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Amnion–Chorion Allograft Barrier Used on Root Surface for Regenerative

Procedures: Case Report

Article  in  Clinical Advances in Periodontics · August 2020

DOI: 10.1002/cap.10125

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 CASE REPORT

Amnion–Chorion Allograft Barrier Used on Root Surface for Regenerative

Procedures: Case Report
Yusuke Hamada,∗ Yu-Ting Yeh† and Steven B. Blanchard∗

Introduction: Guided Tissue Regeneration (GTR) has been well documented with combination of bone graft
substitutes and biologic modifiers to improve the outcomes of periodontal regenerative procedures. Amnion-chorion
allograft membrane (ACM) is a placenta-derived resorbable allograft membrane which contains growth factors found in
the placenta. The primary purpose of the barrier membranes for GTR was to exclude the epithelial down-growth along with
the root surface, however, the ACM can be used as an additional biologic modifier because of the release of growth factors
from the ACM after placement. The aim of this case report is to evaluate the efficacy and the application of ACM on the
previously diseased root surface to treat periodontal intrabony defect.
Case presentation: A 60-year-old Caucasian male with deep and wide intrabony defect on mesial #19 was treated
with a regenerative procedure with combination of application of ACM on the root surface and filling the intrabony defect
with the corticocancellous freeze-dried bone allograft. The bone substitute was covered with another layer of ACM and
primary closure was achieved. Wound healing process was uneventful, and the clinical and radiographic outcomes were
favorable up to 18 months after the surgical procedure.
Conclusion: This case report demonstrated that the application of ACM on the root surface with a combination of
bone substitute might enhance to the radiographic bone fill and the clinical attachment level gain and minimize the risk of
post-operative gingival recession. Clin Adv Periodontics 2020;00:1–5.
Key Words: Biomaterial(s); Bone regeneration; Periodontal regeneration.

Background tissue regeneration (GTR), biologic modifiers and com-

Intrabony defects associated with deep periodontal pock-
ets represent the apical extension of plaque and its
byproducts in the natural course of periodontitis.1 Regen-
erative procedures using bone replacement grafts, guided
∗ Department of Periodontology, Indiana University School of Dentistry,
Indianapolis, IN
† Department of Periodontology, Creighton University School of Den-
tistry, Omaha, NE
Disclaimers: The authors do not have any financial interests in any of
the products mentioned in this article.
Authors Contribution Statement:
Drs. Yusuke Hamada and Steven Blanchard developed the idea and
protocol for this treatment modality. Drs. Yusuke Hamada and Yu-Ting
Yeh performed this surgical procedure and followed up this case in the
clinic.
Received June 3, 2020; accepted August 13, 2020
doi: 10.1002/cap.10125
bination therapies have been shown to be effective in
the treatment of intrabony defects.2,3 GTR is a proce-
dure designed to regenerate the lost periodontal structures
including cementum, periodontal ligament (PDL), and
alveolar bone using barrier membranes to allow selective
cell repopulation of periodontal surgical sites.
Several absorbable barrier materials have been devel-
oped including allograft, xenograft, and alloplastic mate-
rials.4,5 Among these bioabsorbable membranes, the use
of placental tissue based allografts in dentistry is a more
recent development.6 Amnion-chorion allograft mem-
branes (ACM) have been reported for use with GTR and
root coverage procedures.7–9 ACM have biologic prop-
erties and growth factors that actively promote wound
healing for periodontal defects. Koob et al. demonstrated
that ACM possesses an ability to induce the migration
of mesenchymal stem cells (MSCs).10,11 The cell density
of migrated MSCs in response to dehydrated human
amnion/chorion tissue allografts was significantly greater

Ce2020 American Academy of Periodontology Clinical Advances in Periodontics, Vol. 00, No. 0, xxx 2020 1
C A S E R E P O R T

FIGURE 1 Initial clinical presentation on buccal of #19 with 10 mm

Probing depth (PD).
FIGURE 2 The initial radiograph demonstrated deep vertical bone loss
on #19 with the presence of calculus.

than negative control sites such as intact skin and sham-

operated sites.10,11 These reports support the proposition
that ACM should be viewed not only as a barrier mem-
brane but also as a biologically active material containing
multiple growth factors and may be of benefit in enhanc-
ing periodontal regeneration. To date, there are no reports
on the application of ACM on the previously diseased root
surface as a source of biologic modifiers.
The purpose of this case report is to evaluate the
efficacy and application of ACM placed on the root sur-
face within a periodontal intrabony defect in conjunction
with allograft bone substitute using a combination GTR
treatment.

Clinical Presentation
A 60-year-old Caucasian male was referred to Indiana
University School of Dentistry Graduate Periodontics
Clinic for the periodontal evaluation and treatment in Feb
2017. He was classified as an ASA I, and denied history
of smoking habits. Probing depth (PD) on mesial #19 was
10 mm with presence of bleeding on probing. A periapical
radiograph showed that the defect reached to the apical
third of the mesial root with calculus attachment on tooth
#19 (Figs. 1,2). The patient’s O’Leary plaque score12 was
15% and vitality testing showed #19 was vital. This
patient was diagnosed as localized Stage III Grade B
periodontitis.13
Case Management
The patient received oral hygiene instruction and non-
surgical therapy prior to referral to our clinic. Based on the
diagnosis and limitation of the non-surgical periodontal
therapy, the patient opted to proceed with a regenerative
procedure to treat the intrabony defect on the mesial of
tooth #19. Prior to the surgical procedure, the patient
signed the informed consent and authorization forms. Fol-
lowing administration of local anesthesia (2% lidocaine
with 1/100,000 epinephrine), a sulcular incision on the
FIGURE 3 A wide and deep 2 wall intra-bony defect involved the buccal
surface of mesial root of #19.
buccal and lingual aspects on the area was made, and full-
thickness flaps were reflected. The defect was debrided to
remove granulation tissue and thorough scaling and root
planning was performed. A wide and deep 2 wall intra-
bony defect extending to buccal surface of #19 (≈3mm in
width, 4 mm in depth from the buccal wall and 8 mm
in depth from the lingual wall) was present (Fig. 3). A
17% EDTA solution was applied on the root surface with
cotton pellets for 2 minutes. A 25 × 15 mm ACM‡ was
cut in half, and one half was placed on the root surface
first as a biologic modifier. The most coronal portion of
the membrane extended ∼3mm coronal to the cement-
enamel junction (CEJ). After this membrane was placed,
a drop of saline was applied to obtain better adaptation
of membrane along the root surface (Fig. 4). Freeze-dried
bone allograft§ (FDBA) was then placed in the intrabony
defect (Fig. 5) and the coronal portion of membrane along
the root was folded over the graft materials which was
then covered by the remaining piece of ACM (Fig. 6).
‡ BioXclude® membrane, Snoasis Medical LLC, Golden, CO
§ Particle
size of 0.25-0.5mm of corticocancellous blend, Maxxeus® ,
Kattering OH

2 Clinical Advances in Periodontics, Vol. 00, No. 0, xxx 2020 Regeneration with Amnion Chorion membrane

FIGURE 4 Amnion-chorion allograft membrane (ACM) application on
the root surface. Entire exposed root surface was covered and the most
coronal portion of the membrane was placed >3 mm coronal of cement
enamel junction. (Exemplary Figure)
FIGURE 5 The FBDA particles did not exceed the edge of defects in
order to avoid the overfill.
FIGURE 6 The coronal first membrane was folded over the graft mate-
rials and the additional layer of ACM covers all the bone substitutes and
the part of root surface.
The flaps were sutured with 5-0 polytetrafluoroethylene
(PTFE) and primary closure was achieved (Fig. 7). This
patient was prescribed 875mg amoxicillin twice a day for
 PTFE 5/0 Suture Extra cutting needle 3/8, Omnia LLC, Abbottstown,
PA
Regeneration with Amnion Chorion membrane
C A S E R E P O R T
FIGURE 7 Primary closure with 5-0 PTFE sutures in interrupted tech-
niques
FIGURE 8 Two months post-surgical procedure showed approximate 3
mm of the gingival recession on mesial of #19.
7 days and ibuprofen 600 mg three times a day for 3 days.
The patient rinsed twice daily with 0.12% chlorhexidine
for 2 weeks after surgery and was instructed to refrain
from brushing the teeth in the area for 2 weeks.
Clinical Outcome
Overall post-surgical wound healing was uneventful. Two
months after the completion of surgery, tooth #19 showed
3 mm of recession on the mesial aspect with slight loss
of papillary height (Fig. 8). At 6 months post-operatively,
the clinical examination revealed that the PD was reduced
from 10 mm to 4 mm and the post-surgical recession was
reduced to 0.5 mm (Fig. 9). Clinical examination revealed
that the interdental papillae slowly grew back to the pre-
treatment level and the PD was stable with 4 mm PDs
without bleeding on probing (BOP) at 18 months post-
surgically (Fig. 10). Bone fill in the defect was confirmed
with a radiographic examination at 6 months, then the
bone fill was stable at 18 months after the procedure
(Figs. 11–12).
Clinical Advances in Periodontics, Vol. 00, No. 0, xxx 2020 3
C A S E R E P O R T

FIGURE 9 Six months follow-up after the surgical procedure. The

gingival recession reduced to 0.5 mm from 3 mm.

FIGURE 11 Six months post-operative vertical bitewing demonstrated

the bone fill in the area.

FIGURE 10 Eighteen months after the procedure showed soft tissue

maturations and reduction of gingival recession. PD remained 4 mm
without bleeding on probing (BOP).

Discussion
This case report demonstrates the efficacy and safety
of application of ACM along the root surface in the
treatment of an intrabony defect. Earlier studies have
investigated the biological properties of ACM, and the
results revealed that ACM retains platelet-derived growth
factor-AA (PDGF-AA), PDGF-BB, transforming growth
factor α (TGF- α), TGF-β, fibroblast growth factor (FGF),
epidermal growth factor (EGF). and IL-4, 6, 8, and 10,
and tissue inhibitors of metalloproteinases (TIMPs) which
enhances cell proliferation, angiogenesis, inflammation, FIGURE 12 Eighteen months (1.5 years) post-surgical radiographs
showed the stability of bone level following over time. (Exemplary Figure).
metalloproteinase activity, and recruitment of progenitor
cells.10,11 The resorption time of ACM is ≈ 8 to 12 weeks
once fully covered with a flap. However, the time point group. The authors stated that the high concentrations of
and the peak of the growth factor release from ACM laminin-5 in the ACM, with its high affinity for gingival
during the resorption are not fully understood. epithelial cells, could accelerate healing and integration
Kiany and Moloudi14 reported results of a randomized of the membrane with gingival tissue, thereby minimizing
clinical trial comparing the ACM with deproteinized post-operative recession. In addition, one of the major
bovine bone mineral (DBBM) versus a collagen membrane advantages of ACM compared to other resorbable mem-
(CM) with DBBM for the treatment of intrabony defects. branes is its thinness (≈320μm) and good adaptability.
Both groups showed improvement of clinical periodontal Because the mechanical property of ACM for space
parameters. Post-operative gingival recession showed a maintenance may not be preferable for non-containable
significant increase in the CM group but not in the ACM defects, FDBA was utilized with a combination of ACM

4 Clinical Advances in Periodontics, Vol. 00, No. 0, xxx 2020 Regeneration with Amnion Chorion membrane
 C A S E R E P O R T

instead of demineralized freeze-dried bone allograft
(DFDBA).15 We hypothesized that the application of the
ACM directly along the root surface within a periodontal
defect has the potential to enhance healing because of
release of growth factors within the healing wound in
addition to its use as a barrier membrane. In the present
case report, significant defect resolution and radiographic
bone fill was seen at 6 months and remained stable up to
18 months. Additionally, the 3 mm of gingival recession
that was noted 2 months post-surgically decreased to 0.5
mm at 6 months by soft tissue maturation and coronal
migration. Based on the authors’ knowledge, this case is
the first to illustrate this phenomenon in a regenerative
procedure around natural tooth with the combination
of FDBA and ACM. The biological properties of this
material are probably contributing the soft tissue
attachment and maturation as additional benefits to
the conventional GTR procedures. The ACM membrane
was used for two purposes, one as potential reservoir
for growth factor release and secondly as a barrier
membrane as a cost-effective measure for the treatment
of intrabony defects. Well design randomized clinical trial
will be needed to confirm the favorable outcomes in this
case.

Summary
Why is this case new  This case report demonstrated that the application of ACM on the root
information? surface with a combination of bone substitute contributed to the
radiographic bone fill and the clinical attachment level gain and minimize
the risk of post-operative gingival recession.

What are the keys to successful  Patient systemic condition and local factors including non-smoker, good
management of this case? compliance for maintenance protocol, and thick gingival tissue around
the site contributed to the favorable outcomes

What are the primary limitations  Because of the lack of the biopsy and histological analysis, the healing
to success in this case? pattern of the periodontal apparatus such as periodontal regeneration or
new attachment remains unknown.

7. Agarwal SK, Jhingran R, Bains VK, Srivastava R, Madan R, Rizvi I.

Acknowledgments
The ACM and FDBA utilized in this case report were
donated by Snoasis Medical LLC, Golden, CO, USA. Oth-
erwise, the authors do not have any conflicts of financial
interest to this case report.
CORRESPONDENCE
Yusuke Hamada DDS, MSD, Clinical Assistant Professor, Department of
Periodontology, Indiana University School of Dentistry, 1121 W Michigan
St, Rm 425, Indianapolis, IN, 46202.
E-mail: yuhamada@iupui.edu
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