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Root Coverage With Emdogain/
AlloDerm: A New Way to Treat
Gingival Recessions

André P. Saadoun, DDS, MS

Private Practice
Paris, France

Correspondence to: Dr André P. Saadoun

29 rue François 1er, 75008 Paris, France;
phone: 33 1 47 27 17 57; e-mail: [email protected].

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Abstract
The recession of the gingival margin is be- enamel matrix derivative (Emdogain) and
coming a more prominent condition in the acellular dermal matrix allograft (AlloDerm)
oral situation of many patients and should were utilized to correct these gingival
be treated at its earliest detection. The multi- defects, negating the morbidity and the
factorial etiology, decision modality, and cur- requirement for a second palatal surgical
rent trends in the treatment of gingival procedure. Emdogain or AlloDerm materi-
recession are discussed in this article. The als used alone or in combination are a pre-
surgical technique of choice depends on dictable treatment for root coverage, are
several factors, but among the different sur- relatively easy to perform (although they
gical protocols available, the clinician are technique sensitive), present low pa-
should select one that will minimize surgical tient morbidity, offer a significant increase
trauma and achieve predictable esthetic in the percentage of root coverage and
results. All of the approaches described in amount of keratinized tissue, and should
this article can effectively treat deep and be part of the periodontal plastic surgery
shallow Class I or II buccal recessions. armamentarium.
Recently, as an alternative to autogenous
gingival grafts in root coverage procedures, (Eur J Esthet Dent 2008;3:46–65.)

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Gingival recession occurs when the loca- Conventional procedures
tion of the gingival margin is apical to the
cementoenamel junction (CEJ). Clinically, A variety of surgical techniques have been
this results in exposed root surfaces, loss of developed to correct a lack of keratinized
marginal tissue, and loss of attachment.1 tissue and attain root coverage with high
Gingival recession is common in both pop- predictability in Miller Class I and II reces-
ulations with periodontal disease resulting sion defects.15 The root coverage tech-
2
from poor oral hygiene and populations niques used by most clinicians include
with high standards of oral hygiene.3 The pedicle grafts (lateral sliding or double
prevalence and extent of recession in- papillae) with or without connective tissue
crease progressively with age.4 grafts, epithelialized autogenous (free gin-
The most frequent etiologic factors asso- gival) grafts, connective tissue grafts, coro-
ciated with gingival recessions are tooth nally advanced flaps (CAFs) alone, CAFs
malposition, factitious injury,6,7 tooth mobil-
5
preceded by a free gingival graft, and CAFs
ity,8 iatrogenic factors related to the location with a simultaneous connective tissue graft.
of the restoration margin and periodontal Each of these techniques results in varying
treatment procedures,9,10 alveolar bone de- degrees of success depending on the re-
hiscence,11 traumatic tooth brushing/tooth- cession classification.16–24
brush abrasion,12 and high muscle attach- These periodontal plastic surgery proce-
ment with abnormal fraenum.13 dures for treatment of gingival recession
An inadequate band of attached kera- have been improved by constant surgical
tinized tissue has been associated with and material modifications. Most of these
chronic inflammation and progressive re- modifications were developed to enhance
cession in the presence of poor oral hy- blood supply to the graft, thereby increas-
giene.14 Orthodontic appliances, which can ing the success rates. Gingival grafts
impede effective hygiene, can also lead to change the anatomy of the dental environ-
increased gingival recession in areas with ment, and the soft tissue will be more re-
minimal keratinized tissue and a thin labial sistant to future recession. A deeper
cortical plate.3 vestibule with thicker, bound-down kera-
The purpose of this article is to review tinized tissue increases the width of kera-
the conventional mucogingival procedures tinized gingiva with satisfactory results. The
and then describe via clinical cases the intent of these procedures is principally to
coverage of gingival recessions using re- create a tissue barrier that is more resistant
cent bioengineering materials such as an to further recession due to trauma and to
enamel matrix derivative (EMD) (Emdo- treat the mucogingival root defects at the
gain, Straumann) and acellular dermal same time.
membrane (ADM) (AlloDerm, Biohorizons). The indications for connective tissue
grafting are as follows: inadequate donor
site for a horizontal sliding flap, isolated
wide gingival recession, multiple root expo-
sures, and multiple root exposures in com-
bination with minimal attached gingiva or in
sites where ridge augmentation is desired.

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If a dehiscence develops, gingival aug- Therefore, some disadvantages of con-
mentation may be indicated in conjunction nective tissue grafting will contraindicate
with tooth movement in order to halt pro- this procedure, including the need for
gressive recession and facilitate plaque a second surgical procedure to harvest
control and/or patient comfort. Masticatory donor tissue, leading to patient discomfort;
mucosa may be needed around implants a limited amount of donor tissue for multi-
to stabilize and prevent peri-implant gingi- ple recession sites; a longer surgical time;
25
val recession. and a more technique-sensitive result.
The advantage of free gingival and con-
nective tissue grafts is that they are auto-
grafts. The subepithelial connective tissue New bioengeenering
graft covered by a CAF was considered the
materials
most predictable technique for achieving
root coverage by some investigators. Con- The goal of periodontal plastic mucogingi-
nective tissue grafts show greater gain in val procedures is to perform surgery as
root coverage and width of keratinized tis- atraumatically as possible at the recipient
sue compared to guided tissue regenera- and donor sites. Homeostasis, graft cover-
tion (GTR) when used to reduce gingival age with an overlying mucosal flap, and
recessions with concomitant improve- stability of the graft are consistent with the
ments in attachment level. The connective subepithelial connective tissue graft; how-
tissue graft is statistically significantly more ever, as stated above, some limitations and
26
effective than GTR in treating recession. drawbacks are present. Recently, as an al-
The palate is the usual source for con- ternative to autogenous gingival grafts in
nective tissue grafts, and there may be sig- root coverage procedures, EMD and ADM
nificant postoperative morbidity, particular- allografts were utilized to correct these gin-
ly when large epithelialized gingival grafts gival defects, negating the requirement for
are needed to treat generalized multiple a second palatal surgical procedure.27–34
gingival recession. Palatal anatomy may
also limit the amount of autogenous tissue
that can be harvested, thus decreasing the Enamel matrix derivative:
number of procedures that can be per-
Emdogain
formed. This limitation of an adequate
quantity of connective tissue can be further Processing
complicated by the presence of a small EMD is a mixture of freeze-dried enamel
shallow or flat palate, which also impedes matrix proteins harvested from the develop-
the clinician’s ability to obtain an adequate ing crown of a 6-month-old swine. EMD is
amount of tissue to transplant. Furthermore, used during periodontal therapy to promote
a patient may not desire to have addition- regeneration. This material has been in use
al tissue transplanted from the palate and for more than 8 years, but its composition
decline to have both sides of the palate and mechanism of action are poorly under-
harvested simultaneously, due to the in- stood. Nevertheless, clinical reports indicate
creased pain and morbidity associated that the material has positive effects on pe-
with multiple transplant procedures. riodontal healing. Much of the research on

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EMD has focused on its effects on peri- Acellular dermal graft material:
odontal ligament (PDL) cells. In vitro, EMD AlloDerm
stimulates PDL cells to secrete platelet-
derived factor (PDGF)-AB, transforming Processing
35,36
growth factor (TGF)-β1, and interleukin-6. According to the manufacturer, the Allo-
Derm process de-cellularizes the allograft
Advantages skin from screened donors to create an
EMD has been shown to possess the po- acellular biocompatible connective tissue
tential to stimulate and promote the forma- matrix that consistently integrates following
tion of new connective tissue, bone, PDL, transplantation.
and cementum.15,37 It was reported that EMD During the processing of AlloDerm, the
applied to instrumented root surfaces may epithelium is first removed from the donor
remain active for up to 10 days and may in- tissue while the basement membrane is re-
fluence enhancement of PDL cell prolifera- tained to promote faster re-epithelialization.
tion, increase protein/collagen production, Next, the cells are removed from the re-
promote mineralization, and facilitate early maining tissue with a series of detergents
healing of the soft tissue in the dentogingi- to eliminate the chance for an antigenic re-
28
val region. Cumulative evidence indicates sponse by the recipient. The product un-
that EMD can increase proliferation, migra- dergoes two key anti-viral steps: (1) de-cel-
tion, adhesion, and differentiation of the lularization, since viruses reside in human
cells responsible for tissue healing in vivo.38 cells; and (2) the addition of an antiviral
Several studies have shown that EMD may agent, which will inactivate HIV. The tissue
not only enhance periodontal regeneration, is then freeze dried and packaged for im-
it may also influence soft tissue healing via mediate use. The graft material consists of
the migration of PDL cells and gingival fi- a connective tissue surface that readily ab-
broblasts to the root surface through gingi- sorbs blood and a basement membrane
val fibroblast stimulation.39 surface that does not allow for blood
The use of EMD in the treatment of intra- absorption.
bony defects and root coverage proce- The resultant graft is an ADM with nor-
dures was also demonstrated to produce mal collagen bundling organization and
successful bone regeneration and a gain an intact basement membrane complex.
40,41
of keratinized tissue after 4 months. The Since the AlloDerm process removes all
application of EMD during collagen mem- cells, the components necessary for sur-
brane GTR-based root coverage proce- vival and transmission of viruses are re-
dures is easy to perform and has low pa- moved. Furthermore, the removal of cells
tient morbidity, but did not provide leaves no components to cause rejection
additional benefits to the final clinical out- or inflammation. Additionally, the graft is
42
come. EMD application may be an alter- freeze dried. There has never been a re-
native to connective tissue grafts to treat ported case of HIV transmission from a
43
gingival recession. It was also shown to transplant that has been freeze dried.43
improve the predictability of recession cov- The main advantages, disadvantages,
erage in the treatment of Class I and II gin- and indications of the ADM allograft will
gival recession from 62% to 89%.44 now be presented.45

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Advantages and cold air for young patients and/or were
■ No need for palatal autografts or other unesthetic for older patients.
secondary surgica
■ Unlimited material supply
■ Ability to treat larger areas of multiple Preoperative protocol
recession in one surgery
■ Decreased surgical chair time Prior to the surgical procedure, all patients
■ Decreased patient morbidity received scaling, root planing, and prophy-
■ Excellent esthetic results laxis. If needed, oral hygiene instructions
■ Increased patient motivation/ consisting of flossing and the roll technique
acceptance using a soft toothbrush to address the re-
lated etiology of the gingival recession
Disadvantages were also given. Full-mouth peri-apical and
■ Additional costs bitewing radiographs were taken to evalu-
■ Learning curve associated with the ate interproximal alveolar bone level to as-
handling of the material sist in gingival recession classification of
■ Technique-sensitive procedure teeth exhibiting recession defects. Vertical
■ Increased healing time recession (height), horizontal recession
(width), probing depth, and amount of ker-
Indications atinized tissue were measured. Only teeth
■ Root coverage on single and multiple with recession defects classified as Miller
gingival recessions Class I or II were selected for treatment.47
■ Soft tissue flap extension over bone graft Prior to surgery, the patient rinsed for 60
■ Amalgam tattoo correction seconds with a 0.12% chlorhexidine mouth
■ Soft tissue defect repair rinse.
■ Augmentation of a minimal band of Rehydration of the acellular dermal graft
keratinized tissue in shallow vestibule material for a minimum of 10 minutes (with
■ Increasing the zone of keratinized tissue sterile saline combined with metronidazole
around teeth and implants solution) is essential. ADM should be ori-
■ Ridge preservation/augmentation46 ented with the basement membrane side
against the bone and teeth, while the con-
nective tissue should face the overlying
Surgical protocol flap.
The surgical sites were anesthetized
EMD/ADM alone or combination offers an with 2% lidocaine HCI, 1:100,000 epineph-
excellent alternative for patients who do not rine. Teeth with gingival recession ≥ 3 mm
desire a second surgical site or have limit- as well as adjacent teeth with gingival re-
ed tissue available to harvest and transplant. cession ≤ 2 mm were included in the sur-
The clinical cases presented in this article gical procedure.
will illustrate the surgical use of these recent After peri-apical and intrapapillary anes-
materials. All patients treated presented with thesia, bleeding points equivalent to the
very thin, transparent gingival margins. The amount of buccal recession are marked in
exposed root surfaces were sensitive to hot the adjacent interproximal papillae with a

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probe at the location the interdental new Flap elevation
papillae tip. Scalloped sulcular incisions (Clinical case 1: Figs 1 to 10)
are made with the new papillae tips formed
from the existing papillae. To increase the amount/thickness of kera-
Two types of procedure have been used tinized tissue for restorative purposes (lam-
to treat this kind of patient: the flap elevation inate veneers) around teeth presenting
technique and the pouch-tunneling tech- multiple gingival recession, flap elevation
nique using EMD combined with ADM. was planned. The sulcular incision design
using a round blade or a no. 15c blade en-
ables an envelope full-thickness mucoperi-

Figs 1 and 2 Class I and II maxillary and mandibular multiple gingival recessions.

Fig 3 Full-thickness elevation. Fig 4 Acid-gel preparation.

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Fig 5 ADM suturing and EMD-gel application over Fig 6 Coronally advanced flap with interrupted sling
the root under the membrane. sutures.

Figs 7 and 8 Three months after healing, total root coverage and increased keratinized gingiva are evident.

Figs 9 and 10 Six months after healing with laminate veneers in place (Dr C. Raygot).

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osteal flap reflection. This was extended 3 Since ADM is acellular, there are no
mm apical to the alveolar bone crest using blood vessels that could contain blood or
a microperiosteal elevator, followed by dead spaces. Stretching the allograft pro-
split-thickness flap reflection. vides better adaptation to the underlying
The split-thickness flap dissection using periosteal surface and may also aid in the
a no. 15 blade was extended mesially, dis- development of a new blood supply for the
tally, and apically to facilitate adequate mo- graft by opening microspaces in the graft
bility and coronal positioning of the flap to allow the ingrowths of blood vessels
without tension. Releasing incisions were from the adjacent tissue.48
not performed to reduce the possibility of Correct suturing is critical for the suc-
ADM exposure. This is an important factor cess of this procedure, since it must be
since exposure could compromise the vas- used to immobilize the graft and stabilize
cular supply to the ADM graft. The incision the underlying blood supply. Interrupted
is extended to the nearest mesio/distal line sutures between the margin of the graft
angle of the adjacent nondefect tooth. and the base of the papillae lead to immo-
The root surfaces were planed thor- bilization. Next, the ADM graft was further
oughly using curettes to remove contami- secured with sling sutures around the
nated cementum and then prepared using palatal side of the teeth and immobilized in
a fine diamond bur to flatten the prominent the periosteum apically with an Ethicon
root surface as necessary. The exposed 5/0 suture. This suture material is ideal be-
root surfaces were conditioned with pre- cause it is a monofilament with an extend-
gel for 2 minutes to remove the smear lay- ed resorption time of approximately 10
er. After acid application, the area was weeks. Following anchoring of the graft
rinsed with saline solution. material, the flap is coronally advanced
The papillae were then de-epithelialized and sutured to cover the entire ADM graft
to ensure a good visualization of the con- using a double-sling suture technique with
nective tissue bed. The ADM graft was a palatal notch. The flap tension before su-
sized in the mouth. The graft was then re- turing should be passive. Subsequently,
moved from the mouth, adjusted to fit the EMD gel was applied with a syringe to the
area to completely cover the defect, and exposed root surface prior or after placing
positioned at the CEJ. The superior and lat- the ADM, or sometimes after suturing the
eral borders of the graft are extended at flap to better visualize the surgical field.
least 3.0 mm beyond the alveolar defect
margins. The ADM graft is placed with the
basement membrane side against the
bone and teeth, while the connective tissue
side faces the overlying flaps.
Stretching the graft during suturing is
advocated to counteract primary contrac-
tion and make the graft more receptive to
vascularization. Graft stretching also helps
prevent the development of dead spaces
underneath the graft.

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The tunneling-pouch technique croperiosteal elevator and staying in close
(Clinical case 2: Figs 11 to 20) contact with the contour of the bone pe-
riosteum to prevent cutting the muscles
The tunneling technique is used to treat si- fibers, was extended mesially, distally, and
multaneous multiple Class 1 or II reces- apically to facilitate adequate mobility and
49,50
sion. The sulcular incision design is de- coronal positioning of the flap without ten-
veloped using a round blade or a no. 15c sion. This partial dissection is carefully per-
blade. An envelope full-thickness mucope- formed to create a deep pouch beyond the
riosteal flap reflection is extended 3 mm mucogingival junction, being careful not to
apical to the alveolar bone crest using a perforate the alveolar mucosa while keep-
microperiosteal elevator, followed by split- ing the tip of the interproximal papillae at-
thickness flap reflection. Split-thickness flap tached to the teeth below the proximal
dissection, using a no. 15 blade or the mi- contact point.

Fig 11 Class I and II multiple gingival recessions. Fig 12 Sulcular incision performed with an oph-
thalmic blade.

Fig 13 Mini-full thickness flap elevation performed Fig 14 Papillae elevation using the Orban knife with-
with a micro-elevator. out cutting the peak of the papillae.

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Fig 15 After partial dissection, the vertical depth of Fig 16 Continuity of the tunneling is explored with the
the pouch is assessed with a periodontal probe. probe.

Fig 17 ADM is cut into 2 pieces before rehydration. Fig 18 Insertion of the ADM in the tunnel using a su-
ture needle.

Fig 19 Coronally advanced flap with suspended Fig 20 Full root coverage after 3 months of healing.
sling sutures.

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The root surfaces were planed thor- The healing progressed uneventfully with
oughly using curettes to remove contami- the exception of some postoperative oede-
nated cementum and then prepared using ma in the days immediately following sur-
a fine diamond bur to flatten the prominent gery. It is important to prevent as much
root surface as necessary. The rehydrated swelling as possible because clinical ex-
ADM graft should be oriented with the perience has shown that oedema can dis-
basement membrane side against the rupt graft stability and cause the sutures to
bone and teeth, while the connective tissue pull through the papillae, thus resulting in
should face the overlying flap. ADM is del- apical flap displacement.
icately inserted below the papillae inside The patient is seen weekly for postoper-
the pouch using a 4-0 suture on one ex- ative visits to evaluate healing and plaque
tremity and then stabilized with the CAF control. Sutures are not removed until the
using a 5-0 vicryl sutures. 1-month postoperative visit. The patient is
instructed to resume gentle mechanical
tooth brushing on the treated sites using a
Postoperative protocol soft brush with the roll technique after 4
weeks. Professional plaque control, con-
Immediately following surgery, an ice pack sisting of debridement and oral hygiene in-
was applied intermittently at 15-minute in- struction, was performed weekly during
tervals for the first 2 hours at the surgical the first 4 weeks, and scaling was per-
site. All patients were advised to discontin- formed at the 3-month and 6-month re-
ue mechanical oral hygiene measures for calls.
4 weeks following surgery to minimize trau- Complete root coverage in both surgi-
ma to the surgical sites. A cold liquid diet cal techniques was achieved in addition to
was recommended for the first 24 hours. increasing the thickness of the marginal
Several medications are recommended tissue. Following 6 weeks to 3 months of
and prescribed to the patient: healing, the gingiva showed a healthy ap-
pearance. The gingival margins appeared
■ Chlorhexidine gluconate gel (0.2%) ap- thicker and more resistant to trauma. Sul-
plied 6 times a day for 4 weeks. This cular probing depths were 2 mm or less.
regimen should be continued until rou- In approximately 6 months, the tissue will
tine oral hygiene procedures can be re- mature to a smooth contour.
sumed at approximately 1 month.
■ Systemic antibiotic (amoxicillin 500 mg,
3 times a day for 7 days) to prevent bac- Discussion
terial plaque from colonizing the graft
material and enhance optimal healing. The objective of mucogingival plastic sur-
■ Ibuprofen 400 mg 3 times a day to con- gery is successful coverage of exposed
trol postsurgical pain. root surfaces, along with good esthetics
■ Methyl prednisolone tablets (20 mg for and function. In a 2-year prospective study,
3 days) to minimize undesirable post- tooth-brushing habits were shown to be of
surgical problems and reduce post- greater importance than increased gingi-
operative swelling. val thickness for long-term maintenance of

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the surgically established soft tissue mar- The modified technique is more suitable
gin. Modifications in oral hygiene instruc- for root coverage procedures with ADM
tion, consisting of the roll technique using since it had statistically significantly better
a soft toothbrush, meticulous oral hygiene clinical results compared to the traditional
maintenance, and flossing, may help to technique with a connective tissue graft.43
26
improve long-term stability. Many surgi- It can be concluded that both tech-
cal techniques have been evaluated in an niques can provide significant root cover-
attempt to achieve more effective and pre- age in Class I and II gingival recessions
dictable root recession coverage while (76% for the ADM group and 71% for the
minimizing surgical complications. CAF group); however, greater keratinized
tissue thickness can be expected with
ADM.53 Treatments with a CAF plus an
Coronally advanced flap ADM allograft significantly increased gingi-
val thickness compared with a CAF alone.
Zucchelli and Sanctis51 evaluated the effec- Recession defect coverage was signifi-
tiveness of a new surgical approach to cantly improved with the use of ADM.54
CAFs in the treatment of multiple Miller
Class I and II recession defects in patients
with esthetic demands. At the 1-year ex- Subepithelial connective tissue
amination, on average, 97% of root sur-
graft
faces were covered with soft tissue, where-
as 88% showed complete root coverage. Connective tissue grafts are currently con-
Without vertical releasing incisions, blood sidered the gold standard for root cover-
supply to the flap was adequate–a factor age since they are highly predictable pro-
deemed critical to the success of the sur- cedures for treating recession defects with
gery and avoidance of an unesthetic white an average of 65% to 98% root coverage.
scar. However, root coverage with connective
Comparisons between the study tissue grafts appears to be negatively as-
groups revealed no statistically significant sociated with cigarette smoking. Smokers
differences in terms of clinical attachment should consider smoking cessation or re-
gain, probing depth reduction, and in- ducing the use of cigarettes for optimal re-
crease in keratinized tissue from baseline sults with connective tissue grafts.55 A com-
to 6 months. Root coverage was 79% for mon concern of patients is that connective
the test group and 63.9% for the control tissue grafts require an additional surgical
group. The mean gain of keratinized tissue site and produce added morbidity. Har-
was 0.7 mm for the ADM group and 0.2 vesting a palatal or other intraoral donor
mm for the CAF group. site causes additional discomfort to the pa-
Cigarette smoking negatively impacted tient and increases chair time for the sur-
the clinical outcomes, specifically the geon. Although connective tissue grafts
residual recession, percent of root cover- and ADM grafts have a slightly different his-
age, and frequency of complete root tologic appearance, both can be used suc-
52
coverage. cessfully to cover denuded roots with sim-
ilar attachments and no adverse healing.34

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Recession defects may be covered us- Enamel matrix derivative
ing ADM or connective tissue grafts with A CAF alone or with EMD is an effective
no practical differences. However, connec- procedure to cover localized gingival re-
tive tissue grafts result in a significantly cessions. The addition of EMD significant-
greater gain of keratinized gingiva.56 Semi- ly improves the amount of root coverage.44
lunar CAFs and subepithelial connective Both connective tissue grafts and EMD
tissue grafts were effective in providing root proved clinically successful. Connective
coverage in Class I and II gingival reces- tissue grafts showed a higher percentage
sion defects where the patient presented of root coverage and increased amounts
with at least 2 mm of keratinized gingiva of keratinized gingiva. EMD is a valuable,
prior to root coverage; however, subepithe- long-term treatment alternative to achieve
lial connective tissue grafts resulted in root coverage together with an increase in
thicker gingival tissue.57 The use of acellu- height of keratinized gingiva.58
lar dermal graft material in mucogingival At concentrations of < 50 μg/mL, EMD
surgery can minimize or eliminate both of results in significant stimulation of mi-
these problems. crovascular endothelial cells proliferation,
Obtaining predicable and esthetic root suggesting a possible mechanism for pe-
coverage is important, and similar results riodontal wound healing. It is likely that
were obtained with connective tissue graft- EMD stimulates angiogenesis directly by
ing and ADM. However, in long-term cas- stimulating endothelial cells and indirectly
es where multiple defects were treated by stimulating the production of angio-
with an acellular dermal matrix, the mean genic factors via PDL cells. It also likely that
root coverage (70.8%) was greater than EMD enhances the communication be-
the mean root coverage in long-term cas- tween microvascular endothelial cells and
es where a single defect was treated with PDL cells during angiogenesis associated
a connective tissue graft (50.0%). It seems with healing.59
that ADM may be better indicated for mul-
tiple recession defects.30
These results indicate that the extended Acellular dermal matrix
flap technique in the treatment of localized
gingival recessions with an ADM graft ex- ADM grafting has become increasingly
hibit statistically significant superior clinical popular as a substitute for connective
performance compared with the conven- donor tissue in plastic periodontal surger-
tional connective tissue technique. ies in order to achieve more esthetic and
These results indicate that root cover- long-lasting results for gingival recession
age via subpedicle ADM allografts or in the esthetic zone. Recently, ADM graft-
subepithelial connective tissue autografts ing was effectively used as a substitute for
is a very predictable procedure that is sta- autogenous gingival grafts in root cover-
ble for 2 years postoperatively. However, age procedures.53
subepithelial connective tissue autografts This material is available in unlimited
resulted in significant increases in defect supply without creating a second surgical
coverage, keratinized gingival gain, attach- site and can be purchased in small or
ment gain, and residual probing depth.45 large pieces to cover limited or large areas

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of buccal recession in one surgery.60 The opment of the extended flap technique for
main disadvantage is that the material is root coverage with ADM grafts shown in
an allograft, requiring donated tissue from this study was based on this principle. In
a human source and creating more ex- fact, the displacement on the adjacent
penses for the patient. teeth provides more blood vessels, more
ADM was reported to increase gingival nutrients, and a better source of cells. Fur-
thickness and keratinized tissue thickness ther, it allows easier tissue manipulation,
compared to CAF alone, particularly in especially in obtaining a tensionless CAF
cases that involved recessions on multiple to completely cover the allograft. This effort
teeth. Gingival attachment to the root sur- is particularly important because the ADM
face was comparable for connective tissue gaft has the ability to revascularize only
grafts and ADM grafts, demonstrating a when in direct contact with vital tissues.43
long junctional epithelium and connective The results revealed a statistically signif-
tissue adhesion, with the underlying alve- icant improvement in clinical performance
olar bone essentially unaffected. The graft- with the ADM approach. Previous studies
ed ADM appeared to be well incorporated showed that ADM grafts increased margin-
with new fibroblasts, vascular elements, al tissue thickness histologically as well as
and collagen while retaining its elastic fib- clinically. It was suggested that a thin gingi-
bers throughout. From 6-month histologic val biotype and delicate marginal tissues
observations, it was apparent that equiva- could be factors in increasing the risk for
lent attachment to the root surface was gingival recession. Therefore, an increase
present. An increase in marginal tissue in gingival thickness resulting from the
thickness was also present, equivalent to a ADM graft may prevent further recession in
54
palatal graft. patients with a thin periodontal biotype.
In general, the survival capability of grafts
at the receptor site represents a great chal-
lenge for root-coverage surgical proce- EMD and ADM
dures. This is even more challenging when
(Clinical case 3: Figs 21–29)
dealing with ADM grafts in the esthetic zone,
which is a nonvital graft dependent on host EMD or ADM treatments for root coverage
cell infiltration and blood vessel invasion. are relatively easy to perform and present
The use of ADM prevented the need for a low patient morbidity and a significant in-
second surgical site for donor material and crease in the percentage of root coverage
the possible postoperative complications. It and keratinized tissue. Cueva et al33
also enhanced patient comfort and satisfac- demonstrated that EMD increased the per-
tion. It has demonstrated excellent function- centage of root coverage and width of ker-
61
al and esthetic results. atinized tissue.
This new root-coverage technique em- A recent study62 demonstrated that ADM
phasizes the need for a close blood sup- and ADM plus EMD significantly improved
ply evaluation and better tissue manipula- the clinical variables in terms of horizontal
tion when dealing with ADM. The flaps recession, vertical recession, probing at-
should be broad enough at the base to in- tachment level, root surface area, percent-
clude major gingival vessels. The devel- age of root surface coverage, and amount

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of keratinized tissue. EMD used in con-
junction with ADM resulted in a statistical-
ly significant increase in keratinized tissue.
This technique has proved very effective
for the treatment of multiple gingival reces-
sions. The results of the present study
compared favorably with previous studies
reporting an increase in keratinized tissue,
predictable root coverage, and clinical at-
tachment gain following ADM grafting.62
Most of the failures occurred in heavy
smokers. A review of the patients’ health Fig 21 Class I and II multiple gingival recessions with
questionnaires revealed a 100% correla- cervical abrasion.

tion between failure to obtain root cover-

age and heavy smoking. After this correla-
tion was made, heavy smokers were
requested to refrain from smoking during
the initial 2-week phase. Miller Class I and
II recession defects healed with almost
complete defect coverage, regardless of
whether ADM or ADM plus EMD was
used, whereas more predictable clinical
root coverage was observed when ADM
plus EMD was used. No significant differ-
ences in probing attachment level or per-
centage of root surface coverage were ob-
Fig 22 The amount of keratinized gingiva on the left
served when sites treated with ADM plus
canine is > 3 mm with a gingival cleft on the first pre-
EMD were compared to sites treated with molar.
ADM alone.62
The last clinical case presented in this
article (clinical case 3: Figs 21 to 29) is in
accordance with the conclusions of the
above study: (1) If there is no need to in-
crease the amount of keratinized gingiva
≥3 mm), either EMD or ADM could be
used to cover the single or multiple gingi-
val recessions; and (2) If, on the contrary,
there is less than 3 mm of keratinized mar-
ginal gingiva around the recession, or if
there is a particular objective to increase
the quality and quantity of soft tissue, then
Fig 23 Full/partial flap dissection and elevation.
it is recommended to use EMD combined
with ADM.

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Fig 24 Acid-gel application on the root surface Fig 25 Clean root surface after rinsing the gel.

Fig 26 ADM suture on the lateral incisor and premolar. Fig 27 EMD-gel application on the canine only.

Fig 28 Free-tension coronally advanced flap with Fig 29 After 6 months of healing, total coverage of
sling sutures. the gingival recessions is evident, with the same
amount of keratinized gingiva on the canine and adja-
cent teeth.

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Conclusions or, and therefore develops appearance
from the cells of adjacent tissues.63
EMD and ADM grafts have become in- EMD and ADM provide statistically sig-
creasingly popular as substitutes for donor nificant improvements in the adjacent
connective tissue in single and multiple teeth. The use of EMD alone or in conjunc-
gingival recession and augmentation pro- tion with ADM also demonstrates the supe-
cedures because they eliminate the afore- riority of the procedure in the treatment of
mentioned disadvantages of autogenous localized gingival recessions by avoiding
graft materials. One limitation of autoge- the postoperative morbidity associated
nous grafts is the limited supply of donor with harvesting palatal connective tissue.
connective tissue. Multiple sites often need The unlimited supply of EMD and ADM al-
several surgical procedures, which is not lows for extended elevated flaps to achieve
well accepted by patients. multiple site root coverage.64 The proposed
EMD obtained from embryonic pork technique of root coverage with an ADM
enamel may enhance microvascular cell graft could be a good alternative to soft tis-
effects on the tissue-specific cells required sue grafts and should now be part of the
to support the regeneration process. This periodontal plastic surgery armamentarium.65
new finding helps explain the role of EMD
in periodontal healing.59
Alloderm is obtained from human donor References
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