Journal of Indian Society of Periodontology
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Year : 2014  |  Volume : 18  |  Issue : 3  |  Page : 331-335  

Periosteum as a barrier membrane in the treatment of intrabony defect: A new technique

1 Department of Periodontics, Carrier Postgraduate Institute of Dental Sciences and Hospital, Ghaila, Sitapur Hardoi Bypass, IIM Road, Lucknow, Uttar Pradesh, India
2 Department of Periodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Department of Periodontics, Faculty of Dental Sciences, C. S. M. Medical University, Lucknow, Uttar Pradesh, India

Date of Submission24-Apr-2012
Date of Acceptance21-Nov-2013
Date of Web Publication17-Jun-2014

Correspondence Address:
Anju Gautam
Department of Periodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-124X.134571

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Objective: The purpose of the study was to evaluate the clinical effectiveness of periosteum as a barrier membrane for the treatment of intrabony defects. Materials and Methods: The study was conducted in patients having bilateral intrabony defects. A total of 20 intrabony defects in 10 patients were treated, out of which 10 defects received periosteal barrier and the other 10 defects received conventional open flap debridement procedure. The efficacy of the treatment was assessed using clinical parameters and dentascan. Results: Statistically significant gain in clinical attachment level (CAL) was found in the test group (2.00 ± 0.26 mm) as compared to the control group (0.60 ± 0.22 mm). In both the treatment modalities (test and control groups), a significant decrease in probing pocket depth of 3.90 ± 0.35 mm and 2.90 ± 0.31 mm was observed, respectively. The difference between the two groups was not statistically significant. Bone defect fill was 1.40 ± 0.16 mm for the test group and 0.90 ± 0.18 mm for the control group, but the difference observed was not statistically significant. Conclusion: The results of this study show that periosteal barrier membrane can be a better alternative of barrier membranes for the treatment of intrabony defects.

Keywords: Barrier membranes, guided tissue regeneration, intrabony defects, periosteum

How to cite this article:
Saimbi CS, Gautam A, Khan MA, Nandlal. Periosteum as a barrier membrane in the treatment of intrabony defect: A new technique. J Indian Soc Periodontol 2014;18:331-5

How to cite this URL:
Saimbi CS, Gautam A, Khan MA, Nandlal. Periosteum as a barrier membrane in the treatment of intrabony defect: A new technique. J Indian Soc Periodontol [serial online] 2014 [cited 2020 Jul 5];18:331-5. Available from:

   Introduction Top

Regeneration of periodontal tissue that has been lost as a result of disease is the ultimate objective of periodontal therapy in advanced periodontal breakdown. Periodontal regeneration can be achieved by a variety of non-surgical and surgical therapies. Surgical treatment modalities for periodontal disease include conventional and regenerative therapy. Periodontal surgical debridement and resective osseous surgery are the established conventional treatments for advanced periodontal disease, which improve the clinical disease parameters and arrest disease progression, but minimal regeneration of periodontal tissue has been achieved by these treatments. [1] Several regenerative treatment modalities such as osseous grafts [2],[3] and guided tissue regeneration (GTR), [4],[5] alone or in combination with osseous graft, have been employed with varying degrees of success to predictably accomplish periodontal regeneration. Although osseous grafts are effective in reducing probing depth and improving attachment level, they do not promote true regeneration of periodontal tissue.

GTR technique is based on the biological principle of selective cell repopulation that excludes the apical migration of gingival epithelium and facilitates the migration of cells from periodontal ligament and bone toward the defect, thus preventing the formation of long junctional epithelium and promotes periodontal regeneration. [6] GTR techniques use non-absorbable and bioresorbable barrier membranes. Barrier membrane helps the periodontal ligament cells, which are considered the principle cells in periodontal regeneration, to accumulate in the space created. [7],[8],[9]

Several non-absorbable materials have been used for GTR, such as millipore membrane, expanded polytetrafluoroethylene (ePTFE), etc. [10],[11] Non-absorbable barriers can be shaped to provide the desired space beneath the barrier in defects where such space might otherwise not be attainable, which is the main advantage of non-absorbable barrier membranes. But it requires second surgical procedure for the removal of membrane, which is an additional burden to both clinician and patient. In view of this, absorbable GTR membranes such as collagen, ethyl cellulose, polylactic acid, and calcium sulfate have been evaluated for GTR procedure in human and animal studies. [12],[13] The absorbable membranes also have some disadvantages, i.e., they lack rigidity and have no embedded support structure. Various studies indicated that there was no difference in the clinical attachment level (CAL) gain between absorbable and non-absorbable membrane groups. [14],[15] Hence, some periodontists tried to overcome this problem by using autogenous periosteum with a layer of connective tissue as an alternative to the existing barrier membrane, since this meets the requirements of an ideal material and is biologically acceptable. [16],[17],[18]

The periosteum is composed of two tissue layers: The outer fibroblast layer that provides attachment to soft tissue and the inner cambial region that contains undifferentiated mesenchymal cells, osteogenic progenitor cells that support bone formation. [19] Under specific conditions, periosteal cells secrete extracellular matrix and form a membranous structure. [20]

The periosteum has the potential to stimulate bone formation when used as a graft material in animal and human studies. [16],[17],[18],[21],[22],[23],[24],[25],[26],[27] In an animal study, free grafts of periosteum taken from the tibia in rabbits were able to initiate bone and cartilage formation when placed in the anterior chamber of the eye and in the capsule of the kidney. Bone formation was also seen when periosteal grafts were placed in the midline sutures of rabbit mandible. [21] In human studies, the use of periosteum in furcation defects, [23],[24],[25] interproximal defects, [16],[17],[18] gingival recession, [26] and periradicular area [27] showed evidence of bone fill as well as improvement in pocket depths and CAL. The advantages of using an autogenous periosteal membrane are that it requires only one surgical procedure, minimizes any untoward tissue responses during healing, and has the potential for stimulating new bone formation. These properties of periosteal membrane were kept in mind before designing the present study to evaluate the efficacy of periosteum as a barrier membrane in intrabony defects.

   Materials and methods Top

In the present study, 10 subjects (6 females and 4 males, age group 20-50 years) having bilateral intrabony defects in relation to molar were selected from the outpatient clinic, Department of Periodontics, Faculty of Dental Sciences, C. S. M. Medical University, Lucknow. The study was approved by the ethical committee of the university. All patients were free of systemic diseases, without any history of allergy, and were not taking any medications. Sites associated with root concavities/morphologic defects or furcation defects were excluded.

General assessment of the subjects was made through their history, clinical examinations, and routine laboratory investigations. The efficacy of the treatment was determined by soft tissue parameters (probing pocket depth, CAL, gingival margin level, and gingival index score) and hard tissue parameters (depth of intrabony defect). All patients participating in this study were explained the type of operation and its possible outcome and were asked to signed an informed consent. Each patient underwent an initial phase of therapy consisting of oral hygiene instructions, scaling and root planing, and occlusion adjustment if required.

Following phase I therapy, a re-evaluation was done which confirmed the need for periodontal surgery. Two intrabony defects in each patient were randomly assigned to receive a periosteal membrane barrier (test group) or conventional open flap debridement alone (control group).

After 4 weeks of phase I therapy, the patients were subjected to surgical procedure. Prior to surgery, all clinical soft tissue parameters were measured with the help of periodontal probe (UNC 15; Hu-Friedy, Chicago, IL, USA). Computed tomography (CT) dentascan was taken prior to surgery and repeated postoperatively at 6 months. The same examiner measured all defects in a given patient at the initial baseline and post-surgical appointments.

At the time of surgery, the facial skin around the oral cavity was scrubbed with 10% povidone-iodine solution and the intraoral surgical site was painted with 5% povidone-iodine solution. Local anesthesia was achieved with regional nerve block and local administration of a solution of 2% lignocaine with 1:200,000 adrenaline. Before administration of local anesthesia, the sensitivity test was done in each subject.

Following local anesthesia, intracrevicular incisions were made in both the groups, extending to a minimum of two teeth mesially and one tooth distally to the tooth being treated. Then, full-thickness mucoperiosteal flaps were raised. Vertical releasing incisions were performed if deemed necessary for better access to the surgical site [Figure 1]. The entire granulation tissue was removed from the defects, the pocket epithelium was carefully scrapped from the inner surface of the flap, and the roots were thoroughly scaled and planed by means of manual and ultrasonic instruments. The operative area was irrigated with sterile saline.
Figure 1: Mucoperiosteal flap reflected showing intrabony defect on the mesial surface of mandibular first molar

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In the control group, the mucoperiosteal flaps were replaced without placement of any barrier membrane and secured with interrupted interdental sutures, using 3-0 black braided silk suture material.

In the test group, the full-thickness mucoperiosteal flap was elevated, which was extended apically to expose sufficient amount of periosteum. Periosteal membrane was separated from the full-thickness mucoperiosteal flap and released by one vertical incision mesially and one horizontal incision apically. Posteriorly, the periosteum remained attached with the mucoperiosteal flap, so that blood supply could be maintained in the reflected periosteum [Figure 2]. The periosteal membrane was turned over the intrabony defect in such a way that the defect was completely covered by the periosteal membrane and was sutured with a synthetic 5-0 bioabsorbable vicryl suture [Figure 3]. After that, the mucoperiosteal flap was sutured with 3-0 braided silk suture material. All surgical sites of both the groups were dressed with periodontal dressing.
Figure 2: Surgical site showing released periosteum

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Figure 3: Periosteal membrane sutured in place

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Oral antibiotics (Amoxicillin 500 mg three times a day for 5 days) and Ibuprofen 600 mg every 8 h for 3 days were prescribed. The patients of both the groups were instructed not to brush the operated site for 3 weeks and were advised to rinse with 0.2% solution of chlorhexidine gluconate a day.

After 1 week, the periodontal dressing and sutures were removed and the surgical sites were irrigated with povidone-iodine antimicrobial solution. Patients were advised to rinse with 0.2% solution of chlorhexidine twice a day for another 3 weeks. Recall visits were carried out weekly for 1 month following surgery and then monthly for the rest of the observation period of 6 months. The recall appointments consisted of reinforcement of oral hygiene measures and professional tooth cleaning. At 6 months post surgery, soft tissue measurements were recorded and postoperative CT dentascan [Figure 4] was taken for hard tissue measurement.
Figure 4: Preoperative (above) and postoperative (below) panorex views of dentascan. Red arrow shows the test group and yellow shows the control group

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Two dependent groups (pre and post) were compared by using paired two-sample t-test, while two independent groups (control and test) were compared by using independent two-sample t-test. A two-tailed (α =2) probability (P) value less than 0.05 (P < 0.05) was considered to be statistically significant, P < 0.01 as highly significant, and P > 0.05 as not significant.

   Results Top

In 10 patients with a total of 20 interproximal intrabony defects, 10 defects were treated with conventional open flap debridement (control group) and the other 10 defects were treated using periosteum as the barrier membrane (test group). All patients were available for re-evaluation. All surgical sites healed with minimum patient discomfort and no signs of infection. No adverse reactions such as allergies, abscesses, or rejection of the periosteal membrane were observed throughout the entire study period of 6 months. Patients in both treatment groups exhibited consistent and good oral hygiene standards.

Both test and control sites revealed statistically significant decrease in probing pocket depth at 6 months when compared to baseline values [Table 1]. Although the mean decrease was more for the test group as compared to the control group, the results were not statistically significant.

The mean decrease in CAL was 2.00 ± 0.26 mm in the test group and 0.60 ± 0.22 mm in the control group [Table 1]. Both test and control groups showed statistically significant gain in CAL . Clinical attachment gain in the test group was more statistically significant than in the control group.

The defects treated with periosteal membrane achieved greater bone fill (1.40 ± 0.16 mm) than the control group (0.90 ± 0.18 mm) [Table 2]. Significant bone fill was observed in both the groups, but the difference was statistically not significant. Both the groups presented with gingival recession and reduced gingival index, which was greater in the control group than in the test group, but was not statistically significant.
Table 1: Changes in probing pocket depth (mean±SE) and clinical attachment level (mean±SE) in mm

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Table 2: Change in depth of bone defects (mean±SE) in mm

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   Discussion Top

The GTR technique has been widely recognized as a significant method for reducing pocket depth, improving attachment levels, and for bone formation in the defect area. Several non-resorbable and resorbable barrier membranes have been used in human and animal studies. [10],[11],[12],[13],[14],[15] However, these techniques have some limitations. Clinical trials and animal studies have shown bone formation when autogenous periosteal membrane is used as a graft or barrier membrane as GTR procedures for enhancement of the bone formation in vertical [16],[17],[18] or furcation defects. [23],[24],[25]

Aukhil et al. reported that placement of barrier creates two avascular surfaces (root surface and barrier) due to which periodontal regeneration may be limited. [28] In previous studies, [16],[18],[23],[24] periosteum was harvested from palate that lacks vascular supply. Hence, in the present study, the autogenous periosteal membrane was designed in such a way that the periosteum was detached only from the anterior portion of mucogingival flap and posteriorly periosteum remained attached with the flap, so that the blood supply could be maintained in the periosteum. The vascular supply is important for healing and maintenance of vitality of cambium layer of periosteum which has the potential for bone formation.

The present study demonstrated improvement in clinical parameters similar to that reported for several other treatment concepts, including use of autograft, [29] allografts, [30] and GTR, [11],[13],[14] for the treatment of intrabony defects. The present study showed statistically significant gain in CAL of 2.00 ± 0.26 mm in the experimental group treated with periosteum as a barrier membrane compared to the sites treated by the open flap debridement procedure alone, which is comparable to the gain in CAL reported in a previous study [16] that ranged from 1.18 to 1.26 mm. Similarly, another study [17] using a periosteal pedicle graft as an autogenous barrier membrane showed up to 1.4 mm greater CAL gain in treating intrabony defects with the autogenous regenerative technique compared to the sites treated by the open flap debridement procedure alone.

A previous study [18] on the use of autogenous periosteal grafts as barriers and autogenous bone graft in the treatment of human intrabony defects reported up to 2.3 mm greater CAL gain over the open flap debridement group.

In the present study, the intrabony defect treated with periosteum as the barrier membrane resulted in statistically significant decrease in probing pocket depth, which was 3.90 ± 0.35 mm, but was not statistically significant. Previous studies [16],[17],[18] also reported similar results.

The post-surgical gingival recession increase was significantly greater in the open flap debridement group as compared to the test group. These findings are in agreement with the results of a previous study, [16] and this can be explained by the following factors: The greater bone defect fill in intrabony defects in the test group and the periosteal membranes that integrate with the surrounding tissues.

The intrabony defects were decreased in both the treatment modalities. In the test group, the depth of intrabony defect decreased significantly and the amount of bone defect fill was 1.40 ± 0.16 mm, but was not statistically significant as compared with the control group. Similarly, a previous study [16] reported a 1.66-2.04 mm bone fill with the use of periosteal grafts as barriers in the treatment of intrabony defects.

The results with autogenous periosteum as a GTR barrier membrane showed the formation of osseous structure. The osteogenic potential of periosteum may explain the differences in defect fill between the control and test groups. However, the success is directly related to the morphologic features of the defects, duration of healing, flap position, plaque control, [31],[32] and systemic health of the subjects. Limitations of this study include a comparatively small sample size and short study period. Further studies with longer follow-up period and a larger sample size should be performed.

   Conclusion Top

Within the limitations of this study, it has been shown that periosteal membrane as GTR barrier can provide significantly greater improvements in pocket depth, CAL, and bone defect fill in intrabony defects, compared to those treated by the open flap debridement procedure alone. It can be concluded from the present study that autogenous periosteal membrane as a barrier membrane is an effective GTR technique.

   References Top

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29.Rosenberg MM. Free osseous tissue autografts as a predictable procedure. J Periodontol 1971;42:195-209.  Back to cited text no. 29
30.Rummelhart JM, Mellonig JT, Gray JL, Towle HJ. A comparison of freeze-dried bone allograft and demineralized freeze-dried bone allograft in human periodontal defects. J Periodontol 1989;60:655-63.  Back to cited text no. 30
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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