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ORIGINAL ARTICLE
Year : 2021  |  Volume : 25  |  Issue : 3  |  Page : 228-236  

Comparative evaluation of vestibular incision subperiosteal tunnel access with platelet-rich fibrin and connective tissue graft in the management of multiple gingival recession defects: A randomized clinical study


Department of Periodontology, Yenepoya Dental College, Yenepoya (Deemed to be) University, Deralakatte, Mangalore, Karnataka, India

Date of Submission22-Apr-2020
Date of Decision19-Dec-2020
Date of Acceptance26-Jan-2021
Date of Web Publication04-May-2021

Correspondence Address:
Jyosthna Ganapathi Madhurkar
Department of Periodontology, Yenepoya Dental College, Deralakatte, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_291_20

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   Abstract 


Background: The etiology of gingival recession is often multifactorial. Wide array of surgical techniques are available to manage gingival recession. The aim of the present study was to compare, minimally invasive approach (vestibular incision subperiosteal tunnel access [VISTA]), in combination with platelet-rich fibrin (PRF) and connective tissue graft (CTG) in the management of multiple recession defects in maxillary anterior region. Materials and Methods: A total of 32 sites from 10 systemically healthy controls were allocated randomly to VISTA with PRF (VISTA + PRF) and VISTA with CTG (VISTA + CTG). Plaque index, gingival index, Probing probing pocket depth (PPD), relative attachment level (RAL), recession depth (RD), recession width (RW), width of keratinized gingiva (WKG), and percentage of root coverage (%RC) were calculated at 6 months postoperatively. Results: Results showed significant improvement in mean PPD, RAL, RD, RW, and KTW. %RC in VISTA + PRF and VISTA + CTG was 83.25% ± 25.02% and 86.43% ± 22.79%, respectively, at 6 months. There were no significant differences in the parameters between the VISTA + PRF and VISTA + CTG groups. Conclusion: VISTA is a minimally invasive surgical approach, which can be combined with CTG or PRF in the management of Miller's Class I and Class II recession defects, with predictable outcomes. There were significant improvements in the clinical parameters from baseline to 6 months in both the groups. To match with the CTG, which is the gold standard procedure, PRF can be used as an alternative for treating multiple recession defects.

Keywords: Connective tissue graft, minimally invasive, multiple gingival recessions, platelet-rich fibrin, vestibular incision subperiosteal tunnel access


How to cite this article:
Hegde S, Madhurkar JG, Kashyap R, Arun Kumar MS, Boloor V. Comparative evaluation of vestibular incision subperiosteal tunnel access with platelet-rich fibrin and connective tissue graft in the management of multiple gingival recession defects: A randomized clinical study. J Indian Soc Periodontol 2021;25:228-36

How to cite this URL:
Hegde S, Madhurkar JG, Kashyap R, Arun Kumar MS, Boloor V. Comparative evaluation of vestibular incision subperiosteal tunnel access with platelet-rich fibrin and connective tissue graft in the management of multiple gingival recession defects: A randomized clinical study. J Indian Soc Periodontol [serial online] 2021 [cited 2021 Dec 8];25:228-36. Available from: https://www.jisponline.com/text.asp?2021/25/3/228/315434




   Introduction Top


Smile plays a cardinal role to improve esthetics, a perfect smile often radiates health and self-confidence, which is achieved with optimal relationship between the teeth, surrounding oral tissues, and periodontal complex. Any disharmony between these components may lead to smile perceived as unesthetic.[1]

Gingival recession is defined as an apical migration of gingival margin beyond the cementoenamel junction.[2] A broad array of surgical modalities have been introduced for managing gingival recession since 1960.[3]

Numerous studies have described various combinations of tunnel approaches with connective tissue grafts (CTG) or allografts for treating multiple recession defects by avoiding vertical releasing incisions and by maintaining papillary integrity. The limitations of this technique include the challenging nature of the intrasulcular tunneling, to obtain access through a small sulcular access point and higher risk of trauma and perforation of the sulcular tissues, which may lead to unfavorable healing outcome.[4] As a consequence of these limitations, the vestibular incision subperiosteal tunnel access (VISTA) approach was developed by Homayoun H. Zadeh.[5]

The CTG is considered as a gold standard of the soft-tissue grafting procedures because of its high predictability and esthetic outcome. Even though outstanding esthetic outcome has been achieved, root coverage (RC) has been known to range from 69% to 97% in most of the studies, this technique demands a suitable donor site.[4]

Platelet-rich fibrin (PRF), introduced by Choukroun et al. in 2001, is a second-generation platelet concentrate, which has proliferative effect on various types of cells such as dental pulp cells, human osteoblasts, human gingival and periodontal ligament fibroblasts, dermal prekeratinocytes, and preadipocytes. It is autologous in nature and is considered as a healing biomaterial, with its homogenous fibrin network it is used for enhancing healing of the soft tissue in periodontal plastic surgical procedures and implants, in the treatment of intrabony defects and bone regeneration.[5]

The present study was carried out to evaluate and compare the efficacy of RC using a minimally invasive approach (VISTA), in combination with CTG and PRF for managing multiple recession defects in maxillary anterior region.


   Materials and Methods Top


A total of 32 sites from 10 systemically healthy controls (patients with minimum of 2 sites and maximum of 6 sites were included) aged 16–64 years were enrolled in this randomized controlled clinical trial. The research protocol was reviewed and accepted by the ethics committee of the institute (Ethical clearance number 2017/295). Purpose and study design was explained to the participants, and informed consent was obtained.

Participants who fulfillied all the inclusion criteria were enrolled; systemically healthy subjects, subjects with Miller's Class I or II gingival recession in the maxillary anterior region ≥1 mm of attached gingiva, pocket depth (PD) of <3 mm, recession depth (RD) ≥2 mm, loss of attachment ≥4 mm, gingival index (GI) score ≤1. Participants with a history of RC procedures performed in the selected sites for last 2 years, participants with abnormal bleeding time, clotting time, and prothrombin time, participants with smoking, tobacco chewing and alcohol consumption, cervical abrasion, direct and indirect restorations involving the cervical areas of maxillary anteriors were excluded from the study.

The participants were randomly assigned by computer-generated random numbers into two treatment groups. VISTA with PRF was treatment of choice for sites in Group 1 and VISTA with CTG for Group 2.

Participants were subjected for scaling and root planing along with oral hygiene instructions 1 month prior to surgery.

Clinical measurements recorded at baseline and 6 months, were plaque index (PI) (Silness and Loe 1964), gingival index GI (Loe and Silness 1963), probing pocket depth (PPD), relative attachment level (RAL), recession depth (RD), recession width (RW), width of keratinized gingiva (WKG), and percentage of Root Coverage (%RC) was calculated at 6 months postoperatively [Flowchart 1].



The selected surgical sites were anesthetized using 2% lignocaine hydrochloride containing 1:80,000 adrenaline. Selected sites were subjected for VISTA technique, in Group 1 PRF was placed and in Group 2 CTG was placed.

Vestibular access incision was made at the midline frenum which provided access to the entire anterior maxilla [Figure 1]. Subperiosteal tunnel was made to expose the facial osseous plate and root dehiscence using VISTA 1 and 2 instruments, [Figure 2] extending it one tooth beyond the site that requires RC so as to mobilize and coronally reposition the gingival margin. In addition, the tunnel was widened interproximally under each papilla until the embrasure space, avoiding any surface incisions through the papilla using VISTA 3 and 4 instrument [Figure 3]. Once the gingival margin was coronally advanced, PRF membrane for Group 1 and CTG for Group 2 was placed.
Figure 1: Vertical incision placed for vestibular access

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Figure 2: Periosteal tunnel preparation

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Figure 3: Intra sulcular tunnel

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Intravenous blood was collected from the antecubital vein using 10 ml test tube [Figure 4] and centrifuged at 3000 rpm for 10 min in a centrifuge machine (C-852, REMI, Mumbai, Maharashtra, India.). PRF clot thus formed was separated which was transformed into membrane using PRF box [Figure 5] and [Figure 6].
Figure 4: 10ML of blood drawn

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Figure 5: Prepared platelet rich fibrin

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Figure 6: Platelet rich fibrin membrane

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The donor area in the palate was anesthetized, and CTG was harvested using partial-thickness trap door technique [Figure 7].
Figure 7: Harvesting connective tissue graft (trap door technique)

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The PRF membrane (Group 1) and CTG (Group 2) was gently placed in the tunnel [Figure 8] and [Figure 9] and the entire mucogingival apparatus was coronally advanced and stabilized in the new position using coronally anchored suturing technique, which entails placing a horizontal mattress suture at approximately 2–3 mm apical to the gingival margin of each tooth. The suture was then secured at the mid-coronal point facially of each tooth with the help of composite stopper to prevent apical movement of the gingival margin during initial stages of healing [Figure 10] and [Figure 11].
Figure 8: Insertion of platelet rich fibrin into the tunnel

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Figure 9: Placement of connective tissue graft into the tunnel

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Figure 10: Coronally anchored sutures with composite stopper

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Figure 11: Suturing the donor site

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Patients were prescribed antibiotics-Cap Amoxicillin 500 mg thrice a day for 5 days, Analgesics-Tab Diclofenac sodium 50 mg twice daily for 3 days, 0.2% of CHX mouth rinse twice a day postoperatively after 2 days.[4] Sutures were removed 15 days postoperatively. All the participants were provided with periodic periodontal maintenance therapy for every 3 months. All the clinical measurements were noted at baseline and 6 months postoperatively.

Statistical analysis

The data collected were analyzed by both descriptive and inferential methods. Descriptive methods such as mean and standard deviation were computed to summarize the data. Inferential method such as Mann–Whitney U-test and Wilcoxon signed-rank sum test were utilized to compare the parameters across differential time periods between the two groups and within the groups, respectively. P < 0.05 was considered statistically significant and P < 0.01 and < 0.001 were considered highly significant and very highly significant, respectively. Level of significance in the present study was 5%. Data were subjected to the statistical analysis with the Statistical Package for the Social Science (SPSS software version 22.0, SPSS Inc, IBM).


   Results Top


The results showed significant improvement in mean PPD, RAL, RD, RW, and WKG from baseline to 6 months in both groups. At 6 months, mean PPD in Group 1 was 1.31 ± 0.60 and Group 2 was 1.37 ± 0.5, RAL was 5.25 ± 1.77 and 6.5 ± 1.155 in Group 1 and 2, RW was 1.188 ± 1.642 and 1.063 ± 1.642 in Group 1 and Group 2, respectively.

Recession depth

The mean RD of Group 1 at baseline was 2.563 ± 0.964 and at 6 months was 0.813 ± 1.560. Similarly, the mean RD of group 2 was found to be same as Group 1 at baseline and 0.500 ± 0.816 at 6 months. Statistically highly significant difference was achieved in Group 1 from baseline to 6 months, while statistically very highly significance was achieved in Group 2. Intergroup comparison did not show statistical significant difference at baseline (P = 1) and at 6 months (P = 0.721) [Table 1], [Graph 1], [Figure 12],[Figure 13],[Figure 14],[Figure 15].
Table 1: Intergroup and intragroup comparison of recession depth at baseline and 6 months

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Figure 12: Recession depth preoperative–PRF group

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Figure 13: Recession depth 6 months postoperative–PRF group

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Figure 14: Recession depth preoperative–CTG group

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Figure 15: Recession depth 6 months postoperative–CTG group

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Width of keratinized gingiva

Mean WKG was 3.500 ± 0.873 and 5.875 ± 1.784 was noted in Group 1 from baseline to 6 months. Similarly, the mean WKG was 2.438 ± 0.964 and 5.125 ± 0.885 was noted in group 1 from baseline to 6 months. However, within the groups, the difference was noted to be statistically very highly significant (P ≤ 0.001). However, the difference between the groups at baseline (P = 0.287) and 6 months (P = 0.641) was not significant. The difference in Group 1 was 2.37, whereas the difference in Group 2 was 2.687, and this difference between the Groups 1 and 2 was not statistically significant (P = 0.284) [Table 2], [Graph 2], [Figure 16],[Figure 17],[Figure 18].
Table 2: Intergroup and intragroup comparison of width of keratinized gingiva at baseline and 6 months

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Figure 16: WKG preoperative

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Figure 17: Width of keratinized gingiva 6 month postoperative– PRF group

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Figure 18: Width of keratinized gingiva 6 month Width of keratinized gingiva 6 month postoperative–CTG group

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Percentage of root coverage

The percentage of RC achieved was 83.25 and 86.43 in Groups 1 and 2, respectively. Intergroup comparison did not show any statiscally significant difference, even though CTG group showed higher percentage of RC [Table 3], [Graph 3] and [Graph 4], [Figure 19] and [Figure 20].
Table 3: Comparison of percentage of root coverage between the groups

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Figure 19: Preoperative

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Figure 20: Six-months follow up

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   Discussion Top


The current study was carried out for assessing the RC using VISTA with PRF and CTG. The study was carried out for a 6-month period. Evaluation of clinical parameters was performed for comparing the efficacy of the two treatment modalities. To our knowledge, the current study is the first randomized controlled clinical trial comparing VISTA with PRF and CTG. Available literature on combination techniques are case reports and case series.

Significant improvements in the results were observed in clinical parameters (PPD, CAL, RD, RW, and WKG) at 6 months postoperatively, on comparison to the baseline measurements. The significant reduction in PD in PRF group at 6 months was in accordance with case reports by Gupta et al.,[6] and clinical study by Chenchev et al.[7] Bherwani et al.,[8] reported similar results when CTG was used in combination with Pouch and Tunnel technique.

Significant gain in mean RAL was noticed in PRF group at 6 months, Chenchev et al.[7] made a similar observation. In the present study, the CTG group also showed significant gain in mean RAL.

Remarkable reduction in RD was seen in both the groups, which is in accordance with case report by Reddy et al.[4] Gupta et al.,[6] and Chenchev et al.,[7] made similar observations using PRF with VISTA. Pini-Prato et al.,[9] noticed significant reduction in RD when CTG was used with coronally advanced flap.

Significant reduction in RW in PRF group was in concurrence with study carried out by Chenchev et al.[7] Reduction in RW in CTG group was as observed by Uraz A et al.,[10] Pini-Prato et al.,[9] and Wegemund et al.,[11] when CTG was used with coronally advanced flap.

An optimal amount of WKG is essential to maintain the integrity of dentogingival junction. Mean increase in WKG in PRF group (5.75 mm) was similar to Gupta et al.,[6] Chenchev et al.,[7] and Onsu E et al.[12] Mean increase in WKG in CTG group was (5.125 mm) similar to Uraz A et al.,[10] Mansouri et al.,[13] and Fan et al.[14] Combination of VISTA with PRF and CTG resulted in increase of WKG and significant RC.

In the present study, assessment of the gingival biotype was not an objective; however, an additional observation of increase in thickness of the gingival biotype in both the treatment groups was noted using visual method, which was in concurrence with the study carried out by Dayoub et al.,[15] which concluded that CTG and PRF can be used as a successful treatment option for thin gingival biotype.

Success of RC depends on various factors such as anatomical features, periodontal status, flap design, tissue biotype, residual flap tension, and operator's skill. The mean RC in PRF group was 83.25% this is in agreement with Reddy et al.[4] Chenchev et al.,[7] Gupta et al.,[6] Chatterjee et al.,[16] Garg et al.[17] and Rajeswari et al.,[18] when VISTA was used with PRF. The mean percentage RC in CTG group was 86.43% similar to Uraz A et al.[10] and Onsu E et al.,[12] when PRF and CTG were used along with coronally advanced flap. Bherwani et al.[8] and Wegemund et al.[11] noted similar results when CTG was used with tunnel technique.

The original pouch and tunnel technique offered advantages such as optimal healing, adequate blood supply, and good esthetics. However, there were few disadvantages such as insufficient graft coverage and limited ability to advance the flap coronally for RD >5 mm.[5],[13] These drawbacks can be overcome by VISTA technique, as the incisions are far from gingival margin and the detachments are subperiosteal that curtails the risk of marginal tissue loss. The coronalization of the flap is enhanced due to the subperiosteal tissue detachment which prevents stretching of the gingival margin while graft is being placed beneath the flap.[13] VISTA introduced by Zadeh, used absorbable collagen membrane soaked in rhPDGF-BB/TCP composite.[5]

The main feature of VISTA technique is the placement of remote incision which reduces the possibility of trauma to the soft tissue of teeth being treated.[5],[7] The success of VISTA depends on subperiosteal dissection, as the tension of gingival marginis was reduced while advancing it coronally and maintaining the interdental papillary integrity without reflection.[5]

Grafting serves as a scaffold to support wound healing and provide better RC. Thus, this technique was further reinforced by PRF membrane and CTG which re-established the continuity and integrity of the keratinized gingiva and increases the gingival thickness.[19] Connective tissue helps in better circulation, no immunologic reactions and cost-effectiveness. On comparison with previous studies, it is evident that whenever connective tissue is used, the amount of tissue gain and long-term stability are more predictable.[13] PRF offers several advantages over other membranes or grafts as they release high amount of growth factors which take part in soft tissue and hard tissue repair and regeneration, they play multiple vital roles in early wound healing, bone regeneration, hemostasis, development, maturation of a normal vasculature, cost effective, and eliminates any chances of immune reaction.[7],[20],[21]

The vestibular incision brought about adequate blood supply and esthetics which are the prime considerations for the success of RC. In the maxillary esthetic zone, superior alveolar arteries, branches of the internal maxillary artery, run in a superior-inferior orientation. Therefore, a vertically oriented initial incision will less likely disrupt the blood supply than horizontally positioned incisions. The major advantage of present technique is reduction of micromotion, since there is the displacement of gingival margin during facial movement of the flap.[5] There was no visible scaring of the soft tissue as the tunnel entrance was made within the maxillary frenum which is critical for esthetic outcome.[5]

However, long-term studies are essential for evaluating the stability and success of VISTA technique to assess the predictability over the other techniques. For future studies, pin hole technique can be used which works on the principle of MIS.


   Conclusion Top


VISTA is a technique that is considered to be minimally invasive, which may be considered for the successful treatment of multiple recession defects. In the current study, VISTA in combination with PRF and CTG has demonstrated significant increase in WKD and mean RC. Although VISTA has been used in other regions, its application is most advantageous in the esthetic zone. The Mean %RC in PRF group was 83.25% and CTG group was 86.43%, both techniques showing promising results. Although CTG being the gold standard of the soft-tissue grafting procedures, PRF being rich in growth factors, when used in combination with VISTA can be an alternative for treating multiple gingival recession defects.

Declaration of patient consent

All the study participants provided informed consent for images and other clinical information being reported in the journal.

Acknowledgment

We would like to thank all the participants of the study, teaching and nonteaching staffs of the department, all the postgraduate students for helping to complete the study.

Financial support and sponsorship

This study was financially supported by Indian council of medical research (ICMR) awarded a grant for conducting this study.

Ref no-3/2 June-2017/PG-Thesis-HRD (60) Dated-13.03.2018

Conflicts of interest

There are no conflicts of interest



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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