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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 10
| Issue : 3 | Page : 100-104 |
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Evaluation of the efficacy of a coronally repositioned flap with collagen membrane for root coverage of Miller’s class I and class II recession: A randomized controlled trial
Kirti Pal, Shweta Bali, Priyanka Aggarwal, Aruna Nautiyal, Deepali Singhal
Department of Periodontics and Oral Implantology, Santosh Dental College, Santosh Deemed to be University, Ghaziabad, Uttar Pradesh, India
| Date of Submission | 31-Mar-2022 |
| Date of Decision | 23-Sep-2022 |
| Date of Acceptance | 06-Jun-2022 |
| Date of Web Publication | 21-Feb-2023 |
Correspondence Address:
Priyanka Aggarwal
J-201, Sector 77, Prateek Wisteria, Noida, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/DYPJ.DYPJ_23_22
Objective: This study aimed to clinically evaluate the efficacy of coronally repositioned flap in the treatment of isolated Miller’s class I and II gingival recession. Materials and Methods: Twelve patients with Miller’s class I and class II recession were selected. Patients were randomly divided into two groups: Group A (control group): coronally repositioned flap and Group B (test group): coronally repositioned flap with bioabsorbable collagen membrane. Clinical evaluation parameters such as probing depth (PD), clinical attachment level (CAL), width of keratinized tissue (WKT), gingival biotype (thickness), recession width (RW), and recession depth (RD) were recorded at baseline and at 1, 3, and 6 months post-operatively using an acrylic stent. Results: A significant gain in CAL (−0.6, −0.78, and −0.60 mm) and WKT (0.25, 0.48, and 0.83 mm) was observed in both the groups from baseline to 1, 3, and 6 months, respectively. However, the gain was more in the test group than the control group. Similarly, a significant decrease in mean RD and RW was more in the test group when compared with the control group (significant P-value <0.001) 6 months post-operatively. Also, no statistically significant change was found in the two groups in terms of PD and gingival tissue at 6 months. Conclusion: The results of this study suggest that collagen can improve the clinical outcomes of the coronally repositioned flap operation in the therapy of localized recession defects. Keywords: Coronally repositioned flap, gingival recession, guided tissue regeneration, root coverage and width of keratinized gingiva
How to cite this article:
Pal K, Bali S, Aggarwal P, Nautiyal A, Singhal D. Evaluation of the efficacy of a coronally repositioned flap with collagen membrane for root coverage of Miller’s class I and class II recession: A randomized controlled trial. D Y Patil J Health Sci 2022;10:100-4 |
How to cite this URL:
Pal K, Bali S, Aggarwal P, Nautiyal A, Singhal D. Evaluation of the efficacy of a coronally repositioned flap with collagen membrane for root coverage of Miller’s class I and class II recession: A randomized controlled trial. D Y Patil J Health Sci [serial online] 2022 [cited 2023 Mar 23];10:100-4. Available from: http://www.dypatiljhs.com/text.asp?2022/10/3/100/370115 |
| Introduction | |  |
Gingival recession (GR) designates the oral exposure of the root surface due to the displacement of gingival margin apical to the cementoenamel junction.[1] Several factors play a major role in the development of GR, with the most common etiology being plaque-induced periodontitis and faulty tooth brushing. The other causative factors include tooth malpositioning, alveolar bone dehiscence, thin gingival biotype, non-vascularized root surface, aberrant muscle attachment, orthodontic and prosthodontic treatment, and tobacco chewing.[2] GR defects exhibit both esthetic and functional problems.[3]
Various therapeutic surgical procedures have been introduced to treat GR, such as free gingival graft, the coronally advanced flap (CAF), free connective tissue graft, and pedicle flap.[4] However, healing after these procedures is achieved by the formation of long junctional epithelium and not periodontal regeneration. Other drawbacks include patients’ pain, a long recovery period, a new surgical site, insufficient donor tissue supply, and post-surgical hemorrhage.
Guided tissue regeneration (GTR), which is one of the commonly sought treatment modalities, aims at guiding the proliferation of the epithelial cells and at the same time makes sure that they do not proliferate into the areas that are desirous of achieving periodontal regeneration.[3] It is based on the concept of epithelial exclusion (or compartmentalization) and entails putting a barrier membrane between the surgical flap and the root surface to keep gingival epithelial cells and connective tissues from interfering with the process of healing.
The barrier membranes used in GTR can be either resorbable or non-resorbable. The disadvantage of non-resorbable membrane is that they require a second surgical entry for their removal, hence causing additional pain or discomfort to the patient.
Bernmoulin et al. were the first to introduce the coronally repositioned flap, which includes coronal advancing of the gingival tissue which is present apical to the recession defect.[5]
Bioresorbable collagen membranes used in GTR as a part of periodontal plastic surgical procedures have the benefit of being highly predictable, yielding highly esthetic root coverage and can be obtained without the need for a second surgical procedure or a second surgical site, making it an appealing alternative to traditional grafting techniques. There are only a few available studies which highlight the positive outcomes of coronally repositioned flap when augmented by the membrane.[4]
Hence, the purpose of this study was to assess and compare the efficacy of coronally repositioned flaps with and without collagen membranes for the treatment of single tooth Miller’s class I and II recession defects.[1]
| Materials and Methods | | |
The present randomized controlled trial was done in agreement with principal guidelines declared in Helsinki experimentation of human subjects and after the approval of the Ethics Committee of the institution. This study was done in Department of Periodontics and Oral Implantology, Santosh Dental College, Ghaziabad, Uttar Pradesh, India. The total sample size was estimated to be 24 sites for two groups [Figure 1], and it was calculated using the nMaster 2.0 software link. Each patient was informed about the limitations and benefit of treatment, and a written consent was obtained prior to the procedure. Subjects were recruited in the present study based on pre-specified inclusion and exclusion criteria. Subjects with at least two sites of Miller’s class I or class II recession, having platelet count within the normal range and cementoenamel junction (CEJ) present without considerable damage, were included in the study. Subjects with active infection or inflammation in the area of recession, habit of bruxism, clenching, high frenal attachments, and smokers were excluded from the study.
| Evaluation Parameters | | |
The initial therapy was performed with full mouth scaling and root planning, followed by oral hygiene instructions. The baseline parameter were recorded 15 days after initial therapy. All clinical parameters such as probing depth (PD), clinical attachment level (CAL), gingival biotype (thickness), recession width (RW), and recession depth (RD) were then recorded at baseline, 1 month, 3 months, and 6 months. Patients were assigned to one of the two treatment groups using a computer-generated randomization table. Two groups were Group A (control group) coronally repositioned flap and Group B (test group) coronally repositioned flap + bioabsorbable collagen membrane. A sealed, coded opaque envelope contained the treatment information for the specific subject; it was opened at the time of surgery, immediately after completing treatment of the root surfaces. All measurement were recorded by an investigator blinded to the surgical procedures.
Surgical procedure
The clinical and radiographic parameters were recorded before local anesthesia. The surgical area was prepared with adequate anesthesia using 2% lignocaine HCl containing 1:80,000 adrenalin. A coronally repositioned flap technique was done in both the groups. A split thickness flap was prepared by sharp dissection mesial and distal to the recession and connected with an intracrevicular incision. Apical to the receded soft tissue margin on the facial aspect of the tooth, a full thickness flap was elevated to maintain maximal thickness of the tissue flap to be used for root coverage. Approximately 3 mm apical to the bone dehiscence, a horizontal incision was made through the periosteum, followed by blunt dissection in the vestibular lining mucosa to release muscle tension and it was extended both buccally and laterally so that mucosal graft could be easily positioned coronally. The tissue flap was repositioned coronally to the CEJ. In the test group, the first part of the surgical procedure was identical to that of the non-membrane site. However, following the reflection of the flap, a bioresorbable membrane was trimmed, positioned, and sutured to cover the recession up to the CEJ. The coronally repositioned flap was placed over the membrane and sutured. Periodontal dressing was placed over the surgical site.
Post-operative care
Patients were advised to use 0.2% chlorhexidine gluconate twice daily and advised were to follow Charter’s brushing technique. Analgesics and antibiotics were prescribed and advised were to follow the routine post-operative instructions. The dressing and sutures were removed after 10 days post-surgery. Follow-up was done at baseline.
| Statistical analysis | | |
Data were transported from case record proformas to SPSS (Statistical Package for Social Sciences) version 25.0 and MedCalc software for analysis. Descriptive variables were recorded as mean ±SD. Comparative analysis was done using analysis of variance (ANOVA) and unpaired t-test.
Statistics were performed by calculating mean and standard deviation for the continuous variables. Software used was SPSS version 25.0 and MedCalc software. P-value was taken to be significant when less than 0.05 (P < 0.05) and confidence interval of 95% was taken. Non-significant test means that the sample distribution is shaped like a normal curve. Unpaired or independent Student’s t-test is used when two samples are compared.
| Results | | |
On comparing the means and standard deviations of the PD, CAL, WKT, gingival biotype thickness, RD, and RW in the test group with the control group at baseline, there was no statistically significant difference between both the groups (P > 0.05); hence, it is inferred that both groups were similar at baseline. Intragroup comparison in both the groups showed statistically significant difference (P < 0.001 using the ANOVA test) w.r.t. CAL, WKT, RD, and RW at 1, 3, and 6 months from baseline [Table 1][Table 2][Table 3]. The difference in PD and gingival biotype thickness was not significant when comparison was done in test and control groups (P > 0.05) at 1, 3, and 6 months, respectively [Table 1]. The CAL was measured using UNC 15 probe. There was a mean gain of 0.66, 0.78, and 0.60 mm w.r.t. CAL in the test group (P < 0.05) when compared with the control group at 1, 3, and 6 months, respectively [Table 2]. The difference in the mean of WKT between the two groups was statically non-significant at 1 month (P > 0.05). However, the difference in WKT from baseline to 3 months and baseline to 6 months is significantly more in the test group (P < 0.05). Also, the decrease in mean RW and RD was significantly more in the test group (P < 0.001) when compared with the control group at 1, 3, and 6 months from baseline, respectively [Table 3]. | Table 1: Intergroup and intragroup comparison of pocket depth and gingival biotype thickness in test and control groups at baseline, 1, 3, and 6 months using unpaired t-test and ANOVA
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 | Table 2: Intergroup and intragroup comparison of clinical attachment level and width of keratinized tissue between test and control groups at baseline, 1, 3, and 6 months using unpaired t-test and ANOVA
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 | Table 3: Intergroup and intragroup comparison of recession depth and recession width between test and control groups at baseline, 1, 3, and 6 months using unpaired t-test and ANOVA
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| Discussion | | |
GR refers to an undesirable apical shift of the marginal tissue beyond the CEJ. The main goal and advantage of incorporating GTR into RC procedure are to achieve periodontal regeneration that results in new attachment rather than connective tissue repair. The GTR technique offers several advantages over other techniques, including the elimination of the need for a second surgical site for harvesting a graft and its associated morbidity, less post-surgical trauma and discomfort, and an increase in acceptance of the procedure by the patients.[6] The purpose of the current randomized clinical study was to examine the relative efficiency of a CAF and a CAF combined with a collagen membrane for the treatment of Miller’s class I or II defects. Several factors may influence clinical outcomes obtained by GTR, which include the type of the membrane, the shape or size of the defect, tissue thickness, space making ,and presence or absence of membrane exposure.[7] The collagen membrane used in our study was made up of bovine type I collagen membrane. Along with its semi-permeability, collagen tissue allows nutrients and gases to pass through while also assisting in the expansion of the overall tissue volume when it is naturally absorbed and replaced by host tissue also it is biocompatible and facilitates early clot formation and wound stabilization.[1],[8]
With reference to PD and gingival tissue thickness, no statistically significant change was seen in the 6 months when compared with baseline. Similar results were observed in the study done by Amarante et al. in 2000, which indicates that increasing buccal PD is not a common side effect following root coverage procedures.[9]
In the present study, a significant gain in CAL was observed in both the groups from baseline to 3 months and 6 months; attachment gain was significantly more in the test group (1.61 ± 1.04 mm) when compared with the control group (2.21 ± 1.14 mm). The current test group’s clinical improvement was due to periodontal regeneration, whereas the control group’s improvement was due to the creation of long junctional epithelium. Kapare et al.[1] in 2016 and Amarante[2] in 2002 both showed similar results.
A statistically significant increase was seen in the WKT from baseline to 6 months in both test and control groups. Also, the increase in WKT was more in the test group with P < 0.002 at 6 months post-operatively when compared with the control group. The increase in the WKT could be explained by several events taking place during the healing and maturation of the marginal tissue.[10] These results are in accordance with the study done by Shieh et al. in 1997, in which they found a significant gain in keratinized tissue at 6 months post-operatively in sites treated with a collagen membrane along with coronally advanced flap. Kapare et al. in 2016,[1] Tinti et al., Pini Prato et al., and Trombelli et al. in 1997[11] also showed similar results in their studies.
In the present study when the baseline RD and RW values were compared with the 6-month post-operative values, the mean RD and RW on all three surfaces (mesio-labial, mid-facial, and disto-labial) were significantly (P < 0.001) decreased in the test group when compared with the control group. These results were similar to the study by Gupta et al. in 2014 who attributed these findings to the design characteristics of the collagen membrane along with CAF.
This study thus establishes that percentage of root coverage achieved with GTR-based treatment root coverage using collagen as a barrier membrane was significantly better than using coronally advanced flap alone for the treatment of localized gingival recession (Miller’s class I and II). However, histological examination is needed to characterize and confirm the type of healing. Small sample size and short study period was one of our study’s limitations. Long-term studies with a larger sample size are essential to conclusively evaluate the stability of the root coverage achieved using collagen as a barrier membrane in root coverage procedures.[12],[13],[14],[15],[16]
| Conclusion and Summary | | |
GR therapy with GTR procedures has shown good outcomes. Use of a bioabsorbable collagen membrane has been the focus of recent research. In the treatment of Miller’s class I and II recession defects, collagen membrane with CAF was more effective than CAF alone.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Kapare K, Gopalakrishnan D, Kathariya R, Tyagi T, Bagwe S Evaluation of efficacy of a novel resorbable collagen membrane for root coverage of Miller’s class I and class II recession in the maxillary anteriors and premolars. J Indian Soc Periodontol 2016;20:520-24.  |
| 2. | Amarante S Recession, human gingival . Coronally positioned flap procedures with or without a bioabsorbable. J Periodontol 2000;71:989-98. |
| 3. | Agarwal M, Deepa D Coronally repositioned flap with bioresorbable collagen membrane for Miller’s class I and II recession defects: A case series. Med Princ Pract 2019;28:477-80. |
| 4. | Baldi C, Pini-Prato G, Pagliaro U, Nieri M, Saletta D Coronally advanced flap procedure for root coverage. Is flap thickness a relevant predictor to achieve root coverage? A 19-case series. J Periodontol 1999;70:1077-84. |
| 5. | Bernimoulin JP, Luscher B, Muhlemann HR Coronally repositioned periodontal flap. Clinical evaluation after one year. J Clin Periodontol 1975;2:1-13. |
| 6. | Gupta P, Gupta H Comparative evaluation of envelope type of advanced flap with and without type I collagen membrane (NEOMEM TM) in the treatment of multiple buccal gingival recession defects: A clinical study. Indian J Dent 2014;5:190. |
| 7. | Lee E-J, Meraw SJ, Oh T-J, Giannobile WV, Wang H-L Comparative histologic analysis of coronally advanced flap with and without collagen membrane for root coverage. J Periodontol 2002;73:779-88. |
| 8. | Soni N, Soni BW, Jain R, Sikri P Evaluation of the efficacy of 100% type-I collagen membrane of bovine origin in the treatment of human gingival recession: A clinical study. Indian J Dent 2014;5:132. |
| 9. | Tinti C, Vincenzi G, Cortellini P, Pini Prato G, Clauser C Guided tissue regeneration in the treatment of human facial recession. A 12-case report. J Periodontol 1992;63:554-60. |
| 10. | Mehta NT, Mittal M, Mehta R, Horal BS A novel dehydrated amnion allograft for use in the treatment of gingival recession. J Res Adv Dent 2014;3:2:176-81. |
| 11. | Shieh AT, Wang HL, O’Neal R, MacNeil RL Development and clinical evaluation of a root coverage procedure using a collagen barrier membrane. J Periodontol 1997;68:770-78. |
| 12. | Bunyaratavej P, Wang HL Collagen membranes: A review. J Periodontol 2001;72:215-29. |
| 13. | Trombelli L Periodontal regeneration in gingival recession defects. Periodontology 2000 1998;19:138-50. |
| 14. | Wennstorm JL Mucogingival surgery. Ann Periodontol 1996;1:671. |
| 15. | Gunsolley JC, Elswick RK, Davenport JM Equivalence and superiority testing in regeneration clinical trials. J Periodontol 1998;69:521-7. |
| 16. | Waerhaug J Healing of the dento-epithelial junction following subgingival plaque control. I. As observed in human biopsy material. J Periodontol 1978;49:1-8. |
[Figure 1]
[Table 1], [Table 2], [Table 3]
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