Histologic evaluation of new attachment apparatus formation in humans. Part II

Histologic wound healing in studies using different ridge preservation protocols: A review

BACKGROUND

Alveolar ridge preservation (ARP) procedures are designed to lessen dimensional changes in the alveolar ridge after tooth extraction. Wound healing after ridge preservation involves the formation of new vital bone in the former socket, and this vital bone is important in the osseointegration of dental implants.

METHODS

A series of ARP studies have been performed to help clinicians better understand the wound-healing events that occur following tooth extraction and ridge preservation. Different protocols have been examined using various materials and periods of healing time prior to implant placement. The primary aim of these studies was to ascertain the relative percentage of vital bone formation, residual graft material, and connective tissue (CT)/other at the healing site using histomorphometric examination of bone core biopsies obtained during osteotomy preparation.

RESULTS

For allografts, the use of demineralized bone alone or in combination with mineralized is associated with more vital bone formation than the use of mineralized allograft alone. For mineralized allografts, the use of cortical versus cancellous bone has only minimal impact on new bone formation. Xenografts from bovine and porcine sources appear to have similar vital bone formation. Longer healing times prior to implant placement are associated with increased vital bone formation and decreased residual graft material. The most stable component in most studies is the percentage of CT/other.

CONCLUSIONS

The percentage of vital bone and residual graft at ARP sites is dependent on the materials used and the length of healing time prior to obtaining core biopsies.

KEY POINTS

What factors may affect the amount of new bone at the ARP site? At a time point about 4 months after ARP, the type of graft material used for ARP plays a large role in new bone formation. Studies focus on means and standard deviations, but patients often do not "follow the mean." Even if a single ARP protocol is used for all patients, there is great interindividual variability in new bone formation, and there is often variability between sites within a single patient. How long after ARP with an allograft should I wait to place an implant? Longer healing times such as 4-5 months generally provide higher amounts of vital bone formation than shorter healing times like 2-3 months. Differences in vital bone formation between ARP protocols tend to decrease with longer healing time. FDBA that contains demineralized bone, either alone or combined with mineralized FDBA, often provides higher amounts of new bone formation than 100% mineralized allograft, especially at shorter healing periods. Even a year after ARP with an allograft, residual graft material is often still present at the ARP site.

Management of grade II and III furcation defects with intramarrow penetration along with indigenously prepared DFDBA and amniotic membrane: a clinical and radiographic study

Managing furcation defects constitutes a problem in successful periodontal therapy. Guided tissue regeneration (GTR) is the mainstay for the management of such defects but is expensive. This study makes use of indigenously prepared demineralized freeze-dried bone allograft (DFDBA) and amniotic membrane (AM) as a cost-effective alternative. The purpose of the study was to compare the clinical outcome of grade II and III furcation defects with and without using indigenous DFDBA and AM prepared at Central Tissue Bank, MAIDS. 18 systemically healthy patients with chronic periodontitis displaying either grade II or III furcation defects were treated with open flap debridement (OFD) + intramarrow penetration (IMP) (control group) and OFD + IMP + DFDBA + AM (test group). The clinical and radiographic parameters were recorded at 3 and 6 months postoperatively. All parameters were statistically analyzed. Both treatment modalities resulted in improvement in all clinical variables evaluated. Radiographic dimensions evaluating bone fill showed a statistically significant difference in the test group compared to the control group. Within the limitations of this study, data suggest GTR using indigenously prepared DFDBA and amniotic membrane to be an economical and viable option for treating furcation defects.

Bioactive Glasses in Periodontal Regeneration A Systematic Review

Bioactive glasses (BAGs) are surface-active ceramic materials that can be used in bone regeneration due to their known osteoconductive and osteoinductive properties. This systematic review aimed to study the clinical and radiographic outcomes of using BAGs in periodontal regeneration. The selected studies were collected from PubMed and Web of Science databases, and included clinical studies investigating the use of BAGs on periodontal bone defect augmentation between January 2000 and February 2022. The identified studies were screened using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A total of 115 full-length peer-reviewed articles were identified. After excluding duplicate articles between the databases and applying the inclusion and exclusion criteria, 14 studies were selected. The Cochrane risk of bias tool for randomized trials was used to assess the selected studies. Five studies compared using BAGs with open flap debridement (OFD) without grafting materials. Two of the selected studies were performed to compare the use of BAGs with protein-rich fibrin, one of which also included an additional OFD group. Also, one study evaluated BAG with biphasic calcium phosphate and used a third OFD group. The remaining six studies compared BAG filler with hydroxyapatite, demineralized freeze-dried bone allograft, autogenous cortical bone graft, calcium sulfate β-hemihydrate, enamel matrix derivatives, and guided tissue regeneration. This systematic review showed that using BAG to treat periodontal bone defects has beneficial effects on periodontal tissue regeneration. OSF Registration No.: 10.17605/OSF.IO/Y8UCR.

Efficacy of Guided Tissue Regeneration Using Frozen Radiation-Sterilized Allogenic Bone Graft as Bone Replacement Graft Compared with Deproteinized Bovine Bone Mineral in the Treatment of Periodontal Intra-Bony Defects: Randomized Controlled Trial

(1) Background: The aim of this study was to compare the clinical and radiographic outcomes of guided tissue regeneration (GTR) using two biomaterials as bone replacement grafts in the treatment of periodontal intra-bony defects. (2) Methods: Using a split-mouth design, 30 periodontal intra-bony defects were treated with either frozen radiation-sterilized allogenic bone grafts (FRSABG tests) or deproteinized bovine bone mineral (DBBM, controls) combined with a bioabsorbable collagen membrane in 15 patients. Clinical attachment level gains (CAL-G), probing pocket depth reductions (PPD-R), and radiographic changes in linear defect fill (LDF) were evaluated 12 months postoperatively. (3) Results: The CAL, PPD, and LDF values improved significantly in both groups 12 months after the surgery. However, in the test group, the PPD-R and LDF values were significantly higher compared to the controls (PPD-R 4.66 mm versus 3.57 mm, p = 0.0429; LDF 5.22 mm versus 4.33, p = 0.0478, respectively). Regression analysis showed that baseline CAL was a significant predictor for PPD-R (p = 0.0434), while the baseline radiographic angle was a predictor for CAL-G (p = 0.0026) and LDF (p = 0.064). (4) Conclusions: Both replacement grafts when used for GTR with a bioabsorbable collagen membrane yielded successful clinical benefits in teeth with deep intra-bony defects 12 months postoperatively. The use of FRSABG significantly enhanced PPD reduction and LDF.

The use of recombinant human platelet-derived growth factor-BB in combination with β-tricalcium phosphate and rhPDGF-BB in combination with freeze-dried bone allograft plus barrier in two separate complex infrabony defects with long-term follow-up

BACKGROUND

Reports from a large-scale, prospective, masked, randomized controlled clinical trial demonstrated gain in attachment level, linear bone gain, and percentage bone fill in infrabony defects treated with recombinant human platelet-derived growth factor-BB (rhPDGF-BB) and β-tricalcium phosphate (β-TCP) at 6 months. A follow up to that trial at 24 months showed the results were stable in terms of gain in clinical parameters, and assessment of selective cases demonstrated stability at 5 years. The cases presented in this report provide clinical applications to support the use of this biologic in complex infrabony defects. An infrabony defect is described as a periodontal pocket with its base apical to the crest of the alveolar bone. Infrabony defects may have one, two, or three bony walls creating challenges in management.

METHODS

Two complex infrabony defect cases are presented in this report: one using rhPDGF-BB with β-TCP and the other using rhPDGF-BB with freeze-dried bone allograft (FDBA) and a resorbable barrier membrane. The techniques are described with results showing long-term follow up and reentry at 8 and 14 years (respectively).

RESULTS

Both cases demonstrate significant gains in clinical attachment levels as well as bone-like fill as observed radiographically and at reentry.

CONCLUSIONS

These case reports of combining rhPDGF-BB with β-TCP or with FDBA and a barrier membrane support the literature showing improvement in attachment levels and demonstrating bone fill in complex infrabony defects. The results can be maintained long term.

Biphasic Calcium Phosphate Versus Demineralized Freeze-Dried Bone Allograft in the Treatment of Periodontal Disease: A Clinical and Radiographical Evaluation

 Aim

The study aimed to clinically and radiographically evaluate the effect of biphasic calcium phosphate (BCP) versus demineralized freeze-dried bone allograft (DFDBA) in treating periodontal disease.

Method

The study consisted of 44 patients. The sites were randomly assigned to receive one of two treatment modalities (BCP at site 1 and demineralized freeze-dried bone at site 2) by a computerized method. All the clinical data were measured with the help of a University of North Carolina-15 (UNC-15) probe at the baseline, three months, and six months postoperatively. Radiovisiographs were taken using a Rinn XCP® (Dentsply/Rinn Corp, Elgin, IL) system and an oral grid using the paralleling technique. A manual calculation of the defect area was undertaken at the end of six months and was compared with the other groups.

Result

The linear bone growth recorded for site 1 at the end of six months was 3.8 ± 1.14 mm, and site 2 was 4.6 ± 1.07 mm. The intergroup comparison showed more remarkable linear bone growth in site 2, which was statistically insignificant, with a mean difference of 0.8 ± 1.23 mm and a p-value of 0.07.

Conclusion

Improvements were observed on all the documented parameters. However, the sites treated with DFDBA showed better periodontal regeneration.

Composite outcome measure (COM) and pocket closure as clinical endpoints following treatment of infra bony defects with Guided tissue regeneration and Open flap debridement

Background

Clinical outcomes of regenerative periodontal therapy has been traditionally assessed using surrogate markers, primarily clinical attachment level (CAL) gain and probing pocket depth (PPD) reduction. This study tried to assess newer clinical endpoints namely pocket closure and composite outcome measure (COM) apart from CAL gain, PPD reduction and gingival recession in patients who underwent guided tissue regeneration (GTR) and compared the same with open flap debridement (OFD) six months post treatment.

Materials and Methods

Records of 58 sites in 48 patients who had undergone GTR (28 sites) and OFD (30 sites) for infrabony defects were evaluated for CAL gain, PPD reduction, change in GR, FMBS, and FMPS at baseline and 6 months after surgery. Pocket closure and COM were used to assess the efficacy of both treatments.

Results

Statistically significant improvements were seen in both the groups except GR from baseline to 6 months. GTR-treated sites showed better improvements with a statistically significant difference in CAL gain after 6 months. Pocket closure and percentage of treatment success and failure in both the groups assessed using a COM were similar and did not differ statistically.

Conclusion

Treatment of infrabony defects with GTR combined with a xenograft offers better CAL gain after 6 months compared to OFD alone and also found that baseline PPD and FMBS were the factors determining pocket closure.

Clinical effectiveness of anorganic bovine-derived hydroxyapatite matrix/cell-binding peptide grafts for regeneration of periodontal defects: a systematic review and meta-analysis

Aim: To ascertain clinical effectiveness of anorganic bovine-derived hydroxyapatite matrix/cell-binding peptide (ABM/P-15) for regeneration of periodontal defects. Materials & methods: Electronic databases (National Library of Medicine [Medline by PubMed], Cochrane Library [Wiley], CINAHL [EBSCO] and Medline [EBSCO]) were systematically searched up to December 2019. Randomized controlled clinical trials comparing ABM/P-15 grafts to conventional surgery for intrabony and gingival recession defects were included and evaluated intrabony defects including clinical attachment level (CAL), probing depth and gingival recession. Results: A significant gain in CAL (1.37 mm), and reduction in probing depth (1.22 mm) were shown by ABM/P-15 grafts than open flap debridement (p < 0.00001). The subgroup analysis also showed better results for ABM/P-15 grafts in CAL gain for intrabony defects. For furcation and gingival recession defects, no significant difference was seen. Conclusion: The adjunct use of ABM/P-15 grafts in conventional periodontal surgery is useful for periodontal regeneration of intrabony defects.

Platelet-rich fibrin in combination with decalcified freeze-dried bone allograft for the management of mandibular degree II furcation defect: A randomised controlled clinical trial

Background: Treatment of furcation involvement of molars with periodontal disease remains challenging and unpredictable. Platelet-rich fibrin (PRF) has received the attention of researchers due to its pleiotropic properties essential for periodontal wound healing. The osteoinductive property of demineralized freeze-dried bone allograft (DFDBA) has been successfully used in periodontal regeneration. Aim: The present study aimed to explore the effectiveness of PRF alone and with DFDBA in the treatment of mandibular degree II furcation defects in subjects with chronic periodontitis. Material and Methods: Patients treated were from the Department of Periodontology and Implantology, Institute of Dental Sciences, Bareilly. A total of 60 mandibular molars were treated with either open flap debridement (OFD) alone, [Formula: see text] combination or [Formula: see text] combination. The soft and hard tissue parameters such as vertical probing depth (VPD), vertical clinical attachment level (VCAL), gingival marginal level (GML), horizontal probing depth (HPD), vertical bone fill (VBF), horizontal bone fill (HBF) and furcation width (FW) were determined at baseline and 9 months postoperatively. A paired [Formula: see text]-test was conducted to assess the statistical significance between time period within each group for clinical and radiographic parameters. ANOVA and post-hoc Tukey's tests were also conducted for intergroup comparison of soft and hard tissue parameters. Statistical significance was set at [Formula: see text]. Results and Discussion: After 9 months, all treatment groups showed significant ([Formula: see text]) improvement in soft and hard tissue parameters, except GML in all the three groups and HBF and FW in the OFD group as compared to baseline. The mean VBF change was highest in the [Formula: see text] group ([Formula: see text]) mm, followed by that in the [Formula: see text] and OFD groups ([Formula: see text] and [Formula: see text][Formula: see text]mm, respectively). Conclusions: It was shown that both [Formula: see text] and [Formula: see text] combinations were significantly advantageous for the management of mandibular degree II furcation defects. However, the [Formula: see text] combination has significantly greater benefits than [Formula: see text] combination in terms of VBF.

Comparison of GTR, T-PRF and open-flap debridement in the treatment of intrabony defects with endo-perio lesions: a randomized controlled trial

BACKGROUND

Titanium- prepared platelet rich fibrin (T-PRF) is an autologous hemo-component with a high concentration of platelets that also incorporates leukocytes, and growth factors into the dense fibrin matrix and can be used as a healing biomaterial. This study assesses the adjunctive use of T-PRF in intrabony defects (IBDs) with open flap debridement (OFD) in comparison with guided tissue regeneration (GTR) as a gold standard and OFD alone as a control.

MATERIAL AND METHODS

A total of 45 patients (15 per group) were randomized as either T-PRF (test group), GTR (test group), or OFD alone (control group) sites. Probing depth (PD), clinical attachment level (CAL), and IBD were recorded. The radiographic depth of IBD was also measured. Primary outcomes assessed were changes in PD, CAL, and radiographic IBD that were assessed at the beginning and nine months later.  Results: The PRF and GTR group showed significant improvement in clinical parameters compared with the OFD alone (control group) at nine months. While there were no significant differences in PD and CAL between test groups (T-PRF and GTR groups), the significant difference was found in radiographic IBD depth.

CONCLUSION

T-PRF may give similar successful results as GTR in the treatment of IBDs with endo-perio lesions.

Experimental and clinical studies on regenerative periodontal therapy

The recognition of a periodontal therapy as a regenerative procedure requires the demonstration of new cementum, periodontal ligament, and bone coronal to the base of the defect. A diversity of regenerative strategies has been evaluated, including root surface conditioning, bone grafts and bone substitute materials, guided tissue regeneration, enamel matrix proteins, growth/differentiation factors, combined therapies and, more recently, tissue-engineering approaches. The aim of this chapter of Periodontology 2000 is to review the research carried out in Latin America in the field of periodontal regeneration, focusing mainly on studies using preclinical models (animal models) and randomized controlled clinical trials. This review may help clinicians and researchers to evaluate the current status of the therapies available and to discuss the challenges that must be faced in order to achieve predictable periodontal regeneration in clinical practice.

Bone-implant-contact and new bone formation around implants placed in FDB blocks compared to placement at the adjunction of particulate FDB

BACKGROUND

The efficacy of human freeze-dried bone (h-FDB) as particulate vs block forms as a proper onlay augmented bone graft material to accommodate implants is undetermined.

PURPOSE

To evaluate osseointegration and new bone formation at implants placed in FDB blocks (BL group) and those at the adjunction of particulate FDB (PR group).

MATERIALS AND METHODS

Twelve pairs of h-FDB blocks were stabilized bilaterally to the calvaria of 12 rabbits. Twenty-four SLA implants were placed at the remodeled grafted blocks, 4 months later. A circumferential gap was created around one implant in each pair and packed with particulate h-FDB. Section biopsies were obtained at 2-month post implant placement (6 months post-block grafting). Bone-to-implant contact (BIC) and bone-area fraction (BAF) were histomorphometrically calculated.

RESULTS

The mean BIC was 34.4% and 33.5% for the BL and PR groups, respectively. The mean BAF was 23.9% and 26.4% for the corresponding groups, respectively. Osseointegration and newly formed bone were evident mostly between the threaded portions of the implants in proximity to the host rabbit calvaria compared to its cervical neck.

CONCLUSION

The particulate and the cancellous block h-FDB forms yielded similar BIC and BAF outcome. Full revascularization/revitalization is questioned.

The Combined Effect of Bioactive Glass and Platelet-Rich Fibrin in Treating Human Periodontal Intrabony Defects - A Clinicoradiographic Study

Background:

Platelets are richest source for cytokine and growth factors which are two important components for the re-establishment of bone and maturation of the soft tissue.

Aims and Objective:

The additive effect of PRF along with a synthetic bone graft material in treating human intrabony periodontal defects has been evaluated in this study. The appropriate use of platelet-rich fibrin (PRF) as an alternate comfortable graft material to restore the lost periodontal tissues has been well documented and has given clinically promising outcome.

Materials and Method:

Platelet-rich fibrin (PRF) is prepared from patient's own blood which is autologous in nature. Perio Glas (PG) is an easy to use synthetic absorbable osteostimulative as well as osteoconductive bone graft material. The selected 30 sites were randomly divided into two groups such as Test (15 sites using PRF) and Control (15 sites without PRF).

Results:

At the end of Six months, the post-operative evaluations revealed significant reduction in PPD and gain in CAL. Radiographic evidence of bone formation was also noticed. The incorporation of PRF with synthetic bone graft (perioglas) produces effective and rapid periodontal regeneration with improved healing in intrabony osseous defects. The PRF group showed a mean Radiographic Defect Fill (RDL) of 1.24 ± 0.04 compared with 0.79 ± 0.07 of control group which is statistically significant.

Conclusion:

This combination technique can be used as an alternate grafting modality for the treatment of intrabony periodontal defects with satisfactory clinical consequences.

Contemporary Class II Division 2 nonextraction adult treatment

Achieving ideal results when treating a difficult malocclusion is a challenge that orthodontists frequently encounter. Maintaining those results is sometimes more challenging than the correction itself. As specialists in orthodontics, we should be able to apply bone physiology concepts during the diagnosis and treatment planning process and predict how bone will react after biomechanical stimuli. Understanding bone physiology and the biology of tissue response during orthodontic tooth movement should allow us to develop the proper mechanical design and consequently the therapeutic procedures necessary to achieve the expected tooth position and bone architecture. Surgically facilitated orthodontic therapy uses basic bone biology and physiologic bone turnover procedures as well as basic orthodontic biomechanical principles to correct dental malocclusions in the shortest, safest, and most conservative manner. The correction of such malocclusions with this approach is expected to be functional and stable.

Dentascan an excellent tool for assessment of variations in the management of periodontal defects

Background

The purpose of the present study was to envisage the effectiveness of demineralized freeze-dried bone allograft (DFDBA) and bovine bone graft (BBG) for promoting defect fill in periodontal intrabony defects using dentascan.

Materials and Methods

A total of 13 subjects (15 intrabony defects) aged between 24 and 56 years affected by moderate to severe periodontitis were randomly divided into Control (CG) and Test groups (TG1 and TG2). In CG only debridement, TG1 debridement plus DFDBA, and TG2 debridement plus BBG were performed. The clinical parameters probing pocket depth (PPD), clinical attachment level (CAL) was used. The radiological analysis was done by dentascan, which is a single-slice spiral computed tomographic scanner. Six months after, regenerative treatment clinical measurements were recorded. The bone fill was assessed using Dentascan as previously mentioned.

Results

PPD reduction and CAL gain were significant in all the groups after 6 months whereas, on intergroup comparisons, insignificant finding was observed both at baseline and after 6 months. Coronoapical bone status decreased significantly in all groups, buccolingual measurements decreased significantly in TG1 and TG2, but no such trend was seen in CG. Significant reduction in mesiodistal bone status was noticed only in TG1 whereas insignificant on intergroup comparisons.

Conclusion

Dentascan-based analysis attested that DFDBA was superior to BBG.

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.

Dental pulp stem cells. Biology and use for periodontal tissue engineering

Inflammatory periodontal disease is a major cause of loss of tooth-supporting structures. Novel approaches for regeneration of periodontal apparatus is an area of intensive research. Periodontal tissue engineering implies the use of appropriate regenerative cells, delivered through a suitable scaffold, and guided through signaling molecules. Dental pulp stem cells have been used in an increasing number of studies in dental tissue engineering. Those cells show mesenchymal (stromal) stem cell-like properties including self-renewal and multilineage differentiation potentials, aside from their relative accessibility and pleasant handling properties. The purpose of this article is to review the biological principles of periodontal tissue engineering, along with the challenges facing the development of a consistent and clinically relevant tissue regeneration platform. This article includes an updated review on dental pulp stem cells and their applications in periodontal regeneration, in combination with different scaffolds and growth factors.

Management of a Periodontal Pocket Using a Removable Orthodontic Appliance and Nonsurgical Periodontal Therapy

Purpose. As documented in the literature, bony defects can be managed by an orthodontic approach. Methods. This case report describes the treatment of a bony defect caused by orthodontic malposition through phase I periodontal therapy and a simple removable orthodontic appliance used for the first time in a 20-year-old girl. Results. The periodontal pocket was reduced from 8 mm to 3 mm shortly after treatment. Conclusion. This case report concludes that orthodontic therapy can be used successfully in treatment of bony defects caused by mesially tilted molars.

Mandibular tori as bone grafts: an alternative treatment for periodontal osseous defects - clinical, radiographic and histologic morphology evaluation

OBJECTIVES

The present study was designed to evaluate the clinical, radiographic and histochemical significance of using the mandibular tori as autogenous bone graft for treatment of intraosseous defects in patients with chronic periodontitis.

MATERIALS AND METHODS

Twenty-eight sites from 14 patients with chronic periodontitis were included in this study. Each patient was treated with split mouth design; one site received torus mandibularis bone graft and the other site received a full-thickness fap alone. Histopathologic assessment was evaluated on removal of torus mandibularis to evaluate its histologic structure and by the end of the study 9 month later. Clinical and radiographic parameters were re-evaluated at 3 months interval for 1 year.

RESULTS

The results of the present study revealed significant gain in the clinical attachment level (CAL) (88.4%, 4.53 ± 0.06 mm) for torus mandibularis sites compared to (39.7%, 2.01 ± 0.04 mm) for full-thickness fap. Moreover, there was a reduction in the probing pocket depth (PPD) of (75.4%, 5.75 ± 0.12 mm) for torus mandibularis sites and (49.6%, 3.73 ± 0.14 mm) for sites treated with a full-thickness fap only; CAL and PPD differences were significant at p-value ≤0.01. Concomitantly, significant radiographic increase in the bone height and density were recorded in the test group.

CONCLUSION

The use of mandibular tori as autogenous bone graft could provide benefits as a periodontal therapeutic modality and enhance regenerative potential of periodontal intraosseous defects.

A comparative evaluation of platelet-rich plasma in combination with demineralized freeze-dried bone allograft and DFDBA alone in the treatment of periodontal intrabony defects: A clinicoradiographic study

BACKGROUND

The aim of the present clinical trial was to compare PRP combined with a DFDBA to DFDBA mixed with a normal saline solution in the treatment of human intrabony defects.

MATERIALS AND METHODS

Twenty interproximal intrabony osseous defects in twenty non-smoking, healthy subjects diagnosed with chronic periodontitis were treated in this study. Ten subjects each were randomly assigned to the test group (PRP + DFDBA) or the control group (DFDBA + saline). Clinical and radiographic measurements were made at baseline, three month and at six-month evaluation.

RESULTS

The results at three and six months, when compared to the baseline, indicated that both treatment modalities resulted in significant changes in all clinical parameters (gingival index, bleeding on probing, probing depth, clinical attachment level and gingival recession; P < 0.01) and radiographic parameters (hard-tissue fill and bone-depth reduction; P < 0.01). However, the test group exhibited statistically significantly greater changes compared to the control group in plaque index at three months (P = 0.00), probing depth reduction at 6 months (P = 0.02) and the radiographic defect fill at 6 months (P = 0.01).

CONCLUSIONS

Treatment with a combination of PRP and DFDBA led to a statistically significantly greater improvement in plaque index at 3 months, probing depth at 6 months and radiographic defect fill at 6 months in intrabony periodontal defects as compared to DFDBA with normal saline.

Comparison of Nano-Sized Hydroxyapatite and β-Tricalcium Phosphate in the Treatment of Human Periodontal Intrabony Defects

BACKGROUND

Since the advent of nanotechnology, various materials have been introduced for the treatment of the bone defects which have shown promising results.

AIM

The purpose of this study was to compare the effect of nano-sized Hydroxyapatite (NHA) and β-Tricalcium Phosphate (β-TCP) in the treatment of human periodontal defects.

MATERIALS AND METHODS

Tweleve patients with a total of 24 sites which were almost identical as determined clinically and radiographically were selected for the study. The selected sites were treated with access flap surgery were divided into two groups: Group I was treated with NHA and Group II treated with β-TCP. Following clinical and radiographic parameters were recorded at baseline, 3 months and 6 months post operatively: 1) Probing pocket depth (PPD); 2)Clinical attachment level (CAL); 3) Gingival recession (GR); 4) Radiographic Defect Depth.

RESULTS

Groups showed statistically significant improvements in soft and hard tissue parameters after 3 months and 6 months. Greater reduction in PPD, gain in CAL and Radiographic Defect Fill (RDF) was seen in Group I after three months whereas after six months were no statistically significant difference was seen with regard to soft and hard tissue measurements.

CONCLUSION

Within limits of the study, both NHA and β-TCP have proved to be beneficial in the management of periodontal defects. Treatment of intrabony periodontal defects with NHA leads to significant improvement in early clinical and radiographic outcomes as compared to β-TCP.

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.

Clinical outcomes following regenerative therapy of non-contained intrabony defects using a deproteinized bovine bone mineral combined with either enamel matrix derivative or collagen membrane

BACKGROUND

The purpose of this study is to compare clinical outcomes in the treatment of deep non-contained intrabony defects (i.e., with ≥70% 1-wall component and a residual 2- to 3-wall component in the most apical part) using deproteinized bovine bone mineral (DBBM) combined with either enamel matrix protein derivative (EMD) or collagen membrane (CM).

METHODS

Forty patients with multiple intrabony defects were enrolled. Only one non-contained defect per patient with an intrabony depth ≥3 mm located in the interproximal area of single- and multirooted teeth was randomly assigned to the treatment with either EMD + DBBM (test: n = 20) or CM + DBBM (control: n = 20). At baseline and after 12 months, clinical parameters including probing depth (PD) and clinical attachment level (CAL) were recorded. The primary outcome variable was the change in CAL between baseline and 12 months.

RESULTS

At baseline, the intrabony component of the defects amounted to 6.1 ± 1.9 mm for EMD + DBBM and 6.0 ± 1.9 mm for CM + DBBM sites (P = 0.81). The mean CAL gain at sites treated with EMD + DBBM was not statistically significantly different (P = 0.82) compared with CM + DBBM (3.8 ± 1.5 versus 3.7 ± 1.2 mm). No statistically significant difference (P = 0.62) was observed comparing the frequency of CAL gain ≥4 mm between EMD + DBBM (60%) and CM + DBBM (50%) or comparing the frequency of residual PD ≥6 mm between EMD + DBBM (5%) and CM + DBBM (15%) (P = 0.21).

CONCLUSION

Within the limitations of the present study, regenerative therapy using either EMD + DBBM or CM + DBBM yielded comparable clinical outcomes in deep non-contained intrabony defects after 12 months.

Regenerative periodontal therapy: 30 years of lessons learned and unlearned

In this review, we reflect upon advances and hindrances encountered over the last three decades in the development of strategies for periodontal regeneration. In this soul-searching pursuit we focus on revisiting lessons learned that should guide us in the quest for the reconstruction of the lost periodontium. We also examine beliefs and traditions that should be unlearned so that we can continue to advance the field. This learned/unlearned body of knowledge is consolidated into core principles to help us to develop new therapeutic approaches to benefit our patients and ultimately our society.

Clinical and radiographic evaluation of demineralized bone matrix (grafton) as a bone graft material in the treatment of human periodontal intraosseous defects

PURPOSE

The purpose of this clinical trial was to evaluate the efficacy of demineralized bone matrix (DBM) as a bone graft material in the treatment of human intrabony periodontal defects as compared with control defects treated by open flap debridement (OFD) alone.

MATERIALS AND METHODS

A controlled clinical trial was carried out for a period of 9 months in 11 patients (4 males and 7 females) with an age group of 25-50 years, contributing to a total of 30 defects. The selected defects were then randomly divided in to experimental sites (OFD + DBM) and control sites (OFD alone). Probing depth, clinical attachment levels and position of the gingival margin were recorded at baseline 3, 6 and 9 months post-operatively. Standardized radiographs (parallel technique) were also documented at these recall intervals.

RESULTS

On completion of 9 months, the mean percentage of probing depth reduction achieved in the experimental sites and control sites was 61.70%, 23.86% respectively. The mean percentage of clinical attachment level gain was 61.34% and 19.37% in the experimental and control sites respectively. In the experimental sites recession was observed to a lesser extent.

CONCLUSION

The use of DBM was more effective than OFD in improving clinical parameters and radiographic bone fill as shown in the present study. However, there is a need for further long term studies.

Morphology of bone particles after harvesting with 4 different devices

INTRODUCTION

Autogenous bone is routinely used for regeneration of osseous defects around teeth and implants, and different instruments are available for bone harvesting.

OBJECTIVES

The purpose of this study was to describe the morphology of bone particles after harvesting with 4 different instruments.

MATERIALS AND METHODS

Bone particles were harvested from fresh cow ribs with 2 different types of back action chisels, a safescraper and a sonic device. The samples were examined morphologically using light microscopy and scanning electron microscopy.

RESULTS

The bone particles after the back action chisel I had an appearance similar to "pencil shavings." With the back action chisel II, they were like thin paper with an "accordion bellows" appearance. After removal with the safescraper, they had an irregular shape (with an irregular surface) resembling "crushed stone." Finally, the appearance of the bone particles obtained with the sonic device was homogenous, condensed and continuous, and had a "seaweed" appearance.

CONCLUSIONS

Harvesting of bone particles with 4 different devices produce distinctly difference sizes and shapes, which may influence the results of grafting procedures.

In vitro evaluation of demineralized freeze-dried bone allograft in combination with enamel matrix derivative

BACKGROUND

Preclinical and clinical studies suggest that a combination of enamel matrix derivative (EMD) with demineralized freeze-dried bone allograft (DFDBA) may improve periodontal wound healing and regeneration. To date, no single study has characterized the effects of this combination on in vitro cell behavior. The aim of this study is to test the ability of EMD to adsorb to the surface of DFDBA particles and determine the effect of EMD coating on downstream cellular pathways such as adhesion, proliferation, and differentiation of primary human osteoblasts and periodontal ligament (PDL) cells.

METHODS

DFDBA particles were precoated with EMD or human blood and analyzed for protein adsorption patterns via scanning electron microscopy. Cell attachment and proliferation were quantified using a commercial assay. Cell differentiation was analyzed using real-time polymerase chain reaction for genes encoding Runx2, alkaline phosphatase, osteocalcin, and collagen 1α1, and mineralization was assessed using alizarinred staining.

RESULTS

Analysis of cell attachment revealed no significant differences among control, blood-coated, and EMD-coated DFDBA particles. EMD significantly increased cell proliferation at 3 and 5 days after seeding for both osteoblasts and PDL cells compared to control and blood-coated samples. Moreover, there were significantly higher messenger ribonucleic acid levels of osteogenic differentiation markers, including collagen 1α1, alkaline phosphatase, and osteocalcin, in osteoblasts and PDL cells cultured on EMD-coated DFDBA particles at 3, 7, and 14 days.

CONCLUSION

The results suggest that the addition of EMD to DFDBA particles may influence periodontal regeneration by stimulating PDL cell and osteoblast proliferation and differentiation.

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.

Demineralized bone matrix in bone repair: history and use

Demineralized bone matrix (DBM) is an osteoconductive and osteoinductive commercial biomaterial and approved medical device used in bone defects with a long track record of clinical use in diverse forms. True to its name and as an acid-extracted organic matrix from human bone sources, DBM retains much of the proteinaceous components native to bone, with small amounts of calcium-based solids, inorganic phosphates and some trace cell debris. Many of DBM's proteinaceous components (e.g., growth factors) are known to be potent osteogenic agents. Commercially sourced as putty, paste, sheets and flexible pieces, DBM provides a degradable matrix facilitating endogenous release of these compounds to the bone wound sites where it is surgically placed to fill bone defects, inducing new bone formation and accelerating healing. Given DBM's long clinical track record and commercial accessibility in standard forms and sources, opportunities to further develop and validate DBM as a versatile bone biomaterial in orthopedic repair and regenerative medicine contexts are attractive.

Clinical evaluation of a biphasic calcium phosphate grafting material in the treatment of human periodontal intrabony defects

Purpose

The aim of this study was to compare the clinical outcome of open flap debridement (OFD) with a biphasic calcium phosphate (BCP) graft to that of OFD without BCP graft for the treatment of intrabony periodontal defects (IBDs).

Methods

The study included 25 subjects that had at least one intrabony defect of 2- or 3-wall morphology and an intrabony component≥4 mm as detected radiographically. Subjects were randomly assigned to treatment with (BCP group, n=14) or without BCP (OFD group, n=11). Clinical parameters were recorded at baseline and 6 months after surgery and included the plaque index, gingival index, probing depth (PD), clinical attachment level (CAL), and gingival recession (REC). A stringent plaque control regimen was enforced for all of the patients during the 6-month observation period.

Results

In all of the treatment groups, significant PD reductions and CAL gains occurred during the study period (P<0.01). At 6 months, patients in the BCP group exhibited a mean PD reduction of 3.7±1.2 mm and a mean CAL gain of 3.0±1.1 mm compared to the baseline. Corresponding values for the patients treated with OFD were 2.5±0.8 mm and 1.4±1.0 mm, respectively. Compared to OFD group, the additional CAL gain was significantly greater in the patients in BCP group (P=0.028). The additional PD reduction was significant for the BCP group (P=0.048). The REC showed a significant increase in both groups, and the amount of recession was significantly smaller in the BCP group than OFD group (P=0.023). In radiographic evaluation, the height of the bone fill in the BCP group was significantly greater than OFD group.

Conclusions

The clinical benefits of BCP found in this study indicate that BCP may be an appropriate alternative to conventional graft materials.

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.

Clinical evaluation of guided tissue regeneration combined with autogenous bone or autogenous bone mixed with bioactive glass in intrabony defects

Conflicting data exist on the combined use of grafting materials and barrier membranes in comparison to guided tissue regeneration (GTR) with membrane alone. The aim of the present study was to compare the clinical outcomes of GTR with collagen membrane (CM) alone (control group) or CM combined with autogenous bone graft (test group 1) or autogenous bone mixed with bioactive glass (test group 2) in intrabony defects. A total of 32 intraosseous defects in 22 subjects were treated randomly. After 6 months, significant probing depth reduction, clinical attachment level gain (CAL) and defect resolution were observed in all groups with significantly greater improvements in the test groups. There was no significant difference between the two test groups in any parameter. Results of the present study suggest that autogenous bone can be mixed with bioactive glass if the amount of the harvested bone is not sufficient.

Comparative evaluation of bioglass with calcium sulphate β-hemihydrate for the treatment of intraosseous defects-a clinico-radiological study

BACKGROUND

The aim of the present clinical and radiological study was to compare bioglass and calcium sulphate β-hemihydrate in the treatment of intraosseous defect in chronic periodontitis.

METHOD

A total of 50 subjects with bilaterally symmetrical periodontal osseous defects with probing pocket depth = 5 mm and intraosseous defects ≥ 3 mm as seen on the radiographs were undertaken for the study. In one site (group A) bioactive glass was placed in defect and in contralateral site (group B) calcium sulphate β-hemihydrate was used in the defect site.

RESULTS

Clinical improvement was noted in all patients at the end of study. Both the groups showed reduction in probing pocket depth, increase in clinical attachment level, and reduction in osseous defect. Both materials were effective in achieving osseous gain.

CONCLUSION

The osseous gain in group A subjects was 58.93%, whereas in group B subjects it was 48.56%. Calcium sulphate β-hemihydrates showed promising results and were cost effective.

Periodontal regeneration with enamel matrix derivative in reconstructive periodontal therapy: a systematic review

BACKGROUND

Enamel matrix derivative (EMD) is commonly used in periodontal therapy. The aim of this systematic review is to give an updated answer to the question of whether the additional use of EMD in periodontal therapy is more effective compared with a control or other regenerative procedures.

METHODS

A literature search in MEDLINE (PubMed) for the use of EMD in periodontal treatment was performed up to May 2010. The use of EMD in treatment of intrabony defects, furcations, and recessions was evaluated. Only randomized controlled trials with ≥1 year of follow-up were included. The primary outcome variable for intrabony defects was the change in clinical attachment level (CAL), for furcations the change in horizontal furcation depth, and for recession complete root coverage.

RESULTS

After screening, 27 studies (20 for intrabony defects, one for furcation, and six for recession) were eligible for the review. A meta-analysis was performed for intrabony defects and recession. The treatment of intrabony defects with EMD showed a significant additional gain in CAL of 1.30 mm compared with open-flap debridement, EDTA, or placebo, but no significant difference compared with resorbable membranes was shown. The use of EMD in combination with a coronally advanced flap compared with a coronally advanced flap alone showed significantly more complete root coverage (odds ratio of 3.5), but compared with a connective tissue graft, the result was not significantly different. The use of EMD in furcations (2.6 ± 1.8 mm) gave significantly more improvement in horizontal defect depth compared with resorbable membranes (1.9 ± 1.4 mm) as shown in one study.

CONCLUSIONS

In the treatment of intrabony defects, the use of EMD is superior to control treatments but as effective as resorbable membranes. The additional use of EMD with a coronally advanced flap for recession coverage will give superior results compared with a control but is as effective as a connective tissue graft. The use of EMD in furcations will give more reduction in horizontal furcation defect depth compared with resorbable membranes.

Minimally invasive periodontal therapy

Minimally invasive dentistry is a concept that preserves dentition and supporting structures. However, minimally invasive procedures in periodontal treatment are supposed to be limited within periodontal surgery, the aim of which is to represent alternative approaches developed to allow less extensive manipulation of surrounding tissues than conventional procedures, while accomplishing the same objectives. In this review, the concept of minimally invasive periodontal surgery (MIPS) is firstly explained. An electronic search for all studies regarding efficacy and effectiveness of MIPS between 2001 and 2009 was conducted. For this purpose, suitable key words from Medical Subject Headings on PubMed were used to extract the required studies. All studies are demonstrated and important results are concluded. Preliminary data from case cohorts and from many studies reveal that the microsurgical access flap, in terms of MIPS, has a high potential to seal the healing wound from the contaminated oral environment by achieving and maintaining primary closure. Soft tissues are mostly preserved and minimal gingival recession is observed, an important feature to meet the demands of the patient and the clinician in the esthetic zone. However, although the potential efficacy of MIPS in the treatment of deep intrabony defects has been proved, larger studies are required to confirm and extend the reported positive preliminary outcomes.