CPESGMP327 P327 08-01-03 08:24:44 GL a205327 10092

J Clin Periodontol 2003: 30: 1–8 Copyright C Blackwell Munksgaard 2003

Printed in Denmark . All rights reserved

0303-6979

Clinical and radiographic Daniela Bazan Palioto1,

Julio Cesar Joly2,
Antonio Fernando Martorelli de

treatment evaluation of class III Lima2, Luis Fernando Mota3 and

Raul Caffesse4
1
University of São Paulo, São Paulo, Brazil,

furcation defects using GTR with

2
University of Campinas, Piracicaba, Brazil,
3
University of Pittsburgh, Pennsylvania and
4
University of Texas, Houston, Texas, USA

and without inorganic bone matrix

Palioto DB, Joly JC, de Lima AFM, Mota LF, Caffesse R. Clinical and
radiographic treatment evaluation of class III furcation defects using GTR with and
without inorganic bone matrix. J Clin Periodontol 2003; 30: 1–8
C Blackwell Munksgaard, 2003

Abstract
Objective: The aim of this study was to evaluate the effect of guided tissue
regeneration (GTR) alone and in conjunction with a bovine inorganic bone matrix
in furcation defects.
Material and methods: Twenty class III furcation defects were treated in 18 non-
smoker patients, 35–75 years old. Horizontal (CAL-H) and vertical clinical attach-
ment levels (CAL-V), probing depths (PD), gingival margin levels (GML), hori-
zontal (BDL-H) and vertical bone defect levels (BDL-V), and alveolar crest
levels (ACL) were performed at baseline and at 6-month re-entry procedures.
Subtraction radiography was used to assess gain or loss in optical density (OD)
and area of bone fill (A) (baseline/6 months). After flap elevation, the sites were
randomly assigned to receive GTR π Bio-OssA (test) or GTR treatment alone (con-
trol). Results were evaluated using .
Results: Differences were statistically significant between baseline and re-entry
for PD, ACL (p ⬍ 0.01) and GML (p ⬍ 0.05) for the control group, and for
BDL-V (p ⬍ 0.01) for the test group. There was a gain in ACL for the test group
and a reduction in ACL for the control group (p ⬍ 0.01). No differences were ob-
served for OD and A. Key words: guided tissue regeneration; bone
Conclusion: The results of this study indicate that class III furcation defects are graft; furcation defects; subtraction
not predictably resolved utilizing GTR or GTR in combination with an inor- radiography
ganic bone matrix. Accepted for publication 3 December 2001

Periodontitis is one of the most preva-
lent oral diseases (Brown et al. 1989,
1990). The tissues affected by the dis-
ease process may suffer morphological
and biochemical alterations, character-
ized by loss of connective tissue attach-
ment and alveolar bone resorption,
with negative consequences to the den-
tition and to the patients (Page &
Schroeder 1976, Selvig & Hals 1977).
The goal of periodontal therapy is to
arrest the disease progression and ulti-
mately rebuild the architecture and
function of the original support struc-
tures lost by the inflammatory process.
Guided tissue regeneration (GTR) has
been proposed as an effective method
to treat anatomical defects caused by
periodontitis (Nyman et al. 1982,
Karring et al. 1985, Caffesse et al.
1988). The principle of the procedure is
that a physical barrier is interposed be-
tween the roots and the connective gin-
gival tissues, thus avoiding the rapid
migration of the epithelium and gingi-
val connective tissue on the root surface
and allowing selected periodontal cells
to repopulate the coagulum underneath
the barrier (Gottlow et al. 1986).
GTR favours the formation of vari-
able amounts of new cementum, new
periodontal ligament and new alveolar
bone (Caffesse et al. 1990) in angular
bony defects (Gottlow et al. 1986,
Becker et al. 1988, Cortellini et al.
1993a,b) or class II furcation (Pontori-
2 Palioto et al.
ero et al. 1988, Caffesse et al. 1990).
However, in defects with greater sever-
ity, such as class III furcations, this pro-
cedure has demonstrated unpredictable
and conflicting results in animal (Caf-
fesse et al. 1994, Araujo et al. 1996) and
human models (Pontoriero et al. 1989,
Pontoriero et al. 1992).
Bone substitutes with different prop-
erties have been used to favour re-
generation and the repair of peri-
odontal defects (Urist et al. 1967,
Harakas 1984, Meffert et al. 1985,
Bowers et al. 1989, Mellonig 1990, Ko-
kubo 1991, Brunsvold & Mellonig
1993, Caton et al. 1994, Yukna 1993).
Among them, a mineral bone matrix
has been described as a good material
to promote osteoconduction due to its
crystalline structure which is very simi-
lar to the human bone (Spector 1994).
The association of guided tissue re-
generation and graft materials combines
the material properties for creating a
scaffold with a selective cellular re-
sponse, resulting in favourable results
(Guillemin et al. 1993, Wallace et al.
1994) or even an additional improve-
ment when compared with these
techniques used independently (Schall-
horn & McClain 1988, Schultz & Gager
1990). However, the lack of predictabil-
ity in the treatment of class III fur-
cations, particularly in humans, suggests
the need to evaluate the possibility of
achieving better results.
The aim of this study was to evaluate,
clinically and radiographically, the ef-
fect of GTR utilizing a non-resorbable
membrane alone and in conjunction
with a bovine inorganic bone matrix in
the treatment of class III furcation de-
fects.
Material and methods
For this randomized clinical trial, 21
patients (11 females and 10 males), 35–
75 years old, with adult periodontitis
treated at the Integrated Clinic of the
University of Campinas, were selected.
The protocol was reviewed and ap-
proved by the Ethical Committee in Re-
search of the School of Dentistry of Pir-
acicaba – UNICAMP. These patients
were systemically healthy, non-smokers,
and were not using any medication that
could interfere with periodontal aspects
in the last 6 months. Informed consents
from all patients who met the criteria
and agreed to participate in the study
was obtained. Each patient exhibited at
least one class III furcation defect and
two patients had bilateral defects. Two
sites were excluded from the study after
flap elevation and a third defect after 6
months due to endodontic/periodontal
complications. Thus, 20 defects in 18
patients completed the study. The de-
fects, through-and-through lesions as-
sessed by probing at clinical examina-
tion, affecting first or second mandibu-
lar molars, were required to present at
least 2 mm of keratinized gingiva, prob-
ing depths of at least 5 mm, tooth vi-
tality or endodontic treatment per-
formed 5 years before and at least one
of the proximal crests at the level of the
furcation fornix or higher. The test
group (n Ω 10) was treated with GTR
using a non-resorbable membrane plus
an inorganic bovine matrix and the
control group (n Ω 10) was treated with
GTR only. All surgeries were per-
formed by the same operator (DBP)
and the measurements by a blinded
examiner (JCJ).
Clinical data referent to plaque and
gingival index, both dichotomic, were
taken before the beginning of the treat-
ment, considering the presence or ab-
sence of plaque or bleeding at mesial,
distal, buccal and lingual or palatal of
all teeth. The basic therapy was per-
formed 2 months prior to the experi-
mental procedures by scaling and root
planing, occlusal analysis and removal
of caries and overhangs. At pre-surgery,
whole mouth plaque index (PI) and gin-
gival index (GI) were required to be
lower than 20%. Horizontal (CAL-H)
and vertical clinical attachment levels
(CAL-V), probing depths (PD) and gin-
gival margin levels (GML) were as-
sessed at baseline (before surgery). A 2-
mm thick PVC stent was made for each
patient. All the measurements were
taken using an electronic pressure-con-
trolled probe (Florida Probe Co., Gain-
esville, Florida, USA). The centre of the
furcation defect served as a reference to
create a groove on the stent to take all
the measurements at the buccal and lin-
gual surfaces. To perform the horizon-
tal measurement, the probe was in-
serted, buccally and lingually, taking
the furcation roof as a reference, with-
out using the stent. For the statistical
analysis the average of the two record-
ings was considered.
Defects were randomly assigned to
test and control groups. Following anti-
sepsis with 0.2% chlorhexidine gluco-
nate and local anaesthesia, sulcular in-
cisions were made lingually and buc-
cally. Mucoperiosteal flaps were elev-
ated to give access to the root surface
for scaling and planing by ultrasonic,
rotatory and hand instrumentation. No
osteoplasty was performed. The roots
were further decontaminated with satu-
rated tetracycline solution (50 mg/ml)
for 3 min and extensively washed with
saline.
Vertical bone defect level (BDL-V:
distance from the base of the stent to
the bottom of the osseous defect) and
horizontal bone defect level (BDL-H:
roof distance taken from the buccal to
the lingual surfaces and vice-versa), and
alveolar crest level (ACL: distance from
the base of the stent to the alveolar
crest) were assessed using the same stent
and probe. The intraoperative measure-
ments were also taken at the middle of
the buccal and lingual surfaces and the
average of the two recordings was con-
sidered for the statistical analysis.
Following measurements, GTW 1 –
GORE Regenerative MaterialA (W. L.
Gore and Associates, Flagstaff, Ari-
zona, USA) membranes were selected,
trimmed to cover 2–3 mm beyond the
defect and sutured on the buccal and
lingual aspects using a single step e-
PTFE suture (W.L. Gore and Associ-
ates). In the test group, the membranes
were carefully elevated to accommodate
the graft material that was previously
mixed with saline and blood of the pa-
tient. After repositioning of the mem-
brane, the flaps were subsequently su-
tured to their original position with
mattress sutures, taking special care to
cover the membranes. Sutures were re-
moved 10 days after surgery.
In the control group, all surgical pro-
cedures were identical except for the
placement of the inorganic bovine ma-
trix. An example of the baseline and 6-
month defects is illustrated in Fig. 1.
All patients were prescribed 100 mg
doxycycline/twice daily for 1 week. They
were instructed to rinse with 0.12%
chlorhexidine gluconate (Periogard –
Colgate) twice a day for the entire
period of the study.
The membranes were removed be-
tween the fourth and the sixth week
post-operative under local anesthesia,
taking care not to disturb the tissues
under the membrane. In case of mem-
brane exposure before the time required
to allow regeneration, the membrane
was maintained with reinforced chemi-
cal control. All the patients were seen
for professional prophylaxis weekly un-
til the fourth week and monthly until

completing the period of 6 months,
when re-entry procedures were accom-
plished.
Six months after baseline the patients
were scheduled for clinical assessment
and re-entry surgery. Surgical re-entry
consisted of sulcular incisions and elev-
ation of mucoperiosteal flaps. The in-
cisions were conservatively designed to
expose the previously treated defects
and measure the following parameters:
BDL-V, ACL and BDL-H. Flaps were
then replaced and sutured.
Radiographic analysis was carried
out using the digital system Sens-A-Ray
(New Image do Brazil. Imp. Exp. Ltda.,
SP, Brazil). The sensor was positioned
and maintained in place by an acrylic
device coupled to a bite block made of
Fig. 1 Clinical aspects of the furcation defects. (a) Test site – baseline, (b) test site – six months,
(c) control site – baseline, (d) control sites – six months.
GTR plus Bio-OssA in class III furcation
vinyl polysiloxane. A RINN XCP
aiming device (RINN Corporation, El-
gin, Illinois, USA) was also used in or-
der to retain reproducible projection,
with an exposure setting of 60 kV and
10 mA for 0.5 s. Digital radiographs
were taken at baseline and 6 months,
immediately prior to the re-entry pro-
cedure. For the test group, a third set
of radiographs was taken immediately
after the placement of the graft material
to evaluate its radio-opacity and check
for possible interference of the material
in the final evaluation. The two images
(baseline and 6-month) were initially
equalized by a non-parametric method
to reduce variation in density and con-
trast. The images were then subtracted
and analyzed to visualize changes in op-
3
tical density (OD) and area of bone fill
(A). To ensure that the images were
properly equalized and amenable to
subtraction, an area of dentin that had
supposedly not changed during the
study was taken as a ‘standard area’.
When changes in bone defect were
higher than the ‘standard area’ they
were considered as a gain in optical
density and gain in area filled by new
bone. For the test group, the same
analysis was performed with the images
taken immediately after the placement
of the graft and the 6-month radio-
graphs. Measurements were made
blindly with respect to test and control
groups. An example of the subtraction
radiography for test and control groups
is illustrated in Fig. 2.
The normality of the data was de-
fined by the Shapiro–Wilks test. The
data were organized and presented as
means and standard errors and ana-
lyzed by  to test the hypothesis of
no difference between test and control
groups for all the parameters, and to
determine the significance of changes
over time in each group.
A descriptive analysis was conducted
to assess the clinical relevance of the
data. A cut-off, three times the sample
error, was established for each par-
ameter. Measurements that were higher
or lower than this cut-off were con-
sidered as having respective gain or loss
for each parameter.
Results
Clinical results
Table 1 and Table 2 represent the base-
line and 6-month re-entry measure-
ments, whereas Table 3 compares the
differences between test and control
groups for the clinical parameters.
Examination of the data shows that
the mean CAL-V for the test group was
7.29 ∫ 0.22 mm at baseline and 7.40 ∫
0.22 mm at the end of the study. There
was no statistically significant differ-
ence (p ⬎ 0.05) for both test (Table 1)
and control (Table 2) groups between
the initial and final exams. Neither
there was any statistically significant
difference in CAL-V between test (ª
0.11 mm) and control (0.73 mm) groups.
No statistically significant difference in
CAL-H occurred between the baseline
and the final examination in either the
test or the control group. Although
three sites were clinically closed in the
test group, there was no statistically sig-
4 Palioto et al.

tween baseline and re-entry procedures.

Fig. 2 Subtraction radiography. (a) test site, (b) control site.
nificant difference in CAL-H between
the test and control groups.
Gingival recession was observed in
both test and control groups, but these
findings were only statistically signifi-
cant in the control group (p ⬍ 0.05)
(Table 2) and no statistically significant
differences in gingival recession could
be found between the two therapies
(Table 3).
The probing depth reduction was stat-
istically significant (p ⬍ 0.01) in the con-
trol group (1.34 mm) (Table 2), but not in
the test group (0.74 mm) (Table 2), be-
There was no statistically significant dif-
ference (p ⬎ 0.05) between test and con-
trol groups (Table 3).
There was a statistically significant
gain (p ⬍ 0.01) in BDL-V between the
baseline and 6 months in the test group,
but not in the control group. However,
there was no statistically significant dif-
ference between the test and control
groups for BDL-V (p ⬎ 0.05) (Table 3).
No statistically significant difference (p
⬎ 0.05) in BDL-H was found in the test
(Table 1) or control (Table 2) groups be-
tween the first examination and the re-
entry procedures. However, during the
re-entry procedures, three sites (two
buccally and one lingually) exhibited
partial closure of the osseous defects in
the test group. There was no statisti-
cally significant difference (p ⬎ 0.05) be-
tween the test and control groups (Table
3).
The ACL demonstrated a statistically
significant loss (p ⬍ 0.01) in the control
group (Table 2) and a statistically sig-
nificant gain in the test group (p ⬎ 0.01)
(Table 1) between the baseline and re-
entry procedures. A statistically sig-
nificant difference was observed when
the test and control groups were com-
pared (p ⬍ 0.01) (Table 3).

Table 1. Mean values and standard error of clinical parameters at baseline and final examination for test sites
Test sites

Baseline Final Standard error Difference p

CAL-V 7.29 7.40 0.2197 ª 0.11 0.7315
GML 3.03 3.83 0.2773 ª 0.80 0.0718
PD 4.31 3.57 0.3742 0.74 0.1955
CAL-H 7.01 6.42 0.6519 0.59 0.5382
BDL-V 8.75 7.64 0.1793 1.11 0.0014
ACL 7.36 7.12 0.1892 0.24 0.3931
BDL-H 7.30 6.44 0.4683 0.86 0.2264
p ⬍ 0.05 CAL-V Ω vertical clinical attachment level; GML Ω gingival margin level; PD Ω probing depth; CAL-H Ω horizontal clinical attach-
ment level; BDL-V Ω vertical bone defect level; ACL Ω alveolar crest level; BDL-H Ω horizontal bone defect level.

Table 2. Mean values and standard error of clinical parameters at baseline and final examination for control sites
Control sites

Baseline Final Standard error Difference p

CAL-V 6.77 6.04 0.3486 0.73 0.1729
GML 2.46 2.98 0.1341 ª 0.52 0.0228
PD 4.31 2.97 0.2710 1.34 0.0068
CAL-H 6.57 6.85 0.2121 ª 0.28 0.3749
BDL-V 8.14 7.30 0.2602 0.84 0.0940
ACL 6.28 7.00 0.1512 ª 0.72 0.0083
BDL-H 7.55 7.58 0.2147 ª 0.03 0.9325
p ⬍ 0.05 CAL-V Ω vertical clinical attachment level; GML Ω gingival margin level; PD Ω probing depth; CAL-H Ω horizontal clinical attach-
ment level; BDL-V Ω vertical bone defect level; ACL Ω alveolar crest level; BDL-H Ω horizontal bone defect level.
 GTR plus Bio-OssA in class III furcation 5

Table 3. Comparison between test and control mean changes for clinical parameters
Test Control C.V. Pr ⬎ F
CAL-V ª 0.11 0.73 41.901 0.1667
GML ª 0.80 ª 0.52 27.511 0.5284
PD 0.74 1.34 45.091 0.3706
CAL-H 0.59 ª 0.28 52.181 0.3814
BDL-V 1.11 0.84 34.521 0.5506
ACL 0.24 ª 0.72 28.791 0.0118
BDL-H 0.86 ª 0.03 52.311 0.2377
1
Transformed data (x π k), CAL-V Ω vertical clinical attachment level; GML Ω gingival margin level; PD Ω probing depth; CAL-H Ω horizontal
clinical attachment level; BDL-V Ω vertical bone defect level; ACL Ω alveolar crest level; BDL-H Ω horizontal bone defect level.

Radiographic results
Table 4 represents the comparison be-
tween test and control groups for op-
tical density (OD) and area of bone fill.
After 6 months, the subtraction radi-
ography showed a gain in OD of 4.51
grey levels for the test group and 3.53
for the control group (p ⬎ 0.05). There
was a loss of OD of 16.46 grey levels for
the test group and 23.39 for the control
group (p ⬎ 0.05).
The average area of the furcation
filled with new bone was greater in the
test (30.90%) than in the control group
(19.22%). This difference was not statis-
tically significant (p ⬎ 0.05). However,
the test group exhibited a loss in the
furcation area of 69.01%, whilst the
control lost 80.78%. There was no stat-
istically significant difference in fur-
cation fill between test and control
groups (p ⬎ 0.05).
A comparison was carried out to as-
sess any interference caused by the graft
material. There was no statistical differ-
ence when the subtraction radiography
was performed comparing the baseline
X-ray and the final X-ray to that taken
immediately after the placement of the
graft material (p ⬎ 0.05).
Descriptive analysis
The clinical relevance of the data is
shown by the buccal or lingual sites
Table 4. Comparison between test and control groups for radiographic parameters – optical
density (OD) and area of bone fill (A)
Test Control
. 2
OD loss ª 16.46 ª 23.39
OD gain. 4.51 3.53
A loss(%)* 69.01 80.78
A gain (%)* 30.90 19.22
1
Transformed data (x π k), 2transformed data arc sen [root square (¿/100)],
.
optical density: grey levels, *area of furcation fill: percentage.
(dots) that have gained or lost beyond
the cut-off (columns) (Fig. 3).
In the test group, 15% of the sites ex-
hibited gain in CAL-V and 25% ex-
hibited loss, whilst in the control group,
30% of the sites exhibited gain in CAL-
V and 20% exhibited loss. In the test
group there was a 30% reduction in
probing depth, and in the control group
there was a reduction in 50% of the
probing depths, whilst 20% exhibited a
greater probing depth in the test group
and 15% in the control group. Thirty
per cent of the test sites and 30% of the
control sites exhibited greater gingival
recession than at the beginning of the
study. In 10% of the test sites and 15%
of the control sites, less recession was
observed than at the beginning of the
study. The horizontal level of attach-
ment (CAL-H) was reduced in 30% of
the sites and augmented in 15% in the
test group and reduced in 30% of the
sites and augmented in 30% of sites in
the control group.
A greater fill of the osseous defect
(BDL-V) occurred in 55% of the sites
of the test group and a loss of bone oc-
curred in only 5%, whilst a greater fill
was observed in 40% of the sites in the
control group and loss was seen in 10%.
The test group exhibited a gain in 30%
of the sites in ACL and a loss in 25%.
The control group demonstrated a loss
in ACL in 60% of the sites and a gain
in 5% of sites. There was a greater gain
C.V. (%) Pr ⬎ F
44.20 0.4208
43.812 0.2294
30.871 0.2717
73.021 0.2729
in horizontal bone defect level (BDL-
H) in 20% of the sites of the test group
and loss in 5% of test sites. A gain in
BDL-H was observed in 25% of the
control sites and a loss seen in 20% of
the sites.
Discussion
The treatment of severe periodontal de-
fects, such as class III furcations, has
a low degree of predictability and their
regeneration remains a challenge.
The data obtained herein were evalu-
ated using parametric and descriptive
analysis. In the descriptive analysis, a
rigorous scientific criteria considering
three times the error as cut-off was
adopted to identify the clinically rel-
evant results. The use of such analysis
is justified by the reduced number of
controlled clinical trials using GTR
with or without a graft material in class
III furcations. Furthermore, by observ-
ing the data from a clinical point of
view, we can identify the significance of
the changes as a result of GTR therapy
and not only assess whether the mean
values are statistically significant or not.
The statistical analysis in this study was
conducted using the average of the lin-
gual and buccal surfaces. In the descrip-
tive analysis, the data of the buccal and
lingual surfaces can be visualized separ-
ately (Fig. 3) and also the wide vari-
ability of the data can be easily de-
tected.
The results of the present study dem-
onstrate no significant differences for
the clinical parameters, CAL-V, GML,
PD and CAL-H (p ⬎ 0.05), between the
baseline and the 6-month re-evaluation
in the test group (Table 1). There were
also no statistically significant differ-
ences, in the same parameters, between
the results of the test and the control
groups (Table 3). These results showed
that GTR associated with the inorganic
6 Palioto et al.
bovine matrix was not effective in im-
proving the clinical (soft tissue) meas-
urements. In the control group, there
was a significant reduction in PD (p ⬍
0.01) and a significant reduction in
GML between the baseline and six
month procedures (p ⬍ 0.05) (Table 2).
These results are similar to those re-
ported by Becker et al. (1988) although
the numeric values are lower than ours
(Table 3).
Although a statistically significant
difference was not observed in the
CAL-H between the test and control
groups (Table 3), the test treatment re-
sulted in the closure of three sites after
6 months: one became class I and two
became class II furcations. De Leon-
ardis et al. (1999) proposed three hypo-
theses to justify such findings: (1) the
presence of partially resorbed particles
of the graft hindering probe penetra-
tion, (2) true regeneration of connective
attachment due to the presence of the
graft which may have created and main-
tained a large space underneath the
membrane, or (3) true bone formation.
It may be speculated from these find-
ings that the closure of class III fur-
cations, although unpredictable, might
be feasible.
One extremely important factor for
successful regeneration at furcation and
non-furcation sites is the amount of
periodontium that remains apical and
lateral to the defect. In our study the
defects were large, sometimes affecting
proximal surfaces or associated with
vertical or circumferencial defects. Only
one out of 42 defects treated by Pontor-
iero et al. (1989) was identified, by
probing, as a class III furcation before
Fig. 3 Clinical relevance of the sites (buccally and lingually) for all the parameters. Columns Ω
cut-off Ω 3 ¿ the error. Dots Ω sites higher or lower than cut-off.
flap elevation; the soft tissue present in
or immediately outside the defect prior
to treatment prevented probe penetra-
tion and no attempt was made to re-
enter the sites after therapy to ensure
that the eight completely closed fur-
cations were in fact closed. In our study,
the defects were identified by clinical
probing following initial therapy. Dif-
ferences in methodology, especially in
the type of defect selected can explain
such different results.
Bone fill is the only component of a
regenerated periodontium that can be
accurately assessed clinically (Garret
1996). However, clinical evaluation does
not distinguish between bone that is at-
tached to the root surface via peri-
odontal ligament or separated from this
surface by a long junctional epithelium,
nor does it distinguish between bone
and encapsulated particles of graft ma-
terial. Most of the studies investigating
class III furcations do not use re-entry
procedures or subtraction radiography
to assess bone regeneration. In the pres-
ent study, the re-entry measurements
demonstrated significant bone fill in the
test group between baseline and 6
months (Table 1). However, it was poss-
ible to identify particles of the graft ma-
terial. It may be suggested that 6
months is a short time for all the ma-
terial to be resorbed and replaced by
new bone. There was no statistical dif-
ference in BDL-V between the test (1.11
π 0.17 mm) and control (0.84 π 0.26
mm) groups (Table 3). Nevertheless, the
descriptive analysis demonstrated a
gain in the bone defect level in 40% of
the surfaces in the control group and
55% in the test group. Conversely, there
was loss in the BDL-V in 10% of the
surfaces of the test group and 5% in the
control group. These results suggest
that the GTR, with or without bone
graft material, contributes in most
cases to diminish bone defects. In gen-
eral, 6 months after treatment, the teeth
were in function, with no mobility, and
clinically healthy.
The only parameter that exhibited a
statistically significant difference be-
tween test and control groups was the
ACL (Table 3). The descriptive analysis
of the data for the ACL parameter
corroborate the results of the statistical
analysis (Fig. 3). There was a gain in
30% of the sites in the test group and
in 5% of sites in the control group. In
contrast, 60% of the sites in the control
group exhibited a loss in ACL, whilst
25% of the sites of the test group lost
ACL. These results suggest that the di-
rect contact of the membrane with the
alveolar crest in the control group re-
sulted in resorption. Trejo et al. (1998)
demonstrated that contact with the
membrane could cause resorption in
healthy sites contiguous to the site to be
regenerated. The results of this study
are not in accordance with Anderegg
et al. (1991) who related that out of 15
pairs of class II or III furcation defects
treated by GTR, with or without
DFDBA, no difference was observed in
the degree of alveolar crest resorption
at re-entry between test and control
groups. Our results support the findings
of Duro & Lima (1998) who reported a
gain in the alveolar crest level after
GTR with bone autogenous graft in
class II furcations. Thus, it can be sug-
gested that the gain in ACL obtained in
this study is directly related to the use
of the graft material which probably
prevented the collapse of the mem-
brane. Furthermore, as the inorganic
bovine matrix is very similar to the hu-
man bone in its internal surface, po-
rosity, crystal size and calcium-phos-
phorous ratio, it may contribute to
bone regeneration (Table 3).
There were no statistically significant
differences (p ⬎ 0.05) in the BDL-H be-
tween test and control groups, nor be-
tween baseline and re-entry procedures.
The descriptive analysis showed only
two sites had undergone closure of the
furcation defect at the surgical re-entry
procedure. It may be suggested that
each patient has a different healing po-
tential that could directly influence the
response to treatment.
There were no statistical differences

in the parameters analyzed by subtrac-
tion radiography. Our data do not agree
with those of Eickholz & Hausmann
(1997) who demonstrated a gain of 40%
in area in class II and class III fur-
cations. The authors did not evaluate
the loss inherent to the region analyzed
with the argument that, particularly in
class III furcations, the instrumentation
inside the area of the furcation led to a
reduction in cementum and dentin that
could be quantified in the subtraction
radiography as loss of bone. There is no
doubt that cementum and dentin are re-
moved in these procedures, but the loss
assessed in this study for optical density
and area was considerable and may be
explained only by the removal of min-
eral in the roof of the furcation. The
loss assessed here was a consequence of
the treatment performed. This problem
could be resolved by taking a radio-
graph immediately after the surgical
procedure. In the present study, such a
radiograph was taken to assess the in-
fluence of the radiopaced graft material
used. The statistical analysis showed
that there was no difference between the
subtraction radiography of the total
period of the study and the subtraction
performed with the radiographs taken
after the surgical procedure and the fi-
nal evaluation (data not shown). The
radiographic results presented are of in-
terest, but must be taken with caution
as they represent changes which oc-
curred over a 6-month period. Bragger
et al. (1992) observed statistically sig-
nificant differences only after 12
months.
The anatomy of the class III fur-
cation defects in mandibular molars
may be responsible for the lack of pre-
dictability of the guided tissue regenera-
tion with or without the use of the
grafting material. Among these factors,
the morphology of the roots and the
radicular trunk, the morphology of the
bony defect, and the amount of remain-
ing periodontium, may play a role in in-
fluencing the healing capabilities of a
given site. It might be that bilateral de-
fects would have been more reliable in
discriminating between test and control
treatments due to less variability in en-
vironmental factors. However, the re-
sults are so variable that such a design
would hardly have added more to the
outcome because, most of the times,
within the same patients the defects
were considerably different.
The results of this clinical trial re-
jected the null hypothesis for the par-
GTR plus Bio-OssA in class III furcation
ameter ACL. For all the other par-
ameters the null hypothesis was con-
firmed. There is no evidence to prove
that the association of GTR plus bo-
vine inorganic bone matrix is a predict-
able treatment for class III furcations in
humans.
Acknowledgement
This study was supported by grant nos.
97/02801–6 and 97/02800–0 from the
Fundação de Amparo à Pesquisa do Es-
tado de São Paulo – FAPESP.
Zusammenfassung
Klinische und röntgenologische Evaluation der
Behandlung von Furkationsbefall Grad III un-
ter Anwendung der GTR sowohl mit als auch
ohne anorganischen Knochenmatrix
Ziel: Das Ziel dieser Studie war es, bei Fur-
kationsbefall den Effekt der GTR allein und
in Verbindung mit der Applikation einer bo-
vinen anorganischen Knochenmatrix zu eva-
luieren.
Material und Methoden: Bei 18 Patienten,
35–75 Jahre alt und Nichtraucher wurden
zwanzig Furkationen mit Grad III behan-
delt. Bei der Eingangsuntersuchung und bei
der erneuten Aufklappung 6 Monate später
wurden horizontalen (CAL-H) und vertika-
les Attachmentniveau (CAL-V), Sondie-
rungstiefe (PD), Gingivaverlauf (GML),
Ausmaß des horizontalen (BDL-H) und ver-
tikalen Knochendefektes (BDL-V) sowie die
Höhe des Limbus alveolaris (ACL) be-
stimmt. Die Subtraktionsröntgentechnik
wurde verwendet, um den Gewinn oder Ver-
lust an optischer Dichte (OD) und die Fläche
der Knochenauffüllung (A) (Eingangswert/
Sechsmonatswert) zu bestimmen. Nach der
Aufklappung wurden die Stellen nach Ran-
domisierung entweder mit GTR π Bio-OssA
(Test) oder alleiniger GTR-Behandlung
(Kontrolle) behandelt. Die Ergebnisse wur-
den mittels ANOVA evaluiert.
Ergebnisse: Für die Kontrollgruppe ergaben
sich signifikante Unterschiede zwischen der
Eingangsuntersuchung und der erneuten
Aufklappung bezüglich PD, ACL (p⬍0,01)
und GML (p⬍0,05) und in der Testgruppe
waren die Unterschiede bei BDL-V (p⬍0,01)
signifikant. In der Testgruppe gab es einen
Gewinn an ACL und bei der Kontrollgruppe
war eine Reduktion des ACL zu sehen
(p⬍0,01). Bei der OD und der A wurden kei-
ne Unterschiede beobachtet.
Schlussfolgerung: Die Ergebnisse dieser Stu-
die zeigen, dass Furkationsbefall Grad III
unter Anwendung der GTR oder der GTR
in Kombination mit einer anorganischen
Knochenmatrix nicht vorhersagbar beseitigt
werden kann.
Résumé
PLEASE provide missing French abstract.
7
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Address:
Daniela Bazan Palioto
University of São Paulo
School of Dentistry of Ribeirão Preto
Av. Do Café, S/N
Ribeirão Preto SP
Brazil
14040-904
e-mail: dpalioto/forp.usp.br