Aimetti.qxd 10/4/07 11:52 AM Page 440 The International Journal of Periodontics & Restorative Dentistry Aimetti.qxd 10/4/07 11:52 AM Page 441 441 Clinical Evaluation of the Effectiveness of Enamel Matrix Proteins and Autologous Bone Graft in the Treatment of Mandibular Class II Furcation Defects: A Series of 11 Patients Mario Aimetti, MD, DDS* Furcation defects present one of the Federica Romano, DDS** greatest challenges in periodontal clin- Enrico Pigella, DDS** ical practice.1 The anatomic features of Matteo Piemontese, MD, DDS*** furcation-involved molars make peri- odontal treatment difficult and regen- erative outcomes unpredictable.2,3 These shortcomings and advances in developmental biology have caused a The purpose of this study was to evaluate the results of treatment of buccal growing interest in the possibility of mandibular Class II furcation defects with a combination of autologous bone modulating the periodontal wound- grafts and enamel matrix derivative over a 24-month period. Eleven individuals healing process using biologic media- with chronic periodontitis were selected and contributed one furcation defect 4 each. Statistically significant improvements in mean vertical probing attachment tors. Enamel matrix proteins are level and horizontal probing attachment level were obtained at the 2-year evalua- secreted by cells of the Hertwig epithe- tion. Complete clinical closure was achieved in four sites, which exhibited favor- lial root sheath during root develop- able defect morphology for this regenerative procedure. All other residual defects ment and are crucial in stimulating the were reduced to Class I. (Int J Periodontics Restorative Dent 2007;27:441–447.) formation of acellular root cementum and associated tooth-supporting tis- sues.5 The topical application of com- mercially available enamel matrix pro- teins to previously diseased roots appears to promote regenerative processes, mimicking developmental interactions in the clinical setting.6 Several studies have reported clinical and histologic evidence of the regen- *Professor and Head, Department of Biomedical Sciences and Human Oncology, Section of Periodontology, University of Torino, Italy. erative potential of amelogenins in **Instructor, Department of Biomedical Sciences and Human Oncology, Section of periodontal tissues.7–9 Recently, Periodontology, University of Torino, Italy. enamel matrix proteins have been ***Associate Professor, Department of Periodontology, University Politecnica della Marche, employed in the management of Ancona, Italy. mandibular Class II furcation defects Correspondence to: Dr Mario Aimetti, Corso Marconi, 13, 10125 Torino, Italy; fax: +390- and have led to significant clinical 116682286; e-mail: [email protected]. Volume 27, Number 5, 2007 Aimetti.qxd 10/4/07 11:52 AM Page 442 442 Fig 1 (left) Preoperative view of mandibu- lar right first molar. Fig 2 (right) Intrasurgical view of Class II buccal furcation defect at the mandibular right first molar with a straight probe. The horizontal depth amounted to 4 mm, and the furcal bone crest was located below the interproximal bone level. improvements.10,11 However, at pres- Method and materials logic periodontal treatment. Surgical ent, there are no data available on the treatment of the furcation defects was effects of the simultaneous use of Study design and patient not scheduled until patients presented enamel matrix derivative (EMD) and selection with full-mouth plaque and full-mouth bone grafts for the treatment of peri- bleeding scores under 20%. odontal furcation defects. The combi- Eleven patients (five women and six nation of osseous grafting with amel- men; mean age 49.64 ± 5.12 years) ogenins has the potential to result in a referred to the Department of Surgical procedures synergistic effect of both materials. Periodontology, University of Torino, Whereas the bone graft may act as an diagnosed with chronic periodontitis, All surgical procedures were performed osteogenetic, osteoconductive, and and showing at least one mandibular by a single clinician. An intrasulcular osteoinductive material while also facial Class II furcation defect were incision was made on the buccal and maintaining the defect space, amelo- recruited consecutively. These subjects lingual aspects of the experimental site genins can work at the root level, pro- were nonsmokers, free of systemic dis- and extended one or two teeth mesial moting periodontal regeneration. The ease, and receiving no medications. and distal to the treated area and inter- additional effect of the association of Only vital teeth with a minimum of 2 proximally. In this way, as much kera- enamel matrix proteins and bone graft- mm of keratinized tissue (to provide tinized tissue as possible was preserved ing material has been reported for ver- coverage of the furcation entrance dur- and no vertical releasing incisions were tical bone defects.12,13 ing surgery) were included. If suitable performed. Full-thickness buccal and Therefore, the aim of the present first and second mandibular molars lingual flaps were raised approximately investigation was to evaluate, clinically were present in the same patient, the 2 mm beyond the mucogingival junc- and radiographically, the effectiveness first molars were selected for the study. tion, giving access to the furcation. Root of the combination of amelogenins A total of 11 furcation defects were debridement was accomplished using and autologous bone grafts for the treated with a combination of EMD ultrasonic manual instruments and car- treatment of buccal Class II furcation- (Emdogain, Straumann) and autolo- bide burs (Brasseler 7104014). The involved mandibular molars. gous bone grafts. morphology of the furcation defect was Prior to treatment, each patient examined and open surgical measure- received a description of the investi- ments were recorded (Figs 1 and 2). gation and provided written, informed Bone grafts were harvested from consent. Three months before the the maxillary tuberosity, placed into a surgery, all patients completed etio- sterile dappen dish, and mixed with The International Journal of Periodontics & Restorative Dentistry Aimetti.qxd 10/4/07 11:52 AM Page 443 443 Figs 3a and 3b Application of EMD (a, left) and autologous bone graft (b, right) on denud- Fig 4 The flap was sutured to completely ed root surface of the affected tooth. cover the coronal entrance of the furcation. EMD. The preliminary sutures were Postsurgical infection control (PAL-H) and vertical probing attach- made with vertical mattress sutures. and maintenance care ment level (PAL-V) were recorded at Root surfaces were then conditioned the midbuccal aspect of each furcation with a 24% ethylenediaminetetraacetic Patients were placed on amoxicillin (2 site using a Williams probe and a cali- acid (EDTA) gel (pH 6.7, PrefGel, g/day) for 6 days, and nimesulide was brated Nabers probe, respectively. The Straumann) for 2 minutes, after which prescribed for pain control. They were degree of furcation involvement was the surgical area was thoroughly rinsed instructed to clean the surgical sites calculated from the PAL-H according to with sterile saline solution. EMD was using a roll technique with an ultrasoft Hamp et al.14 applied immediately, starting at the toothbrush and to rinse twice daily with Probing depth (PD), clinical attach- farthest end of the involved furcation 0.12% chlorhexidine digluconate ment level (CAL), and location of the and covering the entire denuded root mouthwash (60 seconds) for 4 weeks gingival margin (REC) were scored at surface (Fig 3a). Great care was taken after surgery. six sites around each experimental to control bleeding and to prevent Recall appointments were sched- tooth using a Williams periodontal contamination of the surgical area with uled weekly during the first month and probe and rounded up to the nearest the use of sterile gauzes. The graft was subsequently at 3-month intervals up 0.5 mm. To evaluate oral hygiene sta- packed into the defect using a con- to 2 years postsurgery. Full-mouth pro- tus and the degree of gingival inflam- denser, and EMD was reapplied to fessional tooth cleaning was per- mation, the full-mouth plaque score cover the defect site and the bone formed and oral hygiene reinforced at (FMPS) and full-mouth bleeding score graft (Fig 3b). Flaps were repositioned each appointment. (FMBS) were determined. to the cementoenamel junction and mattress sutures were applied to Intrasurgical measurements obtain primary closure (Fig 4). Measurements The following linear measurements Gentle intermittent pressure was (mm) were recorded along the mid- applied to the surgical site for 4 to 5 Clinical measurements buccal plane of each furcation site to minutes to minimize blood clot for- Subjects were clinically monitored at characterize defect morphology and mation. No periodontal dressing was baseline (1 week before surgery) and root configuration following surgical placed over the surgical area. Sutures 24 months postoperatively by the site preparation. were removed at 7 days after surgery. same calibrated examiner. The primary outcome of the study was the change 1. Distance from the cementoenamel in horizontal furcation depth. junction (CEJ) to the roof of the fur- Horizontal probing attachment level cation (CEJ-ROF) Volume 27, Number 5, 2007 Aimetti.qxd 10/4/07 11:52 AM Page 444 444 Fig 5 Clinical soft tissue healing at the Table 1 Distance from furcation roof to 24-month evaluation. alveolar crest, as determined surgically at included defects Group No. % A (0 to 3 mm) 2 18.2 B (4 to 6 mm) 9 81.8 C (≥ 7 mm) 0 0 Table 2 Intrasurgical characteristics of Table 3 Radiographic characteristics of defects (in mm) defects (in mm) Measurement Mean SD Measurement Mean SD CEJ-BC 5.91 1.32 CEJ-AC 6.08 1.36 CEJ-BD 7.68 2.00 CEJ-Fx 3.41 1.24 CEJ-ROF 3.09 1.22 FW 2.23 0.22 HOPAL 6.27 1.68 CEJ-BL 5.91 1.80 PBH 5.84 1.77 CEJ-AC = CEJ line to alveolar crest at furcation site; CEJ-Fx = CEJ to fur- cation fornix; FW = furcation width at the level of the alveolar crest; CEJ-BC = CEJ line to BC; CEJ-BD = CEJ to base of bone defect; CEJ-ROF = CEJ-BL = CEJ to interproximal bone crest.