Beruflich Dokumente
Kultur Dokumente
17
exclude botfi the gingival quate rigidity tor space mainte- sutures complicates odapta-
epitheliufn and connective tis- nonce, and the ability to allow ticn and is extremely technique
sue from the wound site. This tor tissue integration. sensitive ond time consuming.
opproach allowed for the cre- In addition to the neces- The limitotions mentioned
afion of a space that favored sory membrane characteristics make presently available
cells from fhe pefiodontal liga- listed above, on importont pre- membranes difticult to utilize
ment and endosfeal apices fo requisite for successful peri- and adapt in the treatment of
be the first to migrate olong odontal GTR therapy is proper multiple periodontal defects. It
the root and torm o new membrane placement. The would therefore seem odvan-
attachment apparatus, membrane must completely togeous if an occlusive mem-
Subsequent to the Millipore seal off the defect environ- brane were available that
filter, expanded polytetrafluo- ment. Intimate adaptation ot meets the requirements ot GTi?
roethylene material (e-PTFE; membranes, however, is very while being easily manageoble
Gore-Tex periodontal material difticult in areas of furcations or and completely a d a p t a b l e
(GTPM; WL Gore)) was used as oround irregulor root surfaces around multiple defects.
the barrier membrane in the exposed by periodontal dis- Zaner et al'^ utilized freeze-
successful regenerative ap- ease,'" These root surfaces ore dfled dura mater allogratts os a
proach that became i<nown as concave interproximolly and "biologic bandage" to cover
guided tissue regeneration otten associated with ditferent and protect several adjacent
(GTR),"-'^ Today, the principle degrees of fluting, which can periodontal osseous defects
of GTR forms the basis for most prevent complete adaptation. being treated with autogenous
regenerative periodontal pro- The inability to seal ott the bone gratis. Lekovic et al"'suc-
cedures. detect environment trom cessfully utilized silicone rubber
As the biologic principle of impregnation with oral tluids as occlusive membranes in the
GTf? has become more univer- and bacteria moy compromise treatment ot grade II furcations
sally accepted, efforts have the eorly healing phase ond in dogs. La Rocca suggested
focused on enhancing its suc- therefore the potentiol tor the use ot rubber dam as a
cessful application by improv- ochieving the moximum de- barrier membrane for GTR pro-
ing materials ond surgical tech- gree of regeneration. cedures in humans (Lo Rocca
niques, The barrier membrane, fvlembrane adaptation is F, personal communication,
an integral component ot the even more demanding when it March 1992) (Figs 2a to 2d).
technique, has received o is necessary to treat several
great deol of attention. The adjacent teeth exhibiting multi-
optimal design and attributes ple periodontol osseous de-
tor an occlusive membrane to tects and root irregularities (Figs
be used in the open system cf l o to Id). None of the mem-
the sulcus envionment ore brane materials presently avail-
complex. To date, the charac- able is designed to address the
teristics emphasized hove complex topography of multi-
included biocompatibllity. the ple detects witti Just one mem-
ability to retard epithelial brane. The necessity ot placing
migration, manageability, ade- several membranes and sets ot
Figs lb and Ic One inteipioximoi Goie-Tex periodontol membrane (GTPM) placed to isolate the detect around tooth 37 is no
sufficient to address the defect surrounding tooth 36. which extends to the buccal surfaces.
Fig 2a Infrabony defects between teeth 32 and 33 and 30 Fig 2b Rubber dam membrane in place isolating ttie defects
and 31. from tfie soft tissues.
Figs 2c Sutured flaps Fig 2d Reentry at montais Note the complete osseous tiil of
the detects, inciuding suprocrestot regeneration Figs 2a to 2d
Courtesy of Dr Fabrizio La Rocca. Novara. Italy.
The purpose of this paper is periodontai osseous defects by and disadvantages ot the
to present the resuits of a ciini- GTR. Comparisons of preopera- materiai will be discussed ds
cal triai evaiuatng the paten- tive and postoperative ciinicai they reiate to the accepted
tial use of rubber dam os the measurements as well as reen- criteria for a successfui occiu-
occiusive barrier in the simuita- try procedures are utilized to sive membrane in regenerative
neous treatment of muitipie evaluate resuits. Advantages periodontai therapy.
Fig 3c Rubber dam mernbrane in Fig 3d Reentry at 6 months. The Fig 3e loath IS at reentry.
place, isolating the defects and span- detect around the maxillary right pre-
ning the edentulous ridge. molar is completely tilled, and same
supracrestal bone regeneration is
observed
Fig4a Toath 17 exhit:nts signiticant Fig 4b Rubber dam membrane in Fig 4c Reentry at months. The peak
Intraosseaus defects on the mesial and place. otbone on the palatal aspect of tiie
distal aspects with Class II furcation second molar has been lost, buf almost
involvement. complete fill has been achieved on
the mesial and distal aspects, including
regeneration of the furcation areas.
Fig 5c Rubber dam membtone in position Fig Sd Reentry at 7 months Note the osseous fill at the
angular ond crater defects os well as the buccal furcation cf
tooth 16.
Hfl)
Fig 6a Maxiiiaiy light quadrant. Fig 6b Extensive defect environment,
including Class III trifurcdtion of the first
molar
fig 7a Mesial angutar defects on the centrai incisors. Note Fig 7b tvlemb'one in piace prior to suturing.
the ndge concavities thai are associated with this site
Fig 7c Six weeks prior to membrane removoi Note the per- Fig 7d Reentry at 6 months. Osseous fill ot the delects nas
foration ot the lobial flap by the membrane. been achieved. In addition, the ridge dimensions have been
enhanced. Figs 7a fa 7d Courtesy of Dr Fernando Presser.
Fig 6 Chdnges in mean probing attachment levis meosured after scaling and
roat planing (DayO) and the some sites at 4 months New ottachment gam ranging
between 2 and 5 mm was evident on oil subiects
Fig 9 Changes in mean intraosseous probing depth measulred using the CEJos a
landmark and taken during the initial surgical procedure and ot reentry. Two sub-
jects (7 and 10) were nat ovaiiable tar follow-up reentries and were not included in
the meosurements.
Coronai piacement is impor- The nonporous and imper- branes that wouid have other-
tant for creating more space meable nature of rubber dam wise been necessary for a
for regeneration, it is diso criti- aiiows it to seai and protect the series of staged surgicai proce-
cal because root irregularities regenerative space from infii- dures. While lacking the abiiity
become more pronounced as tration by epitheliai ceils as well to allow tissue integration, the
attachment loss progresses as from the influences of salivo rubber dam demonstrated
apicaiiy into periodontal and baoteria and their by- enough positive attributes to
defects. More coronal plaoe- products. In addition, because consistently achieve successful
ment thus simpiifies the man- it is nonresorbable. this protec- osseous regeneration in this iim-
agement of the most severe tion can be maintained ited patient sampie,
defeot regions. throughout the course of thera- Gottiow and coworkers'^
py, provided that the rubber reported on new attachment
Permeability. Se ver ai dam is not subjected to exces- formation in humans by guided
recent studies indicate that sive movement or tension. tissue regeneratian. They con-
bacteria ore capabie of tra- ciuded that, "despite the evi-
versing through e-PTFE mem- dence ot significant amounts
branes,^'"^' Guiiiemin et al,-'^ in General cansideratians of new cementum and fibrous
scanning electron mioroscopic aftachment at aii sites treoted,
observations of interproximol A careful anaiysis of the regeneration of aiveoiar bone
e-PTFE type membranes in advantages and disadvan- was almost exclusively restrict-
humans, found microbiai con- tages of availabie membranes ed tc sites where angular bony
tamination on both sides of the must be conducted prior to defects were present before
membrane as well as within choosing one for use in GTR treatment." This iack of supra-
the open microstructure ond procedures. Each type of crestai bone formatian is con-
occiusive portions. They con- membrane seems to possess a sistent with cur own previous
ciuded that the presence of unique set of desirabie charac- ciinicai experience with GTR,
iarge plaque loads may be teristics, it is imperative to However, the meosured suc-
one factor that may interfere match these characteristics to cess in achieving supracrestai
with regeneration. During the the particular set of challenges bone regeneration in the pres-
initiai stages of heaiing, Pitaru et presented by each unique ent study prompts the query
ol^^ observed that eariy degra- patient, appiication, and into what attributes rubber
dation of the coronai portion of defect environment. In this ciin- ddm may have toward achiev-
coilagen membranes can be ical trial, we chose rubber dam ing this resuit more consistently,
caused by enzymes originating membranes far their ability to Adaptabiiity and impermeabiii-
from the saiiva and/or the isolate the defect space and ty may piay a roie. Controlled
inflammatory response in the adapt intimateiy about teeth clinical studies are currentiy
coronai aspects of the fiaps. with multiple adjacent peri- underway in our ciinic to
They suggested that this may odontal defects, in addition, explore the histoiogic and
permit the coionization of the the low oost ot the materiai microbiologie aspects of the
coronal root surface by epithe- matched the needs ot the regenerative environment
lial and fibrabiast ceiis, thereby patient pooi, most of whom associated with the use of rub-
compromising new attachment were unabie to afford the cost ber dam as an occiusive mem-
formation. of multiple conventional mem- brane.