Dear colleagues, I am a general dentist , planning to do my first case of root coverage with acellular derma matrix ( to reduce surgical complexity, didn't plan to do harvest autogenous connective tissue).

Planned steps for Root coverage with acellular derma matrix, my first case of this kind

Patient is 55 year old male , medical history: denied any problem, non-smoker; #27 class III recession.

References: 1, Coverage of a singular recession with the coronal advancement flap technique and autologous connective tissue | Quintessence Publishing Company, Inc. (quintessence-publishing.com) most of screen shots were taken from live surgery by Dr. Otto Zuhr in Germany

2, Periodontal Surgery for Root Coverage : a step by step guide a book by Dr. Qi Liu etc. 2019

Patient’s clinical images are shown below: there are about 4mm or so recession, 3mm or so attached gingiva, there are muscle fiber pulls.

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Planned surgical step:

1, The initial incision: Dr. Zuhr holds blade perpendicular to tooth and removed a thin sucular collar later.

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Initial incision by Dr. Qi Liu used blade parallel to tooth, to the crest bone level. I think

this is more practical. What do you think and recommend?

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2, vertical incision design: in the apical base of vertical, the incision slightly goes “ inwards” to the middle

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3, the partial thickness cut: Dr. Zuhr held blade parallel to the tooth orientation as in the picture blow.

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Dr. Qi Liu etc uses blade this way as shown below. The perforation in mucogingival junction happened to me in apically positioned flap while I used blade parallel to the tooth as in Dr. Zuhr’s way, so I think I would try Dr. Qi liu’s way which appears to be safer. What are your comments?

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Once the released partial thickness goes beyond mucogingival junction, check the coronal position of flap, to achieve 1mm over desired coronal coverage without tension. Also, release or cut muscle fibers to reduce the muscle pulls to avoid relapse of coronal positioned flap.

4. de-epithelia papilla. It appears to be technique sensitive with No 12 or scissor. So I wonder if I could just use diamond bur to achieve it, more controllable?

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Also, scaling root planning will be performed and then copiously rinsed with 24 % EDTA . I recalled some recommends 24% EDTA or enamel matrix protein but neither author mentioned the rinse. I wonder what are your views on it?

5, sling sutures to stabilize CT graft in Dr. Zuhr’ s video. In my case , acellular derma matrix will be used ( I never harvest palatal donor site before, so thinking ADM may be easier and faster) , and I plan to use to the same sling suture. What are your comments? Also, I assume resorbable 6.0 suture was used in the demo video, so I would use 6.0 PGA/vicryl.

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6, below are the final sling sutures to coronally advance flap as shown below (the picture didn’t show interrupted sutures to close vertical incision.) Both 5.0 and 6.0 are used in two authors. I assume I could use 5.0 or 6.0 Vicryl or Nylon or PTFE suture. Please advise on the planned suture technique and materials.

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7, finally, Dr Zuhr used a vertical matrix suture to better adapt papilla to tooth surface.

But I am afraid the papilla sutures are too close within 1-2mm to papilla tip, potentially risking tearing the papilla. Do you recommend this final suture to beginners?

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Thank you very much for the help!

Best,

Jun Yu

GP at Nashua, NH