The Rise of Nonautogenous Soft Tissue Grafts

Soft tissue grafting plays a critical role in addressing mucogingival defects, and while autogenous grafts have been the gold standard, nonautogenous alternatives are increasingly favored. Nonautogenous soft tissue grafts — such as allografts and xenografts — are gaining popularity due to their palate-free approach. Their advantages include reduced morbidity, shorter chairtime, unlimited availability, and consistent graft thickness.¹ The advantages and comparable outcomes of non-autogenous soft tissue grafts have led clinicians to utilize this alternative method when treating mucogingival defects.²

Commonly used nonautogenous grafts include acellular dermal matrix (ADM), enamel matrix derivatives (EMD), and xenogeneic collagen matrix (XCM).^2-4

Acellular Dermal Matrix — As a decellularized regenerative human dermal tissue matrix, ADM has historically been used by surgeons for treating burns.⁵ It is composed of the dermal layer and extracellular matrix of thin layers of donated skin that have had the epidermal layer and cellular material removed, which minimizes immunological response in ADM recipients. It consists of a structurally intact connective tissue matrix composed of type I collagen, which acts as a scaffold to facilitate the migration of, and repopulation by, the host’s fibroblasts, blood vessels and epithelial cells. It is subsequently replaced by, and fully integrated into, the host tissues.^6,7 Studies have reported similar recession coverage and keratinized tissue gain when comparing ADM with SCTG using various techniques.^8,9 Furthermore, the 2015 consensus report from the American Academy of Periodontology Regeneration Workshop also concluded that while SCTG provides the best root coverage outcomes, ADM can be used as an alternative.²

Enamel Matrix Derivative — An EMD graft is derived from embryonal enamel of porcine origin, based on the high degree of homology between porcine and human enamel proteins.¹⁰ The ability of EMD to induce acellular cementum formation during tooth development and eruption is also why it is used as a clinical treatment to promote periodontal regeneration.¹¹ This graft material is available in a gel formulation containing porcine-derived enamel matrix proteins, propylene glycol alginate and water.¹² Studies investigating the role of EMD and its potential for treating gingival recession alone, and in conjunction with SCTG, reported that EMD can provide root coverage and keratinized tissue gain in both scenarios.^13,14

Xenogeneic Collagen Matrix — Made with types I and III collagen without cross-linking or chemical treatment, XCM is a resorbable, two-layer, three-dimensional porcine-derived collagen. It has two components, a compact structure of denser collagen and smooth texture to enhance wound healing and facilitate cell adhesion, and a porous surface facing the host tissue that supports clot formation, tissue integration and angiogenesis.¹⁵ This material has been shown to promote regeneration of keratinized gingiva (in both width and thickness), not only around natural teeth, but also around dental implants. As a result, it is commonly used for treating gingival recession,¹⁶ as it has shown promising results and is thought to be a suitable substitute for mucogingival surgical procedures.

Conclusion

With advancements in biomaterials and clinical outcomes comparable to autogenous grafts, nonautogenous soft tissue grafts, such as ADM, EMD, and XCM, provide viable and efficient solutions for treating gingival recession and enhancing periodontal health. Their unique properties and clinical benefits make them a promising choice for modern mucogingival procedures.

References

1. Suárez-López Del Amo F, Rodriguez JC, Asa’ad F, Wang HL. Comparison of two soft tissue substitutes for the treatment of gingival recession defects: an animal histological study. J Appl Oral Sci. 2019;27:e20180584.
2. Tatakis DN, Chambrone L, Allen EP, et al. Periodontal soft tissue root coverage procedures: a consensus report from the AAP Regeneration Workshop. J Periodontol. 2015;86(Suppl 2):S52–S55.
3. Rotundo R, Pini-Prato G. Use of a new collagen matrix (mucograft) for the treatment of multiple gingival recessions: case reports. Int J Periodontics Restorative Dent. 2012;32:413–419.
4. McGuire MK, Scheyer ET, Nunn M. Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue: comparison of clinical parameters at 10 years. J Periodontol. 2012;83:1353–1362.
5. Wei PC, Laurell L, Geivelis M, Lingen MW, Maddalozzo D. Acellular dermal matrix allografts to achieve increased attached gingiva. Part 1. A clinical study. J Periodontol. 2000;71:1297–1305.
6. Cummings LC, Kaldahl WB, Allen EP. Histologic evaluation of autogenous connective tissue and acellular dermal matrix grafts in humans. J Periodontol. 2005;76:178–186.
7. Gallagher SI, Matthews DC. Acellular dermal matrix and subepithelial connective tissue grafts for root coverage: A systematic review. J Indian Soc Periodontol. 2017;21:439–448.
8. Gapski R, Parks CA, Wang HL. Acellular dermal matrix for mucogingival surgery: A meta-analysis. J Periodontol. 2005;76:1814–1822.
9. Moslemi N, Jazi MM, Haghighati F, Morovati SP, Jamali R. Acellular dermal matrix allograft versus subepithelial connective tissue graft in treatment of gingival recessions: a 5-year randomized clinical study. J Clin Periodontal. 2011;38:1122–1129.
10. Esposito M, Grusovin MG, Papanikolaou N, Coulthard P, Worthington HV. Enamel matrix derivative (Emdogain) for periodontal tissue regeneration in intrabony defects. Cochrane Database Syst Rev. 2009;2009:CD003875.
11. Hammarström L, Heijl L, Gestrelius S. Periodontal regeneration in a buccal dehiscence model in monkeys after application of enamel matrix proteins. J Clin Periodontol. 1997;24:669–677.
12. Brookes SJ, Robinson C, Kirkham J, Bonnas WA. Biochemistry and molecular biology of amelogenin proteins of developing dental enamel. Arch Oral Biol. 1995;40:1–14.
13. Rasperini G, Silvestri M, Schenk RK, Nevins ML. Clinical and histologic evaluation of human gingival recession treated with a subepithelial connective tissue graft and enamel matrix derivative (Emdogain): a case report. Int J Periodontics Restorative Dent. 2000;20:269–275.
14. Alkan EA, Parlar A. EMD or subepithelial connective tissue graft for the treatment of single gingival recessions: a pilot study. J Periodontal Res. 2011;46:637–642.
15. Nevins M, Nevins ML, Kim SW, Schupbach P, Kim DM. The use of mucograft collagen matrix to augment the zone of keratinized tissue around teeth: a pilot study. Int J Periodontics Restorative Dent. 2011;31:367–373.
16. Atieh MA, Alsabeeha N, Tawse-Smith A, Payne AG. Xenogeneic collagen matrix for periodontal plastic surgery procedures: a systematic review and meta-analysis. J Periodontal Res. 2016;51:438–452.

This information originally appeared in Shaikh S, Refahi P. Soft tissue graft alternatives for treating mucogingival defects. Decisions in Dentistry. 2023;9(1):26-29.