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 Table of Contents  
REVIEW ARTICLE
Year : 2014  |  Volume : 4  |  Issue : 2  |  Page : 70-80

Treatment of gingival recession with coronally advanced flap combined with connective tissue graft/alloderm: A systematic review


Department of Periodontology, Bapuji Dental College and Hospital, Davangere, Karnataka, India

Date of Web Publication11-Sep-2015

Correspondence Address:
Gunjiganur Vemanaradhya Gayathri
Department of Periodontology, Bapuji Dental College and Hospital, Davangere - 577 004, Karnataka
India
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Source of Support: Nil., Conflict of Interest: There are no conflicts of interest.


DOI: 10.4103/2231-6027.165102

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  Abstract 

The purpose of this systematic review was to compare the efficacy of acellular dermal matrix (ADM) with coronally advanced flap (CAF) to connective tissue graft (CTG) with CAF in the treatment of localized Miller's Class I and II gingival recessions. Systematic review was limited to randomized clinical trials (RCTs) on the treatment of Miller Class I and II gingival recessions with at least 6 months of follow-up. Articles from January 1 1990 to June 2014 related to ADM were searched utilizing the MEDLINE database from the National Library of Medicine and through hand searches of reviews and recent journals. The primary outcome variable was root coverage (RC). A total of 248 Miller Class I and II gingival recessions in 143 patients from 10 RCTs were evaluated in this systematic review. Data collected by this study connote the following: There were no significant differences between ADM with CAF and CTG with CAF for recession coverage, and both procedures may be equally effective in clinical practice. Within the limitations of this study, it appears that ADM-based periodontal plastic surgery can be used successfully to treat gingival recession defects and to increase keratinized gingiva.

Keywords: Acellular dermal matrix, connective tissue graft, gingival recession, mucogingival surgery, systematic review


How to cite this article:
Gayathri GV, Choudary S, Bharath N, Shilpa E, Mehta DS. Treatment of gingival recession with coronally advanced flap combined with connective tissue graft/alloderm: A systematic review. Int J Oral Health Sci 2014;4:70-80

How to cite this URL:
Gayathri GV, Choudary S, Bharath N, Shilpa E, Mehta DS. Treatment of gingival recession with coronally advanced flap combined with connective tissue graft/alloderm: A systematic review. Int J Oral Health Sci [serial online] 2014 [cited 2019 Sep 20];4:70-80. Available from: http://www.ijohsjournal.org/text.asp?2014/4/2/70/165102


  Introduction Top


Gingival recession is a matter of concern for both patients and dental professionals, especially when exposure of the root surface is linked to deterioration in esthetic appearance and increase in dental hypersensitivity.[1]

Several techniques have been developed to obtain the satisfactory results. Among them, the subepithelial connective tissue graft (SCTG) procedure has been viewed as an effective and predictable method to achieve the coverage of denuded root surface in Miller's Class I and II marginal tissue recession. The vitality and high survival potential of SCTGs are achieved by the dual vascular blood supply from the gingival flap facially and the underlying periosteum on the opposite side. It maintains the gingival esthetics by avoiding the keloid appearance of the grafting tissues postoperatively. Even though the SCTG is considered as the gold standard in periodontal plastic surgery, it is associated with some drawbacks such as limited donor tissue availability, requirement of two surgical sites, donor site association with postoperative pain, discomfort, bleeding, and patient morbidity. The procedure is also technically more sensitive.

Recently, an acellular dermal matrix (ADM) allograft has been approved as a substitute for the autogenous connective tissue graft (CTG) in the periodontal plastic surgical procedures.[2] Though it has a dermal origin, recent evidences indicate that the anatomic features observed in this kind of tissue are analogous to that of gingival tissue.[3],[4] Also, it does not have the drawbacks associated with the use of SCTG.

Over the last few years, several studies have evaluated and compared the effects of ADM to CTG for the treatment of gingival recession with variable promising results.[3],[4],[5],[6],[7],[8] Therefore, the purpose of this systematic review was to answer the following focused question: "What is the effect of ADM + coronally advanced flap (CAF) versus CTG + CAF in terms of complete recession coverage (CRC), changes in keratinized tissue (KT), clinical attachment loss, and probing pocket depth (PPD) for patients with localized Millers Class I and Class II gingival recession?"


  Materials and Methods Top


A detailed protocol was designed according to the Preferred Reporting Items Systematic Review and Meta-analyses (PRISMA) statement (Liberati et al. 2009, Moher et al. 2009). The present manuscript was written according to PRISMA checklist.

Information sources and search

Titles derived from this broad search were independently screened by two investigators (AB and CD) on electronic databases until June 2014 for this review. Online evidence source is: The National Library of Medicine (MEDLINE by PubMed), until June 2014, using the strategy: ("{Acellular human matrix OR acellular dermal matrix allograft OR dermal matrix allograft OR alloderm} AND {root coverage OR keratinized gingiva OR gingival recession OR soft tissue OR tooth root surgery OR grafts OR surgical flaps OR gingival recession OR gingival augmentation OR mucogingival surgery OR gingival graft OR connective tissue graft}). Published in the English language.

Hand searching of issues was undertaken from the following journals: International Journal of Periodontics and Restorative Dentistry, Journal of Periodontology, Journal of Clinical Periodontology, Journal of Periodontal Research, and Journal of Indian Society of Periodontology. In addition, other articles were identified from the reference lists of the articles found. The references from AAP position paper (American Academy of Periodontology 1996) and previous systematic reviews dealing with RC procedures [9],[10],[11],[12] were also checked for article identification.

Selection

The criteria for selection of studies for this review were organized by the PICO method and were as follows:

  • P-Types of participants: Patients with a clinical diagnosis of Miller Class I or II localized gingival recession defect
  • I-Types of interventions or test: The surgical procedure for the treatment of single gingival recession was ADM plus CAF (ADM + CAF)
  • C-Comparison or control: The intervention was compared with CTG plus CAF (CTG + CAF)
  • O-Type of outcome measures.


The following outcome measures were considered:

Primary outcome

  • • The primary outcome selected for this analysis was the amount of RC gained.


Secondary outcomes

  • Change in clinical KT levels expressed as KT gain in millimeters at follow-up visit (KT gain),
  • Change in clinical attachment level (CAL) expressed as CAL gain in millimeters at follow-up visit (CAL gain),
  • Change in PPD expressed as probing depth (PD) reduction in millimeters at the follow-up visit (PD red).


Inclusion criteria

The following inclusion criteria were applied: (1) Human studies published in the English language from January 1 1990 to June 30 2014. (2) Randomized controlled clinical trials (RCTs). (3) Studies with a minimum follow-up period of 6 months after periodontal plastic surgery. (4) Studies that assessed systemically healthy patients, were considered.

Exclusion criteria

The following exclusion criteria were applied: (1) Studies not meeting all inclusion criteria. (2) Preclinical (animal) studies. (3) Studies that included smokers. (4) Studies reporting on data from previous publications of the same groups of authors dealing with the same patient's samples.

Selection of studies

Titles derived from this broad search were independently screened by two investigators (AB and CD). Abstracts of all the titles agreed on by both investigators were screened. Full reports were obtained for all the studies that appeared to meet the inclusion criteria or in instances, where there was insufficient information from the title, keywords, and abstract to make a clear decision. Disagreements were resolved by discussion. Finally, the selection based on inclusion/exclusion criteria was made for the full-text articles.

Data extraction

The data retrieved from selected studies were recorded on flow sheets which included:

  1. Name of the authors
  2. Year of publication,
  3. Type and design of study,
  4. Details of participants including, criteria of inclusion/exclusion,
  5. Details of the type of intervention,
  6. Details of the reported outcomes, and
  7. Source of funding.


Validity assessment

According to the Cochrane Handbook Systematic Review of Interventions 4.3.6 (section 6.3).

(Higgins and Green 2006), the methodologic quality assessment of the studies was performed by focusing on the following points:

Method of randomization

Method used to generate the randomization sequence was graded as: (1) Adequate = when random number tables, a tossed coin, or shuffled cards were used; (2) inadequate = when other methods were used such as an alternate assignment, hospital number, or an odd/even date of birth; and (3) unclear = when a method of randomization was not reported or explained.

Allocation concealment

Method used to conceal the randomization sequence from the examiners was graded as: (1) Adequate = when examiners were kept unaware of the randomization sequence (e.g., by means of central randomization, pharmacy sequential numbers, or opaque envelopes); (2) inadequate = when other methods were used such as an alternate assignment or hospital number; and (3) unclear = when the method was not reported or explained.

Masking/blinding of examiners

Masking of examiners with regard to the treatment procedures used in the study period was assessed as yes, no, or unclear.

The completeness of the follow-up/drop outs

The completeness of the follow-up was based on the following question: Were the numbers of subjects at baseline and at the completion of the follow-up period interval reported are same? (yes/no). In addition, the presence of explanations (reasons) for dropouts was checked. Studies that did not report completeness of the follow-up were not included.

Risk of bias

After the quality assessment, studies were grouped into two categories: (a) Low risk of bias if all four quality criteria were met. (b) High risk of bias, if one or more of the four quality criteria were not met.


  Search Results Top


The electronic search in MEDLINE (by PubMed) provided 99 articles and on hand searching found 11 articles. After excluding the duplicate studies, 100 articles were selected for the further screening process. After reviewing the titles and abstracts, 84 articles were excluded. Finally, by crossing the literature searches (electronic and manual data); we were able to select 16 articles. The full-text reading allowed the selection of 10 studies and the exclusion of 6 articles [Figure 1]. At this stage, all the included studies were listed in [Table 1] and excluded studies along with the reason were listed in [Table 2].
Figure 1: Search results

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Table 1: List of included studies

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Table 2: Characteristics of the five excluded studies

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Study characteristics

Excluded studies

Of the 6 excluded studies, three were not RCTs [13],[14],[15] and one study [15] evaluated multiple adjacent sites for each technique in each patient. The other study [16] evaluated changes between 6 and 12 months, and in remaining one study [17] CAF was not followed [Table 2].

Included studies

Of the 10 included studies, 7 studies [7],[18],[19],[20],[21],[22],[23] had an intra-individual (split-mouth) design, 2 studies [8],[24] had parallel group design, and 1 study [6] used split-mouth design for 6 patients and parallel design for 8 patients. Four studies [18],[19],[20],[24] were supported, in part, by companies whose products were being used as interventions in the trials, while the other 6 studies [6],[7],[8],[21],[22],[23] did not report their source of funding [Table 3] and [Table 4].
Table 3: Characteristics of included studies

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Table 4: Characteristics of included studies

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Quantitative data synthesis

For dichotomous outcomes (CRC), the estimates of the effect of an intervention were expressed as odds ratios together with 95% confidence intervals. For continuous outcomes, mean differences and standard deviations were used to summarize the data from each group. Data from split-mouth studies were combined with data from parallel group trials with the method outlined by Elbourne et al.,[25] using the generic inverse variance method in the Rev Man-Version 5.2 (Copen hagen. The Nordic Cochrane Centre, The Cochrane Collaboration, 2012). The techniques described by Follmann et al.[26] were used to calculate the standard error of the difference for split-mouth studies, where the appropriate data were not presented.

The significance of any discrepancies in the estimates of the treatment effects from different trials was assessed by means of Cochran's test for heterogeneity and the I2 statistic, which describes the percentage total variation across studies that is due to heterogeneity rather than change. It was planned to undertake sensitivity analyses to examine the effect of the study quality for CRC.

Methodological quality assessment of the included studies

Randomization

Though the included studies were described as RCTs, but not all of them reported randomization in detail. Seven trials [6],[7],[8],[18],[21],[22],[23] reported an adequate method of randomization, whereas in three trials [20],[24],[27] it was unclear.

Allocation concealment

Allocation concealment was considered adequate in one trial [7] and inadequate in another trial.[20] In remaining all other trials,[8],[18],[19],[21],[22],[23],[24] it was unclear.

Masking/blinding

Examiners were considered masked in four studies [6],[7],[18],[23] and not masked in other four studies,[21],[22],[24],[27] whereas it was unclear in two studies.[8],[20]

Completeness of follow-up/drop outs

Only one study [7] reported dropout.

Risk of bias

All the included studies except one [18] were under the high risk of bias.

Objective evaluation of the included studies

Ten RCTs with a total of 143 patients and 248 recessions were assessed by this systematic review.

Root coverage gain

In the five studies,[6],[7],[8],[19],[20] RC gain by ADM group was more, while in other five studies.[18],[21],[22],[23],[24] RC gain by CTG group was more. However, this difference was statistically significant in only 1 study.[21] The percentage of RC gain was 65.9% and 74.1% by Aichelmann-Reidy et al.,[18] 66.5% and 64.9% by Novaes and Souza,[19] 83.33% and 88.8% by Paolantonio et al.,[24] 89.1% and 88.7% by Tal et al.,[20] 72.08% and 70.12% by Rahmani and Lades,[6] 50.0% and 79.5% by Joly et al.,[21] 71.11% and 85.74% by Sadat Mansouri et al.,[22] 86.93% and 84.72% by Shori et al.,[8] and 89.1% and 96.0% by Thomas et al.[23] for ADM and CTG groups, respectively. Moslemi et al.,[7] showed that the percentage of RC achieved was 87.77% and 66.98% at the end of 6 months and dropped to 54.61% and 39.84% at the end of 60 months for ADM and CTG groups, respectively [Figure 2].
Figure 2: Comparison between CAF + CTG versus CAF + ADM for CRC. CAF: Coronally advanced flap, CTG: Connective tissue graft, ADM: Acellular dermal matrix, CRC: Complete root coverage

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Clinical attachment level gain

Eight studies recorded the CAL gain at the end of the treatment period and 5 of these studies [18],[19],[21],[22],[24] displayed more CAL gain with the CTG group than ADM group. However, this difference was statistically significant in only one study.[21] Three studies [8],[23] showed more CAL gain with the ADM group than the CTG group. But, this difference was not statistically significant. Two studies [7],[20] did not report the CAL postoperatively.

Probing depth reduction

Nine studies [6], 8, [18],[19],[20],[21],[22],[23],[24] reported the PD reduction at the end of the treatment period, but none of them showed statistically significant change. One study 7 did not record the PD levels.

Keratinized tissue gain

Ten studies recorded the KT gain at the end of the treatment period, and seven of these studies [8],[18],[19],[20],[21],[23],[24] revealed more KT gain with the CTG group than the ADM group. However, this difference was statistically significant only in three studies.[8],[20],[24] One study [22] displayed more KT gain with the ADM group than the CTG group. But, this difference was not statistically significant. One study [7] did not record the KT levels.


  Discussion Top


Longitudinal observations and case reports have shown a high success rate and predictability with subepithelial graft procedure.[28],[29],[30] It offered a better color match with the adjacent tissues than that can be obtained with other free graft techniques. However, the disadvantage is that the availability of the inadequate amount of donor material limits the number of teeth that can be treated in a single surgery. Also, this technique involves a certain degree of discomfort for the patient, due to two surgical sites (donor and recipient) which increase the risk of pain and hemorrhage postoperatively. Moreover, if the patient has a shallow palate or thin palatal tissues overall, it becomes difficult to harvest sufficient donor tissue from one site alone. An additional site may be required, and the patient may be subjected to multiple surgeries just to harvest the donor graft tissue. With the availability of an alternative source of donor tissue, patient trauma and the potential morbidity associated with RC procedures could be reduced.

ADM allograft is derived from the processed human donor skin obtained from approved tissue banks. Since its introduction, ADM became widely utilized in the grafting of burn patients.[31] Shulman was the first author to document the use of ADM in dentistry.[32] Today, ADM has been utilized for a wide range of dental applications such as soft tissue augmentation,[33] augmentation of keratinized gingiva as a barrier membrane,[34] and for RC procedures.[19],[34],[35],[36],[37],[38],[39],[40] Over the last few years, several studies have evaluated the effect of ADM for periodontal plastic surgery, and the results have been promising.[8],[18],[19],[20],[21],[23],[24] It's main advantages include avoidance of a second surgical area, decreased patient morbidity, and availability of unlimited graft material for treating the multiple recession defects.

In the era of evidence-based medicine, systematic reviews provide concise information from the available literature by using a clearly formulated question,[41] and they also provide data for rational decision-making. The use of explicit methods allows assessment of previous results, limits bias, and increases the reliability and accuracy of conclusions.[42]

Hence, with the predetermined focused question, only RCTs were considered for this systematic review; as controlled clinical trials, case series, and case reports have serious methodological flaws and their inclusion in a systematic review leads to very weak evidence, and adds little to general knowledge of a problem. Studies dealing with Miller's Class I and II recession were chosen, as this is the most accepted and widespread gingival recession classification;[43] these are also the classes that show the highest success rates for RC procedures. Studies including smokers were not considered to avoid negative impact on the success rates of periodontal therapy.[44] Despite the use of ADM in the test group, few articles [5],[13],[14],[15],[16] were excluded as the additional variable affecting treatment outcome was beyond the scope of this review.

Of the included 10 studies, only one study [21] showed more significant RC in CTG group compared to ADM group. This implies that both procedures may be effective in clinical practice. The publications utilized for analysis may not have reached the possible breakdown effect of ADM yet, reporting comparable results to CTG. Most of the included studies were with short-term follow-up (≤12 months) but only one study [7] compared the long-term results of CTG and ADM in the treatment of gingival recession. The results of this clinical trial showed that at the end of 5 years, which initially achieved RC was reduced by 33% and 27% in ADM and CTG, respectively. More importantly, 53.3% (9 of 11) and 13.3% (2 of 4) of cases treated with ADM and CTG lost CRC from 6 to 60 months. Since this is the only RCT to provide long-term (5 years) outcome for the comparison of these two techniques, the validity of drawing conclusions about the efficacy of ADM for RC is questionable.

The presence of subepithelial CTG or ADM might have performed as shock absorbers and bouncing the undue forces that otherwise would be conveyed to fragile ripening fibrin clot on the root surface.[45] Histological evaluation of autogenous CTG and ADM in humans at the end of 6 months posttreatment found to be well-assimilated within the recipient tissues. Although computed tomography (CT) and ADM have a marginally different histological appearance, both can efficaciously be used to cover denuded roots with similar attachments and no adverse healing.[46] Hence, even in 9 out of 10 included studies, there were no statistical variations observed for CAL gain.

In deeper periodontal pockets, PD reduction is usually associated with the shrinkage of tissue due to a reduction in inflammation or by a gain in CAL following periodontal therapy. Postoperatively, changes in PD were found to be minimal in all the included studies, which may be reflective of the shallow mean PD identified at baseline. The result obtained from this systematic review showed trends of more KT formation by CTG compared to ADM. The CTG has been known to influence epithelial behavior through the secretion of paracrine growth factors such as keratinocytes growth factor (KGF), direct contact, and by communication through the basement membrane.[47] The genotype of underlying connective tissue would govern the characterization of the epithelium.[48] The placement of autogenous connective tissue patented from the keratinized gingiva on to nonkeratinized alveolar mucosa, consequently gained the keratinized features of the gingiva; based on the results of this, it could be ventured as a possible mechanism for the lack of KG in ADM-treated sites. Alloderm has two surfaces; one has characteristic of the basement membrane, and other surface has characteristics of CT with collagen and elastin fibers. Differences in the orientation of these surfaces may influence the cellular healing dynamics of this material in terms of keratinization.[19] Histological data of sites treated with ADM has validated as an inflammatory response within the grafted tissue which resembles a foreign body reaction.[36] Furthermore, the resultant tissue types of ADM were analogous to "scar" tissue and be short of directing cytodifferentiation of the covering epithelium.[36] Therefore, the transplantation of a nonvital graft originating from a genetically different individual and the genetically different epithelium may lack the inherent ability to direct differentiation of the surface oral epithelium. The process of renovation to generate the scar-like tissue may also lead to wound contracture.

Both freeze-dried ADM and solvent-dehydrated ADM exhibited analogous effects in their ability to correct Miller's Class I and II recession defects.[49] In a recent study, labial submucosal tissue (LST) removal during CAF + CTG procedure, exhibited a greater reduction in gingival recession and good esthetic outcome compared to control group even after 1-year follow-up. The main objective of LST removal was to prevent early shrinkage of CAF and graft exposure, which was evident in the control group to produce poor esthetic results.[50] Future studies comparing the present new technique with alloderm may throw more light on the treatment outcomes.

The purpose of this systematic review is to help, understand, and discuss the sources that can cause variability in results across studies. The predetermined inclusion and exclusion criteria of this study resulted in the utilization of a small percentage of the total number of studies available. It is unknown that how many studies were excluded for being reported in other non-English languages and how they would impact the data. Hence, the applicability of present study, and the clinical significance of the obtained findings may be limited at best. It is important to keep in mind that the results may also be significantly affected by other factors such as soft tissue thickness, flap tension, and experience of the operator.[24],[51],[52]

The consolidated standards of reporting trials (CONSORT) guidelines need to be referred while conducting RCTs, as they provide guidance on the appropriate design and improve the transparency and quality of reporting clinical trials. It also ensures that the readers understand the design, conduct, analysis, interpretation of trials, and validity of the results.[53],[54]


  Conclusion Top


The data collected by this study connote the following: In terms of RC gain, PD red, CAL gain there was no significant difference between ADM with CAF and CTG with CAF, but for KT gain though few studies seemed to favor CTG with CAF but most of the studies were not statistically significant. Thus, within the limitations of this study, it appears that ADM-based periodontal plastic surgery can be used successfully to treat gingival recession defects and to increase keratinized gingiva. It is difficult to draw anything other than tentative conclusions from this systematic review, primarily due to weaknesses in the study design and short-term follow-up of the existing trials. Hence, more RCTs referring CONSORT guidelines with larger sample size and longer follow-up are required to reach more definitive conclusions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

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This article has been cited by
1 An Acellular Dermal Matrix Allograft for Treatment of Multiple Gingival Recession Defects: A Case Report)
Fatemah Mohammad AlAhmari
Journal of Dental Health, Oral Disorders & Therapy. 2018; 9(1)
[Pubmed] | [DOI]



 

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