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Dental Tribune Canada Edition No.1, 2016

March 2016 — Vol. 4, No. 1 IMPLANT TRIBUNE The World’s Dental Implant Newspaper · Canada Edition Novel approach to gingival grafting: Single- stage augmentation graft for root coverage By Preety Desai, DDS, Dip Periodontics T he existence and preservation of attached keratinized gingiva around natural teeth and den- tal implants plays an import- ant role in periodontal1 and peri-implant health.46,47 This article describes a novel surgical technique that addresses mul- tiple adjacent Miller Class II and III reces- sion defects5 in a predictable one-staged surgical procedure. The goals of treatment are to improve esthetic outcomes and gain clinical attachment and keratinized tissue levels in addition to possible root coverage. A combination of traditional periodon- tal plastic procedures is used, following sound,evidence-basedtechniques.Todate, more than 100 surgical cases have been completed. Surgical steps and rationale for this new technique are detailed here, and representative cases are shown (Figs. 1–12). Introduction As many epidemiological reports suggest, gingival recession affects the majority of the adult population.2,3 Gingival recession is defined as the apical migration of the soft-tissue margin around teeth leading to exposure of the cementoenamel junction (CEJ) and the dentinal root surface4 and is classically categorized by Miller.5,6 The philosophy for increasing the zone of kera- tinized tissue for teeth is for attachment stability, facilitation of plaque control and to prevent further gingival recession from frenal/muscle pulls.6,7 Periodontal plastic procedure articles in the literature evidentially demonstrate very predictable and esthetic root cover- age in the majority of Miller Class I and II single- or adjacent-tooth sites with and without the adjunct of a subcutaneous connective tissue graft (SCTG).3,7 This holds true irrespective of surgical technique(s) used, i.e., pedicles, tunnels, coronally pos- itioned flaps (CPF), guided-tissue regenera- tion (GTR), etc., provided that biologic principles for obtaining root coverage are satisfied, i.e., interproximal papillary height and interseptal bone height. Additionally, the results of long-term clinical retrospective studies in private practice demonstrate that not only is there effective root coverage but mean root coverage tends to improve over time after initial surgery.8 In acellular dermal matrix and GTR studies over the short and long term, neither showed a statistically signifi- cant increase in root coverage compared with the use of autogenous tissues.9,10 More ” See GRAFTING, page B2 Clinical Fig. 1 recently, the literature also shows clin- ical cases of inexplicable root resorption in SCTG cases performed in a traditional manner.47,48 In contrast, the presence of multiple recessed sites in a posterior sex- tant that have advanced recession beyond Miller Class I/II, presents a clinical conun- drum that has not been addressed until re- cently in the literature of periodontics3,11,12 and clinical periodontal practice. Never- theless, the goal of periodontal therapy should be to address the needs and wishes of each patient, and treatment options should be made available to each patient accordingly.13 Recession in multiple adjacent teeth can occur for a variety of reasons: the pa- tient’s iatrogenic habits; history and/or treatment of chronic periodontal disease by traditional flap therapy; anatomy/mal- positioned teeth in the alveolar ridge cor- ridor compromising attachment appar- atus; muscle/frenal attachment levels at or beyond the mucogingival junction (MGJ); secondary parafunctional habits; and the obvious long-standing results of a history of chronic untreated periodontal disease. A two-staged surgical procedure — free gingival graft (FGG) plus surgical repos- itioning coronally positioned flap (CPF)12,14 — can aid individual sites in some Miller II/III recessed areas. These surgical sites that have experienced two surgeries are prone to double the postoperative surgical shrinkage, fibrotic scar tissues and mor- bidity.30 Patients also report discontent with this two-surgery treatment option because of increased costs, healing time, work absences and scheduling issues. In difficult economic times, the dental pro- fession must streamline treatment op- tionsforpatientsbutstillcontinuetodeliv- er excellent surgical skills and subsequent clinical benefit. No treatment options are available in posterior sextants with mul- tiple recessed Miller Class II/III sites that have a lack of adequate keratinized and attached gingiva regardless of if the adja- cent papillae is affected. As such, an effort has been made to fill this void with a cor- rective surgical procedure able to stabil- ize progressive recession with the added benefit of some root coverage in Miller III recessions.11 Inclusion criteria for single-stage CPF/FGG Patients eligible for the one-stage CPF/FGG procedure included those with: 1) No health issues as a contraindication for periodontal surgery. 2) Presence of at least two to three ad- jacent teeth with Miller Class II/III facial recession with a frenal/ligamental attach- ment deemed to be playing a role in creat- ing a stable gingival margin. 3) Chief complaint of impaired esthetics associated with the recession. 4) Absence of anatomical defects, caries or restorations needed in the site. 5) No periodontal surgical treatment of the involved sites during the previous 24 months. 6) Adequate oral hygiene. 7) Non smokers. Procedure Patients chosen exhibit posterior sextants of recession with interproximal bone loss (Miller II or III) and encroachment of gin- gival recession on the MGJ, commonly with frenal pulls and muscle attachments, which may or may not have played a role in the etiology of attachment loss but will play a role on the success and stability of surgical treatment to resolve progressive recession.15,49 A modified one-staged FGG + CPF12,14 sur- gical approach is suggested: Implementing Sumner’s full-thickness envelope16 and Sorrentino and Tarnow’s17 semilunar pro- cedure augmented with a traditional FGG18 apical to the coronally positioned semilunar flap is suggested. This combina- tion procedure proposes to inhibit the coronal reattachment of the musculature and freni, which can play havoc with graft stability in the long term,49 in addition to increasing the zone of keratinized and at- tached tissues. Results showed that most Class III recessed cases even showed some root coverage in addition to an ample gain in keratinized and attached tissues.11,12 The first incision was performed by the Er,Cr:YSGG laser (with appropriate soft- tissue settings due to its known properties of hemostasis). The T4 laser tip incises pre- cisely at the MGJ in a contact/non-contact manner depending on the extent of fi- brous and ligamentous frenal attachment to make a split-thickness-incision release of all musculature/fibres prior to reaching the periosteum. All elastomeric fibres are thus incised and denatured at the MGJ. This allows the mucosa to apically relax, laying passively, extending the vestibular region without causing any tension on the future graft’s recipient surgical site. Rarely was vestibular suturing needed for hemo- stasis in the region unlike with a trad- itional blade incision. Resorbable 4-0 gut sutures are used in the vestibule for this purpose. Dentinal root preparation is done in a conservative manner if the anatomy is deemed to be inhibitory to coronal-flap positioning and stability (i.e., in root abra- sion,horizontalgrooving,cariescases,etc.). The root surfaces are traditionally modi- fied with root planing to remove calculus, Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 1: Case 1, lower-right sextant presurgery. Fig. 2: Case 1, lower-right sextant pre-op X-ray. Fig. 3: Case 1, post-op. Fig. 4: Case 2, upper left sextant pre-op. Fig. 5: Case 2, surgery — flap elevation. Photos/Provided by Dr. Preety Desai Fig. 6 Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 6: Case 2, surgery — coronally positioned flap. Fig. 7: Case 2, upper-left sextant — four weeks post-op. Fig. 8: Case 2, upper-left sextant — six weeks post-op. Fig. 9: Case 3, upper-left sextant pre-op. Fig. 10: Case 3, upper-left sextant post-op.

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