Clinical Outcome of Root Coverage Following the Treatment of Multiple Gingival Recession Defects Treated with Vista in Combination with PRF and Zucchelli’s Technique: A Case Series

Introduction

According to the Glossary of Periodontology, gingival recession refers to the exposure of the root surface by an apical shift in the position of the gingiva in relation to the cementoenamel junction [1]. By definition, gingival recession is correlated with clinical attachment loss [2]. Gingival recessions can be localized or generalized, affecting one tooth or multiple teeth in the same patient, and associated with one or more surfaces in the same tooth.

In health, free gingival margin, is located about 1-2 mm coronal to the CEJ, and the level of the epithelial attachment is usually at or slightly coronal to the level of the CEJ [3]. In case of gingival recession, an osseous dehiscence is present and the soft tissues around the tooth (free gingiva, attached gingiva and alveolar mucosa) moved in an apical direction to the CEJ, exposing the root surface to external environment [4]. Histologic studies have shown that in buccal-lingual cross-sections of teeth affected by gingival recession is characterized by a keratinized epithelium, which tends to move apically with an increasing recession depth, whereas the position of the mucogingival junction (MGJ) and the alveolar mucosa tends to remain unaltered [5]. These findings confirm that with the increase of the recession depth, the width of keratinized tissue tends to decrease, which leads to the partial or complete loss of the attached gingiva.

Although numerous factors have been implicated in the etiology of gingival recession in both cross-sectional and longitudinal studies [6]. AAP-EFP World Workshop 2017 concluded that the etiology of gingival recession remains unclear [2]. Several predisposing factors have been suggested: mechanical trauma, plaque accumulation, periodontal phenotype and attached gingiva, cervical restorative margins, dental malposition, high frenum attachment and shallow vestibular depth, orthodontic treatment. Miller classified gingival recession in to four classes namely Class I, Class II, Class III and Class IV. Miller’s classified gingival recessions based on the relation of gingival margin to the mucogingival junction, interdental bone level adjacent to defect area and the height of interproximal papillae. The need for gingival recession management is to prevent the accumulation of etiological factors (plaque and calculus), to prevent tooth abrasion, root caries, to avoid hypersensitivity and the most important is the aesthetic concern of the patients.

Root coverage is a successful and predictable procedure in periodontics [7]. Different surgical strategies in the literature have been proposed for the correction and management of gingival recession’s defects, which include free gingival graft, connective tissue grafts, pedicle flaps, guided tissue regeneration with resorbable or non-resorb able membrane. Recent systematic reviews and consensus reports have concluded that connective tissue grafting seems to be the most effective method of root coverage and is the most extensively documented technique [8]. Surgical procedures used in the treatment of gingival recessions can involve the use of pedicle flaps, free soft tissue grafts, additional adjuncts (e.g. PRP, PRF) and combination of the above-mentioned techniques. There were various modifications in the Coronally Advance Flaps given by Allen, Miller, and Zucchelli & De Sanctis. Coronally advanced flap (CAF) is the most frequent approach for treating gingival recessions and it can be combined with a connective tissue graft (CTG) which is accepted as a gold standard therapy [9].

Raetze in 1985 was the first to use an envelope flap technique for covering isolated gingival recession defects.

He created a partial-thickness envelope that allowed for the insertion of a connective tissue graft. Later, a modification was proposed by AL Allen, et al. [10] for the treatment of multiple adjacent recession defects. Further investigated this approach and coined this technique the “tunnel” approach. The “coronally advanced modified tunnel technique” proposed by Aroca S, et al. [11] and comprises a full thickness flap elevation that carefully separates the entire interproximal papillae from bone and places sutures suspended from composite stops at teeth contact points to prevent the flap from collapsing during healing. The positive aesthetic outcomes are attributable to flap elevation that does not dissect the interdental papillae or does not require any vertical releasing incision. A recent systematic review comparing tunnel techniques and CAF showed that CAF seemed to be associated with higher percentage of complete root coverage than was tunnel when the same grafts (connective tissue or a cellular dermal matrix) were used in both techniques [12].

Periodontal tissue loss is typically treated with various regeneration modalities such as bone grafts, Guided Tissue Regeneration and Growth Factors. Growth Factors are large family of polypeptide growth molecules which enhances the healing by modulating the cell responses such as cell attachment, adhesion, survival, proliferation, chemo taxis and differentiation [13]. The Growth Factors are obtained from autogenous source or by Recombinant technology. Recombinant growth factors have positive effect on experimental studies but clinically less effective due to complex application procedures and high cost. Platelets serve as a major resource of autogenous growth factors because they are the first cells to reach the wound site initiating the haemostasis and healing process [14]. Platelet Rich Fibrin (PRF) was the evaluation of PRP which was used in periodontal regeneration. PRF has the same properties as PRP but it is advantageous over PRP in Osteogenicity, Method of preparation and Lack of thrombus and anticoagulants [15]. The minimal invasive techniques for gingival recession coverage when combined with growth factors it provides unique, satisfactory and more advantageous results in terms of predictable clinical and histological outcome.

Therefore, a clinical trial was tried in the form of case series to combine the biological properties of PRF and compare both the techniques VISTA and Zucchelli’s to predict the clinical outcome of gingival recession coverage.

Discussion

Root coverage procedure is becoming an important issue in clinical periodontics because of increasing demand for cosmetic treatment. Aesthetics is the main indication for Perio-plastic procedures. The patient exposes the most coronal aspect of the recession while smiling which is considered as the main aesthetic problem. Different techniques have been developed in the literature to cover the denuded roots, with the ultimate goal is complete root coverage, and many attempts have been made to increase the predictability and success rate. While planning and designing for any root coverage procedure, the clinicians must address many aspects of clinical problems such as correction of etiological factors, root preparation, discomfort and healing of donor site wound, vestibular depth and anatomic contour of the recipient sites.

Dental literature has given many treatment modalities for achieving root coverage such as Coronally Advanced Flap, Lateral Pedicle graft, free gingival and Connective tissue graft. A systemic review conducted by Cairo F, et al. [16] has concluded that Coronally Advanced Flap is predictable and safe approach for recession management. Coronally advanced flap is one of the very effective in treatment of recession defects having the advantages for the patient in terms of aesthetics and morbidity. To obtain the highly successful root coverage, modification of the coronally advanced flap procedures is introduced in which there will not be any vertical releasing incision because it might damage the vascular supply to the flap resulting in unesthetic appearance of the affected site with visible white scar. Therefore, this modified approach provides increased probability of achieving complete root coverage and increase in keratinized tissue height.

The present case series demonstrated the effectiveness of the minimally invasive VISTA technique with PRF and Zucchelli’s technique with PRF for the management of gingival recession defects in the aesthetic zone. There was a significant improvement in the root coverage 3 months post operatively. Patient did not report any discomfort during the healing phase and it was an uneventful. Also, patients were overall satisfied with the clinical outcome. Recent studies have shown that the use of growth factors along with VISTA and Zucchelli’s techniques can be an effective tool in the management of multiple gingival recession defects in the aesthetic zone. The recombinant growth factors have proven good results in the experimental and in animal studies. The presence of the Growth Factors in Platelets was first described by Naik B, et al. [17]. Growth Factors which are released from local application enables better tissue regeneration by having a critical role in cell proliferation, survival, migration and angiogenesis [18]. The platelet derived growth factor (PDGF) acts as a power mitogen in the connective tissue cells, stimulation of osteoprogenitor cell is mediated by transformation growth factor -β (TGF-β). The late-stage differentiation of the osteoblasts is promoted by Insulin like Growth factor and Endothelial migration and proliferation is initiated by Vascular Endothelial Growth Factor (VGEF) thus promoting angiogenesis. Luo H, et al. [19] did a systematic review stating the positive effect along with their additional use of Platelet Concentrates in the treatment of Gingival Recessions and wound healing. Placements of PRF membrane in recession defects have been shown with a positive clinical outcome to repair gingival defects, re- establish the continuity and integrity of the keratinized gingiva and increasing the gingival phenotype.

The recession depth and recession width are the two important clinical parameters for gingival recession treatment. Reduction in the recession depth and recession width will result into root coverage and restoration of aesthetics. In the present case series, both the techniques are effective in reduction of recession depth and recession width and shown a significant positive outcome with a follow up time interval of 3 months. Root coverage is the expected and desirable outcome of mucogingival therapy. Clinically, the amount of root coverage is measured as the distance between the CEJ to the gingival margin. In the present case series, using a PRF along with both the technique provide a successful coverage and better aesthetics.

The minimally invasive VISTA technique, combined with PRF, has a number of advantages for the successful treatment of multiple recession defects. Most importantly maintenance of blood supply in the coronally advanced techniques which involve vertical incision is quite compromised. Moreover, the drawback of creation of a palatal donor site after harvesting of autologous soft tissue graft can be overcome by the use of appropriate biomaterial or growth factor such as PRF. PRF is autogenous in origin with evidence for soft tissue healing and can be a promising biomaterial for periodontal therapy. Although large sample and longer follow time period is required to reach the conclusion and for effective evaluation of VISTA technique with PRF and Zucchelli’s technique with PRF. Both the cases documented in this case series are done in the maxillary arch. There is a need of demonstration of these techniques in managing gingival recession in mandibular teeth also. Future research needs to be directed towards the design of randomized controlled clinical trials (RCTs) aimed at evaluating and comparing different mucogingival procedures in the treatment of buccal gingival recessions on maxillary and mandibular anterior teeth. Therefore, more comparative studies and randomized controlled trials are needed in this regard.

Conclusion

The result of both VISTA and Zucchelli’s technique with PRF are effective in treating the multiple gingival recession defect. Multiple gingival recessions are a great challenge to the clinician especially with large defects. Both VISTA and Zucchelli’s technique are reliable techniques for treatment of multiple recession defects. Both techniques require a high level of surgical clinical skill and expertise. Careful patient selection, treatment planning and precise execution are important for achieving optimal results.