New attachment formation in the Jan Gottlow*, Sture Nyman*, Jan

Lindhe*, Thorkild Karring** and

Jan Wennstrom*

human periodontium by guided 'Department of Periodontoiogy, Facuity of

Odontoiogy, University of Gothenburg, Box
33070, S-400 33 Gothenburg, Sweden
"Department of Periodontology, Royal Dental

tissue regeneration Coiiege, DK 8000 Aarhus, Denmark

Case reports

Gottlow J, Nyman S, Lindhe J, Karring T and Wennstrom J: New attachment

formation in the human periodontium by guided tissue regetieration. J Clin Periodontol
1986: 13: 604-616.

Abstraet. The aim of the present study was to evaluate whether a regenerative
surgical procedure, based on«guided tissue regeneration, could predictably result
in the formation of a new attachment in hutnan teeth. The material included 12
teeth in 10 patients with advanced periodontal disease. Following fiajJ^elevation,
scaling, root planing and retnoval of granulation tissue, a teflon membrane was
placed over the denuded root surface in such a way that the epithelium and the
gingival connective tissue were prevented from reaching contact with the root
during healing. The fiap was replaced on the outer surface of the membrane and
secured with interdental sutures. This design of wound preparatiori givesprgfer-
ence to the cells originating frnm the pp.rjc>drmU\\hg-Arr\pnt (PDL-cells) to repopulate
the wound area adjacent to the root. Histologic~ahalysis"7)lThe resiiTrof treatment
was made in 5 of the 12 teeth scheduled for extraction. In the remaining 7 teeth,
the result was evaluated using clinical measurements. The result of healing dis-
closed that in al! teeth treated, substantial amounts of new attachtnent had Key words: New attachment - periodontal
formed. This suggests that prei!ictahle_xestitt4tion of the attachtnent apparatus ligament - periodontai wound heaiing - tissue
specificity.
can be accomplished by using a method of treatment which is based on the
principle of guided tissue regeneration. Accepted for publication 24 June 1985

Previous studies in dogs and monkeys
from our laboratories have revealed
that the cells, which, during healing fol-
lowing periodontal therapy, repopulate
the wound area adjacent to the root
surface, determine the quality of the
newly fonned tissue in the hard-soft tis-
sue interface of the periodontium (Kar-
ring et al. 1980, 1984, Nyman et al.
1980, Gottlow et al. 1984a,b, Isidor et
al. 1986, Magnusson et al. 1985, Hou-
ston et al. 1985). The cells which re-
populate this area may originate from
any of the different tissue components
of the periodontium: the dentogingival
epithelium, the gingival contiective tis-
sue, the alveolar bone and the periodon-
tal ligament. The shape and size of the
wound (i.e., the distance between the
various tissue cotnponents in the peri-
phery of the wound and the root sur-
face) and the potential of the different
types of tissue cells to migrate, obvi-
ously determine the result of healing.
In the studies referred to above, root
resorption was found to occur when
granulation tissue derived from the gin-
gival connective tissue or the alveolar
bone was proliferating into contact with
the root surface, while re=e]3itjielja]iz-
ation of the surface prevented both con-
nective tissue attachtnent and root re-
sorption. In fact, the only cells which
seemed to have_tlie_capacity_tojorm a
new attachment were cells originatmg
from the periodontal ligament (PDL-
cells). Based on this knowledge of the
biological behaviour of the different
periodontal tissues during_wouridJieal-
ing, the principle of guided tissue regen-
eration was introduced and tested. A
method was developed by which peri-
odontal ligament cells exclusively were
allowed to repopulate^the root surface
after periodontal therapy (Nyman et al.
1982a, Gottlow et al. 1984b). A mem-
brane (Millipore* filter, Millipore S.A.
Molsheitn, France, or Gore-tex® mem-
brane, W.L. Gore and Ass. Inc., Flag-
staff, Arizona, USA) was placed over
the denuded root surface in such a way
that all periodontal tissues except the
PDL-cells were prevented from
reaching contact with the root. Heahng
resulted in extensive atnounts of new
connective tissue attachment, i.e., the
formation of new cementum with insert-
ing collagen fibers, a finding which sug-
gested that the principle of guided tissue
regeneration could be a solution of the
problem of how to predictably produce
a new attachment apparatus.
A pilot experiment was carried out in
one human tooth with a long-standing
periodontal lesion using the method de-
scribed for guided tissue regeneration
(Nyman et al. 1982b). Histological
analysis after 3 months of healing dis-
closed that 7 mm of new connective tis-
sue attachment had formed on the root
surface where the attachment loss be-
fore treatment amounted to 11 mtn. The
finding from this experitnent prompted
the initiation of a more extensive series
of experiments in hutnans, the objective

of which was to assess how predictably
new attachment may fortn when treat-
ment included guided tissue regener-
ation (GTR).
Material and Methods
The material of the present study in-
cluded 12 teeth in 10 patients who were
referred to the Department of Periodon-
toiogy, University of Gothenburg, for
treatment of advanced periodoiital dis-
ease. The comprehensive treattnent plan
for the patients called for the extraction
of 5 of the 12 teeth included in this
study. After the patients had signed the
informed consent forms, 4 out of these
5 teeth were treated with the GTR tech-
nique in conjunction with traditional
flap surgery of neighbouring tooth re-
gions. 1 tooth was treated without the
GTR technique. Following healing, the
experimental teeth were extracted and
could thus provide tnaterial for histo-
logical analysis of the result of healing.
The remaining 7 teeth were all treated
with the GTR method but following
healing, were retained in good function.
The result of healing in these teeth was
evaluated using clinical measurements.
Experimental procedure
Prior to surgery, the probing attach-
ment level (PAL) was determined at the
site (surface) to be subjected to regener-
ative therapy. In molar areas exhibiting
furcation involvements, PAL was meas-
ured both in the vertical (at the entrance
to the furcation) and horizontal direc-
tions into the furcation. The vertical
measurements were made from a fixed
landmark on the tooth (CEJ or from
the margin of., a restoration) and the
horizontal measurements frotn the
buccal/lingual surface of the tooth. The
measurements were rnade to the nearest
mm using a calibrated periodontal
probe; diarneter of the probe tip = 0.5
mm. Following intra-crevicular in-
cisions through the bottom of the pock-
ets, full thickness flaps were raised at
the buccal and lingual aspects of the
tooth. Epithelium and granulation tis-
sue on the inner surface of the flap were
removed with a pair of scissors. The
root surfaces were scaled and planed
using hand instruments and flame-
shaped diamond stones and remaining
granulation tissue was removed. No oss-
eous recontouring was carried out. The
level of the alveolar bone crest (PB) and
the apical extension of angular bony de-
attachment in the human periodontium 605
fects were assessed with the calibrated healing, a final exatnination was made
probe at the satne location points as including tneasurements of the probing
used for the PAL tneasurernents. The attachtnent level.
horizontal measurements into furcation During a 3-week period following
areas were made with the probe placed GTR surgery, the patients rinsed the
on the buccal/litigual bone crest. tnouth twice daily with a 0.2% chlor-
A teflon membrane (Gore-tex®, W.L. hexidine digluconate solution. Mechan-
Gore and Ass. Inc., Flagstaff, Arizona, ical plaque control was initiated when
USA) was adjusted to cover the root the sutures were removed, i.e., 10 days
surface from a level around 5 rntm apical after surgery.
to the bone crest to a level approaching
the CEJ. The membrane was retained
in this position and the tnucoperiosteal
flaps were placed on the outer surface
of the membrane and secured with inter-
dental sutures in such a way that the
coronal border of the tnetnbrane was
consistently located around 1-2 tnm
coronal to the flap margin. This wound
preparation was designed to prevent the
oral epithelium atid the gingival connec-
tive tissue ftotn reaching contact with
the root during healing. The sutures
were removed 10 days after surgery.
After 3 tnonths of healing, the 5 teeth
which initially had been scheduled for
extraction were retnoved together with
surrounding periodontal tissues. The bi-
opsies were fixed in 10% buffered for-
malin, decalcified in EDTA and embed-
ded in paraffin. Serial sections, 8 /an
thick, were cut parallel to the long axis
of the tooth. The sections were stained
with hematoxylitie and eosin. Van Gie-
son's or Mallory's connective tissue
stain and were analyzed tnicroscopically
( X 40). The amount of new attachment,
i.e., the linear distance frotn the apical
extension of root-planed surface (aRP)
to the coronal level of newly fortned
cementum with inserting collagen fibers
(C), was assessed in 5 sections, 80 iim
apart, obtained frotn the central portion
of each experimental root.
In the group of 7 teeth which were
scheduled to be retained, a second surgi-
cal procedure was carried out after 3
months of healing. Thus, an incision,
placed 2-3 mtn from the gingival mar-
gin, was made through the gingiva to
expose the tnetnbrane. The wound edges
on each side of the incision were elev-
ated and the tnembrane was dissected
and removed. Parts of the underlying
soft tissue which, by probing, was found
to be non-attached tQ the root surface,
were excised with a scalpel. The level of
the alveolar bone crest and the apical
extension of angular defects were deter-
mined by probing as described above.
The iticisional wound was closed with
sutures which were removed after 10
days. After another 3-tnotith period of
606 Gottlow, Nyman, Lindhe, Karring and Wennstrom

Results
Histological analysis of regeneration in tiie extracted teeth
CASE: No. 1. (Male. 54 years) A
H: 47 Lingual furcation "

2 -

4 -

8 -
PAL PB
rt. INITIAL

7. Male, 54 years of age (Figs. A-G). The clinical status of the lingual
furcation area of tooth 47 after flap elevation is shown in B. Initial probing
attachment level (PAL) and bone level (PB) in the vertical as well as horizontal
directions are presented in A. The membrane was placed to cover the lingual root
surfaces and the entrance to the interradicular area and the flap was repositioned
and secured with sutures (C). Following a heahng period of 3 months, a soft tissue,
attached to the root, covered the lingual root surfaces including the entrance to
the furcation (D). The furcation defect could not be identified by probing. Mesio-
distal sections from the lingual portion of the furcation showed that the entire
circumference of this area was covered by newly formed cementum (F). The
dehneated areas in F are shown in higher magnification in E and G. Heahng had
resulted in complete closure of the furcation defect.
 607

CASE: No. 2. (Male, 38 years) CASE: No. 2. (Male, 38 years) Q

TOOTH: 36 Mesial root, distal surface TOOTH: 37 Furcation
Control vkfithout membrane

'Through-and-through'
involvement 'Through-and-through'
Invoivement

2-
2 -
4-
4 -
6 -
6 -
8-
PAL PB 8 -
im
INITIAL mm
PAL PB
ve rt. INITIAL

Case 2. Male 38 years of age (Figs. A-G). The lower left

molars (36 and 37) exhibited »through-and-through« fur-
cation involvement (Figs. A, B and C). In tooth 36, the
distance from CEJ to the alveolar bone crest at the buccal
entrance to the furcation area was 7 mm. A similar degree
of bone loss was also noted at the buccal aspect of tooth
37 and at the lingual furcation entrance of both teeth.
Identical surgical procedures were performed around both
teeth with the exception that membranes were placed only
at 36. In this tooth, membranes were placed both at the
buccal and lingual aspects of the roots. After healing, tooth
37 was extracted and tooth 36 was hemisected and the
mesial root removed. The histological mid-section of the
distal surface of this root is shown in D with delineated
areas in higher magnification in E and F. The length of
newly formed cementum with inserting collagen fibers is 2.8
mm. Epithelium is present in the coronal portion of the
root. The histologieal analysis of tooth 37 (G) disclosed
an epithelialized furcation area without any signs of new
attachment formation. ... , ^,, -. r. .