Enamel Matrix Derivative and Coronal Flaps to Cover Marginal Tissue Recessions

Enhancing attachment of human gingival fibroblasts to periodontally compromised teeth: A comparative analysis of hyaluronic acid, EDTA, enamel matrix derivatives

Background

Gingival recession is a characteristic indicator of periodontitis and one of the factors that contributes to increased tooth clinical crown length. Patients with root exposure frequently undergo periodontal surgical procedures in addition to adjunctive therapy to increase root coverage area and soft tissue stability.

Purpose

This study aimed to evaluate fibroblast-root surface adhesion and determine whether periodontitis-damaged root surface microstructure can be restored using ethylenediaminetetraacetic acid (EDTA) and an enamel matrix derivative (EMD), individually or in combination.

Material and methods

Teeth extracted from patients with periodontal disease were used to create 60 samples, with each group containing six specimens. The test groups were provided root planing or root condition-specific materials (hyaluronic acid [HA], 24% EDTA, EMD, or EDTA/EMD) for varying treatment time periods. In contrast, the control group did not undergo any surface modifications. The samples and fibroblast cells were incubated for 72 h. The number of living cells on the root surface in each group was calculated using a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay (cell viability assessment).

Results

The control, root planing, and EMD groups showed that the root surfaces treated with EDTA for 4 min had significantly better cell adhesion. Surface EDTA treatment for 2 min significantly promoted cell attachment compared to root planing treatment. The root surfaces modified with EDTA/EMD for 2 and 4 min showed significantly improved cellular migration and adhesion compared to the root surface treated with root planing.

Conclusion

EDTA and EDTA/EMD substantially affected the root surface, which was related to the length of the treatment process. This effect shifts the surface properties, alters fibroblast interactions with the root surface, and recruits more cells to cover a larger area.

Advanced Platelet-Rich Fibrin and Connective Tissue Graft for Treating Marginal Tissue Recessions: A Randomized, Controlled Split-Mouth Study

OBJECTIVES

 This study aimed to evaluate and compare the clinical outcomes of advanced platelet-rich fibrin (A-PRF) and connective tissue graft (CTG) in treating marginal tissue recessions.

MATERIALS & METHODS

 Fifteen patients with isolated bilateral maxillary gingival recessions were recruited for the study, with 30 defects. The defects were classified as Miller's class I/II gingival recession on the canine or premolar region. Patients were randomly divided into two groups, each receiving one of the two treatment techniques (A-PRF or CTG) on a different side of the maxilla in a split-mouth design. Clinical parameters such as recession height (RH), recession width (RW), probing pocket depth (PPD), clinical attachment level (CAL), a width of attached gingiva (WAG), and keratinized tissue height (KTH) were evaluated at baseline, 3, and 6 months. Changes in biotype, Recession Esthetic Score (RES), and Visual Analogue Score-Esthetics (VAS-E) were also evaluated at 6 months.

TRIAL REGISTRATION

 Ethics approval number (Helsinki): PHRC/HC/877/21 and registered at the Clinical Trials Registry under the number NCT05267015 Results: At the end of 6 months, there was a statistically significant reduction in RH and RW in both groups, with the mean RC% of 69.2±22.91, and 88.66±33.18 in Groups I and II, respectively. Intergroup analysis showed statistically significant differences in recession parameters between groups at 3 and 6 months, with better outcomes for the CTG group.

CONCLUSIONS

 This study demonstrates that A-PRF and CTG effectively manage gingival recession defects. However, CTG resulted in better clinical outcomes in terms of reduction in recession height and width.

Recession coverage using the modified coronally advanced tunnel and connective tissue graft with or without enamel matrix derivative: 5-year results of a randomised clinical trial

OBJECTIVES

To evaluate the 5-year results of single and multiple recession type (RT) 1 and 2 (Miller I to III) recessions treated with the modified coronally advanced tunnel (MCAT) and connective tissue graft (CTG) with or without an enamel matrix derivative (EMD). The main outcome variable was the stability of obtained root coverage from 6 months to 5 years.

MATERIALS AND METHODS

In 24 patients, both complete and mean root coverage (CRC and MRC) and gain of keratinised tissue (KT) were assessed at 6 months and 5 years after recession coverage by means of MCAT and CTG with or without EMD. Aesthetic outcomes after 5 years were evaluated using the root coverage aesthetic score (RES).

RESULTS

At 5 years, 24 patients with a total of 43 recessions were evaluated. Eight patients (57.14%) of the test and 6 (60.0%) of the control group showed complete root coverage. MRC revealed no statistically significant differences between the two groups, with 73.87 ± 26.83% (test) and 75.04 ± 22.06% (control), respectively. KT increased from 1.14 ± 0.57 mm to 3.07 ± 2.27 mm in the test group and from 1.24 ± 0.92 mm to 3.02 ± 1.55 mm in the control group, respectively.

CONCLUSION

Treatment of single and multiple RT 1 and 2 recessions by means of MCAT and CTG with or without EMD yielded comparable clinical improvements which could be maintained over a period of 5 years. The additional use of EMD did not influence the clinical outcomes.

CLINICAL RELEVANCE

The use of MCAT + CTG yielded successful coverage of single and multiple RT 1 and 2 gingival recessions, while the additional application of EMD did not seem to influence the results.

Effects of CEM cement and emdogain on proliferation and differentiation of human stem cells from the apical papilla: a comparative in vitro study

OBJECTIVES

This study compared the effects of calcium-enriched mixture (CEM) cement, Emdogain (EMD), and their combination (CEM/Emdogain) on the differentiation and proliferation of stem cells from the apical papilla (SCAPs).

METHODS

In this in vitro, experimental study, SCAPs were isolated from two sound immature impacted third molars and cultured. After ensuring their stemness by detecting cell surface markers they were exposed to CEM cement, Emdogain, and CEM cement coated with Emdogain for 24 and 72 h. The control cells did not undergo any intervention. Cell viability [by methyl thiazolyl tetrazolium (MTT) assay], expression of odontogenic differentiation genes [by quantitative reverse-transcription polymerase chain reaction (qRT-PCR)], and alkaline phosphatase (ALP) activity (by ALP staining kit) were evaluated. Data were analyzed by one-way ANOVA, t-test, and Mann-Whitney test (α = 0.05).

RESULTS

Cell viability in the CEM cement and CEM/Emdogain groups decreased compared with the control group at 72 h (P < 0.05). Expression of dentin sialophosphoprotein (DSPP), dentin matrix protein 1 (DMP1), bone sialoprotein (BSP) genes, and ALP activity significantly increased in all three experimental groups compared with the control group at both 24 and 72 h. This increase was substantially more significant in CEM/Emdogain group (P > 0.05). The number of mineralized nodules significantly increased in all groups at 72 h, with a higher rate in the CEM/Emdogain group.

CONCLUSION

All biomaterials increased the differentiation of SCAPs, expression of odontogenic differentiation genes, and ALP activity, but CEM/Emdogain was considerably more effective for this purpose.

Efficacy of biologics in root coverage and gingival augmentation therapy: An American Academy of Periodontology best evidence systematic review and network meta-analysis

BACKGROUND

The aim of this systematic review was to assess the efficacy of three biologics, namely autologous blood-derived products (ABPs), enamel matrix derivatives (EMD) and recombinant human platelet-derived growth factor BB (rhPDGF-BB), in root coverage and gingival augmentation therapy.

METHODS

The protocol of this PRISMA 2020-compliant systematic review was registered in PROSPERO (CRD42021285917). After study selection, data of interest were extracted. A network meta-analysis (NMA) was conducted to assess the effect of different surgical interventions on the main clinical outcomes of interest (i.e., mean root coverage [MRC%], complete root coverage [CRC%], keratinized tissue width [KTW], gingival thickness [GT] change, and recession depth [RD] reduction).

RESULTS

A total of 48 trials reported in 55 articles were selected. All studies reported on the treatment of gingival recession defects for root coverage purposes. Forty-six treatment arms from 24 trials were included in the NMA. These arms consisted of treatment with coronally advanced flap (CAF) alone, EMD + CAF, platelet-rich fibrin (PRF) + CAF, and subepithelial connective tissue graft (SCTG) + CAF. Regarding MRC%, SCTG+CAF was associated with a significant higher estimate (13.41%, 95% CI [8.06-18.75], P <  0.01), while EMD+CAF (6.68%, 95% CI [-0.03 to 13.4], P = 0.061) and PRF+CAF (1.03%, 95% CI [-5.65 to 7.72], P = 0.71) failed to show statistically significant differences compared with CAF alone (control group) or with each other. Similarly, only SCTG+CAF led to a significantly higher CRC% (14.41%, 95% CI [4.21 to 24.61], P < 0.01), while treatment arms EMD + CAF (13.48%, 95% CI [-3.34 to 30.32], P = 0.11) and PRF+CAF (-0.91%, 95% CI [-15.38, 13.57], p = 0.81) did not show significant differences compared with CAF alone or with each other. Differences in the CI of PRF+CAF (symmetrical around a zero adjunctive effect) and EMD+CAF (non-symmetrical) suggest that EMD could have some additional value compared with PRF. Treatment with SCTG+CAF led to a statistically significant higher RD reduction (-0.39 mm, 95% CI [-0.55 to 0.22], P < 0.01), however EMD+CAF (-0.13 mm, 95% CI [-0.29 to 0.01], P = 0.08) and PRF+CAF (-0.06 mm, 95% CI [-0.23 to 0.09], P = 0.39) failed to show significant differences compared with CAF or with each other. While SCTG+CAF was associated with a statistically significant higher gain of KTW (0.71 mm, 95% CI [0.48 to 0.93], P < 0.01), EMD+CAF (0.24 mm, 95% CI [-0.02 to 0.51], P = 0.08) and PRF+CAF (0.08 mm, 95% CI [-0.23 to 0.41], P = 0.58) did not result into significant changes compared with CAF alone or with each other. Regarding the use of rhPDGF-BB+CAF, although available studies have reported equivalent results compared with SCTG+CAF, evidence is very limited.

CONCLUSIONS

The use of ABPs, EMD, or rhPDGF-BB in conjunction with a CAF for root coverage purposes is safe and generally promotes significant improvements respective to baseline clinical parameters. However, the adjunctive use of ABPs and EMD does not provide substantial additional improvements in terms of clinical outcomes and patient-reported outcome measures to those achieved using CAF alone, when baseline KTW is >2 mm. Both PRF+CAF and EMD+CAF rendered inferior MRC%, CRC%, RD reduction, and KTW gain compared with SCTG+CAF, which should still be considered the gold-standard in root coverage therapy. Although some studies have reported equivalent results for rhPDGF-BB+CAF compared with the gold-standard intervention, limited evidence precludes formal comparisons with CAF or SCTG+CAF that could be extrapolated to guide clinical practice.

Does the subepithelial connective tissue graft in conjunction with a coronally advanced flap remain as the gold standard therapy for the treatment of single gingival recession defects? A systematic review and network meta-analysis

BACKGROUND

The aim of this systematic review and network meta-analysis was to assess the efficacy of a bilaminar root coverage technique consisting of the combination of an autogenous subepithelial connective tissue graft (SCTG) and a coronally advanced flap (CAF) compared to the five most indicated alternative approaches for the treatment of single gingival recession defects (GRD).

METHODS

The protocol of this PRISMA 2020-compliant systematic review was registered in PROSPERO (CRD42020221362). Three electronic databases were searched up to September 30^th , 2021 to identify randomized controlled trials that involved the treatment of single GRD without interproximal tissue loss via root coverage procedures. A frequentist network meta-analysis was conducted for complete root coverage (CRC), mean root coverage (MRC) and keratinized tissue width (KTW) changes.

RESULTS

A total of 38 studies reporting on 830 patients and 1,265 GRD were included. SCTG+CAF was ranked as the most efficient treatment approach for MRC, CRC and KTW gain at 6 and 12 months after surgery, except for MRC at the 12-month follow-up where enamel matrix derivative (EMD) plus CAF exhibited superior results.

CONCLUSIONS

SCTG+CAF can be considered the gold standard for the treatment of single GRD. This article is protected by copyright. All rights reserved.

Effect of biodentine coated with emdogain on proliferation and differentiation of human stem cells from the apical papilla

BACKGROUND

This study assessed the effect of Biodentine coated with Emdogain (Biodentine/Emdogain) on proliferation and differentiation of human stem cells from the apical papilla (SCAPs). METHODS AND RESULTS: In this in vitro, experimental study, SCAPs were isolated from two immature impacted third molars and cultured. After ensuring the stemness of the cells by assessing the cell surface markers, they were exposed to Biodentine, Emdogain, and Biodentine/Emdogain for 24 and 72 h. The control cells did not receive any intervention. Cell viability was evaluated by the methyl thiazolyl tetrazolium assay. Expression of odontogenic differentiation genes was analyzed by the quantitative reverse transcription polymerase chain reaction. Alkaline phosphatase (ALP) activity was quantified by the respective kit. Data were analyzed by one-way ANOVA, t-test, and Mann-Whitney test (α = 0.05). Cell viability did not change after 24 h of exposure to biomaterials. At 72 h, the viability of the cells exposed to Biodentine and Biodentine/Emdogain decreased compared with the control group. The expression of dentin sialophosphoprotein, dentin matrix protein 1, and bone sialoprotein genes, and ALP activity significantly increased in all three experimental groups, compared with the control group at both 24 and 72 h; this increase was significantly greater in Biodentine/Emdogain group. The number of mineralized nodules significantly increased in all groups after 72 h with a greater rate in Biodentine/Emdogain group.

CONCLUSIONS

All biomaterials increased the differentiation of SCAPs, expression of odontogenic genes, and ALP activity, but Biodentine/Emdogain was significantly more effective for this purpose.

Does enamel matrix derivative application provide additional clinical benefits in the treatment of maxillary Miller class I and II gingival recession? A systematic review and meta-analysis

OBJECTIVE

This review aimed to evaluate the effects of enamel matrix derivative (EMD) in association with coronally advanced flap (CAF) or CAF + connective tissue graft (CTG) when compared with CAF alone or CAF + CTG for the treatment of gingival recessions (GR) in maxillary teeth.

METHODS

Five databases and gray literature were searched up to April 2020, to find randomized clinical trials comparing the clinical effects of CAF + EMD versus CAF alone (first group) or CAF + CTG + EMD versus CAF + CTG (second group) in the treatment of Miller class I and II or Cairo type I gingival recessions (GR). Random effects model of mean differences was used to determine the GR reduction, gain in keratinized tissue width (KTW), and gain in clinical attachment level (CAL). The trial sequential analysis (TSA) was implemented to determine the optimal information size (OIS) and imprecision using the GRADE approach. Bayes factors were calculated as complementary statistical evidence of p value.

RESULTS

From 1349 titles identified, 9 trials representing 336 GR were included. The meta-analysis showed a statistically significant difference for GR reduction and CAL gain in favor CAF + EMD (p ≤ 0.05). The additional effect of EMD showed a statistically significant difference in GR reduction in favor CAF + CTG + EMD (p ≤ 0.05). The differences in KTW gain proved to be not statistically significant in both comparison groups. The OIS were not met among meta-analyses. Evidence certainty according the GRADE approach proved to be moderate for GR reduction and gain in CAL, but very low for gain in KTW.

CONCLUSION

The adjunctive application of EMD in the treatment of GR in maxillary teeth either with CAF or CTG provided moderate certainty evidence in favor of their use for reduction in GR and gain in CAL at 6 and 12 months. However, their effect on the increase in keratinized tissue band height showed very low evidence certainty for its use.

CLINICAL RELEVANCE

To know if EMD could improve the results for root coverage.

Oral Soft Tissue Grafting

The presence of healthy soft tissue at the tooth and implant interface correlates to long-term success and stability in function and esthetics. Grafting procedures utilizing various techniques can be performed during any stage of the implant or restorative therapy. Materials of autogenous, allogeneic, and xenogeneic sources are available for oral soft tissue grafting. This article describes the classifications of soft tissue defects, treatment modalities, and materials used to enhance soft tissue quality and quantity and to achieve optimal esthetics and function around teeth and implants.

Experimental and clinical studies on plastic periodontal procedures

We have compiled, in this Periodontology 2000 review, all Latin American literature on experimental and clinical studies of periodontal plastic procedures. The body of literature on this subject has led to a discussion of the features and treatment outcomes of root-coverage procedures. Over time, knowledge on periodontal plastic procedures has become less empirical and more supportive of the clinical management of recession-type defects. Gingival recession etiology, animal studies, free gingival grafts, pedicle flaps (semilunar, laterally positioned, and coronally positioned), and subepithelial connective tissue grafts are extensively reviewed. The use of allografts as an alternative to subepithelial connective tissue grafts, the treatment of multiple gingival recessions, and the rationale for use of guided tissue regeneration and enamel matrix derivative in plastic periodontal procedure is discussed. We also assess how smoking can affect the treatment outcomes in plastic surgery procedures. Minimally invasive procedures are of great value in improving the features of the final tissues. The following aspects identified in this compilation were of great interest: (a) some factors, anatomical in nature, favor the formation of root recessions, but it is the inflammatory process (caused by the presence of biofilm and/or by traumatic toothbrushing) that is responsible for the development of root recessions; and (b) pedicle flap procedures (especially the coronally positioned flap) are extremely versatile and have the most predictable outcome of all root-coverage procedures, especially when combined with subepithelial connective tissue grafting and/or allogeneic grafts. In summary: subepithelial connective tissue grafting is considered as the first option to augment gingival width and thickness, and it may provide better long-term results; the same principles of root-coverage procedures in individual sites appear be used in clinical practice also for multiple-recession type defects; an allograft is an efficient alternative to a subepithelial connective tissue graft and, when it is the treatment option of choice, the use of wide, extended flaps should be considered; because of the superiority of plastic periodontal procedures over guided tissue regeneration and the technical difficulty of the latter, guided tissue regeneration has become obsolete for root-coverage procedures; there is rather a large body of evidence attesting that smoking negatively influences root-coverage procedures, especially subepithelial connective tissue grafts; and minimally invasive techniques may be of great value for improving the results obtained with plastic periodontal procedures, but these techniques need to be better addressed in clinical trials, both in terms of the quality and quantity of the new tissue generated.

Efficacy of Enamel Derivatives to Improve Keratinized Tissue as Adjunct to Coverage of Gingival Recessions: A Systematic Review and Meta-Analysis

Background: The systematic review was designed to answer the following focused question: Are enamel matrix derivatives able to improve the quantity of keratinized tissue (KT) around natural dentition in patients with recessions defects after their treatment with periodontal plastic procedures? Methods: Only Randomized Clinical Trials (RCT) in English language evaluating root coverage procedures in combination with enamel matrix derivatives (commercially known as Emdogain^®—EMD), with at least 10 subjects and a minimum duration of six months, were included. The search was applied to PUBMED and SCOPUS and it consists of a combination of MeSH terms and free text words (from January 2000 to June 2019). Risk of bias in individual studies and across studies was also evaluated. Results: After the full text analysis and the exclusion of further 18 articles, 12 articles were finally included. In total 639 recessions were treated (334 tests and 305 control). The recessions defects were classified according to the classification of Miller (Class I, II, III, IV). Only one trial included Miller Class III recessions (7 in total). Enamel matrix derivatives were applied in conjunction with Coronally Advanced Flap (CAF), Coronally Advanced Flap + Sub Epithelial Connective Tissue Graft (CAF + CTG), Semilunar Flap (SF). For the group CAF vs CAF + EMD the mean difference between the keratinized tissue gain in the two procedures was 0.40 mm (95% Confindence Interval Lower/Upper: 0.014–0.81) (p < 0.058); for the comparison CAF + CTG + EMD vs. CAF + CTG the mean difference between the two groups resulted in −0.06 mm (95% Confindence Interval Lower Upper −0.45 to 0.33) (p = 0.7603). Discussion: Randomized clinical trials included medium-low quality evidence. The application of Enamel Matrix Derivatives to surgical procedures aimed to cover gingival recessions does not add robust clinical benefit to conventional plastic procedure alone.

Effect of enamel matrix derivative on wound healing following gingival recession coverage using the modified coronally advanced tunnel and subepithelial connective tissue graft: a randomised, controlled, clinical study

OBJECTIVES

The potential effect of enamel matrix derivative (EMD) on wound healing following recession coverage surgery is still controversially discussed in the literature. The aim of this randomised, controlled, single blinded clinical study was, therefore, to investigate clinically and immunologically the potential effects of EMD on early wound healing and clinical results following treatment of single and multiple gingival recessions by the modified coronally advanced tunnel technique (MCAT) and subepithelial connective tissue graft (sCTG).

MATERIALS AND METHODS

A total of 40 systemically healthy patients with Miller class I, II or III single or multiple gingival recessions were treated with MCAT + sCTG with or without EMD. Patients were consecutively enrolled and randomly assigned to test or control treatment. Inflammatory markers (interleukin (IL)-1β, IL-8, IL-10 and matrix metalloprotease (MMP)-8) were measured at baseline, 2 days and 1 week postoperatively. The following clinical parameters were assessed at baseline and at 6 months postoperatively: Recession Depth (RD), Recession Width (RW), Width of Keratinized Tissue (KT) and Probing Depth (PD). Patient-reported outcomes were analysed by means of a visual analogue scale.

RESULTS

No statistically significant differences were detected between the 2 groups in terms of inflammatory markers and patient-reported outcomes during early wound healing. In the test group, RD was reduced from 4.0 ± 1.2 mm at baseline to 0.9 ± 1.3 mm at 6 months (p < 0.001), while the corresponding values in the control group were 4.5 ± 2.0 mm at baseline and 1.0 ± 1.0 mm at 6 months, respectively. At 6 months, mean root coverage measured 78 ± 26% in the test group and 77 ± 18% in the control group, respectively.

CONCLUSION

Within their limits, the present data have failed to show an influence of EMD on the clinical and immunological parameters related to wound healing following recession coverage surgery using MCAT and sCTG.

CLINICAL RELEVANCE

Early wound healing following recession coverage by means of MCAT and sCTG does not seem to be influenced by the additional application of EMD.

Root coverage procedures for treating localised and multiple recession-type defects

BACKGROUND

Gingival recession is defined as the oral exposure of the root surface due to a displacement of the gingival margin apical to the cemento-enamel junction and it is regularly linked to the deterioration of dental aesthetics. Successful treatment of recession-type defects is based on the use of predictable root coverage periodontal plastic surgery (RCPPS) procedures. This review is an update of the original version that was published in 2009.

OBJECTIVES

To evaluate the efficacy of different root coverage procedures in the treatment of single and multiple recession-type defects.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 12) in the Cochrane Library (searched 15 January 2018), MEDLINE Ovid (1946 to 15 January 2018), and Embase Ovid (1980 to 15 January 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 January 2018). No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) only of at least 6 months' duration evaluating recession areas (Miller's Class I or II ≥ 3 mm) and treated by means of RCPPS procedures.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, data extraction and risk of bias assessment were conducted independently and in duplicate. Authors were contacted for any missing information. We expressed results as random-effects models using mean differences (MD) for continuous outcomes and odds ratios (OR) for dichotomous outcomes with 95% confidence intervals (CI). We used GRADE methods to assess the quality of the body of evidence of our main comparisons.

MAIN RESULTS

We included 48 RCTs in the review. Of these, we assessed one as at low risk of bias, 12 as at high risk of bias and 35 as at unclear risk of bias. The results indicated a greater reduction in gingival recession for subepithelial connective tissue grafts (SCTG) + coronally advanced flap (CAF) compared to guided tissue regeneration with resorbable membranes (GTR rm) + CAF (MD -0.37 mm; 95% CI -0.60 to -0.13, P = 0.002; 3 studies; 98 participants; low-quality evidence). There was insufficient evidence of a difference in gingival recession reduction between acellular dermal matrix grafts (ADMG) + CAF and SCTG + CAF or between enamel matrix protein (EMP) + CAF and SCTG + CAF. Regarding clinical attachment level changes, GTR rm + CAF promoted additional gains compared to SCTG + CAF (MD 0.35; 95% CI 0.06 to 0.63, P = 0.02; 3 studies; 98 participants; low-quality evidence) but there was insufficient evidence of a difference between ADMG + CAF and SCTG + CAF or between EMP + CAF and SCTG + CAF. Greater gains in the keratinized tissue were found for SCTG + CAF when compared to EMP + CAF (MD -1.06 mm; 95% CI -1.36 to -0.76, P < 0.00001; 2 studies; 62 participants; low-quality evidence), and SCTG + CAF when compared to GTR rm + CAF (MD -1.77 mm; 95% CI -2.66 to -0.89, P < 0.0001; 3 studies; 98 participants; very low-quality evidence). There was insufficient evidence of a difference in keratinized tissue gain between ADMG + CAF and SCTG + CAF. Few data exist on aesthetic condition change related to patients' opinion and patients' preference for a specific procedure.

AUTHORS' CONCLUSIONS

Subepithelial connective tissue grafts, coronally advanced flap alone or associated with other biomaterial and guided tissue regeneration may be used as root coverage procedures for treating localised or multiple recession-type defects. The available evidence base indicates that in cases where both root coverage and gain in the width of keratinized tissue are expected, the use of subepithelial connective tissue grafts shows a slight improvement in outcome. There is also some weak evidence suggesting that acellular dermal matrix grafts appear as the soft tissue substitute that may provide the most similar outcomes to those achieved by subepithelial connective tissue grafts. RCTs are necessary to identify possible factors associated with the prognosis of each RCPPS procedure. The potential impact of bias on these outcomes is unclear.

Efficacy of xenogeneic collagen matrix in the treatment of gingival recessions: A systematic review and meta-analysis

OBJECTIVES

This review aims to evaluate the efficacy of xenogeneic collagen matrix (XCM) for the treatment of single or multiple gingival recessions in terms of clinical parameters and patient-related outcomes.

MATERIALS AND METHODS

Various electronic databases (The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, etc.) from 1966 to April 2018 and hand literatures were searched. Quality of the included studies was assessed through the Cochrane Collaboration's Risk of Bias tool. A meta-analysis was performed to calculate risk ratios and mean differences.

RESULTS

Nine randomized controlled trials were included. The results revealed a higher percentage of mean root coverage (MRC) and a greater recession reduction (RecRed) for single recessions for the combination of coronally advanced flap (CAF) with XCM compared to CAF alone (n = 3; MD = 10.00%; 95%CI [3.56%; 16.43%]; p = 0.002) (n = 3; MD = 0.35 mm; 95%CI [0.10 mm; 0.60 mm]; p = 0.005). Comparing XCM with connective tissue graft (CTG), no significant differences were detected in MRC or RecRed for single and multiple recessions.

CONCLUSIONS

The addition of XCM under CAF could improve MRC and RecRed at single tooth recessions. Initial data suggest that XCM shows promising results to improve the clinical efficacy of CAF for multiple recessions. In addition, XCM could be a valid alternative to CTG in terms of MRC and RecRed at both single and multiple recessions. Based on limited evidence, XCM may decrease postoperative morbidity and operation time compared to CTG.

[The applications of periodontal gingival surgery. Ⅱ: alternative materials]

The main purposes of periodontal graft surgery include achieving root coverage, improving the clinical attachment level and keratinized tissue, and advancing the procedure of periodontal plastic surgery. Autogenous graft, such as subepithelial connective tissue graft-based procedure, provide the best outcomes for mean and complete root coverage, as well as increase in keratinized tissue. However, a disadvantage of the procedure is in the location of the operation itself: the additional surgical site (palate). Therefore, clinicians are always looking for graft substitutes. This article will discuss the evidence supporting the use of 1) acellular dermal matrix (ADM); 2) xenogeneic collagen matrix (XCM); 3) recombinant human platelet-derived growth factor (rhPDGF); 4) enamel matrix derivative (EMD); 5) guided tissue regeneration (GTR); 6) living cellular construct (LCC), all of which are used in conjunction with coronally advanced flaps as alternatives to autogenous donor tissue. The decision tree for treatments of Miller recession-type defects are also discussed.

Evaluation of peri-implant crevicular fluid prostaglandin E2 levels in augmented extraction sockets by different biomaterials

OBJECTIVES

This study compares peri-implant crevicular fluid (PICF) prostaglandin E₂ (PGE₂) levels, clinical parameters and implant stability quotient (ISQ) values around implants placed in augmented extraction sockets.

MATERIALS AND METHODS

The sockets (24 in total) were randomly augmented using either EMD or Bio-Oss Collagen. Implant placements were performed after three months of healing. ISQ readings were evaluated at three points: at the time of surgery, at the first month and at the third month. PICF was collected for PGE₂ evaluation after the first and the third months of implant surgery.

RESULTS

After the first month, a higher level of PICF PGE₂ was observed in the EMD group than in the Bio-Oss Collagen group, and this increase was of statistical significance; however, at the third month there was no statistically significant difference in PICF PGE₂ levels between the two groups. For implants placed in EMD sites, ISQ values were statistically higher at the third month than at the first month, while no significant differences in ISQ value were detected between the first and third months in Bio-Oss Collagen sites.

CONCLUSIONS

The results of this research suggest that both EMD and Bio-Oss Collagen are effective treatment modalities for stimulating the formation of new bone at extraction sites prior to implant surgery.

Twenty years of enamel matrix derivative: the past, the present and the future

BACGROUND

On June 5th, 2015 at Europerio 8, a group of leading experts were gathered to discuss what has now been 20 years of documented evidence supporting the clinical use of enamel matrix derivative (EMD). Original experiments led by Lars Hammarström demonstrated that enamel matrix proteins could serve as key regenerative proteins capable of promoting periodontal regeneration including new cementum, with functionally oriented inserting new periodontal ligament fibres, and new alveolar bone formation. This pioneering work and vision by Lars Hammarström has paved the way to an enormous amount of publications related to its biological basis and clinical use. Twenty years later, it is clear that all these studies have greatly contributed to our understanding of how biologics can act as mediators for periodontal regeneration and have provided additional clinical means to support tissue regeneration of the periodontium.

AIMS

This review article aims to: (1) provide the biological background necessary to understand the rational for the use of EMD for periodontal regeneration, (2) present animal and human histological evidence of periodontal regeneration following EMD application, (3) provide clinically relevant indications for the use of EMD and (4) discuss future avenues of research including key early findings leading to the development of Osteogain, a new carrier system for EMD specifically developed with better protein adsorption to bone grafting materials.

Does Adjunctive Use of Growth Factors Improve Clinical Outcomes of Soft Tissue Grafting at Miller Class III Recession Defects? A Review of Current Evidence

Focused Clinical Question In patients with gingival recession that is classified as Miller Class III, does adjunctive use of local growth factors with gingival grafting procedures improve clinical outcomes? Clinical Scenario A 31-year-old female presents with a chief complaint of gingival recession (GR) at teeth #4 to #13 (Fig. 1). Interproximal bone loss coronal to the level of the buccal GR is present. She is concerned about esthetics and would like to maximize her chance for complete root coverage. Her medical history is non-contributory, and she has no contraindications to routine dental care. Because of the number of teeth involved and the difficulty in harvesting autogenous tissues, she is treated with acellular dermal matrix^§ and enamel matrix derivative^‖ with a coronally advanced flap at teeth #4 to #13 (Figs. 2 and 3). Final results reveal significant root coverage on all teeth and complete root coverage on teeth #7 to #10. This results in an esthetically acceptable result (Fig. 4).

Periodontal soft tissue root coverage procedures: a systematic review from the AAP Regeneration Workshop

BACKGROUND

This paper aims to create a "bridge" between research and practice by developing a practical, extensive, and clinically relevant study that translates evidence-based findings on soft tissue root coverage (RC) of recession-type defects to daily clinical practice.

METHODS

This review is prepared in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement based on the proposed focused questions. A literature search with no restrictions regarding status or the language of publication was performed for MEDLINE and EMBASE databases up to and including June 2013. Systematic reviews (SRs), randomized clinical trials, controlled clinical trials, case series, and case reports evaluating recession areas that were treated by means of RC procedures were considered eligible for inclusion through the three parts of the study (part I, an overview of the base of SRs; part II, an alternative random-effects meta-analyses on mean percentage of RC and sites exhibiting complete RC; and part III, an SR of non-randomized trials exploring other conditions not extensively evaluated by previous SRs). Data on Class I, II, III, and IV recessions, type of histologic attachment achieved with treatment, recipient- and donor-site anatomic characteristics, smoking-related outcomes, root surface conditions, tooth type and location, long-term effectiveness outcomes, unusual conditions that may be reported during conventional daily practice, and patient-centered outcomes were assessed as well.

RESULTS

Of the 2,456 potentially eligible trials, 234 were included. Data on Class I, II, III, and IV gingival recessions, histologic attachment achieved after treatment, recipient- and donor-site anatomic characteristics, smoking-related outcomes, root surface conditions/biomodification, tooth type and location, long-term effectiveness outcomes and unusual conditions that may be reported during conventional daily practice, and patient-centered outcomes (i.e., esthetic, visual analog scale, complications, hypersensitivity, patients perceptions) were assessed. Subepithelial connective tissue (CT)-based procedures and coronally advanced flap plus acellular dermal matrix grafts, enamel matrix derivative, or collagen matrix led to the best improvements of recession depth, clinical attachment level (CAL) gain, and keratinized tissue (KT). Some conditions, such as smoking and use of magnification, may affect RC outcomes.

CONCLUSIONS

All RC procedures can provide significant reduction in recession depth and CAL gain for Miller Class I and II recession-type defects. Subepithelial CT graft-based procedures provided the best outcomes for clinical practice because of their superior percentages of mean and complete RC, as well as significant increase of KT.

Biologic Agents for Periodontal Regeneration and Implant Site Development

The advancement of molecular mediators or biologic agents has increased tremendously during the last decade in periodontology and dental implantology. Implant site development and reconstruction of the lost periodontium represent main fields in which these molecular mediators have been employed and investigated. Different growth factors trigger different reactions in the tissues of the periodontium at various cellular levels. Proliferation, migration, and differentiation constitute the main target areas of these molecular mediators. It was the purpose of this comprehensive review to describe the origin and rationale, evidence, and the most current understanding of the following biologic agents: Recombinant Human Platelet-Derived Growth Factor-BB (rhPDGF-BB), Enamel Matrix Derivate (EMD), Platelet-Rich Plasma (PRP) and Platelet-Rich Fibrin (PRF), Recombinant Human Fibroblast Growth Factor-2 (rhFGF-2), Bone Morphogenic Proteins (BMPs, BMP-2 and BMP-7), Teriparatide PTH, and Growth Differential Factor-5 (GDF-5).

Enamel matrix derivative improves gingival fibroblast cell behavior cultured on titanium surfaces

OBJECTIVE

Although an extensive amount of research has demonstrated the positive effects of an enamel matrix derivative (EMD) on soft tissue wound healing around intrabony defects, little information is available describing its effect on peri-implant soft tissues, an area that has recently gained tremendous awareness due to the increasing prevalence of peri-implantitis. The aim of the present study was to assess the role of EMD when gingival fibroblasts were cultured on titanium surface with different surface topographies.

METHODS

Human primary gingival fibroblasts were cultured on pickled (PT) and sand-blasted with large grit followed by acid etching (SLA) surfaces and assessed for cell adhesion at 2, 4, and 8 h, cell morphology at 2, 4, 8, and 24 h as well as cell proliferation at 1, 3, and 5 days post-seeding. Furthermore, genes encoding collagen 1a1, vascular endothelial growth factor-A (VEGF-A), and fibronectin were assessed by real-time PCR. Human gingival fibroblasts were also quantified for their ability to synthesize a collagen matrix on the various titanium surfaces with and without EMD by immunofluorescence staining.

RESULTS

The results from the present study demonstrate that EMD significantly increased cell spreading at 2, 4, 8, and 24 h on PT surfaces and 4, 8, and 24 h on SLA surfaces. Furthermore, proliferation at 5 days on PT surfaces and 3 and 5 days on SLA surfaces was also increased for groups containing EMD. Real-time PCR results demonstrated that the culture of gingival fibroblasts with EMD significantly increased extracellular matrix synthesis of collagen 1 as well as improved mRNA levels of VEGF-A and fibronectin. Collagen1 immuno-fluorescent staining revealed a significantly higher area of staining for cells seeded on PT + EMD at 7 and 14 days and 14 days for SLA + EMD when compared to control samples.

CONCLUSION

The results from the present study favor the use of EMD for colonization of gingival fibroblasts on titanium surfaces by increasing cell growth, spreading, and synthesis of an extracellular matrix. The improvements were primarily irrespective of surface topography. Future animal and human studies are necessary to fully characterize the beneficial effects of incorporating EMD during soft tissue regeneration of implant protocols.

CLINICAL RELEVANCE

The use of EMD may speed up the quality of soft tissue integration around dental implants by facilitating gingival cell attachment, proliferation, and matrix synthesis of collagen 1.

Enamel matrix derivative, inflammation and soft tissue wound healing

Over 15 years have now passed since enamel matrix derivative (EMD) emerged as an agent capable of periodontal regeneration. Following thorough investigation, evidenced-based clinical application is now established for a multitude of clinical settings to promote regeneration of periodontal hard tissues. Despite the large number of studies and review articles written on this topic, no single review has compiled the influence of EMD on tissue inflammation, an area of research that merits substantial attention in periodontology. The aim of the present review was to gather all studies that deal with the effects of EMD on tissue inflammation with particular interest in the cellular mechanisms involved in inflammation and soft tissue wound healing/resolution. The effects of EMD on monocytes, macrophages, lymphocytes, neutrophils, fibroblasts and endothelial cells were investigated for changes in cell behavior as well as release of inflammatory markers, including interleukins, prostaglandins, tumor necrosis factor-α, matrix metalloproteinases and members of the OPG-RANKL pathway. In summary, studies listed in this review have reported that EMD is able to significantly decrease interleukin-1b and RANKL expression, increase prostaglandin E2 and OPG expression, increase proliferation and migration of T lymphocytes, induce monocyte differentiation, increase bacterial and tissue debris clearance, as well as increase fibroplasias and angiogenesis by inducing endothelial cell proliferation, migration and capillary-like sprout formation. The outcomes from the present review article indicate that EMD is able to affect substantially the inflammatory and healing responses and lay the groundwork for future investigation in the field.

Evaluation of recession defects treated with coronally advanced flaps and either recombinant human platelet-derived growth factor-BB plus β-tricalcium phosphate or connective tissue: comparison of clinical parameters at 5 years

BACKGROUND

In a previously reported split-mouth, randomized controlled trial, Miller Class II gingival recession defects were treated with either a connective tissue graft (CTG) (control) or recombinant human platelet-derived growth factor-BB + β-tricalcium phosphate (test), both in combination with a coronally advanced flap (CAF). At 6 months, multiple outcome measures were examined. The purpose of the current study is to examine the major efficacy parameters at 5 years.

METHODS

Twenty of the original 30 patients were available for follow-up 5 years after the original surgery. Outcomes examined were recession depth, probing depth, clinical attachment level (CAL), height of keratinized tissue (wKT), and percentage of root coverage. Within- and across-treatment group results at 6 months and 5 years were compared with original baseline values.

RESULTS

At 5 years, all quantitative parameters for both treatment protocols showed statistically significant improvements over baseline. The primary outcome parameter, change in recession depth at 5 years, demonstrated statistically significant improvements in recession over baseline, although intergroup comparisons favored the control group at both 6 months and 5 years. At 5 years, intergroup comparisons also favored the test group for percentage root coverage and change in wKT, whereas no statistically significant intergroup differences were seen for 100% root coverage and changes to CAL.

CONCLUSIONS

In the present 5-year investigation, treatment with either test or control treatments for Miller Class II recession defects appear to lead to stable, clinically effective results, although CTG + CAF resulted in greater reductions in recession, greater percentage of root coverage, and increased wKT.

Connective tissue graft vs. emdogain: A new approach to compare the outcomes

Background:

The aim of this clinical trial study was to clinically evaluate the use of enamel matrix protein derivative combined with the coronally positioned flap to treat gingival recession compared to the subepithelial connective tissue graft by a new method to obtain denuded root surface area.

Materials and Methods:

Thirteen patients, each with two or more similar bilateral Miller class I or II gingival recession (40 recessions) were randomly assigned to the test (enamel matrix protein derivative + coronally positioned flap) or control group (subepithelial connective tissue graft). Recession depth, width, probing depth, keratinized gingival, and plaque index were recorded at baseline and at one, three, and six months after treatment. A stent was used to measure the denuded root surface area at each examination session. Results were analyzed using Kolmogorov-Smirnov, Wilcoxon, Friedman, paired-sample t test.

Results:

The average percentages of root coverage for control and test groups were 63.3% and 55%, respectively. Both groups showed significant keratinized gingival increase (P < 0.05). Recession depth decreased significantly in both groups. Root surface area was improved significantly from baseline with no significant difference between the two study groups (P > 0.05). The results of Friedman test were significant for clinical indices (P < 0.05), except for probing depth in control group (P = 0.166).

Conclusion:

Enamel matrix protein derivative showed the same results as subepithelial connective tissue graft with relatively easy procedure to perform and low patient morbidity.

Histological comparison of healing following tooth extraction with ridge preservation using enamel matrix derivatives versus Bio-Oss Collagen: a pilot study

The goal of the present clinical study was to evaluate new bone formation in human extraction sockets augmented with enamel matrix derivatives (EMD) and Bio-Oss Collagen. Patients with symmetrical single-rooted teeth in the bilateral quadrants of the upper jaw condemned for extraction participated in this study. Following extraction, the sockets (20 sockets) were randomly augmented using either EMD or Bio-Oss Collagen. After 3 months of healing, bone biopsies were obtained and prepared for histological analyses. Dental implants were then placed. Implant stability quotient (ISQ) readings were obtained for each implant at the time of surgery and at 1 and 3 months postoperatively. The mean new bone formation was 34.57 ± 25.67% in the EMD sites and 28.80 ± 16.14% in the Bio-Oss Collagen sites. There was no significant difference between the groups. The ISQ values were significantly higher for the implants placed in the EMD sites at the first and third months, but no significant differences were observed in the ISQ values for the implants placed in the Bio-Oss Collagen sites. The augmentation of the extraction sockets with EMD or Bio-Oss Collagen leads to similar behaviour in bone regeneration.

Coronally advanced flap and combination therapy for root coverage. Clinical strategies based on scientific evidence and clinical experience

During the past three decades, several surgical techniques have been proposed to treat single and multiple gingival recessions. Evidence indicates that coronally advanced flap-based approaches result in the best clinical results. Among all the different techniques, the use of a graft under a coronally advanced flap results in the best short- and long-term outcomes in terms of root coverage and gain in keratinized tissue. The use of a coronally advanced flap + connective tissue graft would appear to be the best choice for root coverage. However, harvesting a graft from the palate adds morbidity, surgical chair-time and requires increased surgical skills. A potential alternative could be the use of enamel matrix derivatives under a coronally advanced flap, and this achieves similar clinical outcomes and is less invasive, but adds economic costs to the treatment. Evidence shows that a coronally advanced flap alone in many instances results in complete root coverage and is stable over time. A coronally advanced flap is less invasive for the patient, requires less chair-time and probably less surgical skill. It would therefore be desirable to use a coronally advanced flap approach when indicated. It has been hypothesized that a coronally advanced flap approach alone could be successfully applied when the residual gingiva is thick and wide, although existing evidence does not support this hypothesis in full. Accordingly, the adjunctive use of a graft or enamel matrix derivatives could be restricted to sites at which there is thin and narrow residual gingiva.

The effectiveness of enamel matrix protein (Emdogain(®)) in combination with coronally advanced flap in the treatment of multiple marginal tissue recession: A clinical study

Background:

Gingival recession resulting in root exposure is a common problem faced by clinicians. This clinical study compared the results obtained by treating gingival recession using enamel matrix derivative (Emdogain gel^®) along with coronally positioned flap and coronally positioned flap alone.

Materials and Methods:

Twenty patients with a total of 46 gingival recession defects, each patient with a minimum of two recession defects, were included in the study. The test group, which consisted of 10 patients with 22 recession defects, was treated by enamel matrix derivatives (Emdogain gel) in combination with a coronally positioned flap, while the control group, which consisted of 10 patients with 24 gingival recession defects, was treated with 24% ethylenediaminetetraacetic acid (EDTA; Prefgel^®) in combination with coronally positioned flap.

Results:

Student's paired and unpaired t-test was used for statistical analysis. If the probability value (P) was less than 0.05, it was considered significant. Data from this study demonstrated that application of (EMD) Emdogain gel resulted in a statistically significant increase in root coverage, gain in the clinical attachment level (CAL), and probing pocket depth (PPD) reduction when compared with coronally advanced flap (CAF) alone, but there was no statistically significant difference in the width of keratinized gingiva (WKG) between the two groups.

Ten-year results following treatment of intrabony defects with an enamel matrix protein derivative combined with either a natural bone mineral or a β-tricalcium phosphate

BACKGROUND

The purpose of the present study is to evaluate the 10-year results following treatment of intrabony defects treated with an enamel matrix protein derivative (EMD) combined with either a natural bone mineral (NBM) or β-tricalcium phosphate (β-TCP).

METHODS

Twenty-two patients with advanced chronic periodontitis and displaying one deep intrabony defect were randomly treated with a combination of either EMD + NBM or EMD + β-TCP. Clinical evaluations were performed at baseline and at 1 and 10 years. The following parameters were evaluated: plaque index, bleeding on probing, probing depth, gingival recession, and clinical attachment level (CAL). The primary outcome variable was CAL.

RESULTS

The defects treated with EMD + NBM demonstrated a mean CAL change from 8.9 ± 1.5 mm to 5.3 ± 0.9 mm (P <0.001) and to 5.8 ± 1.1 mm (P <0.001) at 1 and 10 years, respectively. The sites treated with EMD + β-TCP showed a mean CAL change from 9.1 ± 1.6 mm to 5.4 ± 1.1 mm (P <0.001) at 1 year and 6.1 ± 1.4 mm (P <0.001) at 10 years. At 10 years two defects in the EMD + NBM group had lost 2 mm, whereas two other defects had lost 1 mm of the CAL gained at 1 year. In the EMD + β-TCP group three defects had lost 2 mm, whereas two other defects had lost 1 mm of the CAL gained at 1 year. Compared with baseline, at 10 years, a CAL gain of ≥3 mm was measured in 64% (i.e., seven of 11) of the defects in the EMD + NBM group and in 82% (i.e., nine of 11) of the defects in the EMD + β-TCP group. No statistically significant differences were found between the 1- and 10-year values in either of the two groups. Between the treatment groups, no statistically significant differences in any of the investigated parameters were observed at 1 and 10 years.

CONCLUSION

Within their limitations, the present findings indicate that the clinical improvements obtained with regenerative surgery using EMD + NBM or EMD + β-TCP can be maintained over a period of 10 years.

Enamel matrix protein derivatives: role in periodontal regeneration

The role of regenerative periodontal therapy is the reconstitution of lost periodontal structures, ie, new formation of root cementum, periodontal ligament, and alveolar bone. The outcome of basic research has pointed to the important role of enamel matrix protein derivative (EMD) in periodontal wound healing. Histologic results from animal and human studies have shown that treatment with EMD promotes periodontal regeneration. Moreover, clinical studies have indicated that treatment with EMD positively influences periodontal wound healing in humans. The goal of this paper is to review the existing literature on EMD.

Periodontal regeneration with enamel matrix derivative in reconstructive periodontal therapy: a systematic review

BACKGROUND

Enamel matrix derivative (EMD) is commonly used in periodontal therapy. The aim of this systematic review is to give an updated answer to the question of whether the additional use of EMD in periodontal therapy is more effective compared with a control or other regenerative procedures.

METHODS

A literature search in MEDLINE (PubMed) for the use of EMD in periodontal treatment was performed up to May 2010. The use of EMD in treatment of intrabony defects, furcations, and recessions was evaluated. Only randomized controlled trials with ≥1 year of follow-up were included. The primary outcome variable for intrabony defects was the change in clinical attachment level (CAL), for furcations the change in horizontal furcation depth, and for recession complete root coverage.

RESULTS

After screening, 27 studies (20 for intrabony defects, one for furcation, and six for recession) were eligible for the review. A meta-analysis was performed for intrabony defects and recession. The treatment of intrabony defects with EMD showed a significant additional gain in CAL of 1.30 mm compared with open-flap debridement, EDTA, or placebo, but no significant difference compared with resorbable membranes was shown. The use of EMD in combination with a coronally advanced flap compared with a coronally advanced flap alone showed significantly more complete root coverage (odds ratio of 3.5), but compared with a connective tissue graft, the result was not significantly different. The use of EMD in furcations (2.6 ± 1.8 mm) gave significantly more improvement in horizontal defect depth compared with resorbable membranes (1.9 ± 1.4 mm) as shown in one study.

CONCLUSIONS

In the treatment of intrabony defects, the use of EMD is superior to control treatments but as effective as resorbable membranes. The additional use of EMD with a coronally advanced flap for recession coverage will give superior results compared with a control but is as effective as a connective tissue graft. The use of EMD in furcations will give more reduction in horizontal furcation defect depth compared with resorbable membranes.