J Clin Periodontol 2016; doi: 10.1111/jcpe.

12546

Systematic Review
Twenty years of enamel matrix Richard J. Miron1,2, Anton Sculean2,
David L. Cochran3, Stuart Froum4,
Giovanni Zucchelli5, Carlos

derivative: the past, the present Nemcovsky6, Nikos Donos7, Staale

Petter Lyngstadaas8, James
Deschner9, Michel Dard10, Andreas

and the future Stavropoulos11, Yufeng Zhang12,

Leonardo Trombelli13, Adrian
Kasaj14, Yoshinori Shirakata15,
Pierpaolo Cortellini16, Maurizio
Tonetti17, Giulio Rasperini18,19, Søren
Miron RJ, Sculean A, Cochran DL, Froum S, Zucchelli G, Nemcovsky C, Donos N,
Jepsen20 and Dieter D. Bosshardt2
Lyngstadaas SP, Deschner J, Dard M, Stavropoulos A, Zhang Y, Trombelli L, 1
Department of Periodontology, Nova
Kasaj A, Shirakata Y, Cortellini P, Tonetti M, Rasperini G, Jepsen S, Bosshardt
Southeastern University, Fort Lauderdale,
DD. Twenty years of enamel matrix derivative: the past, the present and the future.
Florida, USA; 2Department of Periodontology,
J Clin Periodontol 2016; doi: 10.1111/jcpe.12546 University of Bern, Bern, Switzerland;
3
Department of Periodontics, Dental School,
Abstract University of Texas Health Science Center at
Bacground: On June 5th, 2015 at Europerio 8, a group of leading experts were San Antonio, San Antonio, TX, USA;
gathered to discuss what has now been 20 years of documented evidence support- 4
Department of Periodontology and Implant
ing the clinical use of enamel matrix derivative (EMD). Original experiments led Dentistry, College of Dentistry, New York
by Lars Hammarstr€ om demonstrated that enamel matrix proteins could serve as University, New York, NY, USA;
5
key regenerative proteins capable of promoting periodontal regeneration includ- Department of Biomedical and Neuromotor
ing new cementum, with functionally oriented inserting new periodontal ligament Sciences, University of Bologna, Bologna,
Italy; 6Department of Periodontology and
fibres, and new alveolar bone formation. This pioneering work and vision by Lars
Dental Implantology, Dental School, Tel-Aviv
Hammarstr€ om has paved the way to an enormous amount of publications related University, Tel-Aviv, Israel; 7Department of
to its biological basis and clinical use. Twenty years later, it is clear that all these Periodontology, Queen Marry University of
studies have greatly contributed to our understanding of how biologics can act as London, London, UK; 8Department of
mediators for periodontal regeneration and have provided additional clinical Biomaterials, Faculty of Dentistry, University
means to support tissue regeneration of the periodontium. of Oslo, Oslo, Norway; 9Section of
Aims: This review article aims to: (1) provide the biological background neces- Experimental Dento-Maxillo-Facial Medicine,
sary to understand the rational for the use of EMD for periodontal regeneration, University of Bonn, Bonn, Germany; 10New
(2) present animal and human histological evidence of periodontal regeneration York University, College of Dentistry, New
York, NY, USA; 11Department of
following EMD application, (3) provide clinically relevant indications for the use
Periodontology, Malmo € University, Malmo
€,
of EMD and (4) discuss future avenues of research including key early findings
Sweden; 12Department of Oral Implantology,
leading to the development of Osteogain, a new carrier system for EMD specifi- Wuhan University, Wuhan, China;
cally developed with better protein adsorption to bone grafting materials. 13
Department of Periodotology, Research
Centre for the Study of Periodontal and Peri-
implant Diseases, University of Ferrara,
Ferrara, Italy; 14Department of Operative
Dentistry and Periodontology, University
Medical Center, Mainz, Germany;
15
Department of Periodontology, Kagoshima
University Graduate School of Medical and
Dental Sciences, Kagoshima, Japan;
16
Accademia Toscana di Ricerca
Odontostomatologica, Firenze, Italy;
17
European Research Group on
Periodontology (ERGOPerio), Genova, Italy;
18
Department of Biomedical, Surgical and
Dental Sciences, University of Milan, Milan,

Conflict of interest and source of funding statement

The authors report no conflict of interest for the present review article. No funding was required/received by any of the co-
authors for the present review article.

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
2 Miron et al.

Italy; 19Foundation IRCCS Ca’ Granda

Polyclinic, Milan, Italy; 20Department of
Periodontology, Operative and Preventive
Dentistry, University of Bonn, Bonn, Germany

This manuscript is dedicated to Professor

Lars Hammarstro €m, to honour his landmark
and pioneering work in discovering the
regenerative capacities of enamel matrix
proteins.

Key words: EMD; Emdogain; enamel matrix

derivative; enamel matrix proteins; intrabony
defect; Osteogain; periodontal regeneration

Accepted for publication 7 March 2016

Over 20 years ago, a team of protein content derived from differ- golis et al. 2006). Although these
researchers in Sweden including Lars ent splice variants and post-secretory proteins are expressed in less quanti-
Hammarstr€ om, Sven Lindskog and regulation, all controlled from the ties, further investigation has con-
Leif Blomloff found that enamel expression of a single gene (Lyn- firmed their valuable roles in various
matrix proteins (EMPs) could be uti- gstadaas et al. 2009). These proteins aspects of periodontal regeneration
lized as a biological agent capable of self-assemble into supramolecular discussed later in this article.
periodontal regeneration (Ham- aggregates that form an insoluble The aim of this review article is
marstr€om et al. 1991, 1992, 1995). extracellular matrix and function to to provide the reader with four
These reports originated from previ- control the ultrastructural organiza- important aspects concerning inte-
ous studies 15 years earlier by Lind- tion of the developing enamel crys- gral research avenues on EMD over
skog et al. and Slavkin et al. tallites (Lyngstadaas et al. 2009). the past 20 years. First, a biological
reported that certain EMPs (which Other proteins found in the enamel background is provided to fully
until then were considered enamel- matrix include enamelin, ameloblas- comprehend the rational for utilizing
specific proteins) were deposited on tin (also called amelin or sheathlin), EMD in periodontal regeneration by
the surface of developing tooth roots amelotin, apin and various pro- summarizing the in vitro research
prior to cementum formation teinases (Bartlett et al. 2006, Mar- that has characterized the numerous
(Fig. 1) and may play a possible role individual roles of EMPs for cells
in cementogenesis (Lindskog 1981a, derived from both soft and hard tis-
b, Lindskog & Hammarstr€ om 1981, sues. Thereafter, studies based on
Slavkin et al. 1989). These observa- animal and human histology analys-
tions led to the hypothesis that ing periodontal regeneration follow-
EMPs may play an integral role in ing application with EMD are
the future differentiation of peri- discussed. The third aim of this arti-
odontal tissues prior to cementum cle is to provide the clinician-scien-
formation, and has been the basis of tist a summary of the clinical trials
a number of biological and clinical utilizing EMD for a number of
studies thereafter demonstrating that regenerative procedures, while, at the
EMPs are proteins secreted by Her- same time, provide a summary of
twig’s epithelial root sheet capable of evidence-based indications for EMD
promoting periodontal regeneration Fig. 1. Histological section depicting in clinical practice. Lastly, the article
(Gestrelius et al. 1997a,b, Ham- enamel matrix proteins localized at the will discuss future avenues of
marstr€om et al. 1997, Heijl 1997, dentinocemental junction (DCJ). Results research including the five key early
Zetterstrom et al. 1997). The purified from the early 1990s demonstrated that studies leading to the development
fraction derived from the enamel enamel matrix proteins (which until then of Osteogain, a new product incor-
layer of developing porcine teeth were considered enamel-specific proteins) porating EMD with better physico-
was given the working name enamel were found also localized at the DCJ chemical properties for improved
matrix derivative (EMD) and has were the hypothesis for numerous subse- protein adsorption of EMPs to bone
been the basis of numerous publica- quent investigations characterizing the grafting materials.
role of EMPs in periodontal tissue differ-
tions investigating its future use in entiation (C = cementum, D = dentin,
periodontal regeneration. DCJ = dentinocemental junction, black Biology of Periodontal Regeneration
The major components of EMD arrow = EMD deposited on the root sur- with Enamel Matrix Proteins
are amelogenins, a family of face (ex vivo experiment), red
hydrophobic proteins that account arrow = enamel matrix proteins found The aim of the first section of this
for more than 90% of the total localized at the DCJ). review article is to summarize the

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 20 years of EMD 3

cell biological data largely but not

exclusively originating from numer-
ous in vitro studies, where cells were
exposed to EMPs and to link these
to their potential beneficial effect on
periodontal wound healing and
regeneration. For those highly inter-
ested in this topic, the authors kindly
point the reader to a number of
review articles covering the diverse
roles of EMPs (Zeichner-David
2001, Bosshardt 2008, Gibson 2008,
Lyngstadaas et al. 2009, Miron et al.
2014b). Within the context of this
manuscript, the effects of different
EMP extracts, recombinant EMPs
or EMD are summarized from
in vitro studies on various cell types
including epithelial cells, gingival
fibroblasts, periodontal ligament
fibroblasts, cementoblasts, osteo-
blasts and bacteria. It has been
demonstrated that EMD exerts a sig-
nificant influence on cell behaviour
of many cell types by mediating cell
attachment, spreading, proliferation,
differentiation and survival, as well
as expression of transcription
factors, growth factors, cytokines,
extracellular matrix constituents and
other molecules involved in the regu-
lation of bone remodelling (Bos-
shardt 2008). Furthermore, EMD
has been shown to play a significant
role in wound healing favouring soft
tissue regeneration and angiogenic
activity (Fig. 2) (Miron et al. 2014b).
Due to the overall size of the current
manuscript, the in vitro section has
been added as a Supporting Infor-
mation to the current article.
Fig. 2. Diagram depicting inflammation-modifying changes induced by enamel matrix
derivative. Following application of EMD, decreased production of IL1b and IL8 (1)
Animal and Human Histological and increased levels of PGE2 (2) are observed with little differences in TNF-alpha
Evidence of Periodontal expression. EMD also substantially changes the OPG/RANKL balance by increasing
Regeneration with the Use of EMD OPG and decreasing RANKL levels, resulting in diminished osteoclast formation/ac-
tivity (3). EMD also increases the proliferation and migration of T-lymphocytes (4),
Approximately two decades ago, the which enable tissue debridement by macrophages (5). Furthermore, EMD promotes
first animal model investigating mesenchymal cell differentiation into hard tissue-forming cells and also improves PDL
EMD as an adjunctive agent to peri- cell regeneration (6). Microvascular cell differentiation and angiogenesis are improved
odontal surgery, involved surgically following EMD application (7) and studies demonstrate that EMD also lowers bacte-
created recession defects treated with rial numbers (8), resulting in a reduced inflammatory state (reprint from the Journal
either coronally advanced flap of Periodontal Research with permission).
(CAF) alone or in combination with
EMD (Hammarstr€ om et al. 1997).
Following an 8-week healing period, periodontal regeneration was defects) (Sculean et al. 2000b,c,
the histological evaluation revealed observed. Following these original Cochran et al. 2003, Donos et al.
formation of acellular cementum, findings, subsequent animal experi- 2003, Sallum et al. 2003, 2004,
periodontal ligament and alveolar ments have evaluated the healing of Regazzini et al. 2004, Sakallioglu
bone in all defects treated with different types of induced periodon- et al. 2004, Nemcovsky et al. 2006,
EMD. In control samples (CAF tal defects treated with EMD or Ivanovic et al. 2014). It was reported
alone), defects presented a long junc- guided tissue regeneration (GTR) in these studies that application of
tional epithelium onto the exposed (i.e. fenestrations, dehiscence-type, EMD resulted in substantially larger
root surface, and only very limited recessions, intrabony and furcation amounts new cementum, periodontal
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
4 Miron et al.

ligament and bone formation when the other hand, in all cases treated large number of techniques, includ-
compared to controls (i.e. flap sur- with GTR, the new connective tissue ing – but not limited to – root sur-
gery alone). Moreover, these studies attachment was followed by bone for- face modification, bone and bone
revealed that the amount and quality mation (Sculean et al. 1999). The sub- substitute grafting, GTR, biological
of the newly formed periodontal tis- stantial amount of newly formed bone mediators, and combination thereof
sues were comparable between EMD following GTR application was have been employed to fulfil true
and GTR. explained by the lack of membrane periodontal regeneration. For each
Human histological studies were exposure and subsequent bacterial of the above-mentioned techniques,
subsequently performed to provide caused infection, well-known factors limitations and complications have
further evidence for periodontal that influence the healing process been associated with their use, and it
regeneration in intrabony and reces- (Tonetti et al. 1996, Sanz et al. 2004). may thus not be surprising that the
sion defects, thus corroborating the In summary, these results demonstrate search for the ideal biomaterial cap-
findings from animals (Heijl 1997, that it is possible to achieve periodon- able of true periodontal regeneration
Mellonig 1999, Sculean et al. 1999, tal regeneration, but this does not continues. Over the years, the use of
2000a, Rasperini et al. 2000, Yukna & occur in all cases; other factors are biologics (growth factors) has
Mellonig 2000, Carnio et al. 2002, also important such as wound integ- become more prominent in daily
McGuire & Cochran 2003, Majzoub rity, infection, patient age and sys- practice. A plethora of documented
et al. 2005). Yukna and Mellonig eval- temic conditions (Tonetti et al. 1996, research from in vitro, in vivo and
uated histologically 10 intrabony Sanz et al. 2004, Jepsen et al. 2008). clinical trials is now available for
defects around teeth with advanced Since EMD is applied in a gel enamel matrix proteins that now
adult periodontitis that were treat- formulation, a relevant question has spans over two decades. In this sec-
ment planned for extraction (Yukna been whether the EMD proteins tion, we briefly summarize 20 years
& Mellonig 2000). Following treat- would remain adsorbed to the root of clinical research and provide an
ment with EMD, biweekly to monthly surface following regenerative sur- evidenced-based flow chart for rele-
recalls were made until removal of gery, or whether they would leak out vant clinical indications for the use
small block section biopsies at about from the site after flap closure. By of EMD either alone or in combina-
6 months showed evidence of peri- using an anti-EMD antibody, it has tion with a bone grafting material or
odontal regeneration (new cementum, been demonstrated in human tooth barrier membrane.
new bone, and new periodontal liga- biopsies that EMD remains on the
ment) in three specimens, new attach- root surface for up to 4 weeks (Scu- Safety of EMD
ment (connective tissue attachment/ lean et al. 2002c, 2003b,c). Further-
adhesion only) in three specimens and more, it was noted that after a We start by describing the
a long junctional epithelium in four period of only 2 to 6 weeks follow- accumulated evidence for EMD used
specimens. No evidence of root ing application of EMD, newly in a clinical setting regarding patient
resorption, ankylosis or untoward formed periodontal tissues were seen safety. It is important to note that
inflammation was found (Yukna & deposited on the treated root sur- amelogenins are a highly conserved
Mellonig 2000). In another human faces that appeared thick, collage- gene across a variety of species
histological study of 14 periodontitis nous and devoid of extrinsic fibres including porcine and human. For
patients, each of them contributing (Sculean et al. 2002c, 2003b,c). His- these reasons, incompatibility or
with one deep intrabony defect tological analysis revealed the pres- allergic reactions after treatment
around teeth scheduled for extraction ence of an electron-dense, organic with EMD have not been reported
were treated with either EMD or a material in the collagenous matrix in any clinical trial that were the
synthetic bioabsorbable membrane indicating that at least partial miner- direct result of EMD (Zetterstrom
(Sculean et al. 1999). The results alization had occurred following et al. 1997, Petinaki et al. 1998,
revealed that at 6 months following application with EMD (Bosshardt Nikolopoulos et al. 2002, Froum
reconstructive surgery using either et al. 2005, 2006). Taken together, et al. 2004). Following a multicentre
EMD or GTR, substantial clinical these results have confirmed that study evaluating the potential for
improvements (i.e. reduction of PD EMD application onto debrided root sensitization following two applica-
and gain of CAL) occurred. In both surfaces is capable of inducing a cas- tions of EMD, 376 patients in 11
groups, the clinical improvements cade of biological events leading to university-based programmes and
were characterized histologically by a de novo formation of cementum and five private practices were treated
new connective tissue attachment, and stimulates matrix deposition on old with open flap debridement, root
to a varying extent, new bone (Sculean native cementum. In context, the conditioning and application of
et al. 1999). In the cases treated with wound maturation process after EMD. No complications were
EMD, the new connective tissue EMD application in a periodontal reported resulting from the applica-
attachment was followed by substan- wound may take up to 6 months tion of EMD. The results from this
tial bone re-growth in only two cases post-surgery. study further showed that treatment
while in four specimens, bone regener- of intrabony defects with EMD
ation was either minimal (0.5 mm) resulted in a significant reduction in
Clinical Applications of EMD
and confined to the apical part of the probing depths (PDs) and gain in
defects or the reformed connective tis- The regeneration of lost periodon- clinical attachment level (CAL)
sue attachment was not accompanied tium remains the ultimate goal in (Froum et al. 2004). Following these
by any signs of bone regeneration. On periodontal regenerative therapy. A preliminary human studies, the use
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 20 years of EMD 5

of EMD has now been utilized for with the outcomes. These findings clinical indications supporting
the treatment of a variety of defects indicate earlier gains in soft-tissue regenerative periodontal therapy
in over 60 randomized clinical trials density following application of with enamel matrix proteins.
and over 1 million patients world- EMD (Tonetti et al. 2004). A third
wide. No patient allergic reaction or study on the healing of soft tissue Clinical outcomes in intrabony defects
adverse event has been reported over wounds following periodontal sur- using EMD alone
this 20 year period. gery failed to demonstrate a statisti-
cally significant positive effect Heijl et al. published the first multi-
following treatment with EMD center, randomized, placebo-con-
Effects on early wound healing
(Hagenaars et al. 2004). trolled study evaluating the
As mentioned previously, certain A recent study in the rat model effectiveness of EMD for the treat-
studies have attempted to character- has shown that EMD improves oral ment of intrabony defects. In that
ize the early wound healing capabili- mucosa incisional wound healing by study, contra-laterally located intra-
ties of EMD in a clinical setting promoting formation of blood ves- bony defects were treated with either
(Wennstr€ om & Lindhe 2002, sels and collagen fibres in the con- open flap debridement (OFD) alone
Hagenaars et al. 2004, Tonetti nective tissue. EMD treatment or with additional application of
et al. 2004). In a double-masked, increased significantly the number of EMD (Heijl et al. 1997). Following
split-mouth, placebo-controlled, ran- blood vessels and the collagen con- 36 months of healing, the results
domized study, 28 patients with tent. EMD also enhanced (by 20– demonstrated that EMD significantly
moderately advanced chronic peri- 40%) the expression of transforming improved CAL gains and pocket
odontitis received scaling and root growth factor (TGF) b1 and depths. It was also concluded from
planning, followed by application of TGFb2, vascular endothelial growth radiographic analysis that a progres-
EDTA and treatment with EMD factor (vEGF), interleukin-1b (IL- sive bone gain following application
versus a PGA carrier (Wennstr€ om & 1b), matrix metalloproteinase-1 with EMD amounted to 2.6 mm
Lindhe 2002). After periods of 1, 2 (MMP-1), versican and fibronectin (66% fill) at the end of the evalua-
and 3 weeks, all sites were re-exam- (Maymon-Gil et al. 2016). There- tion period when compared to con-
ined including a visual analogue fore, it remains difficult to draw con- trol defects, which showed no
scale to score the degree of post- clusions on the wound healing significant bone gain (Heijl et al.
treatment discomfort. The results properties from clinical studies per- 1997). A subsequent controlled clini-
demonstrate that topically applied formed in dentistry on soft tissue cal study further showed that OFD
EMD had a positive effect on the healing as most of the common in combination with EMD led to a
early periodontal soft tissue wounds parameters used in dentistry involve three times greater defect fill when
as determined by the proportion of hard tissue healing. However, the compared to OFD alone (Froum
patients reporting a VAS score ≤20. available literature on XelmaÒ et al. 2001). Furthermore, additional
Tonetti et al. (2004) also evaluated (EMD formulation for the treatment benefits following regenerative proce-
the healing, post-operative morbidity of hard-to-heal wounds as previously dures demonstrated that EMD led
and patient perception of outcomes described) along with in vitro studies to significantly higher soft tissue
following regenerative therapy of strongly suggests that EMD may density in three clinical studies
deep intrabony defects. In this study, additionally improve soft tissue (Trombelli et al. 2002, Yilmaz et al.
papilla preservation flaps were used wound healing, although this may be 2003, Jentsch & Purschwitz 2008).
to obtain access and primary clo- difficult to be evaluated quantita- Tonetti et al. investigated the use of
sure. After debridement and root tively in a clinical setting (Vowden EMD in regenerative therapy of
conditioning, EMD was applied in et al. 2006, 2007a,b, Hampton et al. deep intrabony defects in 172
the test subjects and omitted in the 2007, Huldt-Nystrom et al. 2008, patients with advanced chronic peri-
controls. Healing was monitored 1, Romanelli 2008, Romanelli et al. odontitis in 12 centres (Tonetti et al.
2, 3, 4, 6 and 12 weeks after surgery. 2008, Bond et al. 2009, Chadwick & 2002). All patients had at least one
During the first 12 weeks of healing, Acton 2009). intrabony defect of > or =3 mm. The
supracrestal soft tissue density was surgical procedures included access
evaluated with a computer-assisted for root instrumentation using either
Clinical outcomes following non-surgical
densitometric image analysis system the simplified or the modified papilla
periodontal therapy
using underexposed radiographs preservation flap in order to obtain
taken on 34 patients. Patient percep- To date, only two randomized, pla- optimal tissue adaptation and pri-
tions were also evaluated with a cebo-controlled clinical studies have mary closure. After debridement,
questionnaire immediately after the evaluated the effects of EMD as roots were conditioned for 2 min
procedure, at suture removal 1 week adjunct to non-surgical periodontal with a gel containing 24% EDTA
later and at 1 year (Tonetti et al. therapy (SRP) (Gutierrez et al. 2003, followed by application of EMD in
2004). It was found that up to Mombelli et al. 2005). In both stud- the test subjects, whereas omitted in
6 weeks post-operatively, soft tissue ies, EMD failed to show any benefi- the controls. On average, the test
densities were significantly higher in cial effect. Therefore, it is defects gained 3.1  1.5 mm of
subjects treated with EMD with recommended that EMD is com- CAL, while the control defects
respect to controls. One year after bined with surgical periodontal ther- yielded a significantly lower CAL
completion of the surgery, patients apy and a treatment guideline will gain of 2.5  1.5 mm (Tonetti et al.
reported high levels of satisfaction be later provided highlighting the 2002). Pocket reduction was also
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
6 Miron et al.

significantly higher in the EMD enhance periodontal regeneration tial clinical and radiographic
group (3.9  1.7 mm) when com- (Sculean et al. 2001a, 2003a, 2006, improvements following application
pared to the controls (3.3  Parashis et al. 2006, Eickholz et al. of EMD alone (Fig. 3), concerns
1.7 mm). The results of this trial 2014). regarding the viscous nature of
indicated that regenerative periodon- Interestingly, a new series of EMD which may not be sufficient to
tal surgery with EMD offers an studies have now reported that the prevent a flap collapse and maintain
additional benefit in terms of CAL effects of EMD may be maximized space for periodontal regeneration
gains, PPD reductions and pre- when minimally invasive surgical have been raised (Polimeni et al.
dictability of outcomes with respect techniques (MIST) are applied, thus 2004, Siciliano et al. 2011). In order
to papilla preservation flaps alone improving initial wound stability to overcome this potential limitation
(Tonetti et al. 2002). On the other while minimizing patient morbidity and improve clinical results, various
hand, one randomized, double- (Cortellini & Tonetti 2007, Cortellini combinations of EMD with barrier
masked, placebo-controlled clinical et al. 2008, Harrel et al. 2010). membranes and/or grafting materials
trial failed to demonstrate any Although these authors show that have been tested (Trombelli & Far-
advantage for treatment of EMD MIST alone provides similar results ina 2008).
when compared to placebo for the to MIST plus EMD, these concepts Over 15 years ago, original stud-
treatment of intrabony defects (Ros- have been the basis of more focused ies had assessed the treatment of sin-
ing et al. 2005). In 2009, Esposito research in recent years and future gle intrabony defects following
et al. demonstrated in a Cochrane investigation aims to predictably treatment with EMD, GTR or a
database systematic review that the restore lost periodontal tissues via combination of both (Sculean et al.
use of EMD alone after 1 year sig- minimally invasive surgeries as dis- 2001b). Although the results demon-
nificantly improved probing attach- cussed later in this article. Although strated that all three regenerative
ment levels (1.1 mm) and PPD promising, further evaluation in procedures resulted in a significantly
reduction (0.9 mm) when compared large-scale, multicentre-controlled higher improvement of the clinical
to a placebo or control (Esposito clinical trials are still necessary. parameters compared to the conven-
et al. 2009). However, the high In summary, the results compar- tional flap surgery, no additional
degree of heterogeneity observed ing EMD and GTR did not show benefit could be observed for the
among trials suggests that results significantly different results in the combined treatment of
should be interpreted with caution majority of reports concerning treat- EMD + GTR. Comparable results
(Esposito et al. 2009). ment of single intrabony defects were also reported by other groups,
(Pontoriero et al. 1999, Okuda et al. thus indicating that, for treatment of
Clinical outcomes in intrabony defects
2000, Silvestri et al. 2000, 2003, Scu- single self-contained intrabony
using EMD or GTR lean et al. 2001b, Zucchelli et al. defects, the additional use of a bar-
2002, Esposito et al. 2009). Reports rier membrane in combination with
Another series of experiments from a prospective multicenter, ran- EMD alone led to no additional
focused primarily on comparing the domized, controlled clinical trial has improvements when compared to
use of EMD to GTR using either shown that treatment with GTR EMD alone, or to GTR alone (Min-
non-resorbable or bioabsorbable using a bioabsorbable membrane abe et al. 2002, Sipos et al. 2005).
membranes (Pontoriero et al. 1999). typically demonstrated surgical com- For these reasons, more research
The results from these studies plications, mostly membrane expo- was then performed combining
demonstrated that the use of EMD sure, whereas those treated with EMD with a bone grafting material.
or GTR led to significantly compa- EMD displayed fewer complications A detailed review article is refer-
rable results and that both treat- (Sanz et al. 2004). These data indi- enced for this combination evaluat-
ments led to substantially higher cate that although the use of EMD ing all in vitro, in vivo and
CAL gains and defect fill when com- is generally characterized by randomized clinical trials (Miron
pared to OFD alone for the treat- improved periodontal regeneration et al. 2014c). Within the context of
ment of single intrabony defects with or without membrane use, the this article, a brief overview from
(Heijl et al. 1997, Pontoriero et al. findings from a number of clinical clinical trials investigating the use of
1999, Okuda et al. 2000, Silvestri studies have demonstrated that EMD plus a bone grafting material
et al. 2000, Froum et al. 2001, Scu- anatomical factors such as defect is discussed.
lean et al. 2001b, Tonetti et al. 2002, configuration seem to play an impor- A recent systematic review and
Zucchelli et al. 2002). Furthermore, tant role in EMD-induced periodon- meta-analysis on 12 studies reporting
the use of EMD in combination with tal regeneration. This concept is on 434 patients found that the com-
antibiotics or root conditioning further discussed within the subsec- bination of bone grafting mate-
agents was investigated. It was found tion on clinical indications for rial + EMD led to statistically
that the use of EMD in combination EMD. significant better outcomes (Matar-
with postoperative administration of asso et al. 2015). In that study, the
an antibiotic regimen (i.e. amoxicillin mean CAL gain amounted to
Clinical outcome in intrabony defects
and metronidazole (Sculean et al.
using combinations of EMD with barrier 3.76  1.07 mm following treatment
2001a,b) or doxycycline (Eickholz membranes or grafting materials with EMD + bone graft and to
et al. 2014)), a selective cyclooxyge- 3.32  1.04 mm following treatment
nase-2 inhibitor, or EDTA root Although numerous clinical studies with EMD alone. Mean PD reduc-
conditioning did not additionally have provided evidence for substan- tion measured 4.22  1.20 mm at
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 20 years of EMD 7

2013, Ogihara & Tarnow 2014). In

general, the effects of EMD demon-
strated a significant advantage in
three clinical studies when compared
to either demineralized freeze-dried
bone allograft (DFDBA) alone or
EMD alone, however, no differences
in mean PD or mean CAL changes
were observed in two other studies
(Table 1).
(A) The combination of EMD with a
natural bone mineral (NBM, also
known as bovine-derived xenograft
(BDX), deproteinized bovine bone
mineral (DBBM) or Bio-OssÒ) has
been investigated in five clinical stud-
ies (Table 1). In one study evaluat-
ing intrabony defects > 6 mm, the
combination of EMD with NBM led
to statistically improved mean PD
and CAL changes after 6 months of
healing (Lekovic et al. 2000). In the
remaining four studies, variability
was observed between treatment
with EMD + NBM when compared
to either EMD alone or NBM alone
(B) in the reported studies (Scheyer et al.
2002, Sculean et al. 2002b, Velas-
quez-Plata et al. 2002, Zucchelli
et al. 2003). Zuchelli et al. found
that after a 12 month healing period,
the combination of EMD + DBBM
led to significantly higher CAL gain
(Table 1). In a recent study by Far-
ina et al., 24 periodontal intra-oss-
eous defects were accessed with a
buccal single flap approach (SFA)
and treated with enamel matrix
derivative (EMD) or EMD + NBM
(C)
according to the operator’s discre-
Fig. 3. (A) Pre-operative clinical images depicting a deep intrabony defect. (B) X-rays tion (Farina et al. 2014). Both EMD
demonstrating excellent defect fill following treatment with EMD combined with a with or without NBM were clinically
bone graft. (C) Four year outcome following intrabony defect regeneration with effective in the treatment of peri-
EMD. odontal intra-osseous defects
accessed with a buccal SFA. The
adjunctive use of NBM in predomi-
sites treated with EMD and bone EMD with autogenous bone (AB) nantly one-wall defects seemed to
graft and yielded 4.12  1.07 at sites (Guida et al. 2007, Yilmaz et al. compensate, at least in part, the
treated with EMD alone. Interesting 2010). In a parallel study of 28 intra- unfavourable osseous characteristics
to note however is that while the osseous lesions, the combination of on the outcomes of the procedure
combination of some bone grafting EMD with AB did not offer a statis- (Farina et al. 2014).
materials with EMD seems to favour tically significant advantage when The combination of EMD with
periodontal regeneration, many compared to EMD alone (Guida synthetic bone grafting materials has
other studies show no additional et al. 2007). In a second study evalu- for the most part demonstrated no
benefit when compared to bone ating two- and three-wall intrabony advantage for the combination
grafting material alone or to EMD defects, the effects of EMD with AB approach (Table 1) (Sculean et al.
alone (Lekovic et al. 2000, Velas- led to statistically significant differ- 2002a, 2005, Kuru et al. 2006, Jep-
quez-Plata et al. 2002, Zucchelli ences (Yilmaz et al. 2010) (Table 1). sen et al. 2008, Meyle et al. 2011,
et al. 2003, Gurinsky et al. 2004, Similarly, the combination of EMD De Leonardis & Paolantonio 2013,
Kuru et al. 2006, Guida et al. 2007, with bone allografts has been investi- Peres et al. 2013). In general, Kuru
Trombelli & Farina 2008). gated in five clinical studies (Gurin- et al. and De Leonardis et al. have
To date, only two clinical studies sky et al. 2004, Hoidal et al. 2008, demonstrated a significant advantage
have reported the combination of Aspriello et al. 2011, Jaiswal & Deo in mean PD and mean CAL gains
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 8

Table 1. List of randomized clinical trials comparing the combination of EMD + bone grafting material to either EMD alone or bone grafting material alone.
Author and Year Study design and Defects Healing period Treatment groups Mean PD P value Mean CAL P value
Patient number change (mm) change (mm)
Miron et al.

Guida, 2007 Parallel : 27 patients 28 intra-osseous lesions ≥ 4 mm 6–12 months EMD 5.1–5.6 n.s. 4.4–4.6 n.s.
EMD + AB 4.6–5.1 4.4–4.9
Yilmaz, 2010 Parallel : 40 patients 40 intrabony defects ≥ 3 mm 12 months EMD 4.6 <0.01 3.4 <0.01
EMD + AB 5.6 4.2
Gurinsky, 2004 Parallel : 40 patients 67 intrabony defects ≥ 3 mm 6 months EMD 4.0 n.s. 3.2 n.s.
EMD + DFDBA 3.6 3.0
Hoidal, 2008 Parallel : 32 patients 41 intrabony defects ≥ 3 mm 6 months DFDBA 2.45 n.s. 1.63 n.s.
DFDBA + EMD 2.56 1.47
Aspriello, 2011 Parallel : 56 patients 56 intra-osseous defects 12 months DFDBA 4.0 <0.05 3.25 <0.05
DFDBA + EMD 5.0 4.0
Jaiswal, 2013 Parallel : 30 patients 30 class II furcation defects 12 months DFDBA + GTR 0.81 <0.05 0.85 <0.01
DFDBA + GTR + EMD 1.74 2.12
Ogihara, 2014 Parallel: 69 patients 69 intrabony defects 12–36 months EMD 3.26–3.09 <0.05 3.04–3.00 <0.05
EMD + DFDBA 3.7–3.74 3.52–3.61
EMD + FDBA 4.38–4.43 4.14–4.19
Lekovic, 2000 Split mouth : 21 patients 42 intrabony defects 6 months EMD 1.91 <0.05 1.72 <0.05
EMD + NBM 3.43 3.13
Velasquez- Split mouth : 16 patients 32 intrabony defects ≥ 3 mm 6–8 months EMD 3.8 n.s. 2.9 n.s.
Plata, 2002 EMD + NBM 4.0 3.4
Sculean, 2002 Parallel : 24 patients 24 intrabony defects ≥ 4 mm 12 months BDX 6.5 n.s. 4.9 n.s.
BDX + EMD 5.7 4.7
Scheyer, 2002 Split mouth : 17 patients 34 intrabony defects ≥ 3 mm 6 months BDX 3.9 n.s. 3.7 n.s.
BDX + EMD 4.2 3.8
Zucchelli, 2003 Parallel : 60 patients 60 intrabony defects > 3 mm 12 months EMD 5.8 n.s. 5.8 <0.01
EMD + NBM 6.2 4.9
Sculean, 2002 Parallel : 28 patients 28 intrabony defects ≥ 3 mm 12 months BG 4.22 n.s. 3.07 n.s.
EMD + BG 4.15 3.22
Sculean, 2005 Parallel : 30 patients 30 intrabony defects ≥ 3 mm 12 months EMD 4.5 n.s. 3.9 n.s.
EMD + BG 4.2 3.2
Kuru, 2006 Parallel : 23 patients 23 intrabony defects ≥ 4 mm 8 months EMD 5.03 <0.05 4.06 <0.05
EMD + BG 5.73 5.17
Bokan, 2006 Parallel : 56 patients 56 intrabony defects ≥ 3 mm 12 months EMD 3.9 n.s. 3.7 n.s.
EMD + b-TCP 4.1 4.0
Jepsen, 2008 Parallel : 73 patients 73 intrabony defects ≥ 4 mm 6 months EMD 2.55 n.s. 1.83 n.s.
EMD + BCP 1.93 1.31
Meyle, 2011 Parallel : 73 patients 73 intrabony defect ≥4 mm 12 months EMD 2.9 n.s. 1.9 n.s.
EMD + BC 2.8 1.7
De Leonardis, Parallel : 34 patients 34 intrabony defects ≥3 mm 12–24 months EMD 3.51–3.76 <0.001 2.73–2.95 <0.001
2013 EMD + HA/b-TCP 4.00–4.25 3.47–3.63

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 20 years of EMD 9

for the combination approach (Kuru evaluated whether the combination

et al. 2006, De Leonardis & Paolan- of EMD with a subepithelial connec-
tonio 2013), however, the remaining tive tissue graft (SCTG) plus CAF
five studies have shown no clear would further improve the treatment
advantage (Sculean et al. 2002a, outcomes of Miller class I and II
2005, Jepsen et al. 2008, Meyle et al. gingival recessions in 42 patients
2011, Peres et al. 2013). Longer term (Roman et al. 2013). Both treat-
follow-ups have confirmed the lack ments, STCG plus EMD and SCTG
of an added benefit of a synthetic alone, resulted in a significantly
(A)
bone substitute (Pietruska et al. higher than baseline final mean root
2012, Hoffmann et al. 2015). There- coverage (2.91  0.95 mm and
fore, the results from a number of 2.91  1.29 mm, respectively) and in
clinical trials demonstrate a large a high mean percentage of root cov-
variability between both the bone erage (82.25  22.20% and
grafting groups utilized (autograft 89.75  17.33%, respectively) 1 year
versus allograft versus xenograft ver- after surgery, however, differences
sus alloplast) as well as within indi- between the two techniques were not
vidual groups (Table 1). Possible statistically significant. Cordaro
reasons for this variability will be et al. (2012) compared, in a split-
discussed later in the future perspec- (B) mouth design, CAF with or without
tives section of this review article. Fig. 4. (A) Baseline photograph illustrat- EMD for coverage of multiple gingi-
More recently, it has been demon- ing Multiple Miller Class II recessions. val recession defects with follow-up
strated that the combination of a (B) Two year outcome following reces- at 6- and 24 months. Clinical mea-
graft biomaterial in association with sion coverage with EMD and connective surements (recession length, kera-
biological agents, including EMD, tissue graft. tinized tissue, probing depth and
may reduce the post-surgery reces- clinical attachment level) were
sion following treatment of deep assessed at baseline and 6 and
intra-osseous defects accessed with 2004, Castellanos et al. 2006, Pilloni 24 months after surgery by a blinded
the single flap approach (Farina et al. 2006, Cairo et al. 2008). examiner. At the 6-month evaluation,
et al. 2015). Another study has compared the use both treatment procedures displayed
of EMD to a connective tissue graft good results with significant root
Clinical outcomes in recession defects
(CTG) for the treatment of buccal coverage gain (CAF, 80.7%  20%;
using EMD alone or as adjunct to soft
Miller class I and II recessions with CAF + EMD, 82.8%  14%). No
tissue grafting
CAF (McGuire & Nunn 2003). The significant difference was found
results from that study demonstrated between groups (Cordaro et al.
The use of EMD has been investi- very similar results after 1 year for 2012).
gated in several controlled clinical mean root coverage. A recent con- Thus, the accumulated evidence
studies for the treatment of buccal sensus conference concluded that at from these studies suggests that the
Miller class I and II gingival reces- single recessions, the addition of use of EMD for the treatment of
sions by means of coronally autologous CTG or EMD under gingival recessions utilized alone is
advanced flap (CAF). In the major- CAF improves complete root cover- capable of enhancing regeneration
ity of cases, the additional use of age and may be considered the pro- and improves soft tissue height/
EMD led to more formation of ker- cedure of choice at maxillary thickness, while the combination
atinized tissue and long-term stabil- anterior and premolar teeth (Tonetti with SCTG may further support
ity of the results compared to CAF & Jepsen 2014). recession coverage; however, this
alone (Hagewald et al. 2002, Cueva Histological evaluation of human approach presents great variability
et al. 2004, Spahr et al. 2005, Castel- biopsies in recession defects was then in the clinical parameters analysed
lanos et al. 2006, Pilloni et al. 2006, performed to analyse periodontal (Henriques et al. 2010, Rasperini
Cairo et al. 2008, 2014) (Fig. 4). One regeneration (Heijl 1997, McGuire & et al. 2011).
randomized controlled clinical study Cochran 2003). It was found that
comparing treatment of Miller class the application of EMD during con-
I and II recessions demonstrated Clinical outcomes with EMD in furcation
junction with CAF resulted in
defects
that after a healing period of enhanced formation of root cemen-
2 years, complete root coverage tum, periodontal ligament and alveo- The data on the efficacy of the use
could be maintained in 53% in lar bone while treatment with a of EMD in the regenerative therapy
patients treated with EMD versus CAF and a connective graft or CAF of furcation defects are still limited
23% in the control group (Spahr alone (McGuire & Cochran 2003) (Sanz et al. 2015). When investigat-
et al. 2005). Comparable results were was characterized by a long junc- ing the adjunctive use of enamel
reported from various other groups tional epithelium and even signs of matrix derivative with open flap
for the treatment of either Miller root resorption. Comparable results debridement in 10 patients with 20
class I or class 2 recession defects were reported in a multicenter, con- Class II furcation defects on contra-
with topical application of EMD trolled clinical trial (Rasperini et al. lateral molars by re-entry after
leading to better results (Cueva et al. 2011). More recently, Roman et al. 6 months, a significantly enhanced
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
10 Miron et al.

horizontal resolution (reduction of swelling was superior following research to further understand its
2 mm in the enamel matrix deriva- EMD application. properties and biological effects are
tive versus 0.8 mm in the open flap In proximal class II furcation still ongoing. This section is divided
debridement group) of the bony defects, the use of EMD led to a into the following six subsections:
defects was found in enamel matrix higher conversion rate into class I (1) future use of EMD in minimally
derivative-treated furcations (Chit- when compared to OFD alone invasive surgeries, (2) use of EMD
sazi et al. 2007). In a multicentre, although complete furcation closure for the treatment of supra-alveolar-
randomized, controlled, split-mouth, was only rarely found (Casarin et al. type defects, (3) possible use of
clinical trial of mandibular buccal 2010). In another trial on the treat- EMD for the treatment of peri-
class II furcation defects, a total of ment of proximal class II furcation implantitis and mucosal recessions
45 patients with 90 comparable defects, the effects of OFD + hy- around implants, (4) characteristics
defects on contra-lateral molars were droxyapatite (HA)/b-tricalcium of various fractions of EMD, (5)
treated with either EMD or GTR phosphate (b-TCP) filling, or development of Osteogain, a new
(Jepsen et al. 2004, Meyle et al. OFD + HA/b-TCP + EMD were product incorporating EMD with
2004, Hoffmann et al. 2006). At 8 evaluated (Peres et al. 2013). No sig- better physicochemical properties for
and 14 months, both treatment nificant difference was reported bone grafting material adsorption
modalities led to significant clinical between treatment modalities and (6) final remarks.
improvements. The EMD group 6 months after therapy (Peres et al.
showed significantly better results 2013). In summary, the limited data
Future use of EMD in minimally invasive
with regard to the primary outcome on the effects of EMD in regenera-
surgeries
reduction in horizontal furcation tive furcation therapy is encourag-
depth as assessed during a 14 months ing, however, more evidence from In the great majority of studies, EMD
re-entry procedure. Enamel matrix further well-controlled studies is was applied in reconstructive surgery
derivative demonstrated a mean clearly needed. A clinical treatment using a conventional flap design pre-
reduction in horizontal probing bone guideline has been added to pared by means of intrasulcular inci-
level of 2.6 + /- 1.8 mm, and the Appendix S2 (Fig. 5). sions. More recently, a few studies
guided tissue regeneration-treated have investigated its use in conjunc-
sites showed a horizontal probing tion with minimally invasive surgery.
Future Perspectives
bone level reduction of 1.9 + /- Although minimally invasive surgical
1.4 mm. Furthermore, with regard to Although EMD has been utilized for techniques cannot be utilized in all
patient-centred outcomes, post- a variety of clinical applications over cases, clinical outcomes in certain
operative wound healing as assessed the past 20 years, research concern- cases appear to be associated with
by questionnaires on pain and ing its clinical use as well as basic reduced morbidity of the patient

Fig. 5. Flow Chart – clinical indications for the use of EMD in periodontal surgery. Intrabony defect, furcation defect and recession
defect regeneration have all demonstrated long-term clinical improvements following treatment with EMD in certain clinical
indications.
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 20 years of EMD 11

post-operatively (Cortellini 2012, I(2) = 0%), 0.5 mm for the REC for investigating the treatment of
Cortellini & Tonetti 2015). Both increase (CI: [ 0.8, 0.2], p = 0.003, peri-implantitis and mucosal reces-
MIST and modified MIST (M-MIST) I(2) = 0%). Although no differences sions around implants. In a report
techniques (Cortellini 2014) present were noted in tooth survival, EMD of 51 cases with 3–7.5 year follow-
great opportunities for future application resulted in clinical and up, Froum et al. demonstrated that
research in conjunction with EMD radiographic additional benefits implants showing PDs ≥ 6 mm, and
for a variety of clinical situations. compared to OFD alone (Graziani bone loss ≥4 mm could be success-
Future randomized, multicentre clini- et al. 2014). Future research on this fully regenerated using a combina-
cal trials are necessary to further topic is however still necessary to tion approach including surface
investigate the clinical benefit of uti- fully characterize the additional ben- decontamination, use of EMD, a
lizing EMD during MIST techniques. efit of EMD for the treatment of combination of PDGF with anor-
such defects. ganic bovine bone or mineralized
freeze-dried bone, and coverage with
Uses of EMD for the treatment of supra- a collagen membrane or a subepithe-
alveolar-type defects with access flap Possible use of EMD for the treatment of
peri-implantitis and mucosal recessions lial connective tissue graft. The
surgery
around implants rationale for combining PDGF with
A very limited amount of research EMD was derived from an in vitro
has investigated the use of EMD for The wound healing properties of study conducted by Chong et al.
the treatment of supra-alveolar-type EMD, along with its effect on new (2006) showed that the combination
defects. In a pilot by Jentsch & bone formation have been the basis of PDGF + EMD led to greater cell
Purschwitz (2008), 39 subjects were
either treated with access flap
surgery + EMD versus access flap
surgery alone. In that study, it was
found that significantly higher
attachment gain and PD reduction
was observed for the test group
when compared to controls (Jentsch
& Purschwitz 2008). The data sug-
gest a significant clinical benefit for
additionally combining access flap
surgery with EMD for the treatment
of supra-alveolar-type defects, espe- (A) (B)
cially in deeper pockets (Jentsch &
Purschwitz 2008). Furthermore, in
2013, Di Tullio et al. found similar
results by treating 54 patients with
either simplified papilla preservation
flap technique (SPPF) + EMD versus
SPPF alone (Di Tullio et al. 2013).
After 1 year, the test group showed
significantly greater PD reduction,
and AL gain compared to the con-
trol group (Di Tullio et al. 2013).
(C) (D)
Thus, in the light of these two stud-
ies and the limited clinical data, it
may be suggested to combine either
access flap surgery or SPPF with
EMD to further improve the regen-
erative outcomes following periodon-
tal therapy for the treatment of
supra-alveolar-type defects.
Graziani et al. (2014) investigated
in a systematic review and meta-
analysis the effects of EMD on addi- (E)
tional clinical benefits in residual
periodontal pockets associated with Fig. 6. Treatment of Peri-implantitis utilizing a combination therapy approach with
EMD. (A) A 41-year-old, healthy female presented with peri-implantitis around
suprabony defects. The adjunctive
implant #19i characterized by bleeding on probing, 8 mm probing depths and loss of
mean benefit of EMD was: 1.2 mm bone. (B) Pre-surgical X-ray indicating bone loss. (C) Flap reflection prior to surface
for CAL gain [confidence interval decontamination showing 7 mm of interproximal bone loss on the mesial and distal
(CI): (0.9, 1.4), p < 0.00001, I aspects of the implant, (D) Radiograph 4 years following treatment showing fill of the
(2) = 66%], 1.2 mm for the PPD defect. (E) Clinical photo, 4 year post-op, showing the deepest probing depth of 3 mm
reduction (CI: [0.8, 1.5], p < 0.0001, with a complete absence of bleeding on probing.
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
12 Miron et al.

proliferation and in vitro wound fille While a recent systematic review and over the years, we have learned a
rates when compared to either uti- meta-analysis found that the combi- great deal regarding the biological
lized alone. Patients were divided nation of bone grafting mate- roles of specific enamel matrix pro-
into two groups as follows: (1) the rial + EMD led to statistically teins and future investigation is con-
greatest defect depth was visible on significant better outcomes, large stantly underway to further
radiographs and (2) the greatest loss variability between studies were also characterize their effects on cell and
of bone was on the facial or oral reported (Lekovic et al. 2000, Velas- tissue behaviour. It also becomes
aspect of the implant. The results quez-Plata et al. 2002, Zucchelli clinically important to further inves-
from that study demonstrated that et al. 2003, Gurinsky et al. 2004, tigate the use of EMD in both car-
probing depth reductions were 5.4 Kuru et al. 2006, Guida et al. 2007, rier systems described to determine if
and 5.1 mm with bone level gain Trombelli & Farina 2008). In vitro regenerative outcomes can be even
3.75 mm and 3.0 mm in groups 1 results have also indicated variability further improved by slight modifica-
and 2 respectively (Fig. 6). No in gene expression when primary tions in EMD-carrier systems or
implant in either group was lost or human osteoblasts and PDL cells through minimally invasive surgeries.
demonstrated reduced bone height were cultured on various bone graft- During these 20 years, over 900 pub-
throughout the duration of the ing materials in vitro with or with- lications documenting the use of
study. Although a variety of control out EMD thus raising the concern EMD for a variety of in vitro and
groups were lacking in this study, that protein function, stability or in vivo studies as well as numerous
the regenerative approach utilized by adsorption may be responsible fac- clinical trials. EMD has remained
these authors for the treatment of tors in the gel-delivery system cur- one of the gold standards for peri-
peri-implantitis appears to be rently utilized for EMD (Miron odontal regeneration using biologics
encouraging (Froum et al. 2012). et al. 2012, 2013, 2014a). and it remains of interest to discover
Further research is necessary to con- Recently, the adsorption of amel- how the next 20 years of intensive
firm the beneficial effect of EMD in ogenins to bone grafting materials research will further improve EMD
the treatment of peri-implantitis under various conditions was investi- clinical outcomes.
lesions as it is difficult to assess the gated (Miron et al. 2015a). These
single role of each of the individual results confirm that large variability
regenerative approaches utilized by existed between the adsorption of References
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Tonetti, M. S., Fourmousis, I., Suvan, J., Cortel- growth in an extra-oral rabbit model. Clinical
of this article:
lini, P., Bragger, U. & Lang, N. P. (2004) Heal- Oral Investigations. doi:10.1111/clr.12740.
ing, post-operative morbidity and patient Wennstr€ om, J. L. & Lindhe, J. (2002) Some Figure S1. Scanning electron micro-
perception of outcomes following regenerative effects of enamel matrix proteins on wound graph of an osteoblast seeded on a
therapy of deep intrabony defects. Journal of healing in the dento-gingival region. Journal of deproteinized bovine bone mineral
Clinical Periodontology 31, 1092–1098. Clinical Periodontology 29, 9–14.
Tonetti, M. S. & Jepsen, S. (2014) Clinical effi- Yilmaz, S., Cakar, G., Yildirim, B. & Sculean, A. following coating with EMD.
cacy of periodontal plastic surgery procedures: (2010) Healing of two and three wall intrabony Appendix S1. Biology of Periodontal
consensus report of Group 2 of the 10th Euro- periodontal defects following treatment with an Regeneration with Enamel Matrix
pean Workshop on Periodontology. Journal of enamel matrix derivative combined with auto- Proteins.
Clinical Periodontology 41 (Suppl 15), S36–S43. genous bone. Journal of Clinical Periodontology
Tonetti, M. S., Lang, N. P., Cortellini, P., Suvan, 37, 544–550.
Appendix S2. Clinical Treatment
J. E., Adriaens, P., Dubravec, D., Fonzar, A., Yilmaz, S., Kuru, B. & Altuna-Kirac, E. (2003) Guidelines for EMD.
Fourmousis, I., Mayfield, L., Rossi, R., Sil- Enamel matrix proteins in the treatment of Appendix S3. Characterization of
vestri, M., Tiedemann, C., Topoll, H., Vang- periodontal sites with horizontal type of bone various fractions of EMD.
sted, T. & Wallkamm, B. (2002) Enamel matrix loss. Journal of Clinical Periodontology 30, 197–
proteins in the regenerative therapy of deep 206.
intrabony defects. Journal of Clinical Periodon- Yukna, R. A. & Mellonig, J. T. (2000) Histologic
tology 29, 317–325. evaluation of periodontal healing in humans Address:
Tonetti, M. S., Prato, G. P. & Cortellini, P. following regenerative therapy with enamel Richard J. Miron
(1996) Factors affecting the healing response of matrix derivative. A 10-case series. Journal of Department of Periodontology
intrabony defects following guided tissue regen- Periodontology 71, 752–759.
Nova Southeastern University
eration and access flap surgery. Journal of Clin- Zeichner-David, M. (2001) Is there more to
ical Periodontology 23, 548–556. enamel matrix proteins than biomineralization? Fort Lauderdale, Florida
Trombelli, L., Bottega, S. & Zucchelli, G. (2002) Matrix Biology 20, 307–316. USA
Supracrestal soft tissue preservation with Zetterstrom, O., Andersson, C., Eriksson, L., Fre- E-mail: [email protected]
enamel matrix proteins in treatment of deep driksson, A., Friskopp, J., Heden, G., Jansson,

Clinical Relevance clinical studies have shown the matrix proteins for the regenera-
Scientific rationale for the study: ability for EMD to improve tion of periodontal defects and
Provide an extensive summary of both soft and hard tissue forma- provides future research avenues
the research performed on enamel tion leading to periodontal regener- currently being investigated utiliz-
matrix derivative (EMD) over the ation. ing EMD.
past 20 years. Practical implications: The results
Principal findings: Over the past from this review article demonstrate
20 years, in vitro, in vivo and the safety and efficacy of enamel

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd