe probably would have influenced the present results to some extent. Comparison of the mean reduction in CAL between the two groups at baseline to 3 and 6 months revealed findings, which are consistent with the observations made by Francetti et al.[11517] The mean WKT at site A at 3 and 6 months corroborated with Andrade et al.[15] In site B, the mean increase in WKT at 3 and 6 months was consistent with the studies.[141517] This finding further demonstrates the comparable effectiveness of both conventional (macro) and surgery under magnification (microsurgeries) in the treatment of gingival recession. Comparison of the mean gain in WKT at 3 and 6 months revealed observations similar to Francetti et al.[1]

The aim of this clinical study was to evaluate the advantages offered by magnification in periodontal plastic surgery in terms of both the periodontal condition and esthetic result. Most of patients who participated in the study were satisfied with the esthetic result of the treatment. The efficacy of the free rotated papilla autograft technique was well-established in this study. It is noteworthy to mention that the technique should be only applied in cases of Miller's class I and shallow class II defects as the adjacent papillary dimension becomes a limiting factor in this technique. There was no significant reduction of the donor papillary height or formation of a black triangle at both the sites. Both the marginal gingiva and papillae showed a good esthetic appearance till the end of the study. Furthermore, most of the patients who participated in the study reported less post-operative discomfort and pain at the microsurgical site. This may be attributed to the advantages of the microsurgical approach in atraumatic and accurate handling of soft-tissues. Furthermore, the coronal advancement of the flaps, which was easier and tension free with the operating microscope, could have led to favorable response from patients.

Hence, the importance of magnification in periodontal surgery cannot be underestimated because the magnification under the powerful illumination provided by the microscope definitely enhancing the visualization of the surgical site and the use of smaller micro-knives permitting an extremely fine and accurate incision. Furthermore, after flap reflection, better debridement of the recipient site was accomplished, soft-tissue edges could be better approximated and finer sutures could be used.

CONCLUSION

Within the limitation of the study, it can be concluded that both the treatment groups were effective in the treatment of localized gingival recession by employing the free rotated papilla autograft technique combined with the coronally advanced flap. However, on comparison, the mean difference in clinical parameters between the conventional (macro-surgery) and surgery under magnification (microsurgery) group showed no statistical significance. The smaller sample size and shorter follow-up period may be considered as the main limitations of the present study. Hence, a long term clinical trial with a larger sample size is needed to compare the clinical outcomes of the free rotated papilla autograft technique by conventional macro- and microsurgery utilizing the surgical operating microscope.

Table 2

Intra-group comparison of clinical parameters at site B