|Year : 2009 | Volume
| Issue : 3 | Page : 320-325
|Coronally advanced flap in combination with acellular dermal matrix with or without enamel matrix derivatives for root coverage
Reza Pourabbas1, Mohammad Taghi Chitsazi1, Emad Kosarieh2, Pooya Olyaee1
1 Department of Periodontology, School of Dentistry/Drug Applied Research Center, Tabriz University of Medical Sciences, Golgasht St., Daneshgah St, Tabriz, Iran
2 Zandjan, Iran
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|Date of Submission||11-Jul-2008|
|Date of Decision||29-Jan-2009|
|Date of Acceptance||19-Mar-2009|
|Date of Web Publication||30-Oct-2009|
| Abstract|| |
Background: Coverage of gingival recession defects has been considered as a subject of interest for dental practitioners.
Aim: The present study was aimed to compare the clinical outcomes of root coverage (RC) procedures, using coronally advanced flap (CAF) in combination with acellular dermal matrix (ADM) with or without enamel matrix derivatives (EMD).
Materials and Methods: A total of 36 Miller class I or II recession defects in 15 eligible patients were selected. The defects were randomly allocated to test (CAF+ADM+EMD) and control (CAF+ADM) groups. Recession depth (RD), recession width (RW), width of keratinized tissue (WKT), clinical attachment level (CAL), and the position of mucogingival junction (MGJ) were measured at baseline, two and six months after treatment.
Statistical Analysis: Data were analyzed using repeated measures ANOVA and paired sample t-test with the patients as statistical unit.
Results: At two-month follow-up, the mean RC for CAF+ADM+EMD and CAF+ADM was 82.75 ± 22 and 88.89 ± 22 percent, respectively. However, these values did not change significantly after six months. Both treatments led to significant RC (P < 0.001), whereas no significant differences were observed in WKT, CAL, and MGJ between the study groups.
Conclusion: The application of EMD does not improve the clinical efficacy of ADM in combination with CAF in RC procedures.
Keywords: Acellular dermal matrix, coronally advanced flap, gingival recession, enamel matrix protein, root coverage
|How to cite this article:|
Pourabbas R, Chitsazi MT, Kosarieh E, Olyaee P. Coronally advanced flap in combination with acellular dermal matrix with or without enamel matrix derivatives for root coverage. Indian J Dent Res 2009;20:320-5
Gingival recession has been considered as a common periodontal problem, and its treatment has remained a challenging issue from both esthetic and functional points of view.  Ideally, a root coverage (RC) procedure should be able to re-establish soft tissue coverage on denuded root without bleeding on gentle probing or gingival sulcus deeper than 2 mm.  A coronally advanced flap (CAF) associated with subepithelial connective tissue graft has been revealed as a predictable method to meet the above-mentioned requirements.  However, this procedure is rather technically demanding. Furthermore, the need for a second surgical site to harvest the graft tissue and resulted morbidity acts as limiting factors for this technique. Besides, the donor tissue from the palatal region may be insufficient for multiple recession treatments.
|How to cite this URL:|
Pourabbas R, Chitsazi MT, Kosarieh E, Olyaee P. Coronally advanced flap in combination with acellular dermal matrix with or without enamel matrix derivatives for root coverage. Indian J Dent Res [serial online] 2009 [cited 2015 Feb 1];20:320-5. Available from: http://www.ijdr.in/text.asp?2009/20/3/320/57374
Recently, the use of acellular dermal matrix (ADM) has been reported for increasing the width of keratinized gingiva around the teeth  and implants  but with a lesser amount achievable by the autogenous gingival graft. Application of ADM for RC procedures demonstrated successful clinical results based on recession coverage, keratinized tissue formation, probing depths (PDs), and clinical attachment levels (CALs).  In comparison to CAF, utilizing ADM resulted in significant RC in Class I gingival recession with a greater keratinized tissue thickness achieved with ADM.  Yet the application of ADM in comparison to autogenous connective tissue graft led to slower healing and less keratinized tissue in short-term follow-ups  and by using ADM instead of autogenous tissues reduces the duration of surgery and postoperative complications such as pain, bleeding, and swelling.  A recent meta-analysis on comparison of ADM to common mucogingival surgical procedures failed to draw any definitive conclusion due to inadequate available data and need for further randomized clinical studies emphasized. 
The role of enamel matrix derivatives (EMD) as a growth factor in fostering new cementum formation, connective tissue attachment, and alveolar bone regeneration has been demonstrated.  The EMD also stimulates the differentiation of primary osteoblasts and osteoblastic cell lines.  According to in vitro studies EMD stimulates proliferation of human periodontal ligament-derived cells as well as protein synthesis and mineralization by these cells. 
The effects of EMD on the outcome of RC procedures have been extensively investigated in clinical studies and considered as a factor to provide better results in terms of RC percentage, CAL, and width of keratinized tissue (WKT).  The EMD remained on root surfaces for up to four weeks following periodontal surgery  and accompanied with better long-term results.  A recent systematic review concluded that the clinical outcome of RC procedures using CAF may be enhanced by applying EMD on the root surfaces, while chemical root conditioning or CAF alone led to unpredictable results.  However, the beneficial effects of EMD were not confirmed by some other studies which indicated the insignificant difference between EMD and non-EMD applied study groups. ,,
In combinational use, a synergic effect of CAF, EMD, and ADM is expected theoretically. However, there is a little data about the clinical effects of this combination.  This study was aimed at evaluating the percentage of RC, CAL, width of keratinized gingiva, and the position of muccogingival junction (MGJ) following RC procedures using CAF+ADM with and without EMD.
| Materials and Methods|| |
After approval of the Research and Ethics Committees of the University, 15 subjects (seven male and eight female aged from 26 to 63) were selected from the patients who sought dental treatment at our department. Patients had at least two single or multiple facial Miller Class I or II gingival recession defects (≥2 mm) at incisor/premolar teeth of two quadrants of a jaw. The total of 36 matched gingival recession defects pertaining to the selected patients treated in this study. The recession defects consisted of 11 Miller class I and 7 Miller class II in each group.
Inclusion criteria were having no systemic disease affecting the periodontium, adequate oral hygiene, not being pregnant, not being under treatment with steroids, vital teeth and lack of peri-apical infection, no indication for antibiotic prophylaxis prior to dental treatments, and signing a witness letter. The presence of the following were considered as exclusion criteria, smoking, restorations on tooth surface for test and control teeth, previous surgical attempts for RC at the studying sites, and contraindication for elective surgery.
Random allocation of the treatment sites to test (CAF+EMD+ADM) and control (CAF+ADM) groups was performed by a person who was external to the study and using a computerized selection of random numbers for allocation of the study groups. The patients and data collectors were 'blinded' to the allocation of the recession defects to control and test groups.
Following a comprehensive periodontal treatment that included detailed oral hygiene instruction, scaling and root planing, occlusal adjustment was done where indicated and a stone cast prepared. Acrylic stents were made for the treating sites to increase precision and reproducibility of measurements. Clinical parameters were measured using a periodontal probe in a predetermined position and angulations through the stent's grooves at the deepest part of recession defects. The parameters included were PD, CAL, WKT, recession depth (RD) from cemento-enamel junction, recession width (RW), distance between MGJ and the stent, plaque (PI)  and gingival (GI)  indices, and RC percentage. The RC percentage was calculated as initial RD/(initial RD-final RD) Χ 100.
After obtaining anesthesia, root surface was planed and meticulously debrided by ultrasonic and hand instruments. A sulcular incision was made with a # 15 surgical blade on the buccal aspect of each recipient tooth. Incisions were made in a way that they only partially involved the adjacent papilla, maintained maximum soft tissue, and left buccal gingival margin intact. A flap was made by doing two releasing incisions on mesial and distal extremities of sulcular incision. Trapezoidal flap was elevated and the exposed root planed again with a curette. The exposed root surface was conditioned with 24% EDTA (PrefGel; , Straumann Biologics Division, Waltham, MA, USA) for 2 minutes to remove smear layer and then thoroughly rinsed with saline for 30 s.
The ADM (Alloderm; , LifeCell Corporation, One Millennium Way, Branchburg, NJ, USA) was prepared for grafting as demonstrated by the product's brochure. Briefly, it was rehydrated by submerging in 50 cc of 37°C sterile normal saline for about 30 min. After peeling the backing and once the tissue was fully rehydrated, ADM was placed under the flap in a way that the underlying connective tissue covered at least 3 mm of the bone around the denuded root and the flap was coronally positioned using a sling suturing technique with a Polyglactin 910 suture material. Finally, the surgical sites were covered by periodontal dressing (coe-pak, GC, Alsip, IL, USA) for two weeks with replacing at one-week interval. Only for the test group, EMD (Emdogain; , Straumann Biologics Division Waltham, MA, USA) was applied on the surface of denuded root and the surrounding tissues before application of ADM [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9]. Therefore, the same procedure was performed in test and control groups with the exception of EMD application.
Postoperative care and instructions
All the patients were advised to apply ice pack for the first few hours at the surgical sites for 20 min/h. They were asked to refrain from mechanical oral hygiene measures and avoid trauma to the treated area for four weeks after the operation. Patients were asked for oral rinsing with chlorhexidine 0.2% mouthwash twice a day for 30 s for four weeks. Doxycycline hyclate 100 mg once a day for 14 days and analgesics for pain control were prescribed. The sutures were removed two weeks after surgery.
All the subjects were followed up for four weeks and then once a month for supragingival plaque removal and oral hygiene reinforcement. The clinical parameters were measured at two and six months after surgical procedure.
In order to compare the mean values of clinical parameters during various steps of the study (Baseline, two and six months after surgical intervention), a repeated measures ANOVA test was carried out. The paired sample t-test was conducted to compare the studied variables between the test and control groups noting the patients as statistical unit. Two sided values of P ≤ 0.05 were accepted as significant and 95% Confidence Interval (CI) for means were calculated.
| Results|| |
All the participants satisfactorily pursued the study protocol according to flow chart shown in [Figure 10]. A clinical evaluation of early wound healing revealed a favorable soft tissue response to ADM and EMD with no adverse complication or significant difference between the study groups. However, some exposure of ADM occurred in both the test and control sites that were followed by a spontaneous resolving without any intervention.
Comparison of baseline characteristics between test and control groups conducted using paired sample t-test revealed no significant difference.
Based on repeated measure ANOVA, the following changes at each time point of the study were detected in both groups: A significant RC achievement (P < 0.001), a significant reduction in width and depth of recession defects and CAL (P < 0.001 for all) in comparison to the baseline with two- and six-month recall visits. However, these variables remained without any significant change during the follow-up appointments. There were no statistically significant changes in PD, WKT, and the position of MGJ through the study. Regarding the emphasis on maintaining oral hygiene, patients' plaque and gingival indices remained consistently in an acceptable level throughout the entire study. The statistics relating to the clinical variables are summarized in [Table 1].
Comparison of clinical variables between test and control sites by paired sample t-test revealed no significant difference in any of studying variables.
| Discussion|| |
In agreement with previous studies, , our treatment modalities led to significant RC. In this study, the mean final RC was 89.5% (control) and 84.90% (test). Comparing with previous studies reporting a mean RC of 65.9%,  this study achieved better results and is comparable with the studies stating greater mean RC. , However, some studies have reported 95-99% , RC which are better results than what this study has achieved.
In a recent study using ADM+CAF with and without EMD in RC,  no significant differences were observed in terms of probing attachment level, percentage of RC, vertical and horizontal recession. However, a significant gain in keratinized tissue in the EMD group was achieved. These results demonstrate a consistency in all aspects except for gaining keratinized tissue that was not improved significantly in the present study. This may be attributed to the differences between the methods of the two studies such as inclusion/exclusion criteria, surgical technique, rounding of the data, duration of the study, statistical analysis, and independency from the commercial supports. Our findings were in agreement with the studies performed by Woodyard et al.,  Henderson et al.,  and Aichelman-Reidy et al.  who respectively, reported 0.8, 0.81, and 1.2 mm increase in width of keratinized gingiva at 6 or 12 months after ADM+CAF application. Studies on changes of gingival size following CAF reported that the width of keratinized gingiva decreased at 5 and 12 months postsurgery appointments, , but as the follow-up period prolonged, an increase in gingival size was observed. 
At the present study, coronal displacement of MGJ at the two-month recall visit occurred but these values did not change significantly over time at six-month follow-up appointment. In a study carried out by Gurgan et al.  on changes of MGJ position following CAF, coronal displacement of MGJ was observed during the first six months and then the displacement was in apical direction until the end of the study (12 months).
It has been postulated that RC is fulfilled in two phases of bridging of tissues and creeping attachments. , Although creeping attachment does not have a role in MGJ position, it may affect the amount of keratinized gingiva. Regarding the controversy on the time needed for this phenomenon to occur it may be clinically observed at one month to one year after operation.
Improvement of CAL has been reported in the range between 0.81 and 3.67 mm, with nonsignificant decrease in PD. ,, These findings are in agreement with the results of the present study. However, in the absence of histological studies it is not possible to determine whether this improvement is a result of new connective tissue attachment, development of long junctional epithelium, or a combination of the mentioned conditions. In a recent study conducted by Cummings et al.,  four hopeless teeth with Miller Class III/IV gingival recessions were treated by CAF+ADM and histological sections taken six months postoperation revealed a cementum formation in the apical portion of the recession defects without any sign of new bone formation; ADM adhesion to root surface was achieved via long junctional epithelium and connective tissue adhesion but no signs of PDL entrance to root surface was observed.
Inductive effect of EMD on components of the periodontium; particularly the fibroblasts has been shown by in vitro studies, , whereas the in vivo studies indicate controversial findings. , This may be due to technique sensitiveness of EMD application which can lead to variation in results and controversy. The remaining EMD in the flap site is a critical point in the technique. The ADM application may cause EMD scattering and escape from the wound area due to its physical pressure and effect on flap thickness and tension. On the other hand, ADM permeability to EMD has not been verified and presence of ADM may interrupt the contact between EMD and fibroblasts.
The other point to be mentioned is that, ADM by itself can induce cell proliferation and ultrastructural cellular changes. This has been attributed to existence of extracellular elements in this material.  This may lead to a masking effect of ADM on EMD due to its higher inductive role.
| Conclusion|| |
The EMD does not improve the clinical outcome of RC procedures in Miller's class I or II defects when applied with CAF+ADM. However, regarding the limitations of this study, further investigations with higher statistical power and longer follow-up are recommended. Healing of various RC techniques and the effects of some other variables such as flap thickness and tension of the coronal flaps and vestibular depth on the outcome of RC indicate a necessity for further histological, human, or animal studies to investigate their probable role as prognostic factors.
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Department of Periodontology, School of Dentistry/Drug Applied Research Center, Tabriz University of Medical Sciences, Golgasht St., Daneshgah St, Tabriz
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
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