|Year : 2015 | Volume
| Issue : 6 | Page : 609-612
|Comparison of semilunar coronally advanced flap alone and in combination with button technique in the treatment of Miller's Class I and II gingival recessions: A pilot study
Rajat Bhandari1, Ranjit Singh Uppal2, Karanprakash Singh Kahlon3
1 Department of Oral and Maxillofacial Pathology, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab, India
2 Department of Periodontology and Oral Implantology, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab, India
3 Department of Public Health Dentistry, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab, India
Click here for correspondence address and email
|Date of Submission||21-Nov-2014|
|Date of Decision||09-Dec-2014|
|Date of Acceptance||08-Jan-2016|
|Date of Web Publication||18-Feb-2016|
| Abstract|| |
Background: Gingival recession (GR) is one of the most common esthetic and functional concerns associated with periodontal disease. A variety of surgical procedures has been introduced to the field of cosmetic periodontology for the treatment of GR.
Aim: To evaluate and compare the clinical outcome of semilunar coronally advanced flap (SCAF) with and without button technique in the treatment of Miller's Class I and II GRs.
Study Design: A total of 12 subjects with bilateral single Miller's Class I and II recession were selected for the study. Split mouth design was used.
Materials and Methods: Surgical sites were randomly divided into test and control groups. In control sites, SCAF alone was done whereas in test site, a combination of SCAF and button technique was performed. The clinical parameters including GR, periodontal pocket depth, clinical attachment level (CAL), and width of keratinized gingiva were recorded at baseline and 6 months postsurgery. Data so collected were put to statistical analysis.
Statistical Analysis: Student's t-test was used to find significance of parameters between baseline and 6 months. For inter-group comparisons paired t-test was performed.
Results: Statistically significant improvements were recorded in both groups from baseline to 6 months. Inter-group comparison yielded statistically significant differences in GR and CAL in favor of test group.
Conclusion: Combination of SCAF and button technique resulted in statistically significant improvements in clinical parameters as compared to SCAF alone. Future clinical studies with much larger sample size and longer follow-up periods are warranted.
Keywords: Button technique, gingival recession, root coverage, semilunar coronally advanced flap
|How to cite this article:|
Bhandari R, Uppal RS, Kahlon KS. Comparison of semilunar coronally advanced flap alone and in combination with button technique in the treatment of Miller's Class I and II gingival recessions: A pilot study. Indian J Dent Res 2015;26:609-12
Gingival recession (GR) is one of the most common aesthetic and functional concerns associated with periodontal disease.  It is the displacement of soft tissue margin apical to cementoenamel junction (CEJ)  and is very common in patients having good oral care standards as well.  It may be associated with inflammatory periodontal disease, mechanical trauma or with the presence of factors such as tooth malposition, root prominences, aberrant frenulum attachment, and orthodontic tooth movements. , It is esthetically undesirable condition that may lead to root dentine hypersensitivity and root caries.  A variety of surgical procedures has been introduced to the field of cosmetic periodontology which include free gingival grafts, guided tissue regeneration, pedicle flaps such as semilunar coronally advanced flap (SCAF), lateral sliding flap, and double papilla flap for treatment of GR. , SCAF was introduced in 1986 by Tarnow.  Major advantage of this flap technique are that no sutures are required because of lack of tension on the tissue being coronally positioned. However, concerns regarding flap stability without sutures have been raised in previous studies particularly in teeth with highly scalloped gingiva. Thus various modifications of this flap technique have been introduced.  A previous study had compared SCAF in treatment of GR with and without tissue adhesive. Tissue adhesive was used with an aim to improve stability of the flap.  The objective of our study was to evaluate and compare clinical outcome of SCAF with and without button technique in treatment of Miller's Class I and II GR.
|How to cite this URL:|
Bhandari R, Uppal RS, Kahlon KS. Comparison of semilunar coronally advanced flap alone and in combination with button technique in the treatment of Miller's Class I and II gingival recessions: A pilot study. Indian J Dent Res [serial online] 2015 [cited 2019 May 21];26:609-12. Available from: http://www.ijdr.in/text.asp?2015/26/6/609/176925
| Materials and Methods|| |
The study was conducted in Genesis Institute of Dental Sciences and Research, Ferozepur, India. The clearance for the study was granted by the Institutional Ethical Committee. Twelve subjects with bilateral single Miller's Class I and II recession defects were selected for the study. Selected subjects were nonsmokers, systemically healthy, and had acceptable levels of oral hygiene standards. A written informed consent was obtained from all the participants. Millers's Class III and IV recession defects, smokers, teeth with cervical caries or restorations were excluded. Selected subjects underwent Phase I periodontal therapy. The surgical sites were randomly divided into control group and test group by coin flip method. In control site, SCAF was performed using Tarnow's technique. This flap was advanced coronal to CEJ as far as possible and positioned accordingly without any tension. A gentle pressure was applied to ensure proper adaptation and stabilization of flap. Periodontal dressing was placed. In test sites, same technique was followed, but the flap was stabilized by suture using button technique. Periodontal dressing was placed. Sutures were removed after 10 days [Figure 1], [Figure 2], [Figure 3], [Figure 4]. All the subjects were instructed to discontinue tooth brushing around the surgical sites for 3 weeks. During this period, they were advised to use 0.2% chlorhexidine twice daily. Clinical parameters including GR, clinical attachment level (CAL), probing pocket depth (PPD), and width of keratinized gingiva (WKT) were recorded at baseline (just before surgery), and after 6 months. To ensure minimal operator bias, clinical parameter recording and surgical procedures were performed by separate operators.
Descriptive statistical analysis has been carried out in the present study. Significance is assessed at 5% level of significance. Student's t-test has been used to find the significance of clinical parameters from baseline to 6 months. For inter-group comparisons, paired t-test was performed.
| Results|| |
All the subjects completed the follow-up. There was no postoperative complication in any of the subjects. Healing was uneventful. Mean plaque scores were maintained throughout the study period indicating good standard of plaque control. Mean and standard deviation of clinical parameters for both groups at baseline and after 6 months are shown in [Table 1] and [Table 2], respectively.
A statistically significant reduction in GR was observed in both test group and control group from baseline to 6 months. An overall reduction of 2.35 ± 0.22 mm was reported in test group, whereas it was 1.38 ± 0.17 for the control group. When reduction in GR was compared among groups, a statistically significant result was obtained in favor of test group (P < 0.001) [Table 3]. CAL gain of 2.92 ± 0.21 mm and 2.17 ± 0.13 mm was obtained in test and control group, respectively, after 6 months. Inter-group comparison for CAL yielded a statistically significant result, which was in favor of test group (P = 0.024) [Table 3]. In test group, a mean PPD reduction of 0.42 ± 0.07 mm was recorded after 6 months. For control group, mean reduction of 0.08 ± 0.27 mm in PPD was reported. Statistically nonsignificant results were obtained on inter-group comparison of PPD (P = 0.73) [Table 3]. An increase of 0.58 ± 0.01 mm in keratinized gingiva was reported after 6 months in test groups, which was statistically significant. For control group, a statistically significant gain of 0.33 ± 0.01 mm was reported in keratinized gingiva.
| Discussion|| |
The changing face of dentistry has ushered in a new era where the present day aim is to have a healthy and esthetically pleasing dentition. Thus, esthetics has become an essential criterion of the overall treatment plan in dentistry, which comprises a healthy and beautiful smile at any age.  GR is of great esthetic concern associated with periodontal disease. Coronally advanced flap is one of the most reliable techniques for treatment of single GRs, and different surgical flap designs have been proposed over time increasing the possibility of achieving root coverage. , SCAF has various advantages such as no tension on flap, no suture requirement, and no vestibular shortening, and moreover, papilla remains unchanged. 
The present study was done to compare the clinical outcome of SCAF alone and in combination with button technique in the treatment of GR. In button technique, orthodontic buttons/brackets are used as a passive component for holding sutures so as to provide maximum stability to the flap in coronally displaced position.  A previous study had compared SCAF in the treatment for GR with and without tissue adhesive and concluded that SCAF followed by application of EPIGLU is an effective procedure for root coverage.  Some other studies had also warranted the fixation and stabilization of flap for attaining better results. ,
In the present study, a split mouth designed was used, and sites were randomly assigned to two treatment groups (test and control groups). Eight out of 12 sites in test group gained complete root coverage whereas in control group seven sites achieved complete root coverage. These findings are in agreement with previous studies of Bittencourt et al., 2006,  Bittencourt et al., 2009.  A statistically significant reduction of 2.35 ± 0.22 mm and 1.38 ± 0.17 mm was recorded in GR in both test and control group, respectively. Decrease in GR may be due to the formation of new connective tissue attachment and epithelial attachment.  Inter-group comparison yielded statistically significant results in favor of test group. This may be attributed to the use of button technique in test sites as suturing the flap with button offer better stabilization in desired location.  Less amount of recession reduction in control group may also be due to lack of stability of coronally positioned flap to counteract wound contraction. This may also be the reason for greater gain in CAL in test sites as compared to control sites. Gain in CAL was statistically significant for both the groups after 6 months which was in accordance to previous clinical trials. , Inter-group comparisons revealed a statistically nonsignificant results for PPD. A statistically significant increase in width of keratinized gingiva was reported in both groups after 6 months, but inter-group comparison revealed a statistically nonsignificant difference. In SCAF granulation tissue that fills the semilunar area will generally turn into the same type of tissue that was present before repositioning the tissue. The increase in width of keratinized gingiva is due to the tendency of coronally displaced mucogingival line, to regain its original position. Plaque scores for both groups remained constant throughout the study period as the patients were reinforced towards better oral hygiene at regular intervals. As indicated by the results, many parameters were shown to have statistical significance, but the clinical significance is also an important factor that should also be taken in consideration while evaluating the success of a procedure.
Some previous studies have compared coronally advanced flap with button technique and reported better results with the use of an orthodontic button. ,,, To best of our knowledge, this is the first study which compared SCAF with and without button technique. Limitations of this study included smaller sample size and short follow-up period (6 months). The present study also hinted us regarding the use of a combination of SCAF and button in lower teeth for root coverage as well. As SCAF is a simple procedure in comparison to highly expensive alternatives, so future studies with larger sample size and longer follow-up period are warranted for better exploration of the findings.
| Conclusion|| |
The combination of SCAF and button technique resulted in statistically significant improvements in reduction of GR and CAL gain as compared to SCAF alone. Future clinical studies with much larger sample size and longer follow-up periods are warranted.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Babuz SK, Agila S. Root coverage with a free gingival autograft using a diade laser. J Dent Lasers 2012;6:72-5.
Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures: A systematic review. J Clin Periodontol 2008;35 8 Suppl: 136-62.
Chambrone L, Sukekava F, Araújo MG, Pustiglioni FE, Chambrone LA, Lima LA. Root-coverage procedures for the treatment of localized recession-type defects: A Cochrane systematic review. J Periodontol 2010;81:452-78.
Fatima Z, Bey A, Mian F, Zia A. Managment of gingival recession using coronally advanced flap combined with bracket application. A case report. J Adv Med Dent Scie 2014;2:171-5.
Glover ME. Periodontal plastic and reconstructive surgery. In: Rose LE, Mealay BL, Genco RJ, Cohen DW, editors. Periodontics: Medicine, Surgery and Implants. ElsevierMosby, St. Louis; 2004. p. 406-87.
Haghighat K. Modified semilunar coronally advanced flap. J Periodontol 2006;77:1274-9.
Ozcelik O, Haytac MC, Seydaoglu G. Treatment of multiple gingival recessions using a coronally advanced flap procedure combined with button application. J Clin Periodontol 2011;38:572-80
Kumar GV, Murthy KV. A comparative evaluation of subepithelial connective tissue grafts (SCTG) versus platelet concentrate graft (PCG) in the treatment of gingival recession using coronally advanced flap technique: A 12 month study. J Indian Soc Periodontol 2013;17:771-6.
Tarnow DP. Semilunar coronally repositioned flap. J Clin Periodontol 1986;13:182-5.
Moka LR, Boyapati R, Srinivas M, Swamy N, Swarna C, Putcha M. Comparison of coronally advanced and semilunar coronally repositioned flap for the treatment of gingival recession. J Clin Diag Res 2014;8:zc04-8.
Jahangirnezhad M. Semilunar coronally repositioned for treatment of gingival recession with and without tissue adhesive: A pilot study. J Dent Tehran Univ Med Sci 2006;3:36-9.
Peeran SW, Thirunervannan M, Mugrabhi M. Semilunar coronally repositioned flap. Arch Int Surg 2013;3:166-8.
Ravon NA, Handelsman M, Levine D. Multidisciplinary care: Periodontal aspects to treatment planning the anterior esthetic zone. J Calif Dent Assoc 2008;36:575-84.
Serino G, Wennström JL, Lindhe J, Eneroth L. The prevalence and distribution of gingival recession in subjects with a high standard of oral hygiene. J Clin Periodontol 1994;21:57-63.
Maroo S, Grover S, Luthra S. Button assisted coronally advanced flap: An innovative orthoperio amalgamation. J Indian Orthod Soc 2014;48:129-33.
Tözüm TF, Dini FM. Treatment of adjacent gingival recessions with subepithelial connective tissue grafts and the modified tunnel technique. Quintessence Int 2003;34:7-13.
Bittencourt S, Del Peloso Ribeiro E, Sallum EA, Sallum AW, Nociti FH Jr., Casati MZ. 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;77:174-81.
Bittencourt S, Ribeiro Edel P, Sallum EA, Sallum AW, Nociti FH, Casati MZ. Semilunar coronally positioned flap or subepithelial connective tissue graft for the treatment of gingival recession: A 30-month follow-up study. J Periodontol 2009;80:1076-82.
Tugnait A, Clerehugh V. Gingival recession-its significance and management. J Dent 2001;29:381-94.
Wennström JL. Mucogingival therapy. Ann Periodontol 1996;1:671-701.
Wennström JL, Zucchelli G. Increased gingival dimensions. A significant factor for successful outcome of root coverage procedures? A 2-year prospective clinical study. J Clin Periodontol 1996;23:770-7.
Dr. Ranjit Singh Uppal
Department of Periodontology and Oral Implantology, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]
| Article Access Statistics|
| Viewed||1804 |
| Printed||31 |
| Emailed||0 |
| PDF Downloaded||164 |
| Comments ||[Add] |