CORONALLY ADVANCED FLAP vs THE POUCH TECHNIQUE COMBINED WITH A

CONNECTIVE TISSUE GRAFT TO TREAT MILLER'S CLASS I GINGIVAL RECESSION: A

RANDOMIZED CONTROLLED TRIALSalhi L, Lecloux G, Seidel L, Rompen

E, Lambert F.JCP 2014;41(4):387-395.

Shilpa Shivanand

II MDS

Introduction• The primary goal of periodontal plastic surgery procedures is

to obtain complete root coverage (CRC).• The first techniques described for root coverage of gingival

recession were the lateral displacement of a full or split thickness flap (Grupe HE 1956, Staffileno 1964) and free gingival grafts (Sullivan & Atkins 1968) to cover mandibular gingival recession.

• Coronally advanced flaps (CAF) were introduced in the mid-1980s by several authors

Allen 1988, Miller 1988, Tarnow 1986• According to the available literature, the mean root coverage

(MRC) of CAF procedures remains highly heterogeneous, varying from 55.9% to 86.7%

Del Pizzo et al. 2005, de Queiroz Cortes et al. 2006• To increase the root coverage, associated procedures have

been suggested, such as CAF combined with connective tissue grafts (CTG)

Langer & Langer 1985

• According to several systematic reviews (Roccuzzo et al. 2002, Cheng et al. 2007, Cairo et al. 2008, Chambrone et al. 2010) most of these periodontal plastic surgery procedures were efficient in reducing the depth of Miller’s class I or II recession.

• Nevertheless, CAF in combination with CTG or EMD seems to display the most predictable results in terms of CRC and currently is considered to be the gold standard technique for root coverage.

• However, the success of periodontal plastic surgery procedures is not only related to the root coverage.

• Other parameters, such as the gain of keratinized gingiva, aesthetic outcomes, and patient-centred outcomes related to the morbidity of the procedures, should be taken into account when recommending a specific technique over the other options.

• Only a small number of studies have investigated such parameters.

• In their case series describing the pouch technique, Raetzke 1985, disclosed an increase of keratinized tissue (KT) height in each patient, and in a systematic review, Chambrone et al. 2010, found that the expected gain of KT tissue is higher with CAF + CTG than CAF alone.

• However, none of these studies investigated the aesthetic or morbidity outcomes of such procedures.

• There is a lack of randomized controlled trials that compare several surgical techniques based on these parameters.

Aim • The objective of the present randomized controlled clinical

trial was to compare the CAF (Langer & Langer 1985) versus the pouch technique (Raetzke 1985), both associated with connective tissue graft, in treating Miller’s class I recession (Miller 1985) in the anterior upper maxilla.

• The primary objective was to assess the mean and CRC of both techniques.

• The secondary objectives were to evaluate the gain of keratinized gingiva, the aesthetic outcomes using the pink aesthetic score (PES), and the morbidity for each technique.

Materials and Methods• Forty consecutive patients from the Department of

Periodontology and Oral Surgery at the University of Liege, Belgium were enrolled from May 2011 to February 2012.

• Each patient (experimental unit) contributed a single recession.

• In cases of multiple recessions, the deepest one was included.• All clinical parameters and outcomes were performed at

baseline, after 3 months and after 6 months. • The morbidity outcomes were evaluated 10 days after

surgery.

Inclusion criteria• Miller’s class I recession• Recession of 2 mm to 5 mm• Maxillary incisors, canine or premolars• Identifiable cemento-enamel junction• Minimum of 18 years old• Controlled periodontal disease• Providing a signed informed consent form.

Exclusion criteria • Smokers• Presence of cervical carious lesion• Pocket depth greater than 4 mm• Sites where previous muco-gingival therapy was performed• Pregnancy. • In presence of non-carious cervical lesions, the anatomical CEJ

was reconstructed by the use of a composite before the procedure.

• Patients were subjected to a full periodontal examination. • A pre-surgical full mouth professional prophylaxis

appointment was scheduled 1 week prior to the surgical procedure.

• An alginate impression was taken to fabricate an individual resin stent that was used as a reference point for all measurements (Byun et al. 2009).

Surgical procedure• The patient received 600 mg of ibuprofen prior to surgery, and

chlorhexidine mouthwash for 0.2% was provided for 2 min.• Patients received LA at the donor and recession site. • The harvest of the connective tissue graft was performed

prior to the preparation of the reception site to avoid any bias.

• The graft dimension was calculated according to the recession dimensions; a minimum of 3 mm of the graft was submerged mesially, distally and apically.

• The connective tissue graft was harvested from the palate with the single edge incision and sutured with 4.0 silk.

• The patient was subsequently assigned randomly to the control (CAF) or the test group (pouch).

Control group• The surgical protocol in the control group was performed as

described by Langer & Langer (1985). • A horizontal incision at the level of the CEJ and a two vertical

incisions were designed to raise a split thickness flap beyond the mucogingival line (MGL).

• The papillae were disepithelialized. • The root was planed using a curette, and a chemical

treatment was administered using a doxycycline solution (1 mg/ml)

Rompen et al. 1993, Vanheusden et al. 1998, 1999.

• The connective tissue graft was sutured to the recipient bed by means of a resorbable suture (Vicryl 5.0), and the flap was coronally advanced and sutured by simple interrupted sutures (Silk 5.0; ethicon).

• The connective tissue graft was completely covered by the flap.

Test group • In the test group, the surgical protocol was performed as

described by Raetzke (1985) and Allen (1994). • The sulcular epithelium was removed with a blade and a

partial thickness pouch was created, preserving the papillae.• The roots were treated similarly to those of the control group.• The connective tissue graft was inserted inside the pouch and

stabilized mesially and distally with simple interrupted sutures (silk 5.0), leaving the connective tissue that covered the recession exposed.

The post-op instructions and follow-up

• The patients were asked to take pain killers only if necessary and to count the amount of pain killer intake every day for 1 week.

• Patients were informed to avoid brushing at the surgical site for 2 weeks, to use mouthwash [chlorhexidine 0.2%,Perio-aid] until suture removal, and to consume a soft food diet for 1 week.

• Sutures were removed after 10 days, and patients were seen after 3 months and 6 months.

Data collection• Local plaque score (LPS), local bleeding score, RD, recession

width (RW), gingival thickness (GT) and KT height were recorded at baseline, 3 months and 6 months.

• The gain in KT height, the MRC, and the percentage of CRC were calculated at 3 months and 6 months.

• The PES was assessed at baseline and 6 months according to the seven parameters described by Furhauser et al. (2005).

• All of these measurements were performed intra-orally using the individual resin stent.

• Patient-related aesthetic outcomes were also recorded in a questionnaire using a 0–10 graduated scale.

• The following parameters were recorded in the patient’s morbidity questionnaire (graduated scale from 0 to 10): discomfort during and after the surgical procedure, pain at the donor site, pain at the recipient site, and the number of pain killers consumed per day.

Statistical analyses• The comparisons between groups were performed with

Student’s t-test. • The respective differences between 0 and 3 months, 0 and 6

months, and 3 and 6 months were tested by paired Student’s t-test.

• Results were considered significant if p < 0.05

Results – clinical parameters• At baseline and after 6 months, the test and control groups

were comparable for all clinical parameters (RD, RW, KT, GT, LPS and local bleeding percentage) and for aesthetic scores (PES).

RD RW

Baseline 6 months P value Baseline 6 months P value

Test 2.78±0.94 0.29± 0.61 <0.0001 4.45 ± 1.15 0.32±0.95

<0.0001

Control 3.03± 0.9 0.16± 0.50

<0.0001 4.1 ± 0.85 0.00 ± 0 <0.0001

Significance

0.39 0.47 0.08 0.28 0.15 0.85

GT LPS % LBS %

Baseline

6 month

P value Baseline

6 month

P value Baseline

6 month

P value

Test 1.08 ± 0.34

1.37 ±0.37

0.0075 0± 0 0± 0 0.99 0.05 ± 0.22

1.32 ± 5.74

0.35

Control 1.03 ± 0.26

1.25 ± 0.35

0.0035 0 ± 0 0± 0 0.99 1.25 ± 5.59

1.32 ± 5.74

0.99

Significance

0.60 0.32 0.79 0.99 0.99 0.99 0.34 0.99 0.59

Pink aesthetic score (PES) (mean±SD) at baseline and 6-month post-surgery

Colour Texture PES

Baseline 6 months Baseline 6 months Baseline 6 months

Test 1.85 (0.37)

2.00 (0.0) 1.15 (0.37)

1.95* (0.23)

8.75 (1.48)

11.6* (0.61)

Control 1.85 (0.37)

2.00 (0.0) 1.05 (0.22)

1.32* (0.48)

8.65 (1.23)

11.0* (1.03)

Significance

0.99 0.99 0.30 p < 0.0001 0.82 0.027

Control group – CAF with SCTG

Test group – pouch and tunnel with SCTG

Discussion • The objective of the present study was to compare the

effectiveness of two different surgical protocols to treat Miller’s class I recession in the anterior upper maxilla.

• The Langer & Langer technique (1985), which are still regarded as the gold standard for root coverage, was used in the control group, the pouch technique as described by Raetzke (1985) and Allen (1994), was implemented in the test group.

• The two tested surgical techniques were assessed for root coverage, KT gain and aesthetic outcomes.

Root coverage • The MRC found in this study was fairly high compared to the

existing data in the literature on this particular topic (96% in the control group and 91% in the test group), and no significant differences were observed between the two groups.

• According to the published clinical trials and systematic reviews, the MRC found with the “CAF associated with CTG” and with the “pouch technique” were notably heterogeneous and varied from 75.5% to 97% (Paolantonio et al. 1997, Chambrone & Chambrone 2006) and from 69.2% to 96.4% respectively (Raetzke 1985, Allen 1994, Han et al. 2008).

Keratinized Tissue Gain• An increase in the KT height is a desired effect in that it

decreases the possibility of recurrence of gingival recession due to chronic trauma or inflammatory reactions

Paolantonio et al. 2002• Within the limitation of this study, the present results

demonstrated that the KT height increased in the two groups; however, the augmentation was significantly higher in the test group (pouch technique)

Aesthetic Outcomes• Because the soft tissue maturity is considered stable after a

period of 6 months post-surgery (Roccuzzo et al. 2002, Rotundo et al. 2008, Cairo et al. 2009), the aesthetic outcomes of the present study were evaluated after 6 months by both the dentist and the patient himself.

• According to the patients and the dentists, both surgical techniques promoted significant improvement and optimal aesthetic results.

• In considering the details of the PES rated by the dentist, the texture was significantly better with the pouch technique.

• The inferior score regarding the texture found in the control group seems to be related to the scars left by the vertical releasing incisions of the CAF.

• Vertical releasing incisions impair the vascularization, and soft tissue healing can result in fibrotic scars, jeopardizing aesthetic outcomes.

Allen 1994, Bruno 1994, Zabalegui et al. 1999, Zucchelli & De Sanctis 2000, Carvalho et al. 2006

Conclusion• The findings of this study indicate that the pouch technique

and the coronally advanced flap technique in combination with a connective tissue graft can be successfully used to treat Miller’s class I recession in aesthetic areas.

• Both surgical techniques were effective and predictable for root coverage.

• Moreover, post-operative outcomes and painkiller consumption were moderate and similar for both surgical procedures.

• Nevertheless, the pouch technique displayed greater increases in KT and seemed to offer lower levels of scarring.

Critical evaluation

• Not mentioned method of measuring GT• Not specified which index has been taken in

assessing plaque and bleeding score• No clinical photographs of donor site graft

procurement

CROSS REFERENCE

I. Treatment of gingival recession with coronally advanced flap procedures: a systematic review.Cairo F et al, JCP 2008;35(8):136-62.• The aim of this manuscript was to systematically review the

literature on coronally advanced flap (CAF) alone or in combination with tissue grafts, barrier membranes (BM), enamel matrix derivative (EMD) or other material for treating gingival recession.

• Randomized clinical trials on treatment of Miller Class I and II gingival recessions with at least 6 months of followup were identified. Data sources included electronic databases and handsearched journals. The primary outcome variable was complete root coverage (CRC). The secondary outcome variables were recession reduction, clinical attachment gain, keratinized tissue gain, aesthetic satisfaction, root sensitivity, postoperative patient pain and complications.

• RESULTS: A total of 794 Miller Class I and II gingival recessions in 530 patients from 25 RCTs were evaluated in this systematic review. CAF was associated with mean recession reduction and CRC. The addition of connective tissue graft (CTG) or EMD enhanced the clinical outcomes of CAF in terms of CRC, while BM did not. The results with respect to the adjunctive use of acellular dermal matrix were controversial.

• CONCLUSION: CTG or EMD in conjunction with CAF enhances the probability of obtaining CRC in Miller Class I and II single gingival recessions.

II. Root coverage with subepithelial connective tissue grafts and modified tunnel technique. An evaluation of long term results. Tözüm TF et al, N Y State Dent J 2006;72(4):38-41.• AIM: The goal of the present study was to evaluate and

compare the shortterm and longterm (36 months) root coverage results of SCTG and the modified tunnel procedure.

• METHOD: Patients, each contributing at least two adjacent buccal gingival recessions, were treated with SCTG and modified tunnel technique. The changes in the clinical measurements were compared at baseline, shortterm and longterm.

• RESULTS: The mean root coverage was 95% and 92.2% at eight months and 36 months postsurgery, respectively. These differences were statistically significant compared to the baseline. The mean gain in attachment was 3.79 mm, and the mean root coverage was 3.14 mm after 36 months.

• CONCLUSION: The results of the present clinical study demonstrated that the SCTG with modified tunnel approach was an effective periodontal plastic surgery method to cover the exposed roots.