the International Journol of Periodonhcs & lesloiotive Dentistry

17

The Utilization of Rubber Dam as a Barrier

Membrane for the Simultaneous
Treatment of Multiple Periodontal Defects
by the Biologic Principle of Guided Tissue
Regeneration: Case Reports

Henry Saloma. DMD' In 1976, Melcher^ suggested

Fabio Rigotti. DMD" that the kind of healing fhat fol-
Rodolfo Gianserra, DMD'
lows periodontal therapy Is
Jay Seibert. DDS""
determined by fhe type of cell
fhaf firsf repopulafes fhe roof
surface. Subsequent investiga-
tions ^"^ indicated that healing
in most periodonfol procedures
The principle ot guided tissue regenerotion has demoristroted o level ot occurs by fhe formation of a
success in regenerating /he periadontai attachment apparotus lost fo
long junctional epithelium on
periadontal disease. Several types of membrane barriers, eoct) one with
distinct properties, tiave been utilized to apply this principle in periodontot
previously diseased roof sur-
waund tiealing. A series of case reports introduces and discusses the attri- faces. These results demon-
butes ot rubber dam as a barrier membrone for tiie treatment of multlpie strated that epithelium is usu-
periodantal osseous detects. Comparison at preaperative and pastopera- ally fhe first fo repopulate the
tive clinical meosurements as well as reentry pracedures are ufdized to root surface and suggested
higiilight successtui osseous regeneration. (Int J Periodont Rest Dent that in so doing it may inhibit
]994;14:17-33.) new attachment formation.
In a series of articles pub-
lished in the early 1980s,
Karring, Nyman, and co-
warkers*"^ determined that if
bone or gingiva! conneotive tis-
* Assistont Clinicai Professor of Periodontics ond Periodontal-
sue is selectively put in direct
Prosttiesis, Codirector of Implant Surgeri'. University of contact with the root during
Pennsylvania. Schooi ot Denfol Medicine healing, if will promofe roof
*Po6tgroduate student in Periodonfics, University of
Pennsylyonio, Sctiool of Dentol Medicine.
rsorption rather than the for-
Private Practice, I? o me. Italy. mation of a new conneotive
*Protesso( ond Chairmon of Periodontics. Universiiy of tissue attachment. In 1982,
Pennsylvanio, Scticol of Dental Medicine.
Nyman and coworkers''^ uti-
Correspondence to: Di Heniy Salama. University of lized a Millipare filter (Millipore)
Pennsylvonio, Sctiool of Dentol Medicine. 4001 Spruce Street as a barrier membrane to
Ptiiladelphia. Pennsvivania 19104.

Volume 14, Number 1, 1994

 18
exclude botfi the gingival
epitheliufn and connective tis-
sue from the wound site. This
opproach allowed for the cre-
afion of a space that favored
cells from fhe pefiodontal liga-
ment and endosfeal apices fo
be the first to migrate olong
the root and torm o new
attachment apparatus,
Subsequent to the Millipore
filter, expanded polytetrafluo-
roethylene material (e-PTFE;
Gore-Tex periodontal material
(GTPM; WL Gore)) was used as
the barrier membrane in the
successful regenerative ap-
proach that became i<nown as
guided tissue regeneration
(GTR),"-'^ Today, the principle
of GTR forms the basis for most
regenerative periodontal pro-
cedures.
As the biologic principle of
GTf? has become more univer-
sally accepted, efforts have
focused on enhancing its suc-
cessful application by improv-
ing materials ond surgical tech-
niques, The barrier membrane,
an integral component ot the
technique, has received o
great deol of attention. The
optimal design and attributes
tor an occlusive membrane to
be used in the open system cf
the sulcus envionment ore
complex. To date, the charac-
teristics emphasized hove
included biocompatibllity. the
ability to retard epithelial
migration, manageability, ade-
The International Journal of Periodontics & lestorotive Dentistry
quate rigidity tor space mainte-
nonce, and the ability to allow
tor tissue integration.
In addition to the neces-
sory membrane characteristics
listed above, on importont pre-
requisite for successful peri-
odontal GTR therapy is proper
membrane placement. The
membrane must completely
seal off the defect environ-
ment. Intimate adaptation ot
membranes, however, is very
difticult in areas of furcations or
oround irregulor root surfaces
exposed by periodontal dis-
ease,'" These root surfaces ore
concave interproximolly and
otten associated with ditferent
degrees of fluting, which can
prevent complete adaptation.
The inability to seal ott the
detect environment trom
impregnation with oral tluids
and bacteria moy compromise
the eorly healing phase ond
therefore the potentiol tor
ochieving the moximum de-
gree of regeneration.
fvlembrane adaptation is
even more demanding when it
is necessary to treat several
adjacent teeth exhibiting multi-
ple periodontol osseous de-
tects and root irregularities (Figs
l o to Id). None of the mem-
brane materials presently avail-
able is designed to address the
complex topography of multi-
ple detects witti Just one mem-
brane. The necessity ot placing
several membranes and sets ot
sutures complicates odapta-
ticn and is extremely technique
sensitive ond time consuming.
The limitotions mentioned
make presently available
membranes difticult to utilize
and adapt in the treatment of
multiple periodontal defects. It
would therefore seem odvan-
togeous if an occlusive mem-
brane were available that
meets the requirements ot GTi?
while being easily manageoble
and completely a d a p t a b l e
around multiple defects.
Zaner et al'^ utilized freeze-
dfled dura mater allogratts os a
"biologic bandage" to cover
and protect several adjacent
periodontal osseous defects
being treated with autogenous
bone gratis. Lekovic et al"'suc-
cessfully utilized silicone rubber
as occlusive membranes in the
treatment ot grade II furcations
in dogs. La Rocca suggested
the use ot rubber dam as a
barrier membrane for GTR pro-
cedures in humans (Lo Rocca
F, personal communication,
March 1992) (Figs 2a to 2d).
Figs Ja to Id Complex defect environments requiring more
thon one conventional membrone.

Fig )a Circumferential distoi ond lingual infiobony deteots

onteetti3and37.

Figs lb and Ic One inteipioximoi Goie-Tex periodontol membrane (GTPM) placed to isolate the detect around tooth 37 is no
sufficient to address the defect surrounding tooth 36. which extends to the buccal surfaces.

Fig Id A second interproximal GTPM membrane has been

piaced to isolate both defects completely. (Figs oto Id
oourtesy of Dr Mauiice Saiamd. Atlanta. Georgid.)

Volunte 14. Number 1, 1994

 20

Fig 2a Infrabony defects between teeth 32 and 33 and 30 Fig 2b Rubber dam membrane in place isolating ttie defects
and 31. from tfie soft tissues.

Figs 2c Sutured flaps Fig 2d Reentry at montais Note the complete osseous tiil of
the detects, inciuding suprocrestot regeneration Figs 2a to 2d
Courtesy of Dr Fabrizio La Rocca. Novara. Italy.

The purpose of this paper is
to present the resuits of a ciini-
cal triai evaiuatng the paten-
tial use of rubber dam os the
occiusive barrier in the simuita-
neous treatment of muitipie
periodontai osseous defects by
GTR. Comparisons of preopera-
tive and postoperative ciinicai
measurements as well as reen-
try procedures are utilized to
evaluate resuits. Advantages
and disadvantages ot the
materiai will be discussed ds
they reiate to the accepted
criteria for a successfui occiu-
sive membrane in regenerative
periodontai therapy.

The International Journoi of Penadontics & Restorative Dentistry


Method and materials
Ten patients (seven women
and three men aged 29 to 52
years) who presented with
odvanced periodontai disease
participated in this clinical triai.
The therapeutic approach was
fully explained and each
patient consented to the pro-
posed treatment. The criteria
for selection were (1) the pres-
ence of ot least four sites in a
quadrant exhibiting probing
depths of 7 mm or greater; and
(2) the presence ot existing
multjpie osseous detects for
which regenerative treatment
utiiizing the principies of GTR
wouid require the placement
of more than one commer-
ciaiiy avaiiabie membrane.
Aii patients underwent ini-
tial therapy, which included
oral hygiene instructions, quad-
rant scaling and root planing
under iocai anesthesia, and
caries controi. At ieast weeks
af^ef initiai infiammatory con-
trol and prior to surgery, the
probing attachment ievel (PAL)
was measured for the sites to
receive regenerative therapy.
Where furcation invoivement
was present, PAL was mea-
sured in both the vertlcai and
horizontal dimensions into the
furcation. Vertical measure-
ments utiiized the cemento-
enamel junction CCEJ) as q
fixed index.
Surgical design
Suicular incisions were utilized
to maintain as much tissue as
possibie for membrane cover-
age. The incisionoi design was
extended mesiaiiy and distaHy
to inciude at ieast one reia-
tiveiy heaifhy tooth thot did not
require regenerotive therapy.
This design ensured that any
vertical reieasing incisions
would not lie over on orea
receiving a membrane, in
addition, the extension of the
surgical site was neoessory to
allow the stretching ond proper
adaptation of the dam materi-
al post the teeth that required
treotment. Verticoi reieasing
Incisions, placed to include the
terminai papillae, were utilized
to goin complete access to the
defects, Full-thickness muco-
periosteal tiaps were roised to
expose at least 3 mm ot bone
adjacent to the defects.
Partioi-thickness dissection was
performed apicaily from that
point to oiiow coronal position-
ing ot the buccal flop to further
ensure complete coverage of
the membrane at the time ot
ciosure ond during the early
healing phase.
Subsequent to fiap eleva-
tion, the root surfaces were
scaied and root planed with
hand instruments, ultrasonic
sealers, ond fluted burs. Whiie
all granulation tissue wos
removed, no osseous recon-
touring was performed. The
level of the aiveoiar crest and
21
the apioai extension of the
infrabony defects were mea-
sured with a probe and re-
corded,
Once the defects were
compiefeiy instrumented, a
piece of steriiized rubber dom
was trimmed to conform to the
number of teeth present in the
surgical site ond to the topog-
rophy of the defects. Holes
were made in the dam with a
sterile rubber dam punch. Tne
membrone wos extended to
inciude at ieost one healthy
tooth on either end of the
detect environment to ensure
that the membrone border
would be ot an appropriate
distonoe (3 to 4 mm) beyond
the edges of the defects. In
three subjects it was necessary
to apically suture the mem-
brane to the submuccsoi tissue
with resorbable Vicryl sutures
(Johnson & Johnson) to secure
the edges ot the membrone in
piace. The fiops were then
coronaily positioned and
sutured with Gore-Tex suture
material (WL Gore) to ailow
extended stabilization of the
popilloe over the membrane.
Representative cases are
shown in Figs 3 to 7.
Volume 14. Number 1, 1994
 22

Fig 3a [left) Distal detect araund toath

18 with a Class II tufcatlon involvement.

Fig 3b (right) Circumferential defect

around tooth 5.

Fig 3c Rubber dam mernbrane in
place, isolating the defects and span-
ning the edentulous ridge.
Fig 3d Reentry at 6 months. The Fig 3e loath IS at reentry.
detect around the maxillary right pre-
molar is completely tilled, and same
supracrestal bone regeneration is
observed

Fig4a Toath 17 exhit:nts signiticant Fig 4b Rubber dam membrane in Fig 4c Reentry at months. The peak
Intraosseaus defects on the mesial and place. otbone on the palatal aspect of tiie
distal aspects with Class II furcation second molar has been lost, buf almost
involvement. complete fill has been achieved on
the mesial and distal aspects, including
regeneration of the furcation areas.

The internationai Journdl of Petiodontics & Restorative Dentistry

 23

Fig 5a The maxillary right quadrant hos O series af angulof

detects ond ctofers.

Fig 5b Deep osseous defects ore evident ot initial surgery

inoludirig o Closs li furcotion on the buccal surface of
tooth 16

Fig 5c Rubber dam membtone in position Fig Sd Reentry at 7 months Note the osseous fill at the
angular ond crater defects os well as the buccal furcation cf
tooth 16.

Volume 14, Number t,

24

Hfl)
Fig 6a Maxiiiaiy light quadrant. Fig 6b Extensive defect environment,
including Class III trifurcdtion of the first
molar

Fig 6c Probe in place on the distdl

aspect of the first premolor.

Fig 6d Membrane in place aftei Fig 6f Reentry ot months. Note tne

remdVdi cf the roots of the first moldr complete regeneration of the defects
and splinting of its crown to the adjd including the opicai piate af bone on
cent teeth. Ttie membrane has been the first premolar.
trimmed to span ttie edentulous ridge.

Fig 6e interproximal area between

the premoiars dt membrane removal.

The Intemationol Jourrtol ot Penodon^ics & Restorative Dentistry

 25

fig 7a Mesial angutar defects on the centrai incisors. Note Fig 7b tvlemb'one in piace prior to suturing.
the ndge concavities thai are associated with this site

Fig 7c Six weeks prior to membrane removoi Note the per- Fig 7d Reentry at 6 months. Osseous fill ot the delects nas
foration ot the lobial flap by the membrane. been achieved. In addition, the ridge dimensions have been
enhanced. Figs 7a fa 7d Courtesy of Dr Fernando Presser.

Volume 14, Number 1, 1994

 26

Fig 6 Chdnges in mean probing attachment levis meosured after scaling and
roat planing (DayO) and the some sites at 4 months New ottachment gam ranging
between 2 and 5 mm was evident on oil subiects

Postcperafive care Results Probing attachment ieveis

Foilowing surgery, the patients
were prescribed doxycycline
(100 mg twice o day) for 2
weeks and instructed to rinse
with 0.127o chiorhexidine three
times daily for the duration ot
treatment. The patients were
examined at weekiy intervals.
Tissue response was monitored
and the teeth were polished.
The membranes were removed
4 to 6 weeks after placement.
The PAL was determined at 4
months and reentries were per-
formed at 6 to 7 months post-
surgically.
Ali membranes became ex-
posed interproximally by the
second weekly visit. In four
patients it wos necessary to
resuture the papillae at the 3-
week recali visit to regain
approximation ot the papillae
and to stabilize the flaps. The
levei of gingivai inflamma-
tion around the membranes
ranged from minimai to moder-
ate. None of the sites, howev-
er, exhibited sweiiing or suppu-
ration at any of the recall visits.
Aii membranes were removed
between 4 and weeks.
were recorded just prior to
membrane piacement and 4
months after surgery. There was
a gain of clinical new attach-
ment in all sites measured.
Attachment gain omong sites
ranged between 1 and 8 mm.
The range among patients was
2 to 5 mm of new clinical
ottachment (Fig 8), The mean
goin ot probing attachment
for aii sites in aii potients was
3.64 mm.
The intraosseous probing
measurements were recorded
at membrane piacement and
reentry, which took place 6 to

The Internationai Journal of Periodontics & Restorative Dentistry


jects (7 and 10) were nat ovaiiable tar follow-up reentries and were not included in
7 months lafer. Two pafients
were not available tar reentry
evaluation. The range of
osseous regenerafion (mea-
sured by open probing) among
the remaining eight patients
was 2,4 to 7.5 mm (Fig 9). The
mean osseous fiil for all sites
was 4.25 mm. Three of the
patients exhibited 1.0 to 3.5
mm af supraoresfai osseous
regeneration (see Figs 3, 6, and
7). The remaining tive pafienfs
had d e f e c t fiii that ranged
from 80% to 95%.
Fig 9 Changes in mean intraosseous probing depth measulred using the CEJos a
landmark and taken during the initial surgical procedure and ot reentry. Two sub-
the meosurements.
Discussion
The objective of this clinical trial
was to evaluate the use ot rub-
ber dam as the occlusive barri-
er in the treatment of multiple
periodonfal osseous defects by
the principle af GTR. It has
been suggested that there are
specific design criteria for an
occlusive membrane to meet
the requirements of GTR.'""
These criferia include bioccm-
patibility, manageabiiify,
space-making ability, and the
ability to allow for tissue inte-
gration with fhe membrane,
Resorpfive capacity has also
been discussed as an optiana!
attribute because of its thera-
peutic convenience.'^
27
To date, e-PTFE has been
fhe most successful and widely
sfudied membrane material fo
be utilized for regenerative
therapy. Recently, blodegrad-
abie barriers, such as colla-
membranes, have received
cansiderable attentian and are
alsa being used successfully
in achieving GTR around se-
lected defects. In evaluating
the present clinical results, the
abiiity ot rubber dam ta act as
an occlusive barrier in GTR was
measured against the criteria
that have been established for
existing membranes.
Volume 14, Number 1,1994
28
Biocompatibility
When we considered using
rubber dom material as an
occlusive membrone in GTR
procedures tor our patients, our
first consideration was its bio-
compatability. The transmucos-
al use of rubber-type materials
as drains in oral and maxiilo-
tacial surgery has been ac-
cepted for decades.^^^' In
addition to rubber dam, mony
types of basic rubber drains
are in common medicol
usoge, including Foley
catheters, red rubber French
catheters, tubular "cigarette"
drains, and the widely accept-
ed Penrose drains,^''
There are also precedents
in the literature for using rubber
moterials in GTR procedures.
Lekovic et GL''*'^^ in a series of
experiments on dogs, com-
pared silicone rubber with
three other types ot mem-
branes tor applicotion in GTR
procedures. In on effort to
evaluate the inflammatory
response, they conducted
stereometric surveys of the
treatment sites. Their findings
demonstroted that the per-
centages ot plasma cells in the
sites treoted by silicone rubber
membranes were comparable
to those measured at the sites
treated by PTFE membranes
and those in the control group,
which did not receive any
membranes.
Because of their tendency
to became exposed, the
The Internotionol Journal of Periodontics & Restorative Dentistry
intlommatory response is ot
speoiol concern when mem-
branes are used to treat peri-
odontal detects. It exposed,
they allow intiltration and colo-
nization by bacterial cells and
their by-products into the heal-
ing wound. This intiltrotion may
lead to chronic intlammation
or an acute infection beneath
the surgical flap, probably
compromising healing ond
regenerative capacity and
necessitating early removal of
the membrane. DeMolon et
a|2* studied the bacterial colo-
nizotion associated with GTR
procedures using GTPM in
humans. Utilizing an oligonu-
cleotide DNA probe, they con-
cluded that GTR procedures
result in the presence ot several
periodontal pathogens on the
GTPM and in the surrounding
crevicular fluid. Further, they
found that the moteriol is tre-
quently associated with severe
inflommation that sometimes
includes suppurotion.
While the rubber dam
material invariably became
exposed interproximaily. none
of the subjects treated in our
clinic displayed any hint of
swelling or suppuration at the
treatment sites during their
weei<ly maintenance visits. One
possible explanation may be
that the rubber dam promotes
droinoge. while its nonporous
surface may reduce plaque
adherence and theretore may
be easier to cleanse during the
course of membrone mainte-
nonce. More subjects need to
be studied and the rubber
dam membrones must be cul-
tured, however, to determine
the consistency of these obser-
vations, the mechanisms in-
volved, ond the clinical signiti-
cance to periodontal regen-
eration.
ManageabHity
The obility of rubber dam to
intimately and easily adapt to
severol teeth in one applica-
tion is a unique advontage ot
this material. A related advan-
tage is the elimination of the
need for multiple sutures and
suture knots. This capobility was
felt to be ot clinical signifi-
cance because it decreased
the time required to perform
the surgical procedure. The ini-
tial attempt at designing ond
placing the rubber dom may
be somewhat tedious, but the
technique becomes easier with
experience.
Ability fo maintain a space
In experiments using GTR.
Gottlow ond Nyman" found
thot the volume and shape of
the tissue generated under the
membrane seem to be deter-
mined by the configuration of
the "artificial space." Caton et
al^"" evaluated the potential for
GTR in interproximal defects in
the monkey. They determined
that a larger omouht of regen-
eration occurs when the borrier
is mointained ot a more coro-
nal level. In contrast, when the
barrier coiiapses into the angu-
lar defect, it results in only a
small amount of regeneration.
Their conciusion was that the
amount of regenerotion is
determined by the position of
the borrier membrane.
On its own, rubber dam has
no capability to retoin a given
shape of ony kind. Once
placed ot a levei close to the
CEJ, however, the rubber dam
has the ability to retain its posi-
tion, ollowing a tenting effect
thot creotes and maintains an
enhanced interproximal "re-
generative spaoe" for GTR, For
large defects that inciude sig-
nificont loss of the labiai or lin-
gual plates ot bohe, osseous
grotts may be necessary to
help support this artificial spooe
durihg regenerotion.
Tissue integrotion
Oonnective tissue integration
into the membrane is an impor-
tant requirement for an occlu-
sive barrier utiiized in GTR pro-
cedures. The advantages ot
integration include increosed
stabiiization of the membrane
and surgioai fiops as well as lim-
itation of epithelial migrotion
on the flap's inner suffoce. The
lack of this characteristic was
the main observable disadvan-
tage of the rubber dam mem-
brane. The some nonporaus
surface that minimized micro-
biol coiohization mode tissue
integratioh impossible. This con-
sequently mode maintenance
more demonding, because it
resulted in somewhat eorlier
exposure of the membrone
ond ehhanced epithelioi
migration dovi/n the inner
aspect of the mucogingivai
flap compared with other
materials.
Becouse of the resulting
lock of flap stabilizotion, reces-
sion wos o consistent finding.
While this recession helps to
reduoe evehtual probing
d e p t h , it moy result in an
esthetic compromise ahd must
be token into considration
when treoting the anterior sex-
tants.
As with e-PTFE mem-
brones.^^ removal ot the rubber
dam membrone is suggested
between 4 and weeks, ond
de-epithelialization of the inner
surface of the fiop is required
at membrane removol. It is
apparent from these successful
results that the degree and
amount ot regeneration were
not odversely offected by the
ditficulties caused by lack of tis-
sue integration into the mem-
brane.
Advantages unique to
rubber dam material
In oddition to the estoblished
criteria highlighted, the char-
acteristics that we believe wiil
require more emphosis in the
future inciude odaptability ohd
permeability.
Adoptability. Root irregu-
lorities ore often associated
with conoovities that connot
be bridged by ahy type of
membrone v^/ithout the cre-
otion of o gap. Lu''' tound thot
neorly 94% of the molor teeth
tested hod a concavity depth
that prevented the open
microstructure ot the PTFE
membrane to odapt to the
root surfoce. Those results sug-
gested that this gop may not
prevent the migration of oon-
nective tissue or epithelioi cells
into the regeherotive space
ond thereby may iimit regeher-
ation. We believe thot any
breoch between the tooth ond
the membrone can be o
source for the constant infusion
of oral fluids ond bocteria,
which moy also act to limit new
ooronol attachment. The ditfi-
culty of ochievihg a tight
adaptation of the membrane
to the root surface is further
magnified when it is necessary
to treat o series of adjoceht
periodontal defects.
One ot the most important
advantoges ot o rubber dam-
type of membrane resides in its
abiiity to odopt intimately to
tooth surfaces. This adaptobiiity
con be easiiy achieved and
con be maintained ot o more
coronal level on the root(s)
thon con other materials.
Volume 14, Number 1, 1994
30
Coronai piacement is impor-
tant for creating more space
for regeneration, it is diso criti-
cal because root irregularities
become more pronounced as
attachment loss progresses
apicaiiy into periodontal
defects. More coronal plaoe-
ment thus simpiifies the man-
agement of the most severe
defeot regions.
Permeability. Se ver ai
recent studies indicate that
bacteria ore capabie of tra-
versing through e-PTFE mem-
branes,^'"^' Guiiiemin et al,-'^ in
scanning electron mioroscopic
observations of interproximol
e-PTFE type membranes in
humans, found microbiai con-
tamination on both sides of the
membrane as well as within
the open microstructure ond
occiusive portions. They con-
ciuded that the presence of
iarge plaque loads may be
one factor that may interfere
with regeneration. During the
initiai stages of heaiing, Pitaru et
ol^^ observed that eariy degra-
dation of the coronai portion of
coilagen membranes can be
caused by enzymes originating
from the saiiva and/or the
inflammatory response in the
coronai aspects of the fiaps.
They suggested that this may
permit the coionization of the
coronal root surface by epithe-
lial and fibrabiast ceiis, thereby
compromising new attachment
formation.
The internationai Jaurnai af Periodontics & Restarative Dentistry
The nonporous and imper-
meable nature of rubber dam
aiiows it to seai and protect the
regenerative space from infii-
tration by epitheliai ceils as well
as from the influences of salivo
and baoteria and their by-
products. In addition, because
it is nonresorbable. this protec-
tion can be maintained
throughout the course of thera-
py, provided that the rubber
dam is not subjected to exces-
sive movement or tension.
General cansideratians
A careful anaiysis of the
advantages and disadvan-
tages of availabie membranes
must be conducted prior to
choosing one for use in GTR
procedures. Each type of
membrane seems to possess a
unique set of desirabie charac-
teristics, it is imperative to
match these characteristics to
the particular set of challenges
presented by each unique
patient, appiication, and
defect environment. In this ciin-
ical trial, we chose rubber dam
membranes far their ability to
isolate the defect space and
adapt intimateiy about teeth
with multiple adjacent peri-
odontal defects, in addition,
the low oost ot the materiai
matched the needs ot the
patient pooi, most of whom
were unabie to afford the cost
of multiple conventional mem-
branes that wouid have other-
wise been necessary for a
series of staged surgicai proce-
dures. While lacking the abiiity
to allow tissue integration, the
rubber dam demonstrated
enough positive attributes to
consistently achieve successful
osseous regeneration in this iim-
ited patient sampie,
Gottiow and coworkers'^
reported on new attachment
formation in humans by guided
tissue regeneratian. They con-
ciuded that, "despite the evi-
dence ot significant amounts
of new cementum and fibrous
aftachment at aii sites treoted,
regeneration of aiveoiar bone
was almost exclusively restrict-
ed tc sites where angular bony
defects were present before
treatment." This iack of supra-
crestai bone formatian is con-
sistent with cur own previous
ciinicai experience with GTR,
However, the meosured suc-
cess in achieving supracrestai
bone regeneration in the pres-
ent study prompts the query
into what attributes rubber
ddm may have toward achiev-
ing this resuit more consistently,
Adaptabiiity and impermeabiii-
ty may piay a roie. Controlled
clinical studies are currentiy
underway in our ciinic to
explore the histoiogic and
microbiologie aspects of the
regenerative environment
associated with the use of rub-
ber dam as an occiusive mem-
brane.

We are presently unaware
ot any singie type of mem-
brane that possesses the quali-
ties to address all of the chal-
lenges posed by the many
ditterent osseous defects and
circumstances routinely en-
countered. Indeed, the pur-
pose of the present study was
not tc develop and present on
ideal method tcr the clinicai
appiication ot GTR, father, it
was to introduce the successfui
use of a new barrier and its
appiication, whiie suggesting
areas tor future emphasis and
research.
To reach the fuli potential
ot GTR, we believe that it will
be necessary to set different
requirements for membranes
ufilized in the predominantly
closed environment of ridge or
peri-impiant augmenfation
prooedures and for those used
under the more chalienging
open suicus environment found
in periodontal therapy. These
new standards would require
new membrane designs as weii
as new materiai characteristics,
it is opporenf that the evoiution
in membrane design and
materiai has yet to catch up to
the successful and established
principles of GTR.
31
Canclusions Acknowledgment
A new dental use for rubber The authofs w o u l d like to t^^a^\k Dr
Shirley Brown for her invaluable contri-
dam OS on acceptable barrier bution to the editing of this manuscript.
membrane was evaluated in o
clinical trial in 10 specially
seiected patients. Eoch ot
these patients exhibited exten-
sive multipie periodontai os-
seous detects in at ieast one
quadrant. Comparison of pre-
operotive and postoperative
probing attachment ieveis as
weii as reentry osseous mea-
surements demonstroted highly
suooessfui periodontai regener-
ation.
The main advontages of
rubber dam membranes seem
to be ossocioted with their abil-
ities to intimately odapt coro-
nai to oompiex root topogro-
phies and to seai off the
surgical regenerotive sites trom
oral fiuids and bacterio. In
addition, severai odjaoenf
defect environments can be
easliy treated with just one
membrane. The resuits ot this
preiiminary study suggested
that prediotabie regenerotion
of the ottachment apparotus
can be accompiished when a
rubber dam membrane is used
OS the occiusive barrier in GTR
procedures. Whiie the rubber
dam membrane showed
promise in this appiication qnd
potentiaiiy has other applico-
tions, the limitations of this
materiai moke it clear thot the
evolution of membrane design
ond materiois must continue.
Volume 14, Number I, 1994
32

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Voiume 14, Number 1,1994