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Are Your Results with AlloDerm as Predictable as Using the Patient’s Tissue?
Edward P. Allen, DDS, PhD | Ben Calem, DMD | James Woodyard, DMD, MS
Edward P. Allen, DDS, PhD: The short answer is yes, AlloDerm is as predictable as using autogenous tissue for soft-tissue grafting.
Various outcome parameters are used to gauge success following use of any graft material or technique for coverage of exposed roots. Complete coverage of roots has been considered the most important clinical outcome parameter; however, as many current methods successfully cover roots, other clinical parameters assume greater importance. Those parameters include esthetics, gain of keratinized tissue, increase in tissue thickness, attachment to the root, and long-term success.
A recently published meta-analysis of 24 randomized controlled clinical trials (RCTs) found no significant difference between allografts and palatal connective tissue grafts for root coverage or gain of keratinized tissue. Increase in tissue thickness and attachment have also been demonstrated to be equivalent in RCTs. The 2014 American Academy of Periodontology (AAP) Regeneration Workshop proceedings reported that both allografts and connective tissue grafts provide long-term stable root coverage results. One 5-year RCT comparing AlloDerm to connective tissue grafts found that relapse was not related to the type of graft used, but there was a statistically significant relationship between relapse and return to an aggressive brushing technique.
Patient-based parameters, including patient experience during surgery, postsurgical pain, and postsurgical experience, have recently gained attention. Regarding this, the 2014 AAP Regeneration Workshop proceedings reported that procedures using connective tissue grafts were associated with increased complications and were more painful than procedures using allografts.
Many patients are apprehensive about grafting procedures that involve tissue from the palate and they avoid needed surgery. By using AlloDerm, we can alleviate the fear, complications, and pain associated with palatal tissue harvesting and achieve results equivalent to those achieved with palatal tissue.
In addition, with AlloDerm, the palate plays no role in surgical treatment planning, so there is an unlimited amount and consistent quality of tissue and no limitation on the number of teeth that can be treated in a single appointment. This is beneficial to both the surgeon and the patient, as both surgical time and recovery time are reduced with fewer visits required.
Ben Calem, DMD: I have utilized AlloDerm and other allograft materials for root coverage in my practice. One obvious advantage to this material is that the donor tissue does not have to be harvested along the patient’s palate, thus reducing patient anxiety and postoperative discomfort. However, I still prefer the patient’s own tissue when initiating root coverage procedures.
Case selection is a determining factor when deciding between AlloDerm and the patient’s natural tissue. If I need to provide root coverage for more than three teeth within a quadrant, I will most likely use an allograft material. Even though postoperative discomfort can be minimized through palatal flap design when retrieving the connective tissue, I find that the integrity of the tissue varies based on the harvest location. When a significant section is required for multiple teeth, the thickness/width of connective tissue can vary. For these cases, I recommend that AlloDerm be used due to its standard size and ability to be recontoured based on the exposed root surfaces.
Nonetheless, in my opinion, the patient’s own tissue is still the best treatment option and provides the most predictable results. I am basing my opinion on the concept of vascularity. Once the flap has been undermined and released, and the root surfaces have been decontaminated, the connective tissue is then sutured to the root surfaces. I suture the connective tissue to the periosteum as well, prior to advancing the flap, which is ultimately realigned and sutured. As a result, this “dual vascularity” allows the connective tissue to mature and redevelop into the once-exposed root surfaces. I believe this ability to become predictably revascularized provides a better functional and esthetic outcome for the palatal connective tissue, when compared with AlloDerm or another allograft product.
James Woodyard, DMD, MS: In my practice, I use both AlloDerm and subepithelial connective tissue grafts. This is not a question of superiority, but of knowing when each is indicated. AlloDerm provides many benefits to the patient, such as no donor site and the ability to address many teeth in one surgical visit; whereas, connective tissue grafts offer the benefit of quicker healing than an AlloDerm graft, at the expense of a painful donor site.
Which type of technique is used depends upon several factors, including but not limited to tooth location, tooth position, and patient selection. If the tooth is in ideal position and alignment, with or without keratinized gingiva (Miller Class I and II), AlloDerm is my first choice. In compromised situations, such as when teeth are buccally inclined, rotated, and/or have interproximal bone loss (Miller Class III and IV), I often choose connective tissue over AlloDerm.
Patient selection is a big factor. With AlloDerm, I always use platelet rich fibrin to accelerate the soft-tissue healing. Even with platelet rich fibrin, the graft site is fragile and susceptible to failure for 4 to 5 weeks due to trauma or noncompliance. In contrast, subepithelial connective tissue grafts are usually relatively stable at 2 to 3 weeks. If the patient cannot avoid trauma from eating or sporting activities for 4 to 5 weeks, then connective tissue may be a better choice.
AlloDerm is a little more technique sensitive than connective tissue. When preparing your flap for an AlloDerm graft, the flap must be released to the point that it will stretch to the occlusal surface of the teeth being treated. Having a passive flap that will cover the AlloDerm without tension is the key to success with this material.
In my opinion, AlloDerm is an excellent material with many benefits. It is more technique sensitive than CT and takes additional training to use well. You need to be smart in your choice of when to use it and whom to use it on. Palatal donor sites are by far the most uncomfortable surgeries that I do as a periodontist, and I am happy when I can avoid them.
About the Authors
Edward P. Allen, DDS, PhD is the founder of the Center for Advanced Dental Education in Dallas, Texas.
Ben Calem, DMD has a private practice, Canal and Calem Periodontics, with locations in Moorestown and Medford, New Jersey.
James Woodyard, DMD, MS has a private practice, Woodyard Periodontics, PC, in Newburgh, Indiana.