Clinical and radiographic evaluation of periodontal intrabony defects treated with guided tissue regeneration. A pilot study

Predictability and Clinical Stability of Barrier Membranes in Treatment of Periodontal Intrabony Defects: A Systematic Review and Meta-Analysis

The adjunctive use of GTR membranes helps us to achieve predictable periodontal regeneration. The aim of this systematic review was to evaluate and compare the treatment efficacy of resorbable versus non-resorbable barrier membranes used in guided tissue regeneration in the treatment of intrabony defects in chronic periodontitis patients. The following databases were searched: Medline, the Cochrane Central Register of Controlled Trails (CENTRAL), SCOPUS, EMBASE. Randomized clinical trials (RCTs) published in English languages over the past 25 years were included. The primary outcomes assessed were: change of probing pocket depth (PD), change in clinical attachment level (CAL) and gingival recession coverage (GRC), and intrabony defect fill (IBDF). A total of eight RCTs were included for systematic review. The outcome of GR at a six-month interval revealed a significant difference in treatment effect with a mean difference of 0.42, 95% CI [0.02, 0.81]; Z = 2.09, (p = 0.04) favouring the resorbable membrane group. The intrabony defect depth fill at a 12-month interval revealed a significant difference in treatment effect with MD of 0.79, p = 0.00001; favoring the resorbable membrane group. The resorbable membrane showed a significant improvement in gingival recession coverage and intrabony defect fill, owing to its advantage of avoiding the second surgical intervention.

Clinical and radiographic evaluation of periodontal intrabony defects by open flap surgery alone or in combination with Biocollagen(®) membrane: A randomized clinical trial

BACKGROUND

Guided tissue regeneration (GTR) is often incorporated in regenerative periodontal surgical procedures. However, the actual benefits of adding GTR to such a procedure remain undocumented. The purpose of this randomized controlled trial was to investigate the contribution of GTR to the outcomes of open flap debridement (OFD) in the treatment of intrabony defects.

MATERIALS AND METHODS

A total of 16 patients of both sexes satisfying the criteria of chronic periodontitis and each of whom displayed one intrabony defect were randomly assigned to two groups, i.e. either treated with open flap surgery and GTR (group 1) or with open flap surgery alone (group 2), in this parallel-arm study. The soft tissue and hard tissue measurements, including probing pocket depth (PD), clinical attachment level (CAL), and bone mineral density were recorded at baseline and 3,6 and 12 months after surgery. The differences with a P < 0.05 were considered significant.

RESULTS

Results showed that the membrane group showed significant difference when compared with open flap surgery alone, in relation to the degree of periodontal pocket, clinical attachment loss, and bone density.

CONCLUSION

The findings of this study suggest that biocollagen membrane could be considered as an option in the treatment of intrabony defects. Biocollagen membrane alone gives favorable clinical results in the treatment of intrabony defects. Open flap debridement resulted in acceptable clinical results in the treatment of intrabony defects.

Comparative evaluation of periosteum as a barrier membrane with and without an alloplastic bone graft in periodontal osseous defects: A 9 months follow-up study

BACKGROUND

Regenerative procedures frequently include the use of barrier membranes and bone grafting materials to encourage the growth of key surrounding tissues. The present study aims to evaluate and compare the ability of periosteum in intrabony defect regeneration.

MATERIALS AND METHODS

A total of ten intrabony defects were equally divided in two treatment groups. Group I consisted of Periosteum used as a barrier memebrane and Group II of periosteum as barrier membrane alongwith graft material. Nine months post operative evaluation of defect fill was done radiographically.

RESULTS

Mean defect fill (CEJ-BBD) was found to be significantly lower in Group II as compared to Group I (P = 0.041).

CONCLUSION

Within the limitations of this study, alloplastic graft material supplimentation results in better regeneration with Periosteum used as a barrier membrane.

Comparison of treatment effects of guided tissue regeneration on infrabony lesions between animal and human studies: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

For ethical reasons it is becoming increasingly more difficult to obtain, from clinical studies, histological data on infrabony defects treated with guided tissue regeneration (GTR) techniques. The aim of this systematic review was to find the value of extrapolating animal data on treatment of periodontal infrabony lesions, using GTR only or GTR + bone grafts, to human clinical results.

MATERIAL AND METHODS

Searches of the PubMed and Cochrane databases were combined with hand searching of articles published from 1 January 1969 to 1 August 2012. The search included any type of barrier membrane, with or without grafted materials, used to treat periodontal infrabony lesions. All studies with histological or re-entry methodology outcome parameters that evaluated bone-filling and/or new-cementum-formation ratios from a defect depth were collected. When comparing animal and human outcomes, a meta-analysis was used to evaluate the bone-filling ratio, but only a descriptive analysis of the histological studies was performed.

RESULTS

In total, 22 studies were selected for the meta-analysis. In the GTR + bone graft groups the weighted-average bone-filling ratios were 52% (95% CI: 18-85%) in animals and 57% (95% CI: 30-83%) in humans, which were not statistically significantly different (p = 0.825). Similar results were found in the GTR-only groups, in which the weighted-average bone-filling ratios were 54% (95% CI: 37-72%) in animals and 59% (95% CI: 42-77%) in humans (p = 0.703). New-cementum formation of GTR only and GTR + bone grafts showed comparable ratio outcomes, and both were superior to the control group in animals only (p = 0.042).

CONCLUSION

Although quality assessments differed between animal and human studies, our analysis indicated that animal models and human results showed similar bone-filling ratios in infrabony defects treated with GTR only or with GTR + bone grafting.

Clinical and radiographical evaluation of a bioresorbable collagen membrane of fish origin in the treatment of periodontal intrabony defects: A preliminary study

BACKGROUND

Recently, there has been interest in non-mammalian collagen sources such as fish collagen in periodontal regeneration. In the present study, collagen barrier membrane of fish origin was assessed in the treatment of periodontal intrabony defects.

MATERIALS AND METHODS

Ten systemically healthy chronic periodontitis patients having a paired osseous defect in the mandibular posterior teeth were selected and randomly assigned to receive a collagen membrane (test) or open flap debridement (control) in a split mouth design. Clinical parameters such as Plaque index, Gingival bleeding index, Probing pocket depth, Relative attachment level, and Recession were recorded at baseline, 3, 6, and at 9 months, while radiographic evaluation was done to assess alveolar crestal bone level and percentage of defect fill at 6 and 9 months using autoCAD 2007 software. Student's t test (two-tailed, dependent) was used to find the significance of study parameters on continuous scale. Significance was set at 5% level of significance. Wilcoxon signed rank test was used to find the significance of percentage change of defect fill.

RESULTS

The comparison between the two groups did not show any statistically significant differences in the parameters assessed (P > 0.05) but, within each group, clinical parameters showed statistically significant differences from baseline to 9 months (P < 0.05).

CONCLUSION

Within the limits of the study, it can be inferred that no significant differences were found either by using collagen membrane of fish origin or open flap debridement in the treatment of periodontal intrabony defects.

Evaluation of a bioresorbable collagen membrane of fish origin in the treatment of periodontal intrabony defects: A prospective clinical study

BACKGROUND

Recently, there has been interest in non-mammalian collagen sources such as fish collagen in the development of biomatrices and scaffolds for periodontal regeneration. In the present study, a novel collagen barrier membrane of fish origin was assessed in the treatment of periodontal intra-bony defects.

MATERIALS AND METHODS

Ten systemically healthy chronic periodontitis patients having an osseous defect in the mandibular posterior teeth were selected and following the open flap debridement, a collagen membrane was placed over the defect and the flap was sutured with interrupted sutures. Clinical parameters such as Plaque Index, Gingival Bleeding Index, probing pocket depth (PPD), relative attachment level (RAL), and recession (R) were recorded at baseline, 6 and 9 months, whereas radiographic evaluation was done to assess alveolar crestal bone level and defect depth fill at 6 and 9 months using Auto-computer aided design (ACAD) 2007 software. Statistical significance was set at 5% level of significance.

RESULTS

There was statistical significant differences with respect to periodontal clinical parameters such as Plaque Index, Gingival Bleeding Index, PPD, RAL, and gingival recession assessed at baseline, at 6 and 9 months respectively (P < 0.05), and radiographic evaluation showed a defect fill of 58.62 median % at 9 months.

CONCLUSION

This preliminary study has shown predictable results in using fish collagen membrane, for treating periodontal intra-bony defects. Further, long-term clinical trials are needed to validate the effectiveness of this membrane.

Comparative study between two techniques for alveolar bone loss assessment: A pilot study

OBJECTIVE

To conduct a comparative study between two techniques for assessment of alveolar bone loss.

MATERIALS AND METHODS

Absolute and relative techniques were evaluated. The sample consisted of 16 radiographs supposed to meet a single criterion: The reference points applied (Cementum-enamel junction (CEJ) alveolar bone crest and root apex) should be visible. Bone height was measured in the selected radiographs as the percentage of root length through both techniques. Data were submitted to the Statistical Package for Social Science software. Results obtained by both methods were converted into bone loss index values and then categorized. Sensitivity and specificity of the relative technique, compared to the absolute technique, were calculated. Wilcoxon test and the Bland and Altman's method were employed for comparisons. Significance level was set at 5%.

RESULTS

For the absolute and relative techniques, means of bone loss index were respectively of 4.81 (±2.25) and 4.75 (±1.80). Bone loss index ≥6 (alveolar bone loss ≥50%) was found in 5 (31.2%) teeth, in the absolute technique, and in 4 (25%) teeth, according to the relative technique. There was no statistically significant difference between both methods (P>0.05). According to the Bland and Altman's method, it was verified a bias of 0.06, and limits of upper and lower agreement of, respectively, 1.58 and -1.45. Sensitivity of 0.8 and specificity of 1 were found for the relative technique compared to the absolute one.

CONCLUSION

There was no significant difference between the techniques evaluated, and the relative technique was found to be reliable for measuring alveolar bone loss.

Digital subtraction radiographic analysis of the combination of bioabsorbable membrane and bovine morphogenetic protein pool in human periodontal infrabony defects

OBJECTIVES

This study assessed the bone density gain and its relationship with the periodontal clinical parameters in a case series of a regenerative therapy procedure.

MATERIAL AND METHODS

Using a split-mouth study design, 10 pairs of infrabony defects from 15 patients were treated with a pool of bovine bone morphogenetic proteins associated with collagen membrane (test sites) or collagen membrane only (control sites). The periodontal healing was clinically and radiographically monitored for six months. Standardized pre-surgical and 6-month postoperative radiographs were digitized for digital subtraction analysis, which showed relative bone density gain in both groups of 0.034 ± 0.423 and 0.105 ± 0.423 in the test and control group, respectively (p>0.05).

RESULTS

As regards the area size of bone density change, the influence of the therapy was detected in 2.5 mm² in the test group and 2 mm² in the control group (p>0.05). Additionally, no correlation was observed between the favorable clinical results and the bone density gain measured by digital subtraction radiography (p>0.05).

CONCLUSIONS

The findings of this study suggest that the clinical benefit of the regenerative therapy observed did not come with significant bone density gains. Long-term evaluation may lead to a different conclusions.

Regeneration of periodontal tissues: guided tissue regeneration

The concept that only fibroblasts from the periodontal ligament or undifferentiated mesenchymal cells have the potential to re-create the original periodontal attachment has been long recognized. Based on this concept, guided tissue regeneration has been applied with variable success to regenerate periodontal defects. Quantitative analysis of clinical outcomes after guided tissue regeneration suggests that this therapy is a successful and predictable procedure to treat narrow intrabony defects and class II mandibular furcations, but offers limited benefits in the treatment of other types of periodontal defects.

Predictability of clinical outcomes following regenerative therapy in intrabony defects

BACKGROUND

Demineralized bone matrix (DBM) and guided tissue regeneration (GTR) support substantial gains in clinical attachment level (CAL), reductions in probing depth (PD), and gains in defect fill compared to open flap debridement (OFD) in intrabony defects. Although these regenerative therapies support improvements in mean clinical parameters, it is unclear whether the procedures improve the predictability of clinical outcome. The purpose of this study was to examine the relative variability in clinical outcome measures, independent of the magnitude of gains, in regenerative studies comparing DBM or GTR to OFD therapy for the management of intrabony defects. For comparative purposes, a similar analysis was performed evaluating the consistency of clinical outcomes with other (non-DBM) bone replacement graft (BRG) materials relative to OFD alone.

METHODS

Fifty-five randomized controlled clinical trials comparing regenerative therapy (seven DBM, 22 BRG, and 26 GTR) to OFD and meeting inclusion criteria provided mean change scores (pretreatment to post-treatment) and variance estimates for CAL, PD, and bone fill, allowing for calculation of a coefficient of variability (CV) for each measure within studies. The mean CV for each measure was submitted to an analysis of variance or covariance with repeated measures (P < or =0.05) to compare relative variation in treatment outcomes.

RESULTS

DBM was associated with a significantly lower relative variability (mean +/- SE) in CAL gain (96.3 +/- 38.6 versus 137.7 +/- 30.9) and defect fill (69.1 +/- 11.2 versus 133.1 +/- 15.3) compared to OFD alone. As a group, other BRGs were found to support significant reductions in variation in CAL and defect fill. GTR therapy was associated with significantly lower CV for CAL compared to OFD (50.6 +/- 5.0 versus 68.7 +/- 8.2, respectively). Variability in defect fill was similar for GTR and OFD.

CONCLUSIONS

DBM and GTR therapy support more consistent improvements in clinical parameters; however, with the exception of defect fill following bone grafting, the reduction in variability in clinical outcomes was relatively modest compared to OFD alone. Overall, the treatment of intrabony defects is associated with a relatively high degree of variability in clinical outcome, regardless of therapeutic approach.

Clinical and Radiographic Evaluation of Soft and Hard Tissue Changes Around Implants: A Pilot Study

BACKGROUND

The aim of this study was to evaluate the clinical and radiographic changes in the peri-implant tissues around one-stage implants with different smooth neck portion lengths before and after functional prosthetic loading.

METHODS

Twelve one-stage implants were placed in adult patients with bilateral edentulous posterior mandibular ridges. The sites were randomly assigned into two groups of six each: group 1: 2.8 mm neck implants and group 2: neck implants. The parameters plaque index (PI), gingival index (GI), probing depth (PD), gingival margin level (GML), relative clinical attachment level (r-CAL), and optical density (OD) were measured at loading (4 months) and 12 months after implant placement. The radiographic parameter osseous level (OL) was measured at implant placement, loading, and at 12 months. Analysis of variance and the paired Student t test were used to detect difference over time and between groups.

RESULTS

The results showed significant differences (P<0.05) for both groups for PD, r-CAL, and OL for intragroup comparisons over time. However, no significant differences were found for PI, GI, PD, GML, OD, and OL for between-group comparisons.

CONCLUSION

Bony loss occurred before loading, supporting the soft tissues and maintaining the biologic width irrespective of the smooth portion length.