Successful root coverage for single or multiple teeth can be achieved with a minimally invasive tunneling technique and acellular derail matrix (Alloderm®). Presentation given by Dr. Edward Gottesman, periodontist in New York, New York at the American Academy of Periondontology Meeting in San Francisco in September, 2014. Visit http://perionyc.com for more information.

1. MINIMALLY INVASIVE SURGERY & ACELLULAR
DERMAL MATRIX TO CORRECT
GINGIVAL RECESSION
EDWARD GOTTESMAN, DDS
DIPLOMATE, AMERICAN BOARD OF PERIODONTOLOGY
CLINICAL ASSISTANT PROFESSOR,
SCHOOL OF DENTAL MEDICINE @ STONY BROOK

2. •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

3. •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

4. 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

5. • 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
• 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

6. 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

7. 58
41
22
13
6
0
15
30
45
60
75
1 2 3 4 5
Prevalence of Recession % In US >30
18
30
40
46
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

8. ⬆︎ 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

9. 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.)

10. GINGIVAL RECESSION RISK INDICATORS
• aging
• smoking
• presence of supragingival
calculus

11. IDENTIFY ETIOLOGY RECESSION
• inflammation (Novaes)
• Toothbrushing trauma
(Wennström)
• faulty flossing techniques
(clefts)
• factitial injury
• abberant frenum attachment
• iatrogenic dentistry

12. 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)

13. “I WANT COMPLETE ROOT COVERAGE!”
• Complete root coverage is the most important outcome in
patients with esthetic requests (Consensus report, 1996)

14. GOAL OF ROOT COVERAGE
• Rasperini concluded that the goal of root coverage is
complete resolution of the recession defect and an optimal
esthetic outcome

15. HOW IS RECESSION MEASURED
• identify CEJ
• distance from CEJ to the most apical extension of GM

16. 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

17. DEFINE CEJ - LEVEL EXPECTATIONS

18. ADDITIONAL GOALS OF ROOT COVERAGE
• thin biotype ⤼ thicker biotype ⇒↓risk of further recession
• ↓ root sensitivity
• ↓ risk of root caries
• ↑ interproximal papillary height (volume)

19. ↓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.

20. 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

21. + 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)
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

22. • 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”?

23. 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

24. CURRENT GRAFT PRODUCTS AVAILABLE FOR ROOT COVERAGE
• LifeCell - Alloderm® (Allograft)
• Geistlich - Mucograft® (Xenograft)
• Densply - Perioderm® (Allograft)
• Zimmer - Puros® Dermis
(Allograft)

25. 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

26. • 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
ADM GRAFTS HEAL ⩬ AUTOGENOUS GRAFTS

27. 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

28. 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*

29. 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

30. 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

31. 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

32. • 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!

33. 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

34. • 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

35. MELISSA
CLASS I-II
ANDREA
CLASS I
SHERRY
CLASS II-III
PERIN
CLASS II-III
MICHELLE
CLASS III-IV
DAPHNE
CLASS III-IV

36. DAPHNE

54. MICHELLE

78. PERINE

86. MELISSA

95. ANDREA

111. SHERRY

126. thank you for your
attention!