Fogorvosi szemle, 2007 (100. évfolyam, 1-6. szám)
2007-10-01 / 5. szám
227 FOGORVOSI SZEMLE ■ 100. évf. 5. sz. 2007. tion epithelium and connective tissue encapsulation of the graft particles [120]. Data from controlled clinical studies comparing treatment of intrabony defects with EMD alone or a combination of EMD and different types of bone grafts/bone substitutes seem to indicate that the combination of EMD and DFDBA or a natural bone mineral may additionally enhance the hard and soft tissue parameters compared to treatment with EMD [121-124], However, a recent study comparing the combination of EMD and a bioactive glass to EMD alone failed to show significant differences between the two groups [125]. Furthermore, clinical studies comparing treatment with a combination of EMD and a bone graft/bone substitute to bone graft/bone substitute alone did not demonstrate any advantage of the combination approach [126-128]. Thus, it may be speculated that the type of the bone graft/bone substitute and the volume and configuration of the defects are also important factors which might influence the clinical results. Further, well designed controlled clinical studies are necessary in order to evaluate the advantage of a combination therapy in relation to the single therapies. Controlled clinical studies in recession defects Histological results from animals and humans have shown that treatment of buccal recession defects with a coronally positioned flap and EMD can result not only in a covering of the gingival recession but also in formation of cementum, periodontal ligament and bone [56, 58, 62, 63, 67, 73-75], In two controlled clinical studies the treatment of buccal Miller Class I and II gingival recessions with a coronally positioned flap and EMD or coronally positioned flap were examined using the split-mouth procedure [129, 130]. Over a short period of time (up to 1 year), the results did not show differences between the therapies in terms of root coverage. The additional application of EMD led, however, to statistically significantly higher formation of keratinized tissue than the coronally positioned flap technique alone [130]. A follow-up evaluation of this study has shown that over 2 years, complete root coverage could be maintained in 53% of the EMD group versus 23% in the control one [131]. A total of 47% of the treated recessions in the control group deteriorated again in the second year after therapy compared to 22% in the EMD group indicating that EMD seems to provide better long-term results. Similar results were obtained in a randomized controlled clinical study on 58 contralateral sites in 17 patients with > or = 2 mm of Miller Class I, II, and III buccal recessions treated with coronally positioned flap and EMD (test) or coronally positioned flap alone (control) [132], At 6 months, there was a mean increase in keratinized tissue of 0.60 mm for the test sites and a mean decrease of 0.05 mm for the control sites. Test sites demonstrated better root coverage (i.e. 92.9% root coverage after 6 months) compared to the control sites (i.e. 66.8% root coverage after 6 months) [132], These results were recently corroborated by others [133]. In a controlled, clinical, split-mouth study involving 17 patients the therapy of buccal Miller Class II recessions with a coronally positioned flap and EMD (test group) or with a coronally positioned flap and connective tissue graft (control) was compared [134], The results have shown that 1 year after therapy the mean value of root coverage was 95.1% in the test group and 93.8% in the control group. A 100% root coverage was reached in 89.5% of the cases in the test group and in 79% of the cases in the control group. The additional histological evaluation of two biopsies showed that treatment of recession defects with a coronally positioned flap and EMD resulted in formation of root cementum, periodontal ligament and alveolar bone, while treatment with a coronally positioned flap and a connective graft was characterized by a long junctional epithelium and even signs of root resorption [75]. Comparable results were also reported in a multi-centre, controlled clinical trial [135]. The available data suggest that the use of EMD may enhance the outcome of root coverage procedures, but the additional application of a connective tissue graft seem to result in a higher increase of keratinized tissue [134-136]. It is interesting to note that most controlled clinical studies evaluating treatment of gingival recessions with coronally repositioned flaps and EMD reported stable clinical results after a longer time period (i.e. up to 2 years) and an increase in the width of keratinized tissue, thus indicating that EMD may have an effect upon proliferation of gingival fibroblasts and keratinization [131, 137, 138], Controlled clinical studies in furcation defects Data from controlled clinical studies evaluating the treatment of furcation defects by means of flap surgery with and without EMD are lacking. A multi-centre, randomized, controlled, split-mouth, clinical study compared the treatment of mandibular Class II furcation defects with EMD or GTR [139, 140]. A total of 44 patients with 90 comparable defects on contralateral molars were included. Defects were randomly assigned to treatment with EMD or GTR with a bioresorbable membrane. The results were evaluated at 8 and 14 months and included gingival margin levels, probing depths, bleeding on probing, vertical attachment levels, and vertical bone sounding from a stent at five buccal sites per tooth. The results have indicated that both treatment modalities led to significant clinical improvements. The median reduction of open horizontal furcation depth was 2.8 mm with the corresponding in-
