VOKKALIGARA SANGHA DENTAL COLLEGE AND HOSPITAL,BANGALORE.
COURSE OF STUDY AND SUBJECT
MASTER OF DENTAL SURGERY,
DATE OF ADMISSION TO THE COURSE
TITLE OF THE TOPIC
COMPARATIVE ASSESSMENT OF SUB-EPITHELIAL CONNECTIVE TISSUE GRAFT AND MODIFIED BRIDGE FLAP TECHNIQUE IN THE TREATMENT OF CLASS I AND CLASS II RECESSION DEFECT- A CLINICAL STUDY.
NEED FOR THE STUDY
Marginal tissue recession is a condition commonly encountered in clinical practice and is characterized by the displacement of the gingival margin towards to the mucogingival junction with root surface exposure. It may occur at isolated or multiple areas of oral cavity with different extension degrees.1The main indication for root coverage procedures are aesthetics and/or cosmetic demands followed by root hypersensitivity, root caries or difficulty in plaque control.2
Soft tissue grafts and, in particular, the connective tissue graft provide excellent aesthetics and predictability for coverage of denuded roots. However, the availability of donor material to cover multiple recessions at once may be limited. Likewise, soft tissue grafts will need another surgical area as a donor site. This area is usually the palate that eventually increases the morbidity to the patients. Also, some patients fear the surgical use of the palate as a donor site. Therefore, these complications have led to the search for other techniques for root coverage.3
The bridge flap technique was originally proposed by "Margaff"to cover gingival recession and to increase the attached gingiva in a one-step procedure.4However; this technique requires adequate attached gingiva apical to the recession. So to overcome this limitation, modified form of original bridge flap is imposed to cover the recession.
6.2 AIM OF THE STUDY:- To assess and evaluate the outcome of modified bridge flap technique in the treatment of recession defect.
The objective of the present study is to assess and compare the outcome of root coverage procedure using sub-epithelial connective tissue graft and modified bridge flap in class I and class II recession.
6.4 REVIEW OF LITERATURE
A Randomized controlled trial to compare the outcome of gingival recession therapy using the semilunar coronally positioned flap(SCPF) or the subepithelial connective tissue graft(SCTG) was conducted. Study involves 17 patients with bilateral miller class I buccal recession in maxillary canines or premolars was conducted. After 6 months,the average % of root coverage for SCPF and SCTG were 90.95% and 96.10%, respectively, and the complete root coverage observed was 52.94% and 76.47% respectively.5
Authors conducted a study on 8 patients with 18 teeth having millers class I, II or III recession along with problems of shallow vestibule, inadequate width of AG and with or without frenum pull. Subjects underwent bridge flap technique and were followed up till 9 months postoperatively. The mean root coverage obtained was 55% and the mean average gain width of AG was 3.5mm. The mean % gain in CAL was 41%.4
A case series in which a double lateral bridge flap technique was used for root coverage as a single step solution for coverage of denuded root. Recall examination after a post-operative period of 3 months revealed complete root coverage. In case 1, the width of AG increased from 3 to 5 mm, gain in CAL is 3 mm and PPD of 2mm was present. In case 2, width of AG increased from 2 to 4 mm, gain in CAL of 2 mm and PPD of 2 mm was present.6
Bridge flap technique performed on two cases to increase the width of attached gingiva for treatment of multiple recessions. The postoperative esthetic result was satisfactory for the patients. Clinical results 3-11 months postoperatively were favourable with no recurrence.7
Randomized controlled clinical trial was conducted to evaluate the adjunctive benefit of connective tissue graft (CTG) to coronally advanced flap (CAF) for the treatment of gingival recession. 29 patients with gingival recession associated with inter-dental clinical attachment loss equal or smaller to buccal attachment loss were included in the study. 15 patients were randomly assigned to CAF+CTG while 14 to CAF alone were conducted. After 6 months, CAF+CTG resulted in better outcomes in terms of complete root coverage than CAF alone.8
A clinical study involving 19 patients with gingival recession not more than 6 mm were treated with double lateral bridging flap technique. Clinical evaluation after 2 years showed a root coverage of 72%.9
MATERIALS AND METHODS 7.1 SOURCE OF THE STUDY
Patients of both the sexes who are in the age group of 20-60 years reporting to the Department of Periodontics, Vokkaligara Sangha Dental College and hospital, Bangalore were included in the study.
7.2 METHOD OF COLLECTION OF DATA
20 patients fulfilling the inclusion criteria will be included in the study. Written informed consent will be obtained from those who agree to participate.The selected patients will be randomly allocated to the test and control group. Each group will consist of 10 patients.
Systemically healthy patients within the age range of 20-60 years.
Patient with either Miller’s class I or class II recession defect.
Patients who are cooperative and able to come for regular follow up.
Radiographic evidence of sufficient interdental bone.
20 patients fulfilling inclusion and exclusion criteria will be enrolled. Verbal and written consent will be obtained from the selected patients. The selected patients will be randomly allocated to the test and control group. Each group will consist of 10 patients.
Clinical parameters that will be recorded at the baseline and 6 months are:-
Recession width (RW)
Recession height (RH)
Width of attached gingiva (GW)
Test group will be treated with Modified bridge flap technique and the control group will be treated using Sub-epithelial connective tissue graft.
In Modified bridge flap technique, first horizontal incision will be made slightly coronal to the CEJ at distal/mesial papilla of recession. Second incision will include two vertical incisions which starts from the line angle of adjacent teeth to recession which extends beyond mucogingival junction till the labial mucosa. Third horizontal incision will be given in the labial mucosa to connect two vertical incisions. Sulcular incision will be given in recession area, partial thickness flap will be elevated till the third incision and the entire flap will be mobilized coronally till it covers the recession area and secured using individual sling sutures. Periodontal dressing will be given followed by oral hygiene instructions.
In sub epithelial connective tissue graft procedure,sulcular incision will be made throughout the recession area and tissue will be undermined by doing partial thickness without detaching it completely which extends about 3-5mm laterally and apically till or beyond mucogingival junction to prepare a tunnel. The connective tissue graft will be taken from the palate by using single incision approach which will be inserted into the tunnel and secured by using individual sling sutures. Mild compression with sterile gauze dampened with saline will be applied. Periodontal dressing will be given followed by oral hygiene instructions.
The data gathered from the study will be compared using the student’s t-test.
7.4 Does the study require any investigation or interventions to be conducted on
Yes, Routine investigations for periodontal surgery.
7.5 Has ethical clearance been obtained from your institution in case of 7.3?
Saraiva JA, Campos EA, Cavassim R, De Souza Pinto SC, Fontanari LA, Pimentel Lopes Oliveira GJ. Subepithelial connective tissue graft: a case report. RSBO 2011 Jul-Sep;8(3):357-362.
Shori T, Kolte A, Kher V, Dharamthok S and Shrirao T. a comparative evaluation of the effectiveness of subpedicle acellular dermal matrix allograft with subepithelial connective tissue graft in the treatment of isolated marginal tissue recession: A Clinical study. J Indian Soc Periodontol 2013 Jan-Feb;17(1): 78-81.
Santos A, Goumenos G and Pascual A. Management of gingival recession by the the use of an acellular dermal graft material: A case series. J Periodontol 2005;76:1982-1990.
Vijayalakshmi R, Uma S, Saravana kumar R, Ramakrishnan T, Emmadi P, Anitha V. Double lateral sliding bridge flap for the coverage of denuded roots: Two case reports. PERIO-Periodont Pract Today 2008;5:29-3
Sandro Bittencourt, Erica Del Peloso Ribeiro, Enilson A. Sallum, Antonio W. Sallum, Francisco H. Nociti Jr. and Marcio Zaffalon Casati. Comparative 6 month clinical study of a semilunar coronally positioned flap and subepithelial connective tissue graft for the treatment of gingival recession. J Periodontol 2006;77:174-181.
GuptaV, Bains VK, MohanR, Bains R. Bridge flap technique as a single step solution to mucogimgival problems: A case series .Contemp Clin Dent2011;2:110-4
Cario F, Cortellini P, Tonetti M, Nieri M, Mervelt J, Cincinelli S, Pini-Prato G. Coronally advanced flap with or without connective tissue graft for the treatment of single maxillary gingival recession with loss of inter-dental attachment. A randomized controlled clinical trial. J Clin Periodontal 2012;39:760-768
Marggraf E. A direct technique with a double lateral bridging flap for coverage of denuded root surface and gingival extension. clinical evaluation after 2 years. J Clin Periodontol 1985;12:69-76
Study title: -“COMPARATIVE ASSESSMENT OF SUB-EPITHELIAL CONNECTIVE TISSUE GRAFT AND MODIFIED BRIDGE FLAP TECHNIQUE IN THE TREATMENT OF CLASS I AND CLASS II RECESSION DEFECT”- A CLINICAL STUDY.
Conducted by: Jaspreet Kaur
Post Graduate Student
I……………………………………. son/daughter/wife of…………………………………… aged…………….. resident of…………………………………………………… do hereby give consent to perform the clinical examinations and recommended minor surgical procedures or treatment. The procedure has been explained to me in my own language. Any complications arising with it, if any, I agree that no responsibility will be attached to the surgeon or hospital staff.
Signature of Patient/Parent:
Signature of Witness:
Signature of Researcher:
«.J¸ï.zÀAvÀ ªÉÊzÀåQÃAiÀÄ PÁ¯ÉÃdÄ ªÀÄvÀÄÛ D¸ÀàvÉæ ¨ÉAUÀ¼ÀÆgÀÄ M¥ÀàAzÀzÀ Cfð ¥ÀvÀæ “ªÀUÀð-1 ªÀÄvÀÄÛ ªÀUÀð-2 C¥À¸ÀgÀt £ÀÆå£ÀvÉAiÀÄ aQvÉìAiÀÄ°è ¸À¨ï-J¦yÃ°AiÀÄ¯ï ¸ÀA§A¢üvÀ CAUÁA±ÀUÀ¼À (ssubepithelial connective tissue) ªÀÄvÀÄÛ §zÀ¯ÁzÀ ¸ÉÃvÀÄªÉAiÀÄAvÀ PÀªÀZÀzÀ (modified bridge flap technique) ¥ÀæQæAiÉÄAiÀÄ vÀÄ®£ÁvÀäPÀ ªÀiË®åªÀiÁ¥À£”À: MAzÀÄ ªÉÊzÀåQÃAiÀÄ CzsÀåAiÀÄ£À.
d¹àçÃvï PËgï ¥ÀzÀ«AiÉÆÃvÀÛgÀ «zÁåyð.
ನಾನು…………………………………………………ಮಗ/ಮಗಳು/ಹೆಂಡತಿ…………………………………………….. ವಯಸ್ಸು……………………………… ವಾಸಿಸುತ್ತಿರುವ ………………………………………………….. ನನ್ನ ಚಿಕಿತ್ಸೆ ಮತ್ತು ಹಾಗು ಶಸ್ತ್ರಚಿಕಿತ್ಸಾ ವಿಧಾನಕ್ಕೆ(ಚಿಕ್ಕ) ಸಹಕಾರ ಮತ್ತು ಸಮ್ಮತಿಯನ್ನು ಕೊಡಲು ಒಪ್ಪಿದ್ದೇನೆ. ಸಲಹೆ ನೀಡಿರುವ ವಿಧಾನಗಳನ್ನು ಅಥವಾ ಚಿಕಿತ್ಸೆಯ ಬಗ್ಗೆ ಸಂಪೂರ್ಣ ಮಾಹಿತಿಯನ್ನು ನನ್ನ ಭಾಷೆಯಲ್ಲಿ ಕೊಡಲಾಗಿದೆ.ಇದರಿಂದ, ನನಗೆ ಯಾವುದಾದರು ಹಾನಿ ಅಥವಾ ತೊಂದರೆಗಳುಂಟಾದರೆ, ಶಸ್ತ್ರಚಿಕಿತ್ಸೆ ಮಾಡುವವರಿಗೆ ಅದು ಸಂಬಂಧವಿರುವುದಿಲ್ಲ.
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CASE RECORD PROFORMA
Name of the patient: Date:
Age / Sex: O.P. No. :
Address & Ph. No.: Occupation:
History of Present Illness: Past Dental History: Medical History: