Comparison of freeze-dried bone allograft and porous hydroxylapatite in human periodontal defects

A Clinical and Radiographic Evaluation of the Efficacy of Nanohydroxyapatite (Sybograf™) versus Bioactive Calcium Phosphosilicate Putty (Novabone®) in the Treatment of Human Periodontal Infrabony Defects: A Randomized Clinical Trial

Aim:

The aim of this study is to compare and to evaluate clinically and radiographically the bone regeneration and the amount of bone fill (BL) between nanocrystalline hydroxyapatite (Nc-HA) (Sybograf™) and bioactive synthetic NovaBone Putty in the treatment of intrabony component of periodontal osseous defects.

Materials and Methods:

Twenty sites in 20 patients, within the age range of 25–55 years, showing intrabony defects were selected and divided into Group I (Nc-HA) and Group II (Bioactive synthetic NovaBone Putty). All the selected sites were assessed with the clinical and radiographic parameters such as plaque index, gingival index, sulcus bleeding index, probing pocket depth, clinical attachment level, gingival recession, and radiographic BL. All the clinical and radiographic parameter values obtained at different intervals (baseline, 3, and 6 and 9 months) were subjected to statistical analysis.

Results:

A statistically significant reduction in pocket depth of 4.400 ± 0.843 mm (Group I), 3.800 ± 0.789 mm (Group II) and gain in clinical attachment level of 6.2 mm (Group I), 5.9 mm (Group II) were recorded at the end of the study. A slight increase in gingival recession was observed. The mean percentage changes in the amount of radiographic BL of Group II and Group I were significant, However, when compared between the groups, there is no significant difference in BL observed.

Conclusion:

Both the graft materials appear to have nearly comparable effects, with nanocrystalline hydroxyapatite (Sybograf™), displaying slightly superior effect over bioactive glass especially in relation to clinical parameters. However, long-term, controlled clinical trials are required to confirm these findings.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

A comparative evaluation of freeze dried bone allograft and decalcified freeze dried bone allograft in the treatment of intrabony defects: A clinical and radiographic study

BACKGROUND

Ideal graft material for regenerative procedures is autogenous bone graft but the major disadvantage with this graft is the need for a secondary surgical site to procure donor material and the frequent lack of intraoral donor site to obtain sufficient quantities of autogenous bone for multiple or deep osseous defects. Hence, to overcome these disadvantages, bone allografts were developed as an alternative source of graft material.

MATERIALS AND METHODS

In 10 patients with chronic periodontitis, 20 bilateral infrabony defects were treated with freeze dried bone allograft (FDBA-Group A) and decalcified freeze dried bone allograft (DFDBA-Group B). Clinical and radiographic parameters were assessed preoperatively and at 3 months and 6 months postoperatively. Data thus obtained was subjected to statistical analysis.

RESULTS

Significant improvement in the reduction in probing depth and relative attachment level (RAL) from the baseline to 3 months to baseline to 6 months in group A and group B, which was statistically significant but no statistically significant reduction was seen between 3 months and 6 months. On inter-group comparison, no significant differences were observed at all-time points. In adjunct to the probing depth and RAL, the radiographic area of the defect showed a similar trend in intra-group comparison and no significant difference was seen on inter-group comparison at all-time points.

CONCLUSIONS

Within the limitations of the current study, it can be concluded that DFDBA did not show any improvement in the clinical and radiographic parameters in the treatment of the intrabony defects as compared to FDBA.

A clinical evaluation of a bioresorbable membrane and porous hydroxyapatite in the treatment of human molar class II furcations

Background:

The ultimate goal of periodontal therapy is predictable regeneration of a functional attachment apparatus destroyed as a result of periodontitis. Reconstructive procedures have been used with varying success during the past decades to accomplish this goal.

Aim:

To evaluate whether the use of porous hydroxyapatite alone or a bioresorbable membrane alone would enhance the clinical results in the treatment of class II furcation defects in human lower molars.

Materials and Methods:

Fifteen patients with chronic periodontitis, aged between 39 and 49 years, with a pair of similar bilateral class II furcation defects (classification of Hamp et al.) in mandibular first molars were selected. A split-mouth design was incorporated and the selected 30 furcation defects were assigned to one of the two treatment groups, i.e., Group I treated with a bioresorbable membrane from bovine-derived collagen guided tissue regeneration membrane and Group II treated using porous hydroxyapatite bone graft material on the contralateral sides. Evaluation of clinical parameters, probing depths and attachment levels, and radiographs was done preoperatively and 6 months postoperatively.

Results:

Both the groups showed statistically significant mean reduction in probing depths and gain in clinical attachment levels and linear bone fill. Comparison between Group I and Group II showed insignificant difference.

Conclusion:

Within the limits of this study, both the treatment modalities are beneficial for the treatment of human mandibular class II furcation defects.

Osteoinductivity of demineralized bone matrix is independent of donor bisphosphonate use

BACKGROUND

Demineralized bone matrix is commonly used as a bone graft substitute, either alone or to supplement an osteoconductive material, because of its osteoinductive properties. The aging of the population has led to an increase in the number of prospective donors of demineralized bone matrix who have taken bisphosphonates to prevent osteoclast-mediated bone resorption. The aim of this study was to determine whether oral bisphosphonate usage affects the osteoinductivity of demineralized bone matrix from donors.

METHODS

Sex-matched and age-matched pairs of samples were provided by four tissue banks (three or four pairs per bank). Demineralized bone matrix donors without bisphosphonate treatment had a mean age (and standard deviation) of 69.1 ± 2.5 years, and donors with bisphosphonate treatment had a mean age of 68.9 ± 2.0 years. Each pair included one donor known to have taken bisphosphonates and one who had not taken bisphosphonates. Demineralized bone matrix previously confirmed as osteoinductive was the positive control, and heat-inactivated demineralized bone matrix was the negative control. Demineralized bone matrix incubated with 1 mL of phosphate-buffered saline solution containing 0, 0.002, 2.0, or 2000 ng/mL of alendronate was also tested. Gelatin capsules containing 15 mg of demineralized bone matrix were implanted bilaterally in the gastrocnemius muscle of male nude mice (eight implants per group). The mice were killed thirty-five days after implantation, and hind limbs were recovered and processed for histological analysis. Osteoinductivity was measured with use of a qualitative score and by histomorphometry.

RESULTS

Nine of fifteen samples from donors who had had bisphosphonate treatment and ten of fifteen samples from patients who had not had bisphosphonate treatment were osteoinductive. Qualitative mean scores were comparable (1.7 ± 0.4 for those without bisphosphonates and 1.9 ± 0.7 for those with bisphosphonates). Osteoinductive demineralized bone matrix samples produced ossicles of comparable size, regardless of bisphosphonate usage. Histomorphometric measurements of the area of new bone formation and residual demineralized bone matrix were also comparable. The addition of alendronate to control demineralized bone matrix did not affect its osteoinductivity.

CONCLUSIONS

Demineralized bone matrix samples from donors treated with bisphosphonates and donors not treated with bisphosphonates have the same ability to induce bone formation. However, it is not known if the quality of the new bone is affected, with subsequent consequences affecting bone remodeling.

Prognosis of periapical surgery using bonegrafts: A clinical study

AIM

to evaluate and compares the healing clinically and radiographically following periapical surgery with and without using hydroxyapatite graules.

MATERIALS AND METHODS

Twenty patients were selected for the study & the nature of healing is compared with that of conventional periapical surgery. In the present clinical study chitra hydroxyapatite granules, a freeze-dried hydroxyapatite, is used to fill the osseous defects following periapical surgery. Following surgery all patients were assessed both clinically & radiographically for a period of nine months.

RESULTS

On clinical evaluation the test group did not show any significant immediate or delayed local tissue reactions. Radiographically in the follow up period of 6 - 9 months the bone graft became indistinguishable from the surrounding bone which indicates complete bone regeneration. Where as in the control group ever after 9 months the radiographs showed inadequate bone fills.

CONCLUSION

The bone regeneration following periapical surgery can be facilitated by using bone graft. Hydroxyapatite is found to be very effective alloplastic material. Based on this study it might be concluded that in large bone destruction caused by periradicular lesion bone regeneration can be facilitated by effective bone replacing materials like hydroxyapatite.

Bone replacement grafts for the treatment of periodontal intrabony defects

Bone replacement grafts, including autogenous grafts from intraoral donor sites, allografts, xenografts, and alloplastic bone substitutes, are the most widely used treatment modalities for the regeneration of periodontal osseous defects. Studies suggest a favorable clinical outcome with the use of these materials in terms of improvements in periodontal probing depths, probing attachment gains, and bone fill. In terms of bone fill, most studies report more than 50% resolution of intrabony defects when treated with bone replacement grafts. However, histologic evidence of periodontal regeneration, including new bone, periodontal ligament, and cementum, has been reported only for autogenous bone grafts and demineralized freeze-dried bone allografts.

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.

Effect of a hydroxyapatite tricalcium phosphate alloplast on osseous repair in the rat calvarium

BACKGROUND

Bony defects caused by periodontitis are often treated by regenerative therapy using autografts and/or allografts. Alloplasts, such as hydroxyapatite or ceramics, are also used as osteoconductive materials that serve as a scaffold for new bony ingrowth. The purpose of this study was to determine the effect of hydroxyapatite tricalcium phosphate (HA-TCP) on osseous repair in the rat calvarium.

METHODS

Forty-four adult male Harlan Sprague-Dawley rats were assigned to one of four treatment groups: HA-TCP macroporous disk, HA-TCP microporous disk, HA-TCP granules, and demineralized freeze-dried bone (DFDB). The materials were placed into 8-mm calvarial critical-size defects (CSD). Calvariae were harvested at 10 weeks post-surgery and evaluated histomorphometrically.

RESULTS

The DFDB group had significantly (P <0.05) more new bone formation (47%) than any other group. The HA-TCP macroporous disk group had significantly (P <0.05) more new bone formation (19.7%) than the HA-TCP microporous disk (8.5%) or HA-TCP granule (6.9%) groups.

CONCLUSIONS

The HA-TCP macroporous disk may elicit significant new bone formation due to its rigid space-maintaining scaffold and pore size for vascular ingrowth. It is well tolerated by host tissues and may be a suitable carrier for growth factors.

Position Paper: Periodontal Regeneration

Untreated periodontal disease leads to tooth loss through destruction of the attachment apparatus and tooth-supporting structures. The goals of periodontal therapy include not only the arrest of periodontal disease progression,but also the regeneration of structures lost to disease where appropriate. Conventional surgical approaches (e.g., flap debridement) continue to offer time-tested and reliable methods to access root surfaces,reduce periodontal pockets, and attain improved periodontal form/architecture. However, these techniques offer only limited potential towards recovering tissues destroyed during earlier disease phases. Recently, surgical procedures aimed at greater and more predictable regeneration of periodontal tissues and functional attachment close to their original level have been developed, analyzed, and employed in clinical practice. This paper provides a review of the current understanding of the mechanisms, cells, and factors required for regeneration of the periodontium and of procedures used to restore periodontal tissues around natural teeth. Targeted audiences for this paper are periodontists and/or researchers with an interest in improving the predictability of regenerative procedures. This paper replaces the version published in 1993.

Periodontal regeneration techniques for treatment of periodontal diseases

The ultimate goal of periodontal therapy is the regeneration of structures lost to disease. Conventional surgical approaches such as open-flap debridement offer only limited regeneration potential.Currently, surgical procedures for predictable regeneration of periodontal tissues are being developed, analyzed, and employed in clinical practice. This article addresses current trends in periodontal regeneration. Various materials/agents such as bone replacement grafts, barrier membranes, and biologic modifiers currently used for the regeneration of periodontal infrabony and furcation defects are discussed.

Ultrastructure of bone healing in defects grafted with a copolymer of polylactic/polyglycolic acids

Bone substitutes have been used for the treatment of bone defects. The objective of this study was to ultrastructurally evaluate the healing pattern of bone defects filled with a copolymer of polylactic/polyglycolic acid (FisiograftR) at a time point in which it is expected to be only partially degraded, with the purpose to ultrastructurally analyze how the bone is forming around the grafting material. Three 5-mm-diameter bone defects were created in each tibia from 5 rabbits (average weight 2.5 kg) in which the material was randomly implanted. Animals were sacrificed 30 days after surgery and the 30 bone defects were fixed in 2% glutaraldehyde-2.5% formaldehyde, under microwave irradiation, decalcified in EDTA, embedded in Spurr resin, and examined in a Jeol 1010 TEM. All the bone defects were filled with connective tissue, interspersed with different amounts of the filling material and newly formed bone trabeculae. In areas where the degrading copolymer was present in small amounts, newly formed bone matrix was detected; it was deposited by osteoblast-like cells in close relation to the copolymer. In areas where the degrading copolymer formed accumulates, an amorphous multilayered material was identified between the connective tissue and the copolymer. In summary, the copolymer of PLA/PGA studied appears to be an osteoconductive material when it is used to fill bone defects.

Management of mandibular third molar extraction sites to prevent periodontal defects

PURPOSE

Persistent periodontal defects on the distal aspect of the mandibular second molar (M2) is a reported complication of mandibular third molar (M3) extraction. The purpose of this study was to measure the efficacy of demineralized bone powder (DBP) or guided-tissue regeneration therapy (GTR therapy) in preventing periodontal defects on the distal aspect of the M2 following M3 extraction.

MATERIALS AND METHODS

We implemented a single-blind, randomized, controlled clinical trial composed of a sample of subjects > or = 26 years of age who required extraction of bilateral M3s. The primary predictor variable was treatment group. Each subject was randomly assigned to receive either DBP or GTR therapy. Within subjects, 1 M3 site was randomly selected to be the experimental site and the opposite M3 served as a control and was permitted to heal without intervention. The primary outcome variable was the change in attachment levels (AL) and probing depths (PD) on the disto-buccal aspect of M2 between T 0 (immediate preoperatively) and T 4 (26 weeks postoperatively). Appropriate sample size estimates, descriptive, bivariate, and multivariate statistics were computed.

RESULTS

Twelve subjects in the DBP group and 12 subjects in the GTR-therapy group completed the study. For both treatment and control sites, between T 0 and T 4, there were statistically significant improvements in AL (> or = 2.2 mm; P <.001) and PD (> or = 2.6 mm; P <.001). Within-subjects comparisons showed no significant differences in AL or PD between treatment and control M3 sites ( P > or =.3) at T 0 or T 4.

CONCLUSION

The results of this study suggest that attachment levels and probing depths improve after M3 removal. In this sample, DBP or GTR therapy did not offer predictable benefit over no treatment.

The efficacy of bone replacement grafts in the treatment of periodontal osseous defects. A systematic review

BACKGROUND

Bone replacement grafts (BRG) are widely used in the treatment of periodontal osseous defects; however, the clinical benefits of this therapeutic practice require further clarification through a systematic review of randomized controlled studies.

RATIONALE

The purpose of this systematic review is to access the efficacy of bone replacement grafts in proving demonstrable clinical improvements in periodontal osseous defects compared to surgical debridement alone.

FOCUSED QUESTION

What is the effect of bone replacement grafts compared to other interventions on clinical, radiographic, adverse, and patient-centered outcomes in patients with periodontal osseous defects?

SEARCH PROTOCOL

The computerized bibliographical databases MEDLINE and EMBASE were searched from 1966 and 1974, respectively, to October 2002 for randomized controlled studies in which bone replacement grafts were compared to other surgical interventions in the treatment of periodontal osseous defects. The search strategy included screening of review articles and reference lists of retrieved articles as well as hand searches of selected journals.

INCLUSION CRITERIA

All searches were limited to human studies in English language publications.

EXCLUSION CRITERIA

Non-randomized observational studies (e.g., case reports, case series), publications providing summary statistics without variance estimates or data to permit computation, and studies without BRG intervention alone were excluded.

DATA COLLECTION AND ANALYSIS

The therapeutic endpoints examined included changes in bone level, clinical attachment level, probing depth, gingival recession, and crestal resorption. For purposes of meta-analysis, change in bone level (bone fill) was used as the primary outcome measure, measured upon surgical re-entry or transgingival probing (sounding).

MAIN RESULTS

1. Forty-nine controlled studies met eligibility criteria and provided clinical outcome data on intrabony defects following grafting procedures. 2. Seventeen studies provided clinical outcome data on BRG materials for the treatment of furcation defects.

REVIEWERS' CONCLUSIONS

1. With respect to the treatment of intrabony defects, the results of meta-analysis supported the following conclusions: 1) bone grafts increase bone level, reduce crestal bone loss, increase clinical attachment level, and reduce probing depth compared to open flap debridement (OFD) procedures; 2) No differences in clinical outcome measures emerge between particulate bone allograft and calcium phosphate (hydroxyapatite) ceramic grafts; and 3) bone grafts in combination with barrier membranes increase clinical attachment level and reduce probing depth compared to graft alone. 2. With respect to the treatment of furcation defects, 15 controlled studies provided data on clinical outcomes. Insufficient studies of comparable design were available to submit data to meta-analysis. Nonetheless, outcome data from these studies generally indicated positive clinical benefits with the use of grafts in the treatment of Class II furcations. 3. With respect to histological outcome parameters, 2 randomized controlled studies provide evidence that demineralized freeze-dried bone allograft (DFDBA) supports the formation of a new attachment apparatus in intrabony defects, whereas OFD results in periodontal repair characterized primarily by the formation of a long junctional epithelial attachment. Multiple observational studies provide consistent histological evidence that autogenous and demineralized allogeneic bone grafts support the formation of new attachment. Limited data also suggest that xenogenic bone grafts can support the formation of a new attachment apparatus. In contrast, essentially all available data indicate that alloplastic grafts support periodontal repair rather than regeneration. 4. The results of this systematic review indicate that bone replacement grafts provide demonstrable clinical improvements in periodontal osseous defects compared to surgical debridement alone.

Use of Bioglass for Orbital Volume Augmentation in Enophthalmos

PURPOSE

To investigate the clinical and histologic response of Novabone-C/M as an osteoproductive alloplastic implant for volume augmentation in the orbit in the treatment of enophthalmos and to compare its outcome alone versus its use in combination with autogenous bone or Medpor granules.

METHODS

Novabone-C/M, a bioactive silicone glass material, was implanted in the subperiosteal space of the left orbit of 12 New Zealand White rabbits. The animals were divided into 3 groups, each with 4 animals, based on the material implanted in the orbit: group 1, Novabone alone; group 2, Novabone plus Medpor granules; and group 3, Novabone plus autogenous bone fragments. All rabbits were studied clinically, radiographically, and histologically at 1-, 3-, and 6-month intervals. Animals underwent preoperative and postoperative computed tomography (CT) with 3-dimensional reconstruction, proptosis measurements, and volumetric analysis. Orbit specimens were studied histologically with mineralized bone stain (MIBS) to look for bone formation, reactivity, infection, implant resorption, and migration.

RESULTS

There were no signs of significant inflammation or infection. Subcutaneous migration of the implant was seen radiographically but not clinically in groups 1 and 3. Induced proptosis averaged 2.5 mm (at 1 month) and showed regression in all groups over a 6-month period but was not statistically significant. Implant volume was markedly reduced in all groups, averaging 69% in group 1, 37% in group 2, and 59% in group 3 at 6 months. New bone formation and bone remodeling was present in all 3 groups at 3 months and only in group 2 at 6 months. The rate and amount of implant remodeling and bone formation was greatest in the Novabone/Medpor group (group 2).

CONCLUSIONS

Bioglass particulate is biocompatible, easy to use in the orbit, and stimulates bone growth. Bioglass is associated with volume loss and migration over 6 months and may not provide adequate volume augmentation in the orbit when used alone for the treatment of enophthalmos. The duration and amount of bone formation may be enhanced when Novabone is used in conjunction with Medpor.

The segmental ridge-split procedure

This report details surgical procedures for ridge expansion by means of splitting the crest of an edentulous ridge. Atrophic bony ridges present a unique challenge to the dental implant surgeon. In the past, onlay grafts of bone harvested from the hip, maxillary tuberosity, symphysis of the chin, or external oblique ridge have all been used with success in reconstruction of atrophic ridges. However, bone onlay grafting procedures require a secondary surgical site, which exhibits typical postoperative morbidity associated with bone harvesting performed with chisels and burs. Additionally, onlay grafts often require a healing period of 6 months to a year before dental implants can be placed, and the onlay graft sometimes fails to fuse to the augmented site. The segmental ridge-split procedure provides a quicker method wherein an atrophic ridge can be predictably expanded and grafted with bone allograft, eliminating the need for a second surgical site.

A comparative study of osseointegration of Avana implants in a demineralized freeze-dried bone alone or with platelet-rich plasma

PURPOSE

The purpose of this study was to assess the efficacy of demineralized bone powder (DBP) alone or combined in a mixture with platelet-rich plasma (PRP) used to enhance osseointegration of dental implants in a dog model.

MATERIALS AND METHODS

Tissue integration was assessed using standard histomorphometric methods at 6 and 12 weeks after surgery. A total of 30 Avana dental implants (SooMin Synthesis Dental Materials Co, Busan, Korea) were inserted in the animals. They were self-tapping screw implants, 10 mm in length and 4 mm in diameter, made of commercially pure titanium. A titanium implant was then placed centrally in each defect. In each dog, the defects were treated with 1 of the following 3 treatment modalities:1) no treatment (control), 2) grafting with DBP, or 3) grafting with DBP and PRP.

RESULTS

Histologic analysis showed that all of the bone defects surrounding the implants that were treated with DBP, with and without PRP, were filled with new bone. The defects that were not treated (control) showed new bone formation only in the inferior threaded portion of the implants. Histomorphometric results revealed a higher percentage of bone contact with DBP and PRP compared with control and DBP.

CONCLUSION

These results suggested that bone defects around titanium implants can be treated successfully with DBP and that PRP may improve bone formation.

Thirty-six month follow-up of 25 patients treated with combination anorganic bovine-derived hydroxyapatite matrix (ABM)/cell-binding peptide (P-15) bone replacement grafts in human infrabony defects. I. Clinical findings

BACKGROUND

Long-term evaluation of periodontal therapy is important for clinical decision making.

METHODS

A synthetic cell-binding peptide (P-15) combined with anorganic bovine-derived hydroxyapatite bone matrix (ABM) was evaluated as a bone replacement graft in human periodontal osseous defects. Following initial preparation and reevaluation, flap surgery was performed. A variety of 1-, 2-, 3-wall bony defects were curetted and root surfaces subjected to mechanical debridement only. The bone defects were grafted with ABM/P-15, and the host flaps replaced or slightly coronally positioned. Weekly, then monthly deplaquing was performed until surgical reentry at 6 to 7 months. Patients were then followed on approximate 3-month recalls for 3 years. Twenty-five of the original 31 patients qualified for long-term evaluation in that their ABM/P-15 treated sites did not receive any additional therapy at the time of reentry.

RESULTS

Significant clinical changes for the overall group of bony defects included improvement in mean clinical attachment level from 5.4 mm at surgery to 4.5 mm at the 6-month reentry to 3.8 mm at 3 years. There was also a decrease in mean probing depth from 5.3 mm at surgery to 3.1 mm at the 6-month reentry to 2.9 mm at 3 years. The mean gingival recession changed from +0.1 mm at surgery to 1.4 mm at the 6-month reentry to 0.9 mm at 3 years. All of these differences were at least P <0.05 from surgery to the 6-month reentry, and surgery to 3 years, but were not significant from reentry to 3 years via repeated measures analysis of variance.

CONCLUSIONS

These favorable 3-year results with ABM/P-15 suggest that it may have a beneficial effect in the long-term clinical management of infrabony defects. Further long-term randomized controlled studies are needed to better assess the role of ABM/P-15 in long-term healing of periodontal osseous defects.

Effects of pretreatment clinical parameters on bioactive glass implantation in intrabony periodontal defects

BACKGROUND

The various methods for regeneration of periodontal tissue that have been developed can be classified into guided tissue regeneration and bone implantation. Since the implantation materials have shown both deficiencies and merits, dentists have begun exploring the bioactive glass first used in plastic surgery. This paper examines the effectiveness of this new material on periodontal intrabony defects.

METHODS

Clinical effects of bioactive glass implantation in intrabony periodontal defects were evaluated 6 months after surgery in 38 intrabony defects from 38 patients with chronic periodontitis. Twenty-one experimental defects received bioactive glass implantation (test group), while 17 control defects were treated with a flap procedure only (control group). The criteria for comparative observation were preoperative and postoperative probing depth (PD), clinical attachment level (CAL), bone probing depth (BPD), and gingival recession.

RESULTS

Reductions in PD were observed in both groups (P<0.01). The reduction in PD was significantly greater in the test group when preoperative PD exceeded 7 mm (P<0.01). Improvements in CAL were also observed in both groups (P<0.01), with the test group showing significantly greater gains (P<0.05). In those cases where preoperative CAL was less than 7 mm, there was no statistically significant difference between the two groups. Reduction in BPD was observed in both groups, with the test group showing significantly greater reduction (P <0.01). There was no significant difference in BPD change, however, when preoperative BPD was < or =7 mm. Significantly greater reduction of BPD in the test group was observed when intrabony defect depth was >4 mm (P <0.05). Significant improvements in PD, CAL, and BPD were noted in the test group when the crestal involvement exceeded 100 degrees. Correlation test between various clinical parameters indicated that greater changes in PD and CAL in the test group were observed when preoperative CAL was large (P<0.001), and greater changes in PD (P<0.05), CAL (P<0.01), and BPD (P<0.05) were noted when preoperative BPD was large. Correlation between crestal involvement and CAL change was noted only in the control group (P<0.01). High correlations were observed between PD changes and CAL changes and between CAL changes and BPD changes in both groups.

CONCLUSIONS

Use of a bone substitute in a flap operation resulted in significantly greater improvements in CAL and BPD over flap operation alone and seemed to have positive effects in postoperative PD, CAL, and BPD in those cases with more severe preoperative CAL and BPD.

Tissue banking of bone allografts used in periodontal regeneration

This paper was prepared by the Committee on Research, Science and Therapy of the American Academy of Periodontology for the information of the dental profession. However, it may also be of interest to the lay public. It represents the position of the American Academy of Periodontology regarding tissue banking and the use of bone allografts in periodontal therapy.

Tests for 2 x K contingency tables with clustered ordered categorical data

Ordered categorical data summarized in a 2 x K table usually consist of two-sample multinomial or K-sample binomial observations. In analysing these data, we usually assign scores to the K columns and perform a testing for the equality of two multinomial distributions in the former case and no trend among K binomial proportions in the latter case. Among the most popular score tests are the Wilcoxon rank sum test and the Armitage's linear trend test. In this paper we extend the score tests to be used for clustered data under diverse study designs. Our methods do not require correct specification of the dependence structure within clusters. The proposed tests are based on the asymptotic normality for large number of clusters and are a generalization of the standard tests used for independent data. Simulation studies are conducted to investigate the finite-sample performance of the new methods. The proposed methods are applied to real-life data.

Multi-center clinical comparison of combination anorganic bovine-derived hydroxyapatite matrix (ABM)/cell binding peptide (P-15) and ABM in human periodontal osseous defects. 6-month results

BACKGROUND

Intraosseous periodontal defects present a particular treatment problem. New bone replacement grafts offer promise for improved results.

METHODS

The role of a synthetic cell-binding peptide (P-15), combined with anorganic [corrected] bovine-derived hydroxyapatite bone matrix (ABM), was compared to ABM alone in human periodontal osseous defects in a controlled, monitored, multi-center trial. Following appropriate initial preparation procedures, flap surgery with defect and root debridement was performed. Two osseous defects per patient were treated randomly with each procedure after surgical preparation. Appropriate periodontal maintenance schedules were followed, and at 6 to 7 months, re-entry flap surgery was performed for documentation and finalization of treatment.

RESULTS

T test and Mann-Whitney U analyses of patient mean values from 33 patients revealed that the combination ABM/P-15 grafts demonstrated significantly better mean defect fill of 2.9 +/- 1.2 mm (72.9%) versus a mean defect fill of 2.2 +/- 1.4 mm (50.67%) for defects treated with ABM (P<0.05). Other hard tissue findings showed similar clinically superior results with the use of ABM/P-15. Relative defect fill results showed 81% positive (50% to 100% defect fill) responses with ABM/P-15 and 67% positive responses with ABM. There were 3.5 times as many optimal results (> or = 90% defect fill) with ABM/P-15 and twice as many failures (minimal response) with ABM. Soft tissue findings showed no significant differences between treatments.

CONCLUSIONS

These results suggest that the use of the P-15 synthetic cell-binding peptide combined with ABM yields better clinical results than the ABM alone in intrabony periodontal defects.

Bioactive ceramics for periodontal treatment: comparative studies in the Patus monkey

Four bioactive ceramic materials currently recommended for regeneration of osseous tissues in treatment of periodontal disease have been compared with Bioglass particulates, of equivalent size in two compositions, in a monkey model. Both Bioglass materials were found to be easily manipulated, were haemostatic and osteoproductive allowing restoration of both alveolar bone and periodontal ligament. Epithelial downgrowth was inhibited and epithelial attachment was close to the preimplantation level. The other materials were slower to act and epithelial downgrowth was to the same level as in unfilled control defects.

Bone and bone substitutes

Bone replacement grafts will play a continuing role in periodontal and other regenerative therapy. Several choices are available to the clinician including autogenous, allogeneic, xenogeneic and a variety of alloplastic materials. Except for fresh autogenous bone, bone replacement graft(s) do not provide the cellular elements necessary for osteogenesis nor can they reliably be considered truly osteoinductive, but instead are mostly osteoconductive, providing a scaffold for bone deposition. Currently, significant decrease in clinical probing depth and gain of clinical attachment have been reported following use of bone replacement grafts when compared to flap debridement surgery alone for periodontal osseous defects. Reported differences among bone replacement grafts (autogenous, allogeneic, xenogeneic, and alloplastic) occur with respect to histological outcomes. Overall, probing depth reduction, attachment level gain and degree of defect fill are similar for all bone replacement grafts.

Multi-center clinical evaluation of combination anorganic bovine-derived hydroxyapatite matrix (ABM)/cell binding peptide (P-15) as a bone replacement graft material in human periodontal osseous defects. 6-month results

A synthetic cell-binding peptide (P-15) combined with anorganic bovine-derived hydroxyapatite bone matrix (ABM) was compared to demineralized freeze-dried bone allograft (DFDBA) and open flap debridement (DEBR) in human periodontal osseous defects in a controlled, monitored, multi-center trial. Following appropriate initial preparation procedures, flap surgery with defect and root debridement was performed. Three osseous defects per patient were treated randomly with one of three procedures after surgical preparation. Appropriate periodontal maintenance schedules were followed, and at 6 to 7 months re-entry flap surgery was performed for documentation and finalization of treatment. Analysis of variation (ANOVA) and t test analyses of patient mean values from 31 patients revealed that the combination ABM/P-15 grafts demonstrated significantly better mean defect fill of 2.8 +/- 1.2 mm (72.3%) versus a mean defect fill of 2.0 +/- 1.4 mm (51.4%) for defects treated with DFDBA (P <0.05) and a mean defect fill of 1.5 +/- 1.3 mm (40.3%) (P <0.05) for defects treated with DEBR. Other hard tissue findings showed similar clinically superior results with the use of ABM/P-15. Relative defect fill results showed 87% positive (50% to 100% defect fill) responses with ABM/P-15, 58% positive responses with DFDBA, and 41% positive responses with DEBR. There were 8 to 9 times more failures (minimal response) with DFDBA and DEBR (26% to 29% frequency) than with ABM/P-15. Soft tissue findings showed no significant differences among treatments except for greater clinical attachment level gain with ABM/P-15 compared to DEBR. These results suggest that the use of the P-15 synthetic cell-binding peptide combined with ABM yields better clinical results than either DFDBA or DEBR. Further studies are needed to determine the relative roles of the ABM and/or the P-15 in these improved results.

Comparison of bioactive glass synthetic bone graft particles and open debridement in the treatment of human periodontal defects. A clinical study

The purpose of this study was to compare the repair response of bioactive glass synthetic bone graft particles and open debridement in the treatment of human periodontal osseous defects. Fifty-nine defects in 16 healthy adults were selected. Each patient had at least 2 sites with attachment loss of at least 6 mm with clinical and radiographic evidence of intrabony or furcation defects. One to 3 months after cause-related therapy (oral hygiene instructions, scaling and root planing), the following measurements were recorded prior to surgery: probing depths, clinical attachment level, and gingival recession. Each defect was surgically exposed and measurements made of the alveolar crest height and base of osseous defect. The test defects were implanted with bioactive glass. The other sites served as unimplanted controls. Flaps were sutured at or close to the presurgical level. Radiographs and soft tissue presurgical measurements were repeated at 6, 9, and 12 months. At 12 months all sites were surgically re-entered to record osseous measurements. At the 12-month evaluation, significantly greater mean probing depth reduction was noted in the bioactive glass group compared to the controls (4.26 mm versus 3.44 mm; P = 0.028). Clinical attachment level gain was significantly improved (P = 0.0004) in the bioactive glass sites (2.96 mm) compared to the control sites (1.54 mm). There was significantly less gingival recession in the bioactive glass sites (1.29 mm) compared to the control sites (1.87 mm). Defect fill was significantly greater in the bioactive glass sites (3.28 mm) compared to the control sites (1.45 mm). Defect depth reduction was significantly greater in the bioactive glass sites (4.36 mm) compared to the control sites (3.15 mm). In conclusion, bioactive glass showed significant improvement in clinical parameters compared to open flap debridement.

A combined approach for treatment of developmental groove associated periodontal defect. A case report

Developmental grooves are not rare and often appear on maxillary lateral incisors. This may represent a challenge and sometimes tooth extraction is inevitable. This case report describes a combined technique of regenerative and antimicrobial/root conditioning used to treat a maxillary lateral incisor in a 32-year-old woman. Tooth #10 presented a periodontal probing depth of 8 mm below the cingulum, associated with a developmental groove. The tooth was vital. After initial preparation, a palatal mini-flap was raised, granulation tissue was eliminated by means of ultrasonic bactericidal curettage and radicoloplasty performed. The surface was then treated for 3 minutes with tetracycline-HCl solution (100mg/ml), and the defect filled with sterile, medical grade, calcium sulfate. Clinical measurements were retaken at 6, 12, and 18 months. The results indicated a reduction of probing depth to 2 mm, reestablishment of the lamina dura, and radiographical evidence of bone growth. This combined treatment allowed the tooth to be saved, the palatal surgical approach did not alter the esthetics of the area, and its simplicity is recommended.

Equivalence and superiority testing in regeneration clinical trials

The purpose of this report is to investigate sample size requirements for both equivalence and superiority studies investigating products used in regeneration. The goal of a superiority clinical trial is to determine if a new therapy is superior to an established therapy or placebo. In contrast to superiority trials, equivalence trials are used to determine if a new product has similar therapeutic properties to an established product. The sample sizes for the two different types of clinical trials were based on the following assumptions: an alpha of 0.05, a power of 0.80, a 2 group parallel arm study, and equal variances and sample sizes for both groups. Separate sample size calculations were done for both intrabony defects and Class II furcation defects. Sample sizes for the equivalence and superiority trials using the same criteria were the same. However, criteria for estimating sample sizes for equivalence clinical trials require much smaller differences between groups, resulting in much larger sample sizes. A criterion of a 20% difference between groups of the total therapeutic effect resulted in sample sizes which ranged from 64 to 127 in equivalence clinical trials. These samples sizes are much larger than have been generally used in clinical trials investigating periodontal regeneration.

Periodontal regeneration around natural teeth

1. Evidence is conclusive (Table 2) that periodontal regeneration in humans is possible following the use of bone grafts, guided tissue regeneration procedures, both without and in combination with bone grafts, and root demineralization procedures. 2. Clinically guided tissue regeneration procedures have demonstrated significant positive clinical change beyond that achieved with debridement alone in treating mandibular and maxillary (buccal only) Class II furcations. Similar data exist for intraosseous defects. Evidence suggests that the use of bone grafts or GTR procedures produce equal clinical benefit in treating intraosseous defects. Further research is necessary to evaluate GTR procedures compared to, or combined with, bone grafts in treating intraosseous defects. 3. Although there are some data suggesting hopeful results in Class II furcations, the clinical advantage of procedures combining present regenerative techniques remains to be demonstrated. Additional randomized controlled trials with sufficient power are needed to demonstrate the potential usefulness of these techniques. 4. Outcomes following regenerative attempts remain somewhat variable with differences in results between studies and individual subjects. Some of this variability is likely patient related in terms of compliance with plaque control and maintenance procedures, as well as personal habits; e.g., smoking. Variations in the defects selected for study may also affect predictability of outcomes along with other factors. 5. There is evidence to suggest that present regenerative techniques lead to significant amounts of regeneration at localized sites on specific teeth. However, if complete regeneration is to become a reality, additional stimuli to enhance the regenerative process are likely needed. Perhaps this will be accomplished in the future, with combined procedures that include appropriate polypeptide growth factors or tissue factors to provide additional stimulus.

Reconstruction of alveolar bone defects after extraction of mandibular third molars: a pilot study

INTRODUCTION

A documented complication of mandibular third molar extraction is the development of bony defects on the distal aspect of the adjacent second molar. The primary study purpose was to determine the efficacy of grafting third molar extraction sites with demineralized bone powder to prevent the formation of periodontal defects.

MATERIAL/METHODS

With a randomized clinical trial study design and a third molar extraction surgical model, we enrolled a study sample composed of patients who required extraction of bilateral third molars. Demineralized bone powder was placed in one randomly selected extraction site per patient. The remaining extraction site served as a control. Patients served as their own controls. To assess periodontal healing, we measured plaque and gingival indexes and periodontal attachment loss on the distobuccal aspect of the adjacent second molar preoperatively and 6 months postoperatively.

RESULTS

Of 14 patients enrolled, 7 patients with a mean age of 21.7 +/- 3.7 years completed the study protocol. No statistically significant differences were noted between patients who did and did not complete the study protocol (all p values > or = 0.42). There were noted statistically significant differences for the various anatomic, operative, or periodontal measures between the control and treatment teeth preoperatively (all p values > or = 0.46). Six months postoperatively, there were no statistically significant changes in the plaque or gingival indexes for the control or experimental sites. At the control sites, there was a nonstatistically significant decrease in mean attachment loss from 3.1 +/- 1.3 mm preoperatively to 1.4 +/- 1.6 mm 6 months postoperatively (p = 0.06). At experimental sites, there was a statistically significant decrease in mean attachment loss from 3.3 +/- 1.4 mm preoperatively to 0.6 +/- 0.8 mm 6 months postoperatively (p = 0.02)

CONCLUSIONS

The study results suggest that demineralized bone powder may decrease attachment loss on the distal aspect of the second molar after extraction of the adjacent third molar. Additional studies are indicated to confirm the results of this pilot study. We recommend that future studies limit their study samples to patients at high risk for developing periodontal defects after third molar extraction.

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.

Clinical evaluation of natural coral and porous hydroxyapatite implants in periodontal bone lesions: results of a 1-year follow-up

This study examines the suitability of 2 bone graft substitutes, natural coral skeleton (NCS) and porous hydroxyapatite (PHA) for treating periodontal bone defects in human subjects, and compares them to debridement alone (DEBR). A total of 30 sites in 10 patients were treated. Measurements were made before treatment and during surgical reexamination 12 months after treatment on lesions filled with NCS (10 sites), PHA (10 sites), or DEBR (10 sites). There was no significant difference in the use of NCS or PHA for 1, 2 wall, or combined defects for the group of parameters measured in this study (clinical probing depth, clinical attachment, gingival recession, bone fill, % bone fill, and crest remodelling). Statistical analysis (Wilcoxon non-parametric test for paired values and ANOVA for repeated measurements) revealed the beneficial effects of using each the biomaterials (57.4% for NCS, 58.1% for PHA, p < 0.86) as opposed to simple debridement (22.2%; p < 0.002; p < 0.004).

Clinical evaluation of coralline calcium carbonate as a bone replacement graft material in human periodontal osseous defects

A resorbable coralline calcium carbonate graft material (CalCarb) was compared to open flap debridement (DEBR) in human periodontal osseous defects. Following appropriate initial preparation procedures, flap surgery with defect and root debridement was performed in 20 patients. Alternating defects in each segment of surgery were treated with each procedure. Appropriate periodontal maintenance schedules were followed, and at 6 to 12 months a re-entry flap surgery was performed for documentation and finalization of treatment. Forty defects which received CalCarb grafts demonstrated significantly better mean defect fill of 2.3 mm (67.7%) versus a mean defect fill of 0.7 mm (25.9%) (P < 0.01) for 39 defects treated with DEBR. Other hard tissue findings showed similar clinically superior results with the use of CalCarb. Relative defect fill results showed 88% positive (50% to 100% defect fill) responses with CalCarb and only 13% positive responses with DEBR. There were 7 times more failures (minimal response) with DEBR than with CalCarb. Soft tissue findings showed no significant differences between treatments. These results are similar to those with other synthetic and natural bone replacement graft materials. However, the ease of handling of the CalCarb material, its resorbability, and its potential for improved bone regeneration may be of clinical advantage.

Periodontal therapy: prospects for the future

Prior to the 1950s, periodontitis was treated mostly by tooth exfoliation or extraction, and that is still the predominant treatment for most of the world's populations today. Debridement of the root surface by scaling and root planning came into relatively common use in the first half of the present century and has become the central feature held in common by all currently-used forms of periodontal therapy. Until the 1980s, the most commonly-used treatment consisted of scaling and root planing, followed by resective surgery aimed at achieving zero pocket depth. During the 1980s, data were obtained demonstrating that the thoroughness of root debridement and subgingival infection control, not the presence or absence or periodontal pockets, is the major determinant of successful periodontal therapy, and non-surgical therapy became a commonly-used treatment. Neither resective surgery nor non-surgical therapy results in significant regeneration of periodontal attachment. With the realization that periodontitis is an infectious process, the use of antibiotics and other anti-infective agents came into common use as adjuncts to other standard therapies. An understanding of the pathways by which the soft and calcified tissues of the periodontium are destroyed has led to the likelihood of widespread future use of the non-steroidal, anti-inflammatory family of drugs to suppress alveolar bone destruction by blocking prostaglandin production, and to the use of chemically-modified tetracyclines that chelate divalent cations and thereby block tissue destruction by the metalloproteinases. Recent data clearly show that regeneration of the previously-destroyed periodontal attachment tissues is biologically possible, and regeneration has become the goal of therapy for the 1990s. Use of osteoconductive and osteoinductive graft materials can, under favorable conditions, induce roughly 60% to 70% regeneration of bone lesion height or volume with concomitant improvement in the clinical conditions. Regeneration by grafting may be further enhanced by use of barrier membranes that exclude gingival fibroblasts and epithelium from the healing site. Still further enhancement seems to be possible by local application of various growth factors, although studies in this important area are now only in their infancy. The future of periodontal therapy is exceedingly bright.(ABSTRACT TRUNCATED AT 400 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.

Application of matched pair procedures to site-specific data in periodontal research

Application of standard statistical procedures to site-specific data in periodontal research is invalid unless site-to-site dependencies are accounted for. In this paper, we present the adjustments required for valid application of matched pair procedures, including the paired t-test and McNemar's chi 2 test for correlated proportions. Examples are given involving data arising from: (1) the comparison of pre- and post-treatment clinical measurements; (ii) split-mouth protocols.

Ultrastructural demonstration of the importance of crystal size of bioceramic powders implanted into human periodontal lesions

Stages in bone formation were studied ultrastructurally after the implantation of the following 3 bioceramic powders into human periodontal lesions: (1) beta-tricalcium phosphate whitlockite (Synthograft) consisting of particles with a mean length of 229 +/- 87 microns in SEM and appearing in TEM as crystals with a mean diameter 488 +/- 192 nm; (2) an hydroxyapatite (Bioapatite) which consisted of particles with a mean length of 283 +/- 87 microns in SEM and of crystals with a mean diameter of 146 +/- 47 nm in TEM; and finally (3), a microsized hydroxyapatite consisting of elongated platelets with a mean length of 32 +/- 4 microns in SEM, composed of small crystals with a mean diameter of 38 +/- 16 nm in TEM. In a preliminary experiment in rats, it appeared that the microsized hydroxyapatite implanted into the alveolar region after first molar extraction exhibited biocompatibility. In 6- and 12-month biopsies, it appeared that bone formation in association with the 3 bioceramics tested in human periodontal lesions occurred through similar mechanisms at the ultrastructural level. After the appearance of peripheral fibroblast-like or osteoblast-like cells with an interposed layer reminiscent of an osteoid tissue, collagen fibrils were observed in the intercrystalline spaces. These spaces subsequently underwent mineralization, with deposition of bone apatite crystals followed by the peripheral deposition of a thin inner bone layer with a granular appearance and an outer normal bone layer of either woven bone, lamellar bone or bone with parallel calcified collagen fibrils. These bone nodules, however, formed around the bioceramic particles at highly variable time intervals. Bone formation was observed around Synthograft and Bioapatite implants only in 12-month biopsies, and thicker layers of peripheral bone were observed with the latter hydroxyapatite implant. With microsized hydroxyapatite, a significant amount of peripheral bone formation had already occurred by 6 months, strongly suggesting an important effect of crystal size on bone formation.

A Veterans Administration Cooperative Study of biphasic calcium phosphate ceramic in periodontal osseous defects

One hundred thirty-seven V.A. patients were randomized to one of three treatment groups to evaluate the efficacy of biphasic calcium phosphate (BCP) ceramic in the treatment of periodontal osseous defects. This material was tested against both autogenous bone implant and open flap curettage procedures. Baseline probing attachment level, Navy plaque index, and gingival index were recorded for all patients. These parameters were monitored for 3 years. At the end of this period, 101 patients had completed the study. Although the plaque and gingival indices steadily increased with time, there were no statistically significant differences among the treatment groups. Patients in the ceramic group had a gain in attachment level of 1.0 mm; those in the curettage group, 0.9 mm; and 0.4 mm for those in the bone implant group. Although the BCP patients had a greater gain, the difference was not statistically significant. In this veteran population, not only did BCP patients fail to outperform those in the control groups, all three treatment groups were similarly ineffective.

Regenerating bone in clinical periodontics

Bone autografts and allografts, various alloplastic materials, and guided tissue regeneration are used to reconstruct lost periodontal tissues. This paper focuses on controversies related to these therapeutic modalities as well as their role in periodontal regeneration.

Report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

The growth in the dental literature continues to escalate, as evidenced by the publication of at least 326 new books in 1988 and 1989 and more than 20 new journals in 1989. There still appears to be undue emphasis on quantity instead of quality of research. This proliferation in the literature poses ever increasing difficulties to this Committee in filtering out the articles that are of particular interest to the members of the Academy and identifying those that are most likely to have a major impact on dental practice and service. The subjects covered include periodontics, caries and preventive dentistry, craniomandibular disorders, occlusion, pulp biology, ceramics, and restorative dental materials.