| Abstract|| |
Background: There has been no study to date comparing the effectiveness and predictability of transpositional flap (TF) with that of the gold standard connective tissue graft (CTG) for root coverage. This study was performed during 2001-2002 at Government Dental College and Hospital, Mumbai India.
Objectives: To evaluate the effectiveness and predictability of TF vs CTG for coverage of Miller's class I and class II facial marginal tissue recession defects.
Materials and Methods: Twenty cases fulfilling the selection criteria were identified and randomly allotted to two groups: group I (TF, 10 cases) and group II (CTG, 10 cases). Registered parameters included plaque index (PI), defect-specific plaque index (DPI), gingival index (GI), defect-specific gingival index (DGI), recession depth (RD), recession width (RW), probing depth (PD), attachment level (AL), width of keratinized tissue (KT), percentage defect coverage (DC), and percentage root coverage (RC).
Results: For group I: preoperative PI, DPI, GI, DGI, RD, PD, KT, and RC were 0.38±0.14, 1.1±0.57, 0.02±0.02, 0.36±0.29, 4.45±2.0, 1.5±0.71, 1.45±1.30, and 68.57±14.36, respectively; the corresponding postoperative values were 0.38±0.11, 0.36±0.29, 0.01±0.01, 0.10±0.16, 3.2±2.44, 1.1±0.32, 2.65±1.03, and 77.40±17.23. For group II the preoperative PI, DPI, GI, DGI, RD, PD, KT, and RC were 0.77±0.5, 1.53±0.63, 0.12±0.18, 0.59±0.62, 4.95±1.59, 1.9±0.74, 0.50±1.08, and 65.05±11.22, respectively, and the corresponding postoperative values were 0.49±0.32, 0.8±0.50, 0.03±0.53, 0.03±0.10, 0.90±0.88, 1.2±0.42, 4.4±1.07, and 93.65±6.18, respectively.
Conclusion: The TF technique for coverage of single tooth buccal recession defects of Miller's class I and class II types in mandibular anterior teeth was neither effective nor predictable in defect coverage and defect elimination.
Keywords: Connective tissue graft, effectiveness and predictability, root coverage, transpositional flap
|How to cite this article:|
Baghele ON, Pol DG. An evaluation of the effectiveness and predictability of transpositional flap vs connective tissue graft for coverage of Miller's class-I and class-II facial marginal tissue recession lesions: A clinical study. Indian J Dent Res 2012;23:195-202
Individuals today are increasingly conscious of their personal appearance and smile. Facial disproportions and unsightly dentogingival relationships adversely affect esthetics and thus the personality. This is one of the reasons for carrying out root coverage procedures. The other reasons are control of root hypersensitivity, prevention of root caries, cervical abrasion, fear of tooth loss and possible pulpal pathology, and facilitation of plaque control measures.
|How to cite this URL:|
Baghele ON, Pol DG. An evaluation of the effectiveness and predictability of transpositional flap vs connective tissue graft for coverage of Miller's class-I and class-II facial marginal tissue recession lesions: A clinical study. Indian J Dent Res [serial online] 2012 [cited 2021 Jul 29];23:195-202. Available from: https://www.ijdr.in/text.asp?2012/23/2/195/100425
A new term - marginal tissue recession - was suggested at the 1996 World Workshop in Clinical Periodontics in lieu of gingival recession; and it was defined as 'displacement of the soft tissue margin apical to the cementoenamel junction.' , Marginal tissue recession implies the loss of periodontal connective tissue along with root cementum and alveolar bone. 
The first person to perform a root coverage procedure was most probably WJ Younger in 1902. He reportedly transplanted gingival tissue from behind the third molar to an extensive area of recession in an upper cuspid.  Since then, several procedures were innovated and executed and have had their reliability assessed on the basis of various criteria. One such procedure by Bahat et al. provided a modification for the papillary pedicle graft as described by Pennel et al.,  Hattler,  and Cohen and Ross.  Bahat et al.  transposed the pedicle from the soft tissue adjacent to the recession to about 90°, horizontally over the recession, in an attempt to completely cover the denuded root surface.
After various studies showing its effectiveness, the connective tissue graft (CTG) procedure for root coverage almost became a gold standard in terms of success and esthetics. In 1994, Bruno  described modifications to the original Langer and Langer technique.  Bruno did away with the use of vertical incisions at the recipient site. He described a different technique for securing the graft from the palate and included periosteum as part of the CTG.
The subject of chemical root biomodification has always been controversial. Despite various positive claims, ,,,, the 1996 World Workshop  concluded that available evidence demonstrated that there is no difference in root coverage following the use of root modification agents, e.g., citric acid or tetracycline hydrochloride. Evidence suggests that root modification affects the nature of the attachment. Camargo et al. also stated that whereas mechanical root preparation is highly relevant to the success of root coverage procedures with soft tissue grafts, there is little benefit to be gained by performing chemical root treatment in addition to mechanical scaling and root planing.
Greenwell et al. were the first to define specific parameters to decide the usefulness of a surgical root coverage procedure. They termed these parameters as effectiveness and predictability (a predictable procedure being one that would almost always achieve the desired result). These parameters were calculated from the mean percentage defect coverage and percentage root coverage values. The term 'defect coverage' denotes the amount of postoperative coverage of the gingival recession defect (expressed as a percentage), while the term 'root coverage' denotes the amount of anatomical root (cementoenamel junction to the root apex) covered to the level of the gingival margin (also expressed as a percentage).
This study was designed to evaluate the efficacy of the transpositional flap (TF) as described by Bahat et al. and to compare this procedure with the CTG technique described by Bruno  for coverage of Miller's class I and class II marginal tissue recession defects, without the use of chemical root biomodification. We also wished to evaluate the effectiveness and predictability of both the procedures after a 4-month follow-up period. No histological assessment was done.
| Materials and Methods|| |
The study subjects were selected from amongst those visiting the outpatient section of the Department of Periodontology of Government Dental College and Hospital, Mumbai, India. The inclusion criteria were the following: healthy and systemically normal individuals, with no history of any disease affecting the periodontal status; no tobacco habits; willing for the proposed surgery; single tooth gingival recession; adequate width and height of adjacent interdental papillae; presence of an identifiable cementoenamel junction; absence of grooves, irregularities, caries, or restorations in the area to be treated; no periodontal surgical treatments in the previous 1 year on the involved sites; absence of bleeding on probing at the selected sites before the surgery; and absence of high frenal or muscle attachments at the recipient area.
Twenty patients of both the genders from the age-group of 18-45 years and having at least one Miller's class I or class II gingival recession defect on the facial surface of any anterior mandibular tooth were selected. Out of these, the first 10 patients to be recruited formed group I (TF group) and the next 10 patients formed group II (CTG group).
For group I cases TF was performed according to the method described by Bahat et al.,  and for group II a CTG procedure was done according to Bruno's  description. Thorough mechanical scaling and root planing was done before the surgical techniques but no chemical root biomodification was employed.
An approval for the study was obtained from the Ethical Committee on Research, Government Dental College and Hospital, Mumbai. The purpose of the study was explained thoroughly to the patients and each enrolled patient signed the consent form and agreed to comply with the maintenance and reexamination schedule for the following 4 months.
All patients underwent thorough clinical examination, routine blood examination, and scoring for periodontal status. Initial preparation included oral hygiene instructions to eliminate habits related to the etiology of the recession defects and to improve gingival health. Surgical procedures were performed only after the patients demonstrated acceptable oral hygiene standards and gingival health.
All the patients underwent an initial baseline examination, and the measurements taken immediately before surgery were compared with the postoperative results at the follow-up visit at 4 months. All recordings were performed by the same examiner. The measurements were recorded to the nearest 0.5 mm using a calibrated periodontal probe (William's probe, with markings at each millimeter). Recordings were made immediately before surgery, immediately after surgery, at suture removal (10 days), and at 2-month and 4-month recall visits (except for probing depth and width of keratinized gingiva, which were checked only at the presurgery and 4-months' follow-up visits).
Full-mouth and defect-specific oral hygiene status were evaluated using plaque index (Silness and Loe)  and defect-specific plaque index. Full-mouth and defect-specific gingival inflammation were recorded according to the gingival index (Loe and Silness)  and defect-specific gingival index. Recession depth (RD)  was measured at the midbuccal aspect and recession width (RW)  at the level of the cementoenamel junction from mesial to the distal aspect of intact soft tissue. Probing depth (PD) was measured at the mid-facial aspect of the recession. Attachment level (AL) and width of keratinized tissue (KT) were also recorded.
Postoperative percentage defect coverage (%DC) was calculated for each site using the preoperative and postoperative RD measurements. Preoperative and postoperative percentage root coverage (%RC) were calculated for each site, keeping the root length constant (13.63 mm) as recommended by Craft et al. The same percentages (% RC) were also obtained after calculating the mean root length of mandibular anterior teeth as 14.16 mm (based on the standard textbooks on dental morphology). ,, This exercise was done to appropriately compare the mean differences between the two groups and to obtain near-anatomic root coverage values.
Predictability and effectiveness of TF and CTG were calculated according to the criteria given by Greenwell et al.
Presurgical mouth preparation (including supragingival and subgingival scaling and root planing), complete hemogram, instructions for oral hygiene maintenance, correction of brushing habits, preoperative records, and occlusal correction, if indicated, were done. The TF or CTG procedures were undertaken after a period of 2-3 weeks. Local anesthesia in the form of infiltration or nerve block was given using 2% lignocaine hydrochloride with 1:80000 adrenaline. The infiltration was done slightly away from the surgical site - or else mental nerve blocks were preferred - because of the concern that injections immediately into the area of the graft may jeopardize the blood supply to the pedicle or the CTG or that it may unnecessarily cause obliteration of the vestibule because of swelling. For removing the graft (CTG) from the palate, local anesthetic was deposited just anterior and posterior to the site of harvesting.
The transpositional flap procedure
In 1990, Bahat et al. described the TF as an alternative to lateral repositioned flap for root coverage.  Some modifications to the original procedure were done in this study, i.e., with regard to the type of blade and the suture material used. The TF is a local flap consisting of a segment of gingiva and mucosa that turns around a pivot point. The radius of its arc is the line of greatest tension of the flap. The base is well anchored in the lip substance. Despite the unfavorable length: width ratio, this random flap is well vascularized through perforating arterioles in its base and through its muscular deep layers. The extension into the vestibule allows the point of rotation to be transferred. This flap becomes shorter in effective length the further it rotates. However, the versatility of this flap for root coverage and other oral plastic and reconstructive efforts is greatly enhanced because of the apical extension of the pivot point. The schematics of the flap and full details are available elsewhere. ,
The connective tissue graft procedure
In 1994, Bruno  described modifications to the original Langer and Langer technique. Bruno's technique with some modifications (i.e., no chemical root biomodification, non-removal of excess glandular or fatty tissue, and a different suturing technique) was employed for this study. The recipient site was prepared like an envelope flap, without the vertical releasing incisions and keeping the papillae and papillary epithelium intact, thus providing a butt joint for receiving the graft. With the help of two incisions, one perpendicular and the other parallel to the long axis of the tooth, a full thickness CTG (i.e., connective tissue with periosteum and with a 1-2 mm epithelial collar) was obtained from the palate. Without delay it was stabilized over the recipient site and covered with the overlying flap as much as possible. Refer to [Figure 1], [Figure 2], [Figure 3] and [Figure 4] for sketches; the details are available elsewhere. , For a representative case of TF refer to [Figure 5], [Figure 6] and [Figure 7] and for a case of CTG refer to [Figure 8], [Figure 9] and [Figure 10].
|Figure 1: Recipient site preparation at canine. Deep partial/full/partial thickness envelope reflection into the vestibule, keeping the papillae intact|
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|Figure 2: A separated connective tissue graft (CTG) with a small epithelial collar|
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|Figure 5: Incision outline for transpositional flap at a mandibular central incisor with recession. The flap is extended into the vestibule as much as possible|
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|Figure 6: Flap rotated 90° and sutured properly. Note some amount of tension at the flap base|
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|Figure 8: Recipient bed preparation at mandibular central incisors, keeping the papillae intact|
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|Figure 10: Postoperative results at 1 year follow-up. Note the excellent color match|
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For both the procedures, the postoperative protocol was same. Medications included amoxicillin 250 mg + cloxacillin 250 mg t.i.d for 5 days; ibuprofen 400 mg t.i.d for 5 days; and 0.2% chlorhexidine rinse, 10 ml b.i.d for 4 weeks. Ice-pack applications, minimum facial movements, head elevation during sleep for the first 2 nights, and regular observations were prescribed. After suture removal the patient was advised to continue use of the chlorhexidine rinse and instructed to cleanse the graft site with a cotton swab saturated with chlorhexidine, wiping in an apicocoronal direction, for an additional 2-3 weeks.
| Results|| |
The mean ages of the patients in the two groups were comparable (TF group: 26.90 ± 8.90 years vs CTG group: 21.5±2.64 years; P>.05, non-significant). A total of 90% lesions (including both the groups) were related to the mandibular central incisors and for each group 90% of the teeth were mandibular central incisors. This was a significant finding as it makes the criteria readily comparable. Besides all of the lesions were primarily associated with localized plaque-induced inflammation. All the parameters and their statistical significance are summarized in [Table 1].
|Table 1: Student's 't' test results of paired comparisons between the treatment groups: Means of clinical parameters at baseline and at 4-month evaluation. Intragroup significance values are given in the last column|
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There was a mean recession coverage of 1.25±1.27 mm for the TF group and 4.05±1.66 mm for the CTG group, which was statistically (P<.05) as well as clinically significant [Graph 1]. The mean AL gain for TF was 1.65±1.53 mm, whereas the mean AL gain for CTG was 4.85±1.75 mm; the difference was statistically (P<.05) and clinically significant. The mean increase in KT width for the TF procedure was 1.20±1.21 mm, whereas for the CTG procedure it was 3.90±1.66 mm; this difference was statistically (P<.01) and clinically significant [Graph 2].
The estimation of the predictability and effectiveness of the procedures are summarized in [Table 2]. For TF cases, the mean DC was 32.42±33.43% with ≥90% DC achieved only in 10% of the cases. The mean RC [Graph 3] obtained was 77.40±17.23%, with ≥90% RC occurring in 30% of the cases. Therefore, the TF procedure was neither effective nor predictable. For the CTG procedure the mean DC was 82.06±17.30%, with ≥90% DC achieved in 40% of the cases. The mean RC obtained was 93.65±6.18%, with ≥90% RC occurring in 70% of the cases. Therefore, the CTG procedure was effective in defect coverage but not predictable, and it is almost (nearly) effective in defect elimination but not predictable.
|Table 2: The predictability and effectiveness of transpositional flap vs connective tissue graft procedure|
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| Discussion|| |
Miller and Craddock  stated that, 'surgical correction of exposed roots has become a remarkably successful and predictable procedure with either connective tissue or guided tissue regeneration. In most cases, connective tissue grafting for root coverage should be preferred to guided tissue regeneration as the use of epithelialized palatal tissue for root coverage is a dated procedure.' Since the introduction of the TF procedure in 1990 by Bahat et al. there have been no longitudinal studies of the procedure or comparisons with any other pedicle or free graft procedures. Therefore, the results and conclusions of this study cannot be compared with that of previous studies.
Our main aim in this study was to evaluate and compare the effectiveness and predictability of the two procedures. This type of data recording was first reported by Greenwell et al.  They questioned current reporting standards with several illustrations, one of which we would like to share for better understanding: A 3-mm recession defect on a 12- mm root (cementoenamel junction to apex) would represent initial root coverage of 75%. If a surgical procedure was performed and 2 mm of coverage was obtained, then the final root coverage would be 92%, but only 67% of the original defect would be covered. With current reporting practices this would be considered as 67% root coverage, which creates the deceptive impression that substantial root exposure remains. In fact, the final root coverage was 92%, which can be considered successful by most standards. The use of true root coverage data would give important information about the size of the residual recession defect.  Also the value, e.g., 67% defect coverage, cannot define whether the procedure is a success or failure. Although, ideally, we would like to have 100% of teeth having 100% root coverage with 100% flawless surrounding tissues, the predictability of an operative procedure should be assessed in the light of biological limitations and current human/technological achievements. For assessment of the effectiveness and predictability of a root coverage procedure, Greenwell et al. proposed an attainable criteria and stated that, 'successful mean defect coverage should be 80%-100%, with ≥90% coverage achieved at least 75% of the time. Successful defect elimination would be indicated by mean root coverage of 95%-100%, with ≥90% coverage predictably obtained at least 90% of the time.'
If we modify the criteria for defect elimination and consider that 2 mm of recession defect (85% root coverage) postoperatively is acceptable (and clinically significant) then, according to the findings of our study, the CTG procedure is effective as well as predictable for defect elimination.
For CTG procedures if we consider four studies together [Levine,  Harris (1992),  Allen (1994),  and Tinti and Parma-Benfenati (1996)  ] the results would be as follows: The mean defect coverage (DC) would be 93±6.14%, with ≥90% DC achieved 76±12.53% of the times. The mean root coverage (RC) obtained would be 98±1.89%, with ≥90% RC occurring 96±8.50% of the times.
Thus the CTG procedure can be considered effective and predictable in both defect coverage and defect elimination. We have observed effective but not predictable results. Such type of data is not available for laterally positioned flaps. There is a need to devise a method for reporting data from root coverage procedures that would be universally acceptable and include all the important parameters that can be used in the future for appropriate comparisons.
| Conclusion|| |
We conclude that
- The root coverage achieved by the CTG procedure was statistically and clinically better than the TF technique.
- The TF technique for coverage of single tooth buccal recession defects of Miller's class I and class II type in mandibular anterior teeth was neither effective nor predictable in defect coverage and defect elimination.
- The CTG for coverage of single tooth buccal recession defects of Miller's class I and class II type in mandibular anterior teeth was effective in defect coverage and almost (nearly) effective in defect elimination; however, the procedure is not predictable, either in defect coverage or in defect elimination
| References|| |
|1.||Consensus report: Mucogingival therapy. Ann Periodontol 1996;1:702-6. |
|2.||Wennström JL. Mucogingival therapy. Ann Periodontol 1996;1:671-701. |
|3.||Wennström JL, Zuchelli 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. |
|4.||Shklar G, Carranza FA. The historical background of Periodontology. In: Carranza FA and Newman MG, Editors. Clinical Periodontology. 8 th ed. Philadelphia: WB Saunders; 1998. p. 6. |
|5.||Bahat O, Handelsmen M, Gordon J. The transpositional flap in mucogingival surgery. Int J Periodontics Restorative Dent 1990;10:472-82. |
|6.||Pennel BM, Higgason JD, Towner JD, King KO, Fritz BD, Salder JF. Oblique rotated flap. J Periodontol 1965;36:305-9. |
|7.||Hattler AB. Mucogingival surgery-utilization of interdental gingiva as attached gingiva by surgical displacement. Periodontics 1967;5:126-31. |
|8.||Cohen DW, Ross SE. The double papillae repositioned flap in periodontal therapy. J Periodontol 1968;39:65-70. |
|9.||Bruno JF. Connective tissue graft technique assuring wide root coverage. Int J Periodontics Restorative Dent 1994;14:126-37. |
|10.||Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20. |
|11.||Polson AM, Frederick GT, Ladenheim S, Hanes PJ. The production of a root surface smear layer by instrumentation and its removal by citric acid. J Periodontol 1984;55:443-6. |
|12.||Garrett JS, Crigger M, Egelberg J. Effects of citric acid on diseased root surfaces. J Periodontal Res 1978;13:155-63. |
|13.||Ririe CM, Crigger M, Selvig KA. Healing of periodontal connective tissue following surgical wounding and application of citric acid in dogs. J Periodontal Res 1980;15:314-27. |
|14.||Fine DH, Morris ML, Tabak L, Cole JD. Preliminary characterizations of material eluded from the roots of periodontally diseased teeth. J Periodontal Res 1980;15:10-9. |
|15.||Fardal O, Lowenberg BF. A quantitative analysis of the migration, attachment and orientation of human gingival fibroblasts to human dental root surfaces in vitro. J Periodontol 1990;61:529-35. |
|16.||Camargo PM, Melnick PR, Kenney EB. The use of free gingival grafts for aesthetic purposes. Periodontol 2000 2001;27:72-96. |
|17.||Greenwell H, Bissada NF, Henderson RD, Dodge JR. The deceptive nature of root coverage results. J Periodontol 2000;71:1327-37. |
|18.||Loe H. The gingival index, plaque index and retention index systems. J Periodontol 1967;38(6 Suppl):610-6. |
|19.||Guinard EA, Caffesse RG. Treatment of localized gingival recessions. Part I. Lateral sliding flap. J Periodontol 1978;49:351-6. |
|20.||Craft G, Wang A, Vance G, Yancey J, Greenwell H. The periodontitis progression rate index: Methodological considerations. Periodontal Insights 2000;6:37-44. |
|21.||Ash MM Jr. Wheeler's Dental Anatomy, Physiology and Occlusion, 7 th Ed., Philadelphia: WB Saunders Co., Noida: Prism Books Pvt. Ltd., Indian Ed 1993. |
|22.||Woelfel JB. Dental Anatomy: Its relevance to dentistry, 4 th Ed., USA: Lea and Febiger Co.; 1990. |
|23.||Bhalajhi SI. Dental Anatomy, Histology and Development, 1 st Ed., New Delhi: Arya Publishing House; 1998. |
|24.||Baghele ON, Pol DG. An evaluation of the effectiveness and predictability of transpositional flap versus connective tissue graft for coverage of Miller's class-I and class-II facial gingival recession lesions- a clinical study. Dissertation submitted to the Mumbai University, Mumbai 2002. |
|25.||Miller PD Jr., Craddock RD. Surgical advances in the coverage of exposed roots. Curr Opin Periodontol 1996;3:103-8. |
|26.||Levin RA. Covering denuded maxillary root surfaces with the subepithelial connective tissue graft. Compendium 1991;12:568-72. |
|27.||Harris RJ. The connective tissue and partial thickness double pedicle graft: A predictable method of obtaining root coverage. J Periodontol 1992;63:477-86. |
|28.||Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage. I. Rationale and technique. Int J Periodontics Restorative Dent 1994;14:216-27. |
|29.||Tinti C, Parma-Benfenati S. The free rotated papilla autograft: A new bilaminar grafting procedure for the coverage of multiple shallow gingival recessions. J Periodontol 1996;67:1016-24. |
Om N Baghele
Department of Periodontology, Government Dental College and Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2]