Use of Double Layer of Acellular Dermal Matrix and Modified Tunnel Technique to Treat Multiple Adjacent Gingival Recession Defects

Douglas H. Mahn, DDS

The objective of connective tissue grafting is to gain root coverage and establish a stable soft-tissue architecture that is natural in appearance. In Miller’s classification, four categories of gingival recession defects were described.¹ (Class I: marginal tissue recession not extending to the mucogingival junction [MGJ]; no loss of interdental bone or soft tissue. Class II: marginal recession extending to or beyond the MGJ; no loss of interdental bone or soft tissue. Class III: marginal tissue recession extending to or beyond the MGJ; loss of interdental bone or soft tissue apical to the cementoenamel junction [CEJ] but coronal to the apical extent of the marginal tissue recession. Class IV: marginal tissue recession extending to or beyond the MGJ; loss of interdental bone extending to a level apical to the extent of the marginal tissue recession.) The height of the adjacent papilla was the limiting factor guiding the amount of root coverage that could be expected from any grafting procedure.

Use of a subepithelial connective tissue graft (SCTG) in conjunction with a coronally advanced flap (CAF) has been shown to be a highly successful method for gaining root coverage and augmenting the thickness.^2-7 SCTGs with a thickness of greater than 2 mm have been reported to be more successful in achieving complete root coverage than thinner SCTGs.⁷ The use of an acellular dermal matrix (ADM) with a CAF is also effective in the treatment of gingival recession defects.^8-11 The use of a double layer of an ADM has been reported to yield stable root coverage for 1 year.¹²

Reconstructing lost interdental papillae can be challenging. To protect the integrity of the interdental papillae, several tunnel techniques have been developed for use in treating multiple adjacent teeth with gingival recession defects.^13-17 Tunnel techniques that permit placement of the graft through a lateral access provided by a vertical incision enable simplified placement of larger grafts.^15-17 Previous descriptions of tunnel techniques involved employing a single layer of graft material.^13-17

The purpose of this article is to demonstrate the use of a modified tunnel technique^15,16 in conjunction with a double layer of ADM in the treatment of multiple adjacent gingival recession defects.

Case Report

A 63-year-old nonsmoker female was referred by her restorative dentist for evaluation and treatment of gingival recession affecting her maxillary incisors (Figure 1). The author found teeth Nos. 7 through 10 to have Miller Class II gingival recession defects and noncarious cervical lesions. The interdental papillae completely filled the interdental embrasure spaces. After discussing the findings and treatment options with the patient, the author and patient decided to treat teeth Nos. 7 through 10 with connective tissue grafting using a modified tunnel technique^15,16 and a double layer of ADM.

Profound local anesthesia was achieved using 2% lidocaine with 1:100,000 epinephrine. Intrasulcular incisions were made using a Bard-Parker No. 15 blade along the facial surfaces of teeth Nos. 7 through 10. Vertical incisions were made distal to teeth Nos. 7 and 10 using the “modified tunnel” technique.^15,16 These incisions extended approximately 8 mm from within the attached keratinized gingiva into the elastic mucogingival tissues. Utilizing the lateral access provided by the vertical incisions, the clinician used an Orban knife and periotome to create a patent tunnel and confirm its presence (Figure 2). Careful dissection using the Orban knife and periotome released the mucogingival flap from the underlying tissues. This permitted passive coronal positioning of the mucogingival tissues of teeth Nos. 6 through 11. Prominent root surfaces and root irregularities were then reduced with hand scaling and root planing.

Two ADM strips (AlloDerm®, BioHorizons, www.biohorizons.com) were trimmed to approximately 5 mm in height and 40 mm in length and inserted into the mucogingival tunnel through one of the vertical access openings. The ADM strips were positioned in a layered fashion within the mucogingival tunnel using the Orban knife and periotome. Both ADM strips were positioned with their connective tissue side facing toward the facial. Complete placement was confirmed by visualizing the ADM through both vertical access openings (Figure 3).

A 4.0 chromic suture was first secured to the facial gingiva between teeth Nos. 12 and 13. A continuous suture technique that weaved the suture between the teeth was used. The facial mucogingival tissue was engaged in a manner that secured both it and the underlying ADM strips in a coronal position. The mucogingival flap completely covered the ADM strips and root surfaces. After the suture engaged the mucogingival tissues and ADM strips between teeth Nos. 7 and 8, the process was repeated in the reverse direction. The final knot of this continuous suture was tied over the initial knot. The lateral access openings were closed and secured using interrupted 4.0 chromic gut sutures (Figure 4).

The patient was prescribed amoxicillin (875 mg) twice a day for 1 week. Ibuprofen (600 mg) was prescribed for discomfort. The patient was instructed to use a 0.12% chlorhexidine rinse for 1 week and to not brush the surgical site in the first week. Remaining sutures were removed at the 1-week postoperative appointment. For the next 5 weeks, the patient was permitted to brush gently. After 6 weeks, the patient was allowed to resume normal brushing.

At approximately 12 weeks, teeth Nos. 7 through 10 were found to have complete root coverage with full and natural gingival contours (Figure 5). At 20 months, the teeth continued to have complete root coverage (Figure 6). The soft-tissue architecture appeared natural and healthy.

Discussion

The SCTG has been considered the gold standard procedure in the treatment of Miller Class I and II recession defects.⁵ Chambrone et al performed a systematic review of root coverage procedures for localized recession-type defects; for SCTG+CAF they reported a range of 64.7% to 97.3% root coverage and a range of 53% to 89.5% for complete root coverage.⁶ In addition, SCTG is cellular and vascular. When left partially exposed, SCTG can increase the width of keratinized tissue (KT).¹⁸

Chambrone et al’s systematic review also reported favorable results for recession-type defects using ADMs.⁶ ADM+CAF had a range of 50.7% to 96% for root coverage and a range of 7.7% to 91.6% for complete root coverage. ADMs, however, are a noncellular scaffold. Portions not covered by the gingival flap will disintegrate due to the ADM’s lack of revascularization. Therefore, the potential for increase in KT is limited.¹⁹

Esteibar et al reported that SCTGs with a thickness of greater than 2 mm had a higher rate of complete root coverage.⁷ In an effort to increase the thickness of an ADM and improve complete root coverage, Mahn treated localized Miller Class I and II gingival recession defects using a double-layer technique.¹² After 1 year, ADM+CAF mean root coverage was 94.7%, and 80.9% of the teeth had complete root coverage.¹²

Given the challenges in reconstructing the lost interdental papillae, maintaining its integrity has been deemed important. To that end, several tunnel grafting techniques have been developed.^13-17 The use of tunnel techniques with ADMs has been shown to minimize shrinkage of the interdental papillae and yield excellent esthetics.^20,21 Techniques described by Mahn^15,16 and Zadeh¹⁷ use a vertical incision that provides a lateral access for graft placement. This incision does not disrupt the integrity of the interdental papillae or marginal gingiva. The space provided by this lateral access is sufficient to facilitate placement of a large graft.

The technique described in this report takes advantage of the benefits of a double layer of ADM and a modified tunnel technique.^15,16 The use of a double layer of ADM may increase the long-term stability of the root coverage achieved,¹² and use of a tunnel technique protects the integrity of the interdental papillae.²⁰

Conclusion

The use of a modified tunnel technique and a double layer of an ADM can be effective in the treatment of multiple adjacent gingival recession defects. In this case, this combined approach resulted in a favorable outcome. Complete root coverage was achieved for teeth Nos. 7 through 10. The mucogingival tissues appeared thicker and natural, and the results were stable between 12 weeks and 20 months.

About the Author

Douglas H. Mahn, DDS
Private practice limited to periodontics and implantology, Manassas, Virginia

References

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21 Mahn DH. Use of the tunnel technique and an acellular dermal matrix in the treatment of multiple adjacent teeth with gingival recession in the esthetic zone. Int J Periodontics Restorative Dent. 2010;30(6):593-599.