the International Journol of Periodonhcs & líesloiotive Dentistry 17 The Utilization of Rubber Dam as a Barrier Membrane 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 junctional epithelium 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<nown as concave interproximolly and "biologic bandage" to cover guided tissue regeneration otten associated with ditferent and protect several adjacent (GTR),"-'^ Today, the principle degrees of fluting, which can periodontal osseous defects of GTR forms the basis for most prevent complete adaptation. being treated with autogenous regenerative periodontal pro- The inability to seal ott the bone gratis. Lekovic et al"'suc- cedures. detect environment trom cessfully utilized silicone rubber As the biologic principle of impregnation with oral tluids as occlusive membranes in the GTf? has become more univer- and bacteria moy compromise treatment ot grade II furcations sally accepted, efforts have the eorly healing phase ond in dogs. La Rocca suggested focused on enhancing its suc- therefore the potentiol tor the use ot rubber dam as a cessful application by improv- ochieving the moximum de- barrier membrane for GTR pro- ing materials ond surgical tech- gree of regeneration. cedures in humans (Lo Rocca niques, The barrier membrane, fvlembrane adaptation is F, personal communication, an integral component ot the even more demanding when it March 1992) (Figs 2a to 2d). technique, has received o is necessary to treat several great deol of attention. The adjacent teeth exhibiting multi- optimal design and attributes ple periodontol osseous de- tor an occlusive membrane to tects and root irregularities (Figs be used in the open system cf lo to Id). None of the mem- the sulcus envionment ore brane materials presently avail- complex. To date, the charac- able is designed to address the teristics emphasized hove complex topography of multi- included biocompatibllity. the ple detects witti Just one mem- ability to retard epithelial brane. The necessity ot placing migration, manageability, ade- several membranes and sets ot 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 oral hygiene instructions, quad- periosteal tiaps were roised to (Johnson & Johnson) to secure rant scaling and root planing