Bio-Oss collagen and orthodontic movement for the treatment of infrabony defects in the esthetic zone

The aim of the present study was to evaluate whether it is possible to orthodontically move migrated teeth into infrabony defects augmented with a biomaterial. Three adult patients suffering from chronic periodontitis were treated. Each of the patients presented with an infrabony defect adjacent to a migrated maxillary central incisor. After cause-related therapy was completed, a surgical procedure was performed using the papilla preservation technique. The defects were filled with a collagen bovine bone mineral; after 2 weeks, an orthodontic device was activated using light, continuous forces. Orthodontic treatment time varied from 4 to 9 months; during this period, patients were enrolled in an oral hygiene recall program. At baseline and 6 months after the end of therapy, probing pocket depths (PPD) and clinical attachment levels (CAL) were assessed. In addition, the vertical and horizontal dimensions of the defects were measured on standardized radiographs. Residual mean PPD was 3.33 mm, with a mean reduction of 3.67 mm. Mean CAL gain was 4.67 mm. Radiologic vertical and horizontal bone fills were, on average, 3.17 mm and 2.0 mm, respectively. The present case series shows the effectiveness of a combined periodontic-orthodontic approach for the treatment of infrabony defects. Reduction of PPD to physiologic values, CAL gain, and radiologic defect resolution were obtained. No detrimental effects from the orthodontic movement were observed on the augmentation material.     

Clinical evaluation of anorganic bovine-derived hydroxyapatite matrix/cell-binding peptide (P-15) in the treatment of human infrabony defects

The purpose of the present study was to compare the clinical outcomes of infrabony periodontal defects following treatment with an anorganic bovine-derived hydroxyapatite matrix/cell-binding peptide (ABM/P-15) flow to open flap debridement. Twenty-six patients, each displaying one infrabony defect with probing depth >/=6 mm and vertical radiographic bone loss >/=3 mm participated in the present study. Patients were allocated randomly to be treated with ABM/P-15 flow (test group) or open flap debridement (control group). At baseline and at 12 months after surgery, the following clinical parameters were recorded by a blinded examiner: plaque index, gingival index, probing depth (PD), clinical attachment level (CAL), and gingival recession. Both treatments resulted in significant improvements between baseline and 12 months, in terms of PD reduction and CAL gain (p < 0.001). At 12 months following therapy, the test group showed a reduction in mean PD from 7.8 +/- 1.6 mm to 3.5 +/- 1.0 mm and a change in mean CAL from 8.5 +/- 2.1 mm to 4.6 +/- 1.2 mm, whereas in the control group the mean PD decreased from 7.5 +/- 0.8 mm to 4.9 +/- 0.7 mm and mean CAL from 8.2 +/- 1.2 mm to 6.4 +/- 1.4 mm. The test group demonstrated significantly greater PD reductions (p = 0.002) and CAL gains (p = 0.001) compared to the control group. In conclusion, treatment of infrabony periodontal defects with ABM/P-15 flow significantly improved clinical outcomes compared to open flap debridement.     

Surgical treatment of infrabony defects with autologous platelet concentrate or bioabsorbable barrier membrane: a prospective case series

BACKGROUND: Autologous platelet concentrate (APC) contains concentrated platelet-derived growth factors that promote wound healing and tissue regeneration. The purpose of this prospective case series was to compare the treatment effects of an intralesional graft of APC to guided periodontal regeneration (GPR) using a bioabsorbable barrier membrane (MEM) over a 52-week period. METHODS: Five patients were recruited for the study from two private periodontal practices. There were four females and one male having a mean age of 33 +/- 10.23 years. The five selected contralateral teeth had similar, but not identical, combinations of 1-, 2-, and 3-wall infrabony defects not involving furcations. Probing depths (PDs) of the defects were > or = 6 mm and had radiographic angular infrabony defects > or = 4 mm in depth. The patients had no local or systemic contraindications to minor oral surgical procedures and had not taken systemic antibiotics for > or = 6 months before the commencement of the study. All patients had completed cause-related periodontal therapy up to 6 months previously and had achieved a satisfactory level of oral hygiene. The selected teeth did not have purulent discharge from the pockets and responded normally to pulp sensibility testing. Patients were excluded if they smoked, were pregnant or lactating, or were allergic to any of the materials to be used in the treatment. At baseline and 8, 26, and 52 weeks after surgery, PDs, recession (REC), presence of plaque, and bleeding on probing were recorded, and standardized periapical radiographs were taken. At the time of surgery, the vertical distance to the deepest point of the infrabony defect was measured from the cemento-enamel junction (CEJ) to the buccal and lingual bone crests. The vertical distance to the base of the defect from the CEJ and defect angles were obtained from radiographs. The paired contralateral infrabony defects were treated with a graft APC or MEM after debridement and EDTA root surface conditioning. Surgical flaps were prepared and closed according to the papilla preservation method. Post-surgical care was provided at 1, 2, 8, 26, and 52 weeks after surgery. A mouthwash of 0.2% chlorhexidine gluconate was used twice daily for the first 3 weeks after surgery. Mean PD, REC, clinical attachment level (CAL), radiographic bone loss, and defect angle were computed and compared for each data collection point. RESULTS: From baseline to 52 weeks, a mean PD reduction of 3 +/- 1.41 mm (APC) and 3.6 +/- 1.67 mm (MEM), mean REC increase of 0.8 +/- 1.01 mm (APC) and 0.6 +/- 1.14 mm (MEM), mean CAL gain of 2.2 +/- 1.79 mm (APC) and 3 +/- 1 mm (MEM), mean radiographic bone fill of 3.24 +/- 2.85 mm (APC) and 2.7 +/- 1.9 mm (MEM), and mean defect-angle increase of 15.25 degrees +/- 18.21 degrees (APC) and 22.4 degrees +/- 27.3 degrees (MEM) were calculated. CAL gain was not related clearly to defect angle at baseline, although radiographic bone fill was slightly greater for defect angles <39.4 degrees +/- 7.88 degrees. CONCLUSIONS: This case series of five similar, but not identical, bilateral paired infrabony defects suggests that an APC graft achieves a similar CAL gain and PD reduction to GPR using an MEM over a 52-week period. A larger, controlled clinical trial is needed to evaluate further the efficacy of autologous platelet-rich plasma for the treatment of infrabony defects.     

Subperiosteal connective tissue grafts for pocket reduction and preservation of gingival esthetics: a case report

BACKGROUND: Clinical studies and recent histological evidence following mucogingival surgery for the treatment of gingival recession have documented that when closely adapted to a previously exposed root surface, connective tissue is capable of forming a new attachment. Despite these findings, no clinical tests have been conducted to examine the ability of connective tissue to reduce probing depth (PD) and increase clinical attachment levels (CAL) when it is implanted into periodontal osseous defects. The purpose of this paper is to report the clinical results on a patient following 2 subperiosteal connective tissue grafts. METHODS: Subperiosteal connective tissue grafts were placed in 2 sites of periodontal bone loss and deep pocketing in one patient. Following flap reflection and root preparation, a connective tissue graft 1.5 to 2.0 mm in thickness was draped and sutured over each osseous defect and then completely covered by the external flap. RESULTS: Ten months following subperiosteal connective tissue grafting, tooth #7 had 4 mm of CAL gain. Tooth #10 had 3 mm of CAL gain 8 months postoperatively. Both teeth had 1 mm gain in gingival recession. Both teeth probed 3 mm postoperatively. CONCLUSIONS: When connective tissue was grafted into 2 periodontal osseous defects, there were significant reductions in probing depth and gains in CAL. There was minimal postoperative gingival recession. The new clinical attachment gain remained stable for 8 to 10 months following subperiosteal connective tissue grafting.     

Intrusion of migrated incisors with infrabony defects in adult periodontal patients

This report describes the orthodontic treatment of 10 adult patients who had severe periodontal disease, with migration and radiological evidence of an infrabony defect on a maxillary central incisor. Orthodontic tooth movement, using light and continuous forces, was initiated 7 to 10 days after periodontal surgical therapy. Mean orthodontic treatment time was 10 months. Before surgery and at the end of orthodontic treatment, the following parameters were registered clinically and with standardized intraoral radiographs: probing depth, clinical crown length, marginal bone level, bone defect radiological dimension, and root length. Comparison of pre- and posttreatment values showed a statistically significant improvement for all parameters without a remarkable decrease of root length. The mean residual probing depth was 2.80 mm, and the mean intrusion of the incisors was 2.05 mm. Moreover, radiographs showed a reduction of the infrabony defects. These results show the efficacy of a combined orthodontic-periodontal approach. Intrusive movement, after proper periodontal surgical therapy, can positively modify both the alveolar bone and the soft periodontal tissues.     

Enamel Matrix Derivative in Propylene Glycol Alginate for Treatment of Infrabony Defects With or Without Systemic Doxycycline: 12‐ and 24‐Month Results

Background: This aim of this study is to compare regenerative therapy of infrabony defects with and without administration of post‐surgical systemic doxycycline (DOXY) 12 and 24 months after therapy. Methods: In each of 57 patients, one infrabony defect (depth ≥4 mm) was treated regeneratively using enamel matrix derivative at two centers (Frankfurt am Main and Heidelberg). By random assignment, patients received either 200 mg DOXY per day or placebo (PLAC) for 7 days after surgery. Twelve and 24 months after surgery, clinical parameters (probing depths [PDs] and vertical clinical attachment level [CAL‐V]) and standardized radiographs were obtained. Missing data were managed according to the last observation carried forward. Results: Data of 57 patients (DOXY: 28; PLAC: 29) were analyzed (26 males and 31 females; mean age: 52 ± 10.2 years; 13 smokers). In both groups, significant (P <0.01) PD reduction (DOXY: 3.7 ± 2.2 mm; PLAC: 3.4 ± 1.7 mm), CAL‐V gain (DOXY: 2.7 ± 1.9 mm; PLAC: 3.0 ± 1.9 mm), and bone fill (DOXY: 1.6 ± 2.7 mm; PLAC: 1.8 ± 3.0 mm) were observed 24 months after surgery. However, the differences between both groups failed to be statistically significant (PD: P = 0.574; CAL‐V: P = 0.696; bone fill: P = 0.318). Conclusions: Systemic DOXY, 200 mg/day for 7 days, after regenerative therapy of infrabony defects did not result in better PD reduction, CAL‐V gain, or radiographic bone fill compared with PLAC 12 and 24 months after surgery, which may be attributable to low power and, thus, random chance.     

Favorable periodontal regenerative outcomes from teeth with presurgical mobility: a retrospective study

BACKGROUND: The relevance of tooth mobility on periodontal healing is still controversial. The purpose of the present study was to evaluate the effect of presurgical tooth mobility on periodontal regenerative outcomes. METHODS: The data in this study were derived from three randomized clinical trials which evaluated regenerative procedures. Sixty-four patients with one intraosseous periodontal defect each received one of the following treatments: guided tissue regeneration (GTR) using expanded polytetrafluoroethylene (ePTFE), GTR using a bioabsorbable membrane with or without demineralized freeze-dried bone allograft (DFDBA), or enamel matrix derivative with or without DFDBA. Probing depth (PD), clinical attachment level (CAL), recession (REC), and tooth mobility (TM) were recorded at baseline and 1 year after treatment by a calibrated examiner. The post-surgical follow-up and maintenance periods were designed to optimize plaque control. The teeth were grouped according to their baseline Miller index TM score. The grouping yielded 36 teeth with minimal mobility, score 0; 13 teeth with score 1; and 15 with score 2. The mean changes in PD, CAL and REC from baseline to 1 year were calculated for each group. One-way analysis of variance (ANOVA) was performed to assess differences between the tooth mobility groups considering changes in PD, CAL, and REC at 1 year. RESULTS: The mean PD reduction from baseline to 1 year for teeth with TM score 0 was 3.67 mm; for TM score 1, 2.81 mm; and for score 2, 3.73 mm. The corresponding values for the gain in CAL were 2.73, 1.96, and 2.36 mm, respectively. According to ANOVA, the probing depth reductions and clinical attachment level gains found in each group were not statistically different, P= 0.218 and P= 0.252, respectively. CONCLUSION: Within the limitations of this analysis, it can be concluded that interproximal, intraosseous defects of teeth with limited presurgical tooth mobility; i.e., teeth with Miller's Class 1 and 2 mobility, will respond favorably to regenerative therapy.     

Early and late studies of EMD use in periodontal intrabony defects

Background and Objective: The clinical efficacy of EMDs for the treatment of periodontal infrabony defects has been reported. However, recent publications have questioned the validity of results from early findings. Hence, the purpose of this study was to compare the results obtained from early and late studies when EMD was used as an adjunct in treating human intrabony defects during flap surgery. The aim of this meta‐analysis was to evaluate the validity of results published from early studies compared with those published from later studies. Material and Methods: PubMed and MEDLINE searches were performed. The evaluation period was 1997–2010 and it was divided into two groups of equal periods of time: early studies (1997–2003) and late studies (2004–2010). The clinical parameters assessed were clinical attachment level (CAL), probing pocket depth and bone gain (BG; measured as a percentage or in mm). Results: No statistically significant difference was found between the results obtained from early studies (1997–2003) and late studies (2004–2010) with regards to CAL gain, probing pocket depth reduction and BG. Nonetheless, both study periods showed a benefit for using EMD to treat periodontal infrabony defects when compared with the groups without EMD during open flap surgery. Conclusions: The results obtained from this study failed to show any potential differences between the results published from early studies and late studies with regards to the clinical effectiveness of EMD in treating periodontal infrabony defects.     

Long‐Term Stability After Regenerative Treatment of Infrabony Defects: A Retrospective Case Series

Background: This study aims to evaluate long‐term stability of attachment achieved in infrabony defects (IBDs) by regenerative treatment. Methods: All patients who had received regenerative treatment for at least one IBD between 2004 and 2010 were screened for this retrospective case series. If complete examinations (plaque/gingival index, probing depth [PD], vertical clinical attachment level [CAL‐V]) were available for patients at baseline and 12 months after surgery, they were invited for reexamination 60 ± 12 months after surgery. Reexamination involved testing for interleukin (IL)‐1 polymorphism and counting number of supportive periodontal treatment (SPT) visits. Forty‐one patients (24 males and 17 females; age, median: 62.0 years, lower/upper quartile: 49.8/68.3 years; six smokers, and 9 IL‐1 positive) were included for analysis, each contributing one IBD. Results: Regenerative therapy resulted in significant attachment gain after 1 (median: ?3 mm, lower/upper quartile: ?1.5/?4 mm; P <0.001) and 5 (median: ?3 mm, lower/upper quartile: ?1.9/4.5 mm; P <0.001) years. The study failed to detect median change of CAL‐V from 1 to 5 years after surgery (median: 0 mm; lower/upper quartile: ?1/1.5 mm; P = 0.84). Multiple regression analysis identified that number of SPT visits is correlated with CAL‐V gain from 1 to 5 years after surgery. IL‐1 polymorphism and percentage of sites with PD >6 mm at 5‐year reexamination are correlated with CAL‐V loss from 1 to 5 years after surgery. Conclusions: CAL‐V achieved by regenerative therapy in IBDs may have retained stability over 5 years. Frequent SPT is associated with stability. IL‐1 polymorphism and generalized reinfection are associated with less stability.     

Fibre retention osseous resective surgery: how deep is the infrabony component of the osseous‐resected defects?

Background: The Aims of this retrospective study were: (i) to describe the applicability of Fibre Retention Osseous Resective Surgery (FibReORS) to infrabony defects with different radiographic depths and (ii) to identify significant anatomical elements associated with the decision of tooth extraction or application of FibReORS in the context of a treatment approach aimed at pocket elimination. Material and Methods: Baseline radiographs with detectable infrabony defects were collected from 68 periodontal patients. Selected teeth with radiographic evidence of infrabony defects had probing depths (PD) >4 mm at revaluation following non‐surgical periodontal therapy. Teeth were then surgically treated with FibReORS or extracted on the basis of the decision making of an experienced periodontist and in the context of the overall treatment plan. The total root length and the defect depth were quantified for each selected tooth using radiographic reference points. Results: A total of 324 teeth with infrabony defects were identified. Fifty‐three (16%) teeth with a mean radiographic infrabony defect of 8.5±1.7 mm (range 6–12 mm) were extracted; 271 (84%) teeth with a mean infrabony defect of 3.0±1.4 mm (1–8 mm) were surgically treated, achieving PD 3 mm in all sites at 6‐month follow‐up. Surgically treated teeth showed baseline radiographic infrabony defects 4 mm in 86% of the cases. Logistic multilevel modelling indicated that the probability of extraction was influenced by root length (p=0.0230) and by the radiographic defect depth (p=0.0112). Conclusion: FibReORS is applicable in the treatment of shallow to moderate bony defects and deeper defects associated with longer roots.     

Orthodontic treatment in a patient with Papillon-Lefèvre syndrome

BACKGROUND: Report of a combined periodontal and orthodontic treatment in a patient with Papillon-Lefevre Syndrome (PLS). METHODS: A patient with PLS was treated orthodontically 26 months after the start of a combined mechanical and antibiotic therapy. Clinical periodontal parameters were obtained 26 (t1), 60 (t2), and 79 (t3) months after anti-infective therapy. The deepest site of each tooth was sampled for microbiological analysis at 26 and 60 months. Periodontal maintenance therapy was provided every 6 weeks. After a stable periodontal situation was achieved, orthodontic treatment, consisting of space opening for the upper canines with a multibracket appliance and coil springs, was carried out. In the lower jaw, crowding was resolved by an orthodontic mesialization of the canines. RESULTS: Twenty-six months (t1) after the beginning of the combined mechanical and antibiotic therapy, 6% of the sites exhibited 4 mm probing depth (PD) with bleeding on probing (BOP) or PD > or =5 mm. Sixty months (t2) after therapy the number of sites with 4 mm PD with BOP or PD > or =5 mm had increased to 17%, and 79 months after therapy (t3) 13% of all sites were similarly affected. From 26 to 60 months, a slight mean clinical attachment level (CAL) gain was observed, whereas the mean PD increased. From 60 to 79 months, there was a mean PD reduction. However, a significant mean attachment loss was also noted. After 26 months (t1), RNA probes failed to detect A. actinomycetemcomitans, P. gingivalis, or T. forsythensis from any site. Thirty-four months later (t2), subgingival recolonization was observed. A. actinomycetemcomitans was detected by RNA probes at three sites. At 26 and 60 months (t1, t2), trypticase-soy with serum, bacitracin, and vancomycin (TSBV) culture failed to detect A. actinomycetemcomitans at any of the sampled sites. Eighty-two months after the beginning of therapy (t4), none of the applied methods could detect A. actinomycetemcomitans from the pooled samples from the deepest pockets of each quadrant or the oral mucosa. In the present case, concomitant orthodontic treatment with a fixed appliance could be performed without further pronounced periodontal deterioration. Space for eruption of the canines and premolars was created, in addition to an alignment of the teeth. CONCLUSION: After a successful combined mechanical and antibiotic periodontal therapy of the PLS periodontitis, moderate orthodontic tooth movements may be possible within a complex interdisciplinary treatment regimen.     

120 infrabony defects treated with regenerative therapy: long-term results

Background: The aim of this study is to evaluate the long‐term benefits of regenerative therapy and which factors (i.e., smoking, oral hygiene, radiographic angle, tooth, clinical center, and biomaterial) influence results. Methods: A total of 120 infrabony defects were treated with guided tissue regeneration using bioabsorbable and non‐resorbable membranes with grafts or enamel matrix derivative (EMD) proteins. At baseline, smoking, x‐ray angle, probing depth (PD), recession, and clinical attachment level (CAL) were recorded. CAL was measured 1 year post‐surgery and every 2 years for ≤16 years. The participation of patients in oral hygiene protocols was recorded. Results: The mean ± SD baseline CAL was 8.5 ± 2.3 mm, baseline PD was 7.8 ± 2.1 mm, and baseline x‐ray angle was 31.8° ± 8.9°. One year post‐surgery, CAL gain was 4.1 ± 2.1 mm. EMD was used in 47 defects, bioabsorbable membranes with deproteinized bovine bone were used in 41 cases, non‐resorbable membranes were used in seven defects, bioabsorbable membranes and autogenous bone were used in five defects, and a combination was used in 20 defects. A total of 10% of subjects were smokers, and 20% of subjects did not participate in an oral hygiene program. The average follow‐up was 9 years. A total of 90% teeth survival was achieved at 13 years, and CAL gain was maintained at 82% for 11 years. Statistical analyses demonstrated that smoking and oral hygiene maintenance influenced long‐term outcomes. The x‐ray angle, tooth, clinical center, and biomaterials did not influence results. Conclusions: Regenerative therapy provided a high percentage of long‐term success. Smoking and non‐participation in oral hygiene maintenance negatively influenced the prognosis, whereas other factors did not affect long‐term results.     

Porous titanium granules in the treatment of mandibular Class II furcation defects: a consecutive case series

Background: The osteoconductive potential of titanium is interesting from the perspective of periodontal surgery and reconstitution of osseous defects. The aim of the present consecutive case series is to evaluate a surgical strategy based on the use of porous titanium granules (PTG) in the treatment of Class II buccal furcation defects in mandibular molars in humans. Methods: Surgical intervention with PTG used as a bone graft substitute was performed in 10 patients with 10 mandibular Class II buccal furcation defects. Clinical parameters (probing depth (PD), clinical attachment level (CAL), gingival recession (GR), gingival index (GI), bleeding on probing (BOP), and horizontal and vertical bone sounding) and radiographic measurements of vertical furcation height were compared among baseline (presurgery), 6, and 12 months (post‐surgery). The significance level (α) was set at 0.05. Results: With respect to vertical and horizontal bone sounding measurements, CAL, and GR, no significant improvements between baseline and the 12‐month examination were seen. Both PD and radiographic vertical furcation height were significantly reduced between baseline and 12 months. When comparing the baseline to 12‐month data, a significantly lower GI score was seen but the BOP score was unchanged. None of the treated teeth showed radiographic signs of root resorption. Conclusion: This study suggests that PTG is safe to use in close proximity to root surfaces, but no significant improvements in clinical endpoints of defect resolution were observed.     

Tissue-engineered cultured periosteum used with platelet-rich plasma and hydroxyapatite in treating human osseous defects

BACKGROUND: The aim of the present controlled clinical study was to compare the clinical response of human cultured periosteum (HCP) sheets in combination with platelet-rich plasma (PRP) and porous hydroxyapatite (HA) granules to a mixture of PRP and HA in the treatment of human infrabony periodontal defects. METHODS: Thirty interproximal infrabony osseous defects in 30 healthy, non-smoking subjects diagnosed with chronic periodontitis were included in this study. The subjects were randomly assigned to the test group (HCP sheets combined with PRP and HA) or the control group (PRP with HA). Clinical and radiographic measurements were made at baseline and the 12-month post-surgical evaluation. RESULTS: Compared to baseline, the 12-month results indicated that both treatment modalities resulted in statistically significant changes (P <0.01) in the gingival index, bleeding on probing, probing depth, clinical attachment level, and radiographic infrabony defect depth. Compared to the control group, the test group exhibited a statistically significantly more favorable change in clinical attachment gain (3.9 +/- 1.6 mm versus 2.7 +/- 1.3 mm; P <0.05), vertical relative attachment gain (83.5% +/- 31.7% versus 55.0% +/- 21.9%; P <0.05), and radiographic infrabony defect fill (4.9 +/- 1.2 mm versus 3.2 +/- 1.1 mm; P <0.01). CONCLUSIONS: Compared to PRP with HA, treatment with a combination of HCP sheets, PRP, and HA led to a significantly more favorable clinical improvement in infrabony periodontal defects. A factor likely contributing to these favorable clinical results is the presence of osteogenic cells in the HCP sheets, which provided greater regeneration potential.     

Enamel matrix proteins in the treatment of deep intrabony defects

BACKGROUND: The present study evaluated the healing of enamel matrix derivative (EMD) proteins in the treatment of periodontal lesions with deep intrabony defects. METHODS: Ten deep intrabony defects in 7 periodontal patients were treated and followed for 1 year. The sites had a probing depth (PD) > or = 8 mm; clinical attachment level (CAL) > or = 9 mm, and intrabony component depth > or = 5 mm. All subjects received therapy prior to surgery and had a plaque score (PI) < or = 10%. Full thickness flaps were elevated buccally and lingually, granulation tissue was removed from the defects, and the root surfaces were planed. A 24% EDTA gel was applied followed by the enamel matrix protein preparation. The flaps were closed with interrupted sutures. The patients rinsed with a chlorhexidine solution twice a day for 6 weeks. They were recalled every 2 weeks for 6 months for professional tooth cleaning and then every 4 weeks for an additional 6 months. The experimental sites were re-examined 6 and 12 months after regenerative surgery. RESULTS: At the 1-year examination, the mean CAL gain was 6.5 mm, the mean PD was 3.2 mm, and mean radiographic bone fill was 4.7 mm. CONCLUSIONS: The application of enamel matrix proteins in combination with open flap curettage and root planing resulted in a gain of CAL and bone fill in deep intrabony defects.     

Comparison of two types of synthetic biodegradable barriers for GTR in interproximal infrabony defects: clinical and radiographic 24-month results

The aim of the present study was to compare the efficacy of guided tissue regeneration (GTR) using two different biodegradable barriers (polylactide acetyltributyl citrate; polydioxanon) in three- and two-walled infrabony defects. The polydioxanon barrier is an experimental GTR membrane that consists of a continuous occlusive barrier with a layer of slings on the side that is meant to face the mucoperiosteal flap. Fifteen patients provided 15 pairs of similar contralateral periodontal defects: 12 predominantly two-walled and 18 predominantly three-walled infrabony defects. Each defect was randomly assigned to treatment with polylactide acetyltributyl citrate (control) or polydioxanon (test) devices. At baseline, 6, 12, 18, and 24 months after surgery, clinical measurements were performed and standardized radiographs obtained (not at 18 months). Both treatments revealed a significant Gingival Index reduction, probing depth reduction, and vertical probing attachment level gain 24 months after surgery. Both treatments showed slight resorption of the crestal alveolar ridge after 24 months, which failed to reach statistical significance. A statistically significant bone gain within the infrabony pockets was measured for both treatment options 24 months postsurgical. Regarding Gingival Index and probing depth reduction as well as vertical probing attachment level and bone gain, there were neither statistically significant nor clinically relevant differences between test and control barriers. The use of both biodegradable barriers in GTR therapy may be recommended.     

A novel approach to minimizing gingival recession in the treatment of vertical bony defects

BACKGROUND: In ideal conditions, the gain in clinical attachment following regenerative therapy of infrabony defects should be equal to probing depth reduction; thus, gingival recession should not increase as a consequence of the treatment procedures. The goal of the study was to evaluate the effectiveness of a surgical technique for the treatment of intrabony defects aimed at minimizing gingival recession and increasing the potential for clinical periodontal regeneration. METHODS: Fifteen deep intrabony defects were treated with cause-related therapy aimed at eliminating bleeding on probing in the surgical area with minimal mechanical trauma to the root and the soft tissues. Four weeks later, a surgical technique combining the simplified papilla preservation approach at the level of the defect and the coronally advanced buccal flap at the adjacent teeth was performed. Enamel matrix protein was used in the intrabony defect. Soft tissue measurements were made before cause-related therapy, before and after surgery, and at the 1-, 6-, and 12-month follow-up visits. The clinical reevaluation was made 1 year after the surgery. RESULTS: No changes in the position of the buccal and interproximal soft tissues next to the defect area were observed before and after cause-related therapy or when comparing the baseline (before surgery) and 1-year follow-up visits. The clinical attachment gain (5.9 +/- 1.4 mm), probing depth reduction (6.0 +/- 0.8 mm), and radiographic bone level gain (5.0 +/- 0.5 mm) were statistically and clinically significant, whereas no statistically significant increase in gingival recession (0.1 +/- 1.0 mm) was noted during the observation period. CONCLUSIONS: It is possible to avoid statistically and clinically significant changes in the position of the soft tissues when treating vertical bony defects. This can be accomplished by minimizing soft tissue trauma during cause-related therapy and by advancing the buccal flap coronally during the surgery.     

Evaluation of Efficacy of Chlorhexidine Intracanal Medicament on the Periodontal Healing of Concomitant Endodontic‐Periodontal Lesions Without Communication: An Interventional Study

Background: Treatment of concomitant endodontic‐periodontal lesions remains a challenge in clinical practice and requires effective endodontic and regenerative periodontal therapy. Among other factors, cross seeding and recolonization of flora may affect the outcome of periodontal therapy. Intracanal medicaments have been shown to exert antimicrobial activity on the external root surface, and local delivery of antimicrobials has been suggested to be a complementary approach in the management of periodontitis. Therefore, the objective of this study is to determine the influence of chlorhexidine (CHX) intracanal medicament on the clinical outcomes of therapy. Methods: Thirty‐one patients were divided into two treatment groups: 1) open flap debridement (OFD) in endodontically treated teeth (control); and 2) OFD in endodontically treated teeth with CHX placed in the coronal space (test). The clinical variables evaluated were probing depth (PD), clinical attachment level (CAL), and percentage of sites with PD ≥5 mm. Reevaluation was performed at 3 and 6 months post‐surgery. Results: Both treatments resulted in improvement in all the clinical variables evaluated. Postoperative measurements from test and control groups showed reductions in mean PD of 2.22 ± 1.27 and 0.91 ± 0.81 mm, mean CAL gains of 2.16 ± 1.12 and 0.60 ± 0.93 mm, and 43.33% ± 31.37% and 17.71% ± 14.23% reduction in sites with PD ≥5 mm. Significantly more PD reduction, CAL gain, and percentage reduction in sites with PD ≥5 mm were observed in the test group at 6 months (P <0.05). Conclusion: CHX may be used as an effective intracanal medicament for promoting periodontal healing in concomitant endodontic‐periodontal lesions.     

Effects of Er:YAG laser compared to ultrasonic scaler in periodontal treatment: a 2-year follow-up split-mouth clinical study

BACKGROUND: The aim of this clinical study was to compare the results of non-surgical treatment of periodontal disease with an erbium-doped:yttrium, aluminum, and garnet (Er:YAG) laser to root debridement with an ultrasonic scaler. METHODS: Twenty-five patients furnished two quadrants containing four teeth with probing depths (PD) >4 mm; the quadrants were divided equally between the right and left sides. On one side, teeth were treated by Er:YAG laser using 160 mJ/pulse at 10 Hz (test group); on the contralateral side, teeth were treated by ultrasonic scaler (control group). Clinical baseline data, including plaque index, gingival index, probing depth (PD), and clinical attachment level (CAL), were recorded before treatment and at 3 months and 1 and 2 years. RESULTS: There were statistically significant differences in PD between the test and control groups for pockets of 1 to 4 mm (P <0.05), 5 to 6 mm (P <0.01), and > or =7 mm (P <0.001). However, there were no significant differences between the test and control groups for CAL gain in pockets of 1 to 4 mm; statistically significant differences were found between the test and control groups in pockets of 5 to 6 mm (P <0.01) and > or =7 mm (P <0.001). CONCLUSION: Er:YAG laser periodontal treatment resulted in statistically significant improvements in PD and CAL gain compared to ultrasonic scaler treatment at 2-year follow-up, especially in moderate and deep pockets.     

Radiographic parameters for prognosis of periodontal healing of infrabony defects: two different definitions of defect depth

BACKGROUND: The aim of the present study was to evaluate defect width and two different definitions of defect depth as prognostic factors of periodontal healing in infrabony defects treated by regenerative therapy 6 and 24 months after surgery. METHODS: In 32 patients with moderate to advanced periodontitis, 50 infrabony defects were treated by the guided tissue regeneration (GTR) technique using non-resorbable or bioabsorbable barriers. Clinical parameters were assessed, and 50 triplets of standardized radiographs were taken before surgery and 6 and 24 months after surgery. Using a computer-assisted analysis, the distances cemento-enamel junction (CEJ) to alveolar crest (AC), CEJ to bony defect (BD), horizontal projection of the most coronal extension of the bony wall to the root surface to BD, width, and angle of the bony defects were measured. Depth of the bony defect was 1) calculated as CEJ-BD minus CEJ-AC (INFRA1) and 2) measured as horizontal projection of the most coronal extension of the bony wall to the root surface to BD (INFRA2). RESULTS: Whereas statistically significant vertical clinical attachment level gains (CAL-V: 3.36 +/- 1.59 mm/ 3.41 +/- 1.72 mm; P < 0.001) could be found both 6 and 24 months after surgery, bony fill (0.70 +/- 2.52 mm; P = 0.056/1.21 +/- 2.55 mm; P < 0.005) was significant 24 months post-surgically only. In a multilevel regression analysis, CAL-V gain was predicted by bioabsorbable membrane (P = 0.005), baseline probing depths (PD) (P < 0.001), and actual smoking (P < 0.05). Bony fill could be predicted by baseline depth of the infrabony component as determined by INFRA2 (P < 0.05), angulation of bony defect (P < 0.005), and gingival index at baseline (P < 0.001). In narrow (< 37 degrees) and deep (> or = 4 mm) infrabony defects, bony fill was more pronounced than in wide and shallow defects (P < 0.001). CONCLUSIONS: Improvement achieved by GTR in infrabony defects can be maintained up to 24 months after surgery. Narrow and deep infrabony defects respond radiographically and are to some extent clinically more favorable to GTR therapy than are wide and shallow defects. The infrabony component of bony defects, as determined by the distance from the most coronal extension of the lateral bony wall to BD (INFRA2), is a better predictor of bony fill than that determined by AC-BD (INFRA1).