• No results found

Sources included in the report:

N/A
N/A
Protected

Academic year: 2022

Share "Sources included in the report: "

Copied!
123
0
0

Loading.... (view fulltext now)

Full text

(1)

CORONALLY ADVANCED FLAP USING MICROSURGERY TECHNIQUE IN THE TREATMENT OF MILLER’S CLASS I AND II GINGIVAL RECESSION-

A COMPARATIVE STUDY

A Dissertation submitted in partial fulfillment of the requirements

for the degree of

MASTER OF DENTAL SURGERY BRANCH – II

PERIODONTOLOGY

THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY CHENNAI – 600032

2015 – 2018

(2)
(3)
(4)
(5)

God surely listens, Understands and knows The hopes and fears you keep in

your heart. For when you trust in his love, Miracles happen !

Firstly I thank my Almighty for the wonderful Blessings and strength and beautiful grace to complete my dissertation work.

A Good Teacher knows how to teach the standards

A Great Teacher knows how to teach her students

An Outstanding Teacher knows how to teach the both.

Without a guidance,nothing can be done in a right way.Next to God, I sincerely thank all my staffs for their guidance.

(6)

honourable Vice chairman Prof.Dr.A.Babu Thandapani M.pharm, PhD for providing with all the available facilities and encouragement to do this work.

I would like to thank the principal of our institute, Prof. Dr. K.Vijayalakshmi.,M.D.S., for providing me with all the facilities required for the task at hand. I convey my heartfelt thanks for our vice principal Prof. Dr. K.S.Premkumar.,M.D.S.,who is always understanding, supportive and encouraging to complete my work.

I express my sincere and deepest gratitude to Dr.C.S.PrabhaharM.D.S., Professor and Head of the Department of Periodontology, for his constant guidance,scholary supervision and timely advice.

I sincerely acknowledge my guide Dr.M.Narendra Reddy M.D.S., Professor for his expertise, technical support,invaluable guidance and proper direction.

I owe my special thanks to Dr.V.K.Vijay M.D.S.,MBA.,(HM), Reader for his advice and encouragement. I am highly thankful to Dr.M.Navarasu M.D.S., and Dr.M.Umayal M.D.S., for providing guidance,help & sound advice.

I thank all my staff for their time,excellent guidance intellectual contributions and suggestions to my development.

I take this opportunity to express my deep sense of gratitude and respectful regards to Dr. V. Sivakumar M.D.S., former HOD who helped me during initial period of my study.

I would like to thank from bottom of my heart to my senior Dr. M.Jeevitha who have supported and assisted all my cases and I extend my thanks to my wonderful senior Dr.S.P.Brindhadevi and my wonderful colleague Dr.K.B.R.Ramya Kumari and my juniors Dr.T.Suganya Harshini , Dr.V.Benedict, Dr.Karthigha, Dr.Gomathifor their support and encouragement.

(7)

(Lit) M.L.I.Sc and to the non-teaching staff Mrs.S.Malaiyayee and Mrs.M.Ayammal, who directly or indirectly have helped me during my dissertation work.I sincerely express my gratitude to all the patients who participated in my study with patience and diligence.

Last but not least I thank my father Mr.P.RAVI for making me what I am and my mother Mrs.R.PITCHAIMANI for her incessant prayers and my dear brother Mr.R.BALAJI and my dear husband Mr.S.DINESH BABU for their constant support and my friends for their support and ALMIGHTY for there blessings.

I thank each and every person who supported or helped me in the completion of this dissertation.

(8)
(9)

Urkund Analysis Result

Analysed Document: ilovepdf_merged.pdf (D34476895)

Submitted: 1/9/2018 8:06:00 AM

Submitted By: r.nivetha1109@gmail.com

Significance: 13 %

Sources included in the report:

dr. shivani.docx (D30559807)

EVALUATION OF REGENERATIVE EFFICACY OF 0.docx (D34279692) New Microsoft Word Document (2).docx (D30694454)

https://www.ncbi.nlm.nih.gov/pubmed/24720640

http://www.rguhs.ac.in/cdc/onlinecdc/uploads/02_D026_46164.doc

https://worldwidescience.org/topicpages/c/coronally+advanced+flap.html http://onlinelibrary.wiley.com/doi/10.1111/j.1600-051X.2011.01774.x/abstract http://onlinelibrary.wiley.com/doi/10.1111/jcpe.12207/abstract

http://pubs.sciepub.com/ijdsr/2/1/1/

https://www.researchgate.net/profile/Geoffrey_Lecloux https://www.researchgate.net/

publication/6495305_Coronally_advanced_flap_A_modified_surgical_approach_for_isolated_rec ession-type_defects_Three-year_results

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4788803/

https://www.researchgate.net/

publication/13703690_Treatment_of_Gingival_Recession_With_Titanium_Reinforced_Barrier_Me mbranes_Versus_Connective_Tissue_Grafts

https://www.researchgate.net/publication/269659994_Button-

assisted_Coronally_Advanced_Flap_An_Innovative_Ortho-perio_Amalgamation https://www.researchgate.net/

publication/259453883_Comparison_of_amnion_allograft_with_connective_tissue_graft_for_roo t_coverage_procedures_A_double-blind_randomized_controlled_clinical_trial

https://www.researchgate.net/

publication/51696893_Clinical_evaluation_of_the_efficacy_of_a_GTR_membrane_HEALIGUIDER_

and_demineralised_bone_matrix_OSSEOGRAFTR_as_a_space_maintainer_in_the_treatment_of_

Miller's_Class_I_gingival_recession

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3917208/

https://www.researchgate.net/figure/23559275_Figure-2-Pre-operative-image-of-an-upper-left- cuspid-presenting-with-a-Miller-Class-I-recession

https://www.science.gov/topicpages/c/coronally+advanced+flap.html

https://idauttarakhand.files.wordpress.com/2017/11/management-of-multiple-gingival- recession-defect-using-coronally-advanced-flap-alone-or-with-prf-membrane.pdf

U R K U N D

(10)
(11)
(12)
(13)
(14)

LIST OF ABBREVIATIONS USED

AAP AMERICAN ACADEMY OF PERIODONTOLOGY

ADM ACELLULAR DERMAL MATRIX

ADMA ACELLULAR DERMAL MATRIX ALLOGRAFT

ANOVA ANALYSIS OF VARIANCE

CAL CLINICAL ATTACHMENT LOSS

CEJ CEMENTO ENAMEL JUNCTION

CM COLLAGEN MATRIX

CPF CORONALLY POSITIONED FLAP

CRC COMPLETE ROOT COVERAGE

CTG CONNECTIVE TISSUE GRAFT

EDTA ETHYLENE DIAMINE TETRA ACETIC ACID

EMD ENAMEL MATRIX DERIVATIVE

HKT HEIGHT OF KERATINIZED GINGIVA

GM GINGIVAL MARGIN

(15)

GR GINGIVAL RECESSION

MCAF MODIFIED CORONALLY ADVANCED FLAP

MGJ MUCO GINGIVAL JUNCTION

MMTT MODIFIED MICROSURGICAL TUNNEL TECHNIQUE

PD PROBING DEPTH

RC% ROOT COVERAGE PERCENTAGE

RD RECESSION DEPTH

RES ROOT COVERAGE ESTHETIC SCORE

RW RECESSION WIDTH

SCTG SUBEPITHELIAL CONNECTIVE TISSUE GRAFT

STT SOFT TISSUE TEXTURE

UNC UNIVERSITY OF NORTH CAROLINA

VRI VERTICAL RELEASING INCISION

WKT WIDTH OF KERATINIZED TISSUE

(16)

TABLE NO. CONTENTS PAGE NO.

1 MEAN REDUCTION IN PLAQUE INDEX SCORE 52

2 MEAN REDUCTION IN GINGIVAL INDEX SCORE 53

3 MEAN REDUCTION IN MODIFIED SULCULAR BLEEDING INDEX SCORE

54

4 MEAN REDUCTION IN PROBING DEPTH 55

5 MEAN REDUCTION IN CLINICAL ATTACHMENT LEVEL 56

6 MEAN REDUCTION IN GINGIVAL RECESSION WIDTH 57

7 MEAN REDUCTION IN GINGIVAL RECESSION DEPTH 58

8 MEAN REDUCTION IN WIDTH OF THE KERATINIZED GINGIVA

59

9 MEAN ROOT COVERAGE ESTHETIC SCORE 60

10 PERCENTAGE OF ROOT COVERAGE 60

(17)

LIST OF GRAPHS

GRAPHNO. CONTENTS PAGE NO.

1

PLAQUE INDEX

61

2 GINGIVAL INDEX 61

3 MODIFIED SULCUS BLEEDING INDEX 62

4 PROBING POCKET DEPTH 62

5 CLINICAL ATTACHMENT LEVEL 63

6

GINGIVAL RECESSION WIDTH 63

7 GINGIVAL RECESSION DEPTH 64

8 WIDTH OF THE KERATINIZED GINGIVA 64

9 ROOT COVERAGE ESTHETIC SCORE 65

10 ROOT COVERAGE PERCENTAGE 65

(18)

LIST OF FIGURES

FIGURE NO.

FIGURES

1 Armamentarium For Surgical Procedure

2 Microsurgical Instruments 3

Periodontal Dressing

4 Surgical Procedure – Coronally Advanced Flap

5 Surgical Procedure – Modified Coronally Advanced Flap

(19)

SL NO. TITLE PAGE NO.

1 INTRODUCTION 1-4

2 AIM AND OBJECTIVES 5

3 REVIEW OF LITERATURE 6-31

4 MATERIALS AND METHODS 32-43

5 STATISTICAL ANALYSIS 44-45

6 RESULTS 46-65

7 DISCUSSION 66-71

8 CONCLUSION 72

9 SUMMARY 73-74

10 BIBLIOGRAPHY

10 ANNEXURE

(20)

1 INTRODUCTION :

Periodontium is a complex organ consisting of epithelium as well as both soft and mineralized connective tissues. It is protected by the epithelium that attaches the teeth to the bone of the jaws and provides a continuous apparatus for their support while mastication and other functions.It includes gingiva, periodontal ligament, cementum and alveolar bone.

Periodontitis which is a typical form of periodontal disease involves progressive loss of the alveolar bone around the teeth, and if left untreated, can lead to the loosening and even subsequent loss of teeth. The aim of periodontal therapy is to regenerate and restore the various periodontal components affected by disease to their original form, function, and consistency1.

Gingival recession (GR) is defined as the location of gingival margin apical to the cemento–enamel junction (AAP 2001)1. Many patients seek treatment because of concerns with esthetic appearance, root sensitivity or fear of early loss of the affected teeth. Gingival Recession is often complicated by caries, chemical erosion and mechanical abrasion on the exposed root surface and cervical enamel or a combination of the above1.

The physiologic well being of the patient is an important factor in the success of periodental therapy. The solution for the esthetic problem is that many patients with soft tissue recession consult with periodontists.

Marginal tissue recession is a common feature in populations with high standards of oral hygiene as well as in populations with poor oral hygiene. The predominant cause for localized gingival recessions in populations maintaining high

(21)

2 standards of oral hygiene is tooth brushing trauma. In contrast, all tooth surfaces are usually affected with soft tissue recession in periodontally untreated populations due to loss of attachment. Other causes of gingival recession include, labially/buccally positioned teeth, frenal and muscle attachments that encroach on marginal gingiva and orthodontic tooth movement through a thin buccal osseous plate.

A variety of surgical techniques displaying different degrees of success have been suggested to obtain root coverage in areas of soft tissue recession and they depend mainly on the local anatomical characteristics and on the patient’s demands.

Local characteristics such as depth and width of the root exposure, height and width of the inter-dental soft tissue, the number of recession defects on neighbouring teeth, the presence of root caries or cervical abrasions, height, thickness and colour of the keratinized tissues apical and lateral to the root exposure and of the inter-dental papillae neighbouring the recession must be considered. Other soft-tissue characteristics such as the depth of the vestibule and the presence of marginal frenuli or muscle insertions also to be evaluated in the selection of the techniques.2

The desire for root coverage procedures, materials and surgical researches have advanced tremendously in the world of Periodontics.These advances have produced an abundance of studies in the process.

The coronally advanced flap (CAF) procedure does not involve a palatal donor site, and therefore it is a safe and predictable approach.In case of single tooth recession reported in a meta-analysis, successful (mean root coverage = 83%) and predictable (mean percentage of teeth with complete root coverage = 58%) results. These favorable results are maintainable over a long observation period3.

(22)

3 In patients with high esthetic expectations, the CAF is the first choice when there is adequate keratinized tissue apical to the root exposure. With this technique, the soft tissue used to cover the root exposure is similar in color, texture, and thickness to that actually present at the buccal aspect of the tooth with the recession defect.

Multiple gingival recessions, affecting esthetic areas of the mouth,

were successfully treated with modified coronally advanced flap technique3. The presumed advantage of the modified coronally advanced flap is the lack of vertical

releasing incisions (VRIs), which could damage the lateral blood supply to the flap and might result in unesthetic visible white scars (keloids)3.

Microsurgical approach of mucogingival procedures improved the treatment outcomes comparing with routine and macroscopic conditions4. Microsurgical instruments and smaller sutures has led to more delicate soft tissue management, thus enhancing the final esthetic outcomes5. Also, the sharper and finer surgical blades together with finer suture material used in the microsurgical approach were responsible for the reduced tissue damage and the magnification provided by the microscope may help to split a flap in a well-defined thickness and to keep the thickness for the entire flap preparation which result in decreased vessel injury6.

The Goal of root coverage procedure is the complete coverage of the recession defects which is associated with excellent esthetics and minimal probing depth6. The success criteria performed to improve esthetics is different from those surgical procedures whose main goals are to improve periodontal health and restore compromised function5.

(23)

4 Microsurgery allows high-level of accuracy and less postoperative discomfort than macrosurgical techniques. It is a promising technique in the treatment of gingival recession defects. Patient’s esthetics from the gingival appearance in the microsurgery group were satisfied comparing with the conventional surgery group.

Clinical and histological evidence showed that microsurgical technique may result in primary wound closure. This technique provides complete root coverage.5-7

In the present study, an attempt is made to compare the clinical outcome of coronally advanced flap technique and modified coronally advanced flap technique with microsurgery in the treatment of Miller’s class I and II gingival recession.

(24)

5 AIM AND OBJECTIVES

AIM

The aim of the present study is to compare the clinical outcome of coronally advanced flap and modified coronally advanced flap using microsurgery technique in the treatment of Miller’s class I & II gingival recession.

OBJECTIVES

 To compare the parameters like plaque index, gingival index, modified sulcus bleeding index, recession width, recession depth, width of keratinized gingiva in miller’s class I and II gingival recession defects treated with coronally advanced flap technique and modified coronally advanced flap technique using microsurgery technique at baseline,1,3 and 6 months.

 To compare the probing pocket depth and clinical attachment level in miller’s class I and II gingival recession defects treated with coronally advanced flap technique and modified coronally advanced flap technique using microsurgery technique at baseline,3 and 6 months.

 To evaluate and compare the percentage of root coverage using coronally advanced flap technique and modified coronally advanced flap technique at the end of 6 months.

 To compare the root coverage esthetic score (RES),gingival margin(GM), marginal tissue contour (MTC), soft tissue texture (STT), mucogingival Junction (MGJ) alignment and gingival color (GC) at the end of 6 months.

(25)

6 GENERAL REVIEW

GINGIVAL RECESSION:

Gingival recessions (GR) are described as the location of gingival margin apical to the cement enamel junction (AAP 2001).4 Treatment of the recession defects is indicated for esthetic reasons, to reduce root sensitivity, to remove muscle pull, and to create or augment keratinized tissue.

Clinical outcomes of the root-coverage procedures are described in terms of root coverage percentage and complete root coverage.5-7

Etiologic factors of gingival recession are multifactorial and associated with faulty toothbrushing technique (gingival abrasion), tooth malposition, friction from soft tissues (gingival ablation), gingival inflammation, and abnormal frenum attachment.8

CLASSIFICATION OF GINGIVAL RECESSION9:

Numerous classification systems have been proposed over the years.They are as follows.

• Sullivan and Atkins(1968)9

• Mlinek (1973)9

• Liu and Solt (1980)9

• Bengue (1983)10

• Miller (1985)9

• Smith (1990)10

• Nordland and Tarnow (1998)10

• Mahajan (2010)10

(26)

7

• Cairo et al.(2011)9

• Rotundo et al.(2011)10

• Ashish Kumar and Masamatti (2013)10

• Prashant et al. (2014)10

SULLIVAN AND ATKINS(1968) classified gingival recession into four categories

 Deep-wide

 Shallow-wide

 Deep-narrow

 Shallow-narrow

MLINEK ET AL(1973)9:

Gingival recession was quantified based on the recession dimensions as

A. Shallow-narrow: Recession < 3 mm

(27)

8 B. Deep-wide: Recession > 3 mm

This modification reduced subjective variation, but it does not specify the landmark for horizontal measurement as variable measurement may be present at variable distances.

LIU AND SOLT(1980)9:

 VISUAL RECESSION is measured from the cemento-enamel junction to the soft tissue margin

 HIDDEN RECESSION refers to the loss of attachment within the pocket, i.e., apical to the tissue margin

This is not an informative classification and it did not classify visible recession, the focus being more on attachment loss than visible recession

BENGUE ET AL.(1983)10 classified the recession based on their morphology and coverage prognosis:

1. U-type - poor prognosis 2. V-type - fair prognosis 3. I-type - good prognosis.

(28)

9 MILLER(1985) expanded this classification for gingival recession taking into account the nature and quality of gingival recession and its relationship to the adjacent interproximal tissue height.

 Class I- Marginal tissue recession does not extend to the mucogingival junction. There is no loss of bone or soft tissue in the interdental area. This type of recession can be narrow or wide.

 Class II- Marginal tissue recession extends to or beyond the mucogingival junction. There is no loss of bone or soft tissue in the interdental area. This type of recession can be subclassified into wide and narrow.

 Class III- Marginal tissue recession extends to or beyond the mucogingival junction. There is bone and soft tissue loss interdentally or malpositioning of the tooth.

 Class IV- Marginal tissue recession extends to or beyond the mucogingival junction. There is severe bone and soft tissue loss interdentally or severe tooth malposition.

(29)

10 NORDLAND AND TARNOW(1998)10:

The system utilizes 3 identifiable anatomical landmarks: the interdental contact point, the facial apical extent of the cemento-enamel junction (CEJ) and the interproximal coronal extent of the CEJ.

 Normal. Interdental papilla fills embrasure space to the apical extent of the interdental contact point/area.

 Class I. The tip of the interdental papilla lies between the interdental contact point and the most coronal extent of the interproximal CEJ (space present but interproximal CEJ is not visible).

 Class II. The tip of the interdental papilla lies at or apical to the interproximal CEJ but coronal to the apical extent of the facial CEJ (interproximal CEJ visible).

 Class III. The tip of the interdental papilla lies level with or apical to the facial CEJ.

MAHAJAN’S CLASSIFICATION(2010)10:

 Class I: Gingival recession defect not extending to the MGJ

 Class II:Gingival recession defect extending to the MGJ/beyond it

 Class III: Gingival recession defect with bone or soft-tissue loss in the interdental area up to cervical1/3rd of the root surface and/or malpositioning of the teeth

 Class IV: Gingival recession defect with severe bone or soft tissue loss in the interdental area greater than cervical 1/3rd of the root surface and/or severe malpositioning of the teeth.

(30)

11 PROGNOSIS 10:

Prognosis as per Mahajan’s classification

 BEST: Class I and Class II with thick gingival profile

 GOOD: Class I and Class II with thin gingival profile

 FAIR: Class III with thick gingival profile.

 POOR: Class III and Class IV with thin gingival profile.

The selection of the surgical technique in an attempt to cover a root recession depends mainly on the local anatomical characteristics and on the patient’s demands.

Local characteristics to be evaluated are as follows: the dimensions (depth and width) of root exposure, the height and width of the inter-dental soft tissue, the number of recession defects on neighbouring teeth, the presence of root caries or cervical abrasions2.

Also,the height, thickness and colour of the keratinized tissues apical and lateral to the root exposure and of the inter-dental papillae neighbouring the recession must be considered. The coronal advanced flap technique is recommended in patients with a residual amount of keratinized tissue apical to the recession defect2.

The coronal positioned flap has been described as a technique for coverage of exposed roots11.The coronally advanced flap was first introduced by Norberg (1926)12 as an aesthetic surgical procedure for root coverage.Allen and Miller (1989)11 used this procedure and were able to achieve 3.18 mm root coverage (97.8%) of shallow marginal recession.

Optimum root coverage results, good colour blending of the treated area with respect to adjacent soft tissues and complete recovery of the original (pre-surgical) soft

(31)

12 tissue marginal morphology can be predictably accomplished by means of this surgical approach (Roccuzzo et al. 2002)13. Furthermore, the post-operative course is less troublesome for the patient as other surgical sites distant from the tooth with recession defect are not involved.

Recently, the coronally advanced flap has been demonstrated to be very effective in the treatment of multiple recession defects affecting adjacent teeth with obvious advantages for the patient in terms of aesthetics and morbidity9.

CORONALLY ADVANCED FLAP TECHNIQUE :

This technique has long been used as a root coverage procedure.The following technique was described by Norberg 19269. Under Local anesthesia, the exposed root is scaled and root planed to remove the softened cementum and reduce or eliminate prominent root convexities. Citric acid (pH 1.0) is burnished with moistened cotton pledget for 3-5 minutes. Using 2 vertical incisions, A full thickness periosteal flap is raised and the underlying bone is exposed. A scalloped, inverse beveled incision is made using a no.15 scalpel blade to connect the 2 vertical incisions.

The scalloped incision is made at the gingival crest facially, but interproximally care is taken to create new papillae that will fit their future locations. The remaining portion of the papillae will undergo epithelial denudation with ophthalmic scissors or tissue nippers. The flap is positioned 1mm coronal to the CEJ. To facilitate the coronal movement, base of the flap is undermined and separated from the periosteum with the scissors.The flap is sutured coronally with a sling type papillary suture around

(32)

13 the neck of the tooth.This positions and stabilizes the flap coronally. Interrupted sutures are used laterally.

MODIFIED CORONALLY ADVANCED FLAP:

The surgical technique for gingival recession defects was the modification of coronally advanced flap for multiple teeth recession coverage which was proposed by Zucchelli and De Sanctis 20003. Clinical features of Zucchelli’s technique are the absence of vertical releasing incisions, a variable thickness,combining areas of split and full thickness and the coronal repositioning of the flap. Another characteristic feature is the submarginal oblique incisions in the interdental area. Incisions are given obliquely connecting the CEJ of one tooth to the gingival margin of the adjacent tooth.

A.Gingival recessions in the lateral incisor and a canine B. Elevation of a split-full-split approach with two vertical releasing incision. C. De epithelializion D) Flap sutured coronal to the CEJ of the treated teeth.

E) Follow-up

(33)

14 A horizontal incision was made with a scalpel to design the modified form of flap. The incision was extended to include one tooth on each side of the teeth to be treated in order to facilitate the planned coronal repositioning of the flap tissue over the exposed root surfaces. The horizontal incision of the modified coronally advanced flap consisted of oblique submarginal incisions in the interdental areas, incisions which continued as intrasulcular incisions at the recession defects.

The envelope was raised with a split-full-split approach in the coronal-apical direction: the oblique interdental incisions were carried out keeping the blade parallel to the long axis of the teeth in order to dissect in a split thickness manner the surgical papilla. Gingival tissue apical to the exposure was raised in a full-thickness manner to provide that portion of the flap critical for root coverage with more thickness. Finally the most apical portion of the flap was elevated in a split-thickness manner to facilitate the coronal displacement of the flap. The root surfaces were mechanically treated with the use of curette.

Exposed root surfaces in areas of anatomic bone dehiscence were not instrumented to avoid damaging any connective tissue fibers still inserted in the root cementum. The remaining tissue of the anatomic interdental papillae was de-epithelized to create connective tissue beds to which the surgical papilla were sutured. While advancing the flap coronally,surgical papillae were rotated towards the ends of the flap and were displaced on the prepared connective tissue beds of the anatomical papillae. The flap was secured in place with interrupted sutures. This ensured precise adaptation of the flap .The surgical site was then covered with periodontal dressing (Coe pak)3.

(34)

15

INDICATIONS9:

1.Esthetic coverage of exposed roots

2.For tooth sensitivity owing to gingival recession

REQUIREMENTS:

The main pre requisite is an adequate zone of keratinized gingival (≥ 3mm).

ADVANTAGES:

1.Treatment of multiple areas of root exposure 2.No need for involvement of adjacent teeth

3.High degree of success. Even if the procedure does not work,it does not increase the existing problem

A.Gingival recessions in A lateral incisor, a canine, and the first premolar B) Elevation of the flap by split-full-split approach. C) De epithelializion. D) suturing of the flap E) Follow-up.

(35)

16 DISADVANTAGES9:

The main disadvantage is the need for two surgical procedures if the zone of the keratinized gingiva is inadequate.

MICROSURGICAL TECHNIQUE:

Microsurgical technique always provide better vascularization than macrosurgical technique6.The use of surgical loupes during a periodontal plastic surgical procedure is an economically viable tool that enables utilization of microsurgical instruments, enhances operators visual acuity, allowing better manipulation and more accurate suturing of soft tissues.The instruments used consisted of a microsurgical needle holder, a microsurgical anatomical forceps, a microsurgical scissor, microsurgical (#15c) blade, fixed in a round scalpel handle for an easier rotating movement6. The preparation of the split-thickness flap was performed with the microsurgical scalpel Sharptomes straight (Sharpoints, Surgical Specialties Corporation, Reading, PA, USA), usually used in ophthalmology6.

Patients were treated using minimally invasive surgical technique with the aid of a surgical loupe having a 2.5× magnification (Magnivision 3.5x –R). The surgical technique per se in any mucogingival surgical intervention has a major role in its successful outcome.

The use of magnification devices along with microsurgical instruments facilitates the use of minimally invasive surgical technique that reduces tissue trauma.

Studies by Belcher et al 12, have addressed the advantages of using magnification in

(36)

17 periodontal surgery. The effectiveness of the microsurgical approach for periodontal regeneration and root coverage has been reported by Cortellini et al, Francetti et al,etc6. Magnification, illumination,proper istrumentation and increased precision in tissue manipulations result in minimal tissue damage during surgery with faster revascularization of the grafted tissue and minimal morbidity of the surgical procedure when compared with conventional surgical techniques13. Use of magnification in mucogingival surgery helps in achieving a high degree of success and predictability and excellent esthetic outcome14.

In root coverage, a microsurgical approach substantially improved the vascularization of the grafts and the percentages of root coverage compared with applying a conventional macroscopic approach. It has to be realized, however, that factors influencing the degree of coverage, such as root preparation, delicate tissue handling, tissue thickness, meticulous plaque control have to be controlled in order to maximize treatment outcomes. In that respect, the microsurgical approach clearly contributed with a significant (average 8%) improvement in the present study.6

Microsurgical approach for covering localized gingival recessions resulted in a faster vascularization of the injured tissues and hence, in a statistically significant and clinically relevant higher percentage of root coverage. For the closure of the papilla flap, a 6-0 polyglycolic acid( polycryl) microsutures are used. Therefore, the microsurgical technique of root coverage procedures provide good esthetic results compared to macrosurgical technique.

(37)

18 REVIEW OF LITERATURE:

Burkhardt R et al (2005)6 compared the coverage of localized gingival recessions using microsurgical and macrosurgical techniques and also evaluated the degree of vascularisation of connective tissue grafts by applying a microsurgical approach. In this split-mouth design, immediately after the surgical procedures, and after 3 and 7 days of healing, fluorescent angiograms were performed to evaluate graft vascularization. They concluded that in root surface coverage, a microsurgical approach substantially improved the vascularisation of the grafts and the percentages of root coverage compared with applying a conventional macroscopic approach.

Paulo Carvalho et al (2006)8 clinically evaluated the effectiveness and the predictability of root coverage at adjacent multiple gingival recessions using a modified coronally positioned flap associated with the subepithelial connective tissue graft. Ten non- smoking, healthy subjects (five men and five women; mean age, 28.7 years) presenting 29 Class I or II adjacent multiple gingival recessions were enrolled. Each patient was treated using a modified coronally advanced flap associated with the subepithelial connective tissue graft. Probing depth (PD), clinical attachment level (CAL), recession depth (RD), and width of keratinized tissue (KT) were measured at baseline and 6 months later. The Student t test was used to compare treatment outcomes through time. The results revealed significant CAL gain, RD decrease, and KT increase. The average root coverage was 96.7%, and complete root coverage was found at 93.1% of the defects.

They concluded that the modified coronally advanced flap associated with the subepithelial connective tissue graft was effective and predictable to produce root

(38)

19 coverage at multiple adjacent gingival recessions associated with gain in the CAL and in the width of KT.

Ofer Moses et al (2006)11 clinically evaluated the long-term effect of a coronally advanced flap procedure with the additional use of enamel matrix derivative (EMD) to treat gingival recession versus the subpedicle connective tissue graft (CTG) procedure.

Miller Class I or II buccal recession-type defects in the anterior teeth or premolars in 65 patients (28 in EMD and 37 in CTG groups) were treated in several centers. At baseline and 12 and 24 months post-treatment, vertical recession defect (VRD), height of keratinized tissue (HKT), and probing depth (PD) were recorded, and the percentage of root coverage (PRC) of the original defect was calculated.They concluded that both treatments proved clinically successful. CTG treatment showed a higher percentage of root coverage and HKT increase. EMD is a valuable, long-term effective treatment alternative to achieve root coverage together with an increase in HKT.

Ajay Mahajan et al (2007)15, conducted a randomized controlled trial to evaluate acellular dermal matrix (ADM) graft in terms of patient satisfaction and its effectiveness and efficiency in the treatment of gingival recession. Fourteen patients with Miller Class I and II recessions ≥ 3 mm participated in this 6-month clinical study. They were assigned randomly to the ADM group (ADM graft and coronally positioned flap [CPF]) or the CPF group (CPF alone).Results were evaluated based on patient satisfaction and clinical outcomes associated with the two treatment procedures. They concluded that ADM graft is significantly superior with regard to effectiveness and efficiency in the treatment of gingival recession than CPF alone. CPF emerges as a better option than ADM graft in terms of cost effectiveness and patient comfort.

(39)

20 Francesco Cairo et al (2009)7conducted a case report for evaluating the esthetic outcome following root-coverage surgery. Thirty-one patients with Miller Class I and II recession defects treated with root-coverage procedures were evaluated. Esthetic outcomes were assessed using the root coverage esthetic score (RES) 6 months after surgery. Of the 31 treated recession defects, 24 (77%) exhibited complete root coverage at 6 months. They concluded that the RES system may be a useful tool to assess the esthetic outcome following root-coverage procedures.

Zucchelli et al (2009)3 compared root coverage and esthetic outcomes of the coronally advanced flap (CAF) with and without vertical releasing incisions in the treatment of multiple gingival recessions. The authors concluded that both CAF techniques were effective in reducing recession depth. The envelope type of CAF was associated with an increased probability of achieving complete root coverage and with a better postoperative course.

Francesco Cairo (2009)7 conducted a case study for evaluating the esthetic outcome following root-coverage surgery. Thirty-one patients with Miller Class I and II recession defects treated with root-coverage procedures were evaluated. Esthetic outcomes were assessed using the root coverage esthetic score (RES) 6 months after surgery. This score evaluates five variables: level of the gingival margin, marginal tissue contour, soft tissue texture, mucogingival junction allignment, and gingival color. They concluded that the RES system may be a useful tool to assess the esthetic outcome following root coverage procedures.

Sofia Aroca et al (2009)16 conducted a study to determine whether the addition of an autologous platelet-rich fibrin clot (PRF) to a modified coronally advanced flap (MCAF)

(40)

21 (test group) would improve the clinical outcome compared to an MCAF alone (control group) for the treatment of multiple gingival recessions. They concluded that MCAF is a predictable treatment for multiple adjacent Miller Class I or II recession-type defects. The addition of a PRF membrane positioned under the MCAF provided inferior root coverage but an additional gain in GTH at 6 months compared to conventional therapy.

Tella Asha Latha et al (2009)14 evaluated the success and predictability of a rotated papillary pedicle graft in combination with the coronally advanced flap using surgical loupe (2.5X magnification) for the treatment of Miller’s class Ι gingival recession. Fifteen systemically healthy patients with isolated gingival recession underwent the procedure.

The probing depth, percentage root coverage, width of the keratinized gingiva and the gain in clinical attachment, papilla width, papilla height, area of the papilla at the donor site, were recorded at baseline, 3 months and 12 months. They concluded that the use of magnification in mucogingival surgery resulted in achieving a high degree of success and predictability as well as an excellent esthetic outcome.

Francesco Cairo et al (2010)17assessed the interrater agreement of the RES among expert periodontists. 11 periodontists were selected in different clinical centers. The total interrater agreement for RESs was 0.92 (95% CI: 0.88 to 0.95), which indicated that an almost perfect agreement was achieved. They concluded that tested individually by a group of periodontists, the RES seems to be a reliable method for assessing the esthetic outcomes of root coverage procedures.

Sunitha Jagannathachary et al (2010)18 conducted a randomized controlled single blind study to evaluate the treatment of Miller’s class II gingival recessions by coronally positioned flap (CPF) with or without acellular dermal matrix allograft (ADMA). Ten

(41)

22 patients with 20 sites with maxillary bilateral Miller’s class II facial recession defects were selected randomly into two groups of test (ADMA+CPF) and control (CPF alone) group with each group having 10 recession defects to be treated. The percentage of root coverage for both the experimental and control groups were 82.2% and 50%, respectively. It can be concluded that the amount of root coverage obtained with ADMA + CPF was superior compared to CPF alone.

Aroca S et al (2010)19 evaluated whether a modified tunnel/connective tissue graft (CTG) technique enamel matrix derivative (EMD) combination will improve the treatment of multiple class III recession when compared with the same technique alone.

Twenty healthy subjects with a mean age of 31.7 years, were enrolled and divided into control and test groups. The mean root coverage from baseline to 1 year post-surgery was 82% for the test group and 83% for the control group. Complete root coverage was achieved at 1 year in eight (38%) of the 20 surgeries (experimental and control group).

They concluded that the modified tunnel/CTG technique is predictable for the treatment of multiple class III recession-type defects. The addition of EMD does not enhance the mean clinical outcomes.

Leandro Chambrone et al (2012)20 conducted an individual patient data meta-analysis of randomized controlled clinical trials (RCTs) to evaluate whether baseline recession, patient, and procedure related factors can influence the achievement of complete root coverage (CRC). Of the 70 potentially eligible trials, 22 were included in the meta- analyses. In total, the data from 320 patients and 16 procedures were evaluated. None of the RCTs were classified as low risk of bias. Of the 602 recessions treated, 310 (51.5%) achieved CRC. Subepithelial connective tissue grafts (SCTGs), matrix grafts, and enamel

(42)

23 matrix derivative protein (EMD) procedures were superior in achieving CRC when compared to coronally advanced flap (CAF) alone. They concluded that SCTGs, matrix grafts, and EMD were superior to CAF in achieving CRC, but SCTGs showed the best predictability. The impossibility of inclusion of all identified RCTs should be taken into consideration when interpreting the present findings.

Francesco Cairo et al. (2012)4 evaluated the adjunctive benefit of Connective Tissue Graft (CTG) to Coronally Advanced Flap (CAF) for the treatment of gingival recession associated with inter-dental clinical attachment loss equal or smaller to the buccal attachment loss. A total of 29 patients with one recession were enrolled; 15 patients were randomly assigned to CAF+CTG while 14 to CAF alone. Measurements were performed by a blind and calibrated examiner. Outcome measures included complete root coverage (CRC), recession reduction (RecRed), Root coverage Esthetic Score (RES), intra- operative and post-operative morbidity, and root sensitivity. They concluded that both treatments can provide CRC in single gingival recession with inter-dental CAL loss. The application of CTG under CAF resulted in predictable CRC when inter-dental CAL was

≤3 mm.

Suraj et al (2013)21evaluated and compared the conventional (macro‑surgical) and microsurgical approach in performing the free rotated papilla autograft combined with coronally advanced flap surgery in treatment of localized gingival recession. A total of 20 sites from 10 systemically healthy patients were selected for the study. The selected sites were randomly divided into experimental site. A and experimental site B by using the spilt mouth design. Conventional (macro‑surgical) approach for site A and

(43)

24 micro‑surgery for site B was applied in performing the free rotated papilla autograft combined with coronally advanced flap. Recession depth (RD), recession width (RW) clinical attachment level (CAL) and width of keratinized tissue (WKT) were recorded at baseline, 3 months and 6 months post‑operatively. They concluded that both the surgical procedures were equally effective in treatment of localized gingival recession by the free rotated papilla autograft technique combined with coronally advanced flap.However, surgery under magnification (microsurgery) may be clinically better than conventional surgery in terms of less post‑operative pain and discomfort experienced by patients at the microsurgical site.

Rajan Padma et al (2013)22, conducted a research to study the additional benefits of PRF when used along with coronally advanced flap (CAF). Total of 15 systemically healthy subjects presenting bilateral isolated Miller’s class I and II recession were enrolled into the study. Each patient was randomly treated with a combination of CAF along with a platelet‑rich fibrin (PRF) membrane on the test site and CAF alone on the control site.

Recession depth, clinical attachment level (CAL), and width of keratinized gingiva (WKG) were compared with baseline at 1, 3, and 6 months between test and control sites.

They concluded that CAF is a predictable treatment for isolated Miller’s class I and II recession defects. The addition of PRF membrane with CAF provides superior root coverage with additional benefits of gain in CAL and WKG at 6 months postoperatively.

Zuhr O et al (2013)23 conducted a randomized clinical trial (RCT) to introduce 3D digital measuring methods for evaluating the outcomes after surgical root coverage (RC)

(44)

25 and to assess the clinical performance of the tunnel technique with subepithelial connective tissue graft (TUN) versus the coronally advanced flap (CAF) with enamel matrix derivative in the treatment of shallow localized gingival recession defects.

Twenty-four patients contributed a total of 47 Miller class I or II recessions for scientific evaluation. Clinical outcomes were evaluated at 6 and 12 months. Patient-centred outcomes were evaluated with questionnaires. Final aesthetic outcomes were assessed using the root coverage esthetic score (RES) Results for patient-centred outcomes were equivalent for both groups but evaluation of the final aesthetic outcomes using the RES revealed a significant difference (9.06 versus 6.92, p = 0.0034) in favour of TUN. They concluded that the TUN resulted in significantly better clinical outcomes compared with CAF. The new measuring method provided high accuracy and unforeseen precision in the evaluation of treatment outcomes after surgical RC.

Salhi L et al (2014)24 compared the two different periodontal plastic surgery procedures to treat Miller’s class I recession: a coronally advanced flap (control group) versus the pouch technique (test group), both of which were associated with connective tissue graft.`1 Forty consecutive patients were included, with 20 patients being allocate for each group. The level of recession coverage, the keratinized tissue (KT) quantity, gingival aesthetics (PES) and post-operative outcomes were assessed for a follow-up period of 6 months. They concluded that both the surgical techniques are relevant in treating Miller’s class I recession. The pouch technique seems to increase the height of KT better and provides good gingival-related aesthetic outcomes.

Anna Skurska et al (2015)1 compared the clinical and aesthetic parameters following a connective tissue graft (CTG) combined with the modified coronally advanced flap

(45)

26 (MCAF), or the coronally advanced flap combined with vertical incisions (CAF) in the treatment of Miller class I and II recessions. Twenty patients with 99 recessions were treated in a split-mouth study model. The MCAF with CTG was used on the right side, while the CAF with CTG was applied on the left side. The clinical and aesthetic evaluation was executed. There was no significant difference in the Complete Root Coverage and Root coverage Esthetic Score values or their variables between the two techniques. They concluded that MCAF with CTG and CAF with CTG allow obtaining satisfactory and comparable root coverage as well as an aesthetic outcome without the negative effect of vertical incisions on the appearance of soft tissue.

Santosh Gupta et al (2015)27, compared the clinical efficacy of coronally advanced flap (CAF) alone and in combination with autologous platelet rich fibrin membrane (PRF) in Miller’s class I and II gingival recessions. Thirty isolated Miller class I or II sites in 26 subjects were randomly divided into test (15 sites- CAF+PRF) and control (15 sites- CAF alone). Parameters such as probing pocket depth (PPD), recession depth (RD), Clinical attachment loss (CAL), Keratinised tissue width (KTW) and Gingival tissue thickness (GTH) were evaluated at baseline, 3 months and 6 months postoperatively. They concluded that the combination of PRF to CAF procedure did not provide any added advantage in term of recession coverage in Miller class I and II recessions. Long term trials with more sample size are needed to validate these findings.

Jian Kang et al (2015)28 evaluated whether microsurgery gains better result in root coverage compared to conventional surgical techniques. A number of databases were searched to identify eligible studies from January 1992 to January 2015. The following outcomes were evaluated: number of sites exhibiting complete root coverage and

(46)

27 patients’ esthetic satisfaction. In that, two studies were about coronal advanced flap (CAF) with enamel matrix derivative or free rotated papilla autograft and did not qualify for metaanalysis. Patients’ esthetic satisfaction was analyzed only by one study. They concluded that using microsurgical technique for treating gingival recessions may be effective in achieving complete root coverage for SCTG.

Paulo Sergio Henriques (2015)29 describe a surgical utilizing collagen matrix plus coronally advanced flap (CM+CAF) in a 3 mm buccal gingival recession associated to traumatic brushing in the maxillary left canine. The goal of treatment was determines if a CM with CAF might be as effective in the root coverage procedure of Miller’s class I recession defect. Results were gradual surgical healing with minimal postoperative morbidity and very slight discomfort after 1 week and complete root coverage on 12 months. They concluded that patient satisfaction and esthetics was very high. The results seem to suggest that CM+CAF can provide a valid treatment procedure in root coverage.

Moreover, it has shown a significant reduction in surgery time, maintenance of marginal tissue health, and mainly patient morbidity without the graft harvest.

Luca Gobbato et al (2015) 30 did a randomized controlled clinical trial to compare the patient morbidity and root coverage outcomes of a subepithelial connective tissue grafts(SeCTG) used in combination with acoronally advanced flap (CAF) or with tunneling technique (TT). For this study, patients were randomly assigned to receive SeCTG+CAF (control group) or SeCTG + TT (test group).Postoperative questionnaires at 3 days post intervention were administered to evaluate postoperative discomfort, bleeding and inability to masticate and patients’pain perception was performed using a visual analog scale (VAS). They concluded that SeCTG + TT is associated with a greater

(47)

28 incidence of pain and discomfort compared to SeCTG + CAF in early postoperative periods, as well as a longer chair time. Both treatments showed similar clinical efficacy in terms of root coverage.

Francesco Cairo et al (2016)31 evaluated the success and predictability of a rotated papillary pedicle graft in combination with the coronally advanced flap using surgical loupe (2.5X magnification) for the treatment of Miller’s class Ι gingival recession. 15 systemically healthy patients with isolated gingival recession underwent the procedure.

The probing depth, percentage root coverage, width of the keratinized gingiva and the gain in clinical attachment, papilla width, papilla height, area of the papilla at the donor site, were recorded at baseline, 3 months and 12 months. All parameters except probing pocket depth, significantly improved from baseline to 12 months. They concluded that the use of magnification in mucogingival surgery resulted in achieving a high degree of success and predictability as well as an excellent esthetic outcome.

Adriano Azaripour et al (2016)32 compared the coronally advanced flap (CAF) with the modified microsurgical tunnel technique (MMTT) for treatment of Miller class I and II recessions. Forty patients with 71 gingival recessions were recruited and randomly assigned to either CAF or to MMTT. In both groups, a connective tissue graft was applied. They found that the root coverage was 98.3% for CAF and 97.2% for MMTT.

They concluded that CAF and MMTT with the additional use of a graft are equally successful in covering gingival recessions of Miller class I and II, with high aesthetic results.

Tobias Thalmair et al (2016)33, evaluated the clinical performance of the modified tunnel technique for treatment of multiple gingival recessions in the anterior mandible. A

(48)

29 total of 20 patients with 63 Miller Class I and II defects were treated via a modified tunnel technique with subepithelial connective tissue graft. At baseline and 6 months postoperative, recession depth, probing pocket depth, width of keratinized tissue, and gingival tissue thickness were assessed. At 6 months, the results revealed a mean recession coverage of 93.87%. Complete recession coverage was achieved in 74.60%.The mean reduction of recession depth was 2.79 ± 0.12 mm. The modified tunnel technique showed successful mean root coverage in the delicate anterior mandible and was able to increase the amount of keratinized tissue.

Sweta Kumari Singh et al (2017)34 compared the root coverage of localized gingival recession using modified coronally advanced flap (Sanctis and Zucchelli’s technique) and root conditioning 24% ethylenediaminetetraacetic acid (EDTA) when done under magnification and without magnification. A total of 20 sites were taken with Miller’s Class I GR (10 in test and 10 in control). All clinical parameters were recorded at baseline, 1 month, and 3 months. CAF and root conditioning were done with 24% EDTA.

Surgical procedure at test site was carried under magnification ×3.5 and at control site was done without magnification. They concluded that microsurgery offers less pain and enhanced outcomes when compared to traditional macrosurgery.

Mauro Pedrine Santamaria et al (2017)35, compared the outcomes of trapezoidal coronally advanced flap (CAF) and coronally advanced tunnel flap (TUN) when used in conjunction with CTG. Forty-two patients presenting 42 single maxillary, Miller Class I and II, gingival recession defects were randomly assigned to receive either CAF+CTG (N=21) or TUN+CTG (N=21). Clinical, patient-centred, and aesthetic outcomes were assessed. Six months postoperatively, both groups resulted in significant reduction of

(49)

30 recession depth and increases in keratinized tissue thickness and width. At 7 days postoperatively, TUN+CTG patients reported significantly less pain experience (p=0.04).

Both approaches reduced dentine hypersensitivity by approximately 85% (p<0.05).

Patient-based aesthetic evaluation indicated significant improvement for both groups.

Although patient- and professional-based aesthetic assessments revealed no differences between groups, tissue texture was significantly better for TUN+CTG (p=0.02). They concluded that for root coverage of single maxillary recession defects, CAF+CTG was more effective than TUN+CTG.

Archana Kumar et al (2017)36 evaluated autologous platelet-rich fibrin (PRF)

and autogenous connective tissue graft (CTG) in gingival recession defects in conjunction with coronally advanced flap (CAF) using a microsurgical technique. Forty

five Class I and II recession defects were randomly equally (n = 15) divided into three groups: Group I sites treated with CAF with PRF, Group II sites treated with CAF with CTG, and Group III sites treated with CAF alone using microsurgical approach. They concluded that a long term multicenter randomized controlled clinical study may be necessary to evaluate the clinical outcome for autologous PRF in comparison to CTG and CAF alone.

Priyanka et al (2017)37 assessed the clinical outcome of isolated gingival recession treated by using subepithelial connective tissue graft (SCTG) in combination with coronally positioned flap (CPF) in esthetic areas by using surgical microscope. They concluded that the qualitative aesthetic evaluation of the treated cases showed better searing and marginal profile. This could be due to an atraumatic surgical approach and excellent visualization of the operative field by using surgical microscope. They also

(50)

31 concluded that microsurgery enhances normal vision through magnification and favorable lightening which would lead to an improvement in cosmetic results and patient comfort level.

(51)

32 MATERIALS AND METHODS:

The study design was viewed and approved by the scientific and Ethical Committee review board of Best Dental Science College and Hospital, Madurai. The study was carried out from January 2016 to November 2017.

STUDY POPULATION:

The study population were recruited from patients attending outpatient clinics of Department of Periodontics, Best Dental Science College and Hospital, Madurai.

A total of 24 subjects (22 males and 2 females) with gingival recession were included in this study.The study sample size was determined to ensure an alpha error of 0.05% and 80% power.

All the participants in the study were verbally informed about the nature, risks and benefits of the study and a written informed consent was obtained.

RANDOMIZATION:

Subjects were randomly allocated into two groups by generating the random number using Software Power 3.1.9.1.

GROUP A: Root coverage procedure done microsurgically using coronally advanced flap technique.

GROUP B: Root coverage procedure done microsurgically using modified coronally advanced flap technique.

(52)

33 CRITERIA FOR SELECTION OF SUBJECTS:

Inclusion Criteria:

 Patients age ≥18 years.

 Systemically healthy subjects.

 Single and multiple tooth with miller’s class I and II gingival recession.

 Vital teeth with no history of active periodontal treatment (surgical and non- surgical) for the past 6 months.

Exclusion Criteria:

 Patients with aggressive periodontitis with known systemic illness.

 Taking any medications known to affect the outcomes of periodontal therapy.

 Pregnancy or lactation.

 Using any form of tobacco habits.

 Presence of severe cervical abrasion, erosion or root caries that would require extensive restoration.

 Malocclusions

All the patients were subjected to phase I therapy. Trauma from occlusion if detected was eliminated. At the end, only those patients demonstrating the acceptable oral hygiene standards and gingival health were considered for the present study. Each patient was explained about treatment design. An informed consent was taken from each of the participating subject.

(53)

34 ARMAMENTARIUM:

Armamentarium for clinical evaluation:

1. Mouth mirror.

2. Explorer.

3. UNC-15 probe.

Surgical armamentarium:

1. Surgical Loupes( Magnivision 3.5x –R).

2. Mouth mirror.

3. UNC-15 probe.

4. Explorer.

5. Cotton pliers.

6. Tissue holding forceps.

7. Sterilized cotton pellets and gauze.

8. Povidone iodine.

9. 2% lignocaine local anesthetic agent containing adrenaline in the ratio of 1:80,000.

10. Microsurgical Bard Parker handle.

11. Microsurgical BP blade no. 15 c.

12. Gracey curettes for anterior teeth.

13. Microsurgical castroviejo scissors.

14. Microsurgical Needle holder.

15. Microsutures (6-0 polycryl sutures, Aurolab product).

16. Tetracycline capsule (250 mg).

17. Dapendish.

18. Applicator tip.

(54)

35 19. Normal saline.

20. Disposable syringes- 2 ml and 10 ml.

21. Coe pak.

22. Glass slab.

23. Cement spatula.

CLINICAL PARAMETERS:

The following clinical parameters are measured at baseline, 1, 3 and 6 months.

1. Plaque index (PI)38 2. Gingival index(GI)39

3. Modified sulcus bleeding index(MSBI)40 4. Recession depth (RD)1

5. Recession width (RW)1

6. Width of keratinized gingiva(WKG)1

The following clinical parameters are measured at baseline, 3 and 6 months.

1. Probing pocket depth (PPD)1 2. Clinical attachment level (CAL)1

The probing pocket depth, clinical attachment level, recession depth and recession width were measured using UNC-15 probe.

At 6 months postoperatively, Root coverage Esthetic Score (RES)7 and Root coverage percentage5 (%) was measured.

Plaque Ind e x (S ilne ss a nd Lo e 1964) Tab le 1:Plaque Inde x S co res

Sco re Cr it er ia

0 No plaque

1 A film o f p laqu e ad her ing t o t he fre e g ing iva l ma rg in a nd

(55)

36 ad jac e nt area o f t he t oot h. The p laqu e ma y be s ee n o nly b y running a pro be acro s s t he t oot h sur face.

2 Mo derat e accu mu lat io n o f so ft depo s it s w it hin t he g ing iva l po cket , o n t he g ing iva l ma rg in a nd/ o r ad ja ce nt toot h sur face, w hic h ca n be se e n by t he nak ed e ye.

3 Abu nda nce o f so ft mat t er wit hin t he g ing iva l po cket and/o r o n t he g ing iva l marg in a nd ad ja ce nt to ot h sur face

Calculation of plaque index:

PI for the area: Each area (disto-facial, mesio-facial, facial and lingual) is assigned a score from 0-3.

PI for a tooth: The scores from the four areas are calculated and divided by four.

PI score for the individual: The scores for each tooth were added and then divided by the total number of teeth examined.

Table 2: Plaque Index Interpretation

Excellent 0

Go o d 0.1-0.9

Fa ir 1.0-1.9

Poo r 2.0-3.0

Gingiva l Inde x ( Lo e and S ilne ss 1963) Tab le 3: Gingiva l Ind e x Sco res

Sco re Cr it er ia

0 Abse nce o f in fla mmat io n/ no r ma l g ing iva.

(56)

37 1 M ild in fla mmat io n, s lig ht c ha nge in co lo ur, slig ht ed e ma

a nd no bleed ing o n pro bing .

2 Mo derat e infla mmat io n, mo derat e g laz ing , redne ss, ed e ma, hyp ert ro phy a nd ble ed ing o n pro bing.

3 Severe in fla mmat io n, marked red ne ss, hypert ro phy, u lcerat io n a nd t end e nc y fo r spo nt aneo us ble ed ing.

CALCULATION:

GI Score for the area: Each area (disto-facial, facial, mesio-facial, lingual) is assigned a score from 0 to 3.

GI Score for a tooth: The scores from the four areas of the tooth are added and then divided by four.

GI score for the individual: The indices for each of the teeth are added and then divided by the total number of teeth examined. The scores range from 0 to 3.

Table 4: Gingival Index Interpretation.

Gingival scores Condition

0.1-1.0 Mild Gingivitis

1.1-2.0 Moderate Gingivitis

2.1-3.0 Severe Gingivitis

Probing pocket depth: It was measured from the gingival margin to the bottom of the gingival sulcus.5

Clinical attachment level: It was measured from the CEJ to the bottom of the gingival sulcus5

References

Related documents

It is accomplished by means of post assessment of the effectiveness of honey in relieving constipation among antenatal mothers in third trimester on 4 th day after administration

By comparing the post operative level of serum cortisol , CRP and glucose , the laparoscopic group has much less stress response compared to open surgical

A languages is known as DSPACE(O(n)), if it is accepted using linear space on a Deterministic Turing machine. Clearly, DSPACE is a subset of NSPACE, but it is not known

This is a retrospective study done in 12 patients who underwent Bilateral Sagittal Split Osteotomy to evaluate the predicted post-operative outcome to the surgical outcome

Post-operative pain control is an essential and humanitarian need of every surgical procedure. Management of post-operative pain relief suffering leads to earlier

studied Urinary uric acid and creatinine ratio as a marker of perinatal asphyxia and its correlation with different stages of hypoxic ischemic encephalopathy.Results showed

Helpdesk management system is a process of handling helpdesk tickets, incidents and service requests and timely resolution. Network operator shall prepare a Change

Helpdesk management system is a process of handling helpdesk tickets, incidents and service requests and timely resolution. Network operator shall prepare a Change