Intraoral cancellous bone autografts in the treatment of infrabony pockets

Recombinant human fibroblast growth factor and autogenous bone for periodontal regeneration: Alone or in combination? A randomized clinical trial

AIM

To compare the outcomes of therapy using recombinant human fibroblast growth factor (rhFGF)-2 combined with autologous bone grafting (ABG) therapy with those of rhFGF-2 alone and ABG alone in the treatment of periodontal intraosseous defects.

METHODS

Periodontal intraosseous defects were randomized to receive rhFGF-2 therapy + ABG, rhFGF-2 therapy alone, or ABG alone. Periodontal examination and periapical radiography were performed preoperatively and at 3, 6, and 12 months postoperatively.

RESULTS

At the 12 months follow-up, all three groups showed significant improvement in the clinical attachment level (CAL): 5.6 ± 1.6, 5.8 ± 1.7, and 5.2 ± 1.6 mm in the rhFGF-2 + ABG, rhFGF-2 alone, and ABG alone groups, respectively, with no significant inter-group differences (p < .05). rhFGF-2 therapy (alone or in combination) resulted in greater bone defect filling (BDF) (2.3 ± 1.2 mm and 2.6 ± 1.9 mm, respectively) than ABG therapy alone (1.2 ± 1.2 mm). Gingival recession was lesser in the ABG alone (1.2 ± 1.1 mm) and rhFGF-2 + ABG groups (1.4 ± 0.8 mm) than in the rhFGF-2 alone group (2.2 ± 1.2 mm).

CONCLUSION

The results of this study showed that at 12 months postoperatively, all treatments resulted in statistically significant clinical improvements compared to the baseline. From these results, it can be concluded that rhFGF-2 promotes hard tissue regeneration in intraosseous defects.

Treatment of a Mandibular Periodontal Interproximal Defect with a Bone Graft in a Dog

A 10-year-old German shepherd dog presented with a periodontal 10 mm interproximal defect between the left mandibular fourth premolar and first molar teeth. Bone graft removed from the caudoventral portion of the ipsilateral hemimandible was placed in the defect as a component of the periodontal treatment plan. The use of bone graft likely contributed to periodontal pocket reduction.

Bone Grafts in Periodontal Therapy

This article is limited to a review of bone replacement graft materials used in periodontal therapy. The source, mode of bone regeneration and the respective advantages and disadvantages of autogenous, allogenic, xenogenic and alloplastic materials are discussed.

Storage media for avulsed teeth: a literature review

Dental avulsion is the most severe type of traumatic tooth injuries because it causes damage to several structures and results in the complete displacement of the tooth from its socket in the alveolar bone. The ideal situation is to replant an exarticulated tooth immediately after avulsion because the extraoral time is a determinant factor for treatment success and for a good prognosis. However, it is not always possible. The success of replantation depends on a number of factors that may contribute to accelerate or minimize the occurrence of root resorption or ankylosis, among which is the type and characteristics of the medium used for temporary storage during the time elapsed between avulsion and replantation. Maintaining the tooth in an adequate wet medium that can preserve, as longer as possible, the vitality of the periodontal ligament cells that remain on root surface is the key to success of replantation. Recent research has led to the development of storage media that produce conditions that closely resemble the original socket environment, with adequate osmolality (cell pressure), pH, nutritional metabolites and glucose, and thus create the best possible conditions for storage. Although these storage media can now be purchased in the form of retail products, the most common scenario is that such a product will not be readily available at the moment of the accident This paper reviews the literature on the different storage media that have been investigated for avulsed teeth based on full-length papers retrieved from PubMed/Medline, Lilacs, BBO and SciELO electronic databases using the key words 'storage medium', 'transportation medium', 'avulsion', 'tooth avulsion', 'replantation', 'tooth replantation', 'milk' and 'propolis'. After application of inclusion and exclusion criteria, 39 papers were selected and critically reviewed with respect to the characteristics, efficacy and ease of access of the storage medium. The review of the literature showed that a wide array of types of wet storage media have been evaluated in laboratory studies and clinical reports, including cell and tissue culture solutions like Hank's Balanced Salt Solution (HBSS); medical/hospital products developed specifically for organ storage purposes, such as Viaspan® and Euro-Collins®; culture media, like Minimum Essential Medium (MEM); saline; natural products like water, saliva, bovine milk and its variations, propolis, green tea, Morus rubra (red mulberry), egg white and coconut water; rehydrating solutions, like Gatorade® and Ricetral, and even contact lens solutions. Based on the literature, it could be stated that, so far, apart from Based on the literature, it could be stated that, so far, apart from solutions designed specifically for storage and culture purposes, regular pasteurized whole milk is the most frequently recommended and with the best prognosis among other solutions that are likely to be available at the scene of an accident, such as water, saline or saliva. Its advantages include its high availability, ready accessibility, physiologically compatible pH and osmolality (fluid pressure) with the root-surface adhered PDL cells, presence of nutrients and growth factors. However, there is not yet a single solution that fulfills all requirements to be considered as the ideal medium for temporary storage of avulsed teeth, and research on this field should carry on.

Do the clinical effects of enamel matrix derivatives in infrabony defects decrease overtime? A systematic review and meta-analysis

Previous systematic reviews have demonstrated better results with enamel matrix derivative proteins (EMDP) as compared with open flap debridement (OFD) for the management of infrabony periodontal defects (IPD). The aim of this study was to determine whether these differences vary according to the follow-up and quality of the studies. Cochrane Central Register of Controlled Trials, Medline/PubMed, Lilacs, Embase and Web of Science electronic databases were searched up to August 2013 for randomized clinical trials.Eligible outcomes were changes in probing depth (PD), clinical attachment level (CAL),gingival recession (GR) and bone changes (BC). Studies with follow-up of 12 months showed differences of 0.97 mm (CI95% 0.52 - 1.43) and 1.19 mm (CI95% 0.77 - 1.60) for PD and CAL, respectively, favorable for EMDP. Studies with follow-up ≥ 24 months presented advantages of 1.11 mm (CI95% 0.74 -1.48) for CAL and 0.83 mm (CI95% 0.19 -1.48) for PD,with use of EMDP. Considering the quality of studies, those with low risk of bias showed lower difference between groups, presenting 0.8 mm (CI95% 0.24-1.36) for CAL, favorable for EMDP and without differences for PS (0.51 mm, CI95% -0.21 - 1.23). In conclusion, follow-up time (< or > 2 years) and the risk of bias influence the results of treatment with EMDP in IPD.

Clinical use of allogeneic bone granulates to reconstruct maxillary and mandibular alveolar processes

INTRODUCTION

Lack of adequate mass of a patient's own bone is still a clinical problem in dental implantology; it precludes dental embedment. Surgical widening of an atrophied alveolar process with the use of an allogeneic bone granulate to fill the bone defect constitutes a first-line method to prepare for implant-prosthetic treatment. Transplantation of allogeneic material allows reconstruction of optimal height, thickness, and width of the alveolar process facilitating a procedure with a good long-term outcome. The study assessed outcomes following augmentation of atrophied alveolar processes before intraosseous implantation.

MATERIALS AND METHODS

Filling bone defects in the maxilla and mandible as an introductory measure for implant-prosthetic treatment was performed in 59 patients (24 females and 35 males of age range 22-65 years). Bone granulate was used for maxillary sinus floor elevation (n=29), augmentation of the postextraction alveoli (n=12), and filling of defects in the outer table of the compact bone formed following inflammatory conditions (n=18). The bone grafts were covered with plasma-rich fibrin (PRF) obtained from the patient's blood to accelerate the formation of synostoses and prevent epithelial penetration between the patients' own bone and the bone graft.

RESULTS

In all of the patients normal union was observed, as confirmed by radiological images as well as intraprocedural assessment. Sufficient height and width as well as thickness of the alveolar process was obtained, which allowed embedment.

CONCLUSIONS

Allogeneic bone granulate constitutes a good material to reconstruct maxillary and mandibular alveolar processes in out-patient care.

Clinical effect of autologous platelet-rich fibrin in the treatment of intra-bony defects: a controlled clinical trial

AIM

Platelet-rich fibrin (PRF) may be considered as a second-generation platelet concentrate widely used to accelerate soft and hard tissue healing because of presence of many growth factors. The present study aimed to investigate the clinical and radiological effectiveness of autologous PRF in the treatment of intra-bony defects of chronic periodontitis patients.

MATERIAL AND METHODS

Thirty-two intra-bony defects (one site/patient) were treated either with autologous PRF or a conventional open flap debridement alone. Clinical parameters such as plaque index (PI), sulcus bleeding index (SBI), probing depth (PD), clinical attachment level (CAL) and gingival marginal level (GML) were recorded at baseline and 9 months post-operatively. In both the groups, by using the image analysis software intra-bony defect fill was calculated on standardized radiographs (from the baseline and 9 months).

RESULTS

For all clinical and radiographic parameters test group was performed better than control group, and the difference was found to be statistically significant. Furthermore, images analysis revealed significantly greater bone fill in the test group compared with control (46.92%versus 28.66 %). Mean PD reduction (4.56 ± 0.37>3.56 ± 0.27) and CAL gain (3.69 ± 0.44>2.13 ± 0.43) in test group was found to be more compared with that of control group. In the test group, PD of >4 mm has highest percentage of PD reduction (68.9%) and CAL gain (61.6%). On frequency distribution analysis, there was no more difference for PD reduction in both the groups but CAL gain was much more in the test group than the control group.

CONCLUSIONS

Within the limit of the present study, there was greater reduction in PD, more CAL gain and greater intra-bony defect fill at sites treated with PRF than the open flap debridement alone.

Predictability of clinical outcomes following regenerative therapy in intrabony defects

BACKGROUND

Demineralized bone matrix (DBM) and guided tissue regeneration (GTR) support substantial gains in clinical attachment level (CAL), reductions in probing depth (PD), and gains in defect fill compared to open flap debridement (OFD) in intrabony defects. Although these regenerative therapies support improvements in mean clinical parameters, it is unclear whether the procedures improve the predictability of clinical outcome. The purpose of this study was to examine the relative variability in clinical outcome measures, independent of the magnitude of gains, in regenerative studies comparing DBM or GTR to OFD therapy for the management of intrabony defects. For comparative purposes, a similar analysis was performed evaluating the consistency of clinical outcomes with other (non-DBM) bone replacement graft (BRG) materials relative to OFD alone.

METHODS

Fifty-five randomized controlled clinical trials comparing regenerative therapy (seven DBM, 22 BRG, and 26 GTR) to OFD and meeting inclusion criteria provided mean change scores (pretreatment to post-treatment) and variance estimates for CAL, PD, and bone fill, allowing for calculation of a coefficient of variability (CV) for each measure within studies. The mean CV for each measure was submitted to an analysis of variance or covariance with repeated measures (P < or =0.05) to compare relative variation in treatment outcomes.

RESULTS

DBM was associated with a significantly lower relative variability (mean +/- SE) in CAL gain (96.3 +/- 38.6 versus 137.7 +/- 30.9) and defect fill (69.1 +/- 11.2 versus 133.1 +/- 15.3) compared to OFD alone. As a group, other BRGs were found to support significant reductions in variation in CAL and defect fill. GTR therapy was associated with significantly lower CV for CAL compared to OFD (50.6 +/- 5.0 versus 68.7 +/- 8.2, respectively). Variability in defect fill was similar for GTR and OFD.

CONCLUSIONS

DBM and GTR therapy support more consistent improvements in clinical parameters; however, with the exception of defect fill following bone grafting, the reduction in variability in clinical outcomes was relatively modest compared to OFD alone. Overall, the treatment of intrabony defects is associated with a relatively high degree of variability in clinical outcome, regardless of therapeutic approach.

Bone replacement grafts for the treatment of periodontal intrabony defects

Bone replacement grafts, including autogenous grafts from intraoral donor sites, allografts, xenografts, and alloplastic bone substitutes, are the most widely used treatment modalities for the regeneration of periodontal osseous defects. Studies suggest a favorable clinical outcome with the use of these materials in terms of improvements in periodontal probing depths, probing attachment gains, and bone fill. In terms of bone fill, most studies report more than 50% resolution of intrabony defects when treated with bone replacement grafts. However, histologic evidence of periodontal regeneration, including new bone, periodontal ligament, and cementum, has been reported only for autogenous bone grafts and demineralized freeze-dried bone allografts.

Anorganic bovine matrix/p-15 "flow" in the treatment of periodontal defects: case series with 12 months of follow-up

BACKGROUND

Nowadays there is a trend in developing biologic modalities that may enhance wound healing of specific sites. In this regard, a cell-binding activity of type I collagen provided by a synthetic peptide (P-15) was incorporated in a scaffold (anorganic bovine matrix [ABM]) to facilitate the attachment, migration, and differentiation of cells. This case series describes a surgical protocol for the placement of ABM/P-15 "flow" during regenerative procedures.

METHODS

Wide periodontal defects were treated with sulcular incisions preserving the papillae, full-thickness flap reflection, granulation tissue debridement, mechanical and chemical root surface treatment, placement of the ABM/P-15 "flow," and wound-closure sutures. Weekly, and then monthly, deplaquing was performed until the 12-month postoperative recall, in which the clinical parameters were reevaluated.

RESULTS

Significant clinical changes, including probing depth reduction and relative clinical attachment level gain, were achieved after the 12-month period. The radiographs demonstrated increase in radiopacity when compared to those taken initially, suggesting hard tissue improvements.

CONCLUSIONS

The topography of the defects described here could be understood as a challenge for regeneration, once the previous breakdown of the supporting tissues had diminished the source of cells for the healing process and reduced the number of residual walls to retain the graft material. Thus, it seems that the ABM/P-15 "flow" contributed to the clinical success achieved. Based on this result, ABM/P-15 "flow" could be a useful and beneficial material for the treatment of periodontal defects.

Histomorphometric Analysis of Bone Density in the Maxillary Tuberosity of Cadavers: A Pilot Study

BACKGROUND

Maxillary tuberosities have been widely used as a source of autogenous bone for a variety of oral surgical procedures. However, no previous studies have actually demonstrated the histologic and histomorphometric characteristics of this anatomical region in detail. The aim of this study was to evaluate maxillary tuberosities in cadavers histologically and histomorphometrically.

METHODS

A block section, including the overlying alveolar mucosa, was obtained from a randomly assigned maxillary tuberosity of 20 cadavers (nine females and 11 males). All cadavers were edentulous distal to the second bicuspid teeth, and 14 out of 20 were edentulous distal to the cuspids. A minimum of 35 serial sections were obtained from each cadaver. Description analysis was performed for the presence of either a fibrotic or fatty infiltration of the marrow spaces and thickness and continuity of alveolar bone. Computer-based histomorphometric image analysis of the percentage surface area of bone was also carried out in three sections of each cadaver. Statistical analysis was performed to establish possible differences between genders. The analysis did not control for nutritional status and/or possible systemic or skeletal diseases.

RESULTS

Little variation existed between specimens, regardless of gender, with respect to thickness of oral mucosa overlying the tuberosity. Descriptive bone analysis revealed thin cortical bone and sparse cancellous bone patterns. In addition, the block specimens exhibited no evidence of osteoid or active bone formation, but large marrow spaces infiltrated with loosely organized fibrous connective tissue and/or lipid cells. Histomorphometric analysis demonstrated a mean percentage of vital bone of 24.23% +/- 5.2%. Stratification of the data revealed statistically significant differences in mean percentage of vital bone between genders (27.15% +/- 4.7% for males versus 20.66% +/- 3.4% for females; P = 0.003).

CONCLUSIONS

Within the limitations of this study, maxillary tuberosities seem to mainly consist of marrow spaces, adipose tissue, and a low vital bone profile. Females demonstrated a statistically significant lower amount of vital bone than males. The results suggest that this specific area may not be an ideal source of autogenous bone for grafting purposes in older individuals. However, it is imperative to note that this investigation did not control for nutritional imbalances and skeletal disorders. Further studies are necessary to control all confounding factors.

The efficacy of bone replacement grafts in the treatment of periodontal osseous defects. A systematic review

BACKGROUND

Bone replacement grafts (BRG) are widely used in the treatment of periodontal osseous defects; however, the clinical benefits of this therapeutic practice require further clarification through a systematic review of randomized controlled studies.

RATIONALE

The purpose of this systematic review is to access the efficacy of bone replacement grafts in proving demonstrable clinical improvements in periodontal osseous defects compared to surgical debridement alone.

FOCUSED QUESTION

What is the effect of bone replacement grafts compared to other interventions on clinical, radiographic, adverse, and patient-centered outcomes in patients with periodontal osseous defects?

SEARCH PROTOCOL

The computerized bibliographical databases MEDLINE and EMBASE were searched from 1966 and 1974, respectively, to October 2002 for randomized controlled studies in which bone replacement grafts were compared to other surgical interventions in the treatment of periodontal osseous defects. The search strategy included screening of review articles and reference lists of retrieved articles as well as hand searches of selected journals.

INCLUSION CRITERIA

All searches were limited to human studies in English language publications.

EXCLUSION CRITERIA

Non-randomized observational studies (e.g., case reports, case series), publications providing summary statistics without variance estimates or data to permit computation, and studies without BRG intervention alone were excluded.

DATA COLLECTION AND ANALYSIS

The therapeutic endpoints examined included changes in bone level, clinical attachment level, probing depth, gingival recession, and crestal resorption. For purposes of meta-analysis, change in bone level (bone fill) was used as the primary outcome measure, measured upon surgical re-entry or transgingival probing (sounding).

MAIN RESULTS

1. Forty-nine controlled studies met eligibility criteria and provided clinical outcome data on intrabony defects following grafting procedures. 2. Seventeen studies provided clinical outcome data on BRG materials for the treatment of furcation defects.

REVIEWERS' CONCLUSIONS

1. With respect to the treatment of intrabony defects, the results of meta-analysis supported the following conclusions: 1) bone grafts increase bone level, reduce crestal bone loss, increase clinical attachment level, and reduce probing depth compared to open flap debridement (OFD) procedures; 2) No differences in clinical outcome measures emerge between particulate bone allograft and calcium phosphate (hydroxyapatite) ceramic grafts; and 3) bone grafts in combination with barrier membranes increase clinical attachment level and reduce probing depth compared to graft alone. 2. With respect to the treatment of furcation defects, 15 controlled studies provided data on clinical outcomes. Insufficient studies of comparable design were available to submit data to meta-analysis. Nonetheless, outcome data from these studies generally indicated positive clinical benefits with the use of grafts in the treatment of Class II furcations. 3. With respect to histological outcome parameters, 2 randomized controlled studies provide evidence that demineralized freeze-dried bone allograft (DFDBA) supports the formation of a new attachment apparatus in intrabony defects, whereas OFD results in periodontal repair characterized primarily by the formation of a long junctional epithelial attachment. Multiple observational studies provide consistent histological evidence that autogenous and demineralized allogeneic bone grafts support the formation of new attachment. Limited data also suggest that xenogenic bone grafts can support the formation of a new attachment apparatus. In contrast, essentially all available data indicate that alloplastic grafts support periodontal repair rather than regeneration. 4. The results of this systematic review indicate that bone replacement grafts provide demonstrable clinical improvements in periodontal osseous defects compared to surgical debridement alone.

A systematic review of graft materials and biological agents for periodontal intraosseous defects

OBJECTIVES

To determine the adjunctive effect of grafting biomaterials/biological agents with open flap debridement (OFD) in the treatment of deep intraosseous defects.

BACKGROUND

No systematic review of treatment outcomes in patients who received graft biomaterials or biological agents have been published.

METHODS

A rigorous systematic review of randomized controlled trials of at least 6-month duration was conducted comparing grafting biomaterials/biological agents (alone or in combination) + OFD (test group) to OFD alone or in combination with a placebo (control group).

RESULTS

The difference in CAL change between test and control groups varied from -1.45 mm to 1.40 mm with respect to different biomaterials/biological agents. Meta-analysis showed that CAL change significantly improved after treatment for coralline calcium carbonate (weighted mean difference 0.90 mm; 95% CI: 0.53-1.27), bioactive glass (weighted mean difference 1.04 mm; 95% CI: 0.31-1.76), hydroxyapatite (weighted mean difference 1.40 mm, 95% CI 0.64-2.16), and enamel matrix proteins (weighted mean difference 1.33 mm, 95% CI 0.78-1.88). However, heterogeneity in results between studies was highly statistically significant for most of biomaterials/biologicals and could not be fully explained.

CONCLUSIONS

Overall, the use of specific biomaterials/biologicals was more effective than OFD in improving attachment levels in intraosseous defects. Difference in CAL gain varied greatly with respect to different biomaterial/biological agent. Due to a significant heterogeneity in results between studies in most treatment groups, general conclusions about the expected clinical benefit of graft biomaterials/biologicals need to be interpreted with caution. Further research should focus on understanding this variability.

Autogenous and allogeneic bone grafts in periodontal therapy

This article is limited to a review of bone autografts and allografts, as used in periodontal therapy. The various graft materials are discussed with respect to case reports, controlled clinical trials, and human histology. Other reviewed areas are wound healing with periodontal bone grafts, tissue banking and freeze-dried bone allografts, and the use of bone grafts in guided tissue regeneration.

Regenerating bone in clinical periodontics

Bone autografts and allografts, various alloplastic materials, and guided tissue regeneration are used to reconstruct lost periodontal tissues. This paper focuses on controversies related to these therapeutic modalities as well as their role in periodontal regeneration.

One-wall proximal defects: pretreatment characteristics and bone response following flap curettage

Several characteristics of 53 infrabony defects were compared with changes in bone height, following treatment by flap-curettage and regular maintenance. The mean post-surgical interval was 11.4 years. Proximal angular defects from mandibular posterior teeth comprised the study population. Changes in bone height following therapy were compared with the pre-treatment bone loss, tooth-bone angle, and inter-radicular width. The influence of the post-surgical duration on these factors was also evaluated. Bone height was examined at both the deep and shallow sides of each proximal defect. Data were collected from enlarged tracings of pre- and post-treatment radiographs. Gain or loss of bone was established at greater than 2 SD of the measurement error as determined by replicate calibration trials. Deep-side sites which gained bone exhibited the most pretreatment bone loss at a mean of 57.1%. These sites also exhibited a mean tooth-bone angle of 31.9 degrees and a mean inter-radicular width of 3.1 mm. Gaining sites were those with longer post-surgical durations. Deep-side sites that lost bone following therapy had a mean pre-treatment bone loss of 43.6%, a mean tooth-bone angle of 50.3 degrees, and a mean interradicular width of 2.9 mm. Losing sites were those with shorter post-surgical durations. The majority of deep-side sites with less than 55% pretreatment bone loss remained unchanged. Shallow-side sites which gained bone following treatment had a greater mean pretreatment bone loss and a smaller tooth-bone angle than losing sites.

Healing responses to grafting of combined collagen-decalcified bone in periodontal defects in dogs

The feasibility of a new combined collagen gel-autolysed antigen-extracted allogeneic bone implant was tested. Its effect on gaining new attachment in surgically created defects in four dogs was evaluated over 24 weeks. As controls, sites receiving implants of the bone implant alone, nonimplanted and untreated defects were also evaluated. The collagen gel encouraged ingrowth of regenerative tissue-fibroblasts in the early stages of wound healing while the allogeneic bone induced new bone formation. The graft materials were bicompatible, technically manageable and clinically effective. From the present preliminary study, it was evident that the combined autolysed antigen-extracted allogeneic bone-collagen gel implant may offer advantages over the present implant materials and techniques currently used in the treatment of periodontal intrabony defects.

Healing after treatment of periodontal intraosseous defects. VI. Factors influencing the healing response

84 periodontal intraosseous defects treated with mucoperiosteal replaced flap surgery and citric acid root conditioning were used to study the relationships between various defect characteristics and the healing response as expressed by change of probing attachment level, change of probing bone level and residual probing depth. More gains in probing attachment and probing bone levels were observed in deep defects than in shallower lesions. Other defect characteristics showed weak or no correlations to defect fill. The findings of this study seem to indicate that the outcome of treatment of intraosseous defects may be difficult to predict based upon evaluation of defect characteristics.

Healing after treatment of periodontal intraosseous defects. V. Effect of root planing versus flap surgery

The present study compared surgical therapy to root planing alone in the treatment of periodontal intraosseous defects. 25 defects in 14 patients were subjected to root planing only and another 25 defects in the same patients were surgically exposed and citric acid treated. The healing response was evaluated 6 months after treatment. The mean gain of probing attachment level was 0.8 mm in the root-planed defects as compared to 1.3 mm for the surgically exposed and acid-treated defects. The probing bone level improved an average of 0.2 mm for the root-planed areas as compared to 0.6 mm for the acid-treated defects. The mean preoperative probing pocket depths of 6.7 mm and 6.8 mm for the 2 groups were reduced to 5.2 mm and 4.1 mm, respectively. The differences in these parameters were statistically significant between the 2 groups. However, both groups demonstrated limited regeneration.

Evaluation of durapatite ceramic as an alloplastic implant in periodontal osseous defects. II. Twelve month reentry results

Thirteen patients received Durapatite, a hydroxylapatite ceramic (Periograf), as a bone implant material in various types of intrabony defects following internally beveled full thickness flaps, root planing, and defect debridement. All osseous margins and defects were measured from the cemento-enamel junction (CEJ) at specific locations using a standardized periodontal probe. Similarly debrided, nonimplanted defects served as controls. Defect selection as either experimental or control site was based on an alternating defects design after local therapy was completed. Periodontal dressing and systemic tetracycline were used for 10 days. Postsurgical visits for documentation and plaque control were at 10, 20 and 30 days, and 3, 6, 9 and 12 months. Measurements relating to defect changes were made at the 12-month surgical reentry. For evaluation purposes original defect depths were divided into three groups. In Group I (less than 3 mm) defect fill was 1.0 mm (47%) for the implanted defects and 0.3 mm (33%) for the control sites (significantly different at P less than 0.05). In Group II (3-6 mm) defect fill of 1.7 mm (44%) for implanted sites was significantly better (P less than 0.05) than the 0.8 mm (29%) found in control sites. In the deepest group (Group III, greater than 6 mm) Durapatite placement yielded 2.1 mm (32%) of defect fill while debridement alone resulted in 1.8 mm (26%) of fill (P greater than 0.05). Hard tissue responses demonstrated a substantial advantage for use of Durapatite over controls, while soft tissue changes were similar for both.(ABSTRACT TRUNCATED AT 250 WORDS)

Healing after treatment of periodontal intraosseous defects. IV. Effect of a non-resective versus a partially resective approach

2 regenerative surgical approaches using citric acid conditioning, were compared in the treatment of deep intraosseous periodontal defects. The first approach was non-resective in that no osseous tissue was removed. The second, a partially resective approach, involved reduction of the osseous defect depth by removal of some supporting bone. 16 patients and a total of 26 defects, with probing pocket depth greater than or equal to 7 mm, were included in the study. The depths of the corresponding osseous defect, as revealed during surgery were greater than or equal to 5 mm. The results demonstrated mean gains in probing attachment level of 0.7 mm for the partially resected group and 1.1 mm for the non-resected group. Corresponding gains in probing bone levels were recorded in the defect sites for each group. Probing pocket depth was reduced from 7.5 mm to 4.0 mm in the partially resected group and from 7.9 mm to 5.3 mm in the non-resected group. Both procedures caused loss of attachment and bony support from adjacent tooth surfaces involved by the surgical procedure. Slightly more loss of attachment and bone was experienced by the partially resected group (range 1.2-1.5 mm) than by the non-resective group (range 0.1-0.9 mm).

Healing after treatment of periodontal intraosseous defects. III. Effect of osseous grafting and citric acid conditioning

The present study was performed to determine whether the healing of periodontal intraosseous defects could be improved through the combined use of citric acid conditioning of the root surfaces and grafting of autogenous intraoral cancellous bone. 28 proximal defects in 19 patients were treated surgically including acid conditioning of the root surfaces. Another 25 defects in these patients were treated with acid conditioning combined with osseous grafts using the maxillary tuberosity areas as donor sites. Both therapies, e.g., citric acid conditioning alone and acid conditioning combined with osseous grafting resulted in approximately 1 mm gains of probing attachment and probing bone levels. Within the parameters of this study, osseous grafting did not enhance the effect of citric acid conditioning alone. Limited improvement of the treated defects of the present study was obtained in spite of the use of supplementary regenerative techniques.

Treatment of juvenile periodontitis patients by control of infection and inflammation. Four case reports

Four patients, ages 14-17, who demonstrated characteristics of juvenile periodontitis, underwent antibiotic and surgical therapy to control microbial etiologic factors. No occlusal equilibration or bone grafting techniques were employed. Subsequent to treatment, all four patients demonstrated decreased pocket depths and mobility on teeth associated with vertical osseous defects. Osseous repair was evident on postoperative radiographs. Reentry procedures, on one patient, confirmed that osseous repair had occurred in 2- to 3-wall, 3-wall, hemi-circumferential and furcal defects. If infection and inflammation are controlled, it appears that the potential for osseous repair in juvenile periodontitis patients is greater than has been thought.

Regeneration of infrabony periodontal defects in humans after implantation of allogenic demineralized dentin

Previous studies have suggested that implants of allogenic demineralized dentin might improve bone regeneration and healing in the treatment of infrabony periodontal defects. In order to make a clinical evaluation of this possibility, the material was inserted into 14 infrabony defects in 10 patients undergoing a new attachment operation. Twelve defects in 12 patients served as controls. In half of these cases no grafting material was used and the remaining six defects were filled with autogenous cancellous bone from the jaw. The defects were classified as two-wall and combined three- and two-wall bony defects. Probing from a fix point and periodic identical X-rays were performed before the surgical treatment and 12 months postoperatively. During healing no clinical signs of rejection of the dentin implants were observed, but the soft tissue healing was delayed, probably due to a slow resorption of the dentin implants. After 12 months no statistically significant difference was found between test and control groups regarding the mean coronal displacement of the bottom of the pocket. No conclusive evidence regarding the capacity of allogenic demineralized dentin to induce new connective tissue attachment could be drawn from the present study, but the clinical results, combined with the fact that the dentin implants are time consuming to produce, indicate that this material is not suitable for the treatment of infrabony periodontal defects.

Periodontal healing following open debridement flap procedures. I. Clinical assessment of soft tissue and osseous repair

The healing response of the periodontium was evaluated after periodontal flap and debridement procedures in patients with different levels of postsurgical plaque control. Thirty-one sites in 19 patients were included. Measurements were performed from a fixed reference point presurgically and before reentry surgery. All reentries were performed 24 to 28 weeks after surgery. Surgery consisted of elevating an inverse bevel mucoperiosteal flap, debriding root accretions and osseous defects, penetrating into the marrow, and suturing with interrupted sutures at or near the presurgical level. All patients were recalled at least once every 4 weeks after surgery fof professional maintenance. The number of postsurgical maintenance visits and plaque scores (NPI) before reentry were recorded for each surgical site. Average pocket depth at the 31 sites was 7.4 mm initially and 4.1 mm at the time of reentry. This reduction in pocket depth consisted of gingival recession, which averaged 2.0 mm, and a gain in attachment level, which averaged 1.4 mm. At no site was there a loss in attachment level. Average osseous depth of the 31 defects was 3.7 mm presurgically and 1.7 mm at reentry. In addition, there was an average crestal resorption of 0.8 mm and an average osseous fill of 1.2 mm. A significant positive correlation (P less than 0.001) was found between gain in attachment, osseous fill and number of postsurgical maintenance visits. A significant negative correlation was found between the amount of plaque (NPI) at the study site and both gain in soft tissue attachment and osseous fill. Multiple measurements at various points within several osseous defects revealed that osseous remodeling and fill varied significantly at different locations within the same defect.

Healing after treatment of periodontal intraosseous defects. II. Effect of citric acid conditioning of the root surface

Citric acid conditioning of the root surface as a supplement to replaced flap surgery of intraosseous periodontal defects was evaluated. Thirteen patients and a total of 45 proximal defects with residual probing pocket depth greater than or equal to 6 mm after initial preparation were used. The effect of treatment was studied in matched subsamples of the total material including one acid-treated and one nonacid-treated defect from each subject. The results demonstrated that an average gain of probing attachment level amounting to 2.l0 mm was obtained following acid treatment as compared to 1.1-1.2 mm for the nonacid-treated controls. Corresponding figures for gain or probing bone level were 1.2-1.3 mm for acid treatment and 0.8-0.9 mm for controls. The clinical significance of these findings was discussed.

Evaluation of durapatite ceramic as an alloplastic implant in periodontal osseous defects. I. Initial six-month results

Eight patients received a new polycrystalline ceramic form of pure hydroxylapatite (Durapatite) as a bone implant material in various types of infrabony defects following internally beveled full thickness flaps, root planing, and defect debridement. All osseous margins and defects were measured from the CEJ using a standardized periodontal probe. Similarly debrided defects that were not implanted served as controls. Defect selection as either experimental or control site was based on either split-mouth or alternating defects design. Periodontal dressing and systemic tetracycline were used for 10 days. Results for documentation and plaque control were at 10, 20, and 30 days, and 3 and 6 months. Measurements relating to defect changes were made at the 6-months surgical re-entry. For evaluation purposes original defect depths were divided into three groups. In Group I (less than 3 mm) defect fill was 1.2 mm (60%) for the implanted defects and 0.6 mm (40.5%) for the control sites (significantly different at P less than 0.05). In Group II (3--6 mm) defect fill of 1.7 mm (48.5%) for implanted sites was significantly better than the 0.1 mm (11.1%) for the control sites. In the deepest group (Group III greater than or equal to 6 mm) Durapatite placement yielded 2.6 mm (39.9%) of defect fill while debridement alone resulted in 1.3 mm (14.8%) of fill. Hard tissue changes demonstrated a substantial advantage for use of Durapatite over controls, while soft tissue changes were similar for both. The clinical impression at re-entry and the numerical data indicate that pure hydroxylapatite ceramic has a definite potential as an alloplastic implant in the treatment of periodontal osseous defects.

Healing after treatment of periodontal intraosseous defects. I. Comparative study of clinical methods

Four clinical methods to evaluate healing after reconstructive therapy of intraosseous periodontal defects were compared: 1. probing attachment level, 2. probing bone level, 3. entry/re-entry bone height measurements, 4. radiographic bone height determinations. Thirteen patients with a total of 33 defects volunteered for the study. It was found that the depth of the lesions recorded by the various methods showed differences which seem to relate to the varying nature of the methods. On the average, the periodontal probe penetrated 0.8 mm deeper during probing for bone level than during probing for attachment level and another 0.3 mm deeper after denudation of the lesions during entry/re-entry. The average gain of periodontal support following treatment was approximately 1.4 mm as recorded by probing attachment level, probing bone level and entry/re-entry bone height determinations, respectively. A high degree of correlation was found between all three probing methods when the changes following therapy for the individual sites were compared (r = 0.85, 0.75 and 0.81, respectively). Radiographic bone height showed lower degrees of correlation with all three probing parameters (r = 0.45, 0.46 and 0.47, respectively).

Clinical and radiographic long-term study of teeth with periodontal destruction treated by a modified flap operation

Forty-three patients with severe periodontal destruction were treated by a modified flap operation and their periodontal condition reassessed about 4 years later. The aim of the study was to see what would happen to the periodontium when the responsibility for oral hygiene was left to the patients themselves. Before the operation the importance of plaque in the etiology of periodontal disease was explained to the patients. They were requested to return for reexamination every 6 months, but no recall system was used. A highly significant reduction in the depth of the gingival pockets was achieved and the average loss of bony support during the observation time was only 0.3 mm. However, an increased bleeding index, loss of marginal bone and deepening of the gingival pockets were found around teeth provided with artificial crowns, especially when the crowns had ill-fitting margins extended into the gingival pocket.

Comparison of tricalcium phosphate and frozen allogenic bone implants in man

As part of their treatment, eight patients with 47 infrabony pockets and horizontal bone defects had 29 tricalcium phosphate and 18 frozen allogenic bone implants placed. One year after surgery the sites were reentered. At the tricalcium phosphate implant sites the average amount of bone apposition was 1.2 mm and pocket depth induction 1.8 mm; 38% of the pockets remained deeper than 3.0 mm. At the allogenic bone sites the average amount of bone apposition was 1.5 mm and pocket depth reduction was 2.0 mm; 22% of the pockets remained deeper than 3.0 mm. The implant materials were well tolerated and there were no complications during the period of the study. Though storage and handling of tricalcium phosphate was simpler, use of allogenic bone led to greater bone apposition and reduction in pocket depth.

Osseous repair in infrabony periodontal defects

The present investigation was undertaken to quantitate the osseous changes which occur throughout the entire circumferential extent of infrabony periodontal defects in patients with optimal plaque control. Fifteen defects were selected in nine patients. Periodontal surgery was scheduled after each patient had shown an ability to practice efficient plaque removal. Muco-periosteal flaps were raised and the osseous defects debrided. The dimensions of each defect were measured at several specific location points within the defect. The flaps were replaced at their original location and, post-operatively, optimal plaque control was maintained in the area (Mean Plaque Index 0.04). Six to 8 months after the initial surgery all areas were re-operated and the osseous defects were remeasured at the same specific location points. Each defect showed osseous regeneration at every location point. The mean initial osseous defect depth at a location point was 3.5 mm and the mean amount of bone regeneration which occurred was 2.5 mm. Crestal alveolar bone resorption occurred at almost half of the location points and averaged 0.7 mm. Eleven of the 15 defects had resolved completely. There were isolated areas where a shallow defect persisted in the remaining four defects. The behavior of an osseous defect throughout its circumferential extent was characterized by a combination of coronal bone regeneration (mean 77%) and marginal bone resorption (mean 18%). Infrabony periodontal defects may predictably remodel after surgical debridement and establishment of optimal plaque control.

Present status of osseous grafting procedures

Osseous grafting techniques represent one mode of therapy to manage combination pocket-osseous defects. They have their greatest applicability in the intrabony defect although encouraging results have been noted in furcation and suprabony sites. Like all treatment modalities, their usage is dictated by the therapeutic objectives for specific problems and whether their respective advantages and limitations outweigh other management techniques. They are neither a panacea nor an unproven experimental venture. When properly employed, they are a valuable component of currently accepted therapy. When compared with other treatment approaches, the following relative advantages and limitations have been noted with osseous grafts: Advantages 1. Reconstruct lost periodontium. 2. Idealistic therapeutic objective. 3. Reversal of disease process. 4. Increase tooth support. 5. Enhance esthetics. 6. Improve function. Limitations 1. Additional treatment time. 2. Autograft disadvantages. 3. Availability of graft material. 4. Additional postoperative care. 5. Unique postoperative problems. 6. Variations in repair. 7. Longer post-treatment evaluation interval. 8. Predictability. 9. Greater expense. 10. Multistep therapy common. 11. Vulnerability to recurrence.