The internationai Journai of Periodontics & Restorative Dentistry

579

Surgical Technique for Treatment

of Infrabony Defects with Enamel
Matrix Derivative (Emdogain):
3 Case Reports

Giulio Rasperini. DDS' Bone grafts and guided tissue

Giono Ricci. MD, DDS. MScD" regeneration (GTR) procedures
Mdurizio Siivestri. DOS"' predictabiy result in new attach-
ment in cases ot intrabony de-
fects,^-" Autogenous bone grafts
A surgioai pratocai is described for the piacement of Emdogain enomei have the disadvantage of in-
matrix derivative during new ottaohment procedures. Three coses with creased morbidity associated
infrabony defects were treated ond o signifioont probing ottaohment ievei with a second surgical site to ob-
(PAL) goih. probing depth reduction, and bone fiii were evident on ciinioa! tain the donor gratt materiai.
probing and during reentry procedures. The tirst potient presented a com- Bone allografts have a limited
bined one-walled and circumferanfiai defect ot o moxiiiary centra! incisor possibility of disease transmission
After 1 year the PAL gain was 7 mm. The second case showed a 3-waiied and less bioiogic potentiai, and
defect distai to a maxiiiary canine. After I year the PAL gain was 8 mm, and some patients are not accepting
a reentry procedure showed an aimost totoi fiii of the defect. The third of their use, Severai authors^""!"
patient presented a combined one- and 3-woiied detect in the most api- have demonstrated that GTR
cai part of the mesiai aspect of a maxillary centrai incisor. One year öfter using membranes for periodontai
the surgicai procedure, an orthodontic treatment was performed in this
regeneration is a predictabie and
patient After ó more months the soft tissue showed a very good esthetic
reliable therapeutic approach in
appearanoe, the papilla height was fuiiy maintained, and there was a PAL
periodontai surgery, Nonresorb-
gain of 5 mm; 18 months after surgery reentry showed a significant regen-
able membranes have the dis-
eration of hard tissue that was impossibie to probe. Because of these
advantage of a second surgical
encouraging ciinicai resuits. further studies should be initiated to investigate
the efficacy af the enamei matrix derivative in new attachment proce-
procedure for their removal,'^
dL/res.ClntJ Periodontics Restorative D e n t 1999,19:579-587,)
and aii membranes have the risk
of bocterial infection if exposed
by a soft tissue dehiscence.

Several tactors may account

'Consultant Professor, University of Milan, ifaly, for differences in the success of
"Private Practice in Periodontics, Florence, Italy. regenerative therapy These may
'Consuitant Professor, University Ot Povia, itaiy include the morphology of the
detect, differences in plaque con-
Reprint requests: Dr Giuiio Rosperini, Via XX Settembre 119,1-291 GO
Piacenza, Italy. e-maii:grasperini@agonet,it
trol and gingival inflammation.

Volume 19, Number 6,1999

580

and the presence of risk foctors blood clot''^-^^ the regenerative potients who occepted this
such as smoking.'^ '^The possibil- prooedure by means of EMD de- procedure)
ity that GTR procedures using position onto a root surface is Each patient was treoted
membranes may fail because of based on new cementum forma- with an initial therapy consisting of
infecfious complicafions wos ini- tion and subsequent proper at- orol hygiene instruction, scaling,
tially reported by Selvig et ol.!^ tachment apparatus develop- ond root ploning. One month
The borrier effect of the mem- ment. A layer of EMD on scoled otter completion of the initial
branes on the bacterial ccloni- root surfaces seems to stimulate o phose o réévaluation wos per-
zation of regenerating tissues hos new acellular cementum depo- formed. At baseline, patients
been further investigoted by sition, which in turn will allow new showed FMPS and FMBS scores of
Nowzari and Slots,'^who cleorly periodontol ligament and alveo- less than 25%. At each selected
showed the role of oral mioroflora lor bone tormation.^^The purpose site. PPD, probing attaohment
in reducing the probing attooh- of this preliminary study Is to pre- level (PAL), and morginol reces-
ment gain. Ricci et aP" anolyzed sent initial results and a surgical sion (REC) were recorded to the
the in vitro obilities of adherence, and suturing method for the nearest millimeter with a manual
colonizotion, and cross through plocement of Emdogoin (Bioro). pressure-sensitive probe cali-
ot ó different membranes by pure Three oases ore presented. brated at a force of 0,26 N. After
cultures of Porphyromonas gingi- 1 yeor the same clinicol meo-
vaiis. Scanning electron micros- surements were performed.
copy and microbiologie data Method and materials
trom this study demonstroted thot
PgíngíVofe cells pass through alió Three patients presenting the fol- Surgicai procedure
membranes analyzed in 48 hours. lowing charocteristics were
To keep the membrane and the treated with EMD: The surgical tield was locally
newly formed tissue completely anesthetized with articaine
covered, proper soft tissue mon- • Age more thon 21 yeors chlorhydrate and epinephrine
agement is required, espeoiolly in • Good generol heolth, women 1:100,000, except tor the inter-
esthetic areas where mainte- not pregnant or lactating proximal papillo to ovoid ex-
nance of the interproximal pa- • Nonsmoker cessive ischemia in the areo.
pilla is critical.^" • Presence of severe periodon- Introcrevicular incisions were per-
Recently, the enamel matrix titis treoted with scaling, root formed one tooth distal and
derivative (EMD) has been sug- ploning, ond oral hygiene in- mesial to the area being treated.
gested to be effective in regen- structions Buccol and lingual incisions were
eration ofthe periodontai attach- • Presence of a deep infrabony blended in the attempt to pre-
ment apparatus in animols and defect with a probing depth serve the interdental papillae in
humans^^'^ ond in improving olin- (PPD) ot 10 mm or more in the accordance with Takei et al's
ical attachment level in hu- interproximal areo in maxillary popillo preservation technique.^^
mans.^^ While the biologio princi- onterior teeth Beveled vertical releasing inci-
ple of GTR with a periodontai Full-mouth ploque score sions were placed one tooth
membrane is based on the selec- (FMPS)^' and full-mouth mesiol and distal to the surgiool
tive colonization of the wound bleeding score (FMBS) < 25% sites for optimal occess to the
area by periodontai ligament at baseline detect. The full-thickness muco-
cells,^^ space making, ond stabi- • Reentry surgery at least 1 periosteal flaps were reflected,
lization ond protection of the yeor after treatment (in the preserving fhe marginal and

The Internationol Journal of Periodontios & Restorative Dentistry

 581

interdental tissues to the maxi- hygiene procedures based on mesiai aspect and c lingual cir-
mum possibie extent. avoiding brushing and using cumferenfiai defect up to the
After proper flap reflection, interdental devices in the distal aspeot of the central
the infrabony lesions were de- treated areas during the first ó incisor (Fig ib),Thorough scaiing
granuiated and the roots scaled weeks pcstcperative. During this and root planing were accom-
and pianed. Horizontai matfress period they were instructed to plished. The Gore-Tex sutures
Gore-Tex sutures C3Í/WL Gore) with rinse twice daily with 0.12% were plaoed and ieft untied as
an additional crossing to anchor chlorhexidine, and protessional previously described.
to the lingual U at the mat- supragingival tooth cleaning The detect was then rinsed
tresses—as proposed by Laureii was perfcrmed weekly. Patients with steriie saiine soiution, etched
(oral communication) to better were then placed on 3-mcnth with 24% EDTA for 2 minutes, and
control the underiying papiila and recall visits until the i-year rinsed again vi/ith saline, Emdo-
avoid further trauma to the tis- réévaluation. No attempt to gain gel soiution was placed by
sue—were placed and left probe or perform subgingivai means of a syringe onto the dry
untied. The root was then etched scaling was made before the 1 - root and subsequenfiy the sutures
with ethyienediaminetetraacetic year foiiow-up visit. were tied to complete i y close the
acid (EDTA) 24% for 2 minutes^' interproximal space. Postopera-
and rinsed again with saiine solu- tive healing was uneventful and
tion. At the same time, Emdogain the patient was treated with
Case reports
was mixed with vehioie solution supragingivai debridement as
toliowing the instruotions of the described above.
Case Í
manufacturer. The defects were After 1 year the tissue iooked
rinsed again v^/ith steriie saline soiu- A 35-year-old maie nonsmoking esthetioally pleasing and the PAL
tion and dried with small pieces of patient presented with a deep gain was 7 mm, with a soft tissue
sterile gauze. A syringe was used periodontal defect mesiai tc the reoession of 4 mm. The postop-
to appiy the Emdogain gei soiu- vital maxiiiary ieft centrai incisor, erative PPD was 3 mm. After 1
tion Vi/ith a large-size needle, start- with a PPD of 14 mm. A radi- year the radiograph showed a
ing from the most apical part of ograph showed a severe defeof definitive improvement of the
the root to cover the entire sur- on both the mesiai and distai bcne ievel (Fig Ic). The patient
face.The sutures were then imme- aspects (Fig la). The tooth was was happy with the clinical result
diately tied to completely close spiinted with oomposite to the and refused fhe reentry proce-
the interproximal space. dure, afraid ot damage to the
lateral incisor. At the time of
frame cf fhe gingiva.
surgery there was no mobiiity
and the tooth demonstrated no
Posfsurgicai foiiow-up evidence of occlusai trauma.
A fuil-thickness mucope-
After surgery, a combination of riosteai tlap was refiected with 2
amoxiciliin with ciavulanic acid vertical incisions, retaining the
(Augmentin, SmithKline Beech- interproximai papilla on the buc-
am) 2 g/day for ó days was pre- cai fiap between the 2 central
scribed to protect wound heai- incisors. Upon removai of the
ing processes and avoid infected granulation tissue,
possible bacterial infections. severe bone loss was apparent,
Patients used modified oral with a one-walled defecf on the

Volume 19, Number Ó, 1999

582

Fig l a {ieft} Case 1. Severe defect on

Poth the mesial and distal aspects of
maxiiia'y left centrai Incisor.

Fig Ifa (beiow) Severe bone loss with

one-walled component on mesiai
aspect af centrai incisor.

Fig lc(right) One-year radiograph

shows definitive Pone levei improvement

Case 2 anguiar bony detect on the distal a compiete oiosure of the lingual
aspect of the tooth (Fig 2a). The component were noted. The tis-
A 53-year-oid femaie nonsmoking defect consisted of a 2-wailed sue was consonant with bone
patient presented with a defect component in the most coronal and could not be probed (Fig
disfai and paiatai fo the maxillary part and a 3-walied in the most 2c), The radiograph at reentry
right canine, with a PPD of 12 mm. apical component (Fig 2b). demonstrated an increase in
The tooth had a Miiier mobilify of The Emdogain gel soluficn radiopacify when compared
1 and was previously an abut- was applied onto the root and with the initial one (Fig 2d). At
ment far a removable prosthesis, into the defect as previously reentry the tooth was oonsidered
which the patient had stopped described,Atreentry 1 year after to have a very good prognosis.
wearing prior to the surgery The surgery, ó mm of hard tissue for-
radiograph showed a deep. mation on the distal surface and

The International Journal of Periodonf ics & Restorative Dentistry

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Fig 2a (left) Case 2. Radiograph

shows a deep, dngular bony defect on
the distal aspect of the maxillary right
canine,

Rg 2b (right) Defecf consist of a 2-

waiied component in the most caronal
part and a 3-waiied component in its
most opicai part.

fig 2c (left) Reentry 1 year after

surgery shows Ô mm of hord tissue for-
mafion on the distal surfaoe ond a
complete closure afthe iinguoi com-
ponent.

Pig 2d (right) Radiograph ! year after

surgery demonstrates an increase in
rodiopaoity when compared wifh the
initiol one.

Volume 19, Number Ó, 1999

584

Fig 3a Case 3. Probing depth mesial to the maxillary left centralincisor is 8 mm at fig 30 Raaiogroph shows an onguiar
the mesiobuccol angle of the maxillary left ceritrai incisor. A diastema is also presenf. bony defect an the mesiol aspect af
the tooth.

Case 3 it was possibie to appreciate sig- ciose the diostema; it was com-
nificant bone ioss exoctiy where pieted otter ó months (Fig 3e).
A 25 year-old womon presented the hard tissue shouid sustain the With the consent of the patient,
with o history of repeoted ab- papiiia (Fig 3c). The defecf was reentry surgery was performed
scesses on the maxiiiary ieft cen- degranuiafed, fhe root surface 18 months atter baseiine. Upon
trai incisor. Because of a high scaied. pianed, and treated with reflection of the fap, a significont
smile iine,the interincisive papiiia 24% EDTA, and the Emdogain gei increase of hard tissue was evi-
showed, A diastemo was aiso was applied, in this case, as in dent in oomporison with base-
present. The probing depth those presented above, a com- iine (Fig 30,The newiy formed tis-
mesiai to the maxiiiary ieff centra! mon finding was very quick sott sue had fhe consistency of
incisor was 8 mm at the mesio- tissue heaiing after the use ot the bone: it was dense and couid
buccai angie and 10 mm at the Emdogain gei. not be probed. After 18 months,
mesiopaiatai angie (Fig 3a). The One year ioter the papiiia the postoperative radiograph
tooth was stabie and the radi- height was maintained ond the demonstrated an increase in
ograph showed an anguiar bony PPD was 3 mm, with a PAL gain at radiopacity when compared
defect on the mesiai aspect ot 7 mm (Fig 3d).Atthis point ortho- with those taken initiaiiy (Fig 3g).
the tooth (Fig 3b). During surgery dontic treatment was initiated to

The Internotional Journal of Periodontics & Restorative Dentistry

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fig 3c Intraoperative view shaws sig- Fig 3d One yeor after the surgery the Fig 3e After orthodontic freotment (6
nificant bone loss exoctly where the papilla height has been maintained months), the diastema is dosed ond
hard tissue should sustain the papilla. with a very gaod esthetic resuit: the the papiiia height and periodontol
PPD is 3 mm, with a PAL gain af 7 mm measurements have been maintained.

Fig 3f Reentry surgery ispertormed 16 months after baseline. A significant increose Fig3g At }8 months after treatment,
of hard tissue is evident in comparison with baseline (Fig 3c). radiograph demonstrates an increase
in radiopacity when compared with
those taken initially (Fig 3b),

Voiume 19. Number Ó.1W9

586

Discussion surfaoes caretully befare condi- but a recession was present after
tioning with EDTA and before the i year as compared with base-
This article describes a surgical Emdogain application. The EDTA line measurements.The soft tissue
protocoi for fhe plocement cf use seems to improve the quan- was exactly where it had been
Emdogain and analyzes clinioal tity as weil as the quality of the positioned during the suturing
resuits after 12 and 18 months. availabie root surface before phase. No reentry procedure was
Three case reports in whioh EiViD use.2^There should be max- performed in this patient.
Emdogain was suocessfully used imum adherence befween the
to treat infrabony defects hove root surtace and Emdogain soiu-
been presented. The combina- tion for the best resulf Sutures are Conclusion
tion of the biologic activity of placed and leff loose before
Emdogain with a precise surgi- Emdogain gel application fc pre- Emdogain was successfully used
cal protocol have provided vent ony bleeding when the nee- to treat infrabony defects as evai-
encouroging ciinical results. dle penetrates the soft fissue and uated by ciinicai atfachment
The fiap design described to any displacement of the materiai. gain, reenfry surgery, and radi-
preserve the interdental papiiia The Laureii suture has been ographie evaluation. A teohnique
follows the papilla preservation used to gain better controi has been described to faoilitate
technique^^ or the mcdified below and over the papiiia with- clinical use and optimize results;
papiiia preservation technique.^^ out crossing again through the
The decision criteria to use one tissue, A nonresorbobie monofii- 1. Removal of local etioiogic
technique versus the other can amenf sufure (Gore-Tex) has factors
be infiuenced by the anatomy been used to limit piaque accu- 2. Fiap design to maintain
and position of the bony defecf, mulation and to ailow ccnfroiied papilla architecture
the anatomy of the papiiia, fhe tension of the suture for af ieast 3. Meticulcus defecf debride-
size of the interproximal space, 10 days. Since tension control of ment and root planing
and position of the defect. It is the suture is not as important on 4. Root treatment with 24%
suggested to piace the incision fhe verticai incision, these oouid EDTA for 2 minutes
and the sutures where the highest be sutured with other materials. 5. Lourell sutures placed prior to
bony walls are present to stay The professionals as weii as Emdogoin application
away from the defect, and oon- the patient must carry out the fol- Ó. Postoperative treatmentwith
sequentiy from the area treated low-up very oarefuliy. Three 0,12% chlorhexidine and
with Emdogain; this wiil avoid any patients were treated using this supragingival personal and
possible trauma to the site, any regenerative procedure. In two professionol debridement
flap displacement, and the possi- patients (cases 2 and 3), there
bility of bacterial invasion through was ciinicai attachment gain
the sutures.Takei et al's technique without gingivai recession. At Acknowledgment
should be used in esthetic areas reentry, newiy formed hard tissue
where it is necessary to avoid was evident where previously The authors ttionk iviarc L Nevins tor the
papiiia shrinkage. Indeed, to use fhere had been a bony defecf, Af helpful critical review of the manuscript.

this technique it is necessary to the same fime, the radiographs

have a large interproximal space showed a significant increase in
and a wide papilla. After remcvai radiopacity. In ane patient (case
ct all etioiogic facfors, it is funda- 1), radiographie and clinical
mental fc wash and dry the root results showed a significant gain.

The Internationai Journal of Periodontics S Restorative Dentistry

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Volume 19, Number 6,1999