2000 Intrabony GTR

Copyright C Munksgaard 2000
Periodontology 2000, Vol. 22, 2000, 104132

Printed in Denmark All rights reserved
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 defined 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 defined 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 flap 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).
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-
104
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
benefits 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 difficult to obtain, for ethical reasons, the cited outcomes should be interpreted as evidence of improved healing response in the lack of histological
evidence (56).
Focus on intrabony defects: guided tissue regeneration
Clinical evidence
The year 1982 was the starting-point of guided tissue
regeneration (73). Following the first 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 significant 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 field. The original excitement, however, was soon followed by a great deal
of frustration, since clinicians found it very difficult
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 difficult 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 polytetrafluoroethylene membranes were analyzed with a multivariate
statistical approach with the aim of isolating the relevant variables that could influence the healing response and the final 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 scientific 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 efficacy 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 flap surgery (Table 2) (1, 18, 19, 27, 33, 52, 53,
59, 74, 75, 84). A total of 213 defects treated with
access flap 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 significant greater probing attachment level
gains when compared to the access flap. The only
investigation reporting no significant differences between guided tissue regeneration and access flap
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% confi-
105
Cortellini & Tonetti
Table 1. Clinical studies on guided tissue regeneration with nonresorbable and bioresorbable barrier
membranes
Authors
Type of barrier
Becker et al. (7)
Expanded polytetrafluoroethylene
Chung et al. (18)
Collagen
Probing
attachment gain
SD
Probing pocket
depth at 1 year
SD
4.5
1.7
3.2
10
0.6
0.6
Handelsman et al. (48)
1.4
3.9
1.4
Quteish et al. (75)
Collagen
26
1.5
2.19
0.44
Selvig et al. (77)
26
0.8
1.3
5.4
Proestakis et al. (74)
1.2
1.3
3.5
0.88
Kersten et al. (51)
13
1.1
5.1
0.9
Becker et al. (5)
32
4.5
3.88
0.26
Cortellini et al. (20)
40
4.1
2.5
0.6
Falk et al. (38)
Polymer
25
4.5
1.6
1.1
Laurell et al. (55)
Polymer
47
Rubber dam
Titanium-reinforced expanded
polytetrafluoroethylene
Al-Arrayed et al. (1)
Collagen
19
3.9
14
14
Mattson et al. (59)
Collagen
Collagen
4.9
2.4
1.4
0.7
2.4
0.5
4.1
5.3
1.9
2.2
2.7
2.1
1
0.5
5
3.7
2.1
2.1
2.6
3.2
0.9
1.8
13
9
2.5
2.4
1.5
2.1
3.6
4
0.6
1.1
11
11
4.5
3.3
3.3
1.9
1.7
1.9
Mellado et al. (63)
11
0.9
Chen et al. (16)
Collagen
10
0.4
4.2
0.4
Polymer
12
12
5.2
4.6
1.4
1.2
2.9
3.3
0.9
0.9
Tonetti et al. (88)
23
5.3
1.7
2.7
Becker et al. (6)
Polymer
30
2.9
3.6
1.3
Kim et al. (53)
19
2.1
3.2
1.1
Gouldin et al. (46)
25
2.2
1.4
3.5
1.3
Murphy (67)
12
4.7
1.4
2.9
0.8
Polymer
10
4.5
0.9
3.1
0.7
Falk et al. (39)
Polymer
203
4.8
1.5
3.4
1.6
Caffesse et al. (11)
Polymer
6
6
2.3
3
2
1.2
3.8
3.7
1.2
1.2
Kilic et al. (52)
10
3.7
3.1
1.4
Benque et al. (9)
Collagen
52
3.6
2.2
3.9
1.7
Christgau et al. (7)
Polymer
10
10
4.3
4.9
1.2
1
3.6
3.9
1.1
1.1
Polymer
18
4.9
1.8
3.6
1.2
Tonetti et al. (84)
Polymer
69
1.6
4.3
1.3
Polymer
Weighted mean
dence interval 3.03.7 mm), while the access flap resulted in a mean gain of 1.81.4 mm (95% confidence interval 1.52.1 mm). The analysis of the reported clinical outcomes strongly suggests an added
benefit deriving from the placement of barrier mem-
106
5
15
15
23
943
2.5
1.7
0.9
3.86
1.69
3.35
1.19
branes after elevation of an access flap. This impression is reinforced by the lack of overlap observed
in the 95% confidence intervals.
The data reported in some of the studies summarized in Table 1 (651 defects in 17 investigations (9,
Table 2. Controlled clinical trials comparing guided tissue regeneration procedure with access flap procedures
Authors
Type of membrane
Guided tissue
n (guided
regeneration
tissue
probing attachment
regeneration) gainSD (mm)
n (flap)
Flap probing
attachment
gainSD (mm)
0.70.9
Chung et al. (18)
Collagen
10
0.60.6
10
Quteish & Dolby (75)
Collagen
26
3.01.5
26
1.80.9
Proestakis et al. (74)
1.22.0
0.61.0
Al-Arrayed et al. (1)
Collagen
14
3.9
Mattson et al. (59)
Collagen
2.42.1
Cortellini et al. (27)*
15
4.11.9
15
Titanium-reinforced expanded
polytetrafluoroethylene
15
5.32.2
Cortellini et al. (33)*
12
5.21.4
12
Polymer
12
4.61.2
Kim (53)
19
4.02.1
18
2.01.7
Kilic (52)
10
3.72.0
10
2.12.0
Tonetti (84)
Polymer
69
3.01.6
67
2.21.5
Cortellini (19)
Polymer
23
3.01.7
23
1.61.8
243
3.41.8
213
1.81.4
Weighted mean
14
2.7
0.42.1
2.50.8
2.30.8
* Three-arm studies. Comparisons were made among two different barrier membranes and access flap.
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 efficacious, 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% confidence 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 classified 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 influence diagram
to illustrate how various factors influence regeneration.
The information used to build the influence diagram primarily derive from studies in which multivariate approaches have been employed to identify
107
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 significant 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
108
long axis of the root (82). Wider defects have been

associated with reduced amounts of probing attachment level gain and bone fill 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 significant 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 significance 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 flap dehiscence over the membrane (2).
Based on this evidence and the treatment objectives, deep and narrow defects are the ones that may
benefit most from guided tissue regeneration treatment. It is also desirable to surgically manipulate
thick tissues for membrane coverage and thus reduce the occurrence of flap 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 significantly 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 flaps specifically 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
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

flap 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 inflamed 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 biofilm 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
109
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
Fig. 8. Conventional technique. Baseline radiograph.
The conventional approach consists of a flap approach (access flap or modified Widman flap) not
specifically designed for use with barrier membranes
(7, 22, 31, 48). Full-thickness flaps 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 flap 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 difficult the primary closure of
the interdental tissues over the membrane. Major
complications are gingival dehiscence and membrane exposure.
Modified papilla preservation technique
Fig. 9. Conventional technique. One-year radiograph.
associated with membrane contamination. The

choice of the surgical approach and of a specific type
of barrier membrane is therefore a critical clinical
decision. Finally, operator skill may influence 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 difficult procedure such
as guided tissue regeneration. Other components of
operator skill may relate to the individual skills in
110
The rationale for developing this technique was to

achieve and maintain primary closure of the flap 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 flap, the residual interproximal tissues are dissected from the neighboring teeth and the underlying bone and elevated
towards the palatal aspect. A full-thickness palatal
flap, including the interdental papilla, is elevated
and the interproximal defect exposed. Following debridement of the defect, the buccal flap is mobilized
with vertical and periosteal incisions, when needed.
Fig. 10. Modified papilla preservation technique. Access to

the defect was gained with a buccal horizontal incision at
the base of the papilla.
Fig. 13. Modified papilla preservation technique. The interproximal defect after debridement.
Fig. 11. Modified papilla preservation technique. A buccal

full-thickness flap was elevated. The defect-associated papilla is still in place.
Fig. 14. Modified papilla preservation technique. A titanium-reinforced barrier membrane was positioned near
to the cementoenamel junction.
Fig. 12. Modified papilla preservation technique. The papilla was elevated along with the full-thickness palatal
flap.
Fig. 15. Modified papilla preservation technique. Primary

closure of the interdental space was ensured with a horizontal internal crossed mattress suture to relieve the tension of the flaps and a second suture to close the interdental papilla.
111
Fig. 16, 17. Modified papilla preservation technique.

Drawing of the horizontal internal crossed mattress suture. The suture runs under the flaps, hanging on top of
the titanium reinforcement of the membrane. The buccal
flap is coronally displaced.
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 first suture (horizontal internal crossed mattress suture) is placed beneath the mucoperiosteal flaps between the base of
the palatal papilla and the buccal flap. The interproximal portion of this suture hangs on top of the membrane allowing the coronal displacement of the buccal flap. This suture relieves all the tension of the flaps.
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 flap that includes the
interdental papilla) and the most coronal portion of
the buccal flap. This suture is free of tension.
An alternative type of suture to close the interdental tissues has been proposed by Laurell (54). This
modified internal mattress suture (Fig. 18, 19) starts
from the external surface of the buccal flap, crosses
the interdental area and passes through the lingual
112
flap at the base of the papilla. The suture runs back

through the external surface of the lingual flap and
the internal surface of the buccal flap, about 3 mm
apart from the first 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), significantly greater amounts of probing
attachment were gained with the modified papilla
preservation technique (5.32.2 mm), in comparison with either conventional guided tissue regeneration (4.11.9 mm) or access flap surgery (2.50.8
mm), demonstrating that a modified surgical approach can result in improved clinical outcomes.
The sites accessed with the modified papilla preservation technique showed primary closure of the flap
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
Fig. 18, 19. A modification of the suture described in Fig.

15 and 16, described by L. Laurell. This suture ensures
also an external stabilization to the interproximal tissues.
Fig. 20. Modified papilla preservation technique. A 10 mm

pocket on the mesial surface of the upper left central incisor.
Fig. 23. Modified papilla preservation technique. Primary

closure of the interdental tissues was achieved over the
membrane.
Fig. 21. Modified papilla preservation technique. After debridement a one- and three-wall combination intrabony
defect was evident.
Fig 24. Modified papilla preservation technique. Primary

closure was maintained at week 5. The gingiva was
healthy.
Fig. 22. Modified papilla preservation technique. A titanium-reinforced barrier membrane was positioned at
the level of the cementoenamel junction.
Fig. 25. Modified papilla preservation technique. After

membrane removal a mature, rich in collagen and uninflamed tissue was evident.
113
Fig. 26. Modified papilla preservation technique. The regenerated tissue was properly protected with the gingival
flaps.
Fig. 27. Modified 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 flap 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 modified 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. Modified papilla preservation

technique. Baseline radiograph.
114

technique. One-year radiograph showing almost complete resolution of the
defect.

technique. Upper right cuspid: the intrabony defect is 14 mm deep.

technique. Two membranes were sutured together to cover all the apicocoronal extension of the defect.

technique. Baseline radiograph, showing radiolucency up to the apex of the
tooth.
Simplified papilla preservation flap

technique. One-year radiograph: the
intrabony defect was almost completely resolved.
To overcome some of the technical problems encountered with the modified papilla preservation
technique, including difficult application in narrow
interdental spaces and in posterior areas and a suturing technique not appropriate for use with nonsupportive barriers, a different approach, the simplified papilla preservation flap (Fig. 4958), was subsequently developed (30).
This different and simplified approach to the
interdental papilla includes a first 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
first oblique interdental incision is continued intrasulcularly in the buccal aspect of the teeth neighboring the defect. After elevation of a full-thickness
buccal flap, the remaining tissues of the papilla are
carefully dissected from the neighboring teeth and
Fig. 34. Modified 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. Modified papilla preservation technique. Lingual

view showing the severity and extension of the bone destruction.
115
improve the mobility of the buccal flap. 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 first 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. Modified papilla preservation technique. A titanium-reinforced barrier membrane positioned to isolate the defect (buccal and lingual view).
Fig. 39. Modified papilla preservation technique. Baseline

radiograph.
Fig. 38. Modified 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 flap to fully expose the
interproximal defect. Following defect debridement
and root planing, vertical releasing incisions and/or
periosteal incisions are performed, when needed, to
116
Fig. 40. Modified papilla preservation technique. One-year

radiograph. The defect was almost completely resolved.
Fig. 41. Modified papilla preservation technique with bioresorbable membranes. Upper left central incisor at baseline.
Fig. 44. Modified papilla preservation technique with bioresorbable membranes. Primary closure of the interproximal tissues was obtained over the bioresorbable membrane.
Fig. 42. Modified papilla preservation technique with bioresorbable membranes. A deep one-, two- and three- wall
combination defect was evident after debridement.
Fig. 45. Modified papilla preservation technique with bioresorbable membranes. Primary closure was maintained
through time.
Fig. 43. Modified papilla preservation technique with bioresorbable membranes. A bioresorbable barrier was positioned.
Fig. 46. Modified papilla preservation technique with bioresorbable membranes. At one-year, the final fixed reconstruction was placed.
117
Fig. 49. Simplified papilla preservation flap. Upper right

lateral incisor at baseline.
Fig. 47. Modified papilla preservation technique with bioresorbable membranes. Baseline radiograph.
Fig. 50. Simplified papilla preservation flap. The pocket

depth and the attachment level were 9 mm and 11 mm,
respectively.
Fig. 48. Modified 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 flap. This suture
rubs against the interproximal root surface, hangs on
the residual interproximal bone crest and is anchored to the lingual/palatal flap. When tied, it
allows the coronal positioning of the buccal flap. A
relevant notation is that this suture, laying on the
118
Fig. 51. Simplified papilla preservation flap. 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.
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. Simplified papilla preservation flap. A bioresorbable barrier membrane was positioned to cover the defect.
Fig. 53. Simplified papilla preservation flap. Primary closure of the defect-associated interproximal space. Note
the offset suture positioned on the buccal side of the central incisor.
Fig. 55. Simplified papilla preservation flap. Baseline

radiograph.
Fig. 54. Simplified papilla preservation flap. 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. Simplified papilla preservation flap. One-year

radiograph.
119
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
Fig. 57, 58. Simplified papilla preservation flap. 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 first horizontal mattress suture would relieve all the tension of the flaps,
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 flap 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 simplified papilla preservation flap
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
120
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 reflection of a triangularly
shaped palatal flap that remains contiguous with the
buccal portion of the flap. The triangularly shaped
palatal tissue is referred to as the papillary triangle.
The isthmus of tissue that connects the papillary triangle with the buccal flap 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 inflammation; 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 flap reflection. Full-thickness
flap reflection is made at the level of the mucogingival junction, except in the area adjacent the interproximal defect. No attempt is made to reflect the
interproximal tissue at this stage. Palatal incisions
are made that create the papillary triangle and the
palatal flap. Intrasulcular interproximal incisions are
made with great care not to sever the isthmus of
tissue that connects the papillary triangle to the buccal flap. 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 flap is
examined for any adhesion to the alveolar crest in
the area of the defect. To facilitate coronal repositioning of the flap and passive closure, the buccal
flap is released from the periosteum with split thickness dissection. The defect is debrided thoroughly. A
decalcified 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-
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
Fig. 59. The crestal incision. Maxillary right cuspid at

baseline. The defect was located on the distal aspect.
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 flaps are elevated, the defect debrided
and a membrane positioned. Membrane coverage
and primary closure of the flap over the implanted
material is achieved with interrupted or mattress sutures (Fig. 5967).
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 flaps are sutured using a modified
vertical mattress suture. The suture first passes
through the buccal flap 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 flap engaging the tip of the papillary triangle, and then is
passed through the distal portion of the palatal flap.
The suture exits the palatal flap 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 flap. The
other areas of the flap 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.
121
ated interproximal tissues after membrane removal,

when the occurrence of a dehiscence of the gingival
flap 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 regener-
122
Fig. 67. The crestal incision. One-year radiograph.
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 inflamed.
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 flaps. The graft has to be firmly
stabilized with interrupted sutures placed between
the margins of the graft and the buccal and lingual
margins of the gingival flaps. Compressive sutures
are also positioned to improve stability.
A randomized controlled clinical trial (24) resulted

in significantly 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-
123
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 flap (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
Fig. 75. Free gingival graft. Baseline radiograph.
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 flaps. 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. 76. Free gingival graft. One-year radiograph showing

the complete resolution of the defect.
124
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 polytetrafluorethylene membranes are widely used and successfully
tested in many clinical studies (Table 1). The titanium-reinforced membrane is an evolution of the
expanded polytetrafluoroethylene 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% confidence interval 3.4 to 4.0 mm) for the
nonresorbable group and probing attachment gains
of 3.61.5 mm (95% confidence 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% confidence interval 2.5 to 3.5
mm) for the 139 collagen-treated sites, and 4.11.6
(95% confidence 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.
Combination treatment
Schallhorn & McClain have suggested that a combination therapy consisting of barrier membranes plus
bone grafting may result in significant improvements
of expected outcomes (60, 76). Four studies (16, 52, 53,
63), however, evaluating the added benefit of bone or
bone substitutes used in combination with barrier
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 flap 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 definitive 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 flaps (modified papilla preservation
technique, interproximal tissue maintenance and
simplified papilla preservation flap) specifically 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 flap, 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 flap (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 office. 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 flap or severe exposure of the membrane could
require removal of the material.
125
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
Fig. 78. Decision tree 1, node 1: selection of patient.

Source: modified from Cortellini & Bowers. Int J Periodontics Restorative Dent 1995. FMPS: full-mouth plaque
score. FMBS: full-mouth bleeding score.
126
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 difficulties. 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. 79. Decision tree 1, node 2: selection of defect. Source:

modified from Cortellini & Bowers. Int J Periodontics Restorative Dent 1995.
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:
modified papilla preservation technique. ITM: interproximal tissue maintenance. SPPF: simplified papilla preservation flap. e-PTFE: expanded polytetrafluoroethylene.
ability with the minimal degree of technical difficulty, 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 first 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) fill 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
127
Fig. 81. Decision tree 3: aesthetically sensitive sites. The

objective of treatment is to completely resolve the defect
and minimize recession. MPPT: modified papilla preser-
vation technique. ITM: interproximal tissue maintenance.

SPPF: simplified papilla preservation flap. e-PTFE: expanded polytetrafluoroethylene.
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 first case (non-aesthetically sensitive sites), less invasive and easier techniques, even
though less efficacious, 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 difficulty.
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
filling materials, (iii) the suturing approach to obtain
primary closure of the flap, 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)
128
The interdental space can be accessed (node 1) with

a modified 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 simplified papilla
preservation flap (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 configurations) require the use of stiff membranes or the
combined use of supportive or filling materials.
Among the different commercial proposals, nonresorbable barrier membranes are stiffer than bioresorbable ones and therefore are the first 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
fillers 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 configurations) 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 flap, 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 flap
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 flap is the first 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 modified 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 simplified papilla preservation flap (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 polytetrafluoroethylene 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 polytetrafluoroethy-
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
configurations), a titanium-reinforced expanded polytetrafluoroethylene membrane is again the first
choice. When the defect is narrow and/or has a supportive anatomy (three-wall configurations), 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 flap are mandatory. A
supportive defect (three-wall defect), a self-supporting membrane (titanium-reinforced expanded polytetrafluoroethylene 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 flap edges.
When nonresorbable barrier membranes are used
at the time of membrane removal (node 4), the regenerated tissues can be protected with a replacement flap in case of gingival integrity or with a
saddle-shaped free gingival graft in case of gingival
dehiscence (24).
Conclusions
Evidence demonstrates a clear benefit 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 influenced 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-
129
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 difficulties 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

Focus on intrabony defects:

The biological concept of guided

ment and bone colonize the blood clot, expressing

Clinical and histological outcomes

Focus on intrabony defects: guided tissue regeneration

Fig. 1. Plot of some of the clinical studies on guided tissue

obtained treating 592 intrabony defects (17 studies)

Cortellini & Tonetti

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)

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)

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)

Focus on intrabony defects: guided tissue regeneration

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)

endpoints of most periodontal procedures, including

Factors affecting the clinical

Cortellini & Tonetti

long axis of the root (82). Wider defects have been

The guided tissue regeneration procedure and

Focus on intrabony defects: guided tissue regeneration

Fig. 2. Conventional technique. Mandibular right cuspid: the preoperative

Fig. 3. Conventional technique. After

Fig. 4. Conventional technique. At

Fig. 5. Conventional technique. The regenerated tissue appeared inflamed at

Fig. 7. Conventional technique. At 1