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      Acellular dermal matrix and subepithelial connective tissue grafts for root coverage: A systematic review


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          The aim of this systematic review was to evaluate whether patients with gingival recession would benefit from an acellular dermal matrix graft (ADMG) in ways that are comparable to the gold standard of the subepithelial connective tissue graft (SCTG).

          Materials and Methods:

          A systematic review and meta-analysis comparing ADMG to SCTG for the treatment of Miller Class I and II recession defects was conducted according to PRISMA guidelines. PubMed, Excerpta Medica Database, and Cochrane Central Register of Controlled Trials databases were searched up to March 2016 for controlled trials with minimum 6 months duration. The primary outcome was root coverage; secondary outcomes included attachment level change, keratinized tissue (KT) change, and patient-based outcomes. Both authors independently assessed the quality of each included trial and extracted the relevant data.


          From 158 potential titles, 17 controlled trials were included in the meta-analysis. There were no differences between ADMG and SCTG for mean root coverage, percent root coverage, and clinical attachment level gain. ADMG was statistically better than SCTG for gain in width of KT (−0.43 mm; 95% confidence interval: −0.72, −0.15). Only one study compared patient-based outcomes.


          This review found that an ADMG would be a suitable root coverage substitute for an SCTG when avoidance of the second surgical site is preferred.

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          Most cited references49

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          Subepithelial connective tissue graft technique for root coverage.

          This article describes the use of the subepithelial connective tissue graft as a donor source for root coverage. The success of these grafts has been attributed to the double-blood supply at the recipient site from the underlying connective tissue base and the overlying recipient flap. Four cases have been illustrated to demonstrate the versatility of this procedure for areas of single or multiple root coverage especially in the maxillary arch, coverage of existing crown margins and areas requiring a combination of ridge augmentation and root coverage. An increase of 2 to 6 mm of root coverage has been achieved in 56 cases over 4 years with minimal sulcus depth and no recurrence of recession. The donor site is a closed wound which produces less postoperative discomfort.
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            Postoperative complications following gingival augmentation procedures.

            Postoperative pain, swelling, and bleeding are the most common complications following soft tissue grafting procedures; however, detailed documentation is sparse in the literature. The aims of this prospective study were as follows: 1) to compare the frequency of complication occurrence after free soft tissue grafting (FSTG) or subepithelial connective tissue grafting (SCTG) procedures; 2) to evaluate the use of an acellular dermal matrix (ADM) as the donor tissue alternative to an FSTG or SCTG; and 3) to identify possible predictors for these complications. Seventy-five FSTG and 256 SCTG procedures were performed in 228 patients by a single operator. In five free soft tissue and 84 bilaminar graft procedures, an ADM was used instead of autogenous tissue. Variables such as the duration and location of procedures, smoking history, gender, and age were recorded. Patients were asked to fill out a questionnaire 1 week after the surgeries regarding postoperative pain, swelling, and bleeding. Data were analyzed using the chi2 test and logistic regression analysis. Odds ratios were calculated for moderate and severe adverse outcomes grouped together. The duration of surgical procedures was highly correlated with pain or swelling post-surgically (P = 0.001). Current smokers were three times more likely to experience post-surgical swelling (P = 0.01). Patients who underwent FSTG procedures were three times more likely to develop post-surgical pain (P = 0.002) or bleeding (P = 0.03) compared to those who received SCTG procedures. When an ADM was applied instead of autogenous tissue, the probability of swelling or bleeding was significantly reduced (odds ratio [OR] = 0.46, P = 0.02 and OR = 0.3, P = 0.001, respectively). Long surgical procedures and smoking may increase the severity and frequency of certain post-surgical complications after gingival augmentation procedures. FSTG procedures incur a higher likelihood for postoperative pain or bleeding than SCTG procedures, whereas the application of an ADM may significantly reduce the probability of swelling and bleeding.
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              Can subepithelial connective tissue grafts be considered the gold standard procedure in the treatment of Miller Class I and II recession-type defects?

              The objective of this systematic review was to answer the following question: 'Can subepithelial connective tissue grafts (SCTG) be considered the gold standard procedure in the treatment of recession-type defects?' DATA AND SOURCE: An electronic search (MEDLIINE, EMBASE and CENTRAL) for randomized controlled clinical trials with at least 6 months' follow-up comparing SCTG with other procedures for the treatment of gingival recession was performed up to December 2007.

                Author and article information

                J Indian Soc Periodontol
                J Indian Soc Periodontol
                Journal of Indian Society of Periodontology
                Medknow Publications & Media Pvt Ltd (India )
                Nov-Dec 2017
                : 21
                : 6
                : 439-448
                [1] Department of Dental Clinical Sciences, Faculty of Dentistry, Dalhousie University, Halifax, NS, Canada
                Author notes
                Address for correspondence: Dr. Debora C. Matthews, Faculty of Dentistry, Dental Clinical Sciences, Dalhousie University, 5981 University Avenue, Halifax, NS B3H 4R2, Canada. E-mail: debora.matthews@ 123456dal.ca
                Copyright: © 2018 Indian Society of Periodontology

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

                : 15 September 2017
                : 09 November 2017
                Original Article

                acellular dermis,connective tissue,gingival recession,meta-analysis,systematic review
                acellular dermis, connective tissue, gingival recession, meta-analysis, systematic review


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