The International Journal of Periodontics & Restorative Dentistry © 2019 by QUINTESSENCE PUBLISHING CO, INC. PRINTING of TH

The International Journal of Periodontics & Restorative Dentistry

Evaluation of Demineralized Freeze-Dried Bone Allograft in Combination with Chorion Membrane in the Treatment of Grade II Furcation Defects: A Randomized Controlled Trial

Kanan K. Shah, BDS1 Chronic periodontitis is a bacterially Rajashri A. Kolte, MDS1 induced inflammatory disease that Abhay P. Kolte, MDS1 embroils intricate interaction of the host immunoinflammatory response with the plaque biofilm, which may lead to subsequent alterations in The aim of present study was to evaluate the efficacy of demineralized periodontal tissue homeostasis re- freeze-dried bone allograft (DFDBA) alone and in combination with sulting in destruction of the con- chorion membrane (CM) in the treatment of Grade II furcation defects nective tissue and alveolar bone using cone beam computed tomography (CBCT). Sites were randomly supporting the teeth.1,2 The main assigned to Group I (DFDBA) and Group II (DFDBA + CM). Probing pocket depth (PPD), clinical attachment level (CAL), gingival recession (GR), and goals of periodontal treatment are horizontal probing depth (HPD) were evaluated at 3 and 6 months and elimination of inflammatory process- defect volume at 6 months. DFDBA + CM led to significant improvement in es (in order to arrest the progres- all parameters, indicating additional benefits of combination therapy. Int J sion of the disease), maintenance of Periodontics Restorative Dent 2019;39:659–667. doi: 10.11607/prd.4267 the natural dentition in health, and comfortable function. Inflammatory involvement of the periodontium of the bifurcation and trifurcation of the teeth exhibits various tooth con- founding factors, such as complex anatomic structures posing a great challenge to clinicians to have ad- equate access for instrumentation, thereby deteriorating the prognosis and increasing the mortality of the tooth involved.3 The successful resolution of furcation defects has been validated in the literature by use of guided tissue regeneration (GTR).4–8 The concept of GTR necessitates the exclusion of gingival epithelial and connec- 1Department of Periodontics and Implantology, VSPM Dental College and Research Centre, Digdoh Hills, Nagpur, India. tive tissue cells from the denuded root surface and allows cells from Correspondence to: Dr Abhay P. Kolte, Department of Periodontics and Implantology, the periodontal ligament or alveo- VSPM Dental College and Research Centre, Digdoh Hills, Hingna Road, Nagpur-440017, India. Email: [email protected] lar bone to repopulate the wound area.9 The application of a combined Submitted December 31, 2018; accepted February 23, 2019. ©2019 by Quintessence Publishing Co Inc. therapeutic approach (ie, barrier,

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© 2019 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 660 bone-replacement graft with or constraints, and clinical evaluation apy, patients exhibiting probing without biologics) offers an addi- does not provide confirmation of pocket depth (PPD) ≥ 5 mm, clinical tional advantage and high predict- periodontal regeneration; thus, attachment level (CAL) ≥ 5 mm, and ability for periodontal regeneration bitewings and intraoral periapical at least one pair of bilateral Grade II in Grade II furcation defects as com- radiographs are traditionally used furcation defects22 on contralateral pared to monotherapeutic algo- to assess bone loss. However, ra- sides were included in the study. rithms.10–12 The immuno-privileged diographs are not without limita- Patients were excluded from the human chorion membrane (CM) has tions, which led to the introduction study if they had a history of known antimicrobial and antigenic proper- of cone beam computed tomogra- systemic diseases, allergies, or drug ties13 that have been discussed ex- phy (CBCT) as a reliable tool that use; were pregnant or lactating tensively, and it has been recently offers three-dimensional explora- mothers; and/or had undergone used for periodontal therapy.14–16 tion of periodontal osseous de- periodontal therapy in the last 6 The CM membrane has numer- fects, and its measurements related months. The secondary objectives ous growth factors, proteins, and well to traditional methods.19–21 of the study intended to evaluate stem-cell reserves that induce faster The preliminary results with and compare the changes in PPD wound healing and aid the regen- DFDBA and CM when used indi- and CAL clinically and the reduction eration of lost tissues.13 vidually appear to be encouraging in bone defect volume by CBCT The use of demineralized freeze- in terms of regeneration of the peri- at the end of 6 months in both dried bone allograft (DFDBA) is a odontal structures, and hence the groups. With reference to the study bone replacement graft capable present study aimed to clinically and by Pajnigara et al,23 power analysis of promoting regeneration of the radiographically (by CBCT) evaluate was performed that resulted into attachment apparatus and has and compare the efficacy of DFDBA an effect size of 0.7 for quantity of been the focus of much attention alone and in combination with CM patients and thus a sample size of throughout the past 30 years. Ideal- in the treatment of Grade II furca- 20 patients was needed to achieve ly, a bone replacement graft should tion defects. effect with 90% power and a 95% have the potential to trigger osteo- confidence level. The selected sites genesis. DFDBA’s osteoinductive were randomly assigned to Group I potential is the stimulation of bone Materials and Methods (DFDBA) or Group II (DFDBA + CM), formation in extraskeletal sites and with each patient receiving both is related to the amount of bone The present randomized controlled types of treatment (one per defect), morphogenetic proteins that remain clinical trial comprised 20 patients by computer-generated random ta- after the demineralization process is (13 women and 7 men) with a mean ble number. Treatment procedures completed.17 age of 40.85 ± 7.32 years who were were performed at VSPM Dental Evidence of new attachment affected by chronic periodontitis, se- College and Research Centre in and periodontal reconstruction lected from the Department of Peri- Nagpur, India. Grafting materials can be assessed by clinical, radio- odontics and Implantology of the were obtained from TATA Memo- graphic, histologic, or surgical re- VSPM Dental College and Research rial Cancer Research Hospital in entry procedures. Clinical methods Centre in Nagpur, India. The study Mumbai, India. All regenerative ma- using bone sounding are known was approved by the Institutional terials used in the present clinical to accurately diagnose furcation Ethics Committee and adhered to trial were from the same process- defects; however, it may not be the provisions of the Helsinki dec- ing batch. The treatment procedure able to assess the exact nature of laration. The study was registered to be performed was explained to healing tissue.18 Histologic and with Clinical Trial Registry-India the patients, and informed consent surgical-reentry evaluative proce- (CTRI/2017/10/010265). After evalu- was obtained prior to beginning the dures are limited due to ethical ation of Phase I, nonsurgical ther- study.

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a b c

d e f

Fig 1 Case 1. Group I (DFDBA) clinical views. Preoperative (a) vertical probing depth and (b) HPD of the furcation defect. (c) Placement of DFDBA in the furcation defect. (d) Sutured flap. (e) Placement of periodontal dressing. (f) Vertical probing depth and (g) HPD of the furcation defect.

Each patient was subjected to by a single examiner (R.K.). CBCT Clinical Procedure presurgical hygiene therapy, and scans (Orthophos XG 3D, Dentsply clinical data were recorded after 6 Sirona) were made at baseline and After administration of local anes- weeks. For the evaluation of oral 6 months postoperatively. A sec- thesia, full-thickness mucoperiosteal hygiene and gingival health, Plaque ond examiner (A.K.) performed all flaps were reflected for defect de- Index (PI)24 and Gingival Index (GI)25 pre- and postsurgical radiographic bridement. All surgical procedures were obtained at baseline and 3 and measurements. The CBCT analysis were performed by a single clinician 6 months. PPD, CAL, and gingival included measurements of bone (K.S.) who was blinded to the mea- recession (GR) were recorded prior defect height, depth, and width. surements and type of treatment to surgery and at 3 and 6 months These three parameters gener- to the allotted site. The exposed after the procedure using custom- ated the total volume of the bone root surface and furcation area were made occlusal acrylic stents with defect. The bone defect height scaled and planed using hand and ul- a UNC-15 graduated periodontal and width were measured in sagit- trasonic instruments. In each patient, probe (Hu-Friedy). Horizontal prob- tal view, whereas the bone defect one defect was treated with DFDBA ing depth (HPD) was also measured depth was measured in transverse alone (Fig 1), while the contralateral with a Nabers probe (Hu-Friedy). All view. The same slice was used at defect was treated with DFDBA + pre-, intra-, and postsurgical clini- baseline and 6 months for CBCT CM (Fig 2) on the same day. The furcal measurements were carried out evaluation. cation defect was filled with DFDBA

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a b c

d e f

Fig 2 Case 1. Group II (DFDBA + CM) clinical views. Preoperative (a) vertical probing depth and (b) HPD of the furcation defect. (c) Placement of DFDBA in the furcation defect. (d) Placement of CM. (e) Sutured flap. (f) Placement of periodontal dressing. (g) Vertical probing depth and (h) HPD of the furcation defect.

g h

material, which was hydrated with sa- Postsurgical Evaluation parison was made by Tukey multiple line and then covered with CM. On comparison test. Mean changes in placement, the processed dehydrat- The patients were evaluated clinically these study parameters were com- ed CM became hydrated and self-ad- for PI, GI, PPD, CAL, GR, and HPD at pared between Group I and Group hered to the area. Immediately after 3 and 6 months, and CBCT radio- II by independent t test. Defect placing the membrane, the reflected graphic measurements were per- height, width, and depth before and flap was repositioned over the CM formed at 6 months (Figs 3 and 4). after 6 months were compared by and secured with 3-0 Mersilk sutures paired t test for normalized data. (ALSILK, Aalay Surgicals) using the Volume of defect was compared be- interrupted suturing technique. Peri- Statistical Analyses fore and after 6 months by Wilcoxon odontal dressing was placed, and signed rank test for non-normalized the patients were prescribed non- The data were analyzed using STA- data. Changes in volume of defect steroidal anti-inflammatory medica- TA version 20.0. P < .05 was consid- between the two groups were com- tion and systemic antibiotics. Patients ered significant. PI, GI, PPD, CAL, pared by Wilcoxon rank sum test were instructed to rinse with 0.2% GR, and HPD were compared at (Mann-Whitney test). chlorhexidine gluconate twice daily different time points in each group for 4 to 6 weeks and avoid undue by performing repeated measures trauma to the treated site. analysis of variance. Pairwise com-

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a b a b

c d c d Fig 3 Case 1. Group I (DFDBA) CBCT images at (a, b) baseline and Fig 4 Case 1. Group II (DFDBA + CM) CBCT images at (a, b) (c, d) 6 months. Preoperative radiolucency, indicating (a) defect baseline and (c, d) 6 months. Preoperative radiolucency, indicating height and width in sagittal view and (b) defect depth in transverse (a) defect height and width in sagittal view and (b) defect depth view. Postoperative reduction in radiolucency at 6 months, in transverse view. Postoperative reduction in radiolucency at 6 indicating reduction of (c) defect height and width in sagittal view months, indicating reduction of (c) defect height and width in and (d) defect depth in transverse view. sagittal view and (d) defect depth in transverse view.

Results Table 1 Comparisons of Clinical Parameters (in mm) in Both Groups at Baseline and 3 and 6 Months Patients demonstrated good oral Group I Group II hygiene throughout the study. At Parameter Mean ± SD P Mean ± SD P baseline and 3 and 6 months, mean PPD PI was 2.98 ± 0.27, 2.23 ± 0.46, and Baseline 5.45 ± 0.68 < .0001** 5.80 ± 0.83 < .0001** 3 mo 4.15 ± 0.74 3.80 ± 0.69 1.52 ± 0.35, respectively, and GI 6 mo 3.35 ± 0.87 2.85 ± 0.67 was 1.64 ± 0.29, 1.32 ± 0.22, and CAL 1.09 ± 0.23, respectively. PI and GI Baseline 5.80 ± 0.76 < .0001** 6.10 ± 1.16 < .0001** dropped significantly P( < .001) for 3 mo 4.85 ± 0.74 4.40 ± 1.18 6 mo 4.17 ± 0.87 3.55 ± 0.99 both groups from baseline to 3 and GR 6 months. Comparisons of PPD, Baseline 0.35 ± 0.48 .042* 0.30 ± 0.57 .030* CAL, GR, and HPD from baseline 3 mo 0.70 ± 0.47 0.60 ± 0.75 Baseline 0.35 ± 0.48 < .0001** 0.30 ± 0.57 .004* to 3 months yielded statistically sig- 6 mo 0.82 ± 0.88 0.70 ± 0.73 nificant reductions in PPD P( < .001), HPD gains in CAL (P < .001), increases Baseline 4.50 ± 0.60 < .0001** 4.95 ± 0.99 < .0001** 3 mo 3.55 ± 0.60 3.75 ± 0.91 in GR (P = .042 and P = .030 for 6 mo 2.85 ± 0.48 2.50 ± 0.51 Groups I and II, respectively), and SD = standard deviation; PPD = probing pocket depth; CAL = clinical attachment level; reductions in HPD (P < .001) in both GR = gingival recession; HPD = horizontal probing depth. *Significant. groups (Table 1). Comparisons of **Highly significant.

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Table 2 Comparisons of Radiographic Parameters in Both Groups at Different Time Intervals

Group I Group II Baseline 6 months P Baseline 6 months P Bone defect height (mm) 2.97 ± 0.66 2.01 ± 0.42 < .0001** 2.91 ± 0.49 1.91 ± 0.34 < .0001** Bone defect width (mm) 2.22 ± 0.36 1.69 ± 0.35 < .0001** 2.31 ± 0.37 1.42 ± 0.36 < .0001** Bone defect depth (mm) 2.85 ± 0.49 1.98 ± 0.35 < .0001** 3.12 ± 0.53 1.81 ± 0.47 < .0001** Bone defect volume (mm3) 18.87 ± 6.31 6.69 ± 2.56 < .0001** 21.62 ± 7.70 4.99 ± 2.14 < .0001** **Highly significant.

Table 3 Comparisons of Clinical Parameters (in mm) Between Groups at Baseline and 3 and 6 Months

Baseline vs 3 mo Baseline vs 6 mo 3 mo vs 6 mo Group I Group II P Group I Group II P Group I Group II P PPD 1.30 ± 0.36 2.0 ± 0.45 < .0001** 2.10 ± 0.47 2.85 ± 0.74 .009** 0.80 ± 0.48 0.95 ± 0.67 .114 reduction (NS) CAL 0.95 ± 0.39 1.70 ± 0.57 < .0001** 1.63 ± 0.65 2.55 ± 0.67 .004** 0.68 ± 0.63 0.85 ± 0.74 .651 gain (NS) GR 0.35 ± 0.41 0.30 ± 0.57 .758 0.47 ± 0.59 0.4 ± 0.68 .547 0.12 ± 0.59 0.10 ± 0.41 0.225 increase (NS) (NS) (NS) HPD 0.95 ± 0.22 1.2 ± 0.41 .022* 1.65 ± 0.58 2.45 ± 0.82 .001* 0.70 ± 0.57 1.25 ± 0.78 .016* reduction PPD = probing pocket depth; CAL = clinical attachment level; GR = gingival recession; HPD = horizontal probing depth; NS = not significant. *Significant. **Highly significant. clinical parameters from baseline ± 0.67 mm, respectively. Also at 6 Discussion to 6 months yielded statistically sig- months for Groups I and II, the mean nificant reductions in PPD P( < .001), increase in GR was 0.47 ± 0.59 mm In contrast to repair, regeneration gains in CAL (P < .001), increases and 0.40 ± 0.68 mm, respectively, refers to the reproduction or recon- in GR (P = .0001 and P = .004 for and the mean HPD reduction was stitution of a lost or injured part, Groups I and II, respectively), and 1.65 ± 0.58 mm and 2.45 ± 0.82 mm, whereas repair describes healing reductions in HPD in both groups respectively. The mean reductions of a wound by tissue that does not (P < .001) (Table 1). The defect in PPD and HPD at 6 months were fully restore the architecture or the volume at baseline was 18.87 ± greater in Group II compared to function of the part.26 Regenerative 6.31 mm3 for Group I and 21.62 ± Group I (Table 3). Additionally, CAL periodontal therapy attempts to 7.70 mm 3 for Group II. At 6 months, gain was significantly higher at 6 restore lost periodontal structures it was 6.69 ± 2.56 mm3 for Group I months in Group II (Table 3). Mean and functional attachment. The de- and 4.99 ± 2.14 mm3 for Group II. reductions in bone defect volume mineralized graft induces host cells There was a statistically significant at 6 months were 12.08 ± 4.69 mm3 to differentiate into osteoblasts, decrease in bone defect volume in and 16.62 ± 6.35 mm3 for Groups I whereas a nondemineralized al- both the groups (P < .001) (Table and II, respectively. There were sta- lograft is thought to function by os- 2). At 6 months for Groups I and II, tistically significant differences in teoconduction, acting as a scaffold the mean PPD reduction was 2.1 bone defect volume between both for new bone formation. Also, a fresh ± 0.47 mm and 2.85 ± 0.74 mm, the groups (P = .015) (Table 4) and and dehydrated chorion has greater respectively, and the mean CAL in all the soft and hard tissue param- growth factor and cytokine load gain was 1.63 ± 0.65 mm and 2.55 eters between groups. compared to fresh and dehydrated

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14 amnion. Thus, this study evaluated Table 4 Comparisons of Radiographic Parameters Between the combined efficacy of DFDBA Both Groups and CM on improvements in clinical Group I Group II P parameters and subsequent change in bone volume posttherapy in Gain in bone defect height (mm) 0.96 ± 0.53 1.0 ± 0.37 .759 (NS) Grade II furcation defects. Gain in bone defect width (mm) 0.52 ± 0.18 0.88 ± 0.32 < .001* At baseline, no significant differ- Gain in bone defect depth (mm) 0.87 ± 0.38 1.3 ± 0.32 < .001* ences in any of the investigated pa- Gain in bone defect volume (mm3) 12.08 ± 4.69 16.62 ± 6.35 .015* rameters were observed between NS = not significant. *Significant. Group I and Group II, indicating an effective randomization process. During the course of study, no clini- in accordance with Luepke et al, ed with DFDBA in combination with cal evidence of untoward local and who observed greater PPD reduc- AM than in the group treated with systemic immune response was de- tion and CAL gain in sites treated DFDBA alone.23 tected in either Group I or Group II, with a combination of barrier mem- The current clinical trial resulted indicating the biocompatibility of brane and DFDBA as compared in mean bone-defect volume re- both CM and DFDBA. These find- to sites treated with bioresorbable ductions of 12.08 ± 4.69 mm3 and ings were in accordance with the barrier membranes alone.28 Simi- 16.62 ± 6.35 mm3 in Groups I and findings of Rummelhart et al, who larly, Kiany and Moloudi evaluated II, respectively, demonstrating sta- observed continuity of bone within and compared the efficacy of bo- tistically significant reductions at the defect and surrounding alveolar vine bone mineral with both amnion 6 months compared to baseline. bone without evidence of the pres- membrane and CM in GTR for the However, Group II showed statisti- ence of original particulate graft ma- treatment of intrabony periodontal cally significantly greater reductions terial in the treatment of periodontal defects in a 6-month clinical trial; when compared to Group I, indicat- osseous defects.27 Holtzclaw and significant PPD reduction and CAL ing better results for combination Toscano15 and Kothiwale16 reported gain were reported.29 There was therapy over monotherapy. The syn- CM’s unique biologic and physical significant reduction in HPD in both ergistic effect of DFDBA combined attributes that reduce the complex- groups at 6 months in the present with GTR is in accordance with Kher ity of trimming, suturing, and barrier study, with Group II demonstrating et al’s findings in intrabony defects, placement, minimizing the chances significantly greater HPD reduction where significantly greater radio- of postoperative complications. compared to Group I. These results graphic defect-depth reductions The primary treatment variables were similar to those reported by were found in the DFDBA plus GTR to assess in a furcation defect are re- De Leonardis et al, who reported group postoperatively at 6 months ductions in PPD and HPD. The most that the placement of DFDBA in as compared to GTR alone.31 commonly used soft tissue clinical the furcation defect under the bio- In the present trial, CBCT was outcome variable in regenerative absorbable membrane resulted in used to record minute changes studies is the CAL. In the present a greater mean reduction of HPD within the alveolar bone of furca- study, both groups demonstrated when compared to the regenerative tion defects in terms of gauging the significant reductions in PPD, CAL therapy by GTR alone.30 An analo- height, width, and depth of a defect, gains, and reductions in HPD at 6 gous study conducted by Pajnigara as these parameters can be record- months, and the difference in these et al evaluating the regenerative ed with greater accuracy in CBCT, parameters between the groups efficacy of DFDBA with or without which no other tool is in a position was statistically significant, indicat- amnion membrane in Grade II furca- to record. The accuracy in assessing a better efficacy of combined tion defects reported higher mean ing the volumetric changes in peri- DFDBA + CM. These findings are HPD reductions in the group treat- odontal infrabony defect volume

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using CBCT has been evaluated by Acknowledgments 11. Camelo MC, Nevins ML, Nevins M. Wanikar et al32 in Grade II furcation Treatment of Class II furcations with autogenous bone grafts and e-PTFE 33 defects and by Bodhare et al in in- The authors declare no conflicts of interest. membranes. Int J Periodontics Restor- trabony defects. Wanikar et al evaluative Dent 2000;20:233–243. 12. Camelo M, Nevins ML, Schenk RK, ated the synergistic efficacy of 1% Lynch SE, Nevins M. Periodontal regen- alendronate (ALN) gel in combina- References eration in human Class II furcations using tion with platelet-rich fibrin (PRF) and purified recombinant human platelet- derived growth factor-BB (rhPDGF-BB) of PRF alone in Grade II furcation . 1 Kornman KS. Mapping the pathogen- with bone allograft. Int J Periodontics teeth; it was confirmed radiographi- esis of periodontitis: A new look. J Peri- Restorative Dent 2003;23:213–225. odontol 2008;79(suppl 8):s1560–s1568. 13. Gupta A, Kedige SD, Jain K. Amnion cally by CBCT images that the PRF 2. Page RC, Schroeder HE. Pathogenesis and chorion membranes: Potential stem + ALN group had a greater mean of inflammatory periodontal disease. cell reservoir with wide applications A summary of current work. Lab Invest reduction in bone defect volume.32 in periodontics. Int J Biomater 2015; 1976;34:235–249. 2015:274082. Similarly, Bodhare et al reported an 3. Matia JI, Bissada NF, Maybury JE, 14. Kothiwale S, Ajbani J. Evaluation of anti- achievement of greater bone fill with Richetti P. Efficiency of scaling of the inflammatory effect of chorion mem- molar furcation area with and without brane in periodontal pocket therapy: A BG + PRF than with PRF alone in surgical access. Int J Periodontics Re- clinical and biochemical study. J Indian intrabony defects by pre- and post- storative Dent 1986;6:24–35. Soc Periodontol 2018;22:433–437. 4. Pontoriero R, Nyman S, Lindhe J, Rosen- operative CBCT images.33 The pres- 15. Holtzclaw D, Toscano N. Amnion cho- berg E, Sanavi F. Guided tissue regen- rion allograft barrier: Indications and ent study is perhaps one of the first eration in the treatment of furcation techniques update. J Implant Adv Clin studies evaluating the combined defects in man. J Clin Periodontol 1987; Dent 2012;4:25–38. 14:618 – 620. 16. Kothiwale SV. The evaluation of chori- effect of CM with DFDBA. CM has 5. Schallhorn RG, McClain PK. Combined onic membrane in guided tissue regen- been reported to have additional osseous composite grafting, root con- eration for periodontal pocket therapy: ditioning, and guided tissue regenera- beneficial effects in tissue regenera- A clinical and radiographic study. Cell tion. Int J Periodontics Restorative Dent Tissue Bank 2014;15:145–152. tion, which has aptly been reflected 1988;8:8–31. 17. Urist MR, Strates BS. Bone morpho- in the results. 6. McClain PK, Schallhorn RG. Long-term genetic protein. J Dent Res 1971;50: assessment of combined osseous com- 1392–1406. To advocate and support the posite grafting, root conditioning, and 18. Mealey BL, Neubauer MF, Butzin CA, outcomes of the combination ther- guided tissue regeneration. Int J Peri- Waldrop TC. Use of furcal bone sound- odontics Restorative Dent 1993;13:9–27. apy, further long-term, multicenter ing to improve accuracy of furcation di- 7. Wang HL, O’Neal RB, Thomas CL, Shyr agnosis. J Periodontol 1994;65:649–657. studies with biochemical assays and Y, MacNeil RL. Evaluation of an absorb- 19. Misch KA, Yi ES, Sarment DP. Accuracy histologic evaluation for the regen- able collagen membrane in treating of cone beam computed tomography Class II furcation defects. J Periodontol for periodontal defect measurements. J erated tissues should be performed. 1994;65:1029–1036. Periodontol 2006;77:1261–1266. 8. Eickholz P, Kim TS, Holle R, Hausmann 20. Vandenberghe B, Jacobs R, Yang J. E. Long-term results of guided tissue re- Diagnostic validity (or acuity) of 2D CCD generation therapy with non-resorbable versus 3D CBCT-images for assessing Conclusions and bioabsorbable barriers. I. Class II periodontal breakdown. Oral Surg Oral furcations. J Periodontol 2001;72:35–42. Med Oral Pathol Oral Radiol Endod 9. Melcher AH. On the repair potential of 2007;104:395–401. Within the limits of the present periodontal tissues. J Periodontol 1976; 21. Vandenberghe B, Jacobs R, Yang J. study, both treatment groups re- 47:256–260. Detection of periodontal bone loss us- 10. Reddy MS, Aichelmann-Reidy ME, Avila- sulted in no adverse reaction to ing digital intraoral and cone beam Ortiz G, et al. Periodontal regenera- computed tomography images: An DFDBA or CM and had significant tion—Furcation defects: A consensus in vitro assessment of bony and/or in- periodontal regeneration as as- report from the AAP Regeneration Work- frabony defects. Dentomaxillofac Ra- shop. J Periodontol 2015;86(suppl 2): diol 2008;37:252–260. sessed by clinical and radiographic s131–s133. parameters, but the combined therapy of DFDBA + CM achieved better results in terms of periodontal regeneration as compared to monotherapy using DFDBA.

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22. Glickman I. Clinical Periodontology. The 27. Rummelhart JM, Mellonig JT, Gray 31. Kher VK, Bhongade ML, Shori TD, Kolte Periodontium in Health and Disease: JL, Towle HJ. A comparison of freeze- AP, Dharamthok SB, Shrirao TS. A com- Recognition, Diagnosis, and Treatment dried bone allograft and demineralized parative evaluation of the effectiveness of Periodontal Disease in the Practice freeze-dried bone allograft in human of guided tissue regeneration by using of General Dentistry. Philadelphia: periodontal osseous defects. J Peri- a collagen membrane with or without Saunders, 1953. odontol 1989;60:655–663. decalcified freeze-dried bone allograft 23. Pajnigara NG, Kolte AP, Kolte RA, Pa- 28. Luepke PG, Mellonig JT, Brunsvold MA. in the treatment of infrabony defects: A jnigara NG. Volumetric assessment of A clinical evaluation of a bioresorbable clinical and radiographic study. J Indian regenerative efficacy of demineralized barrier with and without decalcified Soc Periodontol 2013;17:484–489. freeze-dried bone allograft with or with- freeze-dried bone allograft in the treat- 32. Wanikar I, Rathod S, Kolte AP. Clinico- out amnion membrane in grade II furca- ment of molar furcations. J Clin Peri- radiographic evaluation of 1% alendro- tion defects: A cone beam computed odontol 1997;24:440–446. nate gel as an adjunct and smart blood tomography study. Int J Periodontics 29. Kiany F, Moloudi F. Amnion membrane derivative platelet rich fibrin in grade II Restorative Dent 2017;37:255–262. as a novel barrier in the treatment of furcation defects. J Periodontol 2019;90: 24. Turesky S, Gilmore ND, Glickman I. Re- intrabony defects: A controlled clini- 52–60. duced plaque formation by the chlo- cal trial. Int J Oral Maxillofac Implants 33. Bodhare GH, Kolte AP, Kolte RA, Shirke romethyl analogue of victamine C. 2015;30:639–647. PY. Clinical and radiographic evaluation J Periodontol 1970;40:41–43. 30. De Leonardis D, Garg AK, Pedrazzoli and comparison of bioactive bone al- 25. Silness J, Loe H. Periodontol disease V, Pecora GE. Clinical evaluation of the loplast morsels when used alone and in in pregnancy. II. Correlation between treatment of class II furcation involve- combination with platelet-rich fibrin in oral hygiene and periodontal condition. ments with bioabsorbable barriers the treatment of periodontal intrabony Acta Odontol Scand 1964;22:121–135. alone or associated with demineralized defects—A randomized controlled trial. 26. Glossary of Periodontal Terms. Chicago: freeze-dried bone allografts. J Peri- J Periodontol 2018. Epub ahead of print. American Academy of Periodontology, odontol 1999;70:8–12. 2001.

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