Periodontal regeneration of human infrabony defects. I. Clinical measures

Residual vertical defects: risk of disease progression, retreatment rates, and cost: a retrospective analysis

OBJECTIVES

This study aimed to explore the relationship between Radiographic Residual Vertical Defects (RVDs) and the progression of periodontitis in patients undergoing periodontal maintenance therapy (PMT).

MATERIALS AND METHODS

Teeth with RVDs were compared to the same contralateral teeth in the same patient. The study investigated the effect of smoking, diabetes, compliance, disease Stage, and Grade, baseline probing depth (PD), periodontal risk score (PRS), baseline pocket closure (PC) (≤ 4 mm), and tooth mobility on disease progression. We calculated the need for retreatment during PMT and its associated cost. Generalized estimation equations and linear and multilevel logistic regression analyses were employed for data analysis.

RESULTS

Each group had 139 teeth, accounting for 80 patients. Although the group with RVDs had similar PD reduction compared to the control teeth, the prevalence of PC at the last follow-up was reduced to half in the RVDs group (odds ratio OR = 0.5; p-value = 0.028), regardless of PC status at the baseline. RVDs were also significant predictors of tooth loss due to periodontitis (TLP), with an OR of 2.28 (p = 0.043). Patients with diabetes, Stage IV, higher mobility, and higher PRS scores had a higher risk of tooth loss due to periodontitis (OR = 4.71, 3.84, 3.64, and 5.97, respectively (P < 0.01). Incidences of sites requiring retreatment were similar in both groups, but the cost of treatment was 30% higher for teeth with RVDs. Grade C had the most significant influence on receiving retreatments (OR = 18.8, p = 0.005).

CONCLUSION

Teeth with RVDs represent a risk indicator for tooth loss compared to identical contralateral teeth with similar PD in the same patient. Teeth with RVD had more risk of pocket opening during follow-up.

CLINICAL RELEVANCE

While teeth with RVDs can be maintained long-term, they have twice the risk of pocket opening and tooth loss due to periodontitis during follow-up. Patients with systemic and local risk factors need to be monitored closely as they are at the highest risk of losing teeth with RVDs. The increased cost of retreatment for teeth with RVDs also has implications in terms of retention versus extraction and replacement.

Treatment of Unfavorable Intrabony Defects with Autogenous Bone Graft in Combination with Leukocyte- and Platelet-Rich Fibrin or Collagen Membranes: A Non-Inferiority Study

Background and Objectives: Unfavorable intrabony defects (IBDs) are associated with the progression of periodontal disease and tooth loss. Growing scientific evidence has demonstrated the effectiveness of platelet concentrations in periodontal treatment. The aim of our study was to demonstrate the non-inferiority of an autogenous bone graft (ABG) associated with leukocyte- and platelet-rich fibrin (L-PRF) compared to ABG + Collagen Membrane in the treatment of IBDs. Material and Methods: Sixty-four patients with at least one IBD were randomly assigned to two groups: ABG+L-PRF and CM+ABG. Clinical and radiographic evaluations were performed at baseline and 12-month follow-up. Clinical attachment level (CAL), gingival recession (GR), probing pocket depth (PPD), and radiograph defect bone level (DBL) were compared between the two treatments. To evaluate the effectiveness of ABG+L-PRF, a non-inferiority margin of =1 mm (-1 mm for GR) was chosen; a second non-inferiority margin of =0.5 mm (-0.5 mm for GR) was set for clinical relevance. Results: At 12-month follow up, both treatments showed clinical and radiographic improvements. The 90% confidence intervals of the CM+ABG-L-PRF+ABG mean difference for CAL gain (-0.0564 mm [-0.316 to 0.203]), DBL gain (-0.433 mm [-0.721 to -0.145]), and PPD reduction (0.232 mm [0.015 to 0.449]) were below the 0.5 mm non-inferiority margin; the GR increase (0.255 mm [0.0645 to 0.445]) stayed above the -0.5 mm. Conclusions: the L-PRF+ABG treatment of unfavorable IBDs is non-inferior with respect to the CM+ABG therapy for CAL gain, but with a lower GR, a slightly higher PPD, and DBL gain.

Double-sided entire papilla preservation technique in the combination periodontal regenerative therapy: A case report

BACKGROUND

With the entire papilla preservation (EPP) technique, it is possible to perform regenerative therapy without incisions in the interdental papilla and to reduce the risk of papillary rupture. However, one limitation of the EPP is the sole access from the buccal side. Here, we present a case of periodontitis treated by the combination regenerative therapy employing the Double-sided (buccal-palatal) EPP (DEPP) technique, which adds a palatal vertical incision to the EPP.

METHODS

A patient with 1-2 wall intrabony defects received the regenerative therapy using recombinant human fibroblast growth factor (rhFGF)-2 and carbonate apatite (CO3Ap). Using the DEPP technique, vertical incisions at buccal and palatal aspects were placed to gain adequate access to the 1-2 wall intrabony defects between #11 and #12 without incision in the interdental papilla. After debridement, rhFGF-2 and CO3Ap were applied to the defect. Periodontal clinical parameters and radiographic images were evaluated at the first visit, following initial periodontal therapy (baseline), 6, 9, and 12 months postoperatively.

RESULTS

Wound healing was uneventful. Scarring of the incision lines was minimal. At 12 months postoperatively, probing depth reduction was 4 mm, clinical attachment gain was 4 mm, and gingival recession was not observed. An improvement in radiopacity in the previous bone defect was observed.

CONCLUSION

The DEPP is an innovative technique that allows approaching from both the buccal and palatal sides while ensuring flap extensibility without compromising the interdental papilla. This report suggests that the combination of regenerative therapy with the DEPP may be promising in the treatment of intrabony defects.

KEY POINTS

Why is this case new information? The DEPP allows a direct visual approach to a 1-2 wall intrabony defect extending from the buccal to palatal sides, and increases flap extensibility, without compromising the papilla. What are the keys to the successful management of this case? Assessment of three-dimensional bone defect morphology is required. Computed tomography images are very useful. The flap elevation just under the interdental papilla should be carefully performed with a small excavator to avoid damage to the interdental papilla. What are the primary limitations to success in this case? Despite the addition of a palatal incision, it was not possible to obtain complete flexibility of the palatal gingiva. Caution must be taken in a case in which the distance between the interdental papilla is narrow. Even if the interdental papilla is ruptured during the operation, recovery is possible by continuing the operation and suturing the rupture at the end.

Use of ultrasound imaging for assessment of the periodontium: A systematic review

The objective of this study was to systematically review the literature regarding diagnostic applications of ultrasound imaging for evaluation of the periodontium in humans. The search was conducted on Medline, EMBASE, Web of Science, Scopus, Cochrane, and PubMed up to April 3, 2023. The studies included were exclusively human studies that assessed the periodontium with ultrasound (US) imaging (b-mode). Outcomes measured included alveolar bone level, alveolar bone thickness, gingival thickness, and blood flow quantification. References were imported to Covidence. Two reviewers conducted phases 1 and 2. The JBI risk assessment tool for cross-sectional studies was used. Extracted data included the transducer and measurements used and the study's outcomes. The search yielded 4892 studies after removing duplicates. From these, 25 studies were included and selected for extraction. Included studies retrieved outcomes from US examinations of the periodontal tissues. From the selected studies, 15 used US on natural teeth, 4 used US on implants, 2 used US on edentulous ridges, and 4 used color flow/power in US to evaluate the blood flow. The results of the present systematic review suggest that US might be a feasible and valuable diagnostic tool for the periodontium, with the potential to complement shortfalls of current radiographic technologies.

Long-term stability (21-30 years) of root coverage outcomes using sub-epithelial connective tissue grafts at single or multiple gingival recessions: A longitudinal case series

AIM

To evaluate outcomes and predictive factors for the long-term stability of root coverage using a sub-epithelial connective tissue graft.

MATERIALS AND METHODS

One-hundred and two healthy subjects (221 gingival recessions, GRs) were treated from 1987 to 1996. Keratinized tissue width (KTW), GR depth (RD), GR width (RW) and GR area (RA) were evaluated at baseline (M0) and at 1 month (M1), 1 year (M2), 11 years (M3), 21 years (M4) and 27 years (M5) after surgery. Primary outcomes consisted of complete root coverage (cRC) and relative dimensional changes in recession depth (measured in mm [c%-RD]), recession width (measured in mm [c%-RW]) and recession area (measured in mm2 [c%-RA]).

RESULTS

cRC was 88.7% at 1 year (M2), 59.8% at M3, 44.4% at M4 and 51.9% at M5. Average c%-RD was 95.2% at 1 year, 81.9% at M3, 71.5% at M4 and 81.7% at M5. KTW increased after surgery and over time and was positively correlated with favourable outcomes. Increased baseline RA was associated with less favourable clinical outcomes.

CONCLUSIONS

The sub-epithelial connective tissue graft is effective in the treatment of GRs and facilitates long-term stability of clinical outcomes. Wider baseline RA was a strong predictor of unfavourable short- and long-term RC outcomes.

Bioactive glass for periodontal regeneration: a systematic review

BACKGROUND

One of the major clinical challenges of this age could be represented by the possibility to obtain a complete regeneration of infrabony defects. Over the past few years, numerous materials and different approaches have been developed to obtain bone and periodontal healing. Among all biomaterials, bioglasses (BG) are one of the most interesting due to their ability to form a highly reactive carbonate hydroxyapatite layer. Our aim was to systematically review the literature on the use and capability of BG for the treatment of periodontal defects and to perform a meta-analysis of their efficacy.

METHODS

A search of MEDLINE/PubMed, Cochrane Library, Embase and DOSS was conducted in March 2021 to identify randomized controlled trials (RCTs) using BG in the treatment of intrabony and furcation defects. Two reviewers selected the articles included in the study considering the inclusion criteria. The outcomes of interest were periodontal and bone regeneration in terms of decrease of probing depth (PD) and gain of clinical attachment level (CAL). A network meta-analysis (NMA) was fitted, according to the graph theory methodology, using a random effect model.

RESULTS

Through the digital search, 46 citations were identified. After duplicate removal and screening process, 20 articles were included. All RCTs were retrieved and rated following the Risk of bias 2 scale, revealing several potential sources of bias. The meta-analysis focused on the evaluation at 6 months, with 12 eligible articles for PD and 10 for CAL. As regards the PD at 6 months, AUTOGENOUS CORTICAL BONE, BIOGLASS and PLATELET RICH FIBRIN were more efficacious than open flap debridement alone, with a statistically significant standardized mean difference (SMD) equal to -1.57, -1.06 and - 2.89, respectively. As to CAL at 6 months, the effect of BIOGLASS is reduced and no longer significant (SMD = -0.19, p-value = 0.4) and curiously PLATELET RICH FIBRIN was more efficacious than OFD (SMD =-4.13, p-value < 0.001) in CAL gain, but in indirect evidence.

CONCLUSIONS

The present review partially supports the clinical efficacy of BG in periodontal regeneration treatments for periodontal purposes. Indeed, the SMD of 0.5 to 1 in PD and CAL obtained with BG compared to OFD alone seem clinically insignificant even if it is statistically significant. Heterogeneity sources related to periodontal surgery are multiple, difficult to assess and likely hamper a quantitative assessment of BG efficacy.

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.

Efficacy of rh-PDGF-BB and Emdogain with or without DFDBA using M-MIST in the treatment of intrabony defects

Background

The versatile combination of emdogain or enamel matrix derivative (EMD), recombinant human platelet-derived growth factor-BB (rhPDGF-BB), and demineralized freeze-dried bone allograft (DFDBA) has not been utilized in the treatment of intrabony defects yet.

Aim

The present study attempted to investigate the efficacy of a combination of simple, uncomplicated nature of modified minimally invasive surgical technique (M-MIST) with EMD, rhPDGF-BB, and DFDBA in the surgical management of intrabony defects and to assess the possible favorable effects for a period of 6 months.

Patients and Methods

Thirty healthy subjects were included in the present double-blind, randomized controlled, two-arm parallel study. The test group was treated with M-MIST by using rhPDGF-BB, EMD, and DFDBA, and the control group was treated with M-MIST by using rhPDGF-BB and EMD.

Results

Differences between the mean values of primary clinical parameters including relative attachment level, probing depth, and gingival recession at baseline and those at 6 months after surgery were statistically significant in both groups. Inter-group comparison for clinical attachment level gain, probing depth reduction, and change in the position of gingival margin revealed no statistically significant differences. Inter-group comparison revealed significant differences in linear bone growth (LBG) and percentage bone fill (% BF) but no significant differences in the residual defect depth and change in the alveolar crest position.

Conclusion

The additional use of DFDBA provides superior benefits in terms of LBG and % BF in intrabony defects. This improvement might be attributed to the use of an osteoinductive scaffold.

Application of Tissue Engineering in Manufacturing Absorbable Membranes to Improve the Osteopromoting Potential of Collagen

The membranes are an important biomaterial that contribute to osteopromotion. This study aimed to evaluate the osteopromotive potential of collagen membranes associated with Hydroxyapatite (HA) in critical size calvaria rat's defects. Ninety-six Albinus Wistar rats were divided into four groups: (CG) negative control: clot only (CG); positive control: porcine collagen membrane (BG); fish collagen membrane associated with HA (CP); bovine collagen membrane associated with HA (CB), analyzed at 7, 15, 30, and 60 postoperative days. At 30 days, membrane integrity was observed in the CB and fragments in the CP and BG groups were dispersed in the center of the defect. At 60 days, BG demonstrated better results with no statistical difference for the CP group (p = 0.199) and a statistically significant difference for the CB group (p = 0.013). The inflammatory profiles of the BG and CP groups were similar. Immunohistochemistry demonstrated at 60 days moderate osteopontin staining for the BG and CP groups, light staining for the CB, and intense osteocalcin staining for the BG, while the CB and CP groups demonstrated moderate staining. Microtomography revealed the highest mean bone volume (14.247 mm³) in the BG, followed by the CB (11.850 mm³), and CP (9.560 mm³) group. The collagen membranes associated with HA demonstrated an osteopromotive potential.

Intentional replantation combined root resection therapy for the treatment of type III radicular groove with two roots: A case report

BACKGROUND

A radicular groove is an anatomic malformation that usually initiates at the central fossa, extending along the root at varying lengths and depths and predisposes the involved tooth to a severe periodontal defect. Severe grooves that extend to the root apex often lead to complex combined periodontal-endodontic lesions. They are a serious challenge for doctors to diagnose and treat.

CASE SUMMARY

In this report, we described a patient with a maxillary lateral incisor with a deep palatogingival groove with two roots, which led to complex combined periodontal-endodontic lesions. Suggested treatment modalities included curettage of the affected tissues, elimination of the groove by grinding and/or sealing with a variety of filling materials, and surgical procedures. In this case, a combination of endodontic therapy, intentional replantation, and root resection were used, which resulted in periodontal/periradicular healing after 12 mo.

CONCLUSION

Intentional replantation and root resection offer a predictable procedure and should be considered a viable treatment modality for the management of palatogingival grooves, especially for two-rooted teeth.

Ten-Year Stability of Clinical Attachment after Regenerative Treatment of Infrabony Defects and Controls

Background: A similar long-term stable clinical attachment level (CAL) of infrabony defects (IBDs) after regenerative treatment compared to control teeth would indicate a high level of stability resulting from the regenerative approach. Methods: Patients with a regeneratively treated IBD were screened 120 ± 12 months postoperatively for eligibility for study participation, and were included if complete baseline and 12-month examinations (plaque (PlI), periodontal probing depth (PPD), CAL) were available and a respective control tooth could be identified. Re-examination included clinical examination (PPD, CAL, PlI/GI, bleeding on probing, plaque control record, gingival bleeding index). Results: A total of 27 patients (16 females; age (median; lower/upper quartile): 57.0; 44.0/60.0 years; 6 smokers) contributed 27 IBDs (test), for each of which a control tooth was identified. Five test teeth (18.5%) were lost between 12 and 120 months. The remaining 22 test teeth revealed a significant CAL gain after 1 (2.5 mm; 1.0/4.0 mm, p < 0.0001) and 10 (2.5 mm; 0.5/3.5 mm, p < 0.0001) years, whereas control teeth were stable (1 year: 0.0 mm; 0.0/1.0 mm, p = 0.396; 10 years: 0.0 mm; −1.0/1.5 mm, p = 0.215). The study did not detect any significant CAL change between 1 and 10 years for test (−0.5 mm; −1.0/0.5 mm, p = 0.414) and control teeth (0.0 mm; −1.0/1.0 mm, p = 0.739). In 15 patients, test and control teeth revealed stable CAL values between 12 and 120 months. Conclusion: Regenerative treatment of IBDs exhibited stability comparable to non-surgically treated, periodontally reduced sites over a 10-year period.

The granulation tissue preservation technique in regenerative periodontal surgery-a randomized controlled clinical trial

Objectives

To investigate if the application of the granulation tissue preservation technique (GTPT) in regenerative therapy of infrabony periodontal defects results in more clinical attachment level (CAL) gain and more radiographic bone gain (RBG) than the conventional resective approach 12 months after surgery.

Materials and methods

Forty patients exhibiting at least one infrabony defect with a probing pocket depth (PPD) ≥6 mm and a radiographic infrabony component (INFRA_X‐ray) ≥3 mm were randomly treated with the GTPT (test group) or the double‐flap approach with resection of the defect‐filling granulation tissue (control group). Enamel matrix derivatives were applied in both groups. Clinical and radiographic parameters were recorded at baseline (t0), 6 months (t1), and 12 months (t2) after surgery. The primary outcome variable was CAL gain between t0 and t2.

Results

When all patients were considered, ΔCAL_t0–t2 did not differ significantly between the two groups (p = .160). Significant PPD reduction (test group: 4.38 ± 1.36 mm; control group: 4.06 ± 2.38 mm), CAL gain (test group: 3.75 ± 1.24 mm; control group: 2.88 ± 2.09 mm), and RBG (test group: 3.06 ± 1.74 mm; control group: 3.27 ± 2.19 mm) were achieved at t2 in both groups. Using multivariate linear regression, PPD_t0 and group were identified as variables with the greatest influence on ΔCAL_t0–t2. PPD_t0 and INFRA_X‐ray were identified as variables with the greatest influence on RBG_t0–t2. Patients with a defect angle >22° showed significantly more CAL gain in the test group (t0–t1: 3.08 ± 1.38 mm; t0–t2: 3.62 ± 0.96 mm) than in the control group (t0–t1: 1.77 ± 1.54 mm; t0–t2: 2.18 ± 1.83 mm).

Conclusions

Regarding all patients, the study failed to show significant differences between the test and control groups. However, the GTPT appears to lead to more CAL gain in noncontaining infrabony defects.

Current Concepts in the Management of Periodontitis

Periodontitis is a common disorder affecting >40% of adults in the United States. Globally, the severe form of the disease has a prevalence of 11%. In advanced cases, periodontitis leads to tooth loss and reduced quality of life. The aetiology of periodontitis is multifactorial. Subgingival dental biofilm elicits a host inflammatory and immune response, ultimately leading to irreversible destruction of the periodontium (i.e. alveolar bone and periodontal ligament) in a susceptible host. In order to successfully manage periodontitis, dental professionals must understand the pathogenesis, primary aetiology, risk factors, contributing factors and treatment protocols. Careful diagnosis, elimination of the causes and reduction of modifiable risk factors are paramount for successful prevention and treatment of periodontitis. Initial non-surgical periodontal therapy primarily consists of home care review and scaling and root planing. For residual sites with active periodontitis at periodontal re-evaluation, a contemporary regenerative or traditional resective surgical therapy can be utilised. Thereafter, periodontal maintenance therapy at a regular interval and long-term follow-ups are also crucial to the success of the treatment and long-term retention of teeth. The aim of this review is to provide current concepts of diagnosis, prevention and treatment of periodontitis. Both clinical and biological rationales will be discussed.

Efficacy of a new-generation platelet-rich fibrin in the treatment of periodontal intrabony defects: a randomized clinical trial

Background

The aim of the study was to clinically evaluate the healing of intrabony defects after treatment with a new generation of platelet-rich fibrin (A-PRF+) respect to enamel matrix derivative (EMD).

Methods

Thirty (30) intrabony defects of 18 patients (9 males, 9 females) were randomly treated with A-PRF+ (test, n = 15) or EMD (control, n = 15). The following clinical parameters were recorded at baseline and 6 months after surgery: pocket depth (PD), gingival recession (GR) and clinical attachment level (CAL). After debridement the intrabony defects were filled with A-PRF+ in the test group, respectively with EMD in the control group, and fixed with sutures to ensure wound closure and stability.

Results

Both treatment methods resulted in statistically significant PD reductions, respectively CAL gains six months post-operatively. No statistically significant differences were found between the two groups as the mean CAL gain was 2.33 ± 1.58 mm in the A-PRF+ group, respectively 2.60 ± 1.18 mm in the EMD group (p < 0.001).

Conclusion

Within the limits of this study the new-generation platelet-rich fibrin seems to be as clinically effective as EMD during surgical treatment of intrabony defects. Treatment with A-PRF+ or EMD resulted in reliable clinical outcomes. The use of A-PRF+ as a human autologous product can give a positive impact on periodontal healing.

Clinical Relevance A-PRF+ may be suitable for the treatment of intrabony periodontal defects.

Trial registration number (TRN) NCT04404374 (ClinicalTrials.gov ID).

Enamel matrix derivative as an adjunct to minimally invasive non-surgical treatment of intrabony defects: A randomized clinical trial

AIM

To compare the efficacy of minimally invasive non-surgical technique (MINST) with or without enamel matrix derivative (EMD) in the treatment of intrabony defects ≤7 mm.

MATERIALS AND METHODS

Thirty-six patients were randomly assigned to the two groups. The control group received MINST, while the experimental MINST+EMD. Clinical measurements were recorded at baseline and at 6 and 12 months, and radiographic measurements were made at baseline and 12 months.

RESULTS

All subjects completed the study, 18 in each group. Significant improvements were observed in both groups at 12 months (p < .001) with no differences in mean PD reduction (4.0 ± 1.4 vs. 4.2 ± 1.7 mm), CAL gain (3.5 ± 1.4 vs. 3.4 ± 1.6 mm), and defect resolution (1.9 ± 1.1 vs. 1.8 ± 0.9 mm) for the MINST and the MINST+EMD groups, respectively (p > .05). A trend for greater pocket closure (PD ≤4 mm and no BoP) was achieved with the application of EMD (77.8% vs. 55.6% sites), particularly for sites with baseline PD ≤8 mm (92.3% vs. 69.2% sites), accompanied by an increased number of successful composite outcome results (61.1% vs. 44.4% sites).

CONCLUSIONS

MINST demonstrates significant improvements 12 months after treatment of intrabony defects ≤7 mm. The additional application of EMD does not further improve the mean clinical or radiographic outcomes. This study is registered in ClinicalTrials.gov (NCT03622255).

The recent advances in scaffolds for integrated periodontal regeneration

The periodontium is an integrated, functional unit of multiple tissues surrounding and supporting the tooth, including but not limited to cementum (CM), periodontal ligament (PDL) and alveolar bone (AB). Periodontal tissues can be destructed by chronic periodontal disease, which can lead to tooth loss. In support of the treatment for periodontally diseased tooth, various biomaterials have been applied starting as a contact inhibition membrane in the guided tissue regeneration (GTR) that is the current gold standard in dental clinic. Recently, various biomaterials have been prepared in a form of tissue engineering scaffold to facilitate the regeneration of damaged periodontal tissues. From a physical substrate to support healing of a single type of periodontal tissue to multi-phase/bioactive scaffold system to guide an integrated regeneration of periodontium, technologies for scaffold fabrication have emerged in last years. This review covers the recent advancements in development of scaffolds designed for periodontal tissue regeneration and their efficacy tested in vitro and in vivo. Pros and Cons of different biomaterials and design parameters implemented for periodontal tissue regeneration are also discussed, including future perspectives.

Influence of Tooth-Brushing on Early Healing after Access Flap Surgery: A Randomized Controlled Preliminary Study

In the present study, the clinical outcomes obtained using three different protocols of post-operative plaque control for the 4 weeks after surgery were compared. Thirty healthy subjects, presenting at least one periodontal pocket requiring resective surgery, were selected and randomly distributed to three different groups corresponding to respective post-surgical protocols: (A) toothbrushes + chlorhexidine + anti-discoloration system (ADS + CHX); (B) toothbrushes + chlorhexidine (CHX); (C) only toothbrushes. The full-mouth plaque score (FMPS), full-mouth bleeding score (FMBS), probing pocket depth (PPD), recession depth (REC), clinical attachment level (CAL), and bleeding on probing (BoP) were measured in six aspects per tooth (mesio-buccal (MB), buccal (B), disto-buccal (DB), disto-lingual (DL), lingual (L), and mesio-lingual (ML)) at baseline, 3 months, and 6 months after surgery. FMPS and FMBS did not significantly change (p > 0.05), whereas PPD and CAL significantly decreased, and REC significantly increased in all groups during the study (p < 0.05). Clinical results were satisfactory in all cases, with no significant differences between groups 3 months after surgery. Six months after surgery, only PPD-MB was significantly different in the three groups (p < 0.05). Nevertheless, this value was not clinically relevant because the value of PPD-B (about 2 mm) in group C was physiologic. The mechanical plaque control was proven to be fundamental and sufficient in all the six aspects per tooth to guarantee an excellent clinical outcome without the need of chemical plaque control.

A bibliometric study of the top cited papers related to periodontal regeneration

This report identifies the top cited papers in the field of periodontal regeneration since inception of the concept. Using the H-classics approach, 132 papers published between 1970 and 2012 were identified, with 230.0 ± 175.6 (mean ± SD) citations and 10.4 ± 11.5 citations/year. There were 46 clinical reports, 28 animal studies, 23 in vitro studies, 30 reviews, 3 systematic reviews, and 2 combined animal and in vitro studies. Analysis of covariance showed that institution number (≥3, P = 0.011), journal impact factor at publication (>3.0, P = 0.001) and study type (in vitro/reviews vs. clinical trials/animal studies, P = 0.024) were significantly associated with citations/year. This study has characterized the most influential literature in the field of periodontal regeneration and serves as a quick reference resource.

Framework Fracture of Zirconia Supported Full Arch Implant Rehabilitation: A Retrospective Evaluation of Cantilever Length and Distal Cross-Sectional Connection Area in 140 Patients Over an Up-To-7 Year Follow-Up Period

PURPOSE

To evaluate the relationship between different dimensional parameters in implant-supported monolithic zirconia fixed complete dental prostheses (IFCDPs) and the incidence of framework fracture in a large sample of cases in vivo.

MATERIALS AND METHODS

This retrospective observational study evaluated all patients rehabilitated with screw-retained zirconia IFCDPs between January 2013 and April 2019 at a private practice. The minimum follow-up period was 1 year after occlusal loading. Fractures were classified as: type I-fractures that happened between but not involving the two most posterior screw-access openings (SAOs) and type II-fractures of the distal cantilever. Cantilever length, distal connector cross-sectional area, and screw access opening length were measured using data obtained from digital scans. Logistic regression was performed to evaluate the relationship between types I and II fractures and the independent variables (dimensional parameters). Using the receiver operating characteristic curves, two parameters were identified to be useful for establishing a cut-off and predicting type II fractures.

RESULTS

A total of 180 prostheses delivered to 140 patients were analyzed. Five implants failed in three patients: three before delivery of the definitive prostheses and two after. Ten prostheses failed (5.6% prosthetic failure rate): 2 because of implant failures, and 8 because of framework fractures. Five fractures were classified as type I and three as type II. Significant associations were found between cantilever length and type I fractures (Wald = 5.772, df = 1, p = 0.016), distal connector cross-sectional area and type II fractures (Wald = 3.806, df = 1, p = 0.051), and cantilever length and the total number of fractures (Wald = 6.117, df = 1, p = 0.013).

CONCLUSION

Zirconia IFCDPs may be reliable medium-term solutions if some dimensional parameters are followed. The ratios between the cantilever length and cross-sectional connector area should be <0.51, while the ratio between the cantilever length and screw access opening length should be <1.48.

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

AIM

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Diagnostic accuracy of CBCT versus intraoral imaging for assessment of peri-implant bone defects

Background

Early detection of marginal bone loss is vital for treatment planning and prognosis of teeth and implant. This study was conducted to assess diagnostic accuracy of CBCT compared to intra-oral (IO) radiography for detection, classification, and measurement of peri-implant bone defects in an animal model.

Methods

Fifty-four mandible blocks with implants were harvested from nine male health adult beagle dogs with acquisition of IO, CBCT and micro-CT images from all samples. Peri-implant bone defects from 16 samples were diagnosed using micro-CT and classified into 3 defect categories: dehiscence (n = 5), infrabony defect (n = 3) and crater-like defect (n = 8). Following training and calibration of the observers, they asked to detect location (mesial, distal, buccal, lingual) and shape of the defect (dehiscence, horizontal defect, vertical defect, carter-like defect) utilizing both IO and CBCT images. Both observers assessed defect depth and width on IO, CBCT and micro-CT images at each side of peri-implant bone defect via CT-analyzer software. Data were analyzed using SPSS software and a p value of < 0.05 was considered as statistically significant.

Results

Overall, there was a high diagnostic accuracy for detection of bone defects with CBCT images (sensitivity: 100%/100%), while IO images showed a reduction in accuracy (sensitivity: 69%/63%). Similarly, diagnostic accuracy for defect classification was significantly higher for CBCT, whereas IO images were unable to correctly identify vestibular dehiscence, with incorrect assessment of half of the infrabony defects. For accuracy of measuring defect depth and width, a higher correlation was observed between CBCT and gold standard micro-CT (r = 0.91, 95% CI 0.86–0.94), whereas a lower correlation was seen for IO images (r = 0.82, 95% CI 0.67–0.91).

Conclusions

The diagnostic accuracy and reliability of CBCT was found to be superior to IO imaging for the detection, classification, and measurement of peri-implant bone defects. The application of CBCT adds substantial information related to the peri-implant bone defect diagnosis and decision-making which cannot be achieved with conventional IO imaging.

Reconstructive surgical treatment of isolated deep intrabony defects with guided tissue regeneration using entire papilla preservation technique: A prospective case series

BACKGROUND

The aim of this prospective study is to evaluate the clinical applicability of the entire papilla preservation (EPP) technique in the regenerative treatment of isolated deep intrabony defects using native collagen membrane and bone grafting materials.

METHODS

Fifteen healthy and non-smoker patients (nine males and six females; mean age: 47.73 ± 12.18; range 21 to 63 years) with one isolated deep intrabony defect each (baseline probing depth (PD): 9.03 ± 1.62 mm; clinical attachment level (CAL): 11.16 ± 1.81 mm) were treated with guided tissue regeneration. Surgical access to the defect was provided by a single buccal vertical incision with an interdental tunneling flap. Following the granulation tissue removal, intrabony defect was filled with bone substitutes. A collagen barrier was trimmed and placed under the intact defect-associated papilla with palatal positioning suture. Microsurgical sutures were used for primary closure.

RESULTS

At 1 week, healing of the 15 sites was uneventful. During the study, all sites showed 100% primary closure rate. At 1-year follow-up, an average CAL gain of 5.86 ± 1.28 mm (P < 0.0001), PD reduction of 6.1 ± 1.47 mm (P < 0.0001), and minimal increase in gingival recession of 0.23 ± 0.62 mm (P = 0.168) were observed.

CONCLUSION

This novel surgical technique, that keeps the interdental papilla intact, seems promising to provide optimal biomaterial protection and healing conditions, even when a collagen barrier and bone substitutes are applied.

Treatment of intrabony periodontal defects using rhFGF-2 in combination with deproteinized bovine bone mineral or rhFGF-2 alone: A 6-month randomized controlled trial

Aim

To evaluate the use of recombinant human fibroblast growth factor (rhFGF)‐2 in combination with deproteinized bovine bone mineral (DBBM) compared with rhFGF‐2 alone, in the treatment of intrabony periodontal defects.

Materials and Methods

Patients with periodontitis who had received initial periodontal therapy and had intrabony defects of ≥ 3 mm in depth were enrolled. Sites were randomly assigned to receive a commercial formulation of 0.3% rhFGF‐2 + DBBM (test) or rhFGF‐2 alone (control). Clinical parameters and a patient‐reported outcome measure (PROM) were evaluated at baseline and at 3 and 6 months postoperatively.

Results

Twenty‐two sites in each group were evaluated. A significant improvement in clinical attachment level (CAL) from baseline was observed in both groups at 6 months postoperatively. CAL gain was 3.16 ± 1.45 mm in the test group and 2.77 ± 1.15 mm in the control group, showing no significant difference between groups. Radiographic bone fill was significantly greater in the test group (47.2%) than in the control group (29.3%). No significant difference in PROM between groups was observed.

Conclusions

At 6 months, no significant difference in CAL gain or PROM between the two treatments was observed, although combination therapy yielded an enhanced radiographic outcome.

Tensile Properties of Three Selected Collagen Membranes

BACKGROUND

Biological barriers are commonly used to treat alveolar bone defects and guide tissue regeneration. Understanding the biological and mechanical properties of the available membranes is crucial for selecting the one that is optimal for enhancing clinical outcomes.

PURPOSE

To evaluate the mechanical behavior of three different collagen membranes to increasing tensile force in dry and wet conditions.

MATERIALS AND METHODS

Three commercially collagen membranes were selected for analysis: Bio-Gide® (Geistlich Biomaterials, Baden-Baden, Germany), Remaix™ (RX; Matricel GmbH, Herzogenrath, Germany), and Ossix Plus® (Datum Dental Biotech, Lod, Israel). Increasing tensile forces were applied on 10 dry and wet membranes of standard size via a loading machine. Force and extension values were acquired up to maximum load before failure, and maximum stress, maximum extension, and amount of energy needed for membrane tearing were analyzed. Membranes' densities were also calculated.

RESULTS

The Remaix membrane exhibited the highest values of maximum load tensile strength, maximum extension, and maximum energy required for membrane tearing, followed by Bio-Gide. Ossix Plus had the lowest scores in all these parameters. Dry membranes had the highest scores for all parameters except extension. Membrane density was directly and significantly correlated with all tested parameters.

CONCLUSIONS

The study was undertaken to provide clinicians with data upon which to base the selection of collagen membranes in order to achieve optimal clinical results. It emerged that the mechanical properties of dry and wet collagen membranes were significantly different from one another. Among the 3 tested membranes, Remaix exhibited higher performance results in all the mechanical tests. Collagen membrane density seems to have a significant influence upon mechanical resistance. These findings may also guide manufacturers in improving the quality of their product.

Effects of L-PRF and A-PRF+ on periodontal fibroblasts in in vitro wound healing experiments

Objective

To determine whether leukocyte‐platelet‐rich fibrin (L‐PRF) and advanced platelet‐rich fibrin (A‐PRF+) differ in their in vitro capacity to induce proliferation and migration of periodontal fibroblasts.

Background

L‐PRF and A‐PRF + are autologous materials used in periodontal regenerative surgery. They derive from blood from patients, but have different characteristics. The literature is controversial regarding the effects of the two PRF preparations on periodontal tissue fibroblasts.

Materials and methods

L‐PRF and A‐PRF + membranes were prepared from eight patients and incubated in 3 mL of culture medium for 2 days. Gingival fibroblasts (G‐F) and periodontal ligament fibroblast (PDL‐F) primary cells were retrieved from 7 donors. These cells were pre‐cultured for 1 day in wound healing experiment plates leaving a gap of 500 ± 50 µm in a concentration of 3.3 x 10⁵ cells/mL. 70 µL of the cell suspension was placed in each half of the well. Thereafter, the pre‐cultured L‐PRF and A‐PRF + supernatants were added to the experimental plates, and the fibroblasts were incubated for another 24 h. Medium alone (NEG) and fibroblast growth factor II (FGF) were used as controls. Subsequently, cell migration was registered for 24 h with live cell imaging in a time frame microscope at 5% CO₂ in air at 37°C. Images were analyzed using ImageJ. Cell proliferation and cell viability were measured.

Results

L‐PRF and A‐PRF + induced higher cell proliferation than FGF and NEG. Both A‐PRF + and L‐PRF induced significant faster artificial wound closure than controls. Both PRF conditioned media induced faster cell migration in the initial phase (P < .01), but in the stoppage phase, the induced migration was higher for the A‐PRF+, compared with L‐PRF (P < .01).

Conclusion

L‐PRF and A‐PRF + have a stimulatory effect on migration and proliferation of periodontal fibroblasts, and artificial wound closure was longer sustained by A‐PRF + than L‐PRF.

Treatment of intrabony defects with modified perforated membranes in aggressive periodontitis: a 4-year follow-up of a randomized controlled trial

OBJECTIVE

(1) To assess long-term outcomes 4 years following guided tissue regeneration (GTR) of intrabony defects in patients diagnosed with aggressive periodontitis (AgP) and (2) to identify predictors of clinical attachment level (CAL) gain and bone/graft density gain.

MATERIALS AND METHODS

In 15 patients, two deep intrabony defects were randomly treated with xenogenic graft plus modified perforated membranes (MPM, tests) or xenogenic graft plus standard collagen membranes (CM, controls). After 4 years, clinical and radiographic outcomes were evaluated and compared with outcomes at baseline and after 1 year.

RESULTS

After 4 years, 14 test sites and 13 control sites were available for analysis. One tooth was lost as a result of root fracture. There were significant improvements in all evaluated parameters after 1 and 4 years in relation to baseline, but no differences were observed between tests and controls. However, some non-significant changes were found between 1 and 4 years. Regression analyses showed that recurrence of periodontitis was a significant predictor for CAL gain (p = 0.001) and bone/graft density gain (p = 0.024) from 1 to 4 years.

CONCLUSIONS

GTR of intrabony defects in AgP with either standard or modified CM yielded similarly successful and maintainable clinical benefits for compromised teeth 4 years following the surgery. The use of MPM showed no additional benefit.

CLINICAL RELEVANCE

This study demonstrates that most of the positive outcomes of GTR in AgP may be preserved over 4 years. Periodontitis recurrence might influence long-term outcomes.

Clinical and histological reaction of periodontal tissues to subgingival resin composite restorations

OBJECTIVES

To compare the clinical and histological response of supracrestal periodontal tissues to subgingival composite restorations versus natural root surfaces MATERIAL AND METHODS: In 29 subjects with a single tooth requiring subgingival restorations, a deep margin elevation (DME) procedure with composite resin was applied. Full-mouth plaque score (FMPS), full-mouth bleeding score (FMBS), and focal probing depth (PD) were measured at baseline, before DME, and after 3 months. The distance between the coronal marked (CM) point to the apical margin of the composite reconstruction (AMR), at baseline, and to the tip of the periodontal probe inserted to reach the bottom of the sulcus (APP), 3 months later, was measured. An all-around secondary flap, harvested to ensure the subsequent single-crown prosthetic rehabilitation was histologically processed. The histological inflammation degree was evaluated in areas of gingival tissues adjacent to the composite (group B) and adjacent to the natural surface of each single tooth (group A).

RESULTS

Significant FMPS, FMBS, and PD decreases were observed (p < 0.05). CM-AMR and CM-APP were significantly different (p < 0.05), suggesting an attachment gain after 3-months. The inflammation level of gingival tissue was similar in groups A and B (p > 0.05).

CONCLUSIONS

For the first time, this topic was clinically and histologically studied in humans. Subgingival restorations resulted compatible with gingival health, with levels similar to that of untreated root surfaces.

CLINICAL RELEVANCE

Deep margin elevation procedure produces favorable clinical and histological outcomes allowing a routine utilization in reconstructive dentistry.

Treatment of intrabony defects with modified perforated membranes in aggressive periodontitis: subtraction radiography outcomes, prognostic variables, and patient morbidity

Objectives

The main objectives of this study were (1) to evaluate bone/graft density alterations by digital subtraction radiography; (2) to determine factors associated with favorable clinical and radiographic outcomes, and (3) to report on patient morbidity after guided tissue regeneration (GTR) in aggressive periodontitis (AgP) patients.

Materials and methods

Adapting a split-mouth design, 30 comparative intrabony defects in 15 patients were randomly treated with xenogenic graft plus modified perforated membranes (MPM, tests) or xenogenic graft plus standard collagen membranes (CM, controls). The time period of observation was 12 months.

Results

There were significant improvements in clinical and radiographic parameters within each group, without intergroup differences. However, higher PPD reduction for three-wall defects was noted in MPM sites (5.22 versus 3.62 mm; p = 0.033). Moreover, a significant gain in bone/graft density of 4.9% from 6 to 12 months post-operatively was observed in test sites. Multivariate analysis demonstrated that morphology of intrabony defects was a predictor of CAL gain (p = 0.06), while independent prognostic variables effecting changes in bone/graft density were radiographic defect depth (p = 0.025) and radiographic angle (p = 0.033). The majority of patients reported some discomfort, pain, and edema with mild intensity without any significant differences between treatment modalities.

Conclusions

This study demonstrated enhanced bone/graft density gain after GTR with MPM, which may indicate greater area of new bone formation. Independent variables effecting treatment outcomes were intrabony defect morphology, radiographic defect depth, and radiographic angle.

Clinical relevance

This study supports the regenerative treatment of intrabony defects in AgP patients and identifies some variables with prognostic value.

Ultrasonic Surgical Aspirator to Treat Deep Infrabony Defects: A New Flapless Minimally Invasive Approach

The primary outcome of the present study was to assess the percentage of pocket closure, and the secondary aim was to evaluate the clinical performance in terms of clinical attachment level (CAL) gain, probing pocket depth (PPD) reduction, and gingival recession (REC) after the use of cavitron ultrasonic surgical aspirator (CUSA) in deep infrabony defects. Fourteen deep infrabony defects in 11 patients who were previously treated with active periodontal therapy followed by one year of supportive periodontal therapy (at least three sessions) were additionally treated by the aid of CUSA. Eighty-six percent of the initial defects (12 out of 14) resulted in a PD < 5 mm, showing complete resolution six months after CUSA treatment, without any adverse event and with negligible pain (VAS from 0 to 3). CUSA showed potential as a method to promote pocket healing, reduce PPD, and increase clinical attachment (P < 0.001) in deep infrabony defects. This trial is registered with ClinicalTrials.gov NCT03567161.

Comparison of the Clinical Biological Width with the Published Standard Histologic Mean Values

AIMS AND OBJECTIVES

Biologic width (BW) as defined by Cohen is the part of the supracrestal gingival tissues that occupy the space between the base of the gingival crevice and the alveolar crest; it includes the junctional epithelium and the connective tissue element. Interactions between dental crowns and the marginal periodontal tissues analyzed in many review papers concluded that the recognition of the BW, in terms of crown margin placement, is beneficial for periodontal health. Therefore, knowledge of the dimensions of the sum of the junctional epithelium and connective tissue attachment as well as the sulcus depth (SD) is of clinical relevance. The aim of the study is to compare the average SD and BW clinically measured around teeth with the standard application of a mean value of 0.69 mm and 2.04 mm, respectively, found by Gargiulo et al.in a histological study on cadavers.

MATERIALS AND METHODS

Forty-two healthy patients with age ranging from 20 to 50 years presented to the Multidisciplinary Department at the Lebanese University. A total of 504 tooth sites of 126 teeth were selected and measured by two periodontists. All measurements were done on teeth requiring infiltration anesthesia for surgical, restorative, or endodontic procedures on neighboring tooth/teeth, which eliminate any ethical concerns. The SD and the distance from gingival margin to bone crest at four sites per tooth; mesial, midbuccal, distal, and midlingual/palatal were measured. Clinical, BW was calculated by subtracting SD from the distance between gingival margin to bone crest.

STATISTICAL ANALYSIS

Friedman's ANOVA test, independent samples t-tests, and one-sample t-tests were applied. The IBM^® SPSS^® statistics 20.0 statistical package was used to carry out all statistical analyses.

RESULTS

The BW is statistically significantly lower than the value stated by Gargiulo et al. (2.04 mm) with a mean value of 1.13 mm, whereas the SD is statistically significantly greater than the value stated by Gargiulo et al. (0.69 mm) with a mean value of 1.96 mm.

CONCLUSION

It can be concluded that there is a need to create a patient/site-specific distance from the proposed margin of the restoration to the bone crest when restoring subgingivally fractured or carious teeth. This leads to more stable and healthy tissues when performing crown lengthening procedures. Therefore, using the term clinical, BW is more reliable and it should be used to reestablish stability and integrity of periodontal tissues around restored teeth.

Clinical outcome of periodontal regenerative therapy using collagen membrane and deproteinized bovine bone mineral: a 2.5-year follow-up study

BACKGROUND

This study aimed to evaluate, longitudinally, the outcome of periodontal regenerative therapy using a deproteinized bovine bone mineral (DBBM) in combination with a collagen barrier (CB) for the treatment of intrabony defects.

RESULTS

Patients with chronic periodontitis who have completed initial periodontal therapy participated in this study. They had at least one 2- or 3-wall intrabony periodontal defect of ≥3 mm in depth. During surgery, defects were filled with DBBM and covered with CB. Ten patients completed 2.5-year reevaluation. At baseline, mean clinical attachment level (CAL) of the treated site was 8.0 mm and mean probing depth (PD) was 7.5 mm. Mean depth of intrabony component was 4.6 mm. Mean gains in CAL at 6 months and 2.5 years were 2.8 ± 1.0 and 1.4 ± 1.5 mm, respectively, both showing a significant improvement from baseline. CAL gains at 1 and 2.5 years were significantly reduced from that at 6 months. A significant improvement in PD was also noted: mean reductions in PD at 6 months and 2.5 years were 4.0 ± 0.8 and 3.2 ± 0.8 mm, respectively.

CONCLUSIONS

The combination therapy using DBBM and CB yielded statistically significant effects such as CAL gain and PD reduction, up to 2.5 years in the treatment of intrabony defects. However, the trend for decrease in CAL gain over time calls for the need for careful maintenance care.

Evaluation of Cyclosporine A with β-TCP in the Treatment of Human Infra bony Defects - A Randomized Controlled Pilot Study

INTRODUCTION

Cyclosporine A (CsA), an immunosuppressant, is considered a life saver drug in organ transplant cases. It has also been tested in animal and human studies for periodontal applications as it selectively inhibits T lymphocyte proliferation, Interleukin-2 (IL-2) and other cytokine production, without any effect on T suppressor cells, thereby suppressing the cell mediated immunity and suppressing the inflammation. Inflammatory and immunological responses have been found to be decreased and bone formation is found to be increased in immunosuppressed animals. CsA is also supposed to potentiate osseous regeneration due to increase in the bone alkaline phosphatase levels and a direct activating effect on osteoblasts.

AIM

The present study was aimed at evaluating locally administered low dose of CsA which is potent immunosuppressant along with β-Tricalcium phosphate (β-TCP) in comparison with β TCP alone, in the treatment of human infrabony defects, over a period of six months.

MATERIALS AND METHODS

Thirty two systemically healthy chronic periodontitis patients with infrabony defects were included in the randomized, controlled, parallel arm study and were allocated into either Group A (n =16), patients treated with β-TCP + CsA (2 mg) or Group B (n =16), patients treated with β-TCP. Clinical parameters [Relative Attachment Level (RAL), Probing Depth (PD), Gingival Recession (GR)] and radiographic parameters were measured at baseline and six months postoperatively. Statistical analysis was done using SPSS version 16 software. Student's paired and independent t-test were used for intra and inter-group analysis.

RESULTS

Both Group A and Group B showed statistically significant improvements in clinical and radiographic parameters from base line to six months post-operatively. The Clinical Attachment Level (CAL) gain, Linear Bone Growth (LBG) and Percentage Bone Fill (% BF) were 2.38±1.12 mm, 1.90±1.48 mm and 49.83±29.23 mm in Group A and 2.57±1.22 mm, 2.03±1.16 mm and 62.84±29.70 mm in Group B respectively, inter group comparison showed no statistically significant difference.

CONCLUSION

Both the groups revealed statistically significant improvement in clinical and radiographic parameters and adjunctive use of CsA did not prove beneficial.

Treatment of Select Intrabony Defects by Periodontal Regeneration Could Be Cost-effective Long Term in Compliant Patients

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Periodontal regeneration compared with access flap surgery in human intrabony defects: 20-year follow-up of a randomized clinical trial: tooth regeneration, periodontitis recurrence and costs. Cortellini P, Buti J, Prato GP, Tonetti MS.J Clin Periodontolhttp://dx.doi.org/10.1111/jcpe.12638 [Pre pub/accepted manuscript] SOURCE OF FUNDING: Nonprofit, foundations: European Research Group on Periodontology, Genova, Italy; other: Accademia Toscana di Ricerca Odontostomatologica, Florence, Italy TYPE OF STUDY/DESIGN: Randomized controlled trial.

Periodontal regeneration compared with access flap surgery in human intra-bony defects 20-year follow-up of a randomized clinical trial: tooth retention, periodontitis recurrence and costs

AIM

Compare the long-term outcomes and costs of three treatment modalities in intra-bony defects.

MATERIALS AND METHODS

Forty-five intra-bony defects in 45 patients had been randomly allocated to receive: modified papilla preservation technique with titanium-reinforced expanded-polytetrafluoroethylene (ePTFE) membranes (MPPT Tit, N = 15); access flap with expanded-PTFE membranes (Flap-ePTFE, N = 15) and access flap alone (Flap, N = 15). Supportive periodontal care (SPC) was provided monthly for 1 year, then every 3 months for 20 years. Periodontal therapy was delivered to sites showing recurrences.

RESULTS

Forty-one patients complied with SPC. Four subjects were lost to follow-up. Clinical attachment-level differences between 1 and 20 years were -0.1 ± 0.3 mm (p = 0.58) in the MPPT Tit; -0.5 ± 0.1 mm (p = 0.003) in the Flap-ePTFE and -1.7 ± 0.4 mm (p < 0.001) in the Flap. At 20 years, sites treated with Flap showed greater attachment loss compared to MPPT Tit (1.4 ± 0.4 mm; p = 0.008) and to Flap-ePTFE (1.1 ± 0.4 mm; p = 0.03). Flap group lost two treated teeth. Five episodes of recurrences occurred in the MPPT Tit, six in the Flap-ePTFE and fifteen in the Flap group. Residual pocket depth at 1-year was significantly correlated with the number of recurrences (p = 0.002). Sites treated with flap had greater OR for recurrences and higher costs of re-intervention than regenerated sites over a 20-year follow-up period with SPC.

CONCLUSIONS

Regeneration provided better long-term benefits than Flap: no tooth loss, less periodontitis progression and less expense from re-intervention over a 20-year period. These benefits need to be interpreted in the context of higher immediate costs associated with regenerative treatment. These initial observations need to be extended to larger groups and broader clinical settings.

Evaluation of the adjunctive effect of platelet-rich fibrin to enamel matrix derivative in the treatment of intrabony defects. Six-month results of a randomized, split-mouth, controlled clinical study

AIM

This study aimed to compare the results obtained with enamel matrix derivative (EMD) and EMD + platelet-rich fibrin (PRF) in the treatment of intrabony defects (IBDs) in chronic periodontitis patients.

MATERIALS AND METHODS

Using a split-mouth design, 28 paired IBDs were randomly treated either with EMD or with EMD + PRF. Clinical and radiographic measurements including clinical attachment level (CAL), probing depth (PD), gingival recession (GR), defect depth (DD), defect width (DW) and defect angle (DA) were recorded at baseline (BL) and at six months following therapy.

RESULTS

BL clinical and radiographic measurements were similar for EMD and EMD + PRF groups. Although postsurgical measurements revealed significant reduction for PD and CAL in both groups, no intergroup difference was detected. When EMD and EMD + PRF groups were compared, defect fill was not also statistically different.

CONCLUSIONS

Both therapies resulted in significant clinical improvement in IBD treatment. Addition of PRF did not improve the clinical and radiographic outcomes.

Thirty-year stability after regeneration of a deep intrabony defect: a case report

AIMS

Report clinical improvements and 30-year stability of clinical outcomes of an intrabony defect treated with non-resorbable barriers and mucogingival surgery.

METHODS

A 18-year-old male presenting with a very severe intrabony defect at the upper right central incisor was treated with periodontal regeneration with non-resorbable barriers and a fibrin-fibronectin glue. The barriers were removed after 3 months. At 6 months, a free gingival graft (FGG) was positioned to improve mucogingival conditions. The patient was enrolled into a 6-month supportive periodontal care programme (SPC) for 30 years.

RESULTS

Clinical attachment level (CAL) of 16 mm was associated with a 12 mm osseous defect and a pocket (PD) 14 mm deep. At 1 year, a CAL of 5 mm was associated with a PD of 2 mm. The 5 mm gingival recession measured at 6 months and treated with FGG was reduced to 3 mm. Measurements taken at 10, 20 and 30 years showed a consistent creeping of the gingival margin. At 30-year examination, CAL gain was 12 mm associated with a 2 mm PD and a minimal gingival recession.

CONCLUSIONS

This case demonstrates that it is possible to treat a very severe infrabony pocket applying regeneration and mucogingival surgery and to maintain the clinical outcomes for 30 years.

Surgical Treatment of Periodontal Intrabony Defects with Calcium Sulphate in Combination with Beta-Tricalcium Phosphate: Clinical Observations Two Years Post-Surgery

The study was designed to evaluate the clinical outcome of a composite material, beta-tricalcium phosphate in combination with calcium sulphate, in the treatment of periodontal intrabony defects. The combination of these materials is believed to aid in guided tissue regeneration owing to their properties. A total of 47 teeth with intrabony defects in 26 periodontitis patients were treated with Fortoss® Vital (Biocomposites, Staffordshire, UK). Clinical parameters were evaluated which included changes in probing depth, clinical attachment level/loss and gingival recession at the baseline and 2 years postoperatively. The mean differences in measurements between the baseline and 2 years postoperatively were a reduction of 2.07±1.14 mm (p=0.000) in case of probing depth and a gain of 1.93±1.36 mm (p=0.000) in clinical attachment level; but an increase of 0.14±0.73 mm (p=0.571) in gingival recession. The study results show that the treatment with a combination of beta tricalcium phosphate and calcium sulphate led to a significantly favorable clinical improvement in periodontal intrabony defects 2 years after the surgery.

Fabrication of a novel chitosan scaffold with asymmetric structure for guided tissue regeneration

Asymmetric chitosan scaffold with a loose layer and a dense layer exhibited outstanding bone regenerative ability and appropriate degradability.

Clinical and radiographic evaluation of nanocrystalline hydroxyapatite with or without platelet-rich fibrin membrane in the treatment of periodontal intrabony defects

Background:

Nano-sized ceramics may represent a promising class of bone graft substitutes due to their improved osseointegrative properties. Nanocrystalline hydroxyapatite (NcHA) binds to bone and stimulate bone healing by stimulation of osteoblast activity. Platelet-rich fibrin (PRF), an intimate assembly of cytokines, glycan chains, and structural glycoproteins enmeshed within a slowly polymerized fibrin network, has the potential to accelerate soft and hard tissue healing. The present study aims to explore the clinical and radiographical outcome of NcHA bone graft with or without PRF, in the treatment of intrabony periodontal defects.

Materials and Methods:

In a split-mouth study design, 20 patients having two almost identical intrabony defects with clinical probing depth of at least 6 mm were selected for the study. Selected sites were randomly divided into two groups. In Group I, mucoperiosteal flap elevation followed by the placement of NcHA was done. In Group II, mucoperiosteal flap elevation, followed by the placement of NcHA with PRF was done. Clinical and radiographic parameters were recorded at baseline and at 6-month postoperatively.

Results:

Both treatment groups showed a significant probing pocket depth (PPD) reduction, clinical attachment gain, increase bone density 6-month after surgery compared with baseline. However, there was a significantly greater PPD reduction and clinical attachment gain when PRF was added to NcHA.

Conclusion:

The NcHA bone graft in combination with PRF demonstrated clinical advantages beyond that achieved by the NcHA alone.

Considerations for Altering Preparation Designs of Porcelain Inlay/Onlay Restorations for Nonvital Teeth

PURPOSE

The aim of this study was to compare all ceramic inlay/onlay survival rates in vital and nonvital teeth having the same cavity design. Filling the pulp chamber with ceramic materials or not was also discussed.

MATERIALS AND METHODS

Ceramic class II inlays/onlays were made on 11 premolars and 30 molars: 14 vital, 27 endodontically treated. The same tooth preparation design was performed on vital and nonvital teeth: In nonvital teeth the pulp chambers were covered by a glass ionomer cement until the pulpal floor depths were between 2 and 2.5 mm, more likely similar to the vital teeth preparations. In vital teeth, glass ionomer was used as a liner to achieve pulpal floor depths between 2 and 2.5 mm when needed. The restorations were assessed (at baseline, 6 months, 1 and 2 years) according to three criteria: marginal discoloration, marginal integrity, and fracture of teeth/restorations, consistent with United States Public Health Service (USPHS) criteria.

RESULTS

Eight teeth (19%) showed minor marginal discolorations, while three molars (7%) had loss of marginal integrity. These margins were adjusted using rubber polishing cups and were then judged clinically acceptable. From these three molars, one was vital and two were endodontically treated. No fracture of teeth or restorations was observed. Chi square and exact probability tests were used. There was no statistical difference between vital and nonvital teeth (p = 0.719 chi-squared and Fisher) or between premolars and molars (p = 0.564 chi-squared; 1.000, Fisher).

CONCLUSION

Within the limitations of this study there was no difference for the same inlay/onlay cavity design between vital and nonvital teeth. In nonvital teeth, it seems that filling the pulp chamber with a ceramic core material is not important. Long-term observation periods are needed to reinforce the clinical behavior outcome.