Combined Periodontal Regenerative Technique in Human Intrabony

Defects by Collagen Membranes and Anorganic Bovine Bone. A Controlled

Clinical Study
Dr. Michele Paolantonio
University "G. D'Annunzio," Chieti School of Dentistry, Department of
Periodontology, Chieti, Italy.
Background: Combined periodontal regenerative technique (CPRT) is a surgical procedure
that combines the use of barrier membranes with a filling material in the treatment of
periodontal defects. The effectiveness of CPRT has been evaluated in many studies in
comparison to GTR with membranes alone, but conflicting results have been obtained by
different clinicians, particularly in the treatment of intrabony defects. The aim of the present
study was to compare CPRT to GTR with collagen membranes in the treatment of human
intrabony defects characterized by a relevant 1-wall component.
Methods: Thirty-four (34) healthy, non-smoking patients affected by moderate to severe
chronic periodontitis participated in this study. Each patient had good oral hygiene and at
least 1 radiographically detectable intrabony defect 4 mm, with a 1-wall component of at
least 50% of the defect, involving 2 tooth surfaces or more with a probing depth (PD) 6
mm. Seventeen (17) subjects were randomly assigned to the test group and underwent
CPRT by anorganic bovine bone and a collagen membrane, and 17 randomly assigned to the
control group who received GTR with a collagen membrane alone. Pre- and post-therapy
clinical parameters (probing depth [PD]; clinical attachment level [CAL]; gingival recession
[GR]) and intrasurgical parameters (depth of intraosseous component [IOC]; level of the
alveolar crest [ACL]) were compared between test and control groups 1 year after
treatment. Vertical bone gain (VBG) from the base of the defect to the cemento-enamel
junction was also evaluated in both groups.
Results: At the 1-year examination, clinical and intrasurgical parameters showed
statistically significant changes within each experimental group from baseline. A statistically
greater CAL gain was reported in the test group (P <0.05), whereas the control group
exhibited more GR and alveolar crest resorption at a statistically signifi- cant level
(P <0.01). VBG was significantly greater (P <0.01) at test sites (5.23 1.30 mm)
compared to controls (3.82 1.28 mm).
Conclusions: The results suggest that the use of CPRT may be preferred when
bioabsorbable membranes are used to treat intrabony defects characterized by unfavorable
architecture. J Periodontol 2002;73:158-166.

Link: http://www.joponline.org/doi/abs/10.1902/jop.2002.73.2.158

Evaluation of an Absorbable Collagen Membrane in Treating Class II

Furcation Defects

Hom-Lay Wang,* Robert B. O'Neal,* Clifford L. Thomas, Yu Shyr, and R.

Lamont MacNeil*
*Department of Periodontics/Prevention/Geriatrics, School of Dentistry, University of
Michigan, Ann Arbor, MI.
Private practice, Cleveland, OH.
Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI.
RECENT RESEARCH HAS FOCUSED upon the utilization of an absorbable collagen membrane in
guided tissue regeneration (GTR). Concern exists as to whether this type of membrane is
beneficial in the treatment of periodontal defects. The purpose of this study was to evaluate
the effect of a type I bovine collagen membrane on treatment of Class II furcation defects.
Twelve systemically healthy patients (six male and six female, ages 32 to 68) were treated.
Each had bilateral mandibular furcation defects with attachment loss 6 mm. Prior to
surgery all patients completed initial therapy including scaling and root planing. At the time
of the surgery, teeth were randomly assigned to either a control (flap debridement alone) or
test (flap debridement plus collagen membrane) group. Data were collected on the day of
surgery, and 2, 4, and 6 months post-surgery and at the 12 month re-entry surgery. Clinical
measurements included probing depth (PD), clinical attachment level (CAL), gingival
recession (GR), Stent to base of defect (SB), crestal bone to base of defect (CB), width of
defect, and mobility. Statistical analysis was performed utilizing the paired t test. Both
control and test groups demonstrated significant (P< 0.05) improvement at 12 months reentry in PD, CAL, SB, and CB when compared to the presurgery status. While there is no
significant difference in PD, CAL, GR, width of defect, and mobility between control and test
groups, sites treated with the collagen membrane had significantly higher bone fill (SB and
CB) at re-entry. A significant improvement of furcation horizontal bone repair and defect
improvement was noted in the collagen membranes-treated sites as compared to the
presurgery status. No foreign body reaction was observed in either group during this study.
This study suggests that the use of absorbable collagen membrane may have beneficial
effects in the treatment of Class II furcal defects. J Periodontol 1994; 65:10291036.

Link: http://www.joponline.org/doi/abs/10.1902/jop.1994.65.11.1029

Evaluation of a Collagen Membrane With and Without Bone Grafts in

Treating Periodontal Intrabony Defects
Chuan-Chuan Chen,* Hom-Lay Wang, Frederic Smith, Gerald
N. Glickman, Yu Shyr, and Robert B. O'Neal
*Private practice, Taipei, Taiwan.
Department of Periodontics/Prevention/Geriatrics, School of Dentistry, University of
Michigan, Ann Arbor, MI.
Department of Cariology, Restorative Sciences, and Endodontics.

Division of Biostatistics, Department of Preventive Medicine, School of Medicine, Vanderbilt

University, Nashville, TN.
Currently, Department of Periodontology, School of Dentistry, University of Washington,
Seattle; previously, Department of Periodontics/Preventign/Geriatrics, University of
Michigan.
THE AIM OF THIS STUDY was to compare the clinical regenerative capacity of collagen
membrane with and without demineralized freeze-dried bone allografts (DFDBA) in treating
periodontal intrabony defects. Ten systemically healthy patients with similar bilateral
periodontal defects were scheduled for surgery. Each patient had at least 6 mm clinical
probing depth and loss of attachment at selected sites. Baseline measurements included
gingival index (GI), plaque index (PI), gingival recession (GR), clinical attachment level
(CAL), probing depth (PD), and mobility. At the time of surgery, the defects were randomly
assigned to either test (collagen membrane plus DFDBA) or control group (collagen
membrane only). Stent to base of the defects, stent to crest bone, crest of bone to base of
the defect, and width of the defects were recorded at the time of surgery and reentry. Eight
patients returned after 6 months for reentry surgery. Statistical analysis with a paired t test
was used to evaluate the treatment effect and comparison between test and control groups.
In addition, a McNemar test was used to analyze the significance of GI, PI, and mobility at
different times. The result of this study indicated that both the collagen plus DFDBA and the
collagen alone treatment groups had a significant decrease of PD (3.40.4 and 3.20.4
mm), gain of CAL (2.30.5 and 2.00.4 mm), and defect fill (1.70.3 and 1.90.9 mm)
(P < 0.05) when compared to the presurgery status. However, there was no significant
difference in PD, AL, GR, defect fill, crestal bone resorption, GI, PI, or mobility between the
test group and control group. No adverse tissue reaction, infection, or delayed wound
healing was noted throughout the treatment in either group. This study suggests that the
collagen membrane is well tolerated by the human tissues. Both treatments, either collagen
membrane plus DFDBA or collagen membrane alone, promoted significant resolution of
periodontal intrabony defects. The addition of a bone graft (DFDBA) with a collagen
membrane appears to add no extra benefit to the collagen membrane treatment. J
Periodontol 1995;66:838847.

Link: http://www.joponline.org/doi/abs/10.1902/jop.1995.66.10.838

Histologic Assessment of New Attachment Following the Treatment of a

Human Buccal Recession by Means of a Guided Tissue Regeneration
Procedure
P. Cortellini,* C. Clauser, and G.P. Pini Prato*
*Department of Periodontics, University of Siena, Siena, Italy.
Private practice, Florence, Italy.
A DEEP, LONG-STANDING RECESSION on a mandibular incisor was treated in a 56-yearold female
patient. The tooth was tilted buccally and was scheduled for extraction. The recession was 8
mm deep, with a pocket depth of 1 mm and no keratinized tissue. The recession was treated

by guided tissue regeneration; the membrane was left in place for 4 weeks. The tooth was
extracted along with marginal tissues 5 months after the removal of the membrane. At the
time of extraction, 4 mm of root coverage had been achieved and 3 mm of keratinized
tissue were measured buccally. Histologic measurements showed that 3.66 mm of new
connective tissue attachment had been obtained associated with newly formed cementum
(2.48 mm) and bone growth (1.84 mm). The crestal bone level after treatment was located
coronal to the preoperative location of the gingival margin. J Periodontol 1993;64:387391.

Link: http://www.joponline.org/doi/abs/10.1902/jop.1993.64.5.387

Guided Tissue Regeneration Versus Mucogingival Surgery in the Treatment

of Human Buccal Gingival Recession
Giampaolo
Pini Prato,* Carlo Tinti, Giampaolo Vincenzi, Cristina Magnani, Pierpaolo Cortell
ini,* and Carlo Clauser
*Department of Periodontology, Dental School, University of Siena.
Private practice, Flero (Brescia), Italy.
Private practice, Verona, Italy.
Accademia Toscana di Ricerca Odontostomatologica.
A SURGICAL TECHNIQUE INVOLVING MEMBRANES was used to treat localized human buccal
recessions 3 mm to 8 mm. The results on 25 patients (test group) were evaluated 18
months postoperatively and compared with the results obtained in 25 other patients (control
group) having undergone mucogingival surgery. In the test group, a trapezoidal flap with a
large base was raised beyond the mucogingival junction. The exposed root surface was
scaled thoroughly to a concave shape. A membrane was bent and adapted onto the concave
root surface. The flap was sutured far coronally and the membrane removed one month
later. The control patients underwent a 2-step procedure, consisting of a free gingival graft
and a coronally positioned flap. The amount of root coverage obtained was similar in the 2
groups (test = 72.73%; control = 70.87%), although the clinical attachment gain (test =
5.12 mm; control = 3.56 mm) and pocket variation (test = 1 mm reduction; control = 0.06
mm increase) differed significantly (P < 0.001). The keratinized tissue width was greater in
the control group. The regression analysis showed that the amount of covered root surface
after treatment was in strict correlation with the depth of the original recession in the test
group, while no correlation was found in the control group. The expected root coverage was
greater in the test group when the recession was greater than 4.98 mm, while it was
greater in the control group when the recession was less than 4.98 mm. These results
indicate that a guided tissue regeneration procedure can be used to successfully treat
recession. The membrane procedure compared favorably with the mucogingival surgery in
the treatment of deep recession. J Periodontol 1992;63:919-928

Link: http://www.joponline.org/doi/abs/10.1902/jop.1992.63.11.919

Xenogeneic Collagen Matrix With Coronally Advanced Flap Compared to Connective

Tissue With Coronally Advanced Flap for the Treatment of Dehiscence-Type
Recession Defects
Michael K. McGuire* and E. Todd Scheyer*
*Private practice, Houston, TX.
Correspondence: Dr. Michael K. McGuire, 3400 S. Gessner St., #102, Houston, TX 77063. Email: mkmperio@swbell.net.
Background: For root coverage therapy, the connective tissue graft (CTG) plus coronally
advanced flap (CAF) is considered the gold standard therapy against which alternative
therapies are generally compared. When evaluating these therapies, in addition to
traditional measures of root coverage, subject-reported, qualitative measures of esthetics,
pain, and overall preferences for alternative procedures should also be considered. This
study determines if a xenogeneic collagen matrix (CM) with CAF might be as effective as
CTG+CAF in the treatment of recession defects.
Methods: This study was a single-masked, randomized, controlled, split-mouth study of
dehiscence-type recession defects in contralateral sites; one defect received CTG+CAF and
the other defect received CM+CAF. A total of 25 subjects (8 male, 17 female; mean age:
43.7 12.2 years) were evaluated at 6 months and 1 year. The primary efficacy endpoint
was recession depth at 6 months. Secondary endpoints included traditional periodontal
measures, such as width of keratinized tissue and percentage of root coverage. Subjectreported values of pain, discomfort, and esthetic satisfaction were also recorded.
Results: At 6 months, recession depth was on average 0.52 mm for test sites and 0.10 mm
for control sites. Recession depth change from baseline was statistically significant between
test and control, with an average of 2.62 mm gained at test sites and 3.10 mm gained at
control sites for a difference of 0.4 mm (P = 0.0062). At 1 year, test percentage of root
coverage averaged 88.5%, and controls averaged 99.3% (P = 0.0313). Keratinized tissue
width gains were equivalent for both therapies and averaged 1.34 mm for test sites and
1.26 mm for control sites (P = 0.9061). There were no statistically significant differences
between subject-reported values for esthetic satisfaction, and subjects' assessments of pain
and discomfort were also equivalent.
Conclusion: When balanced with subject-reported esthetic values and compared to
historical root coverage outcomes reported by other investigators, CM+CAF presents a
viable alternative to CTG+CAF, without the morbidity of soft tissue graft harvest.

Link: http://www.joponline.org/doi/abs/10.1902/jop.2010.090698

Mucogingival Versus Guided Tissue Regeneration Procedures in the

Treatment of Deep Recession Type Defects

G. Zucchelli,* C. Clauser, M. De Sanctis,* and M. Calandriello*

*Department of Periodontology, Faculty of Odontology, Bologna University, Bologna, Italy.
Private practice, Florence, Italy.
THE OBJECTIVE OF THE STUDY was to compare the clinical efficacy of 3 surgical approaches in
the treatment of deep recession type defects. Fifty-four (54) gingival recessions 5 mm
were randomly assigned, to 1 of the 3 treatment groups by blocking the prognostic
variables. The first group was treated with a guided tissue regeneration (GTR) procedure
using a bioabsorbable membrane, the second with non-resorbable membrane, and the third
with a mucogingival surgical approach consisting of a connective tissue graft combined with
a coronally advanced flap (bilaminar technique). No differences, in terms of baseline oral
hygiene and defect characteristics, were observed among the 3 groups showing an effective
blocking approach. The 1-year results indicated that 1) all treatment approaches resulted in
clinically significant root coverage and attachment gain; 2) a statistically significant
treatment effect (P = 0.012, ANOVA) was observed comparing the bioabsorbable (4.9 0.3
mm), the non-resorbable (4.5 0.8 mm), and the bilaminar (5.3 0.7 mm) groups, in
terms of root coverage; 3) the difference in terms of root coverage between the bilaminar
and the non-resorbable membrane groups was statistically significant while differences
between the 2 GTR groups or between the bilaminar and the bioabsorbable membrane
groups did not reach statistical value; 4) the 95% confidence intervals for the proportions of
complete successes showed a similar pattern; 5) no statistical difference was demonstrated
in the amount of attachment gain among the 3 groups (P = 0.73, ANOVA). A regression
model showed that the amount of root coverage was significantly affected by the initial
recession depth, the procedure and smoking habits: a poorer root coverage result is
expected in case of shallow recession type defects, when either bioabsorbable (P < 0.05) or
non-resorbable (P < 0.001) membranes are used instead of a bilaminar technique and if the
patient smokes (P < 0.01). It was concluded that the mucogingival bilaminar technique is at
least as effective as GTR procedures in the treatment of gingival recession 4 mm and thus
recession depth is not the parameter which influences the selection of the surgical
procedure. J Periodontol 1998;69:138145.

Link: http://www.joponline.org/doi/abs/10.1902/jop.1998.69.2.138

Treatment of Gingival Recession Using a Collagen Membrane with or

without the Use of Demineralized Freeze-Dried Bone Allograft for Space
Maintenance
Kenneth M. Kimble
Private practice, Phoenix, AZ.
Robert M. Eber
Department of Periodontics/Prevention/Geriatrics, School of Dentistry, University
of Michigan, Ann Arbor, MI.

Stephen Soehren
Private practice, Phoenix, AZ.
Yu Shyr
Division of Biostatistics, Department of Preventive Medicine, School of Medicine,
Vanderbilt University, Nashville, TN.
Dr. Hom-Lay Wang
Department of Periodontics/Prevention/Geriatrics, School of Dentistry, University
of Michigan, Ann Arbor, MI.
Background: Studies utilizing collagen membranes for guided tissue regeneration (GTR)based root coverage procedures have reported promising results. However, creating and
maintaining space underneath the membrane remains a challenge. Therefore, the purpose
of this clinical trial was to determine whether the addition of bone graft (i.e., demineralized
freeze-dried bone allograft [DFDBA]) significantly affects the outcome of collagen membrane
GTR-based root coverage procedures.
Methods: Twenty patients participated. One Miller's Class I or II recession defect per
patient was treated with a collagen membrane covered by a coronally positioned flap. Half
of the patients also had DFDBA placed under the membrane. Clinical parameters recorded
included: recession depth, recession width, width of keratinized tissue, clinical attachment
level, and probing depth, measured to the nearest 0.5 mm. Presurgery and postsurgery (6month) data were compared using Student's paired t test for parametric data and the
Wilcoxon matched pairs test for non-parametric data.
Results: Guided tissue regeneration with collagen (COLL) and collagen + DFDBA (COBA)
both resulted in statistically signifi- cant (P <0.05) reductions in recession depth (2.1 0.9
mm and 2.5 0.5 mm), recession width (1.5 1.7 mm and 2.2 1.6 mm), increase in
keratinized tissue (0.7 0.8 mm and 1.2 1.0 mm), and gain of clinical attachment level
(2.1 1.0 mm and 3.0 1.0 mm), when comparing 6-month data to baseline. Mean root
coverage was 68.4 15.2% with COLL and 74.3 11.7% with COBA. However, there were
no statistically significant differences between groups for recession depth, recession width,
width of keratinized tissue, clinical attachment level, and probing depth.
Conclusions: Both techniques are effective in attaining root coverage. Although root
coverage tended to be better with the addition of DFDBA, the difference was not statistically
significant. Further studies with a larger sample size are needed to determine whether
adding DFDBA to GTR-based procedures using collagen membranes is of any benefit. J
Periodontol 2004;75:210-220.

Link: http://www.joponline.org/doi/abs/10.1902/jop.2004.75.2.210
Comparative Clinical Study of Guided Tissue Regeneration With a Bioabsorbable
Bilayer Collagen Membrane and Subepithelial Connective Tissue Graft
Dr. Christine Romagna-Genon

Department of Periodontology, General Hospital, Tonnerre, France.

Background: During the last decade, there have been great strides in the treatment of
gingival recession defects, especially with subepithelial connective tissue graft and guided
tissue regeneration (GTR) procedures. Gingival recession represents a significant concern
for patients. It is necessary to choose the most appropriate procedure in order to obtain
more root coverage while avoiding clinical disadvantages. The purpose of this randomized
clinical trial was to evaluate the use of a bioabsorbable bilayer collagen membrane with GTR
compared to a connective tissue graft in the treatment of gingival recession defects.
Methods: Twenty patients each contributing a pair of Miller Class I or II buccal gingival
recessions were treated. In each pair, one recession was randomly assigned for treatment
with GTR using a bioabsorbable bilayer collagen membrane and the other treated with
subepithelial connective tissue graft (CTG). Clinical measurements taken at baseline (D0)
and 3 and 6 months post-treatment included recession depth (RD), recession width (RW),
probing depth (PD), and clinical attachment level (CAL).
Results: Data were analyzed using the non-parametric Wilcoxon matched pair test. All
results were statistically significant. Both treatments resulted in a significant gain of root
coverage (P <0.0001), amounting to an average of 2.80 mm at 3 months in the GTR group
and 3.34 mm in the CTG group. At 6 months, the decrease of the mean RD remained
statistically significant: 2.70 mm (74.59% root coverage) in the GTR group and 3.19 mm
(84.84% root coverage) in the CTG group. The mean RW also decreased from 4.48 mm at
D0 to 2.42 mm at 6 months in the GTR group, and from 4.38 mm at D0 to 1.35 mm at 6
months in the CTG group, representing a percentage of coverage of 45.98% and 69.18%,
respectively. Mean CAL gain obtained between D0 and 6 months with the GTR procedure
and CTG was 3.31 mm and 3.09 mm, respectively, and was significant within groups. At 3
and 6 months, the differences in the results for RD, CAL, and RW were not statistically
significant between the 2 groups. However, the difference was significant for PD at 3 and 6
months.
Conclusions: The results suggest that a bioabsorbable bilayer collagen membrane can be
used in the GTR treatment of human buccal recession defects, with no statistically
significant differences between this procedure and connective tissue grafts. J Periodontol
2001;72:1258-1264.
Link: http://www.joponline.org/doi/abs/10.1902/jop.2000.72.9.1258

Evaluation of the tissue reaction to a new bilayered

collagen matrix in vivo and its translation to the
clinic
Shahram Ghanaati1,2,8, Markus Schlee3, Matthew J Webber4, Ines Willershausen5, Mike
Barbeck1, Ela Balic6, Christoph Grlach6, Samuel I Stupp7, Robert A Sader2 and C James
Kirkpatrick1

This study evaluates a new collagen matrix that is designed with a bilayered
structure in order to promote guided tissue regeneration and integration within the host
tissue. This material induced a mild tissue reaction when assessed in a murine model and
was well integrated within the host tissue, persisting in the implantation bed throughout
the in vivo study. A more porous layer was rapidly infiltrated by host mesenchymal cells,
while a layer designed to be a barrier allowed cell attachment and host tissue integration,
but at the same time remained impermeable to invading cells for the first 30 days of the
study. The tissue reaction was favorable, and unlike a typical foreign body response, did not
include the presence of multinucleated giant cells, lymphocytes, or granulation tissue. In the
context of translation, we show preliminary results from the clinical use of this biomaterial
applied to soft tissue regeneration in the treatment of gingival tissue recession and exposed
roots of human teeth. Such a condition would greatly benefit from guided tissue
regeneration strategies. Our findings demonstrate that this material successfully promoted
the ingrowth of gingival tissue and reversed gingival tissue recession. Of particular
importance is the fact that the histological evidence from these human studies corroborates
our findings in the murine model, with the barrier layer preventing unspecific tissue
ingrowth, as the scaffold becomes infiltrated by mesenchymal cells from adjacent tissue into
the porous layer. Also in the clinical situation no multinucleated giant cells, no granulation
tissue and no evidence of a marked inflammatory response were observed. In conclusion,
this bilayered matrix elicits a favorable tissue reaction, demonstrates potential as a barrier
for preferential tissue ingrowth, and achieves a desirable therapeutic result when applied in
humans for soft tissue regeneration.

Link: http://iopscience.iop.org/1748-605X/6/1/015010