|Year : 2019 | Volume
| Issue : 6 | Page : 584-588
Root coverage stability with acellular dermal matrix in multiple gingival recessions in esthetic zone: A clinical case report with 12-year follow-up
Ísis De Fátima Balderrama1, Rafael Ferreira1, Daniel Romeu Benchimol Rezende2, Ana Lúcia Raphaelli Nahás Nogueira2, Sebastião Luiz Aguiar Greghi1, Mariana Schutzer Ragghianti Zangrando1
1 Department of Prosthodontics and Periodontics, Division of Periodontics, Bauru School of Dentistry, University of São Paulo, Bauru, São Paulo, Brazil
2 Society for the Social Promotion of Cleft Lip and Palate Patients, Bauru, São Paulo, Brazil
|Date of Submission||11-Sep-2018|
|Date of Acceptance||17-Dec-2018|
|Date of Web Publication||27-Nov-2019|
Ísis De Fátima Balderrama
Al. Dr. Octávio Pinheiro Brisolla 9-75, Department of Prosthodontics and Periodontics, Division of Periodontics, Bauru School of Dentistry, University of São Paulo, Bauru, São Paulo
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The importance of surgical intervention for the maintenance of long-term results by root coverage of multiple gingival recessions in an esthetic area treated with a tissue substitute (acellular dermal matrix [ADM]-Alloderm®) is widely required. The present case report highlights the effectiveness of the ADM for the treatment of multiple recession defects in a female patient with Class I and II gingival recession in relation to maxillary anterior associated with esthetics and dentin hypersensitivity demands. The root coverage rate for the anterior area showed greater value with 70% of coverage; at 90 days and 2 and 12 years of follow-up, it showed 70.5%, 79%, and 77%, respectively. Conversely, for the posterior area, these rates were 68.5%, 63%, and 57% for the same follow-up periods. Results regarding gain of keratinized tissue demonstrated superior values for the anterior area, namely 3.92, 3.34 and 3.22 mm at 90 days and 2 and 12 years. These values for the posterior area were 0.54 mm, 2.41, and 1.87 mm, respectively. These findings suggest that the tissue substitute Alloderm® showed excellent long-term results for areas of multiple recessions, providing root coverage and stability of keratinized tissue gain. After this long period of evaluation, some local factors associated with recurrence of gingival recessions were detected, and a lack of proper periodontal maintenance care was observed. However, esthetic and functional outcomes achieved with surgical procedure were maintained.
Keywords: Acellular dermal matrix, mucogingival surgery, recession, root coverage
|How to cite this article:|
Balderrama &D, Ferreira R, Rezende DR, Nogueira AL, Greghi SL, Zangrando MS. Root coverage stability with acellular dermal matrix in multiple gingival recessions in esthetic zone: A clinical case report with 12-year follow-up. J Indian Soc Periodontol 2019;23:584-8
|How to cite this URL:|
Balderrama &D, Ferreira R, Rezende DR, Nogueira AL, Greghi SL, Zangrando MS. Root coverage stability with acellular dermal matrix in multiple gingival recessions in esthetic zone: A clinical case report with 12-year follow-up. J Indian Soc Periodontol [serial online] 2019 [cited 2019 Dec 11];23:584-8. Available from: http://www.jisponline.com/text.asp?2019/23/6/584/263383
| Introduction|| |
Gingival recession is defined as an apical displacement of the gingival margin in relation to the cementoenamel junction (CEJ), with high population prevalence which may cause esthetic impairment, dentin hypersensitivity, and root caries. Among the therapeutic options for root coverage, the subepithelial connective tissue graft (SCTG) associated with coronally positioned flap (SCTG) is described as gold standard treatment because of superior clinical outcomes and predictability., However, SCTG presents disadvantage associated with a second surgical area, usually the palatal donor site, leading to increased postoperative morbidity.
The aim of SCTG and tissue substitutes, such as the acellular dermal matrix (ADM), is to obtain root coverage and restore the esthetics, as well as correct positioning and stability of the gingival margin. After surgery, with recovery of the quantity and quality of keratinized tissue around the teeth, the area demonstrates periodontal health with stability of the gingival margin (avoiding the progression of gingival recession). Furthermore, an adequate width and thickness of gingiva is related to the maintenance of clinical results and periodontal homeostasis, toward the activity of the dental biofilm. As an alternative to the use of SCTG, tissue substitutes such as ADM offer unlimited material and eliminate the approach of donor areas.
ADM is a tissue substitute obtained from a freeze-drying process of human skin in which the epidermis is removed while preserving the elements of acellular tissue matrix that allow cell migration and revascularization (when adapted to the receptor bed). In periodontics, the first clinical case using ADM was published in 1994. This material can be used to increase the keratinized tissue width, to modify the periodontal biotype, showing similar effectiveness as SCTG. Some studies have shown similar results for SCTG and ADM regarding the gain of keratinized mucosa width,, and root coverage rates.,,,,
However, other studies reported greater gain of keratinized tissue using SCTG.,,, The results of a systematic review with meta-analysis showed that tissue substitutes, for example, ADM, produced significantly better esthetic results, with preference by patients. Moreover, ADM is a safe procedure and can be compared to autogenous grafts (free gingival graft) in the gain of keratinized tissue.
Limited case reports using ADM with long-term follow-up are described in the literature. Only two case reports are available, which suggested satisfactory root coverage with ADM and the presence of “creeping attachment.” Therefore, the aim of this article was to describe clinical outcomes with 12-year follow-up of root coverage in esthetic area involving multiple gingival recessions performed with ADM (Alloderm®). Furthermore, this case evidenced the importance of surgically restoring the physiological architecture of periodontal tissues for the long-term stability of esthetic outcomes, even without adequate maintenance care.
| Case Report|| |
Relevant aspects for dental care procedure
A Caucasoid female patient, aged 21 years [Figure 1]a, presented to the periodontics clinic, with the main complaint of poor esthetic condition and dentin hypersensitivity due to multiple Miller Class I and II gingival recessions [Figure 1]b, [Figure 1]c, [Figure 1]d. The gingival recessions were associated with thin gingival biotype and history of orthodontic therapy as well as traumatic brushing.
|Figure 1: (a) patient smile; (b) Panoramic intra-oral view showing multiple recessions; (c) Multiple recessions from the buccal side (right side); (d) Multiple recessions from the buccal side (left side)|
Click here to view
Treatment and intervention: Surgical procedure
Initially, the patient was submitted to scaling and root planing, oral hygiene instructions, and occlusal adjustments. Instructions to use brush with ultra-soft bristles and a low abrasive dentifrice were made. Initially, treatment with SCTG associated with coronally advanced flap was proposed. However, the patient refused a bilateral palatal approach to remove sufficient quantity of tissue. As a result, the proposed procedure was the use of a tissue substitute, the ADM (AlloDerm®-LifeCell-The Woodlands, TX) associated with coronally advanced flap involving maxillary incisors, canines, and premolars [Figure 2]. The surgical technique was performed by modified interproximal incisions in the papilla (surgical papilla design) and marginal intrasulcular incisions. The anatomical interproximal papilla was de-epithelialized for posterior accommodation of the flap when coronally displaced. The partial-thickness flap surpassed the mucogingival junction acquiring a passive coronal mobility of the flap when coronally positioned. Regularization of the root surfaces was performed using a conical diamond bur at high speed with constant irrigation [Figure 2]b. Biomodification of the root was performed by root scaling with Gracey manual curettes [Figure 2]c followed by conditioning [Figure 2]d with citric acid and tetracycline (pH 1) applied for 3 min.
|Figure 2: Sequence of the surgical procedure to root coverage performed using acellular dermal matrix; (a) partial thickness flap performed for surgical area; (b) Regularization of the root surface (conical diamond bur); (c) Scaling and root planing with manual curettes; (d) Conditioning with citric acid and tetracycline (pH 1) for 3 min; (e) Acellular dermal matrix (Alloderm®) (f) Adaptation of the acellular dermal matrix on the receptor site; (g) Flap coronally positioned with interrupted absorbable sutures (Vicryl 4.0)|
Click here to view
The ADM (Alloderm®-LifeCell-The Woodlands, TX, USA) was adapted according to the shape of width and length of the receptor site [Figure 2]e. According to the manufacturer's instructions, before adapted at receptor site, the matrix should be hydrated by a duplicate cleaning process with sterile saline for at least 10 min. After that, matrix was stabilized at the CEJ [Figure 2]f, and the flap was coronally positioned covering the entire matrix and stabilized by interrupted absorbable sutures [Figure 2]g (Vycril 4.0) above the CEJ.
The patient received postoperative instructions and was advised to use antibiotic (amoxicillin 500 mg every 8 h for 7 days) and anti-inflammatory (nimesulide 100 mg every 12 h for 3 days), as well as mouthwashes with 0.12% chlorhexidine gluconate (2× per day for 10 days), avoiding brushing and flossing in the region during the postoperative period.
The postoperative follow-up and maintenance control of the patient were performed weekly for 90 days; after that period, the patient did not return for personal reasons. Her control was eventually done only 2 and 12 years after the surgical intervention.
Follow-up and outcomes
The surgical area presented slight exposure of the matrix associated with localized inflammatory areas after 15 days [Figure 3]a, [Figure 3]b, [Figure 3]c. After 2-year follow-up, the area showed an expressive gain of gingival width, complete root coverage in the anterior area and partial coverage for premolars. A substantial improvement in root coverage (“creeping attachment”) was demonstrated with satisfactory gingival tissue texture and color [Figure 3]d, [Figure 3]e, [Figure 3]f. At the 12-year follow-up, minor areas of relapse of gingival recession and some interproximal tissue loss were observed, but in general with stability of the outcomes achieved [Figure 3]g, [Figure 3]h, [Figure 3]i. The patient reported traumatic brushing and restorative procedures during this period [Figure 3]g, [Figure 3]h, [Figure 3]i. In addition, the patient did not attend the maintenance care controls after 90 days postoperatively, only 2-and 12-year follow-ups after the surgical procedure, not reporting the reasons for missing the recalls.
|Figure 3: Intra-oral photographs (right, frontal, and left sides) during periods of; (a-c) 14 days; (d-f) 2 years; (g-i) 12 years of follow-up|
Click here to view
[Table 1] and [Table 2] present the clinical results at baseline and at 2- and 12-year follow-up. A formula to access the percentage of root coverage (% RC) and gain or loss of keratinized mucosa (% KM) was adopted according to Zucchelli and De Sanctis.
|Table 1: Clinical parameters (Mean±SD) at baseline and at different periods of evaluation according to surgical sites (anterior region, posterior region and surgical area)|
Click here to view
|Table 2: Results (% and mean) of root coverage and gain of KT at baseline and at different periods of evaluation according to surgical sites (anterior region, posterior region and surgical area)|
Click here to view
This case report comprised the use of ADM associated with coronally advanced flap, and the results evidenced root coverage of the multiple gingival recessions with stability of the clinical outcomes achieved. At 12-year follow-up, the root coverage remained satisfactory, despite small areas of interproximal loss and small increase in gingival recession for posterior upper teeth on the right side [Figure 4].
|Figure 4: Sequence of longitudinal control of root coverage with acellular dermal matrix at different periods: (a) at baseline; (b) 90 days; (c) 2 years; (d) 12 years after root coverage surgery|
Click here to view
| Discussion|| |
ADM associated with coronally advanced flap demonstrated satisfactory long-term outcomes for root coverage of multiple gingival recessions in esthetic area, resulting in a root coverage rate of 77%. In addition, there was stability of the outcomes achieved, evidencing the importance to restore gingival architecture for the maintenance of periodontal health. The anterior area (incisors and canines) showed superior root coverage rate and keratinized tissue gain (92%) compared to the posterior area (70.5%) after 12-year follow-up.
Only two studies investigated ADM with more than 10 years of follow-up., Both studies showed similar clinical outcomes as the present case report with “creeping attachment” and stable root coverage in the upper anterior area after 10-year follow-up and for lower anterior area after 12-year follow-up. However, these studies do not present a detailed description of the clinical measurements in millimeters and root coverage percentage, as described in our study.
Periodontal plastic surgeries associated with ADM for root coverage and keratinized tissue gain are described in the literature with positive outcomes., The use of ADM, besides minimizing morbidity by eliminating a second surgical area, allows intervention in extensive surgical areas in a single operative procedure due to unlimited amount of biomaterial. The advantages of ADM are also related to uniform thickness and easy handling; enables cell repopulation, rapid revascularization, minimal inflammation, and integration capacity to the host tissues., However, ADM presents some disadvantages, such as additional financial cost and longer healing period for root coverage surgeries.
A randomized clinical trial evaluating ADM and SCTG showed, by patient-centered outcomes, the superiority of ADM, because it was related with less pain and postoperative discomfort, despite the additional financial cost for the patient. The literature presents studies,,, comparing surgical interventions between SCTG and ADM, demonstrating conclusive results that the root coverage rates were similar, with slight superiority for SCTG. However, other studies,,, concluded that SCTG obtained minor percentage when compared to ADM. Conversely, the findings of keratinized tissue gain in other studies,,, showed greater gains for SCTG compared to ADM, and other reports,,,, did not find differences between SCTG and ADM for keratinized tissue gains.
It should be considered that, even though SCTG is considered gold standard when compared to ADM or other tissue substitutes for root coverage, the option to use a tissue substitute has superior acceptance by the patient. In our case report, the patient refused surgery on the palate. Furthermore, considering the presence of multiple gingival recessions, it was possible to approach a large esthetic area in a single surgical procedure.
At 12-year follow-up, the present case exhibited slight recurrence and interproximal tissue loss. These clinical outcomes are satisfactory, despite traumatic factors (brushing and restorative procedures) and patient nonattendance to periodontal maintenance care. This fact was justified by the reestablishment of satisfactory gingival architecture with adequate periodontal biotype. Current evidence reinforces the importance to perform surgery for root coverage because gingival recessions can progress over time, even in individuals with good plaque control.
Surgical procedures for root coverage may promote change in the quality and quantity of keratinized tissue, i.e., altering the biotype. These clinical gains prevent the relapse of gingival recession in the long term and facilitate oral hygiene with greater comfort during dental brushing. This highlights the importance of ADM to promote changes in the quantity and quality of keratinized tissue to maintain the obtained esthetic outcomes, but also for periodontal health, as observed in the present case.
| Conclusion|| |
The present case report with 12-year follow-up demonstrated that the use of an ADM associated with coronally advanced flap is a viable and satisfactory option for root coverage procedure of multiple gingival recessions in esthetic area. In addition, this case demonstrated stability of outcomes over time, despite the lack of ideal periodontal maintenance care, demonstrating the importance of surgical restoration of a suitable periodontal architecture.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Academy of Periodontology. Glossary of Periodontal Terms. Vol. 4. American Academy of Periodontology; 2001. p. 56.
Stoner JE, Mazdyasna S. Gingival recession in the lower incisor region of 15-year-old subjects. J Periodontol 1980;51:74-6.
Addy M, Mostafa P, Newcombe RG. Dentine hypersensitivity: The distribution of recession, sensitivity and plaque. J Dent 1987;15:242-8.
Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20.
Chambrone LT. Periodontal soft tissue root coverage: A systematic review from the AAP Regeneration Workhop. J Periodontol 2015;86:344-87.
Wessel JR, Tatakis DN. Patient outcomes following subepithelial connective tissue graft and free gingival graft procedures. J Periodontol 2008;79:425-30.
Chambrone L, Tatakis DN. Long-term outcomes of untreated buccal gingival recessions: A systematic review and meta-analysis. J Periodontol 2016;87:796-808.
Lagos ML, Sant'ana AC, Greghi SL, Passanezi E. Keratinized gingiva determines a homeostatic behavior of gingival sulcus through transudation of gingival crevice fluid. Int J Dent 2011;2011:953135.
Kennedy JE, Bird WC, Palcanis KG, Dorfman HS. A longitudinal evaluation of varying widths of attached gingiva. J Clin Periodontol 1985;12:667-75.
Gapski R, Parks CA, Wang HL. Acellular dermal matrix for mucogingival surgery: A meta-analysis. J Periodontol 2005;76:1814-22.
Zucchelli G, Mounssif I. Periodontal plastic surgery. Periodontol 2000 2015;68:333-68.
Lang NP, Loe H. The relationship between the width of keratinized gingiva and gingival health. J Periodont Res 1972;43:623-7.
Siverstein LH, Callan DP. An acellular dermal matrix allograft substitute for palatal donor tissue Postgrad Dent 1996;3:14-21.
Novaes AB Jr., Pontes CC, Souza SL, Grisi MF, Taba M Jr. The use of acellular dermal matrix allograft for the elimination of gingival melanin pigmentation: Case presentation with 2 years of follow-up. Pract Proced Aesthet Dent 2002;14:619-23.
Andrade PF, Felipe ME, Novaes AB Jr. Souza SL, Taba M Jr., Palioto DB, et al.
Comparison between two surgical techniques for root coverage with an acellular dermal matrix graft. J Clin Periodontol 2008;35:263-9.
Henderson RD, Greenwell H, Drisko C, Regennitter FJ, Lamb JW, Mehlbauer MJ, et al.
Predictable multiple site root coverage using an acellular dermal matrix allograft. J Periodontol 2001;72:571-82.
de Souza SL, Novaes AB Jr. Grisi DC, Taba M Jr. Grisi MF, de Andrade PF, et al.
Comparative clinical study of a subepithelial connective tissue graft and acellular dermal matrix graft for the treatment of gingival recessions: Six- to 12-month changes. J Int Acad Periodontol 2008;10:87-94.
Novaes AB Jr., Grisi DC, Molina GO, Souza SL, Taba M Jr., Grisi MF, et al.
Comparative 6-month clinical study of a subepithelial connective tissue graft and acellular dermal matrix graft for the treatment of gingival recession. J Periodontol 2001;72:1477-84.
Ayub LG, Ramos UD, Reino DM, Grisi MF, Taba M Jr., Souza SL, et al.
Amodified surgical technique for root coverage with an allograft: A 12-month randomized clinical trial. J Periodontol 2014;85:1529-36.
Thomas LJ, Emmadi P, Thyagarajan R, Namasivayam A. A comparative clinical study of the efficacy of subepithelial connective tissue graft and acellular dermal matrix graft in root coverage: 6-month follow-up observation. J Indian Soc Periodontol 2013;17:478-83.
] [Full text]
Harris RJ. A comparative study of root coverage obtained with an acellular dermal matrix versus a connective tissue graft: Results of 107 recession defects in 50 consecutively treated patients. Int J Periodontics Restorative Dent 2000;20:51-9.
Haghighati F, Mousavi M, Moslemi N, Kebria MM, Golestan B. A comparative study of two root-coverage techniques with regard to interdental papilla dimension as a prognostic factor. Int J Periodontics Restorative Dent 2009;29:179-89.
Aichelmann-Reidy ME, Yukna RA, Evans GH, Nasr HF, Mayer ET. Clinical evaluation of acellular allograft dermis for the treatment of human gingival recession. J Periodontol 2001;72:998-1005.
Paolantonio M, Dolci M, Esposito P, D'Archivio D, Lisanti L, Di Luccio A, et al.
Subpedicle acellular dermal matrix graft and autogenous connective tissue graft in the treatment of gingival recessions: A comparative 1-year clinical study. J Periodontol 2002;73:1299-307.
Tal H, Moses O, Zohar R, Meir H, Nemcovsky C. Root coverage of advanced gingival recession: A comparative study between acellular dermal matrix allograft and subepithelial connective tissue grafts. J Periodontol 2002;73:1405-11.
Bertl K, Melchard M, Pandis N, Müller-Kern M, Stavropoulos A. Soft tissue substitutes in non-root coverage procedures: A systematic review and meta-analysis. Clin Oral Investig 2017;21:505-18.
Santos A, Goumenos G, Pascual A, Nart J. Creeping attachment after 10 years of treatment of a gingival recession with acellular dermal matrix: A case report. Quintessence Int 2011;42:121-6.
Batista EL Jr., Goergen JE, Machado LL, Santayana de Lima EM. Unexpected soft tissue changes in response to root coverage using an acellular dermal matrix allograft: 12–year follow up. J Can Dent Assoc 2014;80:e66.
Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13.
Bell LA, Valluzzo TA, Garnick JJ, Pennel BM. The presence of “creeping attachment” in human gingiva. J Periodontol 1978;49:513-7.
Zucchelli G, De Sanctis M. Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol 2000;71:1506-14.
Koudale SB, Charde PA, Bhongade ML. A comparative clinical evaluation of acellular dermal matrix allograft and sub-epithelial connective tissue graft for the treatment of multiple gingival recessions. J Indian Soc Periodontol 2012;16:411-6.
] [Full text]
Tal H. Subgingival acellular dermal matrix allograft for the treatment of gingival recession: A case report. J Periodontol 1999;70:1118-24.
Silverstein LH, Gornstein RA, Callan DP. The similarities between an acellular dermal allograft and a palatal graft for tissue augmentation: A clinical case. Dent Today 1999;18:76-9.
Henderson RD, Drisko CH, Greenwell H. Root coverage using alloderm acellular dermal graft material. J Contemp Dent Pract 1999;1:24-30.
Goyal N, Gupta R, Pandit N, Dahiya P. Analysis of patient acceptance following treatment of Miller's class II gingival recession with acellular dermal matrix and connective tissue graft. J Indian Soc Periodontol 2014;18:352-6.
] [Full text]
Barros RR, Macedo GO, de Queiroz AC, Novaes AB Jr. A modified surgical flap for root coverage in association with grafting materials. J Esthet Restor Dent 2015;27:84-91.
Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: A systematic review from the AAP Regeneration Workshop. J Periodontol 2015;86:S8-51.
Kim DM, Neiva R. Periodontal soft tissue non-root coverage procedures: A systematic review from the AAP Regeneration Workshop. J Periodontol 2015;86:S56-72.
Agudio G, Nieri M, Rotundo R, Franceschi D, Cortellini P, Pini Prato GP, et al.
Periodontal conditions of sites treated with gingival-augmentation surgery compared to untreated contralateral homologous sites: A 10- to 27-year long-term study. J Periodontol 2009;80:1399-405.
Pini Prato GP, Baldi C, Nieri M, Franseschi D, Cortellini P, Clauser C, et al.
Coronally advanced flap: The post-surgical position of the gingival margin is an important factor for achieving complete root coverage. J Periodontol 2005;76:713-22.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]