CASE SERIES

The Use of Enamel Matrix Derivative in Two-Stage Guided Bone

Regeneration Procedures
Robert J. Miller*†

Introduction: Frequently, clinicians are confronted with situations that require the regeneration of a deficient alveolar
ridge before implant placement. This is often the result of the extraction of hopelessly compromised teeth. Enamel matrix
derivative (EMD) has been used successfully in the treatment of periodontal disease, including guided tissue regeneration,
and the treatment of mucogingival defects. Although the exact mechanism of action is not clearly understood, there may in
fact be more uses for this product. This case series reviews a proposed mechanism of action of EMD and depicts its effective
use in guided bone regeneration (GBR).
Case Series: Three cases requiring GBR were treated with a mixture of human freeze-dried bone and EMD. The teeth
were extracted, sockets were thoroughly debrided, and the defects were filled with the EMD-saturated allograft. Dental im-
plants were placed after 10 to 16 weeks of hard and soft tissue maturation.
Conclusions: The use of a freeze-dried bone allograft saturated with EMD can be used successfully in GBR. Three
cases demonstrate both horizontal and vertical bone regeneration with successful implant placement. Clin Adv Periodon-
tics 2015;5:184-191.
Key Words: Bone regeneration; bone transplantation; dental implants; enamel matrix proteins; membranes.

Background a treatment adjunct in open flap debridement, guided tissue

regeneration, and bone grafts.3-6
The use of enamel matrix derivative (EMD) was first tested as ‡

a treatment for periodontal defects as early as 1986. Successful
treatment in animal models paved the way for approval in the
European market in 1995, the United States market in 1996,
and the Japanese market in 1996. Hammarström et al.1,2
published animal studies that documented periodontal re-
generation after the placement of EMD on a bony dehiscence.
Much of the early research centered on its safety and use to
halt the progression of periodontal disease and its use as
* Private practice, Plantation, FL.
†
Community Based Division Program, University of Florida Hialeah Dental
Clinic, Hialeah, FL.
Submitted December 9, 2013; accepted for publication January 27, 2014
doi: 10.1902/cap.2014.130098
Clinicians have been using EMD with a good degree of
predictability primarily in procedures to correct mucogin-
gival defects and regenerate the periodontium. This has
been particularly important in the treatment of cases in
the esthetic zone in which traditional periodontal elimina-
tion surgery would result in recession (Figs. 1 through 3;
supplementary Figs. 1 and 2). There is also a good deal
of literature to support its use in mucogingival surgery.7
It has been shown that, in moderate-to-advanced Miller
Class I defects, a coronally advanced flap with EMD is ef-
fective in resolving the defects without having to harvest
connective tissue from the palate (Figs. 4 and 5; supplemen-
tary Figs. 3 through 5).8,9
‡
Emdogain, Institute Straumann, Basel, Switzerland.

184 Clinical Advances in Periodontics, Vol. 5, No. 3, August 2015

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FIGURE 4 Preoperative view of recession on the labial aspects of teeth

FIGURE 1 Preoperative view of excessive probing on the mesial aspect of
#10 and #11.
tooth #6.

FIGURE 5 One year after surgery, depicting resolution of defect.

FIGURE 2 Full-thickness flap reflection revealing 3-wall bony defect.

The purpose of this case series is to demonstrate that

EMD does in fact have additional uses and can be used
safely and successfully as an adjunct in guided bone regen-
eration (GBR). Some of the biologic signals that have been
isolated have been shown to promote osteogenesis through
early bone marrow formation, as well as angiogenesis.10,11
This is accomplished by the presence of osterix, which is
indicative of osteoblastogenesis and vascular endothelial
growth factor, an angiogenic signaling molecule.10-12 The
following cases depict the use of EMD in conjunction with
human allograft and a barrier membrane for the purpose of
regenerating the ridge for the ultimate placement of dental
implants. All patients in this case series provided written
informed consent prior to treatment.

Clinical Presentation, Case Management,

FIGURE 3 One year after surgery, depicting resolution of defect. and Outcomes
Case I
A 65-year-old male presented to the author’s private practice
(Plantation, Florida) on February 6, 2012 with severe decay

Miller Clinical Advances in Periodontics, Vol. 5, No. 3, August 2015 185

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FIGURE 6 Case 1. Teeth #29 and #30 are non-restorable.
FIGURE 7 Case 1. Extraction of teeth #29 and #30. Flap reflection and
debridement of extraction sockets.
involving teeth #29 and #30. Both clinical evaluation and ra-
diographs revealed that these teeth were no longer salvage-
able, necessitating their removal (Fig. 6). The patient’s
medical history was unremarkable, and he was not taking
any prescription medication at that time. Standard surgical
protocol was observed, and the patient was anesthetized us-
ing three carpules of 2% lidocaine with 1:100,000 epineph-
rine. Full-thickness flap elevation was performed, allowing
for the atraumatic removal of the teeth. The extraction
sockets were thoroughly debrided of any soft tissue remnants
and rinsed with sterile saline (Fig. 7). It was decided at the
time of the extraction that GBR was necessary because there
was a significant amount of bone breakdown around the
teeth before their removal. Approximately 1.0 mL mineral-
ized freeze-dried bone was hydrated, dried with a 2
2 cotton
sponge, and mixed with z0.80 mL EMD (supplementary
Fig. 6). The saturated allograft was used to fill the defects
to the crest of the ridge and sutured with 4-0 mild chromic
gut sutures (supplementary Figs. 7 and 8). No barrier mem-
brane was placed because the buccal plates were intact. The
remaining EMD was placed on the incision line.
186 Clinical Advances in Periodontics, Vol. 5, No. 3, August 2015
FIGURE 8 Case 1. Healed sockets after 11 weeks of hard- and soft-tissue
maturation.
The area was reentered on April 24, 2012 (11 weeks after
the extractions) with the intention of placing dental im-
plants (supplementary Fig. 9). Typical preoperative proce-
dures were followed. The area was anesthetized with three
carpules of 2% lidocaine with 1:100,000 epinephrine. A
crestal incision with full-thickness buccal and lingual flap
elevation from teeth #28 through #31 was necessary to ex-
pose the osseous crest (Fig. 8). Complete horizontal and
vertical regeneration was noted both clinically and radio-
graphically (Figs. 9a and 9b), enabling fixture placement.
Regular-connection bone-level implantsx were used in
tooth sites #29 and #30 using the standard drilling protocol
(Fig. 9c). The implants were restored after 12 weeks of
healing and have been in function for >1 year (supplemen-
tary Fig. 10).
Case 2
A 71-year-old healthy male presented to the author’s pri-
vate practice on February 25, 2013. His medical history
was unremarkable except that he was being treated with
simvastatin‖ for hypercholesterolemia. His chief concern
was the fractured implants in the maxillary left posterior
sextant. He reported that the implants in tooth sites #10
through #13 were placed in the late 1990s. The bridge
had become loose 2 days previously and was diagnosed
with a horizontal fracture of the implant fixture bodies
(tooth sites #10 through #12). The bridge was removed,
and the treatment plan was to extract the fractured fix-
tures, regenerate the ridge, and reevaluate for implant
placement to replace the fractured segment.
The area was anesthetized with 2% lidocaine. Full-thickness
buccal and palatal flap elevation from tooth sites #10
through #14 was necessary to expose the fractured implant
bodies (Fig. 10). Piezosurgery was used to loosen the frag-
ments that were ultimately removed with an elevator and
forceps (supplementary Fig. 11). The residual bony defects
x
Institute Straumann.
‖
Zocor, Merck, Kenilworth, NJ.
Use of Enamel Matrix Derivative in Guided Bone Regeneration

FIGURE 9 Case 1. Radiographs of extractions (9a), healing following GBR procedure (9b), and implant placement (9c).
FIGURE 10 Case 2. With the prosthesis removed, full-thickness flap
reflection revealed the fractured fixture bodies.
were quite significant (Fig. 11), necessitating complete
regeneration of the ridge for successful implant placement.
A mineralized freeze-dried bone allograft (FDBA; 1.0 mL)
was hydrated with sterile saline, dried with a 2
2 cotton
sponge, and mixed with 0.8 mL EMD. The graft was
carefully placed in the osseous defect and covered with
a non-crosslinked bovine collagen membrane (supplementary
Figs. 12 and 13). The defect was sutured with 4-0 mild
chromic gut sutures.
Healing was uneventful both clinically and radiographi-
cally after 3 months and appeared to be ready for reentry
and implant placement. Full-thickness buccal and palatal
flap elevation was performed in tooth sites #10 through
#14 (supplementary Fig. 14). It was decided that, because
of the history of fixture fracture, all three of the implants
would be replaced. Narrow-connection (titanium/zirco-
nium alloy) bone-level implants{ were placed in tooth sites
#10 and #11. A regular-connection bone-level implant was
used in tooth site #12 (supplementary Fig. 15). Cover screws
were used to bury the implants, keeping them out of function
and minimizing the stress associated with the temporary
acrylic removable partial denture. Primary closure was at-
tained, and the site was allowed to heal for 3 months.
Bone removal was necessary at the second stage to ex-
pose the cover screws because there was complete bone
Miller
C A S E S E R I E S
FIGURE 11 Case 2. Extraction site, revealing significant defects.
overgrowth (Fig. 12). This was anticipated when the radio-
graphs obtained before the surgery revealed what appeared
to be a good response to the regenerative treatment (supple-
mentary Fig. 16). Reentry was performed using a soft tissue
advancement procedure that increased the zone of attached
keratinized tissue on the labial aspect of the healing abut-
ments (supplementary Fig. 17). Shortly after initial healing,
the final prosthesis was fabricated and inserted.
Case 3
A 67-year-old male presented to the author’s private prac-
tice on June 29, 2012. He was in good health and not taking
any medications. His chief concern was tooth #5, which
developed pathologic mobility patterns. The etiology ap-
peared to be root resorption, leading to a poor crown/
root ratio. He was advised of this issue in 2005 before
a lateral wall sinus augmentation that enabled implant
placement in tooth site #3. The area was monitored until
2012 when it became symptomatic. The maxillary right
first premolar was removed, leaving a large 3-wall defect.
The mesial, distal, and buccal plates were involved, indicat-
ing that a regenerative procedure would be necessary for
successful implant placement (Fig. 13). It was decided at
{
Roxolid, Institute Straumann.
Clinical Advances in Periodontics, Vol. 5, No. 3, August 2015 187
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FIGURE 12 Case 2. Osseointegrated dental implants. Note bone

overgrowth. FIGURE 15 Case 3. Periapical radiograph of the implant in tooth site #5.

the time of the surgery to use a mineralized bone allograft

FIGURE 13 Case 3. Extraction of tooth #5. Note the significant horizontal
and vertical bone defects.
because of its osteoconductivity and rate of resorption.
The mineralized FDBA was mixed with an EMD to en-
sure the complete regeneration of the substantial defect.
The graft required z0.5 mL bone, which was mixed with
0.4 mL of the biologic (supplementary Fig. 18). A non-
crosslinked bovine collagen barrier membrane was used
to prevent soft tissue ingrowth (supplementary Fig. 19).
Tooth site #5 was reentered after 18 weeks of hard and
soft tissue maturation. Surgical evaluation of the defect
revealed substantial horizontal and vertical bone growth
with resolution of the periodontal defect on the mesial
aspect of tooth #4 (Fig. 14). A regular-neck tissue-level im-
plant# was placed in the newly formed bone (supplemen-
tary Fig. 20). Healing was uneventful with what appeared
to be ample regeneration of the buccal aspect of the ridge.
His treatment options included the restoration of only the
implant in tooth site #5 or the strategic extraction of tooth
#4 and fabrication of a three-unit implant-supported bridge
using the implant in tooth site #3 (Fig. 15).

Discussion
The amelogenin proteins are involved in the formation of
the enamel layer of teeth.13-15 It was first thought that the
use of EMD, which is derived from piglets’ unerupted
teeth, simply emulated the natural development of the
periodontium.1,16,17 Much of the initial enthusiasm for
the product revolved around its ability to regenerate alveolar
bone, periodontal ligament, and cementum. However,
the exact mechanism for its action has been elusive;
Grandin et al.18 proposed a viable model after a compre-
hensive review of in vitro studies. Their analysis of the
literature along with an understanding of the molecular
composition, structure, and components describes its
mechanism of action.
EMD is essentially a protein complex composed of
enamel matrix proteins that consist of two families of
FIGURE 14 Case 3. Healing of ridge. Note the resolution of the periodontal
#
defect on the mesial aspect of tooth #4. Institute Straumann.

188 Clinical Advances in Periodontics, Vol. 5, No. 3, August 2015 Use of Enamel Matrix Derivative in Guided Bone Regeneration

proteins. Enamel matrix proteins consist of amelogenins,
which are z90% of the organic enamel matrix, and
non-amelogenins, including ameloblastin.18,19 It was
shown through exclusion chromatography that the three
major amelogenin peaks have molecular weights corre-
sponding to 20, 13, and 5-6 kDa15,20 The effective use of
this product is a two-step process that includes a mechanical
debridement and cleansing of the affected surface using a va-
riety of methods, including curets, rotary instruments, pol-
ishing, and lasers. This is followed by the chemotherapeutic
step that includes the application of a chelating agent. This is
a pH neutral root conditioner that is composed of 24%
EDTA that effectively removes the smear layer, which is
a very thin layer (5 to 10 mm) of debris composed of fluids
and tooth components remaining on the cementum and den-
tin of the affected area.
EMD is delivered via syringe in a medium of propylene
glycol alginate. This is for the most part insoluble at phys-
iologic pH and temperature. Once applied to the sanitized
root surface, it is proposed that the hydrophobic amelo-
genin proteins form nanospheres whose hydrophilic C
terminus migrate to the outer shell of the complex. The for-
mation of these nanospheres is dependent on temperature,
pH of the environment, and concentration.15,18,21,22
The individual nanospheres aggregate, forming a multi-
layer complex that is adsorbed into the root surface. This is
a direct result of its interaction with aqueous fluids, pH,
and temperature of the oral environment. Initially, it is be-
lieved that assemblage acts as a carrier for the specific bi-
ologic signals and is the interaction with its environment
that directs their release.23 Ultimately, it is enzymatic activ-
ity that degrades the amelogenin proteins, thereby causing
the dissolution of the multilayer complex and release of
Miller
C A S E S E R I E S
some of its components.24 Grandin et al.18 hypothesize that
it is this enzymatic activity that causes the biologic signals,
which enables the profound effects on the tissues of the
host.
EMD has been proven to be a very predictable adjunct in
the treatment of both periodontal disease and mucogingival
surgery for well over a decade. Recently, it has appeared in
the literature in the successful treatment of peri-implantitis.25
The cases depicted in the present case series demonstrate the
fact that there may be other viable uses for the product, in-
cluding GBR. Each of the situations included substantial de-
fects necessitating the regeneration of a large amount of bone
to ensure successful implant placement.
The contention is that EMD, when used in conjunction
with bone grafting materials, may be helpful in improving
the yield of bone in GBR procedures, particularly in large
defects that may not have adequate nourishment or scaf-
folding. The cases presented in this series help to advance
this theory. Cases 1 and 2 depict regeneration of large
extraction sockets and placement of implants in what ap-
peared to be viable bone after hard and soft tissue matura-
tion. Case 3 describes the resolution of a defect that
involved the regeneration of a site that lost its buccal plate.
Note that no additional rigid scaffolding, bone screws, or
reinforced membranes are used in this case. Traditionally,
some resistance to soft tissue compression of the graft is
helpful in maximizing horizontal and vertical augmenta-
tion. Additional research needs to be performed using other
grafting materials and comparing GBR procedures with
and without the use of biologics. Studies should also be per-
formed to determine its mechanism of action, including
whether the use of enamel matrix proteins have any bearing
on the rate of bone growth or maturity. n
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Summary
Why are these cases new j There is very little reported in the scientific literature with respect to the
information? use of EMD and GBR procedures.
j It is interesting to note that the use of EMD in grafting materials is

considered an “off label” use of the product.

j This is a very safe and cost-effective adjunct that can be used in site

preparation before implant surgery.

What are the keys to successful j The key to successful management of regenerative procedures is
management of these cases? careful case selection.
j These cases were all performed on healthy non-smokers.

j Adequate flap in contact with native bone and tension-free closure are

necessary.

What are the primary limitations to j Limitations of this procedure include cases in which compression
success in these cases? from the soft tissue may adversely affect the horizontal yield. These
cases may require bone screws, titanium mesh, or some other rigid
fixation to stabilize the graft.
j This is not a substitute for onlay grafting and is not indicated for
defects that do not have defined walls or are outside of the bony
envelope.

Acknowledgment CORRESPONDENCE:
Dr. Robert J. Miller, 333 N.W. 70th Ave., Plantation, FL 33317. E-mail:
Dr. Miller has received honorarium from Straumann, Andover, DrMiller@WebPerio.com.
Massachusetts, for other projects and lectures but did not
receive any financial support from any company for this
case series.

190 Clinical Advances in Periodontics, Vol. 5, No. 3, August 2015 Use of Enamel Matrix Derivative in Guided Bone Regeneration

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