Present status of osseous grafting procedures

The effect of autogenous tooth bone graft material without organic matter and type I collagen treatment on bone regeneration

Objectives

The aim of this study is to examine the effect of particulate autogenous tooth graft removed with organic matter and type I collagen addition on bone regeneration and to validate the possibility of useful allograft material for jaw defects.

Material and methods

Autogenous tooth bone maker (Korean Dental Solution® KOREA) made particulate autogenous tooth not including organic matter. We used to the developed tooth grafts for experiment. Cell adhesion test with hemacytometer and energy dispersive X-ray spectroscopy (Supra40 VP®, Carl Zeiss, Germany) analysis about the particulate autogenous tooth and type I collagen were performed. Rabbits were divided into three groups: bone graft with organic matter (OM) removing particulate autogenous tooth group, bone graft with OM removing particulate autogenous tooth and type I collagen group, and a control group. Bone grafting was performed in rabbit’s calvaria. The rabbits were sacrificed at different interval at 1, 2, 4, and 6 weeks after bone grafting for the histopathologic observation and observed the effect of bone regeneration by SEM, H-E & Masson stains, osteocalcin IHC staining.

Result

In vitro cytopathological study showed affinity for cells, cell attachment pattern, and cell proliferation in the order of control group, OM-removed and collagen-treated group, OM-removed particulate autogenous tooth group. The results of the degree of mineralization were opposite to those of the previous cell experimental results, and the OM-removed group, OM-removed group and collagen-treated group were relatively higher than the control group. Histopathologic analysis showed that vascularization and neonatal bone formation were higher in particulate autogenous tooth group with removing OM and with addition of collagen than control group and group of OM removed only. Immunohistochemical analysis showed that osteocalcin (OSC) expression was not observed in the control group, but at 4 weeks groups, OSC expression was observed the OM removed and OM-removed-collagen-treated particulate autogenous tooth, and the degree of expression was somewhat stronger in group of the OM removed and collagen additionally treated particulate autogenous tooth.

Conclusion

Particles that do not contain organic matter, the saint tooth, was responsible for sufficient bone graft material through the role of space maintenance and bone conduction, and further improved bone formation ability through additional collagen treatment. Therefore, research on various extracellular substrates and autologous bone grafting materials is necessary, and through this, it is possible to lay the foundation for a new type of autologous bone grafting material with excellent academic and technical utility.

An Overview of Bone Replacement Materials – Biological Mechanisms and Translational Research

Bone defects might develop as a result of various pathological entities. Bone grafting is a widely used procedure that involves replacement of the missing tissue with natural or artificial substitute. The idea for artificial replacement of the missing bone tissue has been known for centuries and the evidence for these treatments has been found ever since prehistoric period. Bone grafting has been practiced for centuries with various non-osseous natural materials. The skeletal system plays a crucial role in the structural support, body movement and physical protection of the inner organs. Regeneration of bone defects is crucial for reestablishing of the form and function of the skeletal system,. While most bone defects can heal spontaneously under suitable conditions, bone grafts or substitute biomaterials are commonly used therapeutic strategies for reconstruction of large bone segments or moderate bone defect. An ideal bone grafting material should provide mechanical strength, be both osteoinductive and osteoconductive and should provide space for vascularization. In order to overcome limitations associated with the standard treatment of bone grafts, there is an increasing interest in studying substitute biomaterials, made of naturally derived or synthetic materials. Bone substitutes can be derived from biological products or from synthetic materials. Prior to testing in human subjects, the bone substitute materials should be tested in vitro and in vivo using animal models. Establishing of a suitable animal model is an essential step in the investigation and evaluation of the bone graft materials.

Evaluation of the relative efficacy of autologous platelet-rich fibrin membrane in combination with β-tricalcium phosphate (Septodont- resorbable tissue replacement)™ alloplast versus β-TCP alloplast alone in the treatment of grade II furcation defects

Introduction:

Platelet-rich fibrin (PRF) is considered as the second-generation platelet concentrate, contains combined properties of fibrin, platelets, leukocytes, growth factors, and cytokines that make it as healing biomaterial with incredible potential for hard tissue and soft tissue regeneration. The present study was aimed to evaluate the effectiveness of PRF with β-tricalcium phosphate (β-TCP) graft (R. T. R) and compare it with β-TCP allograft alone in the treatment of mandibular Grade II furcation defects.

Material and Methods:

A total of 20 mandibular Grade II furcation defects sites were assigned in the study and treated with either β-TCP alone (Group I) or β-TCP with PRF membrane (Group II). The clinical parameters analyzed were probing pocket depth (PPD), clinical attachment level (CAL), gingival recession (GR), horizontal defect depth (HDD), and vertical defect depth (VDD), recorded baseline and at 6 months reentry.

Results:

At 6 months, both groups showed statistically significant results for all parameters from their baseline value, although intergroup changes were statistically insignificant. In Group I, gain in CAL was 2.80 ± 1.40 and in Group II it was 3.00 ± 1.44. Bone fill in Group I was VDD (3.50 ± 2.12) and HDD (3.70 ± 0.67), whereas Group II showed VDD (3.70 ± 1.57) and HDD (4.0 ± 0.88), respectively. PPD reduction was higher in Group I (3.50 ± 2.27) than Group II (2.80 ± 1.93). At reentry GR was established, Group I showed higher GR (0.70 ± 0.67) and Group II (0.40 ± 0.52).

Conclusions:

Significant improvement was found in both groups, but the combination of PRF with β-TCP allograft led to more favorable improvement in the management of Grade II furcation defect except PPD.

One percent alendronate and aloe vera gel local host modulating agents in chronic periodontitis patients with class II furcation defects: A randomized, controlled clinical trial

AIM

Alendronate (ALN) has antiresorptive and osteostimulative properties. The major component of aloe vera (AV) gel is acemannan, which has been found to have osteogenic properties. The aim of the present study is to explore the effectiveness of 1% ALN and AV gel as an adjunct to scaling and root planing (SRP) in chronic periodontitis patients with class II furcation defects.

METHODS

Ninety volunteers were randomly assigned to three treatment groups: (a) SRP plus placebo gel; (b) SRP plus 1% ALN gel; and (c) SRP plus AV gel. Clinical and radiographic parameters were recorded at baseline and at 6 and 12 months.

RESULTS

The mean probing depth reduction and relative horizontal clinical attachment level (CAL) and relative vertical CAL gains were greater in the ALN group than in the AV and placebo groups at 6 and 12 months. Furthermore, a significantly greater mean percentage of defect depth reduction (DDR) was found in the ALN group (38.09 ± 9.53, 44.86 ± 6.29) than the AV groups (11.94 ± 15.10, 14.59 ± 25.49) at 6 and 12 months, respectively.

CONCLUSION

ALN showed significant improvement in all clinical parameters, along with greater DDR, compared to AV in the treatment of class II furcation defects as an adjunct to SRP.

Mandibular Degree II Furcation Defects Treatment With Platelet-Rich Fibrin and 1% Alendronate Gel Combination: A Randomized Controlled Clinical Trial

BACKGROUND

Different materials have been investigated for renewal of lost supporting periodontal structures and tested for furcation defect treatment. Platelet-rich fibrin (PRF) is a pool of growth-promoting factors and cytokines that promote bone regeneration and maturation of soft tissue. Alendronate (ALN), an influential member of the bisphosphonate group, is known to enhance osteoblastogenesis and inhibit osteoclastic bone resorption, thus promoting tissue regeneration. This randomized trial was done to assess effectiveness of PRF and 1% ALN gel combination in mandibular degree II furcation defect treatment in comparison with PRF and access therapy alone.

METHODS

Seventy-two mandibular molar furcation defects were treated with either access therapy alone (group 1), access therapy with PRF (group 2), or access therapy with PRF and 1% ALN (group 3). Plaque index, modified sulcus bleeding index, probing depth (PD), relative vertical attachment level (RVAL) and relative horizontal attachment level (RHAL), and intrabony defect depth were recorded at baseline and 9 months postoperatively. Radiographically, defect fill, assessed in percentage, was evaluated at baseline, before surgery, and 9 months post-therapy.

RESULTS

Group 3 showed greater PD reduction and RVAL and RHAL gain when compared with groups 1 and 2 postoperatively. Moreover, group 3 sites showed a significantly greater percentage of radiographic defect fill (56.01% ± 2.64%) when compared with group 2 (49.43% ± 3.70%) and group 1 (10.25% ± 3.66%) at 9 months.

CONCLUSIONS

Furcation defect treatment with autologous PRF combined with 1% ALN gel results in significant therapeutic outcomes when compared with PRF and access therapy alone. Combining ALN with PRF has potential for regeneration of furcation defects without any adverse effect on healing process.

Histomorphometric Analysis of Contaminated Autogenous Tooth Graft Materials After Various Sterilization

PURPOSE

The purpose of this study was to evaluate histomorphometrically contaminated autogenous tooth graft materials, which were resterilized.

MATERIALS AND METHODS

The intentional defects (diameter: 8 mm, depth: 4 mm) were formed around implant fixture on the iliac crest of 6 mongrel dogs. Autogenous tooth graft materials were made by extracted premolars. After the contamination of the tooth materials, graft procedure was performed; no contaminated group (control group), contaminated groups (nonsterilization group [group 1], ethylene oxide [EO] gas group [group 2], and autoclave group [group 3]). The bone-to-implant contact (BIC) and the new bone formation rate (NBFR) were evaluated after sacrifice.

RESULTS

The BIC and NBFR of groups 1 and 3 were significantly lower than the control group after 4 weeks. The BIC and NBRF of group 3 were significantly lower than the control group after 8 weeks. However, the BIC and NBRF of group 2 was not significantly different comparing with the control group after 4 and 8 weeks.

CONCLUSION

Sterilization using EO gas may be more favorable than high-pressure sterilization in cases the reuse of contaminated autogenous tooth graft materials.

Increased osteogenesis in osteoporotic bone marrow stromal cells by overexpression of leptin

Osteoporosis leads to increased bone fractures and net bone loss, in part because of the dysfunction of bone marrow stromal cells (BMSCs). Leptin is an adipokine that plays important roles in many biological processes, including the regulation of the actions of mesenchymal stem cells. Our aim is to investigate the osteogenic effects of leptin in osteoporotic BMSCs in vitro and in vivo. The leptin gene was transferred into BMSCs isolated from osteoporotic rats by using recombinant adenoviruses. Once the gene and protein expression of leptin had been confirmed, MTT assays were performed; leptin overexpression was confirmed not to affect the viability of osteoporotic BMSCs. However, alkaline phosphatase (ALP) activity measurements, Alizarin red staining and analyses by quantitative real-time reverse transcription with the polymerase chain reaction revealed that leptin upregulated ALP activity, mineral deposition and the mRNA levels of runt-related transcription factor 2, ALP and collagen type І. Lastly, the effects of leptin on osteogenic differentiation were assessed in vivo. Cells transfected with leptin exhibited increased osteogenic differentiation and enhanced formation of bone-like structures. This study thus reveals, for the first time, that the overexpression of leptin in osteoporotic BMSCs (1) enhances their capacity to differentiate into osteoblasts and to form bone-like tissue and (2) might be a useful skeletal regenerative therapy in osteoporotic patients.

Effect on bone formation of the autogenous tooth graft in the treatment of peri-implant vertical bone defects in the minipigs

Background

The aim of this study was to evaluate the effect of autogenous tooth bone as a graft material for regeneration of bone in vertical bony defects of the minipigs.

Material and Methods

Six minipigs were used in this study. Four molars were extracted in the right mandibular dentition and sent to the Korea Tooth Bank for fabrication of autogenous tooth bone. Ten days later, each extraction site was implanted with MS Implant Narrow Ridge 3.0x10mm fixture (Osstem, Seoul, Korea) after standardized 2mm-sized artificial vertical bony defect formation. Pineappleshaped Root-On type autogenous tooth bones were applied to the vertical defects around the neck area of the posterior three fixtures and the fore-most one was not applied with autogenous bone as a control group. Each minipig was sacrificed at 4, 8, 12 weeks after fixture installation and examined radiologically and histologically. Histological evaluation was done under light microscope with Villanueva osteochrome bone staining with semi-quantitative histomorphometric study. Percentage of new bone over total area (NBF) and bone to implant contact (BIC) ratio were evaluated using digital software for area calculation.

Result

NBF were 48.15 ± 18.02%, 45.50 ± 28.37%, and 77.13 ± 15.30% in 4, 8, and 12 weeks, respectively for experimental groups. The control group showed 37.00 ± 11.53%, 32.25 ± 26.99%, and 1.33 ± 2.31% in 4,8,12 weeks, respectively. BIC ratio were 53.08 ± 19.82%, 45.00 ± 28.37%, and 75.13 ± 16.55% in 4,8,12 weeks, respectively. Those for the control groups were 38.33 ± 6.43%, 33.50 ± 29.51 %, and 1.33 ± 2.31% in 4, 8, 12 weeks, respectively.

Conclusion

Autogenous tooth bone showed higher score than control group in NBF and BIC in all the data encompassing 4,8,12 weeks specimens, but statistically significant only 12 weeks data in both NBF and BIC.

Histological and Histometrical Evaluation of two Synthetic Hydroxyapatite Based Biomaterials in the Experimental Periodontal Defects in Dogs

AIM

The present study was to evaluate histologically and histometrically the efficacy of Chitra granules in the regeneration of alveolar bone and to compare it with that of OsteoGenR (HA Resorb)(TM) in iatrogenically created alveolar bone defects in mongrel dogs.

MATERIALS AND METHODS

Four dogs (16 sites) were used for this split-mouth study. The animals were divided randomly into two groups of two animals. Same animals were used as control and test. Each dog had four implantation sites. The periodontal defects were prepared by acute defect model. Animals were sacrificed at 3 months (n=2), 6 months (n=2) and histologic and histometric evaluation was carried out.

STATISTICAL ANALYSIS

The data was analysed using statistical package Graph pad Software. Comparison of the hard and soft tissue parameters in the two groups was done using the Wilcoxan (Man Whitney), two tailed t-test. A p-value less than 0.05 were considered significant.

RESULTS

Maturing bone with immature periodontal ligament fibers were observed at three months and advanced osteogenesis at six months with both the types of bone graft materials. The mean values showed that amount of new bone formed with OsteoGenR (HA Resorb)(TM) was slightly more than that obtained by Chitra granules in histometric evaluation.

CONCLUSION

Histological study showed similar healing pattern with both the types of bone graft materials with maturing bone at 3 months and advanced osteogenesis at six months in experimental intraosseous periodontal defects in dogs. However, histological evaluation for longer period is necessary to determine the time taken for complete replacement of the bone graft materials with new bone.

Platelet rich fibrin (Prf) and β-tricalcium phosphate with coronally advanced flap for the management of grade-II furcation defect

BACKGROUND

Multirooted teeth offer unique and challenging problems due to the furcation area, creates situations in which routine periodontal procedures are somewhat limited and special procedures are generally required.

CASE DETAIL

The present case was showing the management of grade II furcation defect by platelet rich fibrin (PRF) and β-Tricalcium phosphate with coronally advanced flap.

CONCLUSION

Platelet rich fibrin and β-Tricalcium phosphate with coronally advanced flap have been shown to be a promising and successful approach for the treatment of furcation defect. Its gaining clinical attachment significantly manages both the gingival recession and furcation involvement simultaneously.

Bone Induction by Demineralized Dentin Matrix in Nude Mouse Muscles

Purpose:

This study examined the osteoinductive activity of demineralized human dentin matrix for nude mice.

Methods:

Twenty healthy nude mice weighing about 15 to 20 g were used for study. Demineralized human dentin matrix was prepared and implanted into the dorsal portion of nude mice (subcutaneous), which were sacrificed at two, four, and eight weeks after demineralized dentin matrix grafting and evaluated histologically by H&E and Masson trichrome staining. The specimens were also evaluated histomorphometrically.

Results:

The demineralized dentin matrix induced bone and cartilage formation independently in soft tissues. Histological examination showed bone-forming cells such as osteoblasts and fibroblasts at two, four, and eight weeks.

Conclusion:

These results suggest that demineralized human dentin matrix has osteoinductive ability, and is a good alternative to autogenous bone graft materials.

Pulpal and periradicular response to caries: current management and regenerative options

The pulp-dentin complex is a strategic and dynamic barrier to various insults that plague the dentition. Researchers have yet to understand the complete potential of this shifting junction and its components. The most common cause of injury to the pulp-dentin complex is carious breakdown of enamel and dentin. In recent years, there has been a change in restorative management of caries. The emphasis is on strategies to preserve dentin and protect the pulp. This article provides a brief review of the effect of caries on the pulp, of subsequent events on the periradicular tissues, and of current understanding of treatment modalities.

Comparative evaluation of autologous platelet-rich fibrin and platelet-rich plasma in the treatment of mandibular degree II furcation defects: a randomized controlled clinical trial

BACKGROUND

The treatment of molar furcation defects remains a considerable challenge in clinical practice. The identification of clinical measurements influential to treatment outcomes is critical to optimize the results of surgical periodontal therapy. The present study aimed to explore the clinical and radiographical effectiveness of autologous platelet-rich fibrin (PRF) and autologous platelet-rich plasma (PRP) in the treatment of mandibular degree II furcation defects in subjects with chronic periodontitis.

MATERIAL AND METHODS

Seventy-two mandibular degree II furcation defects were treated with either autologous PRF with open flap debridement (OFD; 24 defects) or autologous PRP with OFD (25), or OFD alone (23). Clinical and radiological parameters such as probing depth, relative vertical clinical attachment level and horizontal clinical attachment level along with gingival marginal level were recorded at baseline and 9 mo postoperatively.

RESULTS

All clinical and radiographic parameters showed statistically significant improvement at both the test sites (PRF with OFD and PRP with OFD) compared to those with OFD alone. Relative vertical clinical attachment level gain was also greater in PRF (2.87 ± 0.85 mm) and PRP (2.71 ± 1.04 mm) sites as compared to control site (1.37 ± 0.58 mm), and relative horizontal clinical attachment level gain was statistically significantly greater in both PRF and PRP than in the control group.

CONCLUSIONS

The use of autologous PRF or PRP were both effective in the treatment of furcation defects with uneventful healing of sites.

The use of a natural osteoconductive porous bone mineral (Bio-Oss™) in infrabony periodontal defects

Aim:

The aim of the present study was to evaluate the efficacy of a bovine derived xenograft Bio-Oss™ and to compare with open flap debridement in human infrabony periodontal defects.

Materials and Methods:

Twelve healthy patients (5 males, 7 females; aged 30-50 years), with no systemic disease with moderate to severe periodontitis were treated. Surgically defects were included only if presence of two or more vertical osseous defects as verified by radiographs with associated probing pocket depth of ≥5.0 mm following non-surgical therapy. Final selection included 24 defects. The defects were randomly assigned treatment with bovine derived xenograft Bio-Oss™ as experimental sites or open flap debridement as control sites. Soft tissue and hard tissue measurements were recorded on the day of surgery and six months post-operatively.

Results:

The results showed significant difference statistically between experimental and control sites in all measurements. Soft tissue measurements for the experimental sites included probing pocket depth reduction of 4.33±0.651 mm and attachment gain of 2.92±0.9003 mm, while the control sites showed a probing pocket depth reduction of 2.92±0.669 mm and a attachment gain of 0.583±0.515 mm. Osseous measurements showed bone fill of 1.936±1.046 mm (54.065±12.642%) for experimental sites and 0.02±0.01 mm (0.534±0.384%) for the control sites. Defect resolution was 50.75% for the experimental sites and 5.45% for the control sites.

Conclusion:

Bio-Oss™ is a bone graft material of considerable promise. However, further long term clinical studies with histological evaluation are warranted.

Regenerative therapy: a periodontal-endodontic perspective

Periodontal and endodontic diseases are inflammatory responses leading to periodontal and pulpal tissue loss. Regenerative therapies aim to restore the lost structures to vitality and function. Various materials and treatments methods have been used such as bone grafts, guided tissue regeneration, enamel matrix derivatives, growth and differentiation factors, and stem cells. Although the current materials and methods demonstrated adequate clinical results, true and complete biological tissue regeneration is not yet attainable. The current article reviews chronologically the materials and methods used in periodontal and endodontic regeneration highlighting their clinical success and shortcomings, and discussing future directions in regenerative therapy.

Autologous platelet-rich fibrin in the treatment of mandibular degree II furcation defects: a randomized clinical trial

BACKGROUND

Platelet-rich fibrin (PRF), an intimate assembly of cytokines, glycan chains, and structural glycoproteins enmeshed within a slowly polymerized fibrin network, has the potential to accelerate soft and hard tissue healing. This double-masked randomized study is designed to evaluate the effectiveness of autologous PRF in the treatment of mandibular degree II furcation defects compared with open flap debridement (OFD).

METHODS

Using a split-mouth design, 18 patients with 36 mandibular degree II furcation defects were randomly allotted and treated either with autologous PRF and OFD or OFD. Plaque index, sulcus bleeding index, probing depth, relative vertical and horizontal clinical attachment level, gingival marginal level, and radiographic bone defect were recorded at baseline and 9 months postoperatively. Comparison between indices between the test and control groups was performed using the paired t test except for plaque index and sulcus bleeding index data, which used the χ(2) test.

RESULTS

All clinical and radiographic parameters showed statistically significant improvement at the sites treated with PRF and OFD compared to those with OFD alone.

CONCLUSION

Within the limitation of this study, significant improvement with autologous PRF implies its role as a regenerative material in the treatment of furcation defects.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparative evaluation of decalcified and non-decalcified freeze-dried bone allografts in rhesus monkeys. I. Histologic findings

BACKGROUND

Controversy exists regarding the relative merits of decalcified (DFDBA) and non-decalcified (FDBA) freeze-dried bone allografts when used in periodontal or other oral surgical procedures.

METHODS

Under typical sedation, six rhesus monkeys had nylon mesh cylinders containing either DFDBA or FDBA implanted into surgically created vertical grooves on the facial aspects of all posterior quadrants. Each quadrant received three cylinders containing one type of bone, plus one empty cylinder (E) as negative control, and the full thickness flaps were closed to completely cover the cylinders. Cylinders were retrieved at 1, 2, and 3 months and processed for histologic evaluation. Photomicrographs taken at 8x were randomly evaluated using a histometric grid point counting technique for new bone and old bone within the chambers, and the data were analyzed with analysis of variance plus post-tests.

RESULTS

The nylon chambers and their contents were well-tolerated by the tissues. FDBA chambers contained more new bone and total bone than either the DFDBA or E chambers at all time periods (P <0.05). DFDBA was not statistically significantly different than E at any time period. FDBA had less old bone than DFDBA at 3 months (P<0.05). FDBA and DFDBA had more total bone (grafted plus new) present than E at all time periods (P<0.05).

CONCLUSION

These results suggest that FDBA may stimulate earlier, more rapid, and more substantial new bone formation than DFDBA in a monkey jaw defect model system.

Guided tissue regeneration associated with bovine-derived anorganic bone in mandibular class II furcation defects. 6-month results at re-entry

BACKGROUND

The use of graft materials with guided tissue regeneration (GTR) in Class II furcation defects is aimed at improving the outcome of the regenerative technique. In this regard, however, there are a limited number of studies discussing the results obtained when GTR and graft materials are used in the treatment of Class II furcation defects. Furthermore, most studies employ either allogeneic or autogenous materials. The present trial sought to determine whether the use of a bovine-derived anorganic bone (ABB) in conjunction with GTR influenced the outcome of mandibular Class II furcation treatment.

METHODS

This study included 14 patients who provided 15 pairs of similar periodontal defects. Each defect was randomly assigned to treatment with either a cellulose membrane in combination with bovine-derived anorganic bone (GTR+ABB) or membrane alone (GTR). Following basic therapy, baseline measurements were recorded including probing depth (PD), clinical attachment level (CAL), and gingival margin position (GMP). Hard tissue measurements were performed during surgery to determine alveolar crestal height (CEJ-AC), and vertical (VDD) and horizontal defect depth (HDD). Membranes remained in position for at least 4 weeks. After 6 months, all sites were re-entered and soft and hard tissue measurements were recorded.

RESULTS

Both surgical procedures resulted in statistically significant probing depth reduction and gain in clinical attachment levels, with no significant difference between groups. Gingival recession was more pronounced in the GTR+ABB group (0.87 +/- 0.83 mm), but not statistically different from the GTR group (0.46 +/- 1.19 mm). Vertical defect resolution was significant in both groups (GTR: 1.60 +/- 1.50 mm; GTR+ABB: 1.80 +/- 2.11 mm), without differences between groups. Only horizontal furcation resolution (GTR: 2.47 +/- 0.99 mm; GTR+ABB: 3.27 +/- 1.39 mm) was significantly different between groups (P <0.05).

CONCLUSIONS

The use of ABB with GTR techniques improved horizontal defect resolution in mandibular Class II furcation defects, but did not yield superior results regarding soft tissue changes when compared to sites treated with GTR alone. Evaluation of a larger sample could indicate differences and advantages between the evaluated approaches and confirm the real necessity of associating filling materials with GTR.

Treatment of 3rd molar-induced periodontal defects with guided tissue regeneration

Recent reports provide evidence of increased attachment levels when using guided tissue regeneration (GTR) techniques for the treatment of periodontal defects. Periodontal defects frequently occur at the distal aspect of mandibular 2nd molars which are next to mesioangular impacted 3rd molars that have oral communication. The purpose of this study was to determine whether the use of GTR can enhance probing attachment levels (PALs) following extraction of mesioangular impacted third molars. 12 patients with bilateral soft tissue impacted mandibular 3rd molars entered this split mouth study. After extractions, the previously exposed distal root surface of the 2nd molars were debrided. The defects on the randomly selected experimental sites were covered with expanded polytetraflouro-ethylene (e-PTFE) membrane and the tissue was replaced to cover the membrane. Membranes were removed after 6 weeks. Control sites were treated identically except no membrane was placed. GI, P1I, PD, PAL and BOP records were obtained at 0, 3 and 6 months. The use of barrier material did not provide statistically-significant differences in PAL when comparing experimental versus control sites. Nevertheless, PAL gain was consistently greater at 3 and 6 months when GTR techniques were used in sites with deep impactions.

Effects of polyglactin mesh combined with resorbable calcium carbonate or replamineform hydroxyapatite on periodontal repair in dogs

This study evaluates periodontal repair and biomaterial reaction following implantation of a polyglactin mesh with or without porous resorbable calcium carbonate (RCC) or porous replamineform hydroxyapatite (RHA) in conjunction with reconstructive surgery. Ligature- and surgically-induced interproximal periodontal defects of left and right mandibular premolar teeth in 7 dogs were used. Bilaterally, mesial defects of the 2nd, 3rd and 4th premolar teeth were treated with polyglactin mesh, polyglactin mesh and RHA, or polyglactin mesh and RCC, respectively. The polyglactin mesh, shaped according to the contour of the defect, was adapted to the experimental teeth; its coronal margin positioned immediately apical to the cemento-enamel junction. Gingival flap margins were adapted and sutured to cover the polyglactin mesh completely. Clinical healing was generally uneventful. The dogs were sacrificed to provide block sections for histologic evaluation at 1, 3, 6, 12, 26, 32 and 56 weeks following wound closure. Generally, cementum regeneration was observed beginning at week 6 in all groups. Bone regeneration was observed from week 3 in polyglactin mesh-treated groups, and from week 6 in polyglactin mesh+RCC or polyglactin mesh+RHA treated groups. Bone regeneration appeared enhanced in polyglactin mesh+RCC or polyglactin mesh+RHA treated defects at week 12 and 26, with little difference between the three experimental conditions at week 56. Polyglactin mesh degradation was observed at week 3 and appeared complete at week 12. The RHA did not appear to resorb, while the RCC was gradually replaced by bone from week 3. Within limitations of the study conditions, periodontal regeneration was observed following implantation of a polyglactin mesh with or without RCC or RHA in conjunction with reconstructive surgery. As a conclusion, there seems to be no significant difference in periodontal regeneration after 12 months of healing between the group treated with the membrane only, and the group treated with the membrane and the bone substitution material. Changes in connective fiber orientation over the 1st 12 weeks of healing may suggest that "fibrous encapsulation" observed in earlier studies may only represent a transient stage in periodontal regeneration.

Bone allografts in periodontal therapy

Bone allografts as used in dentistry have a 20-year history of safety and efficacy. Case reports and controlled clinical trials have shown the potential of both mineralized and decalcified cortical freeze-dried bone allograft to reconstruct the bone defects caused by periodontitis. Histomorphometric analysis of human biopsies following grafts of decalcified freeze-dried bone allograft have shown the ability of decalcified freeze-dried bone allograft to promote regeneration of new bone, cementum, and periodontal ligament on a tooth root surface previously exposed to bacterial plaque. The addition of mineralized freeze-dried bone allograft and decalcified freeze-dried bone allograft to the guided tissue and guided bone regeneration procedures have significantly enhanced results, especially in large osseous lesions.

The impact of new technologies to diagnose and treat periodontal disease. A look to the future

The last 25 years have brought unprecedented advances to our understanding of periodontal disease. Consider that in 1970 periodontitis was believed to effect most individuals over the age of 35 years, to progress steadily in an individual once initiated until teeth were lost, to be the primary cause of tooth loss in adults, to be caused by the bacterial mass accumulating on the tooth surface and subgingivally, and to involve the host in some fashion or another. In the 25 years since then, impressive research advances in the epidemiology of periodontal disease, the specific bacterial etiology of periodontal disease and the immunoinflammatory mediators of periodontal tissue destruction have greatly altered our view of periodontal disease. Thus, given these research advances in the understanding of periodontitis, what may the future hold for improved diagnosis and treatment of periodontal disease? Impressive research into new ways to diagnose the periodontal diseases is well underway. Investigators are seeking new ways to diagnose an individual's degree of risk for periodontal disease initiation, susceptibility to disease progression, level of disease "activity" and the likely response to treatment and recurrence of active disease. New diagnostic tests should greatly advance our ability to more accurately and specifically diagnose periodontal disease. The future also looks promising for new treatment strategies to slow or arrest periodontal disease progression. The bacterial specificity of periodontal disease etiology revealed since 1970 has logically led to the use of antibiotics in periodontitis treatment. In the late 1980s the concept of locally delivering antibiotics to the periodontal pocket was introduced, and subsequent clinical trials have indicated that it is possible to reduce pocket depth and inflammation with tetracycline locally delivered to the periodontal pocket. Likely, we have barely scratched the surface in studying the efficacy of locally delivery antimicrobial agents to alter the progression of periodontal disease. As new agents are developed and better delivery systems to the periodontal pocket are developed, the future should see a variety of antimicrobial agents available which can slow periodontal disease progression. The future also holds promise for slowing periodontal disease progression by blocking inflammatory pathways important in periodontal tissue destruction. Clinical trials of flubiprofen, naproxen and ketoprofen indicate that it is possible to slow periodontal disease progression with non-steroidal anti-inflammatory drugs which inhibit one destructive pathway. In addition, data from animal models indicate that chemically modified tetracycline as an inhibitor of collagenase can slow disease progression in animals. Again, we have likely only just begun to explore the wide range of molecular mediators of tissue destruction which may be targeted for blocking and thereby slow or arrest periodontal disease progression. Last, research into regenerating periodontal structures lost as a result of disease has had a noteworthy record of progress in the past 25 years. Techniques that utilize bone grafts, root treatments, tissue guiding membranes or polypeptide growth factors have ably indicated that it is possible to regenerate new attachment structures in humans. As investigators continue to unravel the mysteries of the embryonic development of the periodontium, the ability to predictably regenerate lost periodontal attachment structures holds great promise for the future.

Suitability of the iliac crest as a site for harvest of autogenous bone grafts

Many donor sites have been advocated for obtaining cancellous bone to be used for grafting alveolar defects. Recently, some authors have suggested that the iliac crest site produced an unacceptably high degree of postoperative morbidity. Because of this morbidity, the use of other donor areas, e.g., rib, cranium, and mandible, are advocated. The iliac crest donor site for alveolar bone grafting has been common practice in our institution for years under the assumption that little or no postoperative morbidity occurred. To investigate and document the accuracy of our assumption, the charts of the most recent 50 consecutive patients receiving alveolar bone grafts, all of which used the iliac crest as a donor site, were reviewed. Postoperative pain, numbness, infection, paralysis, or long-term disability were catalogued from the charts. In addition, a questionnaire was sent to the parents and patients requesting their perceptions of these parameters. In the cases reviewed, the average length of skin incision was 4.2 cm. The average quantity of bone harvested was 4.1 cc. The usual hospitalization time was 2-3 days. No patients experienced serious or long-term complications at the surgical donor site. Immediate postoperative complications among the 50 patients studied were limited to one hematoma, one stitch abscess, one case of swelling with pain, one erythema, and one 4-day fever accompanied by slight serosanguineous drainage. Information from the questionnaire suggests that most patients returned to full activity within 4-6 weeks. No patient reported any long-term pain or disability.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of polylactic acid granules and decalcified freeze-dried bone allograft in human periodontal osseous defects

The purpose of this study was to compare the effectiveness of polylactic acid (PLA) granules as an alloplastic grafting material to that of decalcified freeze-dried bone allograft (DFDBA) and a flap procedure for debridement without graft (FPD) when treating periodontal intrabony defects. Ten patients presenting with advanced adult periodontitis, including at least 3 similar periodontal osseous defects (2- and 3-walled), comprised the study group. After completion of a hygienic phase of treatment, measurements were made with calibrated periodontal probes and stents to determine soft tissue recession, probing pocket depths, and probing attachment levels. Each defect was surgically exposed and hard tissue measurements were obtained. Defects were treated with one of the 3 methods above chosen randomly prior to the surgical appointment. Six months postsurgery, soft tissue measurements were repeated and all sites were surgically reentered to obtain hard tissue measurements. All surgical sites healed without clinical complication. The initial pocket depths and initial depth of osseous defects were compared between the groups using ANOVA and no significant differences were found. A mean osseous defect fill of 0.4 mm (11.2%) occurred with the flap procedure for debridement, 3.0 mm (65%) with DFDBA, and 0.1 mm (2.2%) with PLA. Mean crestal bone loss was 1.30 mm for FPD, 0.60 mm for DFDBA, and 1.55 mm for PLA. No statistically significant differences were found in soft tissue recession between groups or in the osseous defect measurement between PLA and FPD. A statistically significant improvement (P < 0.001) was found in the fill of the osseous defects when using DFDBA compared to the initial defect depth and to the other 2 groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Autogenous and allogeneic bone grafts in periodontal therapy

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

Effect of a resorbable bone graft material on orthodontic tooth movement through surgical defects in the cat mandible

beta-Tricalcium phosphate ceramic, a resorbable synthetic bone material, was implanted into surgically created alveolar defects mesial to the mandibular first premolars of 12 adult male cats. Similar defects on the contralateral side were allowed to heal naturally. Six weeks later, nickel-titanium coiled springs were ligated between the mandibular canine and first premolar on both sides and activated to deliver 100 g of force. The distance between the canine and first premolar was measured with dial calipers at 0, 3, 6, and 9 weeks after appliance placement. Regression analysis of amount of tooth movement between the two teeth showed no significant difference between grafted and control sides. This suggests that placement of a resorbable synthetic bone material may have useful applications in situations where loss of alveolar width following extractions may compromise orthodontic tooth movement.

Healing assessment of osseous defects of periapical lesions associated with failed endodontically treated teeth with use of freeze-dried bone allograft

Freeze-dried bone allograft (FDBA) has been used extensively in periodontal surgery and in the treatment of pocket osseous defects resulting from inflammatory periodontal disease. No other endodontic investigation has used this type of graft material in the treatment of bony resorptive defects of the periapical lesions associated with failed endodontic therapy. Therefore this study was conducted with the use of FDBA, to assess healing ability of osseous defects after removal of periapical lesions associated with failed endodontically treated teeth. In all patients periapical lesions were surgically removed with retrograde amalgam seal and the graft material was then carefully packed without pressure into the bony defect. The lesions were fixed in 10% neutral buffered formalin and prepared for histologic examination. Long-term recall demonstrated bone regeneration and good tolerance of allograft material by the periapical tissues. The periapical lesions were either periapical granulomas or apical periodontal cysts. We conclude that FDBA is a biocompatible material of osteogenic potential and can be used effectively in treating osseous defects of periapical lesions associated with failed endodontically treated teeth.

Computerized densitometric analysis of interproximal bone levels in a controlled clinical study into the treatment of periodontal bone defects with ceramic hydroxyapatite implant material

The aim of this controlled clinical study was to utilize computer-assisted densitometric analysis of radiographs to assess the effectiveness of treating periodontal osseous defects with a sintered hydroxyapatite implant material. It was found that over the 2-year period of the study for the osseous defects treated by the implant material, there was a gain in the height of the hard tissue relative to the cemento-enamel junction; this gain was statistically significant compared with the results for the control sites.

Crystal dissolution of biological and ceramic apatites

High resolution transmission electron microscopy (Hr TEM) studies on biological and synthetic calcium phosphate have provided information on the dissolution process at the crystal level. The purpose of this study was to investigate the dissolution of ceramic hydroxyapatite (HA) after implantation using Hr TEM. Recovered HA ceramic implanted in bony and nonbony sites in animals and in periodontal pockets in humans were used for the study. For comparison, sections of human fluorotic enamel with caries and sections of shark enameloid previously exposed to 0.1 HCl were similarly investigated. Hr TEM studies demonstrated that in both the biological and ceramic apatites, the lattice and atomic defects were the starting points in the dissolution process. However, significant differences in the process of dissolution were observed: (1) biological apatite crystals showed preferential core dissolution whereas ceramic apatite crystals showed nonspecific dissolution at the cores and at the surfaces; (2) the dissolution of biological apatites appeared to consistently extend along the crystal's c-axis whereas dissolution of the ceramic HA did not appear to be correlated with the crystal's c-axis. The observed differences in crystal dissolution between biological and ceramic apatites may be attributed to the following: (1) the unique crystal/protein interaction present with biological apatites but absent in ceramic HA; (2) differences in defect distribution between biological and ceramic apatites which are due to the differences in the original of these defects; and (3) the longer morphological c-axis of biological apatites compared with that of ceramic apatites.(ABSTRACT TRUNCATED AT 250 WORDS)

Bioceramic implants in surgical periodontal defects. A comparison study

The healing response of two commercially available bioceramics, beta tricalcium phosphate (TCP) and hydroxylapatite (HA), was compared after implantation in surgically created defects in dogs. Three 18 to 24 month old female Labrador dogs were used. Under general anesthesia 3-wall defects were created on the canines and premolars. The roots were planed, and reference notches were placed to identify the alveolar crest and the apical extent of the defects. TCP or HA was placed in alternating canine defects. The premolars received no implants and served as controls. Plaque management was accomplished by biweekly brushing with 0.2% chlorhexidine. Following healing periods of 5, 12 and 16 weeks, the dogs were sacrificed and perfused with 10% formalin. Six-mu step serial sections were evaluated by light microscopy. Healing against the root planed surface varied from a long junctional epithelium to a connective tissue reattachment in new cementum. TCP particles were actively resorbed by giant cells and macrophages and were incorporated into new bone matrix. The HA particles were encapsulated by fibrous connective tissue and rarely seen in contact with repairing bone. Bone formation was slower around HA particles at all time periods. Some evidence of HA particle resorption was seen at each time period.

Granuloma and plasma cell formation induced by the subcutaneous implantation of beta-whitlockite particles

In this paper, the formation of a granuloma following subcutaneous implantation of beta-whitlockite powder is described. The implants were removed after 3, 5 and 7 wk and examined histologically. In the granuloma giant cells, macrophages, lymphocytes and plasma cells are present. The presence of plasma cells indicates that not only inflammation occurs, but that an immunoresponse also takes place. Resorption and phagocytosis of particles was observed and the particles were found in the regional lymph nodes after 7 wk. beta-Whitlockite powder induces an inflammation and both a cellular and a humoral immunological response, when implanted subcutaneously.

Histologic evaluation of a human periapical defect after implantation with tricalcium phosphate

This case report describes the effect of tricalcium phosphate implantation in the treatment of a chronic periapical abscess. Ceramic implant materials are biocompatible and are currently being used to restore alveolar bone loss resulting from periodontal disease, endodontic infections, and residual alveolar ridge resorption. However, use of such a material in this case led to persistent infection and additional bone destruction. Thus, the use of a ceramic implant material to accelerate periapical bone repair is not recommended in areas where a chronic bacterial infection is present.

The regenerative potential of the periodontal ligament

The current decline in the incidence of dental caries indicates that patients will retain most of their dentition. Reconstruction or regeneration of the entire attachment apparatus, including the periodontal ligament, cementum, and bone, is an attainable therapeutic goal. Clinical treatments designed to reattach connective tissue to exposed root surfaces commonly result in the formation of a long junctional epithelial attachment. This attachment is probably not an effective barrier to bacterial toxins and may allow recurrent pocket formation. To enhance reattachment of connective tissue, root-conditioning agents have been used but their clinical efficacy is questionable. Restoration of destroyed alveolar supporting bone by means of allogenic and autogenous bone-grafting materials has been recommended, but these procedures do not restore the cementum and PDL. Attempts to promote regeneration of the entire attachment apparatus have included clinical studies that used mechanical means to promote repopulation of affected root surfaces by periodontal ligament fibroblasts and prevent contact of epithelial or gingival connective tissue cells. Results thus far have been encouraging, but the practicality of these techniques may be limited. However, these studies have demonstrated that if only PDL cells contact the root surface during healing, a normal PDL can re-form. Dental follicle tissue is capable of inducing the formation of cementum-like structures and is clearly the cell population responsible for cementum and PDL formation. Recent research has demonstrated that the dental papilla probably shares the same inductive capabilities as the dental follicle.(ABSTRACT TRUNCATED AT 250 WORDS)

Flap technique for periodontal bone implants. Papilla preservation technique

A new flap design for placement of implants into osseous defects has been described. The flap design can be used in anterior and posterior areas of human subjects. Photographs of representative cases are presented. Wound healing always occurred by primary intention and without evidence of immediate graft exfoliation. Interdental soft tissue craters did not develop, making it easier for patients to maintain optimal oral hygiene. This type of flap design can also be used without grafts in order to improve postoperative soft tissue contour.