JOURNAL CLUB PRESENTATION

ROBINS DHAKAL
JR-3
Department of periodontology & oral implantology

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 Clinical and Patient-Centered Outcomes Following
Treatment of Multiple Gingival Recessions Using
Acellular Dermal Matrix Allografts

The International Journal of Periodontics & Restorative Dentistry

Volume 37, Number 6, 2017

Alain H. Romanos, DDS, MS

Ramzi V. Abou-Arraj, DDS, MS
Stephanie E. Cruz, DMD
Zeina A.K. Majzoub, DCD, DMD, MScD
2
Assistant Professor, Department
of Periodontology, Lebanese
University, Hadath, Lebanon.
 Acellular dermal
matrix allograft
• Dermis
• Acellular dermal matrices
• Method of extraction
• Sources
• History
• Use in dentistry
• Healing
• Advantages and disadvantages of
ADM
• Placement of ADM
Skin
• The skin is commonly subdivided
into three layers: epidermis,
dermis, and hypodermis

• The dermis, 2 to 3 mm in
thickness, is a layer composed
predominantly of connective
tissue and blood vessels, that
comprises the main bulk of the
skin, supports the epidermis, and
binds it to the hypodermis. 5
Dermis
• Dermal connective tissue contains elastin and collagen; collagen
fibers comprise the biggest volume of the skin and the bulk of its
tensile strength, whereas elastin fibers contribute to elasticity and
resilience.

• The dermis also contains nerve fibers, sensory receptors,

hyaluronic acid (responsible for normal turgor of dermis because of
extraordinary water-holding capacity), and supportive
glycosaminoglycans (GAG).

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Acellular dermal matrices
• The cells within this layer (eg, sweat glands, nerve endings) are rich in
antigenic material, making routine allotransplantation or
xenotransplantation impossible without rapid rejection

• Multiple proprietary methods have been devised to strip the dermis of its
cellular components after harvest from human cadaver, pig, or cow
dermis, as well as intestinal submucosa.

• These methods help the ADM materials to retain many of the structural
elements (matrices) necessary for wound healing without the concern of
rejection (since they are acellular).
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Method of extraction

• ADM is made by taking a full-thickness section of skin from a donor

source—which in most cases is human cadaver, porcine, or bovine
in origin

• In the case of human donors, the tissue is screened for infectious

diseases such as HIV and hepatitis. The tissue is run through a
series of steps, with each company having its own proprietary
process.

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• AlloDerm (LifeCell Corp., Branchburg, New Jersey), one of the most
ubiquitous products on the market, has a manufacturing process
that begins by immersing the tissue in a buffered salt solution to
separate and eliminate the dermis.

• Next, a series of mild detergents are applied to eliminate all cellular

elements from the tissue. The tissue is extensively tested for any
contamination to ensure a sterile product, then freeze-dried to
prevent crystallization and allow for stable packaging and storage

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Sources
Human dermis

Porcine

Bovine

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 The dermis is a layer of the
body rich with wound
matrix, composed of
collagen, elastin, fibrillin,
and glycosaminoglycans.
Cellular component are
removed which produce
antigenicity.

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History
• ADM became widely utilized in the grafting of burn patients during
the 1990s.

• The medical community expanded its use to include tympanic

membrane reconstruction, nasal reconstruction, treatment of
dermal atrophy, repair of fistulae, and facial esthetic plastic surgery
applications.
Wainwright DJ. Use of an acellular allograft dermal matrix (AlloDerm) in the
management of full-thickness burns. Burns 1995;21:243-248

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Use in dentistry
• Shulman (1996) was the first author to document the use of ADM
in dentistry.

Shulman J. Clinical evaluation of an acellular dermal allograft for increasing the

zone of attached gingiva. Pract Periodontics Aesthet Dent 1996;8:201-208.

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• Intraorally, ADM has since been utilized in a wide range of
dental applications such as
• soft tissue augmentation,
• augmentation of keratinized gingiva,
• as a barrier membrane (GTR),
• as a soft tissue grafting material to cover amalgam tattoos, and
• for root coverage procedures (a substitute for palatal donor
tissue in soft tissue surgeries)

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Healing of ADMG
• The biologic structures of the SCTG and the ADMG are different,
which results in different healing processes

• Because of its non-vital structure, the success of the ADMG

depends on the blood vessels and cells from the host recipient
tissues.

• A partial-thickness flap without tension should be performed to

cover the allograft completely
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• The ADMA acts as a scaffold for the vascular endothelial cells and
fibroblasts to repopulate the connective tissue matrix and
encourage the epithelial cells to migrate from the adjacent tissue
margins.

• The ADMA seemed well incorporated with new fibroblasts, vascular

elements, and collagen, while retaining its elastic fibers
throughout; it was apparent that equivalent attachment to the root
surface was observed between SCTG and ADMA
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• With continuous production of new connective tissue and
degradation of the original graft matrix and dead cells, the non vital
grafts are eventually completely replaced by host tissues

• The ADM allograft also must rest on granulation tissues from

adjacent regions to achieve reorganisation. The possible sources of
granulation tissue includes adjacent gingiva, periodontal ligament,
bone marrow spaces and alveolar mucosa

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Advantages of ADM
• There are no dead cells within the dermal matrix that could contain
class I and class II major histocompatibility complex (MHC) antigen,
which pose the potential for inducing rejection.
• In addition, complete dead cell removal eliminates the almost
nonexistent potential for viral disease transmission is a significant
advantage in gaining patient and surgeon acceptance
• the need for palatal donor material is eliminated which reduces
postoperative morbidity. In addition, it provides an unlimited supply
of graft material, thus permitting multiple site root coverage
• an excellent tissue colour match obtained, patient acceptance
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Disadvantages
• High cost

• It was observed that Alloderm was not as predictable as free

gingival autograft in terms of increasing attached keratinized
tissue, due to considerable shrinkage of the Alloderm and
inconsistent quality of the attached gingiva gained after therapy

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31
Placement of ADM
• The basement membrane side of the
graft is easy to identify since, when the
material is saturated with blood and then
wiped with a gauze, the basement
membrane side does not retain the blood
and becomes white. The connective
tissue side retains the blood and when
wiped with a gauze stays red.
• The manufacturer recommends that for
gingival augmentation the basement
membrane side be placed away from the
bone and the connective tissue side be
placed so it rests on the bed and closest
to the bone. For root coverage, 33 it’s
reverse.
Creeping attachment
• Most frequent in cases of FGG
• From 1 month- 11 months
• Harris referred to 0.85 mm creeping attachment through SCTG
following one year and Piniprato et al referred to 0.43 mm through
the coronally advanced flap
• Woodyard et al (from 2 to 6 months) and Henderson et al (from 2 to
12 months) using Alloderm did not show any creeping attachment
indicating a high amount of coverage at the beginning with no more
healing after 2 months

35
 Clinical and Patient-Centered Outcomes Following
Treatment of Multiple Gingival Recessions Using
Acellular Dermal Matrix Allografts

The International Journal of Periodontics & Restorative Dentistry

Volume 37, Number 6, 2017

Alain H. Romanos, DDS, MS

Ramzi V. Abou-Arraj, DDS, MS
Stephanie E. Cruz, DMD
Zeina A.K. Majzoub, DCD, DMD, MScD
36
Assistant Professor, Department
of Periodontology, Lebanese
University, Hadath, Lebanon.
Introduction
• Gingival recessions have been predictably treated using various
surgical approaches and materials.

• The use of subepithelial connective tissue grafts (SCTGs) is

considered the gold standard for root coverage procedures

Technique sensitive
A second surgical site
Limited donor tissues
Variation in the graft quality
37
• Acellular dermal matrix (ADM) has been introduced as an
alternative root coverage approach that overcomes the
shortcomings of autogenous gingival grafts by eliminating the
second surgical site, patient discomfort, and volume and
anatomical limitations in palatal tissue harvesting

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Current evidences
• Similar short- and long-term clinical root coverage outcomes have
been reported when comparing ADM with SCTG
de Souza SL et al, 2008
Moslemi N et al, 2011
Thomas et al, 2013

• Limited information is currently available relative to patient-

reported outcomes and esthetic results achieved with ADM and its
clinical application in the treatment of multiple gingival recessions

Mahn et al 2010
Clozza et al 2014
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Aims & Objectives
• The aim of this prospective case series was to evaluate clinical and
patient-centered outcomes following treatment of multiple gingival
recessions affecting five or more maxillary and/or mandibular teeth
in a single surgical visit using ADM combined with the modified
coronally advanced tunnel (MCAT) flap technique.

• Secondary objectives were to assess the effects of smoking and

clinical variables such as recession class, baseline recession
depth, tooth position, and tooth location on root coverage
outcomes
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Materials & methods
• A total of 24 systemically healthy adult patients attending the
Lebanese University (LU) Department of Periodontology clinics and
a private periodontal practice in Beirut, Lebanon, were enrolled
between December 2013 and July 2014 according to the following
inclusion criteria:
• (1) presence of five or more Miller Class I, II, or III recessions at
the buccal aspect of anterior and/or posterior teeth affecting at
least two adjacent teeth and including at least two sites with a
depth of ≥ 2 mm;
• (2) esthetic or orthodontic indication for root coverage
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• (3) presence of an identifiable cementoenamel junction (CEJ);
• (4) absence of caries or restorations involving the buccal
cervical aspect of the selected sites;
• (5) absence of active periodontal disease; and
• (6) no history of previous mucogingival therapy at the
experimental sites.

Participants were considered smokers if they reported

smoking ≥ 10 cigarettes/day for > 5 years. Past smokers
were considered non-smokers
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• Following approval by the Lebanese University Ethical Committee
(in full accordance with the principles of the Declaration of Helsinki
of 1975, as revised in 2008), study objectives and estimated risks
and benefits were explained to all qualifying patients, and written
informed consent was obtained

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• All participants received detailed nontraumatic oral hygiene
instructions, including a coronally directed roll technique and a
session of professional dental prophylaxis.

• At 1 month following initial therapy, patients who demonstrated

fullmouth plaque scores (FMPS) > 20% were excluded from the
study

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Clinical measurements
• (1) recession depth (REC), measured from the CEJ to the most
apical extension of the gingival margin (GM); and
• (2) width of keratinized gingiva (WKG), calculated from GM to the
mucogingival junction (MGJ).

The measurements were collected using a toothborne acrylic stent

covering up to onethird of the incisal or buccal cusp by a single
calibrated experienced periodontist (Z.M.) blinded to the objectives
of the study at baseline and at 1 year postsurgery. PCP/UNC15
probe, Hu-Friedy was used.
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Surgical procedure
• Root surfaces were prepared via hand scaling and root planing to
the level of sulcular bottom prior to initiating the surgical procedure

• The MCAT flap preparation was performed as described by Aroca et

al(2013).

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• Following sulcular incisions,
sharp dissection was
undertaken to undermine the
buccal gingiva by means of a
split-thickness flap preparation
and to mobilize the papillae
through a full-thickness
approach aiming at the creation
of a continuous tunnel within
the buccal soft tissues

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• The supraperiostal dissection was
extended beyond the MGJ to achieve
passive coronal repositioning.
• After hydration, ADM (Alloderm,
Biohorizons) was trimmed to the
desired mesiodistal extension, leaving
6 to 7 mm of apicocoronal height,
inserted into the continuous tunnel
within the buccal soft tissues, and
stabilized using individual 5-0 tooth
sling sutures, engaging the graft at the
root line angles
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• Using the same suturing technique, the flap was positioned
coronally to achieve full ADM coverage
• Duration of the surgical procedure in minutes was noted using a
digital chronometer from the first incision to the last suture

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Post operative care
• Patients were instructed to discontinue tooth brushing and flossing
around the surgical sites for the first 4 postoperative weeks, rinse
with a 0.12% chlorhexidine gluconate solution three times a day,
and limit hot/hard food intake, sports activities, and heat/sun
exposure for 48 hours.

• Smokers were asked to refrain from smoking during the first

postoperative week. All patients were administered 600 mg of
ibuprofen for pain control at the beginning of surgery and provided
with a prescription of the same analgesic to take as needed.
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Follow up
• Weekly prophylaxis visits were scheduled during the first month,
after which patients were recalled every 3 to 4 months for routine
maintenance and reinforcement of nontraumatic brushing
technique.

• At the 1-year visit , the same clinical measurements were taken by

the calibrated blinded examiner (Z.M.).

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Patient centered outcomes
• For their perception of pain/bleeding/swelling/bruising, patients
were asked to complete a visual analog scale (VAS)-based
questionnaire daily from day 0 (day of surgery) to day 6.

• On this scale, 0 designated no symptoms while 10 corresponded to

severe excruciating pain/bleeding/swelling/bruising.

• Similarly, a VAS-based evaluation was used to report the level of

changes in daily life activities and nutritional habits
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Statistical analysis
• Sample size (110 teeth, 55 in each group) calculation was
performed based on a required study power of 80%, statistical
significance of 5%, and proportion difference of 25% in the
outcome variable complete root coverage (CRC) between smokers
and nonsmokers

• Independent t test was applied to compare mean VAS-based scores

between smokers and nonsmokers

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• Potential effects of smoking, recession class, baseline REC, tooth
position (anterior versus posterior), and tooth location (maxillary
versus mandibular) on root coverage (RC) and CRC was assessed
using independent t test and chi-square test, respectively

• Pearson correlation was performed to evaluate the impact of

surgical chairtime on VAS pain scores and analgesic consumption.

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Results

Patient and
Recession
Characterist
ics at
Baseline

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57
Root
Coverage
Outcomes
at 1 Year

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Patient
centered
outcomes

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Discussion
• Despite the high predictability of SCTGs in the treatment of multiple
recessions, a single surgery involving five or more teeth would be
associated with large or multiple palatal donor sites, exposing the
patients to a more painful postoperative course

• Wessel and Tatakis reported a mean VAS pain score of 3.5 at 3

days postoperatively, an average of 12.5 ibuprofen tablets taken
during the 3-week study, and 3.2 days of analgesic use in SCTG-
treated patients

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• The modified coronally advanced tunnel (MCAT) approach in
combination with ADM results in substantially less postoperative
discomfort at the recipient sites than SCTG procedures that involve
fewer teeth. This can be attributed to the minimally invasive nature
of the MCAT technique and the absence of releasing incisions

• Smoking, which is identified as a risk indicator for pain in

autogenous grafts, was not significantly correlated with increased
postoperative discomfort in the present case series, most likely
owing to the elimination of the donor site wound and possibly to the
nature of the surgical technique (MCAT).
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• The minor postoperative bleeding and swelling at the grafted sites
in the present study are in agreement with the findings of Griffin et
al.

• In addition, daily activities and nutritional habits were not adversely

affected. As highlighted by the patients, the changes reported were
more induced by apprehension of trauma to the treated sites rather
than discomfort associated with the surgery itself.

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• The present 1-year clinical results showed RC of 87.1± 18.3% and
CRC in 61.7% of treated recessions. These root coverage outcomes
are in agreement with the range of values obtained following
treatment of multiple class I/II recessions with MCAT combined
with SCTG (80% to 90%).
Bherwani et al 2014
Aroca et al , 2013

• Studies where multiple Class I/II recessions were treated with CAF
and ADM achieved average RC ≥ 90% and mean CRC exceeding
80%. Ahmedbeyli et al , 2014
63 Henderson et al , 2001
• Comparison of RC and CRC between smokers and nonsmokers
yielded significant differences in favor of nonsmokers, similar to
previous findings

• In the present study, RC in Class III recessions averaged 77.3% and

CRC was obtained in 35.4% of the sites which is lesser when
compared to a systematic review.
Chambrone et al, 2015

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• A negative influence of baseline recession depth 3.5-5 mm as
compared to 1-3 mm on percentage of RC. The findings of the
present study are further corroborated by the conclusions of a
meta-analysis that showed that the chances of achieving CRC are
prejudiced by greater baseline recession depth.
Chambrone et al , 2012

• In the present study, RC was not affected by tooth position (anterior

versus posterior). While most published studies report results
limited to maxillary canines and premolars, limited information is
available relative to RC of molars
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• Multiple maxillary adjacent sites have been shown to perform
better than mandibular sites in mean RC and CRC (98% and 85%
versus 94% and 57%, respectively). Differences in depth of the
vestibular fornix, flap tension, and mucogingival phenotypes may
be influencing factors

ADD A FOOTER 66
Conclusion
• Within the limitations of the present case series, it can be
concluded that ADM combined with MCAT is highly effective in the
treatment of multiple Class I, II, and III recessions affecting more
than five teeth in a single surgical procedure and is associated with
low morbidity and excellent esthetic outcomes

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Critical appraisal
• Suitable alternative to a palatal donor tissue for root coverage,
ridge augmentation
• If patients can afford
• Patient centered outcomes included in the study as well

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 Similar articles

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70
Abstract
• Aim: The aim of this randomized controlled clinical study was to
compare the use of an acellular dermal matrix graft (ADMG) with or
without the enamel matrix derivative (EMD) in smokers to evaluate
which procedure would provide better root coverage.

• Conclusion: Smoking may negatively affect the results achieved

through periodontal plastic procedures; however, the association of
ADMG and EMD is beneficial in the root coverage of gingival
recessions in smokers, 6 months after the surgery
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ADD A FOOTER 72
Abstract
• Objectives: Evaluate the effectiveness of acellular dermal matrix
allograft (ADMA) in comparison to subepithelial connective tissue graft
(SCTG) in the treatment of Miller's class I and II gingival recession

• Results: There were no statistically significant in any of the parameters

between both ADMA and SCTG groups postoperatively. The root coverage
obtained with SCTG group was 83.3 % at 3 months, while for ADMA
group was 80.2 % at 3 months.

• Conclusions: ADMA may be suggested as an acceptable substitute for

connective tissue graft to achieve predictable root coverage
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ADD A FOOTER 74
Abstract
• The aim of this study was to analyze the efficacy of CAF in combination
with ADM in the treatment of gingival recession.

• Results: Ten randomized controlled trials were identified, including six studies that
compared CAFs with ADM and CAFs using connective tissue grafting (CTG) and four
studies that compared CAFs with or without ADM. No statistically significant
differences were found between the use of ADM and CTG, whereas statistically
significant differences were found between groups in which ADM and CAF were
combined and groups that underwent CAF alone with regard to recession coverage,
CAL, and KT. The combination of CAF with an ADM allograft achieved more favorable
recession coverage and recovery of CAL and KT than CAF alone.

• Conclusions: The results from the ADM and CTG groups suggest that
both procedures may be equally effective in clinical practice. Given the
limitations of this study, further investigation is needed to clarify the
effectiveness of ADM and CAF in clinical
75 practice.
References
• Felipe et al. Comparison of Two Surgical Procedures for Use of the
Acellular Dermal Matrix Graft in the Treatment of Gingival Recessions: A
Randomized Controlled Clinical Study. J Periodontol. July 2007.
• Fosnot et al. Acellular Dermal Matrix: General Principles for the Plastic
Surgeon. Aesthetic Surgery Journal 31(7S) 5S–12S. 2011.
• Gapski et al. Acellular Dermal Matrix for Mucogingival Surgery: A Meta-
Analysis. J Periodontol. November 2005;76;11.
• Wei et al. Acellular Dermal Matrix Allografts to Achieve Increased
Attached Gingiva. Part 1. A Clinical Study. J Periodontol. August 2000.
• Carranza’s clinical periodontology. Carranza et al. 12th edition. 2015.
• Carranza et al. Newman and Carranza’s clinical periodontology. 13th
edition. 2019.
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Thank you

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From carranza
• Commercial preparation of this tissue includes a multistep process
that removes the epidermis and the cells that can lead to tissue
rejection and graft failure without damaging the matrix. The
remaining ADM consists of a nondenatured three-dimensional
arrangement of intact collagen fibers, ground substance, and
vascular channels
• Two surgical techniques are suggested for the use of ADM in
treating gingival recession. Each is a coronally positioned pouch
method. The first is the alternate papilla tunnel (APT) method, and
the second is the papilla retention pouch (PRP) method
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• It produces a thicker marginal tissue and has a higher percentage
of root coverage than a coronally advanced flap alone
• The use of AlloDerm under a coronally advanced flap extends the
application of the most aesthetic procedure in root coverage.

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 VIDEO SLIDE

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