Rapid Search Topics
Technique
Autografts
Historically, what was considered the gold standard for grafting? What are the different sources for intraoral grafting? How does this material perform clinically and histologically? Are there limitations to obtaining intraoral autogenous bone graft material? Are these same techniques still utilized today?
Bone swaging
Ewen SJ. Bone swaging. J. Periodontol. 36:57-63, 1965.
Autograft
Ross SE, Malamed EH, Amsterdam M. The contiguous autogenous transplant - its rationale, indications and technique. Periodontics 4:246-255, 1966.
Ross SE, Cohen DW. The fate of a free osseous tissue autograft - a clinical and histologic case report. Periodontics 6:145-151, 1968.
Osseous coagulum
Robinson RE. Osseous coagulum for bone induction. J Periodontol 40:503-510, 1969.
Froum SJ, Thaler R, Scopp IW, Stahl SS. Osseous autografts: II. Histological responses. J. Periodontol. 46:656-661, 1975
Froum SJ, et al. Osseous autografts. III. Comparison of osseous coagulum-bone blend implants with open curettage. J. Periodontol. 47:287-294, 1976.
Push up technique
Rivault AF, et al. Autogenous bone grafts: osseous coagulum and osseous retrograde procedures in primates. J. Periodontol. 42:787-796, 1971.
Cancellous bone and marrow
Rosenberg MM. Free osseous tissue autografts as a predictable procedure. J Periodontol. 42: 195-209, 1971.
Healing extraction sockets (from LR 51): Halliday 1969, Evian 1982, Passanezi 1989
What are the sources for extraoral grafting? What are the benefits/drawbacks to this procedure? Can anything be done to minimize the negative side effects of How does this graft material behave in the recipient site both clinically and histologically?
Schallhorn RG, et al. Iliac transplants in periodontal therapy. J. Periodontol. 41:566-580, 1970.
Schallhorn RG. Postoperative problems associated with iliac transplants. J. Periodontol. 43:3-9, 1972.
Dragoo MR, Sullivan HC. A clinical and histologic evaluation of autogenous iliac bone grafts in humans. I. Wound healing - 2-8 months. J Periodontol 44:599-613,1973
Dragoo MR, Sullivan HC. A clinical and histologic evaluation of autogenous iliac bone grafts in humans. II. External root resorption. J. Periodontol. 44:614-625,1973.
Does grafting with autogenous in infrabony defects work? Are they stable over time?
Nabers C. Long-term results of autogenous bone grafts. Int J Perio Rest Dent 4(3):51-67, 1984.
Evans RL. A clinical and histologic observation of the healing of an intrabony lesion. Int J Perio Rest Dent. 1(2):21-26,1981.
Langer B, et al. Early reentry procedure - Part II - a five year histologic evaluation. J. Periodontol. 52:135-139, 1981
Bowers GM, Schallhorn RG, Mellonig JT. Histologic evaluation of new attachment in human Intrabony defects. A literature review. J. Periodontol. 53:509-514, 1982. (Review)
What sorts of manipulations/modifications have been proposed for autogenous bone graft material? Do they improve success?
Bisch FC, Hanson BS, Best NH, Craft DW. The effect of cold storage and endotoxin challenge on osteoblast viability and interleukin-6 production. J Periodontol Res 33:150-155, 1998
Renvert S, Garrett S, Schallhorn R, Egelberg J. Healing after treatment of periodontal intraosseous defects. III. Effect of osseous grafting and citric acid conditioning. J. Clin. Periodontol. 12:441-455, 1985
Stahl SS, et al. Healing responses of human intraosseous lesions following the use of debridement, grafting and citric acid root treatment. II. Clinical and histologic observations: One year postsurgery. J. Periodontol. 54:325-338, 1983.
Kingsmill VJ, Boyde A, Jones SJ. The resorption of vital and devitalized bone in vitro: Significance for bone grafts. Calcif Tissue Int 64:252-256,1999.
Historically, what was considered the gold standard for grafting? What are the different sources for intraoral grafting? How does this material perform clinically and histologically? Are there limitations to obtaining intraoral autogenous bone graft material? Are these same techniques still utilized today?
Ewen, 1965 ARTICLE
P: Discuss bone swaging techniques
M&M: Discussion of 4 different techniques.
General method: Defect depth, width, and extent are evaluated by both probing and radiograph. Calculus, debris, overhangs, and crevicular soft tissue are removed and SRP is performed. Incision is made next to the defect. Chisel inserted into incision. Mallet blows, moves bone against root surface. Antibiotics usually prescribed.
Direct Approach: Without incision. Debris removed, scaling and root planning, wood stick placed directly against the overlying soft tissues and given several sharp blows then place surgical chisel interproximal to finish pushing bone into space.
Gingivectomy approach: Narrow exploratory gingivectomy performed, debribe, place surgical chisel against bony wall and swag bone.
Flap approach: single incision, raise flap, remove debris, place swager against bone inside the flap, move bone over, and suture flap.
R: All showed success in PD reduction. Healing was within normal limit.
BL: Bone swaging can be an option to consider when trying eradicating periodontal defects. By using a mallet & chisel to force bony walls of defects against teeth, it obliterates defects, and acts as an autogenous graft.
Ross et al, 1966 ARTICLE
Purpose: To present the contiguous autogenous transplant technique.
Disc: Authors described this technique for the treatment of one-wall infrabony pockets utilizing osseous tissue from an edentulous area.
This is similar approach described by Ewen and colleagues in 1958. Authors prefer term contiguous autogenous transplant because term proposed by Ewen, swaging, refers to the process of remolding objects by means of pressure.
Technique:
- Initial preparation. Temporary stabilization, Occlusal adjustment if needed.
- Internally bevel incisions were made on buccal & palatal and then vertical releasing incisions.
- Split thickness flap on buccal and full thickness flap on palatal aspects. Sufficient periosteum is removed from the buccal alveolar crest to permit adequate exposure of alveolar process
- Chisel placed 2-3 mm mesially to the defect at the centre of the alveolar ridge in a bucco-lingual direction. The graft was partially fractured at its base and allows the bone to approximate the root.
- The buccal flap is repositioned to the height of the alveolar crest. The palatal flap is replaced.
The possibilities of repair are 1) ankylosis 2) reattachment and 3) transplant resorption utilized for formation of new bone.
Factors that contribute with the movement of the graft were: a) proximity of the sinus or the inferior alveolar canal, b) width of graft, so complete fractures does not occur, c) adequate access to donor & recipient sites, d) approximation of tissue edges.
BL: Description of the contiguous autogenous technique, which is useful to treat one-wall infrabony, pockets proximal to edentulous area or septum
Ross and Cohen, 1968 ARTICLE
Purpose: Case report to describe the fate of a free osseous tissue autograft in a human infrabony defect, which was studied for 8 months & then removed for histologic evaluation.
M&M: 51 yr old male with infrabony pocket on mesial of #22. Occlusal adjustment & S/RP performed on entire mouth and re-eval at 1 mth. FTF, root planed, granulomatous tissue removed, combination defect (3-2-1 wall), grafted with autogenous (cortical and cancellous) bone from edentulous area distal to #20. At 8 months x-rays were taken with silver point in sulcus. Tooth was extracted and block section was radiographed prior to and histo examination.
R /Disc: Histo showed base of sulcus was more coronal to the alveolar crest at 8 mths . There was PDL, thick new cellular CEM, & bone coronal to ref notch. PDL fibers were parallel to CEM. New bone was found around autograft. New bone had periphery of osteoid & layer of osteoblasts. Authors suggest that autograft may still be remodeling up to 2 yrs after transplantation.
BL: New attachment did occur coronal to original base of pocket. One of the early articles on new attachment formation using autogenous bone.
Robinson, 1969 ARTICLE
Purpose: To describe a technique of obtaining particles of bone to be used as grafting material and show results from operations from 3-24 months.
Discussion: Cortical bone is obtained from areas where osseous correction is required (lingual ridges, exostoses, management of osseous defects), or from edentulous areas. Round carbide bur with slow speed is used (25,000-30,000rpm). Bone dust is obtained using pt’s own fluid (blood and saliva) as the lubricant and coolant.( If the surgical field is dry, the accumulated bone dust must be coated or immersed in blood as soon as possible. It can be stored at the base of the flap or interproximally until enough has accumulated. The coagulum is packed into the defect and compressed with cotton gauze. Author recommends, “overpacking” to provide a biological outer surface bandage, suturing, foil, pack, post op care reviewed, TTC 250mg q 6 hrs x 4 days. Weekly supragingival cleaning during the healing period is desirable. Reports on 6 cases with re-entry from 3-24 months showing bone fill of 2-3 wall defects and one furcation involvement.
Autogenous bone is a good source to induce osteogenesis, and harvesting intraorally is easier than extraoral. Author states this technique seems promising for treatment of 1, 2 & 3-wall defects and perhaps furcation defects.
BL: Bone particles from osteoplasty can be mixed with pt’s blood and used as an autograft (mix of cortical and cancellous). The smaller the particle size, the less the chance for sequestration
Froum, 1975 ARTICLE
P: To observe osseous coagulum-bone blend grafts in human infrabony defects, by looking at histologic findings from the graft sites.
M+M: Three patients were observed in this study. Initial therapy included oral hygiene instructions, SRP, and occlusal adjustment. Pre and post-surgery measurements of PDs, depth of defect with stent and radiographs were taken. Defects were treated using the osseous coagulum-bone blend grafts. Sites were surgically removed in block sections at 6, 9, and 13 weeks after treatment and prepared for histology.
R:
Case Defect PD Post-op PD Osseous Fill Block Section
#1 (#24) 2-wall 7.2mm 3.9 mm 3.4 mm 13 wks
#2 (#7) 1-wall 8.1mm 4.0 mm 2.6 mm 6 wks
#3 (#25) 1-2-wall 8.0mm 2.2 mm 2.4 mm 9 wks
Osteogenesis was the most frequent response at the osseous walls. Most bony spicules observed within the defects were either lined by osteoblasts or both osteoid and an osteoblast lining at their borders. Resorption appeared limited. Exfoliation of the spicules was common at 6 weeks, regeneration of bone and cementum was active even at this early stage. The PDL appeared cellular. CT lined the osseous walls and the spicules. Both functionally oriented and parallel type fibers were observed. Significant amount of new cementum formed, which was present at the root surface in the area of implant. It was acellular, slightly lamellated and had formed on old cementum as well as dentin. The most active phase of bone formation was months after placement of the graft.
BL: Infrabony defects treated with osseous coagulum-bone blend grafts showed periodontal remodeling at the site of the graft in all specimens. High osteogenic activity was shown, as well as new cementum formation, and arrangement of both parallel and functionally oriented PDL fibers.
Froum 1976 ARTICLE
P: To evaluate and compare repair responses of human perio defects following open flap debridement with and without subsequent implantation of osseous coagulum (OC).
M&M: 75 sites in 28 male patients 23-64 years: 37 sites in 23 patients treated with osseous coagulum-bone blend from intra-oral sources, and 38 sites in 13 patients treated with OFD only. In 7 of the pts, both procedures were performed at different sites with similar morphology (13 sites OC/13 sites OFD). Defects were 1,2, and 3-walled. Pts received HOI, SRP, and occlusal adjustment for interferences pre-op. Splinting was performed on teeth with class III mobility. PAs were taken and stents were fabricated to take the measurements. Defect depth >2 mm. Antibiotics for 1 week. Re-entries performed 7 to 13 weeks post-op.
R:
|
OC (mean) |
OFD (mean) |
|
|
1 wall |
3.9 depth, 2.4 mm fill (62.7%) |
3.1 depth, 0.16mm fill (5.6%) |
|
2 wall |
4.2 depth, 3.2 mm fill (77.3%) |
3.0 depth, 1.0mm fill (34.3%) |
|
3 wall |
5.0 depth, 3.0 mm fill (72.4%) |
2.9 depth, 1.4mm fill (48%) |
|
Total |
4.2 depth, 3.0mm fill (70.6%) |
3.0 depth, 0.7mm fill (22%) |
|
Resorption |
0.5mm |
0.8 m |
D: These repair trends were similar within the same patient and between patients. All differences were SS (except for resorption).
BL: A significant greater fill with OC over flap debridement in 1,2, and 3-walled defects. 70% vs 22% overall. It is beneficial to graft vs OFD alone.
Cr: No standardized defects (dimensions) used for the two groups. The healing time was too short for evaluating bone regeneration. Re-entry shows bone fill but no new attachment. No perio indices, CAL, PPD recorded prior and post treatment. No info about maintenance.
Rivault 1971 ARTICLE
Purpose: To compare two techniques of autogenous bone graft: osseous coagulum and osseous retrograde (push-up technique).
Materials and methods: 4 adult rhesus monkeys were used. Each animal was operated in all four quadrants and specimens were taken at 0, 3, 7, 11, 17, 21, 30, 60, 90, 120, and 180 days and the controls at 14, 60 and 180 days.
Scaling was performed, teeth were notched on the buccal surface at the level of the gingival margin an PD was recorded. Full thickness flap was raised from distal of the 2nd molar to mesial of the cuspid. Spaces between 1st and 2nd premolar, and between 2nd premolar and 1st molar were usually selected as graft sites. Defects 3-4mm were created, with an opening on the buccal aspect and most of the times one or two root surfaces were forming parts of the walls.
At 2mm apically to the bottom of the defect selected for the “push-up” technique, a round bur was used and cortical plate was removed. Then an amalgam plugger was used and great pressure was applied in a coronal direction, so that the bone was pushed to fill the coronal defect. Particles obtained with the bur were mixed with blood and used to graft the 2nd site (osseous coagulum).
Results: No clinical differences were noted between graft and control sites.
General Histologic findings
Epithelium 0, 1, 3 Days: Intercellular edema, increased mitotic activity
7 Days: Epithelium looked thinner, keratin layer partially lost
11-180 Days: Overall picture of repair, at 17-day specimens epithelial attachment not yet completed.
Connective tissue returned to normal after 11 days except above the graft areas and the apical fenestration of the push-up defects.
Osseous Coagulum:
0,1, 3 Days: Inflammatory reaction, reached its peak at Day-3
7 Days: Top of the graft invaded by numerous undifferentiated cells
11 Days: Inflammatory cells were replaced by macrophages and polymorphonuclear leukocytes.
14 Days: Young connective tissue was formed with numerous fibroblasts. New bone forming within the graft site. Osteogenic activity most prominent along the osseous walls. Amount of new bone was decreasing from the apical towards the coronal site of the graft.
17, 21 Days: Smaller particles appeared to induce more bone formation than the larger ones.
30 Days: Decrease in cellular density. Near the crest the islands of bone had not yet fused together.
60 Days: Limits of the graft area were fading out. New PDL along the tooth surface, new cementum.
90 Days: No graft particles were found, impossible to distinguish the limits of the graft.
120 and 180 Days: Bone repair was achieved. New cortical bone appeared as dense and regular as the old one.
Push-up Bone Graft
0,1, 3, 7 Days: Graft filled with blood coagulum and concentrated on the crestal part, invaded by great number of inflammatory cells.
11 Days: Granulation tissue and capillaries invading the graft area from the coronal and apical openings.
14 Days: Important osteblastic activity in the apical part, smaller bone particles appeared to have more osteoblasts.
17 Days: Necrosis in the central part of the graft area, osteogenesis in other sites
21 Days: Most of the area filled with new bone, osteogenesis delayed in the coronal surface.
30 Days: Bone repair was advanced and new bone had been formed on the external surface of the crestal alveolar bone
60 and 90 Days: Center of the graft was well ossified but the apical and coronal area closed slowly.
120 and 180 Days: Marrow spaces still showed greater blood supply, but the graft area was difficult to delineate.
Conclusion: Connective tissue of the gingiva seems to provide an important number of capillaries and mesenchymal cells which invade the defects, so grafts should be completely covered by the flaps.
Osteogenic stimulus originates in the osseous walls of the defects as well as on the graft material. Push-up technique therefore may be detrimental to the osteogenic induction because of the fenestration created.
Size of graft particles appear to be of major importance, thin bone chips of 100 microns provided for a sooner and greater osteogenic activity than thick particles.
Greatest numbers of bone particles should be provided, but overpacking may result in delay or failure by holding up the formation of the necessary granulation tissue.
All factors of irritation to the area should be kept under control for limitation of inflammation.
Rosenberg 71 ARTICLE
Free osseous tissue autografts as a predictable procedure
Purpose: to present preoperative and postoperative evidence to support that free osseous tissue autografts can be used predictably.
Materials and methods
Proper case selection plays a vital role in determining predictability
Six cases were presented. The 3 wall defects were as deep as 12mm.
FTF elevated and defects debrided. PTF utilized when tooth position and alveolar housing were prominent, to avoid exposing dehiscences or fenestrations.
Roots were planed until surface was hard and smooth. The donor site was always intraoral.
The cortical bone harvested was discarded, only cancellous bone was utilized (harvested with hand chisels). The defects were decorticated, whenever possible.
Re-entry was performed in all but one case (no pockets) after at least one year. The Sx site was examined at re-entry, and any necessary osseous recontouring was performed.
Follow-ups were performed for different lengths of time, the longest being 4 yr and 7 mo.
No histology only clinical and radiographic evidence
Results
All defects responded favorably to the grafting procedure, although some cases required additional recontouring.
At re-entry, all grafted sites appeared to have hard bone, similar to that of its neighbouring bone, according to the author’s perception. PA x-rays were also taken to confirm the author’s observations and document the cases.
BL: Osseous autografting is a viable option in 3 wall defects and deep interproximal craters to avoid compromising tooth support.
Healing extraction sockets (from LR 51): Halliday 1969, Evian 1982, Passanezi 1989
What are the sources for extraoral grafting? What are the benefits/drawbacks to this procedure? Can anything be done to minimize the negative side effects of How does this graft material behave in the recipient site both clinically and histologically?
Schallhorn, 1970 ARTICLE
P: To assess predictability and feasibility of hemopoetic marrow transplant from iliac crest.
M&M: 182 defects (crestal, furc, 1, 2, & wide 3 wall defects) on 52 pts..PD, osseous contours, radiographs with stent, photos were all recorded. Bone biopsy needle used in post-sup iliac crest to remove cores of cancellous bone & marrow, and the wound covered w/ a Band-Aid. Core were used either frozen or not, one case of immediate placement. FTF w/ maximum tissue preservation, & defects were debrided. Cores of bone were ‘snugly over packed’ w/in defect, and flaps sutured to cover graft completely and dressed. Antibiotic’s for 2wks either tetracycline or erythromycin. Re entry @ 5-24 mos.
R:
|
Complete fill |
50% fill |
Mean increase bone ht |
|
|
Crestal/horizontal |
2.6 mm |
||
|
1-Wall defect |
11/21 |
8/21 |
3.8 mm |
|
2- Wall defect |
33/33 |
4.2 mm |
|
|
Furcation defects Cl II |
7/8 |
1/8 |
4.5 mm |
Although they yielded the lowest level of viable cells, the frozen specimens demonstrated the greatest mean bone apposition, which was believed to be due to cellular breakdown and release of an inductive substance.
There were sites of bone deposition coronal to existing bony walls, attributed to overfill
Radiographic maturation ranged from 4-24 mos- a lot of variation, 2 cases of root resorption in extra large defects w/ fresh marrow.
BL: Hip marrow implants have the potential for bony regeneration when implanted into perio defects. – The most surprising observation was the potential of iliac grafts to gain crestal height beyond pre-op margins.
Schallhorn, 1972 ARTICLE
Purpose: To identify the postoperative problems associated with iliac transplants and suggest methods of avoiding their occurrence.
Discussion: Postoperative problems fall in five categories:
Infection: It is especially important complication in osseous grafts procedures where several complication factors are present such as alveolar bone exposure, necrosis of part of the material and intramarrow penetration seeding bacteria into sites vulnerable to osteomyelitis. In spite of prophylactic antibiotic therapy, infection may occur as a result of organisms not sensitive to the antibiotic employed, premature termination of the antibiotic therapy or an altered local resistance of the host.
Sequestration: It is the most common post-op problem associated with osseous grafting procedures. It can be observed as early as the first post-op visit or several months or years following surgery. The most common type encountered is when part of the material exfoliates. Part of the bone graft becomes necrotic due to the distance from a nutrient source and bacterial contamination. Thus, overfilling technique should be avoided and removal of exposed material should be done carefully to avoid loss of considerable material undergoing reorganization attached to the exposed portion.
Varying rates of healing: Another problem associated with osseous transplants is the variable time required to assess the success or failure of the procedure. In cases requiring replacement therapy, such delays may complicate the restorative treatment plan.
Root resorption: It has been noted in human subjects treated with iliac transplants. All cases observed to date have appeared to initiate at or coronal to the bony crest rather than immediately adjacent to the bony implant. The first factor that may cause root resorption is the maintenance of viability of the marrow elements in the transplant. A second factor may be the degree of root preparation before grafting. On several cases demonstrating root resorption, extensive root planning was accomplished which presumably removed any remaining cementum at the time of surgery. A third factor may be the relative mobility of the treated tooth during the post-op healing period. There are no supportive findings.
Rapid recurrence of defect: It is disheartening for the therapist to observe a successful result to therapy deteriorate. It is important to evaluate a patient’s attitude and ability to maintain plaque control and recall program before establishing a comprehensive treatment plan.
Dragoo, 1973 ARTICLE
Purpose: The literature is conflicted with regard to incidence of root resorption following illiac crest grafts in to periodontal defects. This is a report of 4 cases of external root resorption associated w/ fresh autogenous iliac bone graft.
Result: Case 1: defect on max and mand cuspids treated with fresh autogenous iliac bone graft. Root-resorption, associated with gingival inflammation was noted at 2 months radiographically. At 4 mo, max cuspid was treated by curettage, show partial repair of resorption. Mand cusp, not tx’d, showed progression of dz toward pulp. Biopsy was taken of the mand and active repair and resorption were noted.
Case 2: Gingival inflammation associated with root resorption following fresh iliac bone graft showed at 1wk and at 3wk radiographic evidence of resorption. Thorough repeated curettage and OHI decreased inflammation and showed repair of resorption.
Case 3: pt w/ poor OH after fresh iliac bone graft, showed chronic gingival inflamm at 1 mo. Radiographic evidence apparent at 2mo. Bony sequestra was seen 6 months after sx: the tooth was removed in block and active root resorption was seen in areas adjacent to chronic ging inflammation.
Case 4: gingival inflammation and radiographic appearance at 4.5mo. area was curreted and OHI improved and at 5mo area appeared to be healthy.
Conclusion: Active resorption is associated with chronic ging inflammation. It is possible that root resorption undergoes repair by elimination of chronic inflammation by curettage and meticulous OH procedures. On the other hand, the inflamm may be the result rather than the cause of resorption.
BL: External root resorption may be associated with autogenous iliac bone graft in the presence of chronic inflammation. There may be a potential for repair of the resorptive lesion once the inflammation has been eliminated.
Mick R. Dragoo, 1973 ARTICLE
Purpose: To examine the relation between autogenous iliac bone grafts and root resorption.
Seven external root-resorption lesions were found in observation of over 250 graft sites (2.8%). These sites had all been grafted with fresh autogenous iliac bone and were documented by clinical photographs and radiographs. 4 representative cases of root resporption are described.
Case 1: 31 year old male, severe periodontitis, bony defects in a maxillary cuspid and a mandibular cuspid were treated with autogenous iliac-bone grafts. 2 months after grafting gingival inflammation was noted around these two teeth. The maxillary cuspid was curetted and at 8 months a partial repair of the resorptive lesion was evident radiographically. In contrast, the mandibular cuspid was not curetted and the root resorption progressed toward the pulp.
Case 2: 44 year old male, bony defects in the maxilla were treated with autogenous iliac bone graft. After 3 weeks gingival inflammation was noticed, root resorption was apparent on the radiographs, thorough curettage and OHI were repeated every two weeks, inflammation decreased and repair of resorption was noticed.
Case 3: Patient didn’t perform adequate oral hygiene after fresh autogenous iliac bone graft surgery, chronic inflammation and root resorption were noticed. 6 months after surgery bony sequestration was found, that could make the inflammation worse. The tooth was removed and active root resorption was seen in areas adjacent to the chronic gingival inflammation.
Case 4: 4 months after iliac bone graft surgery, gingival inflammation with root resorption, extensive curettage, OHI for plaque control, at 5 months inflammation decreased, repair of resorption.
Discussion: External root resorption is associated with chronic inflammation of the adjacent gingiva. Root resorption may undergo repair once the chronic inflammation is eliminated by curettage and meticulous oral hygiene. On the other hand, it should be mentioned that the inflammation associated with root resorption may be the result rather than the cause of the resorption. The mechanism by which resorption takes place in unknown. Early detection of root resorption following bone grafting is important.
Does grafting with autogenous in infrabony defects work? Are they stable over time?
Nabers, 1984 ARTICLE
P: A review article that presents long-term results from 6 cases of autogenous bone grafts placed into one- and two-wall defects
Disc: All cases had favorable results (up to 24 years post-op).
The grafting requirements discussed were:
1) pt’s health – no medical complication.
2) pt’s interest and understanding- should be prepared for any complications that may accompany osseous grafting (failure)
3) defect selection- osseous grafts should be limited to areas of the dentition with a favourable prognosis if the graft is to be successful.
4) occlusal adjustment – eliminate lateral stresses.
5) sterility – aseptic surgical techniques are necessary to avoid possible secondary infections.
6) initial preparation —superficial inflammation of the periodontal tissues must be eliminated by the removal of all local irritants and by pt’s daily practice of effective plaque control before sx therapy. If plaque control is not effective, grafting is doomed to failure.
7) antibiotics – a broad spectrum systemic antibiotic coverage should begin the night before the surgical procedure, and a therapeutic blood level should be maintained for 4-7 days post-op. A change in antibiotic may be indicated if post-op complications such as allergic reaction occur.
8) flap design-retain as much IPx gingiva as possible so as to secure complete closure of the IPx embrasure spaces. The inner surface of the flap should be free of granulation tissue and epithelial cells.
9) defect preparation – remove all granulation tissue.
10) root preparation – exposed root surfaces of the defect must be scaled thoroughly and root planed to eliminate all calculus , bacteria and softened root surface that may contain toxins, require up to 20-30 minutes of instrumentation.
11) vascularity—intramarrow perforation with round carbide bur.
12) graft placement—loosely pack and after bleeding fills the defect compress the material loosely with a sterile gauze and an instrument, do not overfill.
13) suturing- complete closure .
14) dressings- should be changed at 4-7 day intervals and sutures should be removed at the first dressing change. Dressings should be continued for 2-3 weeks.
15) post- dressing care – following removal of the last dressing lightly scale the teeth to remove all dressings and plaque and polish teeth. Plaque removal at 2-week intervals and then on 3-month basis. If large embrasures are present, patient should use interdental brush.
16) post-op radiographs – 1,3,6,9,and 12 months. In 3 months, it becomes evident that the graft is being replaced by bone, and the graft may no longer be visible at 6-9 months. (Too frequent)
17) supplemental treatment – rarely 100% bone fill, may need a secondary procedure. The improvement in the defect may make it possible to correct the residual defect by osteoplasty and ostectomy.
18) open contacts need to be addressed so not a food trap,
19) maintenance -- Do not probe graft for 6-9 months
20) keeping pt informed about what you plan to do, what you did and what progress has occurred.
P: A case report on the history and treatment of a periodontal lesion that extended to and beyond the apex of the lower left 2nd molar.
D: Patient presented with a 12 mm pocket on the mesial root with a history of 5 years closed curettage therapy. Pulp testing revealed inconclusive evidence of pulp pathosis. Combination 2-3 wall osseous defect was treated by flap reflection, debridement, RP and was grafted with autogenous bone. At 6 months x-ray revealed blunted root apex and bone fill. PD was 3 mm. At 20 months, re-entry was done and bone fill seen. Tooth was removed in block section 24 months after the bone graft procedure, author does not say why. Histological evaluation showed evidence of new cementum, bone, and PDL in area previously destroyed by periodontal disease (no notches placed). An accessory pulp canal was seen extending to the side of the osseous defect, but the mesial and distal pulps were vital. Author felt formation of new cementum.at the accessory canal exit which confirmed vitality of the pulp at the canal.
BL: In those instances where there is inconclusive evidence of pulp pathosis in presence of periodontal lesions, the treatment of periodontal defect should be done first before undergoing irreversible endodontic therapy.
Langer 1981 ARTICLE
P: To assess histologically the integrity of an autogenous bone graft which had appeared clinically successful at early re-entry 5 years previously.
M&M: A mandibular left 2nd premolar with a circumferential 3-walled intraosseous defect of 8mm in depth along the distal aspect of the tooth was treated with an autogenous bone graft from the tuberosity. Flaps were sutured together leaving 2-3mm of the proximal surface exposed. Dressing was placed directly over the site. The pt was prescribed 1g/day of TTC for 2 weeks. Re-entry was performed 3 months later, at which time the success of the graft was determined because they were unable to probe the graft area (even though still only partially mineralized). The tooth subsequently had endodontic treatment followed by a post & crown. CAL were recorded at recall appointments via radiographic and clinical observations. 5 years later, the pt presented with a labial root fracture (the distal surface appeared uninvolved clinically and rx) and a block section was removed for histology.
R/Disc: Histo showed endo treated root with inflamed granulation tissue and epit proliferation along buccal root surface. Regeneration of bone, PDL (functionally oriented), and cementum were observed. Necrotic bone spicules within areas of otherwise viable periodontium suggested residue of the bone that had not been resorbed and replaced by new bone (after 5 years).
Early re-entry does not appear to significantly compromise the maturation and success of a graft.
BL: New bone, PDL and cementum can form from autogenous grafts. Some of the bony material may never be totally resorbed and replaced with viable osseous tissue, but may remain in the periosteum indefinitely.
Bowers 1982 ARTICLE
Purpose: Review of studies of human biopsies of intrabony defects to assemble information clinical and histologic documentation of healing.
Materials and methods: 123 human biopsies and 40 extracted teeth processed for histologic analysis are included. Bone grafting techniques used in 94/123 specimens, and the 40 extracted teeth were evaluated for new cementum formation.
Results: Bone formation: 87% of the cases showed new bone formation (0-5mm). Bone particles were observed up to 5 years except for the defects grafted with autogenous or allogeneic iliac marrow, which was rapidly replaced by CT and particles were not observed in the 14 and 24 days biopsies.
Cementum: New cementum formation was noted in 85% of the cases, ranged from 0-3.8mm (evaluated both clinically and histologically). New cementum was reported over old cementum, dentin, cemental notches and resorption areas. In most cases cementogenesis and osteogenesis progressed coronally to approximately the same distances, but in the funnel – shaped lesions cementogenesis did not follow. Most of the times root resorption was observed it was considered to be slight.
Periodontal ligament: Most authors reported the eventual formation of a functionally oriented periodontal ligament at post – operative times ranging from 13 weeks to 8 months. Inflammation was minimal, localized in the coronal part and associated with calculus or plaque accumulation.
Junctional epithelium: Junctional epithelium was observed apicacementogenesis.
l to the alveolar crest in 19% of the grafted cases (0.9-4.0mm) and in all 3 cases in which open flap curettage was performed (1.6-4.2mm).
Graft vs nongraft: Hiatt et al. demonstrated new cementum in 84% of grafted and in 33% of non-grafted biopsies, new bone in 85% of grafted and 33% of non-grafted. Listgarten and Rosenberg as well as Moomaw reported that new attachment was greater in grafted experimental defects compared to controls. There is greater possibility for long junctional epithelium formation in non-grafted sites.
Conclusion: 1) New attachment is possible on root surfaces denuded by periodontal disease.
2) It is more likely to occur in grafted sites, bone-grafting materials promote osteogenesis and 3) Ne bone formation can occur sub- and supracrestally.
4) New cementum will most likely be cellular.
5) PDL fibers initially may be parallel to the root but then will gain a functional orientation.
6) Junctional epithelium may extend below the alveolar crest.
7) Autogenous and allogeneic iliac marrow are rapidly replaced by connective tissue, calcified bone graft particles may observed as long as 5 years.
8) Extensive root resorption occurs infrequently.
What sorts of manipulations/modifications have been proposed for autogenous bone graft material? Do they improve success?
Bisch 98 ARTICLE
The effects of cold storage and endotoxin challenge on osteoblast viability and interleukin-6 production
Purpose: to evaluate the effect of 1-14 days of cold storage on bone cell cultures as assessed through alkaline phosphatase activity and IL-6 secretion.
Materials and methods
Cells were isolated from newborn mice calvaria. Culture plates with cells placed in cold storage (4ºC) for 1-14 days then cultures were incubated at 5% CO2 and 37ºC for 1-20 days. Replicate plates were challenged with endotoxin (Escherichia coli lipopolysaccharide) for 4 days.
Cells evaluated daily for alkaline phosphatase and IL-6 production. Positive control cells placed in incubator immediately after harvesting. Negative control cells were fibroblasts.
Results
Microscopically monitoring viability indicated that bone cell cultures remained viable for up to 48 hours of refrigerated incubation (4°C). No cells were able to attach after incubation at 4°C for more than 2 days.
The cultures placed at 4°C for 24 hours showed a delayed alkaline phosphatase activity, beginning on day 6 and lasting until to day 18. The cultures kept for 48 hours at 4°C were weakly alkaline phosphatase positive up until day 10. Cultures kept for longer than 48 hours at 4°C showed no alkaline phosphatase activity since there were no attached (viable) cells.
There was a decrease in IL-6 secretion in all refrigerated cultures and a significant decrease in those cells refrigerated for 48 hours.
Replicate cultures treated with endotoxin secreted significantly increased amounts of IL-6 in both the control cultures and the cultures exposed to 24 hours of cold storage.
BL: These observations suggest that after 48 hours of cold storage autogenous marrow may be safe to use because of the dramatic decrease in IL-6 production by osteoblasts. This reduction in IL-6 production could prove to be efficacious if the therapist plans on using fresh autogenous cells for regenerative procedures.
Renvert et al, 1985 ARTICLE
P: To determine whether the healing of intra-osseous defects following citric acid (CA) conditioning could be further improved through the combined use of CA plus autogenous bone grafts.
M&M: A total of 19 pts (26-66 years old) were part of the study and presenting a PI of less than 15%, with at least ≥2 interproximal defects, and PPD ≥ 6 mm. In these patients, 25 defects (2 and 3 wall) were treated with CA root conditioning and intraoral cancellous bone grafts that were harvested from the tuberosity. Another 28 defects (2 and 3-wall) were treated with re- placed flap surgery without osseous recontouring, and conditioning with CA. Clinical measurements were taken pre-op and then after at 12 months.
R: 1) Both therapies resulted in about 1 mm gain of attachment and probing bone levels.
|
Preop PD |
Gain in PAL |
Gain in bone level |
Residual PD |
|
|
CA+OFD |
6.1 |
1.1 |
0.8 |
4.2 |
|
CA+ABG |
6.3 |
1.2 |
1.4 |
4.4 |
2) Therefore, it was observed a formation of about 0.3 - 0.5 mm of soft tissue craters in both groups.
3) NSSD in characteristics of bone fill or attachment gain between the 2 groups
BL: Authors concluded that within the parameters of this study osseous grafting did not enhance the effect of CA conditioning alone. Both therapies gave similar results to documented results of OFD without using bone graft material
Stahl et al, 1983 ARTICLE
P: Two case reports to observe healing responses both clinically and histologically 12 months postsurgery in defects treated with durapatite (hydroxylapatite: Periograf), DFDBA, or autogenous coagulum - bone blend (ACBB).
Pt#1 M&M: notches were placed slightly below the gingival margin and at the most apical calculus on two teeth (#6 and #9). FTFs were reflected, the areas debrided and one-wall defect (#6) filled with durapatite; the two-walled defect (#9) filled with DFDBA. 10 days antibiotics (Erythromycin due to Penicillin allergy). Post-surgical follow up was every 2 weeks for 2 months. Pt. was gone for next 6 months. Ten months postsurgery, the patient returned to continue dental treatment. Had SRP with OHI. Radiographs and removal of the teeth by block section at 1 year.
R: Both sites showed decreased PD. Defect treated with Durapatite: JE from the most coronal notch almost to the apical notch, then CT more apically. Found Durapatite particles in the non-functional CNT at the apical notch. In the DFDBA defect, coronal notch lined by epithelium, this changes to LJE which is limited apically to level of inserted fibers, where new cementum, CT and some evidence of osteogenesis.
Pt# 2 M&M: Long term periodontal disease, hopeless mandibular incisors with Class II and III mobility, 5-10 mm PDs. Teeth were splinted, then OFD followed by either citric acid treatment for 4 min or irrigation with saline, and the placement of an autogenous osseous coagulum bone blend graft (from maxillary tuberosities). Replaced flaps. 13 months of monthly maintenance then teeth were removed by block section.
R: No notches were placed in the teeth, making it difficult to assess regeneration. However, healing is evident in the form of an elongated JE, crestal remodeling and limited supracrestal cementogenesis with functionally inserted fibers.
BL: Long term implantation of durapatite did not enhance attachment regeneration. Citric acid root treatment did not enhance supracrestal cementogenesis. Healing of autogenous graft was more mature than allograft.
Kingsmill, 1999 ARTICLE
BG: Some studies have shown that using “dead” bone for grafting might have less new bone formation b/c the nonvital bone is resistant to resorption.
Purpose: To evaluate if any difference exists b/w the resorption of bone containing live osteocytes (vital) and that damaged by heating or freezing (nonvital) in order to see whether cell vitality is necessary for grafted sites
M&M: Slices of live bone 600-800µm thick put into experiment I or experiment II.
In experiment I, transverse slices cut from freshly harvested adult rabbit femora were either placed in phosphate buffered saline (Set 1) or subjected to freezing and thawing (Set 2). In experiment II, a heated set (Set 3) was prepared in addition. Experiment I examined the effect of freezing/denaturing live bone on osteoclast activity whereas experiment II had a similar preparation to experiment I but also compared it to the effects of heating. Experiment II then evaluated the osteocytes under magnification and fluorescence. All slices were cultured with osteoclasts for 24 hours then evaluated for osteclastic resorption lacunae or “pits;” these were measured for area, volume and depth.
Results: In both experiments, the mean values for the areas of the pits were smaller in the bone containing live osteocytes, and in experiment II the volumes of the pits in Set 2 were smaller than those in Set 3. However, in neither experiment was there a significant difference between the Sets in the volume: area ratios (mean depths) of the pits.
BL: The findings show that devitalized bone is resorbed by osteoclasts at least as readily as bone containing vital osteocytes in vitro, and indicate that if grafted devitalized bone resorbs less well in vivo it is not because the bone tissue is intrinsically resistant to osteoclastic resorption, but may be attributable to an impaired vascularization that occurs after bone has been frozen.
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