the International Journol of Periodonhcs & líesloiotive Dentistry 17

The Utilization of Rubber Dam as a for the Simultaneous Treatment of Multiple Periodontal Defects by the Biologic Principle of Guided Tissue Regeneration: Case Reports

Henry Saloma. DMD' In 1976, Melcher^ suggested Fabio Rigotti. DMD" that the kind of healing fhat fol- Rodolfo Gianserra, DMD' lows periodontal therapy Is Jay Seibert. DDS"" determined by fhe type of cell fhaf firsf repopulafes fhe roof surface. Subsequent investiga- tions ^"^ indicated that healing in most periodonfol procedures The principle ot guided tissue regenerotion has demoristroted o level ot occurs by fhe formation of a success in regenerating /he periadontai attachment apparotus lost fo long on periadontal disease. Several types of membrane barriers, eoct) one with previously diseased roof sur- distinct properties, tiave been utilized to apply this principle in periodontot waund tiealing. A series of case reports introduces and discusses the attri- faces. These results demon- butes ot rubber dam as a barrier membrone for tiie treatment of multlpie strated that epithelium is usu- periodantal osseous detects. Comparison at preaperative and pastopera- ally fhe first fo repopulate the tive clinical meosurements as well as reentry pracedures are ufdized to root surface and suggested higiilight successtui osseous regeneration. (Int J Periodont Rest Dent that in so doing it may inhibit ]994;14:17-33.) new attachment formation. In a series of articles pub- lished in the early 1980s, Karring, Nyman, and co- warkers*"^ determined that if bone or gingiva! conneotive tis- sue is selectively put in direct * Assistont Clinicai Professor of Periodontics ond Periodontal- Prosttiesis, Codirector of Implant Surgeri'. University of contact with the root during Pennsylvania. Schooi ot Denfol Medicine healing, if will promofe roof *Po6tgroduate student in Periodonfics, University of résorption rather than the for- Pennsylyonio, Sctiool of Dentol Medicine. •Private Practice, I? o me. Italy. mation of a new conneotive *Protesso( ond Chairmon of Periodontics. Universiiy of tissue attachment. In 1982, Pennsylvanio, Scticol of Dental Medicine. Nyman and coworkers''^° uti- Correspondence to: Di Heniy Salama. University of lized a Millipare filter (Millipore) Pennsylvonio, Sctiool of Dentol Medicine. 4001 Spruce Street as a barrier membrane to Ptiiladelphia. Pennsvivania 19104.

Volume 14, Number 1, 1994 18

exclude botfi the gingival quate rigidity tor space mainte- sutures complicates odapta- epitheliufn and connective tis- nonce, and the ability to allow ticn and is extremely technique sue from the wound site. This tor tissue integration. sensitive ond time consuming. opproach allowed for the cre- In addition to the neces- The limitotions mentioned afion of a space that favored sory membrane characteristics make presently available cells from fhe pefiodontal liga- listed above, on importont pre- membranes difticult to utilize ment and endosfeal apices fo requisite for successful peri- and adapt in the treatment of be the first to migrate olong odontal GTR therapy is proper multiple periodontal defects. It the root and torm o new membrane placement. The would therefore seem odvan- attachment apparatus, membrane must completely togeous if an occlusive mem- Subsequent to the Millipore seal off the defect environ- brane were available that filter, expanded polytetrafluo- ment. Intimate adaptation ot meets the requirements ot GTi? roethylene material (e-PTFE; membranes, however, is very while being easily manageoble Gore-Tex periodontal material difticult in areas of furcations or and completely adaptable (GTPM; WL Gore)) was used as oround irregulor root surfaces around multiple defects. the barrier membrane in the exposed by periodontal dis- Zaner et al'^ utilized freeze- successful regenerative ap- ease,'" These root surfaces ore dfled dura mater allogratts os a proach that became i

The International Journal of Periodontics & lîestorotive Dentistry Figs Ja to Id Complex defect environments requiring more thon one conventional membrone.

Fig )a Circumferential distoi ond lingual infiobony deteots onteetti3óand37.

Figs lb and Ic One inteipioximoi Goie-Tex periodontol membrane (GTPM) placed to isolate the detect around tooth 37 is not sufficient to address the defect surrounding tooth 36. which extends to the buccal surfaces.

Fig Id A second interproximal GTPM membrane has been piaced to isolate both defects completely. (Figs ¡oto Id oourtesy of Dr Mauiice Saiamd. Atlanta. Georgid.)

Volunte 14. Number 1, 1994 20

Fig 2a Infrabony defects between teeth 32 and 33 and 30 Fig 2b Rubber dam membrane in place isolating ttie defects and 31. from tfie soft tissues.

Figs 2c Sutured flaps Fig 2d Reentry at ó montais Note the complete osseous tiil of the detects, inciuding suprocrestot regeneration Figs 2a to 2d Courtesy of Dr Fabrizio La Rocca. Novara. Italy.

The purpose of this paper is periodontai osseous defects by and disadvantages ot the to present the resuits of a ciini- GTR. Comparisons of preopera- materiai will be discussed ds cal triai evaiuatíng the paten- tive and postoperative ciinicai they reiate to the accepted tial use of rubber dam os the measurements as well as reen- criteria for a successfui occiu- occiusive barrier in the simuita- try procedures are utilized to sive membrane in regenerative neous treatment of muitipie evaluate resuits. Advantages periodontai therapy.

The International Journoi of Penadontics & Restorative Dentistry 21

Method and materials Surgical design the apioai extension of the infrabony defects were mea- Ten patients (seven women Suicular incisions were utilized sured with a probe and re- and three men aged 29 to 52 to maintain as much tissue as corded, years) who presented with possibie for membrane cover- Once the defects were odvanced periodontai disease age. The incisionoi design was compiefeiy instrumented, a participated in this clinical triai. extended mesiaiiy and distaHy piece of steriiized rubber dom The therapeutic approach was to inciude at ieast one reia- was trimmed to conform to the fully explained and each tiveiy heaifhy tooth thot did not number of teeth present in the patient consented to the pro- require regenerotive therapy. surgical site ond to the topog- posed treatment. The criteria This design ensured that any rophy of the defects. Holes for selection were (1) the pres- vertical reieasing incisions were made in the dam with a ence of ot least four sites in a would not lie over on orea sterile rubber dam punch. Tne quadrant exhibiting probing receiving a membrane, in membrone wos extended to depths of 7 mm or greater; and addition, the extension of the inciude at ieost one healthy (2) the presence ot existing surgical site was neoessory to tooth on either end of the multjpie osseous detects for allow the stretching ond proper detect environment to ensure that the membrone border which regenerative treatment adaptation of the dam materi- would be ot an appropriate utiiizing the principies of GTR al post the teeth that required distonoe (3 to 4 mm) beyond wouid require the placement treotment. Verticoi reieasing the edges of the defects. In of more than one commer- Incisions, placed to include the three subjects it was necessary ciaiiy avaiiabie membrane. terminai papillae, were utilized to apically suture the mem- Aii patients underwent ini- to goin complete access to the brane to the submuccsoi tissue tial therapy, which included defects, Full-thickness muco- with resorbable Vicryl sutures instructions, quad- periosteal tiaps were roised to (Johnson & Johnson) to secure rant expose at least 3 mm ot bone the edges ot the membrone in under iocai anesthesia, and adjacent to the defects. piace. The fiops were then caries controi. At ieast ó weeks Partioi-thickness dissection was coronaily positioned and af^ef initiai infiammatory con- performed apicaily from that sutured with Gore-Tex suture trol and prior to surgery, the point to oiiow coronal position- material (WL Gore) to ailow probing attachment ievel (PAL) ing ot the buccal flop to further extended stabilization of the was measured for the sites to ensure complete coverage of popilloe over the membrane. receive regenerative therapy. the membrane at the time ot Where furcation invoivement ciosure ond during the early Representative cases are was present, PAL was mea- healing phase. shown in Figs 3 to 7. sured in both the vertlcai and Subsequent to fiap eleva- horizontal dimensions into the tion, the root surfaces were furcation. Vertical measure- scaied and root planed with ments utiiized the cemento- hand instruments, ultrasonic enamel junction CCEJ) as q sealers, ond fluted burs. Whiie fixed index. all granulation tissue wos removed, no osseous recon- touring was performed. The level of the aiveoiar crest and

Volume 14. Number 1, 1994 22

Fig 3a [left) Distal detect araund toath 18 with a Class II tufcatlon involvement.

Fig 3b (right) Circumferential defect around tooth ¡5.

Fig 3c Rubber dam mernbrane in Fig 3d Reentry at 6 months. The Fig 3e loath IS at reentry. place, isolating the defects and span- detect around the maxillary right pre- ning the edentulous ridge. molar is completely tilled, and same supracrestal bone regeneration is observed

Fig4a Toath 17 exhit:nts signiticant Fig 4b Rubber dam membrane in Fig 4c Reentry at ó months. The peak Intraosseaus defects on the mesial and place. otbone on the palatal aspect of tiie distal aspects with Class II furcation second molar has been lost, buf almost involvement. complete fill has been achieved on the mesial and distal aspects, including regeneration of the furcation areas.

The internationai Journdl of Petiodontics & Restorative Dentistry 23

Fig 5a The maxillary right quadrant hos O series af angulof detects ond ctofers.

Fig 5b Deep osseous defects ore evident ot initial surgery inoludirig o Closs li furcotion on the buccal surface of tooth 16

Fig 5c Rubber dam membtone in position Fig Sd Reentry at 7 months Note the osseous fill at the angular ond crater defects os well as the buccal furcation cf tooth 16.

Volume 14, Number t, 24

Hfl)

Fig 6a Maxiiiaiy light quadrant. Fig 6b Extensive defect environment, including Class III trifurcdtion of the first molar

Fig 6c Probe in place on the distdl aspect of the first premolor.

Fig 6d Membrane in place aftei Fig 6f Reentry ot ó months. Note tne remdVdi cf the roots of the first moldr complete regeneration of the defects and splinting of its crown to the adjd including the opicai piate af bone on cent teeth. Ttie membrane has been the first premolar. trimmed to span ttie edentulous ridge.

Fig 6e interproximal area between the premoiars dt membrane removal.

The Intemationol Jourrtol ot Penodon^ics & Restorative Dentistry 25

fig 7a Mesial angutar defects on the centrai incisors. Note Fig 7b tvlemb'one in piace prior to suturing. the ndge concavities thai are associated with this site

Fig 7c Six weeks prior to membrane removoi Note the per- Fig 7d Reentry at 6 months. Osseous fill ot the delects nas foration ot the lobial flap by the membrane. been achieved. In addition, the ridge dimensions have been enhanced. Figs 7a fa 7d Courtesy of Dr Fernando Presser.

Volume 14, Number 1, 1994 26

Fig 6 Chdnges in mean probing attachment levéis meosured after scaling and roat planing (DayO) and the some sites at 4 months New ottachment gam ranging between 2 and 5 mm was evident on oil subiects

Postcperafive care Results Probing attachment ieveis were recorded just prior to Foilowing surgery, the patients Ali membranes became ex- membrane piacement and 4 were prescribed doxycycline posed interproximally by the months after surgery. There was (100 mg twice o day) for 2 second weekly visit. In four a gain of clinical new attach- weeks and instructed to rinse patients it wos necessary to ment in all sites measured. with 0.127o chiorhexidine three resuture the papillae at the 3- Attachment gain omong sites times daily for the duration ot week recali visit to regain ranged between 1 and 8 mm. treatment. The patients were approximation ot the papillae The range among patients was examined at weekiy intervals. and to stabilize the flaps. The 2 to 5 mm of new clinical Tissue response was monitored levei of gingivai inflamma- ottachment (Fig 8), The mean and the teeth were polished. tion around the membranes goin ot probing attachment The membranes were removed ranged from minimai to moder- for aii sites in aii potients was 4 to 6 weeks after placement. ate. None of the sites, howev- 3.64 mm. The PAL was determined at 4 er, exhibited sweiiing or suppu- The intraosseous probing months and reentries were per- ration at any of the recall visits. measurements were recorded formed at 6 to 7 months post- Aii membranes were removed at membrane piacement and surgically. between 4 and ó weeks. reentry, which took place 6 to

The Internationai Journal of Periodontics & Restorative Dentistry 27

Fig 9 Changes in mean intraosseous probing depth measulred using the CEJos a landmark and taken during the initial surgical procedure and ot reentry. Two sub- jects (7 and 10) were nat ovaiiable tar follow-up reentries and were not included in the meosurements.

7 months lafer. Two pafients Discussion To date, e-PTFE has been were not available tar reentry fhe most successful and widely evaluation. The range of The objective of this clinical trial sfudied membrane material fo osseous regenerafion (mea- was to evaluate the use ot rub- be utilized for regenerative sured by open probing) among ber dam as the occlusive barri- therapy. Recently, blodegrad- the remaining eight patients er in the treatment of multiple abie barriers, such as colla- was 2,4 to 7.5 mm (Fig 9). The periodonfal osseous defects by mean osseous fiil for all sites the principle af GTR. It has membranes, have received was 4.25 mm. Three of the been suggested that there are cansiderable attentian and are patients exhibited 1.0 to 3.5 specific design criteria for an alsa being used successfully mm af supraoresfai osseous occlusive membrane to meet in achieving GTR around se- regeneration (see Figs 3, 6, and the requirements of GTR.'"" lected defects. In evaluating 7). The remaining tive pafienfs These criferia include bioccm- the present clinical results, the had defect fiii that ranged patibility, manageabiiify, abiiity ot rubber dam ta act as from 80% to 95%. space-making ability, and the an occlusive barrier in GTR was ability to allow for tissue inte- measured against the criteria gration with fhe membrane, that have been established for Resorpfive capacity has also existing membranes. been discussed as an optiana! attribute because of its thera- peutic convenience.'^

Volume 14, Number 1,1994 28

Biocompatibility intlommatory response is ot nonce. More subjects need to speoiol concern when mem- be studied and the rubber When we considered using branes are used to treat peri- dam membrones must be cul- rubber dom material as an odontal detects. It exposed, tured, however, to determine occlusive membrone in GTR they allow intiltration and colo- the consistency of these obser- procedures tor our patients, our nization by bacterial cells and vations, the mechanisms in- first consideration was its bio- their by-products into the heal- volved, ond the clinical signiti- compatability. The transmucos- ing wound. This intiltrotion may cance to periodontal regen- al use of rubber-type materials lead to chronic intlammation eration. as drains in oral and maxiilo- or an acute infection beneath tacial surgery has been ac- the surgical flap, probably cepted for decades.^^•^•' In compromising healing ond ManageabHity addition to rubber dam, mony regenerative capacity and types of basic rubber drains necessitating early removal of The obility of rubber dam to are in common medicol the membrane. DeMolon et intimately and easily adapt to usoge, including Foley a|2* studied the bacterial colo- severol teeth in one applica- catheters, red rubber French nizotion associated with GTR tion is a unique advontage ot catheters, tubular "cigarette" procedures using GTPM in this material. A related advan- drains, and the widely accept- humans. Utilizing an oligonu- tage is the elimination of the ed Penrose drains,^'' cleotide DNA probe, they con- need for multiple sutures and There are also precedents cluded that GTR procedures suture knots. This capobility was in the literature for using rubber result in the presence ot several felt to be ot clinical signifi- moterials in GTR procedures. periodontal pathogens on the cance because it decreased Lekovic et GL''*'^^ in a series of GTPM and in the surrounding the time required to perform experiments on dogs, com- crevicular fluid. Further, they the surgical procedure. The ini- pared silicone rubber with found that the moteriol is tre- tial attempt at designing ond three other types ot mem- quently associated with severe placing the rubber dom may branes tor applicotion in GTR inflommation that sometimes be somewhat tedious, but the procedures. In on effort to includes suppurotion. technique becomes easier with evaluate the inflammatory While the rubber dam experience. response, they conducted material invariably became stereometric surveys of the exposed interproximaily. none treatment sites. Their findings of the subjects treated in our Ability fo maintain a space demonstroted that the per- clinic displayed any hint of centages ot plasma cells in the swelling or suppuration at the In experiments using GTR. sites treoted by silicone rubber treatment sites during their Gottlow ond Nyman" found membranes were comparable weei

The Internotionol Journal of Periodontics & Restorative Dentistry that a larger omouht of regen- brane. The some nonporaus acteristics that we believe wiil eration occurs when the borrier surface that minimized micro- require more emphosis in the is mointained ot a more coro- biol coiohization mode tissue future inciude odaptability ohd nal level. In contrast, when the integratioh impossible. This con- permeability. barrier coiiapses into the angu- sequently mode maintenance lar defect, it results in only a more demonding, because it Adoptability. Root irregu- small amount of regeneration. resulted in somewhat eorlier lorities ore often associated Their conciusion was that the exposure of the membrone with conoovities that connot amount of regenerotion is ond ehhanced epithelioi be bridged by ahy type of determined by the position of migration dovi/n the inner membrone v^/ithout the cre- the borrier membrane. aspect of the mucogingivai otion of o gap. Lu''' tound thot On its own, rubber dam has flap compared with other neorly 94% of the molor teeth no capability to retoin a given materials. tested hod a concavity depth shape of ony kind. Once Becouse of the resulting that prevented the open placed ot a levei close to the lock of flap stabilizotion, reces- microstructure ot the PTFE CEJ, however, the rubber dam sion wos o consistent finding. membrane to odapt to the has the ability to retain its posi- While this recession helps to root surfoce. Those results sug- tion, ollowing a tenting effect reduoe evehtual probing gested that this gop may not thot creotes and maintains an depth, it moy result in an prevent the migration of oon- enhanced interproximal "re- esthetic compromise ahd must nective tissue or epithelioi cells generative spaoe" for GTR, For be token into considération into the regeherotive space large defects that inciude sig- when treoting the anterior sex- ond thereby may iimit regeher- nificont loss of the labiai or lin- tants. ation. We believe thot any gual plates ot bohe, osseous As with e-PTFE mem- breoch between the tooth ond grotts may be necessary to brones.^^ removal ot the rubber the membrone can be o help support this artificial spooe dam membrone is suggested source for the constant infusion durihg regenerotion. between 4 and ó weeks, ond of oral fluids ond bocteria, de-epithelialization of the inner which moy also act to limit new surface of the fiop is required ooronol attachment. The ditfi- Tissue integrotion at membrane removol. It is culty of ochievihg a tight apparent from these successful adaptation of the membrane Oonnective tissue integration results that the degree and to the root surface is further into the membrane is an impor- amount ot regeneration were magnified when it is necessary tant requirement for an occlu- not odversely offected by the to treat o series of adjoceht sive barrier utiiized in GTR pro- ditficulties caused by lack of tis- periodontal defects. cedures. The advantages ot sue integration into the mem- One ot the most important integration include increosed brane. advantoges ot o rubber dam- stabiiization of the membrane type of membrane resides in its and surgioai fiops as well as lim- abiiity to odopt intimately to itation of epithelial migrotion Advantages unique to tooth surfaces. This adaptobiiity on the flap's inner suffoce. The rubber dam material con be easiiy achieved and lack of this characteristic was con be maintained ot o more the main observable disadvan- In oddition to the estoblished coronal level on the root(s) tage of the rubber dam mem- criteria highlighted, the char- thon con other materials.

Volume 14, Number 1, 1994 30

Coronai piacement is impor- The nonporous and imper- branes that wouid have other- tant for creating more space meable nature of rubber dam wise been necessary for a for regeneration, it is diso criti- aiiows it to seai and protect the series of staged surgicai proce- cal because root irregularities regenerative space from infii- dures. While lacking the abiiity become more pronounced as tration by epitheliai ceils as well to allow tissue integration, the attachment loss progresses as from the influences of salivo rubber dam demonstrated apicaiiy into periodontal and baoteria and their by- enough positive attributes to defects. More coronal plaoe- products. In addition, because consistently achieve successful ment thus simpiifies the man- it is nonresorbable. this protec- osseous regeneration in this iim- agement of the most severe tion can be maintained ited patient sampie, defeot regions. throughout the course of thera- Gottiow and coworkers'^ py, provided that the rubber reported on new attachment Permeability. Se ver ai dam is not subjected to exces- formation in humans by guided recent studies indicate that sive movement or tension. tissue regeneratian. They con- bacteria ore capabie of tra- ciuded that, "despite the evi- versing through e-PTFE mem- dence ot significant amounts branes,^'"^' Guiiiemin et al,-'^ in General cansideratians of new and fibrous scanning electron mioroscopic aftachment at aii sites treoted, observations of interproximol A careful anaiysis of the regeneration of aiveoiar bone e-PTFE type membranes in advantages and disadvan- was almost exclusively restrict- humans, found microbiai con- tages of availabie membranes ed tc sites where angular bony tamination on both sides of the must be conducted prior to defects were present before membrane as well as within choosing one for use in GTR treatment." This iack of supra- the open microstructure ond procedures. Each type of crestai bone formatian is con- occiusive portions. They con- membrane seems to possess a sistent with cur own previous ciuded that the presence of unique set of desirabie charac- ciinicai experience with GTR, iarge plaque loads may be teristics, it is imperative to However, the meosured suc- one factor that may interfere match these characteristics to cess in achieving supracrestai with regeneration. During the the particular set of challenges bone regeneration in the pres- initiai stages of heaiing, Pitaru et presented by each unique ent study prompts the query ol^^ observed that eariy degra- patient, appiication, and into what attributes rubber dation of the coronai portion of defect environment. In this ciin- ddm may have toward achiev- coilagen membranes can be ical trial, we chose rubber dam ing this resuit more consistently, caused by enzymes originating membranes far their ability to Adaptabiiity and impermeabiii- from the saiiva and/or the isolate the defect space and ty may piay a roie. Controlled inflammatory response in the adapt intimateiy about teeth clinical studies are currentiy coronai aspects of the fiaps. with multiple adjacent peri- underway in our ciinic to They suggested that this may odontal defects, in addition, explore the histoiogic and permit the coionization of the the low oost ot the materiai microbiologie aspects of the coronal root surface by epithe- matched the needs ot the regenerative environment lial and fibrabiast ceiis, thereby patient pooi, most of whom associated with the use of rub- compromising new attachment were unabie to afford the cost ber dam as an occiusive mem- formation. of multiple conventional mem- brane.

The internationai Jaurnai af Periodontics & Restarative Dentistry 31

We are presently unaware Canclusions Acknowledgment ot any singie type of mem- brane that possesses the quali- A new dental use for rubber The authofs would like to t^^a^\k Dr Shirley Brown for her invaluable contri- ties to address all of the chal- dam OS on acceptable barrier bution to the editing of this manuscript. lenges posed by the many membrane was evaluated in o ditterent osseous defects and clinical trial in 10 specially circumstances routinely en- seiected patients. Eoch ot countered. Indeed, the pur- these patients exhibited exten- pose of the present study was sive multipie periodontai os- not tc develop and present on seous detects in at ieast one ideal method tcr the clinicai quadrant. Comparison of pre- appiication ot GTR, fíather, it operotive and postoperative was to introduce the successfui probing attachment ieveis as use of a new barrier and its weii as reentry osseous mea- appiication, whiie suggesting surements demonstroted highly areas tor future emphasis and suooessfui periodontai regener- research. ation. To reach the fuli potential The main advontages of ot GTR, we believe that it will rubber dam membranes seem be necessary to set different to be ossocioted with their abil- requirements for membranes ities to intimately odapt coro- ufilized in the predominantly nai to oompiex root topogro- closed environment of ridge or phies and to seai off the peri-impiant augmenfation surgical regenerotive sites trom prooedures and for those used oral fiuids and bacterio. In under the more chalienging addition, severai odjaoenf open suicus environment found defect environments can be in periodontal therapy. These easliy treated with just one new standards would require membrane. The resuits ot this new membrane designs as weii preiiminary study suggested as new materiai characteristics, that prediotabie regenerotion it is opporenf that the evoiution of the ottachment apparotus in membrane design and can be accompiished when a materiai has yet to catch up to rubber dam membrane is used the successful and established OS the occiusive barrier in GTR principles of GTR. procedures. Whiie the rubber dam membrane showed promise in this appiication qnd potentiaiiy has other applico- tions, the limitations of this materiai moke it clear thot the evolution of membrane design ond materiois must continue.

Volume 14, Number I, 1994 32

References 11. Goftlow J, Nyman S, Korring T, et ol. New attochmenf formation as o resuit of controlled tissue regenera- !. Meioher AH. On the repair potentiol tion. J Clin Periodohfol 1984:tt: Of periodontol tissue. J Periodontol ^194-503 1976.47:2Sû-2oO. 12. Gottiov/ J, Nyman S. Lindhe J, et al. 2.Yukno RA, A clinical and histoiogic New ottochment foimotion ih the study of heoling following the exi- human by guided tis- sionai new attachment procedure sue regeneration. J Clin Periodonfol in rhesus monkeys. J Periadontol 1986; 13:004-0)6 1970:47:701-709. 13. Nyman S, Gofflow J, Lindhe J, 3. Moskow BS. Korsh h. Stein SD. Karring T, Wennsfrom J. New Histologicol assessment ot autoge- affachment farmation by guided nous bone groft J Periodontol tissue regenerotion. J Periodonf Res 1979;50:29I-300. 1987:22.252-25d 4. Coton J, Zander HA. Osseous repoir 14. Lu HKJ. Topographiool chorooteris- ot on Introbony pocket without neyj fics of root trunk length related to attachment of conneotive tissue J guided tissue regenerotion. J Clin Periodontol 1976:3:54-58. Periodonfol 1992:63:215-219. 5. Coton JG, Nymon S, Zander HA. l5.Zaner DJ. Yukno RA, Molinin Tl. Histometric evoluotion o I periodon- iHumoh freeze-dried duro mafer tol surgery: Conneotive tissue allogroffs os o periodohfol biologic ottochment ieveis atter four regen- bandage. J Periodonfol 1989;60: ero tive procedures. J Clip, 617-623. Periodontol 1980:7:224-231. 16. Lei

The IhtematiohGl Journol of Periodontics & Restorative Dentistry 33

20 Blumenthal N M The use of collogen 28 Kon S. Ruben MP. Bloom AA, membrones to guide regenerotion Mardom-Bey W, Boffo J. Regener- of new connective tissue attach- ofion ot periodontol ligament using ment in dogs. J Periadontol resorbadle ond nonresorbable 1988.59:830-830 membranes- Clinical, histologicol, and histometric study in dogs. Int J 21.Fleisher N. Wool HD. Bloom A Periodont Rest Dent I991;l 1:59-71. Regeneration of lost attachment apparatus in the dog using vicryl 29. Simion M. Boldoni M. Polcan M. absorboble mesh (Polyglactin 910). Effecfiveness of GTAM membrones Int J Periodont Rest Dent wifh ond wifhout eorly exposure: A 1988:8(2)45-54. comporofive study (obstract) Int J Oral tvlQxilloloc Implonts 1992.7 121. 22. Fleming Ptvi, Matz GJ. Poisic WP, et al. Silicone rubber drain in heod 30. Nolbondian J, Tempro PH. Microbial and neck surgery. Trans Am Acad ploque on retrieved Polytetrotluoro- Ophthdlmal Otcl 1975:80:254 ethyiene membranes (obstract] J Dent Res 1991:70:536. 23. Jackson FE. Pratt RA, Teohnicol report: A silicone rubber suction 31. Shorof MN, Reich E, Schmoli G drain for droinoge of subdural Morphologicol and microbiological tiemafomas. Surgery 1971,70:578. exominotian of removed Gore-Tex membranes (obstract). J Dent Res 24. Flynn TR, Hoekstro CW. Lawrence 1991:70:507. FR. Ttie use of droins in oral and maxillofociol surgery: A review and 32. Guillemin MR. Mellonig JT. Holt SC. a new approoch J Oral Moxillofac SEM observations ot bocterial pop- Surg 1983:41:508-511. ulations on e-PTFE membranes in humans (obstractl J Dent Res 25. Lekovic V, Kenney EB, Dimitrijevic 1992:71:217 BB, Corlonza FA Jr. Guided tissue regeneration using four different 33. Pitaru S. Tal H. Soldinger M, membranes in conjunction with Grosskoff A. Noft M. Partial regener- porous tri-calcium phosphote ation of periodonTal tissues using [abstract). J Dent Res 1991:70:467 collagen barriers J Periodontal 1988:59:380. 26. Demolon lA, Monda BJ, Perssan GR. Bacteriol colonizotion osscciated witn guided tissue regenerotion pro- cedure lobstiactl. J Dent Res 1991.70:537. 27. Caton J. Wagener C, Palson A, Nyman S. et al. Guided tissue regen- erotion in interproximal defects in fhe monkey Int J Periodonf Resf Dent 1992:12: 267-277.

Voiume 14, Number 1,1994