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XXXXX B2 Publisher & Chairman Torsten Oemus t.oemus@dental-tribune.com President/Chief Operating Officer Eric Seid e.seid@dental-tribune.com Editor in Chief Dr. Sebastian Saba feedback@dental-tribune.com Group Editor Kristine Colker k.colker@dental-tribune.com Managing Editor Implant Tribune Canada Robert Selleck, r.selleck@dental-tribune.com Managing Editor Implant Tribune U.S. Sierra Rendon s.rendon@dental-tribune.com Managing Editor Fred Michmershuizen f.michmershuizen@dental-tribune.com Product/Account Manager Will Kenyon w.kenyon@dental-tribune.com Product/Account Manager Humberto Estrada h.estrada@dental-tribune.com Product/Account Manager Maria Kaiser m.kaiser@dental-tribune.com BUSINESS DEVELOPMENT MANAGER Travis Gittens t.gittens@dental-tribune.com Education DIRECTOR Christiane Ferret c.ferret@dtstudyclub.com Accounting Department Coordinator Nirmala Singh n.singh@dental-tribune.com Tribune America, LLC Phone (212) 244-7181 Fax (212) 244-7185 Published by Tribune America © 2016 Tribune America, LLC All rights reserved. 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Let us know by emailing feedback@dental-tribune. com. If you would like to make any change to your subscription (name, address or to opt out) please send us an e-mail at database@dental-tribune.com and be sure to include which publication you are referring to. Corrections Implant Tribune strives to maintain the utmost accuracy in its news and clinical reports. If you find a factual error or content that requires clarification, report the details to managing editor Robert Selleck, r.selleck@dental-tribune.com. Implant Tribune Canada Edition | March 2016 “ GRAFTING, Page B1 CLINICAL plaque, debris and to create a flat/convex architecture; and they are etched with the hard-tissue setting with the Er,Cr:YSGG at the coronal gingival margins prior to suturing of the coronal flap. The second incision is the release of the coronally attached keratinized tissues in- cised as an envelope flap19 from the sulcus in a full-thickness manner20 with micro- surgical blades — without the use of verti- cal incisions on the facial aspect and split thickness in the papillary regions. The flap is coronally positioned with vertical mat- tress interrupted sutures using 6-0 non- resorbable monofilament microsurgical sutures. Once the coronally placed flap is secure, then the soft-tissue laser setting of the Er,Cr:YSGG allows gingivoplasty/gin- givectomy via microplastiying of the mar- ginal tissue outline and adaptation of the marginal papillary regions of the gingival margins. An ideal scalloping in the manner of a “paintbrush” stroke of the laser tip allows the coronal architecture of the free gingi- val margin (FGM) adjacent to the teeth to adapt the marginal tissues precisely. This gingivoplasty allows the whole site to have a more finessed marginal gingival adapta- tion and contoured appearance against the dentition. The whole coronally positioned tissue is still attached with its mesial and distal blood supplies intact and is now fixed with interproximal sutures, gaining blood supply from the split-thickness pap- illae and the alveolar bone beneath it. The coronally positioned tissue is immobile and well adapted interproximally to have the best chance of blood vessel anastomo- ses, but at the apical aspect it lays passively on the periosteal bed. The donor FGG is then placed apical to the coronally positioned flap onto the periosteum and alveolar bone, which has been cleared of any elastomeric fibres and sutured with resorbable interrupted 6-0 sutures, which engages the periosteum and the apical aspect of the CPF, binding the coronal aspect of the donor FGG down. This creates immobility and no dead space — to ensure the best blood supply. The Er:YSGG laser is used at appropriate settings to actually “weld” and plasty the donor FGG with paintbrush strokes to the CPF at the junction of the new augmented KT/AT. This creates a more esthetic result and strengthens tissue junction. Pressure on the whole surgical site aids in hemostasis and immobility if needed prior to pack placement, avoiding any dead space or blood clots that may hinder a healthy blood supply for vascularity of the newly placed graft and tissue. Surgical glue is used if necessary for additional stabiliza- tion,mindinganysubtissueleakage,which will impede healing. Thus, the whole site is tension free, with an increased vestibu- lar depth and an increased zone of AT/KT without frenal/muscle hindrance, in addi- tion to the potential of root coverage. Traditional postoperative instructions are provided, and analgesics and anti- inflammatories are prescribed. Patients are followed at one- (pak removal), three- (suture removal) and six-week intervals for follow-up, as with traditional periodontal plastic procedures. Patients were asked to refrain from any mechanical hygiene techniques in the treated area for the three weeks following surgery and were pre- scribed 0.12 percent chlorhexidine mouth- wash three to four times per day during the three weeks after the procedure. Results All patients demonstrated surgical results that had an improved and stable zone of attached and keratinized tissues with no evidence of muscle or frenal reattachment compromising the zone of KT. Most often, there was evidence of partial root cover- age in Class III Miller recessions. The typ- ical white “scar line” evidenced at the MGJ discussed in Sorrentino and Tarnow’s17 ori- ginalpaperisrarelyseeninthisone-staged procedure. Patients also found the proced- ure no more arduous than any other peri- odontal plastic procedure and, more often then not, the treatment was more comfort- able than expected using the Er,Cr:YSGG laser for the initial incision. The author has done this procedure in more than 100 cases with no untoward results and with great patient satisfaction. Discussion In recession studies available to review, Miller I and II recessions are the majority found in the literature. In one such study,21 coronally advanced flaps were used for multiple teeth in the esthetic zone for root coverage and were noted to be stable at one year’s time with a statistically significant increase in the amounts of KT. Yet in an- other study by Gurgan,49 after five years, 50 percent of these cases receded to the presurgical levels as surmised by using alveolar connective tissue as donor as op- posed to gingival tissue as donor. Research papers looking at both animal and human subjects demonstrate that al- tered gingival circulation and vitality, as determined by fluorescein angiography, show that more vascularity is associated with greater graft survival.23 Hwang and Wang24 also indicated that a positive asso- ciation exists between weighted flap thick- ness and mean and complete root cover- age. Langer and Langer’s25 technique used partial-thickness flap elevation to enhance revascularization of the graft, which was then stabilized on the recipient site using periosteal sutures. Raetszke,19 however, advocated the use of the split-thickness envelope in isolated areas only, reporting difficulty in obtaining sufficient tissue for use in more extensive areas of reces- sion. Surgically, though, the elevation of a partial-thickness flap can be arduous to perform, particularly in patients with a thin gingival biotype. A partial-thickness flap also reduces the KT tissue thickness; and mucosal flaps less than 1-mm thick have been correlated with a reduction in the percentage of root coverage in defects treated using coronally advanced flaps.22,27 Because bilaminar vascularity is re- quired only to provide blood supply to a SCTG, a full-thickness CPF was used in this procedure. Anychanceoffenestrationordehiscense over the roots26 remaining after a full- thickness CPF is compensated for by the FGG placed over these denuded sites, and historically that has proven to not be an issue28,29 when grafts were placed straight onto the alveolar bone. No issues were observed due to coronally positioning a full- thickness flap vs. a partial- thickness flap,26,29 and yet, the benefit of maintaining the full buccal lingual thickness of KT re- mains a huge asset.20 Also, the elevation of a full- or partial-thickness flap did not ap- pear to influence the amount of KT or the percentage of root coverage achieved post- surgically.20 Literature comparing the CPF vs. se- milunar flaps showed that both designs were effective in obtaining and main- taining a coronal displacement of the gin- gival margin. The CPF resulted in clinical improvementssignificantlybetterthanse- milunar flaps for percentage of root cover- age, frequency of complete root coverage and gain in clinical attachment level.27 A recent review50 points out that aber- rant frenal pulls are a contraindication to the traditional CPF/SCTG. Aberrant freni cannot be corrected at the time of surgery because incisions would compromise the blood supply available to the graft. When indicated, a frenectomy is scheduled four to six weeks prior to grafting.15,50 The beauty of the single-stage laser CPF/FGG is that all aberrant frenal attachments are dealt with immediately in order not to compromise graft stability, microvascu- latature from the recipient bed and graft longevity — and thus future recession of the new donor tissue. In another paper, Harris10 treated 266 defects with connective tissue grafts as- sociated with a coronally advanced or a double-papilla flap and reported that the average results of deep recessions (≥ 5 mm) were less favorable (87 percent vs. 95 per- cent), when connective tissue grafts were associated with a coronally advanced flap. Although these results were for Miller I and II recessions and showed better results then seen in the Miller III laser CPF/FGG procedure, they confirm limitations when recessions reach 5 mm.30 In the traditional SCTG + CPF without vertical releasing incisions, results in Mil- ler III root coverage ranged from 1 to 3 mm (mean 1 ± 1.5); and Miller IV recessions ranged from 2 to 10 mm (mean 1.86 ± 0.14). The number of Class III and IV recessions were fewer than Class I and II recessions. Nevertheless, the authors noted that these type III/IV clinical situations can be im- proved with this procedure.12 It has also been shown that when CPF plus CTG versus CPF procedures for root coverage were compared, the two surgical procedures resulted in similar degree of root coverage, but the CPFs alone reverted to presurgical positions of the MGJ.31 In addition, other long-term papers evaluat- ing CPF with CTG all show that an apical rebound of the MGJ occurs, resulting in unstable root coverage and increased re- cession.31,45,52 These findings may be ex- plained by Ainamo et al.,51 who reported that the MGJ will regain its original apical position over time, resulting in unstable root coverage – with a brand new MGJ re- established by adding keratinized FGG apically. In a study comparing CPF techniques with and without the use of vertical re- leasing incisions, both were shown to be effective in reducing recession depth, but Fig. 11a Fig. 11b Fig. 12 Fig. 11a,b: Case 4, pre-op surgery. Fig. 12: Case 4, postop surgery. ” See GRAFTING, page B4