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Surgical Technique for Treatmentof Infrabony Defects with EnamelMatrix Derivative (Emdogain):3 Case Reports

Giulio Rasperini. DDS'Giono Ricci. MD, DDS. MScD"Mdurizio Siivestri. DOS"'

A surgioai pratocai is described for the piacement of Emdogain enomeimatrix derivative during new ottaohment procedures. Three coses withinfrabony defects were treated ond o signifioont probing ottaohment ievei(PAL) goih. probing depth reduction, and bone fiii were evident on ciinioa!probing and during reentry procedures. The tirst potient presented a com-bined one-walled and circumferanfiai defect ot o moxiiiary centra! incisorAfter 1 year the PAL gain was 7 mm. The second case showed a 3-waiieddefect distai to a maxiiiary canine. After I year the PAL gain was 8 mm, anda reentry procedure showed an aimost totoi fiii of the defect. The thirdpatient presented a combined one- and 3-woiied detect in the most api-cai part of the mesiai aspect of a maxillary centrai incisor. One year öfterthe surgicai procedure, an orthodontic treatment was performed in thispatient After ó more months the soft tissue showed a very good estheticappearanoe, the papilla height was fuiiy maintained, and there was a PALgain of 5 mm; 18 months after surgery reentry showed a significant regen-eration of hard tissue that was impossibie to probe. Because of theseencouraging ciinicai resuits. further studies should be initiated to investigatethe efficacy af the enamei matrix derivative in new attachment proce-dL/res.ClntJ Periodontics Restorative Dent 1999,19:579-587,)

'Consultant Professor, University of Milan, ifaly,"Private Practice in Periodontics, Florence, Italy.'Consuitant Professor, University Ot Povia, itaiy

Reprint requests: Dr Giuiio Rosperini, Via XX Settembre 119,1-291 GOPiacenza, Italy. e-maii:grasperini@agonet,it

Bone grafts and guided tissueregeneration (GTR) procedurespredictabiy result in new attach-ment in cases ot intrabony de-fects,^-" Autogenous bone graftshave the disadvantage of in-creased morbidity associatedwith a second surgical site to ob-tain the donor gratt materiai.Bone allografts have a limitedpossibility of disease transmissionand less bioiogic potentiai, andsome patients are not acceptingof their use, Severai authors^""!"have demonstrated that GTRusing membranes for periodontairegeneration is a predictabie andreliable therapeutic approach inperiodontai surgery, Nonresorb-able membranes have the dis-advantage of a second surgicalprocedure for their removal,'^and aii membranes have the riskof bocterial infection if exposedby a soft tissue dehiscence.

Several tactors may accountfor differences in the success ofregenerative therapy These mayinclude the morphology of thedetect, differences in plaque con-trol and gingival inflammation.

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and the presence of risk foctorssuch as smoking.'^ '^The possibil-ity that GTR procedures usingmembranes may fail because ofinfecfious complicafions wos ini-tially reported by Selvig et ol.!^The borrier effect of the mem-branes on the bacterial ccloni-zation of regenerating tissues hosbeen further investigoted byNowzari and Slots,'^who cleorlyshowed the role of oral mioroflorain reducing the probing attooh-ment gain. Ricci et aP" anolyzedthe in vitro obilities of adherence,colonizotion, and cross throughot ó different membranes by purecultures of Porphyromonas gingi-vaiis. Scanning electron micros-copy and microbiologie datatrom this study demonstroted thotPgíngíVofe cells pass through aliómembranes analyzed in 48 hours.To keep the membrane and thenewly formed tissue completelycovered, proper soft tissue mon-agement is required, espeoiolly inesthetic areas where mainte-nance of the interproximal pa-pilla is critical.^"

Recently, the enamel matrixderivative (EMD) has been sug-gested to be effective in regen-eration ofthe periodontai attach-ment apparatus in animols andhumans^^'^ ond in improving olin-ical attachment level in hu-mans.̂ ^ While the biologio princi-ple of GTR with a periodontaimembrane is based on the selec-tive colonization of the woundarea by periodontai ligamentcells,̂ ^ space making, ond stabi-lization ond protection of the

blood clot''^-^^ the regenerativeprooedure by means of EMD de-position onto a root surface isbased on new cementum forma-tion and subsequent proper at-tachment apparatus develop-ment. A layer of EMD on scoledroot surfaces seems to stimulate onew acellular cementum depo-sition, which in turn will allow newperiodontol ligament and alveo-lor bone tormation.^^The purposeof this preliminary study Is to pre-sent initial results and a surgicaland suturing method for theplocement of Emdogoin (Bioro).Three oases ore presented.

Method and materials

Three patients presenting the fol-lowing charocteristics weretreated with EMD:

• Age more thon 21 yeors• Good generol heolth, women

not pregnant or lactating• Nonsmoker• Presence of severe periodon-

titis treoted with scaling, rootploning, ond oral hygiene in-structions

• Presence of a deep infrabonydefect with a probing depth(PPD) ot 10 mm or more in theinterproximal areo in maxillaryonterior teethFull-mouth ploque score(FMPS)^' and full-mouthbleeding score (FMBS) < 25%at baseline

• Reentry surgery at least 1yeor after treatment (in the

potients who occepted thisprocedure)Each patient was treoted

with an initial therapy consisting oforol hygiene instruction, scaling,ond root ploning. One monthotter completion of the initialphose o réévaluation wos per-formed. At baseline, patientsshowed FMPS and FMBS scores ofless than 25%. At each selectedsite. PPD, probing attaohmentlevel (PAL), and morginol reces-sion (REC) were recorded to thenearest millimeter with a manualpressure-sensitive probe cali-brated at a force of 0,26 N. After1 yeor the same clinicol meo-surements were performed.

Surgicai procedure

The surgical tield was locallyanesthetized with articainechlorhydrate and epinephrine1:100,000, except tor the inter-proximal papillo to ovoid ex-cessive ischemia in the areo.Introcrevicular incisions were per-formed one tooth distal andmesial to the area being treated.Buccol and lingual incisions wereblended in the attempt to pre-serve the interdental papillae inaccordance with Takei et al'spopillo preservation technique.^^Beveled vertical releasing inci-sions were placed one toothmesiol and distal to the surgioolsites for optimal occess to thedetect. The full-thickness muco-periosteal flaps were reflected,preserving fhe marginal and

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interdental tissues to the maxi-mum possibie extent.

After proper flap reflection,the infrabony lesions were de-granuiated and the roots scaledand pianed. Horizontai matfressGore-Tex sutures C3Í/WL Gore) withan additional crossing to anchorto the lingual U at the mat-tresses—as proposed by Laureii(oral communication) to bettercontrol the underiying papiila andavoid further trauma to the tis-sue—were placed and leftuntied. The root was then etchedwith ethyienediaminetetraaceticacid (EDTA) 24% for 2 minutes^'and rinsed again with saiine solu-tion. At the same time, Emdogainwas mixed with vehioie solutiontoliowing the instruotions of themanufacturer. The defects wererinsed again v̂ /ith steriie saline soiu-tion and dried with small pieces ofsterile gauze. A syringe was usedto appiy the Emdogain gei soiu-tion Vi/ith a large-size needle, start-ing from the most apical part ofthe root to cover the entire sur-face.The sutures were then imme-diately tied to completely closethe interproximal space.

Posfsurgicai foiiow-up

After surgery, a combination ofamoxiciliin with ciavulanic acid(Augmentin, SmithKline Beech-am) 2 g/day for ó days was pre-scribed to protect wound heai-ing processes and avoidpossible bacterial infections.Patients used modified oral

hygiene procedures based onavoiding brushing and usinginterdental devices in thetreated areas during the first óweeks pcstcperative. During thisperiod they were instructed torinse twice daily with 0.12%chlorhexidine, and protessionalsupragingival tooth cleaningwas perfcrmed weekly. Patientswere then placed on 3-mcnthrecall visits until the i-yearréévaluation. No attempt toprobe or perform subgingivaiscaling was made before the 1 -year foiiow-up visit.

Case reports

Case Í

A 35-year-old maie nonsmokingpatient presented with a deepperiodontal defect mesiai tc thevital maxiiiary ieft centrai incisor,with a PPD of 14 mm. A radi-ograph showed a severe defeofon both the mesiai and distaiaspects (Fig la). The tooth wasspiinted with oomposite to thelateral incisor. At the time ofsurgery there was no mobiiityand the tooth demonstrated noevidence of occlusai trauma.

A fuil-thickness mucope-riosteai tlap was refiected with 2vertical incisions, retaining theinterproximai papilla on the buc-cai fiap between the 2 centralincisors. Upon removai of theinfected granulation tissue,severe bone loss was apparent,with a one-walled defecf on the

mesiai aspect and c lingual cir-cumferenfiai defect up to thedistal aspeot of the centralincisor (Fig ib),Thorough scaiingand root planing were accom-plished. The Gore-Tex sutureswere plaoed and ieft untied aspreviously described.

The detect was then rinsedwith steriie saiine soiution, etchedwith 24% EDTA for 2 minutes, andrinsed again vi/ith saline, Emdo-gain gel soiution was placed bymeans of a syringe onto the dryroot and subsequenfiy the sutureswere tied to complete i y close theinterproximal space. Postopera-tive healing was uneventful andthe patient was treated withsupragingivai debridement asdescribed above.

After 1 year the tissue iookedesthetioally pleasing and the PALgain was 7 mm, with a soft tissuereoession of 4 mm. The postop-erative PPD was 3 mm. After 1year the radiograph showed adefinitive improvement of thebcne ievel (Fig Ic). The patientwas happy with the clinical resultand refused fhe reentry proce-dure, afraid ot damage to theframe cf fhe gingiva.

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Fig la {ieft} Case 1. Severe defect onPoth the mesial and distal aspects ofmaxiiia'y left centrai Incisor.

Fig Ifa (beiow) Severe bone loss withone-walled component on mesiaiaspect af centrai incisor.

Fig lc(right) One-year radiographshows definitive Pone levei improvement

Case 2

A 53-year-oid femaie nonsmokingpatient presented with a defectdisfai and paiatai fo the maxillaryright canine, with a PPD of 12 mm.The tooth had a Miiier mobilify of1 and was previously an abut-ment far a removable prosthesis,which the patient had stoppedwearing prior to the surgery Theradiograph showed a deep.

anguiar bony detect on the distalaspect of the tooth (Fig 2a). Thedefect consisted of a 2-wailedcomponent in the most coronalpart and a 3-walied in the mostapical component (Fig 2b).

The Emdogain gel soluficnwas applied onto the root andinto the defect as previouslydescribed,Atreentry 1 year aftersurgery, ó mm of hard tissue for-mation on the distal surface and

a compiete oiosure of the lingualcomponent were noted. The tis-sue was consonant with boneand could not be probed (Fig2c), The radiograph at reentrydemonstrated an increase inradiopacify when comparedwith the initial one (Fig 2d). Atreentry the tooth was oonsideredto have a very good prognosis.

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Fig 2a (left) Case 2. Radiographshows a deep, dngular bony defect onthe distal aspect of the maxillary rightcanine,

Rg 2b (right) Defecf consist of a 2-waiied component in the most caronalpart and a 3-waiied component in itsmost opicai part.

fig 2c (left) Reentry 1 year aftersurgery shows Ô mm of hord tissue for-mafion on the distal surfaoe ond acomplete closure afthe iinguoi com-ponent.

Pig 2d (right) Radiograph ! year aftersurgery demonstrates an increase inrodiopaoity when compared wifh theinitiol one.

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Fig 3a Case 3. Probing depth mesial to the maxillary left centralincisor is 8 mm atthe mesiobuccol angle of the maxillary left ceritrai incisor. A diastema is also presenf.

fig 30 Raaiogroph shows an onguiarbony defect an the mesiol aspect afthe tooth.

Case 3

A 25 year-old womon presentedwith o history of repeoted ab-scesses on the maxiiiary ieft cen-trai incisor. Because of a highsmile iine,the interincisive papiiiashowed, A diastemo was aisopresent. The probing depthmesiai to the maxiiiary ieff centra!incisor was 8 mm at the mesio-buccai angie and 10 mm at themesiopaiatai angie (Fig 3a). Thetooth was stabie and the radi-ograph showed an anguiar bonydefect on the mesiai aspect otthe tooth (Fig 3b). During surgery

it was possibie to appreciate sig-nificant bone ioss exoctiy wherethe hard tissue shouid sustain thepapiiia (Fig 3c). The defecf wasdegranuiafed, fhe root surfacescaied. pianed, and treated with24% EDTA, and the Emdogain geiwas applied, in this case, as inthose presented above, a com-mon finding was very quick sotttissue heaiing after the use ot theEmdogain gei.

One year ioter the papiiiaheight was maintained ond thePPD was 3 mm, with a PAL gain at7 mm (Fig 3d).Atthis point ortho-dontic treatment was initiated to

ciose the diostema; it was com-pieted otter ó months (Fig 3e).With the consent of the patient,reentry surgery was performed18 months atter baseiine. Uponreflection of the fap, a significontincrease of hard tissue was evi-dent in oomporison with base-iine (Fig 30,The newiy formed tis-sue had fhe consistency ofbone: it was dense and couidnot be probed. After 18 months,the postoperative radiographdemonstrated an increase inradiopacity when comparedwith those taken initiaiiy (Fig 3g).

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fig 3c Intraoperative view shaws sig-nificant bone loss exoctly where thehard tissue should sustain the papilla.

Fig 3d One yeor after the surgery thepapilla height has been maintainedwith a very gaod esthetic resuit: thePPD is 3 mm, with a PAL gain af 7 mm

Fig 3e After orthodontic freotment (6months), the diastema is dosed ondthe papiiia height and periodontolmeasurements have been maintained.

Fig 3f Reentry surgery ispertormed 16 months after baseline. A significant increoseof hard tissue is evident in comparison with baseline (Fig 3c).

Fig3g At }8 months after treatment,radiograph demonstrates an increasein radiopacity when compared withthose taken initially (Fig 3b),

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Discussion

This article describes a surgicalprotocoi for fhe plocement cfEmdogain and analyzes clinioalresuits after 12 and 18 months.Three case reports in whiohEmdogain was suocessfully usedto treat infrabony defects hovebeen presented. The combina-tion of the biologic activity ofEmdogain with a precise surgi-cal protocol have providedencouroging ciinical results.

The fiap design described topreserve the interdental papiiiafollows the papilla preservationtechnique^^ or the mcdifiedpapiiia preservation technique.^^The decision criteria to use onetechnique versus the other canbe infiuenced by the anatomyand position of the bony defecf,the anatomy of the papiiia, fhesize of the interproximal space,and position of the defect. It issuggested to piace the incisionand the sutures where the highestbony walls are present to stayaway from the defect, and oon-sequentiy from the area treatedwith Emdogain; this wiil avoid anypossible trauma to the site, anyflap displacement, and the possi-bility of bacterial invasion throughthe sutures.Takei et al's techniqueshould be used in esthetic areaswhere it is necessary to avoidpapiiia shrinkage. Indeed, to usethis technique it is necessary tohave a large interproximal spaceand a wide papilla. After remcvaict all etioiogic facfors, it is funda-mental fc wash and dry the root

surfaoes caretully befare condi-tioning with EDTA and before theEmdogain application. The EDTAuse seems to improve the quan-tity as weil as the quality of theavailabie root surface beforeEiViD use.2^There should be max-imum adherence befween theroot surtace and Emdogain soiu-tion for the best resulf Sutures areplaced and leff loose beforeEmdogain gel application fc pre-vent ony bleeding when the nee-dle penetrates the soft fissue andany displacement of the materiai.

The Laureii suture has beenused to gain better controibelow and over the papiiia with-out crossing again through thetissue, A nonresorbobie monofii-amenf sufure (Gore-Tex) hasbeen used to limit piaque accu-mulation and to ailow ccnfroiiedtension of the suture for af ieast10 days. Since tension control ofthe suture is not as important onfhe verticai incision, these oouidbe sutured with other materials.

The professionals as weii asthe patient must carry out the fol-low-up very oarefuliy. Threepatients were treated using thisregenerative procedure. In twopatients (cases 2 and 3), therewas ciinicai attachment gainwithout gingivai recession. Atreentry, newiy formed hard tissuewas evident where previouslyfhere had been a bony defecf, Afthe same fime, the radiographsshowed a significant increase inradiopacity. In ane patient (case1), radiographie and clinicalresults showed a significant gain.

but a recession was present afteri year as compared with base-line measurements.The soft tissuewas exactly where it had beenpositioned during the suturingphase. No reentry procedure wasperformed in this patient.

Conclusion

Emdogain was successfully usedto treat infrabony defects as evai-uated by ciinicai atfachmentgain, reenfry surgery, and radi-ographie evaluation. A teohniquehas been described to faoilitateclinical use and optimize results;

1. Removal of local etioiogicfactors

2. Fiap design to maintainpapilla architecture

3. Meticulcus defecf debride-ment and root planing

4. Root treatment with 24%EDTA for 2 minutes

5. Lourell sutures placed prior toEmdogoin application

Ó. Postoperative treatmentwith0,12% chlorhexidine andsupragingival personal andprofessionol debridement

Acknowledgment

The authors ttionk iviarc L Nevins tor thehelpful critical review of the manuscript.

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