an alternative to autogenous connective tissue grafting for root coverage

An Alternative to Autogenous Connective Tissue Grafting for

Root Coverage

Glen Head Study Club 2007

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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

136

0

10

20

30

40

50

60

70

1 2 3 4 5

Recession Prevalence (%) by Age

18

30

4046

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 (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”

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)



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



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

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)




• When adequate adjacent gingiva exists, repositioning it over the denuded root surface provides the most esthetic result!





3. Gingival grafts placed directly over the root surface

Cicatrization of the Free Connective Tissue Graft

Cicatrization: To heal or become healed by the formation of scar tissue.


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

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.


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.


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.


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.


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.

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• 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%

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– Urology – bladder slings &

pelvic floor reconstruction– Orthopedics – rotator cuff

repair & periosteal replacement– Hernia repair

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 MatrixUnique 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.

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

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

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

#1/2 Orban DE Knife, ModifiedModified 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.

Allen Micro Periosteal ElevatorDesigned 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, AnteriorSimilar 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



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


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.


8. Re-hydrate in two consecutive 10-20 minute sterile saline baths.

9. Remove paper backing from AlloDerm between first and second baths.


8. ADM is secured against the buccal root surface(s) with 7.0 Polypropylene interupted sling sutures with all knots placed on palatal margins


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 )

2. Doxycyclin Hyclate (ie. Peridex®)

3. 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”

2 MONTH POST-OP

2 months

post-op

Initial

CLINICAL CASE I

CLINICAL CASE II

CLINICAL CASE III

CASE IV

CASE V

CASE VI

12/29/06

1/18/07

2/5/07

5/14/07

8/27/07

8/27/07

12/29/06PRE-OP

POST-OP

8

MONTHS

THANK YOU FOR YOUR ATTENTION

an alternative to autogenous connective tissue grafting for root coverage

Healthcare

gingival recession

root coverage procedures

recession prevalence

additional recession

recession increase

previous recession

future recession

recession defects