View of Comparative Evaluation of Efficacy of Sub Epithelial Connective Tissue Graft and Resin Modified Glass Ionomer Restoration using Coronally Advanced Flap for the treatment of Gingival Recession associated with Non-Carious Cervical Lesion- In Vivo St

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Comparative Evaluation of Efficacy of Sub Epithelial Connective Tissue Graft and Resin Modified Glass Ionomer Restoration using Coronally Advanced Flap for the treatment of Gingival Recession associated with

Non-Carious Cervical Lesion- In Vivo Study

Authors

Prajakta Umarkar¹,Sharath Shetty², Anita Kulloli³, Santosh Martande⁴, Amol Deodhar⁵

D Gopalakrishnan⁶

1Post Graduate Resident, Department of Periodontology, Dr. D. Y. Patil Dental College &

Hospital, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India.

2Professor (Academic), Department of Periodontology, Dr. D. Y. Patil Dental College &

3Professor (Academic), Department of Periodontology, Dr. D. Y. Patil Dental College &

4Associate Professor (Academic), Department of Periodontology, Dr. D. Y. Patil Dental College & Hospital, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India.

5Post Graduate Resident, Department of Periodontology, Dr. D. Y. Patil Dental College &

6The Dean, Professor (Academic) and Head, Department of Periodontology, Dr. D. Y. Patil Dental College & Hospital, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India.

Corresponding Author:

Dr. Prajakta Umarkar, Department of Periodontology, Dr. D. Y. Patil Dental College &

Hospital, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune Maharashtra Email Address: [email protected]

Abstract

Aim: To evaluate and compare the efficacy of Sub-Epithelial Connective Tissue Graft and Resin Modified Glass Ionomer Restoration using Coronally Advanced Flap for the treatment of isolated Gingival recession associated with Non-Carious Cervical Lesion.

Materials and Methods:The study population consisted of a total of 10 patients with 20

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sites between 18 to 45 years with Miller’s Class I and Class II gingival recession associated with 1-2 mm deep NCCL in maxillary anteriors and/or premolars. For group I, a coronally advanced flap (CAF) with Sub-Epithelial Connective Tissue Graft was performed. For group II, a CAF with Resin Modified Glass Ionomer Restoration was performed. At 6 months, post operatively all parameters like Plaque and Gingival Indices, Relative Gingival Recession Depth, Probing Depth, Non-Carious Cervical Lesion Height Reduction, and gain in Relative Attachment Level, increase in the Width of Keratinized Gingiva and reduction in the Dentinal Hypersensitivity were recorded again for statistical evaluation.

Results:Statistically significant reductions were recorded in PI, GI, RGRD, PD, RAL, WKG and NCCLH in both the groups and at all time points when compared to baseline (p<0.05) and significant improvements associated with root coverage percentage were detected at all time points. (p<0.05) At baseline and 6 months there was no statisticallysignificant differences between the groups at any follow-up time point in PI, GI, RGRD, PD, RAL, WKG and NCCLH. The percentages of rootcoverage at 6 month follow-up were 87.1% for test group 62.9% for control group.

Conclusion: In conclusion, the results from this study indicate that in both the groups there was a statistically significant improvement from baseline to 6 months post treatment with respect to improvement. Statistically Significant differences were noted with better results in test group. At 6 months, intergroup comparison did not show any statistically significant difference with respect to all clinical parameters except for NCCLH and VAS score; wherein significant differences were noted.

Keywords: gingival recession, cervical lesion, cervical filling, root coverage, connective tissue graft, resin-modified glass ionomer filling

Introduction

The definition of gingival recession states that it is the apical migration of gingival marginbelow the cemento-enamel junction(CEJ) having an exposure of root surface.¹ It is an usual findingin patients having a general high standard of oral hygiene practice along with theperiodontally compromised individuals having poor oral health.² There are many elementsthat are proposed to majorly inﬂuence the development and progression of marginal tissuerecession, including that of the plaque induced inflammation, the trauma due totoothbrushing, the malalignment of teeth, varied restorative procedures and orthodontictreatment. The peculiar migration of marginal gingival tissue to a more apical

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place maycause hypersensitivity of dentin, various esthetic concerns, probability of root cariesdevelopment and a higher cervical wear.³

It was previously described by Zucchelli et al⁴ that a non-carious cervical lesion (NCCL)particularly presents as a loss of hard tissue primarily at the cemento-enamel junction andthat too in the absence of active caries phenomenon.⁵ Literature has mentioned that most of thecases of recession are seen in conjugation with theNCCL. Main conditions leading to the development of gingival recession and NCCL defectsare faulty tooth brushing techniques, gingival anatomical factors, chronic inflammation,periodontitis, malposed tooth etc.⁶ It was previously mentioned that, due to thepresence of cervical abrasion, there are no peculiar signs of the recessed gingiva along theCEJ in about 50% of the cases. In spite of this close association mainlybetween the non-carious cervical lesions and the presence of gingival recession, it isconsidered that restorations with composite and other resin fillings are successful and the firstchoice of treatment in such cases. Moreover, the exact esthetic along with the functionaloutcomes can be achieved only with the combination of restorative as well as periodontalprocedures.

It was noted that there wereno signs of inﬂammation, no probable bleeding on probing and good esthetics of the patientswhen this treatment modality was used. The coverage of the cervical portion of therestoration was mainly achieved by soft tissue but the apical part of restoration where thecrown and restoration are in conjunction lacked the coverage of cervical tissue. To achieve a long term effect of the treatment, the use of specific restorative material witheffective properties is essential. The material to be used must have sufficient mechanical strength required for overall retention, should provide with good esthetic outcomes, and furthermore be specifically biocompatible so as to achieve enough reattachment of thegingiva. Mostly Glass Ionomer and or Resin-Modified Ionomer is usually recommended forthe restoration of NCCLs. They are preferred as they have high retention properties andfurthermore are biocompatible mainly in cases of reattachment of gingiva.^7,8 But thesematerials show poor esthetic outcomes which in turn are not satisfactory from the patientpoint of view. Hence, many authors have stated that use of newer microfilled resin- basedcomposites, which have more beneficial properties as compared to the conventional GlassIonomer. Since, the NCCL along with the recessed gingiva require a peculiar considerationof both hard as well as soft tissues, so in cases where restoration is of utmost

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importance,the final finishing, polishing and glazing of the restoration should be performed before anymucogingival surgery is done for the achievement of better root coverage.⁹

For correction of these defects i.e., gingival recession associated with NCCL, various surgical procedures were performed which include Coronally Advanced Flap (CAF), CAF with Resin Modified Glass Ionomer Cement (RMGIC), Sub Epithelial Connective Tissue Graft(SECTG) with CAF and SECTG with RMGIC. Also, various comparative literatures^9-11were reported such as CAF vs CAF+RMGIC, SECTG vs SECTG+RMGIC for themanagement of these defects and concluded that there was a comparable soft tissue coverageby CAF and SECTG, despite the fact that there was greater reduction in DentinalHypersensitivity (DHS) only with restoration by RMGIC.

Even though SECTG is the gold standard to manage gingival recession with NCCL, inherent disadvantage associated with these techniques are connective tissue graft shrinkage,

insufficient availability of the donor tissue and also the requirement of second surgical site and inability to reduce dentinal sensitivity in NCCL.

There is paucity of literature regarding comparison of CAF plus SECTG and CAF plus RMGIC (CAF+SECTG vs. CAF+RMGIC) for the treatment of recessed gingiva which is mainly in conjugation with non-carious cervical lesion. Hence, this clinical study was carried out to clinically evaluate and compare the efficacy of RMGIC plus SECTG for management of gingival recession associated with NCCL by using CAF.

Materials and Methods

The study population consisted of a total of 10 patients with 20 sites between 18 to 45 years with Miller’s Class I and Class II gingival recessionassociated with 1-2 mm deep NCCL in maxillary anteriors and/or premolars.The research protocol was approved by the Institutional Ethical Committee and ReviewBoards. An interventional in-vivo study with a split mouth designwas considered.They were included if Miller’s class I or class II Gingival Recession with 1-2mm deep NCCLdefects on Labial/ Buccal aspect of maxillary anteriors and/or premolars was present, recession site with Width of Keratinized Gingiva more than 1mm. or a medium /deep palatal vault was present. They were excluded if they had a known

historysystemic diseases or prolonged use of

antibiotics/steroids/immunosuppressiveagents/aspirin/anti coagulants/other medications or ingestedtobacco in any form.Pregnant/Lactating women were also excluded.All selected

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patients were explained about the study, and written informed consentwas obtained from each of them.

Clinical Evaluation

The following clinical parameters were recorded at baseline and 6 months post treatment:i.

Plaque Index (PI) by Silness and Loe 1964¹²ii. Gingival Index (GI) by Loe and Silness, 1963¹³iii. Relative Gingival Recession Depth (RGRD) which is measured from the lower border ofthe stent to crest of gingival marginiv. Probing depth (PD) which is measured from the crest of the gingival margin to the base ofgingival sulcus.v. Relative Attachment Level (RAL) which is measured from lower border of the stent to thebase of gingival sulcus.vi.

Width of Keratinized Gingiva (WKG) which is measured from gingival margin tomucogingival junction.vii. Non-Carious Cervical Lesion Height (NCCLH)²which isthe distance between coronal andapical margin of non-carious cervical lesion.viii. Dentinal Hypersensitivity (DHS)⁹ will be assessed at baseline and 6 months withthe help of Visual Analogue Scale (VAS). In which every subject places a mark on a 10cm line labelled from no pain to intolerable pain, ix. Percentage of Root Coverage:

(Preoperative RGRD) – (Postoperative RGRD) ×100 (Preoperative RGRD)

and x. Root Coverage Esthetic Score (RES)¹⁵ will be assessed at 6 months post treatment.A single Calibrated examiner other than the primary investigator evaluated all thescores for both the groups.

Grouping

A convenience sampling technique was used and the participants weredivided into two groups; Group I (Control Sites) and Group II (Test Sites), randomly byusing sequential numbered opaque sealed envelopes (SNOSE).

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Presurgical Phase

Preparation of Customized Acrylic Stent: Plaster models were prepared from the alginateimpressions of the arch being treated. Customized Acrylic stents were fabricated for theselected sites. A groove was placed in the stent in the line of recession to have a constantreference for standardized measurements at baseline and 6 months post treatment.

(Figures 1 and 5)The investigations carried out before the procedure were complete haemogram, bleeding time, clotting time, blood glucose level and RVG.

Full mouth supra and sub gingival scaling was doneand detailed instructions for plaque control and oral hygiene maintenance was given.Patients were advised to use Modified Stillman’s brushing technique. Thesurgical procedures for Control Sites and Test Sites was done at separate visits.

Surgical procedure

After the scrubbing of the surgical area and draping of the patient and administration of local Anesthesia, root planing and smoothening was done using Gracy curettes (2R2L,4R4L) and polishing bur. (Mani Composite Polishing Bur)Using a no. 15 C blade Coronally advanced flapwas designed and consisted of the following incisions.An intrasulcular incision was made at the buccal aspect of involved tooth. Theincision was extended horizontally to dissect the buccal aspect of adjacent papillae,both mesially and distally leaving the gingival margin of the adjacent teethuntouched.Two oblique releasing incisions were made from the mesial and distal extremities ofthe horizontal incisions beyond the mucogingival junction.Releasing the flap: Partial-full-partial thickness flap was raised and extended beyondthe mucogingival

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junction. The exposed root surface was thoroughly debrided andprepared to reduce the root convexities, if any.A mesio-distal and apical dissection parallel to the vestibular lining mucosa wasperformed to release the residual muscle tension and facilitate the passive coronaldisplacement of the flap. The papillae adjacent to the involved tooth was de- epithelialized. (Figure 2 and 7)The root and non-carious cervical lesion was planed witha finishing bur and curettes until the root surface becomes clean, smooth.Sub epithelial connective tissue graft was harvested from the palate by using parallelincision technique.¹⁶The graft was completely covering the entire height of NCCL.(Figure 3)The epithelial collar of the SECTG was kept exposed and entire graft was bestabilized by using Sling Suture (Vicryl 4-0) Interrupted sutures were placed closed to releasing incision.(Figure 4) For Test Site, Non-Carious Cervical Lesion restoration was performed by using Resin ModifiedGlass Ionomer Cement(GC Fuji Bond LC).The entire length of non-carious cervical lesion was restored so that the originalcontour of tooth should be restored.(Figure 6)Flap was then Coronally positioned and stabilized by sling suture without tensionusing 4-0 mersilk suture.Interrupted sutures were placed closed to the releasing incision (4-0 vicryl).(Figure 7)Periodontal dressing was given at the surgical site for both Control Sites and Test Sites.Postoperative instructions were given. Patient was recalled 24 hours aftersurgery to check for any postoperative complication. Dressing and Sutures wereremoved 14 days post operatively. Patient was recalled 1 month after surgery andthen once in 3 months for follow up.At six months post operatively all the previously mentioned parameters were recorded.

Photographs of Control Site - Coronally Advanced Flap (CAF) With Sub-Epithelial Connective Tissue Graft(CAF+ SECTG)

Fig 1: Pre-Surgical Illustration of Class 1 Recession with Non-Carious Cervical Lesion (NCCL) With Tooth No. 24 and recording of clinical Parameters Using Acrylic Stent

and UNC 15 Probe.

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Fig 2: Incisions Given for CAF with Tooth No. 24 and harvesting of SECTG from Palate.

Fig 3: Thinning and placement of SECTG after CAF with Tooth No. 24.

Fig 4: Stabilization of SECTG using 4-0 Vicryl Suture Material and suturing of AF+SECTG using 4-0 Mersilk & 4-0 Vicryl with Tooth No. 24.

Photographs of Test Site - Coronally Advanced Flap (CAF) with Resin Modified Glass Ionomer Restoration (CAF + RMGIC)

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Fig 5:Pre-Surgical Illustration of Class I Recession with NCCL and recording of clinical parameters using Acrylic Stent and UNC 15 Probe with Tooth No. 14.

Fig 6: Root Surface Preparation of NCCL with Tooth No. 14.

Fig 7: CAF and Restoration of NCCL using RMGIC with Tooth No. 14 and suturing of CAF Using 4-0 Mersilk and 4-0 Vicryl

Statistical Analysis

The data was entered and analyzed using the Statistical Package for Social Sciences (SPSS) for Windows 26.0. (SPSS, Inc. Chicago, Illinois) Confidence intervals were set at 95%, and a

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p-value ≤ of 0.05 was considered statistically significant. Paired t-testwas used to check the significance of difference for PI, GI, RGRD, PD, WKG, RAL, NCCLH and DHS at baseline and 6 months treatment. Unpaired t-testwas used to check the significance of the difference in mean of PI, GI, RGRD, PD, WKG, RAL, NCCLH and DHS for both controland test sites at 6 months post treatment. Percentage of root coverage was calculated for 6 months post treatment.

Results

A total of 10 patients with 20 sites were included in this study with Miller’s Class Iand Class II gingival recession associated with 1-2 mm deep NCCL in maxillary anteriorsand/or premolars.

Within-Group Comparisons

Statistically significant reductions were recorded in PI, GI, RGRD, PD, RAL, WKG and NCCLH in both the groups and at all time points when compared to baseline (p<0.05) and significant improvements associated with root coverage percentage were detected at all time points. (p<0.05) No significant differences were found in PD valuesbetween time points when periodontal parameters wereevaluated in all groups (p>0.05). In both the groups, RAL was relatively higher at all time points.

Between-Group Comparisons

At baseline, there were no statistically significant differences between the groups in PI, GI, RGRD, PD, RAL, WKG and NCCLH. (p>0.05) At baseline and 6 months there was no statisticallysignificant differences between the groups at any follow-up time point in PI, GI, RGRD, PD, RAL, WKG and NCCLH. The percentages of rootcoverage at 6 month follow-up were 87.1% for test group 62.9% for control group.

Dentin sensitivity and esthetic score

Comparison of mean difference in the VAS score between the control and test sites from baseline to 6 months was 2.20 ± 0.42 and 3.60 ± 0.51 respectively, with a mean difference of 1.40 ± 0.35, which was statistically significant (p=0.001). Comparison of mean difference in the root coverage esthetic score between the control and test sites at 6 months was 0.0 ± 0.09, which was statistically not significant (p>0.05).

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Discussion

Gingival recession is most commonly seen in patients with a higher standard of oral hygiene and also inpatients with poor oral hygiene which are periodontally compromised.^2,3 Many factors have beenproposed to influence the development of marginal tissue recession, including plaque-inducedinflammation, toothbrush trauma, tooth alignment, orthodontics, and restorative procedures.Multiple combination techniques have been used recently incorporating different grafts to correctrecession defects and different techniques to regenerate supporting tooth structures. Amongthem, the sub epithelial connective tissue graft (SECTG) has been regarded as a reliable andpredictable procedure that provides a satisfactory esthetic outcome, making it a popularalternative for clinicians. Major advantages of the (SECTG) are that it is inexpensive, versatile,and easily available; it provides successful outcomes; it is less invasive than other autogenousharvesting techniques; and it has a shorter healing period.¹⁷

Hence, the present study was an interventional in-vivo study with a split mouth design wherein theNCCL’s were divided into Control sites and Test sites, to evaluate and compare the efficacy of Sub EpithelialConnective Tissue Graft and Resin Modified Glass Ionomer Restoration using CoronallyAdvanced Flap.In the present study, systemically healthy patients with presence of Miller’s class I or class IIGingival Recession with 1-2mm deep NCCL defects on Labial/ Buccal aspect of maxillaryanteriors and/or premolars and recession site with Width of Keratinized Gingiva more than 1mmwere included to eliminate any confounding factor which could modify the treatment outcome.Individuals with history of prolonged use of medications (antibiotics, steroids,immunosuppressive agents, and anticoagulants), pregnancy, systemic diseases (diabetes,hypertension, etc.) were excluded from the study to eliminate the alteration of response (due todrugs or hormonal changes) on final treatment outcome. In the diabetic patients, collagenmetabolism is altered, making tissues more vulnerable to destruction. In pregnancy, stresssymptoms resulting from pain can have an adverse influence on the mother and the unborn childthan the negative consequences of treatment.

The present study included only the non-smokers. It has been shown that the number ofcigarettes smoked daily is an important issue. Thus, cigarette smoking may affect the short- termoutcome of the root coverage procedures and should be carefully considered when planning aperiodontal plastic surgery. Patients who smoke have more gingival recession than

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non-smokers.A meta–analysis conducted by Chambrone et al (2009)¹⁸ indicated a statistically significantgreater reduction in gingival recession and gain in clinical attachment level for non-smokerswhen compared to smokers whose gingival recession was treated with Sub- Epithelial connectivetissue graft. Also, non-smokers exhibited significantly more sites with complete root coveragethan did the smokers. The mechanisms of action are unclear but there could be systemic alterations in the immune response or local changes such as reduction in gingival blood flow.

Root preparation usually involves scaling and root planing, which removes necrotic cementum,

softened dentin, and smoothen out the root surface. In the present study, root preparation wasdone by mechanical method by using 2R/2L, 4R/4L curettes.The CAF design used in our study was similar to that described by de Sanctis & Zucchelli(2007)¹⁹, involving the use of vertical releasing incisions and a split-full-split thickness flap. A split-full-split thickness flap approach includes the periosteum in the central portion of the flap tomaximize soft tissue thickness over the avascular root surface. The use of vertical releasingincisions increases the predictability of achieving adequate coronal positioning and completecoverage of the defect.

In similar studies by Felipe et al (2007)²⁰ and Papageorgakopoulos G et al(2008)²¹, a comparison of a CAF with releasing incisions to an envelope flap without releasingincisions was made. The procedure with releasing incisions achieved significantly greaterpercentage of defect coverage than the procedure without releasing incisions. The partialthickness of the surgical papillae facilitated the nutritional exchanges between them and theunderlying de- epithelialized anatomical papillae and improved the blending (in terms of colourand thickness) of the surgically treated area with respect to adjacent soft tissues.²²

The root and non-carious cervical lesion were planned with a finishing bur and curettes until theroot surface becomes clean, smooth and hard followed by the Placement of graft for control sites(control sites). Sub epithelial connective tissue graft was harvested from the palate by usingparallel incision Technique¹⁶ and the graft completely covered the entire NCCL. The epithelialcollar of the SECTG was kept exposed and entire graft was stabilized by using Sling Suture(Vicryl 4-0). Flap was then advanced and stabilized by placing sling sutures and interruptedsutures were placed for the closure of releasing incision.

For the test sites, restoration for Non-Carious Cervical Lesion restoration was performed by

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using Resin Modified Glass Ionomer Cement(GC Fuji Bond LC).The entire length of non- carious cervical lesion was restored so that the original contour of tooth was also restored.

Flap

was then Coronally repositioned and stabilized by sling suture without tension using 4- 0mersilk suture. Followed by placing interrupted sutures for the closure of releasing incisionusing 4-0 vicryl.Six months follow-up period was considered to test the difference in the root coverage procedureand the patient comfort obtained after the surgery using 2 different techniques. This follow-upperiod of six months was considered in our study based on the previous studies.^22-27

The importance of patient’s tooth brushing technique was demonstrated in various studies for thelong-term maintenance of the clinical outcome achieved by root coverage procedure. In the

present study, all the patients enrolled were instructed and motivated to perform a coronally directed roll technique to minimize toothbrush trauma. Also, subjects were recalled for regular

oral prophylaxis and the brushing instructions were reinforced.

In this study, due to positive reinforcement and continued motivation of the patients, the mean

plaque index score showed a reduction of 0.32 ± 0.12 from baseline to 6 months. Similarly, in the test sites, a mean reduction in the plaque index score obtained was 0.32 ± 0.12 from baseline

to 6 months. These findings correlated well with the studies conducted by Dodge et al (2000)²⁸,Kimble et al (2004)²³, Kuis et al (2013)²⁹ and Carvalho et al (2006)²².In our study, the control sites showed a reduction in the Gingival Index mean from 0.87 ± 0.13 to0.42 ± 0.20, showing a mean reduction of 0.45 ± 0.10; whereas in the test sites, the meanGingival Index score at baseline was 0.87 ± 0.13 and at 6 months, scores were reduced to 0.42 ±0.20.

These findings were in accordance with studies conducted by Wennstrom and Zucchelli(1996)²⁰, Dodge et al (2000)²⁸, Kimble et al (2004)²³, Carvalho et al (2006)²² and Kuis et al.(2013)²⁹

In the present study, the mean Relative Gingival Recession Depth (RGRD) at the baseline was

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2.60 ± 1.07 mm in the control sites and at 6 months, it improved to 0.90 ± 0.31 mm, showing amean improvement of 1.70 ± 1.15 mm. Similar findings were obtained by Jankovic et al (2010)³⁰,Eren & Atilla (2012)³¹, Padma et al (2013)³². In a study by Jankovic et al (2012)³³, the meanrecession depth was improved from 3.51 ± 0.70 mm at baseline to 0.68 ± 0.45 mm over a periodof 6 months, showing a mean improvement of 2.83 ± 0.37 mm. In the test sites, the meanrelative gingival recession depth at the baseline was 2.60 ± 1.22. At 6 months, mean relativegingival recession depth improved to 0.80 ± 0.63 mm, showing a mean improvement of 1.70 ±1.24 mm which was statistically significant. These findings were in accordance with Nazareth etal (2011)³⁴ wherein the test sites showed a mean reduction of 2.20 ± 0.54 mm over a period of 6months. Also of relevance is the study conducted by McGuire et al (2014)³⁵ wherein the test sitesshowed the change in recession depth by 2.90 mm at 6 months as compared to baseline and wasstatistically significant. However, in this study, when mean relative gingival recession depthsbetween control and test sitess were compared at 6 months, no statistically significantdifference was observed between them. Since this study is first of its kind, no results areavailable to compare the clinical outcomes between both the groups.

Our study showed that in the control sites, the mean PD at the baseline was 1.80 ± 0.42 mm andwas reduced at 6 months, to 1.10 ± 0.31 mm showing a mean reduction of 0.70 ±0.48mm whichwas statistically significant. These findings were in accordance with Zucchelli and de Sanctis(2000)³⁶, Modica et al (2000)³⁷, Amarante et al (2000)³⁸, Jankovic et al (2010)³⁰, Jankovic et al(2012)33 and McGuire et al (2014)35. However, few literature studies showed dissimilar resultsregard to mean probing depth for the control sites31,32,39,40

In the test sites, the mean PD at the baseline was 1.70 ± 0.67 mm. At 6 months, the mean PD wasreduced to 1.20 ± 0.42 mm, showing a mean reduction of 0.50 ± 0.52 mm which was statisticallysignificant. These findings were in accordance with Duval et al (2000)⁴⁰, Dodge et al (2000)²⁸ andMcGuire et al (2014)³⁵. This minimal decrease in PD may suggest that the gain in RAL wasassociated with new connective tissue attachment. Histologic studies are needed to clarify suchan outcome. In the present study, when mean probing depth between the control and the test siteswere compared at the end of 6 months, no statistically significant difference was observedbetween them.

In the present study, the mean RAL at the baseline was 4.40 ± 0.96 mm in the control sites and at6 months, mean RAL recorded was 2.0 ± 0.47 mm, showing a mean reduction of 2.40 ±

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1.17 mmwhich was statistically significant. Similar results were obtained by studies conducted by

Wennstrom & Zucchelli (1996)⁴¹, Nazareth et al (2011)³⁴ and Aroca et al (2009)⁴². In the testsites, the mean RAL at the baseline was 4.2 ± 0.97 mm. At 6 months, mean RAL recorded was2.0 ± 0.47 mm, showing a mean reduction of 2.2 ± 1.08 mm which was statistically significant.These findings were similar to previous studies by Del Pizzo et al (2005)⁴³, Jankovic et al(2012)³⁰, Jepsen et al (2013)⁴⁴and McGuire et al (2014)³⁵. However, there was no statisticallysignificant difference seen in the mean gain in attachment level between control and test sites.More research should be conducted regarding this for interpretation of appropriate difference inthe test and control sites as various studies use combination of varied kind of graft techniquesfor root coverage.

In the present study, the mean width of keratinized gingiva (WKG) at the baseline was 2.20 ± 0.42 mm in the control sites and at 6 months, mean WKG was 4.2 ± 0.42 mm, showing a mean

increase of 2.0 ± 0.0 mm which was statistically significant. Our findings were in accordance with Aroca et al (2009)⁴², Jankovic et al (2012)³⁰, Padma et al (2013)³³ and Kumar et al (2013)⁴⁵.The WKG gain in the control sites can be explained by properties of Sub-Epithelial connectivetissue graft, which can affect several growth factors influencing the tissue manifestationproliferation of gingival or periodontal fibroblastsIn the test sites, the mean WKG at the baseline was 2.30 ± 0.48 mm. At 6 months, mean WKGwas 3.30 ± 0.48 mm, showing a mean increase of 1.00 ± 0.0 mm which was statisticallysignificant. Similar results were obtained in studies done by Duval et al (2000)⁴⁶, Kimble et al(2004)²¹, Del Pizzo et al (2005)⁴³,Cardaropoli & Cardaropoli (2009)⁴⁷, Jepsen et al (2013)⁴⁴;McGuire et al (2014)³⁵. The increase in WKG for test sites can be correlated with tissuematuration following healing and with the fact that the mucogingival junction tends to be locatedat its genetically determined position. Another factor to consider is the granulation tissueformation derived from the periodontal ligament tissue which forms a connective tissue with thepotential to induce keratinization of the covering epithelium. 97,98 Adequate WKG ensures stabilityof the gingival margin and long-term maintenance of the results obtained with the surgicalprocedure.

The present study showed a mean NCCLH at baseline in control sites as 2.90 ± 0.73 mm; and at 6months, the mean NCCLH was 0.90 ± 0.73 mm, showing a mean reduction of 2.0 ± 0.0 mmwhich was statistically significant. In the test sites, the mean NCLH at the baseline was

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2.90 ±0.73 mm and at 6 months was 0.20 ± 0.42 mm, showing a mean reduction of 2.70 ± 0.48 mmwhich was statistically significant. These results and conclusions were similar to those of

Zucchelli G et al (2011)⁵ and SungEun Yang et al (2016)⁶. They proposed that precise diagnosisand choice of proper treatment procedure should be made on the basis of both restorative andsurgical considerations to ensure successful treatment of NCCLs.

Furthermore, a systematic review conducted by Rovai SE et al (2020)⁴⁸ concluded that in teethwith NCCL’s and gingival recessions, restoration of NCCL’s does not affect the clinical outcomes of surgical root coverage, but helps in the reduction of dentinal hypersensitivity.

Similar conclusions were derived in the present study; wherein the control sites (CAF+RMGIC)showed higher NCCLH after 6 months as compared to test sites suggesting that insufficientcoverage of NCCL’s is noted, if additional technique of restoring the NCCL’s is not performed.In our study, the mean percentage of root coverage for the control sites was 87.1% ± 18.5%. and for the test sites was 62.9% ± 19.14%. However, there was no statistical significant difference inpercentage of root coverage between the two groups at the end of 6months in this study. Sincelimited literature is available, it is difficult to compare results and clinical outcomes betweenboth the groups.

The present study showed a mean VAS score 5.40 ± 0.69 mm in the control sites at baseline andat 6 months, the mean VAS score was 3.20 ± 0.18 mm, showing a mean reduction of 2.20

± 0.42mm which was statistically significant; whereas in the test sites the mean VAS score at thebaseline was 5.40 ± 0.69 mm and at 6 months was 1.80 ± 0.78 mm, showing a mean reduction of3.60 ± 0.51 mm which was statistically significant. The intergroup comparison of the VAS scoreshowed statistically significant differences between the test and control sites suggesting that,specific treatment of NCCL with RMGIC reduces the amount of dentinal hypersensitivity in thepatients thus causing a reduced pain response VAS scale). These results are in consensus with thestudies conducted by Santamaria MP et al (2008)² and Santamaria MP et al (2009)³; wherein thebilateral Miller Class 1 buccal gingival recession associated with non- carious cervical cariouslesion by a coronally advanced flap alone CAF or in combination with a resin modified glassionomer restoration CAF+RMGIC was assessed. The results showed that both the root coverageprocedures provided similar soft tissue coverage after 6 months but a greater reduction in dentinsensitivity was observed after

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CAF+RMGIC. Since this study is first of its kind, no peculiarresults are available to compare the VAS score outcomes post-surgery in such cases.

Root coverage Esthetic Score (RES) was given by Cairo et al in 2010¹⁰. Apart from the factors ofcomplete root coverage, esthetic outcome is also a major consideration in a root coverage

procedure. Many patients presenting with a problem of gingival recession complain about long

tooth syndrome and unesthetic appearance. And in the anterior region especially the esthetic outcome is of prime concern. The RES score concentrates first on the level of the gingival marginwhich contributed to 60% of the RES. And the other factors such as Marginal tissue contour, MGJline, soft tissue texture and color match form the rest of the RES. The maximum RES that can begiven is 10 and minimum is 0.

In the present study, the mean of Root Esthetic Score (RES) in the control sites at 6 months was8.50±1.08 and for the test sites at 6 months was 8.50 ± 1.17. However, there was no statisticallysignificant difference in percentage of root coverage between the two groups at the end of 6 months in this study. The results of the present study indicated that CAF+SECTG and CAF + RMGIC, bothprocedures could be successfully used to treat Miller’s Class I and Class II gingival recessiondefects associated with NCCL. Both the groups demonstrated an overall significant improvementin all the assessed clinical parameters. Although the result of this study found no significantdifference between the two groups with regards to outcome of the treatment. Moreover, asignificant difference in the DHS VAS score and NCCLH height reduction was noted betweenthe two groups suggesting that use of RMGIC for restoring NCCLH is an effective treatmentmodality.The present study must be interpreted with consideration to the following limitations: a relativelysmall sample size (No. of patients = 10) and shorter duration of follow-up (6 months).There is a need for conducting further research studies to adequately analyze and comparedifferent clinical parameters in cases of NCCL’s requiring root coverage procedures as well asrestorations.

Conclusion

In conclusion, the results from this study indicate that in both the groups there was astatistically significant improvement from baseline to 6 months post treatment withrespect to improvement in Relative Gingival Recession Depth, Probing Depth, Non-Carious Cervical

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Lesion Height Reduction, and gain in Relative Attachment Level,increase in the Width of Keratinized Gingiva and reduction in the DentinalHypersensitivity. Statistically Significant differences were noted with better results intest group.At 6 months, intergroup comparison did not show any statistically significant differencewith respect to all clinical parameters except for NCCLH and VAS score; whereinsignificant differences were noted.There is a need for conducting further clinical research studies to adequately analyze andcompare different clinical parameters with the above treatment options in cases ofgingival recession associated with NCCL’s with larger sample size and long term followup.

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Table 1: Comparison of all the Clinical Parameters at 6 months between control and test groups

Clinical Parameters (mm)

Control (CAF+SEC TG) Mean ±

SD

Test (CAF+RMG

IC) Mean ± SD

p-value

Plaque index (PI) 0.32 ± 0.12 0.32 ± 0.12 p>0.05 Gingival index (GI) 0.45 ± 0.10 0.45 ± 0.10 p>0.05 Relative Gingival Recession

depth

1.70 ± 1.15 1.70 ± 1.24 p>0.05

Probing Depth 0.70 ± 0.48 0.50 ± 0.05 p>0.05