Minimally Invasive Surgery Combined with Regenerative Biomaterials in Treating Intra-Bony Defects: A Meta-Analysis

Current status of Er:YAG laser in periodontal surgery

Lasers have numerous advantageous tissue interactions such as ablation or vaporization, hemostasis, bacterial killing, as well as biological effects, which induce various beneficial therapeutic effects and biological responses in the tissues. Thus, lasers are considered an effective and suitable device for treating a variety of inflammatory and infectious conditions of periodontal disease. Among various laser systems, the Er:YAG laser, which can be effectively and safely used in both soft and hard tissues with minimal thermal side effects, has been attracting much attention in periodontal therapy. This laser can effectively and precisely debride the diseased root surface including calculus removal, ablate diseased connective tissues within the bone defects, and stimulate the irradiated surrounding periodontal tissues during surgery, resulting in favorable wound healing as well as regeneration of periodontal tissues. The safe and effective performance of Er:YAG laser-assisted periodontal surgery has been reported with comparable and occasionally superior clinical outcomes compared to conventional surgery. This article explains the characteristics of the Er:YAG laser and introduces its applications in periodontal surgery including conventional flap surgery, regenerative surgery, and flapless surgery, based on scientific evidence from currently available basic and clinical studies as well as cases reports.

Minimally invasive non-surgical periodontal therapy of intrabony defects: A prospective multi-centre cohort study

AIM

To assess the potential benefits of minimally invasive non-surgical therapy (MINST) in teeth with intrabony defects and to explore factors associated with the outcomes.

MATERIALS AND METHODS

A multi-centre trial was conducted in 100 intrabony defects in periodontitis patients in private practice. Steps 1 and 2 periodontal therapy including MINST were provided. Clinical and radiographic data were analysed at baseline and 12 months after treatment, with the primary aim being change in radiographic defect depth at 12 months.

RESULTS

Eighty-four patients completed the 12-month follow up. The mean total radiographic defect depth reduced by 1.42 mm and the defect angle increased by 3° (both p < .05). Statistically significant improvements in probing pocket depth (PPD) and clinical attachment level (CAL) were seen at 12 months compared to baseline (p < .001). Fifty-six defects (66.7%) achieved pocket closure (PPD ≤ 4 mm) and 49 defects (58.3%) achieved the composite outcome (PPD ≤ 4 mm and CAL gain ≥3 mm). Deeper and narrower angled defects were positively correlated with radiographic and clinical improvements, respectively.

CONCLUSIONS

Improvements in clinical and radiographic outcomes were seen after MINST. This study highlights the generalizability and wide applicability of this approach, further supporting its effectiveness in the treatment of intrabony defects.

CLINICAL TRIAL REGISTRATION

NCT03741374. https://clinicaltrials.gov/study/NCT03741374?cond=minimally%20invasive%20non%20surgical%20therapy&locStr=UK&country=United%20Kingdom&distance=50&rank=2.

A Systematic Review of Randomized Clinical Trials Evaluating the Efficacy of Minimally Invasive Surgery for Soft Tissue Management: Aesthetics, Postoperative Morbidity, and Clinical Results

Background and Objectives: The necessity for less invasive and patient-friendly surgical therapies guided the development of the "minimally invasive surgical technique" (MIST). The aim of this systematic review was to evaluate the efficacy of MIST for soft tissue management considering aesthetic results, postoperative morbidity, and clinical outcomes. Materials and Methods: Several databases were used to conduct a thorough analysis of the scientific evidence. To investigate randomized clinical trials (RCTs), MeSH terms and keywords were provided. Results: Eleven RCTs were chosen. These experiments included 273 patients. The trials that explored MIST for papilla preservation presented greater efficacy in increasing papillary height (p < 0.05). MIST showed stable clinical outcomes for the management of excessive gingival display and with a flapless technique for single implant placement. Considering the treatment of gingival recessions, some RCTs presented greater root coverage with MIST (p < 0.05), while other trials did not show differences between groups. Regarding aesthetic perception, five RCTs indicated high patient satisfaction with MIST (p < 0.05). Similarly, six RCTs reported that patients in the MIST group presented significantly less post-surgical pain and lower wound healing scores (p < 0.01). Conclusions: It was concluded that using MIST resulted in more clinical studies reporting better clinical outcomes. Considering aesthetic appearance, slightly more than half of the clinical trials also showed improved results with MIST. Likewise, regarding postoperative morbidity, 60% of the clinical trials also described better scores with MIST. All of this indicates that MIST is a good alternative for the management of soft tissues.

Enamel Matrix Derivatives for Periodontal Regeneration: Recent Developments and Future Perspectives

In the era of the growing population, the demand for dental care is increasing at a fast pace for both older and younger people. One of the dental diseases that has attracted significant research is periodontitis. Periodontal therapy aims to regenerate tissues that are injured by periodontal disease. During recent decades, various pioneering strategies and products have been introduced for restoring or regeneration of periodontal deficiencies. One of these involves the regeneration of tissues under guidance using enamel matrix derivatives (EMDs) or combinations of these. EMDs are mainly comprised of amelogenins, which is one of the most common biological agents used in periodontics. Multiple studies have been reported regarding the role of EMD in periodontal tissue regeneration; however, the extensive mechanism remains elusive. The EMDs could promote periodontal regeneration mainly through inducing periodontal attachment during tooth formation. EMD mimics biological processes that occur during periodontal tissue growth. During root development, enamel matrix proteins are formed on the root surface by Hertwig's epithelial root sheath cells, initiating the process of cementogenesis. This article reviews the challenges and recent advances in preclinical and clinical applications of EMDs in periodontal regeneration. Moreover, we discuss the current evidence on the mechanisms of action of EMDs in the regeneration of periodontal tissues.

The ever-changing landscape in modern dentistry therapeutics - Enhancing the emptying quiver of the periodontist

Introduction/Objectives

Periodontitis comprises of a wide range of inflammatory conditions of the gums leading to soft tissue damage and attachment loss. The initiation of periodontitis constitutes a rather complex disease pathogenesis which is based on pathogenic shifts of the oral microbiota combined with the host-microbiome interactions. The severity of the periodontitis is multifactorial depending on genetic, environmental, as well as host immunity factors.

Data and sources

To make an inclusive analysis on the periodontitis therapeutics, reading of the recent relevant literature was carried out using the MEDLINE/PubMed database, Google Scholar and the NIH public online database for clinical trials (http://www.clinicaltrials.gov).

Conclusions

Tackling the inflammation associated periodontal defects can be succeeded with conventional therapy or resective and regenerative treatment. To date, the mechanical removal of the supragingival and subgingival biofilm is considered the “gold standard” of periodontal therapy in combination with the use of antibacterial compounds. The antimicrobial resistance phenomenon tends to turn all the currently applied antibacterials into “endangered species”. Ongoing efforts through the conduct of clinical trials should be focused on understanding the advantages of modern approaches in comparison to traditional therapies.

Minimally Invasive Periodontology: A Treatment Philosophy and Suggested Approach

Severe periodontitis is a highly prevalent dental disease. With the advent of implant dentistry, teeth are often extracted and replaced. Periodontal surgery, where indicated, could also result in increased trauma to the patient. This literature review discusses different treatment modalities for periodontitis and proposes a treatment approach emphasizing maximum preservation of teeth while minimizing morbidity to the patient. Scientific articles were retrieved from the MEDLINE/PubMed database up to January 2021 to identify appropriate articles that addressed the objectives of this review. This was supplemented with hand searching using reference lists from relevant articles. As tooth prognostication does not have a high predictive value, a more conservative approach in extracting teeth should be abided by. This may involve repeated rounds of nonsurgical periodontal therapy, and adjuncts such as locally delivered statin gels and subantimicrobial-dose doxycycline appear to be effective. Periodontal surgery should not be carried out at an early phase in therapy as improvements in nonsurgical therapy may be observed up to 12 months from initial treatment. Periodontal surgery, where indicated, should also be minimally invasive, with periodontal regeneration being shown to be effective over 20 years of follow-up. Biomarkers provide an opportunity for early detection of disease activity and personalised treatment. Quality of life is proposed as an alternative end point to the traditional biomedical paradigm focused on the disease state and clinical outcomes. In summary, minimally invasive therapy aims to preserve health and function of the natural dentition, thus improving the quality of life for patients with periodontitis.

Pocket resolution in regenerative treatment of intrabony defects with papilla preservation techniques: A systematic review and meta-analysis of randomized clinical trials

AIM

To systematically assess the clinical performance of different approaches for periodontal regeneration of intrabony defects in terms of pocket resolution compared to access surgery with papilla preservation techniques (PPTs).

MATERIAL AND METHODS

Systematic literature searches were conducted on PubMed, EMBASE, and CENTRAL up to April 2020 to identify RCTs on regenerative treatment [guided tissue regeneration (GTR) or enamel matrix derivative (EMD) with or without biomaterials] of intrabony defects using PPTs. Results were expressed as weighted mean percentages (WMP) or risk ratios of pocket resolution at 12 months (considering both final PD ≤ 3 mm and ≤4 mm).

RESULTS

A total of 12 RCTs were included. Based on a final PD ≤ 3 mm or PD ≤ 4 mm, the WMP of pocket resolution was 61.4% and 92.1%, respectively. EMD and GTR obtained comparable results. Pairwise meta-analysis identified a greater probability of achieving pocket resolution for GTR compared to PPTs. The number needed to treat for GTR to obtain one extra intrabony defect achieving PD ≤ 3 mm or PD ≤ 4 mm over PPTs was 2 and 4, respectively.

CONCLUSION

Regenerative surgery represents a viable approach to obtain final PD ≤ 4 mm in the short-term.

Guest Editorial: Time to reflect on new evidence about periodontal regenerative surgery of intrabony defects

This editorial provides a summary of new evidence derived from four recent systematic reviews on regenerative/reconstructive periodontal surgery recently published in the Journal of Clinical Periodontology. We hereby discuss how the results of these papers combined can be useful for the clinical periodontist, in the light of the recent European Federation of Periodontology (EFP) guidelines, and for researcher involved in this field of investigation.

Modified minimally invasive surgical technique plus Bio-Oss Collagen for regenerative therapy of isolated interdental intrabony defects: study protocol for a randomised controlled trial

INTRODUCTION

Periodontal regeneration surgery has been widely used to deal with intrabony defects. Modified minimally invasive surgical technique (M-MIST) is designed to deal with isolated interdental intrabony defects, and has achieved satisfactory periodontal regenerative effect. Bio-Oss Collagen, as a bioactive material, has been applied for periodontal regeneration. It is similar to human cancellous bone, with the ability to promote bone formation; furthermore, it has exceptional plasticity and spatial stability. The combination of different materials and techniques has become a research hotspot in recent years. By combining the superiority of regeneration technology and materials, better regenerative effect can be achieved. This study will search for differences between M-MIST combined with Bio-Oss Collagen, and M-MIST alone in regeneration therapy for intrabony defects.

METHODS AND ANALYSIS

The present research is designed as a two-group parallel randomised controlled trial. The total number of patients is 40. The patients will be randomly assigned to two groups, with 20 participants in each group, for further periodontal regenerative surgery. Test group: M-MIST plus Bio-Oss Collagen.

CONTROL GROUP

M-MIST. After 12 months, the measurement indices will be recorded; these will include clinical attachment gain and radiographical intrabony defect depth change as the primary results, and secondary outcomes of full-mouth plaque scores, probing depth, full-mouth bleeding scores, gingival recession, mobility, gingival papilla height and Visual Analogue Scale. The paired samples t-test will be applied to detect any difference between baseline and 1-year registrations. A general linear model will be performed to study the relationship between the secondary and the primary outcome.

ETHICS AND DISSEMINATION

The present research has received approval from the Ethics Committee of Peking University School and Hospital of Stomatology (PKUSSIRB-202053002). Data of the present research will be registered with the International Clinical Trials Registry Platform. Additionally, we will disseminate the results through scientific dental journals.

TRIAL REGISTRATION NUMBER

ChiCTR-2000030851.

PROTOCOL VERSION

Protocol Version 4, 14 July 2020.

Periodontal regenerative therapy in patients with type 2 diabetes using minimally invasive surgical technique with enamel matrix derivative under 3-year observation: A prospective cohort study

BACKGROUND

Information regarding periodontal regenerative therapy in patients with diabetes mellitus (DM) is limited. This pilot study compared the regenerative outcomes of minimally invasive periodontal surgery using enamel matrix derivative (EMD) between DM and non-DM patients.

METHODS

This prospective study included deep intrabony defects in patients with or without type 2 DM. Minimally invasive surgical technique (MIST) or modified MIST (M-MIST) using EMD, without bone graft materials, was performed. Periodontal examination and intraoral radiography were performed at baseline, 6 months, and 1 and 3 years after surgery.

RESULTS

Ten sites of 10 subjects in the DM group, and 20 sites of 18 subjects in non-DM group were evaluated (mean age; 67.5 ± 7.6 and 63.1 ± 9.7, respectively). Probing depth significantly decreased from 7.1 ± 1.6 and 7.0 ± 1.3 mm to 2.2 ± 0.9 and 2.3 ± 1.1 mm at the 1-year examination in the DM and non-DM groups, respectively. Clinical attachment level (CAL) gain and radiographical defect fill at the 3-year examination were 3.8 ± 1.1 mm and 58.3% ± 10.4%, respectively, in the DM group, and 4.1 ± 1.1 mm and 65.5% ± 18.8%, respectively, in the non-DM group, showing no significant differences between the groups. Multiple regression analysis showed no significant association of CAL gain with DM or age after adjustments for relevant confounders.

CONCLUSIONS

This is the first documented study of successful periodontal tissue regeneration in patients with DM. Minimally invasive surgery combined with EMD yielded significant clinical attachment gain and bone fill in the DM and non-DM groups at comparable levels.

Periodontal infrabony defects: Systematic review of healing by defect morphology following regenerative surgery

BACKGROUND

It is thought that infrabony defect morphology affects the outcome of periodontal regenerative surgery. However, this has not been systematically investigated.

AIMS

To investigate how well defect morphology is described in papers reporting regenerative therapy of periodontal infrabony defects and to investigate its effect on clinical and radiographic outcomes.

MATERIALS AND METHODS

A search was conducted in 3 electronic databases for publications reporting clinical and radiographic outcomes of periodontal intra-bony defects after regenerative therapy, divided by defect morphology.

RESULTS

The initial search resulted in 4487 papers, reduced to 143 after first and second screening. Fifteen of these publications were suitable for a fixed-effects meta-analysis. Initial defect depth was found to influence radiographic bone gain 12 months post-surgery, while narrower angles and increased number of walls influenced both radiographic bone gain and clinical attachment level (CAL) gain at 12 months. These associations seemed to occur irrespective of biomaterials used. Risk of bias ranged from low to high.

CONCLUSION

Deeper defects with narrower angles and increased number of walls exhibit improved CAL and radiographic bone gain at 12 months post-regenerative surgery. More data are needed about other aspects of defect morphology such as extension to buccal/lingual surfaces.

Minimally invasive periodontal therapy

Historically, surgical techniques were governed by specific incisions and surgical designs. With the advent of anesthesia, the complicated cases were managed but at the cost of the tissues leading to morbidities of various degrees. The innovations and the advances in the surgical techniques led to the ideology that surgeries could be done with minimal tissue manipulation and sacrifice. Thus the concept of "minimally invasive dentistry" was introduced with the primary goal to achieve satisfactory therapeutic results with minimal trauma during the process. In context to the management of periodontitis, this modality includes use of conservative incisions which preserves as much soft tissue as possible, avoiding continuous incisions and vertical incisions, use of magnification etc. The ultimate goal of any treatment modality is the resolution of the disease and regeneration if possible with minimal postoperative pain and morbidity. Minimal invasive periodontal therapy involves treatment options which cure the disease with reduced postoperative pain, improved healing and better patient acceptance. This paper covers the advent of minimal invasive periodontal therapy modalities both surgical and non-surgical along with the literature review.