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The International Journal of Periodontics & Restorative Dentistry © 2019 by QUINTESSENCE PUBLISHING CO, INC. PRINTING of TH The International Journal of Periodontics & Restorative Dentistry © 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. 659 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 fur- cation 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, Volume 39, Number 5, 2019 © 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. The International Journal of Periodontics & Restorative Dentistry © 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. 661 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. g 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 fur- cal measurements were carried out evaluation. cation defect was filled with DFDBA Volume 39, Number 5, 2019 © 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.
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