|Year : 2020 | Volume
| Issue : 3 | Page : 159-164
Evaluating the long-term patient satisfaction, esthetic harmony, and creeping attachment levels in patients treated with gingival augmentation surgery: A retrospective study
Mustafa Ozay Uslu
Department of Periodontology, Faculty of Dentistry, Inonu University, Malatya, Turkey
|Date of Submission||26-Nov-2019|
|Date of Decision||04-Jan-2020|
|Date of Acceptance||18-Jan-2020|
|Date of Web Publication||02-Jul-2020|
Mustafa Ozay Uslu
Department of Periodontology, Faculty of Dentistry, Inonu University, Malatya 44280
Source of Support: None, Conflict of Interest: None
Objective: Free gingival grafts (FGGs) are commonly used for increasing the keratinized tissue and root coverage in gingival recessions (GRs). The aim of this retrospective study was to evaluate the long-term patient satisfaction ratings, esthetic adaptation of graft, and creeping attachment (CA) levels after FGG surgery. Methods: Thirty-five surgical areas from thirty patients with Miller Class I, II, and III GRs were included in the study. GRs were treated with FGGs, and palatal donor area was covered with the same surgical pack in all patients. Gingival index (GI), bleeding on probing (BoP), probing depth, plaque index (PI), vertical and horizontal GRs (VGR and HGR, respectively), keratinized gingiva width (KGW), keratinized gingiva thickness (KGT), CA, evaluating the esthetic harmony with modified Manchester Scar Scale (mMSS), and patient satisfactory ratings were collected at the 1st month, 6th month, and 5th year control. Descriptive statistical methods as well as distribution of the data were evaluated by the Shapiro–Wilk test, the Friedman test was used in comparison of three and more dependent groups, and the Wilcoxon test was used in comparison of two dependent groups. Results: The mean follow-up period was 76.91 ± 7.60 months. The last control measurements of clinical parameters such as GI, PI, BoP, VGR, HGR, and mMSS measurements were statistically significantly lower than the baseline and 1st-month measurements (P < 0.01). The 1st-month, 6th-month, and last control measurements of KGW and KGT were statistically significantly higher than the initial measurements (P < 0.01). The last control CA measurements were statistically significantly higher than the 6th-month measurements (P < 0.01). Patient satisfaction ratings were between 2 and 3 at the last control and demonstrated a high satisfaction result. Conclusion: Within the limitations of this study, it can be stated that FGGs provide successful results in terms of esthetics and maintenance of the periodontal health and also patient satisfaction was at the highest level in the long term.
Keywords: Creeping attachment, free gingival graft, long-term healing, patient satisfaction
|How to cite this article:|
Uslu MO. Evaluating the long-term patient satisfaction, esthetic harmony, and creeping attachment levels in patients treated with gingival augmentation surgery: A retrospective study. J Nat Sci Med 2020;3:159-64
|How to cite this URL:|
Uslu MO. Evaluating the long-term patient satisfaction, esthetic harmony, and creeping attachment levels in patients treated with gingival augmentation surgery: A retrospective study. J Nat Sci Med [serial online] 2020 [cited 2020 Aug 10];3:159-64. Available from: http://www.jnsmonline.org/text.asp?2020/3/3/159/280535
| Introduction|| |
Gingival recessions (GRs) are caused by many etiologic factors and can be defined as exposure of root surfaces by relocation of the marginal gingival tissue to the apical direction from the enamel-cement junction. When the etiology of GR is examined, it can be seen that microbial dental plaque, which was the main etiologic factor of periodontal disease, also has an important role in GRs. Apart from periodontal diseases, many factors such as inadequate or excessive toothbrushing in oral hygiene practices, dental trauma, dental position and the thickness of the alveolar bone remaining in the buccal aspect, root angulations, orthodontic tooth movements, and frenulum and muscle attachments may cause GRs.,, In addition, the frequency of GRs increases with aging. In Turkish society, especially in young ages, the frequency of GR is higher, the severity increases with age, and GR occurs frequently in mandibular incisors. GR causes functional and esthetic problems such as dentin hypersensitivity on root surfaces, facilitating plaque accumulation, root caries, abrasion, and erosions., To overcome these problems, many techniques and methods such as laterally positioned flaps, dermal matrix derivatives, guided tissue regeneration, connective tissue, and free gingival grafts (FGGs) had been applied to date.
FGGs have been extensively used in the resolution of many mucogingival problems such as the absence/failure of keratinized attached gingiva, high frenulums, or shallow vestibular sulcus. The FGG operation is a reliable surgical operation in increasing keratinized gingiva and in stopping the progression of GR and has been successfully administered up to date. In addition, it was a treatment option with a high success rate in some cases in the closure of the root surface. When FGG is used for root closure, a partial root closure can only be achieved in further GRs, such as Miller Classes III and IV, although Miller Classes I and II yield sufficient results to achieve complete root closure. Root closure is limited because of the loss of soft tissues and interproximal bone, gingival phenotype, and muscle attachments.
Creeping attachment (CA) occurs as a result of the movement of marginal gingival tissue in the coronal direction over the root surface. The gingiva is firmly attached to the root surface, resulting in no increase in the probing depth (PD). Matter and Cimasoni  found that this creeping was observed by movement of the attachment apparatus in the coronal direction on the root surface or by neoformation of periodontal fibers and keratinized gingiva. CA is best observed, especially in narrow GRs in mandibular incisors.
Since FGGs carry the phenotypic properties of the donor region, this may cause problems such as color disharmony in the recipient regions. In the literature, there were few studies evaluating patient satisfaction in the long term after FGGs. In this retrospective study, we focused on the assessment of the level of CA after the application of FGG, the patient satisfaction ratings, and the long-term results of the patients with different Miller GRs and dentin sensitivity.
| Methods|| |
This study was designed as a long-term retrospective study and started with 79 patients who applied to the Department of Periodontology of Inonu University Faculty of Dentistry between January 2011 and January 2012 with the chief complaint of GRs. Forty-nine patients were excluded from the study; 6 patients had a history of calcium channel blocker usage, 11 patients were smokers, 4 patients had diabetes mellitus, 9 patients had Miller Class IV GRs, 13 patients did not attend regular clinical follow-ups, and 6 patients had insufficient oral hygiene. The study completed with a total of 35 GRs in 30 patients ranging in age from 17 to 50 years, 7 (23.3%) males and 23 (76.7%) females. The mean age of the participants was 35.57 ± 11.62 years. This study was approved by the Malatya Clinical Research Ethics Committee (protocol no. 2019/83) and was carried out in accordance with the Declaration of Helsinki. Patients who were willing to participate in the study were asked to sign the informed consent form.
- Miller Class I, II, or III GRs (with single or multiple GRs) at mandibular anterior region
- Having FGGs at least 5 years
- No systemic disease that may affect gingival wound healing.
- Single or multiple Miller Class IV GRs at mandibular anterior region
- History of chronic systemic disease which may affect healing
- History of oral cancer or nonhealing lesion, osteoporosis–osteopenia, or any bone malformation
- Patients with smoking or any tobacco use
- Bruxism or any parafunctional habit
- Patients using drugs such as immunosuppressant, calcium channel blockers, and anticonvulsants which cause gingival enlargement
- Patients who did not attend regular clinical follow-ups and who were not suitable for oral hygiene were excluded from the study.
Study design and data collection
The patients were evaluated as clinical and radiographic (periapical radiographs) after taking the necessary anamnesis and consultations. Patients with Miller Class I, II, and III GRs in the mandibular anterior area were informed about the operation. Nonsurgical periodontal treatments of the patients were completed in two sessions by a periodontology expert (MÖU) using manual scalers, Gracey curettes (Hu-Friedy, Chicago, IL, USA), and ultrasound scalers (EMS, Mini-Piezon, Nyon, Switzerland). Phase I periodontal treatments of each patient were completed before the operation, and patients who obtained appropriate oral hygiene were included in the study. After local infiltration (Maxicaine Fort: articaine hydrochloride 80 mg/2 ml + epinephrine 0.020 mg/2 ml) anesthesia, Gracey curettes were used to gently scale and plane the root surface and the FGG taken from the donor site was adapted with 6-0 resorbable suture material (polyglycolide-co-lactide, PGLA, Pegelak, Doǧsan). The recipient and donor sites were closed with periodontal surgical pack (Coe-Pak, GC America Inc., IL, USA) and allowed to heal.
Postoperative instructions including discontinuing toothbrushing at surgical areas for 2 weeks were recommended, and 100 mg flurbiprofen (to take as needed for analgesia, twice/day) and 0.12% chlorhexidine digluconate mouthwash (three times/day) were prescribed to patients. Periodontal surgical pack and sutures were taken on the 10th day. The patients were called for follow-up periodically at the 1st-month, 6th-month, and last control visits. The following periodontal parameters were evaluated in all patients at before surgery, the 1st month, the 6th month, and the last control for collecting study data: gingival index (GI), bleeding on probing (BoP) index, plaque index (PI), and PD. Measurements were performed using conventional calibrated Michigan O probe with Williams markings (Hu-Friedy Co. Inc., Chicago, IL, USA) for affected tooth, in three regions (mesiobuccal, mid-buccal, and distobuccal), for GI, BoP, PD, and PI. Vertical gingival recession (VGR) was recorded as the distance between the mid-buccal cement-enamel junction and marginal gingival tissue. The distance between the most distal and mesial edges of GR was recorded as horizontal gingival recession (HGR). The keratinized gingiva width (KGW) and thickness (KGT) were measured by periodontal probe and recorded at follow-up. To evaluate the KGT, a reference point was detected at 2 mm apical of the marginal gingival margin at postoperative 6 months. At the same time, the distance between this point and the incisal edge was recorded and repeated measurements were taken from the same place. KGT was measured by means of a digital caliper measuring the length of the endodontic spreader (size: 15) with rubber stopper at the first contact with the bone. KGT measurement was repeated at 6 months and later. Clinical measurements were repeated for the CA level measurement at the 6th-month and last control visit. To determine the CA, the distance between the most coronal level of the marginal gingiva and the incisal edges of tooth was measured and noted 1 week after the surgery. From this distance, the same distance measured again in the control sessions was subtracted and the CA level was determined. In the control sessions, the modified Manchester Scar Scale (mMSS) was used to evaluate the wound healing level and the compatibility of the FGG with the tissues at the recipient site at the 1st month, 6th month, and last control. Each patient was questioned at the last control visit about satisfaction level with regard to the seven main topics including color of gums; contour and shape of gums; dentinal hypersensitivity; root coverage; surgical process (pain during operation and the discomfort related with the total time of the surgery); cost-effectiveness; and postsurgical period (swelling, pain, and postoperative discomforts). Patient satisfaction was evaluated using a 3-point rating scale: unsatisfied = 1, satisfied = 2, and fully satisfied = 3. Patients who had regular routine control visits and at least a 5-year history of FGG surgery were included in this study, and the data were analyzed statistically.
Error of the method
Intra-examiner error was evaluated by obtaining the ten randomly selected sites which were not included in the study. The beginning and the last PD measurements were performed within a 1-month interval and determined by Cohen's kappa test. The intraclass correlation coefficient for PD was 95% within 1 mm. All measurements including preoperation, maintenance visits, and the last one were performed by the same professional investigator (MÖU).
Number Cruncher Statistical System (NCSS 2007, Kaysville, Utah, USA) was used for statistical analysis. While assessing study data, descriptive statistical methods (mean, standard deviation, frequency, median, ratio, minimum, and maximum) as well as distribution of the data were evaluated by the Shapiro–Wilk test. The Friedman test was used in comparison of three and more dependent groups, the Wilcoxon test was used in comparison of two dependent groups, Cochran's Q-test was used in comparison of dependent qualitative three and above groups, and McNemar's test was used in comparison of qualitative two dependent groups. Significance was evaluated at P < 0.01 and P < 0.05.
| Results|| |
This study included a total of 35 GRs in 30 patients ranging in age from 17 to 50 years, 7 (23.3%) males and 23 (76.7%) females. The mean age of the patients was 35.57 ± 11.62 years. The follow-up period ranged from 57 months to 87 months, with a mean period of 76.91 ± 7.60 months and a median of 76 months. Patient satisfaction ratings were between 2 and 3 at the last control and demonstrated a high satisfaction result [Table 1].
There were statistically significant differences in BoP values according to periods (P < 0.01). The differences between the 1st-month, 6th-month, and last control measurements were significantly different, and it was found that BoP decreased by time (P = 0.001) [Table 2].
|Table 2: Comparison of bleeding on probing scores at baseline, 1st month, 6th month, and the last control|
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GI, PI, and PD values differed significantly between the periods (P < 0.01). The 1st-month, 6th-month, and last control measurements were lower than the baseline measurements (P = 0.001). Furthermore, the last control measurements were higher than the 6th-month measurements (P = 0.033). It was found that the last control measurements were higher than the 1st-month measurements (P = 0.022), higher than the 6th-month measurements (P = 0.013), and lower than the 1st-month measurements (P = 0.005) for PD values. Moreover, the 6th-month measurements were lower than the 1st-month measurements (P = 0.001). It was found that the last control measurements were lower than the 6th-month measurements and it was an average of 0.21 ± 0.04 mm (P = 0.035) [Table 3].
|Table 3: Comparison of clinical outcomes at baseline, 1st month, 6th month, and the last control|
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There was a statistically significant difference between HGR and VGR values according to periods (P < 0.01). The 1st-month, 6th-month, and last control measurements of both of them were lower than the initial measurements (P = 0.001). The last control measurements were lower than the 1st-month measurements (HGR: P = 0.016; VGR: P =0.001) and lower than the 6th-month measurements (HGR: P =0.016; VGR: P =0.001). The 6th-month measurements of HGR and VGR were lower than the 1st-month measurements (P = 0.003) [Table 3].
The KGW and KGT values were statistically significantly different between time lines (P < 0.01). The 1st-month, 6th-month, and last control measurements were higher than the initial measurements (P = 0.001). The last control measurements were higher than the 1st-month measurements (P = 0.001). The 6th-month measurements were higher than the 1st-month measurements (P = 0.001). The last control measurements of KGW were statistically significantly higher than the 6th-month measurements (P = 0.020) [Table 3].
The last control CA level was higher than the 6th-month level (P = 0.002) [Table 3].
There were statistically significant differences in mMSS color, contour, and distortion scores according to periods (P < 0.01). The 6th-month and last control measurements were lower than the 1st-month measurements (P = 0.001). The last control measurements were lower than the 6th-month measurements (color: P =0.014; contour: P =0.002; distortion: P =0.046) [Table 4].
|Table 4: Comparison of the modified Manchester Scar Scale color, contour, and distortion scores|
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| Discussion|| |
FGG operations have been used successfully for many years to cover the exposed root surfaces due to GRs and to increase the amount of keratinized gingiva. Root coverage is not a primary aim of FGG surgery but in some narrow recessions (<3 mm), the root coverage may occur as a result of bridging. The predictability of root coverage with FGGs was researched by Tolmie et al. by a group of multiple clinicians in 103 Miller Class I and Class II GR defects and showed an 87.6% root coverage after 12 months. The success of FGGs seems to be highly dependent on the appropriate case and technique selection. The other mechanism which leads to root coverage is also known as the CA phenomenon and firstly described by Goldman and Cohen. The application of free gingival grafting has been successful in the treatment of multiple or single GRs, especially in cases of Miller Classes I and II. In addition, it is seen that the rate of root closure increases in the long term due to CA, although it provides partial closure in Class III cases. In our study, it was observed that approximately 0.87 mm CA developed in patients and the root closure increased by time. Many investigators had shown that CA was best observed in narrow GRs in mandibular incisors.,, This phenomenon was also reported to occur within 1 month to 1 year after the surgery. The results of our study showed that the amount of keratinized gingiva was increased with time depending on the CA and contributed to the maintenance of periodontal health in accordance with the literature. In our study, the amount of CA that occurred in the first 6 months was 0.67 ± 0.46 mm, and it was observed that there was a significant statistical change in the CA after long-term follow-up. Gul et al. evaluated the CA after FGG in the treatment of isolated GRs for a 6-month period, and recession depth demonstrated a significant reduction from 3.14 ± 1.16 mm at baseline to 1.87 ± 0.92 mm at 6 months later. The CA was reported as 1.27 ± 0.67 mm despite a 6-month study, and it was quite higher than our findings. Although CA phenomenon occurs mostly in the 1st postoperative year and remains stable in the following years, our study was supported by the other studies in the literature suggesting that creeping continues in the long term. On the other side, Agudio et al., reported that the CA continued for a long maintenance time of 10–25 years according to their retrospective long-term evaluation. Factors such as alveolar bone loss, width of GR, tooth position, graft position, and oral hygiene were also effective on the CA phenomenon. Although it is well known that the rate of root closure is limited in Miller Class III GRs accompanied by alveolar bone loss, even in these cases CA develops in the long term and the amount of keratinized gingiva and root closure increase. Reducing mucogingival stress by removing high muscle attachment and increasing the amount of keratinized gingiva contributed to better oral hygiene. As a result, clinical parameters such as GI, BoP, and PI were improved in the long term. In cases of poor oral hygiene, CA is also less developed. Effective oral hygiene is an important factor in successful clinical outcomes after periodontal plastic surgery as well as in the treatment of periodontal diseases. Jahnke et al. reported that FGG technique resulted in a significant improvement in keratinized gingiva and most of the changes were observed up to the first 3 months. In another study, Jenabian et al. compared the use of gingival unit graft with FGG for the treatment of localized GR at 1, 3, and 6 months after the surgery. Clinical parameters such as KGW, CAL, PD, vertical recession depth, and recession width showed better results and significant improvements by time. In our study, while all periodontal indexes such as GI, PI, BoP, and PD showed a significant decrease compared to baseline, the increase in the amount of keratinized gingiva and the patient's attention to oral hygiene contributed to the continuity of periodontal health.
Although the FGG gives very successful results in the treatment of GRs and root surface covering, it can be a problem of adaptation, especially in esthetic areas because it has the structurally histological feature of the donor palatal area. Jenabian et al. and Kuru and Yıldırım evaluated the patients' esthetic satisfactions by VAS for the FGG and gingival unit surgeries and indicated high VAS scores., These results showed that FGGs or modified techniques of FGG can be used in esthetic areas and an acceptable treatment modality in terms of achieving esthetics. Since all cases in our study were in the mandibular incisor area and not in the smile line, no esthetic dissatisfaction was found. Furthermore, patient satisfaction rates such as root coverage, shape and contour of gums, color of gums, and dentinal hypersensitivity were found to be acceptable and at a high level at periodontal maintenance visits. Cevallos et al. reported the 15-year long-term results of FGG and acellular dermal matrix augmentations in terms of both clinical outcomes and esthetic perception of patients using visual analog scales and reported a high esthetic score (7.08 ± 3.03) for FGG.
The compatibility of FGG with the recipient region continued to increase over time in terms of mMSS color, contour, and distortion, and long-term follow-up showed a statistically acceptable improvement. Although not statistically significant, it was found that there was only a slight difference in color. We believe this was due to the genetic structure of the donor site.
| Conclusion|| |
The complete root coverage can be achieved by FGGs for the treatment of narrow GRs at mandibular anterior teeth and highly depends on the right case selection. In other cases, the coverage may increase by CA phenomenon in a long-term period. This increases the keratinized tissue, advances esthetics and patient satisfaction, and provides a healthy surrounding periodontal tissue by enhancing plaque removal during long-time follow-up.
The author thanks statistician Hande Emir, SWOT Statistics, Istanbul, for the help in statistical analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]