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Minimally Invasive Surgery & Acellular Dermal Matrix to Correct Gingival Recession


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Successful root coverage for single or multiple teeth can be achieved with a minimally invasive tunneling technique and acellular derail matrix (Alloderm®).
Presentation given by Dr. Edward Gottesman, periodontist in New York, New York at the American Academy of Periondontology Meeting in San Francisco in September, 2014.
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Minimally Invasive Surgery & Acellular Dermal Matrix to Correct Gingival Recession

  2. 2. •I am receiving an honorarium from BIOHORIZONS •I have no financial interests in any of the materials used or the procedures being presented •the patient cases to be presented are all from my private practice in NYC DISCLOSURE
  3. 3. •provide an evidence based review of the tunneling technique in the context of minimally invasive surgery combined with acellular dermal matrix to achieve predictable root coverage for multiple teeth with gingival recession. OBJECTIVE
  4. 4. GINGIVAL RECESSION DEFINED • an acquired deformity of the gingival marginal tissue displaced apical to the cementoenamel (CEJ), resulting in exposed root surface and loss of attached gingiva
  5. 5. • 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 • 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 GINGIVAL RECESSION CLASSIFICATION
  6. 6. GINGIVAL RECESSION PREVALENCE • common in the US: 23.8 million people (22.5%) in the U.S. above the age of 29 have ≥3 mm gingival recession • prevalence, extent and severity increases with age • males > females • blacks > whites and Mexican Americans • more prevalent and severe at facial surfaces of teeth compared to mesial surfaces • most prevalent for maxillary first molars and mandibular central incisors
  7. 7. 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 RECESSION PREVALENCE AND AGE
  8. 8. ⬆︎ RECESSION PREVALENCE ➤⬆︎TX DEMAND • since sites with previous recession are prone to additional recession, the aging U.S. population may have a large number of sites that may need root coverage grafting
  9. 9. GINGIVAL RECESSION RISK FACTORS • areas with previous recession • thin marginal gingiva phenotype (biotype)(Müller and Eger) • inflammation, poor OH, improper OH habits, tooth position and root shape (Albander et al.)
  10. 10. GINGIVAL RECESSION RISK INDICATORS • aging • smoking • presence of supragingival calculus
  11. 11. IDENTIFY ETIOLOGY RECESSION • inflammation (Novaes) • Toothbrushing trauma (Wennström) • faulty flossing techniques (clefts) • factitial injury • abberant frenum attachment • iatrogenic dentistry
  12. 12. ANATOMIC FACTORS THAT PREDISPOSE TO RECESSION • “thin” gingival biotype (Baldi) • proclination or rotation of teeth (Nyman) • presence of bone fenestration or dehiscence (Lang and Löe)
  13. 13. “I WANT COMPLETE ROOT COVERAGE!” • Complete root coverage is the most important outcome in patients with esthetic requests (Consensus report, 1996)
  14. 14. GOAL OF ROOT COVERAGE • Rasperini concluded that the goal of root coverage is complete resolution of the recession defect and an optimal esthetic outcome
  15. 15. HOW IS RECESSION MEASURED • identify CEJ • distance from CEJ to the most apical extension of GM
  16. 16. PATIENT PERCEIVES ESTHETIC FAILURE • very often the most coronal millimeter of the root exposure is the only visible part of the recession when the patient smiles; therefore, its persistence after therapy, even of a shallow recession, may be considered an esthetic failure
  18. 18. ADDITIONAL GOALS OF ROOT COVERAGE • thin biotype ⤼ thicker biotype ⇒↓risk of further recession • ↓ root sensitivity • ↓ risk of root caries • ↑ interproximal papillary height (volume)
  19. 19. ↓PREDICTABILITY VS. ↑SUCCESS OF ROOT COVERAGE • root coverage procedures are successful but not very predictable • Success of root coverage procedures is related to the average percentage of root coverage achieved, (≈86% for ADM, Giannobile W, et al.) whereas predictability describes the percentage of the treated teeth in which complete root coverage is achieved.
  20. 20. CRITICAL RECESSION <4MM • better results in terms of percentages of complete and mean root coverage can be expected when baseline recession defects are <4 mm
  21. 21. + FGG: Coronal advancement of previously placed free gingival grafts + SECT graft: Gingival grafting performed in conjunction with flap advancement for submersion (multiple variations) + biomaterials (ADM, EMP, Platelet rich fibrin membrane, collagen matrix) + Guided Tissue Regeneration (GTR) THERAPEUTIC APPROACHES TO ROOT COVERAGE FOR GINGIVAL RECESSION DEFECTS • FGG: Gingival grafts placed directly over the root surface • Pedical flap (repositioning of “adjacent” attached gingiva) • lateral sliding flap • double papilla flap • semilunar coronally repositioned flap
  22. 22. • the subepithelial connective tissue graft technique is considered to be the gold standard for gingival recession therapy • however, given the reluctance of patients to have additional surgical sites, potentially greater patient discomfort, limitation of adequate donor tissue, and increased surgical time we have turned to allograft substitutes IS SCTG STILL THE “GOLD STANDARD”?
  23. 23. DISADVANTAGES OF SCTG• requires second surgical site • longer procedure • increased risk of post-op complications (ie. discomfort) • limited available donor supply therefore limiting the number of teeth that can be treated in a single surgery
  24. 24. CURRENT GRAFT PRODUCTS AVAILABLE FOR ROOT COVERAGE • LifeCell - Alloderm® (Allograft) • Geistlich - Mucograft® (Xenograft) • Densply - Perioderm® (Allograft) • Zimmer - Puros® Dermis (Allograft)
  25. 25. WHAT IS ADMG ? • obtained from a human donor skin tissue process that removes its cell components while preserving the remaining bioactive components and the extracellular matrix, which is subsequently freeze dried • avascular and acellular material (its a non-vital structure) • exhibits undamaged collagen and elastin matrices that function as a scaffold to allow ingrowth by host tissues
  26. 26. • Scarano and coworkers microscopically analyzed healing ADM graft sites using graft specimens before the surgery and 4 min and 1, 2, 3, 4, 6, and 10 weeks after grafting • The 6-month outcome of this study revealed that the amount of root coverage achieved with ADM and a tunnel approach to treat multiple Miller Class I recessions was 100%. • the periodontal tissues exhibited a biotype conversion with overall increase in thickness • ADM was substituted and completely re-epithelialized in 10 weeks according ADM GRAFTS HEAL ⩬ AUTOGENOUS GRAFTS
  27. 27. ADM ⩬ SCTG FOR MEASURED OUTCOMES • In 2005, a meta-analysis by Wang et al. of eight randomly controlled clinical trials showed no statistically significant differences between groups (ADM and CTG) for measured outcomes: • recession coverage • keratinized tissue (KT) • probing depth (PD) • clinical attachment levels
  28. 28. ADVANTAGES OF ADMG • safe and biocompatible (equivalent to gold standard SCTG) • unlimited supply, so multiple sites can therefore be treated with a single procedure (sextant, quadrant, full arch) avoiding second surgical site - less morbidity • excellent tissue color match obtained as the graft is repopulated with the recipient’s cells • good track record with favorable outcomes reported in the literature*
  29. 29. DISADVANTAGES OF ADMG • Pini Prato et al. reported that the graft must remain completely covered (need primary closure); avoiding graft exposure is essential when an avascular graft such as ADMG is used • requires tensionless flap to avoid graft exposure during post- operative period to enhance root coverage outcome
  30. 30. ANATOMIC FACTORS AFFECTING ROOT COVERAGE SUCCESS • Miller class and interdental papilla height (Rasperini et al.) • a thin buccal plate provides less a blood supply to nourish the overlying flap as well as graft (Ciancio) • labial protrusions of roots (tooth position) combined with a thin bony plate are predisposing factors for fenestration and dehiscence, which can also complicate the outcome of recession coverage therapy (Pandit et al. and Hirschfeld) • frenulum insertions
  31. 31. SURGICAL FACTORS AFFECTING ROOT COVERAGE SUCCESS1. post-suturing positioning of the flap coronal to the CEJ may contribute to better outcomes (Pini Prato et al. and Zuccelli et al.) 2. flap thickness ⇡ root coverage (Wang & Hwang, Baldi et al. and many others) • thick gingival tissues eases manipulation, maintains vascularity, and promotes wound healing during and after surgery 3. ↑ flap tension ⇣ root coverage (Pini Prato and Tinti) 4. ↑ flap dimension when performing root coverage for multiple rather than a single tooth, the larger flap dimension may favor complete root coverage because of increased stability (Zuccelli) 5. extending the flap margin to uninvolved neighboring teeth may blend things in more naturally (Zuccelli et al.) 6. Verical incisons according to Zuccelli and many others may have a true negative impact on the clinical and esthetic outcomes of a root-coverage surgical procedure, however the negative impact on the clinical and esthetic outcomes of a root-coverage surgical
  32. 32. • VRIs could damage the lateral blood supply to the flap and might result in unaesthetic visible white scars (AKA keloids) (Zucchelli & Desanctis) • greater incidence of swelling, pain, and bleeding: poorer patient morbidity of the patients treated with VRIs (Zucchelli & Desanctis) • VRI’s to coronally advance a flap may reduce blood circulation at the graft site • lateral and papillary areas may play an important role in flap perfusion and graft revascularization • the greater surgical time to complete the CAF with VRIs may be responsible for greater incidence of swelling and pain in patients treated with this surgical approachn (Coretellini et al.) AVOID VERTICAL RELEASING INCISIONS!
  33. 33. FLAP DESIGN FOR GOOD BLOOD SUPPLY • Mörmann and Ciancio investigated changes in gingival and alveolar mucosa microcirculation following different surgical incisions or flaps in a fluorescein angiographic study • they determined that when designing flaps with vertical releasing incisions: 1. flaps should be broad enough at their base to include major gingival vessels 2. a flap's length to width ratio should not exceed 2:1 3. minimal tension should be produced by suturing techniques and the tissue should be managed gently during the surgical procedure 4. partial thickness flap preparations to cover avascular areas should not be too thin so that more blood vessels are included in them
  34. 34. • overcorrection can decrease post-operatory exposure of non-vital allografts such as ADMG • controlling the exact position of ADMG, 1 mm apical to the CEJ, after the flap is sutured may be difficult, but the position before the flap is sutured is a valuable prerequisite to achieve a better root coverage outcome OVERCORRECTION FOR SUCCESSFUL ROOT COVERAGE
  36. 36. DAPHNE
  37. 37. MICHELLE
  38. 38. PERINE
  39. 39. MELISSA
  40. 40. ANDREA
  41. 41. SHERRY
  42. 42. thank you for your attention!