Patient-centered comparative outcome analysis of platelet-rich fibrin-reinforced vestibular incision subperiosteal tunnel access technique and Zucchelli's technique.

BACKGROUND: Multiple gingival recession (MGR) coverage, especially in esthetic area, demands a high patient satisfaction. Coronally advanced flap modifications, namely Zucchelli's technique (ZT) and vestibular incision subperiosteal tunnel access (VISTA), are techniques, recommended in the correction of MGR. AIM: The purpose was to comparatively analyze the ZT and VISTA technique reinforced with the platelet-rich fibrin membrane in the management of MGR.
MATERIALS AND METHODS: This split-mouth, randomized study comprised 16 consenting, systemically healthy participants. The bilateral Miller's multiple class I and II lesions were managed with ZT and VISTA technique and had a follow-up period of 18 months. Gingival thickness (GT), mean percentage of root coverage, and patient-centered outcome scales, including patient comfort score, patient esthetic score, and hypersensitivity score, were the primary outcome measures. Further clinical parameters assessed were gingival index, probing depth, clinical attachment level, and width of keratinized gingiva. STATISTICAL ANALYSIS AND
RESULTS: Paired t-test and unpaired t-test were used for intragroup comparison and intergroup analysis, respectively. While both the techniques exhibited high root coverage percentage (VISTA: 93.95% and ZT: 96.84%), statistically significant difference was noted with patient esthetic score and surgical mortality score in VISTA.
CONCLUSION: Both ZT and VISTA were effective in terms of root coverage and GT augmentation in MGR management. From the patient's perspective, they preferred VISTA technique over ZT, stating its minimal postoperative morbidity and improved esthetic outcome. Hence, within the limitations of this study, the VISTA technique was found to be a superior alternative compared to that of ZT in MGR management. Copyright:

INTRODUCTION

Gingival recession is a common patient-related complaint, occurring with an undesirable shift of marginal gingival position. Two general patterns have been recognized in recession presentation, namely localized and multiple types. Owing to the much prevalent traumatic etiology, multiple gingival recession (MGR) is frequent than that of its localized variant with higher esthetic demand. Moreover, the extensive area of the avascular root surface to be covered further confounds the scenario in MGR management.[1]

The primary objective of buccal recession defect management is to remodel the gingival architecture with or without efforts to improve the tissue characteristics. Conventionally, the recession defects have been treated by choice of techniques including pedicled grafts, free soft-tissue grafts, and guided tissue regeneration. Among the array of modalities, the selection of one technique over another depends on various defects and patient-related factors.[1] High esthetic demand with a need for minimal postoperative distress is the significant patient factor to be contemplated before selecting a particular procedure. MGR has been treated with both coronally advanced flap (CAF) and bilaminar techniques. A systematic review has ascertained that CAF with or without connective tissue graft (CTG) is a predictable method in improving the clinical parameters.[2]

Improved understanding of the wound healing specifics and improvements in flap designs has paved the way for modified surgical techniques with minimal trauma and sustained outcome maintenance. Two recent surgical modifications include a CAF without releasing incisions, namely Zucchelli's technique (ZT)[3] and vestibular incision subperiosteal tunnel access (VISTA) with a single vertical incision and tunnel fashion elevation.[4] ZT is a variation of CAF in envelope fashion, with the flap design taking into account the future position of the flap and thus delineating anatomic and surgical papilla, accordingly. Furthermore, the split-full-split thickness flap approach does not compromise the vascular supply, resulting in more predictable healing.[3] The same authors have conducted a long-term analysis of this technique and concluded that the obtained results were sustained over the observatory period of 5 years.[5] Furthermore, this flap design has been used in raising the access flap for implant placement and deemed advantageous.[6] Bherwani et al. have compared the ZT with tunnel technique and concluded that both had comparable clinical outcome.[7]

Tunneling technique is yet another significant addition in CAF, introduced by Allen in 1994.[8] Numerous procedural modifications have been proposed following its introduction in 1994. A subperiosteal tunnel approach with a single vertical incision providing access to multiple teeth, namely VISTA, was presented by Zadeh with the advantage of being minimally invasive.[4] It further simplifies the tunneling technique and improves the wound healing profile.[910] Moreover, the VISTA in combination with various graft materials has been analyzed and results were encouraging.[4111213]

Surgeons' major challenge is to find a suitable bioactive surgical additive, which will regulate the inflammation and improve the healing. The consequential events following the postoperative period dictate the complex wound remodeling and tissue survival. Adjuvant use of agents such as recombinant growth factors has been shown to improve the periodontal wound healing.[14] Platelet-rich fibrin (PRF) is one such bio-healing material implicated in optimal hard- and soft-tissue healing. It provides dynamics essential for healing process resulting in less postoperative discomfort and advanced tissue healing.[15]

PRF has demonstrated a positive effect on various cell lines with immune activity, and viable platelets in PRF release six growth factors.[16] The beneficial effects of PRF in various surgical procedures have been evaluated and deemed satisfactory.[1617] Furthermore, its positive role on various cell lines, especially the fibroblastic cell line, has been ascertained.[18] A recent histological analysis has compared CTG with and without PRF in recession management and confirmed early vessel formation and tissue maturation with the PRF group.[19] Considering the biological advantages of PRF, the aim of the present study was to compare ZT and VISTA technique in MGR reinforced with PRF.

MATERIALS AND METHODS

Study design

The study was a randomized, prospective, split-mouth study, designed to compare the use of PRF reinforced with either ZT or VISTA technique in the MGR management. The study was approved by the institutional review board, and 16 consenting patients (6 males and 10 females) were enrolled with a mean age of 34.2 ± 9.2 years, presenting Miller's class I or II recession defects on the contralateral sides of the same arch or in different quadrants. In order to ascertain a surgical technique's prospective to procure complete root coverage, Class I and II defects with potential of 100% root coverage were ideal for avoiding defect-related bias and were thus included in the present study. The patients presented with the clinical presentation of hypersensitivity and gum recession.

Power calculation determined the minimum sample size of 14, as required for identifying a difference of 0.8 mm in the recession depth (RD) between the groups with 80% power and 0.05% level of significance. Hence, 16 patients were enrolled in the study, considering any follow-up loss, and a total of 107 defects were treated. Patients who were excluded comprised pregnant or lactating women, those on any medication or systemic conditions that can affect the periodontal homeostasis or interfere with healing, and smokers. Sites with probing depth (PD) more than 3 mm and the presence of bleeding on probing were also excluded. A preliminary periodontal evaluation was performed in all the participants, which included oral hygiene instructions scaling and polishing. Patients were recommended a soft toothbrush and a non-traumatizing brushing technique. The study was conducted in accordance with the Helsinki Declaration of 1972, as revised in 2002. Routine hematological checkups were conducted in all the participants.

Clinical measurements

A blinded and trained examiner, different from that of the surgeon, made customized acrylic stents with guiding grooves for clinical measurements and performed the data collection. The clinical parameters were recorded with the UNC 15 probe and the gingival thickness (GT) with an endodontic spreader and Vernier caliper in the apico-coronal midpoint of the attached gingiva to the nearest 0.5 mm. The primary outcome measures were mean recession coverage, alteration in the GT, and patient-centered outcome (PCO) measures such as patient comfort score (PCS), patient esthetic score (PES), and patient hypersensitivity score. Other parametric factors measured include gingival index, PD, RD, and the width of keratinized gingiva (WKG). The clinical attachment level was computed by summating RD and PD.

The PCO analysis was recorded using face-to-face interviewing method and pencil-and-paper approach with a 1–10 mm Visual Analog Scale.[20] PCS measures the patient's opinion of surgical mortality, comprising perception of pain, edema, and other postoperative complications. The rating was given as 1 – unbearable discomfort to 10 – no discomfort, recorded at the day of surgery. PES records a patient's perception of esthetics both at baseline and 18 months postoperatively in terms of gingival color, contour, and appearance. The rating graded from 1 – unpleasant esthetics to 10 – highly pleasant esthetics. HS relates to the record of the patient's hypersensitivity, at baseline and 18-month review, categorized as 1 – unbearable sensitivity to 10 – no sensitivity. The hypersensitivity was recorded by blasting air from a dental syringe facing the root surface for a period of 3 s. Care was taken to maintain the position of the syringe at 90° and at a distance of 2–3 mm away from the root surface. Furthermore, caution was exerted in shielding the adjacent teeth with the gloved fingers.

Surgical depiction

The clinical parameters were recorded at baseline. The lower half of the patient's face was cleaned with 5% povidone-iodine and was asked to rinse with 10 ml of 0.2% chlorhexidine digluconate mouthwash before commencing the procedure. Anesthesia (local infiltration) was administered with 2% lignocaine plus 1:80,000 epinephrine. The exposed root surfaces were mechanically prepared using an ultrasonic device, curettes, and finishing burs, as required. The PRF to be used was procured using Choukroun's protocol.[21] The surgical procedure to be first performed was decided by the flip of a coin, and subsequent surgery was done after a period of 1 month. Patients were kept in 18 months of observation, wherein all the clinical measurements were repeated.

Zucchelli's technique

A 15C carbon steel blade and a periosteal elevator were used to raise an envelope flap design, as explained by Zucchelli and De Sanctis [Figure 1].[3] The flap was extended to include adjacent teeth on either side of the teeth to be treated if needed to improve the tension-free coronal mobilization. The horizontal incision comprised an oblique submarginal incision in the interdental papilla continued as intrasulcular incisions at the recession defects [Figure 2]. This incisional approach will delineate surgical papilla and anatomic papilla. The surgical papilla was then dissected with the blade directed parallel to the root surface, with respect to the anatomical papilla. Later, periosteal elevator was used to raise full-thickness flap apical to the recession defects. The flap was then undermined apically with the blade until tension-free repositioned was achieved [Figure 3]. Anatomic interdental papilla de-epithelization was completed to create a connective tissue bed over which the surgical papilla was rotated and placed in its final coronal advancement. Procured PRF was positioned at the level of the cementoenamel junction and secured to the interdental papilla with 5-0 absorbable sutures [Figures 4 and 5]. Coronal mobilization of the flap was done, and precise adaptation of each surgical papilla was performed with double loop sling sutures, using 5-0 nonabsorbable sutures [Figure 6]. Eighteen months postoperative is depicted in Figure 7. Figures 8–11 depict ZT-treated two similar cases.

Figure 1

Case 1 – Zucchelli's technique-Miller's Class I recession in 21, 22, 23, and 24

Figure 2

Oblique submarginal and crevicular incisions given

Figure 3

Split-full-split thickness elevation done

Figure 4

Platelet-rich fibrin procured

Figure 5

Positioning of platelet-rich fibrin over the defect area

Figure 6

Coronally anchored sling sutures

Figure 7

Eighteen-month postoperative view

Figure 8

Case 2 – Zucchelli's technique-Miller's class I recession in 13, 14, and 15

Figure 11

Postoperative view

Case 3 – Zucchelli's technique-Miller's class I recession in 21, 22, 23, and 24

Vestibular incision subperiosteal tunnel access technique

Zadeh's surgical description of VISTA procedure was employed and began with the placement of vertical incision 3 mm from the marginal gingiva, extending into the alveolar mucosa with a 15 C blade [Figures 12–15].[4] Planning of this accessing vertical incision is based on the position providing optimal access and the number of teeth to be treated. In general, vertical incision is given in the midline of the flap [Figure 16]. Nevertheless, mesial most teeth were also selected, depending on the ease of access. The customized VISTA elevator set (VISTA 1, 2, 3, 4, 5 Dowell Dental Products, USA) was used for the tunneling purpose, thus avoiding any inadvertent flap tear [Figure 17]. The VISTA elevators 1 and 2 were availed for elevating adjacent and remotely attached gingiva, respectively [Figure 18]. Similarly, the papillary areas were tunneled with VISTA 3 and 4. Care was taken to extend the tunnel well beyond the mucogingival junction to aid in tension-free coronal mobilization. If required, teeth adjacent to the defect area were also included in the tunneling, in order to facilitate the repositioning. The whole mucogingival unit was coronally advanced and secured with 5-0 nonabsorbable coronally anchored sutures. Light-cured composite stops were utilized for stabilizing the sutures. Caution was exercised in maintaining the final position of the gingival margin slightly coronal to the CEJ to prevent potential relapse. Subsequently, PRF was slid inside the tunnel and precisely adapted [Figure 19]. Subsequently, the vertical incision was sutured with interrupted sutures [5-0 nonabsorbable sutures; Figure 20]. Figure 21 is the 18-month postoperative visit. Two similar VISTA-treated case images are depicted in Figures 22–25.

Figure 12

Case 4 – Vestibular incision subperiosteal tunnel access technique-Miller's class I recession in 13, 14, 15, and 16

Figure 15

Blade placement

Figure 16

Full-thickness vertical incision

Figure 17

Vestibular incision subperiosteal tunnel access 1, 2, 3, 4, 5 (Dowell Dental Products, USA)

Figure 18

Subperiosteal tunneling

Figure 19

Platelet-rich fibrin positioning in the coronally anchored tunnel

Figure 20

Midline suturing

Figure 21

Eighteen-month postoperative view

Figure 22

Case 5 - Vestibular incision subperiosteal tunnel access technique-preoperative view

Figure 25

Eighteen-month postoperative view

Root planing in relation to 13, 14, 15, and 16

Root conditioning in relation to 13, 14, 15, and 16

Case 6 – Vestibular incision subperiosteal tunnel access technique-preoperative view

Postoperative care

Written and oral postoperative instructions were given to the patient. Oral antibiotics amoxicillin 500 mg thrice daily and nonsteroidal anti-inflammatory drug ibuprofen 600 mg twice daily for 5 days were prescribed. All the participants were given detailed instructions to avoid undue muscle traction, trauma to the surgical site, and to abstain from mechanical plaque control till the suture removal. Chemical plaque control with 0.2% chlorhexidine twice daily was instituted for a period of 21 days. Postsurgically, all the sutures were removed for ZT, and midline suture removal for VISTA was performed at 15 days. Coronally anchored sutures of VISTA were removed at 21 days. Following suture removal, patients were instructed to resume regular homecare, comprising brushing and flossing. Follow-up was done on 6 month and 18 month post-operative. Oral hygiene instructions were reinforced. Furthermore, oral hygiene instructions were reinforced.

RESULTS

The numerical data were statistically analyzed usingIBM SPSS Statistics 20.0. IBM® SPSS® Statistics 20.0. Paired t-test was used for intragroup comparison and unpaired t-test for intergroup analysis. Mean, standard deviation, and test of significance were calculated in both the groups at baseline and 18 months and tabulated [Tables 1 and 2]. The mean root coverage was calculated using the below formula:

Table 1

Intra- and inter-group analysis of patient-centered outcome parameters

	Patient esthetic scored			Patient hypersensitivity score			Patient comfort score, mean±SD
	Pre, mean±SD	Post, mean±SD	P	Pre, mean±SD	Post, mean±SD	P
ZT	1.95±0.85	6.6±0.72	<0.001	4.6±1.41	6.7±1.54	<0.001	4.3±0.70
VISTA	2.0±0.82	9.1±0.81	<0.001	4.4±1.21	6.5±1.67	<0.001	5.6±1.09
P	0.833	<0.001	0.689	0.743	0.001

ZT - Zucchelli’s technique; VISTA - Vestibular incision subperiosteal tunnel access; SD – Standard deviation; GT- Gingival Thickness; P – P value. P value ≤ 0.05 is considered significant

Table 2

Intra- and inter-group analysis of clinical parameters

	GI			PD			RD			GT			WKG			CAL
	Pre, mean±SD	Post, mean±SD	P	Pre, mean±SD	Post, mean±SD	P	Pre, mean±SD	Post, mean±SD	P	Pre, mean±SD	Post, mean±SD	P	Pre, mean±SD	Post, mean±SD	P	Pre, mean±SD	Post, mean±SD	P
ZT	0.32±0.055	0.35±0.055	0.022	1.41±0.656	1.19±0.482	0.000	2.47±0.600	0.08±0.225	0.00	0.91±0.149	1.20±0.246	0.00	2.11±0.752	2.56±0.708	0.00	3.88±0.881	1.26±0.571	0.00
VISTA	0.37±0.066	0.37±0.060	0.678	1.50±0.720	1.06±0.482	0.006	2.41±0.908	0.15±0.267	0.00	0.90±0.097	1.30±0.173	0.00	3.35±1.058	3.67±0.968	0.00	3.91±1.281	1.21±0.515	0.00
P	0.029	0.215	0.487	0.148	0.678	0.157	0.607	0.012	0.001	<0.001	0.882	0.629

GI – Gingival index; PD – Probing depth; RD: Recession depth; WKG – Width of keratinized gingiva; SD – Standard deviation; ZT – Zucchelli’s technique; VISTA – Vestibular incision subperiosteal tunnel access; CAL – Clinical attachment level; GT – Gingival Thickness; P – P value. P value ≤ 0.05 is considered significant

None of the patients exhibited any postoperative complication and maintained adequate oral hygiene. All the results are summarized in tabular format. Eighteen-month postoperative intraoral examination revealed 93.95% and 96.84% mean percentage of root coverage in VISTA and ZT, respectively. The intragroup analysis showed a significant increase in GT, RD, CAL, and WKG in both the groups. In intergroup comparison, GT and WKG show significant difference postoperatively, with VISTA depicting better results.

DISCUSSION

Unrelenting exploration and focused aim of providing the best of the contemporary science and state of the art to our patients has shaped minimally traumatic surgical techniques. Furthermore, the use of biocompatible materials helps promote wound healing profile and stabilize the outcomes. Recent innovations in material science and the introduction of new atraumatic surgical techniques have paved the way for this realization. Thus, the present study was aimed at assessing and comparing the latest technical innovations, including ZT and VISTA, reinforced with the PRF biomaterial.

About 70%–97% of root coverage has been reported with the bilaminar technique (CAF with CTG) in the dental literature.[22] Although this combination is considered as the gold standard in recession management, other approaches may yield simpler and similar results with less morbidity and invasiveness. PRF could be considered as an autologous cicatricial matrix and is just not a biological additive but rather could be considered as a cell-based therapeutic approach.[23] Being a highly elastic, strong, and flexible mesh with inherent equilateral three-dimensional architecture, PRF results in slower, sustained release of growth factors and cytokines.[24] The rapid angiogenesis owing to the extended growth factor influence and the availability of favorable network for cell ingression promotes the critical initial wound healing and periodontal regeneration.[24] Considering such advantageous bio-healing potential, its adjuvant use with CAF has been shown to exhibit positive results in the literature,[25] and consequently, PRF was utilized in the present study instead of CTG.

In previous clinical work, the PRF and SCTG groups exhibited 75% and 79% root coverage, respectively.[25] In accordance, the present study found root coverage of 93.95% and 96.84% with PRF-reinforced ZT and VISTA techniques, respectively, with no statistical difference between both (P = 0.137). The outcome of the present study results can be credited to the positive attributes of PRF on early wound healing.[1319] Furthermore, it could be postulated that the tissue adhesive property and the inflammatory response of PRF leukocytes brought about better flap integration in initial healing phases.[25]

In the current study, the WKG increase in the ZT and VISTA groups was found to be 0.45 ± 0.16 mm and 0.32 ± 0.14 mm, respectively, with a statistically significant change in ZT compared to that of VISTA. This could be ascribed to the fact that ZT being an envelope flap technique with horizontal releasing incisions, led to maximal ease and control in coronal displacement compared to that of full-thickness tunneling technique employed in VISTA. However, the fact that VISTA exhibits better coronal mobilization than other classical tunneling procedures should also be considered. It is interesting to note that in the ZT, the increase in WKG was found to be inversely related to the apico-coronal dimension of keratinized gingiva apical to the recession and the same was reflected in the present study.[3] In VISTA, the relaxation of the flap is limited and was improved with extending the tunnel in the vestibular region, involving the interpapillary region without compromising the papillary integrity. The current study was in conflict with previous work using ZT and PRF, reporting 1.78 ± 0.44 mm increase in WKG,[11] wherein the study by Zucchelli and De Sanctis (0.6 mm WKG increase) was in accordance.[3]

The absolute mean gain in GT in the present study was 0.29 ± 0.09 mm and 0.4 ± 0.12 mm in the ZT and VISTA groups, respectively, which is comparable to a study evaluating PRF with CAF in MGR management.[26] The long-term growth factor release, positive effect on fibroblast and periodontal ligament cells, and the physical spacing effect of the PRF lead to the positive correlation in the tissue biotype.[18] Interestingly, VISTA was found to have a statistically significant alteration in GT compared to that of ZT, which could be due to the uniform full-thickness elevation of VISTA instead of split-full-split elevation in ZT. Other clinical parameters (RD, CAL, and GI) did not exhibit any statistically significant difference in the intergroup analysis and were in agreement with the previous reports.[311]

Apart from the clinical parameter evaluation, PCO analysis reflects the largely unexplored area of gingival recession and should be included as an integral part of overall treatment assessment. Three PCO parameters were analyzed in the current study to evaluate the subjective patient perception of the esthetics, healing event, and the treatment outcome.[20] The two techniques examined did not exhibit any significance in the HS, since both the groups achieved excellent root coverage. Likewise, Aroca et al. and Kumar et al. reported a reduction in HS in cases treated with modified CAF with PRF.[2026] Patient's perception of pain, and other related morbidity was assessed. The results indicated a significant preference of patients to VISTA. The finding reflects that the subperiosteal tunneling technique in VISTA has exhibited low morbidity, with the lesser perception of pain and discomfort owing to improved healing on account of the surgical design; single vertical incision, sufficient for accessing larger areas; avoidance of releasing incisions; and traumatic papillary incisions, with minimal papillary undermining undertaken. In accordance with the current study, Kumar et al. have reported increased PCS scores in CAF + PRF-treated sites compared to that of CAF alone and CAF + CTG.[20]

PES subjectively assessed the patient's esthetic satisfaction outlook in terms of postsurgical color; contour; shape, it was found to be significantly better in the VISTA group, compared to that of ZT. The results are in concurrence with another study comparing CAF with PRF and CTG.[20] The CTG generally results in thicker tissue in recipient site creating an esthetic disharmony.[7] Owing to the fact that there were optimal initial healing with minor postoperative discomfort; no visible scar formation; minimal invasiveness; inherent simplicity in flap elevation and suturing in VISTA, it can be the preferred treatment in with high esthetic demands.

ZT is an envelope flap with oblique submarginal releasing incision pattern, whereas VISTA is a subperiosteal tunneling procedure. Microvascularization studies postulate that a vertically placed access incision as adopted in VISTA tends to be more esthetic and to minimally disrupt blood supply compared to that of ZT's horizontal marginal releasing incisions in the dentate area.[27] A major limitation of conventional tunneling procedures is the limited access in introducing biomaterials for soft-tissue augmentation and high possibility of tearing of soft-tissue collar during manipulation. The incision used in VISTA provides broader access, thus evading such technical difficulty and reducing chair side time.

Generalized subperiosteal full-thickness elevation carried out in VISTA results in stripping of the periosteum, leading to associated bone loss. Whereas the variable thickness flap with split-full-split elevation in ZT is commendable in its simplicity and effectiveness. The split elevation in the interproximal region avoids stripping of the periosteum on either side of the defect. Concurrently, the flap thickness has been related to improved vascularity, and the full-thickness flap over the recession area ensured an increased probability of complete root coverage.[28] Moreover, it ensures the adequate nutritional exchange and improved tissue blending between the anatomical and the surgical papilla.[29]

The limitation of the current study was that there was no histological analysis, ascertaining the true connective tissue attachment achieved. Furthermore, the factors pertaining to PRF, such as consistency, thickness, platelet viability, and platelet concentration, were not taken into consideration. Within the limitations of the study, even though both the techniques exhibited sound clinical therapeutic outcomes, the VISTA technique had better performance results in the PCO analysis.

CONCLUSION

The results indicated that both ZT and VISTA reinforced with PRF are effective in treating MGRs from an objective clinical standpoint. Nevertheless, the patient preference was more inclined toward VISTA, depicting its superior patient acceptance on account of its nominal morbidity and early satisfactory esthetic outcome.

What is the advantage of surgical techniques?

ZT – Predictable treatment of MGR with good color blend and tissue thickness match; unique split-full-split thickness elevation respecting the vascular specifics; improved coverage even in areas of reduced WKG with increased WKG postsurgically

VISTA – Simultaneous management of MGR with atraumatic incision design allowing easier biomaterial introduction; reduced technical sensitivity and surgical morbidity; improved patient acceptance.

What precautions to be taken?

PRF – Prompt blood collection and processing of PRF

ZT – Careful planning of the oblique incisions, to obtain precise adaptation; the blade orientation needs to be maintained while performing the split-thickness elevation; complete de-epithelization of the anatomical papilla to ensure complete adaptation of the surgical papilla; procedure is technique sensitive and operator skill required: Improper elevation may lead to surface nicks and unesthetic healing

VISTA – Proper placement of the vertical releasing incision, allowing access to the entire defect area: Generally placed in the most mesial aspect; care should be taken while securing the composite anchored sutures; tunneling should be extended till alveolar mucosa to ensure tension-free flap mobilization.

What are the primary limitations of the study?

Histological examination was not done, to evaluate true periodontal regeneration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.