comparison of periosteal pedicle graft and subepithelial connective tissue graft for the treatment...

S C I E N T I F I C A R T I C L EAustralian Dental Journal 2012; 57: 51–57

doi: 10.1111/j.1834-7819.2011.01648.x

Comparison of periosteal pedicle graft and subepithelialconnective tissue graft for the treatment of gingival recessiondefects

A Mahajan,* A Bharadwaj,* P Mahajan�

*Department of Periodontics, Himachal Pradesh Government Dental College and Hospital, Shimla, India.�Department of Preventive and Community Dentistry, Himachal Pradesh Government Dental College and Hospital, Shimla, India.

ABSTRACT

Background: The use of periosteum as a pedicle graft in the treatment of gingival recession defects is a recent advancement.The subepithelial connective tissue graft (SCTG) is considered the gold standard for the treatment of gingival recessiondefects. The present randomized controlled trial was done to compare periosteal pedicle graft (PPG) with SCTG for thetreatment of gingival recession defects.Methods: 10 males and 10 females between the ages of 16 and 40 years (mean age 25.2 years) with Miller’s Class I and IIrecessions ‡3 mm participated in this one-year clinical study. They were assigned randomly to test group (PPG) and controlgroup (SCTG). Results were evaluated based on parameters measuring patient satisfaction and clinical outcomes associatedwith two treatment procedures. Significance was set at p < 0.05.Results: At the end of the study, the defect coverage was 3.1 ± 0.13 mm or 92.6% in the test group compared to the controlgroup in which the defect coverage was 2.70 ± 0.11 mm or 88.5%. The difference between the two groups was statisticallysignificant (p < 0.0001). The average residual defect was comparable between the two groups, i.e. 0.3 ± 0.67 and 0.5 ± 0.84in the PPG and SCTG group respectively. The test group was rated higher in terms of overall patient satisfaction (p < 0.02)and comfort during and after the procedure (p < 0.001).Conclusions: PPG and SCTG have comparable clinical effectiveness, but PPG is superior to SCTG in terms of patient-centred outcomes, reflecting improved patient comfort and overall patient satisfaction.

Keywords: Gingival recession, periosteal pedicle graft, subepithelial connective tissue graft.

Abbreviations: CEJ = cemento-enamel junction; PPG = periosteal pedicle graft; SCTG = subepithelial connective tissue graft.

(Accepted for publication 20 June 2011.)

INTRODUCTION

Multiple techniques have been developed to obtainpredictable root coverage.1–3 Periodontists can chooseamong many surgical techniques to achieve predictableoptimal results. The purpose of developing newermethods for root coverage is to increase predictability,reduce the number of surgical sites, and improve patientcomfort together with a need to reconstruct the lostperiodontal tissues. The selection of one rather thananother technique depends on factors related to defect(size of recession, absence or presence of keratinizedtissue adjacent to defect, width and height of interden-tal soft tissue, depth of vestibulum or the presence offrenenuli), while others related to the patient includedthe attempt to reduce the number of surgeries andintraoral surgical sites together with the need to satisfythe patient’s aesthetic demands such as final colour and

tissue blend of the grafted area. Among all thetechniques used for the treatment of gingival recessiondefects, the subepithelial connective tissue graft (SCTG)is considered the gold standard4–6 but has a number ofshortcomings; the surgery requires a second operationto obtain the donor tissue from the palate; the amountof donor tissue is limited; and the procedure signifi-cantly increases the complications and pain resultingfrom the surgery due to the need to surgically open asecond site to obtain the donor tissue. There has longbeen a need for a graft which has its own blood supplythat can be harvested adjacent to the recession defect insufficient amounts without requiring any second surgi-cal site and has the potential to promote the regener-ation of lost periodontal tissue. The adult humanperiosteum is highly vascular and is known to containfibroblasts, osteoblasts and their progenitor cells, andstem cells.7 Recently, the periosteum has been used

ª 2012 Australian Dental Association 51

Australian Dental JournalThe official journal of the Australian Dental Association

successfully as a pedicle graft to treat isolated as well asmultiple gingival recession defects.8,9 To date, no studyhas been done to compare and evaluate the results ofperiosteal pedicle graft (PPG) with other techniquesused for the treatment of gingival recession defects. Thepresent study was undertaken to evaluate PPG in termsof patient satisfaction and its effectiveness and effi-ciency in the treatment of gingival recession defects,and to compare the results with the established SCTGtechnique.

MATERIALS AND METHODS

Study design

The present study was a randomized controlled trialwith a parallel group design. The Consolidated Stan-dards of Reporting Trials (CONSORT) guidelines forclinical trials were followed. A clinician not involvedwith the study sequenced the study subjects to thetherapy allocated. When performing their study tasks,the study examiner and the operator were not jointlypresent with the study subjects. Study subjects wereinstructed not to discuss therapy with the studyexaminer. The study examiner was unaware of studytreatment allocations and performed all clinical mea-surements. The operator was well experienced and hadperformed both the techniques in the past. Based on acoin toss, subjects (10 males and 10 females betweenthe ages of 16 and 40 years [mean age 25.2 years]) withisolated gingival recession defects in relation to thebuccal aspect of maxillary or mandibular teeth wererandomly selected from the outpatient department ofthe Department of Periodontics, Himachal PradeshGovernment Dental College and Hospital, Shimla,India. Subjects were divided into test (PPG) and control(SCTG) groups. A consent form was signed by allsubjects. Subjects reporting between 1 October 2009and 1 January 2011 were included in the study.

Cases were chosen based on the following inclusioncriteria: non-compromised systemic health and nocontraindication for periodontal surgery; Miller ClassI or II recession defect >3 mm in upper and ⁄ or loweranterior teeth; the involved tooth was well aligned inthe dental arch and free of periapical pathology.Exclusion criteria were: smokers and chewers oftobacco; endodontically treated test or control sites;root surface restorations on test or control sites;pregnant and lactating women; use of fixed orthodonticor removable appliances; and a previous root coverageprocedure at test or control sites.

Clinical parameters

Patient’s satisfaction was assessed using a three-pointrating scale: ‘fully satisfied’, ‘satisfied’ and ‘unsatisfied’

in which the patient was questioned about his ⁄ hersatisfaction with regard to the following patient-centredcriteria: (1) root coverage attained; (2) relief fromdentinal hypersensitivity; (3) colour of gums; (4) shapeand contour of gums; (5) surgical procedure – patientwas asked to rate the procedure depending upon thepain during surgery and discomfort he ⁄ she experiencedrelated to the duration of the procedure and handling bythe operator; (6) post-surgical phase – patient’s opinionregarding pain, swelling and postoperative complica-tions was assessed based on his ⁄ her view of the post-treatment phase; (7) cost-effectiveness – patients wereasked whether the treatment given to them justified thetime and money they spent for their treatment.

The following scores were given by the patients:

Score Interpretation3 fully satisfied2 satisfied1 unsatisfied

Objective criteria used to assess the treatmentoutcome included measurement of: (1) length ofrecession – gingival recession was measured as thedistance between the cemento-enamel junction (CEJ)and the most apical point of the gingival margin;(2) probing depth – probing depth was measured as thedistance from the bottom of the pocket to the mostapical portion of the gingival margin; (3) width ofkeratinized gingiva – the width of keratinized gingivawas measured from the most apical point of thegingival margin to the mucogingival junction; and(4) width of attached gingiva – the width of attachedgingiva was calculated by subtracting the probing depthfrom the width of keratinized gingiva.

All measurements were recorded to the nearestmillimetre preoperatively, i.e. 0 day (just before sur-gery) and postoperatively at 12 months with a cali-brated UNC-15 probe (Hu-Friedy, Chicago, IL, USA).

Pre-surgical management

A general assessment of patients was made based ontheir history, clinical examination and routine labora-tory investigations. All the selected patients receivedPhase 1 therapy, which included oral hygiene instruc-tions, scaling and root planing by both ultrasonic andhand instruments. One month after Phase 1 therapy,the patients were subjected to surgical procedure.

Surgical procedure

Test group (PPG)

After local anaesthesia with a solution of 2%lignocaine with 1:80 000 adrenaline, an intrasulcularincision was made at the buccal aspect of the

52 ª 2012 Australian Dental Association

A Mahajan et al.

involved tooth. Two horizontal incisions were thenmade perpendicular to the adjacent interdentalpapillae at the level of the CEJ preserving thegingival margin of the neighbouring teeth, followedby two oblique vertical incisions extending beyondthe mucogingival junction. A full thickness trapezoi-dal flap was raised 3–4 mm apical to the osseouscrest which was then pulled buccally to create tensionon the periosteum. An incision was made through theperiosteum where the flap was still attached to boneto create a partial thickness flap. The partial thicknessflap was extended to expose a sufficient amount ofthe periosteum which was then separated from theunderlying bone using a periosteal elevator. Theprocess of harvesting the periosteal graft was initiatedat the apical extent of the periosteum which waslifted slowly in a coronal direction. The periosteumwas not separated completely from the underlyingbone, leaving it attached at its coronal most ends.Thus, the periosteal pedicle graft obtained was thenturned over the exposed root surface and suturedwith a synthetic 5-0 bioabsorbable suture (EthiconJohnson and Johnson, Aurangabad, India). Afterstabilizing the periosteal graft, the flap was coronallypositioned and sutured using a sling suture techniquewith a non-resorbable 4-0 silk suture. The releasingincisions were closed with interrupted sutures afterwhich the operated site was covered with non-eugenol periodontal dressing for protection. Post-operative instructions were given to the patient.Nimesulide 100 mg twice daily was also prescribedfor 1 week. During the recovery phase of the wound,the subjects were advised to follow scrupulously allnormal oral postoperative hygiene instructions includ-ing not to brush the operated tooth for 2 weeks andto rinse the oral cavity with chlorhexidine (0.2%)mouthwash twice daily for at least 2 weeks. After1 week the periodontal dressing and sutures wereremoved and the surgical area was flushed withantimicrobial solution. Subjects were recalled everyweek for the first 4 weeks, then every 2 weeks for thenext 8 weeks, and monthly until the end of the study.Figures 1a to 1g show treatment over time.

Control group (SCTG)

The traditional subepithelial connective tissue grafttechnique described by Langer and Langer10 was usedto cover the gingival recession defects. The recipient sitewas prepared by raising a partial thickness flap createdwith two vertical incisions placed at least one-half toone tooth wider mesiodistally than the area of gingivalrecession. The coronal margin of the flap was startedwith a horizontal sulcular incision to preserve allexisting facial gingiva. The proximal papillae were leftintact. Care was taken to extend the flap to the

mucobuccal fold without perforations that could affectthe blood supply. The area was irrigated with sterilesaline solution. A second surgical site was created onthe palate where the location of a greater palatineneurovascular bundle was detected. The incisions wereplaced between the distal aspect of the canine and themidpalatal region of the first molar area with the trap-door technique. A connective tissue graft in an adequatesize of 2 mm thickness was harvested, and pressure wasapplied to the donor area with gauze soaked in salineafter the graft was taken. The donor area was closedwith silk 4-0 sling sutures and graft stabilization wasdone in a similar manner as for the test group after

(a)

(b)

(c)

(d)

(e)

(f)

(g)

Fig 1. (a) Marked gingival recession defect in relation to maxillaryleft canine. (b) Partial thickness flap raised to expose the periosteum.(c) Periosteal pedicle graft. (d) Periosteal pedicle graft sutured to coverthe gingival recession defects. (e) The graft covered with the overlyingmucosal flap and sutured. (f) Postoperative (1 week). (g) Treatment

outcome after 1 year.


Treatment of gingival recession defects

which the operated site was covered with non-eugenolperiodontal dressing for protection. Postoperativeinstructions were given to the subjects similar to thetest group. Subjects were recalled every week for thefirst 4 weeks, then every 2 weeks for the next 8 weeksand monthly until the end of the study.

Statistical analysis

Mean and standard deviation were calculated for bothtest and control groups for all the clinical parameters.Analysis of variance was used to evaluate the degree ofvariation from the mean within a group and among thegroup. On the basis of this variation, a ratio (F-ratio)was calculated. Paired ‘t’ test was used to test thesignificance of change. To test the significance ofchange in groups, the unpaired ‘t’ test was used.P was the level of significance calculated. A p £ 0.05result was considered statistically significant.

RESULTS

Healing was uneventful and the subjects were satisfiedwith the treatment outcome. As the postoperative timeincreased, the progressive adaptation of the edges of thegraft to the surrounding tissues and increased morpho-logic and chromatic resemblance was observed. At theend of the study, sites treated with PPG had a meandefect coverage of (92.6%). For SCTG, the mean defectcoverage was (88.5%). Significant reduction in gingivalrecession length was noticed at the end of the study forboth PPG (Fig. 1g) and SCTG groups. No statisticallysignificant differences were observed between thegroups in the remaining clinical parameters at thebaseline. The results of intragroup analysis are summa-

rized in Table 1. Tables 2 and 3 show change ingingival recession and root coverage predictability inPPG and SCTG groups respectively. No statisticallysignificant differences were observed between thegroups in any of the parameters except in the parametermeasuring reduction in length of gingival recession,which was higher in the PPG group than the SCTGgroup. There was a statistically significant differencebetween the two groups when overall patient satisfac-tion scores were compared (p < 0.02). When the twogroups were compared in terms of individual satisfac-tion criteria, statistically significant differences werenoticed only in parameters measuring patient satisfac-tion relating to comfort during and after the procedures(p < 0.001); in these criteria PPG was rated higher thanthe SCTG group. For the remaining criteria, there wereno statistically significant differences among the twogroups.

DISCUSSION

Successful coverage of exposed roots for aesthetic andfunctional reasons has been the objective of variousmucogingival procedures. Recently, the criteria forsuccess of root coverage procedures has focused notonly on objective outcomes (percent root coverage) butalso on patients’ requirements (aesthetic satisfaction interms of colour match, intra and postoperative dis-comfort and cost-effectiveness). This generates a needfor the clinician to develop newer techniques to fulfilthese requirements without compromising aestheticsand comfort. The periosteum is a highly vascularconnective tissue sheath covering the external surfaceof all bones except sites of articulation and muscleattachment.11 The use of periosteum in medicine and

Table 1. Measurement of clinical parameters (in mm) at baseline and at 12 months for PPG and SCTG treated sites

Clinicalparameter

n = 10 PPG CTG

Initialexamination(mean + SD

[mm])

Finalexamination(mean + SD

[mm])

Meanchanges

in clinicalparameters(in mm) at

baseline andat 6 months

for PPGand SCTGtreated sites

‘t’value

‘p’value

Initialexamination(mean + SD

[mm])

Finalexamination(mean + SD

[mm])

Changes inclinical

parameters(in mm) at

baseline andat 6 months

for PPGand SCTGtreated sites

‘t’value

‘p’value

Gingivalrecessionlength

3.6 ± 0.84 0.3 ± 0.67 3.3 ± 0.17 12.6 <0.0001 (S) 3.30 ± 0.95 0.50 ± 0.84 2.70 ± 0.11 14 <0.0001 (S)

Probing depth 2.10 ± 0.32 2.40 ± 0.52 0.30 ± 0.20 1.55 0.13 (NS) 2.30 ± 0.48 2.60 ± 0.52 0.30 ± 0.04 1.3 0.19 (NS)Width ofkeratinizedgingiva

3.50 ± 0.53 3.80 ± 0.42 0.30 ± 0. 11 1.4 0.17 (NS) 3.10 ± 0.57 3.40 ± 0.52 0.30 ± 0.05 1.23 0.23 (NS)

Width ofattachedgingiva

1.40 ± 0.52 1.60 ± 0.70 0.20 ± 0.18 0.72 0.47 (NS) 1.30 ± 0.48 1.20 ± 0.63 0.10 ± 0.78 0.39 0.69 (NS)


A Mahajan et al.

dentistry is not new. Various research papers havebeen published explaining the osteogenic potential ofhuman periosteal grafts.7,12–14. The use of periosteumas a barrier membrane for the treatment of periodontaldefects was published by Lekovic et al. in 199115

and again in 1998 by Lekovic et al.16 and Kwanet al.17 Recently, the use of periosteum for thetreatment of gingival recession defects has also beensuggested.8,9,18,19

In the present study, 92.6% of root coverage wasobtained in the cases treated with PPG with 90% orgreater root coverage 80% of the time. In contrast,the SCTG group had a mean root coverage of 88.5%and predictability of 70%. The results, althoughimpressive, cannot be compared to other studies asto our knowledge this is the first long-term studyutilizing PPG for the treatment of gingival recessiondefects. The percentage of root coverage obtained andpredictability of more than 90% root coverage in theSCTG is in accordance with the earlier studies whichshow a mean defect coverage ranging from 57% to98% with a mean of all studies of 84% andpredictability of 68%.1 The better predictability and

high percent of root coverage in PPG treated casesmay be attributed to the fact that wound healingafter mucogingival surgery relies on clotting, revas-cularization and maintenance of blood supply.20 Also,a vascular graft is more likely to survive on anavascular root surface. The periosteum has a richvascular plexus and a recent study has shownthat periosteal cells release vascular endothelialgrowth factor.21 These qualities make periosteum asuitable graft over an avascular root surface; also,having an adequate vascularity prevents necrosis ofthe PPG even if it is left uncovered by the overlyingflap.

Other than gingival recession, no other clinicalcriteria showed a significant change. Probing depth didnot show any significant change (p = 1) which wasexpected because only patients whose baseline probingdepth was compatible with a condition of gingivalhealth were included in the study. The fact that therewas no change in the width of keratinized gingiva andprobing depth for the two groups, the width ofattached gingiva, which is a dependent factor, did notchange.

Table 2. Measurement of gingival recession (in mm) at baseline and at 12 months (PPG group)

Toothnumber

Initial recession[in mm]

Final recession[in mm]

Recession defectcoverage [in mm]

% age defectcoverage

Predictability frequency‡90% root coverage

13 4 0 4 100 123 3 0 3 100 123 4 0 4 100 121 3 0 3 100 131 5 2 3 60 041 5 0 5 100 111 3 0 3 100 123 3 0 3 100 113 3 1 2 66 032 3 0 3 100 1Mean ± SD 3.6 ± 0.84 0.3 ± 0.67 3.3 ± 0.17 Predictability

8 of 1080%

Table 3. Measurement of gingival recession defects (in mm) at baseline and at 12 months (SCTG group)

Toothnumber

Initial recession[in mm]

Final recession[in mm]

Recession defectcoverage [in mm]

% age defectcoverage

Predictability frequency‡90% root coverage

13 4 0 4 100 123 3 0 3 100 133 4 1 3 75 021 3 0 3 100 131 5 2 3 60 031 4 2 2 50 011 2 0 3 100 123 2 0 3 100 113 3 0 3 100 123 3 0 3 100 1Mean ± SD 3.3 + 0.95 0.5 + 0.84 2.7 + 0.11 Predictability

7 of 1070%



When the results were compared in terms of patientsatisfaction, PPG emerged as the preferred treatmentoption as it was rated better in terms of comfortduring and after the surgical procedure and overallsatisfaction by the subjects. The better patient satis-faction obtained by the PPG may be attributed to theless traumatic surgical procedure which involvedharvesting of the graft adjacent to the gingivalrecession defect. This not only reduced intraoperativetime but also favoured uneventful postoperative heal-ing, in contrast to the SCTG which increased thecomplications and pain resulting from the surgerybecause of the need to surgically open a second site toobtain the donor tissue.

The periosteum is comprised of at least two layers,an inner cellular or cambium layer and an outerfibrous layer.22 The inner layer contains numerousosteoblasts and osteoprogenitor cells23 and the outerlayer is composed of dense collagen fibre, fibroblastsand their progenitor cells;24 hence the regenerativepotential of the periosteum is immense. Although thisaspect was not seen in our study, it is recommendedthat future studies should also undertake histologicalaspects of healing after the use of PPG for thetreatment of gingival recession defects. Periosteum,being an autogenous graft which can be harvested insufficient amounts adjacent to the gingival recessiondefects, has immense potential to be used for thetreatment of wider gingival recession defects. Althoughthe results show statistically significant differencebetween the two groups, the small study groupwarrants future studies with a larger number ofsubjects. Further studies utilizing PPG technique forthe treatment of multiple gingival recession defectsshould be done and the results compared with alreadyestablished techniques for the treatment of multiplegingival recession defects.25

CONCLUSIONS

Although this is the first study comparing PPG withSCTG, the results are encouraging. Periosteum hasimmense potential to be used as a pedicle graftfor the treatment of gingival recession defects andthe results produced are better in terms of percentroot coverage, predictability and patient satisfactionwhen compared to the connective tissue grafttechnique.

ACKNOWLEDGEMENTS

We would like to thank Dr Jaya Dixit, Professor andHead of the Department of Periodontics, King GeorgeUniversity of Dental Sciences (CSMMU), Lucknow,India, for her guidance and support.

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Address for correspondence:Dr Ajay Mahajan

Department of PeriodonticsHimachal Pradesh Government Dental College and

HospitalShimla 171001

IndiaEmail: [email protected]



comparison of periosteal pedicle graft and subepithelial connective tissue graft for the treatment...

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