Kombinált terápiás eljárások hatása a parodontalis vertikális csontdefektusok regeneratív sebészetében = Effect of combined therapeutical methods on healing of intrabony defects in regenerative periodontal surgery

A parodontalis szövetek gyógyulásának és regenerációjának elősegítésére számos módszer áll rendelkezésre az intraossealis defektusok sebészi kezelése során. A kombinált regeneratív eljárások alkalmazásának fő javallata a csontlaesiók kiterjedése és morfológiája. Az értekezés hat tanulmánya különféle membránok, csontpótló anyagok, zománc mátrixderivátumok és egy növekedési faktorokat tartalmazó autológ adjuváns kombinációinak gyógyulásra történő klinikai hatását vizsgálja parodontalis csontdefektusok esetében. Szintetikus, xenogén és autológ anyagokat használtunk a vizsgálatok során. A tanulmányozott teszt- és kontrollcsoportokban az irányított szövetregenerációhoz (GTR) használt mechanikai barriereket (politetrafluoroetilén és kollagénmembránok), a biológiai barrierként használt zománc mátrixproteineket (EMD), szintetikus (β-TCP) és xenogén (NBM) csontpótlókat, valamint vérlemezkében gazdag plazmát (PRP) kombináltunk. A fő klinikai paraméter a klinikai tapadásszint (CAL), a másodlagos változó pedig a tasakmélység (PPD) volt, ezek értékeit preoperatíve, majd egy év után regisztráltuk. Az eredmények összegzése és a statisztikai értékelések a következő megállapításokhoz vezettek: a) Mind a tizenegy regeneratív módszer (köztük tíz kombinált) szignifikáns CAL-növekedéshez és PPD-csökkenéshez vezetett. b) A teszt- és a kontrollcsoportokban regisztrált értékek közti különbség nem volt statisztikailag szignifikáns β-TCP vagy NBM és EMD együttes alkalmazása, illetve PRP + GTR és GTR-rel történő kombinált alkalmazásuk során. c) Négy vizsgálat igazolta, hogy a PRP hozzáadása a graftokhoz nem növelte szignifikánsan a pozitív klinikai paraméterek értékeit, a membrán és a graft típusától függetlenül. d) A klinikai változók szempontjából nem járt előnnyel a vérlemezkében gazdag plazma polipeptid fehérjéinek hozzáadása a természetes csontásványhoz. e) A vérlemezkében gazdag plazmapolipeptid fehérjéi nem növelték a zománc mátrixproteinek regeneratív hatását. Végeredményben, a parodontalis sebész választását befolyásoló tényezők a fenti módszerek közül a következők: a defektus morfológiája, a páciens különböző típusú anyagokhoz való hozzáállása, a műtő fél orvosi koncepciója, a technikai lehetőségek és a parodontológus klinikai tapasztalata. | Several methods are available to enhance the healing and regeneration of periodontal tissues after surgical therapy of intrabony defects. The main indications for the use of combined regenerative procedures are the extent and morphology of the osseous lesions. The six studies of the present dissertation focused on the clinical effect of different barrier techniques, bone substitutes, enamel matrix derivatives and a growth factors containing adjuvant used in various combinations on the healing of severe periodontal intrabony impairments. Synthetic, xenogenetic and autologous materials were used in these randomized clinical studies. Mechanical barriers (polytetrafluoroethylene and collagen membranes) for GTR, biological barriers/enamel matrix proteins (EMD), synthetic (β-TCP) and xenogeneic (NBM) bone grafts and autologous platelet-rich plasma (PRP) were combined in the test and control groups of the trials. The main clinical variable was the clinical attachment level (CAL) and the subsidiary one was the probing pocket depth (PPD), estimated at baseline and after one year. The summation of the results after the statistical analysis takes cognizance of the followings: a) Each of the eleven regenerative methods evaluated (ten combined procedures) leads to significant CAL gain and PPD decrease. b) Using β-TCP or NBM with EMD or with PRP + GTR and GTR’s, the difference between the parameters of the test and control groups were not statistically significant. c) It was confirmed in four studies that the addition of PRP to graft materials has not increased significantly the positive outcomes independent of the type of barrier or graft. d) Adding platelet-rich plasma to natural bone mineral, no benefit was observed from the point of view of the clinical variables. e) The polypeptide proteins of the platelet-rich plasma do not enhance the clinical regenerative effect of enamel matrix proteins. In conclusion, the option of the periodontal surgeons between these methods depends mainly on the defect morphology, the patient’s approach to the different types of materials, the medical concept of the physician, the technical possibilities and the clinical experience of the periodontist

Microarchitecture of the Augmented Bone Following Sinus Elevation with an Albumin Impregnated Demineralized Freeze-Dried Bone Allograft (BoneAlbumin) versus Anorganic Bovine Bone Mineral: A Randomized Prospective Clinical, Histomorphometric, and Micro-Computed Tomography Study

Serum albumin has been identified as an endogenous protein that is integral to early bone regeneration. We hypothesized that albumin addition to allografts may result in better bone remodeling than what can be achieved with anorganic xenografts. Sinus elevations were performed at 32 sites of 18 patients with the lateral window technique. Sites either received filling with an anorganic bovine bone mineral (ABBM, BioOss, Geistlich, CH) or albumin impregnated allograft (BoneAlbumin, OrthoSera, AT). After 6-months patients received dental implants and 16 bone core biopsy samples were obtained from the ABBM filled, and 16 from the BoneAlbumin augmented sites. The biopsies were examined by histomorphometry and µCT. Percentage of the residual graft in the BoneAlbumin group was 0–12.7%, median 5.4% vs. ABBM 6.3–35.9%, median 16.9%, p < 0.05. Results of the µCT analysis showed that the microarchitecture of the augmented bone in the BoneAlbumin group resembles that of the native maxilla in morphometric parameters Trabecular Pattern Factor and Connectivity. Our data show that while ABBM successfully integrates into the newly formed bone tissue as persisting particles, BoneAlbumin is underway towards complete remodeling with new bone closely resembling that of the intact maxilla. Serum albumin has been identified as an endogenous protein that is integral to early bone regeneration. We hypothesized that albumin addition to allografts may result in better bone remodeling than what can be achieved with anorganic xenografts. Sinus elevations were performed at 32 sites of 18 patients with the lateral window technique. Sites either received filling with an anorganic bovine bone mineral (ABBM, BioOss, Geistlich, CH) or albumin impregnated allograft (BoneAlbumin, OrthoSera, AT). After 6-months patients received dental implants and 16 bone core biopsy samples were obtained from the ABBM filled, and 16 from the BoneAlbumin augmented sites. The biopsies were examined by histomorphometry and microCT. Percentage of the residual graft in the BoneAlbumin group was 0-12.7%, median 5.4% vs. ABBM 6.3-35.9%, median 16.9%, p < 0.05. Results of the microCT analysis showed that the microarchitecture of the augmented bone in the BoneAlbumin group resembles that of the native maxilla in morphometric parameters Trabecular Pattern Factor and Connectivity. Our data show that while ABBM successfully integrates into the newly formed bone tissue as persisting particles, BoneAlbumin is underway towards complete remodeling with new bone closely resembling that of the intact maxilla

Effects of platelet rich plasma (PRP) on human gingival fibroblast, osteoblast and periodontal ligament cell behaviour

The use of platelet rich plasma (PRP, GLO) has been used as an adjunct to various regenerative dental procedures. The aim of the present study was to characterize the influence of PRP on human gingival fibroblasts, periodontal ligament (PDL) cells and osteoblast cell behavior in vitro

Histological Examination of Retrieved ePTFE Membranes Following Regenerative Surgery of Intrabony Defects Treated with Platelet-rich Plasma and Bone Substitutes.

PURPOSE Regenerative periodontal therapy using platelet-rich plasma (PRP) and bone substitutes with guided tissue regeneration (GTR) have been proposed as a therapeutic method to enhance the outcome of regenerative surgery. This includes light microscopic evaluation of retrieved ePTFE membranes to assess formation of new connective tissue attachment, and following the regeneration process. The objectives of this study were to evaluate the histological findings of retrieved ePTFE membranes using PRP and bone substitutes, the effect of PRP on graft materials, and the correlation of the findings with the clinical outcomes. MATERIALS AND METHODS Seventy-two (72) patients with chronic periodontitis, each of whom had one deep intrabony defect, were randomly included in two studies and treated using the same type of membrane and different bone substitutes. In the first study, 17 cases were treated with a natural bone mineral and a non-resorbable membrane (NBM + GTR), and 17 cases were treated with PRP + NBM + GTR. In the second study, 19 patients were treated with β-tricalcium phosphate and a non-resorbable membrane (β-TCP + GTR), and 19 patients were treated with PRP + β-TCP + GTR. In both studies, tissue integration of the retrieved ePTFE membranes and attached remnants were evaluated histologically. RESULTS Histological scores showed that membranes combined with NBM are better integrated than membranes combined with β-TCP; the difference between the two decreased with the addition of PRP. The application of PRP had no significant effect on the quality of membrane integration combined with NBM, whilst significantly improving the integration quality when combined with β-TCP. No correlations were detected between the histological scores and the clinical attachment level (CAL) gain in any of the groups. CONCLUSIONS The present results indicate that: a) application of β-TCP and PRP may enhance membrane integration and periodontal healing, and b) histological examination of retrieved membranes may provide valuable additional information with regard to the clinical findings

Vérlemezkében gazdag fibrinnel kezelt parodontalis csontdefektusok gyógyulásának értékelése

Az autológ vérlemezke-koncentrátumok az orvoslás egyre több területén kerülnek alkalmazásra. A vérlemezkében gazdag fibrin, ebben a kategóriában, az adott terápiás lehetőségek közül a legaktuálisabb. Előnyei, hogy alvadásgátló hozzáadása nélkül preparálható, egy centrifugálást igényel, és több formában alkalmazható. A vérlemezkében gazdag fibrin újabb generációja további lehetőségeket teremthet, így a parodontalis sebgyógyulás terén is. Az esetek bemutatásának célja parodontalis intraossealis csontdefektusok gyógyulásának rövid távú klinikai értékelése autológ vérlemezkében gazdag készítménnyel (advanced platelet-rich fibrin) történt kezelést követően. A bemutatott eseteknél preoperatíven, majd 6 hónappal a műtétet követően történt kiértékelés a következő parodontológiai paraméterek rögzítésével: tasakszondázási mélység (probing depth), illetve klinikai tapadási szint (clinical attachment level). Teljes vastagságú lebenyek képzését követően a csontdefektus kürettálása, illetve gyökérsimítás történt, majd a preoperatíven preparált, vérlemezkében gazdag fibrin applikálására került sor, melyet sebzárás követett. Fél évvel a sebészi beavatkozás után a szondázási mélység csökkenése és a klinikai tapadási nívó növekedése volt tapasztalható. Bemutatott eseteinknél a vérlemezkében gazdag fibrin applikációja pozitív klinikai eredményeket mutatott a parodontalis sebgyógyulás tekintetében. A vérlemezkében gazdag fibrinnek mint humán autológ preparátumnak a használata elősegítheti a parodontalis defektusok sikeres kezelését

Bacterial Contamination of ePTFE Membranes Following Regenerative Surgery of Intrabony Defects Treated with Platelet-rich Plasma and Natural Bone Mineral.

PURPOSE The rationale of using platelet-rich plasma (PRP) in reconstructive periodontal surgery is to amplify or accelerate the wound healing through the growth factors contained in platelets. On the other hand, bacterial colonisation of membranes may negatively affect the healing process. The aim of this study was to evaluate bacterial contamination of non-bio-resorbable membranes (ePTFE) used for regenerative periodontal therapy of intrabony defects and the clinical attachment level (CAL) gain with or without PRP. MATERIALS AND METHODS Seventeen patients were treated with a natural bone mineral (NBM) and guided tissue regeneration (GTR) with an ePTFE membrane (NBM + GTR group; ie, control group), while in another 17 patients PRP was additionally applied (NBM + PRP + GTR group; ie, test group). Furthermore, the retrieved membranes were analysed for the presence of periodontopathogens and data were related to the gain of clinical attachment. In addition, the in vitro sensitivity of selected microbes to PRP was checked by using agar diffusion test. RESULTS Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis were not detected in the PRP group whereas in the controls A. actinomycetemcomitans was detected in five patients (p = 0.022) and P. gingivalis in two cases (difference not statistically significant, p = 0.242). Detection of A. actinomycetemcomitans was not associated with less CAL gain. If the samples were positively tested for Prevotella intermedia/nigrescens and/or P. gingivalis, the CAL gains were lower compared with the negative samples (p = 0.002). PRP did not show any inhibitory effect on bacterial growth in vitro. CONCLUSION Within their limits, the present results appear to suggest that the presence of P. intermedia/nigrescens and/or P. gingivalis at the regenerated site may negatively influence the clinical outcomes. However, the potential influence of PRP on bacterial colonisation and the impact on the clinical outcome is still unclear and remains to be elucidated

Microarchitectural study of the augmented bone following ridge preservation with a porcine xenograft and a collagen membrane: preliminary report of a prospective clinical, histological, and micro-computed tomography analysis.

Socket preservation using a combination of porcine xenograft and collagen membrane maintains the vertical and horizontal dimensions of the ridge. The aim of this study was to evaluate the microarchitecture of the grafted area by histological analysis and micro-computed tomography. Patients in the test group (group 1; nine patients) underwent socket preservation, while the sockets in the control group (group 2; eight patients) were allowed to heal without preservation. After a 6-month healing period, bone core biopsy samples were obtained and implants were placed in the augmented sites in the test group (12 biopsy samples) and the non-augmented sockets of the control group (12 biopsy samples). Analysis of the biopsy samples obtained from group 1 revealed that particles of the graft were surrounded by newly formed bone in eight cases and by granulation tissue in four cases. Micromorphometric data showed statistically significant differences in several parameters between the microarchitecture of the native bone and the newly formed bone within the augmented sites, which suggests that the xenograft particles interfere with the bony healing of the alveoli