P E R I O D O N T O LP O

E R
G IYO D O N T O L O G Y

New Regenerative Technologies:

Rationale and Potential for
Periodontal Regeneration: 1. New
Advances in Established
Regenerative Strategies
GASTON N. KING

growth factors, especially bone

Abstract: Regenerative techniques have been clinically available for over a decade, but
morphogenetic proteins (BMPs) to
with limited success in promoting new bone, cementum and connective tissue attachment.
New understanding of the tissues involved in regeneration and of the materials used to stimulate progenitor cells responsible
promote regeneration have led to new advances. This is the first of two articles that for periodontal regeneration. The
discusses new regenerative technologies with respect to their rationale and potential for source of these cells within the PDL is
periodontal regeneration and focuses on root conditioning, bone grafts and bone of considerable importance in
substitutes, and guided tissue regeneration. understanding the events during
periodontal wound healing. This will
Dent Update 2001; 28: 7-12 be discussed in the second part with
Clinical Relevance: The clinician needs to be aware of the new advances in respect to their potential for
established regenerative strategies. manipulation to promote regeneration.

ROOT CONDITIONING

D estructive periodontal disease

results in the loss of supporting
structures surrounding teeth including
alveolar bone, cementum and
periodontal ligament (PDL). A major
limitation of current methods of the
treatment of periodontal disease is the
difficulty in promoting regeneration of
these lost supporting structures. Wound
healing generally follows that of repair
with reduction in inflammation, the
rapid formation of a long junctional
epithelial attachment along root planed
surfaces, followed by granulation tissue
formation with its organization to a
mature collagen matrix. The formation
Gaston N. King BDS (NZ), MDSc (Melb.),
PhD (Lond.), Senior Lecturer in
Periodontology, Specialist in Periodontics,
Adult Oral Health, St Bartholomew’s and the
Royal London School of Medicine and
Dentistry, Turner Street, London E1 2AD.
of a long junctional epithelial
attachment prevents perpendicular fibre
attachment along the root surface.
Occasionally, new growth of bone,
cementum and connective tissue
occurs, although this is minimal,
unpredictable and limited to the apical
aspects in human intrabony defects.
Methods which have been advocated
for promoting periodontal regeneration
have included: guided tissue
regenerative procedures using barrier
membranes (Figures 1 and 2), the use
of bone grafting materials and
demineralization of the affected root
surface by acid conditioning (Figure 3).
However, clinical trials show these
techniques are limited in their ability to
promote regeneration. This review (the
first of two parts) will discuss the new
advances in established therapeutic
regenerative modalities. Considerable
interest is also shown in the use of
The rationale for root surface
conditioning agents is to create a
substrate which would favour
regeneration by inhibiting epithelial
downgrowth and promoting attachment
of PDL cells to the root surface.1
Conditioning may expose proteins
isolated from the root surface such as
cementum attachment protein and bone
morphogenetic proteins (BMP) and
these may be important in promoting
cellular differentiation. Most of the
conditioning agents that have been
evaluated are acids, the most common
of which are citric and phosphoric
acids, and tetracycline hydrochloride.2-4
Acid conditioning in primates and its
use in controlled human clinical trials
indicate it has little additional effect
over root planing alone in promoting
new attachment.5,6 Root conditioning is
often advocated in the treatment of root
surfaces prior to gingival augmentation

Dental Update – January/February 2001 7

 P E R I O D O N T O L O G Y

increased BMP-2-induced cementum

a c formation compared with non-acid
conditioned root surfaces, suggesting
that root conditioning may increase
retention of BMPs.11

BONE GRAFTS AND BONE

SUBSTITUTES
The rationale for the use of bone grafts
b d
is that they will stimulate new bone
primarily via two mechanisms:
osteoconduction, serving as a scaffold
for new bone formation or
osteoinduction by actively stimulating
the de novo synthesis of bone.

Figure 1. (a) Diagram showing periodontal destruction resulting in loss of connective tissue
Autogenous Grafts
attachment. The technique of guided tissue regeneration incorporates a barrier membrane Autogenous bone is the most effective
under the replaced flap. The large arrows represent movement of cells from the adjacent bone graft material that promotes new bone
and periodontal ligament into the wound space to form new bone, new cementum and new formation in intrabony periodontal
connective tissue. (b) Clinical example of a barrier membrane (nonresorbable ePTFE
membrane) covering a large disto-buccal defect of /7 prior to flap closure. defects and in alveolar ridge
(c) Preoperative periapical radiograph showing large distal defect of tooth 7/ (see arrows). augmentation procedures (Figure 4).
Clinically the probing depth is 9 mm. (d) Two-year postoperative periapical radiograph of (c) Autogenous bone may be harvested
showing an excellent result (clinically 4 mm probing depth) with new bone fill following guided intraorally from alveolar bone adjacent
tissue regeneration. to edentulous sites, chin or retromolar
region. Whilst autogenous bone has
been well documented in intrabony
by coronal and lateral repositioning and monkeys by selective exposure of the defects with equivocal results, the newer
free or connective tissue grafting collagenous fibrillar network.8 techniques of harvesting cortical bone
techniques (Figure 3). However, there However, a clinical study designed to from chin or retromolar region leads to
is little evidence to suggest that root evaluate the effect of root surfaces predictable alveolar ridge augmentation
conditioning enhances root coverage conditioned with EDTA at neutral pH (cf. Figure 4a and 4b). The demand for
following gingival augmentation during periodontal surgery found no ridge augmentation procedures has risen
procedures. Predictable root coverage differences with the unconditioned considerably in recent years prior to
relies more on clinical diagnosis and controls 6 months postoperatively.9 dental implant placement.
technique rather than the use of Therefore, the relevance of EDTA root Bone block grafts provide viable
conditioning agents. Moreover, recent conditioning in routine periodontal osteogenic cells to the donor site. The
studies suggest that the low pH surgery remains questionable. use of vital bone grafts in periodontal
denatures the dentinal collagenous Taken together, the application of therapy and alveolar ridge
matrix and injures the PDL cells and conditioning agents in humans to augmentation procedures derives from
their progenitors by reducing their promote connective tissue attachment the assumption that bone possesses
ability to migrate and differentiate.7 If is not supported by clinical studies. progenitor cells which have the
root conditioning agents with low pH Recently, root conditioning has been potential to form new bone and new
are used clinically then it is good suggested to enhance the binding of attachment apparatus. In addition, the
clinical practice to use a viscous agent growth factors and biologically active substance of the material may provide a
that remains in contact with the root substances. This is supported by structural support for matrix
surface without interfering with the observations in an animal model deposition. Its bulk maintains space
remaining viable periodontal ligament. where a radiolabelled epidermal between the underlying bone and
Rather than etching root surfaces growth factor applied to etched root overlying mucoperiosteal flap.
with agents operating at low pH, the surfaces was present 8 days after
use of a chelating agent such as application.10 Furthermore, the
ethylenediaminetetraacetic acid application of BMP-2 to acid Allografts
(EDTA) at neutral pH has been conditioned root surfaces in a rat model Major drawbacks with the use of
reported to improve healing in of periodontal regeneration showed autogenous grafts are the need for a

8 Dental Update – January/February 2001


a b
c
second surgical site and the lack of
intraoral donor sites. The commercial
availability of human bone as a
substitute for autogenous bone has been
widely used in periodontal defects. The
rationale for the use of cadaveric bone
which is decalcified and freeze-dried
relies on the presence of naturally
occurring biological growth factors
residing within the material which are
able to regulate cell proliferation,
differentiation and migration. However,
its ability to stimulate new bone
formation is inherently unpredictable
owing to the variation in residual BMP
content after preparation. Bone
harvested from younger individuals is
known to have greater amounts of
endogenous BMPs than older
individuals.12 Furthermore, recent
studies have questioned the efficacy of
this allograft. Extraction sockets grafted
with demineralized freeze-dried bone
allografts (DFDBA) healed with non-
vital bone fragments and connective
tissue while autologous bone healed
with woven lamellar bone.13 Other
studies report similar observations when
DFDBA was implanted into muscle
tissue in athymic mice.14 Recently,
various commercial preparations of
DFDBA have been compared with a
new preparation of DFDBA
incorporated in a collagen sponge when
placed in murine muscle.15 No bone
Dental Update – January/February 2001
P E R I O D O N T O L O G Y
macrophage response.18 Preparatory
techniques also may have a significant
effect on the bioavailability and
bioactivity of the bone inductive
proteins, such as the BMPs.19
The risk of disease transmission of
DFDBA is minimized by the processes of
demineralizing, freeze-drying, irradation
and ethylene oxide treatment.18 However,
with the discovery of new viral antigens
such as Hepatitis C, D and E, the human
Figure 2. (a) Preoperative view of recession immunodeficiency virus, as well as non-
defect /3 prior to GTR therapy using a viral but infectious prion proteins,
resorbable membrane. (b) Treatment view
disease transmission nevertheless
of resorbable membrane (impregnated with
blood) sutured in place overlying the /3. (c) remains a potentially serious risk.
Two-year postoperative view of /3 showing Patient awareness about disease transfer
nearly 100% root coverage. is increasing and patients are now
demanding more stringent controls and
assurances. This is likely to result in a
move away from allografts to alloplasts
or synthetic substitutes.
induction was observed with any of the
DFDBA tested, thus questioning the
value of its use in clinical periodontics. Alloplasts
Morphological characteristics of the Alloplasts are inorganic materials and
defect rather than the allograft have therefore have potential advantages over
been suggested to influence treatment allografts. Alloplasts for periodontal
outcome.16 Other investigators, however, applications include the use of synthetic
have failed to find a relationship hydroxyapatite, tricalcium phosphate
between the type of defect and its and bioactive glass (Perio-Glas®, US
regenerative potential with the use of Biomaterials Corp, USA; Biogran®,
allografts.17 These differences may stem Orthovita Inc, USA). None of these
from the characteristics of the bone graft substitutes has been shown to be better
itself, such as the particle size, shape than autogenous bone.
and roughness. Smaller particles in the Synthetic hydroxyapatites have a
100–300 micron range form more bone different microstructure and crystal size
than 1–2 mm particles, whilst the than found in natural bone.20 No
optimum range is 250–800 microns. carbonate ions are present in synthetic
Particles less than 125 microns are hydroxyapatite. Therefore, unlike
ineffective since they induce a natural hydroxyapatite, no substitution
a b
Figure 3. (a) Root conditioning prior to gingival augmentation. Preoperative view of advanced
gingival recession with Class V restorations in 3/, 4/, 5/ and 6/.
(b) Two-year postoperative view of 3/, 4/ and 5/ treated with a root conditioning agent
(tetracycline hydrochloride) and a coronally repositioned flap. Note, the Class V restorations
have been removed and >95% root coverage is evident.
9
 P E R I O D O N T O L O G Y
a c
b d
Figure 4. (a) Alveolar ridge resorption over 1/ (arrow) (b) Postoperative view of (a) showing
successful alveolar ridge augmentation procedure prior to implant placement. (c) Flap elevation
to expose the alveolar defect over 1/ and placement of bone graft (arrow) from the retromolar
region screwed in place. (d) Re-entry 6 months later showing augmentation of ridge by the graft
(large arrow) and removal of bone screw (small arrow). Sufficient bone width is available to
place an implant successfully.
of this ion for phosphate occurs. In
addition, the synthetic hydroxyapatite
crystal structure is larger. This may be
the reason why the material appears
non-resorbable and tends to become
encapsulated by fibrous matrix with
little evidence of any regeneration.21
Another alloplast is tricalcium
phosphate. It is slowly resorbed and
replaced by osseous tissue but its use
has not been reported with much
success.22 Recently, the development of
biphasic calcium phosphate ceramic
(an association of hydroxyapatite and
b-tricalcium phosphate granules 200–
500 microns in diameter) in an
injectable hydrophilic cellulose carrier
appears to improve its replacement by
normal bone. Preliminary studies in
fresh extraction sockets show a similar
bone mineralized phase to normal
bone, without a fibrous interface
between the granules and bone.23
However, the use of this material
produced no significant differences in
alveolar ridge height of the extraction
sockets when compared with controls.
Bioactive glass (Perio-Glas®) is
composed of 90–700 micron
amorphous non-crystalline 45% silica
10
particles. The bioactivity of the glass
particle is based on formation of a
Si(OH)2 gel on the particle surface
which permits a calcium phosphate
precipitate layer to form. This creates a
surface which is conducive for
osteoblasts to initiate the
mineralization process. Whilst several
reports suggest it promotes greater
bone formation compared with DFDBA
or open debridement,24–26 there is no
evidence that Perio-Glas® may
predictably stimulate the formation of
new cementum with inserting collagen
fibres.
Xenografts
Another commercial product available
for clinical application as a bone graft
substitute is the naturally derived
deproteinized cancellous bovine bone
(Bio-Oss®, Geistlich Sohne AG,
Switzerland). Although it is a
xenograft, the risk analysis for disease
transmission, namely bovine
spongiform encephalopathies (BSE) is
negligible as it has had the organic
component extracted.27 It has been used
in a number of clinical settings
Dental Update – January/February 2001
including the treatment of periodontal
defects, alveolar bone augmentation
procedures and sinus lifts. Histological
studies show it is osteoconductive,
becomes incorporated in bone and
eventually follows the remodelling
process of normal bone.28 A recent
report suggests it is more effective than
Perio-Glas® in regenerating bone in
critical-sized defects.29 A case study
reported defects treated with Bio-Oss®
developed 69–85% new cementum
formation and this reached 100% with
the use of a resorbable barrier
membrane.30 No controls were used in
this case report. The staining protocol
to identify new cementum relied on
haematoxylin and eosin rather than a
stain which preferentially stains
collagen such as Van Gieson. This
more clearly enables identification of
the boundaries of the new cementum as
it stains the collagen within the
mineralized matrix. Moreover, the
histology in this study does not
conclusively distinguish between
existing undamaged coronal cementum
and the development of new cementum.
Mechanical removal of cementum
along the root surface appears
incomplete and confined to the region
adjacent to the apical aspect of the
bony defect. No evidence of new fibre
attachment is observed in this region.
Further histology is required in order to
substantiate the claims made by the
investigators that Bio-Oss® enhanced
new attachment formation.
Nevertheless, clinical results show a
significant effect can be achieved with
this material in appropriate defects by
reduced probing depths and promoting
radiographic bone fill. Furthermore,
excellent results have been achieved
using Bio-Oss® in alveolar ridge
augmentation procedures.
GUIDED TISSUE
REGENERATION
Regeneration of periodontal wounds
requires an orderly sequence of events
involving a variety of cell types and
their precursors to reconstitute the lost
supporting structures of the
periodontium. The cell types involved

in this process include junctional and
oral epithelial cells, fibroblasts,
endothelial cells, osteoblasts, and
cementoblasts. In the 1980s, the
technique of guided tissue
regeneration (GTR) was developed for
clinical use following animal studies.
This technique involves placing a
resorbable or non-resorbable
membrane below a surgically raised
flap to prevent collapse of the
overlying flap into the defect as well
as epithelial downgrowth into the
wound, thus promoting wound
repopulation by cells of the PDL and
bone (Figure 1a). The principle of
GTR can also be used to treat isolated
gingival recession defects (Figure 2)
and augment alveolar ridges using
barrier membrane to create a space
between the bone and overlying
mucosa favouring bone forming into
the void. Alveolar ridge augmentation
procedures using barrier membranes is
called guided bone regeneration
(GBR). Though they are technically
demanding, predictable results can be
achieved. Fundamental differences
between GBR and GTR are that the
former relies on the augmentation of
one tissue phenotype and is not
contiguous with the oral environment.
Clinical Studies
Despite the encouraging results in
animal studies, recent clinical results
have shown equivocal results in
promoting periodontal regeneration.
Whilst some favourable results have
been reported using either resorbable
(cf. Figure 2a and 2c) and non-
resorbable membranes (cf. Figure 1c
and 1d),31 other investigators have
found no differences between GTR-
treated sites and controls.32–34 A meta-
analysis report covering both case
reports and controlled studies showed
an increased average attachment gain
with the use of GTR compared with
open flap debridement.35 However, the
authors concluded that few
comparative studies are available to
suggest the benefit of GTR over
conventional periodontal surgery in
the treatment of intrabony defects. The
Dental Update – January/February 2001
P E R I O D O N T O L O G Y
limitations of GTR become much
more apparent in furcation involved
teeth and one-walled and two-walled
defects.
Factors affecting treatment outcome
include defect depth and morphology,
amount of remaining viable PDL
tissue, wound stability and bacterial
contamination of the membrane.16,36 In
addition, patient factors such as
plaque control37 and smoking38 also
play a signficant role in treatment
outcome. Recently, it was suggested
that defect morphology is the major
factor influencing treatment outcome
following GTR and the intrabony
defect has to be at least 4 mm deep to
benefit from the procedure.35,39 In
contrast, in a controlled study where
all subjects had ≥4 mm intraosseous
defects, no significant differences
were observed between GTR and
conventional flap surgery treated
sites.34 Further controlled studies are
required to determine which of the
factors affecting treatment outcome
should be weighted toward treatment
success or failure. This will require
larger studies comparing the clinical
outcome of defects using a split mouth
design with paired defects displaying
similar anatomy within the maxilla or
mandible, treated either with or
without membranes.
Histology
It is only recently that studies in vivo
have suggested that the composition
and structure of new tissues achieved
during GTR procedures may be
different from the original tissue,
indicating that true regeneration
representing replacement of lost
original architecture has not occurred.
Characteristics of the new cementum
formation indicate it is of variable
thickness,40 cellular41 and has no
peripheral hyaline layer between the
cementum and the instrumented
surface.42 Cementum formation during
GTR procedures appears to follow two
distinct patterns.43 One pattern shows
collagen fibrils oriented predominantly
perpendicular to the root surface that
gradually mineralize, thus resembling
acellular extrinsic fibre cementum.
Another pattern of cementogenesis
involves the accumulation of parallel
fibres running axially and
circumferentially, occasionally
embedding cementocytes during
mineralization, and resembling
cellular mixed stratifed cementum.
Although some similarity with
developmental cementum formation is
evident with these two types of
regenerative cementum, both types
lack the interdigitation of collagen
fibrils to the underlying dentine as
seen normally along the cemento-
dentinal junction. This interdigitation
occurs during root formation prior to
mineralization when the collagen
fibrils merge with the predentine layer.
Therefore, root conditioning has been
advocated as it encourages
regeneration by unmasking the fibrils
promoting a connective tissue fibre
attachment with the root surface. This
is supported by the elimination of
artefactual tearing of the newly
formed cementum from the previously
denuded root dentine during
histological preparation.44 It also
eliminates the electron-dense band.42
Whether this artefactual space is a
consequence of a tissue processing
phenomenon rather than highlighting a
weak link between the new cementum
and dentine remains speculative. The
lack of a natural attachment interfering
with the supportive function of the
periodontium also remains to be
determined.
In summary, whilst it is clear that
GTR and bone grafts have limited
potential in periodontal defects,
advocates for their use continue to
focus on the importance of case
selection and patients with optimal
plaque control. Under these criteria
the patient presumably will respond
favourably even to conventional flap
procedures alone. No ideal graft
material is available and little if any
interradicular supracrestal bone
regeneration is possible with the use
of grafts or barrier membranes. One
way forward may be the application of
an appropriate growth factor that will
stimulate the progenitor cells within
11
 P E R I O D O N T O L O G Y
the periodontium. To do so will
require an understanding of how these
factors modulate the normal processes
of wound healing and this will be
discussed in Part 2.
REFERENCES
1. Lowenguth RA, Blieden TM. Periodontal
regeneration: root surface demineralization.
Periodontology 2000 1993; 1: 54–68.
2. Polson AM, Proye MP. Effect of root surface
alterations on periodontal healing. II. Citric acid
treatment of the denuded root. J Clin
Periodontol 1982; 9(6): 441–454.
3. Heritier M. Effects of phosphoric acid on root
dentin surface. A scanning and transmission
electron microscopic study. J Periodont Res
1984; 19: 168–176.
4. Wikesjo UM, Claffey N, Christersson LA et al.
Repair of periodontal furcation defects in
beagle dogs following reconstructive surgery
including root surface demineralization with
tetracycline hydrochloride and topical
fibronectin application. J Clin Periodontol 1988;
15(1): 73–80.
5. Moore JA, Ashley FP, Waterman CA. The effect
of healing of the application of citric acid
during replaced flap surgery. J Clin Periodontol
1987; 14: 130–135.
6. Fuentes P, Garrett S, Nilveus R, Egelberg J.
Treatment of periodontal furcation defects.
Coronally positioned flap with or without
citric acid root conditioning in class II defects. J
Clin Periodontol 1993; 20(6): 425–430.
7. Blomlof J, Lindskog S. Periodontal tissue-vitality
after different etching modalities. J Clin
Periodontol 1995; 22(6): 464–468.
8. Blomlof J, Jansson L, Blomlof L, Lindskog S.
Root surface etching at neutral pH promotes
periodontal healing. J Clin Periodontol 1996;
23(1): 50–55.
9. Mayfield L, Soderholm G, Norderyd O,
Attstrom R. Root conditioning using EDTA gel
as an adjunct to surgical therapy for the
treatment of intraosseous periodontal defects. J
Clin Periodontol 1998; 25: 707–714.
10. Cho MI, Lin WL, Garant PR. Occurrence of
epidermal growth factor-binding sites during
differentiation of cementoblasts and periodontal
ligament fibroblasts of the young rat: a light and
electron microscopic radioautographic study.
Anat Rec 1991; 231(1): 14–24.
11. King GN, King N, Hughes FJ. The effect of root
surface demineralization on bone
morphogenetic protein-2-induced healing of
rat periodontal fenestration defects. J
Periodontol 1998; 69(5): 561–570.
12. Schwartz Z, Somers A, Mellonig JT et al. Ability
of commercial demineralized freeze-dried bone
allograft to induce new bone formation is
dependent on donor age but not gender. J
Periodontol 1998; 69(4): 470–478.
13. Becker W, Becker BE, Caffesse R. A comparison
of demineralized freeze-dried bone and
autologous bone to induce bone formation in
human extraction sockets. J Periodontol 1994;
65(12): 1128–1133.
12
14. Becker W, Urist MR, Tucker LM, Becker BE,
Ochsenbein C. Human demineralized freeze-
dried bone: inadequate induced bone formation
in athymic mice. A preliminary report. J
Periodontol 1995; 66(9): 822–828.
15. Garraway R, Young WG, Daley T, Harbrow D,
Bartold PM. An assessment of the
osteoinductive potential of commercial
demineralized freeze-dried bone in the murine
thigh muscle implantation model. J Periodontol
1998; 69(12): 1325–1336.
16. Steffensen B, Webert HP. Relationship between
the radiographic periodontal defect angle and
healing after treatment. J Periodontol 1989;
60(5): 248–254.
17. Renvert S, Garrett S, Nilveus R, Chamberlain
AD, Egelberg J. Healing after treatment of
periodontal intraosseous defects. VI. Factors
influencing the healing response. J Clin
Periodontol 1985; 12(9): 707–715.
18. Brunsvold MA, Mellonig JT. Bone grafts and
periodontal regeneration. Periodontology 2000
1993; 1: 80–91.
19. Urist MR, Chang JJ, Lietze A, Huo YK, Brownell
AG, DeLange RJ. Preparation and bioassay of
bone morphogenetic protein and polypeptide
fragments. Methods Enzymol 1987; 146: 294–
312.
20. Rey C. Calcium phosphate biomaterials and
bone mineral. Differences in composition,
structures and properties. Biomaterials 1990;
11: 13–15.
21. Froum SJ, Kushner L, Scopp IW, Stahl SS. Human
clinical and histologic responses to Durapatite
implants in intraosseous lesions. Case reports. J
Periodontol 1982; 53(12): 719–725.
22. Stahl SS, Froum S. Histological evaluation of
human intraosseous healing responses to the
placement of tricalcium phosphate ceramic
implants. I. Three to eight months. J Periodontol
1986; 57(4): 211–217.
23. Gauthier O, Boix D, Grimandi G et al. A new
injectable calcium phosphate biomaterial for
immediate bone filling of extraction sockets: a
preliminary study in dogs. J Periodontol 1999;
70: 375–383.
24. Froum SJ, Weinberg MA, Tarnow D. Comparison
of bioactive glass synthetic bone graft particles
and open debridement in the treatment of
human periodontal defects. A clinical study. J
Periodontol 1998; 69(6): 698–709.
25. Lovelace TB, Mellonig JT, Meffert RM, Jones AA,
Nummikoski PV, Cochran DL. Clinical
evaluation of bioactive glass in the treatment of
periodontal osseous defects in humans. J
Periodontol 1998; 69(9): 1027–1035.
26. Anderegg CR, Alexander DC, Freidman M. A
bioactive glass particulate in the treatment of
molar furcation invasions. J Periodontol 1999; 70:
384–387.
27. Sogal A, Tofe AJ. Risk assessment of bovine
spongiform encephalopathy transmission
through bone graft material derived from
bovine bone used for dental applications. J
Periodontal 1999; 70: 1053–1063.
28. Hammerle CH, Olah AJ, Schmid J et al. The
biological effect of natural bone mineral on
bone neoformation on the rabbit skull. Clin Oral
Implants Res 1997; 8(3): 198–207.
29. Schmitt JM, Buck DC, Joh SP, Lynch SE, Hollinger
JO. Comparison of porous bone mineral and
Dental Update – January/February 2001
biologically active glass in critical-sized defects. J
Periodontol 1997; 68(11): 1043–1053.
30. Camelo M, Nevins ML, Schenk RK et al. Clinical,
radiographic, and histologic evaluation of
human periodontal defects treated with Bio-
Oss and Bio-Gide. Int J Periodont Rest Dent
1998; 18: 321–331.
31. Cortellini P, Pini Prato G, Tonetti MS.
Periodontal regeneration of human intrabony
defects with bioresorbable membranes. A
controlled clinical trial. J Periodontol 1996;
67(3): 217–223.
32. Pritlove-Carson S, Palmer RM, Floyd PD.
Evaluation of guided tissue regeneration in the
treatment of paired periodontal defects. Br
Dent J 1995; 179(10): 388–394.
33. Eickholz P, Benn DK, Staehle HJ. Radiographic
evaluation of bone regeneration following
periodontal surgery with or without
expanded polytetrafluoroethylene barriers. J
Periodontol 1996; 67(4): 379–385.
34. Mayfield L, Soderholm G, Hallstrom H et al.
Guided tissue regeneration for the treatment
of intraosseous defects using a biabsorbable
membrane. A controlled clinical study. J Clin
Periodontol 1998; 25(7): 585–595.
35. Laurell L, Gottlow J, Zybutz M, Persson R.
Treatment of intrabony defects by different
surgical procedures. A literature review. J
Periodontol 1998; 69(3): 303–313.
36. Trombelli L, Kim CK, Zimmerman GJ, Wikesjo
UM. Retrospective analysis of factors related
to clinical outcome of guided tissue
regeneration procedures in intrabony defects.
J Clin Periodontol 1997; 24(6): 366–371.
37. Weigel C, Bragger U, Hammerle CH, Mombelli
A, Lang NP. Maintenance of new attachment 1
and 4 years following guided tissue
regeneration (GTR). J Clin Periodontol 1995;
22(9): 661–669.
38. Cortellini P, Paolo G, Prato P, Tonetti MS.
Long-term stability of clinical attachment
following guided tissue regeneration and
conventional therapy. J Clin Periodontol 1996;
23(2): 106–111.
39. Cortellini P, Bowers GM. Periodontal
regeneration of intrabony defects: an
evidence-based treatment approach. Int J
Periodont Rest Dent 1995; 15(2): 128–145.
40. Gottlow J, Nyman S, Lindhe J, Karring T,
Wennström J. New attachment formation in
the human periodontium by guided tissue
regeneration. Case Reports. J Clin Periodontol
1986; 13: 604–616.
41. Araujo MG, Berglundh T, Lindhe J. On the
dynamics of periodontal tissue formation in
degree III furcation defects. An experimental
study in dogs. J Clin Periodontol 1997; 24(10):
738–746.
42. Schupbach P, Gaberthuel T, Lutz F, Guggenheim
B. Periodontal repair or regeneration:
structures of different types of new
attachment. J Periodont Res 1993; 28: 281–293.
43. Luder HU, Zappa U. Nature and attachment of
cementum formed under guided conditions in
human teeth. An electron microscopic study. J
Periodontol 1998; 69: 889–898.
44. Cole RT, Crigger M, Bogle G, Egelberg J, Selvig
KA. Connective tissue regeneration to
periodontally diseased teeth. A histological
study. J Periodont Res 1980; 15: 1–9.