Comparison of Saddle flap technique versus Vestibular Incision Sub-Periosteal Tunnel Access (VISTA) technique with advanced platelet rich fibrin (A-PRF), for treatment of multiple gingival recessions under surgical operating microscope – A Split Mouth Study.

doi:10.21203/rs.3.rs-2857428/v1

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Comparison of Saddle flap technique versus Vestibular Incision Sub-Periosteal Tunnel Access (VISTA) technique with advanced platelet rich fibrin (A-PRF), for treatment of multiple gingival recessions under surgical operating microscope – A Split Mouth Study.

https://doi.org/10.21203/rs.3.rs-2857428/v1

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BACKGROUND

Root coverage procedures have become an integral part for the management of gingival recessions. Treating multiple recessions is the most challenging scenario. For several reasons it is a matter of concern for both patients and clinicians. New surgical techniques for treating multiple recessions have been proposed. Therefore, the purpose of this study was to evaluate and compare the outcomes of root coverage obtained using VISTA with PRF and Saddle flap with PRF in treating multiple gingival recessions.

METHODOLOGY:

This is a prospective randomized controlled, single-blinded comparative study where 108 recession defects were included. Patients were randomized into VISTA and Saddle groups respectively. Recession depth(RD), Recession width(RW), Width of keratinized tissue(WKT), Thickness of keratinized gingiva(TKG), Percentage of root coverage(%RC), and Complete root coverage(CRC) were assessed at baseline, 3, and 6 months.

RESULTS

Both groups showed significant improvement in all the clinical parameters. Inter-group comparison showed better performance in VISTA group in terms of RD,%RC,TKG,WKT, (p < 0.001) compared to Saddle group.

CONCLUSION

VISTA with PRF showed predictable results in terms of all the root coverage parameters. Saddle flap technique could provide a viable and predictable approach in treating multiple gingival recessions.

Gingival recession

Root coverage

VISTA

Saddle flap

PRF

Gingival recession which is the displacement of the gingival margin apical to the cementoenamel junction (CEJ), not only results in hypersensitivity but also disturbs periodontal esthetics.¹The challenge of periodontal plastic surgical procedures is to ensure sustainable and complete root coverage with attachment of the tissue margin at the CEJ, improving the dimensions of keratinized gingiva.²

Despite the various methods recommended for treating isolated gingival recessions, treating multiple gingival recessions still poses a significant challenge.³ A variety of tunnel approaches that can preserve and maintain critical papillary integrity have also been tried for the management of multiple recession defects.⁴

However, these methods are technique-sensitive and traumatic to the sulcular epithelium resulting in poor healing outcomes. Hence limiting the accessibility and thereby ensuring minimal incisions to the underlying tissues, the vestibular incision subperiosteal tunnel access (VISTA) was developed by Homa H Zadeh to prevent the above-mentioned issues, thereby enhancing predictability during treatment procedures.⁵

On the other hand, Coronally advanced flap(CAF) a predictable root coverage technique, that is based on the concept of coronal displacement of the gingiva over the previously denuded root surface improving esthetic outcomes . The saddle flap technique, a modified CAF design provides a variety of unique and distinct advantages for achieving maximal root coverage. The incision resembles a "horse saddle," raising a split-full-split thickness flap and releasing a portion of the attached gingiva and it also helps in preservation of the papillary integrity and the related essential interdental arterial plexus.⁶

Periodontal regeneration still poses a significant challenge to the clinician and biologics have become an integral part. Platelet-rich fibrin (PRF), a second-generation platelet concentrates, that is made from autologous blood was introduced by Choukroun et al.⁷ in 2001. A-PRF is an advanced PRF that influences soft and hard tissue regeneration.⁸ So, A-PRF was advocated in both these surgical techniques outweighing its advantages mentioned at this juncture.

Root coverage procedures are technique sensitive and require high surgical skill and clinical expertise. Hence, the advocation of such procedures under the surgical operating microscope is highly recommended to enhance chances of success and to improve wound healing by promoting minimal incisions, thereby reducing patient morbidity, and improving clinicians' ergonomics as well.

Although a good number of studies have been reported in the literature on the VISTA technique since its inception. However, only one study in the literature exists till now envisaging the predictability of the Saddle flap technique in root coverage procedures, which was limited to isolated root coverage. Hence, the aim of the study was to compare the clinical outcomes of VISTA with A-PRF and the Saddle flap technique with A-PRF in the treatment of multiple gingival recessions.

This is a split-mouth, single blinded randomized clinical trial to compare the outcomes of Root Coverage using VISTA with A-PRF and Saddle flap technique with A-PRF in the treatment of multiple gingival recessions.

All the participants were selected from the outpatient pool of Department of Periodontology, Vishnu Dental College, Bhimavaram. The study was approved by the Institutional research committee (IECVDC/2021/PG01/PI/IVV/18) and ethical clearance was obtained (CTRI/2021/07/034844). Written informed consent was obtained from patients who were willing to participate voluntarily.

Selection criteria:

Patients who met all inclusion and exclusion criteria were included in the study. Patients between the ages of 18 and 60, reduced healthy periodontium, systemically healthy without any contraindications for periodontal surgery, ≥ 2 adjacent Millers’ class I and class II recessions, no clinical signs of active periodontitis were included. Any underlying systemic conditions that could prevent healing, women who are pregnant or lactating, patients taking any medication known to influence the gingival condition, smokers, malaligned teeth were excluded from the study.

The patients who fulfilled the criteria were included in the study and were randomly assigned to either of the groups using the coin flip method i.e., 20 patients with bilateral recessions in the VISTA with A-PRF as control group, Saddle with A-PRF as test group.

Clinical parameters:

A detailed case history, including dental and medical history, was recorded in a specially designed proforma that included the clinical parameters listed below:

Plaque index (FMPS) (Silness and Loe 1964), Gingival index (GI) (Loe and Silness 1963), Probing pocket depth (PPD), Clinical attachment level (CAL), Depth of recession (RD), Width of recession (RW), Keratinized tissue width (WKT), Thickness of Gingiva (TKG), Mean percentage of root coverage(%RC), Complete root coverage (CRC)

At baseline, 3 months, and 6 months, the clinical measurements PI, GI, PPD, CAL, RD, RW, WKT, and TKG were recorded using the UNC 15 probe.

Surgical procedure:

The surgery was carried out under local anaesthesia with 2% lignocaine containing adrenaline at a concentration of 1:2,00,000 at the site. The surgical procedure was carried out under the surgical operating microscope of 0.4X magnification at both the sites. 20 ml of venous blood was drawn and centrifuged immediately in a table-top centrifuge at a rate of 1300 rpm for 11 minutes. A- PRF was separated and made into membranes using a sterile PRF box.⁷

Control group:

VISTA procedure:⁵

Under local anaesthesia VISTA approach begins with a vestibular access incision. An incision was made through the periosteum to elevate a subperiosteal tunnel, this tunnel was extended for multiple gingival recessions that required root coverage to mobilise gingival margins and facilitate coronal repositioning. The A-PRF membrane is placed and suspensory sutures were placed.

Test group:

Saddle flap technique:⁶

Under local anaesthesia saddle flap technique was initiated with an intrasulcular incision followed by horizontal saddle incision in the adjacent teeth. A split-thickness oblique incision was given extending 2 mm submarginally over the adjacent teeth. Beyond the MGJ, split-thickness elevation was done. A-PRF membrane, is placed in the surgical area and sutures were placed. Postoperative instructions were given as a standard practice.

Postsurgical measurements: All clinical measurements were recorded during the recall visits i.e. at the end of 3 and 6 months.

Patient response towards the treatment was assessed by questionnaire, that included Patients discomfort and dentinal hypersensitivity during and after surgery on a VAS scale of 1-10.

All the data collected at baseline, 3 and 6 months was subjected to statistical analysis using Paired t test for intergroup comparison, Repeated measures of ANOVA test and Paired t test for intragroup comparison and P value <0.05 was considered statistically significant for all the analysis.

The study's participants ranged in age from 21 to 58 years, with a mean age of 39.5 years. 14 males and 6 females, constituting 70% and 30% of the total participants. The study included 108 recession defects with either Miller's Class I or Class II recessions. Participants were actively involved, with no dropouts. All the periodontal indices viz, PI, GI, along with periodontal parameters like PPD, CAL, and mucogingival parameters such as RD, RW, WKT, TKG, %RC, and CRC were measured and compared at baseline, 3 and 6 months after the surgery. No cases of post-surgical bleeding, paraesthesia, or surgical complications were encountered. Pain and DH scores were subjectively assessed using the VAS.

Both the groups were statistically comparable at baseline for all the considered parameters. Tables 1 and 2 show intragroup comparison of all the parameters and Table 3 show intergroup comparison of the considered parameters.

PPD, CAL, PI, GI, however showed statistical significance with a mean reduction of PPD and CAL gain in both the groups. RD, RW were statistically reduced favouring the VISTA with PRF group. WKT, TKG, %RC, CRC was statistically improved favouring VISTA with PRF group.

Although quite a few studies in the literature documented on the VISTA technique, paucity of literature exists on the saddle flap technique in treating multiple gingival recessions, hence this study was undertaken to evaluate its effectiveness against VISTA technique.

In terms of assessing the effectiveness of the VISTA group and Saddle group in multiple GR, GI and PI scores decreased significantly in both groups from baseline to 6 months. This could be because of constant reinforcement of oral hygiene measures. As it is a notable fact that root coverage procedures are incompatible with any existing periodontal disease or residual inflammation measures were taken to make sure that all participants were free of gingival inflammation and had stable periodontal health.⁹

There was a significant reduction of PPD from baseline to 6 months in the VISTA group throughout the study period which is in agreement with the study conducted by Chenchev et al¹⁰ and Subbareddy BV et al.¹¹ Significant CAL gain was observed from baseline to 6 months in the VISTA group which was in agreement with the studies conducted by various authors.

The study's findings revealed a significant reduction in mean RD, RW from baseline to 6 months in VISTA group. This was in agreement with the study conducted by various authors^10–17 in treating multiple gingival recessions using VISTA technique. These reductions in mean RD may be attributed to the sub-periosteal incision made mesial to the defect, reducing the possibility of traumatising the gingiva of the teeth being treated.

Significant improvement in the WKT and TKG was observed from baseline 6 months in the VISTA group which was in agreement with the previous studies. This increase in the WKG and TKG might be due to the placement of PRF, which have been shown to accelerate fibroblast proliferation and increase tissue vascularization, which could have also been the probable reason behind the improved parameters.¹⁸

The mean percentage of RC for the VISTA group obtained in our study was 96% which was similar to that of earlier studies done by Chenchev et al¹⁰ which was 87.10 ± 8.92 at the end of 6 months, and by Subbareddy BV et al¹¹ which was 83 ± 8.76 at the end of 6 months. 100% root coverage was noted at the end of 6 months in a case series conducted by Surbhi G et al.¹⁵

In the current study, CRC obtained was achieved in 83.3% of the defect sites which was contrary to the study conducted by Subbareddy BV et al¹¹ which was 30.3%, and in agreement with the study conducted by Aya Kamal et al¹⁷ which was 82%, Rutuja et al¹⁶ which was 91.5%, S Garg et al¹⁵ which was 62.5%.

It has been well established that Millers' class I and II recessions provide the best choice for CRC.¹⁹ It is also vital that the adjacent embrasures are adequately filled by interdental papilla. It was very well ensured that all the treated sites in the study were free from trauma from occlusion which also might be the strong affirmatory factor behind the success of root coverage.

However, in the Saddle group, significant reductions of PPD were observed from baseline to 6 months, improvement in CAL from baseline to 6 months. Statistically significant reductions in mean RD, RW from baseline to 6 months were observed.

WKT, TKG were improved significantly from baseline to 6 months in the Saddle group. These results are in agreement with the study conducted by Rajeswari Selvaraj et al.⁶ in isolated GR, wherein they observed PPD reduction from 1.5 ± 0.53mm at baseline to 1.2 ± 0.42mm at 6 months, and a reduction in CAL from 3.95 ± 0.83mm at baseline to 1.35 ± 0.53mm at 6 months, reduction in RD from 2.45 ± 0.60mm at baseline to 0.15 ± 0.24mm at 6 months and RW from 1.15 ± 0.10mm at baseline to 0.41 ± 0.21 at 6 months.

In the current study, the mean percentage of the root coverage was 86.81 ± 2.43 and is similar to an earlier study⁶ which was 98%. In the present study, CRC was achieved in 63% of the defect sites in the Saddle group. This improvement in parameters can be implied to the extension of a 2mm submarginal incision obliquely avoiding the vertical incision and promoting less bleeding and optimal healing. This technique also helps in maintaining papillary integrity and little trauma to the neighbouring uninvolved tooth.⁶

Surprisingly on the intergroup comparison, statistical significance was observed in the VISTA group in relation to RD, RW, WKT, and TKG when evaluated by comparing to the Saddle group. This can be due to the minimal incision that was placed subperiosteally with a wide dissection of the soft tissues to eliminate possible pull.

The mean percentage of RC was more in the VISTA group than compared to the Saddle group. In the Saddle flap technique, the split-full-split thickness flap is elevated which might hinder blood supply, resulting in post-operative shrinkage of the flap and this may be due to the less percentage of RC in the Saddle flap technique.⁷

All the surgical procedures were done under a surgical operating microscope, which implies a refinement of conventional surgical techniques through delicate tissue manipulation, precise incisions, uniform flap division, and primary wound closure, which led to a more comfortable postoperative period, faster healing, and more predictable outcomes.²⁰

Strengths of the study:

•As the entire study was subjected to a surgical operating microscope the overall benefits of enhanced wound healing leading to patients’ comfort, was the key feature which could be attributed to the placement of precise incisions, minimal movements and enhanced ergonomic benefits. This study is the first of its kind to conduct a split-mouth study with a sample size of 20 patients including 108 Millers class 1 or class 2 recessions.

Limitations:

•There is only one study in the literature anticipating the predictability of the saddle flap technique, which is limited to isolated recessions. Further research and long-term studies are needed to evaluate the efficacy of the saddle flap technique to evaluate the stability of the treatment.

Overall, both the techniques showed satisfactory results, but comparatively VISTA with PRF gave superior results. However, long-term follow-up studies are required to evaluate the efficacy of the saddle flap technique, as there is only one study in the literature that was confined to isolated recessions.

Data availability statement: All the data related to the current research is available in the manuscript. No additional information is required to be available in other sources.

Ethics approval statement: The study was approved, and ethical clearance was obtained from the Institutional ethical committee with RefNo: IECVDC/2021/PG01/PI/IVV/18

Patient consent statement: Before the start of research the study design was explained to all the participants and written informed consent was obtained from all the participants.

Permission to reproduce material from other sources: All the data provided in the article is original and not from any other sources.

Author contributions:

Conceptualization: Sravanthi Vundavalli, Gautami S Penmetsa, Mohan Kumar Pasupuleti

Methodology: Sravanthi Vundavalli, Gautami S Penmetsa, Mohan Kumar Pasupuleti, Anusha B

Investigation: Sravanthi Vundavalli, Gautami S Penmetsa, NVS Sruthima G

Writing - original draft preparation: Sravanthi Vundavalli, Gautami S Penmetsa

Writing - review and editing: Gautami S Penmetsa, Anusha B

Resources: Dinesh Gera

Supervision: Gautami S Penmetsa, NVS Sruthima G

Clinical trial registration: The trial is approved under Clinical Trials Registry - India [CTRI/2021/07/034844]

Source of funding: There is no source of funding or grant from any of the organization or institute or individual towards this study.

A written and informed consent was obtained from study participants.

Conflict of interest: The other authors do not have any financial interests, either directly or indirectly, in the products or information listed in the paper.

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Table 1

Comparison of different parameters within Saddle group.
Parameter	Time intervals	Mean	SD	P value
Plaque index	Baseline	1.6672	.25062	0.000*^a
	3 months	.6702	.09579
	6 months	.4393	.08472
Gingival index	Baseline	1.5769	.10346	0.000*^a
	3 months	.6217	.11411
	6 months	.3965	.06507
Probing pocket depth	Baseline	2.7509	.28902	0.000*^a
	3 months	2.4024	.30214
	6 months	2.0359	.33726
Clinical attachment level	Baseline	5.5472	.80712	0.000*^a
	3 months	3.3098	.62070
	6 months	2.6020	.56028
Recession depth	Baseline	2.0741	.75490	0.000*^a
	3 months	.4907	.57863
	6 months	.3056	.44949
Recession width	Baseline	4.6111	1.55911	0.000*^a
	3 months	1.7222	2.07789
	6 months	1.7222	2.07789
Width of Keratinized Tissue	Baseline	2.7778	.92485	0.000*^a
	3 months	3.2130	.63396
	6 months	3.2130	.63396
Thickness of keratinized gingiva	Baseline	.8717	.03725	0.000*^a
	3 months	1.3506	.12096
	6 months	1.4596	.10946
Pain VAS score	During surgery	.2593	.44234	0.209^b
Pain VAS score	After surgery	.3333	.47583	0.209^b
Dentinal hypersensitivity	Pre surgery	8.5185	1.31380	0000*^b
Dentinal hypersensitivity	Post surgery	1.1667	.96642	0000*^b
Root coverage	-	81.5407	23.03850	-
*statistically significant, ^aRepeated measures of ANOVA, ^b Paired t test

Table 2

Comparison of different parameters within Vista group
Parameter	Time intervals	Mean	SD	P value
Plaque index	Baseline	1.6597	.25141	0.000*^a
	3 months	.6458	.07423
	6 months	.4322	.07358
Gingival index	Baseline	1.5778	.09880	0.000*^a
	3 months	.5909	.10246
	6 months	.4196	.06092
Probing pocket depth	Baseline	2.7438	.28949	0.000*^a
	3 months	2.4247	.30352
	6 months	2.0685	.33658
Clinical attachment level	Baseline	5.4887	.64440	0.000*^a
	3 months	3.2824	.61077
	6 months	2.9655	.53362
Recession depth	Baseline	2.1182	.65237	0.000*^a
	3 months	.1636	.46203
	6 months	.1636	.46203
Recession width	Baseline	4.9636	1.46520	0.000*^a
	3 months	.7091	1.89221
	6 months	.7091	1.89221
Width of Keratinized Tissue	Baseline	2.1818	.82979	0.000*^a
	3 months	2.6091	.56676
	6 months	2.6091	.56676
Thickness of keratinized gingiva	Baseline	.8842	.05377	0.000*^a
	3 months	1.5756	.09587
	6 months	1.6800	.06915
Pain VAS score	During surgery	.2182	.41682	1.000
Pain VAS score	After surgery	.2182	.41682	1.000
Dentinal hypersensitivity	Pre surgery	8.6000	1.35537	0000*^b
Dentinal hypersensitivity	Post surgery	1.1091	1.01238	0000*^b
Root coverage	-	94.2545	16.00372	-
*statistically significant, ^aRepeated measures of ANOVA, ^b Paired t test

Table 3

Inter group comparisons of different parameters
Parameter	Time intervals	Group	Mean	SD	P value
Plaque index	Baseline	Saddle	1.6669	.24830	.881
	Baseline	Vista	1.6597	.25141	.881
	3 months	Saddle	.6704	.09491	.134
	3 months	Vista	.6458	.07423	.134
	6 months	Saddle	.4375	.08499	.729
	6 months	Vista	.4322	.07358	.729
Gingival index	Baseline	Saddle	1.5789	.10363	.955
		Vista	1.5778	.09880	.955
	3 months	Saddle	.6235	.11383	.118
		Vista	.5909	.10246	.118
	6 months	Saddle	.3985	.06626	.085
		Vista	.4196	.06092
Probing pocket depth	Baseline	Saddle	2.7555	.28830	.833
		Vista	2.7438	.28949
	3 months	Saddle	2.4071	.30134	.760
		Vista	2.4247	.30352
	6 months	Saddle	2.0353	.33415	.604
		Vista	2.0685	.33658
Clinical attachment level	Baseline	Saddle	5.5373	.80301	.727
		Vista	5.4887	.64440
	3 months	Saddle	3.3162	.61674	.773
		Vista	3.2824	.61077
	6 months	Saddle	2.6093	.55765	.001*
		Vista	2.9655	.53362
Recession depth	Baseline	Saddle	2.0727	.74795	.735
		Vista	2.1182	.65237
	3 months	Saddle	.4818	.57706	.002*
		Vista	.1636	.46203
	6 months	Saddle	.3000	.44721	.119
		Vista	.1636	.46203
Recession width	Baseline	Saddle	4.5818	1.55981	.189
		Vista	4.9636	1.46520
	3 months	Saddle	1.6909	2.07161	.011*
		Vista	.7091	1.89221
	6 months	Saddle	1.6909	2.07161	.011*
		Vista	.7091	1.89221
Width of Keratinized Tissue	Baseline	Saddle	2.7545	.93230	.061
		Vista	2.1818	.82979
	3 months	Saddle	3.1909	.64901	.000*
		Vista	2.6091	.56676
	6 months	Saddle	3.1909	.64901	.000*
		Vista	2.6091	.56676
Thickness of keratinized gingiva	Baseline	Saddle	.8720	.03699	.169
		Vista	.8842	.05377
	3 months	Saddle	1.3518	.12020	.000*
		Vista	1.5756	.09587
	6 months	Saddle	1.4618	.10965	.000*
		Vista	1.6800	.06915
Pain VAS score	During surgery	Saddle	.2545	.43962	.657
		Vista	.2182	.41682
	After surgery	Saddle	.3273	.47354	.202
		Vista	.2182	.41682
Dentinal hypersensitivity	Pre surgery	Saddle	8.5091	1.30345	.721
		Vista	8.6000	1.35537
	Post surgery	Saddle	1.1636	.95769	.772
		Vista	1.1091	1.01238
Root coverage		Saddle	81.8764	22.95950	.001*
Root coverage		Vista	94.2545	16.00372
*statistically significant, Paired sample t test

No competing interests reported.

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Comparison of Saddle flap technique versus Vestibular Incision Sub-Periosteal Tunnel Access (VISTA) technique with advanced platelet rich fibrin (A-PRF), for treatment of multiple gingival recessions under surgical operating microscope – A Split Mouth Study.

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Discussion

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Limitations:

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