Abstract
Background:
Gingival recession causes apical migration of the gingival margins, resulting in exposed root surfaces that lead to sensitivity, aesthetic concerns, and potential oral health issues. The pouch and tunnel (P and T) and vestibular incision subperiosteal tunnel access (VISTA) techniques are both effective, minimally invasive approaches for root coverage, as both enhance aesthetic outcomes while preserving blood supply and minimizing surgical trauma.
Aim:
To evaluate the clinical outcomes of P and T and VISTA, combined with platelet-rich fibrin (PRF) membrane in the treatment of gingival recession defects.
Materials and Methods:
This randomized clinical trial included 12 systemically healthy patients presenting with bilateral isolated gingival recession defects. Patients were allocated into two groups: Group A (P and T + PRF membrane) and Group B (VISTA + PRF membrane). Clinical parameters, including plaque index (PI), gingival index (GI), pocket probing depth (PPD), clinical attachment level (CAL), recession length (RL), recession width (RW), width of keratinized tissue (WKT), and mean root coverage percentage (MRC), were measured at baseline, 1, 3, 6, and 12 months.
Results:
Results indicated significant improvement in both groups in all clinical parameters. However, Group A demonstrated greater reductions in RL, RW, and gain in CAL and WKT, along with a statistically significantly higher root coverage percentage at 12 months.
Conclusion:
The usage of the pouch and tunnel technique, combining the PRF membrane, demonstrated superior efficacy, highlighting its potential as an effective regenerative approach.
KEYWORDS: Clinical attachment level, gingival recession, platelet-rich fibrin, pouch and tunnel, subperiosteal tunnel access, vestibular incision
INTRODUCTION
Gingival recession is the apical migration of the gingival margin beyond the cementoenamel junction, exposing the root surface, a common aesthetic and clinical concern.[1] Exposure of root surfaces leads to dentinal hypersensitivity, loss of periodontal attachment, and elevated root caries risk. Gingival recession is driven by mechanical, anatomical, and periodontal disease.[2]
The pouch and tunnel (P and T) technique is a minimally invasive periodontal plastic surgery for root coverage, preserving papillae and vascularity to support graft integration.[3] VISTA (Vestibular incision subperiosteal tunnel access) is also an invasive technique for covering isolated or multiple adjacent recession defects via a remote vestibular incision and subperiosteal tunneling.[4]
PRF membranes are autologous fibrin scaffolds rich in growth factors, supporting regeneration in periodontal plastic surgery.[5]
This study was designed to compare P and T and VISTA techniques, both combined with PRF membrane for the treatment of gingival recession defects over 12 months.
MATERIALS AND METHODS
Study population and design
Twelve systemically healthy patients (aged between 18 and 50 years) diagnosed with bilateral isolated gingival recession defects were included. Ethical clearance was obtained, and informed consent was signed by all participants. Patients were randomly assigned to-
Group A (Test)- P and T technique with PRF membrane.
Group B (Control)- VISTA with PRF membrane.
Surgical procedure
After Phase I therapy (scaling and root planing), surgical procedures were performed under local anesthesia.
Group A- Sulcular incisions were made using a microsurgical VIPER blade, elevating a full-thickness flap from the gingival margin and a split-thickness flap beyond the attached gingiva. PRF membrane was inserted into the tunnel, the mucogingival complex advanced to mid-coronal tooth level, and secured with composite buttons and sutures.
Group B- A vestibular access incision enabled introduction of tunneling instruments and gentle placement of the PRF membrane into the tunnel. The flap was coronally anchored and stabilized with sutures.
Postoperative care included antibiotics, analgesics, and 0.12% chlorhexidine rinses. Sutures were removed after two weeks [Figures 1 and 2].
Figure 1.
Recession length (RL) at baseline
Figure 2.
Post-op 12th-month recession length (RL)
Clinical evaluation
PI: Silness and Löe
GI: Löe and Silness
PPD, CAL, RL, RW, and WKT: measured using an UNC-15 probe.
Statistical analysis
Data were analyzed using SPSS v25. Paired t-tests evaluated intragroup changes, and independent t-tests analyzed intergroup differences. Significance was set at P < 0.05.
RESULTS
Clinical outcomes
Both groups showed significant improvements (P < 0.05) in all clinical parameters over 12-month period.
Plaque and Gingival scores- Improved in both groups, but more in Group A.
PPD reduction and CAL gain- Higher in Group A.
RL, RW, and WKT- More pronounced in Group A.
MRC %- Significantly more in Group A [Tables 1 and 2].
Table 1.
Mean and standard deviation of different parameters of group a b/w different time differences
| Parameter | Interval | Mean | SD(Δ) | SE(Δ) | ||||
|---|---|---|---|---|---|---|---|---|
| PI | B–1M | -0.289 | 0.563 | 0.162 | ||||
| 1M–3M | -0.535 | 0.499 | 0.144 | |||||
| 3M–6M | -0.167 | 0.384 | 0.111 | |||||
| 6M–12M | 0.000 | 0.245 | 0.071 | |||||
| GI | B–1M | -0.453 | 0.461 | 0.134 | ||||
| 1M–3M | -0.587 | 0.292 | 0.084 | |||||
| 3M–6M | -0.031 | 0.200 | 0.057 | |||||
| 6M–12M | 0.000 | 0.165 | 0.047 | |||||
| PPD (mm) | B–1M | -0.750 | 0.712 | 0.205 | ||||
| 1M–3M | 0.000 | 0.696 | 0.201 | |||||
| 3M–6M | 0.000 | 0.696 | 0.201 | |||||
| 6M–12M | 0.000 | 0.696 | 0.201 | |||||
| CAL (mm) | B–1M | +0.888 | 0.956 | 0.278 | ||||
| 1M–3M | +0.308 | 0.953 | 0.274 | |||||
| 3M–6M | +0.042 | 0.976 | 0.278 | |||||
| 6M–12M | +0.842 | 0.985 | 0.253 | |||||
| RL (mm) | B–1M | -1.792 | 0.721 | 0.209 | ||||
| 1M–3M | -0.021 | 0.371 | 0.106 | |||||
| 3M–6M | -0.020 | 0.344 | 0.098 | |||||
| 6M–12M | -0.125 | 0.266 | 0.076 | |||||
| RW (mm) | B–1M | -0.546 | 0.923 | 0.270 | ||||
| 1M–3M | -0.510 | 0.824 | 0.237 | |||||
| 3M–6M | -0.360 | 0.653 | 0.189 | |||||
| 6M–12M | -0.521 | 0.392 | 0.112 | |||||
| WKT (mm) | B–1M | +0.834 | 0.784 | 0.226 | ||||
| 1M–3M | +0.660 | 0.825 | 0.241 | |||||
| 3M–6M | +0.423 | 0.842 | 0.242 | |||||
| 6M–12M | +0.375 | 0.846 | 0.243 | |||||
| % Root coverage | 1M–3M | +0.694 | 15.76 | 4.54 | ||||
| 3M–6M | +1.042 | 14.68 | 4.29 | |||||
| 6M–12M | +4.861 | 11.47 | 3.29 |
Group A showed a mean root coverage percentage of 94.443% (P=0.001) at 12 months, demonstrating a statistically significant difference, confirming better esthetic outcomes. PI=Plaque index, GI=gingival index, PPD=pocket probing depth, CAL=clinical attachment level, RL=recession length, RW=recession width, WKT=width of keratinized tissue, SD=standard deviation, SE=standard error
Table 2.
Mean, standard deviation, median, mode, maximum, and minimum scores of different parameters of Group B b/w different time differences
| Parameter | Interval | Δ (End–Start) | SD(Δ) | SE(Δ) | ||||
|---|---|---|---|---|---|---|---|---|
| PI | B–1M | -0.349 | 0.581 | 0.167 | ||||
| 1M–3M | -0.535 | 0.499 | 0.144 | |||||
| 3M–6M | -0.167 | 0.384 | 0.111 | |||||
| 6M–12M | 0.000 | 0.245 | 0.071 | |||||
| GI | B–1M | -0.498 | 0.463 | 0.134 | ||||
| 1M–3M | -0.587 | 0.292 | 0.084 | |||||
| 3M–6M | -0.031 | 0.200 | 0.057 | |||||
| 6M–12M | 0.000 | 0.165 | 0.047 | |||||
| PPD (mm) | B–1M | -0.667 | 0.818 | 0.236 | ||||
| 1M–3M | 0.000 | 0.921 | 0.266 | |||||
| 3M–6M | 0.000 | 0.921 | 0.266 | |||||
| 6M–12M | 0.000 | 0.921 | 0.266 | |||||
| CAL (mm) | B–1M | +0.117 | 0.825 | 0.229 | ||||
| 1M–3M | +0.329 | 0.883 | 0.267 | |||||
| 3M–6M | +0.221 | 0.917 | 0.265 | |||||
| 6M–12M | +0.425 | 0.942 | 0.271 | |||||
| RL (mm) | B–1M | -1.659 | 0.479 | 0.139 | ||||
| 1M–3M | -0.041 | 0.187 | 0.054 | |||||
| 3M–6M | -0.109 | 0.137 | 0.039 | |||||
| 6M–12M | -0.087 | 0.145 | 0.041 | |||||
| RW (mm) | B–1M | -0.299 | 0.899 | 0.262 | ||||
| 1M–3M | -0.226 | 0.473 | 0.136 | |||||
| 3M–6M | -0.183 | 0.404 | 0.117 | |||||
| 6M–12M | -0.163 | 0.313 | 0.089 | |||||
| WKT (mm) | B–1M | +0.625 | 0.765 | 0.217 | ||||
| 1M–3M | +0.242 | 0.777 | 0.222 | |||||
| 3M–6M | +0.316 | 0.700 | 0.202 | |||||
| 6M–12M | +0.350 | 0.570 | 0.166 | |||||
| % Root coverage | 1M–3M | +1.042 | 9.140 | 2.585 | ||||
| 3M–6M | +4.930 | 8.007 | 2.307 | |||||
| 6M–12M | +4.375 | 6.132 | 1.784 |
PI=Plaque index, GI=gingival index, PPD=pocket probing depth, CAL=clinical attachment level, RL=recession length, RW=recession width, WKT=width of keratinized tissue, SD=standard deviation, SE=standard error
DISCUSSION
This study confirmed that both Groups A and B demonstrated significant improvements in clinical outcomes. However, Group A showed superior outcomes.
The pouch and tunnel technique offers long-term stability and reduced morbidity, making it an effective option for soft tissue grafting, as this technique enhances gingival thickness, which helped prevent future recession and ensured lasting results.[6]
Platelet concentrates, particularly platelet-rich fibrin (PRF), have become integral in periodontal therapy for treating gingival recession defects. These autologous preparations harness the body’s natural healing mechanisms to enhance tissue regeneration and repair.
CONCLUSION
Both Group A and Group B proved effective in managing gingival recession defects; however, Group A demonstrated significantly greater clinical efficacy, positioning it as the preferred approach for periodontal regeneration when feasible.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
REFERENCES
- 1.Löe H, Ånerud Å, Boysen H. The natural history of periodontal disease in man: Prevalence, severity, and extent of gingival recession. J Periodontol. 1992;63:489–95. doi: 10.1902/jop.1992.63.6.489. [DOI] [PubMed] [Google Scholar]
- 2.Patil VA, Patil ST. A novel approach in root coverage-Coronally repositioned flap with GTR membrane and frenotomy. J Ind Soc Periodontol. 2013;17:261–4. doi: 10.4103/0972-124X.113094. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage. I. Rationale and technique. Int J Periodontics Restorative Dent. 1994;14:216–27. [PubMed] [Google Scholar]
- 4.Zadeh HH. Minimally invasive treatment of maxillary anterior gingival recession defects by vestibular incision sub-periosteal tunnel access and platelet-derived growth factor BB. Int J Periodontics Restor Dent. 2011;31:653. [PubMed] [Google Scholar]
- 5.He L, Lin Y, Hu X, Zhang Y, Wu H. A comparative study of platelet-rich fibrin (PRF) and platelet-rich plasma (PRP) on the effect of proliferation and differentiation of rat osteoblasts in vitro. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol. 2009;108:707–13. doi: 10.1016/j.tripleo.2009.06.044. [DOI] [PubMed] [Google Scholar]
- 6.Santamaria MP, Neves FS, Silveira CA. Comparative effectiveness of different root coverage techniques: A systematic review and network meta-analysis. J Clin Periodontol. 2018;45:1426–43. [Google Scholar]
