Comparative study of DFDBA and FDBA block grafts.pptx

To evaluate and compare the effectiveness of demineralized freeze dried block graft and freeze dried block graft with chorion membrane as barrier membrane clinically and radiographically for the treatment of residual deep intra bony defects.

1. Comparative study of DFDBA and FDBA block grafts in combination with chorion membrane for the treatment of periodontal intra-bony defects at 12 months post surgery Shaila Kothiwale . Rishi Bhimani . Murtaza Kaderi . Jyoti Ajbani Dr. Beena Vijayan Parvathy Post graduate Department of Periodontics 11 FEB 2019

2. INTRODUCTION M cguire and N unn 1996 Cortellini and Tonetti 2004 Sources of osseous substitute grafts include autogenous , allogeneic , alloplastic , and xenogeneic materials. The periodontally compromised deep intra-bony defects do not provide a natural retention to contain the particulated grafting material. Consequently, block grafts can be recommended in such clinical scenarios. Therefore, such graft must possess strength and rigidity to allow its fixation in the recipient site and have stability to withstand muscular forces.

3. Though autogenous bone grafts have always been the gold standard material, this additional surgical procedure may have increased postoperative morbidity and postoperative complications. Autogenous block graft harvesting may result in upto 43% of some paresthesia ( Nissan et al. 2011 ) The other possible alternative to the block autograft can be block allografts. The studies have also demonstrated the combination of guided tissue regeneration with osseous grafts have resulted in enhanced periodontal regeneration.

4. AIM To evaluate and compare the effectiveness of demineralized freeze dried block graft and freeze dried block graft with chorion membrane as barrier membrane clinically and radiographically for the treatment of residual deep intra bony defects.

5. Materials and Methods Study design 9 systemically healthy patients aged between 35 and 55 years diagnosed with severe chronic periodontitis with radiographic evidence of angular bone defects were selected for this study . The study was conducted from January 2016 to March 2017. Among 9 patients, two sites were selected in posterior area from each patient . The sites were randomly divided into group 1 ( FDBA/ chorion membrane) and group 2 ( DFDBA/ chorion membrane) by flip coin method.

6. Inclusion Criteria 1. PPD > 6 mm with radiographic evidence of osseous defect either in maxillary or mandibular molar tooth. 2. No systemic antibiotics prescribed in past 6 months. 3. No surgical treatment of the site within one year before initiation of the study. 4. Presence of mobility from grade I to II. 5. No systemic disease.

7. E xclusion Criteria 1. Pregnant women and lactating mothers 2. Tobacco smokers 3. History of taking drugs which might affect periodontal healing. 4. Uncooperative patients.

8. Clinical and radiographic measurements The following clinical parameters were recorded at the baseline and at 12 months post operatively: Plaque Index and Gingival Index Periodontal pocket depth (PD ) Clinical attachment level (CAL ) All measurements were taken by the same examiner using graduated William’s probe.

9. Radiographs were taken by the standardized paralleling technique. Pre-operative radiographs were obtained at baseline, 6 months and 12 months postoperatively. The area of the defect was calculated using the RVG software X-ray. The radiographs were statistically assessed at baseline and 12 months only. Radiographic Measurements

10. Eickholz et al 2004 identified the following landmarks, which were used in the current study to calculate the area of defect on the radiographs. 1. Cemento -enamel junction (CEJ): If the CEJ was destroyed by restorative treatment, the margin of the restoration was taken as a landmark. 2. Bony defect was defined as the most coronal point where the periodontal ligament space showed a continuous width. 3. Alveolar crest (AC) was defined as the crossing of the silhouette of the AC with the root surface.

11. Procedure The surgical treatment was performed 6 weeks after phase I therapy . Following phase 1 therapy, surgical treatment was attempted at the defect sites. A Kirkland/conventional flap was designed. After anesthetizing the surgical site, horizontal incisions were taken, and the flap was reflected till the base of the intra-bony alveolar defect sites following which the defects were thoroughly debrided for the inflamed granulation tissue followed by root planning and irrigation. After completion of debridement, the length, width and depth of the defects were measured with the help of a sterile divider. These measurements were used to contour the block allografts of appropriate sizes using micro motor diamond bur.

12. Perforations were drilled into recipient bone surgical site, to induce the bleeding. The graft was placed into the defect with proper adaptation to the defect site. The prepared graft was rinsed with sterile saline solution and stabilized into defect site. A customized template was prepared with a tin foil for the desired length and width to adapt over the block graft at the defect site extending 2–3 mm facially and lingually and 2 mm mesio -distally. This tin foil was used to contour the chorion membrane which was used as a barrier membrane to stabilize the bone graft. Chorion membrane of appropriate sizes was contoured to cover the defect completely.

13. The thickness of the Chorion membrane did not allow itself to shrivel and got adapted firmly over the defect area. Care was taken not to expose the membrane before suturing. The periodontal flaps were adapted on the surgical site and sutured without any exposure of the chorion membrane. Periodontal pack was placed at the surgical site to assure the comfort to the patient

14. d) Flaps sutured a) Flap reflection and assessment of the bone defect. b) Placement of Block graft in the intra-bony defect. c) Chorion membrane placement covering the bone graft.

15. Maintenance Program All the patients received the antibiotics [Amoxicillin (500 mg) and Metronidazole (400 mg)] for 5 days and analgesics for 3 days. The patients were instructed for good maintenance of plaque supported with Chlorhexidine mouthwash 0.12% for 4 weeks. Recall appointment was scheduled after 7 days for suture removal. Patients were placed on maintenance therapy every month to evaluate the oral hygiene maintenance.

16. Statistical analysis Inter group comparison for clinical and radiographic parameters were calculated using Mann–Whitney U test . The intra group comparison was done using Wilcoxon signed rank test.

17. Results 9 recruited patients with 18 sites as split mouth received the DFDBA and FDBA with chorion membrane for treatment of deep intra bony defects and completed 12 months observation period. Clinical parameters in the present study, plaque and gingival index which presented the oral hygiene status showed significant reduction from base line to 12 months on intra group comparison. The periodontal pockets which qualified for the regenerative periodontal treatment had baseline mean in group 1 and group 2 showed reduction post treatment . The treatment resulted with the clinical attachment gain of 4.0922 ± 0.63 and 4.6278 ± 0.45 in group 1 and group 2.

18. At 12 months, post treatment indicates significant pocket reduction and gain in clinical attachment in both the groups (Table1). Both the groups showed significant reduction in the defect depth at 12 months (Table 2).

19. However there was no statistical significance observed on inter group comparison with clinical parameters (Table 4). The intergroup comparison among both the groups for bone fill was statistically insignificant (Table 3).

20. The mobility of both groups significantly reduced (from grade I to grade II) grade 0 to grade I. The mean of radiographic assessment bone defect in group 1 and group 2 at baseline were 7.3333 ± 0.66 and 7.2222 ± 1.02 and the mean bone fill of 2.5556 ± 0.41 and 2.9444 ± 0.58 respectively at 12 months.

21. Discussion There are various studies which have compared DFDBA and FDBA particles in furcation involvement and intra-bony defect with and without GTR membranes. Clinical parameters showed reduction in Plaque Index from baseline for group 1 and 2 to post treatment indicated good plaque maintenance . The pocket depth reduced with gain in the clinical attachment level in both the groups with no statistical differences. The clinical gain in attachment was 3.96 ± 1.15 (FDBA) and 2.66 ± 0.33 (DFDBA) (Table 1). There was no statistical significance on intergroup comparison (Table 4). Similar results were reported by Rummelhart et al 1989 where DFDBA and FDBA particulate block grafts were used.

22. In the present study both the groups showed increase in bone density in radiograph (Table 2) indicating formation of vital bone. Though radiovisiography revealed increase in the bone density in both the groups. Group 1 showed statistical increase in bone density with FDBA. The FDBA and DFDBA block grafts received from tissue bank were cortico-cancellous. The percentage of cortical or cancellous components in each block graft might have differed in each block graft. This variation among cortico-cancellous component of block grafts might have resulted in increased density in group 1. The separate healing patterns occurring in cancellous and cortical bone have earlier been studied by histology and micro angiography Kenzora et al 1978 .

23. Cortical bone first undergoes a stage of Resorption Creating cavities in the dense bone Wide-spread osteogenesis Cancellous bone heals primarily by osteogenesis Bone resorption Weeks after the initiation of the healing phase Old, dead cancellous trabeculae are partly surrounded by newly developed vital bone This appears as an increased X-ray density. The consecutive resorption process re-establishes the bone density found before surgery. The mobility of the selected teeth for both groups was between grade I and grade II at base line reduced to physiological mobility and grade I respectively.

24. The vascularisation of the graft is essential for healing and bone modeling . Early vascularization means early remodeling . The vascularisation starts 5 days post- grafting. At 20 days the grafts may be fully vascularised Albrektsson 1980 . In the present study perforations were created at recipient surgical site to aid in vascularization at the site. This may aid in proliferation of growth factors and platelets, which are essential in wound healing Se´rgio et al. 2000 . The radiovisiography of the present study revealed increase in the bone density in both the groups, with statistical significant in group 1 (FDBA + Chorion membrane) (Table 2) The bone fill in the defect area indicates placement of bone grafts results in partial or complete resolution of the intra-bony defect. However, the nature of the resolution of the defect whether the graft acted as a scaffold or replaced for the growth of the bone cannot be inferred from the radiographic observations.

25. Piattelli et al 1996 demonstrated histologically observations between these two allografts . The DFDBA may serve as a scaffold for bone formation in an osteoconductive fashion. The mechanisms for bone formation induced by DFDBA could be: ( a) the particles undergo a biochemical change that brings about the remineralisation of the particles; ( b) the demineralized particles are colonized by mononuclear osteoclasts from the neighboring bone that are able to attract osteoblasts on their surface, thus allowing successive bone layering. DFDBA particles located far from the host bone tended to be surrounded by a scarcely cellular connective tissue, composed mainly of collagen fibers . In the DFDBA the osteocytic lacunae tended, for the most part, to remain empty.

26. In the FDBA, all the osteocytic lacunae were filled by osteocytes and in some areas Haversian systems with a capillary at the center were found. In the FDBA particles many particles were completely surrounded by newly formed bone. Even the particles that were farthest from the host bone were lined by osteoblasts actively secreting osteoid and newly formed bone. They pointed the results stating more osteoconductive effect of FDBA. Similarly in this study also, sites with FDBA has shown better bone fill and significant increase in bone density. In the present study chorion membrane used as a GTR played a dual role in stabilizing the block grafts along at the surgical site and provided additional advantage of anti-inflammatory, adhesion, growth factors and vascularisation properties Koob et al. 2013; Kothiwale 2014 . The chorion membrane which is thicker than amnion provided stability and support to the graft. Hence, the combination of Block grafts with the chorion membrane aided in the statistically significant results in both the groups of the study.

27. Conclusion The application of FDBA and DFDBA block grafts in conjunction with chorion membrane resulted in significant improvement in clinical and radiological parameters . With increasing loss of height, in wide angular defects, where the placement of particles may be hard, combination approach with block allograft graft and chorion membrane may be beneficial to achieve predictable periodontal regeneration.

28. References Albrektsson T (1980) Repair of bone grafts. Scand J Plast Reconstr Surg 14:1–12 Chambrone L et al (2010) Predictors of tooth loss during longterm periodontal maintenance: a systematic review of observational studies. J Clin Periodontol 37(7):675–684 Cortellini P, Tonetti MS (2004) Long-term tooth survival following regenerative treatment of intrabony defects. J Periodontol 75(5):672–678 Eickholz P et al (2004) Radiographic parameters for prognosis of periodontal healing of infrabony defects: two different definitions of defect depth. J Periodontol 75(3):399–407 Kenzora JE et al (1978) Experimental osteonecrosis of the femoral head in adult rabbits. Clin Orthop Relat Res 130:8–46 Koob TJ et al (2013) Biological properties of dehydrated human amnion/chorion composite graft: implications for chronic wound healing. Int Wound J 10(5):493–500 Kothiwale SV (2014) The evaluation of chorionic membrane in guided tissue regeneration for periodontal pocket therapy: a clinical and radiographic study. Cell Tissue Bank 15(1):145–152

29. McGuire MK, Nunn ME (1996) Prognosis versus actual outcome. II. The effectiveness of clinical parameters in developing an accurate prognosis. J Periodontol 67(7):658–665 Miller SC (1950) Textbook of periodontia: oral medicine. Blakiston , Philadelphia Nissan J, Mardinger O, Calderon S, Romanos GE, Chaushu G (2011) Cancellous bone block allografts for the a ugmentation of the anterior atrophic maxilla. Clin implant dent relat res 13(2):104–111 piattelli A et al (1996) comparison of bone regeneration with the use of mineralized and demineralized freeze-dried bone allografts: a histological and histochemical study in man. Biomaterials 17(11):1127–1131 rummelhart JM et al (1989) A comparison of freeze-dried bone allograft and demineralized freeze-dried bone allograft in human periodontal osseous defects. J periodontol 60(12):655–663 schwartz Z, boyan BD (1994) underlying mechanisms at the bone–biomaterial interface. J cell biochem 56(3):340–347 se´rgio P et al (2000) influence of bed preparation on the incorporation of autogenous bone grafts: a study in dogs. Int J oral maxillofac implants 15(4):565–570 silness J, lo¨e H (1964) periodontal disease in pregnancy II. Correlation between oral hygiene and periodontal condition. Acta odontologica scandinavica 22(1):121–135 sivertson JF, burgett FG (1976) probing of pockets related to the attachment level. J periodontol 47(5):281–286

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