Root coverage stability with acellular dermal matrix in multiple gingival recessions in esthetic zone: A clinical case report with 12-year follow-up.

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. Copyright:

INTRODUCTION

Gingival recession is defined as an apical displacement of the gingival margin in relation to the cementoenamel junction (CEJ),[1] with high population prevalence[2] which may cause esthetic impairment, dentin hypersensitivity, and root caries.[3] 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.[45] However, SCTG presents disadvantage associated with a second surgical area, usually the palatal donor site, leading to increased postoperative morbidity.[6]

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).[7] Furthermore, an adequate width and thickness of gingiva is related to the maintenance of clinical results and periodontal homeostasis,[8] toward the activity of the dental biofilm.[9] As an alternative to the use of SCTG, tissue substitutes such as ADM[10] offer unlimited material and eliminate the approach of donor areas.[11]

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).[12] In periodontics, the first clinical case using ADM was published in 1994.[13] This material can be used to increase the keratinized tissue width,[14] to modify the periodontal biotype,[15] showing similar effectiveness as SCTG.[16] Some studies have shown similar results for SCTG and ADM regarding the gain of keratinized mucosa width[171819] and root coverage rates.[2021222324]

However, other studies reported greater gain of keratinized tissue using SCTG.[21232425] 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.[26]

Limited case reports using ADM with long-term follow-up are described in the literature. Only two case reports are available[2728] 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 1a], presented to the periodontics clinic, with the main complaint of poor esthetic condition and dentin hypersensitivity due to multiple Miller Class I and II[29] gingival recessions [Figure 1b–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)

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 2b]. Biomodification of the root was performed by root scaling with Gracey manual curettes [Figure 2c] followed by conditioning [Figure 2d] 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)

The ADM (Alloderm®-LifeCell-The Woodlands, TX, USA) was adapted according to the shape of width and length of the receptor site [Figure 2e]. 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 2f], and the flap was coronally positioned covering the entire matrix and stabilized by interrupted absorbable sutures [Figure 2g] (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 3a–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”)[30] was demonstrated with satisfactory gingival tissue texture and color [Figure 3d–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 3g–i]. The patient reported traumatic brushing and restorative procedures during this period [Figure 3g–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

Tables 1 and 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.[31]

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)

Parameter and Periods		Anterior region (13-23)	Posterior region (14-15 and 24-25)	Surgical Area (15-25)
Recession Depth (mm)	Baseline	6.88±1.35	8.05±1.03	7.36±1.32
	90 days	2.03±0.86	2.53±1.86	2.22±1.28
	2 years	1.4±0.42	2.94±0.54	2.05±0.88
	12 years	1.57±0.7	3.49±1.35	2.54±1.86
Recession Width (mm)	Baseline	6.35±1.34	6.29±1.59	6.32±1.36
	90 days	4.03±0.97	3.58±1.05	3.85±0.97
	2 years	3.18±0.91	3.28±0.51	3.22±0.74
	12 years	2.36±1.86	4.01±0.94	3.02±1.71
Keratinized Tissue Width (mm)	Baseline	3.49±0.81	2.65±0.83	3.07±0.78
	90 days	7.41±0.9	5.19±0.95	6.03±1.87
	2 years	6.83±0.85	5.06±0.58	5.96±1.33
	12 years	6.71±1.39	4.52±0.41	5.61±1.80

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)

Parameter and Periods compared		Anterior region (13-23)	Posterior region (14-15 and 24-25)	Surgical Area (15-25)
Root Coverage	0-90 days	70.5% (4.85mm)	68.5% (5.52mm)	69% (5.14mm)
	0-2 years	79% (5.44mm)	63% (5.11mm)	72% (5.31mm)
	0-12 years	77% (5.31mm)	57% (4.56mm)	65% (4.82mm)
Gain of KT	0-90 days	112%(3.92mm)	95% (2.54mm)	96% (2.96mm)
	0-2 years	96% (3.34mm)	91% (2.41mm)	94% (2.89mm)
	0-12 years	92% (3.22mm)	70.5% (1.87mm)	82% (2.54mm)

KT – Keratinized tissue

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

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.[2728] 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[27] and for lower anterior area after 12-year follow-up.[28] 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.[1032] 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.[33] 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.[3334] However, ADM presents some disadvantages, such as additional financial cost and longer healing period for root coverage surgeries.[35]

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.[36] The literature presents studies[20212324] 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[18222537] concluded that SCTG obtained minor percentage when compared to ADM. Conversely, the findings of keratinized tissue gain in other studies[21232425] showed greater gains for SCTG compared to ADM, and other reports[1617181920] did not find differences between SCTG and ADM for keratinized tissue gains.

It should be considered that, even though SCTG is considered gold standard[5] when compared to ADM or other tissue substitutes for root coverage, the option to use a tissue substitute has superior acceptance by the patient.[26] 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[7] 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[38] and facilitate oral hygiene[39] with greater comfort during dental brushing.[40] 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,[41] 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

Nil.

Conflicts of interest

There are no conflicts of interest.