Q U I N T E S S E N C E I N T E R N AT I O N A L
PERIODONTOLOGY
Clinical evaluation of a porcine acellular dermal matrix
for the treatment of multiple adjacent class I, II, and III
gingival recessions using the modified coronally
advanced tunnel technique
Raluca Cosgarea, Dr med dent, DMD1/Raluca Juncar, DMD2/Nicole Arweiler, Prof Dr med dent3/
Liana Lascu, Prof Dr 4/Anton Sculean, Prof, Dr med dent, MS, Dr hc 5
Objective: To evaluate the clinical efficacy of a new porcine acel-
lular dermal matrix (PADM) for the treatment of Miller Class I, II,
and III multiple gingival recessions using the modified coronally
advanced tunnel technique (MCAT). Method and Materials:
Twelve nonsmoking, systemically healthy patients presenting at
least two adjacent Miller Class I, II, or III gingival recessions (GR),
with a minimal depth of 2 mm, were treated consecutively with
MCAT in conjunction with PADM. At baseline and 12 months post-
operatively, complete root coverage (CRC, eg 100% root cover-
age), mean root coverage (RC), recession depth, recession width,
attached gingiva (AG), keratinized tissue (KT), periodontal pocket
depths (PD), and clinical attachment level (CAL) were evaluated.
The main outcome variable was CRC. Results: Postoperative
Key words: clinical study, coronally advanced tunnel, gingival recession, porcine acellular dermal matrix, root coverage
1 Assistant Professor, Department of Periodontology, Philipps University Marburg,
Marburg, Germany; and Clinic for Prosthetic Dentistry, University Iuliu Hatiega-
nu, Cluj-Napoca, Romania.
2 Postgraduate Student, Clinic for Prosthetic Dentistry, University Iuliu Hatieganu,
Cluj-Napoca, Romania.
3 Professor and Chair, Department of Periodontology, Philipps University Mar-
burg, Marburg, Germany.
4
Professor and Chair, Clinic for Prosthetic Dentistry, University Iuliu Hatieganu,
Cluj-Napoca, Romania.
5
Professor and Chair, Department of Periodontology, University of Bern, Bern,
Switzerland.
Correspondence: Dr Raluca Cosgarea, Department of Periodontology,
University of Marburg, Georg-Voigt Str. 3, 35039 Marburg, Germany.
Email: ralucacosgarea@gmail.com
VOLUME 47 • NUMBER 9 • OCTOBER 2016
Raluca Cosgarea
healing was uneventful in all cases, without any matrix loss or
exposure or infection. Statistically significant improvements
(P < .0001) were observed 12 months postoperatively in 53 of
the included 54 GR (98.15%). Twenty two recessions (40.74%)
showed CRC while the mean RC measured 73.20 ± 27.71%.
Mean GR reduction was 2.06 ± 1.18 mm while the gain of AG
amounted to 0.84 ± 0.73 mm and of KT to 0.69 ± 0.51 mm, re-
spectively. There were no statistically significant changes for PD
at 12 months; CAL showed a significant decrease (P < .05) at 12
months from 3.77 ± 1.28 mm to 2.30 ± 1.02 mm. Conclusion:
PADM in conjunction with MCAT may be successfully utilized for
the treatment of Miller Class I, II, and III multiple adjacent GR.
(Quintessence Int 2016;47:739–747; doi: 10.3290/j.qi.a36565)
When treating gingival recession defects (GR), the main
goals of plastic periodontal surgery are to predictably
obtain complete, long-lasting root coverage and to
achieve an optimal blending of the soft tissues, thus
improving esthetics. A very recent review and
meta-analysis highlighted the importance of treating
GR, pointing out not only the high probability of reces-
sion progression over time (78.1% of the GR showed an
increase in recession depth), but also an increase in the
number of GR (79.3%).1
Successful treatment of multiple adjacent gingival
recessions (MAGR) still represents a challenge for the
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Cosgarea et al
clinician, considering the need for coverage of a wider
and more extensive avascular surface, with different
recession depths (RDs) and recession widths (RWs) or
tooth positions.2,3 Several authors reported successful
outcomes using the coronally advanced flap (CAF), the
simple or modified tunneling technique with or with-
out connective tissue grafts (CTG).4-9 In a review evalu-
ating the efficacy of periodontal plastic procedures for
the treatment of MAGR, CAF in conjunction with a graft
showed the best treatment outcomes, while CAF and
tunnel approaches expressed the highest levels of
complete root coverage (CRC).3 Furthermore, in recent
years, the modified coronally advanced tunneling tech-
nique (MCAT) has been successfully employed for the
treatment of MAGR defects. Several clinical studies
have shown predictable results with this technique in
conjunction with CTG or other tissue replacement
grafts in Miller Class I, II, and III GR.2,4,6,10,11
Another literature review has evaluated the clinical
benefit of the adjunctive use of CT, enamel matrix deriv-
ative (EMD), nonresorbable and resorbable barrier mem-
branes (BM), and acellular dermal matrix (ADM) com-
pared to CAF alone for the treatment of class I-II single
recessions. Results have shown that only CTG or EMD in
conjunction with CAF were able to enhance the probabil-
ity to achieve CRC and to improve recession reduction.12
However, in many clinical cases, especially in patients
with a thin gingival biotype, the availability of connective
tissue at the donor site, especially for coverage of MAGR,
is limited. Furthermore, connective tissue harvesting is
associated with increased surgical time and patient mor-
bidity, and higher risk for postoperative complications.
In recent years, attempts have been made to
develop new surgical techniques and materials aiming
to improve the predictability of root coverage proced-
ures and to reduce patient morbidity. These included
the application of biologic factors such as EMD13,14 or
platelet rich fibrin (PRF),15 or the use of ADM or various
bioabsorbable membranes16 instead of CTG to support
the gingival margin and increase the thickness of the
gingiva.17,18 Histologic and clinical studies indicate that
ADM may show comparable results to CTG.19-22 How-
ever, in some countries, ADM is still a controversial
740
replacement for CTG due to its human origin and
potential risk for disease transmission.23 So far, the use
of a porcine-derived collagen matrix for the treatment
of multiple GR has been effectively applied in some
preclinical and clinical studies.6,11,24-28 Recently, a new
porcine-derived acellular dermal collagen matrix
(PADM; Mucoderm, Botiss Dental) has been introduced
for the treatment of GR. In-vitro and in-vivo findings
have provided evidence that this matrix can promote
growth and proliferation of human gingival fibroblasts,
osteoblasts, and endothelial cells.23,29,30 A very recent
histologic study provided evidence that this matrix in
conjunction with enamel matrix derivatives may pro-
mote periodontal regeneration in GR.31
However, the literature is still scarce regarding the
outcomes following treatment of MAGR by means of
various types of soft tissue replacement grafts.
Therefore, the aim of this consecutive case series
was to evaluate the clinical efficacy of PADM for the
treatment of MAGR defects by means of MCAT.
METHOD AND MATERIALS
Patient selection
Twelve nonsmoking, systemically healthy patients (3
men, aged from 26 to 48 years, mean age 34 ± 7.97
years) presenting at least two adjacent Miller Class I, II,
or III GR, with a minimal depth of 2 mm, were included
in this case series evaluation. All patients underwent
professional tooth cleaning and received oral hygiene
instructions so that prior to surgery patients showed a
good oral hygiene level (full-mouth plaque
score ≤ 25%).32 The study was conducted according to
the Declaration of Helsinki (1964, revision 2008) and
approved by the Ethical Committee of the Faculty of
Medicine and Pharmacy of Cluj-Napoca (Application
#579/13.04.2012). Informed written consent to partici-
pate in this study was obtained from all participants.
Surgical procedure
In all 12 patients, surgical GR coverage was performed
with the MCAT as described by Sculean et al.4,33,34
Briefly: under local anesthesia, scaling and root planing
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Fig 1 Clinical situation prior to surgery of a patient with multiple Fig 2 Scaling and root planing of the root surfaces to be covered
Miller GR. surgically.

Fig 3 Intrasulcular incision. Fig 4 Preparation of the tunnel with tunneling knives.

a b
Figs 5a and 5b Prepared tunnel so as to allow total coronal advancement.

was performed at all teeth scheduled for root coverage
(Figs 1 and 2). Thereafter, a mucoperiosteal flap was
raised using several tunneling knives beyond the
mucogingival junction, maintaining interdental papil-
lae intact, thus creating a tunnel flap (Figs 3 and 4). The
tunnel was then extended apically and laterally in a
split flap, sectioning and releasing all attached muscle
and collagen fibers from the inner aspect of the flap.
After gentle undermining but not disruption of the
interdental papillae, the tunnel flap was mobilized so as
to allow complete coronal tension-free advancement
(Figs 5 and 6).
Subsequently, the PADM (Mucoderm, Botiss Dental)
was adapted in size for the entire recession area to be

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covered and hydrated for 5 minutes in sterile saline

solution (Fig 7). By means of a mattress suture, the
membrane matrix was then pulled into the tunnel and
fixed mesially and distally at the inner aspect of the
flap. Subsequently, the membrane matrix was fixed
with sling sutures (6.0 Seralon, Serag-Wiessner) at the
cementoenamel junction (CEJ) of each treated tooth
(Fig 8). Finally, using sling sutures, the tunnel was
moved and fixed coronally covering completely the
membrane matrix and the recessions (Fig 9).
Fig 6 Tension-free coronal displacement of the tunnel. The postsurgical protocol consisted of analgesics (3
x 400 mg/day ibuprofen) for 2 to 3 days and antibiotics
(1 x 1,000 mg amoxicillin plus clavulanic acid) for 7
days. For 3 weeks postoperatively, patients were
instructed not to brush the surgical area, to rinse twice
a day for 2 minutes with 0.2% chlorhexidine digluco-
nate mouthwash, and to apply 0.12% chlorhexidine
digluconate toothpaste (Elugel, Pierre Fabre). Sutures
were removed 21 days postsurgically, when patients
also resumed toothbrushing at the surgical site. All
surgeries were performed by two experienced and
a previously calibrated periodontists (RC and AS).

b
Figs 7a and 7b Adaptation of the PADM. Fig 8 Fixation of the PADM in the tunnel.

Fig 9 Coronal advancement of the flap, covering totally the Fig 10 Clinical situation 12 months postsurgically.
PADM and saturation.

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Table 1 Clinical evaluated parameters at baseline and 12 months and their changes

Parameters Mean ± SD Min. Max. P value

Baseline 2.90 ± 1.16 2.00 6.00
< .001*
RD (mm) 12 mo 0.84 ± 0.87 0.00 4.00
Reduction 2.06 ± 1.18 0.00 6.00 < .001*
Baseline 3.48 ± 1.13 2.00 6.00
< .001*
RW (mm) 12 mo 1.39 ± 1.41 0.00 4.00
Reduction 2.11 ± 1.67 0.00 6.00 < .001*
Baseline 2.69 ± 1.26 0.00 6.06
.360
AG (mm) 12 mo 2.87 ± 1.01 0.00 6.00
Gain 0.84 ± 0.73 0.00 3.00 < .001*
Baseline 2.56 ± 1.12 0.00 5.00
.140
KT (mm) 12 mo 2.70 ± 1.08 0.00 5.50
Gain 0.69 ± 0.51 0.00 1.70 < .001*
Baseline 1.47 ± 0.68 1.00 3.00
PD (mm) .022*
12 mo 1.41 ± 0.50 1.00 2.00
Baseline 3.77 ± 1.28 1.00 7.00
CAL (mm) < .001*
12 mo 2.30 ± 1.02 0.00 4.00
RC (%) 73.20 ± 27.71 0.00 6.00
*Statistically significant P < .05.
AG, attached gingiva; CAL, clinical attachment level; KT, keratinized tissue; Max., maximal value; Min., minimal value; mo, months; PD, periodontal pocket
depth; RC, root coverage; RD, recession depth; RW, recession width; SD, standard deviation.

Evaluated parameters
At baseline and at 12 months postoperatively, the fol-
lowing clinical parameters were assessed by the same
two clinicians that performed the surgeries: probing
depths (PD), clinical attachment level (CAL), complete
and mean root coverage (CRC and RC), width of kerati-
nized tissue (KT), and attached gingiva (AG).
The demarcation between the KT and alveolar
mucosa was performed visually by an experienced peri-
odontist.
Statistical analysis
Statistical analysis was performed using the commer-
cially available software SPSS (version 18; IBM). Descrip-
tive statistics were performed using mean ± standard
deviation (SD) for quantitative variables; percentages
were used for qualitative variables (CRC). CRC (eg, 100%
root coverage) was defined as the primary outcome
variable. Differences between baseline and 12 months,
and between mandible and maxilla were checked for
significance using Wilcoxon signed ranks test. The stat-
istical significance level was set at P < .05.
RESULTS
Twelve patients with 54 recessions were included in
this case series. The postoperative healing was
uneventful in all cases: neither matrix loss or exposure,
nor infection or allergic reactions were observed.
Recession coverage occurred to a varying extent at
all defects with the exception of one Miller Class III GR
located at a mandibular central incisor. At 12 months,
mean RC improved statistically significantly (P < .0001)
compared to baseline and measured 73.20 ± 27.71%
(Table 1). Twenty-two GR (40.74%) showed CRC while
53.70% of the recessions (29 GR) had RC > 80%, 40.75%
(22 GR) had RC between 50% and 99% and 15.82% (8
GR) had RC < 50%.
Twenty six (48.14%) of the total number of GR were
Miller Class I recessions, out of which 50% (13 GR)

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Table 2 Clinical evaluated parameters at baseline and 12 months and their changes in the
maxilla and mandible (n = 28 recessions maxilla, n = 26 recessions mandible)

Parameters Maxilla (n = 28), mean ± SD Mandible (n = 26), mean ± SD P value, maxilla-mandible

Baseline 3.06 ± 1.15 2.77 ± 1.19 .280
RD (mm) 12 mo 0.54 ± 0.74* 1.15 ± 0.91* .014*
Reduction 2.51 ± 1.15* 1.57 ± 1.02* .007*
Baseline 4.20 ± 0.99 2.71 ± 0.66 < .001*
RW (mm) 12 mo 1.28 ± 1.58* 1.52 ± 1.22* .440
Reduction 2.92 ± 1.68* 1.23 ± 1.16* .001*
Baseline 3.14 ± 1.19 2.22 ± 1.17 .043*
AG (mm) 12 mo 3.21 ± 1.16 2.50 ± 0.66 .003*
Gain 0.82 ± 0.72* 0.87 ± 0.75* .640
Baseline 2.83 ± 1.00 2.22 ± 1.17 .091
KT (mm) 12 mo 3.12 ± 1.14 2.25 ± 0.82 .011*
Gain 0.76 ± 0.51* 0.62 ± 0.49* .190
Baseline 1.30 ± 0.47 1.50 ± 0.81 .240
PD (mm)
12 mo 1.00 ± 0.00 1.20 ± 0.05 .780
Baseline 4.07 ± 1.13 3.54 ± 1.36 .160
CAL (mm)
12 mo 1.46 ± 0.51* 1.34 ± 0.48* .710
RC (%) 84.06 ± 21.62 61.50 ± 29.12 .007*
*Statistically significant P < .05.
AG, attached gingiva; CAL, clinical attachment level; KT, keratinized tissue; mo, months; PD, periodontal pocket depth; RC, root coverage; RD, recession
depth; RW, recession width; SD, standard deviation.

showed CRC, 38.46% had 50% to 84% (10 GR) RC, and 3
recessions had 30% to 50% RC. Three recessions out of
the 54 were Miller Class II; two of these had a RC of 60%
and one had 80% RC. The rest of 25 recessions out of
the initial 54 were Miller Class III recessions, of which
36% (9 GR) showed CRC, 40% (10 GR) had 50% to 84%
RC, 20% (5 GR) had under 50% RC, and one recession
showed no RC compared to baseline (Table 1).
Twenty eight GR were localized in the maxilla and
57.14% (16 GR) showed CRC, 71.42% (20 GR) had over
80% RC, 35.71% (10 GR) of the maxilla GR had 50% to
80% RC, and 2 recessions had under 50% (Table 2).
Total mean RC in the maxilla was 84.06 ± 21.62%. In the
mandible, 26 GR were localized and they showed a
mean RC of 61.50 ± 29.12% (Table 2). Six GR (23.07%)
exhibited CRC, 9 GR (34.61%) had RC over 80%, 13 GR
(50%) had RC between 50% and 80%, 6 GR had under
50% RC, and one recession showed no additional RC
compared to baseline.
There were no statistically significant differences
regarding RD between the maxilla and mandible at
baseline. However, mean RD, reduction of RD, and RC
at 12 months were statistically significantly higher in
the maxilla as compared to the mandible (Table 2;
P < .05).
Twelve recessions were localized at canines, 26 at
lateral and central incisors, and 16 at premolars
(Table 3). Results obtained by tooth type are depicted
in Table 3. Incisors obtained the highest percentages in
RC (66.07 ± 33.39%) and a CRC of 48.00% (canines: CRC
41.66%, RC 57.64 ± 22.73%; premolars: CRC of 31.25%,
RC of 53.66 ± 29.30%) (Fig 10).
DISCUSSION
The aim of the present case series was to evaluate the
effectiveness of a new porcine-derived dermal matrix
for the treatment of MAGR using the MCAT. All selected

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Table 3 Clinical evaluated parameters at baseline and 12 months and their changes by type of teeth
(n= 28 recessions maxilla, n = 26 recessions mandible)

CRC RC RD reduction RW reduction AG gain KT gain

Parameters (%) (%, mean ± SD) (mm, mean ± SD) (mm, mean ± SD) (mm, mean ± SD) (mm, mean ± SD)
All 48.00 66.07 ± 33.39 1.35 ± 0.74 1.35 ± 1.13 0.65 ± 0.45 0.60 ± 0.46
Incisors
Maxillary (n = 12) 63.66 91.34 ± 13.89 2.33 ± 0.91 3.18 ± 1.34 0.72 ± 0.72 0.72 ± 0.64
(n = 26)
Mandibular (n = 14) 35.71 66.07 ± 33.39 1.35 ± 0.75 1.35 ± 1.13 0.65 ± 0.45 0.60 ± 0.46
All 41.66 57.64 ± 22.73 2.16 ± 1.57 0.83 ± 1.21 0.83 ± 1.12 0.25 ± 0.27
Canines
Maxillary (n = 6) 83.33 91.66 ± 20.41 3.45 ± 1.59 4.22 ± 1.73 0.88 ± 0.83 0.84 ± 0.49
(n = 12)
Mandibular (n = 6) 0.00 57.63 ± 22.73 2.16 ± 1.57 0.83 ± 1.21 0.83 ± 1.12 0.25 ± 0.27
All 31.25 53.66 ± 29.30 1.20 ± 0.57 1.50 ± 1.41 1.30 ± 0.75 0.70 ± 0.57
Pre-
molars Maxillary (n = 11) 36.33 72.63 ± 24.97 2.18 ± 0.87 1.96 ± 1.46 0.87 ± 0.74 0.77 ± 0.41
(n = 16)
Mandibular (n = 5) 20.00 53.66 ± 29.31 1.20 ± 0.57 1.50 ± 1.41 1.30 ± 0.75 0.70 ± 0.57
AG, attached gingiva; CRC, complete root coverage; KT, keratinized tissue; RC, root coverage; RD, recession depth; RW, recession width; SD, standard deviation.

patients presented multiple adjacent Miller Class I, II, or
III GR, with a minimal depth of 2 mm. The main out-
come variable in the present study was CRC, while the
significance level was set at P < .05.4
The results show a general decrease (Table 1) in
the depth and width of the recessions, with 40.64%
of the defects exhibiting 100% RC. The total mean
RC was 73.20% with a total mean RD reduction of
2.06 ± 1.18 mm. These outcomes are comparable to
other studies in the literature evaluating multiple reces-
sion coverage with various types of soft tissue replace-
ment grafts and/or techniques. A multicenter study
evaluating the use of a xenogeneic collagen matrix
in conjunction with CAF for the treatment of multiple
Miller Class I and II GR obtained, after 6 months, similar
results regarding mean RC (75.29%) and CRC (36%).26
In a further study by Aroca et al,6 CRC in Miller Class I
and II multiple GR using MCAT and the same collagen
matrix was achieved in 42% of the sites, with a total
mean RC of 71 ± 21%. Using the same collagen matrix
as in the study by Aroca et al,6 but combined with
CAF technique, Cardaropoli et al24 obtained after 12
months a twice higher percentage of recessions with
100% RC and a mean RC of 93.25 ± 10.01%. However,
the recession reduction and gain in AG obtained at
12 months are comparable to the present outcomes
(Cardaropoli et al:24 RD reduction 2.28 mm, AG gain
0.97 mm; present study: RD reduction 2.06 mm, AG
gain 0.84 mm). Explanations for the higher percent-
age of CRC obtained by Cardaropoli et al24 may be
related to differences in the included defects (only
Miller Class I and II GR were included) and by dif-
ferences in the used surgical technique, that might
be less sensitive compared to MCAT, especially when
collagen matrices are utilized. This view seems to be
supported by the current literature, which indicates
that better clinical outcomes may be expected when
soft tissue replacement grafts are used in conjunc-
tion with CAF than with the tunnel technique.35 How-
ever, the outcomes reported by Ozenci et al35 with
the tunnel technique using ADM are comparable to
those obtained in the present study, ie mean RC was
75.72% (present study 73.20%), recession reduction
was 2.45 ± 0.20 mm (present study 2.06 ± 1.18 mm),
RW reduction was 1.83 ± 0.6 mm (vs 2.11 ± 1.67 mm),
KT gain was 0.87 ± 0.42 mm (vs 0.69 ± 0.51 mm), AG
was 0.85 ± 0.73 mm (vs 0.84 ± 0.72 mm), CRC was
in 37.36% of the sites (vs 40.74% CRC in the present
study).35 Furthermore, the present results in the max-
illary arch are comparable with those of Chaparro et
al,36 who used the tunneling technique combined with
ADM (CRC: 67.9% vs 57.14% in the present study; RD:
3.02 ± 1.17 mm vs 2.51 ± 1.15 mm in the present study;
Table 2). However, Chaparro et al36 obtained higher

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improvements in the mandible as compared to the
present study (CRC 52.5%, RD 3.12 ± 1.28 mm). The dis-
crepancies between these results might be due to the
higher number of recessions included in the study by
Chaparro et al,36 the present study being just a report of
12 consecutive patients. The present results regarding
RC, RD reduction, and gain in KT are also comparable
with those obtained by Nevins et al38 using CAF and
a placental allograft (RC 55.81 ± 25.26%; RD reduction
2.65 ± 1.53 mm, 0.86 ± 1.21 mm; for the present results
see Table 1) and by Tunaliota et al37 that used autolo-
gous PRF combined with CAF (mean RC 76.63% in the
PRF+CAF group).38
In conclusion, the present findings suggest that the
new PADM may be successfully utilized for the treat-
ment of Miller Class I, II, and III MAGR.
ACKNOWLEDGMENT
The present study was partly supported by Botiss, Berlin, Germany.
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