Clinical efficacy of periosteal pedicle graft with subepithelial connective tissue graft in gingival recession coverage.

INTRODUCTION: Correction of gingival recession (GR) involves eliminating the cause of recession and it often requires surgical correction. Subepithelial connective tissue graft (SCTG) technique by Langer and Langer provides excellent esthetics and is considered most predictable in obtaining marginal tissue recession coverage. However, the requirement of a second surgical procedure for harvesting CTG remote from planned site of recession coverage increases the chances of postoperative infection. There is also a limitation in the amount of graft that can be harvested and an increased operative time contributing to patient discomfort.
MATERIALS AND METHODS: Overcoming these difficulties has become possible with the introduction of "periosteal pedicle graft" (PPG). The study is a split-mouth design where patients with bilateral, isolated GR defects were treated using two different surgical techniques, i.e., PPG versus the SCTG in obtaining GR coverage. The objective was to analyze the comparative amount of root coverage and the gain in width of attached gingiva achieved by both the techniques.
RESULTS: All the clinical parameters evaluated were comparable between SCTG and PPG when recorded at 6 and 9 months posttreatment.
CONCLUSION: Both techniques produced satisfactory and predictable results. PPG eliminated the need for the 2nd operative site, lesser intraoperative time, and hence, patient comfort was enhanced.

INTRODUCTION

Growing awareness and increased expectations of people paves the way for the need to attain optimal esthetics and refinement in procedures. Management of marginal tissue recession involves eliminating the cause of the recession, and it often requires surgical correction.[1] Advanced surgical techniques exist with varied predictability of marginal tissue recession coverage.[2] The subepithelial connective tissue graft (SCTG) technique by Langer and Langer, provides excellent esthetics and is considered the most predictable in obtaining marginal tissue recession coverage.[34] However, it requires a second surgical procedure for harvesting CTG remote from the planned site of recession coverage which increases the chances of postoperative infection. There is a limitation in the amount of graft that can be harvested so addressing multiple recessions become difficult. Furthermore, there is an increase in operative time which contributes to patient discomfort.

In an endeavor to predictably increase root coverage (RC), avoid a second surgical site for harvesting the graft, reduce the intraoperative time and improve patient comfort, marginal tissue recession coverage with periosteum was undertaken. The technique called “periosteal pedicle graft” (PPG) uses periosteum to cover the recession defect from the area apical to recession used as a pedicle and a coronally advanced flap (CAF).[56] The present study is a split-mouth design consisting of patients with bilateral, isolated gingival recession (GR) defects treated using two different surgical techniques, i.e., PPG versus the SCTG in obtaining GR coverage to compare the clinical efficacy of PPG with SCTG. The objective was to analyze the comparative amount of RC and the gain in width of attached gingiva (AG) achieved by both the techniques.

MATERIALS AND METHODS

Twenty participants aged between 25 and 40 years having localized Millers Class II GR in the maxillary and/or mandibular anterior region including premolars were selected for the study [Table 1]. The ethical clearance was taken from the Institutional board of Ethical committee. The study and details of the surgical procedure were explained to the patients and written informed consent was obtained. Bilateral, isolated defects were selected having a depth of ≥3 mm [Figure 1]. Noncompromised systemically healthy individuals were selected with no contraindication for periodontal surgery and the involved teeth free of periapical pathology. Smokers and chewers of tobacco, pregnant/lactating women and malposed teeth were excluded from the study. The sample size was calculated with 5% level of significance, 80% power of the test, and the effect size of 3. The patients were kept on an observation period of 6 weeks following phase I therapy. Sulcular bleeding index was done at regular intervals to assess the health of the gingival tissues as per the procedure given by Muhlemann and Son at baseline, 6, and 9 months.[7] Also recorded were the probing depth (PD), clinical attachment level (CAL), GR height, and width of AG at baseline. Being a split-mouth study, the bilateral GR defects were randomly divided into two groups by the flip of a coin. Group A, constituted individuals with GR managed with PPG and CAF and Group B with SCTG. The clinical parameters were also measured postoperatively at 6 and 9 months after the surgery [Figure 2]. The percentage of RC (% RC) obtained from both the procedures was calculated according to the following formula:

Table 1

Demographic data and defect allocation

Patient	Data	Age (years)	Tooth number
			Group-A (PPG)	Group-B (SCTG)
1	Female	26	12	22
2	Male	35	32	42
3	Male	31	22	12
4	Female	37	13	23
5	Female	33	13	23
6	Male	27	23	13
7	Male	26	43	33
8	Male	36	24	14
9	Female	35	33	43
10	Female	27	22	12
11	Male	30	32	42
12	Female	40	42	32
13	Female	32	43	33
14	Female	35	33	43
15	Female	36	33	43
16	Male	26	13	23
17	Female	33	23	13
18	Female	37	23	13
19	Male	38	23	13
20	Male	40	13	23

PPG – Periosteal pedicle graft; SCTG – Subepithelial connective tissue graft

Figure 1

Bilateral isolated gingival recession

Figure 2

Postoperative 9 months recession with respect to 13 and 23 region

All measurements were taken with the University of North Carolina-15 periodontal probe and the measurement was recorded to the nearest 0.5 mm.

Surgical procedure

Group A (periosteal pedicle graft)

An intrasulcular incision was made with B. P No 15 blade at the buccal surface of the involved tooth followed by two horizontal incisions perpendicular to the adjacent interdental papillae, at the level of cemento-enamel junction. Two oblique vertical incisions are made which extend beyond the mucogingival junction (MGJ), and a full-thickness trapezoidal flap raised 2–3 mm apical to the osseous crest. The flap was held buccally to create tension on the periosteum and further continued as a partial-thickness flap [Figure 3a and b]. Adequate connective tissue and periosteum are retained on the buccal surface of bone on which a three-sided incision is made on mesial, distal, and apical extent making sure 3–4 mm of periosteum coronally is left attached. Initiate the separation of the periosteum from the underlying bone using a periosteal elevator [Figure 3c]. The periosteum is lifted in a coronal direction leaving it as a pedicle which is turned over to cover the exposed root surface and sutured with a synthetic 5-0 absorbable suture. The overlying flap is coronally positioned and sutured using a nonresorbable 4-0 black braided silk (BBS) suture [Figure 3d].

Figure 3

Management of 13 using periosteal pedicle graft; (a) periosteal pedicle graft-gingival recession height (4 mm); (b) periosteal pedicle graft-partial-thickness flap; (c) periosteal pedicle graft-periosteum being rotated over recession defect; (d) periosteal pedicle graft-flap coronally advanced and sutured; (e) periosteal pedicle graft-postoperative 9 months (periosteal pedicle graft treated site)

Group B (subepithelial connective tissue graft)

An intrasulcular and two vertical releasing incisions were made in a trapezoidal form. The epithelial tissue was removed at the mesial and distal papillae followed by a full-thickness flap up to the MGJ and continued as a partial-thickness flap [Figure 4a and b]. Debridement of the surgical site was carried out. The recipient bed was measured to serve as a guide for procuring the graft from the palate. Liu's Type I-A incision was used for harvesting the palatal graft [Figure 4c]. The graft was secured with 5-0 polyglycolic acid absorbable sutures [Figure 4d]. The flap was then coronally positioned making no attempt to completely cover the graft and secured with interrupted sutures using 4-0 BBS [Figure 4e].

Figure 4

Management of 23 using subepithelial connective tissue graft; (a) subepithelial connective tissue graft-gingival recession height (4 mm); (b) subepithelial connective tissue graft-partial-thickness flap; (c) subepithelial connective tissue graft-connective tissue graft harvested from palate; (d) subepithelial connective tissue graft-connective tissue graft sutured over recession defect; (e) subepithelial connective tissue graft-overlying flap sutured; (f) subepithelial connective tissue graft-postoperative 9 months (subepithelial connective tissue graft treated site)

Postoperative care

The operated sites were covered with noneugenol periodontal dressing (Coe-Pak) and postoperative instructions given. The periodontal dressing and sutures were removed 8 days postoperatively. Patients were recalled after every 1 week for the first 4 weeks then every 2 weeks for the next 8 weeks and monthly till the end of the study period.

RESULTS

The healing of all the surgical sites was satisfactory and uneventful. Statistical analysis of all the clinical parameters was performed using statistical software MINITAB 15.2 (Pennsylvania State University, USA). Parameters within the group were compared with paired t-test and in between groups with two-sample unpaired t-test. Bleeding index was carried out at baseline, 6, and 9 months which indicated good plaque control. Demographic data of 20 patients consisting of 9 females and 11 males including tooth number allotted for the two treatment procedures are shown in Table 1.

Table 2 shows the baseline comparison of GR, PD, CAL, and AG which were comparable between Group A (PPG) and Group B (SCTG) evidenced by the “t” and “P” values with no statistically significant difference.

Table 2

Inter-group comparison of all baseline measurement

	Group	Mean±SD	t	P
GR-B	A	4.35±1.14	0.14	0.88
	B	4.30±1.08
PD-B	A	1.35±0.58	0.30	0.76
	B	1.30±0.47
CAL-B	A	5.70±1.30	0.26	0.79
	B	5.60±1.14
AG-B	A	0.40±0.50	-0.25	0.80
	B	0.45±0.74

P value is statistically significant at 0.001. GR – Gingival recession height; PD – Probing depth; CAL – Clinical attachment loss; AG – Width of attached gingiva (GR, PD, CAL, and AG measured in mm); mm – millimeter; B – Baseline; SD – Standard deviation

Table 3 shows the measurement of clinical parameters (in mm) at baseline, 6 and 9 months, respectively, for PPG treated sites as well as the mean changes from baseline to 9 months (Group A). The comparison of mean GR values between baseline and 9 months shows a reduction of 3.650 mm which is statistically highly significant (t = 17.49, P = 0.0001). While the mean PD values between baseline and 9 months show a reduction of 0.775 mm at 9 months from 1.350 mm found at baseline. The difference of 0.575 mm was also statistically significant (t = 4.06, P = 0.001). Similarly, the mean CAL at 9 months was 1.475 mm which reduced from a baseline value of 5.70 mm with a statistically highly significant (t = 16.08, P = 0.0001) difference of 4.22 mm. The mean width of AG at 9 months is 2.35 mm as compared to 0.40 mm found at the baseline. The difference of which was 1.95 mm and was statistically significant (t = −11.0, P = 0.001).

Table 3

Measurement of clinical parameters (mm) at baseline, 6, and 9 months for periosteal pedicle graft treated sites (Group A)

	Mean±SD (mm)				t	P
	Baseline	6 months	9 months	Mean changes in clinical parameters at baseline and 9 months
GR	4.35±1.14	0.97±0.65	0.70±0.47	3.65±0.67	17.49	0.0001
PD	1.35±0.58	0.82±0.29	0.77±0.34	0.58±0.24	4.06	0.001
CAL	5.7±1.3	1.77±0.61	1.47±0.59	4.23±0.71	16.08	0.0001
AG	0.4±0.5	2.20±0.44	2.35±0.58	−1.95±−0.08	−11.0	0.0001

P value is statistically significant at 0.001. PPG – Periosteal pedicle graft; GR – Gingival recession height; PD - Probing depth; CAL – Clinical attachment loss; AG – Width of attached gingiva (GR, PD, CAL, and AG measured in mm); mm – millimeter; SD – Standard deviation

Table 4 shows the measurement of all clinical parameters (in mm) at baseline, 6 and 9 months for SCTG treated sites as well as the mean changes in clinical parameters (mm) at baseline and 9 months (Group B). The mean GR values from baseline to 9 months show a reduction of 3.65 mm which is statistically highly significant (t = 18.65, P = 0.0001). The mean CAL at 9 months was 1.450 mm as compared to 5.60 mm at baseline with a difference of 4.15 mm which was again highly significantly (t = 20.52, P = 0.0001). The comparison of the mean width of AG between baseline and 9 months shows a mean increase in the width of AG of 2.32 mm at 9 months from 0.45 mm found initially at baseline. The increase of 1.87 mm is statistically highly significant (t = −15.67, P = 0.0001).

Table 4

Measurement of clinical parameters (mm) at baseline, 6, and 9 months for subepithelial connective tissue graft treated sites (Group B)

	Mean±SD (mm)				t	P
	Baseline	6 months	9 months	Mean changes in clinical parameters at baseline and 9 months
GR	4.30±1.08	0.90±0.44	0.65±0.43	3.65±0.65	18.65	0.0001
PD	1.30±0.47	0.85±0.36	0.80±0.34	0.5±0.13	4.36	0.0001
CAL	5.60±1.14	1.75±0.69	1.45±0.6	4.15±0.54	20.52	0.0001
AG	0.45±0.74	2.27±0.55	2.32±0.52	−1.87±0.22	−15.67	0.0001

P value is statistically significant at 0.001. GR – Gingival recession height; PD – Probing depth; CAL – Clinical attachment loss; AG – Width of attached gingiva (GR, PD, CAL, AG measured in mm); mm – millimeter; SD – Standard deviation

Comparison of the various clinical parameters between two procedures (Groups A and B) at baseline, 6 and 9 months is evident by Tables 3 and 4. The values of mean GR, PD, CAL and width of AG at baseline were comparable in both the groups and were statistically not significant. Furthermore, the comparison at 6 and 9 months of all clinical parameters was comparable between both the groups and statistically not significant.

Table 5 compares the % RC of all individuals of Groups A and B at 6 and 9 months respectively. The mean % RC for Group A (PPG) made at 6 months was 78.58% and at 9 months was 84.18%. The difference of 5.59% is statistically significant (t = −3.29, P = 0.004). Similarly, for Group B mean % RC at 6 months is 79.23% as compared to 83.73% found at 9 months. The difference of 4.5% is also statistically significant (t = 3.0, P = 0.007). Table 5 also compares the mean % RC of both groups. At 6 months for Group A (PPG) the % RC was 78.58% and for Group B (SCTG) was 79.23%. Difference in mean % RC was 0.65% which is statistically not significant (t = −0.22, P = 0.83). Similarly, mean % RC of both the groups at 9 months was 84.18% for Group A compared to 83.73% for Group B, respectively. The difference between both the groups at 9 months is 0.45% which is statistically not significant (t = 0.15, P = 0.88).

Table 5

Comparison of percentage of root coverage at 6 and 9 months between the groups

% RC	Mean±SD (mm)			t	P
	6 months	9 months	Mean changes in clinical parameters from 6 to 9 months
Group A PPG	78.58±9.99	84.18±9.12	−5.56±0.87	−3.29	0.004
Group B SCTG	79.23±8.96	83.73±9.45	−4.5±−0.49	−3.00	0.007

P value is statistically significant at 0.001. %RC – Percentage of root coverage; PPG – Periosteal pedicle graft; SCTG – Subepithelial connective tissue graft; SD – Standard deviation; mm – Millimeter; P – P<0.05; t – 3.29, 3.0

DISCUSSION

High success and predictability of SCTG have established it as the most predictable technique for marginal tissue recession coverage.[8] The requirement of the 2nd surgery to obtain graft from the palate, restricted availability of donor tissue limits coverage of long span multiple recession defects along with an increased intraoperative time which contributes to patient discomfort. There is a requirement of an ideal graft having rich vascularity, close to the recession defect, sufficient enough to cover multiple recession defects, not requiring a second surgical site and having potential to promote regeneration of lost periodontal tissues.

Human periosteum has rich vascularity. It contains stem cells along with fibroblasts, osteoblasts, and their progenitor cells.[9] It has an inner cellular layer called cambium that houses osteoblasts and osteoprogenitor cells which along with osteoblasts initiate and drive the cell differentiation process of bone repair. The outer layer is more fibrous and composed of fibroblasts, collagen fibers, and their progenitor cells. The cells of periosteum can differentiate into many cells such as fibroblasts, osteoblasts, and chondrocytes and can secrete extracellular matrix and vascular endothelial growth factor.[10]

In view of the above factors, Mahajan introduced a novel technique for the treatment of localized isolated and multiple marginal tissue recession using autogenous periosteum. The periosteum was harvested from the surgical site apical to the recession defect, rotated, and used as a pedicle. The technique showed successful RC of 90.95% along with a significant increase in the width of keratinized and AG (P = 0.0001).[56]

The present study is a split-mouth comparison of Group A (PPG) and Group B (SCTG). Twenty patients aged between 25 and 40 years with bilateral localized GR in the maxillary or mandibular anterior region including the premolars were selected for the study. The sites with bilateral GR defects were randomly divided into two groups by the flip of a coin.

The baseline parameters of GR, PD, CAL, and AG were comparable between the groups. The differences between these parameters between both the groups were statistically not significant as seen in Table 2. RC of 84.18% was obtained in the cases treated with PPG and 83.73% with the SCTG group at the end of 9 months posttreatment [Tables 3 and 4]. The percentage of RC obtained and predictability of RC achieved with SCTG is in accordance with the earlier studies which show a mean defect coverage ranging from 57% to 98% with a mean of 84% and predictability of 68%.[11] High percentage of RC in PPG-treated cases may be attributed to the fact that wound healing after mucogingival surgery relies on clotting, revascularization, and maintenance of blood supply.[12] Adequate vascularity prevents necrosis of the PPG when left uncovered by the overlying flap making it a suitable graft for placement over an avascular root surface.[13]

Statistically significant differences were observed in CAL from baseline to 9 months in both the groups. The gain in attachment is directly related to the amount of RC obtained in both groups. The mean CAL of both the groups at 9 months was 1.475 mm for Group A and 1.450 mm for Group B with a difference of 0.025 mm between both the groups which was not statistically significant (t = 0.13, P = 0.896) [Tables 3 and 4].

Significant gain in the width of AG was observed from baseline and 9 months in both the groups [Figures 3e and 4f]. This finding may be due to the migration of keratinized epithelial cells over the periosteum during wound healing in the PPG group[6] and over the CTG[1] in the SCTG group, which resulted in the formation of keratinized attached tissue. Management of localized single and multiple marginal tissue recession has been carried out predictably and successfully using PPG. Previously carried out randomized controlled trial comparing PPG with SCTG have shown comparable clinical effectiveness; however, PPG was found to be superior to SCTG in terms of patient-centered outcomes and in terms of increased levels of overall satisfaction.[14]

The success of the PPG technique may be attributed to: the high vascularity of the graft, single surgical site, reduced intraoperative time, and minimum postoperative complications. The technique described, although simple, needs surgical dexterity on the part of the operator, especially during the lifting up of the periosteum, which is firmly adherent to the underlying bone. Furthermore, the long-term complications of this technique, such as the potential for resorption of the root surface by the periosteum, are yet to be assessed.

CONCLUSION

In the present study, all the clinical parameters were comparable between SCTG and PPG when recorded at 6 and 9 months posttreatment. Both techniques produced satisfactory results in terms of esthetics and coverage of denuded roots. There was a gain in CAL along with an increase in the width of AG. PPG eliminated the need for the 2nd operative site due to which the intraoperative time was also greatly reduced, the ability to cover multiple adjacent recession defects as periosteum can be harvested adjacent to the site of defect. All of these factors along with the increased levels of patient comfort and satisfaction thus contributed to the success of this procedure. This technique, however, warrants longitudinal studies, larger sample size with a long-term follow-up to assess the predictability of this new modality of marginal tissue recession coverage. Although PPG is a considerably new technique, it definitely holds promise in being considered as a routine procedure for marginal tissue recession coverage.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.