m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 8 ( 2 0 2 2 ) S 2 5 1 eS 2 5 7

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Original Article

Comparison of acellular dermal matrix allografts

and connective tissue autografts in soft-tissue
augmentation around immediate implants: A pilot
study

M. Panwar a,*, Manab Kosala b, Dushyant Malik c, Deepak Sharma d

a
Brig DS (E&S), O/o DGDS, New Delhi, India
b
Professor, Department of Dental Surgery, Armed Forces Medical College, Pune, India
c
Graded Specialist (Periodontology), 12 CDU, C/o 56 APO, India
d
Resident, Department of Dental Surgery, Armed Forces Medical College, Pune, India

article info abstract

Article history: Background: Immediate implant has multiple advantages but does not prevent the reduc-
Received 22 July 2020 tion in dimension of the labial cortical plate due to bone remodelling and soft-tissue
Accepted 28 November 2020 collapse along with gingival recession. This Randomised Controlled Trial (RCT) was car-
Available online 2 April 2021 ried out to evaluate the changes in peri-implant soft-tissue dimensions after the imme-
diate implant along with soft-tissue augmentation with acellular dermal matrix and
Keywords: connective tissue autografts.
Immediate implant Methods: Twenty clinical cases requiring tooth extraction in the anterior region of the
Acellular dermal matrix maxilla (single rooted tooth) were selected and randomly divided. An immediate implant
Connective tissue graft with soft-tissue augmentation with acellular dermal matrix (group A) and connective tis-
sue autografts (group B) was carried out. Clinical parameters such as thickness of the
marginal gingiva (mm), width of the keratinized mucosa (KMW) (mm), dimensions of the
interdental papilla between the implant and the adjacent teeth (mesial and distal) and
gingival biotype around the implant at the baseline (before extraction of the tooth) and at
180 days (after implant placement during second-stage surgical exposure) were evaluated.
Results: The mean postoperative gingival thickness and KMW were statistically higher in
group B than in group A. There was statistically significant intragroup decrease in papillary
height in both the groups; however, intergroup change was insignificant. In both the groups,
there was an increase in thickness of gingival tissue, but the gingival biotype remained thin.
Conclusion: Immediate implants augmented with connective tissue autografts showed an
increase in thickness of the gingiva and KMW, reduced papillary collapse and improve-
ment in tissue biotype as compared with the acellular dermal matrix.
© 2021 Director General, Armed Forces Medical Services. Published by Elsevier, a division of
RELX India Pvt. Ltd. All rights reserved.

* Corresponding author.
E-mail address: [email protected] (M. Panwar).
https://doi.org/10.1016/j.mjafi.2020.11.029
0377-1237/© 2021 Director General, Armed Forces Medical Services. Published by Elsevier, a division of RELX India Pvt. Ltd. All rights
reserved.
S252 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 8 ( 2 0 2 2 ) S 2 5 1 eS 2 5 7

Ethical clearance from the institutional ethical committee was

Introduction
obtained before the start of the study. The aim of this study
was to compare the changes in soft-tissue dimensions after
The placement of immediate implants after tooth extraction
soft-tissue augmentation using either ADM or sCTG, i.e.,
has already been accepted as a reliable and predictable
thickness of the marginal gingiva, keratinized mucosa width
treatment modality.1 Although immediate implant placement
(KMW), dimensions of the interdental papilla between the
has multiple advantages, i.e., a reduced number of surgical
implant and the adjacent teeth and effect on the gingival
interventions and less rehabilitation time, it still does not
biotype.
prevent the reduction in dimension of the labial cortical plate
and soft-tissue collapse including collapse of the interdental
papilla.2 In addition, implants and teeth differ in their con-
Patient selection
nective tissue attachment. The collagen fibres around dental
implants exhibit a parallel orientation along with a reduced
Twenty systemically healthy patients requiring tooth extrac-
number of fibroblasts and vascularization.3 Thus, implants
tion in the anterior region of the maxilla (single rooted tooth)
are more susceptible to developing inflammation and bone
were selected from the age group of 18e60 years. The selected
loss from plaque accumulations or microbial invasion. The
tooth had no active periapical or periodontal disease, no pu-
aforementioned drawbacks lead to unfavourable biological,
rulent discharge, trauma to the tooth affecting alveolar bone
functional and aesthetic outcomes.
or root fracture or endodontic treatment failures. The
Lack of keratinized tissue (KT) around implants has been
randomization into group A and group B was carried out with
associated with higher plaque accumulation, inflammation,
the flip of a coin. Simultaneous implant placement was car-
mucosa recession, alveolar bone loss and less aesthetic
ried out after extraction of the tooth in both groups along with
appearance.4e6 Furthermore, soft-tissue thickness (STT) has
soft tissue augmentation using AlloDerm® in group A and
been regarded as a key protective feature in preventing metal
using the sCTG in group B. Informed consent was recorded in
colour exposure and minimizing mucosal recession.7,8 Soft-
presence of a witness after explaining about the nature and
tissue augmentation promotes increase in KT width (KTW)
purpose of the study to each subject during enrolment. Pa-
and STT, which are the two most critical factors in esthetics,
tients with systemic diseases affecting osseointegration and
function and long-term implant stability. Hence, it is often
tissue healing, e.g., osteoporosis and uncontrolled diabetes
suggested to carry out soft-tissue augmentation in thin tissue
mellitus; patients undergoing chemotherapy and radio-
biotype and highly aesthetic areas.9,10
therapy; those with immunocompromised diseases; pregnant
With respect to soft-tissue augmentation surgery, different
and lactating women; smokers and patients under medication
preferred materials and timings have been reported in various
affecting bone metabolism, e.g., bisphosphonates and so on,
studies and reviews.6,9e13 The timing for soft-tissue augmen-
were excluded from the study.
tation can be before implant placement, during the phase of
tissue integration or after final restoration. However, the
literature still lacks consensus on effectiveness of timing.10
Investigations
Over the years, autogenous soft-tissue graft, i.e., sub-
epithelial connective tissue graft (sCTG) has been considered
All the cases were assessed by cone beam computed tomog-
as the gold standard for peri-implant soft-tissue augmenta-
raphy (CBCT) (to identify the intactness of the labial cortical
tion, although some studies have stated that collagen matrix
plate and also to exclude fenestration and dehiscence in
such as acellular dermal matrix (ADM) derived from xenoge-
relation to the tooth) (Figs. 1(A and B), 2(A and B)). Periapical
neic origin or human dermis could attain equivalent out-
and panoramic radiographs were taken, as and when needed
comes.14e16 ADM processing starts with extensive serology
in addition to CBCT. Routine blood and urine investigations
tests, which is followed by removal of the epidermis using
were carried out for the selected patients.
buffer salt solution. Subsequently, it is freeze-dried after a
string of washes using mild non-denaturing detergents to
eliminate the remaining cells.16 ADM, as compared with sCTG,
Procedure
may be a suitable alternative in patients sensitive to pain and
sites having a thick tissue biotype.17
Chlorhexidine mouthwash (0.2%) was used to rinse before the
The literature lacks evidence comparing effectiveness of
application of 2% lidocaine with 1:80,000 epinephrine. The
ADM with that of sCTG around single-tooth immediate im-
planned tooth was atraumatically extracted using periotome
plants. Thus, the present study was aimed at comparing the
to maintain the integrity of the alveolar bone, especially the
soft-tissue dimensions after augmentation with ADM and
labial cortical plate. After inspecting the extracted site,
connective tissue autografts in immediate implant cases.
osteotomy for implant placement was carried out by drilling
in an incremental pattern using the adjacent bony walls as a
guide (Figs. 1(C), 2(C)). Subsequently, integrity of the bony
Materials and methods walls was again checked using a periodontal probe. All the
implants were subcrestally placed and snugly fitted into the
The present study is a randomized, comparative clinical trial socket with 3- to 4-mm periapical engagement of bone.
and was carried out on patients visiting the outpatient Adequate primary stability with at least 35 N cm torque was
department at the dental college in Pune in western India. achieved.
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In group A, the AlloDerm® graft was soaked in sterile water d) Gingival biotype around the implant on augmentation
to hydrate, rinsed in a second container of sterile water and (Table 4): The gingival biotype was assessed by assessing
trimmed to the appropriate size resembling to the size of the the transparency of the periodontal probe while probing
sCTG. AlloDerm® was oriented in such a way that the base- the implant site in mesial, buccal and distal direction.
ment membrane faced the root surface and the exposed ma-
trix faced the covering flap. In group B, the autogenous sCTG
was harvested from the palate between the first maxillary Statistical analysis
molar and first premolar region, at least 2 mm from the
margin of the gingiva. The harvesting of the graft was per- The entire data were compiled in an MS Excel worksheet and
formed by using the ‘single-incision technique’ described by were analyzed statistically by using Statistical Package for
Hurzeler et al.18 i.e., Liu class 1a incision. A combination of full Social Sciences (SPSS version 21.0; IBM Corporation, USA) for
thickness and partial thickness flap design without any ver- MS Windows. The comparison of intergroup categorical vari-
tical releasing incisions was used to create a recipient bed for ables was performed by using the chi-square test or Fisher's
the graft. Both AlloDerm® and sCTGs were positioned over the exact probability test. The results were represented as
implant and under the buccal and palatal flaps (Figs. 1(D), 2(D)) mean ± standard deviation (SD), with P < 0.05 being considered
and further stabilized using the 5-0 vicryl suture by anchoring statistically significant. Statistical significance of difference of
to the buccal periosteum and palatal flap. It was then means of continuous variables was calculated using the inde-
passively covered with a buccal flap (4-0 silk suture) after pendent samples t-test or unpaired t-test for intergroup com-
slightly coronally advancing it using a periosteal releasing parisons and the paired t-test for intragroup comparisons. The
incision to release tension. study results were presented in tabular and graphical format to
Postoperatively, medications were prescribed such as anti- assess the statistical significance of the data more clearly.
inflammatory agents and antibiotics along with mouthwash,
i.e., chlorhexidine. The patients were reviewed after 7 days for
removal of sutures. Wound dehiscence in group A led to 6 Results
graft exposures, whereas in group B, it led to 1 graft exposure.
All complications were resolved by the 8-week follow-up (Figs. Categorical variables of the data were depicted as n (per-
1(E) and 2(E)). At six months, a second surgical intervention centage of cases), and continuous variables of the data are
was performed. The cover screw of the implant was exposed, presented as mean and SD across the two study groups.
with minimal incision at the crest of the placed implant. The
healing abutment was placed. All the cases were successfully Age distribution
rehabilitated with a cement-retained prosthesis (Figs. 1(G) and
2(G)). The distribution of mean age of cases in group A (immediate
implant placement with AlloDerm®) was 32.5 ± 4.7 years and
in group B (immediate implant placement with connective
Clinical parameters measured tissue grafts) was 31.9 ± 4.9 years. It was non-significant be-
tween both the groups (P-value > 0.05).
A single calibrated operator recorded clinical parameters at
baseline (immediately after extraction) and 180 days (after Gingival thickness
placement of the implant), i.e., at the time of permanent
prosthetic rehabilitation. The distribution of mean ± SD of preoperative gingival thick-
ness of cases in group A (0.50 ± 0.09 mm) and group B
a) Thickness of the marginal gingiva (mm) (Table 1): The (0.45 ± 0.10 mm) was statistically non-significant between the
thickness of the marginal gingiva was measured using the two groups (P-value > 0.05) (Table 1).
vernier caliper at 3 mm apical to the estimated free gingival The distribution of mean ± SD of postoperative gingival
margin (based on the cementoeenamel junction [CEJ] of thickness of cases in group A (0.56 ± 0.10 mm) and group B
the adjacent teeth) at the following times: after atraumatic (0.57 ± 0.08 mm) was statistically significant in both the groups
extraction of the teeth (Fig. 1(F)) and after surgical exposure (intragroup comparison) and was higher in group B than in
of the cover screw of the implant at 180 days (Fig. 2(F)). group A (intergroup comparison) (P-value < 0.001).
b) Width of the keratinized mucosa (mm) (Table 2; Figs. 1(I),
2(I)): Width of the keratinized mucosa was measured Width of the keratinized mucosa
using the periodontal probe after determining the muco-
gingival junction using the jiggle method. The distribution of mean ± SD of preopertive width of the
c) Dimensions of the interdental papilla between the implant keratinized mucosa of subjects in group A (3.20 ± 0.42 mm)
and the adjacent teeth (mesial and distal) (Table 3): Using and group B (2.8 ± 0.78 mm) was statistically not significant
the obtained clinical photographs, with the help of the grid, between the two groups (P-value > 0.05) (Table 2).
a reference line was drawn over the preoperative and The distribution of mean ± SD of postoperative width of the
postoperative photograph from the most apical points of keratinized mucosa of cases in group A (2.95 ± 0.28 mm) and
gingival margins on the adjacent teeth, and papillary di- group B (3.40 ± 0.86 mm) was statistically significant (intra-
mensions were calculated both on the mesial and distal group comparison) and was higher in group B than in group A
site [Figs. 1(H), 2(H)]. (intergroup comparison) (P-value < 0.05).
S254 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 8 ( 2 0 2 2 ) S 2 5 1 eS 2 5 7

Fig. 1 e (A) Preoperative photograph (fractured 11). (B) Preoperative CBCT evaluation. (C) Implant (3.8 £ 11 mm) placement.
(D) Stabilization of Alloderm. (E) Six months postoperatively. (F) Postoperative measurement (6 months) of thickness of the
gingiva (0.2 mm). (G) Rehabilitation at 6 months. (H) Postoperative measurement of papillary height (I) Postoperative
measurement (6 months) of width of the keratinized mucosa. CBCT, cone beam computed tomography.

Fig. 2 e (A) Preoperative photograph (vertically fractured 11 with endodontic failure). (B) Preoperative CBCT evaluation. (C)
Immediate implant (3.8 £ 11 mm) placement. (D) Connective tissue graft stabilization at the recipient site. (E) Postoperative
follow-up at 6 months. (F) Postoperative measurement (6 months) of thickness of the gingiva (0.5 mm). (G) Rehabilitation at 6
months. (H) Postoperative measurement of papillary height. (I) Postoperative measurement (6 months) of width of the
keratinized mucosa (3 mm). CBCT, cone beam computed tomography.
 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 8 ( 2 0 2 2 ) S 2 5 1 eS 2 5 7 S255

Table 1 e Intergroup and intragroup comparison of thickness of the marginal gingiva before and after operation (6 months).
Group Thickness of the gingiva Thickness of the gingiva Difference (mm) p-value Remarks
(preoperative) (mm) (M ± SD) (postoperative) (mm) (M ± SD) (M ± SD)
A 0.500 ± 0.0943 0.560 ± 0.1075 0.060 ± 0.0699 0.015 Significant
B 0.450 ± 0.108 0.570 ± 0.082 0.12 ± 0.07 0.001 Significant
p-value 0.626 0.034 0.001
Remarks Non-significant Significant Significant

Table 2 e Intergroup and intragroup comparison of width of the keratinized mucosa before and after operation (6 months).
Group Width of the keratinized mucosa Width of the keratinized mucosa Difference (mm) p- Remarks
(preoperative) (mm) (M ± SD) (postoperative) (mm) (M ± SD) (M ± SD) value
A 3.200 ± 0.4216 2.950 ± 0.2838 0.250 ± 0.2635 0.009 Significant
B 2.8 ± 0.788 3.4 ± 0.864 0.65 ± 0.411 0.001 Significant
p-value 0.328 0.024 0.001
Remarks Non-significant Significant Significant

Table 3 e Intergroup comparison of change in papillary height.

Change after Prosthesis Mesial Distal
Group A Group B Group A Group B
Change after 0.25 ± 0.25 0.06 ± 0.44 0.45 ± 0.37 0.22 ± 0.25
operation (mm)
P value 0.119 0.363
Remarks Not significant Not significant

comparison, the change was statistically non-significant in

Table 4 e Gingival biotype in group A and group B after mesial and distal locations in both the groups.
soft-tissue augmentation (6 months).
Patients Gingival biotype Gingival biotype
Group A Group B
The gingival biotype showed an increase in thickness of
1 Thin Thin
gingival tissue but was still thin after 6 months post-
2 Thin Thin
3 Thin Thin operatively in both group A and group B (Table 4).
4 Thin Thin
5 Thin Thin
6 Thin Thin Discussion
7 Thin Thin
8 Thin Thin
The gains in gingival thickness when measured at 3 mm
9 Thin Thin
10 Thin Thin
apical from the CEJ, obtained in this study (0.12 mm in the
sCTG group and 0.06 mm in the AlloDerm® group), very well
fall within the range of data provided by the few available
Papillary height measurement reports to compare in the literature. The difference between
the groups was statistically significant, with the sCTG group
The distribution of mean ± SD of preoperative papillary height having a higher gain. Although there are ample data available
in mesial and distal locations of subjects in group A in the literature on the comparative or independent use of the
(2.6 ± 0.49 mm, mesial; 2.85 ± 0.39 mm, distal) and group B sCTG and AlloDerm®, specifically around natural teeth,
(2.67 ± 0.47 mm, mesial; 2.94 ± 0.28 mm, distal) was statisti- studies comparing different techniques of gingival thickness
cally not significant (P-value > 0.05) (Table 3). augmentation around implants are not present. In a recent
There was a decrease in papillary height postoperatively, systematic review evaluating the different procedures of
and the distribution of mean ± SD of postoperative papillary augmenting STT and soft-tissue width around the implants,
height of cases in group A was (2.50 ± 0.32 mm, mesial; the sCTG was advocated to be the ‘preferential treatment’
2.40 ± 0.37 mm, distal) and group B was (2.61 ± 0.39 mm, irrespective of the procedural technique.10 The authors also
mesial; 2.72 ± 0.42 mm, distal). On intragroup comparison, the mentioned that there is a ‘paucity of clinical data’ for soft-
decrease was statistically non-significant in mesial papillary tissue substitutes and they cannot be currently advocated.10
height in group B, whereas it was significant in other sites, i.e., Group B showed a statistically significant increase of
mesial and distal sites of group A and the distal sites of group 0.65 þ0 .0411 mm in KTW; however, the gain is comparatively
B (P-value < 0.05). On intergroup postoperative change less than that present in the literature. The reason was
S256 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 8 ( 2 0 2 2 ) S 2 5 1 eS 2 5 7

delay the soft- and hard-tissue dimensional changes that

Table 5 e Implant survival rate.
may appear.27 The sCTG even today is still considered the
Group A Group B normal gold standard, but it has few disadvantages: (1) its
No. of participants 10 10 harvesting is a surgically challenging technique, which is
Implant success rate 100% 100% commonly associated with significant intraoperative and
Complication Nil Nil postoperative bleeding as well as postoperative risk of
infection or necrosis, and (2) it results in a considerable
amount of postoperative morbidity.28 On the other hand, a
attributed to the buccal flap advancement to submerge the
few advantages have been seen with the ADM such as (1)
immediate implant. In group A, a statistically significant
there is no second surgical site, thus reduced intraoperative
decrease of 0.250 þ 0.2635 mm in KTW was seen. The loss was
and postoperative morbidity, (2) there is no constraint of
credited slightly to the flap advancement to submerge the
availability and (3) the total procedure time is greatly
immediate implant. However, predominantly, it was due to
reduced. Owing to all these advantages, acceptance of bio-
the high occurrences of graft exposures due to wound dehis-
materials such as ADMs has increased in patients. A certain
cence. In many of the exposures, the graft had to be partially
group of patients such as those with diabetics who generally
removed to prevent infection to the rest of the graft. The high
have wound healing issues, patients with higher risk of
graft exposures were first due to the absence of cellularity of
bleeding, patients without enough palatal tissue and patients
the ADM; second, owing to non-placement of vertical release
with heightened perception of pain can certainly benefit with
incisions, advancement of the buccal flap to completely cover
ADM.
the graft was difficult; third, for tension-free primary closure,
When the aforementioned information is taken into
a periosteal release incision was made, which further reduced
consideration, the use of the ADM over CTG can be considered
blood supply to the coronal aspect of the flap;19 and finally,
if not preferred as a viable option (Table 5).
because a majority of the portion of already avascular ADM
was placed on a cover screw, it further limited blood supply to
the graft (Table 2).
Conclusion
In concurrence with the aforementioned data, in a study
performed by Park et al.20 in 2006, wherein the ADM was used
Based on the findings, we conclude immediate implant
as a barrier, sandwiched between the facial flap and particu-
placement with soft-tissue augmentation, both with Alloderm
late bone allograft to cover up the bony dehiscence over the
and connective tissue grafts, is a safe, viable and predictable
implant, exposure of the ADM was seen in 3 of 5 patients.
method.
Fascinatingly, ADM in few case reports showed increased
Although the aformentioned study achieved favourable
width of the keratinized mucosa when placed under a partial-
results in the sCTG group compared with the ADM group, ADM
thickness flap.21
use can still be considered, especially when the patient is not
On intragroup comparison, there was a statistically sig-
consenting for sCTG use or there is not enough palatal tissue
nificant decrease in papillary height postoperatively in mesial
and in case of patients with coagulopathies. For more clarity,
and distal locations of group A and the distal location of group
the aforementioned study with a large sample size and long-
B, whereas decrease was non-significant in mesial papillary
term follow-up should be carried out.
height in group B. On intergroup postoperative change com-
parison, the papillary change was statistically non-significant
in mesial and distal locations in both the groups. In implants,
Disclosure of competing interest
the level of the peri-implant papilla is guided by the level of
proximal bone of the adjoining teeth, and the most suitable
The authors have none to declare.
way to preserve the papilla is supporting the hard tissue
straight away after tooth extraction. The absence of immedi-
ate provisionalization in the given study produced the
resulting papillary collapse.22 Previous studies have stated Acknowledgements
that enhanced papilla fill was seen at 1 or more years after
crown placement.23 The data of the study correspond well This paper is based on Armed Forces Medical Research Com-
within the earlier narratives of papilla fill at the point of crown mittee Project No. 4803/2016 granted and funded by the office
placement.24 of the Directorate General Armed Forces Medical Services and
It has been found out by various long-term studies that a Defence Research Development Organization, Government of
thin biotype of the gingiva is commonly related to a consid- India.
erably lower dimension of the peri-implant gingiva than the
thicker tissue biotypes.25 The postoperative gingival thickness
references
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enough, so no change in the gingival biotype was seen in any
of the groups.
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