This document provides an overview of root coverage procedures and the use of acellular dermal matrix (ADM) as an alternative to autogenous connective tissue grafting. It describes the processing of ADM to remove cells while retaining the collagen matrix. ADM provides a scaffold that supports natural revascularization and tissue remodeling during healing. When used in conjunction with flap procedures, ADM can augment areas where adjacent tissue is insufficient, avoiding secondary donor site morbidity associated with palatal grafting.

1. An Alternative to
Autogenous
Connective Tissue
Grafting for Root
Coverage
Glen Head Study Club
2007

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
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

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. 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
“Increase in gingival thickness will help prevent future
recession in patients with a thin periodontal phenotype”

10. 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

11. 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)

12. 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

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)
 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

14. 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)

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

17. 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

18. 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

19. 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)

20. 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!

21. 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

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
3. Gingival grafts placed directly over the root surface

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

27. 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

28. ROOT COVERAGE
PROCEDURES

29. 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

30. 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.

31. 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.

32. 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.

33. 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.

34. 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.

35. 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

36. 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.

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

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

39. 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.

40. 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.

57. 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

71. 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

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

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

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

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

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

77. 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)
• 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.

83. 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

84. 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.

85. 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

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

87. Knowledge of Donor Area Anatomy
Neurovascular bundle

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

89. 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%

102. 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.

103. 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.

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

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

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

113. 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.

114. 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.

115. 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.

116. 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

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

118. ACELLULAR DERMAL MATRIXACELLULAR DERMAL MATRIX

119. 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.

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

121. 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.

122. 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

123. 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

137. 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

141. #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

142. 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.

143. 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.

144. #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.

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

146. Diamond Dusted
Micro-pickups for assistant.

147. 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.

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

149. 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

150. 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

152. 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

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

157. 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.

159. 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.

161. 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

163. 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

165. 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.)

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

167. 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)

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

170. 2 MONTH POST-OP

172. 2 months
post-op
Initial

173. CLINICAL CASE I

176. CLINICAL CASE II

180. CLINICAL CASE III

183. CASE IV

186. CASE V

192. CASE VI

193. 12/29/06

194. 12/29/06

195. 12/29/06

196. 12/29/06

198. 1/18/07

199. 2/5/07

200. 5/14/07

201. 8/27/07

202. 8/27/07

203. 8/27/07
12/29/06PRE-OP
POST-OP
8
M
O
N
T
H
S

204. THANK YOU FOR YOUR ATTENTION