Defectos Infraoseos y Regeneracion

Periodontology 2000, Vol.
22, 2000, 104132 Printed in Denmark All rights reserved
Copyright C Munksgaard 2000
PERIODONTOLOGY 2000
ISSN 0906-6713
Focus on intrabony defects: guided tissue regeneration

P IERPAOLO C ORTELLINI & M AURIZIO S . T ONETTI
The American Academy of Periodontology has dened regeneration as the reproduction or reconstitution of a lost or injured part to restore the architecture and function of the lost or injured tissues. Periodontal regeneration is dened as regeneration of the tooth-supporting tissues including cementum, periodontal ligament and alveolar bone (41). Melcher (61) suggested that the cells that repopulate the root surface after periodontal surgery determine the nature of the attachment that will form. Following ap elevation, the instrumented root surface can be repopulated by epithelial cells, gingival connective tissue cells, bone cells and periodontal ligament cells. Under normal healing conditions, epithelial cells rapidly migrate in an apical direction to reach the most apical portion of the instrumentation, forming a long junctional epithelium (10, 14, 57, 72) and preventing the formation of a new attachment. The aim of regenerative procedures is to displace the epithelial attachment at a more coronal position than before treatment, allowing cells from periodontal ligament and bone to repopulate the root surface and to form a new periodontal attachment (49, 50, 62, 72). ment and bone colonize the blood clot, expressing their potential for regeneration. Cementum, periodontal ligament and alveolar bone are expected to form.
Clinical and histological outcomes

The clinical methods to evaluate the outcomes of a regenerative therapy include assessment of periodontal probing (pocket depth and clinical attachment levels) and bone levels (re-entry procedures, bone sounding and radiographs) (41). Histological evaluation, however, remains the only reliable method of determining the nature of the attachment apparatus resulting from regenerative procedures. Several studies in animals (3, 4, 12, 13, 15, 43, 44, 71) and some human biopsy material (8, 20, 32, 45, 73, 80, 81) have documented that guided tissue regeneration is capable of promoting new attachment formation. The overall treatment rationale of applying guided tissue regeneration in deep intrabony defects comes from the need to increase the periodontal support in teeth severely compromised by periodontal disease. The clinical goals of the use of regenerative procedures are improvements in the local anatomy and/ or the functioning and prognosis of teeth. The major benets the patient can expect from guided tissue regeneration treatment are improved masticatory function, comfort and prognosis of the involved teeth, with minor detriment to the aesthetic appearance. The primary outcomes in the treatment of intrabony defects are (i) increase in functional tooth support (clinical attachment and bone levels); (ii) reduction in pocket depth; and (iii) minimal gingival recession. Since human biopsy material is very difcult to obtain, for ethical reasons, the cited outcomes should be interpreted as evidence of improved healing response in the lack of histological evidence (56).
The biological concept of guided tissue regeneration

Guided tissue regeneration with barrier membranes has been demonstrated to be effective in preventing epithelial and gingival connective tissue cells from migrating into the blood clot about the instrumented root surface (44, 45, 71, 73). A physical barrier (membrane) is placed to cover the area in which the regenerative process is to take place. The barrier is properly shaped and positioned to form a space around the bony defect and the root surface. In the space under the barrier, cells from periodontal liga-
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Clinical evidence
The year 1982 was the starting-point of guided tissue regeneration (73). Following the rst case published by Sture Nyman, other authors (7, 22, 45, 76) reported encouraging results in independent case series. That evidence, in fact, demonstrated that applying guided tissue regeneration to deep intrabony defects could promote signicant clinical improvements in terms of clinical attachment and bone gains and reducing pocket depth. These pioneering experiences have opened the road to a new era of excitement in the periodontal eld. The original excitement, however, was soon followed by a great deal of frustration, since clinicians found it very difcult to predictably duplicate the clinical outcomes reported in the cited studies in daily practice. The application of the biological concept of guided tissue regeneration appeared to be very difcult and affected by many different unknown variables. The turning point in the guided tissue regeneration arena was the year 1993, when the clinical outcomes of a group of 40 intrabony defects treated with non-resorbable expanded polytetrauoroethylene membranes were analyzed with a multivariate statistical approach with the aim of isolating the relevant variables that could inuence the healing response and the nal clinical outcomes of guided tissue regeneration (23, 31, 32, 85, 89). The results from the cited studies demonstrated that the variability in clinical outcomes was affected by patient-, defect- and procedure-associated factors. Understanding the factors determining the clinical outcomes rendered their control, at least in part, possible, allowing remarkable improvements in their extent and predictability (Fig. 1). At the end of 1997, 35 scientic investigations had been published and reported 943 intrabony defects treated with guided tissue regeneration (Table 1) (1, 57, 9, 11, 1619, 21, 24, 26, 27, 2931, 33, 38, 39, 46, 48, 5153, 55, 59, 63, 67, 74, 75, 77, 84, 88). These studies have addressed the issue of the evaluation of the extent and predictability of the clinical outcomes following application of guided tissue regeneration. The weighted mean of the reported results indicates gains in clinical attachment of 3.861.69 mm and residual probing pocket depths of 3.351.19 mm. Different types of nonresorbable and resorbable barrier membranes have been used in the cited studies. Guided tissue regeneration treatment of 351 defects (20 studies) with nonresorbable barrier membranes resulted in clinical attachment level gains of 3.71.8 mm; this was similar to the results
Fig. 1. Plot of some of the clinical studies on guided tissue regeneration published between 1988 and 1998. The dots (red for nonresorbable barriers and blue for resorbable barriers) indicate the average probing attachment level (PAL) gain reported by each author. The yellow line, connecting some of the studies published by the group of Cortellini, Pini Prato & Tonetti, shows the improvements obtained by these clinicians through time in terms of probing attachment level gains. Such improvements were achieved by controlling the critical factors involved in the guided tissue regeneration procedure.
obtained treating 592 intrabony defects (17 studies) with bioresorbable barrier membranes (3.61.5 mm). The reported outcomes indicate that the application of nonresorbable or bioresorbable barrier membranes consistently and predictably results in clinical improvements in intrabony defects. The efcacy of guided tissue regeneration treatment of infrabony defects has been evaluated in 11 randomized controlled clinical trials in which guided tissue regeneration has been directly compared with access ap surgery (Table 2) (1, 18, 19, 27, 33, 52, 53, 59, 74, 75, 84). A total of 213 defects treated with access ap and 243 defects treated with guided tissue regeneration were included in these studies. Ten of the 11 investigations concluded that guided tissue regeneration resulted in statistically and clinically signicant greater probing attachment level gains when compared to the access ap. The only investigation reporting no signicant differences between guided tissue regeneration and access ap surgery was carried out in only 9 pairs of defects located on maxillary premolars; in this study the intrabony component of the defects was shallow and 10 of the 18 defects had a furcation involvement (74). The weighted mean of the evidence reported in the 11 studies listed in Table 2 indicated that the gain of clinical attachment in sites treated with guided tissue regeneration was 3.41.8 mm (95% con-
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Cortellini & Tonetti
Table 1. Clinical studies on guided tissue regeneration with nonresorbable and bioresorbable barrier membranes
Authors Becker et al. (7) Chung et al. (18) Handelsman et al. (48) Quteish et al. (75) Selvig et al. (77) Proestakis et al. (74) Kersten et al. (51) Becker et al. (5) Cortellini et al. (20) Falk et al. (38) Laurell et al. (55) Cortellini et al. (21) Cortellini et al. (27) Type of barrier Expanded polytetrauoroethylene Collagen Expanded polytetrauoroethylene Collagen Expanded polytetrauoroethylene Expanded polytetrauoroethylene Expanded polytetrauoroethylene Expanded polytetrauoroethylene Expanded polytetrauoroethylene Polymer Polymer Rubber dam Expanded polytetrauoroethylene Titanium-reinforced expanded polytetrauoroethylene Collagen Expanded polytetrauoroethylene Expanded polytetrauoroethylene Collagen Collagen Expanded polytetrauoroethylene Expanded polytetrauoroethylene Expanded polytetrauoroethylene Collagen Expanded polytetrauoroethylene Polymer Expanded polytetrauoroethylene Polymer Expanded polytetrauoroethylene Expanded polytetrauoroethylene Expanded polytetrauoroethylene Polymer Polymer Polymer Expanded polytetrauoroethylene Expanded polytetrauoroethylene Collagen Expanded polytetrauoroethylene Polymer Polymer Polymer Polymer n 9 10 9 26 26 9 13 32 40 25 47 5 15 15 19 14 14 13 9 11 11 11 10 12 12 23 30 19 25 12 10 203 6 6 10 52 10 10 18 69 23 943 Probing attachment gain 4.5 0.6 4 3 0.8 1.2 1 4.5 4.1 4.5 4.9 4 4.1 5.3 3.9 5 3.7 2.5 2.4 4.5 3.3 2 2 5.2 4.6 5.3 2.9 4 2.2 4.7 4.5 4.8 2.3 3 3.7 3.6 4.3 4.9 4.9 3 3 3.86 2.1 2.1 1.5 2.1 3.3 1.9 0.9 0.4 1.4 1.2 1.7 2 2.1 1.4 1.4 0.9 1.5 2 1.2 2 2.2 1.2 1 1.8 1.6 1.7 1.69 4.2 2.9 3.3 2.7 3.6 3.2 3.5 2.9 3.1 3.4 3.8 3.7 3.1 3.9 3.6 3.9 3.6 4.3 3 3.35 1.3 1.1 1.3 0.8 0.7 1.6 1.2 1.2 1.4 1.7 1.1 1.1 1.2 1.3 0.9 1.19 0.4 0.9 0.9 2.5 1.6 2.4 0.7 1.9 2.2 SD 1.7 0.6 1.4 1.5 1.3 1.3 1.1 3.9 2.19 5.4 3.5 5.1 3.88 2 3 3 2.4 2.7 2.1 2.5 2.6 3.2 3.6 4 1.7 1.9 0.9 1.8 0.6 1.1 0.88 0.9 0.26 0.6 1.1 1.4 0.5 1 0.5 1.4 0.44 Probing pocket depth at 1 year 3.2 SD 1
Al-Arrayed et al. (1) Cortellini et al. (24) Mattson et al. (59) Cortellini et al. (26) Mellado et al. (63) Chen et al. (16) Cortellini et al. (33) Tonetti et al. (88) Becker et al. (6) Kim et al. (53) Gouldin et al. (46) Murphy (67) Cortellini et al. (29) Falk et al. (39) Caffesse et al. (11) Kilic et al. (52) Benque et al. (9) Christgau et al. (7) Cortellini et al. (30) Tonetti et al. (84) Cortellini et al. (19) Weighted mean
dence interval 3.03.7 mm), while the access ap resulted in a mean gain of 1.81.4 mm (95% condence interval 1.52.1 mm). The analysis of the reported clinical outcomes strongly suggests an added benet deriving from the placement of barrier mem-
branes after elevation of an access ap. This impression is reinforced by the lack of overlap observed in the 95% condence intervals. The data reported in some of the studies summarized in Table 1 (651 defects in 17 investigations (9,
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Table 2. Controlled clinical trials comparing guided tissue regeneration procedure with access ap procedures
Guided tissue n (guided regeneration tissue probing attachment regeneration) gainSD (mm) 10 26 9 14 9 15 15 12 12 19 10 69 23 243 0.60.6 3.01.5 1.22.0 3.9 2.42.1 4.11.9 5.32.2 5.21.4 4.61.2 4.02.1 3.72.0 3.01.6 3.01.7 3.41.8 Flap probing attachment gainSD (mm) 0.70.9 1.80.9 0.61.0 2.7 0.42.1 2.50.8 2.30.8 2.01.7 2.12.0 2.21.5 1.61.8 1.81.4
Authors Chung et al. (18) Quteish & Dolby (75) Proestakis et al. (74) Al-Arrayed et al. (1) Mattson et al. (59) Cortellini et al. (27)* Cortellini et al. (27) Cortellini et al. (33)* Cortellini et al. (33) Kim (53) Kilic (52) Tonetti (84) Cortellini (19) Weighted mean
Type of membrane Collagen Collagen Expanded polytetrauoroethylene Collagen Collagen Expanded polytetrauoroethylene Titanium-reinforced expanded polytetrauoroethylene Expanded polytetrauoroethylene Polymer Expanded polytetrauoroethylene Expanded polytetrauoroethylene Polymer Polymer
n (ap) 10 26 9 14 9 15 12 18 10 67 23 213
* Three-arm studies. Comparisons were made among two different barrier membranes and access ap.
1719, 27, 2931, 33, 38, 39, 48, 55, 59, 75, 84, 88) allowed a further analysis to address the issue of predictability of obtaining relevant amounts of attachment level gains in intrabony defects. The frequency distribution of clinical attachment level changes at 1 year has been evaluated subdividing the data in 5 classes of probing attachment level changes: loss of attachment, gain of 01 mm, gain of 23 mm, gain of 45 mm and gain of 6 mm or more. Only 2.7% of 651 treated cases lost attachment, while gains of less than 2 mm were observed in 11% of the cases. Most of the sites gained considerable attachment. In fact, gains of 23 mm were observed in 24.8% of the cases, gains of 45 mm in 41.3%, and gains of 6 mm or more in 21.2% of defects. These encouraging data demonstrate that guided tissue regeneration is not only efcacious, but also predictable. Five investigations reported changes in bone levels (7, 32, 48, 51, 78). Bone gains ranged from 1.1 mm to 4.3 mm and seemed to correlate well with the gains in clinical attachment. The existence of a correlation between gains in clinical attachment and gains in bone levels in intrabony defects was demonstrated in an investigation by Tonetti et al. (89). In this study, the expected position of the bone 1 year after guided tissue regeneration was consistently found to be located 1.5 mm apical to the position of the clinical attachment. Reduction of pocket depths is one of the critical
endpoints of most periodontal procedures, including guided tissue regeneration. An important parameter to evaluate the successful outcomes of guided tissue regeneration, therefore, is the depth of the residual pockets. In most of the studies listed in Table 1, shallow pockets were consistently measured at 1 year. The weighted mean of residual pocket depths was 3.31.2 mm, with a 95% condence interval ranging from 3.2 to 3.5 mm. It is interesting to note that deep residual pockets (greater than 5 mm) were observed in only two studies, which reportedly resulted in minimal amounts of attachment and bone gains (51, 78).
Factors affecting the clinical outcomes

The primary factors affecting the clinical outcomes of periodontal surgery have been classied by Kornman in this volume as: 1) bacterial contamination, 2) innate wound-healing potential, 3) local site characteristics and 4) surgical procedure. These factors have been summarized in an inuence diagram to illustrate how various factors inuence regeneration. The information used to build the inuence diagram primarily derive from studies in which multivariate approaches have been employed to identify
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factors associated with the observed clinical outcomes (58, 8587). These studies have evaluated three types of possible sources of variability: (i) the patient; (ii) the morphology of the defect; (iii) the guided tissue regeneration procedure and the healing period. The patient Physiological, environmental, behavioral and genetic patient factors may affect the healing outcome of guided tissue regeneration procedures. So far, a highly signicant environmental exposure, cigarette smoking, has been associated with reduced outcomes (86). The ability to maintain high levels of plaque control has also been associated with improved outcomes (23, 28, 86, 87). Since these factors can be controlled through behavioral interventions, clinicians should discuss with the patient the opportunity to further improve hygiene and discontinue the smoking habit. Another important variable associated with guided tissue regeneration outcomes is the level of residual periodontal infection in the dentition, evaluated clinically as the percentage of sites with bleeding on probing, or microbiologically as the persistence of periodontal pathogens after completion of initial therapy (58, 85). A clinical implication of such observation is to defer guided tissue regeneration procedures until the periodontal infection is adequately controlled. Despite the lack of direct evidence, other factors, such as diabetes, intraoral accessibility and stressful life events, should be kept in mind in patient selection. The defect Defect morphology plays a major role in the healing response of guided tissue regeneration therapy in intrabony defects. It has been demonstrated that greater amounts of clinical attachment and bone can be gained in deeper defects (42, 85, 87). Defects deeper than 3 mm have been found to result consistently in greater probing attachment gains than defects of 3 mm or less (19). The potential for regeneration, however, has been reported to be similar in deep and shallow defects. In fact, in the cited study (19) similar results were observed in shallow and deep defects, when probing attachment gains were expressed as a percentage of the baseline intrabony component of the defects. Another important morphological characteristic is the width of the intrabony component of the defect, measured as the angle that the bony wall of the defect forms with the
long axis of the root (82). Wider defects have been associated with reduced amounts of probing attachment level gain and bone ll at 1 year (85). In a recent study on 242 intrabony defects, defects with a radiographic defect angle of 25 or less gained consistently more attachment (1.5 mm on average) than defects of 37 or more (35). Two investigations failed to demonstrate a signicant association between the number of residual bony walls and the clinical outcomes (85, 87). In one study, clinical improvements were associated with the depth of the three-wall intrabony component of the defect (78). All investigations agree on the lack of signicance of defect circumference and/or number of tooth surfaces involved (78, 85, 87). In a study, gingival thickness of less than 1 mm was associated with higher prevalence and severity of ap dehiscence over the membrane (2). Based on this evidence and the treatment objectives, deep and narrow defects are the ones that may benet most from guided tissue regeneration treatment. It is also desirable to surgically manipulate thick tissues for membrane coverage and thus reduce the occurrence of ap dehiscence.
The guided tissue regeneration procedure and the healing period Evidence from 2 randomized, controlled clinical trials indicates that the choice among different guided tissue regeneration strategies affects the expected outcomes resulting in signicantly greater improvements in clinical attachment levels (24, 27, 87). Different membranes, i.e. resorbable vs. non-resorbable or self-supporting membranes, possess different abilities to create and maintain the necessary space for regeneration. Different surgical approaches to access the interdental spaces, to preserve tissues and to protect the area of regeneration, are associated with different outcomes. In particular, membrane exposure is a major complication of guided tissue regeneration with a prevalence in the 70% to 80% range (7, 22, 31, 36, 37, 65, 78). Membrane exposure has been reported to be highly reduced (range 40 to 5%) with the use of access aps specically designed to preserve the interdental tissues (25, 29, 30, 67, 84). This is a relevant issue, since membranes exposed to the oral environment have been shown to be contaminated by bacteria (36, 37, 47, 58, 64, 6870, 77, 79, 83). Several independent studies have associated contamination of both non-resorbable and resorbable membranes with reduced amounts of probing attachment gains
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Fig. 2. Conventional technique. Mandibular right cuspid: the preoperative pocket depth was 5 mm and the probing attachment level 11 mm.
Fig. 3. Conventional technique. After ap elevation a 7-mm two- and threewall defect was exposed. The total depth of the defect measured 12 mm.
Fig. 4. Conventional technique. At week 2, the nonresorbable barrier membrane was partially exposed and thus contaminated.
Fig. 5. Conventional technique. The regenerated tissue appeared inamed at membrane removal.
Fig. 6. Conventional technique. The regenerated tissue was not properly protected in the interproximal area.
Fig. 7. Conventional technique. At 1 year, the residual pocket depth was 4 mm. A gain of 3 mm of clinical attachment and a substantial increase of the gingival recession were measured.
(36, 37, 69, 70, 77). Antimicrobial prophylaxis of exposed membranes has been shown to be effective in reducing the bacterial load but ineffective in preventing biolm formation (40, 69). This evidence
suggests the importance of keeping the membranes submerged to obtain optimal results. Further, reduction of bacterial load by an appropriate antimicrobial approach may reduce the negative effects
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patient and site selection and postoperative management.
The guided tissue regeneration procedures

Various surgical approaches and suturing techniques have been proposed in the literature. Clinicians should incorporate in their clinical armamentarium all the possible alternatives to optimize the procedure. Conventional approach The conventional approach consists of a ap approach (access ap or modied Widman ap) not specically designed for use with barrier membranes (7, 22, 31, 48). Full-thickness aps are elevated to try to preserve the marginal and the interdental tissues to the maximum possible extent. Vertical releasing incisions are performed as needed to increase defect accessibility. Periosteal incisions are normally performed to allow coronal displacement of the ap and to improve the ability to cover the membrane. Mattress and passing sutures are placed in the interproximal spaces in order to attempt primary closure of the interdental tissues over the membranes (Fig. 29). This approach normally does not allow a complete preservation of the interdental papilla, therefore rendering very difcult the primary closure of the interdental tissues over the membrane. Major complications are gingival dehiscence and membrane exposure. Modied papilla preservation technique The rationale for developing this technique was to achieve and maintain primary closure of the ap in the interdental space over the membrane (Fig. 10 15). Access to the interproximal defect consists of a horizontal incision traced in the buccal keratinized gingiva at the base of the papilla, connected with mesiodistal buccal intrasulcular incisions. After elevation of a full-thickness buccal ap, the residual interproximal tissues are dissected from the neighboring teeth and the underlying bone and elevated towards the palatal aspect. A full-thickness palatal ap, including the interdental papilla, is elevated and the interproximal defect exposed. Following debridement of the defect, the buccal ap is mobilized with vertical and periosteal incisions, when needed.
Fig. 8. Conventional technique. Baseline radiograph.
Fig. 9. Conventional technique. One-year radiograph.
associated with membrane contamination. The choice of the surgical approach and of a specic type of barrier membrane is therefore a critical clinical decision. Finally, operator skill may inuence the clinical outcomes (84). Different ability in tissue management, membrane manipulation, attention to blood supply, suturing technique and other factors may play a major role in a difcult procedure such as guided tissue regeneration. Other components of operator skill may relate to the individual skills in
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Fig. 10. Modied papilla preservation technique. Access to the defect was gained with a buccal horizontal incision at the base of the papilla.
Fig. 13. Modied papilla preservation technique. The interproximal defect after debridement.
Fig. 11. Modied papilla preservation technique. A buccal full-thickness ap was elevated. The defect-associated papilla is still in place.
Fig. 14. Modied papilla preservation technique. A titanium-reinforced barrier membrane was positioned near to the cementoenamel junction.
Fig. 12. Modied papilla preservation technique. The papilla was elevated along with the full-thickness palatal ap.
Fig. 15. Modied papilla preservation technique. Primary closure of the interdental space was ensured with a horizontal internal crossed mattress suture to relieve the tension of the aps and a second suture to close the interdental papilla.
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Fig. 16, 17. Modied papilla preservation technique. Drawing of the horizontal internal crossed mattress suture. The suture runs under the aps, hanging on top of the titanium reinforcement of the membrane. The buccal ap is coronally displaced.
ap at the base of the papilla. The suture runs back through the external surface of the lingual ap and the internal surface of the buccal ap, about 3 mm apart from the rst two bites. Finally, the suture is passed through the interproximal area above the papillary tissues, passed through the loop of the suture on the lingual side and brought back to the buccal side, where it is tied. This suture is very effective in ensuring stability and primary closure of the interdental tissues. In a randomized controlled clinical study of 45 patients (27), signicantly greater amounts of probing attachment were gained with the modied papilla preservation technique (5.32.2 mm), in comparison with either conventional guided tissue regeneration (4.11.9 mm) or access ap surgery (2.50.8 mm), demonstrating that a modied surgical approach can result in improved clinical outcomes. The sites accessed with the modied papilla preservation technique showed primary closure of the ap in all but one case, and no gingival dehiscence until membrane removal, in 73% of the cases (Fig. 2040). This surgical approach has been also attempted in combination with non-supported bioresorbable barrier membranes (29), with positive results. Clinical
This technique was originally designed for use in combination with self-supporting barrier membranes (25). In fact, the suturing technique requires a supportive (or supported) membrane to be effective (Fig. 16, 17). To obtain primary closure of the interdental space over the membrane, a rst suture (horizontal internal crossed mattress suture) is placed beneath the mucoperiosteal aps between the base of the palatal papilla and the buccal ap. The interproximal portion of this suture hangs on top of the membrane allowing the coronal displacement of the buccal ap. This suture relieves all the tension of the aps. To ensure passive primary closure of the interdental tissues over the membrane, a second suture (a vertical internal mattress suture) is placed between the buccal aspect of the interproximal papilla (that is, the most coronal portion of the palatal ap that includes the interdental papilla) and the most coronal portion of the buccal ap. This suture is free of tension. An alternative type of suture to close the interdental tissues has been proposed by Laurell (54). This modied internal mattress suture (Fig. 18, 19) starts from the external surface of the buccal ap, crosses the interdental area and passes through the lingual
Fig. 18, 19. A modication of the suture described in Fig. 15 and 16, described by L. Laurell. This suture ensures also an external stabilization to the interproximal tissues.
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Fig. 20. Modied papilla preservation technique. A 10 mm pocket on the mesial surface of the upper left central incisor.
Fig. 23. Modied papilla preservation technique. Primary closure of the interdental tissues was achieved over the membrane.
Fig. 21. Modied papilla preservation technique. After debridement a one- and three-wall combination intrabony defect was evident.
Fig 24. Modied papilla preservation technique. Primary closure was maintained at week 5. The gingiva was healthy.
Fig. 22. Modied papilla preservation technique. A titanium-reinforced barrier membrane was positioned at the level of the cementoenamel junction.
Fig. 25. Modied papilla preservation technique. After membrane removal a mature, rich in collagen and uninamed tissue was evident.
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Fig. 26. Modied papilla preservation technique. The regenerated tissue was properly protected with the gingival aps.
Fig. 27. Modied papilla preservation technique. At 1 year, no recession of the interdental tissues was observed. The pocket depth was reduced to 3 mm with a gain of attachment of 7 mm.
attachment level gains at 1 year were 4.50.9 mm. In all the cases primary closure of the ap was achieved, and about 80% of the sites maintained primary closure over time (Fig. 4148). It should be emphasized, however, that the horizontal internal crossed mattress suture most probably caused an apical displacement of the interproximal portion of the membrane, thereby reducing the space for regeneration. The surgical access of the interproximal space with the modied papilla preservation technique is
technically very demanding, but it has been reported to be very effective and applicable in wide interdental spaces (wider than 2 mm at interdental tissue level), especially in the anterior dentition. In properly selected cases, large amounts of attachment gain and consistent reduction of pocket depths associated with no or minimal recession of the interdental papilla are consistently expected. It is, therefore, especially indicated in cases in which aesthetics is particularly important.
Fig. 28. Modied papilla preservation technique. Baseline radiograph.
Fig. 29. Modied papilla preservation technique. One-year radiograph showing almost complete resolution of the defect.
Fig. 30. Modied papilla preservation technique. Upper right cuspid: the intrabony defect is 14 mm deep.
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Fig. 31. Modied papilla preservation technique. Two membranes were sutured together to cover all the apicocoronal extension of the defect.
Fig. 32. Modied papilla preservation technique. Baseline radiograph, showing radiolucency up to the apex of the tooth.
Fig. 33. Modied papilla preservation technique. One-year radiograph: the intrabony defect was almost completely resolved.
Simplied papilla preservation ap To overcome some of the technical problems encountered with the modied papilla preservation technique, including difcult application in narrow interdental spaces and in posterior areas and a suturing technique not appropriate for use with nonsupportive barriers, a different approach, the simplied papilla preservation ap (Fig. 4958), was subsequently developed (30). This different and simplied approach to the interdental papilla includes a rst incision across the
defect associated papilla, starting from the gingival margin at the buccal-line angle of the involved tooth to reach the mid-interproximal portion of the papilla under the contact point of the adjacent tooth. This oblique incision is carried out keeping the blade parallel to the long axis of the teeth to avoid excessive thinning of the remaining interdental tissues. The rst oblique interdental incision is continued intrasulcularly in the buccal aspect of the teeth neighboring the defect. After elevation of a full-thickness buccal ap, the remaining tissues of the papilla are carefully dissected from the neighboring teeth and
Fig. 34. Modied papilla preservation technique. Upper right central incisor: the intrabony defect is deeper than 15 mm. Total bone loss is greater than 20 mm.
Fig. 35. Modied papilla preservation technique. Lingual view showing the severity and extension of the bone destruction.
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improve the mobility of the buccal ap. After application of a barrier membrane, primary closure of the interdental tissues above the membrane is attempted in the absence of tension, with the following sutures: 1) a rst horizontal internal mattress suture (offset mattress suture) is positioned in the defect-associated interdental space running from the base (near the mucogingival junction) of the kera-
Fig. 36, 37. Modied papilla preservation technique. A titanium-reinforced barrier membrane positioned to isolate the defect (buccal and lingual view).
Fig. 39. Modied papilla preservation technique. Baseline radiograph.
Fig. 38. Modied papilla preservation technique. One-year re-entry surgery. The distance from the cementoenamel junction and the bottom of the defect was 10 mm: the bone gain was greater than 10 mm.
the underlying bone crest. The interproximal papillary tissues at the defect site are gently elevated along with the lingual/palatal ap to fully expose the interproximal defect. Following defect debridement and root planing, vertical releasing incisions and/or periosteal incisions are performed, when needed, to
Fig. 40. Modied papilla preservation technique. One-year radiograph. The defect was almost completely resolved.
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Fig. 41. Modied papilla preservation technique with bioresorbable membranes. Upper left central incisor at baseline.
Fig. 44. Modied papilla preservation technique with bioresorbable membranes. Primary closure of the interproximal tissues was obtained over the bioresorbable membrane.
Fig. 42. Modied papilla preservation technique with bioresorbable membranes. A deep one-, two- and three- wall combination defect was evident after debridement.
Fig. 45. Modied papilla preservation technique with bioresorbable membranes. Primary closure was maintained through time.
Fig. 43. Modied papilla preservation technique with bioresorbable membranes. A bioresorbable barrier was positioned.
Fig. 46. Modied papilla preservation technique with bioresorbable membranes. At one-year, the nal xed reconstruction was placed.
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Fig. 49. Simplied papilla preservation ap. Upper right lateral incisor at baseline.
Fig. 47. Modied papilla preservation technique with bioresorbable membranes. Baseline radiograph.
Fig. 50. Simplied papilla preservation ap. The pocket depth and the attachment level were 9 mm and 11 mm, respectively.
Fig. 48. Modied papilla preservation technique with bioresorbable membranes. One-year radiograph.
tinized tissue at the mid-buccal aspect of the tooth not involved by the defect to a symmetrical location at the base of the lingual/palatal ap. This suture rubs against the interproximal root surface, hangs on the residual interproximal bone crest and is anchored to the lingual/palatal ap. When tied, it allows the coronal positioning of the buccal ap. A relevant notation is that this suture, laying on the
Fig. 51. Simplied papilla preservation ap. The intrabony defect was a deep one-wall defect with a shallow threewall component at the bottom. Note the bone crest adjacent to the central incisor.
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interdental tissues above the membrane are then sutured to obtain primary closure with one of the following approaches: a) one interrupted suture whenever the interproximal space is narrow and the interdental tissues thin; b) two interrupted sutures, when the interproximal space is wider and the interdental tissues thicker; c) an internal vertical/oblique mattress suture (25), when the interproximal space is
Fig. 52. Simplied papilla preservation ap. A bioresorbable barrier membrane was positioned to cover the defect.
Fig. 53. Simplied papilla preservation ap. Primary closure of the defect-associated interproximal space. Note the offset suture positioned on the buccal side of the central incisor.
Fig. 55. Simplied papilla preservation ap. Baseline radiograph.
Fig. 54. Simplied papilla preservation ap. The treated area at 1 year. Probing depth is 2 mm.
interproximal bone crest, does not cause any compression at the mid-portion of the membrane, therefore preventing its collapse into the defect. 2) The
Fig. 56. Simplied papilla preservation ap. One-year radiograph.
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that these results were obtained by different clinicians treating different populations of patients and defects including also narrow spaces and posterior areas of the mouth. Interdental tissue maintenance Interproximal tissue maintenance is a technique proposed by Murphy (67) to be used in combination with nonresorbable barrier membranes and grafting material. It involves the reection of a triangularly shaped palatal ap that remains contiguous with the buccal portion of the ap. The triangularly shaped palatal tissue is referred to as the papillary triangle. The isthmus of tissue that connects the papillary triangle with the buccal ap provides the primary coverage for the interproximal guided tissue regeneration material during wound healing. The success of this technique depends upon the following factors: excellent preoperative tissue tone and absence of local inammation; the thickness of the palatal tissue; the use of wide, inverse bevelled palatal incisions; a minimal interradicular width of 2 mm measured at the osseous crest; and atraumatic management of the tissue intraoperatively. The surgical procedure starts with initial buccal intrasulcular incisions extending one to two teeth on either side of the defect. Vertical releasing incisions are made to facilitate ap reection. Full-thickness ap reection is made at the level of the mucogingival junction, except in the area adjacent the interproximal defect. No attempt is made to reect the interproximal tissue at this stage. Palatal incisions are made that create the papillary triangle and the palatal ap. Intrasulcular interproximal incisions are made with great care not to sever the isthmus of tissue that connects the papillary triangle to the buccal ap. Full-thickness elevation of the papillary triangle is performed using small periosteal elevators. From the palatal aspect, the isthmus of interproximal tissues is carefully released from the interproximal alveolar defect using the back hand of a large surgical curette. Before the papillary triangle is displaced under the contact point, the buccal ap is examined for any adhesion to the alveolar crest in the area of the defect. To facilitate coronal repositioning of the ap and passive closure, the buccal ap is released from the periosteum with split thickness dissection. The defect is debrided thoroughly. A decalcied freeze-dried allograft is placed into the defect and over the alveolar crest in an attempt to maintain space. The barrier is shaped and sized so that it will remain passively in position over the de-
Fig. 57, 58. Simplied papilla preservation ap. Drawing representing the offset mattress suture. This suture rubs against the root surface of the tooth approximal to the defect, hangs on the residual bone crest preventing the apical displacement of the resorbable barrier membrane.
wide and the interdental tissues thick. Special care has to be paid to ensure that the rst horizontal mattress suture would relieve all the tension of the aps, and to obtain primary passive closure of the interdental tissues over the membrane with the last suture. When tension is observed, the sutures should be removed and the primary passive closure attempted a second time. This approach has been preliminarly tested in a case series of 18 deep intrabony defects in combination with bioresorbable barrier membranes (30). The average clinical attachment level gain observed at 1 year was 4.91.8. In all the cases it was possible to obtain primary closure of the ap over the membrane, and 67% of the sites maintained primary closure over time. The same approach was then tested in a multicenter controlled randomized clinical trial involving 11 clinicians from 7 different countries and a total of 136 defects (84). The average clinical attachment gain observed at 1 year in the 69 defects treated with the simplied papilla preservation ap and a resorbable barrier membrane was 31.6 mm. More than 60% of the treated sites maintained primary closure over time. It is important to underline
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of 12 defects. Primary closure was obtained in 95% of the cases. This technique can be applied only to defects located in the upper jaw, preferably bicuspids, with an interdental space wide at least 2 mm. The crestal incision When a defect is located at a tooth side adjacent to an edentulous area (frequently occurring to abutment teeth), a crestal incision is performed to access the area (34, 88). The incision extends 2 to 3 mm further from the defect and can be associated with vertical releasing incisions. Full-thickness buccal and lingual aps are elevated, the defect debrided and a membrane positioned. Membrane coverage and primary closure of the ap over the implanted material is achieved with interrupted or mattress sutures (Fig. 5967).
Fig. 59. The crestal incision. Maxillary right cuspid at baseline. The defect was located on the distal aspect.
Fig. 60. The crestal incision. A crestal incision and distal vertical releasing incisions uncovered a one-, two- and three-wall combination intrabony defect.
fect. No suturing of the barrier is performed. The papillary triangle is returned to its original position by gently pushing the papillary triangle under the contact area. The aps are sutured using a modied vertical mattress suture. The suture rst passes through the buccal ap and exits the tissue at the edge of the papillary triangle. The suture overlays the mesial aspect of the papillary triangle, and the needle is passed in a mesial to distal direction through the mesial portion of the palatal ap engaging the tip of the papillary triangle, and then is passed through the distal portion of the palatal ap. The suture exits the palatal ap at this point and will overlay the distal aspect of the papillary triangle. The suture is then passed under the contact area and tied to the free end of the suture on the buccal ap. The other areas of the ap are closed in a standard manner using interrupted sutures. The author reports an average clinical attachment level gain of 4.71.4 mm after 1 year in a population
Fig. 61. The crestal incision. Filling material was positioned into the defect to support the bioresorbable barrier membrane.
Fig. 62. The crestal incision. A bioresorbable barrier was positioned.
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ated interproximal tissues after membrane removal, when the occurrence of a dehiscence of the gingival ap does not allow a primary coverage of the interdental area (24). The free gingival graft is positioned in the interdental space to cover the interproximal regenerated tissue (Fig. 6876). The gingival graft consists of an interproximal, saddle-shaped epithelialconnective tissue portion and two disepithelialized buccal and lingual portions. The buccal and lingual connective tissue portions of the grafts
Fig. 63. The crestal incision. Primary closure was obtained over the membrane.
Fig. 64. The crestal incision. The primary closure was maintained over time. Fig. 66. The crestal incision. Baseline radiograph.
Fig. 65. The crestal incision. One-year clinical appearance of the treated area.
Free gingival graft at membrane removal The use of free gingival grafts has been proposed to afford better coverage and protection of the regenerFig. 67. The crestal incision. One-year radiograph.
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Fig. 68. Free gingival graft. Mandibular right cuspid at baseline. The defect was positioned on the distal side.
Fig. 69. Free gingival graft. The intrabony component of the three-wall defect was 5 mm.
Fig. 70. Free gingival graft. A nonresorbable barrier membrane was positioned.
Fig. 71. Free gingival graft. Exposure of the barrier occurred at week 4.
Fig. 72. Free gingival graft. The regenerated tissue at membrane removal (week 5) was slightly inamed.
Fig. 73. Free gingival graft. A saddleshaped free gingival graft was positioned in the interproximal space to protect the regenerated tissue.
extend 2 to 3 mm below the margin of the residual buccal and lingual aps. The graft has to be rmly stabilized with interrupted sutures placed between the margins of the graft and the buccal and lingual margins of the gingival aps. Compressive sutures are also positioned to improve stability.
A randomized controlled clinical trial (24) resulted in signicantly greater probing attachment level gains in the 14 sites where a free gingival graft was positioned to cover the regenerated tissues, after membrane removal (52.1 mm) compared with the 14 sites where a conventional protection of the re-
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extended for 6 to 8 weeks. After this period, patients are re-instructed to gradually resume mechanical oral hygiene, including interdental cleaning, and to discontinue chlorhexidine. Patients are then enrolled in a periodontal care program on a monthly basis until 1 year. Probing or deep scaling in the treated area is generally avoided before the 1-year follow-up visit.
Fig. 74. Free gingival graft. At 1 year, the probing depth was 3 mm.
generated tissue was afforded with coronal positioning of the gingival ap (3.72.1 mm). In 12 of the 14 grafted sites the free gingival graft succeeded; in the other 2 it was lost.
Postoperative regime
The postoperative regime prescribed to patients is aimed at controlling wound infection or contamination as well as mechanical trauma to the treated sites (27, 31, 39, 55, 84). It generally includes the prescription of systemic antibiotics (tetracycline or amoxicillin) in the immediate postoperative period (1 week), 0.2 or 0.12% chlorhexidine mouthrinsing two or three times per day and weekly professional tooth cleaning until the membrane is in place. Professional tooth cleaning consists of supragingival prophylaxis with a rubber cup and chlorhexidine gel. Patients are generally advised not to perform mechanical oral hygiene and not to chew in the treated area. Nonresorbable membranes are removed 4 to 6 weeks after placement, following elevation of partial thickness aps. Patients are re-instructed to rinse two or three times per day with chlorhexidine, not to perform mechanical oral hygiene and not to chew in the treated area for 3 to 4 weeks. In this period, weekly professional control and prophylaxis are recommended. When bioresorbable membrane are used, the period of tight infection control regime is
Fig. 75. Free gingival graft. Baseline radiograph.
Fig. 76. Free gingival graft. One-year radiograph showing the complete resolution of the defect.
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Barrier membranes
Nonresorbable and bioresorbable barrier membranes are available. The main clinical difference among the two types is the need of a second surgery to remove the nonresorbable barrier membranes. Among the latter, the expanded polytetrauorethylene membranes are widely used and successfully tested in many clinical studies (Table 1). The titanium-reinforced membrane is an evolution of the expanded polytetrauoroethylene barrier. The design of this barrier enhances its ability to save space for regeneration and to support the gingival tissues. In recent years bioresorbable barrier membranes have been introduced in guided tissue regeneration to avoid further surgery. Barrier membranes of collagen (Table 1) and of polylactic acid or copolymers of polylactic acid and polyglycolic acid (Table 1) have been evaluated in independent studies, with various degrees of clinical success. From a clinical standpoint, these membranes are generally easy to manipulate and position about the defect, but have a limited ability to save room for regeneration and to support the gingival tissues. A subset analysis performed on the studies listed in table 1 to compare the 351 sites treated with non-resorbable barriers and the 592 treated with bioresorbable ones shows probing attachment gains of 3.71.8 mm (95% condence interval 3.4 to 4.0 mm) for the nonresorbable group and probing attachment gains of 3.61.5 mm (95% condence interval 3.4 to 3.8 mm) for the bioresorbable one. When the bioresorbable group is further subdivided into two subgroups, one for collagen material, the other for polymers, the weighted mean in terms of probing attachment gain is 3.01.7 mm (95% condence interval 2.5 to 3.5 mm) for the 139 collagen-treated sites, and 4.11.6 (95% condence interval 3.9 to 4.4 mm) for the 453 sites treated with polymers. These data seem to indicate that similar outcomes can be expected using nonresorbable and bioresorbable barriers. Among the bioresorbable membranes, however, better outcomes are to be expected using polymers.
membranes failed to demonstrate an additive effect of these adjunctive materials to barrier membranes alone in deep intrabony defects. On the other hand, negative effects of the employed materials have not been reported, indicating a possible use of these materials in combination with barrier membranes with the aim of providing better support to the ap and to save room for regeneration (Fig. 5967). The design and the sample size of the cited studies, however, does not allow any negative effect of the implanted materials on the guided tissue regeneration process to be excluded, thereby preventing denitive conclusions.
Complications
Complication of guided tissue regeneration procedures are frequent and frequently associated with impairment of the clinical outcomes. Membrane exposure has been reported in many investigations to be the major complication with a prevalence in the range of 70 to 80% (7, 22, 31, 36, 37, 65, 78). Prevalence of membrane exposure has been highly reduced with the use of access aps (modied papilla preservation technique, interproximal tissue maintenance and simplied papilla preservation ap) specically designed to preserve the interdental tissues (25, 29, 30, 67, 84). Control of membrane exposure is of great importance for the clinical outcomes, since in many studies exposed membranes have been shown to be contaminated with bacteria (36, 37, 47, 58, 64, 6870, 77, 79, 83). Contamination of exposed nonresorbable and resorbable barrier membranes has been associated with reduced probing attachment gains in intrabony defects (36, 37, 69, 70, 77). Other postoperative complications such as swelling, erythema, suppuration, sloughing or perforation of the ap, membrane exfoliation and postoperative pain have been reported in independent studies. An investigation reported the prevalence of pain (16% of cases), suppuration (11%), swelling and sloughing of the marginal portion of the ap (7%) in the immediate postoperative period (65, 66). Postsurgical pain can be easily controlled with administration of pain-killers. The events connected with local bacterial contamination are treated by enhancing the infection control regime both at home and in the dental ofce. This is based on the use of chlorhexidine rinses and gels, wiping devices such as soft toothbrushes and cotton pellets and frequent professional cleaning and prophylaxis. Perforation of the ap or severe exposure of the membrane could require removal of the material.
Combination treatment
Schallhorn & McClain have suggested that a combination therapy consisting of barrier membranes plus bone grafting may result in signicant improvements of expected outcomes (60, 76). Four studies (16, 52, 53, 63), however, evaluating the added benet of bone or bone substitutes used in combination with barrier
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Fig. 77. Decision tree 1: selection of patient, defect and objective of treatment.
Treatment strategies
Guided tissue regeneration in the year 2000 can no longer be considered as a single treatment approach. In fact, today there is evidence to consider guided tissue regeneration as a multifactorial treatment approach comprising careful selection of patients and
defects, different surgical techniques, various types of membranes and adjunctive materials and many suturing approaches. All the cited components could be variously combined to build up different treatment strategies loaded with different degrees of technical difculties. Various combinations of factors are expected to produce different clinical results. The treatment philosophy proposed in this chapter is based on selecting the combination of factors able to guarantee the maximum degree of predict-
Fig. 78. Decision tree 1, node 1: selection of patient. Source: modied from Cortellini & Bowers. Int J Periodontics Restorative Dent 1995. FMPS: full-mouth plaque score. FMBS: full-mouth bleeding score.
Fig. 79. Decision tree 1, node 2: selection of defect. Source: modied from Cortellini & Bowers. Int J Periodontics Restorative Dent 1995.
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Fig. 80. Decision tree 2: non-aesthetically sensitive sites. The objective of treatment is to increase the periodontal support and decrease the probing pocket depth. MPPT:
modied papilla preservation technique. ITM: interproximal tissue maintenance. SPPF: simplied papilla preservation ap. e-PTFE: expanded polytetrauoroethylene.
ability with the minimal degree of technical difculty, to reach the desirable objective of the treatment. With this in mind, three operative decision trees, based on a stepwise approach with subsequent decision nodes, have been built up to assist clinicians in the process of selecting the proper treatment strategy in different clinical cases. A rst decision tree (decision tree 1) will help clinicians in selecting patients, defects and setting the objectives of treatment. Then, two different trees, one for non-aesthetically sensitive sites (decision tree 2) and the other for aesthetically sensitive sites (decision tree 3), will help clinicians in selecting the treatment strategy. The starting-point of the decision process is the selection of the patient (decision tree 1, node 1; see paragraph the patient). According to the evidence, patients with less than 15% of sites presenting with plaque and residual infection, nonsmokers, with a high degree of compliance, and systemically healthy are the best candidates for guided tissue regeneration. The second step is the selection of the defect (de-
cision tree 1, node 2; see paragraph the defect). Defects presenting with a radiographic angle of 25 or less, an intrabony component deeper than 3 mm and gingival tissues at least 1 mm thick have the greatest chances to result in consistent amounts of clinical attachment and bone gains, irrespective of the number of residual bony walls. The thickness of the gingival tissues, if unfavorable, can be improved with mucogingival surgery. The third step sets the objectives of the treatment (decision tree 1, node 3). The primary outcomes and desirable clinical results of the regenerative treatment of intrabony defects are (i) gain of clinical attachment and bone, (ii) ll of the intrabony component of the defect, (iii) reduction of pocket depth and (iv) minimal gingival recession. In some instances, however, such as in non-aesthetically sensitive sites, a partial result could be the desirable objective of treatment if combined with a more simple and less invasive approach. The main objective of treatment will be the gain of periodontal support and the reduction of pocket depth, with a minor interest for the complete resolution of the defect and
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Fig. 81. Decision tree 3: aesthetically sensitive sites. The objective of treatment is to completely resolve the defect and minimize recession. MPPT: modied papilla preser-
vation technique. ITM: interproximal tissue maintenance. SPPF: simplied papilla preservation ap. e-PTFE: expanded polytetrauoroethylene.
the amount of gingival recession. In aesthetically sensitive sites, on the contrary, it is desirable to maximize the clinical result. The objective of treatment is to gain periodontal support and reduce pocket depth associated with full resolution of the intrabony component of the defect and minimal or no gingival recession. In the rst case (non-aesthetically sensitive sites), less invasive and easier techniques, even though less efcacious, may be chosen, whereas in the second case the most effective procedures and combination of materials will be included in the treatment strategy, even if associated with great technical difculty. Once the objectives of treatment have been set, the next steps are the selection of (i) the surgical access of the interproximal defect-associated papilla, (ii) the type of membrane and the possible use of lling materials, (iii) the suturing approach to obtain primary closure of the ap, and (iv) the modality of protection of the regenerated tissues at the time of nonresorbable membrane removal. All these decisions are based on anatomical considerations.
Non-aesthetically sensitive sites (decision tree 2) The interdental space can be accessed (node 1) with a modied papilla preservation technique (25) when the interdental space is wider than 2 mm at soft tissue level. A possible alternative is the interdental tissue maintenance (67), applicable only on upper premolars. When the interdental width is 2 mm or less, the treatment of choice is a simplied papilla preservation ap (30). Selection of the barrier membrane (node 2) is based mainly on the anatomy of the intrabony defect. Wide defects (ample radiographic angle) and/ or nonsupportive anatomy (one- and two-wall congurations) require the use of stiff membranes or the combined use of supportive or lling materials. Among the different commercial proposals, nonresorbable barrier membranes are stiffer than bioresorbable ones and therefore are the rst choice. The use of bioresorbable membranes, which render the procedure easier and less invasive for the patient (1 surgery only), could be associated with the use of
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llers to avoid its collapse. The ideal material for use in combination with membranes, however, is far from being established. Narrow and/or supportive defects (3 wall congurations) indicate the use of bioresorbable barrier membranes. The suturing approach (node 3) will be chosen according to the defect anatomy and the type of membrane or combination material used in the given case. In every instance, however, a combination of 2 sutures, one to relieve the tension, the other to close the ap, are strongly suggested. When a supportive defect or a supported membrane is the case, suture of the interdental space can be attempted with an internal horizontal crossed mattress suture (25) to relieve the tension. If a non-supported membrane or a non-supportive defect is the case, an offset internal mattress suture (30) will be chosen, to limit the apical displacement of the barrier and the consequent reduction of the space for regeneration. Primary closure of the interdental space will be attempted in both the instances with a single passing suture when the papilla is very narrow; with two parallel passing sutures when the papilla is wider; or with a mattress suture (54) to get the best apposition of the ap edges. When nonresorbable barrier membranes are used, the regenerated tissue needs to be protected at the time of membrane removal (node 4). If the gingiva has not been impaired by a dehiscence, a replacement ap is the rst choice. In case of gingival dehiscence, the use of a saddle-shaped free gingival graft will allow proper protection of the delicate regenerated tissues (24). Aesthetically sensitive sites (decision tree 3) When the interdental space is wider than 2 mm, it can be accessed (node 1) with a modied papilla preservation technique (25) or with the interdental tissue maintenance (67) on upper premolars only. When the interdental width is 2 mm or less, the treatment of choice is a simplied papilla preservation ap (30). For the selection of the barrier membrane (node 2) it is important to consider not only the intrabony component of the defect, but also the suprabony component. When the defect has a consistent suprabony component, the material of choice is a titanium-reinforced expanded polytetrauoroethylene membrane that can properly support the soft tissues, limiting the gingival recession and, thereby, preventing aesthetic damages. In fact, the use of titanium-reinforced expanded polytetrauoroethy-
lene membranes has been reported to result in clinical attachment level gains in the supracrestal portion of the defects (27). When the defect is purely intrabony, if it is a wide (ample radiographic angle) and/or a nonsupportive defect (one- and two-wall congurations), a titanium-reinforced expanded polytetrauoroethylene membrane is again the rst choice. When the defect is narrow and/or has a supportive anatomy (three-wall congurations), bioresorbable membranes, eventually associated with supportive materials (bone or bone substitutes), can be successfully applied. The suturing approach (node 3) will be chosen according to the defect anatomy and the type of membrane or combination material used in a given case. A combination of two sutures, one to relieve the tension, the other to close the ap are mandatory. A supportive defect (three-wall defect), a self-supporting membrane (titanium-reinforced expanded polytetrauoroethylene membrane) or a supported membrane (combination therapy) requires suturing the interdental space with an internal horizontal crossed mattress suture (25) to relieve the tension. If a nonsupported membrane (bioresorbable material) or a nonsupportive defect (one- or two-wall defect) is the case, an offset internal mattress suture (30) will be chosen. Primary closure of the interdental space will be attempted in both the instances with a single passing suture when the papilla is very narrow; with two parallel passing sutures when the papilla is wider; with an internal mattress suture or with an internal mattress suture (54) to get the best apposition of the ap edges. When nonresorbable barrier membranes are used at the time of membrane removal (node 4), the regenerated tissues can be protected with a replacement ap in case of gingival integrity or with a saddle-shaped free gingival graft in case of gingival dehiscence (24).
Conclusions
Evidence demonstrates a clear benet from the use of barrier membranes in the treatment of intrabony defects. The clinical outcomes, in terms of gain of periodontal support, pocket depth reduction and minimal recession of the gingival margin, are inuenced by a series of factors that can be controlled, at least in part. Control of these factors is of paramount importance to enhance the predictability of guided tissue regeneration treatment. Clinicians should carefully select patients and defects, set the objec-
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tives of treatment and then design the surgical strategy. Several surgical alternatives and different materials can be variously combined to optimize the treatment strategy. The decision-making process should be undertaken while keeping in mind the ratio between the difculties of the selected procedures and the expected outcomes. A good balance between these two components will be the key to success.
13.
14.
15.
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Periodontology 2000, Vol.

22, 2000, 104132 Printed in Denmark All rights reserved

Copyright C Munksgaard 2000

Focus on intrabony defects: guided tissue regeneration

Clinical and histological outcomes

The biological concept of guided tissue regeneration

Focus on intrabony defects: guided tissue regeneration

Cortellini & Tonetti

Focus on intrabony defects: guided tissue regeneration

Factors affecting the clinical outcomes

Cortellini & Tonetti

Focus on intrabony defects: guided tissue regeneration

Cortellini & Tonetti

patient and site selection and postoperative management.

The guided tissue regeneration procedures

Fig. 8. Conventional technique. Baseline radiograph.

Fig. 9. Conventional technique. One-year radiograph.

Focus on intrabony defects: guided tissue regeneration

Cortellini & Tonetti

Focus on intrabony defects: guided tissue regeneration

Cortellini & Tonetti

Fig. 28. Modied papilla preservation technique. Baseline radiograph.

Focus on intrabony defects: guided tissue regeneration

Cortellini & Tonetti

Fig. 39. Modied papilla preservation technique. Baseline radiograph.

Focus on intrabony defects: guided tissue regeneration

Cortellini & Tonetti

Focus on intrabony defects: guided tissue regeneration

Fig. 55. Simplied papilla preservation ap. Baseline radiograph.

Fig. 56. Simplied papilla preservation ap. One-year radiograph.

Cortellini & Tonetti

Focus on intrabony defects: guided tissue regeneration

Fig. 62. The crestal incision. A bioresorbable barrier was positioned.

Cortellini & Tonetti

Focus on intrabony defects: guided tissue regeneration

Cortellini & Tonetti

Fig. 75. Free gingival graft. Baseline radiograph.

Focus on intrabony defects: guided tissue regeneration

Cortellini & Tonetti

Focus on intrabony defects: guided tissue regeneration

Cortellini & Tonetti

Focus on intrabony defects: guided tissue regeneration

Cortellini & Tonetti

Focus on intrabony defects: guided tissue regeneration

Cortellini & Tonetti

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