INTRODUCTION is prevalent in patients with good


In modern medicine, marginal gingival tissue
recession is becoming a common concern of the patient often requiring treatment
for aesthetic reasons. Deep recessions often affecting the anterior teeth in
young age group is significantly associated with patient request for treatment.

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The displacement
of the soft tissue margin apical to the cementoenamel junction (CEJ) not only exposes the root surface but also impairs
the aesthetics. Marginal gingival tissue recession is associated with several
factors with complex etiology. Traumatic
tooth brushing is considered as one of the main causative factor for the development
of recessions commonly creating a wedge shaped defect at cervical area. A
five year study showed that with the level of oral hygiene education,
probability of gingival recession also increases.1

the exact mechanism of gingival recession is not well understood. Risk factors considered
to be associated with gingival recession include tooth
malposition, path of eruption, tooth shape, profile and position in the arch,
alveolar bone dehiscence, muscle attachment and frenal pull, periodontal
disease and treatment, iatrogenic restorative or operative treatment, improper
oral hygiene methods (e.g. tooth brushing, floss, interproximal brush) and
other self-inflicted injuries (e.g. oral piercing) while the most important
factor increasing the risk of gingival recession may be a thin gingival biotype
where a delicate marginal tissue is covering a non-vascularized root surface.4


Gingival recession of 1 mm or more at one or more
sites is one of the common finding seen in More than 50% of the population. It
is prevalent in patients with good as well as poor oral hygiene. Buccal
surfaces are often involved in patients with good oral hygiene, whereas all
tooth surfaces get affected in patients suffering from periodontal disease or
after periodontal treatment. 5,6,7

Gingival recession has also been linked to
ethnicity. It has been seen that Mexican Americans and non-Hispanic whites exhibited lesser prevalence
and extent of gingival recession compared to non-Hispanic blacks.7
Refuting this observation no difference in terms of prevalence of gingival
recession was found between whites and non-whites in an epidemiological study.3

The extent and prevalence of gingival recession
increases with age. As compared to females, males have shown to exhibit greater
levels of recession. 3 The association  of tobacco smoking in the etiology and
prevalence of recession as discussed by several authors is controversial.
However, more extensive recessions were seen in smokers than non-smokers in
some studies.3


A clinical classification of gingival recession proposed
by Miller (1985) in four categories according to the relationship with the mucogingival
line and interproximal bone is widely accepted and a predictive value for root
coverage in each class has been proposed.9  This classification is as follows –

Class I: Marginal tissue recession not extending to the mucoginvival junction (MGJ)
with no interdental bone loss

Class II: Marginal
tissue recession extending to or beyond the MGJ with no interdental bone loss

Class III: Marginal tissue recession extending to or
beyond the MGJ with bone or soft tissue loss in the interdental area or malpositioning
of the teeth

Class IV: Marginal tissue recession extending to or
beyond the MGJ and bone or soft tissue loss in the interdental area and/or severe
malpositioning of teeth

Although in this classification some important
factors such as biotype, root prominency and supporting bone were not
considered, it is used in most studies considering its use in communication and

Treatment of Gingival Recession

Formerly occasional attempts were made to cover the
denuded root surfaces solely for the cosmetic purpose and to decrease the root
sensitivity. One of the main concern in not attempting these cosmetic surgeries
was the poor predictability of the treatment outcome. Hence the treatment of
gingival recession was mainly focused on halting the progression of gingival
recession, preserving a band
of keratinized tissue thus enhancing plaque control, decreasing frenum pull and
preventing post-orthodontic and post-prosthetic marginal tissue recession.
With the coming years focus was shifted and objectives were modified for the
benefit of patient. Regeneration of lost tissue along with arresting the
progression of disease became the aim of gingival recession treatment.
Considering the higher aesthetic concern the goal of root coverage procedure now is not only to
obtain full root coverage of a denuded root but also to blend the mucosa and or
keratinized gingiva around the recession defect in most aesthetic way and
reduced root sensitivity without any residual periodontal pocket.

The use of predictable
periodontal surgical procedure determines the outcome of treatment. The term predictable
periodontal surgery was first proposed by Miller in 1988 comprising different surgical techniques intended to correct and prevent anatomical,
developmental, traumatic or plaque disease-induced defects of the gingiva,
alveolar mucosa or bone.

Since the
beginning of the 20th century, various surgical procedures have been proposed
for achieving root coverage. Use of pedicle or free soft tissue
grafts to cover denuded root surfaces was first described by Younger in 1902, Harlan in 1906 and
Rosenthal in 1911.10 These techniques were abandoned for a long time
up to the end of the 1950s. . From these decades laterally repositioned flaps, free gingival grafts (FGG), subepithelial
connective tissue grafts (SCTG) and CAFs have been used to improve
various clinical parameters such as recession depth (RD), clinical attachment level (CAL) and KTW.

Plastic periodontal procedures used for root
coverage are usually classified as pedicle soft tissue graft (lateral sliding
flap and its modifications) and free soft tissue grafts. Coronally positioned or coronally
advanced flap (CAF) procedure is based on the coronal shift of soft
tissue present apically to the denuded root surface which can be used as an
alternative to lateral sliding
flap.11,12 Applicability of this procedure for the treatment
of multiple recession type defects makes it an preferable modality. Tarnow
(1986) suggested a semilunar approach in shallow single recessions.13

CAF may be used in combination with other grafting
materials such as connective tissue graft (CTG),4 barrier membranes,14
EMDs,15 acellular dermal matrix (ADM)16 or other. Cairo et al. (2008) in a systematic review stated that the recession reduction in Miller’s
Class I and II recession defects and the probability of obtaining complete root coverage
increases with the use of  CTG and the enamel matrix derivative
(EMD) in combination with CAF procedure.17

The avascular
nature of the root surface poses a great challenge in achieving complete root
coverage of exposed root  by hampering
survival of the most graft. Accordingly, the difficulty is increased for the
clinician with a wider area of root exposure.

Multiple adjacent
recession type defects (MARTD) differs in
localized recession type defects in many aspects. Not only the extensive
avascular exposed root surface but certain anatomical factors such as thin biotype, decreased keratinized
tissue width (KTW), root prominence and root proximity difficult the choice of
surgical treatment used for the treatment of MARTD. Systematic reviews by Roccuzzo
et al. (2002), Cheng et al. (2007) and Oates et al. (2003) have extensively reviewed
the outcome of the different treatment modalities used in the treatment of
isolated gingival recession type defects. On the contrary, little scientific
literature is available regarding treatment modalities used for treating MARTD.

The different techniques used in the treatment of
MARTD include CAF,18
a supraperiosteal envelope technique in combination with  CTG,19 or its evolution as a
tunnel technique.20 To reduce the morbidity of the technique, addition
of biological factors such as; EMD;21,22 platelet rich plasma (PRP);23
platelet rich fibrin (PRF)24 have been suggested so as to increase
the predictability of the root coverage treatment.


The success and predictability of the therapy
depends on various patient related, dentist-related, site-related and
technique-related factors. In a technical manner; ?ap thickness, ?ap tension
before suturing and the position of the gingival margin (GM) at the end of the
surgery appeared to be fundamental in achieving complete root coverage (CRC). Aroca et al. (2010) evaluated and
compared the efficacy of CAF and PRF membrane with CAF alone in which they gave
suspended sutures in the interproximal spaces held in the position with composite
stops at contact point this facilitating the more coronal displacement of the flap.28

At present, several methods are available for
evaluating the soft tissue thickness. The use of needles and periodontal probes
has been documented since the 1970s. To avoid the need for local anesthesia,
non-invasive techniques involving ultrasonic devices and computed tomography
(CT) have also been studied. However, these approaches have been criticized for
either questionable reliability or additional radiation risk. On the other
hand, the accuracy of cone-beam computed tomography (CBCT) for both soft tissue
and bone thickness measurements in the maxillary anterior region has recently
been confirmed, and a simple technique is introduced by Januário AL (2008) for
measuring the gingival tissue and dimension of dentogingival unit by CBCT.29

The literature search revealed that there are few
clinical studies that have been carried out to check the efficacy of CAF with
PRF membrane. The preliminary results appear to be encouraging in terms of root
coverage, and so, it was felt necessary to further study this material in the
treatment of MARTD. Also, CBCT is
one of the latest methods of evaluation and till date there are no studies in
the literature that have used CBCT for evaluating root coverage after CAF in
gingival recession. So, the present study was planned to evaluate and compare
the effectiveness of CAF with orthodontic button application with and without
PRF membrane in the treatment of MARTD clinically and radiographically by CBCT.