Treatment of grade II furcation involvement using resorbable guided tissue regeneration membrane: A six-month study

CALCIUM PHOSPHATE GRAFTS COMBINED WITH GUIDED TISSUE REGENERATION IN THE TREATMENT OF PERIODONTAL BONY DEFECTS- A SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

The objective of this systematic review is to assess the clinical outcomes of intrabony and furcation defects treated using a regenerative approach with calcium phosphate (CP) grafts combined plus guided tissue regeneration (GTR) membrane in comparison to open flap debridement (OFD).

METHOD

A review protocol was created under PRISMA checklist to find randomized clinical trials (RCTs) in English that compared CPs plus GTR with OFD in humans with intrabony and/or furcation defects. Both electronic and manual searches were conducted. The studied outcomes were probing pocket depth (PD) and clinical attachment level (CAL). To evaluate the treatment effect, a random effects model using restricted maximum likelihood method was performed to estimate the pooled effect size and corresponding 95% confidence interval. The quality assessment of the included studies was performed using Cochrane risk of bias tools version 5.1.0.

RESULTS

Out of the 451 records identified, 7 studies were subjected to meta-analysis after discarding duplicates and excluding the studies that did not meet the inclusion criteria. While treated sites were intrabony defects in 5 papers, 2 studies focused on furcation defects. Based on the findings of the meta-analysis, the weighted mean difference (WMD) of 1.536 mm (95% CI -0.933 to 2.139) and 1.601 mm (95% CI -0.727 to 2.474) was obtained for CAL gain and PD reduction, respectively, in intrabony defects. The differences between CP grafts plus GTR groups and OFD groups for CAL gain and PD reduction were statistically significant. Similarly, for furcation defects, the application of CP grafts with GTR resulted in adjunctive advantages over OFD in terms of CAL gain (WMD of 1.807 mm; 95% CI 0.346-3.268), and PD reduction (WMD of 1.519 mm, 95% CI 1.215-4.253). The analysis on the limited number of study on furcation treatment revealed a statistically significant difference in CAL gain between CP grafts plus GTR groups and OFD groups, but a nonsignificant difference for PD reduction.

CONCLUSION

The results revealed that calcium phosphate grafts combined with GTR are superior to OFD in the healing of periodontal intrabony and furcation defects, considering the limitations of the present systematic review.

Combined surgical and conservative endodontic management of Oehler's type 3b dens invaginatus aided by guided tissue regeneration

The present case describes the successful healing of a periapical lesion associated with the left maxillary lateral incisor (# 22, Federation Dentaire Internationale) having a type 3b dens invaginatus tooth morphology. The treatment was complicated by the presence of blunderbuss root apex and large periapical lesion (>10 mm) with through and through bone defect (Bucco palatal cortical bone perforation, Von Arx Type 1b). An adolescent boy reported palatal swelling and pus discharge in relation to tooth #22. A thorough clinical and radiographic examination revealed tooth #22 as having a type 3b dens invaginatus with an open apex and a diagnosis of pulp necrosis and acute apical abscess. The case was managed by non-surgical root canal treatment followed by endodontic surgery using principles of guided tissue regeneration. A 5-year recall revealed an asymptomatic functional tooth with complete healing.

Clinical and Radiographic Evaluation of Autologous Platelet-Rich Fibrin With or Without Demineralized Bone Matrix in the Treatment of Grade II Furcation Defects

Introduction This study aims to differentiate the employment of demineralized bone matrix (DMBM; Osseograft, Advanced Biotech Products (P) Ltd, Chennai, India) and platelet-rich fibrin (PRF) alone to a composite graft consisting of both materials in the surgical actions toward the anomalies of the human periodontal furcation imperfection. Methods In a split-mouth study, 30 patients with mandibular molars affected by the furcation were allocated without conscious choice to test (PRF + DMBM, n = 30) or control (PRF, n = 30) categories. At the starting point, three months after surgery, and six months later, the following modifiable factors were evaluated: probing pocket depth (PPD), full-mouth plaque scores, full-mouth gingival scores, radiographic defect depth, relative vertical clinical attachment level (RVCAL), and relative horizontal clinical attachment level (RHCAL). Results Results at three and six months demonstrated substantial differences between baseline values for both treatment methods in clinical and X-ray imaging appraisal. Nonetheless, the PRF/DMBM group manifests statistically significantly soaring changes observed in comparison to the PRF group. Overall, the probing depth (PD) in the test site was significantly lower than that in the control site, showing a reduction of 68% (95% CI=41%, 95%, p<0.001). Conclusion Clinical indications significantly improved with PRF and DMBM combined instead of PRF alone. On radiographs, the test group also showed higher bone fill.

Comparative Analysis of Various Forms of Local Drug Delivery Systems on a Class 2 Furcation - A Systematic Review

Class II mandibular furcation defect is a periodontal condition characterized by a cul-de-sac lesion, a definite parallel constituent with only a portion of alveolar bone remaining intact. There may be involvement of vertical bone loss. Local drug deliveries such as Boric acid, alendronate gel, and other drugs exhibited anti-inflammatory, antibacterial & osteoblastic differentiation activity. The present systematic review compares the drugs based on their outcomes and pharmacological action. To analzse & compare various forms of local drug delivery systems on a class II furcation. A search was conducted using PubMed, Google scholar, science direct, and Pub Med central using MeSH terms - local drug delivery in periodontics, boric acid in the management of class II mandibular furcation, simvastatin in the treatment of furcation. A total of 560 articles were screened; 58 out of 560 were full-text articles accessed for eligibility, and five articles were included in the systematic review. PRISMA guidelines were used for reporting this review. In addition, five randomized controlled trials were enclosed and used in this systematic review. The various local drugs used in treating class II mandibular furcation defects are effective in the prevention of bleeding on probing, bone resorption, gingival bleeding index and increase in the bone fill, and microbial deposit removal. The managing of class II mandibular furcation defect with the drugs mentioned in this review can be effective by reducing several clinical parameters such as bleeding on probing, gingival indices, osteoblastic differentiation, bone fill, etc., Considering the results of the studies, it can be concluded that it can be used as a therapeutic therapy against class II furcation defects with positive outcomes.

Clinical and Radiographic Evaluation of Applying Atorvastatin 1.2% Bio Adhesive with Plasma Rich in Growth Factor (PRGF) for Treatment of Mandibular Class II Furcation Defects: a Randomized Clinical Trial

Statement of the Problem

Molar teeth with furcation involvement are one of the most common problems in patients with periodontal disease. Regeneration methods are of the most controversial treatment strategies for these lesions.

Purpose

The purpose of this study was to determine the effect of plasma rich in growth factors (PRGF) with 1.2% Atorvastatin (ATV) in the treatment of furcation involvement of mandibular molars.

Materials and Method

The present randomized clinical trial was conducted on 15 patients with moderate periodontitis and class II furcation involvements; 24 defects were located in four groups of six, including debridement, ATV1.2%, PRGF, PRGF with ATV1.2%. The parameters of vertical probing depth (VPD), vertical clinical attachment level (VCAL), gingival index (GI), horizontal probing depth (HPD) and gingival recession (GR) were measured at baseline (T0), immediately before surgery (T1), 3 (T2), and 6 (T3) months after surgery. Moreover, the bone conditions were evaluated by digital subtraction radiography before and six months after surgery. Data were analyzed using SPSS23 software.

Results

No significant difference in radiographic parameters was observed among the groups (p= 0.08). There was no significant difference in the mean levels of VPD, VCAL and HPD among the groups at different times (p<0.05). Comparison of clinical parameters of VPD, VCAL and GI in the treatment groups compared to the baseline showed a significant improvement in each group (p< 0.05) but there was no significant difference among different groups (p< 0.05).

Conclusion

The use of PRGF with ATV 1.2% in grade II furcation involvement in mandi-bular molars was effective in the improvement of clinical and radiographic parameters six months after treatment, but this effect revealed no difference in comparison with the other groups.

Bone replacement grafts with guided tissue regeneration in treatment of grade II furcation defects: a systematic review and meta-analysis

AIM

The present systematic review appended with meta-analysis aimed to evaluate the efficacy of bone replacement graft (BRG) with guided tissue regeneration (GTR) over BRG or open flap debridement (OFD) alone in the treatment of grade II furcation defects.

MATERIALS AND METHODS

An electronic literature search of PubMed, Cochrane Library and Google Scholar databases accompanied with manual searching was done. Randomized controlled trials (RCTs) up to October 2019, comparing BRG+GTR with BRG or OFD in grade II furcation defects, were identified. Clinical attachment level (CAL) gain, changes in gingival marginal level (GML), vertical defect fill (VDF), horizontal defect fill (HDF) and reduction in defect volume were the outcome parameters.

RESULTS

Of a total of 12, 9 studies compared BRG+GTR vs BRG while 3 compared BRG+GTR vs OFD. Meta-analysis was carried out for CAL gain, VDF, HDF and GML changes. In the BRG+GTR vs BRG comparison group, out of 9 studies, 6 RCTs showed standardized mean difference (SMD) of 0.513 for VDF, 9 RCTs showed SMD of 0.83 for HDF and 2 RCTs showed SMD of 0.651 for CAL gain, whereas only 2 studies in the same group reported reduction in defect volume. Three studies of the BRG+GTR vs OFD group exhibited significant VDF and CAL gain with SMD of 2.002 and 1.161 respectively. However, no significant change was recorded for GML in both groups.

CONCLUSION

The present systematic review indicates supplemental benefits of combination therapy of BRG+GTR over monotherapy in resolving grade II furcation defects.

CLINICAL RELEVANCE

In our quest to achieve maximum regeneration in grade II furcation defects, combination therapies such as BRG+GTR have been accepted as treatment choices over other modalities. Clinical situations warranting near-complete regeneration of the tissues in such defects are better suited for combination therapies.

Comparative evaluation of platelet-rich fibrin versus beta-tri-calcium phosphate in the treatment of Grade II mandibular furcation defects using cone-beam computed tomography

OBJECTIVE

The objective of the study was to evaluate clinically and radiographically the efficacy of platelet-rich fibrin (PRF) versus β-tri-calcium phosphate (β-TCP) in the treatment of Grade II mandibular furcation defects.

MATERIALS AND METHODS

Forty-five Grade II furcation defect in mandibular molars which were assigned to open flap debridement (OFD) with PRF Group I (n = 15), to OFD with β-TCP Group II (n = 15), and to OFD alone Group III (n = 15) were analyzed for clinical parameters (probing pocket depth [PPD], vertical clinical attachment level [VCAL], horizontal clinical attachment level [HCAL], gingival recession, relative vertical height of furcation [r-VHF], and relative horizontal depth of furcation [r-HDF]) and radiographical parameters (horizontal depth of furcation [H-DOF], vertical height of furcation [V-HOF]) using cone-beam computed tomography (CBCT) at 6 months interval.

RESULTS

For clinical parameters, reduction in PPD and gain in VCAL and HCAL were higher in Group II as compared to Group I. Change in r-VHF and r-HDF was greater in Group II as compared to Group I. Mean percentage clinical vertical defect fill was higher in Group II as compared to Group I (58.52% ± 11.68% vs. 53.24% ± 13.22%, respectively). On CBCT, mean change at 6 months for all parameters showed nonsignificant difference between the two experimental groups. Mean change in V-HOF was higher in Group I as compared to Group II, but mean change in H-DOF and furcation width was more in Group II as compared to Group I.

CONCLUSION

For both experimental and control groups, there was statistically significant improvement at 6 months follow-up from baseline values.

Comparative evaluation of platelet-rich fibrin membrane and collagen membrane along with demineralized freeze-dried bone allograft in Grade II furcation defects: A randomized controlled study

Background:

The management of the furcation areas in multirooted teeth is often challenging due to difficulty in access. Platelet-rich fibrin (PRF), a second-generation platelet concentrate, has shown to accelerate the healing of soft and hard tissues. This study was designed to evaluate the efficacy of autologous PRF as a membrane in treatment of Grade II furcation defects in molars as compared to collagen membrane along with demineralized freeze-dried bone allograft in both the groups.

Materials and Methods:

A split-mouth study was planned with 18 patients having 2 sites of Grade II furcation defects each. Random allocation of the defect site was done for the test and control group. Plaque index, probing depth (PD), relative vertical clinical attachment level (RVCAL), gingival marginal level, and radiographic bone levels were recorded at baseline, 3 months, and 6 months postoperatively.

Results:

Both the groups showed statistically significant outcomes in intragroup comparison from baseline to 3 and 6 months. However, there was no statistical difference between PRF membrane and collagen membrane groups on intergroup comparison.

Conclusion:

There was a significant reduction of PD, improvement in RVCAL, and defect fill with autogenous PRF as membrane. This indicates its role as a regenerative material in treating furcation defects, which can be used as alternative to other expensive membranes.

Periodontal regeneration - furcation defects: a systematic review from the AAP Regeneration Workshop

BACKGROUND

The aim of this review is to present the available evidence regarding the effectiveness of different regenerative approaches for the treatment of furcation defects in specific clinical scenarios compared with conventional surgical therapy to provide clinical guidelines for the therapeutic management of furcation defects and to identify priorities for future research that may advance the understanding of periodontal regenerative medicine.

METHODS

A comprehensive search based on predetermined eligibility criteria was conducted to identify human original studies and systematic reviews on the topic of periodontal regeneration of furcation defects. Two reviewers independently screened the title and abstract of the entries yielded from the initial search. Subsequently, both reviewers read the full-text version of potentially eligible studies, made a final article selection, and extracted the data of the selected studies considering specific clinical scenarios. The clinical scenarios contemplated in this review included the following: 1) facial and interproximal Class I defects in maxillary molars; 2) facial and lingual Class I defects in mandibular molars; 3) facial and interproximal Class II furcation defects in maxillary molars; 4) facial and lingual Class II furcation defects in mandibular molars; 5) Class III furcation defects in maxillary molars; 6) Class III furcation defects in mandibular molars; and 7) Class I, II, or III furcation defects in maxillary premolars. Endpoints of interest included different clinical, radiographic, microbiologic, histologic, and patient-reported outcomes.

RESULTS

The initial search yielded a total of 1,500 entries. The final selection consisted of 150 articles, of which six were systematic reviews, 109 were clinical trials, 27 were case series, and eight were case reports. A summary of the main findings of previously published systematic reviews and the available evidence relative to the indication of regenerative approaches for the treatment of furcation defects compared with conventional surgical therapy are presented. Given the marked methodologic heterogeneity and the wide variety of materials and techniques applied in the selected clinical trials, the conduction of a meta-analysis was not viable.

CONCLUSIONS

On the basis of the reviewed evidence, the following conclusions can be drawn. 1) Periodontal regeneration has been demonstrated histologically and clinically for the treatment of maxillary facial or interproximal and mandibular facial or lingual Class II furcation defects. 2) Although periodontal regeneration has been demonstrated histologically for the treatment of mandibular Class III defects, the evidence is limited to one case report. 3) Evidence supporting regenerative therapy in maxillary Class III furcation defects in maxillary molars is limited to clinical case reports. 4) In Class I furcation defects, regenerative therapy may be beneficial in certain clinical scenarios, although most Class I furcation defects may be successfully treated with non-regenerative therapy. 5) Future research efforts should be primarily directed toward the conduction of clinical trials to test novel regenerative approaches that place emphasis primarily on patient-reported outcomes and also on histologic demonstration of periodontal regeneration. Investigators should also focus on understanding the influence that local, systemic, and technical factors may have on the outcomes of regenerative therapy in furcation defects.

A comparative evaluation of freeze-dried bone allograft with and without bioabsorbable guided tissue regeneration membrane Healiguide(®) in the treatment of Grade II furcation defects: A clinical study

Background:

Furcation defects represent one of the most demanding therapeutic challenges for periodontal therapy. Various treatment modalities have been tried with different success rates. The present study was undertaken to evaluate the efficacy of freeze-dried bone allograft (FDBA) with and without bioabsorbable guided tissue regeneration (GTR) membrane Healiguide^® in the treatment of Grade II furcation defects.

Materials and Methods:

Ten patients with bilateral Grade II furcation defects were selected for the study. After phase I therapy, subjects were divided into two arms and treated in a split-mouth design. Ten defects were treated with FDBA alone in the control arm. Ten defects were treated with FDBA in conjunction with bioabsorbable GTR membrane Healiguide^® in test arm. Clinical parameters like plaque index, gingival index, vertical probing depth, horizontal probing depth, and relative attachment level (RAL) were assessed at baseline, 3 months, and 6 months postoperatively.

Results:

At 6 months, clinical improvement was seen in both the arms with mean pocket depth reduction of 1.2 ± 1.032 mm and 1.7 ± 0.948 mm and mean horizontal probing depth reduction being 2.1 ± 1.969 mm and 1.6 ± 1.264 mm in control and test arm, respectively. Both surgical procedures resulted in a statistically significant reduction in vertical and horizontal probing depths.

Conclusion:

Both the arms demonstrated a significant improvement in the probing depth, horizontal furcation depth, and RAL at 6 months postsurgery in the treatment of Grade II furcation defects. However, on the intergroup comparison, there was no statistically significant difference in the results achieved between two arms.

Clinical evaluation of porous hydroxyapatite bone graft (Periobone G) with and without collagen membrane (Periocol) in the treatment of bilateral grade II furcation defects in mandibular first permanent molars

BACKGROUND

Furcation invasions represent one of the most demanding therapeutic challenges in periodontics. This investigation assessed and compared the clinical efficacy of hydroxyapatite bone graft material when used alone and with collagen membrane in the treatment of grade II furcation defects.

MATERIALS AND METHODS

Ten patients with comparable bilateral furcation defects in relation to mandibular first molars were selected and treated in a split-mouth design. After the hygiene phase of therapy was completed, the groups were selected randomly either for treatment with hydroxyapatite bone graft (Periobone G) alone or with a combination of bone graft and guided tissue regeneration (GTR) membrane (Periocol). Clinical parameters like plaque index, gingival index, vertical probing depth, horizontal probing depth, clinical attachment level, position of marginal gingiva, and the amount of bone fill were used at baseline and at 3 and 6 months postoperatively.

RESULTS

At 6 months, both surgical procedures resulted in statistically significant reduction in vertical and horizontal probing depths and gain in the clinical attachment level.

CONCLUSION

The use of combination technique yielded superior results compared to sites treated with bone graft alone. However, the difference was not statistically significant.