Management of Gingival Recession by Coronally Advanced Flap with and Without Amniotic Membrane: A Clinical Study.

Purpose: Recently, human amniotic membrane (AM) has been reported to have regenerative potential that facilitate repair in the field of oral and periodontal surgeries.
Methods: Eighteen subjects with bilateral Miller's class I gingival recession defects were selected. Subjects were allocated randomly to treatment with coronally positioned flap + amnion allograft (test group) and coronally positioned flap alone (control group). The clinical parameters used in this study were width of attached gingiva (AG), clinical attachment level (CAL), pocket depth (PD), width of keratinized gingiva (WKG), length of gingival recession (RL), width of gingival recession (RW).
Results: The mean width of attached gingiva at the control sites (A) was found to be 1.33 ± 0.50 mm (range 1.00-2.00), 2.00 ± 0.71 mm (range 2.00-3.00) and 2.22 ± 0.67 mm (range 2.00-3.00) on day 0, 90 and 180, respectively. Thus, it was increased by 0.67 mm and 0.89 mm on day 90 and 180 compared to that of the baseline, which are 50% and 67%, respectively. Conclusions: It can be concluded that combined coronally advanced flap and amniotic membrane have additional advantage in the outcome of periodontal therapy in the management of gingival recession. Copyright:

INTRODUCTION

The human gingiva is constantly subjected to mechanical, chemical and bacterial trauma, which results in an inflammatory reaction causing the gingiva to detach from the root surface and subsequently result in pocket formation and/or gingival recession.[1] In 1926, Norberg introduced coronally repositioned periosteal flap operation for the management of gingival recession, for which later on Prato et al.[12345] coined the term coronally advanced flap (CAF). Various regenerative materials have been tried with CAF. Recently, human amniotic membrane (AM) has been reported to have regenerative potential that facilitate repair in the field of oral and periodontal surgeries. Self-adherence ability of the AM makes it an attractive option for correction of recession defects involving multiple teeth in particularly inaccessible areas like the molar region.[6789101112131415] Thus, based on this information, the present study was proposed to evaluate the efficacy of AM in the management of gingival recession along with CAF with the following aims and objectives:

To evaluate the extent of root coverage obtained by CAF alone.

To evaluate the extent of root coverage obtained by CAF along with the AM. To compare the extent of root coverage obtained by CAF with and without the AM.

To compare the width of attached gingiva post surgically attained by CAF with and without AM in the treated sites.

To compare the width of keratinized gingiva attained by CAF with and without AM in the treated sites.

To compare the clinical attachment level post surgically in both sites treated with either CAF alone or with the AM.

METHODOLOGY

The present study was carried out involving 18 numbers of sites in 9 subjects to evaluate the role of the amniotic membrane (AM) in the management of gingival recession. The subjects were selected from the out-patient department (OPD) of the Department of Periodontics and Oral Implantology, Regional Dental College and Hospital, Guwahati. A full mouth clinical examination was carried out on all of the participants and thorough scaling and root planing was performed. All of the participants were instructed to carry out proper oral hygiene procedures. In each of the selected subjects, two sites were considered and the sites were named as A (control) and B (test).

Site A: gingival recession managed by coronally advanced flap (CAF) alone.

Site B: gingival recession managed by CAF and AM.

Recording of parameters

Gingival recession was recorded on day 0 (baseline) and on day 90 and 180, post surgically. Parameters were recorded for both the control and test sites using UNC-15 periodontal probe which comprises of a 15-mm-long working end with markings at each millimeter and colour codes at the 5th, 10th, and 15th mm. To reduce the variability in measurement at different time points, an occlusal stent with a groove was used. Occlusal stents were prepared using self-cure acrylic that covers the occlusal1/3rd of the buccal and lingual surfaces of the teeth to be recorded, and two adjacent teeth, one on mesial and other on distal side. A straight vertical groove corresponding to the midline on the facial aspect of tooth was made. The stent was used to ensure that all of the serial measurements taken at different time points were at the same location and with the same orientation of the periodontal probe to the tooth using cementoenamel junction (CEJ) of tooth as fixed reference point. If the measurement fell between two markings of the probe, then the reading was rounded off to the next higher marking. Subjects selected for the study underwent phase I therapy before the periodontal surgical procedures. Site A was treated with CAF alone, whereas site B was treated with AM and CAF. Upon placement, the processed dehydrated amnion allograft became hydrated and adhered to the exposed root and proximal bone, thus eliminating the need for suture. Care was taken not to move the AM after placement and during flap closure. The reflected flap was coronally positioned and sutured using 4-0 Mersilk by interrupted suturing technique followed by placement of periodontal dressing. Both the dressings and sutures were removed one week after surgery. Modified Stillman brushing technique was demonstrated and the subjects were instructed to gently brush the area with a soft bristled toothbrush. Follow-up care was given. The collected data were analyzed statistically. The study was carried out involving 18 sites in 9 subjects with Miller's class I or II gingival recession, each having 2 sites of gingival recession. The sites were named as A and B.

Site A: gingival recession managed by CAF, referred to as control site.

Site B: gingival recession managed by CAF and AM, referred to as test site.

The clinical parameters used in this study were width of attached gingiva (AG), clinical attachment level (CAL), pocket depth (PD), width of keratinized gingiva (WKG), length of gingival recession (RL), width of gingival recession (RW). All the parameters were recorded on day 0 (considered as baseline), day 90 and day 180 post surgically. The mean width of AG at the control sites (A) was found to be 1.33 ± 0.50 mm (range 1.00–2.00), 2.00 ± 0.71 mm (range 2.00–3.00), and 2.22 ± 0.67 mm (range 2.00–3.00) on day 0, 90 and 180, respectively. Thus, it was increased by 0.67 mm and 0.89 mm on day 90 and day 180 compared to that of the baseline, which were 50% and 67%, respectively. The changes in width of AG were found to be highly significant. As shown in Table 1, the mean CAL between control and test sites were found to be 1.00 mm and 1.22 mm on day 90 and day 180, respectively. The change in CAL on day 90 was 28.1% which was found to be very highly significant statistically (P = 0.00) whereas, the change on day 180 was 33% which was statistically significant (P = 0.02).

Table 1

Mean changes in clinical attachment level (CAL) (in mm) (ranges are in brackets) at control and test sites at different time points

Sites	Day 0 Mean±SD (Range)	Day 90 Mean±SD (Range)	Day 180 Mean±SD (Range)	Day 0 vs 90 Mean difference P	Day 0 vs 180 Mean difference P	Day 90 vs 180 Mean difference P
Control (n=9)	4.56±0.73 (4.00-6.00)	3.56±0.88 (2.00-5.00)	3.67±0.71 (3.00-5.00)	1.00 0.02*	0.89 0.02*	−0.11 0.59ns
Test (n=9)	4.89±0.78 (4.00-6.00)	2.56±0.73 (1.00-3.00)	2.44±0.88 (1.00-4.00)	2.33 0.000***	2.44 0.000***	0.11 0.76ns

SD=standard deviation; ns=not significant; *=Significant (P<0.01); ***=very highly significant (P<0.001)

The mean PD between control and test sites were 0.11 and 0.22 on day 90 and day 180, respectively. These changes in PD on days 90 and 180 were found to be 6.2% (P = 0.76) and 12% (P = 0.51), respectively, which were not statistically significant. The mean changes in PD are shown graphically in Figure 1.

Figure 1

Changes in pocket depth (PD)

The mean difference in WKG between control and test sites were 0.56 and 0.33 on days 90 and 180, respectively. These changes in WKG on days 90 and 180 were found to be 14.7% and 8%, respectively, which were not statistically significant (P> 0.05). The mean difference in RL between the control and test sites were 1.00 mm on both days 90 and 180. The reduction in RL at test site on day 90 was 50% in comparison to control site which was not statistically significant (P = 0.2). However, the reduction in RL on day 180 was found to be of 53% and was statistically significant (P = 0.03). The mean difference in RW between control and test sites were 0.78 mm and 0.83 mm on days 90 and 180, respectively. These changes in RW both on days 90 and 180 were found to be of 56% which was statistically significant (P = 0.02 on day 90; P = 0.03 on day 180).

DISCUSSION

The ultimate goal of periodontal plastic surgical procedure for coverage of the root recession is complete regeneration of the supporting components of the periodontium, resulting in complete coverage of the denuded root surfaces to fulfill esthetic as well as functional demands. In the present study with AM, width of the attached gingiva was found to be increased significantly in both the control and the test sites postoperatively on days 90 and 180 (P < 0.05), however more at the test sites. This is in accordance with previous observations by other investigators (Amarante et al., 2000[1]; Huang et al., 2005[2]; Gurinsky, 2009).[3] This may be correlated with more reduction in PD at test sites. Gain in CAL was seen in both the sites on days 90 and 180 compared to that of the baseline. It supports the observation of previous researchers (Sharma et al.,[4] 2015; Mahajan et al.,[5] 2015; Kiany and Moloudi, 2015[6]; Pundir et al., 2016[7]). The gain in CAL level was mostly attained due to the formation of epithelial and connective tissue attachment (Pini-Prato et al., 2000[8]; Berlucchi et al., 2005[9]; Silva et al., 2006[10]). However, the exact mechanism of gain in CAL in this study is not known; it may be correlated with the reduction in PD. Significant increase in width of WKG was found in both the sites on days 90 and 180 in comparison to day 0. It supports the findings of Amarante et al. in 2000[1]; Huang et al. in 2005;[2] and Chakraborthy et al. in 2016.[11] Both the length and width of recession decreased significantly at both the sites on days 90 and 180 in comparison to the baseline. Similar findings were reported by various investigators (Singh and Singh 2013[12]; Mehta et al., 2014[13]; Shah et al., 2014).[14] Again, decrease in the length and width of gingival recession was more at test sites than that of the control sites which supports the findings of Agarwal et al. in 2016.[15]

CONCLUSION

From the observations made in the present study, we may draw conclusions that combines coronally advanced flap and amniotic membrane have additional advantage in the outcome of periodontal therapy in the management of gingival recession. However, further study involving a larger sample size and of a longer duration is required to confirm the findings of the present study. Again, longitudinal and histological studies to evaluate long-term effects of amniotic membrane and to assess the regeneration of attachment apparatus, respectively, are required. Thus, a long-term follow-up study is on demand for better understanding of the role of amniotic membrane in the management of gingival recession.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.