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

2. An Alternative to Autogenous
Connective Tissue Grafting for Root
Coverage

3. Holiday gift ideas!

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

7. 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

8. 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.

9. “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

10. 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

11. 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

12. 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)

13. 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

14. 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

15. • 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

16. 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

17. 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”

18. 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)

19. 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)

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

21. 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

22. 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

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
4. Gingival grafting performed in conjunction with flap
advancement for submersion (SECT graft)
5. Guided Tissue Regeneration (GTR)

24. 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!

25. 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

26. 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

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

31. 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

32. ROOT COVERAGE PROCEDURES

33. ROOT COVERAGE PROCEDURES

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. 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.

36. 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.

37. 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.

38. 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.

39. 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.

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. 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.

42. Connective Tissue Graft Using an
Envelope Flap by Raetzke (1985)
Envelope flap is
prepared.

43. Connective Tissue Graft Using an
Envelope Flap by Raetzke (1985)
Connective tissue is
placed in envelope
flap.

44. 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.

45. 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.

62. 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

76. 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

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

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

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

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

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

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

83. Harris

88. 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.

89. 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

90. 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.

91. 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

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

93. Knowledge of Donor Area Anatomy
Neurovascular bundle

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

95. 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%

107. 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.

108. 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.

109. 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

110. Multiple Applications
AlloDerm®
Reconstructive
Repliform®
Urogynecology
GraftJacket®
Orthopedics

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

118. 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.

119. 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.

120. 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.

121. 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

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

123. ACELLULAR DERMAL MATRIX

124. 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.

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

126. 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.

127. 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

128. 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

142. 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

145. #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.

146. 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.

147. 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.

148. #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.

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

150. Diamond Dusted
Micro-pickups for assistant.

151. 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.

152. Perma Sharp Goldman Fox Scissors
Perfect for cutting sutures.

153. 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

154. 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

156. 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

160. ADM and the Alternate Papilla Tunnel
Technique
7. Remove from outer foil pack and drop graft
into saline bath directly from inner package.

161. 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.

163. 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.

165. 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

167. 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

169. 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.)

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

171. 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)

173. 2 MONTH POST-OP

175. 2 months
post-op
Initial

176. CLINICAL CASE I

179. CLINICAL CASE II

183. CLINICAL CASE III

186. CASE IV

189. CASE V

190. 12/29/06

191. 12/29/06

192. 12/29/06

193. 12/29/06

195. 1/18/07

196. 2/5/07

197. 5/14/07

198. 8/27/07

199. 8/27/07

200. 8/27/07
12/29/06PRE-OP
POST-OP
8
M
O
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T
H
S

201. THANK YOU FOR YOUR ATTENTION