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Dental Medicine and Oral Health Sciences

Subepithelial connective tissue graft may yield greater root coverage than acellular dermal matrix graft

Clinical Question: In adults requiring root coverage procedures, to what extent do acellular matrix allografts affect root coverage compared to subepithelial connective tissue grafts?

Clinical Bottom Line:  Limited and low-quality evidence suggests that the acellular dermal matrix graft (ADMG) results in less sites with complete root coverage compared to subepithelial connective tissue graft (SCTG) in adults over the follow up period of 6-12 months. The results are clinically meaningful, not statistically significant and not clinically precise. The evidence validity is compromised by the risk of selection and performance bias, lack of transparency in the methodology for reproducibility, small number of studies with small sample sizes. Thus, this C.A.T analysis is not yet applicable for clinical practice because of lack of evidence. More methodologically sound and adequately powered studies that consider adverse effects and cost of interventions are needed.

Evidence search

Search date: October 16th, 2019; 30 articles found

Search strategy:

("Gingivoplasty"[Mesh] OR "Gingival Recession/surgery"/[Mesh] OR "Guided Tissue Regeneration, Periodontal"[Mesh] or gingivoplasty[tiab] or root coverage[tiab]) AND ("Accelular Dermis"[Mesh] or acellular[tiab]). Limits applied: Systematic Reviews

Author, year Source of evidence Population Characteristics Methods

1. Chambrone et al., 2018

Pubmed ID:

Cochrane  systematic review

(RCTs: Paolantonio et al., 2002; Shori et al., 2013)

Population: healthy adults with single or multiple recession type defects with Miller Class 1 or 2 of at least 3 mm

Sample size/age:  

  • Paolantonio, 2002: N=30, aged 29-51 years, 19F
  • Shori, 2013: N=20, aged 18-50 years (F/M)

Location/Setting: India, Italy; university-based setting

Search: Cochrane Library, MEDLINE Ovid, Embase Ovid

Intervention: Acellular dermal matrix graft (ADMG)

Control: subepithelial connective tissue graft (SCTG)

Primary Outcome: sites with complete root coverage
Follow up: 6-12 months

Key Results

OR= 0.43 (CI 95% 0.13,1.37): sites with complete root coverage are 57% more likely to occur in SCTG group as opposed to ADMG group. The effect varies from 0.13 to 1.37.

Evidence Quality

Participants received ADMG intervention had 28% (95% CI -8%, 48%) less chance of having sites with complete root coverage compared with the participants received SCTG intervention. The results are not statistically significant, not clinically precise and clinically meaningful (20% threshold).

Strengths: Cochrane SR is based on RCTs and used rigorous methodology: more than three data bases included plus additional search, two independent reviewers and one arbitrator; no date, language or publication status restrictions;  quality of studies was assessed with validated instrument; low statistical heterogeneity; meta -analysis; GRADE approach for overall quality assessment.

Limitations: low number of studies, small sample sizes, low quality of primary studies: allocation concealment (selection bias) and the participants blinding (performance bias) approaches are unclear in both studies.


Despite its lackluster experimental designs, the study population of both studies (university-treated patients in India, Shori 2013, and Italy, Paolantonio 2002) are representative to our population of interest (Canadians requiring root coverage treatment in private sector). Despite the relative lower SES of patients in India compared to Canada, we consider that both surgery techniques are just as accessible for both the study subjects (subsidized university patients) and the Canadian patients (higher SES, but expensive private clinic setting). The intervention (acellular dermal matrix allograft) is feasible to implement in Canadian setting and can be used in situations where the tissue from the palate can’t be used, but it is not as practical as SCTG, because of materials required, costs, and ease of technique (flap and graft must contact in ADMG). The outcome (root coverage) is a patient important outcome for esthetic reasons. The follow up time (6-12 months) is enough time to observe the final surgery outcome. The cost difference between the intervention (ADMG) and the comparison (SCTG) are not mentioned or compared in these studies. However, SCTG is a more affordable option for patients since it does not require purchasing of additional materials, the graft itself comes from the patient’s own palate, while ADMG requires external acquisition of products, which leads to higher cost.   With regards to benefits and harms between the two techniques, a benefit of SCTG is that the flap does not need to completely cover the connective tissue graft, while the ADMG relies completely on the connection between the flap and the graft, and if there is no contact, it can lead to failure. The two studies of interest included in the Cochrane review (Shori 2013, Paolantonio 2002) did not measure the adverse effects of either techniques. Acellular dermal matrix grafts (ADMG) is an acceptable alternative when tissue from the palate cannot be used.

Authors:  Ioana Fugariu, Sep Pouresa, Michael Aronoff, Nicole Shen, Li-Chieh Lin (DMD3 students)

Faculty mentor(s): Farzeen Tanwir, Svetlana Tikhonova

Acknowledgments: Martin Morris (McGill librarian)

Date: March 27th, 2020


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