1145

Guided Tissue Regeneration and Bone

Grafts in the Treatment of Furcation
Defects*
Raul G. Caffesse, Carlos E. Nasjleti, Anthony E. Plotzke, Gissela B. Anderson, and
Edith C. Morrison

The present study evaluated the effects of guided tissue regeneration (GTR), with
and without demineralized freeze-dried cortical bone grafts, in the treatment of furcation
defects in 4 female beagle dogs with naturally occurring periodontal disease. The root
surfaces were thoroughly debrided. Four weeks later, full thickness facial and lingual
mucoperiosteal flaps were reflected using inverse bevel incisions on both sides of the
mandible involving the 2nd, 3rd, and 4th premolar, and the 1st molar teeth. Following
debridement, notches were placed on the roots at the level of supporting bone. Test
quadrants were randomly selected and furcations were filled with reconstituted, demi-
neralized, freeze-dried human cortical bone grafts. Following bone grafting, all defects
were covered with an expanded polytetrafluoroethylene (ePTFE) membrane, which was
sutured with 4-0 sutures. Afterward, interproximal sutures were placed through the flaps,
assuring the flaps covered the membranes completely. The contralateral side, serving as
control, was treated by debridement only and application of ePTFE membrane. All
membranes were removed 6 weeks after surgery. Dogs were sacrificed at 4 months after
surgery. Both mesio-distal and bucco-lingual histologie sections were evaluated by de-
scriptive histology. Linear measurements and surface area determination of the furcal
tissues were carried out using the microscope attached to a digitizer. Twelve to 20 non-
serial sections were made of the mid-buccal aspects of each root of each treated tooth.
Half of these sections were stained with Harris' hematoxylin and eosin (H&E) and the
other half stained with Mallory's trichrome stain. Additionally, another group of 12 to
20 non-serial sections cut in the mesio-distal direction were secured for the surface area
measurements of the furcations. Mean values for each dog were obtained for test and
control teeth. ANOVA procedure for a split plot design was employed. Periodontal
healing following the use of guided tissue regeneration procedures resulted in an increase
in connective tissue and alveolar bone regeneration. Adjunctive bone grafting did not
appear to enhance regeneration. / Periodontol 1993; 64:1145-1153.

Key Words: Bone, demineralized, freeze-dried; guided tissue regeneration; grafts/sur-

furcation; surgical flaps; membranes, artificial; polytetrafluoroethylene/therapeutic
gery;
use.

The predictable regeneration of a new attachment appara- tween the gingiva

tus, after the natural attachment has been destroyed by peri-
odontal disease, is one of the most challenging problems in
dentistry. Several recent studies in animals1"5 and in
humans611 have demonstrated that extensive regeneration
of the attachment apparatus (new cementum, new bone, and
a functional periodontal ligament) occurred with the use of
a surgical procedure termed guided tissue regeneration (GTR).
This procedure includes the placement of a membrane be-
*Department of Periodontics, The University of Texas Health Science
Center at Houston, Houston, TX.
and the root surface. This membrane
serves as a barrier preventing the gingival epithelium and
the gingival connective tissue from reaching contact with
the root during healing, and at the same time, giving pref-
erence to cells originating from the periodontal ligament
and bone to repopulate the wound area adjacent to a pre-
viously exposed root surface.
Previously, Nyman et al.1 reported that regeneration of
periodontal tissues was obtained when a filter1" was inter-
posed between the gingival tissue on one side and the ex-
+Millipore Corporation, Bedford, MA.

1146 GTR AND BONE GRAFTS IN THE TREATMENT OF FURCATIONS
posed root surfaces and the surrounding alveolar bone on
the other. However, since the filter is difficult to remove
at the end of the treatment, it is considered impractical in
routine clinical practice. Recently, the case reports of Ny-
mn et al.,6 Becker et al.,7,8 Gottlow et al.,9 Pontonero et
al.,10 and Caffesse et al.,11 coupled with animal studies,4,5
have generated major interest in the GTR procedure, with
the use of an expanded teflon membrane rather than filters.
These authors611 reported successful treatment of furca-
tions and vertical defects after treatment with ex-
panded polytetrafluoroethylene* (ePTFE) membranes.
Also, in a number of reports,1218 the flap procedure has
been combined with insertion of different kinds of bone
grafts into the curetted bony defects in order to enhance
new attachment. These studies showed an increased bone
fill and it was postulated that new attachment occurred where
new bone was present. Clinical parameters such as probing
depth, attachment level, and radiographie bone height showed
significant improvement and were considered to represent
evidence of new attachment. Recently, in human studies,
Bowers et al.19,20 presented evidence of new attachment
apparatus following placement of decalcified freeze-dried
bone allografts in intrabony defects, both in a submerged
and non-submerged environment. For these studies, grafted
and non-grafted sites were histometrically evaluated and
compared 6 months after surgery. Results indicated that
significantly more new attachment, including cementum,
bone, and periodontal ligament, formed in intrabony defects
grafted with demineralized bone than in non-grafted defects.
The present study in beagle dogs combined the procedure
of epithelium and gingival connective tissue exclusion via
ePTFE with demineralized freeze-dried cortical human bone
grafts (DFDCB) to enhance regeneration. The aim was to
histologically and histometrically evaluate and compare the
effectiveness of ePTFE membranes, with and without the
use of DFDCB graft, in periodontal regeneration.
MATERIALS AND METHODS
This animal study was approved by the Animal Welfare
Committee of The University of Texas Health Science Cen-
ter at Houston, and was performed in accordance with the
National Institutes of Health Guide for the Care and Use
of Laboratory Animals.
Four purebred female beagle dogs with naturally occur-
ring periodontal disease, 4 to 6 years old, were used in this
study. They were maintained on a hard diet except for a 2-
week period of time following surgery, when a soft diet
was used. The dogs were subjected to a thorough intra-oral
examination which included periodontal probing and intra-
oral radiographs. Removal both of bacterial plaque and su-
pra- and subgingival calculus plus root planing with local
anesthesia was performed with an ultrasonic sealer8 using
*Gore-Tex periodontal material, W.L. Gore & Associates, Inc.,
AZ.
5Cavitron Corporation, Long Island, NY.
J Periodontol
November 1993 (Supplement)
aP-10 universal tip and Gracey curettes.11 Teeth were sub-
sequently polished. Plaque control was maintained by top-
ical application of a .12% solution of Chlorhexidine glu-
conate, 5 times weekly. Surgical wounding of the animals
started 2 weeks following the scaling and plaque control
phase.
Surgical Procedures
Prior to surgery, each dog was sedated with ketamine given
intramuscularly (10 mg/kg body weight) and subsequently
anesthetized with isoflurane gas. In addition, the dog was
locally infiltrated with 2% Xylocaine (1:50,000 epineph-
rine) to reduce hemorrhage. Two mandibular quadrants in
each dog were surgically treated. Each quadrant included
the 2nd, 3rd, and 4th premolar and the 1st molar. The test
quadrant was selected by the toss of a coin. Reverse bevel,
full thickness, mucoperiosteal flaps were raised with ver-
tical releasing incisions at the mesial and distal aspects of
the surgical sites. Following the elevation of the soft tissue
flaps, removal of granulation tissue, and complete root in-
strumentation, reference notches were placed in the roots
at the level of the alveolar bone crest, using a number 1/2
round bur. These notches were positioned on the buccal
aspects of the roots and extended interproximally and into
the furcation areas as deep as the involvement of the Class
II furcation permitted. Following the placement of the
notches, the surgical sites were thoroughly flushed with
sterile saline, and then blotted dry with a sterile gauze sponge.
The Class II furcation defects of the teeth in 1 of the 2
mandibular quadrants (test quadrant) were filled with re-
constituted DFDCB grafts. Following bone grafting, all teeth
involved received the ePTFE membrane. The material was
placed so that 2 to 3 mm of crestal bone was covered. Once
the periodontal material was in place, it was sutured using
a suspensory suture around each tooth with a 4-0 suture.1
Afterwards, interproximal sutures were placed through the
flap assuring that it covered the membrane completely. Fol-
lowing this, the vertical releasing incisions were also su-
tured. Once suturing was completed, moderate pressure was
applied over the sites for 4 to 5 minutes using a sterile
gauze moistened with sterile saline, so as to minimize clot
thickness and tissue gaping. On each tooth of the contra-
lateral side, serving as control, the same procedure was
performed, but without bone graft. Therefore, a split mouth
design was obtained: test, DFDCB graft plus ePTFE; and
control, ePTFE only.
Post-Surgical Procedures
During the 2 weeks following surgery, all dogs were fed a
soft diet, and during the first week, tooth brushing was
suspended in order to prevent unnecessary disruption of the
ePTFE membrane and healing flap.
Seven days after surgery, the dogs were sedated to allow
Flagstaff,
'Hu-Friedy Company, Chicago, IL.
'W.L. Gore & Associates, Inc., Flagstaff, AZ.
 Volume 64
Number 11
a rubber cup prophylaxis and intra-oral photographs. In the
following weeks, the surgical sites were maintained by
brushing with a .12% Chlorhexidine gluconate solution, 5
times weekly.
Six weeks after surgery, the ePTFE membrane was re-
moved. Under general anesthesia, a split thickness flap pro-
cedure was performed to permit removal of the ePTFE
membrane. The flaps were then replaced and secured with
sutures. Sutures were removed in 7 days. Tooth brushing
with Chlorhexidine solution continued as before.
Four months after surgery, the dogs were anesthetized as
was done for surgery with isoflurane gas. Final radiographs,
clinical measurements, and intra-oral photographs were taken.
Each dog was then given additional anesthetic and sacri-
ficed by exsanguination. The heads of the animals were
perfused with a 10% neutral formalin solution and then
refrigerated for 1 to 2 days. The jaws were dissected free,
labelled, and placed in formalin for further fixation.
Laboratory Procedures
In order to enhance the speed of demineralization, the jaws
were sectioned into one tooth blocks. Demineralization was
accomplished with 10% tri-fluroacetic acid (TFA), the end-
point of which was determined radiographically. Following
demineralization, the blocks were washed, dehydrated, in-
filtrated, and embedded in paraffin, and then sectioned at
6 intervals. Twelve to 20 non-serial sections were made
of the mid-buccal aspects of each root of each treated tooth.
Half of these sections were stained with Harris' hematox-
ylin and eosin (H&E) and the other half stained with Mal-
lory's trichrome stain. Additionally, another group of 12 to
20 non-serial sections cut in the mesio-distal direction were
secured for the surface area measurements of the furcations.
These microscopic slides were examined under a binocular
microscope and descriptive histologie and histometric eval-
uations were performed.
Histologie Evaluation
The descriptive histologieevaluation determined the pres-
ence or absence of root rsorption and/or dento-alveolar
ankylosis, bone formation, the location of cementum dep-
osition, the direction of the periodontal fibers, as well as
the degree of inflammation in the tissues.
Histometric Evaluation
Linear measurements. Under the microscope and using a
micrometer eye piece,* 10 bucco-lingual tissue sections per
tooth were measured by orienting the micrometer grid par-
allel to the shortest line which connected the apical extent
of the root notch to the landmark measured.21 The following
measurements were performed: 1) from the apical extent of
the root notch to the coronal extent of the newly-deposited
cementum; 2) from the root notch to the alveolar bone crest;
#Filar micrometer eyepiece, Bausch & Lomb Optical Company,
ter, NY.
CAFFESSE, NASJLETI, PLOTZKE, ANDERSON, MORRISON 1147
3) from the root surface notch to the apical extent of the
junctional epithelium; and 4) from the free gingival margin
to the apical extent of the junctional epithelium.
Surface area determination. In approximately 10 mesio-
distal sections per tooth, including test and control teeth,
surface area determinations (in mm2) relative to the furca-
tions were made, evaluating: 1) the whole interradicular
space; 2) the area occupied by connective tissue plus bone;
3) the area occupied by bone; 4) the area occupied by ep-
ithelium; and 5) the area occupied by ankylosis. Images
were digitized using a microscope-image processing sys-
tem** attached to a microcomputer, as described previously.21
Statistical Evaluation
Mean values for the experimental and control teeth were
obtained, and both linear and surface area measurements
were analyzed using an analysis of variance procedure for
the split plot design. The tooth as a unit of analysis within
the dog permitted the investigation of the influence of tooth
type on treatment outcomes.
RESULTS
Histologie Observations
On the bucco-lingual histologie sections, those teeth treated
with GTR only and those treated with DFDCB grafts plus
GTR showed almost identical healing. New connective tis-
sue attachment was evident including cementum deposition
as well as bone regeneration in the area coronal to the root
notch. In these sections, newly-formed connective tissue
fibers were oriented perpendicular or nearly perpendicular
to the root surface and were clearly inserted into the regen-
erated bone and the highly cellular new cementum. Fibers
could be seen coursing from the adjacent regenerated peri-
odontal ligament into the newly-formed bone. The newly-
formed periodontal ligament was very cellular and highly
vascularized, yet free of inflammatory cells. No signs of
root rsorption or dentoalveolar ankylosis were seen in these
bucco-lingual sections. Hence, the results demonstrated that
the reformation of a connective tissue attachment was con-
siderably favored by the placement of the ePTFE mem-
branes which seemingly have prevented the gingival epi-
thelium and the gingival connective tissue from interfering
with healing, as shown in Figures 1A and IB.
On the mesio-distal sections from teeth treated with GTR
only, the furcations demonstrated extensive connective tis-
sue and alveolar bone regeneration, as well as cemento-
genesis. New cementum with inserting collagen fibers, as
well as tissue attachment uncomplicated by root rsorption
was observed (Figs. 2A through 2D).
However, many mesio-distal sections from teeth treated
with the adjunctive bone grafts demonstrated that ankylotic
manifestations did occur in the area of the implanted DFDCB.
Three patterns were evident. First, some specimens showed
Roches-
**Zeiss Int., Okekochen, Germany.

1148 GTR AND BONE GRAFTS IN THE TREATMENT OF FURCATIONS
1A. GTR, with and without DFDCB grafts, successfully inhibited
Figure
connective tissue and epithelial participation in the healing process, thus
allowing new attachment on a previously altered root surface to take
place. (H&E stain; original magnification x 25.)
both newdeposited cementum and regenerated bone pen-
etrating an irregular manner into the periodontal ligament
in
space. These projections of cementum and bone reduced
the periodontal ligament space (Figs. 3A and 3B). A second
pattern would appear to be a somewhat later state in the
sequence of events. Many specimens demonstrated "true"
bony ankylosis bridging between new deposited cementum
and bone, as shown in Figure 4. Still other specimens showed
a third pattern with the furcation area almost completely
filled with regenerated bone (Figs. 5A and 5B). This pattern
of healing was the less common among the group. It was
usually depicted in second premolars where the small sep-
aration of the roots produced a narrow furcation area.
Linear Measurements
When the linear measurements were analyzed (Table 1), no
significant differences between procedures (GTR only vs.
GTR plus DFDCB graft) were found. Nevertheless, both
procedures gained connective tissue attachment as well as
new cementum and new bone deposition (Fig. 6).
) Periodontol
November 1993 (Supplement)
Figure IB. Higher magnification of notch area seen in Figure 1A showing
new deposited cementum, regenerated alveolar bone, and new connective
tissue attachment. (H&E stain; original magnification x 100.)
Surface Area Determinations
Table 2 shows the comparison of mean furcation fill mea-
surements in mm2 for the treatment modalities. Results
showed that adjunctive bone grafting did not enhance peri-
odontal tissue regeneration beyond that achieved in sites
treated with ePTFE membrane alone (Fig. 7).
DISCUSSION
The present study was undertaken to provide histologie ob-
servation on the effectiveness of DFDCB grafts in regen-
erating lost periodontal attachment when used as an adjunct
to the GTR procedure. Results of the study have shown
that the graft material used was well-tolerated by the host
tissues. Despite the fact that xenogeneic DFDCB was used,
there was no evidence of any inflammatory or immunologie
reaction to the material. This finding is consistent with Sonis
et al.22 who also used xenogeneic bone grafts and demon-
strated the relative biocompatibility of DFDCB. However,
xenogeneic material may produce an adverse immune re-
sponse, but such grafts have also been used,23,24 in spite of
the fact that they may give a very much weaker response
or no response at all.25
Also, the study has shown that significant amounts of
new attachment may form with the use of a GTR procedure
which gives preference to cells originating from the peri-
odontal ligament tissue to repopulate the wound area ad-
jacent to the periodontally-diseased root surfaces. Such
guidance of the ingrowth of the periodontal ligament tissue
into the wound area was accomplished by placing the ePTFE
 Volume 64
Number 11
Figure 2A. Photomicrograph of representative mesio-distal section show-
ing regenerative connective tissue and new alveolar bone filled completely
furcation area following application of ePTFE only. (H&E stain; original
magnification x 25.)
Figure 2B. Higher magnification of left notch area seen in Figure 2A
demonstrating new deposited cementum, regenerated alveolar bone, and
new connective tissue attachment. (H&E stain; original magnification x
100.)
CAFFESSE, NASJLETI, PLOTZKE, ANDERSON, MORRISON 1149
:^*i..y _' -''.^wx&' ~-.ty , .fri-- . -1 Hi I
-
Figure 2C. Higher magnification of the coronal area in Figure 2A dem-
.
onstrating newly-deposited cementum and new connective tissue attach-
ment. (H&E stain; original magnification x 100.)
Figure 2D. A higher power view of the right notch area seen in Figure
2A exhibiting new cementum, newly-formed alveolar bone, and repaired
periodontal space. (H&E stain; original magnification x 100.)
over the root surface which prevented granulation tissue
derived from the gingival connective tissue from reaching
contact with the root. This is also in agreement with the
findings of Gottlow et al.,3-9 Caffesse et al.,4-5-11 Becker et
al.,7'8 and Pontoriero et al.,10 who used ePTFE membranes
for the exclusion of gingival connective tissue and epithe-
lium during healing. Their results showed that the refor-
mation of a connective tissue attachment was considerably
favored by the placement of the membranes.
The histologie analysis of the teeth treated with GTR
alone disclosed that new cementum with inserting collagen
fibers had formed on the previously periodontally-involved
root surfaces. New bone was also depicted in these speci-
 J Periodontol
1150 GTR AND BONE GRAFTS IN THE TREATMENT OF FURCATIONS November 1993 (Supplement)

Figure 3A. Photomicrograph of a furcation from a tooth treated with GTR

and adjunctive DFDCB graft. Note irregular deposition of new cementum
and new bone as well as the reduced periodontal ligament space. (H&E
stain; original magnification x 25.)

Figure 5A. Other specimens from teeth also treated with the adjunctive
Figure 3B. A higher power view of the furcation fomix of Figure 3A bone grafts showed furcation areas almost completely filled with ankylotic
depicting new cementum and bone projecting into the periodontal ligament bone. (H&E stain; original magnification x 35.)
space. (H&E stain; original magnification x 100.)
 Volume 64
Number 11 CAFFESSE, NASJLETI, PLOTZKE, ANDERSON, MORRISON 1151

Table 1. Linear Histometrics in Buccal-Lingual Sections from 4 Beagle Dogs After 4 months of Healing (in mm)

Cementum Bone Connective Tissue Epithelium

GTR GTR GTR GTR GTR GTR GTR GTR
Only + DFDCB Only + DFDCB Only + DFDCB Only + DFDCB
Tooth Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
p2 1.32 0.75 0.78 0.29 0.88 0.35 0.93 0.46 1.48 0.82 1.37 0.44 1.30 0.18 1.96 0.48
P3 1.33 0.18 1.57 0.92 0.82 0.17 0.70 0.77 1.50 0.16 1.56 0.92 1.41 0.33 1.80 0.93
P4 1.34 0.61 0.81 0.38 1.17. 0.58 1.46 0.79 1.57 0.62 1.70 0.65 1.83 0.44 1.61 0.17
M, 1.49 0.48 0.94 0.33 1.04 0.66 1.26 0.98 1.51 0.45 0.99 0.38 1.94 0.89 2.21 1.00
1.37 0.49 1.03 0.59 0.97 0.45 1.09 0.76 1.51 0.51 1.41 0.63 1.62 0.55 1.90 0.69
Source of
Variation DF* Prob* Prob Prob Prob
Dog 3 1.28 0.3271 1.00 0.4275 0.55 0.6556 1.90 0.1843
Tooth 3 1.02 0.4187 1.72 0.2160 0.69 0.5757 0.82 0.5085
Dog Tooth 9 1.18 0.3879 2.21 0.1006 1.54 0.2397 0.38 0.9248
Treatment 1 3.50 0.0861 0.32 0.5805 0.30 0.5957 1.32 0.2738
Tooth Treatment 3 1.11 0.3819 0.23 0.8739 0.55 0.6592 0.60 0.6291
Total 19 1.28 0.3372 1.53 0.2281 1.03 0.4962 0.77 0.7040

'Degrees of freedom.
*F value of test statistic.
*P value for the test.

mm
mens. Root rsorption and/or dentoalveolar ankylosis were
2.5 GTR
negligible. However, in furcation areas where ePTFE mem-
g GTR + DFDCB branes were used in combination with DFDCB grafts, vary-

MM
2.0 ing patterns of ankylosis were clearly observed.
In this study, the observation that root rsorption was
1.5 almost absent on the roots of both test and control treated
areas is not surprising. Repeatedly, ePTFE membranes ef-

1.0
fectively prevented granulation tissue derived from the gin-
gival connective tissue from reaching contact with the roots.
Previous studies in dogs and monkeys by Nyman et al.,1
0.5 Gottlow et al.,3 and Karring et al.,26 have postulated that
root rsorption occurred when granulation tissue derived
from the gingival connective tissue was proliferating into
CEMENTUM BONE CONNECTIVE EPITHELIUM contact with the root surface.
TISSUE However, the observation that varying amounts of den-
Figure 6. Both procedures gained connective tissue attachment as well as toalveolar ankylosis formed in furcation defects treated with
new cementum and new bone deposition. the adjunctive DFDCB graft was unexpected. Previous au-
thors have reported20,27 29 that root rsorption and dentoal-
veolar ankylosis are not common sequelae of grafting fur-
cation defects with DFDCB. Because the real cause for the
observed ankylosis is unknown, it is only possible to spec-
ulate about it. Since the graft material used in this study
DFDCB
has been reported to be highly osteogenic, it is possible that
the osteoinductive effect triggered an early and greater bone
replacement resulting in the ankylosis observed. Previ-
ously, Urist and co-workers25,30"31 have shown that demin-
eralization of bone resulted in enhanced osteogenic activity.
This osteogenic activity has been cited in numerous
human16 20 and animal studies.32"34 According to Urist31'35
a hydrophobic glycoprotein within the bone matrix, termed
bone morphogenic protein (BMP), is responsible for the
osteoinductive effect by eliciting the differentiation of host
TOTAL FILL CONNECTIVE BONE
TISSUE mesenchymal cells into osteoblasts. Mundy and Poser36 have
Figure 7. Adjunctive bone grafting did not enhance periodontal tissue demonstrated the chemotactic effect of osteocalcin, another
regeneration beyond that achieved in sites treated with ePTFE membrane bone matrix protein. They showed that osteocalcin is a po-
alone. tent chemoattractant for cultured osteoblast-like cells and
 J Periodontol
1152 GTR AND BONE GRAFTS IN THE TREATMENT OF FURCATIONS November 1993 (Supplement)
Table 2. Furcation Fill Achieved in 4 Beagle Dogs (Measured in mm2)

Total Area
EPI+ CT + Connective Tissue (CT)
GTR GTR GTR GTR
Only + DFDCB Only + DFDCB
Tooth Mean SD Mean SD Mean SD Mean SD
p2 5.93 1.60 4.44 1.71 2.33 0.78 0.94 0.21
p, 6.00 1.66 4.45 1.24 2.28 0.88 1.09 0.48
P. 6.32 1.48 9.64 4.09 1.52 0.33 5.31 4.20
M, 8.92 0.79 11.96 5.05 1.96 0.51 2.19 1.21
6.79 1.81 7.62 4.56 2.02 0.68 2.38 2.68
Source of
variation DF* Prob* Prob
Dog 3 0.11 0.9527 0.75 0.5417
Tooth 3 7.90 0.0036 2.28 0.1310
Dog tooth 9 1.47 0.2617 1.32 0.3188
Treatment 1 0.86 0.3723 0.43 0.5262
Tooth treatment 3 2.29 0.1301 4.77 0.0206
Total 19 2.37 0.0648 1.88 0.1320

'Degrees of freedom.
*F value of test statistic.
*P value for the test.

monocytes. Therefore, it is possible that any single factor
or any combination of factors could have contributed to the
ankylosis observed.
A close look at the histometric results depicted in Tables 1
and 2 clearly indicates that the adjunctive use of DFDCB graft
in this study did not enhance periodontal attachment over that
observed when ePTFE was used alone. These results seem to
follow Egelberg's view,37 in relationship to the use of bone
grafts. He stated that "there is little reason to believe that
such bone grafts would stimulate connective tissue attachment
to root surface." Apparently, the results achieved were the
effect of guided tissue regeneration, independent of the pres-
ence of the bone graft. Others have also questioned the value
of bone grafts and whether or not a graft contributes to new
connective tissue attachment.38^2
Probably, the function of a grafting material in associa-
tion with guided tissue regeneration would be as a scaffold
to provide and maintain space whenever the membrane may
have the possibility to collapse, and therefore, reducing the
chances for periodontal ligament cells to repopulate the pre-
viously-exposed root surface.
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 Volume 64
Number 11 CAFFESSE, NASJLETI, PLOTZKE, ANDERSON, MORRISON 1153

Bone () Epithelium (EPI) Ankylosis

'

GTR GTR GTR GTR GTR GTR

Only + DFDCB Only + DFDCB Only + DFDCB
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
3.44 2.04 2.76 0.96 0.0 0.0 0.0 0.0 0.15 0.17 0.75 0.90
3.72 1.39 3.06 0.69 0.10 0.13 0.0 0.0 0.0 0.0 0.30 0.52
4.64 1.25 4.33 1.39 0.0 0.0 0.0 0.0 -

0.24 0.18 0.0 0.0

6.78 0.46 8.97 4.71 0.10 0.13 0.04 0.09 0.12 0.24 0.81 1.40
4.64 1.84 4.78 3.42 0.05 0.10 0.01 0.04 0.13 0.18 0.46 0.85

F Prob F Prob F Prob

0.53 0.6713 0.64 0.6037 2.68 0.0943
10.46 0.0011 1.93 0.1781 0.91 0.4653
1.53 0.2432 1.21 0.3702 1.24 0.3564
0.04 0.8446 2.25 0.1597 2.99 0.1092
1.04 0.4116 0.87 0.4856 1.15 0.3703
2.62 0.0456 1.24 0.3612 1.49 0.2414

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Send reprint requests to: Dr. Raul G. Caffesse, Department of Perio-
dontics, Dental Branch, The University of Texas at Houston, 6516 John
Freeman Avenue, Houston, TX 77030.