Single Flap Approach With and Without Guided Tissue Regeneration and a Hydroxyapatite Biomaterial in the Management of Intraosseous Periodontal Defects

Current status of Er:YAG laser in periodontal surgery

Lasers have numerous advantageous tissue interactions such as ablation or vaporization, hemostasis, bacterial killing, as well as biological effects, which induce various beneficial therapeutic effects and biological responses in the tissues. Thus, lasers are considered an effective and suitable device for treating a variety of inflammatory and infectious conditions of periodontal disease. Among various laser systems, the Er:YAG laser, which can be effectively and safely used in both soft and hard tissues with minimal thermal side effects, has been attracting much attention in periodontal therapy. This laser can effectively and precisely debride the diseased root surface including calculus removal, ablate diseased connective tissues within the bone defects, and stimulate the irradiated surrounding periodontal tissues during surgery, resulting in favorable wound healing as well as regeneration of periodontal tissues. The safe and effective performance of Er:YAG laser-assisted periodontal surgery has been reported with comparable and occasionally superior clinical outcomes compared to conventional surgery. This article explains the characteristics of the Er:YAG laser and introduces its applications in periodontal surgery including conventional flap surgery, regenerative surgery, and flapless surgery, based on scientific evidence from currently available basic and clinical studies as well as cases reports.

Minimally invasive non-surgical periodontal therapy of intrabony defects: A prospective multi-centre cohort study

AIM

To assess the potential benefits of minimally invasive non-surgical therapy (MINST) in teeth with intrabony defects and to explore factors associated with the outcomes.

MATERIALS AND METHODS

A multi-centre trial was conducted in 100 intrabony defects in periodontitis patients in private practice. Steps 1 and 2 periodontal therapy including MINST were provided. Clinical and radiographic data were analysed at baseline and 12 months after treatment, with the primary aim being change in radiographic defect depth at 12 months.

RESULTS

Eighty-four patients completed the 12-month follow up. The mean total radiographic defect depth reduced by 1.42 mm and the defect angle increased by 3° (both p < .05). Statistically significant improvements in probing pocket depth (PPD) and clinical attachment level (CAL) were seen at 12 months compared to baseline (p < .001). Fifty-six defects (66.7%) achieved pocket closure (PPD ≤ 4 mm) and 49 defects (58.3%) achieved the composite outcome (PPD ≤ 4 mm and CAL gain ≥3 mm). Deeper and narrower angled defects were positively correlated with radiographic and clinical improvements, respectively.

CONCLUSIONS

Improvements in clinical and radiographic outcomes were seen after MINST. This study highlights the generalizability and wide applicability of this approach, further supporting its effectiveness in the treatment of intrabony defects.

CLINICAL TRIAL REGISTRATION

NCT03741374. https://clinicaltrials.gov/study/NCT03741374?cond=minimally%20invasive%20non%20surgical%20therapy&locStr=UK&country=United%20Kingdom&distance=50&rank=2.

Early periodontal wound healing after chlorhexidine rinsing: a randomized clinical trial

OBJECTIVES

This single-center randomized, parallel design, clinical trial with a 2-week follow-up involved patients affected by periodontitis undergoing periodontal surgery. The aim was to evaluate periodontal surgical wound healing with the use of chlorhexidine-based mouth rinses versus an untreated control group.

MATERIALS AND METHODS

Periodontal surgery was performed following a standardized protocol. Patients were randomly prescribed i) chlorhexidine (CHX) + anti-discoloration system (ADS) + hyaluronic acid (HA), ii) CHX + ADS or iii) no treatment (control group). Plaque score, gingival inflammation, and Early Healing Index (EHI), assessing the degree of wound closure and the presence of fibrin and necrosis, were evaluated at 3, 7 and 14 days after surgery.

RESULTS

In total, 33 patients were enrolled. Patients were comparable at baseline for all measured clinical parameters. At 3-days wound healing was significantly improved in all patients treated with CHX + ADS-based mouth rinses with a lower EHI score at the interdental papillae compared with control group (p < 0.01). CHX + ADS + HA group presented improved healing across all time points in terms of EHI, plaque containment, and gingival inflammation when compared to control group (p < 0.01).

CONCLUSIONS

The usage of CHX-ADS following periodontal surgery improved early wound healing, reduced plaque accumulation and gingival inflammation. During the early post-operative period the adjunct of HA further improved soft tissue closure.

CLINICAL RELEVANCE

This study aims at evaluating the response of gingival tissues to mouth rinsing with chlorhexidine and anti-discoloration system (CHX + ADS) or CHX + ADS + hyaluronic acid (CHX + ADS + HA) versus no rinse in terms of healing of the periodontal surgical wound. CHX + ADS mouth rinses enhanced early soft tissue closure after periodontal surgery and contributed to the reduction in plaque accumulation and gingival inflammation. The adjunct of HA may be beneficial especially in the early post-operative period. CHX + ADS administration following periodontal surgery may improve soft tissue healing in the first two post-operative weeks.

Clinical benefits of autologous platelet concentrate in periodontal intrabony defects: A network meta-analysis of randomized controlled trials

This study aimed to compare clinical benefits of autologous platelet concentrate with other periodontal regenerative approaches in intrabony defects. An electronic and hand search of studies up to December 2022 was conducted. Randomized controlled trials with at least 6 months of follow-up were identified to compare autologous platelet concentrates with enamel matrix derivative, bone graft, guided tissue regeneration, and open-flap debridement. All approaches involved papilla preservation flap surgery. The outcomes included probing depth reduction, clinical attachment level gain, linear bone fill, and safety. A network meta-analysis and meta-regression were performed. Fifty-seven studies were included in five network meta-analyses. Autologous platelets concentrate and its adjunct treatments achieved significantly greater clinical and radiographic parameters than did open-flap debridement, and had comparable or better performance than other regenerative treatments. Platelet-rich fibrin showed superiority over platelet-rich plasma in probing depth reduction at 6-month follow-up. Minimal pain and improved wound healing were observed in the treatments with autologous platelet concentrate. Meta-regression showed that deeper baseline intrabony defects resulted in larger probing depth reductions, while smoking impaired the effectiveness of regenerative surgeries. Minimal invasive flap designs led to less effect of regenerative materials. Autologous platelet concentrate is a promising biomaterial in periodontal regeneration due to its convenience, safety, and biocompatibility characteristics.

Comparison of early wound healing using modified papilla preservation technique between enamel matrix derivative and recombinant human fibroblast growth factor

PURPOSE

Enamel matrix derivative (EMD) has demonstrated beneficial effects on wound healing following surgery. However, the effects of recombinant human fibroblast growth factor 2 (rhFGF-2) in periodontal regeneration therapy have not been extensively studied. This retrospective study was conducted to compare the wound healing outcomes of the modified papilla preservation technique (mPPT) between EMD and rhFGF-2 therapies.

METHODS

A total of 79 sites were evaluated for early wound healing using the modified early wound healing index (mEHI), which included 6 items: incision, fibrin clotting, step, redness, swelling, and dehiscence. A numeric analog scale, along with postoperative images of the 6 mEHI items, was established and used for the evaluations. The inter-rater reliability of the mEHI was assessed via intraclass correlation coefficients (ICCs). After adjusting for factors influencing the mPPT, the differences in mEHI scores between the EMD and rhFGF-2 groups were statistically analyzed. Additionally, radiographic bone fill (RBF) was evaluated 6 months after surgery.

RESULTS

The ICC of the mEHI was 0.575. The mEHI, redness score, and dehiscence scores were significantly higher in the rhFGF-2 group (n=33) than in the EMD group (n=46). Similar results were observed in the subgroup of patients aged 50 years or older, but not in those younger than 50 years. In the subgroup with non-contained bone defects, related results were noted, but not in the subgroup with contained bone defects. However, early wound healing did not correlate with RBF at 6 months after surgery.

CONCLUSIONS

Within the limitations of this study, the findings suggest that early wound healing following the use of mPPT with rhFGF-2 is somewhat superior to that observed after mPPT with EMD. However, mEHI should be improved for use as a predictive tool for early wound healing and to reflect clinical outcomes after surgery.

Prognostic value of a composite outcome measure for periodontal stability following periodontal regenerative treatment: A retrospective analysis at 4 years

BACKGROUND

Recently, a composite outcome measure (COM) was proposed to describe the short-term results of periodontal regenerative treatment. The present retrospective study aimed at evaluating the prognostic value of COM on clinical attachment level (CAL) change over a 4-year period of supportive periodontal care (SPC).

METHODS

Seventy-four intraosseous defects in 59 patients were evaluated at 6 months and 4 years following regenerative treatment. Based on 6-month CAL change and probing depth (PD), defects were classified as: COM1 (CAL gain ≥3 mm, PD ≤4 mm); COM2 (CAL gain <3 mm, PD ≤4 mm); COM3 (CAL gain ≥3 mm, PD >4 mm); or COM4 (CAL gain <3 mm, PD >4 mm). COM groups were compared for "stability" (i.e., CAL gain, no change in CAL or CAL loss <1 mm) at 4 years. Also, groups were compared for mean change in PD and CAL, need for surgical retreatment, and tooth survival.

RESULTS

At 4 years, the proportion of stable defects in COM1, COM2, COM3, and COM4 group was 69.2%, 75%, 50%, and 28.6%, respectively, with a substantially higher probability for a defect to show stability for COM1, COM2, and COM3 compared with COM4 (odds ratio 4.6, 9.1, and 2.4, respectively). Although higher prevalence of surgical reinterventions and lower tooth survival were observed in COM4, no significant differences were detected among COM groups.

CONCLUSIONS

COM may be of value in predicting CAL change at sites undergoing SPC following periodontal regenerative surgery. Studies on larger cohorts, however, are needed to substantiate the present findings.

Hydroxyapatite-based composites: Excellent materials for environmental remediation and biomedical applications

Given their unique characteristics and properties, Hydroxyapatite (HAp) nanomaterials and nanocomposites have been used in diverse advanced catalytic technologies and in the field of biomedicine, such as drug and protein carriers. This paper examines the structure and properties of the manufactured HAp as well as a variety of synthesis methods, including hydrothermal, microwave-assisted, co-precipitation, sol-gel, and solid-state approaches. Additionally, the benefits and drawbacks of various synthesis techniques and ways to get around them to spur more research are also covered. This literature discusses the various applications, including photocatalytic degradation, adsorptions, and protein and drug carriers. The photocatalytic activity is mainly focused on single-phase, doped-phase, and multi-phase HAp, while the adsorption of dyes, heavy metals, and emerging pollutants by HAp are discussed in the manuscript. Furthermore, the use of HAp in treating bone disorders, drug carriers, and protein carriers is also conferred. In light of this, the development of HAp-based nanocomposites will inspire the next generation of chemists to improve upon and create stable nanoparticles and nanocomposites capable of successfully addressing major environmental concerns. This overview's conclusion offers potential directions for future study into HAp synthesis and its numerous applications.

Bioactive Glasses in Periodontal Regeneration A Systematic Review

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

The effect of dental pulp stem cells and L-PRF when placed into the extraction sockets of impacted mandibular third molars on the periodontal status of adjacent second molars: a split-mouth, randomized, controlled clinical trial

PURPOSE

To compare the clinical and radiographic effectiveness of dental pulp stem cells (DPSCs) seeded onto L-PRF and L-PRF alone in the extraction socket of mandibular third molars.

METHODS

This study analyzed 13 patients who required surgical removal of impacted bilateral mandibular third molars. The main outcome measures were the probing pocket depth (PPD) and clinical attachment levels (CAL) that were recorded for the adjacent second molars (LM2) at the baseline and 6 months after surgery. The secondary outcomes were radiographic vertical bone loss (VD) and relative bone density (rBD) distal to the LM2.

RESULTS

Twenty-six LM2s were evaluated. After 6 months, the L-PRF and L-PRF + DPSC groups showed a significant reduction in PPD (1.65 ± 1.01 mm and 1.54 ± 0.78 mm) and CAL (2.23 ± 1.45 mm and 2.12 ± 0.74 mm), respectively. There was no difference between the groups for any periodontal parameters. No significant differences were found between the groups regarding the VD or rBD at the sixth month.

CONCLUSIONS

This study found that there was a significant improvement regarding the PPD, CAL, and VD measurements with the application of L-PRF, both alone and with the addition of DPSC, at the extraction socket. DPSC did not significantly contribute to the results compared to L-PRF therapy alone.

TRIAL REGISTRATION

This study was registered on 23 December 2020 on ClinicalTrials.gov under the number NCT04641533.

Minimal invasiveness in the surgical treatment of intraosseous defects: A systematic review

The modern approach to regenerative treatment of periodontal intraosseous defects should aim at maximizing the clinical outcomes while minimizing the invasiveness (pain, complications, aesthetic impairment, chair time, and costs) of the procedure. The present systematic review evaluated the effect of flap design, regenerative technology, and perioperative and postoperative adjunctive protocols on invasiveness. Overall, the results of the 13 included trials indicate that: (a) the elevation of a single (buccal or lingual) flap positively influences the intensity of postoperative pain and improves the quality of early wound healing compared with double flaps; (b) while the adjunctive use of a membrane is associated with significantly longer surgery-related chair time and higher postoperative pain, the adjunctive use of enamel matrix derivative at sites receiving a graft significantly reduces postoperative pain; also, graft materials showed no significant impact on invasiveness; (c) open flap debridement performed through the elevation of a single flap may lead to substantial clinical improvements of the lesion with reduced surgery-related chair time and costs, thus representing a promising alternative to regenerative treatment. However, for such an approach, a histological evaluation of the nature of the reconstructed tissues is still lacking, and the presurgery conditions (eg, probing depth, defect severity, and defect morphology), which may benefit in terms of invasiveness, have not yet been defined; and (d) intraoperative and postoperative low-level laser biostimulation of the defect site may favorably modulate the postoperative course.

Minimally Invasive Non-Surgical Technique in the Treatment of Intrabony Defects-A Narrative Review

Intrabony defects occur frequently in periodontitis and represent sites that, if left untreated, are at increased risk for disease progression. Although resective or repair procedures have been used to treat intrabony defects, aiming at their elimination, the treatment of choice is surgical periodontal regeneration. The development of periodontal regeneration in the last 30 years has followed two distinctive, though totally different, paths. The interest of researchers has so far focused on regenerative materials and products on one side, and on novel surgical approaches on the other side. In the area of materials and products, three different regenerative concepts have been explored namely, barrier membranes, bone grafts, and wound healing modifiers/biologics, plus many combinations of the aforementioned. In the area of surgical approaches, clinical innovation in flap design and handling, as well as minimally invasive approaches, has radically changed regenerative surgery. Recently, a minimally invasive non-surgical technique (MINST) for the treatment of intrabony defects was proposed. Initial clinical trials indicated comparable results to the surgical minimally invasive techniques in both clinical and radiographic outcomes. These results support the efficacy of this treatment approach. The aim of this review is to present the evidence on the application of minimally invasive non-surgical techniques and their efficacy in the treatment of intrabony defects.

A pioneer surgical technique for isolated periodontal defects by “closed” retraction of the papilla; A feasibility study

Aim

A pioneer periodontal surgical approach employing the closed surgical technique (CST) in combination with the tissue-engineered biocomplex aimed to gain access to the osseous defect and improve soft-tissue architecture.

Methods

The CST was applied in four systemically healthy periodontitis patients/defects who were followed for 12-months. It avoids papilla dissection and retraction of flaps in an open manner thus, suturing is not required. It is designed for the reconstruction of residual isolated periodontal defects and is best indicated in the aesthetic region. It can be applied as a sole treatment approach to facilitate deep instrumentation of the defect, or it could be combined with subgingival application of regenerative materials. Hereby, the biocomplex was applied containing autologous alveolar Bone-Marrow Mesenchymal-Stem-Cells, seeded into collagen scaffolds, enriched with autologous fibrin/platelet lysate.

Results

The CST minimized post-operative discomfort and led to improved treatment outcomes with probing pocket depth reduction [average (SD)] of 24.4 (18.5) %, gain in clinical attachment levels of 25.8 (20.1) %, and evidence of remineralisation of the alveolar crest.

Conclusion

The CST is a tissue-friendly operation and facilitates subgingival application of biological agents via tunneling the soft-tissues. However, surgical experience is required for non-traumatic manipulation of the gingival tissues during “closed” retraction of the flaps.

Clinical trial registration

Registered with Clinicaltrials.gov; ClinicalTrials.gov ID: NCT02449005.

A, Prakash P, Bahammam SA, Bahammam MA, Almarghlani A, Assaggaf M, Kamil MA, Subramanian S, Balaji TM, Patil S. The Efficacy of Low-Level Laser Therapy Combined with Single Flap Periodontal Surgery in the Management of Intrabony Periodontal Defects: A Randomized Controlled Trial

This study aimed at assessing the clinical outcomes of the Single Flap Approach (SFA) with the additional use of Low-level laser therapy (LLLT). The defects were treated as per the principles of SFA, whereby 20 defects received only SFA (control group) and 20 defects received additional LLLT for bio stimulation/bio modulation (test group). Stable primary closure of the flaps was obtained with vertical internal mattress sutures. Plaque indices (FMPS), clinical attachment levels (CAL), probing pocket depth (PPD), and gingival bleeding scores (FMBS) were calculated at baseline, and at the 3rd and 6th months in both groups. An EHI score of 1 was observed at all sites except for two, where a score of 2 in the control group at week 2 was observed. In the test group, the PPD reduction at 6 months was 3.60 ± 0.95 and in the control group it was 3.75 ± 0.91 mm. CAL gain at 6 months was 2.70 ± 1.36 mm and 3.45 ± 1.2 mm in the test group and showed no statistical significance. These data suggested the positive effect of LLLT over CAL gain; thus, LLLT may be combined with SFA to potentially enhance the early wound healing and higher clinical outcomes in terms of increase in CAL and decrease in PPD.

Modified minimally invasive surgical technique in human intrabony defects with or without regenerative materials-10-year follow-up of a randomized clinical trial: Tooth retention, periodontitis recurrence, and costs

AIM

The modified minimally invasive surgical technique (M-MIST) optimizes wound stability in the treatment of intrabony defects. Short-term observations show similar results as with flap alone or adjunctive regenerative materials. This study aims to compare the stability of the long-term outcomes, complication-free survival, and costs of the three treatment options.

MATERIALS AND METHODS

Forty-five intrabony defects in 45 patients were randomized to M-MIST alone (N = 15), combined with enamel matrix derivative (M-MIST + EMD, N = 15), or EMD plus bone-mineral-derived xenograph (M-MIST + EMD + BMDX, N = 15). Supportive periodontal care (SPC) and necessary re-treatment were provided for 10 years.

RESULTS

Three subjects were lost to follow-up. Clinical attachment level differences between 1 and 10 years were -0.1 ± 0.7 mm for M-MIST, -0.1 ± 0.8 mm for M-MIST + EMD, and -0.3 ± 0.6 mm for M-MIST + EMD + BMDX (p > .05 for within- and between-group differences). Four episodes of recurrence occurred in the M-MIST group, four in the M-MIST + EMD group, and five in the M-MIST + EMD + BMDX group. No significant differences in complication-free survival were observed between the three groups (p = .47). Complication-free survival was 7.46 years (95% confidence interval: 7.05-7.87) for the whole population. The M-MIST + EMD + BMDX group lost one treated tooth. Data indicated no significant inter-group difference of the total cost of recurrence over 10 years. When the baseline cost of treatment was considered, the total cost was lower for M-MIST alone.

CONCLUSIONS

Teeth with deep pockets associated with intrabony defects can be successfully maintained over the long term with either M-MIST alone or by adding a regenerative material in the context of a careful SPC programme. M-MIST alone provided similar short- and long-term benefits as regeneration, at a lower cost. These findings need to be confirmed in larger, independent studies.

Bioactive Glasses in Periodontal Regeneration: Existing Strategies and Future Prospects-A Literature Review

The present review deals with bioactive glasses (BGs), a class of biomaterials renowned for their osteoinductive and osteoconductive capabilities, and thus widely used in tissue engineering, i.e., for the repair and replacement of damaged or missing bone. In particular, the paper deals with applications in periodontal regeneration, with a special focus on in vitro, in vivo and clinical studies. The study reviewed eligible publications, identified on the basis of inclusion/exclusion criteria, over a ranged time of fifteen years (from 1 January 2006 to 31 March 2021). While there are many papers dealing with in vitro tests, only a few have reported in vivo (in animal) research, or even clinical trials. Regardless, BGs seem to be an adequate choice as grafts in periodontal regeneration.

3D gel-printed porous magnesium scaffold coated with dibasic calcium phosphate dihydrate for bone repair in vivo

Background

/Objective: The treatment of bone defect has always been a difficult problem in orthopedic clinic. The search for alternative biodegradable implants is a hot topic. The development of biodegradable magnesium scaffolds for the treatment of bone defects has long been a goal of the public.

Methods

In this study, we proposed a porous magnesium scaffold prepared by 3D gel printing and surface modification with an additional calcium phosphate coating and use of its strength, degradability and slow degradation rate in a bone graft substitute material. The porous magnesium granular scaffold was prepared by 3D gel printing technology and modified by DCPD (Dibasic Calcium Phosphate Dihydrate) coating. The biocompatibility, degradation rate, and osteogenic ability of the scaffold were evaluated in vitro and in vivo.

Results

The biocompatibility, in vivo degradation and bone defect healing response of the implants were investigated. Porous magnesium scaffolds were successfully prepared, and the strength of sintered scaffolds reached 5.38 ​MPa. The degradation rates of scaffolds were significantly reduced after coating with DCPD. The cell compatibility evaluation showed that DCPD-coated Mg scaffold was suitable for cell proliferation. In vivo biosafety monitoring showed that scaffold implantation did not cause an increase in Mg ion concentration in vivo, and no toxic damage was detected in the liver or kidney. Micro-CT and pathological results showed that a large amount of new bone was formed at 6 weeks. At 12 weeks, approximately 52% of the scaffold volume remained. At 24 weeks, osteogenesis, which was stimulated by some residual scaffold, still can be observed. In summary, this study suggests that 3D gel-printed DCPD-coated porous magnesium scaffolds have great potential as bone graft alternatives.

Conclusion

In summary, this study suggests that 3D gel-printed DCPD-coated porous magnesium scaffolds have great potential as bone graft alternatives.

The Translational potential of this article

The translational potential of this article is to make use of the advantages of 3D gel printing technology with higher efficiency and lower cost compared with SLM and SLS technologies, and use pure magnesium powder as raw material to prepare degradable porous magnesium metal scaffolds, opening up a new technical route for the preparation of degradable porous magnesium scaffolds which are made for bone defect regeneration in the future.

Apical approach in periodontal reconstructive surgery with enamel matrix derivate and enamel matrix derivate plus bone substitutes: a randomized, controlled clinical trial

Objectives

This parallel, randomized controlled clinical trial evaluated the influence of bone substitutes (BS) on the efficacy of the non-incised papillae surgical approach (NIPSA) with enamel matrix derivate (EMD) in resolving deep, isolated, combined non-contained intrabony and supra-alveolar periodontal defects, preserving the soft tissue.

Material and methods

Twenty-four patients were randomized to treatment with NIPSA and EMD or NIPSA plus EMD and BS. Bleeding on probing (BoP), interproximal clinical attachment level (CAL), interproximal probing depth (PD), recession (REC), location of the tip of the papilla (TP), and width of the keratinized tissue (KT) were evaluated before surgery and at 1 year post-surgery (primary outcomes). Wound closure was assessed at 1 week post‐surgery, and supra‐alveolar attachment gain (SUPRA-AG) was recorded at 1 year post‐surgery.

Results

At 1 week, 87.5% of cases registered complete wound closure and there were no cases of necrosis, without differences between groups (p > .05). At 1 year, all cases showed negative BoP. A significant PD reduction (NIPSA + EMD 8.25 ± 2.70 mm vs. NIPSA + EMD + BS 6.83 ± 0.81 mm) and CAL gain (NIPSA + EMD 8.33 ± 2.74 mm vs. NIPSA + EMD + BS 7.08 ± 2.68 mm) were observed (p < .001) in both groups, without significant between-group differences (p > .05). The residual PD was < 5 mm in all defects (NIPSA + EMD 2.50 ± 0.67 mm vs. NIPSA + EMD + BS 2.67 ± 0.78 mm). Soft tissues were preserved without significant between-group differences (REC: NIPSA + EMD 0.25 ± 0.45 mm vs. NIPSA + EMD + BS 0.17 ± 0.58 mm, p > .05; KT: 0.00 ± 0.43 mm vs. 0.08 ± 0.67 mm, p > .05). There were improvements in the papilla in both groups (TP: NIPSA + EMD 0.33 ± 0.49 mm vs. NIPSA + EMD + BS 0.45 ± 0.52 mm, p > .05), which was only significant in the NIPSA EMD + BS group (0.45 ± 0.52 mm; p < .05). In both groups, CAL gain was recorded in the supra-alveolar component, showing full resolution of the intrabony component of the defect in all cases (SUPRA-AG: NIPSA + EMD 1.83 ± 1.11 mm vs. NIPSA + EMD + BS 2.00 ± 1.76 mm, p > .05).

Conclusions

NIPSA and EMD with or without BS seem to be a valid surgical approach in the treatment of isolated, deep non-contained periodontal defects. In our study, both treatments resulted in significant PD reduction and CAL gain, that extended in the supra-alveolar component, without differences with the use of BS. Both treatments resulted in soft tissue preservation. However, the addition of BS may improve interdental papillary tissue.

Clinical relevance

NIPSA, with or without bone substitutes, resulted in significant periodontal improvement, with soft tissue preservation in isolated, deep non-contained periodontal defects. The application of bone substitutes may provide interproximal soft tissue gain.

Clinical trial registration

Clinicaltrials.gov: NCT04712630.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00784-021-04256-1.

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 role of surgical flap design (minimally invasive flap vs. extended flap with papilla preservation) on the healing of intrabony defects treated with an enamel matrix derivative: a 12-month two-center randomized controlled clinical trial

Objectives

Minimally invasive flap designs have been introduced to enhance blood clot stability and support wound healing. Limited data appear to suggest, that in intrabony defects, better clinical outcomes can be achieved by means of minimally invasive flap compared to more extended flaps. The aim of this study was to evaluate the healing of intrabony defects treated with either minimally invasive surgical flaps or with modified or simplified papilla preservation techniques in conjunction with the application of an enamel matrix derivative (EMD).

Materials and methods

Forty-seven subjects were randomly assigned to either test (N = 23) or control (N = 24) procedures. In the test group, the intrabony defects were accessed by means of either minimally invasive surgical technique (MIST) or modified minimally invasive surgical technique (M-MIST) according to the defect localization while the defects in the control group were treated with either the modified or simplified papilla preservation (MPP) or the simplified papilla preservation technique (SPP). EMD was used as regenerative material in all defects. The following clinical parameters were recorded at baseline and after 12 months: full-mouth plaque score (FMPS), full-mouth bleeding score (FMBS), probing depths (PD), clinical attachment level (CAL), and gingival recession (GR). Early healing index (EHI) score was assessed in both groups 1 week following the surgery. CAL gain was set as primary outcome.

Results

After 12 months follow-up, the CAL gain was 4.09 ± 1.68 mm in test group and 3.79 ± 1.67 mm in control group, while the PD reduction was 4.52 ± 1.34 mm and 4.04 ± 1.62 mm for test and control sites. In both groups, a minimal GR increase (0.35 ± 1.11 mm and 0.25 ± 1.03 mm) was noted. No residual PDs ≥ 6 mm were recorded in both groups. CAL gains of 4–5 mm were achieved in 30.4% and in 29.2% of test and control group, respectively. Moreover, CAL gains ≥ 6 mm were recorded in 21.7% of experimental sites and in 20.8% of control sites. No statistically significant differences in any of the evaluated parameters were found between the test and control procedures (P > 0.05). After 1 week post-surgery, a statistically significant difference (P < 0.05) between the groups was found in terms of EHI score.

Conclusions

Within the limits of this pilot RCT, the results have failed to show any differences in the measured parameters following treatment of intrabony defects with EMD, irrespective of the employed surgical technique.

Clinical relevance

In intrabony defects, the application of EMD in conjunction with either MIST/M-MIST or M-PPT/SPPT resulted in substantial clinical improvements.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00784-021-04155-5.

Efficacy of periodontal minimally invasive surgery with and without regenerative materials for treatment of intrabony defect: a randomized clinical trial

OBJECTIVES

The minimally invasive surgical technique was modified in suture (MISTms) in this study. The trial was to determine the efficacy of MISTms with and without regenerative materials for the treatment of intrabony defect and to identify factors influencing 1-year clinical attachment level (CAL) gain.

METHODS

Thirty-six patients with interdental intrabony defects were randomly assigned to MISTms (MISTms alone, 18) or MISTms plus deproteinized bovine bone mineral and collagen membrane (MISTms combined, 18). Wound healing was evaluated by early healing index (EHI) at 1, 2, 3, and 6 weeks. Probing depth (PD), CAL, gingival recession, radiographic defect depth, and distance from the base of defect to the cementoenamel junction were recorded at baseline and 1 year postoperatively. A one-year composite outcome measure based on the combination of CAL gain and post-surgery PD was evaluated. Factors influencing 1-year CAL gain were analyzed.

RESULTS

Fifteen patients in MISTms-alone and 16 in the MISTms-combined group finished the study. The MISTms-alone group showed significantly better wound healing at 1 week. CAL significantly gained in the MISTms-alone and MISTms-combined group, with 2.53 ± 1.80 mm and 2.00 ± 1.38 mm respectively. The radiographic bone gain was 3.00 ± 1.56 mm and 3.85 ± 1.69 mm respectively. However, there were no significant differences between the two groups about 1-year outcomes. Lower EHI (optimal wound healing) and more baseline CAL positively influenced 1-year CAL gain.

CONCLUSIONS

MISTms is an effective treatment for intrabony defects. The regenerative materials do not show an additional effect on 1-year outcomes. Early wound healing and baseline CAL are factors influencing 1-year CAL gain.

CLINICAL RELEVANCE

MISTms with and without regenerative materials are both effective treatments for intrabony defect.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: ChiCTR2100043272.

Minimally Invasive Periodontology: A Treatment Philosophy and Suggested Approach

Severe periodontitis is a highly prevalent dental disease. With the advent of implant dentistry, teeth are often extracted and replaced. Periodontal surgery, where indicated, could also result in increased trauma to the patient. This literature review discusses different treatment modalities for periodontitis and proposes a treatment approach emphasizing maximum preservation of teeth while minimizing morbidity to the patient. Scientific articles were retrieved from the MEDLINE/PubMed database up to January 2021 to identify appropriate articles that addressed the objectives of this review. This was supplemented with hand searching using reference lists from relevant articles. As tooth prognostication does not have a high predictive value, a more conservative approach in extracting teeth should be abided by. This may involve repeated rounds of nonsurgical periodontal therapy, and adjuncts such as locally delivered statin gels and subantimicrobial-dose doxycycline appear to be effective. Periodontal surgery should not be carried out at an early phase in therapy as improvements in nonsurgical therapy may be observed up to 12 months from initial treatment. Periodontal surgery, where indicated, should also be minimally invasive, with periodontal regeneration being shown to be effective over 20 years of follow-up. Biomarkers provide an opportunity for early detection of disease activity and personalised treatment. Quality of life is proposed as an alternative end point to the traditional biomedical paradigm focused on the disease state and clinical outcomes. In summary, minimally invasive therapy aims to preserve health and function of the natural dentition, thus improving the quality of life for patients with periodontitis.

A tissue-engineered biocomplex for periodontal reconstruction. A proof-of-principle randomized clinical study

AIM

To assess the safety/efficacy of a tissue-engineered biocomplex in periodontal reconstruction.

METHODS

Twenty-seven intrabony defects were block-randomized across three treatment groups: Group-A (N_A  = 9) received autologous clinical-grade alveolar bone marrow mesenchymal stem cells (a-BMMSCs), seeded into collagen scaffolds, enriched with autologous fibrin/platelet lysate (aFPL). In Group-B (N_B  = 10), the collagen scaffold/aFPL devoid of a-BMMSCs filled the osseous defect. Group-C (N_C  = 8) received Minimal Access Flap surgery retaining the soft tissue wall of defects identically with Groups-A/-B. Subjects were clinically/radiographically assessed before anaesthesia (baseline) and repeatedly over 12 months.

RESULTS

Quality controls were satisfied before biocomplex transplantation. There were no adverse healing events. All approaches led to significant clinical improvements (p < .001) with no inter-group differences. At 12 months, the estimated marginal means for all groups were as follows: 3.0 (95% CI: 1.9-4.1) mm for attachment gain; 3.7 (2.7-4.8) mm for probing pocket depth reduction; 0.7 (0.2-1.3) mm increase in recession. An overall greater mean reduction in the radiographic Cemento-Enamel Junction to Bottom Defect (CEJ-BD) distance was found for Groups-A/-C over Group-B (p < .023).

CONCLUSION

Radiographic evidence of bone fill was less pronounced in Group-B, although clinical improvements were similar across groups. All approaches aimed to trigger the innate healing potential of tissues. Cell-based therapy is justified for periodontal reconstruction and remains promising in selected cases.

Single flap approach with or without enamel matrix derivative in the treatment of severe supraosseous defects: a retrospective study

Aim

To comparatively evaluate the clinical effectiveness of the single flap approach (SFA) with and without enamel matrix derivative (EMD) in the treatment of supraosseous defects (SDs) associated with deep pockets.

Materials and methods

Twenty patients, each contributing one SD associated with a deep (≥ 6 mm) pocket and treated with buccal SFA either alone (SFA group; n = 10) or in combination with EMD (SFA+EMD group; n =10), were retrospectively selected. Clinical parameters (probing depth, PD; clinical attachment level, CAL; gingival recession, REC) had been assessed at pre-surgery and 12 months post-surgery.

Results

Complete wound closure was observed in 70% and 80% of defects treated with SFA and SFA+EMD, respectively. Treatments resulted in a significant PD reduction of 3.1±1.0 mm (p=0.005). In SFA+EMD group, 100% of closed pockets was obtained, while 90% of closed pockets was observed in SFA group. Both treatments resulted in a significant CAL gain of 2.1±0.9 mm and 1.9±1.7 mm in SFA and SFA+EMD group, respectively (p= 0.465). In both groups, REC significantly increased 1.0±1.1 mm in SFA group and 1.1±1.1 mm in SFA+EMD group (p= 0.722).

Conclusions

Within their limits, the findings of present study suggest that SFA may represent a valuable option for the surgical treatment of SDs associated with deep pockets. EMD did not result in a significant clinical benefit to the procedure.

Clinical relevance

SFA may represent a valuable option in obtaining pocket closure when treating SDs associated with deep residual pockets.

Non-Incised Papilla Surgical Approach and Leukocyte Platelet-Rich Fibrin in Periodontal Reconstruction of Deep Intrabony Defects: A Case Series

We present the preliminary results of the treatment of teeth with a deep, non-contained periodontal residual defect, vestibular bone dehiscence, and soft tissue recession, by combining an apical non-incised papilla surgical approach (NIPSA) to the defect and leukocyte platelet-rich fibrin (L-PRF) in the vestibular aspect. Four patients (upper left first premolar, upper left central incisor, upper right central incisor and upper right lateral incisor) have been treated. At one year of follow up, all cases showed a considerable reduction in the periodontal pocket depth, a gain in clinical attachment and no bleeding on probing, as well as an improvement in the marginal soft tissue minimizing soft tissue contraction (recession and/or loss of papilla) and improving soft tissue architecture. NIPSA plus L-PRF seem to improve clinical outcomes in deep non-contained intrabony defects associated with soft tissue recession.

Analysis of geometrical tomographic parameters of furcation lesions in periodontitis patients

Objectives

This study was aimed to investigate the relationship between geometric parameters of furcation lesions - maximum area of lesion opening (MALO), angle formed between the roots (ABR), lesion volume (LV) and presence and height of infra-osseous defects (IOD) - and the success of therapy with enamel matrix derivative proteins (EMD) in patients with grade C periodontitis, using cone-beam computed tomography (CBCT).

Methods

The study consisted of two groups of patients with grade C periodontitis: control (surgery) (n = 17) and test (surgery + EMD) (n = 17). Images parameters on CBCT were recorded using OnDemand3D and ITK-SNAP software.

Results

Pearson's correlation coefficient demonstrated that only IOD was statistically significant in the probing depth PD (P = 0.01), with a moderate positive correlation (R = 0.59). MALO was found to be statistically significant (P = 0.03) in the test group (surgery + EMD), with moderate negative correlation (R = -0.5).

Conclusion

The presence of infra-osseous defects and height were relevant in relation to the success of the type of treatment addressed in this study.

Minimally Invasive Surgical Strategies in Regenerative/Reconstructive Periodontal Therapy

FOCUSED CLINICAL QUESTION

After a quick overview on the original principles of guided periodontal regeneration (GTR), the aim of this paper focuses on the advantages of minimally invasive surgical techniques for periodontal regeneration/reconstruction. The specific clinical question to answer is: Are there new clinical parameters useful to choose the best minimal invasive surgery approach for each periodontal defect? An update of the decision trees is to propose after highlighting some clinical parameters deemed relevant for the choice of the most suitable minimally invasive surgical approach and which therefore are considered by us having a place in the new decision trees.

SUMMARY

Starting from the paper of Evian dated 1985 until that of Aslan in 2017, we have analyzed the minimal periodontal surgical techniques proposed for the periodontal regeneration. In addition to the parameters set in the various flowcharts, we have highlighted the following additional parameters: papilla height loss; supra bone component of the defect; Δ Bone Sounding; width of keratinized tissue.

CONCLUSION

The decision-making chart improved with the new clinically relevant factors may serve as a useful guideline for dentists, but to definitively validate it, further studies need to be developed in the future. In order to clarify the proposed flow chart, the authors present two different clinical cases.

Single-flap versus double-flap approach for periodontal pocket reduction in supraosseous defects: a comparative study

Purpose

The single-flap approach (SFA) is a minimally invasive technique with limited mucoperiosteal flap elevation to gain access to the buccal/palatal aspects, thus limiting post-surgical complications. The purpose of the present study was to gain insights into the impact of the SFA over the double-flap approach (DFA) on periodontal flap treatment outcomes and patient compliance in terms of discomfort and time taken for surgical procedures.

Methods

Twenty patients with persistent probing pocket depths of ≥5 mm were scheduled for the SFA (test site) and for the DFA (control site). All the clinical periodontal parameters were recorded at baseline, 3 months, and 6 months. Radiographic bone level (cone-beam computed tomography) was evaluated at baseline and 6 months. Patients' postoperative pain perception and wound healing were also assessed.

Results

The SFA showed a significant reduction in periodontal pocket depth, gain in clinical attachment level (CAL), and gain in bone level when compared with the DFA. The SFA substantially improved wound healing and induced less postoperative pain than the DFA.

Conclusions

The SFA resulted in substantial improvement in the composite outcome measures, as shown by a reduction in pocket depth with minimal gingival recession, gain in CAL, early wound healing, less postoperative discomfort, and better patient-centered outcomes.

Trial Registration

Clinical Trials Registry-India Identifier: CTRI/2018/05/013562

Impact of adjunctive procedures on recombinant human fibroblast growth factor-2-mediated periodontal regeneration therapy: A retrospective study

BACKGROUND

Human fibroblast growth factor-2 (rhFGF-2) therapy has been used for periodontal tissue regeneration. However, few studies have reported their adjunctive procedures based on strategy of tissue engineering. The aim of this retrospective study is to assess the adjunctive effects of modified papilla preservation technique (mPPT) and combination with autogenous bone grafts (AG) on the rhFGF-2 therapy.

METHODS

Total of 44 sites underwent rhFGF-2 therapies and the evaluations in the survey periods. The primary outcome was set to the radiographic bone fill by radiographic examinations at 6 and 12 months after surgeries. We analyzed the correlation between influencing factors and the primary outcome, and differences of therapeutic effect by combination therapy with mPPT and that with AG.

RESULTS

After surgeries, probing depth (PD), clinical attachment level (CAL) and bone defects significantly improved. The improvements of radiographic bone fill were significantly positive correlated with a number of bone walls, combination with mPPT, and AG at 6 months after surgeries, and with combination with mPPT and AG at 12 months after surgeries. The significant differences of improvements of radiographic bone fill were demonstrated between combination with or without mPPT at 12 months after surgeries, and with or without AG at 6 and 12 months after surgeries. Moreover, the multiple linear regression analysis for the radiographic bone fill indicated the significant regression coefficient with conducts of mPPT.

CONCLUSIONS

mPPT and AG had powerfully adjunctive effects on rhFGF-2 therapy. Further studies are needed in order to verify by randomized clinical trials.

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.

Effect of Flap Design for Enamel Matrix Derivative Application in Intraosseous Defects

Objective:

To systematically review the literature addressing the focused question: What is the effectiveness of different surgical and nonsurgical procedures combined with enamel matrix derivative (EMD) on clinical, radiographic, and patient-centered outcomes in intraosseous defects?

Methods:

Electronic (Medline, Scopus, and Cochrane databases) and hand literature searches were performed for studies including at least 1 treatment arm where EMD had been applied according to 1 of the following procedures: modified Widman flap; papilla preservation variants (PPVs), including papilla preservation technique, modified papilla preservation technique, and simplified papilla preservation technique; minimally invasive variants, including minimally invasive surgical approach and minimally invasive surgical technique; single-flap variants (SFVs), including single-flap approach and modified minimally invasive surgical technique; or nonsurgical application (flapless approach). Data from 42 selected articles were used to perform a network meta-analysis, and a hierarchy of surgical and nonsurgical applications of EMD was built separately for EMD and EMD + graft based on 6- to 12-mo clinical and radiographic outcomes.

Results:

Among surgical approaches, EMD was associated with best regenerative outcomes when applied through SFVs, with a mean clinical attachment level gain of 3.93 mm and a reduction in the intrabony component of the defect of 3.35 mm. For EMD + graft, limited differences in regenerative outcomes were observed among surgical procedures. PPVs were associated with the highest residual probing depth for EMD (4.08 mm) and EMD + graft (4.32 mm).

Conclusions:

In the treatment of periodontal intraosseous defects, 1) SFVs appear to optimize the regenerative outcomes of EMD; 2) substantial regenerative outcomes can be obtained with SFVs and conservative double flaps (i.e., PPVs and minimally invasive variants) when EMD is combined with a graft; and 3) residual probing depth was higher following PPVs for EMD and EMD + graft.

Knowledge Transfer Statement:

The results of the present systematic review and meta-analysis can be used by clinicians to identify the most effective surgical or nonsurgical procedure to treat an intraosseous defect with EMD or EMD + graft. The main findings indicate that when EMD application is indicated, surgical access based on a single flap seems the most appropriate to optimize clinical outcomes. The application of EMD + graft can be effectively combined with single flaps and conservative double flaps.

Single-Flap Approach in Periodontal Regeneration for Intraosseous Defects: Case Series

INTRODUCTION

A single-flap approach (SFA) is the elevation of a periodontal flap to access the defect only from one side. Several studies have reported that the SFA is at least as clinically effective as the elevation of a flap at both buccal and palatal/lingual aspects. However, studies regarding the SFA have reported only 6 to 10 months follow-up clinical outcomes. The purpose of this case series was to investigate the outcomes of the SFA for periodontal regeneration with a collagen membrane and bone grafts in regard to linear bone defect fill and clinical parameters such as gingival recession (GR), pocket depth (PD), and clinical attachment level (CAL) for the 15-month follow-up.

CASE SERIES

Based on the deepest pocket depth site, the flap retraction side for each case, either buccal or palatal/lingual, was determined. After retraction of a one-side full thickness flap, complete removal of granulation tissue and thorough scaling and root planing were performed. Demineralized ground cortical bone grafts were gently packed into the defect areas and an absorbable collagen membrane was placed over the grafts in 13 cases from 11 patients.

CONCLUSION

This case series demonstrated that the SFA for periodontal regeneration with a collagen membrane and bone grafts resulted in decreased PD with minimum GR, gain in CAL, and bone fill at defect sites for the 15-month follow-up.

Periodontal reconstructive surgery of deep intraosseous defects using an apical approach. Non-incised papillae surgical approach (NIPSA): A retrospective cohort study

BACKGROUND

The objective of this study was to compare a minimally-invasive surgical technique (MIST) and a non-incised papilla surgical approach (NIPSA) in periodontal reconstructive surgery of deep intraosseous defects.

METHODS

Data on 30 patients with a deep intraosseous defect treated with MIST (n = 15) or NIPSA (n = 15) were analyzed retrospectively. All patients met the same inclusion criteria and were treated following the same protocol, except for the surgical management of soft tissue (MIST versus NIPSA). Clinical parameters at baseline and at 1-year post-surgery, early healing at 1 week, and postoperative pain were assessed.

RESULTS

NIPSA and MIST resulted in significant clinical attachment gain (CAG) (P < 0.001) and probing depth reduction (PDr) (P < 0.001) at 1-year post-surgery. However, NIPSA resulted in significantly lower recession of the tip of the interdental papilla compared with MIST (P < 0.001). Smoking negatively influenced early healing in both techniques (P < 0.05).

CONCLUSIONS

NIPSA and MIST both resulted in significant improvements in clinical parameters. NIPSA showed significant soft tissue preservation. NIPSA may represent a promising papillae preservation technique in the treatment of intraosseous periodontal defects.

Combination Therapy for Reconstructive Periodontal Treatment in the Lower Anterior Area: Clinical Evaluation of a Case Series

Clinically, periodontal regeneration may be achieved by the application of barrier membranes, grafts, wound-healing modifiers, and their combinations. Combination therapy refers to the simultaneous application of various periodontal reconstructive treatment alternatives to obtain additive effects. This approach may lead to assemblage of different regenerative principles, such as conductivity and inductivity, space provision and wound stability, matrix development and cell differentiation. The application of autogenous connective tissue grafts during periodontal regenerative treatment with enamel matrix proteins derivative (EMD) has been previously reported. The present case series present a modified approach for treatment of severe periodontally involved lower incisors presenting with thin gingival biotype, gingival recession, minimal attached and keratinized gingiva width and muscle and/or frenum pull. In all cases a combination therapy consisting of a single buccal access flap, root conditioning, EMD application on the denuded root surfaces and a free connective tissue graft was performed. Clinical and radiographic outcomes were consistently satisfactory, leading to probing depth reduction, clinical attachment gain, minimal gingival recession, increased attached and keratinizing gingival width, elimination of frenum and/or muscle pull together with radiographic bone fill of the defects. It may be concluded that the present combination therapy for reconstructive periodontal treatment in the lower anterior area is a valuable alternative for indicated cases.

Stem cell-like populations and immunoregulatory molecules in periodontal granulation tissue

BACKGROUND AND OBJECTIVES

Determine the presence of mesenchymal stem cells (MSCs) in healthy periodontal tissue and periodontal granulation tissue (GT) and explore associations between immuno-regulatory molecules and selected subgingival microorganisms.

MATERIAL AND METHODS

Mesenchymal stem cells were isolated, propagated and characterised by flow cytometry from a region of healthy gingival tissue and inflamed GT of 10 systemically healthy non-smokers with chronic periodontitis. Tissue levels of immunoregulatory molecules were determined by qPCR and Gingival Crevicular Fluid (GCF) levels by ELISA. Subgingival plaque levels of periodontal pathogens were determined by qPCR RESULTS: Cells with MSC-properties were isolated from both inflamed GT and healthy gingival (G) tissue. A pro-inflammatory process predominated in GT which was partly reflected in GCF and putative periodontal pathogens were higher at diseased sites. However, there was no significant difference in surface levels of mesenchymal (CD90, CD73, CD146, CD271, STRO-1), endothelial (CD105, CD106), hematopoietic (CD34, CD45) and embryonic (SSEA-4) stem cell markers between MSCs isolated from GT and G tissue.

CONCLUSION

Periodontal lesions, albeit inflamed, retain healing potential as inferred by the presence of MSC-like cells with similar immunophenotypic characteristics to those found in healthy periodontal tissue. Therefore, there might be merits for healing in preserving sufficient GT in-situ during periodontal surgery.

Recent progress on fabrication and drug delivery applications of nanostructured hydroxyapatite

Through this brief review, we provide a comprehensive historical background of the development of nanostructured hydroxyapatite (nHAp), and its application potentials for controlled drug delivery, drug conjugation, and other biomedical treatments. Aspects associated with efficient utilization of hydroxyapatite (HAp) nanostructures such as their synthesis, interaction with drug molecules, and other concerns, which need to be resolved before they could be used as a potential drug carrier in body system, are discussed. This review focuses on the evolution of perceptions, practices, and accomplishments in providing improved delivery systems for drugs until date. The pioneering developments that have presaged today's fascinating state of the art drug delivery systems based on HAp and HAp-based composite nanostructures are also discussed. Special emphasis has been given to describe the application and effectiveness of modified HAp as drug carrier agent for different diseases such as bone-related disorders, carriers for antibiotics, anti-inflammatory, carcinogenic drugs, medical imaging, and protein delivery agents. As only a very few published works made comprehensive evaluation of HAp nanostructures for drug delivery applications, we try to cover the three major areas: concepts, practices and achievements, and applications, which have been consolidated and patented for their practical usage. The review covers a broad spectrum of nHAp and HAp modified inorganic drug carriers, emphasizing some of their specific aspects those needed to be considered for future drug delivery applications. This article is categorized under: Implantable Materials and Surgical Technologies > Nanomaterials and Implants Therapeutic Approaches and Drug Discovery > Nanomedicine for Respiratory Disease Nanotechnology Approaches to Biology > Cells at the Nanoscale.

Synthesis, Characterization, and Biological Evaluation of Nanostructured Hydroxyapatite with Different Dimensions

Nanosized hydroxyapatite (HA) is a promising candidate for a substitute for apatite in bone in biomedical applications. Furthermore, due to its excellent bone bioactivity, nanosized strontium-substituted HA (SrHA) has aroused intensive interest. However, the size effects of these nanoparticles on cellular bioactivity should be considered. In this study, nanosized HA and SrHA with different dimensions and crystallization were synthesized by hydrothermal methods. The phase, crystallization and chemical composition were analyzed by X-ray diffraction (XRD) and Fourier transform infrared spectroscopy (FT-IR), respectively. The morphology was observed under field emission scanning electron microscopy (FE-SEM) and transmission electron microscopy (TEM). The degradation behaviors of the samples were monitored by determining the ions release profile with inductively coupled plasma mass spectrometry (ICP-MS). The releasing behavior of Ca2+ and Sr2+ showed that the degradation rate was proportional to the specific surface area and inversely proportional to crystallization. The in vitro experiment evaluated by MG63 cells showed that SrHA nanorods with a length greater than 100 nm had the best biological performance both in cell proliferation and differentiation (* p < 0.05 compared with HA-1 and SrHA-1; * p < 0.01 compared with HA-2). In addition, HA nanoparticles with a lower aspect ratio had better bioactivity than higher ones (* p < 0.05). This study demonstrated that nanosized HA and SrHA with subtle differences (including dimensions, crystallization, specific surface area, and degradation rate) could affect the cellular growth and thus might have an impact on bone growth in vivo. This work provides a view of the role of nano-HAs as ideal biocompatible materials in future clinical applications.