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Journal of Oral Science & Rehabilitation Issue 01/2016

Journal of Oral Science & Rehabilitation Volume 2 | Issue 1/2016 57 C o r o n a l l y a d v a n c e d f l a p i n t h e t r e a t m e n t o f b i l a t e r a l m u l t i p l e g i n g i v a l r e c e s s i o n s Introduction The coronally advanced flap (CAF) is a surgical procedurefortreatinggingivalrecessions(RECs)1 by advancing the residual keratinized tissue sur­ rounding an exposed root to coverthe cemento­ enamel junction. It can be used alone or in com­ bination with a connective tissue graft,2 an enamel matrix derivative3 or various connective tissue graft substitutes,4, 5 especiallywhen kera­ tinized tissue limiting the REC is not adequate to allow stable results. It can be performed on multiple adjacent root exposures and can be considered the technique of choice for such a clinical purpose,6 with speci­ fic advantages when treating gingival RECs in esthetic areas. On multiple adjacent RECs, CAF can even be performedwithoutverticalreleasing incisions7 with increased possibility of achieving complete root coverage (CRC), better esthetic results owing to the complete absence of keloid aspects sometimes shown after healing of the vertical releasing incisions and a better post­ operative course for the patient.8 A modified approach was introduced in the treatment of bilateral gingival RECs in the es­ thetic area using CAF.9 Later, other authors10, 11 described a minimally invasive technique for the management ofthe papilla situated betweenthe central incisors using the tunneling approach to advance a flap for covering either a subepithelial connective tissue graft or a substitute graft in association with a specific flap design.12 Atunnel can be surgically created underneath the buccal aspect of the midline papilla, allowing the mobi­ lization of the gingival margin on both the adja­ cent centralincisors and maintaining postopera­ tive ideal soft-tissue stability. The aim of the present study is to compare theresultsobtainedatone-yearclinicalfollow-up in the treatment of multiple Miller Class I gingi­ valRECsofthemaxillaryestheticarea,usingCAF with the papilla tunneling technique or with the conventional technique. Furthermore, the aim is to compare the specific results obtained at the buccal aspect of the maxillary central incisors with CAF and the maxillary midline papilla tun­ neling technique and with the conventional CAF technique. Materials & methods Twenty subjects with multiple maxillary bilater­ algingivalRECs inthe area betweenthe left sec­ ond premolar and the right second premolar (at least two adjacent teeth with Miller Class I REC with at least 2 mm of residual keratinized tissue and at least one such tooth on each side of the maxilla), 11 females and 9 males (age range of 22–60) in good general health were selected. After the first examination, all of the patients underwent a single session of prophylaxis with instructions on proper oral hygiene techniques, scalingandprofessionaltoothcleaningbymeans of rubber cups and prophylaxis paste. Further examinations were scheduled once each patient was able to demonstrate adequate supragingival plaque control with an effective and atraumatic brushing technique. At baseline, immediately prior to surgery, for each tooth in­ volvedinthetreatment,RECwasmeasuredfrom the cementoenameljunctiontothe gingivalmar­ gin and residual keratinized tissue apical to each REC was measured from the gingival margin to the mucogingivaljunction. Probing pocket depth was measured on the mesial and distal aspects of each tooth involved in order to identify Miller Class III RECsthatwould not be evaluated. RECs withresidualkeratinizedtissueoflessthan2mm atbaselineweretreatedduringsurgerybutexclu­ dedfromthe evaluation.Asequence ofrandomi­ zation was generated by a subject not involved in the research, instructed to randomlyplace ten sheets of paper bearing “tunneling” and ten “notunneling” inside 20 progressivelynumbered envelopes. The surgicalprotocolwasthefollowing:After local anesthesia (articaine with 1:100,000 epinephrine), exposed roots were gently instru­ mentedbymeansofGraceycurettesandrotating diamond burs mounted on a micromotor hand­ piece. The envelope was then opened in order to determinewhetherthesurgicaldesignoftheflap was to be performed according to a tunneling procedure onthe midline papilla orwhethercon­ ventional CAF was to be performed. In the case of conventional CAF, the flap was designed with marginal and papillary incisions performed with a #15C blade, accordingtothe CAFtechniquefor monolateral multiple RECs7 without vertical re­ leasingincisions,ideallydividingtherightandthe left sequence of RECs located at each side ofthe midline as an independent monolateral root cover­age procedurewith its centre ofrotation on Volume 2 | Issue 1/201657

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