An Alternative to Autogenous Connective Tissue Grafting for Root Coverage

An Alternative to
Autogenous Connective
Tissue Grafting for
Root Coverage
Staten Island
Hospital
____________________________________________
General Practice Residency
Program

218 East 61st
Street, New York City

Periodontal Plastic
Surgery
• Defined as the surgical procedures
performed to correct or eliminate
anatomic, developmental, or traumatic
deformities of the gingiva or alveolar
mucosa.

Recession Prevalence and Age
Prevalence of Recession %In US >30
58
41
22
13
6
0
10
20
30
40
50
60
70
1 2 3 4 5
Recession Prevalence (%) by Age
18
30
40
46
60
0
10
20
30
40
50
60
70
40 50 60 70 80
Recession (mm) Age
60% of 80 year olds have recession58% of population have at
least 1mm of recession

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.

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 in patients with a thin
periodontal phenotype (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

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)

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)

2. Root coverage:
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 cementum

2. Root coverage:
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

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)

Sullivan & Atkins, Per 68
• shallow or deep
• narrow or wide
• shallow-narrow, shallow-wide
• deep-narrow, deep-wide

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

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

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)

Cicatrization of the Free
Connective Tissue Graft
Cicatrization: To heal or become healed by the formation of scar tissue.

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.

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.

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.

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.

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.

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.

Envelope flap is
prepared.

Connective tissue is
placed in envelope
flap.

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.

• 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.

The Connective Tissue and Partial
Thickness Double Pedicle Graft by
Harris (1992)

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.

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.

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

Care must be taken not to damage
the palatine artery.
• Potential Intra-operative bleeding

Knowledge of Donor Area Anatomy
Neurovascular bundle

Excision of Donor Tissue (Reiser/Bruno)
(Range 7-17mm)

FGG Shrinkage
(average 30%)
• 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:
– Very thin, 45%
– Thin, 44%
– Intermediate, 38%
– If taken with scalpel 30%
• Rossman, Rees: 24% of graft surface area
• Wei: 16%

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.

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.

What is Acellular Dermal
Regenerative Tissue Matrix?
• A human soft
tissue
• Used in various
applications since
1995
–Burns
–Head and Neck
Reconstructions
–Dental, 1997

Multiple Applications
AlloDerm®
Reconstructive
Repliform®
Urogynecology
GraftJacket®
Orthopedics

ADM – Safe Tissue
» Over 13 years
» Over 900,000
cases
Safe History

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.

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.

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.

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

AlloDerm® Preserved Tissue
AlloDerm
LifeCell patented freeze-drying
Commercially available dermis
Conventional freeze-drying

ACELLULAR DERMAL MATRIXACELLULAR DERMAL MATRIX

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.

Healing by “Repair” (fibrous encapsulation)
or “Regeneration” (incorporation)
Inflammation Matrix & Stem Cells
Scar Tissue Normal Tissue
Fibrosis
Intrinsic
Tissue
Regeneration
Process

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.

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

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

Advantages of ADM
1. Equivalent to “gold standard”
– Provides effective and predictable root coverage
compared to connective tissue
1. Unlimited supply
– Multiple sites can therefore be treated with a single
procedure (sextant, quadrant, full arch)
1. 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

#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

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.

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.

#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.

Micro Suture Pliers
Allows better visibility of small tissue margins for precise suture placement.

Diamond Dusted
Micro-pickups for assistant.

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.

Perma Sharp Goldman Fox Scissors
Perfect for cutting sutures.

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

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

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

Tunnel Technique
7. Remove from outer foil pack and drop graft
into saline bath directly from inner package.

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.

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.

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

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

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.)

Overcorrect for more severe
recession defects by 1mm when
using CAF because there is no
creeping attachment
• Pini Prato et al.

Post-op Medications
1. Analgesics
• non-steroidal anti-inflammatory agents
• steroids (ie. methylprednisolone )
1. Doxycyclin Hyclate (ie. Peridex®)
2. NO ANTIBIOTICS
• RISK OF INFECTION POST PERIODONTAL
SURGERY IS LESS THAN 1%
(Pack and Haber)

“Nothing gets an old dental bill
paid like a new toothache”

PRE-OP
POST-OP
2/8/08
3/5/08
1
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PRE-OP
POST-OP
12/21/07
3/5/08
3
M
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S

PRE-OP
POST-OP 03/27/08
12/6/07

8/27/07
12/29/06PRE-OP
POST-OP
8
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S

An Alternative to Autogenous Connective Tissue Grafting for Root Coverage

An Alternative to Autogenous Connective Tissue Grafting for Root Coverage

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