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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 13  |  Issue : 1  |  Page : 48-53

Comparison of effectiveness of hyaluronic acid in combination with polylactic acid/polyglycolic acid membrane and subepithelial connective tissue graft for the treatment of multiple gingival recession defects in human: A clinical study


1 Department of Periodontics, Dr. Rajesh Kambe Dental College and Hospital, Akola, Maharashtra, India
2 Department of Periodontics, Sharad Pawar Dental College and Hospital, DMIMS, Sawangi (Meghe), Wardha, Maharashtra, India
3 Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College and Hospital, DMIMS, Sawangi (Meghe), Wardha, Maharashtra, India

Date of Web Publication10-Sep-2018

Correspondence Address:
Dr. Akash Kasatwar
Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College and Hospital, Sawangi (Meghe), Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_39_18

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  Abstract 


Background: The patients today are increasingly conscious of personal appearance, and much attention has been focused on denuded roots that are exposed during smiling which look unesthetic. These concerns have given rise to numerous approaches for covering denuded root surfaces; however, difference of opinions is prevailing among the clinicians. Objectives: Therefore, the present study was undertaken to compare the effectiveness between hyaluronic acid (HA) in combination with polylactic acid/polyglycolic acid (PLA/PGA) membrane with that of subepithelial connective tissue graft (SCTG) for the treatment of multiple gingival recession defects. Material and Methods: Twenty-four systemically healthy patients were randomly assigned to the test guided tissue regeneration (GTR-HA) and control SCTG groups. Clinical measurements, including probing pocket depth, relative attachment level, and relative gingival margin level, were measured at baseline and at the 6-month follow-up. Result and Conclusions: After 6 months, the mean reduction in gingival recession in the test group was 2.55 ± 0.45 mm whereas in the control group, it was 2.11 ± 0.58 mm. The test group showed mean root coverage of 92.93%, and the control group showed 84% at 6 months postsurgery. When HA in combination with bioresorbable PLA/PGA membrane was compared with SCTG group; there was signifi cantly greater root coverage, clinical attachment level gain, and increased width of keratinized gingiva in the test group.

Keywords: Bioresorbable polylactic acid/polyglycolic acid membrane, gingival recession, hyaluronic acid, subepithelial connective tissue graft


How to cite this article:
Nandanwar J, Bhongade ML, Puri S, Dhadse P, Datir M, Kasatwar A. Comparison of effectiveness of hyaluronic acid in combination with polylactic acid/polyglycolic acid membrane and subepithelial connective tissue graft for the treatment of multiple gingival recession defects in human: A clinical study. J Datta Meghe Inst Med Sci Univ 2018;13:48-53

How to cite this URL:
Nandanwar J, Bhongade ML, Puri S, Dhadse P, Datir M, Kasatwar A. Comparison of effectiveness of hyaluronic acid in combination with polylactic acid/polyglycolic acid membrane and subepithelial connective tissue graft for the treatment of multiple gingival recession defects in human: A clinical study. J Datta Meghe Inst Med Sci Univ [serial online] 2018 [cited 2019 Jun 26];13:48-53. Available from: http://www.journaldmims.com/text.asp?2018/13/1/48/240895




  Introduction Top


Root coverage procedures are indicated to correct the areas of localized or generalized soft-tissue recession, to resolve root sensitivity, and to treat shallow areas of root caries, especially in the anterior teeth, where esthetics is a prime concern to the patient. These concerns have given rise to numerous approaches for covering denuded root surfaces; however, difference of opinions is prevailing among the clinicians.

The use of subepithelial connective graft combined with coronally advanced flap technique showed a significantly greater degree of predictability in the correction of multiple gingival recessions with a mean root coverage ranging from 84% to 100%.[1],[2] Although most studies suggest healing through a long junctional epithelium or through connective tissue adaptation with adjacent root surfaces.[3] The use of guided tissue regeneration (GTR) technique showed improved soft-tissue condition of gingival recession defects, regarding clinical attachment gain, recession depth reduction and increase in keratinized tissue, the healing of periodontal defect using GTR therapy occurs by new attachment [4] rather than true periodontal regeneration. Therefore, periodontal regeneration in the context of GTR therapy has been questioned.[5] This indicates that further theoretical and technical developments are needed in the field of periodontal regeneration therapies before such therapy can be widely used in daily practice.

Recently, research has focused on a new substance, hyaluronic acid (HA), which is widely applied in other medical specialties such as ophthalmic and orthopedic surgery.[6],[7] HA has a number of embryological and bone healing properties including the facilitation of cell migration and differentiation during tissue formation and repair.[8],[9] HA shares bone induction characteristics with osteogenic substrates such as bone morphogenic proteins.[10] It has been recently reported that HA increases osteoblastic bone formation in vitro through increased mesenchymal cell differentiation and migration. However, few studies [11],[12] have examined its possible regenerative effects in dentistry particularly in periodontics. Therefore, the present study was undertaken to compare the effectiveness between HA in combination with polylactic acid/polyglycolic acid (PLA/PGA) membrane with that of subepithelial connective tissue graft (SCTG) for the treatment of multiple gingival recession defects.


  Materials and Methods Top


Study population

Twenty-four systemically healthy patients aged between 19 and 37 years (mean age 28.08 ± 5.45) with multiple gingival recession defects on labial or buccal surfaces of the teeth were selected. The patients included in the study were the presence of multiple gingival recession (more than one) defects on the labial/buccal surfaces of the teeth either in maxilla or mandible classified as either Miller's Class I or II, presence of ≥2 mm gingival recession depth, radiographic evidence of sufficient interdental bone (the distance between the crestal bone and cementoenamel junction (CEJ) as ≤2 mm), and presence of width of keratinized gingiva (WKG) apical to recession ≥3 mm. Patients using tobacco products, with unacceptable oral hygiene after phase I therapy and showing plaque score ≥1, history of periodontal surgical treatment in quadrant selected for the study, pregnant ladies or lactating mother, presence of badly carious teeth, and presence of mobile teeth were excluded from the study.

Study design

Patients were randomly assigned to one of the following two groups. The test group was treated using GTR + HA (GTR-HA) [Figure 1] while control group was treated using SCTG alone [Figure 2].
Figure 1: (a) Gingival recession measurement using University of North Carolina-15 probe with acrylic stent in position preoperatively. (b) After reflection of the flap. (c) Hyaloss gel applied at the defect site beneath the polylactic acid/polyglycolic acid membrane. (d) Gingival recession measurement using University of North Carolina-15 probe with acrylic stent in position at 6 months. (e) Six months postoperatively

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Figure 2: (a) Gingival recession measurement using University of North Carolina-15 probe with acrylic stent in position preoperatively. (b) After reflection of flap. (c) Subepithelial connective tissue graft sutured at recipient site. (d) Gingival recession measurement using University of North Carolina-15 probe with the acrylic stent in position at 6 months. (e) Six months postoperatively

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Clinical measurements

Indices

  1. Plaque index [13]
  2. Papillary Bleeding Index.[14]


Probing measurements

A stent was fabricated with a reference point (slot) impressed on the stent at the mid-labial area of the involved tooth to allow reproducible periodontal probe positioning. The following clinical parameters were recorded for assessment of the results. The probing pocket depth (PPD), relative attachment level (RAL), and relative gingival margin level (RGML) were measured with a University of North Carolina (UNC)-15 calibrated (UNC, HuFriedy) periodontal probe. All the probing measurements were recorded at maximum depth of recession (mid-facially) per tooth. These clinical parameters were recorded using acrylic stent at baseline and again at 6 months after surgery.

Surgical procedure for test group

Before the surgical procedure, the patients were instructed to rinse with 0.2% chlorhexidine gluconate (Hexidine-ICPA Health Product Ltd. India) for 1 min. The patients were draped to expose only the oral cavity. Asepsis was maintained throughout the entire procedure. The area subjected to surgery was anesthetized by infiltration anesthesia, using local anesthetic solution of 2% xylocaine containing 1:100,000 epinephrine (Ligno-Ad local anesthetic, Proxim Remedies, India).

Recipient site preparation

Intrasulcular incision was made at the buccal/labial aspect of the involved teeth, and the incision was extended horizontally into the adjacent interdental areas, at the level slightly coronal to the cementoenamel junction without interfering with the gingival margin of the neighboring teeth. Two oblique vertical incisions mesial and distal to the selected sites were placed extending beyond the mucogingival junction and a trapezoidal mucoperiosteal flap was raised upto the margin of alveolar bone. After this point, a split thickness flap was extended apically beyond the MGJ for releasing the tension and favoring the coronal positioning of the flap. The epithelium from the adjacent papillae was stripped away so as to create a connective tissue bed for suturing the coronally positioned flap. The root surface was instrumented with curettes and washed with saline solution.

A sterile aluminum foil was utilized to obtain the approximate dimensions and shape of the membrane. The bioabsorbable membrane (BioMesh-S ®, Biodegradable GTR barrier, Samyang crop, Korea) was trimmed in such a way that it completely covers the root surface and extends at least 2 mm beyond the defect on all sides and sutured in place using continuous sling 4-0 resorbable sutures (black-braided polyglactin 910, vicryl, Johnson and Johnson Ltd.). Hyaloss matrix (HA – Esterified HA in the form of fibers, Hyaloss matrix ®, Meta, Italy) was mixed thoroughly with a few drops of physiological saline solution, in a sterile mixing container and hydrated. After hydration, hyaloss matrix transformed into gel. Hyaloss matrix gel was applied on denuded root surfaces with the help of a fine, sterile, disposable brush after raising the membrane upward. The flap was then coronally positioned, ensuring the membrane was not exposed and sutured in such a way that the flap margin was located 1–2 mm coronal to CEJ, thereby completely covering the membrane. Slight pressure was applied to the area with saline-soaked gauze for approximately 2 min, to adapt the soft tissue well to the tooth surface and eliminate any space in which a clot might form and disrupt reattachment. The surgical site was dressed with periodontal dressing (CoE-Pak™, GC, INC, ALSIP, IL, USA) on buccal aspects.

Surgical procedure for control group

Recipient site preparation for control group was identical to the test group.

Harvesting of connective tissue graft

The template was designed for recipient site extending coronally up to CEJ and apically 2–3 mm to the crest of the alveolar bone. Then, an incision was made in the palate parallel to the maxillary canine and first molar at a distance of approximately 2–3 mm apical to gingival margin toward the midline. Perpendicular incisions were made to establish width of graft. A split thickness flap was raised with an incision straight to the bone to expose the underlying connective tissue. Finally, the graft was removed and was then placed on a sterile gauze pad and irrigated with saline and then modified as per the required dimensions after removal of excess fatty and glandular tissue. The primary flap at the donor site was then returned to its original position and sutured with 3–0/4–0 Mersilk sutures to obtain primary closure using interrupted suturing technique or crossed horizontal suspension suturing technique. Primary tension-free wound closure was achieved to avoid postoperative contamination.

Placement of connective tissue graft over the recipient site

The connective tissue graft obtained from the donor site was placed at the recipient site at the level of CEJ, covering the entire recession area and adjacent connective tissue bed, and it was sutured by sling sutures (4-0 absorbable suture, black braided polyglactin 910, vicryl, Johnson and Johnson Ltd.). After approximating graft over recession, the flap was positioned coronally to completely cover the connective tissue graft and the deepithelialized portion of the papilla. The coronal margin of the flap was placed slightly coronal to CEJ and stabilized with simple interrupted 3-0 silk sutures laterally and coronally. Light pressure was applied to the area with saline-soaked gauze for approximately 2 min to adapt the soft tissue to the tooth surface.

Postoperative care

Immediately after surgery, periodontal dressing (Coe-Pak, TM, GC, America Inc, ALSIP, IL, USA) was placed on the recipient site as well as donor site. Nonsteroidal anti-inflammatory tab. Ibugesic Plus (Ibuprofen 325 mg + Paracetamol 400 mg), t.i.d and systemic antibiotic Cap. Mox (Amoxicillin 500 mg), t.i.d were prescribed for 5 days during the postsurgical period. Patients were instructed not to brush the teeth for first 3 weeks after surgery at the treated sites. All patients were instructed to rinse with 0.2% chlorhexidine gluconate (Hexidine-ICPA) twice daily, for 2 weeks. They were instructed not to disturb the pack and to avoid undue trauma to the treated sites.

Statistical analysis

The mean and standard deviation (mean ± SD) values were calculated for all the parameters. The mean data were analyzed for statistical significance by standard statistical methods.[15] Student's paired t-test was used to compare data from baseline to those at 6 months for each treatment group. Comparisons between treatment groups at baseline and 6 months were student's unpaired t-test. If the probability value (P) was more than 0.05, the difference observed was considered nonsignificant and if <0.05, it was considered statistically significant.


  Results Top


Healing was uneventful for all 24 patients (57 recession defects) and none of the selected patients drop out before the termination of the study.

Clinical indices

In general, patients showed good oral hygiene throughout the study. The mean full mouth plaque index (FMPI) score and full mouth papillary bleeding index (FMPBI) scores at baseline and 6 months' follow-up for test and control groups were statistically significant [Table 1].
Table 1: Mean Full Mouth Plaque Index (FMPI) and Mean Full Mouth Papillary Bleeding Index (FMPBI) Scores at Baseline and 6 Months follow-up (mean±SD)

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Clinical outcome at 6 months

Changes in gingival recession depth

In the test group, the mean RGML at baseline was 8.85 ± 0.95 mm (range 6–12 mm) and at 6 months follow-up, it was 6.30 ± 0.83 mm (range 4–7 mm), with a mean renewable energy certificate (REC) reduction of 2.55 ± 0.45 mm [Table 2]. Student's paired t-test indicated that the mean REC reduction at 6 months was statistically significant (P < 0.05) compared to the baseline value. This value corresponds to the mean root coverage of 92.93% ±13.54% in the test group [Table 4]. In the control group, the mean RGML at baseline was 8.88 ± 1.03 mm (range 6–12 mm) and at the 6 months follow-up, it was 6.77 ± 0.88 mm (range 4–7 mm), with a mean REC reduction of 2.11 ± 0.58 mm [Table 2]. Student's paired t-test indicated that the mean REC reduction at 6 months was statistically significant (P < 0.05) compared to the baseline value. This corresponds to mean root coverage of 84% ± 21.74% [Table 4].
Table 2: Clinical parameters

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Table 3: Comparison of clinical parameters between Test and Control groups at 6 Months follow-up (Mean±SD; in mm)

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Table 4: Comparison of mean percentage of root coverage corresponding to mean reduction in Gingival Recession between Test and Control groups (Mean±SD; in mm)

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At 6 months, when mean reduction in the gingival recession was compared between the test group (2.55 ± 0.4 mm) and the control groups (2.11 ± 0.58 mm), a greater reduction was found in the test group [Table 3]. When comparison was made for mean root coverage between test and control groups, at 6 months using Student's unpaired t-test, significantly higher root coverage was observed in the test group (92.93 ± 13.54 vs. 84 ± 21.74) [Table 4].

Changes in probing pocket depth

In the test group, the mean PPD at baseline was 1.53 ± 0.36 mm (range 1–2 mm), and at 6 months, it was 1.15 ± 0.36 mm (range 1–2 mm) with a mean reduction of 0.38 ± 0.57 mm [Table 2]. Student's paired t-test indicated that the mean PPD reduction at 6 months was statistically significant (P < 0.05) when compared to the baseline data. In the control group, the mean pocket depth at baseline was 1.45 ± 0.50 mm (range 1–2 mm), and at 6 months, it was 1.06 ± 0.24 mm (range 1–2 mm) with mean reduction of 0.38 ± 0.55 mm.[Table 2].

When the mean PPD reduction in test group (0.38 ± 0.57 mm) was compared with the mean PPD reduction in control group (0.38 ± 0.55 mm) using Student's unpaired t-test, there were nonsignificant differences between test and control groups [Table 3].

Changes in clinical attachment level

In the test group, the mean RAL at baseline was10.50 ± 1.14 mm (range 7–13 mm), and at 6 months, it was 7.46 ± 0.76 mm (range 5–8 mm) with mean gain in clinical attachment level (CAL) of 3.03 ± 0.87 mm. Student's paired t-test indicated that the mean CAL gain at 6 months was significantly greater (P < 0.05) [Table 2]. In the control group, the mean RAL at baseline was10.19 ± 1.16 mm (range 7–13 mm), and at 6 months, it was 7.83 ± 0.93 mm (range 5–8 mm), with a mean gain of CAL of 2.35 ± 0.83 mm. Student's paired t-test indicated that the mean CAL gain in control group at 6 months was significantly greater (P < 0.05) [Table 2]. When the mean CAL gain in test group (3.03 ± 0.87 mm) was compared with the mean CAL gain in control group (2.35 ± 0.83 mm) using Student's unpaired t-test, the mean CAL gain was significantly higher in the test group (P < 0.05) [Table 3].

Width of keratinized gingiva

In test group, the mean WKG at baseline was 3.23 ± 0.65 mm (range 3–5 mm), and at 6 months it was 5.76 ± 0.90 (range 3–8 mm) with a mean increase of 2.53 ± 0.50 mm. Student's paired t-test indicated that the mean WKG increase at 6 months was statistically significant (P < 0.05) when compared to the baseline data [Table 2]. The mean WKG at baseline for the control group was 3.03 ± 0.17 mm (range 3–5 mm) and at 6 months, it was 5 ± 0.57 mm (range 3–8 mm). Student's paired t-test indicated that there was a statistically significant increase in the WKG (1.96 ± 0.54 mm) at 6 months, when compared to the baseline value [Table 2]. When the mean increase in the WKG in the test group (2.53 ± 0.50 mm) at 6 months was compared with the mean increase in WKG in control group (1.96 ± 0.54 mm) using Student's unpaired t-test, there was significantly greater increase in WKG in the test group [Table 3].

When the mean percentage of root coverage in the test group (92.93 ± 13.54) was compared with the mean percentage of root coverage in the control group, using Student's unpaired t-test, there was significantly greater percentage of root coverage (8.92% ±7.39%) in the test group [Table 4].


  Discussion Top


A total of 57 buccal/labial recession defects in 24 patients were treated. Twenty-six recession defects were treated with HA in combination with PLA/PGA membrane with coronally positioned flap in the test group, while 31 recession defects were treated with subepithelial connective tissue graft in combination with coronally positioned flap in control group. There was no sign of allergy, infection, or any other complication in any patient after the use of HA and PLA/PGA membrane, which indicates that the product was well tolerated. In the present study, all the operated patients were generally satisfied with both the treatment modalities.

Each patient participated in the study showed good oral hygiene. The FMPI score and FMPBI scores were low at baseline and remained low (<1) during 6 months' study period.

At 6 months, statistically significant reduction in gingival recession was found in both the treated groups (2.55 mm for test group and 2.11 mm for control group). In the control group, mean recession defect depth was decreased from 2.61 mm (range 2–5 mm) to 0.49 mm (range 0–3 mm) at 6 months postsurgery, which corresponds to mean recession defect coverage of 84%. The frequency data regarding effectiveness and predictability for root coverage in control group, 21 out of 31 treated recession defects showed complete root coverage (65.27%). The results of the present study on the use of SCTG in combination with coronally positioned flap for the treatment of multiple gingival recession are comparable to those reported by Zanwar et al.[16] and Singh and Bharti.[17]

In the test group, a statistically significant reduction in the mean recession defects was observed at 6 months' postsurgery compared to baseline. Mean gingival recession in the test group was decreased from 2.86 mm (range 2–4 mm) to 0.30 mm (range 0–2 mm) at 6 months, which corresponds to a mean recession defect coverage of 92.93% and 20 out of 26 treated recession defects (77.77%) showed complete root coverage. Since no clinical data are available in the literature on the use of HA in combination with PLA/PGA membrane for the treatment of multiple gingival recession defects; the results of the present study were compared with the studies reported on individual use of PLA/PGA membrane alone as well as use of HA alone for the treatment of multiple gingival recession defect by Tatakis and Trombelli,[18] Paolantonio,[19] Kumar et al.,[20] and Rajan et al.[21]

In the present study, the mean gain in the CAL at 6 months was 3.03 mm for the test group and 2.35 mm for the control group. At 6 months, mean CAL gain in test group was compared with the control group, significantly higher CAL gain was observed in the test group. The type of healing obtained in test group (HA in combination with PLA/PGA) can only be speculated on since no histological studies are available due to ethical considerations. Based on the histological evidence from human material,[22] it may be assumed that the clinical improvements following the use of esterified HA may represent, at least to some extent, a real periodontal regeneration characterized by the increase in osteoblastic activity by stimulating differentiation and migration of mesenchymal cells.

In the present study, both test and control groups showed statistically significant mean PPD reduction of 0.38 mm at 6 months. Similar findings have been reported in the literature by other authors. Vandana and Sikri [23] evaluated the effectiveness of PLA/PGA membrane in the treatment of human buccal gingival recession and observed PPD reduction of 1 mm, at 6 months postoperatively.

In the present study, mean WKG was significantly increased in both the test (HA in combination with PLA/PGA group 2.53 mm) and control groups (SCTG group 1.96 mm) at 6 months. The results obtained in the present study are comparable with the findings reported in the previous studies. Deshpande et al.(2014)[24] examined the effectiveness of connective tissue graft for the treatment of Miller's Class I and II multiple gingival recession and reported 1.5 mm increase in WKG.


  Conclusion Top


From the analysis of the results and within the limitations of the present study, the following conclusions were drawn:

  1. Treatment with HA in combination with bioresorbable PLA/PGA membrane was effective for multiple gingival recession defects regarding significant reduction of gingival recession, which corresponded to 92.93% of root coverage with significant CAL gain, PPD reduction, and gain in WKG
  2. Treatment with SCTG was effective for the management of multiple gingival recession defects regarding significant reduction of gingival recession, which corresponded to 77.77% of root coverage with significant CAL gain, PPD reduction, and gain in WKG
  3. When HA in combination with bioresorbable PLA/PGA membrane was compared with SCTG group, there was significantly greater root coverage, CAL gain, and increased width of keratinized gingiva in test group.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Zanwar K, Laxmanrao Bhongade M, Kumar Ganji K, B Koudale S, Gowda P. Comparative evaluation of efficacy of stem cells in combination with PLA/PGA membrane versus sub-epithelial connective tissue for the treatment of multiple gingival recession defects: A clinical study. J Stem Cells 2014;9:253-67.  Back to cited text no. 16
    
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[PUBMED]  [Full text]  
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Kumar R, Srinivas M, Pai J, Suragimath G, Prasad K, Polepalle T, et al. Efficacy of hyaluronic acid (hyaluronan) in root coverage procedures as an adjunct to coronally advanced flap in millers class I recession: A clinical study. J Indian Soc Periodontol 2014;18:746-50.  Back to cited text no. 20
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    Figures

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