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PubMed2005

Enamel matrix proteins associated with GTR and bioactive glass in the treatment of class III furcation in dogs.

This study investigated, both histologically and histometrically, the efficacy of enamel matrix derived proteins (EMD) associated with bioactive glass (BG) and an absorbable membrane in the treatment of class III furcation defects in mongrel dogs. After surgical defect creation and chronification, the lesions were randomly divided into three groups according to the treatment employed: Test Group 1--EMD + BG + membrane, Test Group 2--EMD + membrane and Control Group--BG + membrane. After a 90-day healing period, the dogs were sacrificed. The descriptive analysis and the histometric data showed similar results for the experimental groups in all studied parameters (MANOVA, p > 0.05). The association of Emdogain with bioglass and GTR, or with GTR only, showed similar results when compared with the ones obtained with bioglass associated with membrane in the treatment of class III furcation defects in dogs. The three modalities of treatment showed partial filling of the furcations, with bone and cementum regeneration limited to the apical portion of the defects.

Animals↗

PubMed2001

Periodontal tissue regeneration by combined applications of recombinant human osteogenic protein-1 and bone morphogenetic protein-2. A pilot study in Chacma baboons (Papio ursinus).

Native and recombinant human bone morphogenetic/osteogenic proteins (BMPs/ OPs) singly initiate bone induction in vivo. The finding of synchronous but spatially different BMPs/OPs expression during periodontal tissue morphogenesis suggests novel therapeutic approaches using morphogen combinations based on recapitulation of embryonic development. Twelve furcation defects prepared in the first and second mandibular molars of three adult baboons (Papio ursinus) were used to assess whether qualitative histological aspects of periodontal tissue regeneration could be enhanced and tissue morphogenesis modified by combined or single applications of recombinant hOP-1 and hBMP-2. Doses of BMPs/OPs were 100 microg of each protein per 1 g of insoluble collagenous bone matrix as carrier. Approximately 200 mg of carrier matrix was used per furcation defect. Undecalcified sections cut for histological analysis 60 d after healing of hOP-1-treated specimens showed substantial cementogenesis with scattered remnants of the collagenous carrier. hBMP-2 applied alone induced greater amounts of mineralized bone and osteoid when compared to hOP-1 alone or to combined morphogen applications. Combined applications of hOP-1 and hBMP-2 did not enhance alveolar bone regeneration or new attachment formation over and above the single applications of the morphogens. The results of this study, which is the first to attempt to address the structure-activity relationship amongst BMP/OP family members, indicate that tissue morphogenesis induced by hOP-1 and hBMP-2 is qualitatively different when the morphogens are applied singly, with hOP-1 inducing substantial cementogenesis. hBMP-2 treated defects, on the other hand, showed limited cementum formation but a temporal enhancement of alveolar bone regeneration and remodelling. The demonstration of therapeutic mosaicism in periodontal regeneration will require extensive testing of ratios and doses of recombinant morphogen combinations for optimal tissue engineering in clinical contexts.

Alveolar Process↗

PubMed1995

Observer variation in the radiographic assessment of the bone level on the buccal and lingual surfaces of mandibular molars.

OBJECTIVES: To assess accuracy and precision of observers' diagnostic performance in locating the buccal/lingual bone level using conventional periapical radiographs. METHODS: Standardized radiographs of molar regions of 10 dried mandibles were obtained. The bone crest on buccal and lingual surfaces of first and second molars was then marked with thin lead foil strips and fresh radiographs taken. A series of increasingly extensive furcation defects was created by sequential bone removal and radiographs with and without markers obtained after each step. The radiographs without indicators were presented to 10 observers on two separate occasions and the most apically located bone level marked on a transparent film. The distance between observers' markings and 'true' bone level on the radiographs was determined. RESULTS: There was wide interobserver variation which increased as the bone loss increased. Lack of consistency was largely attributable to intra-observer variation except when a furcation defect was present. The underestimation of bone loss became more marked as the amount of bone loss increased. CONCLUSIONS: Radiographic determination of bone loss on buccal and lingual surfaces is associated with a considerable lack of accuracy and precision, both of which get worse as bone loss increases.

Alveolar Bone Loss↗

PubMed2004

Root trunk concavities as a risk factor for regenerative procedures of class II furcation lesions in humans.

BACKGROUND: The purpose of this study was to evaluate the influence of root trunk concavities on guided tissue regeneration in humans and to determine if a modification in membrane design could improve the results. METHODS: Ten patients who provided 10 pairs of similar Class II furcation defects were recruited for the study. Each defect was randomly assigned to treatment with either a normal expanded polytetrafluoroethylene (ePTFE) membrane (NM) or a modified ePTFE membrane (MM). The MM were made by removing the collar from an NM, cutting it into 2 mm segments, and suturing each of the segments to the collar of each MM. Following basic therapy, baseline clinical measurements were recorded using an acrylic stent, including probing depth (PD) and clinical attachment level (CAL). Full flaps were elevated, the defects were carefully debrided, and the root surfaces were decontaminated with manual and ultrasonic instruments. Hard tissue measurements were performed during surgery to determine vertical (VD) and horizontal defect (HD) depths. Then, NM and MM were sutured to their corresponding tooth and the flaps sutured. Membranes remained in position for 6 weeks. After 1 year, all sites were re-entered and soft and hard tissue measurements were recorded. RESULTS: After 1 year, there were no statistically significant differences (Mann-Whitney test) between NM and MM groups in percentages of PD reduction (P= 0.27), CAL change (P= 0.26), or VD resolution (P = 0.13). However, percentage of HD resolution (NM: 24.3+/-11.8; MM: 44.8+/-16.0) was significantly different between groups (P= 0.008). CONCLUSIONS: The modified membranes resulted in greater horizontal resolution of Class II furcation defects. The collars of the membranes should be modified to improve results when root trunk concavities are present.

Biocompatible Materials↗

PubMed1995

Platelet-derived growth factor-modulated guided tissue regenerative therapy.

The goal of this study was to develop an effective regenerative therapy capable of achieving periodontal regeneration of Class III furcation defects. We attempted to achieve this goal by combining three therapeutic approaches. First, the lesion was protected by an expanded polytetrafluoroethylene barrier membrane that prevents migration of gingival fibroblasts as well as osteogenic cells from the mucoperiosteal flaps. Second, platelet-derived growth factor-BB (PDGF-BB), which has potent chemotactic and mitogenic effects on periodontal ligament fibroblasts (PDL), was used to promote migration of fibroblasts and their proliferation on the root surface. Third, the root surface, demineralized by citric acid conditioning, was chosen as the primary site for PDGF-BB application. The demineralized root surface appeared to have the capability of providing a sustained release of the applied growth factor. This seemed to facilitate rapid repopulation of PDL fibroblasts on the root surface and new PDL formation in the early stages of repair, which contributed to complete periodontal regeneration without root resorption and ankylosis in later stages. Combining these approaches, we developed a therapy referred to as "PDGF-modulated guided tissue regenerative therapy." Unlike guided tissue regenerative therapy alone (without PDGF-BB), this therapy effectively promoted periodontal regeneration of Class III furcation defects in the beagle dog without significant ankylosis or root resorption.

Animals↗

PubMed2006

Effect of two different approaches for root decontamination on new cementum formation following guided tissue regeneration: a histomorphometric study in dogs.

BACKGROUND AND OBJECTIVE: The aim of the present study was to evaluate comparatively the effect of two different approaches for root decontamination on new cementum formation following guided tissue regeneration (GTR). MATERIAL AND METHODS: Nine mongrel dogs were used to obtain bilateral chronic class III furcation defects by placing cotton ligatures around both third mandibular premolars. The teeth were randomly assigned to receive one of the following treatments: scaling and root planing, by means of hand and rotatory instruments, in order to remove soft and hard deposits as well as all root cementum (group A); or removal of only soft microbial deposits, by polishing the root surface with rubber cups and polishing paste, aiming for maximum root cementum preservation (group B). Both groups were treated with GTR, with the use of resorbable polyglycolic-lactic acid membranes (RESOLUT XT). RESULTS: Four months later, data analysis showed that a superior length (mm) (3.59 +/- 1.67 and 6.20 +/- 2.26 for groups A and B, respectively; p = 0.004) and a thicker layer (microm) (18.89 +/- 9.47 and 52.29 +/- 22.48 for groups A and B, respectively; p = 0.001) of new cementum was achieved by keeping the root cementum in place during root decontamination (group B). Regardless of the treatment modality, the new cementum was predominantly of a reparative, cellular extrinsic and intrinsic fiber type. CONCLUSION: Within the limits of the present study, it may be concluded that root cementum preservation may affect the new cementum formation following GTR in class III furcation defects, and the treatment modality did not influence the type of newly formed cementum.

Animals↗

PubMed2006

A randomized clinical multicentre trial comparing enamel matrix derivative and membrane treatment of buccal class II furcation involvement in mandibular molars. Part III: patient factors and treatment outcome.

OBJECTIVE: Evaluation of effects of patient factors on the outcome of regenerative treatment of buccal mandibular class II furcation defects. MATERIAL AND METHODS: Fifty-one patients were recruited. In the intention-to-treat population 21 patients were allocated into the sequence left treatment with enamel matrix protein derivative (EMD) and right guided tissue regeneration (GTR) and 27 in the sequence left GTR and right EMD. Evaluated patient factors were: smoking, age, gender, hypertension and oral hygiene status. Outcome parameters included change of: (a) horizontal depth of the defect at the deepest point (b) distance from the fornix of the furcation to bone crest of the defect, (c) distance from stent to the bottom of the defect, (d) pocket depth and (e) attachment level at the middle of the furcation. RESULTS: In patients 54 years of age and older, in males, in non-smokers and in patients with "poor" hygiene EMD-treated sites showed a significant higher mean reduction of the parameters d (age), b (gender, hygiene) a (smoking, hygiene) when compared with sites treated with GTR. CONCLUSIONS: These data provided an indication of a possible effect of patient factors on the outcome of regenerative treatment of buccal mandibular class II furcation defects.

Age Factors↗

PubMed1991

Clinical evaluation of guided tissue regeneration in the treatment of maxillary class II molar furcation invasions.

This investigation assessed and compared the clinical efficacy of combined open flap debridement/occlusive membrane therapy versus open flap debridement therapy alone, in the treatment of maxillary periodontal furcation defects. Seventeen patients presenting with advanced adult periodontitis, including at least one pair of Class II maxillary furcal defects, comprised the study group. Following completion of a hygienic phase of treatment, measurements were made with calibrated periodontal probes to determine soft tissue recession, probing pocket depths, and attachment levels. Each pair of furcation defects was surgically exposed and hard tissue measurements obtained. Defects were treated with either open flap debridement and a polytetrafluoroethylene periodontal membrane or open flap debridement alone. Membranes were removed at 4 to 6 weeks. Six months postsurgery, soft tissue measurements were repeated and all sites were surgically re-entered to obtain hard tissue measurements. No statistically significant differences were found in recession, probing depth reductions, clinical attachment gains, or resorption of alveolar crest height between test and control groups. Results for these parameters were inconsistent and unpredictable. Statistically significant improvements were found, however, in horizontal open probing attachment (HOPA) and vertical open probing attachment (VOPA) between experimental and control sites. The GTR procedure as used in this study likely has limited application as a therapeutic modality for Class II furcations of maxillary molars. Modifications or improvements in the procedure may result in more predictable healing of these lesions.

Adult↗

PubMed2006

Pleiotropism of bone morphogenetic proteins: from bone induction to cementogenesis and periodontal ligament regeneration.

Bone morphogenetic and osteogenic proteins (BMPs/OPs), pleiotropic members of the transforming growth factor-beta (TGF-beta) supergene family, induce de novo endochondral bone formation and act as soluble signals of tissue morphogenesis, sculpting the architecture of multicellular mineralized structures, including the periodontal tissues. The presence of multiple forms of BMPs/OPs has a therapeutic significance and the choice of a suitable protein will be a formidable challenge to the practising periodontologist. Amino acid sequence variations in the carboxy terminal domain, the molecular basis of the structure/activity profile of each isoform, confer specialized and pleiotropic activities to each morphogenetic protein. Naturally derived BMPs/OPs regenerate cementum and alveolar bone in mandibular furcation defects of the primate Papio ursinus. Tissue morphogenesis induced by hOP-1 and hBMP-2 is qualitatively different when the morphogens are applied singly, indicating that the structure/activity profile amongst BMPs/OPs is controlling pleiotropic tissue induction and morphogenesis. Furcation defects of Papio ursinus with root surfaces exposed long-term to periodontal pathogens and filled with granulation tissue after inoculation of a pathogenetic human strain of Porphyromonas gingivalis twice a month for 12 months were implanted with hOP-1 osteogenic devices. Six months after surgery there was regeneration of alveolar bone and induction of cementogenesis, with Sharpey's fibres uniting the regenerated bone to the newly formed cementum. Although within the natural milieu of the bone matrix a plurality of morphogens may be required to initiate the cascade of pattern formation and the attainment of tissue form and function, recombinant y-irradiated hOP-1 delivered by a xenogeneic collagenous matrix induces complete periodontal tissue regeneration on periodontally affected root surfaces, showing an additional specific function of hOP-1 for tissue morphogenesis in clinical contexts. The pleiotropy of the signalling molecules of the TGF-beta superfamily is additionally highlighted by the redundancy of molecular signals initiating endochondral bone induction by the TGF-beta isoforms per se, powerful inducers of endochondral bone, but in the primate only. A novel approach in periodontal tissue regeneration is to induce heterotopic bone to be transplanted as morcellised autogenous grafts into established periodontal defects. The induction of bone develops a mosaic structure in which the osteogenic proteins of the TGF-beta superfamily singly, synergistically and synchronously initiate and maintain tissue induction and morphogenesis, with specific roles at different time points of the morphogenetic cascade.

Animals↗

PubMed1990

Class II furcations treated by guided tissue regeneration in humans: case reports.

In the cases reported here, the response of Class II mandibular molar furcation defects to guided tissue regeneration (GTR) versus sham operation was evaluated. Base-line information, including probing pocket depth (PD) and clinical attachment level (CAL) measurements, was recorded after completion of the hygienic phase. Eleven experimental and six control furcations, randomly assigned, are included in this report. The furcations were surgically exposed, using a flap approach and the areas were debrided. On the experimental teeth, Gore-Tex periodontal material was adapted and sutured, using a suspensory suture. The flaps were then sutured tightly, assuring complete coverage to the material. For 1 month all patients were seen weekly and rinsed their mouths with an 0.12% chlorhexidine solution daily. After 4 to 6 weeks the Gore-Tex membranes were removed. Clinical measurements were repeated at 3 and 6 months following surgery. Changes from baseline in PD and CAL were calculated for each case. Results indicated that PD measurements were reduced by both procedures, but the reduction was better for GTR at 3 and 6 months. At six months the test sites showed 2.8 +/- 1.0 mm pocket reduction, while the control sites showed an average of 1.6 +/- 0.9 mm reduction in pocket depth. CAL recordings were improved by both treatments, but were better for GTR at 6 months, with an average gain in CAL of 1.8 mm for the GTR and 0.6 mm for the controls. These cases in which GTR was compared to sham-operated controls indicate that GTR can improve the response to therapy of Class II furcation defects.

Adult↗

PubMed1989

[Guided tissue regeneration in degree III furcation involved teeth].

Present investigation was designed to evaluate the regenerative potential of the periodontal ligament tissue in degree III furcation defects. The upper 2. and 3. premolar teeth of 3 dogs were used. Periodontal breakdown was induced around the teeth by experimental periodontitis model. After the breakdown occurred, mucoperiostal flaps were elevated and granulation tissue removed. The roots were curretted and cementum of the periodontitis involved parts of the roots was removed. The resorbable material was trimmed to approximate size needed to cover the root surfaces. The material provisionally adapted to the both buccal and palatinal root surfaces and flaps were sutured. After 42 days of post operative period histological examination of experimental and control groups showed that chances of obtaining new connective tissue attachment may be enhanced in treatment of Cl III furcation defect by Guided Tissue Regeneration.

Animals↗

PubMed2000

Treatment of Class II furcations with autogenous bone grafts and e-PTFE membranes.

This article reports a successful clinical regimen of treatment for the Class II furcation defect. Twenty-eight patients with molar teeth demonstrating Class II furcations were treated with regenerative therapy with the goal of regenerating lost interradicular periodontium. The treatment selected included scaling and root planing, surgical flap design that would enable the flap to completely cover the surgical site, complete enucleation of granulation tissue, tetracycline root conditioning, a particulate autogenous bone graft, and an expanded polytetrafluoroethylene (e-PTFE) membrane. Of the twenty-eight consecutive patients treated, twenty-five demonstrated no postoperative clinical evidence of furcation invasion, for a success rate of 89%. Eleven sites were reopened 8 to 9 months postsurgical and presented complete furcation fill with a hard, bone-like tissue. Three teeth were judged to be failures because clinical assessment revealed persistent furcation invasion. The absence of histologic evidence precludes the presumption that complete periodontal regeneration occurred.

Anti-Bacterial Agents↗

PubMed2000

New clinical materials and techniques in guided tissue regeneration.

AIM: To review the evidence on using Guided Tissue Regeneration (GTR) techniques and materials in various clinical circumstances. METHOD: Literature review. MAIN OUTCOME MEASURES: The success of GTR techniques and materials in halting or reversing the destruction of tooth attachment apparatus caused by progressive periodontal disease. RESULTS: GTR and osseous grafting are the two techniques with the most clinical and histological documentation of periodontal regeneration. CONCLUSIONS: GTR materials, whether non-resorbable or bioabsorbable, give similar clinical results. GTR procedures have been demonstrated to be clinically effective in treating infrabony osseous defects, recession defects, preserving alveolar bone in recent extraction sites and in some types of furcation defects. GTR procedures are technique sensitive and are adversely affected by poor home oral hygiene care, poor follow-up professional maintenance care and smoking.

Alveolar Bone Loss↗

PubMed1998

Regenerative periodontal surgery with non-resorbable and biodegradable barriers: results after 24 months.

The aim of the present study was to compare the effects of guided tissue regeneration (GTR) with non-resorbable (ePTFE) and biodegradable barriers (Polyglactin 910). 23 patients provided 29 pairs of similar contralateral periodontal defects (12 pairs of interproximal intrabony lesions, 11 pairs of degree II and 6 pairs of degree III furcation defects). Each defect was randomly assigned to treatment with either non-resorbable (control [c]) or biodegradable (test [t]) devices. At baseline, 6, 12, 18, and 24 months after surgery, clinical measurements (PlI, GI, PPD, PAL-V, PAL-H) were performed. Standardized radiographs were obtained at baseline 12 and 24 months postsurgically. On the radiographs, the linear distances from the cemento-enamel junction (CEJ) to the alveolar crest (AC) and from the CEJ to bottom of the bony defect (BD) were measured using a computer-assisted analysing method (LMSRT). Both treatments revealed a significant (p<0.05) PPD reduction [all defects: -2.97 +/- 1.90 mm (t), -2.21 +/- 1.73 mm (c); intrabony defects: -4.00 +/- 1.96 mm (t), -3.00 +/- 1.87 mm (c); degree II furcations: -2.67 +/- 0.97 mm (t), -2.08 +/- 1.54 mm (c)], PAL-V gain [all defects: 2.02 +/- 1.83 mm (t), 1.18 mm +/- 1.50 (c); intrabony defects: 3.45 +/- 1.48 mm (t), 1.95 +/- 1.64 mm (c); degree II furcations: 1.33 +/- 0.94 mm (t), 0.92 +/- 1.47 mm (c)], PAL-H gain [degree II furcations: 2.22 +/- 0.94 mm (t), 1.86 +/- 0.60 mm (c)], and radiographic changes [CEJ-AC: -0.56 +/- 1.98 mm (t), -0.06 +/- 1.19 mm (c); CEJ-BD: 2.10 +/- 1.92 mm (t), 1.24 +/- 2.04 mm (c)] after 24 months. For degree III furcations, neither statistically significant PPD reduction nor PAL-V gain was observed. Similar clinical and radiographic results were found 12 and 24 months after surgical treatment using either non-resorbable or biodegradable barriers. More favorable results concerning PAL-V gain in interproximal intrabony defects could be observed with biodegradable barriers after 24 months than using nonresorbable membranes. Whereas interproximal intrabony lesions and degree II furcation defects responded favorably to GTR therapy, through-and-through furcations must be looked upon as a contraindication for this regenerative technique. Based on the results of the present study, the use of biodegradable barriers in GTR may be recommended and, thereby, a surgical re-entry to remove nonresorbable barriers can be avoided.

Adult↗

PubMed1999

Treatment of Class II furcation lesions using an autogenous periosteal barrier.

Over the last two decades, guided tissue regeneration has achieved significant advances in periodontal healing that confirm the efficacy of periodontal regeneration. Several types of barriers have been utilized to apply this principle to periodontal wound healing. The objective of this article is to review the literature and principles of guided periodontal tissue regeneration (GPTR) in the treatment of Class II furcation defects and to describe a surgical technique that utilizes the neighboring periosteum of the furcation lesion as a barrier for the clinical application of GPTR.

Adult↗

PubMedDate not supplied

Clinical evaluation of guided tissue regeneration procedure in the treatment of grade II mandibular molar furcations.

The management of furcation defects remains a challenge in periodontal therapy, Traditionally, furcation therapy involved scaling, rootplaning, furcation plasty and resective techniques. The purpose of this study was to clinically evaluate the potential of guided tissue regeneration in the treatment of mandibular molar grade II furcations using a nonresorbable barrier, TefGen-GTR and compare it with open flap debridement alone. Ten patients with similar bilateral grade II furcation lesions participated in the study. TefGen-GTR was placed in the experimental sites while the contralateral sites served as controls. Treatment effects were evaluated at six months reentry. Both groups showed gain in vertical and horizontal open probing attachment and defect depth reduction when compared to baseline values, with experimental sites showing statistically significant improvement over the controls. The results suggest that the nonresorbable Teflon barrier, TefGen-GTR, may be used as an alternative for treatment of grade II furcation invasions.

Adult↗

PubMed2000

Improved closure rate of Class III furcations using a layered GTR technique.

In this study, 24 furcation defects in 12 patients were treated by either (1) a polylactide resorbable membrane (Guidor) plus a polyglactin mesh (Vicryl) and demineralized freeze-dried bone allograft (DFDBA), or (2) a polylactide resorbable membrane and DFDBA. All defects were reentered after 9 months. Class III furcations closed 66% of the time when treated by the first method, while the closure rate was only 33% when treated by the second method (no polyglactin mesh). Defects with a vertical opening of < or = 4 mm closed 74% of the time, while those with vertical openings > 4 mm closed only 11% of the time.

Absorbable Implants↗

PubMed2004

Morphometric analysis of the furcation anatomy of mandibular molars.

BACKGROUND: Successful treatment of molar furcation defects remains a challenge in clinical practice. Knowledge of anatomic factors facilitates predictable management of furcation involvement lesions. The degree of success in managing furcation involvement is inversely related to the horizontal probing depth. The depth of the horizontal component of attachment loss can vary depending on the external tooth-surface reference points used. However, the anatomical factors affecting horizontal component of attachment loss have not been previously assessed. Therefore, this study determined the bucco-lingual measurements of the cemento-enamel junction and the mesial and distal roots and at the level of root separation. METHODS: One hundred extracted permanent human mandibular first (N = 50) and second (N = 50) molars were studied. Four horizontal bucco-lingual widths were measured with calibrated calipers: 1) furcation entrance/roof (FE); 2) cemento-enamel junction level (CEJ); 3) mesial root width (MRW); and 4) distal root width (DRW). RESULTS: The mean widths at FE, CEJ, MRW, and DRW were, respectively, 5.53 +/- 0.45 mm, 8.71 +/- 0.54 mm, 8.57 +/- 0.54 mm, and 7.97 +/- 0.65 mm in the first molars and 5.61 +/- 0.65 mm, 8.40 +/- 0.65 mm, 7.95 +/- 0.88 mm, and 7.16 +/- 0.84 mm in the second molars. Analysis of variance revealed significant differences between FE and the other variables tested. The results showed that the bucco-lingual width of the furcation roof is considerably shorter than the MRW and DRW. The difference in the mean bucco-lingual dimension between FE and the other measurements occurred in all teeth evaluated and varied between 0.7 and 4.30 mm. CONCLUSIONS: Our findings demonstrate that clinical measurements of horizontal probing depth that use the external surfaces of roots as reference points overestimate the true anatomical component of furcation involvement in mandibular molars. Conversely, positive treatment outcomes in these teeth may be underestimated. This has implications not only for clinical practice but also for clinical research studies evaluating treatment outcomes.

Furcation Defects↗