Clinical concepts for regenerative therapy in furcations

Can vitamins improve periodontal wound healing/regeneration?

Periodontitis is a complex inflammatory disorder of the tooth supporting structures, associated with microbial dysbiosis, and linked to a number if systemic conditions. Untreated it can result in an irreversible damage to the periodontal structures and eventually teeth loss. Regeneration of the lost periodontium requires an orchestration of a number of biological events on cellular and molecular level. In this context, a set of vitamins have been advocated, relying their beneficial physiological effects, to endorse the biological regenerative events of the periodontium on cellular and molecular levels. The aim of the present article is to elaborate on the question whether or not vitamins improve wound healing/regeneration, summarizing the current evidence from in vitro, animal and clinical studies, thereby shedding light on the knowledge gap in this field and highlighting future research needs. Although the present review demonstrates the current heterogeneity in the available evidence and knowledge gaps, findings suggest that vitamins, especially A, B, E, and CoQ10, as well as vitamin combinations, could exert positive attributes on the periodontal outcomes in adjunct to surgical or nonsurgical periodontal therapy.

Probing pocket depth reduction after non-surgical periodontal therapy: Tooth-related factors

BACKGROUND

To investigate tooth-related factors that influence the reduction of probing pocket depths (PPD) after non-surgical periodontal therapy (NST).

METHODS

Seven hundred forty-six patients with a total of 16,825 teeth were included and retrospectively analyzed. PPD reduction after NST was correlated with the tooth-related factors; tooth type, number of roots, furcation involvement, vitality, mobility, and type of restoration; using logistic multilevel regression for statistical analysis.

RESULTS

NST was able to reduce probing depth overall stratified probing depths (1.20 ± 1.51 mm, p ≤ 0.001). The reduction was significantly higher at teeth with higher probing depths at baseline. At pockets with PPD ≥ 6 mm, PPD remains high after NST. Tooth type, number of roots, furcation involvement, vitality, mobility, and type of restoration are significantly and independently associated with the rate of pocket closure.

CONCLUSIONS

The tooth-related factors: tooth type, number of roots, furcation involvement, vitality, mobility, and type of restoration had a significant and clinically relevant influence on phase I and II therapy. Considering these factors in advance may enhance the prediction of sites not responding adequately and the potential need for additional treatment, such as re-instrumentation or periodontal surgery, to ultimately achieve the therapy end points.

Evaluation of hyaluronic acid gel with or without acellular dermal matrix allograft in the treatment of class II furcation defects in dogs: A histologic and histomorphometric study

Aim

To evaluate the histologic and histomorphometric effects of hyaluronic acid (HA) gel with or without acellular dermal matrix allograft (ADMA) on periodontal regeneration in Class II furcation defects in dogs.

Materials and methods

Class II furcation defects were surgically created in the mandibular first and second premolars bilaterally in eight beagle dogs. The Class II furcation defects were assigned randomly, using the split-mouth design, into the test and control sides. The teeth on the test sides were equally and randomly divided into the HA/ADMA group (n = 8) treated with 0.8% HA gel followed by ADMA, and the HA-only group (n = 8) treated with 0.8% HA only. The furcation defects of the control sides (n = 16) were subjected to open flap debridement (OFD group). The animals were euthanized for histologic and histomorphometric analyses after one month (n = 4) and three months (n = 4).

Results

At one month, the newly formed bone area (NFBA) was larger in the HA/ADMA (6.23 ± 1.41 mm2) and HA-only (5.90 ± 1.43 mm2) groups than in the OFD group (2.42 ± 1.62 mm2) (p < 0.05). The newly formed cementum (NFAC) and periodontal ligament (NFPL) were similar in the HA/ADMA and HA-only groups but significantly lesser in the OFD group (p < 0.05.) At three months, the NFBA, NFAC, and NFPL were greater in the HA/ADMA group than in the HA-only group (p < 0.05). New regenerative tissue was significantly greater in both the test groups than in the OFD group (p < 0.05), while epithelial downgrowth predominated the healing in the latter.

Conclusions

These results suggest that HA with ADMA positively affects the periodontal regeneration and wound healing in Class II furcation defects.

Adjunctive use of platelet-rich fibrin in surgical treatment of furcation defects: A systematic review

Periodontitis is an infectious disease characterized by the inflammatory destruction of the tooth supporting tissues. In multi-rooted teeth, this process leads to periodontal destruction within furcations creating defects demanding in terms of treatment. Regeneration of class II furcation involvement, although possible, is considered an unpredictable procedure, especially in terms of the bone fill. The interest in wound healing improvement by additional use of autologous concentrates of growth factors remains high in many fields of dentistry. Platelet-rich fibrin (PRF) is a second-generation platelet concentrate and biomaterial. PRF forms a solid fibrin matrix, which is slowly remodeled comparable to the natural blood clot. Its utilization is associated with release of growth factors and glycoproteins over a long period of time. PRF activates alkaline phosphates, which show osteoblastic activity and this activation influences the bone formation. The aim of this review of randomized controlled trials (RCTs) was to evaluate the adjunctive use of platelet-rich fibrin in surgical treatment of furcation defects.

Histologic and histomorphometric evaluation of Aloe vera adjunctive to β-tricalcium phosphate in class II furcation defects in dogs

Aloe vera has antimicrobial activity and enhances the osseointegration process, thus it may have the potential in treating periodontal defects. This study aimed to evaluate the effect of Aloe vera as an adjunction to Beta-tricalcium phosphate (β-TCP) bone graft in Grade II furcation defects. A randomized study was conducted on six healthy mongrel dogs' premolars. A total of twenty-four Grade II furcation critical-sized defects were surgically created after reflecting a full-thickness flap, twelve defects were filled with β-TCP while the other twelve defects were filled with Aloe vera mixed with β-TCP and both covered by collagen membrane. Animals were euthanized at the end of the fourth and eighth week and defects were analyzed histologically and histomorphometrically. Histologically, Aloe vera mixed with β-TCP resulted in more bone formation and new PDL fibers compared to β-TCP alone. After 2 and 4 weeks, the experimental group had significantly higher newly formed interradicular bone height (p < 0.0001, and p < 0.0001, respectively), bone thickness (p < 0.0001, and p < 0.0001, respectively), and percentage of the surface area (p = 0.009, and p = 0.023, respectively). Aloe vera gel adjunctive to β-TCP is an effective bioactive agent that enhances periodontal tissue regeneration and bone formation in critically sized defects.

The predictive performance of surgical treatment in upper molars with combined bony defect and furcation involvement: a retrospective cohort study

BACKGROUND

To evaluate the impact of combined defects, bony destruction and furcation involvement, on disease resolution after surgery in terms of pocket elimination, absence of inflammation, furcation improvement and predictive performance.

METHODS

Combined bony (intrabony (+) or (-)) and furcation defects (FI degree 1 or 2) at maxillary molars in patients diagnosed as periodontitis stage III to IV, being through periodontal surgery and at least 6 months follow-up were retrospectively screened. Cumulative predictability (CR, %), failure of treatment and the change of clinical parameters from baseline at pre-operative visit to the latest maintenance care, including pocket depth (PD), horizontal and vertical furcation involvement (FI) were analyzed. Failure of treatment with low predictability was defined as residual PD > 4 mm with bleeding on probing during maintenance period.

RESULTS

Thirty-three patients with fifty-one combined defects were included. Statistical analysis showed significant overall PD reduction and FI improvement (p < 0.001). Combined FI degree 2 with intrabony (+) defects revealed more horizontal furcation improvement compared with FI degree 2 with suprabony defect (p = 0.007). However, type of combined defects was not relevant to CR (p = 0.702) and PD reduction (p = 0.707). Among all parameters, baseline PD with proximal FI degree 2 was indicated to failure of treatment.

CONCLUSIONS

Different types of combined defects, deep baseline pocket and proximal FI degree 2 would compromise the predictability of treatment outcomes in upper molars. Nevertheless, the combination of surgical treatment and strict maintenance care could still yield high predictability and survival rate.

TRIAL REGISTRATION

retrospectively registered.

The added benefit of L-PRF to autogenous bone grafts in the treatment of degree II furcation involvement in mandibular molars

BACKGROUND

Tissue regeneration within the periodontally involved furcation area is one of the most challenging aspects of periodontal surgery. The aim of this study was to evaluate the additional benefit of leukocyte and platelet-rich fibrin (L-PRF) to autogenous bone grafts (ABGs) in the treatment of mandibular molar degree II furcation involvement, comparing the clinical outcomes with those from open flap debridement (OFD)+ABG and OFD alone treatments.

METHODS

Fifty-four patients, exhibiting one buccal or lingual mandibular molar furcation defect, were randomly assigned to three treatment groups: OFD+ABG+L-PRF(n = 18); OFD+ABG (n = 18); and OFD (n = 18). Clinical [probing pocket depth (PPD), horizontal clinical attachment level (HCAL), vertical clinical attachment level (VCAL), gingival recession (GR)] and radiographic [vertical bone level (VBL)] parameters were evaluated at baseline and 6 months after treatment. HCAL change was the primary outcome.

RESULTS

No significant differences within each group were reported for GR changes, but statistically significant improvements in HCAL, VCAL, PPD and VBL were observed in all groups, except for VBL in the OFD group. At 6 months, the mean HCAL gain was 2.29±0.18 mm in the OFD+ABG+L-PRF group, which was significantly greater than that in the OFD+ABG (1.61±0.18 mm) and OFD (0.86±0.18 mm) groups. Both OFD+ABG+L-PRF and OFD+ABG therapies produced a significantly greater clinical and radiographic improvement than OFD.

CONCLUSION

The addition of L-PRF to ABG produces a significantly greater HCAL gain and PPD reduction as compared to OFD+ABG treatment in mandibular degree II furcation involvements. This article is protected by copyright. All rights reserved.

Immunohistochemical Evaluation of Periodontal Regeneration Using a Porous Collagen Scaffold

(1) Aim: To immunohistochemically evaluate the effect of a volume-stable collagen scaffold (VCMX) on periodontal regeneration. (2) Methods: In eight beagle dogs, acute two-wall intrabony defects were treated with open flap debridement either with VCMX (test) or without (control). After 12 weeks, eight defects out of four animals were processed for paraffin histology and immunohistochemistry. (3) Results: All defects (four test + four control) revealed periodontal regeneration with cementum and bone formation. VCMX remnants were integrated in bone, periodontal ligament (PDL), and cementum. No differences in immunohistochemical labeling patterns were observed between test and control sites. New bone and cementum were labeled for bone sialoprotein, while the regenerated PDL was labeled for periostin and collagen type 1. Cytokeratin-positive epithelial cell rests of Malassez were detected in 50% of the defects. The regenerated PDL demonstrated a larger blood vessel area at the test (14.48% ± 3.52%) than at control sites (8.04% ± 1.85%, p = 0.0007). The number of blood vessels was higher in the regenerated PDL (test + control) compared to the pristine one (p = 0.012). The cell proliferative index was not statistically significantly different in pristine and regenerated PDL. (4) Conclusions: The data suggest a positive effect of VCMX on angiogenesis and an equally high cell turnover in the regenerated and pristine PDL. This VCMX supported periodontal regeneration in intrabony defects.

Comparative Evaluation of Efficacy between Recombinant Human Bone Morphogenetic Protein-2 Impregnated with Absorbable Sponge and Platelet-Rich Fibrin in the Treatment of Grade II Furcation Defects: A Randomized Controlled Trial

Aim and Objectives:

The objective of the study was to clinically and radiographically compare and evaluate the regenerative potential of recombinant human bone morphogenetic protein-2 (RhBMP-2) impregnated with absorbable collagen sponge and platelet-rich fibrin (PRF) in the treatment of Grade II furcation defects.

Patients and Methods:

Thirty-two subjects were randomly assigned to each of the following groups: bone morphogenetic protein (BMP) group and PRF group, with one defect/subject. Sixteen Grade II furcation defects were treated with RhBMP-2 impregnated with absorbable collagen sponge in the BMP group and the remaining 16 defects were treated with PRF in the PRF group. Clinical and radiographic parameters which were evaluated at baseline, postoperative 1 week, 3 months, and 6 months were probing pocket depth, clinical attachment level, scoring of plaque index, and gingival index, and the bone fill was evaluated using Digital Subtraction technique and morphometric area analysis with ImageJ^® software.

Results:

RhBMP-2 in absorbable collagen sponge was effective in increasing the bone fill in Grade II furcation defects when compared to PRF alone (P = 0.05). In relation to clinical parameters, both the groups showed no statistical significance between them.

Conclusion:

The unique regenerative potential of RhBMP-2 impregnated with absorbable collagen sponge makes it a potential agent to be used as a graft material for the treatment of Grade II furcation defects.

Clinico-radiographic comparative evaluation of 1% metformin gel plus platelet-rich fibrin over platelet-rich fibrin alone in treatment of Grade II furcation defects: A randomized controlled double-blind clinical trial

BACKGROUND

The present study was aimed to evaluate and compare the effects of 1% MF plus PRF over PRF alone in treatment of Grade II furcation defects, clinically and radiographically by using cone-beam computed tomography.

METHODS

This split-mouth clinical trial randomly allotted 21 patients with 42 bilateral Grade II furcation defects into two groups. Group I was treated with PRF alone while Group II with 1% MF gel and PRF. The primary outcome parameters were clinical attachment level (CAL) and horizontal probing depth (HPD) while the secondary outcome parameters were probing depth (PD) and defect volume (DV). The clinical parameters were evaluated at 3, 6, and 12 months and the radiographic parameters at 12 months.

RESULTS

Both the study groups yielded improvements in assessed parameters; however, significantly greater mean reduction of PD, HPD, and CAL gain was observed in Group II (3.90 ± 0.78 mm, 2.94 ± 0.80 mm, and 3.42 ± 0.93 mm) in comparison with Group I (3.23 ± 0.90 mm, 1.96 ± 0.80 mm, and 2.67 ± 0.88 mm) at 12 months, respectively. A significant reduction of DV was exhibited radiographically in Group II (12.61 ± 4.01 mm³ ) as compared with Group I (9.14 ± 4.31 mm³ ) at the end of 12 months.

CONCLUSIONS

Better clinical and radiographic findings in terms of reduction in PD, HPD, CAL gain, and significant reduction in DV in Group II patients indicated that the combination therapy of 1% MF + PRF promotes regenerative ability within the periodontal tissues in Grade II furcation defects to a greater extent.

Regenerative benefits of using growth factors in treatment of periodontal defects: A systematic review and meta-analysis with Trial Sequential Analysis on preclinical studies

The ultimate goal in periodontal treatments is to achieve a functional and anatomical regeneration of the lost tissues. Numerous studies have in some way illustrated the beneficial effects of biologic modifiers in this process, yet they are subject to a rather large degree of diversity in their results. Thanks to the promising outcomes of bioengineering techniques in the field of periodontal regeneration, this systematic review aims to evaluate the effect of various biologic modifiers used in periodontal defects of animal models. Electronic databases (Medline, Scopus, Embase, Web of Science, and Google Scholar) were searched (March 2010-December 2020) for every study that used biomolecules for regeneration of periodontal osseous defects in animal models. Regenerated bone height or area, new cementum, new connective tissues, new regenerated periodontal ligament and the dimensions of epithelial attachment (either in mm/mm² or percentage) were the investigated outcomes. The risk of bias of the included studies was assessed using the SYRCLE tool. In closing, there was a meta-analysis carried out on the outcomes of interest. Trial Sequential Analysis was also carried out to figure out the power of meta-analytic outcomes. From 1995 studies which were found in the initial search, 34 studies were included in this review, and 20 of them were selected for the meta-analysis. The eligible studies were categorized according to the morphology of the experimental periodontal defects as one-, two-, and three-wall intrabony defects; furcation defects, and recession-type defects. The most studied biomolecules were rhFGF-2, rhGDF-5, platelet-derived growth factor, bone morphogenetic protein-2, and enamel matrix derivative (EMD). Based on the meta-analysis findings, combined application of biomolecules with regenerative treatments could improve new bone and cementum formation near 1 mm when compared to the control groups in one, two and three-wall intrabony defect models (p < 0.001). In furcation grade II defect, the addition of biomolecules was observed to enhance bone area gain and cementum height regeneration up to almost 2 mm (p < 0.001). Trial Sequential Analysis results confirmed the significant effect in the aforementioned meta-analyses. In cases of the buccal recession model, the application of rhFGF-2 and rhGDF-5 decreased the dimension of epithelial attachments besides regenerative advantages on bone and cementum formation, but EMD deposition exerted no inhibitory effect on epithelial down-growth. Application of biologic modifiers especially FGF-2 and GDF-5, could positively improve the regeneration of periodontal tissues, particularly cementum and bone in animal models. Trial Sequential Analysis confirmed the results but the power of the evidences was high just in some subgroup meta-analyses, like bone and cementum regeneration in furcation grade II model and cementum regeneration in one-wall intrabony defects. The outcomes of this study can potentially endow clinicians with guidelines for the appropriate application of growth factors in periodontal regenerative therapies.

Multivariate outcome evaluation of furcation-involved molars treated with non-surgical mechanical therapy alone or combined with open flap debridement: A retrospective study

BACKGROUND

This retrospective study assessed the effect of non-surgical and surgical mechanical therapy for furcation-involved molars.

METHODS

Furcation defects treated and followed for at least 1 year were selected. Data relative to the clinical outcomes were recorded. The immediate (3- to 6-month) clinical outcomes and the long-term survival of the treated molars were assessed. The potential variables influencing the treatment outcomes through multi-level regression analysis, and Cox Proportional-Hazards Models were also analyzed.

RESULTS

One hundred and eighty-four molars were included with an average follow-up of 7.52 years. At the 3- to 6-month re-evaluation 1.39 ± 0.99 mm pocket depth reduction, 0.88 ± 1.29 mm clinical attachment gain, and a 0.51 ± 1.13 mm increase in recession was observed. The 5- and 10-year survival rates were 88.3% and 61.3%, respectively. The horizontal and vertical extent of furcation involvement, baseline probing depth, mucoperiosteal flap elevation, and the frequency of supportive periodontal therapy influenced the clinical outcomes and tooth survival.

CONCLUSION

Non-surgical and surgical mechanical root debridement is a viable treatment for the management of furcation involved molars with shallow horizontal and vertical components.

Clinical study of periodontal endoscope-assisted subgingival scaling in the treatment of residual pocket

OBJECTIVES

To compare the treatment effects of periodontal endoscope-assisted and traditional subgingival scaling on residual pockets.

METHODS

A total of 13 patients with periodontitis from Dept. of Periodontics, West China Hospital of Stomatology, Sichuan University were recruited. After 4-6 weeks of initial treatment, the residual pockets with a probing depth (PD) of ≥4 mm and attachment loss (AL) of ≥4 mm and bleeding on probing were examined with traditional (control group) and periodontal endoscope-assisted subgingival scaling (endoscopy group) in a randomly controlled split-mouth design. At baseline and 6 weeks and 3 months after treatment, plaque index (PLI), PD, AL, and bleeding index (BI) were measured. Differences in these clinical parameters within and between groups and patient-reported outcomes were compared.

RESULTS

A total of the 694 sites of 251 teeth were included in this trial. Both groups showed significant improvement in each periodontal parameters 6 weeks and 3 months after treatment (P<0.001). For sites in a single-rooted tooth, sites with PD≥5 mm, and sites without vertical alveolar bone resorption and furcation involvement, the PD in endoscopy group was significantly lower than that in the control group at 6 weeks and 3 months after treatment (P<0.05).

CONCLUSIONS

Periodontal endoscope-assisted subgingival scaling resulted in better effects than traditional subgingival scaling when the residual pockets were in a single-rooted tooth, with a PD of ≥5 mm but without vertical alveolar bone resorption and furcation involvement.

Guided Tissue Regeneration Treatment Yields Better Results in Class II Furcations in the Mandible Than in the Maxilla: A Retrospective Study

Absorbable porcine collagen membrane with a bovine bone graft can be considered for regenerative treatment in periodontal class II furcation defects. We evaluated the clinical efficacy of guided tissue regeneration (GTR) treatment with bovine bone xenograft and a porcine collagen membrane in molars with class II furcations. Probing depth (PD), clinical attachment level (CAL), and bone level (BL) were recorded at baseline and at 3, 6, and 9 months postoperatively. Thirty class II furcation defects from the lower and upper molars were assessed. Significant improvements in PD and CAL were observed from baseline to 9 months in all groups (p < 0.01). BL improved in all groups except group A in the upper molars in radiographic assessment (p < 0.05). The lower and upper molars showed PD reduction of 50.5% ± 7.44% and 46.2% ± 11.2%, respectively, at 9 months (p = 0.044). In furcations of 1–3 mm, the lower and upper molars showed PD reductions of 51.2% ± 4.49% and 36.5% ± 16.14%, respectively (p = 0.035). The lower and upper molars showed a CAL gain of 51.1% ± 4.64% and 33.6% ± 18.8%, respectively (p = 0.037). Thus, GTR with bovine bone graft and porcine collagen membrane yielded good results in class II furcations, with better results in the lower than in the upper molars.

Resective surgery for the treatment of furcation involvement: A systematic review

OBJECTIVE

To evaluate the benefit of resective surgical periodontal therapy (root amputation or resection, root separation, tunnelling) in periodontitis patients exhibiting class II and III furcation involvement (FI) compared with non-surgical treatment (SRP) or open flap debridement (OFD).

MATERIAL

Outcomes were tooth survival (primary), vertical probing attachment gain, and reduction in probing pocket depth (secondary) evidenced by randomized clinical trials, prospective and retrospective cohort studies and case series with ≥ 12 months of follow-up. Search was performed on 3 electronic databases from January 1998 to December 2018.

RESULTS

From a total of 683 articles, 66 studies were identified for full-text analysis and 7 studies finally included. Six hundred sixty-seven patients contributed 2,021 teeth with class II or III FI. Data were very heterogeneous regarding follow-up and distribution of FI. A total of 1,515 teeth survived 4 to 30.8 years after therapy. Survival ranged from 38%-94.4% (root amputation or resection, root separation), 62%-67% (tunnelling), 63%-85% (OFD) and 68%-80% (SRP). Overall, treatment provided better results for class II FI than class III.

CONCLUSION

Within their limits, the data indicate that in class II and III FI, SRP and OFD may result in similar survival rates as root amputation/resection, root separation or tunnelling.

A controlled study on the diagnostic accuracy of panoramic and peri-apical radiography for detecting furcation involvement

BACKGROUND

The aims of this study were (1) to determine the accuracy, sensitivity, and specificity of panoramic and peri-apical radiographs in diagnosing furcation involvement, as well as (2) to evaluate the possible impact of clinical experience on these diagnostic parameters.

METHODS

An existing radiographic dataset of periodontitis patients requiring implant surgery was retrospectively examined for furcation involvement. Criteria for inclusion were the presence of a CBCT, panoramic and peri-apical radiograph of the site of interest within a one-year time frame. All furcation sites were classified using the CBCT, which was considered as the gold standard, according to Hamp's index (1975). Ten experienced examiners and 10 trainees were asked to assess furcation involvement for the same defects using only the corresponding panoramic and peri-apical radiographs. Absolute agreement, Cohen's weighted kappa, sensitivity, specificity and ROC-curves were analyzed.

RESULTS

The study sample included 60 furcation sites in 29 multi-rooted teeth from 17 patients. On average, 20/60 furcations were correctly classified according to the panoramic radiographs, corresponding to a weighted kappa score of 0.209, indicating slight agreement. Similarly, an average of 19/60 furcations were correctly classified according to the peri-apical radiographs, corresponding to a weighted kappa score of 0.211, also indicating slight agreement. No significant difference between panoramic and peri-apical radiography was found (P = 0.903). When recategorizing FI Grades into 'no to limited FI' (FI Grade 0 and I) and 'advanced FI' (FI Grade II and III), the panoramic and peri-apical radiography showed low sensitivity (0.558 and 0.441, respectively), yet high specificity (0.791 and 0.790, respectively) for identifying advanced FI. The ROC-curves for the panoramic and peri-apical radiographs were 0.79 and 0.69 respectively. No significant difference was found between experienced periodontists and trainees (P = 0.257 versus P = 0.880).

CONCLUSION

Panoramic and peri-apical radiography are relevant tools in the diagnosis of FI and provide high specificity. Ideally, they are best used in combination with furcation probing, which shows high sensitivity. Furthermore, clinical experience does not seem to improve the accuracy of a radiological diagnosis of furcation sites.

TRIAL REGISTRATION

Patient radiographic datasets were retrospectively analyzed.

Regenerative surgical treatment of furcation defects: A systematic review and Bayesian network meta-analysis of randomized clinical trials

AIMS

To investigate the clinical performance of regenerative periodontal surgery in the treatment of furcation defects versus open flap debridement (OFD) and to compare different regenerative modalities.

MATERIAL AND METHODS

A systematic search was conducted to identify RCTs evaluating regenerative surgical treatment of furcations with a minimum of 12-month follow-up. Three authors independently reviewed, selected and extracted data from the search conducted and assessed risk of bias. Primary outcomes were tooth loss, furcation improvement (closure/conversion) (FImp), gain of horizontal bone level (HBL) and attachment level (HCAL). Secondary outcomes were gain in vertical attachment level (VCAL), probing pocket depth (PPD) reduction, PROMs and adverse events. Data were summarized into Bayesian standard and network meta-analysis in order to estimate direct and indirect treatment effects and to establish a ranking of treatments.

RESULTS

The search identified 19 articles, reporting on 20 RCTs (19 on class II, 1 on class III furcations) with a total of 575 patients/787 defects. Tooth loss was not reported. Furcation closure ranged between 0% and 60% (10 trials), and class I conversion from 29% to 100% (six trials). Regenerative techniques were superior to OFD for FImp (OR = 20.9; 90% CrI = 5.81, 69.41), HCAL gain (1.6 mm), VCAL gain (1.3 mm) and PPD reduction (1.3 mm). Bone replacement grafts (BRG) resulted in the highest probability (Pr = 61%) of being the best treatment for HBL gain. Non-resorbable membranes + BRG ranked as the best treatment for VCAL gain (Pr = 75%) and PPD reduction (Pr = 56%).

CONCLUSIONS

Regenerative surgery of class II furcations is superior to OFD. FImp (furcation closure or class I conversion) can be expected for the majority of defects. Treatment modalities involving BRG are associated with higher performance.

Pre-clinical evaluation of the effect of a volume-stable collagen matrix on periodontal regeneration in two-wall intrabony defects

AIM

To histologically evaluate the effect of a new collagen matrix on periodontal regeneration.

MATERIALS AND METHODS

Two-wall intrabony defects were surgically created bilaterally distally to the maxillary first and third pre-molars in beagle dogs. The defects were randomly allocated to open flap debridement either with (test) or without (control) a volume-stable collagen matrix (VCMX). After 12 weeks, the dogs were euthanized, and the specimens histologically processed. Descriptive, histomorphometrical (vertical gain of periodontal tissues) and statistical analyses were then performed.

RESULTS

Healing was uneventful in most cases. Residual VCMX was still present and showed integration into new bone, new periodontal ligament, connective tissue and, in some specimens, into new cementum. Periodontal regeneration occurred to a varying extent in both groups. New continuous cementum and new bone formation were statistically significantly greater in the test group (4.12 mm and 3.28 mm, respectively) than in the control group (1.54 mm and 2.47 mm, respectively) (p = .009 and p = .037, respectively). The junctional epithelium was longer in the control group (2.21 mm) than in the test group (1.49 mm, p = .16).

CONCLUSION

The present results have for the first time provided histologic evidence for the potential of this novel VCMX to facilitate periodontal regeneration thus warranting further pre-clinical and clinical testing.

Effect of endodontic treatment on periodontal healing of grade 3 endo-periodontal lesions without root damage in periodontally compromised patients-a retrospective pilot study

OBJECTIVES

There is little evidence about the effect of different treatment protocols for grade 3 endo-periodontal lesions without root damage in patients with periodontitis according to the new classification of periodontal disease. The aim of this study is to evaluate the impact of endodontic treatment on the achievement of periodontal healing.

MATERIALS AND METHODS

Teeth with the initial diagnosis endo-periodontal lesion without root damage grade 3, treated with a standardized endodontic treatment protocol, were included in this study. A retrospective analysis was performed to assess the impact on periodontal healing by evaluating probing pocket depth (PPD), clinical attachment gain (CAL), and periapical index score (PAI).

RESULTS

Nineteen teeth and 13 patients were included. A mean reduction of 3.19 ± 3.41 mm in PPD was recorded. The mean CAL gain was 2.33± 3.75 mm. Five teeth (45.4%) showed an improvement of PAI and were classified as treatment success.

CONCLUSIONS

The results failed to show a highly predictable treatment outcome for endo-periodontal lesion grade 3 without root damage in patients with periodontitis. However, endodontic therapy alone resulted in treatment success for some of the teeth, which would otherwise have had a poor prognosis.

CLINICAL RELEVANCE

Endo-periodontal lesions can often be challenging for dentists in daily clinical practice. To date, there is not much evidence for practitioners to rely on. Therefore, this study aims to strengthen the evidence for the management and treatment of endo-periodontal lesions. Although the outcome is not highly predictable yet, teeth with the initial diagnosis endo-periodontal lesion without root damage grade 3 can benefit from an endodontic treatment.

Treatment of mandibular grade III furcation involvement using platelet-rich fibrin and allogenic graft with 12-month follow-up - A case report

Introduction

Furcation involvement (FI) in multi-rooted teeth is challenging for proper oral hygiene, clinical treatment, and leads to poor prognosis. Traditional treatment modalities often result in sacrificing periodontal bone. Multiple regenerative approaches have been attempted to treat furcation defects, but complete regeneration of the periodontal apparatus in grade III furcation has not been reported. Platelet rich fibrin (PRF) shows great potential in enhancing tissue regeneration, angiogenesis, and prevention of infection. This case report introduces a treatment combining allogenic bone grafts with PRF to treat mandibular grade III furcation lesions with a one-year follow-up.

Case presentation

Two patients presented with grade III FIs of the mandibular first molars, with intrabony defects requiring guided tooth regeneration (GTR). PRF was collected from each patient to serve as biologics, by mixing with allogenic bone graft, and packed into the furcation and intrabony defects. The PRF membranes were also used for space maintenance. The twelve-month postoperative follow-up demonstrated quicker tissue healing, significant pocket reduction, clinical attachment gain, as well as radiographic bone fill in both cases.

Conclusion

Successful periodontal regeneration of grade III furcation defects can be achieved by using PRF in combination with bone allograft.

A novel approach in the management of mandibular degree II furcation defects using bone grafts in conjunction with a biomimetic agent: A randomized controlled clinical trial

Aim

Of the periodontal defects requiring regeneration, degree II furcation defects pose a substantial challenge to clinicians. This study was designed to evaluate the relative effectiveness of bone autograft (BA) and autologous platelet-rich fibrin (PRF) as against decalcified freeze-dried bone allograft (DFDBA) along with autologous PRF in the management of degree II mandibular furcation defects.

Materials and Methods

Fourteen patients (11 men and 3 women; mean age: 42.36 years), with bilateral degree II buccal furcation defects in the mandibular molars, were enrolled in the study. In each patient, randomly selected sites were divided into control site (site A) which received BA with PRF membrane and test site (site B) received DFDBA + PRF mixed with graft and also as a membrane using split-mouth design. Clinical parameters including plaque index, gingival index, gingival marginal levels, probing depth, and clinical attachment level were recorded at baseline and at 3 and 6 months' postsurgery. Horizontal and vertical furcation measurements were taken prior to the surgery through sounding and after degranulation. These measurements were repeated after 6 months.

Results

The mean reduction in the horizontal defect depth was 1.86 ± 0.66 mm (70.75%) in site A and 1.71 ± 0.73 mm (74.25%) in site B. The mean improvement in the vertical defect fill was 1.64 ± 0.74 mm (55.8%) in site A and 1.43 ± 1.34 mm (64.86%) in site B was achieved.

Conclusion

The use of combination therapy using either BA or DFDBA in conjunction with PRF appears to be effective in treating furcations.

Treatment of Grade III furcation involvement in upper molars: Case Series with 2-16-year follow-up

Frequently, the clinicians are addressed to decide between the preservation of Grade III furcation molar and the implant replacement, due to the increased access among the population to this therapy over the years and high success rate of the osseointegrated implants. This case series presents clinical and radiographic data collected from 10 patients who underwent 13 root amputations for the treatment of degree Grade III furcation in maxillary molars with follow-up until 16 years. The results showed improvements in probing depth, bleeding on probing, and radiographic aspects. The follow-up time indicates that root amputation is an effective long-term treatment solution, especially when the patient's local, systemic, or financial conditions make it difficult or impossible to implant placement.

Vital root resection in severely furcation-involved maxillary molars: Outcomes after up to 7 years

AIMS

To introduce a novel therapeutic approach for the treatment of furcation-involved maxillary molars by vital root resection and report longer-term outcomes of a case series.

METHODS

Eleven patients with 15 maxillary molars affected by double/triple class II (n = 10) or single/double class III (n = 5) furcation defects and advanced vertical bone loss around one root participated. Teeth were treated with deep pulpotomy using a calcium silicate-based cement. After 4 weeks, the affected roots were removed by periodontal microsurgery and processed for histological evaluation of the pulp. All patients were enrolled into a supportive periodontal care programme. During the follow-up period, assessments of tooth sensitivity, response to percussion, mobility, pocket probing depth (PPD) and bleeding on probing (BOP) were made, periapical radiographs obtained and patient-reported outcomes collected.

RESULTS

All teeth remained sensitive to pulp testing. After 1 year and 3-7 years of follow-up, PD was ≤5 mm at all resected teeth. Furcation status was much improved. Neither increasing mobility nor clinical or radiographic signs of periapical pathology were observed throughout the individual observation period. All patients were pleased with the result of therapy. Histologic sections revealed a functional dentin-pulp complex.

CONCLUSIONS

This case series demonstrates the possibility of maintaining severely furcation-involved molars by vital root resection for up to 7 years. Root canal therapy and its associated costs and complications can thus be avoided.

Factors affecting decision making at reassessment of periodontitis. Part 4: treatment options for residual periodontal pockets

This paper is the final in a four-part series outlining treatment planning at periodontal reassessment. The first article (part 1) focused on the information that should be gathered at the reassessment appointment. Parts 2 and 3 discussed systemic and local factors that can relate to residual periodontal probing depths. Treatment can involve a range of non-surgical and surgical approaches. A variety of general, practical and local site factors can affect the choice of one option over another in choosing the most predictable treatment option. Decision-making can be challenging and this paper aims to aid this process by discussing the assessment of prognosis, factors that need to be considered in decision-making and treatment options available. A flow chart to summarise this process is presented.

Management of Furcal Perforation with Advanced Furcation Defect by a Minimally Invasive Tunnel Technique

A perforation in the furcation area is a potential risk factor for extension of pulpal inflammation into the periodontium and formation of advanced furcation defect with severe loss of clinical attachment and interradicular bone. Furthermore, the management of such furcal perforation is difficult due to poor accessibility, visibility, and regenerative potential. The development of such advanced furcation defects further compromises the prognosis of the treatment as they preclude effective plaque control and maintenance by the patient. Therefore, the management of advanced furcation defects remains an enigmatic and challenging task for the clinician. This case report describes a minimally invasive approach for the treatment of a furcal perforation by a conservative tunnel preparation. The present case report aims to highlight the importance of surgical tunnel preparation as an alternative to conventional flap procedure to repair furcal perforation with advanced furcation defects.

Histologic evidence of periodontal regeneration in furcation defects: a systematic review

OBJECTIVE

To systematically review the available histologic evidence on periodontal regeneration in class II and III furcations in animals and humans.

MATERIALS AND METHODS

A protocol including all aspects of a systematic review methodology was developed including definition of the focused question, defined search strategy, study inclusion criteria, determination of outcome measures, screening methods, data extraction and analysis, and data synthesis. The focused question was defined as follows: "What is the regenerative effect obtained by using or not several biomaterials as adjuncts to open flap surgery in the treatment of periodontal furcation defects as evaluated in animal and human histological studies?"

SEARCH STRATEGY

Using the MEDLINE database, the literature was searched for articles published up to and including September 2018: combinations of several search terms were applied to identify appropriate studies. Reference lists of review articles and of the included articles in the present review were screened. A hand search of the most important dental journals was also performed.

CRITERIA FOR STUDY SELECTION AND INCLUSION

Only articles published in English describing animal and human histological studies evaluating the effect of surgical treatment, with or without the adjunctive use of potentially regenerative materials (i.e., barrier membranes, grafting materials, growth factors/proteins, and combinations thereof) for the treatment of periodontal furcation defects were considered. Only studies reporting a minimum of 8 weeks healing following reconstructive surgery were included. The primary outcome variable was formation of periodontal supporting tissues [e.g., periodontal ligament, root cementum, and alveolar bone, given as linear measurements (in mm) or as a percentage of the instrumented root length (%)] following surgical treatment with or without regenerative materials, as determined histologically/histomorphometrically. Healing type and defect resolution (i.e., complete regeneration, long junctional epithelium, connective tissue attachment, connective tissue adhesion, or osseous repair) were also recorded.

RESULTS

In animals, periodontal regeneration was reported in class II and III defects with open flap debridement alone or combined with various types of bone grafts/bone substitues, biological factors, guided tissue regeneration, and different combinations thereof. The use of biological factors and combination approaches provided the best outcomes for class II defects whereas in class III defects, the combination approaches seem to offer the highest regenerative outcomes. In human class II furcations, the best outcomes were obtained with DFDBA combined with rhPDGF-BB and with GTR. In class III furcations, evidence from two case reports indicated very limited to no periodontal regeneration.

CONCLUSIONS

Within their limits, the present results suggest that (a) in animals, complete periodontal regeneration has been demonstrated in class II and class III furcation defects, and (b) in humans, the evidence for substantial periodontal regeneration is limited to class II furcations.

CLINICAL RELEVANCE

At present, regenerative periodontal surgery represents a valuable treatment option only for human class II furcation defects but not for class III furcations.

Periodontitis: facts, fallacies and the future

This volume of Periodontology 2000 represents the 25th anniversary of the Journal, and uses the occasion to assess important advancements in periodontology over the past quarter-century as well as the hurdles that remain. Periodontitis is defined by pathologic loss of the periodontal ligament and alveolar bone. The disease involves complex dynamic interactions among active herpesviruses, specific bacterial pathogens and destructive immune responses. Periodontal diagnostics is currently based on clinical rather than etiologic criteria, and provides limited therapeutic guidance. Periodontal causative treatment consists of scaling, antiseptic rinses and occasionally systemic antibiotics, and surgical intervention has been de-emphasized, except perhaps for the most advanced types of periodontitis. Plastic surgical therapy includes soft-tissue grafting to cover exposed root surfaces and bone grafting to provide support for implants. Dental implants are used to replace severely diseased or missing teeth, but implant overuse is of concern. The utility of laser treatment for periodontitis remains unresolved. Host modulation and risk-factor modification therapies may benefit select patient groups. Patient self-care is a critical part of periodontal health care, and twice-weekly oral rinsing with 0.10-0.25% sodium hypochlorite constitutes a valuable adjunct to conventional anti-plaque and anti-gingivitis treatments. A link between periodontal herpesviruses and systemic diseases is a strong biological plausibility. In summary, research during the past 25 years has significantly changed our concepts of periodontitis pathobiology and has produced more-effective and less-costly therapeutic options.

Twenty years of enamel matrix derivative: the past, the present and the future

BACGROUND

On June 5th, 2015 at Europerio 8, a group of leading experts were gathered to discuss what has now been 20 years of documented evidence supporting the clinical use of enamel matrix derivative (EMD). Original experiments led by Lars Hammarström demonstrated that enamel matrix proteins could serve as key regenerative proteins capable of promoting periodontal regeneration including new cementum, with functionally oriented inserting new periodontal ligament fibres, and new alveolar bone formation. This pioneering work and vision by Lars Hammarström has paved the way to an enormous amount of publications related to its biological basis and clinical use. Twenty years later, it is clear that all these studies have greatly contributed to our understanding of how biologics can act as mediators for periodontal regeneration and have provided additional clinical means to support tissue regeneration of the periodontium.

AIMS

This review article aims to: (1) provide the biological background necessary to understand the rational for the use of EMD for periodontal regeneration, (2) present animal and human histological evidence of periodontal regeneration following EMD application, (3) provide clinically relevant indications for the use of EMD and (4) discuss future avenues of research including key early findings leading to the development of Osteogain, a new carrier system for EMD specifically developed with better protein adsorption to bone grafting materials.

Mandibular Class II Furcation Defect Treatment: Effects of the Addition of Platelet Concentrates to Open Flap: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

BACKGROUND

To improve the efficacy and outcomes of regenerative therapy for furcation defects, the use of platelet concentrates (PCs) in addition to open flap debridement (OFD) has been investigated. The aim of this systematic review is to evaluate whether mandibular Class II furcation defects treated with the addition of PC to OFD heal with a significant improvement in the following: 1) horizontal clinical attachment level (HCAL); 2) vertical clinical attachment level (VCAL); 3) probing depth (PD); and 4) level of gingival margin (LGM).

METHODS

Electronic databases (MEDLINE, EBSCO Library, Cochrane Database of Systematic Reviews, and SCOPUS) were searched for randomized clinical trials to address the use of PCs in combination with OFD compared with a control group without PCs for the treatment of mandibular Class II furcation defects in humans and to provide data on the above reported outcome measures. The results of selected studies were converted to mean difference and standard error and interpolated using the inverse of variance test. Heterogeneity was investigated using both the Higgins index and the Q test.

RESULTS

Of 254 articles screened, only 11 were read in full text, and three of these were included in the meta-analysis. The addition of PCs to OFD revealed a small improvement in the following: 1) HCAL (mean difference, 1.36 mm; 95% confidence interval [CI] = 1.07 to 1.65); 2) VCAL (mean difference, 1.54 mm; 95% CI = 1.23 to 1.85); and 3) PD (mean difference, 1.83 mm; 95% CI = 1.36 to 2.29). No differences were found for the LGM. Heterogeneity across the studies was high, and all the three included studies were performed in one country.

CONCLUSIONS

Adding PCs to OFD for the treatment of mandibular Class II furcation defects may lead to slight improvements in clinical parameters. Nonetheless, because of the high heterogeneity of the very small number of reported studies and the small effect size, no definitive conclusion can be achieved about the clinical application of such a treatment option.

Wound models for periodontal and bone regeneration: the role of biologic research

The ultimate goals of periodontal therapy remain the complete regeneration of those periodontal tissues lost to the destructive inflammatory-immune response, or to trauma, with tissues that possess the same structure and function, and the re-establishment of a sustainable health-promoting biofilm from one characterized by dysbiosis. This volume of Periodontology 2000 discusses the multiple facets of a transition from therapeutic empiricism during the late 1960s, toward regenerative therapies, which is founded on a clearer understanding of the biophysiology of normal structure and function. This introductory article provides an overview on the requirements of appropriate in vitro laboratory models (e.g. cell culture), of preclinical (i.e. animal) models and of human studies for periodontal wound and bone repair. Laboratory studies may provide valuable fundamental insights into basic mechanisms involved in wound repair and regeneration but also suffer from a unidimensional and simplistic approach that does not account for the complexities of the in vivo situation, in which multiple cell types and interactions all contribute to definitive outcomes. Therefore, such laboratory studies require validatory research, employing preclinical models specifically designed to demonstrate proof-of-concept efficacy, preliminary safety and adaptation to human disease scenarios. Small animal models provide the most economic and logistically feasible preliminary approaches but the outcomes do not necessarily translate to larger animal or human models. The advantages and limitations of all periodontal-regeneration models need to be carefully considered when planning investigations to ensure that the optimal design is adopted to answer the specific research question posed. Future challenges lie in the areas of stem cell research, scaffold designs, cell delivery and choice of growth factors, along with research to ensure appropriate gingival coverage in order to prevent gingival recession during the healing phase.