Role of space provision in regeneration of localized two-wall intrabony defects using periosteal pedicle graft as an autogenous guided tissue membrane

Effect of Connective Tissue Grafts in the Regenerative Treatment of Intrabony Defects: A Systematic Review and Meta-Regression Analysis

AIM

To assess the effect of connective tissue graft (CTG) in the treatment of periodontal intrabony defects (IDs), focusing on changes in postoperative gingival recession (GR) depth and regenerative outcomes.

METHODS

A systematic search was conducted across MEDLINE-PubMed, EMBASE, Cochrane CENTRAL, and Google Scholar for articles published through December 31, 2024. Randomized controlled trials (RCTs) comparing treatment outcomes in IDs treated with or without CTG were included in a meta-regression analysis. A mixed-effect linear regression model was employed to estimate the effect of CTG on postoperative GR depth, probing depth (PPD) reduction, clinical attachment level (CAL) gain, and bone fill (BF).

RESULTS

Twenty-three studies were selected, with five RCTs (176 IDs) included in the meta-regression. Of these, two RCTs compared bone graft (BG) + CTG to BG + resorbable membrane (MB), one compared periosteal vs. nonperiosteal CTG combined with BG, one compared open flap debridement (OFD) + CTG to OFD alone, and one compared BG + CTG to either OFD or MB. The use of CTG was significantly associated with a reduction in GR (mean effect size of 0.981 mm, 95% CI: 0.573 to 1.389, p = 0.001), PPD (mean effect size of 1.160 mm, 95% CI: 0.318 to 2.002, p = 0.010), as well as improvements in CAL (mean effect size of 1.105 mm, 95% CI: 0.420 to 1.790, p = 0.004) and BF (mean effect size of 1.382 mm, 95% CI: 0.595 to 2.169, p = 0.002).

CONCLUSION

Within the limitations of the study, the use of CTG in periodontal regenerative therapy for IDs appears beneficial in reducing postoperative GR and might further enhance regenerative outcomes compared to treatments without CTG.

Clinical efficacy of periosteal pedicle graft as a barrier membrane in guided tissue regeneration: A systematic review and meta-analysis

Background:

The study aims to assess the clinical efficacy of periosteal pedicle graft (PPG) as a barrier membrane in guided tissue regeneration (GTR) for gingival recession, intrabony, and furcation defects.

Materials and Methods:

Electronic and hand searches were performed to identify randomized controlled/clinical trials investigating GTR using PPG, with 6-month follow-up. Primary outcomes recorded: probing depth (PD), clinical attachment level (CAL), bone fill, recession depth (RD) reduction, percentage of mean root coverage, keratinized tissue width (KTW), and bone defect area (BDA).

Results:

Thirteen articles were selected; 6 for recession, 2 for furcation, and 5 for intrabony. Meta-analysis was performed whenever possible, results expressed as pooled standardized mean differences (SMDs). In recession defects, the RD pooled SMD is 0.47 (95% confidence interval (CI) = [−0.50–1.44]), KTW pooled SMD is 1.30 (95% CI = [−0.30–2.91]), favoring PPG over the comparator. In furcation defects, PD pooled SMD is 1.12 (95% CI = [−2.77–0.52]), CAL pooled SMD is 0.71 (95% CI = [−1.09–2.50]), and bone fill pooled SMD is 0.67 (95% CI = [−3.34–4.69]) favoring PPG. In intrabony defects, PD pooled SMD is 0.54 (95% CI = [−2.12–1.04]), CAL pooled SMD is 0.23 (95% CI = [−1.13–0.68]), and BDA pooled SMD is 0.37 (95% CI = [−1.58–2.31]) favoring PPG. The results were not statistically significant.

Conclusion:

The current evidence indicates that PPG constitutes a valid and reliable alternative to collagen barrier membranes for successful GTR.

Tricalcium phosphate (-containing) biomaterials in the treatment of periodontal infra-bony defects: A systematic review and meta-analysis

OBJECTIVES

This study aimed to investigate the additional clinical benefit of tricalcium phosphate (TCP) (-containing) biomaterials compared to open flap debridement (OFD) in periodontal infra-bony defects.

DATA

A literature search was conducted in Pubmed, Embase and Cochrane library for entries published up to 14th July 2021. All randomized controlled trials (RCTs) that compared a TCP (-containing) material with OFD and studies that assessed a beta-TCP group alone, with vertical defect sites with PPD of ≥ 6 mm and/or presence of infra-bony defects of ≥ 3 mm and a minimum follow-up of 6 months were included. Risk of bias was assessed with the Oxford scale. The random-effects (RE) model was synthesized as differences between weighted average (MD) for probing pocket depth (PPD) and clinical attachment level (CAL) between TCP and OFD groups. An RE analysis was also performed for the beta-TCP group alone.

STUDY SELECTION

Data from 16 RCTs were included in the analysis. Six studies that represented 151 patients and sites were selected for meta-analysis. The overall MD with 95% CI at 6 months was calculated to be -0.47 [-0.83, -0.12; P = 0.0087] and -1.06 [-1.67, -0.46; P = 0.0006] for PPD and CAL, respectively. Whereas MD at 12 months for PPD and CAL was -0.89 [-1.54, -0.23; P = 0.0078] and -1.25 [-1.85, -0.66; P<0.0001], respectively. All results were in favor of TCP (-containing) group over OFD.

CONCLUSIONS

The results of the study suggest that the use of a TCP (-containing) material may have the potential for additional clinical improvement in PPD and CAL compared with OFD in infra-bony defects, given the limitations of the included evidence.

CLINICAL SIGNIFICANCE

The use of TCP as a bone graft substitute is becoming increasingly common. Therefore, it would be advantageous if an adjunctive benefit in the regeneration of infra-bony defects could be demonstrated to facilitate material selection.

The use of hydroxyapatite bone substitute grafting for alveolar ridge preservation, sinus augmentation, and periodontal bone defect: A systematic review

OBJECTIVES

We determined and structurally analyzed the reported effect of hydroxyapatite (HA) bone substitute on alveolar bone regeneration. To the best of our knowledge, no systematic reviews have previously reported the bone regenerative effect of the HA bone substitute.

MATERIALS AND METHODS

A literature search was performed for articles published up to August 2015 using MEDLINE with the search terms "hydroxyapatite," "bone regeneration," and "alveolar bone" as well as their known synonyms. The inclusion criteria were set up for human trials with at least five patients. The literature search, eligible article selection, and data extraction were independently performed by two readers, and their agreement was reported by κ value.

RESULTS

Of the 504 studies found using the MEDLINE literature search, 241 were included for further steps (inter-reader agreement, κ = 0.968). Abstract screening yielded 74 studies (κ = 0.910), with 42 completely fulfilling the inclusion criteria (κ = 0.864). In a final step, 42 studies were further analyzed, with 17 and 25 studies with and without statistical analysis, respectively. The 17 studies reporting similar outcome measures were compared using the calculated 95% confidence intervals. The effect of HA on ridge preservation could not be evaluated.

CONCLUSIONS

The use of the HA bone substitute interfered with the normal healing process, with significant differences found for sinus augmentation but not for periodontal bone defects. Thus, a bone substitute with optimal bone regenerative properties for alveolar ridge or socket preservation, sinus augmentation, and periodontal bony defect should be developed.

A review of the literature: antibiotic usage and its relevance to the infection in periodontal flaps

OBJECTIVE

This study aimed to investigate the systemic antibiotic usage in the perioperative period of periodontal flaps and its relevance to the infection after surgeries through reviewing the papers of the last decade.

MATERIALS AND METHODS

A search was conducted for the studies of randomized clinical trials between 2005 and 2014 that reported periodontal flaps in chronic periodontitis patients. Data were extracted and the rate of the systemic antibiotic use, the infection rate after surgeries and the number needed to treat (NNT) to prevent one infected case were calculated. The impact of antibiotic use and materials used in surgeries on the infection was evaluated.

RESULTS

Eighty-three trials were included. Antibiotics were used in 73.7% of the patients and 75.4% of the flaps. Infection occurred in only five flaps where enamel matrix proteins (EMD) or EMD + bone grafts were used in intrabony defects. Only 0.170% of the surgeries got infected in total. When all kinds of surgeries were included for analysis, the infection rate was 0.073% for the surgeries using antibiotics, which was lower than the infection rate 0.693% for the surgeries not using antibiotics (p < .05). The infection rate was very low in general. NNT was 203 when all the surgeries were included for analysis. Therefore, the difference of the infection rates between using antibiotics and not might lack clinical significance.

CONCLUSIONS

Considering the very low incidence of the infection and the disadvantages of the systemic antibiotic use, we suggest not using systemic antibiotics in the perioperative period of periodontal flaps to prevent infection.

Periosteum as a lateral pedicle graft for the treatment of single tooth root recession: A novel approach

The treatment of gingival recession defects is indicated for esthetic and functional reasons to reduce root sensitivity, to remove muscle pull, to create or augment keratinized tissue, and to prevent disease progression. The presence of sufficient amount of periosteum adjacent to gingival recession defects makes it a suitable graft. The adult human periosteum is a highly vascular connective tissue with immense regenerative potential. It contains fibroblasts, osteogenic progenitor cells, and stem cells as a result of which it has the ability to differentiate into fibroblast, osteoblast, chondrocytes, adipocytes, and skeletal myocytes. The tissue provided by these cells includes cementum with periodontal ligament fibers and bone. Therefore, in the present case, periosteum has been used as a lateral pedicle graft for the coverage of the single tooth gingival recession (mandibular central incisor). The procedure is justified by the evidence that periosteum is capable of proliferation and osteogenesis after injury.

Periosteal Pedicle Flap Harvested during Vestibular Extension for Root Coverage

Root exposure along with inadequate vestibular depth is a common clinical finding. Treatment option includes many techniques to treat such defects for obtaining predictable root coverage. Normally, the vestibular depth is increased first followed by a second surgery for root coverage. The present case report describes a single-stage technique for vestibular extension and root coverage in a single tooth by using the Periosteal Pedicle Flap (PPF). This technique involves no donor site morbidity and allows for reflection of sufficient amount of periosteal flap tissue with its own blood supply at the surgical site, thus increasing the chances of success of root coverage with simultaneous increase in vestibular depth.

Regenerative Medicine for Periodontal and Peri-implant Diseases

The balance between bone resorption and bone formation is vital for maintenance and regeneration of alveolar bone and supporting structures around teeth and dental implants. Tissue regeneration in the oral cavity is regulated by multiple cell types, signaling mechanisms, and matrix interactions. A goal for periodontal tissue engineering/regenerative medicine is to restore oral soft and hard tissues through cell, scaffold, and/or signaling approaches to functional and aesthetic oral tissues. Bony defects in the oral cavity can vary significantly, ranging from smaller intrabony lesions resulting from periodontal or peri-implant diseases to large osseous defects that extend through the jaws as a result of trauma, tumor resection, or congenital defects. The disparity in size and location of these alveolar defects is compounded further by patient-specific and environmental factors that contribute to the challenges in periodontal regeneration, peri-implant tissue regeneration, and alveolar ridge reconstruction. Efforts have been made over the last few decades to produce reliable and predictable methods to stimulate bone regeneration in alveolar bone defects. Tissue engineering/regenerative medicine provide new avenues to enhance tissue regeneration by introducing bioactive models or constructing patient-specific substitutes. This review presents an overview of therapies (e.g., protein, gene, and cell based) and biomaterials (e.g., resorbable, nonresorbable, and 3-dimensionally printed) used for alveolar bone engineering around teeth and implants and for implant site development, with emphasis on most recent findings and future directions.

The periosteum eversion technique for coverage of denuded root surface

The periosteum is highly cellular connective tissue with rich vascularity and regenerative potential, which make it suitable autogenous graft. The periosteum eversion technique utilized periosteum for coverage of denuded root surface. The purpose of this case report was to evaluate the periosteum eversion technique that involves a single surgical site, in terms of root coverage, gingival height, and probing depth. A patient with Miller class I gingival recession of 3.0 mm, gingival height of 2.0 mm and probing depth of 2.0 mm was treated by the periosteum eversion technique. Root conditioning was done with 24% ethylenediaminetetra-acetic acid. In this technique, marginal periosteum was used as a pedicle graft. At the end of 6 months, 100% root surface was covered successfully with 5.0 mm of gingival height and 1.0 mm of probing depth. The periosteum eversion technique can be used for the treatment of gingival recession defect successfully.

Connective tissue graft as a biological barrier for guided tissue regeneration in intrabony defects: a histological study in dogs

BACKGROUND

The use of the autogenous periosteal graft as biological barrier has been proposed for periodontal regeneration. The aim of this study was to evaluate the histometric findings of the subepithelial connective tissue graft as barrier in intrabony defects compared to a bioabsorbable membrane.

METHODS

Three-walled intrabony defects were created surgically in the mesial aspect of the right and left maxillary canines in five healthy mongrel dogs. The defects were chronified, and two types of barriers were randomly carried out for guided tissue regeneration in a split-mouth design: the test group with a subepithelial connective tissue graft and the control group with a bioabsorbable membrane. The specimens were processed for histometric analyses of the epithelium (E), connective tissue (CT), newly formed cementum (NC), new bone (NB), and total newly formed tissues (NFT).

RESULTS

The test side showed smaller mean of NC (3.6 ± 1.2), NB (2.1 ± 0.7), and NFT (7.7 ± 0.8) than the control group (NC 7.3 ± 0.5; NB 5.3 ± 1.3; NFT 10.1 ± 2.2; P < 0.05). No statistically significant differences were verified for E (test 3.1 ± 2.0; control 2.8 ± 2.1; P > 0.05) and CT (test 2.5 ± 1.1; control 2.0 ± 0.5; P > 0.05) between groups.

CONCLUSION

The bioabsorbable membrane was more effective in maintaining the space for periodontal regeneration than periosteal connective graft when used as barrier.

CLINICAL RELEVANCE

The bioabsorbable membrane showed more favorable regenerative results in intrabony defects in dogs than the subepithelial connective tissue graft as biological barrier.

Comparative evaluation of periosteum as a barrier membrane with and without an alloplastic bone graft in periodontal osseous defects: A 9 months follow-up study

BACKGROUND

Regenerative procedures frequently include the use of barrier membranes and bone grafting materials to encourage the growth of key surrounding tissues. The present study aims to evaluate and compare the ability of periosteum in intrabony defect regeneration.

MATERIALS AND METHODS

A total of ten intrabony defects were equally divided in two treatment groups. Group I consisted of Periosteum used as a barrier memebrane and Group II of periosteum as barrier membrane alongwith graft material. Nine months post operative evaluation of defect fill was done radiographically.

RESULTS

Mean defect fill (CEJ-BBD) was found to be significantly lower in Group II as compared to Group I (P = 0.041).

CONCLUSION

Within the limitations of this study, alloplastic graft material supplimentation results in better regeneration with Periosteum used as a barrier membrane.