|Year : 2019 | Volume
| Issue : 2 | Page : 128-134
Laser-assisted root coverage procedure in gingival recessions: A randomized controlled clinical study
R Divakaran, Joann Pauline George, Ankita Jha, Smiti Bhardwaj, Divya Khanna
Department of Periodontics, Krishnadevaraya College of Dental Sciences, Bengaluru, Karnataka, India
|Date of Web Publication||14-May-2019|
Dr. Joann Pauline George
Department of Periodontics, Krishnadevaraya College of Dental Sciences, International Airport Road, Bengaluru - 560 157, Karnataka
Source of Support: None, Conflict of Interest: None
BACKGROUND: Laser de-epithelialization (LD) facilitates periodontal wound healing. This clinical trial aims to evaluate the clinical outcome of coronally advanced flap with subepithelial connective tissue graft and LD (CAF + SCTG + LD) and compare it with CAF + SCTG in the treatment of gingival recession.
MATERIALS AND METHODS: Fifteen patients presenting with one pair of bilaterally symmetrical Miller's Class I/Class II buccal gingival recessions were enrolled for the study. De-epithelialization of the test sites was performed with diode laser (810 m), whereas control sites received sham laser application followed by CAF and SCTG.
RESULTS: Six months postsurgically, comparable complete root coverage was observed in sites treated with CAF and SCTG with LD and CAF and SCTG alone. Mean root coverage (MRC) in the control group and the test group was similar (P > 0.05). Photogrammetric analysis showed similar MRC in the control group and the test group (P > 0.05).
CONCLUSION: The clinical outcomes of recession coverage with CAF and SCTG and LD are comparable to CAF and SCTG. LD did not show any added clinical advantage over CAF and CTG in the management of gingival recessions.
Keywords: Coronally advanced flap, gingival recession, laser de-epithelialization, root coverage, subepithelial connective tissue graft
|How to cite this article:|
Divakaran R, George JP, Jha A, Bhardwaj S, Khanna D. Laser-assisted root coverage procedure in gingival recessions: A randomized controlled clinical study. Int J Health Allied Sci 2019;8:128-34
|How to cite this URL:|
Divakaran R, George JP, Jha A, Bhardwaj S, Khanna D. Laser-assisted root coverage procedure in gingival recessions: A randomized controlled clinical study. Int J Health Allied Sci [serial online] 2019 [cited 2019 Nov 17];8:128-34. Available from: http://www.ijhas.in/text.asp?2019/8/2/128/258179
| Introduction|| |
Gingival recession affects a large segment of the population and varies in individuals based on age, sex, habits, and surfaces.,, Esthetic needs and dentin hypersensitivity is the common driving force for patients to seek treatment.,
Coronally advanced flap with subepithelial connective tissue graft (CAF + SCTG) has consistently shown greater probability in obtaining complete root coverage (CRC). CAF + SCTG generally heals with long junctional epithelium (JE) and connective tissue adhesion. New attachment can be facilitated based on the tenets of delaying epithelial migration through guided tissue regeneration (GTR). Laser-assisted modified Widman flap (MWF), laterally positioned flap, and excisional new attachment procedure, have reported excellent clinical results. Laser de-epithelialization (LD) of the mucoperiosteal flap forms a necrotic layer on the wound site; this decreases wound contraction and acts as an impermeable dressing that consists of denatured collagen and reduces inflammation. Histologic evidence of true regeneration of the periodontium was also noted in laser-assisted regeneration of intrabony defects and laser-assisted new attachment procedure (LANAP).,,
However, there is no documentation of laser-assisted root coverage procedures. Hence, the aim of this novel clinical trial was to compare the clinical outcome of CAF and SCTG alone and CAF and SCTG with LD in the treatment of gingival recession
| Materials and Methods|| |
The study was designed as a double-blind, placebo-controlled, randomized controlled clinical trial for the treatment of Miller's Class I/II gingival recession defects according to the principles outlined in the World Medical Association Declaration of Helsinki (version V120002) on experimentation involving human subjects as revised in 2000 and reported according to the CONSORT guidelines, 2010. The study protocol (ClinicalTrial.org– NCT02626117), was approved by the Institutional Review Board of Krishnadevaraya College of Dental Sciences, affiliated to Rajiv Gandhi University of Health Sciences, Bangalore, India (Ref no. 02_D012_36651). Informed consent was obtained from all the participants included in the study after a thorough explanation of the nature, risks, and benefits of the clinical investigation. Fifteen patients from the Department of Periodontology, Krishnadevaraya College of Dental Sciences and Hospital, Bengaluru, presenting with thirty recessions were enrolled from July 2013 to September 2014. Participants satisfying the following inclusion criteria were recruited: bilateral Miller's Class I/II recession defects involving maxillary or mandibular canines or premolars, periodontally healthy, full-mouth plaque and bleeding score ≤20%, systemically healthy, age group of 21–57 years, esthetic concerns, have not undergone any type of regenerative periodontal therapy 6 months before the initial examination, and no history of smoking. Pregnant patients and patients with orthodontic therapy in progress were not included.
Operator and investigators
All surgical procedures were performed by a single operator from the Department of Periodontology, Krishnadevaraya College of Dental Sciences and Hospital, Bengaluru. A blinded examiner recorded all the clinical measurements. The examiner underwent a training and calibration session with respect to data collection and measurement protocol for recession depth, clinical attachment level (CAL), probing depth (PD), keratinized tissue width (KTW), plaque index (PI), gingival index, and gingival bleeding index. The examiner measured 10 patients twice within a time span of 48 h. Intraclass test was carried out to analyze the reproducibility. An intraclass correlation >0.81 was reported and considered acceptable.
Clinical measurements and standardized photographs (horizontal format 1:1) were taken at baseline, 6 weeks, 3 months, and 6 months postsurgery.
Two different treatment modalities were compared: CAF and SCTG (n = 15) with CAF + SCTG with LD (n = 15) [Figure 1]. The primary endpoint assessed was mean root coverage (MRC) and CRC at 6 months. The secondary endpoints were reductions in recession depth (RecRed) and differences in gingival recession width (GRW), PD, CAL, and KTW.
|Figure 1: Consort flow chart of the study. CAF + SCTG + LD = Coronally advanced flap + subepithelial connective tissue graft + laser de-epithelialization|
Click here to view
After the initial therapy, the following parameters were recorded full-mouth PI, full-mouth sulcus bleeding index, recession depth – distance from GM to cementoenamel junction (CEJ) at the mid-buccal site, GRW at the coronal extent of the recession measured from mesial to distal at the CEJ level, PD – distance from the gingival margin to the bottom of the sulcus at the central buccal site, CAL – gingival recession depth (GRD) at central buccal site + PD at central buccal site, and KTW from the gingival margin to the mucogingival junction (MGJ) (identified by visual method using Lugol's solution) at the mid-buccal site.
The clinical measurements of GRD were compared with photogrammetric analysis. Standardized digital photographs that included the entire teeth were taken at baseline, 6 weeks, 3 months, and 6 months. The GRD was calculated with computer-assisted digitizing software (Digimizer version 4.3.0, MedCalc Software, USA).
Aesthetic satisfaction of the patient was evaluated on a visual analog scale (VAS) scores ranging from 0 to 100 (0 indicating very bad, 50 indicating average, and 100 indicating excellent) in terms of overall satisfaction, color match, and the amount of root coverage 6 months postoperatively.
Patients were instructed with nontraumatic toothbrushing and oral hygiene instructions 2 months before surgery. Etiotropic phase of periodontal therapy was completed 2 months before surgery. Periodontal surgery was performed only when the patient demonstrated adequate plaque control.
A computerized randomization sequence was generated. Allocation concealment was followed in sealed and coded envelope that was opened immediately before the graft was harvested. Both the patient and the investigator were blinded to the treatment protocol.
The control group was treated with CAF and SCTG alone and the test group with CAF and SCTG with LD [Figure 2]. After local anesthesia, an intrasulcular incision was performed with surgical blade on the buccal aspect of the recession tooth. This incision was extended horizontally both in mesial and distal directions to dissect the interdental papilla but not incising the gingival margin of the adjacent teeth. This was followed by two oblique, divergent releasing incisions extending beyond the MGJ from the mesial and distal extremes of the horizontal incision. A small elevator was used to raise a full-thickness flap till the MGJ. Subsequently, a partial-thickness flap was raised beyond the MGJ to allow a passive coronal displacement of the flap completely covering the CEJ. Root planing was done. At this juncture, the sealed and opaque envelope was opened, to randomly allot the test and control sites. De-epithelialization of the adjacent papilla was carried with scalpel in the control sites and laser in the test sites. The connective tissue graft was harvested from palate and placed on the root surface at the level of the CEJ and then secured with 5–0 absorbable sutures (Vicryl, Ethicon, Somerville, NJ, USA) in both test and control sites using sling suture. The overlying flap was freed of all muscle insertions to enable passive mobility of the flap to reach a level coronal to the CEJ of the teeth with recession defect. The overlying flap was advanced 1–2 mm coronal to the CEJ and sutured. Pressure was applied with gauze soaked in saline for 2 min to prevent dead space under the flap.
|Figure 2: Surgical procedure: (a) Incision. (b) Flap elevation. (c) Laser de-epithelialization. (d) Incision in the donor site. (e) Harvesting of graft. (f) Final position of flap|
Click here to view
The test site received an application of gallium–aluminum–arsenide diode laser (A.R.C Laser GmbH, Nürnberg, Germany) with a wavelength of 810 nm and a power of 1.5 watt in a continuous mode [Figure 2] Laser irradiation was directed from the coronal to the apical aspect in parallel direction along the inner surface of the flap aimed at a 45° angle without contacting the root surface or alveolar bone and also on the outer surface of the flap. Sulcular epithelium was removed by moving the laser beam laterally and apically. The inner surface was lased to remove the epithelium, but the periosteum and connective tissue were not irradiated. A controlled laser irradiation protocol was followed with a 30-s interruption in the laser emission when the irradiation exceeded 10 s and not exceeding a total dosage of 4J/cm2. The resultant char layer was removed totally with a moist gauze piece before replacing the flaps because wound healing studies have shown that gingival fibroblasts do not adhere to the root surface covered by a laser char. In the control sites, laser application was simulated, without pushing the start button (Sham radiation).
After LD and simulation, the flaps were repositioned 1–2 mm coronal to the CEJ and stabilized with a sling suture in a coronal position, followed by interrupted sutures on the vertical incisions in an apico-coronal direction using 5–0 absorbable sutures. The palatal flap was sutured with silk 4–0 sling sutures (Mersilk, Ethicon, Somerville, NJ, USA). The surgical sites were protected with a noneugenol periodontal dressing (Coe Pack, GC America Inc., IL, USA).
Following surgery, patients were instructed to avoid toothbrushing and mechanical trauma to the surgical area for 2 weeks and intermittently apply an ice bag on the operated area for the first 4 h. Patients were advised to rinse their mouth twice daily for 1 min for 3 weeks using 0.2% chlorhexidine mouthwash. An analgesic ibuprofen 400 mg for pain control every 8 h was advised for 3 days. Sutures were removed after 14 days. Mechanical tooth cleaning of the treated tooth using an ultra-soft toothbrush and roll technique for 1 month was advised after suture removal. LD was also done once every 15 days for the first 4 weeks of healing.,
Patients were recalled for prophylaxis 2 and 4 weeks after suture removal and subsequently once every 2 months until 6 months. All the patients were evaluated clinically at 6 weeks, 3 months, and 6 months clinically.
The value of 0.62 mm obtained from a previous study was considered as covariate. The minimum clinically significant value (d) considered was 0.5 mm. The sample size was calculated to detect 0.5-mm differences between the test and control treatments for root coverage after 6 months and for a power of 80%, with α error = 0.05. Based on these data, a sample of 14 recessions per group was required. With a sample of 15 recessions in each group, the power value was >80%. The analyses were performed by a blind examiner. Statistical analysis was performed using computerized software package (Statistical Package for Social Science, Ver. 10.0.5). Normality of data was tested using Shapiro–Wilk test. Proportions were compared using Chi-square test of significance. The Student's t-test was used to determine whether there was a statistical difference between groups in the following parameters (CRC, MRC, RecRed, difference in GRW, CAL, KTW, VAS) as the data were normal. The Wilcoxon signed-rank test used to compare repeated measurements on a single sample (GRD, GRW, PD, CAL, and KTW) to assess whether their population mean ranks differ. In all the above tests, P < 0.05 was accepted as significance level.
| Results|| |
None of the enrolled patients dropped out of the study. Out of the 15 patients, 11 (73.3%) were males and 4 (26.7%) females. The age group ranged from 34 to 48 years. The mean age was 41.3 ± 4.62 years. Study teeth were maxillary canines (3), maxillary premolars (17), and mandibular canines (2) and mandibular premolars (8), yielding 10 pairs of defects in the maxilla and 5 pairs in the mandible. Surgeries and postoperative sequelae were uneventful and no patient in any group developed any significant complication.
[Table 1] depicts the descriptive statistics for all clinical parameters. At 6 months, the primary endpoint MRC and CRC were similar for test sites [Figure 3] and control sites (P = 0.914) [Table 2]. Both the test and control groups showed similar RecRed with no statistical significance. The reductions in recession width showed no difference between both the treatment options (P = 0.422). The decrease in PD in both test and control groups from baseline to 6 months postsurgery was not significant (P = 0.6). The CAL gain was similar (P = 0.6) for both control (3.3 ± 0.5 mm to 2.6 ± 1.2 mm) and test groups (3.6 ± 1.06 mm to 2.4 ± 0.7 mm). The KTW gain was not statistically significant (P = 0.247) in both the groups [Table 1].
|Figure 3: Presurgical and postsurgical follow-up of test site. (a) Preoperative view of coronally advanced flap with subepithelial connective tissue graft and laser de-epithelialization test site. (b) Clinical outcome after 6 months of the coronally advanced flap with subepithelial connective tissue graft and laser de-epithelialization test site|
Click here to view
MRC was also evaluated with photogrammetric analysis. Photogrammetric analysis showed a P = 0.841. No significant difference at different time intervals in both the groups and between the groups was seen. Photogrammetric analysis was similar to the clinical measurements (P = 0.943). Both the groups showed satisfactory and similar esthetic VAS assessments (P = 0.4) [Table 2].
| Discussion|| |
The concept of LD that retards epithelial migration to obtain new attachment and to prevent repair by long JE has enabled successful clinical outcome with true regeneration in periodontal pockets.,, To the best of our knowledge, this is the first randomized clinical trial designed to evaluate the additional benefit of the use of LD if any in combination with the CAF and SCTG procedure for the treatment of localized gingival recessions.
LD has shown to retard the epithelial down growth when used as an adjunct to regenerative periodontal procedures in the management of chronic periodontitis with conventional surgical procedures such as MWF and LANAP., De-epithelialized laser wound as carried out in the current trial will cause a delay in re-epithelialization due to interference caused from thermal necrosis and firm eschar. The decreased wound contraction associated with decreased number of myofibroblast and decreased inflammation in laser-induced wounds leaves a greater area to be re-epithelialized and provides less stimulation for epithelial migration., The epithelial cell exclusion facilitates new attachment similar to GTR procedures with barrier membranes., The present study demonstrated that CAF and SCTG with LD showed no added advantage and was similar to CAF and SCTG in a 6-month clinical outcome.
The clinical outcome of the current study is similar to those of da Silva et al., Bouchard et al., and Haghighati et al. in the management of Miller's Class I and II gingival recession defect. However, the current study does not compare favorably to these studies probably due to shallower recessions (<3 mm) being included in the trial and smaller sample size. There are no similar studies for root coverage with LD as an adjunct to compare the results of this study. However, the results when compared with GTR-based root coverage procedures have shown similar outcome.,,, In the current study, professional evaluation of outcome was more stringent than the subject evaluated outcome, as the patients reported >90% VAS score for 50% of MRC.
The comparison between the clinical and photogrammetric analyses with MRC (P = 0.841) as an outcome parameter was similar and did not show any statistical significance which is contradictory to Koseoglu's observation 2013.
LD is not deleterious and is comparable with CAF and SCTG. LD can be proposed as an alternate method of de-epithelialization during CAF and SCTG procedures when compared with the conventional GTR measures. The added clinical advantage of laser epithelialization if any was not noted in the current trial.
The relatively small study population constitutes a limitation to generalize the results and any conclusive decisions to be drawn. Regression analyses have shown that root coverage was better for recession defects >5 mm in depth. In the present study, the baseline GRD was 2 mm and could have contributed to a lesser than favorable clinical outcome. LD did not show any added clinical advantage over the gold standard CAF + CTG. Diode lasers (810 nm) can be effectively used for LD. Histological studies have shown that diode laser leads to complete epithelial removal and the current trial corroborates the same.
| Conclusion|| |
Within the limitations of this study, it can be summarized that there was generalized reduction in GRD from baseline to 6 months in both the groups. The MRC and CRC were similar in both the groups. Photogrammetric assessments correlate with the clinical analyses and showed no statistically significant difference. Time-consuming clinical measurements can be replaced with photogrammetric analysis. Subjective evaluation of esthetics of the treatment outcome showed good results. Future research should be directed at long-term controlled clinical trials and histologic evidences of true regeneration to assess the benefit of LD in root coverage procedures. The results of this trial suggest that LD as adjunct to CAF + CTG is similar and produces satisfactory clinical and patient-centered esthetic outcomes as CAF + CTG alone. The additional use of laser for de-epithelialization did not show any benefit clinically.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Susin C, Haas AN, Oppermann RV, Haugejorden O, Albandar JM. Gingival recession: Epidemiology and risk indicators in a representative urban Brazilian population. J Periodontol 2004;75:1377-86.
Chang LC. Comparison of age and sex regarding gingival and papillary recession. Int J Periodontics Restorative Dent 2012;32:555-61.
Chrysanthakopoulos NA. Prevalence and associated factors of gingival recession in Greek adults. J Investig Clin Dent 2013;4:178-85.
Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent Assoc 2003;134:220-5.
Reddy MS. Achieving gingival esthetics. J Am Dent Assoc 2003;134:295-304.
Chambrone L, Pannuti CM, Tu YK, Chambrone LA. Evidence-based periodontal plastic surgery. II. An individual data meta-analysis for evaluating factors in achieving complete root coverage. J Periodontol 2012;83:477-90.
McGuire MK, Scheyer T, Nevins M, Schupbach P. Evaluation of human recession defects treated with coronally advanced flaps and either purified recombinant human platelet-derived growth factor-BB with beta tricalcium phosphate or connective tissue: A histologic and microcomputed tomographic examination. Int J Periodontics Restorative Dent 2009;29:7-21.
Lundgren D, Laurell L, Gottlow J, Rylander H, Mathisen T, Nyman S, et al.
The influence of the design of two different bioresorbable barriers on the results of guided tissue regeneration therapy. An intra-individual comparative study in the monkey. J Periodontol 1995;66:605-12.
Salaria SK, Madaan V, Bala D. A report of laser-assisted modified widman flap for periodontal regeneration: Clinical and radiographic evaluation. Contemp Clin Dent 2010;1:115-8.
] [Full text]
Yilmaz E, Ozcelik O, Comert M, Ozturan S, Seydaoglu G, Teughels W, et al.
Laser-assisted laterally positioned flap operation: A randomized controlled clinical trial. Photomed Laser Surg 2014;32:67-74.
Yukna RA, Carr RL, Evans GH. Histologic evaluation of an nd: YAG laser-assisted new attachment procedure in humans. Int J Periodontics Restorative Dent 2007;27:577-87.
Nevins ML, Camelo M, Schupbach P, Kim SW, Kim DM, Nevins M, et al.
Human clinical and histologic evaluation of laser-assisted new attachment procedure. Int J Periodontics Restorative Dent 2012;32:497-507.
Rossmann JA, Israel M. Laser de-epithelialization for enhanced guided tissue regeneration. A paradigm shift? Dent Clin North Am 2000;44:793-809.
Rossmann JA, McQuade MJ, Turunen DE. Retardation of epithelial migration in monkeys using a carbon dioxide laser: An animal study. J Periodontol 1992;63:902-7.
Fernandes-Dias SB, de Marco AC, Santamaria M Jr., Kerbauy WD, Jardini MA, Santamaria MP, et al.
Connective tissue graft associated or not with low laser therapy to treat gingival recession: Randomized clinical trial. J Clin Periodontol 2015;42:54-61.
Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25:229-35.
Mühlemann HR, Son S. Gingival sulcus bleeding – A leading symptom in initial gingivitis. Helv Odontol Acta 1971;15:107-13.
Köseoǧlu S, Duran İ, Saǧlam M, Bozkurt SB, Kırtıloǧlu OS, Hakkı SS, et al.
Efficacy of collagen membrane seeded with autologous gingival fibroblasts in gingival recession treatment: A randomized, controlled pilot study. J Periodontol 2013;84:1416-24.
de Sanctis M, Zucchelli G. Coronally advanced flap: A modified surgical approach for isolated recession-type defects: Three-year results. J Clin Periodontol 2007;34:262-8.
Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinised gingiva. J Clin Periodontol 1974;1:185-96.
Shapiro M. A reattachment operation. Dent Clin North Am 1960;4:5-10.
Centty IG, Blank LW, Levy BA, Romberg E, Barnes DM. Carbon dioxide laser for de-epithelialization of periodontal flaps. J Periodontol 1997;68:763-9.
Ozturan S, Durukan SA, Ozcelik O, Seydaoglu G, Haytac MC. Coronally advanced flap adjunct with low intensity laser therapy: A randomized controlled clinical pilot study. J Clin Periodontol 2011;38:1055-62.
da Silva RC, Joly JC, de Lima AF, Tatakis DN. Root coverage using the coronally positioned flap with or without a subepithelial connective tissue graft. J Periodontol 2004;75:413-9.
Bouchard P, Etienne D, Ouhayoun JP, Nilvéus R. Subepithelial connective tissue grafts in the treatment of gingival recessions. A comparative study of 2 procedures. J Periodontol 1994;65:929-36.
Haghighati F, Mousavi M, Moslemi N, Kebria MM, Golestan B. A comparative study of two root-coverage techniques with regard to interdental papilla dimension as a prognostic factor. Int J Periodontics Restorative Dent 2009;29:179-89.
Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: A systematic review from the AAP regeneration workshop. J Periodontol 2015;86:S8-51.
Leknes KN, Amarante ES, Price DE, Bøe OE, Skavland RJ, Lie T, et al.
Coronally positioned flap procedures with or without a biodegradable membrane in the treatment of human gingival recession. A 6-year follow-up study. J Clin Periodontol 2005;32:518-29.
Nickles K, Ratka-Krüger P, Neukranz E, Raetzke P, Eickholz P. Ten-year results after connective tissue grafts and guided tissue regeneration for root coverage. J Periodontol 2010;81:827-36.
Trombelli L, Scabbia A, Tatakis DN, Calura G. Subpedicle connective tissue graft versus guided tissue regeneration with bioabsorbable membrane in the treatment of human gingival recession defects. J Periodontol 1998;69:1271-7.
Amarante ES, Leknes KN, Skavland J, Lie T. Coronally positioned flap procedures with or without a bioabsorbable membrane in the treatment of human gingival recession. J Periodontol 2000;71:989-98.
Israel M, Rossmann JA, Froum SJ. Use of the carbon dioxide laser in retarding epithelial migration: A pilot histological human study utilizing case reports. J Periodontol 1995;66:197-204.
Pini Prato G, Clauser C, Cortellini P, Tinti C, Vincenzi G, Pagliaro U, et al.
Guided tissue regeneration versus mucogingival surgery in the treatment of human buccal recessions. A 4-year follow-up study. J Periodontol 1996;67:1216-23.
Romanos GE, Henze M, Banihashemi S, Parsanejad HR, Winckler J, Nentwig GH, et al.
Removal of epithelium in periodontal pockets following diode (980 nm) laser application in the animal model: An in vitro
study. Photomed Laser Surg 2004;22:177-83.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]