SCIENTIFIC ARTICLE

Australian Dental Journal 1999;44:(1):31-39

A clinical comparison of the new attachment obtained by guided tissue regeneration and coronally positioned flap techniques in the management of human molar furca tion defects
Varunee Kerdvongbundit, BSc, DDS, GradDipClinSc (Periodontics), MSc* Mullika Sirirat, DDS, GradDipClinSc (Periodontics)* Anongporn Sirikulsathean, DDS, GradDipClinSc (Periodontics)*

Abstract The present clinical trial was designed to evaluate the regenerative potential of the periodontal tissue in Class II furcation defects in mandibular molars using reconstructive surgery based on the guided tissue regeneration (GTR) technique versus the coronally positioned flap (CPF) technique. After the completion of the initial phase of therapy and four to six weeks healing period, 20 furcation-involved molars were examined for baseline data which included plaque index, gingival condition, probing depth (PD), probing attachment level (PAL-V, PAL-H) and radiographs. All parameters were reexamined after three, six and twelve months of healing, except PD, PAL-V and PAL-H which were not measured at three and six months. A nonparametric analysis was used. The study showed that there were no significant differences in the mean baseline measurements between the treatment groups. After 12 months following surgical treatment, both GTR and CPF procedures showed gains in new clinical attachment levels. When comparing parameters between the two surgical procedures, GTR molars showed significantly more improvement in probing depth as well as vertical and horizontal attachment level of the interradicular osseous defect than did the CPF molars (p<0.05). About 80 per cent of the sites treated with the GTR technique showed complete clinical resolution of the furcation problem. CPF therapy reached the same treatment goal in about 50 per cent of the cases which were treated. Guided tissue regeneration appeared to be more effective in promoting regeneration than the coronally positioned flap.
Key words: Guided tissue regeneration, coronally positioned flap, periodontal disease/therapy, furcation therapy. (Received for publication December 1996. Revised April, May 1997. Accepted July 1997.)
*Associate Professor, Department of Oral Medicine and Periodontics, Faculty of Dentistr y, Mahidol University, Bangkok, Thailand.
Australian Dental Journal 1999;44:1.

Introduction Periodontal treatment involves scaling and root planing, or is combined with periodontal surgery followed by proper postoperative maintenance care. It results in the resolution of periodontal pathology and the arrest of disease progression in most cases. Nevertheless, an exception seems to be the furcation defect. Regenerative treatment of furcation defects is a treatment of choice that will result in bone fill and closure of these defects. A number of techniques have been proposed to delay the epithelial downgrowth during healing and to provide an opportunity for the progenitor cells within the periodontal ligament to migrate and form a connective tissue attachment on the previously diseased root surfaces. These led to a clinical trial by Gottlow and coworkers,1,2 which was the first extensive evaluation of the potential of GTR to enhance new attachment in humans. Many investigations have demonstrated the clinical efficacy of GTR. Pontoriero et al.3,4 presented the results of the first clinical study evaluating the effects of GTR for furcation involvement. They reported that 14 out of 21 sites which were treated with barriers showed complete closure of the furcation defects, while only two out of 21 sites which were treated with conventional surgery without the barriers resulted in furcation closure. The same investigators5 further made the evaluation on the treatment of Class III furcations in mandibular molars, and reported that out of 21 through-and-through furcation defects which were treated with GTR, eight of them exhibited complete closure and 10 exhibited partial closure of the furcation as they were observed clinically. None of the previous 21 Class III furcations treated by conventional surgery alone healed with complete
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closure. In 1990, Stahl et al.6 reported that there had been a histological response to GTR techniques in nine sites. Three of the sites showed no evidence of new attachment. In six sites, new cementum with functionally oriented fibres was noted. These results differed from those of Gottlow et al .2 who reported histological evidence of new attachments at all five sites. This study noted the formation of 2.8 to 4.5 mm of new cementum, while Stahl et al.6 found 0.5 to 1.7 mm of new cementum. The reason for the limited success of regeneration in human furcation lesions may be related to the difficulties in obtaining adequate wound closure in most human situations. This may result in the mechanical disruption of the organizing blood clot from the root surface with subsequent salivary and bacterial contamination. This will favour epithelial migration along the root surface, thereby preventing new connective tissue attachment to the treated root. Polson and Proye7 examined the relationship between the coagulum and the root surface during early healing. The fragile nature of this interface seems to make wound stabilization imperative. The protection of the blood clot/root surface interface in the early stage of healing seems essential if successful regeneration is to be achieved. Kling et al.8,9 proposed a crown-attached suturing technique after a moderate coronal positioning of a surgical flap. This method increases the distance epithelium needs to migrate before contacting the defect and allows the clot to become stabilized and ultimately organized. Gantes et al .10 studied bone regeneration in mandibular Class II furcation defects in man. These teeth were treated by using regenerative surgical therapy that included citric acid root conditioning and a coronally positioned flap which was secured by crown-attached sutures. Soft and hard tissue measurements demonstrated notable improvement within 12 months following the therapy. On average, 67 per cent of the defect volume became filled with bone, 43 per cent of the treated defects were completely closed by bone fill. Garrett et al.11 reported on mandibular Class II furcation defects with a coronally positioned surgical flap secured by crown-attached sutures. An average of 70 per cent of the defect volume became filled with bone, with complete closure by the bone fill for 9 of the 16 treated defects. The probing depth reduction was 2.6 mm. Their results supported the potential of this technique. The treatment of furcation involvement is certainly not definitive. Many treatment modalities improve the furcation defect, but each is still unpredictable. Therefore, the present study was designed for comparison of the clinical results of new attachment in human buccal Class II furcations involving mandibular molars which were treated
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with guided tissue regeneration or coronally positioned flap by: 1. Assessment of the predictability of new attachment formation when treated with guided tissue regeneration or a coronally positioned flap. 2. Comparison of the amount of new attachment gain when using guided tissue regeneration versus the coronally positioned flap. Materials and methods Twenty subjects, 11 females and 9 males with a mean age of 49.8 years (range 30 to 65 years), were selected from the Faculty of Dentistry, Mahidol University, on the basis of having buccal Class II furcations on the first or second lower molar s.12 All subjects were physically, medically, and psychologically able to undergo periodontal surgery. They had no significant medical histories and were nonsmokers. They had mild to moderate chronic generalized gingivitis with localized periodontitis. A total of 20 molars were selected with the following criteria: they had an adequate band of keratinized gingiva (1.0 mm or more), no enamel projection or enamel pearls in the furcation that could not be removed at the time of surgery; they also had advanced periodontal tissue destruction within the interradicular area (PAL-V 5.0 mm or more and PAL-H 3.0 mm or more from the buccal aspect of the tooth), with normal response to electrical pulp testing and radiographic evidence of intact interproximal bone. The selected patients were required to sign a consent form indicating their willingness to participate in the study. After the initial examination and a treatment planning session, each patient received detailed instructions in proper self-performed plaque control and was subjected to a series of full mouth scaling and root planing, including occlusal adjustment in those cases where traumatic occlusion was present. After a period of healing and plaque control supervision, about four to six weeks after this initial therapy, the patients were recalled for a baseline examination and only those furcations with a pocket depth of 5 mm or more were used in this study. At the baseline examination, lower molar furcations were examined with respect to oral hygiene status (plaque index, P1I),13 gingival condition (gingival index, GI,14 and bleeding on probing to the orifice of the buccal pockets, GBI 15). Gingival recession (GR) was measured from reference points to the gingival margin. The probing pocket depth (PD) was measured from the gingival margin to the base of the pocket. Probing attachment level (PAL) was measured from the reference points to the base of the pocket and was classified as probing
Australian Dental Journal 1999;44:1.

Fig. 1. Three restorations as reference points 1-2 mm above CEJ.

attachment in both vertical (PAL-V) and horizontal (PAL-H) directions. PAL-V was measured in a vertical direction using the margin of three restorations as the fixed reference levels and PAL-H was measured in the horizontal direction in the midfurcation area using the buccal root surface as the fixed reference level. During the measurement, another straight probe was placed to bridge the prominences of the buccal roots to provide a reference line for the recording. Tooth mobility,12 photographic documentation and radiographic examination from the furcation fornix using a paralleling technique with film holder, acrylic bite mark and grid was made. P1I and GI were recorded at the mesiobuccal, mid-buccal, mid-lingual and distolingual surfaces. GR, PD and PAL-V were recorded at three restorations which were made at the centre of the furcation areas and at the mesial and distal line angles of the two roots at the buccal furcation (Fig. 1) by using a periodontal probe. Measurements were recorded to the nearest millimetre. Following the baseline examination, each furcationinvolved molar was randomly assigned by a numbering system to either the guided tissue regeneration (GTR group) or coronally positioned flap (CPF group) procedure.16 Ten defects were treated by GTR and the other 10 defects with the CPF technique. For the GTR group, elevation of mucoperiosteal flaps on the buccal and lingual aspect of the alveolar process was performed. The inner surface of each flap was carefully curetted to remove the epithelium and granulation tissue. The root surfaces were scaled and planed. Any enamel projections or enamel pearls were removed. The e-PTFE membrane was adjusted to cover the entrance of the
Hu-Friedy PCPUNC 15, Hu-Friedy Mfg. Inc., Chicago, Ill, USA. Australian Dental Journal 1999;44:1.

furcation area and the adjacent root surfaces as well as a portion of the alveolar bone apical to the crest, in such a way that the epithelium and the gingival connective tissue were prevented from reaching contact with the root during healing (Fig. 2). The flaps were repositioned and placed on the outer surface of the membrane and were secured with interdental sutures which were removed after one week of healing. Gentle brushing of the flap margin began on the second day after surgery, but flossing of the treated area was delayed until barrier removal. This avoided material/wound disruption. Then, gentle brushing with an end tuft or soft bristle brush was recommended. The patients were instructed to rinse twice daily for one minute with a 0.2 per cent chlorhexidine gluconate solution. The mouthrinse regimen was continued for a period of four weeks. The interdental sutures were removed one week after surgery. Postoperative care included atraumatic oral hygiene and weekly to biweekly professional visits for six consecutive weeks. At each visit the tissues were inspected for material coverage and the teeth were cleaned with cotton pellets and saline. The exposed membrane was not trimmed unless it caused complications. If the membrane became clinically exposed, whether at placement or postoperatively, it was easier to maintain with a combination of gentle mechanical and chemical plaque control. In these instances, a brilliant red granulation tissue growing from underneath the membrane was observed attached to the roots. Each patient was monitored at least once a week if exposure was present.

Fig. 2. The use of GTR in regenerating the periodontal tissues. Placement of a barrier (B) between the gingival flap and the root surface excludes gingival epithelial (E) and connective tissue (CT) cells from the wound area, and creates a space into which progenitor cells from the periodontal ligament (P) and/or the alveolar bone (AB) can migrate.
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3a 3b

3d 3c
Fig. 3. (a) Two buttons have been attached to the tooth surface. The mesial and distal vertical incisions and the sulcular incision are illustrated. (b) The surgical flap has been raised and the granulomatous tissue removed, exposing the furcation defect. The incision line for the periosteal scoring is indicated. (c) Debridement of the defect has been completed and the enamel projection removed. The periosteum has been fenestrated allowing elongation of the flap. (d) The flap is coronally positioned and the sutures placed.

For the second surgical phase, after a healing period of about six weeks, the e-PTFE membrane was removed. In the CPF group, the surgical procedure followed the same pattern as in the GTR group with the exception of the placement of the e-PTFE membrane. In addition, the flap was coronally positioned and secured by crown-attached sutures and buttons (Fig. 3). Antibiotic coverage was routinely prescribed for seven days (tetracycline 250 mg four times per day), which was occasionally extended for an additional 14 days. Appropriate analgesics were prescribed as needed. During a period of twelve months following the surgical procedures, the patients were maintained on a professional tooth cleaning regimen at six and twelve months and a self plaque control programme (Bass technique). The patients were re-examined at three, six and twelve months following surgical treatment by assessing the same parameters by the same examiner as baseline except that PD and PAL were not measured at three and six months. Statistical analyses The data collected in this study were calculated by non-parametric analysis. The results of the GTR group and CPF group at baseline three, six and twelve months were compared by Mann-Whitney UWilcoxon Rank Sum W Test and Fishers Exact Test. The level of significance was set at 0.05.
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Results A total of 20 sites (10 in each group) from 20 patients were studied. All studied teeth had Grade II enamel projections. All surgical sites healed uneventfully without any signs of infection, sloughing of the flap, pulpal complications, tooth mobility or patient discomfort. The gingival margin gradually receded from its coronal position in both treatment groups. Only one case in the GTR group showed membrane exposure. A randomly re-entered GTR case clinically demonstrated new attachment in a Class II mandibular furcation involvement (Fig. 4, 5). In the CPF group, the coronal flap elevation created an uneven contour of the interdental papilla mesial and distal to the treated teeth during the early post-operative weeks. Gradually, however, these uneven contours disappeared and did not seem to present any concern. One randomly re-entered case showed clinical evidence of a new attachment in a Class II mandibular molar furcation defect (Fig. 6, 7). An analysis of the PAL data revealed that eight and five furcations treated by the GTR principle and CPF principle respectively, were completely closed at 12 months. That is, the furcation space was occupied by tissue which prevented probe penetration. About 80 per cent of the sites treated with the GTR technique showed complete clinical resolution of the furcation problem. CPF therapy reached the same treatment goal in about 50 per cent of the cases treated.
Australian Dental Journal 1999;44:1.

4a

4b

4c

4d

5a

5b

Fig. 4. (a) The furcation of the mandibular left first molar treated with a barrier membrane. The tooth has a buccal Class II furcation invasion with actual probing attachment levels of 9 and 6 mm for vertical and horizontal measurement. (b) A single tooth wide e-PTFE membrane has been shaped and secured in place with e-PTFE sling suture to cover the buccal furcation. (c) Six weeks post surgery. The membrane had been removed. The furcation defect and both radicular surfaces on the first molar were completely filled with a dense newly regenerated tissue. (d) Twelve months re-entry of treated site. There was a 6 mm gain in bone height vertically and a 3 mm gain horizontally. Fig. 5. (a) The original radiograph revealed a radiolucent Class II furcation on the mandibular first molar. (b) Radiograph at the time of 12 month re-entry demonstrated the complete resolution of the defect with decreased radiolucency.

There was no statistical difference for all parameters which were measured at baseline for both treatment groups. Plaque index, gi n gi val index, gi n gi va l bleeding index (Fishers Exact Test) and gingival recession for GTR and CPF groups calculated throughout the study demonstrated no statistical significance for any of these changes in either group. The initial means and standard deviations of pocket depth was 61.2 mm for the GTR group and
Australian Dental Journal 1999;44:1.

61.1 mm for the CPF group. Twelve months after the surgical treatment, the GTR group had a mean and standard deviation of pocket depth of 21 mm, while the CPF group had 40.9 mm. The means at 12 months between the groups were statistically significantly different (p<0.05). The mean and standard deviation of probing depth improvement for the barrier treated defect was 41.8 mm compared with 20.7 mm for the CPF group. The
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6a

6b

7a

7b

Fig. 6. (a) A buccal Class II furcation defect after thorough debridement on the mandibular first molar with 6 mm probing pocket depth and a 3 mm vertical intrabony defect. (b) Surgical re-entry at twelve months. The gain of vertical and horizontal probing attachment was found to be 3 and 2 mm respectively. Fig. 7. (a) The initial radiograph demonstrates a radiolucency in the furcation, treated in accordance with the CPF principle. (b) Radiograph at 12 month re-entry evaluation shows the slight increase in radiopacity of the defect when compared with the initial radiograph.

changes between baseline and 12 months in pocket depth were also significantly greater in the GTR group (p<0.05) (Table 1). This improvement was more pronounced at the furcation sites of the GTR than at those of CPF teeth. During the 12 months of observation, the means and standard deviations of changes in vertical probing attachment levels at the centre furcation sites of GTR teeth were on average 41.9 mm, while the corresponding figures for the CPF sites were 20.7 mm resulting in a statistically significant difference (Table 2). Treatment resulted in a significantly improved vertical probing attachment level of the GTR teeth in all sites. At the baseline examination, the mean and standard deviation of PAL-H of the GTR teeth was 51.1 mm with a range of 3-7 mm. The corresponding depth of the CPF teeth was 51.3 mm with a range of 3-6 mm. At the 12 month re-examinations, the mean and standard deviation of PAL-H of GTR teeth and CPF teeth were 11 mm and 11 mm. The mean and standard deviation gain in PAL-H for the barrier sites was 51.1 mm, whereas the change in the
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mean PAL-H for the CPF group was 41.4 mm. This change of the PAL-H value was statistically significant (p<0.05). Horizontal probing attachment levels were significantly improved with both surgical treatments but with significant differences between the treatments (Table 3). After 12 months following the surgical treatment, both GTR and CPF procedures demonstrated new attachments clinically: PD reduction (mean SD) of 41.8 mm and 20.7 mm; PAL-V gain (mean SD) 41.9 mm and 20.7 mm; and PAL-H gains (mean SD) 51.1 mm and 41.4 mm, respectively. Probing depths and probing attachment levels were significantly improved in both groups when compared with the baseline. When compared between the two surgical procedures, GTR molars showed significantly more improvement in probing pocket depth as well as the vertical and horizontal attachment level of the interradicular osseous defect than the CPF molars (p<0.05). Guided tissue regeneration appeared to be more effective in promoting regeneration than did the coronally positioned flap technique.
Australian Dental Journal 1999;44:1.

Table 1. Changes of probing pocket depth in mm: comparison between two techniques at baseline and 12 months after operation (Mann-Whitney U-Wilcoxon Rank Sum W Test)
Time M Baseline Mean Range SD p value* 12 months Mean Range SD p value* Change Mean Range SD p value* 4 3-5 (2) 1 M=0.8415 2 1-4 (3) 0.9 M=0.2620 2 1-4 (3) 1.0 M=0.1419 GTR group F 6 5-9 (4) 1.2 F=0.1532 2 1-4 (3) 1.0 F=0.0196 4 2-8 (6) 1.8 F=0.0068 D 4 3-5 (2) 1 D=0.7137 2 1-2 (1) 0.5 D=0.2821 2 1-4 (3) 1.3 D=0.3278 M 5 2-7 (5) 1.7 CPF group F 6 5-8 (3) 1.1 D 3 2-6 (4) 1.4

3 1-5 (4) 1.3

4 2-5 (3) 0.9

2 1-5 (4) 1.1

2 0-3 (3) 1.0

2 1-3 (2) 0.7

1 0-3 (3) 0.8

M=Mesial line angle of buccal furcation. F=Centre of the furcation. D=Distal line angle of buccal furcation. *p value between groups. Statistically significant difference, p<0.05.

Discussion The present study supports the effectiveness of the e-PTFE periodontal material in new attachment gain and agrees with previous reports supporting the benefits of guided tissue regeneration. Through a series of studies, it has been postulated that the primary source of the cells that repopulates the root will determine the result.17-19 On the other hand, CPF techniques could improve regeneration as shown in previous studies. A membrane placed over the furcation aperture may provide good wound protection, similar to the coronally positioned flap.5 Pontoriero et al .3 also pointed out that, especially in furcation treatment using teflon membranes, it

should be realized that the soft tissue coverage of the entrance of the furcation may be a factor of importance in success. A membrane placed over the furcation aperture may provide good wound protection, similar to the coronally positioned flap. Results obtained with the coronally displaced flap procedure are similar to those reported by Lekovic et al.20 using a periosteal graft as a membrane, and Gantes et al.10 using a coronally displaced flap and citric acid root conditioning. It is possible that the coronal displacement of the full-thickness flap places the periosteum over the furca in much the same fashion as the technique utilizing a free autogenous periosteal graft. In both situations the placement of

Table 2. Changes of vertical probing attachment level in mm: comparison between two techniques at baseline and 12 months after operation (Mann-Whitney U-Wilcoxon Rank Sum W Test)
Time M Baseline Mean Range SD p value* 12 months Mean Range SD p value* Change Mean Range SD p value* 6 4-9 (5) 1.5 M=0.5853 4 1-4 (3) 0.9 M=0.5828 2 0-4 (4) 1.3 M=0.1114 GTR group F 8 6-11 (5) 1.7 F=0.2420 4 3-6 (3) 1.2 F=0.1141 4 2-8 (6) 1.9 F=0.0099 D 5 4-7 (3) 1.2 D=0.6126 3 2-6 (4) 1.1 D=0.2821 2 1-4 (3) 1.1 D=0.1675 M 6 3-8 (5) 1.8 CPF group F 7 6-10 (4) 1.3 D 5 3-8 (5) 1.5

5 3-8 (5) 1.6

5 4-8 (4) 1.1

4 3-8 (5) 1.5

1 0-3 (3) 1.1

2 1-3 (2) 0.7

1 0-3 (3) 1.0

M=Mesial line angle of buccal furcation. F=Centre of the furcation. D=Distal line angle of buccal furcation. *p value between groups. Statistically significant difference, p<0.05.
Australian Dental Journal 1999;44:1. 37

Table 3. Changes of horizontal probing attachment level in mm: comparison between two techniques at baseline and 12 months after operation (Mann-Whitney U-Wilcoxon Rank Sum W Test)
Time Baseline Mean Range SD p value=0.2487 12 months Mean Range SD p value=0.2453 Change Mean Range SD p value=0.0451* GTR group 6 3-7 (4) 1.1 CPF group 5 3-6 (3) 1.3

1 0-2 (2) 1.0

1 0-2 (2) 1.0

5 3-6 (3) 1.1

4 1-6 (5) 1.4

*Statistically significant difference, p<0.05.

the periosteum in direct contact with a furca defect may modify the cellular dynamics of wound healing. The importance of preventing gingival recession in the early postoperative period has been demonstrated in a series of studies in which periodontal tissue regeneration was found to increase as a result of treatment using the coronally repositioned flap technique. The coronally repositioned flap technique used for wound closure has been considered to play a significant role in preventing salivary and bacterial contamination or mechanical disruption of blood clots and their detachment from the root surface.21 For CPF, Klinge et al.8 suggested that the first two postoperative weeks were critical in determining the final healing result and that complete flap coverage of the furcations during this period was essential. In addition, the morphology of the periodontal defect may be a factor influencing not only the amount of new attachment but also the amount of gingival recession after surgery. Higher alveolar bone level proximal to the defect seems to give better postoperative support for the flaps and blood supply resulting in gingival coverage of the defect. Response to regenerative periodontal therapy varies widely. Gottlow et al.2 pointed out that several factors might influence the process of regeneration. One of them was the degree of gingival recession after surgery; the more the gingiva recedes, the shorter the root surface portion that is available for PDL cell repopulation. Another factor that may influence the degree of new attachment formation is the morphology (size and shape) of the periodontal defect. The number of bony walls surrounding the defect, length of root trunk, root divergence, presence of enamel projections and the strategic
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value of the tooth are critical factors when evaluating teeth for regenerative procedures. The variation in anatomy in the furcation area of different teeth is also difficult to control. The size and especially the height of the furcation defect may be determining factors for success or failure following regenerative therapy at furcation defects. In other words, the larger and/or higher the defect, the smaller is the chance for complete regeneration. Not only the volume or height of the defect but also the shape of the defect and the amount of periodontal ligament tissue bordering the various walls of the defect may influence the amount of regeneration that can occur. Thus, it is likely that a wide and shallow furcation defect has a greater chance for regeneration than a defect with the identical volume but which is narrow and high.5 Studies on dried skulls and after surgical exposure of furcations demonstrate wide variability in the geometry of Class II furcation involvements in the lower molars.22-24 An important factor with respect to the potential of a site for new attachment formation is the amount of the remaining periodontium. The less periodontium that remains, the smaller is the source of progenitor cells for the formation of a new attachment. Further studies are needed in order to clarify how important the size and volume of the remaining periodontium is for the potential of a site to develop a new attachment. This might be due to the fact that the progenitor cells competent for new attachment formation are located in a limited zone (200-400 m) of the coronal part of the remaining periodontium.25 These cells proliferate and may generate new attachment for a limited time span (7-21 days) postoperatively.26 Another likely explamation for the above variability is the difference in the initial pocket depths. Numerous studies have confirmed that deep pockets tend to show greater improvement than shallow pockets. Another reason for these differences could be explained by the methodology of probing. The position of measurement may influence the results. Some studies27 were measured at the middle of the mesiofacial and distofacial roots and in the middle of the furcation, while others recorded probing depth and clinical attachment in the furcation, using two locations on the furcation aspects on mesial of the distal root and on the distal of the mesial root. Machtei28 presented vertical probing attachment levels (PAL-V) by using true vertical rather than oblique-vertical measurement of the distance from the stent to the most coronal extension of the attachment apparatus at the orifice of the furcation defect. The differences with these measurements may be due to different probing forces and techniques which were not standardized in either study, or to variation in surgical success.
Australian Dental Journal 1999;44:1.

Conclusions All sites treated with GTR or CPF procedure showed improvement of the clinical parameters of pocket depth reduction, probing attachment level and partial or complete furcation fill. No adverse clinical effects of therapy were observed. Eight of ten furcation defects (80 per cent) for the GTR group resulted in complete furcation fill, while five of ten furcation defects (50 per cent) for the CPF group had complete furcation fill. The GTR procedure used in this study gave a statistically significant improvement in healing as compared with CPF in Class II furcation invasion of the mandibular molars. The results of the present study indicate that regenerative surgical therapy, based on the principle of guided tissue regeneration or the coronally positioned flap technique, predictably results in new attachment. Acknowledgement This study was supported by the Faculty of Graduate Studies Research Fund, Mahidol University, 1991. References
1. Gottlow J, Nyman S, Karring T, Lindhe J. New attachment formation as the result of controlled tissue regeneration. J Clin Periodontol 1984;11:494-503. 2. Gottlow J, Nyman S, Lindhe J, Karring T, Wennstrom J. New attachment formation in the human periodontium by guided tissue regeneration. Case reports. J Clin Periodontol 1986;13:604-616. 3. Pontoriero R, Lindhe J, Nyman S, Karring T, Rosenberg E, Sanavi F. Guided tissue regeneration in degree II furcationinvolved mandibular molars. A clinical study. J Clin Periodontol 1988;15:247-254. 4. Pontoriero R, Nyman S, Lindhe J, Rosenberg E, Sanavi F. Guided tissue regeneration in the treatment of furcation defects in man. J Clin Periodontol 1987;14:618-620. 5. Pontoriero R, Lindhe J, Nyman S, Karring T, Rosenberg E, Sanavi F. Guided tissue regeneration in the treatment of furcation defects in mandibular molars. A clinical study of degree III involvement. J Clin Periodontol 1989;16:170-174. 6. Stahl SS, Froum S, Tarnow D. Human histologic responses to guided tissue regeneration techniques in intrabony lesions. Case reports on 9 sites. J Clin Periodontol 1990;17:191-198. 7. Polson AM, Proye MP. Fibrin linkage: A precursor for new attachment. J Periodontol 1983;54:141-147. 8. Klinge B, Nilv eus R, Egelberg J. Effect of crown-attached sutures on healing of experimental furcation defects in dogs. J Clin Periodontol 1985;12:369-373. 9. Klinge B, Nilv eus R, Kiger RD, Egelberg J. Effects of flap placement and defect size on healing of experimental furcation defects. J Periodont Res 1981;16:236-248. 10. Gantes B, Martin M, Garrett S, Egelberg J. Treatment of periodontal furcation defects. (II) Bone regeneration in mandibular class II defects. J Clin Periodontol 1988;15:232-239. 11. Garrett S, Martin M, Egelberg J. Treatment of periodontal furcation defects. Coronally positioned flaps versus dura mater membranes in Class II defects. J Clin Periodontol 1990;17:179185.

12. Hoag PM, Pawlak EA. Essentials of periodontics. 4th edn. St Louis: The CV Mosby Company, 1990:134-136. 13. Silness J, L o e H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964;22:121-135. 14. L oe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:535-551. 15. Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25:229-235. 16. Martin M, Gantes B, Garrett S, Egelberg J. Treatment of periodontal furcation defects. (I) Review of the literature and description of a regenerative surgical technique. J Clin Periodontol 1988;15:227-231. 17. Nyman S, Lindhe J, Karring T, Rylander H. New attachment following surgical treatment of human periodontal disease. J Clin Periodontol 1982;9:290-296. 18. Anderegg CR, Martin SJ, Gray JL, Mellonig JT, Gher ME. Clinical evaluation of the use of decalcified freeze-dried bone allograft with guided tissue regeneration in the treatment of molar furcation invasions. J Periodontol 1991;62:264-268. 19. Isidor F, Karring T, Nyman S, Lindhe J. The significance of coronal growth of periodontal ligament tissue for new attachment formation. J Clin Periodontol 1986;13:145-150. 20. Lekovic V, Kenney EB, Carranza FA, Martignoni M. The use of autogenous periosteal grafts as barriers for the treatment of Class II furcation involvements in lower molars. J Pe ri o d o n t o l 1991;61:775-780. 21. Garrett S, Loss B, Chamberlain D, Egelberg J. Treatment of intraosseous periodontal defects with a combined adjunctive therapy of citric acid conditioning, bone grafting, and placement of collagenous membranes. J Clin Periodontol 1988;15:383-389. 22. Larato DC. Furcation involvements: Incidence and distribution. J Periodontol 1970;41:499-501. 23. Larato DC. Some anatomical factors related to furcation involvements. J Periodontol 1975;46:608-609. 24. Bower RC. Furcation morphology relative to periodontal treatment. Furcation entrance architecture. J Periodontol 1979;50:23-27. 25. Aukhil I, Iglhaut J. Periodontal ligament cell kinetics following experimental regenerative procedures. J Clin Periodontol 1988;15:374-382. 26. Iglhaut J, Aukhil I, Simpson DM, Johnston MC, Koch G. Progenitor cell kinetics during guided tissue regeneration in experimental periodontal wounds. J Periodont Res 1988;23:107117. 27. Yukna RA. Clinical human comparison of expanded polytetrafluoroethylene barrier membrane and freeze-dried dura mater allografts for guided tissue regeneration of lost periodontal support. I. Mandibular molar Class II furcations. J Periodontol 1992;63:431-442. 28. Machtei EE, Dunford RG, Norderyd OM, Zambon JJ, Genco RJ. Guided tissue regeneration and anti-infective therapy in the treatment of Class II furcation defects. J Periodontol 1993;64:968-973.

Address for correspondence/reprints: Associate Professor Varunee Kerdvongbundit, 6 Yothi Street, Ratchathewi, Bangkok 10400, Thailand.

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