Root Surface Biomodification with Nd:YAG Laser
for the Treatment of Gingival Recession
with Subepithelial Connective Tissue Grafts
Alparslan Dilsiz, D.D.S., Ph.D.,1Tugba Aydin, D.D.S.,1
Varol Canakci, D.D.S., Ph.D.,1and Yasin Cicek, D.D.S., Ph.D.1
Background=Aim: Root surface biomodification has been used to treat gingival recession and periodontitis. The
principle for this procedure is that removing the smear layer from the root surfaces exposes collagen fibers,
which leads to improved healing. Clinical studies generally have failed to find any improvement in clinical
parameters when using such procedures, however. The aim of this study was to evaluate and compare the
outcome of gingival recession therapy using the subepithelial connective tissue graft (SCTG) with or without
Nd:YAG laser application for root surface biomodification. Materials and Methods: Thirty-four teeth in
17 patients with Miller Class 1 and 2 recession were treated with SCTG with (test group) or without (control
group) the application of Nd:YAG laser (1W, 10Hz, 100mj, 60s, 1064nm). Clinical attachment level (CAL),
recession depth (RD), recession width (RW), and probing depth (PD) were measured at baseline and six months
postsurgery. Results: Both treatments yielded significant improvements in terms of RD and RW decrease and
CAL gain compared to baseline values. For test and control groups, the average root coverage was 33% and 77%,
respectively (p<0.05), and the complete root coverage was 18% and 65%, respectively (p<0.05). The control
group showed a greater reduction in RD and RW compared with the test group (p<0.05). Conclusions: The use
of Nd:YAG laser as a root surface biomodifier negatively affected the outcome of root coverage with the SCTG.
gingival margin apically from the cemento-enamel junction
(CEJ) and the exposure of the root surface to the oral envi-
ronment. The principal objective in the treatment of gingival
recession is to cover the exposed root surfaces to improve
esthetics and to reduce hypersensitivity. Additional benefits
that result from treating areas of gingival recession may in-
clude an increase in the width and thickness of keratinized
gingiva. Coverage of denuded roots has become one of the
most challenging procedures in periodontal mucogingival
surgery.1–4The search for the appropriate root coverage
technique has taken many different approaches. Various
surgical options have been developed to achieve the above
goals and include the use of subepithelial connective tissue
grafts (SCTGs),5free gingival grafts,6laterally sliding flaps,7
coronally advanced flaps,8double papillae flaps,9guided
Among these surgical options, variations of subepithelial
ingival recession, a most common and undesirable
condition, is characterized by the displacement of the
connective tissue graft (SCTG) procedures demonstrated a
high percentage of root coverage with a high predictability
and without significant post-surgical complications.12–18
Also, the root coverage gained with SCTG procedures was
reported to be stable over the long-term.14Therefore, SCTG
procedures have commonly served as the ‘‘gold standard’’ to
evaluate the safety and results of new root-coverage tech-
So far, a concerted effort has been made in the field of
root conditioning to improve the outcome of regenerative
periodontal therapies by favoring the attachment of the
regenerated periodontal structures. Mechanical instrumen-
tation (scaling and root planing) leaves a smear layer, which
inhibits cell re-attachment and can serve as a reservoir for
microbial growth.19Therefore, chemical conditioning of the
roots is performed in order to remove the smear layer and to
improve their biocompatibility. After the removal of the
smear layer, the dentinal collagen is exposed and these col-
lagen fibers supposedly serve as chemo-attractants for peri-
adjunctive agents have been applied to promote healing and
1Department of Periodontology, Faculty of Dentistry, Atatu ¨rk University, Erzurum, Turkey.
Photomedicine and Laser Surgery
Volume 28, Number 3, 2010
ª Mary Ann Liebert, Inc.
further enhance clinical outcomes. These include root con-
ditioners (e.g., citric acid,20–25tetracycline HCI,26EDTA,19,27
phosphoric acid,28and hydrogen peroxide),3enamel matrix
proteins,29recombinant human growth factors, platelet-rich
plasma,30and dentin bonding conditioner.31In addition to
chemical conditioning, the applicability of different laser sys-
tems such as CO2, Nd:YAG, diode and Er:YAG laser in the
removal of the smear layer have been demonstrated.32–43
However, until now, no published data have been avail-
able concerning the clinical outcomes following root surface
biomodification with Nd:YAG laser for the treatment of gin-
gival recession. Therefore, the aim of the present study was to
evaluate and compare the outcome of gingival recession ther-
apy using the SCTG with or without Nd:YAG laser appli-
cation for root surface biomodification.
Materials and Methods
The research protocol and consent forms were initially
submitted to the Ethics Committee and The Institutional
Internal Review and Ethics Board at the Atatu ¨rk University.
The Faculty of Dentistry approved the study (AU-IIREB
reference code:018). All participants provided written in-
Selection of subjects and test teeth
The study population consisted of 17 patients with esthetic
problems due to the exposure of recession-type defects dur-
ing smiling (9 women and 8 men; age 21–49 years, mean age
31.3?8.4 years) who visited the periodontology department
of Atatu ¨rk University, Erzurum, Turkey. Teeth with cracked
structure, carious lesions, restorations, and non-vital were
excluded. All recessions defects (34 teeth) fell into class 1 or
class 2 according to the Miller classification, since no loss of
interdental soft and hard tissue height was present.44
All patients were non-smokers, systemically and peri-
odontally healthy, with no contraindications for periodontal
surgery, and none were taking medications known to inter-
fere with periodontal tissue health or healing.
Following examination, all of the teeth received scaling,
root planing and crown polishing, and oral hygiene in-
structions were given four weeks before surgery. All patients
demonstrated optimal oral hygiene (Plaque Score ?15%).45
After the baseline clinical measurements [recession depth
(RD), recession width (RW), clinical attachment level (CAL),
and probing depth (PD)], the teeth were randomly assigned
to the test group or control group. All measurements were
performed by means of a Williams periodontal probe (Hu
Friedy, Chicago, IL) and 1730-1calipers (Castroviejo, Schwert,
The following clinical measurements were taken at the
facial aspect to the experimental teeth one week before the
surgery and at 6 months follow up:
- recession depth (RD), measured from the CEJ to the most
apical extension of the gingival margin;
- recession width (RW), measured at the level of the CEJ;
- clinical attachment level (CAL), measured from the CEJ
to the bottom of the gingival sulcus;
- probing depth (PD), measured from the gingival margin
to the bottom of the gingival sulcus.
The percentage of recession coverage was calculated ac-
cording to the following formula: Recession coverage¼
depth]=preoperative recession depth)?100.
The investigator charged with clinical assessments was
calibrated for intraexaminer repeatability prior to the start of
the trial. Twelve patients with a total of 23 teeth with gin-
gival recession were enrolled for this purpose. Duplicate
measurements of CAL were collected with an interval of 24 h
between the first and the second recording. The intraclass
correlation coefficient, as a measure of intraexaminer repro-
ducibility, was 0.99.
The exposed root surfaces were planed with curettes to
remove edges, grooves, and dental plaque and to reduce the
convexity of the root. The area was gently irrigated with
sterilized physiological saline solution. Relative isolation of
the region was carried out with the aid of a cotton roll and
the drying of the buccal surface with gauze. Lasing was
performed in the test group, and the exposed root surface
was conditioned with Nd:YAG laser, two times.
Lasing was performed using a Smarty A10 laser machine
(Smarty A10, DEKA, Italy). Root surfaces in the test group
were radiated by a laser beam of 1W, 10Hz, 60s, 1064nm
with sweeping motion and without any coolants. In ad-
dition, the distance between the end of the fiber optic (di-
ameter: 300mm) hand piece and tooth surface was adjusted
at about 2mm. When the lasers were in use, protective
eyewear of appropriate optical density was worn by the in-
vestigator and patients.
Before surgery, extraoral antisepsis was performed with
10% Povidone-Iodine solution (Glividon?, Bikar Drug Ltd.,
Istanbul, Turkey) and intraoral antisepsis with 0.12% chlor-
hexidine rinse (Kloroben?, Drogsan Drug Ltd., Istanbul,
Turkey). All defects were treated by using the Langer and
Langer technique.5A local anesthetic (Ultracaine DS Forte?,
Hoechst Roussel, Frankfurt, Germany) was administered to
donor and recipient sites to achieve anesthesia. A partial
thickness flap was created with two vertical incisions placed
at least one-half to one tooth wider mesiodistally than the
area of gingival recession. The coronal margin of the flap was
started with a horizontal sulcular incision to preserve all
existing facial gingiva. The proximal papillae were left intact.
Care was taken to extend the flap to the mucobuccal fold
without perforations that could affect the blood supply. The
area was irrigated with sterile saline solution.
The connective tissue graft was harvested from the palate
using the ‘‘trap-door’’ approach described by Harris.15A
connective tissue graft in an adequate size of 2mm thickness
was harvested, and pressure was applied to the donor area
with gauze soaked in saline after the graft was taken. The
donor area was closed with silk 4-0 sling sutures. The graft
was trimmed with a sharp surgical blade, if necessary, and
the SCTG was introduced to the recipient site, where the flap
was pulled over a major portion of the SCTG. The recipient
338 DILSIZ ET AL.
flap was then sutured directly over the graft with silk 5-0
sutures. The overlying flap covered the donor tissue as much
as possible to provide more blood supply to the graft. The
vertical incisions were also closed with silk 5-0 sutures. A
mild compress with gauze soaked in saline was applied for
5min. Dry foil was applied to the recipient area, and then a
non-eugenol periodontal dressing (Coe-Pak, GC America,
Alsip, IL) was placed over the dry foil to stabilize and protect
the donor site for 14 days postsurgery. Techniques were
performed with an interval of six weeks between surgeries.
All patients were instructed to take antibiotics [amoxicillin
(Remoxil?, I.E. Ulagay Drug Ltd., Istanbul, Turkey) 500mg,
every 8 h, 7 days] and analgesic medication [Naproxen
(Apranax?, Abdi I.brahim Drug Ltd., Istanbul, Turkey)
550mg, every 12 h, 5 days], to discontinue tooth-brushing
around the surgical sites for the first 14 days after surgery, and
an extraoral cold compress and bland diet were advised.
During this period, plaque control was provided by rinsing
with 0.12% chlorhexidine digluconate (Kloroben?, Drogsan
Drug Ltd., Istanbul, Turkey) solution twice a day for 1min.
After this period, the sutures were removed. Plaque control in
the surgically treated area was maintained by 0.12% chlor-
hexidine rinses for an additional 2 weeks, and gentle tooth-
brushing with a soft-filamented toothbrush was permitted
twice daily. The patients were instructed to perform a non-
traumatic brushing technique (roll technique) using a stan-
dardized soft toothbrush and toothpaste during the trial.
All patients were recalled for prophylaxis 1 and 3 weeks
after suture removal and, subsequently, monthly until the
end of the study period. All participants completed the study
and reported 100% compliance.
The initial therapy, the laser application, and the surgical
treatments were performed by one investigator and the clin-
ical measurements were assessed by another investigator.
The data thus collected were assessed using SPSS 11.0
statistical software (SPSS, Inc., Chicago, IL). The Wilcoxon’s
signed ranks test was chosen to compare test and control
group differences in RD, RW, CAL, and PD. The differences
in mean RD, RW, CAL, and PD values between baseline and
six months were evaluated using Wilcoxon’s signed ranks
test. In addition, the Wilcoxon’s signed ranks test was used
to compare recession coverage (percentages and mm) be-
The 34 experimental non-molar teeth were identified and
randomly balanced into two groups. Seventeen test group
teeth, including six incisors, four canines, seven premolars,
and 17 control group teeth, including seven incisors, five
canines, and five premolars, were subjected to one treatment
modality in each group (Table 1).
Following the initial oral hygiene phase as well as at the
post-treatment examinations, all subjects showed low fre-
quencies of plaque harboring tooth surfaces (PI<20%) and
bleeding gingival units (GI<15%), indicating a good stan-
dard ofsupragingival plaque control during the study period.
The statistical analyses for the clinical parameters at base-
line and after six months for both groups are presented in
Table 2 and Fig. 1.
No statistically significant differences between groups
were observed for any of the clinical parameters at baseline
(p>0.05). In comparison, at 6 months, statistically significant
differences were found between the test and control groups
for RD, RW, and CAL. A mean RD of 2.25?1.23mm was
calculated for cases in the test group, and the corresponding
value was 0.83?1.34mm for cases in the control group
(p<0.05). A mean RW of 2.33?1.31mm was calculated for
cases in the test group, and the corresponding value was
0.92?1.38mm for cases in the control group (p<0.05). A
mean CAL of 3.75?1.16mm was calculated for cases in
the test group, and the corresponding value was 2.33?
1.25mm for cases in the control group (p<0.01).
In the test group, statistically significant changes from
baseline were found for RD, RW, and CAL. RD decreased
from 3.29?1.18 to 2.25?1.23mm (p<0.05), RW decreased
from 3.42?1.19 to 2.33?1.31mm (p<0.01), and CAL de-
creased from 4.67?1.33 to 3.75?1.16mm (p<0.01).
In the control group, statistically significant changes from
baseline were found for RD, RW, and CAL. RD decreased
from 3.42?1.04 to 0.83?1.34mm, RW decreased from
3.58?1.26 to 0.92?1.38mm, and CAL decreased from
4.88?1.12 to 2.33?1.25mm (p<0.01).
Probing depths did not show a statistically significant
change after treatment in both groups (p>0.05). PD values
were 1.38?0.51mm, 1.46?0.63mm at baseline, and 1.50?
Table 1. Frequency Distributions of the Two Groups
Gingival recessionClass 1Class 2 Class 1Class 2
Table 2. Clinical Parameters (in mm) at Baseline
and 6 Months Postoperatively
Parameters Test groupControl group p Value
Recession depth (RD)
Recession width (RW)
Probing depth (PD)
*p<0.05, **p<0.01, significant differences between baseline and
ROOT SURFACE BIOMODIFICATION USING A ND:YAG LASER 339
0.50 and 1.50?0.50mm at 6 months in the test and control
The recession coverage at six months postoperatively for
the test and the control groups are shown in Table 3.
The mean recession coverage value for the test group
was 1.04?1.03mm and 32.49%?36.01%. The corresponding
value for the control group was 2.58?1.50mm and 76.67%?
35.85%. These values were statistically different (p<0.05).
Complete recession coverage was accomplished in 17.6%
(3 of 17) of the treated cases in the test group and in 64.7%
(11 of 17) of the treated cases in the control group (Table 4).
The aim of this randomized-controlled, split-mouth, double-
blind designed clinical trial was to evaluate and compare the
outcome of gingival recession therapy using the SCTG with
or without Nd:YAG laser application for root surface bio-
modification. Data from the present study indicated that
Nd:YAG laser use negatively affected recession coverage
with SCTG. The test group had lower percentages of reces-
sion coverage (33%) and complete root coverage (18%)
compared with the control group (77% and 65%, respec-
tively). Both of these results compare well with those of
others. Chambrone et al.,1Oates et al.,3and Roccuzzo et al.4
have reported that an average mean root coverage in 64.7–
97.3% and complete root coverage in 18.1–96.1% of the
studies when SCTG was used to obtain root coverage.
Patients with gingival recessions who complain of esthetic
concerns and hypersensitivity are possible candidates for
root coverage procedures. Before performing periodontal
plastic surgery, the clinicians should select the most pre-
dictable way to achieve successful root coverage. Although
the more accepted techniques were free gingival grafts and
various pedicle grafts during the 1960s and 1970s,6–9SCTGs
began to be used to enhance covering of localized areas of
root exposure in the early 1980s.5Different flap procedures
further modified this technique.16–18Longitudinal observa-
tions and case studies have shown a high success rate and
predictability.1–4To fulfill patients’ esthetic requirements and
to obtain successful root coverage, surgical techniques with
SCTG continued to be improved.11–18In the present study,
SCTG was therefore chosen for treatment of gingival reces-
Complete root coverage is considered the true goal of
treatment because only complete coverage assures recovery
from the hypersensitivity and esthetic defects associated
with recession areas.1–4Previous studies have tried to im-
prove the percentages of complete coverage with root surface
biomodification. Root surface conditioning has been intro-
duced, using a variety of agents, in order to detoxify, de-
contaminate, and demineralize the root surface, thereby
removing the smear layer and exposing the collagenous
matrix of dentin and cement.19–28However, the literature is
controversial with respect to root conditioning. The results of
some studies have demonstrated that the conditioned root
surfaces had a higher percentage of complete root coverage
compared with sites not treated with root conditioning
agents.21–23Conversely, however, the results of other studies
mm) at baseline and six months
Clinical Parameters (in
Table 3. Recession Coverage at 6 Months
Test group Control groupp Value
Table 4. Frequency of Recession Coverage in Test
and Control Groups
340 DILSIZ ET AL.
have shown no significant clinical benefit from root condi-
tioning in conjunction with root coverage procedures.24,26,27
The results of the present study for the control group (non-
conditioned root surfaces) are in agreement with the results
of the latter studies. Our study showed no clinical benefit
from root conditioning with Nd:YAG laser.
So far, no published data are available concerning the clin-
ical outcomes following root surface biomodification with
Nd:YAG laser for the treatment of gingival recession,
whereas the use of lasers has often been propagated for this
indication. In previous clinical studies, it has been demon-
strated that lasers are an effective tool in the field of root
conditioning to improve the outcome of regenerative peri-
odontal therapies by favoring the attachment of the re-
generated periodontal structures.32–43
The Nd:YAG laser has been reported to remove the smear
layer, uncovering dentinal tubules and exposing collagen
fibers on root surfaces.37,38The Nd:YAG laser, with non-
contact delivery mode and short irradiation time, has caused
no damage to or alteration of root surfaces.37In addition,
Tewfik et al.39reported effects of Nd:YAG laser on root ce-
mentum topography and fibroblastic attachment, and sug-
gested that the modification of cementum surfaces depends
on the energy level of the laser irradiation. Similar results
have also been found with CO2and Er:YAG laser.32–34,40–43
In contrast to the favorable effects of laser application
found in the above studies, several studies have reported
negative effects of the Nd:YAG laser when used directly on
root surfaces due to carbonization and melting effects. The
Nd:YAG laser application reported by some investigators
exhibited, under SEM analysis, surface alterations such as
charring, crater formation, and cement meltdown.38,46–54
Studies with Nd:YAG laser using different parameters47,48
have shown that mean power settings ranging between 1.25–
3.00W promote a root surface change leading to fusion and
resolidification of the cement mineral portion alongside crack
and fissure formation. Thomas et al.46reported that the
Nd:YAG laser denatures root surface proteins, and they
suggest that the complement of the conventional mechanical
treatment of the root surface would be important on the re-
duction of these irregularities aiming for a more biocom-
patible root surface. Meanwhile, Trylovich et al.49found that
Nd:YAG laser application modifies biocompatibility of root
surfaces and reduces the number of attached fibroblasts in
comparison with untreated controls. Their study suggested
that Nd:YAG laser could alter the biocompatibility of the
cementum surface, making it unfavorable for fibroblast at-
tachment. The laser parameters used in the present study
(1W, 10Hz, 100mJ) were based on some literature stud-
ies,47,48which demonstrated that the Nd:YAG laser, when
used with mean power up to 2W, promoted minimal root
surface hazard effects.
The results of the present study demonstrate that root
surface conditioning with Nd:YAG laser has no additional
clinical benefit when compared with root planing alone with
regard to the CAL, RD, and RW. In the control group (non-
conditioning with laser), the mean CAL, RD, and RW values
showed decreases from baseline to six months, and these
changes were statistically significant. Caffessse et al.24and
Bouchard et al.25compared the SCTG in conjunction with
citric acid to the SCTG where no root conditioning was
performed, and reported that root conditioning did not affect
the clinical outcome of the surgical technique. Our findings
are in accord with these reports. However, there are differ-
ences between the results seen in the present study, which
found no improvements after Nd:YAG laser irradiation, and
other studies with opposite results. Perhaps this was due to
the Nd:YAG laser’s ability to alter the biocompatibility of the
root surface, which might inhibit cell migration, making it
unfavorable for fibroblast attachment, leading to changes in
the dentin’s protein structure. In addition, Nd:YAG laser ir-
radiation might have a negative influence on the prolifera-
tion of periodontal ligament fibroblasts and subsequently on
periodontal wound healing.
The laser parameters affecting the amount of energy ap-
plied to a given surface include power level (W), exposure
time (seconds), pulsed versus continuous wave energy, en-
ergy density (J=cm2), distance from the surface, and the
angle between the target tissue and the fiber tip. As a laser
beam strikes a target tissue surface, the light energy can be
affected in four ways: it can be reflected, transmitted, ab-
sorbed, or scattered, and the changes seen in target tissues
are largely due to the absorbed energy.54Therefore, the most
important issue in laser therapy is to determine the correct
parameters to use to achieve satisfactory results, without
inducing detrimental thermal effects in the pulp, or causing
fracturing or carbonization.
The present study suggests that surgical treatment of
gingival recessions with SCTG result in satisfactory root
coverage and attachment gain. The most significant and in-
teresting finding of the present study is that the use of Nd:
YAG laser as a root surface biomodifier material negatively
affected the outcome of root coverage with the SCTG. Fur-
ther comparative studies are needed in order to clarify this
issue and to evaluate the long-term effects of this type of
The investigation was supported by Grant (PN-2005=243)
from Atatu ¨rk University, Turkey. We would like to thank
Dr Erkan Oktay for statistical assistance.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Alparslan DILSIZ, D.D.S., Ph.D.
Department of Periodontology
Faculty of Dentistry, Atatu ¨rk University
ROOT SURFACE BIOMODIFICATION USING A ND:YAG LASER343