INTRODUCTIONIn modern medicine, marginal gingival tissuerecession is becoming a common concern of the patient often requiring treatmentfor aesthetic reasons. Deep recessions often affecting the anterior teeth inyoung age group is significantly associated with patient request for treatment.
The displacementof the soft tissue margin apical to the cementoenamel junction (CEJ) not only exposes the root surface but also impairsthe aesthetics. Marginal gingival tissue recession is associated with severalfactors with complex etiology. Traumatictooth brushing is considered as one of the main causative factor for the developmentof recessions commonly creating a wedge shaped defect at cervical area. Afive year study showed that with the level of oral hygiene education,probability of gingival recession also increases.1However,the exact mechanism of gingival recession is not well understood. Risk factors consideredto be associated with gingival recession include toothmalposition, path of eruption, tooth shape, profile and position in the arch,alveolar bone dehiscence, muscle attachment and frenal pull, periodontaldisease and treatment, iatrogenic restorative or operative treatment, improperoral hygiene methods (e.g. tooth brushing, floss, interproximal brush) andother self-inflicted injuries (e.
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g. oral piercing) while the most importantfactor increasing the risk of gingival recession may be a thin gingival biotypewhere a delicate marginal tissue is covering a non-vascularized root surface.4PREVALENCE/FREQUENCYGingival recession of 1 mm or more at one or moresites is one of the common finding seen in More than 50% of the population.
Itis prevalent in patients with good as well as poor oral hygiene. Buccalsurfaces are often involved in patients with good oral hygiene, whereas alltooth surfaces get affected in patients suffering from periodontal disease orafter periodontal treatment. 5,6,7Gingival recession has also been linked toethnicity. It has been seen that Mexican Americans and non-Hispanic whites exhibited lesser prevalenceand extent of gingival recession compared to non-Hispanic blacks.7Refuting this observation no difference in terms of prevalence of gingivalrecession was found between whites and non-whites in an epidemiological study.3The extent and prevalence of gingival recessionincreases with age. As compared to females, males have shown to exhibit greaterlevels of recession.
3 The association of tobacco smoking in the etiology andprevalence of recession as discussed by several authors is controversial.However, more extensive recessions were seen in smokers than non-smokers insome studies.3CLASSIFICATIONA clinical classification of gingival recession proposedby Miller (1985) in four categories according to the relationship with the mucogingivalline and interproximal bone is widely accepted and a predictive value for rootcoverage in each class has been proposed.9 This classification is as follows -Class I: Marginal tissue recession not extending to the mucoginvival junction (MGJ)with no interdental bone lossClass II: Marginaltissue recession extending to or beyond the MGJ with no interdental bone loss Class III: Marginal tissue recession extending to orbeyond the MGJ with bone or soft tissue loss in the interdental area or malpositioningof the teethClass IV: Marginal tissue recession extending to orbeyond the MGJ and bone or soft tissue loss in the interdental area and/or severemalpositioning of teeth Although in this classification some importantfactors such as biotype, root prominency and supporting bone were notconsidered, it is used in most studies considering its use in communication andsimplicity.Treatment of Gingival RecessionFormerly occasional attempts were made to cover thedenuded root surfaces solely for the cosmetic purpose and to decrease the rootsensitivity. One of the main concern in not attempting these cosmetic surgerieswas the poor predictability of the treatment outcome. Hence the treatment ofgingival recession was mainly focused on halting the progression of gingivalrecession, preserving a bandof keratinized tissue thus enhancing plaque control, decreasing frenum pull andpreventing post-orthodontic and post-prosthetic marginal tissue recession.
With the coming years focus was shifted and objectives were modified for thebenefit of patient. Regeneration of lost tissue along with arresting theprogression of disease became the aim of gingival recession treatment.Considering the higher aesthetic concern the goal of root coverage procedure now is not only toobtain full root coverage of a denuded root but also to blend the mucosa and orkeratinized gingiva around the recession defect in most aesthetic way andreduced root sensitivity without any residual periodontal pocket.The use of predictableperiodontal surgical procedure determines the outcome of treatment. The term predictableperiodontal surgery was first proposed by Miller in 1988 comprising different surgical techniques intended to correct and prevent anatomical,developmental, traumatic or plaque disease-induced defects of the gingiva,alveolar mucosa or bone.Since thebeginning of the 20th century, various surgical procedures have been proposedfor achieving root coverage. Use of pedicle or free soft tissuegrafts to cover denuded root surfaces was first described by Younger in 1902, Harlan in 1906 andRosenthal in 1911.
10 These techniques were abandoned for a long timeup to the end of the 1950s. . From these decades laterally repositioned flaps, free gingival grafts (FGG), subepithelialconnective tissue grafts (SCTG) and CAFs have been used to improvevarious clinical parameters such as recession depth (RD), clinical attachment level (CAL) and KTW.Plastic periodontal procedures used for rootcoverage are usually classified as pedicle soft tissue graft (lateral slidingflap and its modifications) and free soft tissue grafts. Coronally positioned or coronallyadvanced flap (CAF) procedure is based on the coronal shift of softtissue present apically to the denuded root surface which can be used as analternative to lateral slidingflap.11,12 Applicability of this procedure for the treatmentof multiple recession type defects makes it an preferable modality. Tarnow(1986) suggested a semilunar approach in shallow single recessions.
13CAF may be used in combination with other graftingmaterials such as connective tissue graft (CTG),4 barrier membranes,14EMDs,15 acellular dermal matrix (ADM)16 or other. Cairo et al. (2008) in a systematic review stated that the recession reduction in Miller’sClass I and II recession defects and the probability of obtaining complete root coverageincreases with the use of CTG and the enamel matrix derivative(EMD) in combination with CAF procedure.
17 The avascularnature of the root surface poses a great challenge in achieving complete rootcoverage of exposed root by hamperingsurvival of the most graft. Accordingly, the difficulty is increased for theclinician with a wider area of root exposure.Multiple adjacentrecession type defects (MARTD) differs inlocalized recession type defects in many aspects. Not only the extensiveavascular exposed root surface but certain anatomical factors such as thin biotype, decreased keratinizedtissue width (KTW), root prominence and root proximity difficult the choice ofsurgical treatment used for the treatment of MARTD.
Systematic reviews by Roccuzzoet al. (2002), Cheng et al. (2007) and Oates et al.
(2003) have extensively reviewedthe outcome of the different treatment modalities used in the treatment ofisolated gingival recession type defects. On the contrary, little scientificliterature is available regarding treatment modalities used for treating MARTD.The different techniques used in the treatment ofMARTD include CAF,18a supraperiosteal envelope technique in combination with CTG,19 or its evolution as atunnel technique.20 To reduce the morbidity of the technique, additionof biological factors such as; EMD;21,22 platelet rich plasma (PRP);23platelet rich fibrin (PRF)24 have been suggested so as to increasethe predictability of the root coverage treatment.PRF……The success and predictability of the therapydepends on various patient related, dentist-related, site-related andtechnique-related factors. In a technical manner; ?ap thickness, ?ap tensionbefore suturing and the position of the gingival margin (GM) at the end of thesurgery appeared to be fundamental in achieving complete root coverage (CRC).
Aroca et al. (2010) evaluated andcompared the efficacy of CAF and PRF membrane with CAF alone in which they gavesuspended sutures in the interproximal spaces held in the position with compositestops at contact point this facilitating the more coronal displacement of the flap.28At present, several methods are available forevaluating the soft tissue thickness.
The use of needles and periodontal probeshas been documented since the 1970s. To avoid the need for local anesthesia,non-invasive techniques involving ultrasonic devices and computed tomography(CT) have also been studied. However, these approaches have been criticized foreither questionable reliability or additional radiation risk. On the otherhand, the accuracy of cone-beam computed tomography (CBCT) for both soft tissueand bone thickness measurements in the maxillary anterior region has recentlybeen confirmed, and a simple technique is introduced by Januário AL (2008) formeasuring the gingival tissue and dimension of dentogingival unit by CBCT.29The literature search revealed that there are fewclinical studies that have been carried out to check the efficacy of CAF withPRF membrane.
The preliminary results appear to be encouraging in terms of rootcoverage, and so, it was felt necessary to further study this material in thetreatment of MARTD. Also, CBCT isone of the latest methods of evaluation and till date there are no studies inthe literature that have used CBCT for evaluating root coverage after CAF ingingival recession. So, the present study was planned to evaluate and comparethe effectiveness of CAF with orthodontic button application with and withoutPRF membrane in the treatment of MARTD clinically and radiographically by CBCT.