ABSTRACT
Aim:
To evaluate “coronally advanced flap” with or without “a platelet-rich fibrin membrane for the root coverage.”
Materials and Methods:
All the clinical parameters were assessed at different time intervals (at baseline, 1, 3, and 6 months) in both experimental and control group. Following “clinical parameters” were recorded using “UNC-15” “Probe-Plaque Index (PI)” (Silness and Loe, 1964), “Gingival Index” (GI) (Loe and Silness, 1963), “Recession depth (RD),” “Recession width (RW),” “Clinical attachment level (CAL),” and “Width of keratinized gingiva (WKG)”.
Results:
At final evaluation (i.e., mean change from baseline to 6 months), “the decrease in Plaque Index was 2.5% higher in Group B (66.0%) as compared to Group A (63.5%). The decrease in Gingival Index was 6.1% higher in Group B (91.4%) as compared to Group A (85.3%), and the decrease in recession width was 4.0% higher in Group B (75.2%) as compared to Group A (71.2%). The decrease in clinical attachment level was 4.4% higher in Group B (53.2%) as compared to Group A (48.4%). The increase in width of keratinized gingiva was 1.9% higher in Group A (28.8%) as compared to Group B (26.9%).”
Conclusion:
The controlled, randomized, split mouth design showed that CAF surgery, either by alone or in combination with PRF, is an efficient treatment method for covering denuded roots. “This design was used to treat bilateral isolated Miller’s class I and II recessions in gingival part. When compared to the CAF approach, the results from a combination of CAF and PRF after a 6-month period showed additional advantages in addition to mean root coverage in the treatment of Miller’s classes I and II recessions in gingival part.”
KEYWORDS: Flap, keratinized, platelet rich fibrin
INTRODUCTION
The term “gingival recession” refers to the movement of the junctional epithelium toward the apex, exposing the root surfaces.[1] Adults might have “gingival recession” anywhere between 20% and 100% of the time. This causes periodontal attachment loss, root cavities, unsightly gingival appearance, and dentinal hypersensitivity in addition to pain and discomfort.[2] “Periodontal plastic surgery’s” key goal is to provide reliable root coverage that is supported by a sizable amount of tissue regeneration.[3,4,5]
Combining “CAF with other regenerative methods,” such as “connective tissue grafts, enamel-matrix derivatives, synthetic allografts, and autologous platelet” concentrates, such as “platelet-rich fibrin (PRF),” can improve the results.[6]
“Angiogenesis, growth factors, and mesenchymal stem cell” activity are three crucial elements in the maturation of soft tissues and the healing process. “Platelet-rich fibrin,” or PRF, is made up of “platelet-derived growth factors,” “transforming growth factors,” “fibroblast growth factor,” “insulin-derived growth factor,” and “platelet-derived epidermal growth factor.”
MATERIALS AND METHODS
The patients reporting to “Department of Periodontology (OPD)” were included in this study based on the following selection criteria.
Inclusion criteria
Millerion criteriaed in this sgingival recession” in maxillary or mandibular incisors and canine teeth (present two anterior teeth).
Age 18 to 40 years.
Exclusion criteria
Mal aligned teeth.
Mucosal disorders like high frenal attachments and ulcers.
Patients who are unable to perform routine oral hygiene procedures or not cooperative.
Previous surgical attempts to correct the oral hygiene proce.”
Smokers or patients with tobacco chewing habits.
Medically compromised patients.
Pregnant or lactating women.
Patients under anticoagulation treatment for bleeding disorder.
Method of collection of data
Sample size
“A total of 28 systemic healthy patients with Miller’s class I or class II gingival recession confirmed by radiographic analysis were included in this study.” Approval from the ethical committee was obtained to conduct this study.
Study period
The duration of this comparative clinical study was for 6 months.
Clinical parameters
-
All the clinical parameters were assessed at different time intervals (at baseline, 1, 3, and 6 months) in both experimental and control group. Following clinical parameters were recorded using UNC-15 probe.
“Plaque Index (PI)” (Silness and Loe, 1964)
“Gingival Index (GI)” (Loe and Silness, 1963)
“Recession depth (RD)”
“Recession width (RW)”
“Clinical attachment level (CAL)”
“Width of keratinized gingiva (WKG)”
Study design
This was a “split mouth study design.” A sample size of 28 patients both male and female was taken. Surgical procedure was refund for the root coverage of the exposed teeth due to recession on either maxillary or mandibular anterior teeth. It was mandatory to have at least two sites indicated for root coverage to perform the comparative surgical procedure.
Patients were randomly divided into the following groups
Experimental group- 28 sites treated with coronally advanced flap with platelet-rich fibrin membrane.
Control group- 28 sites were treated with coronally advanced flap alone.
Sampling technique
Stent preparation
Gingival stent was prepared to measure “gingival recession” at baseline and at recall intervals.
Surgical protocol
“2% xylocaine and adrenaline (1:200000)” were used to anaesthetize the surgical site. The surgical site saw the use of a “coronally positioned flap” method. Scalpel number 15 is used with “Bard Parker handle number 3.” “Two oblique releasing incisions” were made at the mesial and distal portions of the location, and sulcular incisions were made all the way around the impacted teeth to define it. At least “3 mm of marginal bone apical” to the “dehiscence area” was exposed by elevating a “full thickness flap.” At the base of the flap, a “horizontal releasing incision” was created in the periosteum to allow for “tension-free coronal displacement.” “Ultrasonic scaler and universal curette (2R-2L)” were used to scale and root plane the exposed root surfaces. Platelet-rich fibrin (PRF) membrane preparation was done followed by placement of PRF membrane. In the postoperative care, patients were managed by antibiotics and analgesics.
RESULTS
The present study deals with “clinical evaluation of coronally advanced flap” with or without “platelet-rich fibrin (PRF)” membrane for the root coverage. Totally, 28 patients were selected randomized and treated according to spilt mouth design, i.e., one side without “PRF (Group A)” or other side with “PRF (Group B).” The outcome measures of the study were “Plaque Index (PI)” and “Gingival Index (GI),” “recession depth (RD),” “recession width (RW),” “clinical attachment level (CAL),” and “width of keratinized gingival (WKG).” The outcome measures “RD, RW, CAL, and WKG” were measured in mm, while PI and GI were measured in scores. The outcome measures were assessed at “pre-treatment (baseline) and post-treatment (1, 3, and 6 months).” The objective of the study was to compare the outcome measures between the two groups.
“Plaque index”
The pre- (baseline) and post-treatment (1, 3, and 6 months) “Plaque Index” (mm) of “two groups (Group A and Group B).” In both groups, mean “Plaque Index” decreases comparatively after the treatment and the decrease was evident similar between the two groups. “For each group, comparing the mean Plaque Index within the groups (i.e., between periods), Tukey test showed significant (P < 0.001) decrease in Plaque Index at all after periods (1, 3, and 6 months) as compared to pre-treatment (baseline) in both the groups. Furthermore, in both groups, it also decreases significantly (P < 0.05 or P < 0.01) at both 3 and 6 months as compared to 1 month.
“Gingival Index”
The pre- (baseline) and post-treatment (1, 3, and 6 months) “Gingival Index” (mm) of “two groups (Group A and Group B).” In both groups, mean “Gingival Index” decreases comparatively after the treatment and the decrease was evident similar between the two groups.
“For each group, comparing the mean Gingival Index within the groups (i.e., between periods), Tukey test showed significant (P < 0.001) decrease in Gingival Index at all after periods (1, 3, and 6 months) as compared to pre-treatment (baseline) in both the groups. Furthermore, in both groups, it also decreases significantly (P < 0.05) at 6 months as compared to 1 month.
DISCUSSION
“Gingival recession” is treated with a variety of “periodontal plastic surgery” techniques. The three types of treatment plans that are most frequently employed are free graft, which comprises free “gingival graft, subepithelial connective tissue graft, and pedicle flap,” which includes “lateral pedicle flap” and “coronally advanced flap (CAF).”[7]
“In order to help regenerate functional attachment apparatus and improve root coverage, CAF is frequently combined with a variety of regenerative materials, including guided tissue regeneration membranes, enamel matrix proteins derivatives, alloderm, and living tissue-engineered human fibroblast-derived dermal substitute.”[8]
Combining “CAF (Coronally advanced flap)” with other regenerative methods like autologous platelet concentrates and “platelet-rich fibrin (PRF)” can make the outcome more predictable.
The current study focuses on the clinical assessment of coronally advanced flaps for root covering that have “platelet-rich fibrin (PRF)” membrane or not. In total, 28 patients were chosen at random, divided into two groups, Group A for the side without PRF and Group B for the side with PRF, and treated accordingly. The study’s outcomes included the “Plaque Index (PI),” “Gingival Index (GI),” “recession depth (RD),” “recession width (RW),” “clinical attachment level (CAL),” and “width of keratinized gingiva (WKG).” In contrast to PI and GI, which were quantified in scores, the outcome measures “RD, RW, CAL, and WKG” were measured in millimeters. The outcome measures were evaluated prior to treatment (baseline), as well as 1, 3, and 6 months after treatment. The study’s goal was to compare the outcome metrics between the two groups.
In the present study, the recession depth decreases significantly after the treatment in both the groups. In Group A, the baseline mean recession depth was 1.64 ± 0.13 mm, while at 6 months post-treatment, it was 0.25 ± 0.08 mm. In Group B, the baseline mean recession depth was 1.61 ± 0.14 mm, while at 6 months post-treatment, it was 0.18 ± 0.07 mm. The Group B showed more decrease (improvement) in recession depth as compared to Group A.
The percentage of root coverage of two groups is also evaluated. The root coverage of Group A and Group B ranged from 0-100% and 50-100%, respectively, with mean (±SE) 85.12 ± 5.58% and 92.86 ± 3.02%, respectively. The mean percentage root coverage of Group B was slightly higher than Group A. Comparing the mean percentage root coverage of two groups, though it was 8.3% higher in Group B as compared to Group A.
In this study, the recession width decreases significantly after the treatment in both the groups. In Group A, the baseline mean recession width was 3.71 ± 0.16 mm, while at 6 months post-treatment, it was 1.07 ± 0.18 mm. The Group B showed more decrease (improvement) in recession width as compared to Group A, but “the improvement in recession depth was statistically insignificant between the two groups. Sofia Aroca et al. (2009) presented almost similar recession width reduction in patients treated with CAF in combination with PRF.[9] In another study, Thamaraiselvan et al. (2015) reported almost similar results for recession width when treated with and without PRF.”[10]
In this study, the width of keratinized gingiva increases significantly after the treatment in both the groups. In Group A, the baseline mean of the width of keratinized gingiva was 3.36 ± 0.22 mm and 4.71 ± 0.22 mm at the end of 6 months postoperative.
“In this study, the treatment of bilateral Miller’s class I and II recessions in gingival part indicated that CAF surgery alone or in combination with PRF are effective procedures to cover denuded root surfaces. The data obtained from a combination of CAF with PRF after a period of 6 months showed additional benefits 8.3% of mean percentage root coverage the treatment of Miller’s class I and II recessions in gingival part when compared with the CAF technique alone.”
CONCLUSION
Following conclusion have been drawn from the present study:
The “Gingival Index” and “Plaque Index” for both groups decreased as compared to baseline. Postoperative recession depths were significantly reduced in both groups. Change was larger in Group B. Both groups experienced a small improvement in the width of the gingiva after keratinization. The percentage of recession breadth decreased in both groups when it was assessed at baseline and at the post-operative check-up. “This controlled, randomized, split mouth design for the treatment of bilateral isolated Miller’s class I and II recessions in gingival part demonstrated the efficacy of PRF or CAF surgery alone in covering denuded roots. Results obtained from a CAF and PRF combination indicated extra benefits over and above mean root coverage in the treatment of Miller’s class I and II recessions in gingival part after a six-month period when compared to the CAF approach.”
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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