Bangalore, karnataka annexure II proforma for registration of subjects for dissertation



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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

ANNEXURE - II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION


1.




NAME OF THE CANDIDATE AND ADDRESS (in block letters)




Dr. GEETHA PRIYADHARSHINI D. S.

THE OXFORD DENTAL COLLEGE,HOSPITAL AND RESEARCH CENTRE

BOMMANAHALLI, HOSUR ROAD,

BANGALORE- 560068.



2.




NAME OF THE INSTITUTION




THE OXFORD DENTAL COLLEGE,

HOSPITAL AND RESEARCH CENTER,

BANGALORE- 560068.



3.




COURSE OF THE STUDY AND SUBJECT



MASTER OF DENTAL SURGERY

PERIODONTICS



4.



DATE OF ADMISSION TO COURSE


13TH JUNE 2008





5.



TITLE OF THE TOPIC




MACRO AND MICROSURGICAL MANAGEMENT OF GINGIVAL RECESSION WITH SUBEPITHELIAL CONNECTIVE TISSUE GRAFT– A COMPARATIVE STUDY



6



BRIEF RESUME OF INTENDED WORK

6.1 NEED FOR THE STUDY

Gingival recession is one of the commonest problems seen in clinical practice. Patient seeks treatment of denuded roots for reasons like esthetics, root sensitivity, root caries and for fear of loosing affected teeth.1 Obtaining predictable and esthetic root coverage has become an ultimate goal for a periodontal plastic surgeon. Of the various conventional surgical techniques, the success rate of subepithelial connective tissue graft in conjugation with coronally advanced flap is known to be superior2 but the amount of root coverage and percentage of subjects with complete root coverage showed marked variability.3 However, it is realized that, factors such as root preparation, delicate tissue handling and tissue thickness are to be controlled in order to maximize the treatment outcome. These factors may be improved by carrying out surgery with specially designed instruments and under magnification.

Microsurgery amplifies normal vision through magnification, favorable lighting and with the use of finer instrument leading to gentle tissue handling, minimal invasiveness in surgery, precise approximation of the wound margin, minimum damage to flap and periosteum. The application of magnification in mucogingival surgery accomplishes better results in terms of success and predictability and may help achieve excellent aesthetic outcome compared to conventional technique in addition to better root coverage.

In order to improve the predictability and consistency of achieving the desired clinical results, more research is essential to identify and quantify the impact of the use of magnification during surgical procedures. As there are few reports documenting the use of magnification in the treatment of gingival recession, the outcome of coronally advanced flap with subepithelial connective tissue graft procedure carried out by conventional and microsurgical approach need to be compared and evaluated.


6.2 REVIEW OF LITERATURE

In a systematic review of treatment of gingival recession, coronally advanced flap with subepithelial connective tissue graft resulted in better clinical outcome in terms of complete root coverage, recession reduction, gain in clinical attachment level and increase in keratinized tissue as compared to coronally advanced flap alone and coronally advanced flap with enamel matrix derivatives.2

A systematic review of periodontal plastic surgery for the treatment of localized gingival recession showed that the connective tissue graft was statistically significant and more effective than other procedure in recession reduction.3 The percentage of complete root coverage showed marked variability.

In a study of coronally advanced flap with subepithelial connective tissue graft as a donor source for root coverage, an increase of 2-6 mm root coverage was achieved and the donor site was closed with less postoperative discomfort.4

In another study, coronally advanced flap alone and in combination with connective tissue graft was undertaken to compare clinical outcome and patient morbidity.5 Adjunctive application of connective tissue graft under coronally advanced flap increased the probability of achieving complete root coverage in maxillary teeth for Millers class I and II defects. Patient perception of hardship between the two procedures showed no statistical difference.

A controlled clinical study by Fanciti et al showed that the application of magnification in mucogingival surgery accomplished better results in terms of success and predictability. At the end of 12 months, the mean defect coverage was 86% where magnification was used as compared to 78% in the conventional technique group, whereas the rate of complete root coverage was 58.3% and 33.4% respectively in the two groups.6

In a comparative study, Lang et al showed microsurgical approach substantially improves vascularization of the graft and percentage of root coverage as compared to conventional macroscopic approach.7 The clinical measurement revealed mean recession coverage of 99.5±1.7% in microsurgery and for the control it was 90.8±12.1%.

6.3 OBJECTIVES OF THE STUDY

To evaluate the effectiveness of magnification in plastic periodontal surgery procedure with coronally advanced flap and subepithelial connective tissue graft in treatment of Millers class I and II recession in terms of:

1. Amount of root coverage.

2. Predictability of successful root coverage.

3. Increase in width of keratinized gingiva.

4. Intraoperative and postoperative morbidity.

5. Addressing patients concerns as compared with conventional periodontal surgery done without magnification.


MATERIALS AND METHODS

7.1 SOURCE OF DATA

Patients will be recruited from the Department of Periodontics, The Oxford Dental College, Hospital and Research centre, Bangalore.


7.2 METHOD OF COLLECTION OF DATA

INCLUSION CRITERIA

1. Patient aged between 20-50 years.

2. Patient compliant of maintaining good oral hygiene.

3. Isolated buccal gingival recession classified as Millers class I and II.

4. Minimum width of keratinized gingiva of 1 mm.

5. Recession depth greater than 2 mm.



EXCLUSION CRITERIA

1. Root surface restoration.

2. Root caries.

3. Medically compromised patient.

4. Probing pocket depth greater than 3 mm.

5. Smokers.

6. Thin palatal mucosa and presence of palatal tori.







STUDY DESIGN

20 adult patients attending the Department of Periodontics, The Oxford Dental College, Hospital and Research centre will be recruited for the study. They will be randomly allocated into two groups of 10 each viz. control group (conventional surgery) and test group (surgery under magnification) respectively. All the patients will be given thorough phase I therapy. The details of the study would be explained and informed consent will be obtained from the patient.


Following baseline clinical parameters are recorded for each patient:

  1. Recession width.

  2. Recession height.

  3. Surface area of the recession.

  4. Width of the keratinized tissue.

  5. Thickness of the keratinized gingiva.

  6. Probing pocket depth.

  7. Clinical attachment level.


PROCEDURE

Surgical technique

Conventional surgical technique: Area of recipient and donor palatal site is anaesthetized with 2% lignocaine hydrochloride with 1:2,00,000 adrenaline. An intracrevicular incision is made on the buccal aspect of the involved tooth. The incision then extended horizontally to dissect the buccal aspect of the adjacent papilla, both mesially and distally, leaving the gingival margin of the adjacent teeth untouched. Two oblique releasing incisions were made from the mesial and distal extremities of the horizontal incision beyond the mucogingival junction. A full thickness flap is raised initially up to the mucogingival junction and then a partial thickness dissection carried out leaving the underlying periosteum in place. A mesiodistal and apical dissection parallel to the vestibular lining mucosa is performed to release the residual muscle tension and facilitate the passive coronal displacement of the flap. The papilla adjacent to the involved tooth will be de-epithelialized.

The recession defect will be measured using a sterile tin foil and the required amount of graft is harvested from the palate between the distal aspect of canine and mesial aspect of palatal root of first molar using Trapdoor technique which was first described by Edel.8 The palatal wound will be closed with 4-0 silk suture. The graft will be then placed on the recipient bed and stabilized by suturing to the adjacent marginal gingiva using absorbable 4-0 suture (vicryl). The coronally advanced flap will be sutured over the graft using horizontal mattress suture and sling suture around the tooth. A tin foil will be placed on the recipient site and periodontal dressing placed over it. Postoperative instruction will be given to the patient. Patient is refrained from tooth brushing in the operated area for 4 weeks. Amoxycillin 500 mg thrice a day for 5 days will be prescribed, analgesics (Ibuprofen 400mg+ Paracetamol 333mg) will be used as and when required and 0.2% chlorhexidine mouth rinse 3 times a day for the first 4 weeks will be prescribed. These patients will be recalled every week for the first 4 weeks. The periodontal dressing will be removed after one week, surgical site will be cleaned and the dressing will be replaced to be removed at the end of second week. Patient will be followed up with a monthly interval for 6 months and all clinical parameters will be rerecorded.



Microsurgical technique: The same surgical procedure described above will be conducted with loupes having magnification 5.5x and microsurgical instruments along with the use of 8-0 absorbable suture (vicryl).
The duration of the entire study will be one year.

The results will be evaluated statistically employing standard statistical method.


7.4 Does the study require any investigation or intervention to be conducted on patients or other humans or animals?

Yes


7.5 Has ethical clearance been obtained from your institution?

Yes (copy of the report enclosed).










8.




LIST OF REFERENCES

  1. Consensus report. Mucogingival therapy. Ann Periodontol 1996; 1: 702-706.

  2. Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures: A systematic review. J Clin Periodontol 2008; 35 (Suppl 8): 136-162.

  3. Ruccazzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for treatment of localized gingival recessions: A systematic review. J Clin Periodontol 2002; 29 (Suppl. 3): 178-194.

  4. Langer B, Laureen L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985 Dec; 715-720.

  5. Cortellini P, Tonetti M, Baldi C, Francetti L, Rasperini G, Rotundo R, et al. Does placement of connective tissue graft improve the outcome of coronally advanced flap for coverage of single gingival recession in upper anterior teeth? A multi-centre, randomized, double-blind clinical trial. J Clin Periodontol 2009; 36: 68-79.

  6. Francitti L, Fabbro M, Calace S, Testori T, Weinstein R. Microsurgical treatment of gingival recession: A controlled clinical study. Int J Periodontics Restorative Dent 2005; 25: 181-188.

  7. Buchardt R and Lang NP. Coverage of localized gingival recessions: Comparison of micro and macrosurgical techniques. J Clin Periodontol 2005; 32: 287-293.

  8. Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinized gingival. J Clin Peridontol 1974; 2: 185-96.






9.


Signature of the candidate:







10.


Remarks of the Guide:





11.


Name and Designation of:

    1. Guide:



    1. Signature:




    1. Head of the Department:



    1. Signature



Dr. A.V. RAMESH

PROFESSOR

DEPARTMENT OF PERIODONTICS


Dr. C.D. DWARAKANATH

PROFESSOR AND HEAD

DEPARTMENT OF PERIODONTICS


12.


12.1 Remarks of the Chairman and Principal:


12.2 Signature:




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