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Dental Tribune Canada Edition No.1, 2016

XXXXX B4 Implant Tribune Canada Edition | March 2016 CLINICAL Ad “ GRAFTING, Page B2 the envelope type of CAF was associated with an increased probability of achieving complete root coverage — and with a bet- ter postoperative course. Keloid formation along the vertical re- leasing incisions was responsible for a poor esthetic outcome along with a longer healing period and a more uncomfort- able postoperative course.32 Complete root coverage has been shown to be more likely in Miller I and II type recessions, when marginal tissue recessions are shallower: 66 percent for an average attachment level of 3.81 mm, compared with 50 percent and 33.3 percent for mean attachment levels of 5.23 and 5.5 mm, respectively.33,34 Glise and Monnet-Corti also reported that percent- age of root coverage was inversely propor- tional to width and height of initial reces- sion dimensions.35 Thus, even though the literature indicates that Miller III and IV re- cessions have little probability of 100 per- cent root coverage, increasing the KT and AT can increase the longevity of a patient’s dentition. Even if only some slight root coverage (based on individual anatomy and physiology) is possible, this may be a significant improvement for the patient esthetically; and it also increases the chan- cesofadditionalrootcoverageasaresultof creeping attachment for the patient.36 The Er,Cr:YSGG laser is used here for the first time in surgical grafting procedures because it achieves a precision not possible with a surgical blade. Erbium lasers also have the unique ability to vaporize water- containing tissue because of its wave- length and provide a hemostatic effect to cauterize blood vessels. What is clearly observed is that the Er:YSGG laser enables the operator to take a “microsurgical approach” — to finesse the marginal-tissue adaptation at the cor- onal edges along with “laser welding” the FGG-donor portion to the CPF portion of the surgical site and control the hemo- stasis without additional suturing. Pini Prato37 showed that the gingival marginal position at the end of plastic surgery al- lowed for complete root coverage in Class I and Class II gingival recession defects, and applying this philosophy of treatment to the laser CPF/FGG will only enhance any probability of root coverage in Miller III/IV recession defects. The elevation of a full- vs. partial- thickness flap does not appear to influence either the amount of keratinized tissue or the percentage of root coverage achieved post-surgically.20 In fact, the thicker cor- onal tissue, allows an increase in blood supply, surgical anchorage and less tissue trauma with better potential root cover- age.38 Pedicle and envelope flaps are suc- cessful if the grafted tissues remain vital on the exposed dental avascular root sur- face, and soft-tissue healing is critically controlled by this vascularity.28,29 Most re- affirming was Romanos et al.43 showing that the lateral bridging flap technique, designed similar to this paper’s CPF, ex- hibited the most stable location of the re- positioned MGJ, which was 2-3 mm coron- allyoverfivetoeightyears,withstableroot coverage and gingival margins. Of further interest is that treatment success is more predictable, with limited interproximal bone loss and undamaged interproximal soft tissue.5,39 Gurgan commented that tooth location, vestibular depth, and muscular and fre- numinsertionsmayaffectwoundstability once a flap is advanced.50 Fombellida analyzed the significance of the “vascular supply” as a critical factor on the prediction of root coverage success; a positive balance between the vascularized and nonvascularized areas of the surgical field yields better results in terms of root coverage,eveninthoselessfavorablecases, such as Miller Class III recessions.40 Conclusions Clinicians all too often are faced with the request: “Can you not do something to cover these teeth?” Many times the con- cern is not related to sensitivity but rather that of esthetics, after recession has in- creased over a period of time for a patient on a stable maintenance schedule. Once the periodontal health was assessed to be stable, the remaining compromised zone of KT/AT and the location of the muscle/ frenal attachment often appeared to play a role in progressive recession. Thus, the single-stagedlaserCPF/FGGwas developed and completed in more than 100 patients — and was reported to be a comfortable procedure with an esthetic improvement. Additionally, there have even been docu- mented areas of root coverage in Miller III and IV situations and, over the years, some “creeping attachment” has been docu- mented.36 Additional investigation through a pro- spective clinical study with volumetric methodology44 needs to be done to assess the statistical significance of increases in KT and root-coverage results of this new procedure — or with the adjunct of tissue engineering and biological adjuncts, such as enamel matrix derivative, PRP (platelet rich plasma) or PRF (platelet rich fibrin).41 The CAF procedure is effective in the treatment of gingival recessions. However, recession relapse and reduction of KT oc- curred during follow-up periods without any FGG adjunct.42 The baseline width of KT is a predictive factor for recession re- duction when using the CAF technique. Thus the new single-staged laser CPF/FGG is an effective and predictable method to increase the zone of KT and AT width. The technique can also anecdotally be shown to increase root coverage in Miller III and IV cases and fulfills the need of the patient, while at the same time reducing the num- ber of appointments and patient costs. A list of references is available from the publisher on request. Preety Desai, BSc, DDS, Dip Periodontics, has been in full- time specialty periodontal prac- tice in Kamloops, British Colum- bia, since 1997. She has no financial interests in, and has re- ceived no materialistic or finan- cial benefit from, corporations with respect to this article. She can be contacted by email at

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