|Year : 2012 | Volume
| Issue : 2 | Page : 72-75
Root coverage with a free gingival autograft using a diode laser
S P K Kennedy Babu, S Agila
Department of Periodontics, Mahatma Post Graduate Institute of Dental Sciences, Indira Nagar, Gorimedu, Pondicherry, India
|Date of Web Publication||31-Jan-2013|
Department of Periodontics Mahatma Post Graduate Institute of Dental Sciences Indira Nagar, Gorimedu, Pondicherry
Source of Support: None, Conflict of Interest: None
Gingival recession is a most common condition affecting the supporting structures of the teeth, in which the change in the position of the gingiva affects the esthetics and also hypersensitivity due to the exposure of the cementum. Coverage of denuded roots has become one of the most challenging procedures in periodontal mucogingival surgery. The principal objective in the treatment of gingival recession is to cover the exposed root surfaces to improve esthetics and to reduce hypersensitivity. Grafting procedures can be performed traditionally by use of a scalpel or by the use of lasers. A case of gingival recession with a shallow vestibule, treated with a free gingival autograft using a Diode laser is presented here. The recipient bed preparation and harvesting of graft from donor site were done with the Diode laser using the appropriate laser parameters so as to ensure proper healing of the free gingival graft. The results showed uneventful healing of donor site with complete root coverage and increased width of attached gingiva in the recipient site. The results of the therapy were assessed after 3 months.
Keywords: Diode laser, free gingival autograft, root coverage
|How to cite this article:|
Babu SK, Agila S. Root coverage with a free gingival autograft using a diode laser. J Dent Lasers 2012;6:72-5
| Introduction|| |
Gingival recession according to the glossary of Periodontics terms is defined as displacement of the soft-tissue margin apical to the cementoenamel junction. Major causes for this condition includes, plaque induced periodontal disease, mechanical force such as faulty tooth brushing, iatrogenic factors like orthodontic movements, faulty restorations, and anatomic factors such as malposition, frenum pull, etc.  To improve esthetics and treat root sensitivity in cases of gingival recession, to increase a width of an attached gingiva in individuals who are unable to maintain a narrow zone of attached gingiva, and to obtain optimal depth of vestibule and enhance plaque control  in which the free gingival autograft is performed. Free gingival autograft is one of the most dependable gingival augmentation procedures available. ,
According to Miller, root coverage procedure is quite predictable and produces patient satisfaction; it should be the therapist's obligation to make patients aware of this treatment modality. Autogenous gingival grafting/epithelized free gingival grafting is a well established pure mucogingival procedure for increasing the width of attached gingiva. The procedure has proven reliable in increasing attached gingiva and stopping the progressive recession. 
These can be accomplished with conventional scalpel surgery as well as by lasers. At present, Diode lasers have shown promising results when used as an alternative to scalpel surgery. Lasers can easily reshape soft-tissue by ablation, improve hemostasis through heat induced coagulation thus providing a clear surgical field, reduce patient discomfort and anxiety during surgery and above all have a bactericidal and biostimulatory effect on the target tissue. , In this case report, Diode laser was used to accomplish complete root coverage and to increase the width of an attached gingiva in relation to 31.
| Case Report|| |
A 18-year-old female patient came to the Department of Periodontics, Mahatma Gandhi Post Graduate Institute of Dental Sciences, Puducherry, with a complain of root sensitivity in relation to lower front teeth. Clinical examination of the area revealed Miller's class 1 recession measuring around 3 mm in relation to 31 with a positive tension test [Figure 1]. Based on these clinical findings, Frenotomy and later Root coverage with free gingival autograft using a Diode laser* was planned to treat the mucogingival problem. Routine blood investigations were done and the patient was verbally informed about the surgical procedure and a written informed consent was obtained from the patient.
Supra/subgingival scaling and root planing was done in relation to 31 and after one week, Frenotomy was done by the Scalpel method and the patient was put under maintenance phase for one month. Re-evaluation of the patient after one month revealed Millers class 1 gingival recession in relation to 31. Palatal mucosa in relation to 14, 15 and 16 was selected to be the donor site [Figure 2]. Recipient and donor sites for the free gingival graft were anesthetized. The recipient site was marked with a trapezoidal incision and deepithelialization was done [Figure 3] under the following parameters of Diode laser: Wavelength of 810 nm, 400 micron fiber, 2.5 Watts power, pulsed mode.
A tin foil, with the dimensions of the recipient site was placed on the palatal mucosa in relation to 14, 15 and 16. The dimensions of the graft at the donor site were marked with the continuous wave (CW) mode and the power was reduced to 2.0 Watts. After incisions were made around the tin foil, one corner of the graft was held with a tissue holding forceps and the under surface of graft was dissected with the laser beam. After harvesting the graft [Figure 4], hemostasis was achieved in the donor site using the laser parameters. The graft was transferred to the recipient site, held under pressure with wet gauze and sutured with Oschenbein's technique using vicryl sutures [Figure 5]. Periodontal dressing was placed at the surgical site. No stent was given to protect the donor site. Post-operative instructions were given to the patient. After 2 weeks, sutures were removed and wound healing was satisfactory. The results of the therapy were assessed after 1 and 3 months [Figure 6] and [Figure 7], which revealed complete coverage of the recession.
*ZOLAR TM Technology and Mfg. Co. Inc., Canada.
| Discussion|| |
The diode laser has become an important tool in the dental armamentarium due to its exceptional ease of use and affordability.  Among the various wavelengths in dental lasers, Diode has generally caught the attention of the dentists in general, simply because of its versatility in clinical applications, compact design, light weight, technologically advanced and affordability.
Diode laser is a compact semi conductor, emitting in the near infra red range at a wavelength of 810-980 nm, which makes it suitable for all soft-tissue procedures in the oral cavity. The diode laser is well absorbed by melanin, hemoglobin, and other chromophores that are present in periodontal disease. The Laser energy is transmitted through the thin fiber. Diode lasers are very effective for soft-tissue applications, including incision, hemostasis and coagulation.  The advantages include a bloodless operating field, minimal swelling and scarring, and much less or no postsurgical pain. , Studies have shown enhanced, faster and more comfortable wound healing when the diode laser is used. 
Lasers are said to be running in either CW or pulsed mode. This relates to the rate of emission of laser light with time and the prime benefit of a pulsed mode will be the capacity of the target tissue to cool between successive pulses.  The CW mode is generally the fastest way to ablate tissues but heat can build up and cause collateral damage to the target and adjacent tissues. Hence in our case the recipient site preparation was done using pulsed mode to prevent damage to the adjacent tissues.
With regard to diode laser surgery, the laser hand-piece tip is generally held very close to the tissue surface. This allows the laser energy to minimize the build-up of debris on the tip, which can lead to unwanted thermal damage to the tissue. For most minor intra-oral surgical procedures, the recommended average power setting is in the range of 2-4 W. The 810 nm wavelength diode laser transverses the epithelium and penetrates 2-6 mm into the tissue. When laser cutting is in progress, small blood and lymphatic vessels are sealed due to the generated heat, thereby reducing or eliminating bleeding and edema. Denatured proteins within tissue and plasma are the source of the layer termed "coagulum" or "char", which is formed because of laser action and serves to protect the wound from bacterial or frictional action.  Clinically, during 48-72 h post-surgery, this layer becomes hydrated from saliva, swells and eventually disintegrates to later reveal an early healing bed of new tissue. 
In this case report, the experience as reported by the patient was least traumatic and healing of the palatal wound was observed to be faster than it is after a scalpel surgery. In Periodontics, many cases of soft-tissue growth excisions, frenectomy, frenotomy and periodontal pocket management of up to 5 mm have been done with Diode lasers, very few studies have been done on the free gingival graft procedures. Thus, this case report emphasizes the use of Diode lasers in Gingival Augmentation procedures.
| Conclusion|| |
Although, lasers are extremely useful therapeutic tools, there are not without risk. Lasers differ from conventional mechanical tools; lasers exert their effect in both contact and non-contact mode. As Dentist, we must be aware of the possible risks and must exercise precaution to minimize these risks. Special care has to be taken to prevent accidental irradiation to the eyes. Though no laser system is capable of completely replacing conventional mechanical instruments, they do play an important role in reducing post-operative discomfort to the patient with improved clinical results. Based on the concept of evidence-based medicine, more comparative clinical studies should be conducted to clarify the effectiveness and outcomes of laser periodontal therapy and to support its application in clinical practice.
| References|| |
|1.||Dorfman HS, Kennedy JE, Bird WC. Longitudinal evaluation of free autogenous gingival grafts. J Clin Periodontol 1980;7:316-24. |
|2.||Newman. Carranza's Clinical Periodontology. 10 th ed. W B Saunders;2006. p. 1008-10. |
|3.||Hangorsky U, Bissada NF. Clinical assessment of free gingival graft effectiveness on the maintenance of periodontal health. J Periodontol 1980;51:274-8. |
|4.||Parker S. Lasers and soft tissue: 'Loose' soft tissue surgery. Br Dent J 2007;202:185-91. |
|5.||Parker S. Lasers and soft tissue: 'Fixed' soft tissue surgery. Br Dent J 2007;202:247-53. |
|6.||Raffetto N. Lasers for initial periodontal therapy. Dent Clin North Am 2004;48:923-36. |
|7.||Romanos G, Nentwig GH. Diode laser (980 nm) in oral and maxillofacial surgical procedures: Clinical observations based on clinical applications. J Clin Laser Med Surg 1999;17:193-7. |
|8.||Pick RM, Colvard MD. Current status of lasers in soft tissue dental surgery. J Periodontol 1993;64:589-602. |
|9.||Pirnat S. Versatility of an 810nm diode laser in dentistry: An overview. J Laser Health Academy 2007;4:1-9. |
|10.||Ciancio. Wound healing of periodontal pockets using the diode laser. Applications of 810 nm Diode Laser Technology: A Clinical Forum:14-7. |
|11.||Gold SI, Vilardi MA. Pulsed laser beam effects on gingiva. J Clin Periodontol 1994;21:391-6. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]