Volume 76 • Number 11
Case Series
Management of Gingival Recession by the Use of an Acellular
Dermal Graft Material: A 12-Case Series
A. Santos,* G. Goumenos,† and A. Pascual‡
Background: Different soft tissue defects can be
treated by a variety of surgical procedures. Most of
these techniques require the palatal area as a donor
site. Recently, an acellular dermal graft has become
available that can substitute for palatal donor tissue.
Methods: This study describes the surgical tech-
nique for gingival augmentation and root coverage
and the results of 12 clinical cases. A comparison be-
tween the three most popular mucogingival proce-
dures for root coverage is also presented.
Results: The results of the 12 patients and the 26
denuded surfaces have shown that we can obtain
a mean root coverage of 74% with the acellular dermal
graft. Thirteen out of the 26 denuded surfaces had
complete root coverage. The average increase in kera-
tinized tissue was 1.19 mm. It seems that the long-
term results of the cases are stable.
Conclusion: The proposed technique of root cover-
age with an acellular dermal graft can be a good alter-
native to soft tissue grafts for root coverage, and it
should be part of our periodontal plastic surgery
armamentarium. J Periodontol 2005;76:1982-1990.
KEY WORDS
Connective tissue/surgery; gingival recession;
gingival recession/surgery; guided tissue
regeneration.
* Postgraduate Program in Periodontics, International University of
Catalonia, Barcelona, Spain.
† Private practice, Athens, Greece.
‡ Postgraduate Program in Periodontics, International University of
Catalonia.
1982
D
ifferent soft tissue defects can be treated by
a variety of surgical procedures. Most of these
techniques require the palatal area as a donor
site. Recently, an acellular dermal graft has become
available that can substitute for palatal donor tissue.
This study describes the surgical technique for gingival
augmentation and root coverage and the results of 12
clinical cases. The three most popular mucogingival
procedures for root coverage are also compared.
Currently, one of the main objectives in dentistry
and, in particular, the field of periodontology is to
achieve the best esthetic results. The treatment of gin-
gival recession is a clear example of the thorough
search for a satisfactory and predictable method of
aiming at maximal esthetics.
In the last few years, root coverage has become a
predictable periodontal plastic surgical procedure.
Traditionally, the coverage of denuded root surfaces
has been performed with numerous surgical tech-
niques.1-16 The success of all these procedures varies
considerably and is not always predictable. The type
of gingival recession and the adaptation to the surgi-
cal principles seem to play key roles in the predictabil-
ity.17 Although soft tissue grafts and, in particular, the
connective tissue graft provide excellent esthetics and
predictability, sometimes the quantity of donor mate-
rial needed is limited when treating several gingival re-
cessions at once. Likewise, soft tissue grafts will need
another surgical area as a donor site. This area is usu-
ally the palate that eventually increases the morbidity
to the patients. Also, some patients fear the surgical
use of the palate as a donor site. Therefore, these com-
plications have led to the search for other techniques
for root coverage.
The principles of guided tissue regeneration have
been applied to the treatment of soft tissue recession
with the aim not only of root coverage but also to
achieve new connective tissue attachment.18 In the last
two decades, the principles of guided tissue regenera-
tion have been used with satisfactory success for root
coverage. The review of the literature confirms the sur-
gical advances with different types of membranes as
well as an increase in the degree of root coverage and
predictability.19-21 However, the guided tissue regen-
eration technique is a highly sensitive technique, and
J Periodontol • November 2005
Figure 1.
A) Clinical appearance of teeth #6 and #7. B) Clinical appearance after flap elevation. A partial-thickness flap was performed.
C) Placement and suturing of the acellular dermal graft. D) Sutured overlying flap. E) Clinical appearance at 6 months postoperatively.
F) Clinical appearance at 2 years.
the predictability seems to be related to the technique
itself and the quality of the tissue covering the mem-
brane.22 The exposure of the barrier seems to be a com-
mon complication of this technique.22-25 The exposure
is proportional to the degree of success: the more ex-
posure we have, the less success we are going to
achieve. Therefore, a key factor for obtaining complete
root coverage is to avoid the barrier exposure.
In summary, each of these surgical techniques for
root coverage has advantages and disadvantages,
and there is not a unique procedure that works in all
situations.
Recently, an acellular dermal graft§ has become
available as a substitute for palatal donor tissue and
could be an effective alternative to autogenous and
freeze-dried skin graft materials. This acellular dermal
graft has been extensively used in medicine for full-
thickness burns.26-28 It has been used for revision of
depressed scars, nasal reconstruction, rhytid revision,
facial defect repair, septal perforation repair, and
parotidectomy defect repair.29-36
Recently, this acellular dermal allograft material
has been used in dentistry. It has been used as a sub-
stitute for palatal donor tissue in soft tissue surgeries
around natural teeth and implants to increase the zone
of keratinized tissue. This allograft is obtained from
human cadavers, from which the cell component is re-
moved and the ultrastructural integrity of the extracel-
lular matrix is maintained. The dermal matrix exhibits
Santos, Goumenos, Pascual
undamaged collagen and elastin and does not elicit an
inflammatory response in the host tissue. By remov-
ing all cellular components, the source of disease
transmission and immunologic reaction is minimized,
leaving a structurally intact connective tissue matrix
composed of type I collagen. The tissue is, therefore,
considered to be acellular and non-immunogenic;
healing occurs by repopulation and revascularization
rather than granulation to limit scarring.26-30 The spe-
cial qualities of the acellular dermal allograft make
it a suitable dermal transplant.26-36
The use of acellular dermal graft has been recom-
mended to increase the zone of attached gingiva
around teeth and implants, obtain root coverage in
gingival recessions, preserve and/or increase the gin-
gival thickness in edentulous areas, and eliminate gin-
gival melanin pigmentation.37-67
The purpose of this article is to show the use of acel-
lular dermal grafts for the treatment of denuded root
surfaces and/or increase in keratinized tissue through
clinical cases recruited from 1999 to 2000 from the
private practice of AS. Three cases were selected ac-
cording to the number of the teeth to be covered. All of
the patients provided informed consent, and the study
was conducted in accordance with the Helsinki Dec-
laration of 1975, as revised in 2000.
§ Alloderm, Lifecore Biomedical, Chaska, MN.
1983
Acellular Dermal Graft Treatment of Gingival Recession Volume 76 • Number 11

Figure 2.
A) Clinical appearance preoperatively of tooth #6. B) Flap elevated with a partial-thickness dissection. C) Sutured acellular dermal graft.
D) Sutured overlying flap. E) Clinical appearance at 6 months. F) Clinical appearance at 3 years.

Figure 3.
A) Clinical appearance preoperatively of teeth #4, #5, and #6. B) A partial-thickness flap dissection was performed.
C) The cellular dermal graft placed and sutured. D) Sutured overlying flap. E) Clinical appearance at 8 months postoperatively.

CASE 1 agents with minimal resolution of her symptoms. Be-

A 30-year-old female patient presented with a com- cause the patient did not want to have surgery on the
plaint of progressive recession and hypersensitivity palate, it was decided to use the acellular dermal graft
on the buccal side of teeth #6 and #7 (Fig. 1A). The as a material for increasing the gingival tissue and
patient had been treated with several desensitizing coverage of the denuded roots.

1984
J Periodontol • November 2005 Santos, Goumenos, Pascual

Table 1. sions, extending the incision horizontally

3 mm mesially and distally at the level of
Results of 12 Cases (26 sites)
the cemento-enamel junction (CEJ). Two
oblique corono-apical incisions were made
Recession Recession Root Attached
extending into alveolar mucosa. A partial
Pretreatment Post-Treatment Coverage Gingiva Gain
thickness flap was raised by sharp disection
Case Tooth # (mm) (mm) (%) (mm)
(Fig. 1B). The adjacent papillae were slightly
1 13 5 2 60 2 denuded. The exposed root surfaces were
treated with an acellular dermal matrix
2 15 3 0 100 2 allograftk that was aseptically rehydrated in
2 14 2 0 100 1 sterile saline, according to the manufac-
turer’s instructions. The graft was trimmed
2 13 3 0 100 2 to a shape and size designed to cover the root
surfaces and the surrounding bone. The base-
3 13 3 0 100 3
ment membrane side of the material was
4 33 1 1 0 0 placed facing up toward the vestibule. The
acellular dermal matrix was sutured over the
4 34 3 0 100 2
defect with 5-0 bioabsorbable sutures (Fig.
4 35 1 0 100 1 1C). The previously reflected flap was coro-
nally positioned to cover the entire graft.
5 16 3 1 66 1 The flap was then sutured into place using ei-
5 15 3 0 100 1 ther 5-0 bioabsorbable or non-resorbable su-
tures (Fig. 1D). No periodontal dressing was
5 14 4 1 75 2 placed. The patient was instructed to discon-
tinue tooth brushing and avoid trauma or
5 44 3 0 100 2
pressure at the surgical site. A 0.12% chlor-
6 23 2 0 100 1 hexidine or an essential oil mouthrinse was
prescribed 2 to 3 times daily for 2 to 3 weeks
6 24 3 0 100 1 following surgery, and an anti-inflammatory
7 13 3 1 66 1 drug was also prescribed as needed. The su-
tures were removed from 10 to 15 days after
7 12 2 0 100 1 surgery. After this period, the patient re-
sumed mechanical tooth cleaning of the
8 44 2 2 0 0
treated areas using a soft toothbrush. The pa-
8 45 3 2 33 1 tient was recalled for control and prophylaxis
after 2 and 4 weeks and every 3 months. The
9 23 4 1 75 2
clinical appearances at 6 months (Fig. 1E)
10 43 2 1 50 0 and after 2 years (Fig. 1F) show complete root
coverage and an excellent esthetic result.
10 44 3 0 100 1
CASE 2
10 45 2 1 50 1
A 65-year-old female patient presented with
11 44 1 0 100 1 a complaint of progressive recession and
tooth sensitivity on tooth #6. After discussing
11 45 2 1 50 1
with the patient the different treatment op-
12 44 2 1 50 0 tions, the patient decided to avoid the palate
as a donor surgical site. The surgical tech-
12 45 2 1 50 1 nique was similar to the one described in case
1. The clinical appearance of the surgical
procedure is seen in Figures 2A through
After induction of local anesthesia, the exposed 2D. At 6 months, incomplete root coverage was ob-
root surfaces were carefully planed with curets and served, but with a good esthetic result (Fig. 2E). At
ultrasonic instruments. The root surfaces were not 3 years, without any additional surgery, complete root
subjected to any chemical conditioning. The patient coverage was noticed (Fig. 2F).
was treated as follows: a scalloped beveled intrasul-
cular incision was made corresponding to the reces- k Alloderm, Lifecore Biomedical.

1985
Acellular Dermal Graft Treatment of Gingival Recession Volume 76 • Number 11

Table 2.
Literature Review

Range of Mean Increase

Mean % of Coverage of Keratinized Tissue Type of Root
Reference Number of Sites Root Coverage (%) (mm) Recession Coverage (%)

Dodge et al.42 6 patients/18 sites 96.12 – 12.43 50 to 100 NR Class I and II 88.88

Harris50 25 patients/65 sites 95.8 75 to 100 1.2 (0 to 2.8) Class I and II 87.72

Santos52 12 patients/26 sites 74 0 to 100 1.19 (0 to 3) Class I and II 50

Aichelmann-Reidy et al.58 22 patients/22 sites 65.9 – 46.7 0 to 100 1.2 – 1.3 Class I and II NR
55
Henderson et al. 10 patients/20 sites 95 67 to 100 0.8 – 1.14 Class I and II 75

Novaes et al.60 Nine patients/15 sites 66.5 60 to 98.9 0.63 – 0.85 Class I and II 33.3

Paolantonio et al.61 15 patients/15 sites 83.3 – 11.4 NR 0.53 – 0.51 Class I and II 26.6

Tal et al.64 7 patients/7 sites 89.1 70 to 100 86 (0 to 2) Class I and II 42.8

NR = not reported.

Table 3.
Comparison Among Most Common Mucogingival Procedures

Increase of Keratinized Postoperative

Tissue Surgical Sites Discomfort Success (%) Predictability (%) Esthetic Outcome

Rotational flaps ++ 1 + 68 43 ++

Coronally positioned + 1 + 83 58 ++
flaps
Free gingival graft +++ 2 +++ 73 57 +

Connective tissue graft ++ 2 ++ 91 66 +++

Guided tissue + 1 + 74 30 ++
regeneration
Acellular dermal graft ++ 1 + 82 60 +++
+ = minor/small; ++ = moderate; +++ = maximum.

CASE 3 out of the 26 teeth had complete root coverage. Two

A 30-year-old male patient presented with a com-
plaint of hypersensitivity on teeth #4 through
#6 and the gingival tissues surrounding those
teeth. The surgical technique was similar to the pre-
vious cases. The surgical procedure and the excel-
lent esthetic result are shown in Figures 3A through
3E.
RESULTS
The three cases demonstrated root coverage of both
single and multiple teeth.
The results of the 12 patients and the 26 denuded
surfaces are shown in Table 1. A mean root coverage
of 74% was achieved for the 26 treated teeth. Thirteen
denuded root surfaces had no root coverage because
of postoperative sloughing of the tissue (the patient
was a heavy smoker). The average increase of kerati-
nized tissue was 1.19 mm. It seems that the long-term
results of the cases are stable.
DISCUSSION
Based on the previous literature, this technique is rec-
ommended for treating Miller Class I and II recession
type defects. Prior to the surgical procedure, it is ad-
visable to perform the preparatory phase of periodon-
tal treatment.
Although there are an increasing number of articles
published on this technique,37-67 the results of using

1986
J Periodontol • November 2005 Santos, Goumenos, Pascual

Table 4. The mean root coverage

obtained by different authors
Comparison of Advantages Among Connective Tissue Graft,
is shown in Table 2. As with
Guided Tissue Regeneration, and Acellular Dermal Graft other surgical procedures, it
is clear that there exists a
Advantages learning curve. The results
Connective Tissue Graft Guided Tissue Regeneration Acellular Dermal Graft of these cases are, however,
a little less predictable than
Predictable Predictable? Predictable other authors. A possible ex-
Single and multiple recessions Unlimited quantity Single and multiple recessions
planation could be the failed
case with no coverage at all.
No additional economical cost Histology Unlimited quantity As we have stated before,
this case was performed in
Fewer postoperative visits Only one surgical site Only one surgical site
a heavy smoker. This is in
More augmentation of Less postoperative discomfort Less postoperative discomfort agreement with previous
keratinized tissue periodontal surgical litera-
ture.20-24 If we eliminate the
Less risk of postoperative No need for primary healing heavy smoker patient, the
discomfort
mean root coverage increases
No problem in case of exposure
to almost 79%.
No need for a second surgery The data presented have
for its removal also shown that the average
increase of keratinized tis-
sue was 1.19 mm, which
an acellular dermal matrix allograft for root coverage agrees with previous results50,51,55,58,60,61,64(Table 2).
are comparable to the results of soft tissue grafting When compared with the connective tissue graft tech-
procedures. Harris,50 in a longer comparative study nique, the acellular dermal matrix allograft produces
than the present one, has shown similar results in a lower increase in keratinized tissue. Therefore, it
terms of root coverage between the connective tissue should not represent the technique of choice when
graft and the acellular dermal graft. The use of an acel- a maximal increase in keratinized tissue is the goal
lular dermal graft material eliminates the need for of the surgical procedure. However, in a comparative
a donor tissue surgical site that may result in compli- clinical evaluation of three techniques (free gingival
cations (e.g., bleeding and necrosis of the palate) and graft, connective tissue graft, and acellular dermal
an increase in patient morbidity. matrix) to augment keratinized tissue without root

Table 5.
Comparison of Disadvantages Among Connective Tissue Graft, Guided Tissue
Regeneration, and Acellular Dermal Graft

Disadvantages

Connective Tissue Graft Guided Tissue Regeneration Acellular Dermal Graft

Requires a second surgical site Predictable? Predictable

More postoperative discomfort Multiple recessions Contraction of the graft

Anatomical limitations Risk of membrane exposure and risk of Less formation of keratinized gingiva
(shallow palate) postoperative infection

Limited quantity Requires primary healing and certain amount of Additional economical cost
keratinized tissue

More postoperative visits

Less formation of attached gingiva

Additional economical cost

1987
Acellular Dermal Graft Treatment of Gingival Recession
coverage, Harris56 found a clinically and statistically
significant increase in the amount of keratinized tissue
with the three procedures.
Table 3 shows the comparison of the most popular
mucogingival techniques with the acellular dermal
graft. The acellular dermal graft results are compara-
ble to the results of the most successful mucogingival
procedures.
CONCLUSIONS
In summary, root coverage can be obtained by a vari-
ety of surgical procedures. All of these techniques
have advantages and disadvantages (Tables 4 and
5). The proposed technique can be, to our knowledge,
a new alternative for root coverage, and it should be
part of the periodontal plastic surgery armamentar-
ium.
The long-term results of two of the cases presented
in this study confirm the stability and longevity of
the technique. However, it is clear that additional
long-term cases and long-term comparative studies
are needed to determine the predictability and longev-
ity of this technique.
ACKNOWLEDGMENT
The authors acknowledge Dr. H. Greenwell, associate
professor and director of graduate periodontics, Uni-
versity of Louisville, Kentucky, for his editorial con-
tribution.
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Correspondence: Dr. Antonio Santos, Department of Peri-
odontology, International University of Catalonia, C/Gomera
S/N Sant Cugat del Vallés, 08017 Barcelona, Spain. Fax: 34-
934177392; e-mail: asantos@geodental.com.
Accepted for publication April 6, 2005.