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Guided Tissue Regeneration Using aResorbabie iViembrane inGingivai Recession-Type Defects:A Histoiogic Case Report in Humans

Gianpaoio Vincenzi, MD, DDS'Alberto De Chiesa. MD, DDS"PaoioJfisi.DDS,PhD"'

This case report ciinicoiiy ond histaiogicaiiy evaiuated the regeneration afgingivoi fissues with the use of resarbabie membranes. The study was per-formed on a premolor for which exfractlan was pianned. The exposed roatsurface was thoroughiy cleaned and pianed with curettes ond rotaryinstruments, ond two notches were created on fhe taciol ospeot of fheexpased root surfoce. A resarbabie Resalufe membrane (WL Gore) wosappiied obove the defecf to aiiaw for gingival regenerofion. After o6-manth heoiing period, a black secfian canfalning the root ond theregenerated tissues was removed. The biopsy specimen was processed toobtain thin graund sectians. The histologie onalysis demonstroted the for-mation afa newly generoted periodontai tissue trom the deepest notohtowdrd the caronai gingiva. The newiy formed tissue was composed of ocoronai area of connective tissue affochment ond an opicoi oreo ofbane ñbers and cementum. The present report histoiogicaily demonstrotesthe ability of a resorbabie membrane to ailow compiete regenerotion ofthe periodantai iigament in the caverage af gingival recessions.(Inf J Periodonf Resf Dent 1998; 18:25-33.)

•Piivofe Practice, Verono. Italy"Privóte Practice, Saiuzzo, Ifaly'Scienfitic Director, Biamateriais Ciinicai Research Association, andPrivate Prootice. Pescara, ifaiy.

fieprint requests: Dr Paolo Trisi, Biomaferiais Ciinicai ResearchAssociof ion. Vio Son Siivesf ro 163/3,65132 Pescaro, Italye-maii: pault)ioc@mbox.voi.it

One of fhe major objectives ofperiodontai surgery is fo covera roof surface exposed by buc-cai gingivai recessions. In the1980s, authors^"' reported theuse ot free autogenous gingivalgrofts to cover exposed root sur-faces with increasing success.Recently, guided tissue regener-ation has been successfuiiyused in the treatment cf buccalgingivai recessions by means ofexpanded polytetratluoroethyl-ene (e-PTFE) membranes.^-'"Many techniques have beensuggested to improve ciinicaiand histoiogic resuifs.^^-^^ Thenature of the tissue fhat hasregenerated over an exposedroot in humons^''"''' and in ani-mais'^"" has been investigatedand has demonstrated thatnew connective tissue atfach-ment can be expected with theuse cf either e-PTFE or the freegingivai graft. The disadvantagewith the use of the free gingivaigraft is fhe need for a donorsite; fhe main problem associ-ated with the use of e-PTFEmembranes is the necessity of

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surgical reentry to remove thenonresorbabie membrane,iiesorbabie membrones havebeen infroduced fo eliminatefhe need for second-stogesurgery2°-2 j however, fhe suc-cess of resorbadle membranesin fhe treatment ot buooal gin-givai recessions has not beencompieteiy evaluoted.

The goal of this cose reportwas to clinically and histologi-caiiy evaluate tissue regenero-fion with the use of resorbablemembranes.

Method and materials

Case report

The patient, a 36-year-oldwoman in good gêneraihealth, presented with a buo-oai recession on the moxiilaryright second premolar that wasfhe lasf abutment of o failedfixed complete denture. Sincethe patient was scheduled foundergo impiant surgery andextraction of this tooth waspianned, she was asked toundergo regenerative theropyof the gingivai buccai reces-sion before footh extraction.Atter having obtained thepatient's informed consent, itwas decided to cover the buc-cai recession wifh a resorbabiemembrone.

A mucoperiosteai sulcuiartrapezoidai flap was elevatedon fhe buccai aspect of fhetoofh with a releasing incisionthat extended 3 mm apicaiand iaferal to the osseous de-tect occording to the meth-od described by Tinti andVincenzi.2* The papulae werepreserved, and the epitheliumof the overioying mucosa wasexcised. The exposed root sur-foce was thoroughly cleanedand planed with curettes androtary instruments, ond twonotches were created on fhefacial exposed roof surface; themost coronai notch was piaced1 mm beyond the adjacentcrest, and the apical notch wasplaced 3 mm beyond the crest,ie, at the bottom of the bonydehiscence (Figs 1 ond 2). Theperiodontal iigament surround-ing the defect was stimuiatedby gentiy penetrating the liga-ment wifti the surgicol blade.The papillae were then fuiiy dis-secfed fo sfabiiize the mem-brane. A resorbabie Resoiutemembrane (WL Gore) was ap-piied above fhe detect tc allowfor gingivol regenerotion (Fig 3).A resorbabie suture was usedfhrough fhe membrone to allowthe curvature of the membraneabove fhe root surface to re-main raised, as indicated byTinfi et ai. '^ The flap was re-leased by dissecting the muscu-lar tibers to ooronally reposition

without muscular tension, A cir-cumferentiai suture, 4 mm coro-nai fo the tirsf nofch, was usedto stabiiize the membranearound the tooth occording tothe standard sling techniqueused to stabiiize e-PTFE mem-branes. The tlap was then su-tured to cover thie membrane1 mm coronol to the tinishingiine of the abutment (Fig 4).

The patient received a 300mg daiiy dose of oral fefracy-cline for 6 doys postoperativeond 275 mg of noproxen fhreefimes daiiy for 4 doys. A 0.12%chlorhexidine rinse was pre-scribed twice a day for 14days, ond lighf foothbrushingwas prescribed 2 weeks öfterthe surgery

At the 1-week recall, a par-tial 0.5-mm membrone expo-sure was noted that reached 1mm by the 2-week recaii. in thesubsequent visits no turfherexposure was noted. The sufureswere removed 3 weeks postop-erative. The footh heaied undis-furbed tor 6 months. At fhe6-monfh recall the regenerotedgingiva showed a 2-mm reces-sion, but the taciai probingdepth wos 2 mm. The gingivawas not inflamed buf the as-pect was siightly different fromnormal atfoched gingiva in fhatit wos thicker and presented thesuperficial aspecf of free gin-giva, buf wos attached fo thedeeper planes.

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Fig I Fociai dehiscence defect añernap elevation. Arrows indicate thenotches thot were made on theexposed root

Fig 2 Measurement of the dehis-cence defects and the two notches.

Fig 3 Resorbdbie membrane suturedonto the defect.

Fig 4 Finai aspect after suturing af fhe fiap. Note the absence of muscuiar tension.

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fig 5 Hisfoiagic specimen. Arrowsindicate the two notches that weremade on fhe exposed root. (Originalmagnification x 6: toiuidine blue-tightgreen stain.)

After ó months of healing, oblock section containing theroot and regenerated fissueswas extracted. The gingivai fis-sues were removed 2 mmmesiai and distal to the root,and 3 mm apicaliy to thedeepest area ot the initialrecession. The root was sec-ticned in a taciai and a paiataipart with the taciai bone cor-tex with a rofary high speedbur.

After the tooth extraction,the detect was treated with afiling materiai for bone regener-ation, ond an e-PTFE membraneand an endasseous titanium im-piant were piaced. A loteraliypositioned fiap was used focover the extroction sife.

Histologie processing

The biopsy specimen was im-mediateiy rinsed in saiine, fixedin 10% neutrol buffered formaiin,and processed to obtain fhinground secfions. The specimenwas dehydroted in an ascend-ing series of oicohoi rinses andfhen embedded in i?emacrylresin. After poiymerization, thespecimen wos sectioned at 200to 250 Mm by a Micromet high-speed rotating biade micro-tome and ground down toabout 40 to 50 |jm by an LS2grinding machine. The histoiogicsiides were routineiy stoined withtoiuidine biue-iight green.

A hisfomorphometric anoly-sis was pertormed with Ksiiteimage anolysis sottware con-nected to the microscope viaa iHitachi KP-113 camera.

Results

The heaiing was unevenffui.excepf for fhe initiai exposure ofthe membrone. The exposuredid nof give rise to any compii-cations, but a certain recessionot the regenerated tissue wasnoted. The final probing depthof 1 fo 2 mm demonstrated theregeneration oi a clinicaiattachment apparatus. No ciini-cal signs cf inflammation werenoted on the gingiva.

The histoiagic anaiysis dem-onstrated the formafion ofnewiy generated periodonfaitissue from the deepest notch

toward the coronai gingiva (Fig

5).The newiy formed fissue

was composed of a corcnaiarea of connective fissueattachment and an apicalarea ot bone fibers andcementum. A 2.3-mm-thickband of connective fissue waspresent over the bone crest.The first crestai miiiimeter oi thisfissue was composed ot coiia-gen tiber bundies inserting per-pendicularly into the rootcementum (Figs 6 and 7), whilethe remaining coronal 1.3 mmconsisted of coiiagen fibersparaiiei tc the root surface (Fig8). The ccronol natch was filledwifh iayers ot unottoched coi-iagen fibers running paraiiei tofhe root surface.

Marginoi epithelium wasfound 2 mm beneoth fhe ce-mentoenamel junction. Themost coronal root surface fac-ing fhe poci<ef epitheiiumshowed exposed dentinaltubules ond a small layer otbacteria.

One miiiimeter beneath thegingivoi margin, the root woscovered by a iayer of aceiiuiarcemenfum, whiie a layer of cei-iular remodeling cementumwas detected in the deepestregion (Fig 6).

The most coronai region otthe regenerated bone con-sisted of woven bone with areasof bone remodeiing (Figs 7 and9). Poiarized light microscopydemonstrated fhe layeredospecf of the regenerated

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Fig 6 (left) Magnification of the mid-dle region in Fig 5. The deepest area offhe regenerated connective tissueshows signs of cementum remodeling(arrowheads). (Original magnificationX 100: taiuidine blue stain.)

Fig 7 (right) Magnification af fhe mid-die region in Fig 5. The deepest area ofthe regenerated connective tissue iscomposed of collagen fíber bundlesinserting perpendicularly inta the rootcementum (orrowheads). The mostcoronal portion of the regeneratedbone ^owed the aspect of wovenbone with numerous large, raundedosteocytes and Sharpey's fibers(arrows). (Original magnificafian x 100:toluidine blue-iight green stain.)

Fig 8 (ieft) Magnification ot the cara-nai reglan Ih Fig 5. The most coronaiarea af the roat in the regeneratedarea (first notch) is covered by a layerof parallel-running connective tissuefibers. The arrow points out the mostcorohal notch. (Original magnificationX 40. taiuidine blue-light green stain.)

Fig 9 (right) Magnification of the mid-dle region in Fig 5. Gênerai view of theregenerated bone consisting ot wovenbone (arrow) with areas of bone remod-eiing. Criented collagen fibers (arrow-heads) and blood vessels (asterisks) arepresenf in the regenerated periodontaispace. (Original magniñoation x 40:toiuidlne blue-light green stain.)

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Fig W Poiarized iighf microscopy ofthe fieid in Fig 9 demonstrotes the ioy-ered aspeot of the regeneratedoemenfum (c) and the woven aspeotof the newiy formed bone (b), os weiias fhe orientation of fhe periodonfaiñbers. (Originai magnification x 40:poiarized iight microscopy.)

cementum and the wovenaspect ot the newiy tormedbone (Fig 10). This bone showedthe presence of many iarge,rounded osteccytes. fypicai ofwoven bane. The apicai notchof fhe root was covered by iay-ers ot newly formed ceiiuiarcemenfum (Fig 11).

The regenerated bane withthe interposed periodontai

Fig 11 Magnifioatlon of the apicoiregion in Fig 5. i-iistoiogic ospect of theapicoi notch (arrow) is covered by iay-ers of newiy formed ceiiuiar cemen-tum. The regenerated bone wifh theinterposed periodonfai fibers extendedfor 2.3 mm coronai to the apioai notch.A sound periodontai iigomenf wastound in this area, with oriented fibers(f) and vesseis (asf erisi<s). (Originai mag-niñcation y. 40: toluidine biue sfain.)

fibers extended for 2.3 mm tothe opioal notch (Figs 9 to 11 ). Asound periodontai iigament wastcund in this area, with orientedfibers and vesseis (Fig 11).

Some remnants ot fheresorbabie membrane were stiiivisibiy embedded in thesupraperiosteal connective tis-sue, but there was no sign o^infiammatory cells.

Discussion

Guided tissue regeneration hosdemonstrated the possibiiity ofpredicfobiy covering exposedroot surfaces.*-'^ The success ofGore-Tex augmentation mater-iai and free aufogenous gingi-val grafts in humans has beenhistoiogicaiiy anolyzed.^^"^^ Re-sorbabie membranes have aisabeen evaiuated in a clinicalcase report, 2'' but histoiogic evi-dence of periodcnfai regenera-tion is absent from fhe literature.

The use of the Gore-Texmembrane requires a secondsurgery tor fhe membroneremoval, and tree autogenousgingivai gratts require the useot paiatai donor sites that, inmany instances, heal poinfuilyand siowly Therefore, the use ofresorbabie membranes maybe preferred fa the use ote-PTFE or an outogenous grattbecause neither second-stagesurgery nor a donor site arerequired.

The present report demon-strated the regeneration of theperiodontai apparatus associ-ated with the use cf o resor-babie membrane in the treat-ment ot gingivai recession.

The surgicai techniqueused in the present case repii-cated the standord techniquesuggested tor Gore-Tex moter-iai^; the oniy difference in tech-nique was the use of a resor-babie membrane. The useresorbabie or ncnresorbablemembranes differs in the length

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of time during which fhe de-fect sife is isoiated. From o the-oreticol sfandpoinf, a barriershouid stay in place longenough fo aiiow tor the colo-nization and orgonization ofnewly formed tissue. Guided tis-sue regenerotion procedureswith a nonresorbabie mem-brane require an early removalof fhe membranes, usually after4 weeks.

Early removal of the e-PTFEmembrane is imposed by earlyexposure,^^ which has beenshown to reduce the amountof regenerated tissue.^"^°

Experimental studies in themonkey also have shown thatnewiy generated tissue is sus-ceptible to infection.^' The useof resorbabie maferiais elimi-nafes the trauma to the regen-erated fissue induced by fhereentry procedure. Moreover, itseems that fhe exposure rate ofresorbabie membranes is lowerthan that of fhe e-PTFE ma-feriai.^^ Aifhough if has beensuggested that the division ofperiodontal iigamenf ceiis iscomplete at 21 days,^^ it is noti<nown how iong these ceiisneed an undisturbed healingphase fo ailow for completeregenerafion. Gofflow et ol^''found that the resorbabie poiy-ioctic acid membrones werestiil intact 3 months after posi-tioning, whiie in a rabbit study.Miiler et al^^ found on aimostcomplete degradation otter

the same amount of time.Different animal modeis mayinfluence fhe résorption rafe.

The Resoiufe regenerofivemoteriol is made of a synfheficbioabsorbabie copolymer ot agiyoolide and iactide derivedfrom glycolic and iactic acids.These materiais hove beenused for years in absorbablesutures and meshes. " ond fherésorption has been assessedto be minimai in the initioi 4 fo 6weei<s. buf compiete atter 8monfhs.

The onimai sfudy byCaffesse et al^^ demonsfrafedthof résorption ot Resolutematerial begins by the tourthweek and is aimost completeat 6 months. This study alsofound that, in animals, bioob-sarbable membranes oliowedfor a periodontal regenerationoomparable to the regenera-fion of proven, nonresorbobiee-PTFE membranes. The presentciinical and hisfoiogic cosereport supports fhese findings inhumans, demonsfroting from ohistoiogic point of view thotbioabsorbabie membranes areable fo induce periodontolregeneroticn in the treotmentot gingival recession.

Acknowledgment

This study was portly supported by agrant from the nonprofit reseorch foun-dation, Biomaterials Clinicai ResearchAssooiation. Pescara, Italy.

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References

1. Mille; PD, Rcct coverage using a freesoft tissue autograft folicwing citricacid application, i. Technique, int JPericdont Rest Dent 1982:2(1 ):Ó5-7O,

2. Milier PD, Root coverage using tiiefree soft tissue autograft foiiowingcitric acid appiication, li. Treatmentof tine caricus root, Int J PericdontRest Dent 1983:3(5):38-5I.

3. Hoibrock T, Ochsenbein C, Com-plete coverage of denuded rootsurfaces with o cne-stage gingivalgraft. Int J Periodont Rest Dent1982:3C3):9-31,

4. Com H. Morks MH, Gingivai groftingfor deep-wide recession—A statusrepart. Part I, Rationale, cose seieo-tion ond root preparation. Com pendContin Educ Dent 1983:4:53.

5. Com H, Marks MH, Gingivai graftingfor deep-wide recession—A statusreport. Port il. Surgicai probiems,Compend Contin Educ Dent1983:d:ló7-173,

6. Miller PD. Root coverage using thefree soft tissue autograft tcllcwing cit-rio ocid appiicotion. 111, A successfulond prediotable procedure in areascf deep-wide recession. Ini JPeriodont Rest Dent 1990:10:2)7-229.

7. Miohaeiides PL Wiison SG, An auto-genous gingivai graft technique, intJ Periodont Rest Dent 1994,14:113-125,

8. Tinti C, Vinoenzi G.Treatment of gin-givol recession by guided tissueregeneration technique with Gore-Tex membrane, Ciinicai variation.Quintessence Inf 1990:6:465-468.

9. Corteiiini R Pini Proto GR De SanctisM, Boldi C, Ciauser C, Guided tissueregenerotron procedure in thetreatment of a bone dehisoenceossociated with a gingivai reoes-sion, A case report, inf J PeriodontRest Dent 1991:11:472-479.

10. Tinti C, Vinoenzi G, Corteiiini P PiniProto GR Clauser C, Guided tissueregenerotion in the treatment ofhuman fooiai recession, A 12-oosereport. J Periodontoi 1992:63:554-560,

11. pini Prafo GRTinti C, Ccrteliini RMognoni C, Ciauser C. Periodontairegenerotion ttierapy with caverageof previousiy restored root surfaces,A two-oose report, int J PeriodontRest Dent 1992:12:451-461,

12. Pini Prato GRTinti C.Vincenzi G,Mognani C, Corteiiini R Ciouser C,Guided tissue regeneration versusmucogingivai surgery in the treot-ment cf human buccal recession, JPeriodcntoi 1992:63:919-928.

13. Tinii C, Vincenzi G, Cocchetio R,Guided tissue regenerotion inmucogingival surgery, J Periodontoi1993:64:1l8d-1l9l.

14. Trombeili L Soriincagliq G, CheochiL Coiura G. Combined guided tissueregeneration, root conditioning, ondflbrin-fibronectin system applicationin the treotment of gingival reces-sion. A 15-oase report, J Reriodontoi1994:65:796-803,

15. Roccuzzo M, Buser D, Treatment ofbuooai gingivai recession with e-RTFE membranes and miniscrews:Surgical prooedure ond resuits of 12cases. Int J Periodont Rest Dent1996:16:357-365

16. Posquineili KL, The histology of newottochment ufiiizing a thici< autoge-nous soft tissue groft in an areo ofdeep recession' A cose report, Int JReriodont Rest Dent 1995:15:248-257.

17. Corteiiini R Ciouser C, Pini Proto GPHistologie assessment of newattachment foiiowing the treat-ment of a human buccoi reoessionby meons of a guided tissue regen-eration prooedure. J Periodontoi1993:64:387-391,

18. Gottiow J, Nyman S, Karring T, UndeJ. Treatment of iocaiized gingivairecessions with ooronaily dispiacedflops and citric acid. An experimen-tol study in the dog. J Periodontoi1986:13:57-63,

19. Gotticw J. Karring T, Nyman S.Guided tissue regeneration foilow-ing treotment cf recession-typedefects in the moni<ey J Periodontoi1990:61:680-685,

The international Journai of Reriodontics & Restorative Dentistry

33

20. Greenstein G, Catón JG. Biade-grodabie borriers and guided tissueregenerat ion. Penodontot 20001993:1:36-45.

21. Mognusson I. Botioh C. Coilins BR.New atfoohment formotion foiiow-ing oontroiled tissue regenerationusing biodegradabie membranes. JPeriodontoi 1986:59:1-6.

22. Kon S. Ruben MR Bloom AA,Mardam-Bey W. Boffo M. Regen-eration of periodontai arrongementiigament using resorba ble ond non-resoibabie membranes: Clinical, his-tological ond histometric study mdogs. Inl J Pedodont Rest Dent1991:11 59-71.

23. Mognusson I. Stenberg WV, BotichC, Egelberg J. Connective tissuerepair in ciroumferentiai periodcn-toi defects in dogs following use ofo biodegrodable membrane. J ClinPeriodontoi 1990:17:243-248.

24. Fleisher N, De Wool H, Bloom A.Regeneration of iost at tachmentoppofotus in the dog using vicrylobsorbabie mesh (Poiygiactin 910).Int J Periodant Rest Dent 1988:17:45-55.

25. Schultz AJ. Goger AH. Guided tissueregenerat ion using absorbob lemembrane (Polyglootin 910) ondosseous graff ing. Int J PeriodontRest Dent 1990:10:9-17.

26. Tinti C, Vincenzi GR Expanded poiy-tetrofiuoroethyiene titanium-rein-forced membranes for regenera-fion af mucoging iva i reoessiondefects. A 12-oase reporf. JReriodontoi 1994:05:1088-1094.

27. De Sonctis M, Zucohelli G. Guided fis-sue regeneration with a resorbablebarrier membrone (Vicryl) for ihemanagement of buoool recession:A case report. Int J Periodonf RestDent 1996:16:435-441.

28. Becker W. Becker BE. Prichard F,Caffesse R. Rosenberg E, Gian-Grassa J. Roof isolation for newQttaohmenl procedures, A surgicaiond suturing method: Three casereports. J Reriodontoi 1987:58:819-82Ó.

29. Tonetti MS. Pini-Pratc G. Corteilini PPeriodontoi regenerotion of humanintrobony defects. iV: Determinantsof heaiing response. J Reriodontoi1993,64:934-940.

30. Fiorès de Jocoby L Zimmermann A.Tsalikis L. Experiences with guidedbone regeneration of odvancedperiodontai diseose. A ciinicai re-entry study part i. Vertical, horizontolond combined vertioai and hori-zonfai defects. J Ciin Reriodontoi1994:2M13-117.

31. Ling L. Lai Y, Hwang H, Chen H.Response of regenerative tissue toplaaue: A histoiogicai study in mon-keys.J Periodontoi 1994:65:781-787

32. Ldureil L Folk H. Fornell J. Johard G.Gottlow J. Ciinioai use of a biore-sorboble matrix borrier guided tissueregeneration Iheropy. Cose series. JReriodontoi 1994:05:967-975.

33. Iglhaut J, Aukhii I. Simpson DM.Johnston MC, Progenitor oeiis kinet-ics during expérimentai guided tis-sue regenerat ion procedure. JPeriadont Res 1988:23:107-117.

34 Gott low J, Lauren L. Lundgren D.Mathisen T. Nyman S. Rylander H. etal. Reriodontai tissue response toGTR theropy using o bioresorboblemotrix borrier. A iongitudinai study inmonkeys. Int J Reriodont Rest Dent1994:14:437-449.

35. Miiler N, Penoud J. Foliguet B,Membre H. Ambrosini P Plombas M.Resorption rotes of 2 commerciaiiyovoi ioble bioresorbobie mem-branes. A histomorphomelrio studyin a robbit modei. J Clin Periodonfoi1996:23:1051-1059.

36 Lewis DH. Controi ied reiease ofbioacfive agenfs from ioctide/gly-ooi ide poiymers. In: Chosin M,Longer R (eds) B iodegradablePoiymers as Drug De i i very SystemsNew York: Mofcei Dekker. 199O'1-4I

37. Caffesse RG, Nosjlefi CE, MorrisonEC. Sonchez R. Guided tissue regen-erotion: Comparison of a bioab-sorbable ond nonbioabsorbabiemembranes, i-listoiogio ond histo-metrio study in dogs. J Periodontoi1994:65:583-591,

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