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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 16  |  Issue : 2  |  Page : 81-88

Clinical evaluation of acellular dermal matrix allograft (Alloderm®) with coronally advanced flap in the treatment of multiple gingival recessions: A clinical study


1 Department of Periodontics, Sathyabama Dental College and Hospital, Chennai, Tamil Nadu, India
2 Dental Consultant, Periodontist at Dental Health Clinic, Bull Temple Road, Chamarajpet, Bangalore, Karnataka, India
3 Professor at Dayanand Sagar Dental College and Hospital, Bangalore, Karnataka, India
4 Department of Periodontics, Vishnu Dental College and Hospital, Bhimavaram, Andhra Pradesh, India

Date of Web Publication18-Jan-2018

Correspondence Address:
Gayathri Somasheker
Plot 67, Sindhu Heaven, F1 Block A, 22nd Street, Maxworth Nagar, S. Kolathur, Kovilambakkam, Chennai - 600 117, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajmhs.ajmhs_37_17

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  Abstract 


Aims: The purpose of this study was to clinically evaluate the efficacy of Alloderm® with the coronally positioned flap in the treatment of multiple gingival recessions and to assess the esthetic and hypersensitivity evaluation from patient's perspective using visual analog scale (VAS).
Subjects and Methods: A total of 10 systemically healthy male and female patients aged 18–50 years with Miller's class I and class II gingival recessions, who had dentin hypersensitivity and esthetic concern were selected for the study. Root coverage (RC) was done using coronally advanced flap with Alloderm®. Statistical Analysis: Descriptive statistical analysis was performed in the present study. Significance was assessed at 5% level of significance. Student's t-test was conducted to find the pairwise significance of the study parameters. Wilcoxon signed-rank test was used to find the significance of percentage of linear RC and percentage of volumetric RC (% of VRC) between 3 and 6 months. Results: A total 31 defects were treated with mean volumetric percentage RC (%RC) at 3 months of 35.21%. This remained the same at 6 months (P = 1.000). There was no statistically significant difference in the volumetric and Linear percentage of root coverage. Dentine hypersensitivity and esthetics were evaluated from patient's perspective using VAS ranging from a score of 0–10. Where 0 indicates very low and score of 10 indicates very high score. VAS indicated a decrease in the sensitivity after treatment. VAS mean score before treatment was 6.22 ± 0.83 with a mean score of 3.90, standard deviation (SD) of ± 1.37 after treatment and mean score of 5.10, SD of ± 0.57 for esthetic evaluation. Conclusions: The use of Alloderm® with coronally positioned flap provided a significant improvement in all the clinical parameters, but did not result in favorable outcome in terms of root coverage of facial gingival recessions of multiple adjacent teeth.

Keywords: Alloderm®, grafts, periodontal plastic surgery, root coverage


How to cite this article:
Somasheker G, Ramesh AV, Roopa K, Dwarakanath CD. Clinical evaluation of acellular dermal matrix allograft (Alloderm®) with coronally advanced flap in the treatment of multiple gingival recessions: A clinical study. Afr J Med Health Sci 2017;16:81-8

How to cite this URL:
Somasheker G, Ramesh AV, Roopa K, Dwarakanath CD. Clinical evaluation of acellular dermal matrix allograft (Alloderm®) with coronally advanced flap in the treatment of multiple gingival recessions: A clinical study. Afr J Med Health Sci [serial online] 2017 [cited 2018 Aug 18];16:81-8. Available from: http://www.ajmhs.org/text.asp?2017/16/2/81/223583




  Introduction Top


Obtaining predictable and aesthetic root coverage (RC) has become an important goal of periodontal therapy. In the recent years, periodontal plastic surgical procedures have seen spectacular advancement and technical improvement enabling the periodontist to provide quality treatment to their patients. Gingival recession is defined as the displacement of the marginal tissue apical to the cement-enamel junction (CEJ).[1]

Multiple gingival recessions may lead to hypersensitivity, root caries, and esthetics. These conditions can be associated with periodontal diseases or mechanical factors such as aggressive tooth brushing. The treatment of multiple gingival recessions includes esthetic demand, root hypersensitivity, enhancement of restorative outcomes, and prevention of progressive periodontal disease. Many different surgical procedures have been in use for obtaining root coverage (RC). Systematic reviews have demonstrated that among the techniques presently available, subepithelial connective tissue grafts, and coronally advanced flaps have the highest predictability in terms of RC. Most of these studies indicate that on an average, 70%–90% of RC has been obtained with these techniques.[2] However, these procedures have their limitations. While coronally advanced flap technique requires at least 3 mm of keratinized gingiva apical to the recession as a major prerequisite, the subepithelial, connective tissue graft not only needs surgery at two sites but also depends on the amount of tissue that can be harvested. Subepithelial connective tissue graft technique is also technique sensitive. One common problem for these procedures is the management of multiple adjacent recessions. The need of the day is a surgical procedure, which not only provides RC of multiple recessions in one attempt but also augments keratinized gingiva, increases clinical attachment level (CAL), and ensures an esthetically satisfying outcome.

AlloDerm ®(ADM) an acellular dermal matrix allograft [Figure 1], which has been in extensive use in general, orthopedic, urogenital surgeries, and in the rehabilitation of patients with burn injuries, has been thought to be one such material which could satisfy our needs of an ideal graft which has the ability to treat multiple adjacent gingival recessions, increase in width of keratinized gingiva (WKG), gain in CAL and avoiding harvesting tissue from a donor site, thereby eliminating morbidity and comparatively is less technique sensitive procedure.[3],[4] Hence, the present study was taken up to assess the clinical efficacy of ADM allograft (Alloderm ®) along with coronally advanced flap in the treatment of multiple gingival recessions.
Figure 1: Alloderm® graft

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  Subjects and Methods Top


Ten systemically healthy patients with multiple adjacent teeth facial gingival recessions of Miller's class I or class II recession, reporting to the Department of Periodontics, The Oxford Dental College, Hospital and Research Centre Bangalore, were recruited for the study. All selected patients had dentin hypersensitivity and were esthetically concerned due to gingival recession. The ethical committee of the Institute approved the study protocol. Written informed consent was obtained after explanation of the surgical procedure and the postoperative possibilities to the patients.

Inclusion criteria

  • Patients aged 18–50 years
  • Patient requiring treatment for hypersensitivity and concerned with aesthetics
  • Miller's class 1 and Miller's class 2 recession with recession depth (RD) 2 mm to 3 mm
  • Maxillary or mandibular multiple adjacent teeth with facial recessions involving two or more teeth
  • Systemically healthy patients.


Exclusion criteria

  • Tobacco use
  • Periodontal surgery in the past 6 months in the involved site
  • Medically compromised patients
  • Pregnant women
  • Generalized lingual or palatal recession
  • Malpositioned teeth
  • Presence of caries, restorations, cervical abrasions
  • Patients whose religious beliefs preclude the use of an allogenic material.


Study models of the teeth were prepared, and preoperative photographs were taken. Data were collected on the standard case history proforma. Plaque index (PI) was according to the criteria for the Plaque Index (PI) by Silness and Loe 1964. Recordings for gingival status was made according to the criteria for the Gingival Index (GI) it is by Loe and Silness.[5]

The following measurements were recorded:

Recession Depth (RD), Recession width (RW), Surface area of defect (SA), Width of keratinized gingiva (WKG) Clinical attachment level (CAL) and Probing sulcus depth (PD).

RD was measured from the midfacial point of the cementoenamel junction (CEJ) to the free gingival margin. The RW was recorded at the greatest mesiodistal diameter. The surface area of the defect (SA) was measured by placing tin foil over the defect, conforming it to the shape of the defect, placing this foil over a graph paper, and counting the number of squares in the area of the foil. The surface area was calculated in square millimeters. All the parameters were again measured at 3 and 6 months.

The percentage of RC (%RC) was calculated according to the following formula [6]



Dentin hypersensitivity and esthetics was evaluated from patient's perspective on a visual analog scale (VAS)[7] ranging from a score of 0–10. Where score of “0” indicates, very low reading and score of “10” indicates very high reading.

The following questions were asked, and the patients had to answer “Yes” or “No” and mark a score accordingly on the VAS.

VAS (Tick the appropriate):

  • Are your teeth sensitive? YES/No


    • 0 1 2 3 4 5 6 7 8 9 10


  • Is the sensitivity reduced after treatment? YES/NO


    • 0 1 2 3 4 5 6 7 8 9 10


  • Do you notice any color change in your gums at the treated site compared to the nontreated site? YES/NO (Score of 10 indicates “Excellent color match” and Score of 0 indicates “Poor color match”)


    • 0 1 2 3 4 5 6 7 8 9 10


The surgical procedure was performed under local infiltration. Horizontal incisions were made at the level of CEJ. Two vertical releasing incisions extending beyond the mucogingival junction was made on the facial aspect of the involved teeth. Sulcular incisions were given on the involved teeth [Figure 2] and [Figure 3]. A trapezoidal mucoperiosteal flap was elevated by blunt dissection up to the recession defect. In the area apical to the recession defect, partial thickness dissection was employed. The exposed root surface was thoroughly planed and contoured by the use of curettes. A template was made with sterilized tin foil outlining the recession defect. An ADM allograft, after rehydration in sterile saline for a minimum of 20 min is trimmed to shape to cover the recession defect [Figure 4]. The connective side of the ADM was identified by placing a drop of patient's blood on the graft; the side that absorbs blood and appears smoother was identified to be the connective tissue side of the allograft. The flap was then coronally positioned to completely cover the graft and secured by sling suture using No. 4-0 bioabsorbable suture [Figure 5]. Periodontal dressing (Coe-Pak, GC) was adapted and postoperative instructions given. Antibiotic (amoxicillin 500 mg thrice daily) was prescribed for 5 days, and analgesic (ibuprofen 400 mg + paracetamol 325 mg thrice daily) was prescribed for 3 days. Patients were asked to refrain from oral hygiene measures on the treated areas for 10–14 days and instructed to rinse the mouth with 0.2% chlorhexidine gluconate every 12 hrs for 2 weeks. The clinical parameters were measured during the follow-up visits at 3 and 6 months [Figure 6].
Figure 2: Preoperative recession defects

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Figure 3: Incisions

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Figure 4: Flap raised and alloderm placed

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Figure 5: Sutures placed

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Figure 6: Six months postoperative

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  Results Top


The PD was <2 mm in the baseline and remained the same at 6 months postoperative period [Table 1] and [Graph 1].
Table 1: Clinical parameters

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The CAL The change in CAL was statistically significant from baseline to 3 months and baseline to 6 months (24.81% and P < 0.001) [Table 1] and [Graph 2].



The change in PI score and GI score from baseline, 3 and 6 months was not found to be statistically significant [Table 1].

The baseline RD: the change in RD was highly significant from baseline to 3 months with a difference of 0.81. This change from baseline to 3 months and baseline to 6 months was statistically significant with P < 0.001. The percentage of decrease in RD was 32.1% at 3 and 6 months [Table 2] and [Graph 3].
Table 2: Clinical parameters

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The baseline RW was 3.00 ± 0.86, which reduced to 2.42 ± 1.06 with the difference of 0.58. The change from baseline to 3 months and baseline to 6 months was statistically significant with P < 0.001. There was no change in the width from 3 months to 6 months. The percentage of decrease in width was 19.33% at 3 and 6 months [Table 2] and [Graph 4].



The baseline WKG was 2.71 ± 0.59 which was increased to 4.03 ± 0.75 with the difference of 1.32. The change in WKG from baseline to 3 months and baseline to 6 months was highly significant P < 0.001. The percentage of increase in WKG was 48.7% [Table 2] and [Graph 5].



The baseline width of attached gingiva (WAG) was 1.23 ± 0.67 which was increased to 2.61 ± 0.67 with a difference 1.38. The change in the width of attached gingiva from baseline to 3 months and baseline to 6 months was statistically significant with P < 0.001 [Table 2] and [Graph 6].



The surface area of the defect (SA) at baseline was 6.77 ± 2.40. The surface area was reduced to 4.71 ± 2.64 with a difference of 2.06 (30.4%) at 3 months and 2.03 (29.9%) at 6 months. The reduction of in the surface area of the recession was statistically significant [Table 3].
Table 3: Surface area, percentage of linear and volumetric root coverage parameters

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The percentage of linear RC at 3 months was 31.31% and remained the same at the end of 6 months (P = 1.000) [Table 3].

The percentage of volumetric RC (%VRC) at 3 months was 35.21% and remained the same at the end of 6 months (P = 1.000) [Table 3] and [Graph 7].



Patients gave a mean score of 5.10, standard deviation (SD) of ± 0.57 for esthetic evaluation. All of them reported sensitivity of teeth before treatment with a mean score of 6.22, SD of ± 0.83. All of them reported a decrease in the sensitivity after treatment, with a mean score of 3.90, SD of ± 1.37 [Table 4].
Table 4: Visual analogue scale

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  Discussion Top


Connective tissue grafts are considered to be the gold standard for RC since they are highly predictable procedures for treating recession defects with an average RC between 52% and 98%.[8] A common concern of patients is that connective tissue grafts require a second surgical site which causes additional discomfort and increases chairside time. All the above disadvantages were overcome by the use of Alloderm ®. The results of the present study indicate that plaque and gingival indices remained relatively constant at all-time intervals during the study. Matter [7] has reported that when treating gingival recessions one of the criteria for optimal results is maintaining good oral hygiene. In the present study, there was no increase in PI which suggests that the patients were well motivated to maintain good oral hygiene. This is in agreement with Chen et al.[9] Probing depth measured at baseline was 1.5 mm. There was no statistically significant difference between probing depth measured at 3 and 6 months. These findings corelate well with studies of Pini Prato et al.[10]

There was a mean gain in CAL of 3.03 ± 1.30 at 3 and 6 months with a difference of 1.00 mm from baseline to 3 and 6 months which was statistically significant. Harris [11] reported a range of 1.5–4.5 mm of clinical attachment gain which compares well with the results obtained in this study. The mean RD was reduced to 1.71 mm at 3 and 6 months postoperatively, from baseline reading of 2.52 mm with a mean difference from baseline to 3 and 6 months is 0.8 mm, which was statistically significant. A study by Pini Prato et al.[10] showed a mean RD reduction of 4.12 mm with coronally advanced flap technique. This difference in reduction can be explained based on the selection of the size of the defect sites. In the present study, RD was in the range of 2–3 mm, whereas in the group selected by Pini Prato et al. the depth of the recession was in the range of 3–8 mm. The RW reduced to 2.42 mm from a baseline reading of 3.00 mm with a difference of 0.58 mm from baseline to 3 and 6 months. This RW reduction compares well with results obtained by Harris.[12]

Paolantonio et al. have reported 2.13 mm gain of keratinized gingiva at 1 year postoperatively using Alloderm ®.[13] In the present study, there was a mean increase of WKG to 4.03 mm from a baseline measurement of 2.71 mm. The mean width of attached gingiva increased from 1.03 mm at baseline to 2.61 mm at 6 months with a difference of 1.38 mm from baseline to 3 and 6 months which was statistically significant. This indicates that Alloderm ® caused an increase in width of attached gingiva. A systemic review of periodontal plastic surgical procedures in the treatment of localized gingival recessions with coronally advanced flap reported a mean defect coverage ranging from a minimum of 55% to a maximum of 91.2% with a mean for all studies of 78%.[2] In the present study, there was only 35.2% of RC which is very low compared to earlier studies which include, Dodge et al. who found defect coverage of 96%; Harris reported 94% of defect coverage and Henderson reported 97%.[11],[14] Many studies included in the review were incomplete both in the presentation of the methodology and the results achieved. This could be contributing to the wide difference in the %RC obtained between the previous studies and in this study. The current study measured RC by calculating the surface area in square millimeters, whereas in previous studies, only linear measurements were considered, this could be a reason of wide variation in the results obtained.

The esthetic and hypersensitivity assessment were evaluated from patient's perspective on a VAS. All patients had hypersensitivity before treatment with a mean score of 6.22, SD of ± 0.83 and there was a decrease in sensitivity after treatment, with a mean score of 3.90, SD of ± 1.37. Patients gave a mean score of 5.10, SD of ± 0.57 for esthetic evaluation in terms of the color match at the grafted site compared to the nontreated site which correlates well with the results reported by Aichelmann-Reidy et al.[3] This indicates that Alloderm ® produced predictable aesthetics.

It is not only the technique or material that is critical for success of a surgical procedure, other factors like clot stability, plaque control, maintenance therapy, thickness of flap and graft, systemic health, orientation of the graft, adequate blood supply and case selection, all of these play an important role in treatment success. The lower %RC of 35.21% could be due to the lack of statistical power, because of small sample size. Other anatomical factors such as root prominence, depth of vestibule, soft-tissue quality all these variables were not considered, which are the drawbacks of this study. Furthermore, technical factors such as operator experience/surgical skills and the occurrence of a learning curve during the study may also account for the difference in the results between the studies.


  Conclusions Top


This clinical study indicates that Alloderm ® along with coronally advanced flap is a less predictable approach to treat Miller's class I and class II multiple adjacent teeth facial gingival recessions. The overall effectiveness of this expensive biomaterial in obtaining significant RC of multiple adjacent facial gingival recessions is questionable. Within the confines of this study, it is difficult to recommend the use of Alloderm ® in the management of gingival recessions. However, keeping more stringent inclusion and exclusion criteria and with larger sample size along with latest surgical advancements like the use of periodontal microsurgery might show a more favorable outcome.

Acknowledgments

The authors would like to thank M/S Biohorizons (Life Cell) Branchburg, New Jersery 008876, Mr Dayanand S. K. Area manager Biohorizons Implant systems for providing the Alloderm ® and Mr. K. P. Suresh Scientist (Biostatistics), National Institute of Animal nutrition and physiology Bangalore for going the statistical analysis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
The American Academy of Periodontology. Glossary of Periodontal Terms. 3rd ed. Chicago: The American Academy of Periodontology; 1992. p. 41.  Back to cited text no. 1
    
2.
Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for treatment of localized gingival recessions: A systematic review. J Clin Periodontol 2002;29 Suppl 3:178-94.  Back to cited text no. 2
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3.
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.  Back to cited text no. 3
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4.
Silverstein L, Callan D. An acellular dermal matrix allograft substitute for palatal donor tissue. Post Grad Dent 1997;3:14-21.  Back to cited text no. 4
    
5.
Löe H. The gingival index, the plaque index and the retention index systems. J Periodontol 1967;38:Suppl: 610-6.  Back to cited text no. 5
    
6.
Shieh A, Wang HL, O'Neal R. Development and clinical evaluation of root coverage procedure using collagen barrier membrane. J Periodontol 1997;68:770-8.  Back to cited text no. 6
    
7.
Matter J. Free gingival grafts for the treatment of gingival recession. A review of some techniques. J Clin Periodontol 1982;9:103-14.  Back to cited text no. 7
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8.
Camargo PM, Melnick PR, Kenney EB. The use of free gingival grafts for aesthetic purposes. Periodontol 2000 2001;27:72-96.  Back to cited text no. 8
    
9.
Chen CC, Wang HL, Smith F, Glickman GN, Shyr Y, O'Neal RB, et al. Evaluation of a collagen membrane with and without bone grafts in treating periodontal intrabony defects. J Periodontol 1995;66:838-47.  Back to cited text no. 9
    
10.
Pini Prato G, Tinti C, Vincenzi G, Magnani C, Cortellini P, Clauser C, et al. Guided tissue regeneration versus mucogingival surgery in the treatment of human buccal gingival recession. J Periodontol 1992;63:919-28.  Back to cited text no. 10
    
11.
Harris RJ. A comparative study of root coverage obtained with guided tissue regeneration utilizing a bioabsorbable membrane versus the connective tissue with partial-thickness double pedicle graft. J Periodontol 1997;68:779-90.  Back to cited text no. 11
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12.
Harris DR. A comparative study of root coverage obtained with an acellular dermal matrix allografts to achieve increased attached gingival. Part 2. A histological comparative study. J Periodontol 2002;73:257-65.  Back to cited text no. 12
    
13.
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.  Back to cited text no. 13
    
14.
Henderson R. Root coverage using acellular dermal matrix allograft. J Contem Dent Pract 1999;1:1-9.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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