ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Acellular Dermal Matrix Allograft is An Acceptable Clinical Substitute for Subepithelial Connective Tissue for Root Coverage Procedures
Clinical Question For an otherwise healthy patient, can you achieve better long-term root coverage using acellular dermal matrix or the patient’s own connective tissue as the graft material?
Clinical Bottom Line Acellular dermal matrix is an acceptable substitute material to subepithelial connective tissue in cases where the patient’s needs for root coverage overwhelm the amount of donor tissue and where patients are not tolerant to a second surgical site.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 25644302Chambrone/2015234 articlesMeta-Analysis
Key resultsAll procedures done with connective tissue or acellular dermal matrix in conjunction with coronally advanced flaps showed significant reduction in recession, even complete root coverage, in a highly predictable fashion. Acellular dermal matrix with coronally advanced flaps is an adequate substitute for subepithelial connective tissue, even in the posterior mandible.
#2) 24174728Thomas/201310 patients, 20 sites treatedSplit Mouth Design study
Key results180 days post-op, there was no significant difference between the sites treated with subepithelial connective tissue and acellular dermal matrix. Both showed significant reduction in recession depths.
#3) 12546089Tal/20027 patients, 14 sites treatedSplit Mouth Design Study
Key resultsAfter one year, root coverage was similar across the two groups. The difference in keratinized tissue gain was statistically better for the subepithelial connective tissue graft group.
Evidence Search ((root coverage) AND acellular dermal matrix) AND connective tissue
Comments on
The Evidence
Validity: - The meta-analysis was performed by searching MEDLINE, EMBASE, and CENTRAL databases for randomized control trials comparing sub-epithelial connective tissue graft material versus other means of treating gingival recession. Only those trials that included at least six month’s follow up were included. The patient pools were adequately similar and across the RCT’s, Miller classifications I-IV were included. There is limited information for Miller class IV’s. - In the first listed split mouth design study, ten patients with multiple recession sites bilaterally were treated by a single operator and observed by a different clinician who was unaware as to which sites were treated with which material, thus taking away any opportunity for bias. The two groups were Group I with subepithelial connective tissue graft (SCTG) and acellular dermal matrix allograft (ADMA) in Group II. The follow up at 180 days is adequately long, and the patients all had similar recession height (RH) and (RW) widths to start with (RH Group I: 3.3 +/- 0.7 mm and Group II: 3.2 +/- 0.4 mm, P = 0.56; RW Group I: 3.3 +/- 0.3 mm and Group II: 3.1 +/- 0.3 mm, P= 1.00). They all showed significant improvement in RH and RW (RH P = 0.003 and 0.004; RW P = 0.002 and 0.003) and ended with no significant difference between them (RH P = 0.16 and RW P = 0.32). Statistical analysis showed that there was no difference in width of keratinized gingiva gained at the end of 180 days (P = 0.16), however, at 90 days the SCTG group did show a significant increase in keratinized gingiva of 6.6 +/- 0.07 mm (P=0.046) compared to 6.1 +/- 0.07 mm for the ADMA group. There was however a statistically significant difference in gain of attachment level for the subepithelial connective tissue (Group I: 0.9 +/- 0.3 mm, Group II: 1.3 +/- 0.5 mm, P = 0.02). - In the second listed split mouth design, seven patients with multiple bilateral lesions were included. Sites were randomly divided, and each site had 4 or more millimeters of recession. After twelve months, the group that received acellular dermal matrix allograft (ADMA) saw root coverage on average of 4.57 mm, where the sites that received subepithelial connective tissue grafts (SCTG) had mean gains of 4.29 mm (P=NS). Both groups showed shallow probing depths (ADMA 0.22mm and SCTG 0mm). There was a statistically significant difference in keratinized tissue gain across the two groups, however, with the ADMA group showing 0.86 mm of gain and the SCTG group saw 2.14 mm in keratinized gingival gain (P < 0.05). Perspective: While SCTG are almost always a possibility, ADMA is also widely accessible and requires minimal additional training. Both are usable in conjunction with coronally advanced flaps. The first split mouth study shows the results for multiple teeth treated, which have no significant difference to our current gold standard of treatment, SCTG, when it comes to root coverage. The second split mouth study also showed results with extensive recession (equal to or greater than 4 mm), which were comparable to SCTG long-term root coverage. While patients that receive SCTG gain more keratinized gingiva after 12 months, there is no practical difference between the two grafting materials.
Applicability In patients with mild to extensive gingival recession or for patients not wanting to endure the discomfort of a second surgical site, acellular dermal matrix allograft can be used for multiple areas of recession as successfully as the patient’s own connective tissue.
Specialty/Discipline (Periodontics)
Keywords Acellular dermal matrix, ALLODERM, subepithelial connective tissue, root coverage, coronally advanced flaps
ID# 2848
Date of submission: 04/10/2015spacer
E-mail bowmanse@livemail.uthscsa.edu
Author Shelby Bowman
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Richard S. Finlayson, DDS
Faculty mentor/Co-author e-mail finlaysonr@uthscsa.edu
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