Melcher AH, Bowen W,HLondon: Academic Press; 1969
Melcher AH On the repair potential of periodontal tissues. J Periodontol. 1976; 47:256-260
Nyman S, Lindhe J, Karring T, Rylander H New attachment following surgical treatment of human periodontal disease. J Clin Periodontol. 1982; 9:290-296
Susin C, Fiorini T, Lee J Wound healing following surgical and regenerative periodontal therapy. Periodontol 2000. 2015; 68:83-98
Tonetti MS, Pini-Prato G, Cortellini P Effect of cigarette smoking on periodontal healing following GTR in infrabony defects. A preliminary retrospective study. J Clin Periodontol. 1995; 22:229-234
Herrera D, Sanz M, Kebschull M Treatment of stage IV periodontitis: The EFP S3 level clinical practice guideline. J Clin Periodontol. 2022; 49:4-71
Nibali L, Sultan D, Arena C Periodontal infrabony defects: systematic review of healing by defect morphology following regenerative surgery. J Clin Periodontol. 2021; 48:100-113
Rasperini G, Acunzo R, Barnett A, Pagni G The soft tissue wall technique for the regenerative treatment of non-contained infrabony defects: a case series. Int J Periodontics Restorative Dent. 2013; 33:e79-87
Tsitoura E, Tucker R, Suvan J Baseline radiographic defect angle of the intrabony defect as a prognostic indicator in regenerative periodontal surgery with enamel matrix derivative. J Clin Periodontol. 2004; 31:643-647
Nibali L, Sun C, Akcalı A The effect of horizontal and vertical furcation involvement on molar survival: a retrospective study. J Clin Periodontol. 2018; 45:373-381
Tonetti MS, Christiansen AL, Cortellini P Vertical subclassification predicts survival of molars with class II furcation involvement during supportive periodontal care. J Clin Periodontol. 2017; 44:1140-1144
Pontoriero R, Lindhe J Guided tissue regeneration in the treatment of degree III furcation defects in maxillary molars. J Clin Periodontol. 1995; 22:810-812
Cortellini P, Tonetti MS Evaluation of the effect of tooth vitality on regenerative outcomes in infrabony defects. J Clin Periodontol. 2001; 28:672-679
Cortellini P, Tonetti MS, Lang NP The simplified papilla preservation flap in the regenerative treatment of deep intrabony defects: clinical outcomes and postoperative morbidity. J Periodontol. 2001; 72:1702-1712
Sentineri R, Lombardi T, Berton F, Stacchi C Laurell–Gottlow suture modified by Sentineri for tight closure of a wound with a single line of sutures. Br J Oral Maxillofac Surg. 2016; 54:18-19
Tonetti MS, Cortellini P, Lang NP Clinical outcomes following treatment of human intrabony defects with GTR/bone replacement material or access flap alone. A multicenter randomized controlled clinical trial. J Clin Periodontol. 2004; 31:770-776
Cortellini P, Tonetti MS Clinical and radiographic outcomes of the modified minimally invasive surgical technique with and without regenerative materials: a randomized-controlled trial in intra-bony defects. J Clin Periodontol. 2011; 38:365-373
Levin L, Halperin-Sternfeld M Tooth preservation or implant placement: a systematic review of long-term tooth and implant survival rates. J Am Dent Assoc. 2013; 144:1119-1133
Schwendicke F, Graetz C, Stolpe M, Dörfer CE Retaining or replacing molars with furcation involvement: a cost-effectiveness comparison of different strategies. J Clin Periodontol. 2014; 41:1090-1097
Cortellini P, Stalpers G, Mollo A, Tonetti MS Periodontal regeneration versus extraction and prosthetic replacement of teeth severely compromised by attachment loss to the apex: 5-year results of an ongoing randomized clinical trial. J Clin Periodontol. 2011; 38:915-924
Cortellini P, Stalpers G, Mollo A, Tonetti MS Periodontal regeneration versus extraction and dental implant or prosthetic replacement of teeth severely compromised by attachment loss to the apex: a randomized controlled clinical trial reporting 10-year outcomes, survival analysis and mean cumulative cost of recurrence. J Clin Periodontol. 2020; 47:768-776
Nibali L, Koidou VP, Nieri M Regenerative surgery versus access flap for the treatment of intra-bony periodontal defects: a systematic review and meta-analysis. J Clin Periodontol. 2020; 47:320-351
Jepsen S, Gennai S, Hirschfeld J Regenerative surgical treatment of furcation defects: a systematic review and Bayesian network meta-analysis of randomized clinical trials. J Clin Periodontol. 2020; 47:352-374
Sanz M, Herrera D, Kebschull M EFP workshop participants and methodological consultants. Treatment of stage I–III periodontitis – The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020; 47:4-60
West N, Chapple I, Claydon N BSP implementation of European S3-level evidence-based treatment guidelines for stage I–III periodontitis in UK clinical practice. J Dent. 2021; 106
Miron RJ, Sculean A, Cochran DL Twenty years of enamel matrix derivative: the past, the present and the future. J Clin Periodontol. 2016; 43:668-683
Hammarström L Enamel matrix, cementum development and regeneration. J Clin Periodontol. 1997; 24:658-668
Esposito M, Grusovin MG, Papanikolaou N Enamel matrix derivative (Emdogain) for periodontal tissue regeneration in intrabony defects. Cochrane Database Syst Rev. 2009; 2009:(4)
Miron RJ, Fujioka-Kobayashi M, Zhang Y Osteogain improves osteoblast adhesion, proliferation and differentiation on a bovine-derived natural bone mineral. Clin Oral Implants Res. 2017; 28:327-333
Shirakata Y, Miron RJ, Shinohara Y Healing of two-wall intra-bony defects treated with a novel EMD-liquid – a pre-clinical study in monkeys. J Clin Periodontol. 2017; 44:1264-1273
Shirakata Y, Miron RJ, Nakamura T Effects of EMD liquid (Osteogain) on periodontal healing in class III furcation defects in monkeys. J Clin Periodontol. 2017; 44:298-307
Miron R, Zhang Y: Quintessence Publishing Co; 2019
Kitamura M, Akamatsu M, Kawanami M Randomized placebo-controlled and controlled non-inferiority phase III trials comparing trafermin, a recombinant human fibroblast growth factor 2, and enamel matrix derivative in periodontal regeneration in intrabony defects. J Bone Miner Res. 2016; 31:806-814
Nevins M, Giannobile WV, McGuire MK Platelet-derived growth factor stimulates bone fill and rate of attachment level gain: results of a large multicenter randomized controlled trial. J Periodontol. 2005; 76:2205-2215
Miron RJ, Moraschini V, Fujioka-Kobayashi M Use of platelet-rich fibrin for the treatment of periodontal intrabony defects: a systematic review and meta-analysis. Clin Oral Investig. 2021; 25:2461-2478
Pilloni A, Rojas MA, Marini L Healing of intrabony defects following regenerative surgery by means of single-flap approach in conjunction with either hyaluronic acid or an enamel matrix derivative: a 24-month randomized controlled clinical trial. Clin Oral Investig. 2021; 25:5095-5107

Step 3 for the treatment of periodontal diseases: surgical regeneration of the periodontium

From Volume 51, Issue 5, May 2024 | Pages 332-339


Devan S Raindi

BDS Hons (Birm) MJDF RCS (Eng) MClinDent Hons (KCL) MPerio RCS (Edin) AFHEA, BDS Hons (Birm), MJDF RCS (Eng), MClinDent Hons (KCL), MPerio RCS (Edin), AFHEA

Specialist in Periodontics, Guy‘s Hospital, London

Articles by Devan S Raindi

Email Devan S Raindi

Jay Parmar

BDS (Hons), MJDF RCS (Eng), BDS Hons (KCL), MClinDent Hons (KCL), MPerio RCS (Eng)

Specialty Registrar in Periodontology, Guy's Hospital, London

Articles by Jay Parmar

Iain Chapple


Professor and Honorary Consultant in Restorative Dentistry, Birmingham Dental Hospital and School

Articles by Iain Chapple


Surgical regeneration can offer significant benefits in the management of teeth affected by severe periodontitis that continue to demonstrate pocketing following steps 1 and 2 of periodontal therapy. To gain the maximum benefit from this treatment modality, an understanding of the biological principles of regeneration, appropriate case selection and the latest surgical techniques are required. The most recent S3-level guideline released by the European Federation of Periodontology (EFP) and adoloped by the British Society of Periodontology is evidence based, and can support the clinician in such decision-making.

CPD/Clinical Relevance: Surgical regenerative techniques can play an important role in the treatment of complex periodontal defects.


The ultimate goal of periodontal therapy is to restore periodontal tissue architecture, namely alveolar bone, cementum, periodontal ligament and gingival tissue to its original form and level of attachment. Despite significant advances in regenerative biology and surgical techniques over recent decades, case selection remains the most important criterion when considering whether a surgical regenerative approach is appropriate for a specific site in an individual patient. This article provides an overview of regenerative biology, surgical factors and the current S3-level guidelines when considering surgical regenerative techniques in the treatment of periodontitis.

Regenerative periodontology requires an understanding of the biological principles of wound healing to enable the clinician to guide or manipulate the process clinically to attain optimal outcomes. Before considering regenerative biology, it is important to understand the different healing scenarios for the periodontium following surgical intervention, namely:

The first concept in regenerative wound healing was known as ‘domain theory’, leading to a focus on guiding the correct cells to the root surface by exclusion of the epithelial and gingival connective tissue cells, allowing development of new alveolar bone and periodontal ligament rather than a long junctional epithelium or gingival connective tissue attachment.2 Based on this theory, the first successful regenerative procedure was completed in 1982 on a lower lateral incisor using a non-resorbable membrane, which aimed to prevent occupation of the wound with epithelial and gingival connective tissue cells – a concept termed guided-tissue regeneration (GTR).3

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