MINIMALLY INVASIVE SURGERY & ACELLULAR

DERMAL MATRIX TO CORRECT

GINGIVAL RECESSION

EDWARD GOTTESMAN, DDSDIPLOMATE, AMERICAN BOARD OF PERIODONTOLOGY

CLINICAL ASSISTANT PROFESSOR,

SCHOOL OF DENTAL MEDICINE @ STONY BROOK

•I am receiving an honorarium from BIOHORIZONS

•I have no financial interests in any of the materials used or the procedures being

presented

•the patient cases to be presented are all from my private practice in NYC

DISCLOSURE

•provide an evidence based review of the tunneling technique in the context of

minimally invasive surgery combined with acellular dermal matrix to achieve

predictable root coverage for multiple teeth with gingival recession.

OBJECTIVE

GINGIVAL RECESSION DEFINED

• an acquired deformity of the gingival marginal tissue displaced

apical to the cementoenamel (CEJ), resulting in exposed root

surface and loss of attached gingiva

• 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

• 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

GINGIVAL RECESSION CLASSIFICATION

GINGIVAL RECESSION PREVALENCE• common in the US: 23.8 million people (22.5%) in the U.S. above the age of 29 have ≥3

mm gingival recession

• prevalence, extent and severity increases with age

• males > females

• blacks > whites and Mexican Americans

• more prevalent and severe at facial surfaces of teeth compared to mesial surfaces

• most prevalent for maxillary first molars and mandibular central incisors

58

41

22

136

0

15

30

45

60

75

1 2 3 4 5

Prevalence of Recession % In US >30

18

30

4046

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

RECESSION PREVALENCE AND AGE

⬆︎ RECESSION PREVALENCE ➤⬆︎TX DEMAND

• since sites with previous recession are prone to additional recession, the

aging U.S. population may have a large number of sites that may need

root coverage grafting

GINGIVAL RECESSION RISK FACTORS

• areas with previous recession

• thin marginal gingiva phenotype (biotype)(Müller and Eger)

• inflammation, poor OH, improper OH habits, tooth position

and root shape (Albander et al.)

GINGIVAL RECESSION RISK INDICATORS

• aging

• smoking

• presence of supragingival

calculus

IDENTIFY ETIOLOGY RECESSION• inflammation (Novaes)

• Toothbrushing trauma

(Wennström)

• faulty flossing techniques

(clefts)

• factitial injury

• abberant frenum attachment

• iatrogenic dentistry

• occlusal interferences?

ANATOMIC FACTORS THAT

PREDISPOSE TO RECESSION

• “thin” gingival biotype (Baldi)

• proclination or rotation of teeth (Nyman)

• presence of bone fenestration or dehiscence (Lang

and Löe)

“I WANT COMPLETE ROOT COVERAGE!”

• Complete root coverage is the most important outcome in

patients with esthetic requests (Consensus report, 1996)

GOAL OF ROOT COVERAGE

• Rasperini concluded that the goal of root coverage is

complete resolution of the recession defect and an optimal

esthetic outcome

HOW IS RECESSION MEASURED

• identify CEJ

• distance from CEJ to the most apical extension of GM

PATIENT PERCEIVES ESTHETIC FAILURE

• very often the most coronal millimeter of the root exposure is the

only visible part of the recession when the patient smiles;

therefore, its persistence after therapy, even of a shallow

recession, may be considered an esthetic failure

DEFINE CEJ - LEVEL EXPECTATIONS

ADDITIONAL GOALS OF ROOT COVERAGE

• thin biotype ⤼ thicker biotype ⇒↓risk of further recession

• ↓ root sensitivity

• ↓ risk of root caries

• ↑ interproximal papillary height (volume)

↓PREDICTABILITY VS. ↑SUCCESS OF ROOT COVERAGE

• root coverage procedures are successful but not very predictable

• Success of root coverage procedures is related to the average percentage of

root coverage achieved, (≈86% for ADM, Giannobile W, et al.) whereas

predictability describes the percentage of the treated teeth in which complete

root coverage is achieved.

CRITICAL RECESSION <4MM

• better results in terms of percentages of complete and mean root

coverage can be expected when baseline recession defects are <4 mm

+ FGG: Coronal advancement of previously placed free

gingival grafts

+ SECT graft: Gingival grafting performed in conjunction with

flap

advancement for submersion (multiple variations)

+ biomaterials (ADM, EMP, Platelet rich fibrin membrane,

collagen matrix)

+ Guided Tissue Regeneration (GTR)

• Tissue engineering (i.e. cell based therapies in matrices)

THERAPEUTIC APPROACHES TO ROOT COVERAGE

FOR GINGIVAL RECESSION DEFECTS• FGG: Gingival grafts placed directly over the root

surface

• Pedical flap (repositioning of “adjacent” attached

gingiva)

• lateral sliding flap

• double papilla flap

• semilunar coronally repositioned flap

• the subepithelial connective tissue graft technique is considered to be the gold

standard for gingival recession therapy

• however, given the reluctance of patients to have additional surgical sites,

potentially greater patient discomfort, limitation of adequate donor tissue, and

increased surgical time we have turned to allograft substitutes

IS SCTG STILL THE “GOLD STANDARD”?

DISADVANTAGES OF SCTG• requires second surgical site

• longer procedure

• increased risk of post-op complications (ie.

discomfort)

• limited available donor supply therefore

limiting the number of teeth that can be treated

in a single surgery

• decreased patient acceptance

CURRENT GRAFT PRODUCTS AVAILABLE FOR ROOT COVERAGE

• LifeCell - Alloderm® (Allograft)

• Geistlich - Mucograft® (Xenograft)

• Densply - Perioderm® (Allograft)

• Zimmer - Puros® Dermis

(Allograft)

WHAT IS ADMG ?

• obtained from a human donor skin tissue process that removes its cell components

while preserving the remaining bioactive components and the extracellular matrix,

which is subsequently freeze dried

• avascular and acellular material (its a non-vital structure)

• exhibits undamaged collagen and elastin matrices that function as a scaffold to allow

ingrowth by host tissues

• Scarano and coworkers microscopically analyzed healing ADM graft sites

using graft specimens before the surgery and 4 min and 1, 2, 3, 4, 6, and 10

weeks after grafting

• The 6-month outcome of this study revealed that the amount of root

coverage achieved with ADM and a tunnel approach to treat multiple Miller

Class I recessions was 100%.

• the periodontal tissues exhibited a biotype conversion with overall increase in

thickness

• ADM was substituted and completely re-epithelialized in 10 weeks according

to histologic and ultrastructural results

ADM GRAFTS HEAL ⩬ AUTOGENOUS GRAFTS

ADM ⩬ SCTG FOR MEASURED OUTCOMES

• In 2005, a meta-analysis by Wang et al. of eight randomly controlled clinical

trials showed no statistically significant differences between groups (ADM and

CTG) for measured outcomes:

• recession coverage

• keratinized tissue (KT)

• probing depth (PD)

• clinical attachment levels

ADVANTAGES OF ADMG• safe and biocompatible (equivalent to gold standard SCTG)

• unlimited supply, so multiple sites can therefore be treated with a single

procedure (sextant, quadrant, full arch) avoiding second surgical site - less

morbidity

• excellent tissue color match obtained as the graft is repopulated with the

recipient’s cells

• good track record with favorable outcomes reported in the literature*

DISADVANTAGES OF ADMG

• Pini Prato et al. reported that the graft must remain completely

covered (need primary closure); avoiding graft exposure is

essential when an avascular graft such as ADMG is used

• requires tensionless flap to avoid graft exposure during post-

operative period to enhance root coverage outcome

ANATOMIC FACTORS AFFECTING ROOT COVERAGE SUCCESS

• Miller class and interdental papilla height (Rasperini et al.)

• a thin buccal plate provides less a blood supply to nourish the overlying flap as well as graft

(Ciancio)

• labial protrusions of roots (tooth position) combined with a thin bony plate are predisposing factors

for fenestration and dehiscence, which can also complicate the outcome of recession coverage

therapy (Pandit et al. and Hirschfeld)

• frenulum insertions

vestibular depth

SURGICAL FACTORS AFFECTING ROOT COVERAGE

SUCCESS1. post-suturing positioning of the flap coronal to the CEJ may contribute to better outcomes (Pini Prato et al. and Zuccelli et al.)

2. flap thickness ⇡ root coverage (Wang & Hwang, Baldi et al. and many others)

• thick gingival tissues eases manipulation, maintains vascularity, and promotes wound healing during and after surgery

3. ↑ flap tension ⇣ root coverage (Pini Prato and Tinti)

4. ↑ flap dimension when performing root coverage for multiple rather than a single tooth, the larger flap dimension may favor

complete root coverage because of increased stability (Zuccelli)

5. extending the flap margin to uninvolved neighboring teeth may blend things in more naturally (Zuccelli et al.)

6. Verical incisons according to Zuccelli and many others may have a true negative impact on the clinical and esthetic outcomes of a

root-coverage surgical procedure, however the negative impact on the clinical and esthetic outcomes of a root-coverage surgical

procedure has not been evaluated.

• VRIs could damage the lateral blood supply to the flap and might result in unaesthetic visible white scars (AKA

keloids) (Zucchelli & Desanctis)

• greater incidence of swelling, pain, and bleeding: poorer patient morbidity of the patients treated with VRIs

(Zucchelli & Desanctis)

• VRI’s to coronally advance a flap may reduce blood circulation at the graft site

• lateral and papillary areas may play an important role in flap perfusion and graft revascularization

• the greater surgical time to complete the CAF with VRIs may be responsible for greater incidence of swelling

and pain in patients treated with this surgical approachn (Coretellini et al.)

AVOID VERTICAL RELEASING INCISIONS!

FLAP DESIGN FOR GOOD BLOOD SUPPLY • Mörmann and Ciancio investigated changes in gingival and alveolar mucosa microcirculation following different

surgical incisions or flaps in a fluorescein angiographic study

• they determined that when designing flaps with vertical releasing incisions:

1. flaps should be broad enough at their base to include major gingival vessels

2. a flap's length to width ratio should not exceed 2:1

3. minimal tension should be produced by suturing techniques and the tissue should be managed gently during the

surgical procedure

4. partial thickness flap preparations to cover avascular areas should not be too thin so that more blood vessels

are included in them

5. the apical portion of periodontal flaps should be full thickness when possible

• overcorrection can decrease post-operatory exposure of non-vital

allografts such as ADMG

• controlling the exact position of ADMG, 1 mm apical to the CEJ,

after the flap is sutured may be difficult, but the position before the

flap is sutured is a valuable prerequisite to achieve a better root

coverage outcome

OVERCORRECTION FOR SUCCESSFUL

ROOT COVERAGE

MELISSACLASS I-II

ANDREACLASS I

SHERRYCLASS II-III

PERINCLASS II-III

MICHELLECLASS III-IV

DAPHNECLASS III-IV

DAPHNE

MICHELLE

PERINE

MELISSA

ANDREA

SHERRY

thank you for your

attention!