J Periodontol • February 2009

Acellular Dermal Matrix Graft

for Gingival Augmentation:
A Preliminary Clinical, Histologic,
and Ultrastructural Evaluation
Antonio Scarano,* Raquel R.M. Barros,† Giovanna Iezzi,* Adriano Piattelli,* and Arthur B. Novaes Jr.†

Background: The aim of this study was to evaluate clini-

cally, histologically, and ultrastructurally the integration pro-
cess of the acellular dermal matrix used to increase the band
of keratinized tissue while achieving gingival inflammation
control.
Methods: Ten patients exhibiting a mucogingival problem
with bands of keratinized tissue £1 mm and gingival inflamma-

I
t is generally accepted that the pres-
tion of the related teeth were included in the study. The surgi- ence of an adequate width of kerati-
cal procedures were performed to augment the gingival tissue nized tissue is important to maintain a
using acellular dermal matrix. Clinical measurements were healthy dentogingival junction. A width of
assessed at baseline and after 3 months. A specimen of the al- 2 mm of gingiva with a correspondent
lograft and surrounding tissues was obtained immediately be- 1 mm of attached keratinized tissue has
fore the surgery and 4 minutes and 1, 2, 3, 4, 6, and 10 weeks been postulated to guarantee a healthy
after grafting. periodontium.1 However, the presence of
Results: Clinically, a gain of keratinized tissue of 2.92 – a narrow band of keratinized tissue is not
0.65 mm was observed after 3 months. Histologically and ul- an indication for a surgical intervention.
trastructurally, many macrophages were observed phagocy- Clinical and experimental investiga-
tosing preexisting collagen fibers in the first weeks. From tions2,3 demonstrated that the absence
week 2 on, fibroblasts synthesizing new collagen, epithelial of attached keratinized tissue is compat-
cells colonizing the graft surface, and revascularization were ible with the maintenance of periodontal
noticed. After 6 weeks it was difficult to find the acellular health. The gingival complex is not dras-
dermal matrix preexisting collagen fibers. This process of tically compromised with the progression
substitution was completed after 10 weeks, when the reepithe- of gingival recession when traumatic
lialization of the entire graft throughout a well-structured base- toothbrushing and inflammation are con-
ment membrane was achieved. trolled.2-5
Conclusion: The acellular dermal matrix graft seemed to be The need for keratinized tissue around
an easily handled material for use in keratinized tissue aug- implants is also not well established;6-9
mentation that, in humans, was substituted and completely however, Han et al.8 showed that kerati-
reepithelialized in 10 weeks according to histologic and ultra- nized gingival–augmentation procedures
structural results. J Periodontol 2009;80:253-259. with free soft tissue grafts make plaque
KEY WORDS control more effective, facilitate impres-
sion taking, and possibly prevent further
Analysis; gingiva; graft; wound healing.
recession. In orthodontics, mucogingival
treatment may be indicated to augment a
narrow band of attached gingiva and
* School of Dentistry, University of Chieti–Pescara, Chieti, Italy.
† School of Dentistry of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil. prevent marginal tissue recession, along
with tooth movement therapy.10-12 In
addition, the presence of thick attached
keratinized tissue may constitute a pro-
tective factor against marginal tissue
inflammation for patients undergoing

doi: 10.1902/jop.2009.080326

253
Acellular Dermal Matrix Graft for Gingival Augmentation Volume 80 • Number 2

prosthetic treatment.13 Furthermore, gingival aug- flammatory conditions, but plaque control remained
mentation may be considered in other situations, inadequate on the teeth with mucogingival problems.
such as in the presence of high frenulum, a need Professional hygiene, consisting of plaque control and
for vestibular deepening in association with remov- polishing, was performed again, and the patients were
able partial dentures, and implants. scheduled for keratinized gingival–augmentation sur-
The autogenous free gingival graft has been con- gery; 14 teeth were treated.
sidered a predictable procedure for keratinized tissue The clinical parameters, including plaque and gingi-
augmentation and vestibular deepening.14,15 How- val indices, gingival recession, and width of keratinized
ever, the free gingival graft procedure requires an ad- tissue, were assessed by one examiner at the mid-buccal
ditional donor surgical site, which results in a limited point of the teeth scheduled for surgery at baseline and
amount of donor tissue. after 3 months (Table 1). The gingival recession was
The acellular dermal matrix graft (ADMG)16-19 has measured from the cemento-enamel junction to the gin-
been widely used as a substitute for autogenous grafts gival margin, and the width of keratinized tissue was
in mucogingival surgeries, although it was originally measured from the gingival margin to the mucogingival
developed for the treatment of full-thickness burn junction. Most of the areas presented a partial loss of in-
wounds. This allograft is aseptically obtained from hu- terproximal papillae and a partial loss of interproximal
man donor skin. The donor tissues are processed to bone corresponding to a Class III recession according
remove the epidermis and cellular components of to the Miller classification.21
the dermis and to maintain the available basement The use of the ADMG was scheduled for the treatment
membrane and the extracellular matrix. Based on of the selected patients to avoid a secondary surgical
this, it could be expected that the resulting immuno- site; the patients presented a very thin palatal tissue,
logically inert allograft may serve as an architectural and the amount of graft would have been insufficient.
framework to support fibroblast migration and revas- Patients were informed that the aim of the surgical
cularization from the host tissues. Although histologic procedure was to augment the keratinized tissue and
studies of the acellular dermal matrix incorporation that partial root coverage could be expected (Fig.
process are limited, an animal study20 reported that 1A). Under local anesthesia, two releasing vertical in-
this graft seemed to be well integrated into a single cisions were made at the proximal line angles of the
highly vascularized structure, showing almost com- adjacent teeth. Sulcular incisions were made to con-
plete incorporation after 12 weeks. nect the vertical incisions; a partial-thickness flap
The aim of the present investigation was to evaluate was made, with sharp dissection close to periosteum,
the clinical use of the ADMG for keratinized tissue and extended until the flap could be passively moved.
augmentation and to follow-up, histologically and The root planing was completed, taking care to elimi-
ultrastructurally, the allograft reepithelialization and nate as much of the root convexity as possible to facil-
integration process in humans. itate root coverage. No conditioning of the root was
performed. The acellular dermal matrix was rehy-
MATERIALS AND METHODS drated before anesthesia, and it was cut to size and
Ten non-smoking, healthy patients (six males and adapted over the bleeding periosteal bed and some-
four females), averaging 32 – 5.2 years of age (range, times partially over the denuded root(s). In most cases,
24 to 45 years) were selected for the study; they a 1 · 2-cm ADMG was used, although larger sizes are
signed a written informed consent form that included available for treatment of wider areas. The connective
the permission for biopsy. The study was developed at tissue side of the allograft was sutured against the
the University of Chieti-Pescara, and its protocol was bleeding recipient bed, and the basement membrane
approved by the Ethics Committee of this university in side was always left as the outer layer. No particular
accordance with the World Medical Association Dec- effort is required to recognize the basement mem-
laration of Helsinki. The patients were enrolled from brane side because when saturated with blood and
June 2004 to September 2007. wiped with moistened gauze it does not retain blood,
Periodontal examination did not reveal the pres- whereas the connective tissue side remains red when
ence of pathologic probing depth. The inclusion crite- wiped. Before suturing, light digital pressure was
ria were a band of keratinized gingiva £1 mm, poor placed over the graft for better adaptation. Interrupted
oral hygiene (plaque index and gingival index ‡2) of sutures, using bioabsorbable 5-0 sutures, were placed
the related teeth, and lack of vestibular depth. Most from the acellular dermal matrix to the interdental pa-
patients complained of gingival bleeding and pain pillae (Fig. 1B). Mattress-crossed periosteal sutures
during toothbrushing. Patients were reevaluated 4 to from the base of the flap anchored around the teeth
5 weeks after initial treatment that consisted of root were tied over the graft for primary stabilization. No at-
scaling and polishing of all teeth and oral hygiene in- tempt was made to suture the primary flap over the
structions. There was clinical improvement of the in- graft; it was sutured at the base of the newly created

254
J Periodontol • February 2009 Scarano, Barros, Iezzi, Piattelli, Novaes

Table 1.
Clinical Parameters at Baseline and 3 Months After the Mucogingival Surgeries

Plaque Index Gingival Index Gingival Recession (mm) Width of Keratinized Tissue (mm)

Patient Baseline Postoperative Baseline Postoperative Baseline Postoperative Baseline Postoperative

1 3 1 3 1 9 1.6 0.9 4.5

2 2 1 1 1 8 1.2 1.2 3
3 2 1 1 1 9 1 1 4.2
4 3 0 3 0 8 1.9 1 3.9

5 2 1 1 1 7 1.5 0.9 4.9

6 1 0 1 1 6 1.2 1.2 4
7 1 1 1 1 7 1.5 0.6 3

8 2 0 1 1 6 0.9 0.7 4
9 1 1 2 1 7 1 1 3.2
10 1 1 1 1 8 1.9 1 4
Mean 1.8 0.7 1.5 0.9 7.53 – 0.8 1.37 – 0.4 0.95 – 0.6 3.88 – 0.6

Figure 1.
A) Clinical aspect before keratinized tissue augmentation. B) ADMG sutured. C) Clinical aspect 3 months postoperatively.

vestibule using periosteal ‘‘t’’ mattress sutures. The ing. Half of each biopsy was fixed in 10% neutral buff-
allograft was covered with oxidized regenerated cel- ered formalin for light microscopic observations and
lulose, dry-adhesive foil, and surgical periodontal the other half in 2.5% glutaraldehyde in phosphate buff-
dressing. No antibiotics were prescribed. Anti-inflam- ered saline 0.1 M for ultrastructural analysis. Semi-thin
matory therapy was given (ibuprofen, 400 mg, twice a sections were stained with toluidine blue for light mi-
day for 5 days); the patients were instructed to rinse croscopy. Thin sections were stained with uranyl ace-
with chlorhexidine twice a day for 10 days; and the dress- tate and lead citrate and observed for ultrastructural
ings were substituted after 1 week and removed after 10 characterization.
days. At the 6-week reevaluation, a gingivoplasty was
carried out using a round diamond bur to reduce gin-
gival asymmetries in three of 10 patients. RESULTS
The clinical parameters were reevaluated 3 months Clinical Results
postoperatively (Fig. 1C; Table 1). A specimen of the The clinical measurements of each patient were
allograft was obtained immediately before the surgery, reevaluated after 3 months. The mean gain in width
and biopsies were retrieved, using an incision 1.5 mm of keratinized gingival tissue was 2.92 – 0.65 mm.
from the gingival margin on the grafted area, 4 minutes Mean residual gingival recession was 1.37 – 0.49
after grafting and 1, 2, 3, 4, 6, and 10 weeks after graft- mm, with root coverage of 82%. Plaque and gingival

255
Acellular Dermal Matrix Graft for Gingival Augmentation Volume 80 • Number 2

indices were £1 and were considered acceptable (Ta- matrix production. A great number of newly formed
ble 1). blood vessels of small dimensions were present, espe-
cially in the deepest part of the graft where the ADMG
Histologic and Ultrastructural Analysis was in direct contact with the host tissues (Fig. 4A). No
The examination of the ADMG before suturing showed important changes were observed after 3 weeks. How-
a fibrous reticular connective tissue with bundles of ever, there was a significant decrease in the inflamma-
collagen fibers (Fig. 2), which appeared to be hyper- tory infiltrate (Fig. 4B), whereas it was possible to
chromatic. No cells were evident (Fig. 2C). The retic- observe an increase in the epithelial cells that were
ular pattern showed the presence of lacunae filled with covering the surface of the graft. Newly formed blood
a matrix presenting metachromatic affinity by tolui- vessels were present on the outer portion of the graft.
dine blue staining. No epithelium could be detected After 4 weeks, the graft structure was still recognized,
(Fig. 2C). At 4 minutes, no significant differences from but it was drastically modified. Many collagen fibers
the initial examination could be detected, except for were completely resorbed, a basement membrane
the presence of erythrocytes between the collagen fi- was evident, and a consistent increase in the number
bers. In general, many macrophages were observed of blood vessels was observed. Lymphocytes, plasma
phagocytosing preexisting collagen fibers during the cells, and histiocytes between residual graft collagen
first week (Fig. 3A). After 1 week, fibroblasts, probably fibers infiltrated the gingival stroma. Also, some newly
involved in the formation of new collagen fibers, were formed collagen fibers were present (Fig. 4C). The
found; some epithelial cells were observed on the pe- most superficial layers showed newly formed stroma
riphery of the allograft (Figs. 3B and 3C). After 2 resembling granulation tissue, and newly formed
weeks, although inflammatory cells could still be vessels could be detected. The preexisting external
observed, the numbers of fibroblasts and epithelial squamous layer was characterized by degenerative
cells were significantly increased. Ultrastructurally, necrotic processes, with detachment from the basal
the epithelial cells appeared very organized, and the membrane. The deepest layers showed some collagen
cytoplasm of the fibroblasts was full and probably fibers surrounded by histiocytic cells, sometimes with
engaged in non-collagen and collagen extracellular multiple nuclei. Some residual collagen fibers were

Figure 2.
A) Before the implantation, a fibrous reticular connective tissue with bundles of collagen fibers was present. B) Higher magnification of A.
C) Histologic lack of cells that colonized the alloderm, which appeared to be hyperchromatic. (Hematoxylin and eosin, C; original magnification: A, ·40;
B, ·1,000; C, ·50.)

Figure 3.
A) Many macrophages (arrows) were observed phagocytosing preexisting collagen fibers during week 1. B) After 1 week, fibroblasts (arrows),
probably involved in the formation of new collagen fibers, were found. C) Epithelial cells (arrows) can be seen on the periphery of the allograft.
(Uranyl acetate and lead citrate; original magnification: A through C, ·2,000.)

256
J Periodontol • February 2009 Scarano, Barros, Iezzi, Piattelli, Novaes

from the underlying bleeding recip-

ient bed.28 After 3 months, a mean
increase of 2.92 – 0.65 mm in the
width of keratinized tissue was ob-
served, which was related to the
achievement of satisfactory plaque
and gingival indices. The final
results demonstrated highly ac-
ceptable color matching with the
surrounding gingival tissue, cor-
roborating previous findings.16,27
However, the present technique
must take into consideration a
greater shrinkage of the graft com-
pared to autologous connective
tissue or gingival tissue. Although
root coverage was not the primary
objective of the mucogingival pro-
cedure applied in this study, a sig-
nificant value of 82% root coverage
Figure 4. was achieved after 3 months. This
A) A great number of newly formed blood vessels of small dimensions are present, especially in the result was not predictable, consid-
deepest part of the graft. B) There was a significant decrease in the inflammatory infiltrate.
C) Some newly formed collagen fibers (arrows) are present. D) Connective tissue and epithelial
ering that most cases had Class III
tissue formation were observed after 10 weeks. There are no inflammatory cells or macrophage gingival recession at baseline.
cells in this specimen. (Uranyl acetate and lead citrate; original magnification: A through D, ·2,000.) However, interesting results were
recently reported with the use of
the ADMG for the treatment of gin-
detectable in the cytoplasm of histiocytic cells. At 6 gival recessions.17,18,29
weeks, an entirely reepithelialized gingiva was evident, Because only a limited number of histologic stud-
and a well-structured basement membrane could be ies19,20 on the ADMG have been reported, and that
seen histologically. Finally, in the 10-week specimens, controversial information about its capacity for kera-
no more inflammatory cells were present; only a few tinization was described, it was decided to perform
preexisting collagen fibers were present. The complete the present histologic and ultrastructural evaluation
reepithelialization and ‘‘restitutio ad integrum’’ of the to elucidate the allograft reepithelialization and inte-
grafted area were observed (Fig. 4D). gration processes. In the present study, specimens
of the allograft were obtained immediately before the
surgery, 4 minutes after grafting, and 1, 2, 3, 4, 6,
DISCUSSION and 10 weeks after grafting. In the specimens analyzed
Several techniques have been developed to obtain before grafting, the process of removing cells had not
augmentation of the keratinized tissue width and ves- altered the collagen and extracellular matrices, and, as
tibular deepening;22-26 most of them use autogenous expected, no cells were observed. After 4 minutes of
free gingival grafts. Although the incidence of compli- grafting, only erythrocytes were found between the
cations is very low, discomfort and pain at the donor collagen fibers; this fact is probably related to the sur-
site are frequently observed.23 The use of the ADMG gical procedure. In the first few days it was possible to
eliminates the need for a secondary surgical site and observe an acute inflammatory infiltrate, mainly com-
provides an unlimited amount of donor tissue. It also posed of lymphocytes and granulocytes. In later
was reported that the esthetic results with the ADMG stages, there was a progressive decrease of the inflam-
might be better than with the autogenous free gingival matory cell infiltrate, with phagocytosing of the grafted
graft.16,27 collagen, which was replaced by new collagen pro-
In the present study, the ADMG was used for keratin- duced by the fibroblasts. In another animal study30 ex-
ized tissue augmentation, aiming at better plaque con- ploring biodegradation31 and angiogenic aspects of
trol and resolution of the inflammation of the gingival different collagen membranes, it was shown that the
margins. Based on this, no attempt was made to cover biodegradation time, inflammatory response, and
the graft; the ADMGs were left partially denuded in some vascularization were mainly influenced by membrane
cases, withtheexpectation of the growth of new vascular properties (tissue origin, compactness, and technique
buds and the migration of epithelial cells and fibroblasts of cross-linking). Despite the fact that the ADMG is

257
Acellular Dermal Matrix Graft for Gingival Augmentation Volume 80 • Number 2

apparently an open-porous dermal matrix graft, there results were uniformly good, and no undesirable ef-
is no information about the time of integration com- fects were observed.
pared to other membranes in vivo, which precludes
a better understanding about the biodegradation pro-
ACKNOWLEDGMENT
cess of this kind of graft. However, it has to be consid-
The authors report no conflicts of interest related to
ered that the severe inflammatory response seen in the
this study.
first biopsies, as a result of the contamination with sa-
liva and oral pathogens in this open-healing model
without the use of additional antibiotics, could have REFERENCES
influenced the biodegradation time of the ADMG.31 1. Lang NP, Löe H. The relationship between the width of
Histologically and ultrastructurally, it was possible keratinized gingiva and gingival health. J Periodontol
to see some epithelial cells on the periphery of the al- 1972;43:623-627.
2. Wennström J, Lindhe J, Nyman S. Role of keratinized
lograft in the first week after grafting. The way that the gingiva for gingival health. Clinical and histologic
reepithelialization started is in agreement with the study of normal and regenerated gingival tissue in
statements made by Wei et al.,28 i.e., that the non-vital dogs. J Clin Periodontol 1981;8:311-328.
allograft lacked the capability to direct cytodifferenti- 3. Wennström JL. Lack of association between width of
ation of the covering epithelium. Thus, the type of ep- attached gingiva and development of soft tissue re-
ithelium that covered the allograft seems to have been cession. A 5-year longitudinal study. J Clin Periodontol
1987;14:181-184.
determined by the surrounding tissues. 4. Dorfman HS, Kennedy JE, Bird WC. Longitudinal
During weeks 3 and 4 there was complete reepithe- evaluation of free autogenous gingival grafts. J Clin
lialization of the ADMG with the formation of a basal Periodontol 1980;7:316-324.
membrane; it was possible to see newly formed blood 5. Dorfman HS, Kennedy JE, Bird WC. Longitudinal
vessels in the deeper layers. The reepithelialization evaluation of free autogenous gingival grafts. A four
and neoangiogenesis might have been due to the ad- year report. J Periodontol 1982;53:349-352.
6. Adell R, Lekholm U, Rockler B, et al. Marginal tissue
equate scaffold function provided by the ADMG, which reactions at osseointegrated titanium fixtures (I). A
permitted the cellular migration and revascularization 3-year longitudinal prospective study. Int J Oral Max-
from the host tissues. A similar ADMG integration pro- illofac Surg 1986;15:39-52.
cess was observed in a dog study20 in which after 12 7. Bower RC, Radny NR, Wall CD, Henry PJ. Clinical and
weeks, the ADMG and the connective tissue seemed microscopic findings in edentulous patients 3 years
after incorporation of osseointegrated implant-sup-
to be well integrated into a single highly vascularized
ported bridgework. J Clin Periodontol 1989;16:580-
structure, indicating almost complete incorporation 587.
of the ADMG. Additionally, Cummings et al.19 com- 8. Han TJ, Klokkevold PR, Takei HH. Strip gingival
pared histologically the results between autogenous autograft used to correct mucogingival problems
connective tissue graft and ADMG in humans. The around implants. Int J Periodontics Restorative Dent
connective tissue graft and the ADMG were well incor- 1995;15:404-411.
9. Wennström JL, Bengazi F, Lekholm U. The influence
porated within the recipient tissues after 6 months. of the masticatory mucosa on the peri-implant soft
New fibroblasts, vascular elements, and collagen were tissue condition. Clin Oral Implants Res 1994;5:1-8.
present throughout the ADMG, whereas retention of 10. Batenhorst KF, Bowers GM, Williams JE Jr. Tissue
the transplanted elastic fibers was apparent. It was dif- changes resulting from facial tipping and extrusion of
ficult to locate the preexisting collagen fibers in the incisors in monkeys. J Periodontol 1974;45:660-668.
6-week specimens of the present study. The process 11. Coatoam GW, Behrents RG, Bissada NF. The width of
keratinized gingiva during orthodontic treatment: Its
of substitution was finished after 10 weeks, when the significance and impact on periodontal status. J Peri-
reepithelialization of the entire graft throughout a odontol 1981;52:307-313.
well-structured basement membrane was also com- 12. Foushee DG, Moriarty JD, Simpson DM. Effects of
plete. This property of the ADMG was very important mandibular orthognathic treatment on mucogingival
when dealing with keratinized tissue–augmentation tissues. J Periodontol 1985;56:727-733.
13. Stetler KJ, Bissada NF. Significance of the width of
procedures as described in this study.
keratinized gingiva on the periodontal status of teeth
with submarginal restorations. J Periodontol 1987;58:
CONCLUSIONS 696-700.
ADMG seems to be an easily handled material that, in 14. Edel A. The use of a free connective tissue graft to
humans, is integrated and completely reepithelialized increase the width of attached gingiva. Oral Surg Oral
in 10 weeks. The histologic and ultrastructural analy- Med Oral Pathol 1975;39:341-346.
15. Ouhayoun JP, Sawaf MH, Gofflaux JC, Etienne D,
sis performed at regular intervals demonstrated that
Forest N. Re-epithelialization of a palatal connective
wound healing of the grafts proceeded without any ad- tissue graft transplanted in a non-keratinized alveolar
verse complications and with complete integration of mucosa: A histological and biochemical study in
the ADMG by the host’s gingival tissue. The clinical humans. J Periodontal Res 1988;23:127-133.

258
J Periodontol • February 2009 Scarano, Barros, Iezzi, Piattelli, Novaes

16. Yan JJ, Tsai AY, Wong MY, Hou LT. Comparison of 25. Harris RJ. A comparison of two techniques for obtain-
acellular dermal graft and palatal autograft in the ing a connective tissue graft from the palate. Int J
reconstruction of keratinized gingiva around dental Periodontics Restorative Dent 1997;17:260-271.
implants: A case report. Int J Periodontics Restorative 26. Reiser GM, Bruno JF, Mahan PE, Larkin LH. The sub-
Dent 2006;26:287-292. epithelial connective tissue graft palatal donor site:
17. Barros RR, Novaes AB, Grisi MF, Souza SL, Taba MJ, Anatomic considerations for surgeons. Int J Periodon-
Palioto DB. A 6-month comparative clinical study of a tics Restorative Dent 1996;16:130-137.
conventional and a new surgical approach for root 27. Wei PC, Laurell L, Geivelis M, Lingen MW, Maddalozzo D.
coverage with acellular dermal matrix. J Periodontol Acellular dermal matrix allografts to achieve increased
2004;75:1350-1356. attached gingiva. Part 1. A clinical study. J Periodontol
18. de Queiroz Cortes A, Sallum AW, Casati MZ, Nociti FH 2000;71:1297-1305.
Jr., Sallum EA. A two-year prospective study of co- 28. Wei PC, Laurell L, Lingen MW, Geivelis M. Acellular der-
ronally positioned flap with or without acellular dermal mal matrix allografts to achieve increased attached
matrix graft. J Clin Periodontol 2006;33:683-689. gingiva. Part 2. A histological comparative study. J Peri-
19. Cummings LC, Kaldahl WB, Allen EP. Histologic odontol 2002;73:257-265.
evaluation of autogenous connective tissue and acel- 29. Mahajan A, Dixit J, Verma UP. A patient-centered
lular dermal matrix grafts in humans. J Periodontol clinical evaluation of acellular dermal matrix graft in
2005;76:178-186. the treatment of gingival recession defects. J Peri-
20. Luczyszyn SM, Grisi MF, Novaes AB Jr., Palioto DB, odontol 2007;78:2348-2355.
Souza SL, Taba M Jr. Histologic analysis of the acellular 30. Schwarz F, Rothamel D, Herten M, Sager M, Becker J.
dermal matrix graft incorporation process: A pilot study Angiogenesis pattern of native and cross-linked colla-
in dogs. Int J Periodontics Restorative Dent 2007;27: gen membranes: An immunohistochemical study in
341-347. the rat. Clin Oral Implants Res 2006;17:403-409.
21. Miller PD Jr. A classification of marginal tissue reces- 31. Rothamel D, Schwarz F, Sager M, Herten M, Sculean A,
sion. Int J Periodontics Restorative Dent 1985;5:8-13. Becker J. Biodegradation of differently cross-linked colla-
22. Bohannan H. Studies in the alteration of vestibular gen membranes: An experimental study in the rat. Clin
depth I. Complete denudation. J Periodontol 1962;33: Oral Implants Res 2005;16:369-378.
120-127.
23. Egli U, Vollmer WH, Rateitschak KH. Follow-up stud- Correspondence: Dr. Adriano Piattelli, Via F. Sciucchi
ies of free gingival grafts. J Clin Periodontol 1975;2: 63, 66100 Chieti, Italy. Fax: 39-0871-3554076; e-mail:
98-104. apiattelli@unich.it.
24. Han TJ, Takei HH, Carranza FA. The strip gingival
autograft technique. Int J Periodontics Restorative Dent Submitted June 18, 2008; accepted for publication Sep-
1993;13:180-187. tember 11, 2008.

259