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An Alternative to Autogenous Connective Tissue Grafting for Root Coverage

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Using Acellular Dermal Matrix as an Alternative to Autogenous Connective Tissue Grafting for Root Coverage to Treat Gingival Recession

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An Alternative to Autogenous Connective Tissue Grafting for Root Coverage

  1. 1. An Alternative to Autogenous Connective Tissue Grafting for Root Coverage
  2. 2. Holiday gift ideas!
  3. 3. Periodontal Plastic Surgery • Defined as the surgical procedures performed to correct or eliminate anatomic, developmental, or traumatic deformities of the gingiva or alveolar mucosa.
  4. 4. Recession Prevalence and Age 58 41 22 13 6 0 15 30 45 60 75 1 2 3 4 5 Prevalence of Recession % In US >30 18 30 40 46 60 0 15 30 45 60 75 40 50 60 70 80 Recession Prevalence (%) by Age Recession (mm) Age 60% of 80 year olds have recession58% of population have at least 1mm of recession
  5. 5. Why is Prevalence of Recession Important? • Since sites with previous recession are prone to additional recession, the aging U.S. population may have a large number of sites that need root coverage grafting.
  6. 6. “Increase in gingival thickness will help prevent future recession in patients with a thin periodontal phenotype” 1. Prevention: • restoring or increasing marginal width of keratinized gingiva and/or marginal soft tissue thickness  may offer increased resistance to further recession caused by inflammation secondary to plaque (weak evidence ) Purposes of Treating Recession
  7. 7. 1. Prevention: • restoring or increasing marginal width of keratinized gingiva and/or marginal soft tissue thickness  may offer increased resistance to further recession caused by inflammation secondary to plaque (weak evidence)  may guard against factitial injury (faulty toothbrushing) (weak evidence)  pre-prosthetically may protect against iatrogenic dentistry (ie. invading biologic width) (weak evidence)  may offer “protection” to the alveolar bone from resorbing as a result of all of the above (weak evidence) Purposes of Treating Recession
  8. 8. 1. Prevention: • restoring or increasing marginal width of keratinized gingiva and/or marginal soft tissue thickness  prior to orthodontic treatment may prevent or minimize the formation of a dehiscence (strong evidence) Purposes of Treating Recession
  9. 9. Purposes of Treating Recession 2. Root coverage: • bridging the soft tissue fenestration with either keratinized or non-keratinized gingiva  reduce risk of root caries (strong evidence)  reduce root sensitivity following abrasion, erosion, abfraction or prior to tooth bleaching (strong evidence)
  10. 10. Purposes of Treating Recession 2. Root coverage: • bridging the soft tissue fenestration with either keratinized or non-keratinized gingiva  improve esthetics (very strong evidence)  Pre-prosthetically • prior to crown placement or class V restoration enabling the clinician to control the incis-ogingival dimension of the crown/restoration and to make crown/restoration height compatible with the height of the adjacent teeth • prior to porcelain veneer placement can eliminate the difficult task of bonding to cementumb
  11. 11. Purposes of Treating Recession 2. Root coverage: • bridging the soft tissue fenestration with either keratinized or non-keratinized gingiva  improve esthetics (very strong evidence)  Post-prosthetically • may be used to satisfy esthetic requirements such as exposed crown margins or exposed implant abutments eliminating the need to replace existing crowns
  12. 12. • In medicine, prevention is any activity which reduces the burden of mortality or morbidity from disease (recession). This takes place at primary, secondary and tertiary prevention levels. PREVENTION
  13. 13. Primary Prevention • Primary prevention avoids the development of a disease. • Most population-based health promotion activities are primary preventive measures. – ie. educating patients on good oral hygiene and an appropriate tooth brushing technique can prevent soft tissue recession
  14. 14. Secondary Prevention • Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease (further recession) and emergence of symptoms (ie. root sensitivity, caries). – Periodic evaluation of a patients’ periodontium including documenting changes in marginal soft tissue health compared to initial baseline values (first visit “x” years/months ago) using periodontal charting and “clinical photos”
  15. 15. Tertiary Prevention • Tertiary prevention reduces the negative impact of an already established disease by restoring function and reducing disease- related complications (ie. root sensitivity, caries). – Treating recession with Auto/Allo STG and/or PF (CAF, LSF)
  16. 16. First step in treating recession defect(s) is to identify the etiology and correct it ! • What Caused the Gingival Recession? – Tooth malposition • (rotated, tilted, facially displaced teeth) – Faulty tooth-brushing technique – Gingival inflammation – Abnormal frenum attachment – Iatrogenic dentistry (tooth preparation, margin placement, impression taking) – Occlusion? (weak controversial evidence)
  17. 17. Sullivan & Atkins, Per 68 • shallow or deep • narrow or wide • shallow-narrow, shallow-wide • deep-narrow, deep-wide
  18. 18. Miller PD, IJPRD 85 • Class 1: REC not to MGJ, no IP bone or papilla loss, 100% coverage • Class 2: REC past MGJ, no IP bone or papilla loss, 100% coverage • Class 3: REC past MGJ, IP bone or papilla loss, malposition, partial coverage • Class 4: REC past MGJ, severe IP bone or papilla loss, malposition, no coverage
  19. 19. All STG heal by New Attachment • The union of connective tissue or epithelium with a root surface that has been deprived of its original attachment apparatus. This new attachment may be epithelial adhesion and/or connective tissue adaptation or attachment and may include new cementum
  20. 20. ROOT COVERAGE PROCEDURES 1. Pedical flap (repositioning of “adjacent” attached gingiva) • Laterally positioned (AKA repositioned) flap • Coronally positioned (AKA repositioned) flap 2. Coronal advancement of previously placed free gingival grafts 3. Gingival grafts placed directly over the root surface 4. Gingival grafting performed in conjunction with flap advancement for submersion (SECT graft) 5. Guided Tissue Regeneration (GTR)
  21. 21. ROOT COVERAGE PROCEDURES 1. Pedical flap (repositioning of “adjacent” attached gingiva) • Laterally positioned (AKA repositioned) flap • Coronally positioned (AKA repositioned) flap • When adequate adjacent gingiva exists, repositioning it over the denuded root surface provides the most esthetic result!
  22. 22. ROOT COVERAGE PROCEDURES 1. Pedical flap (repositioning of “adjacent” attached gingiva) • Laterally positioned (AKA repositioned) flap • Coronally positioned (AKA repositioned) flap 2. Coronal advancement of previously placed free gingival grafts
  23. 23. ROOT COVERAGE PROCEDURES 1. Pedical flap (repositioning of “adjacent” attached gingiva) • Laterally positioned (AKA repositioned) flap • Coronally positioned (AKA repositioned) flap 2. Coronal advancement of previously placed free gingival grafts 3. Gingival grafts placed directly over the root surface
  24. 24. Cicatrization of the Free Connective Tissue Graft Cicatrization: To heal or become healed by the formation of scar tissue.
  25. 25. ROOT COVERAGE PROCEDURES 4. Gingival grafting performed in conjunction with flap advancement for submersion • Adequate gingiva does not always exist in adjacent locations, therefore grafting of gingiva from a remote location is often required to augment the area
  26. 26. ROOT COVERAGE PROCEDURES
  27. 27. ROOT COVERAGE PROCEDURES
  28. 28. ROOT COVERAGE PROCEDURES 4. Gingival grafting performed in conjunction with flap advancement for submersion • Adequate gingiva does not always exist in adjacent locations, therefore grafting of gingiva from a remote location is often required to augment the area
  29. 29. Subepithelial Connective Tissue Graft Technique for Root Coverage by Langer and Langer (1985) A horizontal incision is placed at the level of the cementoenamel junction of both teeth. This is connected to vertical incisions on either side.
  30. 30. Subepithelial Connective Tissue Graft Technique for Root Coverage by Langer and Langer (1985) A partial thickness flap is elevated. Care is taken to preserve the periosteum apical to the area of recession. The flap is elevated to the mucobuccal fold. Convexities on the denuded roots are flattened with curettes.
  31. 31. Subepithelial Connective Tissue Graft Technique for Root Coverage by Langer and Langer (1985) A view of the palate showing the donor site. Two horizontal incisions are placed 2 to 3 mm apical to the free gingival margin. These are connected by vertical incisions which facilitate flap elevation and connective tissue graft removal.
  32. 32. Subepithelial Connective Tissue Graft Technique for Root Coverage by Langer and Langer (1985) The donor tissue is placed directly over the denuded area. The size of the graft permits it to extend onto the remaining periosteal covering on the nondenuded portion of both teeth. This will help supply circulation to the donor tissue.
  33. 33. Subepithelial Connective Tissue Graft Technique for Root Coverage by Langer and Langer (1985) The donor connective tissue and epithelium are sutured to the underlying connective tissue interproximally. The recipient flap is then sutured directly over the graft. If possible, the flap is pulled over a major portion of the graft to ensure temporary nourishment with an additional source of circulation.
  34. 34. ROOT COVERAGE PROCEDURES 4. Gingival grafting performed in conjunction with flap advancement for submersion • Adequate gingiva does not always exist in adjacent locations, therefore grafting of gingiva from a remote location is often required to augment the area
  35. 35. Connective Tissue Graft Using an Envelope Flap by Raetzke (1985) Perform root planning of the exposed root and use a finishing bur to recontour it.
  36. 36. Connective Tissue Graft Using an Envelope Flap by Raetzke (1985) Envelope flap is prepared.
  37. 37. Connective Tissue Graft Using an Envelope Flap by Raetzke (1985) Connective tissue is placed in envelope flap.
  38. 38. Connective Tissue Graft Using an Envelope Flap by Raetzke (1985) Cover the exposed root with the connective tissue graft and perform compressive hemostasis. No suture is required. Cyanoacrylate may be used to hold the graft.
  39. 39. Connective Tissue Graft Using an Envelope Flap by Raetzke (1985) • Advantages of this technique include minimal trauma to both donor and recipient sites with rapid healing, favorable healing over wide and deep areas of recession, and excellent esthetic results. • A disadvantage is that the envelope flap cannot be displaced coronally.
  40. 40. ROOT COVERAGE PROCEDURES 4. Gingival grafting performed in conjunction with flap advancement for submersion • Adequate gingiva does not always exist in adjacent locations, therefore grafting of gingiva from a remote location is often required to augment the area
  41. 41. ROOT COVERAGE PROCEDURES 4. Gingival grafting performed in conjunction with flap advancement for submersion • Adequate gingiva does not always exist in adjacent locations, therefore grafting of gingiva from a remote location is often required to augment the area
  42. 42. The Connective Tissue and Partial Thickness Double Pedicle Graft by Harris (1992)
  43. 43. The Connective Tissue and Partial Thickness Double Pedicle Graft by Harris (1992)
  44. 44. The Connective Tissue and Partial Thickness Double Pedicle Graft by Harris (1992)
  45. 45. The Connective Tissue and Partial Thickness Double Pedicle Graft by Harris (1992)
  46. 46. The Connective Tissue and Partial Thickness Double Pedicle Graft by Harris (1992)
  47. 47. The Connective Tissue and Partial Thickness Double Pedicle Graft by Harris (1992)
  48. 48. Harris
  49. 49. The Connective Tissue and Partial Thickness Double Pedicle Graft by Harris (1992) • The greatest advantage of this technique is that a pedicle graft can cover connective tissue grafts on root surfaces lacking a vascular supply. • In addition to root coverage, the width of keratinized gingiva can be increased. Therefore, this technique may be used in areas of gingival recession with narrow keratinized gingiva.
  50. 50. ROOT COVERAGE PROCEDURES 4. Gingival grafting performed in conjunction with flap advancement for submersion • Adequate gingiva does not always exist in adjacent locations, therefore grafting of gingiva from a remote location is often required to augment the area
  51. 51. TRADITIONALLY • Augmentation of the gingival complex at the time of root coverage has been performed with autogenous connective tissue (CT) harvested from the palate or edentulous ridge.
  52. 52. Limitations of autogenous CT grafts which have led to the search for non-autogenous substitutes for palatal tissue • Second surgical site morbidity • Limited available quantity
  53. 53. Care must be taken not to damage the palatine artery. • Potential Intra-operative bleeding
  54. 54. Knowledge of Donor Area Anatomy Neurovascular bundle
  55. 55. Excision of Donor Tissue (Reiser/Bruno) (Range 7-17mm)
  56. 56. FGG Shrinkage • Ward: 47% of A-C width • Rateitschak: 25% of A-C width • Soehren: 30% of A-C width • James, McFall: 1.5 to 2X more if on periosteum instead of bone • Mormann, JP 81: – Very thin, 45% – Thin, 44% – Intermediate, 38% – If taken with scalpel 30% • Rossman, Rees: 24% of graft surface area • Wei: 16%
  57. 57. Creeping Attachment • Matter (1980) described a phenomenon of additional root coverage during healing which may be observed between 1 month and 1 year post-grafting. He reported an average of 1.2 mm of coronal creep at 1 year with no additional change.
  58. 58. Acellular Dermal Regenerative Tissue Matrix (ADM) Defined ADM is an acellular dermal matrix derived from donated human skin tissue supplied by US AATB- compliant tissue banks utilizing the standards of the American Association of Tissue Banks (AATB) and Food and Drug Administration's (FDA) guidelines. Since ADM is regarded as minimally processed and not significantly changed in structure from the natural material, the FDA has classified it as banked human tissue.
  59. 59. What is Acellular Dermal Regenerative Tissue Matrix? • A human soft tissue • Used in various applications since 1995 –Burns –Head and Neck Reconstructions –Dental, 1997 –Urology – bladder slings & pelvic floor reconstruction –Orthopedics – rotator cuff repair & periosteal replacement –Hernia repair
  60. 60. Multiple Applications AlloDerm® Reconstructive Repliform® Urogynecology GraftJacket® Orthopedics
  61. 61. ADM – Safe Tissue » Over 13 years » Over 900,000 cases Safe History
  62. 62. Procurement of Alloderm • AlloDerm is a processed tissue that comes from donors who are extensively screened and tested for presence of diseases including HIV and hepatitis. The processing procedure has been demonstrated to reduce HIV and hepatitis C surrogate virus to non-detectable levels. Additional testing for presence of pathogens is performed prior to and following processing to ensure that Alloderm is disease-free before release for patient care.
  63. 63. Processing of Alloderm • A buffered salt solution removes the epidermis, and multiple cell types within the dermis are then solubilized and washed away using a patented series of non-denaturing detergent washes that rapidly diffuse into the dermis.
  64. 64. ADM Processing • Acellular Dermal Matrix is of human origin. • It has been especially processed to remove both the epidermis and the cells that can lead to tissue rejection and graft failure, without damaging the matrix. • The processed tissue matrix is preserved with a patented freeze-drying process that prevents damaging ice crystals from forming.
  65. 65. Regenerative Tissue Martix The processed regenerative human tissue matrix is then preserved using LifeCell’s patented amorphous freeze- drying process, thereby retaining the critical biochemical and structural components needed to maintain the tissue’s natural regenerative properties. The matrix has a two-year shelf life. Cryopreservation
  66. 66. AlloDerm® Preserved Tissue AlloDerm LifeCell patented freeze-drying Commercially available dermis Conventional freeze-drying
  67. 67. ACELLULAR DERMAL MATRIX
  68. 68. ADM works like an Autograft Provides a bioactive matrix consisting of collagens, elastin, blood vessel channels, and bioactive proteins that support natural revascularization, cell repopulation, and tissue remodeling.
  69. 69. Healing by “Repair” (fibrous encapsulation) or “Regeneration” (incorporation) Inflammation Matrix & Stem Cells Scar Tissue Normal Tissue Fibrosis Intrinsic Tissue Regeneration Process
  70. 70. Regenerative Tissue Matrix Unique Outcome Rapid revascularization and repopulation The vascular architecture is endothelialized, and host stem cells migrate and bind specifically to protein components of the matrix. Host cells respond to the three-dimensional architecture and adapt to the local environment.
  71. 71. Regenerative Tissue Matrix Remodeling to the patient’s own tissue The matrix is now fully revascularized, repopulated and integrated into the host tissue. Proteins undergo normal breakdown and regeneration. Unique Outcome
  72. 72. Regenerative Tissue Matrix Transitioning into the host tissue Host cells continue to respond to the local environment, and the matrix transitions into the tissue it is replacing at the site of the transplant. Unique Outcome
  73. 73. Advantages of ADM 1. Equivalent to “gold standard” – Provides effective and predictable root coverage compared to connective tissue 2. Unlimited supply – Multiple sites can therefore be treated with a single procedure (sextant, quadrant, full arch) 3. Excellent tissue color match obtained as the graft is repopulated with the recipient’s cells and the final gingival color exactly matches the recipient’s pre-treatment gingiva
  74. 74. #1/2 Orban DE Knife, Modified Modified with a flattened surface on one side and a domed surface on the other, plus a reduced cutting edge at the shank. Ideal for intrasulcular sharp, supraperiosteal dissection. Used after the initial blunt dissection (using the HF-PPAEL or HF-PPAELA) to complete the preparation of the pouch recipient site. The flat side is positioned against the bone and the domed side faces the soft tissue facilitating dissection without perforation. Reduced cutting surface lessens the possibility of inadvertently incising the pouch margin during dissection.
  75. 75. Allen Micro Periosteal Elevator Designed for elevation of a mucoperiosteal pouch with an intrasulcular approach (following an intrasulcular incision from the base of the sulcus to the alveolar crest). May be used with the curve angled inward as well as outward. Especially useful for papilla elevation using the curved end angled outward. Also placed between the pouch and the graft to prevent needle penetration of the graft during suturing.
  76. 76. Allen Micro Periosteal Elevator, Anterior Similar in design but smaller than the HF-PPAEL (above), with a reduced curvature. Designed for use in the mandibular anterior region where the tooth diameter is smaller. It is also useful in more delicate dissections where the tissue is thin and/or the bony topography is irregular.
  77. 77. #7/8 Younger-Good Curette, #6 Handle Used for root planing prior to root coverage grafting. Also used for passing the AlloDerm into the tunnel.
  78. 78. Micro Suture Pliers Allows better visibility of small tissue margins for precise suture placement.
  79. 79. Diamond Dusted Micro-pickups for assistant.
  80. 80. Micro Non-Serrated Castroviejo Perma Sharp 7” Str. Round Handle A smaller diameter jaw allows retrieval of the needle tip in tight quarters. For use with 6-0 and smaller sutures.
  81. 81. Perma Sharp Goldman Fox Scissors Perfect for cutting sutures.
  82. 82. ADM and the Alternate Papilla Tunnel Technique 1. Local anesthetic by local infiltration using Lidocaine 1:100, 000 epi. 2. Root planing with #7/8 younger good curette to remove any existing resin or irregularities in root suface assuring the line angles of the root surface are smooth as they meet the buccal surfaces. – Root planing is “A definitive treatment procedure designed to remove cementum or surface dentin that is rough, impregnated with calculus, or contaminated with toxins or microorganisms. 3. Interproximal flossing of teeth
  83. 83. EDTA Dentinal surface of a sample covered with debris and smear layer. SEM 1500X magnification. Dentinal surface of a sample covered with less than 25% debris. SEM 1500X magnification. 30-60 sec. 4. Application of a chelating agent EDTA (Ethylenediaminetetracetic acid) for 30-60 sec with cotton tip applicator to remove smear layer and produce canals with patent dentinal tubules obstructed by root planing; this doesn’t harm blood supply of marginal tissue due to neutral pH ADM and the Alternate Papilla Tunnel Technique
  84. 84. ADM and the Alternate Papilla Tunnel Technique 5. Alternating papilla are incised 6. Split thickness dissection is performed to create a pouch adjacent to involved teeth using the flat side of a modified #1/2 Orban DE knife which is positioned against the bone and the domed side faces the soft tissue facilitating dissection without perforation
  85. 85. ADM and the Alternate Papilla Tunnel Technique 7. Remove from outer foil pack and drop graft into saline bath directly from inner package.
  86. 86. Important: Before use, clinicians should review all risk information, which can be found on the packaging and in the “Information for Use” attached to the packaging of each AlloDerm graft.
  87. 87. ADM and the Alternate Papilla Tunnel Technique 8. Re-hydrate in two consecutive 10-20 minute sterile saline baths. 9. Remove paper backing from AlloDerm between first and second baths.
  88. 88. ADM and the Alternate Papilla Tunnel Technique 8. ADM is secured against the buccal root surface(s) with 7.0 Polypropylene interupted sling sutures with all knots placed on palatal margins
  89. 89. ADM and the Alternate Papilla Tunnel Technique 5. Flaps/pouch are coronally advanced over the graft with 6.0 Polypropylene interupted sling sutures with all knots placed on palatal margins
  90. 90. When performing a CAF + ADM, the following measures have to be taken to prevent flap retraction and exposure of the ADM as described by Bernimoulin et al. • A double sling suture (as described by Dodge et al.)
  91. 91. Overcorrect for more severe recession defects by 1mm when using CAF because there is no creeping attachment • Pini Prato et al.
  92. 92. Post-op Medications 1. Analgesics • non-steroidal anti-inflammatory agents • steroids (ie. methylprednisolone ) 2. Doxycyclin Hyclate (ie. Peridex®) 3. NO ANTIBIOTICS • RISK OF INFECTION POST PERIODONTAL SURGERY IS LESS THAN 1% (Pack and Haber)
  93. 93. 2 MONTH POST-OP
  94. 94. 2 months post-op Initial
  95. 95. CLINICAL CASE I
  96. 96. CLINICAL CASE II
  97. 97. CLINICAL CASE III
  98. 98. CASE IV
  99. 99. CASE V
  100. 100. 12/29/06
  101. 101. 12/29/06
  102. 102. 12/29/06
  103. 103. 12/29/06
  104. 104. 1/18/07
  105. 105. 2/5/07
  106. 106. 5/14/07
  107. 107. 8/27/07
  108. 108. 8/27/07
  109. 109. 8/27/07 12/29/06PRE-OP POST-OP 8 M O N T H S
  110. 110. THANK YOU FOR YOUR ATTENTION

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