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Periodontics/Gingival regenerative surgery with graft

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Question
Hello Dr David Scharf, i am a practicing general dentist from India. I have a case of class IV Miller's gingival recession with lower anterior teeth. Please advice all possible treatment plans for such case. I wanted to avoid palatal connective tissue graft so is there any substitute i can use? i need to put a graft since the teeth are denuded badly and there is poor root coverage. so please suggest some available materials or grafts with a step by step treatment plan.
Sir, I have information on alloderm and bioxclude and its use in India and got to know that not much people are using it in routine practice. So it is not easily available in my country. I also came to know about "PERIODERM" manufactured by Dentsply which is an allograft and is available in India. So can you advice what should i use?
Now I would request you to resolve my queries  regarding the surgery.
1. The case is with class IV recession, 2-3mm attached gingiva width and a shallow vestibular depth(5-7mm).(Teeth involved 31,32,33,41,42,43.)So my query is how to proceed to correct all the issues at once (if possible) or in 2 parts in what sequence? I have read about the Bridge flap technique for such cases. Can i use it or i can have any other better option?
2. How about the lingual aspect of the defect? Do i need to correct it the same way i will correct the labial part or i just need to pull the flap coronally or should not even touch the lingual side?
3. Do I need any bone regeneration in this case or only soft tissue graft will correct it?
4. What is the success and failure rate if i use graft? and what precautions i should take to avoid any complication and failure?and will the autograft (palatal tissue) be better?
5. The patient has Xerostomia (not severe) so do i need to prescribe her for this? can it affect the healing? if yes then how to manage it?
6. I have read that perio pack should not be used if a graft has been put because it might displace the graft. How true and practical it is? What should i do?
7. With a shallow vestibule and narrow width of gingiva, can i pull the flap so high so that the graft is fully covered with the flap? I guess that will decreased the vestibular depth even more.so what should i do?
8. Sir, I am taking a lot of your time. But i don't have any other option coz i couldn't get helpful information in my physical world. And i am always eager to do new surgeries and new work. Please bare with me.
Thank you in advance.
Ritu

Answer
Your question is beyond the scope of this website.  In general miller class IV does not respond well to attemps at root coverage or bone regeneration. If  there is a band of keratinization tissue you can probably leave it alone and theo prognosis will be the same as it you treated it.  The defect should be viewed within the context of whatever else is happening in the mouth.  

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David Scharf

Expertise

I am a board Certified periodontist which means that I am an expert in treating gum disease (periodontal disease) and placing dental implants. I can answer questions related to treating gum disease, bleeding gums, maintaining healthy gums, and structural issues with the gums such as recession, to gummy a smile, crown lengthening etc. I am also certified in Laser Periodontal therapy which allows me to treat gum disease with a laser rather than a scalpel. I can address those questions as well.

Experience

I have been practicing periodontics and placing dental implants since 1990. I have treated thousands of patients for both gum disease and dental implants. I currently an a Clinical Assistant Professor in the Department of Periodontics and Implant Dentistry at the nations largest dental school.

Publications
Journal of the American Dental Association, Journal of Periodontology, International Journal of Oral and Maxillofacial Surgery, International Journal of Oral and Maxilofacial Implants

Education/Credentials
BA/DMD Boston University Cum Laud. Certificate of Advanced Graduate Study in Periodontics fro New York University. Board Certification in Periodontics 1995

Awards and Honors
e was elected to Omicron Kappa Upsilon (the "Phi Beta Kappa" for dentists), and received the Boston University award for Excellence in Periodontology, the Boston University Predoctoral Prosthetic Award for Excellence in Prosthetics, and the Academy of General Dentistry Outstanding Senior Student Award, the Boston University Operative Dentistry Special Achievement Award, and the Quintessence Publishing Company Outstanding Senior Award for Excellence in Clinical Practice. Following dental school, Dr. Scharf completed a year long General Practice Residency at The Long Island College Hospital in Brooklyn, New York. As a resident at this top New York program, he gained extensive clinical experience in such fields as prothodontics, periodontics, endodontics, orthodontics, oral surgery, management of the medically compromised patient, and general dentistry. This experience was completed by clinical rotations in the departments of general medicine, anesthesia, and emergency medicine.

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