Comparison of Modified Vestibular Incision Subperiosteal Tunnel Technique (MVISTA) with Advanced Platelet Rich Fibrin Plus (A-PRF+) with and without use of adjunctive Low Level Laser Therapy (LLLT) in management of Cairo’s RT1 gingival recessions: A Randomized Clinical Trial

Gingival recession is defined as the displacement of the marginal tissue apical to the cementoenamel junction  resulting in exposure of the root surface and potentially creating aesthetic and functional problems such as dentine hypersensitivity and root caries It affects populations worldwide, occurring across all age groups with multiple etiological factors contributing to its development, and prevalence is seen to increase with age Common etiological factors are inadequate oral hygiene faulty toothbrushing, smoking or chewing tobacco and malocclusion among others  The classification of gingival recession has evolved significantly over time aimed at improving diagnosis prognosis and treatment planning The earliest classification by Sullivan and Atkins in 1968 categorized recessions based on the depth and width of the defect into four types deep wide shallow wide deep narrow and shallow narrow This was followed by Miller classification in 1985 which became the most widely used system Miller divided recessions into four classes based on the extent of recession relative to the mucogingival junction  and the presence or absence of interdental bone and soft tissue However Miller classification of gingival recession has several drawbacks including difficulty locating the MGJ  lack of information on keratinized tissue vague criteria for interdental bone loss and inability to classify palatal recessions or cases where interdental bone loss occurs without recession extending beyond the MGJ. Moreover, its prognostic predictions are often inaccurate, as clinical outcomes do not always conform to Miller’s expectations for root coverage. To address these shortcomings, newer classifications were introduced. For example, in 1998, Nordland and Tarnow proposed a classification based on the height of interdental papillae. The Cairo classification, introduced in 2011, utilized interproximal clinical attachment level as a more objective and reproducible criterion. The Cairo system categorizes recessions into three types depending on the severity of interproximal attachment loss relative to buccal attachment loss. RT1 Gingival recession with no loss of interproximal attachment. Interproximal CEJ was clinically not Detectable at both mesial and distal aspects of the tooth. RT2: Gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment Loss was less than or equal to the Buccal attachment loss RT3: Gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment Loss was Higher than the buccal attachment loss. This allows a clearer distinction among recession types and more accurate prediction of root coverage outcomes. Studies have shown that Cairo classification is more reliable, with higher intra- and inter-examiner agreement than Miller’s, and offers a clearer, treatment-oriented approach by focusing on attachment loss rather than the variable MGJ This makes the Cairo classification more practical and precise for diagnosis, prognosis, and treatment planning in periodontology. Other contemporary modifications and new systems incorporate details such as keratinized tissue, tooth malposition, and palatal recessions to provide a more comprehensive clinical picture.The primary objectives of treating gingival recession are to achieve root coverage, restore esthetics, facilitate plaque control and reduce hypersensitivity Tunnel techniques represent a minimally invasive surgical approach to treat multiple gingival recessions by creating a subperiosteal tunnel through a single incision, allowing graft placement without disrupting the blood supply to the flap. The absence of vertical incisions and papilla detachment provides better blood supply, promotes post-operative healing and  reduces visible scarringThe Vestibular Incision Subperiosteal Tunnel Access  technique is an advancement in tunnel procedures. It utilises a vestibular incision to enhance flap mobilization, thus covering multiple recession defects with minimal trauma The Modified Vestibular Incision Subperiosteal Tunnel Access  technique differs from the VISTA technique mainly with respect to incision design, the supra-periosteal tunnel, graft material used and the method of suturing. In MVISTA, a single vestibular incision is used to establish a wider mucoperiosteal tunnel for complete elevation and passage of grafts, thus reducing trauma and increasing flap mobility These modifications enhance access, facilitate multiple root coverage at once, and have been seen to achieve more predictable and stable long term clinical results in gingival recession treatment. Platelet-Rich Fibrin is a second-generation autologous platelet concentrate platelet rich fibrin is simple to prepare and affordable since it requires no additional activation factors or anticoagulants. Its fibrous structure forms a three-dimensional fibrin scaffold that retains more cytokines and growth factors, releasing them gradually over 10 days, creating a natural, sustained healing environment. Additionally platelet rich fibrin dissolves more slowly in tissue, forming a solid fibrin matrix resembling a natural blood clot, for better tissue integration.Thus .platelet rich fibrin promotes tissue healing and regeneration, and when combined with  Vestibular Incision Subperiosteal Tunnel Access  technique  improves biotype and healing of tissue and covers multiple recession areas well  Third generation PRF Advanced Platelet-Rich Fibrin Plus  offers superior healing and regenerative benefits over earlier platelet rich fibrin generations, mainly due to its enhanced release of growth factors achieved by slower and shorter centrifugation processes. Studies consistently show that Advanced Platelet-Rich Fibrin Plus improves bone formation supports gingival and periodontal healing, and enhances outcomes in bone graft integration and ridge preservation when compared with both conventional platelet rich fibrin and other blood-derived biomaterials. The increased concentration of key growth factors and cytokines in A-PRF+ results in faster neoangiogenesis, more efficient cellular responses, and better maintenance of tissue dimensions at surgical sites, making it a preferred adjunct in contemporary periodontal and oral surgical procedures. Advanced Platelet-Rich Fibrin Plus  demonstrates superior clinical performance compared to earlier platelet rich fibrin generations, primarily due to increased release of growth factors and cytokines that promote tissue healing and regeneration, with studies showing improved bone formation, better graft integration, and enhanced periodontal outcomes in various surgical protocols.   Photobiomodulation refers to the therapeutic use of low-level laser light to stimulate cellular activity and enhance tissue repair without causing thermal damage. Low-Level Laser Therapy  is a form of photobiomodulation applied in periodontal treatment to reduce inflammation, pain, and promote wound healing, often used adjunctively with surgical techniques to improve clinical results. Low level laser therapy supports post-surgical healing by employing low-intensity laser light to stimulate cellular processes at the wound site, enhancing tissue repair and regeneration without causing thermal damageLow-Level Laser Therapy accelerates healing by promoting mitochondrial activity and ATP production, which boosts cellular energy and facilitates fibroblast proliferation, angiogenesis, and collagen synthesis essential for soft tissue recovery after surgery. Low-level laser therapy  sterilizes tissue surfaces, modulating inflammatory response and reducing the risk of bacteremia and minimizing swelling, edema, and scarring by decreasing inflammatory cytokines, improving lymphatic drainage, and lowering vascular permeability ClinicallyLow-Level Laser Therapy has been shown to significantly decrease postoperative pain and the consumption of analgesics, optimize tissue repair, and promote wound closure, giving it a valuable adjunctive role in the post-surgical management of gingival recessions and periodontal procedures