The Internationai Journai ot Periodontics & Restorative Dentistry

589

The Simplified Papilla Preservation

Flap. A Novel Surgical Approach for
the Management of Soft Tissues in
Regenerative Procedures

Pierpaolo CorfeHini. MD. DMD'/Giovanpaolo Pini Prato. MD, DMD"/ Treatment of deep intrabony
Maurizio $. Toneffl DMD. PhD. MSc' defects with guided tissue regen-
erotion (GTR) hos been reported
to prediotobiy resuit in significant
A novel surgical procedure speaHcaily designed to access interdenfai
amounts of ciinical ottachment
spaces in the regenerative treatment of deep intrabony defects is present-
ond bone gains at 1 year (for
ed. This procedure (simpiified papiHa preservation flap. SPPF) was designed to
review seeTonetti and Corteliini^.
provide surgical access to interproximoi bony defects while preserving inter-
A great variabiiity in oiinioai aut-
dental soft tissues, even in narrow interdental spaces and posterior teeth. A
comes, however, is evident
modified mattress suture aliaws coranai positianing of the buccol tlop ond
among the different studies. This
primary closure af the interdental space without tension. The modified mat-
tress suture minimizes ti-\e coliapse of the membrane into the defect An voriability couid be dependent
experimental papulaticn af 18 patients in good generoi heaith whc present- on the insufficient controi of a
ed wUh one intrabony defect each was seiected for ttiis clinicai study. The series of factors associafed wifh
application of the SPPF in combination with bioresorbable membranes fhe patient, the defect, the
resulted in clínica! attachment ieve! (CAL) gains of 4.9 ± 1.8 mm at 1 yearThe empioyed surgioai technique,
difference between baseline CAL and ? year CAL wos highly clinically and and the healing period, aii of
statistically significant. Tiie residual poci<ets at 1 year measured 3.6 ± i.2mm. which aftect ciinicai out-
A slight increase in gingivai recession was noted. Primary closure of the flap in comes,^"''
the interdental space over the membrane was obtained in 100% of the
One of the major probiems in
cases after compietion ot surgery and maintained in 67% of the cases during
the GTR treotment of intrabony
the healing period. The appiication of SPPF in combination with biore-
defects is the surgical manage-
sorbable barrier membranes aiiowed primary closure of the interdentai
ment of the tissues in the detect-
space in most of the treated sites and resuited in consistent CAL gains at I
associated interdentoi spaoe. in
year, (int J Periodontics Restorative Dent 1999:19:589-599.)
tact, iack of primory ciosure of the
interdental space, tlop dehis-
cence. or membrane exposure
reportedly occurs in 70% tc 80% of
'Professor, Deportment of Period ontology and Fixed Prosttiodontics,
cases.'"'^ Exposed membranes
School of Dental Medicine, Univeisify of Bern, Switzerland.
'Professor, Dental Schooi, University of Florence, itoly. are contaminated with bacte-
ria,'^"'^ and such exposures have
Reprinf requests: Dr Pierpaolo Corteliini, via Carlo Botta I ó, 1-50136 been associated wifh reduced
Firenze, Italy.

Voiume 19,Numberó,1999
590
amounts of clinical attachment
level (CAL) gains at 1 year. ' 2. ' 3, l s-16
It should be emphasized that
in the c i t e d ciinicai studies,
access flaps and suturing tech-
niques were not specificolly
designed to obtain and mointain
primary closure over the borrier
membranes. To overcome this
problem, new surgioal t e c h -
niques specifically designed for
appliootion with regenerative
procedures in the interproximal
area hove been recently devel-
oped ond tested. The modified
papilla preservation teohnique'''
resulted in a significant reduction
of the omount of membrone
exposures in the interdentol
space (27% of the 15 treated
coses). Furthermore, when there
was exposure its extent was lim-
ited. This teohnique was success-
tully performed in wide interden-
tal spaces in the anterior and
premolar region, while its appli-
cation in norrow ond/of poste-
rior interdentol spaces was
reported to be technioolly more
demanding and clinically less
successful. Another procedure
speoificolly designed for use with
barrier membranes Is the inter-
d e n t a l tissue m o i n t e n a n c e
approach.^" This resulted in a
mere 5% membrane exposure in
a populotion cf 12 treated intra-
bony defects. The outhor, how-
ever, suggests limiting application
of this surgiool flap fc maxillary
premolars with thick palotal tis-
sues o n d interdental spaces
wider thon 2 mm. Both reported
procedures incorporóte a high
The International Journal of Periodontics & Restorative Dentistry
degree of technical difñculty and
have specific clinioal indicotions.
Recently, a novel surgical
a p p r o a c h (simplified popilla
preservoticn flap, SPPF) was
designed in on attempt to (1)
obtain and mointain primory clo-
sure of the flaps in interdental
spaces; (2) avoid/limit the col-
lopse of non-self supporting bar-
rier membranes into interproxi-
mol defects: ond (3) render the
procedure oppliooble to narrow
and/or posterior interdentol
spaces.
The aim of the present clini-
cal study was to describe the
SPPF in combination with biore-
sorboble barrier membranes in
the treatment of deep intrabony
defects ond to preliminarily
evaluate its etfioooy.
Mettiod and materials
Subject popuiafion
The patient population consisted
of 18 subjecfs (7 men. 11 women)
34 to 60 years ot oge (mean 49,1
± 7.7) in good general health,
with no known allergies ond
good oral hygiene. All patients
gave informed consent to par-
ticipate in this cose series. In each
patient an experimental site that
met the following selection crite-
ria wos identified: (i) oliniool and
radiographie evidence of the
presence cf a deep interproxi-
mol detect with an intrabony
component of 4 mm or more; (2)
olinical attachment loss equal to

or greater than 6 mm; (3) no fur-
cation involvement; and ("4) pres-
ence of at least 2 to 3 mm of
thick keratinized tissue to allow
surgical manipulation and sutur-
ing. The tooth population con-
sisted cf 8 incisors, 3 canines, 4
premolars, and 3 molars; 9 teeth
were located in the maxiiia.
Experimenfai design
This study population consisted of
a longitudinal cohort of eiigible
patients selected at periodontal
réévaluation (baseiine) after
completion of an initial phase of
periodontal treatment that
included scaiing, root planing,
and orai hygiene instructions. At
baseiine, ciinicai measurements
were reccrded. Patients under-
went GTR therapy of the selected
defects as detailed belov«/.
Clinioai outcomes were evaiu-
ated every week for ó weeks after
oompletion of GTR freatment
and at a 1 -year foilow-up visit.
Ciinicai measuremenfs
The foiiowing parameters were
determined at baseline, ie, imme-
diately prior to the surgicai pro-
cedure, and 1 year iater. Full-
mouth plaque scores (FMPS) were
recorded as the percentage of
total surfaces (4 aspects per
tooth) that revealed the pres-
ence of plaque.^' Bleeding on
probing was assessed dichoto-
mcusly at a force of 0.3 N wifh a
59i
manual pressure-sensitive probe
(Brodontic probe equipped with
the PCP-UNC 15, Hu-Friedy). Fuli-
mouth bleeding scores (EMBS)
were calculated. Probing pocket
depths (PPD), gingival recessions
(REC), and ciinicai attachment
levels (CAL) were recorded to the
nearest millimeter by a single
investigator at a force of 0.3 N with
a manual pressure-sensitive probe
(Brodontic probe equipped with
the PCP-UNG 15) at the deepest
interproximal point of the selected
tooth. Coverage of the mem-
brane and primary cicsure of the
inferdentai spaoe were deter-
mined diohotomously (interdental
spaoe closed or open) immedi-
ateiy postsurgery and at weekly
intervals for 6 weeks.
Surgicai procedure
Following iocai anesthesia, o first
incisicn was traced across the
defect-assooicted papiiia (Figs
l a and lb).The incision started
from the gingivai margin at the
buccal line angle of the involved
tooth to reach the mid-inter-
proximai portion of the papilla
under the contact point of the
adjacent tooth. This oblique inci-
sion was carried out l<eeping the
blade paraiiel to the iong axis of
the teeth to avoid exoessive thin-
ningofthe remaining inferdentai
tissues. The first obiique interden-
tal incision was continued intra-
suiouiarly in the buccal aspect
of the teeth neighboring the
defect and extended to parfialiy
Voiume 19, Number 6.1999
592
Fig la Presurgicai appearance of the
area fhat will be accessed wifh the SPPF.
The defecf is located on fhe mesial as-
pect of fhe maxillary right iaterai incisor.
Fig id Buccoiinguai horizontai incision
af base of the papilla is as close as pos-
siPle ta the inferproximai bone crest.
Care is taken ta avoid a ilnguai/palafal
perforafion
The Infernational Journal af Periodonfics & Restorative Dentistry
Fig Ib First oblique incision in defect-
associated papilia begins af gingivai
margin of mesiobucoal line angle of lat-
erai incisor Blade is kept parallel to fhe
iong axis of fhe tooth and reaches fhe
midpoint of the distal surface of fhe cen-
trai incisor just beiow the contact point.
Fig Ie Intrasulcuiar interdental incisions
continue in the palatal aspect ofthe
incisors untii the adjacent parfiaiiy dis-
sected papillae. Fuii-thickness palatal
flap including the interdental papiiia is
elevated.
I.
I \
I'
1 1
Fig ÍC First oblique incision continues
intrasuicuiarly in fhe buccal aspect of
the lateral and central incisors, extend-
ing until the adjacent papillae, and a
buccal full-thickness flap is eievated to
expose 2 to 3 mm of bone. Note the
defecf-associoted populo still in place.
Fig If Infrabany defect following
dePridernent. Note the position of the
bone crest on the distai aspect af the
centrai incisor.
Fig ]g (left) Membrane is positioned to
cover defect and 2 to 3 mrvi of re-
maining bone and secured fo neighbor-
ing teeth. Horizontal internal mattress
suture runs from the base af fhe kera-
tinized tissue ot the midbuccal äde of
the central incisor to a symmetric loca-
tion at the base of the palatal flap. This
suture causes no direct compression of
fhe midpartion of the membrane, pre-
venting its coliapse into the defect.
Fig Jh (right) Primary dosure and
compiete coverage of the membrane
are obtained.

dissect the papiiiae cf the adja-
cent interdental spaces. These
inoisicns ailowed the elevotion of
a buccal flap and exposure of 2
tc 3 mm ot alveoiar bone (Fig 1 c). extended at least 3 mm beyond
The remoining tissues of the
defect-asscciated papillo were
carefully dissected from the root
surtaces of the 2 neighbcring
teeth, A buccolingual horizcntai
incision was then performed at
the base cf the papiilo os close as
possible to the interproximol bone
crest, taking care to ovoid a lin-
guai/paiatal perforation (Fig Id),
Intrasulcular inoisicns were per-
formed in the lingual/paiatal as-
pect of the 2 teeth neighboring
the defect and extended to the
interdentol papiiiae of the adja-
cent interdental spaces, A full-
thickness lingual/palatai flap was
gently elevated, starting trom the
extremities cf the intrasulcular in-
cisiens,Tl-ie interproximal papillary
tissues at the defect site were
gently elevated along with the
linguai/palatai flap, in this phase,
extreme care was taken to avoid
any tearing of the interdental tis-
sues during flap eievation; if tis-
sue tags were present, further
sharp dissection was performed,
A tuil-thickness lingual/paiatal
flap including the interdentai tis-
sues was then eievoted to fuiiy
expcse the interproximal defect
(Fig 1 e). The defect was fully de- gual/palatal flaps were sutured
brided and the root surfaces
were carefully scaled ahd planed
with a combination cf manual
ond sonic instruments (Fig 1 f)
An interproximai biore-
sorbable barrier membrone
(Resoiut, 3Í/WL Gore) was
adapted and positioned just
ooronal to the interpreximol alve-
olarcrest(Fig lg).The membrane
the margin of the defect ond
was secured to the neighboring
teeth with resorbobie sling sutures
(Resoiut),
Primcry ciosure of the inter-
dental tissues above the mem-
brane without tension was
attempted acccrding tc a step-
wise approach:
1, In a first effcrt, closure was
attempted by simply reposi-
tioning the fuli-thickness buc-
cal and iingual/paictal flaps,
2, If tensicn-free primcry closure
was not obtained, the buo-
cal full-thickness flap wcs fur-
ther extended mesiedistally
3, If this was still insufficient, o
poriosteol incision was per-
formed in the most apicai por-
tion otthe bucool flap, taking
care not tc compromise the
bieed supply of the flop.
4, Vertical reieasing inoisiens
were used enly cs c last resort.
After ccntrelling the proce-
dure to aiiow for compiete cov-
erage of the membrane and pri-
mary closure of the interdental
tissues, the bucoal and the iin-
asfollows.Afirst horizontal internal
mattress suture (expanded pely-
tetrof1ueroethylene(e-PTFF),3i/WL
Gore) was placed ih the defect-
asscciated interdental space,
running from the base (near the
593
mucogingival junction) of the ker-
ctinized tissue at the midbuccal
aspect ot the tooth not invoived
by the defect to a symmetrio
iocction at the bose of the lin-
gucl/palotal flap (Fig lh).This
suture ceuld lie en tep ef the inter-
proximal roet surfaoe by rubbing
the residual interpreximal bone
crest, and was onohored to the
lingual/paiatol flap. When tied, it
allowed the ooronal positioning
ef the buocai ficp. A relevont
note is that this suture en the inter-
proximal bone crest does not
oause any compression at the
midportioh of the membrone,
therefore preventing its coilapse
into the defect,The interproximal
spoces edjocent tc the defect
were subsequently closed with
interrupted sutures,The interden-
tei tissues above the membrane
were then sutured te complefe
primary oiosure with one of the
feliowing approaches: (1) one
interrupted suture was used when
the interpreximol space wos nar-
row and the interdentai tissues
thin: (2) 2 interrupted sutures were
used when the interproximal
space wcs wider and the inter-
dental tissues thicker: or (3) an
internal vertiool oblique mattress
suture'"' wos used when the inter-
proximal space was wide and the
interdental tissues thick. Special
core was taken to ensure that the
first horizentai mattress suture
would relieve all tension of the
flaps, and to obtain primory pos-
sive oiosure ef the interdental tis-
sues ever the membrane with the
lost suture. When tension was
Volume 19, Number ó, 1999
594
Fig 2a Preoperative clinical view of a
representative cose. A defect is present
Oh the rnesial aspect of the right oen-
trai inoisor. Note the presence ofoPout
4 mm of keratinizeú tissue in the area of
the defeat.
Fig 2d Baiiiei membrane is complete-
ly covered with the flaps. Note fhe 2
interproximai sutures to obtaih primary
ciosure without tension.
observed, the sutures were
removed ond the primary pas-
sive ciosure was attempted a
second time, A representative
cünical case is shown in Fig 2,
Intraoperotive clinical
measurements
The foiiowing intraoperative ciin-
icai measurements were tai<en
The International Journal of Periodontics a Restoraliue Dentistry
Fig 2b Foiiowing flap elevation, a 7-
mm intrabony detect is evident. Note
the residuai bone crest at the mesiai
aspect of the iett centrai incisor.
Fig 2e Clinical appearance at 6
mohlhs.
after compietion ot defect
debridemenf. essentially as pre-
viousiy described'''^^: (1) dis-
tonce from the cementoenomel
junction (CEJ) tc the bottom of
fhe defecf (CEJ-BD) and (2) dis-
tance from the CEJ to the most
coronai extension of the inter-
proximal bone crest (CEJ-BC).
The infrabany component otthe
defects (iNFRA) was defined as
iNFRA = CCEJ-BD) - (CEJ-BC).
Fig 2c Bioresorbdbie barrier mem-
brane is positioned to oover the aefect.
Fig2f At I year the residual pocket
depth is 3 mm.
Dota were expressed as
means ± standard deviation.
Differences between baseiine
and 1-year measurements were
evaiuated using the paired f test.
Postsurgical instructions and
infection control
Patients were instructed to rinse
3 times a day with 0,12%
 595

chlorhexidine. No meohanioal
BWHI Oral hygiene (FMPS),full-mouth bleeding on probing
oral hygiene procedures or
chewing in the treated area was
allowed for 11 weeks. In the first
•HI (FMBS), and clinical measurements
1 year Difference
postoperative week, patients Baseline (mean ± SD] (mean ±SD) Significance'

were prescribed amoxicillin 500 FMPS (%) 13.9 ±2.2 9.9 ±2.8 4.0 ± 3.3 < 0.001
mg 3 times a day. Professional FMBS(%) 11.1 ±2.4 6.5 ± 2.3 4.6 ±2.1 < 0.001
CAL(mm¡ 11.2 ±2.1 6.3 ±2.1 4.9 ± 1.3 < 0.001
tooth cleaning consisting of < 0.001
PPDImm) 9.3 ±2.0 3.6 ± 1.2 5.8 ±2.5
supragingival prophylaxis with o REC{rT>m) 1.9 ±1-8 2-7 ± 1.5 0.8 ± 1.6 -0.019
rubber cup and 1% ohlorhexi- "Pairedf lest
dine gel (Corsodyl gel, ICI) wos FMPS = fuli-moulh piague ifore; i-MBi = fuli-moutii aieedmg ^cor&CAL = dinitai anachmeni Ievei:
PPD = probing pocket depih;REC = gingivai recession.
performed weekly for 11 weeks.
Affer this period, patients were
instructed to grodually resume
mechanical oral hygiene includ-
ing interdental cleaning and to
Primary closure of
discontinue chlorhexidine. All
patients were maintained in a •^H• 1 interdental space
supportive core program at
monthly intervals; this included
compiete-mouth prophylaxis
^•.
Time
over membrane
(closed sites)
n %
CEJ-BD
t
12.6 +
ClJ-äC5ät2.2[
1

INFRA 7.2 ±2.0

and orol hygiene remotivation Postsurgery 18 100
tor 1 yeor. No probing or deep 1 wk 15 83.3
2wk 12 66.6
subgingivai instrumentation was 12 66.6 Fig 3 Baseline characteristics of the
3wk
attempted in the treated sites experimental defects. CEJ-BD = CEJ to
4 wk 12 66.6
bottom ofthe defect: CEJ-BC = CEJ to
until the 1-year visit. 5wk 12 66.6
bone crest: iNFRA = infrabony compo-
6 wk 12 66.6 nent of the defect.

Results

Defect characteristics

Patients' oral hygiene and base-

line defect characteristics are
disployed in Table 1 and Fig 3.
Mean FMPS and FMBS were 13.9
± 2.2 and 11.1 ± 2.4, respectively.
The selected defects presented
with a CAL of 11.2 ± 2.1 mm and
a PPD of 9.3 ± 2.0 mm. The dis-
tance from the CEJ fo the bot-
tom ot the defect was 12.Ó ± 2.4
mm. The infrabcny component
was 7.2 ±2 mm (Fig 3).

Volume 19, Number Ó. 1

59Ó
Membrane coverage
At baseiine, primary closure of
the interproximal soft tissues over
the membrane was obtained in
all treated cases (100%). Exposure
occurred in 3 cases at 1 week
and in 3 more oases at 2 weeks.
At ó weeks, 12 sites (66.6%) still
showed complete coverage ot
the membrane (Table 2).
One-year oufcome measures
One-year outcome measures
are displayed in Table 1, Mean
CAL gain was 4.9 ± 1.8 mm. The
difference befween baseline
and 1 year CAL was clinicaliy and
statistically significant (P< 0.001 ).
PPD reduction was 5,8 ± 2.5 mm.
The ditference between baseline
and 1-year PPD was clinically
and statistically significant (P <
0,001 ). Mean residual pockets at
1 year were 3.6 ± 1,2 mm. A slight
increase cf 0.8 ± 1,6 mm in gingi-
val recession ot the expérimentai
sites between baseline and 1
year was observed.
Discussion
The novel surgicai approach
described in this case series (SPPF)
was specifically designed to
increase the predictability of pri-
mary ciosure of the interdental
tissues over bioresorbable barrier
membranes. The following issues
were addressed in designing the
SPPF: (1) allow a simple and safe
The International Journal of Periodontics & Restorative Dentistry
manipulation of the interdental
tissues, not only in wide and/or
anterior interdental spaces, but
also in narrow and/or posterior
ones; (2)facilifate primary closure
of the interdental tissues over
bioresorbable membranes with-
out tension; ond (3) prevent the
collapse of the membranes into
the defect because of suture
compression.
The first objective was fo pre-
serve ail of fhe interdental tissues
for the subsequent coverage of
the membrane. The first oblique
papillary incision was aimed at
splitting the interdentai papiiia in
2 parts, the largest being the lin-
gual/palatal one. As a result ot
this incision, iarge and thick con-
nective tissue surfaces af bofh fhe
buccal and the lingual/paiafai
flaps were warranfed. In addifion,
any thinning of the papillary tis-
sues was avoided.
A second goal was to facili-
tate the elevation of the papillary
tissues along with the lingual/
palatal flap fhrough a narrow
inferdentai space. Previcus expe-
riences with papiiia preservation
procedures (the modified papilla
preservation technique'^ and
the interdental tissue mainte-
nance technique^ showed that
when the interdental space was
narrow, the manipulation of a
large buccal er palatai "saddie-
shaped" flap incorporating the
interdental tissues was techni-
cally very demanding. With the
SPPF, the amount oi interdental
tissue elevated through the inter-
dentol space did not exoeed the
amount of tissue originally in that
space, thereby rendering the
procedure very easy and atrau-
matic.A basic step to prevent tis-
sue damage was to avoid any
tearing during flap eievation,This
was ensured by a carefui sharp
dissection of the interdentai tis-
sues from the root cementum of
fhe 2 neighboring feeth and from
the underiying connective tissue.
The objective of obtaining
primary passive olosure in the
interdentai space over the mem-
brane was pursued with a step-
wise approach.The first sfep was
to ascertain the potentiai fcr pri-
mary closure of the flaps in the
interdental space, facilitating it
with a mesiodistal extension of
the buocai incisions and/or with
a periosteal incision ond/orwith
buccai verticai incisions.The sec-
ond step was to coronoiiy posi-
tion the buccal flap with an otf-
set internal maflress suture; this
suture was anchored to the lin-
gual/palatal flap, and by rub-
bing against the root surfaoe
and lying on top of the residual
bcne crest, it aiiowed the coro-
nal positioning of the buccal flap
and relieved most of the tension
in the interdental space. The final
step was to close the interdental
tissues without tension, using one
of 3 approaches as described
above.
An adjunctive positive etfect
of the empioyed suturing ap-
proach was the avcidance of
suture compression on the bar-
rier membrane in the area of the
defecf. In fact, a non-self

supporting barrier membrane
would collapse into the defect
against the residuai bony walis
when compressed by fhe suture.
For this reason, the interdentai
suture was designed ta lie on the
residuai proximal bone cresf
away from the area where the
membrane cavered the defecf,
in the authors' opinion this could
improve preservation ofthe nec-
essary space for regenerafion
under the membrane.
The resuits af fhe present clin-
ical study demonstrate that the
main objective for which tfie SPPF
was designed (ie, primary closure
of the interdental tissues over
bioresorbable barrier mem-
branes) was achieved in 100% of
18 freafed sites (Table 2), Affer 1
week, 3 sites reopened. After
another week, 3 more sites
showed some degree of mem-
brane exposure, in fhese ó sites,
the observed fiap dehiscence
wos minimal. As an overali result,
primary closure was maintained
over time in Ó7% of the sites. This
favorably compares with fhe 20%
to 40% primary closure reported in
studies in which conventional
techniques not specificaily
designed for use with bar-
rier membranes were em-
ployed,'^'^'^^ On the other hand,
the percentage cf primary clo-
sure maintained over time with
the SPPF is siightiy less than that
obtained with the modified
papilla preservation teohnique
with titanium-reinfarced mem-
branes^'' ar with bioresorbabie
membranes^" and the inferdenfal
597
fissue maintenance technique Acknowledgments
with e-PTFE membranes,^° To bef-
ter understand the potentiai of The authors express their gratitude fa Ms
this novei teohnique, however. It is Cristiano Paoli tor expert assistonoe wifh
fhe initial artwork,This study was supported
important fo emphasize that the in part by Academia Toscona di Ricerca
present study pcpuiatian in- Odontostomatologie a, Firenze, Ifaiy.
cluded maxiliary and mandibular
detects in both anterior and pos-
terior parts ot the mouth, with no
restriotions in terms of minimal
interdental width; the above-
mentioned techniques were
restricted to anterior and/or wider
interdental spaces. The SPPF
therefore seems to be a suitabie
alternative to the modified
papilla preservation or interden-
tal fissue maintenance technique
in many instances, including nar-
row interdental spaces and/or
posterior sites,
it shouid be emphasized that
the clinicai autoomes in terms of
CAL gains (4.9 ±1,8 mm) and PPD
reduction (5,8 ± 2,5 mm) ob-
tained wifh the application of this
fechnique favorabiy compare
with the oiinical outcomes ob-
tained in other clinicai studies in
which differenf bioresorbable
membranes were employed,^^"^'
This novel technique showed
a potential to heip increase the
sucoess of GTR procedures by
providing a predictable cover-
age of the barrier membranes,
even in instances in which tissue
manipulation is very difficult. The
efficacy and prediotabiiity ofthe
appiication of SPPF, however,
should be further evaluated in
multicenter studies, Suoh studies
are currently being performed.
Voiume 19,Number 6,1999
 598
References
1. Tonetti M, Corteliini RCose seieotion
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Volume 19. Number 6,1999