|Year : 2022 | Volume
| Issue : 4 | Page : 363-366
|Semilunar vestibular incision technique for treatment of multiple gingival recession in maxillary teeth - An evaluative study
P Hema1, Pratebha Balu2, Saravana Kumar2, Gayathri Haritheertham1, S Thirumalai1, E Ahila1
1 Department of Periodontology, Sri Venkateshwaraa Dental College, Pondicherry University, Ariyur, Pondicherry, India
2 Department of Periodontology, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth University, Puducherry, India
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|Date of Submission||10-Jun-2021|
|Date of Decision||31-Oct-2022|
|Date of Acceptance||23-Nov-2022|
|Date of Web Publication||30-Mar-2023|
| Abstract|| |
Background: Recession is a mucogingival condition affecting teeth causing hypersensitivity. Although many techniques are there for recession coverage, semilunar vestibular incision technique (SVIT) is a novel procedure for management of multiple gingival recession in maxillary teeth. Aim: To evaluate the efficacy of root coverage in maxillary teeth with multiple gingival recession using SVIT. Methodology: Twenty systemically healthy patients were recruited with Miller's class I and II gingival recessions in maxillary teeth. Parameters such as recession height (RH), recession weight (RW), avascular surface area (ASA), width of keratinized gingiva (WKG), width of attached gingiva (WAG), and clinical attachment level (CAL) were measured at baseline three and six months post-surgery. Results: The outcome measures were statistically significant at baseline, three and six months. A reduction of 86% was achieved in terms of RH and RW. Gain in WKG and WAG as achieved at six-month follow-up was 31.5% and 55%, respectively. An 87% decrease in ASA was obtained and reduction in CAL was 82.4%. Between three and six months there was a significant increase in WAG. Conclusion: SVIT results in improved measures of attached gingiva on six-month follow-up.
Keywords: Aesthetics, attached gingiva, multiple gingival recessions, root coverage, semilunar vestibular incision
|How to cite this article:|
Hema P, Balu P, Kumar S, Haritheertham G, Thirumalai S, Ahila E. Semilunar vestibular incision technique for treatment of multiple gingival recession in maxillary teeth - An evaluative study. Indian J Dent Res 2022;33:363-6
|How to cite this URL:|
Hema P, Balu P, Kumar S, Haritheertham G, Thirumalai S, Ahila E. Semilunar vestibular incision technique for treatment of multiple gingival recession in maxillary teeth - An evaluative study. Indian J Dent Res [serial online] 2022 [cited 2023 Jun 9];33:363-6. Available from: https://www.ijdr.in/text.asp?2022/33/4/363/372913
| Introduction|| |
Gingival recession is the exposure of root surface resulting from the migration of gingival margin apical to the cementoenamel junction (CEJ). With multifactorial aetiology that includes inflammation, calculus, iatrogenic factors, convexity of roots, and uncontrolled orthodontic movements, most often it is implicated with faulty tooth brushing, mechanical trauma, and periodontal disease.,,,
In patients with good oral hygiene, gingival recession on the buccal surface of teeth is a frequent occurrence, affecting single or multiple root surfaces, and is most often due to overzealous or faulty tooth brushing., Periodontal plastic surgical procedures addresses these aesthetic and functional demands and have become an integral part of the periodontal treatment plan., The root coverage may be achieved by a number of surgical techniques, including pedicle gingival grafts, free gingival grafts, connective tissue grafts, and guided tissue regeneration.
The advantage of pedicle grafts over the free gingival soft tissue grafts is that it retains flap vascularity. Coronally advanced flap (CAF) is one of the most commonly used pedicle flaps for the management of Miller's class I and class II gingival recession defects.
A novel procedure for root coverage of multiple gingival recession in maxillary teeth, semilunar vestibular incision technique (SVIT), was first described by P. D. Miller. The technique was later reported in two case reports with successful root coverage in three months of follow-up.
In the present study, cases with Millers Class I and Class II gingival recession in Maxillary teeth were treated by SVIT. Recession coverage (height and width), avascular surface area (ASA), width of keratinized and attached gingiva (WKG and WAG), and CAL were observed.
| Methodology|| |
Subjects who attended Department of Periodontology, Indira Gandhi institute of Dental Sciences, Pondicherry from February 2017-July 2018. The study was approved from institutional ethical committee (IGIDSIEC2016NDP28PGHPPAI). A total of 20 were selected based on inclusion and exclusion criteria and written informed consent was obtained from all the subjects.
Individuals between 20 and 50 years of age who presented with multiple Miller's Class I or II gingival recession in at least two-well aligned maxillary teeth (incisors, canine, and premolars only).
Patients with Miller's class III and IV gingival recession in maxillary teeth, patients with systemic diseases, history of smoking, and teeth with erosion, root caries, abrasion, and abfraction were excluded.
Semilunar vestibular incision technique
Local anaesthesia (2% lignocaine with 1:200,000 adrenaline) was administered followed by a horizontal incision at the base of the interdental papilla, the second, intra-crevicular incision was given along the curvature of the receded gingival margin and terminates 2–3 mm short of the tip of the papillae. De-epithelialization of the papillae was done. From the intra-sulcular incision, a full thickness dissection up to 3–4 mm was done apically, a semilunar incision was made in the vestibule and dissection was connected to the vestibular incision. Flap was secured coronally with sling suture using 4.0 vicryl. Periodontal dressing was placed over the surgical site, followed by post-surgical instructions [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e.
|Figure 1: (a) Pre-Op gingival recession in 22, 23, and 24. (b) Semilunar incision, both incisions connected. (c) Sling suture placed. (d) Follow-up at three months. (e) Follow-up at six months|
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Initial therapy and clinical measurements
All the subjects recruited for the study underwent scaling, root planning, sub-gingival curettage, and oral hygiene instructions, with an emphasis on proper brushing technique. One month after initial periodontal therapy, the subjects were recalled and checked for oral hygiene compliance. All the subjects presented with good oral hygiene.
Individual acrylic stents were prepared to serve as a standard reference to align the probe in the same position at all the time and CEJ was used as a reference point for the clinical measurements. All the measurements were carried out by a single examiner at baseline, three and six months following the surgery.
Statistical analysis of the clinical parameters was carried out to compare the baseline value with the six months post-operative. The scores were statistically analysed by calculating their mean values and standard deviation. The mean difference between the intervals was calculated using descriptive statistics and t test.
| Results|| |
Comparison of periodontal parameters in at baseline, three months and six months
The recession height (RH) was measured at baseline three and six months after SVIT. The mean RH at baseline, at three months and at six months was 2.60 ± 0.83, 0.44 ± 0.65 and 0.44 ± 0.73, respectively. The reduction in RH from baseline to three months and six months was significant (p = 0.001). Post hoc test shows that the reduction of RH from baseline to three months and baseline to six months period were significant (p = 0.00). There was no significant reduction of RH from three months to six months (p = 1). The mean root coverage was achieved 85.6% from baseline to six months in terms of RH [Table 1] and [Graph 1].
|Table 1: Comparison of clinical parameters at baseline, three and six months|
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The reduction in recession width (RW) at baseline, three and six months was significant (p = 0.001) post-operatively. The mean reduction in RW from 3.62 ± 0.60 mm at baseline to 0.92 ± 1.41 mm at three months was statistically significant reduction (p = 0.00). Similarly, the mean reduction in RW from baseline to six months was 3.62 ± 0.60 to 0.82 ± 1.36, respectively, and the reduction in RW from baseline to six months was also significant (p = 0.001). There was no significant reduction in RW between three to six months post-operatively. Eighty percent of root coverage was achieved in RW from baseline to six months [Table 1] and [Graph 1].
Avascular surface area
The ASA was measured at baseline and three and six months. The decrease in ASA from baseline, three and at six months was 9.38 ± 4.17, 1.18 ± 2.12 and 1.26 ± 0.23, respectively. The decrease in ASA from baseline to three months and baseline to six months was significant (p = 0.00). There was no significant difference in ASA between three and six months and 87% of root coverage was achieved in terms of ASA [Table 1] and [Graph 1].
The gain in WKG was measured at baseline, three and six months was significant (p = 0.00) post-operatively. The mean gain in WKG from 3.78 ± 1.01 mm at baseline to 1.26 ± 0.23 mm at three months was significant (p = 0.00). Likewise, there was a significant gain (p = 0.001) in KG from baseline 3.78 ± 1.01 to six months 4.94 ± 1.03. No significant gain in WKG between three and six months post-operatively. Gain of 31.4% in WKG was achieved from baseline to six months [Table 1] and [Graph 1].
The WAG was measured at baseline and at three months and at six months post-surgically. The mean gain in attached gingiva at baseline, three months and six months was 2.36 ± 1.12, 3.40 ± 1.05 and 3.64 ± 0.96, respectively. There was a statistically significant gain in AG from baseline to three months (p = 0.00), and baseline to six months (p = 0.00). However, there was a significant gain in AG between three months to six months (p = 0.002). The gain in attached gingiva was achieved by 55.2% from baseline to six months [Table 1] and [Graph 1].
Clinical attachment level (CAL)
The change in CAL was measured at baseline three and six months post-operatively. The mean reduction in CAL from baseline, three months and six months was 2.76 ± 1.08, 0.46 ± 0.67 and 0.50 ± 0.76, respectively. The gain in CAL from baseline to three months and six months was significant (p = 0.001). Post hoc test shows that the improvement in CAL from baseline to three months and baseline to six months period were significant (p = 0.00). There was no significant reduction of RH from three months to six months. The CAL gain was achieved by 82.4% from baseline to six months [Table 1] and [Graph 1].
The change in probing depth (PD) was measured at baseline and three and six months post-operatively. The mean change in PD at baseline and at three months and at six months was 1.50 ± 0.56, 1.62 ± 0.49 and 1.60 ± 0.49, respectively. The comparison of changes in the CAL from baseline, three months and six months did not show significant differences [Table 1] and [Graph 1].
| Discussion|| |
In the present study, 20 systemically healthy patients with Millers class I and class II multiple gingival recessions in maxillary teeth were selected on the basis of inclusion and exclusion criteria. Parameters like RH, RW, ASA, WKG, WAG, CAL, and PD were measured. All the clinical parameters obtained were entered in the standard proforma. The scores were statistically analyzed by calculating their mean values and standard deviation. The mean difference between the intervals was calculated.
According to a case report, the final assessment at three months post-surgically showed successful root coverage with a significant gain in the height of keratinized tissue. The good colour match of the treated area with the adjacent soft tissue and the reduction of sensitivity were obtained with this technique.
They reported that the technique can be used for root coverage of multiple gingival recession by increasing the WAG and enhancement of vestibular depth was observed with predictable results along with advantages like a good colour match of the treated area with respect to adjacent soft tissues. The only disadvantage of the technique reported is an extensive wound with moderate pain post-surgically for two days.
In our study, we observed significant changes in all parameters from baseline to six months, in terms of reduction in RH (2.60 ± 0.83 mm to 0.44 ± 0.73 mm), reduction in RW (3.62 ± 0.60 to 0.82 ± 1.36 mm), decrease in ASA (9.38 ± 4.17 to 1.26 ± 0.23 mm), increase in WKG (3.78 ± 1.01 to 4.94 ± 1.03 mm), and gain in CAL (2.76 ± 1.08 to 0.50 ± 0.76 mm), respectively. In contrast to CAF, we achieved a 55% increase in WAG for SVIT from baseline to six months (2.36 ± 1.12 to 3.64 ± 0.96 mm), but it was not statistically significant.
Better results with SVIT might be because of the possibility that this technique provides better blood supply, better advancement and extending to the tooth adjacent to a mesial and distal aspect of gingival recessions (semilunar vestibular incision).
This difference may be attributed to the fact that SVIT facilitates coronal positioning and prevents flap retraction due to the semilunar incision thereby increasing the WAG.
| Conclusion|| |
Based on the outcome of our study, we conclude that SVIT shows better results in terms of esthetics and clinical parameters in particular, the width of attached gingiva. Hence SVIT may be indicated as a root coverage procedure in maxillary teeth.
A limitation of our study is a single group and we have followed up patients for a period of only six months due to reasons of time restraints. The stability of the results achieved can be established beyond doubt with a long-term follow-up of greater than two years.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. P Hema
Senior Lecturer, Department of Periodontology, Sri Venkateshwaraa Dental College, Ariyur, Pondicherry
Source of Support: None, Conflict of Interest: None
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