Comparative clinical evaluation of laterally positioned pedicle graft and subepithelial connective tissue graft in the treatment of Miller's Class I and II gingival recession: A 6 months study.

AIM: The purpose of the study was to compare clinical outcomes of laterally positioned pedicle graft (LPPG) and subepithelial connective tissue graft (SCTG) for treatment of Miller's Class I and II gingival recession defects, at the end of 6 months.
MATERIALS AND METHODS: Sixty Miller's Class I or II gingival recession defects (≥3 mm) (n = 30 each) on the labial aspect of anterior teeth were treated by either of the above techniques. Clinical parameters including recession depth (RD), width of keratinized gingiva (WKG), percentage of root coverage (%RC), and complete RC were recorded at baseline and 6 months postoperatively. Data were recorded and statistical analysis was done for both intergroup and intragroup. STATISTICAL ANALYSIS USED: Paired t-test intragroup and Student's t-test intergroup.
RESULTS: In LPPG, RD decreased from 4.9 ± 0.99 mm to 1.1 ± 0.3 mm and WKG increased from 0.7 ± 0.87 to 4.5 ± 0.86 mm at 6 months, while in SCTG, RD decreased from 4.67 ± 1.12 mm to 0.46 ± 0.68 mm and WKG increased from 1.1 ± 0.99 to 5.33 ± 0.72 mm at 6 months postoperatively. The values of the soft tissue coverage remained stable for 6 months.
CONCLUSIONS: Highly significant and effective soft tissue coverage was obtained by both techniques. LPPG resulted in effective soft tissue coverage for isolated deep narrow defects while SCTG in isolated and multiple, deep narrow and wide defects.

INTRODUCTION

Nowadays, patients have become increasingly aware of the gingival recession and its unaesthetic features. The exposure of cementum and dentin leading to dentinal hypersensitivity becomes a constant discomforting factor to patients in everyday life. Such defects associated with or without abrasion cavities, increase the susceptibility to root caries.[1] A variety of mucogingival procedures exist for treating gingival recession. The efficacy and predictability of various techniques are important considerations for both the patient and clinician. Among patient related factors, an attempt to reduce the number of surgeries, which satisfy the patient's esthetic demands and cost factor, must be taken into consideration.[1]

The laterally positioned pedicle graft (LPPG)[2] is a simple and less invasive surgical technique. Subepithelial connective tissue graft (SCTG)[3] is a standard technique with predictable and reproducible results.

In the present study, an attempt has been made to compare above two surgical procedures for predictable root coverage (RC) of Miller's Class I and II gingival recession defects at the end of 6 months and whether LPPG can substitute SCTG on patient's demand.

MATERIALS AND METHODS

The study was a clinical, comparative, randomized control trial with a time period of 6 months. The study design was approved by the Ethical Committee of the Institution, and emphasis was laid on obtaining informed and written consent by patients. The sample subjects were selected randomly (by DKS) from amongst the patients referred to the Department of Periodontology and Implantology, Government Dental College and Hospital, Ahmedabad, for complaints associated with gingival recession such as unaesthetic looks and dentinal hypersensitivity. Patient inclusion criteria (by BNV) were systemically healthy adults with realistic expectations, age up to 50 years, nonpregnant, nonsmokers, no history of antibiotic treatment within 3 months from the time of commencement of study, good oral hygiene, presence of at least one Miller's Class I or II gingival recession defect of ≥3 mm (deep narrow) on labial aspect of anterior teeth. A total of 60 defects were treated (by DKS). Tooth selected as a donor site should have gingiva that was wide enough to permit proper coverage of the recipient site and thick gingival morphology, high palatal vault with no pathology (donor site), and at least 3 mm of soft tissue thickness from maxillary first molar to maxillary canine region. All selected subjects were explained the nature of the study and a written consent was obtained on a consent form approved by the Ethical Committee (by TSR). Initial therapy consisted predominantly of oral hygiene instructions. Inappropriate or faulty oral hygiene maintenance techniques were rectified. Patients were instructed to adopt Modified Stillman's method for cleaning in areas with gingival recession. Scaling and root planing was done prior to surgical therapy. Any existing trauma from occlusion was eliminated (by TR). An appointment for the surgical procedure generally was arranged 10 days after the initial procedure. At the preoperative examination, the teeth demonstrating recession were examined with respect to soft tissue parameters. Randomization was performed by coin toss method (by TSR). Coin toss was performed by the patient only at the time of treatment and accordingly surgical procedure was performed. The head was assigned to LPPG and tails to SCTG. 30 patients (n = 30) were treated by SCTG[3] and 30 patients (n = 30) were treated LPPG (Grupe and Warren 1956 modified by Grupe 1966).[4]

Clinical parameters: Soft tissue parameters (measured at the selected sites)

An acrylic stent was used, both preoperatively and postoperatively. It acted as a fixed point at the level of cemento-enamel junction to make accurate measurements of root exposure with the help of UNC-15 probe (UNC-15 probe, InSci, Equinox India: InSci, Equinox). The measurements were taken (by DKS) at the midfacial aspect of the tooth. Parameters were: Gingival recession depth (RD); width of keratinized gingiva (WKG); the percentage of RC = (postoperative RD − preoperative RD × 100%)/preoperative RD; and complete RC (CRC). RD and WKG were recorded preoperatively and postoperatively at 10 days, 1-month, 3 months, and 6 months. Percentage of RC and CRC were calculated at 6 months postoperatively.

Surgical procedure

LPPG group [Figure 1a–f]: LPPG was performed according to Grupe and Warren technique[2] with it modification by Grupe.[4]

Figure 1

Lateral positioned pedicle graft. (a) Preoperative surgical site; (b) Removal of epithelial lining and horizontal and vertical incisions given; (c) Flap reflection; (d) Flap placement at recipient site; (e) Suturing; (f) Periodontal pack applied; (g) Follow-up after 10 days; (h) Postoperative 6 months

SCTG group [Figure 2]: SCTG was performed according to Langer and Langer 1985[3] [Figure 2a–c].

Figure 2

Subepithelial connective tissue graft. (a) Preoperative surgical site; (b) Vertical incisions given; (c) Flap reflection; (d) Incisions for trap door at donor site; (e) Graft placed at recipient site; (f) Suturing of graft; (g) Suturing of recipient flap; (h) Periodontal pack applied; (i) Follow-up after 10 days; (j) Postoperative 6 months

Donor site was palate. SCTG was retrieved by Trap door method as described by Nelson 1987[5] [Figure 2d].

The connective tissue graft was placed over the denuded roots and sutured in place [Figure 2e–h]. The donor connective tissue was sutured to the underlying connective tissue interproximally using 4-0 polyglycolic braided vicryl bioabsorbable sutures (4-0 Vicryl™ [polyglycolic braided] Nw2494 Ethicon Johnson and Johnson Ltd., Baddi - 173 205, Himachal Pradesh, India). The partial thickness, recipient flap was positioned coronally in a manner to cover as much of the graft as possible and sutured in this position with 4-0 silk suture (4-0 Mersilk™ [Braided Silk Black] NW 5050 Ethicon Johnson and Johnson Ltd., Baddi - 173 205, Himachal Pradesh, India) and atraumatic needle. No attempt was made to completely cover the graft as this would create an excessive pull on the vestibular fold.

The recipient site was dressed with periodontal dressing (COE PAK™ Periodontal Dressing Regular Set, GC America Inc., Alsip, IL 60803 USA), and the patient was instructed in normal postsurgical management. A dressing was optional on the palate.

Follow-up care

Postsurgical instructions were given. Antibiotic and anti-inflammatory drugs were prescribed. Sutures were removed after 10 days. Patients were seen at 10 days [Figure 1g and 2i] 1-month, 3 months, and 6 months [Figure 1h and 2j]. After removing periodontal dressing, brushing was avoided at the treated site. Instead, the cotton pellet was used to clean and slightly comb the area, an apical to the coronal direction for the next 4 weeks. Data were recorded at every visit. Reinforcement of oral hygiene instruction was also performed. A patient response form was obtained by each patient at the end of 6 months (by BNV), to evaluate patient's experience with either of the technique [Figure 3]. The evaluator was blinded for the type of surgical technique used and refrained from enquiring patient about the technique performed (one surgical site or two surgical sites).

Figure 3

Patient response form

Statistical methodology

The information gathered from the present study was tabulated and analyzed using suitable techniques (by TR). Data were reported as a mean ± standard deviation. To study the effect overtime within groups, the paired t-test was used. The changes in average RD and WKG values at 1, 3, and 6 months from preoperative values were tested. Further, the average change from preoperative to 6 months of the above-mentioned parameters was compared in between groups to see the difference using student t-test. The t-test values were compared with table values to show the level of significance.

RESULTS

Sixty defects of Miller's Class I and II recession defects were treated with either LPPG or SCTG. No case was reported for any postsurgical complications. On the analysis of data, there was a highly significant improvement in all parameters for both the techniques [Table 1]. The mean reduction of RD at 6 months in LPPG was 3.8 ± 0.95 mm; P < 0.001 [Table 1]. The %RC obtained at 6 months was 76.78 ± 6.78% with no site with CRC [Table 2]. The mean reduction of RD at 6 months in SCTG was 4.2 ± 1.45 mm; (P < 0.001) [Table 1]. The %RC obtained at 6 months postoperatively was 88.33 ± 17% with 63.33% sites with CRC [Table 2]. When statistical comparison was done between groups, mean RD of both groups was comparable at baseline (difference not significant). After 6 months of treatment, the difference was statistically significant (0.83 ± 0.46; P < 0.05) [Table 3] with better result for SCTG. The difference between the %RC and CRC was highly significant (P < 0.001) between both the techniques [Table 2]. The mean increase in WKG at 6 months in LPPG was 4.5 ± 0.86 mm; (P < 0.001) and in SCTG was 5.33 ± 0.72 mm; (P < 0.001) [Table 1]. When statistical comparison was done between groups, mean WKG of both groups was comparable at baseline (difference not significant). After 6 months of treatment, the difference was statistically significant (0.83 ± 0.14; P < 0.05) [Table 3] with better result by SCTG.

Table 1

Comparison of mean change of RD and WKG from baseline to postoperative 6 months within group

Table 2

Comparison of mean change of percentage of root coverage and sites with CRC at 6 months between LPPG and SCTG group

Table 3

Comparison of parameters between the groups (LPPG and SCTG)

Table 4 shows the evaluation of patient response form.

Table 4

Data of patient response form

DISCUSSION

The results of the present study agree with those of previous studies reporting on the clinical behavior of LPPG.[67891011121314151617] The results show significant improvement in RD reduction [Table 1] and 76.78 ± 6.78% RC [Table 2] which is comparable to Kunjamma et al.,[13] Ricci et al.,[14] Wennstrom and Pini Prato[15] and Dixit et al.[16] who found 72.95%, 61.9%, 68%, and 68.67% RC, respectively.

The results for SCTG show significant reduction in RD [Table 1] and 88.33 ± 17.78% RC with 63.33% sites with CRC [Table 2] which is in accordance Jahnke et al.,[18] Allen,[19] Ricci et al.,[14] and Dixit et al.[16] who obtained 80% RC and 55.56% CRC, 84% RC and 61% CRC at 6 months, 77.08% RC and 40% CRC at 12 months, 86% RC at the end of 3 months, respectively. Better results were obtained by many other studies.[181920212223242526272829] For the present study while comparing RD reduction between both groups, the SCTG was found to be statistically better than LPPG [Table 3] which is in accordance to Dixit et al.[16] who concluded SCTG to be more effective than LPPG. While a study by Ricci et al.[14] showed no statistically significant difference in RD reduction between both groups.

There is statistically significant increase in WKG in both the groups at the end of 6 months [Table 1]. This appears to be dependent on the amount of tissue transplanted and the durability of the grafts. The relatively intact blood supply within mucoperiosteal flaps together with the factors assisting healing provide a summation effect[30] which would account for the favorable results obtained in the study. The mean increase in WKG for LPPG was 4.5 ± 0.86 mm, [Table 1] which is similar to that obtained by Smukler,[6] Dixit et al.[16] and Santana et al.[17] who reported a mean gain of WKG of 3.18 mm at the end of 9 months, 4.5 ± 1.00 mm at 3 months, and 4.2 ± 1.7 mm at 6 months, respectively. The result obtained by SCTG for increase in WKG was 5.33 ± 0.72 mm [Table 1]. This result is in accordance to Paolantonio et al.,[21] Milano[23] and Rosetti et al.,[24] who reported mean gain on WKG of 4.3 ± 0.9 mm, in 5 years study, 4.3 ± 1.1 at 12 months, and 4.58 mm at the end 18 months, respectively. When both groups were compared after 6 months of treatment, SCTG was statistically significantly better than LPPG in terms of gain in WKG [Table 3]. This could be explained by the fact that SCTG being bilaminar technique wherein dense connective tissue harvested from the palate has the potential to induce keratinization of the epithelial cells of the covering flap and postsurgery reversal of the mucoginigival junction toward its genetically determined location.[28]

The sites treated with SCTG resulted in a significantly higher number of recessions completely corrected, that is, 63.33% as compared to LPPG (0%) [Table 2]. This could be explained on the basis of the presence of a connective tissue graft under the flap (SCTG) that is associated with reduced soft tissue contraction resulting in a significantly greater amount of sites completely covered at 6 months.[29] The prevalence of CRC is poorly documented for LPPG.[17] Thus, in terms of %RC obtained, gain in WKG and CRC, SCTG procedure was more effective than LPPG.

The results obtained by both the procedures in terms of soft tissue coverage and gain in WKG remained stable postoperatively at 6 months. When patient response forms were evaluated [Table 4], it was found that patients found SCTG uncomfortable, and many would not want to recommend others. Furthermore, procedures that made a reduction in the operatory-time eliminated the need for a second surgical site and its associated morbidity were better accepted by patients. However, some patients were not satisfied with results of LPPG as complain of hypersensitivity was not resolved (CRC not obtained).

LPPG procedure provides effective RC in the treatment of gingival recession. The procedure offers many advantages over other surgical procedure. The color and morphology of the position tissue blends with the healed surgical side. Graft survives because of its blood supply from the base of flap. The procedure does not require a separate surgical site for obtaining graft. This procedure is simple to perform and less time consuming. Unfortunately, if sufficient adjacent keratinized tissues do not exist, or if the recession is present on multiple teeth, then this technique is unsuitable. In addition, they have limited applications, working best for deep narrow defects only (Sedon et al. 2005).[31] Careful case selection is essential for CRC. Although this is a single surgical step technique, the disadvantage may be there for the development of gingival recession and/or loss of gingival height at the donor area.

SCTG used for RC combines features of the free gingival graft and the pedicle graft. Advantages of this combination include the retention of the blood supply both from the periosteum and the underside of the covering flap, a closer color blend of the graft with the adjacent tissue, avoiding the patchy healing seen with the free gingival graft,[3] healing of the donor site by primary intention, which involves less postoperative pain. This technique provides the best RC in areas of thin gingival and alveolar bone Nelson,[5] isolated tooth with wide recession, and in multiple recession defects. LPPG resulted in effective soft tissue coverage for isolated deep narrow defects. Highly significant and effective soft tissue coverage was obtained by SCTG procedure even in isolated wide and multiple gingival recession defects.

CONCLUSION

Improvement in esthetic appearance is evident by both the techniques, that is, LPPG and SCTG. The stability of results after 6 months is observed which can give the clinician an accurate assessment of the long-term behavior of periodontal procedures. SCTG is the ideal procedure for the treatment of gingival recession defect deep, wide or narrow, and isolated or multiple. However, where a patient does not consent for involvement of the second surgical site, LPPG can be used to achieve RC with satisfactory results in deep, narrow, and isolated defects only.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.