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

Biomaterials for Alveolar Ridge Preservation as a Preoperative Procedure for Implant Treatment: History and Current Evidence

In implant treatment, the reduction and structural changes in the alveolar ridge that occur after tooth extraction limit the length, width, and placement position of the implant body, impair esthetics, and, in some cases, make implant placement difficult. To solve these problems, an alveolar ridge preservation (ARP) technique, which is performed simultaneously with tooth extraction, generally aims to promote bone regeneration and prevent alveolar ridge reduction by filling the extraction socket with bone graft material and then covering it with a barrier membrane to protect against the invasion of epithelial tissue. The extraction socket provides a favorable environment for bone regeneration throughout the healing period because the blood supply is abundant, and it effectively retains the bone graft material by using the remaining bone wall of the socket. In recent years, advances in bioengineering technology have led to the development of graft materials with various biological properties, but there is currently no clear consensus regarding the selection of surgical techniques and materials depending on the condition of the alveolar ridge. This review will provide a comprehensive survey of the evidence accumulated to date on ARP, present many cases according to the clinical situation, and discuss various treatment options.

The Antioxidant Supplementation with Filipendula ulmaria Extract Attenuates the Systemic Adverse Effects of Nanosized Calcium Phosphates in Rats

The aim of this study was to investigate and compare the systemic toxicity of three nanosized calcium phosphates (CaPs): hydroxyapatite (HA), tricalcium phosphate (TCP), and amorphous calcium phosphate (ACP) in rats. Since those metallic compounds are widely used as bone replacement materials, including their use in oral surgery, CaPs were applied (per os) equimollary (17.8 mg/kg, 11 mg/kg, and 9.65 mg/kg b.w., respectively) for 30 days in order to mimic the previously described release rate from dental composites. Also, we employed antioxidant supplementation with Filipendula ulmaria (FU) extract. All the applied CaPs significantly increased serum calcium, triglycerides, LDL, and LDH, while serum levels of testosterone and LH declined, with no alterations in the liver enzymes. The evaluation of oxidative stress markers (in the liver, kidney, and testicle) showed an increase in TBARS values, while SOD and CAT activities and GSH levels were significantly reduced. The relative gene expression of Bax and Bcl-2 was shifted to proapoptotic action, accompanied by intense characteristic histological changes in architecture in all investigated organs. The toxic effects were most prominent in groups treated by ACP. FU administration attenuated the majority of nanosized CaP-induced adverse effects, thus recommending this therapeutic approach to minimize nano-CaP systemic toxicities.

The Antioxidant Supplementation with Filipendula ulmaria Extract Attenuates the Systemic Adverse Effects of Nanosized Calcium Phosphates in Rats

The aim of this study was to investigate and compare the systemic toxicity of three nanosized calcium phosphates (CaPs): hydroxyapatite (HA), tricalcium phosphate (TCP), and amorphous calcium phosphate (ACP) in rats. Since those metallic compounds are widely used as bone replacement materials, including their use in oral surgery, CaPs were applied (per os) equimollary (17.8 mg/kg, 11 mg/kg, and 9.65 mg/kg b.w., respectively) for 30 days in order to mimic the previously described release rate from dental composites. Also, we employed antioxidant supplementation with Filipendula ulmaria (FU) extract. All the applied CaPs significantly increased serum calcium, triglycerides, LDL, and LDH, while serum levels of testosterone and LH declined, with no alterations in the liver enzymes. The evaluation of oxidative stress markers (in the liver, kidney, and testicle) showed an increase in TBARS values, while SOD and CAT activities and GSH levels were significantly reduced. The relative gene expression of Bax and Bcl-2 was shifted to proapoptotic action, accompanied by intense characteristic histological changes in architecture in all investigated organs. The toxic effects were most prominent in groups treated by ACP. FU administration attenuated the majority of nanosized CaP-induced adverse effects, thus recommending this therapeutic approach to minimize nano-CaP systemic toxicities.

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.

Natural graft tissues and synthetic biomaterials for periodontal and alveolar bone reconstructive applications: a review

Periodontal disease is categorized by the destruction of periodontal tissues. Over the years, there have been several clinical techniques and material options that been investigated for periodontal defect repair/regeneration. The development of improved biomaterials for periodontal tissue engineering has significantly improved the available treatment options and their clinical results. Bone replacement graft materials, barrier membranes, various growth factors and combination of these have been used. The available bone tissue replacement materials commonly used include autografts, allografts, xenografts and alloplasts. These graft materials mostly function as osteogenic, osteoinductive and/or osteoconductive scaffolds. Polymers (natural and synthetic) are more widely used as a barrier material in guided tissue regeneration (GTR) and guided bone regeneration (GBR) applications. They work on the principle of epithelial cell exclusion to allow periodontal ligament and alveolar bone cells to repopulate the defect before the normally faster epithelial cells. However, in an attempt to overcome complications related to the epithelial down-growth and/or collapse of the non-rigid barrier membrane and to maintain space, clinicians commonly use a combination of membranes with hard tissue grafts. This article aims to review various available natural tissues and biomaterial based bone replacement graft and membrane options used in periodontal regeneration applications.

Sandcastle Worm-Inspired Blood-Resistant Bone Graft Binder Using a Sticky Mussel Protein for Augmented In Vivo Bone Regeneration

Xenogenic bone substitutes are commonly used during orthopedic reconstructive procedures to assist bone regeneration. However, huge amounts of blood accompanied with massive bone loss usually increase the difficulty of placing the xenograft into the bony defect. Additionally, the lack of an organic matrix leads to a decrease in the mechanical strength of the bone-grafted site. For effective bone grafting, this study aims at developing a mussel adhesion-employed bone graft binder with great blood-resistance and enhanced mechanical properties. The distinguishing water (or blood) resistance of the binder originates from sandcastle worm-inspired complex coacervation using negatively charged hyaluronic acid (HA) and a positively charged recombinant mussel adhesive protein (rMAP) containing tyrosine residues. The rMAP/HA coacervate stabilizes the agglomerated bone graft in the presence of blood. Moreover, the rMAP/HA composite binder enhances the mechanical and hemostatic properties of the bone graft agglomerate. These outstanding features improve the osteoconductivity of the agglomerate and subsequently promote in vivo bone regeneration. Thus, the blood-resistant coacervated mussel protein glue is a promising binding material for effective bone grafting and can be successfully expanded to general bone tissue engineering.

Histologic Evaluation of Tissue Response to Hydroxylapatite Implanted on Human Mandibles

The tissue response to hydroxylapatite implants was examined histologically in samples taken from four patients three to six months after the material had been used to augment deficient mandibular alveolar ridges. Minimal inflammation was found, but the implants had not induced new hone formation and were instead surrounded by a fibrous connective tissue scar.

Bone Replacement Materials and Techniques Used for Achieving Vertical Alveolar Bone Augmentation

Alveolar bone augmentation in vertical dimension remains the holy grail of periodontal tissue engineering. Successful dental implant placement for restoration of edentulous sites depends on the quality and quantity of alveolar bone available in all spatial dimensions. There are several surgical techniques used alone or in combination with natural or synthetic graft materials to achieve vertical alveolar bone augmentation. While continuously improving surgical techniques combined with the use of auto- or allografts provide the most predictable clinical outcomes, their success often depends on the status of recipient tissues. The morbidity associated with donor sites for auto-grafts makes these techniques less appealing to both patients and clinicians. New developments in material sciences offer a range of synthetic replacements for natural grafts to address the shortcoming of a second surgical site and relatively high resorption rates. This narrative review focuses on existing techniques, natural tissues and synthetic biomaterials commonly used to achieve vertical bone height gain in order to successfully restore edentulous ridges with implant-supported prostheses.

Clinical and radiographic evaluation of periodontal intrabony defects by open flap surgery alone or in combination with Biocollagen(®) membrane: A randomized clinical trial

BACKGROUND

Guided tissue regeneration (GTR) is often incorporated in regenerative periodontal surgical procedures. However, the actual benefits of adding GTR to such a procedure remain undocumented. The purpose of this randomized controlled trial was to investigate the contribution of GTR to the outcomes of open flap debridement (OFD) in the treatment of intrabony defects.

MATERIALS AND METHODS

A total of 16 patients of both sexes satisfying the criteria of chronic periodontitis and each of whom displayed one intrabony defect were randomly assigned to two groups, i.e. either treated with open flap surgery and GTR (group 1) or with open flap surgery alone (group 2), in this parallel-arm study. The soft tissue and hard tissue measurements, including probing pocket depth (PD), clinical attachment level (CAL), and bone mineral density were recorded at baseline and 3,6 and 12 months after surgery. The differences with a P < 0.05 were considered significant.

RESULTS

Results showed that the membrane group showed significant difference when compared with open flap surgery alone, in relation to the degree of periodontal pocket, clinical attachment loss, and bone density.

CONCLUSION

The findings of this study suggest that biocollagen membrane could be considered as an option in the treatment of intrabony defects. Biocollagen membrane alone gives favorable clinical results in the treatment of intrabony defects. Open flap debridement resulted in acceptable clinical results in the treatment of intrabony defects.

Biomaterials in periodontal osseous defects

INTRODUCTION

Osseous defects in periodontal diseases require osseous grafts and guided tissue regeneration (GTR) using barrier membranes. The present study was undertaken with the objectives to clinically evaluate the osteogenic potential of hydroxyapatite (HA), cissus quadrangularis (CQ), and oxidized cellulose membrane (OCM) and compare with normal bone healing.

MATERIALS AND METHODS

Twenty subjects with periodontitis in the age group ranging from 20 years to 40 years were selected from our outpatient department on the basis of presence of deep periodontal pockets, clinical probing depth ≥5 mm, vertical osseous defects obvious on radiograph and two- or three-walled involvement seen on surgical exposure. Infrabony defects were randomly divided into four groups on the basis of treatment to be executed, such that each group comprised 5 defects. Group I was control, II received HA, III received CQ and IV received OCM. Probing depth and attachment level were measured at regular months after surgery. Defects were re-exposed using crevicular incisions at 6 months.

RESULTS

There was gradual reduction in the mean probing pocket depth in all groups, but highly significant in the site treated with HA. Gain in attachment level was higher in sites treated with HA, 3.2 mm at 6 months.

CONCLUSION

Hydroxyapatite and OCM showed good reduction in pocket depth, attachment level gain and osseous defect fill. Further study should be conducted by using a combination of HA and OCM in periodontal osseous defects with growth factors and stem cells.

Investigation of bone formation using calcium phosphate glass cement in beagle dogs

Purpose

Among available biomaterials, bioceramics have drawn special interest due to their bioactivity and the possibility of tailoring their composition. The degradation rate and formulation of bioceramics can be altered to mimic the compositions of the mineral phase of bone. The aim of this study was to investigate the bone formation effect of amorphous calcium phosphate glass cement (CPGC) synthesized by a melting and quenching process.

Methods

In five male beagle dogs, 4 × 4 mm 1-wall intrabony defects were created bilaterally at the mesial or distal aspect of the mandibular second and fourth premolars. Each of the four defects was divided according to graft materials: CPGC with collagen membrane (CM), biphasic calcium phosphate (BCP) with CM, CM alone, or a surgical flap operation only. The dogs were sacrificed 8 weeks post-surgery, and block sections of the defects were collected for histologic and histometric analysis.

Results

There were significant differences in bone formation and cementum regeneration between the experimental and control groups. In particular, the CPGC and BCP groups showed greater bone formation than the CM and control groups.

Conclusions

In conclusion, CPGC was replaced rapidly with an abundant volume of new bone; CPGC also contributed slightly to regeneration of the periodontal apparatus.

Bone cements and their potential use in a mandibular endoprosthesis

Bone cement was first used in the 1950s. Since then many modifications have been made and alternatives developed to the original polymethylmethacrylate (PMMA) cement. In view of the use of bone cement in a novel mandibular endoprosthetic system, we performed a review of the current literature on this material. Different cements are described and their potential use in a mandibular endoprosthetic system discussed. The PMMA-based cements are currently the most suitable choice. Plain PMMA has the longest track record and is the default choice for the initial development phase of this system. If there is a significant risk of infection, then an antibiotic-loaded PMMA cement can be selected. However, modified PMMA cements, composite resin cements, osteoinductive calcium phosphate compounds, and cementless fixation are options that offer advantages over PMMA cements, and further research should be conducted to study their suitability.

Histologic and histomorphometric evaluation of two bone substitute materials for bone regeneration: an experimental study in sheep

INTRODUCTION

In the past decade, there has been an increase focus on regeneration approaches as related to periodontics and implant therapies. The main objective of the present study is the evaluation of quality, density, and thickness of the newly formed bone in experimental defects treated with deproteinized bovine bone mineral (DBBM) and bioapatite-collagen.

MATERIALS

Fifteen identical cuboidal defects were prepared in the alveolar edentulous mandibular ridges in 10 male sheep. Defects were randomly assigned to be treated either with DBBM, Bioapatite-collagen or remained unfilled as the control group. Defects of these 3 groups were histologically examined after 6 months.

RESULTS

The mean percentages of bone regeneration with DBBM, Bioapatite-collagen, and control group were 51.40% +/- 3.57%, 27.66% +/- 4.18%, and 19% +/- 1%, respectively (P < 0.05). Defects filled with Bio-Oss and control defects did not show foreign body reaction, whereas Biostite particles had a reaction in 40% of the specimens. Trabecular thickness and type of new regenerated bone were also significantly different between Bio-Oss and Biostite (P < 0.05) and control group (P < 0.05).

CONCLUSION

The results of the present study suggest that using of DBBM particles can promote bone regeneration more effectively than Bioapatite-collagen, and both materials were more promising than the control group.

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.

Comparison of injectable calcium phosphate bone cement grafting and open flap debridement in periodontal intrabony defects: a randomized clinical trial

BACKGROUND

Regeneration of lost periodontium is the ultimate goal of periodontal therapy. Bone grafts, guided tissue regeneration, and application of growth factors are used for periodontal regeneration. This study aimed to evaluate the clinical efficacy of a new, injectable calcium phosphate bone cement (CPC) in human periodontal intrabony defects.

METHODS

Thirty subjects (mean age, 53.4 +/- 9.1 years) with periodontitis and narrow intrabony defects were enrolled in the study. Subjects were classified randomly into the CPC graft group (N = 15) or the open flap debridement (OFD) alone group (N = 15). Clinical measurements were performed at baseline and at 3, 6, 9, and 12 months; radiographs were taken at baseline, 2 weeks, and 6 and 12 months after surgery. The Student t test was used for statistical analysis.

RESULTS

In the CPC group, six cases showed exposure or loss of the CPC within 12 months, whereas the remaining nine cases (CPC-R group) showed no adverse reaction, including infection or suppuration. Overall, CPC-R and OFD treatment groups exhibited a significant reduction in probing depth and a significant gain in clinical attachment level at 3, 6, 9, and 12 months compared to baseline values. However, there were no significant differences in any of the clinical parameters between the groups. In the CPC-R group, radiographic bone level gain appeared to be greater than in the OFD group.

CONCLUSIONS

The present study failed to demonstrate any superior clinical outcomes for the CPC group compared to the OFD group; however, radiographs revealed more favorable results in the CPC-R group. The filling volume and stiffness of CPC may compromise the clinical outcomes for periodontal intrabony defects.

Clinical evaluation of anorganic bovine-derived hydroxyapatite matrix/cell-binding peptide (P-15) in the treatment of human infrabony defects

The purpose of the present study was to compare the clinical outcomes of infrabony periodontal defects following treatment with an anorganic bovine-derived hydroxyapatite matrix/cell-binding peptide (ABM/P-15) flow to open flap debridement. Twenty-six patients, each displaying one infrabony defect with probing depth>or=6 mm and vertical radiographic bone loss>or=3 mm participated in the present study. Patients were allocated randomly to be treated with ABM/P-15 flow (test group) or open flap debridement (control group). At baseline and at 12 months after surgery, the following clinical parameters were recorded by a blinded examiner: plaque index, gingival index, probing depth (PD), clinical attachment level (CAL), and gingival recession. Both treatments resulted in significant improvements between baseline and 12 months, in terms of PD reduction and CAL gain (p<0.001). At 12 months following therapy, the test group showed a reduction in mean PD from 7.8+/-1.6 mm to 3.5+/-1.0 mm and a change in mean CAL from 8.5+/-2.1 mm to 4.6+/-1.2 mm, whereas in the control group the mean PD decreased from 7.5+/-0.8 mm to 4.9+/-0.7 mm and mean CAL from 8.2+/-1.2 mm to 6.4+/-1.4 mm. The test group demonstrated significantly greater PD reductions (p=0.002) and CAL gains (p=0.001) compared to the control group. In conclusion, treatment of infrabony periodontal defects with ABM/P-15 flow significantly improved clinical outcomes compared to open flap debridement.

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.

Effect of calcium phosphate glass on bone formation in calvarial defects of Sprague-Dawley rats

The purpose of this study was to investigate the bone regenerative effect of calcium phosphate glass in vivo. We prepared two different sizes of calcium phosphate glass powder using the system CaO-CaF2-P2O5-MgO-ZnO; the particle size of the powders were 400 microm and 40 microm. 8 mm calvarial critical-sized defects were created in 60 male Sprague-Dawley rats. The animals were divided into 3 groups of 20 animals each. Each defect was filled with a constant weight of 0.5 g calcium phosphate glass powder mixed with saline. As controls, the defect was left empty. The rats were sacrificed 2 or 8 weeks after postsurgery, and the results were evaluated using radiodensitometric and histological studies; they were also examined histomorphometrically. When the bigger powders with 400 microm particle were grafted, the defects were nearly completely filled with new-formed bone in a clean healing condition after 8 week. When smaller powders with 40 microm particle were transplanted, new bone formation was even lower than the control group due to a lot of inflammatory cell infiltration. It was concluded that the prepared calcium phosphate glass enhanced the new bone formation in the calvarial defect of Sprague-Dawley rats and it is expected to be a good potential materials for hard tissue regeneration. The particle size of the calcium phosphate was crucial; 400 microm particles promoted new bone formation, while 40 microm particles inhibited it because of severe inflammation.

Periodontal Regenerative Potential of Autogenous Periodontal Ligament Grafts in Class II Furcation Defects

BACKGROUND

The aim of the present study was to evaluate the regenerative potential of autogenous periodontal ligament (PDL) grafts in the treatment of Class II furcation defects.

METHODS

Twenty mandibular Class II furcation defects from 10 systemically healthy patients with chronic periodontitis were selected. In experimental defects, flaps were coronally positioned following placing autogenous PDL grafts that were obtained from third molars; in controls, coronally advanced flap procedure without graft was applied. Clinical measurements including plaque index, gingival index, probing depth (PD), vertical and horizontal clinical attachment level (CAL), and gingival recession (GR) were obtained at baseline and after 3 and 6 months postoperatively. Vertical and horizontal defect fill was evaluated with open clinical measurements at initial surgery and reentry after 6 months. Gingival biopsies from the experimental and control defects were obtained at reentry and evaluated histopathologically in order to examine the soft tissue response towards PDL grafts.

RESULTS

Sites treated with PDL grafts demonstrated significant improvement in vertical and horizontal defect fill, PD, and CAL at 3 and 6 months compared to presurgical values. The difference determined for the PD values of both groups at a statistically significant degree in favor of grafted sites was maintained at all observation periods. No foreign body reaction was observed in PDL grafts.

CONCLUSIONS

These short-term results point to the potential of PDL grafts in promoting healing of furcation lesions. This preliminary study suggests that the use of PDL grafts may have beneficial effects in the treatment of furcation defects.

Autologous transplantation of gingival fibroblast-like cells and a hydroxylapatite complex graft in the treatment of periodontal osseous defects: cell cultivation and long-term report of cases

Autogenous cell transplantation via hydroxylapatite (HA) vehicle has been reported to have beneficial effects on the treatment of human periodontal osseous defects. The aim of this study was to explore the possibility of using gingival fibroblast-like cells in the therapy of osseous defects caused by inflammatory periodontitis by reporting long-term results of gingival fibroblast-coated hydroxylapatite (GF-HA) grafting for healing these defects. Gingival fibroblasts were cultured from healthy gingivae of treated subjects. Growth of cells on HA particles was established in vitro, and then the GF-HA complex was transplanted into the periodontal osseous defects. Clinical parameters of gingival and plaque indices, probing depth, and periapical x-ray were monitored at baseline and at various periods from 50 months to 6 years after surgery. Grafting with only HA in the osseous defects of the same patient was used for comparison. The present study shows that GF-HA-treated sites could achieve marked pocket reduction and probing attachment gain at reentry and later recalls. Good clinical bone filling of osseous defects in GF-HA-treated sites was also demonstrated in periapical radiographs (increased bone height and reappearance of the crestal cortex) and in some reentry sites. One HA-treated site was filled with connective tissue only, and the absence of new bone formation was noted during a reentry operation. Another HA-treated site exhibited a comparable increase in radiographic density, while part of HA particles were gradually lost in longer recalls. These limited observations conclude that GF-HA grafting may provide a treatment modality leading to regeneration of periodontal tissues in periodontitis-affected osseous defects. Further studies including more cases and demonstration of the deposition of differentiated periodontal tissues are necessary before further application of this therapy.

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.

Thirty-six month follow-up of 25 patients treated with combination anorganic bovine-derived hydroxyapatite matrix (ABM)/cell-binding peptide (P-15) bone replacement grafts in human infrabony defects. I. Clinical findings

BACKGROUND

Long-term evaluation of periodontal therapy is important for clinical decision making.

METHODS

A synthetic cell-binding peptide (P-15) combined with anorganic bovine-derived hydroxyapatite bone matrix (ABM) was evaluated as a bone replacement graft in human periodontal osseous defects. Following initial preparation and reevaluation, flap surgery was performed. A variety of 1-, 2-, 3-wall bony defects were curetted and root surfaces subjected to mechanical debridement only. The bone defects were grafted with ABM/P-15, and the host flaps replaced or slightly coronally positioned. Weekly, then monthly deplaquing was performed until surgical reentry at 6 to 7 months. Patients were then followed on approximate 3-month recalls for 3 years. Twenty-five of the original 31 patients qualified for long-term evaluation in that their ABM/P-15 treated sites did not receive any additional therapy at the time of reentry.

RESULTS

Significant clinical changes for the overall group of bony defects included improvement in mean clinical attachment level from 5.4 mm at surgery to 4.5 mm at the 6-month reentry to 3.8 mm at 3 years. There was also a decrease in mean probing depth from 5.3 mm at surgery to 3.1 mm at the 6-month reentry to 2.9 mm at 3 years. The mean gingival recession changed from +0.1 mm at surgery to 1.4 mm at the 6-month reentry to 0.9 mm at 3 years. All of these differences were at least P <0.05 from surgery to the 6-month reentry, and surgery to 3 years, but were not significant from reentry to 3 years via repeated measures analysis of variance.

CONCLUSIONS

These favorable 3-year results with ABM/P-15 suggest that it may have a beneficial effect in the long-term clinical management of infrabony defects. Further long-term randomized controlled studies are needed to better assess the role of ABM/P-15 in long-term healing of periodontal osseous defects.

Multi-center clinical comparison of combination anorganic bovine-derived hydroxyapatite matrix (ABM)/cell binding peptide (P-15) and ABM in human periodontal osseous defects. 6-month results

BACKGROUND

Intraosseous periodontal defects present a particular treatment problem. New bone replacement grafts offer promise for improved results.

METHODS

The role of a synthetic cell-binding peptide (P-15), combined with anorganic [corrected] bovine-derived hydroxyapatite bone matrix (ABM), was compared to ABM alone in human periodontal osseous defects in a controlled, monitored, multi-center trial. Following appropriate initial preparation procedures, flap surgery with defect and root debridement was performed. Two osseous defects per patient were treated randomly with each procedure after surgical preparation. Appropriate periodontal maintenance schedules were followed, and at 6 to 7 months, re-entry flap surgery was performed for documentation and finalization of treatment.

RESULTS

T test and Mann-Whitney U analyses of patient mean values from 33 patients revealed that the combination ABM/P-15 grafts demonstrated significantly better mean defect fill of 2.9 +/- 1.2 mm (72.9%) versus a mean defect fill of 2.2 +/- 1.4 mm (50.67%) for defects treated with ABM (P<0.05). Other hard tissue findings showed similar clinically superior results with the use of ABM/P-15. Relative defect fill results showed 81% positive (50% to 100% defect fill) responses with ABM/P-15 and 67% positive responses with ABM. There were 3.5 times as many optimal results (> or = 90% defect fill) with ABM/P-15 and twice as many failures (minimal response) with ABM. Soft tissue findings showed no significant differences between treatments.

CONCLUSIONS

These results suggest that the use of the P-15 synthetic cell-binding peptide combined with ABM yields better clinical results than the ABM alone in intrabony periodontal defects.

Reconstruction of bone using calcium phosphate bone cements: a critical review

The calcium phosphate cements (CPCs) are rapidly emerging as a new technology in craniofacial surgery and will soon impact many areas of orthopedic and maxillofacial reconstructive surgery as well. These materials are, in many ways, substantially different from the previously marketed dense, crystalline, hydroxyapatite (HA) ceramic materials of the 1980s. The CPCs are blends of amorphous and crystalline calcium phosphate compounds and set to produce HA. These materials 1) have x-ray diffraction spectra similar to the mineral phase of bone, 2) set endothermically at body temperature, 3) are capable of being injected into fractures or bone defects, 4) have compressive strengths equal to or greater than bone, 5) form chemical bonds to the host bone, and 6) may exhibit osteoconductive properties. This review provides an overall commentary on the different types of CPCs, emphasizing those materials currently on the market or soon to emerge in the marketplace.

Bone and bone substitutes

Bone replacement grafts will play a continuing role in periodontal and other regenerative therapy. Several choices are available to the clinician including autogenous, allogeneic, xenogeneic and a variety of alloplastic materials. Except for fresh autogenous bone, bone replacement graft(s) do not provide the cellular elements necessary for osteogenesis nor can they reliably be considered truly osteoinductive, but instead are mostly osteoconductive, providing a scaffold for bone deposition. Currently, significant decrease in clinical probing depth and gain of clinical attachment have been reported following use of bone replacement grafts when compared to flap debridement surgery alone for periodontal osseous defects. Reported differences among bone replacement grafts (autogenous, allogeneic, xenogeneic, and alloplastic) occur with respect to histological outcomes. Overall, probing depth reduction, attachment level gain and degree of defect fill are similar for all bone replacement grafts.

Multi-center clinical evaluation of combination anorganic bovine-derived hydroxyapatite matrix (ABM)/cell binding peptide (P-15) as a bone replacement graft material in human periodontal osseous defects. 6-month results

A synthetic cell-binding peptide (P-15) combined with anorganic bovine-derived hydroxyapatite bone matrix (ABM) was compared to demineralized freeze-dried bone allograft (DFDBA) and open flap debridement (DEBR) in human periodontal osseous defects in a controlled, monitored, multi-center trial. Following appropriate initial preparation procedures, flap surgery with defect and root debridement was performed. Three osseous defects per patient were treated randomly with one of three procedures after surgical preparation. Appropriate periodontal maintenance schedules were followed, and at 6 to 7 months re-entry flap surgery was performed for documentation and finalization of treatment. Analysis of variation (ANOVA) and t test analyses of patient mean values from 31 patients revealed that the combination ABM/P-15 grafts demonstrated significantly better mean defect fill of 2.8 +/- 1.2 mm (72.3%) versus a mean defect fill of 2.0 +/- 1.4 mm (51.4%) for defects treated with DFDBA (P <0.05) and a mean defect fill of 1.5 +/- 1.3 mm (40.3%) (P <0.05) for defects treated with DEBR. Other hard tissue findings showed similar clinically superior results with the use of ABM/P-15. Relative defect fill results showed 87% positive (50% to 100% defect fill) responses with ABM/P-15, 58% positive responses with DFDBA, and 41% positive responses with DEBR. There were 8 to 9 times more failures (minimal response) with DFDBA and DEBR (26% to 29% frequency) than with ABM/P-15. Soft tissue findings showed no significant differences among treatments except for greater clinical attachment level gain with ABM/P-15 compared to DEBR. These results suggest that the use of the P-15 synthetic cell-binding peptide combined with ABM yields better clinical results than either DFDBA or DEBR. Further studies are needed to determine the relative roles of the ABM and/or the P-15 in these improved results.

Comparison of bioactive glass synthetic bone graft particles and open debridement in the treatment of human periodontal defects. A clinical study

The purpose of this study was to compare the repair response of bioactive glass synthetic bone graft particles and open debridement in the treatment of human periodontal osseous defects. Fifty-nine defects in 16 healthy adults were selected. Each patient had at least 2 sites with attachment loss of at least 6 mm with clinical and radiographic evidence of intrabony or furcation defects. One to 3 months after cause-related therapy (oral hygiene instructions, scaling and root planing), the following measurements were recorded prior to surgery: probing depths, clinical attachment level, and gingival recession. Each defect was surgically exposed and measurements made of the alveolar crest height and base of osseous defect. The test defects were implanted with bioactive glass. The other sites served as unimplanted controls. Flaps were sutured at or close to the presurgical level. Radiographs and soft tissue presurgical measurements were repeated at 6, 9, and 12 months. At 12 months all sites were surgically re-entered to record osseous measurements. At the 12-month evaluation, significantly greater mean probing depth reduction was noted in the bioactive glass group compared to the controls (4.26 mm versus 3.44 mm; P = 0.028). Clinical attachment level gain was significantly improved (P = 0.0004) in the bioactive glass sites (2.96 mm) compared to the control sites (1.54 mm). There was significantly less gingival recession in the bioactive glass sites (1.29 mm) compared to the control sites (1.87 mm). Defect fill was significantly greater in the bioactive glass sites (3.28 mm) compared to the control sites (1.45 mm). Defect depth reduction was significantly greater in the bioactive glass sites (4.36 mm) compared to the control sites (3.15 mm). In conclusion, bioactive glass showed significant improvement in clinical parameters compared to open flap debridement.

Influence of particle size of calcium phosphate ceramics as a capping agent on the formation of a hard tissue barrier in amputated dental pulp

The purpose of this research was to compare the effect of two different particle sizes of hydroxyapatite and beta-tricalcium phosphate as capping agents on hard tissue barrier formation after experimental pulpotomy in canine dental pulp. By the thirtieth day after pulp exposure and capping with hydroxyapatite-300 (particle size, 300 microns), a hard tissue barrier was formed in 8 of 17 specimens. A newly formed barrier was seen around the hydroxyapatite particles and connecting neighboring particles. Capping with tricalcium phosphate-300 (particle size, 300 microns) led to the formation of a hard tissue barrier surrounding the particles in 11 of 17 specimens. In contrast, using hydroxyapatite-40 (particle size, 40 microns) and beta-tricalcium phosphate-40 (particle size, 40 microns), hard tissue barrier formation was poor and almost all pulp tissues showed infiltrations of inflammatory cells or abscess formation. These findings suggest that the particle size of hydroxyapatite and beta-tricalcium phosphate is an important factor in reparative hard tissue formation.

Effect of addition of hydroxyapatite on the physical properties of IRM

The aim of this study was to evaluate the effect of adding 10% and 20% hydroxyapatite (HAP) to Intermediate Restorative Material (IRM) on physical properties such as working time, setting time, compressive strength and disintegration rate. The working and setting times were determined by an indentation method. The ISO recommended method was used to determine compressive strength. The rate of disintegration in vitro was evaluated in buffered sodium citrate at pH 4.5, 5.8, buffered phosphate at pH 7.0 and in bovine serum (pH 6.8), and examined using a replica method and scanning electron microscopy. Kalzinol and EBA were used as control materials for the disintegration experiment. IRM had longer mean working (4 min 43.5 s) and mean setting (6 min 28.5 s) times than IRM + 10 or 20% HAP (P < 0.001), the mean reductions being 16% and 9% for IRM + 10% HAP, and 29% and 19% for IRM + 20% HAP, respectively. IRM had a greater compressive strength (68.5 MPa, P < 0.01) than IRM + 10% HAP (65.0 MPa) or IRM + 20% HAP (60.0 MPa, P < 0.001). Kalzinol, IRM + 10% HAP and IRM + 20% HAP were found to disintegrate after 8 weeks in buffered phosphate and in bovine serum. In contrast, IRM and EBA showed no noticeable signs of disintegration after 6 months in the same media. The physical properties of IRM + 10% HAP and IRM + 20% HAP were reduced compared with IRM but the reductions were not considered to be of clinical significance.

Clinical evaluation of coralline calcium carbonate as a bone replacement graft material in human periodontal osseous defects

A resorbable coralline calcium carbonate graft material (CalCarb) was compared to open flap debridement (DEBR) in human periodontal osseous defects. Following appropriate initial preparation procedures, flap surgery with defect and root debridement was performed in 20 patients. Alternating defects in each segment of surgery were treated with each procedure. Appropriate periodontal maintenance schedules were followed, and at 6 to 12 months a re-entry flap surgery was performed for documentation and finalization of treatment. Forty defects which received CalCarb grafts demonstrated significantly better mean defect fill of 2.3 mm (67.7%) versus a mean defect fill of 0.7 mm (25.9%) (P < 0.01) for 39 defects treated with DEBR. Other hard tissue findings showed similar clinically superior results with the use of CalCarb. Relative defect fill results showed 88% positive (50% to 100% defect fill) responses with CalCarb and only 13% positive responses with DEBR. There were 7 times more failures (minimal response) with DEBR than with CalCarb. Soft tissue findings showed no significant differences between treatments. These results are similar to those with other synthetic and natural bone replacement graft materials. However, the ease of handling of the CalCarb material, its resorbability, and its potential for improved bone regeneration may be of clinical advantage.

Tissue response to biphasic calcium phosphate ceramic with different ratios of HA/beta TCP in periodontal osseous defects

The purpose of this study was to determine the optimal ratio of calcium hydroxyapatite (HA) to beta tricalcium phosphate (beta TCP) in a biphasic porous calcium phosphate (BCP) ceramic for effective repair of periodontal osseous defects. Defects were surgically produced in beagle dogs and made chronic for 4 months to simulate periodontal disease. Mucoperiosteal periodontal flaps were reflected, followed by osseous defect debridement and root planing. Specially prepared ceramic with different HA/beta TCP ratios were implanted into the prepared defects. The sites were allowed to heal for 6 months, animals were euthanized, and site-blocks were removed for histological study. During the follow-up phase, scaling and polishing were done once a month, and standardized probing attachment levels were recorded pre- and 6-months postoperatively. The Duncan's multiple range test showed that all the treatments produced statistically significant higher gain in probing attachment levels than the control group (0HA/0 beta TCP) (P < 0.05). Among the 7 "active" treatment groups, 2 (65/35 and 85/15) had significantly higher gain in probing attachment levels than those in 3 groups (50/50, 100/0, and 0/100) (P < 0.05). Histologically, higher HA ratio (but not 100% HA) showed accelerated new bone formation and new attachment levels. Based on histological results, the 85HA/15 beta TCP ratio appears to demonstrate greater gain in attachment level and bone regeneration in the treatment of periodontal osseous defects.

The effect of therapeutic radiation on canine alveolar ridges augmented with hydroxylapatite

The purpose of this investigation was to evaluate the effect of radiation on hydroxylapatite (HA) implanted subperiosteally for alveolar ridge augmentation in dogs. All bicuspids and molars were extracted from 16 dogs. After 6 weeks, nonporous HA granules were implanted subperiosteally on the alveolar ridge. Following 4 months of healing, 12 dogs (experimental group) underwent therapeutic radiation therapy (Co60, 4,000 rad [40 Gy]) to the head and neck region. Four dogs were not irradiated and served as controls. Four animals (three experimental and one control) were killed at 5,6,7, and 8 months after HA augmentation. Light microscopic evaluation showed that approximately 25% of HA granules were encased by bone while the others were surrounded by fibrous connective tissue. Dissolution of the HA was observed. Microparticles of HA were phagocytized as part of a granulomatous inflammatory reaction. This reaction decreased significantly as time elapsed after implantation. Osteoclastic activity was seen at the junction of HA and periosteum and as part of bone remodeling. Dissolution of the HA granules and the granulomatous inflammatory reaction were not significantly increased by therapeutic radiation. The radiation did not cause development of dehiscence or osteonecrosis.

Ultrastructural and ultracytochemical characteristics of multinucleated cells after hydroxyapatite implantation into rat periodontal tissue

Multinucleated cells (MNCs) that appeared after hydroxyapatite (HAP) implantation into experimentally-produced bone defects in rat periodontal tissues were investigated both ultrastructurally and ultracytochemically. At day 5 after implantation, MNCs first appeared along the HAP surface. They had no features of typical osteoclasts such as ruffled border and clear zone. By d 14, these cells acquired features similar to osteoclasts, including ruffled border and clear zone. With the appearance of ruffled borders in MNCs, new bone deposited around the implanted HAP. MNCs appeared to excavate both newly-formed bone and implanted HAP simultaneously. Ingested HAP particles were observed not only in MNCs but also in macrophages. MNCs contained both tartrate-resistant acid phosphatase (ACPase) and carbonic anhydrase (CAase). ACPase activity was detected along all the biosynthesizing pathways in MNCs. Extracellular ACPase activity around the ruffled border region was also demonstrable. CAase activity could be detected only in the cytosol, vesicles and mitochondrial cristae of the MNCs. These cytochemical characteristics were almost the same regardless of the time elapsed after implantation.

Effects of calcium-phosphate-based materials on proliferation and alkaline phosphatase activity of newborn rat periosteal cells in vitro

The effects of dental materials, intended for bone substitution, on cell growth and alkaline phosphatase activity of newborn rat periosteal cells have been studied in vitro. Confluent periosteal cells were exposed to three apatite-based materials (400 micrograms/mL) with different physico-chemical properties. The materials were a beta-tricalcium phosphate with a microporous granular structure obtained by sinterization (Synthograft, Johnson & Johnson, East Windsor, NY), a 40-60-mesh microporous durapatite ceramic (Periograf, Sterling Drug, Inc., Rensselaer, NY), and a 1-2-mm-diameter hydroxyapatite ceramic (Osprovit, Feldmuhle Aktiengeselschaft, Plochingen, Germany) with macropores larger than 100 microns. Cell proliferation and alkaline phosphatase activity were assessed by incorporation of 3H-thymidine into trichloroacetic-acid-precipitable material and by a fluorimetric method, respectively. Cell viability and compatibility with the materials were determined by morphology in phase-contrast microscopy. Periosteal cells showed increased proliferation following exposure to Synthograft, but were unaffected by Osprovit, whereas Periograf caused significantly reduced cell growth. Alkaline phosphatase activity was unaffected by Osprovit, but was decreased by both Synthograft and Periograf. The results indicated a differential response of periosteal cells to bone-substituting materials with heterogeneous physico-chemical characteristics.

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.

Bone formation in tricalcium phosphate-filled periodontal intrabony lesions. Histological observations in humans

The capacity of a tricalcium phosphate (TCP) ceramic to promote bone formation after grafting in intrabony defects was studied in humans. Five biopsies were collected from 4 patients during reentry surgery 16 to 40 months after implantation. They were processed without demineralization for histological examination. In the less mature samples, the grafted material was surrounded by a highly fibrous, highly cellular, and poorly vascularized connective tissue. Howship's lacuna-like cavities were clearly visible at the surface of the material. They contained resorbing mononuclear phagocytes. At a more mature stage, TCP granules were embedded in an acellular fibrous material which underwent mineralization from the medullary spaces towards the granules. The bone formed was subsequently remodeled. The implanted material itself was progressively modified. It first acquired the staining appearance of bone. After its structure became loose and vacuolated, it was invaded by cells and vessels. The present data indicate that TCP has osteogenic potential and is subject to degradation. Unlike in experimental wounds, these processes are of long duration in human defects.

A comparison of freeze-dried bone allograft and demineralized freeze-dried bone allograft in human periodontal osseous defects

This study was conducted to clinically compare freeze-dried bone allograft (FDBA) and demineralized freeze-dried bone allograft (DFDBA). Twenty-two defects (11 intrapatient pairs) in 9 patients were grafted with either DFDBA or FDBA. Evaluations were based on standardized radiographs, presurgical and postsurgical soft tissue measurements using the cemento-enamel junction as a fixed reference point, and osseous measurements at the time of surgery. Grafted sites were re-entered at a minimum of 6 months following placement. A mean osseous repair of 1.7 mm (59%) occurred with DFDBA and 2.4 mm (66%) with FDBA. A mean clinical attachment gain of 1.7 mm was obtained with DFDBA and 2.0 mm with FDBA. Probing depths decreased a mean of 2.00 mm with both DFDBA and FDBA. These findings reveal no significant differences between the two materials in primarily intraosseous defects when evaluated at a minimum 6 months postsurgery.

Human freeze-dried dura mater allografts as a periodontal biological bandage

Freeze-dried dura mater allografts (FDDMA) were used as a biologic bandage covering periodontal osseous defects which were grafted with autogenous bone particles. Seven consenting adult patients having multiple one-, two-, and wide three-wall periodontal osseous defects participated in the study. Four to 6 weeks following initial preparation, all defects were treated by full thickness flap surgery, debridement of defects, root planing, intramarrow penetration as needed, and autogenous bone grafts that filled the defects. Randomly selected grafted defects in each patient were then covered with FDDMA (experimental) or by the host flap (RF) (control). Periodontal dressing and systemic tetracycline (250 mg q.i.d.) were used for 7 days. Frequent maintenance was performed until reevaluation at 6 months postsurgically. Soft tissue results showed no significant differences in initial probing pocket depths, recession, or gain of probing attachment. There was a significantly greater amount of probing pocket depth reduction and significantly shallower residual pockets when FDDMA was used. Hard tissue findings indicated that there were no significant differences in initial defect depth, amount of crestal resorption, or amount or percent of defect fill with either treatment. There were significant differences in the percent of defect resolution and the depth of the residual defect in favor of the FDDMA treatment. None of the FDDMA sites were felt to need a secondary surgery to correct residual defects or residual pockets. This study suggests that FDDMA may be beneficial as a "biologic bandage" to cover periodontal osseous defects that were filled with autogenous bone grafts. The trends in this study suggest that FDDMA may be very useful in periodontal regeneration procedures.

5-year evaluation of durapatite ceramic alloplastic implants in periodontal osseous defects

Six patients who participated in a clinical study comparing the response of periodontal osseous defects to either grafting with Periograf (durapatite) hydroxylapatite (HA) ceramic or debridement alone (DEBR) were followed under an active maintenance program for 5 years. Mean values for gingival recession and attachment levels remained essentially stable following either treatment over the 5 year period. However, mean probeable pocket depths shifted from being significantly (P less than 0.05) shallower for DEBR sites at 6 months and 1 year to being significantly shallower for HA sites at 5 years. The probing pocket depth change for grafted sites was steady and the change from presurgical values was significantly greater than the change for DEBR areas, which became about 1.5 mm deeper over the 5 year postsurgical period. Intrapatient comparisons showed that recession, attachment gain, and pocket depth decrease were most frequently greater for the Periograf-treated sites. Assessment of the pattern of clinical changes during the 5 year postsurgical period demonstrated that the attachment level of grafted sites improved or stayed the same 86% of the time compared to only 62% stability or improvement in the DEBR only sites. In fact, 38% of the DEBR sites were worse at 5 years than at the time of surgery, a 3 times greater failure rate than that found in the HA-grafted sites. Pocket depth measurements showed that 98% of the Periograf-treated sites were better or the same as presurgically (2% worse), while only 80% of DEBR sites showed positive results and 20% had deeper pockets than at the time of surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of various graft materials with tetracycline in localized juvenile periodontitis

Ten patients with bilateral, posterior osseous defects associated with localized juvenile periodontitis (LJP) completed the study. Following the initial therapy, osseous defects were surgically debrided and grafted with a 4:1 volume ratio combination of either Synthograft/tetracycline (b-TCP/TTC), Periograf/tetracycline (HA/TTC) or freeze-dried bone allograft/tetracycline (FDBA/TTC). Graft materials were selected randomly for each half mouth following defect debridement, with a different material used on the opposite side for that patient. Immediately following each surgery, patients were placed on doxycycline 100 mg/day for 10 days. Direct re-entry evaluation of 51 osseous defects demonstrated no significant differences among the graft materials regarding hard tissue or soft tissue changes, except for greater percent defect fill for HA/TTC compared to b-TCP/TTC. Significant decreases in defect depth and pocket depth were achieved with each graft material. No adverse reactions to the use of any of the graft materials in combination with local and systemic tetracycline were found. The results indicate all three graft materials used in conjunction with TTC are acceptable and beneficial for the treatment and repair of osseous defects associated with localized juvenile periodontitis.

Osseous defect responses to hydroxylapatite grafting versus open flap debridement

Data from a large number of defects (152) treated with hydroxylapatite (HA) grafts were compared to those from a large number of defects (111) treated by surgical debridement alone (DEBR). Comparison of initial and re-entry surgery measurements showed that both the analysis of relative defect fill and the intrapatient comparisons demonstrated an advantage to the use of HA graft material. 58% of the HA-grafted defects were judged to have a positive (greater than or equal to 50% defect fill) hard tissue response compared to 30% for DEBR. Minimal responses (failures) were 4 times as numerous with DEBR. Similarly, within each patient, HA grafting proved of benefit, particularly regarding hard tissue changes. The use of HA graft materials appears to be of clinical benefit in a majority of defects and a majority of patients.

Comparison of freeze-dried bone allograft and porous hydroxylapatite in human periodontal defects

This study was conducted to clinically compare the efficacy of freeze-dried bone allograft (FDBA) and porous hydroxylapatite granules. Nineteen pairs of intraosseous defects were grafted in seven patients. One defect of each pair was implanted with FDBA, the other with granular porous hydroxylapatite. Matching defects were treated similarly in all other aspects. Evaluations were based on both preoperative and postoperative measurements from a fixed reference point, standardized radiographs, surgical osseous measurements, and histology of degranulated tissues. Grafted sites were reentered 6 to 11 months postsurgery. Results showed a mean osseous fill of 2.1 mm for FDBA versus 1.3 mm for granular porous hydroxylapatite (P = .07). A mean clinical attachment gain of 2.2 mm for FDBA versus 1.3 mm for granular porous hydroxylapatite (P less than .05), and a mean decrease in probing depths of 3.0 mm for FDBA versus 1.4 mm for granular porous hydroxylapatite (P less than 0.5) was found. FDBA was clinically indistinguishable from host bone, whereas porous hydroxylapatite appeared to be separated from host bone by soft tissue. The data and clinical findings suggested that FDBA may have some enhanced reparative potential when compared to granular porous hydroxylapatite in the treatment of periodontal defects in humans.

Tissue response to subperiosteal implantation of dense hydroxyapatite: case report

Hydroxyapatite is becoming a popular implant material, yet reports on the tissue response it evokes in humans have been few in number and are based on relatively short periods of implantation. In the present case, implant material became available when it proved necessary to modify an alveolar ridge augmentation procedure carried out 18 month previously. Histology showed that whilst some parts of the implanted material were embedded only in fibrous tissue, others had become fully integrated within partly remodelled bony trabeculae. These findings confirm the status of hydroxyapatite as a biocompatible implant material and provide further evidence of its bone-bonding and osteoconductive capacities.

A comparative clinical study of solid and granular porous hydroxylapatite implants in human periodontal osseous defects

Solid and granular porous hydroxylapatite implants were compared in the surgical treatment of angular interproximal periodontal defects in 10 subjects. After completion of initial therapy, presurgical measurements of pocket depth, attachment level, gingival recession, gingival fluid and tooth mobility were recorded. Six months after the surgery the measurements were repeated. The use of both forms of porous hydroxylapatite resulted in reduction in pocket depth, and probeable attachment level gains as well as gingival recession and reduction of gingival fluid and tooth mobility. These changes were similar for both granular and solid forms of porous hydroxylapatite.