Bone regeneration in a periodontally challenged ...

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Case Report

Bone regeneration in a periodontally challenged hopeless tooth Jammula Surya Prasanna, Parupalli Karunakar1, Dasari Rajashree, Raji V. Solomon1 Departments of Periodontics, and 1Conservative and Endodontics, Panineeya Maha Vidyalaya Institute of Dental Sciences and Research Centre, NTR University of Health Sciences, Hyderabad, Andhra Pradesh, India

ABSTRACT Periodontitis is a disease characterized by varying the amount of bone loss and the regeneration of the bone structure, which is lost, is an uphill task. Grafts have been used extensively for regeneration, but each of these materials has its own limitations. No single alternative graft material except autograft provides all three components (osteoconduction, osteoinduction and osteogenic cells) for bone regeneration. The clinical applications for each type of material are dictated by its particular biochemical and structural properties. In situations where the grafting site is compromised, composite grafts consisting of several materials have been used, with a successful outcome. A non-contained defect was treated with de-mineralized bone matrix (Xenograft with Type I collagen granules), hydroxyapatite mixed with peripheral blood (PB) and Type I collagen guided tissue regeneration membrane was used to cover and stabilize the graft. Treatment was done using resorbable membrane and composite graft mixed with PB. Dramatic reduction in pocket depth, with radio opacity and outstanding bone fill was seen at the end of the treatment. Key words: Bone grafts, collagen, de-mineralised bone matrix, hydroxyapatite, regeneration, resorbable membrane, Xenograft

INTRODUCTION Autogenous cancellous bone is widely regarded as an ideal construct for graft procedures, supplying osteoinductive growth factors, osteogenic cells and a structural scaffold. However, procurement morbidity and constraints on obtainable quantities limit its use. Allograft is the next best alternative at present; however, minor immunogenic rejection and risk of disease transmission are unresolved issues. Although synthetic grafting materials eliminate these risks, these materials do not transfer osteoinductive or osteogenic elements to the host site. To offer the Address for correspondence Dr. J. S. Prasanna, Department of Periodontics, Panineeya Maha Vidyalaya Institute of Dental Sciences and Research Centre, NTR University of Health Sciences, Dilsukh Nagar, Hyderabad, Andhra Pradesh, India. E-mail: [email protected] Access this article online Quick Response Code: Website:

advantages of autograft and allograft, a composite graft may be considered. Such a graft can combine a synthetic scaffold with biologic elements to stimulate cell infiltration and new bone formation.[1] A bone graft can aid in bone regeneration by three different methods: (i) Osteogenesis, which is the formation of new bone by the cells contained within the graft material, (ii) osteoinduction, a chemical process in which molecules contained within the graft (bone morphogenetic proteins [BMPs]) convert the patient’s cells into cells that are capable of forming bone, (iii) osteoconduction, a physical effect by which the matrix of the graft forms a scaffold on which cells in the recipient site are able to form new bone.[2] It is important to note that all bone grafting materials have one or more of these three modes of action. Mixing of bone grafting substitutes can assist in bringing about a desired combination of modes of action for bone formation as a replacement of bone is a complex and demanding undertaking.[3]

CASE REPORT

www.jdrntruhs.org DOI: 10.4103/2277-8632.122180

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Systemically healthy, non-smoking 40-years-old female patient was referred to the Department of Periodontology, with the complaints of severe Journal of Dr. NTR University of Health Sciences 2013;2(4): 296-301


Prasanna, et al.: Strive to save

sensitivity, discomfort and mild to moderate pain in #22. The patient had non-contributory medical history. Intraoral examination revealed a deep pocket simultaneous presence of clinical attachment loss (CAL) corresponding to the distal side of #22 [Figure 1], with Grade II mobility (Glickman’s Index 1972). Dull aching pain on percussion was noticed. The tooth was vital with a remarkable dentinal hypersensitivity. Probing depth (PD) and CAL measurements were performed using a manual probe. Intra oral periapical radiographs were taken. Radiolucency was seen in relation to #22 in the radiograph [Figure 2]. A comprehensive periodontal and restorative treatment plan was presented to the patient and a signed informed consent was taken. Pre-operative hematological assessment was done. Initial therapy was consisted of oral hygiene instructions, scaling and root planning. Symptoms of trauma from occlusion were corrected. 3 weeks following the Phase-1 therapy, periodontal re-evaluation was performed at each visit followed

by subgingival curettage. A stain less steel wire splint was given [Figure 3] 1 week after root canal treatment. Chlorhexidine gluconate 0.2% (b.i.d) mouth wash was advised 2 weeks prior to the surgical procedure. The surgical procedure was performed using local anesthesia of 2% lidocaine. A full thickness mucoperiosteal flap was elevated and thorough root planning and degranulation were done followed by irrigation. The defect extended below the apex, revealing a non-contained defect [Figure 4]. Surgical endodontic procedure apicoectomy was done and intermediate restoration material was placed. The defect was filled with a composite graft (synthetic, osteoconductive, non-ceramic form of hydroxylapatite (HA) and de-mineralized bone matrix (DMBM) Xenograft — Type — I collagen granules) both together mixed with patient’s peripheral blood (PB). The coagulated mixture was then tightly packed to the level of the bony crest. Type-I resorbable collagen membrane was placed at the buccal side of

Figure 1: Pre-operative deep pocket simultaneous presence of clinical attachment loss

Figure 2: Pre-operative radiograph with radiolucency

Figure 3: Stain less steel wire splint Journal of Dr. NTR University of Health Sciences 2013;2(4)

Figure 4: The defect extended below the apex, revealing noncontained defect 297



the tooth. Flap was sutured at the original level and periodontal dressing was given Antibiotics and oral analgesics along with 0.2% chlorhexidine gluconate rinse were prescribed. Patient was suggested not to brush for 2 weeks. Membrane exposure was seen upon the removal of dressing and sutures postoperatively after 2 weeks [Figure 5], intentionally membrane was removed. The patient was examined weekly, up to 1 month after surgery and then every 1 month up to 9 months and every 3 months until 1 year. No probing or any subgingival instrumentation was done in the treated area between the visits. The post-operative care included the reinforcement of oral hygiene wherever necessary. After 3, 6, 9 and 12 months post-operative radiographs were taken [Figures 6-9]. Surgical re-entry was done in between 8 and 9 months [Figure 10]. In spite of removal of the membrane, the results showed excellent bone fills in the defect and PD and CAL were dramatically reduced [Figure 11]. Only drawback was that the buccal bone could not be regained.

DISCUSSION

Figure 5: Exposed membrane+

Figure 6: Three months radiograph

Figure 7: Six months radiograph

Figure 8: Nine months radiograph

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Successful periodontal regeneration is similar to the development of an organ because it requires a series of orchestrated biologic events, including cell mitogenesis, chemotaxis, adhesion, and differentiation which results in the formation of the functional periodontal unit. Because of its multi-factorial nature, the technique directed at enhancing various relevant biologic phenomena in periodontal regeneration has a greater potential to result in more favorable clinical outcomes than those that address a single unit. In this study periradicular surgery is expected to remove the causes of the disease and to provide the favorable environment for healing of the root end which is critical for a successful outcome. It prevents the passage of microorganisms or their products from the root canal system into the adjacent periradicular area. The ideal healing response after periradicular surgery is the re-establishment of an apical attachment

Journal of Dr. NTR University of Health Sciences 2013;2(4)



dentinal root surface surrounded peripherally by cementum with a root canal in the middle. The cementum provides a “biological seal” in addition to the ‘physical seal’ of the root end fillings, thereby creating a “double seal.”[4] Periapical healing involves the repair and regeneration of alveolar bone and the periodontal ligament. It is believed that large group of mediators such as BMPs, epidermal growth factor, interleukin (IL)-1 and IL-6 can accelerate infiltration, proliferation and differentiation of progenitor cells into osteoblasts.[5-7]

Figure 9: Twelve months radiograph showing gradual bone fill and more opacity

Figure 10: Surgical re-entry showing the defect filled with new bone

Figure 11: Post-operative probing depth and clinical attachment loss was reduced

apparatus and osseous repair. The deposition of cementum on the cut root surface is considered a desired healing response and a prerequisite for the reformation of a functional periodontal attachment. Resection of the root end results in an exposed Journal of Dr. NTR University of Health Sciences 2013;2(4)

In this study, DMBM Xenograft with Type — I collagen granules was used. They are also referred as an organic bone, since they are believed to remove all cells and proteinaceous material leaving behind inert absorbable bone scaffolding upon which revascularization, osteoblast migration and woven bone formation can supposedly occur. [8] DMBM Xenograft is a bone inductive sterile bio-resorbable Xenograft composed of Type I collagen. It is prepared from bovine cortical samples, resulting in nonimmunogenic flow- able particles of approximately 250 m that are completely replaced by host bone in 4-24 weeks. [8] Sampath and Reddi reported that subcutaneous implantation of course powder (74-420 m) of DMBM result in local differentiation of bone. Once the graft is placed in the osseous defect, a sequential differentiation of mesenchymal type cell occurs to form cartilage and bone. There are four types of cell differentiation and bone formation. Stage 1 includes mesenchymal cell migration into vascular spaces of matrix within 2 days. In Stage 2, mesenchymal cells differentiate into giant cells and chondrocytes between day 2 and 18. In Stage 3, the poorly vascularized areas of matrix show cartilage formation at day 8 and 20 and from day 10 to 20 woven bone develops in the vascularized areas of matrix. During Stage 4, bone formation occurs between day 20 and 30.[9-12] Type I collagen is derived from bovine tendon, which is the major structural protein in the periodontal ligament as well as most extracellular organic matrices and connective tissues throughout the body. The properties that favor its use as a biomaterial are numerous. It is biodegradable and when implanted in the body is absorbed at a rate that can be controlled by the degree of cross-linking to which it is subjected. For all practical purposes, collagen is immunologically inert and safe.[13] 299



Porous HA is an abundantly available non-toxic material that is bioactive and allows new bone to be formed directly on its surface without any intervening layer of fibrous tissue. Synthetic HA possesses a similar composition to HA crystals present in bone, enamel and dentin and exhibits osteoconduction by acting as a scaffold for new bone to grow through the implant material as long as there is enough vital host bone surrounding it. HA, when implanted does not evoke an inflammatory or foreign body response and has a good tissue tolerance. HA granules used merely act as a trellis for blood vessels and migration of osteoblasts from surrounding healthy bone, a process called “creeping substitution,” whereby it slowly resorbed and replaced by bone.[14] HA supports cell growth and fibroblast metabolism including collagen production, hence it is biocompatible.[15]

by wound closure over the exposed site to regenerate, the newly formed tissues matured into alveolar bone, cementum and a functionally oriented periodontal ligament, even in sites where the wound failure/ membrane exposure occurred as early as 1 week postsurgery.[19] Many studies so far have shown positive results in periodontal regeneration by using composite grafts. [20,21] The nature of the biologic attachment between the newly regenerated tissue and the root surface cannot be assessed by a re-entry surgery. Hence histological studies are necessary to confirm the presence of new attachment. A long junctional epithelium may be present between the root surface and the regenerated bone that does not constitute periodontal regeneration. Human histological studies are necessary to confirm if the technique employed in this study promotes true periodontal regeneration.

PB by nature clots as soon as it is dropped out. Assuming that if we mix it with other inert material like bone substitutes, it acts as a plug and produces all beneficiary effects like the primary clot does after injury. PB contains endothelial progenitor cells which are helpful in angiogenesis. Various cytokines, growth factors and hormones cause hematopoietic cells and endothelial progenitor cells, to be mobilized into the peripheral circulation, ultimately homing to regions of blood vessel formation.[16] Another possible mechanism could be that the blood clot itself, being a rich source of growth factors, play an important role in regeneration. Platelets isolated from PB are an autologous source of various growth factors.[17] They stimulate differentiation, growth and maturation of fibroblasts, odontoblasts, cementoblasts, etc., from the immature, undifferentiated mesenchymal cells in the newly formed tissue matrix.[17] If PB-fulfills all the requirements of bone regeneration like plate rich plasma (PRP), it can avoid the lengthy procedure for preparation of PRP and drawing of excess blood from the patient. Further longitudinal studies are required on this issue.

In the present clinical case, we have seen a reduction in the PD and CAL and an increase in the radiographic bone fill. The effect of growth factors on cells are essential steps in the favorable regeneration of periodontal defects and may explain the improved results found in the present case. Controversy still exists regarding the complete restoration of the attachment apparatus in every treated defect. Many factors are involved in the successful incorporation of a grafted material, including graft type, preparation site, vascularity, mechanical strength and pore size of the material. These parameters make the use of bone substitutes challenging in terms of reliability and predictability. Larger trials encompassing clinical and histological investigations are needed. Questions on the effect of different combinations of bone graft substitutes have to be addressed before a wider recommendation for the use of composite ceramic bone graft substitutes can be given. Currently most bone substitutes have little biological activity. They act as fillers and have osteointegrative and conductive properties. Ideally bone substitutes of the future will have structural integrity, provide a framework for host bone formation and act as delivery systems for factors important in regulating local bone response.

Epithelial cells migrate approximately 10 times faster than other periodontal cells types, which is why periodontal therapy typically results in the formation of long junctional epithelium which can be prevented by guided tissue regeneration (GTR).[18] Controversy exists on the exposed membrane to be removed/left in place. Wound failure including membrane exposure is a calamity of periodontal-regenerative therapy utilizing GTR techniques, making the procedure unpredictable in clinical practice.[18] In contrast, when GTR membranes were removed immediately upon exposure followed 300

SUMMARY AND CONCLUSION This case documents, the regeneration of new bone in periodontally challenged teeth shows that PB can be used as regenerating media and composite bone grafts may yield better results than single bone graft. The key success factors of this case are patient Journal of Dr. NTR University of Health Sciences 2013;2(4)



factors, morphology of the defect, selection of graft material, surgical procedure, post-surgical healing period influencing graft success and maintenance, are of prime importance. Primary limitations of this case are characteristic of a single case report and additional studies are needed to confirm the results. Due to use of compound products, it is hard to pin-point which factor stimulated the bone growth. There is a need for individual studies on this issue. Studies are required with other bone graft combinations. Histological confirmation was not done. Although, there can be merits and demerits, in this study, the fact remains that bone regeneration is definitely not a myth.

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ACKNOWLEDGMENT

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The authors would like to thank Rekha Rani K., HOD, Department of Periodontics.

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How to cite this article: Prasanna JS, Karunakar P, Rajashree D, Solomon RV. Bone regeneration in a periodontally challenged hopeless tooth. J NTR Univ Health Sci 2013;2:296-301. Source of Support: Nil. Conflict of Interest: None declared.

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