Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Research Protocol
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : ZK08 - ZK11 Full Version

Effectiveness of Titanium Prepared Platelet Rich Fibrin Membrane vs Platelet Rich Fibrin Membrane in the Treatment of Multiple Gingival Recession Defects using M-VISTA Technique: Protocol for a Randomised Clinical Trial


Published: January 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/59059.17420
Shrishti Satish Salian, Prasad V Dhadse

1. Postgraduate Student, Department of Periodontics and Implantology, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India. 2. Professor and Head, Department of Periodontics and Implantology, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India.

Correspondence Address :
Shrishti Satish Salian,
Department of Periodontics and Implantology, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences Campus, Sawangi (Meghe), Wardha-442001, Maharashtra, India.
E-mail: shristisworld@gmail.com

Abstract

Introduction: The focus of root coverage procedures is now shifting to minimally invasive surgical approaches. Periodontists are being required to adopt newer and more unique procedures to thoroughly cover the exposed roots. Due to the sensitivity of various techniques and the fact that it involves a wide variety of operations and their variants, periodontal plastic surgery provide a substantial challenge. A variety of minimally invasive techniques and platelet concentrates which are abundant in growth factors have been assimilated that provide the added benefit of better and rapid healing.

Aim: This study aims to evaluate the effectiveness of Titanium-Prepared Platelet Rich Fibrin (T-PRF) and Platelet Rich Fibrin (PRF) membrane in Miller’s Class-I and Class-II multiple Gingival Recession (GR) using Modified-Vestibular Incision Supra-Periosteal Tunnel Access (M-VISTA) technique.

Materials and Methods: The planned protocol would be randomised clinical trial and will be performed over a period of two years. Twenty-two patients will be selected according to the inclusion criteria, each having multiple GR (>2 mm, Class I or II recession) on buccal/labial aspects of teeth in maxilla or mandible, and would be randomly distributed into the two groups (control and test). The M-VISTA technique would be carried out for root coverage using T-PRF (test group) and PRF (control), respectively as regenerative materials and their effectiveness will be compared by measuring the Pocket Probing Depth (PPD), Clinical Attachment Level (CAL), Relative Gingival Marginal Level (RGML), Recession Depth (RD) and Width of Keratinised Gingiva (WKG). Student’s paired and unpaired t-tests will be used to evaluate data from the baseline to 3 and 6 months for each group.

Expected Results: The authors expect better results of root coverage using the M-VISTA technique in combination with T-PRF (test group). Better results in terms of PPD, CAL, RGML, RD, and increase in thickness of attached gingiva are expected.

Conclusion: Combined effect of using T-PRF in the M-VISTA procedure is expected to improve the periodontal parameters including, the soft tissue outcomes and the plaque and bleeding index.

Keywords

Biomaterials, Periodontal plastic surgery, Root coverage, Modified vestibular incision supra-periosteal tunnel access

Periodontitis is the world’s sixth most prevalent oral disease in humans (1). Periodontitis can result in the destruction of periodontium leading to the one of the most common clinical findings that is pocket formation and GR (1). GR is defined as “the displacement of the gingival margin apical to the Cemento-Enamel Junction (CEJ)” (1). GR can be further classified into localised (restricted to a particular site) and generalised (widespread or multiple sites) GRs (1). The line of treatment for GR aims to eliminate all causative factors and is then followed by surgical treatment for predictable root coverage (2).

There are various surgical interventions available for GR especially for Miller’s Class I and II like the Coronally Advanced Flap (CAF), apically displaced flap, Connective Tissue Graft (CTG), to name a few (1),(3). The main aim for the surgical treatment for GR is to thoroughly cover the exposed roots. Periodontists are being required to adopt newer and more unique procedures with minimal invasive surgical approaches for GR. Due to the sensitivity of its techniques and the fact that it involves a wide variety of operations and their variants, periodontal plastic surgery provides a substantial challenge (4).

The tunneling technique was introduced by Allen AL, which is another key advance to CAF. Following its inception in 1994, numerous procedural changes have been proposed (5). Zadeh HH presented VISTA in the year 2011, which is a minimally invasive technique for root coverage (6). Furthermore, the VISTA has been tested in conjunction with a variety of graft materials such as CTG, PRF and PRF membrane with promising results (1),(4),(5),(7).

M-VISTA is a contemporary, minimally invasive approach used for the treatment of both generalised and localised GR defects. The procedure is the modification of the traditional VISTA technique, hence the name. The modification includes the location of incision (instead of a sub-periosteal incision, a supra-periosteal incision is given). This method is specifically precise because it allows more access in the vestibule by giving a single vestibular incision which provides access to an entire region. Thus, it allows a good access and proper visualisation of root and bone morphology and dehiscence. It also improves the wound healing by simplifying the tunneling process (1).

Platelets function as reservoirs for growth-factors and cytokines that are required for soft tissue and bone regeneration, as discovered by Robert Marx in 1971. Choukroun’s platelet research resulted in the development of a second-generation platelet concentrate (PRF) in 2001 (8). The PRF clot forms a strong natural fibrin matrix that has a variety of growth-factors that aid tissue regeneration. The health risks linked with silica containing glass tubes used to collect blood for PRF are still a source of concern. T-PRF was developed to overcome the limitations of PRF (9).

T-PRF was created in 2013 by Tunali using biocompatible titanium tubes (10). It’s a fibrin, rich in platelets and leukocytes that’s similar to PRF but has a denser fibrin network than PRF. This denser fibrin structure is essential for extending intra-tissue fibrin resorption and releasing growth-factors in a drop-by-drop fashion over time (11). PRF’s ability to regenerate has been established in various studies (6),(8),(11). T-PRF’s efficacy profile, on the other hand is scarcely known (10),(12).

Hence, this research protocol has been made with a novel approach to use T-PRF as a regenerative material in the M-VISTA technique of root coverage.

This randomised clinical trial protocol is made with aim to evaluate the comparative effectiveness of T-PRF membrane and PRF membrane in Miller’s Class-I and Class-II multiple GR defects using M-VISTA technique in terms of Root Coverage (RC), gain in CAL, Gingival Thickness (GT) and improvement in the WKG.

Material and Methods

The present study is a randomised clinical trial and will be performed over a period of two years and has started in January 2023. The study is planned to be conducted on 22 participants each having multiple GR (>2 m, Millers Class I or II recession) (8) on buccal/labial aspects of teeth in maxilla or mandible from the Outpatient Department (OPD) of Periodontics and Implantology, Sharad Pawar Dental College, Sawangi (Meghe), Wardha, Maharashtra, India after taking written informed consent. Study protocol has been approved by the Institutional Ethics Committee of the chosen study institute. (Ref.No. DMIMS(DU)/IEC/2022/749). The M-VISTA technique would be carried out for root coverage using T-PRF (test group) and PRF (control), respectively as biomaterials and their effectiveness will be compared.

Sample size calculation: It was done by using the data provided by the previous study of Subbareddy BV et al., by using Statistical Package for Social Sciences(SPSS) version 27.0 open-source calculator (13). The result of the calculation is 40. Sample size formula for difference between two means:

N=(za+zb)2 (d12+d2)/D2

Where Za is the level of significance at 5% i.e., 95% confidence
interval=1.96, Zß is
power of test= 80%=0.84
d1=SD of CAL in test group=1.47
d2=SD of CAL in control group=0.91
.=Difference between two means= 3.97-2.58=0.76
K=1

n=(1.96+0.84)2 (1.472+0.912/1)//0.762=40 total patients. Hence, 20 subjects would be randomly distributed in each group by computer-generated random numbers.

Inclusion criteria: Multiple Recessions >2 mm (GR depth) on buccal/labial aspects of teeth in maxilla or mandible with Class I or II recession Miller’s Classification 1950 (8). The cases with intraoral radiographic evidence of sufficient interdental bone (a radiolucency of less than 2 mm between the crestal bone and the CEJ) and patients with the presence of gingival biotype with varying thickness of 0.7 to1.5 mm are planned to be included in the study.

Exclusion criteria: Smokers and those who use tobacco products (kharra, gutka,paan, betel nut etc.,), those patients who are unwilling to cooperate, those patients with poor oral hygiene and a plaque score of =1 (Turesky-Gilmore-Glickman Modification of Quigley-Hein Plaque Index 1970) (14). Patients who report Periodontal surgery treatment history in the study area, lactating mothers or a pregnant lady, those who will show presence of teeth with caries or presence of mobile teeth Grade III and crowding in teeth (at the region of concern) are planned to be excluded from the study.

Procedure

Initial therapy: Scaling and Root Planing (SRP), and polishing will be performed on each patient. Wherever necessary, coronoplasty and tooth recontouring will be performed. Patients will be taught how to employ “Modified Stillman’s brushing technique” to overcome brushing injury (8). Oral hygiene instructions such as brushing technique (as mentioned above) will be given to the subjects until their plaque score reaches <1 which will be evaluated again 6 weeks later. If the patient’s dental hygiene isn’t maintained, he or she will be excluded from the study. The patient will be educated about the study strategy and given the opportunity to sign a consent form.

Clinical measurements

A) Indices

The dental hygiene and gingival health of all patients will be assessed on the day of the surgical treatment, three, six & nine months later.

1. Turesky-Gilmore-Glickman Modification of Quigley-Hein Plaque Index (PI) 1970) (14): Plaque will be examined on the labial/buccal and lingual/palatal surfaces of all teeth after a disclosing agent (Skinner’s iodine solution) has been used. This system had the scoring criteria as:

• Score 0: No plaque.
• Score 1: Separate flecks of plaque at the cervical margin of the tooth.
• Score 2: A thin, continuous band of plaque (up to 1mm) at the cervical margin of the tooth.
• Score 3: A band of plaque wider than 1mm but covering less than one-third of the crown.
• Score 4: Plaque covering atleast one-third but less than two-thirds of the crown.
• Score 5: Plaque covering two-third or more of the crown.

Calculations: The sum of the scores around each tooth will be divided by two to obtain the PI score for the tooth. The PI score per person will be obtained by adding the PI score for all teeth and divided by the number of teeth examined.”

2. “Papillary Bleeding Index by Muehlemann HR 1977 (15): On the mesial side, a University of North Carolina (UNC)-15 Probe will be carefully placed into the crevicular sulcus at the base of the interdental papilla and moved coronally to tip of the papilla. On the distal aspect of the same papilla, the procedure will be repeated. On a scale of 0 to 4, the severity of any resulting bleeding will be recorded.

B) Clinical parameters

The ‘CAL’, ‘RGML’, ‘RD’, ‘WKG’, all of which will be assessed using a UNC-15 probe and GT will be measured. Acrylic stents will be made to integrate the clinical parameters and will be used as a reference point enveloping the occlusal surfaces of the test tooth. The periodontal probe is inserted at an angle to reach the deepest area of the defect. Burs will be used to create longitudinal grooves on the stent, which is going to be used as a guide for the periodontal probe. RD will be calculated from cemento-enamel junction to the margin of gingiva. WKG will be achieved by calculating the sulcular depth plus the attached gingiva by UNC-15 Probe.

Clinical measurements will be recorded in the areas to be treated on the day of the procedure and three, six and nine months postoperatively. The GT will be measured with a No.15 endodontic spreader and topical anaesthetic, this measurement is taken in the relevant area. The spreader is inserted perpendicular to the gingiva through the gingival edge’s apical 1.5 mm and thrust forward till it reaches the bone and then secured using a rubber stop. The distance between the rubber stop and the endochuck tip is measured with a Vernier Caliper.

C) Radiographic Measurement

Intraoral Periapical (IOPA) and grid specification for evidence of sufficient interdental bone.

Preparation of T-PRF membrane

Ten millilitre of blood sample will be collected from antecubital vein by venipuncture within one minute from the participants for the preparation of T-PRF. The samples will be immediately transferred within 30 seconds in the Titanium test tubes and placed in the centrifugation machine. It will be centrifuged at 2700 rpm for 12 minutes. Following centrifugation, the T-PRF clot will be obtained. The fibrin clot that has developed in the middle of the tube will be removed, and the red blood cell remnants will be discarded. The clot will be moved to the PRF box and pressed in order to obtain T-PRF membranes (16).

Surgical Procedure

Preparation of PRF membrane

Using a 24-gauge needle, ten-millimeter blood will be drawn from antecubital vein and the blood samples will be collected in 10 ml glass test tubes and centrifuged for 10 minutes at 3000 rpm on a table centrifuge equipment. The fibrin clot that has developed in the middle of the tube will be removed, and the red blood cell remnants will be discarded. The clot will be moved to the PRF box and pressed in order to obtain PRF membranes (8),(17).

Test group surgical procedure: Prior to surgery, patients will be directed to rinse their mouths with a mouthwash containing 0.2% chlorhexidine gluconate for one minute. Exposed root surfaces will be scaled and planned using Gracey curettes after local anesthetic is administered. Flowable composite will be applied on the mesial side and distal side of the teeth to be treated (without etching, interdentally) to facilitate the sling sutures.

The modified procedure will begin with a long vertical incision made with a no.15 blade starting 1-2 mm from the marginal gingiva and will extend all the way to the periosteum and just past the mucogingival junction and the incision will be created in the most central region, taking into account the extension of the teeth to be treated. Following that, all intracrevicular incisions will be made with a no.15 blade. These incisions will extend to atleast one tooth, beyond the ones to be treated. A full-thickness tunnel will be constructed, extending beyond the mucogingival border into the alveolar mucosa supra-periosteally. This will be accomplished by releasing the tunnel-papillae complex fully through a vertical incision and then gingival borders, allowing for passive coronal replacement. Using 4.0 silk suture. sling sutures will be engaged 2-3 mm apical gingival border of each tooth. After coronal stabilisation, a freshly made T-PRF membrane will be introduced through the tunnel using a small periosteal elevator and uniformly spread across recession defects. The vertical incision will be sutured for the primary closure after the membrane has fully adapted. The Coe PakTM will cover the entire surgical site (16),(18).

(Table/Fig 1) shows a diagrammatic representation the of M-VISTA technique.

Control group surgical procedure: The surgical procedure for the control site will be similar to the procedure for the test site, with the exception that PRF membrane that will be used over the exposed root surfaces.

Postoperative care

After the treatment, a periodontal pack (Coe pakTM) will be placed on the surgical sites. Systemic antibiotic will be given. Subjects will be told not to brush their teeth at the treated site for three weeks after surgery. All patients will be taught to rinse with Chlorhexidine (CHX) gluconate (0.2%) Hexidine (ICPA Health Products ltd.,) twice daily. The periodontal pack will be removed 7 days after the treatment. The sutures will be removed after 14 days and saline irrigation will be done. Before brushing using Modified Stillman’s technique, patients will be directed to clean the treated area with cotton dipped in CHX 0.2% for another seven days. The patients will be recalled three, six and nine months after the procedure.

Statistical Analysis

Mean and SD will be calculated for the above-mentioned parameters. Mean data will be analysed using a standard statistical approach for statistical significance. Unpaired and paired t-tests will be used to assess data from the baseline through three, six and nine months for each group. The result is considered not significant if the value of probability is larger than 0.05. It is considered significant if it is less than 0.05. The p-value<0.05 is considered significant.

Results

Expected outcomes

When the M-VISTA approach is combined with T-PRF, The authors anticipate improved and faster outcomes for root coverage. Better results are anticipated in terms of “PPD,” “CAL,” “RGML,” “RD,” “plaque and bleeding indices” and an increase in the thickness of attached gingiva.

Discussion

There are various studies done on tunneling procedures after its inception by Allen AL in 1994 (5), although numerous procedural changes have been proposed (1),(6),(19),(20),(21). Zadeh HH presented VISTA, which is a minimally invasive technique (6). A modification of this was then introduced, known as M-VISTA. A case series was conducted by Fernandez-Jimenez A et al., in which the results of the M-VISTA procedure in patients with multiple GR (Miller class III) after 6 months was evaluated. The result of this study showed mean root coverage of 58.72% after the intervention, with total root coverage in 29% of the GR cases. The authors concluded that M-VISTA may have various advantages over other techniques for class III recession (1).

Mitra DK et al., in their split mouth Randomized Control Trial (RCT) study evaluated the clinical and radiographic effects of autologous T-PRF and PRF in the treatment of infra bony defects, as well as the histologic differences between both the PRF techniques. Clinical parameters such as RAL, PPD were evaluated at baseline, three months and nine months. The result of this study shows reduction in PPD and RAL at three months and nine months. The authors concluded that in an intragroup comparison, clinical metrics and radiographic outcomes with both groups showed considerable improvement. T-PRF displayed denser fibrils in light and scanning electron microscopy than PRF, according to histological analysis (11).

Uzun BC et al., in their study compared the effects of autogenous T-PRF and CTG for the management of multiple GRs. Before surgery as well as during 6- and 12-month follow-up exams, clinical periodontal indices, Keratinized Tissue Width (KTW), GT, and RD were noted (12). The visual analogue scale and healing index values were additionally evaluated. The results of this study demonstrated that the mean root coverages were 93.29% and 93.22% in the T-PRF and CTG groups, respectively at 12 month interval. Furthermore, the mean amounts of KTW increased by 1.97 and 0.75 mm in the T-PRF and CTG groups. T-PRF is safe and effective for treatment of multiple Miller Class I/II GR defects. The clinical relevance of this was that T-PRF can serve as a good autogenous alternative to CTG, which is the gold standard for root coverage (12).

The M-VISTA approach was also utilised to repair soft tissue deficit surrounding an implant supported restoration in a case report by Lee CT et al., (20). A 25-year-old systemically healthy woman, with a tissue deficiency around a single tooth implant in the anterior portion of maxilla was treated using the m-VISTA technique (22). There was increased tissue height and width around the implant supported restoration in the aesthetic zone. Thus concluding, it can be used to treat soft tissue deficit in the future (20),(23).

Conclusion

Combined effect of using T-PRF in the M-VISTA procedure will expect novel outcomes with reduced time for regeneration. This study plan will serve many advantages in terms of improving the periodontal parameters including, the soft tissue outcomes at a faster rate.

References

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Sethiya KR, Dhadse P, Bajaj P, Durge K, Subhadarsanee C, Hassan S. Platelet rich fibrin in combination with bioabsorbable guided tissue regeneration (GTR) membrane and GTR membrane alone using double lateral sliding bridge flap for treatment of multiple gingival recession defects in humans: A randomised controlled clinical trail. J Indian Soc Periodontol. 2022;26(3):245-53. [crossref] [PubMed]
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Sehdev B, Ganji KK, Bhongade ML, Toriya J, Imanishi T, Shoumura M, et al. Evaluation of the impact of the clinical periodontal status on volumetric features of gingival crevicular fluid by using periotron® 8000. Journal of Hard Tissue Biology. 2017;26(2):187-94. [crossref]

DOI and Others

DOI: 10.7860/JCDR/2023/59059.17420

Date of Submission: Jul 13, 2022
Date of Peer Review: Aug 11, 2022
Date of Acceptance: Nov 12, 2022
Date of Publishing: Jan 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 14, 2022
• Manual Googling: Nov 09, 2022
• iThenticate Software: Nov 11, 2022 (16%)

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