Polynucleotides and Hyaluronic Acid (PN-HA) Mixture With or Without Deproteinized Bovine Bone Mineral as a Novel Approach for the Treatment of Deep Infra-Bony Defects: A Retrospective Case-Series

Polynucleotides and Hyaluronic Acid (PN-HA) mixture showed several effects in modulation of healing process. The aim of this study was to assess the safety and clinical performance of PN-HA alone or in association with Deproteinized Bovine Bone Mineral (DBBM) with papillary preservation flaps (PPF) in the treatment of residual pockets. A total of 43 patients with 55 infra-bony defects were recruited; 30% were smokers. The mean baseline Probing Depth (PD) was 7.7 ±1.9 mm with a corresponding mean recession (Rec) of 1.9± 1.3 mm. The depth of infra-bony defect at the surgical measurement was 5.2±2.1 mm. DBBM was applied at 56% of the defects considered as not-containing based on clinical judgment. Healing was uneventful at all sites. After one year, PD reduction was 4.4±1.8 mm with a Rec increase of 1.0 ±0.8 mm. Detected bone fill at x-ray was 3.5 ± 1.9mm. The multilevel analysis showed that absence of smoking habits was associated with improved PD reduction (P =0.026) and bone gain (P= 0.039). PN-HA mixture is a safe product for periodontal surgery and seems to promote clinical benefit in the treatment of residual pockets associated to infra-bony defects.

Preclinical evaluation of a new synthetic carbonate apatite bone substitute on periodontal regeneration in intrabony defects

OBJECTIVE

To evaluate the potential of a novel synthetic carbonate apatite bone substitute (CO3 Ap-BS) on periodontal regeneration.

BACKGROUND

The use of various synthetic bone substitutes as a monotherapy for periodontal regeneration mainly results in a reparative healing pattern. Since xenografts or allografts are not always accepted by patients for various reasons, a synthetic alternative would be desirable.

METHODS

Acute-type 3-wall intrabony defects were surgically created in 4 female beagle dogs. Defects were randomly allocated and filled with CO3 Ap-BS (test) and deproteinized bovine bone mineral (DBBM) or left empty (control). After 8 weeks, the retrieved specimens were scanned by micro-CT, and the percentages of new bone, bone substitute, and soft tissues were evaluated. Thereafter, the tissues were histologically and histometrically analyzed.

RESULTS

Healing was uneventful in all animals, and defects were present without any signs of adverse events. Formation of periodontal ligament and cementum occurred to varying extent in all groups without statistically significant differences between the groups. Residues of both bone substitutes were still present and showed integration into new bone. Histometry and micro-CT revealed that the total mineralized area or volume was higher with the use of CO3 Ap-BS compared to control (66.06 ± 9.34%, 36.11 ± 6.40%; p = .014, or 69.74 ± 2.95%, 42.68 ± 8.68%; p = .014). The percentage of bone substitute surface covered by new bone was higher for CO3 Ap-BS (47.22 ± 3.96%) than for DBBM (16.69 ± 5.66, p = .114).

CONCLUSIONS

CO3 Ap-BS and DBBM demonstrated similar effects on periodontal regeneration. However, away from the root surface, more new bone, total mineralized area/volume, and higher osteoconductivity were observed for the CO3 Ap-BS group compared to the DBBM group. These findings point to the potential of CO3 Ap-BS for periodontal and bone regeneration.

Prehydrated collagenated cortico-cancellous heterologous bone gel and papillae tunneling for isolated intrabony defects: 12-month noninferiority trial

OBJECTIVES

This study assessed the effectiveness of prehydrated collagenated xenogenic bone gel and a collagenated cortico-cancellous heterologous bone mixture in conjunction with papillae tunneling techniques (PTT) for treating isolated periodontal intraosseous defects.

MATERIALS AND METHODS

Twenty patients with periodontitis stage III/IV and at least one deep isolated interdental 2/3-wall intraosseous defect were included in the study. Surgical incisions were made vertically at the adjacent tooth or horizontally at the mucogingival junction. A full-thickness flap was then carefully lifted under the papillae using special tunneling instruments. The root surfaces were completely cleaned, and the defects were randomly filled with either prehydrated collagenated bone gel (test group; n = 10) or collagenated cortico-cancellous heterologous bone mixture (control group; n = 10). Wounds were closed with microsurgical sutures. We predicted that the lower 95% confidence interval for the difference between the two procedures would exceed a prespecified noninferiority threshold.

RESULTS

All wounds closed sufficiently to prevent biomaterial exposure. The test and control groups showed similar mean pocket depth reduction (3.5 ± 1.0 vs. 3.9 ± 1.7 mm; p = 0.52), similar gingival recession (-0.10 ± 0.99 vs. 0.2 ± 0.8 mm; p = 0.46), and similar clinical attachment gain (3.6 ± 1.51 vs. 3.7 ± 1.8 mm; p = 0.89) at the 12-month follow-up. All results were below the noninferiority margin of the sample.

CONCLUSIONS

At 12 months, prehydrated collagenous bone gel performed similarly to collagenous heterologous bone granules in the treatment of intraosseous lesions with PTT. In addition, both biomaterials preserved soft tissue with minimal further recession at 1 year.

CLINICAL RELEVANCE

When combined with PTT, collagenous xenogeneic bone granules and prehydrated collagenous bone gel achieve comparable clinical outcomes in intrabony defects. The study was registered under the NCT04782921 on ClinicalTrails.

Two-stage method of free gingival graft prior to periodontal regenerative surgery for the treatment of intrabony defects with insufficient keratinised tissue width: a study protocol for an open-label randomised controlled trial

INTRODUCTION

Guided tissue regeneration (GTR) combined with bone grafting for periodontal regenerative surgery has ideal clinical results for intrabony defect. However, some sites of intrabony defects often suffer from insufficient keratinised gingival width, which affects the efficacy and long-term prognosis of periodontal tissue regeneration. Free gingival graft (FGG) is an effective surgical procedure to widen the keratinised gingiva, but there are few clinical studies on FGG prior to GTR combination with bone grafting to improve clinical outcomes.

METHODS

This study is an open-label randomised controlled trial. 68 patients with periodontitis with at least one intrabony defect depth with ≥3 mm are recruited and randomly grouped. In the test group, FGG is performed first, followed by GTR and bone grafting 3 months later; while in the control group, only periodontal tissue regenerative procedures are performed. After completion of all procedures, the patients will be recalled at 3 months, 6 months and 12 months and the relevant clinical and radiographic examinations will be carried out and statistical analysis of the data will also be performed. The present research has received approval from the Ethics Committee of Shanghai Stomatological Hospital (No.2022-007) on 4 August 2022.

DISCUSSION

Exploring the effectiveness of the two-stage approach of FGG prior to periodontal tissue regenerative surgery for the treatment of keratinised gingival width deficient intrabony defects can provide a high-level evidence-based basis for the formulation of relevant treatment strategies in clinical practice.

ETHICS AND DISSEMINATION

The present research has received approval from the Ethics Committee of Shanghai Stomatological Hospital (No.2022-007) on 4 August 2022. The patients will be incorporated into this trial only after their written informed consent has been obtained. The study will be performed according to the 2013 revision of the Helsinki Declaration of 1975. Personal information of all subjects will be stored in the Department of Periodontology of Shanghai Stomatological Hospital. Data of the present research will be registered with the Clinical Trials Registry Platform. Additionally, we will disseminate the results through scientific journals.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ID: ChiCTR 2200063180. Registered on 1 September 2022.

Complications and treatment errors related to regenerative periodontal surgery

Regenerative periodontal surgical procedures are an important component in the treatment of advanced periodontitis. They aim to improve the long-term prognosis of teeth that are periodontally compromised by the presence of intrabony and/or furcation defects, resulting biologically in formation of root cementum, periodontal ligament, and alveolar bone and evidenced clinically by reduction of deep pockets to maintainable probing depths and/or improvements of vertical and horizontal furcation depth. Over the last 25 years, substantial clinical evidence has been accumulated to support the value of regenerative procedures in periodontally compromised dentitions. However, treatment success requires close attention to certain factors on the level of the patient, the tooth/defect, and the operator. Ignoring these factors in case selection, treatment planning, and treatment execution will increase the risk of complications that may jeopardize clinical success and may even be considered as treatment errors. Based on the currently available evidence from clinical practice guidelines, treatment algorithms, and on expert opinion, the present article provides an overview on the main factors, which influence the outcomes of regenerative periodontal surgery and gives recommendations on how to prevent complications and treatment errors.

A short note on bioglass in Periodontics

Bone augmentation grafts may act as space-maintaining devices to allow coronal migration of periodontal progenitor cells. The ideal bone replacement graft should be able to trigger osteogenesis, cementogenesis and formation of a functional periodontal ligament. It has been theorized that bioactive glass, which is a ceramic has bioactive properties that guide and promote osteogenesis allowing rapid formation of bone. Bioactive glass consists of sodium and calcium salts, phosphates and silicon dioxide for dental applications. When this material comes into contact with tissue fluids, the surface of the particles becomes coated with hydroxy carbonate apatite, incorporates organic ground proteins such as chondroitin sulfate and glycosaminoglycans and attracts osteoblasts that rapidly form bone.

Injectable platelet-rich fibrin polymerized with hydroxyapatite bone graft for the treatment of three-wall intrabony defects: A randomized control clinical trial

Background

The study was aimed to compare and evaluate the clinical and radiographic outcomes of injectable platelet-rich fibrin (i-PRF) polymerized with hydroxyapatite (HA) bone graft and HA bone graft alone for treating three-wall intrabony defects (IBDs).

Materials and Methods

The trial was planned as a randomized, prospective clinico-radiographic study with inclusion of 34 three-wall IBDs in patients with stage III periodontitis. IBDs were assigned randomly to one of the groups, i.e., Group I - experimental (i-PRF + HA) and Group II - control (HA alone). At baseline and 6 and 9-month intervals, both the clinical and radiographic measurements were taken and baseline and 9-month data were tabulated and imported into SPSS 22 software. Student unpaired and paired t- tests were used to find significant differences (p<0.05).

Results

Both the groups showed substantial changes in all clinical and radiographic measures on comparison from baseline values. On intergroup comparison, the i-PRF + HA group reported significantly higher original defect resolution and original defect fill as compared to the HA group.

Conclusion

i-PRF polymerized with HA graft has shown better results as compared to HA graft alone in three-wall IBDs and therefore can be used as a better possible alternative for the treatment of three-wall IBDs.

Radiographic angle width as predictor of clinical outcomes following regenerative periodontal therapy with enamel matrix derivative. A retrospective cohort study with a mean follow-up of at least 10 years

OBJECTIVES

To assess the association between the baseline radiographic defect angle and the long-term clinical outcomes following periodontal regenerative therapy with Enamel Matrix Derivative (EMD).

METHOD AND MATERIALS

Baseline peri-apical radiographs obtained from a cohort of patients treated with periodontal regenerative therapy were digitized and the radiographic angle width between the root surface and the bony wall of the adjacent intraosseous defect was calculated and reported in degrees (°). Changes in pocket probing depth (PD) and clinical attachment level (CAL) were assessed and reported in mm. Clinical outcomes were evaluated at baseline (T0), 6 months following therapy (T1) and at the latest follow-up (T2).

RESULTS

Thirty-eight defects in 26 patients enrolled in supportive periodontal care for a mean period of 10.4 years (range: 8.0 - 15.5 years) were available for analysis. The mean PD change between T0 and T2 was 2.33 ± 1.66 mm at teeth with a defect angle width < 20° and 0.86 ± 1.66 mm at teeth with a defect angle width > 30° (p = 0.021). When the baseline radiographic angle width was < 20° the probability of obtaining a CAL gain > 3 mm was 1.5x higher (95% CI: 0.19 - 13.8) at T1 and 2.5x higher (95% CI: 0.40 - 15.6) at T2 compared with defects with a radiographic angle width > 30°.

CONCLUSION

Within their limitations, these results indicate that pre-therapeutic measurement of the radiographic defect angle width might provide relevant information on the short/long-term clinical outcomes following regenerative periodontal therapy with EMD.

Use of Enamel Matrix Derivative in Minimally Invasive/Flapless Approaches: A Systematic Review with Meta-Analysis

PURPOSE

The aim of the present systematic review with meta-analysis was to investigate the clinical effectiveness of EMD (enamel matrix derivative) using a minimally invasive surgical technique (MIST) or flapless approach for the treatment of severe periodontal probing depths.

MATERIALS AND METHODS

A systematic review of the literature including searches in PubMed/Medline, Cochrane Library, Google Scholar, and Grey Literature databases as well as manual searches was performed on September 1st, 2021. Studies utilising EMD in a non-surgical or minimally invasive approach were included. The eligibility criteria comprised randomised controlled trials (RCTs) comparing minimally-invasive/flapless approaches with/without EMD for the treatment of probing depths >5 mm.

RESULTS

From 1525 initial articles, 7 RCTs were included and 12 case series discussed. Three studies investigated a MIST approach, whereas 3 studies utilised a flapless approach. One study compared EMD with either a MIST or a flapless approach. The RCTs included ranged from 19-49 patients with at least 6 months of follow-up. While 5 of the studies included smokers, patients smoking >20 cigarettes/day were excluded from the study. The meta-analysis revealed that EMD with MIST improved recession coverage (REC) and bone fill (BF) when compared to MIST without EMD. However, no difference in CAL or PD was observed between MIST + EMD vs MIST without EMD. No statistically significant advantage was found for employing the EMD via the flapless approach.

CONCLUSIONS

Implementing EMD in MIST procedures displayed statistically significant improvement in REC and BF when compared to MIST alone. These findings suggest that MIST in combination with EMD led to improved clinical outcomes while EMD employed in nonsurgical flapless therapy yielded no clinical benefits when compared to nonsurgical therapy alone without EMD. More research is needed to substantiate these findings.

Effect of Er:YAG laser combined with ethylenediamine tetra acetic acid on three-walled periodontal intrabony defects adjacent to implant sites

OBJECTIVES

To investigate the clinical effect of Er:YAG laser combined with ethylenediamine tetra acetic acid (EDTA) on three-walled periodontal intrabony defects adjacent to implant sites.

METHODS

A total of 30 patients with three-walled periodontal intrabony defects adjacent to implant sites were treated with the combination therapy. Patients with three-walled intrabony defects were divided into two groups according to the depth of the intrabony pocket between the implant and natural teeth. Evaluation of wound healing was performed 10 days after the operation, and bone augmentation was evaluated 6 months after the operation.

RESULTS

Primary healing in group 1 was 92.31%, primary healing in group 2 was 82.35%. No significant difference was observed between the two groups (P>0.05). Bone augmentation in group 1 and group 2 were (2.85±1.81), (4.92±2.22) mm. There was significant difference between the two groups (P<0.05). New bone growth occurred more slowly in group 1 (0.70 mm±0.32 mm) than in group 2 (1.25 mm±0.47 mm) (P>0.05). Probe depths (PD), clinical attachment levels (CAL), and sulcus bleeding indices (SBI) showed no statistically significant difference between the two groups (P>0.05). The one-year survival rate of natural tooth in group 1 and group 2 were 100%, 94.2%, and the one-year survival rate of implants in both groups was 100%.

CONCLUSIONS

The effect of bone augmentation with combination therapy was more ideal in group 2 than in group 1. Implant placement with combination therapy may be a viable technique to reconstruct three-walled intrabony defects due to the space maintenance provided by implants and bone grafts and the good root surface biocompatibility provided by the Er:YAG laser and EDTA.

Immunohistochemical Evaluation of Periodontal Regeneration Using a Porous Collagen Scaffold

(1) Aim: To immunohistochemically evaluate the effect of a volume-stable collagen scaffold (VCMX) on periodontal regeneration. (2) Methods: In eight beagle dogs, acute two-wall intrabony defects were treated with open flap debridement either with VCMX (test) or without (control). After 12 weeks, eight defects out of four animals were processed for paraffin histology and immunohistochemistry. (3) Results: All defects (four test + four control) revealed periodontal regeneration with cementum and bone formation. VCMX remnants were integrated in bone, periodontal ligament (PDL), and cementum. No differences in immunohistochemical labeling patterns were observed between test and control sites. New bone and cementum were labeled for bone sialoprotein, while the regenerated PDL was labeled for periostin and collagen type 1. Cytokeratin-positive epithelial cell rests of Malassez were detected in 50% of the defects. The regenerated PDL demonstrated a larger blood vessel area at the test (14.48% ± 3.52%) than at control sites (8.04% ± 1.85%, p = 0.0007). The number of blood vessels was higher in the regenerated PDL (test + control) compared to the pristine one (p = 0.012). The cell proliferative index was not statistically significantly different in pristine and regenerated PDL. (4) Conclusions: The data suggest a positive effect of VCMX on angiogenesis and an equally high cell turnover in the regenerated and pristine PDL. This VCMX supported periodontal regeneration in intrabony defects.

Long-term clinical outcomes of periodontal regeneration with Enamel Matrix Derivative (EMD): a retrospective cohort study with a mean follow-up of 10 years

BACKGROUND

Despite the large body of evidence on the efficacy of Enamel Matrix Derivative (EMD) in the treatment of periodontal intrabony defects, few studies reported long-term data (≥ 10-year).

METHODS

Periodontal patients treated with regenerative surgery with EMD between 1999 and 2012 were invited to participate in a clinical examination. The following clinical parameters were recorded and compared at baseline (T0), 6 months after surgery (T1) and after at least 8 years of follow-up (T2): probing depth (PD), gingival recession (GR), clinical attachment level (CAL), plaque and bleeding scores. The primary outcome variable was CAL change.

RESULTS

Forty-one patients with 75 treated teeth were available for analysis. Out of these, 68 (tooth survival rate: 90.7%) reached the latest follow-up with a mean observation period of 10.3 years (range: 8.0-21.3). The most frequent reason for tooth loss was recurrence of periodontal disease. Tooth survival curves showed a statistically significant difference between smokers and non-smokers (p = 0.028). Mean CAL changed from 8.43 ± 1.86 (T0) to 6.47 ± 1.70 (T1) (p<0.001) and to 5.91 ± 1.83 (T2) (p<0.001). At T1, a CAL gain of ≥3 mm was measured in 35% of the defects while at T2 it was detected in 51% of cases.

CONCLUSIONS

Within their limitations, the present results have shown that in intrabony defects, the clinical improvements obtained following regenerative surgery with EMD can be maintained on a mean period of 10 years. Smoking status and maxillary molars were correlated with an increased risk for tooth and CAL loss, respectively. This article is protected by copyright. All rights reserved.

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

AIM

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Periodontal wound healing/regeneration of two-wall intrabony defects following reconstructive surgery with cross-linked hyaluronic acid-gel with or without a collagen matrix: a preclinical study in dogs

OBJECTIVES

In-vitro data have shown that cross-linked hyaluronic acid (HA) enhances the proliferative and migratory properties of cells involved in periodontal wound healing/regeneration, stabilizes the blood clot, reduces the inflammatory response, and facilitates angiogenesis. The aim of this study was to histologically evaluate the effects of cross-linked HA alone or combined with a collagen matrix (CM) on the periodontal wound healing/regeneration in intrabony defects.

METHOD AND MATERIALS

Two-wall intrabony defects (5 mm wide, 5 mm deep) were surgically created at the distal and mesial aspects of mandibular premolars in six beagle dogs. The 24 defects were randomly treated as follows: open flap debridement (OFD) + HA, OFD + CM, OFD + HA + CM (HA/CM), and OFD alone (control). At 2 months, the animals were euthanized for histologic evaluation.

RESULTS

The HA (2.43 ± 1.25 mm) and HA/CM (2.60 ± 0.99 mm) groups yielded statistically significantly (P < .05) greater formation of new attachment (ie, linear length of new cementum adjacent to newly formed bone, with inserting collagen fibers) compared with the OFD (0.55 ± 0.99 mm) group. Among the four treatment groups, the HA/CM group demonstrated the highest amount of regenerated tissues, although no statistically significant differences in any of the histometric parameters were observed between the HA and HA/CM groups.

CONCLUSION

Within their limits, it can be concluded that cross-linked HA alone or combined with CM promotes periodontal wound healing/regeneration in two-wall intrabony defects in dogs.

Pre-clinical evaluation of the effect of a volume-stable collagen matrix on periodontal regeneration in two-wall intrabony defects

AIM

To histologically evaluate the effect of a new collagen matrix on periodontal regeneration.

MATERIALS AND METHODS

Two-wall intrabony defects were surgically created bilaterally distally to the maxillary first and third pre-molars in beagle dogs. The defects were randomly allocated to open flap debridement either with (test) or without (control) a volume-stable collagen matrix (VCMX). After 12 weeks, the dogs were euthanized, and the specimens histologically processed. Descriptive, histomorphometrical (vertical gain of periodontal tissues) and statistical analyses were then performed.

RESULTS

Healing was uneventful in most cases. Residual VCMX was still present and showed integration into new bone, new periodontal ligament, connective tissue and, in some specimens, into new cementum. Periodontal regeneration occurred to a varying extent in both groups. New continuous cementum and new bone formation were statistically significantly greater in the test group (4.12 mm and 3.28 mm, respectively) than in the control group (1.54 mm and 2.47 mm, respectively) (p = .009 and p = .037, respectively). The junctional epithelium was longer in the control group (2.21 mm) than in the test group (1.49 mm, p = .16).

CONCLUSION

The present results have for the first time provided histologic evidence for the potential of this novel VCMX to facilitate periodontal regeneration thus warranting further pre-clinical and clinical testing.

Histological Evaluation of Gingival and Intrabony Periodontal Defects Treated with Platelet-rich Fibrin Using Different Protocols: A Canine Study

PURPOSE

To histologically compare the effects of platelet-rich fibrin (PRF) produced using different protocols on periodontal wound healing/regeneration in periodontal defects in dogs.

MATERIALS AND METHODS

Dehiscence-type gingival recession and two-wall intrabony defects were created bilaterally in the maxillary canines and mandibular premolars, respectively, in four beagle dogs. The recession defects were randomly treated with coronally advanced flap (CAF) alone, CAF and PRF produced via fixed-angle centrifugation (F-PRF; Leukocyte and PRF (L-PRF) protocol) or CAF and PRF produced via horizontal centrifugation (H-PRF). After 2 weeks, the two-wall intrabony defects were randomly treated as follows: open flap debridement (OFD), OFD + F-PRF, OFD + H-PRF and OFD + heated albumin with PRF using bio-heat technologies (Alb-PRF). Eight weeks after the 2nd reconstructive surgery, the animals were euthanised for histological evaluation.

RESULTS

In the PRF-applied defects, new bone and new cementum formation occurred to varying degrees regardless of the protocols used to produce PRF. Particularly in the two-wall intrabony defects, new bone formation extended from the host bone toward the coronal region of the defects in the H-PRF applied sites compared with those in the OFD, F-PRF and Alb-PRF groups, and the H-PRF group showed the greatest amount of newly formed cementum.

CONCLUSION

PRF induced periodontal regeneration in gingival recession and two-wall intrabony defects in dogs. Further studies are needed to determine the optimal protocol for obtaining predictable periodontal regeneration in periodontal defects in humans.

Efficacy of FGF-2 in Periodontal Regeneration in a Case of Severe Intrabony Defect and Furcation Involvement With 15-Month Follow-Up

INTRODUCTION

Several studies have demonstrated that basic fibroblast growth factor (FGF-2) is one of the most effective growth factors for periodontal regeneration. The Ministry of Health, Labor and Welfare in Japan have approved 0.3% human recombinant FGF-2 for periodontal regeneration, and it has been commercially available since 2016. In this case report, a patient was treated with this periodontal regenerative medicine and demonstrated success at 15-month follow-up, as confirmed by dental X-ray and on cone-beam computed tomography (CBCT).

CASE PRESENTATION

A 42-year-old woman with a one by two walled intrabony defect and Class III furcation involvement in tooth #19, and Class II furcation involvement in tooth #18 (lingual) underwent periodontal regenerative surgery with FGF-2 without any bone graft materials. Favorable clinical and radiographic outcomes were noted 15 months after the procedure. The vertical bone defect in tooth #19 showed a clinical attachment level gain of 8 mm. Moreover, CBCT analysis revealed considerable new bone formation in the Class II furcation involvement in tooth #18 and limited bone formation in the Class III furcation involvement in tooth #19.

CONCLUSIONS

This case report indicates that FGF-2 showed a positive outcome in terms of periodontal regeneration in a case of one by two wall intrabony defects with Class III furcation involvement. A complete recovery of Class II furcation involvement was observed without artificial bone graft materials.

Clinical and Radiographic Evaluation of Nanohydroxyapatite Powder in Combination with Polylactic Acid/Polyglycolic Acid Copolymer as Bone Replacement Graft in the Surgical Treatment of Intrabony Periodontal Defects: A Retrospective Case Series Study

The aim of this retrospective case series was to evaluate the clinical efficacy of nanohydroxyapatite powder (NHA) in combination with polylactic acid/polyglycolic acid copolymer (PLGA) as a bone replacement graft in the surgical treatment of intrabony periodontal defects. Medical charts were screened following inclusion and exclusion criteria. Periodontal parameters and periapical radiographs taken before surgery and at 12-month follow-up were collected. Intra-group comparisons were performed using a two-tailed Wilcoxon signed-rank test. Twenty-five patients (13 males, 12 females, mean age 55.1 ± 10.5 years) were included in the final analysis. Mean probing depth (PD) and clinical attachment level (CAL) at baseline were 8.32 ± 1.41 mm and 9.96 ± 1.69 mm, respectively. Twelve months after surgery, mean PD was 4.04 ± 0.84 mm and CAL was 6.24 ± 1.71 mm. Both PD and CAL variations gave statistically significant results (p < 0.00001). The mean radiographic defect depth was 5.54 ± 1.55 mm and 1.48 ± 1.38 mm at baseline and at 12-month follow-up, respectively (p < 0.0001). This case series, with the limitations inherent in the study design, showed that the combination of NHA and PLGA, used as bone replacement graft in intrabony periodontal defects, may give significant improvements of periodontal parameters at 12-month follow-up.

Enamel Matrix Derivative and Autogenous Bone Graft for Periodontal Regeneration of Intrabony Defects in Humans: A Systematic Review and Meta-Analysis

The combination of enamel matrix derivative (EMD) with an autogenous bone graft in periodontal regeneration has been proposed to improve clinical outcomes, especially in case of deep non-contained periodontal defects, with variable results. The aim of the present systematic review and meta-analysis was to assess the efficacy of EMD in combination with autogenous bone graft compared with the use of EMD alone for the regeneration of periodontal intrabony defects. A literature search in PubMed and in the Cochrane Central Register of Controlled Trials was carried out on February 2019 using an ad-hoc search string created by two independent and calibrated reviewers. All randomized controlled trials (RCTs) comparing a combination of EMD and autogenous bone graft with EMD alone for the treatment of periodontal intrabony defects were included. Studies involving other graft materials were excluded. The requested follow-up was at least 6 months. There was no restriction on age or number of patients. Standard difference in means between test and control groups as well as relative forest plots were calculated for clinical attachment level gain (CALgain), probing depth reduction (PDred), and gingival recession increase (RECinc). Three RCTs reporting on 79 patients and 98 intrabony defects were selected for the analysis. Statistical heterogeneity was detected as significantly high in the analysis of PDred and RECinc (I² = 85.28%, p = 0.001; I² = 73.95%, p = 0.022, respectively), but not in the analysis of CALgain (I² = 59.30%, p = 0.086). Standard difference in means (SDM) for CALgain between test and control groups amounted to −0.34 mm (95% CI −0.77 to 0.09; p = 0.12). SDM for PDred amounted to −0.43 mm (95% CI −0.86 to 0.01; p = 0.06). SDM for RECinc amounted to 0.12 mm (95% CI −0.30 to 0.55. p = 0.57). Within their limits, the obtained results indicate that the combination of enamel matrix derivative and autogenous bone graft may result in non-significant additional clinical improvements in terms of CALgain, PDred, and RECinc compared with those obtained with EMD alone. Several factors, including the surgical protocol used (e.g. supracrestal soft tissue preservation techniques) could have masked the potential additional benefit of the combined approach. Further well-designed randomized controlled trials, with well-defined selection criteria and operative protocols, are needed to draw more definite conclusions.

Evaluation of Efficacy of Surgical Periodontal Therapy with the Use of Bone Graft in the Treatment of Periodontal Intrabony Defects

INTRODUCTION

One of the most important goals of periodontitis therapy is the elimination of deep periodontal pockets. In regenerative periodontal therapy, different types of bone grafts, membranes, growth factors, etc. are used to improve regeneration of lost periodontal tissue. The aim of this study was to evaluate the effect of surgical therapy supported by the use of bone replacement material in the treatment of deep intrabony pockets, compared to surgical treatment (flap surgery) without the use of bone replacement in advanced periodontitis.

METHODS AND MATERIALS

The study included 50 patients of both sexes with advanced periodontitis, divided into two groups. After initial periodontal therapy was performed, plaque index (PI), papillary bleeding index (PBI) were verified, and depth of periodontal pockets was measured in both groups. One group (group 1) of the patients underwent surgical therapy, open flap surgery, while the other group (group 2) underwent the same surgical treatment method (open flap surgery), during which bone defects were filled with bone replacement material.

RESULTS

The results showed that both group 1 and group 2 experienced improvements after periodontal surgical therapy. In group 1, there are no statistically significant changes in all three plaque index measurements (PI), while there has been a significant reduction in PI in group 2 following the surgery. For the PBI index, it was determined that there were statistically significant changes in values in group 1, both after surgical procedures and six months later, as well as in group 2. Statistical analysis of the results of the probing depth of pockets has shown that there are significant changes in the measurement of the depth of periodontal pocket one month after the surgery, as well as six months later, meaning that there has been a significant reduction in the depth of the periodontal pocket one month following the surgery as well as six months later, for both groups. However, we did not determine a statistically significant difference in the probing depth of pockets between these two groups.

CONCLUSION

Six months after a surgical therapy, clinical parameters showed a reduction of the probing depth of the periodontal pocket in both examined groups. The use of bone replacement did not yield significantly better results in reducing the depth of probing compared to the standard flap surgery. We believe that future research should focus on testing the effectiveness of new regenerative methods and materials (bone replacements with various properties, membranes, and surgical methods) that will result in better treatment results with predictable outcomes.

Use of an amniotic membrane as a novel barrier in a tooth with a questionable prognosis

The chief goal of combination therapy using guided tissue regeneration along with bone grafts is to optimally and predictably regenerate the periodontal attachment apparatus. The evolution of regenerative therapy along with careful patient selection and treatment planning can have positive results even in cases which are not ideal. The present case report describes a tooth with a questionable prognosis treated successively by endodontic then periodontal therapy using an amniotic membrane along with a bone graft to treat an intrabony defect. The follow-up, 12 months later showed a resolution of the interradicular lesion and a radiographic bone fill.

Comparative Evaluation of the Efficacy of Platelet-rich Fibrin and Calcium Phosphosilicate Putty alone and in Combination in the Treatment of Intrabony Defects: A Randomized Clinical and Radiographic Study

Background:

Combination of platelet-rich fibrin (PRF) and bone substitutes for the treatment of intrabony pockets is based on sound biologic rationale. The present study aimed to explore the clinical and radiographic effectiveness of autologous PRF and calcium phosphosilicate (CPS) putty alone and in combination in treatment of intrabony defects.

Materials and Methods:

A total of 45 intrabony defects were selected and randomly divided into three groups. In Group I, mucoperiosteal flap elevation followed by placement of PRF was done. In Group II, mucoperiosteal flap elevation followed by placement of CPS putty was done. In Group III, mucoperiosteal flap elevation followed by placement of PRF and CPS putty was done. Clinical parameters such as gingival index (GI), pocket depth (PD), clinical attachment level (CAL), gingival marginal position and radiographic parameters such as bone fill, changes in crestal bone level, and defect depth resolution were recorded at baseline and after 6 months postoperatively.

Results:

Statistically significant changes in GI, PD reduction, CAL gain, defect fill, and defect depth resolution from baseline to 6 months were seen in all the three groups (P < 0.05). On intergroup comparison, no statistically significant changes were seen in all clinical parameters. However, the difference in defect fill and defect depth resolution between the Groups I and III and Group II and III was significant.

Conclusion:

Within limitations of study, combination of PRF and CPS putty showed a significant improvement in PD reduction, CAL gain, and bone fill.

Management of localized advance loss of periodontal support associated Grade II furcation and intrabony defect in chronic periodontitis patient through amalgamation of platelet-rich fibrin and hydroxyapatite bioactive glass composite granules

Periodontal disease is infectious, complex, multifactorial, chronic inflammatory disease of supporting periodontal tissues that not only alters the bone morphology but also leads to the reduction in bone height. Different types of bony deformities such as horizontal, vertical, craters, and furcation result from periodontal disease, but vertical and Grade II furcation defects are more amenable to regenerative periodontal therapy. The present case report describes the current concept of periodontal diagnosis and the clinical radiographical efficiency of platelet-rich fibrin and hydroxyapatite bioactive glass composite granules graft combination in the management of localized advance osseous defects with respect to tooth number 36 in chronic periodontitis patient at 1 year postoperatively.

Six-month results of a randomized, split-mouth, controlled clinical study

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Twenty years of enamel matrix derivative: the past, the present and the future

BACGROUND

On June 5th, 2015 at Europerio 8, a group of leading experts were gathered to discuss what has now been 20 years of documented evidence supporting the clinical use of enamel matrix derivative (EMD). Original experiments led by Lars Hammarström demonstrated that enamel matrix proteins could serve as key regenerative proteins capable of promoting periodontal regeneration including new cementum, with functionally oriented inserting new periodontal ligament fibres, and new alveolar bone formation. This pioneering work and vision by Lars Hammarström has paved the way to an enormous amount of publications related to its biological basis and clinical use. Twenty years later, it is clear that all these studies have greatly contributed to our understanding of how biologics can act as mediators for periodontal regeneration and have provided additional clinical means to support tissue regeneration of the periodontium.

AIMS

This review article aims to: (1) provide the biological background necessary to understand the rational for the use of EMD for periodontal regeneration, (2) present animal and human histological evidence of periodontal regeneration following EMD application, (3) provide clinically relevant indications for the use of EMD and (4) discuss future avenues of research including key early findings leading to the development of Osteogain, a new carrier system for EMD specifically developed with better protein adsorption to bone grafting materials.

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

Background:

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

Materials and Methods:

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

Results:

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

Conclusions:

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

Platelet rich fibrin combined with decalcified freeze-dried bone allograft for the treatment of human intrabony periodontal defects: a randomized split mouth clinical trail

OBJECTIVE

Polypeptide growth factors of platelet rich fibrin (PRF) have the potential to regenerate periodontal tissues. Osteoinductive property of demineralized freeze-dried bone allograft (DFDBA) has been successfully utilized in periodontal regeneration. The aim of the present randomized, split mouth, clinical trial was to determine the additive effects of PRF with a DFDBA in the treatment of human intrabony periodontal defects.

MATERIALS AND METHODS

Sixty interproximal infrabony defects in 30 healthy, non-smoker patients diagnosed with chronic periodontitis were randomly assigned to PRF/DFDBA group or the DFDBA/saline. Clinical [pocket depth (PD), clinical attachment level (CAL) and gingival recession (REC)] and radiographic (bone fill, defect resolution and alveolar crest resorption) measurements were made at baseline and at a 12-month evaluation.

RESULTS

Compared with baseline, 12-month results indicated that both treatment modalities resulted in significant changes in all clinical and radiographic parameters. However, the PRP/DFDBA group exhibited statistically significantly greater changes compared with the DFDBA/saline group in PD (4.15 ± 0.84 vs 3.60 ± 0.51 mm), CAL (3.73 ± 0.74 vs 2.61 ± 0.68 mm), REC (0.47 ± 0.56 vs 1.00 ± 0.61 mm), bone fill (3.50 ± 0.67 vs 2.49 ± 0.64 mm) and defect resolution (3.73 ± 0.63 vs 2.75 ± 0.57 mm).

CONCLUSION

Observations indicate that a combination of PRF and DFDBA is more effective than DFDBA with saline for the treatment of infrabony periodontal defects.

Clinical and radiographic evaluation of recombinant human platelet derived growth factor with beta tricalcium phosphate in the treatment of a periodontal intrabony defect

The need to increase the predictability of successful periodontal regeneration has led to the use of cell-stimulating proteins in combination with osteoconductive scaffolds and cells based on the principles of tissue engineering. The present case report describes the treatment of an intrabony defect with recombinant human platelet derived growth factor (rhPDGF) + β-tricalcium phosphate (β-TCP). A 25-year-old patient presented with a probing pocket depth of 9 mm mesial to the left maxillary molar. The radiograph revealed an intrabony defect with a depth of 4.23 mm. The defect was treated by open flap debridement and grafting with rhPDGF + β-TCP. On 9 months follow-up, the pocket depth reduced to 3 mm and the defect was completely filled as observed in radiographs and surgical re-entry. A gain in alveolar crest height was also observed.

Platelet-rich fibrin, "a faster healing aid" in the treatment of combined lesions: A report of two cases

Anatomically the pulp and periodontium are connected through apical foramen, and the lateral, accessory, and furcal canals. Diseases of one tissue may affect the other. In the present case report with two cases, a primary periodontal lesion with secondary endodontic involvement is described. In both cases, root canal treatment was done followed by periodontal therapy with the use of platelet-rich fibrin (PRF) as the regenerative material of choice. PRF has been a breakthrough in the stimulation and acceleration of tissue healing. It is used to achieve faster healing of the intrabony defects. Absence of an intraradicular lesion, pain, and swelling, along with tooth stability and adequate radiographic bone fill at 9 months of follow-up indicated a successful outcome.

Evaluation of bioactive glass and demineralized freeze dried bone allograft in the treatment of periodontal intraosseous defects: A comparative clinico-radiographic study

AIM

The purpose of this study was to evaluate the efficacy of demineralized freeze dried bone allograft (DFDBA) and bioactive glass by clinically and radiographically in periodontal intrabony defects for a period of 12 months.

MATERIALS AND METHODS

Ten systemically healthy patients diagnosed with chronic periodontitis, with radiographic evidence of at least a pair of contralateral vertical osseous defects were included in this study. Defect on one-side is treated with DFDBA and the other side with bioactive glass. Clinical and radiographic measurements were made at baseline 6 month and 12 month after the surgery.

RESULTS

Compared to baseline, the 12 month results indicated that both treatment modalities resulted in significant changes in all clinical parameters (gingival index, probing depth, clinical attachment level (CAL) and radiographic parameters (bone fill); P < 0.001*). However, sites treated with DFDBA exhibited statistically significantly more changes compared to the bioactive glass in probing depth reduction (2.5 ± 0.1 mm vs. 1.8 ± 0.1 mm) CAL gain 2.4 ± 0.1 mm versus 1.7 ± 0.2 mm; (P < 0.001*). At 12 months, sites treated with bioactive glass exhibited 56.99% bone fill and 64.76% bone fill for DFDBA sites, which is statistically significant (P < 0.05*).

CONCLUSION

After 12 months, there was a significant difference between the two materials with sites grafted with DFDBA showing better reduction in probing pocket depth, gain in CAL and a greater percentage of bone fill when compared to that of bioactive glass.