Abstract
Background:
The long-term stability for both the patient and periodontist remains an important priority after connective tissue graft to manage the gingival recession cases. The goal of this analysis was to assess and compare the connective tissue graft with Pouch/Tunnel technique versus connective tissue graft with coronally advanced tunnel flap for the treatment of maxillary recession cases in severe periodontitis.
Methods:
The total sample size was comprised of 200 subjects. The control group, coronally advanced flap along with connective tissue graft (CTG) was comprised of 100 samples and test group, pouch/tunnel technique with connective tissue graft (POT + CTG) was also comprised of 100 samples. The clinical findings included medium root coverage (MRC) and absolute root (CRC) coverage, gingival (GT) distribution and keratinized tissue (KT) gain. Esthetic findings were also evaluated. All findings analyzed initially after 6th months and have been expanded to 4 years.
Results:
There were no major variations between the MRC and CRC patient classes with non significant values. In the POT + CTG category, GT and KT improvements were slightly greater at 4 years, with a substantial improvement in texture in control group.
Conclusion:
Pouch/Tunnel technique along with connective tissue graft allows for the clinical coverage of gingival recessions that is equivalent to Coronally advanced flap with CTG, however this may improves the gingival thickness, KT and esthetic performance.
Keywords: Gingival recession, Specialized coronary flap, Tunnel flap, Connective tissue transplant
Introduction
Ginigval recession (GR) has been characterized as an apical gingival rim migration beyond the cement-enamel junction and exposure of root surface [1, 2]. Dentine hypersensitivity and gingival inflammation are sometimes linked with GR [3]. Several treatment procedures for gingival recession, including free gingival grafts and repositored flaps, have been suggested in recent decades by various studies [4]. The advanced flaps were commonly represented either alone or in conjunction with the connective tissue graft (CTG) [5, 6]. Coronally advanced flap in combination with coronally advanced flap (CAF) has been suggested as the most powerful approach in the management of a recession, as per systematic examination and meta-analysis [7–9]. It was also seen that after a 5-year period with less chance of recession relapse, that the addition of CTG generates more stable outcomes [10, 11]. Previous studies also showed that the CAF + CTG has been found to permit secure recession coverage and long-term keratinized tissue (KT) gain in the past 20 years [11].
In order to eliminate the papillary incisions and to diminish the surgical damage, alternate tunnel approaches in conjunction with CTG had been proposed [12]. Raetzke defined the tunnel technique for recessions with single dents for the first time in the literature and later revised to cover a variety of recessions [13]. This method has been improved by many clinicians to make it more significant and less traumatic [14]. The key goal of these improvements was to improve the root coverage and the maximum esthetic of soft tissue.
According to systematic reviews and meta-analysis [14], CAF combined with CTG is the most effective technique to treat a single or a multiple recession, and both European Federation of Periodontology (EFP) and American Association of Periodontology (AAP) consensus conferences concluded that this approach should be considered as the gold-standard, whereas conjunction of enamel matrix derivative (EMD) or acellular dermal matrix graft may be considered as alternatives.
Latest systematic analysis on the effectiveness of the tubular/tunnel technologies and the authors stated MRC and CRC for localized recessions to be 82.75% and 47.15% respectively [14]. The effectiveness of the tunnel technique with CTG and coronally advanced flap with CTG were compared by many studies. The outcome was irreconcilable because there were no statistical variations between both the flaps, However, one randomized controlled trial (RCT) is in favour of CAF + CTG, the other in terms of more successful tunnel-approach outcomes [15, 16]. As we know, there are little evidence available for more than 12 months of follow-up and more monitored tests are needed to check the clinical advantages.
One of the previous research concluded that both surgical procedures are important when treatment of Miller's class I recession, while the tunnel technique tended to improve the height of KT and have adequate esthetic results relative to gingival tissue as compared to other flaps [17].
Although, as reviewed above, a few studies have evaluated pouch/tunnel (POT) outcomes, their mean follow-up period is only 11 months. Evidence addressing the long-term stability of results and efficacy of POT technique when compared to CAF, in combination with CTG, is lacking. The primary aim of the study was to was to assess and compare the connective tissue graft with POT technique versus connective tissue graft with coronally advanced tunnel flap for the treatment of maxillary recession cases in severe periodontitis.
Material and methodology
Study design
The total sample size was 200 patients from Department of Stomatology, School & Hospital of Stomatology, Wuhan University, who needed esthetics or dental hypersensitivity treatment of gingival recessions has been enrolled for the study.
In a single recession, each patient (experimental unit) contributed. All of the recessions were discussed in situations of several recessions, but only the deepest one was included. The surgical treatments included four periodontists. The clinical evidence was obtained by a single examiner (L.S.) and the result measurements were carried out. Both therapeutic criteria and results were measured at baseline, after 6 months, and patients were recalled after 4 years for the present analysis.
Inclusion criteria
The conditions relating to inclusion were: Class I Recessions of Miller; Recession from 2 to 5 mm; Involvement of Maxillary Incision, Canine and premolar; Identified (CEJ); age of minimum 18 year; No sign of Periodontal disease;; those who privided written informed consent.
Exclusion criteria
Exclusion conditions applied were:. Patients give history of smokers; Presence of carious lesions in the cervix; Pocket depth of over 4 mm; Sites at which prior muco-gingival therapy was conducted; patients in pregnancy period or lactation period.
Periodontal review has been done for all the subjects. Before surgical procedure, intensive oral infection prophylaxis consultation was arranged. An impression was made out of a resin stent with alginate composition to calibrate the calculation. After CTG harvesting, patients were arbitrarily assigned to therapy (CTG + CAF) or monitoring (CTG + POT) procedures. The experiment was randomized by means of numbered packets in sealed envelopes.
Surgical procedure
Before surgery, the patient had been prescribed with 300 mg of ibuprofen and 0.12% of chlorhexidine mouthwash. local anesthesia was administered at donor and recession sites.CTG Regulated harvesting was undertaken prior to the preparing of the reception site. According to dimensions of the graft that had to be applied: The single inscion was used to harvest the CTG from the palate and then suturing was done with 3.0 silk. Control group received the same protocol of surgical as of experiment group. To lift a split thickness flap above the mucogingival floor (MGL), a horizontal incision on the surface of the CEJ to the level of the gingival was given A biopsy was taken from the root using a curette. Then, in order to reduce the chance of infecting the neoplasm, an antibiotic solution of 1 mg/mL of doxycycline was administered. Subcutaneous Connective tissue graft was placed on the recipients bed and suturing was done with Vycril, then wound was supplemented with simple interrupted sutures. The whole patch was completely protected by the tunnel flap. A partial thickness excision was made around the papilla, and the sulcular epithelium was cut. The CTG was placed inside the pouch and secured within with broken sutures (silk 4.0), thus left the connective tissue that covered the recession exposed.
Follow up
The patients were told that they have to use analgesics only if they feel pain, and mention the everyday use over one week. Since suture removal, subjects were asked to stop using tooth brush on surgical site and recommended with 0.2% chlorhexidine for one week. After the removal of suture at 10 days, all the subjects were reviewed at 6th month and after 4 years.
Clinical assessment
All the parameters such as width of Recession (RW), score of bleeding, plaque score, thickness of gingiva (GT) and height of KT has been expressed at baseline, 6th month and after 4 years. The width of the recession (RW) was measured at the mid-buccal aspect of the tooth (both Relative GR and GR using a caliper with a precision of 0.01 mm and a pair of dividers). The relative GR (RGR) was measured as distance from gingival margin (GM) to apical border of stent. Endo-lime with a stop 1 mm below the cervical limit has been used for the gingival thickness assessment. Pocket depth (PD): measured in millimeters with a periodontal. RCAL: calculated as PD + RGR The keratinized tissue thickness (KTT) was measured at the midpoint location between the GM (gingival margin) and MGJ (marginal gingival junction). A masked and calibrated investigator carried out all clinical evaluations. The improvement in KT height, % of CRC and lastly MRC was measured at 6 months and after 4 years.
The examiner calibration was performed for PD and RGR using Kappa statistic and intra-class correlation (k = 0.88 and ICC = 0.81, respectively).
Esthetic evaluation
The esthetics score in terms of RES (Root coverage ethics score) was also measured at baseline, after 6th month and after 4th year. To determine the reliability of all measurements, four (10%) of the ten (100%) first patients were rated twice in an interval of one week. Photographs of treated GR sites from baseline, 6 months and 4 years after surgery were set in a panel and evaluated by two different masked and calibrated (k > 0.8) examiners with cosmetic dentistry experience (CAS and IFM).
Assessment of the patient outcome
A visual analogue scale (VAS) scale (0 = no pain, 10 = extreme pain) was adopted to measure dentin hypersensitivity (DH), after a 5-s air blast from a triple syringe was applied on the exposed buccal cervical area. DH values were recorded at baseline, 6 months and at 4 years postoperatively. Patients were asked to express their overall satisfaction with the treatment outcomes.
Statistics
Statistical Analysis was done with version 9.4 SAS program (SAS Institute, Cary, NC, USA). Expression of results as mean and standard deviation for quantitative variables Bell's transformation or Kruskal–Wallis tests were used for contrasting classes, whereas unpaired Student's t-test was to measure changes between two time points. Both estimates were often rendered on a “intent-to-treat” basis (including drop-outs). The findings were important at the 5% of statistical significance (p < 0.05).
Results
The baseline characteristics for the control and evaluation groups has been shown in Table 1. All the included patients were stick to the protocol and provided with full follow up.
Table 1.
Demographics of the patients
| CAF + CTG N = 100 | POT + CTG N = 100 | |
|---|---|---|
| Gender | 50/50 | 50/50 |
| Age in years (mean ± SD) | 31.2 ± 8.6 | 45.1 ± 17.8 |
| No. of teeth treated | 122 | 127 |
| Ratio teeth/patient | 4.5 | 3.5 |
| Single recession site | 117 | 118 |
| Multiple recession site | 16 | 15 |
| Incisor | 81 | 71 |
| Canine | 51 | 54 |
| Premolar | 82 | 78 |
Recession coverage
The mean score of the RD has been decreased to significant level in both the groups from the baseline level till 6 months, with significant p value of less than 0.001, however, this study did not assess the significant difference in RD between the period of 6 months till 4 years. The level of MRC in POT + CTGgroup at the 6th months was 98.1 ± 22.1 and 4 years it was 93.2 ± 20.2, with non significant p value. The same analysis has been found in the other group regarding the MRC. In CAF + CTG group, MRC at 6th month was 99.1 ± 22.5, and after 4 years 98.12 ± 15.2. The Level of CRC was 93.4% at 6th month and after 4 yaesr it was 91.2% for POT + CTG group with non significant p value Table 2.
Table 2.
Comparative assessment of periodontal parameters in the test group and control group from baseline level to 4 years
| Parameter | Group | Baseline Mean ± SD | Six months Mean ± SD | Four years Mean ± SD | p-value baseline versus 6 months | p-value 6 months versus 4 years |
|---|---|---|---|---|---|---|
| RD (mm) | POT + CTG | 3.11 ± 0.14 | 0.35 ± 0.11 | 0.54 ± 0.712 | < 0.001 | 0.89 |
| CAF + CTG | 5.01 ± 0.60 | 0.19 ± 0.30 | 0.23 ± 0.18 | < 0.001 | 0.41 | |
| p-value | 0.11 | 0.17 | 0.13 | 0.070 | 0.67 | |
| GT (mm) | POT + CTG | 2.09 ± 0.14 | 1.89 ± 0.21 | 2.02 ± 0.87 | 0.0055 | 0.0055 |
| CAF + CTG | 1.09 ± 0.18 | 2.11 ± 0.67 | 1.19 ± 0.11 | 0.067 | 2.00 | |
| p-value | 0.50 | 0.12 | 0.005 | 0.89 | 0.020 | |
| KT (mm) | POT + CTG | 3.89 ± 0.15 | 6.18 ± 2.06 | 7.12 ± 0.12 | 0.0001 | 0.21 |
| CAF + CTG | 4.1 ± 0.17 | 4.13 ± 2.22 | 4.51 ± 1.34 | 0.67 | 0.21 | |
| p-value | 0.24 | 0.001 | 0.001 | 0.02 | 0.71 | |
| MRC (%) | POT + CTG | NA | 98.1 ± 22.1 | 93.2 ± 20.2 | NA | 0.11 |
| CAF + CTG | NA | 99.1 ± 22.5 | 98.12 ± 15.2 | NA | 0.19 | |
| p-value | NA | 0.67 | 0.68 | NA | 0.98 | |
| CRC (%) | POT + CTG | NA | 93.4 | 91.2 | NA | 0.32 |
| CAF + CTG | NA | 100.0 | 100.0 | NA | 0.88 | |
| p-value | NA | 0.27 | 0.31 | NA | 0.41 | |
| LPS (%) | POT + CTG | 0.00 ± 0.00 | 0.00 ± 0.00 | 1.71 ± 31 | 0.11 | 0.22 |
| CAF + CTG | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.88 | 0.88 | |
| p-value | 0.99 | 0.99 | 0.38 | 0.99 | 0.38 |
KT gain
A slightly higher KT benefit was found in patients treated with POT + CTG after 4 years, as previously observed at 6 months with non significant p value. Table 2. shows clearly that while height of KT increased dramatically in POT + CTG group from baseline to 6 months, no improvement was observed in the CAF + CTG group; consequently, KT remained unchanged in both the groups after 6 months.
Thickness of gingiva
Gingival thickness increased significantly from the baseline to 6 months in both the groups with significant p value of < 0.001; subsequently, a further rise in GT was reported in the control group in comparison to the test group. In research study, the test group showed slightly thicker gingiva at 4 year (Table 2).
VAS assessment
VAS aesthetic assessment by the patients significantly improved from baseline to 4 years for both groups (p < 0.05), with no significant differences between group (p = 0.5).
The pink score of esthetic
The PES slightly improved in both classes with greater performance in the POT + CTG category at 6th month and after 4th years in contrast with the CAF + CTG group (p = 0.022). This was mostly attributed to the texture, which in research patients was 1.97 ± 0.21 and in control patients averaged 1.12 ± 0.18 (p < 0.0001). The other PES characteristics did not vary between the two classes.
Esthetic effects related to patients
Testing and control patients have noted a substantial increase in esthetics over the four-year follow-up era, especially in features such as presentation, colour, gum contour and scars (Table 3).
Table 3.
Comparative assessment of the esthetic parameters between test group and control group
| Parameter | Various groups | Baseline level | After 6 months | After 4 years | Baseline versus 6 months p value | 6 months versus 4 years p value |
|---|---|---|---|---|---|---|
| Papilla on Mesilla side | POT + CTG | 1.89 ± 0.16 | 1.93 ± 0.11 | 1.98 ± 0.11 | 0.22 | 0.11 |
| CAF + CTG | 1.89 ± 0.11 | 1.93 ± 0.17 | 1.81 ± 0.21 | 0.22 | 0.28 | |
| p-value | 0.31 | 0.89 | 0.42 | 0.55 | 0.12 | |
| Papilla On distal side | POT + CTG | 1.79 ± 0.21 | 1.86 ± 0.21 | 1.99 ± 0.12 | 0.18 | 0.16 |
| CAF + CTG | 1.88 ± 0.11 | 1.96 ± 0.12 | 1.88 ± 0.11 | 0.71 | 0.11 | |
| p-value | 0.61 | 0.78 | 0.33 | 0.69 | 0.71 | |
| Margin of soft tissue | POT + CTG | 0.79 ± 0.11 | 2.11 ± 0.00 | 2.12 ± 0.00 | < 0.0001 | 0.1 |
| CAF + CTG | 0.81 ± 0.45 | 2.16 ± 0.00 | 1.99 ± 0.11 | < 0.0001 | 0.1 | |
| p-value | 0.61 | 0.8 | 0.19 | 0.21 | 0.1 | |
| Contour | POT + CTG | 1.20 ± 0.11 | 2.10 ± 0.11 | 1.98 ± 0.14 | < 0.0001 | 0.22 |
| CAF + CTG | 1.23 ± 0.11 | 2.09 ± 0.34 | 1.89 ± 0.22 | < 0.0001 | 0.33 | |
| p-value | 0.41 | 0.81 | 0.89 | 0.81 | 0.82 | |
| Color | POT + CTG | 1.82 ± 0.22 | 2.12 ± 0.00 | 2.12 ± 0.00 | 0.03 | 0.88 |
| CAF + CTG | 1.82 ± 0.33 | 2.12 ± 0.00 | 1.98 ± 0.11 | 0.03 | 0.77 | |
| p-value | 0.89 | 0.89 | 0.22 | 0.88 | 0.22 | |
| Texture | POT + CTG | 1.10 ± 0.17 | 1.99 ± 0.12 | 1.97 ± 0.21 | < 0.0001 | 0.88 |
| CAF + CTG | 1.02 ± 0.11 | 1.12 ± 0.18 | 1.12 ± 0.18 | 0.011 | 0.89 | |
| p-value | 0.10 | < 0.0001 | < 0.0001 | 0.0003 | 0.89 | |
| Esthetic Score (PES) | POT + CTG | 7.10 ± 2.12 | 13.1 ± 0.21 | 13.4 ± 0.12 | < 0.0001 | 2.00 |
| CAF + CTG | 7.52 ± 1.23 | 12.01 ± 2.01 | 11.1 ± 1.65 | < 0.0001 | 1.29 | |
| p-value | 0.69 | 0.011 | 0.022 | 0.32 | 0.20 |
Discussion
The findings of this study revealed that both the techniques culminated in a substantial decrease in recession cases and that results stayed consistent in both categories over time. In the tunnel pouch technique, the gain in Kertanized tissue and ethetics score was slightly higher both at 6th month and after 4 years, and a gingival thickness gain also found at 6 months and further consistent till 4 year. In both groups, the esthetic progress for both approaches has been sustained equally during the follow-up period.
Long-lasting follow-up period has been much required to determine the stability of periodontal treatment technique. To the best of its understanding, the present article for such a long time of follow-up is the first RCT-based comparison of tunnel approach versus coronaally advanced flat in cojucation with CTG techniques.
Very less studies measured the effectiveness of tunnel approach vs coronally advanced flap with proper follow up. However, some authors identified MRC's comparable efficacy of the two strategies and MRC's was ranged between 80 and 97.3% [15, 17] Just a single analysis of tunnel technique recorded less successful MRC. This discrepancy may be due to surgical ability and stringent requirements for inclusion. Our study is the only analysis which showed that benefit in MRC has been accomplished by the tunnel pouch technique and had become stable for 4 years and considered to be equivalent with the Gold Standard technique Finally, a new systemic review noticed that the 83.08% MRC utilized the tunnel pouch technique for localized maxillary gingival recession therapy [14]. It must be stressed, however, that the analysis included only the POTs with maximum coverage by the CTG while the present study reports the original methodology mentioned by Raetzke, in which the CTG remained partially exposed [13].
The present research shows strong reliability of the CRC findings of in both the groups up to 4 years. These long-term findings are comparable to other researches dealing with recession care [5, 6]. Four years after tunnel approch method, the low rate of recession recurrence reported in the present research. Another retrospective study testing the tunnel technique following 11.4 years of follow-up showed same results [18] On the opposite, the number of places with CRC declines dramatically overtime in studies documenting the long-term outcomes of the CAF alone without the inclusion of a CTG [19].
The benefit from KT following root coverage varies, depending on the techniques applied, from 0.4 to 4.7 mm according to a recent systematic analysis [8]. Long-term studies suggested that the highest benefit in tunnel approach [18] was reported and the lowest gain was observed in CAF + resorbable membranes [20]. The current research found an improvement in KT and consistency in both groups between 6 months and 4 years, but the increase in the POT + CTG was considerably higher relative to the CAF + CTG Community. Accordingly, the POT + CTG technique may also be viewed as an option technique if the current KT is small. When it comes to the durability of the KT with the CAF + CTG technique, our findings tend to be compatible with other long-term experiments, albeit restricted to 4 years, which find that the CAF + CTG's KT changes can be maintained over a span of 10 to 20 years [19]. However, details on KT gain in the current literature are sparse as regards the tunnel-envelope technique. 20 years long term case series was observed focused on 20 patients treated with tunnel approach [18] and the authors identified an average 4.7 mm KT benefit, which was constant over the subsequent time. This value of KT is much higher than what was observed in the current analysis—but the discrepancy should be closely interpreted because the scope of the research was quite different. The two strategies demonstrated a substantial increase in GT; however, a further gain has been noted in the test group over time, although it was constant in the control group. In a recent structural analysis of the root coverage processes, the authors stressed that the usage of subepithel-connecting tissue grafts is showing a marginal increase in outcome in cases where both root and width coverage of keratins are required.
Harris et al. concluded that POT + CTG sites were much more likely than CAF + CTG sites to exhibit improvement in root coverage between 6 months and 2 years (55% and 10.5% of sites, respectively; p < 0.009). The observed creeping attachment was in the order of 0.5 mm for both groups and within the reported range for comparable CTG procedures.
Both from a patient and the clinical viewpoint, esthetic effects were analyzed. The PES index was used for the esthetic evaluation by the practitioners as the previous research report used this particular index [21]. This is restricting since the PES was designed to assess the esthetics of implant, whereas the esthetic root coverage (RES) defined by Cairo et alis.'s regarded as a more accurate index [22]. However, higher score of esthetic were seen in the test group community both at 6th month and after 4 years. Some authors also suggested that better esthetic results were recorded with a tunnel technique [23]. These results implied that both of these techniques permitted a substantial improvement in esthetics. After 4 years, in reality, residual scars from releases were sometimes still seen.
Kerner et al. suggested that studies including professional aesthetic evaluations have at least 12 months of follow-up. At 2 years, POT + CTG was rated as having a more harmonious mucogingival junction (MGJ) alignment than CAF + CTG. Any attempt to explain this difference is speculative, but it could be related to the interruption of the MGJ caused by the vertical releasing incisions performed for CAF; it could also be related to the aforementioned tissue maturation over time.
The RCT was not accompanied in particular by a 4 years comparative review of the control and test classes of the patients. Results must also be measured and carefully viewed. After 4 years, not all patients originally reported may be reviewed due to declines. The number of patients remained, however, satisfactory and data were examined by either full patients or outsiders in all accessible longitudinal data. Finally, the new examiner was not blinded and this constitutes a further disadvantage of the current research.
In conclusion, as well as coronally advanced flap technologies together with the CTG have greatly decreased the contraction and been steady for 4 years in all categories. The effects of the recession are stable. The POT Technique allowed the growth of keratins and gingival thickness to become long-term stable. Over time, both techniques presented patient esthetic satisfaction—however, the esthetic outcomes evaluated by the dentists were more in favor of the pouch/tunnel technique.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical statement
There are no animal experiments carried out for this article.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Wei Tian and Fang Hu have contributed to this work equally.
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